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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1500
} | Medical Text: Admission Date: [**2118-4-18**] Discharge Date: [**2118-7-5**]
Date of Birth: [**2054-9-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / meropenem / cefepime / vancomycin
Attending:[**First Name3 (LF) 38616**]
Chief Complaint:
Admission for allogenic stem cell transplant
Major Surgical or Invasive Procedure:
allogenic stem cell transplant
Right subclavian central venous line placement and removal
Right internal jugular cental venous line placement
bronchoscopy
Bone marrow biopsy
History of Present Illness:
63 year old woman with AML progressing out of MDS. She was
induced with 7+3 (daunorubicin and cytarabine) and achieved
remission. She has received 1 cycle of MiDAC for consolidation
on [**2118-2-28**].
She is admitted in CR1 for allogenic transplant on protocol
07-384. She reports feeling well, except for mild persistent
fatigue. She was examined today by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3236**], NP and Dr.
[**Last Name (STitle) **], who determined that she was OK to be admitted for
transplant today.
Past Medical History:
ONCOLOGY HISTORY:
- Panyctopenia noted on preop for excisional biopsy, CBC
revealed a white blood count of 2.2, hematocrit of 34.2,
platelet count of 116,000, and MCV of 101 at OSH.
- BM Bx at OSH on [**2117-12-7**] showed dyspoietic granulocytes and
13%
myeloblasts. There was no immunophenotypic evidence for
lymphoproliferative disorder and the findings were most
suggestive of a clonal myeloid neoplasm thought to be MDS with
excess blasts.
- Referred to [**Hospital1 18**], repeat BM bx on [**1-13**] showed 15% blasts on
aspirate and translocation between chromosome 6 at band 6p23 and
chromosome 9 at band 9q34
- s/p Idarubicin 7+3 induction Day 1: [**2118-1-21**] Cycle end:
[**2118-2-17**]. During her neutropenic period, she developed acute
fevers with focal erythroderm on her L forearm and distal L>R
leg. Prior to the hospitalization, she had a L parotidectomy for
what turned out to be parotiditis and sialadenitis with a large
retained duct stone. Ultimately, it became clear she had no
persistent infectious process in the parotid bed, but had
evolving carbapenem and cephalosporin erythroderm. Her rashes
improved dramatically with transition to from meropenem to
cefepime to aztreonam. Her course was further complicated by a
fever curve that had regular Tmax in the 101 range, resolving
while on vancomycin, aztreonam, clindamycin and micafungin, but
then recurred first low grade then becoming very hectic and high
grade to 104 without any focal findings. The vancomycin was
stopped and she defervesced after 72 hours. She soon thereafter
recovered her counts and all antibiotics were discontinued when
her ANC approached 500.
- [**2118-2-28**] - MiDAC Consolidation
OTHER PAST MEDICAL HISTORY:
-Osteoarthritis
-Left total knee replacement
-Remote cholecystectomy and appendectomy.
-Epilepsy with a history of grand mal seizures. Her last
seizure was four to five years ago. She is followed by a
neurologist in [**Hospital1 392**].
-Hypertension
-Anxiety.
Social History:
She has been married for 41 years. She is a retired post-office
worker. She has three daughters who all live locally. She is a
smoker who quit 26 years ago. She smoked one pack per week for
about 30 years. She does not drink any alcohol due to her
antiepileptic medications.
Family History:
Her mother died of heart complications. Her father died of
emphysema. She has a healthy brother. She has a daughter who was
diagnosed with colon cancer at age 29, currently in remission.
She has another daughter age 31 with a pituitary
tumor and she has a third daughter who is healthy.
Physical Exam:
Admission Physical Exam:
VS: 98.6 133/86 89 18 99%RA Weight: 276 Height 62 BMI:
50.5
Gen: WD/overnourished in NAD
HEENT: alopecia, anicteric, [**Last Name (LF) 3899**], [**First Name3 (LF) 13775**], clear OP, supple neck,
no masses
Lungs: CTAB
CV: RRR NL S1,S2; no murmurs, rubs or gallops
Abd: Soft, obese, non-tender no HSM or masses
Skin: Reddish reticular flat pruritic rash on left side of back
Ext: without C/C/E; petechial and confluent rash on bilteral LE
resolved
Neuro: Non-focal and symmetric
.
Discharge Physical Exam
VS: tc 98.0, 142-158/72-78, 70, 18-20, 99% RA.
Gen: obese woman in NAD
HEENT: alopecia, anicteric, [**Last Name (LF) 3899**], [**First Name3 (LF) 13775**], clear OP, supple neck,
no masses
Lungs: CTAB
CV: RRR NL S1,S2; no murmurs, rubs or gallops
Abd: Soft, obese, non-tender no HSM or masses
Skin: Reddish reticular flat pruritic rash on left side of back
Ext: without C/C/E; petechial and confluent rash on bilteral LE
resolved
Neuro: Non-focal and symmetric
Pertinent Results:
ADMISSION LABS:
[**2118-4-18**] 08:00AM BLOOD WBC-4.6 RBC-3.72* Hgb-12.6 Hct-37.8
MCV-102* MCH-33.9* MCHC-33.4 RDW-17.2* Plt Ct-211
[**2118-4-19**] 12:00AM BLOOD WBC-6.9 RBC-3.34* Hgb-11.4* Hct-33.3*
MCV-100* MCH-34.1* MCHC-34.1 RDW-17.1* Plt Ct-109*
[**2118-4-20**] 12:00AM BLOOD WBC-5.5 RBC-3.12* Hgb-10.8* Hct-31.3*
MCV-100* MCH-34.6* MCHC-34.5 RDW-16.8* Plt Ct-100*
[**2118-4-18**] 08:00AM BLOOD Neuts-53.6 Lymphs-24.1 Monos-10.2
Eos-10.4* Baso-1.7
[**2118-4-19**] 12:00AM BLOOD Neuts-94* Bands-2 Lymphs-2* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2118-4-20**] 12:00AM BLOOD Neuts-95.9* Lymphs-0.7* Monos-3.1 Eos-0
Baso-0.2
[**2118-4-19**] 12:00AM BLOOD Fibrino-211
[**2118-4-20**] 12:00AM BLOOD Fibrino-250
[**2118-4-21**] 12:20AM BLOOD Fibrino-234
[**2118-5-30**] 03:20PM BLOOD CD3%-89.1 CD3Abs-307 16/56%-9.9
16/56Ab-34
[**2118-4-23**] 12:00AM BLOOD Ret Aut-1.6
[**2118-5-30**] 03:20PM BLOOD WBC-4.3 Lymph-8* Abs [**Last Name (un) **]-344 CD3%-80 Abs
CD3-275* CD4%-39 Abs CD4-135* CD8%-38 Abs CD8-130* CD4/CD8-1.0
[**2118-4-18**] 09:15AM BLOOD UreaN-18 Creat-0.9 Na-140 K-4.8 Cl-103
HCO3-29 AnGap-13
[**2118-4-19**] 12:00AM BLOOD Glucose-174* UreaN-16 Creat-0.8 Na-137
K-4.3 Cl-101 HCO3-24 AnGap-16
[**2118-4-20**] 12:00AM BLOOD Glucose-178* UreaN-16 Creat-0.8 Na-133
K-4.3 Cl-99 HCO3-26 AnGap-12
[**2118-4-18**] 09:15AM BLOOD ALT-12 AST-18 LD(LDH)-189 AlkPhos-61
TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2118-4-21**] 12:20AM BLOOD LD(LDH)-175
[**2118-4-22**] 12:00AM BLOOD ALT-12 AST-11 LD(LDH)-163 AlkPhos-46
TotBili-0.2
[**2118-5-20**] 07:37AM BLOOD CK-MB-4 cTropnT-0.06*
[**2118-5-20**] 02:37PM BLOOD cTropnT-0.15*
[**2118-5-20**] 08:32PM BLOOD CK-MB-4 cTropnT-0.08*
[**2118-4-18**] 09:15AM BLOOD TotProt-6.6 Albumin-4.2 Globuln-2.4
Calcium-10.1 Phos-3.4 Mg-1.9 UricAcd-5.9*
[**2118-4-19**] 12:00AM BLOOD Calcium-9.6 Phos-2.7 Mg-1.5*
[**2118-4-20**] 12:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.1
Test
----
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results Reference Ranges
------- ----------------
<31 pg/mL Negative Less than
60 pg/mL
Indeterminate 60 - 79
pg/mL
Positive Greater
than or equal to
80 pg/mL
Test Result Reference
Range/Units
ASPERGILLUS ANTIGEN 0.1 <0.5
URINE:
CSF:
[**2118-5-23**] 05:12PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-285*
Polys-33 Lymphs-10 Monos-0 Eos-2 Macroph-55
[**2118-5-23**] 05:12PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-81* Polys-3
Lymphs-17 Monos-0 Macroph-80
[**2118-5-23**] 05:12PM CEREBROSPINAL FLUID (CSF) TotProt-31 Glucose-74
LD(LDH)-18
Test Result Reference
Range/Units
CMV DNA, QL PCR NOT DETECTED Not
Detected
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Herpes Virus 6 DNA, Qualitative Real-Time PCR
HHV-6 DNA Not Detected Not
Detected
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
[**Doctor Last Name 3271**] [**Doctor Last Name **] Virus DNA, Qualitative Real-Time PCR
EBV DNA, QL PCR Not Detected
Not Detected
Test Name Flag Results Unit
Reference Value
--------- ---- ------- ----
---------------
Herpes Simplex Virus PCR
Specimen Source CSF
Result Negative Not
Applicable
MICRO:
WOUND CULTURE (Final [**2118-4-29**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
C. difficile DNA amplification assay (Final [**2118-5-1**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
Blood Culture, Routine (Final [**2118-5-9**]):
STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 4 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final [**2118-5-7**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN @ 0231 ON
[**2118-5-7**].
Aerobic Bottle Gram Stain (Final [**2118-5-7**]):
GRAM POSITIVE COCCI IN CLUSTERS.
WOUND CULTURE (LINE TIP) (Final [**2118-5-10**]):
STAPHYLOCOCCUS EPIDERMIDIS. <15 colonies.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
Blood cultures ([**5-7**], [**5-14**], [**5-15**], [**5-17**], [**5-19**], [**5-20**], [**5-21**], [**5-22**],
[**5-24**], [**5-25**], [**5-26**]): no growth
Urine cultures ([**5-15**], [**5-17**], [**5-20**], [**5-22**], [**5-24**]): no growth
CMV Viral Load (Final [**2118-5-18**]):
1,040 copies/ml.
Respiratory Viral Culture (Final [**2118-5-19**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
[**2118-5-17**] 2:23 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
PLS R/O KLEBSIELLA. R/O CMV.
GRAM STAIN (Final [**2118-5-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2118-5-19**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2118-5-24**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2118-5-17**]):
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
[**2118-5-17**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2118-5-18**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE (Final [**2118-5-20**]):
TEST CANCELLED, PATIENT CREDITED.
FURTHER [**Location (un) **] OF THE CULTURE WILL BE PERFORMED ON
REQUEST ONLY.
Refer to CMV early antigen test result for further
information.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
CULTURE REQUESTED BY DR [**First Name (STitle) **].
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2118-5-20**]):
POSITIVE FOR CYTOMEGALOVIRUS.
Early antigen detected by immunofluorescence.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2118-5-20**]
11:10AM.
[**2118-5-17**] 2:23 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
PLS R/O KLEBSIELLA. R/O CMV.
GRAM STAIN (Final [**2118-5-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2118-5-19**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final [**2118-5-24**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2118-5-17**]):
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
[**2118-5-17**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2118-5-18**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE (Final [**2118-5-20**]):
TEST CANCELLED, PATIENT CREDITED.
FURTHER [**Location (un) **] OF THE CULTURE WILL BE PERFORMED ON
REQUEST ONLY.
Refer to CMV early antigen test result for further
information.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
CULTURE REQUESTED BY DR [**First Name (STitle) **].
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2118-5-20**]):
POSITIVE FOR CYTOMEGALOVIRUS.
Early antigen detected by immunofluorescence.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2118-5-20**]
11:10AM.
Respiratory Viral Culture (Final [**2118-5-20**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2118-5-18**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
CMV Viral Load (Final [**2118-5-20**]):
9,380 copies/ml.
Performed by PCR
CMV Viral Load (Final [**2118-5-24**]):
1,470 copies/ml.
Performed by PCR.
CSF: CRYPTOCOCCAL ANTIGEN (Final [**2118-5-23**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
STUDIES:
ECG ([**4-18**]): rate 86. Sinus rhythm. Within normal limits.
EEG ([**4-20**]):
IMPRESSION: This is an abnormal EEG due to the presence of
moderate
diffuse background slowing and frequent generalized bursts of
high
amplitude slow waves. These findings are indicative of a
moderate
diffuse encephalopathy which suggests widespread cerebral
dysfunction
but is etiologically non-specific. There were no epileptiform
features.
ECG ([**4-23**]): Sinus rhythm. Non-specific inferior ST-T wave
flattening.
INVESTIGATION OF TRANSFUSION RXN ([**2118-4-29**]):
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mrs. [**Known lastname **]
experienced
chills and urticaria after receiving an infusion of
hematopoietic stem
cells. The laboratory work-up revealed no evidence of hemolysis.
Noncryopreserved allogeneic stem cell products are generally
well
tolerated. Approximately 2% of infusions will be complicated by
chills
likely resulting from recipient anti-HLA antibodies reacting
with donor
white blood cells. Additionally, recipient antibodies against
plasma
proteins present in the component may cause allergic type
reactions
characterized by urticaria. We recommend no changes in infusion
practice
in the patient at this time.
INVESTIGATION OF TRANSFUSION RXN ([**2118-5-4**]):
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mrs. [**Known lastname **]
experienced a
urticarial reaction after transfusion of an apheresis platelet
transfusion. Urticarial transfusion reactions are thought to be
triggered by exposure to soluble substances/antigens within the
donor
product that cause IgE mediated histamine release. Urticarial
reactions
complicate 1-3% of transfusions. The presence of one urticarial
transfusion reaction does not predict future reactions. We
recommend no
changes in standard transfusion practices in this patient at
this time.
CT Head noncon ([**2118-5-4**]):
1. No acute intracranial hemorrhage, edema or mass effect.
2. Highly symmetric confluent hypoattenuation in bihemispheric
white matter, unusual for typical sequelae of chronic small
vessel ischemic disease, and more characteristic of intrathecal
methotrexate or other treatment-effect, which should be
correlated with more detailed clinical information.
INVESTIGATION OF TRANSFUSION RXN ([**2118-5-13**]):
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [**Known lastname **] developed
an
urticarial reaction after receiving a bag of apheresis platelets
on
[**2118-5-13**]. Urticarial transfusion reactions are thought to be
triggered by
exposure to soluble substances/antigens within the donor product
that
cause IgE mediated histamine release. Urticarial reactions
complicate
1-3% of transfusions. The presence of occasional urticarial
transfusion
reactions does not typically predict future severe reactions. We
recommend no changes in transfusion practices in this patient at
this
time.
ct head noncontrast ([**5-13**]):
1. No acute intracranial process.
2. Stable periventricular and subcortical white matter
hypodensities may be
related to intrathecal methotrexate or other treatment effect
and less likely the sequela of chronic microvascular ischemic
disease.
3. Mild global atrophy.
ct chest non-con([**5-16**]):
1. Diffuse ground-glass opacities within the entire right lung.
These
findings are not typical of any one particular etiology. Given
that the
patient is status post bone marrow transplant prior to
engrafting, bacterial, viral, and fungal etiologies should all
be considered including infections such as toxoplasmosis or CMV.
2. Bilateral trace pleural effusions, right greater than left.
Echo ([**5-17**]):
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. No masses or vegetations are seen on the aortic valve.
There is no aortic valve stenosis. No aortic regurgitation is
seen. No mass or vegetation is seen on the mitral valve. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2118-3-29**], no
change.
renal u/s ([**5-17**]):
IMPRESSION: No hydronephrosis bilaterally.
cxr ([**5-18**]);
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The severity and extent of the pre-existing extensive
bilateral
parenchymal opacities is constant. Also constant is the absence
of pleural
effusions, the moderate cardiomegaly and the position of the
right internal
jugular vein catheter.
LENI ([**5-19**]):
1. No DVT to the popliteal veins bilaterally. Bilateral calf
veins not well
visualized.
2. Right popliteal [**Hospital Ward Name 4675**] cyst.
CXR ([**2118-5-21**]):
1. Right internal jugular central line has its tip in the distal
SVC,
unchanged. When compared to the most recent prior study, there
has been
slight interval improvement in the bilateral airspace process
suggestive of
moderate-to-severe pulmonary edema. However, there is still a
substantial
residual pulmonary edema present on the current examination.
Overall, cardiac and contours are likely unchanged. No evidence
of pneumothorax.
CT head noncon ([**5-21**]):
1. No acute intracranial process.
2. Stable periventricular and subcortical white matter
low-attenuating
regions may be related to treatment effect or the sequelae of
chronic small
vessel ischemic disease.
3. Mild age-related involutional changes.
EEG ([**5-22**]):
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of a diffuse encephalopathy manifest by a mild to moderate
background
slowing. Superimposed upon this is focal slowing in the left
central
temporal region with superimposed admixed paroxysmal
epileptiform
transients in the same region. No seizures were identified.
CXR ([**5-22**]);
There is a right central venous catheter with distal lead tip in
distal SVC.
Heart size is upper limits of normal. There are again seen
diffuse airspace
densities and more confluent areas of opacity within the left
lobe. These may represent pulmonary edema; however, superimposed
infection is not entirely excluded. A small left-sided pleural
effusion is also seen.
UENI ([**5-22**]):
IMPRESSION: No evidence of DVT in the right upper extremity.
EEG ([**5-23**]):
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of disorganized theta and delta background indicative of mild to
moderate diffuse encephalopathy. In addition, there is focal
slowing in
the left frontocentral region with superimposed epileptiform
discharges.
There were no electrographic seizures. Compared to the prior
day's
recording, there were no significant changes.
CSF ([**5-23**]):
Cerebrospinal fluid:
NEGATIVE FOR MALIGNANT CELLS.
Rare lymphocytes.
EEG ([**5-24**]):
MPRESSION: This is an abnormal continuous ICU monitoring study
because
of disorganized theta and delta background indicative of mild to
moderate diffuse encephalopathy. In addition, there is focal
slowing in
the left frontocentral region with superimposed epileptiform
discharges.
There were no electrographic seizures. Compared to the prior
day's
recording, there were no significant changes.
KUB ([**5-25**]):
IMPRESSION: Limited study. No evidence of obstruction.
CT Chest non-con ([**5-27**]):
IMPRESSION: Increased pulmonary ground-glass opacities and
interstitial
abnormality. New pleural and increased pericardial effusions.
Appearance is
most compatible with viral infection, such as CMV, or
Pneumocystis. Graft
versus host disease could also have this appearance, but should
also produce extrathoracic manifestations.
BMB [**2118-5-31**]:
Peripheral Blood Smear:
The smear is adequate for evaluation. Red blood cells are
normochromic and normocytic with slight anisopoikilocytosis
including rare teardrop microcytes and schistocytes seen. The
white blood cell count appears decreased. Platelet count
appears decreased; large forms are seen. Differential shows 72%
neutrophils, 4% monocytes, 10% lymphocytes, 4% eosinophils, 2%
basophils, 3% metamyelocytes.
Aspirate Smear:
The aspirate material is suboptimal for evaluation due to
paucity of spicules and hemodilution. M:E ratio is 5:1
(hemodilution). Erythroid precursors are relatively,
proportionately decreased in number and exhibit dyspoietic
maturation; forms with irregular nuclear contours are seen.
Myeloid precursors appear relatively increased in number.
Abnormal nuclear lobation and hypogranular forms are seen.
Megakaryocytes are not seen.
A 200 cell differential shows 4% Promyelocytes, 7% Myelocytes,
22% Metamyelocytes, 45% Bands/Neutrophils, 7% Lymphocytes, 15%
Erythroid.
Clot Section and Biopsy Slides:
The core biopsy material is suboptimal for evaluation, severely
limited by aspiration and crush artifact. It consists of a 0.8
cm core, trabecular marrow with a cellularity of 5%. Minimal
hematopoietic tissue is seen in one space. No excess of blasts.
Erythroid precursors are decreased in number and exhibit mildly
dyspoietic maturation. Myeloid precursors are decreased in
number with complete maturation to neutrophilic stage with left
shifted maturation with dyspoietic maturation. Blood clot is
non-contributory.
SKIN BIOPSY [**2118-6-2**]:
Skin, left inferior abdomen, biopsy (A-B):
Mild superficial perivascular lymphocytic infiltrate, with
occasional eosinophils, see note.
Note: Rare dyskeratotic keratinocyte are seen. The interface
changes are minimal, and although early graft versus host
disease cannot be entirely excluded, the findings are more in
favor of a drug hypersensitivity reaction. Clinical correlation
is recommended. Multiple levels examined.
MR HEAD [**2118-6-1**]:
1. No acute intracranial abnormality.
2. No pathologic focus of enhancement.
3. Extensive FLAIR-signal abnormality in bihemispheric
subcortical and
periventricular, as well as central pontine white matter.
Though this likely represents sequelae of chronic small vessel
ischemic disease, a contribution of treatment effect is a
consideration, and should be closely correlated with detailed
history (e.g. Is there any history of intrathecal methotrexate
or other chemotherapeutic [**Doctor Last Name 360**]?).
NCHCT [**2118-6-9**]:
There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. Periventricular and subcortical white matter
hypodensities are suggestive of chronic small vessel ischemic
disease. The ventricles and sulci are normal in size and
configuration. There is no fracture. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
Chest CT [**2118-6-17**]:
There is been marked improvement in the interstitial opacities
in
the lungs with mild residual or recurrent disease seen in the
right lower
lobe. Bilateral pleural effusions have resolved. A small
unchanged cyst is seen in the left upper lobe. Right internal
jugular catheter terminates in the distal SVC.
The thyroid is normal and symmetric in appearance. Normal three
vessel
branching aortic arch is seen with mild atherosclerotic
calcification. The heart appears normal with mitral and aortic
valvular calcifications and perhaps mild calcification of the
left main coronary artery. Small
pericardial effusion is unchanged or minimally more prominent
than the
previous examination. No pathologically enlarged axillary,
supraclavicular, mediastinal or hilar nodes are seen. The
esophagus is normal in appearance. The trachea and central
airways are patent to the segmental level.
Although this study is not tailored for subdiaphragmatic
evaluation imaged
upper abdomen reveals unchanged left adrenal lipoma. Rounded
low-attenuation structure in the pancreatic tail is likely
invaginated fat. Calcification is seen at the celiac and SMA
origins
[**2118-6-20**] Radiology MR HEAD W/O CONTRAST
IMPRESSION: 1. No evidence of acute infarct or hemorrhage. 2.
Stable bilateral subcortical and periventricular T2/FLAIR
hyperintensities likely representing microangiopathic ischemic
changes versus post-treatment changes.
[**2118-6-20**] Radiology CT ABD & PELVIS W/O CON .
IMPRESSION: 1. No evidence of PTLD on this non-contrast CT of
the abdomen. 2. Diverticulosis, without evidence of
diverticulitis. 3. Pericardial thickening, unchanged from
[**2118-1-23**]. 4. Nonspecific peribronchovascular ground-glass
opacity in the right lower lobe. 5. Hypodense blood pool,
consistent with anemia.
[**2118-6-21**] Neurophysiology EEG .
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of one electrographic seizure in the left temporal
region with spread to the left parasagittal area lasting 48
seconds. On video, patient's view is limited but there is no
obvious ictal clinical correlation; however, immediately in the
postictal phase, she has an arousal with purposeful movements.
In addition, there are frequent left temporal epileptiform
discharges and intermittent prominent slowing in this region.
These findings are indicative of an epileptogenic focus with
underlying subcortical dysfunction in the left temporal lobe.
Furthermore, the posterior dominant rhythm was poorly sustained
with further bursts of bifrontal intermittent rhythmic delta
(FIRDA) slowing indicative of mild to moderate diffuse cerebral
dysfunction. Potential causes include, but are not limited to,
medication effect, or metabolic, toxic, and infectious
disturbances.
[**2118-6-22**] Neurophysiology EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of occasional left temporal epileptiform discharges as
well as intermittent significant slowing in this region. These
findings are suggestive of a potentially epileptogenic focus in
the left temporal region with underlying subcortical
dysfunction. In addition, the posterior dominant rhythm was not
well-sustained and there were frequent bursts of bifrontal
intermittent rhythmic delta (FIRDA) slowing indicative of mild
to moderate diffuse cerebral dysfunction. Potential causes
include, but are not limited to, medication effect or metabolic,
toxic, and infectious disturbances. There are no electrographic
seizures. Compared to prior day's recording, this study shows
improvement due to less frequent left temporal epileptiform
discharges and the absence of electrographic seizures.
[**2118-6-23**] Neurophysiology EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of intermittent focal slowing and rare epileptiform
discharges in the left temporal region. These findings are
indicative of a potentially epileptogenic focus in the left
temporal region with underlying subcortical dysfunction. There
is also a poorly sustained alpha rhythm, excess diffuse admixed
theta and delta activity and rare bursts of frontal intermittent
rhythmic delta activity. These findings are indicative of mild
to moderate diffuse cerebral dysfunction which is etiologically
non-specific. There are no electrographic seizures. Compared to
the prior day's recording, there is less frequent and less
prominent left temporal slowing and epileptiform discharges have
also decreased in frequency.
Discharge labs:
[**2118-7-5**] 12:00AM BLOOD WBC-2.1* RBC-2.58* Hgb-7.9* Hct-24.0*
MCV-93 MCH-30.7 MCHC-33.0 RDW-19.1* Plt Ct-83*
[**2118-7-5**] 12:00AM BLOOD WBC-2.1* RBC-2.58* Hgb-7.9* Hct-24.0*
MCV-93 MCH-30.7 MCHC-33.0 RDW-19.1* Plt Ct-83*
[**2118-7-5**] 12:00AM BLOOD Neuts-67 Bands-1 Lymphs-21 Monos-4 Eos-6*
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2118-7-5**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Tear Dr[**Last Name (STitle) 833**]
[**Name (STitle) 4486**] Ellipto-OCCASIONAL
[**2118-7-5**] 12:00AM BLOOD Plt Ct-83*
[**2118-7-3**] 11:39PM BLOOD Gran Ct-2450
[**2118-6-30**] 01:43PM BLOOD WBC-1.4* Lymph-19 Abs [**Last Name (un) **]-266 CD3%-71
Abs CD3-188* CD4%-31 Abs CD4-84* CD8%-35 Abs CD8-93* CD4/CD8-0.9
[**2118-6-30**] 01:43PM BLOOD CD3%-79.2 CD3Abs-211 16/56%-19.0
16/56Ab-51
[**2118-7-5**] 12:00AM BLOOD Glucose-107* UreaN-24* Creat-1.7* Na-134
K-4.1 Cl-106 HCO3-20* AnGap-12
[**2118-7-5**] 12:00AM BLOOD ALT-7 AST-16 LD(LDH)-311* AlkPhos-65
TotBili-0.3
[**2118-7-5**] 12:00AM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.6 Mg-2.0
[**2118-6-30**] 01:43PM BLOOD IgG-1471 IgA-222 IgM-122
[**2118-7-5**] 09:45AM BLOOD Cyclspr-PND
[**2118-7-3**] 09:43AM BLOOD Cyclspr-112
Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
63 year old woman with AML progressing out of MDS who was
admitted in CR1 on [**2118-4-18**] for allogenic transplantation.
Admission complicated by bacteremia, hyponatremia/SIADH, mild
mucositis, CMV pneumonitis and altered mental status.
ISSUES:
# AML: s/p 7+3 (daunorubicin and cytarabine) and achieved
remission. She has received 1 cycle of MiDAC for consolidation
on [**2118-2-28**]. The patient was admitted for allogenic stem cell
transplant with conditioning regimen of TLI, ATG, and
clofarabine. Transplant on [**2118-4-29**]. She tolerated the transplant
well. She was provided zofran for nausea. The patient was on
acyclovir for prophylaxis. Fluconazole prophylaxis was not
initiated during admission secondary to medication interaction
with anti-epileptic medications, micafunfin was used instead.
Her counts started to recover near the beginning of [**Month (only) 116**], but
then decreased again. She needed support with intermittent blood
transfusions and injections of filgrastim. She had a repeat bone
marrow biopsy on [**2118-6-29**], which preliminarily showed hypoplastic
marrow consistent w/ suppression from medication (suspected to
be due to valgancyclovir, see below). Pt will need to have
continued follow-up for her continued neutropenia. For now, Pt
will need continued filgrastim 480 mcg sc on Mon and Thursday,
with 2x weekly CBC with differential. Pt was started on
cyclosporine and mycophenolate for graft-versus host
prophylaxis, which has been tapered to current dosage of
cyclosporine 50mg po q12h and mycophenolate mofetil 250mg po
bid. Pt will need continued cyclosporine levels weekly with
results faxed to primary oncologist Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 21962**].
# Bacteremia: Patient found to have staph epidermitis bacteremia
[**2-24**] line infection, complicated by fevers to 103 and severe
rigors. Fevers resolved and blood cultures cleared with addition
of Daptomycin and Aztreonam and replacement of her central line.
Other infectious sources, including UA and CXR remained normal.
# Hypoxia: Patient desaturated on night of [**5-20**] and was in
respiratory distress. Was in ICU for 5 days for respiratory
distress (likely caused by CMV pneumonitis and pulmonary edema).
CMV VL positive. Never required intubation. Now stable on 3-5L
NC, on meropenem, micafungin and gancyclovir. Received IVIG as
well. Of note, pt has many allergies, most notably antibiotic
allergies that have caused severe and painful body rashes.
Patient was desensitized of meropenem in ICU, and if pt comes
off of meropenem, would need to be desensitized again if want to
put it back on. Per ID, will continue meropenem through
Monday, [**5-30**], as low likelihood infection in lung is a bacterial
cause. Follow-up CT scan done [**5-27**] shows worsening of pulm
interstitial and ground glass, but patient clinically much
better. Patient has had no fevers since [**5-25**]. qMON CMV VL were
drawn. Patient also had pulmonary edema. Has already been
diuresed about 11L in ICU and a couple more slowly on floor.
Patient responded to PRN 40mg IV lasix doses.
.
# CMV PNEUMONITIS: patient was admitted to the ICU on [**5-20**] in
the setting of acute respiratory distress as above. At this
time a CMV viral load returned elevated at 9000. She was
initially treated with gancyclovir and anti-CMV IVIG starting on
[**5-18**]. Her over all clinical status improved and she was
gradually weaned from oxygen. On [**5-30**] her CMV VL again was
elevated to 22,000 raising concern for gancylcovir resistance
and she was switched to foscarnate on [**5-31**]. She continued to do
well clinically, but developed acute renal insufficency with a
gradual rise in her creatinine from 1.0 to 2.2 over the 2 weeks
she recieved foscarnate. Pt was switched to gancyclovir on [**6-11**]
and placed on maintenace dosing of 1.4 mg/kg on [**6-17**]. Interval
Chest CT on [**6-17**] showed dramatic improvement in her pulmonary
infiltrates. A CMV resistance genotype was sent and was
negative for any resistant mutations. Pt was switched to
valgancyclovir and on a dose of 450mg po daily after discussion
with ID attending and CMV viral load was not detectable x 4
after [**2118-6-6**], to be continued until 12 months after her
transplant ([**2119-4-29**]). Pt will need to have weekly CMV
viral loads. Given her continued need for valgancyclovir, Pt
will need filgrastim and 2x weekly CBC (see below).
# Hyponatremia. While undergoing conditioning for transplant,
the patient became hyponatremic to 129. Serum/Urine OSM
consistent with SIADH. The patient is chronically on
oxcarbamazepine, but no other new offending medications were
identified as the source of her hyponatremia. The patient was
started on a 1L fluid restriction, but continue to have
persistent hyponatremia. The patient was evaluated by the renal
team and was started on 1 salt tab TID. Sodium stabilized around
130. The patient was also on hypertonic saline for a brief
amount of time. While anti-epileptics changed in ICU, pt was
able to keep Na of low 130s w/ no need for hypertonic saline or
salt tabs, only fluid restriction. However, later during her
admission, Pt's sodium was still low but her hyponatremia was in
the setting of [**Doctor First Name 48**] and appropriately dilute urine (low osms).
Pt's hyponatremia was resolved and sodium was stable by
discharge at ~135, although pt continued to have mild diuresis.
Pt will need 2x weekly Chem 7 (Na, K, Cl, HCO3, BUN, Cr, Gluc).
# Back pain: Patient with low midline back pain that began when
getting onto a CT scanner table. Back pain-free at rest, but
present with movement. Back pain likely mechanical secondary to
strain. Pain improved with lidocaine patch.
.
# Esophagitis: While neutropenic, the patient experienced mild
symptoms of mucositis. However, she was able to tolerate food
by first eating something cold, such as a popsicle.
Breakthrough symptoms were controlled on oxycodone 5 mg PO and
resolved prior to discharge.
# Seizures : The patient's home regimen was: LeVETiracetam 500
mg [**Hospital1 **], Clonazepam 0.5 mg TID:PRN, Oxcarbazepine 900 mg PO BID.
Patient had 48hrs EEG w/out definitive seizures, but
seizure-like activity while in the ICU. neuro changed
anti-epileptics, and they are following. currently on keppra and
lacosamide. CT head on [**5-21**] had no acute intracranial changes.
Patient also had altered mental status in the ICU, unclear
whether etiology was seizures vs. ICU delirium. Patient's mental
status at baseline prior to discharge from the ICU. Begining the
week of [**6-16**] the patient was again noted to be slightly
lethargic and confused. Neurology was contact[**Name (NI) **] and agreed with
decreasing her dose of keppra in the setting of her renal
insufficency this change was made on [**6-18**]. Pt had more seizures,
as evidenced on EEG. Her keppra was increased back to 750mg po
bid as her renal function improved, and her seizure activity
lessened as viewed on EEG. Pt was discharged on levetiracetam
750mg po bid and Lacosamide 150 mg po bid for seizure
prophylaxis. She should see neurology for possible uptitration
of her medications as an outpatient since her latest EEG showed
some minor epileptiform activity, although she is currently
asymptomatic.
# acute renal insufficiency: Patient initially developed acute
renal insufficency on [**5-5**] in the setting of gancyclovir
administration and her acute clinical deterioration related to
CMV infection. She was maintained supportively and her
creatinine reached a max of 2.0 before returning to baseline of
1.0 on [**5-27**]. On [**6-1**] her creatinine was again noted to be
elevated in the setting of foscarnate administration for
refractory CMV infection as described above. This trend
continued before hitting a max of 2.4 on [**6-16**], nephrology was
again consulted and felt that her [**Doctor First Name 48**] was multifactoral from
several nephrotoxic medications. Micafungin and foscarnate were
discontinued and her renal function improved slightly but then
regressed. Renal service was reconsulted on [**2118-6-27**]. Urine only
had a few muddy brown casts, not really consistent with ATN or
AIN. Renal service is also unclear on etiology of [**Name (NI) 1094**] continued
diuresis or hyponatremia (see above). Renal feels that it may be
related to medications, including cyclosporin and suggested
lower dosing. Also felt that hypovolemia may be contributing and
mild response with fluids. Cyclosporin was decreased, with level
112 on [**2118-7-3**]. Pt's creatinine on discharge is 1.7. Pt will
need 2x weekly chemistry panels (see above).
.
# HYPERCALCEMIA: on [**6-14**] the patient's calcium was noted to be
elevated to 11.0 despite her hypoalbuminemia. A venous free
calcium was sent and returned elevated at 1.5 confirming
hypercalcemia. Initially her fluids were increased to promote
diuresis without effect. PTH was inappropriately elevated at 29,
but not felt to be the primary driving mechanism of her
hypercalcemia. Endocrinology was consulted and felt that her
elevated calcium and phosphate was the result of primary
hyperparathyroidism combined with secondary causes including
imobility. Various efforts to control her hypercalceima were
trialed including diuresis with lasix, calcitonin, phosphate
binders and promindronate none of which substantially reversed
her hypercalcemia which was felt to be driving her symptoms of
constipation, abdominal pain and lethargy. Her calcium was
finally controlled after receiving IV palmindronate. Her PTH
then increased further to 141, suggestive of primary
hyperparathyroidism. Endocrine service recommended outpatient
MIBI parathyroid scan for adenoma. Pt will need 2x weekly
calcium and albumin levels (to calculate corrected calcium). Pt
was started on vitamin d [**2106**] u daily per endocrine service.
# hypertension: previously on lisinopril, held due to [**Doctor First Name 48**]. Was
on labetalol, switched to nifedipine but back to labetalol 200mg
po bid on [**2118-6-25**]. [**Month (only) 116**] need to increase dose as BP has been
130s-140s/60s-80s.
# deconditioning: Pt has been hospitalized for over two months.
She is extremely weak and deconditioned from her stay and needs
intensive physical therapy. She occasionally suffers from
"buckling" of her knees and is currently a high fall risk.
# increased urinary frequency: Pt had increased urinary
frequency for the last 2 days of her admission, no fevers. UA on
[**2118-7-5**] showed WBC 85, RBC 33, no bacteria. Urine culture
pending at the time of discharge.
TRANSITIONAL ISSUES:
-needs 2x weekly complete blood count with differential
-needs weekly CMV viral load
-needs 2x weekly cyclosporine levels
-monitor 2x weekly chemistry panel, calcium and albumin for
sodium, Cr, Ca
-outpatient MIBI parathyroid scan
-outpatient neurology follow-up to further uptitrate
anti-epileptics / consider further seizure treatment as needed
-needs continued filgrastim 480mcg sc on Mondays and Thursdays
-urine culture from [**2118-7-5**] results still pending
Medications on Admission:
acyclovir 400 mg PO q8hrs
clonazpam 0.5 mg PO BID
levetiracetam 500 mg PO BID
lisinopril 20 mg PO daily
oxcarbazepine 900 mg PO BID
paroxetine 5 mg PO daily
docusate sodium 100 mg PO BID
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. lacosamide 150 mg Tablet Sig: One (1) Tablet PO twice a day.
4. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a
day for 10 months.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day: Pt may refuse if ambulating.
6. filgrastim 480 mcg/0.8 mL Syringe Sig: Four [**Age over 90 11578**]y
(480) mcg Injection q Mon and q Thurs.
7. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
8. atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily).
9. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. cyclosporine modified 50 mg Capsule Sig: One (1) Capsule PO
twice a day.
12. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): hold for sbp < 100 or hr < 60.
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stool.
15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
-Myelodysplastic syndrome, with allogenic matched unrelated
donor stem cell transplant
-epilepsy
-acute renal insufficiency
-CMV pneumonitis / pneumonia
-hypercalcemia (likely primary hyperparathyroidism)
-hyponatremia (resolved)
Secondary:
-hypertension
-anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to the hospital for an allogenic stem cell
transplant. You also were treated with antibiotics for an
infection with your bloodstream and a severe viral infection of
your lungs. You were also treated for low blood sodium,
reduction of your kidney function, and seizures.
We have made the following changes to your medications:
-STOP acyclovir
-STOP lisinopril
-STOP oxcarbazapine
-INCREASE your levetiracetam (Keppra) to 750mg tablets, 1 tab by
mouth twice daily
-START fluconazole 200mg tabs, 2 tabs by mouth daily
-START senna 8.6mg tabs, 1 tab by mouth twice daily
-START polyethylene glycol (miralax) 17g packet, 1 packet as
needed for constipation
-START mycophenolate 250mg tabs, 1 tab by mouth twice daily
-START cyclosporine 50mg tabs, 1 tab by mouth twice daily
-START labetalol 200mg tabs, 1 tab by mouth twice daily
-START lacosamide 150mg tabs, 1 tab by mouth twice daily
-START atovaquone liquid, 1500mg by mouth once daily
-START filgrastim 480 mcg subcutaneous injections every Monday
and Thursday
-START vitamin D 1,000 unit tabs, 2 tabs by mouth daily
-START valganciclovir 450mg tabs, 1 tab by mouth daily
Please continue to take your other medications as previously
prescribed. We have made an appointment for you to be seen by
your oncologist. Please have your rehab facility make
arrangements for your transportation to your appointment.
Followup Instructions:
Department: HEMATOLOGY/BMT
When: THURSDAY [**2118-7-7**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3920**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: THURSDAY [**2118-7-7**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 11021**] [**Name8 (MD) 11022**] MD [**MD Number(2) 38620**]
Completed by:[**2118-7-5**]
ICD9 Codes: 7907, 5849, 4280, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1501
} | Medical Text: Admission Date: [**2188-6-2**] Discharge Date: [**2188-6-5**]
Date of Birth: [**2110-5-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6578**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 78 year old female with a remote history of lung
cancer s/p lobectomy, COPD on 2L at baseline, type II diabetes
and hypertension who presents from [**Hospital 100**] Rehab with shortness
of breath. Per notes over the past weekend she developed upper
respiratory tract symptoms with nasal congestion, and cough
productive of thick sputum. She was not experiencing any fevers.
She was given increased nebulizer treatments with some relief.
She was not experiencing chest pain or pleuritic type pain. She
was not experiencing nausea, vomiting, abdominal pain,
constipation, dysuria, hematuria, leg pain or swelling. She does
endorse some mild diarrhea. She says that her breathing has been
getting progressively worse over the past three days despite
increasing nebulizer and oxygen therapy (titrated to 4L). She
appeared progressively worse and EMS was called for transport to
[**Hospital1 18**]. When EMS arrived she was complaining of shortness of
breath. Initial oxygen saturations were in the low 80s and these
improved to 94% on a non-rebreather. She was noted to have scant
wheezes in her upper lung fields. EKG showed sinus tachycardia,
right bundle branch block, q waves in III, avF, TWF V1-V3. She
was taken to the emergency room.
.
In the ED, initial vs were: T: 98.8 P: 113 BP: 130/84 R: 25 O2
sat: 85% on RA. Initial CXR showed possible infiltrate in the L
upper lobe. EKG showed sinus tachycardia, left axis, right
bundle branch block, TWI V1-V3, q waves III, avF, no change
compared to prior earlier in the day. She received vancomycin 1
gram IV x 1, zosyn 4.5 grams x 1, combivent nebulizers x 3,
solumedrol 125 mg IV x 1. She was placed on BIPAP with mild
improvement. She also received nitroglycerine for potential
volume overload as well as lasix 20 mg IV x 1. Her BNP was
elevated at 1122. Her WBC was 15.1 with 91% neutrophils. She had
one set of negative cardiac enzymes. She was admitted to the
intensive care unit for further management.
.
On arrival to the ICU she reported that her shortness of breath
has improved somewhat from this morning. She denied fevers,
chills, chest pain, nausea, vomiting, abdominal pain,
constipation, dysuria, hematuria, leg pain or swelling. Comes
from rehab. Has had recent rhinorrhea and productive cough
without fevers. Mild diarrhea at rehab. All other review of
systems negative in detail.
Past Medical History:
Lung Cancer s/p chemotherapy and lobectomy (date unknown)
Type II Diabetes on insulin
Macular Degeneration (legally blind)
Hypertension
COPD
Breast Cancer s/p lumpectomy
Hypercholesterolemia
Diverticulosis
Obesity
Depression/Anxiety
Anemia
B12 deficiency
Colon Polyps s/p polypectomy [**2186**]
Social History:
Positive smoking history, quit at the time of her diagnosis of
lung cancer. No current smoking, alcohol or illicit drug use.
She has been living at [**Hospital 100**] rehab for one year.
Family History:
No history of lung disease
Physical Exam:
Vitals: T: 99.6 BP: 151/76 P: 111 R: 27 O2: 99% on NRB
General: Aggitated, oriented, mild respiratory distress using
abdominal musculature
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP 12 cm, no LAD
Lungs: Decreased breath sounds throughout, scarce expiratory
wheezes, no crackles or ronchi appreciated, right sided
thoracotomy scar well healed
CV: Tachycardic, normal s1 + s2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neurologic: Grossly intact
Pertinent Results:
Labs on Admission
[**2188-6-2**] 06:35PM BLOOD WBC-15.1* RBC-4.00* Hgb-10.5* Hct-31.8*
MCV-80* MCH-26.2* MCHC-32.9 RDW-15.2 Plt Ct-269
[**2188-6-2**] 06:35PM BLOOD Neuts-91.0* Lymphs-5.2* Monos-3.1 Eos-0.5
Baso-0.2
[**2188-6-2**] 06:35PM BLOOD PT-12.1 PTT-24.8 INR(PT)-1.0
[**2188-6-2**] 06:35PM BLOOD Glucose-201* UreaN-25* Creat-1.2* Na-139
K-4.3 Cl-97 HCO3-31 AnGap-15
[**2188-6-2**] 06:35PM BLOOD Calcium-11.1* Phos-3.0 Mg-1.9
[**2188-6-2**] 06:44PM BLOOD Lactate-1.2
[**2188-6-2**] 06:35PM BLOOD proBNP-1122*
[**2188-6-2**] 06:35PM BLOOD CK(CPK)-126 CK-MB-5 proBNP-1122*
[**2188-6-3**] 02:54AM BLOOD CK(CPK)-204* CK-MB-7 cTropnT-0.02*
[**2188-6-2**] 10:17PM BLOOD Type-ART pO2-51* pCO2-47* pH-7.44
calTCO2-33* Base XS-6
.
[**2188-6-3**] Influenza DFA: negative
[**2188-6-3**] Urine legionella Ag: negative
[**2188-6-2**] Blood cultures x 2: no growth
[**2188-6-3**] Urine culture: no growth
.
[**2188-6-2**] CXR: Opacities at the left lung base, left upper lung,
and right mid lung as above, these are nonspecific. Multifocal
pneumonia is primarily considered. In addition, note is made of
cardiomegaly and sequelae of thoracic surgery.
Labs on discharge:
[**2188-6-5**] 08:50AM BLOOD WBC-16.0* RBC-4.01* Hgb-10.2* Hct-32.4*
MCV-81* MCH-25.5* MCHC-31.5 RDW-15.6* Plt Ct-422
[**2188-6-5**] 08:50AM BLOOD Plt Ct-422
[**2188-6-5**] 08:50AM BLOOD Glucose-177* UreaN-55* Creat-1.6* Na-146*
K-3.6 Cl-104 HCO3-29 AnGap-17
[**2188-6-5**] 08:50AM BLOOD Calcium-10.0 Phos-3.4 Mg-2.3
[**2188-6-4**] 09:58AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2188-6-5**] 08:50AM BLOOD WBC-16.0* RBC-4.01* Hgb-10.2* Hct-32.4*
MCV-81* MCH-25.5* MCHC-31.5 RDW-15.6* Plt Ct-422
[**2188-6-5**] 08:50AM BLOOD Glucose-177* UreaN-55* Creat-1.6* Na-146*
K-3.6 Cl-104 HCO3-29 AnGap-17
VBG
[**2188-6-4**] 12:15PM BLOOD Type-[**Last Name (un) **] pO2-41* pCO2-42 pH-7.49*
calTCO2-33* Base XS-7 Comment-GREEN TOP
Brief Hospital Course:
This is a 78 year old female with a history of lung cancer s/p
lobectomy, COPD on two liters at baseline, insulin dependent
diabetes, hypertension who presents with rhinorrhea, cough and
shortness of breath likely due to COPD exacerbation and
multifocal pneumonia.
Cough/Shortness of Breath: Questionable small infiltrate in left
upper lung field in setting of low grade fevers, leukocytosis,
and upper respiratory tract symptoms. Likely represents
exacerbation of patients known COPD in the setting of possible
viral versus bacterial lung infection. There may be a component
of volume overload although no clear cardiac history. Started on
vancomycin, zosyn and levofloxacin for HCAP as coming from rehab
facility and titrated from BIPAP to 4 liters nasal cannula in
ICU. Urine legionella negative. Influenza DFA was negative.
Solumedrol weaned to prednisone for possible COPD exacerbation
with plan for quick taper, which was completed while patient was
in house. Ruled out for MI. Patient was started on vancomycin,
zosyn and levofloxacin x 7 day course (D1 = [**2188-6-2**] for
Vancomycin and Zosyn and D1 = [**2188-6-6**] for Levofloxacin.) Blood
cultures were negative for growth at discharge. On the floor,
patient had an episode of persistent hypoxia to 85% on oxygen
likely in the setting of delerium that was relieved with ativan
and anti-psychotics. She was satting >90% on discharge, but
still had evidence of multifocal pneumonia on CXR and expiratory
wheezes on exam.
COPD: On 2L nasal cannula at baseline. Started on solumedrol and
standing ipratropium and albuterol nebs for likely exacerbation.
Finished a quick prednisone taper given emotional lability. O2
sats were titrated sats 88-92%
.
Acute Renal Failure: Baseline of 0.9-1.0 as of 10/[**2186**].
Creatinine up to 1.9 this morning from 1.2 on presentation.
Likely prerenal in the setting of infection and decreased PO
intake. Differential diagnosis includes ATN v. AIN with zosyn.
Urine eosinophils negative. Patient was hydrated with normal
saline. Creatinine improved from 1.9 to 1.6. Hydration was
changed to 1/2 normal saline in the setting of mild
hypernatremia. Her lisinopril and hydrochlorothiazide were held.
All medications were renally dosed.
.
Delirium: Patient was noted to be delirious on the floor. This
is likely caused by a combination of being in a hospital setting
with underlying infectious process and uremia. It should
resolve with the patient returning to the familiar setting and
treating the underlying infectious process and prerenal causes
of ARF.
Hypertension: Blood pressures were stable throughout
hospitalization. Home amlodipine continued but lisinopril and
HCTZ held in setting of ARF.
.
Positive UA: Urine culture negative during this hospitalization.
.
Hypercalcemia: Calcium levels elevated at 11.1. Calcium
supplement was held with improvement in Ca from 11.1 to 9.9 with
IV fluids.
.
Anion gap: The patient has an anion gap, likely secondary to
dehydration in setting of decreased PO intake. Lactate was
normal. Gap closed with administration of IV fluids and
resumtion of diet on repeat labs.
.
Depression/Anxiety: The patient was very tearful, anxious
throughout hospitalization and reported ongoing difficulties
with depression. Continued home venlafaxine, trazodone prn and
ativan with holding parameters. The patient was given Ativan IV
q12h:PRN for anxiety. Pt. stated that she has suicidal
ideations if she stays in the hospital. Should resolve with
return to her home environment.
.
Anemia: Hematocrit remained stable at baseline 26-28. We
continued iron supplements
Type and screen was active.
.
Type II Diabetes: The patient was continued on Lantus [**Hospital1 **] and
Humalog sliding scale. Home lantus dose initially halved given
NPO status but increased when diet was restarted. The patient
had elevated FSG, likely secondary to steroid treatment, Humalog
Insulin Sliding Scale tightened and pt restarted on home dose
lantus.
.
Hypercholesterolemia: Continued statin.
.
Lung Cancer: Details are unclear but patient is s/p chemotherapy
and lobectomy at unknown date. This is not currently considered
an active issue.
.
FEN: Low Sodium / Heart Healthy / Diabetic Diet.
Prophylaxis: Patient was on PPI for GI prophylaxis and
Subutaneous Heparin for DVT Prophylaxis.
.
Access: peripheral IV
.
Code: DNR/DNI (discussed with patient)
.
Communication: [**Name (NI) **] [**Name (NI) 22090**] (friend) [**Telephone/Fax (1) 22091**]
Dispo: Pt. with improved oxygenation. Discharge to [**Hospital 100**] Rehab
MACU.
Medications on Admission:
Bactrim DS [**Hospital1 **] (started [**6-2**])
Lorazepam 1 mg QHS
Trazodone 25 mg QHS
Albuterol nebulizers Q4H (started [**6-2**])
Ipratropium nebulizers Q4H (started [**6-2**])
Fluticasone inhaler 1 Puff [**Hospital1 **]
Iron 1250 mg [**Hospital1 **]
Lorazepam 0.5 mg daily:RPN
Tylenol 650 mg Q4H:PRN and QHS
Amlodipine 10 mg daily
Cholecalciferol 1000 U daily
Hydrochlorothiazide 25 mg daily
Lisinopril 40 mg daily
Insulin glargine 54 U QAM, 30 U QPM
Calcium Carbonate 650 mg [**Hospital1 **]
Venlafaxine XR 75 mg daily
Simvastatin 40 mg daily
Albuterol
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 1
injection Injection TID (3 times a day).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 2 doses: Needs 1 dose on [**2188-6-7**] and a final dose
on [**2188-6-9**].
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6
hours).
12. Fluticasone 100 mcg/Actuation Disk with Device Sig: One (1)
puff Inhalation twice a day.
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed for anxiety.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 4 days: Start
date: [**2188-6-5**]
End date: [**2188-6-8**]
Pt. received antibiotics at [**Hospital1 18**] from [**2188-6-2**] to [**2188-6-5**].
Total course of antibiotics should be 7 days.
16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours) for 4 days: Start date:
[**2188-6-5**]
End date: [**2188-6-8**]
Pt. received antibiotics at [**Hospital1 18**] from [**2188-6-2**] to [**2188-6-5**].
Total course of antibiotics should be 7 days.
17. Insulin Glargine 100 unit/mL Cartridge Sig: Fifty Four (54)
units Subcutaneous qAM.
18. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty (30)
units Subcutaneous qPM.
19. Insulin Lispro 100 unit/mL Cartridge Sig: as directed units
Subcutaneous four times a day: Per attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: COPD Exacerbation, Pneumonia and Delirium
Secondary: DM2, HTN, Lung Ca (s/p lung resection), depression
Discharge Condition:
Vitals stable, O2 saturation >90% on 2 liters nasal canula.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with shortness of breath, which
likely resulted from a combination of exacerbation of your COPD
and a respiratory infection, likely pneumonia. You were treated
for pneumonia with antibiotics (Vancomycin, Zosyn, Levaquin).
You were given nebulizer treatments and steriods (Solumedrol,
followed by Prednisone) for COPD exacerbation. You initially
were put on noninvasive positive pressure respiration (BiPAP) to
help with you breathing and later were switched to oxygen. Your
kidney function has worsened over the past several days likely
secondary to dehydration. You should continue to receive IV
fluids and drink plenty of fluids over the next several days to
help your kidneys.
Your breathing and oxygenation have improved over several days.
You should continue taking IV antibiotics (Zosyn, Vancomycin and
Levaquin) for a period of 7 days total (you received 4 days in
the hospital). We treated you with a fast steroid taper which
has completed while in the hospital. You should also continue
with nebulizer treatments (Albuterol, Atrovent) for now.
We have made the following medication changes. We have held
your Lisinopril and hydrochlorothiazide because of your acute
renal failure. We have also stopped your Advair Discus and
switched you to Fluticasone inhaler, because you were
tachycardic and because your are already getting Albuterol and
Atrovent nebs. We have made the changes to your sliding scale to
control your blood sugars while you were on steroids. We do not
recommend that you receive any further antipsychotics or Lasix.
You should return to the hospital should your breathing worsen
or you develop new chest pain, fever, severe cough. You should
follow up with your PCP at [**Hospital 100**] Rehab upon discharge from the
hospital.
Followup Instructions:
You should follow up with your PCP at [**Hospital 100**] Rehab upon
discharge.
You should follow up with your psychiatrist upon discharge.
Completed by:[**2188-6-5**]
ICD9 Codes: 486, 5849, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1502
} | Medical Text: Admission Date: [**2100-11-5**] Discharge Date: [**2100-11-9**]
Date of Birth: [**2027-9-18**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
rigors
Major Surgical or Invasive Procedure:
[**2100-11-6**] CT-guided aspiration of right hepatic abscess
History of Present Illness:
73 year-old Cantonese-speaking-only man s/p cholecystectomy on
[**2100-10-17**] presents after syncopal episode. He was noted on
post-op day #1 to be unsteady on his feet and complaining of
dizziness but was not orthostatic, and physical therapy consult
cleared him on post-op day #2 to go home without any assistance,
despite oxygen desaturation to mid 80s without dyspnea. He now
has 2-3 days of subjective fever, chills, night sweats, shaking,
malaise, poor PO intake, and diffuse abdominal ache. At the
time of consultation he had a prodrome of lightheadedness and
syncope in the morning. There was brief loss of consciousness,
and he was incontinent of stool. He has no history of previous
syncope or seizures. He had stopped taking tramadol on [**2100-11-2**]
because his PCP said it might be affecting his appetite. CT scan
performed in the ED showed a fluid collection in the gallbladder
fossa and an additional fluid collection (likely abscess) in the
liver parenchyma.
Past Medical History:
Past Medical History: hypertension, GERD, H. Pylori, symptomatic
cholelithiasis
Past Surgical History: laparoscopic cholecystectomy
Social History:
Denies alcohol/drug use
Denies tobacco use
Cantonese-speaking
Lives alone
Family History:
notable for a family history of TB. otherwise
non-contributory
Physical Exam:
On admission:
Vitals: T 97.1, HR 88, BP 118/63, RR 16, 98% 2L NC
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused
On discharge:
Vitals: 99.2 70 140/70 18 94% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding, no
palpable masses
Ext: No LE edema, LE warm and well perfused, + pedal pulses
Pertinent Results:
17.7>12.9/39.6<344
N 95.0, L 3.4, M 1.3, E 0.1, B 0.2
.
136/98/20
---------<134
4.1/26/1.5
.
Lactate 2.7
PT 13.5, PTT 26.8, INR 1.3
ALT 47, AST 45, AP 61, Lip 19, Tbili 0.7
[**11-4**]
CXR: Stable moderate right pleural effusion and resolution of
previously noted left pleural effusion. Bibasilar airspace
opacities likely reflect atelectasis, though infection cannot be
completely excluded.
[**2100-11-4**] CT abdomen/pelvis
1. Post-surgical changes related to recent cholecystectomy.
There is fluid
collection within the resection bed, which may represent a
biloma, hemorrhage, or alternatively an abscess formation. Just
superior to the resection bed within segment [**Doctor First Name 690**]/b, there is a
multicystic lesion involving the liver parenchyma, most
compatible with an abscess formation. This lesion appears new
from [**2100-10-17**] ultrasound exam. There is apparent
hyperemia surrounding the lesion. Dilated tubular structures
within the resection bed likely represent residual cystic ducts.
2. Multiple liver cysts or hamartomas. 3. Right lung base
consolidation may represent aspiration, infection in the
appropriate setting, or atelectasis with adjacent small pleural
effusion.
[**2100-11-4**] Blood culuture results: KLEBSIELLA PNEUMONIAE
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2100-11-5**] with fevers, rigors s/p syncope
on [**2100-11-4**]. Labs and imaging were concerning for peri-hepatic
abscess. He was admitted to the floor and started on zosyn and
IV fluids for hydration. While on the floor he had persistent
fevers and rigors, with oxygen desaturation and tachycardia, so
was transferred to the ICU. In the ICU he remained stable and
underwent CT guided drainage of intra-abdominal abscess: drained
18cc of purulent fluid, no drain left in place. The intrahepatic
collection not amenable to perc drainage. He was subsequently
transferred back to the floor, where he remained hemodynamically
stable with a heart rate in the 70s-80's. His oxygen was weaned
at his O2 sats remained in the mid 90's on room air. He had
minimal low grade temps, not above 100.0. ON [**11-8**] his blood
cultures (which grew kleibsiella pneumoniae) came back as
sensitive to ciprofloxacin, and his antibiotic regimen was
changed to PO cipro.
On [**2100-11-9**], he remained afebrile and hemodynamically stable on
oral antibiotics. His respiratory status remained uncompromised.
He denied further syncopal episodes or abdominal pain. He was
tolerating a regular diet and out of bed ambulating
indepdendently with a steady gait. He felt well and was
discharged to home with VNA services and scheduled follow up in
[**Hospital 2536**] clinic.
Medications on Admission:
MEDS at previous discharge:
- sertraline 50 mg qd
- omeprazole 20 mg qd
- acetaminophen 1000 mg tid
- oxycodone 5 mg Q4H PRN
- docusate sodium 100 mg [**Hospital1 **]
- bisacodyl 10 mg qd PRN
- magnesium hydroxide PRN
- senna 8.6 mg [**Hospital1 **] PRN
- atenolol 50 mg
- vitamin D3 [**2088**] IU qd
- alendronate 70mg 1x/wk
- vitamin D [**Numeric Identifier 1871**] IU 1x/wk
Discharge Medications:
1. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*9 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Bacteremia
2. Intraabdominal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with fevers, chills and a report of a
syncopal episode. On CT scan, you were found to have a fluid
collection near the area where your gallbladder was removed on
your previous hospital admission. You were also found to have
bacteria in your blood. You were given IV antiotics, and are not
being discharged home with a prescription for oral antibiotics.
It is important that you take the entire course of antibiotics
as prescribed, even if you are feeling better.
You may resume a regular diet.
You should resume all of your regular home medications that you
were taking prior to coming to the hospital.
You are being given a prescription for narcotic pain medication.
Take the medication as need, but do not take it more frequently
than prescribed. You may also take tylenol as needed for pain,
but do not take more than 4 grams (4,000 mg) of tylenol in 24
hours. Narcotic medications can cause constipation so be sure to
drink plenty of fluids to avoid this. You may take an over the
counter stool softener such as colace or milk of magnesia if
needed to prevent constipation. Do not drink alcohol or
drive/operate heavy machinery while taking narcotics.
Please call your doctor 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.
*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.
Completed by:[**2100-11-9**]
ICD9 Codes: 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1503
} | Medical Text: Admission Date: [**2163-12-6**] Discharge Date: [**2163-12-30**]
Date of Birth: [**2078-5-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Latex / lisinopril / levothyroxine sodium
Attending:[**First Name3 (LF) 13685**]
Chief Complaint:
Leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85F history of aortic aneurysm s/p repair, diastolic CHF, Afib,
severe aortic regurgitation, and multiple recent admissions for
CHF exacerbation and pneumonia, presenting with bilateral lower
extremity swelling. Says her leg swelling has been persistent
for the past month despite hospital admission and diuresis with
IV lasix. She is on home torsemide increased on [**2163-12-5**] to 30
mg daily from 20 mg. No shortness of breath, chest pain,
palpitation, fevers, chills, cough, URI symptoms, changes in
diet or salt intake, medication noncompliance, nausea, vomiting.
Of note, patient had multiple readmissions, 3 at [**Hospital1 5109**] and 2 at [**Hospital6 **] over the past 3 months
per patient's report. At [**Last Name (un) 1724**] admission on [**2163-9-27**], she was
treated with doxycycline and uptitrated her home Lasix to 120 mg
daily. Patient reports hospital admissions for 7 days at
[**Hospital3 **] in early [**11/2163**] for CHF exacerbation,
pneumonia, and LLE cellulitis for which she is on a course of
Clindamycin (exact timecourse is unclear, will obtain OSH
records).
At baseline, patient is on home O2 2L which she wears all the
time. Denies CP, SOB, lightheadedness at home. Sleeps on 2
pillows, denies PND. Mobility limited by leg swelling and pain.
In the ED, initial VS: 96.3 77 98/65 20 95% 4L Nasal Cannula.
Labs notable for Cr of 1.7 ([**12-2**]: cr 1.28). EKG showed A. fib
at 67, QTC 478, and nonspecific ST changes. CXR concerning for
RLL inflitrate c/f CAP. Per ED report, assessed to be volume
overloaded on exam. Patient was given ASA 325 and Levofloxacin
750 mg IV. VS prior to transfer: 97 76 107/58 16 98% room 4LNC
(wears 02 4lnc at home).
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
?????? Aortic Aneurysm, Thoracic s/p open heart surgery and repair
?????? Aortic valve insufficiency
?????? COPD (chronic obstructive pulmonary disease)
ANEMIA
?????? HYPERCHOLESTEROLEMIA
?????? HYPERTENSION - ESSENTIAL, BENIGN
?????? HYPOTHYROIDISM
?????? LOW BACK PAIN
?????? ATRIAL FIBRILLATION
?????? HEART FAILURE - DIASTOLIC, CHRONIC
?????? MYOCARDIAL INFARCT - INFERIOR, UNSPEC CARE
?????? LOW BACK PAIN
?????? GASTRITIS - ACUTE
?????? DIVERTICULITIS
?????? THORACIC BACK PAIN
Social History:
Lives in same house as son in [**Name (NI) 4444**], MA. Worked as elderly
caretaker until last year. Able to perform ADLs well, feels
like memory has declined over past few years.
Smoking - Quit 40 yrs ago, previously [**1-9**] ppd
Alcohol - None currently, used to have occasional wine.
Illicits - None.
Family History:
Family history positive for "heart disease."
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.0 96.2 108/68 72 18 99%2L
GENERAL - Elderly-appearing woman in NAD, comfortable, pleasant
HEENT - MMM, OP clear
NECK - Supple, JVD at 15cm, no carotid bruits
LUNGS - Mild crackles at the bases bilaterally, no r/rh/wh,
decreased air movement, resp unlabored, no accessory muscle use
HEART - Irregular rhythm, loud S2, RV heave, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ to 3+ pitting edema bilaterally to mid-thigh,
chronic venous stasis changes on left ankle, warm and well
perfused, tender to palpation throughout, DP and PT pulses
intact, no cellulitis noted on LEs.
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact.
DISCHARGE PHYSICAL EXAM:
VS: Afebrile, BP 80/50-110/60 50-72 94%2L
GENERAL: Elderly-appearing woman in NAD, comfortable, pleasant
NECK: Supple, JVD at 15cm with markedly dilated peripheral neck
veins
LUNGS: Crackles at the bases bilaterally, with decreased air
movement throughout, respirations unlabored
HEART: Irregular rhythm, at times bradycardic, loud S2, RV heave
ABDOMEN: NABS, slightly protuberant with mild diffuse tenderness
throughout, without rebound or guarding
EXTREMITIES - 2+ to 3+ pitting edema bilaterally to mid-thigh,
chronic venous stasis changes on left ankle, warm and well
perfused, mildly tender to palpation throughout
Pertinent Results:
ADMISSION LABS:
[**2163-12-6**] 03:00PM GLUCOSE-91 UREA N-50* CREAT-1.7* SODIUM-134
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-31 ANION GAP-11
[**2163-12-6**] 03:00PM WBC-5.2 RBC-3.35* HGB-9.9* HCT-30.9* MCV-92
MCH-29.5 MCHC-32.0 RDW-18.2*
[**2163-12-6**] 03:00PM NEUTS-64.7 LYMPHS-23.0 MONOS-9.2 EOS-2.2
BASOS-0.9
[**2163-12-6**] 03:00PM PLT COUNT-154
[**2163-12-6**] 03:00PM PT-15.8* PTT-43.1* INR(PT)-1.5*
[**2163-12-6**] 03:00PM proBNP-6945*
[**2163-12-6**] 03:00PM cTropnT-<0.01
DISCHARGE LABS:
[**2163-12-28**] 04:16AM BLOOD WBC-6.7 RBC-2.93* Hgb-8.6* Hct-27.3*
MCV-93 MCH-29.4 MCHC-31.5 RDW-18.0* Plt Ct-173
[**2163-12-27**] 02:58AM BLOOD PT-14.1* PTT-36.9* INR(PT)-1.3*
[**2163-12-28**] 04:16AM BLOOD Glucose-97 UreaN-71* Creat-3.0* Na-128*
K-4.7 Cl-84* HCO3-33* AnGap-16
[**2163-12-24**] 08:25AM BLOOD ALT-14 AST-29 LD(LDH)-303* AlkPhos-120*
TotBili-0.8
[**2163-12-23**] 03:50PM BLOOD proBNP-7498*
[**2163-12-28**] 04:16AM BLOOD Calcium-8.9 Phos-9.2* Mg-3.0*
STUDIES:
CXR [**2163-12-6**] IMPRESSION:
1. Opacity in the right lower lobe consistent with pneumonia or
aspiration.
2. Emphysema
2. Severe cardiomegaly with mild interstitial edema.
EKG [**2163-12-6**] Afib at 67, diffuse TWI, no ST changes, normal axis
CXR [**2163-12-8**] 1. Minimally increased right lower lobe opacity,
either representing aspiration or pneumonia. 2. Cardiomegaly
with unchanged mild interstitial edema.
KUB [**2163-12-18**] AP supine and left decubitus views of the abdomen
show that the gut is fluid filled and not demonstrably
distended. There is no free
intraperitoneal gas.
ECHO [**2163-12-27**]: The left atrium is moderately dilated. The
estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thickness and regional/global systolic function
are normal (LVEF >55%). The right ventricular cavity is markedly
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. The aortic arch is mildly dilated. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. Trace aortic regurgitation
is seen. Moderate (2+) mitral regurgitation is seen. Severe [4+]
tricuspid regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Dilated and hypokinetic right ventricle.
Severe functional tricuspid regurgitation. Small left ventricle
with normal global and regional systolic function.
Normally-functioning aortic valve bioprosthesis. Moderate mitral
regurgitation.
ECG [**2163-12-28**]: Sinus bradycardia, rate 54. Sinus bradycardia
persists. There is low voltage throughout raising question of
hypothyroidism. Otherwise, tracing is unchanged.
Brief Hospital Course:
85F with history of aortic aneurysm s/p repair, diastolic CHF,
Afib, severe aortic regurgitation, and multiple recent
admissions for CHF exacerbations and pneumonia, presenting with
bilateral lower extremity swelling and dyspnea.
#. Acute on chronic diastolic congestion heart failure: She
presented with substantial peripheral edema, JVD, and
hepatomegaly felt to be severe right-sided heart failure from
severe tricuspid regurgitation. Also has some moderate to
severe MR felt to be contributing to her dyspnea. She has had
multiple recent admissions for her difficult to control CHF.
Denies any chest pain or palpitations during this admission, but
did have waxing and [**Doctor Last Name 688**] shortness of breath. She was
aggressively diuresed on a lasix drip (sometimes with metolazone
augmentation) with some improvement in her symptoms. She was
transitioned once to oral torsemide but began to gain weight
again and was placed back on a lasix drip. However, eventually
her urine output downtrended despite a lack of improvement in
her dyspnea and she became oliguric with rising creatinine. She
still had evidence of profound volume overload at that time.
she was evaluated by cardiac surgery regarding her severe TR but
was not deemed to be a surgical candidate. She was transferred
to the CCU in the setting of hypotension and oliguria, where she
was continued on a lasix drip without improvement in her
symptoms or urine output. A meeting with the family and patient
was held, and she decided to transition to comfort measures only
and decided to be DNR/DNI. She is being discharged to home on
hospice.
#. Acute Kidney Injury: She had admission Cr of 1.7 which
fluctuated during her hospital course. This is above her
baseline of around 1.3 and was felt to be prerenal in the
setting of CHF with poor forward flow. Her creatinine initially
improved with diuresis but her diuresis limit was reached and
she became oliguric. Her creatinine remained elevated around
3.0 at the time of discharge.
#. Clostridium difficile colitis: She had been treated with
clindamycin at an OSH for possible cellulitis of the legs. She
became delirious on [**12-17**] with fevers and increased stool
output, and was found to be C.diff positive. She was started on
PO vancomycin on [**12-18**] for a fourteen day course. She remained
afebrile, without leukocytosis and with KUB showing no signs of
colonic dilatation, just stool. Her diarrhea and abdominal
cramping were improving at the time of discharge. She will
continue PO vancomyin q6h until [**2163-12-31**].
#. History of deep vein thrombosis: She has a history of recent
DVT that was complicated by GI bleed so was discharged from OSH
without anticoagulation. Repeat LENIs normal on [**2163-12-7**].
Despite her history of DVT and CHADS2 score of 3,
anticoagulation was held due to her history of multiple GI
bleeds in the past. She will not be anticoagulated at
discharge.
#. GI Bleed: She was guaiac positive, with occasional dark
stools but stable Hct. OSH endoscopies this year/late last year
have shown duodenal AVMs and moderate gastritis. She was
started on IV PPI but as patient's Hct remained stable, she was
switched back to her home dose PPI. Heparin SC was decreased in
dose initially, and discontinued after she was made CMO.
#. Thrombocytopenia: She was noted to have downtrending
platelets during this admission with nadir of 103. Patient with
intermittent dried blood in nose from nasal cannula and with one
episode of hemoptysis. Platelet count rebounded and was back to
the normal range at the time of discharge. It was not felt to
be associated with heparin use.
#. COPD: She was maintained on her home oxygen at 2L NC. Patient
continued on her home regimen, which will be continued for
comfort after discharge.
#. Back pain: She had continued chronic right-sided back spasms
that were controlled with her home regimen of Vicodin and
Fentanyl patch.
#. Atrial fibrillation: She has been previously on coumadin
which was held permanently due to recurrent GI bleeds. Despite
CHADS2 score of 3, we continued no anticoagulation and she will
not be anticoagulated at discharge. She was rate controlled on
metoprolol for much of her admission, which was stopped in the
ICU for bradycardia to the 40's. HR at the time of discharge
was about 60.
#. HTN: Systolic blood pressures ran in 90's-100's for most of
her admission which is at her baseline. We monitored pressures
closely in setting of diuresis and held metoprolol for SBP
<100's. She did have episodes of hypotension in the setting of
worsening renal function necessitating CCU transfer for 2 days.
At discharge, metoprolol has been discontinued due to low blood
pressures and heart rates.
#. HLD: Continued Simvastatin during admission, this was stopped
at discharge because she is CMO.
#. Hypothyroidism: Continued Levothyroxine.
#. Code status and goals of care: She was admitted as full
code, which was transitioned to DNR/DNI while she was in the
CCU. After she failed medical therapy with IV diuretics and was
determined not to be a surgical candidate, a family meeting was
held. She was transitioned to CMO and was discharged to home
with hospice.
TRANSITIONAL ISSUES:
- Sent home with hospice, goals of care are to focus on comfort
Medications on Admission:
Budesonide-Formoterol (SYMBICORT) 80-4.5 mcg/Actuation
Inhalation HFA Aerosol Inhaler take 1 puff twice per day
Torsemide 30 mg Oral Tablet Take 1 tablet daily or as directed
Clindamycin HCl 150 mg Oral Capsule Take 2 capsules 3 times a
day 10 days
Fentanyl 25 mcg/hr Transdermal Patch 72 hr apply 1 patch every
72hrs
Hydrocodone-Acetaminophen (VICODIN) 5-500 mg Oral Tablet 1 tab
qid prn
Simvastatin 40 mg Oral Tablet Take 1 tablet every evening for
cholesterol
Levothyroxine 200 mcg Oral Tablet 1 tab daily
Omeprazole (PRILOSEC) 20 mg Oral Capsule, Delayed Release(E.C.)
1po qd
Nitroglycerin 0.4 mg Sublingual Tablet, Sublingual 1 tablet
sublingually every 5 minutes as needed for chest pain
Metoprolol Succinate 25 mg Oral Tablet Extended Release 24 hr 1
tab daily
Polyethylene Glycol 3350 17 gram/dose Oral Powder 17gm in liquid
daily
Senna 187 mg Oral Tablet take 1-2 tablets daily as needed
Ferrous Sulfate 325 mg (65 mg Iron) Oral Tablet take two times
daily
Docusate Sodium 100 mg Oral Capsule Take [**1-9**] capsules daily as
needed; available over the counter
CALCIUM CARBONATE-VITAMIN D3 600 MG, 1,500 MG,-400 UNIT CAP 600
mg(1,500mg) -400 unit Oral Cap Take 1 tablet twice daily;
available over the counter
Discharge Medications:
1. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
2. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for Back pain.
Disp:*120 Tablet(s)* Refills:*0*
3. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) puff Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
4. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal
every seventy-two (72) hours.
Disp:*30 patches* Refills:*2*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN PAIN Q5MIN as needed for chest pain:
Please take only up to 3 times.
Disp:*15 Tablet, Sublingual(s)* Refills:*0*
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
unit PO DAILY (Daily) as needed for constipation.
Disp:*30 units* Refills:*2*
8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: [**1-9**] Capsules PO BID (2
times a day) as needed for Constipation.
Disp:*60 Capsule(s)* Refills:*2*
10. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days: Last dose on [**12-31**].
Disp:*8 Capsule(s)* Refills:*0*
11. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
Disp:*120 nebs* Refills:*2*
12. torsemide 20 mg Tablet Sig: Four (4) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Disp:*3600 ML(s)* Refills:*3*
14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
Disp:*120 Tablet, Chewable(s)* Refills:*2*
15. nystatin 100,000 unit/mL Suspension Sig: 5-10 MLs PO QID (4
times a day) as needed for thrush for 3 days.
Disp:*1200 ML(s)* Refills:*2*
16. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-9**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
Disp:*240 sprays* Refills:*2*
17. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*90 Tablet(s)* Refills:*2*
18. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*360 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Location (un) 1121**]
Discharge Diagnosis:
Primary Diagnosis:
Acute on chronic diastolic congestive heart failure
C.diff colitis
Secondary Diagnosis:
COPD
HYPERCHOLESTEROLEMIA
HYPERTENSION
HYPOTHYROIDISM
LOW BACK PAIN
ATRIAL FIBRILLATION
HISTORY OF GASTRITIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 92530**],
You were admitted to [**Hospital1 18**] for an exacerbation of congestive
heart failure. You were given a medicine to help remove excess
fluid from your body and your shortness of breath improved. You
also acquired an infection called Clostridium difficile (also
called C.diff), which is a bacteria that leads to inflammation
of the gut and causes diarrhea. We will send you home with
antibiotics to treat this infection.
After discussion with you and your family, we have decided to
focus on comfort measures after you return home. You will be
seen by a home hospice service after discharge.
The following changes were made to your medications:
START vancomycin 125mg by mouth every six hours until [**12-31**]
STOP clindamycin
STOP simvastatin
STOP metoprolol
STOP ferrous sulfate (iron pills)
INCREASE torsemide to 80mg daily
Followup Instructions:
Please follow-up with your hospice nurses for any questions or
concerning symptoms.
ICD9 Codes: 5849, 2875, 4589, 2761, 4280, 4240, 2859, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1504
} | Medical Text: Admission Date: [**2168-3-27**] Discharge Date: [**2168-4-1**]
Date of Birth: [**2116-5-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14820**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary catheterization
History of Present Illness:
51 yo M smoker w/ hx HTN, dyslipidemia, pafib, CAD s/p STEMI x2
s/p DESX2 to proximal and middle RCA and BMS to distal RCA, p/w
CP [**2-22**] dull L chest w/ N, SOB, diaphoresis, simlar to MI in
[**10-21**] relieved w/ NTG, took ASA 325 en route. The patient had
been drinking and smoking while watching a ball game this
afternoon. He reports that he had sudden onset of substernal
chest pain occuring at rest, radiating to this neck and
associated with diaphoreis. No SOB, diaphoresis, nausea, or
vomiting. He reports this is similar to angina he had prior to
MI in [**Month (only) **]. He called EMS 1 hour later and came to the ED.
CP relieved somewhat by SL nitro but not completely. When seen
on the floor CP about [**1-24**], left-sided, not radiating.
Diaphoresis resolved. No N/V/LH.
When seen on the floor pt states he has not takn any cocaine
since his last MI. He also states he has been nauseous lately
which he attributed to labetalol which he stopped taking one
week ago with resolution of nausea.
.
In the ED, initial vitals were BP112/69, HR83, RR26, O2 96%RA.
CXR was unremarkable. EKG showed NSR with ventricular bigemy
(no ST changes). Upon arrival to the ED he received SL Nitro x
1 and 1" nitro paste. Also received morphine 4mg IV x 1.
Cardiology was consulted and he was started on a heparin drip.
Past Medical History:
# CAD
- s/p STEMI on [**2165-7-10**] s/p DESx2 to proximal and mid RCA
- s/p STEMI on [**2167-11-27**] s/p BMS to distal RCA
# paroxysmal atrial fibrillation
# depression
# possible personality disorder
# external hemorrhoids by history
# ACL tear of the right knee
# osteoarthritis of the left knee
# Hypertension
# Dyslipidemia
# Substance abuse - cocaine and MJ
# Current Smoker
.
Cardiac Risk Factors: positive family history (father with 2
MI's at age 55); past and present smoking (2 packs per day X 35
years); and cocaine use. + Dyslipidemia, + Hypertension
Social History:
Social history is significant for smoking 1ppd. There is no
history of alcohol abuse. Occasional marijuana use. no cocaine
since last STEMI
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
(on admission)
VS - 99.2 159/93 65 18 100RA
Gen: NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 6 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
2D-ECHOCARDIOGRAM performed on [**2168-3-24**] demonstrated:
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. LV systolic
function appears moderately-to-severely depressed (ejection
fraction 30 percent) secondary to akinesis of the inferior free
wall and severe hypokinesis of the posterior (inferolateral)
wall; the inferior septum is also hypokinetic. There is no
ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic root
is mildly dilated at the sinus level. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild to
moderate ([**12-16**]+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension.
.
Prelim cath ([**2168-3-28**]): 1. Coronary angiography in this right
dominant system demonstrated an LMCA without angiographically
apparent disease. The LAD had a 50% mid-vessel lesion. The LCX
system had a 70-80% OM1 lesion and a 50%OM2 lesion. The RCA was
totally occluded in the distal aspect of the previously placed
stents. 2. Limited resting hemodynamics showed normal systolic
arterial pressure. 3. Successful stenting of the OM1 with a 3.0
X 18 mm Vision bare metal stent postdilated proximally to 3.5 mm
with no residual stenosis (see
PTCA comments for detail). Residual 50% ostial disease in OM2
with
normal flow. 4. Aborted attempt at recanalization of the
chronically totally occluded RCA stents.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful stenting of OM1 with bare metal stents.
3. Aborted chronic total occlusion RCA intervention.
4. Successful closure of the right femoral arteriotomy with Mynx
device.
.
[**2168-3-31**] Cardiac MRI: Impression:
1. Moderately increased left ventricular cavity size and
moderately decreased left ventricular systolic function with
mild global hypokinesis and akinesis of the entire inferior wall
and the mid and basal inferoseptum. The LVEF was moderately
decreased at 33%. Delayed contrast-enhanced MR [**First Name (Titles) 38373**] [**Last Name (Titles) 4579**]d areas of delayed enhancement as described above.
These findings are consistent with poor likelihood of functional
recovery of the entire inferior wall and the mid and basal
inferoseptum after mechanical revascularization.
2. Mildly increased right ventricular cavity size and moderately
decreased systolic function with mild global hypokinesis and
akinesis of the mid and basal inferior segments. The RVEF was
moderately depressed at 29%. Delayed contrast-enhanced MR [**First Name (Titles) 38373**] [**Last Name (Titles) 4579**]d areas of delayed enhancement in the mid and basal
inferior segments, suggestive of prior right ventricular
infarction.
3. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
4. Biatrial enlargement.
Brief Hospital Course:
51 yo M smoker w/ hx HTN, dyslipidemia, pafib, CAD s/p STEMI x2
s/p DESX2 to proximal and middle RCA and BMS to distal RCA, p/w
SSCP, diaphoresis, simlar to MI in [**10-21**] found to have NSTEMI
entered two 30s runs of vtach prior to cath, now s/p BMS to OM1
.
# CAD s/p STEMI x2 now s/p NSTEMI and BMS to OM1
- taken to cath with BMS to OM1 (70-80% OM1 lesion on cath)
- CK peaked at 242 and MBI 21
- continued ASA, atorvatatin, plavix
- integrillin for 18hrs
- changed BB to carvedilol given nausea wih labetalol and wanted
to maintain for alpha blockade givenhx of cocaine use
- restarted lisinopril
.
# Pump
- no evidence of failure on exam but with known EF 30% (from
last week prior to NSTEMI)
- cardiac MRI confirmed low EF with EF 33%
- continued on BB, ACEi
- EP consult for possible AICD given known previous EF 30% but
EP did no think beneficial
.
# Rhythm
- pt had 2 runs of symptomatic VT on the night of admission,
each lasting 30 seconds and associated with LH with spont
resolution
- was given lidocaine bolus with drip with no further
arrhythmias after the night of admission
- was taken off lido gtt after cath per EP recommendation (EP
was consulted)
- had cardiac MRI with mild global hypokinesis and akinesis of
the entire inferior wall and mid/basal inferoseptum with delayed
contrast-enhanced MR images in these areas as well as mild
global hypokinesis and akinesis of the mid and basal inferior
segments of the RV with areas of delayed enhancement in the mid
and basal inferior segments, suggestive of prior right
ventricular infarction.
- pt was taken to lab for EP study and ablation in the
posterior/inferior wall and cleared by EP to be safely
discharged the following day since no further arrhythmias
.
# Hypertension
- BB and ACEi as above
.
# Dyslipidemia
- cont lipitor
Medications on Admission:
ASA 325 mg
labetalol 100mg [**Hospital1 **] --> stopped taking a week ago
Plavix 75 mg
Simvastatin 80 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain: - may repeat x3 q
minutes
- if use call 911.
Disp:*15 tabs* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
# CAD
- s/p STEMI on [**2165-7-10**] s/p DESx2 to proximal and mid RCA
- s/p STEMI on [**2167-11-27**] s/p BMS to distal RCA
- s/p NSTMEI on [**2168-3-27**] s/p BMS to OM1
# Symptomatic ventricular tachycardia, peri-MI
# Hypertension
# Dyslipidemia
# Current Smoker
Secondary Diagnoses:
# paroxysmal atrial fibrillation
# depression
# possible personality disorder
# external hemorrhoids by history
# ACL tear of the right knee
# osteoarthritis of the left knee
# Hypertension
# Dyslipidemia
# Substance abuse - cocaine and MJ
# Current Smoker
Discharge Condition:
Stable, chest pain free
Discharge Instructions:
You were admitted to [**Hospital1 18**] with a myocardial infarction. We
placed a cardiac stent into one of your coronary arteries. You
also had symptomatic ventricular tachycardia due to a scar in
you heart for which an ablation in order to prevent another
episode was attempted, but it was unsuccessful. You may need a
defibrillator in the future, but this decision will be made with
you and your doctor at a later date.
Please take your previous medications as prescribed. The
following changes has been made to your medications:
- Please start taking lisinopril 5 mg daily for your heart and
blood pressure (prevents remodelling of the heart)
- Please start taking carvedilol 3.125 mg [**Hospital1 **] for your heart and
blood pressure (prevents remodelling of the heart)
If you develop chest pain, jaw pain, or chest pressure with pain
radiating into arm, or if you for any reason become concerned
about your medical condition please call 911 or present to
nearest ED.
We also gave you Nitroglycerin tablets to take if you experience
chest pain, please call 911 or your doctor if chest pain recurs
even if it dissapears with nitroglycerine.
**DO NOT STOP TAKING THE ASPIRIN OR PLAVIX UNLESS INSTRUCTED TO
DO SO BY YOUR CARDIOLOGIST EVEN IF ANOTHER DOCTOR TELLS YOU TO**
We strongly recommend you stop smoking as discussed.
Please go to your scheduled appointments listed below.
Followup Instructions:
Please call you PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2393**], to confirm
the appointment we have set up for you on [**4-20**]
Please call Dr. [**Last Name (STitle) 22478**] at [**Telephone/Fax (1) **] for an appointment to be
seen within 1-2 weeks
Please call Dr. [**Last Name (STitle) 38374**] at [**Telephone/Fax (1) **] for an appointment to
be seen within 1-2 weeks
ICD9 Codes: 4271, 4019, 4280, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1505
} | Medical Text: Admission Date: [**2193-11-28**] Discharge Date: [**2193-12-10**]
Service: MEDICINE
Allergies:
Calcium Channel Blocking Agents-Benzothiazepines /
Beta-Adrenergic Blocking Agents / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Left main stem stent obstruction
Major Surgical or Invasive Procedure:
Bronchoscopy and left main stem stent removal
History of Present Illness:
80 yo female with COPD, tracheobonchomalacia, CAD s/p MI (12yrs
ago), seizure d/o, HTN, Type II DM s/p left mainstem stent [**10-11**]
who presented to [**Hospital 1562**] hosp [**11-24**] with SOB and respiratory
failure [**1-14**] LLL mucus plugging and L mainstem 90% occlusion.
Also had seizure with sub-therapeutic dilantin level.
Transferred to [**Hospital1 18**] for w/u of L mainstem stent obstruction.
Dr.[**Last Name (STitle) 57475**] took patient to bronch, which revealed
granulation tissue obstruction, then entire stent removed [**11-29**].
Since the patient did not feel better when the stent was
placed, she was not considered to be a good candidate for
tracheoplasty. Ms.[**Known lastname 17562**] could not be extubated after stent
removal because of laryngeal edema/spasm, finally extubated
[**12-4**] with no plans for further intubation if necessary (i.e.
DNI). Vanc (started at OSH on [**11-24**])/levo (started [**11-30**]) to
complete 10 day course for LLL opacities suspicious for PNA.
Initially started on Nipride for tight BP control, weanded off
on [**11-30**]. Started on captopril on [**12-2**] with good response to
borderline hypotension.
Past Medical History:
Tracheobronchomalacia
Respiratory distress
COPD
Depression
Hypothyroid
Hypertension
Diabetes
Hyperlipidemia
Seizure disorder
s/p MI (~12 years ago)
Social History:
Smoker since [**2132**], 1pack/week, quit ~12 years agoDenies alcohol
and IDU useLives in nursing home, [**Location (un) 6598**] Manor, [**Hospital3 **]
Family History:
Father with COPD
Brother with stomach cancer
Brief Hospital Course:
1. Stent Obstruction: Pt presented with shortness of breath
and fever to [**Hospital 1562**] hospital [**11-24**] with SOB and LL mucus
plugging. Bronch revealed left mainstem occlusion and pt
transferred to [**Hospital1 18**] for care. Bronchoscopy at [**Hospital1 18**] also
revealed nearly totally occluded L main stem stent, which was
removed. No tracheostomy was placed since pt had no subjective
improvement when stent initially went in, late [**9-16**]. Ms.[**Known lastname 17562**]
was unable to be extubated second to lack of air-leak, and
presumed laryngeal edema/spasm. Finally, she was extubated
[**12-4**] and tolerated the extubation well. Currently, denies
shortness of breath, cough, sputum production or chest pain.
Interventional pulmonary no longer feels Ms.[**Known lastname 17562**] to be an
interventional candidate for her tracheobronchiomalacia.
2. Seizure D/O: Pt experienced a seizure at OSH, by report.
She was placed on dilantin and dosed by level. No further
seizure activity.
3. DMII: Kept on insulin sliding scale and diabetic diet. No
episodes of hyperglycemic coma or hypoglycemia.
4. ID: Vanc (started at OSH [**11-24**]) and levoquin (started
[**11-30**]) to complete a 10 day course of possible post-obstructive
PNA (will finish [**12-10**]). Now without features of pneuomonia by
physical. No septic hemodynamics. Lactate normal.
5. HTN: Transiently required nipride gtt for BP control,
easily transitioned to PO ACE-inhibitor, with good control.
6. Mental Status Change: Pt noted to have a decreased
sensorium and behaving inappropriately. This was attributed to
sedatives (while intubated), possible hypoxia, ICU psychosis and
sundowning. She was at baseline by time of discharge.
Medications on Admission:
[**Last Name (un) **] prn
phenobarbital 120 po qhs
dilantin 200 IV q8h
levothyroxine 75 mic/d
hep 5000 sq tid
protonix 40 IV qD
solumedrol 125 mg IV q8h
levaquin 500 IV qd
vanc 1g q12h
propofol gtt
atrovent nebs q6h
albuterol nebs prn
Discharge Medications:
1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*qs * Refills:*0*
3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
Disp:*180 neb* Refills:*2*
6. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO TID (3 times a day).
Disp:*270 Tablet, Chewable(s)* Refills:*2*
7. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] mannor
Discharge Diagnosis:
Primary:
1. Tracheo-bronchomalacia.
2. Post-Obstructive Left Lower Lobe Pneumonia.
3. Delirium.
4. Larnygeal Edema.
Secondary:
1. Hypertension.
2. Seizure D/O NOS.
3. Diabetes Mellitis.
Discharge Condition:
Good
Discharge Instructions:
If you have these symptoms, call your doctor or go to the ER:
- fever/chills
- shortness of breath (slowly worsening or sudden)
- cough with blood/sputum
- weakness
- Headache
- visual changes
Followup Instructions:
Pulmonary.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7631**], MD
[**Hospital1 57476**], [**Numeric Identifier 19665**]
([**Telephone/Fax (1) 57477**]
Completed by:[**2193-12-10**]
ICD9 Codes: 486, 496, 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1506
} | Medical Text: Admission Date: [**2124-5-9**] Discharge Date: [**2124-5-22**]
Date of Birth: [**2069-5-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
Intubation, Sedation
Femoral line placement and removal
History of Present Illness:
The patient is a 54 yoM w/ a h/o ETOH and hep C related
cirrhosis, ETOH cardiomyopathy (although last EF was normal in
[**1-24**]), atrial fibrillation and ETOh abuse who presents after
being found by [**Location (un) **] police in an ally way. He was unable
to get up and so EMS was called and he was brought to the ER.
.
In the emergency department, initial vitals: T 97.0 HR 120 BP
116/82 RR 28 O2 100%. Last drink 10 a.m. this a.m., found by
[**Location (un) **] police who asked he get up and leave and he could not.
FSBH 35 by EMS, improved w/ amp of D50. He felt like he was
withdrawing in the ER and got valium 40mg IV valium (in 10mg
increments). Given levo / flagyl in ER for aspiration PNA. Got
rectal ASA given that he had CP in ER upon initial presentation.
Given 7L IVF in ER. Thiamine given by EMS. In addition the
patient had 3 runs of NSVT up to 20 seconds and spontaneously.
He was given an amiodarone bolus and started on 1mg / hr of
amiodarone- in addition he was given 1 amp of bicarbonate.
.
VS prior to transport to ICU: HR 130 121/68 RR 39 O2 97% on
4L
.
In the ICU the patient complains of only nausea x 1 day,
diarrhea x 2 days, chronic low back and knee pain as well as
some chills. No abdominal pain, no current chest pain although
did have chest pressure associated w/ SOB in the ER, he is
unsure how long this lasted, no radiation. This has happened
to him 2 x in the past month, independent of any exertion. Has
happened occasionally for the past "many years." Baseline
functional capacity is "walking around," not up stairs and no
longer than a city block- without symptoms. No unexplained
syncope or LH, no palpitations. No orthopnea, or PND. No
bleeding. No pedal edema. Rest of ROS is negative. No h/o
w/d seizures, no h/o DTs. Has had w/d characterized by tremor
and agitation in the past.
Past Medical History:
Atrial fibrillation
Cardiomyopathy (although EF [**1-24**] was normal)
Alcohol abuse
Hypertension
Pancreatic cyst
Status post knee replacement
Hepatitis C cirrhosis
Back arthritis
Social History:
Active drinker, drinks at least [**11-19**] pint vodka daily, + tobacco
2ppd for 40 years, denies other drug use. Lives alone in
[**Location (un) **] housing. Not married.
Family History:
Positive for coronary artery disease (details unknown) and
hypertension. His father had an aortic aneurysm. There is a
history of cancer of the brain and the breast.
Physical Exam:
VITAL SIGNS: T 96.5 (PO) HR 130 BP 151/92 RR 28 O2 sat 94% 3L
NC
GEN: NAD, AOx3
HEENT: EOMI, MMM, OP clear
CHEST: bibasilar rales, diffuse wheezes bilaterally, tachypneic
CV: tachycardic, RR, no m/r/g
ABD: soft, moderate distension, NT, no masses, liver felt 3cm
below R costal margin, no splenomegaly
EXT: WWP, no c/c/e
NEURO: 5/5 strength all 4 extremities, CN2-12 normal, AOx3
Pertinent Results:
Osmolar gap:
calculated osms: 144x2 + 75/18 + 30/2.8 + 90/4.6 = 322.5
serum osm 342
osmolar gap 19.5
.
MICROBIOLOGY:
Blood cultures [**2124-5-9**] P
.
STUDIES:
[**2124-5-9**] CT head w/o contrast: No acute intracranial abnl.
[**2124-5-9**] CXR: R basilar atelectasis, lungs otherwise clear
[**2124-5-9**] EKG: sinus tachycardia with a rate of 128, normal axis
and intervals. no ST T WAve changes, no Q waves. normal R wave
progression
.
Old studies:
[**1-24**] ECHO: mild symmetric LVH, normal EF, no valvular
dysfunction, indeterminate PASP.
.
[**2124-5-10**] 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%). 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) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Dilated
thoracic aorta. No structural heart disease or pathologic flow
identified.
Compared with the prior study (images reviewed) of [**2124-1-17**], the
findings are similar.
.
[**2124-5-18**] VIDEO SWALLOW STUDY:
RECOMMENDATIONS:
1. PO diet: regular solids, thin liquids
2. PO meds whole with thin liquids
3. TID oral care
4. Distant supervision with meals to maintain aspiration
precautions and assist with self-feed as willing.
5. Please page/reconsult if we can be of further assistance.
.
LABS:
[**2124-5-9**] 01:40PM WBC-5.0 RBC-3.52* HGB-12.3* HCT-39.9*
MCV-113*# MCH-35.0*# MCHC-30.8* RDW-17.5*
[**2124-5-9**] 01:40PM NEUTS-34* BANDS-32* LYMPHS-21 MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-6* MYELOS-1* NUC RBCS-1*
[**2124-5-9**] 01:40PM PLT SMR-LOW PLT COUNT-132*
.
[**2124-5-9**] 01:40PM ASA-NEG ETHANOL-90* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2124-5-9**] 01:40PM OSMOLAL-342*
[**2124-5-9**] 01:40PM GLUCOSE-75 UREA N-30* CREAT-3.2*# SODIUM-144
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-6* ANION GAP-39*
.
[**2124-5-9**] 01:50PM LACTATE-9.6*
.
[**2124-5-9**] 04:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-TR
[**2124-5-9**] 04:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-TR
.
[**2124-5-9**] 04:20PM BLOOD Lipase-481*
[**2124-5-10**] 05:42AM BLOOD Lipase-68*
.
[**2124-5-9**] 01:40PM BLOOD CK-MB-11* MB Indx-2.9 cTropnT-<0.01
[**2124-5-9**] 01:40PM BLOOD CK(CPK)-378*
[**2124-5-9**] 08:56PM BLOOD CK-MB-31* MB Indx-2.4 cTropnT-<0.01
[**2124-5-9**] 08:56PM BLOOD CK(CPK)-1308*
[**2124-5-10**] 05:42AM BLOOD CK-MB-34* MB Indx-2.1 cTropnT-<0.01
.
[**2124-5-10**] 05:42AM BLOOD ALT-70* AST-175* CK(CPK)-1636* AlkPhos-61
TotBili-1.0
[**2124-5-11**] 04:05AM BLOOD ALT-56* AST-112* LD(LDH)-346*
CK(CPK)-654* AlkPhos-61 TotBili-0.7
Brief Hospital Course:
#. Anion gap metabolic acidosis: combination of lactic acidosis
and alcoholic ketoacidosis with bicarbonate of 6 at admission.
Lactic acidosis from unclear reason, possibly from hypoperfusion
from relative hypotension and the pneumonia seen on imaging.
Lactate normalized after 7 liters of fluid. Acidosis improved
with bicarbonate gtt as patient was unable to bring pH above
7.19 on his own, initially. pH then corrected and bicarb was
stopped. He was intubated due to escalating alcohol withdrawal
(see below).
#. Alcohol withdrawal/Agitation: At admission, had positive
alcohol level. He had been drinking the night of admission. He
drinks [**11-19**] pints of vodka per day. At the end of HD1, he
demonstrated signs/sypmtoms of withdrawal with tachycardia,
hypertension, agitation, diaphoresis, tremors and anxiety. He
was treated with escalating doses of benzodiazepines and
ultimately required intubation. He was maintained on a propofol
gtt and then was transitioned to standing valium. On [**5-10**] he
had received nearly 300 mg of valium. He was extubated after 4
days of intubation. Psychiatry was consulted for continued
agitation post-extubation requiring high doses of haldol. He
eventually stablized out off of benzos and on haldol scheduled.
- Psyche following
#. Aspiration risk: Patient presented with aspiration pna vs.
community acquired Pneumonia. Initial S&S evaluation showed
patient aspirating ->Placed NG tube but patient pulled it out
shortly after placement. Repeat Video S&S on [**2124-5-18**] showed no
aspiration and he tolerated a regular diet.
- Completed levofloxacin x 5 days on [**2124-5-13**] for aspiration pna
#. Black stool: reports liquid black stool as baseline.
Hematocrit decreased after aggressive hydration but stabilized.
Did not require transfusion and was continued on PPI [**Hospital1 **].
# C Diff positive: presented with Diarrhea. Treated with flagyl
for 14 day course to end on [**2124-5-24**].
#. Acute renal failure: in the setting of extreme dehydration at
admission. Improved with hydration and supportive care to Cr of
0.6 - 0.8.
#. Chest pain: vague description at presentation. Ruled out for
MI, but elevated CK indicative of some rhabdomyolysis. This
improved with hydration. No further long runs of NSVT. Echo
with mild symmetric left ventricular hypertrophy with preserved
global biventricular systolic function. Dilated thoracic aorta.
No structural heart disease or pathologic flow identified.
#. COPD: extensive wheezing at admission and smoking history.
Treated with frequent nebs and steroids initially. Steroids
discontinued following intubation as wheezing improved with
nebs. He was extubated on [**5-14**] and did not require any further
O2 or nebs.
#. HCV cirrhosis/EtOH pancreatitis/EtOH hepatitis: LFTs trended
down and remained stable.
# Smoking history: nicotine patch
# NSVT: 20 sec in ED in setting of multiple electrolyte
abnormalities. Started on beta blocker, and had only 1 repeat
episode since ED. Lytes were repleted aggressively.
# Disposition: Patient was discharged to the street per his
request. Patient was repeatedly offered our help in brokering
housing at a shelter, as despite his insistence to contrary he
seemed to be a homeless man. He repeatedly declined offers of
help in arranging housing / shelter. At discharge, as he was
leaving, he declared however that we were "throwing him out" and
that he would spend the night sleeping in front of the hospital.
Medications on Admission:
Aspirin 325 mg po daily
Multivitamin po daily
Hydrochlorothiazide 12.5 mg po daily
Omeprazole 20 mg Capsule po bid
Atenolol 100mg po daily
Diltiazem HCl 300 mg SR po daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 7 days: Until [**5-27**].
Disp:*21 Tablet(s)* Refills:*0*
7. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Alcohol withdrawal
2. Aspiration Pneumonia
3. C. diff colitis
Secondary Diagnoses:
Alcohol dependence
Atrial fibrillation
Cardiomyopathy
Alcohol abuse
Hypertension
Hepatitis C cirrhosis
Discharge Condition:
Afebrile, vital signs stable and wnl, tolerating PO, ambulating,
AOx3, pleasant
Discharge Instructions:
You have been admitted to the hospital for alcohol withdrawal.
While you were here you were sent to the ICU, intubated and put
on medicine for withdrawal. You developed a pneumonia (lung
infection) and an infectious diarrhea for which you are
currently undergoing treatment. We urge you to accept treatment
for alcoholism and have provided you with resources to do so.
There have been several changes to your medicines, please take
as directed.
Please call your doctor or 911 for any concern of alcohol
withdrawal, chest pain, difficulty breating or any other medical
concern.
Followup Instructions:
Please call [**Last Name (LF) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2205**] for an appointment
after discharge.
Please also call the gastroeneterology (stomach doctors') clinic
([**Telephone/Fax (1) 2233**] for an appointment to have a colonoscopy, because
you had some stomach track bleeding while you were in the
hospital.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2124-5-26**]
ICD9 Codes: 5070, 2762, 5849, 4254, 5789, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1507
} | Medical Text: Admission Date: [**2181-6-26**] Discharge Date: [**2181-6-29**]
Date of Birth: [**2099-8-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 y/o spanish speaking only, from [**Country 26231**], on family visit in
US. Reports falling yesterday afternoon in restroom. Pt is poor
historian but he denied CP, SOB, seizure or LOC before or after
fall. c/o CP and back pain today that prompted ER visit to OSH
where CXR was done, then a CT SCAN showing type B dissection,
extending from L sblcv artery all the way down to both iliacs.
Was given labetalol during transport and in ER. Denies any prior
medical problems, but no PCP visit for "a while". pt reports no
extremity weakness in ER.
Past Medical History:
Denies
Social History:
Tobacco: remote, 20 y ago
ETOH remote, 5-6 beers/WE
Family History:
Denies
Physical Exam:
Pulse: 67 Resp: O2 sat: 98
B/P Right: 115/78 Left: 112/80
Height: Weight:
General: relatively comfortable
Skin: Dry [x] intact []
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact, moves 4 ext, R handed. follows commands
Pulses:
Femoral Right: Left:
DP Right: + Left: +
PT [**Name (NI) 167**]: Left:
Radial Right: + Left: +
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2181-6-26**] CT Scan Chest
1. Aortic dissection as described above originating just at the
level of the origin of the left subclavian and extending through
the entire descending thoracic aorta, the abdominal aorta, and
both common iliac arteries. The SMA, celiac axis, both renal
arteries, and [**Female First Name (un) 899**] all originate from the true lumen with no flap
visualized. Good opacification of both true and false lumens.
Aneurysmal dilation of the descending abdominal aorta most
prominent just at the bifurcation with associated thrombus
formation up to 5.8 x 5.5 cm.
2. Cirrhosis of the liver with sequelae of portal hypertension
such as
recanalization of the umbilical vein and gastroepiploic varices.
[**2181-6-29**] 05:45AM BLOOD WBC-5.6 RBC-3.88* Hgb-13.4* Hct-37.5*
MCV-97 MCH-34.5* MCHC-35.7* RDW-13.9 Plt Ct-157
[**2181-6-29**] 05:45AM BLOOD Glucose-89 UreaN-21* Creat-0.9 Na-139
K-4.1 Cl-103 HCO3-24 AnGap-16
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2181-6-26**] for further
medical management of his Type B aortic dissection. His blood
pressure was tightly controlled with labetalol for a target
systolic blood pressure of less then 120mmHg. He was
transitioned to oral blood pressure medications. The vascular
surgery service was consulted. Medical management was optimized
and Mr. [**Known lastname **] was discharged to home with VNA services. He was
advised to obtain a chest CT every 3 months for one year.
Medications on Admission:
None
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Type B Aortic Dissection
Discharge Condition:
Good
Discharge Instructions:
1) Monitor blood pressure and keep systolic blood pressure less
then 130mmHg.
2)Call 911 for chest pain, or burning pain radiating to your
back.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**1-12**] weeks.
Please obtain a CT scan of the chest every 3 months for the next
year.
Mandarse a hacer una tomografia computarizada de [**First Name9 (NamePattern2) 83540**] [**Last Name (un) 33424**] tres
meses por un ano.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2181-6-29**]
ICD9 Codes: 5715, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1508
} | Medical Text: Admission Date: [**2132-7-31**] Discharge Date: [**2132-8-1**]
Date of Birth: [**2048-7-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
urosepsis
Major Surgical or Invasive Procedure:
CMO
History of Present Illness:
84M with advanced dementia, atrial fibrillation, CHF (EF 25%),
BPH presenting from rehab with acute renal failure and urinary
tract infection/hematuria.
He was noted to have an increase of creatinine from 1.2 to 2.6.
He was started on a cefepime for a proteus urinary tract
infection diagnosed on [**2132-7-29**]. He had an ultrasound on
[**2132-7-28**] that showed hydronephrosis.
Of note, he is confused at baseline but seems more agitated
recently. He has no documented fevers. He denies chest pain,
shortness of breath, vomiting.
In addition, patient was admitted from [**2132-6-13**] to [**2132-6-19**] for
confusion x 1 days and noted to have a congestive heart failure
exacerbation. Cardiology evaluation and consultation advised
medical management and ECHO showed wall motion abnormalities
consistent with multivessel coronary artery disease.
He was also noted that have a 3 month cognitive decline, which
was corroborated with his wife and [**Hospital 228**] health care proxy
[**Name (NI) **].
In the ED, initial VS were: Triage 12:51 0 99.5 74 92/66 16 92%
He was noted to have a foley with purulent red urine. His was
AAOx1 and very lethargic (said "yes" to some questions) - he has
been like this for past 4 weeks per wife. [**Name (NI) **] does have history
of attacking people at rehab.
Current access includes left PICC and 18G on right arm.
He was given cefepime at 11:30 AM today and vancomycin 1gm IV in
[**Hospital1 18**] ER.
His initial SBP was in the 90s, which then dropped to the 80s.
He was given 250 mL normal saline with SBP 100-110s.
Labs were performed
- Lactate 2.4
- cTropnT 0.05
- Na 141, Cl 105, K 3.6, HCO3 20, BUN 55, Cr 3, Glc 95
- ALT 31, AST 97, ALP 97, Lipase 12, tbili 0.8, Alb 3.4
- WBC 25.2, Hgb 13.4, Plt 171 Diff N 93.8 L 3.3 INR 1.5
- UA Cloudy, pH 9, Tbili Lg, LE Lg, Nit Pos, Prot > 300, Glu >
1000, Ket 150, RBC > 182, WBC > 182, Bacteria None
A prelim CT Abd showed no renal stones, discrepancy in renal
size (11cm right, 7.4cm left) likely reflects chronic kidney
disease. Moderate perinephric stranding is consistent with
pyelonephritis in the appropriate clinical setting, which
appears worse on the right. A foley is present within the
bladder, which is decompressed. A recently passed stone could
also account for these findings although none is seen. In
addition, there was moderate cardiomegaly. Overall, this scan is
limited by lack of contrast and respiratory motion, but
no other significant abnormalities are detected.
Blood and urine cultures were obtained; however, patient did
receive antibiotics before arrival at rehab.
He is being admitted to the ICU for sepsis with hemodynamic
changes including tachycardia in 110-120s and relative SBP 90s.
On arrival to the MICU pt had an episode of pulseless VTACH,
spontaneously converted. he was dyspneic and received IV metop
5mg x 1 for RVR, lasix 20 IV, IV morphine.
Review of systems:
Past Medical History:
Congestive heart failure (EF 25 %)
- advanced dementia
- Atrial fibrillation not on coumadin
- Hypertension
- Osteoporosis
- Mild aphasia
- s/p hip fracture
- benign prostatic hypertrophy
Social History:
Lives at [**Location 19582**] Point at [**Location (un) 1887**] ([**Hospital3 **]). Lives with
wife in apartment. Former hospital overseer of [**Hospital **]
Hospital.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM: Vitals: T 98.8 HR 1354 in a fib BP 143/106 RR 31
SpO2 81%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DEATH EXAM:
General: motionless
CV: no heart sounds
Pulses: no radial, carotid, or femoral pulses
Neuro: no corneal blink reflex, eyes do not track
Pertinent Results:
[**2132-7-31**] 01:15PM BLOOD WBC-25.2*# RBC-4.29* Hgb-13.4* Hct-40.2
MCV-94 MCH-31.3 MCHC-33.3 RDW-15.0 Plt Ct-171
[**2132-7-31**] 01:15PM BLOOD Neuts-93.8* Lymphs-3.3* Monos-2.8 Eos-0
Baso-0.2
[**2132-7-31**] 01:15PM BLOOD PT-16.1* PTT-29.3 INR(PT)-1.5*
[**2132-7-31**] 01:15PM BLOOD Glucose-95 UreaN-55* Creat-3.0*# Na-141
K-3.6 Cl-105 HCO3-20* AnGap-20
[**2132-7-31**] 01:15PM BLOOD ALT-31 AST-47* AlkPhos-97 TotBili-0.8
[**2132-7-31**] 01:15PM BLOOD Lipase-12
[**2132-7-31**] 01:15PM BLOOD cTropnT-0.05*
[**2132-7-31**] 06:00PM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1
[**2132-7-31**] 08:29PM BLOOD Type-[**Last Name (un) **] pO2-66* pCO2-29* pH-7.37
calTCO2-17* Base XS--6
[**2132-7-31**] 01:51PM BLOOD Lactate-2.4*
[**2132-7-31**] 08:29PM BLOOD Lactate-2.1*
[**2132-7-31**] 01:15PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.005
[**2132-7-31**] 01:15PM URINE Blood-LG Nitrite-POS Protein->300
Glucose->1000 Ketone-150 Bilirub-LG Urobiln->8 pH-9.0* Leuks-LG
[**2132-7-31**] 01:15PM URINE RBC->182* WBC->182* Bacteri-NONE
Yeast-NONE Epi-0
Micro:
Blood culture [**7-31**]- PENDING
urine culture [**7-31**]- PENDING
Cdiff assay [**7-31**]- PENDING
Brief Hospital Course:
Mr. [**Known lastname **] is an 84 yo gentleman with PMH of ischemic congestive
heart failure with depressed ejection fracture, atrial
fibrillation not on anti-coagulation, moderate dementia, mild
expressive aphasia who was admitted to the MICU with urosepsis
and made CMO.
# Sepsis from a urinary source (pyelonephritis): On presentation
to the ED, the patient met [**1-12**] SIRS criteria and he had a
urinary tract infection per UA. He had an elevated lactate at
24. He was hypotensive and unable to be fluid resuscitated due
to worsening respiratory status. He was started on pressors with
improvement in his BP. He was started on Vanc/Cefepime and
Ciprofloxacin for antibiotics and he was admitted to the ICU. In
the ICU he continued to be hypotensive and was volume
resuscitated which transiently improved his hemodynamics, but
was complicated by acute pulmonary edema (attributed to his
depressed EF and 3+ MR). In addition, he developed A fib with
RVR in the acute setting and was treated with beta blockade, but
subsequently developed frequeny runs of non-sustained V tach.
Despite these interventions, the patient continued to clinically
deteriorate hemodynamically and respiratorially. He was DNR/I on
admission and given the accuity and severity of his acute
presentation and his progressive deterioration despite
aggressive medical management with broad spectrum antibiotics,
goal-directed volume resuscitation, supplemental oxygen, and
beta-blockade, the decision was made, in concert with his wife,
health care proxy (attorney [**Name (NI) **] [**Name (NI) **]), and his primary care
provided (Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]), to transition to CMO care. The
patient passed away within several hours of transitioning his
goals of care. He appeared to be comfortable, without pain or
dyspnea. The time of death was 3:14PM, [**2132-8-1**]. His
wife, health care proxy, and primary care provider were
informed. The medical examiner was contact[**Name (NI) **] as the patient had
died within 24 hours of admission and Dr. [**Last Name (STitle) 9037**] declined the
case.
Medications on Admission:
Metoprolol Succinate XL 12.5 mg PO DAILY
hold for sbp<90 hr <60
2. Simvastatin 20 mg PO DAILY
3. Valsartan 20 mg PO DAILY
hold for sbp <90
4. Aspirin 325 mg PO DAILY
5. Furosemide 20 mg PO DAILY
hold for sbp<90
6. Quetiapine Fumarate 12.5 mg PO DAILY:PRN agitation
7. Quetiapine Fumarate 12.5 mg PO Q4PM
8. Tamsulosin 0.4 mg PO HS
Discharge Medications:
N/A - expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2132-8-2**]
ICD9 Codes: 5849, 4271, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1509
} | Medical Text: Admission Date: [**2172-2-26**] Discharge Date: [**2172-3-1**]
Date of Birth: [**2103-7-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABG x 3
History of Present Illness:
The patient is a 68-year-old gentleman who
presented with acute coronary syndrome last week. Cardiac
cath on Friday evening showed severe two-vessel coronary
disease. The patient did rule-in for a minor non-ST elevation
myocardial infarction which was treated medically. Due to
Plavix load, it was felt that he was stable enough to return
home for Plavix washout and return 1 week from his diagnostic
cath for elective coronary artery bypass grafting. The
patient did well for several days as an outpatient but
presented last night with prolonged chest pain with low level
of enzyme leak with a troponin bump. The patient was
hemodynamically stable without chest pain prior to bringing
the patient to the operating room on heparin and
nitroglycerin. It was felt that the patient needed to proceed
with urgent coronary bypass grafting at this time. The
patient understood the risks, benefits and possible
alternatives including, but not limited to, bleeding,
infection, myocardial infarction, stroke, death, renal and
pulmonary insufficiency, as well as the possibility of a
blood transfusion and future revascularization procedures and
agreed to proceed.
Past Medical History:
Dyslipidemia
Hypertension
blood in semen
BPH
[**Last Name (un) 865**] esophagus
Social History:
Lives at home. Quit smoking 25 years ago, prior to that 2 packs
per day for 20 years. One to two drinks per day. Exercises
regularly. He plays paddle tennis and golf.
.
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is a family history of premature coronary artery disease
in his uncle.
Uncle died of MI in 40s.
Physical Exam:
a/o
nad
grossly intact
supple farom
neg lymphandopathy
cta
rrr
abd - benign
palp pulses
all surgical sites C/D/I
Pertinent Results:
[**2172-2-29**] 06:50AM BLOOD
WBC-8.5 RBC-3.35* Hgb-10.1* Hct-29.3* MCV-87 MCH-30.1 MCHC-34.4
RDW-12.9 Plt Ct-185
[**2172-2-29**] 06:50AM BLOOD
Glucose-110* UreaN-15 Creat-1.0 Na-137 K-4.1 Cl-101 HCO3-29
AnGap-11
[**2172-2-26**] 06:00AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2172-2-29**] 9:07 AM
CHEST (PA & LAT)
Lung volumes are improved, though substantial atelectasis
persists in the right lower lobe. Lungs are otherwise clear.
There is no pulmonary edema. Bilateral pleural effusion is
minimal and there is a very tiny right apical pneumothorax.
Heart size normal.
Brief Hospital Course:
pt admitted
pre-op'd
PROCEDURE:
1. Urgent coronary artery bypass grafting x3 with left
internal mammary artery to the left anterior descending
coronary artery; reverse saphenous vein single graft
from the aorta to the first obtuse marginal coronary
artery; reverse saphenous vein single graft from the
aorta to the first diagonal coronary artery.
2. Endoscopic left greater saphenous vein harvesting.
no complications
transfered to the cvicu in stable conditions
weaned from pressure support / extubated
ct removed - cxr small left pnuemo repeat stable
pw and foley removed
pt clears for home
taking po / ambulating and urinating on dc
Medications on Admission:
[**Last Name (un) 1724**]:toprol xl 25', lipitor 80', asa 325', flomax 0.4',
lisinopril 2.5', nexium 20', zetia 10 qod
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
CAD
^chol, HTN, BPH
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
PLEASE TAKE NEW MEDICATIONS AS DIRECTED UNTILL YOU SEE YOUR PCP.
[**Name10 (NameIs) **] PCP [**Month (only) **] WANT TO START YOU ON THE MEDICATIONS THAT YOU WERE
ON BEFORE PROCEDURE
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 2697**], call and make an appointment
for 2 weeks.
[**Last Name (LF) **],[**First Name3 (LF) 177**] C. [**Telephone/Fax (1) 170**] Call to schedule appointment in
four weeks
Completed by:[**2172-3-1**]
ICD9 Codes: 4111, 5180, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1510
} | Medical Text: Admission Date: [**2168-1-5**] Discharge Date: [**2168-1-15**]
Date of Birth: [**2097-2-20**] Sex: F
Service: [**Location (un) 259**] M
CHIEF COMPLAINT: Nausea, vomiting, fevers.
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
female with a history of coronary artery disease and chronic
obstructive pulmonary disease recently admitted status post
fall with surgical resection of damaged lung parenchyma,
multiple compound rib fractures. Her course was complicated
by acute abdominal infections. She was found to have a
gangrenous right colon status post colectomy with end
ileostomy, second look on [**10-23**] small bowel resection and end
ileostomy preceded by third look, found to have small bowel
perforations times two. She had multiple bowel resections
with end jejunostomy. She was placed on a tracheostomy on
[**11-9**] and was noted to have positive Klebsiella sputum
Methicillin resistant Staphylococcus aureus and Pseudomonas
at that time; she was discharged on [**11-21**] to rehabilitation
on TPN via PICC line.
She presents this evening after two day history of fever,
temperature around 103.0 F., mild abdominal pain, nausea,
vomiting. No diarrhea and no bright red blood per ostomy.
She was cultured on [**2167-11-4**], and found to have GPCs in
blood and was sent to [**Hospital1 69**].
In the Emergency Room, the patient was noted to be
hypotensive at 80/47, was given Solu-Medrol 125 intravenously
times one, started on Linezolid, Ciprofloxacin and
Ceftazidime with aggressive intravenous volume resuscitation.
Temperature at that time was 103.0 F., heart rate 92;
respiratory rate 23, 92% on three liters nasal cannula.
The patient was admitted to the Medical Intensive Care Unit
Service for septic shock physiology.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease status post myocardial infarction
and percutaneous transluminal coronary angioplasty with stent
in [**2162**].
3. Hypercholesterolemia.
4. Hypothyroidism.
5. Status post fall with multiple rib fractures, spontaneous
pneumothorax and hemothorax requiring Intensive Care Unit
level care.
6. Post care complications with gangrenous colon resection,
small bowel perforation status post multiple bowel
resections.
7. Diabetes mellitus type 2.
8. Nutritionally compromised secondary to short gut.
ALLERGIES: Rash to penicillin; codeine with nausea and
vomiting.
MEDICATIONS ON ADMISSION:
1. Lopressor 12.5 p.o. twice a day.
2. Levothyroxine 100 micrograms p.o. q. day.
3. Regular insulin sliding scale.
4. Ceftazidime which was started in the Emergency Room, one
gram q. eight.
5. Micronidasol cream.
6. Klobesterol.
7. Atrovent.
8. Octreotide 0.1 mg subcutaneously twice a day.
9. B12 shots.
10. Ativan 1 mg p.r.n.
11. Lasix 40 mg p.o. q. day.
12. Hydroxyzine 25 q. four p.r.n.
13. Tylenol p.r.n.
14. Albuterol.
15. Linezolid 600 mg intravenously q. 12.
SOCIAL HISTORY: Positive for tobacco, smoking one pack per
day, 100 pack years; occasional alcohol.
LABORATORY: She was anemic with a hematocrit of 27.5, white
blood cell count of 13.5 without left shift, hyponatremic at
122. Potassium 3.8, chloride 86, bicarbonate 27, BUN 15,
creatinine 0.8, glucose 159, lactate 2.3, ALT 27, AST 35,
alkaline phosphatase 110, amylase 52, lipase 19, total
bilirubin 0.7.
Sinus tachycardia on EKG at a rate of 130. Reciprocal S
waves leads I, II, AVL, V5, V6, right bundle branch block.
Echocardiogram on [**2167-10-20**] revealed an ejection fraction of
greater than 55%, left atrial mild dilatation.
HOSPITAL COURSE: This is a 70 year old female with coronary
artery disease, chronic obstructive pulmonary disease status
post lengthy surgical admission requiring multiple bowel
resections, who presented from a rehabilitation facility on
TPN via PICC. The patient was admitted for a sepsis
protocol.
1. Started on Dopamine a.d., weaned off [**First Name8 (NamePattern2) **] [**Last Name (un) **] of greater
than 70; started on Vancomycin to cover Methicillin resistant
Staphylococcus aureus possible line infection. Outside
hospital microdata revealed six out of six enterococcus
species; later speciated to be pan sensitive as well as three
cultures positive for fungal, later speciated to be C.
albicans. Repeat blood cultures were drawn on [**12-2**]
and [**1-10**], of which only [**1-5**] revealed C. albicans moderate
growth.
The PICC line was discontinued and culture of tip grown again
positive for fungemia and bacteremia. In light of high grade
sepsis, the patient was continued on Linezolid initially and
transitioned to Vancomycin to cover enterococcus species.
She was initially started on a dose of amphotericin
transitioned to intravenous fluconazole. Transthoracic
echocardiogram and transesophageal echocardiogram revealed no
presence of endocarditis or vegetations.
An ophthalmology consultation was obtained to rule out fungal
retinopathy which was negative. The patient was weaned off
pressors on hospital day one and stabilized. She was
afebrile on hospital day one with a decreasing white count
and no true evidence of leukocytosis or intra-abdominal
process. A CT scan of the abdomen was obtained given
patient's multiple anastomoses with concern for abdominal
abscess and/or free fluid collection. CT scan of the abdomen
revealed no abscess, no fluid collection and no
intra-abdominal process. Empiric antibiotic coverage was
discontinued at that time.
The patient was weaned off pressors and successfully volume
resuscitated and given one unit of packed red blood cells as
well as normal saline boluses to maintain MAP. The patient
remained afebrile throughout hospital days two through ten
with no leukocytosis, no physical examination findings
suggestive of intra-abdominal process. Culture data remained
no growth to date after [**1-6**]. A PICC line was placed on
[**2168-1-12**] via Interventional Radiology.
The patient has per report a history of a penicillin allergy.
On questioning, the patient's allergies were small facial
rash. Given lack of anaphylactic reaction or hives, a trial
of Ampicillin was performed with 250 mg intravenously times
once. The patient did not have pruritus, rash, hives or any
evidence of hemodynamic compromise. Transition from
Vancomycin to Ampicillin 2 grams three times a day was made.
The patient to continue on Intravenous Ampicillin times two
weeks and transition to amoxicillin for an additional two
more weeks at rehabilitation facility.
Anti-fungal [**Doctor Last Name 360**], fluconazole was transitioned from
intravenous to p.o. without sequelae. Will continue on
fluconazole for remaining four week course as well to be
terminated at same time as amoxicillin.
Note: In rehabilitation facility, PICC line may be removed
once completion of Ampicillin therapy.
2. Cardiac: The patient has a history of percutaneous
transluminal coronary angioplasty with stent. At outside
hospital EKG with deep S waves and tachycardia. Cycled
enzymes revealed small troponin leak of 0.04. In light of
sepsis, likely due to demand ischemia without significant EKG
changes. Continued on a beta blocker titrated up, metoprolol
and an addition, Lisinopril once blood pressure stabilized
was made. Hemodynamics remained stable throughout remaining
hospital course. One event on Telemetry in the Medical
Intensive Care Unit pertinent for a 25 beat of nonsustained
ventricular tachycardia. Electrolytes were repleted
appropriately. No further events were recorded on Telemetry.
The patient would benefit from outpatient stress test once
intravenous antibiotics are complete.
3. Gastrointestinal: Status post multiple bowel surgeries.
The surgical team is following. No significant findings on
examination, although in light of extent of resection, the
patient was unable to meet p.o. nutrition requirements on her
own. The decision to place a G-tube was made on hospital day
seven. G-tube was placed by General Surgery. The patient
tolerated the procedure well and began continued tube feeds
with goal of cycle tube feeds at night to meet 100% of
nutritional requirements. The patient will be able to eat
during the day for additional caloric needs.
4. Pulmonary: Initially with hypoxia on admission. Chest
x-ray with no clear indication of pneumonia nor aspiration
pneumonia. The patient remained on nebulizers and aggressive
pulmonary toilet, appropriately diuresing once hypotension
resolved and mobilization of extra vascular fluid was
achieved. At time of discharge, the patient was saturating
97% on two liters nasal cannula with a goal of weaning per O2
saturations greater than 92%. The patient to continue on
nebulizers and appropriate respiratory Physical Therapy,
incentive spirometry, at outpatient rehabilitation.
5. Endocrine: The patient was noted to be hypothyroid.
Continued on Synthroid.
Diabetes per patient; the patient was non-diabetic in the
[**Month (only) **] admission after her fall. Blood sugar is
consistently in the 100s, not requiring regular insulin
sliding scale coverage. Insulin sliding scale was continued
during hospital course in concern for insulin resistance
secondary to hypercortisol state during sepsis, currently
resolved. No requirements for insulin.
DISCHARGE MEDICATIONS:
1. Ampicillin two grams intravenously q. eight hours times
two weeks.
2. At completion of #1, amoxicillin 875 mg p.o. twice a day
times an additional two weeks.
3. Fluconazole 400 mg p.o. q. day times four weeks.
4. Captopril 6.25 mg p.o. three times a day.
5. Albuterol nebulizers, one nebulizer inhaler q. two p.r.n.
6. Metoprolol 12.5 mg p.o. twice a day.
7. Fentanyl patch 50 micrograms an hour transdermal q. 72
hours.
8. Micronidasol powder, 2%, one application topical four
times a day p.r.n.
9. Albuterol Ipratropium one to two puffs inhaler q. four
hours.
10. Tylenol 650 mg q. four to six p.r.n.
11. Zofran 2 mg intravenously q. six p.r.n. nausea.
12. Pantoprazole 40 mg p.o. q. day.
13. Heparin 5000 units subcutaneously q. hour until
ambulating.
14. Aspirin 325 mg p.o. q. day.
15. Octreotide acetate 100 micrograms subcutaneously twice a
day.
16. Levothyroxine 100 micrograms p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient is to continue with rehabilitation and
Physical Therapy as well as Respiratory Therapy with goal to
wean O2 to oximetry saturation of greater than 92%.
2. Will continue course of intravenous antibiotics times two
weeks; at that point, PICC line will be discontinued and
transitioned to oral for a total of one month of therapy.
3. Per recommendations of Rehabilitation facility, the
patient will be returning to primary care physician in
[**Name9 (PRE) 108**] for remainder of care and rehabilitation.
4. As caloric goals are met via G-tube, if patient is able
to tolerate increased p.o., discontinuation of G-tube can be
made at that time.
5. Recommend follow-up closely per General Surgery in
[**State 108**] and/or sooner.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], M.D. [**MD Number(1) 1208**]
Dictated By:[**Last Name (NamePattern1) 972**]
MEDQUIST36
D: [**2168-1-13**] 14:02
T: [**2168-1-13**] 14:03
JOB#: [**Job Number 50869**]
(cclist)
ICD9 Codes: 2761, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1511
} | Medical Text: Admission Date: [**2134-6-15**] Discharge Date: [**2134-6-25**]
Date of Birth: [**2072-7-8**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Optiray 300 / Keflex /
Ciprofloxacin
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
[**2134-6-21**]: Percutaneous pinning right SI joinig
History of Present Illness:
Ms. [**Known lastname **] is a 62 y.o. female unrestrained driver presents
[**6-15**] after high speed MVC (45-50mph), patient was ejected via
driver's side window and landed 15-20 feet away. No LOC. Patient
was flown from the scene via [**Location (un) **] to [**Hospital1 18**] for further
evaluation.
Past Medical History:
(1) IDDM type 2
(2) DVT, PE, and pulmonary infarct (greater than 20 years ago)
(3) Lumbar disc herniations
(4) osteoarthritis
(5) COPD
Social History:
no tobacco, drugs; occ ETOH
Family History:
NC
Physical Exam:
VITAL SIGNS: tmax ([**6-22**]):100.0 tc:98.7 bp:117/77 hr:95 (92-106)
rr:14, 98%NC
PHYSICAL EXAM
GENERAL: Obese female sitting in chair in NAD
HEENT: MMM, no pharyngeal erythemia, no lymphadenopathy, No
conjunctival pallor. Non icteric sclera. PERRLA
CV: Tachycardic, Normal S1, S2. RRR No murmurs, rubs or [**Last Name (un) 549**].
Difficult to assess JVP.
PULM: CTA BL, no wheezes, no ronchi
ABD: Obese. Soft, NT, ND. No HSM
EXTREMITIES: Multiple ecchymoses on extremities, including right
anticubitis, and left forearm, and right calf which patient
reports are from trauma. Right hand with healing laceration and
stitches in place, no drainage, no erythemia.
SKIN: ecchymosis over right hip
NEURO: A&Ox3. Appropriate. CN II_XII grossly intact.
Pertinent Results:
[**2134-6-15**] 01:15PM BLOOD WBC-10.6 RBC-4.19* Hgb-12.7 Hct-38.5
MCV-92 MCH-30.4 MCHC-33.0 RDW-13.2 Plt Ct-278
[**2134-6-15**] 01:15PM BLOOD PT-13.1 PTT-23.1 INR(PT)-1.1
[**2134-6-15**] 11:10PM BLOOD Glucose-172* UreaN-18 Creat-0.7 Na-139
K-4.0 Cl-103 HCO3-25 AnGap-15
[**2134-6-15**] 11:10PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8
.
[**2134-6-16**] 04:30AM BLOOD WBC-11.8* RBC-3.61* Hgb-11.2* Hct-32.5*
MCV-90 MCH-31.1 MCHC-34.5 RDW-13.0 Plt Ct-227
[**2134-6-17**] 07:30AM BLOOD WBC-12.3* RBC-3.04* Hgb-9.4* Hct-27.9*
MCV-92 MCH-30.9 MCHC-33.6 RDW-13.1 Plt Ct-155
[**2134-6-20**] 12:50PM BLOOD WBC-7.5 RBC-2.86* Hgb-9.0* Hct-26.6*
MCV-93 MCH-31.4 MCHC-33.8 RDW-13.9 Plt Ct-189
[**2134-6-22**] 06:10AM BLOOD WBC-7.9 RBC-2.64* Hgb-8.1* Hct-24.8*
MCV-94 MCH-30.6 MCHC-32.6 RDW-14.6 Plt Ct-108*
[**2134-6-22**] 01:30PM BLOOD WBC-9.2 RBC-2.77* Hgb-8.5* Hct-26.8*
MCV-97 MCH-30.7 MCHC-31.7 RDW-14.1 Plt Ct-193#
[**2134-6-22**] 04:15PM BLOOD WBC-9.1 RBC-2.64* Hgb-8.2* Hct-25.1*
MCV-95 MCH-31.2 MCHC-32.8 RDW-13.7 Plt Ct-181
[**2134-6-23**] 04:20PM BLOOD WBC-7.3 RBC-2.92* Hgb-9.0* Hct-27.4*
MCV-94 MCH-30.9 MCHC-33.0 RDW-14.7 Plt Ct-265
[**2134-6-24**] 06:40AM BLOOD WBC-7.7 RBC-2.86* Hgb-8.7* Hct-26.8*
MCV-94 MCH-30.3 MCHC-32.4 RDW-15.3 Plt Ct-279
[**2134-6-25**] 06:50AM BLOOD WBC-8.4 RBC-3.08* Hgb-9.0* Hct-29.0*
MCV-94 MCH-29.2 MCHC-31.0 RDW-15.3 Plt Ct-359
[**2134-6-16**] 04:30AM BLOOD Glucose-158* UreaN-18 Creat-0.6 Na-136
K-3.9 Cl-105 HCO3-26 AnGap-9
[**2134-6-17**] 07:30AM BLOOD Glucose-153* UreaN-17 Creat-0.6 Na-137
K-4.2 Cl-101 HCO3-30 AnGap-10
[**2134-6-22**] 06:10AM BLOOD Glucose-191* UreaN-13 Creat-0.4 Na-132*
K-4.0 Cl-99 HCO3-28 AnGap-9
[**2134-6-25**] 06:50AM BLOOD Glucose-166* UreaN-16 Creat-0.5 Na-133
K-4.0 Cl-96 HCO3-30 AnGap-11
[**2134-6-15**] 01:15PM BLOOD Lipase-19
IMAGING:
CT HEAD
EXAM: CT head exam dated [**2134-6-15**].
COMPARISON: None.
CLINICAL INFORMATION: 62-year-old female in an MVC.
TECHNIQUE: Contiguous 5-mm axial images were acquired of the
head without the
use of intravenous contrast, and these were reformatted in the
coronal and
sagittal planes.
FINDINGS: There is no intracranial hemorrhage. There is no mass
effect or
midline shift. The ventricles and sulci are normal in size and
configuration.
[**Doctor Last Name **]-white differentiation is preserved. The orbits are
unremarkable.
Visualized soft tissue structures are normal in appearance. The
mastoid air
cells are clear. The visualized paranasal sinuses are clear.
Incidental note
is made of hyperostosis frontalis.
IMPRESSION: No acute intracranial injury.
.......................................................
EXAM: CT of the torso.
COMPARISON: None.
CLINICAL INFORMATION: 63-year-old female involved in motor
vehicle collision.
TECHNIQUE: 5-mm axial images were acquired of the chest, abdomen
and pelvis.
Intravenous contrast was not administered due to history of
anaphylactic
reaction. Images were reformatted in the coronal and sagittal
planes.
FINDINGS:
CHEST: The lungs are clear, with the exception of minimal
bibasilar
atelectasis. While limited by lack of intravenous contrast,
there is no
evidence of injury to the thoracic aorta. No pericardial
effusion is seen.
The heart is normal in size and configuration. Incidental note
is made of
coronary artery calcifications. There are fractures of the left
fourth
through eighth ribs laterally, additionally with anterior
fractures of the
sixth and seventh ribs anteriorly. No pneumothorax is seen.
There is no
pleural effusion. The central airways appear patent.
ABDOMEN: While limited by lack of intravenous contrast, the
liver, spleen,
pancreas, gallbladder, adrenals, and kidneys are unremarkable.
No
intraperitoneal free fluid is seen. The small bowel and its
mesenteries
appear unremarkable.
PELVIS: There is a comminuted fracture of the right hemisacrum,
posterior
iliac spine, and inferior and superior pubic rami. Hematoma is
seen within
the pelvis in the area of these fractures, which measures 4.5 x
7 cm at the
right ischium. Additionally, there are distracted fractures of
the right
transverse processes of L4 and L5. The bladder is deviated to
the left by
hematoma but otherwise demonstrates no evidence of injury. The
uterus is
normal in appearance. The colon is significant for
diverticulosis, with no
evidence of diverticulitis.
BONES: The thoracolumbar spine is significant for flowing
osteophytes along
the anterior thoracic spine, consistent with DISH. There is
degenerative
disease of the lumbar spine with vacuum phenomenon and disc
space narrowing,
most significant at the L5-S1 level. Alignment is preserved. A
posterior
disc osteophyte complex at the L2-3 level causes moderate
central canal
narrowing.
IMPRESSION:
1. Comminuted fractures of the right hemisacrum, right posterior
iliac spine,
and right superior and inferior pubic rami. Pelvic hematoma
surrounds these
fractures. Additionally, there are right L4 and L5 transverse
process
fractures.
2. Left-sided fourth through eighth rib fractures, with no
evidence of
pneumothorax.
3. While limited by lack of intravenous contrast, there are no
other injuries
identified of the chest, abdomen or pelvis.
.......................................................
EXAM: CT of the C-spine.
COMPARISON: None.
CLINICAL INFORMATION: 62-year-old female involved in a motor
vehicle
collision.
TECHNIQUE: Contiguous 2.5-mm axial images were acquired of the
cervical
spine, and these were reformatted in the coronal and sagittal
planes.
FINDINGS: There is no fracture, and alignment is preserved. The
prevertebral
soft tissues are normal in appearance. There is multilevel disc
space
narrowing, most prominent at C5-6, where a posterior disc
osteophyte complex
mildly narrows the central canal. Facet joint, and uncovertebral
joint
hypertrophy narrow the neural foramina at multiple levels, most
severely on
the right at the C5-6 level. The visualized lung apices are
clear. The
thyroid and soft tissues of the neck are unremarkable.
IMPRESSION:
1. No evidence of acute injury to the cervical spine.
2. Multilevel degenerative change, with mild narrowing of the
central canal
at the C5-6 level. If there is concern for cord injury, an MRI
would be
helpful for the evaluation of this.
.......................................................
HISTORY: Right percutaneous SI joint pinning.
Fluoroscopic assistance provided to the surgeon in the OR
without the
radiologist present. Seven spot views obtained. These
demonstrate steps
related to placement of screws across the right SI joint and
right sacral ala.
Correlation with real-time findings and when appropriate
conventional
radiographs are recommended for full assessment. Fluoro time not
recorded on
the electronic requisition.
.......................................................
EXAM: Bilateral lower extremity ultrasound to rule out DVT.
CLINICAL INFORMATION: 61-year-old female with history of
peristent
tachycardia, prior pelvic surgery, question lower extremity DVT.
COMPARISON: None.
FINDINGS: Real-time [**Doctor Last Name 352**]-scale and color Doppler son[**Name (NI) 493**]
evaluation of
bilateral common femoral, superficial femoral, and popliteal
veins was
performed. There is normal compressibility, color flow, and
augmentation seen
throughout. Color flow is also seen in the peroneal veins in the
proximal
calves bilaterally. There is limited evaluation of the posterior
tibial
veins.
IMPRESSION: No evidence of deep venous thrombosis in bilateral
lower
extremities.
.......................................................
V/Q scan
RADIOPHARMACEUTICAL DATA:
8.2 mCi Tc-[**Age over 90 **]m MAA ([**2134-6-22**]);
40.3 mCi Tc-99m DTPA Aerosol ([**2134-6-22**]);
HISTORY: increased oxygen requirement and tachycardia after hip
surgery
INTERPRETATION:
Perfusion images obtained with Tc-[**Age over 90 **]m MAA in 8 views show a
defect in the
superior segment of the left lower lobe and a partial defect in
the superior
portion of the basal segments of the left lower lobe. There is
also an overall
decrease in perfusion in the left lobe when compared with the
right lobe.
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in the same 8
views demonstrate
a defect in the same region, partially matching the perfusion
defects.
Chest x-ray (portable film from [**2134-6-21**]) shows possible new
retrocardiac
opacity and blunting of left costophrenic sulcus.
In view of her prior history of pulmonary embolism, these
findings may represent
chronic changes; however acute embolus cannot be excluded.
The above results are consistent with an indeterminate
likelihood for acute
pulmonary embolism.
IMPRESSION: Indeterminate likelihood for acute pulmonary
embolism. The perfusion
defects may be chronic and related to her prior pulmonary
embolism. If clinical
suspicion remains, a CT pulmonary angiogram using gadolinium may
be warranted
.
.
.
.
.
.
.
.
.
.
.
................................................................
HISTORY: 61-year-old female with multiple traumatic injuries
after MVC, now
with oxygen requirement and tachycardia after hip surgery,
concerning for
pulmonary embolism.
COMPARISON: CT torso from [**2134-6-15**]. V/Q scan was also performed
on [**2134-6-22**].
TECHNIQUE: MDCT axial imaging was performed through the chest
initially using
low-dose technique during full inspiration prior to
administration of IV
contrast, and then after administration of IV contrast. Axial
images were
displayed using 5- and 2.5-mm collimation. Coronal and sagittal
reformations
as well as bilateral oblique maximal-intensity projection images
were then
obtained on a separate workstation.
Due to the patient's reported history of prior reaction to CT IV
contrast, the
study was performed after uneventful intravenous administration
of 50 mL of IV
gadolinium-DTPA.
CTA CHEST WITH IV GADOLINIUM: Unfortunately, due to multiple
technical
factors including timing of the contrast bolus and timing of the
CT table,
post-contrast images show insufficient opacification of the
pulmonary arteries
for diagnosis of pulmonary embolism. The pulmonary artery and
aorta are of
normal caliber. Mitral annular calcifications are noted. There
is no
pericardial effusion. Multiple mediastinal nodes are
subcentimeter, not
meeting size criteria for adenopathy.
Multiple both anterior and posterolateral left rib fractures are
redemonstrated, with stranding noted in the overlying soft
tissues, but no
pneumothorax or subcutaneous gas. There is moderate left pleural
effusion
which measures fluid density, with secondary compressive
atelectasis of the
left lower lobe, sparing only the anterior basal segment.
The central airways are patent to the subsegmental levels. On
the right,
there are dependent atelectatic changes. Additionally, there are
multiple
small peripheral ground-glass opacities in the right upper,
right middle, and
right lower lobes, which were not present on [**2134-6-15**].
No focal abnormality is demonstrated within the visualized upper
abdomen on
this exam not tailored for subdiaphragmatic diagnosis.
Degenerative changes
are redemonstrated in the thoracic spine.
IMPRESSIONS:
1. Multiple anterior and posterolateral left rib fractures
redemonstrated.
Moderate left pleural effusion, with associated left lower lobe
atelectasis.
2. Non- diagnostic study for pulmonary embolism.
3. New small peripheral ground-glass opacities in the right
upper, right
middle, and right lower lobes are nonspecific. While infection
is possible,
location and morphology raise the possibility of small areas of
infarction in
setting of clinical suspicion for PE.
Findings and recommendations were discussed in detail with Dr.
[**First Name8 (NamePattern2) 2092**] [**Last Name (NamePattern1) **]
over the phone at 3:30 p.m., who states that the patient reports
her prior
contrast reaction consisted of hives and lightheadedness. If
this can be
confirmed, then CTA after pre-medication may be considered.
Otherwise, a non-
contrast, flow-related MRA study would be recommended.
...................................
Brief Hospital Course:
Ms. [**Known lastname **] presented to the [**Hospital1 18**] on [**2134-6-15**] via [**Hospital **]
transfer from the scene of her MVC where she was ejected. She
was found to have a right hemi sacral and iliac fracture, pubic
rami fractures and multiple left sided rib fractures, 4-8th rib
fractures, with 6th and 7th ribs fractured in two places, and a
right transverse process fractures, L4 and 5. She was admitted
to the TICU for observation and serial hematocrits. On [**2134-6-16**]
she was transferred to the floor. She was taken to the
operating room on [**2134-6-21**] and underwent a percutaneous pinning
of her right hemisacral fracture. She toleratd the procedure
well, was extubated, and transferred to the floor. her pain was
well controled with dilaudid 6mg. She will need follow up with
[**Hospital1 18**] ortho clinic for revaluation 2 weeks after discharge and
to remove the stitches on her right hand.
.
# Tachycardia: patient was observed to be persistently
tachycardic to the 120's despite adequate fluid resussitation
and a stable hematocrit. Medicine was consulted. The patient
states that she has been 'known to have a higher heart rate' but
is unsure how high her rates have been. Given immobility after
surgery and history of DVT/PE (28 years ago) concern for
pulmonary embolism was elevated. Lower ext dopplars were
negative for DVT. She was sent for a V/Q scan which was
equivical and followed up with a CTA with gadolinium (given hx
anaphalaxis to contrast). The study was incomplete and unable to
rule in or out PE. Discussed these findings with the patient and
the need for repeat imaging, and she refused repeat scan.
Discussed with her the importance of diagnosing and treating PE
to prevent respiratory distress, cardiac compromise and death.
She acknowledges these risks and declines repeat imaging. Given
recent surgery and equivical studies she was not anticoagulated
and is being discharged in lovanox 40mg [**Hospital1 **] for 4 weeks for DVT
prophylaxis post surgery.
.
# Pneumonia: patient developed productive cough while in the
hospital. Initially, there was concern for hospital acquired
pneumonia and she was started on vancomycin/zosyn. After a two
day course of abx, she reported having had the cough prior to
admission and she was switched to augmentin (given allergy to
fluroquinolones and cephalosporins) and azithromycin. She will
complete a 7 day course of antibiotics.
Medications on Admission:
Iinsulin sliding scale
Metformin 500mg Daily
Lantus 50 Units daily
Flexaril 20mg daiy
Albuterol prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day). Tablet, Chewable(s)
5. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO ONCE (Once)
for 4 days. Tablet(s)
6. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q 8H (Every 8 Hours) for 4 days.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. Cyclobenzaprine 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous once a day.
10. Humalog 100 unit/mL Solution Sig: asdir Subcutaneous asdir:
At Breakfast/lunch/dinner/bed time:
Below 120: no coverage
120-159 4 Units
160-199 6 Units
200-239 8 Units
240-279 10 Units
280-319 12 Units
.
11. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: One (1)
Tablet PO three times a day.
12. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO
Q6H (every 6 hours) as needed for itching.
13. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain: Hold for sedation, hold for rr<12.
Disp:*30 Tablet(s)* Refills:*0*
14. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia. ML(s)
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] rehab [**Hospital1 **] NH
Discharge Diagnosis:
s/p MVC
Right acetabular fracture
Left sided rib fractures, [**3-4**], with 6th and 7th ribs fx in 2
places
Right transverse process fractures, L4 and 5
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:
Ms. [**Known lastname **],
As you know, you were admitted to the hospital with pelvic and
rib fractures after your motor vehicle accident on [**2134-6-15**].
You were treated by our orthopedic surgeons who put a pin into
your pelvis to hold the bone in place. As we discussed, the
broken ribs will take six to ten weeks to heal, you will need to
use pain as your guide regarding your activity level.
Orthopedics recommends that you ontinue to touchdown weight
bearing on your right leg.
.
You were found to have pneumonia and are being treated with
antibiotics (Amoxicillin-Clavulanic and Azithromycin). You will
need to continue to take the anti biotics for four days after
you are discharged from [**Hospital1 18**].
Continue your lovenox injections as instructed for a total of 4
weeks after surgery
Please take all medication as prescribed
If you have 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.
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
.
Please follow up with your PCP 2-4 weeks after discharge
Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Location: [**Hospital **] MEDICAL CENTER
Address: [**Doctor Last Name 80300**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 66328**]
Phone: [**Telephone/Fax (1) 63696**]
ICD9 Codes: 486, 2761, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1512
} | Medical Text: Admission Date: [**2171-8-13**] Discharge Date: [**2171-8-14**]
Date of Birth: [**2114-11-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfonamides / Fioricet / Fiorinal / Phenytoin
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
CC:[**CC Contact Info 80161**]
Major Surgical or Invasive Procedure:
Cerebral angiogram with partial coiling of cerebral aneurysm
History of Present Illness:
HPI: 56F p/w 4d h/o HA unrelieved by Imitrex. Presents to [**Hospital1 18**]
ED for pain control. vomited 5x since Fri. Seized in ED.
Past Medical History:
PMHx:
migraine HA
endometriosis
depression
^chol
Social History:
Social Hx: married, w children, no EtOH, no tob
Family History:
Family Hx: no aneurysms per husband
Physical Exam:
ON ARRIVAL
PHYSICAL EXAM:
98.9 70 166/80 22
Gen: WD/WN, comfortable, NAD, originally conversant.
HEENT: Pupils: 4->2mm bilaterally
Neck: nuchal rigidity.
Lungs: CTAB.
Cardiac: RRR. nl S1/S2.
Abd: +BS, S, NT/ND
Extrem: Warm and well-perfused. no c/c/e.
Neuro:
Mental status: Eyes closed, not cooperative with exam.
Orientation: Oriented to person, and place.
Cranial Nerves:
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No observed abnormal
movements or tremors. No pronator drift.
Pt unable to cooperate with motor exam. Moves all 4 extremities,
withdraws to noxious stimuli.
Toes downgoing bilaterally.
Exam this am as desribed in progress note
Pertinent Results:
RADIOLOGY Preliminary Report
CT HEAD W/O CONTRAST [**2171-8-14**] 8:16 AM
CT HEAD W/O CONTRAST
Reason: EVD placement, eval for changes
[**Hospital 93**] MEDICAL CONDITION:
56F presents with SAH intubated in ED, EVD placed
REASON FOR THIS EXAMINATION:
EVD placement, eval for changes
CONTRAINDICATIONS for IV CONTRAST: None.
NON-CONTRAST HEAD CT SCAN
HISTORY: Subarachnoid hemorrhage, intubated in the Emergency
Department. Ventricular drain placed. Evaluate for changes.
TECHNIQUE: Non-contrast head CT scan.
COMPARISON STUDY: Non-contrast head CT scan.
FINDINGS: Once again, there is massive subarachnoid hemorrhage
identified. There is also intraventricular hemorrhage layering
within both atria and occipital horns. Blood is also noted
within the fourth ventricle.
In the interval between scans, a right-sided ventriculostomy
catheter has been placed via the right frontal lobe, with its
tip in the region of the foramen of [**Last Name (un) 2044**]. Despite catheter
placement, there appears to be moderate interval enlargement of
the supratentorial ventricular system. There are no other
definite interval changes seen other than the burr hole which
provides passage for the catheter as well as a tiny amount of
gas within the adjacent scalp, presumably postoperative in
nature.
CONCLUSION: Findings of concern for mild interval enlargement of
the supratentorial ventricular system, despite placement of the
right-sided ventriculostomy catheter.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
RADIOLOGY Preliminary Report
CTA HEAD W&W/O C & RECONS [**2171-8-13**] 5:22 PM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS
Reason: r/o hemorrhage
[**Hospital 93**] MEDICAL CONDITION:
56Y F w/ headache. Just seizure attack while in ED
REASON FOR THIS EXAMINATION:
r/o hemorrhage
CONTRAINDICATIONS for IV CONTRAST: None.
EMERGENCY HEAD CT SCAN AND CT ANGIOGRAPHY
HISTORY: 56-year-old woman with headache. Seizures attack while
in the emergency department.
TECHNIQUE: Non-contrast head CT scan.
COMPARISON STUDIES: None.
FINDINGS:
There is massive subarachnoid hemorrhage filling virtually all
of the basal cisternal spaces. There is a small amount of
hemorrhage within both occipital horns as well as the fourth
ventricle. There is mild dilatation of the temporal horns.
Remainder of the ventricular system is of normal size. There is
no shift of normally midline structures. The brain parenchyma
has normal density at this time. There is no sign for the
presence of an overt mass lesion or infarction. The surrounding
osseous and soft tissue structures do not display additional
abnormalities.
CONCLUSION: Massive subarachnoid hemorrhage. Clearly, a ruptured
aneurysm needs to be excluded.
CT ANGIOGRAPHY OF THE NECK AND HEAD:
TECHNIQUE: Bolus intravenously enhanced imaging with multiplanar
reconstructions.
FINDINGS: There is a normal configuration and caliber of the
origins of both vertebral arteries, the left common carotid and
innominate arteries as well as the origin of the right common
carotid artery from the innominate artery. Both common carotid
bifurcations are within normal limits. Particularly as the right
vertebral artery enters the skull, at the level of the foramen
magnum, its caliber is rather attenuated, which could simply be
a congenital variant. However, just beyond this point, the
artery undergoes a relatively fusiform dilatation, which
measures 13 mm in length x 4 mm in maximum width. The
configuration appears more in keeping with a fusiform, rather
than a saccular aneurysm. The remainder of the visualized
tributaries of the circle of [**Location (un) 431**] are within normal limits.
There is no definite sign of an aneurysm elsewhere nor a
definable vasospasm at this time.
CONCLUSION: Unusually configured fusiform aneurysm arising from
the distal right vertebral artery.
COMMENT: It appears that the right posterior inferior cerebellar
artery arises likely to the distal aspect of this aneurysm. This
vascular origin should be carefully assessed, during what is
likely to be selective angiography.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
CEREBRAL ANGIOGRAM FINAL REPORT NOT COMPLETE AT THIS TIME
[**2171-8-13**] 05:20PM PT-12.3 PTT-20.7* INR(PT)-1.1
[**2171-8-13**] 05:20PM PLT COUNT-244 LPLT-1+
[**2171-8-13**] 05:20PM NEUTS-68.3 LYMPHS-23.1 MONOS-7.0 EOS-1.1
BASOS-0.4
[**2171-8-13**] 05:20PM WBC-14.7*# RBC-5.09 HGB-15.6 HCT-44.4 MCV-87#
MCH-30.6 MCHC-35.1* RDW-13.4
[**2171-8-13**] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-7.4
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2171-8-13**] 05:20PM CALCIUM-10.1 PHOSPHATE-3.7 MAGNESIUM-2.7*
[**2171-8-13**] 05:20PM estGFR-Using this
[**2171-8-13**] 05:20PM GLUCOSE-105 UREA N-18 CREAT-0.8 SODIUM-134
POTASSIUM-5.5* CHLORIDE-94* TOTAL CO2-28 ANION GAP-18
[**2171-8-13**] 08:21PM TYPE-ART RATES-18/0 TIDAL VOL-500 PEEP-5
O2-100 PO2-528* PCO2-30* PH-7.55* TOTAL CO2-27 BASE XS-5
AADO2-158 REQ O2-36 -ASSIST/CON INTUBATED-INTUBATED
[**2171-8-13**] 11:30PM PT-13.2* INR(PT)-1.2*
[**2171-8-13**] 11:30PM PLT COUNT-239 LPLT-1+
[**2171-8-13**] 11:30PM WBC-18.6* RBC-4.80 HGB-14.6 HCT-41.4 MCV-86
MCH-30.3 MCHC-35.2* RDW-13.6
[**2171-8-13**] 11:30PM CALCIUM-9.6 PHOSPHATE-3.7 MAGNESIUM-2.3
[**2171-8-13**] 11:30PM GLUCOSE-162* UREA N-15 CREAT-0.7 SODIUM-140
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16
[**2171-8-13**] 11:54PM GLUCOSE-152* LACTATE-1.8 NA+-137 K+-3.4*
CL--100
[**2171-8-13**] 11:54PM TYPE-ART PO2-416* PCO2-31* PH-7.56* TOTAL
CO2-29 BASE XS-6
Brief Hospital Course:
56 yo woman with h/o migraines, presented with headache since
friday. Witnessed seizure in ED and had SAH, intraventricular
blood and fusifor aneurysm off the right
vertebral artery. On examination initially she had inattention,
somnolence,
impaired right eye abduction, possibly right dorsiflexion
weakness but exam difficult. SHe was intubated for airway
protection and an external ventricular drain was placed after CT
revealed hydrocephalus and SAH. CTA was performed. She was
admitted to the ICU and anti-seizure medications were continued.
The am of Hospital day 2 she had a formal cerebral angiogram
after CT. She had partial obliteration of Right vertebral
artery aneurysm. CT this am demonstrated slightly enlarged
ventricles. Catheter in place. Pt care was discussed by Dr.
[**Last Name (STitle) 548**] with attending Dr. [**Last Name (STitle) 97607**] at [**Hospital1 112**]. Her care is going to
be transferred over to Dr. [**Last Name (STitle) **].
Pt report and status discussed with Dr. [**Last Name (STitle) 101269**]. Transpor tis
being arranged. Her EVD this 230pm was with dampened wave form.
It flushes proximally without difficulty / 1 cc PFNS, the
distal catheter was flushed as well. Her current ICP is 11
however the CSF flow is limited. Dr. [**Last Name (STitle) 548**] made aware - we will
continue to assess until transport.
Medications on Admission:
simvastatin
claritin
effexor
imitrex
codeine
klonipin
wellbutrin
Discharge Medications:
see list
Discharge Disposition:
Home
Discharge Diagnosis:
SAH
Resp failure
Right vertebral artery aneurysm with partial coiling
Discharge Condition:
neurologically stable at present / condition remains guarded
Discharge Instructions:
per receiving neurosurgical team
Followup Instructions:
per receiving neurosurgical team
Completed by:[**2171-8-14**]
ICD9 Codes: 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1513
} | Medical Text: Admission Date: [**2124-10-20**] Discharge Date: [**2124-11-16**]
Date of Birth: [**2066-12-31**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
failure to thrive
Major Surgical or Invasive Procedure:
[**2124-10-25**]: Orthotopic liver [**Month/Day/Year **] (retransplant)
[**2124-11-5**]: Exploratory laparotomy, Roux-en-Y, hepaticojejunostomy
History of Present Illness:
Mr. [**Known lastname 64239**] is a 57 year-old man with a history of hepC
cirrhosis s/p OLT [**12-31**]. He was recently admitted [**Date range (1) 64240**] and
found to have hepatic artery thrombosis. He was anticoagulated
and transitioned to coumadin. During that admission he was also
found to have bile lakes, likely secondary to biliary ischemia
secondary to hepatic artery thrombosis, as well as a common bile
duct stricture, for which sphincterotomy with placement of two
stents was peformed.
.
In light of the hepatic artery thrombosis, he also underwent
evaluation for repeat [**Date range (1) **]. He was recently re-listed for
[**Date range (1) **] on [**10-12**] with a MELD of 25. Rapamycin was stopped and
prograf started during that admission.
.
Since the time of his [**Month/Year (2) **], Mr. [**Known lastname 64239**] has had loss of
appetite with failure to thrive. He initially required tube
feeds that were stopped [**3-30**]. He reports no nausea, vomitting,
or abdominal pain, but "lack of taste buds." His weight was 206
lbs prior to [**Month/Year (2) **], fell peri-[**Month/Year (2) **] to 136 lbs. He
then gained weight and was 158 in [**4-30**], but since then has been
gradually losing weight. Since the time of his recent discharge
two weeks ago, he has not eaten more than a few bites daily. He
continues to drink water. He has tried supplemental shakes but
can not stand them. His current weight is 128.
.
He has also not been able to carry out his usual activities and
has not been working. He attributes this to physical weakness,
including shortness of breath with walking more than
room-to-room. His sleeping pattern is unchanged (helped by
Ambien), no trouble concentrating, reports mood is generally
"fine."
.
He has also been having fevers as high as 101-102 intermittently
since the time of [**Date Range **]. No nausea or vomitting, no change
in bowel movements or blood in bowel movements. No change in
urine output or dysuria. No chest pain.
Past Medical History:
-History of UGIB ([**2120**])
-Hepatitis C cirrhosis - s/p OLT [**12-31**] in the setting of
decompensated liver failure [**12-25**] infection. Hepatitis thought to
be from blood transfusions vs tattoos, noticed on random LFTs.
Genotype 1, treated with Peg-IFN and ribavirin several times
with no response. He has three Grade II varices with portal
gastropathy s/p banding. Last EGD in [**5-29**] showed Varices at the
lower third of the esophagus w/ scarring from previous banding,
portal hypertensive gastropathy.
-hx L leg cellulitis, necrotizing fascitis, osteomyelitis and
group A strep sepsis [**11/2123**], requiring skin graft
-Chronic thrombocytopenia
-Hypersplenism
-Cellulitis [**2119**]
-MVA [**2101**], surgery to R leg, multiple fractures to L leg
-Failure to thrive after liver [**Year (4 digits) **]
-Multiple episodes of acute renal failure with unclear baseline
creatinine (was as low as .8 in [**12-31**], range .8-4.5)
Social History:
Denies tobacco use. No alcohol x 18 years. Denies ever using IV
drugs. Lives with wife, has 6 children, 5 grandchildren. Owns
his own towing/auto body repair business.
Family History:
Son died of colon cancer, grand father died of colon cancer. No
history of liver disease
Physical Exam:
PE: VS T 95.5 BP 84/58 Pulse 60 RR 20 O2 96% on RA
Gen: NAD, cachectic, pale
HEENT: oropharynx clear, dry mucous membranes
CV: RRR, no murmurs
Lungs: clear bilaterally
Abd: well-healed y-scar. Normoactive bowel sounds. Nondistended,
nontender. No appreciable ascites.
Ext: warm, no cyanosis. Left leg extensively scarred below
mid-shin with nonpitting edema below ankle, nontender, distal
pulses strong.
Skin: multiple tattos on trunk and arms
Pertinent Results:
Admission labs: [**2124-10-20**]
WBC-11.4*# RBC-2.89* Hgb-7.5* Hct-23.9* MCV-83 MCH-25.9*
MCHC-31.2 RDW-15.8* Plt Ct-257#
PT-36.3* PTT-49.4* INR(PT)-3.9*
Glucose-121* UreaN-64* Creat-3.1*# Na-131* K-4.9 Cl-98 HCO3-22
AnGap-16
ALT-59* AST-94* LD(LDH)-200 AlkPhos-789* TotBili-0.6
Albumin-2.8* Calcium-8.9 Phos-4.3 Mg-2.1
At Discharge [**2124-11-15**]
WBC-3.5* RBC-3.27* Hgb-10.0* Hct-28.2* MCV-86 MCH-30.5
MCHC-35.4* RDW-17.3* Plt Ct-108*
PT-32.5* INR(PT)-3.4*
Glucose-76 UreaN-64* Creat-1.4* Na-134 K-5.7* Cl-110* HCO3-19*
AnGap-11
ALT-50* AST-41* AlkPhos-201* TotBili-0.6
Calcium-8.8 Phos-2.7 Mg-2.0 Alb 2.3
TacroFK-9.2
Brief Hospital Course:
A 57 year-old man 9 months s/p OLT and 2 weeks after hepatic
artery thrombosis presents with failure to thrive, acute renal
failure, hypotension, leukocytosis, and fevers.
WBC on presentation was 11.7 with 14% bands. Wife and patient
both stated that he had been having intermittent fevers as high
as 102 measured at home since the time of [**Month/Day/Year **], although
this had not previously been documented. Blood cultures grew
enterococcus and Neisseria, and urine cultures grew pseudomonas.
He underwent CT guided drainage of a hepatic collection on [**10-23**].
The fluid grew out Enterococcus and [**Female First Name (un) 564**]. Vanc and Zosyn were
initially started, then coverage was broadened to Vanco, Zosyn,
Cipro and Caspofungin.
US showed there is slow flow in the main hepatic artery with a
tardus and parvus waveform (velocity up to 32 cm/s), but no flow
in the right hepatic artery. There is no intrahepatic biliary
dilation. The portal vein and its branches are patent.
Patient was continued on coumadin.
Regarding failure to thrive: This was likely multifactorial,
with acute bacteremia and renal failure playing a role.
However, he had a long history of weight loss and poor PO intake
(had required feeding tube for several months after [**Female First Name (un) **])
and was thought to also have some underlying depression. Given
that he was on the [**Female First Name (un) **] list, feeding tube was considered
however patient had refused initially at admission and then was
transplanted. He was maintained on TPN post [**Female First Name (un) **] and was
using PO supplements with good tolerance and was encouraged to
use the supplements at home following discharge.
On [**2124-10-25**] a liver became available and the patient
underwent a second orthotopic liver [**Year (4 digits) **] due to the
hepatic artery thrombosis and subsequent biliary necrosis and
hepatic abscess. He was taken to the OR with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
An Orthotopic deceased donor liver [**Last Name (NamePattern1) **] (piggyback),
portal vein - portal vein
anastomosis, common bile duct -common bile duct anastomosis (no
T tube). Donor iliac artery conduit from the supraceliac aorta
was performed. He received routine induction immunosuppression
to include Cellcept, solumedrol with prednisone taper and
Prograf restarted on the evening of the [**Last Name (NamePattern1) **]. The broad
coverage with antibiotics was continued with patient receiving
12 days of Vanco, 15 days of Cipro, 19 days of Zosyn and 14 days
of Caspo which was then converted to PO fluconazole.
He initially did well in the SICU, remained afebrile. On POD 6
his coumadin was restarted. The lateral drain was removed on POD
3. The medial drain was noted to be becoming more bilious in
nature and he was having increased abdominal pain and an
elevation in his WBC. An ERCP was attempted and extravasation of
contrast was noted at the duct to duct anastamosis and a stent
was placed. However, it was determined that he was going to
require Roux-en-Y hepaticojejunostomy and was taken back to the
OR with Dr [**Last Name (STitle) **]. He did well following the surgery but was
continued on the TPN until he was able to start tolerating
liquids and started supplements. He was still refusing Dobhoff
tube placement and instead wanted to eat and use supplements.
Calorie counts showed him getting about [**11-24**] to [**12-26**] of caloric
needs and he was instructed to take 4 of the Ensure bottles
daily.
On POD 13/3 he was switched to oral Fluconazole off the
Caspofungin with appropriate adjustment in the Prograf dosing.
ID recommended changing to Ceftrixone and getting him off the
other antibiotics and keeping him on the antibiotic until the
second JP drain was removed. That drain continued with about 1
Liter output daily, but remained serous, so it was decided to
remove the drain and suture. The Ceftrixone was taken off at
this time.
His Coumadin was managed, INRs followed daily. The INR was 5.4 2
days prior to discharge and the dose was dropped with followup
with outpatient labs.
Cholangiogram on [**11-10**] showed no leak and tube was capped with
no subsequent fever.
LFTs dropped appropriately and were WNL at time of discharge.
Medications on Admission:
metoprolol 25 mg [**Hospital1 **]
Cellcept [**Pager number **] mg [**Hospital1 **]
tacrolimus 2 mg [**Hospital1 **] (previously 3 mg [**Hospital1 **])
metoprolol 25 [**Hospital1 **]
Bactrim SS qd
calcium carbonate 500 mg tid (takes [**Hospital1 **])
coumadin 1 mg qd (previously 2 mg qd)
Ambien 5 mg qhs
Senna, Docusate PRN (not using)
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO once a day: Per
[**Hospital1 **] clinic taper.
Disp:*105 Tablet(s)* Refills:*2*
10. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*120 Capsule(s)* Refills:*2*
11. 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*
12. Outpatient Lab Work
CBC, Chem10, AST, ALT, alk phos, albumin, T.bili, and tacrolimus
PT/INR
biweekly - Monday and Thursday
13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
INR/PT
Discharge Disposition:
Home With Service
Facility:
Diversified VNA
Discharge Diagnosis:
Hepatic artery thrombosis
s/p re-[**Hospital1 **]: orthotopic liver [**Hospital1 **]
s/p Exploratory laparotomy, Roux-en-Y, hepaticojejunostomy
Discharge Condition:
Stable/Fair
Discharge Instructions:
Please call the [**Hospital1 **] clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting , diarrhea, increased abdominal
pain or girth, inability to take or keep down food, fluids or
medications.
Monitor the incision for redness, drainage or bleeding
No heavy lifting
Drink enough fluids to keep urine light yellow in color.
You may shower, allowing water to run over abdomen. Pat dry, do
not rub. No tub baths
No driving if you are taking narcotic pain medication
Please call your PCP, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2405**] at [**Telephone/Fax (1) 64241**], to
manage your coumadin levels with outpatient INR/PT labs.
Followup Instructions:
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-1-30**] 1:00
Please call the [**Year/Month/Day 1326**] Surgery Clinic at [**Telephone/Fax (1) 673**] to set
up a follow up appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2124-11-17**]
ICD9 Codes: 5849, 2761, 7907, 2875, 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1514
} | Medical Text: Admission Date: [**2176-7-8**] Discharge Date: [**2176-7-10**]
Date of Birth: [**2110-2-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim DS
Attending:[**Known firstname 23009**]
Chief Complaint:
Angina (Transfer from [**Hospital3 1280**] for Interventional Cath)
Major Surgical or Invasive Procedure:
cardiac catheterization with drug eluting stent x1 and bare
metal stents x2 to right coronary artery
History of Present Illness:
Mrs. [**Known lastname **] is a 66 year old woman with COPD and PVD transfered
from [**Hospital3 1280**] for interventional cath after worsening CP X 4
days. Over the past 3-4 months, she endorses recurrent
non-exertional substernal chest pressure. These last 4 days the
chest pressure worsened, increasing in intensity and frequency.
She called 911 and was taken to [**Hospital3 **] by ambulance. In the
ED she reported same chest pain- ECG revealed no ischemic
changes. Sx were relieved with SL nitroglycerine. Patient was
admitted to [**Hospital3 1280**] where she received Nitro and heparin gtt,
ASA, plavix, metoprolol, and lipitor. She had no CP since
receving Nitro in [**Location 44023**]. Troponin T peaked at 0.2.
Diagnostic cardiac catheterization at [**Hospital3 1280**] revealed:
1.Severe single vessel CAD, with a focal 90% stenosis of the
distal RCA involving the origin of the PDA. Diffuse
calcification and mild-to-moderate disease of all three coronary
arteries 2.Normal LV systolic function. 3. Mild LV diastolic
dysfunction 4.No evidence of valvular disease. She was
transferred to [**Hospital1 18**] this AM for interventional catheterization.
.
At [**Hospital1 18**], she underwent cardiac catheterization with
identification of significant RCA disease. She received a DES to
the distal RCA and BMS x 2 to the mid RCA. The procedure was
complicated by closure of the PDA. The patient also experienced
significant oozing with a drop in hematocrit from 29.8 to 22.9.
.
Following the procedure, the patient was transfered from the
cath lab to the CCU for close overnight monitoring.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: CAD
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2176-7-8**] DES to distal
RCA and BMS x 2 to mid RCA
3. OTHER PAST MEDICAL HISTORY: COPD, Glaucoma, Anemia
Social History:
- Tobacco history: 80 pack-years, now [**12-24**] pack per day
- ETOH: History of EtOH abuse, quit 15 years ago
- Illicit drugs: None
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Brother passed at age 58 from CAD
Brother and Sister with HTN/HLD
Brother and Sister with arrhythmias
Sister with breast and colon cancer
Father and brother with alcoholism
Physical Exam:
ADMISSION EXAM:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, loud P2. left 2nd intercostal 2/6 systolic murmur. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Prolonged expiratory
phase.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No edema. No femoral bruits. Cath site without
bruit or oozing.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ PT 2+
Left: Carotid 2+ Femoral 2+ PT 2+
.
DISCHARGE EXAM:
T 97.8 HR 74-78 RR 18 BP 112-145/61-68 O2 Sat 100% RA Wt 57.5kg
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, loud P2. 1/6 systolic murmur best heart at the L upper
sternal border. No thrills, lifts.
LUNGS: CTAB, no chest wall deformities, scoliosis or kyphosis.
Resp were unlabored, no accessory muscle use. Prolonged
expiratory phase.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No edema. No femoral bruits, cath site with
moderately sized hematoma, not pulsatile, not expanding. Pulses
2+ bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2176-7-8**] 08:00PM BLOOD Hct-25.1*
[**2176-7-9**] 12:56AM BLOOD Glucose-110* UreaN-6 Creat-0.5 Na-137
K-3.6 Cl-106 HCO3-20* AnGap-15
[**2176-7-9**] 12:56AM BLOOD CK-MB-7 cTropnT-0.11*
[**2176-7-9**] 05:26AM BLOOD CK-MB-15*
[**2176-7-9**] 06:00PM BLOOD CK-MB-14* cTropnT-0.25*
[**2176-7-9**] 12:56AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.5*
.
DISCHARGE LABS:
[**2176-7-10**] 06:35AM BLOOD WBC-7.6 RBC-3.72* Hgb-11.1* Hct-31.8*
MCV-86 MCH-30.0 MCHC-35.0 RDW-15.9* Plt Ct-267
[**2176-7-10**] 06:35AM BLOOD Plt Ct-267
[**2176-7-10**] 06:35AM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-144
K-4.1 Cl-109* HCO3-27 AnGap-12
[**2176-7-10**] 06:35AM BLOOD CK-MB-8
[**2176-7-10**] 06:35AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.0
.
Cardiac Cath ([**2176-7-8**]):
1. Limited coronary angiography in this right-dominant system
demonstrated one-vessel disease. The RCA had a 30% proximal
stenosis,
diffuse stenosis in the mid-RCA to 60% with a question of
thrombus and a
distal RCA 95% stenosis and an ostial rPDA 99% stenosis.
2. Successful PTCA and stenting of the distal RCA into the PL
system
with a 2.75 x 15 mm Promus [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] to 3.5 distally and
3.0
proximally complicated by loss of the rPDA (see PTCA comments).
3. Successful PTCA and stenting of the mid-RCA with overlapping
2.75 x
12 mm (distally) and 3.0 x 26 mm Integrity (proximally) stents
postdilated to 3.0 (see PTCA comments).
.
TTE ([**2176-7-9**]):
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
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
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: 66 year-old woman with COPD and
worsening CP/[**Hospital **] transferred from OSH for interventional cath
now status post PCI with stent x 3 to RCA.
.
ACTIVE DIAGNOSES:
.
# CAD: Cardiac cath showed significant RCA disease now s/p PCI
with stent x3. She had BMS x2 placed to the mid RCA (2.75 x 12
mm (distally) and 3.0 x 26 mm Integrity (proximally) stents
postdilated to 3.0) and DES x1 to the distal RCA (2.75 x 15 mm
Promus [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] to 3.5 distally and 3.0 proximally). PCI
was c/b jailing of the rPDA which resulted in cessation of flow
to the PDA that was confirmed by angiography. She had a slight
bump in CKMB post procedure consistent with this finding, but
CKMB was downtrending at the time of discharge. Post-cath echo
showed normal RV size and wall motion.
.
# Post Procedure Hct Drop: Cardiac cath was c/b significant
oozing at the femoral insertion site and the pt's Hct dropped to
23 immediately post cath. She was transfused 2U pRBCs with an
appropriate response, and her Hct at the time of discharge was
stable at 32. She was admitted to the CCU for monitoring
overnight and remained hemodynamically stable throughout her
course. There was no evidence of femoral bruit or expaning
hematoma at the femoral sheath site, but there was moderate
superficial ecchymoses.
.
CHRONIC DIAGNOSES:
.
# COPD: She has a ~80 year smoking history and was maintained on
her home medications while hospatilized. A nicotine patch was
provided. She was counseled on the importance of smoking
cessation. Pt was never SOB after cardiac cath and never had any
signs of symptoms of COPD exacerbation.
.
# Anxiety: Pt was continued on her home Citalopram and had no
problems with anxiety during her course.
.
TRANSITIONAL ISSUES: Pt was discahrged home with ASA 325, Plavix
75, Metoprolol, Nitro, Lipitor 80mg and nicotine patches as well
as her existing COPD meds. She was instructed on the importance
of continuing ASA/Plavix and was counseled extensively on
smoking cessation. She will follow up with Cardiology and her
PCP.
Medications on Admission:
Ipratropium Bromide 17- 2INH by mouth QID PRN
Fluticasone 110 mcg/Actuation- 2 INH [**Hospital1 **]
Budesonide-Formoterol (Symbicort)- 160-4.5- 2INH [**Hospital1 **]
Citalopram 10mg QAM
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day) as needed for
shortness of breath or wheezing.
6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
8. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 6 weeks.
Disp:*45 Patch 24 hr(s)* Refills:*0*
10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
11. Outpatient Lab Work
Please check labs at [**Location (un) 2274**] [**University/College **] on Friday [**7-12**]
Discharge Disposition:
Home
Discharge Diagnosis:
Non ST Elevation Myocardial Infarction
Chronic Obstructive Pulmonary disease
S/P Bunion Surgery
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 blockages were found in your right
coronary artery at [**Hospital **] Hospital. You were transferred to
[**Hospital1 18**] for a procedure to open the blocked artery and you had one
drug eluting stent and two bare metal stents placed in your
right coronary artery. It is crucially important that you take
aspirin and plavix every day to prevent the stents from clotting
off and causing another heart attack. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or
stop taking aspirin and plavix for any reason unless Dr.
[**Last Name (STitle) **] tells you it is OK. You had some bleeding from the
catheterization site and required two units of blood to replace
the blood that was lost. You are recovering well and have had no
further chest pain. During the catheterization, you received a
lot of contrast (dye) and we will check your kidney blood tests
on Friday to make sure that your kidneys are functioning well.
It is very important that you quit smoking in order to prevent
the arteries from developing blockages and causing another heart
attack. You have been given a prescription for a nicotine patch
to help with the cravings.
Please get your blood checked on Friday [**7-12**] at [**Location (un) 2274**] in
[**University/College **].
.
We made the following changes to your medicines:
1. Start taking aspirin 325 mg and Plavix 75 mg every day for at
least one year to prevent the stents from clotting off.
2. Start taking metoprolol to lower your heart rate and help
your heart recover from the heart attack.
3. Start taking a high dose of Lipitor (Atorvastatin) to lower
your cholesterol and help your heart recover.
4. Use nitroglycerin under your tongue as needed for chest pain.
Please take one pill, wait 5 minutes and you can take one more
pill if the chest pain is still there. Please call Dr.
[**Last Name (STitle) **] if you have any chest pain and take nitroglycerin.
5. Start nicotine patches daily to help you quit smoking.
Followup Instructions:
Primary care:
[**Doctor Last Name **],MAHMOODA [**Telephone/Fax (1) 17465**]. Date/Time: [**7-24**] at 1:40pm.
[**Location (un) 2274**] [**Location (un) 38**]
.
Cardiology:
You will have an appt with Dr. [**Last Name (STitle) **] in about a month, her
office will call you at home with an appt.
ICD9 Codes: 496, 4439, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1515
} | Medical Text: Admission Date: [**2136-5-17**] Discharge Date: [**2136-6-8**]
Date of Birth: [**2064-5-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
PTC - biliary drain
Multiple cholangiographies
ERCP
Embolization of hepatic artery
PICC placement
History of Present Illness:
Ms. [**Known lastname 11622**] is a 71 y/o F w/ DM2, pancreatic CA (dx'd [**3-31**]), who
was admitted on [**5-17**] after she had presented with biliary
obstruction. ERCP attempted [**5-17**] but unable to cannulate CBD. On
[**5-18**] the patient underwent placement of a percutaneous biliary
drain. She tolerated the procedure well and bili was trending
down. On [**5-18**] she began complaining of RUQ pain and Hct trended
down from 33 -> 28 -> 26.9 from [**Date range (1) **]. On the morning of
[**5-22**] Hct was seen to drop from 28.9 to 19.1 and pt became
hypotensive with sBP's in the 80's and HR in the 110's. She was
complaining of diffuse tenderness in her abdomen and had guaiac
positive brown stool. Transferred to ICU.
.
[**Hospital Unit Name 153**] brief course: A R subclavian line was attempted but not
successful, and R IJ was similarly unsuccessful. A cordis was
placed in the R groin and she received a total of 5 units pRBC's
over the next few hours (17->29). She was taken to IR but
pullback cholangiogram was normal. She was then taken for a pRBC
scan which revealed bleeding in the liver parenchyma.
Arteriogram performed w/ positive bleeding from pseudoaneurysm
at a posterior branch of the right hepatic artery. Successful
embolization of the lesion w/ 2 straight coils. She was given
another two units of packed red blood cells on morning of [**5-23**]
when hct dropped from 29 -> 22. Her hct remained stable
(31->32->27->29->29). Her CT abdomen [**5-23**] noon showed no
retroperitoneal bleed but did show hemoperitoneum and two
sources within the liver.
Past Medical History:
Type 2 DM with Retinopathy
h/o Gastric Ulcer as per [**3-/2136**] EGD, H. pylori (-)
HTN
Pancreatic CA underwent EUS at [**Hospital1 18**] with bx which demonstrated
mass in the head of the pancreas)
Hypercholesterolemia
.
Social History:
Retired cook, lives with dtr. 40pk-year tob history. No EtOH or
IV drug use.
Family History:
Father with HTN and Cancer; many Aunts with [**Name2 (NI) **].
Physical Exam:
: laying in bed, NAD
HEENT: NCAT, +Jaundiced
Neck: supple, JVD flat, no carotid bruits
Chest: crackles at bases
CVS: rrr, no m/r/g
Abd: soft, hypoactive bs's, RUQ drain in place
Extrem: no c/c/e
Neuro: CN II-XII intact
MSK: no joint effusions, normal ROM
Pertinent Results:
[**2136-6-8**] 06:30AM BLOOD WBC-26.9* RBC-3.24* Hgb-10.0* Hct-29.2*
MCV-90 MCH-30.8 MCHC-34.2 RDW-16.4* Plt Ct-397
[**2136-6-7**] 07:18PM BLOOD Hct-29.8*
[**2136-6-4**] 05:00AM BLOOD WBC-26.2* RBC-3.37* Hgb-10.2* Hct-30.3*
MCV-90 MCH-30.2 MCHC-33.6 RDW-16.1* Plt Ct-532*
[**2136-5-17**] 08:30AM BLOOD WBC-11.8* RBC-4.11* Hgb-11.7* Hct-34.5*
MCV-84 MCH-28.5 MCHC-34.0 RDW-16.0* Plt Ct-435
[**2136-5-22**] 04:39AM BLOOD WBC-17.3* RBC-2.26*# Hgb-6.7*# Hct-19.1*#
MCV-84 MCH-29.6 MCHC-35.1* RDW-17.1* Plt Ct-394
[**2136-6-2**] 06:22AM BLOOD PT-18.9* PTT-31.9 INR(PT)-1.8*
[**2136-6-8**] 06:30AM BLOOD Glucose-84 UreaN-33* Creat-1.2* Na-124*
K-5.0 Cl-86* HCO3-25 AnGap-18
[**2136-6-1**] 05:00AM BLOOD Glucose-82 UreaN-16 Creat-1.0 Na-129*
K-4.8 Cl-91* HCO3-26 AnGap-17
[**2136-5-17**] 05:20PM BLOOD Glucose-79 UreaN-18 Creat-0.8 Na-131*
K-3.8 Cl-94* HCO3-28 AnGap-13
[**2136-6-8**] 06:30AM BLOOD ALT-53* AST-127* AlkPhos-514*
TotBili-20.9*
[**2136-5-28**] 05:52AM BLOOD ALT-196* AST-94* AlkPhos-436* Amylase-30
TotBili-10.9*
[**2136-5-22**] 08:14AM BLOOD ALT-374* AST-875* AlkPhos-527*
TotBili-3.9*
[**2136-5-17**] 05:20PM BLOOD ALT-374* AST-260* AlkPhos-1177*
Amylase-78 TotBili-10.1*
[**2136-6-4**] 05:00AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.2
[**2136-5-31**] 06:06AM BLOOD Osmolal-261*
[**2136-5-21**] 07:30AM BLOOD Cortsol-28.0*
[**2136-5-21**] 07:30AM BLOOD TSH-0.72
[**2136-5-22**] 03:33PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
[**2136-5-22**] 03:37PM BLOOD HIV Ab-NEGATIVE
[**2136-5-17**] 05:54PM BLOOD CA [**47**]-9 -Test
[**2136-5-29**] 12:13PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005
[**2136-5-29**] 12:13PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-250 Ketone-NEG Bilirub-MOD Urobiln-NEG pH-7.0 Leuks-NEG
[**2136-6-2**] 04:18PM URINE Hours-RANDOM Creat-78 Na-17
[**2136-6-7**] 4:46 pm BILE
**FINAL REPORT [**2136-6-10**]**
GRAM STAIN (Final [**2136-6-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
FLUID CULTURE (Final [**2136-6-10**]):
YEAST, PRESUMPTIVELY NOT C. ALBICANS. MODERATE GROWTH.
[**2136-5-28**] 12:19 pm BILE
**FINAL REPORT [**2136-6-3**]**
GRAM STAIN (Final [**2136-5-28**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 109900**] 5PM [**2136-5-28**].
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2136-6-3**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
ENTEROCOCCUS SP.. HEAVY GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
ENTEROCOCCUS SP.. MODERATE GROWTH. 2ND STRAIN.
ENTEROCOCCUS SP..
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS. 3RD STRAIN.
GRAM POSITIVE RODS. GROWING IN BROTH ONLY.
UNABLE TO GROW FOR FURTHER IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| | ENTEROCOCCUS
SP.
| | |
AMPICILLIN------------ =>32 R <=2 S =>32 R
LINEZOLID------------- 2 S 2 S
PENICILLIN------------ =>64 R 8 S =>64 R
VANCOMYCIN------------ =>32 R <=1 S =>32 R
[**2136-5-22**] 8:14 am BILE
**FINAL REPORT [**2136-5-25**]**
GRAM STAIN (Final [**2136-5-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final [**2136-5-25**]):
RESEMBLING MICROCOCCUS/STOMATOCOCCUS SPECIES. MODERATE
GROWTH.
LACTOBACILLUS SPECIES. SPARSE GROWTH.
Cholangiogram -
IMPRESSION:
1. Pullback cholangiogram demonstrates biliary leak at the
posterior and inferior aspect of the right hepatic lobe with
extravasation of contrast into the abdominal cavity. There is no
communication with vascular structures.
2. Successful placement of a 10 French biliary catheter with
side holes draining the left biliary system and the common bile
duct. The pigtail was coiled within the duodenum. An ultrasound
of the abdomen is recommended in order to determine if there is
any abdominal collections in the right upper quadrant.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
PreliminaryApproved: [**Doctor First Name **] [**2136-6-7**] 2:28 PM
CT abdomen: IMPRESSION:
1. Contrast administered during recent cholangiogram collects at
the base of the liver extending subhepatically and represents a
biloma. Previously described heterogeneous hepatic
intraparenchymal lesions demonstrate hyperdense material within
and it is difficult to tell whether this represents bleeding or
recent contrast administration. Previously noted evolving
hemoperitoneum has decreased in size.
2. Poor evaluation of pancreatic head mass extending into
portahepatus and portal vein thrombosis without IV contrast.
3. Increased size of small right pleural effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: FRI [**2136-6-8**] 5:28 PM
Cholangiogram: IMPRESSION:
1. Cholangiogram via existing catheter demonstrates decompressed
intrahepatic ducts and good drainage of contrast through the
catheter into the duodenum.
2. 10 cc of bile were sent for culture analysis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Approved: [**Doctor First Name **] [**2136-5-31**] 11:25 AM
IMPRESSION: Active extravasation originating from the region
around the right liver edge. The findings were discussed with
Dr. [**Last Name (STitle) 15785**] by Dr. [**Last Name (STitle) **].
Brief Hospital Course:
72 F with Metastatic pancreatic cancer - with a complicated
hospital ourse -
1. Blood loss anemia - due to hemoperitoneum as a complication
of the procedur (PTC) - after transfusion, hepatic artery
branches were embolised with stoppage of bleeding. The
hematocrit remained stable thereafter.
2. Obstructive jaundice, s/p biliary drain placed by IR. After
initial decrease in bilirubin, the bili started rising and
peaked >20. Cholangigram showed a bile leak. The patient did not
want further interventions as her goal was home with hospice.
the cath was left in and hospice/VNA arranged for cath
checks/dressings.
3. Bile infection with micrococcus, VRE, yeast - to complete 2
weeks on linezolid, metronidazole and fluconazole as per our ID
service. Blood culures remained negative at the time of
discharge.
4. Leucocytosis - likely due to 3. above. No other source of
infection found.
5. SIADH - Na maintained in the mid-120's with 1 lit water
restriction/day.
6. Hypertension - po meds as below.
7. Metastatic pancreatic cancer - deemed inoperable by surgery.
Med oncology did not think chemo would be indicated unless the
current bleeding, infection clear up. The patient did not wish
any further treatment for cancer and her goal was to go home
with her family. She was disharged to her daghter, [**Doctor First Name 109901**] home
with hospice. Case management, SW, palliative care all involved
in a safe and appropriate discahrge plan. Pain control was
fairly well achieved. There was a concern that one of the
patient's son has psychiatric issues ([**Name (NI) 5656**]) and would
occasionally verbally abuse patient. SW involved and elder svcs
were contact[**Name (NI) **] who refused to take report as the patient was in
hospital. The patient was not dicharged to her home (where [**Doctor Last Name **]
lives) but to [**Doctor First Name **] (daughter's) home. Patient did not want to
file a restraining order against this son. Our palliative care
SW, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10794**] will relay this to the hospice palliative care
SW.
The above was communicated to Dr [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 42604**] (PCP) on the
[**Last Name (un) **] of discharge.
Medications on Admission:
Metformin
Lisinopril
Avandia
Glipizide
ASA
Plavix (recently held)
Prilosec
Insulin (15-20U) qam
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO every [**6-1**]
hours as needed for constipation.
Disp:*3 ML(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. 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:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
7. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO QID (4 times a day) as needed.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-27**]
Drops Ophthalmic Q4H (every 4 hours) as needed.
Disp:*2 * Refills:*0*
9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
13. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous before breakfast every morning.
Disp:*3 * Refills:*0*
14. [**Hospital 12106**]
Hospital bed,
Bedside commode,
Shower chair
Discharge Disposition:
Home With Service
Facility:
[**Hospital 109902**] HealthCare of [**Location (un) 86**]
Discharge Diagnosis:
Metastatic pancreatic cancer
Blood loss anemia
Obstructive jaundice, s/p biliary drain
Bile infection with micrococcus, VRE, yeast
Leucocytosis
SIADH
Acute renal failure
Hypertension
Discharge Condition:
Fair
Discharge Instructions:
Please contact the hospice services or your primary doctor if
you have worsening pain or any other symptoms of concern to you.
Take medicines as prescribed.
Followup Instructions:
Provider: [**Name10 (NameIs) 1948**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2136-6-22**] 12:30
Provider: [**Name10 (NameIs) **] WEST,ROOM THREE GI ROOMS Date/Time:[**2136-6-22**] 12:30
If you decide on further treatment for cancer - call Dr [**Last Name (STitle) **] and
make a follow up appointment -- [**Telephone/Fax (1) 13006**].
Dr [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 109903**] - your primary doctor will care for your
further medical needs.
ICD9 Codes: 2851, 5849, 4271, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1516
} | Medical Text: Admission Date: [**2111-3-24**] Discharge Date: [**2111-4-6**]
Date of Birth: [**2048-2-19**] Sex: F
Service: VSU
CONTINUED...
Patient was discharged to rehabilitation in stable condition.
She should follow up with Dr. [**Last Name (STitle) **] in one to two weeks. She
should follow up with her orthopedic surgeon upon discharge
from rehabilitation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3186**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2111-4-6**] 16:56:26
T: [**2111-4-6**] 18:29:59
Job#: [**Job Number 61142**]
ICD9 Codes: 2851, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1517
} | Medical Text: Admission Date: [**2150-8-29**] Discharge Date: [**2150-9-2**]
Date of Birth: [**2077-9-5**] Sex: M
Service: MEDICINE
Allergies:
Enalapril
Attending:[**First Name3 (LF) 15519**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 year old male with h/o type 2 diabetes mellitus who presented
with hyperglycemia, hypertension and seizure. Up until one day
prior to admission, he had been feeling well, then on the day of
admission he noted that his right hand was shaking. That night
he had lethargy, no focal symptoms, just not feeling well and
ate dinner with his wife. [**Name (NI) **] then went to bed. His wife checked
on him at about 21:30 and found him in tonic-clonic seizure.
He was brought to the ED by EMS his VS on arrival were 98.9,
130, 192/122, 17 96%NRB. Got head CT and had another seizure on
the way back from CT. Glucose was critically high. He was
given 2mg ativan, 10 units IV insulin, decadron, ceftriaxone,
and vancomycin. LP was done. He was also given 2.5 liters of
normal saline. Neuro saw him and felt his seizures were most
likely secondary to hyperglycemia, but checked LP and there was
no evidence of infection. LFTs normal. Pt. was noted to be
"post-ictal" in the ED, not responding to commands.
On the floor, he is following commands, but still lethargic and
delerious.
Past Medical History:
- Diabetes mellitus type II, dx'ed 15-20 years ago, followed at
[**Last Name (un) **]
- Chronic renal insufficiency, Cr baseline 1.8-2.2
- Hypertension, patient states BPs in 130s/70s
- Colon cancer, s/p resection
- Gout (proven with joint fluid analysis)
- Cataracts
- Secondary hyperparathyroidism
- Cholelithiasis
- Mild Diastolic Dysfunction
Social History:
Originally from [**Country 2045**], the patient has lived in [**Location 86**] for 40+
years. He retired as a CPA, and lives at home with his wife. His
children are grown. He manages his ADLS. He used tobacco for 5
years many years ago, occasional social alcohol, no IVDU.
Family History:
Family hx of hypertension. Pt denies family hx of CAD, stroke,
cancer.
Physical Exam:
Vitals- BP: 198/108 P: 108 R: 16 100% RA
Gen- AOx 2 says that year is [**2076**], well appearing, well
nourished, NAD
HEENT- NC/AT, EOMI, PERRL, fleks of blood on lower lip. No
tongue lesions noted.
Neck: supple, JVP not elevated
Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial,
DP/PT pulses
Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no
supraclavicular or subcostal retractions
Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding,
no organomegaly, negative [**Doctor Last Name 515**] sign
Skin- no rashes, lesions
Extremities/Spine: extremities warm and well perfused, no
clubbing, cyanosis, trace lower extremity edema
Neurologic: no focal deficits, CN II-XII intact, moving all 4
extremities independently, but only intermittently following
commands.
Pertinent Results:
LABORATORY DATA:
[**2150-8-28**] 11:10PM WBC-6.7 RBC-4.20* HGB-11.4* HCT-36.4* MCV-87
MCH-27.2 MCHC-31.4 RDW-16.7*
[**2150-8-28**] 11:10PM PLT COUNT-137*
[**2150-8-28**] 11:10PM GLUCOSE-663* UREA N-37* CREAT-2.8*
[**2150-8-28**] 11:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-8-28**] 11:10PM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-133* TOT
BILI-0.2
[**2150-8-28**] 11:10PM LIPASE-37
[**2150-8-28**] 11:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-8-29**] 03:00AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1*
POLYS-17 LYMPHS-33 MONOS-50
[**2150-8-29**] 03:00AM CEREBROSPINAL FLUID (CSF) PROTEIN-32
GLUCOSE-276
CSF:
GRAM STAIN (Final [**2150-8-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2150-9-1**]): NO GROWTH.
IMAGING:
[**2150-8-28**] CT head: No acute hemmorhage. MRI is more senitive for
acute ishemia.
[**2150-8-29**] CXR: Mild volume overload
EEG: This is a mildly abnormal extended routine EEG due to low
voltage of the background rhythm with diffuse beta activity.
There were
no focal, lateralized, or epileptiform features noted.
EKG: Sinus tachycardia, rate 127. There are slight non-specific
ST-T wave changes in leads I, II, aVF and leads V4-V6. Consider
left atrial abnormality. Compared to the previous tracing of
[**2149-3-22**], except for the change in rate, no other diagnostic
interval change.
MRI/MRA Brain:
1. Motion-limited head MRI and MRA.
2. No acute infarction. New chronic microvascular infarcts since
[**2142**].
3. Unremarkable head MRA.
Brief Hospital Course:
72 year old male with history of type 2 diabetes mellitus who
presented with hyperglycemia, hypernatremia, hypertension and
seizures. He was originally admitted to the MICU and once
stabilized, was transferred to the floor.
# Seizures: He presented with two seizures in the setting of
severe hyperglycemia. He had a lumbar puncture and his CSF did
not suggest meningitis or encephalitis. His tox screen was
negative. His seizures could also have been secondary to
hyperosmolality due to both hyperglycemia and hypernatremia. He
had altered mental status after his seizures which cleared prior
to discharge. He had an MRI with no acute changes (although it
did show chronic microvascular infarcts). He also had an EEG
that showed no epileptiform activity. Neurology followed the
patient while he was in the hospital, and recommended to start
dilantin if he were to have another seizure in the future. The
patient was advised not to drive for 6 months. He is scheduled
for outpatient follow-up in epilepsy clinic.
# Hyperglycemia: On admission, his blood sugars were so high
they could not be measured. He was initially on an insulin drip
and then rapidly switched to NPH and sliding scale insulin. His
blood sugars remained slightly labile during the rest of his
admission, and he was transitioned back to his home regimen. It
is not clear what incited this hyperglycemic episode, as he
reports no history of medication or diet changes, recent
insomnia, or recent illness. On discharge, he was instructed to
keep a blood sugar diary and check his blood sugars at least
three times daily.
# Hypertension: Upon arrival to the ICU, he had hypertension
with systolic blood pressures in the 190-200's. Quickly after
admission, his hypertension resolved and he was restarted on his
home medications. He had one episode of relative hypotension
with BP of 100/60 after receiving his morning medications.
Therefore, his clonidine was switched to an evening medication.
He was continued on minoxidil, valsartan, and metoprolol at his
home dosing regimens.
#. Hypernatremia: He was hypernatremic on admission and for a
2-3 days after admission with a serum Na of 145-147. This was
likely caused by osmotic diuresis from his hyperglycemia. Also
there was likely some contribution by impaired access to free
water with change in mental status. Seizures can also cause
intracelluluar osmole generation and transient hypernatremia.
Free water intake was encouraged and his sodium level returned
to normal range by the time of discharge.
#. Diastolic CHF: He has a history of diastolic heart failure
but was thought to be volume depleted on admission. His
torsemide was held throughout the hospitalization and at
discharge.
#. Chronic renal insufficiency: He has a baseline creatinine of
about 2.1 (although fluctuates substantially) and his creatinine
was elevated on admission to 2.8. His urine electrolytes were
consistent with a prerenal etiology and his creatinine came back
to baseline with rehydration.
#. Gout: His allopurinol was initially held due to concern for
worsening renal failure, but he was started back on his home
dose at discharge.
#. Prophylaxis: He was given subcutaneous heparin for DVT
prophylaxis
#. Code Status: He was full code during this hospitalization
Medications on Admission:
-Allopurinol 300 mg once a day on Mon, Wed, Fri and 200mg qd
on other days
-Clonidine 0.3 mg Tablet 1 Tablet(s) by mouth once a day
-Insulin Glargine 9 units at bedtime
-Insulin Lispro
-Metoprolol Tartrate 50 mg Tablet 1 Tablet(s) by mouth twice a
day
-Minoxidil 10 mg Tablet 1 Tablet(s) by mouth twice a day
-Paricalcitol 4 mcg Capsule 1 Capsule(s) once a day
-Simvastatin 20 mg Tablet once a day \
-Torsemide [Demadex] 20 mg Tablet once a day
-Valsartan 160 mg Tablet q day
-Ascorbic Acid 500 mg Tablet once a day
-Aspirin 81 mg Tablet, once a day (OTC)
-Multivitamin with Iron-Mineral once a day
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO once a
day: Take 300mg daily on Monday, Wednesday, and Friday.
2. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day:
Take 200mg daily on Tuesday, Thursday, Saturday, and Sunday.
3. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO at bedtime.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Insulin Glargine 100 unit/mL Solution Sig: 9 (nine) units
Subcutaneous at bedtime.
6. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale
Subcutaneous three times a day: Please take insulin per sliding
scale as you were doing prior to hospitalization.
7. Minoxidil 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Zemplar 4 mcg Capsule Sig: One (1) Capsule PO once a day.
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Multivitamin with Iron-Mineral Capsule Sig: One (1)
Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Seizures
Hypertension
Diabetes Mellitus
Secondary Diagnosis:
Chronic diastolic heart failure
Discharge Condition:
Good, vital signs stable, ambulating independently
Discharge Instructions:
You were admitted to the hospital with seizures. Your sugar was
found to be very high, which may have contributed to your
seizure. You were evaluated by neurology, and you underwent an
MRI/MRA to evaluate for any acute pathology. You were found to
have very tiny strokes which can be a complication of renal
disease and diabetes. You will follow up with the neurologists
in their clinic.
Weigh yourself every morning, call Dr. [**First Name (STitle) **] if your weight is
increased by 3 lbs or more.
Changes to your medications:
STOPPED torsemide temporarily. If you experience swelling in
your legs, you should restart this medication at your home dose
(20 mg Tablet once a day by mouth)
CHANGE clonidine from 0.3mg by mouth every morning to 0.3mg by
mouth every evening. Start taking this dose on [**2150-9-3**].
You should also check your blood sugars three times per day and
use insulin as you were at home before you were admitted to the
hospital. You should write your blood sugars in a diary and
bring it with you to your follow-up appointment with Dr. [**First Name (STitle) **].
If you find that your blood sugars are higher than normal, you
should call Dr. [**First Name (STitle) **]. If you experience any shaking,
increasing thirst, or increased urination, you should check your
blood sugar. You should also call your primary care doctor. If
you experience any chest pain, shortness of breath, or seizures,
you should call 911 and go to the nearest hospital
You should NOT DRIVE for at least 6 months since you've had a
seizure.
Followup Instructions:
You have the following appointments scheduled:
Primary care:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone: [**Telephone/Fax (1) 250**] Date/Time:
[**2150-9-9**] 9:50
Neurology:
Provider: [**First Name11 (Name Pattern1) 3292**] [**Last Name (NamePattern1) 3293**], MD Phone:[**Telephone/Fax (1) 44**]
KS [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), 4TH
FLOORDate/Time:[**2150-9-16**] 1:00
ICD9 Codes: 5849, 2760, 5859, 4280, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1518
} | Medical Text: Admission Date: [**2201-2-27**] Discharge Date: [**2201-3-10**]
Date of Birth: [**2122-4-8**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Oxycodone / Dilaudid
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Delerium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 y/o F with PMHx of CAD s/p MI/PTCA & recent BMS [**1-17**],
systolic HF (LVEF 45-50%, MGUS, recent c.diff infxn, seen by her
PCP on day of admission and found to be delerious with labs,
showing new hyponatremia (127), hypercalcemia (12.2), and acute
on chronic renal failure (Cr 2.4 up from baseline Cr 1.8-2.0).
She was sent to ER where family also reported worsening back
pain, also some cough with white "spit".
The family reported to the PCP that the patients mental status
had been clouded for several months and that the presentation
was typical of this new baselin.
Denied any fever, chills, or SOB prior to admission. At the time
of admission she reported no dysuria, N/V, abd pain, hematuria,
or diarrhea. Recently her oncologist had been concerned about
development of multiple myeloma.
In the ED she was afebrile, and VSS were stable. CXR showed a ?
LLL infiltrate vs atelectasis, wbc count normal. She was given
Levaquin 750mg IV and admitted to the floor.
Past Medical History:
1) HTN
2) CAD s/p MI with PCTA in [**2190**] @ [**Hospital1 2025**], s/p PCI [**2198**] with stent
to LAD, RCA totally occluded and filled by collaterals
3) Breast cancer B Masectomy in [**2175**]
4) B/L ORIF
5) R Olecranon fracture
6) Ulnar nerve surgery x 3
7) Pulmonary stenosis s/p valvuloplasty in [**2183**]
8) s/p appendectomy
9) MGUS BM in [**3-15**] nml flow with 5% plasma cells; receives
transfusion on regular basis
10) H/o anxiety
11) Hypercholesterolemia
12) GERD
13) Recent c.dif infection treated with Flagyl/PO Vanco
([**1-/2201**])
14) CRI - baseline Cr 1.8-2.0
Social History:
Significant for the absence of current tobacco use. There is no
history of alcohol abuse. 1 daughter in CT and 1 daughter in [**Name2 (NI) **].
Family History:
Father died of heart disease in this 40s.
Sister-congenital pulmonary stenosis
Physical Exam:
ON ADMIT
T:98.0 BP:134/79 P:111 RR:20 O2 sats:100% on RA
Gen: Elderly, frail female in Resp distress, on NRB, confused,
+rigors
HEENT: NCAT, PERRL, EOMI, Anicteric, MM dry
Neck: JVP difficult to assess [**3-14**] rigors
CV: Reg, nml s1,s2.
Resp: Crackles throughout (anteriorly)
Abd: Soft, NTND, NABS
Ext: No c/c/e
Neuro: Oriented to person, but not place/time
Pertinent Results:
Stool: positive for c diff
CXR: possible consolidation atelectasis
SPEP consistent with multiple myeloma
Serum viscosity within normal
Skeletal survey with many lytic lesions
MRI of l and t spine and CT of L spine and pelvis without
fracture. Diffuse myelomatous invasion of bones (entire spinal
cord, pelvis)
Serum lambda and kappa pending
Brief Hospital Course:
#C diff colitis: No response to Flagyl and so started on po
vancomycin with good response. Plan to continue vancomycin with
taper.
#Pneumonia: On hospital day # 3 became sob and febrile. At same
time pt was in acute chf, as well as septic, though possibly
from c diff colitis. Given CXR with consolidation v atelectasis
and severity of illness, started on zosyn for possible HAP.
Planned 10 day course of Zosym with final day on [**3-11**]. Midline
placed for access.
#Acute on chronic systolic CHF: On hospital day #3 pt became
hypoxic after blood transfusion (receives chronic transfusions
for anemia assoc w/ MGUS), transferred to ICU for monitoring,
did not require intubation; managed well with IV lasix daily.
# Delerium: Multifactorial, hypercalcemia, sepsis, and finally
from dexamethosone treatment for multiple myeloma; resolved with
treatment.
# Multiple myeloma: Spep/upep c/w new dx of multiple myeloma.
Heme/onc team consulted and recommended to start treatment with
dexamethasone 40 mg q wk. Pt received first treatment of
dexamethasone [**2201-3-4**]. Follow up to be arranged via. pt.s
oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2539**] - this discussed with oncology team
and with pt.s daughter and health care proxy. Instructions
below.
# Pain - pain team consulted. No focal area on imaging
indicating indication or utility of focal, palliative,
irradiation, or injection. Recommended fentanyl patch.
# High TSH low T4, during acute illness. Will need repeat check
once acute infectious process treated and resolved; as TFTs not
reliably interpretable in acute illness.
Medications on Admission:
asa 325mg daily
colace
furosemide 20mg daily
saline nasal spray prn
senna
Lidoderm
Lipitor 80mg daily
MVI
tylenol prn
metoprolol SR 150mg daily
pantoprazole 40mg daily
propoxyphene 65mg q6hrs -hold if lethargic
Discharge Medications:
1. Dexamethasone 4 mg Tablet Sig: Forty (40) mg PO Q Wednesday
for 3 doses.
Disp:*30 tablets* Refills:*0*
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u
Injection at bedtime.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for low back pain: apply to area of pain over the right
SI joint. Adhesive Patch, Medicated(s)
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets 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).
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) as needed for pain.
9. pipercillin-tazobactam
2.25g IV q 8 hours with last day of treatment [**2201-3-11**]
10. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**6-20**]
MLs PO Q6H (every 6 hours).
14. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q2H (every 2 hours) as needed.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
16. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO twice a
day for 35 days: as follows:
1 capsule [**Hospital1 **] for 7 days;
1 capsule QD for 7 days;
1 capsule QOD for 7 days;
1 capsule Q 3 days for 14 days.
17. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
20. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
21. Furosemide 10 mg/mL Solution Sig: Two (2) mL Injection DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
multiple myeloma widely metastatic to bones diffusely
heart failure (acute on chronic systolic)
acute renal failure
c diff colitis
Discharge Condition:
stable
Discharge Instructions:
Please call your PCP with increasing shortness of breath, fever,
dizziness, or other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2201-3-13**] 9:30
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of oncology will contact pt's daughter [**Name (NI) 5627**]
directly during the week of [**3-8**] - [**3-13**] to notify her of
appointment time/day, and name of her assigned physician in
[**Name9 (PRE) 20722**]; if you have not heard from him, call Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2539**] to find out when and who will be following up with
you, at: ([**Telephone/Fax (1) 16387**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
ICD9 Codes: 5849, 486, 2930, 2761, 4280, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1519
} | Medical Text: Admission Date: [**2123-2-26**] Discharge Date: [**2123-3-3**]
Date of Birth: [**2052-2-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71M with MMP including CHF, afib, CAD, and COPD and multiple
admissions to [**Hospital1 18**] (recently D/C'd [**2-15**] from [**Hospital Unit Name 196**]/MICU for
admission for CHF/chest pain) found at HebReb to have change in
MS and O2 sat 76-80% RA. In [**Name (NI) **], pt initially placed on 3L O2:
91% then dropped to 86%. ABG initially 7.3/44/66, pt placed on
bipap: 7.24/50/90. Per previous DC summaries, pts base ABG is nl
(no hypercarbia). She was noted to have thick yellow sputum. At
some pt in ED, BP dropped and ED team unable to find pulse. LIJ
attempted, but unsuccessful. R groin line placed and pt started
on dopamine and levophed. Lactate in ED 1.5. UA positive and pt
started on empiric coverage with Vanc, Levo, flagyl. CXR showed
CHF. Cr elevated at 2.9 from baseline 0.8-1.2.
Pt was transferred to the [**Hospital Unit Name 153**] on [**2-25**], where she was treated
for her hypotension with pressors and IVF (7 L). She was also
continued on vanc/levo/flagyl for emperic treatment of sepsis
while cultures were pending. Pt was off pressors on [**2-28**] and
transferred to medical floor.
During medical evaluation pt revealed that she may have had
diarrhea for 2 weeks prior to admission, however, [**Hospital **] rehab
was unable to corroberate since no evidence that pt had diarrhea
there. During this hospitalization, pt was found to be c.
difficile toxin positive.
Past Medical History:
1. CHF diastolic dysfunction (EF 65% 1/05 MIBI normal)
DRY WEIGHT 194 lbs
2. DM 2 on insulin
3. Atrial Fibrillation
4. Anemia
5. CAD s/p PTCA x 3 (RCA '[**09**], LCx '[**10**], RCA '[**13**])
6. Pulmonary HTN
7. Hypercholesterolemia
8. COPD/[**Year (2 digits) 105496**] on home O2 (sometimes on home O2)
9. Thyroid CA s/p resection/now hypothryoid
10. Myoclonic tremors
11. H/O PE
12. OSA on CPAP (started last admission)
13. Depression/Anxiety
14. h/o MRSA/VRE. ICU admit x 2 for MRSA aortic valve
endocarditis and pseudomonal sepsis (secondary to wound
infection), status post intubation x 2.
15. S/p laproscopic cholecystectomy
[**34**]. s/p right throcoscopy and decortication. Right lung bx.
17. s/p right hip ORIF
18. s/p right ankle ORIF
Social History:
Pt is divorced with three children. Former CPA. Quit smoking in
[**2104**] after a history of 1 ppd x 15 years. No etoh. No drugs.
Family History:
F: Died at 47 of MI; M: Colon ca; brother with DM
Physical Exam:
Physical exam upon transfer to medical floor: WEIGHT 204
V/S Tm 99.7 BP 109-169/50-70 P 95-120 RR 24 O2 sat 88-99%, at
time of transfer 91% on 4L
Gen: awake, alert, oriented x 3, REJ in place
Lungs: scattered wheezing in all lung fields
Heart: irregularly irregular
Abd: obese, soft, +bs, mild tenderness in all quadrants
ext: bilateral hyperpigmentation of LE, 1+ pitting edema, L 1st
toe ulcer, L heel ulcer, RLE shin ulcer
Pertinent Results:
INR on [**3-2**]- 3.0 on 2mg coumadin
CXRAY [**2123-2-27**]- The cardiac silhouette is mildly enlarged, but
stable. There is upper zone [**Month/Day/Year 1106**] redistribution, perihilar
haziness, and a bilateral interstitial pattern which has
progressed in the interval compared to the previous study. There
is a small right pleural effusion.
at admission:
EKG: Atrial fibrillation with a controlled ventricular response.
[**2123-2-25**] 10:25PM WBC-6.4 RBC-3.47* HGB-9.5*# HCT-29.6*# MCV-85
MCH-27.3 MCHC-32.0 RDW-15.4
[**2123-2-25**] 10:25PM ALBUMIN-3.1*
[**2123-2-25**] 10:25PM LIPASE-23
[**2123-2-25**] 10:25PM ALT(SGPT)-42* AST(SGOT)-69* ALK PHOS-100
AMYLASE-14 TOT BILI-0.2
[**2123-2-25**] 10:25PM GLUCOSE-121* UREA N-46* CREAT-2.9*#
SODIUM-130* POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-14
Brief Hospital Course:
Pt is a 71 yo female with mult medical problems including afib,
chf, CAD, DM who presents from the [**Hospital Unit Name 153**] with resolved
hypotension, and hypoxia. Now treat for C.diff colitis (most
likely from recent tx with levaquin).
Diarrhea- cdiff +
-po flagyl (continue for six days post discharge)
-IV vanco/flagyl and levaquin d/c'd after transfer to medical
floor
-we did not give IV fluid since she looked overloaded on exam
Hypoxia- was on 4L NC in [**Hospital Unit Name 153**] weaned down to 2l on floor. She
was placed on bipap at night (10,5,3L) in [**Hospital Unit Name 153**] but refused it on
the medical floor.
-d/c'd levaquin since did not seem to have clinical pneumonia
-given nebulization treatments to help with the her sob/wheezing
with good result
The initial hypoxia that brought her to the hospital was never
revealed, perhaps as a result of refusing bipap although in
house her saturation was okay without bipap at night.
Sepsis is a possibility- perhaps from her picc line that was
placed many months ago
-PICC was d/c'd on this admission
Hypertension- on ace and bb as outpt, held due to hypotension
initially but restarted bb and ace when on medical floor
Afib- was continued on amioderone, beta blocker, coumadin
ARF- Cr now normalized with fluids (baseline .8-1.2)
-we restarted lasix on transfer to medical floor
CHF- noted to have JVD, 1+ pitting edema so lasix was restarted
Leg ulcers- chronic superficial ulcer on right calf, left big
toe, and l heel, +MRSA
-tx'd with vit c/zinc/collagenase
-dressing changes and bactroban
-wound care consult was familiar with pt and recommended
aquacell ag, adaptic on left big toe, dry dressing on L heel
-podiatry cut her toenails since they were causing skin
breakdown
S/p thryoidectomy for thyroid ca
-continued synthroid
Neuro/pain-
-we continued fentanyl patch
-we also continued oxycodone, neurontin (renally dosed), topomax
DM
-was placed on insulin ss, lantus
Code on this admission was DNI, but pt DOES want to be
resuscited.
Medications on Admission:
Meds on admission:
1. Aspirin 325 mg PO qD
2. Amiodarone HCl 200 mg PO qD
3. Simvastatin 20 mg PO qD
4. Gabapentin 900 mg Capsule PO BID
5. Ferrous Sulfate 325 (65) mg PO qd
6. Lansoprazole 30 mg PO qD
7. Citalopram Hydrobromide 60 mg PO qD
8. Multivitamin Capsule qD
9. Topiramate 25 mg PO qD
10. Methylphenidate HCl 10 mg PO qAM
11. Methylphenidate HCl 5 mg PO qnoon
12. Levothyroxine Sodium 200 mcg PO qD
13. Warfarin Sodium 3.5 mg PO qHS
14. Lisinopril 5 mg PO qD
15. Furosemide 40 mg PO qD
16. Miconazole Nitrate 2 % Powder TP [**Hospital1 **]
17. Metoprolol Tartrate 25 mg PO TID
18. Oxycodone HCl 5-10 mg PO Q4-6H prn
19. Albuterol INH q6 prn
20. Ipratropium Bromide INH q6 prn
21. Fentanyl 25 mp patch q 72h
22. Insulin Glargine 15U qHS
23. Insulin Lispro SS
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary diagnoses
1. c. difficile diarrhea
2. hypoxia
Secondary diagnoses.
1. CHF diastolic dysfunction (EF 65% 1/05 MIBI normal)
2. DM 2 on insulin
3. Atrial Fibrillation
4. Anemia
5. CAD s/p PTCA x 3 (RCA '[**09**], LCx '[**10**], RCA '[**13**])
6. Pulmonary HTN
7. Hypercholesterolemia
8. COPD/[**Year (2 digits) 105496**] on home O2 (sometimes on home O2)
9. Thyroid CA s/p resection/now hypothryoid
10. Myoclonic tremors
11. H/O PE
12. OSA on CPAP (started last admission)
13. Depression/Anxiety
14. h/o MRSA/VRE. ICU admit x 2 for MRSA aortic valve
endocarditis and pseudomonal sepsis (secondary to wound
infection), status post intubation x 2.
15. S/p laproscopic cholecystectomy
[**34**]. s/p right throcoscopy and decortication. Right lung bx.
17. s/p right hip ORIF
18. s/p right ankle ORIF
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
Please take all your medications as prescribed. You have been
treated for c. difficile infection with flagyl. Please call
your doctor immediately if you have diarrhea. Please come to the
ED if you have chest pain, shortness of breath or any other
concerning symptoms.
Followup Instructions:
Please check your INR each week
Please follow up with Dr. [**Last Name (STitle) **] in 1 week
Call [**Telephone/Fax (1) 250**] for an appointment as soon as you leave the
hospital.
Other appointments:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2123-3-2**] 10:30
Completed by:[**2123-3-4**]
ICD9 Codes: 5849, 5990, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1520
} | Medical Text: Admission Date: [**2164-6-3**] Discharge Date: [**2164-6-5**]
Date of Birth: [**2086-10-6**] Sex: M
Service: TRAUMA SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 77-year-old
male status post a fall off a bicycle over the handlebars,
hitting his face and head with loss of consciousness,
hemodynamically stable on transfer. The only complaint is
facial pain and lip pain. No abdominal pain or chest pain.
No extremity pain.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Atrial fibrillation.
3. Status post cardioversion.
4. Mild aortic insufficiency.
5. History of recurrent prostatitis.
PAST SURGICAL HISTORY: Cyst removal as a child, per the
patient.
ADMISSION MEDICATIONS:
1. Aspirin 325 mg p.d.
2. Univasc 7.5 mg q.d.
3. Atenolol 12.5 mg q.d.
4. Prozac 10 mg p.o. q.d.
5. Citrucel p.r.n.
6. Ciprofloxacin p.r.n.
7. Multivitamins.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a nonsmoker, nondrinker.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The vital
signs were stable. The patient had multiple facial lacs and
lip lacerations. Chest: Clear. Heart: Regular rate and
rhythm. Abdomen: Soft. Extremities: Positive pulses. No
deformities noted. Rectal: Normal tone. Grossly positive
Guaiac. Back: Mild lumbar tenderness. No deformities
noted. Neck: Nontender. Neurologic: GCS 15. No defects
noted.
LABORATORY/RADIOLOGIC DATA: White count 7.3, hematocrit
37.3, platelets 236,000. Electrolytes were within normal
limits as were his coagulations. Amylase slightly elevated
at 113. The patient was tox negative. The U/A was 69 red
blood cells, [**2-22**] white blood cells, occasional bacteria.
The chest x-ray was negative.
Pelvic was negative.
Head CT had a small subarachnoid bleed, anterofrontal
bilaterally.
CT of the spine was negative.
Abdominal CT was negative.
T&L spine was negative.
HOSPITAL COURSE: Neurosurgery was consulted and recommended
neurologic checks and repeat CT scan of the head which showed
that the subarachnoid hemorrhage was not worsened. A CT of
the face was done which showed no fractures. The patient's
diet was advanced. The patient was with good p.o. pain
control and ambulating well. The patient was felt to be
ready for discharge with a follow-up. The patient is to be
following up with Dr. [**Last Name (STitle) 665**] in one week for workup for
Guaiac positive stool. Also, Dr. [**Last Name (STitle) **] for Cardiac
Services for reevaluation. Trauma Surgery Clinic with Dr.
[**Last Name (STitle) **] for suture removal and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/Dr. [**First Name (STitle) **] for
neurology follow-up.
DISCHARGE MEDICATIONS:
1. Bacitracin to apply topically to his facial wounds t.i.d.
2. Standard over the counter pain medications.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Status post traumatic closed head injury after a fall
from a bicycle.
2. Small subarachnoid hemorrhage.
3. Lip laceration.
4. Multiple small lacerations and contusions.
5. Transient hyperamylasemia.
6. Other comorbidities as above, including atrial
fibrillation, recurrent prostatitis, hypertension, coronary
artery disease with aortic insufficiency, and cyst removal as
a child, and paroxysmal atrial fibrillation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2164-6-8**] 04:55
T: [**2164-6-16**] 19:43
JOB#: [**Job Number **]
cc:[**Last Name (STitle) 93361**]
ICD9 Codes: 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1521
} | Medical Text: Admission Date: [**2173-6-14**] Discharge Date: [**2173-6-23**]
Date of Birth: [**2102-11-22**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 70-year-old male with
no known previous diagnosed coronary artery disease and a
history of diabetes mellitus who was transferred from [**Hospital6 27375**] for cardiac catheterization after he
developed shortness of breath with difficulty breathing. He
had been noticing increasing dyspnea on exertion. When he
presented to [**Hospital 4199**] Hospital he was found to be in
congestive heart failure. He was then started on Lasix, an
ACE inhibitor and enteric coated aspirin. It was thought
that the shortness of breath was secondary to ischemia. The
patient was transferred to [**Hospital6 2018**] on the [**2-14**] for a cardiac catheterization for
subsequent work up after he had an electrocardiogram that
showed recent T-wave inversions in V4 to 6. The patient had
noticed a prior episode about two weeks before presentation
and again six months prior. The patient had had no chest
pain, palpitations, diaphoresis, nausea or vomiting.
PAST MEDICAL HISTORY:
1. Diabetes mellitus
2. Hypertension
3. Hypercholesterolemia
4. Vitiligo
5. Chronic renal insufficiency
6. Anxiety
MEDICATIONS ON PRESENTATION:
1. Lipitor 20 mg q hs
2. Enalapril 25 mg [**Hospital1 **]
3. Metoprolol 50 mg [**Hospital1 **]
4. Aspirin 325 mg po qd
5. Lorazepam prn
6. Lovenox 80 mg [**Hospital1 **]
PHYSICAL EXAM:
VITAL SIGNS: His temperature was 97.3??????, pulse 66, blood
pressure 175/85, saturating 97% on three liters O2 by nasal
cannula.
APPEARANCE: Pleasant middle aged white male lying
comfortably in bed.
NECK: Jugular venous distention about 7 cm, no carotid
bruits.
LUNGS: Slight basilar crackles bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, nontender, 2+ groin pulses, no bruits.
EXTREMITIES: Trace bilateral edema.
LABS: His white blood count was 9.0, hematocrit 36.5,
platelets count 163. PT 13.3, PTT 41.9, INR 1.2, calcium
8.8, magnesium 1.7, phosphate 3.9. ALT 9, AST 9. His
troponin was 0.22. His CKs were negative.
IMAGING: Electrocardiogram showed normal sinus rhythm, no
ischemic STs. Echocardiogram done on the [**2-15**] showed
an ejection fraction of 30% with left ventricular
hypertrophy. Cardiac catheterization done the [**2-15**]
showed three vessel coronary artery disease. He was taken to
the Operating Room on [**2173-6-17**] where a five vessel
coronary artery bypass graft was performed. He tolerated the
procedure well. It was found postoperatively that the
patient was found postoperatively to have some upper and
lower extremity weakness with decreased bilateral hand grips.
Over the course of the next few days, his neurologic status
noted some improvement, however he continued to have some
clumsiness on his left side. Neurology was consulted and he
was thought to have had a perioperative stroke. Head CT was
performed and he a had a bilateral complex duplex study done.
Head CT showed multiple chronic lacunar infarcts with a
possible lesion in the right parietal area. Carotid duplex
showed greater than 90% right ICA stenosis with significant
plaque and 60% to 69% stenosis on the left internal carotid
artery with moderate plaque. The patient was continued on
aspirin which he had been on pre and postoperatively. He was
transfused to keep his hematocrit above 30 and blood pressure
was managed above 140 systolic. The patient otherwise had an
uncomplicated postoperative recovery with respect to his
cardiac status and is found to be stable for discharge to an
acute rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Status post five vessel coronary bypass grafting
2. Perioperative stroke
3. Diabetes mellitus
4. Hypertension
5. Hypercholesterolemia
6. Vitiligo
7. Chronic renal insufficiency
FOLLOW UP: The patient is to follow up with vascular surgery
in three weeks and follow up with neurology, Dr.
[**Last Name (STitle) 623**], #[**Telephone/Fax (1) **], in six to eight weeks. The patient
is to follow up with Dr. [**First Name (STitle) 10102**] in three to four weeks.
DISCHARGE MEDICATIONS:
1. Lipitor 20 mg q hs
2. Enalapril 25 mg [**Hospital1 **]
3. Aspirin 325 mg po qd
4. Lovenox 80 mg subcutaneous [**Hospital1 **]
5. Colace 100 mg po bid
6. Captopril 12.5 mg po qid
7. Lopressor 75 mg po bid
8. Tylenol 650 mg po q4h prn pain
9. Milk of Magnesia 30 mg po q hs prn
10. Lorazepam 0.5 mg po q8h prn anxiety
The patient has been accepted at the On [**Location (un) **] Nursing and
Rehabilitation Center which should receive a copy of this
dictation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13625**]
Dictated By:[**Last Name (NamePattern1) 27376**]
MEDQUIST36
D: [**2173-6-23**] 11:39
T: [**2173-6-23**] 12:39
JOB#: [**Job Number 27377**]
cc:[**Location (un) 27378**]
ICD9 Codes: 4280, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1522
} | Medical Text: Admission Date: [**2125-10-10**] Discharge Date: [**2125-10-31**]
Date of Birth: [**2072-11-5**] Sex: F
Service:
ADDENDUM:
DISCHARGE MEDICATIONS: Synthroid 100 micrograms po q.d.,
vitamin E 400 units po q day, Protonix 40 mg po q.d., Colace
100 mg po q.d., Miconazole powder b.i.d. to affected areas.
Regular insulin sliding scale, NPH 18 units subQ b.i.d.,
Haldol 1 to 2 mg po intravenous IM q 2 to 4 hours prn
agitation. Tylenol 650 mg po q 4 to 6 hours prn. Benadryl
25 mg po q 4 to 6 hours prn.
The patient will follow up with her outpatient psychiatrist
Dr. [**First Name (STitle) **] [**Name (STitle) 67071**] in two weeks. The patient will also follow
up with her primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] in one
to two weeks after discharge from rehab.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 97811**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2125-10-31**] 11:41
T: [**2125-10-31**] 11:45
JOB#: [**Job Number 96089**]
ICD9 Codes: 5849, 486, 5990, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1523
} | Medical Text: Admission Date: [**2131-5-20**] Discharge Date: [**2131-5-24**]
Date of Birth: [**2064-6-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Gastrointestinal bleed
Major Surgical or Invasive Procedure:
Right Internal Jugular central line placement and removal
History of Present Illness:
Mr. [**Known lastname 916**] is a 66 year old man with DM, CAD, s/p recent STEMI,
Ischemic cardiomyopathy LEVF 25%, errosive gastritis, and colon
polyps who is admitted from [**Hospital **] rehabilitation for 1 week of
black stool, and a slow hct drop. According to the report HCT
trend: 30 ([**5-15**]) -> 27 ([**5-19**])->22 today and he was transferred
to the emergency department.
.
In the ED, initial vs were: T: not recorded, P:92 BP:120/69
RR:28 Sa02:100% FiO2: 40%. He subsequently spiked to T:102.6.
Labs were remarkable for HCT 20.9, WBC 6.7 83.2% Lactate 2.4, Cr
1.5, UA positive. Patient was given Vanc/zosyn, pantoprazole
drip and 80mg bolus, and a RIJ was placed, GI was consulted who
recommended non-urgent scope, and to continue pantoprazole 40mg
IV BID vs drip. Not transfused in the ED. VS prior to transfer:
T99.8 HR 84 122/67 22 on vent 100% AC 450x12 Peep 5 fi02 50%
.
On arrival to the ICU, T:99.9 BP: P:84 R: 18 O2:100% AC 450x12
50% FiO2. He reported that his breathing is comfortable, denies
chest pain. He complained of pain at the site of his saccral
decubitis.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills. Denied shortness of breath. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting.
.
Of note patient was hospitalized recently in the MICU [**Date range (1) 29015**].
He was admitted for STEMI, urosepsis and hypotension. STEMI was
medically managed with heparin, plavix, asa, statin, ECHO showed
newly depressed EF to 25% with wide LV hypokinesis. He grew VRE
from blood and urine and was treated with daptomycin, meropenem
and linezolid. He was intubated for increased work of breathing
and treated for heart failure and VAP however the MICU team was
unable wean him off of the vent, he is s/p trach and PEG.
Hospital course was also complicated by pulseless VT x4 managed
with synchronized cardioversion and amiodarone. Goals of care at
end of hospital course were DNR, do not escalate care
Past Medical History:
Ventilator dependent last vent settings PSV 12/5 ATC 40% Fio2
Coronary Artery Disease c/b STEMI [**4-/2131**] medically managed
Ventricular tachycardia s/p cardioversion
Ischemic cardiomyopathy LVEF 25% [**4-/2131**]
Erosive esophagitis c/b recurrent GI bleeds
Bilateral CEA
Diabetes mellitus
Sacral Decubitis
BL heel pressure ulcers
Chronic kidney disease baseline creatinine 1.4-1.6
PVD: mild-moderate aorto-[**Hospital1 **]-ilac disease as noted in [**2119**]
GERD
Colonic polyps
VRE UTI
MRSA Pneuomonia
Hyperlipidemia
Macular Degeneration
Chronic back/leg pain secondary to DJD
Essential Tremor
Peripheral Neuropathy
s/p Left and Right Total hip replacements
COPD
Depression
Social History:
Denies current tobacco use (h/o 20+ pack year, quit 15-20 years
ago) Admits to approximately 2+ beers most nights of the week.
Denies h/o illicit drug use. Resident at [**Hospital1 **] health.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAMINATION
Vitals: T:99.9 BP: P:84 R: 18 O2:100% AC 450x12 50% FiO2 CVP:16
General: Alert; follows simple commands
HEENT: Tracheostomy in place on ventilator tube in place; MMM,
PERRL
Neck: supple, JVP elevated at 10cm, Right IJ catheter in place
Lungs: Left basilar rales, otherwise clear to auscultation in
posterior lung fields.
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Back: Deep sacral decubitis ulcer with packing in place
GU: Foley in place
Ext: Right lower ext cool to touch, left warm to the touch.
Radial pulses 1+ BL. Bilateral R>L heel ulceration with granular
base and eschar; no exudates/purulence visible; 1+ pedal edema
Pulses:
Right PT palpated, DP not dopplerable
Left PT and DP dopplerable
DISCHARGE EXAM:
T96.2, HR66 BP135/69, RR21, 100% on pressure support 8cm/5cm,
RR20,Fi02 40%
General: Alert; follows simple commands
HEENT: Tracheostomy in place on ventilator tube in place; MMM,
PERRL
Neck: supple, Right IJ catheter in place
Lungs: Bibasilar rales on anterior/lateral auscultation
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Ext: Cool, 1+ radial pulses, bandages over heels b/l, trace
pedal edema
Pertinent Results:
ADMISSION LABS:
[**2131-5-20**] 06:45PM BLOOD WBC-6.7 RBC-2.17* Hgb-6.9* Hct-20.9*
MCV-96 MCH-31.7 MCHC-33.0 RDW-17.9* Plt Ct-157#
[**2131-5-20**] 06:45PM BLOOD Neuts-83.2* Lymphs-11.4* Monos-4.3
Eos-0.7 Baso-0.5
[**2131-5-20**] 06:45PM BLOOD PT-14.3* PTT-37.1* INR(PT)-1.2*
[**2131-5-20**] 06:45PM BLOOD Glucose-155* UreaN-82* Creat-1.5* Na-147*
K-3.8 Cl-99 HCO3-36* AnGap-16
[**2131-5-20**] 06:45PM BLOOD ALT-96* AST-73* LD(LDH)-249 CK(CPK)-22*
AlkPhos-125 TotBili-0.4
[**2131-5-20**] 06:45PM BLOOD Calcium-8.3* Phos-5.3*# Mg-2.7*
[**2131-5-20**] 06:45PM BLOOD Hapto-380*
[**2131-5-20**] 07:08PM BLOOD Lactate-2.4*
CARDIAC ENZYMES
[**2131-5-20**] 06:45PM BLOOD CK-MB-1 cTropnT-0.49*
.
DISCHARGE LABS:
[**2131-5-24**] 03:17AM BLOOD WBC-8.5 RBC-3.36* Hgb-11.2* Hct-32.3*
MCV-96 MCH-33.2*# MCHC-34.6# RDW-17.8* Plt Ct-175
[**2131-5-24**] 03:17AM BLOOD Plt Ct-175
[**2131-5-24**] 03:17AM BLOOD PT-14.3* PTT-38.7* INR(PT)-1.2*
[**2131-5-24**] 03:17AM BLOOD Glucose-74 UreaN-66* Creat-1.6* Na-148*
K-3.3 Cl-104 HCO3-31 AnGap-16
[**2131-5-24**] 03:17AM BLOOD Calcium-8.0* Phos-4.3 Mg-2.3
[**2131-5-21**] 04:29AM BLOOD Lactate-1.1
.
IMAGING:
[**5-20**] CXR
1. Interval placement of right internal jugular central venous
catheter
terminating in the proximal to mid SVC, without evidence of
pneumothorax.
2. Bilateral layering pleural effusions, increased, with
overlying
atelectasis, underlying consolidation not excluded. Additional
peripheral
right upper lobe patchy opacity may be due to additional site of
infection
and/or aspiration. Pulmonary edema. Cardiomegaly.
.
[**5-21**] TTE
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is severely depressed (LVEF= 25-30
%) secondary to akinesis of the inferior and posterior walls,
and hypokinesis of the interventricular septum. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular free wall is hypertrophied.
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. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Severe (4+) 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.] There
is a small pericardial effusion. There are no echocardiographic
signs of tamponade. Compared with the findings of the prior
study (images reviewed) of [**2131-4-9**], there has been marked
progression of mitral and tricuspid regurgitation (both of the
functional ischemic classification) consistent with the natural
history of this patient's recently documented untreated
extensive inferior posterior and right ventricular myocardial
infarction.
Brief Hospital Course:
HOSPITAL COURSE
66yo chronically-ventilated M PMH recent STEMI, ischemic
cardiomyopathy LEVF 25%, errosive gastritis, a/w slow upper
gastrointestinal bleed and PNA, bleeding stabilized without
surgical/endoscopic intervention, started on high-dose cefepime
for MDR psuedomonal PNA, clinical status improving with patient
discharged to ECF.
.
ACTIVE
# GI Bleed: Patient w h/o errosive gastritis on EGD [**2-/2131**], who
presented w downtrending HCT (30 to 20.9), guaiac + stool.
Patient received 3 units pRBCs w stabilization of Hct in low
30s. Patient was continued on IV PPI and started on carafate.
HCT stabilized (>48 hours) without invasive intervention and GI
service opted not to scope.
.
# Respiratory Failure [**3-7**] PNA and Chronic Systolic CHF:
Ventilator dependent patient [**3-7**] MRSA pneumonia [**4-/2131**] and heart
failure, with pulmonary infiltrates on admission. Sputum grew
out psuedomonas with sensitivities demonstrating carbapenem
resistance. Per ID recommendations, patient was started on high
dose extended infusion cefepime. ID fellow [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**]
agreed to follow up further micro data on patient. He was
continued on home lasix, nebulizers.
.
# Coronary artery disease c/b ischemic cardiomyopathy: Patient
with recent STEMI [**4-/2131**] that was medically managed (given his
prior bleeds) with ASA, plavix, and a statin, who was w/o signs
ischemia on admission, but w signs c/w worsening failure. Given
some hypotension on admission, metoprolol dosing was decreased.
TTE demonstrated LVEF 25%, 4+MR. Cardiology was consulted, who
recommended started ACE-I. If he remained stable, they also
recommended starting spironolactone (not started at discharge,
recommended to start at ECF).
.
INACTIVE
# h/o VT: Patient was continued on amiodarone.
.
# DM: Patient was continued on standing glargine and sliding
scale insulin
.
# Thrombocytopenia: Patient continued to have thrombocytopenia
on this admission. Heparin antibody was negative in prior
admission. On discharge platelets 175.
.
# Sacral decubitis: Patient with deep sacral decubitis,
bilateral heel ulcers. Followed by wound care during inpatient
stay. Should be followed at rehab center.
.
TRANSITIONAL
1. Code status: Patient remained DNR for duration of hospital
stay
2. Pending: At time of discharge, additional sensitivities for
psuedomonas (doripenem and colistin) were pending. ID fellow
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6137**] would follow-up.
3. Transition of Care: Patient discharged to [**Hospital1 **], with
follow-up planned with heart failure clinic.
4. Barriers to Care: Recurrent GI bleeds have had major effect
on patient management (rehospitalizations, inability to manage
STEMI w cath), and may necessitate recurrent transfusions or
future readmissions
Medications on Admission:
acetaminophen 650 mg/20.3 mL Oral Soln Q6H PRN
albuterol sulfate HFA 90 mcg 6 puffs Q6-8 hrs PRN
amiodarone 400 mg daily
ascorbic acid 500 mg daily
atorvastatin 80 mg Daily
Chlorhexedine 0.12% 12mL Q12H
Diphenhydramine 25mg Q4H PRN itching
Diphenhydramine cream 1appl Q8H PRN
Docusate 100mg [**Hospital1 **]
Glucerna 1.2 tube feed 75ml/H
furosemide 80 mg IV BID
collnaagese clostridium histolyticum 250 unit/g Ointment Topical
[**Hospital1 **]
insulin glargine 14 QHS
insulin regular Sliding scale
Ipratropium/Albuterol 3mL Q2H PRN
Lorazepam 1mg Q8H PRN
metoprolol tartrate 75 mg Q8H
pantoprazole 40 mg IV BID
sucralfate 1 gram 4x daily
Polyethylene glycol 17g daily
free water 200cc Q6H
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. Pantoprazole 40 mg IV Q12H
6. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
8. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H
(every 12 hours): to be infused over 3 hours.
9. Furosemide 80 mg IV BID
Hold for SBP<90; please contact MD if going to hold.
10. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) Inhalation q2h as needed for
shortness of breath or wheezing.
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day). Tablet(s)
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
16. insulin glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime.
17. Sliding Scale
Regular Insulin Sliding Scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY
Hospital Acquired Pneumonia
SECONDARY
GI Bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 916**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with decreasing blood levels,
likely due to bleeding from your gastrointestinal tract.
You were transfused with red blood cells. Your blood levels
returned to [**Location 213**] levels, and remained stable for 3 days. We
discussed your care with gastroenterologists who felt that you
did not need to have an endoscopy as long as your blood levels
remained stable.
Given your recent history of a heart attack and heart failure,
we discussed your case with cardiologists, who felt that certain
medications should be started to help your heart function.
You were found to have a pneumonia with a very resistant
bacteria called psuedomonas. You were seen by infectious
disease doctors, who started you on a strong antibiotic called
cefepime that you will need to continue for 2 weeks.
During the course of this hospitalization, the following changes
were made to your medications:
-DECREASED metoprolol to 50mg [**Hospital1 **]
-STARTED cefepime (to be continued for 13 days)
-STARTED captopril
-STARTED aspirin
-STARTED sucralfate
Followup Instructions:
Name: [**Last Name (LF) **], [**Name8 (MD) **] NP
Location: [**Hospital1 18**] DIVISION OF CARDIOLOGY
Address: [**Location (un) **], E/RW-453, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
We are working on a follow up appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
NP within 1-2 weeks. You will be called with the appointment. If
you have not heard from the office within 2 days or have any
questions, please call the number above.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5990, 2760, 2851, 4280, 5859, 2875, 496, 2724, 2768, 4240, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1524
} | Medical Text: Unit No: [**Numeric Identifier 70045**]
Admission Date: [**2130-12-16**]
Discharge Date: [**2131-1-12**]
Date of Birth: [**2130-12-16**]
Sex: F
Service: NB
HISTORY: [**First Name9 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Known lastname 5936**]-[**Known lastname **] was born at 32 and 5/7
weeks and admitted to the newborn intensive care unit with
respiratory distress and prematurity. She was born at 32 and
5/7 weeks to a 37-year-old gravida 2, para 0, 2, 2 mother.
[**Name (NI) **] [**2131-2-5**].
Prenatal labs included a blood type A negative, antibody
negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune and group B strep negative.
Pregnancy was intrauterine insemination assisted resulting in
a di-di twin gestation. Pregnancy was uncomplicated until
mother presented on [**12-3**], with premature prolonged
rupture of membranes. She was found to be having preterm
contractions without cervical change and was admitted for bed
rest. She was treated with magnesium sulfate, betamethasone
and erythromycin C for latency. She had some transient
elevations in blood pressures but was without proteinuria.
Ultrasound remained reassuring. Biophysical profile 8 out of
8. On the evening prior to delivery, the mother developed
increased preterm contractions, uterine tenderness and a
mildly elevated fetal heart rate. Due to concern for
developing chorioamnionitis, she was brought for cesarean
section delivery. There were no interpartum antibiotics.
At delivery this twin, twin B, emerged with moderate tone and
weak cry, responding to stimulation and blow-by oxygen.
Apgars were 7 at 1 and 8 at 5 minutes with mild respiratory
distress and the infant was transported to the NICU.
PHYSICAL EXAMINATION: Weight 1665 grams, 25th to 50th
percentile; head circumference 29 cm, 25th percentile; length
43 cm, 25th to 50th percentile. GENERAL: A well developed
premature infant, active with examination. Moderate
respiratory distress at rest. Overall appearance consistent
with estimated gestational age. HEENT: Mild positional
deformity of left side concavity, fontanel soft and flat.
Sutures approximate. Ears, nares normal. Nondysmorphic,
intact palate, positive red reflex noted bilaterally. NECK:
Supple. No lesions. CHEST: Coarse symmetric moderate
aeration. Mild grunting. Mild retractions. CARDIAC: Regular
rate and rhythm. No murmur or gallop. Femoral pulses of 2+
and equal. ABDOMEN: Soft. No hepatosplenomegaly. No masses.
Quiet bowel sounds. Three-vessel cord. GENITOURINARY: Normal
female. Anus patent. EXTREMITIES: Hips and back normal. No
lesions. NEUROLOGIC: Appropriate tone and activity for
gestational age. Symmetric Moro.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Month (only) **]
demonstrated mature lungs and remained comfortable in room
air from admission to the NICU. She developed apnea of
prematurity and had up to 2 to 3 apneic episodes daily which
resolved spontaneously without the use of methylxanthine. She
has been spell free for 5 days.
CARDIOVASCULAR: She remained hemodynamically stable with AP's
130s to 160s, blood pressure 60/32 with a mean of 42.
Infant has had an intermittent murmur, which was not appreciated
on discharge exam today but will need to be followed. Infant
initially had an IV access via double lumen UVC line which was
placed upon admission and remained in place through day 6 for
parenteral nutrition administration.
FLUIDS, ELECTROLYTES AND NUTRITION: Initially [**Month (only) **] was
maintained NPO, total fluids of 80 per kg with PN and D10W.
She was euglycemic upon admission and remained so as feeds
were advanced and IV fluids were decreased. She started
feeding on day of life 1 with expressed breast milk or
Similac Special Care 20 and increased 10 cc per kg twice a
day reaching full enteral volume by day of life 7. Thereafter
calories were increased to a maximum of breast milk 26
calories with Beneprotein utilizing human milk fortifier and
MCT oil. On day of life 13 she was noted to have some frank
blood in her stool. She had a KUB at that time which was
normal. CBC and blood culture were drawn which were
reassuring and feeds were reassumed, however 2 days later, on
day of life 15, there was gross blood in the stools. [**Month (only) **]
was again made NPO. CBC and blood culture were obtained.
There was mild temperature elevation to 100.1. CBC showed
increased I to T ratio with a white blood cell count of 6.4,
41 polys, 9 bands, 31 lymphs and 5 metamyelocytes. Hematocrit
was 35% and platelets were mildly elevated at 715,000. Serial
KUBs were obtained which remained normal. She was kept NPO
for a period of 48 hours on repeat CBC demonstrated
significant eosinophilia with resolved bandemia. Given the
presentation and the eosinophilia, it was felt that the
bloody stools were due to milk protein allergy. Therefore
feeds were resumed with breast milk and fortified with
Nutramigen powder. These have been well tolerated and the
stools have been heme negative since that time. Of note the
mother is a vegetarian and has a diet that is with a large
concentration of dairy products which she has been instructed
to modify. Discharge weight is 2210g.
GASTROINTESTINAL: The baby was treated with single
phototherapy from day 2 through day 5 with a peak bilirubin
of 7.1/0.3. With initiation of phototherapy, this problem is
now resolved.
HEMATOLOGY: [**Month (only) **] was started on supplemental iron when full
feeds were achieved and continues on that at the time of
discharge with a dose of 0.4 cc po q day.
INFECTIOUS DISEASE: Initially a CBC and blood culture were
drawn. There was relative neutropenia with an ANC of 612
which resolved on subsequent CBC on day of life 2. Blood
cultures remained sterile. Ampicillin and gentamycin were
administered for the first 48 hours and discontinued at that
time. As aforementioned when [**Month (only) **] was made NPO on day of
life 15, a repeat sepsis assessment was undertaken during
which time she received 48 hours of ampicillin and
gentamycin, discontinued for negative cultures and improved
clinical course.
NEUROLOGIC: [**Month (only) **] has remained appropriate for gestational
age in terms of her examination.
SENSORY: Audiology, hearing screen was performed with
automated auditory brain stem responses which was passed.
OPHTHALMOLOGY: An eye examination was not indicated at this
gestational age.
PSYCHOSOCIAL: Mother is married and quite involved and
invested in these twin girls. The sister of this baby was
discharged a few days ago and is doing well at home.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66546**] of [**Hospital **]
Pediatrics.
CARE RECOMMENDATIONS:
1. Feed at the time of discharge is breast milk fortified
with Nutramigen powder to 24 calories per ounce.
2. Medications: Fer-In-[**Male First Name (un) **]. Elemental iron 0.4 ml by mouth
each day.
3. Car seat position screening was done and the baby passed
this screening test as well.
4. State newborn screen was done on day of life 3 and more
recently on day of life 14 which was [**12-30**]. REsults
are pending and will need to be followed by the pediatrician.
5. Immunizations received: Initial Hepatitis B vaccine given
on [**1-7**].
6. Immunizations Recommended:
Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following three criteria.
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with two of the
following: daycare during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities,
or school age siblings or with chronic lung disease.
Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
Follow up appointments recommended are:
1) primary pediatrician on Monday.
2) hip ultrasound at 4-6 weeks of age due to breech in utero
positioning
3) VNA on Sunday. [**2131-1-14**]
DISCHARGE DIAGNOSES:
1. Premature twin No. 2 at 32 and 5/7 weeks.
2. Sepsis suspect ruled out.
3. Presumed Milk protein allergy.
4. Breech presentation at risk for congenital hip dysplasia.
5. Physiologic jaundice, resolved
6. Anemia of prematurity, resolved
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) 61558**]
MEDQUIST36
D: [**2131-1-11**] 22:36:14
T: [**2131-1-12**] 00:00:12
Job#: [**Job Number 70046**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1525
} | Medical Text: Admission Date: [**2166-11-7**] Discharge Date: [**2166-11-8**]
Date of Birth: [**2108-5-7**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
elective admission
Major Surgical or Invasive Procedure:
cerebral angiogram with stent and coiling of aneurysm
History of Present Illness:
thisis a 58 year old man who was electively admitted for coiling
of basilar aneurysm
Past Medical History:
basilar aneurysm
Social History:
Works as a window installer; primary language is Portuguese
Family History:
Unknown
Physical Exam:
on the day of admission10/12/[**2166**]: neurologically intact
On the day of discharge10/13/[**2166**]: neurologically intact - angio
site right groin intact no eccymosis, or hematoma, pedal pulses
are present.
patient ehibits full strength
sensation intact
pupils equal and reactive
face symetric
Pertinent Results:
[**2166-11-7**] 10:45AM PT-12.0 PTT-29.3 INR(PT)-1.1
[**2166-11-7**] 10:45AM PLT COUNT-337
[**2166-11-7**] 10:45AM WBC-7.8 RBC-4.95 HGB-15.5 HCT-43.8 MCV-89
MCH-31.4 MCHC-35.5* RDW-12.8
Brief Hospital Course:
The patient is a 58 year old man who was electively admitted on
[**2166-11-7**] for a cerebral angiogram and coiling and stenting of
his basilar aneurysm. The procedulre was performed by Dr [**Known firstname **]
and tolerated well. The patient was recovered in the intensive
care unit and stayed there overnight on a heparin intravenous
gtt. The patient was initiated on Aspirin 325 mg daily and
plavix 75 mg daily for his coiling and stent. The heparin gtt
was discontinued in the morning. The patient remained
neurologically intact throughout his hospital course. The
patient was able to tolerate a regular diet and ambulate
independently and was discharged to home.
Medications on Admission:
unknown
Discharge Medications:
1. Aspirin 325 mg PO DAILY
first dose tonight
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*5
2. Atorvastatin 10 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY for 1 month post coiling and
stenting of aneurysm Duration: 30 Days
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule by mouth twice a
day Disp #*30 Capsule Refills:*0
5. Finasteride 5 mg PO DAILY
6. Senna 1 TAB PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
7. Methocarbamol 500 mg PO TID
8. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-27**] tablet(s) by mouth q 6-8 Disp #*40 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
basilar aneurysm
Discharge Condition:
the patient is neurologically intact
strength is full
sensation is full
pupils are equal and reactive
face is symetric
patient is alert and oriented to person/place and time
Discharge Instructions:
Angiogram with Embolization and Stent placement
Dr. [**First Name8 (NamePattern2) **] [**Known firstname **]
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily indefinitely.
?????? Take Plavix (Clopidogrel) 75mg once daily for 1 month.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
please call Dr [**First Name8 (NamePattern2) **] [**Known firstname **] office for an appointment to be
seen in 2 months with a MRI/MRA per Dr [**Known firstname **] protocol You may
call to make an appointment at [**Telephone/Fax (1) 1669**].
Completed by:[**2166-11-8**]
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1526
} | Medical Text: Admission Date: [**2116-10-19**] Discharge Date: [**2116-10-21**]
Date of Birth: [**2043-3-17**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Post-cardiac arrest
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 12129**] is a 73yoF with h/o bipolar d/o on Lithium who is
transferred from OSH s/p cardiac arrest. Patient is currently
unable to provide history, therefore details of HPI are obtained
from family and OSH records. Per pt's family, pt had c/o
flu-like sx a week ago, with URI sx and cough. Had also had
progressive DOE for past few weeks, to the point that she became
dyspneic when walking from her apartment to parking lot (~100
feet). No h/o cardiac disease, however recently had stress test
which was reportedly negative and was scheduled to see
cardiologist this week. Today the elevator in her apartment
building was broken, and when walking up 2 flights of stairs to
her apartment she became extremely SOB and called for help. EMS
was called, started CPAP but she did not tolerate it, became
agitated, then became bradycardic and suffered asystolic arrest.
CPR was started and she receieved epi 1mg x3 and lidocaine 100
in field then was taken to OSH. At OSH ED received atropine x2
and additional epi x4. Total time to ROSC estimated 25 minutes.
She received chilled saline at OSH and was transferred to
[**Hospital1 18**], with T 33.9 en route.
In the ED, initial VS were T 33F, HR 85, BP 90/40 on dopa 20mcg
and epi 12.5mcg. GCS 3, not responding to commands but
withdrawing to painful stimuli. Labs were notable for pH 6.94,
pCO2 64, HCO3 15, lactate 9.9. EKG showed sinus rhythm with LAD
and RBBB, low voltage. (Of note initial ECG at OSH had anterior
STE, but resolved.) Bedside TTE showed no RV enlargement,
global hypokinesis with depressed LVEF, c/w post-arrest. No
significant valvular disease. FAST exam negative. CTA showed no
PE but large bibasilar consolidations c/w aspiration pna.
Post-arrest consult team was consulted for initiation of arctic
sun cooling protocol. Epi gtt was increased to max, and she was
started on neo gtt. She received IV vancomycin 1g x1, IV
cefepime 2g x1, and IV levofloxacin 500mg x1. She was admitted
to MICU for arctic sun cooling protocol.
.
On arrival to the MICU, she is intubated and sedated. Vitals T
32.2F, HR 103, BP 97/70, O2 sat 94% on 100% FIO2.
Past Medical History:
-Bipolar disorder
-Severe asthma requiring hospitalizations years ago, no
exacerbations for many years (not currently treated)
Social History:
Per family, pt lives in [**Hospital3 4634**] but is very independent
with ADLs. Occ smoking (1 pack per month), no EtOH or drug use.
Family History:
Notable for CAD in patient's parents and siblings, but no known
h/o sudden cardiac death.
Physical Exam:
Admission Exam:
Vitals T 32.2F, HR 103, BP 97/70 (on dopamine/epi/neo gtt), O2
sat 94% on 100% FIO2.
HEENT: NCAT, pupils fixed at 5mm bilaterally
Chest: Quiet breath sounds anteriorly, symmetric
Cardiovascular: RRR, nl S1 S2, no m/r/g
Abdominal: soft NTND, RUQ surgical incision scar
Extremities: Cool, no clubbing/cyanosis/edema
Neuro: Not following commands, not responsive to painful
stimuli
Pertinent Results:
Admission Labs:
[**2116-10-19**] 07:00PM BLOOD WBC-15.6* RBC-3.80* Hgb-12.1 Hct-41.2
MCV-108* MCH-31.8 MCHC-29.4* RDW-11.5 Plt Ct-276
[**2116-10-20**] 01:42AM BLOOD Neuts-86* Bands-5 Lymphs-8* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2116-10-19**] 07:00PM BLOOD PT-15.1* PTT-60.5* INR(PT)-1.3*
[**2116-10-20**] 01:42AM BLOOD Glucose-364* UreaN-19 Creat-1.1 Na-139
K-4.4 Cl-112* HCO3-14* AnGap-17
[**2116-10-20**] 01:42AM BLOOD ALT-189* AST-348* AlkPhos-77 TotBili-0.4
[**2116-10-20**] 09:56PM BLOOD ALT-430* AST-515* LD(LDH)-1438*
AlkPhos-28* TotBili-0.4
Cardiac enzymes:
[**2116-10-20**] 08:45AM BLOOD CK(CPK)-1424*
[**2116-10-20**] 04:32PM BLOOD CK(CPK)-1221*
[**2116-10-20**] 08:45AM BLOOD CK-MB-87* MB Indx-6.1* cTropnT-1.48*
[**2116-10-20**] 04:32PM BLOOD CK-MB-77* MB Indx-6.3* cTropnT-0.96*
Lithium Level:
[**2116-10-20**] 08:45AM BLOOD Lithium-0.4*
Serum tox:
[**2116-10-19**] 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CT HEAD W/O CONTRAST [**2116-10-19**]
FINDINGS: There is no evidence of acute hemorrhage, edema, mass
effect, or
recent infarction. The ventricles and sulci are age appropriate
in
appearance. Areas of periventricular and subcortical white
matter hypodensity likely reflect sequela of chronic small
vessel ischemic disease. No concerning osseous lesion or
fracture is identified. There are air-fluid levels within the
nasopharynx and mild mucosal thickening of the ethmoid air
cells, compatible with intubation. The mastoid air cells are
grossly clear. There is minimal mucosal thickening of the right
maxillary sinus.
IMPRESSION: No evidence of acute intracranial process.
CTA CHEST [**2116-10-19**]
FINDINGS: There are massive bilateral dependent consolidations.
Additionally, within the aerated portions of the lungs, there
are bilateral ground-glass opacities extending from the hila.
Additional nodular opacities are likely related to acute
process, though no prior exams are available for comparison.
A small amount of free air is noted along the left base. While
this is not
clearly localized, there is suggestion on coronal images
(601B:24-26) that the collection is above the diaphragm and
within the pleural space.
The pulmonary arterial tree is well opacified and no filling
defect to suggest pulmonary embolism is seen. No evidence of
acute aortic syndrome is identified. There are coronary artery
calcifications. No pericardial
effusion is seen.
The patient is intubated with the endotracheal tube tip low
lying at the level of the carina. Additionally, the balloon of
the endotracheal tube appears hyperinflated. There is a
left-sided subclavian central venous catheter with tip reaching
the SVC.
An esophageal catheter is in place, incompletely imaged;
however, coursing to the stomach at least.
No lymphadenopathy is identified.
The left thyroid lobe is enlarged. Limited views of the upper
abdomen
demonstrate at least two calcified splenic artery aneurysms.
Bone windows demonstrate a nondisplaced sternal fracture
(602B:34), which may be related to chest compressions.
IMPRESSION:
1. Massive bilateral dependent consolidations, compatible with
aspiration. Ground-glass opacities consistent with pulmonary
edema.
2. Air collection at the left base felt more likely above the
diaphragm
representing small pneumothorax vs bulla as opposed to contained
within the peritoneum. In comparison with prior radiographs of
the chest, it appears this was present prior to placement of
central line.
3. Low-lying endotracheal tube with tip at the level of the
carina and
hyperinflation of the endotracheal tube balloon.
4. Enlargement of the left thyroid lobe.
5. Non-displaced sternal fracture may be related to chest
compressions.
TTE [**2116-10-20**]
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with distal septal hypokinesis. The remaining segments contract
normally (LVEF = 45%). The right ventricular cavity is
moderately dilated with focal hypokinesis of the apical free
wall. 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.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Dilated right ventricle with mild systolic
dysfunction. Mild regional left ventricular systolic
dysfunction. Mild mitral regurgitation. Moderate pulmonary
hypertension.
Brief Hospital Course:
Primary Reason for Hospitalization:
73yo F with history of bipolar d/o transferred from OSH s/p
asystolic cardiac arrest, likely secondary to respiratory
etiology.
Brief Hospital Course:
Ms. [**Known lastname 12129**] presented after witnessed episode of respiratory
distress of unclear etiology which progressed to asystolic
cardiac arrest. Per EMS records, CPR was started in field and
ROSC occured after 25 minutes of pulselessness. Post-cardiac
arrest hypothermia protocol was initiated at OSH and she was
transferred to [**Hospital1 18**] for continued management. On arrival to
[**Hospital1 18**] she was intubated, cooled to 33 degrees F and was
requiring maximum dose of 3 pressors (neo, levo, VPA) to
maintain blood pressure. She became progressively hypoxic and
acidotic on CMV ventilation despite max vent support with 100%
FIO2 and PEEP 24. Rewarming was started at 1600 on [**10-20**]. She
had continuous EEG monitoring per hypothermia protocol which
showed evidence of seizure activity, and she was loaded with IV
keppra. On [**10-21**] she became bradycardic and was noted to be
pulseless. A code blue was called for pulseless arrest and CPR
was initiated. Rhythm showed asystole, received epi 1mg x3, 1
amp NaHCO3. Attending physician met with patient's family, who
decided to terminate resuscitation. Time of death was declared
at 1:39AM. [**Location (un) 511**] Organ Bank notified, declined patient as
donor. Medical examiner was notified and declined autopsy.
Medications on Admission:
lithium carbonate 300 mg Tab Oral 1 Tablet(s) [**Hospital1 **] -> recently
changed to daily
lorazepam 0.5 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
fluvoxamine 50 mg Tab Oral 1 Tablet(s) Once Daily -> just
discontinued
nabumetone 500 mg Tab Oral 1 Tablet(s) as directed
propranolol 10 mg Tab Oral 1 Tablet(s) Twice Daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory arrest
Cardiac arrest
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 5070, 2762, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1527
} | Medical Text: Admission Date: [**2166-1-3**] Discharge Date: [**2166-1-6**]
Date of Birth: [**2116-4-12**] Sex: M
Service: CSU
Mr. [**Known lastname **] is a 49-year-old man with known mitral valve
disease, referred for cardiac catheterization, which was done
on [**2165-12-30**], and showed no angiographically-apparent
coronary artery disease with a EF (ejection fraction) of 67
percent. There is 3+ MR (mitral regurgitation, no pulmonary
hypertension with an LVEDP (left ventricular end diastolic
pressure) of 19 and a wedge of 13. The index was 4.6 liters
per minute.
HISTORY OF PRESENT ILLNESS: This is a 49-year-old HIV
positive man with a history of mitral valve disease followed
over the years, last echo showing an EF of 60 percent with an
LV that was moderately dilated and trace AI (aortic
insufficiency), moderate to severe mitral prolapse and 4+ MR
(mitral regurgitation) and trivial TR (tricuspid
regurgitation). A cardiac MR done in [**2165-8-1**] showed an EF
of 61 percent with an effective forward EF of 40 percent,
bileaflet mitral valve prolapse with moderately severe MR,
moderately enlarged left and right atriums. The patient
reports that he has been asymptomatic and is feeling well.
He has a history of hypertension, HIV and mitral valve
disease.
No known drug allergies.
MEDICATIONS: Sustiva 600 q.day, Neurontin 300 q.day, Epival
300 q.day, Diovan 80 q.day, Pepcid p.r.n., albuterol p.r.n.
and Viread 300 mg q.day.
SOCIAL HISTORY: Single, lives alone. Works in fund raising.
PHYSICAL EXAM: Height 6 feet, 3 inches, weight 195 pounds.
GENERAL: In no acute distress.
NEUROLOGIC: Alert and oriented x3. Moves all extremities.
Nonfocal exam. RESPIRATORY: Clear to auscultation
bilaterally.
CARDIAC: S1-S2. There is a diastolic murmur.
ABDOMEN: Soft, nontender, nondistended with normal active
bowel sounds. EXTREMITIES: Warm and well-perfused with no
edema or varicosities.
LABORATORY DATA: White count 7, hematocrit 38.6, platelets
148, sodium 141, potassium 5.1, chloride 104, CO2 31, BUN
14, creatinine 1.0, glucose 71. Chest x-ray showed no
evidence of acute pulmonary disease. Urinalysis was
negative.
Following catheterization, the patient was discharged to home
and scheduled to return as an outpatient for minimally
invasive repair of mitral valve, as stated. The patient is a
direct admission to the operating room. Please see the OR
report for full details and summary. He had a minimally
invasive mitral valve repair with a No. 32 [**Last Name (un) 3843**]-[**Doctor Last Name **]
annuloplasty band. 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
in a sinus rhythm at 70 beats per minute with a mean
arterial pressure of 62 and a CVP of 14. He had propofol at
40 mics/kilogram/minute and epinephrine at 0.03
mics/kilogram/minute. The patient did well in the immediate
postoperative period. His anesthesia was reversed. He was
weaned from the ventilator and successfully extubated. On
postoperative day 1, the patient remained hemodynamically
stable. He was weaned from all IV cardioactive medications,
transitioned to oral medications, all central lines were
removed, as was his Foley catheter and he was transferred
from the Cardiothoracic Intensive Care Unit to 52 for
continuing postoperative care and cardiac rehabilitation.
Additionally on postoperative day 1, the patient's chest
tubes were removed.
Over the next 2 days, the patient's activity level was
increased with the assistance of the nursing staff as well as
physical therapy staff. He otherwise had an uneventful
postoperative course.
On postoperative day 3, it was decided that the patient was
stable and ready for discharge to home.
At the time of this dictation, the patient's physical exam is
as follows: Vital signs temperature 98.9, heart rate 67
sinus rhythm, blood pressure 95/52, respiratory rate 18, O2
sat 94 percent on room. Weight preoperatively 89 kg, at
discharge is 96.9 kg.
PHYSICAL EXAM: GENERAL: No acute distress. Neurologically
alert and oriented x3. Moves all extremities. Follows
commands. Nonfocal exam.
PULMONARY: Clear to auscultation bilaterally.
CARDIAC: Regular rate rhythm, S1-S2 with no murmur.
Incision is a right thoracic minimally evasive incision with
Steri-Strips, is open to air, clean and dry without erythema
or drainage.
ABDOMEN: Soft, nontender, nondistended with normal active
bowel sounds. EXTREMITIES: Warm and well-perfused with no
edema.
The patient is to be discharged to home with visiting nurses.
CONDITION AT TIME OF DISCHARGE: Good.
FO[**Last Name (STitle) **]P: In the [**Hospital 409**] Clinic in 2 weeks and with Dr. [**Last Name (Prefixes) **] in 4 weeks.
DISCHARGED DIAGNOSES:
1. Mitral regurgitation, status post minimally invasive
mitral valve repair with a No. 32 [**Last Name (un) 3843**]-[**Doctor Last Name **]
annuloplasty band.
2. Hypertension.
DISCHARGE MEDICATIONS: Include aspirin 81 mg q.day, Colace
100 mg b.i.d., Neurontin 300 mg q.day, Percocet 5/325 1-2
tablets q.[**5-7**] h. p.r.n., ibuprofen 800 mg q.8 h., metoprolol
25 mg b.i.d, Epival 300 mg q.day, Sustiva 600 mg q.day, and
Viread 300 mg q.day.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2166-1-6**] 17:48:24
T: [**2166-1-7**] 03:29:44
Job#: [**Job Number 13352**]
ICD9 Codes: 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1528
} | Medical Text: Admission Date: [**2140-6-1**] Discharge Date: [**2140-6-5**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
diabetic ketoacidosis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
27 yo male with T1DM admitted with DKA. Unclear precipitant--had
sudden onset abd pain/diarrhea/n/v this morning. No
fever/chills. States compliant with insulin but has not seen his
[**Name8 (MD) **] MD since [**2137**]
Past Medical History:
T1DM on 75/25 split mix 50 units qam and 40-50 units q supper
gastroparesis -- gastric emptying study in [**2137**]
GERD
Social History:
lives with roomate
Family History:
noncontributory
Physical Exam:
Gen- no acute distress
HEENT-anicteric, oral mucosa moist
CV-rrr, no r/m/g
resp-clear to auscultation bilaterally
abdomen- soft, nontender, nondistended, good bowel sounds
extremities- no edema
Pertinent Results:
[**2140-6-1**] 08:30AM PLT SMR-NORMAL PLT COUNT-241
[**2140-6-1**] 08:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2140-6-1**] 08:30AM NEUTS-92.6* BANDS-0 LYMPHS-4.6* MONOS-2.7
EOS-0 BASOS-0.1
[**2140-6-1**] 08:30AM WBC-11.7*# RBC-4.70 HGB-13.6* HCT-40.0 MCV-85
MCH-28.9 MCHC-34.0 RDW-11.9
[**2140-6-1**] 08:30AM CALCIUM-10.0 PHOSPHATE-3.3# MAGNESIUM-1.9
[**2140-6-1**] 08:30AM GLUCOSE-479* UREA N-26* CREAT-1.6* SODIUM-135
POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-18* ANION GAP-27*
[**2140-6-1**] 08:43AM LACTATE-2.2*
[**2140-6-1**] 08:55AM LACTATE-1.5 K+-4.3
[**2140-6-1**] 08:55AM TYPE-ART PO2-96 PCO2-31* PH-7.39 TOTAL
CO2-19* BASE XS--4 COMMENTS-ADD ON K+
[**2140-6-1**] 08:55AM TYPE-ART PO2-96 PCO2-31* PH-7.39 TOTAL
CO2-19* BASE XS--4 COMMENTS-ADD ON K+
[**2140-6-1**] 09:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2140-6-1**] 09:45AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2140-6-1**] 09:45AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2140-6-1**] 09:45AM URINE GR HOLD-HOLD
[**2140-6-1**] 09:45AM URINE UHOLD-HOLD
[**2140-6-1**] 09:45AM URINE HOURS-RANDOM
[**2140-6-1**] 09:45AM URINE HOURS-RANDOM
[**2140-6-1**] 01:00PM CALCIUM-9.1 PHOSPHATE-2.7 MAGNESIUM-1.8
[**2140-6-1**] 01:00PM GLUCOSE-213* UREA N-23* CREAT-1.3* SODIUM-142
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-22 ANION GAP-16
[**2140-6-1**] 04:42PM %HbA1c-10.9* [Hgb]-DONE [A1c]-DONE
[**2140-6-1**] 06:14PM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-2.0
[**2140-6-1**] 06:14PM GLUCOSE-227* UREA N-20 CREAT-1.4* SODIUM-138
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-20* ANION GAP-18
Brief Hospital Course:
27yo M with Type I DM and gastroparesis presented with DKA. He
was on insulin drip for several day for aggressive control of
anion gap. He remained nauseous and unable to take po intake
until the anion gap is well controlled. IV fluid with dextrose
was used while patient was NPO. As soon as the anion gap was
well controlled, patient resumed extremely good appetite and was
able to be transitioned to sc insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] reccomendation.
Of note, patient also has domented gastroparesis on gastric
emptying study and this also may have contributed to the nausea.
Reglan was increased, LFTs and Ultrasound of the abdomen were
normal.
Of note, he was also hypertensive with sbp running 170-180
systolic. He was on ACE inhibitor a few years ago according to
[**Last Name (un) 387**] records but has discontinued that due to insurance issue.
ACE inhibitor was restarted while he was in the hospital.
Social work consult was obtained to help him handle the medical
insurance issue. As mentioned above, he had not seen a doctor
for years and has discontinued/not compliant with medication.
On the day of discharge, patient insisted on leaving. The ICU
team explained to him that he had just been transitioned to sc
insulin at that time and would need to stay for the afternoon
for observation. He seem to have understood at the time of
discussion and was very agreeable. However, he left without
telling any medical staff shortly after that. Effort was made to
contact him by phone but to no avail .
Medications on Admission:
75/25 insulin
anzamet
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Compazine 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Discharge Condition:
Left hospital AMA without telling staff. Condition was Good at
time of last assessment by nursing personnel.
Discharge Instructions:
please return to the hospital or call your doctor if your blood
sugar is out of control, if you have dizziness, nausea/vomiting
or if there are any other concerns
Please make sure you follow up with a PCP
You have just been started on lisinopril for your blood
pressure, you will need to have close follow up of your
electrolytes
Followup Instructions:
Please call [**Telephone/Fax (1) 250**] to schedule an appointment with a PCP
of your choice within 1 weeks of your discharge.
Please call the [**Hospital **] CLinic for follow up appointment within 2
weeks of discharge
Completed by:[**2140-6-22**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1529
} | Medical Text: Admission Date: [**2144-10-3**] Discharge Date: [**2144-10-6**]
Date of Birth: [**2064-12-3**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Codeine / Ranitidine
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 24214**] is a 79 F with h/o seizures now transferred from
neurosurg service for workup of syncope. Pt was in USOH on
[**2144-10-3**] when had apparent syncope while grocery shopping. She
remembers purchasing groceries and walking outside and seeing
her car. Next thing she remembers is waking up on ground near
her car surrounded by people. No aura/prodrome. No postictal
confusion, no incontinence or tongue biting. There were many
people around; no reported tonic-clonic activity. No HA, fever,
palpitations, N/A, weakness, numbness. Notes that it was a hot
day and she had not had much to eat or drink.
.
Pt has history of 2 or 3 prior seizure events, last more than 20
years ago. Has been on Dilantin for many years. During prior
seizures she was observed to have GTC activity, aura, post ictal
confusion, +/- urinary incontinence. She does not feel that
this particular episode was similar to her prior seizures. She
does have a history of atrial tachycardia to 160's during prior
admission, asymptomatic. She also notes one month history of
intermittent regularly irregular heartrate (skipped beats, see
[**9-11**] PN from Dr. [**Last Name (STitle) 1007**]. Notes this when feeling her pulse but
is otherwise asymptomatic. She also had a mechanical fall down
stairs at her house about 1 week PTA. States she fell on her
hip; did not hit her head but did hit the back of her neck. No
LOC.
.
In [**Name (NI) **] pt found to have subdural hematoma and admitted to
neurosurgery. By CT hematoma has shown stability. Transferred
to medicine for workup of her syncope.
Past Medical History:
Seizure disorder, last Sz about 20 y ago, on dilantin.
Chronic HA
OA
Osteopenia
Endometrial polyp
h/o atrial tachycardia during admit [**3-/2137**]
Tricuspid regurg (mod-severe on echo)
Social History:
Retired social worker. Denies EtOH, illicits. Past h/o
smoking, quit 20 years ago.
Family History:
Cousin with Sz disorder, mother with MI, father with COPD
Physical Exam:
VS: T 96, P 71, R 18, BP 118/64, O2 sat 98%
Orthostatics: Lying 110/66; sitting 120/72; standing 132/74
General: Thin, elderly female, NAD
HEENT: Ecchymosis/edema under L orbit. Healing skin tear at
hairline of L forehead, no active bleeding. PERRL, EOMI. OP
clear. No oral trauma. MMM.
Neck: full ROM, no carotid bruit
Chest: CTA bilat
Heart: RRR with occ early then skipped beat (~one out of [**1-9**]
beats). S1 S2, 2/6 systolic murmur at LLSB.
Abdomen: +BS, slightly distended, soft, NT. Tympanic
throughout, no shifting dullness.
Extrem: Thin, no edema. Normal muscle tone, bulk.
Neuro Exam:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-28**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-30**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
No pronator drift
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2144-10-3**]
WBC-5.3 HGB-12.5 HCT-35.8* MCV-96 RDW-14.0 PLT-271
NEUTS-69.7 LYMPHS-24.3 MONOS-4.2 EOS-1.2 BASOS-0.5
PT-12.7 PTT-27.3 INR(PT)-1.1
GLUCOSE-103 UREA N-12 CREAT-0.5 SODIUM-134 POTASSIUM-3.8
CHLORIDE-97 TOTAL
CO2-28 ANION GAP-13
CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.4
PHENYTOIN-13.2
ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
CT head: Right subdural hematoma (3.1 x 1.1), appearing
partially organizing, with local mass effect, as described
above. Mixed density in the adjacent subdural space may
represent hyperacute-on-acute bleeding or acute-on-chronic
bleeding. Superficial soft tissue swelling along the left
frontal region. There is local mass effect, without shift of
normally midline structures.
.
CT head (repeat [**10-4**]) No increase in size in the right subdural
hematoma.It may be slightly decreased in size.
.
CT head (repeat [**10-5**]) Stable right-sided subdural hematoma
.
CXR: No displaced rib fracture or acute cardiopulmonary process.
.
ECG: Sinus rhythm at 71. Frequent ventricular premature beats.
Left axis deviation with left anterior fascicular block.
.
CT spine: Prevertebral soft tissue structures are normal.
Advanced degenerative changes are present at C5 through C7 with
anterior osteophytes, subchondral sclerosis, and joint space
narrowing. Multilevel degenerative changes are present in the
facet joints. No acute fracture or dislocation is identified.
.
Echo ([**2142-4-6**]): The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated. The ascending aorta is mildly dilated. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is no pericardial effusion.
.
Review of telemetry: No Vtach. Frequent PVCs, no couplets, at
times trigeminy or every fourth beat is PVC.
Brief Hospital Course:
A&P: Ms. [**Known lastname 24214**] is a 79 F with h/o seizure disorder on
Dilantin, multiple PVCs on telemetry, h/o atrial tachycardia;
initial admit to neurosurgery with subdural hematoma (now
stable); transfer to medicine for syncope workup.
.
# Syncope: Pt's fall and LOC seemed most consistent with syncope
(vs. seizure). Although she had h/o seizure disorder, this
episode was not c/w priors. No prodrome, no postictal
confusion, no incontinence/tongue biting. Stated that she did
not remember good chunk of time prior to her LOC. Other DDx
included vasovagal, cardiac arrhythmia, orthostasis, mechanical
fall with concussion. Her orthostatics were normal. Carotid
dopplers were normal. She had a normal EEG. Echo was unchanged
from previous (normal EF, no aortic stenosis). She had frequent
PVCs here (frequently in trigeminy) but no NSVT or couplets. EP
was consulted and saw no evidence of syncope due to arrhythmia.
Could be vasovagal (hot weather, etc). No known
toxins/electrolyte abnormalities. Neurology was also consulted
and autonomic tilt table testing was done (report pending). She
also had some unsteadiness on her feet (unclear how much of this
was due to the SDH) with occasional falls at home. It was also
quite likely that she had a mechanical fall with head trauma
severe enough to cause mild retrograde amnesia. She was
instructed not to drive until seeing her PCP [**Name Initial (PRE) **]/or neurologist.
.
# Subdural hematoma: Initially admitted to neurosurgery. She
had serial CT scans to evaluate progression and the hemorrhage
continued to show stability/improvement. There was no
neurologic deficits. She will followup with neurosurgery as an
outpatient.
.
# Seizure disorder. She had had no seizure x 20 years but has
continued on dilantin mainly because she has felt uncomfortable
off antiepileptics. Dilantin level was within range. She had a
neurology consult and EEG as above.
.
# Osteopenia: contined Fosamax. Also encouraged her to take
calcium and vitamin D.
.
# Anemia: Normocytic, near baseline and stable.
.
# Hyperlipidemia: continued atorvastatin
Medications on Admission:
Dilantin 300 mg QAM, 400 mg QPM
Fosamax 35 mg Qweek
Lipitor 10 mg QHS
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Alendronate 35 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: [**2-29**] Capsules PO
BID (2 times a day): Please take Dilantin as per prior dosing
(200 mg twice daily alternating with 200 mg in AM and 300 mg in
PM).
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural hematoma
Syncope
Seizure disorder
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for an episode of falling with a related head
injury. There was a small amount of bleeding inside your head
(subdural hematoma) that has not changed while we have been
monitoring you. You will followup with the neurosurgeons in the
future. We also tried to figure out why you had this fall. We
looked at your heart rhythms and brain rhythms to look for
abnormalities. So far we have not been able to uncover a
definite reason for why you had this fall.
.
Please DO NOT DRIVE until you followup with your primary care
physician and your neurologist.
.
Please return to the hospital if you have further episodes of
fainting, seizure, dizziness, palpitations, difficulty with
memory or confusion, or any new symptoms that you are concerned
about.
.
Please keep all of your appointments with your doctors and take
[**Name5 (PTitle) **] of your medications as prescribed.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 1007**] ([**Telephone/Fax (1) 10492**]) to schedule a followup
appointment in 1 week.
.
We would like you to followup with Dr. [**Last Name (STitle) 2442**] again regarding
your seizures and Dilantin. Please call ([**Telephone/Fax (1) 5563**] to
schedule an appointment with him in [**2-29**] weeks.
.
The neurosurgery team (Dr. [**Last Name (STitle) **] will be in contact with you
to schedule a followup appointment. Please call ([**Telephone/Fax (1) 88**]
if you do not hear from them within one week.
.
You also have the following upcoming appointments at [**Hospital1 18**]:
Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2144-12-3**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 24672**], MD Phone:[**Telephone/Fax (1) 24673**]
Date/Time:[**2145-4-1**] 2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
ICD9 Codes: 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1530
} | Medical Text: Admission Date: [**2176-11-19**] Discharge Date: [**2176-11-24**]
Date of Birth: [**2104-3-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Fentanyl / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath, palpitations, chest pressure and worsening
fatigue
Major Surgical or Invasive Procedure:
s/p ASD closure
History of Present Illness:
70 year old woman with history of shortness of breath,
palpitations, chest pressure and worsening fatigue who was
worked up by her PCP for dysphagia. As part of workup, she had
a transesophageal echocardiogram that showed an atrial septal
defect with normal pulmomary veins. Cardiac catheterization
showed normal coronary arteries.
Past Medical History:
Dyslipidemia
Thyroid cancer s/p ablation with radioactive iodine
Hiatal hernia
Enterogastric ulcers
Migraines
Skin cancer
s/p c-section x3
s/p right femoral hernia repair
s/p TAH
Social History:
Retired and lives with her husband in [**Name (NI) 17566**]. She never
smoked and consumes alcohol rarely.
Family History:
Non-contributory
Physical Exam:
Admission:
HR 72 Right BP 142/76 Left BP 122/64 Height 5'5" Weight 66KG
General: no acute distress
Neck: supple with full range of motion, no JVD
Chest: lungs clear to auscultation bilaterally
COR: regular rate and rhythm. III/VI systolic ejection murmur.
Abdomen: soft and nontender without rebound or guarding
Extremities: warm without edema. 2+ peripheral pulses
Neuro: grossly intact
Pertinent Results:
ECHO [**2176-11-19**]
Pre- Bypass:
1. The left atrium is normal in size. The right atrium is
dilated. A two secundum atrial septal defects present with
bidirectional flow.
2. Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). with mild
global free wall hypokinesis.
3. There are simple atheroma in the descending thoracic aorta.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. Trace
aortic regurgitation is seen.
5. The mitral valve leaflets are myxomatous.Trace mitral
regurgitation is seen.
6. There is no pericardial effusion.
Post-Bypass:
1. Left and right ventricular function is preserved.
2.The aorta is intact.
3.Both of the ASDs are repaired with minimal bidirectional flow
across the repaired atrial septum is seen.
4. Dr. [**Last Name (STitle) **] was notified of these results intraoperatively.
[**2176-11-24**] 06:45AM BLOOD WBC-4.2 RBC-3.06* Hgb-10.2* Hct-28.8*
MCV-94 MCH-33.2* MCHC-35.4* RDW-13.0 Plt Ct-223
[**2176-11-24**] 06:45AM BLOOD Glucose-105 UreaN-16 Creat-0.9 Na-137
K-4.1 Cl-102 HCO3-28 AnGap-11
Brief Hospital Course:
Mrs [**Known lastname 80232**] was brought to the operating room on [**2176-11-19**] and
underwent an ASD closure with Dacron Patch per the ususal
routine (please see operative note for further details). She was
transferred to the CVICU post-operatively for invasive
monitoring. She was extubated within a few hours and was
transferred to the floor on POD 1. 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 on [**2176-11-21**] with
hypotension. She was transferred back to the intensive care unit
for closer monitoring. Amiodarone was started. The patient
converted back to sinus rhythm before discharge. She was
continued on oral amiodarone, as well as beta blocker.
Anticoagulation was not initiated. By the tiem of discharge on
POD 5, the patient was ambulating freely, the wound was healing
and pain was controlled with oral analgesics.
Medications on Admission:
Levoxyl 75 mcg po daily
Ambien 5mg po QHS PRN
Fiorinal
MVI daily
Protonix 40 mg po daily
ASA 325 mg po daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. 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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg 2x/day for 2 weeks, then 200mg daily.
Disp:*60 Tablet(s)* Refills:*0*
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Ambien 5 mg Tablet Sig: One (1) Tablet PO hs prn as needed
for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
9. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
s/p ASD closure with dacron patch
Dyslipidemia
Thyroid Cancer s/p thyroidectomy
Migraines
Hiatal hernia
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr. [**First Name (STitle) **] in 1 week please call for appointment
Dr. [**First Name (STitle) 1075**] in [**3-10**] weeks please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2176-11-24**]
ICD9 Codes: 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1531
} | Medical Text: Admission Date: [**2195-5-11**] Discharge Date: [**2195-6-2**]
Date of Birth: [**2166-9-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
jaundice and fatigue
Major Surgical or Invasive Procedure:
Paracentesis, diagnostic
Paracentesis, therapeutic
History of Present Illness:
28 year old man with hx of chronic etoh use presenting with
fatigue, jaundice and found to be anemic. He stated that ~[**12-10**]
months ago he noticed that he was more fatigued with increasing
abdominal girth, leg swelling and fatigue. He denies abdominal
pain, chest pain, cough, dysuria, rash, or headache. He denied
bloody or black stools, as well as no grey stools. He was
encouraged by his mother to come to the hospital for evaluation.
He initially presented to [**Hospital3 **] where he was
hemodynamically stable with markedly elevated bilirubin and Hct
~15. He was guaiac negative x1.
Prior to transfer he received vitamin K po, and lactulose 30 g
as well as a banana bag of IVF
.
In the ED, his initial vital signs were 101.5 122 144/63 30
95%RA. He received zosyn IV x1 and motrin 600 mg po x1. He had a
diagnostic para that showed no evidence of SBP. He was guaiac
negative x 1. He received 1 unit of pRBCs and admitted to the
ICU.
In ICU he was continued on CTX because of fevers x 24 hours and
defervesced.
Past Medical History:
tooth abscess ([**8-16**])
car accident at age 17 (received blood transfusion)
Social History:
divorced. 5 kids (10 year old son and 8 year fraternal twins
(boy and girl) with ex-wife. 5 year old son, 2 year old girl
with present girlfriend. works small construction jobs.
incarcerated in [**2194-7-9**].
Family History:
sister with HepC. dad with heavy etoh use. mom with
anxiety/depression
Physical Exam:
VS: 99.7 118 138/57 32 100%NRB
GEN: marked jaundice and distended abdomen
HEENT: AT, NC, PERRLA (5->2mm bilat), EOMI, no conjuctival
injection, icteric, OP clear, dental depression in left 2nd
mandibular molar, MMM, Neck supple, no LAD, no carotid bruits
CV: regular tachy, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: marked distension with ascites, NT, + BS, no HSM, no caput.
marked penile and scrotal swelling
EXT: warm, +2 distal pulses BL, no femoral bruits, marked
peripheral edema
NEURO: alert & oriented x3, coherent response to interview, CN
II-XII intact, 5/5 strength throughout. No sensory deficits to
light touch appreciated. asterixis
PSYCH: appropriate affect
Pertinent Results:
[**2195-5-11**] 05:15PM WBC-15.6* RBC-1.28* HGB-5.2* HCT-14.8*
MCV-116* MCH-41.0* MCHC-35.3* RDW-23.5*
[**2195-5-11**] 05:40PM HGB-5.2* calcHCT-16 O2 SAT-90
[**2195-5-11**] 07:10PM WBC-19.7* RBC-1.39* HGB-5.5* HCT-15.7*
MCV-113* MCH-39.7* MCHC-35.1* RDW-25.5*
[**2195-5-11**] 05:15PM ASA-NEG ETHANOL-193* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2195-5-11**] 05:15PM NEUTS-77* BANDS-15* LYMPHS-2* MONOS-3 EOS-1
BASOS-0 ATYPS-0 METAS-2* MYELOS-0 NUC RBCS-2*
[**2195-5-11**] 05:15PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-1+ SCHISTOCY-1+
BURR-1+ TEARDROP-1+ ACANTHOCY-1+
[**2195-5-11**] 05:15PM PT-26.4* PTT-43.6* INR(PT)-2.6*
[**2195-5-11**] 05:15PM ALBUMIN-2.5* CALCIUM-7.7* PHOSPHATE-3.3
MAGNESIUM-1.9
[**2195-5-11**] 05:15PM calTIBC-142* VIT B12-GREATER TH FOLATE-14.9
HAPTOGLOB-<20* FERRITIN-1374* TRF-109*
[**2195-5-11**] 05:15PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2195-5-11**] 05:15PM GLUCOSE-104 UREA N-22* CREAT-0.8 SODIUM-122*
POTASSIUM-5.7* CHLORIDE-90* TOTAL CO2-22 ANION GAP-16
[**2195-5-11**] 06:10PM ASCITES TOT PROT-0.5 GLUCOSE-135 LD(LDH)-177
AMYLASE-18 ALBUMIN-LESS THAN
[**2195-5-11**] 06:10PM ASCITES WBC-13* RBC-4100* POLYS-95* BANDS-0
LYMPHS-5* MONOS-0 EOS-0
[**2195-5-11**] 07:10PM RET MAN-15.0*
.
RUQ ultrasound: IMPRESSION: 1. Constellation of findings,
consistent with longstanding liver disease, including
splenomegaly and portal vein flow reversal. 2. Gallbladder
contains sludge, no evidence of acute cholecystitis.
.
CXR: IMPRESSION: No acute cardiopulmonary process.
.
CT abd/pelvis: IMPRESSION:
1. Extremely limited exam due to lack of IV and oral contrast.
2. Splenomegaly and shrunken liver consistent with cirrhosis.
Multiple varices are incompletely identified on this study.
3. Extensive amount of intra-abdominal and pelvic ascites with a
small layering fluid level.
4. Extensive anasarca and scrotal edema.
5. Large ill-defined left gluteal hematoma as described above.
6. Multiple ground-glass nodules at the lung bases. This may be
infectious etiology.
Brief Hospital Course:
28 year old man with history of chronic etoh use presenting with
fatigue found to have marked hepatic dysfunction and
gastrointestinal bleed. Hepatic failure most likely secondary to
alcoholic cirrhosis. Patient not a transplant candidate due to
continued EtOH use. Patient with signs of worsening hepatic
function including increasing abdominal girth, leg swelling,
fatigue and jaundice for which he presented to [**Hospital3 3583**].
He was transferred from [**Hospital3 **] for his markedly
elevated bilirubin and Hct ~15. He received 1 unit of pRBCs in
the ED and was admitted to MICU Green, where he received 3 units
pRBCs, Hct improved to 21. Got therapeutic tap of 8L performed
on [**5-14**] without complications or signs of infection. Transferred
to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] on [**5-14**]. Started on prednisone; furosemide
increased to 80 qday; albumin 50 gm started [**2195-5-16**]. On [**2195-5-18**]
patient experienced hematemesis of 700 ml on the floor, was
transferred to MICU [**Location (un) **], where NG suctioned out 1.5 L of
blood. Patient was emergently intubated. Given 5 units of pRBCs,
4 units of FFPs, 1 bag of platelets, vasopressin, octreotide.
Patient felt to have fulminant hepatic failure with poor
prognosis as after his transfer to MICU [**Location (un) **] he remained he
hemodynamically unstable with active bleeding at oropharynx/UGI,
IV sites, via Foley and lower gastrointestinal tract bleeding
requiring several units blood and FFP daily. The patient was
also felt to have hepatic encephalopathy. Patient also had a
fever with no clear source of infection, but was treated
empirically with ceftriaxone. In this setting patient required
intubation for airway protection. He also developed hepatorenal
syndrome non responsive to fluids, octreotride, or midrodrine.
The patient also developed a lactic acidosis likely from his
liver failure with global hypoperfusion. Given the patient's
multisystem organ failure and the fact that he was not a
candidate for a transplant, a family meeting was held with his
mother. The decision was made to shift the patient's goals of
care to comfort measures. He was started on iv morphine. Organ
bank notified and will intervene and meet with family to discuss
organ donation in more detail. The patient died from
complications of his liver disease.
Medications on Admission:
none
Discharge Medications:
Discharge due to death
Discharge Disposition:
Expired
Discharge Diagnosis:
Fulminant Hepatic Failure due to Alcoholic Cirrhosis
Hepatorenal syndrome with renal failure
Hepatic Encephalopathy
Hematemesis due to Variceal Bleed
Coagulopathy with lower gi bleed due to liver failure
Respiratory Failure
Discharge Condition:
Dead
Discharge Instructions:
Discharge due to death
Followup Instructions:
Discharge due to death
Completed by:[**2195-6-12**]
ICD9 Codes: 5849, 2851, 7907, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1532
} | Medical Text: Admission Date: [**2199-5-26**] Discharge Date: [**2199-5-28**]
Service: MICU
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: This is an 84-year-old woman
with a history of tracheobronchiomalacia and chronic
respiratory failure who was transferred to the [**Hospital1 346**] from [**Hospital3 672**] Hospital. The
patient originally had her respiratory failure following an
episode of aspiration pneumonia back in [**Month (only) 404**], at which
time she had failed attempts at stenting of her
tracheobronchiomalacia and required tracheostomy and PEG tube
placement for her chronic respiratory failure. She has been
at [**Hospital3 672**] Hospital since that time and has been
unable to wean from the ventilator. Her usual vent settings
are SIMV, respiratory rate of 8, tidal volume of 500,
pressure support of 15, PEEP of 5, FIO2 of 0.3. The patient
had been doing well and had been gradually weaned off the
ventilator until the day of admission. At that time she was
noted to be in respiratory distress. She was tachypneic and
short of breath. Two saturations decreased to 90%. She went
from CPAP back to IMV. Arterial blood gas was
7.23/70/123/30/96%. Breath sounds were noted to be distant
and chest x-ray could not be obtained for a significant
period so she was sent to [**Hospital1 188**] for further evaluation.
In the Emergency Department the patient was bagged and
suctioned. No obvious mucous plugs were removed and Lasix 60
mg IV x 1 was given. The patient's symptoms improved and she
was transferred to the medical intensive care unit for
further evaluation.
PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2.
Hypertension. 3. Tracheobronchiomalacia as above. 4.
Anemia. 5. Moderate to severe mitral regurgitation.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Ritalin 5 mg
p.o. q.d. 3. Zoloft 50 mg p.o. q.d. 4. Albuterol p.r.n. 5.
Subcutaneous heparin 5,000 mg subcutaneous b.i.d. 6. Ativan
0.25 mg p.o. q. 8 hours p.r.n. 7. Lasix 40 mg p.o. q.d. on
hold x 1 week.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: The patient is currently a resident at
[**Hospital3 672**] Hospital. She has some family members who
are involved in her care. She has no known history of
tobacco or drug use.
PHYSICAL EXAMINATION: Vital signs were 98.8, heart rate 82,
blood pressure 92/47, respiratory rate 18, 100% bagged. In
general she was an obese, confused woman who was in no acute
distress at the time of the medical intensive care unit
evaluation. HEENT: Left eye cataract with some ptosis.
Oropharynx was noted to have thrush, otherwise dry. Neck:
No jugular venous distension, no lymphadenopathy.
Tracheostomy in place. Cardiac: Regular rate and rhythm, no
murmurs, gallops, or rubs. Lungs: Rhonchi noted diffusely
with decreased breath sounds at the bases bilaterally,
occasional expiratory wheezes. Abdomen: Soft, nontender,
distended abdomen, positive bowel sounds. PEG in place with
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1356**] clamp. Extremities: No cyanosis, clubbing or edema,
warm with good pulses, no calf tenderness, no palpable cord.
Neurological: The patient was able to move all extremities,
decreased hearing and unable to communicate or take p.o.
LABORATORY DATA: White blood count 18.2, hematocrit 36.4,
platelet count 425, and 87.5, no bands. Sodium 132, BUN 49,
creatinine 1.1, glucose 231. Urinalysis had large blood,
greater than 50 white blood cells, [**12-5**] red blood cells,
nitrite negative, leukocyte esterase moderate.
HOSPITAL COURSE: 1. Pulmonary: The patient was admitted
with respiratory distress of unclear etiology. She was given
Lasix initially for congestive heart failure, although this
was unlikely to be congestive heart failure. The patient was
thought to have a mucous plug given the rapid improvement of
her symptoms after suctioning. The patient had follow-up
chest x-ray which demonstrated right middle lobe pneumonia
and question of pneumonia at the left base. The patient was
initially started on ceftriaxone and azithromycin in the
Emergency Department, but was then changed to vancomycin and
Zosyn to cover a ventilator-associated pneumonia. The
patient was then put back on her [**Hospital3 672**] Hospital
ventilator settings and her white count decreased. She
continued to have low-grade temperatures which were thought
to be due to her lack of adequate antibiotics. Sputum
culture showed greater than 25 polys, less than 10 epithelial
cells with mixed flora and final culture is pending at the
time of this dictation.
2. Cardiac: The patient was treated empirically in the
Emergency Department for congestive heart failure. She
underwent transthoracic echocardiogram to evaluate her
ejection fraction given possible congestive heart failure.
This demonstrated left atrium with moderate dilatation, right
atrium with moderate dilatation, mild left ventricular
hypertrophy, minimal aortic stenosis, 1+ aortic
regurgitation, mild to moderate mitral regurgitation,
impaired ventricular relaxation. It was not clear if the
patient was in any congestive heart failure and she was not
given Lasix. This can be restarted should her symptoms
worsen.
3. Weakness: On hospital day number one the patient was
noted to have some left-sided weakness. It is unclear
exactly what her baseline is. She was able to move all four
extremities, however she had some flaccidity and
hyperreflexia in the left upper and lower extremities. She
underwent CT scan of the head which demonstrated no acute
changes but chronic microvascular changes and atherosclerosis
of the internal carotid and vertebral arteries. Given the
patient's condition and unclear age of her findings, no
additional work-up was undertaken.
4. Endocrine: The patient was maintained on fingersticks
q.i.d. and a Regular Insulin sliding scale for her diabetes
mellitus. This should be maintained at her discharge for
optimal blood sugar control during her time of infection.
5. Anemia: The patient's blood counts decreased from
admission of 36 down to 26 on hospital day number two. Some
of this was thought to be dilution as the patient did receive
some intravenous fluids during her admission. She was guaiac
negative and did not have any signs of active bleeding.
Blood count is stable at the time of her discharge. She did
not have a history of coronary artery disease so no packed
cells were given. Should her hematocrit decreased to less
than 24, blood transfusion may be of benefit to her.
6. Access: The patient had a PICC line placed for
intravenous antibiotics to complete a 14-day course of
vancomycin and Zosyn.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged back to [**Hospital3 **] Hospital for continued weaning and intravenous
antibiotic therapy.
DISCHARGE DIAGNOSES:
1. Ventilator-associated pneumonia.
2. Cerebrovascular accident of unclear duration.
3. Mitral regurgitation.
4. Anemia.
5. Diabetes mellitus.
6. Urinary tract infection: Positive urinary tract infection
with Gram-negative rods and beta streptococcus.
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gram q. 48 hours started on [**2199-5-27**] to
receive a 14-day course.
2. Zosyn 2.25 grams IV q. 6 hours started on [**2199-5-27**] to
complete a 14-day course.
3. Sertraline 50 mg p.o. q.d.
4. Methylphenidate 5 mg p.o. b.i.d.
5. Albuterol nebulizer inhaled q. 6 hours p.r.n.
6. Atrovent 2 puffs inhaled q.i.d.
7. Heparin 5,000 mg subcutaneous b.i.d.
8. Fluticasone 110, 2 puffs inhaled b.i.d.
9. Regular Insulin sliding scale.
10. Fluconazole 100 mg p.o. q. 24 hours for thrush to
complete four additional doses.
11. Lansoprazole 30 mg via nasogastric tube q.d.
12. Ativan 0.25 mg p.o./IV t.i.d. p.r.n.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36
D: [**2199-5-28**] 10:50
T: [**2199-5-28**] 11:03
JOB#: [**Job Number 46668**]
ICD9 Codes: 486, 5990, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1533
} | Medical Text: Admission Date: [**2155-3-1**] Discharge Date: [**2155-3-4**]
Date of Birth: [**2111-3-24**] Sex: M
Service: MEDICINE
Allergies:
Valium
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
This is a 43 yo M who presents with increased urinary frequency
x one week, found to have new onset [**Hospital 23051**] transferred to MICU for
management on HONC. He complained of urinary incontinence and
episodic R-sided weakness. He reports 3 falls at home in last
week. He woke up on the floor, not remembering how he got from
the bed to the floor.
.
In the ER he was given a regular insulin bolus of 4 units (0.05
u/kg of ideal weight) at 4 units insulin gtt (0.05u/kg/hr) at 1
a.m. At 4:30 am he received a 10 unit bolus with 6 units/hr
gtt. EKG showed worsening ST depressions in leads 2, 3, 4, and
v4-v6. He received 325 mg of ASA. Head CT and CXR were
negative. UA negative for infection and ketones. IVF were
given via 20g IV. The IV team was unable to obtain second IV.
He was given 1.5 grams of amoxicillin.
History of Present Illness:
This is a 43 yo M who presents with increased urinary frequency
x one week, found to have new onset [**Hospital 23051**] transferred to MICU for
management on HONC. He complained of urinary incontinence and
episodic R-sided weakness. He reports 3 falls at home in last
week. He woke up on the floor, not remembering how he got from
the bed to the floor.
.
In the ER he was given a regular insulin bolus of 4 units (0.05
u/kg of ideal weight) at 4 units insulin gtt (0.05u/kg/hr) at 1
a.m. At 4:30 am he received a 10 unit bolus with 6 units/hr
gtt. EKG showed worsening ST depressions in leads 2, 3, 4, and
v4-v6. He received 325 mg of ASA. Head CT and CXR were
negative. UA negative for infection and ketones. IVF were
given via 20g IV. The IV team was unable to obtain second IV.
He was given 1.5 grams of amoxicillin.
Past Medical History:
-Type A Aortic Dissection Repair (hemiarch and ascending aorta
repair, aortic valve repair) - [**1-/2152**]
-Strokes: several peri-procedural embolic strokes involving
bilateral hemispheres.
-chronic renal insufficiency (ARF due to ATN during admission
for aortic dissection in [**2151**] and required transient HD); cr
baseline 2.0-2.2
-bilateral peroneal neuropathies
-chronic low back pain
-peripheral neuropathy
-hypertension
-prurigo nodularis
-Hypercholesterolemia
-Asthma
-Sarcoid
-h/o ishemic hepatitis s/p celiac stent along with L CIA/EIA
stent
-h/o Klebsiella UTI
Social History:
lives with wife, no ETOH, no drugs, no tobacco
Family History:
Non-contributory.
Physical Exam:
Vitals: 99.6 89 125/70 21 94% RA
GEN: Morbidly obese male in NAD, breathing comfortably
HEENT: Sclera anicteric, OP clear with dry MM
Neck: thick, unable to assess JVP
CV: RRR, S1/S2 with mechanical click. no MRG
Resp: CTAB
Abd: Obese, soft, NT/ND, +BS
Ext: No peripheral edema
Skin: xerosis to LE
Neuro: PERRLA, EOMI intact, L Amblyopia (previously noted),
+Horizonal Nystagmus bilaterally, CN otherwise intact.
Decreased sensation to light touch on bilateral lower
extremities. 4+ strength og R LE, otherwise 5/5 strength
throughout.
Pertinent Results:
Head CT [**2-28**]: No evidence of acute intracranial pathology.
Please note that MRI with diffusion-weighted sequences is more
sensitive for detection of acute ischemia.
.
CXR [**3-1**]: No pneumonia or CHF. Improving right discoid
atelectasis.
.
EKG [**2-28**]: NSR @ 87, nl axis/intervals, STD in II, III, aVF,
V4-V6 (new since [**11-11**])
.
.
[**2155-2-28**] 09:50PM WBC-7.3 RBC-4.49* HGB-15.0 HCT-47.1 MCV-105*
MCH-33.4* MCHC-31.9 RDW-15.1
[**2155-2-28**] 09:50PM NEUTS-64.0 LYMPHS-30.4 MONOS-2.3 EOS-2.8
BASOS-0.6
[**2155-2-28**] 09:50PM PLT COUNT-192
.
[**2155-2-28**] 09:50PM CK-MB-3 cTropnT-0.02*
[**2155-2-28**] 09:50PM CK(CPK)-197*
[**2155-3-1**] 08:49AM CK-MB-3 cTropnT-0.03*
[**2155-3-1**] 10:12PM CK-MB-4 cTropnT-0.03*
[**2155-3-1**] 10:12PM CK(CPK)-194*
.
[**2155-2-28**] 09:50PM GLUCOSE-989* UREA N-45* CREAT-3.9*#
SODIUM-120* POTASSIUM-4.4 CHLORIDE-75* TOTAL CO2-30 ANION GAP-19
[**2155-3-1**] 08:49AM GLUCOSE-250* UREA N-42* CREAT-3.5* SODIUM-134
POTASSIUM-3.0* CHLORIDE-92* TOTAL CO2-26 ANION GAP-19
.
[**2155-2-28**] 10:53PM URINE RBC-0-2 WBC-[**4-9**] BACTERIA-RARE YEAST-RARE
EPI-[**7-15**]
[**2155-2-28**] 10:53PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2155-2-28**] 10:53PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
.
[**2155-3-1**] 02:25PM TYPE-ART PO2-82* PCO2-49* PH-7.40 TOTAL
CO2-31* BASE XS-3 INTUBATED-NOT INTUBA
[**2155-3-1**] 02:25PM LACTATE-1.8
[**2155-2-28**] 10:53 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2155-3-2**]**
URINE CULTURE (Final [**2155-3-2**]): NO GROWTH.
Brief Hospital Course:
A/P: 42 yoM with MMP, including morbid obesity, aortic
dissection s/p repair and complicated by h/o multiple embolic
strokes, CKD who presents with hyperglycemia now on insulin gtt.
.
1) Hyperglycemia: the patient was given IV insulin, aggressive
IVF and placed in the [**Hospital Unit Name 153**] for further care. A TLC was placed
given the patient's poor IV access. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was
obtained for titration of lantus and humalog. The patient's BG
trended down and he was transitioned to sc regimen without
difficulty. He was transferred to the floor with diabetic
teaching. He will follow up with [**Last Name (un) **] the day after discharge
for further care.
2) Altered Mental Status: combination of hyperglycemia and
uremia. head CT was unremarkable. This resolved with adequate
control of BG.
3) History of aortic dissection: No active issues.
- Continue lopressor
.
4) Status post CVA: No active issues.
- Continue ASA, lopressor, trileptal
.
5) Peripheral neuropathy: No active issues.
- Continue amitryptiline, vitamin B12
6) Hypertension: The patient's HCTZ was held during the
admission as he was admitted with severe volume depletion and
ARF that improved with IVF. The HCTZ will need to be restarted
by his PCP as an outpatient.
Medications on Admission:
albuterol IH prn wheezing
amitriptyline 50 mg QHS
androgel 1.25g transdermal QDay
aspirin 81 QD
calcitriol 0.25 mcg TIW
cyanocobalamin [**2147**] mcg QDay
gabapentin 600 mg TID
hydrochlorothiazide 25 mg QDay
Lopressor 200 mg [**Hospital1 **]
amlodipine 10 mg QDay
Trileptal 300 mg [**Hospital1 **]
Xalatan 1 drop OU daily
- amoxicillin 500 mg PO QDay x 3 days (for recent dental
procedure)
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Metoprolol Tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO three
times a week.
8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
10. Lantus 100 unit/mL Solution Sig: One (1) 40 Subcutaneous at
bedtime.
Disp:*1 bottle* Refills:*5*
11. Humalog 100 unit/mL Solution Sig: One (1) as directed by
sliding scale Subcutaneous four times a day.
Disp:*2 bottles* Refills:*5*
12. Syringe (Disposable) Syringe Sig: One (1) Miscellaneous
four times a day.
Disp:*1 box* Refills:*5*
13. Lancets,Ultra Thin Misc Sig: One (1) Miscellaneous four
times a day.
Disp:*1 box* Refills:*2*
14. Humalog sliding scale
Please see attached sliding scale for your Humalog dose. You
should check your blood sugar four times daily (prior to each
meal and once at bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Diabetes Type II, insulin dependent
hyperglycemia
HTN
dyslipidemia
asthma
ARF
Discharge Condition:
stable
Discharge Instructions:
You were admitted with hyperglycemia and diagnosed with diabetes
Type 2. You will need careful follow up in the future from both
your PCP and the [**Name9 (PRE) **] Clinic. Please call your PCP if you
develop increased urinary frequency, thirst, dizziness, or new
symptoms.
Followup Instructions:
[**Hospital **] Clinic [**Telephone/Fax (1) 2384**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] [**2155-3-5**] at
2:30 PM
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2155-3-7**] 9:45
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2155-4-1**]
1:45
Provider: [**Name8 (MD) 23218**],MD Phone:[**Telephone/Fax (1) 1091**]
Date/Time:[**2155-4-10**] 9:10
Your hydrochlorathiazide is currently on hold until your renal
function improves.
ICD9 Codes: 5849, 5859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1534
} | Medical Text: Admission Date: [**2183-5-20**] Discharge Date: [**2183-5-23**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
None - intubated in the field and initially admitted to the ICU
History of Present Illness:
Patient is a 90 RHW with HTN and afib on coumadin presents from
OSH. She is
intubated and HPI obtained from family who was at bedside.
She is very healthy at baseline, lives alone and is independent.
She works as a volunteer at [**Hospital **] Hospital. She was at work
this morning, and didn't appear her usual self this am. She was
somewhat confused at the front desk at work. Around noon, she
was found down in the restroom and was confused. After fall,
when asked by family when they reached OSH ED, she denies
seizure and didn't recall how she fell. BP on arrival at OSH
:187/75 which became 206/98 shortly. Labs at OSH showed CBC
8.2, 13.9/40, 226. Chem 7 was normal. INR was 3.4. She became
drowsy and was intubated after 10 mg vit K, 2 FFP, 1 gram
dilantin, 5 lopressor, with lido/eto/succ/ and put on propofol.
INR after the FFP was 2.3.
She was then sent to [**Hospital1 18**] ED.
Past Medical History:
1.Hypertension
2. Atrial fibrillation on Coumadin
3. Osteoporosis
Social History:
Lives alone and volunteers at the hospital gift shop. Denies
smoking, EtOH. Full code.
Family History:
Mother had stroke.
Physical Exam:
Physical Exam on Admission:
Vitals: 98.4 76 136/84 14 99% 2L Nasal Cannula
General: Intubated
HEENT: NC/AT, no scleral icterus noted,
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Clear
Cardiac: [**Last Name (un) **] Rare rhythm nl. S1S2, no M/R/G noted
Abdomen: soft, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: intubated, off propofol follows commands on the
left side, doesnt follow on right side.
-CN:
PERRL 3 to 2mm and brisk. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages. face appears symmetric
though limited by intubated status.
-Motor: moves left side spontaneously and to pain. doesnt move
right side even to painful stimuli.
-DTRs: [**Name2 (NI) **] in arms but none for patellar or achilles. Plantar
response was extensor on right and flexor on left
-Coordination: Intact FNF.
-Gait: Defd.
Pertinent Results:
[**2183-5-21**] 02:22AM BLOOD WBC-10.0 RBC-3.81* Hgb-12.5 Hct-35.8*
MCV-94 MCH-32.9* MCHC-35.0 RDW-14.2 Plt Ct-233
[**2183-5-21**] 02:22AM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-134
K-4.3 Cl-99 HCO3-24 AnGap-15
[**2183-5-20**] 11:00PM BLOOD Calcium-8.4 Phos-2.1* Mg-1.6
[**2183-5-22**] 07:45AM BLOOD %HbA1c-5.7 eAG-117
[**2183-5-21**] 02:22AM BLOOD Triglyc-86 HDL-62 CHOL/HD-2.7 LDLcalc-91
[**2183-5-20**] 05:30PM URINE RBC-3* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2183-5-20**] 05:30PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-300 Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
CT C-spine:
1. No evidence of fracture or malalignment.
2. Multilevel degenerative changes of the cervical spine, as
described above.
3. Mild pulmonary edema.
CT head:
Stable 2 x 1 x 1.6-cm left thalamic acute-to-subacute
intraparenchymal
hemorrhage is surrounded by stable mild edema. There is
hemorrhagic extension into the ventricular system with blood
layering in the left occipital [**Doctor Last Name 534**]. There is no hydrocephalus.
No new intracranial hemorrhage. No significant mass effect or
shift of normally midline structures. The [**Doctor Last Name 352**]-white matter
differentiation is well preserved.
There are no suspicious lytic or sclerotic bony lesions. There
are mild
aerosolized secretions in the left sphenoid sinus, likely
related to
endotracheal and nasogastric intubation. The patient is status
post bilateral lens replacement.
IMPRESSION: Unchanged left thalamic hemorrhage with
intraventricular
extension.
Brief Hospital Course:
Patient is a 90 RHW with HTN and afib on coumadin presents from
OSH. Patient was working at [**Hospital **] Hospital, where she has
been volunteering at the gift shop for the past 30 years. She
reportedly collapsed at the hospital and was intubated in the
field. She was found to have R sided weakness and CT showed
left BG hemorrhage with minimal intraventricular extension. She
was also reportedly hypertensive upto 200/90.
Patient received vitamin K and FFP before the transfer. Patient
was admitted to the ICU and repeat head CT here showed stable L
BG hemorrhage. Given the location of blood and her BP, this is
most consistent with hypertensive hemorrhage. She was able to
be extubated the day after admission to ICU and she was
transferred out to the neurology floor on hospital day #2.
Patient's exam is consistent with left basal ganglia hemorrhage
- mild R facial droop with right sided weakness of arm and leg.
Patient underwent repeat scan which shows stable hemorrhage with
no further expansion.
Given the hemorrhage, patient remained off Coumadin or heparin
during this admission. Patient is to start ASA 81mg on [**5-27**] for
stroke prevention given her atrial fibrillation. Then Coumadin
needs to be started on [**5-30**] with ASA 81mg daily bridging until
INR >2.0. Goal INR is between 2~3 for stroke prevention given
her atrial fibrillation. Possibility of dabigatran instead of
Coumadin was discussed with Dr. [**Last Name (STitle) 23246**] (cardiologist) but
given the lack of strong evidence in her age group and no known
reversing [**Doctor Last Name 360**], the decision was made to restart Coumadin on
[**5-30**] rather than switching.
Patient was evaluated per PT and OT who recommend discharge to
acute rehabilitation facility for inpatient physical and
occupational therapy.
Medications on Admission:
coumadin 2.5 mg po daily except on wed and saturday
metoprolol 25 mg po bid
hctz 25 mg po daily
alendronate 20mg po weekly
calcium and D 2 xs per day
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain fever.
4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day for 1 weeks: Please
start ASA 81mg daily on [**2183-5-27**] and stop once INR > 2.0 with
Coumadin.
8. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
goal INR 2~3 and please stop ASA 81mg daily once INR > 2.0.
9. alendronate 10 mg Tablet Sig: Two (2) Tablet PO once a week.
10. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
11. heparin (porcine) 5,000 unit/mL Cartridge Sig: One (1)
Injection TID (3 times a day): can stop once patient ambulating
regularly.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left basal ganglia hemorrhage witn minimal intraventricular
extension
Atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent about self and hospital.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro deficits: Alery and mostly oriented to self and place.
Fluent speech with intact repetition. Mild R facial droop with
right sided weakness of R arm and leg in upper motor neuron
pattern.
Discharge Instructions:
You were transferred from [**Hospital **] Hospital after being intubated
and found to have left basal ganglia hemorrhage. Your blood
pressure was elevated up to 200/90 per field report. Given the
location of hemorrhage and blood pressure, your hemorrhage is
most likely due to hypertension.
You were successfully extubated the day after your admission and
you were transferred out of the intensive care unit on your
hospital day #2. You have slight right facial droop and right
sided weakness due to your hemorrhage. Notably, your INR was
within therapeutic range and you are recommended to restart
Coumadin for your on [**2183-5-30**]. You will be started on ASA 81mg
daily on [**5-27**] as bridging therapy and please remain on ASA 81mg
until your INR is therapeutic (INR > 2.0). Please stop ASA once
INR > 2.0.
You were evaluated per physical and occupational therapy and
recommended to go to acute rehabilitation facility. You are
also scheduled to follow-up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
neurologist who ovesaw your care during this admission.
Followup Instructions:
Please follow-up with your primary health care providers 1~2
weeks after your discharge from rehabilitation facility
including Dr. [**Last Name (STitle) 23246**] (cardiologist) and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 911**] (PCP).
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2183-7-25**] 2:30
Please call [**Telephone/Fax (1) 10676**] to complete registration and you will
need a referral from your PCP before the scheduled appointment
as listed above.
Completed by:[**2183-5-23**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1535
} | Medical Text: Admission Date: [**2119-3-31**] Discharge Date: [**2119-4-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
ICU stay
History of Present Illness:
88 yo F w/COPD, Emphysema, HTN, remote h/o endometrial CA with ?
pulm mets recent admission [**Date range (1) 93122**] for weakness sent to rehab,
now admitted for weakness, fever at home 102, increasing SOB and
cough. Pt was discharged from rehab on [**3-30**] to home, at baseline
able to ambulate with walker. On [**3-30**] felt relatively weak, per
[**Name (NI) 269**] unable to get up from toilet, no episodes of syncope or fall
at home. Overnight she slept on cough without changing her
clothes. In am, her housekeeper found her sleeping on her couch.
Temp taken 102, given weakness, fever, SOB and cough since
thursday pt was sent into ED. Pt is unable to recall events in
terms of why she was sent into ED. She did c/o some DOE,
wheezing and cough, she is not O2 dependent at home. Sick
contacts from rehab, no recent travelling. No GI symptoms, no
N/V/Abdominal pain, no diarrhea, no dysuria, no BRBPR, no
melena, no hematuria. Pt with poor PO intake. Per pt no HA,
confusion, visual changes. No changes in her meds.
Past Medical History:
- endometrial cancer, s/p TAH [**2097**]
- spinal stenosis
- hypertension
- emphysema
- deviated septum
- hemorrhoids (recent colonoscopy [**11-10**])-
- s/p left shoulder replacement
- s/p right hip replacement
- right rotator cuff tear
- hyperlipidemia
Social History:
Lives alone at [**Street Address(2) **], senior center. She has a lifeline.
Her daughter is close by and very involved. She moved from New
Jersey one year ago. She quit tobacco in [**2097**] (smoked for 50
years). Very rare EtOH.
Family History:
NC
Physical Exam:
VS: 96.0 BP 120/66 HR 83 RR 17 97% 2L NC; pulsus=5
GEN: NAD
HEENT: Dry MM, PERRL
RESP: Distant breath sounds with minimal exp wheeze, no crackles
CV: Reg Nml S1, S2, no M/R/G
ABD: soft ND/NT +BS
EXT: no peripheral edema, warm, 2x3cm blister on foot-no
drainage, no lesions, no warmth/erythema
NEURO: A&O x3, no focal deficits, following commands
appropriately, strength 3/5 LE, [**4-8**] UE b/l, normal sensation,
dop DP pulses b/l
Pertinent Results:
[**2119-3-31**] 12:15PM BLOOD WBC-8.2 RBC-5.12 Hgb-16.4*# Hct-46.7
MCV-91 MCH-32.0 MCHC-35.1* RDW-12.3 Plt Ct-225
[**2119-4-1**] 03:55AM BLOOD WBC-4.9 RBC-4.37 Hgb-13.4 Hct-40.5 MCV-93
MCH-30.7 MCHC-33.2 RDW-12.4 Plt Ct-184
[**2119-4-6**] 06:30AM BLOOD WBC-9.3 RBC-4.55 Hgb-14.0 Hct-41.8 MCV-92
MCH-30.8 MCHC-33.6 RDW-12.4 Plt Ct-286
[**2119-4-7**] 06:54AM BLOOD WBC-10.9 RBC-4.83 Hgb-14.7 Hct-44.5
MCV-92 MCH-30.4 MCHC-33.0 RDW-12.9 Plt Ct-329
[**2119-3-31**] 12:15PM BLOOD PT-13.2 PTT-26.7 INR(PT)-1.1
[**2119-4-7**] 06:54AM BLOOD PT-12.5 PTT-57.3* INR(PT)-1.1
[**2119-3-31**] 12:15PM BLOOD Glucose-132* UreaN-18 Creat-0.8 Na-137
K-3.6 Cl-95* HCO3-29 AnGap-17
[**2119-4-1**] 03:55AM BLOOD Glucose-155* UreaN-18 Creat-0.7 Na-142
K-3.1* Cl-108 HCO3-27 AnGap-10
[**2119-4-2**] 06:33AM BLOOD Glucose-97 UreaN-21* Creat-0.7 Na-139
K-4.5 Cl-106 HCO3-25 AnGap-13
[**2119-4-7**] 06:54AM BLOOD Glucose-80 UreaN-26* Creat-0.7 Na-140
K-4.0 Cl-97 HCO3-32 AnGap-15
[**2119-3-31**] 12:15PM BLOOD CK(CPK)-303*
[**2119-4-3**] 06:30AM BLOOD ALT-19 AST-23 LD(LDH)-239 AlkPhos-42
TotBili-0.3
[**2119-3-31**] 12:15PM BLOOD CK-MB-3 cTropnT-<0.01
[**2119-3-31**] 12:15PM BLOOD cTropnT-<0.01
[**2119-3-31**] 08:37PM BLOOD CK-MB-4 cTropnT-<0.01
[**2119-3-31**] 12:15PM BLOOD Calcium-9.0 Phos-3.4 Mg-1.7
[**2119-4-1**] 03:55AM BLOOD Calcium-7.5* Phos-3.4 Mg-1.6
[**2119-4-1**] 03:55AM BLOOD TSH-0.27
[**2119-3-31**] 12:15PM BLOOD Cortsol-28.5*
[**2119-3-31**] 12:15PM BLOOD CRP-40.0*
[**2119-3-31**] 12:19PM BLOOD Lactate-1.9 K-3.5
CTA
1. No evidence of aortic dissection, pulmonary embolism, or
etiology for acute shortness of breath identified. No interval
change in multiple metastatic nodules within the chest.
2. Marked atherosclerotic disease involving the aorta and
coronary circulation.
3. Unchanged appearance of sclerotic foci within the thoracic
vertebral bodies which are worrisome for metastatic disease.
4. Reidentification of a left adrenal nodule with Hounsfield
units suggesting that it is a benign adenoma. If alteration
clinical management will occur this can be further evaluated
with dedicated CT adrenal protocol or MRI.
ECHOCARDIOGRAM
The left atrium is normal in size. 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)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. No 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.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Brief Hospital Course:
INFLUENZA / SEPSIS
Ms. [**Known lastname 93123**] was initally admitted to the intensive care unit
from the emergency department with sepsis, fever, hypotension.
The patient did have CTA which showed no e/o PE and also had
serial cardiac enzymes which showed no new MI. She was found to
be influenza A positive, and treated with oseltamivir for five
day course. She was called out to the floor after brief stay.
She did not require mechanical ventilation or vasopressor
support.
COPD
The patient was treated for COPD exacerbation in the setting of
influenza.
She received po pulse of prednisone for five days. She received
azithromycin for five days. She required frequent nebulizer
treatments that became less frequent over time. She was still on
1L NC for sats in the low 90s. She should be titrated to range
of 89-94%, as higher O2 sats can worsen COPD.
HYPERTENSION
The patient was hypertensive in setting of steroids requiring
PRN hydralazine, worse at night. This improved after steroids.
She is being discharged on her most recent outpatient
medications.
LUNG NODULES
The patient has suspicious lung nodules on CT and history of
endometrial cancer. She had recent bronchoscopy last admission,
which was negative for malignancy. However, this was not a very
sensitive test. Our team felt that if the patient desired, she
should be seen in thoracic oncology clinic.
Thoracic [**Hospital **] Cancer Center [**Hospital1 18**] ([**2119**]
Her prior oncologist was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2406**] at [**Hospital1 112**] per patient.
Medications on Admission:
1. Acetaminophen 500 mg q6hr prn
2. Tiotropium Bromide 18 mcg daily
3. Aspirin 81 mg daily
4. Sucralfate 1 gram Tablet qid
5. Ezetimibe/simvastatin 10/20mg daily
6. Zinc Oxide-Cod Liver Oil 40% PRN
7. Cyanocobalamin 100mcg daily
8. Hexavitamin 1 daily
9. Metoprolol Succinate 25 mg DAILY
10. Benazepril 20 mg [**Hospital1 **]
11. Levofloxacin 250mg daily for 5 days.
12. Albuterol Q4HR prn
13. Fluticasone-Salmeterol 100-50 mcg/Dose [**Hospital1 **]
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): While in [**Location (un) **] Home to be
given if not ambulatory .
2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
7. Vytorin [**10-23**] 10-20 mg Tablet Sig: One (1) Tablet 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. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-13**]
MLs PO Q6H (every 6 hours) as needed for cough.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-4**] Sprays Nasal
QID (4 times a day) as needed.
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed.
13. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
14. Benazepril 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
16. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Topical
once a day as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY COPD
Influenza
SECONDARY h/o endometrial cancer
Hypertension
Discharge Condition:
Improved but still on 1L NC
Discharge Instructions:
You were admitted with shortness of breath and found to have
influenza. This exacerbated your emphysema/COPD. You were
briefly in the intensive care unit.
You were treated with Tamiflu for five days.
Your blood pressure was elevated during your stay. You are being
discharged on your home blood pressure medications. Please
discuss your blood pressure with your primary care physician.
If you develop fevers, chills, worsening shortness of breath or
other concerning symptoms, please call your doctor and return to
the hospital.
Followup Instructions:
Please follow-up with your primary care physician
[**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 608**]
Please follow-up with the thoracic oncolocy.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1536
} | Medical Text: Admission Date: [**2111-8-4**] Discharge Date: [**2111-8-9**]
Service: SURGERY
Allergies:
Penicillins / Lyrica
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Right lower extremity rest pain with non-healing right toe ulcer
Major Surgical or Invasive Procedure:
Right femoro-peroneal bypass graft with lesser saphenous vein
graft
History of Present Illness:
This patient is an 85 year old male with a history of severe
coronary artery disease s/p myocardial infarction, congestive
heart failure, hypertension who presents with chronit
unremitting right lower extremity rest pain and a non-healing
right toe ulcer. The patient received an extensive coronary
work-up prior to presentation and was felt to be a poor
operative candidate given his other co-morbidities. This poor
candidate status was discussed at length with the patient and
his family, who remained quite insistent that, despite the high
risks, we procede with a limb-saving intervention
Past Medical History:
CAD,MI ,CHF,HTN,hypercholestremia,DUJd of rt. hip,hx TISs/p left
CEA [**2094**]'s,BPH s/p turn-now w frequency/nocturia
Social History:
Remote history of smoking, quit 40 years ago, social ETOH use.
Physical Exam:
Awake and alert, NAD
RRR w/ SEM at base
Crackles at lung bases on auscultation bilaterally
Abdomen soft, obese, non-tender
Pulse exam: DP/PT dopplerable bilaterally
Brief Hospital Course:
The patient was admitted to the hospital and started on IV
antibiotics to treat his non-healing ulcer. Cultures were taken,
and ultimately grew out gram-positive cocci and gram-negative
rods. He was taken to the operating room on [**8-6**] for a right
femoro-peroneal bypass graft with lesser saphenous vein. The
patient initially tolerated this procedure well and was taken to
the vascular surgery ICU for recovery. On the morning of
post-operative day #2, the patient began to complain of chest
pain and was found to have a systolic blood pressure of 85 with
elevated pulmonary artery pressures of 60/30. This picture was
concerning for an active coronary event. The patient was
immediately transferred to the cardiovascular surgery ICU for
further monitoring and treatment. An electrocardiogram showed
new lateral precordial ST-segment elevation. Troponins were
checked and were found to be rising to 0.67. At 2:30am on
post-operative day #3, the patient was found to be tachypnic and
tachcardic. Lasix was given emperically, however, soon after the
patient became unresponsive and asystolic. ACLS protocol was
initiated and the patient was coded for 30 minutes without
return of cardiac function. The patient was pronounced deceased
at 3:57am.
Medications on Admission:
lasix 80mgm qam,lasix 40mgm qpm,plavix 75mgm',kcl
20meq",atorvastatin 40mgm',lopressor25mgm"percoset
Discharge Disposition:
Expired
Discharge Diagnosis:
Coronary artery disease, s/p myocardial infarction
Peripheral vascular disease
Congestive heart failure
Hypercholesterolemia
Benign prostatic hyperplasia
Carotid stenosis s/p carotid endarterectomy
Discharge Condition:
Expired
ICD9 Codes: 4280, 4241, 412, 4439, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1537
} | Medical Text: Admission Date: [**2181-12-19**] Discharge Date: [**2182-4-10**]
Date of Birth: [**2127-4-15**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
Intraventricular drain placement
History of Present Illness:
54 yo man with PMH of HTN, but otherwise unknown who was at work
today whe he collapsed atound 1330. Was noted to have right
themiparesis, aphasia and MS changes. Rapidly lost
consciousness and was taken to [**Hospital **] Hospital. CT there
showed 5.5cm left lentiform nucleus bleed with 14mm shift and
intraventricular spread. He was intubated and transfered to
[**Hospital1 18**]. In the ED, neurosurgery placed an intraventricular drain.
Past Medical History:
HTN
Social History:
Wife is [**Name (NI) 8003**] speaking only therefore an interpreter was
present and assisted
wife with calls to family members to update them. Social work
met a second time with wife, daughter, son-in-law and neuro-med
re: possible outcomes, family able to confirm their
understanding and request that trach, peg and rehabilitation be
pursued. Wife seemed unable to speak to what the pt would
consider as quality
of life, rather stated her commitment to caring for her husband
and her knowledge of people who have been given poor prognosis
and "are out walking in the street now". Supported wife's
decisions and assisted her with completion of
paper work for NH Medicaid and [**Social Security Number 76688**]social security disability.
Family History:
NC
Physical Exam:
BP- 225/118 HR- 63 RR-16 O2Sat 100 vented
Gen: intubated and off propofol for 10 minutes
HEENT: NC/AT, moist oral mucosa with some blood
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: intubated and off sedation 10 minutes now. Does
not follow commands. Moves trunk and arms weakly, right>left to
nox stim. DOes not withdraw legs. No spont movements.
Cranial Nerves:
Pupils equally round and slugglishly reactive to light, 2.5 to 2
mm bilaterally. No occulocephalics. Corneals intact weakly
bilatearlly. intubated.
Motor:
Normal bulk bilaterally. Tone normal. Right arm postures to nox
stim and left arm withdraws weakly. Legs do not withdraw.
Sensation: withdraws right arm > left
Reflexes:
+1 and symmetric at Biceps. no reflexes in LE. Toes mute
bilaterally
Coordination: NA
Pertinent Results:
[**2181-12-19**] 05:40PM BLOOD WBC-7.6 RBC-4.24* Hgb-11.1* Hct-35.3*
MCV-83 MCH-26.2* MCHC-31.5 RDW-13.8 Plt Ct-244
[**2181-12-21**] 03:17AM BLOOD WBC-8.7 RBC-4.04* Hgb-10.8* Hct-32.6*
MCV-81* MCH-26.8* MCHC-33.2 RDW-14.1 Plt Ct-230
[**2181-12-19**] 05:40PM BLOOD PT-12.8 PTT-24.3 INR(PT)-1.1
[**2181-12-20**] 03:00AM BLOOD PT-12.8 PTT-26.0 INR(PT)-1.1
[**2181-12-19**] 05:40PM BLOOD Glucose-174* UreaN-13 Creat-0.8 Na-138
K-4.9 Cl-107 HCO3-19* AnGap-17
[**2181-12-19**] 05:40PM BLOOD cTropnT-<0.01
[**2181-12-20**] 03:06AM BLOOD CK-MB-6 cTropnT-<0.01
[**2181-12-20**] 10:51AM BLOOD CK-MB-5 cTropnT-<0.01
[**2181-12-19**] 05:40PM BLOOD Albumin-3.7 Calcium-7.8* Phos-3.3 Mg-1.8
[**2181-12-20**] 10:51AM BLOOD Triglyc-46 HDL-71 CHOL/HD-2.3 LDLcalc-84
[**2181-12-20**] 12:29PM BLOOD %HbA1c-5.8
[**2181-12-19**] 05:40PM BLOOD Phenyto-7.7*
[**2181-12-19**] 05:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
================================
Head CT [**12-19**]:
Stable size of left basal ganglia hemorrhage with
intraventricular extension, associated mass effect, subfalcine
and uncal herniation. Interval ventricular shunt placement with
mild decompression of the ventricles.
---------
HEAD CT [**12-20**]: There is no change in the left basal ganglia
bleed, which extends into the centrum semiovale superiorly and
has surrounding vasogenic edema. There is persistent compression
of the ventricles and midline shift and residual uncal
herniation. No fractures are identified. There is opacification
of the sinuses consistent with intubation. The intraventricular
drain tip lies in the thalamus.
---------
HEAD AND NECK CTA [**12-20**]: The carotid and vertebral arteries and
their major branches are patent with no evidence of stenosis.
There is no evidence of aneurysm formation or other vascular
abnormality.
Impression: Peristent left basal ganglia hemorrhage and mass
effect. No aneurysm or other vascular abnormality. Final
addendum to follow when volume- rendered images are available
for evaluation.
---------
CT-head [**2182-1-2**]:
IMPRESSION:
1. Ventriculostomy catheter terminates in the third ventricle
with unchanged appearance of the known intraparenchymal
hemorrhage and 9 mm of rightward midline shift.
2. Right scalp soft tissue swelling and fluid collection
measuring 12 mm thick, likely secondary to recent
ventriculostomy catheter revision.
---------
CT head [**2182-1-9**]:
IMPRESSION: Since [**2182-1-2**], minimal decrease in size of the
hyperdense
component of the left basal ganglia/centrum semiovale hemorrhage
but with
minimal worsening of the surrounding edema which is causing
minimal worsening of the left to right shift of the normally
midline structures, now measuring approximately 7 mm.
Tiny amount of blood layering within the occipital [**Doctor Last Name 534**] of the
right lateral ventricle.
Basal cisterns are still patent. There is diffuse effacement of
the left
cerebral sulci.
-----
CT head ([**2182-2-2**]):
IMPRESSION:
1. No hydrocephalus or evidence of shunt malfunction is
identified.
2. Hypoattenuation without evidence of acute hemorrhage in the
region of old intraparenchymal hemorrhage within the left basal
ganglia/centrum semiovale
-----
CT head ([**2182-2-27**]):
IMPRESSION: No intracranial hemorrhages. No change in
ventricular size.
-----
CT head ([**2182-3-5**]):
IMPRESSION: No short interval change. No intracranial
hemorrhages and stable ventricular size.
-----
CT head ([**2182-3-13**]):
CONCLUSION:
No interval change in the appearances of the ventricular system
post-stent
placement. No new abnormality.
======
Video Oropharyngeal Swallow ([**2182-2-8**]):
IMPRESSION: Mild-to-moderate impairment of oral phase; however,
there is no penetration or aspiration. For further details, see
speech and swallow
evaluation from the same date.
=====
Renal ultrasound ([**2182-2-27**]):
IMPRESSION: Non-obstructing left renal stone. No evidence of
hydronephrosis. Nearly symmetric size and flow of the kidneys.
===============
ECHO [**2181-12-21**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. The increased transaortic velocity is likely related
to high cardiac output. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Dilated thoracic aorta.
========================
EEG [**2181-12-24**]:
This is an abnormal portable EEG due to the disorganized,
low voltage, and slow background consistent with a marked/severe
encephalopathy which suggests dysfunction of bilateral
subcortical or
deep midline structures. Medications, metabolic disturbances,
infection, and anoxia are among the common causes of
encephalopathy but
there are others. The increased voltage amplitude seen about the
C4-P4
and P4-O2 electrode channels likely represent a breach rhythm
from a
skull defect. There were no epileptiform features. No
electrographic
seizure activity was noted.
----
EEG ([**2182-3-9**]):
IMPRESSION: This is an abnormal portable EEG due to an
intermittent
asymmetry between the two hemispheres, with loss of faster
frequencies
and more prominent delta slowing noted broadly over the left
side.
Findings are consistent with an underlying region of cortical
and
subcortical dysfunction on the left. In addition, the background
was
disorganized, poorly modulated and slow with frequent bursts of
generalized slowing. This constellation of findings is
consistent with
a moderate global encephalopathy, due to dysfunction of
bilateral
subcortical or deep midline structures. Medications, metabolic
disturbances, and infection are among the common causes of
infection.
There were no epileptiform features and no electrographic
seizure
activity was noted.
-----
EEG ([**2182-3-14**]):
IMPRESSION: This is an abnormal routine EEG due to the low
voltage fast
and disorganized background with intermittent bursts of moderate
amplitude generalized mixed frequency slowing consistent with a
mild
encephalopathy suggesting dysfunction of bilateral subcortical
or deep
midline structures. Medications, metabolic disturbances, and
infection
are among the common causes of encephalopathy but there are
others.
There were no areas of prominent focal slowing although
encephalopathic
patterns can sometimes obscure focal findings. There were no
epileptiform features.
=======
Brief Hospital Course:
Mr. [**Known lastname 6633**] was admitted to the ICU and subsequently transferred
to the floor. His hospital course by problem is as follows:
1) Neuro / L basal ganglia bleed:
- He was very hypertensive and his mechanism for bleeding was
felt to be likely secondary to this. A CTA showed no vascular
abnormalities. His blood pressure was initially maintained
between 120-170 with a MAP of less than 130. He was also
maintained normothermic and normoglycemic. His blood pressure
was somewhat difficult to control requiring metoprolol 100 TID,
lisinopril 40mg daily, norvasc 10mg daily and HCTZ 25mg daily.
His LDL and A1c were checked and were WNL.
- upon arrival to the floors, multiple adjustments were made to
her blood pressure medications and proper control was eventually
obtained.
- sustained clonus was noted on multiple occasions on the right
side and occasionally misinterpreted as seizure activity, but
this was then followed by some reports of facial twitching and
an EEG was obtained. The EEG was not suggestive of epileptiform
activity, but due to increasing somnolence (thought to be in
part related to depression from being in the hospital for so
long)that could have been related to seizure activity (that
might be too deep to have been picked up by EEG), the decision
was made to start him on Keppra.
- Provigil was trialed with regard to his increasing somnolence,
but there was no benefit from this. He was also started on
lexapro and psychiatry team was consulted. Lexapro provided
little benefit, and psychiatry believed that a lack of response
to ritalin made one lean away from the diagnosis of depression
and more toward a diffuse encephalopathic state entered after
his large hemorrhage.
2) The patient had an extraventricular drain (EVD) placed by the
neurosurgical service for hydrocephalus. An attempt was made to
clamp and remove the EVD, but the pressure rose steeply to 30
cmH20. The drain was reopened and the patient was taken for a
ventriculoperitoneal shunt placment. The patient tolerated this
well.
3) The patient's decreased arousal prevented him from taking
adequate nutrition. A PEG tube was placed. He was started on
tube feeds. Eventually he alerted enough to taking more PO
feeds. He passed his speech and swallow study and was then
started on PO feeds.
4) The patient's decreased arrousal and decreased mobility was
felt to put him at risk for an aspiration event. He had a
tracheostomy performed to prevent aspiration. He required
oxygen via trachmask for a significant proportion of his stay.
Eventually, his trach was decannulated and he remained stable on
room air.
5) Hypertension was also a major area of concern during this
admission. Etiology of this was not well known, and further
workup included a renal ultrasound in order to rule out renal
artery stenosis (found to be negative).
6) There were considerable insurance impediments to appropriate
discharge. He stayed on the floor for >90 days awaiting
insurance issues. Please refer to the documentation from Social
Work and the Case Manager. He was markedly abulic and barely
interactive, with terse answers and limited interaction, and a
stable, dense R hemiplegia. There were no further in-hospital
complications.
7) He was evaluated by psychiatry on [**2182-3-11**] for a question
depression, and it was felt that depressive symptoms more often
seen in left hemisphere strokes. Aphasia by itself can lead to
depression especially if too many motor deficits elements given
the frustration of not being able to communicate one's thoughts
and feelings in words. He was started on Lexapro, eventually up
to 20 mg QD, but efficacy may not be evident until 6 - 8 weeks
out. Regarding activating medication like Provigil, it was of no
effect and discontinued - as outlined above.
8) He was notoriously constipated during this admission and was
kept on an intense bowel regimen.
PS The patient has his BIRTHDAY in 5 days ([**4-15**]). The nurses
were planning on a party.
Medications on Admission:
unknown
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO three
times a day. Tablet(s)
2. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) 10 mL PO BID
(2 times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) mL
Injection TID (3 times a day).
5. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
6. Hydrochlorothiazide 12.5 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO
DAILY (Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
9. Escitalopram 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
10. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
11. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO BID (2
times a day) as needed.
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day). NOTE THAT THERE IS PLENTY OF ROOM TO GO UP ON
THE METOPROLOL, HE WAS ON 100 MG TID AT SOME POINT IN TIME
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary
1. Left basal ganglia hemorrhage.
Secundary
2. Hypertension.
3. Abulia
4. Major Disposition Problem
Discharge Condition:
Vital signs stable. The patient interacts minimally with the
examiner. There is a right facial droop. The right side of the
body is densely paretic with increased tone.
Discharge Instructions:
Please take all your medications excactly as directed and please
attend all your follow-up appointments.
Please report to the nearest ER or call 911 or your PCP
immediately when you experience recurrence of weakness,
numbness, tingling, problems with vision, speech, language,
walking, thinking, headache, or difficulties arousing, or any
other signs or symptoms of concern.
Followup Instructions:
Please arrange for obtaining a primary care physician in [**Name9 (PRE) **]
[**Name9 (PRE) **] for this patient.
Completed by:[**2182-4-10**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1538
} | Medical Text: Admission Date: [**2189-10-9**] Discharge Date: [**2189-10-14**]
Date of Birth: [**2104-1-18**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Penicillins
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Transfer for ERCP
Major Surgical or Invasive Procedure:
ERCP.
History of Present Illness:
85 year old male w/ h/o HTN, GERD, Gout who is transferred to
[**Hospital1 18**] from [**Hospital3 **] for ERCP for rising tbili, ERCP
aborted today b/c of hypoxia and laryngeal spasms, now
transferred to [**Hospital Unit Name 153**] for further management.
.
Patient was in usual state of health [**10-7**], went to PCP at VA,
and reportedly had normal labs (including t bili). When he
arrived home, his wife describes pt having chills. The
following day [**10-8**], pt experienced mid epigastric abdominal
pain and presented to OSH. In the ED, he was febrile w/ tmax
102. He had an US of the abdomen by ED physician reportedly
negative. His labs on admission was notable for WBC 10.8, w/
83.6% PMN, hct 47 (trended to 37.4 on [**10-9**]), Cr 1.6, t bili 3.2
(trended 5.6 on [**10-9**]), AP 98, AST/ALT 167/184, lipase 730
(trended to 54), and trop I 0.01. UA + leuk est, nit, wbc,
bacteria. Blood cx reportedly positive for GNR. There he had a
CT abdomen w/o contrast that showed unremarkable liver, tiny
calcifications in the gallbladder representing small stones,
pancreas w/ fatty infiltrations of the head, CBD not dilated,
ileus vs enteritis w/o evidence of obstruction and 3.5cm AAA.
There was concern for possible passed gallstone, concern for
cholangitis and gallstone pancreatitis. He was started on iv
levo, flagyl, aztreonam and transferred to [**Hospital1 18**] for ERCP.
.
Patient went to ERCP. On introduction of EGD scope pt desatted
to low 80s while in prone poisition and c/o L sided chest pain.
He was also noted to have laryngeal spasms and so procedure was
stopped. Positioned pt upright and desats resolved. He was
given dilaudid for pain, zofran for nausea, and started on
lactate ringer. Post procedure his HR remained in 90s, RR 20s,
O2 mid 90s on nc. An ECG was checked and notable for nl axis,
pvc, hr 99, sinus rhythm, twi in III, no st changes. CXR w/
hilar fullness.
.
He was transferred to the medical floor once medically stable,
and ERCP with stone extraction and sphicterotomy done and was
successful. The [**Hospital3 3583**] lab faxed micro data that
showed his blood cultures initially grew out pan-sensitive
[**Last Name (LF) **], [**First Name3 (LF) **] he was put on cipro and flagyl once on the medical
floor.
Past Medical History:
HTN
Gout
GERD
MI, medically managed in his 40s
Social History:
- Tobacco: quit 50 yrs ago, but smoked 3ppd
- Alcohol: rare
- Illicits: unknown
Former plumbing contractor
Family History:
Mother w/ alzheimer dementia, Father w/ AAA
Physical Exam:
Vitals: T: 99.6 - febrile initially, but deferevesced during the
course of the admission BP: 133/63 P: 95 R: 15 O2: 99% on RA
General: Alert, oriented to self/place and time, very pleasant
HEENT: Sclera anicteric, dry MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, anterior breath sounds clear, No stridor
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: distended, tender though w/o guarding or rebound
tenderness, +BS
Ext: warm, well perfused, palpable pulses, no clubbing, cyanosis
or edema
Pertinent Results:
[**2189-10-9**] 06:14PM PT-14.9* PTT-23.7 INR(PT)-1.3*
[**2189-10-9**] 06:14PM PLT COUNT-122*
[**2189-10-9**] 06:14PM WBC-9.4 RBC-4.70 HGB-14.7 HCT-42.3 MCV-90
MCH-31.2 MCHC-34.7 RDW-14.3
[**2189-10-9**] 06:14PM CALCIUM-9.1 PHOSPHATE-2.0* MAGNESIUM-1.9
[**2189-10-9**] 06:14PM CK-MB-5 cTropnT-<0.01
[**2189-10-9**] 06:14PM LIPASE-226*
[**2189-10-9**] 06:14PM ALT(SGPT)-170* AST(SGOT)-128* LD(LDH)-197 ALK
PHOS-109 AMYLASE-169* TOT BILI-6.7*
[**2189-10-9**] 06:14PM estGFR-Using this
[**2189-10-9**] 06:14PM GLUCOSE-142* UREA N-27* CREAT-1.3* SODIUM-136
POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-25 ANION GAP-17
[**2189-10-9**] 09:11PM URINE HYALINE-1*
[**2189-10-9**] 09:11PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2189-10-9**] 09:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-SM UROBILNGN-4* PH-6.0 LEUK-NEG
[**2189-10-9**] 09:11PM URINE COLOR-AMBER APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2189-10-9**] 09:11PM URINE OSMOLAL-909
[**2189-10-9**] 09:11PM URINE HOURS-RANDOM UREA N-1153 CREAT-134
SODIUM-137 CHLORIDE-143
Brief Hospital Course:
85 year old male w/ h/o HTN, GERD, [**Hospital **] transferred to [**Hospital1 18**]
from [**Hospital3 3583**] with choledocholithiasis, gram negative
sepsis, gallstone pancreatitis and ? of cholangitis.
1. Initial ERCP unsuccessful because of laryngeal spasm, but
repeat procedure successfully completed on [**10-11**]. Ducts swept,
stone removed and sphincterotomy done. Patient tolerated
procedure well, and abdominal pain largely resolved soon
afterwards. Lipase continued to trend downwards.
Patient was put on aztreonam and flagyl initially, but this was
changed to cipro and flagyl once it became clear that the [**Month/Year (2) 14594**]
in his blood was pan sensitive. He had diarrhea through much of
his hospital course, but it became worse on cipro/flagyl, and he
developed nausea as well. Flagyl was stopped, and he had a
flexible sigmoidoscopy to look for evidence of cdiff, of which
there was none. The cipro was held when he was markedly
symptomatic.
He was discharged with levaquin for five additional days, to
complete a 10 day course of antibiotics for gram negative
sepsis. Levaquin was chosen as cipro gave him rather severe
antibiotic associated diarrhea.
2. Choledocholithiasis: Patient met with surgeon [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who
will contact him after discharge to set up an appointment for
cholecystectomy.
3. Hypertension: Meds held initially, but patient advised to
resume them on return home has sbp in 140-150 range.
Medications on Admission:
pantoprazole 40mg iv daily
levo 750mg iv q48hr
zofran 4-8mg prn
morphine 3-4mg prn
allopurinol 100mg daily
flagyl 500mg iv q8hr
dilaudid 1mg/1ml
trazadone 50mg daily
aztreonam 2gm q8hr
Discharge Medications:
1. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
Patient advised to resume home meds for gout and hypertension.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Choledocholithiasis
2. Gram negative sepsis
3. Antibiotic associated diarrhea
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**] because a gallstone was stuck in
your bile dict. You had a procedure called ERCP in which they
removed the stone. You also were found to have bacteria in the
blood at [**Hospital3 3583**]. You were started on antibiotics for
this bacteria, but then you developed severe diarrhea. You had
a flexible sigmoidoscopy to make sure that you did not have
another infection in the bowel.
We will give you a prescription for an additional 5 days of
antibiotics, as it important to re-attempt them given that you
had bacteria in your blood. If you find that your diarrhea and
gas becomes unbearable on the antibiotic, please contact me (Dr
[**First Name (STitle) **] with the contact information on my business card.
You also need to have your gallbladder removed in the near
future. You were evaluated by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] while you were
hospitalized, and her office will call you with an appointment
time to schedule your gallbladder surgery.
Followup Instructions:
Please make an appointment to see your primary care doctor at
the VA to discuss the details of this admission.
ICD9 Codes: 4019, 2749, 2875, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1539
} | Medical Text: Admission Date: [**2152-12-6**] Discharge Date: [**2152-12-29**]
Date of Birth: [**2098-6-11**] Sex: F
Service: SURGERY
Allergies:
Ivp Dye, Iodine Containing / Tetracycline
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
MVA
Major Surgical or Invasive Procedure:
Ex-Fix RLE [**12-5**]
ORIF R tib-fib [**12-7**]
Ex-Fix LLE prox fib and distal fib pilon fx [**12-7**]
Intracranial pressure monitor (bolt) placed [**12-5**] and removed [**12-7**].
IVC Filter placed [**12-7**] and removed [**12-29**]
TTE, intra-operative, [**12-7**].
Gracilus flap and STSG RLE [**12-11**]
STSG LLE over ex-fix [**12-22**]
History of Present Illness:
54yo F unrestrained driver in MVA with ejection. +LOC with
subsequent GCS 15. Brought in by EMS to trauma plus. Pt could
not recall events leading to accident.
Past Medical History:
Lupus
asthma
COPD
Social History:
family very involved, daughter, sister, brother, son
Family History:
unknown
Physical Exam:
Afebrile, HR 105, BP 110/palp, RR 18, O2 sat 100%
A&Ox3, GCS 15.
PERRL
Neck: no c-spine step off, NT
CTAB
NT ND. FAST negative.
DRE: nl tone, guaiac negative
R open tib-fix fx, L superficial abrasion over shin. R forearm
abrasion.
BL palp DP. ABI: L 1.1, R 1.3
neuro grossly intact
Pertinent Results:
[**2152-12-5**] 07:09PM BLOOD WBC-14.7* RBC-3.97* Hgb-12.6 Hct-37.2
MCV-94 MCH-31.6 MCHC-33.7 RDW-12.5 Plt Ct-339
[**2152-12-6**] 12:58AM BLOOD WBC-13.7* RBC-2.58*# Hgb-7.9*# Hct-25.1*#
MCV-97 MCH-30.6 MCHC-31.5 RDW-12.8 Plt Ct-206
[**2152-12-6**] 04:17AM BLOOD Hct-36.1#
[**2152-12-5**] 07:09PM BLOOD PT-12.5 PTT-25.5 INR(PT)-1.0
[**2152-12-5**] 07:09PM BLOOD Plt Ct-339
[**2152-12-6**] 12:58AM BLOOD Glucose-117* UreaN-10 Creat-0.7 Na-134
K-3.2* Cl-105 HCO3-24 AnGap-8
[**2152-12-5**] 07:09PM BLOOD Amylase-40
[**2152-12-6**] 12:58AM BLOOD CK(CPK)-491*
[**2152-12-6**] 12:58AM BLOOD Calcium-6.6* Phos-3.3 Mg-1.3*
[**2152-12-5**] 07:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2152-12-7**] 04:10PM BLOOD Glucose-114* Lactate-1.2 Na-136 K-4.1
Cl-111
[**2152-12-17**] 04:36AM BLOOD Glucose-137* UreaN-16 Creat-0.3* Na-137
K-4.4 Cl-103 HCO3-26 AnGap-12
[**2152-12-25**] 10:30AM BLOOD WBC-10.1 RBC-3.47* Hgb-10.4* Hct-32.4*
MCV-93 MCH-29.9 MCHC-32.0 RDW-14.7 Plt Ct-842*
[**2152-12-25**] 10:30AM BLOOD Plt Ct-842*
[**2152-12-29**] 05:37AM BLOOD Plt Ct-612*
CT ABD/PELVIS 1/4/5
IMPRESSION:
IMPRESSION:
1. Bilateral sacral alar fractures extending into the neural
foramen. S1, and probably L5 transverse process fracture on the
right.
2. Right rib fractures with small right pulmonary contusion.
Repeat
1) Comminuted sacral fractures as previously described, with
mildly increased presacral hematoma and thickening adjacent to
the psoas muscles. Otherwise unchanged abdominal and pelvic exam
from four hours prior. The examination is somewhat limited by
the lack of IV contrast.
CT head 1/4/5
IMPRESSION: Findings suspicious for a small left subdural
hematoma.
CT Cspine 1/4/5
IMPRESSION: There are fractures of the C6 right posterior
foramen transversarium and transverse process, the right C7
transverse process, the right medial first and second ribs and
transverse processes. Degenerative change, multilevel.
There is also a fracture of the right medial clavicle.
Tib Fib B/L 1/4/5
IMPRESSION:
1). Oblique fractures of the distal right tibia and fibula, with
moderate displacement and override.
2). Ill-defined lucencies overlying the bones of the right mid
and hindfoot are inadequately evaluated due to overlying cast
material.
3). Oblique fracture of the proximal left fibula and comminuted
fracture of the distal left tibia, mildly displaced.
RUE 1/4/5
IMPRESSION:
1. No fracture of the right elbow.
2. Comminuted fracture of the left fifth metacarpal, with
extension of fracture line to the CMC joint articular surface.
3. Polygonal density adjacent to the base of the right first
metacarpal. Tiny avulsion fragment versus foreign body cannot be
entirely excluded.
CT T spine 1/8/5
IMPRESSION: Tiny fracture involving the T3 spinous process which
is associated with cortication of the donor site and is most
likely chronic. Alternatively, this could represent ligamentous
calcification as well.
Brief Hospital Course:
54yo W bib EMS to trauma bay for trauma plus where underwent
thorough evaluation by trauma and ER staff. Notable injuries
included R open tib-fib fracture with intact distal pulses,
stable vitals, and a GCS 15. Ortho consult was obtained and the
R foot was splinted. Pt was placed in C-collar and stabilized.
She was taken for emergent radiography notable for Head CT
showing small ? L SDH, nl Chest CT, Abd-Pel showed BL sacral
alar fx's but no acute abdominal pathology, and extremity plain
films showed the R tib-fix fx, a L Maissonerve fx, a L distal
tib fx, and a L 5th metacarpal fx. Later reads also revealed
multiple rib fx's, a pulmonary contusion, and a clavicular fx.
Injury also significant for C7 transverse process fx and C6
transverse process/ posterior foramen fracture.
Neurosurgery consult was obtained for the L SDH and who
recommended frequent neuro checks; it was decided therefore to
place an epidural for anesthesia for Ortho's RLE ex-fix and LLE
splint. Towards the end of the case, the patient experienced a
seizure. Apparently, she became hypertensive, was given a
b-blocker, went into bronchospasm (possibly related to her
asthma), significantly retained CO2, had a seizure with a blown
pupil, got stat intubated, given propafol and dropped her BP. A
femoral a-line was placed by anesthesia. She was urgently
returned to the CT scanner; Head CT showed mild cerebral edema
and no L SDH as previously noted. An Abd-Pel CT also obtained
for ? tense abdomen was also negative. She was brought to the
the T-SICU in intubated and critical condition. Neurosurgery
placed a bolt for intracranial monitoring at the bedside. She
was hypotensive 90s/50s, given volume fluid resuscitation, and
transfused 2 units PRBCs for a Hct 25 (down from 37 on
presentation). She required neo for BP support for 24 hours,
and a R subclavian triple-lumen was placed. Ortho splinted the
L hand. The abdomen was soft. She was placed on stress dose
steroids with taper to her home daily dose, given mannitol for
ICP control, given dilantin loading dose and then tid, and
Ancef/Gent for Abx.
On HD 2 a swan-ganz catheter was placed in the L subclavian but
resulted in a L pneumothorax. A L chest tube was placed, this
had a mild air leak. Serial Hcts were performed revealing a
slowly downtrending Hct.
On HD 3 the intracranial bolt was removed. She was taken to the
OR for an IVC filter for PE prophylaxis as the pt could not
receive heparin nor could pneumoboots be applied to her LE
because of her orthopedic injuries. Ortho performed an ORIF for
the RLE and an Ex-Fix LLE. An intraoperative TTE revealed no
aortic injury and an EF 65%. Transferred to the floor after CT
removal in stable and improving condition on HD 11.
A plastic surgery consult was obtained for the RLE degloving
injury- throughout hospital course the plastic surgery team
completed a gracilis flap and split thickness skin grafts to RLE
and LLE (HD 7, 17).
Throughout hospitalization, pt continued to improve steadily.
Tolerating POs well, maintained on PO pain meds, converted to
lovenox for anticoagulation, IVC filter removed, moving bowels,
and OOB to chair as tolerated. She was transferred to rehab on
HD# 25 for continued physical therapy within her limitations of
PWB for transfer only RLE and NWB LLE, and ROM exercises for
LUE. She was given instructions for followup with Neurosurgery
(2weeks for Cspine eval, hard collar at all times), Ortho (5
weeks for LLE exfix removal), Plastics (1 week for graft eval),
and Trauma (2 weeks for interval fup).
Medications on Admission:
Prednisone 20mg po qd
? plaquinel
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
Disp:*qs * Refills:*0*
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q2-3H (every 2-3 hours).
Disp:*qs * Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*0*
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as
needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for for agitation/sleep.
Disp:*30 Tablet(s)* Refills:*0*
10. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
11. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Disp:*qs * Refills:*0*
13. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane Q4H (every 4 hours) as needed.
Disp:*qs * Refills:*0*
14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
Disp:*20 Capsule(s)* Refills:*0*
15. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous [**Hospital1 **] (2 times a day).
Disp:*qs * Refills:*0*
16. Dolasetron Mesylate 12.5 mg IV Q4-6H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
MVA
L frontal SDH, small
BL sacral alar fx c presacral hematoma
R 7th posterior rib fx c contusion
R 3rd anterior rib fx
R 1st and 2nd rib fxs
R distal tib-fib fx
L proximal fibula and distal tibia fx.
L 5th metacarpal fx
S1/L5 transverse process fx
R medial clavicle fx
R C6 transverse process / posterior foramen fx
R C7 transverse process fx
bronchospasm
seizure
Discharge Condition:
stable
Discharge Instructions:
-Regular diet as tolerated
-Continue to wear the cervical collar at all times.
-Non-weight-bearing Left leg at all times. [**Month (only) 116**] weight-bear
Right leg for transfers only, otherwise non-weight-bearing Right
leg for ambulation.
Followup Instructions:
1. Follow-up with Orthopedics, Dr. [**Last Name (STitle) 1005**], for removal of
your external fixation device (left leg) in 5 weeks after
discharge. Call [**Telephone/Fax (1) 4845**] for an appointment.
2. Follow-up with Plastic Surgery [**Telephone/Fax (1) 23144**] for [**Hospital 2974**] clinic
next week to evaluate your skin grafts and your left hand
fracture.
3. Follow-up with Neurology, [**Telephone/Fax (1) 1690**], for further
evaluation of your closed head injury
4. Follow-up with Neurosurgery, Dr. [**Last Name (STitle) 739**], in 2 weeks
for evaluation of your cervical collar. Call [**Telephone/Fax (1) 1669**] for an
appointment.
ICD9 Codes: 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1540
} | Medical Text: Admission Date: [**2169-4-5**] Discharge Date: [**2169-4-16**]
Date of Birth: [**2125-10-11**] Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Penicillins / Codeine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43F H/O IPF, COPD/Asthma (Multiple Intubations), Current
Smoking, Schizoaffective Disorder/Depression with URI symptoms
and dyspnea. Patient was well until about one week ago when she
developed rhinorrhea, productive cough of yellow sputum, chills,
fevers, mild right ear pain, fatigue and then increased dyspnea,
PND, orthopnea and decreased exercise tolerance. There was no
rash, headache, sore throat, nausea, vomiting, diarrhea,
constipation, chest pain, leg pain, but has chronic mild
swelling. She saw her PCP and had mild improvement with
nebulizers. Her symptoms then worsened and she called EMS.
ED Course: Afebrile. OS85%RA. Peak flow at 250 (baseline of
350). CXR showing perihilar haziness with asymmetric hilar
fullness and no definite infiltrate. Started on Levofloxacin,
Nebs and admitted to Medicine.
Past Medical History:
1. IPF: DIP, transthoracic lung bx ([**2166**]) negative
2. COPD/Asthma: Spirometry ([**5-/2164**]) FVC 2.48 (67%), FEV1 1.96
(68%), FEV1/FVC 101%, DLCO ([**4-/2163**]) 51%, Lung vol ([**4-/2163**]): TLC 64%,
FRC 48%, RV 49%, ERV 47%, multiple admissions, intubation x 1
[**2163**]
3. Current Smoking
4. Schizoaffective Disorder (VH/AH/Paranoia/Olfactory
Hallucinations)
5. Depression
6. H/O Heavy ETOH Use and DTs
7. TLE (Most Recent Sz five years ago)
8. H/O VRE/MRSA
9. PPD Positive S/P INH
10. H/O Meningitis
11. S/P Ex Lap
12. Hyperlipidemia
13. DM
Social History:
She lives alone and is a jewlery maker. She currently smokes and
has 30 pack-years. She is detemited to quit smoking today. She
used marijuana, cocaine and LSD as a teenager but has not used
drugs since then. She rarely drinks ETOH.
Family History:
No lung or known autoimmune disease (such as SLE, Rh or
Sjogrens). Her father and mother died from MIs at ages 55 and
63, resp. Her siblings had MIs in their 40s.
Physical Exam:
T100.3 HR115 BP144/69 OS95%2L.
GEN - NAD. SPEAKING IN FULL SENTENCES. EATING.
HEENT - MMM. CLEAR OP. ANICTERIC.
RESP - B/L EXP WHEEZES WITH POOR AIR MOVEMENT. Improving with
peak flows > 300 and minimal wheezes by discharge.
CV - TACHY AND REGULAR. NML S1/S2. NO MGR.
ABD - S/NT/ND. POS BS.
EXT - TRACE PEDAL EDEMA.
NEURO - A&OX3. CNII-XII GROSSLY INTACT. STRENGTH AND [**Last Name (un) **] TO LT
INTACT THROUGHOUT.
Pertinent Results:
[**2169-4-16**] 07:00AM BLOOD WBC-13.0* RBC-4.51 Hgb-12.4 Hct-36.5
MCV-81* MCH-27.4 MCHC-33.9 RDW-14.7 Plt Ct-313
[**2169-4-9**] 05:33AM BLOOD PT-13.4 PTT-22.9 INR(PT)-1.1
[**2169-4-16**] 07:00AM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-142
K-4.0 Cl-103 HCO3-33* AnGap-10
[**2169-4-15**] 07:00AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.0
[**2169-4-11**] 04:13PM BLOOD Type-ART O2 Flow-50 pO2-110* pCO2-56*
pH-7.38 calHCO3-34* Base XS-6 Intubat-NOT INTUBA
[**2169-4-9**] 03:12AM BLOOD Glucose-141* Lactate-0.9 Na-138 K-3.6
Cl-99*
[**2169-4-9**] 03:47PM BLOOD O2 Sat-94
Brief Hospital Course:
43F H/O IPF, COPD/Asthma (Multiple Intubations), Current
Smoking, Schizoaffective Disorder/Depression with URI symptoms
and dyspnea - presumed atypical PNA and COPD exacerbation in
setting of poor lung substrate.
1) Dyspnea: Likely multifactorial and includes Atypical PNA,
COPD/Asthma and underlying IPF. Stable on 2L NC. WBC mildly
elevated and afebrile.
- Continue Levofloxacin 500 mg PO Q24H for typical and atypical
coverage.
- Continnue Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **],
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H, Ipratropium
Bromide Neb 1 NEB IH Q6H, Albuterol 0.083% Neb Soln 1 NEB IH
Q3H, and Guaifenesin [**5-23**] ml PO Q6H:PRN.
- Prednisone Taper: Prednisone 60 mg PO DAILY.
- Smoking Cessation; counseled at bediside. Providing Nicotine
14 mg TD DAILY.
2) DMII: Continue SSI/FS QID, Pioglitazone HCl 30 mg PO DAILY
and Glipizide 10 mg PO BID.
3) Psychosis/Depression: Stable now without symptoms or SI/HI.
- Continue Clozapine 100 mg PO QAM and 400 mg PO HS.
- Continue Risperidone 1 mg PO HS and Fluoxetine HCl 40 mg PO
DAILY.
4) TLE: Most recent seizure five years ago.
- Continue Gabapentin 600 mg PO TID.
5) PPx: PPI, Colace/Senna, Heparin SQ.
6) Code: Full.
7) Access: pIV.
8) FEN: Diabetic/Consistent Carbohydrate.
43F with history of IPF, COPD/Asthma (multiple admissions and
intubation x1), current smoking, Schizoaffective Disorder and
Depression who was originally admitted to the general medicine
floor on [**2169-4-5**] with fevers, URI symptoms and dyspnea. She was
started on levofloxacin for atypical pneumonia and nebulizers
(peak flow 250, BL 350). On the floor, the patient was given
corticosteroids, albuterol and atrovent nebs, fluticasone and
continued on levofloxacin (given a penicillin allergy). Her
oxygen saturations ranged 89-98% and it was thought that she was
generally improving. Alas, she took a turn for the worse as she
had desaturation to high 80s thought [**2-15**] mucous plugging. She
was noted to have hypercarbia on ABG (7.40/54/71). [**Hospital Unit Name 153**] team
evaluated the patient and encouraged increased frequency of nebs
with frequent evals by Respiratory Therapy. She did well until
that evening when she was found to be somnolent and difficult
to arouse. Her oxygen saturation was in the high 90s. An ABG
revealed 7.39/58/72. Nursing was concerned and the patient was
transferred to unit for closer monitoring. While in the unit,
she was noted to have a combined respiratory acidosis and
metabolic alkalosis. She was started on BiPAP and gradually
weaned down. She was transferred to the floor for further
management of her pulmonary disease. By [**2169-4-15**] the patient
was feeling much better with stable SpO2 >94% on 2L oxygen, and
dramatically improved peak flow >300 and minimal wheezing on
exam.
The patient was stable for discharge on [**2169-4-16**], with minimal
wheezing. She has home O2 set up from previous use, and will be
discharged with home services.
During [**2169-4-15**] patient had elevated FBS readings 200-300. She
was initiated on a glargine / humalog insulin regimen, with 15
units glargine qPM giving improved control. She will go home
with this regimen (glargine + humalog sliding scale tid), and
understands that this will need to be adjusted as she
discontinues her steroid medication.
Ms. [**Known lastname 5923**] will receive a slow prednisone taper over one week,
and follow up with her primary care physician and pulmonology.
Medications on Admission:
Albuterol / atrovent
Protonix
Risperidone 2 mg qd
Clozapine 100 mg qAM, 400 mg qhs
Fluoxetine 40 mg po qd
Fluticasone
Metformin / Glipizide
NPH 4U [**Hospital1 **]
Home O2
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) Units
Subcutaneous at bedtime.
Disp:*1 vial* Refills:*0*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Clozapine 100 mg Tablet Sig: One (1) Tablet PO twice a day:
Take ONE tablet (100mg) in morning, and take FOUR tablets
(400mg) in evening.
(100 mg qAM, 400 mg qPM).
Disp:*150 Tablet(s)* Refills:*0*
7. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) inhaled Inhalation Q12H (every 12 hours).
Disp:*2 discs* Refills:*0*
8. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*0*
10. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 inhalers* Refills:*0*
11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*90 Capsule(s)* Refills:*0*
14. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H
(every 6 hours) as needed for cough.
15. Prednisone 10 mg Tablet Sig: As written Tablet PO once a day
for 8 days: Take 4 tablets for two days (starting and including
[**4-17**]), then 3 tablets for two day, then 2 tablets for two days,
then 1 tablet for two days, then discontinue use.
Disp:*20 Tablet(s)* Refills:*0*
16. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 2 doses.
Disp:*2 Capsule(s)* Refills:*0*
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
treatment Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
Disp:*50 nebulizer treatment* Refills:*0*
18. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
20. Fluoxetine HCl 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
Disp:*90 Capsule(s)* Refills:*0*
21. Humalog 100 unit/mL Solution Sig: As written Subcutaneous
three times a day: Take with meals according to written sliding
scale.
Disp:*2 vials* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6012**]
Discharge Diagnosis:
Pneumonia, asthma, diabetes
Discharge Condition:
Good
Discharge Instructions:
Patient will need home O2, start 2L/min.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
[**Name (STitle) 1395**], early this week. You will likely have to reduce your
insulin dose as you reduce your steroid medication (prednisone.)
Followup Instructions:
Please follow up with pulmonary service and your primary care
physician. [**Name10 (NameIs) **] is essential that you see your PCP this week.
ICD9 Codes: 486, 2762, 3051, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1541
} | Medical Text: Admission Date: [**2198-2-13**] Discharge Date: [**2198-2-22**]
Date of Birth: [**2119-4-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
cardiopulmonary arrest
Major Surgical or Invasive Procedure:
pulmonary intubation
central line placement
History of Present Illness:
78yo male with history of COPD found by nursing home staff to be
unresponsive.
.
The patient was in his usual state of health until yesterday
when he went into atrial fibrillation with shortness of breath.
He was treated with propanolol, digoxin, prednisone, and
azithromycin but looked somewhat worse this morning. Shortly
afterwards, he was found to be unresponsive. A code blue was
called and CPR was initiated at 1035am. It is unclear if he was
wearing is oxygen prior to this event. AED applied and delivered
a shock at 1038am with CPR afterwards. EMS arrived at 1040am
and CPR was stopped, patient with agonal breathing and
bradycardic rhythm. Patient intubated, given epinephrine and
atropine, and taken to the ambulance at 1044am, which
transported him to [**Hospital 8125**] Hospital. He was thought to be down for
about 10 minutes before ACLS was initiated.
.
On arrival to OSH, central line was placed and he was started on
levophed and given amiodarone load and hydrocortisone 100mg IV.
He was then transferred to [**Hospital1 18**] for further management.
.
On arrival to [**Hospital1 18**] ED, patient was intubated and sedated.
Post-arrest team consulted and ArticSun protocol was initiated.
Head CT demonstrated no acute process. Patient transferred to
CCU for further management.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-Atrial fibrillation (? if this is accurate)
-COPD- on home oxygen
-Pulmonary hypertension
-CKD- stage III (baseline Cr 1.5-1.6)
-GERD
-Hypothyroidism
-Psoriasis
-Renal cysts
-Hyperlipidemia
-Hx of diverticulitis
Social History:
Widower, quit smoking cigarettes 6 years ago. Smoke rare
tobacco pipe. Does not drink alcohol. Lives with a nephew.
[**Name (NI) **] ADLs. Has daughter [**Name (NI) **] who is very involved in his care.
Family History:
Positive for COPD secondary to smoking and asbestos exposure.
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: T=90.5 BP= 109/46 HR= 68 RR= 15 O2 sat=100% (intubated)
GENERAL: Intubated, sedated.
HEENT: Pupils 2+ and sluggish.
NECK: Supple with JVP of 16 cm.
CARDIAC: RRR, normal S1, S2. No m/r/g.
LUNGS: Bilateral wheezes, scattered crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-distended. Cooling pads in place
EXTREMITIES: 2+ edema bilaterally, cool to touch.
SKIN:
PULSES: Right DP/PT- dopplerable
.
Discharge exam:
Vitals - Tm 97.9/97.9 BP: 99-122/60-69 P: 58-89 RR 20 SaO2
88-94% 4L NC
Weight: 82 (82.9)
.
Tele: run or AF, RVR at 0600, lasting 10 minutes. Otherwise SR.
.
GENERAL: 78 yo M in no acute distress
HEENT: mucous membs moist, JVD at 12 cm
CHEST: faint crackles BB, tubular BS overall.
CV: S1 S2 Normal in quality but distant. RRR
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, 2+ pitting edema 1/2 up calf.
NEURO: Memory impaired with short term events but clearer today.
Speech clear. 4/5 strength in U/L extremities.
SKIN: no rash, PIV OK
PSYCH: A/O
Pertinent Results:
Labs on Admission:
[**2198-2-13**] 12:57PM BLOOD WBC-8.6 RBC-5.15 Hgb-15.5 Hct-46.6 MCV-91
MCH-30.1 MCHC-33.2 RDW-13.3 Plt Ct-158
[**2198-2-13**] 12:57PM BLOOD Neuts-85.3* Lymphs-7.7* Monos-4.8 Eos-1.0
Baso-1.3
[**2198-2-13**] 12:57PM BLOOD PT-13.4* PTT-28.2 INR(PT)-1.2*
[**2198-2-13**] 12:57PM BLOOD Glucose-129* UreaN-53* Creat-2.1* Na-137
K-4.6 Cl-109* HCO3-16* AnGap-17
[**2198-2-13**] 12:57PM BLOOD ALT-218* AST-231* AlkPhos-58 TotBili-1.2
[**2198-2-13**] 12:57PM BLOOD Albumin-2.8* Calcium-7.0* Phos-7.3*
Mg-2.0
Cardiac Enzymes:
[**2198-2-13**] 06:45PM BLOOD CK-MB-11* MB Indx-13.1* cTropnT-0.26*
[**2198-2-14**] 12:52AM BLOOD CK-MB-13* MB Indx-15.9* cTropnT-0.23*
[**2198-2-14**] 12:12PM BLOOD CK-MB-15* MB Indx-20.5*
[**2198-2-14**] 06:34PM BLOOD CK-MB-16* MB Indx-22.9*
[**2198-2-15**] 12:32AM BLOOD CK-MB-14* MB Indx-24.1*
[**2198-2-15**] 05:28AM BLOOD CK-MB-13* MB Indx-24.1*
TTE [**2-13**]:
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
The estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses and cavity size are normal. There
is severe global left ventricular hypokinesis (LVEF = 15-20 %).
There is no ventricular septal defect. The right ventricular
cavity is moderately dilated with severe global free wall
hypokinesis. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate to severe
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Biventricular systolic dysfunction. Dilated RV. Mild
AR. Mild TR. At least moderate to severe pulmonary artery
systolic hypertension.
CT Head [**2-13**]:
IMPRESSION:
1. No acute intracranial process.
2. Region of encephalomalacia in the left frontal lobe,
subjacent to the
craniotomy site
3. Bilateral proptosis.
LENI [**2-14**]:
IMPRESSION: Normal Doppler evaluation of both lower extremities.
No evidence of deep venous thrombosis.
TTE [**2-16**]:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is mildly depressed (LVEF= 40 %).
No masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Severe [4+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
ECG [**2198-2-21**]:
Sinus rhythm. Atrial ectopy. Left axis deviation. Right
bundle-branch block with left anterior fascicular block.
Compared to the previous tracing of the same day there is no
significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 160 158 386/429 56 -107 56
.
Labs at discharge:
[**2198-2-22**] 06:45AM BLOOD WBC-13.3* RBC-5.64 Hgb-16.1 Hct-48.5
MCV-86 MCH-28.6 MCHC-33.2 RDW-14.2 Plt Ct-206
[**2198-2-22**] 06:45AM BLOOD Glucose-88 UreaN-60* Creat-1.8* Na-138
K-4.2 Cl-95* HCO3-34* AnGap-13
[**2198-2-22**] 06:45AM BLOOD Calcium-9.8 Phos-3.8 Mg-2.1
Brief Hospital Course:
ASSESSMENT AND PLAN- 78yo male with history of COPD found to be
unresponsive s/p cardiopulmonary arrest.
.
# Cardiopulmonary arrest- Unclear etiology at this time but
thought [**2-8**] severe hypoxia at rehabilitation causing a possible
VF or PEA event. Patient with no known coronary artery disease
and extensive history of COPD. EKG on arrival to hospital
demomstrated LAD, RBBB, STD V1-V4, TWI aVL, V4-V5. Previous EKG
([**1-18**]) revealed RBBB and left axis deviation. Other contributing
factors are new medications (digoxin, propanolol) and
bradycardic-induced VT/VF is also possible in this situation.
Given history of COPD and pulmonary hypertension, cor pulmonale
is a definite possibility. He had no further episodes of
bradycardia or arrhythmia on telemetry and was aggressively
diursed to prevent further severe hypoxia. At discharge, he
would desat to the mid 80's on 4L NP. He underwent an artic sun
protocol and his mental status has improved greatly over his
hospital course. OT evaluated pt and felt he had mild short term
memory defecits only.
.
# Acute on Chronic Systolic CHF with right heart failure: Pt was
aggressively diuresed over his hospital stay and transitioned to
PO lasix today. His dry weight is 180 pounds. IV furosemide has
been added prn for use with weight gain more than 3 pounds in 1
day or 5 pounds in 3 days. Despite apparant dry weight, pt
continues to have 2+ pitting edema [**1-8**] way up LE that is thought
[**2-8**] right heart failure. TEDS stockings and leg elevation is
recommended. Consider repeat ECHO as an outpt. Should also
consider ACEi or [**Last Name (un) **] for CHF once kidney function is improved as
it has been held for a high creatinine here.
.
#Atrial fibrillation: He has had 3 spisodes of AF/RVR. This
appears to be a new rhythm for him and he was started on
warfarin 4mg daily. His tachycardia was treated wtih increasing
doses of metoprolol.
.
# HLD- continue home statin
.
# COPD- patient with extensive smoking history and known COPD
s/p recent exacerbation in [**1-18**]. His medical regimen was
optimized with increased dose of Advair, slow prednisone taper
and nebulizeer treatement. He currently has a non productive wet
sounding cough. Azithromycin course has been completed. He will
need continuing monitoring of his oxygen level, especially with
ambulation. As his cardiac arrest is thought [**2-8**] hypoxia,
treatment for his COPD and CHF is paramount.
.
# Hypothyroidism
- continue home levothyroxine
.
# Acute on Chronic Kidney disease- baseline Cr 1.5-1.6. His
Creatining high was 2.7 thought [**2-8**] ATN, now 1.8.
.
#Transaminitis. LFTs stably elevated. Likely [**2-8**] right heart
failure.
Medications on Admission:
1. Digoxin 0.125mg daily (recently initiated for episode of RVR
a few days prior to presentation)
2. Propanolol 20mg [**Hospital1 **]
3. Trazadone 25mg qHS
4. Liquid antacid 30ml PO q4h prn
5. Milk of magnesia- 30ml PO daily prn
6. Albuterol 2.5mg neb via INH q6hr prn SOB
7. Azithromycin 500mg daily x 3 days (day 1- [**2-12**])
8. Levothyroxine 75mg daily
9. Calcitriol 0.25mg daily
10. Spiriva INH 1puff daily
11. Advair 250/50 1 puff q12hr
12. Simvastatin 10mg qHS
13. Guaifenisin q12hr
14. Lasix 40mg daily x 2 days (day 1- [**2-12**])
15. Prednisone 10mg q8hr x 5 days (day 1- [**2-12**])
16. MVI daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
3. Milk of Magnesia 400 mg/5 mL Suspension Sig: Ten (10) cc PO
at bedtime as needed for constipation.
4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours).
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a
day.
8. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for pain.
12. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Stop once
prednisone is finished.
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): give pm dose at 1500.
14. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
15. prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 2 days.
16. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 days: [**2-26**], 21 and 22.
17. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: [**3-1**], 24 and 25, then d/c.
18. furosemide in 0.9 % NaCl 100 mg/100 mL (1 mg/mL) Solution
Sig: Forty (40) mg Intravenous twice a day as needed for for
weight gain of more than 3 pounds in 1 day or 5 pounds in 3
days.
19. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day for 3
days: Then check INR and adjust dose.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Acute on chronic systolic congestive heart failure
Sudden cardiac death
Chronic Obstructive pulmonary disease on home O2
Acute on Chronic kidney injury
Atrial fibrillation with rapid ventricular response
Pulmonary hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Your heart stopped and you needed to be shocked to restore a
normal heart rhythm. You were transferred to [**Hospital1 18**] for treatment
and was placed on a cooling protocol to help you recover. You
were on a ventilator and medicines to keep your blood pressure
up. We have given you medicine to get rid of extra fluid, we
think that may be why you became so sick. You continued to have
episodes of atrial fibrillation at a rapid rate and we have
adjusted your medicines to keep your heart rate low and help
your heart pump better.
.
We made the following changes to your medicines:
1. START taking furosemide 40 mg twice daily to prevent fluid
from building up again. IV furosemide may be needed if your
weight is increasing. You should wear TEDS stockings every day
as well.
2. STOP taking digoxin and propanolol
3. INCREASE the Advair to 500/50 dosing
4. INCREASE Furosemide to 40 mg twice daily
5. TAPER prednisone as noted
6. START aspirin to prevent a stroke in the setting of atrial
fibrillation
7. START omeprazole to protect your stomach from the prednisone.
You can stop this once the prednisone is finished
8. START Metoprolol to lower your heart rate and help your heart
pump better.
9. START warfarin to prevent a stroke because of your atrial
fibrillation. You will need to have this monitored closely by
your primary care doctor after you get out of rehabilitation.
.
Weigh yourself every day once you are home. Your goal weight is
180 pounds.
Followup Instructions:
Name: [**Last Name (LF) 3321**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: [**Doctor Last Name 37166**], [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 5315**]
*Please schedule an appointment to see Dr. [**Last Name (STitle) 3321**] within 2
weeks.
ICD9 Codes: 5845, 2762, 4168, 4280, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1542
} | Medical Text: Admission Date: [**2141-10-11**] Discharge Date: [**2141-10-18**]
Date of Birth: [**2079-1-26**] Sex: M
Service: C-MEDiCINE
HISTORY OF PRESENT ILLNESS: The patient is a 63 year old
male with type 1 diabetes mellitus times 36 years, coronary
artery disease, status post coronary artery bypass graft in
[**2133**], who presented to the Emergency Department with a two
day history of nausea, vomiting and fingerstick glucose of
greater than 500 by home monitor. Two days prior to
admission, the patient was seen in Pain Clinic for worsening
of chronic low back pain and was given a prescription for
Percocet. Since that time, the patient experienced nausea
and vomiting with six to seven episodes of nonbloody,
nonbilious vomiting associated with mild shortness of breath
and mild diffuse abdominal pain. The patient denied chest
pain or diaphoresis (of note, the patient has never had chest
pain). The patient noted at this time fingerstick glucose of
greater than 500 by home monitor with associated polyuria,
On review of systems, the patient denied any fever, chills,
headaches, cough, diarrhea, bright red blood per rectum,
melena, changes in medications other than starting Percocet,
recent illness or sick contact.
The patient called his primary care physician about his
elevated fingerstick and was told to go to the Emergency
Department.
In the Emergency Department, the patient had temperature of
95.2, pulse 79, blood pressure 111/42, oxygen saturation 97%
in room air, negative orthostatics. Initial laboratories
were notable for a pH of 7.2, bicarbonate 11, anion gap of
31, and white blood cell count of 20.4. The patient was
given two liters of normal saline and started on an insulin
drip.
Initial cardiac enzymes showed a CPK of 224 with troponin of
1.9, cycle #2 showed CPK 302 with troponin of 3.4.
Electrocardiogram showed normal sinus rhythm with old Q waves
in aVF, II and III with new 1.[**Street Address(2) 2811**] depression in
V4 through V6.
The patient was given Aspirin, Lopressor 5 mg intravenously
and started on continuous infusion of Aggrestat and Heparin.
PAST MEDICAL HISTORY:
1. Type 1 insulin dependent diabetes mellitus for 36 years
with insulin pump began in [**2138**]. Diabetes mellitus
complicated by neuropathy and retinopathy.
2. Coronary artery disease, status post silent myocardial
infarction, and status post coronary artery bypass graft
times four in [**2131**]. Persantine Sestamibi in [**2141-8-16**],
showed an ejection fraction of 55%. Old inferior myocardial
infarction and mild fixed inferior wall perfusion defect and
mild inferior wall hypokinesis.
3. Status post abdominal aortic aneurysm repair in [**2131**].
4. Status post aortopopliteal bypass in [**2131**].
5. Hypertension.
6. Hypercholesterolemia.
7. History of gastrointestinal bleed in [**2140**].
8. Chronic gastritis/colitis.
9. Chronic low back pain with L5 to S1 disc space narrowing.
10. Status post left eye cataract surgery in [**2141-8-16**].
MEDICATIONS ON ADMISSION:
1. Lopressor 25 mg p.o. b.i.d.
2. Insulin pump.
3. Lipitor 10 mg p.o. q.d.
4. Zestril 20 mg p.o. q.d.
5. Aspirin 81 mg p.o. q.d.
6. Neurontin 300 mg p.o. q.d.
7. Vioxx.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives at home with his wife,
worked for the [**Name (NI) 2318**], now retired. Ninety pack year history
of tobacco, quit 30 years ago. No alcohol.
LABORATORY DATA: On admission. White blood cell count 20.4,
hematocrit 32.9, platelets 206,000. Urinalysis greater than
1000 glucose, no white blood cells. Sodium 125, potassium
6.1, anion gap 33, creatinine 2.0, blood urea nitrogen 65,
glucose 925. ALT 108, AST 102, amylase 33, total bilirubin
0.5,
CPK #1 224, CPK #2 302, CPK #3 1557.
Anemia workup - Iron 22, TIBC 200, ferritin 383, transferrin
154, reticulocyte count 0.9, Vitamin B12 1735, folate 8.5.
Microbiology - Urine culture and blood cultures from
admission showed no growth.
Chest x-ray - no acute cardiopulmonary process.
HOSPITAL COURSE:
1. Endocrine - The patient was admitted with diabetic
ketoacidosis with peak anion gap of 37 and initial blood gas
showing pH of 7.2 and bicarbonate of 14. The patient was
given two liters normal saline in the Emergency Department
and started on an insulin drip. Electrolytes were repleted
as necessary.
On hospital day two, the patient's anion gap decreased to 5.0
and the patient was restarted on his insulin pump. The
patient's anion gap subsequently rose to 14 with blood
glucose of 583 and the patient was restarted on an insulin
drip. On testing of the insulin pump, it was noted that the
battery pump had died. The battery was replaced and the day
prior to discharge the insulin pump was restarted with good
control of blood sugar.
2. Cardiovascular - The patient ruled out in non Q wave
myocardial infarction with peak CPK of 2189 and
electrocardiogram showing 1.[**Street Address(2) 2811**] depressions in V4
through V6. In the Emergency Department, the patient was
given Aspirin and started on continuous infusion of Aggrestat
and Heparin. The patient subsequently went for cardiac
catheterization which found occlusion of saphenous vein graft
to posterior descending artery with widely patent saphenous
vein graft to diagonal and OM. The patient underwent
percutaneous transluminal coronary angioplasty with stent
placement of saphenous vein graft to posterior descending
artery anastomotic site with no residual stenosis. After the
procedure, the patient remained hemodynamically stable and
without chest pain.
3. Hematology - On admission, the patient had a hematocrit
of 32.0 which decreased to 28.0 with hydration. The patient
was transfused one unit of packed red blood cells with
increased hematocrit to 32.0. Anemia laboratories were sent
which showed a low iron, low TIBC and high ferritin
consistent with anemia of chronic disease. Vitamin B12 and
folate levels were both within normal limits.
The patient's hematocrit remained stable at 32.9 at the time
of discharge.
4. Gastrointestinal - On admission, the patient had a
transaminitis of unclear etiology. The patient's Lipitor was
discontinued with resolution of transaminitis at the time of
discharge with an AST of 34 and ALT of 60.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient is discharged to home with
follow-up with primary care physician in one week.
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis.
2. Myocardial infarction, status post percutaneous
transluminal coronary angioplasty with stent.
3. Anemia.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 mg p.o. q.d.
2. Vitamin E 400 international units p.o. q.d.
3. Neurontin 300 mg p.o. q.h.s.
4. Atenolol 50 mg p.o. q.d.
5. Zestril 30 mg p.o. q.d.
6. Plavix 75 mg p.o. times 25 days.
7. Eye drops.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12978**], M.D. [**MD Number(1) 12979**]
Dictated By:[**Last Name (NamePattern1) 1297**]
MEDQUIST36
D: [**2141-10-18**] 16:13
T: [**2141-10-21**] 08:44
JOB#: [**Job Number 19119**]
ICD9 Codes: 4280, 3572, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1543
} | Medical Text: Admission Date: [**2115-3-8**] Discharge Date: [**2088-4-12**]
Date of Birth: [**2046-10-19**] Sex: M
Service:
ADMISSION DIAGNOSIS:
1. Myocardial infarction.
2. Ventricular tachycardia.
HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old
male who was taking his garbage out to the curb when he had
the sudden onset of severe chest pain associated with
diaphoresis and shortness of breath. It was described as
similar to chest pain he had during a CHF exacerbation at
[**Hospital1 18**] in [**2112-7-14**]. The patient contact[**Name (NI) **] the EMS System
who found him in ventricular tachycardia and he was
cardioverted in the field to sinus and brought in and
referred to an outside hospital. There, he was given
aspirin, Lopresor, and transferred to [**Hospital1 18**].
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post MI in his 30s.
2. Status post cardiac catheterization with LAD stenting in
[**2112**].
3. Ejection fraction 23%.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Aspirin q.d.
2. Toprol XL 50 mg q.d.
3. Zantac 150 mg b.i.d.
4. Cozaar 25 mg q.d.
5. Lasix 20 mg q.d.
6. Coenzyme Q.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Heart rate
69, blood pressure 110/62, respirations 14, saturations 96%.
General: The patient was in no acute distress. HEENT:
EOMI. PERRL, anicteric. The throat was clear. Chest:
There were coarse breath sounds bilaterally with right
greater than left. Cardiovascular: Regular rate and rhythm
without murmurs, rubs, or gallops. Abdomen: Soft,
nontender, nondistended, without masses or organomegaly.
Extremities: Warm, noncyanotic, nonedematous times four.
Neurological: Grossly intact.
ADMISSION LABORATORY DATA: CBC 7.8/42.5/111. Chemistries:
136/4.0/97/28/12/1.2/288. CKs 154 with an MB of 14.9 and
troponin of 9.4.
The chest x-ray showed only mild atelectasis at the right
lower lobe, no acute CHF picture.
HOSPITAL COURSE: The patient was initially on a lidocaine
drip for his ventricular tachycardia. He was admitted to the
ICU for close monitoring. On hospital day number two, the
patient was transferred down to the floor. At that time, he
was stabilized in preparation for cardiac catheterization and
possible ablation. The patient did rule in for an MI,
although there were no ST elevations detected on the EKG.
The Electrophysiology Service was consulted in regards to his
episode of ventricular tachycardia. VT ablation versus ICD
were discussed and both were possibilities. Catheterization
was performed on [**2115-3-11**] which revealed an ejection fraction
of 20%, as well as diffuse disease of a right dominant
system. It was felt that the patient would benefit from
revascularization. It was also noted that the patient had a
very large abdominal aortic aneurysm greater than 7 cm at
this time. The patient was recommended further delineation
of CT angiography for sizing of the aorta as well as possible
endostenting.
The patient went for VT ablation later that day. The patient
continued, however, to have an episode of ventricular
tachycardia postprocedure. It was asymptomatic and identical
to the episode described three days prior.
Cardiothoracic Surgery was consulted for the patient's three
vessel disease. Vascular Surgery was also consulted for his
large AAA. The patient underwent CABG times three on
[**2115-3-13**] with LIMA to diagonal artery, saphenous vein graft
to LAD and acute marginal.
Postoperatively, the patient was taken to CRSU for closer
monitoring. It was complicated only by having to reopen to
remove a lap pad. The patient was extubated on the evening
of postoperative day number zero and tolerated this well. He
continued to have recurrent ventricular tachycardia status
post ablation and the patient remained A-paced using
temporary pacing wires. The patient also had multiple
episodes of NSVT and Amiodarone bolus was given as well as
Amiodarone drip.
The patient had recurrent prolonged runs of NSVT on
postoperative day number two and the EP Service continued to
follow. It was felt with the patient's multiple arrhythmias
the patient would most likely benefit from implantation of an
AICD. The patient was transitioned to p.o. Amiodarone which
did not seem to be as effective as a drip. He was restarted
on the Amiodarone drip.
On postoperative day number three, the patient's chest tubes
were removed and the insulin drip was weaned to off.
Physical Therapy began seeing the patient. The patient did
begin ambulating some. The patient's Cordis was changed over
a wire to a lumen CVL on postoperative day number five.
By postoperative day number five, the patient was seen to be
stable overnight and the patient was transferred to the
floor. On the floor, the patient had a largely unremarkable
course and was preopped appropriately for the Vascular
Service.
The rest of this dictation summary will be completed either
by Vascular Surgery or the other subsequent services to have
this patient.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2115-3-26**] 05:49
T: [**2115-3-26**] 18:04
JOB#: [**Job Number 31997**]
ICD9 Codes: 4271, 4280, 5990, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1544
} | Medical Text: Admission Date: [**2123-3-9**] Discharge Date: [**2123-3-15**]
Date of Birth: [**2042-11-1**] 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:
[**2123-3-10**] - AVR (23mm [**Company 1543**] Mosaic Porcine)
History of Present Illness:
80 year old female with history of hypertension and
hyperlipidemia with known aortic stenosis for 6 months who
presents for evaluation for aortic valve replacment. The patient
is limited by dyspnea on exertion that has affected
her daily activities.
Past Medical History:
Past Medical History:
Hypertension
Hyperlipidemia
Aortic Stenosis
History of falls
Osteoporosis
Past Surgical History:
s/p Right hip replacement
S/p left hip plate and screw
s/p THS and BSO 30 years ago
s/p Tonsillectomy
Social History:
Family History:NC
Race: Causasian
Last Dental Exam: Full dentures
Lives with: Senior living center (estranged from husband; has 2
grown sons)
Occupation: none
Tobacco: denies
ETOH: denies
Family History:
None
Physical Exam:
Pulse: 89 Resp: 16 O2 sat: 97
B/P Right: 136/75 Left: 128/66
Height:5'0" Weight:138 lbs
General: well-developed 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 [X] Irregular [] Murmur 4/6 systolic
Abdomen: Soft [X] non-distended [] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [X]
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 Right/Left: transmitted murmur
Pertinent Results:
[**2123-3-10**] ECHO
Pre Bypass: The left atrium is mildly dilated and elongated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Right ventricular chamber size and free
wall motion are normal. There are complex (>4mm) atheroma in the
aortic root, aortic arch, and the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is moderate aortic valve
stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. No
mitral regurgitation is seen.
Post Bypass: Patient is in sinus rhythm with pac's on
phenylepherine infusion. Preserved biventricular function LVEF
>55%. There is a bioprosthetic valve in the aortic position (#23
mosaic per surgeons) without AI or perivalvular leaks. Peak
gradient 7 mm Hg, mean 6 mm Hg on aortic valve. Aortic contours
intact. Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
[**2123-3-9**] Cardiac Catheterization
Clean coronaries
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2123-3-9**] for a cardiac
catheterization in preparation for an aortic valve replacement.
Her cardiac catheterization revealed clean coronaries and severe
aortic stenosis. She was worked-up in the usual preoperative
manner. On [**2123-3-10**] she was talken to the operating room where
she underwent an aortic valve replacement with a bioprosthesis.
Please see operative note for details. Postoperatively she
wastaken to the intensive care unit for invasive hemodynamic
monitoring. Over the next 24 hours, she awoke neurologically
intact and was extubated. She was transferred to the stepdown
unit on POD#2. She was started on betablockade and diuresed
toward her pre-operative weight. Her chest tubes and temporary
pacing wires were removed per protocol. She was evaluated by
physical therapy for strength and conditioning and rehab was
recommended. She was cleared for discharge on POD#5 by Dr. [**Last Name (STitle) **].
Medications on Admission:
Fosamax
Lipitor 10mg qd
Lisinopril 2mg qd
Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Until at pre-op weight of 59kg. Then chnage to home diuretic
HCTZ.
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily): while
on lasix.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**] Health Care Center
Discharge Diagnosis:
AS s/p AVR
Hypertension
Hyperlipidemia
History of falls
Osteoporosis
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.[**Last Name (STitle) 15942**] in [**1-30**] weeks
Cardiologist Dr. [**Last Name (STitle) 10543**] in [**1-30**] weeks
Completed by:[**2123-3-15**]
ICD9 Codes: 4241, 4019, 2724, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1545
} | Medical Text: Admission Date: [**2118-3-17**] Discharge Date: [**2118-3-31**]
Date of Birth: [**2056-4-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EDG
[**Last Name (un) **] placement
Tracheal intubation
TIPS procedure
CPR
Transfusion of blood products
History of Present Illness:
61 YOM with history fo HCV genotype 2 cirrhosis complicated by
mild encephalopathy and varices s/p EGD with banding 3 weeks ago
presets to ED with CC of melena. Patient reports that over the
last 3-4 days he has had increasing dark stools. This morning he
had some mild epigastric discomfort and rpesented to the ED for
eval. No hematemsis, no BRBPR. No Dyspnea. + Light heasded ness
this afternoon.
.
With regards to his HCV cirrhosis, He has remote IVDU history
int he 60s' as well as a period of heavy drinking in the [**2096**]'s.
In [**2115**] he had a major Gi bleed requiring banding. In [**2107**] he
apprently bled while in [**State 622**].
.
He was seen by GI in [**Month (only) **] who scheduled him for EGD on
[**2118-2-25**]. He underwent the procedure with visualization of
grade 2 varices. Was banded and discharge din stable condition.
.
In the ED he underwent NG lavage wtih 100cc of BRB returned but
nothign further. He had no other episodes of bleeding and was HD
stable. He was transferred to te MICU in stable condition with
plans for EGD in the evening or AM.
.
VS prior to transfer
VS HR 90 BP 135/70 T 97.6 RR 18 Sattign 100% RA
.
A Loquacious gentleman, nn arrival to the MICU, he is stable
with no complaints or distress.
Past Medical History:
Chronic hepatitis C, genotype 2.
Cirrhosis.
Portal hypertension with a history of esophageal varices.
Tonsillectomy at age ten.
Social History:
Former smoker, quit 25 years ago. Occasional EtOH once every
other week but drank [**9-23**] drinks/night in late [**2096**]/early [**2106**]
for [**3-18**] yrs. IV drug use in late [**2066**]. Works in a Nucor Plant.
Travels in US by RV.
Family History:
Denies FH of diabetes, CAD, liver disease, liver cancer
Physical Exam:
ADMISSION EXAM:
VS: T 98, HR 70, BP 116/65, RR 19, POx 97%RA
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Abdominal: Tender: epigastric, splenomegaly
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
.
DISCHARGE EXAM
VS: 97.6 108/64 74 20 96% RA
I/O 1280/800 BM x 2
GENERAL: Comfortable, appropriate.
NECK: Supple with JVP 6 cm
CARDIAC: RRR, S1 S2 without murmurs, rubs or gallops.
LUNGS: Resp were unlabored. crackles bilaterally to 1/3 up back
ABDOMEN: Distended but Soft, non-tender to palpation.
EXTREMITIES: Warm and well perfused. 2+ [**Location (un) **] bilaterally to
knees.
NEURO: CN II-XII intact grossly, strength 5/5 on L [**5-19**] on R
Pertinent Results:
ADMISSION LABS:
[**2118-3-17**] 10:45PM BLOOD WBC-4.9 RBC-3.45* Hgb-11.1* Hct-31.2*
MCV-90 MCH-32.1* MCHC-35.5* RDW-15.3 Plt Ct-94*
[**2118-3-17**] 10:45PM BLOOD Neuts-73.7* Lymphs-19.4 Monos-4.0 Eos-2.3
Baso-0.6
[**2118-3-17**] 10:45PM BLOOD PT-14.2* PTT-33.8 INR(PT)-1.3*
[**2118-3-17**] 10:45PM BLOOD Glucose-122* UreaN-21* Creat-0.7 Na-134
K-5.7* Cl-104 HCO3-24 AnGap-12
[**2118-3-17**] 10:45PM BLOOD ALT-151* AST-267* AlkPhos-68 TotBili-1.3
[**2118-3-17**] 10:45PM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.0 Mg-2.0
[**2118-3-17**] 10:50PM BLOOD Lactate-1.7
[**2118-3-18**] 01:08PM BLOOD Glucose-201* Lactate-3.8* K-4.2
[**2118-3-18**] 03:15PM BLOOD Glucose-112* Lactate-1.6 Na-139 K-4.1
Cl-110*
.
DISCHARGE LABS
[**2118-3-31**] 04:21AM BLOOD WBC-4.5 RBC-3.26* Hgb-10.5* Hct-30.3*
MCV-93 MCH-32.2* MCHC-34.7 RDW-18.5* Plt Ct-104*
[**2118-3-31**] 04:21AM BLOOD PT-20.6* PTT-35.9 INR(PT)-2.0*
[**2118-3-31**] 04:21AM BLOOD Glucose-100 UreaN-10 Creat-0.7 Na-136
K-4.0 Cl-109* HCO3-24 AnGap-7*
[**2118-3-31**] 04:21AM BLOOD ALT-99* AST-202* LD(LDH)-251*
AlkPhos-210* TotBili-19.9*
[**2118-3-31**] 04:21AM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.3*
Mg-2.1
.
CXR [**2118-3-18**]:
Endotracheal tube is seen terminating at least 2.5 cm from the
carina while neck is in flexion. Right-sided catheter sheath is
seen entering the right IJ and terminating within the superior
vena cava. Proximal end of this sheath is kinked.
.
[**2118-3-24**]
As compared to the previous radiograph, there is no relevant
change. The monitoring and support devices are in constant
position.
Constant size of the cardiac silhouette. Moderate pulmonary
edema with
bilateral areas of pleural effusions and subsequent areas of
atelectasis.
Interval appearance of focal parenchymal opacity suggesting
pneumonia.
.
AXR [**2118-3-18**]:
Cross-table lateral and supine frontal views of the abdomen are
obtained.
Note is made of Sengstaken-[**Last Name (un) **] tube, with esophageal and
gastric
balloons inflated. There is large gaseous distention of the
colon and small bowel in a pattern suggesting ileus. There is no
evidence of pneumoperitoneum on the cross-table lateral image.
.
CT head [**2118-3-23**]
IMPRESSION: Multifocal hypodensities in the right frontal, left
occipital,
and cerebellar regions concerning for subacute infarction given
the clinical history. If there is no contraindication, MRI of
the brain is recommended for further characterization.
.
MRI/MRA head and neck
There are bilateral multiple foci of restricted diffusion,
predominantly in the cortex of the frontal and parietal lobes.
There is also some involvement of the temporal lobes. No
abnormality is noted in the hippocampi or the basal ganglion.
Focal restricted diffusion is also seen in the right occipital
lobe which could represent an acute infarction.
Intracranial flow voids are maintained.
MRA of the circle of [**Location (un) 431**] demonstrates the proximal
vasculature to be
patent. The study is technically limited for evaluation of the
distal
branches. No aneurysm is noted. There is a hypoplastic left A1.
The left
distal vertebral artery is not visualized and may terminate as a
PICA.
MRA of the neck demonstrates mild plaquing at bilateral ICAs. No
high-grade stenosis is seen. Both vertebral arteries are patent.
The origins of the vertebral arteries are not well visualized
due to technique. The left distal vertebral artery is
hypoplastic.
There is a probable lipoma in the right suboccipital region.
IMPRESSION:
Hypoxic injury in the bilateral cerebral cortices. Acute
ischemia in the
right occipital lobe.
No vascular abnormalities.
.
CT Abdomen Pelvis [**2118-3-23**]
1. TIPS is patent.
2. Thrombosed right posterior portal vein branch is seen
secondary to
covering of the origin of that vessel by the stent.
3. Subacute/chronic SMV thrombosis.
4. Liver cirrhosis.
5. Splenomegaly.
6. Gallbladder sludge and stones are seen.
7. Bilateral small pleural effusion with secondary atelectases
.
RUQ US
1. Patent TIPS shunt with normal-appearing flow and pulse
Doppler waveforms.
No evidence of portal vein thrombosis.
2. Cirrhotic liver with splenomegaly.
3. Gallstones but no bile duct dilatation.
.
TTE
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size,
and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
MICROBIOLOGY
blood cultures negative [**3-17**], [**3-19**], [**3-20**]
Urine culture negative [**3-19**], [**3-20**]
GRAM STAIN (Final [**2118-3-20**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2118-3-22**]):
RARE GROWTH Commensal Respiratory Flora.
Brief Hospital Course:
61 YOM with history of HCV cirrhosis complicated by 2 prior
variceal bleeds and intermittent hepatic encephalopathy, s/p
banding of known grade 2 varices on [**2118-2-25**] presenting on
[**2118-3-17**] with melena and NG lavage demonstrating BRB.
.
# GI bleed: Upper source. Concern for sentinal bleed from varix
vs arterial bleed from ulcer in the setting of recent banding.
Admission Hct was 31 from baseline 39. Pt was intubated for
airway protection after active bleeding was found on EGD on [**3-18**],
during the second attempt following intubation he became
hypotensive and had a PEA arrest. Pt was resuscitated and
received massive transfusion (10 units PRBC, 4 units FFP, 1 bag
platelets, 2 bags cryoprecipitate); [**Last Name (un) **] was placed and
emergent TIPS was performed, with gradient reduction from 11-->4
mm Hg. The balloons were deflated on [**3-19**] and the [**Last Name (un) **] was
removed on [**3-21**]. Pt had melenic stool but no further evidence of
GI bleed following TIPS. Octreotide drip was continued from
[**Date range (1) 71218**]. Patient was transferred to the floor where HCT remained
stable and stools were noted to be guaiac negative. He was
initially given an IV PPI and was transitioned to PO PPI prior
to discharge. His home lasix restarted at 40 mg daily however
with instructions to hold this medication if systolic blood
pressure is less than 90. Nadolol was started at a low dose in
place of his home propanolol
.
# Possible aspiration pneumonia: Pt was intubated in the
setting of EGD on [**3-18**] (as above). Developed fever to 101.2, GNR
on sputum gram stain; 8 day course of vanc/zosyn was started on
[**3-20**]. WBC and fever curve trended down [**3-21**], [**3-22**], sputum culture
grew only commensal flora, CXR improved following diuresis [**3-21**].
Pt was successfully extubated morning of [**3-22**]. He remained
afebrile without signs of infection throughout the remainder of
his hospitalization.
.
# Abnormal LFTs: Pt has had transaminitis throughout admission
(ALT/AST 151/267 on admission, discriminant function 16).
Transaminases peaked [**3-20**] with ALT/AST 226/348, trending down
since. Tbili trending up after TIPS, from 1.3 on admission to
14.3 (11.8 direct) on [**3-22**]. TIPS patent per abdominal CT [**3-23**] and
RUQ US on [**3-29**]. There was also no evidence of bilary dilitation
on US to suggest obstructive etiology. Fracination demonstrated
a direct hyperbilirubinemia making hemolysis unlikely. Possible
etiology for the elevation includes relative liver hypoperfusion
in ther setting of TIPS placement. Bili was noted to trend
downward and was 19.9 at discharge from a peak value of 22.6.
Patient will need a repeat EGD in 1 month.
.
# Peripheral/pulmonary edema- Patient received a large amount of
volume in the setting of massive transfusion. He was markedly
volume overloaded on exam. He was initially diuresed in the ICU
with 10 mg IV lasix boluses. Diuresis on the floor was
complicated by hypotensions. Patient was still net negative for
length of stay at the time of discharge. His weight was 214Ibs
from a baseline of 207.6 lbs. It was felt given his recent bleed
initiation of nadolol was more important than diursis as his
respiratory status was stable. His home lasix was restarted at
the time of discharge as above. The patient will follow-up with
Dr. [**Last Name (STitle) **] regarding restarting this medication.
.
# HCV Cirrhosis: Was on lactulose intermittently and propranolol
at home, has never been on rifaximin or SBP prophylaxis at home.
On vanc/zosyn as inpatient. Developed encephalopathy s/p TIPS
(and PEA arrest) which improved with lactulose and rifaximin. He
will likely require evaluation for possible liver transplant as
an outpatient.
.
# Stroke: CT head was performed on [**3-22**] to look for watershed
infarcts after PEA arrest given L>R arm and leg strength, slow
recovery of mental status. Imaging revealed multifocal
hypodensities concerning for subacute infarcts R frontal, L
occipital, bilateral cerebella. TTE was performed to look for
embolic source and showed no evidence of vegitation or septal
defects. Patient underwent MRI/MRA which demonstrated bilateral
multiple foci of restricted diffusion, predominantly in the
cortex of the frontal, parietal, and occipital lobes, in
addition to ,mild plaquing of bilateral ICAs but with other
vessels patent. He was evaluated by neurology who felt
presentation was most consistent embolic events in the setting
of PEA arrest. They did not recommend anti-coagulation as the
patient had a recent severe [**Hospital1 **] bleed. Patient will follow-up
with neurology as an outpatient.
.
TRANSITIONAL ISSUES
- Patient will follow-up at the liver clinic and with neurology
- Patient possibly require evaluation for liver transplant
- Patient will discuss restarting diuretics with Dr. [**Last Name (STitle) **]
- Patient was full code throughout this admission
Medications on Admission:
1. Lasix 40 mg p.o. daily.
2. Hydromorphone 2 mg p.r.n. pain.
3. Lactulose 10 gram/15 mL solution titrating to one to two
bowel movements a day.
4. Propranolol 10 mg p.o. three times a day.
5. Omeprazole
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
sob/whz/bronchospasm.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: please
hold for SBP < 90.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis
Upper GI bleed
[**Hospital **]
Hospital Acquired Pneumonia
.
Secondary diagnosis
Chronic hepatitis C cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted because you were having bleeding from one of
the vessels in your esophagus. You had a large amount of
bleeding and required intubation to protect your airway. You
also developed a pneumonia for which you were treated with
anti-biotics. You experienced some weakness and a MRI of your
head showed that you had a small stroke. You were seen by the
neurologists who did not feel that there was anyhting that
needed to be done right now. Our physical therapist did feel
you would benefit from a stay at a rehab facility and therefore
you were discharged to rehab.
We made the following changes to your medications
1. STOP lasix 40 mg dialy (you should discuess restarting this
medication with Dr. [**Last Name (STitle) **]
2. START nadolol 20 mg daily
3. STOP propanolol
4. START tramadol as needed for pain
You should continue to take all other medications as instructed.
Please call with any questions or concerns
Followup Instructions:
Department: LIVER CENTER
When: THURSDAY [**2118-4-7**] at 11:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: MONDAY [**2118-5-23**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5715, 2760, 5070, 4275, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1546
} | Medical Text: Admission Date: [**2194-7-26**] Discharge Date: [**2194-7-27**]
Date of Birth: [**2167-7-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
seizure and hypoglycemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 27 yo M with a past medical history significant for
ESRD secondary to HTN on HD, beginning in [**2192**]. He reports one
previous incident of seizure also in the setting of a
hypoglycemic episode following HD. He presents today with
hypoglycemia following a witnessed seizure in his cousin's car
after HD. HD today was uncomplicated, though he states that
more fluid was removed and faster than usual (3L in 2.5 hours).
He denies any recent illnesses or ingestions.
.
He states that before these seizures he experiences an aura in
which he "blacks out" and cannot see anything. He frequently
has these auras during or immediately after dialysis, but
without the seizures. He receives dialysis on Tues/Thurs/Sat at
[**Location (un) 105764**]. Kidney Center.
.
In the ED, his neuro exam was felt to be nonfocal. He was given
1 amp of D50 x 1 to which he responded from a FS of 57 to a FS
of 120. Following eating, however, his glucose began to drift
downwards once again to a nadir in the 60's, for which he was
given another amp of D50. He is admitted to the MICU for
frequent blood glucose monitoring and to initiate further
work-up for hypoglycemia in a non-diabetic.
Past Medical History:
HTN - diagnosed [**2191**] (?"small stroke" per [**State **] OSH)
ESRD - diagnosed [**2191**], felt [**2-15**] HTN (dx [**2191**] also). pt on
dialysis
since [**12/2192**] (kidney center, comme ave, [**Telephone/Fax (1) **],
nephrologist
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on transplant list, s/p failed R AVF, with L AVF
placed [**10/2192**], usual dialysis day Tu/Th/Sa).
seizure presumed to be [**2-15**] hypoglycemia [**1-20**] (seen by neuro, no
intervention)
Seizures as noted above
Social History:
worked in construction, now on disability, denies tobbacco,
alcohol, or IVDU.
Family History:
denies family history of premature cad, dm, htn, or seizures.
Father has psoriasis. Grandmother died of cancer, type unknown.
Physical Exam:
Vitals - T 98.4 BP 153/102 HR 76 RR 18 99%RA
GENERAL: laying in bed, NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, good dentition, supple neck, no LAD, no JVD
CARDIAC: regular rate. III/VI holosystolic murmur heard at the
LUSB, radiating up to clavicle on left, but not to carotids.
Breast: Left breast with subareolar mass, about 2x2cm, tender to
palpation, no discharge, no skin changes
LUNG: CTAB no w/r/r
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally. thrill over fistula L arm.
NEURO: CN II-XII intact, strength 5/5 bilaterally, sensation to
light touch in tact bilaterally. A&Ox3. Normal speech, prosidy,
cerebellar function. Normal gait.
Pertinent Results:
Admission Labs:
WBC-8.5 Hgb-14.3 Hct-44.8 MCV-94 MCH-29.9 Plt Ct-204
Neuts-67.2 Lymphs-25.6 Monos-4.8 Eos-1.9 Baso-0.6
UreaN-28* Creat-16.0*# Na-143 K-3.9 Cl-89* HCO3-17*
ALT-19 AST-31 AlkPhos-81 TotBili-0.4
Lipase-59
Calcium-9.7 Phos-5.5* Mg-3.1*
[**2194-7-27**] 02:54AM BLOOD Cortsol-18.0
[**2194-7-27**] 04:31AM BLOOD Cortsol-32.1*
.
Studies:
[**2194-7-26**] CT FINDINGS: Non-contrast head CT. There is no
intra-axial or extra-axial hemorrhage, mass effect, shift of
normally midline structures, or evidence of major vascular
territorial infarction. [**Doctor Last Name **]-white matter differentiation is
preserved. There is no hydrocephalus. Paranasal sinuses are well
aerated as are the mastoid air cells and middle ear cavities.
The surrounding calvarium and soft tissue structures are
unremarkable.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
27 yo M with history of ESRD on HD with history of seizures in
the setting of hypoglycemia, who presents with hypoglycemia
after a witnessed seizure.
.
1. Hypoglycemia: Unclear etiology, however he is clearly
symptomatic given seizure in this setting. Etiologies in a
non-diabetic include insulinoma, adrenal insufficiency, and
malignancy. Adrenal insufficiency is unlikely given high blood
pressures, cosyntropin stim test performed with good response.
His blood sugars remained entirely normal with q1 hour
fingerstick monitoring.
- c peptide checked and pending
- ultrasound of breast mass, as outpt.
.
2. Seizure: No further seizures following admission and thought
to have occurred in the setting of hypovolemia and hypoglycemia.
CT head was negative for bleed and mass. As below, he was
advised to eat prior to each dialysis session. Hypoglycemia
evaluation pending as above.
.
3. AG Metabolic Acidosis: Likely uremia exacerbated by s/p
seizure. Lactate normal at 1.3.
.
4. ESRD: Continue HD as outpatient. Patient advised to make
sure to eat prior to hemodialysis.
.
5. HTN: Home antihypertensives continued.
.
6. FEN: Low Na diet.
.
7. PPx: Heparin sc for DVT prophylaxis
Medications on Admission:
Labetalol 300 mg PO BID
Felodipine SR 2.5 mg PO QAM
Catapres 2 patch QWeek
Lisinopril 5 mg PO QD
Calcium Acetate 667 mg capsules, 2 PO TID
Acetaminophen prn
Discharge Medications:
1. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
5. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Catapres-TTS-2 0.2 mg/24 hr Patch Weekly Sig: One (1)
Transdermal once a week.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Hypoglycemia
Seizure
Hypertension
End-stage renal disease on hemodialysis
Discharge Condition:
Stable, normoglycemic.
Discharge Instructions:
You were admitted to the hospital because of a seizure
associated with a low blood sugar after hemodialysis. You were
monitored in the medical ICU with frequent blood sugar checks,
all of which were normal.
You should always eat something when you have hemodialysis.
Also, you should schedule an appointment with your physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], to follow-up on the results of the tests that were
done while you were in the hospital. You should also make an
appointment to have the mass in your breast further evaluated.
You should continue to take your home medications, especially
your phosphate binders (Calcium acetate or Phoslo) as your
phosphate level is high. In addition, you should also take the
phosphate binder Sevelamer or Renagel.
If you have any additional seizures, low blood sugar, or other
concerning symptoms, you should contact your physician or return
to the hospital.
Followup Instructions:
You should schedule an appointment to see Dr. [**Last Name (STitle) **] within the
next week or two.
You should make an appointment to have the mass in your breast
evaluated as you were instructed when you were seen in the
Emergency Department a few days ago.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]
ICD9 Codes: 5856, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1547
} | Medical Text: Admission Date: [**2115-8-9**] Discharge Date: [**2115-8-19**]
Date of Birth: [**2048-9-18**] Sex: M
Service: Thoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
with a history of acute myeloplastic leukemia diagnosed in
[**2114-10-1**] who was treated with Ara-C but complicated by
infection and myelosuppression.
The patient was readmitted on [**8-9**] for an acute
myeloplastic leukemia relapse. The patient has been
complaining of right pleuritic chest pain, cough, and fevers.
A chest CAT scan was done on [**8-10**] which revealed a right
upper lobe consolidation. A biopsy of this consolidation
showed that it was a mucoid mycosis, and consequently
Thoracic Surgery was consulted on [**8-14**] to evaluate the
need to resect the right upper lobe.
The patient was started on AmBisome and Levaquin while he was
admitted on the Oncology Service.
PAST MEDICAL HISTORY: (His past medical history was
significant for)
1. Questionable aspergillus pneumonia in [**2115-11-1**]
which was treated with four weeks of AmBisome.
2. He also has a history of hypertension.
3. Recurrent acute myelogenous leukemia.
4. Gout.
5. Prostate cancer 10 years ago.
SOCIAL HISTORY: The patient has a social history significant
for cigarette smoking; although he quit. He also has a
history of asbestos exposure four years ago and possible
tuberculosis exposure since he was working in a tuberculosis
institute.
FAMILY HISTORY: His family history is significant for
father and brother both having prostate cancer.
ALLERGIES: The patient is allergic to PENICILLIN, DEMEROL,
ASPIRIN.
MEDICATIONS ON ADMISSION: He was admitted on Ambien,
allopurinol, hydroxyurea, colchicine, Paxil, multivitamin,
Tylenol, Ativan. The patient was placed on Levaquin and
AmBisome by the Oncology Service on admission.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, the
patient's temperature was 100.6, pulse was 112, respirations
were 20, blood pressure was 140/80, 98% on 35% shovel mask.
He saturated 88% on room air. His head, eyes, ears, nose,
and throat examination was significant for lymphadenopathy in
the cervical and submandibular region. His sclerae were
anicteric. No evidence of jugular venous distention or
carotid bruits. His pupils were equally round and reactive.
Chest examination revealed the patient was noted to right
inspiratory and expiratory wheezes with rales. His left
chest was clear to auscultation. He was also noted to have
palpable axillary lymph nodes including one that was
significantly enlarged in the left axilla. His heart was
regular rate and rhythm. First heart sound and second heart
sound were present. No murmurs or gallops were appreciated.
The abdomen was soft and nontender, though moderately
protuberant. Extremities were warm with palpable distal
pulses. No evidence of edema. Neurologically, he was alert
and oriented, and no focal neurologic deficits were noted.
PERTINENT LABORATORY DATA ON PRESENTATION: His white blood
cell count was 36.1, with a hematocrit of 25.7, and platelets
were 44. His electrolytes revealed sodium was 141, potassium
was 4.4, chloride was 106, bicarbonate was 27, blood urea
nitrogen was 20, creatinine was 1, and blood glucose was 110.
RADIOLOGY/IMAGING: He had a chest CT which revealed a right
upper lobe opacity measuring 6.7 cm X 8.7 cm; which was
increased from his previous CT scan of 4.1 cm X 4.5 cm.
There was extensive mediastinal and hilar lymphadenopathy.
A CAT scan of his abdomen also showed right basilar nodules
in the right base of his lung measuring approximately 8 mm.
There was also lymphadenopathy at the porta hepatis and the
retroperitoneum.
HOSPITAL COURSE: He has been receiving chemotherapy during
his admission to the Oncology Service. A biopsy of his left
axilla lymph node showed that there was no evidence of
disseminated fungal infection.
Therefore, discussion with the patient as well as his family
was started to determine whether or not they would wish to
have this consolidation in his right upper lobe removed. A
discussion was also carried in conjunction with the Oncology
Service. After much discussion, the decision was made to go
ahead with this thoracotomy and resection of his right upper
lobe.
The patient was then consented for this procedure and was
taken to the operating room on [**2115-8-16**].
Intraoperatively, an initial attempt to remove the patient's
right upper lobe appeared to be difficult, and the patient
had a significant amount of blood loss intraoperatively. He
lost approximately 3 liters of blood, requiring a 5-liter
transfusion. The patient also received multiple units of
platelets. Moreover, it was determined that it was necessary
intraoperatively to perform a complete right pneumonectomy.
Postoperatively, the patient was transferred to the Recovery
Unit in stable condition, though remained intubated.
The next morning the patient was transferred to the Cardiac
Surgery Recovery Unit where it became extremely difficult to
ventilate the patient. Initially, the patient's ventilator
was placed on pressure control ventilation, trying to control
his airway pressures so that the stump of the side where the
pneumonectomy was performed would not be blown out.
However, despite a pressure of 30 with a positive
end-expiratory pressure of 5, leaving a plateau pressure of
around 35, it was very difficult to ventilate the patient.
The patient's PCO2 increased precipitously to the 90s. At
this point, the patient was then switched over to assist
control which temporarily improved his ventilation. However,
the patient's creatinine increased from 1 to 1.9. Moreover,
his blood pressure began to drop, requiring the addition of
Neo-Synephrine to maintain an adequate mean arterial
pressure.
However, the patient's respiratory status continued to
deteriorate despite the fact that we ventilated him. His
oxygenation then became a problem requiring high FIO2 of up
100%. We attempted to wean this down slightly to 80%;
however, the patient did not tolerate this and required going
back to 100%. Next, his blood pressure became an issue again
requiring the addition of a second [**Doctor Last Name 360**]; we added Levophed
to maintain his blood pressure. Fluid boluses did not appear
to help his blood pressure or his perfusion. The patient
became progressively acidotic. Moreover, his renal function
also deteriorated with his creatinine increasing to 3.7 the
next morning, which quickly increased to over 5 the same
afternoon.
In the morning of [**8-19**], the patient's systolic blood
pressure dropped to the 70s despite very high doses of
Neo-Synephrine and Levophed. Moreover, his kidney stopped
making urine, and his oxygenation became a main issue since
the patient was unable to get rid of any of the fluids that
he had been receiving. His oxygen saturation dropped into
the 80s despite being on 100% FIO2.
At this point, the family was then contact[**Name (NI) **] as well as the
attending to explain that the patient was not doing well and
may not survive. At this point, the family decided to make
the patient do not resuscitate; however, they did not
withdraw care.
Nevertheless; at 7:55 a.m. on [**2115-8-19**], the patient's
blood pressure continued to drop, followed by his heart rate,
and finally he became asystolic and expired at exactly
7:55 a.m. on [**2115-8-19**].
CONDITION AT DISCHARGE: The patient expired.
DISCHARGE STATUS: The patient expired.
DISCHARGE DIAGNOSES:
1. Disseminated acute myelogenous leukemia.
2. Status post right pneumonectomy.
3. Multiple organ failure.
[**Known firstname 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Name8 (MD) 20292**]
MEDQUIST36
D: [**2115-8-19**] 08:31
T: [**2115-8-24**] 21:24
JOB#: [**Job Number 21208**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1548
} | Medical Text: Admission Date: [**2134-5-16**] Discharge Date: [**2134-6-1**]
Date of Birth: [**2068-12-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
leg swelling, DOE
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Colonoscopy
Tracheostomy
PICC line placement
Arterial line placement
Trauma line placement
History of Present Illness:
65yo M with a PMH of afib on coumadin, diabetes, HIV, HTN and
CHF BIBA after calling 911 for several months of increasing LE
edema x2months and concerns that he was not doing well at home
w/ lightheadness, DOEx4days, disorientation. Upon further
questioning he does note DOE x4days and several weeks of dark
malodorous loose stool with intermittent BRBPR in the toilet
bowl. Does recall some mild abdominal pain 4 days ago that has
resolved. States he has had a colonoscopy and EGD previously at
[**Hospital1 2025**], does not know why, states he does not remember being told
anything was wrong. Denies ETOH use, occasional Aleve use. Of
note, he states his VNA stopped checking his blood levels about
1 month ago. He continued to take his coumadin as previously
instructed (1.5pills/day, unknown dose). Denies F/C/CP/SOB at
rest/N/V/hematemesis, diaphoresis. Noted LE edema has worsened
over the last 2 days.
In the ED, initial VS were Temp 98 HR 148 BP 98/58 RR 15 sat
100% 3LNC. He was noted to be pale appearing and tachycardic
with guaiac positive black stool on rectal exam. Labs were
significant for a hct of 12.8 (last noted to be 37.4 in [**2121**]),
hgb 3.6, INR 14.2, plts 216, Cr 2.7 (last noted to be 1.2 in
[**2121**]) with a BUN of 73, Bicarb 20, glucose 216, trop 0.07,
lactate 1.3, LFTs normal, Alb 3.6. Repeat Hct 1.5hrs later was
stable at 12.4 prior to PRBC transfusions. Blood cultures were
sent. ECG showed afib with RVR (HR120s) and poor baseline. CXR
showed mild cardiomegaly, clear lungs without acute process.
Patient received 1 liter NS with improvement in his SBP from 80s
to 100s and HR from 140s to 120s. Patient was ordered for 4PRBCs
ad 3 units FFP, however only the first unit of FFP had been
completed prior to transfer. Patient was receiving the second
unit of FFP on arrival and had not received any PRBCs. He
received pantoprazole 40mg IV and vitamin K 10mg IV. GI was
consulted and plans to do EGD and colonoscopy early this week,
when hct is >25 and INR is therapeutic. Admitted with a presumed
diagnosis of subacute lower GI bleed. VS on transfer HR 120-130
BP94/60 rr16 100% RA.
On arrival to the MICU, he is comfortable lying in bed without
chest pain, SOB, lightheadedness. C/o trembling.
Past Medical History:
afib on coumadin (CHADS 3, denies h/o strokes)
diabetes on oral hypoglycemics
HTN
HL
CHF
CAD s/p MI 15yrs ago (denies PCI or CABG)
CKD (unknown baseline)
HIV, pt reports undetectable viral load
s/p right hernia repair
Social History:
Retired, lives in [**Location 669**]. States an old girlfriend gave him HIV
many yrs ago.
- Tobacco: 1/2ppdx10yrs, quit 20yrs ago
- Alcohol: none, quit 30yrs ago (used to drink on the weekends)
- Illicits: denies
Family History:
Mother w/ HTN. Father w/ HTN and h/o MI. Denies DM, CVA, cancers
including stomach and colon cancer.
Physical Exam:
Admission Exam:
Vitals: T: 98.4 BP: 117/66 P: 133 R: 18 O2: 100%2LNC
General: Alert, oriented, no acute distress, pleasant and
interactive
HEENT: Sclera anicteric, MMM, oropharynx clear w/ dentures,
EOMI, PERRL
Neck: supple, JVP could not be assessed [**12-24**] large neck, no LAD,
trauma line in right JVP with moderate hematoma posteriorly
CV: rapid irreg irreg, normal S1 + S2, no murmurs, rubs, gallops
appreciated
Lungs: Clear to auscultation bilaterally with mild rales at the
bases bilaterally, no wheezes, rhonchi
Abdomen: Obese, soft, non-tender, mildly distended, bowel sounds
present- normoactive, unable to assess for organomegaly. healed
scar to the right of the umbilicus
GU: no foley
Ext: [**11-23**]+ symmetric edema to knees bilaterally, warm, well
perfused, 1+ pulses, no clubbing, cyanosis, verucous lesions on
anterior shins bilaterally
Neuro: A&Ox3, CNII-XII intact, 5/5 strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred
Discharge Exam:
General: Awake, sitting in chair, interactive, following
commands.
HEENT: PERRL, anicteric sclera.
CV: S1S2 RRR w/o m/r/g??????s.
Lungs: CTA bilaterally w/o crackles or wheezing.
Ab: Positive BS??????s, NT/ND, no HSM.
Ext: Brawny LE skin changes.
Neuro: Alert and interactive. Moving all extremities. No focal
motor deficits noted.
Pertinent Results:
Admission Labs:
[**2134-5-15**] 11:10PM BLOOD WBC-6.2# RBC-1.33*# Hgb-3.6*# Hct-12.8*#
MCV-97 MCH-27.3# MCHC-28.3*# RDW-17.4* Plt Ct-216
[**2134-5-15**] 11:10PM BLOOD Neuts-75.1* Lymphs-18.3 Monos-6.1 Eos-0.3
Baso-0.2
[**2134-5-15**] 11:10PM BLOOD PT-136.7* PTT-45.9* INR(PT)-14.2*
[**2134-5-16**] 03:06AM BLOOD Fibrino-217
[**2134-5-15**] 11:10PM BLOOD Glucose-216* UreaN-73* Creat-2.7*# Na-143
K-4.5 Cl-114* HCO3-20* AnGap-14
[**2134-5-15**] 11:10PM BLOOD ALT-11 AST-8 AlkPhos-114 TotBili-0.1
[**2134-5-15**] 11:10PM BLOOD cTropnT-0.07*
[**2134-5-16**] 03:06AM BLOOD Calcium-7.6* Phos-3.5 Mg-2.2
[**2134-5-15**] 11:10PM BLOOD Albumin-3.6
[**2134-5-16**] 03:17AM BLOOD Type-[**Last Name (un) **] pH-7.30*
[**2134-5-15**] 11:25PM BLOOD Lactate-1.3
[**2134-5-15**] 11:25PM BLOOD Hgb-3.9* calcHCT-12
[**2134-5-16**] 03:17AM BLOOD freeCa-1.02*
[**2134-5-16**] 05:59AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2134-5-16**] 05:59AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2134-5-16**] 05:59AM URINE RBC-2 WBC-6* Bacteri-NONE Yeast-NONE
Epi-<1
[**2134-5-16**] 05:59AM URINE Hours-RANDOM UreaN-616 Creat-84 Na-43
K-27 Cl-33
[**2134-5-31**] 03:51AM BLOOD WBC-8.0 RBC-2.80* Hgb-7.9* Hct-25.0*
MCV-89 MCH-28.1 MCHC-31.5 RDW-16.4* Plt Ct-369
[**2134-6-1**] 05:39AM BLOOD WBC-7.8 RBC-2.75* Hgb-7.9* Hct-24.5*
MCV-89 MCH-28.7 MCHC-32.1 RDW-16.6* Plt Ct-366
[**2134-5-27**] 03:15AM BLOOD PT-12.0 PTT-24.4* INR(PT)-1.1
[**2134-5-29**] 12:58AM BLOOD PT-13.6* PTT-26.7 INR(PT)-1.3*
[**2134-5-30**] 04:01AM BLOOD PT-16.5* PTT-25.0 INR(PT)-1.6*
[**2134-5-31**] 03:51AM BLOOD PT-19.9* PTT-29.2 INR(PT)-1.9*
[**2134-5-29**] 12:58AM BLOOD Glucose-153* UreaN-36* Creat-1.8* Na-150*
K-3.0* Cl-112* HCO3-28 AnGap-13
[**2134-5-29**] 12:00PM BLOOD Na-149* K-3.5 Cl-114*
[**2134-5-29**] 11:13PM BLOOD Glucose-180* UreaN-31* Creat-1.7* Na-145
K-3.4 Cl-110* HCO3-25 AnGap-13
[**2134-5-30**] 04:01AM BLOOD Glucose-139* UreaN-29* Creat-1.6* Na-145
K-3.7 Cl-111* HCO3-27 AnGap-11
[**2134-5-31**] 03:51AM BLOOD Glucose-112* UreaN-25* Creat-1.5* Na-146*
K-3.8 Cl-110* HCO3-26 AnGap-14
[**2134-5-31**] 10:04PM BLOOD Glucose-120* UreaN-18 Creat-1.5* Na-147*
K-3.6 Cl-112* HCO3-24 AnGap-15
[**2134-6-1**] 05:39AM BLOOD Glucose-90 UreaN-17 Creat-1.5* Na-147*
K-4.0 Cl-112* HCO3-27 AnGap-12
[**2134-6-1**] 05:39AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.0
[**2134-6-1**] 05:35AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-PND
[**2134-6-1**] 05:35AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-PND
[**2134-5-28**] 03:56PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2134-5-28**] 03:56PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
[**2134-5-28**] 03:56PM URINE RBC-1 WBC-12* Bacteri-NONE Yeast-NONE
Epi-0
[**2134-5-28**] 3:56 pm URINE Site: NOT SPECIFIED
Source: Line-PICC line.
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2134-5-25**] 4:00 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2134-5-26**]**
C. difficile DNA amplification assay (Final [**2134-5-26**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
ECG Study Date of [**2134-5-15**] 11:12:34 PM
Atrial fibrillation with rapid ventricular response rate of 126
beats per
minute. Multifocal premature ventricular complexes. Delayed R
wave
transition. Non-specific ST segment changes in the lateral and
high lateral leads. No previous tracing available for
comparison.
CT ABD & PELVIS W/O CONTRAST Study Date of [**2134-5-17**] 10:29 AM
FINDINGS:
CT OF THE ABDOMEN WITHOUT CONTRAST: Although this study is not
tailored for
the evaluation of supradiaphragmatic contents, the visualized
lung bases show
bilateral consolidations/collapse on the right greater than the
left with air
bronchograms and trace bilateral pleural effusions on the right
greater than
the left. Diffuse ground-glass opacification in the aerated
portions of the
lung bases is also noted. No pulmonary nodules are seen.
Limited imaging of
the heart shows moderately enlarged size without pericardial
effusion. The
visualized portion of the descending thoracic aorta is slightly
tortuous in
its course. The esophagus contains an enteric tube and
otherwise appears
unremarkable.
Evaluation of the solid organs is limited without intravenous
contrast.
Within these limitations, no gross abnormality is detected
within the liver.
There is trace perihepatic fluid. No intrahepatic or
extrahepatic biliary
ductal dilatation is seen. The gallbladder contains several
calcified
gallstones in the dependent portion measuring up to 6 mm in
size. No
gallbladder wall thickening, edema, or pericholecystic fluid is
seen. The
pancreas is unremarkable. The spleen contains a 2.1-cm
hypodensity with
internal fluid density of 19 Hounsfield units, likely
representing a splenic
cyst. The spleen is otherwise unremarkable. The bilateral
adrenal glands and
kidneys are within normal limits.
The stomach contains an enteric tube in the distal body. The
intra-abdominal
loops of small and large bowel are unremarkable without evidence
of wall
thickening or obstruction. The appendix is normal in
appearance. Minimal
fluid is noted tracking along the left paracolic gutter. There
is no large
volume abdominal ascites or retroperitoneal fluid collection.
No free air is
present. No mesenteric or retroperitoneal lymphadenopathy is
noted, although
there are scattered small retroperitoneal and iliac lymph nodes
which do not
meet CT size criteria for lymphadenopathy.
The abdominal aorta is normal in caliber throughout.
CT OF THE PELVIS WITHOUT CONTRAST: The urinary bladder is
decompressed by
Foley catheter in appropriate position. The prostate and
seminal vesicles are
unremarkable. A small amount of simple free fluid is noted
superior to the
urinary bladder, within the superior pelvis. The rectum and
sigmoid colon are
unremarkable. Several prominent pelvic side wall and inguinal
lymph nodes are
noted measuring up to 12 mm in short axis.
OSSEOUS STRUCTURES AND SOFT TISSUES: There is a compression
fracture
deformity at the L5 vertebral body which is indeterminate in
age. No
suspicious lytic or sclerotic lesions are detected in the bone.
There is mild
generalized anasarca. No focal fluid collections are noted
within the soft
tissue to suggest hematoma.
IMPRESSION:
1. No evidence of retroperitoneal or subcutaneous fluid
collection to suggest
hematoma. Mild generalized anasarca and minimal perihepatic and
pelvic
ascites is noted.
2. Bibasilar consolidation/collapse of the lungs, on the right
greater than
the left, with trace pleural effusions.
3. Cholelithiasis.
4. Nonspecific prominent pelvic side wall and inguinal lymph
nodes.
TTE (Complete) Done [**2134-5-24**] at 10:56:45 AM FINAL
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is moderately dilated. There
is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**11-23**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild-moderate mitral regurgitation. Pulmonary artery
hypertension.
PORTABLE ABDOMEN Study Date of [**2134-5-31**] 11:51 AM
*** UNAPPROVED (PRELIMINARY) REPORT *** !! WET READ !!
Preliminary report has not yet been released for viewing.
CHEST (PORTABLE AP) Study Date of [**2134-5-28**] 2:50 PM
NG tube tip is in the stomach. Tracheostomy tube is in the
standard position. Left PICC tip is in the mid-to-lower SVC.
Moderate cardiomegaly is stable. There is mild vascular
congestion. Bibasilar opacities, larger on the left side are
unchanged, could be due to atelectasis and/or pneumonia. There
are no new lung abnormalities.
EGD [**2134-5-17**]
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
General anesthesia. A physical exam was performed prior to
administering anesthesia. Supplemental oxygen was used. The
patient was placed in the left lateral decubitus position and an
endoscope was introduced through the mouth and advanced under
direct visualization until the third part of the duodenum was
reached. Careful visualization of the upper GI tract was
performed. The vocal cords were visualized. The procedure was
not difficult. The patient tolerated the procedure well. There
were no complications.
Findings: Esophagus:
Mucosa: Esophagitis with no bleeding was seen in the GE
junctoin, compatible with mild esophagitis.
Stomach:
Mucosa: Erythema of the mucosa with no bleeding was noted in
the antrum. These findings are compatible with mild gastritis.
Other linear erosion on the greater curvature of the stomach
consistent with NG tube trauma
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Esophagitis in the GE junctoin compatible with mild
esophagitis
Linear erosion on the greater curvature of the stomach
consistent with NG tube trauma
Erythema in the antrum compatible with mild gastritis
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: No clear explanation for the patient's GI bleed
from this EGD.
Will need colonoscopy when more stable
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSIS are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology.
Bronchoscopy [**2134-5-26**]
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
standard time out was performed as per protocol. The procedure
was performed for diagnostic and therapeutic purposes at the
operating room. A physical exam was performed. The bronchoscope
was introduced through an endotracheal tube and advanced under
direct visualization until the tracheobronchial tree was
reached.The procedure was not difficult. The quality of the
preparation was good. The patient tolerated the procedure well.
There were no complications.
Recommendations: Admit to ICU
Additional notes: Patient medication list was reconciled.
Attending was present for the entire procedure. FINAL DIAGNOSES
are listed in the impression section above. Estimated blood loss
= 25 ml. No specimens were taken for pathology.
Colonoscopy [**2134-5-31**]
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. The
efficiency of a colonoscopy in detecting lesions was discussed
with the patient and it was pointed out that a small percentage
of polyps and other lesions can be missed with the test. A
physical exam was performed. The patient was administered
moderate sedation. The physical exam was performed prior to
administering anesthesia. Supplemental oxygen was used. The
patient was placed in the left lateral decubitus position.The
digital exam was normal. The colonoscope was introduced through
the rectum and advanced under direct visualization until the
cecum was reached. The appendiceal orifice and ileo-cecal valve
were identified. Careful visualization of the colon was
performed as the colonoscope was withdrawn. The colonoscope was
retroflexed within the rectum. The procedure was not difficult.
The quality of the preparation was fair. The patient tolerated
the procedure well. There were no complications.
Findings:
Protruding Lesions Three sessile non-bleeding polyps of benign
appearance and ranging in size from 5 mm to 6 mm were found in
the ascending, descending, sigmoid.
Excavated Lesions A single circular ulcer was found in the
rectum. A single linear ulcer was found in the rectum.
Impression: Polyps in the ascending, descending, sigmoid
Ulcer in the rectum
Ulcer in the rectum
Otherwise normal colonoscopy to cecum
Recommendations: Colonoscopy in 6 mos.
Additional notes: The procedure was performed by the fellow and
the attending. The attending was present for the entire
procedure. Degree of difficulty 1 (5 most difficult) FINAL
DIAGNOSES are listed in the impression section above. Estimated
blood loss = zero. No specimens were taken for pathology
Brief Hospital Course:
65yo M with a PMH of afib on coumadin, diabetes, HIV, HTN, and
CHF admitted to the ICU with likely subacute GIB, with hct 12.8
in the context of supratherapeutic INR at 14.2. Originally he
was hypotensive secondary to significant blood loss. Patient was
noted to have SBPs in the 80s on admission, was responsive to
IVF bolus. He then receivied 6 units PRBCs and FFP with a
massive transfusion protocol with SBPs in the 100s with a trauma
line that was placed. All his at home antihypertensives were
held clonidine, monixidil, isosorbide dinitrate. His atrial
fibrillation normally treated with coumadin and diltiazem at
home became Afib with RVR likely 2ndary to anemia (rates in the
120s to 140s). Patient then became agitiated and went into flash
pulmonary edema. he was intubated and then was stablaized. He
failed 3 extubation attmepts, 1 planned and 2 self attmepts. He
then got a tracheosomty placed. He improved afterwards and was
able to breath off of the ventilator without hemodynamic
compromise.
# Anemia [**12-24**] gastrointestinal bleeding: Patient reports a
history of weeks of dark stools and was noted to have dark
guaiac positive stool on rectal exam. He does not carry a
diagnosis of liver disease or known GI pathology, however he has
also not seen a GI physician and has not had an EGD or
colonoscopy previously. LFTs are normal, MCV normal. Hcts
stabilized, then dropped again and he was transfused another 2
more units. His EGD showed esophagitis in the GE junctoin
compatible with mild esophagitis, linear erosion on the greater
curvature of the stomach consistent with NG tube trauma,
erythema in the antrum compatible with mild gastritis. He had a
colonoscopy that showed several rectal ulcers and polyps in the
ascending, descending, and sigmoid colon. No clear explanation
of the GI bleed was discovered and a colonscopy was recommened
in 6 months.
# Supratherapeutic INR: patient is on coumadin for atrial
fibrillation. It is currently unclear how or for how long his
INR has been supratherapeutic. He was given vitamin K 10mg IV
and multiple units of FFP. Patient is a poor historian and may
have inadvertantly taken more than recommended. He was continued
without anticoagulation due to the GIB. At the end of the
hospitalization his coumadin was restarted at his home dose and
will be continued to be montiored and managed as an outpatient.
#A. fib. with RVR on multiple occasion led to flashing during
the extubation attempts. He was managed as above for coumadin
and rate controlled with diltiazem and metoprolol.
#CHF Pt required large doses of iv lasix and lasix drips to
treat vol overload and lost over 19 kilograms during the
hospitalization likely due to a fluid overloaded state and LE
edema that resolved by the time of discharge.
#Hypertension: History of htn he was treated before with
clonidine, Isosorbide Dinitrate, Lisinopril, Diltiazem ER,
Metoprolol, and Minoxidil. He was treated with clonidine,
diltiazem, metoprolol mainly, but several medicines were used on
a prn basis including hydralazine and a nitroglycerin drip. We
discharged him with lisinopril, metoprolol, clonidine, and
isosorbide dinitrate.
# [**Last Name (un) **]/CKD: It is unknown whether the patient carries a diagnosis
of CKD, however he does related that he has been told his
kidneys do not work well. States he does not urinate a lot as
well. Admission Cr is 2.7. Last known Cr is 1.2 from [**2121**]. [**Last Name (un) **]
could be due to renal hypoperfusion [**12-24**] acute/subacute blood
loss. Final Cr during hospitalization 1.5.
# Elevated troponin: Likely due to demand ischemia [**12-24**]
tachycardia and significant anemia. Following trops flat.
Outpatient management should be continued.
# Diabetes: Blood glucose 216 on admission. Patient managed on
oral hypoglycemics as an outpatient. Managed with 10 units of
glargine and a sliding scale, may be continued as an outpatient
or transitioned to oral medications.
# HIV: patient reports an undetectable viral load. Inactive
issue during this hospitalization.
-continued home meds and needs to continue outpt followup
Hypernatremia -Pt required free water flushes to resolve his
hypernatremia. This issue resolved in the hospitalization.
UTI- He was found to have a E.Coli UTI and we decided to treat
for 7 days with ceftriaxone staring on [**2134-6-1**]. End dat [**2134-6-8**].
Transitional issues:
Colonoscopy with GI within 6 months
Gi says the flexiseal- would be best to avoid, but can continue
for patient comfort/ skin issues.
[**Month (only) 116**] start glipizide when taking PO, now discharging on insulin
per regimen in the hospital
Diet per Page 1: pureed and nectar thick with cuff deflated, no
PMV
Discharged on subq heparin for dvt prophylaxis will read address
the issue of anticoagulation as an outpatient
Pt was send out on 7 days on ceftriaxone for a UTI end on
[**2134-6-8**].
PICC line
Hypertension medications may need uptitration
Holding lasix as patient diuresed during hospitalization over 20
pounds and was borderline hypernatremic at time of discharge,
during cardiology appointment, reconsideration of restarting
lasix.
Blood cultures pending
Emergency contact [**Name (NI) **] [**Telephone/Fax (1) 28767**]
Sister [**Name (NI) **] [**Name (NI) 28768**] [**Telephone/Fax (3) 28769**], not official
emergency contact.
Full code during this admission
Medications on Admission:
Unable to obtain information regarding preadmission medication
at this time. Information was obtained from dc list from [**Hospital1 2025**]
in [**3-4**].
1. Abacavir Sulfate 600 mg PO HS
2. Efavirenz 600 mg PO HS
3. LaMIVudine 150 mg PO HS
4. Azithromycin 250 mg PO Q24H
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Isosorbide Dinitrate 20 mg PO TID
9. Minoxidil 5 mg PO BID
10. CloniDINE 0.4 mg PO BID
11. Furosemide 40 mg PO DAILY
12. Furosemide 20 mg PO PRN lower extremity edema
13. Pravastatin 40 mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. Warfarin 5 mg PO DAILY16
16. GlipiZIDE 5 mg PO DAILY
take 30 minutes before a meal
17. traZODONE 25 mg PO HS
18. Calcitriol 0.25 mcg PO MWF
19. Cyanocobalamin 1000 mcg PO DAILY
20. Doxazosin 8 mg PO HS
21. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
22. Omeprazole 40 mg PO DAILY
23. Docusate Sodium 100 mg PO BID
24. Polyethylene Glycol 17 g PO DAILY:PRN constipation
25. Lactulose 15 mL PO Q8H:PRN constipation
26. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Abacavir Sulfate 600 mg PO HS
2. CloniDINE 0.4 mg PO BID
3. Efavirenz 600 mg PO HS
4. Isosorbide Dinitrate 40 mg PO TID
HOLD for SBP<100
5. LaMIVudine 150 mg PO HS
6. Senna 1 TAB PO BID:PRN constipation
7. Warfarin 5 mg PO DAILY16
8. Diltiazem Extended-Release 240 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Heparin 5000 UNIT SC TID
11. Lisinopril 20 mg PO DAILY
12. Glargine 10 Units Dinner
Insulin SC Sliding Scale using REG Insulin
13. Omeprazole 40 mg PO DAILY
14. Metoprolol Tartrate 100 mg PO TID
hold for SBP < 100, HR < 60
15. Aspirin 81 mg PO DAILY
16. Calcitriol 0.25 mcg PO MWF
17. Cyanocobalamin 1000 mcg PO DAILY
18. Lactulose 15 mL PO Q8H:PRN constipation
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. Pravastatin 40 mg PO DAILY
21. traZODONE 25 mg PO HS:PRN Sleep aide
22. Quetiapine Fumarate 50 mg PO Q12H:PRN agitation
23. CeftriaXONE 1 gm IV Q24H Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Lower gastrointestinal bleed
Congestive heart failure
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was our pleasure to care for you at [**Hospital1 18**].
You were treated in the hospital for low blood pressures likely
from a gastrointestinal bleed in the setting of a high INR,
which is a measure of the thinness of your blood on coumadin.
You received several blood transfusions. You were also seen by
the gastroenterology doctors who recommended a colonoscopy that
showed rectal ulcers, which may be where the bleed was coming
from. You should have another colonoscopy in 6 months. Because
you stopped bleeding your coumadin was restarted on discharge.
Because you were critically ill, you were treated in the
intensive care unit and were intubated for several days due to
fluid in your lungs. Since you had the breathing tube in for
several days and it had been replaced several times, we changed
your tube to a tracheostomy, which is the breathing tube that
was placed in your neck. As you improve this may be able to be
removed in the future. Since you cannot eat safely right now,
you have a feeding tube in as well which can be removed when you
can safely swallow.
Changes to your medications:
STOP taking minoxidil
STOP taking doxazosin.
STOP taking glipizide
STOP taking azithromycin
STOP taking Lasix
CHANGE dose of lisinopril to 20 mg daily
CHANGE dose of isosorbide dinitrate to 40 mg three times a day
CHANGE metoprolol to three times daily
START taking heparin shots three times a day. This can help
prevent blood clots.
START taking lantus insulin 10 units at night and insulin
sliding scale with meals.
START taking seroquel 50 mg twice a day as needed
START taking ceftriaxone 1 g daily x 7 days, starting [**2134-6-1**],
given in the ICU.
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2134-6-16**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2134-6-24**] at 8:40 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: WEST PROCEDURAL CENTER
When: THURSDAY [**2134-8-5**] at 1:30 PM
With: WPC ROOM THREE [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 5789, 5849, 2760, 2762, 5990, 2851, 412, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1549
} | Medical Text: Admission Date: [**2128-11-27**] Discharge Date: [**2128-12-4**]
Date of Birth: [**2086-10-4**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 20506**]
Chief Complaint:
Status epilepticus
Major Surgical or Invasive Procedure:
Intubation (at outside hospital)
Extubation
History of Present Illness:
The pt is a 42 year-old man, with a past medical history
significant for TBI and seizure disorder, reported EtOH use,
who presents after being found down at or around his house, and
then taken to an OSH where he was intubated and sedated out of
concern for status.
There is not a great deal of information known about this
patient. All information is obtained throughout the [**Hospital3 **]
chart and EMS report. He had an address without a phone number
listed, there was no contact information otherwise and could not
find a number for the given address.
What is known is that EMS was called to his house where he was
found lying on the floor breathing, presumed post ictal from a
seizure. At first he was given Narcan because there was a
concern that there was an overdose, but here was no effect.
fter learning the patient has a seizure d/o he was given ~4mg of
Ativan in the field and taken to [**Hospital6 **]. There he
was noted on exam to have brainstem reflexes, but minimal
withdrawal to pain. A head CT was obtained but did not show any
acute pathology. He had levels of the two AEDs he is reportedly
on (PHT and VPA), pHT was 12 and VPA 44, but it is not clear if
these are pre or post load. He may have gotten 2 more mg of
Ativan at this point. He was seen by neurology at the outside
hospital who felt that he was still not very responsive and that
this may be due to "subtle" status, and recommended intubating
the patient, he was bolused 500mg PHT and started on a versed
gtt and transferred to BIMDC for further neurological
management.
Past Medical History:
Traumatic brain injury
Epilepsy
Previous alcohol dependence
Social History:
He lives with his mother who is [**Name8 (MD) **] RN at [**Hospital 1263**] Hospital. He
smokes (unclear amount), and has not drunk any alcohol for many
years.
Family History:
non-contributory
Physical Exam:
Physical Exam:
Vitals: T: 99 P: 100 R: 16 BP: 136/92 SaO2: 100
General: Intubated/sedatated
HEENT: NC/AT, no scleral icterus noted, MMM,
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally,
Neurologic:
-Mental Status: Intaubted and sedated, grimaces and slightly
opens eyes to deep sternal rub. Pulls away from painful
stimulus. No tracking.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.
III, IV, VI: VOR intact
V, VII: corneal intact
IX, X: gag
-Motor: Normal bulk, tone throughout. Withdraws to pain at all 4
ext
-Sensory: feels pain at all 4
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
No clonus
-Coordination and gait: not tested
Pertinent Results:
[**2128-11-27**] 08:15PM GLUCOSE-98 UREA N-10 CREAT-0.6 SODIUM-145
POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-23 ANION GAP-16
[**2128-11-27**] 08:15PM cTropnT-<0.01
[**2128-11-27**] 08:15PM CALCIUM-8.2* PHOSPHATE-4.4 MAGNESIUM-2.0
[**2128-11-27**] 08:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2128-11-27**] 08:15PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2128-11-27**] 08:15PM WBC-9.5 RBC-4.03* HGB-14.0 HCT-38.6* MCV-96
MCH-34.8* MCHC-36.4* RDW-13.4
[**2128-11-27**] 08:15PM NEUTS-77.5* LYMPHS-15.9* MONOS-5.5 EOS-0.7
BASOS-0.4
[**2128-11-27**] 08:15PM PLT COUNT-196
[**2128-11-27**] 08:15PM PT-12.7 PTT-25.0 INR(PT)-1.1
[**2128-11-27**] 08:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2128-11-27**] 08:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2128-11-29**] EEG showed no epileptiform features
Brief Hospital Course:
Initial Impression / Hospital Course:
The pt is a 42 year-old man, with a past
medical history significant for TBI and seizure disorder,
reported EtOH use, who presents after being found down at or
around his house, and then taken to an OSH where he was
intubated
and sedated out of concern for status. The patient was found
down after a presumed seizure, and he received 4-6mg of Ativan
on
route to the local hospital (it is not clear why so much was
given). At the OSH he was noted to have brainstem reflexes but
not much response to pain. He had two AEDs level drawn which
indicated he was slightly subtherapuetic . A neurologist saw
the
patient at [**Hospital3 **] and was concerned that the patient had
not
returned to baseline and was possibly in status, so was given
more Ativan, intubated and placed on a versed gtt. AT [**Hospital1 18**], on
exam
he is more rousable then before. He moves and grimaces to pain,
withdraws at all fours to pain. This patient is currently
intubated and will need admission to the ICU and an EEG to help
determine if he is in sub-clinical status. Given the patient
history of EtOH/drug, his sub-therapeutic AEDs level were likely
provoking factors.
Mr. [**Known lastname **] was admitted to the ICU. His tox screen was
negative except for benzos. He was weaned off of versed and
then extubated and transferred to the ICU. His AEDs were
adjusted. He received 1 gram fosphenytoin for low dilantin
level, and then was maintained on Dilantin 500mg QHS. Due to
the difficulty in maintaining therapeutic dilantin levels with
Valproate, his valproate was decreased to 500mg [**Hospital1 **]. Valproate
was not completely removed due to need for mood stabilization.
He was started on Zonegran, which is titrating up. Currently
the dose is at 200mg QHS, but will continue to increase as an
outpatient to 300mg QHS. Infectious work-up was negative.
Medications on Admission:
He was on Depakote and Dilantin but the drug doses were not the
same as what his neurologist prescribed, as his doses were
checked with his pharmacy. The patient was non-compliant with
his meds so the actual drug dose was unclear. [**Name2 (NI) **] was supposed to
be on Dilantin 400 mg QHS and Depakote 1 g [**Hospital1 **] as per his
neurologist Dr. [**Last Name (STitle) 35852**].
Discharge Medications:
1. divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO BID (2 times a day).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. phenytoin sodium extended 100 mg Capsule Sig: Five (5)
Capsule PO QHS (once a day (at bedtime)).
Disp:*150 Capsule(s)* Refills:*2*
3. zonisamide 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*60 Capsule(s)* Refills:*2*
4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Generalized seizure
Secondary
Traumatic brain injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were found unresponsive, likely after having a generalized
seizure. You were taken to an outside hospital, intubated,
before transfer to [**Hospital1 18**] for further management. Your stayed in
the ICU briefly. On the floor service, we adjusted your
anti-epileptic medications (Dilantin and Depakote). We also
started a new anti-epileptic medication called Zonisamide.
Followup Instructions:
Please follow-up with your outpatient neurologist Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 35852**]
(tel:([**Telephone/Fax (1) 88263**]) in one week, he requested that you call to
schedule an appointment. Your Dilantin level at the time of
discharge was 10.3.
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1550
} | Medical Text: Admission Date: [**2170-12-2**] Discharge Date: [**2170-12-14**]
Date of Birth: [**2090-3-5**] Sex: M
Service: MEDICINE
Allergies:
Ceftazidime
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Increased respiratory secretions and inability to swallow meds.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
80 y.o. man with P.D., s/p 2 admissions over last month for
falls. Pt was just discharged to rehab yesterday, but is now
returning with inability to take PO meds, requiring frequent
suctioning. When pt was here last he was admitted after a
witness fall and injured his left elbow. On that admit, he was
witness to aspirate with meds, food, and liquids but family was
refusing NGT or PEG tube. Therefore, pt was discharged with
rehab with understanding that he could take food and meds but
was at high risk of aspiration and ensuing complications. This
morning at [**Hospital 599**] rehab in [**Location (un) **], pt was noted to have
increased resp secretion requiring q30min suctioning. He also
could not swallow his medications.
Though pt did pass swallow study at [**Hospital1 5595**] about 2 weeks ago, he
was clearly witnessed to aspirate over last 2 days while here.
..
Currently, pt denies pain, SOB, CP, cough. He understands why
he is here.
Past Medical History:
1. CAD s/p CABG [**2165**]-3VD--CABG by [**Last Name (un) 2230**]
-[**2146**] IMI (Rx'd with SK), CATH with 75% mid RCA.
-Noted to have VEA and ?PAF, Rx'd with quinidine and later
digoxin.
[**11/2153**] normal ETT, [**2158**] 10" ETT/neg EKG/neg Sx.
- [**10/2160**] admitted for eval palpitations, MI R/O, HOLTER with VEA,
quinidine/dig stopped, atenolol begun.
2. hypercholesterolemia
3. HTN
4. parkinson's
5. colon cancer
-S/P RESECTION [**2158**] WITH CLEAR MARGINS (R-colon), f/u
colonoscopies negative [**12/2160**], [**6-/2161**]; [**6-/2163**]; [**6-/2165**]- two small
(4mm) sessile adenomatous polyps were identified and removed
6. anemia
7. hx hip fracture w/right total hip replacement
8. actinic keratoses, SCC on forehead, s/p MOHS excision
9. h/o PAF
Social History:
SH: Has been at [**Hospital 599**] rehab in [**Location (un) **] x2 days since last
admission. Son and family live nearby. Son heavily involved in
pt's care and is healthcare proxy. Former [**Name2 (NI) 1818**] (+20 pack year
h/o), quit 25 years ago. Seldom EtOH, no drugs. No longer able
to ambulate secondary to frequent falls and rigidity from
Parkinson's. He passed a speech and swallow eval at [**Hospital 100**]
Rehab ~1 month; he was taking his Parkinson's Meds at that time.
Family History:
FH - CAD, HTN
Physical Exam:
97.8---91---102/72---17---95%RA
Gen: cogwheeling tremor, pt in no resp distress.
HEENT: Pupils min reactive to light. Anicteric. OP clear with
dry MM.
Neck: supple
Lungs: b/l rhonchi and occ insp and exp wheezing.
CV: irreg irreg rhythm, nml S1S2, no m/r/g
Abd: soft, NT, ND, na BS
Ext: no edema, Left elbow wrapped but nontender.
Neuro: A&Ox2 (not date), cogwheelng tremor of left hand
mostly. Gait not tested.
Pertinent Results:
[**2170-12-1**] 07:20AM WBC-5.8 RBC-3.50* HGB-11.2* HCT-32.9* MCV-94
MCH-32.1* MCHC-34.1 RDW-14.2
[**2170-12-1**] 07:20AM NEUTS-78.8* LYMPHS-18.1 MONOS-1.3* EOS-1.4
BASOS-0.4
[**2170-12-1**] 07:20AM PLT COUNT-195
[**2170-12-1**] 07:20AM GLUCOSE-102 UREA N-12 CREAT-0.8 SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2170-12-1**] 07:20AM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.1
[**2170-12-1**] 01:42AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2170-12-1**] 01:42AM URINE RBC-5* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
CXR: no acute infiltrate.
EKG: poor baseline, irregular, likely AF with nml vent
response, Qs inf (old), no ST changes.
Brief Hospital Course:
80 y.o. man with Parkinson disease, h/o recent aspiration
presenting with increasing resp secretions and now worsening
dysphagia.
.
# MRSA aspiration pna:
Patient developed respiratory failure in the MICU from MRSA
aspiration pna. He was maintained on Levo, Vanco, and Flagyl.
He initially was afebrile, with normal WBC and clear CXR.
Inability to swallow and take his PD regimen is the likely
reason that his dysphagia worsened. Over the hospital stay, the
patient developed aspiration pna. PD sublingual meds were
attempted, but were not successful. Patient had an NGT placed
for administration of his meds, but placement attempts failed
because of anatomical variant in his pharynx. Pulmonary and GI
both attempted to place the NGT without success.
.
Patient was frequently suctioned, underwent chest PT, and had
nebs. Oxygen saturation were in the high 90s on nc until the
last two days before passing. The patient's son was called to
patient's bedside for desaturation to 80s for the first time,
and code status was changed from full to DNR/DNI, consitent with
the patient's previously expressed wishes. With the focus of
care on patient [**Last Name (LF) **], [**First Name3 (LF) **] infusion of morphine was used to
provide relief of pain and airhunger. The patient passed away
in the MICU, with the patient's son by his bedside. [**Name (NI) **]
son [**Name (NI) 382**] did not wish to have an autopsy.
.
# C diff diarrhea:
Patient was being treated for C diff with IV flagyl.
.
# AFIB with RVR:
Patient was rate controlled on digoxin, and was anticoagulated
on heparin gtt.
.
# CAD with CABG:
Hct was maintained at > 30, on digoxin, well controlled.
.
# Parkinson disease:
Continued on sinemet and mirapex.
Medications on Admission:
1. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qid ().
2. Carbidopa-Levodopa 25-100 mg One Tablet PO TID.
3. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY
7. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO tid ().
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2171-2-18**]
ICD9 Codes: 5070, 0389, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1551
} | Medical Text: Admission Date: [**2115-10-20**] Discharge Date: [**2115-11-1**]
Date of Birth: [**2039-9-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76 yo male w/ severe COPD (FEV1 28%) p/w acute worsening of
dyspnea this PM, called 911, brought by EMS to [**Hospital1 18**] ED. Pt
reports that he did not have any precipitating symptoms to note
such as fevers/chills/cough/allergies but that this "has
happened before. He denies CP/orthopne/N/V/Abd
Pain/hemoptysis/diarrhea. IN ED the patient was tachtpneic to
the 30's, he was placed on a non-rebreather w/ nebs every hour.
He was also given solumedrol and a dose of levofloxacin w/ good
improvement.
Past Medical History:
1. COPD ?????? Pt with severe COPD. His last PFTs on [**2115-9-25**] were
consistent with marked obstructive defect. Measurements included
a FVC of 59% predicted, FEV1 28% predicted, and FEV1/FVC of 48%
predicted. There was no significant change since a prior study
from [**2115-8-12**]. Pt is on 3 L home O2.
2. Asthma ?????? Diagnosed in [**2104**].
3. Crohn??????s disease ?????? Diagnosed in [**2104**]
4. Steroid-induced NIDDM ?????? Present for two to three years.
5. Peripheral Neuropathy
6. Hypertension
7. Osteoarthritis
8. Osteoporosis
9. Cervical spinal stenosis
10. BPH s/p TURP
11. GERD
Social History:
Former banker. Retied since [**2104**]. Wife is deceased; patient
lives alone at home. Has four children ?????? 2M, 2F.EtOH: Denies
use Tob: 25 pack-year prior historyDrugs: Denies use
Family History:
Brother ?????? NIDDM
Sister ?????? ??????Chest cancer??????
Physical Exam:
On admission:
Temp BP 106-193/59-101 RR 25 O2 sat 95% NRB
Gen: able to speak in complete sentences
HEENT: + pursed lips when breathing, anicteric, dry mm, EOMI,
Neck: JVP 8 cm
CV: Tachycardic no m/r/g
Resp: scattered diffuse expiratory wheezes
Ext: no c/c/e
Neuro: grossly intact
.
On transfer out of MICU
VS: t96.5, p93, 115/59, rr24, 100%4Lnc
Gen- Alert and oriented. Able to speak in full sentences.
Appears mildly uncomfortable but reports that he is at his
respiratory baseline.
Cardiac- RRR.
Pulm- Poor air movement bilaterally. Diffuse wheezing. Pt using
ascesory muscles which he reports is baseline for him.
Abdomen- Soft. NT ND. Positive BS.
Extremities- No c/c/e.
Neuro- Alert and oriented. 5/5 strength in upper and lower
extremities bilaterally.
Pertinent Results:
[**2115-10-20**] 01:45AM WBC-13.3* RBC-4.19* HGB-12.1* HCT-36.5*
MCV-87 MCH-28.9 MCHC-33.1 RDW-13.6
[**2115-10-20**] 01:45AM PLT COUNT-360#
[**2115-10-20**] 01:45AM NEUTS-63.6 LYMPHS-29.2 MONOS-5.8 EOS-1.2
BASOS-0.2
.
[**2115-10-20**] 01:45AM GLUCOSE-228* UREA N-17 CREAT-1.1 SODIUM-141
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16
[**2115-10-20**] 09:25AM CALCIUM-9.0 PHOSPHATE-3.0 MAGNESIUM-2.0
.
[**2115-10-20**] 01:45AM CK(CPK)-154
[**2115-10-20**] 01:45AM CK-MB-15* MB INDX-9.7* cTropnT-0.08*
[**2115-10-21**] 01:26AM BLOOD CK(CPK)-162
[**2115-10-21**] 01:26AM BLOOD CK-MB-16* MB Indx-9.9* cTropnT-0.13*
[**2115-10-21**] 06:25AM BLOOD CK(CPK)-71
[**2115-10-21**] 06:25AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2115-10-21**] 04:29PM BLOOD LD(LDH)-774* TotBili-0.3
[**2115-10-21**] 04:29PM BLOOD CK-MB-15* cTropnT-0.15*
[**2115-10-21**] 10:46PM BLOOD CK(CPK)-140
[**2115-10-21**] 10:46PM BLOOD CK-MB-13* MB Indx-9.3* cTropnT-0.21*
[**2115-10-22**] 05:03AM BLOOD CK(CPK)-127
[**2115-10-22**] 05:03AM BLOOD CK-MB-12* MB Indx-9.4* cTropnT-0.18*
.
[**2115-10-20**] CXR portable
CHEST X-RAY, PORTABLE AP: Comparison is made to prior study of
[**2115-7-29**]. The heart is at the upper limits of normal in
size. The aorta is calcified. There is increased density in the
right middle lobe and left suprahilar region which has been
demonstrated on multiple prior studies and is likely chronic. No
new infiltrates are seen. There is stable blunting of the left
costophrenic angle. There is no pneumothorax.
.
IMPRESSION: Stable appearance of the chest from [**2115-7-29**].
No acute pulmonary process. No pneumothorax.
.
[**2115-10-22**] CXR:
CHEST X-RAY, PORTABLE AP: Comparison is made to prior study of
[**2115-7-29**]. The heart is at the upper limits of normal in
size. The aorta is calcified. There is increased density in the
right middle lobe and left suprahilar region which has been
demonstrated on multiple prior studies and is likely chronic. No
new infiltrates are seen. There is stable blunting of the left
costophrenic angle. There is no pneumothorax.
IMPRESSION: Stable appearance of the chest from [**2115-7-29**].
No acute pulmonary process. No pneumothorax.
.
Echo ([**2115-10-22**])- Mild symmetric LVH with LVEF of 40 to 45%.
NOrmal RV chamber size and wall motion. Severely
thickened/deformed aortic valave leaflets with severe AS. Aortic
valve area is 0.7 cm2 with a peak gradient of 82 and a mean of
52. 1+ AR and 2+ MR. [**First Name (Titles) **] [**Last Name (Titles) **] regurgitation.
Trivial/physiologic pericardial effusion.
.
[**2115-10-27**] CXR:
AP SEMI-ERECT PORTABLE CHEST @ 3:40 P.M.: Compared to prior
study on [**2115-10-25**], there appears to be increased interstitial
markings in the left lung and at the right base sparing the
right upper lung zone. This pattern may be seen in interstitial
edema in a patient with emphysema.
.
Brief Hospital Course:
Floor course 1:
Pt was initially admitted to the floor service for further care
of a COPD exacerbation. On the evening of admission ([**10-21**]), pt
had an episode of [**7-9**] left sided CP with concurrent SOB that
improved with SL NTG. Pt's troponin and CK were subsequently
positive (0.13 and 162) and EKG had lateral ST depressions so he
was started on a heparin drip. A cardiology consult was obtained
on [**10-21**] and further medical management was initially presued.
On the evening of HD #1, the pt developed acutely worsening SOB
with tachypnia to the 40s. ABG showed 7.24/57/222 so he was
transferred to the MICU for management of hypercarbic
respiratory failure including noninvasive ventilation.
.
MICU course:
In the MICU, pt's respiratory status improved with noninvasive
ventilation, continuous nebs, IV steroids, and lasix. Anxiety
related SOB was also been an issue for which pt received
klonipin. Pt continued to be followed by cardiology for his
NSTEMI and had a peak troponin of 0.21 at 10:46 PM on [**10-21**].
Echo was done on [**10-22**] showing a LVEF of 40 to 45% with severe
AS. Pt continued to have severe respiratory distress requiring
continuous BIPAP and persistent troponin elevation thought to
bue due to secondary demand ischemia. A cardiac cath was not
obtained as it would have required intubation which the pt did
not desire. TPN was started for nutritional support on [**10-24**]. Pt
was weaned off of noninvasive ventilation on the evening of
[**10-26**] and has been having an oxygen sat of 100% on 6L NC. He was
also started on an insulin drip on [**10-26**] secondary to
persistently elevated blood glucose levels. Insulin drip was
weaned off prior to being transferred to the floor for further
care; pt was continued on NPH and insulin sliding scale.
.
Floor course 2:
.
1. Respiratory- On the floor, pt continued to have good O2
saturations ranging from 97-100% on 1-2Lnc. Pt was continued to
be aggressively treated for COPD with standing and prn albuterol
nebs, atrovent nebs, montelukast, azithromycin, and steroid
taper. Pt was seen by pulmonary consult. From their
recommendations, we discontinued atrovent and started spiriva.
We also switched from azithromycin to bactrim. Azithromycin has
anti-inflammatory properties, but there is still little good
evidence for its benefit in COPD. Pulmonary felt that Bactrim
would be a better antibiotic, in the the setting of long-term
steroids since it has PCP [**Name Initial (PRE) 21150**]. Advair was added the the
regimen. Prednisone taper was continued. The taper is to be as
follows: Prednisone 50 x 7 days, 40mg x 7 days, 30mg x 7days,
then continue with 20mg. Klonipin which was given for anxiety
was discontinued secondary to lethargy. Pt will follow-up with
outpatient pulmonologist Dr. [**First Name4 (NamePattern1) **] [**Known firstname **].
.
2. CAD/[**Name (NI) 102410**] Pt had a NSTEMI on [**10-21**] which was felt to be
most probably due to demand but acute coronary syndrome could
not be absolutely excluded. He was on heparin for 5 days and was
d/c'ed in setting of left subconjunctival hemorrhage. Since pt
is just recovering from his COPD exacerbation, we felt that it
would be safer to defer cardiac cath as an outpatient. Pt agreed
with this plan and stated his wish not to be cath'ed during this
admission. Cardiology was okay with this plan and they plan to
re-evaluate him in 4 weeks. In the meantime, pt was continued on
with medical management. He was continued on diltiazem for rate
control (beta blocker not used in order to avoid it's
bronchospastic effects). However, diltiazem was unable to be
titrated up secondary to blood pressure intolerance; pt's HR
remained in 90-110 range. Pt was continued on captopril, but
most doses were held secondary to blood pressure intolerance.
For now, we will discontinue ACEi; please add it back on as
tolerated. Pt was continued on aspirin and statin.
.
3. Severe aortic stenosis- Pt found to have severe aortic
stenosis on echo during this admission. The plan to be have
cardiac cath as an outpatient after pulmonary rehab for a formal
assessment of the aortic valve. We avoided beta blocker and
nitoglycerin.
.
4. Steroid induced diabetes mellitus- Pt was continued on NPH
and sliding scale. Oral [**Doctor Last Name 360**] glipizide was added. Pt is on
Metformin as an outpatient, but we did not restart that since pt
may be at increased risk for lactic acidosis in the setting of
hypoxia or cardiac ischemia. Please continue to titrate up
glipizide and adjust NPH as indicated.
.
5. [**Name (NI) 12329**] Pt had a difficult time tolerating diltiazem and ACEi
given his low blood pressures ranging from 90-100 systolic. We
will continue diltiazem for rate control and hold ACEi for now.
Please titrate up dilt for better rate control. If BP tolerates,
can consider restarting ACEi
.
6. Subconjunctival hemorrhage- Occurred in setting of IV heparin
and noninvasive positive pressure. There was slow resolution of
the hemorrhage. Pt was continued on erythromycin ointment qid.
Ophtho stated that it may take 2 weeks for the hemorrhage to
resolve. After then, pt should be safe for elective cardiac
cath. Should anti-coagulation be urgently indicated prior to
resolution of hemorrhage, ophtho feels the hemorrhage should not
be an absolute contraindication. Pt will f/u with [**Hospital **] clinic
one week after discharge.
.
7. [**Name (NI) 14983**] Pt was continued on PPI.
.
8. Crohn's disease- Stable Pt was continued on mesalamine DR.
.
9. FEN- Was on TPN in MICU which was discontinued. Pt was
continued on cardiac, [**Doctor First Name **] diet.
.
10. Proph- SC heparin; PPI; bowel regimen.
.
11. Access- PICC line ([**10-22**])
.
12. Code- DNR/DNI.
Medications on Admission:
Meds on admission:
1. Prednisone 20mg qd
2. Prozac
3. Azithromycin 250mg qd
4. Singulair 10mg qhs
5. Alb/Atrovent tid
6. Glucophage 850mg [**Hospital1 **]
7. Univasc 7.5mg qd
8. Hytrin
9. Asacol 400mg qd
10. Serevent [**Hospital1 **]
.
Meds on transfer from MICU:
1. Albuterol nebs IH Q4H
2. ASA 325 mg PO daily
3. Atorvastatin 40 mg PO daily
4. Azithromycin 250 mg PO daily
5. Captopril 6.25 mg PO TID
6. Clonazepam 1 mg PO BID
7. Diltiazem 30 mg PO QID
8. Docusate 100 mg PO BID
9. Erythromycin 0.5% opth oint 0.5 in OU QID
10. Famotidine 20 mg PO BID
11. SC heparin 5000 units TID
12. Ipratropium bromide neb IH Q6H
13. Mesalamine DR 400 mg PO TID
14. Montelukast sodium 10 mg PO daily
15. Prednisone 50 mg PO daily
16. Senna PRN
17. Bisacodyl PRN
18. Albuterol neb PRN
19. Tylenol PRN
20. Insulin- being weaned off drip
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-30**] Sprays Nasal
QID (4 times a day) as needed.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed for wheezing.
8. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily) for 2 days: Last day is [**11-3**].
14. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: From [**11-4**] to [**11-10**].
15. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 7 days: From [**11-11**] to [**11-17**].
16. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day:
Start [**11-18**] and continue.
17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed.
20. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
21. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
22. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
23. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Capsule, w/Inhalation Device Inhalation qd ().
24. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
25. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
26. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) Injection q4h
prn as needed for air hunger, pain.
27. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO qhs prn as
needed for aggitation, anxiety: Hold for sedation or for RR<12.
28. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
29. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: One (1)
Subcutaneous twice a day: 24U qAM
12U qPM.
30. Insulin Regular Human 300 unit/3 mL Syringe Sig: One (1)
Subcutaneous four times a day: Please follow insulin sliding
scale QID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
COPD exacerbation
s/p NSTEMI
severe AS
steroid induced DM
Discharge Condition:
Stable
Discharge Instructions:
If you develop difficulty breathing or chest pain, call your
doctor or return to the emergency room.
Followup Instructions:
Follow up with Ophthamology on: [**2121-11-17**]:15am with Dr.
[**Last Name (STitle) **] located in [**Hospital Ward Name 23**] [**Location (un) 442**]
follow up with your primary care doctor : [**Name6 (MD) **] [**Name8 (MD) **], MD
Where: [**Hospital6 29**] [**Hospital3 249**]
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2115-11-19**], 10am
Provider PULMONARY BREATHING TEST Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2115-12-23**]
9:45
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. Where: [**Hospital6 29**]
Phone:[**Telephone/Fax (1) 5091**] Date/Time:[**2115-12-4**] 10:30
Follow up with cardiology on [**12-2**] with Dr. [**Last Name (STitle) **] at 11am
located in [**Hospital Ward Name 23**] [**Location (un) 436**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 4241, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1552
} | Medical Text: Unit No: [**Numeric Identifier 66861**]
Admission Date: [**2196-4-22**]
Discharge Date: [**2196-8-1**]
Date of Birth: [**2196-4-22**]
Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 30041**], twin A was a 748 gram product
of a 25 and [**4-8**] week gestation born to a 36-year-old G7, P4,
now 7 mom.
Prenatal screens - B positive, antibody negative, hepatitis
surface antigen negative, RPR nonreactive, rubella immune,
and GBS unknown. This was a spontaneous di-di twin gestation.
Mother had some early bleeding and shortening of cervix.
Mother was transferred from [**Hospital3 **] with preterm
labor. She received betamethasone prior to delivery. She was
also treated with antibiotics prior to delivery. The infant
was delivered by cesarean section. She emerged with a nuchal
cord, was given positive pressure ventilation, intubated in
the delivery room. Apgars were 6 at 1 minute, and 8 at 5
minutes.
PHYSICAL EXAMINATION: Birth weight 748 grams, 25th to 50th
percentile; head circumference 24 cm, 25th percentile; length
32 cm, 25th to 50th percentile. Neck supple. Lungs shallow
respirations with intercostal retractions. CARDIOVASCULAR:
Regular rate and rhythm. No murmurs. Femoral pulses palpable.
Abdomen soft. No bowel sounds appreciated. No masses or
organomegaly. GENITOURINARY: Normal preterm female. Anus
patent. Spine midline but no dimples. Hips stable. Clavicles
intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname 18488**]
was intubated in the delivery room for management of
respiratory distress syndrome. On admission to the newborn
intensive care unit, the infant received a total of 3 doses
of surfactant therapy for management of respiratory distress
syndrome. The infant remained ventilated for a total of 38
days on a combination of conventional ventilation and high
frequency ventilation. Her maximum respiratory support
included high frequency ventilation with a mean airway
pressure of 16 and amplitude of 26. She was exutbated and then
transitioned to CPAP. She remained on CPAP for a total of 21 days
at which time she transitioned to nasal cannula oxygen. She
currently is stable on nasal cannula oxygen flow between 13 to 25
ml per minute and is otherwise stable. [**Known lastname 18488**] was treated with
caffeine citrate until [**2196-7-11**] for
management of apnea bradycardia of prematurity. She continues
to have occasional apnea bradycardiac episodes with the last
documented episode being on [**2196-7-29**].
CARDIOVASCULAR: [**Known lastname 18488**] is status post two courses of
indomethacin therapy for patent ductus arteriosus. Following
completion of her second course of indomethacin an
echocardiogram documented a patent ductus arteriosus. A
decision was made to have the infant ligated. A PDA ligation
was completed on [**2196-4-29**] and the infant has been
cardiovascularly stable until [**2196-7-8**] with the onset of
an increasing blood pressure. Renal service was consulted
after the infant had a renal ultrasound which demonstrated an
echogenic kidney. Her urinalysis was negative at that time
and her BUN and creatinine were 15 and 0.2. Renal service was
consulted at that time and they suggested starting the infant
in Captopril. She was started on her Captopril on [**2196-7-13**] with little effect. She was receiving intermittent
hydralazine for immediate management of hypertension. On [**7-23**], the infant continued to received hydralazine around the
clock in addition to her Captopril dosing. Recommendations
were made by renal to start the infant on Lasix. She was
started on her Lasix therapy on [**2196-7-23**] at 2 mg per kg
per day. At the same time she was receiving Captopril at 0.2
mg per kg per day and hydralazine 0.5 mg per kg per dose. She
demonstrated a nice response with this therapy. Her last dose
of hydralazine was on [**2196-7-25**]. Her Lasix was
discontinued on [**2196-7-28**]. She is currently receiving
Captopril 0.32 mg PO t.i.d which is 0.1 mg per kg t.i.d. Her
blood pressure ranges have been 73/49 to 54 and has otherwise
been stable.
The renal team would like a post discharge follow up 1 month
after discharge from [**Hospital3 **] with Dr.
[**Last Name (STitle) 66862**]. His telephone number is [**Telephone/Fax (1) 50498**]. They also
recommend a DMSA scan during the month of [**Month (only) **] as an
outpatient.
FLUIDS, ELECTROLYTES AND NUTRITION: The infant's birth weight
was 748 grams. Her discharge weight is 3495 grams. The infant
was initially started on 100 cc per kg per day of D10W via UAC,
and we were unsuccessful in receiving a UVC. The infant has
central percutaneous intravenous catheter placed on day of
life 1 which was maintained throughout the remainder of her
IV therapy needs. Enteral feedings were started on [**2196-5-2**]. She achieved full enteral intake by [**5-14**]. Her maximum
enteral intake was 130 cc per kg per day of premature Enfamil
30 calorie with ProMod. She is currently receiving a 140 cc
per kg per day of special care 24 calorie, working PO skills,
demonstrating good weight gain. Her most recent set of
electrolytes were on [**2196-8-1**] and they are Na 128 K 5.4 Cl
95 CO2 27.
GASTROINTESTINAL: Her peak bilirubin was 6.4/0.3. She was
treated with phototherapy. This issue resolved and her most
recent bilirubin level was 4.8/0.4.
HEMATOLOGY: Blood type is A positive, Coombs negative.
Hematocrit on admission was 48.1. She received a total of 5
packed red blood cell transfusions with her most recent being
on [**2196-5-9**]. On [**2196-7-27**], her hematocrit was 30.7
with a reticulocyte count of 9.2%. She is currently receiving
ferrous sulfate supplementation of 0.35 mg PO once daily.
INFECTIOUS DISEASE: CBC and differential were obtained on
admission. CBC was benign. Blood cultures remained negative
at 48 hours at which time ampicillin and gentamicin were
discontinued. During her hospital course she also received 48
hour rule out of vancomycin and gentamycin secondary to
increased concerns of itis. This was discontinued on [**2196-5-6**]. She was also treated with erythromycin ophthalmic
ointment secondary to gram positive cocci culture from her
eye. She completed this 7-day course on [**2196-6-18**].
NEUROLOGICAL: She has had several head ultrasounds which were
within normal limits, most recent being on [**2196-7-6**].
SENSORY/AUDIOLOGY: Hearing screen is yet to be performed but
should be done prior to discharge to home.
OPHTHALMOLOGY: The infant has been seen and followed closely
by Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) 50313**]. Most recent examination on [**7-25**],
demonstrated immature retinal vessels to zone 3 with a
recommended follow up in 3 weeks.
PSYCHOSOCIAL: Parents are interested and involved and visit
on a daily basis. The baby's father's name is [**Name (NI) **] [**Name (NI) 10269**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 **].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 23340**]. Telephone
No.: [**Telephone/Fax (1) 37501**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: Continue 140 cc per kg per day of
special care 24 calorie, working NPO enteral feeding.
2. Medications: Captopril 0.32 mg t.i.d, (0.1 mg per kg
t.i.d). Ferrous sulfate 0.35 kg PO once daily.
3. Car seat position screening has not yet been performed.
4. State newborn screens have been sent per protocol and
have been within normal limits.
5. Immunizations received: [**Known lastname 18488**] received Hepatitis B
vaccine on [**2196-5-26**]. She received Pediarix on [**6-26**], [**2196**]. Pneumococcal 7-Valent on [**2196-6-27**]. HIV on
[**2196-6-27**].
6. The renal team would like a post discharge follow up 1 month
after discharge from [**Hospital3 **] with Dr.
[**Last Name (STitle) 66862**]. His telephone number is [**Telephone/Fax (1) 50498**]. They also
recommend a DMSA scan during the month of [**Month (only) **] as an
outpatient.
DISCHARGE DIAGNOSES:
1. Premature infant, twin No. 1 born at 25 and 4/7 weeks
gestation.
2. Respiratory distress syndrome.
3. Rule out sepsis with antibiotics.
4. Patent ductus arteriosus ligation.
5. Hyperbilirubinemia.
6. Apnea/ bradycardia of prematurity.
7. Anemia of prematurity.
8. Hypertension of unknown etiology.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2196-7-31**] 03:14:42
T: [**2196-7-31**] 07:28:58
Job#: [**Job Number 66863**]
ICD9 Codes: 769, 7742, 4019, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1553
} | Medical Text: Admission Date: [**2193-9-27**] Discharge Date: [**2193-10-2**]
Date of Birth: [**2135-10-8**] Sex: M
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 36633**] is a 57-year-old
male with a history of laryngeal cancer, status post
tracheostomy and percutaneous endoscopic gastrostomy
placement approximately five years ago with recent admission
and [**9-26**] secondary to traumatic subarachnoid hemorrhage
and intraventricular hemorrhage secondary to a fall caused by
alcohol intoxication.
He was on the Surgical Intensive Care Unit Service and
subsequently was discharged to [**Hospital6 6296**]. He
was in [**Hospital6 6296**] for approximately one to two
[**Hospital6 6296**] in the setting of a temperature
spike to 103. He was also noted to have increased agitation
complicated by self discontinue of Foley catheter which led
to hematuria. He also had one witnessed seizure episode in
this setting.
He was initially brought to an outside hospital where a
workup included a head CT which revealed an improving
right-sided hematoma and no new bleed. Chest x-ray which
revealed question of right lower lobe infiltrate. The
patient was empirically diagnosed with aspiration pneumonia
and treated with clindamycin. He was also loaded with
Dilantin with a transfer to [**Hospital1 188**].
At [**Hospital1 69**] he presented
hypotensive with a systolic blood pressure in the 90s,
without response to 2 liters of intravenous fluids. The
workup was notable for left shift leukocytosis, negative
chest x-ray, negative head CT. The patient was given one
dose of vancomycin to expand antibiotic coverage, as he has a
recent history of methicillin-resistant Staphylococcus aureus
pneumonia, and the patient was admitted to the Medical
Intensive Care Unit for supportive care for presumed sepsis.
PAST MEDICAL HISTORY:
1. Laryngeal cancer.
2. Status post tracheostomy.
3. Status post percutaneous endoscopic gastrostomy.
4. Subarachnoid hemorrhage/intraventricular hemorrhage on
[**2193-9-11**].
5. Alcohol abuse.
6. Osteoarthritis.
7. Peripheral vascular disease.
8. Seizure disorder; unclear how old this is.
9. History of aspiration pneumonia.
10. History of detached retina.
MEDICATIONS ON ADMISSION: (At [**Hospital6 6296**])
Lisinopril 30 mg p.o. q.d., Dilantin 100 mg p.o. t.i.d.,
thiamine 100 mg p.o. q.d., folate 1 mg p.o. q.d.,
multivitamin, Prevacid suspension 30 cc p.o. q.d., and
Ultra-Cal tube feeds 75 cc per hour goal.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature 98.9,
blood pressure 91/63, pulse 96, respirations 20, oxygen
saturation 100% on 6-liter tracheostomy mask. In general, he
was response, alert, followed commands, nontoxic, eating
without difficulty. Complained of penile pain. HEENT
revealed tracheostomy was in place. The patient was stable.
No jugular venous distention. Lungs were clear to
auscultation bilaterally. Heart had sinus tachycardia, faint
S1 and S2, no extra sounds. The abdomen was soft, nontender,
and nondistended, active bowel sounds. Percutaneous
endoscopic gastrostomy site stable on the left side.
Extremities had no edema, 2+ distal pulses. Neurologic
examination revealed right-sided weakness, [**12-24**] in the lower
extremities. Upper right extremity had [**2-21**]; otherwise
nonfocal.
LABORATORY DATA ON PRESENTATION: White blood cell
count 22.3, hematocrit 32.7, platelets 233. White blood cell
count differential was 89 neutrophils, 3 bands,
4 lymphocytes, and 2 monocytes. Sodium 134, potassium 4.2,
chloride 97, bicarbonate 27, BUN 12, creatinine 0.6, glucose
of 116. Dilantin level was 8.5 (which was low). Urinalysis
had large blood, negative nitrites, small bilirubin, 11 to 20
red blood cells, 6 to 10 white blood cells, and occasional
bacteria. Microbiology from previous admission revealed
methicillin-resistant Staphylococcus aureus sputum culture
which was sensitive to gentamicin, levofloxacin, and
vancomycin.
RADIOLOGY/IMAGING: Chest x-ray revealed a patchy opacity in
the right lower lobe; otherwise, no infiltrates or congestive
heart failure. Cardiac silhouette was within normal limits.
Head CT revealed hematoma in the posterior corpus collasum
extending into the right lateral ventricle which was improved
since prior studies.
Electrocardiogram revealed sinus tachycardia at 106 beats per
minute, normal axis and intervals. No acute ST changes.
HOSPITAL COURSE BY SYSTEM:
1. INFECTIOUS DISEASE: His blood cultures grew 1/4 bottles
of methicillin-resistant Staphylococcus aureus; and
therefore, the patient was continued on vancomycin
intravenously. His Flagyl and Levaquin were stopped. A
transthoracic echocardiogram was done to rule out
endocarditis, which was negative. A peripherally inserted
central catheter line was placed for long-term antibiotic
treatment. There was no evidence of osteomyelitis or septic
joints on examination throughout his hospital course.
2. PULMONARY: The patient received good tracheostomy care.
He was able to tolerate being weaned from the oxygen and had
no issues with his tracheostomy.
3. CARDIOVASCULAR: The patient's blood pressures were
initially treated with fluid hydration and Neo-Synephrine.
He was ultimately weaned off the Neo-Synephrine and was
transferred to the floor. The patient's ACE inhibitor was
held initially, but then was restarted before discharge.
4. GASTROINTESTINAL: The patient developed abdominal pain
on hospital days two and three, and his liver function tests,
and amylase, and lipase increased. When he was admitted the
differential for this was between biliary stone disease, tube
feed induced and shock liver. His liver function tests,
amylase, and lipase returned back to normal. He also had no
further complaints of abdominal pain.
5. NUTRITION: The patient's tube feeds were held in the
initial setting of pancreatitis; however, they were restarted
and ProMod with fiber was increased to a goal of 75 cc per
hour. He tolerated this well. He received a swallowing
evaluation and a video swallowing study to evaluate for
aspiration, and there was evidence of Macroaspiration.
Therefore, he only received a small amount of apple sauce,
but was otherwise kept n.p.o., and tube feeds were continued.
6. RENAL: There were no issues.
7. ENDOCRINE: There were no issues.
8. HEMATOLOGY: There were no issues.
9. NEUROLOGY: The patient was given a loading dose of
Dilantin when he came into the outside hospital, and free
Dilantin level was checked which was slightly low; and,
therefore, the patient's Dilantin dose was increased to
125 mg p.o. t.i.d. He was continued at this dose until
discharge. He had no further seizure activity or neurologic
complaints during this admission.
DISCHARGE PLAN: Discharged back to [**Hospital6 19936**]. Outpatient transesophageal echocardiogram was
arranged to definitively rule out endocarditis.
CONDITION AT DISCHARGE: The patient was stable and at his
current baseline.
MEDICATIONS ON DISCHARGE:
1. Lisinopril 30 mg p.o. q.d.
2. Dilantin 125 mg p.o. q.8h.
3. Thiamine 100 mg p.o. q.d.
4. Folate 1 mg p.o. q.d.
5. Multivitamin.
6. Prevacid suspension 30 cc p.o. q.d.
7. Vancomycin 1 g intravenously q.12.h. times two weeks
total for methicillin-resistant Staphylococcus aureus
bacteremia through peripherally inserted central catheter
line.
DISCHARGE DIAGNOSES:
1. Methicillin-resistant Staphylococcus aureus bacteremia.
2. Question of methicillin-resistant Staphylococcus aureus
pneumonia, right lower lobe.
3. Seizure disorder.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 35154**], M.D. [**MD Number(2) 36634**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2193-10-1**] 16:10
T: [**2193-10-1**] 15:31
JOB#: [**Job Number 36635**]
(cclist)
ICD9 Codes: 5070, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1554
} | Medical Text: Admission Date: [**2114-4-23**] Discharge Date: [**2114-5-9**]
Date of Birth: [**2050-4-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
CHF & severe aortic stenosis
Major Surgical or Invasive Procedure:
aortic valvululoplasty
swan ganz catheter
History of Present Illness:
Mr. [**Known lastname 1511**] is a 64 yo man with dilated cardiomyopathy (presumed
non-ischemic) and severe aortic stenosis (valve are 0.8, peak
gradient 87) who was transferred from Holy [**Hospital 82745**] hospital for
further care of his aortic stenosis. According to his initial
H&P on [**4-15**] Mr. [**Known lastname 1511**] was admitted for dyspnea with minimal
activity, fatigue, orthopnea, and ankle edema. He is delerius
on transfer and is unable to provide any more information. Per
his wife he gets dyspneic usually upon ambulating from room to
room; this has worsened recently. At [**Hospital3 **] he was (hct
24.7 & BUN 100) he was found to have have GI bleed; upper GI
showed minimal erosions; c-scope showed residual blood & R-colon
AVM that was cuaterized; he was also placed on octreotide. For
an unclear reason he underwent cardiac cath today which showed
EF 25%, clean coronaries. AVG 58 peak with mean 40. PCW 16,
LVEDP 15, PA pressures of 85/29 & RVEDP 8. After the cardiac
cath he became agitated, agressive, and was dyspneic requiring
4L. bp 79/59, He was given 80mg IV lasix for presumed CHF. He
was in afib with RVR at the time in 110-130's and was given po
toprol (50mg) & IV metoprolol (10mg). no temp recorded. Na
136, K 3.6, BUN 45, Cr 1.1, chloritde 105, bicarb 24. WBC
increased to 15.8. VS prior to transfer: BP 160/56 HR 106 100%
on 4L. RR 26-32.
.
Mr. [**Known lastname 1511**] remembers nothing of the event. Upon speaking with is
wife, he was not delerious, febrile, or agitated prior to the
cath.
.
On transfer Mr. [**Known lastname 1511**] is delerius and febrile to 102.3, knows he
is in the hospital, unsure of which one. Thinks the year is
[**2049**]. He cannot recall any of the symptoms leading up to his
hospitalization. Currently he complains of fever and abdominal
pain. He denies orthopnea, pnd, cough. He is mildly dyspneic.
.
Past Medical History:
COPD; ?home oxygen
aortic stenosis
dilated CMP; last EF 25%. RV hypertrophy & hypokinesis
Lumbar disc disease
OSA
A fib
MRSA of R leg
atrial fibrillation
Social History:
former smoker. married with 3 chilldren. Denies EtoH
Family History:
n/c
Physical Exam:
On admission -
T 101.4 oral, 103.8 rectal, then T 105. RR 30-40 96% on 4L n/c.
BP 92/54 with HR 120 & irregular
Gen: ill-appearing, jaundiced
CV: tachycardic. Very difficult to appreciate heart sounds over
tachypnea
Pulm: Tachypneic but CTA B
Abdomen: obese, soft, non-distended diffusely TTP; maximally TTP
in RUQ. + [**Doctor Last Name **] sign.
Extremity: 1+ BLE edema
Neuro: oriented x 1. thinks it is [**2049**]. Knows hospital, but
not [**Location (un) 86**] or [**Hospital1 18**]. No meningismus.
Pertinent Results:
ADMISSION LABS:
[**2114-4-23**] 08:15PM BLOOD WBC-17.6* RBC-4.00* Hgb-10.9* Hct-34.4*
MCV-86 MCH-27.2 MCHC-31.7 RDW-19.2* Plt Ct-173
[**2114-4-23**] 08:15PM BLOOD Neuts-94.9* Lymphs-2.2* Monos-2.6 Eos-0.1
Baso-0.1
[**2114-4-23**] 08:15PM BLOOD PT-18.9* PTT-38.6* INR(PT)-1.7*
[**2114-4-25**] 01:34PM BLOOD FDP-40-80*
[**2114-4-23**] 08:15PM BLOOD Glucose-188* UreaN-45* Creat-2.0* Na-137
K-5.1 Cl-103 HCO3-21* AnGap-18
[**2114-4-23**] 08:15PM BLOOD ALT-321* AST-459* CK(CPK)-39 AlkPhos-75
Amylase-22 TotBili-2.7* DirBili-1.7* IndBili-1.0
[**2114-4-23**] 08:15PM BLOOD Albumin-3.7 Calcium-8.8 Phos-5.5* Mg-1.8
[**2114-4-23**] 08:15PM BLOOD Hapto-215*
[**2114-4-25**] 03:42AM BLOOD IgM HAV-NEGATIVE
[**2114-4-23**] 11:19PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2114-4-25**] 02:17PM BLOOD Smooth-NEGATIVE
[**2114-4-23**] 11:19PM BLOOD HCV Ab-NEGATIVE
.
cardiac cath:
hemodynamics:
peak gradient 59, mean gradient 40. [**Location (un) 109**] 0.8cm2. CO 4.73
LV pressure 135/14/17, AO 78/60/64
RA 23/26/23
RV [**2098-6-26**]
PA 85/29/55
PCW 21/23/16
RVEDP 8
.
original EKG on [**4-17**]: a fib with normal axis. IVCD & QRS of 91.
delayed RWP. lat ST depressions (V5-6)
.
EKG on arrival to CCU: irregular wide complex-tachycardia, axis
about 180. IVCD with QRS of 152. ?possible concordance of
precordial leads.
.
ECHO on [**2114-4-10**]. EF 20%, global LV hypok. dilated with
concentric hypertrophy. atrium dilated. 1+ MR. AS with [**Location (un) 109**]
0.88cm2. peak gradient 87, mean gradient 57. LVOT velocity
111cm/s, peak velocity 477 cm/s. 1+ TR. rheumatic aortic valve
with AS, 2+ AR, rheumatic MS, 1+ MR, 1+ TR. mild PA htn
CXR: no pulm edema
RUQ US: no gall stones, biliary ductal dilation or
cholecystitis. Neg [**Doctor Last Name **]
blood cultures: MSSA in [**3-24**] bottles on admission. negative
thereafter.
Brief Hospital Course:
Mr. [**Known lastname 1511**] is a 64 yo man with dilated cardiomyopathy and severe
aortic stenosis, OSA & pulmonary hypertension who was admitted
to the hospital for worsening dyspnea and is transferred to
[**Hospital1 18**] for further care. He expired after developing sepsis,
renal failure, acidosis and hypotension not responsive to
pressors.
# Sepsis/bacteremia: Mr. [**Known lastname 1511**] was febrile to 105 on admission.
He was empirically covered with vancomycin/cipro/flagyl on
admission. A central venous line was placed and he was
aggressively hydrated. He became hypotensive on the night of
admission and was started on dobutamine + levophed. Admission
blood cultures quickly turned positive for [**3-24**] MSSA. His
antibiotics were changed to nafcilling. TTE and TEE were
negative for endocarditis and repeat blood cultures remained
negative. He completed his course of nafcillin in-house. WBC
trended up and patient developed lactic acidosis in addition to
his leukocytosis. Culture data was negative at the time of
death. Patient was on broad spectrum antibiotics on [**2114-5-7**]
including vancomycin and zosyn. Patient was dependent on
pressors to keep MAPs greater than 55. As acidosis worsened,
patient became less pressor responsive and died in the presence
of his family.
# Cardiogenic shock: secondary to depressed EF and severe AS.
Maintained on dobutamine + levophed. Diuresed with guidance of
swan-ganz catheter. Mr. [**Known lastname 1511**] was evaluated by Dr. [**Last Name (STitle) 28946**] of CT
surgery for consideration of AVR, but was
# Dyspnea: likely multifactorial from fever, severe pulmonary
hypertension, COPD, and CHF. Swan Ganz Catheter was placed and
he was found to have severe pulmonary hypertension; some of
which was responsive to diuresis (at near-systemic pressures at
highest). He was aggressively diuresed.
# Transaminitis: From shock liver. Resolved with supportive
care
.
# Abdominal pain: due to hepatitis. RUQ US negative and pain
resolved.
.
# Aortic Stenosis: severe based on gradient and valve area.
Patient has had symptoms of refractory heart failure, but no
angina or syncope. Depressed EF alone is indication for valve
repair.
- consider dobutamine echo to r/o pseudo aortic stenosis
.
# Atrial fibrillation - given amiodarone for rate control. Had
rate-related BBB
.
# Lower GIB: stable
.
# Diabetes: decrease lantus to 26 while not eating much
.
# hyperlipidemia: continue statin
.
# Access: placed chordus with RIJ CVC [**2114-4-23**]. Will place swan
in AM
.
# FEN/GI: clears while unstable/poor mental status.
.
# Code: full
Medications on Admission:
torsemide 20mg po bid
metolazone 2.5mg po daily
lipitor 20mg po daily
lisinopril 20mg po daily
niaspan 500mg po daily
omeprazole 20mg po daily
prandin 2mg po tid
coumadin
metoclopramide
januvia 50mg o [**Hospital1 **]
carvedilol 6.25mg po bid
aspirin
lantus
advair
spiriva
.
meds on transfer
coreg 6.25mg po bid
valium prior to procedure
digoxin 0.25mg IV x 2
lovenox 40mg SQ daily
ferrous sulfate
advair daily
lasix 80mg IV x 1
lisinopril 20mg po daily
insulin levemir 34U QHS
Toprol 50mg po daily
niacin 500mg po daily
octerotide 0.05mg SQ tid
potassium 20mg po daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
primary: cardiogenic shock
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2114-5-15**]
ICD9 Codes: 4254, 5990, 5845, 2762, 4280, 2875, 496, 2724, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1555
} | Medical Text: Admission Date: [**2164-5-18**] Discharge Date: [**2164-5-25**]
Date of Birth: [**2088-12-17**] Sex: M
Service: NEUROSURGERY
Allergies:
Neosporin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
SOB at OSH
Major Surgical or Invasive Procedure:
[**2164-5-20**] C3-5 Laminectomy and Fusion, posterior
History of Present Illness:
75 y/o male with congestive heart failure, ejection fraction
of 50%, CAD status post MI, hyperglycemia while on steroids,COPD
on home oxygen, atrial fibrillation/flutter on Coumadin, history
of lung cancer, status post resection, who presented to the
[**Location (un) 620**] ER on [**5-20**], with increasing dyspnea over the last few
days. He
noted bilateral shoulder weakness and is unable to lift his arms
over his head to the medical service at [**Location (un) 620**]. He reports
this
began approximately 2 years ago; however, it has progressively
worsened over the last several weeks to days, to the point where
he is unable to feed himself, especially with his right. The
symptoms first started to worsen on the R side 1-2 weeks ago and
in the past several days he has started having increased
symptoms
on the L.
Past Medical History:
- CHF: EF 50% 5/07 with dilated left atrium, 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) 5348**]
he sleeps with 3 pillows.
- COPD: on 2.5-3L NC home O2, [**Last Name (Titles) 5348**] 10mg prednisone daily,
recent admit for exacerbation [**6-13**] with steroid taper. Has had
[**4-10**] hospitalizations for COPD in last 3 years, never intubated
- Atrial Fibrillation (on coumadin 2.5 mg): INR 1.6 at [**Location (un) 620**]
- Neuropathy with chronic pain
- Lung cancer, diagnosed 5 years ago, s/p resection of ?R lung
per family [**4-10**] yrs ago
- depression
- hiatal hernia
- Tracheobronchomalacia per previous CT
- Small cystic lesions in the liver and kidneys, incompletely
characterized.
Social History:
He lives with his wife, 60 pack-year smoking hx, quit 30 yrs
ago, social drinker.
Family History:
Non-contributory
Physical Exam:
Admission:
PHYSICAL EXAM:
O: T: 97.5 BP: 98/60 HR:100 R 20 O2Sats 97% 3L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: Crackles right base, wheezes throughout
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 1 4 4 4 4 5 5 1 1 5
L 1 4 4 4 4 5 5 1 1 5
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
Pertinent Results:
[**2164-5-18**] 09:54PM PT-27.0* PTT-32.1 INR(PT)-2.7*
[**2164-5-18**] 09:54PM PLT COUNT-251
[**2164-5-18**] 09:54PM NEUTS-87.2* LYMPHS-8.2* MONOS-4.4 EOS-0.2
BASOS-0
[**2164-5-18**] 09:54PM WBC-10.2 RBC-4.60 HGB-12.3* HCT-38.3* MCV-83
MCH-26.7* MCHC-32.0 RDW-14.9
[**2164-5-18**] 09:54PM CALCIUM-9.5 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2164-5-18**] 09:54PM estGFR-Using this
[**2164-5-18**] 09:54PM GLUCOSE-96 UREA N-27* CREAT-0.9 SODIUM-138
POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-39* ANION GAP-11
Brief Hospital Course:
75 y/o male with congestive heart failure, ejection fraction
of 50%, CAD status post MI, hyperglycemia while on steroids,COPD
on home oxygen, atrial fibrillation/flutter on Coumadin, history
of lung cancer, status post resection, who presented to the
[**Location (un) 620**] ER with increasing dyspnea over the last few days. He
noted bilateral shoulder weakness and is unable to lift his arms
over his head to the medical service at [**Location (un) 620**]. He reports
this
began approximately 2 years ago; however, it has progressively
worsened over the last several weeks to days, to the point where
he is unable to feed himself, especially with his right. The
symptoms first started to worsen on the R side 1-2 weeks ago and
in the past several days he has started having increased
symptoms
on the L.
He was treated for pneumonia, and COPD flare with
antibiotics,
prednisone and lasix. He was transferred to the neurosurgery
service for further evaluation.
On [**2164-5-20**] he underwent an urgent pPosterior cervical
laminectomies C3,
C4, C5, with instrumentation and arthrodesis from C3-C5 with
lateral mass screws with approximately 900cc blood loss.
Post operatively he went to the ICU where he was monitored
closely and BP was kept at a normal range to perfuse his cord.
He was successfully extubated on post operative day one. He was
able to move his shoulders with improvement and his right arm
was somewhat stronger according to the patient. On POD#2 he was
moved to the floor where he remained hemodyanmically stable. His
respiratory status improved and he was weaned off oxygen. A
follow CXR on [**5-24**] showed resolved pneumonia and mild CHF he was
started back on his Lasix. He was treated for a UTI on [**5-20**] he
should complete 7 days of Levaquin his foley was dc'd and he is
able to void using a condom cath.
Neurologically he had at least 4+ strenght in trapezius, 4- in
his deltoids and biceps on right were 4+to 5s and tricep the
same on left his bicep was 3 and tricep was 4. He has previous
bilateral foot drops prior to admission. He was tolerating a
regular diet on discharge and had stood at the side of the bed
with physcial therapy.
He was fitted with a new collar on discharge.
Medications on Admission:
At [**Location (un) 620**]: Levaquin 500 mg IV daily, Lasix 80 mg IV daily,
Zestril 5 mg daily, bisoprolol 2.5mg daily, Cardizem 180 mg
daily, Spiriva 18 mcg daily, DuoNebs q.
6 hours as needed, Advair 250/50 one puff b.i.d., Lipitor 80mg
daily,. Zoloft 50 mg daily, Nexium 40 mg p.o. daily, Neurontin
600 mg every morning, 300 mg every afternoon, 600 mg every
evening. [**Doctor First Name **] 120 mg daily. Percocet as needed. Fentanyl
patch 50 mcg q. 72 hours. Prednisone 40 mg daily. Vitamin B-12
1000 mcg daily. Colace 100 mg.
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) as needed for in afternoon.
10. Fexofenadine 60 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
15. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
22. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours).
23. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
24. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Cervical Spine Stenosis
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Do not smoke
?????? Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for signs of
infection
?????? If you are required to wear one, wear cervical collar or back
brace as instructed
?????? You may shower briefly without the collar unless instructed
otherwise
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? 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:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
You may restart coumadin on [**6-19**].
Keep collar on at all times
Followup Instructions:
Have your staples removed on [**5-31**] at rehab facility
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) 14074**] TO BE SEEN IN [**5-13**] WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2164-5-25**]
ICD9 Codes: 486, 5990, 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1556
} | Medical Text: Unit No: [**Unit Number 41750**]
Admission Date: [**2186-6-11**]
Discharge Date: [**2186-7-20**]
Sex: Male
Service: General Surgery
HISTORY OF PRESENT ILLNESS: This is an 80 year old Caucasian
male who was admitted to [**Hospital3 **] from [**Hospital1 1444**] on [**2186-6-10**], with the
following diagnoses of fatigue, dehydration, status post
resection of gastrointestinal stromal tumor in [**2185-12-26**].
The patient is an 80 year old male patient with a past
medical history of Crohn's and had just had tumor resected by
Dr. [**Last Name (STitle) 957**], noninsulin dependent diabetes mellitus,
metastases of the chest, status post Gleevec tumor therapy.
He was readmitted, after discharge from [**Hospital1 190**] on [**2186-6-9**], on [**2186-6-11**], when he
represented via the Emergency Department for fatigue,
decreased appetite, diarrhea and came in complaining of
dehydration, increased lethargy and hypotension. The patient
was seen in the Emergency Department by the surgical service
and was assessed to have a distended, tender and tympanitic
abdomen.
PAST MEDICAL HISTORY: Crohn's disease.
Melanoma.
Spinal stenosis.
Cataract.
Noninsulin dependent diabetes mellitus.
PAST SURGICAL HISTORY: Small bowel resection.
HOSPITAL COURSE: X-ray obtained in the Emergency Department
illustrated free air with evidence of an acute abdomen and
was taken to the operating room by Dr. [**First Name (STitle) 2819**] who was covering
for Dr. [**Last Name (STitle) 957**] as he was out of town. The patient was found
to have a perforated viscus. Please see operative note on
[**2186-6-11**], for further information. He was seen to have a
perforation at the distal transverse colon on the proximal
sigmoid and he was having a transverse left end sigmoid
colectomy, colostomy, Hartmann's pouch with placement of a
gastrostomy tube, jejunostomy tube and take-down of the
splenic flexure.
The patient was admitted to the Intensive Care Unit and
continued to have a complicated course. The patient received
blood transfusions, as well as aggressive Intensive Care Unit
care. Various services were consulted for management of this
acutely ill patient including oncology service. The patient
was eventually weaned off the vasopressin for support and was
started on TPN for nutritional support due to his prolonged
Intensive Care Unit admission. The patient was managed by
the Intensive Care Unit team in the interim with consults
from the general surgery service. The patient continued to
oscillate in terms of his respiratory status alternating
between vent settings and at times being able to support
decreasing PEEP and pressure support. The patient in the
beginning of [**Month (only) **] continued to have hemodynamic instability
and despite noninvasive imaging immediate source was not
obtained. The patient was given fluid and Levophed and
packed red blood cells in hopes to increase blood pressure
and hemodynamic stability and was thought origin might be due
to intra-abdominal sepsis and was reintubated for airway
protection. CT scan of the chest illustrated bilateral
pleural effusions. On [**2186-6-29**], thoracic surgery was
consulted and chest tube was placed and 750 cc of serous
fluid was obtained in the pleurovac. With this increased
serous output, the patient required less Levophed and
appeared to clinically improve. Over the next few days, the
patient continued to have massive drainage from the chest
tube and was eventually stabilized. In the beginning of
[**Month (only) **], the patient continued to have a few intermittent
episodes of hypotension and intermittent fevers which were
appropriately treated. An infectious disease consultation
was obtained for management of his intermittent fevers and
for further investigation of his intra-abdominal sepsis.
Infectious disease made numerous recommendations which were
taken into consideration. General surgery consultation was
appreciated and continued to follow closely in conjunction
with Dr. [**Last Name (STitle) 957**]. The patient continued to have hemodynamic
instability despite numerous attempts to wean the patient
from ventilatory support secondary to hemodynamic
instability, hypovolemia and intra-abdominal sepsis. The
patient was restarted on nutritional support via TPN and
stopped on tube feeds. Chest tubes continued to drain
considerable amount of serosanguineous fluid with the
drainage from his gastrostomy tube continuing. The patient
on [**2186-7-9**], went into atrial fibrillation with heart rates
in the 110 to 130 range with blood pressure dropping to the
80s. Fluid boluses provided only transient effect. Initial
Lopressor given provided no effect. The patient was
cardioverted and remained in sinus rhythm and improved with
two additional fluid boluses. The patient was monitored
closely for additional cardiac events. The patient was tried
on continuous positive airway pressure and eventually was
weaned after an extended period of time and was extubated on
the morning of [**2186-7-11**], and he appeared to be clinically
improving for a few days, however, began to have some mental
confusion the day after extubation on [**2186-7-12**]. Neurology
was consulted for evaluation of a stroke. The patient was
decided to become DNI on approximately [**2186-7-16**], after
requiring multiple fluid boluses and restarted on Levophed
overnight due to additional hemodynamic instability. The
patient was thought to have a multifactorial cause of his
confusion but could not rule out an underlying neurological
cause such as stroke given his recent events. CT scan was
obtained. A family meeting on [**2186-7-18**], was held and it
was decided for the patient to be DNR/DNI. The patient
continued to deteriorate hemodynamically and clinically. The
patient expired on [**2186-7-20**], at approximately [**2202**]. He
became apneic and asystolic on the monitor. As the patient
was DNR/DNI as per family, his status was confirmed with no
vital signs. Dr. [**Last Name (STitle) 957**] was made aware and he would contact
the family personally. Death report was in progress soon
after expiration.
CONDITION ON DISCHARGE: Expiration.
DISCHARGE STATUS: Not applicable.
DISCHARGE DIAGNOSES: Hemodynamic instability requiring
multiple fluid boluses and pressors.
Crohn's disease.
Just had tumor resection.
Small bowel resection.
Noninsulin dependent diabetes mellitus.
Mental status changes.
Intermittent episode of atrial fibrillation.
MEDICATIONS ON DISCHARGE: Not applicable.
FOLLOW UP PLANS: Not applicable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 26005**]
Dictated By:[**Doctor Last Name 31967**]
MEDQUIST36
D: [**2186-11-17**] 08:46:48
T: [**2186-11-17**] 10:06:30
Job#: [**Job Number 41751**]
ICD9 Codes: 5119, 2875, 0389, 2851, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1557
} | Medical Text: Admission Date: [**2188-5-30**] Discharge Date: [**2188-11-10**]
Date of Birth: [**2160-10-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
1. right craniectomy with evacuation of SDH and partial
frontotemporal lobectomy
2. debridement and irrigation of craniotomy wound
3. lumbar puncture
4. endotracheal intubation
5. placement of PEG tube
6. Tracheostomy
7. central venous line placement
8. placement of ventriculoperitoneal shunt
9. right cranioplasty
10. placement of inferior vena cava filter
History of Present Illness:
27 y.o. male, found down on sidewalk by EMS. At scene, pt
unconscious, exibiting decorticate posturing with no response to
painful stimuli. Intubated in the field and brought emergently
to [**Hospital1 18**].
Past Medical History:
none
Social History:
Ukranian grad student at [**University/College **]; family in [**Location (un) 3156**]
Family History:
non-contributory
Physical Exam:
In the ED
Vitals: Temp: 91.4 HR 60 BP 90/p sats 100% on BMV
GCS 3T
Gen: unreponsive, c-collar in place, intubated, sedated on
propofol
HEENT: Pupils 8mm and fixed, left periorbital contusion, large
hematoma over right parietal scalp, TM clear, no obvious
oralpharyngeal trauma, midface stable
Neck: no crepitus, trachea midline
Chest: equal BS bilaterally
CV: RRR
Abd: SNTND, FAST neg
Rectal: nl tone, no gross blood, heme neg
Pelvis: stable to AP and lateral compression
Back: no step-offs on palpation of TL spine, no obvious
abrasions
Ext: no long-bone deformities, no abrasions, lacerations
Neuro: decorticate posturing, no withdrawal to painful stimuli,
no gag, no corneal reflex
Pertinent Results:
Study Date of [**2188-6-16**] ECHO: Normal LVEF
CT HEAD W/O CONTRAST [**2188-6-13**] 10:48 AM
IMPRESSION: 1) s/p craniectomy with herniation of the right
cerebral hemisphere from the craniectomy defect 2) Interval
resolution of the subdural hematoma. Improved grey white
differentiation and reduced effacement of the sulci on the left
cerebral hemisphere. 4) Widened subdural cerebrospinal fluid
spaces on the right. 5) Opacification of multiple paranasal
sinuses as described above.
CT C-SPINE W/CONTRAST [**2188-5-30**] 6:28 AM
IMPRESSION: Normal study. No evidence of fracture or
subluxation.
CT HEAD W/O CONTRAST [**2188-5-30**] 6:27 AM
IMPRESSION: Large, acute right sided subdural hematoma with
subfalcine and uncal herniation. Fractures of the right
frontoparietal calvarium and left lamina papyracea.
*
CSF culture:
[**7-18**]: no growth, no fungus, neg GS
[**9-2**]: no growth, neg GS
*
Blood Cultures:
[**7-17**]: mycolytic cx:[**Female First Name (un) 564**] parapsilosis
[**7-18**]: mycolytic cx: Coag-negative staph, [**Last Name (un) 57818**] parapsilosis
[**7-18**]: anaerobe/aerobe cx:neg x1/1
[**7-19**]: Mycolytic cx: coag neg staph x 1 (final)
[**7-19**]: anaerobe/aerobe:neg x 2 (final)
[**7-20**]: coag neg staph x 1
[**7-20**]: (left IV tip) coag neg staph
[**7-22**]: anaerobe/aerobe cx:neg x 2 (final read)
[**7-22**]: mycolytic cx: neg x 1 (final read)
[**7-28**]: anaerobe/aerobe cx:neg x 2
[**8-7**]: blood cx [**11-23**]: coag neg staph
[**8-7**]: mycolytic cx: coag neg staph
[**8-8**]: blooc cx [**11-23**]: coag neg staph
[**Date range (1) **]: no growth
[**10-28**], [**10-29**], [**10-30**], [**10-31**] negative x2 each set
*
Urine cx
[**7-22**]: no growth
[**8-7**]: pseudomonas and klebsiella
[**9-2**]: no growth
[**9-3**]: no growth
[**10-26**], [**10-27**], [**10-29**], [**10-30**], [**10-31**], [**11-1**]: contamination with mixed
bacterial flora
*
UA 9/16,9/17,[**8-9**]: Positive nitrite, many bacteria, but 0-2 WBC
Brief Hospital Course:
1. traumatic brain injury/ right subdural hemorrhage:
Pt was admitted on [**2188-5-30**] and was unresponsive with fixed
pupils. Emergent CT revealed a large acute R subdural hematoma
with subfalcine and uncal herniation, as well as fractures of
the right frontoparietal calvarium and left lamina papyracea.
Pt was taken to the OR for emergent evacuation. He underwent a
R craniectomy with evacuation of subdural hemorrhage and
frontotemporal lobectomy. He was transferred to the trauma
surgery ICU for further care and was begun on mannitol to lower
ICP (discontinued [**6-4**]) and dilantin to prevent seizure
(discontinued [**6-6**]).
Pt was closely followed but remained basically unresponsive.
Sedation was weaned, but pt remained basically unresponsive and
without spontaneous movement, gag, or corneal reflexes. Pt was
noted to have extensor posturing to painful stimuli on upper
extremities. A neurology consult was called to help evaluate
for prognosis. On [**6-17**], an EEG showed R hemispheric
subcortical dysfunction and mild encephalopathy, without
evidence of ongoing seizure. It was thought that his prognosis
ranged from limited verbal abilities and a dense left
hemiparesis to a persistent vegetative state. Pt was
transferred to the floor on [**7-12**], where he continued to be
followed by neurology and neurosurgery. Multiple family
meetings were held throughout [**Hospital 228**] hospital course to
discuss the prognosis, both in the TSICU and on the floor, in
conjunction with social work.
On [**7-13**], pt was noted to have fluid draining from the wound
site. This was felt to be necrotic brain fluid. Neurosurgery
placed additional sutures on [**7-16**], and the issue resolved.
Serial head CTs were performed to evaluate for interval changes.
On [**7-17**], head CT showed increased size of the ventricles after
the ventricular drain had been removed; neurosurgery did not
believe that this represented an increase in ICP. There were
intermittent changes in the amount of bulging at the R
craniectomy site, thought to represent liquefaction necrosis as
well as hydrocephalus. On [**8-27**], the amount of bulging was
significantly greater, and another head CT was performed, which
showed significantly worsening hydrocephalus. On [**9-1**],
therefore, a VP shunt was placed, and a repeat head CT on [**9-3**]
showed interval improvement of the hydrocephalus.
In mid-[**Month (only) 359**], pt was noted to have slow improvement of mental
status, and was able to respond to voice, move his R fingers,
and begin to follow simple commands. His family continued to
work with him, and he slowly improved. Eventually, he was able
to answer yes/no questions with finger movements and to follow
more commands.
On [**9-30**], repeat head CT showed foci of relative [**Name (NI) 13215**]
within the right temporal lobe, which could be consistent with
parenchymal hemorrhage, but pt's hydrocephalus was improved. As
pt was reporting headaches, another CT was performed on [**10-3**],
which revealed an area of acute hemorrhage inferior to the
frontal portion of the infarct along the inferior edge of the
craniotomy, more dense than on the previous CT. Neurosurgery
felt there was no indication for surgical intervention, and this
remained stable on repeat head CT [**10-10**]. Pt had no further
episodes of acute hemorrhage, and overall his neurological
status continued to improve.
On [**10-27**], pt underwent an elective R cranioplasty to repair the
defect in his skull. He tolerated the procedure well. Of note,
a repeat head CT on [**10-30**] showed no interval hemorrhage. Pt will
get a repeat head CT to evaluate for interval bleed on [**12-25**],
and will follow up with Dr. [**Last Name (STitle) 739**].
2. infectious disease:
A. POD #4 s/p craniotomy and SDH evacuation - [**2188-5-31**] - pt was
febrile, and sputum grew H. influenza; was started on Zosyn for
aspiration pneumonia. Repeat sputum culture [**6-5**] did not grow H
flu.
B. suspected encephalitis - Pt treated with levofloxacin
[**Date range (1) 57819**]
C. MRSA/Pseudomonas pneumonia (LLL) - vancomycin was begun on
[**7-4**], and was given for 3 weeks given the concomitant meningitis
(see below); for Pseudomonal coverage, pt was treated with
ceftazidime 2g IV q8h x 10 days ([**Date range (1) 57820**])
D. MRSA meningitis/infection of head wound - frank pus was
expressed from head wound by neurosurgery; a lumbar puncture on
[**7-4**] eventually grew MRSA. Pt was taken to OR for
washout/debridement of wound edges and subcutaneous tissue on
[**7-6**], and a ventricular drain was placed. Tissue culture
eventually grew sparse coag + Staph. For the MRSA meningitis,
pt was treated with vancomycin 2g IV q12h x 21 days. Repeat LP
on [**7-18**] showed WBC 585, RBC 8, protein 132, and glucose 38,
bacterial and fungal cultures remained negative. ID felt that
elevated WBC was most likely secondary to brain injury and not
infection since cultures remained negative. It was felt that
MRSA meningitis was resolved.
E. [**Female First Name (un) 564**] parapsilosis fungemia - Blood cultures from [**7-17**] and
[**7-18**] were positive for yeast, and Ambisome was begun. When the
culture data returned with [**Female First Name (un) 564**] parapsilosis, pt was switched
to fluconazole. Ophthalmology was consulted, and they found
vitritis of the right eye, which they did not feel was specific
to fungal endophthalmitis. He completed two weeks of antifungal
therapy.
F. Positive urine cultures for Klebsiella and Pseudomonas -
this was felt to be colonization in the setting of an indwelling
Foley x2 months and was not treated.
G. Within 24 hours after the VP shunt was placed, pt became
hypotensive and tachycardic. He was started on
meropenem/vancomycin empirically, but all cultures were negative
and no source found. Pt's hypotension resolved with fluids.
Antibiotics discontinued.
H. LOW GRADE TEMPS - found to have DVT - see below
3. Deep venous thrombosis:
Bilateral LENIs on [**6-11**] revealed no evidence of DVT. Pt was
noted to have left leg swelling back in [**Month (only) 359**]. However, in
the setting of his traumatic subdural hemorrhage, as well as his
poor neurologic prognosis at that time, the risks of
anticoagulation were thought to outweigh the potential benefits,
and so pt was not imaged at that time. This was discussed with
the family at length. Pt was continued on subcutaneous heparin
for DVT prophylaxis.
However, after the elective cranioplasty on [**2188-10-27**], pt was
noted to have daily temperature spikes. All cultures were
negative including 8 sets of blood cultures, 4 urine cultures, 4
cxr with only atelectasis, Abd CT negative. Neurosurgery thought
that accessing the shunt was unnecessary given his improving MS
and minimal headache. At this point DVT was considered again.
LENIs were performed on [**10-30**], which revealed L superficial
femoral and L common femoral DVTs. After discussion with
neurosurgery it was felt that his immediate risk of bleed is
high but that it should decrease after 6 weeks or so, to the
point where he may be able to be anticoagulated with coumadin.
An IVC filter of intermediate duration was placed on [**10-30**]; this
retrievable filter was placed with the plan for removal in 6
weeks if he has no further bleeding. Pt continued to have
low-grade fevers, but all cultures were negative and this was
attributed to the presence of DVTs, and possible atelectasis.
Plans are made for followup to have the IVC filter removed in
[**4-29**] weeks.
4. Cardiovascular, pulmonary, gastrointestinal, renal,
endocrine:
No acute problems since transfer to the general medical floor.
5. Supportive care:
A tracheostomy was placed on [**2188-6-6**]. Over the course of the
hospitalization, the trach size was changed to a smaller size on
[**10-1**], and a Passy Muir valve was ultimately introduced to
maximize pt's ability to speak on [**10-3**], which was in place only
during waking hours.
A PEG tube was placed on [**2188-6-5**], and nutrition followed pt. He
was at goal tube feeds for the majority of his hospitalization,
at 80cc/hr. A repeat speech and swallow evaluation on [**10-7**]
confirmed that pt was aspirating all consistencies of liquid.
However, there was concern that the family may have been feeding
him, as residuals showed unexpected material once and pt with
apparent crumbs all over chest the week before discharge. Pt's
family was made aware of the grave danger of feeding this
aspirating patient and they acknoledged the importance of not
feeding him by mouth.
Pt had meticulous skin care and never developed a sacral decub.
Physical and Occupational Therapy continue to work with the
patient, and his progress has been remarkable.
Medications on Admission:
none
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
2. Methylphenidate HCl 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
6. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-23**]
Drops Ophthalmic PRN (as needed).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
9. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Morphine Sulfate 8 mg/mL Syringe Sig: 2-4 mg Injection Q4H
(every 4 hours) as needed for pain.
15. Triamcinolone Acetonide 0.025 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. subdural hemorrhage, status post right craniotomy and
partial frontotemporal lobectomy, ventriculoperitoneal shunt
placement, and elective cranioplasty
Secondary:
1. left common femoral and left superficial femoral deep vein
thrombosis
2. MRSA meningitis, now resolved
3. MRSA pneumonia, Pseudomonas pneumonia, now resolved
4. fungemia with [**Female First Name (un) 564**] parapsilosis, now resolved
Discharge Condition:
able to communicate yes and no questions, mental status good,
with trach and PEG tube in place
Discharge Instructions:
Please let the staff know if you are in pain or have any other
symptoms that are concerning to you.
Followup Instructions:
[**Month (only) **]:
Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2188-11-26**] 8:45
You have an appointment with Dr. [**Last Name (STitle) 739**] on [**11-26**] at
noon, after the head CT, so that interval change can be
evaluated.
[**Month (only) **]:
Provider: [**Name10 (NameIs) **] SCAN Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2188-12-25**] 8:00
You should not have tube feeds three hours before this study.
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2188-12-25**] 8:30
You have an appointment with Dr. [**Last Name (STitle) 739**] (neurosurgery) at
1:30PM on [**2188-12-25**]. This islocated in the [**Location (un) 470**]
(3B) of the [**Hospital Unit Name **] on [**Last Name (NamePattern1) **]. Phone number is
([**Telephone/Fax (1) 88**].
You have an appointment with Dr. [**First Name (STitle) **] (interventional radiology)
to discuss when the IVC filter should be removed on [**2187-12-26**] at 10AM. This is located on the [**Location (un) 10043**] of the
Clinical Center on the [**Hospital Ward Name 517**]. Phone number is ([**Telephone/Fax (1) 57821**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 5185, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1558
} | Medical Text: Admission Date: [**2170-7-16**] Discharge Date: [**2170-8-2**]
Service: [**Hospital1 **]
CHIEF COMPLAINT: Mental status change and bilateral upper
extremity swelling.
HISTORY OF PRESENT ILLNESS: The patient presented on
[**7-16**] at [**Hospital6 2910**] with 24 hours
of worsening mental status changes and bilateral upper
extremity swelling. Patient has a past medical history of
being a nursing home resident, dementia with behavioral
disturbance/depressed features, recent admission to [**Hospital 1474**]
Hospital with urosepsis of unknown etiology requiring
intubation, and discharged on [**2170-9-11**], diabetes
mellitus, coronary artery disease status post MI, CHF, COPD,
status post pacemaker placement, which required replacement
for low battery in [**Month (only) 404**] of this year.
At the outside hospital, a chest CT with contrast was
performed, which showed obstruction of the superior vena cava
at the level of the origin of the SVC. A head CT was also
done which was negative with no acute hemorrhage, an old left
frontal infarct, and thalamic calcifications and cortical
atrophy.
It was uncertain what the etiology of obstruction was and
ultimately the patient was started on Heparin drip and
transferred to [**Hospital1 69**] for
further evaluation and possible intervention. At the time of
the arrival of the patient to the Emergency Room, the patient
was slightly febrile at 101.4. Had a blood pressure of
124/84. Pulse of 105. Breathing at 30 and sating 94% on
room air. Vascular Surgery evaluated the patient and
recommended a venogram and a possible SVC stent at that time.
Patient was admitted for further workup.
PAST MEDICAL HISTORY:
1. Nursing home resident at [**Hospital1 2670**] in [**Location (un) 5110**].
2. Dementia with behavioral disturbance and depressed
features, although baseline is alert, conversant, and fairly
self sufficient with activities of daily living, although
requires wheelchair.
3. Recent admission at [**Hospital 1474**] Hospital with urosepsis of
unknown etiology requiring intubation, but discharged on
[**2169-9-11**] and admission on [**2169-9-3**].
4. Diabetes mellitus.
5. Coronary artery disease status post MI.
6. CHF with recent admission with 24 hour intubation.
7. COPD.
8. Status post pacemaker placement replaced on [**2169-12-7**] for low battery leads and without lead transition at
that time.
9. Status post traumatic brain injury.
10. GERD.
11. Hypertension.
12. Status post left knee surgery.
13. Status post appendectomy.
MEDICATIONS ON ARRIVAL:
1. Nitro patch 0.2 mg q.a.m.
2. Annulose 10 mg in 30 cc q.a.m.
3. Zyprexa 5 mg p.o. q.h.s.
4. Protonix 40 mg p.o. q.d.
5. Metoprolol 50 mg p.o. q.d.
6. Magnesium oxide 40 mg p.o. t.i.d.
7. Calcium carbonate 1.2 grams t.i.d. with food.
8. Dulcolax p.o. q.a.m.
9. Procardia XL 60 mg q.d.
10. Cardura.
11. Multivitamin.
12. Artificial tears.
13. Aspirin 325 mg p.o. q.d.
14. Trazodone 50 mg p.o. q.d.
15. Albuterol.
16. Insulin.
ALLERGIES: The patient reportedly had an allergy to
shellfish and IVP dye, however, at the outside hospital the
patient received contrast with a CT scan without any problems
as well as an inpatient. Although of note, the IV dye used
was nonionic ............
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: The patient is a former smoker, unknown
alcohol use, and his surviving relatives is an elderly
sister, who knows him poorly.
PHYSICAL EXAM AT TIME OF ADMISSION: Generally, patient in
some distress, was intermittently screaming at baseline.
Patient's vital signs were a temperature of 99.7, pulse of
105, blood pressure 130/86, respiratory rate 24, and
saturation 97% on 2 liters.
PERTINENT PHYSICAL FINDINGS: The patient had great
significant periorbital edema or facial swelling. The
patient did have 3+ bilateral pitting upper extremity edema
without lower extremity edema and had 2+ DP and PT pulses.
The patient's heart rate was tachycardic, but regular with a
normal S1, S2 with no murmurs. Lungs: Patient was making
poor effort with bibasilar crackles. Chest had numerous
dilated and tortuous superficial veins that were apparent.
The abdomen was benign.
LABORATORY STUDIES BEFORE THE PATIENT WAS ADMITTED: At the
outside hospital, the patient had a CBC which had a white
count of 3.7, hematocrit 32.6, and platelets of 214.
Coagulation showed a PT of 13.8, PTT of 33.4, and an INR of
1.2 previous to starting Heparin. Chem-7 was significant for
a potassium of 3.5, creatinine of 0.9, and bicarb of 33.
LFTs were significant for an ALT of 31, AST of 27, alkaline
phosphatase of 606, and total bilirubin of 1.64, direct
bilirubin of 1.1, and an albumin of 2.8. Patient's CK and
troponin-I were both negative.
Additional laboratory studies on arrival in the Emergency
Room showed a lactate of 1.8. A differential on his white
count with 83% polys. A urinalysis showed a large amount of
blood with trace leukocyte esterase, 150 ketones, but was
otherwise negative.
Electrocardiogram showed sinus tachycardia at 107 with left
axis deviation and new poor R-wave progression in leads V2
through V5 with T waves consistent with normal EKG. The
calcium, magnesium, and phosphorus were 9.7, 2.0, and 3.3
respectively. Uric acid and iron studies were normal.
Cholesterol study was normal. TSH was 1.5. A LP was
performed due to the patient's mental status change which had
175 reds, 1 white cell with a differential of 73% polys, 27%
lymphocytes, total protein was 22, and glucose was 125, Gram
stain was negative, and subsequent LP culture never grew out
any organisms.
Chest x-ray at the time of admission showed no effusion or
infiltrate, but did have a tortuous aorta.
HOSPITAL COURSE BY SYSTEMS: This is up to date to the
evening of [**8-2**]. Future dictation is to be
addended.
1. SVC syndrome: Patient had notable SVC syndrome on chest
CT at outside hospital and the chest CT was repeated while
the patient was in-house on [**7-18**], which was
performed with contrast and showed occlusion of the SVC
without obvious evidence of clot or external compression, and
also of note, on the chest, the lungs were clear and the
abdomen had no significant pathology.
On the evening of [**7-19**], the patient was taken for a
SVC graft and attempted wire transversal of the occlusion
with theoretical stent placement. However, the SVC was found
to be totally occluded above the level of the azygos and
subsequently wires cannot be passed either above or below.
The occlusion cannot be opened. At that time, the
recommendation was made for sharp recanalization potentially
some time in the future. However, at that time the patient's
guardianship status arrived, and it was not until the
patient's guardian was appointed and a discussion was
arranged between patient's guardian and Dr. [**Last Name (STitle) 2036**] of
Interventional Radiology. We were able to reconsider the
sharp Recanalization.
On [**7-24**], Dr. [**Last Name (STitle) 2036**] visited the patient and found the
patient to be somewhat hesitant to have the procedure done,
although his mental status was not completely clear.
Consequently, we arranged for a family meeting on [**7-26**] with the guardian and Dr. [**Last Name (STitle) 2036**]. At this time, it was
decided with the patient's seeming approval, the procedure
should go ahead on [**7-31**] with sharp recanalization.
However, over the following several days the patient became
increasingly clear of mental function and on about [**7-29**], patient's expressed to the attending, Dr. [**Last Name (STitle) **]
that he did not want to have the procedure done.
Consequently, on the 15th, Dr. [**Last Name (STitle) 2036**] and legal guardian were
[**Name (NI) 653**], and it was felt that the procedure should not be
performed. Specifically, Dr. [**Last Name (STitle) **] talked with the
guardian, and decided that procedure would be of no
significant benefit to the patient at this time, and could be
deferred until future. Specific argument was that a cerebral
blood flow study was performed which showed no significant
venous stasis, and thus, it was unclear whether or not the
patient's mental function would improve after the procedure,
and the patient also did not seem to be significantly
bothered by his upper extremity swelling.
At that time, SVC was electively not to be treated and the
upper extremity swelling was noted on daily examinations, but
was otherwise not treated.
2. Mental status change: By report, the patient at the
outside nursing home was fairly functional with his
activities of daily living, is able to carry on conversations
with his problems. However, in the Emergency Room, the
patient's mental status had declined to the point of
intermittent screaming without provocation. Consequently,
the patient was started on Haldol prn, and was maintained on
this throughout his course up until the point at the time of
this dictation on [**8-2**].
The patient's mental status gradually cleared, although there
was some waxing and [**Doctor Last Name 688**] component. It was unclear exactly
what the cause of the decline in mental status was. Multiple
urinalyses showed fungus in the urine, however, it was not
felt that this was significant. A cerebral blood flow study
was obtained on [**7-26**] which showed no significant
venous stasis nor retrograde flow into the jugular veins
indicating no extension of the clot superior. Consequently,
it was felt that the mental status was not necessarily
subsequent secondary to occlusion of the jugular veins due to
obstruction secondary to the SVC occlusion.
Also as the patient developed MRSA bacteremia in his hospital
course, the patient's mental status remained improved from
the time of his admission, and the patient was able to carry
on intermittent conversations.
3. Left thigh hematoma: Early on the morning of [**7-18**], the patient lost IV access. Consequently, a femoral
line was placed in the left. Patient, at this time, was
continuing to be maintained on Heparin and there was
difficulty in regulating the patient's Heparin level, and
there were several periods of time in which the patient's PTT
was elevated greater than 150. The maximum level in which at
which the test could be measured.
On the morning of [**7-21**], the patient was noted to
have a hematocrit which had dropped down to 18.9 from 25.3
the previous day, and the previous day it has actually fallen
as well from 32.3. Consequently, a CT of the abdomen was
obtained and this showed a bleed to the left thigh around the
site of the left femoral line.
The patient subsequently developed some hypotension as well
as respiratory failure with worsening mental status.
Consequently, was transferred to the Medical ICU. In the
Medical ICU, the patient's hematocrit reached a low of 17.7
on the morning of [**7-21**], and consequently, the
patient was transfused with 6 units of packed red blood cells
and 2 units of fresh-frozen plasma, and the Heparin was
obviously stopped.
The patient required intubation for 24 hours due to worsening
respiratory functioning in the setting of mental status
decline, but was extubated uneventfully on [**7-22**], and
was transferred back to the floor on [**7-23**]. The
patient's hematocrits were serially drawn every 12 hours and
later every 24 hours. After transfer out of the Medical ICU,
the patient's remained stable in the mid 30s for the
remainder of his stay up until this dictation, [**8-2**].
4. Fungus in urine: The patient had numerous urinalyses
performed during his hospitalization, which showed blood and
urine cultures repeatedly grew out fungus, which was
identified as presumptively not [**Female First Name (un) 564**] albicans. Patient
was generally afebrile and consequently, it was felt that
this was probably a spurious result. However, to be safe,
the patient was transferred over to a condom catheter.
The patient's fungal urine cultures were drawn after this
time and found to have fungus, but presumptively not C.
albicans, but again this was probably thought to be a
spurious result, although it was requested that the
speciation be performed and this was being completed at the
time of this dictation on [**8-2**].
5. MRSA bacteremia: The patient's femoral line was
maintained after the time of this hematoma. Because it was
his only access for blood draws and delivery of medications.
However, the patient began having mild fevers over the
weekend, [**7-28**] and 14th, and consequently, it was
decided that the femoral line should be changed over wire.
This was done without event maintaining sterile procedure
throughout. However, the following day, the patient's blood
cultures began to grow out coag positive staph, which
subsequently grew out methicillin-resistant Staphylococcus
aureus. The two femoral line tips were cultured and this
also grew out MRSA, and in addition to Pseudomonas which was
pansensitive except for ciprofloxacin. In addition, there is
also a single culture which grew out coag negative staph,
which was resistant to oxacillin, but sensitive to
Vancomycin.
Patient was started on Vancomycin on [**7-31**] after the
blood cultures began to return positive and the patient was
significantly afebrile, but this is complicated by the lack
of access issue, which will be discussed in the next problem.
Consequently only two doses of Vancomycin over the 16th and
17th were given and one dose of gentamicin 1 mg/kg dosing.
On the evening of [**8-2**], no access was available and
consequently the patient was given p.o. linezolid. Further
events regarding his MRSA bacteria will be dictated in the
near future.
6. Access: After the left femoral line was pulled, the
patient's access became very difficult. A brief IV was
placed in one of the varices in the patient's left chest, but
this fell out after a single dose of IV Vancomycin was given.
A subsequent IV was placed in the patient's left ankle, but
this fell out after another dose of Vancomycin was given.
The following day on [**8-2**], repeated IVs were
attempted, but unable to be performed. Consequently, it was
decided that should attempts to replace a right IJ central
line.
The patient was taken to the Interventional Pulmonology
Procedure Unit, where there were three attempts made to place
the line without success. After this, the patient was taken
to the Interventional Radiology for an angiographically
placed line, but this was declined on the 18th with possible
repeat attempt on the 19th, and future events and this
problem will be dictated in subsequent addendum.
7. Diet: The patient was initially made NPO due to his
decline in mental status. On the patient's discharge for the
Medical ICU on [**7-23**], the patient had a swallow study
done, which showed the patient was able to tolerate nectar
thickened liquid diets and full sized medications.
Consequently, this patient was started on this diet, and
maintained throughout the rest of his hospital stay up until
[**8-2**], the time of this dictation.
Nutrition was also consulted, and found the patient to be
serially lacking in calorie intake and protein intake,
however, it was decided that the patient would not tolerate
placement of a nasogastric tube for tube feeding and that the
patient's dietary intake would probably increase once he was
discharged.
8. Hypertension: Patient was maintained on his baseline
metoprolol 12.5 p.o. b.i.d. once he was known to be able to
tolerate p.o.
9. Code status and guardianship: On the arrival, the patient
was known to have only one surviving relative, whose name is
[**First Name4 (NamePattern1) **] [**Name (NI) 10141**]. This person was [**Name (NI) 653**]. It was found that
she did not really know the patient and was unable to assess
what his wants would be in terms of aggressiveness of care.
At the previous hospital stay, she had been his healthcare
determining person, but it was decided that she was probably
inadequate for the task and consequently, legal guardianship
was requested and obtained on the evening of [**7-20**].
The new guardian was [**Name (NI) 2411**] [**Name (NI) 9192**], phone number
[**Telephone/Fax (1) 10142**], who wanted to reverse the patient's DNR/DNI
status to full code. In addition, this person subsequently
spoke with Drs. [**Last Name (STitle) 2036**] and [**Name5 (PTitle) **] regarding sharp
Recanalization procedure and maintained her guardianship
status throughout the remainder of the hospital stay.
Of note, the patient's legal guardian found her job difficult
as she did not know the patient previously and was forced to
decide what the patient's wants would be in terms through
discussions with the staff and other residents at the
[**Hospital 228**] nursing home.
Disposition at the time of this dictation, [**8-2**] is
pending treatment of the patient's infection and will be
further decided upon on further dictation.
As well as condition on discharge, discharge status,
discharge diagnosis, discharge medications, and followup
plans will all be dictated in future addendum.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 10143**]
MEDQUIST36
D: [**2170-8-2**] 18:51
T: [**2170-8-6**] 10:57
JOB#: [**Job Number 10144**]
ICD9 Codes: 4280, 496, 5849, 7907, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1559
} | Medical Text: Admission Date: [**2193-8-14**] Discharge Date: [**2193-8-23**]
Date of Birth: [**2143-2-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation/Extubation, Mechanical Ventilation
History of Present Illness:
50 yo male with h/o COPD, CAD s/p
STEMI, CHF, OSA, DM2 who presented with 2-3 days of increasing
dyspnea, wheezing and lower extremity edema; family also reports
cough, no fevers. Pt describes LE edema as acute onset on
[**2193-8-9**], associated with intense pruritis of the soles/ankles of
both feet developing into swelling. After significant
encouragement from family/friends, presented to [**Hospital1 18**] ER on
[**2193-8-14**] and was found to be hypercarbic and hypoxic. Pt became
somnolent and was intubated in the ED for hypercarbic
respiratory
failure and admitted to the MICU. VS in the ED were 98.8,
136/85,
125, 26, 75% 2L NC, ABG 7.22/96/59 --> 7.11/134/77. Pt was also
given solumedrol, nebs, levofloxacin, magnesium in ED for COPD
exacerbation/?PNA; heparin gtt and CTA ordered for ?PE. CTA neg
for PE, CT head neg for bleed.
.
ROS was otherwise negative for chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. No syncope, near-syncope.
.
MICU course: Pt remained on NIPPV [**11-11**] with FiO2 50% and started
on Ceftriaxone/Azithromycin for ?PNA, lasix for fluid overload,
nebulizers for COPD exacerbation. Solumedrol was changed to
prednisone taper on [**2193-8-19**] starting at 30mg/day. Pt also had
BAL
on [**2193-8-17**] showing tracheobronchomalacea and mucus in LLL,
sputum
cx NGTD. Pt was extubated w/o issues the morning of [**8-18**] (day 5
of mechanical ventilation) and has remained stable since.
Past Medical History:
1. CAD: 2vd s/p inferior STEMI and BMS to LCx ([**2183**]). cath [**5-15**]
showed 30% stenosis of prox LAD, 60% stenosis of mid-LCx before
patent OM1 stent, 100% RCA occlusion w/ good lt to rt
collaterals
2. PVD s/p stenting of rt common iliac ([**2183**])
3. CHF w/ preserved EF on MIBI ([**4-14**]) and ECHO ([**1-12**])
4. COPD, FEV1 1.23 ([**4-15**])
5. OSA on CPAP [**11-16**] 50%
6. DM2, HbA1c 7.0 ([**6-15**])
7. Hypercholerolemia
8. Hypertension
9. Obesity
Social History:
Works in shipping/receiving.
T - prev 2ppd X many years, now quit
A - few beers per month
D - h/o marijuana, no IVDU
Family History:
Father died in sleep at 59yo, h/o COPD. Mom died at 79yo, had
breast cancer. Sister w/ CAD and h/o stroke
Physical Exam:
On admission to MICU from ED:
Gen: Obese caucasian male intubated, sedated, moves to voice
HEENT: blood noted around bilateral nares and around mouth; not
currently oozing.
NECK: Supple, No LAD, No JVD
CV: RRR. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: BS heard throughout lung fields. no wheezes
ABD: normo-active BS, soft, NT, ND.
EXT: 1+ edema in the feet bilaterally, DP pulses not palpable.
NEURO: sedated
On transfer to CC7:
VITALS: T 97.4, HR 84, BP 100/66, R 20, 97% 3L NC --> 93% 2L
GEN: NAD, A&O X3
HEENT: NCAT, EOMI, normal oro/nasopharynx
NECK: Soft, supple, no JVD
CV: RRR, no m/g/r, nl S1/S2
PULM: CTAB, no w/r/r, ?mild bilateral basilar crackles on exam
ABD: soft, nt/nd, +BS (hypoactive), overweight
EXT: no c/c/e, palpable 2+ DP/PT pulses bilaterally, no edema
bilaterally
Pertinent Results:
Admit Labs
WBC-13.6*# RBC-5.92 Hgb-17.3 Hct-55.7* MCV-94 MCH-29.3 MCHC-31.1
RDW-12.7 Plt Ct-277 Neuts-61 Bands-16* Lymphs-10* Monos-9 Eos-0
Baso-0 Atyps-4* Metas-0 Myelos-0 Hypochr-OCCASIONAL
Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL
Microcy-NORMAL Polychr-OCCASIONAL
Glucose-171* UreaN-16 Creat-0.6 Na-139 K-4.0 Cl-94* HCO3-36*
AnGap-13 cTropnT-<0.01
Calcium-9.1 Phos-4.1 Mg-2.2
pO2-69* pCO2-96* pH-7.22* calTCO2-41* Base XS-7
Glucose-168* Lactate-1.4
ERYTHROPOIETIN: 8.7 4.1-19.5 MU/ML
JAK2 V617F NEGATIVE (r/o polycythemia [**Doctor First Name **], etc)
.
CTA CHEST ([**8-14**]) - IMPRESSION:
1. No evidence of large pulmonary embolus. Evaluation of distal
branches are limited.
2. Diffuse subcentimeter ground-glass nodules and more
solid-appearing 6-mm nodule in the right lower lobe. Followup CT
within 6 months is recommended.
3. Diffuse mediastinal and hilar adenopathy as described above.
ECHO ([**8-16**]) - IMPRESSION: No large amounts of right-to-left
shunting seen, although images are suboptimal. Normal global
biventricular function.
Compared with the prior study (images reviewed) of [**2193-1-9**],
current images are technically suboptimal, so precise comparison
is difficult. No
ASD/PFO/VSD detected on bubble study.
CXR: The ET tube tip is 8 cm above the carina. NG tube tip is in
the stomach. There is no change in the left basal opacity that
might represent a developing aspiration pneumonia versus
infectious process in combination with atelectasis. Upper lungs
are clear and there is no appreciable right pleural effusion.
Small amount of left pleural fluid cannot be excluded.
BAL Cx: NGTD. Neg legionella, PCP, [**Name10 (NameIs) 3019**], CMV
Blood Cx: Neg
Sputum Cx: Neg
Brief Hospital Course:
50 yo male with h/o COPD, CAD s/p STEMI, CHF, OSA, DM2 who
presented with 2-3 days of increasing dyspnea and was intubated
emergently in ED for hypercarbic respiratory failure. Pt has
since been extubated and almost back to baseline pulmonary
function. Etiology remains unclear.
HOSPITAL COURSE BY PROBLEM:
# RESPIRATORY FAILURE. Combined hypercarbic and hypoxic
respiratory failure. Etiology unclear. Chronically elevated
hematocrit suggestive of some level of chronic hypoxia. Likely a
combination of COPD, OSA. No obvious infection on CXR to suggest
PNA. Could also have been in setting of volume overload but did
not
appear wet on physical exam.
- Pt was given a seven day course of Ceftriaxone and five day
course of Azithromycin which he finished prior to discharge.
- Pt was diuresed with Lasix 40mg daily while in MICU and on the
Medicine floors. Pt is to resume home dose of Lasix 20mg upon
discharge.
- Pt started on a Prednisone taper, 30mg X 3days, 20mg X3days,
10mg X3 days then stop
- Pt was continued on Albuterol inhaler, Albuterol/Ipratropium
nebs PRN.
.
# HYPERTENSION. Patient was normotensive during hospital stay.
He did have 2 episodes of self-limited, mild hypotension with
dizziness (SBP 100) with negative orthostatics. Home metoprolol
was continued in house. Lisinopril was held in MICU but
restarted on discharge.
.
# CAD. S/p inferior MI w/ BMS placement.
- Continued ASA 325mg, plavix 75mg, pravastatin, metoprolol in
house. Lisinopril was held in the MICU [**3-11**] CTA contrast dye.
Lisinopril was restarted on discharge home.
.
# DIABETES, Type II. Well controlled during hospital stay on
HISS.
- Pt on metformin as outpatient and was restarted on discharge.
Medications on Admission:
ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler -
2
puffs inhaled every 6 hours as needed
BENZOYL PEROXIDE - 2.5 % Gel - apply to acne on the back qday
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 75 Tablet(s) by mouth once a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff inhaled twice daily rinse mouth after use
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day
KETOCONAZOLE - 2 % Shampoo - apply to body and keep for 5
minutes
and then wash. use for 7 days. after that can use once a week
for
prevention qday
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth qday
METFORMIN - 500 mg Tablet - [**2-8**] Tablet(s) by mouth twice daily
take two tabs in the morning and one tab at night
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a
day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually q5min X 3 doses as needed for chest pain call 911
if
no relief after 2nd pill; take up to 3 pills
PORTABLE OXYGEN SYSTEM - 4L - to keep O2 sat > 87% when walking
PRAVASTATIN - 40 mg Tablet - one Tablet by mouth once a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - one capsule inhaled daily
UREA [CARMOL 40] - 40 % Cream - apply to affected areas daily
Medications - OTC
ASPIRIN - 325 mg Tablet - one Tablet(s) by mouth daily
MELATONIN - (OTC) - 3 mg Tablet - 1 Tablet(s) by mouth taken at
8 pm nightly
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) -
Tablet - 1 Tablet(s) by mouth Daily
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Melatonin 3 mg Tablet Sig: One (1) Tablet PO once a day: At
8pm.
7. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Metformin 500 mg Tablet Sig: 1-2 Tablets PO twice a day: Take
1000mg in the morning, 500mg at night.
10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes as needed for chest pain: Do not
exceed 3 doses in 15 minutes. Call 911 if chest pain persists
after 3 doses.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
13. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
14. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
15. CARMOL 40 40 % Cream Sig: One (1) application Topical once a
day.
16. Benzoyl Peroxide 2.5 % Gel Sig: One (1) application to back
Topical once a day.
17. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a week.
18. Prednisone 10 mg Tablet Sig: Starting tomorrow, [**8-24**],
take 20mg daily for two days
* Starting [**8-26**], take 10mg daily for three days
* Starting [**8-29**], do NOT take any more prednisone.
Disp:*10 Tablet(s)* Refills:*0*
19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q8H (every 8 hours) as
needed for SOB.
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
22. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours) as needed for SOB.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypercarbic respiratory failure
Secondary:
1. CAD: Two vessel disease s/p inferior STEMI and bare metal
stent to LCx ([**2183**], cath [**5-15**])
2. Peripheral Vascular Disease s/p stenting of right common
iliac ([**2183**])
3. Congestive Heart Failure w/ preserved ejection fraction on
MIBI ([**4-14**]) and ECHO ([**1-12**])
4. COPD, FEV1 1.23 ([**4-15**])
5. Obstructive Sleep Apnea on CPAP [**11-16**] 50%
6. Type 2 Diabetes Mellitis, HbA1c 7.0 ([**6-15**])
7. Hypercholerolemia
8. Hypertension
9. Obesity
Discharge Condition:
Improved. Vital signs are stable, patient ambulating and on 3L
supplemental oxygen.
Discharge Instructions:
-You were admitted in acute respiratory distress which required
that you be intubated, to help you breath. Your respiratory
problems were likely due to a combination of COPD, usual
breathing difficulties and a respiratory infection.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> ADDED Famotidine 20mg twice daily for GERD
--> ADDED Prednisone. You are to slowly decrease your daily dose
of this medication as follows:
* Starting tomorrow, [**8-24**], take 20mg daily for two days
* Starting [**8-26**], take 10mg daily for three days
* Starting [**8-29**], do NOT take any more prednisone.
--> CONTINUE your home medications: Benzoyl peroxide 2.5% (back
wash), Plavix 75mg daily, Lasix 20mg daily, Ketoconazole 2%
shampoo, Carmol 40% cream daily, Lisinopril 5mg daily, Metformin
1000mg (two tablets) in the morning/500mg at night, Pravastatin
40mg daily, aspirin 325mg daily, Melatonin 3mg at 8pm daily,
Centrum Silver 1 tablet daily, Nitroglycerin 0.4mg sublingual
tablets as needed.
--> RESUME your breathing medications: Advair 250-50mcg 1 puff
twice daily, Spiriva 18mcg inhale one capsule daily, Albuterol 2
puffs every 6 hours as needed, supplemental oxygen.
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6303**] [**Last Name (NamePattern1) **], in [**3-13**] weeks.
You can call her office to make an appointment at: [**Telephone/Fax (1) 250**]
.
Please follow-up with your pulmonary doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
in [**2-8**] weeks. You can call his office to make an appointment at:
[**Telephone/Fax (1) 612**]
ICD9 Codes: 2762, 4280, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1560
} | Medical Text: Admission Date: [**2195-7-13**] Discharge Date: [**2195-7-18**]
Date of Birth: [**2134-9-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Left lower extremity ischemia with
ulceration.
Major Surgical or Invasive Procedure:
Left SFA to TPT bypass with NRGSV
History of Present Illness:
This is a 60-year-old man who has
left leg ulceration in the heel. Arteriogram showed occlusion
of the above-knee popliteal artery with reconstitution of the
below-knee popliteal artery and a single-vessel runoff via
the peroneal which had a patent posterior tibial artery.
Given these findings, the patient was consented for a femoral
to tibial bypass to help assist him with wound healing
Past Medical History:
CHF with EF < 20%, global right and left ventricle hypokinesis
DM2 on insulin
HTN
CAD: CABG [**2187**], on asa, plavix; MIBI in [**1-31**] w/out rev [**First Name (Titles) 110951**]
[**Last Name (Titles) 110952**]
Social History:
- no current etoh
- no cigarette smoking, no illegal drug use
- blood transfusion once before, at hospitalization at [**Hospital1 18**] in
[**1-/2193**]
Family History:
non-contributory
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: 2/6 SEM
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness
EXT:
rle - palp fem, [**Doctor Last Name **], dop pt
lle - palp fem, [**Doctor Last Name **], dop pt, dp
ulcer on the left heel, debrided bedside
graft palp
Pertinent Results:
[**2195-7-17**] 07:10AM BLOOD
WBC-11.7* RBC-3.39* Hgb-10.3* Hct-29.2* MCV-86 MCH-30.3
MCHC-35.1* RDW-14.2 Plt Ct-276
[**2195-7-17**] 07:10AM BLOOD
Glucose-61* UreaN-32* Creat-2.4* Na-140 K-3.7 Cl-103 HCO3-25
AnGap-16
[**2195-7-17**] 07:10AM BLOOD
Calcium-8.3* Phos-4.2 Mg-2.2
[**2195-7-13**] 06:00PM BLOOD
Glucose-255* Lactate-2.2* Na-134* K-4.8 Cl-108
[**Known lastname **],[**Known firstname **] I [**Medical Record Number 110955**] M 60 [**2134-9-18**]
Cardiology Report ECG Study Date of [**2195-7-13**] 7:33:08 PM
Baseline artifact. Sinus rhythm. P-R interval prolongation. Left
bundle-branch block. Compared to the previous tracing of [**2195-7-8**]
there is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 186 150 490/490 75 -26 -179
Brief Hospital Course:
Patient is a 60 year old male with multiple medical problems
including severe peripheral vascular disease and a non-healing
left foot ulcer on which an angiogram was performed on previous
admission [**2195-7-7**] without complication. Patient was scheduled
for surgery [**2195-7-13**] and discharged home. Patient was found to
have chronic renal insufficiency on previous admission and was
discharged with stable Cr.
On this admission patient underwent a Left superficial femoral
artery to
dorsalis pedis trunk bypass with reverse greater saphenous vein.
The operation was uncomplicated. Patient returned to the
floor. During his post-operative recovery patient experienced
an episode of tachycardia for which he was followed by
cardiology. ECG and cardiac enzymes were found to be negative
and the patient was asymptomatic. Cardiology was consulted and
it was determined no further workup was necessary. During his
hospital admission patient's creatinine rose to 2.5. He was
given IV bicarbonate and at discharge his creatinine has
stabilized.
Patient was discharged home on POD5 with visiting nurse to
monitor his leg incision for signs of infection and with PT to
help patient ambulate.
Medications on Admission:
xanax 1mg TID, Amlodipine 5 mg Tablet QD, Coreg 25 QD, Clonidine
0.2 mg Tablet TID, Plavix 75, Lasix 80mg [**Hospital1 **], Hydralazine 25
mg Tablet TID, Vicodin prn, Lantus 55 units in a.m., 22 units at
night, Lisinopril 2.5 mg Tablet QD, zocor
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
4. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Insulin
Sliding Scale & Fixed Dose
Fingerstick QACHS
Insulin SC
Fixed Dose Orders
Breakfast Bedtime
Glargine 55 Units Glargine 22 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-50 mg/dL 4 oz. Juice
51-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
> 400 mg/dL Notify M.D.
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO four times a
day for 10 days: prn.
Disp:*31 Tablet(s)* Refills:*0*
11. [**Last Name (un) 1724**]
xanax 1mg TID, Amlodipine 5 mg Tablet QD, Coreg 25 QD, Clonidine
0.2 mg Tablet TID, Plavix 75, Lasix 80mg [**Hospital1 **], Hydralazine
25 mg Tablet TID, Vicodin prn, Lantus 55 units in a.m., 22 units
at night, Lisinopril 2.5 mg Tablet QD, zocor 40mg QD
12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
On Hold check with PCP before taking.
Discharge Disposition:
Home With Service
Facility:
caritas home care
Discharge Diagnosis:
Peripheral Vascular Disease
Gangrenous ulcer left heel
CRI
Low HCT post op requiring PRBC
Bedside debridement of leftheel ulcer
Diabetes mellitus type 2, HTN, coronary artery disease, CHF
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.
-If you have staples, they will be removed during at your follow
up appointment.
.
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 ([**10-8**] lbs) until your follow up appointment.
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-27**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
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 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Followup with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2195-8-6**] 11:30
Follow-up with Podiatry: Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name (STitle) **] for appt. Phone: ([**Telephone/Fax (1) 19882**]
ICD9 Codes: 9971, 4271, 5859, 3572, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1561
} | Medical Text: Admission Date: [**2166-9-9**] Discharge Date: [**2166-9-17**]
Service: MEDICINE
Allergies:
Lithium / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 84 yom with history of COPD, Prostate Ca,
Schizoaffective disorder, Depression, Hypothyroidism, Gout, +PPD
in [**2140**] s/p treatment who presents from his Nursing Home today
for hypoxia and malaise. Per report from PCP, [**Name10 (NameIs) **] has been
found to be coughing with liquids and food at his nursing home.
Patient was found to have increasing weakness and malaise at his
nursing home yesterday, O2 sat noted to be 67% which rose to 90%
on 3L NC. PCP was notified today and patient was referred to
[**Hospital1 18**] ED. Per ED report, patient also complaining of left knee
pain.
.
Per nursing home report: Patient found sitting on toilet,
unable to get himself up. Patient complaining of left leg/left
hip pain. V/S Temp 100.4, HR 94, RR 20, BP 103/74. 94% on RA.
Patient then had O2 desaturation to 67% as above, with
patient to ER>
.
In the ED: Temp 103.8, HR 128, RR 35 98% on NRB. CXR was done
in the ED and was concerning for LLL PNA. Patient was started
on Vanco/Zosyn. HR in 130s with Afib. He was given Diltiazem
10mg IV x 2, with HR 100s, also given 2L NS. Patient had
increased work of breathing and was placed on BIPAP. Patient was
transferred to MICU for further care.
.
On arrival to MICU, patient was on BIPAP and unable to answer
questions.
Past Medical History:
Atrial fibrillation
COPD
Hypothyroidism
S/P left hip bipolar hemiprosthesis
Prostate Ca
Schizoaffective disorder
Depression
Gout
thoracic abdominal aortic aneuysm
Social History:
Lives at [**Hospital **] Nursing home
Family History:
NC
Physical Exam:
Gen: NAD.
HEENT: Anicteric. PERRL 3 to 2 mm bilaterally. Oral mucosa
dry.
Resp: Mildly increased respiratory effort. On shovel mask 50%
O2. Clear at right apex. Slight inspiratory rales left apex.
Decreased breath sounds at bases bilaterally.
CV: JVP to angle of jaw. Irregular rhythm. S1, S2. No M/G/R.
Abd: Bowel sounds present. Soft. Non-tender.
Ext: 2+ to 3+ LE edema left, perhaps worsened from yesterday.
1+ LE edema right.
Peripheral Vascular: (Right radial pulse: 2+), (Left radial
pulse: 2+), (Right DP pulse: present by doppler), (Left PT
pulse: present by doppler)
Neurologic: Neurologic exam limited by mental status. Responds
to simple commands. Keeps repeating ??????at 5:38??????. Speech limited
to short phrases. Not oriented. PERRL 3 mm to 2 mm
bilaterally. EOMI. Symmetric smile. Elevates palate in
midline. Protrudes tongue min midline. Moves all 4
extremities.
Brief Hospital Course:
84 yo M with COPD, Afib, prostate cancer, thoracic aortic
aneurysm, s/p hip partial replacement, presented on [**2166-9-9**] with
altered mental status, tachycardia, hypoxemia, LLE edema, and
left hip/knee pain. Imaging studies revealed pneumonia, large
thoracic aortic aneurysm, and multiple blastic bone lesions.
The patient initially required non-invasive respiratory support
but his respiratory status improved, and he has been off of
respiratory support since last night [**2166-9-10**].
healt care acquired pneumonia/respiratory distress: The patient
presented with desaturation and increased work of breathing, for
which he was started on BIPAP in the ED.
The patient continued to require non-invasive ventilatory
support (CPAP with pressure support) until the evening of
[**2166-9-10**], after which time, oxygenation was maintained with a face
tent mask. Chest radiography was consistent with pneumonia,
which was treated as healthcare associated pneumonia, given the
patient's residence in a nursing home. The patient was treated
with Zosyn, vancomycin, and azithromycin. At the time of
transfer out of the MICU, the plan was to continue azithromycin
for a 5-day course, which will be complete in the early morning
of [**2166-9-14**], and to continue Zosyn and vancomycin for a 10-day
course, which will be complete on [**2166-9-17**]. Legionella urinary
antigen was negative. At the time of transfer out of the MICU,
blood cultures x 2 were pending and were found to be negative.
Altered mental status: Per nursing home, patient A&Ox3 without
dementia at baseline. Mental status has fluctuated from hour to
hour and tends to be better in the afternoon. At his best, the
patient was able to respond to simple commands and answer simple
questions. The patient's mental status changes were felt to be
due todelirium in the setting of acute infection. However, CVA
was considered in the differential diagnosis. The patient had
a negative head CT. Neurology was consulted and felt that the
patient's exam was non-focal and not consistent with CVA. The
patients electrolytes remained stable during the duration of his
hospital course. A repeat head CT showed no interval change.
Atrial fibrillation with RVR: On presentation, the patient was
tachycardic to 128. In the ED, he received diltiazem 10 mg IV x
2 and bolused with 2L NS, with improvement of the tachycardia.
In the MICU, the tachycardia recurred and
responded only transiently to diltiazam boluses. The patient
was started on a diltiazem drip, on which he remained until the
early morning of [**2166-9-11**]. At that time, digoxin was initiated to
provide rate control while enhancing blood pressure, cardiac
output, and renal perfusion. Rate control and BP were good on
digoxin. The patient is not on anticoagulation. The MICU team
contact[**Name (NI) **] the patient's PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], who did not believe that
anticoagulation was in the patient's interest given his fall
risk. At the time of transfer out of the MICU, the plan was to
continue digoxin for rate control, monitoring the patient's ECG
and checking a digoxin level in the a.m. of [**2166-9-13**]. The
patient's digoxin level remained therapeutic and he his EKG was
unchanged.
COPD ?????? Baseline COPD likely contributed to intiail poor
respiratory status. Started on 60 mg q8 solumedrol bolus.
Tapered methylprednisolone to 20 mg IV and then transitioned to
PO, where he was tapered off.
Blastic bone lesions ?????? Likely metastasis given history of
prostate cancer and PSA 279.9. Consulted PCP regarding
management of patient??????s prostate cancer, likely would not want
medical interventions. AFter discussion with guardian, the
conclusion was to not pursue aggressive intervention, including
escalating the patients status to an ICU. She will consider a
Do not hospitalize order during the upcoming days after
discussion with Dr. [**First Name (STitle) **], as well as referral to hospice. She
preferred the patient be transported back to his nursing
facility where he was comfortable, rather than spend additional
time in the hospital.
Externally rotated hip. LLE shortened and externally rotated.
No evidence of fracture of dislocation on CT. External rotation
likely chronic per ortho. MRI of spine ordered to rule out
metastatic lesion. MRI positive for lesions in the thoracic and
cervical spine, no lesions in lumbar spine or evidence of
stenosis.
LLE edema ?????? No clot. DDx includes venous insufficiency, CHF
(although worse on left).
Elevated CK ?????? [**Month (only) 116**] be due to traumatic muscle injury in the
setting of a fall. Continuing to trend down.
Schizoaffective disorder
Home meds were held while NPO, then restarted
Medications on Admission:
Levothyroxine 100mcg daily
Prilosec 20mg daily
Diltiazem 120mg daily
Acetaminophen 1000mg [**Hospital1 **]
Docusate 200mg [**Hospital1 **]
Depakote 750mg [**Hospital1 **]
Milk of Magnesia 30mg M/W/F
Zyprexa 10mg qHS
Doxazosin 2mg daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
3. Acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q 8H
(Every 8 Hours).
4. Levothyroxine 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**1-8**]
Drops Ophthalmic PRN (as needed).
6. Olanzapine 2.5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO HS (at
bedtime).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Valproate Sodium 250 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) 750 mg syrup
PO Q12H (every 12 hours).
9. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 16662**] - [**Street Address(1) **]
Discharge Diagnosis:
1. Pneumonia
2. Hypotension
3. Respiratory distress
4. Urinary retention s/p foley placement
5. Atrial fibrillation with rapid ventricular response
6. Weakness
7. L arm swelling
Secondary
1. Schizoaffective disorder
2. Hypothyroidism
3. Metastatic prostate cancer
4. Thoracic aortic anneurysm
Discharge Condition:
Hemodynamically stable, tolerating PO intake
Discharge Instructions:
You have been diagnosed with altered mental status, respiratory
distress and hypotension during your hospital stay.
You should return to the hospital as needed for changes in
mental status, difficulty breathing, fever, or other symptoms
concerning to you, but during your hospital stay it was
discussed with your guardian the possibility of do not
hospitalize in the future.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in [**1-8**] weeks. You can call
[**Telephone/Fax (1) 608**] to schedule an appointment.
Completed by:[**2166-9-17**]
ICD9 Codes: 5070, 2930, 4271, 496, 4280, 2749, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1562
} | Medical Text: Admission Date: [**2106-8-27**] Discharge Date: [**2106-8-31**]
Date of Birth: [**2023-2-21**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 yo W with PMH of Type II DM, HTN presents with hypoglycemia.
Patient woke this morning and fell out of bed. She was unable to
get up. She had no head trauma or loss of consciousness. Son
found her and called EMS. In the field, her FS was in the 20's
associated with altered mental status. She received oral glucose
+ juice and both mental status and FS's improved. She also
reports epigastric/ substernal CP, nonradiating that lasted for
several hours and improved on arrival to the ED without
intervention.
.
On arrival to the ED, VS: T97.5 HR 76 BP 148/103 RR 17 100%RA.
FS was 29. She received 1 amp of D50, 50 ucg of octreotide and
was started on D5 infusion. There was a question of new
infiltrate in R base and received Levaquin x 1. Labs notable for
elevated CE's. Per notes, patient was seen by cards, but was
refusing heparin or ASA at this time Pt was refusing treatment
with heparin and ASA.
Past Medical History:
DM type II
Mild-moderate diabetic retinopathy
HTN
Arthritis
Cataracts
Social History:
Patient was born in [**Country **]. Moved to the United States in [**2075**].
Currently living with her daughter. Previously worked as a
housekeeper at [**Hospital 13128**]. Denies tobacco/EtOH.
Family History:
Son in good health.
Physical Exam:
Vitals Stable.
GEN: elderly female, pleasant, NAD.
HEENT: eomi, mmm.
RESP: CTA B. No wrr.
CV: RRR. No mrg.
Abd: benign.
Ext: No cee.
Pertinent Results:
[**2106-8-27**] 09:00PM BLOOD cTropnT-0.10*
[**2106-8-28**] 10:15AM BLOOD CK-MB-10 MB Indx-7.0* cTropnT-0.22*
[**2106-8-29**] 09:05AM BLOOD CK-MB-4 cTropnT-0.21*
[**2106-8-30**] 02:00PM BLOOD cTropnT-0.21*
.
[**2106-8-30**] 02:00PM BLOOD WBC-6.3 RBC-3.54* Hgb-10.6* Hct-31.4*
MCV-89 MCH-29.9 MCHC-33.8 RDW-15.0 Plt Ct-263
.
[**2106-8-30**] 02:00PM BLOOD Glucose-175* UreaN-37* Creat-1.3* Na-139
K-4.2 Cl-109* HCO3-20* AnGap-14
.
[**2106-8-27**] 09:00PM BLOOD ALT-15 AST-24 LD(LDH)-217 CK(CPK)-135
AlkPhos-87 TotBili-0.2
.
[**2106-8-28**] 10:15AM BLOOD CK(CPK)-143*
[**2106-8-29**] 09:05AM BLOOD CK(CPK)-73
.
[**2106-8-28**] 10:15AM BLOOD Triglyc-33 HDL-65 CHOL/HD-2.2 LDLcalc-70
.
[**8-27**] EKG:
Sinus rhythm. Poor R wave progression, probably a normal
variant. Compared to the previous tracing of [**2103-7-24**] there is no
significant diagnostic change.
.
CXR:
IMPRESSION: No acute cardiopulmonary abnormality
.
Cardiac Echo:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Diastolic dysfunction. Mildly thickened aortic valve leaflets
without stenosis and mild aortic regurgitation.
Brief Hospital Course:
83 yo W with PMH of Type II DM, HTN presents with hypoglycemia.
Patient woke and fell out of bed at home. She was unable to get
up. She had no head trauma or loss of consciousness. Son found
her and called EMS. In the field, her FS was in the 20's
associated with altered mental status. She received oral glucose
+ juice and both mental status and FS's improved. She also
reports epigastric/ substernal CP, nonradiating that lasted for
several hours and improved on arrival to the ED without
intervention.
.
On arrival to the ED, VS: T97.5 HR 76 BP 148/103 RR 17 100%RA.
FS was 29. She received 1 amp of D50, 50 ucg of octreotide and
was started on D5 infusion. There was a question of new
infiltrate in R base and received Levaquin x 1. Labs notable for
elevated CE's. Per notes, patient was seen by cards, but was
refusing heparin or ASA at this time Pt was refusing treatment
with heparin and ASA.
In the ICU she was found to have an NSTEMI with her troponin
peaking at 0.22 the am prior to transfer to the floor. Her care
in the ICU was complicated by her refusing labs and medications.
Thus they were not able to continue to cycle her enzymes.
Started on lovenox 60 mg SQ x 3 doses first one given at 1600 on
[**2106-8-28**] while asleep. She was initially on an insulin gtt and
this was changed to SQ insulin. Family is aware of her refusing
many interventions. She remains full code with full treatment.
.
Pt completed treatment with 3 days of SQ Lovenox, without
recurrance of chest pains. Pt remained off of her glyburide,
however metformin was restarted. Geriatrics consulted, and
recommended pt have VNA after discharge to assist with
medications at home, and recommended Geriatrics follow up as an
outpt for formal eval and treatment (if needed) of dementia,
with formal memory assessment. Appointments scheduled.
.
Pt also c/o some constipation which was relieved during
hospitalization. Pt discharged on standing colace and prn senna.
.
Pt discharged to home with VNA, feeling well.
Medications on Admission:
Acetaminophen
Amitryptiline 10mg PO qHS
Cozaar 100 mg q daily
glipizide 10mg PO bid
metformin 500 mg [**Hospital1 **]
pravastatin 40mg qHS
Colace
Discharge Medications:
1. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] ().
7. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
[**Hospital1 **] (2 times a day).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
# NSTEMI
# Hypoglycemia
.
Secondary diagnoses:
Type II Diabetes
Hypertension
Discharge Condition:
stable
Discharge Instructions:
Take all of your medications as prescribed. Keep your follow up
appointments as scheduled.
Please return to the Emergency Department if you develop new
chest pain, shortness of breath; otherwise contact your primary
care provider with concerns.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2106-9-7**] 8:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12898**], DPM Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2106-9-14**]
12:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2983**] Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2106-11-11**] 9:00
ICD9 Codes: 2930, 4019, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1563
} | Medical Text: Admission Date: [**2150-10-29**] Discharge Date: [**2150-11-6**]
Date of Birth: [**2114-1-27**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 36-year-old female
with a past medical history of alcohol abuse, cocaine use,
with hepatitis C cirrhosis who presented to .......... for
detox. She was transferred to [**Hospital1 18**] on [**2150-10-29**] for mental
status changes, hallucinations, auditory and visual.
She was admitted to the Medical Intensive Care Unit for
further evaluation. In her MICU course she had a lumbar
puncture which was negative, right upper quadrant ultrasound
which was negative. She had a temperature spike to 103. She
was found to have pyelonephritis.
During her hospital course she had a questionable history of
coffee ground emesis and nasogastric lavage cleared after 100
cc. The patient was transferred to the Medicine floor after
her mental status improved. She had been started on
Levofloxacin, Ampicillin and Flagyl.
PAST MEDICAL HISTORY:
1. Alcohol abuse.
2. Cocaine abuse.
3. Heroin abuse.
4. History of hepatitis C.
5. Anemia.
MEDICATIONS:
1. Trazodone.
2. Celexa.
3. Serax.
It is unclear if she is actually taking them or not.
ALLERGIES: Percocet; do not know what reaction is causes.
SOCIAL HISTORY: Abuses alcohol, cocaine, and tobacco.
PHYSICAL EXAMINATION ON ADMISSION TO THE MEDICAL INTENSIVE
CARE UNIT: Her temperature is 101.3, blood pressure is
108/54, heart rate is 96, satting 99% on room air. In
general, she is somnolent but speaking nonsensibly. She can
follow commands. Her pupils are 2 mm, minimally reactive.
Sclerae are anicteric. Oral mucosa is dry. Neck is supple;
there is no jugular venous distention. Cardiovascular:
Regular rate and rhythm; normal S1, S2; no murmurs. Lungs
are clear. Abdomen is soft. Extremities: There is no
edema. Neuro: Unable to assess because of her inability to
cooperate.
LABORATORY DATA ON ADMISSION: Her hematocrit was 29.3, white
blood cell count was 6.3, platelets were -2, Chem-7 was
significant for creatinine of 2.0. Her ABG was 7.45, 29, 67
on room air. Liver function tests: Her ALT was 57, AST was
85, alkaline phosphatase was 89, total bilirubin was 1.8,
albumin was 3.2, amylase was 66, lipase was 58.
Her urine toxicity screen was positive for benzodiazepines.
Her urinalysis had positive leukocyte esterase, positive
blood, 30 protein, 20 to 50 white blood cells, moderate
bacteria.
CT of the abdomen showed some perinephric stranding, no
stones. CT of the head was negative.
Micro: Blood culture, urine culture, and cerebrospinal fluid
cultures were pending.
EKG: Sinus tachycardia; normal axis; 1 to [**Street Address(2) 1766**] depression
in V4 through V6.
The patient was admitted to the Medical Intensive Care Unit.
REVIEW OF HOSPITAL COURSE BY SYSTEMS:
1. Mental status changes: Likely secondary to withdrawal
versus from the pyelonephritis. She was continued on
intravenous antibiotics. CIWA Scores were followed. Four to
five days into her hospital course her mental status
improved. Feel like it was secondary to her infection.
2. Pyelonephritis: She was continued on intravenous
antibiotics in the Intensive Care Unit, Levaquin and Flagyl.
When she was transferred to the floor she was continued only
on the Levaquin if it was apparent that they were only
treating pyelonephritis.
3. Acute renal failure and hypernatremia: The acute renal
failure was likely secondary to hypovolemia. The patient was
fluid resuscitated and her creatinine improved to 0.8 on the
day of discharge.
4. Hypernatremia: The patient's free water deficit was
corrected daily. The patient's sodium was 145 on the day of
discharge.
5. Gastrointestinal: Pancreatitis. The patient was kept
NPO and was given intravenous fluids until her abdominal pain
improved. Her diet was advanced as tolerated.
6. Anemia: Likely secondary to chronic disease and her
alcohol use. The patient did not receive any blood
transfusions. Her hematocrit was 24.6 on discharge. She was
asymptomatic.
7. Hepatitis C cirrhosis: She will follow up with
Gastroenterology.
8. Diarrhea: The patient developed diarrhea during her
hospital course. Clostridium difficile was sent; it was
negative for Clostridium difficile. The patient was not
interested in taking Imodium for symptomatic relief.
9. Psych: The patient was followed on CIWA Scale for
alcohol withdrawal throughout her hospital course, getting
p.r.n. Valium as needed and had a one-to-one sitter. On
discharge, it was recommended to the patient that she return
to ........... for further outpatient treatment, but the
patient refused to go to ........... and went home with her
mother instead and promised to go to A.A. for further
support.
DISCHARGE CONDITION: Stable.
DISPOSITION: Home.
DISCHARGE INSTRUCTIONS:
1. You should not drink any alcohol or use drugs once you
are discharged from the hospital. That was emphasized.
2. Take all medications as prescribed. Take all of the
remaining antibiotic pills.
3. Return to ............ for detox or another outpatient
detoxification facility of your choice.
4. Follow up with Dr. [**First Name4 (NamePattern1) 12589**] [**Last Name (NamePattern1) 12590**], Gastroenterology, within
three weeks.
5. Follow up with your primary care physician within the
next week.
FINAL DIAGNOSES:
1. Alcoholic hepatitis.
2. Alcohol withdrawal.
3. Acute pyelonephritis.
4. Metabolic-respiratory disorder, acid-based acidosis.
5. Toxic metabolic encephalopathy.
DISCHARGE MEDICATIONS:
1. Levaquin 500 mg p.o. q.d. times seven more days.
2. Protonix 40 mg p.o. q.d.
3. Trazodone 25 mg p.o. q. h.s. p.r.n. insomnia.
4. Folic acid 1 mg p.o. q.d.
5. Multivitamins 1 mg p.o. q.d.
6. Thiamine 1 mg p.o. q.d.
7. Loperamide 2 mg p.o. q.i.d. p.r.n. diarrhea.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2151-3-1**] 15:32
T: [**2151-3-3**] 21:21
JOB#: [**Job Number 12591**]
ICD9 Codes: 5849, 2761, 2765, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1564
} | Medical Text: [** **] Date: [**2171-2-16**] Discharge Date: [**2171-2-21**]
Date of Birth: [**2093-5-31**] Sex: F
Service: MEDICINE
Allergies:
Oxycodone / Codeine / morphine / OxyContin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypotensive, concern for cholangitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
77F history of CAD, hypertension, atrial fibrillation on
coumadin, IBS, epilepsy, diabetes, and dementia presents with ?
cholangitis.
She is being transferred from [**Location (un) 620**] with fever, elevated
LFTs/bili.
Her nursing home was concerned about increased abdominal pain,
increased LFTs, and hypoxemia. There was also a concern about ?
CHF. Labs signifcant for AST 195, ALP 293, ALT 223, Tbili 3.1
(mostly direct - 2.5). She was sent to the ER at [**Location (un) 620**]. VS on
transfer were BP 180/80, HR 81, RR 20, T 97.2. At [**Location (un) 620**],
initial VS in ER were 100.8 HR: 89 BP: 133/67 Resp: 22 Sat: 98
Normal. Her chief compliant was chest pain intermittent for
weeks. She was noted to be lethargic appearing and unable to
given an adequate history. Patient also would desat to 85 %
depending on position. Exam was significant for skin mottling of
lower extremity, cyanotic finger tips, and significant swelling
of left leg.
Labs performed showed WBC 8.2, Hgb 11.2 (unknown baseline), Hct
34.9, Plt 125 with Diff N 93.6. Lactate was 2.2. Coags
significant for INR was 7.6. Chemistry panel showed Na 138 K 4.1
Cl 101 Glu 319 BUN 39 Cr 1.6 (unknown baseline, last Cr 1.1 in
[**2167**] and 1.3 in [**2168**]), Ca [**69**].2 (H). LFTs were albumin 3.4, Tbili
3.79, ALP 369, ALT 236, ALT 177. Lipase was wnl. Initial
troponin T was < 0.01. ECG showing atrial fibrillation at rate
of 96, NA, NI (except QTc 463 ms). No ST/T changes. Compared to
prior dated [**2164-1-10**], atrial fibrillation is new. UA showed
many bacteria, 0 epi, negative LE/nitrate.
Blood cultures were drawn and per prelim report are [**4-24**] for GNR.
CXR, Abdominal US, CT Abd and pelvis without contrast were
performed. CXR showed minimal opacity in left lung base likely
representing atelectasis/scar as there is no obscuration of the
hemidiaphgragm. There are low lung volumes, which may represent
COPD. Cardiomegaly persists. RUQ US was "negative" per reports.
CT abdomen/pelvis showed "no acute abnormality."
Patient appeared ill with fever. Impression was sepsis. She was
covered with flagyl/levaquin/vancomycin for ? cholangitis. She
had gradual worsening of hemodynamics with BP trending down from
130s to 90s for which she received 4 L NS. She was transferred
to [**Hospital1 18**] for ICU [**Hospital1 **] and ERCP.
In the main [**Hospital1 18**] ED inital vitals were, 0 99.0 80 110/58 22 94%
2L
Upon arrival to [**Hospital1 18**] ER, she was complaining of lower abdominal
pain and nausea. She was alert and oriented x 2.
ERCP was consulted and recommended [**Hospital1 **] to [**Hospital Unit Name 153**] with ?
ERCP. She had no further episodes of hypotension in the [**Hospital1 18**]
ER.
Labs in [**Hospital1 18**] ER were performed. Chemistry panel was within
normal limits except BUN 33, Cr 1.4, glucose 227 with no anion
gap. LFTs were abnormal with ALT 167, AST 86, AP 257, Tbili 3.2.
CBC showed WBC 5.9, Hgb 10, plt 118 with neutrophilia. Coags
were significant for INR 8.7, PTT 55.5.
She was given zofran and morphine for the aforementioned
symptoms. She was also given flagyl 500 mg IV x 1.
VS on transfer: HR 83 BP 127/58 RR 22 pOx 100 on 2L
.
On arrival to the ICU, patient was AAOx3 (unable to name year
exactly). She was able to say the days of the weeks backwards.
She complained primarily of RUQ abdominal pain. She denied any
history of chest pain.
Past Medical History:
- DM2 (last A1c 7.2 on [**2170-3-2**])
- CAD
- atrial fibrillation on coumadin
- IBS
- epilepsy
- meningioma
- urinary retention with prior history of UTI
- gait abnormality
- osteoarthritis
- GERD
- hypertension
- hyperlipidemia
- hypercalcemia
- bronchitis
- Hyperparathyroidism
- History of stroke
- glaucoma
- Depression/personality disorder
- Cerebral aneurysm
- Pancreatitis mass (?cyst)
- ? Recent left lower extremity DVT
SURGICAL HISTORY:
1. Total abdominal hysterectomy, [**2119**].
2. Colectomy for colon cancer, [**2148**].
3. Meningioma of the right frontal lobe, [**2152**]
Social History:
Patient denies current alcohol, tobacco, or illicit drug usage
Family History:
Patient denies family history of hepatic disease
Physical Exam:
[**Year (4 digits) **] Exam:
General Appearance: No acute distress, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, Right EJ
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , Diminished: bases)
Abdominal: Soft, Bowel sounds present, Tender: RUQ, - [**Doctor Last Name **]
sign
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: 3+, ? lymphedema with some patches of erythema
with ? cellulitis vs. stasis changes
Skin: Warm
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Tone: Not assessed, right sided UE and LE weakness,
[**4-25**]
Pertinent Results:
[**Month/Day (1) **] Labs:
[**2171-2-16**] 05:46AM BLOOD WBC-5.9 RBC-3.33* Hgb-10.0* Hct-30.2*
MCV-91 MCH-29.9 MCHC-33.0 RDW-13.2 Plt Ct-118*#
[**2171-2-16**] 05:46AM BLOOD Neuts-89.3* Lymphs-6.0* Monos-3.9 Eos-0.5
Baso-0.3
[**2171-2-16**] 05:46AM BLOOD PT-85.1* PTT-55.5* INR(PT)-8.7*
[**2171-2-16**] 05:46AM BLOOD Fibrino-742*
[**2171-2-16**] 05:46AM BLOOD Glucose-227* UreaN-33* Creat-1.4* Na-138
K-3.7 Cl-108 HCO3-23 AnGap-11
[**2171-2-16**] 05:46AM BLOOD ALT-167* AST-86* CK(CPK)-23* AlkPhos-257*
TotBili-3.2* DirBili-2.7* IndBili-0.5
[**2171-2-16**] 05:46AM BLOOD Lipase-12
[**2171-2-16**] 05:46AM BLOOD CK-MB-1 cTropnT-<0.01
[**2171-2-16**] 05:46AM BLOOD Albumin-3.5
[**2171-2-16**] 09:59AM BLOOD Lactate-1.4
Brief Hospital Course:
77F history of CAD, hypertension, atrial fibrillation on
coumadin, prior stroke, epilepsy, diabetes mellitus type II,
and dementia presents with cholangitis, sepsis, GNR bacteremia.
# Sepsis/cholangitis: Patient meets sepsis criteria on
presentation with fever, tachpynea with blood cultures
suggestive of high grade bacteremia from GNR (in OSH cultures).
Patient was placed on vancomycin and zosyn initially. UA with
bacteria, but negative nitrate/LE. CXR not suggestive of
pulmonic process initially. Her sacral decubitus ulcer, present
on [**Month/Day/Year **], does not appear infected. Hypotension responded to
4 L fluid resuscitation. Intra-abdominal imaging and US at OSH
not suggestive of gallstone or other acute intraabdominal
process however given RUQ pain, elevated LFTs/Tbili, and fever,
ERCP was performed with sphincterotomy, decompression with
extraction of pus and stone. Patient remained hemodynamically
stable with LFTs improving, on broad spectrum antibiotics,
ultimately tailored to ceftriaxone for bacteremia and with
flagyl given ? of aspiration pneumonia (see below).
# Hypoxemia: Per nursing home notes, there was some concern
about a heart failure exacerbation (although do not have formal
documentation of such history) with home medications including
lasix and spironolactone. She was given lasix for ? tachypnea at
nursing home. CXR was without pulmonary edema or other pulmonic
process but did have cardiomegaly. Per nursing home notes,
concern about CHF given weight increased 9 lbs from [**2170-12-5**].
She has been on lasix 80 mg PO qD since [**Month (only) 359**] in addition to
spironolactone. Patient has also been on systemic
anticoagulation making PE less likely. Respiratory thought to be
secondary to sepsis. Patient given several doses of lasix IV
(80mg) after FFP administration, with moderate UOP and stable
oxygenation saturation in the mid90s. Trop neg x1. Echo showed
preserved function. Patient is at aspiration risk, and though
she's been given nectar thick liquids, she may have aspirated
contributing to her oxygen sats in the low 90s at times, and
repeat chest xray suggested possible aspiration pneumonia in the
mid left and lower lung zones. Treated with ceftriaxone and
with flagyl (latter for 8 day course total).
# Supratherapeutic INR: Reversed for ERCP. Heparin bridge to
therapeutic warfarin initiated. Heparin d/c'd once INR over
two. At time of discharge INR was 2.8.
# ARF: Patient appears to have CKD III-IV at baseline. Baseline
Cr around 1.3, but was up to 1.5 during [**Month (only) **]. Likely
pre-renal etiology on [**Month (only) **] given insensible losses with
fevers with Cr trending down with fluid resuscitation.
# Left leg swelling: Patient has reported history of both LLE
DVT and ? lymphedema. Per nursing home staff, her leg has been
swollen for some time - but unclear history overall. No evidence
of DVT on LENI U/S performed at [**Hospital1 18**] this [**Hospital1 **].
# Skin impairments: Stage 3 decubitus ulcer and multiple skin
breakdowns on left lower extremities was managed by wound care,
and with frequent turnings.
# Atrial fibrillation: Patient with atrial fibrillation on
[**Hospital1 **], high CHADS2 score given ?CHF, HTN, age, diabetes
mellitus type II, prior stroke. High risk for cardioembolic
issues. INR was temporarily reversed for ERCP and warfarin was
restarted within 36hrs of procedure. Beta blocker was held in
the setting of sepsis, but restarted soon after.
# Hypertension: Held atenolol given sepsis, discharged on
metoprolol given eGFR.
# Epilepsy: continued keppra.
# Diabetes mellitus type II: Managed on HISS and lantus.
# Dementia: Patient appeared to be AAOx3 on [**Hospital1 **]. Per
nursing home documents, she cannot make medical decisions due to
underlying dementia
# Aspiration risk: Patient with known aspiration risk per
nursing home records. Patient was given thickened nectar
liquids.
# QTc prolongation: QTc was 463 ms [**First Name (Titles) **] [**Last Name (Titles) **]. Qtc prolonging
drugs were avoided. Repeat EKG showed QTc of 422.
# Mood disorder: continued home psychiatric medications.
Medications on [**Last Name (Titles) **]:
- acetaminophen 650 mg PO q 4 hr prn pain, fever
- hydrocodone/APAP 5-500 mg PO q 4 hr prn pain
- nitrostat 0.4 mg SL prn
- coumadin 4.5 mg PO every Tues, Thurs, Sat
- coumadin 5 mg PO every Monday, Wed, [**Last Name (LF) 2974**], [**First Name3 (LF) **]
- SSI
- lantus 17 units qhS
- abilify 5 mg PO qD
- atenolol 50 mg PO qD
- cranberry 425 mg PO BID
- vitamin B12 1000 mcg INH qmonth
- docusate/senna
- furosemide 80 mg PO qD
- [**First Name9 (NamePattern2) 32469**] [**Male First Name (un) **] 0.005 % 1 drop each eye qHS
- levetiracetam 1000 mg PO qAM
- levetiracetam 500 mg PO qHS
- melatonin 6 mg PO qHS
- omeprazole 20 mg PO qD
- spironolactone 25 mg PO qD
- vitamin C tab 500 mg PO qD
- vitamin D 1000 units PO qD
- sertraline 200 mg PO qD
- tylenol 650 mg PO qD
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever > 100.5.
2. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
6. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. petrolatum Ointment Sig: One (1) Appl Topical DAILY
(Daily).
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: inr goal is 2.5-3.5.
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 10 days.
16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 7 days. Tablet(s)
17. insulin glargine 100 unit/mL Solution Sig: Twenty (20)
units, insulin Subcutaneous at bedtime.
18. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units, insulin Subcutaneous QIDACHS: see attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
1. choledocholithiasis s/p ercp and sphincterotomy with stone
extraction
2. probable aspiration pneumonia
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:
see below
Followup Instructions:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2171-2-21**]
ICD9 Codes: 0389, 5070, 5849, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1565
} | Medical Text: Admission Date: [**2195-5-13**] Discharge Date: [**2195-5-22**]
Date of Birth: [**2173-5-29**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
? GBS/[**Doctor First Name 1557**] [**Doctor Last Name 957**] syndrome
Major Surgical or Invasive Procedure:
intubation and extubation
History of Present Illness:
21 year-old right-handed M who presents with numbness of
hands and feet, progressive weakness, and diplopia.
The patient has had URI symptoms for 2 weeks, including sore
throat, cough and congestion. He received Z-pack on [**5-8**] for
possible sinus infection. On [**5-10**], his R hand felt numb and
tingling (whole hand, all digits, to wrist), which he thought
might be a side effect of antibiotic. That day, he also felt
subjective R thigh/quad weakness, though he could still walk
normally and do stairs. On [**5-11**], his L hand also became numb and
tingly. He developed a strange numb feeling on his anterior
abdomen, it was not around his entire torso, not like a band or
constriction, and it did not affect his respirations. Both legs
felt weaker as well, and he went to [**Hospital1 2436**] ED, sent home.
On [**5-12**] (yesterday), patient was weaker in his legs, and his
walking was "wobbly." He was not dragging one leg or catching
his
toes. His feet were now tingling, up to the ankles bilaterally.
He also noticed that speaking and swallowing was difficult and
tiring. Per his parents, his voice is more nasal, as well as
slurred and much softer. He has not been eating or drinking much
since swallowing is tiring, he had some nasal regurgitation
once,
but no choking or frank aspiration.
Today, the patient was worse in terms of weakness and ability to
ambulate. He nearly fell walking down stairs, but parent was
there to support him and avoided fall. He has trouble sitting up
from lying position and getting out of bed.
The patient also noticed diplopia today. He noticed something
strange with his vision x 2 days, but could not define it
before.
Today, he has noticed horizontal diplopia that is constant.
He has been able to urinate and move bowels normally, but has
loss of sensation in the groin and rectal areas.
The patient had a similar presentation 6 years ago at age 15. He
was treated at CHB, and father thinks the diagnosis was [**Name (NI) 1557**]
[**Doctor Last Name 957**] syndrome. At that time, he developed weakness and loss
of
balance. His mother notes that his gait looked strange in a
similar way as it does now, and his voice sounded similar. His
mother thinks he was actually weaker then vs. now. His
respiratory status remained stable. He did not have sensory
symptoms at that time, nor diplopia. He received IVIG and
improved quickly within a few days. He was out of school for 2
weeks. After some PT to build up strength in the legs after
disuse, he was back to baseline without residual symptoms or
deficits.
Past Medical History:
none other than episode [**Doctor First Name 1557**] [**Doctor Last Name 957**] syndrome 6 yrs ago
Social History:
works in construction. No tobacco. EtOH- 4-5 drinks
most weekends. No illicits. No recent travel, sick contacts,
toxic or environmental exposures.
Family History:
negative for neurologic disease, no seizures, no MS.
Physical Exam:
At admission:
Vitals: T: 98.5 P:86 R: 16 BP:114/76 SaO2:98/RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Speech is possibly mildly dysarthric (based on
parents' assesment), becomes increasingly quiet and effortful
after a long conversation. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall [**3-28**] at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation with red
pin.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: Impaired abduction of L eye, otherwise EOMI, no
nystagmus. Smooth saccades. There is diplopia in all extremes
of
gaze, worst on far right gaze, worse far than near. Images are
horizontal side by side, farthest apart on R gaze.
Resolves with covering either eye.
V: Facial sensation intact to light touch, cold and pinprick.
VII: No facial droop, upper and lower facial musculature full
strength and symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate does not elevate well on either side, weak gag
reflex.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal strenght on lateral
movements.
-Motor: Normal bulk, tone throughout. No pronator drift but
bilateral arms titubate up and down, cannot hold them out
steadily. No pseudoathetosis.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5-* 5 5 5 5 5 5 3 5 4 5 5 5 5
R 5 5 5 5 5 5 5 3 5 4+ 5 5 5 5
* limited by L shoulder pain, giveway
L ADM 4+, finger flexors 5
hip abduction [**4-30**] bilaterally, adduction [**5-30**]
neck flexion [**4-30**], extension [**5-30**]
-Sensory: No deficits to light touch. Decreased pinprick at L
medial forearm only (80%). Decreased cold sensation L toes,
intact on foot. Decreased vibratory sense (nearly absent L great
toe and present L medial malleolus, 2-3 seconds at R great toe).
Intact proprioception at bilateral great toes. No extinction to
DSS.
-DTRs: absent throughout
Plantar response was flexor bilaterally.
-Coordination: slow and clumsy on finger to crease tapping
bilaterally. On FNF there is severe ataxia bilaterally, with no
intention tremor. All limbs movements are wobbly and unsteady.
On mirroring task there is overshoot and rebound with bilateral
upper extremities. Unable to perform HKS due to weakness.
-Gait: unable to ambulate
At transfer out of NeuroICU:
horizontal diplopia in upward extremes of gaze only, conjugate
EOMI, palate rises in midline, [**5-30**] full strength throughout,
including neck flex/ext. Dysmetric in all 4 ext (greatest in
LUE. Areflexic, toes down. Gait (with supervision) is slightly
unsteady but independent.
NIF [**5-13**]: -65 --> -50 ------> [**5-20**] -70
V cap [**5-13**]: 2.7 --> 1.9 -----> [**5-20**] 3.5-4L
PHYSICAL EXAM AT DISCHARGE:
VS - 97.8, 120/80's, 70's, 18, 99 on RA
GEN: young man lying in bed in NAD
HEENT: OP clear
CV: RRR
PULM: CTAB
ABD: soft, NT, ND
EXT: no edema
.
NEURO EXAM:
MS - AAOx3
CN - EOMI, PERRL 4-->2mm, face symmetrical, facial sensation
intact, tongue midline
MOTOR - [**5-30**] throughout
REFLEXES - absent throughout (per pt this is chronic since his
first GBS episode)
SENSORY - intact to light touch throughout
GAIT - narrow based, good arm swing, good initiation
Pertinent Results:
ADMISSION LABS:
[**2195-5-13**] 08:05PM BLOOD WBC-11.5* RBC-5.43 Hgb-16.3 Hct-47.2
MCV-87 MCH-29.9 MCHC-34.4 RDW-12.2 Plt Ct-252
[**2195-5-16**] 02:09AM BLOOD WBC-19.1* RBC-4.61 Hgb-13.7* Hct-40.4
MCV-88 MCH-29.8 MCHC-34.0 RDW-12.4 Plt Ct-214
[**2195-5-21**] 03:15AM BLOOD WBC-8.2 RBC-4.78 Hgb-14.0 Hct-42.5 MCV-89
MCH-29.2 MCHC-32.8 RDW-12.3 Plt Ct-297
[**2195-5-13**] 08:05PM BLOOD Neuts-77.9* Lymphs-17.2* Monos-4.1
Eos-0.4 Baso-0.5
[**2195-5-13**] 08:05PM BLOOD Plt Ct-252
[**2195-5-16**] 02:09AM BLOOD PT-14.2* PTT-30.6 INR(PT)-1.3*
[**2195-5-13**] 08:05PM BLOOD Glucose-87 UreaN-16 Creat-1.0 Na-139
K-3.9 Cl-103 HCO3-24 AnGap-16
[**2195-5-21**] 03:15AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-138
K-3.9 Cl-101 HCO3-26 AnGap-15
[**2195-5-15**] 02:29AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
[**2195-5-18**] 01:42AM BLOOD Triglyc-211*
[**2195-5-15**] 04:03PM BLOOD TSH-0.72
[**2195-5-13**] 08:05PM BLOOD IgA-241
[**2195-5-18**] 05:33AM BLOOD Vanco-1.9*
[**2195-5-14**] 09:43AM BLOOD Type-ART pO2-104 pCO2-43 pH-7.38
calTCO2-26 Base XS-0
[**2195-5-14**] 09:43AM BLOOD Glucose-88 Lactate-1.4
[**2195-5-15**] 04:03PM BLOOD GQ1B IGG ANTIBODIES-PND
[**2195-5-14**] 11:51PM URINE Color-YELLOW Appear-Cloudy Sp [**Last Name (un) **]-1.027
[**2195-5-14**] 11:51PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2195-5-14**] 11:51PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
DISCHARGE LABS:
[**2195-5-22**] 05:17AM BLOOD WBC-7.2 RBC-4.85 Hgb-14.6 Hct-42.4 MCV-88
MCH-30.1 MCHC-34.3 RDW-12.4 Plt Ct-303
[**2195-5-22**] 05:17AM BLOOD Glucose-90 UreaN-15 Creat-0.6 Na-135
K-4.3 Cl-101 HCO3-25 AnGap-13
[**2195-5-22**] 05:17AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
MICROBIOLOGY:
[**2195-5-13**] 09:55PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0
Lymphs-82 Monos-18
[**2195-5-13**] 09:55PM CEREBROSPINAL FLUID (CSF) TotProt-64*
Glucose-54
[**2195-5-13**] 9:55 pm CSF;SPINAL FLUID #3.
**FINAL REPORT [**2195-5-17**]**
GRAM STAIN (Final [**2195-5-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2195-5-17**]): NO GROWTH.
[**2195-5-16**] 1:03 am SPUTUM
**FINAL REPORT [**2195-5-18**]**
GRAM STAIN (Final [**2195-5-16**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2195-5-18**]):
SPARSE GROWTH Commensal Respiratory Flora.
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..
[**2195-5-16**] 6:19 am URINE Source: Catheter.
**FINAL REPORT [**2195-5-17**]**
Legionella Urinary Antigen (Final [**2195-5-17**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2195-5-16**] 10:00 pm BRONCHOALVEOLAR LAVAGE Site: LUNG
LEFT LUNG.
**FINAL REPORT [**2195-5-18**]**
GRAM STAIN (Final [**2195-5-17**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2195-5-18**]): NO GROWTH, <1000
CFU/ml.
[**2195-5-14**] CXR:
FINDINGS: A single portable view of the chest is provided. The
lungs are
essentially clear. The cardiomediastinal silhouette and hilar
contours are
unremarkable. There are no pneumothoraces or pleural effusions.
The bones
are intact.
IMPRESSION: No evidence of acute intrathoracic process.
[**2195-5-16**] CXR: CHEST, SINGLE AP PORTABLE VIEW.
An ET tube is present, tip approximately 7.3 cm above the
carina. The tip
lies relatively high, approximately 14 mm above the upper edge
of the medial clavicle. Slight asymmetry of the clavicles is
present, unchanged, with the right medial clavicular head more
angulated and inferior compared to the left. An NG-type tube is
present -- the tip is not well delineated and cannot be traced
beyond the lower mediastinum.
There is increased retrocardiac density, worse compared with
[**2195-5-14**], and
bibasilar atelectasis. Possible slight clearing at the right
base. Doubt
gross effusion. No CHF.
IMPRESSION:
1. ET tube as described, relatively high. Clinical correlation
requested.
2. Left lower lobe collapse and/or consolidation, slightly
worse.
Atelectasis at right base, slightly better.
3. Asymmetric positioning of the right and left clavicular
heads. Is there a history of trauma to account for this?
[**2195-5-17**] Abd XR:
ABDOMEN, TWO VIEWS.
Gas and stool are seen throughout the colon down to level of the
rectum. No air-filled dilated loops of large or small bowel to
suggest ileus are
identified. No free air is seen beneath the diaphragm. An NG
tube is
present, tip overlying stomach.
[**5-18**] ECG:
Baseline artifact. Probable sinus rhythm with right axis
deviation and
early precordial R wave progression. No previous tracing
available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
100 146 94 [**Telephone/Fax (3) 110477**] 106 179
[**5-20**] CXR:
FINDINGS: In comparison with the study of [**5-19**], the endotracheal
tube and
nasogastric tubes have been removed. Right subclavian catheter
remains in
satisfactory position. There is persistent opacification in the
region of the costophrenic angle on the left. However, the more
medial portion of the right hemidiaphragm is quite well seen,
suggesting some decrease in the left lower lobe volume loss,
possibly related to clearing of a mucus plug. Asymmetry is again
seen in the left infrahilar region, consistent with the previous
suggestion of consolidation. The right lung is clear with the
heart border and hemidiaphragm sharply seen.
[**5-21**] CXR: IMPRESSION: AP chest compared to [**5-17**] through 23:
Left lower lobe collapse developed over preceding 24 hours.
Aeration in the
left lower lobe has improved but there is still a large
infrahilar region of what could be pneumonia, and now there is
new consolidation at the right lung base, also suspicious for
infection due to aspiration.
Endotracheal tube ends above the thoracic inlet, no less than
6.5 cm from the carina and should be advanced 3 cm for more
secured seating. Enteric tube passes as far as the upper stomach
and out of view. Heart size is normal. There is no appreciable
pleural effusion. Right PIC line ends in the low SVC. No
pneumothorax.
Brief Hospital Course:
21 year-old right-handed M with history of [**Doctor First Name 1557**] [**Doctor Last Name 957**]
syndrome s/p IVIG 6 years ago who presented with numbness of
hands and feet, progressive weakness, dysphagia, saddle
anesthesia with bowel/bladder changes, and diplopia. Neuro exam
at admission was remarkable for binocular horizontal diplopia on
extremes of gaze, with impaired L eye abduction c/w CNVI palsy,
weak gag/palate elevation. Motor exam revealed weak neck flexion
and proximal LE weakness (IP, hip abductors, hamstring). Sensory
deficits were minimal except for decreased vibratory sensation
at great toes. There was limb ataxia, rebound and overshoot with
bilateral UEs. He is areflexic, although this is his baseline
since his prior episode of GBS. His presentation on this
admission was consistent with [**Doctor First Name 1557**] [**Doctor Last Name 957**] variant of GBS. CSF
protein was mildly elevated, with normal cell count and diff,
which was consistent as well. Similarly to his past
presentation, there was a preceeding viral URI. He was initially
admitted the the general neurology step down unit on [**2195-5-13**],
however, due to increased difficulties with swallowing oral
secertions and worsening respiratory status, he was transferred
the to NeuroICU early [**5-14**]. He was electively intubated a few
hours later for airway protection and started on IVIG. Of note,
his hospital course was complicated by pneumonia, for which he
was started on empiric abx on [**2195-5-16**] to cover VAP, which were
later narrowed when Haemo influenza was identified. He was
extubated [**5-19**] without complication.
NEURO: s/p intubation [**5-14**] for inability to swallow secretions
and increasing resp distress. Completed 5 days IVIG [**2106-5-13**].
Neurological exam was then significant for dysmetria in all
extremities, LUE greatest, as well as mild diplopia on upward
gaze. Prior to intubation he had NIFs that were -65 --> -50 -->
-48; VC 2.7--> 1.9 --> 1.58; [**5-18**] NIF -35. [**5-20**] NIF -70 and VC
4L. While at admission the patient was having bladder/bowel
retention and saddle anesthesia these symptoms subsequently
improved and he was no longer having bowel/bladder retention.
At discharge he had an essentially normal neurological exam.
CARDS: patient was temporarily on metoprolol for tachycardia,
which was weaned prior to discharge.
GI: patient was NPO with TF's while intubated in the ICU.
Afterwards, his diet was advanced until he was tolerated regular
foods. When he initially began taking solid foods he had lots
of nausea and vomiting, which require reglan for improvement.
He was subsequently able to be weaned off of reglan and eat
solid foods with no nause or other ill effects.
ID: Pt diagnosied here with Haemo influenza pneumonia, likely
acquired in the ICU during intubation. Patient had copious
secretions, with CXR [**5-16**] showing RLL infiltrate. He was tarted
on vanc/cefepime d1= [**5-16**] for VAP. Narrowed to CTX [**5-20**]. He
completed 7 days total treatment (end date [**5-22**])
PENDING RESULTS:
G1QB Antibody
TRANSITIONAL CARE RESULTS:
Patient told to return to the hospital if he develops any
further similar sx. He understands that if his sx recur again
he may need to be on prophylactic immunosuppressant medication
as he more likely would have CIDP. He agreed to be vigilant if
he had any further sx and always seek out medical care.
Medications on Admission:
Recently finished azithromycin course for URI. Otherwise no
daily meds
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
[**Last Name (un) 4584**] [**Location (un) **] Syndrome
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were seen in the hospital for weakness and were diagnosed
with [**Last Name (un) **] [**Location (un) **] syndrome.
We made no changes to your medications.
If you experience 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:
Department: NEUROLOGY
When: MONDAY [**2195-9-7**] at 4:00 PM
With: DRS. [**Name5 (PTitle) 43**] & [**Doctor Last Name 2336**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1566
} | Medical Text: Admission Date: [**2135-7-14**] Discharge Date: [**2135-7-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
intubation (electively for EGD only; otherwise DNR/DNI)
colonoscopy
EGD
History of Present Illness:
86M with h/o recent NSTEMI [**1-17**], and recent admission to OSH
for GIB of unclear source (plavix stopped x5d, then restarted),
presenting to [**Hospital1 18**]-N this morning for altered mental status,
lethargy, and black stools. VS there 97.7 118 16 78/48
90%RA. Exam notable for guaic positive stool and lethargy. Labs
revealed HCT 22, K 6.0 (hemolyzed), CRE 2.9. NG lavage revealed
green gastric contents, no blood, no coffee grounds.
He received 2 PIVs, nexium gtt, CTX 1 gm, azithromycin, and 2U
PRBC, with BP improvement to 101/42 HR 89 at time of transfer to
[**Hospital1 18**].
Of note, he was admitted to [**Hospital **] Hospital [**Date range (1) 30614**] in the
setting of weakenss and [**Doctor Last Name **] large dark bowel movement, found to
be anemic (HCT 21.3 on admission, up to 34.1 at discharge after
total 5U PRBCs), and was admitted for evaluation of GIB with
EGD, with course c/b respiratory failure requiring intubation
(per family x3d) felt [**3-14**] CHF vs PNA. EGD at that time revealed
esophagitis and duodenitis per discharge summary.
In ED VS = 97.8 93 128/58 20 100%. Labs upon arrival notable
for K 5.8, CRE 2.4 (baseline 1.3 at time of discharge [**6-30**]), HCT
25.6 (after 2U PRBC from OSH), WBC 20.1, INR 1.2. SBP dropped
to 77/42 with HR 103, so CVL was placed and he was started on
levophed, and received an additional . SBP improved to 120s
after 1L NS and an additional 1U PRBC, which is still hanging.
GI consult obtained, cardiology made aware.
Past Medical History:
- CAD s/p 2 vessel CABG in [**2126**], bioprosthetic AVR, NSTEMI [**1-17**]
with DES to RCA (>90% stenosis), and PL, otherwise open SV
grafts x 2 (LAD, DIAG), native 90% LCx dx.
- CHF (EF= 30-44%), mod TR, LAE on TTE [**6-18**] at OSH.
- PVD - known R SFA occlusion @ cath [**1-17**].
- HTN
- DM2 - on oral meds.
- Hyperlipidemia
- h/o CVA in [**5-19**] with slurred speech, found to have (atrophy,
small vessel ischemic changes, subtle chronic left pontine
infarct) on CT HEAD at OSH [**6-18**].
Social History:
Lives alone, 7 children. No tobacco, drinks [**2-11**] glasses of wine
a week, denies IVDU.
Family History:
HTN, CAD, DM.
Physical Exam:
Vitals: 97.4 95 150/55 27 99%2L
General: lethargic, oriented x1, no acute distress
HEENT: MM dry, oropharynx clear, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
ronchi
CV: Regular rate, normal S1 + S2, 2/6 SEM @ RSB, no rubs,
gallops
Abdomen: soft, non-tender, non-distended, hypoactive bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2135-7-14**] 08:35PM WBC-18.7* RBC-2.82* HGB-8.5* HCT-25.0* MCV-89
MCH-30.2 MCHC-34.1 RDW-18.7*
[**2135-7-14**] 08:35PM PLT COUNT-214
[**2135-7-14**] 08:28PM GLUCOSE-232* UREA N-111* CREAT-2.0*
SODIUM-142 POTASSIUM-5.5* CHLORIDE-112* TOTAL CO2-20* ANION
GAP-16
[**2135-7-14**] 08:28PM CK(CPK)-152
[**2135-7-14**] 08:28PM CK-MB-23* MB INDX-15.1* cTropnT-0.63*
[**2135-7-14**] 04:51PM TYPE-ART PO2-475* PCO2-40 PH-7.32* TOTAL
CO2-22 BASE XS--5
[**2135-7-14**] 04:51PM LACTATE-0.8
[**2135-7-14**] 03:37PM WBC-17.6* RBC-2.66* HGB-8.3* HCT-23.5* MCV-88
MCH-31.1 MCHC-35.2* RDW-18.7*
[**2135-7-14**] 03:37PM PLT COUNT-215
[**2135-7-14**] 01:03PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2135-7-14**] 10:36AM LACTATE-1.4
[**2135-7-14**] 09:47AM HGB-9.0* calcHCT-27
[**2135-7-14**] 09:45AM GLUCOSE-231* UREA N-123* CREAT-2.4*#
SODIUM-136 POTASSIUM-5.8* CHLORIDE-104 TOTAL CO2-19* ANION
GAP-19
[**2135-7-14**] 09:45AM ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-43 TOT
BILI-1.0
[**2135-7-14**] 09:45AM LD(LDH)-163 CK(CPK)-95
[**2135-7-14**] 09:45AM LIPASE-85*
[**2135-7-14**] 09:45AM cTropnT-0.42*
[**2135-7-14**] 09:45AM calTIBC-291 HAPTOGLOB-163 FERRITIN-94 TRF-224
[**2135-7-14**] 09:45AM WBC-20.1* RBC-2.83* HGB-8.6* HCT-25.6*
MCV-90# MCH-30.4# MCHC-33.7 RDW-17.9*
[**2135-7-14**] 09:45AM NEUTS-92.3* LYMPHS-5.7* MONOS-1.9* EOS-0.1
BASOS-0.1
[**2135-7-14**] 09:45AM PLT COUNT-245
[**2135-7-14**] 09:45AM PT-14.1* PTT-24.6 INR(PT)-1.2*
STUDIES:
[**2135-7-14**] ECG: LBBB (old), nl axis, no STE per sgarbossa criteria,
STD and TWI in 1, avl, V4-6 c/w LVH.
[**2135-7-14**] CXR: no obvious infiltrate, pulmonary edema. ?free air
under right diaphragm. prior cabg and avr seen.
[**2135-7-15**]: Colonoscopy:
There was a very tight bend at the sigmoid colon which could
represent previous anastomosis if patient has had prior surgery.
There were a few areas of a few red drops of blood seen in the
ascending colon which were washed without underlying lesion
seen. Mucosa appeared very friable and occasional contact
bleeding was seen. However, this was minimal and does not
account for transfusion requirement. Polyp in the sigmoid colon
Bile was seen in the terminal ileum and cecum without evidence
of blood. Ileum was normal up to 25 cm. Otherwise normal
colonoscopy to terminal ileum to 20 cm.
[**2135-7-15**]: EGD:
Impression: Mild gastritis.
Otherwise normal EGD to second part of the duodenum
[**2135-7-15**]: CT ABD/PELVIS
1. No retroperitoneal bleed. Right femoral venous catheter in
expected position.
2. Two rim calcified infrarenal abdominal aortic aneurysms
measuring up to 3 cm in diameter are chronic, without adjacent
paraaortic abnormality. These may be the sequelae of prior
penetrating ulcer or focal dissection. Dense calcification at
the origin of the renal arteries and SMA; significant stenosis
cannot be excluded.
3. Cholelithiasis without evidence for cholecystitis on this
limited non-contrast exam.
[**2135-7-16**] Echo
The left atrium is elongated. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
moderate regional left ventricular systolic dysfunction with
inferior and infero-lateral akinesis with septal hypokinesis. No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is mild functional mitral
stenosis (mean gradient 5 mmHg) due to mitral annular
calcification. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
# GIB - Patient having melanotic stools with hemodynamic
instability requiring total of (6units, last transfusion on
[**2135-7-15**]) of pRBCs at [**Hospital1 18**]. GI was consulted. EGD was negative
for acute bleed. Colonoscopy was negative for acute bleed. CT
scan was negative for RP bleed. Hemolysis labs were negative.
Hct remained stable since last transfusion on [**2135-7-15**]
# hypotension - Initially concerning for GIB given guaic
positive stool, decreased HCT, and recent similar admission.
ddx also included sepsis, so evaluated for possible sources with
CXR, Bcx, and UCx. CXR was negative. Bcx and Ucx were negative
Patient was given aggressive IVF and blood as above. After the
colonoscopy he did require levophed briefly, but then was able
to maintain BPs without pressor-support.
# confusion - per family, confusion was typical of pt's
hospitalizations, and likely multifactorial with contribution
from poor neurologic reserve (h/o CVA, chronic vascular
changes), hypotension, and possible septic picture. No evidence
to suggest primary CNS infection (no meningismus, headache,
kernig, brudzinki negative), no focal neurologic deficits on
exam. Seroquel was held, then restarted at home dose. Pt
returned alert and oriented x 3 once transferred out of ICU.
# hyperkalemia - likely [**3-14**] ARF. no ECG changes c/w
hyperkalemia. Resolved.
.
# ARF - likely [**3-14**] volume depletion. lactate negative. Resolved
with IVF.
.
# CAD - s/p NSTEMI. denies chest pain or dyspnea, and EKG
without frank evidence of ischemia though has old LBBB, and
worsening TWI and STD in V4-6 in setting of sinus tach and
anemia (likely reflects both LVH and some demand ischemia).
feels ACS is unlikely, but given +troponin and recent NSTEMI,
will proceed as follows:
- held ASA and plaivx initially, then restarted when EGD
revealed no active bleeding.
- held metoprolol, lisinopril given initial hypotension, then
restarted when pt actually became hypertensive on the floor
- transfuse to maintain HCT > 27.
- Echo done, result as above
.
# CHF - EF 40% at OSH in [**6-18**], on lasix at home. Held lisinopril
and lasix initially, then restarted prior to discharge.
# DM2 - on orals at home; covered with ISS during hospital stay.
.
# hyperlipidemia - held statin initially, then restarted prior
to discharge.
.
# Code: DNR/DNI
Medications on Admission:
- metformin 500mg po bid
- plavix 75mg po qdaily (stopped x5d during [**6-18**] admission)
- glipizide 10mg po bid
- metorolol 50mg po bid
- isosorbide mononitrate 30mg po qdaily
- lisinopril 20mg po qdaily
- digoxin 125mg po qdaily
- hydralazine 25 mg po tid
- lipitor 20mg po qdaily
- senna
- colace
- aspirin 81mg po qdaily
- mvi
- seroquel 25mg po bid (started [**6-18**])
- lasix 40mg po qdaily
- prilosec 40mg po bid
Discharge Medications:
1. Equipment
3-in-1 commode (diagnosis of CVA)
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO twice
a day.
7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
13. Lipitor 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
14. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
17. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
18. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for yeast infection on buttocks.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
GI bleed
Acute renal failure
.
Secondary:
Coronary artery disease
Hypertension
Chronic systolic heart failure
Discharge Condition:
Improved
Discharge Instructions:
You were admitted to the hospital for bleeding in the
gastrointestinal tract. Upper and lower endoscopy was done
however we could not find the source of the bleeding because it
had stopped bleeding by then.
.
A capsule study has been scheduled for you. You will receive
instructions by mail, but you should also call [**Location (un) 13544**] at
[**Telephone/Fax (1) 30615**] to confirm the appointment and learn more about the
procedure.
.
Some changes were made to your medications:
- Stopped hydralazine (blood pressure medication)
- Stopped Prilosec and instead started Ranitidine
- Changed Seroquel from 25 mg twice a day to 25 mg once at
bedtime
- Added Nystatin cream as needed for fungal infection of the
buttocks
.
CT scan of your abdomen and pelvis done during this
hospitalization showed some changes that should be followed up
with a repeat scan in 3 months ([**Month (only) 216**]-[**2135-10-11**]). Your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] this.
.
Please weigh yourself every morning and call your doctor if
weight > 3 lbs. Please adhere to 2 gm sodium diet.
.
If you experience dizziness, palpitations, black tarry stools,
red blood with stools, or any other symptoms concerning to you,
please call your doctor or return to the emergency room.
Followup Instructions:
Please go to the following appointments as scheduled:
Capsule study: [**2135-7-26**] 8:00 AM with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**]
Phone:[**Telephone/Fax (1) 463**]
Follow up appointment with gastroenterology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8718**], MD
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2135-8-2**] 1:30 PM
.
Please call Dr.[**Name (NI) 30616**] office at [**Telephone/Fax (1) 29110**] to follow up in
[**4-13**] weeks (sometime after your appointment with Dr. [**Last Name (STitle) 4539**].
Please mention that you were asked to get a repeat imaging of
your abdomen for the findings seen on CT scan during your
hospital stay. A summary of your hospitalization will be faxed
to her office.
Completed by:[**2135-8-3**]
ICD9 Codes: 5789, 5849, 4280, 2859, 2767, 4019, 2724, 4439, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1567
} | Medical Text: Admission Date: [**2125-1-8**] Discharge Date: [**2125-1-23**]
Date of Birth: [**2052-3-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vasotec / Codeine / Ismo / Hytrin / Procardia / Erythromycin
Ethylsuccinate / Inderal / Amoxicillin / Indocin / Lotensin /
Ceftin / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
[**1-8**] Cardiac catheterization
[**1-16**] Coronary artery bypass graft (left internal mammary artery >
left anterior descending, Saphenous vein graft > obtuse
marginal)
History of Present Illness:
72 year old male presented to emergency department at [**Hospital3 17021**] with chest pain. After dinner
[**2125-1-5**] he started having 8/10 chest pain unrelieved with
sublingual nitroglycerin which he took twice. He was brought in
by ambulance. He ruled in for Non ST elevation myocardial
infarction with troponin 0.94 and CK MB 11.7. He was stabilized
and was transferred a few days later for cardiac evaluation.
Past Medical History:
cerebral vascular incident [**2107**]
Diabetes mellitus type 2
Right bundle branch block
Obesity
Gastroesophageal reflux disease
H/o nephrolithiasis
S/p hernia repair
S/p cataract surgery
S/p appendectomy
Social History:
Quit smoking 40 years ago.
Rare alcohol
Lives with spouse
Retired auto mechanic
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Admission:
VS: T 98.7, HR 75, BP 120/73, RR 18, POx 95% on RA
Gen: Obese male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Unable to assess [**12-18**] body habitus
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. 2/6 systolic mm loudest at base. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Obese, Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits. R groin - non-tender, no
hematoma.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 17022**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 17023**]TTE (Complete)
Done [**2125-1-9**] at 3:43:23 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) 2052**], [**First Name11 (Name Pattern1) 2053**] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Interventional Cardiolo
[**Street Address(2) 8667**], [**Hospital Ward Name **] 4
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2052-3-19**]
Age (years): 72 M Hgt (in): 69
BP (mm Hg): 132/60 Wgt (lb): 208
HR (bpm): 67 BSA (m2): 2.10 m2
Indication: Left ventricular function. Right ventricular
function. Valvular heart disease.
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2125-1-9**] at 15:43 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 16812**] [**Last Name (un) 16813**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W005-0:56 Machine: Vivid [**5-22**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.3 cm
Left Ventricle - Fractional Shortening: 0.35 >= 0.29
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 11 < 15
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: *4.0 cm <= 3.4 cm
Aorta - Arch: *3.2 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *2.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *25 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 14 mm Hg
Aortic Valve - LVOT VTI: 22
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: *297 ms 140-250 ms
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Moderately
dilated ascending aorta. Mildly dilated aortic arch.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Minimally increased gradient c/w minimal AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Indeterminate
PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve
leaflets. No PS. Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - body habitus.
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is moderately dilated. The aortic arch is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. The pulmonic valve
leaflets are thickened. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Dilated thoracic aorta. Minimal aortic stenosis.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-1-9**] 16:39
[**2125-1-8**] CARDIAC CATH:
1. Coronary angiography of this right dominant system revealed
three vessel coronary artery disease. The LMCA had a distal hazy
30% ulcer extending into the LAD and LCx. The LAD had mild
diffuse disease with a
long 85%-90% lesion in the mid vessel. The LCx had an ostial 60%
lesion. The RCA was diffusely diseased and occluded in the mid
vessel.
2. Limited resting hemodynamics demonstrated severe systemic
arterial
hypertension (SBP 184 mm Hg).
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 17022**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 17024**] (Complete)
Done [**2125-1-16**] at 1:53:32 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2052-3-19**]
Age (years): 72 M Hgt (in): 69
BP (mm Hg): 126/70 Wgt (lb): 208
HR (bpm): 57 BSA (m2): 2.10 m2
Indication: Intraoperative TEE for CABG procedure. Aortic valve
disease. Cerebrovascular event/TIA. Chest pain. Hypertension.
Left ventricular function. Mitral valve disease. Myocardial
infarction. Preoperative assessment. Right ventricular function.
ICD-9 Codes: 402.90, 786.51, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2125-1-16**] at 13:53 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 #: 2009AW5-: Machine: AW5
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 8 mm Hg < 20 mm Hg
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 2.33
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Mild regional LV systolic
dysfunction. Mildly depressed LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Simple atheroma in ascending aorta. Simple
atheroma in aortic arch. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Prebypass
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. There is mild
regional left ventricular systolic dysfunction with hypokinesia
of the apex, apical and mid portions of the anterior and
anteroseptal walls.. Overall left ventricular systolic function
is mildly depressed (LVEF= 50 %). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. There are simple atheroma in the ascending aorta. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results on [**2125-1-16**] at 1330.
Post bypass:
The patient is on no infusions, AV paced. Preserved
biventricular systolic fxn. Trace - mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact
post decannulation. Post bypass study performed and read by Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**].
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) **] [**2125-1-17**] 14:48
.
[**2125-1-8**] EKG: Sinus rhythm. Left atrial abnormality. Right
bundle-branch block. Borderline left axis deviation. Possible
left anterior fascicular block. Borderline left ventricular
hypertrophy with ventricular premature depolarizations and
diffuse non-diagnostic repolarization abnormalities. Compared to
the previous tracing of [**2118-2-15**] right bundle-branch block is now
present.
.
.
[**2125-1-9**] CAROTID U/S: Less than 40% stenosis of the internal
carotid arteries bilaterally.
Brief Hospital Course:
Transferred from outside hospital for cardiac catherization that
revealed moderate diffuse disease. He was referred for surgical
evaluation and underwent preoperative workup and plavix was
discontinued. He continued to have intermittent episodes of
chest pain relieved with nitroglycerin and no EKG changes. On
[**1-16**] he was brought to the operating room and underwent
coronary artery bypass graft surgery, see operative report for
further details. He received vancomycin for perioperative
antibiotics because he was in the hospital preoperatively. He
was transferred to the intensive care unit for hemodynamic
monitoring. In the first twenty four hours he was weaned from
sedation, awoke neurologically intact, and was extubated without
complications. He was started on beta blockers and diuresis. He
had hyperkalemia and was treated with insulin and dextrose with
resolution. He remained in the intensive care unit for
monitoring and was transfered to the floor post operative day 2.
He was started on flomax due to failure to void, foley
reinserted, after two days it was removed with no further
difficulty. His nasal swab was positive for methicillin
resistant staph aureus and started on bactroban. He continued
to progress and was ready for discharge to rehab postoperative
day 7.
Medications on Admission:
On transfer:
Heparin at 400u/hr
Ecotrin 325mg
Plavix 75mg (rec'd today, s/p loading dose of 300mg on [**1-6**] -
separate doses of 75 and 225 given)
Nexium 40mg
NTG paste (0.5" at 8am)
.
At home:
Aspirin 325mg daily
Nexium 40mg daily
Diovan 160mg daily
Imdur 60mg daily
Niacin 500mg daily
Folic acid 1mg daily
Zinc
Lecithin
Natoff
L-carnitine
CoQ10
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Niacin 250 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for moderate to severe pain.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for mild-moderate pain.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at Silver [**Doctor Last Name **]
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft
Methicillin resistant staph aureus from nasal swab
Non ST elevation myocardial infarction
Gastroesophageal reflux disease
Diabetes mellitus type 2
nephrolithiasis
cerebral vascular accident in [**2107**]
Discharge Condition:
deconditioned
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call and schedule the following appointments
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17025**] after discharge from rehab [**Telephone/Fax (1) 17026**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17027**] after discharge from rehab
Completed by:[**2125-1-23**]
ICD9 Codes: 5849, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1568
} | Medical Text: Admission Date: [**2131-5-10**] Discharge Date: [**2131-5-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central Venous Line
History of Present Illness:
85 y/o female with a h/o CAD, CVA, AF/sick sinus syndrome s/p
pacer placement, T2DM, hyperlipidemia, and COPD who presented to
the ED with fever. Pt was transferred from [**Hospital 100**] Rehab where
she is a resident when she spiked a temp to 101 and subsequently
sent to [**Hospital1 18**] ED for further evaluation. Of note, she is s/p
recent left BKA c/b MRSA wound infection treated with
vancomycin, ceftriaxone, and Flagyl. In the ED, she was given
cefepime and clindamycin for broader coverage.
Past Medical History:
CAD s/p stenting of MI [**2124**]
history of left CVA1/[**2129**] manafested with left hemiparesis
history of cardiac arrythmia, sick sinus syndrome, AF ,s/p
paacemaker
history of DM2, diet controlled
hsitory of GI bleed while on anticoagulation for renal thrombus
history of hyperllpdemia
history of COPD
history of aortic valve stenosis
history of Left ventricular diastolic dysfunction
history of asscending aortic aneurysem
history of pulmonary hypertension
history of urosepsis [**2128**]
history of dysphasia
history of hyperlipdemia
postoperative hypovolemia with low urinary output-fluid
resustated
postoperative blood loss anemia-transfused
posopterative electrolyte imbalance-corrected
Social History:
nursing home resident since [**2129**] post CVA
Family History:
NC
Physical Exam:
Vitals - T 102.4, BP 108/57, HR 85, RR 17, O2 sat 94% 7L FM
General - elderly female, no acute distress
HEENT - mild anisocoria; R>L pupil, both reactive; OP clr, MMM,
no LAD
CV - RRR; [**3-20**] crescendo-decrescendo murmur @ LUSB
Chest - coarse crackles with expiratory wheezes throughout
Abdomen - NABS, soft, NT/ND
Extremities - L lower extremity surgically absent; AKA stump
with ~3-5 mm skin defect with minimal surrounding erythema,
minimal whitish drainage
Pertinent Results:
[**2131-5-10**] 07:52PM GLUCOSE-189* UREA N-13 CREAT-0.6 SODIUM-142
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-24 ANION GAP-12
[**2131-5-10**] 07:52PM CK(CPK)-34
[**2131-5-10**] 07:52PM CK-MB-NotDone cTropnT-0.07*
[**2131-5-10**] 07:52PM CALCIUM-8.5 PHOSPHATE-3.8 MAGNESIUM-1.8
[**2131-5-10**] 07:52PM WBC-7.7 RBC-3.16* HGB-10.6* HCT-31.8*
MCV-101* MCH-33.6* MCHC-33.4 RDW-15.7*
[**2131-5-10**] 07:52PM PLT COUNT-157
[**2131-5-10**] 04:20PM PO2-89 PCO2-43 PH-7.37 TOTAL CO2-26 BASE XS-0
[**2131-5-10**] 03:47PM TYPE-ART PO2-46* PCO2-46* PH-7.37 TOTAL
CO2-28 BASE XS-0 INTUBATED-NOT INTUBA
[**2131-5-10**] 01:00PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.030
[**2131-5-10**] 01:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2131-5-10**] 01:00PM URINE RBC-0-2 WBC-[**12-4**]* BACTERIA-MOD
YEAST-NONE EPI-[**3-19**]
[**2131-5-10**] 11:52AM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF
[**2131-5-10**] 11:52AM GLUCOSE-108* LACTATE-1.2 NA+-143 K+-5.1
CL--109
[**2131-5-10**] 11:48AM GLUCOSE-113* UREA N-10 CREAT-0.7 SODIUM-145
POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-29 ANION GAP-10
[**2131-5-10**] 11:48AM estGFR-Using this
[**2131-5-10**] 11:48AM CALCIUM-8.7 PHOSPHATE-3.7# MAGNESIUM-2.0
[**2131-5-10**] 11:48AM WBC-6.9 RBC-3.51* HGB-11.7* HCT-35.8*#
MCV-102*# MCH-33.4* MCHC-32.8 RDW-15.9*
[**2131-5-10**] 11:48AM PLT COUNT-176
[**2131-5-10**] 11:48AM PT-12.5 PTT-25.5 INR(PT)-1.1
Echo [**2131-5-11**]:
EF 70-75%, 3+TR 2+MR, 2+AR, mod AS, mod pulm HTN.
CXR [**2131-5-10**]:
1. Left internal jugular central venous catheter likely
terminating within the brachiocephalic confluence. No definite
pneumothorax identified; however, left apex was not included on
current radiograph.
2. Grossly unchanged appearance to bilateral pleural effusions
and basilar atelectasis. More dense opacity within the
retrocardiac region also likely represents atelectasis; however,
underlying consolidation cannot be excluded.
Brief Hospital Course:
85 F s/p recent left AKA on [**2131-3-23**], transferred from [**Hospital 100**]
Rehab with fever and hypotension.
Felt to be related to possibly multiple sources including AKA
stump (cellulitis vs abscess vs osteo), C Diff colitis, UTI;
also possible early pneumonia with retrocardiac opacity on CXR).
Pt initially covered broadly with vanco/cefepime/metronidazole
without good effect. Hemodynamics continued to decline as well
as respiratory status with increasing CO2 retention despite
non-invasive positive pressure ventilation.
Pressors initially started with moderate effect, however, pt's
mental status began to decline despite improved mean arterial
pressures. Family meeting was held given continued decline, and
pt was made comfort measures only by son. Pt expired at 19:49
[**2131-5-12**] and family was informed. Autopsy was declined.
Medications on Admission:
Acetaminophen 650 TID
Aspirin 325
Ceftriaxone 1 gm QD
Iron 325 QD
Gabapentin 300 QHS
Heparin 5000 SQ TID
Lactobacillus [**Hospital1 **]
Toprol XL 37.5 QD
Flagyl 500 PO Q8h
Mirtazapine 30 PO QHS
Protonix 40 PO QD
Senna 2 QHS
Simvastatin 40 QHS
Vancomycin 750 IV QD
Discharge Medications:
na
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Hypotension
Probable C diff colitis
Probable nosocomial pneumonia
Probable stump cellulitis
Congestive heart failure
Atrial fibrillation with sick sinus syndrome
Hypoxic respiratory distress
Hypercarbic respiratory failure
Discharge Condition:
expired
ICD9 Codes: 4275, 2720, 0389, 496, 4241, 486, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1569
} | Medical Text: Admission Date: [**2193-4-8**] Discharge Date: [**2193-4-9**]
Date of Birth: [**2131-11-10**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
[**Doctor Last Name 5656**] ([**Known firstname **]) [**Known lastname 1022**] is a 60 year old man with a history of
hemorrhagic strokes who presents this evening after being found
unresponsive. His wife reports that he was doing well today,
his
typical routine of exercises and such. He was watching TV as
they normally do in the evening when she went to prepare dinner.
A few minutes later, she came to feed him his dinner (she often
helped to feed him) when he suddenly said to her "I'm sick, I'm
in pain". His head then deviated to the right. She was unable
to get his head back to midline. His son was home at the time
in
another room and he realized that something was very wrong, as
his father was unresponsive; 911 was called. When EMS arrived,
there was concern for possible seizure activity given the head
deviation and so he was given 5 of Valium without effec.
Fingerstick 120.
On arrival to the ED, he was felt to have decerebrate posturing
in arms. He had son[**Name (NI) 7884**] respirations and a clenched jaw and he
was rapidly intubated. CT of the head demonstrated a large ICH
and neurology was initially consulted, but this hemorrhage was
felt to be not compatible with life. Neurology was then
consulted.
The patient's wife reports that he was recently started on
coumadin (unknown reason) and there may have been some changes
to
blood pressure medications. There was otherwise no recent
illness and the patient had no complaints. Further ROS could
not be obtained.
Past Medical History:
- Hypertension
- Hemorrhagic Stroke x 2: 1 in [**2181**] treated at [**Location (un) **] [**Hospital **]
hospital, one in [**2187**] treated here (left BG hemorrhage). Wears
an
AFO on the right leg; can walk with a cane and leg brace
- ASD on Echo [**2187**]
Social History:
SH: Married, 2 sons, owns Chinese restaurant.
Family History:
unknown
Physical Exam:
< ON ADMISSION >
180/100, HR 77, Intubated O2 sat 100%
GEN: Intubated, sedated.
CV: RRR
PULM: symmetric mechanical breaths
ABD: Soft
EXT: well perfused
NEURO: Off of sedation. Initially right pupil 6mm and minimally
reactive, left 3mm and ovoid, then bilateral 6mm and unreactive.
+ corneals bilaterally, + cough, unable to elicit OCR. Right
arm
with hand flexion. Increased tone on the right arm and leg
compared to left. + reflexes in the arms, 3+ patella. Unable to
elicit AJ. Toes up bilaterally.
Pertinent Results:
[**2193-4-8**] 09:03PM URINE HOURS-RANDOM
[**2193-4-8**] 09:03PM URINE HOURS-RANDOM
[**2193-4-8**] 09:03PM URINE GR HOLD-HOLD
[**2193-4-8**] 09:03PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2193-4-8**] 09:03PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2193-4-8**] 09:03PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-600
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2193-4-8**] 09:03PM URINE RBC-13* WBC-9* BACTERIA-NONE YEAST-NONE
EPI-0
[**2193-4-8**] 09:03PM URINE HYALINE-1*
[**2193-4-8**] 09:03PM URINE MUCOUS-RARE
[**2193-4-8**] 08:54PM PH-7.27* COMMENTS-GREEN TOP
[**2193-4-8**] 08:54PM GLUCOSE-123* LACTATE-6.8* NA+-144 K+-5.4*
CL--105 TCO2-24
[**2193-4-8**] 08:54PM HGB-16.7 calcHCT-50 O2 SAT-83 CARBOXYHB-3 MET
HGB-0
[**2193-4-8**] 08:54PM freeCa-1.14
[**2193-4-8**] 08:51PM UREA N-26* CREAT-1.3*
[**2193-4-8**] 08:51PM estGFR-Using this
[**2193-4-8**] 08:51PM LIPASE-109*
[**2193-4-8**] 08:51PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2193-4-8**] 08:51PM WBC-8.5 RBC-5.13 HGB-16.3 HCT-46.6 MCV-91
MCH-31.8 MCHC-35.1* RDW-13.5
[**2193-4-8**] 08:51PM PT-111.1* PTT-46.4* INR(PT)-13.5*
[**2193-4-8**] 08:51PM PLT COUNT-183
[**2193-4-8**] 08:51PM FIBRINOGE-350
NCHCT:
large amount of acute intraventricular
hemorrhage involving bilat lateral ventricles R>>L, third and
4th
ventricles and inferior. evolving hydrocephalus. perivent
hypodensity could = transependymal spread of CSF. acute
hemorrhage extends intraparenchymal into right temporoparietal
region and right thalamus. focus of left frontal hemorrhage
appears to involve corpus collosum. ~ 8mm leftward midline shift
at level of third ventricle. concern for impending right uncal
herniation.
Brief Hospital Course:
Mr. [**Known lastname 1022**] was admitted to the SICU as described above. He shortly
thereafter became hypertensive to the 230s SBP (nicardipine gtt
was briefly started for this) and then hypotensive to the 40s
SBP (pressors were started for this), a presumed herniation
event given that all cranial nerve reflexes were lost at that
point overnight. In the morning, pupils remained fixed and
dilated (as described above, with ovoid Left pupil 5mm and round
Left pupil 7mm) and fundoscopic examination was notable for
bilateral irregular and blurred optic disc margins. There were
no eye movements on either side to cold calorics testing, no
VOR, no corneal reflexes, no spontaneous breaths on the
ventilator, no cough, no gag.
A cerebral nuclear perfusion study confirmed the complete
absence of cerebral blood flow, which is diagnostic of brain
death (time of study = 1:40pm = time of death). The family were
informed, and after a son arrived from out of town in the
evening, the Mr. [**Known lastname 1022**] was extubated. They were contact[**Name (NI) **] by the
NE organ transplantation bank. The family was not interested in
organ donation. His family (wife and son) declined autopsy. The
medical examiner office asked our thoughts re: the INR of 13,
which Dr. [**Last Name (STitle) 54849**] told them was unexplained; the ME office
waived the case and Dr. [**Last Name (STitle) **] completed and submitted the
Death Report [**4-9**] in the evening around 9pm.
Medications on Admission:
- Coumdain 5mg daily
- Unknown antihypertensives
Discharge Medications:
n/a (died)
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraparenchymal Hemorrhage
Discharge Condition:
n/a (died)
Discharge Instructions:
n/a (died)
Followup Instructions:
n/a (died)
Completed by:[**2193-4-10**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1570
} | Medical Text: Admission Date: [**2104-7-14**] Discharge Date: [**2104-7-17**]
Date of Birth: [**2039-1-16**] Sex: M
Service: CT Surgery
ADMISSION DIAGNOSES:
1. Esophageal mass.
2. Upper gastrointestinal bleed, questionably secondary to
esophageal mass.
3. Hypertension.
4. History of chronic renal insufficiency.
5. Claudication.
6. Hyperlipidemia.
7. History of alcohol abuse.
8. Depression.
DISCHARGE DIAGNOSES:
1. Esophageal mass-pathology pending.
2. Upper gastrointestinal bleed
3. Hypertension.
4. History of chronic renal insufficiency.
5. Claudication.
6. Hyperlipidemia.
7. History of alcohol abuse.
8. Depression.
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
male who had had multiple episodes of hematemesis along with
associated nausea but without abdominal pain most recently,
about two days prior to admission, on [**2104-7-14**], but
noted that this had been going on for about two weeks. The
hematemesis was definitely bright red and bloody. According
to the patient, he initially presented to an outside hospital
and underwent an esophagogastroduodenoscopy which observed
distal esophageal bleeding at 28 to 30 cm and was injected
with epinephrine. It was subsequently re-evaluated with an
EGD which showed no bleed. Initially, his hematocrit at that
time was 21 and he had been transfused with four units of
packed red blood cells. Notably on EGD, there was a
significant tumor which was described as "large, ulcerating,
bulky, extending 28 to 35 cm from the incisor". This was
thought to be the origin of the bleeding. The patient was
transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for
definitive evaluation of this tumor with a possibility of
operative intervention.
LABORATORY DATA: On admission to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **], the patient's white blood cell count was 14.1
with a hematocrit of 34.8 and platelet count of 171,000 with
a prothrombin time of 13, partial thromboplastin time 22.5
and INR of 1.1. His admission potassium was 3 (which was
subsequently repleted) with a BUN and creatinine of 31 and
0.7. Liver function tests were within normal limits with an
ALT of 12, AST 17, alkaline phosphatase 47, and total
bilirubin 0.5.
PHYSICAL EXAMINATION: On admission, the patient had a
temperature of 97.8 with a pulse of 69 which was regular,
with a blood pressure of 130/60, respiratory rate 20 and
oxygen saturation 99% in room air. He appeared to be in no
acute distress. Head, eyes, ears, nose and throat:
Unremarkable, no lymphadenopathy, no jugular venous
distention. Chest: Clear to auscultation bilaterally and
symmetric. Cardiovascular: Regular rate and rhythm without
rub. Abdomen: Soft, nontender, nondistended, no
hepatosplenomegaly, no ascites noted. Extremities: Warm and
well perfused with 2+ dorsalis pedis and posterior tibialis
pulses, no notable clubbing or edema.
HOSPITAL COURSE: The patient was admitted and initially
underwent a CT scan of the chest, abdomen and pelvis in order
to assess for the extent of the lesion and also possible
metastatic disease if this was, in fact, a cancer. Notably,
the CT scan showed thickening of the mid-esophagus which
likely corresponded to the known esophageal mass. There was
an enlarged subcarinal node but this could have also been a
direct extension of the mass. Right sided pulmonary nodules
were seen and an 8 mm gastrohepatic ligament node and soft
tissue nodules posterior to the liver were seen, which may
have represented metastatic disease. There was a right
greater than left septal thickening and ground-glass opacity
in the lungs, which were consistent with congestive heart
failure, but there is a possibility of these being
lymphangitic carcinomatosis. Incidentally, there were renal
cysts and diverticula present.
Subsequent to this evaluation by cardiothoracic surgery, the
patient underwent a bronchoscopy and esophagoscopy to
evaluate the extent of disease and also to determine what
treatment options the patient could undergo. He was taken to
the Operating Room on [**2104-7-16**] and underwent the
procedure without notable complication. There were no
definitive intraoperative findings aside from the likelihood
that there was not any notable esophageal perforation.
On postprocedure day one, the patient was scheduled to have a
clinic visit for further evaluation of this and we will
schedule him for an outpatient PET CT scan for evaluation for
metastatic disease. Otherwise, at the time of discharge, the
patient is doing quite well. He has been ambulating and
maintaining good oxygen saturations in the 90% range. His
discharge hematocrit is 36.6 with a white blood cell count of
11.4 and platelet count 203,000. Otherwise, the patient is
to follow up with Dr. [**Last Name (STitle) 51205**] in one week. He is to have his
PET scan prior to that and he is also to follow up with his
primary care physician. [**Name10 (NameIs) **] patient has been instructed to
maintain a mechanical soft diet as tolerated. He has also
been asked to follow up with his primary care physician this
week in order to discuss the events of the week.
DISCHARGE MEDICATIONS: The patient will not be discharged
with any new medications. The patient takes atenolol, Paxil,
trazodone, Lipitor and Maxzide but is currently unaware of
the dosages of these medications. He has been instructed to
resume these at their current doses when he is discharged.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 26688**]
MEDQUIST36
D: [**2104-7-17**] 01:20
T: [**2104-7-25**] 19:11
JOB#: [**Job Number 51206**]
ICD9 Codes: 2724, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1571
} | Medical Text: Admission Date: [**2169-5-25**] Discharge Date: [**2169-5-31**]
Date of Birth: [**2136-9-18**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 32 year-old
woman with a recurrent demyelinating illness brought to the
Emergency Room by her parents on the recommendation of her
neurologist for evaluation of behavior changes including
increased sexual promiscuity, increased spending and
report that she is compulsively wanting to have sexual
activity and unable to control it to the degree that she is
placing herself and her parents at risk. She has contact[**Name (NI) **]
many men by computer and phone. Several nights prior to
admission her father heard noises in the middle of the night
and found a strange man in the patient's bedroom. The father
called the police and the police knew him to be a dangerous
the patient left the house unbeknown to the parents and was
waiting outside for a cab to take her to a motel where she
had arranged a liaison with the same man. The father stated
he had also escorted other strange men out of the house and
is very worried about the patient and the families safety.
She also has had increased spending and has had a progressive
decline in her ability to care for herself including
decreased ambulation. The other stresses beside her
declining physical abilities was that her fiance who was
bipolar committed suicide by jumping in front of a train in
[**2169-1-20**]. On [**2169-5-11**] she was seen by a neurologist
and an MRI was ordered. The patient was then referred for
evaluation for psychiatric admission for behavioral control.
PAST PSYCHIATRIC HISTORY: Admission to [**Hospital1 190**] in [**2164-2-18**] for a psychotic disorder with
hallucinations secondary to prescribed steroids. In [**2158**] she
was seen by a psychiatrist when her neurological illness was
first diagnosed and she started to exhibit disinhibited
behavior and impulsiveness with late night phone calls. Her
neuropsychologist is Dr. [**Last Name (STitle) 3085**].
PAST MEDICAL HISTORY: She was diagnosed with a demyelinating
illness in [**2158**], which has involved frontal lobe dysfunction
and neurogenic bladder as well as difficulty with the
ambulation. She has chronic sinusitis. Her primary care
physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3086**]. Her neurologist is Dr. [**Last Name (STitle) 3087**]
and her consulting neurologist at [**Hospital1 190**] is Dr. [**Last Name (STitle) 3088**].
ALLERGIES: Flu shots.
MEDICATIONS ON ADMISSION: Baclofen 820 mg tablets q.d.,
Ditropan XL 20 mg q.d., Beconase nasal spray two times a day,
ferrous sulfate 325 mg a day, Solu-Medrol q.m. intravenous
last dose [**2169-5-4**] next dose scheduled for [**2169-6-1**] and Celexa
20 mg q.d.
SUBSTANCE ABUSE HISTORY: The patient denies.
SOCIAL HISTORY: Both the patient and her 28 year-old brother
were adopted and live with their parents in [**Location (un) 38**]
[**State 350**]. She was six weeks old when she was adopted.
She was an average student with no academic difficulties.
Question of history of sexual assault in [**2159-7-21**]. She
graduated from [**Last Name (Prefixes) 3089**] College where she studied early
childhood development. She is single. Never married.
FAMILY PSYCHIATRIC HISTORY: Not available.
LABORATORY DATA ON ADMISSION: CBC and SMA were within normal
limits. RPR was negative. HCG was negative. TSH was within
normal limits. Tox screen was negative.
MENTAL STATUS EXAMINATION ON ADMISSION: The patient was
pleasant, well groomed and appropriately dressed sitting on a
stretcher. Her attitude was cooperative. Her speech was
articulate. Very matter of fact with little affect. Mood
was depressed. Affect minimally reactive. Thought form was
linear and coherent. She denied any preoccupations,
obsessions and delusions except for her thoughts about sex.
She did not appear to have any delusions. She denied
suicidal or homicidal ideation. Her insight and judgment
were impaired. Her cognitive examination was abnormal in her
inability to do serial sevens. She was able to do serial
threes. She remembered 2 out of 3 in five minutes.
Calculations and fund of knowledge were within normal limits.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 **] Four.
A trial of Depakote ER was begun to help with her impulsive
behaviors. Her family and her outpatient physicians were
contact[**Name (NI) **]. The patient was pleasant and involved in MILU
activities. She did have a fall on the unit with no acute
injuries noted and fall precautions were put into place. Her
family met with the inpatient team as well as Dr. [**Last Name (STitle) 3088**] who
reviewed her recent MRI and said that it showed worsening of
her demyelinating disorder, which could be consistent with
her current change in behavior. He would continue to follow
her. The patient had no further urges or attempts to engage
anyone sexually and was in very good control on the unit.
She did have another fall using her walker and began to use
her wheel chair more frequently. She denies side effects
from the Depakote. On [**5-30**] she complained of an upset
stomach, diarrhea and a productive cough for three days with
some blood in her sputum. She denied any shortness of
breath. Lungs were clear on examination. The patient had an
extensive physical therapy consult and evaluation and further
physical therapy was recommended.
Discharge planning proceeded with the patient agreeing to go
to a brief rehab stay for continued physical therapy before
returning home. On [**2169-5-31**] the patient was being assisted in
transfer from bed to her wheel chair and had a sudden cardiac
and respiratory arrest. CPR was initiated and she was
transferred to the Intensive Care Unit.
In the MICU, the patient was in pulseless electrical activity
(PEA) and was felt to have suffered a massive pulmonary
embolism. She was given thrombolysis with restoration of pulse
and blood pressure while being maintained on vasopressors and
mechanical ventilation. However, despite maximum supportive
measures, hypotension became refractory and the patient died
within 24 hours of transfer to the ICU. The patient's family was
notified of the events and was with the patient in her final
hours.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D.
[**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 3092**]
MEDQUIST36
D: [**2169-7-24**] 17:18
T: [**2169-8-1**] 07:09
JOB#: [**Job Number 3093**]
ICD9 Codes: 4275, 5185, 5845, 2762, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1572
} | Medical Text: Admission Date: [**2185-1-29**] Discharge Date: [**2185-2-22**]
Date of Birth: [**2163-1-27**] Sex: M
Service: Trauma Surgery
CHIEF COMPLAINT: Status post motor vehicle collision.
HISTORY OF PRESENT ILLNESS: The patient is a 23-year-old
male, unrestrained driver, high-speed motor vehicle
collision, with significant front end damage to the
automobile and shattered windshield.
The patient presented hemodynamically stable with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**]
Coma Scale of 14. The patient's left lower extremity was
splinted by Emergency Medical Service. The patient was
complaining of lower extremity pain.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS AT HOME: None.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: The patient is an occasional ethanol
drinker. He denies tobacco. Denies recreational drugs.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99.4,
his blood pressure was 108/palp, his heart rate was 86, his
respiratory rate was 20, and his oxygen saturation was 100%.
On examination, his pupils were equal and reactive to light.
The extraocular muscles were intact. The tympanic membranes
were clear. The oropharynx was clear. The patient had a
left-sided facial laceration. Chest was regular in rate and
rhythm. Clear to auscultation bilaterally. The abdomen was
soft, nontender, and nondistended. The pelvis was stable.
No costovertebral angle tenderness bilaterally. Cervical
spine and thoracolumbosacral had no deformities, stepoff, or
tenderness. Guaiac-negative with good rectal tone. The
patient had bruises, ecchymosis, and abrasions of the right
shoulder and ecchymosis and tenderness at the middle humerus,
and the right lower extremity revealed full range of motion
with no deformities. The left lower extremity was positive
for a deformity of the middle shaft of the femur. The
patient had 2+ radial pulses bilaterally, 2+ femoral pulses
bilaterally, 2+ dorsalis pedis pulses bilaterally, and 2+
posterior tibialis pulses bilaterally. The patient had an
ankle-brachial index of 1.2 on the right and 0.98 on the
left. The patient had a Foley catheter inserted at the
scene.
PERTINENT RADIOLOGY/IMAGING: The patient had a head computed
tomography on admission and on the 17th which were both
negative.
He also had a computed tomography of the cervical spine which
was negative and a computed tomography of the chest which was
normal.
The patient's abdominal computerized axial tomography showed
a tiny focus, decreased attenuation of the posterior spleen,
question of a very small laceration but no hematoma or
extravasation was seen.
Films of the right humerus and left shoulder were negative.
Plain films of the left femur showed a fracture at the middle
shaft.
PERTINENT LABORATORY VALUES ON PRESENTATION: Complete blood
count, chemistries, and coagulations were all within normal
limits. Urine and serum toxicology screens were negative.
His lactate was 1.7.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was taken to
the operating room by Orthopaedics on [**2-1**] and is
status post intramedullary nail of the left femur on [**2185-2-1**].
Upon admission to the Intensive Care Unit, the patient
developed respiratory distress with oxygen saturations in the
77th percentile. An arterial blood gas was performed and
showed a very low PAO2. The patient was subsequently
intubated and sedated on propofol for hypertension and
increased heart rates. Prior to this time, the patient was
brought to the operating room by Orthopaedics, and the left
femur was placed in traction. The patient had a right chest
tube placed on [**2185-1-29**] and a computed tomography
angiogram was obtained. This showed multiple peripheral
pulmonary emboli bilaterally, but no large central pulmonary
embolus. It also showed multifocal areas of consolidation,
which were new from prior examination. The patient also had
the presence of secretions in the airway which suggested
multifocal pneumonia as well. As mentioned, bilateral chest
tubes was placed for the respiratory distress a right
pneumothorax.
During the Intensive Care Unit course, the patient was
treated with antibiotics for pneumonia (as per culture data).
The patient also developed transient thrombocytopenia. For
this, Pepcid was discontinued, Protonix was started, and a
heparin-induced thrombocytopenia antibody was sent which was
negative. The patient was also transfused as needed for low
hematocrits.
The patient had a repeat head computed tomography on [**2-1**] which showed no change, and no intracranial bleed. The
patient's heparin drip was started postoperatively secondary
to the pulmonary emboli.
Throughout the Intensive Care Unit course, the patient was
also diuresed as needed. A feeding tube was placed, and tube
feeds were started and were tolerated well. The patient also
had periodic temperature spikes which were cultured and
adequately treated.
On [**2185-2-8**] the patient's bilateral chest tubes were
discontinued, and the patient tolerated this procedure well.
A chest x-ray was obtained and showed no pneumothorax. The
patient was also started on Coumadin during the Intensive
Care Unit stay, and the heparin drip was continued until a
therapeutic INR was obtained.
On [**2185-2-11**] the patient was extubated and tolerated
this well with an arterial blood gas within normal limits.
The Speech and Swallow therapists were consulted throughout
the hospital stay, performing multiple swallow studies. As
the patient became more alert, the patient improved with the
swallowing studies and was able to tolerate good oral intake
by discharge.
After extubation, it was noted that the patient had a
decreased level of alertness. The Neurology Service was
consulted to comment whether this was pharmacological,
metabolic, infectious, or an intracranial hemorrhage. They
recommended a repeat head contrast to rule out bleed given
the patient was being anticoagulated at this time.
Neurology recommended obtaining a magnetic resonance imaging
of the brain to evaluate for axonal injury. The magnetic
resonance imaging showed a nonspecific increased T2 signals
in the white matter of the left frontal lobe and linear areas
of restricted diffusion at the bilateral parietal white
matter which could represent areas of diffuse axonal injury
consistent with a motor vehicle collision. A magnetic
resonance imaging of the spine also showed right-sided disc
herniation at L5-S1 with no evidence of fracture in the
lumbar region. Neurosurgery was consulted regarding these
findings and recommended an elective repair in the future and
to follow up as an outpatient.
The patient was transferred to the floor on [**2185-2-16**] in
a stable condition. The [**Hospital 228**] hospital course on the
floor was remarkable for an increased alertness and
orientation. Prior to discharge, the patient was alert and
oriented times three. He was able to follow commands and
without any neurologic deficits. The hospital course on the
floor was unremarkable.
The patient passed a swallowing study and video swallow and
was able to tolerate a ground diet with thin liquids by
discharge. The patient's INR was therapeutic upon discharge,
and the heparin drip was discontinued. The patient was
afebrile and finished a course of antibiotics with a
decreased white count and no signs of infection. As the
patient increased oral intake, tube feeds were weaned, and
the feeding tube was discontinued.
Physical Therapy worked with the patient and deemed him safe
to receive physical therapy as an outpatient and recommended
disposition to be home.
DISCHARGE DISPOSITION: The patient's disposition was to
home.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Status post motor vehicle collision.
2. Left femur fracture.
3. Multiple pulmonary emboli.
4. Diffuse axonal injury.
5. Right pneumothorax.
6. Bilateral diffuse pulmonary opacities.
7. Acute respiratory distress.
8. Adult respiratory distress syndrome.
9. L5-S1 disc bulge.
10. Pneumonia.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was set up with a primary care physician to
follow Coumadin dosage and INR levels. An appointment with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was made for [**2-25**] at 1:30. The
patient was to have an INR check two times per week and have
followup that Friday of discharge.
2. The patient was to follow up at the [**Hospital 9696**] Clinic
regarding left femur fracture.
3. The patient was to follow up at the [**Hospital 4695**] Clinic
if the patient desired an elective repair of disc herniation.
MAJOR SURGICAL/INVASIVE PROCEDURES PERFORMED:
1. Status post bilateral chest tube placement.
2. Status post PA catheter placement.
3. Status post tracheal intubation secondary to respiratory
distress.
4. Status post open reduction/internal fixation of left
femur on [**2185-2-1**].
MEDICATIONS ON DISCHARGE:
1. Albuterol 1 to 2 puffs inhaled q.6h. as needed.
2. Methadone 5 mg by mouth twice per day.
3. Levofloxacin 500 mg once per day (times seven days - to
finish a 14-day course).
4. Coumadin 10 mg five times per week and 12.5 mg two times
per week.
The patient was to have an INR draw on Friday, [**2-25**],
prior to his appointment with his primary care physician
regarding Coumadin dosing. The rest of follow-up
appointments were to be made by the patient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 27744**]
MEDQUIST36
D: [**2185-3-2**] 16:14
T: [**2185-3-3**] 07:53
JOB#: [**Job Number 52648**]
ICD9 Codes: 486, 5070, 2875, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1573
} | Medical Text: Admission Date: [**2118-10-3**] Discharge Date: [**2118-10-6**]
Service: TSURG
Allergies:
Codeine
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Dyspnea secondary to right sided obstructing small cell lung
cancer.
Major Surgical or Invasive Procedure:
Rigid bronchoscopy and stent placement.
History of Present Illness:
Patient is 85 yo female transferred from [**Hospital 1562**] Hospital where
she was hospitalized for several weeks of dyspnea. CXR and CT
chest at the outside hospital revealed complete right hemithorax
white-out and large right lung mass. Pleural effusion was
aspirated at that time, later to reveal small cell lung cancer.
Patient was then transferred to [**Hospital1 18**] for further evaluation and
treatment.
Past Medical History:
1. Diabetes mellitus
2. Hypertension
3. Hypothyroidism
4. Osteopenia
Social History:
Unremarkable.
Family History:
Unremarkable.
Physical Exam:
Gen: intubated, sedated
HEENT: no scleral icterus, atraumatic
Neck: no masses
CV: regular rate rhythm
Pulm: diminished breath sounds on right
Abd: soft, NT, ND, + BS
Ext: no C/C/E
Neuro: MAE, PERRLA
Pertinent Results:
[**2118-10-3**] 09:02PM TYPE-ART TEMP-37.6 RATES-/10 TIDAL VOL-400
PEEP-5 O2-100 PO2-198* PCO2-42 PH-7.29* TOTAL CO2-21 BASE XS--5
AADO2-489 REQ O2-81 INTUBATED-INTUBATED
Brief Hospital Course:
Patient is an 85 yo female transferred from outside hospital
with obstructing right sided lung malignancy with extension to
the trachea and mediastinum. She arrived intubated. Dr.
[**Name (NI) **] took patient for rigid bronchoscopy and stent
placement on [**2118-10-4**]. Post-procedure, patient returned to the
ICU where she did not progress. Poor oxygenation on maximal
ventilator settings and poor urine output ensued. After
discussion with the family regarding bleak long term prognosis,
the decision was made to make the patient DNR/DNI and later
comfort measures only. Patient was place on morphine drip at 10
PM [**2118-10-5**]. Pt. expired at 8:00 AM, [**2118-10-6**]. Daughters were at
the bedside and decline a post-mortem.
Medications on Admission:
1. Humalog insulin
2. Lantus insulin
3. Altace
4. Synthroid
5. Trental
6. Fosamax
7. Lipitor
Discharge Medications:
N/A
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Small cell lung cancer
2. Diabetes mellitus
3. Hypertension
4. Hypothyroidism
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1574
} | Medical Text: Admission Date: [**2119-5-26**] Discharge Date: [**2119-5-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
CC:[**CC Contact Info 15218**]
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI: 81M w/recent subdural hematoma s/p evacuation in [**3-30**], CHF,
Afib, aortic aneurysm, recently ([**4-29**]) admission to [**Hospital Unit Name 153**] for
altered
mental status and hypoxia ([**2039-5-11**]) found to have RML MRSA PNA
plus CHF with intubation. Sent to ED for evaluation for
somnolence, and apnea from [**Hospital1 599**] at [**Location (un) 55**]. This am pt's
RR fluctuated from 24/min to periods of 30-40 sec apneic
episodes with O2 sats ranging from 88-94% on RA. In the ED,
found to be somnolent but arouseable and able to eat and answer
questions. Weight is stable at 126 lbs on lasix 40 mg PO daily.
His Vancomycin course is due to end [**5-27**]. Dose is 500 mg IV
q24h due to high troughs. In ED afebrile, BP 110/70 P 80 O2 97%
RA.
.
Also in his hospitalization in [**3-30**] at [**Hospital1 18**] he was found to
have an Enterobacter UTI and a LLL pneumonia (treated with
Levoflox).
.
Pt denies any complaints at this time. Endorses feeling confused
this morning and reports that sometimes he "loses days" and that
bothers him.
.
ROS: Denies CP, SOB, orthop, PND, palpitations, cough, fevers,
new weaknesses, changes in sensation or vision, nausea,
vomiting, diarrhea, abdominal pain, hematuria, dysuria, blood in
the stools.
Past Medical History:
1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2. 3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine. No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia
12. ?progressive dementia
Social History:
Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards).
Family History:
no Alzhemer's or Parkinson's
Physical Exam:
VS: T 96.9 HR 109/41 HR 71 R 19 98% 3L
Gen: NAD, A&O X 2
Skin: no rash
HEENT: EOMI, PERRL, O/P clear
Neck: supple, no LAD
CV: RRR nl s1 s2 2/6 sem at llsb
Pulm: CTAB
Abd: soft, NT, ND +BS
Ext: cachetic, no edema
Neuro: A&O X [**1-27**], moves all 4, sensation intact to LT, 2+ DTR at
[**Name2 (NI) 15219**] b/l, [**Last Name (un) **] down b/l
Pertinent Results:
Studies:
[**5-26**]: CT Head: no intracranial hemorrhage, unchanged hypodense
fluid collection subdural R frontal lobe.
[**5-26**]: CXR: no new infiltrate
Brief Hospital Course:
A/P: 81M w/recent subdural hematoma s/p evacuation in [**3-30**],
CHF,
Afib, aortic aneurysm, recent MRSA PNA and CHF flare now
admitted with somnolence and periods of apnea.
.
# Somnolence: Now seems to be resolved. Pt's family noted him to
be unresponsive, or minimally responsive this morning. DDx
includes infection, hypercarbia, extension of subdural hematoma.
UA, CXR clear, ABG without hypercarbia, CT head OK. ?Worsening
of baseline dementia vs. post-ictal from seizure? Likely
secondary to severe sleep apnea and daytime sleepiness.
.
# Apnea: Unclear if this is new, or newly recognized. Pt has
characteristic findings of [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing. Will need
outpt sleep study for titration of CPAP if necessary. Pt
reports that he would not want CPAP, can be discussed with PCP.
.
# hx CHF: Currently euvolemic, no evidence of CHF flare.
last echo ([**2119-4-3**]) w/EF >55%, 2+ MR, mod AR.
-- Continue home doses of lasix, BB, ACE-I
.
# PNA: Hx MRSA PNA during last admission.
- CXR shows resolving infiltrate.
- No leukocytosis or febrile episodes. Last thoracocentesis in
[**4-29**] showed transudative fluid c/w CHF exacerbation
- Recent sputum grew MRSA ([**5-12**] & [**5-14**]), sensitive to vanco. 10
day course to end [**5-27**].
.
# Subdural hematoma:
- No change on today's head CT
- On Keppra for seizure prophylaxis post-craniotomy (to be
continued until out-pt neurology or neurosurgical follow-up).
.
# AAA: ascending; measured >5cm in [**11-27**] & pt refused surgical
intervention at that time.
.
# CRI: (baseline creatinine 1.2-1.6) Today 1.1.
.
# Paroxysmal Afib:
-- continue metoprolol for rate control
-- No anticoagulation with warfarin given recent subdural
hematoma and h/o frequent falls.
.
# DM2:
-- RISS
-- Diabetic diet.
.
# Anemia: iron studies most c/w chronic dz (ferritin 86). Hct
stable. Cont ferrous sulfate. Guaiac all stools.
.
# Hypothyroidism: clinically euthyroid. Continue synthroid.
.
# Depression: remained stable. Continue celexa.
.
# FEN: PO diet, monitor lytes, replete prn.
# Prophylaxis: protonix and pneumoboots. bowel regimen.
# Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (5) **] 248
2146
# Code: DNR/I, confirmed with pt and last d/c summary
# Dispo: back to rehab.
Medications on Admission:
1. Ferrous Sulfate 325 PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Furosemide 40 mg PO DAILY
4. Levetiracetam 250 mg PO QAM
5. Levetiracetam 250 mg PO HS
6. Citalopram 10 mg PO DAILY
7. Ascorbic Acid 250 mg PO DAILY
8. Vancomycin 500 mg IV q24h
9. Levothyroxine 25 mcg PO DAILY
10. Metoprolol Tartrate 50 mg PO BID
11. Lisinopril 5 mg PO once a day.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
6. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO DAILY (Daily).
9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 1 doses: pt has one dose
left in his course for [**5-27**] evening.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
[**Last Name (un) 6055**]-[**Doctor Last Name **] breathing pattern
Sleep Apnea
CHF
Resolving MRSA PNA.
Discharge Condition:
Stable.
Discharge Instructions:
Call your primary care physician or return to the emergency room
if you have shortness of breath, chest pain, or any other
symptom that bothers you.
Followup Instructions:
Please call [**Hospital1 18**] Sleep Lab for a sleep study [**Telephone/Fax (1) 15220**].
Please call your primary care physician for an appointment at
[**Telephone/Fax (1) 3070**].
ICD9 Codes: 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1575
} | Medical Text: Admission Date: [**2126-11-16**] Discharge Date: [**2126-12-3**]
Date of Birth: [**2063-10-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Shortness of breath, transfer for new finding of flail mitral
valve
Major Surgical or Invasive Procedure:
[**2126-11-18**] - Cardiac Catheterization
[**2126-11-20**] - CABGx2, MVR (26mm Mechanical St. [**Male First Name (un) 923**]).
History of Present Illness:
This is a 63 year-old gentleman with hypercholesterolemia
admitted to the [**Hospital3 13313**] on [**2126-11-16**] after he
developed dyspnea on exertion on [**2126-11-12**]. He also noted having
a cough that was exacerbated by lying flat and productive of
pinkish phlegm. He noted no chest pain, palpitations or
diaphoresis. No dizziness, or loss of consciousness. He did
not note any swelling of his extremities. In addition, he did
report that had had a mild fever and nausea over the past few
days. Also of note, the patient had a minor dental procedure on
the 18th; he had been started on amoxicillin on [**11-14**] by his
PCP.
[**Name10 (NameIs) **] presentation to the OSH, the patient was afebrile,
tachycardic (P 110-120) with a BP of 108/70 R of 20 and O2 sat.
of 93 on RA. He was given a one time dose of lopressor, 5 mg
with bought his rate to the 100's. Pt had rales on lung exam.
Chest x-ray revealed RUL infiltrate and pulmonary edema. EKG
revealed some ST depressions in V4 to V6, troponin I level 0.19
(0.5 or higher is consistent with MI) BNP found to be 538. WBC
mildly elevated Echo was performed revealing prolapse of the
posterior leaflet of the mitral valve with 4+ MR. Systolic
function reportedly normal.
Pt was started empirically on ceftriaxone and azithromycin for
presumed community acquired pneumonia. Also given one time dose
of Lasix for CHF exacerbation. Pt also received 1x dose of 90
mg subcutaneous lovenox at 1700 today.
No recent sick contacts. [**Name (NI) **] had been nauseous but not vomiting
or diarrhea. No changes in urine or bowel movements. He has
not had any prolonged travel recently.
Past Medical History:
Hypercholesterolemia
HTN
Right DVT in past
Pneumonia
s/p right TKR
Social History:
Married, former athletic director at local high school.
Occasional alcohol use, no smoking. No heroin or other IV drug
use. No cocaine use.
Family History:
Non-contributory.
Physical Exam:
T 98.6 P 115-120 BP 118/72 RR 20-22 O2 81-85 on RA 95 on 2L FM
Gen: WD/WN male Caucasian in no acute distress, speaking in full
sentences. [**Name (NI) **], friendly, and cooperative.
Head: NCAT
Eyes: PERRL, sclerae anicteric
Mouth: MMM, no lesions
Neck: JVD to 8 cm, no HJR. No bruits
Chest: Decreased breath sounds at bases, no rales, rhonchi, or
wheezes.
Heart: Tachycardic, RR, S1 difficult to hear S2 loud
holosytolic murmur most prominent at apex and radiating to
axilla, occasional extra sound which may be S3 gallop. PMI not
displaced
Abd: Obese, nl bowel sounds, no bruit, no HSM
Ext: No edema
Pulses:
Carotid pulses, b/l 2+ with no bruit
Radial pulses b/l 2+
Inguinal pulses b/l 2+
DP pulses b/l 2+
Pertinent Results:
EKG: Sinus tachycardia, nl intervals, axis 60, isolated q wave
in III ST depressions in V4 to v6. No changes from EKG at OSH.
Echo from OSH: LV function preserved, MV prolapse with flail
posterior leaflet of mitral valve, 4+ MR [**First Name (Titles) 151**] [**Last Name (Titles) 34486**] jet
directed medially.
[**2126-11-16**] 09:13PM WBC-12.9* RBC-4.67 HGB-15.6 HCT-42.9 MCV-92
MCH-33.3* MCHC-36.2* RDW-12.9
[**2126-11-16**] 09:13PM ALT(SGPT)-10 AST(SGOT)-11 CK(CPK)-51 ALK
PHOS-53 TOT BILI-1.1
[**2126-11-16**] 09:13PM GLUCOSE-148* UREA N-35* CREAT-1.0 SODIUM-141
POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-23 ANION GAP-20
[**2126-11-28**] 06:20AM BLOOD Hct-27.6*
[**2126-11-28**] 06:20AM BLOOD PT-14.9* INR(PT)-1.5
[**2126-11-28**] 06:20AM BLOOD UreaN-12 Creat-1.1 K-5.0
[**2126-11-18**] 05:15PM BLOOD %HbA1c-5.3 [Hgb]-DONE [A1c]-DONE
[**12-3**] Hct 31.2
[**2126-11-18**] CT Chest
1. No pulmonary embolus.
2. There are diffuse ground-glass opacities within both lungs,
with associated left atrial enlargement and bilateral pleural
effusions, findings consistent with congestive heart failure.
3. There is a focal confluent opacity within the right upper
lobe, and to a lesser degree in the left upper lobe. This is
associated with multiple mediastinal lymph nodes. These findings
are consistent with an infectious process or pneumonia
superimposed upon underlying CHF.
[**2126-11-18**] ECHO
The left atrium is dilated. 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 aortic root is moderately
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. There is partial
mitral leaflet flail. Moderate to severe (3+) mitral
regurgitation is seen. The mitral regurgitation jet is
[**Month/Day/Year 34486**]. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
No vegetation seen (cannot exclude).
[**2126-11-18**] Cardiac Catheterization
1. Selective coronary arteriography revealed a right dominant
system
with severe three vessel CAD. The LMCA had 60-70% stenoses both
at its
ostium and distally. The LAD had a 70% ostial stenosis and had
60%
distal stenosis. The remainder of the vessel had mild diffuse
disease
with apparently good touch-down targets. The LCX had a 60%
proximal
stenosis. The OM branches had mild luminal irregularities. The
RCA was
diffusely disease proximally and 100% occluded in its mid
section. The
distal vessel filled via left to right collaterals.
2. Hemodynamics revealed markedly elevated wedge pressures with
significantly depressed cardiac output/index. There was mild
pulmonary
hypertension.
3. Left ventricuolography was not performed.
4. Because of the patient's low blood pressure and low cardiac
index,
the decision was made to place a 40cc IABP via the right femoral
artery.
The patient was transferred to the CCU.
[**2126-11-26**] CXR
1. Cardiomegaly without acute pulmonary edema.
2. Bibasilar patchy opacities most likely represent atelectasis.
3. Bilateral small to moderate pleural effusions
[**2126-11-26**] EKG
Sinus rhythm with first degree A-V delay and a brief pause which
is probably second degree AV block (Wenckebach).
Modest nonspecific ST-T wave changes. Since previous tracing of
[**2126-11-23**], A-V dissociation with junctional rhythm now absent.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2126-11-16**] for further
management. A CT scan was obtained which ruled out a pulmonary
embolism. As he had 4+ mitral valve regurgitation by echo at an
outside hospital, the cardiac surgical service was consulted for
evaluation. Blood cultures were obtained to assess for
endocarditis which were negative. A repeat echo revealed a
normal ejection fraction, 3+ mitral regurgitation with a partial
flail leaflet. A cardiac catheterization was performed which
revealed severe mitral valve regurgitation, a 70% stenosed left
main, a 70% stenosed left anterior descending artery, a 60%
stenosed circumflex artery and a chronically occluded right
coronary artery. A intra-aortic ballon was placed for a low
cardiac index and coronary perfusion. Heparin was started for
brief runs of atrial fibrillation. He was taken to the cardiac
care unit for further management. Mr. [**Known lastname **] was worked-up in the
usual preoperative manner including a carotid duplex ultrasound
which revealed no significant internal carotid artery stenosis.
On [**2126-11-20**], Mr. [**Known lastname **] was taken to the operating room where he
underwent coronary artery bypass grafting to two vessels and a
mitral valve replacement with a 26mm St. [**Male First Name (un) 923**] mechanical valve.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) **]e neurologically intact and was extubated. His intra-aortic
balloon was slowly weaned off and removed without difficulty.
Coumadin was started for anticoagulation. On postoperative day
two, Mr. [**Known lastname **] was transferred to the cardiac surgical step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. He
developed atrial flutter followed by a high grade heart block.
The electrophysiology service was consulted for a possible
pacemaker. All nodal agents were held and it was decided that if
his AV conduction system did not return, that a pacemaker would
be placed. Coumadin was subsequently held and heparin was
started. As his conduction system began to recover, the
pacemaker was put on hold and telemetry was continued. Coumadin
was resumed for anticoagulation.
Mr. [**Known lastname **] continued to make steady progress and was discharged
home on postoperative day #13. He will follow-up with Dr.
[**Last Name (STitle) **], the electrophysiology service, his cardiologist and his
primary care physician as an outpatient. His coumadin will be
managed by Dr. [**Last Name (STitle) 36897**] for a target INR of 2.5-3.5. He will have
his blood draw on [**12-4**] at [**Hospital3 13313**]. Coumadin 5 mg
dose tonight and further dosing by Dr. [**Last Name (STitle) 36897**].
HR88 107/67 RR 18 96% RA sat T 97.3
Medications on Admission:
Medications at home:
Amoxicillin since [**11-14**]
No regular medications
Medications on transfer
Zithromax 500 PO daily
Ceftriaxone 1 g IV daily
ASA 162 mg PO daily
Lopressor 50 (?) mg IV
Lovenox 90 mg SC
Robitussin/Codeine cough medication
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 5 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: take 5mg (1 tablet) today ([**12-1**]), then VNA to draw INR,
call to Dr.[**Name (NI) 62995**] office for continued dosing.(Discharge
dose on [**12-3**])
Disp:*60 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Hyperlipidemia
Hypertension
Right deep vein thrombosis
Third degree heart block
Atrial Fibrillation
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 more then 2 pounds in 24 hours.
4) No lotions, creams or powders to wound until it has healed.
5) No lifting more then 10 pounds for 4 weeks.
6) you will take coumadin for a St. [**Male First Name (un) 923**] Mechanical valve. Your
goal INR is 3.0-3.5. You will need to have your blood (PT/INR)
checked on Wednesday ([**12-4**]) with Dr. [**Last Name (STitle) 36897**]. Your discharged
dose will be 5mg. Please note that your dose may change based on
your blood levels. Only take as directed by Dr. [**Last Name (STitle) 36897**].
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks.
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks ([**Telephone/Fax (1) 8793**].
Follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 36897**] in [**3-1**]
weeks. ([**Telephone/Fax (1) 62996**]
Blood draw (PT/INR) for coumadin dosing on [**2126-12-4**] at
[**Hospital3 13313**]. Have lab call Dr. [**Last Name (STitle) 36897**] with results,
([**Telephone/Fax (1) 62996**]
Completed by:[**2126-12-4**]
ICD9 Codes: 4280, 4240, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1576
} | Medical Text: Admission Date: [**2192-5-29**] Discharge Date: [**2192-6-7**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9152**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname 3968**] [**Known lastname 79941**] is a 90 woman with a history of a seizure
disorder
on Keppra. She is known to the neurology department from prior
admissions, most recently in [**2191-9-16**] when she presented
to the hospital with altered mental status and was found to be
in
status. Neurology has been today for concern of a similar
presentation.
The patient lives with son who does her ADLS. Per report, last
night he briefly left the home and on return he found her
unresponsive with her lips blue. EMS came and put her on
non-rebreather. Enroute to the hospital, she was documented as
having a GTC of unclear duration. She was given 5mg valium and
the seizure resolved by the time she reached the emergency room.
In the ED, EKG demonstrated ST elevations in V2-V4. It was
initially felt that the patient was CMO so she was treated only
with rectal aspirin and admitted to the medicine floor. However,
after discussion with her family it was felt the patient would
be
DNR/DNI and so she was started on a heparin drip, ordered for
rectal plavix (not yet given) and transferred to the cardiology
floor.
At present, the patient is arousable but not able to speak. She
has been noted to have flexure posture left UE but the RUE is
rhythmically contracting. LEs are quiet. The team is loading her
with 1g Keppra IV and continuous EEG has been ordered. Because
of
her DNR/DNI status, there is a goal to avoid sedating
medications.
Per her family, the patient has not had any recent illness.
They
deny any siezures since [**Month (only) 359**] and state they always bring her
to the hospital when she has a seizure. They have not noticed
any episodes of unresponsiveness at home. She has not had any
known head trauma or falls.
The patient is unable to offer any history at this time.
Past Medical History:
-Seizure disorder: Diagnosed 9/[**2188**]. Etiology uncertain.
Episodes of speech arrest with gaze deviation, occasional
generalized convulsion. Was initailly treated with
benzo/dilantin load which led to respiratory depression and
intubation. On Keppra since that time. Saw Dr. [**First Name (STitle) **] of [**Location (un) 2274**]
once in [**10/2191**] after discharge in [**2190**].
-Dementia NOS
-Hypertension
-Coronary artery disease
-Mild LV [**Year (4 digits) 7216**] dysfunction
-Mitral regurgitation
-Rheumatoid arthritis
-COPD/asthma on inh steroid/[**Last Name (un) **] (Advair) and PRN nebs
-Hypertension
-Coronary artery disease
-Mild LV [**Last Name (un) 7216**] dysfunction
-Mitral regurgitation ([**12-18**]+)
-Mild pulmonary artery systolic hypertension
-Rheumatoid arthritis
-h/o hospitalization for PNA [**4-24**], now [**5-26**]
Social History:
Immigrant from [**Country 38213**]; lived at home with son. At baseline, the
family says that she talks, eats purees, and walks with a
walker. Over the last few months, however, she has no longer
been able to go to the bathroom on her own. No [**Country **],
smoking, or ETOH use
Family History:
No family history of seizures.
Physical Exam:
< ON ADMISSION >
Afebrile BP 178/88 HR 80 RR 22 O2% 80% Non-rebreather
General: Laying in bed, seizing.
Head and Neck: Dried blood in the mouth. MMD.
Neck: Supple
Pulmonary: Rapid, shallow breaths, Lungs clear
Cardiac: regular rate and rhythm, could not appreciate a murmur
Abdomen: soft, non apparent tenderness
Extremities: warm, well perfused. Multiple [**Last Name (un) 2043**] deformities in
the hands and feet related to arthritis
Skin: no rashes or lesions noted.
Neurologic:
Pt is seizing- Unresponsive to verbal stim/commands. Does not
speak. Eyes are intermittanly deviated to the right. Pupils are
3mm and minimally reactive (has bilateral lense
opacities/cataracts). Right eye intermittently blinking, + lip
smacking. Right arm is flexed and contracting at the elbow,
wrist and shoulder. Right foot is occasionally extending at the
ankle. Tone is increased throughout, could not elicit reflexes.
Withdraws all limbs except the right upper extremity to noxious
stim.
< ON DAY OF DISCHARGE >
VS are stable/normal. Satting 92-97% on RA with HR in 60s-70s.
Gen: cachectic. Lying in bed in NAD.
HEENT: edentulous, MMM.
Pulm: increased air movement at the Right base, no wheezes or
rhonchi. Scattered dry crackles (?atalectasis with resolving PNA
on R and bilateral mild effusions on CXR). No wet crackles.
Decreased BS and dullness to percussion at both bases, R>L.
CV: HS are regular. No JVD. No [**Location (un) **]. Hand/wrist edema 3-4d ago
has since resolved.
Abd: Soft, flat, non-tender. +BS.
Neuro: eyes open. Tracks. Does not speak. Does not follow
commands, including son's commands in her native language. CN
exam unchanged with PERRL, conjugate EOMs, no nystagmus, +weak
blink to threat in all quadrants, +corneals, symmetric face.
Turns neck occasionally, but does not move arms or legs
spontantously, but withdraws briskly from pain in all four
extremities. Hands/wrists are flaccid (with profound RA
changes), while arms are contracted, but extendable. Patient can
hold arms up antigravity bilaterally, but does not follow
commands for sensory/motor testing. No movement in either leg.
On Discharge:
Lying in bed, NAD, op clear, rrr, cta, abd soft, ext
nonedematous, Awake, not speaking or following commands but
unclear if this is related to language barrier as patient
primarily speaks Albanian. PERRL, blinks to threat bilaterally,
EOMI, face symm, withdraws to noxious stim in all extremities.
Pertinent Results:
[**2192-6-7**] 05:18AM BLOOD WBC-7.2 RBC-4.32 Hgb-13.1 Hct-39.2 MCV-91
MCH-30.4 MCHC-33.5 RDW-13.6 Plt Ct-299
[**2192-6-6**] 05:00AM BLOOD WBC-7.7 RBC-4.52 Hgb-13.6 Hct-40.0 MCV-89
MCH-30.1 MCHC-33.9 RDW-13.7 Plt Ct-314
[**2192-6-5**] 05:55AM BLOOD WBC-6.7 RBC-4.36 Hgb-13.3 Hct-40.0 MCV-92
MCH-30.4 MCHC-33.1 RDW-13.7 Plt Ct-268
[**2192-6-4**] 10:00AM BLOOD WBC-UNABLE TO RBC-UNABLE TO Hgb-UNABLE
TO Hct-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO Plt Ct-UNABLE TO
[**2192-6-3**] 06:20AM BLOOD WBC-6.1 RBC-3.89* Hgb-12.0 Hct-36.0
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.4 Plt Ct-288
[**2192-6-2**] 09:30AM BLOOD WBC-4.9 RBC-3.87* Hgb-11.3* Hct-34.9*
MCV-90 MCH-29.3 MCHC-32.5 RDW-13.3 Plt Ct-261
[**2192-6-1**] 06:15AM BLOOD WBC-8.0 RBC-3.92* Hgb-11.9* Hct-35.2*
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.2 Plt Ct-230
[**2192-5-31**] 08:31AM BLOOD WBC-14.2* RBC-3.72* Hgb-11.1* Hct-33.1*
MCV-89 MCH-29.7 MCHC-33.5 RDW-13.2 Plt Ct-246
[**2192-5-30**] 03:59AM BLOOD WBC-13.3* RBC-4.16* Hgb-12.4 Hct-36.5
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.5 Plt Ct-283
[**2192-5-29**] 11:29AM BLOOD WBC-9.9 RBC-4.36 Hgb-13.2 Hct-39.1 MCV-90
MCH-30.2 MCHC-33.7 RDW-13.3 Plt Ct-285
[**2192-5-29**] 01:48AM BLOOD WBC-8.6 RBC-4.21 Hgb-13.1 Hct-38.7 MCV-92
MCH-31.1 MCHC-33.8 RDW-13.2 Plt Ct-348
[**2192-6-3**] 06:20AM BLOOD Neuts-84.1* Lymphs-11.1* Monos-4.2
Eos-0.2 Baso-0.4
[**2192-6-2**] 09:30AM BLOOD Neuts-82.9* Lymphs-13.1* Monos-3.7 Eos-0
Baso-0.2
[**2192-5-29**] 11:29AM BLOOD PT-12.2 PTT-25.8 INR(PT)-1.0
[**2192-5-29**] 01:48AM BLOOD PT-12.8 PTT-27.0 INR(PT)-1.1
[**2192-5-29**] 01:48AM BLOOD Fibrino-394
[**2192-6-7**] 05:18AM BLOOD Glucose-83 UreaN-11 Creat-0.5 Na-140
K-4.0 Cl-99 HCO3-34* AnGap-11
[**2192-6-6**] 09:02PM BLOOD Glucose-86 UreaN-12 Creat-0.4 Na-142
K-3.0* Cl-99 HCO3-34* AnGap-12
[**2192-6-6**] 05:00AM BLOOD Glucose-97 UreaN-15 Creat-0.4 Na-141
K-3.0* Cl-93* HCO3-41* AnGap-10
[**2192-6-5**] 05:55AM BLOOD Glucose-80 UreaN-17 Creat-0.5 Na-142
K-3.5 Cl-98 HCO3-32 AnGap-16
[**2192-6-4**] 10:00AM BLOOD Glucose-[**2180**]* UreaN-7 Creat-0.6 Na-LESS
THAN K-2.0* Cl-50* HCO3-19*
[**2192-6-3**] 06:20AM BLOOD Glucose-119* UreaN-16 Creat-0.6 Na-137
K-3.6 Cl-101 HCO3-29 AnGap-11
[**2192-6-2**] 09:30AM BLOOD Glucose-139* UreaN-18 Creat-0.5 Na-139
K-3.8 Cl-102 HCO3-28 AnGap-13
[**2192-6-1**] 06:15AM BLOOD Glucose-91 UreaN-12 Creat-0.5 Na-134
K-3.7 Cl-99 HCO3-27 AnGap-12
[**2192-5-31**] 08:31AM BLOOD Glucose-111* UreaN-17 Creat-0.6 Na-133
K-3.6 Cl-97 HCO3-28 AnGap-12
[**2192-5-30**] 03:59AM BLOOD Glucose-99 UreaN-12 Creat-0.5 Na-129*
K-4.1 Cl-93* HCO3-24 AnGap-16
[**2192-5-29**] 11:29AM BLOOD Glucose-84 UreaN-14 Creat-0.5 Na-130*
K-4.5 Cl-93* HCO3-26 AnGap-16
[**2192-5-30**] 03:59AM BLOOD CK(CPK)-68
[**2192-5-29**] 07:49PM BLOOD CK(CPK)-85
[**2192-5-29**] 11:29AM BLOOD CK(CPK)-60
[**2192-5-29**] 01:48AM BLOOD CK(CPK)-29
[**2192-5-30**] 03:59AM BLOOD CK-MB-6 cTropnT-0.17*
[**2192-5-29**] 07:49PM BLOOD CK-MB-9 cTropnT-0.19*
[**2192-5-29**] 11:29AM BLOOD CK-MB-11* MB Indx-18.3* cTropnT-0.27*
[**2192-5-29**] 01:48AM BLOOD CK-MB-5
[**2192-5-29**] 01:48AM BLOOD cTropnT-LESS THAN
[**2192-6-7**] 05:18AM BLOOD Calcium-8.7 Phos-2.0* Mg-1.8
[**2192-6-6**] 09:02PM BLOOD Mg-1.7
[**2192-6-6**] 05:00AM BLOOD Calcium-9.0 Phos-2.3* Mg-1.9
[**2192-6-5**] 05:55AM BLOOD Calcium-8.9 Phos-1.9* Mg-1.8
[**2192-6-3**] 06:20AM BLOOD Calcium-8.6 Phos-1.9* Mg-2.0
[**2192-6-2**] 09:30AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1
[**2192-6-1**] 06:15AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.8
[**2192-5-31**] 08:31AM BLOOD Calcium-8.7 Phos-2.0* Mg-1.7
[**2192-5-30**] 03:59AM BLOOD Albumin-3.7 Calcium-9.0 Phos-2.5* Mg-1.7
[**2192-5-29**] 11:29AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8
[**2192-6-6**] 05:00AM BLOOD Osmolal-293
[**2192-6-3**] 08:50AM BLOOD Vanco-15.6
[**2192-6-2**] 09:30AM BLOOD Vanco-5.0*
[**2192-6-1**] 06:15AM BLOOD Digoxin-1.3
[**2192-5-29**] 01:48AM BLOOD Digoxin-0.4*
[**2192-6-7**] 05:18AM BLOOD Valproa-86
[**2192-6-6**] 05:00AM BLOOD Valproa-73
[**2192-6-5**] 05:55AM BLOOD Valproa-64
[**2192-6-3**] 06:20AM BLOOD Valproa-60
[**2192-6-2**] 09:30AM BLOOD Valproa-64
[**2192-6-1**] 06:15AM BLOOD Valproa-62
[**2192-5-31**] 08:31AM BLOOD Valproa-58
[**2192-6-1**] 10:00AM BLOOD Type-ART Temp-36.6 Rates-/36 O2 Flow-5
pO2-61* pCO2-42 pH-7.44 calTCO2-29 Base XS-3 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2192-6-1**] 10:00AM BLOOD Lactate-1.1 Na-132* K-3.2* Cl-97*
[**2192-5-29**] 01:55AM BLOOD Glucose-239* Lactate-5.2* Na-130* K-4.4
Cl-90* calHCO3-24
[**2192-6-1**] 10:00AM BLOOD freeCa-1.22
MOST RECENT AVAILABLE LTM-EEG 24h report [**6-3**]:
FINDINGS:
ROUTINE SAMPLING: Shows a mixed [**5-22**] Hz theta frequency and [**2-17**]
Hz delta
frequency background. In addition, there were frequent sharp
transients
seen broadly over the left hemisphere.
SPIKE DETECTION PROGRAMS: There were four entries in these files
which
do not include any epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There was one entry in these files
which
consists of lead artifact.
PUSHBUTTON ACTIVATIONS: There were no entries in these files.
SLEEP: The patient progressed from wakefulness into stages I-IV
of
sleep.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 70-80 bpm.
IMPRESSION: This is an abnormal continuous EEG due to the
presence of a
mixed [**5-22**] Hz theta and [**2-17**] Hz delta frequency background
consistent with
a mild diffuse encephalopathy. In addition, there are frequent
sharp
transients seen broadly over the left hemisphere; however,
compared to
the previous tracing, there are fewer definite interictal sharp
discharges. There were no electrographic seizures seen. Compared
to
the previous tracing, this tracing is slightly improved.
CXR [**5-30**]
IMPRESSION: AP chest compared to [**5-29**]:
A new large area of homogeneous opacification has developed at
the base of the right hemithorax, at least some of which is
pleural effusion. The rest could be a large area of pneumonia or
collapse, or a larger collection of pleural effusion. Upright
and right decubitus positioning for the subsequent radiographic
studies might be helpful in elucidating that. Left lung is
clear. Heart size is normal. No pneumothorax.
NCHCT [**5-30**]
FINDINGS: Study is limited by motion artifact. Within this
limitation, there is no evidence for acute intracranial
hemorrhage, large mass, mass effect, edema, or hydrocephalus.
Very prominent sulci and ventricles likely reflect age-related
involutional changes. White matter hypodensities are likely
secondary to sequela of chronic small vessel ischemic disease.
Visualized bones and soft tissues are grossly unremarkable. The
visualized portions of the paranasal sinuses and mastoid air
cells are grossly well aerated, although note is made of
under-pneumatization of the mastoid air cells bilaterally.
IMPRESSION: Limited study without evidence for an acute
intracranial process.
Brief Hospital Course:
Ms. [**Known lastname 79941**] was admitted initially to [**Hospital1 18**] Cardiology for ST
depressions and a mild (peak ~0.3) trop elevation. She was found
to be in NCSE with non-responsiveness and left-gaze deviation,
so she was transferred to the Neuro-ICU for seizure management.
Options for NCSE were limited by her DNR/DNI status and family
concerns over her [**2188**] experience in which she was intubated
after respiratory failure followed PHT/LZP for seizure.
Conservative measures were therefore taken with their permission
-- levetiracitam (Keppra) was increased (from home dose of
750bid) to 1500mg [**Hospital1 **]. Depakote (VPA) was added, and her seizure
frequency decreased gradually to zero with levels of VPA in the
60s. Goal VPA is 60-70. She was switched to PO sprinkles
Depakote on the day of discharge (prev IV 200q8 --> 150q6, now
250/375 [**Hospital1 **] PO dosing; goal 60-70 VPA trough level). She was
transferred to the hospital floor on the Epilepsy Neurology
service. She remained seizure free on these two AEDs (LEV and
VPA), and EEG leads were removed several days before discharge.
She took several days to awaken and track and start eating, but
has not yet recovered to her sons' stated baseline of talking
and following commands.
She arrived on the floor in respiratory distress with a RLL
pneumonia and COPD exacerbation. We continued Vancomycin and
Zosyn (plan = 10-day course) for PNA, and started q3h albuterol
/ q6h ipratropium nebs as well as qdaily 40mg methylprednisolone
for 5-day course (no taper), which she completed [**6-5**]. The nebs
were spaced to PRN:q6 by the following week (several days prior
to discharge and her respiratory status improved dramatically
with the aforementioned treatment regimen. She will complete the
IV abx on [**6-8**], and she is continued on her COPD home Rx regimen
(Advair [**Hospital1 **] and PRN nebs for wheezing / dyspnea). Her ASA and
dig were continued. Dig level was therapeutic (see above) on her
home 0.1mg dosing, which was given here by injection while NPO.
She was started on metoprolol 5mg q6hr IV (no BB in home med
regimen despite known MR [**First Name (Titles) **] [**Last Name (Titles) 7216**] CHF), which can be
switched to PO if she continues tolerating
She was deemed by S&S contult as tentatively safe for swallowing
with puree/honey-thick liquids, with the acknowledged risk that
she may aspirate. This was discussed with her sons, who agreed
that this is the best course for her and she would not want
artificial/invasive means of feeding (i.e. no PEG). On the day
of discharge, she was doing quite well with cautious feeds of
applesauce. Her Depakote was switched to PO sprinkles mixed with
the applesauce; her other medicines can be switched as well if
she continues tolerating PO feeds.
Medications on Admission:
- Keppra 1 gram qAM, 500mg qPM
- ASA 325mg daily
- Combivent 2 puffs by mouth 3-4 times daily
- Advair 250/50 [**Hospital1 **]
- Digoxin 0.125 (1 tablet daily Monday thru Friday, no Digoxin
on
Saturday and Sundays)
Discharge Medications:
1. aspirin 300 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever>100.5.
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): For DVT ppx.
6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for skin redness.
7. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing/respiratory distress.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing/respiratory distress.
9. metoprolol tartrate 5 mg/5 mL Solution Sig: One (1)
Intravenous Q4H (every 4 hours): Hold for HR < 60 or SBP < 90;
[**Month (only) 116**] switch to PO dosing as tolerated.
10. famotidine(PF) in [**Doctor First Name **] (iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours).
11. digoxin 250 mcg/mL Solution Sig: 0.1 mg Injection DAILY
(Daily).
12. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 gm
Intravenous Q6H (every 6 hours) for 2 days: Day 1 = [**2192-5-30**]
contine through [**6-8**] to finish 10day course.
13. levetiracetam 500 mg/5 mL Solution Sig: 1500 (1500) mg
Intravenous Q12H (every 12 hours): may switch to PO
levetiracitam as tolerated.
14. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) as needed for
RLL-pneumonia for 2 days: Day 1 = [**2192-5-30**]
contine THROUGH [**6-8**] to finish 10day course.
15. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
16. Depakote Sprinkles 125 mg Capsule, Sprinkle Sig: Three (3)
Capsule, Sprinkle PO qPM: 250mg in the morning (2caps); 375mg in
the evening (3caps).
17. Depakote Sprinkles 125 mg Capsule, Sprinkle Sig: Two (2)
Capsule, Sprinkle PO qAM: 250mg in the morning (2caps); 375mg in
the evening (3caps).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary diagnoses:
1. Non-convulsive status epilepticus
2. Pneumonia
3. COPD exacerbation
4. mild NSTEMI
Secondary diagnoses:
<see discharge summary, PMH>
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Awake and alert -- tracks and swallows
applesauce/purees, but does not speak or follow commands.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mrs. [**Known lastname 79941**], you were admitted initially to the Cardiology
service out of concern for your heart, which suffered a very
minor injury and seems to have recovered well. You were then
moved to the Neurology-ICU service due to seizures. Your Keppra
dose was increased to 1500mg (still twice per day). A new
anti-epileptic drug was added, called Depakote (sodium
valproate), and your seizures stopped, so you were transferred
to the hospital floor on the Epilepsy Neurology service, where
we have been caring for you for over a week. You did not have
any more seizures, so we removed the EEG monitoring leads.
When you arrived on the floor, you were in respiratory distress
for a pneumonia and COPD exacerbation. You were given IV
antibiotics for the pneumonia, and albuterol + ipratropium
nebulizer treatments with IV steroid x five days for the COPD
(reactive airways disease / bronchospasm). Your breathing
improved greatly over the next few days, and the antibiotics
will finish after a 10-day course. You should continue taking
your COPD medicines (Advair twice per day, every day, plus
albuterol whenever you are wheezing or short of breath). For
your heart, we continued your home medications (aspirin,
digoxin, and metoprolol, which you should continue after
discharge as before.
Finally, you took a long time to wake up from all the illnesses
you developed (mild heart attack, pneumonia, COPD exacerbation,
and seizures with new seizure medicines) and you were not safe
for swallowing due to the risk that you would aspirate water and
food into your lungs and worsen your pneumonia. At the end of
your hospital stay, our colleagues in SPEECH & SWALLOW evaluated
you, and suggested it would be OK to try eating pureed foods and
specially-thickend liquids, as long as you and your family
understand that you are at elevated risk for developing another
pneumonia. Your sons determined that you would not want a
feeding tube implanted into your abdomen/stomach, so this was
not pursued. You are initially doing well with very cautious
feeding with purees (e.g. applesauce, ground eggs).
It was a pleasure taking care of you and discussing your care
with your sons, Ms. [**Known lastname 79941**]! Best of luck to all of you in the
future; be well!
Followup Instructions:
1. With Neurologist. Please call if you need to reschedule your
appointment.
- Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Location (un) 2274**]: [**Telephone/Fax (1) 63931**] -- [**7-16**] ([**2191**])
at 1:00pm
-location: [**Location (un) 2129**] (2blks down [**Location (un) **], across the
street [**Hospital1 79945**]).
2. With your PRIMARY CARE PROVIDER [**Name9 (PRE) 2678**] after discharge from
Rehab facility. Please call for appointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9153**]
Completed by:[**2192-6-7**]
ICD9 Codes: 486, 4280, 4019, 4240, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1577
} | Medical Text: Admission Date: [**2176-10-24**] Discharge Date: [**2176-12-7**]
Date of Birth: [**2176-10-24**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] was born by
emergency section due to brisk vaginal bleeding from a
placental abruption. He was born at 31 and 6/7 weeks
gestation, weighing [**2140**] grams. He was admitted to the NICU
for prematurity and respiratory distress.
MATERNAL HISTORY: Mother is a 35 year-old, Gravida I, Para
0, now I with an EDC of [**2176-12-20**]. Blood type 0 positive,
antibody negative, HBSAG negative, RPR nonreactive, GBS
unknown. Rubella immune. Mother had a 10 cm subchorionic
hematoma that resolved and she had P-PROM with clear fluid at
22 weeks gestation at a hospital in Bermuda. There was no
preterm labor or vaginal bleeding at that time. On [**2176-9-14**],
she presented with vaginal bleeding and spotting. She was
treated with betamethasone, Penicillin and transferred from
Bermuda to [**Hospital1 18**] on [**2176-9-16**] at 26 weeks gestation for further
management. She completed a course of betamethasone on
[**2176-9-17**], was treated with Ampicillin and Erythromycin also.
On arrival to [**Hospital1 18**], she had no active bleeding. There were
good fetal movements and no further complications until the
day of delivery when she began to have the brisk large
bleeding. In the delivery room, the infant was initially
limp and cyanotic but became more vigorous with a spontaneous
cry with just stimulation. He pinked centrally on his own.
He had good tone but did develop some respiratory distress
with increased retractions, requiring facial C-Pap in the
delivery room. The infant was transferred to the NICU for
further management. Apgars were 8 and 8 at 1 and 5 minutes.
Of significant note in the delivery room, the infant's
umbilical cord was found to be small and withered in
appearance with a greenish stain to it. No meconium stained
fluid. Large amount of bloody, amniotic fluid at delivery
with clot.
PAST MEDICAL HISTORY: Non contributory to the infant's
issues.
SOCIAL HISTORY: Non contributory to the infant's issues.
FAMILY HISTORY: The family lives in Bermuda.
PHYSICAL EXAMINATION: On admission to the NICU, birth weight
was [**2140**] grams. Head circumference was 30 cm. Length was 46
cm. Length was 90th percentile. Weight was 90th percentile.
The head circumference was 75th percentile. HEENT: Normal
head with mild molding. Eyes: Normal. Nose, ears, mouth
normal. Normal palate. Neck supple. No masses. Chest:
Decreased breath sounds equal bilaterally with some
retractions. CV: Normal heart sounds, no murmur, normal
pulse and perfusion. Abdomen: No masses. Nontender,
nondistended. Umbilical cord: Yellowish, green stain.
Genitourinary: Normal premature male, patent anus. Sac
normal. Extremities: Normal skin. Normal neuro
developmental. Active. Normal tone, normal strength.
HOSPITAL COURSE: Respiratory: The infant was intubated on
admission to the NICU and given Surfactant therapy, 2 doses.
Was placed on high frequency ventilation on admission to the
NICU as well. The infant remained on high frequency
ventilation and was actually found to have a
pneumomediastinum and a right pneumothorax on day of life 1
while on high frequency ventilation. The infant was weaned to
nasal cannula on that same day. The pneumomediastinum and
right sided pneumo, both resolved on their own without
intervention. The infant weaned to room air on day of life 4,
[**2176-10-28**] and has remained on room air since that time. The
infant has had rare apneic and bradycardiac episodes. Never
required methylxanthine therapy. He was noted to have occasional
bradycardia with or without desaturation whic was completely
resolved. He did not have any epsiode for 5 consecutive days
prior to discharge.
Cardiovascular: He was initially cardiovascularly stable, not
requiring any inotropic support but did develop a murmur on
day of life 25 which is [**2176-11-18**]. Echocardiogram was done at that
time which showed trivial left pulmonary artery stenosis, a small
PFO and no PDA. The infant has had no further cardiac
evaluations but it is recommended that follow-up with a
cardiologist takes place at some point for the PFO. Otherwise,
the infant at this present times does have a murmur but does
maintain normal heart rates and blood pressures.
Fluids, electrolytes and nutrition: IV fluids were initiated
on the newborn day. The infant had peripheral IV placed at
that time. Enteral feedings were initiated on day of life 2
and slowly advancing fine up until day of life 6 on [**2176-10-30**]
when the infant presented with a grossly bloody stool at that
time. The infant was then made n.p.o. IV fluids were
reinitiated. Prior to that taking place, the infant had
achieved almost full feedings, was up to 130 ml/kg per day of
enteral feedings. The feedings were then stopped. KUB was
done and there was concern for necrotizing enterocolitis but
non specific. There was no bowel perforation but concern for
pneumatosis. The CBC at that time was normal. Due to the
bloody stools, the infant was made n.p.o. and treated for a
14 day course for NEC. The infant had a PICC line placed on
[**2176-11-3**] for prolonged IV nutrition. The infant remained
n.p.o. for the full 14 day course and enteral feedings were
again initiated on [**2176-11-13**] and slowly advanced to full
feedings. Full feedings were achieved on [**2176-11-22**] and
calories were further advanced to 24 calories per ounce
breast milk or Special Care 24 cals per ounce which was weaned
down to 20 cal/oz on [**2176-12-5**] and she demonstrated god weight
gain. Infant is voiding and stooling normally on his own. Most
recent head circumference is 34 cm and the length is 50 cm
The discharge weight is 3220 gm.
Gastrointestinal: The infant was treated for the 14 days of
necrotizing enterocolitis as mentioned above. Also, the
infant developed hyperbilirubinemia with a peak bilirubin
level of 11.1 over 0.5. He received a total of 4 days of
phototherapy.
Hematology: Hematocrit at birth was 49; platelet count 56.
The infant has required no blood product transfusions and the
most recent hematocrit was 27.4 with a retic count of 2.3%
and that was on [**2176-11-21**]. The infant has required no blood
product transfusions. The infant's blood type is 0 positive,
DAP negative. The infant was started on elemental iron or
Ferinsol on [**2176-11-25**]. The infant is presently getting 0.2 ml
per day of Ferinsol.
Infectious disease: CBC and blood culture were screened on
admission to the NICU. The infant received a 36 hour rule out
of Ampicillin and Gentamycin which were subsequently
discontinued. When the clinical status improved, the blood
culture remained negative. The CBC was benign on admission to
the NICU. The infant was restarted on antibiotics when he
developed bloody stools on day of life 6, [**2176-10-30**]. The CBC
at that time was not shifted but within 12 hours from that
point in time, the CBC did then become shifted with a
bandemia. The blood culture that was drawn on [**2176-10-30**] did
grow gram positive cocci which was identified as staph epi.
The infant was started on Vancomycin and Gentamycin on
[**2176-10-30**] which was subsequently switched to Zosyn and
Vancomycin on [**2176-10-30**] shortly thereafter starting the
Gentamycin. The infant continued on antibiotics for a full
14 days from that point in time. The antibiotics were
subsequently discontinued on [**2176-11-12**]. There had been no
further issues with infectious disease.
Neurologic: Head ultrasound was screened on [**2176-10-31**] which
was found to be within normal range. A 1 month head
ultrasound was done on [**2176-11-27**] and the results are normal.
Sensory:
Hearing: A hearing screen was performed with automated
auditory brain stem responses and the result is .
Ophthalmology: The infant had 2 eye exams performed. One was
on [**2176-11-10**] which showed immaturity to zone 2. Follow-up was
[**2176-11-25**] which showed immaturity but in the zone 3 range.
Recommendation is for a repeat eye exam in 3 weeks from the
date of [**2176-11-25**].
Psychosocial: [**Hospital1 18**] social worker has been involved with the
family. There have been ongoing issues with returning the
infant back to home in Bermuda. If there are any psychosocial
issues or questions, the [**Hospital1 18**] social worker can be reached
at [**Telephone/Fax (1) 8717**].
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: Home with the parents to Bermuda on
commercial airline.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 69070**], telephone
number [**Telephone/Fax (1) 69071**].
CARE RECOMMENDATIONS: Ad lib p.o. feedings of 20 calorie,
either breast milk or Similac 20 calorie with iron and breast
feeds as well.
MEDICATIONS: Ferinsol .2 ml p.o. daily.
CAR SEAT SCREENING: Performed on [**2176-11-26**].
STATE NEWBORN SCREENS: Sent on [**9-4**] and [**11-7**]. The
initial state screen sent on [**10-27**] showed an elevated 17 OH.
Follow-up state screens both remained normal.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine was given on
[**2176-11-25**].
The initial Synagis dose was given on [**2176-11-26**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: (1) Born at less than
32 weeks; (2) Born between 32 weeks and 35 weeks with two of
the following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; (3) chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP: The infant should follow-up with the pediatrician
within 2 days of discharge from the NICU.
The infant should also have follow-up at an ophthalmologist
by the end of [**Month (only) **].
Follow-up with cardiologist for PFO.
Follow-up with early intervention.
DISCHARGE DIAGNOSES:
1. Prematurity born at 31 and 6/7 weeks gestation.
2. Respiratory distress syndrome resolved.
3. Pneumomediastinum resolved.
4. Right pneumothorax resolved.
5. Sepsis ruled out.
6. Necrotizing enterocolitis resolved.
7. Hyperbilirubinemia resolved.
8. Patent foramen ovale (PFO) murmur, L trivial PA stenosis
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2176-11-27**] 00:35:45
T: [**2176-11-27**] 05:46:38
Job#: [**Job Number 69072**]
ICD9 Codes: 769, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1578
} | Medical Text: Admission Date: [**2102-11-10**] Discharge Date: [**2102-11-17**]
Date of Birth: [**2025-1-20**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 77 year old male had an
abnormal electrocardiogram at a recent routine visit with his
primary care physician. [**Name10 (NameIs) **] had been having increasing
fatigue for greater than one year and dyspnea on exertion
also for greater than one year. His stress test was positive
after his abnormal electrocardiogram. He had a cardiac
catheterization performed at [**Hospital6 3872**] in
late [**2102-9-22**], which showed left anterior descending
coronary artery 90 percent lesion, diagonal two 90 percent
lesion, diagonal three 60 percent lesion, circumflex 90
percent lesion, right coronary artery 70 to 75 percent
lesion., posterior descending coronary artery 60 percent
lesion and an ejection fraction of 40 percent, a dilated
aortic root and mildly elevated left ventricular end
diastolic pressure. Cardiac catheterization done in [**2101-6-21**], showed an ejection fraction of 35 to 40 percent with
mild mitral regurgitation. The patient was admitted to the
hospital on [**2102-11-10**], in preparation for his surgery. He
was to be done electively but called complaining of shortness
of breath so the patient was admitted to the hospital.
PAST MEDICAL HISTORY: Murmur.
Myocardial infarction twenty years ago.
Hiatal hernia.
Gastroesophageal reflux disease.
History of atrial fibrillation twenty years ago.
PAST SURGICAL HISTORY: Cataract removal in [**2088**], and [**2089**].
PREOPERATIVE MEDICATIONS:
1. Toprol XL 100 mg daily.
2. IMDUR 30 mg p.o. daily.
3. Lisinopril 5 mg p.o. daily.
4. Reglan 10 mg p.o. daily.
5. Naproxen 250 mg p.o. twice a day but was stopped prior to
his admission.
6. Ecotrin 325 mg p.o. daily.
7. Glucosamine combination drug p.o. daily.
8. Prilosec p.r.n.
ALLERGIES: He had no known drug allergies.
PHYSICAL EXAMINATION: On examination, he was sitting up in
bed in no apparent distress. He was alert and oriented times
three and appropriate. He had crackles of his right base and
diminished breath sounds of his left base. His heart was
regular rate and rhythm with S1 and S2 and grade II/VI
systolic ejection murmur. His abdomen was soft, round,
nontender, nondistended with positive bowel sounds. His
extremities were warm and well perfused with trace edema
bilaterally. He had two plus bilateral radial, dorsalis
pedis and posterior tibial pulses.
LABORATORY DATA: His preoperative laboratories were as
follows: White blood cell count 7.3, hematocrit 46.7,
platelet count 419,000. Sodium 140, potassium 4.1, chloride
100, bicarbonate 29, blood urea nitrogen 19, creatinine 1.0
with a blood sugar of 61. His HbA1C was 4.9 percent.
Prothrombin time 12.3, partial thromboplastin time 27.7, INR
1.0. ALT 21, AST 24, alkaline phosphatase 90, total
bilirubin 0.6, albumin 4.6. Preoperative urinalysis was
negative. His preoperative chest x-ray showed no acute
cardiopulmonary process.
HO[**Last Name (STitle) **] COURSE: He was given intravenous Lasix for diuresis
prior to surgery. The next day, [**2102-11-11**], the patient
underwent coronary artery bypass grafting times four by Dr.
[**Last Name (Prefixes) **] with left internal mammary artery to the left
anterior descending coronary artery, saphenous vein graft to
the posterior descending coronary artery, saphenous vein
graft to the obtuse marginal and saphenous vein graft to the
diagonal. He was transferred to the Cardiothoracic Intensive
Care Unit in stable condition on Neo-Synephrine drip at 0.3
mcg/kg/minute, a Dobutamine drip at 3.0 mcg/kg/minute and a
Propofol drip at 10 mcg/kg/minute. On postoperative day
number one, the patient had been extubated overnight. He was
given volume, remained on Dobutamine drip at 3.0 and the Neo-
Synephrine drip had been weaned off. He was also on insulin
drip at 4 units per hour. Aspirin was restarted.
Postoperative white blood cell count was 12.1, hematocrit
27.0, potassium 4.4, blood urea nitrogen 15, creatinine 1.0.
He was hemodynamically stable with a blood pressure of 109/58
and in sinus tachycardia at 103. On postoperative day number
two, he had been transfused one unit of packed red blood
cells for a hematocrit of 24.0, remained in sinus rhythm with
no other significant events. He began intravenous Lasix
diuresis 20 mg twice a day. His examination was
unremarkable. His creatinine remained stable at 1.0. He
started his beta blocker. His Swan-Ganz was discontinued and
he was transferred out to the floor. On postoperative day
number three, the patient was ambulating independently on the
floor although complaining of a little bit of weakness. He
had a full evaluation done by physical therapy. He remained
stable. His hematocrit rose to 28.7. He had good blood
pressure. His examination was unremarkable with trace
peripheral edema. His incisions were clean, dry and intact.
His pacing wires remained in place. His chest tubes had
minimal drainage. His chest tubes and pacing wires were
discontinued later in the day without incident. The patient
was encouraged to increase his p.o. intake and increase his
level of activity by increased amounts of ambulation. He was
receiving Percocet which gave him nausea, so this was
switched over to Tylenol number three for pain. On
postoperative day number four, the patient continued to
progress very well and was waiting to do a complete level
five prior to his discharge. His beta blocker was increased
to Lopressor 50 mg twice a day. He was receiving p.o.
Tylenol with Codeine for pain management. His lungs were
rhonchorous but his examination was otherwise unremarkable.
He was alert and oriented with a nonfocal neurologic
examination. On postoperative day number five, he was doing
very well but had some persistent tachycardia with a heart
rate in the 90 to 105 range. His Lopressor was discontinued.
He started Toprol 100 mg p.o. daily. He was alert and
oriented. This was changed at patient request for the
simplicity of once a day dosing. His creatinine remained
stable at 0.9. He had occasional premature ventricular
contractions with couplets and a six beat run of
supraventricular tachycardia at 11:00 p.m. on the evening of
[**2102-11-17**], without any symptoms whatsoever, was saturating
94 to 97 percent in room air with decreased breath sounds at
his bases. The following morning the day of discharge, he
was in sinus rhythm at 84 beats per minute with a temperature
maximum of 98.9, blood pressure 120/63. Laboratories the day
prior were white blood cell count 8.3, hematocrit 29.3,
platelet count 386,000, potassium 4.0, blood urea nitrogen
20, creatinine 0.9. He had small blisters on his right
distal leg incision. His examination was otherwise
unremarkable other than some rhonchorous sounds in his
bilateral lung bases but he was much improved with better
heart rate control and the patient was deemed able to go home
with VNA services and was discharged on [**2102-11-17**].
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting times four.
Myocardial infarction twenty years ago.
Hiatal hernia.
Gastroesophageal reflux disease.
History of atrial fibrillation twenty years ago.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. twice a day for ten days.
2. Potassium Chloride 20 mEq p.o. twice a day for ten days.
3. Colace 100 mg p.o. twice a day.
4. Enteric Coated Aspirin 81 mg p.o. once daily.
5. Protonix 40 mg p.o. once daily.
6. Reglan 10 mg p.o. once daily.
7. Sustained Release Metoprolol 100 mg one tablet p.o. once
daily.
8. Niferex 150/50 mg tablet, one capsule p.o. once a day for
one month.
9. Vitamin C 500 mg p.o. twice a day for one month.
10. Folic Acid 1 mg p.o. once a day for one month.
FO[**Last Name (STitle) 996**]P: The patient was instructed to follow-up with Dr.
[**First Name (STitle) **], his primary care physician, [**Name10 (NameIs) **] one to two weeks
postdischarge, to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1655**] in
approximately one to two weeks postdischarge and to follow-up
with Dr. [**Last Name (Prefixes) **], his surgeon, in the office for a
postoperative surgical visit in approximately three to four
weeks postdischarge.
DISCHARGE STATUS: He was discharged home with VNA services
in stable condition on [**2102-11-17**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2102-12-28**] 16:26:43
T: [**2102-12-30**] 09:06:11
Job#: [**Job Number 60201**]
ICD9 Codes: 4280, 4111, 412, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1579
} | Medical Text: Admission Date: [**2124-5-9**] Discharge Date: [**2124-5-24**]
Service: VASCULAR
HISTORY OF PRESENT ILLNESS: The patient was an 88-year-old
male with a history of cerebrovascular disease who presented
with signs and symptoms of peptic ulcer disease, but work-up
revealed the fact that the patient had postprandial abdominal
pain and was ultimately evaluated for mesenteric ischemia.
The patient's symptoms included intermittent abdominal pain,
as well as a description of an episode of diffuse abdominal
pain and "feeling lousy" after meals for the past several
months. The patient discouraged the patient from eating and
resulted in an [**7-1**] lb weight loss over the prior four months
before admission. Additionally, the patient noted a drastic
................., as well as an overall abdominal girth.
REVIEW OF SYSTEMS: He denied nausea or vomiting. He denied
diarrhea. No chills. Per the patient, he never had a [**Last Name 16423**]
problem "with his heart." He denied history of myocardial
infarction. No previous echocardiogram data. No prior
catheterization or rhythm disturbances. He did state that he
did have stress test long ago and could not remember exactly
what the nature or results of that were.
After being admitted for the work-up of mesenteric ischemia,
he did receive an arteriogram that showed significant
mesenteric vessel disease requiring likely operative
intervention. Prior to him going to the operating room, he
did get a cardiac consultation. Cardiology had seen the
patient, and given his multiple comorbidities, they
recommended work-up.
PAST MEDICAL HISTORY: Significant for diabetes times 30
years which is "labile." Prior history of stroke and
transient ischemic attacks. History of hypoglycemia from his
diabetes. Coronary artery disease with prior myocardial
infarction. History of hypertension. He denied tobacco. He
used alcohol occasionally.
SOCIAL HISTORY: He lived at home. He worked in a leather
factory. He repaired televisions and radios as his prior
occupations, but was retired on admission.
MEDICATIONS ON ADMISSION: Zestoretic q.d., Plavix 75 mg
q.d., Aspirin 325 mg q.d., Humulin N 15 q.a.m., Ambien 5 mg
q.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.0??????, pulse
101, respirations 18, blood pressure 150/80, oxygen
saturation 95% on room air. General: The patient was in no
acute distress. He was a well-developed, well-nourished
white male. HEENT: Pupils equal, round and reactive to
light and accommodation. Extraocular movements intact.
Normocephalic, atraumatic. Conjunctivae normal. Oropharynx
negative. Neck: Supple. Trachea midline. No palpable
lymphadenopathy. Lungs: Clear to auscultation but decreased
throughout. Heart: Regular, rate and rhythm. Normal S1 and
S2. Abdomen: Scaphoid. Minimally distended. Tympanitic.
Nontender. Rectal: Heme negative. Normal tone. No masses.
Musculoskeletal: Grossly intact. Pulse exam was 2+ femoral,
2+ dorsalis pedis, 2+ posterior tibial bilaterally. No
evidence of tissue loss.
HOSPITAL COURSE: The patient was admitted on [**2124-5-9**],
for his mesenteric ischemia work-up. He did receive a
preoperative carotid ultrasound that revealed no significant
hemodynamic lesions, either on the right or left carotid
bifurcation. [**Last Name (un) **] consultation was obtained for blood
sugar management while he was in-house. Ultimately he was
given prehydration Mucomyst for his in-house angiogram which
showed significant three-vessel disease. Additionally his
work-up included not only cardiac work-up but also PFT
evaluation.
On [**2124-5-14**], he was received preoperative work-up, and
his labs were notable for a white count of 10.6, hematocrit
39.1, and a platelet count 243, BUN and creatinine of 31 and
1.6; coags were with a PT and INR of 13.9 and 1.3, with a PTT
of 29.4. He had cardiac clearance. Carotid ultrasound as
previously stated was negative. Chest x-ray showed mild
congestive heart failure. Recheck showed some worsening
failure. Urinalysis was negative. He was placed on
perioperative beta-blocker.
On [**2124-5-15**], the patient went to the Operating Room
where he underwent aorto-SMA bypass with an 8 x 40 mm PTFE
graft under the assistance of Drs. [**Last Name (STitle) 1391**], [**Name5 (PTitle) **], and
Shan. At the time of operation, the findings were a
calcified aorta and occluded left CIA. The patient's blood
loss was 100 cc. He received 2200 cc of Crystalloid. Urine
output was 420 cc for the case. There were no complications.
He went to the PACU with palpable popliteals bilaterally, and
his feet were warm. He received Heparin 500 U/hr, as well as
Neo-Synephrine, and Dobutamine. The patient remained
intubated.
Cardiac consultation was required ..................
postoperative due to the patient's Dobutamine requirement and
low cardiac index. Initial index was 1.1 intraoperative with
a PA pressure of 61/30, and CVP of 14. Dobutamine had been
started intraoperatively empirically for hemodynamic
findings. Electrocardiogram postoperatively was unchanged
with left bundle branch block. Cardiology recommended
following cardiac outputs, as well as PA saturations and
aortic saturations. Echocardiogram was rechecked with a goal
wedge stated to be approximately 18. His enzymes were
ordered to be cycled accordingly.
At the time of postoperative check at 6:30 p.m. on [**2124-5-15**], he was still on Dobutamine drip at 2.5, Heparin drip at
500 U/hr, and epidural for pain. He remained intubated and
sedated. His temperature was 38.1??????C, 80, with frequent APCs,
blood pressure 110/50, CVP 15, PA pressure 52/24, wedge 24.
Fick Cardiac output index numbers were 4.07 and 2.31, with an
SVR of 1179. Non-Fick output index were 3.89 and 2.21. He
was on ................... with an SIMV, pressure support of
60%, 700 x 10, 5 and 5. Arterial blood gases on that were
7.32, 35, 158, 22, and 98%. He had a mixed mean of 70. He
received a total 2700 cc of fluids. Immediately
postoperatively he received 1 U packed red blood cells. His
postoperative hematocrit was 29.2, with a creatinine of 1.8,
and PTT of 85 on Heparin drip as noted. His CK was 90,
troponin less than 0.3.
Postoperative chest x-ray showed mild congestive heart
failure. Swan-Ganz catheter was in good position. There was
no evidence of pneumothorax. Electrocardiogram showed no
acute ischemia. No changes. Echocardiogram postoperatively
demonstrated an ejection fraction of 25%, with decreased
right ventricular motion, which was a new finding. Overall
echocardiogram findings showed global hypokinesis which drove
the service to rule the patient out for myocardial
infarction. Adequate oxygenation had to be ensured.
The plan was to keep the patient intubated over night, rule
him out serially, and support him hemodynamically. The
patient was therefore admitted to the [**Hospital Unit Name 153**] for postoperative
management.
By postoperative day #1, he was doing well hemodynamically,
although he did have a temperature to 101.3??????. He was in
sinus rhythm at 93, with a blood pressure of 111/49. CVP was
9, PA pressure 48/20, output index of 6.1 and 3.49, with an
SVR of 630. He remained vented and supported. He was doing
otherwise satisfactory. He was noted to have a postoperative
creatinine at this time of 2.5 which was markedly elevated.
Again this was thought to be secondary to his recent contrast
load and intraoperative fluid shift and questionable
transient hypotension and low index output.
Over the next several days, the patient was weaned from the
vent on postoperative day #3. He was reintubated for
respiratory distress. He was noted to have a troponin leak
as well. At this time, his hematocrit was 29.9, and his BUN
and creatinine were up to 112 and 4.3, falling into acute
postoperative renal failure. He remained intubated and
sedated. He was noted to have some cool cyanotic toes. He
had a left posterior tibialis present by Doppler. He was
being supported with Dobutamine and being diuresed with
Natrecor for his pulmonary edema which had occurred
postoperatively from fluid shifts. He had a lactate of 1.8
at this time. He was continued on Heparin drip. He was on
broad-spectrum antibiotics of Vancomycin and Flagyl.
Renal was consulted shortly thereafter for his management of
acute renal failure. He continued to have fevers and
ultimately developed thrombocytopenia. A combination of
thrombocytopenia, fevers, respiratory failure, and acute
renal failure, metabolic acidosis was ominous at best. He
ultimately ruled in for myocardial infarction
postoperatively. His .................. was decreased
serially. He was supported. His Dobutamine was switched to
Milrinone and Natrecor, and he was started on Amiodarone for
ventricular ectopy/atrial fibrillation.
By [**2124-5-21**], the patient continued to be managed for his
congestive heart failure. Cardiology at this time had noted
that he was begun on Amiodarone for supraventricular
tachycardia. His blood pressure was 108/57, pulse ranging
90-120 for supraventricular tachycardia. He was continued on
Vancomycin, Levofloxacin, and Flagyl, with Lopressor 2.5
.................., Natrecor, Milrinone drip 0.5, Versed
drip, and Protonix. His hematocrit was 30. His platelet
count was down to 44, and his BUN and creatinine were
119/4.1.
His Natrecor was increased serially to assist with his heart
failure, and he continued to go into renal failure.
Ultimately he developed, on postoperative day #6, some new
wide complex tachycardia with stable blood pressure. He was
continued on Amiodarone drip, and he was changed to Milrinone
earlier. His Natrecor was increased serially. He was noted
to have a cold cyanotic right lower extremity with decreased
pulses. His index at this time remained to be 2.
The patient was being covered by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as Dr.
[**Last Name (STitle) 1391**] was out of time. Overall his cardiac parameters
improved. Although his right leg was worrisome, there was
nothing they could do in light of the situation except for
heparinization. There was nothing that could be done in
terms of revascularization. This was all thought to be due
to his overall hypoperfused state.
Over the ensuing days, the patient's clinical status
deteriorated; renal function was worse. The family at this
time had discussed on [**2124-5-23**], that the patient be made
DNR. He was given a 48-hour trial. The patient clearly had
a poor prognosis. Cardiology at this time recommended
instead of continuing with Milrinone, to try to introduce
Hydralazine for afterload reduction to stop his Natrecor
drip, as it had no affect on his pulmonary edema management.
His antibiotics were continued accordingly. By postoperative
day #9, the patient continued on Vancomycin, Levofloxacin,
and Flagyl. At this time, the day was [**2124-5-24**]. He was
on Lopressor, Protonix, Levaquin, Aspirin, Flagyl, Milrinone,
Amiodarone, and Vancomycin. His weight was up 16 kg, and he
was being supported with total parenteral nutrition. He
remained intubated on full ventilatory support. Overall his
outlook was grim.
A family discussion was held, and the patient was CMO.
Shortly after the removal of support, the patient expired at
approximately 3:30 p.m. on [**2124-5-24**]. The family was
accordingly notified.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2124-8-28**] 15:26
T: [**2124-8-28**] 15:56
JOB#: [**Job Number 43132**]
ICD9 Codes: 4280, 5849, 2762, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1580
} | Medical Text: Admission Date: [**2159-6-2**] Discharge Date: [**2159-6-5**]
Date of Birth: [**2082-10-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77-year-old male with diabetes mellitus type 2,
hypercholesterolemia, hypertension, status post porcine mitral
valve replacement in [**2137**],
diabetic nephropathy and retinopathy who presents w/ ? of
altered mental status. In [**2137**] patient had developed bacterial
endocarditis, having received a six week course of antibiotics
prior to mitral valve replacement. For the patient two years,
the patient has noted an increased symptom burden from heart
failure, with worsened dyspnea on exersion, 4 pillow orthopnea,
lower extremity edema. At present pt describes dyspnea with
minimal exertion (dressing himself, or toileting). The patient
has had ongoing conversations with his outpatinet cardiologist
regarding the necessity of valve replacement. Over the last
month the patient has an even more progression of his symptoms.
The patient was discharged from BIDNH 2 days prior to
presentation after a MVA [**3-3**] to a syncopal episode. The patient
reports prior synocopal epsides while standing from sleep. The
etiology of his LOC was attributed to hypotension in the setting
of increased BP meds in the setting of MS. The patient was
discharged with plans for cardiology follow up to plan for valve
replacement.
.....On the morning of presentation, the patient was awakening
from sleep, and for the first 1-2 minutes he was confused,
thinking he was in [**Country 9819**]. The patients family reports
recurrent episodes of acute, short-duration confusion while
awakening for the last few months. The patients family does not
feel that he is confused during day to day activities, but does
note that he is somnlanent throughout the day. In review of
systoms, the patient endoreses an englarging abdomen over the
last 2-4 weeks. He denies abdominal pain, blood in stool,
change in stool quality. He has no history of liver disease.
.....With this ? of altered mental status, the patinet was
brought into the ED for further evaluation. while there his BP
was 90/53, HR 70, 89% 2L, 97% on 3L. He was given an aspirin,
and admitted for further manegment.
Past Medical History:
1. Diabetes mellitus-2.
2. Hypercholesterolemia.
3. Hypertension.
4. Strangulated hernia, status post surgery in [**2158-10-30**].
5. Mitral valve replacement, porcine, [**2137**].
6. Diabetic retinopathy.
7. Diabetic nephropathy.
8. Gout.
9. Severe mitral regurgitation with chronic systolic heart
failure.
Social History:
The patient lives at home with his wife. Former computer
programer. No alcohol, tobacco or drugs.
Family History:
noncontributory.
Physical Exam:
Gen: WDWN middle aged male tachypnic slouched forward. Oriented
x3. Mood, affect appropriate. + RLS
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Difficultly
keeping eyes open.
Neck: Supple with [**Doctor Last Name **] V waves JVP at mandible.
CV: RRR, S1,S2, III/VI holosystolic murmur heard best at base.
+ S3
Chest: Wet crackles b/l heard 1/2 up lung fields
Abd: Soft, NT. + abdominal distension w/ + FW. No HSM or
tenderness. Surigcal vental scar noted.
Ext: 1+ - 2+ LE edema. 2+ dp/pt. No femoral bruits.
Pertinent Results:
[**2159-6-2**] 09:50AM BLOOD WBC-8.0 RBC-3.64* Hgb-12.0* Hct-36.0*
MCV-99* MCH-33.0* MCHC-33.4 RDW-18.5* Plt Ct-128*
[**2159-6-2**] 09:50AM BLOOD Neuts-83.1* Lymphs-9.4* Monos-5.0 Eos-2.1
Baso-0.4
[**2159-6-2**] 09:50AM BLOOD Glucose-217* UreaN-70* Creat-2.2* Na-144
K-3.9 Cl-106 HCO3-29 AnGap-13
[**2159-6-2**] 09:50AM BLOOD CK-MB-4 proBNP-[**Numeric Identifier **]*
[**2159-6-2**] 09:50AM BLOOD cTropnT-0.17*
[**2159-6-2**] 09:50AM BLOOD CK(CPK)-141
[**2159-6-2**] 11:31AM BLOOD Lactate-1.5
[**2159-6-2**] 09:50AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.8*
NCHCT: [**2159-6-2**]
1. No acute intracranial process.
2. Slight prominence of the right MCA, most likely represents
slight tortuosity. However, a small aneurysm cannot be excluded.
.
CXR ([**2159-6-2**]):
IMPRESSION: Subtle reticulonodular pattern in the lower lobes
bilaterally. In the absence of a prior chest radiograph this
could represents an atypical pneumonia or chronic changes. If
clinical suspicion for infection is high consider chest CT.
TTE ([**2159-5-30**]):
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-15mmHg. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). The right
ventricular cavity is mildly dilated There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The prosthetic mitral valve leaflets are
thickened. Motion of the prosthetic mitral valve leaflets/poppet
is abnormal. There is a question of flail leaflet motion There
is moderate valvular mitral stenosis (area 1.0-1.5cm2). Severe
(4+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension.
Brief Hospital Course:
Patient is a 76 year old male with history of MVR ('[**37**]), DM,
CRI, w/ known severe mitral regurgitation who presents with ?
AMS, found to be in acute heart failure.
On initial exam, there was clear evidence of volume overload,
with Lower Extremity edema, hypoxia, pulmonary edema, and
abdominal ascietes. No evidence of LV systolic dysfunction on
TTE. Patient's complaints of fatigue and SOB/DOE were thought
to be due to mitral valvular dysfunction, and patinet was
considered for MVR. CT surgery was consulted. On the afteroon
of [**2159-6-4**], the patient was sent for cardiac catheterization for
pre-operative evaluation. In the holding area the patient
became increasingly altered, hypotensive, and Short of breath.
Due to his worsened status, he was transferred to the CCU for
concern of sepis. Broad spectrum antibiotics were started prior
to transfer, he was placed on Vancomycin, Levofloxacin and
Meropenem. His respiratory and mental status continued to
decline and he was intubated. He became hypotensive and
required pressors. The family was notified and the wife decided
to make no further interventions, he was DNR/DNI. Pressors were
increased due to continued hypotension. Blood cultures came
back positive for gram + cocci. The patient went into cardiac
arrest and expired on the morning of [**2159-6-5**].
Medications on Admission:
1. Allopurinol 100 mg daily.
2. Iron 325 t.i.d.
3. Klor-Con at least 40 daily.
4. Procrit weekly.
5. Bumex 4 mg twice daily.
6. Avapro 75 mg daily.
7. Folic acid 1 mg daily.
8. Zetia 10 mg daily.
9. Januvia 50 mg daily.
10. Crestor 10 mg daily.
11. Glimepiride 2 mg daily.
12. Insulin 70/30 ten units in the morning.
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 5849, 0389, 5715, 5859, 4240, 4280, 4589, 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1581
} | Medical Text: Admission Date: [**2154-8-23**] Discharge Date: [**2154-8-29**]
Date of Birth: [**2097-11-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypoxia, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 yo M with widely metastatic renal cell CA on sutent
presenting with hypoxia and hypotension.
The patient states that approximately 2-3 days ago he awoke in
the middle of the night to go to the bathroom and noted
significant dyspnea on exertion. His shortness of breath was
persistent and slightly worsened until the time of admission. On
the day of admission, the patient was seen in oncology clinic
for a scheduled transfusion for anemia thought to be associated
with sutent myelosuppresion. The patient complained of SOB and
was found to be hypoxic to the 80's%. He was sent to the ED. The
patient denies any recent fevers, chest pain, pleuritic pain or
dizziness. He notes a non-productive cough over this time period
with increased RLE swelling more than LLE swelling. The
patient's wife notes that his RUE also was transiently swollen.
The patient describes a small amount of increased shortness of
breath when supine. He notes possible sick contacts.
In the ED, the patient was hypoxic to 80s% improved on 4L NC
with sbp 80. He received approximately 1.5L NS and 1U PRBC (for
Hct 22 down from 29 1 month prior). Lactate was noted to be 2.8.
CXR revealed a multifocal infiltrate and he received 1 dose of
levofloxacin. The patient was felt not stable for CTA and he was
admitted to the ICU for further care.
Past Medical History:
--Metastatic RCC diagnosed [**7-/2152**] after developing hematuria.
S/p debulking nephrectomy in 10/[**2151**]. His disease progressed,
and he received radiation to the lumbar spine, left chest wall,
and left humerus. Mets also to R temporal bone, T10 vertebral
body with compression and extension into epidural space. He
developed a left humeral pathologic fracture in [**12/2152**]
requiring an IM nail procedure. S/p laminectomy and poterior
T3-L1 fusion for back pain from spinal met. He started high-dose
interleukin-2 therapy in [**2-/2153**], but his disease continued to
progress. He entered the Avastin and sorafenib trial on
[**2153-4-18**] and has had a decrease in size of his lesions.
Sorafenib had to be held for four weeks because of weight loss.
His sorafenib was restarted after gaining some weight but at a
reduced dose on [**2153-7-25**]. His Avastin was held because of
excessive proteinuria. He was withdrawn from the study on
[**2153-11-28**] because of osseous metastases. Started Sutent
[**2153-12-26**], discontinued soon after that and then restarted on
[**2154-5-15**] at reduced doses due to myelosuppression. Cord
compression at T10 [**2154-3-8**]. He underwent spinal embolization on
[**3-9**] followed by transpedicular decompression at T10, total
laminectomy for excision of tumor at T11, and T3-L1 fusion on
[**3-12**]. He then received radiation therapy to T10-T11 and T5-T6,
completed [**5-3**].
-- HTN
-- GERD
-- Bilateral knee replacements
Social History:
The patient lives in [**Location **] with his wife. [**Name (NI) **] is retired, but
previously worked as a combat engineer in the military for 15
years and as a post officer in the post office for 30 years. He
smokes approximately 1 pack over the span of 3 days. He reports
having smoked one pack per day since the age of 15. He drinks
very occasionally. He is married. He has two daughters.
Family History:
Brother w/ early heart disease. DM in both mom and dad. Mother
and daughter both have "thyroid problems."
Physical Exam:
97.8 101 94/53 63 22 98% 4L NC 71.3kg, desats to 80's% with
minimal movement.
Gen: Cathectic, pale. NAD.
Integumentary: No rashes or lesions.
HEENT: PERRL.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Bilateral crackles R>L.
Abd: Soft, nontender, nondistended.
Ext: RLE edema 2+, LLE edema 1+.
Back: Large thoracic spinal surgical scar.
Neuro: A&Ox3.
Pertinent Results:
[**2154-8-23**] CTA -
1. No evidence of pulmonary embolism or aortic dissection.
2. New extensive multifocal bilateral ground-glass opacity with
septal thickening and increase of size of preexisting pulmonary
nodules. These findings are most likely secondary to pneumonia,
less likely CHF. Recommend evaluation of pulmonary nodules
following resolution of these opacities.
3. Extensive bony metastatic disease within the spine, ribs and
sternum.
[**2154-8-23**] CT Head -
1. New right cerebellar enhancing 1 cm lesion concerning for a
metastatic focus.
2. Worsening right frontal bone expansile lytic lesion
consistent with bony metastasis.
[**2154-8-23**] US RUE/RLE - No evidence of acute deep venous thrombosis
in the right upper or right lower extremity.
Brief Hospital Course:
56 yo M with metastatic renal cell CA on palliative chemo and
XRT with mets to spine with hypoxia and hypotension.
# Hypoxia. The patient was hypoxic to 80s% on admission to the
ED but improved on 4L NC. Also hypotensive to SBP 80's. He
received approximately 1.5L NS and 1U PRBC (for Hct 22 down from
29.1 month prior). Lactate was noted to be 2.8. CXR revealed a
multifocal infiltrate and he received 1 dose of levofloxacin. A
CTA was negative for PE, but showed multifocal infiltrates
consistent with PNA. His antibiotics were broaden upon
admission to the ICU to vancomycin, ceftazidime, and
levofloxacin. The patient continued to deteriorate during the
next few days with increasing oxygen requirements. He was
started on bactrim to cover for possible bactrim given his
relative [**Name (NI) 28729**]. A family meet was held given his
worsening respiratory status that was felt to be a combination
of infection, worsening metastatic disease, and bilateral
pleural effusion. He and his family decided on CMO and all
medications were discontinued. He passed away on [**2154-8-29**] at
11:01am. His wife was with him at this bedside. His family
declined autopsy.
Medications on Admission:
IBUPROFEN 800 mg--1 tablet(s) by mouth twice a day as needed for
pain
LISINOPRIL 40 mg--1 tablet(s) by mouth once a day
METOPROLOL SUCCINATE 50 mg--1 tablet(s) by mouth daily
OXYCODONE 5 mg--1 tab by mouth every 4 hours as needed for pain
OXYCONTIN 80 mg--2 tablet(s) by mouth twice a day
PROTONIX 40MG--Take one pill each day
VITAMIN B-6 100 mg--3 tablet(s) by mouth once a day
SUTENT 12.5 mg--3 capsule(s) by mouth once a day
TUMS 500 mg--[**11-20**] tablet(s) by mouth four times a day as needed
Discharge Medications:
The patient passed away on [**2154-8-29**] at 11:01am.
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Discharge Condition:
The patient passed away on [**2154-8-29**] at 11:01am.
Discharge Instructions:
The patient passed away on [**2154-8-29**] at 11:01am.
Followup Instructions:
The patient passed away on [**2154-8-29**] at 11:01am.
ICD9 Codes: 486, 4280, 2762, 2761, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1582
} | Medical Text: Admission Date: [**2186-5-4**] Discharge Date: [**2186-5-10**]
Date of Birth: [**2120-4-21**] Sex: F
Service:
ADMITTING DIAGNOSIS: Diabetic ketoacidosis.
HISTORY OF PRESENT ILLNESS: This is a 66 year old female
with a history of Stage 2 breast cancer, hypertension,
hypercholesterolemia where family found her on the day of
admission unresponsive. Per the Triage, she did not complain
of any chest pain, shortness of breath, fever or chills. Per
family a few days ago, she was feeling weak, slurred speech
but had not been eating. She was back to herself the day
before admission until, on the day of admission, she had
mental status changes per her grandson upon arrival to the
Emergency Department. Denies any nausea or vomiting. In the
Emergency Room, she had abdominal pain, cool extremities,
hypotensive in the 70s over 30s systolic and diastolic,
started on Levophed but weaned after intravenous fluid
hydration which improved her blood pressure. She was
intubated for a questionable concern of tiring with arterial
blood gas of 7.09, 18, and 400 O2. Post intubation, she was
transferred to the Medical Intensive Care Unit for further
treatment.
PAST MEDICAL HISTORY:
1. Stage 2 breast cancer, invasive, ductal cell, diagnosed
in [**2183**], status post Radiation therapy and chemotherapy.
2. Hypertension.
3. Hypercholesterolemia.
4. Spinal stenosis.
5. Myoclonus in bilateral lower extremities.
6. History of B12 deficiency.
HOME MEDICATIONS:
1. Aspirin.
2. Lipitor.
3. Klonopin.
4. Ibuprofen.
5. Lisinopril.
6. Os-Cal.
7. Triamterene.
8. Vitamin B12.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No history of diabetes mellitus or other
history in siblings or other family members.
SOCIAL HISTORY: No tobacco, no ethanol. Lives alone.
Independent of all activities of daily living. Daughter
calls and visits frequently every day.
PHYSICAL EXAMINATION: On admission in the Emergency Room,
vital signs were temperature 96.4 F.; blood pressure 74/37;
pulse 110; respiratory rate 18; saturation of 85% on room air
and then afterwards was intubated on AC-500, 14, FIO2 of 80%,
tidal volume 700 to 800. On examination, generally was
intubated and sedated. Skin dry. HEENT: Pupils equally
round and reactive to light and accommodation. No
lymphadenopathy. Mucous membranes were moist.
Cardiovascular with tachycardia with a regular rhythm; no
murmurs, rubs or gallops. Pulmonary clear to auscultation
bilaterally. Abdomen with decreased bowel sounds but
present. Positive tenderness per Emergency Room diffusely.
Positive guaiac. No masses appreciated. Extremities with no
cyanosis, clubbing or edema. Fingers and toes were cool with
decreased capillary refill greater than two seconds.
Neurologic is sedated with occasional myoclonic jerking.
LABORATORY: On admission, white blood cell count 16.2,
hematocrit 31.4, platelets 241, MCV 90. Sodium 138,
potassium not logged; chloride 85, bicarbonate 7, BUN of 113
and creatinine of 8.3. Glucose of 1034.
Chest x-ray showed no failure; line in place. D-Dimers were
27 and 53, fibrinogen 604. CEA 13.
Urinalysis showed many bacteria with 6 to 10 epithelials,
large blood, moderate leukocyte esterase, negative nitrites,
250 glucose, 15 ketones, 11 to 20 red blood cells, greater
than 50 white blood cells.
HOSPITAL COURSE: The patient is a 66 year old female with a
history of Stage 2 invasive ductal cancer who now presents
with new onset diabetes mellitus and in diabetic ketoacidosis
with questionable urosepsis, admitted to Medical Intensive
Care Unit.
Per Medical Intensive Care Unit summary, the patient was
intubated after course as dictated. Had done well; was
extubated. Her diabetic ketoacidosis was treated with
insulin drip and intravenous fluids aggressively and the gap
was closed two days prior to transfer to the floor.
The patient extubated the day prior to transfer to the [**Hospital1 139**]
Medicine Floor and did well. Hypotension resolved with
intravenous fluid boluses. She was also ruled out for
myocardial infarction. She was transferred then to [**Hospital1 139**]
Medicine and extubated on the day prior to the transfer to
the Medicine Floor, doing well, and weaned off of her O2
nasal cannula, at which point on the day prior to discharge
the patient was educated about diabetic medication through [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] consultation recommendations. Also, multiple
educational summaries were given by the nursing staff and
physicians of how to use insulin at home and how to check
blood glucose levels. The family was involved.
The patient was able to self administer insulin and will have
education by [**Hospital **] Clinic later on this afternoon on
discharge date. She is to follow-up with [**Hospital **] Clinic and
also with Dr. [**Last Name (STitle) 4844**] with whom she has an appointment in two
weeks.
Otherwise the patient is discharged in good condition.
Pulmonary status was all recovered and no other issues.
For her urinary tract infection she was to complete a 14 day
course. She has remained afebrile since transfer back to the
floor. She is continuing eight more days of Levaquin q. day.
She is to follow-up again with Dr. [**Last Name (STitle) 4844**].
DISPOSITION: The patient was discharged to home with
[**Hospital6 407**] services.
DISCHARGE INSTRUCTIONS:
1. She was told to seek medical attention as soon as
possible if symptoms return or new symptoms arise.
2. She has appointment with [**Last Name (un) **] Diabetes Center today at
02:00 o'clock and get educated on what to further follow-up
with [**Hospital **] Clinic.
3. Also appointment with Dr.[**Name (NI) 4864**] office, with [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 8271**], on [**2186-5-24**], at 03:00 p.m.
4. Other recommended follow-ups as noted.
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis.
2. Diabetes mellitus.
3. Urinary tract infection.
There were no major surgical or invasive procedures except
intubated in the unit.
CONDITION AT DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Ipratropium p.r.n.
2. Levofloxacin 500 mg p.o. q. day.
3. Aspirin 325 mg p.o. q. day.
4. Protonix 40 mg p.o. q. day.
5. Insulin 70/30, 18 units q. a.m. and 70/30, 10 units q.
p.m.
The patient and family are aware of diagnosis, treatment and
frequency as indicated and managed by primary care physician.
Diet: Diabetic, low carbohydrate, low cholesterol diet.
Arranging home health services with Physical Therapy and
[**Hospital6 407**] to teach medications and
administration and checking blood glucose at home. Home
Health Service, again, as discussed above, Physical Therapy
with weight bearing, activity as tolerated with caution.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 6307**]
Dictated By:[**Name8 (MD) 12818**]
MEDQUIST36
D: [**2186-5-10**] 14:25
T: [**2186-5-11**] 18:38
JOB#: [**Job Number 12819**]
ICD9 Codes: 5849, 5990, 2765, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1583
} | Medical Text: Admission Date: [**2195-11-30**] Discharge Date: [**2195-12-25**]
Date of Birth: [**2118-5-13**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
carotid stenosis
Major Surgical or Invasive Procedure:
rt. CEA with patch [**2195-12-1**]
PEG placement [**2195-12-11**]
Trach placement [**2195-12-11**]
History of Present Illness:
77y/o male s/p left CEA, known to Dr. [**Last Name (STitle) 1391**] with followup
carotid u/s q6months.
Hospitalized [**10-19**] with stroke . manfested by left hemiparesis,
visual changes OS ( neglect) and difficulty swallowing with
aspiration. Swallowing has impproved with speech thearphy.
Presents for rt. crotid endarectomy. Has been wheel chair bound
since stroke.
ROS: hx cad with arrythmia
hx aspiration
hx c. diff treated with flagyl x 1 week
hx BPH with nocturnal frequency
denies: headaches, seizzures, syncopy, PND<Orthopnea,
palpa,pneumonia, asthma, claudication or DVT
now admitted for elective CEA
Past Medical History:
CVA [**2183**], [**10-19**]
CAD ,s/p IWMI
hx GI bleed [**8-19**] s/p EGD/colonoscopy @ [**Last Name (un) 11560**] Gen. results??
BPH
cardiomyopathy ef 30%
hx VT
s/p left CEA [**2190**]
CAGB"Sx4 [**2184**]
AICD [**2193**]
Social History:
retired [**Doctor Last Name **]
married lives with spouse
wheel chair bound
Habits: smoking d/c [**2187**] previous 2ppd x years
ETOH: denies
Family History:
unknown
Physical Exam:
Vital signs: 96.0-71-20 b/p 110/70 oxygen saturatiion 93% room
air Wt.: 85.5 Kg
general: oriented x3 mild dysarthia
HEENT:normal cephalic tongue midline
Lungs: clear to ausculattion >a/P chest diameter
Heart: regular rate rythmn. no mumur
abd: begnin
rectal: enlagred prostate smooth. guiac negative stool
PV: feet pink warm pulses 2+ symmetrical intaact
Neuro: oriented x3 CN intact, Motor sensory intact. strength
5+/5+ bilaterally upper and lower. hand grasp rt.5+/5+, lt.
hand grasp 4+/5+
Romberg not tested
DTR"S 2= plantar rt. down, let up
wt. 85.5 KG
Pertinent Results:
[**2195-11-30**] 11:56PM WBC-6.9 RBC-4.65 HGB-13.8* HCT-41.2 MCV-89
MCH-29.6 MCHC-33.5 RDW-13.5
[**2195-11-30**] 11:56PM PLT COUNT-180
[**2195-11-30**] 11:56PM PT-12.8 PTT-32.0 INR(PT)-1.0
[**2195-11-30**] 08:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2195-11-30**] 08:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2195-11-30**] 11:56PM GLUCOSE-89 UREA N-23* CREAT-0.9 SODIUM-144
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-27 ANION GAP-13
[**2195-11-30**] 11:56PM CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-1.9
Brief Hospital Course:
[**2195-11-30**] admitted and prepared for surgery.
[**12-1**] s/p rt. CEA with patch, neck rexploration and carotid
exploration with intraoperative angiogram. Acute stroke. Neuro
consulted.
[**2195-12-2**] POD#1 speech and swallow consluted. recommended NPO .
[**2195-12-3**] POD#2 hypoxic unresponsive intubated and transfered to
ICU. head CT rt, MCA stroke. sapiration?? began on Vanco ,levo
flagyl.
[**2195-12-5**] POD# 4 sputum c/s gram postive organisms and gran
negative organisms. Zosyn began for aspiration pneumonia.
VANCO?LEVO?Flagyl discontinued. Failed extubation secondary to
secreations re in;tu;bated. TPN began.
[**2195-12-9**] POD# 6 u/s of left arm for swelling negative for DVT.
[**2195-12-11**] POD# 8 c diff sent, positive flagyl restarted. PEG
placed. Tracheostomy with #8 portex placed. Zosyn d/c'd.
[**2195-12-13**] POD# [**10-17**] TPN discontinued. tube feeds began. Trach
mask all day!! sputum culture for persistant temp. GNR levo
restarted/ Vancomyci for blood c/s of GPC.CVL d/c'd
[**2195-12-16**] POD# 13/5 Transfered to VICU. PT/OT consults
[**2195-12-21**] POD# 18/10 o2 weanening began. tolerating tube feeds.
[**2195-12-22**] POD# 19/11 continues to progress. await rehab. bed
[**2195-12-24**] POD# 21/13 still with secreations and could not be
evaluated by speech and swallow at this time. Will need eval at
rehabilitation.
[**2195-12-25**] POD# 22/14 discharged to rehabilitation stable
Medications on Admission:
asa 81mgm
plavix 75mgm
iron 325mgm
toporl xl 50mgm
proscar 5mgm
folic acid 2mgm
beconase NU
cozaar 50mgm [**Hospital1 **]
combivent MDi pudd 2 [**Hospital1 **]
zeta 10mgm HS
Discharge Medications:
1.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal QD ().
3. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4-6H (every 4 to 6 hours) as needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-16**]
Drops Ophthalmic PRN (as needed).
8. Acetaminophen 160 mg/5 mL Elixir Sig: 325-360 mgm PO Q4-6H
(every 4 to 6 hours) as needed for fever.
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Insulin Reg (Human) Buffered 100 unit/mL Solution Sig: as
directed Injection every six (6) hours: glucoses <70 [**1-16**] amp
D50%
glucoses 71-120/no insuin
glucoses 121-140/2u
glucoses 141-160/4u
glucoses 161-180/6u
glucoses 181-200/8u
glucoses 201-220/10u
glucoses 221-240/12u
glucoses 241-260/14u
glucoses 261-280/16u
glucoses 281-300/18u
glucoses 301-320/20u
glucoses 321-340/22u
glucoses 341-360/24u
glucoses 361-380/26u
glucoses 381-400/28u
glucoses > 400 [**Name8 (MD) 138**] Md.
15. Tears Naturale Drops Sig: One (1) gtts Ophthalmic four
times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
carotid stenosis rt. s/p RT. CEA
postoperative rt. MCA stroke
respiratory failure s/p trach
aspiration s/p PEG
aspiration pneumonia , treated with Zosyn
C. diff, treated
rt. neck hematoma, resolved
Discharge Condition:
improved, stable
Discharge Instructions:
trach care per routine
Followup Instructions:
4 weeks Dr. [**Last Name (STitle) 1391**]. call for appoiontment. [**Telephone/Fax (1) 1393**]
Completed by:[**2195-12-25**]
ICD9 Codes: 5070, 5185, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1584
} | Medical Text: Admission Date: [**2140-8-6**] Discharge Date: [**2140-8-10**]
Date of Birth: [**2065-1-7**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
woman with diabetes, hypertension, hyperlipidemia, and
hypothyroidism who presented to [**Hospital3 1280**] Hospital for [**7-18**]
chest pressure, facial pain, shortness of breath, and
diaphoresis after skipping her evening medications.
She was given 81 mg of aspirin, sublingual nitroglycerin
times three, and 4 mg of morphine by Emergency Medical
Service in the field. An electrocardiogram was done that
revealed ST elevations in the inferior leads. She was given
3000 units of heparin, a nitroglycerin drip, Lasix 40 mg, and
started on Integrilin. She was premedicated with Solu-Medrol
and Benadryl due to a suspected allergy to contrast and sent
to [**Hospital1 69**] for cardiac
catheterization.
The patient denied any previous myocardial infarction but
states she was hospitalized once for congestive heart
failure. A transthoracic echocardiogram on [**2139-6-26**]
demonstrated an ejection fraction of 65% with 1+ mitral
regurgitation and delayed relaxation of left ventricular
inflow. She currently denies orthopnea and paroxysmal
nocturnal dyspnea. She has used a walker for a number of
years and currently gets short of breath with minimal
exertion.
Her current chest pressure had completely resolved upon
arrival to [**Hospital1 69**] where she was
taken straight to the catheterization laboratory. Cardiac
catheterization showed normal left main coronary artery with
20% ostial left anterior descending artery, normal right
coronary artery, 30% proximal left circumflex, 30% first
obtuse marginal. The obtuse marginal and left posterior
descending artery demonstrated cutoffs consistent with
embolism and spontaneous thrombolysis. No interventions were
made.
Of note, during the cardiac catheterization the femoral
artery was unable to be cannulated, and a right radial
approach was necessary.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes.
3. Pulmonary hypertension.
4. Urinary incontinence.
5. Anemia.
6. Osteoarthritis.
7. Hypothyroidism.
8. Congestive heart failure.
PAST SURGICAL HISTORY:
1. Left shoulder replacement.
2. Varicose vein surgery.
3. T12-L2 arthrodesis with pedicle screw fixation.
FAMILY HISTORY: Family medical history was significant for
mother who died of a myocardial infarction in her 80s.
SOCIAL HISTORY: The patient denies tobacco or alcohol use.
She lives at home with her husband in [**Name (NI) 47**]. Five of
her children are living in the area. She is a retired
receptionist.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature of 98,
blood pressure of 162/82, heart rate of 81, respiratory rate
of 12, and oxygen saturation of 99% on 2 liters nasal
cannula. In general, the patient was obese and talkative, in
no apparent distress. Head, eyes, ears, nose, and throat
revealed jugular venous pressure was not appreciated. Pupils
were equal, round, and reactive to light. Extraocular
movements were intact. Possible 3-cm X 3-cm goiter on the
left lobe of the thyroid. Chest was clear to auscultation
bilaterally and anteriorly; unable to assess posterior lung
fields. Cardiovascular examination revealed a regular rate.
Normal first heart sound and second heart sound. Positive
fourth heart sound. No murmurs. The abdomen was obese,
soft, nontender, and nondistended. Normal active bowel
sounds. Extremities revealed 2+ pitting edema bilaterally to
the knees. Good dorsalis pedis pulses bilaterally.
Neurologically, alert and oriented times three, nonfocal.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed a white blood cell count of 11.9,
hemoglobin of 11.9, hematocrit of 33.9, platelets of 140.
Chemistry revealed a sodium of 140, potassium of 4.9,
chloride of 102, bicarbonate of 20, blood urea nitrogen
of 49, creatinine of 1.9, blood glucose of 23, with an anion
gap of 18. PT of 14.8, PTT of 150, INR of 1.5. Initial
arterial blood gas was 7.39/43/66/23.
RADIOLOGY/IMAGING: Electrocardiogram done on admission pain
free revealed 2-mm to 3-mm ST elevations in the inferior lead
with ST depressions in V2 through V4, aVL; all new compared
to electrocardiogram dated [**2139-6-30**].
IMPRESSION: The patient is a 76-year-old female status post
inferior myocardial infarction with spontaneous thrombolysis.
HOSPITAL COURSE:
1. CARDIOVASCULAR: (a) Coronary artery disease: The
patient was transferred to the Coronary Care Unit and was
started on aspirin, Plavix, Integrilin drip, and Lipitor.
The Integrilin drip was stopped prematurely, approximately
eight hours after staring, status post catheterization due to
concern over bleeding from central venous site as well as a
femoral sheath.
Cardiac enzymes were cycled and showed a peak creatine
phosphokinase at 7 a.m. after admission at 1306, CK/MB of 84,
and an index of 6.4, with a troponin of greater than 50. All
cardiac enzyme markers trended downward for the remainder of
the hospital course.
Lipids were checked on hospital day four, and the patient was
found to have an low-density lipoprotein of 95; and therefore
Lipitor was stopped.
(b) Pump: The patient was on six antihypertensive
medications at home. On admission, she stated she was
compliant with all.
Status post catheterization, her medications were started and
titrated up slowly, and she was discharged on an
antihypertensive regimen of metoprolol 100 mg p.o. b.i.d.,
enalapril 40 mg p.o. q.d., Lasix 40 mg p.o. b.i.d. The
patient's blood pressure at the time of discharge was 130/78.
A repeat echocardiogram was performed on [**2140-7-10**] which
showed an ejection fraction of 35%, hypokinesis of basal
inferolateral walls consistent with systolic dysfunction,
moderate pulmonary hypertension.
(c) Rate and Rhythm: The patient had a 10-beat run of
ventricular tachycardia on hospital day two; presumed due to
reperfusion.
2. HEMATOLOGY: The patient was transfused 2 units of packed
red blood cells during her hospital course for a hematocrit
fall from a hematocrit of 31 with concern over excessive
bleeding from central line sites.
3. ENDOCRINE: The patient was started on her outpatient
regimen of glyburide 2.5 mg and a regular insulin
sliding-scale. Synthroid 175 mcg, believed to be the correct
outpatient dose, was started. The patient's glucose was well
controlled during her hospital course with a maximum
fingerstick not greater than 150. No signs of hypothyroidism
were noted during her hospital course.
4. GASTROINTESTINAL: On hospital day four, the patient had
four loose stools in the morning due to concern for
Clostridium difficile toxin, an assay was sent which came
back negative. The patient's diarrhea resolved by hospital
day five.
5. REHABILITATION: The patient was seen and evaluated by
Physical Therapy who believed that the patient was back to
baseline and safe for discharge back to home. The patient's
family did not feel it was necessary for [**First Name (Titles) 1587**] [**Last Name (Titles) **] nurse assistance at this time.
CONDITION AT DISCHARGE: Condition on discharge was much
improved and stable.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 100 mg p.o. b.i.d.
2. Enalapril 40 mg p.o. q.d.
3. Enteric-coated aspirin 325 mg p.o. q.d.
4. Lasix 40 mg p.o. b.i.d.
5. Plavix 75 mg p.o. q.d. (times 30 days).
6. Glyburide 2.5 mg p.o. q.d.
7. Synthroid 175 mcg p.o. q.d.
8. Paxil 20 mg p.o. q.d.
DISCHARGE DIAGNOSES:
1. Diabetes.
2. Hypothyroidism.
3. Hypertension.
4. Acute inferior myocardial infarction.
5. Congestive heart failure.
DISCHARGE FOLLOWUP:
1. Follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) 1968**] ([**Hospital3 1280**] Hospital
Cardiology); appointment scheduled for [**2140-8-19**].
2. Follow up with Dr. [**First Name4 (NamePattern1) 2411**] [**Last Name (NamePattern1) 17103**] ([**Hospital 27252**] Medical),
primary care physician; to be scheduled by the patient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D:
T: [**2140-8-11**] 11:38
JOB#: [**Job Number 33117**]
cc:[**Telephone/Fax (1) 33118**]
ICD9 Codes: 4280, 4019, 2720, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1585
} | Medical Text: Admission Date: [**2131-5-16**] Discharge Date: [**2131-5-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Bradycardia, hypotension
Major Surgical or Invasive Procedure:
Intubation
Thoracentesis
History of Present Illness:
Pt is an 88 yo male with h/o CHF (EF 45%), CAD, CKD, TIIDM
admitted to the MICU from rehab with hypotension, junctional
bradycardia, and mental status change [**2131-5-16**]. The patient was
admitted to [**Hospital3 1196**] [**Date range (1) 39358**] after a
mechanical fall and treated for UTI and CHF exacerbation. He was
discharged to [**Hospital 18979**] rehab on [**2131-5-5**]. For the past few days he
complained of worsening weakness and fatigue. He was noted to be
bradycardic and metoprolol was held as of [**2131-5-15**]. On the day of
admission he was found to be hypotensive (SBP 90s), bradycardic
(HR 30s), and with mental status changes; he was sent to [**Hospital1 18**]
ED.
.
In the ER the pt was in a junctional rhythm with a rate in the
30s and was treated with atropine. He was treated for
hyperkalemia and also given glucagon due to beta-blockade. He
reverted to NSR with rate in the 60s. The patient was intubated
in the ER for mental status changes and airway production in
setting of uremia and patient vomiting. He was seen by
cardiology who thought the bradycardia was secondary to
hyperkalemia, which was secondary to renal failure, and
recommended dialysis. Renal was consulted and did not believe
dialysis was indicated at this time.
Past Medical History:
Type II diabetes mellitus
CKD with baseline creat 2.0 in [**1-/2131**], thought secondary to
diabetic nephropathy
CAD s/p CABG 13yrs ago, s/p NSTEMI with PCI x3 ~2 months prior
CHF (EF 45% echo [**2131-4-25**] with inferior hypokinesis, left atrial
enlargement)
Chronic 02 requirement of 2.5 L NC for CHF
Hypothyroidism
h/o Proteus UTI
Vertigo
Left eye blindness s/p childhood accident
HOH R ear
s/p recent mechanical fall
Social History:
Lives with wife. [**Name (NI) **] three daughters, two that live in the area
and visit twice a week.
Family History:
Mother died of MI at 67.
Physical Exam:
Wt 82.2kg T 96.6 HR 59 BP 119/67 RR 14 99%
A/C Tv 550 RR 14 FiO2 40% PEEP 5
Gen: intubated, sedated male in NAD
HEENT: right pupil reactive, left opacified, anicteric, MMM
Neck: supple, JVP nondistended
Cardio: bradycardic with reg rhythm, nl S1 S2, no m/r/g
Pulm: occasional bilateral wheeze, o/w CTA
Abd: soft, NT, distended with fluid wave, + BS, no masses, no
HSM
Ext: 2+ peripheral edema (R>L); decreased DP and PT pulses B
Pertinent Results:
[**5-21**] chest ct:
1. No evidence of that moderate to large right pleural effusion
is anything other than a transudate. Relaxation atelectasis
probably responsible for collapsed right middle and lower lobe.
2. Mild mediastinal adenopathy could be due to congestive heart
failure.
3. Severe atherosclerosis, predominantly in coronaries, also in
the aorta, innominate artery, and upper abdomen.
4. Probable pulmonary arterial hypertension. Mild cardiomegaly.
Aortic valvular calcification, hemodynamic significance
uncertain.
5. Ascites.
6. No evidence of sternotomy complications.
ecg:
Normal sinus rhythm with left anterior fascicular block. Cannot
exclude prior
inferior myocardial infarction. Compared to the previous tracing
of [**2131-5-18**] no
diagnostic interval change.
Brief Hospital Course:
A/P: 88yo male with h/o TIIDM, CAD, CHF, CKD p/w hyperkalemia,
bradycardia, hypotension, and acute on chronic renal failure.
Admitting diagnoses improved on discharge. Pt discharged to
rehab for PT/OT.
.
1) Bradycardia/hypotension/hyperkalemia: Likely multifactorial
due to hyperkalemia in the setting of beta-blocker and
amiodarone in addition to the recent diagnosis of
hypothyroidism. Initial rhythm was junctional bradycardia in 40s
which improved to sinus rhythm/sinus brady with atropine,
treatment of hyperkalemia, and increase of levothyroxine. Blood
pressure also improved with treatment of bradycardia. The pt had
no further episodes of bradycardia after his initial
stabilization. Amiodarone and metoprolol were restarted in the
intensive care unit prior to transfer to the floor.
.
2) Renal Failure: Current presentation likely acute on chronic
renal failure due to overdiuresis (and subsequent CHF
precipitated by volume load to treat hypovolemia). Etiology of
CKD most likely diabetic nephropathy. Nephrology believes he
will need dialysis within the year. [**Last Name (un) **] discontinued during
hospitalization and was not restarted on discharge. Recent creat
2.0-2.6 at OSH; 2.2 on discharge. Pt was followed in house by
nephrology, who by discharge recommended: discontinuing renagel,
decreasing calcium to 500mg tid, decreasing lasix to 40mg po qd
to decrease risk of hypovolemia, and continuing epogen 10,000u
qmwf. Pt discharged with caudet catheter and is scheduled for
follow-up with urology. Pt will follow-up with nephrology
locally as he will need close observation.
.
3) CHF: Diastolic dysfunction with EF 60% and home O2
requirement of 2.5L. Pt diuresed with lasix IV and po.
Outpatient regimen of ASA, metoprolol, statin continued; [**Last Name (un) **]
discontinued because of ARF. At dry weight and baseline O2
requirement on discharge. Lasix 40mg po qd on discharge with
care not to overdiurese. Pt will follow-up with his cardiology
at [**Hospital1 **].
.
4) Right pleural effusion: The pt received a
therapeutic/diagnostic thoracentesis for non-resolving right
pleural effusion the day prior to discharge. 2L fluid removed,
with subjective improvement in dyspnea. The effusion was found
to be transudative and is most likely secondary to heart
failure. The effusion is less likely secondary to infection in
this pt who remained afebrile and appear nontoxic. Gram stain
negative, although cultures pending. Also of concern is
malignant effusion in setting of ascites. Pleural fluid culture
and cytology will need follow-up.
.
5) Ascites/liver function: Likely secondary to right heart
failure; RUQ showed no liver pathology. Repeat US showed mild
ascites. Improved with diuresis. Repeat LFTs showed resolved
transaminases with alk phos 192, GGT 147, total bili 0.3. Pt
without symptoms of biliary disease. Recommend follow-up LFTs
for resolution within one month of discharge.
.
6) CAD: Pt denied CP during admission. Outpatient regimen of
ASA, lipitor, and metoprolol continued; as above, [**Last Name (un) **] held for
ARF.
.
7) TIIDM: QID FS's, RISS. Glyburide held in house with adequate
blood sugar control; consider restarting as outpatient as
needed.
.
8) Communication: Wife
.
9) Code status: Full
Medications on Admission:
RISS
Tylenol 650 PO q 3 hrs
milk of magnesia PRN
dulcolax PRN
lasix 80 mg qd
prilosec 20 mg PO BID
glyburide 2.5 mg
colace 100 mg PO BID
folic acid 1 mg qd
vitamin B12 500 mg qd
Vitamin B6 50 mg PO qd
Ambien 5 mg qhs PRN
Lopressor 50 mg PO BID ( d/c'd [**5-15**])
ASA 325 mg PO qd
Plavix 75 mg qd
Amiodarone 200 mg PO qd
Lipitor 40 mg qd
Metolazone 2.5 PO qd
Losartan 50 mg PO
Levothyroxine 25 mcg qd
Flomax 0.4 PO BID
Remeron 15 mg PO qhs
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) 10,000
Injection QMOWEFR (Monday -Wednesday-Friday).
13. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Haloperidol Lactate 5 mg/mL Solution Sig: 2.5 mg Injection
Q4H (every 4 hours) as needed for agitation.
17. Insulin Regular Human 100 unit/mL Solution Sig: as directed
units Injection ASDIR (AS DIRECTED): sliding scale is attached.
18. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Vitamin B-6 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Bradycardia
Congestive heart failure
Acute on chronic renal failure
Right pleural effusion
Discharge Condition:
On 2.5L O2 as per outpatient, afebrile, vital signs stable
Discharge Instructions:
Please contact a physician if you have shortness of breath that
does not improve.
.
Please contact a physician if you have chest pain that does not
resolve.
.
Please take your medications as prescribed.
Followup Instructions:
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4027**]
Please follow-up with you cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 39359**]
Please follow-up with a renal physician in your area or you may
call the renal clinic at [**Hospital1 18**] ([**Telephone/Fax (1) 773**] for an
appointment- you should see them within 1 month of discharge
Please f/u with urology on [**2131-6-1**] at 10:15 am on [**Hospital Ward Name **] 3
([**Hospital1 18**])
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
ICD9 Codes: 5849, 2767, 5119, 4280, 412, 5859, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1586
} | Medical Text: Admission Date: [**2147-10-27**] Discharge Date: [**2147-11-10**]
Date of Birth: [**2096-9-24**] Sex: F
Service: CT [**Doctor First Name 147**]
ADMISSION DIAGNOSIS:
Coronary artery disease requiring revascularization.
HISTORY OF PRESENT ILLNESS: This is a 51-year-old female
with a history of increasing fatigue, increasing dyspnea on
exertion and chest discomfort with known rheumatic fever, who
was admitted for cardiac catheterization on [**2147-10-27**]. This
demonstrated 80% left main coronary artery with moderate
mitral regurgitation and mitral stenosis.
PAST MEDICAL HISTORY: The past medical history was
significant for noninsulin dependent diabetes mellitus,
hypertension and rheumatic fever.
MEDICATIONS ON ADMISSION: Her medications on admission
included Diovan, atenolol, Glucophage, Glucotrol, aspirin,
Lasix, Flonase, iron sulfate and Claritin.
ALLERGIES: The patient had an allergy to Tylenol #3.
PHYSICAL EXAMINATION: On physical examination, the patient
was a 51-year-old obese female in no apparent distress.
Neurologically, she was grossly intact. The lungs were clear
to auscultation bilaterally. The cardiac examination was
significant for an S1 and S2 and a grade II/VI systolic
ejection murmur. The abdomen was obese and soft with active
bowel sounds. The extremities were warm with palpable
dorsalis pedis pulses bilaterally and no peripheral edema
noted.
PLAN: The plan was to perform coronary artery bypass
grafting and mitral valve replacement, which was scheduled
tentatively with Dr. [**Last Name (STitle) 1537**] for [**2147-10-30**].
HOSPITAL COURSE: The patient was admitted to the medicine
service. She stated that she needed a root canal for two
broken teeth. The oromaxillofacial surgery service was
called and the patient underwent a tooth extraction on
[**2147-10-28**]. She developed chest discomfort that she
associated with the stress of surgery. Given what appeared
to be angina, she was started on heparin drip.
The patient was taken to the operating room by Dr. [**Last Name (STitle) 1537**] on
[**2147-10-30**], where coronary artery bypass grafting times two
was performed as follows: left internal mammary artery to
left anterior descending artery and radial artery to obtuse
marginal artery as well as mitral valve replacement with a
#29 Carbomedics. The patient was maintained on nitroglycerin
postoperatively in the cardiac surgery recovery unit, given
her radial artery bypass graft. She did well and was
extubated without complications. Lasix, Lopressor, aspirin
and Imdur were begun. Her chest tubes were removed and she
was transferred to the floor.
The patient was doing well on the floor until postoperative
day #2, when she developed rapid atrial fibrillation with a
heart rate in the 160s, requiring intravenous Lopressor for
rate control. She was also begun on amiodarone. She was
relatively well rate controlled in a rhythm that alternated
between atrial fibrillation and atrial flutter when, on
postoperative day #4, it was noted that the patient had a
long, approximately 4.2 second, pause in which there was no
ventricular response to her atrial flutter. The cardiology
service was consulted and she subsequently had two further
episodes with syncopal symptoms.
At this time, her amiodarone was decreased and her Lopressor
was stopped. She was started on a heparin drip, given her
persistent atrial flutter/fibrillation. Coumadin had also
been started. The cardiology consultant recommended that the
patient would benefit from pacemaker placement; however, the
patient requested if there were any alternative treatments
and was informed that cardioversion would be an appropriate
second choice to try to disrupt the atrial fibrillation and
see if the patient had persistent pauses post cardioversion.
A transesophageal echocardiogram was obtained to ensure that
there was no clot in the left atrium. At that time, a
significant clot was found in the left atrial appendage,
which contraindicated cardioversion. Hence, the patient was
scheduled for pacemaker placement. Her Coumadin was held.
Once her INR dropped to below 1.8, the patient underwent dual
chamber pacemaker placement with a Medtronics bipolar pacing,
bipolar sensing pacemaker. She tolerated the procedure well
and was restarted immediately on her Coumadin as well as on a
heparin drip.
CONDITION ON DISCHARGE: The patient was doing well and on
postoperative day #11, given the fact that she was afebrile
with a relatively well controlled heart rate and she was
doing well despite being in persistent atrial
fibrillation/flutter with excellent rate control, that she
would be stable for discharge. On the day of discharge, the
patient was clear to auscultation and in a regular rhythm.
Her sternum was stable and dry. Her abdomen was soft. Her
extremities were well perfused with minimal edema.
DISCHARGE DIET: The patient was discharged on a cardiac
diet.
DISCHARGE MEDICATIONS:
Lopressor 50 mg p.o. t.i.d.
Lasix 20 mg p.o. b.i.d. times ten days.
Potassium chloride 20 mEq p.o. b.i.d. times ten days.
Colace 100 mg p.o. b.i.d.
Imdur 30 mg p.o. q.d.
Glucophage 1000 mg p.o. b.i.d.
Glucotrol 10 mg p.o. b.i.d.
Aspirin 81 mg p.o. q.d.
Motrin 600 mg p.o. every six hours p.r.n.
Zantac 150 mg p.o. b.i.d.
Sliding scale insulin.
Coumadin 2 mg p.o. q.d.
Heparin intravenous drip at 700 units per hour.
Percocet.
DISCHARGE INSTRUCTIONS: The instructions for anticoagulation
were that a target INR of 3 to 3.5 should be attained. Until
that occurs, heparin should be maintained with a target
partial thromboplastin time of 60 to 80.
FOLLOW UP: The patient is scheduled for a follow up
appointment with Dr. [**Last Name (STitle) 1537**] in one month and a pacemaker clinic
follow up in one week. The phone number for the clinic is
[**Telephone/Fax (1) 59**].
The patient was instructed
DISCHARGE DIAGNOSES:
1. Noninsulin dependent diabetes.
2. Hypertension.
3. Rheumatic fever.
4. Rheumatic mitral valve disease, status post mitral valve
replacement.
5. Coronary artery disease, status post coronary artery
bypass grafting.
6. Atrial fibrillation/atrial flutter, status post pacemaker
insertion.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 4720**]
MEDQUIST36
D: [**2147-11-10**] 14:57
T: [**2147-11-10**] 17:22
JOB#: [**Job Number 95534**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1587
} | Medical Text: Admission Date: [**2149-10-7**] Discharge Date: [**2149-10-20**]
Date of Birth: [**2103-6-23**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Amoxicillin / Blood-Group Specific Substance /
Adhesive Tape
Attending:[**Doctor First Name 3290**]
Chief Complaint:
productive cough
Major Surgical or Invasive Procedure:
ORTHOPEDIC:
1. Removal implant deep left fibula.
2. Open biopsy bone deep left medial malleolus
CARDAIC:
Cardiac Catherization ([**10-17**])
History of Present Illness:
Per report patient was in USOH when began experiencing cough
productive of clear sputum with nausea worse than baseline. (She
felt sx were related to left ankle infection; as it was not
chararacteristic of CHF excerbation which includes PND,
orthopnea) Called EMS and admitted to [**Hospital1 34**]. On initial
presentation febrile to 100.1 BP: 80/50, tachycardiac,
leukocytosis to 10.7. Initial CXR: flash pulmonary edema vs PNA.
She was admitted to ICU, initially requiring 100% Fio2, started
on stress dose steriods, IV vanc and levofloxacin 750mg QD and
diuresis with IV lasix 20mg. Notable OSH labs: influenza A and
B: neg, urine legionella neg, urine strep pneum antigen neg.
Urine cx neg. Blood cx positive 2/4 bottles for gram + cocci in
clusters (coag neg staph) - deemed contaminant by ID
(levofloxacin stop date per notes [**10-8**]). Creatinine at time of
transfer: 2.0 (1.4 admission -> 2.0; per renal recs at OSH stop
Lasix). Vancomycin had been stopped and patient continued on
Levofloxacin (750mg IV q48hrs) for atypical PNA vs brochitis
Per report initially hyperglycemic neccisitating insulin gtt on
night of admission b/c of mild DKA which resolved and pt
transitioned to SQ inusulin. Prior to transfer transitioned to
home regime. At time of transfer she was saturating well on 3L
NC, BG controlled.
.
Of note, patient with history of left ankle fracture in
[**2148-10-1**] status post ORIF, c/b complicated by failure of
healing of the medial malleolar wound and medial malleolar
hardware-associated osteomyelitis with coag-negative staph. Drs.
[**Name5 (PTitle) **] ([**Name5 (PTitle) 1957**]), [**Doctor Last Name **] (ID), and [**Last Name (un) 3407**] (vascular) have been
following. She is s/p wash out and 2 courses of prolonged IV
vanco (6weeks) currently on doxycycline suppression therapy
(100mg PO BID). In the last 1-2 weeks (while on doxy), her
infection has returned with increased drainage and tenderness of
medial malleolar wound as well as rising inflammatory markers
(CRP: 3 ->100). Per [**Last Name (un) **] plan is to return to the OR with Dr.
[**Last Name (STitle) **] for a repeat wash out in effort to treat this
infection. After she no longer has an infectious source and she
is no longer as deconditioned, then she may be considered for
MVR to prevent her recurrent CHF.
.
On arrival, initial vital signs were 98.8 118/57 87 18 3L
NC. Overall patient in no distress. Reports persistent wet cough
but denies SOB, PND, orthopnea, peripheral edema. Complains of
left ankle pain as well as pain in right hip (at baseline).
Reports abdominal pain, blaoting and minimal nausea (again
baseline sx). Denies any fevers, chills, weight loss or gain.
Denies chest pain, palp. Denies diarrhea, constipation, dysuria.
Past Medical History:
PAST MEDICAL HISTORY:
# CAD and MI, s/p CABG:
- LIMA to LAD, SVG to OM, SVG to Diagonal, and SVG to PDA. SVG
to
the OM and diagonal occluded
# Diastolic Heart Failure
# Peripheral vascular disease c/b chronic heel ulcers
# Hypertension
# Diabetes Mellitus-type I c/b retinopathy (legally blind) and
neuropathy, gastroparesis
# osteoporosis
# Sarcoid, reported lung nodule
# depression
# s/p right tibial fracture
# s/p right leg fracture (cast), [**2147**]
# s/p left wrist fracture, [**2147**]
# s/p fall and intracranial bleed, [**2147**]
# Blood group specific substance. Blood products (red cells and
platelets) should be leukoreduced.
Past Surgical History
.
Cardiovascular:
# CABG [**5-1**]- LIMA to LAD, SVG to OM, SVG to Diagonal, and SVG to
PDA. SVG to the OM and diagonal occluded
# s/p right femoropopliteal bypass and left SFA drug-eluting
[**Last Name (LF) **],
[**2147-5-2**]
RENAL:
# s/p living-related kidney transplant [**2140-10-31**] (baseline Cr
1.2-1.3 over the last year)
[**Year (4 digits) **]:
# s/p Open Reduction Internal Fixation of Left Bimalleolar
Fracture
([**2148-10-15**])
# s/p left patella open reduction and fixation, [**2147**]. Hardware
removed [**2148-10-15**]
# s/p left ankle washout and hardware removal ([**3-/2149**])
GI:
# s/p cholecystectomy
Social History:
Patient lives with her mother who is her primary care giver.
Ambulates with assistance
-Tobacco history: smokes half a [**4-3**] cig/day
-ETOH: none
-Illicit drugs: smokes marijuana several times per week to help
with nausea and appetite
Family History:
There is no history of diabetes or kidney disease. Her father
had an MI at 74 and mother has hypertension. Grandfather had
leukemia and hypertension.
Physical Exam:
Vitals: 97.9 151/69 (primarily: 120-130s/50-80s) 69 (70s) 99%
RA
FS: 91, 108, 118, 126
General: Chronically-ill appearing, sitting upright in bed, NAD.
HEENT: Legally blind. Scleral anicetric. Moist mucous membranes.
OP without exudates or lesions
Neck: supple, no LAD
Heart: RRR, II/VI systolic ejection murmur best heard at LSB, no
appreciable carotid bruit, no peripheral edema
Lungs: CTA-B, no wheezes, no crackles, good aeration b/l, no
accessory muscle use
Abdomen: soft, NT, ND +BS, no guarding
Extremities: warm, well perfused, no clubbing, cyanosis.
#Left ankle: medial and lateral ankle with gauze: dressing with
serosangious drainage; non-tender, FROM,
# Right toe: quarter size eschar on tip of toe with mild
erythema, non-tender, no drainage.
Neuro: Alert and oriented x3; moving all extremities with no
focal deficits, decreased sensation on b /l LE.
T/L/D
- PICC line: R arm: dressing c/d/i, no surrounding tenderness or
erythemia
Pertinent Results:
OSH labs and imaging:
Trop negx3.
[**10-6**] BMP: 134/4.698/17/31/1.4
.
Imaging:
CXR ([**10-5**]) OSH
Minimal interstitial edema compatible with mild CHF, no focal
alveolar opacity or pleural effusion
.
[**Hospital1 18**] labs:
Trop neg
CRP: 15.3
ESR: 57
.
CBC at discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
4.7 3.17* 9.5* 28.7* 91 29.9 33.1 14.5 467*
BMP at discharge:
Glucose UreaN Creat Na K Cl HCO3 AnGap
152 23* 1.9* 134 4.2 98 27 13
.
IMAGING:
.
RENAL US ([**10-8**])
RENAL TRANSPLANT ULTRASOUND: The right lower quadrant renal
transplant is
identified. There is no hydronephrosis or perinephric fluid. The
urinary
bladder is decompressed around a Foley catheter, and therefore
not well
visualized.
DOPPLER EXAMINATION: The main renal artery and vein are patent
with
appropriate waveforms. Resistive indices of the upper, mid, and
lower pole of the transplant kidney are 0.64, 0.71 and 0.60
respectively. Arterial
waveforms are appropriate, with sharp systolic upstrokes and
preserved flow through diastole.
IMPRESSION:
1. Normal renal transplant ultrasound.
2. Normal renal transplant Doppler examination
.
TTE ([**10-10**])
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with inferolateral hypokinesis.
The remaining segments contract normally (LVEF = 45%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. No masses or vegetations are seen on the aortic valve.
The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No vegetations seen (adequate-quality study). Mild
regional left ventricular systolic dysfunction, c/w CAD. Normal
global and regional biventricular systolic function. In presence
of high clinical suspicion, absence of vegetations on
transthoracic echocardiogram does not exclude endocarditis.
.
CXR ([**10-16**])
FINDINGS: Interval removal of endotracheal and nasogastric tube.
Right PICC position stable with tip in the mid SVC. No
pneumothorax. Sternotomy sutures are midline and intact.
Improved aeration of the left retrocardiac space. The three
faint rounded opacities first demonstrated in the left lung on
[**2149-10-9**] chest x-ray are less conspicuous than prior. The
cardiac silhouette is top normal. The mediastinal and hilar
contours are unremarkable.
IMPRESSION: Improved aeration of retrocardiac space. Less
conspicuous
rounded opacities in left lung, recommend continued radiographic
followup.
.
Cardiac Cath ([**10-17**])
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 8-
6A) SEPTAL-1 NORMAL
7) MID-LAD DISCRETE
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 DISCRETE 90
11) INTERMEDIUS NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
17) LEFT PDA NORMAL
17A) POSTERIOR LV NORMAL
**ARTERIOGRAPHY RESULTS TO SEGMENTS MORPHOLOGY % STENOSIS
LOCATION
**BYPASS GRAFT
28) SVBG #1 NORMAL
29) SVBG #2 NORMAL
30) SVBG #3 NORMAL
31) SVBG #4 NORMAL
32) LIMA NORMAL
33) RIMA NORMAL
.
COMMENTS:
1. Coronary angiography in this right dominant system revealed
diffuse
multivessel multivessel disease. The LMCA had no
angiographically significant disease. The LAD had an 80%
proximal stenosis. The large D1 had no angiographically
apparent disease. The
small D2 had 90% stenosis, as in prior angiographic images. The
prior
PTCA site in the Cx was patent with normal flow. THe RCA was
known to
be occluded. The SVG-RCA was patent. THE LIMA-LAD was patent.
2. Resting hemodynamics revealed normal right-sided filling
pressures
and pulmonary capillary wedge pressures. The cariac index was
preserved.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease with patent SVG to PDA,
LIMA to
LAD and patent PTCA site to the LCx.
2. Normal right-sided filling pressures.
.
MICRO:
[**2149-10-9**] 10:55 pm URINE Source: Catheter.
**FINAL REPORT [**2149-10-11**]**
URINE CULTURE (Final [**2149-10-11**]): NO GROWTH.
.
[**2149-10-14**] 11:30 am TISSUE Site: ANKLE LT LATERAL ANKLE.
GRAM STAIN (Final [**2149-10-14**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2149-10-17**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2149-10-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2149-10-15**]):
NO FUNGAL ELEMENTS SEEN.
[**2149-10-14**] 11:30 am TISSUE Site: ANKLE
MEDIAL LEFT ANKLE TISSUE.
GRAM STAIN (Final [**2149-10-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2149-10-17**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2149-10-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2149-10-15**]):
NO FUNGAL ELEMENTS SEEN.
.
Blood Cx ([**10-8**], [**10-9**]): NGTD
Brief Hospital Course:
Ms [**Known lastname 19419**] is a 46yo female with h/o poorly controlled
diabetes type 1, CAD, MI status post CABG and PCI, end-stage
renal disease status post living-related renal transplant in
[**2140-10-31**] on tacrolimus and prednisone immunosuppression,
transferred from OSH for continued treatment of URI/atypical PNA
and CHF exacerbation; hospital course c/b aspiration event
requiring intubation, transferred back to the floor for
continued mgmt of CHF, chronic osteo of L. ankle and coronary
artery disease.
.
# CHF. Patient with multiple prior admissions to [**Hospital1 **] and OSH with
CHF exacerbations. On this admission to it was thought that
possible URI/atypical PNA/bronchitis triggered mild CHF
exacerbation. Initial presentation at OSH notable for low-grade
fever, leukocytosis to 10.6. CXRs from OSH consistent with
pulmonary edema: interstitial edema and Kerley B lines, no focal
consolidations noted. On admission to [**Hospital1 **] patient afebrile with
normal WBC. She was diuresised with improvement in respiratory
symptoms. Finished 7day course of levofloxacin for coverage of
atypical PNA. Initially, patients underlying CAD causing
ischemia in setting of hypertension thought to account for
tendency to flash. However, patient was taken for cardiac
catherization on [**10-17**] which was clean. Question if recurrent
flashes simply resulted from med and diet noncompliance. At time
of discharge patient hemodynamically stable, without need for
supplemental oxygen. Lasix dose at time of discharge 80mg PO
daily with blood pressures and fluid status well controlled.
.
# Episode of respiratory failure thought to be secondary to an
aspiration event. Patient was found cyanotic on floor with
evidence of recent emesis. A code blue was called, patient
intubated and transferred to ICU. Of note patient was never
pulseless. The patient was able to be extubated after one day in
the unit. She rapidly improved and was able to tolerate nasal
cannula oxygen without difficulty. A speech and swallow eval
was done and she passed without difficulty. She was restarted on
her home meds, full diet and transferred back the floor with no
further aspiration events.
.
# Wall motion abnormality. After the episode of respiratory
distress requiring intubation TTE was ordered to assess for any
cardiac cause. TTE demonstrated a new inferior wall motion
abnormality when compared to most recent echo in [**Month (only) 958**]. Trops
cycled and neg. Initially, no further cards work-up was
performed prior to orthopedic wash-out of left ankle. Cardiac
cath performed later in hospitalization was clean.
.
# Medial malleolus osteomyelitis - On admission oral suppressant
regimen of doxycyline stopped per ID request to optimize yield
of bone biopsy. Due to increasing concern over recurrent
infection, evident by increased inflammatory markers, patient
started on IV vancomycin. She was taken to OR on [**10-14**] for Left
ankle wash-out. Tissue and bone biopsies were obtained during
the procedure: no growth to date. Patient to follow-up with ID
and [**Month/Year (2) **] as outpatient. Plan to continue likely 6wk course of
IV antibiotics. Will follow-up in [**Month/Year (2) **] clinic in 2-3wk for
suture removal. At time of discharge, medial and lateral
incision sites clean, dry, intact with no surrounding erythema
or stigmata of infection. Patient discharged on vancomycin 750mg
IV QD. Regarding pain patient discharged on outpatient percocet
regimen as well as lidocaine patch and small supple (30tablets)
of dilaudid 2mg PO for breakthru pain in the post-operative
period.
.
# Diabetes Mellitus with gastroparesis - Blood sugars difficult
to control in house. Initial hyperglycemia likely aggravated by
stress dose steriods that were received at outpatient hospital
and again in our ICU, Insulin was dosed as [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recommendations. At time of discharge lantus 10u [**Hospital1 **], ISS.
Metoclopramide and Zofran used to control nausea secondary to
gastroparesis while hospitalized.
.
# ESRD s/p post living-related renal transplant in [**2140-10-31**]
on tacrolimus and prednisone immunosuppression. Baseline
creatinine in recent months: 1.2 - 1.8. [**10-7**] OSH labs: creatinine
2.0. Concern for acute on chronic kidney failure as admission
creatinine elevated slightly above base at 2.2. Renal ultrasound
ordered to assess transplant kidney; dopplers were normal with
no sign of rejection. Tacrolimus levels were monitored daily and
at time of discharge patient on 2.5mg PO BID with plan to follow
level with outpatient labs. Patient continued on prednisone 4mg
daily. Creatinine at time of discharge 1.9. Elevated creatinine
at time of discharge thought secondary to both elevated
tacrolimus level as well as recent dye insult from cardiac cath
(though patient pre-hydrated and received mucomyst pre and post
procedure)
.
# HTN: Patient with history of labile BP. During this admission
pressures oscilated between asymptomatic hyper and hypotension.
Most accurate read taken in left thigh. Patient continued on
home regimen with strict holding parameters. In days leading up
to discharge, blood pressures well controlled on labetalol,
lasix, nifidipine; deferred re-initiation of ACEI to PCP and
cardiologist.
.
# PVD/CAD s/p MI, s/p CABG. Trops negx3 at OSH, neg x5 at [**Hospital1 **].
Plavix and ASA continued in house, held in peri-operative
period. Cardiac catherization performed due to concern of
worsening of CAD, valvular disease. Cardiac cath clean. No
intervention required. Patient discharged on Plavix; ASA dose
decreased from 325 -> 81 to decrease risk of bleed.
.
# Normocytic Anemia: Likely secondary to chronic kidney disease
and iron deficiency.
Patient received 1u pRBC with appropriate bump in HCT. Stable at
time of discharge.
Iron supplementation continued
.
# Depresssion. Appropriate affect in house. Continued Bupropion,
Citalopram
.
# Insomnia. Continue Trazadone 100mg qhs
.
Code: Full
Medications on Admission:
Active Medication list as of [**2149-10-3**]:
.
Medications - Prescription
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day
BUPROPION HCL - 75 mg Tablet - 1 Tablet(s) by mouth daily
CITALOPRAM - 40 mg Tablet - one and one half Tablet(s) by mouth
in a.m.
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
COMPAZINE - 25 mg Suppository - 1 Suppository(s) rectally three
times a day as needed for nausea
DOXYCYCLINE MONOHYDRATE - 100 mg Capsule - 1 Capsule(s) by mouth
twice a day
FUROSEMIDE - 40 mg Tablet - 2 Tablet(s) by mouth twice a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times
a
day
GLUCAGON (HUMAN RECOMBINANT) [GLUCAGON EMERGENCY] - 1 mg Kit -
ASDIR once as needed for for hypoglycemia PATIENT USES 2 PER
MONTH
HEPARIN FLUSH (PORCINE) IN NS - 100 unit/mL Kit - 3cc heparin
once a day per protocol post infusion
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider:
[**Name Initial (NameIs) 10088**]) - 100 unit/mL Cartridge - 9 units Twice a Day
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider:
[**Name Initial (NameIs) 20522**]) - 100 unit/mL Cartridge - per sliding scale
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol
Inhaler - 2 puffs inh q6 hours as needed for coughing
LABETALOL - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 200 mg Tablet - 2 Tablet(s) by mouth three times a day
hold for SBP<100 or HR<60
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - ASDIR once apply 15
min before drawing blood
METOCLOPRAMIDE - 10 mg Tablet - 1 (One) Tablet(s) by mouth daily
do not take more than 5 - 6 times per week
NIFEDIPINE - 90 mg Tablet Extended Rel 24 hr - 1 Tablet(s) by
mouth once a day
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**2-1**] Tablet(s) by
mouth q8hr as needed for ankle pain
PANTOPRAZOLE - (Dose adjustment - no new Rx) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth qeday
POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17
gram/dose Powder - by mouth PRN
PREDNISONE - 1 mg Tablet - 4 Tablet(s) by mouth daily
SODIUM CHLORIDE 0.9 % [SALINE FLUSH] - 0.9 % Syringe - as
directed once a day 3-5cc saline flush pre and post infusion
TACROLIMUS [PROGRAF] - 1 mg Capsule - 3 Capsule(s) by mouth
twice
a day brand name medically necessary, no substitution
TALKING SCALE - - Use once daily for use with CHF protocol
TRAZODONE - 100 mg Tablet - one Tablet by mouth at bedtime
VANCOMYCIN - 750 mg Recon Soln - infuse 750 mg once a day
.
Medications - OTC
ASPIRIN - (OTC) - 325 mg Tablet - One Tablet(s) by mouth daily
BLOOD SUGAR DIAGNOSTIC [PRECISION XTRA TEST] - Strip - use to
monitor your blood sugar up to 10 times per day or as directed
CALCIUM CARBONATE-VITAMIN D3 - 600 mg-400 unit Tablet - 1
Tablet(s) by mouth twice a day
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - [**2-1**] Capsule(s) by
mouth twice a day
FERROUS SULFATE - 325 mg (65 mg) Tablet - 1 Tablet(s) by mouth
twice a day
NUT.TX.GLUC.INTOL,LAC-FREE,SOY [GLUCERNA] - Liquid - 1 can by
mouth six times per day Diabetes Mellitus Type I Gastroperisis
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (OTC; Dose adjustment - no
beverage and drink daily as needed for as needed for
constipation
.
Discharge Medications:
1. Outpatient Lab Work
REQUIRED LABORATORY MONITORING:
LAB TESTS: CBC, BUN, Crea, ESR, CRP, Vanco trough
FREQUENCY: Qweekly
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
3. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
4. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q8H (every 8 hours) as needed for pain.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
11. Furosemide 80 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).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
13. Tacrolimus 1 mg Capsule Sig: 2.5 Capsules PO Q12H (every 12
hours).
Disp:*150 Capsule(s)* Refills:*2*
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
SOB/wheeze.
Disp:*1 bottle* Refills:*2*
15. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
16. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) u subQ
Subcutaneous twice a day.
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Sig:
Three (3) ml every eight (8) hours: Sodium Chloride 0.9% Flush
3 mL IV Q8H:PRN line flush
.
Disp:*30 flush* Refills:*2*
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Sig:
Heparin Flush (10 units/ml) 2 mL IV PRN line flush flush Qday
and prn.
Disp:*30 flush* Refills:*2*
20. Humalog 100 unit/mL Solution Sig: per sliding scale u/mL
Subcutaneous with meals, at bedtime: PLEASE HOLD AM HUMALOG
UNTIL AFTER BREAKFAST - if able to eat, dose per AM scale; if
nausea prevents eating, dose per BEDTIME SCALE.
21. SLIDING SCALE
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-150mg/dL 0u 0u 0u 0Units
151-250mg/dL 6u 6u 6u 0Units
251-300 mg/dL 8u 8u 8u 4Units
301-350mg/dL 10u 10u 10u 6units
351-400mg/dL 12u 12u 12u 8Units
22. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
23. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
24. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
25. Calcium Carbonate-Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
26. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
27. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO once a
day: Do not take more than 5-6x/week.
28. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO once a
day.
29. Citalopram 40 mg Tablet Sig: one and one half tablet Tablet
PO QAM.
30. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation every six (6) hours as needed for cough.
31. Vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous once a day: Will complete 6 week course of
vancomycin. tentative stop date: [**11-25**].
Disp:*30 bags* Refills:*2*
32. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three
times a day.
33. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
PRIMARY:
CHF exacerbation
Chronic osteomyelitis
.
SECONDARY:
End-stage kidney disease
Diabetes Mellitus
Coronary Artery Disease
Peripheral Vascular Disease
Discharge Condition:
Mental status: clear and coherent
Ambulates with assistance' weight bearing activity as tolerated.
Discharge Instructions:
Dear Ms [**Known lastname 19419**] it was a pleasure taking care of you.
.
You were initially transferred to [**Hospital1 18**] for continued treatment
of an upper respiratory infection and CHF exacerbation. During
your stay you were actively diuresised, continued on antibiotics
and your respiratory symptoms improved.
.
Unfortunately you had an episode of respiratory distress
necessitating ICU transfer and intubation. The episode was
thought secondary to an aspiration event. Shortly after transfer
to the ICU you were extubated, your respiratory status improved
and you were transferred back to the floor.
.
While hospitalized the infectious disease, orthopedic, renal,
and cardiology services participated in your care. There was
concern for recurrent osteomyelitis of your left ankle. Your
doxycyline was stopped and you were restarted on IV vancomycin
to complete a 6wk course. On [**10-14**] you were taken to the OR by
Dr. [**Last Name (STitle) **] for a wash-out of your left ankle. Biopsies were
taken of bone and soft tissue during the procedure and at time
of discharge had demonstrated no bacterial growth. You will need
to follow-up with both infectious disease and [**Last Name (STitle) **] for
continued care of this infection as an outpatient. Until
follow-up you will continue taking IV vancomycin 750mg daily for
likely 6wk course. Your sutures will be removed in [**Last Name (STitle) **] clinic
in 2-3wks. Until that time be sure to keep incision sites,
clean and dry. You may ambulate with assistance with weight
bearing activities as tolerated.
.
While hospitalized your underlying coronary artery disease was
evaluated. You had a cardiac catherization done on [**10-17**] which
was clean with no interventions necessary. You will follow-up
with Dr. [**Last Name (STitle) 20523**] as an outpatient.
.
Regarding your renal function, you were followed by the renal
service. An ultrsound of your transplanted kidney was obtained
which was negative for any signs of rejection. You were
continued on tacrolimus and prednisone to prevent rejection.
.
CHANGES TO YOUR MEDICATIONS:
--We DECREASED your Aspirin from 325mg -> 81mg by mouth daily
--We DECREASED your LASIX to 80u by mouth to once daily
--We STOPPED your DOXYCYLINE.
--We STARTED VANCOMYCIN , 750mg IV every day (6week course:
Start date: [**2149-10-14**] Stop date: [**2149-11-25**]) You levels will be
checked with weekly lab draws.
--We DECREASED your dose of TACROLIMUS to 2.5mg twice daily.
--YOUR HOME INSULIN REGIMEN WAS CHANGED TO THE FOLLOWING: LANTUS
10u twice daily with insulin sliding scales with meals and
bedtime.
Regarding sliding scale: Check sugar and administer AM humalog
AFTER breakfast - if you have eaten full meal use AM sliding
scale, if nausea has made it difficult to eat use BEDTIME
sliding scale to avoid hypoglycemia.
--PAIN REGIMEN: We continued your PERCOCET; We added daily
LIDOCAINE patchs, we discharged you with 30 pills of DILAUDID
2mg for breakthough pain as needed every 4-6hrs (please do not
take more than 4 pills daily to avoid over-sedation)
--We also added an albuterol inhaler to use as needed to help
with your breathing.
.
Followup Instructions:
[**Last Name (un) **] FOLLOW-UP
Wednesday @ 9am with Dr [**Last Name (STitle) 10088**]
[**Name (STitle) **] Center [**Location (un) **], [**Location (un) **]
.
Department: [**Hospital3 249**]
When: TUESDAY [**2149-10-28**] at 10:00 AM
With: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
DEPT: ORTHOPEDICS - suture removal
Tuesday [**10-28**] at 1120
[**Location (un) **] [**Hospital Ward Name 23**] Center [**Location (un) **]
.
Department: INFECTIOUS DISEASE
When: MONDAY [**2149-11-3**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2149-12-1**] at 9:30 AM
With: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], 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: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2149-11-19**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2149-10-21**]
ICD9 Codes: 5849, 412, 3572, 4439, 4280, 4240, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1588
} | Medical Text: Admission Date: [**2137-11-8**] Discharge Date: [**2137-12-3**]
Date of Birth: [**2085-9-12**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old
female with a history of advanced human immunodeficiency
virus/acquired immunodeficiency syndrome for 10 to 15 years
complicated by human immunodeficiency virus nephropathy,
human immunodeficiency virus cardiomyopathy (with an ejection
fraction of 15% to 20%), acquired immunodeficiency syndrome
related dementia and encephalopathy for the past who presents
with a history of lactic acidosis while taking proteus
inhibitors.
The patient was admitted to the hospital with lactic acidosis
presumed to be due to proteus inhibitors while on highly
active antiretroviral therapy. She was admitted to the
Medical Intensive Care Unit with hypoglycemia, hypothermia,
and hypotension.
The patient's blood pressure was stabilized without pressors.
Her hypoglycemia resolved. The patient revealed evidence of
hepatic failure with liver function tests in the 100s, and a
total bilirubin of 26, and coagulopathy with an INR of
greater than 5. This occurred after all her ACE inhibitors
and highly active antiretroviral therapy were discontinued.
The patient was initially made comfort measures only, and
after mentating better the patient was made do not
resuscitate/do not intubate, cardiopulmonary resuscitation
not indicated, due to her severe illness. However, the
patient continued to receive full treatment of all of her
issues.
The patient was transferred to the floor for further
management by the medical team under the care of Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. The patient's liver function tests did not improve
greatly; however, the patient was occasionally mentating and
was occasionally able to take oral intake; although, never
adequate for her poor nutritional status.
On [**2137-12-1**] the patient had a subsequent event of
hypoglycemia, hypotension, and bradycardia into the 30s. A
code was called. The patient was given atropine and her
heart rate rebounded. Her blood pressure increased and
continued to increase with aggressive intravenous fluid
hydration. The patient was given multiple ampules of
dextrose 50 every hour to maintain her glucose greater than
70. It was presumed that the patient had no glycocin stores
and severe hepatic dysfunction prohibiting proper
gluconeogenesis.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's blood
pressure was maintained with a systolic blood pressure in the
110s with intravenous fluid boluses. The patient was felt to
be severely dehydrated. The patient was also persistently
hypothermic with a temperature of 96 degrees Fahrenheit
regularly, increasing to 97 degrees Fahrenheit rectally with
warming blankets. Her heart rate was 50 to 74. Her
respiratory rate was 22 to 27. The patient's oxygen
saturation was 97% on room air. In general, the patient was
a very thin and frail woman breathing deeply. She had her
eyes closed and was not responding well. Head, eyes, ears,
nose, and throat examination revealed the patient's sclerae
were icteric. Her pupils were reactive. The oropharynx was
clear with no evidence of thrush. On cardiovascular
examination, the patient had a regular rate and rhythm.
There was a 3/6 systolic murmur and third heart sound. No
rubs. Radial and dorsalis pedis pulses were 1+ bilaterally.
The lungs were clear with crackles halfway up bilaterally.
There was good air movement. The patient's abdomen had
hypoactive bowel sounds. The abdomen was distended and
nontender. There was no organomegaly was appreciated. The
patient's extremities were cool and dry with no edema. The
patient's sacrum had erythema on the perineum. Skin revealed
tinting on the forehead. The patient had a right midline
peripherally inserted central catheter line placed with no
erythema or swelling. She had a left fistula site on her
wrist that was bandaged due to subsequent spontaneous
bleeding.
IMPRESSION: Our impression was that the patient was a frail
50-year-old female with advanced human immunodeficiency
virus/acquired immunodeficiency syndrome, multiple
complications, with poor cardiac function, renal function
dependent on dialysis, and hepatic failure unlikely to
improve.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
for further management, and a family meeting was called to
discuss the patient's code status.
On the evening prior to the family meeting, the patient had
11 beats of nonsustained ventricular tachycardia with
electrocardiogram changes. The patient ruled out for a
myocardial infarction and was maintained on aspirin, and beta
blocker, and oxygen through nasal cannula.
Due to the spontaneously bleeding arteriovenous fistula site,
the patient was given multiple units of fresh frozen plasma
as well as packed red blood cells. Over that night, the
patient's hematocrit dropped to 12%.
In the morning, the patient was not responding well. A chest
x-ray was done because of agonal breathing. The patient was
found to have total white out of the left lung. It was
unclear if this due to an isolated effusion or spontaneous
pulmonary hemorrhage in the setting of a hematocrit drop.
It was also clear that over the past two days the patient had
low fibrinogen, an elevated prothrombin time and partial
thromboplastin time, an elevated lactate dehydrogenase, and a
haptoglobin of less than 20 which would also be consistent
with hemolysis and possible disseminated intravascular
coagulation; however, a full disseminated intravascular
coagulation panel was never checked, and it was thought to be
uninterpretable in the setting of liver failure. The patient
was maintained on a D-10 drip to keep her glucose level above
70.
Up until this point, the patient had been receiving
hemodialysis every other day with ultrafiltration due to an
inability to take much off because of blood pressure demands.
The patient was also known to have chronic hypercalcemia due
to hyperparathyroidism from her renal failure which was
managed with hydration.
During the patient's hospitalization, she was off of highly
active antiretroviral therapy but was maintained on
Pneumocystis carinii pneumonia and Mycobacterium
avium-intracellulare prophylaxis with azithromycin and
Bactrim.
For nutrition, it was very difficult to give the patient
proper nutrition as she would not tolerate tube feeds. She
pulled out her postpyloric tube and could not mentate long
enough to take in oral intake adequate enough to improve her
nutritional status.
A family meeting was held. The patient's primary nurse,
intern hospital attending (Dr. [**First Name (STitle) **], and the patient's
primary care provider over the 15 years (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7626**])
were all present. As the patient's sister and health care
proxy ([**Name (NI) **]) as well as her sister [**Doctor First Name **], and daughter.
It was discussed that the patient's health was extremely
poor. It was unclear if the patient would ever survive to
discharge. The patient's family still wanted all treatment
to be pursued but understood that it would extremely
difficult to resuscitate or ventilate her should she need
cardiopulmonary resuscitation or mechanical ventilation. It
was determined that the patient would be do not
resuscitate/do not intubate.
One hour after signing this order, the patient had agonal
breathing. She continued to have bradycardia in the 20s
which responded to atropine. However, her respiratory status
worsened until full respiratory arrest. The patient died on
[**2137-12-3**] due to respiratory failure secondary to a
pulmonary effusion and possible pulmonary hemorrhage
secondary to coagulopathy and liver failure, secondary to
human immunodeficiency virus and acquired immunodeficiency
syndrome. The patient's family and primary care provider
(Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7626**]) were all made aware. An autopsy was
refused.
[**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**]
Dictated By:[**Last Name (NamePattern1) 6374**]
MEDQUIST36
D: [**2137-12-9**] 14:33
T: [**2137-12-13**] 08:43
JOB#: [**Job Number 109899**]
ICD9 Codes: 0389, 2762, 4254, 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1589
} | Medical Text: Admission Date: [**2130-9-20**] Discharge Date: [**2130-9-26**]
Service: MICU
ADMISSION DIAGNOSIS:
1. Respiratory distress.
2. Respiratory failure.
3. Pneumonia.
4. COPD exacerbation.
HISTORY OF PRESENT ILLNESS: Patient is a 79 year old with
multiple medical problems including a history of chronic
obstructive pulmonary disease, atrial fibrillation who was
recently discharged from [**Doctor First Name **]-[**Country **] on [**2130-9-8**] for a
history of cellulitis who presented to the Emergency Room on
[**2130-9-20**] with increasing dyspnea times one day. The
morning of admission the patient was without complaints per
the nursing home staff, however having increasing shortness
of breath throughout the day. Patient noted to be
unresponsive at 1:45 p.m. and vital signs recorded at the
time were 96.9, 88, 102/66, 22. Patient became more
responsive with an O2 sat of 85% prior to transfer to the
Emergency Room. Wheezes at the time were noted which
decreased with Combivent nebulizer treatment in the Emergency
Room.
In the Emergency Room patient noted to be in moderate
respiratory distress. O2 sats were noted to be in the 80s on
face mask. Patient also noted to have periorbital cyanosis
at nursing home. Patient was intubated in the Emergency Room
secondary to decreased O2 saturations and persistent
respiratory distress. An arterial blood gas performed at the
time demonstrated a pH of 7.27, 54, 98 on 60% FIO2, AC 12 x
600. Patient was transferred to the Medical Intensive Care
Unit for continued care.
PAST MEDICAL HISTORY:
1. COPD, prior intubations three times on home O2 two liters
to three liters. No pulmonary function tests available.
2. Atrial fibrillation. MAT EF of 50% on last TTE in [**2128**].
3. Hypertension.
4. Anemia.
5. Status post left kidney donation.
6. Prostate cancer status post radiation.
7. Peptic ulcer disease status post Billroth.
8. Venous insufficiency.
9. Left leg cellulitis 09/[**2129**].
10. Osteopenia status post multiple compression fractures, on
chronic opiates.
11. History of VRE.
12. Decreased thyroid.
13. History of thigh burns.
14. History of DVT in [**2129**].
MEDICATIONS ON LAST DISCHARGE:
1. Protonix 40.
2. Synthroid 100.
3. Oxycodone 10.
4. Miconazole
5. Oxazepam
6. Albuterol.
7. Flovent.
8. Atrovent.
9. Fentanyl.
10. Levofloxacin 250 mg p.o. q.d.
11. CACO3.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Patient is a former smoker who currently
lives at the [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **].
PHYSICAL EXAMINATION: Vital signs: 98.6, blood pressure
105/63, irregular, respiratory rate 12, heart rate around 60,
O2 sats 88% preintubation, 99% post intubation, FIO2 post
intubation, vent AC 12 x 600 FIO2 of 60%, general intubated,
sedated, no spontaneous movement, not in acute distress.
HEENT: Pupils 2:1 bilateral. Neck: Supple; jugulovenous
pressure flat. Cardiovascular: Irregularly irregular; no
murmurs, rubs, or gallops. Respiratory: Decreased breath
sounds throughout. Cardiovascular: Midline sternotomy scar.
Abdomen: Midline surgical scar left transverse upper
abdomen; positive bowel sounds; nontender, nondistended.
Extremities: Left shin erythema and warmth; 1+ edema.
Neuro: Sedated; pupils 2:1; 1+ deep tendon reflexes.
Rectal: Guaiac positive.
SOCIAL HISTORY: Lives in [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **]. Former smoker; quit
two years ago.
LABORATORY DATA: White blood cell count 17, differential
neutrophils 75, lymphs 21, monocytes 2. Urinalysis: Large
blood, positive protein, greater than 50 red blood cells, 0
to 2 white blood cell count. Electrolytes 142/3.1, 107/19;
BUN 27/2.2, baseline is 1.2-1.5; glucose 162, INR 3.7; ABG
7.27, 54, 98; troponin 0.14; lactate 1.2.
Chest x-ray: Diffuse patchy linear infiltrates, question
loculated effusion.
EKG: MAT at 99, 0.5 mm ST segment depressions in V4, V5, low
voltage in limb leads, Q-waves in 3.
HOSPITAL COURSE:
1. Respiratory failure: Patient presented to the Emergency
Room with respiratory failure requiring intubation. Patient
was extubated on [**2130-9-22**]. Patient's respiratory failure
was considered secondary to COPD flare up versus secondary to
possible pneumonia. Patient was continued on Levofloxacin.
Patient was also provided with Vancomycin. Patient's sputum
subsequently grew up Staph aureus. Staph aureus is likely a
colonization. Patient's x-ray reportedly is baseline.
Patient was continued on Albuterol and Atrovent. Patient's
white blood cell count subsequently decreased to 10.6 by
[**2130-9-26**].
2. Troponin: Patient presented with troponin 0.14.
Patient's enzymes were cycled. Patient's troponin decreased
in nature. There was likely secondary to demand ischemia.
Patient showed no EKG changes.
3. Renal failure: Patient with elevated creatinine from
baseline. Patient's creatinine responded to volume.
Patient's creatinine was 1.5 on [**2130-9-26**].
4. Cellulitis: Patient with a history of cellulitis.
Patient's cellulitis was actually improved on presentation.
However, given possible decompensation, Vancomycin was
initiated.
5. MAT atrial fibrillation: Patient with history of MAT
atrial fibrillation. Blood pressures not provided given
history of COPD. Patient is on Coumadin; initially held,
then reintroduced throughout his hospitalization. Patient's
Coumadin level should be checked as outpatient INR.
6. Heme: Patient with baseline anemia. Patient anemic in
physical exam. Patient transfused two units on [**2130-9-22**]
after hematocrit of 24. Patient responded appropriately.
Patient with history of guaiac-positive stools. Patient
should likely receive an outpatient colonoscopy per primary's
team.
7. Patient with a history of opiate use. Secondary to
chronic back pain, multiple fractures.
8. Cellulitis: Further assessed with a CT. A CT performed
demonstrated a fluid density along the anteromedial skin
surface which was most consistent with edema. However, the
possibility of a fluid conduction could not be excluded by
Radiology. The patient, however, subsequently resumed
refusing MRI. The patient's symptoms improved, and it was
felt that an MRI would be low yield, and the patient did
refuse the test.
9. Muscle: Patient complained of shoulder pain. Therefore,
an x-ray was performed on [**2130-9-25**]. The [**2130-9-25**] x-ray
of the left shoulder showed diffuse osteopenia
catheter-imposed humeral diaphysis most likely representing a
PICC line. No fractures noted. The humeral head was
subluxed superiorly consistent with the chronic rotator cuff
tear. Access midline was placed on [**2130-9-25**] in the left
arm, code full.
10. Gastrointestinal: Of note, patient during his
hospitalization, developed possible epididymitis. Urology
was consulted. Patient's symptoms resolved.
11. Infectious Diseases: Patient with diarrhea. Patient's
C. difficile titer was sent. First one was negative.
Additional two should be sent. Patient was empirically
initiated on Metronidazole. Patient's symptoms have
improved.
DISPOSITION: To [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **].
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subq q. 12 hours.
2. Vancomycin 1000 mg IV q. day dose with trough levels.
3. Aspirin 325 mg p.o. q.d.
4. Fentanyl patch 150 mcg q. 72 hours.
5. Pantoprazole 40 mg p.o. q.d.
6. Levothyroxine sodium 100 mcg p.o. q.d.
7. Trazodone HCL 25 mg p.o. h.s. p.r.n.
8. Ipratropium bromine nebulizer, one nebulizer IH q. six.
9. Loperamide HCL 2 mg p.o. t.i.d. p.r.n.
10. Oxycodone 5 mg p.o. q. 4 to 6 hours p.r.n.
11. Prednisone 20 mg p.o. q.d. times five days.
12. Metronidazole 500 mg p.o. q. 8 hours times seven days.
13. Levofloxacin 250 mg p.o. q.d. times 10 days.
14. Hydromorphinol 2 mg p.o. q. 4 to 6 hours p.r.n.
15. Miconazole powder 2%, one application topical, b.i.d.
p.r.n.
DISCHARGE INSTRUCTIONS:
1. Physical Therapy, Occupational Therapy: Assistance with
activities of daily living.
2. Cardiac-healthy diet.
3. Keep leg raised and wrapped.
4. Coumadin monitoring.
5. Vancomycin monitoring.
RECOMMENDATIONS:
1. Colonoscopy possible per outpatient team.
2. Follow-up leg [**Hospital 4338**] Clinic should all symptoms deteriorate.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 201**]
Dictated For [**Doctor Last Name 40957**], Intern
MEDQUIST36
D: [**2130-9-26**] 15:42
T: [**2130-9-26**] 16:20
JOB#: [**Job Number 40958**]
ICD9 Codes: 486, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1590
} | Medical Text: Admission Date: [**2103-5-6**] Discharge Date: [**2103-5-18**]
Date of Birth: [**2021-2-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
fevers, leukocytosis
Major Surgical or Invasive Procedure:
IR percutaneous drainage of left perinephric fluid collection
_____
History of Present Illness:
82M with multiple medical comorbidities s/p sigmoid colectomy
with end transverse [**Hospital 47427**] transfered from OSH for further
management of a retroperitoneal abscess. Pt initially presented
from his nursing home to [**Hospital3 **] [**2103-5-4**] with fever to
102.6 and increasing leukocytosis. He was found to be
hypotensive
to SBP 85, which improved with resuscitation, and WBC 33. CXR
revealed a LLL pneumonia and UA was consistent with a UTI, for
which he was started on empiric Vanc/Zosyn and admitted to the
ICU. He underwent CT A/P which was interpreted as showing left
hydronephrosis with a 16x10x8cm peri-nephric / retroperitoneal
abscess with air, along with a LLL pneumonia. Given the lack of
interventional radiology capabilities at the OSH, the pt was
directly transfered to [**Hospital1 18**] TSICU for anticipated percutaneous
drainage pf the per-nephric abscess.
Past Medical History:
Past Medical History:
-Hypertension, GERD, Atrial fibrillation, Hx positive PPD,
Urinary retention, BPH, Hx basal cell CA, SIADH, Hypothyroidism,
glaucoma, Insomnia, Constipation
Past Surgical History:
-Sigmoid colectomy w/ Hartmann's / end transverse colostomy
-Cataract surgery
-Total thyroidectory [**2091**]
Social History:
Lives in a nursing home. Denies tobacco, EtOH, illicits.
Family History:
NC
Physical Exam:
GEN: elderly male, frail appearing, shovel mask w/ humidified
air in place, oriented to self and medical center, intermittent
weak cough with thick secretions
HEENT: oropharynx clear
CV: S1, S2 regular rhythm, normal rate, no murmurs
LUNG: rhonchi bibasilarly, decreased BS right base
ABD: soft, non-tender, non-distended, drain w/ yellow fluid,
ostomy with brown stool
EXT: warm, distal pulses intact, [**1-15**]+ edema, RUE > LUE, picc in
place in RUE
Neuro: face w/ right sided droop, asymmetry w/ smile, tongue
midline, EOMI, moves toes bilaterally
Pertinent Results:
Laboratory:
10.2
21.9 >------< 425
34.0
PT: 14.6 PTT: 29.5 INR: 1.4
154 123 31
-------------< 102
3.6 21 0.5
Ca: 7.7 Mg: 2.3 P: 2.9
Imaging:
CT A/P (OSH [**2103-5-6**]):
1. Obstructed left kidney with a large perirenal/RP abscess
(16x10x8cm) with air, involving psoas muscle and extending to
the
lower pelvis to just above the acetabulum.
2. RLL consolidation with air bronchograms
3. Extensive atherosclerotic disease of the abdominal aorta
without aneurysm
4. Aneurysmal dilitationof the common left iliac artery with the
lumen narrowed.
5. Bladder calculi
Brief Hospital Course:
This is an 82 M who initially presented to [**Hospital3 **]
[**2103-5-4**] with fever, leukocytosis, and hypotension found to have
16x10x8cm peri-nephric / retroperitoneal fluid collection and
pneumonia he was started on vancomycin and zosyn and transferred
to [**Hospital1 18**] surgery service for further management
.
#PSOAS / PERINEPHRIC ABSCESS: The etiology was unclear although
most likely from complication of GU infection in patient with
chronic indwellling foley catheter. He was initially admitted to
surgery service but was not a surgical candidate. Patient
underwent IR guided drainage on [**2103-5-8**] with removal of 400cc of
fluid resulting in partial decompression of hydronephrosis.
There was evidence that the collecting system was communicating
with the fluid collection during the procedure. Subsequently
fluid from the drain was found to have elevated creatinine c/w
urine. Likely he developed GU infection with nephric/ureter
abscess with loss of collecting system integrity and spread to
perinephric/psoas. Unclear if calculi (bladder calculi seen on
imaging) or ureter mass (not found on imaging) predisposed to
rupture. He was startd on vancomycin and zosyn. Urine culture
and fluid collection culture returned with no growth (although
had already been on antibiotics for several days. Urine and
drain cytology returned without evidence of malignant cells.
Infectious disease was consulted. Repeat abdominal imaging on
[**5-15**] showed a well placed drain and signficant improvement in
fluid collection. Plan for percutaneous nephrostomy tube and
eventual removal of abdominal drain was was discussed with the
son [**Name (NI) 382**]. However, the patient continued to slowly decline and
there was concern about his ability to tolerate the procedure
and whether it was consistent with his overall goals of care
given his poor overall prognosis. In coordination with the son,
it was decided to not pursue further procedures, such as
nephrostomy tube placement. At [**Doctor First Name 391**] Bay, in discussion with
the son, if the abdominal drain were to accidentally come out
the, then he would not be rehospitalized to replace it. Zosyn
was stopped on [**2103-5-17**] as, in consultation with the son, it was
felt to not aid in patient comfort.
.
#HYPERNATREMIA: Patient's sodium was 137 at OSH and on admission
to [**Hospital1 18**] was found to be 154. The most likely etiology is
over-resuscitation with normal saline in setting of reduced
access to free H20. His sodium continued to remain slighly
elevated in the setting of decreased access to free water. He
was given D5W at a rate of 75-125cc/hr while he was NPO. Per
discussion with the son, he wants to continue the PICC line and
continue D5W (rate of 75cc/hr) for hydration at this time to
have family members the opportunity to come in this weekend and
see the patient.
.
#HCAP: Patient is nursing home resident found to have fever,
increased secretions and cough, and radiographic evidence with
opacity in the right lung base of pneumonia with differential
icluding aspiration vs HCAP. During his hospital stay he was
noted to have a weak cough with difficulty managing secretions.
He completed an 8 day course of vanc/zosyn on [**5-15**]. Legionella
negative.
.
#NUTRITION: The patient has failed several speech/swallow
evaluations and was determined to be high risk of aspiration.
This was discussed with the HCP, who was not interested in NG
tube placement. We held off on oral nutrition initially in the
hope that his condition may improve. At discharge, the risk of
aspiration was again addressed with the HCP and the options to
either continue NPO status or have the patient be allowed to
have nectar thick liquids for comfort if he verbalizes. The HCP
felt that it could be ok for him to eat/drink for comfort
knowing that this might lead to the patient's demise. Please
continue aspiration precautions.
.
#RUE SWELLING: He was found to have a PICC associated
non-occlusive subacute-to-chronic right subclavian thrombus.
PICC functining appropriately. He was discharged with the PICC
line given his healthcare proxy wanted the pt to continue
hydration during the weekend so family could come and see him.
.
#HEMATOCRIT DROP: His hematocrit trended down on [**5-16**] from mid
twenties to 18. He was transfused four units of blood with
improvement up to 26. His hematocrit trended down to 23 on [**5-17**]
and he was given another unit of blood. The etiology of blood
loss was unclear. GI bleed considered, particularly stress
ulcer, although no melana or bright red blood in ostomy. He was
evaluated by the GI service. RP bleed considered but CT abdomen
negative. No evidence of hemolysis on labs.
.
GOALS OF CARE: Addressed with [**Doctor Last Name **], the healthcare proxy,
[**Name (NI) 6028**] the hospitalization. We discussed that even with
standard medical care in this situation that he has a poor
prognosis. The HCP informed us that his father would not want
extraordinary measures and would want to focus more on comfort
in this situation. [**Doctor Last Name **] agreed with stopping antibiotics at
discharge, as well as no additional transfusions, or further lab
testing, or re-hospitalization. If the abdominal drain were to
fall out he would not want his father rehospitalized for more
procedures. He wanted to keep the PICC line in place and
continue IV hydration over the weekend so that family members
could visit him. Would readdress whether continuing IVF after
this weekend is c/w goals of care.
.
.
CHRONIC ISSUES:
.
#HYPERTENSION: Blood pressure ranged from 100-130. His home
antihypertensives were held during this hospitalization.
.
#ATRIAL FIBRILLATION: He has a history of atrial fibrillation,
managed with rate control with beta blocker. His beta blocker
was changed to IV during the hospitalization given he was NPO.
Aspirin was held. Beta blocker not continued due to goals of
care.
.
#FACIAL DROOP: Patient noted to have facial droop on admission
with garbled speech and right sided weakness. The [**Hospital1 2519**] note also reported that his speech was not clear. I
spoke w / [**Doctor First Name 391**] Bay Skilled Nursing who confirmed that the
unclear [**Name2 (NI) 16019**] was chronic.
.
#INSOMNIA: His ambien was held
.
#GLAUCOMA: His Methazolamid 25mg [**Hospital1 **] (hold while NPO) was held.
.
#HYPOTHYROID: The levothyroxine daily was changed from PO to IV
while hospitalized and NPO. It was stopped at discharge as not
c/w goals of care change to comfort focused care.
.
#URINE RETENTION: The oxybutynin was held
.
This was prepared by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D.(cell phone [**Telephone/Fax (1) 47428**] if
any questions)
Medications on Admission:
Brimonidine Tartrate 5ml solution 0.15% OP
Protonix 40mg daily
Amlodipine 5mg daily
Levothyroxine 0.1mg daily
Artificial tear solution 2 gtt [**Hospital1 **] PRN
tylenol 650mg Q6H PRN pain
ambien 5mg HS PRN insomnia
Vitamin B-12 Inj 1000 mcg IM q3 months
Methazolamid 25mg [**Hospital1 **]
ASA 325mg daily
Lactulose 30ml daily
Metoprolol Tartrate 25mg [**Hospital1 **]
Oxybutynin Chloride 5mg TID
Levofloxacin 500mg daily
Flagyl 250mg TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. 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.
3. Senna 1 TAB PO BID:PRN constipation
4. Intravenous fluid order -> D5W at 75cc per hour for three
days
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
Psoas / Perinephric abscess
Healthcare Associated Pneumonia
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Mental Status: Confused - sometimes.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname **]. You
were admitted with a fluid collection near your kidney and a
pneumonia.
For the fluid collection, a drain was placed to remove the
fluid. The fluid appears to be urine from a rupture in your
kidney or ureter. You were treated for an infection with
antibiotics. You were followed by the urology and infectious
disease services.
For the pneumonia, you were treated with antibiotics and your
condition improved.
Your blood counts were low and you were given a transfusion.
Followup Instructions:
-
ICD9 Codes: 5070, 0389, 2760, 2851, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1591
} | Medical Text: Admission Date: [**2175-7-25**] Discharge Date: [**2175-7-26**]
Date of Birth: [**2112-2-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Name13 (STitle) **] presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for dyspnea on exertion,
lower extremity edema, 2 days of worsening productive cough.
Also with PND, nausea, denies chest pain. He is scheduled for
MVR/TVR and CABG with Dr. [**Last Name (STitle) **] on [**2175-7-31**].
.
He reports that he has had a cough which is productive of white
sputum which has been very persistent for the past day and did
not improve with NyQuil. The patient reports that he thought he
had pneumonia so he came to the ED. He feels like he has "a
tickle in my throat" that he can't clear. He also reports that
he has a tightness in his back, which is C7-T2 area, which he
reports is a "tightness" and feels different from the back pain
that he had during his presentation during the last
hospitalization, which was sharper. The patient does endorse
paryoxysmal nocturnal dyspnea and orthopnea, but he cannot
clarify it is due to discomfort from lying where his neck hurts
him or if it is because he feels SOB. He says he has been
compliant with his medications. He also reports DOE but this is
unchanged from his baseline and is felt to be due to his severe
MR/TR. As well, he does not endorse LE edema.
.
In the ED, initial vitals were 98.4 93-125/46-73 82-88 20 100%
RA 108.6kg.
Labs and imaging significant for a BNP of 336, negative
troponins and WBC of 22. CXR without acute cardiopulmonary
process and UA was negative.
Patient given Lasix 20mg IV once and dextromethamorphan,
Tessalon Perles, he felt that his cough improved with these
interventions.
.
On arrival to the floor, patient had ongoing productive cough,
did endorse ongoing "tightness" in the superior aspect of his
back and otherwise felt well.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
Past Medical History:
severe MR/TR
CAD with small LAD
EF 50-55%
atrial fibrillation (paroxysmal)
alcohol abuse
chronic leukocytosis (WBC 15-16)
Hypertension
Hyperlipidemia
Psoriasis
Diverticulitis
s/p sigmoid resection [**2175-5-19**]
Social History:
lives with girlfriend in [**Name (NI) **]. Maintenance worker.
-Tobacco history: quit 7 yrs ago. [**11-20**] ppd for 40 yrs
-ETOH: [**3-24**] drinks nightly, wine/beer/liquor, no history of
withdrawal symptoms. last drink Sunday [**7-9**]
-Illicit drugs: none
Family History:
Mother, died of lymphoma age 81. Father, with DM died of
alzheimers ag 84. Broather, throat cancer age 64.
No family history of heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.9 BP 104/60 HR 77 RR 12 O2 sat 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CN II-XII intact.
NECK: no cervical lymphadenopathy, no thyroid nodules or
thyromegaly appreciated. Neck veins not appreciated due to body
habitus. No carotid bruits.
CARDIAC: irregularly irregular. No m/r/g.
LUNGS: CTAB, no crackles, wheezes or rhonchi. Resp were
unlabored, no accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace edema in LE bilaterally. No c/c. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right:DP 1+ PT 1+
Left: DP 1+ PT 1+
DISCHARGE PHYSICAL EXAM:
afebrile, tachycardia to 100 with atrial fibrillation which
resolved spontaneously to HR of 80s-90s. BP 98-113/56-66.
No pericardial rub appreciated. No crackles or wheezes in the
lungs bilaterally.
No LE edema.
Pertinent Results:
ADMISSION LABS:
[**2175-7-25**] 05:20PM BLOOD WBC-16.9* RBC-3.84* Hgb-10.9* Hct-32.6*
MCV-85 MCH-28.5 MCHC-33.5 RDW-14.6 Plt Ct-328
[**2175-7-25**] 05:20PM BLOOD PTT-47.2*
[**2175-7-25**] 05:20PM BLOOD Plt Ct-328
[**2175-7-25**] 05:20PM BLOOD Glucose-101* UreaN-16 Creat-1.2 Na-141
K-5.0 Cl-104 HCO3-28 AnGap-14
[**2175-7-25**] 05:20PM BLOOD Calcium-9.6 Phos-5.5* Mg-2.4
PERTINENT LABS AND STUDIES:
CXR [**2175-7-25**]: In comparison with study of [**7-19**], the cardiac
silhouette may be slightly larger without definite pulmonary
vascular congestion. Probable mild pleural effusion and
atelectatic changes at the bases on the left. The increasing
cardiac size with little change in pulmonary vascularity raises
the possibility of pericardial effusion
ECHOCARDIOGRAM: [**2175-7-25**]: Focused study to assess pericardial
effusion.
There is a small to [**Month/Day/Year 1192**] sized pericardial effusion. There
are no echocardiographic signs of tamponade.
Compared with the prior study dated [**2175-7-14**] (images reviewed),
the amount of pericardial effusion has increased (previously
trivial). It appears circumferential, but predominantly located
along the infero-lateral wall of the LV.
DISCHARGE LABS:
[**2175-7-26**] 06:00AM BLOOD WBC-18.1* RBC-3.75* Hgb-10.7* Hct-31.7*
MCV-85 MCH-28.5 MCHC-33.7 RDW-14.2 Plt Ct-392
[**2175-7-26**] 06:00AM BLOOD Glucose-115* UreaN-17 Creat-1.1 Na-137
K-4.9 Cl-103 HCO3-25 AnGap-14
[**2175-7-26**] 06:00AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.2
Brief Hospital Course:
63yo male with past medical history of severe MR [**First Name (Titles) **] [**Last Name (Titles) **] who is
scheduled for surgery on [**2175-7-31**], here with productive cough for
1-2 days and pressure in his scapulae.
.
ACUTE ISSUES:
# Cough: productive of white sputum, patient is afebrile. CXR
without signs of pneumonia. Treated with
dextromethamorphan-guiafenesin, tessalon perles for symptomatic
control and had improvement of symptoms with this.
.
# Pericardial effusion: the patient has worsening positional
back pain, which is potentially consistent with pericarditis,
among other etiologies, including MSK. No cardiac rub
appreciated. He has a known pericardial effusion which was
considered to be insignificant, he did not undergo
pericardiocentesis during the prior hospitalization.
Cardiomegaly has worsened on his CXR (3cm difference), which is
concerning for worsening pericardial effusion. No signs of
tamponade--blood pressure stable, no JVD appreciated (pulsus not
assessed as patient looked very stable). Repeat echocardiogram
performed and showed that the effusion had increased but was
still small. The cardiac surgery team was updated on the new
finding.
.
# Leukocytosis: seen during prior hospitalization and stable
from prior hospitalization at 15-20. ID saw him during prior
hospitalization and cleared him for surgery. The patient's UA
was negative, his CXR was not concerning for pna, and bacterial
blood and urine cultures were pending at time of discharge.
.
CHRONIC ISSUES:
# CORONARIES: patient with known CAD in the LAD. Questionable
plan for CABG during MR/TR on Monday [**2175-7-31**]. Continued on
simvastatin, lisinopril, ASA, metoprolol.
.
# PUMP: borderline CHF 50-55%, appears euvolemic at this time.
Maintain on home dose of Lasix 20mg Daily. Discussed at length
the importance of fluid restrictions to 1500mL per day, taking
Lasix.
.
# RHYTHM: paroxysmal afib, on dabigatran. Rate control on
metoprolol succinate and diltiazem, patient does become
tachycardic with heart rate to low 100's but remains
asymptomatic and will return to atrial fibrillation in the
70-80s. No cardioversion scheduled because of plan for cardiac
surgery next week ([**2175-7-31**]).
.
# History of alcohol abuse, last drink prior to previous
hospitalization on [**2175-7-9**]. Continued on thiamine, B12, folic
acid, MVI
ISSUES OF TRANSITIONS IN CARE:
PENDING STUDIES:
- blood cultures x2
- urine culture
CODE STATUS: FULL CODE (CONFIRMED)
CONTACT: [**Name (NI) **] [**Name (NI) 91703**] (girlfriend) [**Telephone/Fax (1) 91702**]
Medications on Admission:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
3. aspirin 325 mg Tablet daily
4. furosemide 20 mg Tablet daily
5. multivitamin One tablet PO DAILY
6. folic acid 1 mg Tablet 1 Tablet PO DAILY
7. thiamine HCl 100 mg Tablet One Tablet PO DAILY
8. metoprolol succinate 100 mg Tablet ER DAILY
9. cyanocobalamin (vitamin B-12) 50 mcg Tablet PO DAILY
10. Diltzac ER 240 mg Capsule once a day.
11. dabigatran etexilate 150 mg Capsule PO twice a day.
12. trazodone 25 mg Tablet PO HS as needed for insomnia.
.
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
9. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
12. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
Disp:*100 ML(s)* Refills:*0*
13. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*15 Capsule(s)* Refills:*0*
14. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
primary: viral upper respiratory infection; paroxysmal atrial
fibrillation
secondary: severe mitral valve regurgitation; severe tricuspid
valve regurgitation; pericardial effusion; coronary artery
disease; dyslipidemia; hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Name13 (STitle) **],
You were admitted to the hospital for a cough. It is felt that
this cough is most likely just a simple virus. You do not have a
pneumonia. Reasons to return to the hospital would include
development of a fever, which is a temperature of greater than
100.5 degrees. You have also complained of some back
pressure/tightness, and this current pain is not because of your
heart. It is most likely due to a muscle strain because you have
been lying down so much recently. If you cannot tolerate this
pain, you may take Tylenol. Do not take Advil, Ibuprofen, Motrin
or other NSAIDs as they will interfere with your Aspirin, which
is very important for you.
It is of the utmost importance that you DO NOT DRINK ALCOHOL. DO
NOT SMOKE CIGARETTES.
Please note that the following changes have been made to your
medications:
- NO major changes, however, you may use Tessalon Perles,
Dextromethomorphan-guaifenesin (which is Mucinex) as needed for
your cough.
- Please continue to take your medications as directed during
your last hospitalization. The following medications you MUST
take daily: Aspirin, Simvastatin, Lisinopril, Lasix, Metoprolol,
Diltzac, Dabigatran. Your multivitamin, thiamine, B12, folic
acid, and trazadone are very important too.
Followup Instructions:
Your cardiac surgery is on [**2175-7-31**] at 6 am with Dr. [**Last Name (STitle) **].
ICD9 Codes: 2767, 4240, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1592
} | Medical Text: Admission Date: [**2175-3-10**] Discharge Date: [**2175-5-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Aspiration
Major Surgical or Invasive Procedure:
Intubation, repostitioning G-Tube, change of G-tube to G-J tube
History of Present Illness:
Mr. [**Known lastname 4476**] is a [**Age over 90 **] year old man with a long history of
end-stage dementia for at least 10 years with recurrent
aspiration pneumonias and pressure ulcers who presents to the
[**Hospital1 18**] ED from [**Hospital **] Rehab with an aspiration. He was recently
discharged from [**Hospital1 18**] [**3-3**] after he had an aspiration and had a
prolonged intubation. He was treated with vanc/zosyn for a two
week course which was completed [**3-5**]. Today, nursing at [**Hospital1 **]
noted that his abdomen was somewhat distended. A KUB was
performed that showed the feeding tube was coiled in his stomach
in a different position. Tube feeds were restarted and the
feeding tube was noted to be further displaced with the phlange
out of place. The patient was turned and began vomiting and
gagging and was suctions. His VS when he was evaluated there
were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM.
.
The patient was brought to the [**Hospital1 18**] ED evaluation. In the ED,
he was immediately intubated, and started on
levaquin/vanc/flagyl for presumed aspiration pneumonia. He
transiently dropped his blood pressure to a systolic of 80's
over 30's and was started on levophed.
Past Medical History:
End-stage Alzheimers
Atrial fibrillation
Recurrent aspiration pneumonias
h/o MRSA and VRE colonization
Myoclonus
Social History:
Recently discharged from [**Hospital1 18**] to [**Hospital **] rehab.
Has been cared for by his daughter for the past three years.
Family History:
Noncontributory
Physical Exam:
VS: (on arrival to the MICU) T 98.9 HR 100 BP 75/33 RR 21 Sat
98%
Vent: AC Tv 500 RR 14 PEEP 8 FiO2 60%
GEN: unresponsive, intubated man on a intubated and sedated on a
ventilator
HEENT: Dry MM, sclerae anicteric, pinpoint pupils.
CV: Distant heart sounds, irregular
PUL: Coarse rhonchi throughout
ABD: Distended, no rebound or guarding.
EXT: 1+ edema
Pertinent Results:
ADMISSION LABS
[**2175-3-9**] 11:00PM BLOOD WBC-9.6 RBC-3.73* Hgb-10.9* Hct-33.8*
MCV-91 MCH-29.2 MCHC-32.3 RDW-18.5* Plt Ct-314
[**2175-3-9**] 11:00PM BLOOD Neuts-69.8 Lymphs-21.3 Monos-4.6 Eos-4.2*
Baso-0.2
[**2175-3-9**] 11:00PM BLOOD PT-13.3* PTT-25.6 INR(PT)-1.2*
[**2175-3-9**] 11:00PM BLOOD Glucose-128* UreaN-32* Creat-1.0 Na-139
K-4.4 Cl-97 HCO3-30 AnGap-16
[**2175-3-9**] 11:00PM BLOOD ALT-26 AST-41* AlkPhos-159* Amylase-66
TotBili-0.5
[**2175-3-9**] 11:00PM BLOOD Lipase-63*
[**2175-3-9**] 11:00PM BLOOD Albumin-3.6 Calcium-10.0 Phos-3.6 Mg-2.3
[**2175-3-9**] 11:00PM BLOOD Cortsol-26.2*
[**2175-3-9**] 11:00PM BLOOD CRP-158.4*
[**2175-3-10**] 04:13AM BLOOD Type-ART pO2-68* pCO2-38 pH-7.49*
calHCO3-30 Base XS-5
[**2175-3-9**] 11:00PM BLOOD Lactate-2.0
LAB TRENDS
CBC
[**2175-3-10**] 11:00AM BLOOD WBC-13.9* RBC-3.22* Hgb-9.6* Hct-29.1*
MCV-90 MCH-29.9 MCHC-33.1 RDW-19.1* Plt Ct-259
[**2175-3-13**] 04:28AM BLOOD WBC-10.7 RBC-3.01* Hgb-8.8* Hct-27.5*
MCV-92 MCH-29.4 MCHC-32.1 RDW-19.6* Plt Ct-274
[**2175-3-16**] 03:18AM BLOOD WBC-11.5* RBC-2.90* Hgb-8.9* Hct-26.8*
MCV-92 MCH-30.5 MCHC-33.1 RDW-19.3* Plt Ct-286
[**2175-3-20**] 04:52AM BLOOD WBC-10.0 RBC-2.79* Hgb-8.4* Hct-25.3*
MCV-91 MCH-30.3 MCHC-33.4 RDW-19.9* Plt Ct-380
[**2175-3-22**] 03:00AM BLOOD WBC-9.7 RBC-2.88* Hgb-8.6* Hct-26.3*
MCV-91 MCH-29.8 MCHC-32.7 RDW-19.9* Plt Ct-410
[**2175-3-26**] 03:49AM BLOOD WBC-11.9* RBC-2.68* Hgb-8.1* Hct-24.6*
MCV-92 MCH-30.2 MCHC-32.9 RDW-20.4* Plt Ct-283
[**2175-4-1**] 05:00AM BLOOD WBC-15.0* RBC-2.69* Hgb-8.2* Hct-25.4*
MCV-94 MCH-30.3 MCHC-32.2 RDW-21.6* Plt Ct-299
[**2175-4-3**] 04:10AM BLOOD WBC-15.1* RBC-2.87* Hgb-8.8* Hct-27.3*
MCV-95 MCH-30.8 MCHC-32.4 RDW-22.0* Plt Ct-349
[**2175-4-7**] 05:27AM BLOOD WBC-9.8 RBC-2.50* Hgb-7.5* Hct-23.8*
MCV-95 MCH-30.1 MCHC-31.6 RDW-21.8* Plt Ct-334
[**2175-4-13**] 03:24AM BLOOD WBC-8.1 RBC-3.00* Hgb-9.5* Hct-28.2*
MCV-94 MCH-31.5 MCHC-33.6 RDW-19.7* Plt Ct-263
[**2175-4-18**] 03:42AM BLOOD WBC-7.7 RBC-2.89* Hgb-8.7* Hct-27.5*
MCV-95 MCH-30.1 MCHC-31.7 RDW-19.7* Plt Ct-329
CHEMISTRY
[**2175-3-11**] 02:42AM BLOOD Glucose-124* UreaN-23* Creat-0.9 Na-141
K-3.1* Cl-105 HCO3-24 AnGap-15
[**2175-3-14**] 03:51AM BLOOD Glucose-103 UreaN-32* Creat-1.0 Na-144
K-4.5 Cl-110* HCO3-24 AnGap-15
[**2175-3-17**] 03:52AM BLOOD Glucose-118* UreaN-41* Creat-0.9 Na-141
K-4.2 Cl-107 HCO3-25 AnGap-13
[**2175-3-18**] 04:07AM BLOOD Glucose-710* UreaN-38* Creat-1.0 Na-137
K-5.5* Cl-103 HCO3-26 AnGap-14
[**2175-3-20**] 04:52AM BLOOD Glucose-87 UreaN-46* Creat-0.9 Na-138
K-3.7 Cl-104 HCO3-27 AnGap-11
[**2175-3-23**] 05:15AM BLOOD Glucose-105 UreaN-54* Creat-0.9 Na-142
K-3.7 Cl-111* HCO3-21* AnGap-14
[**2175-3-27**] 03:58AM BLOOD Glucose-127* UreaN-72* Creat-1.1 Na-143
K-4.1 Cl-112* HCO3-21* AnGap-14
[**2175-3-30**] 02:18AM BLOOD Glucose-125* UreaN-76* Creat-1.2 Na-147*
K-4.0 Cl-113* HCO3-22 AnGap-16
[**2175-4-3**] 04:10AM BLOOD Glucose-122* UreaN-55* Creat-1.2 Na-143
K-4.2 Cl-110* HCO3-23 AnGap-14
[**2175-4-8**] 01:28AM BLOOD Glucose-139* UreaN-32* Creat-1.3* Na-144
K-4.2 Cl-111* HCO3-21* AnGap-16
[**2175-4-15**] 01:55AM BLOOD Glucose-103 UreaN-40* Creat-1.3* Na-138
K-3.5 Cl-103 HCO3-23 AnGap-16
[**2175-4-18**] 02:03PM BLOOD Glucose-128* UreaN-39* Creat-1.4* Na-142
K-3.9 Cl-104 HCO3-28 AnGap-14
COAGS
[**2175-3-11**] 02:42AM BLOOD PT-17.4* PTT-31.4 INR(PT)-1.6*
[**2175-3-16**] 03:18AM BLOOD PT-15.2* INR(PT)-1.4*
[**2175-3-18**] 04:07AM BLOOD PT-14.6* INR(PT)-1.3*
[**2175-3-31**] 12:38PM BLOOD PT-16.6* PTT-29.4 INR(PT)-1.5*
[**2175-4-8**] 01:28AM BLOOD PT-17.1* PTT-31.2 INR(PT)-1.6*
[**2175-4-18**] 03:42AM BLOOD PT-15.5* PTT-30.6 INR(PT)-1.4*
~
~
~
~
~
~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
RADIOLOGY
CHEST (PORTABLE AP) [**2175-3-9**] 10:48 PM
IMPRESSION: Bilateral pleural effusions with perihilar haze and
upper zone redistribution present. A focal opacity is present in
the left mid lung zone. Findings may represent CHF/volume
overload with concern for concomitant infection.
CHEST (PORTABLE AP) [**2175-3-19**] 3:49 PM
IMPRESSION: Mild-to-moderate pulmonary edema has developed since
[**3-16**], partially obscuring multifocal consolidation, and
accompanied by increasing moderate right pleural effusion. Large
cardiac silhouette is stable. No pneumothorax. ET tube and right
central venous line are in standard placements. No pneumothorax.
CHEST (PORTABLE AP) [**2175-3-21**] 9:51 AM
IMPRESSION: Worsening of the left upper lobe and left lower lobe
consolidations vs. left pleural effusion. 2) Improvement of the
right lower lobe consolidation.
CHEST (PORTABLE AP) [**2175-4-2**] 1:02 PM
FINDINGS: There is a frontal and a view dedicated to the right
lateral chest. The tracheostomy tube is unchanged. The right IJ
line with tip in the superior vena cava is unchanged. There
continue to be patchy areas of opacity in both lower lungs and
in the perihilar regions suggesting multifocal pneumonia. There
could also be an element of CHF
C1894 INT.SHTH NOT/GUID,EP,NONLASER [**2175-4-5**] 1:24 PM
CHANGE G-TUBE TO G-J TUBE
IMPRESSION: Successful placement of a MIC gastrojejunostomy tube
with the tip of the tube in the small bowel loop. This catheter
is ready to use
CHEST (PORTABLE AP) [**2175-4-6**] 12:33 PM
Right pleural effusion is again demonstrated grossly unchanged
as well as pleural effusion on the left. The position of the
various lines and tubes is unaltered and the left lower lobe
consolidation is again demonstrated
CHEST (PORTABLE AP) [**2175-4-11**] 5:59 AM
Moderately severe pulmonary edema and moderate left and small
right pleural effusion have increased over the past five days.
More discrete region of consolidation seen in the left perihilar
lung is now partially obscured but has not cleared and other
areas of pneumonia could be obscured by the effusions and edema.
Heart size is top normal. Tracheostomy tube and left subclavian
central venous catheter are in standard placements. No
pneumothorax.
CHEST (PORTABLE AP) [**2175-4-13**] 1:12 PM
IMPRESSION: Mild improvement of previously described pulmonary
edema
CHEST (PORTABLE AP) [**2175-4-17**] 4:48 AM
Elevation of the right lung base which has progressed slowly
since early [**Month (only) 547**] is probably due to a combination of lower lobe
atelectasis and moderate right pleural effusion. Left perihilar
consolidation and hazy opacification of most of the left lung is
probably due to a combination of mild pulmonary edema and
increasing moderate left pleural effusion. Although the heart is
not grossly enlarged, there is persistent mediastinal venous
engorgement. More intense consolidation in the left upper lung
is consistent with a coexistent pneumonia, unchanged since [**4-14**].
~
~
~
~
~
~
~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CARDIOLOGY
ECG Study Date of [**2175-3-10**] 3:51:00 AM
Atrial fibrillation with rapid ventricular response
Left axis deviation - anterior fascicular block
Ant/septal+lateral ST-T changes may be due to myocardial
ischemia
Repolarization changes may be partly due to rate/rhythm
Incomplete right bundle branch block
Since previous tracing, right bundle branch block now incomplete
ECHO Study Date of [**2175-3-11**]
Conclusions:
The left atrium is normal in size. There is symmetric left
ventricular
hypertrophy. Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. Overall left ventricular
systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated. Right ventricular systolic function is normal.
The aortic root is moderately dilated. The ascending aorta is
mildly dilated. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are thickened. There is
probably mild aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension.
ECG Study Date of [**2175-3-19**] 12:11:06 PM
Atrial fibrillation. Axis to the left. T wave inversion in lead
aVL.
QR complexes in leads VI-V2. Non-specific T wave inversion in
lead aVL and low amplitude T waves in lead I. Right
bundle-branch block. Anteroseptal myocardial infarction. Left
axis deviation. Atrial fibrillation. Non-specific T wave
abnormalities. Compared to the previous tracing of [**2175-3-10**]
atrial fibrillation with tachycardia is no longer present.
Quality of tracing does not permit further assessment.
~
~
~
~
~
~
~
~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
MICROBIOLOGY
Sputum: Pseudomonas multidrug resistant. Sensitve to Tobra,
intermediate to [**Last Name (un) **] and Gent.
KLEBSIELLA PNEUMONIAE
MRSA
C.Diff positive last on [**4-2**]
Brief Hospital Course:
CC:[**CC Contact Info 4477**].
HPI:
Mr. [**Known lastname 4476**] is a [**Age over 90 **] year old man with a long history of
end-stage dementia for at least 10 years with recurrent
aspiration pneumonias and pressure ulcers who presents to the
[**Hospital1 18**] ED from [**Hospital **] Rehab with an aspiration. He was recently
discharged from [**Hospital1 18**] [**3-3**] after he had an aspiration and had a
prolonged intubation. He was treated with vanc/zosyn for a two
week course which was completed [**3-5**]. Today, nursing at [**Hospital1 **]
noted that his abdomen was somewhat distended. A KUB was
performed that showed the feeding tube was coiled in his stomach
in a different position. Tube feeds were restarted and the
feeding tube was noted to be further displaced with the phlange
out of place. The patient was turned and began vomiting and
gagging and was suctions. His VS when he was evaluated there
were T 98.8 BP 119/76 RR 32 Sat 90% on 60% FM.
.
The patient was brought to the [**Hospital1 18**] ED evaluation. In the ED,
he was immediately intubated, and started on
levaquin/vanc/flagyl for presumed aspiration pneumonia. He
transiently dropped his blood pressure to a systolic of 80's
over 30's and was started on levophed.
Surgery was consulted
.
[**Age over 90 **]M with end-stage dementia noncommunicative for last 10 years
and inability to be weaned off vent p/w recurrent aspiration
pneumonias and likely aspiration. On IV flagyl for +c diff.
+Sputum cx pseudamonas on [**4-3**] in setting of hypotn, elevated
WBC and low grade fevers. s/p Tracheostomy [**3-31**].
.
# Pseudomonas pneumonia: Initially admitted with hypoxia, fevers
and hypotension with ?aspiration pneumonia however CXR unchanged
and started on vancomycin/zosyn ([**Date range (1) 4478**]) for coverage of
nosocomial peumonia. Subsequently abx d/c'd [**1-19**] +c diff in
stool. On [**3-24**] and [**3-26**] sputum cx grew resistant pseudamonas
([**Last Name (un) 36**] tobra, zosyn, meropenum) and pansensitive klebsiella
however clinically stable and no clear indication of pna on CXR.
s/p trach on [**3-31**]. [**Date range (1) 4479**] increasing WBC, hypotn and low
grade temp. Initially started on zosyn. Sputum again +for
pseudamonas and pt. started on meropenem, tobra. On [**4-11**]
meropenem was d/c and on [**4-14**] pt. grew pseudomonas out of sputum
- ID recommended only starting again if clinical picture
worsened. Pt's clinical picture did not worsen after this. Ctx
sensitive to zosyn and question if pt. was infected vs.
colonized as pt. w/ stable white count and not spiking
temperatures so decision was made to switch to single coverage.
The decision was made to start Zosyn on [**4-23**] and was scheduled to
complete a 14 day course. Because of the proximity of the end
date to the projected date of discharge, vanco and zosyn were
continued through the date of discharge. These antibiotics
should be discontinued 1-2 days after the patient is transferred
to his long term treatment facility.
## C. Diff Colitis: Pt. was also found to have C. diff colitis
during hospitalization likely [**1-19**] antibiotics. Pt. initially
started on vanco and flagyl. Per ID recs, pt. only needs single
coverage for this, so vanco was d/c and flagyl continued. It is
imperative that the patient continue flagyl for 14 days AFTER
the last dose of Zosyn. Hence, this would correspond to 16 days
after transfer from [**Hospital1 18**].
.
## Hypotension: likely due to sepsis originally, but responsive
to fluid boluses. In SICU, pt. was started on pressors, but
stopped on [**3-13**]. Pt. maintained goal MAPs. IN the MICU pt.
likely remained hypotensive due to poor forward flow. - given
total clinic pictures decision was made that pressors were not
indicated and the goal MAP was b/t 50-60. Throughout stay in
MICU, pt. w/ stable BP w/ occassional fluid boluses for
decreasting MAPS. and infection responsive to fluid boluses. It
was decided by the MICU team, other medical and subspecialty
teams directly involved w/ pt's care, ethics committee that CPR
was not medically indicated in this pt
.
## Acute renal failure: Pt. w/ acute renal failure during his
stay at [**Hospital1 **]. Renal was consulted and this was felt to be
secondary to poor forward flow. Pt. appears to have pre-renal
failure in the setting of total volume overload. Per renal,
this is not reversible and therefore the decision was made that
dialysis was not medically indicated. Pt. w/ increasing
creatinine throughout stay. Renal followed and pt. was startd
on bicarb.
.
# Atrial fibrillation: was in good control until arrival to
floor but developed some RVR. Stable throughout SICU and MICU
stay. Pt. was rate controlled on his own.
.
# Decubitus ulcers: Pt. w/ sacral decubitus - stage 1 and right
heel stage 1. Pt. also w/ multiple skin tears from tape. Pt.
w/ hip wound. Wound care following. Pt. w/ wet to dry
dressings.
.
## G/J Tube - Pt. had a G/J tube placed by IR. During MICU
stay, there was a question of increased leakage around tube and
surgery was consulted. An IR study was done that showed that
tube was in place w/ no evidence of obstruction. On [**5-4**], it
was decided to feed the J portion of the tube and suction the G
portion as there was no surgery indicated. On [**5-5**], there was a
hole noted at the distal portion of the feeding tube. Pt. was
taken back to IR and a G tube was placed at daughter's
insistence despite the strong recommendation by the MICU team
and IR team to have G/J tube replaced.
.
# F/E/N: Pt. was originally on TPN because of aspiration event.
When pt. was in the MICU he was on TF. At the end of MICU stay,
pt. was tolerating Vivonex.
.
# Ppx: Throughout hospital stay, pt. was on PPI and Heparin
prophylaxis.
Medications on Admission:
Vancomycin 1gm q24h until [**3-5**]
Zosyn 2.25gm q8h until [**3-5**]
Docusate liquid 150 twice daily
ASA 325mg daily
Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: 1-2 Drops
Ophthalmic PRN
Magnesium Hydroxide 15mg daily
Heparin 5000u sc bid
Albuterol neb q6h
Atrovent neb q6h
Lansoprazole 30mg daily
Donepezil 10mg qhs
Lasix 20mg daily
Milk of Magnesia 15cc daily
Lopressor 6.25 mg [**Hospital1 **]
Tylenol elixir prn
Tube feeds: Nepro 0.45% @ 70cc/hr
Discharge Medications:
1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please give 5000 units
subcutaneous heparin tid.
13. Potassium Iodide 1 g/mL Solution Sig: Ten (10) Drop PO TID
(3 times a day) as needed for via J tube.
14. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily) as needed for down J-tube.
15. Artificial Tears Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection ASDIR (AS DIRECTED).
17. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
(3 times a day).
18. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
19. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours).
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: Please use 10 mL NS
followed by 2 ml of 100units/ml heparin (200 units heparin) each
lumen daily and PRN.
21. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): please give 40 mg solution
IV q 24 hours.
22. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams
Recon Solns Intravenous Q 12H (Every 12 Hours) for 2 days:
Please give 2.25 g IV q 13 hours.
23. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg IV Intravenous Q12H (every 12 hours) for
15 days: Please give 500 mg IV q 12 hrs .
24. Wound Care
25. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 gram
Recon Soln(s)IV Intravenous Q8H (every 8 hours).
26. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram (200ml piggyback) Intravenous Q48H (every 48 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Aspiration Pneumonia
Acute Renal Failure
Hypotension
Alzheimers
Discharge Condition:
Stable
Discharge Instructions:
IT IS VERY IMPORTANT THAT THIS PT'S TRACH BE HUBBED AT ALL TIMES
AS IT SLIPS SOME DUE TO GRANULATION TISSUE IN TRACT.
Patient should follow up with your primary care physician in the
next week. Please take all the medications as directed. Pleas
continue wound care as outlined.
Followup Instructions:
You should follow up with your primary care physician in the
next week.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 5070, 4280, 0389, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1593
} | Medical Text: Admission Date: [**2145-5-5**] Discharge Date: [**2145-5-10**]
Date of Birth: [**2083-8-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Niacin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
asymptomatic.abnormal stress test on routine yearly physical
exam
Major Surgical or Invasive Procedure:
[**2145-5-6**]
1. Coronary artery bypass grafting x4, with left internal
mammary artery to left anterior descending coronary
artery; reversed saphenous vein single graft from the
aorta to the first diagonal coronary artery; reversed
saphenous vein single graft from the aorta to the first
obtuse marginal coronary artery; as well as reversed
saphenous vein single graft from the aorta to the distal
right coronary artery.
2. Epiaortic duplex scan.
3. Exploration of right atrial appendage to rule out or
rule in atrial septal defect.
4. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
61 yo male with HTN, dyslipidemia and diabetes recently seen
for routine physical. Referred for nuclear stress test on [**4-19**]
due to risk factors for CAD- showing medium area of moderate
stress induced ischemia in the PDA territory and diagonal
artery,
NL LV function. Pt now presents for cardiac catheterization to
further evaluate.
Past Medical History:
Hypertension
Dyslipidemia
Diabetes (type II with retinopathy)
BPH
Colon Polyps s/p polypectomy
Lung Nodule (right side- stable)
Basal cell CA
Diverticulosis
Social History:
Lives with: married with two adult children.
Occupation: Retired. Previously employed with [**Company 22957**].
Tobacco: Quit 30 years ago
ETOH: 10 beers per week
Family History:
Mother and father died of CAD in their 60's
Physical Exam:
Pulse:48 SB Resp:16 O2 sat: 99% RA
B/P Right: 117/50 Left:
Height: 5' 7" Weight: 225#'s
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
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: cath site Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit Right: None Left:None- s/p CEA
Pertinent Results:
[**2145-5-8**] 06:02AM BLOOD WBC-14.6* RBC-3.12* Hgb-9.2* Hct-27.4*
MCV-88 MCH-29.7 MCHC-33.7 RDW-13.5 Plt Ct-205
[**2145-5-6**] 01:46PM BLOOD PT-13.5* PTT-21.9* INR(PT)-1.2*
[**2145-5-8**] 06:02AM BLOOD Glucose-121* UreaN-23* Creat-0.9 Na-137
K-4.1 Cl-102 HCO3-26 AnGap-13
Pre-CPB:
No mass/thrombus is seen in the left atrium or left atrial
appendage.
No inter-atrial flow could be demonstrated with doppler or
bubble studies.
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 regurgitation. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
An epi-aortic scan showed no significant disease at the aortic
cannulation site.
Post-CPB:
The patient is AV-Paced, on low dose phenlephrine.
Preserved biventricular systolic fxn. No MR, no AI.
Aorta intact.
No interatrial flow.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2145-5-6**] where the patient underwent coronary
artery bypass x 4. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Cefazolin was
used for surgical antibiotic prophylaxis. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. [**Last Name (un) **] was consulted for assistance with
blood glucose management. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Rehab in good condition with appropriate
follow up instructions.
Medications on Admission:
atenolol 37.5mg
HCTZ 25mg
lisinopril 10mg
metformin 1000mg [**Hospital1 **]
Actos 15mg daily
Simvastatin 80mg
ASA 325mg
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for PAIN.
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
13. Repaglinide 2 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals.
14. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig:
One (1) Subcutaneous four times a day: dose prn for
BG>200mg/dL, per sliding scale.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
16. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 weeks.
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
18. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
coronary artery disease, s/p CABG [**2145-5-6**]
PMH:
Hypertension
Dyslipidemia
Diabetes (type II with retinopathy)
BPH
Colon Polyps s/p polypectomy
Lung Nodule (right side- stable)
Basal cell CA
Diverticulosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] I. [**Telephone/Fax (1) 17794**] in [**12-12**] weeks
Cardiologist Dr. [**First Name (STitle) **],[**First Name3 (LF) 2922**] S. [**Telephone/Fax (2) 2258**]in 1-2 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2145-5-10**]
ICD9 Codes: 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1594
} | Medical Text: Admission Date: [**2131-12-26**] Discharge Date: [**2132-1-17**]
Date of Birth: [**2087-6-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
SOB and R arm swelling
Major Surgical or Invasive Procedure:
R AV fistula ligation
History of Present Illness:
Pt. is a 44 y/o with a hx of ESRD on HD (Tu, Th, Sat), Type II
DM, who p/w SOB x 2 day and R arm pain x 2 weeks. Pt. reports
she has had SOB with exertion since returning from HD on
Tuesday. Reports she has been getting a cold for the last week,
with rhinorrhea and cough productive of yellow sputum. Denies
HA, CP, fevers, reports chronic chills. Says she has had similar
episodes of SOB in the past "when I get fluid overloaded from
dialysis" but that she has been regular about HD so doesn't know
why she would be fluid overloaded now.
.
Pt. also reports getting a R AV fistula placed 1 month ago. She
reports her arm has been becoming painful and swollen for the
past 2 weeks. Says occasionally she'll get pain shooting from
elbow to R thumb, and sometimes her R hand goes numb if she
sleeps on her R, but otherwise denies weakness or numbness in R
hand.
.
In ED: A/A Nebs, ASA, Blood Cx x 2. Transplant surgery asked to
eval R arm fistula, Renal asked to eval for HD.
Past Medical History:
Type II DM, +retinopathy
ESRD on HD
HTN
Hx Pre-eclampsia
CHF- EF unknown, pt. reports "leaky valves"
Sleep Apnea -> CPAP, Home O2 PRN
CVA [**8-19**] with residual L arm and leg weakness
Social History:
No EtOH, hx tobacco quit 1 year ago, used to smoke 3 ppd x 33
years. Lives with cousin, [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 26707**], on
disability
Family History:
Adopted, unknown
Physical Exam:
VS: 96.8 116 167/93 18 99% on 2L
Gen: A+O, sitting on stretcher in NAD
HEENT: EOMI, PERRL
CV: tachycardic, regular rhythm, harsh 4/6 systolic murmer
Lungs: decreased BS at bases bilat, mild bibasilar crackles
Abd: obese, soft, NTND, +BS
Ext: fistula in R forearm, +thrill, R arm markedly swollen from
elbow to shoulder, TTP in this area. + radial pulse bilat
Pertinent Results:
CTA Chest [**2131-12-26**]: 1) No evidence of pulmonary embolism.
2) Congestive heart failure with mild bilateral pleural
effusions.
3) Nonspecific borderline mediastinal lymphadenopathy.
4) Tiny ill defined alveolar opacities in the anterior left
upper lobe
anteriorly, nonspecific; possibly infectious in nature; these
should be
reassessed to ensure resolution.
.
Right upper extremity venous ultrasound and Doppler examination,
[**2131-12-26**]:
Examination of the right internal jugular, right subclavian,
right axillary, paired brachial and basilic veins shows no
evidence of deep vein thrombosis. A very limited evaluation of
the fistula suggests that it is patent.
.
Fistulogram [**2131-12-28**]: Central subclavian occlusion. Limited
outflow of the AV fistula through multiple collaterals in the
arm, shoulder and thoracic wall. The AV anastomosis is patent.
Recommend MR venogram to determine central end of occlusion.
Based on MRI, decision to attempt further venous recanalization
under anesthesia could be considered.
.
MRI/MRA Chest [**2132-1-2**]: MRA of the thorax shows normal pulmonary
arteries bilaterally without central filling defects to suggest
pulmonary embolus. Pulmonary veins are patent and have a normal
appearance. The left ventricle wall appears mildly thickened
raising the question of left ventricular hypertrophy. Chamber
size is within normal limits for all four [**Doctor Last Name 1754**] of the heart.
The ascending and descending aorta have a normal appearance
without aneurysmal dilatation, ulcer, or large amount of
atherosclerosis. Bilateral common carotid arteries are widely
patent proximally and patent to their bifurcations. Bilateral
subclavian arteries are also widely patent giving rise to
respective vertebral arteries. The left vertebral artery appears
slightly dominant. No concerning lesions within the arteries.
.
There is marked narrowing of the right subclavian vein a few
centimeters
central to the right chest wall that extends over the entire
more central
portion of the right subclavian vein and right brachiocephalic
vein. The
caliber of the vessel at this level measures between 3 and 9 mm
with multiple areas of stenosis. PICC does extend through the
stenoses and into the superior vena cava. The right jugular vein
is completely thrombosed.
.
The left subclavian vein is markedly irregular with moderate
stenoses but
remains patent to the left brachiocephalic vein. Within the left
lateral
subclavian vein are some filling defects that could represent
chronic thrombus that are nonocclusive. The patient's
double-lumen dialysis catheter enters through the central left
subclavian vein and into the brachiocephalic vein and SVC. There
is minimal contrast around the dialysis catheter throughout its
course within the brachiocephalic vein and superior SVC, which
is narrowed superiorly, however there is slow flow around the
catheter. The left jugular vein is completely thrombosed.
.
Large number of venous collaterals shunting venous blood from
the neck and bilateral upper extremities around the bilateral
subclavian vein and
brachiocephalic vein stenoses. Collaterals are seen within
anterior chest
walls bilaterally, left much greater than right, within the
posterior thorax including the intercostal veins and within the
supraclavicular veins bilaterally. Early on after the injection,
contrast is seen to flow more through these collaterals than
through the bilateral subclavian veins, right brachiocephalic,
and proximal left brachiocephalic vein. The two largest central
collaterals are the azygos vein and the left superior
intercostal vein.
.
There are multiple bilateral enlarged axillary lymph nodes,
which are
nonspecific and were seen on the recent CT scan. Clinical
correlation to
explain this lymphadenopathy is recommended.
.
No definite abnormalities are seen within the upper abdomen on
limited
evaluation. Within the right latissimus dorsi muscle is a 8.6 x
3.6 x 4.0 cm lesion with predominantly fat within it, though
there is some central soft tissue with intermediate T1 and T2
signal. This is not definitely a simple lipoma and therefore
dedicated MRI is recommended to better characterize.
.
IMPRESSION:
1. Multifocal high-grade stenosis within the right subclavian
vein centrally and right brachiocephalic vein. These vessels are
patent though there is slow flow through them with large venous
collaterals.
.
2. Moderate stenoses within the left subclavian vein and minimal
flow through the left brachiocephalic vein about the patient's
dialysis catheter as well as in the superior SVC which is
slightly narrowed. These lumens are patent, however there is
decreased flow as evidenced by delayed filling and the extensive
collaterals.
.
3. Bilateral jugular vein occlusion inferiorly.
.
4. 8.6 cm fat-containing lesion within the right latissimus
dorsi does
contain soft tissue elements and therefore is not definitely a
simple lipoma. Dedicated MRI is recommended to better
characterize.
.
5. Right greater than left axillary lymphadenopathy is
non-specific and
clinical correlation is recommended
.
CTA Chest [**2132-1-6**]: 1. No evidence of pulmonary embolism.
2. Findings most consistent with congestive heart failure.
3. New bibasilar opacities, probably atelectases.
4. Prominent axillary lymph nodes.
Brief Hospital Course:
SOB: CTA showed findings c/w CHF. Pt. was aggressively
dialyzed with improvement in her SOB. After HD #3 she did not
require O2 during the day to maintain O2 sats. A TTE was
checked and showed and EF of 75% with moderate LV outflow
obstruction, [**12-17**]+ MR, and mild PA hypertension, and high outflow
CHF [**1-17**] her AV fistula was thought to contribute to SOB.
Pulmonary was consulted re: PA HTN contributing to SOB and
recommended PFTs, which showed a restrictive defect, as well as
a RA ABG, which showed a pH of 7.39, PO2 73, PCO2 46, HCO3 29.
She was continued on her CPAP at night. PA HTN was also thought
to contribute to her SOB. PE was considered on admission,
however CTA was negative for PE. It was considered again when
pt. was transferred to the MICU on [**1-5**] for hypotension and
hypoxia, especially given known UE thrombi, however repeat CTA
was negative for PE.
.
CHF: As mentioned above pt. was found to have high output CHF,
making her pro-load dependant. On [**1-5**] she became hypotensive
and hypoxic, and was transferred to the MICU for further
management. She briefly required pressors, but responded to
fluid resuscitation (3L NS), and briefly required BiPAP for
management of hypoxia, though she was quickly weaned to O2 by
NC. All blood cultures were negative, so this episode was
thought be be [**1-17**] decreased pre-load from decreased PO intake
and fluid removal at HD, and not sepsis. She was continued on
ASA QD throughout her hospitalization, as well as her BB (though
this was held during her episode of hypotension) She was
started on an ACE at the beginning of her hospitalization,
however this was stopped during her hypotensive episode and was
not restarted in order to maintain a higher basal BP. This was
later restarted at the time of discharge.
.
Arm Swelling: RUE dopplers were checked on admission and were
negative for DVT. Transplant evaluated pt in ED and reviewed
dopplers, and concluded that no intervention was necessary.
However given clinical concern for thrombosis, this was followed
up with an AV fistulogram which showed central subclavian
occlusion. Pt. was started on Heparin gtt. Transplant was
reconsulted and again recommended no intervention. Therefore
interventional radiology was consulted re: recanalization of R
subclavian vein. They recommended an MRI/MRV prior to
intervention, and this was obtained (see results above) and
showed bilateral thrombi and stenoses. While these studies were
being obtained pt. also developed LUE swelling, due to L sided
clots. On [**1-9**] recanalization of R subclavian clot was
attempted by IR, but was unsuccessful. Pt. was transferred to
the MICU for infusion of tPA overnight, and recanalization was
attempted again on [**1-10**], again unsuccessfully. Transplant was
contact[**Name (NI) **] again after these procedures, and on [**1-12**] they ligated
her R AV fistula.
.
ESRD: Renal was consulted, and pt. was continued on HD through
her L subclavian HD catheter. Her PhosLo was d/ced as her Phos
was WNL, and her Epogen at HD was continued. She was started on
Nephrocaps.
.
Type II DM: Actos was held given concern for fluid retention,
pt. was covered with RISS, with good blood glucose control over
admission.
.
Dispo: At the time of discharge the patient INR was to be drawn
at dialysis and followed up by Dr. [**First Name8 (NamePattern2) 26708**] [**Name (STitle) **]. The patient
would later be transitioned to the coumadin clinic at [**Hospital 6308**].
Medications on Admission:
Metoprolol 100 mg [**Hospital1 **]
Lansoprazole 30 mg [**Hospital1 **]
Pioglitazone 30 mg QD
Diltiazem Er 360 mg QD
Calcium Acetate 667 mg TID with meals
Reglan 10 mg TID
ASA 325 mg QD
Epogen with HD
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
PRN.
Disp:*qs inhaler* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED): Will be given at dialysis.
8. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*5 Bottles* Refills:*2*
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-17**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*qs bottles* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
12. trazadone Sig: 25mg at bedtime.
Disp:*30 pills* Refills:*2*
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Patient needs INR level monitored on Tuesday, Thursday and
Saturday.
Please report value to Dr. [**First Name8 (NamePattern2) 26708**] [**Name (STitle) **] [**Numeric Identifier 26709**]
[**Hospital 191**] clinic
16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis
Bilateral Upper Extremity Thrombus
.
Secondary Diagnosis
Type II DM, retinopathy
ESRD on HD
HTN
Pre-eclampsia
CHF: EF 75%
Sleep Apnea: CPAP
CVA [**8-19**] with L arma and leg weakness
Discharge Condition:
Good, vitals stable, patient ambulating and eating,
Discharge Instructions:
Seek medical services immediately if you should have any fevers,
chills, worsening upper extremity swelling or any other
worrisome sympmtom. Please take your medications as prescribed.
Please restrict your sodium intake to 2g per day.
.
Your INR will be checked at dialysis. They will report the
results to me. Do not take your Coumadin tonight. Take it on
Friday. I will contact you on Saturday as to whether or not you
need to take it.
.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-1-22**]
4:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-2-5**]
1:30
Completed by:[**2132-1-22**]
ICD9 Codes: 5856, 4168, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1595
} | Medical Text: Admission Date: [**2174-3-30**] Discharge Date: [**2174-4-6**]
Date of Birth: [**2109-1-7**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Cortisone
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
L facial rash and swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 65 yo woman with MG on immunosuppression who presents
with zoster ophthalmicus and a possible bacterial
superinfection. Her symptoms started two weeks ago when she
noted sharp shooting pain on the [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of her face and scalp.
The following day she developed marked swelling and vesicular
rash around her left eye. Because of the swelling she could not
see through the left eye. She contact[**Name (NI) **] her ophtholmologist who
diagnosed her with shingles and referred her to her PCP. [**Name10 (NameIs) **] was
prescribed po valacyclovir and took it for 3 days. As her
symptoms failed to improve, she contact[**Name (NI) **] her neurologist Dr.
[**Last Name (STitle) 1206**] who urged her to present to [**Hospital1 18**] for IV acyclovir
treatment.
.
In the ED she received IV acyclovir and was admitted to
neurology for further management ([**2174-3-30**]). Initially stable
w/o complaints. On [**4-1**] patient was noted to be weak and did
poorly on her respiratory testing (NIF 24, FVC 0.9). She was
subsequently transferred to the ICU amid concerns of myasthenia
flare and related respiratory distress. On admission to ICU
patient was stable with repeated NIF -50 and FVC 2.4. She did
not require intubation and was started on IVIg for myasthenia.
Patient was transferred to medicine on [**4-2**] for further
management.
.
On the floor, she denies any facial pain or headache. Notes some
difficulty seeing w her left eye because of the swelling. Denies
recent fevers, chills, night sweats, sore throat, cough, SOB.
Denies chest pain, palpitations. Denies abdominal pain, N/V/D.
Denies new vessicles or any rashes at other parts of her body.
Denies sick contacts but notes distant history of chickenpox as
a child. Notes fatigue w repeated physical activity unchanged
from her baseline MG.
Past Medical History:
myasthenia [**Last Name (un) 2902**]
osteoporosis
breast calcifications
mitral valve prolapse
Social History:
Married lives with husband, works this past year, part-time,
teaching [**Location (un) 1131**]. No tob, etoh or drugs.
Family History:
breast cancer, emphysema, cardiac arrest
Physical Exam:
PHYSICAL EXAM:
VS: Tc:97.8 Tmax:98.2 BP:122/68 HR:95 RR:20 O2 sat: 98% @ RA
GEN: NAD.
HEENT:
- EOMI, PERRL bilaterally; vision intact bilaterally. Resolving
edema/erythema in CN V1 distribution with crusted areas medially
w/o new vessicles.
- R ear tympanic membrane non-inflammed with intact light reflex
and no pooling of fluid; mild edema/erythrema of the external
ear epithelium inferiorly; No vessicles noted. No pus or
drainage noted. L ear exam unremarkable.
- OP clear without lesions. MMM. No sinus tenderness.
NECK: Supple; No LAD; no JVD appreciated
CV: RRR, nl S1, S2. No m/r/g.
CHEST: CTAB, no crackles/wheezes/rhonchi; unlabored respiration
w/o accessory muscle use
ABD: +BS, Soft, NT/ND, no masses or organomegally appreciated
EXT: WWP, No c/c/e
SKIN: Erythematous rash with crusted edges and central resolving
area contained within left CNV1 dermatome; Minimal edema of
surrounding skin and eyelid, now resolving. No vessicles
appreciated. No puss production or drainage noted; Resolving
left conjunctival injection with scant viscous drainage. No
other lesions or rashes appreciated.
NEURO: A&O x 3. CN II-XII intact. Normal bulk, strength and tone
throughout. Sensation intact. No nystagmus, dysarthria,
intention or action tremor. Downgoing Babinski bilaterally.
Pertinent Results:
[**2174-4-3**] 05:35AM BLOOD WBC-8.9 RBC-3.41* Hgb-10.3* Hct-31.0*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.8 Plt Ct-279
[**2174-4-4**] 04:45AM BLOOD WBC-7.6 RBC-2.99* Hgb-9.1* Hct-26.7*
MCV-89 MCH-30.6 MCHC-34.2 RDW-14.8 Plt Ct-281
[**2174-4-2**] 02:49AM BLOOD WBC-10.7 RBC-3.36* Hgb-10.2* Hct-29.8*
MCV-89 MCH-30.3 MCHC-34.2 RDW-14.7 Plt Ct-235
[**2174-3-30**] 04:02PM BLOOD WBC-9.4 RBC-3.66* Hgb-11.5* Hct-32.6*
MCV-89 MCH-31.5 MCHC-35.3* RDW-14.7 Plt Ct-253
[**2174-4-1**] 08:00AM BLOOD Neuts-88.5* Lymphs-7.3* Monos-4.0 Eos-0.1
Baso-0.1
[**2174-3-30**] 04:02PM BLOOD Neuts-90.4* Lymphs-6.6* Monos-2.8 Eos-0.1
Baso-0.1
[**2174-4-2**] 02:49AM BLOOD PT-13.3 PTT-30.1 INR(PT)-1.1
[**2174-3-31**] 05:26AM BLOOD PT-13.0 PTT-23.2 INR(PT)-1.1
[**2174-4-4**] 04:45AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-138
K-3.4 Cl-102 HCO3-31 AnGap-8
[**2174-4-3**] 05:35AM BLOOD Glucose-99 UreaN-12 Creat-0.6 Na-138
K-3.3 Cl-101 HCO3-31 AnGap-9
[**2174-4-2**] 02:49AM BLOOD Glucose-97 UreaN-8 Creat-0.5 Na-137 K-3.5
Cl-100 HCO3-32 AnGap-9
[**2174-4-1**] 08:00AM BLOOD Glucose-144* UreaN-7 Creat-0.5 Na-135
K-3.5 Cl-93* HCO3-36* AnGap-10
[**2174-3-31**] 05:26AM BLOOD ALT-37 AST-18 LD(LDH)-282* AlkPhos-47
TotBili-0.4
[**2174-4-4**] 04:45AM BLOOD Calcium-8.8 Iron-38
[**2174-4-1**] 08:00AM BLOOD Albumin-3.9 Calcium-7.5* Phos-3.4 Mg-2.0
[**2174-3-31**] 05:26AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.0*
[**2174-4-4**] 04:45AM BLOOD calTIBC-267 Ferritn-49 TRF-205
[**2174-4-1**] 08:00AM BLOOD IgG-425* IgA-47* IgM-56
[**2174-4-1**] 11:15PM BLOOD Type-ART pO2-94 pCO2-45 pH-7.45
calTCO2-32* Base XS-6
[**2174-4-1**] 07:34PM BLOOD Type-ART FiO2-20 pO2-76* pCO2-41 pH-7.48*
calTCO2-31* Base XS-6
[**2174-4-1**] 07:34PM BLOOD Lactate-1.6
.
CHEST X-RAY: The lungs are clear without infiltrate or effusion.
On prior chest x-ray, there is a history of a lung nodule, but
this is not evident on today's study. Compared to the prior
exam, there has been no significant interval change.
.
CULTURES: Blood, urine, MRSA, and C. diff cultures negative
Brief Hospital Course:
65 year old female with myasthenia [**Last Name (un) 2902**] on prednisone,
CellCept and IVIg immunosuppression presenting with zoster
ophthalmicus and superimposed cellulitis.
.
1.) MICU Course:
Pt was transferred from floor to MICU for concern of respiratory
fatigue secondary to myasthenia [**Last Name (un) 2902**]. On the floor NIF -> -24
and FVC 900cc, however there was concern this low value may have
been related to anxiety. In the MICU the patient remained
stable and not show signs of respiratory fatigue. ABG showed
normal pCO2. NIF overnight was -44 with an FVC of 2.4L. NIF in
the AM ([**4-2**]) was -50. The patient tolerated room air for the
majority of the night. She was given IVIg for treatment of
possible myasthenia crisis.
.
2.) ZOSTER OPTHALMICUS:
Zoster opthalmicus in L CNV1 distribution with associated
cellulitis. Patient completed seven days of IV acyclovir and 7
days of IV Unasyn while inpatient. Discharge on 14 days of
valacyclovir 1g PO TID and on augmentin 875 mg PO BID for total
on 10 days as per ID recs. Continue with topical bacitracin and
polymyxin B. Continue lidocaine and gabapentin PRN pain;
.
2.) MYASTHENIA [**Last Name (un) **]:
Following ICU stay, patient remained stable and in no
respiratory distress. NIF remained around -50 and FVC at 1.7.
She completed 5 days of IVIg with last dose on [**4-4**]. She was
continued on home prednisone, Cellcept, pyridostigmine. She was
insructed to start on dapsone 100mg PO QD for PCP prophylaxis
until prednisone < 20mg per day on discharge. Also started on
Calcium and Vitamin D.
.
3.)R EAR PAIN: Patient complained of ear pain contralateral to
zoster 2 days prior to discharge. On exam, no evidence of
vesicles but possible dullness of TM c/w viral infection.
Patient was already on antibiotics. Her symptoms improved the
next day.
.
4.) ANEMIA:
Patient has baseline anemia and has had history of iron
deficiency in the past reuqiring supplemental iron. Iron labs
significant for normocytosis, low-normal Fe (38), low-normal
TIBC (267) and normal ferritin (49). This data suggests mixed Fe
deficiency and ACD, as her ferritin would be expected to be much
higher in the setting of acute infection and inflammation. No
evidence of hemolysis on exam or from history. No evidence of
acute bleeding and gastrocult negative on admission.
- Futher outpatient eval if symptomatic.
.
5.) HYPOTHYROIDISM: Stable. Continue home synthroid.
Medications on Admission:
Medications (at home):
Levothyroxine 25 mcg
Cellcept [**Pager number **] mg [**Hospital1 **]
protonix 40 mg daily
Prednisone 20 daily
Pyridostigmine 90 mg [**Hospital1 **] and 60 mg qhs
Forteo (takes 1 shot per day, has not been taking past 1-2 weeks
while sick with GI bug)
Cholestyramine prn for loose stools
Discharge Medications:
1. Valacyclovir 1 g Tablet Sig: One (1) Tablet PO three times a
day for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
2. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Dapsone 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: 7.5 ml PO BID (2
times a day).
9. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: Five (5) mL PO
QHS (once a day (at bedtime)).
10. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
11. Neurontin 300 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for pain.
Disp:*90 Capsule(s)* Refills:*0*
12. Trifluridine 1 % Drops Sig: One (1) Drop Ophthalmic Q4H
(every 4 hours).
Disp:*QS 1 month * Refills:*0*
13. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic
Q2-4H () as needed for eye comfort.
Disp:*QS 1 month * Refills:*0*
14. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical TID (3 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ZOSTER OPTHALMICUS
BACTERIAL SUPERINFECTION
.
Secondary:
myasthenia [**Last Name (un) 2902**]
Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for Zoster opthalmicus, a reactivation of the
chicken pox virus in one of the nerves of your face. You were
treated with IV acyclovir. Given you myasthenia [**Last Name (un) 2902**] and
concern for your respiratory status, you were treated with IVIG.
You were also treated with antibiotics for a possible bacterial
infection that may have occured in the skin that had broken down
from the viral infection. You should complete the course of
prescribed medications and follow up with the doctors as below.
You were started on dapsone for prophylaxis against an infection
called PCP. [**Name10 (NameIs) **] should take this medication while you are on
high doses of prednisone.
If you have new fevers, increasing pain, or any other concerning
symptoms, please seek medical attention.
Followup Instructions:
You should follow up with Dr. [**First Name (STitle) **] from opthomology. Date/Time:
[**4-26**] at 3PM in the [**Last Name (un) **] diabetes center. You may need to get
a referral from your PCP prior to this appointment. You can
call [**Telephone/Fax (1) 28100**] if you need to change this.
Infectious disease: Fri [**5-13**] at 10:00 AM with Dr. [**First Name (STitle) **] [**Last Name (NamePattern1) 12939**] (basement)
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2174-6-8**] 1:00
Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) 162**] [**Telephone/Fax (1) 40969**].
Date/Time: [**2174-4-12**] 2:15 PM
You have an appointment scheduled with your neurologist, Dr.
[**Last Name (STitle) 1206**]. Phone: [**Telephone/Fax (1) 44311**] Date/Time: [**2174-4-14**] 11:00 AM.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2174-4-12**]
ICD9 Codes: 2859, 2449, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1596
} | Medical Text: Admission Date: [**2137-9-7**] Discharge Date: [**2137-9-12**]
Date of Birth: [**2099-9-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracyclines / Succinylcholine / Clozaril /
Calcium Channel Blocking Agents-Benzothiazepines /
Beta-Adrenergic Blocking Agents
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
MICU admission
Hemodialysis
History of Present Illness:
37 year old female with schizoaffective d/o, depression, seizure
d/o, ESRD from IGA nephropathy, very poor access with
transhepatic HD catheter on coumadin; now admit with UGIB
(melena, hematemesis). Patient denies past history of
hematemesis but noted to have some in last DC summary, no EGD at
that time. States hematemsis started today, melena last night.
STR notes of dark bloody stool x 3 incontinent episodes. SBP
111 at STR. Patient was receiving coumadin for line as detailed
below; also started on fondaparineux 7.5 daily (appears to have
received 3 doses only) for subtherapeutic INR.
Past Medical History:
ESRD [**3-9**] IgA nephropathy
Schizoaffective disorder
Depression
Chronic anemia
GERD
Cardiomyopathy: ECHO [**2137-8-6**] EF >65%, hyperdynamic, LVH, no
valvular disease
Hypothyroidism
GI bleed
RLE DVT
Seizure disorder
tracheal stenosis s/p trach, on TM at 7L/min at rehab
malignant hypothermia
Surgical History:
s/p L upper and lower extremity AV fistulae(failed),
s/p R upper extremity AV fistula (basilic vein
transposition(failed),
s/p R forearm AV graft (failed),
s/p attempted insertion of a peritoneal dialysis catheter
(failed), central venous stenosis,
Innominate venous stenosis,
s/p R brachioarterial->axillary AV graft, nonfunctional,
status post multiple thrombectomies and angioplasties,
s/p tracheostomy,
s/p thrombectomy of AV graft x5,
s/p Transhepatic HD catheter placement
Social History:
Currently living at [**Hospital **] rehab. No tobacco, EtOH, illicit
drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T98.5, 95/46, 105, 21, 100% on 50% TM
General: Alert, conversant, flat affect, NAD
HEENT: NC/AT, PERRL, MM moist, small dried blood in nares.
Neck: Trach, no adenopathy
Lungs: coarse but clear, somewhat poor effort
Heart: slightly tachy, regular, no murmur appreciated
Abdomen: Soft, NT/ND. R lateral transhepatic HD line.
Extrem: Warm, no edema, L femoral line in place.
Neuro: Alert and oriented to place
Pertinent Results:
[**2137-9-7**] 10:07PM HCT-17.8*
[**2137-9-7**] 10:07PM PT-16.6* PTT-31.9 INR(PT)-1.5*
[**2137-9-7**] 03:21PM GLUCOSE-108* UREA N-45* CREAT-4.1* SODIUM-139
POTASSIUM-5.4* CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2137-9-7**] 03:21PM ALT(SGPT)-10 AST(SGOT)-13 LD(LDH)-150 ALK
PHOS-80 TOT BILI-0.3
[**2137-9-7**] 03:21PM ALBUMIN-2.7* CALCIUM-7.6* PHOSPHATE-3.0
MAGNESIUM-1.4*
[**2137-9-7**] 03:21PM VANCO-16.6
[**2137-9-7**] 03:21PM WBC-8.3 RBC-2.16* HGB-6.9* HCT-20.3* MCV-94
MCH-31.8 MCHC-33.7 RDW-17.2*
[**2137-9-7**] 03:21PM PLT COUNT-333
[**2137-9-7**] 11:15AM cTropnT-0.10*
[**2137-9-7**] 11:15AM CK(CPK)-15*
Brief Hospital Course:
#UGIB. The patient has had a history of GIB, with last EGD in
[**2134**]. During her last admission previous to this, she again had
a small amount of bleeding but was not scoped. This admission,
the patient again complained of hematemesis in the setting of
anticoagulation with fondaparinaux (however, normal INR due to
prophlactic doses of 1mg Coumadin daily to keep her transhepatic
vein patent) Given her ESRD and recent fondaparinux doses which
is renally cleared, the patient was at particulary high risk of
bleeding. A discussion with heme-path was had and it was
confirmed that there was no specific antidote for fondaparinux.
Therefore, the patient was monitored closely in the ICU due to
her GIB and on [**9-8**] the patient underwent an EGD. At that time,
a bleeding vessel was identified, possibly arterial in source,
and the vessel was clipped and injected with epinephrine.
Following the EGD, the patient had no clinical signs of active
rebleeding and no further investigative radionuclear scans were
needed. Of note, the patient recieved a large amount of FFP and
also recieved ~15 units PRBC this admission. The patient was
maintained on an IV PPI during this admission, which was
switched to sucralfate after several days, and now is being
considered for transfer back to [**Hospital **] rehab after several
days of no hematemesis and stable Hct.
.
# Hypotension. At baseline, pt has a low blood pressure with
SBP's running in the 80's - 100's. During this admission, the
patient had episodes of hypotension below her baseline that were
likely related to hypovolemia/blood loss from her large GIB. BP
was maintained with aggresive therapy with blood products.
Underlying infection/sepsis was considered but there was no
evidence of active infection or this admission. The patient
had two blood cultures on [**9-7**] that were drawn from a left
femoral line, and one of the two bottles showed gram negative
and gram positive rods. The patient had been in the ICU for
several days when these results were received, and was improving
clinically, without an elevated white count, so after discussion
with the team, it was thought that this was most likely a
contaminant. Blood cultures redrawn [**9-11**] are pending. The
patient was continued on treatment with Vancomycin that had been
started during a previous admission for a MRSA bactermia in the
past, with the plan to continue it with dialysis until [**9-15**]. will tolerate SBP in the 80s-use HR as indicator for
volume status as pt was tachycardic originally w acute bleed and
has not been since. In addition, Midodrine was stopped (had
been on 5 mg TID prn for SBP < 90), can consider restarting in
future.
.
# Thrombocytopenia: New development this admission, platelets
have continued to decrease but stabilized and recovered to the
130K range, 104 on discharge. Effect was suspected to be
medication related as fondaparineaux not usually associtaed with
thrombocytopenia, and PPI was switched to Carafate after which,
an improvement in the patient's thrombocytopenia was noted.
.
# ESRD on HD. HD M/W/F. History of extremely difficult access;
currently accessed via transhepatic catheter. On low dose
Coumadin 1mg daily for this with NO GOAL INR.
Pt was dialyzed during this admission without complication.
.
# History of line sepsis. Pt continued to recieve Vanco with HD
while here and recieved an extra 500mg dose early during the
admission secondary to her large volume blood loss and low
Vancomycin levels at that time. The course of Vancomycin
therapy was confirmed with ID and the patient is to continue
Vancomycin with HD through [**2137-9-15**].
.
# History of respiratory failure s/p trach. The patient's
respiratory status was stable during this admission, she was
continued on her trach mask at 40-50% FiO2 with no issues while
in the ICU.
.
# Hypothroidism. Patient was continued on her Synthroid.
.
# Schizoaffective disorder/depression: Patient was continued on
her fluphenazine.
.
# GERD: on Sucralfate, now off PPI/H2 blockers.
.
Medications on Admission:
Albuterol MDI 2 puffs QID
Calcium Acetate 667 mg TID with meals
Cinacalcet 90 mg daily
Fluphenazine 2.5 mg [**Hospital1 **], and 10 mg HS
Fondaparinux 7.5 mg daily (started [**9-4**])
Levothyroxine 100 mcg daily
Midodrine 5 mg TID for SBP <90
Pantoprazole 40 [**Hospital1 **]
Vancomycin 1 gram with HD (reportedly complete on [**9-6**])
Warfarin 3 mg daily
APAP prn
Miconazole prn
Alteplase prn to HD cath
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluphenazine HCl 2.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for wheeze.
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Vancomycin 1000 mg IV HD PROTOCOL
Give one dose after hemodialysis session
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Upper Gastro-intestinal Bleed secondary to bleeding esophageal
vessel and esophagitis
Discharge Condition:
Stable, trach in place
Discharge Instructions:
You were admitted to the hospital with a concern for bleeding.
You underwent a procedure called an EGD to control the bleeding.
You also received blood transfusions to keep your blood level
stable.
.
There were changes made to your medications. You will only
take coumadin 1mg daily and not adjust this for your INR. In
addition, you were started on Sucralfate 1 g four times per day.
This is to help protect your stomach given the recent bleed.
Your Fondaparineux was stopped.
.
If you have any further bleeding, coughing up of blood,
abdominal pain, shortness of breath, or other concerning
symptoms, please return to the ER.
.
You should follow up with your primary care doctor in the next
2-3 weeks.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-9-19**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2137-9-24**] 9:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5856, 4254, 0389, 311, 2449, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1597
} | Medical Text: Admission Date: [**2125-1-22**] Discharge Date: [**2125-1-29**]
Date of Birth: [**2098-6-30**] Sex: F
Service: MEDICINE
Allergies:
Famotidine
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Acetaminophen intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 26 year old female with history of anxiety,
depression and multiple past suicide attempts who is transferred
to [**Hospital1 18**] from the OSH for the management of the acetaminophen
overdose. Per report, patient ingested approximately 7.5g of
acetaminophen in a suicude attempt on [**1-19**]. Patient presented to
the [**Hospital3 **] ED on [**1-20**] with acetaminophen level of 132. She
received 20 hour course of IV n-acetylcysteine. The 16-hr
component of the infusion was repeated due to evolving liver
failure. Her AST and ALT levels were 4500 and 7400,
respectively, with INR 1.8. She was transferred to [**Hospital1 18**] for
further management.
On presentation at [**Hospital1 18**], patient was in no distress. She had no
specific complaints except headache. She denied any nausea,
vomiting, abdominal pain, diarrhea, fever, chills, confusion.
Past Medical History:
-Hypothyroidism: on levothyroxine
-Amenorrhea secondary to low body weight: s/p recent 10-day
course of medroxyprogesterone 10 mg po daily to stimulate
ovulation ([**Date range (1) 89743**]), not successful
Past Psychiatric History:
-Depression with chronic thoughts of suicidality and self-harm:
history of prior suicide attempt at age 16 via Tylenol overdose.
Two prior hospitalizations at age 16 for Tylenol overdose and at
age 20 in context of severe SI.
-Anorexia: diagnosed at age 12, no prior hospitalizations
related to anorexia, currently with stable weight, working with
new nutritionist.
Social History:
Lives with parents, grandmother and older sister in [**Name (NI) 38**],
middle of 3 girls. Graduated [**Doctor Last Name **] undergrad and grad school
LCSW. Recently working as social worker at [**Hospital3 **] Mental
Health. She has a few friends, does not date. Exercise
'fanatic'. No known hx of abuse or trauma.
Family History:
Paternal grandmother and father with depression, both sisters on
antidepressants.
Physical Exam:
VS: 100.8 54 114/65 16 100% RA
Gen: NAD, sad affect, appropriate
Neuro: no focal deficit, no aterixis
HEENT: No icterus, oropharynx moist, without exudate, no LAD, no
thyromegaly
CV: RRR, S1S2, no mur
pulm: CTA b/l
abdom: soft, ND/NT, + BS, no hepatomegaly
extremities: no edema, no cyanosis, well perfused
Pertinent Results:
ADMISSION LABS
[**2125-1-22**] 06:50PM PT-20.1* PTT-36.0* INR(PT)-1.8*
[**2125-1-22**] 06:50PM PLT COUNT-112*
[**2125-1-22**] 06:50PM NEUTS-78.6* LYMPHS-15.8* MONOS-1.9* EOS-3.4
BASOS-0.3
[**2125-1-22**] 06:50PM WBC-5.0 RBC-3.54* HGB-12.2 HCT-33.8* MCV-96
MCH-34.5* MCHC-36.1* RDW-13.3
[**2125-1-22**] 06:50PM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-2.0*#
MAGNESIUM-1.8 IRON-25*
[**2125-1-22**] 06:50PM LIPASE-23 GGT-37*
[**2125-1-22**] 06:50PM ALT(SGPT)-6860* AST(SGOT)-4114* LD(LDH)-2390*
ALK PHOS-65 AMYLASE-41 TOT BILI-0.7
[**2125-1-22**] 07:28PM LACTATE-1.3
[**2125-1-22**] 07:28PM TYPE-ART PO2-42* PCO2-36 PH-7.42 TOTAL CO2-24
BASE XS-0
.
DISCHARGE and PERTINENT LABS
[**2125-1-27**] 04:50AM BLOOD WBC-4.0 RBC-3.44* Hgb-11.8* Hct-33.1*
MCV-96 MCH-34.1* MCHC-35.6* RDW-13.2 Plt Ct-259
[**2125-1-27**] 04:50AM BLOOD Gran Ct-1780*
[**2125-1-27**] 04:50AM BLOOD ALT-[**2079**]* AST-104* AlkPhos-76 TotBili-0.2
[**2125-1-27**] 04:50AM BLOOD Albumin-3.7 Calcium-8.9 Phos-4.5 Mg-2.2
[**2125-1-26**] 04:35AM BLOOD WBC-2.7* RBC-3.45* Hgb-11.7* Hct-33.1*
MCV-96 MCH-33.7* MCHC-35.2* RDW-13.0 Plt Ct-201
[**2125-1-26**] 04:35AM BLOOD Neuts-35* Bands-0 Lymphs-51* Monos-5
Eos-7* Baso-2 Atyps-0 Metas-0 Myelos-0
[**2125-1-25**] 06:59AM BLOOD Fibrino-329
[**2125-1-25**] 06:59AM BLOOD VitB12->[**2113**] Folate->20
[**2125-1-23**] 01:43AM BLOOD TSH-2.0
[**2125-1-22**] 10:29PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM
HBc-NEGATIVE
.
IMAGING:
[**2125-1-22**] Abdominal U/S With Dopplers: FINDINGS: The liver is
normal in echogenicity and contour. No focal liver lesions are
seen. No intra- or extra-hepatic biliary dilation is identified.
The CBD measures 2 mm. Note is made of a small amount of
ascites. The gallbladder is mildly distended. There is
asymmetric gallbladder wall edema with the wall measuring up to
1 cm. Views of the pancreas are unremarkable, though the distal
tail is obscured by overlying bowel gas. Normal hepatic arterial
and venous waveforms are seen. Normal portal venous flow is
seen.
IMPRESSION:
1. No focal liver lesions. Small amount of intra-abdominal
ascites and
gallbladder wall edema likely related to acute liver
failure/hepatitis.
2. Patent hepatic vasculature with normal waveforms.
.
[**2125-1-23**] Chest X-ray (PA and Lat): No evidence of acute
cardiopulmonary disease. No pneumonia, vascular congestion, or
pleural effusion.
.
[**2125-1-23**] Trans-thoracic Echocardiogram: The left atrium is
elongated. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Normal study. No structural heart disease or
pathologic flow identified. Normal estimated pulmonary artery
systolic pressure.
Brief Hospital Course:
Mrs. [**Known firstname **] [**Known lastname 89742**] is a 26 year-old woman with history of prior
suicide attempts with overdose of multiple medications
(including acetaminophen), depresion, anorexia, anxiety and
hypothyroidism who comes after a suicidal attempt with 150
tablets of extre-strength tylenol on [**1-19**] at about 2pm on
[**2125-1-19**].
.
#. Tylenol induced Hepatitis: The patient was treated per
tylenol overdose protocol with NAC. AST and ALT peaked at 7575
and 3777 and have since improved significantly. The most
worrisome makers for high-risk are INR >6.5 and pH <7.3, which
she did not have. Normal protocol recommends 16 hours of NAC and
she got it for longer until her INR was <1.5 x2 days. Currently
her LFTs are improving up to ALT of 1572, AST 74 with INR of
1.1. She is out of the danger window and we would only expect
improvement in those values within the next weeks. She most
likely will recover 100% of her liver function. The albumin is
low, most likely as a negative stress reactant, but may be low
secondarily to the hepatitis or anorexia.
.
#. Depression / Suicidal attempt: Pt severly depressed and given
current and past episodes of SI/SA she is at high risk for
recurrence. She was placed on a 1:1 sitter, evaluated by
pscyhiatry, and discharged to inpatient psychiatry [**Hospital1 **].
.
#. Leukopenia: The patient developed leukopenia with a nadir of
2.2 WBC, which was thought to be secondarely to
stress/famotidine. This is also corroborated by the anemia with
low-reticulocyte count (see below). There was also a temporal
relationship with starting famotidine, which was stopped her
absolute neutrophil count is 1500. We expect the WBC to continue
improving back to her baseline. We should encourage good PO
intake. There is no need to trend this lab.
.
#. Anemia: Normocytic, normochromic anemia with normal RDW. She
has an iron/TIBC <15 (8%) with a ferritin of ~600 (most likley
falsely elevated given stress). Her MCV is in the high level of
normal (90s). Reticulocyte count was inappropriately low likely
due to bone marrow suppression from severe illness. B12 and
folate levels were normal.
.
#. Elevated INR: The patient's INR is downtrending and nearly
normal at 1.1. It is now to expected to remain normal.
.
#. Anorexia - Pt's BMI is 17.2 with a weight of 49.9 kg (80% of
her IBW of 60.2 Kg). She is tolerating diet well and her
electrolytes are within normal limits. Her WBC are low as
described above. She should be evaluated by nutrition and
psychiatry during her inpatient psychiatry stay. She should
have bone mineral density testing as an outpatient and receive
daily vitamin and mineral (neutra-phos) supplementation.
.
#. Hypothyroid - The patient is hypothyroid. She was continued
on her home dose of levothyroxine 88 mcg daily. A TSH was
checked and found to be wnl at 2.0.
.
#. Code - Full code
.
#. Contact: mother: [**Telephone/Fax (1) 89757**]
.
#. Transition of Care: The patient should be set-up with an
outpatient psychiatric provider and also have primary care
follow-up after her inpatient psychiatric course.
Medications on Admission:
Levothyroxine 88mcg daily
N-acetylcystine 310mg/hr
Famotidine 20mg PO BID
Discharge Medications:
1. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. potassium & sodium phosphates 280-160-250 mg Powder in Packet
Sig: One (1) Powder in Packet PO DAILY (Daily).
4. Outpatient Lab Work
Please check CBC with Diff, AST, ALT, and INR on [**2125-1-29**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: Tylenol Induced Hepatitis, Depression
Secondary Diagnoses: Anorexia, Leukopenia, Anemia,
Hypothyroidism
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 tylenol overdose. You
were treated with a medication to decrease the toxicity from
tylenol. You were monitored in the ICU and then transferred to
the medical liver service. You were seen by psychiatry who
recommended inpatient psychiatric treatment for depression. You
are discharged to an inpatient psychiatric hospital.
.
The following changes were made to your medications:
You should START taking Vitamin D.
You should START taking Neutra-Phos.
.
It was a pleasure taking care of you.
Followup Instructions:
Please follow-up with your PCP 2-4 weeks after you are
discharged.
ICD9 Codes: 2449, 311, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1598
} | Medical Text: Admission Date: [**2109-12-20**] Discharge Date: [**2110-1-5**]
Date of Birth: [**2045-2-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Quinine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2109-12-20**] Right posterolateral thoracotomy, replacement of the
proximal descending thoracic aortic aneurysm using a 26mm
Vascutek Dacron interposition tube graft
[**2109-12-20**] Diagnostic bronchoscopy pre-aortic reconstruction and
bronchoscopy with toilet aspiration of secretions post aortic
reconstruction
[**2109-12-23**] Right Bronchial Y-stent placement
[**2109-12-23**] Flexible bronchoscopy and Therapeutic aspiration of
secretions
[**2109-12-27**] Flexible bronchoscopy through endotracheal tube,
Therapeutic aspiration of secretions, Bronchoalveolar lavage of
the right middle lobe
History of Present Illness:
64 y/o female with complex past medical history (see below) who
has had intermittent bouts of dyspnea on exertion and hoarseness
(along with wheezing and dysphagia) over the past several years.
Underwent coronary artery bypass graft x 1 with respiratory
function continuing to decline. Further work-up revealed right
sided arch with aberrant takeoff of left subclavian and dilated
aorta. Also noted to have right mainstem bronchus compression.
Has already underwent 2 surgical procedures with vascular
surgery (Dr. [**Last Name (STitle) **] and now presents for surgical
replacement of her descending aorta.
Past Medical History:
Descending thoracic aortic aneurysm with aberrant left
subclavian artery and Kumeral's diverticulum with aortic sling
compressing the right main stem bronchus, s/p Left Carotid to
Subclavian bypass [**7-7**], s/p Amplatzer plugging of Aberrant left
subclavian [**9-6**], Coronary artery bypass graft x 1 (LIMA to LAD),
Connective tissue disorder with features of Lupus, Sjogren's and
raynaud syndrome, Stroke, Interstitial lung disease,
Hypothyroidism, Gastroesophageal Reflux disease, Right kidney
cyst, s/p cholecystectomy, s/p carcinoid tumor removal during
colonoscopy, s/p right lung resection?wedge
Social History:
She is a retired administrative assistant. She quit smoking 15
years ago and has wine daily with dinner. She is currently
living with her husband.
Family History:
She has a noncontributory family history.
Physical Exam:
At Discharge:Expired
Pertinent Results:
[**12-20**] Echo: PREBYPASS: 1. The left atrium is mildly dilated. 2.
Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal. 4. The descending thoracic aorta is moderately dilated.
The patient has a known right sided arch. 5. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. 6. The mitral valve
appears structurally normal with trivial mitral regurgitation.
7. There is no pericardial effusion. 8. Dr. [**Last Name (STitle) 914**] was notified
in person of the results during the surgical procedure.
POSTBYPASS: Patient is on an phenylephrine infusion and is in
sinus rhythm 1. Biventricular function is preserved. 2.
Descending thoracic graft not clearly appreciated. 3. Other
findings are unchanged.
[**Known lastname 44356**],[**Known firstname 3049**] [**Age over 90 44357**] F 64 [**2045-2-20**]
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2109-12-31**]
8:43 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2109-12-31**] SCHED
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # [**Clip Number (Radiology) 44358**]
Reason: elevated lft's, not tolerating tube feeds, elevated INR
not
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman s/p right sided descending aorta repair
REASON FOR THIS EXAMINATION:
elevated lft's, not tolerating tube feeds, elevated INR not
on coumadin. Please
do chest and abdominal CT WITH PO contrast
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: AJy TUE [**2109-12-31**] 6:33 PM
PFI:
1. The feeding tube appears to be coiled within the stomach and
is not
post-pyloric. Remainder of the supporting and monitoring lines
and tubes
appear in adequate position.
2. Bilateral lower lobe focal consolidation with air
bronchograms consistent
with pneumonia. Aspiration should be considered given location.
Further
interstitial and ground-glass opacities likely reflect a
combination of
atelectasis and fluid overload.
3. Ascites and diffuse anasarca suggest fluid overload.
4. Borderline fatty infiltration of the liver, but no biliary
dilatation or
mass lesions to explain patient's liver function test
abnormalities.
5. Status post repair of descending thoracic aortic aneurysm,
without
evidence for immediate complication.
Final Report
HISTORY: 64-year-old female, status post repair of descending
thoracic aortic
aneurysm. Referred for evaluation of persistent fever, elevated
LFTs and INR,
and poor tolerance of tube feedings.
COMPARISON: CT of the chest dated [**2109-5-10**].
TECHNIQUE: MDCT axial imaging of the chest and abdomen was
performed
following the administration of oral but not IV contrast.
Sagittal and
coronal reformatted images were reviewed.
CT CHEST: An endotracheal tube terminates approximately 2.5 cm
from the
carina. Tracheal Y-stent is seen with branches extending into
the right and
left main stem bronchi. Two right-sided central venous lines,
one subclavian
and one internal jugular, terminate in the distal SVC. There is
an NG tube
terminating in the stomach. A Dobbhoff-type feeding tube is also
seen
extending into the stomach and is coiled extensively, not
extending post-
pylorically. A right-sided chest tube courses along the
posterior margin of
the lung and terminates adjacent to the superior mediastinum.
Right-sided aortic arch is again noted. Patient is status post
repair of
descending thoracic aortic aneurysm, with graft anastomoses seen
at the level
of the arch and inferiorly. The graft appears to extend
approximately 10 cm
in the craniocaudal direction, and has a diameter of 2.9 cm at
the level of
the carina. There is no significant mediastinal hematoma. The
heart and
pulmonary vessels appear unremarkable. Coronary vascular
calcifications are
appreciated.
There are diffuse reticular and ground-glass opacities in both
lungs, left
greater than right, and more pronounced at the lung bases, where
there are
also areas of focal consolidation and air bronchograms
appreciated. The
crowding of vessels and bronchi suggests a component of
atelectasis, and
generalized anasarca indicates that a degree of fluid overload
is also likely
involved. However, an underlying pneumonia cannot be excluded;
dependent
location would suggest aspiration as possible etiology. There is
no
significant pleural effusion on the right. Pleural effusion on
the left is
small.
There is no mediastinal lymphadenopathy appreciated. There is no
axillary or
supraclavicular lymphadenopathy.
CT ABDOMEN: Oral contrast is seen in the stomach only.
Evaluation of intra-
abdominal organs is limited in lack of IV contrast. There is
moderate amount
of ascites present. The liver is of somewhat low attenuation,
suggesting
fatty infiltration. Liver is otherwise unremarkable without
focal lesions or
intra-/extra-hepatic biliary dilatation. Patient is status post
cholecystectomy. The pancreas, spleen, and adrenal glands appear
normal. The
left kidney is unremarkable. There is a large 5 x 6 cm cystic
structure
arising from the superior pole of the right kidney and has the
density of
simple fluid and is likely a simple cyst. This is unchanged
compared to [**Month (only) 547**]
of [**2109**]. There is no soft tissue stranding or significant
lymphadenopathy
present. There is no free air. Vascular calcifications are seen
without
aneurysmal dilatation.
IMPRESSION:
1. The feeding tube is coiled in the stomach. The remainder of
the
supportive and monitoring devices appear in adequate position.
2. Status post repair of descending thoracic aortic aneurysm,
with no
evidence for immediate post-surgical complication.
3. Diffuse interstitial and ground glass opacities in the lungs,
left
greater than right, with focal consolidations at the bilateral
bases. While
atelectasis and fluid overload are present, underlying pneumonia
cannot be
excluded. The location suggests aspiration as possible etiology.
4. Mild ascites and soft tissue anasarca suggests fluid
overload.
5. Stable large right renal cyst.
6. Borderline fatty infiltration of the liver, without evidence
for focal
liver lesions, biliary dilatation, or masses. Patient is status
post
cholecystectomy.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: WED [**2110-1-1**] 10:03 AM
Imaging Lab
[**Known lastname 44356**],[**Known firstname 3049**] [**Age over 90 44357**] F 64 [**2045-2-20**]
Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
Study Date of [**2109-12-29**] 4:57 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2109-12-29**] SCHED
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL Clip #
[**Clip Number (Radiology) 44359**]
Reason: evaluate flow, increased LFT ? obstruction
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with s/p descending aorta replacement
REASON FOR THIS EXAMINATION:
evaluate flow, increased LFT ? obstruction
Wet Read: KYg SUN [**2109-12-29**] 7:13 PM
limited exam. no e/o bil dil. patent hepatic vasculature.
Final Report
CLINICAL HISTORY: 64-year-old female with lupus, status post
descending aorta
surgery, with increased LFTs. Evaluate for obstruction.
COMPARISON: None.
ABDOMINAL ULTRASOUND: Limited exam as indwelling chest tubes
limits acoustic
windows. The liver is somewhat heterogeneous in appearance. No
focal hepatic
lesion is identified. There is no intra- or extra-hepatic
biliary dilatation.
The common duct measures 5 mm. There is no ascites.
DOPPLER ULTRASOUND: With the exception of the left portal vein,
which could
not be interrogated, the main/right portal veins and hepatic
veins are patent
with appropriate waveforms. The main, right and left hepatic
arteries show
normal flow.
IMPRESSION:
1. Limited exam as patient with indwelling chest tubes which
limits acoustic
windows. No focal hepatic lesion or evidence of biliary
dilatation.
2. Patent hepatic vasculature. The left portal vein was not
interrogated.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
Approved: MON [**2109-12-30**] 10:40 AM
Imaging Lab
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit and on [**12-20**] was brought to the
operating room where she underwent a right posterolateral
thoracotomy, replacement of the proximal descending thoracic
aortic aneurysm using a 26-mm Vascutek Dacron interposition tube
graft and bronchoscopy. Please see operative report for complete
surgical details. Post-surgery bronchoscopy revealed right
mainstem bronchus to still be collapsed. Following surgery she
was transferred to the CVICU for invasive monitoring in stable
condition. On post-op day one she was weaned from sedation,
awoke neurologically intact and extubated. Pulmonary medicine
was consulted for stent placement on post-op day two.
Post-operatively she required several blood transfusions d/t
anemia. Lumbar drain was removed on post-o p day two. Also on
this day she had episode of atrial fibrillation and was treated
appropriately. She continued to have bouts of atrial
fibrillation during post-op course. On post-op day three she was
brought to the operating room where she underwent Y-stent
placement by interventional pulmonology. Later this day she
required a bronchoscopy which found significant mucus retention
and mucus plug in the lumen of the Y-stent. And had successful
therapeutic aspiration. Later on this day she was again weaned
from sedation and extubated. Aggressive pulmonary therapy/toilet
were performed but she continued to require several
bronchoscopies and increasing oxygen requirements over next
several days. Overnight on post-op day six Mrs. [**Known lastname **] was
progressively getting more dyspneic and was in respiratory
distress the morning of post-op day seven, requiring intubation
and mechanical ventilation. Respiratory distress and hypoxia
seemed to be from developing pneumonia (Chest x-rays were
consistent with pneumonia and acute lung failure with ground
glass opacities) and acute respiratory distress syndrome. Blood
cultures taken on post-op day seven were positive for
Enterobacter Aerogenes and COAG negative Staphylococcus.
Bronchoalveolar Lavage and Urine cultures were positive as well
and she was started on broad-spectrum antibiotics until final
sensitivities were performed. Also on this day she had
increasing metabolic acidosis and hypotension (d/t septic shock)
and required multiple pressor support. She received similar
medical care over the next several days (including multiple
pressors and antibiotics) and infectious disease was consulted
on post-op day 11.
The patient remained intubated and her condition worsened with
the family asking that the patient be made comfort measures
only. The patient was extubated and expired shortly thereafter.
Medications on Admission:
Atenolol 12.5mg qd, Lipitor 10mg qd, Restasis, Plaquenil 400mg
qd, Synthroid 100mcg qd, Protonix 80mg qd, Effexor 75mg qd,
Zolpidem 10mg qd, Spiriva, Advair, Albuterol
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Descending thoracic aortic aneurysm with aberrant left
subclavian artery and Kumeral's diverticulum with aortic sling
compressing the right main stem bronchus s/p Right
posterolateral thoracotomy, replacement of the proximal
descending thoracic aortic aneurysm [**12-20**] and Right Bronchial
Y-stent placement [**12-23**]
Post-op Pneumonia
Post-op Sepsis
Post-op Acute Respiratory Distress Syndrome
Post-op Atrial Fibrillation
Post-op Anemia
PMH: s/p Left Carotid to Subclavian bypass [**7-7**], s/p Amplatzer
plugging of Aberrant left subclavian [**9-6**], Coronary Artery
Disease s/p Coronary artery bypass graft x 1 (LIMA to LAD),
Connective tissue disorder with features of Lupus, Sjogren's and
raynaud syndrome, Stroke, Interstitial lung disease,
Hypothyroidism, Gastroesophageal Reflux disease, Right kidney
cyst, s/p cholecystectomy, s/p carcinoid tumor removal during
colonoscopy, s/p right lung resection?wedge
Acute lung injury and respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2110-1-28**]
ICD9 Codes: 2851, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1599
} | Medical Text: Admission Date: [**2193-8-25**] Discharge Date: [**2193-8-31**]
Date of Birth: [**2117-2-10**] Sex: M
Service: MEDICINE
Allergies:
Procainamide / Niacin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
PRBC
FFP
EGD
History of Present Illness:
76 yo man with CML on gleevec, CHF EF 25%, CAD, ?CKD (baseline
1.1-1.7) p/w fatigue, lightheadedness. Patient went to the Va on
tuesday to receive what sounds to be neupogen (per wife, for
'low white blood count'). He then became progreesively more
tired, lightheaded and short of breath with light activity. He
also reports feeling more cold. Given his increasing fatigue, he
presented today to the ED. He had 1 glass of wine today, but
otherwise denies NSAIDS, steroids, alcohol, recent antibiotics.
.
In ED, VS HR 82, BP 106/36 (baseline) , RR 13, O2 Sat 96% RA.
Hct down drom baseline around 30 to 15.6, INR 6.0, rest of CBC,
Chem 7 unremarkable. TroT negative. cross match sent, ~600cc NS
given, 2 PIV placed, Tx to MICU for further management.
.
ROS: (+) melena, fatigue
(-) N/V/SOB/CP/abd apin/diarrhea
Past Medical History:
chronic myelogenous leukemia on Gleevec
s/p ICD implantation [**10-28**] as cannot take quinidine with Gleevec
CKD - baseline Cr 1.7
MI late [**2155**]'s - was asymptomatic
bilateral hearing aides
Lumbar disc disease
Depression
[**2177**] CVA d/t LV thrombus - no residual deficits
[**2183**] Cath - RCA 90% proximal, totally occ distally, akinetic
inferoposterior segment, EF 25-30%
[**10-28**] ECHO - LVEF 25%, severe global LV hypokinesis, 2+ MR, 2+
TR, mild pulmonary hypertension
Social History:
Married x48 years. Lives with his wife. Quit smoking 25 yrs
ago, smoked 1 ppd x 20-25 years. ETOH 1 glass wine/day. No
IVDU. Worked in construction, worked only part-time after CVA
in [**2178**], now retired. Was in the military, worked with
automatic weapons.
Family History:
(-) FHx CAD
no leukemia/lymphoma
Physical Exam:
Vitals - T 97.5, BP 99/60, HR 69, RR 16, O2 100%RA;
General - awake, alert, in NAD
HEENT - PERRL, EOMI, MMM, OP clear, pale conjunctiva
Neck - no JVD
CV - RRR, no r/m/g
Lungs - on ant exam CTA b/l
Abd - S/NT/ND/+BS
Ext - no e/c/c
Neuro- AOx3, grossly intact
Pertinent Results:
[**2193-8-25**] 10:15PM GLUCOSE-95 UREA N-35* CREAT-1.2 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-11
[**2193-8-25**] 10:15PM estGFR-Using this
[**2193-8-25**] 10:15PM CK(CPK)-53
[**2193-8-25**] 10:15PM cTropnT-<0.01
[**2193-8-25**] 10:15PM CK-MB-NotDone
[**2193-8-25**] 10:15PM CALCIUM-8.8 PHOSPHATE-3.2 MAGNESIUM-1.8
[**2193-8-25**] 10:15PM WBC-5.9 RBC-1.37*# HGB-5.1*# HCT-15.6*#
MCV-113* MCH-37.5* MCHC-33.1 RDW-18.9*
[**2193-8-25**] 10:15PM NEUTS-74.5* LYMPHS-19.4 MONOS-4.8 EOS-1.2
BASOS-0.2
[**2193-8-25**] 10:15PM PLT COUNT-317#
[**2193-8-25**] 10:15PM PT-50.6* PTT-34.6 INR(PT)-6.0*
Brief Hospital Course:
76 M with CML on gleevec, CHF EF 25%, CAD, chronic renal disease
(baseline Cr 1.1-1.7), presents with fatigue, lightheadedness,
and Hct 15 from slow GI bleeding.
.
# GI Bleeding:
EGD performed on [**8-29**] showed old blood in stomach with fresh
blood in duodenum but no source of bleeding. Serial Hcts were
checked, showing a slow GIB. Hct was maintained at >28 for
cardiac ischemia. He was guaiac positive in the ED with stable
VS throughout. His baseline hematocrit was 30, attributed to CML
and gleevec therapy. In the MICU, he received 5U PRBC. Iron
studies were consistent with anemia of chronic disease, with
normal B12 and folate. INR was unremarkable at 1.3, likely from
nutrition. Patient was placed on PPI [**Hospital1 **]. Plan is for patient to
follow up for Hcts intermittently, to monitor whether periodic
pRBC transfusions will be required. For cardiac ischemia, goal
Hct would be >28.
.
# Elevated INR:
INR on admission was 4.9, was brought down to <1.5 for EGD.
Patient is on coumadin, likely for severe left global
hypokinesis (apex was not commented) and history of CVA.
Coumadin was held during admission. Plan is to follow up with
PCP as outpatient regarding whether Coumadin should be
restarted.
.
# CML:
Follows with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**], and has been seen by Dr. [**Last Name (STitle) **] in
the past. Gleevec was continued throughout admission. In
response to Gleevec, patient had vomiting when he was not able
to eat meals, but he tolerated Gleevec well with no vomiting
when he was able to take his med with meals.
.
# CAD:
Patient was maintained on metoprolol, but not on ASA inhouse
because of possible interaction with Gleevec. Statin was
continued. Issue of restarting ASA should be addressed with his
PCP.
.
# CHF:
He has an EF 25% in [**2190**] with ICD in place. Repeat ECHO showed
unchanged LV function but worsening mitral regurgitation. He was
euvolemic on exam throughout admission.
.
# Depression:
Effexor was continued during admission.
Medications on Admission:
1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. Fluvastatin 80 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Imatinib 400 mg Tablet Sig: One (1) Tablet PO daily ().
7. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. 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*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: GI bleeding
Secondary diagnosis: CML on Gleevec, CHF with ICD
Discharge Condition:
VSS, feels well, no dizziness, walks well.
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please return to the emergency room if you experience
increased gastrointestinal bleeding such as black or bright red
blood in stool, dizziness, lightheadedness, or fatigue.
3. Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5762**], if you
have questions regarding your medical care.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2193-11-25**] 8:00
.
2. Please have your hematocrit checked on [**Last Name (LF) 766**], [**9-2**],
and have the results faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**]. Or have your
hematocrit checked on Tues, [**9-3**] at your appointment with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**].
Completed by:[**2193-8-31**]
ICD9 Codes: 4280, 5859, 5119, 4240 |
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