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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1700
} | Medical Text: Admission Date: [**2148-12-12**] Discharge Date: [**2148-12-19**]
Date of Birth: [**2079-6-19**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Code stroke: right sided weakness, right facial droop, slurred
speech, left eye deviation, right field cut
Major Surgical or Invasive Procedure:
TPA - incomplete
PEG placement
History of Present Illness:
HPI: The pt is a 69 year-old R-handed male with minimal PMH who
presents with new onset R sided weakness, slurred speech, left
eye deviation, and right sided field cut. Per wife at 8:30 pm
patient developed 'tunnel vision' which then progressed into a
headache. Patient who has had a history of migraine head aches
with what sounds like fortification auras did not think much of
it. He took a Xanax to help him fall asleep which he did so
around 10 pm. He then woke up at 11pm and he told wife that he
still has headache. However, no neurologic symptoms were noted
at this time. However, when he woke up at again at 1am and his
speech was garbbed and his wife called ambulance and to come to
[**Hospital1 **] and code stroke was activated. In the ED, he presented
with
with eye deviation left eye deviation and right hemiparesis and
aphasia. His CT showed left MCA sign and his CTA shows left ICA
occlusion( can not rule out carotid dissection) and MCA
occlusion. his CTP shows increased mean transit time and reduced
cerebral volume and decread CBF. He was given tPA at 323am, but
tPA was held due to severe vomiting and headache( also noticed
trace
blood in the emesis). His exam then worsened at 430am and he had
hemiplegia and worsening aphasia. His score is 18. A repeat CT
of head and did not show any hematoma.
On general review of systems, the wife denies any recent
illness,
fevers, chills, chest pain, SOB. No recent trauma
Past Medical History:
1. Patient had a history of what he believed to be angina
however had a negative Thallium stress test.
2. The patient has a history of left knee pain and has
undergone arthroscopy several times.
3. HTN
4. Prostate Cancer, s/p radiation seeding
Social History:
About 2 EtOH drinks per night no tobacco, or illicit drug use
Family History:
father with cardiac problems
Physical Exam:
Physical Exam (Initial EXAM):
General: Awake, cooperative,
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND,
Extremities: warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 2 (stating [**2108**]). Language
was
dysarthric.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. No reaction to threat on Right
side. III, IV, VI: eyes deviated to the left
V: Facial sensation intact to light touch.
VII: Right sided facial droop
VIII: Hearing intact to voice
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Was able to lift the
right
side against gravity but with significant drift. left side was
full
-Sensory: stated a decrease to pinprick on the right upper and
lower extremity
-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.
-Coordination: No intention tremor, [**Doctor First Name **] intact
-Gait: not tested
Pertinent Results:
MRI:
FINDINGS: Diffusion imaging demonstrates an extensive left MCA
territory
infarct without associated hemorrhage. There is subtle FLAIR
abnormality at
this time indicating the acute nature of the infarct. T2
sequences
demonstrate lack of the normal flow void in the left MCA,
particularly the M1
and M2 segments.
There is no other area of infarct. There is no edema, mass or
mass effect.
Ventricles and sulci are normal in size and configuration. Other
intracranial
flow voids are unremarkable.
IMPRESSION: Extensive acute left MCA infarct . No hemorrhage.
NCHCT:
1. No hemorrhage.
2. Hyperdense appearance of the Left ICA and Left MCA,
concerning
for
thrombosis.
CTA:
1. There is thrombosis of the left cervical ICA extending to the
terminal
portion of ICA,. thrombus in the left MCA, M1 and M2 segments,
with narrowing
of the distal branches.
2. Few section of the cervical portion of R ICA have a fillind
defect,
question thrombus/ dissection.
3.Posterior circualtion is patent.
3 D recons pending. CTP pending.
CTP: MTT is increased in the entire L MCA territory, with mild
decrease in the cerebral blood volume and cerebral blood flow.
TTE [**2148-12-12**]
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%). 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 are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No pathologic valvular abnormality seen.
Compared with the report of the prior study (images unavailable
for review) of [**2139-8-5**], mild symmetric LVH is seen on the
current study
[**2148-12-12**] 04:24PM CK(CPK)-237
[**2148-12-12**] 04:24PM CK-MB-6 cTropnT-<0.01
[**2148-12-12**] 08:09AM GLUCOSE-148* UREA N-21* CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2148-12-12**] 08:09AM ALT(SGPT)-23 AST(SGOT)-29 LD(LDH)-208
CK(CPK)-119 ALK PHOS-29* TOT BILI-0.6
[**2148-12-12**] 08:09AM CK-MB-3 cTropnT-<0.01
[**2148-12-12**] 08:09AM ALBUMIN-3.8 CALCIUM-8.0* PHOSPHATE-2.7
MAGNESIUM-1.9 CHOLEST-165
[**2148-12-12**] 08:09AM %HbA1c-5.8 eAG-120
[**2148-12-12**] 08:09AM TRIGLYCER-44 HDL CHOL-62 CHOL/HDL-2.7
LDL(CALC)-94
[**2148-12-12**] 08:09AM WBC-8.2 RBC-4.73 HGB-14.8 HCT-40.8 MCV-86
MCH-31.3 MCHC-36.3* RDW-13.8
[**2148-12-12**] 08:09AM PLT COUNT-226
[**2148-12-12**] 08:09AM PT-12.8 PTT-22.0 INR(PT)-1.1
[**2148-12-12**] 04:19AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2148-12-12**] 02:48AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2148-12-12**] 02:21AM LACTATE-1.7
[**2148-12-12**] 02:00AM GLUCOSE-152* UREA N-24* CREAT-1.0 SODIUM-141
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16
[**2148-12-12**] 02:00AM LIPASE-33
[**2148-12-12**] 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2148-12-12**] 02:00AM WBC-6.6 RBC-4.84 HGB-15.3 HCT-41.6 MCV-86
MCH-31.6 MCHC-36.7* RDW-13.9
[**2148-12-12**] 02:00AM PT-12.3 PTT-21.4* INR(PT)-1.0
[**2148-12-12**] 02:00AM PLT COUNT-238
[**2148-12-12**] 02:00AM FIBRINOGE-267
[**2148-12-19**] 06:25AM BLOOD WBC-8.2 RBC-4.90 Hgb-15.0 Hct-43.1 MCV-88
MCH-30.7 MCHC-34.9 RDW-13.3 Plt Ct-285
[**2148-12-18**] 05:40AM BLOOD WBC-9.5 RBC-4.99 Hgb-15.2 Hct-43.2 MCV-87
MCH-30.4 MCHC-35.1* RDW-13.2 Plt Ct-269
[**2148-12-17**] 05:47AM BLOOD WBC-7.5 RBC-5.65 Hgb-17.0 Hct-48.8 MCV-86
MCH-30.1 MCHC-34.8 RDW-13.1 Plt Ct-281
[**2148-12-16**] 07:35AM BLOOD WBC-6.2 RBC-5.13 Hgb-15.3 Hct-43.5 MCV-85
MCH-29.9 MCHC-35.3* RDW-13.2 Plt Ct-259
[**2148-12-15**] 07:45AM BLOOD WBC-6.8 RBC-5.20 Hgb-16.3 Hct-45.4 MCV-87
MCH-31.4 MCHC-35.9* RDW-13.5 Plt Ct-243
[**2148-12-14**] 08:05AM BLOOD WBC-7.8 RBC-5.43 Hgb-16.2 Hct-46.9 MCV-86
MCH-29.8 MCHC-34.4 RDW-13.4 Plt Ct-246
[**2148-12-13**] 12:49AM BLOOD WBC-10.0 RBC-5.01 Hgb-15.4 Hct-43.6
MCV-87 MCH-30.6 MCHC-35.2* RDW-13.6 Plt Ct-265
[**2148-12-12**] 08:09AM BLOOD WBC-8.2 RBC-4.73 Hgb-14.8 Hct-40.8 MCV-86
MCH-31.3 MCHC-36.3* RDW-13.8 Plt Ct-226
[**2148-12-12**] 02:00AM BLOOD WBC-6.6 RBC-4.84 Hgb-15.3 Hct-41.6 MCV-86
MCH-31.6 MCHC-36.7* RDW-13.9 Plt Ct-238
[**2148-12-15**] 07:45AM BLOOD PT-12.6 PTT-25.5 INR(PT)-1.1
[**2148-12-14**] 08:05AM BLOOD PT-12.4 PTT-24.4 INR(PT)-1.0
[**2148-12-12**] 08:09AM BLOOD PT-12.8 PTT-22.0 INR(PT)-1.1
[**2148-12-12**] 02:00AM BLOOD PT-12.3 PTT-21.4* INR(PT)-1.0
[**2148-12-12**] 02:00AM BLOOD Fibrino-267
[**2148-12-14**] 08:05AM BLOOD ESR-7
[**2148-12-13**] 09:15PM BLOOD ACA IgG-PND ACA IgM-PND
[**2148-12-19**] 06:25AM BLOOD Glucose-148* UreaN-27* Creat-0.8 Na-139
K-4.0 Cl-104 HCO3-28 AnGap-11
[**2148-12-18**] 05:40AM BLOOD Glucose-116* UreaN-29* Creat-0.9 Na-142
K-4.2 Cl-107 HCO3-28 AnGap-11
[**2148-12-17**] 05:47AM BLOOD Glucose-118* UreaN-25* Creat-0.9 Na-139
K-4.2 Cl-100 HCO3-31 AnGap-12
[**2148-12-16**] 07:35AM BLOOD Glucose-152* UreaN-25* Creat-0.8 Na-136
K-4.2 Cl-100 HCO3-27 AnGap-13
[**2148-12-15**] 07:45AM BLOOD Glucose-135* UreaN-29* Creat-0.8 Na-142
K-3.3 Cl-103 HCO3-28 AnGap-14
[**2148-12-14**] 08:05AM BLOOD Glucose-129* UreaN-25* Creat-0.8 Na-142
K-3.9 Cl-104 HCO3-31 AnGap-11
[**2148-12-13**] 12:49AM BLOOD Glucose-122* UreaN-18 Creat-0.8 Na-138
K-3.5 Cl-104 HCO3-29 AnGap-9
[**2148-12-12**] 08:09AM BLOOD Glucose-148* UreaN-21* Creat-0.8 Na-140
K-3.9 Cl-107 HCO3-24 AnGap-13
[**2148-12-12**] 02:00AM BLOOD Glucose-152* UreaN-24* Creat-1.0 Na-141
K-3.9 Cl-104 HCO3-25 AnGap-16
[**2148-12-16**] 07:35AM BLOOD ALT-20 AST-44* AlkPhos-32*
[**2148-12-14**] 08:05AM BLOOD ALT-20 AST-27 AlkPhos-34* TotBili-0.8
[**2148-12-13**] 12:49AM BLOOD CK(CPK)-264
[**2148-12-12**] 04:24PM BLOOD CK(CPK)-237
[**2148-12-12**] 08:09AM BLOOD ALT-23 AST-29 LD(LDH)-208 CK(CPK)-119
AlkPhos-29* TotBili-0.6
[**2148-12-13**] 12:49AM BLOOD CK-MB-3 cTropnT-<0.01
[**2148-12-12**] 04:24PM BLOOD CK-MB-6 cTropnT-<0.01
[**2148-12-12**] 08:09AM BLOOD CK-MB-3 cTropnT-<0.01
[**2148-12-14**] 08:05AM BLOOD Albumin-4.1 Calcium-9.2 Phos-2.5* Mg-2.3
[**2148-12-12**] 08:09AM BLOOD Albumin-3.8 Calcium-8.0* Phos-2.7 Mg-1.9
Cholest-165
[**2148-12-14**] 08:05AM BLOOD VitB12-507
[**2148-12-12**] 08:09AM BLOOD %HbA1c-5.8 eAG-120
[**2148-12-14**] 08:05AM BLOOD Homocys-8.6
[**2148-12-12**] 08:09AM BLOOD Triglyc-44 HDL-62 CHOL/HD-2.7 LDLcalc-94
[**2148-12-14**] 08:05AM BLOOD CRP-54.3*
[**2148-12-14**] 08:05AM BLOOD TSH-0.76
[**2148-12-12**] 02:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2148-12-12**] 02:21AM BLOOD Lactate-1.7
Brief Hospital Course:
Initial Assessment / Hospital Course:
The pt is a 69 year-old R-handed male with minimal PMH who
presents with new onset R sided weakness, slurred speech, left
eye deviation, and right sided field cut. Patient presented
about 3 hours and 52 mintues following the onset of symptoms. In
the ED, he presented with with eye deviation left eye deviation
and right hemiparesis and aphasia. His CT showed left MCA sign
and his CTA shows left ICA occlusion( can not rule out carotid
dissection) and MCA occlusion. His CTP shows increased mean
transit time and reduced cerebral volume and decread CBF. He was
given tPA at 323am, but tPA was held due to severe vomiting and
headache (also notice trace blood in the emesis). His exam then
worsened at 430am and he had hemiplegia and worsening aphasia.
His score was 18. Head CT was repeated and did not show
hematoma.
Mr. [**Known lastname **] was admitted to the neurology ICU for monitoring after
tPA, and was then transferred to the neuromedicine stroke team
on the floor, attending Dr. [**First Name (STitle) **]. He had an MRI/MRA which
showed an acute L-ICA thrombotic occlusion with a large left
hemispheric infarct. The etiology of ICA occlusion could be
either atherosclerotic or
due to a dissection. He was started on Aspirin 325mg. His TTE
was negative. His HbA1c was 5.8. His homocysteine was 8.6. TG
was 42. LDL was 94, HDL was 62, cholesterol was 175. He was
started on simvastatin 10mg. Fibrinogen was 267. ESR was 7.
Toxicology was negative.
Mr [**Known lastname **] was evaluated by speech and swallow, and was unable to
consistently initiate oral transit with a high risk of
aspiration. He had a video swallow which also showed significant
aspiration. He initially had an NGT placed, and then had a PEG
placed by surgery on [**2148-12-17**]. He has been tolerating G-tube
feeds.
Mr. [**Known lastname **] has a severe global aphasia, although it does appear
at times he is comprehending information, responding with
occasionally appropriate yes/no head responses. Speech pathology
worked with Mr. [**Known lastname **] with AAC picture boards and a Lightwriter
were, but neither were successful at this time. He also was
unable to type at this type.
Mr. [**Known lastname **] did seem to have complaints of leg pain, though it was
difficult to assess given his severe global aphasia. There was
no warmth or erythema or tenderness to palpation, although he
was noted by sursing to have a slight asymmetry in his calf
size, with the left side larger (circumference 1.5" greater).
Therefore, lower extremity ultrasound was obtained, which was
negative for DVT.
Also, 2d after Foley was removed, he exhibited urinary frequency
and seemed to c/o lower abdominal discomfort. A UA was
unremarkable overnight 1/5-6/[**2148**]. A bladder scan was + for
retention (800cc) [**2148-12-19**] (day of discharge). He was
straight-cathed at that time, and may require repeat Foley
catheterization or straight catheterization for urination
initially.
Medications on Admission:
Citracell OTC
Terazosin 10 mg daily
HCTZ 12.5 mg daily
Aspirin 81 mg
Naproxen daily
MVI daily
vitamin D
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG
PO BID (2 times a day).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for stroke.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day) as needed for DVT ppx.
7. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Principle diagnosis:
- Stroke (Left ICA/MCA-territory ischemic infarction)
Secondary diagnoses:
1. Patient had a history of what he believed to be angina
however had a negative Thallium stress test.
2. The patient has a history of left knee pain and has
undergone arthroscopy several times.
3. HTN
4. Prostate Cancer, s/p radiation seeding
Discharge Condition:
alert, awake.
Global aphasia.
Right facial droop.
Right sided hemiplegia.
Discharge Instructions:
You were admitted to our Neurology service at [**Hospital1 18**] and found to
have a large stroke on the left side of your brain. It was the
result of clot formation in the blood vessels to your brain
(Middle Cerebral Atery and Internal Carotid Artery). The stroke
has caused you to have weakness on your right side and to be
unable to communicate verbally or fully understand language. You
were started on Aspirin 325mg to reduce the odds of another
stroke in the future. You were unable to swallow without
aspirating food into your lungs, so you had a PEG placed so that
you could continue to receive food. If your swallowing ability
recovers, this could be taken out in the future. You are being
transferred to an inpatient facility for acute Rehabilitation.
Followup Instructions:
Neurology: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2149-1-27**] 1:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2148-12-19**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1701
} | Medical Text: Admission Date: [**2145-3-9**] Discharge Date: [**2145-3-13**]
Date of Birth: [**2070-8-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Exertional chest pain and shortness of breath
Major Surgical or Invasive Procedure:
[**2145-3-9**] Aortic Valve Replacement(21 St. [**Male First Name (un) 923**] Epic Porcine Valve)
and Single Vessel Coronary Artery Bypass Grafting utilizing the
left internal mammary artery to LAD.
History of Present Illness:
Mr. [**Known lastname 70228**] is a 74 year old male with history of known
aortic stenosis and coronary artery disease. Serial
echocardiograms have shown progression of aortic valve
gradients. Most recent ECHO from [**2144-10-29**] revealed EF 70%
with mean aortic gradient of 50mmHg. Over the last several
months, he admits to worsening exertional chest discomfort and
dyspnea on exertion. He has no history of syncope. Recent
cardiac catheterization from [**2145-1-29**] showed a right
dominant system and three vessel coronary artery disease. He
underwent routine preoperative evaluation and was eventually
cleared for surgery.
Past Medical History:
Coronary Artery Disease
Aortic Valve Stenosis
Hypertension
Elevated Cholesterol
Chronic Renal Insufficiency
Type II Diabetes Mellitus
History of Gout
History of Kidney Stones - prior Lithotripsy
Polypectomy
Tonsillectomy
Hemrrhoidectomy
Social History:
Quit tobacco over 50 years ago. Admits to occasional ETOH. He is
married. He is a retired construction worker.
Family History:
Brother died of MI in his early 50's.
Physical Exam:
Vitals: 120/64, 68, 16
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI. + rhinophyma
Neck: Supple, no JVD. Some soft tissue fullness in
supraclavicular area
Lungs: CTA bilaterally
Heart: Regular rate and rhythm. 3/6 systolic ejectiom murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally. Transmitted murmur in carotid region.
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2145-3-9**] Intraop TEE:
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are complex (>4mm) atheroma in the ascending
aorta. There are focal calcifications in the aortic arch. There
are complex (>4mm) atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. There
is severe aortic valve stenosis (area <0.8cm2). Mild to moderate
([**12-30**]+) aortic regurgitation is seen. The mitral valve leaflets
are moderately thickened. There is no pericardial effusion.
POST-BYPASS:
Preserved biventricular systolic function and it is normal.
Preserved ascending aortic contour. Mild to Moderate mitral
regurgitation.
A bioprosthesis is seen in the native aortic valve position,
stable and functioning well with a mean gradient of 10mm of Hg.
CHEST (PA & LAT) [**2145-3-13**]
There is slightly better aeration of the lungs since the prior
study. There is a small left pleural effusion and there is very
minimal left lower lobe atelectasis. The right lung is clear.
Cardiomediastinal silhouette is unremarkable. Status post median
sternotomy.
IMPRESSION:
Improved aeration of the left lung. Small left pleural effusion,
minimal left lower lobe atelectasis.
[**2145-3-9**] WBC-12.0* RBC-3.02*# Hgb-9.7*# Hct-27.6*# Plt Ct-143*
[**2145-3-12**] WBC-14.5* RBC-3.81* Hgb-12.2* Hct-35.4* Plt Ct-129*
[**2145-3-9**] UreaN-25* Creat-1.1 Cl-114* HCO3-25
[**2145-3-12**] Glucose-117* UreaN-19 Creat-1.1 Na-136 K-4.1 Cl-100
HCO3-31
Brief Hospital Course:
Mr. [**Known lastname 70228**] was admitted and underwent aortic valve
replacement and coronary artery bypass grafting surgery. For
surgical details, please see separate dictated operative note.
Following the operation, he was brought to the CVICU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. He maintained stable
hemodynamics. Postoperatively he was taken to the cardiac
surgical intensive care unit for monitoring. On postoperative
day one, he was transferred to the step down unit for
monitoring. Mr. [**Known lastname **] was gently diuresed towards his
preoperative weight. He was restarted on his preoperative
medications. Tolerated a regular diet and had good pain control
with PO pain medications. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. He continued to make steady progress and was
discharged to home on POD #4. He will follow-up with Dr. [**Last Name (Prefixes) **] as an outpatient.
Medications on Admission:
Allopurinol 100 [**Hospital1 **], Norvasc 5 qd, Lipitor 80 qd, Zetia 10 qd,
Tricor 145 qd, Lasix 20 qd, Gabapentin 300 qd, Glipizide 2.5
am/1.25 pm, Imdur 60 qd, Lopressor 50 [**Hospital1 **], KCL, Diovan 160 qd,
ASpirin 325 qd
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
5. 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*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5
days: then 20 mg daily previous home dose.
Disp:*5 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 5 days.
Disp:*5 Tablet Sustained Release(s)* Refills:*0*
11. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO Qam: 0.5 mg QPM.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Coronary Artery Disease, Aortic Valve Stenosis - s/p AVR/CABG
Hypertension
Elevated Cholesterol
Chronic Renal Insufficiency
Type II Diabetes Mellitus
Lung Nodule
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
1)Dr. [**Last Name (STitle) 1290**] in [**4-3**] weeks, call for appt
2)Dr. [**Last Name (STitle) 7047**] in [**1-31**] weeks, call for appt
3)CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-3-3**] 11:30 AM
[**Hospital Ward Name 23**] [**Location (un) **]. Nothing to eat or drink for 3 hours prior to
scan. Arrive by 11:00 AM. For lung nodule follow up.
Completed by:[**2145-3-13**]
ICD9 Codes: 4241, 2720, 5859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1702
} | Medical Text: Admission Date: [**2161-6-5**] Discharge Date: [**2161-6-10**]
Date of Birth: [**2088-11-10**] Sex: M
Service: SURGERY
Allergies:
Procardia / Benadryl
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
RLE pain x1 day and difficulty ambulating bilaterally
Major Surgical or Invasive Procedure:
Right leg 3-compartment fasciotomy ([**2161-6-6**])
Wound vac placement ([**2161-6-8**])
History of Present Illness:
72M presenting with 1-2 day h/o sudden onset of pain in RLE that
has progressed over past day to point where he has had
difficulty ambulating. Patient states initially he felt like he
'pulled a muscle' in his hamstring. Pain also in calf. He was
having difficulty moving legs and had numbness of his right foot
causing difficulty ambulating and causing him to fall. Also
states difficulty
moving left leg, feels like he has to pull his leg forward.
Patient also claims he syncopized today.
Past Medical History:
PMH:
-coronary artery disease
-EF 20%
-complete heart block, pacer dependent
-diabetes mellitus type 2
-obstructive sleep apnea on CPAP
-history of syncope
-hypertension
-benign prostatic hypertrophy
-peripheral vascular disease
-hiatal hernia
-Meniere's disease
-psoriasis
-cervical and lumbar spinal stenosis
-GERD
-right eye blindness
PSH:
-CABGx3 '[**44**] (LGSV)
-pacemaker and ICD '[**54**]
-laminectomy of the cervical and lumbar spine
Social History:
Lives alone, widowed, Tobacco - quit cigars 30 yrs ago, No eTOH,
no illicits
Family History:
No family history of cardiac disease
Physical Exam:
PE:
97.5 96 138/96 96RA
A&Ox3
Obese male in no acute distress
Regular rate/rhythm
CTA b/l
Abd obese, +bs, non-distended, non-tender, unable to palpate
abdominal aorta.
RLE minimal lower leg. Motor diminished in LE
Able to move toes b/l but diminished in Rt
VAC dressing in place. Fasciotomy site is c/d/i
B/l popliteal aneurysms.
Pulses:
F [**Doctor Last Name **] PT DP
R 2+ 3+ 1+ Trip
L 2+ 3+ 1+ 1+
Pertinent Results:
[**2161-6-10**] 05:59AM BLOOD
WBC-11.3* RBC-3.11* Hgb-9.1* Hct-27.4* MCV-88 MCH-29.3 MCHC-33.3
RDW-13.8 Plt Ct-388
[**2161-6-10**] 05:59AM BLOOD
PT-17.4* PTT-56.5* INR(PT)-1.6*
[**2161-6-10**] 05:59AM BLOOD
Glucose-59* UreaN-12 Creat-0.8 Na-141 K-4.1 Cl-106 HCO3-24
AnGap-15
[**2161-6-7**] 09:09PM BLOOD
CK(CPK)-5571*
[**2161-6-9**] 03:51AM BLOOD
CK(CPK)-2291*
[**2161-6-10**] 05:59AM BLOOD
Calcium-8.8 Phos-3.7 Mg-2.2
[**2161-6-6**] 1:10 am MRSA SCREEN NASAL.
MRSA SCREEN (Final [**2161-6-8**]): No MRSA isolated.
HISTORY: 72-year-old male with mottled right foot, concern for
vascular
disease.
FINDINGS:
CT OF ABDOMEN AND PELVIS: Imaged lung parenchyma reveals 5-mm
pulmonary
nodule in the lingula and a calcified 2-mm nodule in right
middle lobe that are stable since [**2157**]. Previously described
nodule in the anterior right middle lobe appears to be of
ground- glass density on today's study and is unchanged in size.
There is no pericardial or pleural effusion.
Gallstones in otherwise unremarkable gallbladder. A 9-mm nodule
with
indeterminate features in the left adrenal gland seems to be
present in [**2159**] study, but it is difficult to compare due to
different techniques. The liver, spleen, right adrenal gland,
and kidneys are unremarkable. The pancreas is atrophic without
focal lesions. Bowel loops are normal in caliber. There are no
pathologically enlarged mesenteric or retroperitoneal lymph
nodes.
CT OF THE PELVIS: Urinary bladder appears unremarkable. Prostate
gland is
enlarged and heterogenous, with gross calcifications, measuring
up to 72 mm in laterolateral diameter. Seminal vesicles are
unremarkable. There are no pathologically enlarged pelvic lymph
nodes. There is no free fluid or free air in pelvic cavity.
CT ANGIOGRAM: Abdominal aorta is normal in size without evidence
of
dissection. Atherosclerotic changes with calcifications and
mural plaques,
some of them ulcerated, are noted along the arterial tree. A
focal ectasia of proximal celiac artery is identified, although
the origin is not narrowed. The origins of the superior
mesenteric, single renals and inferior mesenteric arteries are
patent.
On the right side, the common and external iliac arteries are
patent. There is a tight stenosis (60%) with post-stenotic
dilatation of the right internal iliac artery (3A:135). The
common, deep and superficial femoral arteries are unremarkable.
There is a 41 x 32 mm mostly thrombosed aneurysm of the
popliteal artery that extends for approximately 60 mm. There is
no opacification of AT. PT is patent, giving off branches to the
plantar arch. The DP opacifies from the collaterals coming from
the plantar arch. Peroneal artery has a narrowed origin, and
presents with multilevel disease.
On the left side, the origin of the common iliac artery is
narrowed, and then becomes aneurysmal, measuring up to 20 mm and
with large irregular areas of contrast pooling about the
periphery and separated from the vessel lumen by curvilinear
density, an appearance that may represent extensive ulcerated
plaque but could also represent chronic focal dissection. The
internal iliac artery presents a focal 12- mm aneurysm. The
external iliac artery and femoral arteries are unremarkable.
There is a 42 x 41 x 42-mm mostly thrombosed aneurysm in the
popliteal artery. There is no opacification of AT. The flow in
PT and peroneal arteries is delayed compared to the
contralateral side (could be due to proximal disease). The
peroneal artery has a narrowed origin, opacifies well only until
the mid- calf, and then shows faint opacification, but could be
due to a very slow flow. The patent PT gives off dorsalis pedis.
DP is filled by collaterals from the plantar arch.
OSSEOUS STRUCTURES: Bilateral spondylolysis and grade 1
anterolisthesis are noted at L5- S1. Degenerative changes in
spine.
IMPRESSION:
1. Bilateral mostly thrombosed popliteal artery aneurysm,
measuring up to 42 mm.
2. Aneurysm of the left common iliac artery that presents with
complicated
probable ulcerated plaques vs focal dissection with multiple
areas of saccular foci of contrast, measuring up to 20 mm.
3. Focal aneurysm of the left internal iliac artery.
4. No opacification of anterior tibialis arteries bilaterally.
5. Delayed flow in the left PT and peroneal arteries.
6. Narrowing at the origin of the left common iliac, the right
internal iliac and both peroneal arteries.
7. Gallstones.
8. Left adrenal gland nodule, indeterminate but possibly
previously present.
9. Stable lingular and right middle lobe nodules stable since
[**2157**] consistent with benignity. Ground- glass opacity in right
middle lobe is stable. Continued attention may be paid at next
follow up.
Brief Hospital Course:
Admitted through ED. Currently coming in with 1-2 day h/o
sudden onset of pain in RLE that has progressed over pastday to
point where he has had difficulty ambulating. Patientstates
initially he felt like he 'pulled a muscle' in his
hamstring. Pain also in calf. He was having difficulty moving
legs and had numbness of his right foot causing difficulty
ambulating and causing him to fall. Also states difficulty
moving left leg. feels like he has to pull his leg forward.
Diagnosis of Compartment syndrome. He agreed to have an elective
surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preperations were
made.
Pt started on IV heparin drip. Moniter of PTT. To be DC'd on
Lovenox untill surgery.
Bicarb drip started.
He underwent a:
Right leg 3-compartment fasciotomy.
VAC dressing placed.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, he was extubated and transferred to the CVICU
for further stabilization and monitoring.
His CK's were followed:
[**Numeric Identifier 35553**]*, [**Numeric Identifier **]*, [**Numeric Identifier 97371**]*, 9357*, 7560*, 5571*, 2291*. All in a
downtrend. On Dc his leg has less pan, improved movement and
sensation.
It was noticed that he had significant hematuria in the post op
period. A urology consult was obtained. Pt currently in being
worked up. Has out patient cystoscopy planned on the 14th. Most
labs are outptient. He currently has a CBI. This has been in
place since urology has seen the patient. Can remove at rehab.
If so clamp CBI. Hand irrigate if needed. If clears can pull
foley. If cannot urinate replace.
Pt also had an acute episode on chronic systolic dysfuntion.
Recieved lasix IV. responded appropriatly. Cardiology on board.
managed care. Resolved with lasix.
He was then transferred to the VICU for further recovery. While
in the VICU he recieved monitered care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabalized from the acute setting of post operative care,
he was transfered to floor status.
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged to a rehabilitation
facility in stable condition.
Medications on Admission:
Aspirin 81, Lipitor 40', Diovan 40', Coreg 12.5", Flomax 0.4',
Actos 15', Advair 250/50', Gemfibrozil 600", Omeprazole 20",
Ranitidine 150', Glyburide 10", Nasonex 1", Albuterol, Metformin
500 QID, Lasix 20'
Discharge Medications:
1. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) puffs Inhalation [**Hospital1 **] (2 times a day) as needed for
shortness of breath or wheezing.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. CPAP 13
50 cc EERS, 2 liters oxygen
For severe mixed sleep disordered breathing
6. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation PRN as needed for shortness of breath
or wheezing.
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal twice a day.
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
17. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
19. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a
day: STOP THE MORNING DOSE THE DAY OF YOUR SURGERY WITH DR
[**Last Name (STitle) 1111**].
20. Metformin 500 mg Tablet Sig: One (1) Tablet PO qid: 8 AM,
NOON, 4 PM AND [**2152**].
21. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Bilateral popliteal aneurysms
Right lower extremity distal ischemia
Anemia secondary to blood loss requiring PRBC's.
hematuria
Acute CHF on chronic CHF systolic dysfunction
Discharge Condition:
Good
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from your incision site, chest pain, shortness of
breath, or anything else that is troubling you.
* 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.
YOU ARE ON LOVENOX. THE DAY BEFORE YOUR SCHEDULED SURGERY YOU
MUST STOP THE MORNING DOSE.
Followup Instructions:
1. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Name (STitle) **] on [**2161-6-15**] at 4:00 p.m.
for your outpatient cystoscopy. Call the office at [**Telephone/Fax (1) 921**]
to confirm your appointment.
2. Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2161-6-15**] 4:00
3. Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2161-7-2**] 2:00
4. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2161-7-15**] 10:10
5. You are scheduled for b/l popiteal stents. Call Dr [**Last Name (STitle) **]
office to get the exact date. His number is [**Telephone/Fax (1) 3121**]. It
should be scheduled [**7-1**]. This is not affirmed as of yet.
Completed by:[**2161-6-10**]
ICD9 Codes: 2851, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1703
} | Medical Text: Unit No: [**Numeric Identifier 72923**]
Admission Date: [**2195-7-5**]
Discharge Date: [**2195-7-21**]
Date of Birth: [**2195-7-5**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 72924**] was the
2.630 kg product of a 36 and [**6-15**] week gestation, born to a 32
year-old, G1, P0 now 1 mother. Prenatal [**Name2 (NI) **]: Blood type A
positive, antibody negative, RPR nonreactive, Rubella immune,
hepatitis surface antigen negative, GBS negative. This
pregnancy was complicated by mild PIH over the prior weeks to
delivery. The patient presented with spontaneous rupture of
membranes overnight, progressing to spontaneous vaginal
delivery. No intrapartum fever was noted. Mother did not
receive intrapartum antibiotics. Variable decelerations were
noted during labor.
At delivery, tight nuchal cord and knot in cord were noted.
Infant emerged with moderate tone and respiratory effort,
requiring stimulation and blow-by oxygen by labor and
delivery. Heart rate was reportedly greater than 100
throughout and Apgars were 7 and 8. NICU was called at
approximately 5 minutes of life. At that time, infant was
found to have diminished tone with moderate grunting.
Aeration was adequate. Infant was left in labor and delivery.
At approximately 30 minutes of life, symptoms had improved
but grunting persisted one hour and infant was brought to the
Neonatal Intensive Care Unit.
PHYSICAL EXAMINATION ON DISCHARGE: General: Infant was in
room air, open crib. Skin was warm and dry. Color pink, well
perfused. Left chest tube site healing. No drainage or
erythema. Anterior fontanel open, level, sutures opposed.
Eyes clear. Chest with clear and equal breath sounds, easy
respirations. Regular rate and rhythm, no murmur, normal S1
and S2. Pulses 2+. Abdomen soft, no masses. Positive bowel
sounds. Cord on and drying. Genitourinary: Normal male.
Testes descended. Extremities: Moving all extremities.
Intact suck, grasp, Moro and symmetric tone.
HOSPITAL COURSE:
1. Respiratory: Infant admitted to the NICU with moderate
grunting, was noted within the first 12 hours of age. Did
have a left sided pneumothorax, treated with an oxygen
[**Doctor Last Name **] wash with progressive grunting, flaring and
retracting and increasing 02 needs. Decision was made to
place a left chest tube. The chest tube remained in for a
total of 5 days at which time it was discontinued. The
pneumothorax had resolved and chest had been stable. The
infant was requiring nasal 02. He was transitioned to
room air on [**2195-7-18**]. He had occasional episodes
where he required some brief periods of oxygen during
feeding but has been stable out of oxygen since [**98**] p.m.
on [**7-18**].
2. Cardiovascular: Infant has an intermittent audible
murmur, has otherwise been cardiovascularly stable
without issue.
3. Fluids, electrolytes and nutrition: Infant was started
on 60 cc/kg per day. Enteral feedings were started on
day of life #4. He advanced to full enteral feedings by
day of life number 6. He is currently ad lib feeding,
breast milk 20 calorie and breast feeding, taking in good
amount. His discharge weight is 2995 grams.
4. Gastrointestinal: Peak bilirubin was 14.8 over 0.5. He
was treated with phototherapy. His rebound bilirubin was
less than 9 and he has been stable since that time.
5. Hematology: Hematocrit on admission was 49. Infant has
not required any blood transfusions.
6. Infectious disease: CBC and blood culture were obtained
on admission. CBC was benign. He was treated for pneumonia
with a total of 14 days of antibiotics.
Lumbar puncture was within normal limits. Gentamycin levels
were all within normal limits. Antibiotics were discontinued
on [**7-19**].
7. Neuro: The infant has been appropriate for gestational
age. The time which the infant had an indwelling chest
tube, he was receiving some Fentanyl and morphine sulfate
for pain control and has not had any further issues.
8. Sensory: Hearing screen was performed with automated
auditory brain stem responses and passed both ears.
9. Psychosocial: This family has been invested and involved
in the infant's care.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**Name6 (MD) 72925**] [**Name8 (MD) 17470**], MD, [**Telephone/Fax (1) 70900**].
CARE RECOMMENDATIONS: Continue ad lib feeding, breast milk
20 calorie.
Medications: Continue Tri-Vi-[**Male First Name (un) **] with 1 ml p.o. daily and
ferrous sulfate supplementation of 0.2 ml p.o. daily (25
mg/ml).
Iron and vitamin D supplementation: Iron supplementation is
recommended for preterm and low birth weight infants until 12
months corrected age. All infants fed predominantly breast
milk should receive Vitamin D supplementation at 200 i.u.
(may be provided as a multi-vitamin preparation) daily until
12 months corrected age.
Car seat position screening was performed for a 90 minute
screen and the infant passed.
State newborn screen was sent on [**7-8**] and has been within
normal limits.
The infant received hepatitis B vaccine on [**2194-7-18**].
DISCHARGE DIAGNOSES:
1. 36 and [**6-15**] week infant with delayed transition.
2. Left pneumothorax.
3. Pneumonia.
4. Rule out sepsis with antibiotics.
5. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2195-7-20**] 22:43:15
T: [**2195-7-21**] 04:55:11
Job#: [**Job Number 72926**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1704
} | Medical Text: Admission Date: [**2144-2-27**] Discharge Date: [**2144-3-6**]
Date of Birth: [**2076-4-27**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
less interactive and independent after a fall at home
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 year old man with history of bilateral frontal strokes and
hypertension who presents with left intracranial hemorrhage. Two
days ago, his son was helping him dress while standing. patient
then started to fall backwards, hitting his head without loss of
consciousness. The next day, patient began to have decreased
verbal output but appeared understand his son. [**Name (NI) **] complained of
headache and started having increasing general weakness to the
point that he could not even stand with assistance (he normally
walks with a walker). His swallowing requires thickened food but
it now appeared to be unable to hold
this food. Son took him to [**Hospital **] hospital around 11 am where
NCHCT showed 1 x 1 x 1 cm left frontal hemorrahge. His sbp was
running 157-186. He was then given 1 gm dilatin and caused him
to be more sedated. Patient was then transferred for further
management
ALL: ?statin
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. Type 2 diabetes mellitus.
4. Coronary artery disease with a myocardial infarction 20
years ago. The patient is status post coronary artery bypass
graft in [**2140-2-11**], for five-vessel disease.
5. History of gastrointestinal bleed.
6. Bifrontal stroke s/p right CEA when Left ICA was totally
occluded [**2141**]
7. Chronic renal insufficiency 1.8-2
Social History:
The patient lives with son and was a part time at a court house
as a security guard. He quit smoking in [**2124**] and use to drink
heavy etoh but quit months ago. no ivdu
Family History:
no seizure or stroke
Physical Exam:
PE: 98 59 137/59 20 100% room air
Gen: sleeping
Neck: no carotid bruit
CV: RRR
Chest: CTA
Abd: soft, nontender
ext: no edema
Neuro:
sleeping but easily opens eyes to voice and stay awake for exam
decreased verbal output with maximum of 2 words for spontaneous
speech. intact comprehension and repetition.
Pupil 3 to 2 mm bilaterally. unable to see fundi. visual fields
grossly full to finger counting. no facial assymetry. tongue
midline and palate elevates symmetrically.
Motor: increased tone throughout. raises arms antigravity
without drift. strong left grasp but weak right grasp. right
leg externally rotates but both legs move symmetrically at 2/5
spontaneously and to stimuli
Sensory: localizes pain in four extremities. has more brisk
withdrawal on left than right arm.
Reflex: brisk DTRs with [**Name2 (NI) 11849**] toes bilaterally
Coordination/Gait: unable to test 2nd to cooperation
Pertinent Results:
Admission Labs:
[**2144-2-27**] 07:22PM BLOOD WBC-7.9 RBC-3.66* Hgb-9.8* Hct-29.1*
MCV-79*# MCH-26.8*# MCHC-33.8 RDW-17.6* Plt Ct-351
[**2144-2-27**] 07:22PM BLOOD Neuts-65.9 Lymphs-24.8 Monos-2.6 Eos-5.6*
Baso-1.1
[**2144-2-27**] 07:22PM BLOOD PT-13.7* PTT-26.3 INR(PT)-1.2
[**2144-2-27**] 07:22PM BLOOD Glucose-142* UreaN-43* Creat-1.8* Na-142
K-4.5 Cl-107 HCO3-24 AnGap-16
[**2144-2-27**] 07:22PM BLOOD Calcium-10.2 Mg-2.0
Other lab results:
[**2144-2-27**] 07:22PM BLOOD CK(CPK)-35*
[**2144-2-28**] 04:00AM BLOOD ALT-12 AST-12 CK(CPK)-44
[**2144-2-29**] 03:48AM BLOOD CK(CPK)-43
[**2144-2-28**] 04:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2144-2-29**] 03:48AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2144-2-29**] 03:48AM BLOOD VitB12-622 Folate-GREATER THAN 20
[**2144-2-28**] 04:00AM BLOOD calTIBC-333 Ferritn-532* TRF-256
[**2144-2-29**] 03:48AM BLOOD TSH-1.4
[**2144-2-29**] 03:48AM BLOOD Phenyto-2.8*
[**2144-3-3**] 04:55AM BLOOD Phenyto-11.8
[**2144-2-28**] 10:00AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2144-2-28**] 10:00AM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
[**2144-2-28**] 10:00AM URINE RBC-0-2 WBC-21-50* Bacteri-MANY
Yeast-NONE Epi-0
MIcro:
BLOOD CULTURE [**2-28**] negative
URINE CULTURE (Final [**2144-3-3**]):
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing E. coli and Klebsiella species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S =>32 R
CEFAZOLIN------------- 16 I =>64 R
CEFEPIME-------------- <=1 S R
CEFTAZIDIME----------- <=1 S R
CEFTRIAXONE----------- <=1 S R
CEFUROXIME------------ 4 S R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S =>16 R
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN----------<=0.25 S =>8 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 32 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S 8 I
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
ECG: no st-t changes
NCHCT [**2-27**]: left frontal hemorrhage 1 x 1 x 1.2 cm anterior to
left lateral ventricle and located parasagitally. (scan at OSH
at noon shows 1x1x1 cm bleed)
MR brain [**2-27**]:
Area of hemorrhage in the left corona radiata unchanged in size
since the prior CT obtained on the same day. There is
questionable rim enhancement in postcontrast studies around the
area is not certain if these are related to the patient's
motion. There is evidence of multiple prior infarctions.
Echo [**2-28**]:
1.The left atrium is normal in size. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mild depressed. Resting regional wall
motion abnormalities include basal septal hypokinesis,
inferobasal akinesis, with inferior and basal septal
hypokinesis.
3.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic root is moderately dilated. The ascending aorta is
moderately dilated.
5.The aortic valve leaflets (3) are mildly thickened.
6.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
7.The estimated pulmonary artery systolic pressure is normal.
8.There is no pericardial effusion.
Brief Hospital Course:
1. Parasagittal hemorrhage. 67 year old man with history of
bilateral ischemic strokes, vascular risk factors, and
hypertension who presented with worsening weakness, dysphagia,
and speech 2 days after a fall. The patient was admitted to the
neurology service. Head CT was done and showed small left
parasagittal hemorrhage. MR of the brain was done but did not
visualize the area of the hemorrhage because the bleeding was
located above where the cuts were taken. The differential
diagnoses included hypertensive bleed, bleeding secondary to
AVM, aneurysm, mass, or amyloid. The patient's blood pressure
control was optimized with goal to keep SBP between 120-140. He
was also started on insulin sliding scale for glycemic cont tol.
The patient underwent CT Angio on [**3-4**] which was negative for
aneurysm. The patient was loaded with dilantin on [**2-28**] for
seizure prophylaxis. Dilantin was tapered and discontinued prior
to discharge. His symptoms improved prior to the discharge. He
became more alert, demonstrated improved spontaneous movement
and was able to speak in full sentences although his voice
remained soft. The patient was evaluated by PT and OT and felt
to be a candidate for rehab.
2. UTI. The patient had urinalysis on admission that was c/w
UTI. He was initially started empirically on Levofloxacin which
on [**3-2**] was changed to Zosyn after his urine culture grew
resistant E coli and sensitive Klebsiella. He spiked fevers up
to 100.7. On [**3-3**] CXR showed new LLL infiltrated and Clindamycin
was added to cover aspiration pneumonia. The patient has been
afebrile since [**3-4**]. He should complete 7 days course of
antibiotics.
3. Parkinsonism. Sinemet was resumed on [**3-4**].
4. Apnoea. Initially, the patient had episodes of central and
obstructive apnea with >20 sec frequent apneic pauses. Per
family he has a history of not breathing followed by loud
snoring at home. It was thought that he would benefit from being
initiated on CPAP given obstructive component of apnea. The
patient went to ICU but did well in the ICU and did not require
CPAP.
5. Chronic renal insufficiency. Baseline Cr 1.4-1.8. Patient
received Mucomyst and hydration with bicarb IV fluids for renal
protection pre- and post- contract administration for CT Angio
on [**3-4**]. His medications were renally dosed. His renal function,
urine output will need to be monitored closely given risk of
nephrotoxicity. On the day of discharge, his creatinine was
stable at 1.4.
5. Anemia. Patient received one unit pRBC for HCT 28 given h/o
CAD on [**2-28**]. His HCT has been stable close to 30. Fe studies
(pre-transfusion) were checked and showed normal serum iron,
high ferritin and normal TIBC. He was not restarted on Fe
supplements.
6. Hypernatremia - hypovolemic hypernatremia due to NPO and
being on IV NS. This was corrected slowly with free water
boluses.
7. Hypertension. The patient's goal SBP 120-140 in the acute
period after the hemorrhage and then can be lowered to goal SBP
<130. He was restarted on an ACE inhibitor. HCTZ was added to
his medications for BP control. His SBP was in 130-150 range on
these medications. His medications will need to be adjusted to
achieve goal BP gradually.
8. Nutrition. The patient initially failed speech and swallow
eval. He received several days of NG tube feedings. He underwent
video swallowing study on [**3-5**] and did well. He was resumed on a
cardiac/diabetic/low sodium diet prior to discharge and
tolerated it well. He requires assistance with feeding at all
times and should be maintained on aspiration precautions.
Medications on Admission:
Meds:
isordil 60 mg po qd
lisinopril 2.5 mg po qd
gemfibrozil 600 mg po bid
insulin NPH 10 units qam
regular insulin sliding scale
glyburide 7.2 mg o qam and 5 mg po qhs
sinemet 25/100 po tid
asa 81 mg po qd
atenolol 12.5 mg po qhs
folate
thiamine
effexor 75 mg po qd
feso4
prevacid 30 mg po bid
colace
actos 30 mg po qd
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **]Nursing Home
Discharge Diagnosis:
1. Intracranial bleed, parasagital
2. Parkinsonism
3. Urinary tract infection
4. Hypertension
5. History of alcohol dependence
6. Diabetes
7. Hypernatremia
8. Pneumonia, aspiration
Discharge Condition:
Improved, slightly bradykinetic, able to move all four
extremities, eat with assistance and supervision, and answer
simple questions.
Discharge Instructions:
Please keep all follow- up appointments.
Please take all medications as prescribed.
Please do not take aspirin or other blood thinners/anti-platelet
agents for 3 weeks after discharge.
Please return to care if you develop new weakness, numbness,
difficulty speaking, or other concerning sympomts.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 656**] ([**Telephone/Fax (1) 102424**]) in [**1-12**] weeks
after discharge. Please follow up with your neurologist in [**1-12**]
months.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2144-3-6**]
ICD9 Codes: 431, 5070, 5990, 2765, 2760, 412, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1705
} | Medical Text: Admission Date: [**2122-10-19**] Discharge Date: [**2122-10-21**]
Date of Birth: [**2068-2-26**] Sex: M
Service: MEDICINE
Allergies:
Toradol / Celebrex
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
ICD pocket infection
Major Surgical or Invasive Procedure:
ICD generator and lead extraction
History of Present Illness:
54 y old male w/ hx of CHF w/ EF of 30% s/p biV ICD/pacer in
[**9-18**], and NYHA functional class II-III, CAD s/p MI in '[**15**] with
BMS to OM1, CABG and MV repair [**9-19**] (LIMA to LAD, SVG to OM,
SVG to PDA, 30 mm [**Doctor Last Name **] Physio-Ring), L shoulder replacement,
Left TKA, cervical spine fusion with hardware tx'd from [**Hospital 3856**] for pacer pocket infection.
Approximately 3 weeks ago the skin over the pacer started to
turn dark red/purple and became exquisitely tender. The patient
denied any fever, chills, nausea, headache, or general malaise.
He has not had any recent rash, skin breakdown or insect bite.
He did notice increase in cough but no increased rhinorrhea,
sputum production, or sinus pressure.
Last Friday, the patient went to his PCP and was prescribed
Keflex for presumed soft tissue infection overlying the
ICD/Pacer. He had normal WBC and no fever at that time. The
symptoms of redness and swelling did not improve so was taken
for pacer generator revision on [**10-19**] at [**Hospital **] hospital. They
discovered a large pus pocket, placed a drain and transferred
the patient to [**Hospital1 18**] for emergent pocket washout and lead
removal.
ABG on arrival was 7.23/72/209/30/1 with a lactate of 1.0. Was
taken directly to OR where pacer pocket and lead extraction
which was uncomplicated although one pacer in the LV had to be
abandoned.
Past Medical History:
# Congestive Heart Failure w/ EF of 30% s/p single Chamber
pacer [**12-19**], with upgrade to biV in [**9-18**]
# Coronary Artery Disease
- s/p Myocardial Infarction [**2115**] with thrombectomy and BMS to
OM1
- s/p CABG and MV repair [**9-19**] (LIMA to LAD, SVG to OM, SVG to
PDA, 30 mm [**Doctor Last Name **] Physio-Ring)
# Hypertension
# Hyperlipidemia
- Most recent panel: Total chol 225, LDL 116, HDL 35, Trig 372
(from over 500)
# Cervical disc herniation s/p fusion with hardware
# s/p lumbar disc surgery x 2
# s/p Cholecystectomy
# s/p Left shoulder surgery
# s/p Left total knee replacement
# s/p pericarditis [**2115**]
# Osteoarthritis
# GERD
Social History:
Tobacco: 70pack/yr hx, one PPD currently
ETOH: denies
Family History:
Father w/ CABG at 57. Brother w/ Myocardial Infarction at 42.
Physical Exam:
(on admission)
VS: T 97.3 ,BP 144/70, HR 70
Vent settings: AC 650/12, FiO2 50%, PEEP 5
Gen: Middle aged male intubated and sedated, with occacional
coughing
HEENT: Sclera anicteric. PERRL, tracking intact. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple
CV: RR with mild systolic murmur best heard at LUSB, normal S1,
S2. No S4, no S3.
Chest: L upper chest with large dressing c/d/i. well healed
midline scare over sternum. No obvious chest wall deformities.
Bilateral crackles anteriorly.
Abd: Obese, soft, NTND, No HSM or tenderness.
Ext: No c/c/e. R groin with access.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2122-10-20**] 12:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2122-10-20**] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2122-10-19**] 11:27PM TYPE-ART TEMP-38.7 RATES-18/ TIDAL VOL-690
O2-40 PO2-106* PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED VENT-CONTROLLED
[**2122-10-19**] 08:01PM TYPE-ART PO2-108* PCO2-46* PH-7.37 TOTAL
CO2-28 BASE XS-0
[**2122-10-19**] 08:01PM O2 SAT-97
[**2122-10-19**] 06:12PM GLUCOSE-93 UREA N-15 CREAT-0.7 SODIUM-139
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
[**2122-10-19**] 06:12PM CALCIUM-8.2* PHOSPHATE-3.4 MAGNESIUM-2.2
[**2122-10-19**] 06:12PM NEUTS-71.6* LYMPHS-23.8 MONOS-3.7 EOS-0.9
BASOS-0.1
[**2122-10-19**] 06:12PM PLT COUNT-235#
[**2122-10-19**] 03:12PM GLUCOSE-79 LACTATE-1.0 NA+-142 K+-4.3 CL--102
[**2122-10-19**] 03:12PM freeCa-1.15
.
CXR ([**2122-10-20**]): FINDINGS: In comparison with the study of
[**2121-9-26**], the pacemaker device has been removed. A prosthetic
mitral valve is again seen. There is continued enlargement of
the cardiac silhouette with relatively mild vascular congestion.
No evidence of acute pneumonia.
Endotracheal tube tip lies about 4 cm above the carina and the
nasogastric
tube extends to at least the upper stomach. Metallic fixation
device
involving the lower cervical spine is again seen.
.
CXR ([**2122-10-20**]): FINDINGS: In comparison with the study of [**10-19**],
there is little change in the appearance of the heart and lungs.
The endotracheal and nasogastric tubes have been removed.
IMPRESSION: No acute pneumonia.
Brief Hospital Course:
54 y old male w/ hx of CAD s/p MI in '[**15**] with BMS to OM1, CABG
and MV repair [**9-19**], CHF w/ EF of 30% s/p Dual Chamber ICD [**9-18**]
w/ epicardial lead, Left TKA, L shoulder replacement, cervical
spine fusion with hardware tx'd from [**Hospital3 1280**] for pacer pocket
infection on [**10-19**]
At [**Hospital1 18**], was taken to the OR urgently and he had the atrial and
RV leads explanted along with the generator. A ventricular lead
was pulled back, cut and allowed to self-retract. In the OR, the
patient was hypotensive on neosynephrine for much of the case.
The episode of hypotension and fever to 101.5 was concerning for
sepsis and the patient was started on Vanco/Zosyn.
Intraoperative TEE did not show any evidence of endocarditis.
.
In the CCU at [**Hospital1 18**] pt was intially febrile to 101 when arriving
with sbp's in low 90's although appearing quite well with good
mentation, UOP and perfusion. Pt's ABG quickly normalized and
pt was extubated on the day after admission. Sbp's responded to
gentle fluid boluses and maintenance IVFs during the night of
the admission and was never on pressors in the CCU. Pt has
since continued to be afebrile and HD stable with sbps in the
120s and without an elevation in white count. Pt was re-started
on BB prior to d/c.
.
On the day of transfer the following plan was discussed:
# ID/ICD pocket infection s/p ICD lead extraction with abandoned
pacer in LV remaining
- Cont vancomycin and zosyn for empiric abx therapy since we
have no cultures to follow. Cultures from [**Hospital1 **] also NGTD
including cultures from pacer pocket; it is possible the
infection was treated with keflex prior to drainage if the
infection was g-staph
- ID recommended cont. current abx for now and for at least 4
weeks to be followed by oral supressive therapy
- cough productive of clear sputum positive with 4+ G- rods and
1+ G+ cocci; If truly has a pulm infecton as sputum suggests it
is covered with vanc/zosyn although CXR without obvious
infiltrates
- PICC line placed prior to transfer
- f/u culture of pacer tips, blood cultures, and sputum cultures
- daily wet to dry dressing changes
.
# Pump/CHF w/ EF of 30% s/p Dual Chamber ICD [**9-18**] now s/p ICD
lead extraction
- appears euvolemic to mildly overloaded
- cont. titrate up on BB, [**Last Name (un) **] as tolerated
- pt to go home with life-vest: This will need to be set up via
case management at [**Hospital1 **] and with the patient's
cardiologist.
- pt will likely need a new ICD implanted at some point in the
future
.
# Rhythm
- monitor on tele
- pt should go home with life-vest
.
# Ischemia/Coronary Artery Disease, s/p MI in '[**15**] with
thrombectomy and BMS to OM1, s/p CABG and MV repair [**9-19**]
- cont ASA 81, atorvastatin 80 mg
- cont. titrate up on BB, [**Last Name (un) **] as tolerated
.
# Pulm
- cough productive of clear sputum possitive with 4+ G- rods and
1+ G+ cocci; If truly has a pulm infecton as sputum suggests it
is covered with vanc/zosyn although CXR without obvious
infiltrates
- f/u sputum cultures
.
# Hypertension
- cont. titrate up on BB, [**Last Name (un) **] as tolerated
.
# Hyperlipidemia
- cont atorvastatin
.
# Code Status: Full code
.
# Dispo: transfer to [**Hospital1 **]. will need VNA when going home
from [**Hospital1 **] to assist with medications and IV antiobiotics.
Patient will also need teaching with IV antiobiotic dosing prior
to discharge from [**Hospital1 **]. He has a right PICC placed at
[**Hospital1 18**], with a CXR performed showing good placement (in SVC) and
no pneumothorax.
.
# Communication: Wife, [**Name (NI) **] [**Name (NI) 17111**] [**Telephone/Fax (1) 17112**]
Medications on Admission:
HOME MEDICATIONS (per wife and pt):
Aspirin 325 mg po DAILY
Protonix 40 mg [**Hospital1 **]
Prilosec 20mg po bid
Carvedilol 25 mg po BID
valsartan 160mg po bid
Spironolactone 25mg po bid
lasix 40mg po bid
hydral 25 mg po bid
norvasc (amlodopine) 10mg po bid
Atorvastatin 40 mg po DAILY
keflex
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H () as needed for pain.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Docusate Sodium 50 mg Capsule Sig: [**12-16**] Capsules PO twice a
day as needed for constipation.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Vancomycin 1000 mg IV Q 12H
day 1 [**10-19**]
14. Piperacillin-Tazobactam Na 4.5 gm IV Q8H
day 1 [**10-19**]
Discharge Disposition:
Extended Care
Discharge Diagnosis:
ICD pocket infection
Discharge Condition:
Stable
Discharge Instructions:
You were admitted and treated for ICD pocket infection.
.
If you develop fever greater than 101F chest pain, shortness of
breath, or if you at any time become concerned about your health
please contact your PCP, [**Name10 (NameIs) **] or [**Hospital1 18**] at [**Telephone/Fax (1) **] or
present to the nearest ED.
.
Please take your medications as prescribed.
.
Please make sure to have appointments with electrophysiology and
infectious disease prior to discharge from [**Hospital1 **] for this
serious infection of your ICD pocket.
Followup Instructions:
Please make sure [**Hospital1 **] has scheduled appointments with the
following prior to dicharge or schedule follow-ups to be seen
within 1-2 weeks with the following:
- electrophysiology
- infectious disease
- your cardiologist
- your PCP
ICD9 Codes: 0389, 4019, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1706
} | Medical Text: Admission Date: [**2121-1-27**] Discharge Date: [**2121-2-1**]
Date of Birth: [**2055-3-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Colon tumor
Major Surgical or Invasive Procedure:
s/p Right colectomy, primary anastamosis
History of Present Illness:
Mr. [**Known lastname 8271**] is a 65yo male with a 50yo h/o of cigarette smoking
and h/o CAD, HTN, obesity who underwent a colonoscopy and was
found to have a sessile 50 mm polyp in the hepatic flexure which
could not be removed by colonoscopy and therefore the area was
marked with a tattoo and the patient was referred for surgery.
He was a heavily built man and he had co-morbid conditions of
chronic obstructive pulmonary disease and prior cardiac disease.
His Plavix was stopped 5 days prior to surgery.
Past Medical History:
CAD s/p stent '[**15**], s/p brachytherapy stent, restenosis '[**15**], HTN,
DM, obesity, smoker(50yrs), h/o ETOH abuse-sober 20years
Social History:
Single. Lives alone. Retired engineer from Mass Maritime-[**State 1727**].
Supportive family & friends. H/O ETOH abuse-sober 20 years.
Currently smokes 1-2 packs per day for past 50years. Denies
illicit drug use.
Family History:
Non-contributory
Physical Exam:
PRE-OP
Vitals:T-97.5,HR-76,BP-125/54,RR-20,O2 sat-95% RA
Well-appearing, NAD
Cardiac-RRR, no m/r/g
Lungs-CTAB
ABD obese, soft, NT
Extrem:WWP, no c/c/e
Pertinent Results:
[**2121-1-31**] 06:10AM BLOOD WBC-8.0 RBC-4.73 Hgb-14.5 Hct-42.6 MCV-90
MCH-30.6 MCHC-34.0 RDW-13.7 Plt Ct-120*
[**2121-1-27**] 03:05PM BLOOD WBC-16.0*# RBC-5.10 Hgb-16.0 Hct-46.9
MCV-92 MCH-31.4 MCHC-34.1 RDW-14.8 Plt Ct-169
[**2121-1-31**] 06:10AM BLOOD Plt Ct-120*
[**2121-1-28**] 03:13AM BLOOD PT-15.2* PTT-29.2 INR(PT)-1.3*
[**2121-1-27**] 03:05PM BLOOD PT-17.1* PTT-30.3 INR(PT)-1.5*
[**2121-1-31**] 06:10AM BLOOD Glucose-121* UreaN-15 Creat-0.7 Na-142
K-3.6 Cl-104 HCO3-31 AnGap-11
[**2121-1-27**] 03:05PM BLOOD Glucose-124* UreaN-16 Creat-0.9 Na-142
K-4.9 Cl-108 HCO3-27 AnGap-12
[**2121-1-28**] 03:13AM BLOOD ALT-24 AST-32 LD(LDH)-233 CK(CPK)-466*
AlkPhos-44 Amylase-25 TotBili-1.0
[**2121-1-27**] 03:05PM BLOOD ALT-26 AST-34 LD(LDH)-254* CK(CPK)-234*
AlkPhos-49 Amylase-30 TotBili-1.0
[**2121-1-30**] 11:05AM BLOOD proBNP-1164*
[**2121-1-31**] 06:10AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.0
[**2121-1-27**] 03:05PM BLOOD Albumin-3.9 Calcium-8.4 Phos-2.4* Mg-1.8
.
RADIOLOGY Final Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2121-1-27**] 5:54 PM:
[**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION
65 year old man with h/o CAD and COPD, s/p hypoxic event
peri-operatively, with increased A-a gradient
IMPRESSION:
1. No evidence of pulmonary embolism in central or segmental
branches. Limited evaluation of the subsegmental branches due to
bolus timing.
2. Bilateral lower lobe airspace consolidation likely
representing atelectasis.
3. Small perihepatic fluid.
4. ETT at the thoracic inlet. Advancement is recommended.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2121-1-27**] 2:25 PM
[**Hospital 93**] MEDICAL CONDITION:
65 year old man with
REASON FOR THIS EXAMINATION:
DESATS IN OR
SINGLE PORTABLE SEMI-UPRIGHT CHEST: Compared to [**2120-6-20**]. A large
portion of the right lung has been excluded from field of view.
Patient is intubated with the tip of the endotracheal tube 8 cm
above the carina at the superior margin of the clavicles. There
has been clearing of the previous left lower lobe consolidation
with some residual opacity in the medial basilar aspect of the
left lower lobe, likely atelectasis. No pneumothorax.
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2121-1-30**] 11:31 AM
REASON FOR THIS EXAMINATION:
Rule out pneumonia, effusions, and changes lung anatomy
IMPRESSION: Persistent low lung volumes with atelectasis at both
bases and small right pleural effusion. Findings discussed with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13289**], nurse practitioner, at the time of dictation.
.
[**2121-1-27**] Pathology Tissue: right colectomy. [**2121-1-27**]
[**Last Name (LF) **],[**First Name3 (LF) **] M. Not Finalized
Brief Hospital Course:
Mr. [**Known lastname 13290**] operative course was complicated by difficult
intubation, decreased oxygen saturations, bradycardia, and
hypotension. He was stabilized with successful intubation, and
IV hydration. His surgery was completed, and he ws transferred
to ICU for further management.
.
POD1-He was extubated in the ICU in the morning, & monitored
closely. He was weaned to 4L of nasal cannula with sats>95%. He
appeared stable, and was transferred to [**Hospital Ward Name **].
.
RESP:He had audible bibasilar crackles post-op. He was diuresed
with IV Lasix, and responded with decreased demand in oxygen via
nasal cannula. He required more time to wean from oxygen. His
sats are currently 92% on RA. Pulmonary Team was consulted who
recommended PFT's on outpatient basis and sleep studies to rule
out sleep apnea. Recommendations also included daily diuresis,
BNP>1200, Spiriva/albuterol/atrovent and aggressive IS
use/CPT/and frequent ambulation. He was taught proper use of
MDI's. Smoker cessation was offered. Patient made it clear he
had no intention of quitting. His [**Last Name (LF) 802**], [**Name (NI) **], will make a
follow-up appointment for PFT's on outpatient basis.
.
ABD:His abdomen is large, soft, NT/ND with active bowel sounds.
His abdominal incision is OTA with staples with a small amount
of erythema along the incision line. He was started on IV
cephazolin, and switched to PO Augmentin due to reports of GI
upset with PO Keflex in the past. He will have the staples
removed at the follow-up appointment with Dr. [**Last Name (STitle) **].
.
NUT:He was NPO post-op. His diet was advanced as his bowel
function resumed. He has been tolerating a regular diet without
complaints of nausea and/or vomiting.
.
ELIM:He had a foley catheter inserted intra-op. The catheter was
removed, and he was able to urinate without difficulty. He
reports passing flatus, but has not had a bowel movement since
surgery.
.
PAIN:His pain was managed with an IV PCA post-op. He was
advanced to oral Percocet once tolerating oral fluids. He
reports her pain 0-2/10 at rest, and increases to [**5-31**] with
activity which is well tolerated. He will be discharged with a 2
week supply of percocet, and colace to prevent constipation.
.
He reports not having a current PCP, [**Name10 (NameIs) **] does not have interest
inestablishing a relationship with a family physician. [**Name10 (NameIs) **] was
encouraged to follow-up with Pulmonology, and to consider
finding a PCP. [**Name10 (NameIs) **] will be discharged home with VNA services for
assessment of respiratory status.
Medications on Admission:
Glyburide/metformin 2.5/500", Avandia 4', Lantus 45Uqhs, Cozaar
50', atenolol 100', Lipitor 10', Plavix 75', testosterone patch.
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Glyburide-Metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. Lantus 100 unit/mL Solution Sig: 45 units Subcutaneous at
bedtime.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*1 Cap(s)* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheeze/SOB.
Disp:*1 * Refills:*1*
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
polyp at hepatic flexure
Post-op hypotension
Post-op hypoxemia
.
Secondary:
Smoker
Obese
CAD
HTN
DM2
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your 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.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow-up appointment with
Dr. [**Last Name (STitle) **].
-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.
Followup Instructions:
1. Please make a follow-up appointment with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) **] in [**1-22**] weeks.
2. Make an appointment with Dr. [**First Name8 (NamePattern2) 13291**] [**Last Name (NamePattern1) 4507**] [**Telephone/Fax (1) 13292**] for
Pulmonary Function Tests in [**2-24**] weeks.
3. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2041**]
Date/Time:[**2121-2-20**] 10:20
4. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2121-7-2**] 11:00
ICD9 Codes: 5180, 9971, 4019, 4280, 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1707
} | Medical Text: Admission Date: [**2197-5-28**] Discharge Date: [**2197-6-1**]
Date of Birth: [**2120-2-10**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 77 yo M with multiple medical conditions including
Stage IV NSCLC (adenocarcioma) s/p chemoradiation, CAD and PVD
on [**Hospital **] transferred from [**Hospital6 **] ED for BRBPR.
.
Patient began having BRBPR last night. He presented to [**Hospital1 112**] ED
and was found to have a Hct of 20 (baseline in high 20s/low
30s). He received 1U PRBC there. Given that he receives most of
his medical care here, including treatment for his NSCLC, he was
transferred to [**Hospital1 18**] to further management.
.
In the ED, initial vs were: T- 100.3, P- 84, BP-151/64, RR-18,
SaO2- 100% on RA. Patient complained of abdominal pain, mainly
in the suprapubic region. CT scan was negative but did show
significant fecal load. He received 3L NS in the ED. In
addition, he received IV PPI. His temp went up to 103.0 so he
was given tylenol and cultured. UA was positive so he was
started on Cipro. He was also given a dose of flagyl for
abdominal pain and fever. He complained briefly of chest pain so
troponins were sent- came back at 0.04.
.
On the floor, patient was fatigued but arousable. Vital signs:
T- 99.0, HR- 103, BP- 124/65, RR- 19, SaO2- 98% on 2L. He did
not complain of any abdominal tenderness.
Past Medical History:
1. Stage IV non-small cell lung cancer. Histology:
adenocarcinoma. Status post 5 doses of chemotherapy with
carboplatin AUC of 2 and paclitaxel 50 mg/m2 weekly with
radiation, for 6 weeks. Week 2 was held for evaluation of chest
pain. Completed daily fractionated radiation to 5040 cGy in
5/[**2194**].
.
Other PAST MEDICAL HISTORY:
- HTN
- Peripheral [**Year (4 digits) 1106**] disease s/p R CIA stent and L EIA
angioplasty [**8-30**] and s/p R SFA balloon angioplasty and stent x2
[**9-30**] and right lower extremity claudication status post right
common femoral to above knee popliteal graft with PTFE on [**4-10**], [**2193**].
- S/p bilateral shoulder displacement.
- CAD s/p MI '[**85**]
- Hypercholesterolemia,
- GI bleed '[**87**]
- Gout
- Osteoarthritis
- Herniated L4-5 disc
- L5-S1 stenosis
Social History:
The patient started smoking at age 15 and continues smoking now.
He smoked less than a pack per day for most of his life and
recently smokes only approximately five cigarettes a day. He
currently lives alone in [**Location (un) 538**]. He consumes alcohol on
occasion. He previously consumed significant amounts of rum. He
has been in the United States for over 20 years. He was born and
raised in [**Country 5976**]. He only speaks Spanish. He is a retired musician
and automobile mechanic.
.
Family History:
Sister that died from a throat cancer apparently. There is no
other history of cancer in the family. There is history of
coronary disease in the family.
Physical Exam:
Physical Exam:
Vitals: T- 99.0, HR- 103, BP- 124/65, RR- 19, SaO2- 98% on 2L
General: Fatigued but arousable. No acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic. Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. TTP to suprapubic
region.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2197-5-28**] 09:10PM URINE HOURS-RANDOM
[**2197-5-28**] 09:10PM URINE GR HOLD-HOLD
[**2197-5-28**] 09:10PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.025
[**2197-5-28**] 09:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2197-5-28**] 09:10PM URINE RBC-[**1-27**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0
[**2197-5-28**] 07:30PM LACTATE-2.3*
[**2197-5-28**] 06:25PM cTropnT-0.04*
[**2197-5-28**] 06:25PM WBC-3.7* RBC-3.46* HGB-9.0* HCT-27.3* MCV-79*
MCH-26.0* MCHC-32.8 RDW-16.7*
[**2197-5-28**] 06:25PM NEUTS-90.3* BANDS-0 LYMPHS-7.4* MONOS-1.2*
EOS-0.9 BASOS-0.1
[**2197-5-28**] 06:25PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-2+
TEARDROP-OCCASIONAL ACANTHOCY-OCCASIONAL
[**2197-5-28**] 06:25PM PLT SMR-NORMAL PLT COUNT-203#
[**2197-5-28**] 06:25PM RET AUT-0.3*
[**2197-5-28**] 03:06PM COMMENTS-GREEN TOP
[**2197-5-28**] 03:06PM LACTATE-1.7
[**2197-5-28**] 03:06PM HGB-10.4* calcHCT-31
[**2197-5-28**] 03:00PM GLUCOSE-112* UREA N-22* CREAT-1.2 SODIUM-134
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13
[**2197-5-28**] 03:00PM estGFR-Using this
[**2197-5-28**] 03:00PM ALT(SGPT)-31 AST(SGOT)-43* LD(LDH)-346* ALK
PHOS-113 TOT BILI-1.5 DIR BILI-0.3 INDIR BIL-1.2
[**2197-5-28**] 03:00PM ALBUMIN-3.2*
[**2197-5-28**] 03:00PM HAPTOGLOB-366*
Brief Hospital Course:
Pt was initially evaluated in the [**Hospital1 756**] ED for BRBPR but was
transfered to the [**Hospital1 18**] ED where he recieves oncologic care. GI
bleed resolved and HCT stabilized. Pt was evaluated by GI in the
ED who did not feel intervention was needed at that time and
recommended close Hct monitoring and tagged scan/angio if
patient re-bleeds. He received one unit of PRBC in the ED.
Patient found to have UTI on UA, which corresponded with his
suprapubic pain. He was started on cipro in ED. He was febrile
to 103 in ED.
.
Pt was transferred to the [**Hospital Ward Name 332**] ICU on [**2197-5-28**]. His HCT remained
stable from 27.3--> 26.1. He was kept NPO overnight, was given
pantoprazole 20 mg iv q24. C. diff cultures were sent and he was
started on flagyl while those cultures were pending. His plavix
and home anti-hypertensives were held. He showed no evidence of
further GI bleed and he remained hemodynamically stable. He did
have a mild bump in troponin due to demand ischemia.
.
For his UTI, we continued the ciprofloxacin started in the ED.
He was also given morphine prn for his described [**7-4**] suprapubic
pain. His blood cultures returned [**12-27**] gram negative rods.
.
On the floor, the pt continued on IV antibiotics for bacteremia
with cipro-sensitive E.Coli. GI recommended outpatient
follow-up for likely ischemic colitis. His ASA and plavix were
held, and he should follow-up with his primary care physician,
[**Name10 (NameIs) 44284**], or [**Name10 (NameIs) 1106**] surgeon about restarting them. He was
transfused for a falling Hct, which bumped appropriately and
remained stable thereafter. He complained of bony pain and was
seen by palliative care for pain management, with tweaking of
his pain medication regimen.. He is FULL code.
Medications on Admission:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Oxycodone 5 mg Tablet Sig: 3-5 Tablets PO Q2H (every 2 hours)
as needed for pain.
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
every eight (8) hours as needed for constipation.
17. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: One
(1) tsp PO every 4-6 hours as needed for cough.
18. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
19. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
21. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1)
tablet Sustained Release 12 hr PO twice a day.
22. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for nausea/anxiety.
.
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release(s)* Refills:*0*
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Metoprolol Succinate 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. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: Please apply to shoulder 12 hours on and 12
hours off.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheeze.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Morphine 15 mg Tablet Sig: 2-3 Tablets PO Q2H (every 2
hours) as needed for pain.
Disp:*1080 Tablet(s)* Refills:*0*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
18. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
19. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
every eight (8) hours as needed for constipation.
20. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: One
(1) tsp PO every 4-6 hours as needed for cough.
21. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for nausea, anxiety.
22. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
23. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Ten (10)
mL PO once a day.
Disp:*300 mL* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Multicultural Home Care
Discharge Diagnosis:
Primary Diagnoses: Ischemic Colitis, Urinary Tract Infection,
Bacteremia
Secondary Diagnoses: Stage IV Non-Small Cell Lung Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after passing bright red blood
through your rectum. At the time you were also found to have an
infection of your blood stream and urine. You were treated with
bowel rest and antibiotics. During your hospitalization you
also complained of your chronic bone pain due to your cancer.
Your pain medications were changed to give you better pain
control.
.
The following changes were made to your medications:
Aspirin and Plavix were STOPPED. You should see your primary
care doctor [**First Name (Titles) **] [**Last Name (Titles) 1106**] surgeon within the next week or two to
consider restarting these medications.
.
OxyContin and Oxycodone were STOPPED.
.
You were STARTED on MSContin for long-acting pain relief and
Morphine IR for short-term pain relief. You were STARTED on a
Lidoderm Patch that you can place over your shoulder/back where
you are having severe pain. You were STARTED on Megace
(Megestrol) to increase your appetite.
.
Your metoprolol dose was INCREASED.
.
You should STOP taking lisinopril. You should discuss
restarting lisinopril with your primary care doctor or
cardiologist.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD
Phone:[**0-0-**]
Date/Time:[**2197-6-22**] 10:30
ICD9 Codes: 5990, 7907, 3051, 2749, 2720, 412, 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1708
} | Medical Text: Admission Date: [**2187-11-7**] Discharge Date: [**2187-11-15**]
Date of Birth: [**2117-1-25**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Severe coronary artery disease.
HISTORY OF PRESENT ILLNESS: This is a 70-year-old man, who
was transferred from outside hospital. He has been
experiencing chest pain at rest with left arm pain while
eating breakfast. He has no shortness of breath. No nausea,
vomiting, no lightheadedness, no history of coronary artery
disease, no hypertension, and no shortness of breath, no
tobacco use. He is an active person, who participates in
both golf and tennis.
One day prior to admission, he had an exercise tolerance test
that was discontinued after three minutes because of EKG
changes.
PAST MEDICAL HISTORY:
1. Type 2 diabetes.
2. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. Appendectomy.
2. Bilateral knee arthroscopies.
ALLERGIES: He has no known drug allergies.
MEDICATIONS:
1. Glucophage.
2. Lipitor.
3. Viagra.
SOCIAL HISTORY: He lives in [**Location 47**] with his wife. [**Name (NI) **] is
currently retired and also has a summer house in [**Last Name (Titles) 54050**]. He has no tobacco use and he drinks 2-4
drinks per week.
REVIEW OF SYSTEMS: He has no history of any sort of strokes.
PHYSICAL EXAMINATION: He is afebrile. Vital signs stable.
He is in general, a well-developed and well-nourished man
lying in bed in no apparent distress. Head and neck: There
is no JVD, no lymphadenopathy, and no bruits. His oropharynx
is clear. Cardiovascular: Regular, rate, and rhythm, no
murmurs. Lungs are clear to auscultation bilaterally.
Abdomen is soft, nontender, nondistended. Extremities: No
cyanosis, clubbing, or edema. Saphenous vein has no
varicosities. His pulses are 3+ throughout the spine.
LABORATORY VALUES ON ADMISSION: Were within normal limits.
EKG: Was normal sinus rhythm, no ischemic changes.
An echocardiogram showed mild inferior hypokinesis and
ejection fraction of greater than 55%.
The catheterization performed on the day of admission showed
a 90% occlusion of the left main coronary artery and a 60%
occlusion of diagonal #1, 95% occlusion of diagonal #2. He
was also shown to be right dominant.
[**Last Name (STitle) 2708**]was admitted to [**Hospital1 69**]
in preparation for a CABG procedure. On [**11-8**], patient was
preoped for this procedure. An ultrasound of the carotid
arteries was unremarkable and chest x-ray and EKG were within
normal limits. He was consented, and made NPO after
midnight, and was taken to the operating room on [**2187-11-9**].
Please refer to the previously dictated operative note by Dr.
[**Last Name (Prefixes) **] of [**11-9**].
In brief, the left internal mammary artery was anastomosed to
the left anterior descending artery and two saphenous vein
grafts were connected to the diagonal and oblique arteries.
The patient tolerated the procedure well, and transferred
postoperatively to the Intensive Care Unit.
Over the next day, the patient was weaned off his various
drips including Neo-Synephrine, propofol, and insulin. On
postoperative day two, he was transferred to the floor in
good condition. He was tolerating a regular diet, and was
alert and oriented times three.
On the floor, his major issues were physical therapy, and by
the day of discharge, he was up walking about the floor and
ambulating up stairs. Activity level ............. His
diet, he is tolerating a full regular diet. He did have some
constipation, which resolved with some Colace and at the time
of discharge, he is having regular bowel movements, and
finally, there was some tweaking of his cardiac medications
increasing his Lopressor to maintain a regular heart rate.
Therefore, on [**2187-11-15**], postoperative day six, patient is
being discharged home in good condition.
DISCHARGE DIAGNOSES:
1. Hypercholesterolemia.
2. Diabetes mellitus type 2.
3. Coronary artery disease.
4. Unstable angina.
5. Status post coronary artery bypass graft.
6. Status post coronary angiography.
7. Constipation.
8. Tachycardia.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg once a day for seven days.
2. Potassium chloride 20 mg twice a day for seven days.
3. Aspirin 325 mg once a day.
4. Percocet 1-2 tablets p.o. q.4h. as needed for pain.
5. Lipitor 40 mg once a day.
6. Glucophage 500 mg p.o. twice a day.
7. Pioglitazone 30 mg p.o. once a day.
8. Metoprolol 100 mg p.o. twice a day.
9. Colace 100 mg p.o. twice a day.
10. Benadryl 25 mg as needed for help with sleep.
FO[**Last Name (STitle) **]P INSTRUCTIONS: He has a follow-up appointment with
his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8049**] in about 10 days, and he
has a follow-up appointment with Dr. [**Last Name (Prefixes) **] in four
weeks.
FRANK [**Last Name (Prefixes) 413**], M.D.
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2187-11-14**] 22:27
T: [**2187-11-15**] 06:07
JOB#: [**Job Number 54051**]
ICD9 Codes: 4111, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1709
} | Medical Text: Admission Date: [**2161-10-20**] Discharge Date: [**2161-10-25**]
Date of Birth: [**2078-12-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue and lightheadedness
Major Surgical or Invasive Procedure:
[**2161-10-20**] Aortic Valve Replacement (21 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic-tissue)
History of Present Illness:
82 year old female with known aortic stenosis which has been
followed by serial echocardiograms over the past 10 years. Her
most recent echocardiogram revealed an increased mean systolic
gradient from 72 mm Hg to 93 mmHg with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.3cm2. Ms.
[**Known lastname 32245**] is fairly adament that she does not experience any
symptoms related to her disease however, when pressed, over the
last couple of months she reports mild intermittent
lightheadedness and increasing fatigue. At one point she did
experience some chest pain with walking however this is not a
frequent occurrence. Overall she is very active, climbing a
couple of flights of stairs with laundry and or groceries daily.
She denies any palpitations or syncope. Given the severity of
her disease, she now presents for surgical consultation.
Past Medical History:
Aortic Stenosis s/p Aortic valve replacement
Past medical history:
- Moderate MR
- Non sustained VT, NSVT, multifocal VEA on Holter [**2157-12-22**]
- Peripheral vascular disease
- Mild Carotid Artery Disease
- Anemia - [**2152**] found incidentally, GI workup was negative
except
for the "beginning of Barrett's Esophagus. Received 11 units of
PRBC. No recent bleeding or further work. She avoids Aspirin.
- History of hematochezia. W/U negative and this resolved. FeSO4
started.
- Irritable Bowel Syndrome
- Dyslipidemia
- Hypertension
- Vulvodynia
- Rheumatic fever at age 7
- Vertigo
Past Surgical History:
- s/p Tonsillectomy
- s/p Vocal Chord Nodule Excision (benign)
- Cataract surgery OD. Awaiting surgery for OS.
- D+C
- Cystoscopy
- H/O Varicose vein sclerosing therapy. (Posteriorly in thighs
Social History:
Race: Caucasian
Last Dental Exam: 3 weeks ago
Lives alone. Widow and lost her husband in [**2160-11-12**] with
dementia. She lives in [**Hospital1 3494**] MA. She has three supportive
children.
Contact: Phone #
Occupation: Retired
Cigarettes: Smoked no [X] yes [] Hx:
Other Tobacco use:
ETOH: < 1 drink/week [X] [**1-19**] drinks/week [] >8 drinks/week []
Illicit drug use: Never
Family History:
No premature coronary artery disease. Father with valvular heart
disease and RHD. Died at 62.
Physical Exam:
Pulse: 60 Resp: 16 O2 sat: 99%
B/P Right: 148/75 Left: 149/69
Height: 5"3" Weight: 150 lbs
General: WDWN in NAD. Appears younger then stated age.
Skin: Warm, Dry and intact. Faint inframammary
erythematous/scaly
rash c/w fungal infection.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, NlS1-S2, IV/VI harsh systolic ejection murmur.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema- trace left, none
on right
Varicosities: Multiple distal lspider varicosities. Dilated
veins
posteriorly and laterally. GSV appears suitable on standing.
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit Transmitted R>L
Pertinent Results:
[**2161-10-20**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. The
mitral valve leaflets are myxomatous. Mild to moderate ([**12-14**]+)
mitral regurgitation is seen. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results at time of
surgery.
POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Biventricular function is unchanged. There is a
well-seated bioprosthetic valve in the aortic position. There is
a mean gradient of 12 mmHg at a cardiac output of 3.2 L/min. No
aortic regurgitation is seen. No paravalvular leak is seen.
Mitral regurgitation is mild (1+). The aorta is intact
post-decannulation.
Brief Hospital Course:
The patient was brought to the operating room on [**10-18**] where the
patient underwent Aortic valve replacement 21-mm St. [**Hospital 923**]
Medical Biocor tissue valve.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. Pt went into afib post op. Amio
was started. pt in afib longer then 24 hrs. Coumadin was
iniated, Now on a amio taper with coumadin ofr new onset afib.
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 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to rehab in good
condition with appropriate follow up instructions.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 0.5
(One half) Tablet(s) by mouth once a day
PREGABALIN [LYRICA] - (Prescribed by Other Provider) - 100 mg
Capsule - 1 (One) Capsule(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth once a day
Medications - OTC
FERROUS SULFATE - (OTC) - 325 mg (65 mg iron) Tablet - 1 (One)
Tablet(s) by mouth every other day
FOLIC ACID -
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. pregabalin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): TAPE 400 [**Hospital1 **] X 7 DAYS, THEN 200 [**Hospital1 **] X 7 DAYS, THEN 200
QD UNTILL F/U WITH PCP.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. warfarin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: INR
GOAL IS 2=3, FOR AFIB. PLEASE FOLLOW INR.
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
15. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 7 days: HOLD FOR K
OF GREATER THEN 4.5.
16. INSULIN
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 2 Units 2 Units 2 Units 0 Units
160-199 mg/dL 4 Units 4 Units 4 Units 2 Units
200-239 mg/dL 6 Units 6 Units 6 Units 4 Units
240-280 mg/dL 8 Units 8 Units 8 Units 6 Units
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic valve replacement
Past medical history:
- Moderate MR
- Non sustained VT, NSVT, multifocal VEA on Holter [**2157-12-22**]
- Peripheral vascular disease
- Mild Carotid Artery Disease
- Anemia - [**2152**] found incidentally, GI workup was negative
except
for the "beginning of Barrett's Esophagus. Received 11 units of
PRBC. No recent bleeding or further work. She avoids Aspirin.
- History of hematochezia. W/U negative and this resolved. FeSO4
started.
- Irritable Bowel Syndrome
- Dyslipidemia
- Hypertension
- Vulvodynia
- Rheumatic fever at age 7
- Vertigo
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2161-11-25**] at 1pm in the
[**Hospital **] Medical Office Building, [**Last Name (NamePattern1) **]., [**Hospital Unit Name **].
Cardiologist: Dr. [**Last Name (STitle) **] on [**2161-11-13**] at 1;30pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name (STitle) 15316**] [**Name (STitle) 12646**] ([**Telephone/Fax (1) 4615**]) in [**3-17**] 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:[**2161-10-25**]
ICD9 Codes: 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1710
} | Medical Text: Admission Date: [**2114-8-1**] Discharge Date: [**2114-8-7**]
Date of Birth: [**2068-6-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1491**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD with banding
History of Present Illness:
46 yo F s/p liver transplant '[**05**] for acute Hep A who is
undergoing liver/kidney transplant eval at [**Hospital1 18**] had colonoscopy
and EGD on [**7-31**] which was notable for grade 3 varices which were
banded and an unremarkable colonoscopy. However, she developed
abd pain after the colonoscopy. She went home, noted severe abd
pain and presented to [**Hospital3 **] hospital. Presented with mildly
increased distension of abdomen - KUB and CT showed no free air,
but did show increased air in colon which could have resulted
from [**Last Name (un) **]. [**Hospital3 **] spoke with Dr. [**Last Name (STitle) 497**] who recommended
paracentesis, but they did not feel comfortable doing this.
Therefore, Dr. [**Last Name (STitle) 497**] requested she receive a dose of ceftriaxone
and be transferred to [**Hospital1 18**].
.
In the ED at [**Hospital1 18**], the patient had a diagnostic and therapeutic
paracentesis which drained 2.7L of amber liquid. Peritoneal
fluid was negative for SBP with 31 WBC, culture pending. She
also received phenergan, morphine, and 1000cc NS.
.
The patient was admitted to medicine for further evaluation of
abdominal pain. Upon arrival to the floor, the patient had 3
episodes of coffee ground emesis (approx 350cc total) with a 6
point drop in Hct. Liver fellow was contact[**Name (NI) **] who recommended IV
protonix, octreotide, and transfer to MICU for emergent EGD and
monitoring. In the MICU an EGD was performed which showed grade
III varices which were banded. Following this procedure and
multiple blood transfusion, her Hct has stabilized at 34. Given
persistent complaints of tense abdomen and pain, have made
multiple attempts to repeat paracentesis - hindered by dilated
loops of bowel. As her HCT remains stable she was transfered
back to medicine for further care.
Past Medical History:
-liver transplant '[**05**] for acute hep A (obtained after eating
chinese food) now complicated by cirrhosis documented by bx
[**10-26**].
-h/o variceal bleeding s/p banding
-osteopenia
-h/o scarlet fever
Social History:
no etoh, drugs, or tobacco. Lives with parents. From [**Location (un) 86**].
Family History:
noncontributory
Physical Exam:
PE: 98.7 151/80 116 18 94% RA
Gen: appears uncomfortable, lying still
HEENT: anicteric, MM slightly dry.
Neck: supple, no JVD
CV: tachy, possible +S4/split S1
Back: no CVA tenderness
Abd: +BS, tense, diffuse tenderness to palpation; previous
transplant scars; +caput; no obvious rebound, + ventral hernia
easily reducable.
Ext: no LE edema
Skin: +spider [**Last Name (LF) 61458**], [**First Name3 (LF) **] erythema
Neuro: somnolent but interactive. A&Ox3. MAEW. strenght [**4-26**]
throughout. sensation in tact to LT.
Pertinent Results:
[**2114-8-1**] 09:20PM HCT-33.1*
[**2114-8-1**] 08:43PM URINE HOURS-RANDOM UREA N-470 CREAT-89
SODIUM-<10
[**2114-8-1**] 08:43PM URINE OSMOLAL-349
[**2114-8-1**] 08:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2114-8-1**] 08:43PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-8-1**] 08:43PM URINE RBC-[**2-24**]* WBC-[**2-24**] BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2114-8-1**] 08:43PM URINE HYALINE-<1
[**2114-8-1**] 04:00PM GLUCOSE-153* UREA N-47* CREAT-2.3* SODIUM-135
POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-20* ANION GAP-19
[**2114-8-1**] 04:00PM CALCIUM-8.2* PHOSPHATE-6.1* MAGNESIUM-1.7
[**2114-8-1**] 04:00PM WBC-18.6* RBC-3.74* HGB-9.5* HCT-30.0*
MCV-80* MCH-25.5* MCHC-31.8 RDW-20.3*
[**2114-8-1**] 04:00PM PLT COUNT-113*
[**2114-8-1**] 04:00PM PT-13.8* PTT-27.5 INR(PT)-1.3
[**2114-8-1**] 01:04PM HCT-30.6*
[**2114-8-1**] 01:04PM PT-13.5* PTT-27.8 INR(PT)-1.2
[**2114-8-1**] 05:45AM ASCITES WBC-31* RBC-9800* POLYS-45* LYMPHS-5*
MONOS-0 MESOTHELI-10* MACROPHAG-40*
[**2114-8-1**] 03:40AM GLUCOSE-123* UREA N-37* CREAT-2.2* SODIUM-138
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17
[**2114-8-1**] 03:40AM ALT(SGPT)-34 AST(SGOT)-27 ALK PHOS-200* TOT
BILI-0.8
[**2114-8-1**] 03:40AM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-5.7*
MAGNESIUM-1.8
[**2114-8-1**] 03:40AM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-5.7*
MAGNESIUM-1.8
[**2114-8-1**] 03:40AM WBC-12.6*# RBC-4.48# HGB-11.0*# HCT-36.1#
MCV-81* MCH-24.6* MCHC-30.5* RDW-20.9*
[**2114-8-1**] 03:40AM NEUTS-88.2* LYMPHS-6.3* MONOS-4.0 EOS-1.3
BASOS-0.2
[**2114-8-1**] 03:40AM HYPOCHROM-3+ ANISOCYT-2+ MICROCYT-3+
[**2114-8-1**] 03:40AM PLT COUNT-150
[**2114-7-31**] 08:20AM CYCLSPRN-80*
Brief Hospital Course:
46 y/o female w/ h/o liver transplant for Hep A c/b cirrhosis,
and grade 3 esophageal varices, originally admitted with diffuse
abdominal pain after colonscopy, now with coffee ground emesis x
3 s/p EGD with banding of varices and persisting ascites.
.
1) UPPER GI BLEED: pt w/ coffee ground emesis on [**8-1**] had grade
3 varices on EGD [**8-1**], banded. She received a total of 3 U PRBC
during MICU course. She is now hemodynamically stable and her
HCT has remained stable since transfusions. Patient recieved
Octreotide for total of 5 days Patient continued on Protonix 40
mg po BID. Patient given sucralfate. Nadolol was held.
.
2) ABDOMINAL PAIN - There was concern for perforation given
recent colonoscopy; however, X-ray and Abd CT @ OSH did not show
evidence of free air, and repeat upright CXR @ [**Hospital1 18**] shows no
free air. Also considered was SBP from bacterial translocation
from colonoscopy. Pt received ceftriaxone at OSH, but pt only
had 31 WBC by paracentesis. Abdominal pain improved since
initial paracentesis in ED; now ascites redeveloped and pain has
returned. Ceftriaxone/Rifaximin was given immunosuppression and
elevated WBC. She recieved morphine prn for pain.
.
A second paracentesis was attempted; however only 10 cc of fluid
was removed. She was then taken to have U/S-guided paracentesis,
but found to have significantly dilated loops of bowel which
hindered further attempts. On repeat US guided paracentesis for
[**8-6**] for symptomatic relieve was successful. Her abdominal pain
resolved prior to discharge.
.
3) RENAL FAILURE - likely [**1-24**] to nephrotoxity from cyclosporin;
appears to have resolved as pt's creatinine at baseline of 2.2.
She was given 25 grams of Albumin after her paracentesis. Her
medications were renally dosed
.
4) CIRRHOSIS - Cirrhosis of transplanted liver is thought to be
[**1-24**] to prior noncompliance with immunosuppressive meds. Patient
being evaluated for a re-transplant by Dr. [**Last Name (STitle) 28609**] at [**Hospital1 18**]. pt
intially w/ varices and now w/ asterixis. possibly
enephalopathic due to increased urea load w/ GIB. Her
encephalopathy resolved. Decreased cyclosporin to 50 qd and
started sirolimus 4 mg qd on [**8-3**].
She continued Lactulose and rifamixin for encephalopathy ppx.
Diuretics were held given GIB and renal dysfunction. She
continued prednisone. Her cyclosporin and sirolimus levels were
checked.
.
5) DIARRHEA - likely related to Lactulose, resolved prior to
discharge
.
Medications on Admission:
1. levaquin 250 po qd
2. Lactulose prn
3.Lasix 40mg po qd
4. Aldactone 50mg po qd
5. Rifaximib
6. Iron sulfate
7. Protonix 40mg po qd
8. Neoral 100mg po qd
9. Morphine SR 60mg po prn
10. Prednisone 10 mg po qd
11. Calcium supplements
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO tid-qid:
Tritrate to 3 bowel movement a day.
Disp:*q/s ml * Refills:*2*
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sirolimus 2 mg Tablet Sig: One (1) Tablet PO once a day: Do
not take on [**8-8**] and [**8-9**]. Restart on [**8-10**] (Friday).
Disp:*30 Tablet(s)* Refills:*2*
4. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
9. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
SBP, Upper GI bleed
Discharge Condition:
stable
Discharge Instructions:
Please call primary care provider or come to emergency room if
have increased abdominal pain, vomiting of blood,
lightheadedness or any other concerning symptoms.
** Do not take Rapamune for next 2 days ([**8-8**] and [**8-9**], then
restart om [**8-10**] Friday at 2mg daily.
Followup Instructions:
1.Dr. [**Last Name (STitle) 497**] on Monday, transplant coordinator will call
2.Transplant coordinatro will call with appointment
Completed by:[**2114-8-13**]
ICD9 Codes: 5715, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1711
} | Medical Text: Admission Date: [**2114-3-21**] Discharge Date: [**2114-3-22**]
Date of Birth: [**2048-9-5**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
right subdural hematoma
Major Surgical or Invasive Procedure:
right craniotomy and evacuation of subdural hematoma
History of Present Illness:
65 yM fell on Saturday; presented to OSH today with severe
headache and projectile emesis, became unresponsive and
developed
decorticate posturing and fixed pupils, and a head CT revealed a
large R-sided subdural hematoma with midline shift. The patient
was intubated for airway protection, and he was transferred to
[**Hospital1 18**] for further care.
Past Medical History:
MS
[**First Name (Titles) **]
[**Last Name (Titles) **]
Hypothyroidism
Social History:
non-contrib
Family History:
non-contrib
Physical Exam:
O: T: BP:212/80 HR:80
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: fixed @ 5cm bilat
Neck: in c-collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated and sedated, unresponsive, with
decorticate posturing
Pertinent Results:
[**2114-3-21**] 02:25PM TYPE-ART PO2-231* PCO2-32* PH-7.46* TOTAL
CO2-23 BASE XS-0
[**2114-3-21**] 12:38PM PHENYTOIN-9.1*
CT HEAD W/O CONTRAST [**2114-3-21**] 12:12 AM
IMPRESSION: Large acute on chronic right subdural hematoma
causing marked mass effect and midline shift causing entrapment
of the left lateral ventricle. Subfalcine herniation with
effacement of the basal cisterns without frank uncal herniation.
CT HEAD W/O CONTRAST [**2114-3-21**] 3:33 AM
IMPRESSION:
1. Status post evacuation of large right subdural hematoma with
interval improvement in the degree of mass effect and midline
shift. Effacement of the basal cisterns is unchanged. There
remains subfalcine herniation. The left lateral ventricle
remains enlarge.
MR HEAD W & W/O CONTRAST [**2114-3-21**] 5:19 PM
IMPRESSION:
1. Status post evacuation of large right subdural hematoma with
interval improvement of leftward subfalcine herniation.
2. Diffusion-weighted imaging abnormality indicating acute
ischemic changes involving the medial temporal lobes
bilaterally, right greater than left, mid brain, and pons.
Hemorrhages associated with the abnormalities in the mid brain.
These likely represent manifestations of prior herniation injury
or possibly contusions from prior trauma.
3. Periventricular white matter T2/FLAIR hyperintensity which
likely represents transependymal edema from hydrocephalus. More
focal areas of signal abnormality within the periventricular
white matter may also represent manifestation of transependymal
edema or preexisting white matter disease.
Brief Hospital Course:
Pt arrived in the ED @ [**Hospital1 18**] intubated and unresponsive, with
fixed/dilated pupils and decorticate posturing. After a head CT
that showed a large right-sided subdural hematoma with 2cm
midline shift, he was taken emergently to the OR for a right
craniotomy and evacuation of hematoma. Post-operatively, his
left pupil decreased to 3mm (but still unreactive), and his R
eye remained fixed and dilated @ 5mm; he was transferred
post-operatively to the SICU.
There was no change in examination over the first 24 hours. An
MRI was ordered to determine what brain tissue had infarcted,
and DWI positive lesions consistent with infarct were seen in
the temporal lobes, midbrain and pons. A stroke consult was
called on [**2114-3-22**] and the stroke team evaluated the patient and
informed the family of the poor prognosis.
Based on their discussions with neurology and neurosurgery, the
family decided to make the patient comfort measures only. This
was done around 1900 [**2114-3-22**] and the patient expired at 2045.
Medications on Admission:
lisinopril, aspirin, atenolol, amantadine, synthroid
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1712
} | Medical Text: Admission Date: [**2106-2-5**] Discharge Date: [**2106-2-12**]
Date of Birth: [**2061-7-7**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Sent from NWH with left sided hemorrhage
Major Surgical or Invasive Procedure:
Cerebral Angio
History of Present Illness:
The pt is a 44 year-old right handed woman with no signifcant
PMH and family history significant for stroke (father, paternal
uncle and sister @ 46 years) who was transferred from [**Location (un) 745**]
[**Hospital 3678**] Hospital with a left sided intraparenchymal hemorrhage.
The patient was in her USOH when she developed speech
difficulties at work at 5pm on [**2106-2-4**]. She was having
difficulting speaking cohorently and was noted by co-workers to
be repeating the same sentence. She was saying something about
how cold she was and how hungry she was. She also noted a
headache. The co-workers called her husband and the patient was
brought by EMS to NWH. There blood pressure was 109/55 and pulse
was 70. GCS was 14 losing a point for confusion and the patient
was noted to move all extremities. A CBC and coagulation panel
were unremarkable, but a CT can revealed a 9X4X3cm left temporal
hemorrhage. The patient was transferred here for further
management.
The patient is unable to augment the history as she is aphasic.
Past Medical History:
Had an ulcer at age 10
Social History:
Works at the [**Last Name (un) **] Laboratories in [**Location (un) 2624**].
Married. Has a son.
[**Name (NI) **] ETOH, TOBACCO, or Drugs.
Family History:
Father died of multiple strokes at age 63.
Paternal Uncle died of stroke.
Patient sister died of stroke (not clear if ischemic or
hemorrhagic) in [**Country **] at age 46.
Physical Exam:
Vitals: T:96.7 P:72 R:14 BP:111/58 SaO2:99%RA
General: Awake, 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: The patient has fluent aphasia. When asked how
she was doing she said, "My father cares for me....(and trailed
off)" . When asked where she was, she said, "I went to school
and i...(trailed off)" No response when asked her age. When
asked to name items off of the NIHSS picture sheet, she called
the chair "Ashes". She was able to follow commands variably. Sh
closed her
eyes, showed her right hand and kept all four limbs aloft to
command. She intiailly woudn't show her teeth and she never
showed her tongue. Unable to read, name, or repeat.
-Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and brisk.
VFF difficult to assess, but the patient doesn't appear to blink
to threat from any angle. There is mild left ptosis. Funduscopic
exam wsa limited by patient inattention (will not hold still).
EOMI unable to assess. No facial droop, facial musculature
symmetric. Patient can hear the examiner.
-Motor: All four extremities are antigravity. She has no drift
in any of her limbs. Formal muscle testing was not feasible.
-Sensory: Intact to pain. She winces.
-Coordination: Not testable.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Gait: Not testable.
Pertinent Results:
[**2106-2-5**] 12:00AM BLOOD WBC-9.9 RBC-4.48 Hgb-14.1 Hct-39.8 MCV-89
MCH-31.5 MCHC-35.5* RDW-12.2 Plt Ct-367
[**2106-2-5**] 03:48AM BLOOD ESR-5
[**2106-2-5**] 12:00AM BLOOD PT-13.2 PTT-33.4 INR(PT)-1.1
[**2106-2-5**] 12:00AM BLOOD Glucose-132* UreaN-8 Creat-0.5 Na-140
K-4.0 Cl-105 HCO3-22 AnGap-17
[**2106-2-5**] 12:00AM BLOOD ALT-55* AST-38 LD(LDH)-167 CK(CPK)-54
AlkPhos-67 Amylase-90 TotBili-0.8
[**2106-2-5**] 12:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2106-2-5**] 03:48AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2106-2-5**] 03:48AM BLOOD %HbA1c-5.2
[**2106-2-5**] 03:48AM BLOOD Triglyc-33 HDL-88 CHOL/HD-2.2 LDLcalc-95
[**2106-2-5**] 03:48AM BLOOD TSH-0.65
[**2106-2-5**] 03:48AM BLOOD HCG-<5
[**2106-2-5**] 03:48AM BLOOD CRP-0.6
[**2106-2-5**] 03:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT HEAD W/O CONTRAST [**2106-2-4**] 11:47 PM
FINDINGS: There is a large approximately 4 x 2.7 cm (on axial
view) focus of hyperdensity of the left temporal lobe consistent
with intraparenchymal hemorrhage. There is a surrounding rim of
hypodensity indicating vasogenic edema. No definite underlying
mass is seen. There is no definite underlying aneurysm on this
non-contrast study. The septum pellucidum appears to be shifted
approximately 2 mm to the right which may be positional or
possibly due to slight mass effect. The ventricular system is
symmetric and normal in size. The paranasal sinuses and mastoid
air cells are clear.
IMPRESSION: Large intraparenchymal hemorrhage of the left
temporal lobe with surrounding vasogenic edema. Septum
pellucidum shifted approximately 2 mm to the right may be
positional or indicate slight mass effect.
MRA BRAIN W/O CONTRAST [**2106-2-5**] 2:15 AM
As seen on CT, there is a large area of intraparenchymal
hemorrhage in the left temple lobe with a fluid-fluid hematocrit
level seen within it. FLAIR images demonstrate surrounding edema
without shift of normally midline structures or hydrocephalus.
There is central high signal on DWI and low signal on ADC
consistent with acute hemorrhage. The intracranial flow voids
are preserved without any evidence of high-flow arteriovenous
malformation. There is no abnormal contrast enhancement or mass.
Minimal ethmoid air cell mucosal thickening versus fluid is
noted anteriorly. The mastoid air cells remain clear. The orbits
appear unremarkable.
MRA OF THE BRAIN: The distal internal carotid and vertebral
arteries are normal in caliber, as are their intracranial
branches. There is no evidence of occlusion, flow limiting
stenosis, or aneurysm. Note is made of an infundibulum at the
takeoff of the right MCA inferior temporal branch. There is no
evidence on this MRA study of arteriovenous malformation, or
other vascular abnormality.
IMPRESSION:
1. Large left temporal intraparenchymal hemorrhage. No
underlying etiology identified. In the absence of other
explanation, a catheter angiogram may be of value to exclude
abnormalities such as small arteriovenous malformations, which
are below the resolution of MRA.
EEG:
This is an abnormal portable EEG in the waking and sleeping
states due to persistent mixed theta and delta frequency
slowing, moderate in amplitude, noted in the left
fronto-temporal region, at times with periodic admixed slow
blunted sharp waves with phase reversal at T3. The findings are
consistent with an underlying area of cortical and subcortical
dysfunction with the periodic blunted slow sharp waves raising
concern for a potential focus of epileptogenesis. However, no
runs of more frequent or sustained discharges were noted. No
electrographic seizures were noted.
Conventional Cerebral Angiogram:
Notable for left temporal lobe arteriovenous malformation.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the ICU for closer monitoring. She had
an MRI/MRA which did not show an underlying mass or AVM. She had
screening labs which were normal. She was therefore taken to the
angio suite and found to have a left temporal lobe AVM. She was
monitored initially in the ICU, and when felt to be stable
neurologically, she was watched clinically on the floor by the
neurology service. She continued to have a fluent aphasia, with
impaired comprehension for commands but some intact repetition
for single words and recognition of phrases (and appropriate
answers) for questions regarding headache. On [**2-10**] she
underwent embolization of the AVM with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in the
angio suite. Most of the feeding vessels were embolized
successfully, though a very small feeding vessel remains. She
will follow up with Dr. [**Last Name (STitle) 3929**] next week for consideration of
cyberknife. She will see Dr. [**First Name (STitle) **] in four weeks, she will need
a repeat MRI/MRA of the brain just prior to her visit with Dr.
[**First Name (STitle) **]. She was discharged on Keppra given left temporal sharp
waves. This should be tapered to off in the months following her
treatment. She should follow up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] at the
stroke neurology center in [**4-25**] weeks.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain. Tablet(s)
2. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
3. Outpatient Occupational Therapy
Please evaluate and treat
4. Outpatient Speech/Swallowing Therapy
Please evaluate speech and treat
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): For seizure prevention.
Disp:*120 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Intracerebral hemorrhage
Arteriovenous malformation of the left temporal lobe
Discharge Condition:
Stable. Fluent Aphasia.
Discharge Instructions:
You were admitted for sudden difficulty speaking (fluent
aphasia) that was related to a left temporal lobe hemorrhage.
The was caused by an arteriovascular malformation. You underwent
embolization of the vessels, but will need further treatment
with cyberknife to completely seal the vessels.
You are being treated for a urinary tract infection (two days
remaining). You are on a medicine to prevent seizures. This may
eventually be tapered off under the guidance of your physicians
in a few months following further treatment.
Call your doctor or 911 immediately if you experience worsening
headache, worsening difficulty speaking or comprehending speech,
weakness, numbness, tingling, chest pain, shortness of breath,
or any other concerning symptoms.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 3929**] next week for planning for
radiotherapy/cyberknife. Office number: ([**Telephone/Fax (1) 8082**].
Follow up with neurosurgery, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in four weeks, on
the [**Hospital1 18**] [**Hospital Ward Name **] [**Hospital **] Medical Office Building [**Location (un) **],
Thursday, [**3-11**] at 1pm. You will need to have a repeat
MRI/MRA just prior to this visit.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 431, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1713
} | Medical Text: Admission Date: [**2200-4-23**] Discharge Date: [**2200-4-30**]
Date of Birth: [**2126-6-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Shortness of breath, fatigue.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 73 y/o M with CMML who was admitted on [**2200-4-2**] at
[**Location (un) 5871**] for splenic rupture where he underwent emergent
splenectomy on [**4-2**], course complicated by intra-abdominal staph
infection. There is no discharge summary available but per the
patient the procedure was without complications, no pressor
requirement per operative report. Culture of hematoma revealed
coagulase negative staphylococcus with multiple resistances but
sensitive to vancomycin. He was started on vancomycin for this.
Per pt he also had diarrhea related to c. diff infection and
flagyl was started. He was discharged from the OSH to complete a
course of vancomycin and flagyl. Since discharge the patient
reports that he has generally remained somewhat tired and
occasionally has felt some soreness in his ankles. This morning
he reports feeling much more tired and noticed that,
intermittently, he has felt some shortness of breath. No
associated chest pain or diaphoresis. The patient was taken by
hospital to the oncology clinic. There he was afebrile and
hemodynamically stable; however, his O2 saturation was noted to
be 90 on room air. He was subsequently admitted to the hospital.
Currently the patient reports he doesn't feel short of breath
except with exertion. He believes his diarrhea has resolved.
Past Medical History:
myelodysplastic syndrome
diverticulosis
AML 12 years ago(treated with chemo and recovered)
HTN
Social History:
Married, two children, does not smoke, having stopped some time
ago. Social alcohol. Perhaps two glasses of wine per day. Coffee
none. He is retired, having worked at D.E.C.
Family History:
Notable for coronary disease and diabetes mellitus.
Physical Exam:
VS: T 98.9 P 80 BP 112/80 RR 20 O2 95 on 2L
Gen: Elderly Caucasian gentleman in NAD.
Head: NCAT.
Eyes: PERRL, EOMI, anicteric,
Mouth: Small black spot on L lateral tongue, otherwise MMM, no
other lesions
CV: RR, nl S1S2, 3/6 systolic murmur at LLSB
Lungs: Slightly diminished at R base, otherwise fair air
movement with no adventitial sounds heard.
Abdomen: Purpuric bruising at abdomen LUQ and LLQ. Non-tender,
non-distended, normoactive BS,
Extrem: no c/c/e
Pertinent Results:
WBC 38 (was 23.1 on [**4-1**]), monocytic predominance
Hct 39.6
Plt 54
Cr 3.3 (baseline 2.1 to 2.4)
K 3
CK/CK MB nl. Trop 0.07
Microbiology
urinalyisis: negative for LE, nitrates. Few bacteria.
from OSH
LUQ hematoma: coag negative staphylococcus PCN resistant but
vancomycin sensitive.
Brief Hospital Course:
This is a 73 year old man with CMML with recent admission to OSH
for emergent splenectomy after splenic rupture who is admitted
for hypoxemia and worsening bilateral ground glass opacities.
He was treated aggressively on the floor with antibiotics and
other etiologies (PE, MI, etc) were appropriately addressed. He
was fluid resusitated and continued on his CMML regimen.
Despite this, the patient became progressively hypotensive and
was transfered to the ICU for further care.
In the ICU the patient continued to deteriorate and developed
progressive hypotension and acidosis despite aggressive fluid
repletion, pressor support, and bicarbonate drip. He received >
8L NS, 8amps bicarb, pressor support w/ levophed and
vasopressin, and maximum ventilatory support. Despite these
measures, his lactate continued to trend upwards and he became
progressively more hypotensive on the PEEP settings required to
adequately oxygenate him. Furthermore, the patient developed
tumor lysis syndrome in the setting of his chemotherapy and
became anuric producing only 40cc of urine over 8hr. Renal
service was called emergently to consider dialysis but the
family elected to change his code status to DNR/DNI and focus
care on comfort as a priority, after discussion w/ his
oncologist Dr [**First Name (STitle) 1557**] and to defer more aggressive therapy.
Medications on Admission:
MED Danazol 200 mg PO BID Start: 4 pm
MED Folic Acid 1 mg PO DAILY
MED Pantoprazole 40 mg PO Q24H
MED Atenolol 25 mg PO DAILY Start: In am
Please hold for SBP less than 100, HR less than 55.
MED Prednisone 12.5 mg PO DAILY Start: In am
MED Metronidazole 500 mg PO TID
MED Hydroxyurea 1500 mg PO DAILY
MED Ipratropium Bromide Neb 1 NEB IH Q6H:PRN
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
CMML, splenic rupture, hypotension
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2200-9-23**]
ICD9 Codes: 5849, 4280, 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1714
} | Medical Text: Admission Date: [**2155-4-27**] Discharge Date: [**2155-5-2**]
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
female, who presented with one-day history of severe
bilateral upper quadrant pain and epigastric pain with
radiation to the back and right shoulder. The patient
reports that she had an acute onset of pain with no known
precipitant. She was unable to tolerate PO the day before
presentation and reported nausea and vomiting times 3, the
day before. She was taken to an outside hospital and
reported significant pain during her travel with any sudden
movements. Her pain was controlled when lying still. She
received no relief with Maalox and Tums, but did improve when
admitted secondary to morphine at the outside hospital. She
denied pain with deep inspiration or pleuritic pain. No
dysuria or diarrhea. No melena, hematemesis, fever, chills,
or shortness of breath. No chest pain. No history of
gallstones or gallbladder disease. No history of
pancreatitis, dark urine, or weight loss.
PAST MEDICAL HISTORY: Significant for hypertension, coronary
artery disease, diabetes, and elevated cholesterol. She is
status post CABG.
MEDICATIONS: Medications on admission were:
1. Atenolol.
2. Glyburide.
3. Aspirin.
4. Lipitor.
5. Klonopin.
6. Meclozine.
7. Zetia.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives alone and no tobacco or
history of alcohol use.
PHYSICAL EXAMINATION: Vital Signs: Temperature 98.2, pulse
67, blood pressure 110/54, and saturations 95 percent on room
air. The patient was lying very still on bed, but was alert
and oriented. Cardiac exam: Regular rate and rhythm. No
murmurs, rubs, or gallops. Respiratory exam: Bibasilar
crackles. No pain or discomfort with deep inspiration.
Negative [**Doctor Last Name 515**] sign. Abdominal exam: She had positive
bowel sounds. No tenderness to percussion. Abdomen was soft
with mild epigastric tenderness. No rebound. No guarding.
She reported that her exam was different from when she
presented to outside hospital where she was much more
uncomfortable. Her rectal exam was negative for blood and
guaiac negative. Extremities: Warm and well perfused. No
peripheral edema.
LABORATORY DATA: At the outside hospital included, sodium of
145, potassium 3.8, chloride 106, bicarbonates 28, BUN 23,
creatinine 1.1, and glucose 139. Her white count was 20.7,
hematocrit 42.9, and platelets 291. Her magnesium was 1.8.
Albumin 3.5, alkaline phosphatase 205, ALT 134, AST 313,
lipase 22,460, and total bilirubin was 1.4. CT scan at the
outside hospital showed distention with edematous gallbladder
and common bile duct dilatation. No pseudocyst.
HOSPITAL COURSE: It was decided that the patient would be
admitted as her presentation was consistent with acute
cholecystitis and possible gallstone pancreatitis. She had
received levofloxacin and Flagyl at an outside hospital for
presumptive cholecystitis. She was admitted and aggressively
resuscitated with fluid. Ampicillin was given in the
emergency department. An ultrasound was obtained. She was
made nothing by mouth and ordered for IVP medication as
needed. She was monitored closely. She was initially
admitted to the Intensive Care Unit. The patient was started
on Lactated Ringers 200 cc per hour. Her ultrasound revealed
cholelithiasis with evidence of cholecystitis. Common bile
duct dilatation was present. It was thought that the patient
should receive an MRCP when she stabilized.
On hospital day number 1, her labs were checked, which
revealed an ALT of 214, AST of 494, amylase 1705, and lipase
of 4435, alkaline phosphatase is 178 and total bilirubin 2.1.
On hospital day number 2, her white count was down to 9.7,
her ALT was 113, AST 126, alkaline phosphatase 130, lipase
428, amylase 407, and total bilirubin 0.6. She was doing
well clinically on hospital day number 2 with her pain well
controlled. Her white blood count had normalized. She
continued to be monitored carefully. On hospital day number
2, she was transferred to the floor. On hospital day number
3, the patient reported some increase in pain that was
consistent with her presentation on admission. She continued
to be given IVP medication as needed, it consisted of a
hydromorphone 0.2-1 mg IV q.3-4h. p.r.n. Physical therapy
was ordered for her. Urine output remained good at this
time. A CT with IV contrast was obtained on hospital day
number 3. She was started on clears and was then advanced to
a low-fat diet on hospital day number 5. The CT scan, which
had been obtained showed significant improvement. Hence the
patient was improving clinically, it was decided on hospital
day number 6 that she would be ready for discharge.
On the day of discharge, her white count was 8.5. Her vital
signs were stable. She was afebrile. She was ambulating
regularly and tolerating a low-fat diet. Her amylase was
stable and it was decided that she would return to clinic
with Dr. [**Last Name (STitle) **] to schedule an appointment for surgery in
the future.
DISCHARGE DIAGNOSIS: Gallstones pancreatitis.
DISCHARGE INSTRUCTIONS: She was instructed to call the
clinic or come to the Emergency Department if she experienced
increased abdominal pain, nausea, vomiting, inability to take
p.o., fevers, chills, chest pain, or shortness of breath.
She was instructed to maintain a low-fat diet and to call Dr.[**Name (NI) 41561**] clinic to schedule a followup appointment and to
schedule a date for cholecystectomy.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Vicodin 5-500 mg 1 to 2 tablets p.o. q. 4-6h. She was
given 40.
2. Sucralfate 1 g 1 tablet p.o. q.i.d. She was given 120
tablets.
3. Pantoprazole 40 mg tablet delayed release one tablet p.o.
q. 24h. She was given 30 and she was instructed to
restart her home medications.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**]
Dictated By:[**Last Name (NamePattern1) 15009**]
MEDQUIST36
D: [**2155-6-21**] 17:36:14
T: [**2155-6-21**] 23:18:51
Job#: [**Job Number 41562**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1715
} | Medical Text: Admission Date: [**2118-7-28**] Discharge Date: [**2118-8-11**]
Date of Birth: [**2040-2-5**] Sex: M
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Mr. [**Known lastname 78131**] is a 78M with stageIV NSCLC on palliative Tarceva
who presents from his nursing facility with fevers x2d as high
as 103.6F. Per paperwork from rehab, he was given levofloxacin
500mg.
.
Of note, he was recently admitted to the OMED service, having
presented with fevers and discharged on [**7-14**] on cefpodoxime and
azithromycin for suspected pneumonia.
.
In the ED, initial vs were T98 P 73 BP 86/51 RR 22 98% on . He
was given vancomycin, cefepime, flagyl, acetaminophen, zofran,
and started on peripheral dopamine. Awake and mentating, making
small amounts of dark urine. CT abdomen done for h/o 1day of
diarrhea, noncontrast showed ?of colitis. Got 5L of saline. BP
remains 70's systolic on 15mcg dopamine and levophed.
.
On the floor, he denies any complaints - though initially
reported some abdominal pain to the RN. Review of systems
otherwise negative, though unclear if patient's history is
reliable.
Past Medical History:
Past Medical History:
1. Hypertension
2. Atrial Fibrillation
3. COPD
4. h/o bilateral hernia repair
5. aspiration
.
Oncologic History: (Per OMR note [**2118-6-15**] by Dr. [**Last Name (STitle) **]
1. Stage IIB nonsmall cell lung cancer (adenocarcinoma) s/p
surgical resection and adjuvant chemotherapy.
2. FDG avid left lower [**Last Name (STitle) 3630**] lung nodule with non-malignant
biopsy in [**2117-2-13**].
3. Stage IV nonsmall cell lung cancer (bone and lung
recurrence)diagnosed in [**2118-4-15**].
TREATMENT:
1. Status post right thoracotomy with right lower lobectomy,
mediastinal lymph node sampling in [**2117-4-13**].
2. Status post 4 cycles of carboplatin 5AUC and pemetrexed
500mg/m2 every 21 days of a 3 week cycle today. Started in
[**2117-6-29**] and last dose was given [**2117-8-31**].
3. Status post 3000 cGy of radiotherapy to left hip lesion
completed in [**2118-5-10**].
4. Started erlotinib 150 mg/day in [**2118-5-24**].
5. h/o mets to sacral spine s/p radiation, on narcotics for pain
control
Social History:
70+ year h/o smoking. Currently at rehab facility.
Family History:
Unknown cause of death of mother or father. The patient does
have siblings that are alive. No recurrent cancers in the
family.
Physical Exam:
On [**Hospital Unit Name 153**] admission:
Vitals 96.3 102 101/58 21 100% on 4L
General Chronically ill appearing man, appears anxious
HEENT Sclera anicteric, dry MMM
Neck supple
Pulm Lungs with few bibasilar rales L>R
CV Tachycardiac regular S1 S1 no m/r/g
Abd Soft +bowel sounds tender to palpation throughout without
rigidity or guarding
Extrem Warm tr bilateral edema palpable distal pulses
Neuro Awake and interactive, oriented to hospital in [**Location (un) 86**],
does not know date
Derm No rash or jaundice
Lines/tubes/drains Foley with yellow urine, RIJ
Pertinent Results:
On admission [**2118-7-28**]:
WBC-10.9 RBC-3.71* Hgb-10.3* Hct-32.1* MCV-87 MCH-27.8 MCHC-32.2
RDW-17.1* Plt Ct-410
Neuts-55 Bands-27* Lymphs-6* Monos-10 Eos-0 Baso-0 Atyps-0
Metas-2* Myelos-0
PT-17.9* PTT-33.4 INR(PT)-1.6*
Glucose-143* UreaN-35* Creat-1.6* Na-130* K-4.1 Cl-94* HCO3-26
AnGap-14
ALT-17 AST-34 AlkPhos-60 TotBili-0.7
Albumin-2.6* Calcium-7.6* Phos-3.7 Mg-2.0
[**7-29**] FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA
[**7-28**] EKG: Probable sinus rhythm with low amplitude P waves
(visible in lead V1) versus ectopic atrial rhythm. Right
bundle-branch block. Left anterior fascicular block. Q-T
interval prolongation. Compared to the previous tracing of
[**2118-7-7**] P waves are less apparent. Q-T interval is more
prolonged.
[**7-28**] CXR: 1. Stable post-surgical changes in the right lung from
prior right lower lobectomy and upper [**Month/Year (2) 3630**] wedge resection due
to known non-small cell lung cancer.
2. Hazy opacity in the left lower [**Last Name (LF) 3630**], [**First Name3 (LF) **] reflect atelectasis.
[**7-28**] CT Abd/pelvis:
1. Bibasilar lung consolidations, worse when compared to prior
exam.
Differential diagnosis includes infectious etiologies as well as
a slow
growing lesion such as bronchoalveolar carcinoma. Clinical
correlation is
recommended.
2. No evidence of small bowel obstruction. Colon appears
relatively
featureless with air-fluid levels and possibly pericolonic fat
stranding
versus third spacing. These findings may suggest a colitis.
3. Extensive vascular calcifications.
4. Large prostate.
5. S1 vertebral body fracture with buckling of the superior
cortex, worse
when compared to prior exam.
[**7-30**] Left LENI:
IMPRESSION: No left lower extremity DVT.
[**7-31**] KUB:
FINDINGS:
Small bowel loops containing air are seen without distension.
There is a
paucity of air in the left lower quadrant which might be due to
liquid stool within the descending colon. No free air is seen on
the right lateral decubitus film. The visualized osseous
structures are unremarkable. The right lung base is not well
seen with the dome of the diaghragm being pushed superiorly.
This correlates with the right lower [**Month/Year (2) 3630**] atelactasis on the
corresponding CT.
IMPRESSION: No distended loops of bowel seen.
Brief Hospital Course:
Mr. [**Known lastname 78131**] is a 78M with stage IV NSLC who presents with
fevers from his rehab facility.
.
* Hypotension: Patient presented with hypotension concerning for
sepsis. He was briefly on levophed and was taken off of
pressors when SBP 100s-110s. His hypotension was probably due
to hypovolemia from diuresis but severe hypotension in setting
of developing sepsis was also considered. Lactate down to 1.0
from 1.3 on admission with SVO2 73.
On the floors, his SBP's ranged in the 130's to 140's and he was
restarted on his home doses of LASIX WAS HELD FOR THE SEVERAL
DAYS PRIOR TO DISCHARGE BECAUSE HE WAS AUTODIURESING. HE NEEDS
TO BE RE-EVALUATED REGULARLY FOR WHETHER LASIX NEEDS TO BE
RESTARTED. HE WILL LIKELY NEED HIS LASIX RESTARTED AT SOME POINT
AT REHAB. His pressures remained stable throughout
hospitalization.
.
* Fever: Patient's fever likely caused by C diff as patient is
toxin positive, although aspiration pneumonia was also
considered a possibility given evidence of dysphagia on prior
video swallow. His underlying pulmonary malignancy predisposes
him to a post-obstructive pneumonia. However the absence of
cough or hypoxia made a pulmonary etiology less compelling.
Blood and urine cultures are negative. His C difficile colitis
was originally treated with PO vancomycin and IV flagyl. Prior
to discharge, as diarrhea began to resolve, he was switched to
PO flagyl alone, to be continued for a two week course (until
[**2118-8-12**]).
.
* L leg swelling and pain: Patient had lower extremity pain
edema greater on left than right after receiving fluid
resuscitation in the ICU. LENI showed no evidence of DVT. He
was diuresed with lasix until his fluid output was negative. He
was autodiuresing on discharge so his lasix was held. His fluid
status should be reassessed daily to determine if he needs to be
restarted on lasix.
* Hyponatremia: Patient's hyponatremia resolved after
intravenous fluids, which supports hypovolemia as cause on
admission. Review of OMR shows Na's running ~130. At last
discharge, thought to have a component of SIADH.
* Acute renal failure: Patient had creatinine elevated to 1.4
and FeNa was 0.1 on admission. Creatinine has improved to
0.7-0.8 (his baseline). His acute renal failure has resolved and
was likely pre-renal as it improved with IVF.
* Anemia: His hematocrit is down from admission but suspect
this was secondary to hemoconcentration. His anemia is
consistent with baseline.
* NSCLC: Advanced disease, on palliative chemotherapy. Social
work and palliative care were consulted throughout this
hospitalization and discussed goals of care with the family.
Erlotinib will be restarted on [**2118-8-19**] and should be taked every
other day. He will follow up with Dr. [**Last Name (STitle) **].
* Atrial fibrillation: His sotalol was restarted now that his
hypotension resolved.
# Nutrition ?????? Patient has aspiration risks and is unable to
swallow pills easily. He was evaluated by nutrition and kept on
a pureed diet with TID ensure. He also had an elevated INR
despite not being on anticoagulation which possibly could be due
to malnutrition. INR improved after administration of one dose
of vitamin K.
# Oral thrush: Patient failed nystatin swish and swallow. He was
loaded with 400mg fluconazole and should continue 200mg daily
until [**2118-8-25**].
#Pain control: Patient was maintained on methadone and diluadid
PRN during hospitalization. His methadone should be tapered and
pain reassessed daily while in rehab.
Medications on Admission:
At rehab:
Erlotinib 100mg daily
Simvastatin 10mg daily
Lasix 20mg daily
Sotalol 80mg [**Hospital1 **]
Nifedipine 30mg daily
Methadone 15mg tid
Folate
Lidoderm patch
[**Name (NI) **], [**Name (NI) 78132**], MOM, dulcolax, lactulose, senna, guiafenesin,
colace, tylenol all prn
Zofran prn
Neurontin 300mg q12h
Heparin 5000 units SQ TID
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: One (1)
injection Injection TID (3 times a day).
2. Metronidazole 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q8H (every
8 hours): continue util [**2118-8-12**].
3. Neurontin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO every twelve
(12) hours.
4. Docusate Sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2
times a day) as needed for constipation: once diarrhea subsides,
please start taking as standing dose [**Hospital1 **].
5. Methadone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
6. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: no more than 4g in 24 hours.
8. Sotalol 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off.
10. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
11. Nifedipine 30 mg Tablet Sustained Release [**Hospital1 **]: One (1)
Tablet Sustained Release PO DAILY (Daily).
12. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
13. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO
DAILY (Daily).
14. Oral Wound Care Products Gel in Packet [**Hospital1 **]: One (1) ML
Mucous membrane TID (3 times a day) as needed.
15. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for fungal rash-groin.
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
18. Dilaudid 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every four (4)
hours as needed for pain.
19. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO twice a day as
needed for constipation: Please start taking after diarrhea has
resolved.
20. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
[**Last Name (STitle) **]: One (1) dose PO once a day as needed for constipation:
Please use as needed after diarrhea has resolved.
21. Dulcolax 10 mg Suppository [**Last Name (STitle) **]: One (1) Rectal once a day
as needed for constipation: Please start using as needed after
diarrhea has resolved.
22. Zofran 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every eight (8)
hours as needed for nausea.
23. Ambien 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia.
24. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every
24 hours): continue until [**2118-8-25**].
25. Erlotinib 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QOD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 4444**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Clostridium difficil colitis
2. Dehydration
3. Hyponatremia
4. Hypotension
SECONDARY DIAGNOSIS:
1. Non Small Cell Lung Cancer
Discharge Condition:
Stable, afebrile [**2-16**] BM's per day.
Discharge Instructions:
You were admitted to the hospital on [**2118-7-28**] with fevers
secondary to clostridium dificile colitis (an infection in your
colon). You are being treated with an antibiotic called flagyl.
You need to continue this antibiotics until [**2118-8-12**].
You should STOP taking lasix (water pill). Your body has been
eliminating excess fluid well without the lasix. Your doctors
[**Name5 (PTitle) **] [**Name5 (PTitle) 4656**] your fluid status at rehab and decide whether or
not you need lasix in future.
You can continue to take methadone with dilaudid as needed for
breakthrough pain. Your doctors at rehab [**Name5 (PTitle) **] taper your
methadone as needed. Never drive while taking these medications
or perform any activities requiring a fast reaction time. Never
drink alcohol with these medications. Once your diarrhea stops,
you should start taking colace and senna daily to prevent
constipation, which is a common side effect of narcotics.
You also had thrush in your mouth. Continue to take fluconazole
200mg daily until [**2118-8-25**].
You should restart your erlotinib on [**2118-8-19**] and take it every
other day.
Use miconazole for the fungal rash in your groin. Apply it four
times a day.
Please return to the emergency room if you have worsening
diarrhea >10 BM per day, bloody/black stools, fever>100.4, chest
pain, shortness of breath, or any other symptoms concerning to
you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**12-17**] weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
Completed by:[**2118-8-11**]
ICD9 Codes: 0389, 5849, 2761, 2859, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1716
} | Medical Text: Admission Date: [**2111-6-12**] Discharge Date: [**2111-6-16**]
Date of Birth: [**2052-2-23**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
cc:[**CC Contact Info 45809**].
History was obtained from ED report and from medical record
.
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5700**] in [**Location (un) 583**], MA.
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Ms. [**Name14 (STitle) **] is a 59 yo female with a h/o HTN,
hypercholesterolemia, who presents after witnessed 45 second GTC
seizure. She has no known history of seizure activity. Per
history obtained by Neurology resident prior to intubation,
patient was visiting her mother here in the hospital and seized
while exiting the hospital. She reported feeling well earlier in
the day but that after visiting her mother, on the way out of
the [**Hospital Ward Name 517**] building, she felt nauseous, lightheaded and
vertiginous. She experienced visual changes and could only see
blue and red. She told someone who was outside that she didn't
feel well and that was the last thing she remembers. Per report,
patient sat down and then had witnessed generalized tonic clonic
seizure x45 seconds, with tongue biting but no urine or bowel
incontinence. She was then transported to ED.
.
On arrival to ED at 3 p.m., T 98.8, HR 105, BP 133/83, RR 24,
SpO2 99% on RA. She was reported to be alert and seated on the
bench without evidence of injury. She had a head CT which was
negative for intracranial process. Neuro was consulted and
recommended admission to medicine for toxic-metabolic and
infectious work-up. She subsequently had two witnessed
generalized tonic/clonic seizures in the ED, each lasting 20-30
seconds. Her mental status did not resolve following these
seizures, and nonsensical speech and agitation requiring
restraints were reported. She received a banana bag, Mag sulfate
2 grams IV, Keppra 500 mg IV, and Ativan 2 mg IV x 5, and Valium
10 mg IV. Patient was noted to be warm to touch and repeat temp
was 104 (rectal). Given extreme agitation, she was electively
intubated at that time for LP. She received vancomycin 1 gram
and ceftriaxone 2 grams IV. She received a total of 2 L IVF in
the ED.
Past Medical History:
1. Uterine fibroid of 3.1 cm to 3.5 cm found in [**Month (only) 1096**] of
[**2104**].
2. Rosacea in [**2105**]
3. ? h/o ETOH abuse and withdrawal; admitted in '[**06**] at [**Hospital1 18**]
with suspicion of EtOH withdrawal
4. HTN
5. Hypercholesterolemia
6. ? s/p CCY
Social History:
Husband died in [**Month (only) 404**]. Father w/prostate illness and mother
is currently hospitalized here at [**Hospital1 18**]. Understands and speaks
English but primary language is Romanian. Per Neurology note
"Denies current etoh use, last drank on her b-day this past
[**Month (only) 956**]." No tobacco or drug use.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
VS: T 101.2, HR 82, BP 100/60, SpO 97% on FiO2 100%
Gen: intubated, agitated
HEENT: PERRL 3->2 mm bilaterally, MMM, evidence of tongue
laceration
CV: regular rhythm, normal s1 and s2, no m/r/g
Resp: lung fields CTA
Abdomen: no scars, soft, non-distended, non-tender, no
hepatosplenomegaly, no palpable masses
Extrem: no edema, clubbing, or cyanosis
Neuro: non-purposeful movements in all 4 extremities, toes
upgoing bilaterally
Rectal: rectal vault empty, guiac-negative
Pertinent Results:
[**2111-6-12**] 11:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-23
GLUCOSE-94
[**2111-6-12**] 11:00PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-26*
POLYS-0 LYMPHS-0 MONOS-0
[**2111-6-12**] 11:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-31*
POLYS-0 LYMPHS-0 MONOS-100
[**2111-6-12**] 08:50PM URINE HOURS-RANDOM
[**2111-6-12**] 08:50PM URINE HOURS-RANDOM
[**2111-6-12**] 08:50PM URINE UHOLD-HOLD
[**2111-6-12**] 08:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2111-6-12**] 08:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2111-6-12**] 08:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2111-6-12**] 08:50PM URINE RBC-0-2 WBC-[**3-25**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2111-6-12**] 08:50PM URINE GRANULAR-0-2 HYALINE-[**6-30**]*
[**2111-6-12**] 08:50PM URINE MUCOUS-FEW
[**2111-6-12**] 05:04PM LACTATE-2.1*
[**2111-6-12**] 04:52PM GLUCOSE-140* UREA N-25* CREAT-2.2* SODIUM-136
POTASSIUM-2.8* CHLORIDE-98 TOTAL CO2-26 ANION GAP-15
[**2111-6-12**] 04:52PM LD(LDH)-175 DIR BILI-0.6*
[**2111-6-12**] 03:19PM GLUCOSE-161* LACTATE-9.3* NA+-138 K+-2.9*
CL--97* TCO2-18*
[**2111-6-12**] 03:10PM UREA N-27* CREAT-2.9*
[**2111-6-12**] 03:10PM estGFR-Using this
[**2111-6-12**] 03:10PM ALT(SGPT)-91* AST(SGOT)-112* ALK PHOS-150*
AMYLASE-85 TOT BILI-1.7*
[**2111-6-12**] 03:10PM ALBUMIN-4.5 CALCIUM-9.3 PHOSPHATE-5.3*
MAGNESIUM-1.6
[**2111-6-12**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2111-6-12**] 03:10PM WBC-12.8* RBC-4.46 HGB-15.2 HCT-43.7 MCV-98
MCH-34.1* MCHC-34.8 RDW-13.5
[**2111-6-12**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2111-6-12**] 03:10PM PT-12.9 PTT-27.4 INR(PT)-1.1
[**2111-6-12**] 03:10PM PLT COUNT-217
[**2111-6-12**] 03:10PM FIBRINOGE-260
.
CXR [**2111-6-12**]: ET tube tip is 2.9 cm top of the carina. Cardiac
size is top normal. NG tube tip is in the stomach. There is mild
fluid overload. The left lateral CP angle was not included on
the field. There are no ____ pleural effusions. Small
atelectasis in the left lower lobe in the retrocardiac area is
new. There is no pneumothorax.
.
RUQ u/s [**6-12**]: IMPRESSION:
1. Diffusely echogenic liver, consistent with fatty
infiltration. Other forms of liver disease, including
significant hepatic fibrosis or cirrhosis cannot be excluded.
2. No evidence of intra- or extra-hepatic biliary duct
dilatation.
Findings entered into the ED dashboard at the time of
interpretation.
.
[**6-12**] CT head: IMPRESSION:
1. No acute intracranial process.
2. Likely small arachnoid cyst in the left temporal region.
Brief Hospital Course:
Assessment: Ms. [**Known lastname 45810**] is a 59 yo female s/p CCY who presents
with seizure activity, fever, and ARF
.
1) Seizure activity: The initial concern given the constellation
of thrombocytopenia, ARF, neurologic event, and fever was for
TTP/HUS. Platelets were reduced by 50% on repeat CBC and
hematocrit dropped by 10 points; however, there was no evidence
of schistocytes on peripheral smear. Neurologic exam reported as
normal by neurology consult, and non-contrast head CT negative
for bleed or obvious seizure focus. Differential included EtOH
withdrawl, infection, vs. other toxic-metabolic process.
Admission labs were also notable for multiple electrolyte
derangements, including ARF, hypokalemia, hypomagnesemia.
Patient was normoglycemic throughout hospital course. Urine and
serum tox screens were negative. Prior discharge summary invoked
possible h/o alcohol abuse, and serum ethanol level were
negative at time of admission, supporting possible delirium
tremens, although patient denied EtOH use on both occasions
consistently. Benzo withdrawl was also considered as patient
reports taking Lorazapam but urine tox negative. CSF was
unremarkable with negative gram stain. Upon arrival to the ED,
the neurology team was consulted and recommended that the
patient be loaded with IV Keppra. She had two further episodes
of generalized tonic clonic activity in the ED and was
subsequently confused. She was treated in the ICU for close
monitoring. She was electively intubated at that time and lumbar
puncture performed. CSF gram stain and preliminary culture was
negative so the vancomycin and ceftriaxone were not continued.
CSF cytology and HSV PCR were sent and the patient continued on
IV acyclovir for empiric treatment of HSV encephalitis. She was
placed on a CIWA scale for possible EtOH withdrawal, but had
very low scores. She was also started on MVI, folic acid, and
thiamine. While in the ICU, the patient self-extubated and did
well off of the ventilator. She was called out to the medicine
floor. She displayed no seizure activity while there and
remained afebrile. MRI and EEG were both were unremarkable. LFTs
remained abnormal as well as thyroid function tests which are
both further areas of exploration for inciting event for new
seizures.
.
2) Acute Renal Failure: Upon admission, her creatinine was 2.9,
with no known h/o renal insufficiency. She was treated with IVFs
as this was felt to be due to possible rhabdomyolysis, and
creatinine now improved to 0.9.
.
3) Transaminitis: Upon admission, she had elevated LFTs, with
AST>ALT, suggestive of alcohol use. RUQ ultrasound notable only
for echogenic fatty liver. Patient does have a discharge summary
from [**Hospital1 18**] from [**2106**] which describes a suspicion of alcohol
withdrawl, although patient persistently denied. INR of 1.1
supports that synthetic hepatic function is preserved. Viral
hepatitis serologies were checked but were pending at time of
discharge. Also, ferritin was found to be persistently elevated
at >[**2103**], so hemochromatosis should also be excluded as an
outpatient. Her transaminases normalized prior to discharge.
.
4) Anemia: Hematocrit dropped 10 points at admission, then
stablized. Iron studies showed as above a very high ferritin and
also low B12. She was started on po B12 supplementation, but
will require close monitoring to determine if replacement is
adequate. Anti-intrinsic factor antibodies as well as H. pylori
serologies were sent; H. pylori antibody was equivocal and
anti-IF antibodies were pending at discharge.
.
5) FEN/GI: the patient had multiple electrolyte abnormalities at
admission. She required recurrent repletement of potassium,
which was maintained at >4, and magnesium, which was maintained
at >2, given her seizures.
.
6) Code status: Full code, confirmed with patient
Medications on Admission:
Lorazepam
Folic acid
Lipitor
Med for her bones
Liver med
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Cyanocobalamin 2,000 mcg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
7. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Mobic 15 mg Tablet Sig: One (1) Tablet PO once a day.
9. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
12. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO every four
(4) hours for 5 days: take while awake. to complete course on
[**6-21**]. thank you.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Generalized tonic clonic seizure
2) Hypertension
3) Abnormal thyroid tests
4) hypercholesterolemia
5) Transaminitis
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital after having several seizures.
You were initially treated in the intensive care unit for closer
monitoring. You were started on a new medication called Keppra
to prevent recurrence of seizures. You were also started on a
medication called acyclovir for the possibility of HSV
infection. An MRI of your brain was normal. It is very important
that you see your primary care provider and that you see a
neurologist after discharge for continued workup to determine
the cause of your seizures. In particular, you will need to have
further workup of your liver and thyroid function.
.
It is very important that you do NOT drive after discharge from
the hospital until you see your neurologist. Also, do not work
at heights, with open fires, take a bath while home alone, or
swimming in
unguarded pools. You should call to make an appointment with Dr.
[**First Name4 (NamePattern1) 2431**] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] in the neurology deparement at
[**Hospital1 18**].
.
If you experience additional seizure activity - uncontrolled
muscle movement, visual changes, lightheadedness, dizziness,
falls, loss of consciousness, or if you feel worse in any way
seek [**Hospital 5121**] medical attention or call 911.
Followup Instructions:
Call Dr. [**First Name4 (NamePattern1) 2431**] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] in the neurology
department to make an appointment at [**Telephone/Fax (1) 541**] within the
next 2 weeks.
.
Also, call Dr. [**First Name (STitle) 5700**], your PCP, [**Name10 (NameIs) **] discharge to make an
appointment as soon as possible.
ICD9 Codes: 5849, 2720, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1717
} | Medical Text: Admission Date: [**2179-1-18**] Discharge Date: [**2179-1-22**]
Date of Birth: [**2118-12-6**] Sex: F
Service: MEDICINE
Allergies:
Trazodone / Risperdal / Indocin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
CC:[**CC Contact Info 109704**]
Major Surgical or Invasive Procedure:
Total Knee Replacement R
History of Present Illness:
Patient is a 60 yo F with mult med probs including obstructive
and restrictive lung dx (from asbestos), HTN, Diastolic HF, and
recent laminectomy presents s/p R knee total knee replacement
for respiratory monitoring. During patient's last surgery [**12-3**]
patient devoloped post operative pulmonary edema in the setting
of intraoperative IV fluids and underlying diastolic hf. She
was intubated for 6 days and agressively diuresed. This
admission patient feels well and just complains of some post op
pain in her right knee and her chronic back pain. She denies
cp/sob/n/v/d.
Intraop patient was given 1100 cc and had an output of 790 cc.
Pulse was in the 80's. She also rec'd 1 dose of vanco intraop.
.
HPI on transfer from ICU: 60 yo F c obesity, diabetes,
obstructive/restrictive combined lung disease, hypertension,
diastolic CHF, and s/p laminectomy with complicated post op
course involving intubation for CHF who was admitted to [**Hospital Unit Name 153**] for
respiratory monitoring following surgery. Pt. presented for
surgery with no complaints. Seemed to have tolerated surgery
well from anesthesia/ortho notes. Received 1 u pRBCs intraop.
In [**Name (NI) 153**] pt. required NC 4-5 L to maintain O2 sat. Beta blocker
dose uptitrated. Started on lovenox post op. On my exam, pt.
groggy but conversant. Reporting diffuse pain over knee.
Unable to further characterize. No CP, SOB, N/V, HA, abd pain.
Past Medical History:
CHF- Diastolic HF, echo: ef 65% with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 13385**], mod ra
dilatation,nl valves with tr MR and no AR
Hypertension
Hypercholesterolemia
Palpitations daily
COPD- O2 dependent (3 L) pft [**2178-12-8**] fev1 1.75 (84%), fvc 2.29
(90%), last hospitalization [**11-1**] in [**Hospital1 **] [**Location (un) **] requiring
intubation, steroids, iv abx
DM-last hbaic 5.5%
Recurrent UTI's
Melanoma- excised between toes of right foot
OSA- cannot tolerate cpap
Hiatal hernia- s/p repair in the 70's w/ recurrance
h/o Siezures- TLE, no meds
RA- recent dx
OA
interstitial lung dx due to asbestos
LBP w/ lle pain intermittent, fractured screw from prior
laminectomy
GERD
Bipolar disorder
MRSA
PSH: 1/04 L tkr, 6/03 L knee scope, '[**77**] periumbilical
herniorrhaphy
[**12-3**] laminectomy, [**10-29**] RLL bx
Social History:
Social Hx: smokes- 40-50 pack year hx ("quit" 1 wk ago), no
etoh. retired. formerly worked on pc boards. Lives alone,
housekeeper helps with adl's. can walk [**11-30**] blocks- limited by
knee.
Family History:
NC
Physical Exam:
PE: on admission to ICU
60 in, 220 lb, 3L nc 02 92-95% P 92 BP 117/54
7.45/41/99 on 3L
Gen: morbidly obese f in nad, speaking in full sentences, slow
speech
HEENT: PERRLA, EOMI, no oropharyngeal lesions, jvp elevated to
jaw
Lungs: ant clear with decreased air movement in apices, no
wheezes or rales appreciated
Heart: s1 s2 no m/r/g
Abdomen:obese, midline scar, soft nt +bs
Extremities: R leg in tracking device wrapped post op, LLE with
no edema or cyanosis, +pulse on left foot
Neuro: AOx3, able to follow commands
.
PE on transfer from ICU
VS - Tm 99.9, Tc 99.3, HR 96, BP 97/46 [97-126/46-66], RR 22,
93% NC 5
HEENT - dry MM, no elevation JVP, OP clear, no LAD
LUNGS - diffuse expiratory wheezing, bibasilar crackles, rhonchi
HEART - RRR, S1, S2, + [**1-4**] SM at LUSB
ABD - soft, NT, ND, BS+
EXT - wwp. R leg with elaborate brace and ACE bandage; thin
drainage tube extending out of brace draining blood. No ttp
over foot; yellow discoloration likely [**12-31**] betadine
Pertinent Results:
ADMIT LABS:
[**2179-1-18**] 05:20PM TYPE-ART TEMP-36.0 O2 FLOW-3 PO2-85 PCO2-59*
PH-7.30* TOTAL CO2-30 BASE XS-0 INTUBATED-NOT INTUBA
COMMENTS-NASAL [**Last Name (un) 154**]
[**2179-1-18**] 05:20PM LACTATE-1.0
[**2179-1-18**] 05:20PM freeCa-1.20
[**2179-1-18**] 04:50PM GLUCOSE-97 UREA N-25* CREAT-0.9 SODIUM-138
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
[**2179-1-18**] 04:50PM PHOSPHATE-5.2* MAGNESIUM-1.8
[**2179-1-18**] 04:50PM WBC-10.7 RBC-3.01* HGB-9.3* HCT-27.0* MCV-90
MCH-30.9 MCHC-34.5 RDW-14.9
[**2179-1-18**] 04:50PM PLT COUNT-252
[**2179-1-18**] 04:50PM PT-12.2 PTT-22.9 INR(PT)-1.0
[**2179-1-18**] 12:13PM GLUCOSE-152* UREA N-24* CREAT-0.8 SODIUM-140
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12
[**2179-1-18**] 12:13PM WBC-8.5 RBC-2.97* HGB-9.2* HCT-26.8* MCV-90
MCH-30.9 MCHC-34.3 RDW-14.0
[**2179-1-18**] 12:13PM PLT COUNT-245
[**2179-1-18**] 10:58AM GLUCOSE-134* LACTATE-2.4* NA+-138 K+-4.2
CL--103
[**2179-1-18**] 10:58AM TYPE-ART PO2-99 PCO2-41 PH-7.45 TOTAL CO2-29
BASE XS-3 INTUBATED-INTUBATED
[**2179-1-18**] 10:58AM HGB-9.4* calcHCT-28
[**2179-1-18**] 10:58AM freeCa-1.19
[**2179-1-18**] 09:11AM HGB-10.2* calcHCT-31
[**2179-1-18**] 08:46AM TYPE-ART PO2-118* PCO2-44 PH-7.43 TOTAL
CO2-30 BASE XS-4
[**2179-1-18**] 08:46AM GLUCOSE-149* LACTATE-1.5 NA+-135 K+-4.2
[**2179-1-18**] 08:46AM HGB-7.7* calcHCT-23
[**2179-1-18**] 08:46AM freeCa-1.24
.
DISCHARGE LABS
[**2179-1-22**] 07:30AM BLOOD WBC-7.5 RBC-3.01* Hgb-9.1* Hct-26.9*
MCV-89 MCH-30.3 MCHC-33.9 RDW-14.6 Plt Ct-236
[**2179-1-22**] 07:30AM BLOOD Plt Ct-236
[**2179-1-19**] 04:23AM BLOOD PT-12.3 PTT-21.2* INR(PT)-1.0
[**2179-1-19**] 04:23AM BLOOD Fibrino-436*
[**2179-1-22**] 07:30AM BLOOD Glucose-155* UreaN-16 Creat-0.8 Na-131*
K-3.8 Cl-96 HCO3-29 AnGap-10
[**2179-1-22**] 07:30AM BLOOD Calcium-9.2 Phos-1.8* Mg-1.6
[**2179-1-21**] 03:09PM BLOOD Type-ART pO2-65* pCO2-42 pH-7.46*
calHCO3-31* Base XS-5
[**2179-1-21**] 03:09PM BLOOD Lactate-1.3
[**2179-1-21**] 03:09PM BLOOD O2 Sat-95
.
STUDIES:
Right knee bone:
1. Bony fragments with prominent articular cartilage
degeneration.
2. Abundant trilineage hematopoiesis is noted. Iron stains are
negative.
.
cxr post op
Mild pulmonary edema, greater in the left lung and mediastinal
venous engorgement, it has worsened slightly since [**1-7**].
Asymmetric enlargement of the right pulmonary artery has been
present for many years. A CT angiogram of the chest on [**12-14**], [**2176**] showed this was due to a combination of enlarged lymph
nodes and pulmonary veins, with no pulmonary embolism. Heart
size is top normal. There is no appreciable pleural effusion or
indication of pneumothorax.
.
cxr: prior to d/c
FINDINGS: AP single view of the chest has been obtained with the
patient in semi-erect position and analysis performed in direct
comparison with a similar previous chest examination of [**1-19**], [**2178**]. The lung fields are now clear, and no evidence of
significant congestion or acute parenchymal infiltrates is
noted. The lateral pleural sinuses are free. No pneumothorax is
present.
In comparison with the next previous study, the suggested
pulmonary edema pattern has normalized.
Brief Hospital Course:
A/P: Patient is a 60 yo female who presents s/p R TKR for
respiratory monitoring. Patient has diastolic heart failure and
had a prolonged course s/p her last surgery [**12-3**] with chf
exacerbation.
.
Post Op - received vancomycin for 24 hrs post op. Treated
initially c hydromorphone PCA and then switched to oral
percocets. Walking with PT on discharge. Should be weaned off
percocets at rehab as tolerated.
.
Diastolic CHF- Her last echo [**1-3**] shows nl ef, but impaired
relaxation c/w diastolic hf. Her daily weights were monitored
and strict I/Os were kept. She required some additional
diuresis with IV lasix. On d/c she was well compensated with
good O2 sat on [**1-30**] L NC which is her baseline.
.
Rhythm- has episode of svt in [**2173**], and episode of avnrt in sicu
[**1-3**]. She was continued on her aspirin and monitored on
telemetry, her beta blocker was restarted for better rate
control. During her admission, she had an episode of
tachycardia, an EKG was done suggestive of atrial flutter
(reviewed by cardiology in house). Started pt. on coumadin on
discharge; this needs to be monitored with serial INR. Also
considered other etiologies of tachycardia including PE post op;
felt unlikely as no change in O2 saturation, no new pain in leg.
Likely related to recent albuterol inhaler use prior to episode
vs. pain.
.
Chronic LBP- control with percocets after she is off
hydromorphone pca for her knee
.
HTN- well controlled in the 100's systolic. She was continued
diltizem and lisinopril, her betablocker was reinitiated with
better control of her heart rate. She needs f/u with her outpt.
cardiologist re: her HTN and her atrial flutter.
.
DM- She was continued on her oral antiglycemic regiment and an
insulin sliding scale. On d/c she was kept on an oral regimen
only.
.
COPD- She has a combination of obstructive and restrictive with
a FEV of 1 of 1.75 and fev1/fvc ratio 1.75/2.29. She was
maintained on nebulizers and 3L NC to keep her oxygen saturation
above 92%.
.
GERD- continued outpt regimen of protonix [**Hospital1 **]
.
Bipolar dx- continued olanzapine qd, clonazepam, venlafaxine
Medications on Admission:
advair
albuterol nebs
asa 81
klonipin .5mg [**Hospital1 **] and prn
combivent nebs
diltiazem 240'
effexor 150'
lasix 40 mg [**Hospital1 **]
glipizide 2.5'
lipitor 20'
lisinopril 5'
metformin 850'''
Nabumetone 750''
percocet [**12-4**] daily
protonix [**Hospital1 **]
tramadol 50 mg prn
zyprexa 15''
sulfasalazine 500'''
Discharge Medications:
1. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-30**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Olanzapine 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
12. Sulfasalazine 500 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): to be stopped once INR [**1-1**]; also discuss
with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1022**] from orthopedics prior to stopping: [**Telephone/Fax (1) 109705**]
[**Numeric Identifier 109706**].
15. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
20. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
23. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
24. Outpatient Lab Work
Please check INR q 2-3 days at rehab. Received last dose
coumadin 5 mg on [**1-22**]. For questions, page orthopedic surgeon ,
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1022**] - [**Telephone/Fax (1) 109705**], [**Numeric Identifier **]
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Primary
1. Total knee replacement
2. Restrictive, Obstructive lung disease
3. Congestive heart failure
Discharge Condition:
Good
Discharge Instructions:
You should take all your medications as directed. You should
follow up with your PCP and your cardiologist in [**1-1**] weeks
following your discharge. You have been started on coumadin, an
anticoagulation medication, for atrial flutter. You will need
to have your INR monitored when taking this medication. This
should be arranged through your PCP. [**Name10 (NameIs) **] should also see Dr.
[**First Name (STitle) 1022**] for follow up of your knee replacement.
Followup Instructions:
You should call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30197**], [**Telephone/Fax (1) 19980**] for follow
up in [**1-1**] weeks following discharge from the hospital. You
should call your cardiologist for an appointment in [**1-1**] weeks as
well. You should follow up with Dr. [**First Name (STitle) 1022**] (orthopedics) in 3
weeks as well. His phone number is: [**Telephone/Fax (1) 7807**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 4280, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1718
} | Medical Text: Admission Date: [**2145-6-25**] Discharge Date: [**2145-7-13**]
Date of Birth: [**2090-12-8**] Sex: M
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This patient is a 55-year-old
man status post cadaveric renal transplant on [**2145-4-21**],
complicated by wound hematoma and opening of the wound. The
patient has been managed on an outpatient basis with a VAC
dressing and has been discharged to rehabilitation prior to
this admission. The patient presented today to the Clinic
where an exposed renal graft was noted in the wound.
PHYSICAL EXAMINATION: Temperature 97.9 degrees Fahrenheit,
heart rate 83, blood pressure 182/86, respiratory rate 20 and
oxygen saturation 100 percent on room air. The patient was
awake and alert in no apparent distress. The patient's heart
was in regular rate and rhythm with no murmurs, rubs or
gallops. His lungs were clear to auscultation bilaterally.
His abdomen was noted to have a wound VAC dressing in place;
otherwise, it was soft, non-tender, non-distended,
normoactive bowel sounds. His extremities were warm. Distal
pulses were two plus and he had no peripheral edema in both
lower extremities and slight peripheral edema in his left
upper extremity at the site of where he had a prior fistula
for hemodialysis.
HOSPITAL COURSE: At this point the patient was admitted to
[**Hospital1 69**] and was continued on his
prior medications from a recent discharge medicine list and
his VAC was placed to continuous suction. The patient was
also followed by the Renal Transplant Service who also noted
his creatinine to reveal excellent graft function. The
patient was on vancomycin during this time one gram q. 48h.
to protect against potential wound pathogens. The plan at
this time was to have Plastic Surgery to see the patient to
evaluate a possible wound flap to cover the exposed graft.
On [**2145-6-29**], hospital day five, the patient continued to
progress well. Was voiding without complaint and the service
was waiting for Plastic Surgery evaluation at this time for
potential wound flap coverage. The patient's vital signs
were stable during this time. The patient was afebrile
throughout his hospital stay up until this point. The
patient was given nutritional supplements with meals, Boost
three times a day, and on [**2145-6-30**], the patient was
visited by the Plastic Surgery service. On [**2145-6-30**],
the patient was found in his room to be complaining of
feeling hot and generally "not well." Vital signs were taken
revealing a blood pressure of 204/109 with a heart rate of
144, breathing at 70 percent on room air. The patient
received 5 mg of intravenous push Lopressor. Blood pressure
at this point was 208/111, heart rate 137. Blood gases were
drawn. Electrolytes and blood cultures were sent and Foley
catheter was inserted. A second dose of intravenous
Lopressor was given and his blood pressure was 206/90 at this
point, heart rate of 137 and at this point 10 mg of
intravenous Lopressor was hung and 10 mg was pushed. The
patient continued to have labored breathing. Was alert and
oriented but sleepy and arousable. Chest x-ray revealed what
looked like a likely pneumonia. Electrocardiogram showed
sinus tachycardia. His blood gases at this point were pO2 of
82, pCO2 of 54 and a pH of 7.19. The patient at this point
was transferred to the Surgical Intensive Care Unit. A
central venous line was also placed at this point without
complications with the patient having insufficient peripheral
access for the purpose of ABG drawing, hemodynamic
monitoring. The patient at this point was on metoprolol on
hydralazine 25 mg q. 6h. The plan was for serial ABG's. The
patient was placed on nonrebreathable oxygen mask. On the
same day Plastic Surgery saw the patient and recommended that
patient would likely benefit from right gracilis flap to
protect and cover the open wound with kidney graft exposed.
The patient was then consulted to see Cardiology after this
bout of respiratory distress and sinus tachycardia who
recommended tighter blood pressure control and metoprolol was
thus restarted at a dose of 150 mg p.o. b.i.d. and aspirin
was continued 325 mg q. day. On SICU day two, the patient
was noted to be significantly improved and vital signs were
within normal limits. His blood pressure was 161/82 at this
point and he was saturating at 95 percent on room air with a
heart rate of 83. The patient at this point was on
vancomycin, Zosyn and Bactrim. This was the second day of
Zosyn. At this point the plan was for Plastic Surgery, after
seeing the patient on hospital day eight, [**2145-7-2**], to
bring the patient to the Operating Room on Monday for likely
gracilis flap, possible rectus flap and they would pre-op the
patient for surgery. The patient then was transferred back
to the floor later in the day after noted to be doing very
well. His vital signs were stable. The patient was
saturating well and his heart rate and blood pressure were
within normal limits. Blood pressure at this point was
115/68. He had no complaints of shortness of breath or chest
pain at this time. On the 17th day of [**Month (only) 30676**] hospital day
nine, the patient continued to progress well and the patient
was scheduled for stress echocardiogram as preoperative
evaluation after events that led to the patient being
transferred to the Surgical Intensive Care Unit.
Echocardiogram revealed moderate inferior wall hypokinesis
with an ejection fraction of approximately 27-28 percent and
it was determined at this point that the patient would likely
benefit from cardiac catheterization. The patient, however,
required two negative sets of blood cultures which were drawn
on the 16th and [**7-3**] which eventually came back
negative and the patient was brought to cardiac
catheterization on [**7-9**] revealing that the patient had
normal coronary arteries. No signs of stenosis. Ejection
fraction at this point was noted to be in the mid 30's,
approximately 35 percent. The patient continued to progress
well during his hospital stay, was afebrile and without
complaint and at this point was awaiting possible of Plastic
Surgery flap closure for his open wound. The patient was
also followed by Physical Therapy and Occupational Therapy
who suggested that the patient would likely benefit from a
stint in rehabilitation before being discharged to home and,
upon learning that the patient would not be able to be
scheduled for plastic surgery closure until the following
week, likely to occur on [**7-20**] or 4th of [**2144**], it was
determined that the patient could be discharged to
rehabilitation on the wound VAC.
The patient was stable on the day of discharge. The patient
was afebrile. The rest of his vital signs were within normal
limits.
DISCHARGE DIAGNOSES: Status post cadaveric renal transplant
[**2145-4-17**] with open wound and exposed kidney.
End-stage renal disease.
Diabetes mellitus type 2.
Hypertension.
Hepatitis C virus.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: The patient was to be discharged to
rehabilitation facility where patient would have wound VAC
changes every fourth day, to [**Name8 (MD) 138**] M.D. if patient had any
increasing fevers, chills, nausea, vomiting, decreased urine
output, excessive blood coming from site of wound VAC or if
there were any other questions.
DISCHARGE MEDICATIONS:
1. Bactrim one tab q. day.
2. Metoclopramide 10 mg p.o. q.i.d.
3. Protonix 40 mg p.o. q. day.
4. Percocet 5/325 one to two tablets p.o. q. 4-6h. as needed
pain.
5. Regular insulin sliding scale as directed per sliding
scale.
6. Colace 100 mg p.o. b.i.d.
7. Prednisone 10 mg p.o. q. day.
8. ____________ 450 mg p.o. q. day.
9. Epogen 20,000 units three times per week, Monday,
Wednesday and [**Name8 (MD) 2974**].
10. Nystatin 5 mL p.o. q.i.d.
11. Metoprolol 150 mg p.o. b.i.d.
12. Heparin 5000 units one injection three times a day.
13. Azathioprine 75 mg p.o. q. day.
14. Furosemide 40 mg p.o. q. day.
15. Clonidine 0.2 mg p.o. t.i.d.
16. Aspirin 325 mg p.o. q. day.
17. Cyclosporin 125 mg p.o. b.i.d.
18. Hydralazine 37.5 mg q.i.d.
DISPOSITION: Patient stable and to be discharged to
rehabilitation facility.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2145-7-13**] 12:49:02
T: [**2145-7-13**] 14:01:07
Job#: [**Job Number 19457**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1719
} | Medical Text: Admission Date: [**2185-3-9**] Discharge Date: [**2185-4-20**]
Date of Birth: [**2145-10-21**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Zithromax / Biaxin / Plaquenil / Amantadine /
Amoxicillin / Fish Product Derivatives / Hydromorphone / Ativan
/ Versed / Tegaderm / Zyrtec / Vicodin / Dilaudid / Midazolam /
Shellfish Derived / Fentanyl / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
[**2185-3-10**]
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Small bowel resection.
4. Temporary abdominal closure.
5. primary classical cesarean delivery
[**2185-3-11**]
Re-exploration, washout and temporary closure
[**2185-3-14**]
Re-exploration of the abdomen, end-ileostomy, abdominal fascial
closure.
History of Present Illness:
Patient is a 38 year old female with an extensive past medical
history significant for chronic abd pain and Sphincter of Oddi
stenosis. She is s/p major duodenal papilla sphincteroplasty
with open J tube and open G tube placement on [**2184-4-20**]. She
responded very well to this surgery in terms of management of
her chronic abdominal pain.
She is now 25 weeks pregnant. She presents [**2185-3-9**] with
exquisite epigastric abdominal pain that woke her from sleep at
4am. It started suddenly and has been unremitting and not
controlled with her home darvocet pain meds. She was seen
earlier this month with less intense abd pain and was monitored
clinically. Per pt, she saw Dr. [**Last Name (STitle) **] in clinic and he reduced
a hernia.
Pt denies fevers or chills, vomiting, or diarrhea. She has some
nausea and still has flatus. She also has abdominal wall pain
secondary to known neuromas from her previous surgeries that had
been treated by Dr. [**Last Name (STitle) 957**] with
injections.
Past Medical History:
Past Medical History:
- Sphincter of Oddi dysfunction with stricture of the main
pancreatic duct s/p major duodenal papilla sphincteroplasty with
open J tube and open G tube placement
- Pancreatic insufficiency and pancreatitis
- h/o Lyme disease
- Thyroiditis
- [**Last Name (un) 8061**] syndrome with vasculitis
- Chronic neuropathic pain and optic neuritis
PSH:
Age 4, tonsillectomy and an adenoidectomy.
[**2173**] - rhinoplasty.
[**2164**] - cystoscopy.
[**12/2169**] and [**4-/2173**] - pelviscopy (? hystero-salpingoscopy or
colposcopy)
[**2172**] to [**2175**] - three Hickman catheters for IV antibiotics for
Lyme disease.
[**2174**] - Laparoscopic cholecystectomy @ [**Hospital1 112**], [**2174**]
[**2177**] - Hernia repair
[**2-/2183**] - EGD
[**5-/2183**] - Lipoma and incisional hernia on the left side and a
lipoma on the right side 1.5 cm2.
[**4-/2184**] - Biliary and pancreatic sphincteroplasty, open G tube
and
J tube for sphincter of oddi stenosis
Social History:
lives with husband, does not work
denies tobacco, alcohol, or illicit drug use
Family History:
non-contributory
Physical Exam:
On day of admission:
T 97.9 P 84 BP 100/52 R 20 SaO2 99%RA
Gen: mild distress with obvious pain
Neck: supple
Heent: an-icteric
Lungs: clear
Heart: RRR
Abd: well healed horizontal incisions, very tender over
epigastric incision site. Small palpable nodule. No hernia
palpated although exam limited by tenderness.
soft, nondistended,
gravid, nontender uterus
Extrem: warm, well-perfused
Pertinent Results:
[**2185-3-9**] 04:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2185-3-9**] 03:13PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2185-3-9**] 09:00AM GLUCOSE-90 UREA N-6 CREAT-0.3* SODIUM-136
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-21* ANION GAP-15
[**2185-3-9**] 09:00AM ALT(SGPT)-12 AST(SGOT)-17 LD(LDH)-149 ALK
PHOS-52 AMYLASE-54 TOT BILI-0.2
[**2185-3-9**] 09:00AM LIPASE-20
[**2185-3-9**] 09:00AM CALCIUM-8.3* PHOSPHATE-3.2 MAGNESIUM-1.6 URIC
ACID-2.3*
[**2185-3-9**] 09:00AM HBsAg-NEGATIVE
[**2185-3-9**] 09:00AM WBC-7.9 RBC-3.57* HGB-11.5* HCT-34.6* MCV-97
MCH-32.2* MCHC-33.2 RDW-14.2
[**2185-3-9**] 09:00AM NEUTS-81.9* LYMPHS-13.0* MONOS-4.7 EOS-0.4
BASOS-0
[**2185-3-9**] 09:00AM PLT COUNT-182
[**2185-3-9**] 09:00AM PT-13.0 PTT-36.1* INR(PT)-1.1
.
[**2185-3-10**] Pathology:
SPECIMEN SUBMITTED: terminal illium, placenta:
DIAGNOSIS:
1. Terminal ileum (A - C):
Recent hemorrhage and mucosal necrosis consistent with ischemic
type injury. The changes extend to the margins of resection
focally.
2. [**Doctor Last Name 11468**] placenta (156 grams) D - G:
A. Umbilical cord with three vessels.
B. Fetal membranes: No evidence of chorioamnionitis.
C. A thrombus is noted in a vessel beneath the amniotic surface
of the placenta.
Clinical: Fetal demise/? bowel obstruction. Small bowel
volvulus/fetal demise. 38 year old IU FD at 25 weeks.
Hysterotomy for delivery.
Gross: The specimen is received fresh, in two parts, each
labeled with the patient's name "[**Known firstname 1154**] [**Known lastname 11469**]" and the medical
record number.
Part 1 is additionally labeled "terminal ileum", and consists of
an unoriented segment of small intestine measuring 44 cm in
length x 3.5 cm in diameter. The two stapled ends each measure
3.0 cm in length. The serosa of the entire specimen appears dark
red to black. The specimen is opened along the antimesenteric
side to reveal a dark red to black lumen filled with blood. The
attached mesentery measures 9.5 x 4.5 x 0.5 cm, pink to red in
color. The specimen is sectioned to reveal dark red to black cut
surfaces. The specimen is represented as follows: A=stapled
margins, B=representative sections of mucosa, C=section of
mucosa with adjacent mesentery.
Part 2 is additionally labeled "placenta", and consists of a
[**Doctor Last Name **] placenta. The umbilical cord has three vessels, is 8.0
cm in length and 1.0 cm in average diameter and has a normal
insertion. The umbilical cord has no twists and is otherwise
unremarkable. The fetal membranes have a 100% marginal
insertion, are normal in color and do not have attached granular
deposits of decidua. The point of rupture is not identified. The
trimmed disc weighs 156 grams and measures 18 x 17.5 x 1.3 cm.
The fetal identified shows patchy subchorionic fibrin and a
normal arborizing fetal vascular pattern without thrombosis. The
maternal surface is complete and does not have adherent blood
clot or decidual hemorrhage. On cut sections, the placenta is
unremarkable. The specimen is represented as follows: D=cross
sections of the vocal cord, E=sections of placental membrane,
F-G=sections of placental disc.
.
[**2185-3-9**] Abdominal MRI:
1. Pancreas divisum anatomy. The pancreas otherwise appears
normal.
2. Small amount of free fluid in the abdomen and pelvis.
3. Moderate amount of stool throughout the colon. The patient
may be
constipated, worsened by compressive effect of the gravid uterus
on the
sigmoid colon. No evidence of bowel obstruction.
4. No anterior abdominal wall hernia is identified.
Brief Hospital Course:
She was admitted to labor and delivery for evaluation and
management of abdominal pain. General sugery consult was
obtained. Initial workup included an MRI on HD#1 which did not
report any significant findings. Her pain persisted and on the
morning of hospital day 2 her clinical picture changed with the
development of oliguria, leukocytosis, change in hematocrit, and
change in abdominal exam. In addition, sadly
at this time an intrauterine fetal demise was diagnosed. The
decision was made to proceed to the operating room for
exploratory laparotomy by the general surgeons as well as
cesarean delivery for the intrauterine fetal demise.
Intraoperatively, the demised fetus was delivered by primary
classical cesarean section and found to be grossly normal.
Please see Dr.[**Name (NI) 11470**] (obstetrics) and Dr.[**Name (NI) 11471**] (surgery)
operative notes for full details.
[**3-10**]: exploratory laparotomy, c-section, resection 10cm TI,
abdomen remained open, continued on pressors, given prbc for low
hematocrit, remained intubated
[**3-11**]: returned to the operating room for a second look, bowel
looked better, abdomen still open to suction, remained
intubated, weaned off pressors; given 4units albumin, 1u prbc
[**3-12**]: remained intubated, on vasopressors
[**3-14**]: returned to the operating room for end-ileostomy, closure,
started cipro/vanc/flagyl, TPN
[**3-15**]: remained intubated, back on pressors, bladder pressures
okay, hct falling, kept paralzyed, started diflucan for
candidiasis, got 1 upRBC
[**3-16**] off pressors, cont TPN, remained intubated
[**3-17**] 1 u pRBC, autodiuresing, still on vent, no pressors, TPN
[**3-18**] febrile, TPN, autodiuresing, pan cultured, on CPAP
[**Date range (1) 11472**] extubated, autodiuresing, discontinued vancomycin,
ciprofloxacin and flagyl, started meropenem
[**3-21**] continued ICU care, episodes of emesis, NGT replaced
[**3-22**] bolused for high NGT output, pain control, transferred to
floor for continued monitoring, continued meropenem and
fluconazole
[**3-23**] foley catheter removed
[**3-24**] NGT clamping trials started, discontinued meropenem and
fluconazole
[**3-25**] NGT removed, diet advanced to clears
[**3-27**] diet advanced to fulls, seen by PT, ostomy care
[**3-28**] - [**3-30**] regular diet, increased loperamide for high ostomy
output; TPN cycled, TPN fat taken out, cycled, volume halved
[**3-31**] ostomy leaking
[**4-1**] hydrocort for benzoin reaction, started hydrocort
[**4-2**] -[**4-7**] continued cycled TPN, monitor ostomy output and
adjust medications as needed; Calorie counts performed x 3days
with results as follows: [**4-4**] cal counts = 880 cal, 24g fat,
18.5g prot, [**4-5**] cal counts = 1000cal, [**4-6**] cal counts = 1236
cal, 24.5g protein.
[**4-7**] no events
[**4-8**] started tincture of opium
[**Date range (1) 11473**] No events
[**4-13**] advanced to clears.
[**4-14**] TPN returned to 24 hour infusion from cycled. Continued on
clears and IV fluids. No events.
[**Date range (1) 11474**] continued clears and IVF; no major events
[**4-17**] decreased IVF, but still thirsty. No leakage from ostomy.
Complaint of migraine; started on fioricet prn with good effect.
[**4-19**] On clears/TPN. No events.
At the time of discharge on [**2185-4-20**], the patient was doing well,
afebrile with stable viral signs. The patient was tolerating a
clear/full diet, ambulating, voiding without assistance, and
pain was well controlled. The patient was dischaged home with
VNA for ostomy care and infusion services for TPN. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
Flonase
Prilosec 20mg [**Hospital1 **]
Sucralfate 1g QID
Creon 20 3 capsules TID
Metamucil 2 caplets [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Folic acid 400 mcg daily
Demerol prn
Darvocet N100 [**Hospital1 **]-TID
Zofran 8mg QD-TID PRN
Fioricet PRN migraine
[**Doctor First Name **] 180mg PRN
Vitamin B-6
Vitamin B-12
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed).
2. Omeprazole 20 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*
3. Loperamide 2 mg Capsule Sig: [**12-10**] Capsules PO Q4H (every 4
hours) as needed for excessive ostomy output.
Disp:*120 Capsule(s)* Refills:*2*
4. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q4-8HOURS as needed for nausea.
Disp:*120 Tablet, Rapid Dissolve(s)* Refills:*2*
5. Psyllium Packet Sig: One (1) packet PO TID (3 times a
day).
6. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for migraine.
7. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**12-10**]
Tablets PO Q6H (every 6 hours) as needed.
Disp:*120 Tablet(s)* Refills:*2*
9. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO
Q6HOURS ().
Disp:*QS - 1 month mL* Refills:*0*
10. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
12. Xanax 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Small bowel mesenteric volvulus around a fixed point of a
former jejunostomy tube
2. 25-week fetal demise.
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-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.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
.
TPN Instruction:
-Continue to cycle TPN for 12 hours overnight.
-Weekly Labwork: Your electrolytes will be checked weekly per
the VNA. Adjustments to your TPN formula will be made
accordingly [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) 553**] [**Last Name (NamePattern1) 11475**](Home Hyperal Service
Coordinator), [**Telephone/Fax (1) 11476**], FAX: [**Telephone/Fax (1) 11477**].
-Check you blood sugars 4 times per day, at the same time each
day.
-Treat with insulin injections as indicated.
Followup Instructions:
Please call the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] to arrange a
follow up appointment in [**1-11**] weeks at ([**Telephone/Fax (1) 6347**]
Please call the office of Dr. [**Last Name (STitle) **] (Obstetrics) to arrange a
follow up appointment in 2 weeks at ([**Telephone/Fax (1) 11478**]
Completed by:[**2185-4-20**]
ICD9 Codes: 0389, 2851, 5185, 2762, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1720
} | Medical Text: Admission Date: [**2106-3-26**] Discharge Date: [**2106-4-12**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest tightness
Major Surgical or Invasive Procedure:
s/p cardiac catheterization
s/p CABGx2 [**3-29**]
LIMA-LAD, SVG-OM
History of Present Illness:
Mrs. [**Known lastname **] is an 80 yo woman with a known h/o CAD who has had
PCI to her RCA, presented to the ED with SOB and chest tightness
on [**3-26**].
Past Medical History:
CAD
s/p RCA PCI
PVD
s/p R popliteal PCI
HTN
anxiety
HOH
collagenous colitis
hypercholesterolemia
glaucoma
macular degeneration
s/p bilateral cataract surgery
Social History:
Mrs. [**Known lastname **] lives at home with her husband. She denies tobacco
or EtOH.
Pertinent Results:
[**2106-4-9**] 07:08AM BLOOD WBC-11.0 RBC-3.87* Hgb-11.8* Hct-35.2*
MCV-91 MCH-30.5 MCHC-33.6 RDW-15.1 Plt Ct-433
[**2106-4-9**] 07:08AM BLOOD Plt Ct-433
[**2106-4-9**] 07:08AM BLOOD PT-12.9 PTT-27.0 INR(PT)-1.1
[**2106-4-9**] 07:08AM BLOOD Glucose-91 UreaN-23* Creat-1.0 Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
Brief Hospital Course:
Mrs. [**Known lastname **] presented to [**Hospital1 18**] on [**3-26**] with c/o chest tightness
and shortness of breath. Her cardiac catheterization showed a
normal ejection fraction and significant 2 vessel disease. She
was taken to the operating room on [**3-29**] with Dr. [**Last Name (STitle) **] on [**3-29**]
for CABGx2. She tolerated the procedure well and was
transferred to the ICU in stable condition. She was weaned and
extubated from mechanical ventilation without difficulty and
transferred to the regular floor on POD#2. On POD#2 she
required PRBC transfusion and had several episodes of atrial
fibrillation. She was started on amiodarone and began to
develop periods of bradycardia. On the morning of POD#5 she
developed HTN, SOB and rales. She was treated with diuretics
and IV nitroglycerine and the decision was made to transfer her
to the ICU for close monitoring. Her EKG was without ischemic
changes, and echocardiogram did not show any wall motion
abnormality or pericardial effusion. Her symptoms of heart
failure resolved with continued diuresis and she was transferred
back to the regular floor. Her beta blockers were discontinued
due to her bradycardia, however she continued to have episodes
of atrial fibrillation. On POD#10 an electrophysiology consult
was obtained due to continues episodes of rapid atrial
fibrillation and it was recommended to decrease her dose of
amiodarone and restart a low dose of atenolol. She was started
on Coumadin for anticoagulation, and by POD#14, her INR was 2.1
and she was cleared for discharge to home.
Medications on Admission:
lisinopril 2.5mg qd
atenolol 25 mg qd
zocor 10 mg qd
ativan prn
asprin 325 mg qd
imdur 60mg qd
trusopt eye gtts
occuvite
paxil 10mg qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Dorzolamide HCl 2 % Drops Sig: One (1) Drop Ophthalmic TID
(3 times a day).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
5. 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*
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a
day.
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO once a
day for 2 days: then check with Dr.[**Name (NI) 12389**] office for
continued dosing.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
s/p CABG
PVD
anxiety
HTN
collagenous colitis
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not swim or take a bath for 1 month
do not drive for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
do not lift anything heavier than 10 pounds for 1 month
Followup Instructions:
Follow up with PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 457**] in [**1-17**] weeks
follwo up with Dr. [**Last Name (STitle) **] in [**3-19**] weeks
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD follow up in [**1-17**] weeks
Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2386**]
follow up with Dr. [**Last Name (STitle) **] in [**2-18**] weeks ([**Telephone/Fax (1) 12390**]
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2106-5-13**] 3:15
Provider: [**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2106-7-13**] 1:30
Completed by:[**2106-4-12**]
ICD9 Codes: 4280, 4019, 2720, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1721
} | Medical Text: Admission Date: [**2103-12-28**] Discharge Date:
Date of Birth: [**2064-2-21**] Sex: F
Service: MEDICINE SERVICE TO THE MICU ON [**First Name4 (NamePattern1) 640**] [**Last Name (NamePattern1) 31397**]
SERVICE AND THEN TRANSFERRED TO THE GENERAL MEDICINE SERVICE
WITH [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AS THE ATTENDING.
The patient was admitted on [**2103-12-28**], as a
transfer from [**Hospital3 3583**] for further management of
hypertension and respiratory failure.
HISTORY OF THE PRESENT ILLNESS: The patient, [**Known firstname 31398**]
[**Known lastname 17029**], is a 39-year-old woman who presented to [**Hospital3 6265**] Emergency Room on [**12-27**], in the afternoon
with a three-day history of back pain, which is chronic,
nausea, vomiting, and possibly diarrhea. The patient also
noted weakness and hand numbness, left greater than right.
The patient also has a rash over her right upper extremity,
shoulder, and axilla. Vital signs, on arrival to the
emergency room of the outside hospital, were the following:
temperature 104.2, blood pressure 83/50, heart rate 148,
respiratory rate 12. The patient was menstruating near the
end of her cycle and had a tampon in her vagina. The
patient's blood pressure decreased to 60 systolic and she was
started on fenethylline drip for hypotension. The tampon was
removed and the patient received 2-g IV oxacillin and 100 mg
IV gentamicin. While in the emergency room, the patient
apparently had a cyanotic episode and was intubated. The
patient was transferred to [**Hospital1 188**] Emergency Room via [**Location (un) **] on hospital day #2,
[**2103-12-28**]. In the [**Hospital1 188**] Emergency Room, the patient had a blood pressure of
90/palp on neosynephrine with a heart rate in the 140s.
Temperature was 37.9. She was ventilated. She received
Vancomycin 1-g IV, Ceftriaxone 2-g IV. She was also given
fentanyl and Ativan for sedation. A left femoral line was
inserted for central access and a right brachial artery line
was inserted for blood pressure monitoring. At that point,
the patient was transferred to the medical ICU.
PAST MEDICAL HISTORY:
1. L5 spinal surgery one year ago in [**2103-11-29**].
2. Splenectomy secondary to trauma.
MEDICATIONS: None.
ALLERGIES: The patient is allergic to ERYTHROMYCIN, CODEINE,
CORTISONE, AND SULFA; reactions are unknown to those
medications.
SOCIAL HISTORY: The patient's primary care physician is
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 31399**] in [**Location (un) 3320**], who is an OB-GYN physician. [**Name10 (NameIs) **]
patient lives in [**Location 3320**] with her sister and her own four
children. Her sister [**Name (NI) **] [**Name2 (NI) 31400**] phone # is:
[**0-0-**]. She is disabled and the patient is a former
nurses aid.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Physical examination on admission to
the medical ICU revealed the following: [**Known firstname 31398**] is an obese,
middle-aged woman, intubated, and sedated. Vital signs:
Temperature 99.1, blood pressure 84/52, on 340 mcg per minute
of neosynephrine. Heart rate was 100. She is on assist
control, tidal volume 800, respiratory rate 10, PEEP 5, FIO2
50%. HEENT: Conjunctivae are clear, no scleral icterus, no
mucosal ulcerations. NECK: Obese, neck veins not well
visualized. CHEST: Coarse breath sounds bilaterally with
occasional wheezes. CARDIOVASCULAR: Tachycardiac, regular,
no murmur appreciated. ABDOMEN: Examination was soft,
nontender, nondistended, bowel sounds present, midline
abdominal scar. EXTREMITIES: Warm with no edema. Back
examination revealed surgical scar over the lumbar spine.
NEUROLOGICAL: The patient is sedated and not responding to
painful stimuli. SKIN: Skin showed petechiae and pustules
over her left inner thigh and petechiae with erythema over
the right axilla and shoulder.
LABORATORY DATA: Laboratory data revealed the following:
ABG at the outside hospital on 100% nonrebreather 7.34, CO2
35, pO2 173. White count, at the outside hospital was 35.6,
hematocrit 43.5, platelet count 547,000. SMA 7 at the
outside hospital 131, 4.5, 96, 20, 32, 2.8, glucose 210,
anion gap 50. AST 125, ALT 124, alkaline phosphatase 91,
T-bilirubin 2.2, albumin 3.0, total protein 6.1, calcium 8.3.
Chest x-ray at the outside hospital showed right mainstem
intubation, low lung volume, no infiltrate. EKG at the
outside hospital showed sinus tachycardia with normal axis.
At [**Hospital1 69**] in the Emergency Room
the labs were as follows: white count 37.9, hematocrit 33.5,
platelet count 478,000, SMA 7 138, 4.1, 106, 19, 32.2,
glucose 161, anion gap 13. The PT was 20.8, PTT 39.0, INR
3.0. CK 604, troponin 0.9, alkaline phosphatase 68, lipase
3, phosphorus 4.3, magnesium 1.0. Urinalysis revealed
moderate blood, positive protein, trace ketones, 6 to 10
white cells, 6 to 10 epithelial cells, 0 to 2 granular casts,
6 to 10 hyaline casts.
MICROBIOLOGY DATA: Blood cultures and urine cultures are
pending. The ABG revealed pH of 7.22, carbon dioxide 33,
oxygen 364 with a bicarbonate 14.
IMPRESSION: This is a 39-year-old woman with hypertension,
fever, and multiorgan failure including DIC and renal failure
and metabolic acidosis. The patient is in septic shock
secondary to an unknown cause; likely causes include
toxic-shock syndrome, meningeal coxemia and gram-negative
sepsis. She has a history of back pain and spinal surgery,
also concerning, but no recent surgeries noted and no
inflammation or localizing signs on examination.
Other etiologies included [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**] Spotted fever,
although that is thought to be less likely.
The patient was given oxacillin and Clindamycin for toxic
shock, Ceftriaxone for meningeal coxemia and gram-negative
sepsis. The patient was given Doxycycline for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**]
Spotted fever. The patient was given aggressive volume
resuscitation and pressors to maintain blood pressure with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] greater than 60. The patient was intubated and placed
on a ventilator. The patient's renal function will be
followed as will her urine output as it appears that the
patient is in acute tubular necrosis. A DIC panel was
checked on admission as the patient had elevated coagulation
panel.
On hospital day #2, the patient pressor was switched to
Levophed and the neosynephrine was discontinued. The patient
was started on an activated protein C. Oxacillin,
Clindamycin, Ceftriaxone were all continued. During her
entire time, the patient was given supportive care on the
ventilator and with fluids.
On hospital day #3, pressors were weaned to off. Cultures of
the tampon came back positive for Staphylococcus aureus,
which was Penicillin resistant, but methicillin sensitive.
Sedation was decreased with the goal of a spontaneous
breathing trial prior to extubation.
On hospital day #4, all cultures, urine and blood, have been
negative to date. The Clindamycin, Oxacillin, Ceftriaxone
and activated protein C were continued and stool was sent for
C-difficile analysis. The patient is still in nonoliguric
renal failure, likely acute tubular necrosis secondary to
ischemia. The original blood samples on the tampon from
[**Hospital3 3583**] were transferred to [**Hospital1 190**] and then sent on to the CDC for toxic shock
syndrome toxin #I and for antibodies to toxin #1.
Hospital day #5, the patient had right upper lobe and left
lower lobe infiltrates on chest x-ray. PICC line was placed.
On hospital day #6, antibiotics were changed to oxacillin and
Ciprofloxacin. The Ciprofloxacin was added to treat a
ventilator-associated pneumonia, presumptively. The other
antibiotics were discontinued. The Propofol was weaned to
off.
On hospital day #7, the patient continued to wean off the
ventilator support. On hospital day #8, the patient was
extubated. A new rash was noted and thought secondary to
antibiotics or other medications. Consequently, the
antibiotic were discontinued. The patient maintained good
urine output and the creatinine started to come down. On
hospital day #9 the patient was eating well and her
saturation was maintained on minimal oxygen.
On hospital day #10 the patient complained of weakness in her
hands, which she complained for three to four days prior to
the outside hospital emergency room. She also said that she
felt like she was breathing hard and she complained of her
usual chronic back pain. However, the patient was deemed
stable enough to be transferred to the floor. On transfer to
the floor team, current issues included pulmonary bilateral
infiltrates, ARDS versus ventilator-associated pneumonia.
The saturation was 87% on room air and 97% on three liters.
The patient complained subjectively of dyspnea.
INFECTIOUS DISEASE: The patient has all cultures negative.
The tampon grew out Staphylococcus aureus and the patient had
clinical criteria for toxic shock syndrome. The toxic shock
syndrome toxin #1 test and antibody are pending from the CDC
at this point in time. The patient is off all antibiotics.
HEMATOLOGICAL: The patient DIC has resolved and the
activated protein C was discontinued on [**1-3**],
hospital day #7. The hematocrit is stable at 25 and the
patient will not be transfused until the hematocrit drops
below 22. The patient is in post ATN diuresis phase with
high urine output and slowly decreasing creatinine.
GASTROINTESTINAL: The patient complained of mild abdominal
pain and cramping.
CARDIOVASCULAR: The patient has been cardiovascularly
stable, off pressors, for five to six days.
FLUIDS: The patient is making significant amounts of urine
and keeping herself 3-4 liters negative per day.
MUSCULOSKELETAL: The patient continues to complain of her
chronic low back pain and weakness of her hands bilaterally.
NEUROLOGICAL: The patient has sensory deficit to her elbow
bilaterally and weakness of her hands.
SKIN: The rash that the patient had on admission is now
resolved.
On hospital day #11, which was [**1-7**], stool was sent
for C. difficile and Flagyl was started empirically for loose
stool, crampy abdominal pain, and persistently elevated white
count to 22. The patient continued to improve in all areas.
On hospital day #12, the patient was weaned off oxygen to
room air. The patient continued to regain some function and
feeling in her hands bilaterally. The left one is
persistently worse than her right. The patient's abdominal
pain and cramping persisted with minimal p.o. intake. The
patient's creatinine continued to drop.
On hospital day #13, the patient's reported resolving loose
stool and decreased abdominal cramping and the patient was
able to take some POs. The patient also reported continued
improvement in her neurological symptoms of her hands
bilaterally.
On hospital day #14, [**1-10**], the patient regained her
voice. It had been hoarse previous to this. The patient
tolerated a full breakfast for the first time and having form
stool of two to three per day. The patient continues to take
the Flagyl 500 mg p.o. t.i.d.
The neurological deficits continued to resolved slowly. MRI
of the cervical spine was obtained to rule out any central
pathology. The results of the toxic shock syndrome toxin and
antibody test returned on Thursday, [**1-10**], or Friday,
[**1-11**]. The patient was screened for rehabilitation
on [**1-9**]. On [**1-10**], after tolerating a good
breakfast, the patient was deemed stable for discharge if the
patient could each a good lunch without any abdominal
cramping or loose stool.
The patient will be discharged on [**1-10**], in the
afternoon or possibly [**1-11**], early in the morning to
[**Hospital 46**] Rehabilitation, who should receive a copy of this stat
dictation summary.
After the patient tolerates good p.o. intake, the patient
will be discharged on the following medications:
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o.q.d.
2. Tums 1000 mg p.o.t.i.d.
3. Vitamin D 400 IU p.o.q.d.
4. Nystatin power to affected areas b.i.d. as needed.
5. Flagyl 500 mg p.o.t.i.d. until [**2104-1-18**].
6. Tylenol 650 mg p.o. q.4 to 6h.p.r.n.
7. Colace 100 mg p.o.b.i.d.
8. Serax 15 mg p.o.q.h.s. as needed on a regular diet.
The patient is in stable condition on discharge with the
diagnoses of the following:
1. Toxic shock syndrome.
2. Low back pain, chronic.
3. Neuropathy of upper extremities.
4. Acute tubular necrosis.
5. Adult respiratory distress syndrome, now resolved.
FOLLOW-UP CARE: The patient will followup with her OB-GYN
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 31399**]. The patient will return to see the
[**Hospital 878**] Clinic here for followup.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-955
Dictated By:[**Last Name (NamePattern1) 31401**]
MEDQUIST36
D: [**2104-1-10**] 11:19
T: [**2104-1-10**] 11:20
JOB#: [**Job Number 31402**]
cc:[**Hospital1 31403**]
ICD9 Codes: 486, 5185, 5845, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1722
} | Medical Text: Admission Date: [**2121-5-14**] Discharge Date: [**2121-5-17**]
Date of Birth: [**2048-12-27**] Sex: M
Service: [**Year (4 digits) 662**]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with DES to the RCA
History of Present Illness:
72yoM with h/o HTN, multiple basal/squamous cell skin ca
admitted for inferior STEMI. He was in his USOH until 0800 this
AM when he noticed L-sided chest pain. He thought it was
indigestion at the time and went about his normal day - cleaning
up a house he is renovating. He then went to his regularly
scheduled appt to have a skin cancer removed from his neck in
[**Location (un) **]. After the appt, he went to IHOP where he ate a large
meal. He then went home and was laying down in bed when his
L-sided chest pain acutely worsened to an 8 or [**8-16**] - radiating
across his R chest associated with diaphoresis and tingling in
both his hands. His friend called 911 and he was brought to
[**Hospital1 18**] ED.
.
In the ED, initial VS 96.6 72-82 179-200/105-106 22 97% on
4L. EKG showed NSR, rate 74, RAD and 3 mm STE in II, III, and
aVF with depressions in I, aVL, and V2. Initial Trop was < 0.01,
Cr 1.1, Hct 48.7. The patient was given ASA 325 mg, Plavix 600
mg, heparin bolus and gtt, integrillin gtt, SL nitro and
morphine. Code STEMI was called and he was taken directly to the
cath lab. Cath showed 80% proximal LAD stenosis w/ diffuse
disease, 70% stenosis in the diagonal, subtotal occlusion of the
distal RCA (prox to PDA and RLV) with thrombus - this was not
collateralized, and 50% stenosis in the mid-PDA. DES was placed
to the RCA. Metoprolol 5 mg IV was given for slow Vtach. There
are plans for repeat PCI to the LAD.
.
Currently the patient denies CP, endorses mild pain in his
groin. He denies ever experiencing CP before today. No history
of heart problems. [**Name (NI) **] recent illness.
.
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 dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, ? Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: as above
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Hypertension
-Squamous cell skin cancer
-Basal cell skin cancers
-Rheumatic fever as child
- hospitalized 1 year ago for 'respiratory problem' after
inhaling paint fumes, said that w/u was normal
Social History:
Renovates houses. Lives with a significant other. [**Name (NI) **] 2
biological daughters and 5 children from 2nd marriage.
- Tobacco history: none
- ETOH: none
- Illicit drugs: none
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death.
mother - died young of breast cancer
father - died age 69 of ulcers
brother - died of kidney disease
Physical Exam:
On admission to CCU:
VS: 96.8 71 156/92 15 98% on RA
GENERAL: NAD. Lying flat after cath. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP not elevated
CARDIAC: RR, quiet S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTA -
anteriorlly
ABDOMEN: Obese, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. 2+ pt/dp pulses, 2+
radial pulses
SKIN: L posterior head is bandaged w/ clean bandage
.
On discharge:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP not elevated
CARDIAC: RR, quiet S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB
ABDOMEN: Obese, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. 2+ pt/dp pulses, 2+
radial pulses, R groin bandage with some dried blood.
SKIN: L posterior head is bandaged w/ clean bandage
Pertinent Results:
Labs on admission:
.
[**2121-5-14**] 02:52PM BLOOD WBC-9.1 RBC-5.22 Hgb-16.7 Hct-48.7 MCV-93
MCH-32.0 MCHC-34.3 RDW-13.1 Plt Ct-296
[**2121-5-14**] 02:52PM BLOOD Neuts-64.7 Lymphs-23.7 Monos-6.5 Eos-1.7
Baso-3.4*
[**2121-5-14**] 02:52PM BLOOD PT-12.9 PTT-20.5* INR(PT)-1.1
[**2121-5-14**] 02:52PM BLOOD Glucose-222* UreaN-17 Creat-1.1 Na-142
K-3.5 Cl-102 HCO3-26 AnGap-18
[**2121-5-14**] 02:52PM BLOOD cTropnT-<0.01
.
[**5-14**] Cardiac cath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated 2 vessel coronary artery disease. The LMCA was free
of
angiographically significant disease. The LAD had an 80%
stenosis
proximally. The distal vessel was diffusely diseased with 70-80%
stenosis at its worst. There was a 70% stenosis in the diagonal.
There
was a subtotal occlusion of the distal RCA (proximal to the PDA
and RLV)
with thrombus. This was not collateralized. There was a 50%
stenosis in
the mid-PDA.
2. Limited resting hemodynamics demonstrated moderate to severe
systemic
arterial hypertension (range 160-210mmHg systolic).
3. The patient had slow VT during the procedure with drop in
blood
pressure to the 90s systolic.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Distal RCA occlusion with thrombus
3. Moderate to severe systemic arterial hypertension
4. Slow ventricular tachycardia.
.
On discharge:
[**2121-5-17**] 09:00AM BLOOD WBC-8.0 RBC-4.51* Hgb-14.2 Hct-42.1
MCV-94 MCH-31.5 MCHC-33.7 RDW-13.1 Plt Ct-225
[**2121-5-17**] 09:00AM BLOOD Neuts-74.9* Lymphs-18.2 Monos-4.0 Eos-1.7
Baso-1.1
[**2121-5-17**] 09:00AM BLOOD Glucose-166* UreaN-22* Creat-1.0 Na-138
K-3.8 Cl-105 HCO3-21* AnGap-16
[**2121-5-16**] 06:50AM BLOOD cTropnT-1.92*
[**2121-5-17**] 09:00AM BLOOD Calcium-8.6 Phos-1.9* Mg-2.3
[**2121-5-15**] 02:58AM BLOOD %HbA1c-6.6* eAG-143*
[**2121-5-15**] 04:33AM BLOOD Triglyc-231* HDL-40 CHOL/HD-4.9
LDLcalc-109
Brief Hospital Course:
72yoM with h/o HTN, multiple basal/squamous cell skin ca
admitted for inferior STEMI
.
# CAD w/ Inferior STEMI: The patient presented to the ED with
complaints of acute onset chest pain. EKG showed inferior ST
elevations. Code STEMI was called and he was taken urgently to
the cath lab. Trops peaked at 5.25. He was Plavix loaded and
started on a heparin and integrillin gtt. Aspirin 325 mg was
administered. Cath showed thrombus in the proximal RCA and this
was stented. Atorvastatin 80 mg qhs and metoprolol succinate 25
mg qday were started. On discharge, he was continued on ASA at
325 mg per day and Plavix 75 mg qday x 12 months. Cath also
showed an 80% LAD lesion - this was not stented and plans are
for this to be medically managed. He is to have a stress test
arranged by his PCP [**Name Initial (PRE) 176**] 2 weeks. A cardiology appt was
scheduled though the patient may request a referral to a
cardiologist close to home.
.
# PUMP: TTE showed normal EF, mild LVH, regional LV systolic
dysfunction - hypokinesis of the basal and mid-inferolateral
segments.
.
# RHYTHM: NSR at rate of 69. Had slow Vtach in cath lab for
which he received 5 mg IV metoprolol. He had rare PVCs in the
CCU, no further therapy was administered.
.
# HTN: He was hypertensive w/ SBPs in the 180s on admission -
initially captopril was used to control BP. His discharge
regimen was Toprol 25 mg qday and Losartan 50 mg qday.
.
# Squamous cell ca: Lesion removed on L occiput on [**5-14**], plans
for repeat dressing change on [**5-16**]. Outpatient f/u.
.
# DM: Blood sugars were elevated on admission. A1c was sent and
was 6.6%. The patient was counseled that he had a new diagnosis
of diabetes and was encouraged to improve his diet. A nutrition
consult was placed. He was encouraged to follow-up with his PCP
[**Last Name (NamePattern4) **]: this new diagnosis.
.
DVT prophylaxis was with subQ heparin
CODE: Full Code, confirmed
COMM: daughter [**Name (NI) 17**] [**Name (NI) 22916**] [**Telephone/Fax (1) 89602**]
Medications on Admission:
HCTZ 25 mg qday
ASA 81 mg qday
Losartan 50 mg qday
Fluorouracil 40 gm
Discharge Disposition:
Home
Discharge Diagnosis:
STEMI s/p DES to the RCA
Diabetes Mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 54184**],
It was a pleasure participating in your care. You were
admitted for a heart attack caused by a clot in one of your
coronary arteries. You had a cardiac catheterization and a drug
eluting stent was placed. You were started on plavix which you
will need to take for at least a year to prevent clotting of
this stent. You were also started on atorvastatin to reduce risk
of coronary artery disease.
During your cardiac cath an area of narrowing was seen in one
of your vessels. As this has not caused you any symptoms, we
will medically manage you at present and you should have a
stress test in about 2 wks. A test has been ordered and you need
to speak with your primary care doctor in order to schedule this
test. You will have follow up with a cardiologist to further
manage your problems - if you choose to see a cardiologist
closer to home, that's fine and you can cancel the appointment
we have made.
During this admission it was also found that you have
diabetes. This can significantly increase your risk of cardiac
diseases. You should exercise and eat healthily to try to
decrease this risk. You should also follow up with your PCP to
discuss whether you would benefit from starting on medication.
Please call or return to the hospital if you develop chest
pain, shortness of breath, leg swelling, or any other symptoms
that concern you.
-------------------
Please START the following medications:
- Plavix (Clopidogrel) 75mg daily
- Atorvastatin 80mg daily
- Metoprolol succinate 25mg daily
Please STOP the following medications:
- hydrochlorothiazide
Please CONTINUE Losartan 50 mg per day
The following medications have CHANGED:
- Aspirin should now be taken at 325mg daily (not 81mg)
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] F.
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**]-[**Location (un) **]/WESTW
Address: [**Street Address(2) 21600**], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 17753**]
Appt: [**5-22**] at 9:30am
Name: [**Last Name (LF) 5858**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD
Location: [**Hospital1 **] CARDIOLOGY
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 4105**]
Appt: [**6-3**] at 10:30am
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1723
} | Medical Text: Admission Date: [**2147-1-2**] Discharge Date: [**2147-1-9**]
Date of Birth: [**2089-4-7**] Sex: F
Service: OME
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
female with a history of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau disease and
metastatic renal cell carcinoma being admitted for cycle one,
week one high dose IL2 therapy. Her oncologic history began
in [**2130**], when she was diagnosed with bilateral renal masses
consistent with renal cell carcinoma and underwent bilateral
partial nephrectomy. She did well until [**2139-9-9**], when
disease progression was noted in her right kidney and a liver
lesion was noted. Needle biopsy of the liver lesion
confirmed metastatic renal cell carcinoma. She received IL2
and Interferon phase III protocol with stable disease. She
underwent resection of an isolated thyroid met in [**2141-12-9**], and had radiofrequency ablation of renal masses in
[**2142**], [**2143**], and [**2144**]. Recent scans revealed progression of
disease in her liver and an enlarging mass in her left
kidney. She was planned for high dose IL2, but developed
pyelonephritis/urosepsis and was hospitalized from
[**2146-12-14**], through [**2146-12-19**], for intravenous fluids and
intravenous antibiotics. She has recovered well and
completed her last antibiotic dose this morning. Her MG has
returned to 100 percent. She is now being admitted for cycle
one, week one high dose IL2 therapy.
PAST MEDICAL HISTORY: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau disease.
History of seizures.
Recent urosepsis.
History of hemangioma, status post cerebellar resection times
two.
Hypothyroidism.
ALLERGIES: Levofloxacin causes a rash.
MEDICATIONS ON ADMISSION:
1. Levoxyl 50 mcg p.o. daily.
2. Phenobarbital 64.8 mg p.o. three times a day.
3. Fosamax 70 mg p.o. weekly.
PHYSICAL EXAMINATION: General reveals a well appearing
middle age female in no acute distress. Vital signs revealed
temperature 97.8 heart rate 68, respiratory rate 20, blood
pressure 136/83, oxygen saturation 96 percent in room air.
Head, eyes, ears, nose and throat is normocephalic and
atraumatic. Sclera anicteric. The mucous membranes are
moist without lesions. The neck is supple, no jugular venous
distention. Lymph nodes - No cervical, supraclavicular,
axillary or bilateral inguinal lymphadenopathy. Heart is
regular rate and rhythm, S1 and S2, without murmurs, rubs or
gallops. The chest is clear to percussion and auscultation
bilaterally. Abdomen is soft, positive bowel sounds,
rounded, soft, nontender, no hepatosplenomegaly or masses.
Extremities revealed no lower extremity edema. Skin intact
without breakdown. On neurologic examination, the patient is
alert and oriented times three. Speech clear and fluent.
She is moving all extremities well with strength 5/5.
LABORATORY DATA: On admission, white blood cell count 5.0,
hemoglobin 15.0, hematocrit 45.4, platelet count 323,000.
Blood urea nitrogen 26, creatinine 1.2. Sodium 136,
potassium 4.3, chloride 101, CO2 30, ALT 15, AST 18, LDH 138,
CK 24, alkaline phosphatase 156, total bilirubin 0.2, albumin
3.7, calcium 9.3, phosphorus 3.6, magnesium 1.9, uric acid
6.6. INR 1.0.
HOSPITAL COURSE: The patient was admitted for high dose IL2
therapy. Her admission weight was 56 kilograms and she
received Interleukin2 600,000 international units per
kilogram equaling 33.6 million units intravenously q8hours
times fourteen planned doses. During this week, she received
thirteen of fourteen doses with dose number four held related
to hypotension and hypoxia. Side effects initially included
chills improved with Demerol and nausea improved with Ativan.
She developed an erythematous pruritic skin rash treated with
topical lotion, as well as diarrhea improved with Lomotil.
On treatment day number five, she developed mild dyspnea on
exertion with oxygen saturation in the high 90s in room air
and examination consistent with small pleural effusions with
dullness at bilateral bases without crackles. She received
dose number thirteen of IL2 at approximately 3:00 p.m. and
three hours later became hypotensive requiring the initiation
of Dopamine. She developed crackles on her pulmonary
examination and was subjectively short of breath and 20 mg of
intravenous Lasix was given. She was started on Neo-
Synephrine to help support her blood pressure. She developed
mild chest pain and underwent electrocardiogram revealing
probable supraventricular tachycardia. Given need for
maximum doses of Dopamine and Neo-Synephrine with systolic
blood pressure remaining in the 80 range, she was transferred
to the Medical Intensive Care Unit for further management and
monitoring.
In the Medical Intensive Care Unit, she was fluid
resuscitated and cultured to rule out infection as a source
of her hypotension. She was maintained on Dopamine and Neo-
Synephrine for blood pressure support. During her initial
hypotension on seven [**Hospital Ward Name 1826**], she was also noted to be
hypoxic with an oxygen saturation in the mid 80s, markedly
improved with oxygen by face mask. She initially remained in
supraventricular tachycardia but ruled out for myocardial
infarction by CK and troponin. She was maintained overnight
in the Medical Intensive Care Unit with vasopressor support
slowly weaned. By the evening of [**2147-1-7**], her blood
pressure had stabilized and she had been weaned completely
off Neo-Synephrine. Her systolic blood pressure was
maintaining over 90 on Dopamine. Her oxygen saturation was
in the 90s in room air. She had spontaneously converted to
normal sinus rhythm after transfer to the Medical Intensive
Care Unit. Her Dopamine was successfully weaned down and was
discontinued early in the morning of [**2147-1-8**]. She
underwent echocardiogram on [**2147-1-9**], revealing left
ventricular wall thickness, cavity size and systolic function
to be normal with a left ventricular ejection fraction
greater than 55 percent. Regional left ventricular wall
motion normal. There was mild pulmonary artery systolic
hypertension and a small pericardial effusion without
echocardiographic signs of tamponade.
Laboratory abnormalities during this week included creatinine
rise to 2.6, improved to 2.1 on the day of discharge;
hyperbilirubinemia with a peak bilirubin of 3.8, improved to
1.7 on the day of discharge; metabolic acidosis with a
bicarbonate low at 16, improved to 25 on the day of
discharge; and an elevated alkaline phosphatase with peak
alkaline phosphatase [**Location (un) 1131**] of 383 on the day of discharge.
She had no transaminitis during her hospitalization. She
developed mild INR elevation on [**2147-1-7**], improved the next
day to 1.1 after Vitamin K administration, and she had no
evidence of myocarditis based on enzymes or echocardiogram.
She was mildly anemic with a hemoglobin of 12.1 and
hematocrit of 35.1 without need for packed red blood cell
transfusion. She was thrombocytopenic with a platelet count
low of 27,000 on the day prior to discharge which had
improved to 36,000 on the day of discharge. She had no
evidence of bleeding throughout her hospitalization. She
required intermittent electrolytes repletion throughout her
hospitalization. By [**2147-1-9**], she had recovered
sufficiently from side effects to allow for discharge to
home. She had significant weight gain of approximately
thirty pounds during her hospitalization. Her blood cultures
drawn during her Medical Intensive Care Unit stay were
negative. Her central line tip was sent for culture upon
discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with her husband.
DISCHARGE INSTRUCTIONS: The patient is to notify us for
persistent fever, chills or fluid retention.
MEDICATIONS ON DISCHARGE:
1. Nystatin 5 cc p.o. four times a day.
2. Keflex 500 mg p.o. twice a day times five days.
3. Ranitidine 150 mg p.o. twice a day p.r.n. nausea, acid
stomach or while taking nonsteroidals.
4. Lomotil one to two tablets p.o. q6hours p.r.n. diarrhea.
5. Compazine 10 mg p.o. q6hours p.r.n. nausea.
6. Ativan 1 mg p.o. q6hours p.r.n. nausea, anxiety or for
sleep.
7. Benadryl 25 to 50 mg p.o. q6hours p.r.n. pruritus.
8. Tylenol p.r.n.
9. Ibuprofen p.r.n.
10. Lasix 20 mg p.o. four times a day times five days or
until achieves baseline weight.
</DISCHARGE DIAGNOSIS>
Metastatic renal cell carcinoma, status post high dose IL2
therapy complicated by hypotension and hypoxia.
[**First Name11 (Name Pattern1) 449**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**MD Number(1) 21348**]
Dictated By:[**Last Name (NamePattern1) 18853**]
MEDQUIST36
D: [**2147-1-13**] 16:11:51
T: [**2147-1-14**] 12:10:55
Job#: [**Job Number 21349**]
cc:[**Numeric Identifier 21350**]
ICD9 Codes: 5849, 5119, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1724
} | Medical Text: Admission Date: [**2195-9-19**] Discharge Date: [**2195-9-25**]
Service: MEDICINE
Allergies:
Penicillins / Evista / Tetanus / Fosamax / Actonel / Ibuprofen /
Fluoxetine
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
C2 Fracture and PE
Major Surgical or Invasive Procedure:
Placement of IVC filter
History of Present Illness:
The patient is an 87 yo woman with h/o osteoporosis, multiple
recent falls, CAD, who presents from nursing home with C2
fracture and evidence of pulmonary embolus. The patient was in
her usual state of health at her nursing home until yesterday
morning when she sustained a fall when trying to get up to go to
the bathroom. The fall was not witnessed, but the patient
reportedly did not lose consciousness. At 3:30 that afternoon,
the patient complained of neck and rib pain. She was taken to
OSH, where she was found to have a comminuted fracture of C2.
She was transferred to [**Hospital1 18**] for further evaluation. Of note,
the patient was recently treated for CDiff infection at her
nursing facility, per discussion with her daughter.
.
In the ED, the patient's VS were T 99.1, BP 106/42, P 101, R 24.
She had an ECG which showed sinus tachycardia and ST
depressions in V3 and V4. CT head was negative for ICH. She
was seen by Trauma surgery, who recommended stabalization with a
cervical collar for the next six to eight weeks, but they deemed
that she is not an operable candidate. While imaging the
patient's cervical spine, she was found to have a large saddle
pulmonary embolism. After discussion with the surgery team and
the patient's family, agreement was made to start the patient on
systemic anticoagulation. She was thus transferred to the ICU
for further monitoring.
.
In the MICU, the patient states that she still has pain in her
neck, but it has decreased from previously. The patient is a
poor historian. Per discussion with the patient's daughter, she
is interested in initiating anticoagulation if recommended.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
DM2 (due to pancreatic injury)
CAD s/p MI
Depression
COPD
Dementia
HTN
Anxiety
CHF
Social History:
The patient currently lives at [**Hospital 82992**] Nursing and Rehab center.
Her family is actively involved in her care.
Family History:
Non-contributory
.
Physical Exam:
Admission physical exam:
Vitals: T: 100.0, P 116, BP: 118/39, R 14 O2: 98% on 2L
General: Elderly woman, lying flat in bed with cervical collar,
in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Cervical collar in place
Lungs: Clear to auscultation anteriorly, no wheezes, rales,
rhonchi
CV: Tachycardic. no murmurs, rubs, gallops appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission laboratories:
[**2195-9-18**] WBC-31.1* RBC-3.19* Hgb-10.2* Hct-32.1* MCV-101*
MCH-31.9 MCHC-31.7 RDW-14.2 Plt Ct-342
[**2195-9-18**] Neuts-92.7* Lymphs-4.9* Monos-2.2 Eos-0.2 Baso-0.1
[**2195-9-18**] PT-11.7 PTT-23.0 INR(PT)-1.0
[**2195-9-18**] Glucose-53* UreaN-38* Creat-1.2* Na-140 K-4.1 Cl-103
HCO3-28 AnGap-13 Calcium-8.5 Phos-3.3 Mg-1.8
Iron studies:
[**2195-9-22**] 04:24AM BLOOD calTIBC-124* VitB12-[**2121**]* Folate-10.9
Hapto-224* Ferritin-780* TRF-95* LD(LDH)-299* Ret Aut-3.2
FDP-0-10
Cardiac enzymes:
[**2195-9-18**] 09:57PM BLOOD CK(CPK)-21* cTropnT-0.02* CK-MB-NotDone
[**2195-9-19**] 07:43AM BLOOD CK(CPK)-15* CK-MB-NotDone cTropnT-0.01
EKG: ([**9-19**]): Sinus tachycardia. Non-specific ST-T wave changes.
No previous tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
106 150 76 324/[**Telephone/Fax (2) 82993**]
Laboratories on discharge:
[**9-25**]: INR=3.0
*/21: WBC count=14.6
Imaging studies:
CT of the spine: IMPRESSION:
Comminuted fracture of the C2 vertebral body extending to the
transverse
foramina bilaterally and involving the base with a minimally
displaced
fragment anteriorly. A CTA or MRA of the neck is recommended to
exclude
vertebral arterial injury.
Minimal anterolisthesis of C3 on C4 with widening of the disc
space
anteriorly, which may suggest ligamentous injury. MRI is
recommended for
further evaluation.
Linear slightly hyperdense material extending from the clivus,
along the
anterior spinal canal, to the C3-C4 level, may represent
epidural hemorrhage. No evidence of spinal cord compression.
This can be evaluated at the time of MRI of the cervical spine.
Disc bulges at C3-C5 with narrowing of the central canal.
CT of the neck:
IMPRESSION:
No definite evidence for dissection. MRA would be more sensitive
for
detection of mural hematoma using fat-sat T1-weighted images.
Filling defects suggesting pulmonary emboli in the right greater
than left
pulmonary arteries. These findings were discussed by Dr [**Last Name (STitle) 82994**]
with Dr. [**Last Name (STitle) **] at 12:05 a.m. on [**2195-9-19**].
Lower extremity doppler: IMPRESSION:
1. Fairly extensive thrombus in the right superficial femoral
vein.
2. No thrombus on the left.
Echo ([**9-21**]): The left atrium and right atrium are normal in
cavity size. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is mild functional mitral stenosis (mean
gradient 6 mmHg) due to mitral annular calcification. No mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild functional mitral stenosis. Mild pulmonary artery systolic
hypertension.
Brief Hospital Course:
The patient is an 87 yo woman with h/o osteoporosis, DM2,
dementia, depression, and anxiety who presents s/p fall with
evidence of C2 fracture, bilateral pulmonary emboli and C. diff
colitis.
.
# Pulmonary emboli: CTA of the patient's neck showed evidence
of right and left pulmonary artery emboli which straddle the
bifurcation but it is not occlusive. Given that the patient had
a recent hospitalization for pneumonia, she might have developed
the PE while in the hospital, i.e. this was a provoked PE. The
patient remained hemodynamically stable and required 2L of
oxygen initially. An echo revealed a normal right ventricle with
mild pulmonary artery systolic hypertension. The patient was
anticoagulated with a heparin gtt and started on Coumadin. On
transfer to the general medicine floors, the patient remained
stable. The family decided for placement of an IVC filter which
will be removed in four weeks. Her INR on the day of
discharge=3.0. She will need INR checks for the next 5 days with
a goal INR=[**3-10**].
.
# C2 Fracture: The patient has a transverse comminuted fracture
of C2. Neurosurgery evaluated her and determined that she is not
a surgical candidate. The neurosurgery team recommends a
cervical collar until after her followup appointment on [**11-5**].
Her pain is controlled with Tylenol 1 g QID and breakthrough
Oxycodone.
.
# C diff colitis: The patient presented with a WBC count to 30K
on admission and diffuse abdominal pain. Vancomycin was added to
her Flagyl while in the ICU. On transfer to the floors, the
Flagyl was discontinued. Vancomycin will be continued until
[**10-4**]. On discharge, the patient's WBC count has been trending
downwards. She still has left-sided abdominal tenderness.
.
Urinary tract infection: The patient was diagnosed with a UTI,
urine culture pending at discharge. She has been on a three day
course of Cipro that will end on [**9-26**].
# DM2: The patient has a history of DM2, for which she takes
Lantus daily and Novalog insulin SS. Her SSI does not start
until FSBG of 300, as the patient reportedly has very brittle
DM2. She was continued on her home regimen and there were no
episodes of hypoglycemia or glucose>400.
# CAD s/p MI: The patient had some complaints of atypical chest
pain overnight. The pain was reproducible, no EKG changes. The
patient says that she always has the pain. Her home aspirin and
Zocor were continued. Continue ASA and Zocor. She was started on
her home dose of metoprolol on discharge.
Heart failure: Her home medications of Enalapril and Lasix were
held due to adequate BP and no signs of fluid overload. She had
an Echo which showed mild symmetric left ventricular hypertrophy
with preserved global and regional biventricular systolic
function. Mild functional mitral stenosis. Mild pulmonary artery
systolic hypertension.
Outpatient followup:
1. Has an appointment to remove IVC filter
2. Need to check PT/INR until [**10-1**] for a goal INR=[**3-10**].
3. Holding Enalapril and Lasix on discharge. If patient develops
HTN or signs of fluid overload, consider starting these
medications.
4. Ortho spine followup appointment on [**11-5**]. Keep hard collar in
place until after that appointment.
Medications on Admission:
Singulair 10 mg daily
Wellburtin 75 mg daily
Sliding scale insulin (301-350 --> 4 U Novalog; 351-399 --> 6 U
Novalog; 400-500 --> 8 U Novalog
Lantus 25 U daily
Ativan 0.5 mg PO TID prn agitation
Ativan 0.25 mg PO qid
Percocet PO q4h prn pain
Percocet PO TID
Duonebs q4h while awake
ASA 81 mg daily
Calcium 500 mg daily
Vit D daily
Citalopram 20 mg daily
Colace 100 mg [**Hospital1 **]
Aricept 10 mg qhs
Enalapril 5 mg daily
Advair 100/50 [**Hospital1 **]
Lasix 40 mg daily
Lopressor 25 mg PO BID
Florastor 250 mg PO BID
Senna 2 tabs PO qhs
Zocor 20 mg PO daily
Prednisone 5 mg daily?
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Novolog 100 unit/mL Cartridge Sig: see below cartridge
Subcutaneous qachs: Sliding scale:
301-350: 4 units of novalog
351-399: 6 units of novalog
400-500: 8 units of novalg.
4. Lantus 100 unit/mL Cartridge Sig: Twenty Five (25) units
Subcutaneous once a day.
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for agitation.
6. Lorazepam 0.5 mg Tablet Sig: half Tablet PO Q6H (every 6
hours).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H:PRN as
needed for pain: Please hold for RR<12.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours):
mix with ipratropium.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours): Mix with albuterol.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
16. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
18. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 9 days: Last day=[**10-4**].
19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days: Last day=[**9-26**] (needs PM dose on
[**9-25**]).
20. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP<100 or HR<60. Tablet(s)
21. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34004**] Nursing & Rehabilitation Center - [**Location (un) 14663**]
Discharge Diagnosis:
Primary:
1. Bilateral pulmonary embolism
2. C. diff colitis
3. C2 neck fracture
.
Secondary
1. diabetes mellitus, Type II
Discharge Condition:
Stable. Patient breathing room air.
Discharge Instructions:
You came to the hospital after suffering a fall at your nursing
home. You were found to have a fracture in your neck. There will
be no surgical intervention. You need to wear the hard collar
around your neck for 5 more weeks.
.
While scanning your neck to assess for the fracture, you were
also found to have bilateral pulmonary emboli, or blood clots.
Heparin, a blood thinner, was started. You were also found to
have a clot in your right leg and a filter was placed in your
vein to prevent that clot from going into your lungs. You have a
followup appointment with interventional radiology to remove
that filter--it can be removed at any time. You are also on
Coumadin, a blood thinner, to prevent future clots. You are no
longer on heparin.
.
You were also treated for C. diff colitis with Vancomycin, an
antibiotic. You should continue to take this antibiotic until
[**10-4**].
.
You also have a urinary tract infection and you will be treated
with Cipro until [**9-26**].
.
You should come back to the hospital if you become short of
breath, have increased leg swelling, have increased chest pain,
or have increased abdominal pain.
Followup Instructions:
Appointment #1
MD: Dr. [**Last Name (STitle) 9441**] (might change though due to schedule)
Specialty: Interventional Radiology
Date and time: [**2195-10-27**]-Tuesday, 9:30am pt should arrive @
daycare
Location: [**Hospital1 7768**], [**Hospital3 **] Hospital, [**Hospital Ward Name 121**] 1
(daycare unit)
Phone number: [**Telephone/Fax (1) 41473**]( daycare unit, daytime #)
[**Telephone/Fax (1) 53981**]( actual angio suite #)
Special instructions if applicable: Interventional radiology
(removal of IVC filter)
If problems or questions, call [**First Name8 (NamePattern2) **] [**Name (NI) 6745**]: [**Telephone/Fax (1) 6747**]
Appointment #2:
MD: Dr. [**Last Name (STitle) 1352**]
Specialty: Orthopedic Spine
Date and time: 10/01/09-2:00pm
Location: [**Location (un) **], [**Location (un) 86**], MA Floor 2
Phone number: [**Telephone/Fax (1) 3736**]
ICD9 Codes: 5990, 4280, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1725
} | Medical Text: Admission Date: [**2197-4-4**] Discharge Date: [**2197-4-6**]
Date of Birth: [**2128-2-1**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Tremor
Major Surgical or Invasive Procedure:
Attempt at Stage 1 DBS, Stereotactic frame and burr hole
placement
History of Present Illness:
Mr. [**Known lastname 80234**] is a 69 year old gentleman with a 20 year history
of Parkinsons disease. Presenting symptom, right arm tremor. Now
things are progressed
and they are still strongly asymmetric with the right side still
being the worse. Major problems are tremor, rigidity, muscle
cramping, bradykinesia, and dyskinesias as well. Gait is not as
bad. Freezing is an issue as well. Poor balance and dysarthria
is also a problem. [**Name (NI) 28118**] problems are stooped posture and
swallowing trouble, whereas he has [**Last Name **] problem with memory loss
or
hallucinations. He needs assistance when he is walking and he is
off. He has to to use a walker. The difference between his best
on and worst off is extreme and he thinks he spends at the most
about 50% on during the day. He takes Sinemet six times a day.
Past Medical History:
PD, R>L tremor, gait Ds, mild hypothyroidism, knee surgery,
pilonidal cyst surgery
Social History:
Lives with family
Family History:
Non contributory
Physical Exam:
Upon discharge:
Patient afebrile and heamodynamically stable.
He is oriented to person, place, day, date, time of the day.
Mild difficulties in obeying commands. But otherwise no clear
cranial nerve deficits. Able to move all 4 limbs. Power grossly
normal in all 4 limbs.
Motor: Appears dyskinetic all over, hypomimic and hypophonic.
There was no rest, action, or postural tremor.
He had mild cogwheeling bilaterally, right more than left
Pertinent Results:
[**2197-4-4**] CT Head
FINDINGS: The patient is status post cannulation of the left
frontal bone for deep brain stimulation procedure. A small
amount of subarachnoid hemorrhage adjacent to the surgical
defect interdigitates along left frontal sulci, which
demonstrate mild cortical swelling. A small subdural hemorrhage
may be present in this location as well. A moderate amount of
expected pneumocephalus is seen. As seen on prior MR, there is
moderate dilatation of the ventricles. A small hypodense area in
the left temporal lobe ( se 2, im 6) is likely artifactual.
Basal cisterns appear patent. The visualized paranasal sinuses
are clear. Globes and orbits are intact.
IMPRESSION: Status post aborted DBS with small amount of
subarachnoid
hemorrhage, mild cortical swelling, and possibly a small
subdural hematoma
present adjacent to the surgical site.
[**2197-4-5**] CT Head
FINDINGS: Small left frontal subarachnoid hemorrhage with
minimal associated sulcal effacement adjacent to craniotomy due
to aborted attempt of place deep brain stimulator is stable.
Previously suspected thin left frontal subdural hematoma is more
evident on current study, but measures only 2-3 mm at greatest
depth (2:21). Stable moderate amount of post-procedural
pneumocephalus evident. Moderate ventriculomegaly is unchanged.
The mastoid air cells and middle ear cavities are clear. Minimal
mucosal thickening identified within the ethmoid air cells.
IMPRESSION: Status post aborted DBS, with stable small amount of
subarachnoid hemorrhage layering in the left frontal sulci with
mild sulcal effacement; there is a very thin subdural hematoma
at the surgical site, minimally-increased and measuring only [**2-17**]
mm in maximal thickness.
Brief Hospital Course:
69M elective admission for stage 1 DBS which was aborted
secondary to bleeding. Post-op head CT showed a small SAH on the
left side. He was admitted to the Neuro ICU. He had a repeat
head CT for an episode of freezing/ increased tremor/
unresponsive. CT head was stable. Heme was called to consult. On
[**4-5**] his exam was stable and appeared at his baseline. Heme felt
the increased bleeding could be from a platelet dysfunction
secondary to herbal supplements and recommended that patient
discontinue taking these supplements.
On [**4-6**], PT evaluation was obtained and they recommended home.
Additionally, a CXR and UA was obtained to ensure that is post
op confusion was not infectious. This was essentially negative.
Now DOD, he is afebrile, VSS, and neuro stable. He is
ambulating at baseline. He is set for d/c home in stable
conditon and will follow-up accordingly.
Medications on Admission:
Sinemet 25/100 two tablets six times per day
ReQuip XL 2 mg at 8:00 a.m. and 10:00 a.m
Discharge Medications:
1. carbidopa-levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO 6
TIMES DAILY ().
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/temp/ha.
4. Requip XL 2 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO daily ().
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Healthcare of [**Location (un) **] CT
Discharge Diagnosis:
Parkinson's Disease
SAH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please remove your dressing on [**2197-4-6**]. Keep sutures clean and
dry until they are removed.
Followup Instructions:
Please call [**Telephone/Fax (1) 1272**] to re-schedule your surgery and for a
suture removal appointment in [**7-25**] days from the date of your
surgery.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2197-4-6**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1726
} | Medical Text: Admission Date: [**2125-9-7**] Discharge Date: [**2125-9-10**]
Date of Birth: [**2050-1-19**] Sex: M
Service: CCU/MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 75 year-old male with
a history of diabetes, coronary artery disease. He is status
post a silent myocardial infarction and also has a history of
chronic obstructive pulmonary disease (he has 100 pack year
of smoking tobacco and is still smoking). He also has a
history of hypercholesterolemia, hypertension. He also has a
history of lower gastrointestinal bleed and anemia. The
patient presented to the [**Hospital 882**] Hospital on [**2125-9-7**]
with shortness of breath and diaphoresis. He was found to
have an ST segment elevation myocardial infarction and
congestive heart failure at the [**Hospital1 882**] and was transferred
to the [**Hospital1 69**] for cardiac
catheterization. In the catheterization laboratory revealed
three vessel disease, 100% left anterior descending coronary
artery and right coronary artery, short left main carotid
artery without any lesions, and an 80% left circumflex artery
and an 80% OMI. There were no interventions done during the
catheterization. Many collaterals were noted at the time.
CT Surgery was consulted in the catheterization laboratory
during the procedure for a potential coronary artery bypass
graft. The patient's catheterization was uncomplicated and
he was scheduled to undergo coronary artery bypass graft on
Monday [**2125-9-10**].
In preparation preoperatively he had an echocardiogram, which
showed an ejection fraction of 15 to 20% and apical inferior
and basal akinesis. This was in contrast to his
transthoracic echocardiogram study in [**2124-5-5**] that
showed an ejection fraction of 50%, mild hypokinesis of the
inferobasal wall. The patient was also noted post
catheterization to have a mild groin hematoma. Further
preoperative evaluation included diuresis with Lasix as well
as carotid doppler ultrasound studies, which demonstrated 60%
occlusion in the left carotid artery and essentially clean
right carotid artery. The patient was stable throughout his
course of his hospitalization until the morning of [**2125-9-10**] when the house staff was called for an expanding
hematoma of the right groin. Initially his vital signs were
stable. Repeat hematocrit showed that this was stable since
the prior study four hours earlier.
Over the next couple of minutes the patient's blood pressure
was noticed to drop from the systolic high 110s to 80/40.
The patient was given wide open fluids and a code was called
and eventually Dopamine was started. The patient's blood
pressure responded to this intervention. During the code a
unit of packed red blood cells was ordered and begun to
transfuse. Shortly after this time the patient was noted to
seize briefly and then go into ventricular fibrillation
rhythm. The patient was shocked repeatedly for ventricular
fibrillation. He subsequently went in and out of asystole
alternating with ventricular fibrillation. The patient had
over the course of the one hour code received multiple
shocks, calcium carbonate, bicarbonate, magnesium, amiodarone
as well as atropine. None of these measures were sufficient
to sustain life and the patient expired at approximately 1:05
p.m. on [**2125-9-10**]. The family, which included his two
sisters [**Name (NI) **] and [**First Name8 (NamePattern2) 1743**] [**Name (NI) 12163**] were notified in a timely
fashion and they refused the postmortem examination.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Doctor Last Name 25109**]
MEDQUIST36
D: [**2125-9-10**] 15:28
T: [**2125-9-13**] 13:33
JOB#: [**Job Number 25110**]
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1727
} | Medical Text: Admission Date: [**2157-12-4**] Discharge Date: [**2157-12-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
Upper endoscopy [**2157-12-5**]
History of Present Illness:
Ms. [**Known lastname 303**] is an 88-year-old woman with a history of diabetes,
hypertension, prior episode of UGIB in distant past, who
presents with hematemesis. She was in USOH until this evening
when, after having an uneventful dinner, she awoke in the middle
of the night and had one episode of approximately 500 cc of
hematemesis. She denied abdominal pain, diarrhea, or blood in
her stool, but she did have a single brown, nonbloody bowel
movement per her daughter. She was transported to the E.D. for
further evaluation. Her recent history is negative for alcohol,
aspirin, or other NSAID use.
.
In the ED, vital signs were initially: 95.4 112 156/94 16 98.
Labs were notable for a hct of 32 down from a baseline of 35-40,
and an NGL was positive for blood and coffee grounds and
remained pink in color after lavage with ~1L. She was guaiac
negative per rectum. GI was consulted and felt that she was
hemodynamically stable with a plan for EGD in the a.m. She was
started on pantoprazole and given 2L IVF and admitted to the
[**Hospital Unit Name 153**] for further management.
.
REVIEW OF SYSTEMS:
No fevers, chills, weight loss, diaphoresis, headache, visual
changes, sore throat, chest pain, shortness of breath, diarrhea,
melena, pruritis, easy bruising, dysuria, skin changes,
pruritis.
Past Medical History:
- Diabetes, diet controlled.
- Choledocholithiasis status post sphincterotomy in [**2150**]
- Distant history of hepatic abscess s/p drainage
- UGIB in [**Country 3587**] in distant past, no work-up performed
- Hypertension
- Hypercholesterolemia
Social History:
No tobacco or alcohol. She splits her time between this country,
living with her granddaughter, and [**Country 3587**].
Family History:
No history of bleeding disorders.
Physical Exam:
VS: 94 154/71 20 100%
GEN: The patient is in no distress and appears comfortable
SKIN: No rashes or skin changes noted
HEENT: No JVD, neck supple, No lymphadenopathy in cervical,
posterior, or supraclavicular chains noted.
CHEST: Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: No apparent scars. Non-distended, and soft without
tenderness
EXTREMITIES: trace peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**5-10**], and BLE [**5-10**] both proximally and distally. No pronator
drift. Reflexes were symmetric. Downward going toes.
.
Pertinent Results:
STUDIES:
Upper endoscopy [**2157-12-5**]:
Erythema in the antrum compatible with gastritis
Angioectasia in the fundus (endoclip)
Abnormal mucosa in the stomach
Otherwise normal EGD to third part of the duodenum
.
.
LABS:
[**2157-12-4**] 09:55PM BLOOD WBC-9.5 RBC-3.66* Hgb-10.4* Hct-32.9*
MCV-90 MCH-28.5 MCHC-31.7 RDW-14.1 Plt Ct-248
[**2157-12-5**] 12:59AM BLOOD WBC-8.6 RBC-3.51* Hgb-10.3* Hct-31.0*
MCV-88 MCH-29.5 MCHC-33.3 RDW-13.4 Plt Ct-229
[**2157-12-5**] 05:04AM BLOOD Hct-28.4*
[**2157-12-5**] 02:48PM BLOOD Hct-31.0*
[**2157-12-5**] 11:45PM BLOOD WBC-8.5 RBC-3.58* Hgb-10.4* Hct-30.4*
MCV-85 MCH-29.0 MCHC-34.2 RDW-14.4 Plt Ct-181
[**2157-12-6**] 06:55AM BLOOD WBC-7.5 RBC-3.41* Hgb-10.0* Hct-29.7*
MCV-87 MCH-29.2 MCHC-33.5 RDW-14.7 Plt Ct-170
[**2157-12-6**] 04:10PM BLOOD WBC-7.7 RBC-3.45* Hgb-10.2* Hct-30.2*
MCV-88 MCH-29.7 MCHC-33.9 RDW-14.5 Plt Ct-174
[**2157-12-4**] 09:55PM BLOOD Neuts-47.0* Lymphs-43.1* Monos-4.1
Eos-5.0* Baso-0.8
[**2157-12-6**] 04:10PM BLOOD Plt Ct-174
[**2157-12-4**] 09:55PM BLOOD PT-12.5 PTT-18.9* INR(PT)-1.1
[**2157-12-4**] 09:55PM BLOOD Glucose-202* UreaN-32* Creat-1.2* Na-140
K-4.3 Cl-102 HCO3-28 AnGap-14
[**2157-12-5**] 12:59AM BLOOD Glucose-206* UreaN-30* Creat-1.1 Na-138
K-4.4 Cl-102 HCO3-27 AnGap-13
[**2157-12-6**] 06:55AM BLOOD Glucose-126* UreaN-22* Creat-1.1 Na-141
K-4.1 Cl-107 HCO3-26 AnGap-12
[**2157-12-6**] 06:55AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0
MICRO:
Time Taken Not Noted Log-In Date/Time: [**2157-12-5**] 10:03 am
SEROLOGY/BLOOD CHEM # 00229F [**12-5**].
HELICOBACTER PYLORI ANTIBODY TEST (Negative):
Brief Hospital Course:
Ms. [**Known lastname 303**] is an 88-year-old woman with a history of diabetes,
hypertension, prior episode of UGIB in distant past, who
presents with hematemesis.
.
# Hematemesis: Hct 33 from baseline of 35-40. Upper endoscopy
showed Angioectasia in the fundus, which was clipped. She was
initially treated with IV pantoprazole [**Hospital1 **]. She was transferred
to the medical floor, where her PPI was switched to an oral
preparation [**Hospital1 **]. Her HCT remained stable without additional
transfusion. Her diet was advanced without difficulty.
.
An H pylori antibody was negative. She was instructed to avoid
NSAIDs or aspirin until seeing her primary care physician [**Name Initial (PRE) 176**]
2-3 weeks. She was instructed to arrange for a follow-up
appointment within 2-3 weeks.
.
# Hypertension: Her home regimen was initially held due to
acute bleeding, but were restarted upon arrival to the medical
floor without difficulty (HCTZ, lisinopril).
.
# Diabetes, Type 2 - diet controlled as an outpatient. Pt was
covered with sliding scale insulin, this was discontinued upon
discharge.
.
# Disposition - pt was evaluated by physical therapy due to
deconditioning and weakness. She walks with a walker at home at
baseline, but lives with her daughter only. She was felt to
benefit from 24 hour supervision, which her daughter was
initially unable to provide. Additional family members
ultimately arrived, and she was discharged into their care with
24 hour supervision.
Medications on Admission:
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth
daily
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE - 40 mg Capsule - 1 Capsule(s)by mouth daily
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
hemetemesis
gastric AV malformation, s/p clipping.
Discharge Condition:
Tolerating oral diet.
Discharge Instructions:
You were admitted to the hospital because you were vomiting
blood. You were found to have an artery-vein malformation in
you stomach, which was the source of the bleeding, and was
clipped to stop the bleeding.
The following changes were made in your medication regimen:
1. You were started on a regimen of protonix 40mg by mouth twice
daily.
Followup Instructions:
Upon arriving home, please arrange to be seen by your primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 2-3 weeks. [**Last Name (LF) **],[**First Name3 (LF) **] J.
[**Telephone/Fax (1) 7976**]
ICD9 Codes: 2851, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1728
} | Medical Text: Admission Date: [**2155-5-15**] Discharge Date: [**2155-5-21**]
Date of Birth: [**2081-4-2**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Ischemic ulcer of the right great toe.
Major Surgical or Invasive Procedure:
Right below-knee popliteal artery to dorsalis pedis artery
bypass with non-reverse right greater saphenous vein and
angioscopy.
History of Present Illness:
This 74-year-old gentleman has a nonhealing
ischemic ulcer of his right great toe. He underwent an
arteriogram recently which showed extensive tibial occlusive
disease with reconstitution of the dorsalis pedis artery at
the level of the ankle. The ulcer has shown no signs of
healing and he is advised to have bypass to heal his foot.
He has had longstanding type 2 diabetes and takes insulin.
Past Medical History:
PMH: PAD, DM, CAD, s/p MI, HTN, Hyperlipidemia, Obesity
PSH: [**2149**] CABG x 5; Cholecystectomy
Social History:
He is widowed, lives alone. He has never smoked or drank.
Family History:
There is a history of heart disease and vascular disease in his
family.
Physical Exam:
On physical examination, he is an elderly obese gentleman in no
acute distress. He is 5'7" and 250 lbs. Blood pressure is
179/89. Pulse is 60. Respirations are 16. He has no cervical
bruits. Chest is clear. Heart is in regular rhythm. Abdomen
is
very obese. His femoral and popliteal pulses are palpable. His
left dorsalis pedis pulse is faintly palpable. He has
nonpalpable foot pulses on the right. He has some suggestion of
diabetic neuropathy with some bony deformities of his feet,
although not Charcot foot or rocker bottom deformities, but more
prominent metatarsal heads and some interosseous muscle wasting.
On the lateral aspect of the right metatarsophalangeal joint,
there is a black eschar. It is approximately 4 mm in diameter
and slightly tender to the touch and does not look infected.
Pertinent Results:
[**2155-5-19**] 05:00AM
BLOOD WBC-7.0 RBC-3.38* Hgb-10.4* Hct-29.5* MCV-87 MCH-30.7
MCHC-35.1* RDW-13.6 Plt Ct-198
[**2155-5-19**] 05:00AM BLOOD
Plt Ct-198
[**2155-5-20**] 04:42AM BLOOD
Glucose-141* UreaN-27* Creat-0.9 Na-143 K-3.7 Cl-108 HCO3-27
AnGap-12
[**2155-5-18**] 09:22AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
URINE Blood-LG Nitrite-NEG Protein-30 Glucose-1000 Ketone-10
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
URINE RBC->182* WBC-8* Bacteri-FEW Yeast-NONE Epi-0
URINE CastHy-3*
CXR:
Cardiomegaly, widened mediastinum and elongated aorta are
stable.
Mild-to-moderate pulmonary edema is new. Right IJ catheter
remains in place. Bilateral pleural effusions are small.
Sternal wires are aligned. The patient is status post CABG.
ECHO:
Suboptimal image quality. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve is not well
seen. The mitral valve leaflets are not well seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname **],[**Known firstname **] was admitted on [**5-15**] with Ischemic ulcer of the
right great
toe.
He agreed to have an elective surgery. Pre-operatively, he was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preparations were made.
It was decided that she would undergo a:
Right below-knee popliteal artery to dorsalis pedis artery
bypass with non-reverse right greater saphenous vein and
angioscopy.
He was prepped, and brought down to the operating room for
surgery.
Before the procedure, there was difficulty placing the Foley
catheter. Urology was consulted. They found a Urethral
stricture. They placed a Foley catheter. This was kept in place
for 5 days.
Intra-operatively, he was closely monitored and remained
hemodynamically stable. He tolerated the procedure well without
any difficulty or complication.
Post-operatively, he was extubated and transferred to the PACU
for further stabilization and monitoring.
Pt was experiencing chest pressure in the PACU. A cardiology
consult was obtained. pt was given Nitro drip, started on
Labetalol drip, and a ASA. With these medications the chest
pressure improved. Pt transferred to the CVICU for monitoring.
We cycled his troponins. The were elevated.
Pt diuresed in the CIVU.
He was then transferred to the VICU for further recovery. While
in the VICU he received monitored care. His labetalol drip was
DC'd, changes to Lopressor, The IV Nitro was DC'd changed to
Imdur. His troponins continued to rise.
It was decided to an echo:
Suboptimal image quality. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve is not well
seen. The mitral valve leaflets are not well seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
With the continued rise in troponins it was decided to do a
cardiac cath.
Cath: patent vein grafts/LIMA, LAD occluded, elevated PA
pressures.
With the elevated PA pressures it was decided to add Lasix to
his regime
When stable he was delined. His diet was advanced. A PT consult
was obtained, he was transferred to floor status
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home with VNA in stable
condition.
POd #5, the Foley was DC'd, the pt had [**Last Name **] problem urinating.
He is to follow up with his PCP regarding his BP.
Medications on Admission:
carvedilol 12.5 mg [**Hospital1 **]; Lantus 100 unit/mL Solution 75 units
every morning; isosorbide mononitrate xr 60 mg qd; lisinopril 40
mg qd; nitroglycerin prn; rosuvastatin 40 mg qd; tamsulosin 0.4
mg qd; valsartan-hydrochlorothiazide 320 mg-12.5 mg qd; aspirin
325 mg qd; Humulin R 100 unit/mL Solution
20 units with meals (adjusts per SS)
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: prn for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Diovan HCT 320-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
4. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: 1.5 tabs Tablet Extended Release 24 hrs PO DAILY (Daily):
90 mg total.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*6*
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*6*
6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
8. INSULIN
Sliding Scale & Fixed Dose
Fingerstick q4hours
Insulin SC Fixed Dose Orders
Breakfast
Glargine 37 Units
Insulin SC Sliding Scale
q6hrs
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
> 350 mg/dL Notify M.D.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. metoprolol tartrate 50 mg Tablet Sig: 1.5 tabs Tablets PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*6*
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day.
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
care for life, [**Hospital 89927**] health care
Discharge Diagnosis:
Ischemic ulcer of the right great toe.
HTN
Increase in Troponins, demand ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-13**]
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:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2155-6-9**] 9:15
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Address: [**Location (un) 35593**], [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 35276**]
Fax: [**Telephone/Fax (1) 35649**]
Completed by:[**2155-5-21**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1729
} | Medical Text: Admission Date: [**2187-5-1**] Discharge Date: [**2187-5-8**]
Date of Birth: [**2108-10-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Known sinus of Valsalva aneurysm for surgical repair. Same day
admit
Major Surgical or Invasive Procedure:
AVR
Sinus of Valsalva Aneurysm repair
History of Present Illness:
78 yoM known sinus of valsalva aneurysm from previous
admission([**2187-4-8**]) for scheduled surgical repair
Past Medical History:
h/o prostate cancer s/p XRT
Epidermal inclusion cysts
Right inguinal hernia s/p repair in [**2183**]
Emphysema, negative smoking history
Osteoporosis
Social History:
The patient lives alone in a 1 story apartment. He is
independent with his own ADLs. He drinks on occasion on the
weekends but denies any smoking history. His father and brother
were heavy smokers.
Family History:
Father deceased at 71 from MI
Mother died suddenly
Brother deceased at 70 from MI
Physical Exam:
Preop
T 98 HR71 BP 120/60 RR 18 Sat 97%RA
Gen NAD
Psych A&Ox3 MAE folows commands non focal exam
CV RRR 3/6 SEM
Pulm CTAB
Abdm Soft NABS
Ext Warm well perfused no edema
Discharge
T 98.5 HR 84 SR BP 122/62 RR 20 O2 sat 98% 3LNP
Gen NAD
Psych A&Ox3 MAE non focal exam
Pulm CTA
CV RRR, sternum stable, Wound clean and dry no erythema or
drainage
Abdm soft NT/ND/NABS
Ext Warm, well perfused, no C/C/E
Pertinent Results:
[**2187-5-1**] 04:55PM UREA N-19 CREAT-0.8 CHLORIDE-116* TOTAL
CO2-24
[**2187-5-1**] 04:55PM WBC-12.9* RBC-3.25* HGB-10.5* HCT-30.0*
MCV-93 MCH-32.3* MCHC-34.9 RDW-15.3
[**2187-5-1**] 04:55PM PLT COUNT-151
[**2187-5-8**] 06:10AM BLOOD WBC-7.9 RBC-3.40* Hgb-11.0* Hct-31.8*
MCV-94 MCH-32.2* MCHC-34.4 RDW-15.2 Plt Ct-228#
[**2187-5-8**] 06:10AM BLOOD UreaN-21* Creat-0.9 K-4.5
Brief Hospital Course:
Pt admitted directly to operating room where he underwent
AVR(#23pericardial) and repair of aneurysm of the sinus of
valsalva w/dacron patch. Seee OR report for full details.
Pt was transferred from OR to Cardiac surgery recovery unit. The
patient was somewhat hypoxic in the immediate postop period and
remained intubated and sedated throughout the day of surgery. On
POD1 a TEE was done, it showed good LV and valvular function
w/no signs of tamponade. Interventional pulmonary was also
consulted. Additionally the patient had an episode of atrial
fibrilllation for which he was started on Amiodarone and
Metoprolol, following which he converted to SR.
Following the echo the sedation was discontinued and over the
next day the patient was weaned from the ventilator and
successfully extubated on POD2.
On POD3 the patient was transferred to the cardiac surgery floor
for continued postop recovery. He had an uneventful recovery
once on the floors and on POD 7 it was decided that he was ready
for discharge to rehabilitation
Medications on Admission:
Colace 100mg [**Hospital1 **]
Metoprolol 25mg [**Hospital1 **]
Flomax 0.4mg QD
MVI 1 tab QD
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks. Tablet(s)
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 2 weeks.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1wk then 400mg QD x1wk
then 200mg QD.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
sinus of valsalva aneurysm repair
aortic regurgitation s/p AVR
COPD
prostate CA
Discharge Condition:
good
Discharge Instructions:
may shower, no bathing or swimming for 1 month
take all medications as preescribed
no lifting > 10# for 10 weeks
call for any fever redness or drainage from wounds
no creams, lotions or powders to any incisions
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (STitle) 2204**] in [**2-16**] weeks
with Dr. [**Last Name (STitle) **] in [**2-16**] weeks
with Dr. [**Last Name (Prefixes) **] in 4 weeks
Completed by:[**2187-5-8**]
ICD9 Codes: 4241, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1730
} | Medical Text: Admission Date: [**2187-12-25**] Discharge Date: [**2188-1-3**]
Date of Birth: [**2123-1-24**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 32226**] is a pleasant
64-year old gentleman who presented to [**Hospital1 **]
for a cardiac catheterization after an equivocal stress test.
His catheterization on [**2187-12-25**] showed left dominant
system with three vessel disease. The left main had a distal
20% stenosis, mid LAD had 60-70% stenosis. There was a 50%
distal LAD stenosis. The circumflex was large with a tubular
70% stenosis of mid vessel and a long 70-80% stenosis before
the left PDA. The first marginal had an 80% stenosis, the
left PDA was diffusely diseased. RCA was non-dominant and
was totally occluded proximally. The distal vessels filled
via left-sided collaterals. The ventriculogram showed
severely reduced systolic function with an ejection fraction
of 30%. There was global hypokinesis present with
inferoposterior basal segments reversed. The valves were
normal. Given this, Mr. [**Known lastname 32226**] was assessed to require a
coronary bypass as the best option for his care. He elected
for this surgery after the risks and benefits were explained
to him and elected to have this done during this admission.
PAST MEDICAL HISTORY:
MEDICATIONS ON ADMISSION:
ALLERGIES:
PHYSICAL EXAMINATION:
LABORATORY:
HOSPITAL COURSE: He received a coronary bypass on [**2187-12-27**] with the following anatomy:
1. LIMA to LAD.
2. Vein to OM.
3. Vein to distal circumflex.
4. Vein to D2.
PDA was not grafted because it was too small.
Mr. [**Known lastname 32226**] was transferred to the CTICU for his
postoperative care and was transferred out without any
complications on postoperative day #2 to the floor. During
his recovery, he was found to have a slight wobble with his
walk. According to a family member, this was an exacerbation
of a condition that existed prior to the operation. Given
this neurological change, a Neurology consult was obtained
for evaluation. There was an initial question of a mid
cerebellar hypoperfusion, however over time as the patient
improved and his gait improved, as per Neurology, cerebellar
infarct was unlikely. An MRI of the brain focusing on the
cerebellum is recommended and given that the patient is post
coronary bypass, it will be scheduled as an outpatient basis.
Mr. [**Known lastname 32226**] is ambulating with some assist, tolerating a
regular diet. He is being transferred to rehabilitation for
further recuperation. He is to follow up with Neurology
after his MRI with Dr. [**First Name (STitle) 10102**] within a month and with his
primary care physician. [**Name10 (NameIs) **] is also to follow up with
Cardiology.
Pertinent tests - Cardiac catheterization: Low cardiac index
of 2.2 liters per minute per meter squared. Left
ventriculography shows reduced systolic function with an
ejection fraction of 30%, and a global hypokinesis with
inferoposterior basal segments reversed. There was no mitral
regurgitation. Selective coronary arteriography shows left
dominant system with three vessel disease. Left main has
distal 20% stenosis, mid LAD has 60-70% stenosis. There is a
50% distal LAD stenosis. The circumflex is large with a
tubular 70% stenosis of mid vessel and a 70-80% stenosis
before the left PDA. The first marginal has an 80% stenosis.
The left PDA is diffusely diseased. RCA is non-dominant and
totally occluded proximally. The distal RCA fills via left
left-sided collateral. In summary, Mr. [**Known lastname 32226**] has three
vessel coronary artery disease with moderate to severe
systolic and diastolic ventricular dysfunction and moderate
pulmonary hypertension. This report is obtained prior to his
coronary bypass.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81 milligrams p.o. q.d.
2. Glyburide 5 milligrams p.o. q.d.
3. Glucophage 500 p.o. b.i.d.
4. Lasix 20 milligrams p.o. b.i.d.
5. Lopressor 50 milligrams p.o. b.i.d.
6. Carafate 1 gram t.i.d.
7. Colace 100 milligrams p.o. b.i.d.
8. Ibuprofen 600 milligrams every 6 hours p.r.n.
9. Captopril 6.25 p.o. b.i.d.
10. Potassium chloride 20 milliequivalents p.o. q.d.
11. Sliding scale insulin for 200-260, give 6 units, for
260-299, give 9 units, for 300-350, give 12 units. For
sugars above 350, please call house officer.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES:
1. Coronary artery bypass graft.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13625**]
Dictated By:[**Name8 (MD) 180**]
MEDQUIST36
D: [**2188-1-3**] 13:52
T: [**2188-1-3**] 13:56
JOB#: [**Job Number 32227**]
ICD9 Codes: 4111, 4280, 3572, 4019, 4168, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1731
} | Medical Text: Admission Date: [**2131-2-15**] Discharge Date: [**2131-2-26**]
Date of Birth: [**2088-1-5**] Sex: M
Service: CCU
ADDENDUM: This dictation is for the [**Hospital 228**] hospital
course up to [**2131-2-18**]. Later events will be dictated at a
later date.
HISTORY OF THE PRESENT ILLNESS: This is a 43-year-old male
with a history of tobacco use but otherwise previously
healthy, transferred from an outside hospital after
presenting with a large anterior ST elevation MI with Q waves
at that time. The patient was transferred to [**Hospital1 18**] for
cardiac catheterization and was found to have a totally
occluded LAD which could not be revascularized despite
attempts at PTCA and thrombolytics at the outside hospital.
The patient was sent from his chiropractor to the Emergency
Room at an outside hospital today after presenting with two
days of upper back, chest, and neck pain. He complained of
[**11-2**] pain between his scapula and at the outside hospital
was found to have a CK of 2,827, MB 235, and troponin of 33.
The patient was given Retivase lytics, Lopressor, heparin,
nitroglycerin, aspirin at the outside hospital. In the
Emergency Room, an echocardiogram showed large anterior wall
motion abnormality and he was sent to [**Hospital1 18**] for
catheterization.
In the Catheterization Laboratory, the patient's hemodynamics
showed a wedge of 31, right atrial pressure of 28, aortic
pressure of 115/88, PA pressure 46/83, right ventricle 48/26.
He had a totally occluded LAD which could not be opened up.
Otherwise, he had a normal MCA, D1, D2 circumflex and RCA all
without flow-limiting lesions. He received 200 cc of
contrast. After catheterization, the patient had an
intra-aortic balloon placed. His cardiac index pre balloon
pump was 1.3 and increased to 2.2 after his balloon pump. He
had an SVR of 6,092, PVR 92. His PA saturation went from 58
before the balloon pump to 75 after the balloon pump.
PAST MEDICAL HISTORY: None.
MEDICATIONS AT HOME: None.
ALLERGIES: None.
SOCIAL HISTORY: Two packs per day of cigarette smoking,
alcohol use that was initially said to be occasional and now
known to be heavy. The patient is a construction worker who
is currently unemployed. His significant other is [**Name (NI) **], phone
number [**Telephone/Fax (1) 46012**] or [**Telephone/Fax (1) 46013**].
FAMILY HISTORY: Father with CAD.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
100.6, blood pressure 116/76, mean arterial pressure of 91,
pulse 108, respirations 14, 99% on AC800/14/5/50%, PA
pressure 32/22. The intra-aortic balloon pump with assisted
systole of 91, augmented diastole of 112, 1:1. General:
Intubated and sedated. HEENT: Pupils equal and reactive.
Anicteric sclerae. The mucous membranes were moist. Neck:
The patient was lying flat. Chest: Rhonchorus. Vented
breath sounds bilaterally. Cardiac: Tachycardiac, regular,
no rubs, gallops, or murmurs. Normal S1, S2. Abdomen:
Mildly distended, bowel sounds present, nontender, no
organomegaly. Extremities: Right femoral Swan in place with
A line. No clubbing, cyanosis or edema. Dorsalis pedis
pulses were 2+ bilaterally. Neurological: He was sedated on
propofol and paralyzed with succinylcholine.
LABORATORY DATA AT THE OUTSIDE HOSPITAL: White blood count
23,000, hematocrit 51, platelets 295,000. The differential
showed 84% polys, 6% lymphs. Sodium 138, potassium 4.2,
bicarbonate 27, chloride 100, BUN 9, creatinine 1.3, glucose
135. INR 1.1, PTT 22.
The EKG showed normal sinus rhythm at 104, ST elevations in
I, II, aVL, V2 through V6 of 5 mm with Q waves in V1 through
V4.
Chest x-ray showed evidence of heart failure, no infiltrate.
HOSPITAL COURSE: From [**2131-2-15**] to [**2131-2-18**].
The patient is a 43-year-old male with positive tobacco use
admitted with ST elevation anterior MI with Q waves already
present and found to have a total occlusion of LAD which
could not be revascularized. The patient was admitted with
cardiogenic shock with an index of 1.3 and increased to 2.2
status post intra-aortic balloon pump and a wedge pressure of
30.
1. CORONARY ARTERY DISEASE: The patient is status post LAD
occlusion with no revascularization possible after attempted
lytics and PTCA. He was continued on aspirin. His beta
blocker was started slowly and increased to the current dose
of 75 p.o. b.i.d. His CKs had peaked at the outside hospital
and trended down at his first CK here.
PUMP: The patient had a large anterior MI. His cardiac
index was initially down to 1.3 and increased to 2.2 after
intra-aortic balloon pump. He was maintained on an
intra-aortic balloon pump times 48 hours to rest his
ventricle. His cardiac index did increase to 3.2 on the
morning after admission.
The patient was found to have an EF of 20-25% by
echocardiogram with large anterior and apical akinesis and a
likely apical thrombus. For this reason, he was started on
heparin with the plan to eventually start him on Coumadin at
a later date.
The intra-aortic balloon pump was discontinued on [**2131-2-17**] and the patient did well, maintaining stable blood
pressures. We will currently increase his dose of Captopril
as his blood pressure tolerates, is currently at 25 mg p.o.
t.i.d. This will be to reduce his afterload.
EP: Mr. [**Known lastname 46014**] has sinus tachycardia status post his MI and
low EF. Other contributing factors are also likely alcohol
withdrawal and infection. We will continue to give him
Tylenol, a cooling blanket, benzodiazepines to treat his
alcohol withdrawal and Captopril to decrease his afterload
and increase his cardiac output. We will continue the beta
blocker as well and increase that to 100 as tolerated if
required.
2. PULMONARY/ID: The patient initially had a white count
and fever on admission and was found to have gram-negative
rods which are likely Hemophilus influenzae. He was started
on vancomycin, and piperacillin/Tazobactam initially and the
vancomycin has been discontinued when the gram-negative rods
were found. He was continued on pip/tazo which can likely be
further narrowed in spectrum when he can take p.o.
The patient was initially on a ventilator for agitation in
the Catheterization Laboratory with an intra-aortic balloon
in place. The sedation required him to be intubated. He was
extubated with no adverse problems on [**2131-2-18**]. He
did tolerate extubation well.
3. ALCOHOL WITHDRAWAL: The patient was agitated on
admission and required a large dose of benzodiazepines and
intubation. He will be continued on standing dose Valium for
his alcohol withdrawal and be on a CIWA scale.
4. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient has had
to have his potassium repleted; however, his other
electrolytes and renal function have been stable this
hospitalization. He will be started on a p.o. diet when he
can take p.o. which will likely be on [**2131-2-19**]. He
is currently euvolemic.
5. PROPHYLAXIS: Continue the H2 blocker. Start the patient
on a bowel regimen. Continue his heparin drip.
6. TUBES/LINES/AND DRAINS: He has a right radial A line,
and Foley in place. His right femoral Swan has been
discontinued.
MEDICATIONS AT THE TIME OF THIS DICTATION:
1. Valium 5 t.i.d.
2. Heparin 2,000 units an hour.
3. Lopressor 75 b.i.d.
4. Atorvostatin 20 q.d.
5. Aspirin 325 mg q.d.
6. Famotidine.
7. Captopril 25 t.i.d.
8. Piperacillin/Tazobactam 4.5 q. six hours.
The patient has a chest x-ray pending at this time to further
evaluate his pneumonia.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2131-2-18**] 06:05
T: [**2131-2-18**] 19:03
JOB#: [**Job Number 46015**]
ICD9 Codes: 4280, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1732
} | Medical Text: Admission Date: [**2172-10-30**] Discharge Date: [**2172-11-9**]
Date of Birth: [**2102-5-29**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient was admitted on
[**2172-10-30**], for coronary artery bypass grafting. On
[**11-3**], the patient underwent coronary artery bypass
grafting times four.
PAST MEDICAL HISTORY: The patient is with significant
medical history of diabetes, anemia, hypertension,
hypercholesterolemia, and coronary artery disease.
HOSPITAL COURSE: Postoperatively the patient did well. The
only complication was folliculitis which was treated with
Clindamycin. Upon discharge, the patient's condition was
stable, ambulatory status was 4.
DISCHARGE MEDICATIONS: Lopressor 75 mg p.o. b.i.d., Zocor 40
mg p.o. q.i.d., Protonix 40 mg p.o. q.d., Clindamycin 450 mg
p.o. q.a.h. x 7 more days, Lasix 20 mg p.o. q.12h., KCl 20
mEq p.o. q.a.h., Docusate Sodium 100 mg p.o. b.i.d., ASA 81
mg p.o. q.d., Glynase 6 mg p.o. b.i.d., Percocet [**2-11**] p.o.
q.4-6h. p.r.n.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 70**] in
[**4-12**] weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2172-11-9**] 08:16
T: [**2172-11-9**] 08:12
JOB#: [**Job Number 36675**]
ICD9 Codes: 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1733
} | Medical Text: Admission Date: [**2149-1-17**] Discharge Date: [**2149-2-22**]
Date of Birth: [**2081-11-28**] Sex: M
Service: Cardiothor
DATE OF EXPIRATION: [**2149-2-22**].
REASON FOR ADMISSION: A 67 year-old known vascular path who
has history of coronary artery disease, peripheral vascular
disease and carotid stenosis. The patient presented to [**Hospital6 3622**] on [**2149-1-12**] status post MVA. He had been
watching the Patriot's game, went for a couple of beers and
then on his drive home sustained crushing chest pain
accompanied by visual changes and shortness of breath, right
leg numbness, nausea, diarrhea, diaphoresis. He had a blood
alcohol level of 0.170 and was arrested for DWI.
He was brought to the [**Hospital6 33**] where he had an
extensive work up revealing critical stenosis of his left
internal carotid artery, total occlusion of his right carotid
artery and RCI in his right internal carotid artery. Given
his known cardiac history he was transferred to the [**Hospital1 1444**] for diagnostic
catheterization which showed 80% PLAD, 90% PRCA right CIH was
stented.
Cardiac surgery was consulted. Vascular surgery was
consulted. The patient was then seen by Drs. [**Last Name (STitle) 1537**] and
[**Name5 (PTitle) **] who felt the patient would undergo a combined
procedure of coronary artery bypass graft and a left CEA.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Carotid stenosis. 90% left internal carotid artery, 80%
right internal carotid artery. Patent right vertebral, left
vertebral no visualization.
3. History of coronary artery disease.
4. Chronic obstructive pulmonary disease.
5. Alcohol abuse.
6. ASAI.
7. Hypertension.
MEDICATIONS:
1. Lopressor.
2. Cardizem.
3. Isordil.
4. Folate.
5. Thiamin.
6. Multi vitamins.
7. Zocor.
8. Inderal.
9. Trental 400 milligrams po four times a day.
PHYSICAL EXAMINATION: He is a well appearing white male in
no apparent distress. Neck - 1+ carotids. There is a III/VI
systolic ejection murmur heard. Lungs are clear. COR - rate,
regular rhythm, III/VI systolic ejection murmur at the right
upper sternal border. Abdomen is benign. Extremities - no
cyanosis, clubbing or edema. Neuro is nonfocal.
HOSPITAL COURSE: Preoperatively the patient underwent a
stent on [**2149-1-17**] to his RCIA. The patient was on the
Cardiac [**Hospital Unit Name 196**] service. At this time the work up between
cardiac and vascular continues. Dr. [**Last Name (STitle) **] saw the
patient and discussed it with Dr. [**Last Name (STitle) 1537**] and the patient agreed
to combined carotid coronary artery bypass graft procedure.
On [**2149-1-21**] the patient went to the operating room and
underwent a left carotid artery endarterectomy by Dr.
[**Last Name (STitle) **] and a coronary artery bypass graft surgery times
three; LIMA to LAD, saphenous vein to OM, saphenous vein to
RPL by Dr. [**Last Name (STitle) 1537**]. The patient tolerated the procedure well and
was transferred to the CSIU in satisfactory, hemodynamically
stable condition.
The patient was extubated that night and was doing well.
Vascular Surgery saw him and felt he was doing well. From
cardiac surgery point of view he was doing excellent. He was
then transferred to the .................... floor. He had
his large chest tube discontinued as scheduled. However on
[**2149-1-22**] the patient developed respiratory insufficiency at
the same time the patient was being worked up for an ischemic
leg. Because the patient was acidotic the patient was
intubated by anesthesia. At this point though Vascular
Surgery turned their attention to his ischemic right leg.
The patient was taken to the operating room and underwent fem
fem bypass operation.
The patient also had a head CT scan which showed a large
right .................... infarct with a small left para
.................... infarct.
At this point GI was involved because they thought he had
some infarct of his bowel due to persistent acidosis. CT scan
of his abdomen showed some little contrast and hepatic artery
but no defects to the [**Female First Name (un) 899**] or the SMA of bowel infarcts could
be determined.
The patient continued to do poorly. He had developed acute
renal failure, ARF. He was seen by Renal. He was also seen by
Hematology for what was thought to be possibly a platelet
dysfunction. Hematology felt that giving him platelets and
fresh frozen plasma for any bleeding would be appropriate.
At this point he continued to be intubated. He was seen
daily by Renal and had not yet at this point started on
dialysis.
At this point the patient was consulted to the SICU service
for long term care. Infectious Disease was consulted and
felt at the present time his abdominal exam was benign.
However it would be possible that gram negative rods may end
up being an enteric organism and they felt that starting him
on Cipro Ceftazidine today and Vancomycin would be okay and
also continue Flagyl and in the ensuing days they would be
able to get a definite organism out of a culture.
The patient from Renal received a left femoral venous
dialysis catheter. This was placed by Cardiothoracic Surgery
nurse practitioner. The patient continued to do poorly in
the CTVSIU he however was on the SICU service being seen
every day by the SICU team as well as Renal, Infectious
Disease. He was then seen by critical nutrition for
nutritional support. He was on CVVH. Renal was following him
for that. Despite all intensive measures the patient
continued to do poorly. The patient's abdomen continued to
do poorly. They had a CT scan of his abdomen which showed no
free fluid but he still underwent an exploratory laparoscopy.
At that point he underwent the exploratory laparoscopy for
questionable ischemic bowel, gangrene in his gallbladder.
Postoperative diagnosis was ischemic small bowel. Exploratory
laparotomy, SMA exploration, cecotomy, jejunostomy, mucous
fistula with mesh closure. The findings show small bowel
ischemia, LOT to TI in cecum, normal gallbladder, stomach and
colon. SMA had a water .................... applicable
explored and demonstrated flow in it. Small bowel
demarcation at 8 cm from LOT to cecum.
The patient was then returned to recovery room. However he
continued to do poorly hemodynamically. He developed
acidosis. The family at this point felt that they would not
like any extraordinary measures and eventually the patient on
[**2149-2-4**] underwent a PermaCath placement and a
tracheostomy. The patient continued with dialysis. He was in
ATN. The prognosis was poor at this point.
Despite all intensive measures the patient became more and
more acidotic over the ensuing days and on [**2149-2-22**] at 12:45
despite all aggressive measures Mr. [**Known lastname 37938**] continued to have
severe, persistent acidosis and became asystolic. Atropine
and Sodium bicarb were administered with no response. He was
pronounced dead at 12:43 A.M. Family was informed. Dr. [**Last Name (STitle) 1537**]
was informed.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 37939**]
MEDQUIST36
D: [**2149-3-25**] 13:24
T: [**2149-3-26**] 09:58
JOB#: [**Job Number 37940**]
ICD9 Codes: 4439, 5185, 5845, 7907, 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1734
} | Medical Text: Admission Date: [**2191-11-30**] Discharge Date: [**2191-12-4**]
Date of Birth: [**2135-8-26**] Sex: F
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Fulminant hepatic failure.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year old
female of Indian origin with no known prior history of liver
disease and a past medical history significant for rheumatoid
arthritis and hypercholesterolemia who had been on Arava and
Lipitor who was transferred from [**Hospital 59596**] to [**Hospital1 1444**] for acute hepatic failure.
The patient has a history of rheumatoid arthritis and has
been on Arava on 10 mg once daily with an increasing dose of
20 mg once daily since [**2191-6-16**]. The patient was also on
Lipitor 20 mg by mouth once daily which was also increased to
40 mg by mouth once daily at the time of [**Month (only) **] of [**2191-6-16**]. The patient traveled to [**Country 11150**] during the Summer and
while there developed some fatigue, anorexia, nausea, and
dark urine. The patient was worked up as an outpatient in
the United States. Subsequently, the patient developed a
fever, nausea, vomiting, abdominal pain, and diarrhea, and
jaundice. The patient was found to have elevated liver
function tests and was noted to have mild ascites on
ultrasound on [**2191-11-23**].
The patient was admitted to [**Hospital3 8544**] on [**2191-11-25**] and was found to have an elevated INR to 4 and an
elevated bilirubin. She underwent a paracentesis at [**Hospital3 52139**] which demonstrated 4500 white cells per cc. The
patient was started on third-generation cephalosporin for
concern of spontaneous bacterial peritonitis. The patient's
mental status worsened over the next 24 hours with elevations
in INR and bilirubin, and the patient was transferred to [**Hospital1 1444**].
PAST MEDICAL HISTORY: Rheumatoid arthritis,
hypercholesterolemia, hypertension, and hypothyroidism.
HOME MEDICATIONS: Arava 20 mg by mouth once daily and
Lipitor 50 mg by mouth once daily (both of which were stopped
on [**2191-11-4**]), Tylenol as needed for pain relief
(which was stopped on [**11-18**]), and Levoxyl.
ADDITIONAL MEDICATIONS ON TRANSFER: Zofran, Protonix,
Demerol, Aldactone, Lasix, vitamin K, cholestyramine, and
Cefotetan.
ALLERGIES: SULFA.
SOCIAL HISTORY: No alcohol use. No tobacco use.
FAMILY HISTORY: No known history of liver disease.
PHYSICAL EXAMINATION ON ADMISSION: The temperature was 96.6,
the heart rate was 110 and regular, sinus tachycardia, the
blood pressure was 147/69, the respiratory rate was 19, and
100 percent on nonrebreather. Obtunded. On mental status,
responding only to painful stimuli. Markedly jaundiced with
icteric sclerae. The pupils were equally round and reactive
to light. The neck was supple. Cardiovascular examination
revealed a regular rhythm, sinus tachycardia. No murmurs.
The lungs were clear to auscultation bilaterally. The
abdomen was mildly distended, soft, and nontender. The right
flank with ecchymosis noted.
PERTINENT LABORATORY DATA ON ADMISSION: On admission to [**Hospital1 1444**] the white count was 9.3, the
hematocrit was 34.4, and the platelets were 104. Chemistries
revealed the sodium was 134, potassium was 3.7, chloride was
106, bicarbonate was 21, blood urea nitrogen was 13,
creatinine was 0.8, and glucose was 125. AST was 541, ALT
was 469, alkaline phosphatase was 162, total bilirubin was
23.9, albumin was 2.4, and amylase was 174. Coagulations
revealed PT was 34.8, PTT was 138.5, and INR was 7.6.
RADIOLOGY STUDIES: A CT of the abdomen and pelvis done at
[**Hospital3 8544**] on [**2191-11-28**] with the report from
Study Hospital of small nodule in the liver, normal size
spleen, moderate ascites, bilateral pleural effusion, and
positive gallstones.
BRIEF HOSPITAL COURSE: The patient was admitted to the
Surgical Intensive Care Unit late in the evening of [**2191-11-30**]. The patient was given 4 units of fresh frozen
plasma given her severe coagulopathy. Because of continued
deteriorated mental status, the patient was intubated.
Early in the morning of [**2191-12-1**] the patient's
mental status changes were deemed to be due to hepatic
encephalopathy and received a head CT STAT after intubation
which was within normal limits without any masses or
bleeding. The patient was found to be tachycardic, and
reexamination was found to have a systolic ejection murmur.
A cardiac echocardiogram was done which revealed a left-to-
right shunt consistent with an atrial septal defect or patent
foramen ovale. The patient also had increased pulmonary
artery pressures. The patient also underwent an ultrasound
of the abdomen which showed a very small nodule in the liver
and some ascites. A CT of the abdomen also done at the same
time showed generalized anasarca with edematous small bowel,
again a small nodule in the liver about the size of a spleen.
The patient's liver function tests and bilirubin continued to
rise with the total bilirubin peaking at 31.7. This was
fulminant hepatic failure. The patient's renal system
continued to be poor. The patient did not make much urine on
arrival, and her creatinine - while it was normal - did not
explain her cause of oliguria. Because the patient was
oliguric, the patient became volume overloaded given the
medication that was necessary to sustain her life.
Eventually, the patient was started on continuous venovenous
hemofiltration. Because the patient had severe coagulopathy,
the patient was put on a fresh frozen plasma drip and
received packed red blood cells as needed to keep her
hematocrit from falling. The patient also received platelets
as needed to keep her platelets above 100.
The patient's respirations were difficult to maintain. A
chest x-ray revealed possible right-sided consolidative
processes, and it there was concern that the patient might
have had an aspiration event. The patient underwent a
bronchoscopy which did not show any pockets of thickened
sputum or purulence within the bronchial system.
The patient was maintained on ceftriaxone prophylaxis as well
as on Levaquin. Despite all our best efforts, the patient
went into multisystem failure with pulmonary hypertension
with left-to-right shunting, respiratory failure with
possible aspiration pneumonia, fulminant liver failure, and
acute renal failure. The multisystem failure became
overwhelming, and the patient's life could not be sustained
despite our best efforts.
The patient was comfort measures only [**2191-12-3**] - on
the fourth day of her Intensive Care Unit stay at the [**Hospital1 1444**] - after conferring with the
family who understood the patient's grave prognosis. The
patient's supports were turned off. The patient was placed
on a morphine drip, and the patient expired without
discomfort in the early morning of [**2191-12-4**].
DISCHARGE STATUS: Expired.
DISCHARGE DIAGNOSES:
1. Acute fulminant hepatic failure; likely due to medication
toxicity from Arava and Lipitor.
2. Multisystem organ failure with cardiovascular failure,
respiratory failure, hepatic failure, and renal failure.
DATE OF DEATH: [**2191-12-4**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 12164**]
MEDQUIST36
D: [**2191-12-26**] 16:41:10
T: [**2191-12-26**] 17:28:10
Job#: [**Job Number 59597**]
ICD9 Codes: 486, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1735
} | Medical Text: Admission Date: [**2106-6-25**] Discharge Date: [**2106-6-30**]
Date of Birth: [**2082-2-28**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 16920**]
Chief Complaint:
s/p assault on [**2106-6-24**] with SAH, large sugaleal hematoma, and
multiple facial fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
24 year old male who was attacked by multiple assailants and
struck on his head and to his chest on [**2106-6-24**]. He was discovered
by a [**Hospital3 **] who notified 911. Because of somnolence on
arrival to ED, he was given 2mg of narcan by EMS. Following this
he became agitated and combative. On arrival the patient was
combative and agitated with clear signs of narcotic withdrawal.
He became combative and was given ample doses of haldol as well
as Fentanyl so he could settle down for necessary exams/testing.
Past Medical History:
Unknown--pt poor/unreliable historian
Social History:
Self reported abuse of heroin and prescriptive medications over
the past three years or so. Possibly participating in a needle
exchange program (card was found in his pocket but not sure
where this was from). Possible ETOH abuse. Smokes 1 PPD x past
10 years. Parents did have a formal restraining order in the
recent past so he could not come to the house but they did have
that lifted recently. He has been in prison in the past, has
gone through rehab programs and was living in a halfway house in
the past. He has recently been homeless and living on the
streets with a girlfried named 'KiKi' who witnessed the assault,
fled the scene, and then waited 12 hours to call his parents to
let them know what happened.
Family History:
non-contributory
Physical Exam:
P/E:
VS: 99.4 99.4 77 120/54 11 99% RA
NPO; 640cc urine/6 hours; 615 IVF
GEN: WD/WN M obtunded and unable to cooperate w exam; in
restraints [**1-19**] intermittent agitation; rousable to sternal
rub/noxious stimuli
HEENT: moving eyes without identifiable deficit upon arrival to
hospital per ED; 2cm lateral supra-orbital lac w suture repair;
presently with ecchymosis and peri-orbital edema L>R; pupils
pharmacologically dilated by ophtho
CV: RRR
PULM: CTA B/L
ABD: S/NT/ND
EXT: No edema
Pertinent Results:
[**2106-6-25**] 11:05AM GLUCOSE-125* UREA N-11 SODIUM-142
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-32 ANION GAP-13
[**2106-6-25**] 11:05AM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-2.0
[**2106-6-25**] 11:05AM WBC-9.6 RBC-4.47* HGB-13.5* HCT-39.8* MCV-89
MCH-30.2 MCHC-33.9 RDW-14.0
[**2106-6-25**] 11:05AM PLT COUNT-400
[**2106-6-25**] 03:06AM GLUCOSE-199* LACTATE-2.0 NA+-141 K+-3.1*
CL--96* TCO2-28
[**2106-6-25**] 03:00AM UREA N-11 CREAT-1.0
[**2106-6-25**] 03:00AM estGFR-Using this
[**2106-6-25**] 03:00AM LIPASE-21
[**2106-6-25**] 03:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2106-6-25**] 03:00AM WBC-14.2* RBC-4.59* HGB-13.4* HCT-40.9 MCV-89
MCH-29.2 MCHC-32.8 RDW-14.0
[**2106-6-25**] 03:00AM PLT COUNT-340
[**2106-6-25**] 03:00AM PT-11.7 PTT-21.7* INR(PT)-1.0
[**2106-6-25**] 03:00AM FIBRINOGE-391
.
RADIOLOGY
Final Report
HISTORY: Trauma.
.
AP RADIOGRAPH OF THE CHEST. AP RADIOGRAPH OF THE PELVIS.
.
COMPARISON: None.
.
CHEST: Lung volumes are low. The cardiac silhouette and hilar
contours
appear normal. The mediastinum is likely exaggerated by supine
technique. No pneumothorax or pleural effusion is present.
Osseous structures appear
intact.
PELVIS: Evaluation is limited by underlying trauma backboard.
The pubic
symphysis appears intact. There are no obvious pelvic fractures.
Evaluation of the right sacroiliac joint is limited but appears
normal.
IMPRESSION: Limited examination, but no evidence for traumatic
pathology.
The study and the report were reviewed by the staff radiologist.
~~~~~~~~~~~~
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 85446**]
Reason: H/O ASSAULT. EVAL
.
[**Hospital 93**] MEDICAL CONDITION:
28 year old man with h/o assault
REASON FOR THIS EXAMINATION:
?head trauma
CONTRAINDICATIONS FOR IV CONTRAST:
None.
.
Wet Read: JMGw FRI [**2106-6-25**] 3:31 AM
large left sided soft tissue swelling and temporal-parietal
subgaleal
hematoma.
.
Depressed zygomatic arch fx. fxs of the lateral and anterior
maxillary sinus walls, inferior and lateral left orbital wall
fx, possible inferior right orbital wall fx. globes and lenses
appear intact. no intracrainal injury.
.
Final Report
1HISTORY: 20-year-old man with assault.
CT HEAD: Axial imaging was performed through the brain without
IV contrast
administration. Sagittal and coronal reformats were prepared.
COMPARISON: None.
FINDINGS: There is hyperdense material layering along the corpus
callosum
compatible with a SAH (4001b:59). There is no edema, mass
effect, or evidence for acute vascular territorial infarction.
[**Doctor Last Name **]-white matter differentiation is well preserved and there is
no shift of normally midline structures.
There is marked soft tissue swelling along the region of the
left orbit, left temporal, and left parietal bones with a large
10 mm thick left
temporoparietal subgaleal hematoma.
There is a depressed zygomatic arch fracture with overriding
ends. The
zygomatic arch may be fractured at two sites (3:7). There is a
comminuted
medially displaced fracture of the medial orbital wall. There is
a depressed fracture of the inferior orbital wall with blood and
bone fragments in the left maxillary sinus. There is a depressed
comminuted fracture of the lateral and anterior walls of the
left maxillary sinus. There is a depressed fracture of the right
inferior orbital wall, which may be chronic.
Hypodense fluid compatible blood is seen within the left
maxillary sinus.
Remaining paranasal sinuses, mastoid and ethmoid air cells are
well aerated.
IMPRESSION:
1. Hyperdense material layering along the corpus callosum
compatible with a SAH.
2. Depressed zygomatic arch fracture. Fracture of the lateral
and anterior
left maxillary sinus walls. Inferior and lateral left orbital
wall fracture. Possible right inferior orbital wall fracture.
Globes and lenses are intact.
3. Large left-sided temporoparietal subgaleal hematoma with soft
tissue
swelling extending to the orbits.
If indicated, facial bone CT could be performed for better
evaluation of these fractures.
Finding of the subarachnoid hemorrhage was communicated to Dr.
[**First Name8 (NamePattern2) 7656**] [**Name (STitle) **] at 9:45AM.
The study and the report were reviewed by the staff radiologist.
~~~~~~~~~~~~
CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 85447**]
Reason: S/P ASSAULT. ? FX.
.
[**Hospital 93**] MEDICAL CONDITION:
28 year old man with h/o assault
REASON FOR THIS EXAMINATION:
?spine injury
CONTRAINDICATIONS FOR IV CONTRAST:
None.
.
Wet Read: JMGw FRI [**2106-6-25**] 3:31 AM
no traumatic injury
.
Final Report
HISTORY: 20-year-old man after assault.
CT C-SPINE: Helical imaging was performed through the cervical
spine without IV contrast administration. Sagittal and coronal
reformats were prepared.
COMPARISON: CT head performed same day.
FINDINGS: There is no fracture or malalignment. Vertebral body
height and
alignment appears normal. There is no prevertebral fluid. The
visualized
outline of thecal sac appears normal; however, CT is unable to
provide
intrathecal detail comparable to MRI. Incompletely assessed is a
complex
fracture involving the left maxillary sinus, which is filled
with hyperdense fluid, likely blood. The visualized lung apices
are clear.
IMPRESSION:
1. No traumatic injury to the cervical spine.
2. Incompletely visualized complex left maxillary sinus
fracture.
The study and the report were reviewed by the staff radiologist.
~~~~~~~~~~~~~~~
CT ORBIT, SELLA & IAC W/O CONT Clip # [**Clip Number (Radiology) 85448**]
Reason: bilateral to further define fracture
.
[**Hospital 93**] MEDICAL CONDITION:
28 year old man s/p assult to right face
REASON FOR THIS EXAMINATION:
bilateral to further define fracture
CONTRAINDICATIONS FOR IV CONTRAST:
None.
.
Provisional Findings Impression: CXWc FRI [**2106-6-25**] 4:11 PM
PFI:
1. Left lateral facial fractures, including an extensively
comminuted
fracture involving the left inferior orbital wall and left
lateral maxillary sinus wall and the zygomatic arch, with
displacement at the zygomaticofrontal suture, compatible with a
tripod fracture. A bony fragment impinges upon the left lateral
rectus muscle, concerning for entrapment.
2. Fragmentation of the right inferior orbital wall, with fat
herniating
through the defect into the right maxillary sinus, but there is
only minimal mucosal thickening in the right maxillary sinus. In
the absence of prior imaging, this is an age-indeterminate
fracture.
Final Report
INDICATION: 28-year-old man status post assault.
COMPARISON: Head CT obtained approximately 10 hours earlier.
TECHNIQUE: Non-contrast axial images were obtained through the
facial bones. Multiplanar reformatted images were generated.
FINDINGS: There are multiple comminuted and displaced fractures
along the
left lateral face involving the zygomaticomaxillary complex. The
left orbital floor demonstrates an extensively comminuted
fracture extending into the lateral wall of the left maxillary
sinus, which is nearly filled with hyperdense material, with an
air-fluid level and some aerosolized contents. The lateral wall
of the left maxillary sinus is depressed medially. Fracture
fragments extend upward through the lateral wall of the left
orbit, with relatively large fracture fragments displaced
medially along the lacrimal gland and muscles. In particular, a
bony fragment impinges upon the left lateral rectus muscle,
which is concerning for entrapment. Additionally, a large
fragment impinges upon the left lacrimal gland, which is
displaced posteromedially. There is no evidence of retrobulbar
hemorrhage. The lens is in place. The globe demonstrates normal
signal intensity. Overlying this constellation of fractures is
extensive subcutaneous stranding and edema.
Additional fractures involve the left zygomatic arch.
Thezygomaticofrontal
suture is separated and displaced medially. The zygomatic
fracture fragments are overriding by several millimeters.
The floor of the right orbit demonstrates bony fragmentation
with a small
amount of fat herniating caudally into the right maxillary
sinus. However,
there is only a small amount of mucosal thickening or
intermediate density
fluid layering in the dependent portion of the sinus. In the
absence of prior studies, this is an age-indeterminant fracture.
On the right, there is no retrobulbar hemorrhage. The right
globe and lens are appropriately
positioned. Mild soft tissue swelling overlies the right orbit.
No other fractures are identified. There is mild mucosal
thickening of the
ethmoid air cells, with trace mucosal thickening in the right
sphenoid air
cell. Mastoid air cells are normally aerated. Frontal air cells
are normally pneumatized and aerated.
IMPRESSIONS:
1. Comminuted and displaced left lateral face fractures
involving the left
zygomaticomaxillary complex. A bone fragment impinges upon the
left lateral rectus muscle, concerning for entrapment.
Separation and displacement of the zygomaticofrontal suture
displaces the left lacrimal gland posteromedially.
2. Bony discontinuity of the floor of the right orbit contains a
small amount of fat herniating into the right maxillary sinus,
with minimal mucosal thickening or fluid in the sinus. In the
absence of prior films, this is an age-indeterminate fracture.
The study and the report were reviewed by the staff radiologist.
~~~~~~~~~~~~~
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 85449**]
Reason: assess interval change
.
[**Hospital 93**] MEDICAL CONDITION:
28 year old man s/p assult to face
REASON FOR THIS EXAMINATION:
assess interval change
CONTRAINDICATIONS FOR IV CONTRAST:
None.
.
Provisional Findings Impression: CXWc FRI [**2106-6-25**] 4:27 PM
PFI: No new abnormality. Decreased conspicuity of small amount
of blood
along the corpus callosum. No new hemorrhage. Left subgaleal
hematoma
stable. Left facial fracture is better delineated on the
dedicated facial
bone CT.
.
Final Report
INDICATION: 28-year-old man status post assault. Assess interval
change.
COMPARISON: Head CT obtained approximately 10 hours earlier.
TECHNIQUE: Non-contrast axial images were obtained through the
brain.
FINDINGS: Since the prior study, there has been no acute change.
A small
amount of hyperdense material layering along the surface of the
corpus
callosum is slightly decreased in conspicuity. There is no new
area of
intracranial hemorrhage. There is no edema, shift of normally
midline
structures, or evidence of acute major vascular territorial
infarct.
Ventricles and sulci are normal in size and configuration. The
[**Doctor Last Name 352**]-white
matter differentiation is preserved. The basilar cisterns are
symmetric.
Assessment of bony structures demonstrates extensive left facial
fractures, better delineated on the concurrently obtained facial
bone CT. Mastoid air cells are well aerated. No calvarial
fractures are identified.
A left subgaleal hematoma is unchanged, with associated
subcutaneous tissue edema. Right-sided subcutaneous tissue edema
is also unchanged.
IMPRESSION:
1. Slight interval decrease in conspicuity of blood layering
along the corpus callosum.
2. Left facial fractures, better evaluated on the concurrently
obtained
facial bone CT ([**Numeric Identifier 85450**]).
3. Unchanged left subgaleal hematoma and bilateral scalp edema.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Patient was immediately assessed by Trauma Team in the Emergency
Department (ED). Stat labs were obtained and sent. He was sent
for CT Orbit/Sella*IOC which showed multiple facial fractures,
CT spine was negative, CT head showed SAH and a large left-sided
temporoparietal subgaleal hematoma. A left brow laceration was
thoroughly washed out and then sutured while in the ED by Trauma
staff. Patient was evaluated by Ophthalmology service who found
no evidence of muscle entrapment or open globe or intraocular
involvement. Patient was evaluated by Neurosurgery service who
initially had trouble with exam due to sedation and recommended
patient be transferred to Trauma ICU (TICU) for Q1h neurochecks.
Patient was evaluated by Plastic Surgery service who felt that
facial fractures, specifically the left ZMC and orbital floor
fractures, needed surgical repair. Patient was started on
Unasyn and maintained on sinus precautions and facial fracture
repair was planned for the morning of [**2106-6-30**]. Social Work
became involved with the yet unidentified patient at the time on
[**2106-6-26**]. Patient became progressively more communicative and
alert during the day on [**2106-6-26**] and was eventually tranferred
out of ICU onto the floor. He was able to identify who he was
to the staff. In addition, patient's sister [**Name (NI) **] was able to
call the floor and identify herself as the patient's family.
Patient was then placed on 'Privacy Alert' for protection as
circumstances of assault remained unknown. Patient's mental
status continued to improve over the next few days and patient's
family very involved and present. Patient working with Physical
Therapy to improve steadiness of gait. Patient had a repeat
head CT on [**2106-6-27**] which was stable and showed stable SAH and
subgaleal hematoma. Neurosurgery signed off and cleared patient
for facial fracture repair. On the evening of [**2106-6-29**] patient
was all cleared for surgical repair on the morning of [**2106-6-30**]
and he was aware and in agreement with this plan. He was given
Benadryl for sleep for complaints of insomnia. He was NPO after
midnight. At about 2am on [**2106-6-30**] began requesting that he be
allowed to leave the hospital and stating that he did not intend
to pursue surgery in the morning. The risks of not getting the
surgery were explained to patient and he said he understood
those risks. The RN Supervisor was called and the on-[**Name6 (MD) 138**]
Plastics MD [**First Name (Titles) **] [**Last Name (Titles) 18**] Security. Patient told staff that he was
not 'a section-12' and therefore he couldn't be held against his
will. [**Hospital1 18**] Police confirmed this. Patient signed out of
hospital Against Medical Advice (AMA) but refused to sign AMA
paperwork.
Medications on Admission:
None
Discharge Medications:
None---signed out AMA
Discharge Disposition:
Home
Discharge Diagnosis:
Patient signed out AMA
Discharge Condition:
Patient signed out AMA
Discharge Instructions:
Patient signed out AMA
Followup Instructions:
Patient signed out AMA
Completed by:[**2106-7-8**]
ICD9 Codes: 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1736
} | Medical Text: Unit No: [**Numeric Identifier 70939**]
Admission Date: [**2186-12-15**]
Discharge Date: [**2186-12-25**]
Date of Birth: [**2186-12-15**]
Sex: F
Service: Neonatology
ID/CC: [**Female First Name (un) **] was delivered at 28 5/7 weeks and was admitted
to the newborn ICU for management of prematurity and
respiratory distress syndrome of prematurity.
MATERNAL HISTORY: The mother is a 35-year-old G1, para 0 to
1 woman with past medical history notable for hypertension,
nephrolithiasis status post stent placement, and recent
sinusitis treated with azithromycin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: No illicit substance use. Both parents are
GI fellows here at [**Hospital1 18**].
PRENATAL SCREENS: A positive, DAT negative, hepatitis B
surface antigen negative, RPR nonreactive, rubella immune,
group B strep unknown.
ANTENATAL HISTORY: [**Last Name (un) **] [**2187-3-4**] by LMP with confirmatory
7.5 week ultrasound. Estimated gestational age 28 5/7 weeks
at delivery. Pregnancy was complicated by preeclampsia,
oligohydramnios and growth restriction leading to admission 6
days prior to delivery. Treatment with betamethasone,
nifedipine and magnesium sulfate with eventual cesarean
section under spinal anesthesia. Rupture of membranes
occurred at delivery and yielded clear amniotic fluid. There
was no labor and no intrapartum fever or other clinical
evidence of chorioamnionitis.
NEONATAL COURSE: The infant was vigorous at delivery. Orally
and nasally, bulb suctioned, dried. Facial CPAP administered
for mild to moderate intercostal retractions. Apgars were 7
at 1 minute and 8 at 5 minutes. The infant was transferred
uneventfully to the NICU on CPAP and intubated with
surfactant administered at approximately 20 minutes of age.
ADMISSION PHYSICAL EXAMINATION: Preterm infant on warmer with
moderate respiratory distress. Birth weight 940 grams, [**9-13**]
percentile. OFC 25.5 cm, 25% percentile. Length 35th to 5.5
cm, 25th percentile. Heart rate 158, respiratory rate 50s-60s.
Temperature 96.9. BP 49/22, mean 33. SaO2 96% in 25% oxygen.
HEENT: Anterior fontanel soft, flat, nondysmorphic, palate
intact. Neck and mouth normal, normal cephalic, red reflex
bilaterally with vitreous haze, 2.5 endotracheal tube in
place orally. Chest: Mild to moderate intercostal
retractions, fair breath sounds bilaterally, no adventitious
sounds. CVS: Well perfused, regular rate and rhythm. Femoral
pulses normal. S1, S2 normal. No murmur. Abdomen soft,
nondistended, no organomegaly, no masses, bowel sounds
active. Anus patent. Three vessel umbilical cord. GU: Normal
preterm female genitalia. CNS: Active, alert, responsive to
stimulation. Tone appropriate for gestational age and
symmetric, moves all extremities symmetrically. Gag intact.
Faces symmetric. Integument: Normal preterm. Musculoskeletal:
Normal spine, limbs, hips and clavicles.
HOSPITAL COURSE:
1. Respiratory: [**Female First Name (un) **] received her initial dose of
surfactant at 20 minutes of age. She was extubated to
CPAP of 6 cm in 29-35% FIO2. A cap gas of 7.33/38 was
noted on CPAP. She was started on caffeine citrate for
apnea of prematurity.
On day of life 3, she developed a spontaneous left sided
pneumothorax which was treated with a thoracentesis and
then chest tube drainage. The infant was reintubated
orally and placed back on conventional mechanical
ventilation with settings of 18/5 and a rate of 30 and
30% oxygen. The air leak persisted and multiple
replacements and manipulations of the left thoracostomy
tube were necessary to maintain drainage of the air leak.
In spite of these maneuvers, the air leak persisted and
on day of life 9, a second chest tube was placed,
positioned subpulmonic to relieve reaccumulation of the
air leak on the left side. On day of life 9, a persistent
airleak was present in the posterior subpulmonic region
necessitating a third chest tube on the morning of day 10
of life.
On day of life 8, [**Female First Name (un) **] developed atelectasis versus
consolidation on the right side. Over this period to day
of life 10 she required increased ventilatory support.
Due to issues of inadequate ventilation, she was changed
from conventional ventilation to high frequency
ventilation on [**12-23**], DOL 8. On DOL 9, due to
acidosis and hypoxemia, various ventilator strategies
were tried, but ultimately returned to high frequency
ventilation. On the morning of DOL 10, she was last
tried on conventional ventilation.
2. Cardiovascular. Access: An umbilical venous catheter was
placed upon admission and was utilized for fluid and
nutrition administration throughout her hospital stay.
On day of life 9, a peripheral arterial line was placed
for increasing severity of illness and need for additional
monitoring.
There was no evidence of a patent ductus or other
cardiovascular compromise until day of life 9 when
[**Female First Name (un) **] started to become hypotensive requiring volume
and vasopressor resuscitation.
The baby alternated between periods of tachycardia and
sinus bradycardia over the last few days of life. On the
morning of [**2186-12-25**] She had sinus bradycardia to
the 60s and required a short interval of chest
compressions and a single dose of epinephrine to improve
cardiac output.
3. Fluids, electrolytes and nutrition. [**Female First Name (un) **] was
maintained n.p.o. throughout her hospital stay. On day of
life 8, she was given initial trophic feeding of breast
milk which was subsequently discontinued in light of her
worsening clinical status.
Serial electrolytes were
monitored and [**Female First Name (un) 61633**] course initially was complicated
by hyponatremia, necessitating up to a maximum of 8.8 mEq
of sodium per kilo in her parenteral nutrition to correct
her sodium deficits.
Over the last 48 hours, [**Female First Name (un) **] developed a metabolic
acidosis despite aggressive bicarbonate replacement.
She was transiently hyperglycemic in the initial phase of
illness, necessitating a decreased glucose infusion rate;
however, on day of life 10, likely in the setting of
sepsis, she was noted to be significantly hypoglycemic
with a glucose of 7. She was treated with multiple
boluses of 2 ml/kilogram of D10W infused followed by an
increase in her glucose IV infusion rate. Subsequent
glucoses were in the 60 range.
4. GI. [**Female First Name (un) **] was treated with phototherapy for physiologic
unconjugated hyperbilirubinemia and light therapy was
discontinued on day of life 8. A rebound was obtained on
day of life 9 at 2.6.
5. Heme/ID. A CBC and blood culture were initially obtained
upon admission with initial CBC notable for a white count
of 5.9 with 7 polys and 0 bands, 89 lymphs and an
absolute neutrophil count of 413. Hematocrit 41.8%,
243,000 platelets. [**Female First Name (un) **] received multiple packed red
blood cell transfusions. Her hematocrit dropped by day of
life 6 to 29.6 at which time she received her initial
transfusion. On day of life 9 with the return to it was
noted that her hematocrit was again in the 30% range and
she was again neutropenic with a white blood cell count
of 4.2 and 26 polys, 6 bands, 47 lymphs, 280,000
platelets. Metas and myelos also present as well as toxic
granulation. She received another blood transfusion at
this time. On day of life 10, she was noted to be
extremely neutropenic with a white blood cell count of
1.6 with 0 neutrophils, 0 bands, 70 lymphs, and 23,000
platelets.
Due to the persistent neutropenia, [**Female First Name (un) **] was
continually on antibiotics. Initially, she received a 7
day course of ampicillin and gentamicin for the first 7
days with appropriate gentamicin levels. She was started
on vancomycin and gentamicin on day of life 8 for the
initial decompensation and concerning CBC as explained
above. She was also given oxacillin for her multiple
manipulations of the thoracostomy tubes and was started
on cefotaxime for broader coverage on day of life 10. The
blood cultures remained negative to date. Lumbar
puncture was performed by DOL 7 which ruled out spinal
meningitis.
6. Neurologic. [**Female First Name (un) **] had an initial head ultrasound on day
of life 4 which was normal. It was repeated on day of
life 10 and it remained without evidence for intracranial
hemorrhage. She received morphine sulfate p.r.n. when
intubated and during chest tube insertion. She was
started on a fentanyl drip which was escalated to 5 mcg
per kilogram and continued to get morphine p.r.n. and
fentanyl p.r.n. mostly for procedures.
Given the persistent hypoxemia and acidemia especially over
the final 12 hours of [**Female First Name (un) 61633**] life, discussion with the
family ensued regarding the likely neurodevelopmental
compromise that may result given the prolonged nature and
severity of her metabolic acidosis and hypoxemia. With regard
for the futility in continuing to provide [**Hospital 17073**] medical
ervention, the decision was made to discontinue support. t.
The parents held the infant as the lines were clamped off and
the endotracheal tube was removed. The fentanyl infusion
continued. The time of death was 1 p.m. The parents had
multiple friends with them at the bedside for support. They
declined clergy presence. Limited autopsy request obtained
for the chest only and the parents will be made aware of any
new information that is received. Social worker was present
as well to assist the family.
DIAGNOSES:
1. Intrauterine growth restriction, small for gestational
age premature infant at 28-5/7 weeks.
2. Respiratory distress syndrome requiring Surfactant
replacement.
3. Left pneumothorax.
4. Right pulmonary atelectasis versus consolidation.
5. Presumed sepsis.
6. Severe metabolic acidosis.
7. Hyperbilirubinemia.
8. Neutropenia.
9. Hyperglycemia/hypoglycemia.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 70940**]
MEDQUIST36
D: [**2186-12-25**] 19:44:48
T: [**2186-12-25**] 21:50:39
Job#: [**Job Number 70941**]
ICD9 Codes: 7742, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1737
} | Medical Text: Admission Date: [**2174-11-14**] Discharge Date: [**2174-11-22**]
Date of Birth: [**2109-8-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex / Latex / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2174-11-14**] - Coronary artery bypass grafting x3 (Left internal
mammary artery sequential graft to the diagonal and left
anterior descending artery, Free right internal mammary artery
to the obtuse marginal artery)
History of Present Illness:
65 year old female who developed dyspnea on exertion in [**Month (only) 958**],
now with progression, occurring with less activity and more
frequently. She underwent a Dobutamine stress in [**Month (only) 216**] which
was negative, however due to ongoing symptoms she underwent an
Adenosine stress test where she reported DOE and developed 1mm
planar ST depressions inferior/laterally. Imaging revealed a
medium area of moderate stress induced ischemia. She was started
on Aspirin and beta blockers last week without any change in her
present symptoms. She was referred for cardiac catheterization
which found her to have severe two vessel coronary artery
disease. She was seen by Dr. [**Last Name (STitle) **] in [**Month (only) 359**] while an
inpatient and returns today for preadmission testing. Her
surgery is scheduled for Monday [**2174-11-14**]. She has had a recent
upper respiratory infection treated with azithromycin and
albuterol.
Past Medical History:
Hypertension
Diabetes
Mild PVD
Hypercholesterolemia
Right Breast CA in [**2166**] s/p lumpectomy and radiation therapy
with recurrence in [**2170**] s/p right breast mastectomy and
reconstruction
Left great toe to left shin cellulitis s/p Cephalexin and
Bactrim course completed 1-2 weeks ago with resolution. This is
an intermittent problem.
Depression
Restless leg syndrome
Hypothyroidism
DVTs in the past
s/p appendectomy
Social History:
Lives with:daughter
Occupation:retired meat manager at grocery store
Cigarettes: Smoked no [] yes [x] Hx:1ppd for 15 years and quit
25
to 30 years ago
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-17**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
non-contributory
Physical Exam:
Pulse:70 Resp:14 O2 sat:95/RA
B/P Right:no BP in right arm d/t mastectomy Left:155/64
Height:5'3" Weight:191 lbs
General:NAD, alert and cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] no Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] 1+ (B) LE Edema. Left
lower extremity with edema, venous stasis changes, shiny and
tense. It is nontender to touch and no significant erythema
noted. The calf muscle feels tight/knotted causing an abnormal
appearance of LE with a tense softball like calf and then an
abruptly thin LE distal to calf.
Right with venous stasis changes however not as significant as
left lower leg. Negative [**Last Name (un) **] signs bilaterally.
Varicosities: Multiple varicosities noted on bilateral lower
extremities particularly in thighs. Likely thrombosis of GSV vs
Superficial vein just above right knee and Left Lesser saphenous
vein.
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2174-11-14**] ECHO: PRE BYPASS No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is chordal systolic
anterior motion without systolic anterior motion of the mitral
valve leaflets. There is no left ventricular outlow tract
obstruction. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **]
was notified in person of the results in the operating room at
the time of the study.
POST BYPASS There is normal biventricular systolic function. No
change in valvular function. The left to right flow across the
interatrial septum at the foramen ovale is no longer seen. The
thoracic aorta is intact after decannulation. No other changes
from the pre bypass study.
.
[**2174-11-16**] CT Head: An ill-defined hypodensity involving the dorsal
aspect of the right thalamus, just lateral to the third
ventricle is noted. The chronicity of this finding cannot be
determined given the lack of prior imaging. In the setting of
high clinical suspicion for acute infarction, may consider MR
for further assessment if not contra-indicated or close followup
with CT if MRI cannot be obtained. No acute hemorrhage or mass
effect. Out of proportion dilation of the lateral and third
ventricles compared to cerebral sulci- while this can be due to
central volume loss, other etiologies such as normal pressure
hydrocephalus can look similar and need clinical correlation.
.
[**2174-11-18**] Head MRI: 1.Three small foci of high signal intensity
identified on the diffusion-weighted sequences, suggesting
acute/subacute thromboembolic ischemic event. There is no
evidence of hemorrhagic transformation. 2. Chronic microvascular
ischemic disease is identified. Small chronic lacunar infarct is
noted on the left cerebellar hemisphere.
3. Bilateral mucosal thickening noted on the maxillary sinuses
with air-fluid level on the left side, the possibility of an
ongoing inflammatory process is a consideration.
.
[**2174-11-20**] CXR: Postoperative widening of the cardiomediastinal
silhouette is slightly larger today than yesterday. Small left
pleural effusion is presumed. There is no pulmonary edema or
pneumothorax. Right jugular line ends at the junction of
brachiocephalic veins.
.
[**2174-11-14**] 02:15PM BLOOD WBC-7.5 RBC-3.65* Hgb-10.6* Hct-31.7*
MCV-87 MCH-29.1 MCHC-33.5 RDW-14.9 Plt Ct-100*
[**2174-11-20**] 06:51AM BLOOD WBC-9.6 RBC-3.79* Hgb-10.6* Hct-33.0*
MCV-87 MCH-28.1 MCHC-32.3 RDW-14.5 Plt Ct-236
[**2174-11-14**] 02:15PM BLOOD PT-13.6* PTT-32.9 INR(PT)-1.3*
[**2174-11-17**] 01:57AM BLOOD PT-14.5* PTT-23.8* INR(PT)-1.4*
[**2174-11-14**] 02:15PM BLOOD UreaN-25* Creat-0.9 Na-140 K-5.2* Cl-111*
HCO3-23 AnGap-11
[**2174-11-21**] 05:35AM BLOOD UreaN-34* Creat-0.9 Na-138 K-4.4 Cl-100
[**2174-11-18**] 01:49AM BLOOD ALT-57* AST-68* LD(LDH)-309* AlkPhos-92
Amylase-33 TotBili-0.5
[**2174-11-21**] 05:35AM BLOOD Albumin-PND Mg-2.3
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2174-11-14**] for surgical
management of her coronary artery disease. She was taken to the
operating room where she underwent coronary artery bypass
grafting to three vessels. Please see operative note for
details. Postoperatively she was taken to the intensive care
unit for monitoring. On postoperative day one she was extubated.
Neurologically she did not follow commands and her speech was
delayed. She was seen by neurology who felt she had a stroke
involving the left cerebral hemisphere - either deep or frontal.
The major finding was abulia - a lack of spontaneity, prolonged
latency in response and short terse replies with easy
distractibility. A CT scan was performed which showed an
ill-defined hypo density involving the dorsal aspect of the
right thalamus was noted. MRA done on [**11-18**] showed three small
foci of high signal intensity identified on the
diffusion-weighted sequences, suggesting acute/subacute
thromboembolic ischemic event. Neurology felt she had a Left PCA
embolic stroke. Her right-sided weakness improved. She was seen
by Speech and swallow who recommended regular diet with thin
liquids. Long and short acting insulin was continued to maintain
blood sugars < 150. Chest tubes and epicardial wires were
removed without complications. She was gently diuresed toward
her preoperative weight. Patient was transferred to the
step-down unit on post-op day 4 for further recovery. She
remained in sinus rhythm and hemodynamically stable. She was
followed by physical and occupational therapy for strength and
mobility. She was discharged to rehab - [**Hospital1 **] [**Location (un) **] on
post-op day seven with the appropriate medications and follow-up
appointments.
Medications on Admission:
CITALOPRAM 20mg daily
ERGOCALCIFEROL (VITAMIN D2) 50,000 unit [**Unit Number **] Capsule
weekly/saturday
INSULIN GLARGINE 110 units SQ at bedtime
INSULIN LISPRO SQ below with meals 56 units AM, 16 units a
lunch, and 60 units at dinner time
LEVOTHYROXINE 50 mcg daily
LOSARTAN-HYDROCHLOROTHIAZIDE 50 mg-12.5 mg Tablet daily
METFORMIN 500 mg 2 [**Hospital1 **]
METOPROLOL SUCCINATE 25 mg daily
OMEPRAZOLE 20 mg [**Hospital1 **]
PRAVASTATIN 40 mg 2 Tablets daily
ASPIRIN 325 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
10. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation q2h as needed for
shortness of breath or wheezing.
12. Lantus 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous QBreakfast : home dose 110 units please continue to
titrate up to home dose based on BG .
13. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
14. Imdur 60 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day for 3 months.
15. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO
qsaturday.
16. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. Insulin scale insulin
Humalog
10 units premeal plus sliding scale
100-140 - 4 units
141-180 - 8 units
181-210 - 12 units
211-240 - 14 units
241-280 - 16 units
281-320 - 18 units
18. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
TBD
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Left PCA embolic stroke
Hypertension
Diabetes Mellitus
Mild PVD
Hypercholesterolemia
Right Breast CA in [**2166**] s/p lumpectomy and radiation therapy
with recurrence in [**2170**] s/p right breast mastectomy and
reconstruction
Left great toe to left shin cellulitis s/p Cephalexin and
Bactrim course completed 1-2 weeks ago with resolution. This is
an intermittent problem.
Depression
Restless leg syndrome
Hypothyroidism
DVTs in the past
s/p appendectomy
Discharge Condition:
Alert and oriented x3 right arm weakness
Ambulating with assistance
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Edema: Trace bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Doctor Last Name **] [**Telephone/Fax (1) 170**] Date/Time: [**2174-12-21**] 1:30
Location: [**Hospital Unit Name **] [**Last Name (NamePattern1) **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 101253**] office will call with
appt.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (2) 6803**]in 4-5 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:[**2174-11-21**]
ICD9 Codes: 4019, 2720, 2449, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1738
} | Medical Text: Admission Date: [**2148-10-30**] Discharge Date: [**2148-11-16**]
Date of Birth: [**2083-1-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
malaise, dry cough
Major Surgical or Invasive Procedure:
DCCV
avj modification
Intubation and mechanical ventilation
central line placement
Swan Ganz placement
FNA of right axillar lymph node
pounch biopsy of anterior mass/nodule
Throcentesis
arterial line placement
History of Present Illness:
This is a 65 year old male with a PMH significant for HTN,
dyslipidemia, DMII, who presented to the ED with malaise, poor
appetite, and dry cough for 5 days PTA. 3 days prior to
admission he noted onset of bilateral lower extremity edema. 1
day prior to admission, noted severe generalized weakness. He
notes he has been sleeping in a chair for the last 2 nights
because he could not get into bed. He denies any recent HA,
visual changes, chest pain, palpitations, shortness of breath,
orthopnea, PND, abd. pain, N/V/D, fevers, chills, rash, or
dysuria. He sleeps on 2 pillows normally and this has not
changed. He notes prior to this episode that he was able to walk
for 30 minutes a day without any symptoms.
.
In the ED, initial vitals were 97.8, 118/90, 88, 96% RA.
However, shortly there after he went into a.fib with RVR, rates
in the 130s to 150s.
Given diltiazem 10 x 3, without improvement. Then given
metoprolol 5 x 1 without improved. Started on amiodarone load
but stopped due to hypotension, with SBP in the 80's. Then he
was given 100mg PO metoprolol and levofloxacin for ? infiltrate
on exam. Received KCL 60 mg and 2L IVF. Noted to be more
tachypneic after the fluids with cxr showing large heart, ?
effusion. He was then admitted to the CCU for further management
of RVR with hypotension.
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, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. He
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
.
On arrival the patient states that he feels generally weak but
otherwise well.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes Mellitus II,
(+)Dyslipidemia, (+)Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
.
-OTHER PAST MEDICAL HISTORY:
- Arthritis
- Gout
- Obesity
Social History:
He is a retired funeral home director. Lives with wife, and son.
[**Name (NI) **]-time helps his son with his work. The patient has never
smoked. One to two cans of beer per month, never more, no
drinking recently. No illicits.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. The patient is
married with two children ages 26 and 28 who are healthy and
well. Family history of hypertension and mother died of reported
questionable food poisoning at age 38.
Physical Exam:
VS: 98, 94/67, 140, 98% 2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to just below angle of the jaw.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachy, [**Last Name (un) **], normal S1, S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 3+ bilateral LE edema No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2148-10-30**] 08:50AM BLOOD WBC-5.4 RBC-3.84*# Hgb-10.6*# Hct-30.9*#
MCV-81* MCH-27.6 MCHC-34.2 RDW-16.7* Plt Ct-196
[**2148-11-16**] 06:19AM BLOOD WBC-12.1* RBC-3.00* Hgb-8.0* Hct-23.7*
MCV-79* MCH-26.8* MCHC-33.9 RDW-17.3* Plt Ct-68*
[**2148-10-30**] 08:50AM BLOOD Neuts-57 Bands-1 Lymphs-31 Monos-8 Eos-1
Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-2*
[**2148-10-30**] 08:50AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-1+ Microcy-1+ Polychr-1+
Spheroc-OCCASIONAL Target-1+ Tear Dr[**Last Name (STitle) 833**]
[**2148-10-30**] 08:50AM BLOOD PT-13.0 PTT-24.8 INR(PT)-1.1
[**2148-11-4**] 03:06AM BLOOD Fibrino-960*
[**2148-11-8**] 08:55PM BLOOD Fibrino-1004*#
[**2148-11-9**] 11:34PM BLOOD Fibrino-1061*#
[**2148-11-12**] 11:19AM BLOOD Fibrino-957*
[**2148-11-12**] 11:19AM BLOOD FDP-40-80*
[**2148-11-4**] 03:06AM BLOOD CD5-DONE CD23-DONE CD45-DONE HLA-DR[**Last Name (STitle) 7735**]
[**Name (STitle) 7736**]7-DONE Kappa-DONE CD10-DONE CD19-DONE CD20-DONE Lambda-DONE
[**2148-11-4**] 03:06AM BLOOD CD3%-DONE
[**2148-11-1**] 06:46AM BLOOD Ret Aut-2.3
[**2148-11-8**] 04:17AM BLOOD Ret Aut-1.1*
[**2148-11-12**] 01:43PM BLOOD Fact V-133 FacVIII-345*
[**2148-10-30**] 08:50AM BLOOD Glucose-236* UreaN-46* Creat-1.2 Na-135
K-2.8* Cl-89* HCO3-33* AnGap-16
[**2148-11-16**] 06:19AM BLOOD Glucose-223* UreaN-115* Creat-2.5* Na-133
K-4.1 Cl-88* HCO3-29 AnGap-20
[**2148-10-31**] 01:05AM BLOOD ALT-50* AST-69* LD(LDH)-4410*
CK(CPK)-230* AlkPhos-143* TotBili-0.6
[**2148-11-15**] 02:05AM BLOOD ALT-71* AST-109* LD(LDH)-4210*
AlkPhos-213* TotBili-1.0
[**2148-10-30**] 08:50AM BLOOD CK-MB-7 proBNP-2677*
[**2148-10-30**] 08:50AM BLOOD cTropnT-0.07*
[**2148-10-31**] 01:05AM BLOOD CK-MB-7 cTropnT-0.06*
[**2148-10-31**] 11:02PM BLOOD CK-MB-7 cTropnT-0.06*
[**2148-10-30**] 08:50AM BLOOD Calcium-9.5 Phos-5.6* Mg-2.6
[**2148-11-8**] 08:55PM BLOOD Calcium-9.0 Phos-4.6* Mg-2.1 UricAcd-7.1*
[**2148-11-16**] 06:19AM BLOOD Calcium-7.7* Phos-6.2* Mg-2.0
[**2148-10-30**] 03:30PM BLOOD calTIBC-239 Hapto-460* Ferritn-GREATER TH
TRF-184*
[**2148-11-4**] 03:06AM BLOOD D-Dimer-9918*
[**2148-11-12**] 01:43PM BLOOD D-Dimer-[**Numeric Identifier 10112**]*
[**2148-11-12**] 11:19AM BLOOD Hapto-270*
[**2148-10-30**] 08:50AM BLOOD TSH-2.2
[**2148-11-4**] 03:06AM BLOOD Cortsol-32.7*
[**2148-10-30**] 08:14PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2148-11-5**] 04:23AM BLOOD Digoxin-1.4
[**2148-10-30**] 04:53PM BLOOD pO2-52* pCO2-41 pH-7.49* calTCO2-32* Base
XS-7
[**2148-11-15**] 06:12AM BLOOD Type-ART Temp-37.4 Rates-20/0 Tidal V-600
PEEP-12 FiO2-50 pO2-110* pCO2-49* pH-7.43 calTCO2-34* Base XS-6
-ASSIST/CON Intubat-INTUBATED
[**2148-10-30**] 08:57AM BLOOD Glucose-228*
[**2148-10-30**] 03:30PM BLOOD Lactate-2.2* K-3.4*
[**2148-11-15**] 06:12AM BLOOD Lactate-1.9
[**2148-11-10**] 05:25PM BLOOD freeCa-1.11*
[**2148-11-15**] 02:12AM BLOOD freeCa-1.07*
Portable TTE (Complete) Done [**2148-10-30**]
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 is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20 %). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. RV with
moderate global free wall hypokinesis. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The tricuspid valve leaflets are mildly
thickened. There is severe pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
IMPRESSION: Dilated cardiomyopathy (tachycardia mediated?)
Portable TEE (Complete) Done [**2148-10-31**]
IMPRESSION: No left atrial/appendage thrombus. Severely
depressed left ventricular systolic function (EF 20%).
UNILAT LOWER EXT VEINS PORT LEFT Study Date of [**2148-11-1**]
FINDINGS: Please note, the study is somewhat limited due to
patient's inability to Valsalva. Grayscale and Doppler
evaluation of the left common femoral, superficial femoral, and
popliteal veins was performed. There is normal compression,
augmentation and flow. The posterior tibial and peroneal veins
are also visualized and patent. IMPRESSION: No evidence of DVT.
ECG Study Date of [**2148-11-2**]
Sinus rhythm. Left atrial abnormality. Left bundle-branch block.
Compared to the previous tracing of [**2148-11-1**] sinus rhythm has
appeared. There is occasional atrial ectopy. Clinical
correlation is suggested.
CT CHEST/ABDOMEN/PELVIS W/CONTRAST Study Date of [**2148-11-2**]
IMPRESSION:
1)Multiple subcutaneous nodules with larger necrotic masses in
the right axilla and further nodules in the left perinephric
region are highly suspicious for metastases, possible melanoma.
Biopsy of the right axillary lymph node is recommended.
2)Loculated large left pleural effusion with atelectasis in the
left lung and small right pleural effusion.
3)Moderately large pericardial effusion in the presence of
moderate cardiomegaly. Subcentimeter hypodensities in the liver
and lower pole of the left kidney could be cysts.
Brief Hospital Course:
# Atrial fibrillation with RVR: Pt was admitted with symptoms of
HF for several months and was found to be in afib with RVR.
During the admission, he was cardioverted several times without
success, loaded on amiodarone, and also administered an esmolol
gtt during periods of refractory tachycardia, which did not help
improve his rate but did make him hypotensive. In general, the
above interventions were ineffective at controlling his rate
until he was fully loaded on amiodarone and went for partial AV
nodal ablation and pacemaker placement, at which point he
remained in sinus rhythm for several days. Shortly thereafter
he was also started on low dose digoxin. He had periods of
return to AF c RVR, initially rate controlled with PO
amiodarone, digoxin and PRN metoprolol, with rates generally in
the 90s-100s and stable BPs. Later in the hospital course the
patient developed RVR refractory to amiodarone gtt + IV
metoprolol. The etiology of his refractory afib was unclear but
likely resulting from chronic hypertension. There was also
concern for tumor mets or catecholamine surge from
neuroendocrine tumor that may be contributing to his refractory
afib. He continued to have periodic atrial fibrillation that
respond to metoprolol or self-resolves throughout the rest of
his hospitalization.
# Cardiomyopathy: Newly found EF of 20% with globally dilated
RV. The etiology of his cardiomyopathy was unclear. [**Name2 (NI) **] was
treated with rate control as above and diuresis with lasix gtt
and PRN lasix boluses + PRN metolazone.
# Hypotension: Patient became significantly hypotensive during
this admission and required substantial pressor support while on
nodal agents to control his arrhythmia. The etiology of his
hypotension was thought to be cardiogenic vs. septic shock. He
continued to require pressors to the time of his passing.
# [**Location (un) 5668**] cell tumor: Mr [**Known lastname 10113**] had multiple concerning nodules
on exam and by CT which were biopsied and showed [**Location (un) 5668**] cell
carcinoma. Later in the hospitalization pOncology was consulted
but given his tenuous state treatement was deferred. CT scan
and MRI of the head was performed and multiple intracranial
metastasis were found with a possible intraparenchial bleed in
the cerebellum.
# Respiratory distress: Pt was intubated early in the admission
out of concern for changing mental status and inability to
protect his airway. On [**11-4**], pt had increasing oxygen
requirements and was found to have white-out of the left lung by
CXR. 600 ccs were drained from L pleural effusion. He was also
bronched out of concern for a mucus plug and secretions were
removed from his airways with subsequent improvement of his
respiratory status. However, he was not able to come off the
ventilator.
# Altered mental status: On admission to the hospital, pt was
alert and oriented x3 but his mental status rapidly deteriorated
and he required intubation to help protect his airway. CT head
was obtained on [**11-4**] and showed no acute intracranial proccess,
no bleed, but did showed extra-axial lesions which were
concerning for meningiomas vs. metastiatic cancer.
Additionally, his hypoxia/hypercarbia were likely contributing
to his altered mental status, as well as his poor perfusion in
the context of cardiogenic shock.
.
# Fever: most likely represents B sxs related to his new
malignancy, however also concerning for infection in the context
of sputum cxs growing gram neg rods and gram positive cocci as
well as positive influenza testing. He was treated with 6 day
course of vanc/cefepime/cipro, then ID consulted for persistent
fevers despite abx tx. These antibiotics were then discontinued
and he was started on ceftriaxone given that there was no growth
in any other cultures.
# Influenza: pt tested positive for influenza A, which may
explain the URI sxs that the patient complained of the week
prior to admission. He was placed on droplet percautions and
treated with osteltamavir and ramantidine. Samples sent to
state lab for further analysis and results were pending.
# Anemia: No clear source of bleed during the admission however
crit was lower than baseline and pt required PRBCs to stabilize
his crit.
# Hyperlipidemia: Cholesterol not well controlled according to
last lipid panel measured in [**11-24**]. Chol: 295, LDL: 192, HDL:
79, TG: 120. His statin dose was increased to 80 mg PO daily.
# DMII: Last A1c in [**2-26**] was 7.4%. He was initially treated with
long acting insulin/ISS but later transitioned to insulin gtt
for better control of his sugars.
# LE edema: LE doppler performed early in the admission out of
concern for DVT unequal edema of the LEs, however studies were
negative and the LE edema was attributed to his heart failure
and he was treated with diuresis.
# Epistaxis: pt with significant nosebleed and was seen by ENT
who packed the bleed. No further bleeding after this
intervention.
# Thrombocytopenia: HIT abx negative. DIC labs WNL.
# Arthritis: Stable.
# Gout: Stable. Allopurinol continued
Medications on Admission:
MEDICATIONS:
- allopurinol 600mg PO daily
- glipizide 10mg PO BID with meals
- hydrochlorothiazide 50mg PO qam
- lisinopril 10mg PO qam
- metformin 500mg SR daily with dinner
- salsalate 500mg PO TID
- simvastatin 20mg PO qhs
- verapamil 180mg SR PO daily
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
shock
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 5849, 4254, 4280, 2768, 2875, 2724, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1739
} | Medical Text: Admission Date: [**2192-7-5**] Discharge Date: [**2192-7-17**]
Date of Birth: [**2118-12-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfonamides / Lasix
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
bioprosthetic mitral regurgitation
Major Surgical or Invasive Procedure:
[**2192-7-6**] redo sternotomy, reoperative mitral valve replacement/
resection of Left Atrial Appendage and subsequent re-exploration
for bleeding
History of Present Illness:
This 73 year old Hispanic male underwent mitral valve repair in
[**2179**]. he developed hemolytic anemia requiring valve replacement
later the same year. He now has heart failure, pulmonary
hypertension and progressive silattion of ther left atrium. he
was admitted for reoperation.
Past Medical History:
hypercholesterolemia
congestive heart failure with pulmonary hypertension
mitral stenosis
aortic stenosisfibrillation
h/o hemolytic anemia
gastric erosions
syncope
h/o subdural hematoma
h/o subarachnoid hematoma
Insomnia
Depression
Bilateral Carotid Artery Disease, Right carotid bruit
[CTA showing cath fragment in right common carotid artery
probaly since in MVR [**12/2179**]] - [**2189-7-15**]
Social History:
Retired clinical psychologist. Quit tobacco in [**2164**]. Lives with
wife [**Name (NI) 5627**] in [**Location (un) 3146**] and HCP is son, [**Name (NI) **] [**Name (NI) 14763**]
([**Telephone/Fax (1) 14764**]) and is full code. Reports to be independent in
ADLs and still drives but finances taken care per wife.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother died of breast cancer. Father died of
Parkinson' Disease, lung cancer (smoker).
Physical Exam:
Admission:
heart rate of 58 which is regular.
Respiratory rate is 20. Blood pressure is 140/70. Height is
5'2". Weight is 131 pounds.
HEENT, normocephalic and atraumatic. Pupils are equal, round,
and reactive to light and accommodation. Extraocular movements
are intact. Oropharynx is within normal limits.
Chest is clear to auscultation bilaterally except for some mild
crackles at the bases bilaterally.
Cardiac examination shows the pulse shows an irregular rhythm
with a IV/VI systolic murmur heard best at the left parasternal
border and left apex which radiates to left axilla.
Abdomen is soft, nontender, and nondistended. Bowel
sounds are present. There is no costovertebral angle
tenderness.
Extremities are warm and well perfused. There is
1+ edema. There are no varicosities. Pulses are 2+
Pertinent Results:
Intra-op TEE
[**2192-7-6**]
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is mildly
depressed (LVEF= 45-50 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is dilated with
focal severe hypokinesis of the mid and apical free wall. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. There is a minimally increased gradient consistent
with minimal aortic valve stenosis. Trace aortic regurgitation
is seen. A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral valve leaflets are thickened. There is
prolapse of the prosthetic mitral valve leaflets. The gradients
are higher than expected for this type of prosthesis. There is
mild valvular mitral stenosis (area 1.5-2.0cm2). Moderate to
severe (3+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Mild pulmonic regurgitation is
seen. There is a trivial/physiologic pericardial effusion. Dr.
[**Last Name (STitle) 914**] was notified in person of the results in the operating
room at the time of the study.
POST BYPASS The patient is receiving milrinone and epinephrine
by infusion. The patient is AV paced. The right ventricular free
wall shows some mild improvement of the mid and apical segments
but there is still moderate hypokinesis. The left ventricle
dispalys somewhat improved systolic function with an ejection
fraction of about 55%. There is a bioprosthesis in the mitral
position. It appears well seated. There is occassional trace
valvular mitral regurgitation. No perivalvualr regurgitation is
seen. Leaflet motion appears normal. The thoracic aorta appears
intact status post decannulation. No other significant changes
from the pre-bypass study.
Admission:
[**2192-7-5**] 06:20PM BLOOD %HbA1c-5.5 eAG-111
[**2192-7-5**] 06:20PM PT-17.9* PTT-27.8 INR(PT)-1.6*
[**2192-7-5**] 06:20PM PLT COUNT-200
[**2192-7-5**] 06:20PM WBC-7.2 RBC-3.07* HGB-9.7*# HCT-29.0* MCV-95
MCH-31.4 MCHC-33.2 RDW-17.2*
[**2192-7-5**] 06:20PM ALBUMIN-3.8
[**2192-7-5**] 06:20PM LIPASE-33
[**2192-7-5**] 06:20PM ALT(SGPT)-37 AST(SGOT)-61* LD(LDH)-879* ALK
PHOS-144* AMYLASE-48 TOT BILI-1.0
[**2192-7-5**] 06:20PM GLUCOSE-114* UREA N-47* CREAT-1.7* SODIUM-134
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-27 ANION GAP-14
[**2192-7-5**] 08:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
Discharge:
[**2192-7-17**] 05:41AM BLOOD WBC-9.0 RBC-3.61* Hgb-11.1* Hct-32.2*
MCV-89 MCH-30.6 MCHC-34.4 RDW-15.7* Plt Ct-230
[**2192-7-17**] 05:41AM BLOOD Glucose-99 UreaN-34* Creat-1.4* Na-137
K-3.6 Cl-98 HCO3-34* AnGap-9
[**2192-7-17**] 05:41AM BLOOD PTT-31.5
[**2192-7-15**] 05:19AM BLOOD PT-27.4* INR(PT)-2.7*
[**2192-7-14**] 09:19AM BLOOD PT-26.1* INR(PT)-2.5*
[**2192-7-13**] 05:15AM BLOOD PT-21.0* INR(PT)-1.9*
[**2192-7-12**] 03:02AM BLOOD PT-15.6* PTT-26.6 INR(PT)-1.4*
Radiology Report CHEST (PA & LAT) [**2192-7-16**] 1:58 PM
Final Report
CHEST RADIOGRAPH, PA AND LATERAL VIEWS: Patient is status post
CABG and
median sternotomy. A right upper extremity PICC is again seen
coiled in the mid SVC, with tip terminating likely in the upper
SVC. This appears unchanged since [**2192-7-9**].
Small right greater than left pleural effusions remain, slightly
decreased on the right. There is adjacent bibasilar atelectasis.
Otherwise, there is no evidence of pulmonary edema.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Brief Hospital Course:
On [**7-6**] he went to the Operating Room where redo sternotomy and
redo mitral valve replacement were performed. He required
reexploration for bleeding in the immediate post-op course, then
remained stable. Within 24 hours he woke neurologically intact
was extubated and weaned from all vasoactive infusions. All
tubes lines and drains were removed per cardiac surgery
protocol. He remained in the ICU for close monitoring and was
ultimately transferred to the floor on POD #6. Once on the
stepdown floor he began to increase his activity level. He was
treated with amiodarone/coumadin for recurrent atrial
fibrillation. Speech and swallow team evaluated him for possible
aspiration risk with weak mastication. Diet recommendations made
by team. He was cleared for a regular diet. He took several
days to diurese adequately and to wean from oxygen. He was
aggressively diuresed for a moderate right sided pleural
effusion and general volume overload. The patient was
re-started on his home dose of sotalol. He remained in SR with
1st degree AV block for the remainder of the hospital course.
By the time of discharge on POD 11 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home in good condition
with appropriate follow up instructions. Dr [**Last Name (STitle) **] will follow his
INR and adjust the Coumadin dose accordingly.
Medications on Admission:
Proventil 90 mcg two puffs inhaler p.r.n.,
Pulmicort Flexhaler, Symbicort, Edecrin 50 mg p.o. daily,
Lisinopril 20 mg p.o. daily, Ativan 0.5 mg p.o. p.r.n.,
Singulair 10 mg p.o. daily, Nifedipine 90 mg p.o. daily,
Sertraline 50 mg p.o. daily, Simvastatin 20 mg p.o. daily,
Sotalol 80 mg quarter tablet p.o. t.i.d., Trazodone 100 mg p.o.
q.h.s., Warfarin 3.5 mg p.o. daily, Folic Acid 1 mg p.o. daily,
Multivitamin one p.o. daily, and Omeprazole 20 mg p.o. daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
bioprosthetic mitral regurgitation
s/p mitral valve replacement x2
s/p reoperation for postoperative bleeding
s/p mitral valve repair
pulmonary hypertension
congestive heart failure
paroxysmal atrial fibrillation
h/o hemolytic anemia secondary to valve dysfunction
chronic obstructive pulmonary disease
hypercholesterolemia
h/o subdural hematoma
h/o subarachnoid hematoma
erosive gastritis
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with percocet
Sternal Incision: healing well, no erythema or drainage
Edema: 2+ bilateral LEs
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming until cleared by surgeon. Look at your
incisions daily for redness or drainage.
No lotions, cream, powder, or ointments to incisions.
Each morning you should weigh yourself and then in the evening
take your temperature, These should be written down on the chart
.
No driving for approximately one month, until follow up with
surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns ([**Telephone/Fax (1) 170**]).
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2192-8-7**] 1:15
Please call to schedule appointments with:
Primary Care: Dr.[**Last Name (STitle) 131**] [**Telephone/Fax (1) 133**] in [**1-7**] weeks
Cardiologist: Dr. [**Last Name (STitle) **] in [**2-8**] weeks [**Telephone/Fax (1) 5768**]
**Dr. [**Last Name (STitle) **] to resume management of INR/coumadin dosing**
1st INR draw [**2192-7-18**]
**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:[**2192-7-17**]
ICD9 Codes: 5849, 9971, 5119, 2851, 4240, 4168, 2724, 4280, 2720, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1740
} | Medical Text: Admission Date: [**2165-6-4**] Discharge Date: [**2165-7-3**]
Date of Birth: [**2112-7-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
SAH
Major Surgical or Invasive Procedure:
[**6-3**]: Rt EVD
[**6-4**]: Distal L ICA aneurysm coiling
[**6-26**]: PEG placment
History of Present Illness:
52F w/o PMH, reportedly collapsed in early evening of [**6-4**];
transported to OSH where whe was intubated; head CT showed
diffuse SAH; tx to [**Hospital1 18**] for definitive treatment
Past Medical History:
None
Social History:
unknown
Family History:
unknown
Physical Exam:
On Admission:
102/64 107 20 100%
Intubated, not sedated.
Pupils: 3 mm, trace reactive, bilat.
No eye opening. No vocal response.
Motor: internal rotation/flexion of UE to stim, symetrically.
Min. withdrawal LE to stim, symetrically.
DTRs 2+ throughout and symetric; toes downgoing; tone: normal;
On Discharge:
XXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2165-6-3**] 10:38PM BLOOD WBC-14.9* RBC-3.83* Hgb-12.5 Hct-39.2
MCV-102* MCH-32.7* MCHC-31.9 RDW-12.8 Plt Ct-258
[**2165-6-3**] 10:38PM BLOOD Neuts-73.8* Lymphs-21.1 Monos-3.9 Eos-0.7
Baso-0.5
[**2165-6-4**] 04:28AM BLOOD PT-13.9* PTT-23.7 INR(PT)-1.2*
[**2165-6-3**] 10:38PM BLOOD Glucose-245* UreaN-22* Creat-0.9 Na-140
K-3.5 Cl-105 HCO3-20* AnGap-19
[**2165-6-4**] 04:28AM BLOOD CK(CPK)-304*
[**2165-6-4**] 04:28AM BLOOD cTropnT-0.96*
[**2165-6-4**] 12:31PM BLOOD CK-MB-21* MB Indx-6.2* cTropnT-0.51*
[**2165-6-4**] 09:36PM BLOOD CK-MB-12* MB Indx-4.5 cTropnT-0.31*
[**2165-6-5**] 02:55PM BLOOD cTropnT-0.13*
[**2165-6-3**] 10:38PM BLOOD Calcium-7.5* Phos-5.2* Mg-2.0
Labs on Discharge:
XXXXXXXXXXXXXX
Imaging:
CTA Head [**6-5**]:
IMPRESSION:
Diffuse subarachnoid hemorrhage as described above with a
multilobulated left ICA terminus aneurysm measuring
approximately 4 x 6 mm as the presumed source. Traditional
angiography pending.
Cardiac Echo [**6-4**]:
Conclusions
Overall left ventricular systolic function is severely depressed
(LVEF= 20--25%). There is severe regional left ventricular
systolic dysfunction with akinesis of mid-to-apical myocardioum.
Basal and Apex areas are spared. Right ventricular chamber size
and free wall motion are normal. The left atrium is normal in
size. No atrial septal defect is seen by 2D or color Doppler.
The number of aortic valve leaflets cannot be determined. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. No mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal.
IMPRESSION: Severe left ventricular systolic dysfunction (EF
20-25 %) with regionality; akinesis of mid-to-apical walls with
sparing of the apex. Right ventricular systolic function and
size is normal. Moderate to severe (3+) tricuspid regurgitation.
CT C-spine [**6-4**]:
IMPRESSIONS:
1. No acute traumatic injury seen in the cervical spine.
2. Blood in the basal cisterns tracking inferiorly and
anteriorly along the brainstem and upper spinal cord. Thecal sac
contents are not adequately assessed on the present study. MR
can be considered if there is concern based on neurological
examination.
3. Airspace consolidation in the posterior lung apices with
smooth septal
thickening. Findings along with chest radiograph likely
represents some
pulmonary edema, although aspiration cannot be excluded.
CT Head [**6-5**]:
FINDINGS: The diffuse subarachnoid hemorrhage appears stable in
extent.
Overall, ventricular size has further decreased, compared to the
prior study. The ventriculostomy catheter terminating in the
region of the third ventricle remains present. There has been
further interval progression of bilateral regions of
hypoattenuation involving the medial inferior frontal lobes.
There is no associated parenchymal hemorrhage. There is no shift
of normally midline structures. The streak artifact produced by
left distal internal carotid artery coils obscures evaluation in
area. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Trace
intraventricular hemorrhage layering posteriorly in the
occipital horns as well as small amount in the third ventricle
are stable. The mastoid air cells and imaged paranasal sinuses
remain well aerated.
IMPRESSION:
1. Slight decrease in ventricular size, compared to the prior
study.
2. Further evolution of bifrontal hypoattenuation, which may
represent
infarcts rather than non-hemorrhagic contusion, given the
progression. No
parenchymal hemorrhage. MR [**First Name (Titles) **] [**Last Name (Titles) **] head can be considered, if
necessary to
assess extent and vessels as recommended earlier.
3. Stable extent of diffuse subarachnoid hemorrhage.
CXR [**2165-6-5**]
Final Report
INDICATION: 52-year-old female with subarachnoid hemorrhage,
dilated
cardiomyopathy. Evaluate for pulmonary edema.
Single AP chest radiographs compared to 13 hours prior shows no
change. ET
tube tip is 2.3 cm above the carina. Left internal jugular
central venous
catheter terminates in the mid SVC. The NG tube tip is in the
stomach, the
sidehole slightly below the gastroesophageal junction. The
cardiomediastinal silhouette is stable. Again seen are bilateral
perihilar opacities consistent with pulmonary edema, not
significantly changed from prior exam. There is no pneumothorax
or pleural effusion.
IMPRESSION: Compared to prior exam from [**2165-6-5**], there is
no change in the extent of pulmonary edema.
Cardiac Echo : [**2165-6-11**]
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is good (>20 cm/s). No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. No masses or
thrombi are seen in the left ventricle. Overall left ventricular
systolic function is severely depressed (LVEF= 20-25 %). with
mild global free wall hypokinesis. with focal hypokinesis of the
apical free wall. There is no mass/thrombus in the right
ventricle. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are structurally normal. Trivial mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2165-6-4**], left ventricular systolic function has improved.
Akinesis of mid-to-apical walls with sparing of the apex has
resolved.
Final Report
PORTABLE CHEST [**2165-6-19**]:
COMPARISON: Study of earlier the same date.
INDICATION: Feeding tube assessment.
FINDINGS: Feeding tube tip is directed cephalad in region of
gastroduodenal
junction. Appearance of the chest is similar to the recent
radiograph of
about 2 hours earlier except for minimal improved aeration in
the left
retrocardiac region.
[**2165-6-25**] 12:25 PM CT
HEAD CT: Axial imaging was performed through the brain without
IV contrast
administration.
COMPARISON: CT head [**2165-6-23**].
FINDINGS: There is a tract of hypodensity extending along the
course of the prior right frontal approach ventriculostomy
catheter (2:13). There is no hyperdensity along this tract to
suggest the presence of hemorrhage. The ventricles are unchanged
in size and configuration. There is streak artifact from a left
ICA aneurysm coil. [**Doctor Last Name **]-white matter differentiation remains
well preserved. There is no evidence of prior subarachnoid
hemorrhage. There is no shift of normally midline structures.
There is hypodensity in the territory of the left MCA related to
prior infarct (2:15), which appear stable without evidence for
hemorrhagic transformation. There is a right frontal burr hole
otherwise osseous structures are intact. The paranasal sinuses,
ethmoid, and mastoid air cells are clear.
IMPRESSION:
1. Post-right frontal approach ventriculostomy catheter removal
without
evidence for hemorrhage. Stable ventricular size.
2. Unchanged appearance to region of infarction in the left MCA
distribution without hemorrhagic transformation.
SAT [**2165-6-22**] 12:08 PM
Final Report
INDICATION: 52-year-old female with transaminitis and fevers.
Evaluate right
upper quadrant.
COMPARISON: CT chest dated [**2165-6-7**].
FINDINGS: The liver is normal in contour and echotexture. There
is a single 1.2-cm cyst identified in the periphery of the right
dome. There are no other focal liver lesions identified. There
is no intrahepatic or extrahepatic biliary ductal dilatation.
The common bile duct measures 5 mm. The gallbladder is
unremarkable, with no wall thickening, no pericholecystic fluid.
There are no stones or sludge identified within the gallbladder.
There is normal antegrade flow identified in the main portal
vein. The spleen measures 8.7 cm and is normal in appearance.
There is no free fluid in the abdomen. Small right pleural
effusion is noted.
IMPRESSION:
1. 1.2-cm cyst in the right lobe of the liver, as appreciated on
CT of the
chest dated [**2165-6-7**]. Liver is otherwise unremarkable.
2. No son[**Name (NI) 493**] evidence for acute cholecystitis. No
cholelithiasis.
Brief Hospital Course:
52F admitted to [**Hospital1 18**] after transfer from OSH following a
witnessed syncopal episode. Head CT performed showing diffuse
SAH. CTA of head also performed with preliminarily identified an
aneurysm at the left ICA bifurcation. She was loaded with
dilantin, and started on nimodipine, and emergent bedside
external ventricular drain was placed. She also had a cardiac
echo done for concerns of a catacholamine induced
cardiomyopathy(had developed pulmonary edema), which showed
significantly depressed cardic function. She was placed on a
[**Last Name (un) 18821**] monitor to more closely monitor for this. She had an
angiogram done on [**6-4**], when the left distal ICA aneurysm was
coiled. She then returned to the ICU postoperatively.
On [**6-5**](overnight) she had a ICP elevation to 50 and the drain
was promplty dropped to 10cm, and ICP normalized. Emergent head
CT was done which showed likely evolving brifrontal
hypoattenuations/possible stroke. She again returned to angio on
[**6-6**] to further evaluate vascualar patency given this new CT
finding.The patient was febrile with a Tmax 101.6 and was pan
cultured,the urine and cerebral spinal fluid cultures were both
neagtive. On [**6-6**] The Dobutamine intravenous drip was off,
vasopressors Levophed and neo cont. The Nimodipine cut in [**12-21**]
to maintain goal blood pressures. The patient was brought to
angio, there was no significant spasm and given 5mg
verapamil-aneurysm stable. Blood cultures were found to be
negative. The sputum culture was positive for rare yeast.On
[**6-7**]: The patient had an acute PaO2 decrease to 50%. There was
a concern for Pulmonary embolusE. The CTA of the Chest was not
consistent with Pulmonary embolus. The CT Head was unchanged.
The patient was moniotored for possible Central Diabetes
Insipidus. The urine and sputum cultures were both negative. On
[**6-8**], The patient was pan-cultured for a fever to 102. A head
CT ordered for elevated ICP to 44, Mannitol was initiated for
increased ICPs. A CTA was performed which was consistent with a
slight decrease in intercranial vasospasm. On [**6-9**], The patient
required 3 doses of mannitol for sustained ICP levels of 23.
There were no changes in the patients mental status with these
ICP increases.On exam the patient was intermitently following
commands in the right upper extremity, the left upper extremity
moved to command, the left lower extremity and Right upper
extremity withdrew to pain,the patients eyes were open and
tracked with her eyes. On [**6-10**], The patient was back on a
dobutamine gtt continuously to maintain a goal blood pressure,
The patient had a TEE which was consistent with Ejection F of
20%. The LENIS were negative for deep vein thrombosis, The CSF
and sputum cultures were negative. On [**6-11**], The patient
underwent an angio which was consistent with mild to mod
vasospasm. She recieved 2 doses of verapamil.Nimodipine at 15mg
every 2 hours was restarted. On [**6-12**], The patient was bolused
with dilantin 300mg for a 7.9 level. The Head CT was repeated
and was stable. The patient was extubated and stopped nimodpine
for systolic blood pressure in 60's.The goal MAP > 100 and
dobutamine was restarted.
[**6-14**] CT shows:new stroke in the posterior left MCA distribution
CTA shows diffuse, severe vasospasm involving the bilateral MCAs
(left worse than right)the following day she underwent a
cerebral angiogram which showed Mild to moderate spasm Left A1,2
and M1,2 segments though her exam seemed to slightly improve
with brisk localization on LUE and localization on RUE though
not as brisk as left. She had some intermittent eye opening. A
stroke neurology consult was obtained and they agreed with our
continued HHH management and requested starting a Statin.
On [**6-17**], she was again febrile, and pan cultured. CVL
access was changed and catheter tip sent. OR was cancelled for
the day for her temperature, and possibly to re-attempt [**6-19**] or
[**6-20**] if afebrile and no positive cultures. Positive blood cx from
arterial line and appearance of axillary A line, concerned for
line infection and she was treated for line associated
bacteremia for 7 day course. PEG placed by surgery team on
[**2165-6-26**] without event. Meds and diet were advanced through PEG
as recommended without issue.
On discharge her neurological exam she preferred her eyes closed
would open to voice, questionable following commands with left
side. She is essentially plegic on right side but will withdraw
both arm and leg to pain. Her pupils are 4mm and reactive, her
incision are well healed. She was tolerating her tube feeds
without difficulty. Speech and swallow recommends video swallow
before initiating any oral feeds.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fevers.
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. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every
8 hours) as needed for fever.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for stridor.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Levetiracetam 100 mg/mL Solution Sig: One (1) PO BID (2
times a day).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
14. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
SAH
Left ICA bifurcation aneurysm
dysphagia
pulmonary edema
cerebral vasospasm
cardiogenic shock d/t sympathetic surge
stroke left MCA distribution
bifrontal strokes
fever / central
bacteremia / coag neg staph
altered mental status
mutism
Discharge Condition:
Neurologically with right sided plegia and mutism intermittently
follows commands
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest Eme
Followup Instructions:
Please call [**Telephone/Fax (1) 1669**] to schedule an appointment to be seen
by Dr. [**First Name (STitle) **] in approx 4 weeks after your discharge. You will
need to have a CT scan of the head without contrast at that time
Completed by:[**2165-7-3**]
ICD9 Codes: 7907, 2761, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1741
} | Medical Text: Admission Date: [**2198-3-12**] Discharge Date: [**2198-3-22**]
Date of Birth: [**2147-7-28**] Sex: M
HISTORY OF PRESENT ILLNESS: This is a 50 year old male with
a history of HIV, Hepatitis C, intravenous drug abuse and
poly-substance abuse, who was admitted from an outside
hospital with continued mental status changes after being
[**2198-3-9**]. He was taken initially to [**Hospital 1474**] Hospital
where he was given Narcan for presumed opiate overdose. He
became awake and agitated following the Narcan and was
admitted to the [**Hospital 1474**] Hospital Intensive Care Unit with
the diagnosis of acute renal failure and rhabdomyolysis. His
creatinine at that time was 13.2 and he had an initial CK of
14,000. He was treated with intravenous fluids, urine
His mental status continued to be abnormal as he demonstrated
both agitation and excessive somnolence. He was transferred
to [**Hospital1 69**] on [**3-12**], for
further evaluation of change in mental status after he had
become progressively lethargic and unresponsive to questions
at [**Hospital 1474**] Hospital. Of note, he was treated with Tequin
for a three-day course at [**Hospital 1474**] Hospital for a urinary
tract infection.
On arrival to [**Hospital1 69**], the
patient was noted to have a temperature of 100.2 F., and an
examination notable for delirium, nuchal rigidity, and
questionable right sided weakness. Head CT scan showed a 6
mm left posterior frontal hemorrhage. Lumbar puncture showed
approximately 1400 red blood cells and one white blood cell.
The patient was placed on empiric Acyclovir for coverage of
HSV encephalitis pending results of HSV PCR from
cerebrospinal fluid. An MRI and MRA study was consistent
with focal leukoencephalopathy of toxic, HIV, PML or other
origin.
In the Medical Intensive Care Unit, the patient received a
five day course of Fluconazole for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**] albicans urinary
tract infection. He defervesced. He was transfused with a
total of three units of blood for a hematocrit of 20. He was
treated aggressively for hypertension including diastolic
hypertension. An EEG performed in the Intensive Care Unit
showed encephalopathic but not epileptiform activity. On [**3-19**], he was transferred to the ACOVE Service for continued
care.
REVIEW OF SYSTEMS: Negative for headache, visual changes,
shortness of breath, cough, chest pain, back pain, abdominal
pain.
PAST MEDICAL HISTORY:
1. Human Immunodeficiency Virus diagnosed in [**2194**]; recent
CD4 count 309; HIV viral load less than 50.
2. Intravenous drug abuse with cocaine and heroin.
3. Poly-substance abuse.
4. Status post laparotomy for abdominal stab wound.
5. Herpes zoster in [**2194-8-14**].
ALLERGIES: No known drug allergies.
MEDICATIONS: (Outpatient)
1. Neurontin 600 mg p.o. three times a day.
2. Zerit 40 mg p.o. twice a day.
3. Sulfamethoxazole.
MEDICATIONS: (Transfer from Intensive Care Unit)
1. Prevacid 30 mg p.o. twice a day.
2. Multivitamin one p.o. q. day.
3. Nystatin 5 cc swish and swallow twice a day.
4. Folate 1 mg p.o. q. day.
5. Thiamine 100 mg p.o. q. day.
6. Ativan 1 mg p.o. twice a day.
7. Dyazide 50/25 q. day.
8. Lisinopril 40 mg p.o. q. day.
9. Haldol 5 mg p.o. twice a day.
10. P.R.N. Tylenol, Lomotil, Haldol, Ativan.
SOCIAL HISTORY: Positive for marijuana, cocaine, heroin,
alcohol use. The patient is married with three children. He
is currently unemployed.
PHYSICAL EXAMINATION: At admission, temperature 101.2 F.;
heart rate 90; blood pressure 150/92; respirations 14; pulse
oximetry 98% on room air. Generally, somnolent but arousable
African American male not following commands. HEENT: Pupils
equally round and reactive to light. Dry mucous membranes.
Neck: Nuchal rigidity present. Lungs: Coarse breath sounds
bilaterally with no wheezes. Cardiovascular: Regular rate
and rhythm, without murmurs, rubs or gallops. Abdomen:
Laparotomy scar present. Soft, nontender, nontender. Bowel
sounds present. Liver palpated at the right costal margin.
Extremities: Warm without edema. A left groin line is
intact. Foley catheter is present. There is an NG tube.
Neurologic: Somnolent and minimally arousable. Unable to
follow simple commands. Grossly intact strength and
sensation throughout. Reflexes two plus bilaterally.
LABORATORY STUDIES: (At admission) white blood cell count
of 5.7, hematocrit of 23.9, platelets 152, 68% neutrophils,
21% lymphocytes. PT 13.7, PTT 32.5, INR 1.3. Sodium 148,
potassium 3.3, chloride 115, bicarbonate 23, BUN 27,
creatinine 1.0. Arterial blood gas is 7.47/29/86 on room
air.
ALT 82, AST 249, alkaline phosphatase 55, total bilirubin
1.1, calcium 7.7, albumin 2.9, magnesium 1.9.
EKG normal sinus rhythm at 95 beats per minute, without
ischemic changes.
Urinalysis: Cloudy, specific gravity 1.010, large blood, 100
protein, pH 7.0, moderate leukocytes, 26 red cells, 110 white
cells, no bacteria, no epithelial cells.
Chest x-ray: No evidence of pneumonia.
Other laboratory studies: Serum tox screen positive for
opiates. Direct COOMBS test negative. LD 557, total
bilirubin 1.0, haptoglobin less than 20, fibrin split
products 10 to 40, D-Dimer 500 to 1000, fibrinogen 206, B12
491, folate 5.6. Iron 110, total iron binding capacity 221,
ferritin 280. ESR is 4. Reticulocyte count 3.0.
HOSPITAL COURSE: This is a 50 year old male with history of
HIV, Hepatitis C, intravenous drug and poly-substance abuse
who was admitted with persistent mental status changes from
[**Hospital 1474**] Hospital on [**2198-3-12**], for continued care.
1. Mental status: The patient was noted to be somnolent and
unable to follow simple commands and unable to answer
questions on admission. The differential diagnosis of
meningitis, HSV encephalitis, subarachnoid hemorrhage,
seizure activity or post-ictal state, or toxic metabolic
ingestion were considered. Given the patient's admission
fever, nuchal rigidity and questionable right sided
neurologic findings, a lumbar puncture was performed showing
1405 red blood cells and one white blood cell. At this
point, a differential was considered that included
subarachnoid hemorrhage or HSV encephalitis.
Acyclovir was empirically started on [**3-13**] and an HSV PCR
was sent from the cerebrospinal fluid. A head CT scan showed
a 6 mm left posterior frontal hemorrhage. A Neurologic
consultation was obtained and recommended MRI/MRA, which
showed diffuse white matter, T2 hyperintensity, involving the
cerebral and cerebellar white matter, brain stem, internal
capsule. These findings were considered to be consistent
with a toxic demyelinating process, HIV leukoencephalopathy
or progressive multi-focal leukoencephalopathy.
An EEG was performed showing left temporal lobe slowing, but
no evidence of epileptiform activity. There were
encephalopathic findings.
On [**3-18**], Acyclovir was discontinued when the HSV PCR from
cerebrospinal fluid result was negative. During the
Intensive Care Unit course, the patient required Haldol,
Ativan and at one point, restraints for patient's safety.
The patient was transferred from the Intensive Care Unit to
the ACOVE Unit on [**3-19**]. He continued to demonstrate
clearing of his mental status over the next 48 hours and at
the time of discharge, had returned to his baseline mental
status.
2. Infectious Disease:
HIV - The patient was noted to have a recent viral load of
less than 50 and a CD4 count in the 300s, and so these levels
were not repeated. His HIV medications were held on
admission per his primary care physician's request, and then
restarted on [**3-21**].
Urine - The patient was noted to have a urinary tract
infection at [**Hospital 1474**] Hospital treated with Tequin and was
also noted to have a urinary tract infection on admission to
the Intensive Care Unit at [**Hospital1 188**]. He was initially treated with Ceftriaxone from [**3-12**] through [**3-15**], as it was presumed to be bacterial.
Ceftriaxone was discontinued on [**3-15**], and Fluconazole was
started for a five-day course at that time when urine
cultures showed 100,000 colonies of [**Female First Name (un) 564**] albicans.
Blood - The patient was treated between [**3-14**] and [**3-15**],
with Vancomycin when one out of four blood cultures bottles
grew Gram positive cocci. The Vancomycin was discontinued
when the identification showed coagulase negative
Staphylococcus. The patient also had a positive serum RPR.
At the time of this dictation, a quantitative RPR is pending
at the State Laboratory.
Cerebrospinal fluid - At the lumbar puncture, the patient had
1,405 red blood cells and one white blood cell. HSV PCR was
negative; Cryptococcal antigen negative; [**Male First Name (un) 2326**] virus PCR is
pending at the time of this dictation. There was no viral,
bacterial, fungal growth from the cerebrospinal fluid culture
at the time of this dictation. On [**3-21**], the Infectious
Disease Service was consulted regarding need for continued
Acyclovir therapy. Infectious Disease recommended no further
treatment with Acyclovir as there was a very low suspicion
that the mental status changes were of HSV origin.
Stool - The patient was found to have diarrhea during
Intensive Care Unit stay. It was thought that this was
possibly due to opiate withdrawal. Stool studies were
negative for infectious etiologies.
3. Renal: The patient initially presented at the outside
hospital with acute renal failure and rhabdomyolysis. The
patient returned to baseline renal function and had resolving
rhabdomyolysis at the time of his admission to [**Hospital1 346**].
4. Gastrointestinal: The patient was noted on admission to
have a trans-aminitis consistent with chronic alcohol abuse.
He also presented, as mentioned, with diarrhea which was
thought to be due to opiate withdrawal as his stool studies
where negative. He was noted to have guaiac positive stool
during the admission. He was prophylaxed with Protonix
initially and then changed to Prevacid after he developed
thrombocytopenia. Otherwise, he tolerated a regular diet and
had no further gastrointestinal issues.
5. Genitourinary: Note is made that the patient was treated
during his entire hospital course for a total of two urinary
tract infections with yeast. This may require outpatient
follow-up.
6. Hematologic: The patient was noted to have an anemia at
admission which was thought to be multi-factorial related to
but not limited to HIV, HIV medications, nutritional
deficiencies and alcohol abuse. Iron studies were consistent
with anemia of chronic disease. The patient was transfused a
total of three units of packed red blood cells for a
hematocrit of 20, beginning on [**3-16**]. There were some
abnormalities of the hemolysis labs suggesting hemolysis, but
this was thought to be due to possible effect of blood
transfusion.
7. Cardiovascular: At a concern that the patient may have
had endocarditis, a transthoracic echocardiogram was
performed on [**3-15**], which showed an ejection fraction of
greater than 55% and no obvious vegetations. The patient was
also noted to be hypertensive at times during the Intensive
Care Unit stay and his blood pressure was successfully
controlled by the time of discharge with Lisinopril and
Dyazide.
8. Nutrition: The patient tolerated a regular diet which
was supplemented with a multivitamin, supplemental thiamine
and folate.
9. Musculoskeletal: The patient developed bilateral elbow
abrasions as well as a coccyx abrasion secondary to profound
agitation during Intensive Care Unit admission. These
abrasions were dressed with Duoderm and will be dressed as an
outpatient by visiting nurses.
10. Psychiatric: A Code Purple was called on the morning of
[**3-19**], when patient became agitated, began swearing and
attempted to leave the hospital. The patient was treated
with Haldol for acute delirium. Per the Psychiatry Consult
Service, the patient was continued on Haldol for agitation as
well as restraints, given that he was unable to be
re-oriented successfully. He was also maintained on a sitter
for periods of the hospital stay. Per Psychiatry
recommendations, a TSH was sent which was normal.
In terms of the patient's poly-substance abuse, he is to be
followed at the [**Hospital 96653**] Health Center as an outpatient as he
has declined inpatient therapy at this time.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient is being discharged to home.
DISCHARGE INSTRUCTIONS:
1. Diet regular.
2. Activity as tolerated.
DISCHARGE DIAGNOSES:
1. Mental status change.
2. Human Immunodeficiency Virus.
3. Hepatitis C.
4. Poly-substance abuse.
5. Intravenous drug abuse.
6. Leukoencephalopathy of uncertain origin.
7. Hypertension.
8. Acute renal failure.
9. Rhabdomyolysis.
MEDICATIONS AT DISCHARGE:
1. Multivitamin one p.o. q. day.
2. Dyazide 50/25 p.o. q. day.
3. Lisinopril 40 mg p.o. q. day.
4. Kaletra 3 capsules p.o. twice a day.
5. Didanosine 400 mg p.o. q. day.
6. Stavudine 40 mg p.o. twice a day.
7. Vitamin C 500 mg p.o. twice a day.
8. Zinc 220 mg p.o. q. day.
9. Oxycodone 10 mg p.o. q. four to six hours p.r.n. pain.1 week
supply6 ONLY
10. Neurontin 600 mg p.o. three times a day or as directed.
11. Duoderm CGF to bilateral elbows and coccyx, change q. 48
hours, normal saline cleansing at dressings changes; extra
thin Duoderm to the right ear, change q. 48 hours.
FOLLOW-UP INSTRUCTIONS:
1. Dr. [**First Name (STitle) **] [**Name (STitle) 2340**], [**Hospital1 69**]
Neurology, [**4-25**], at 03:00, in [**Hospital Ward Name 23**], [**Location (un) 858**].
2. [**Hospital 96653**] Health Center, phone number [**Telephone/Fax (1) 75084**]55, with Dr. [**Last Name (STitle) 724**], within one to two weeks.
3. Follow-up with Dr. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **] after [**5-7**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17014**], M.D. [**MD Number(1) 17015**]
Dictated By:[**Last Name (NamePattern1) 737**]
MEDQUIST36
D: [**2198-3-22**] 15:11
T: [**2198-3-22**] 18:44
JOB#: [**Job Number 96654**]
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1742
} | Medical Text: Admission Date: [**2102-7-27**] Discharge Date: [**2102-7-29**]
Date of Birth: [**2063-8-23**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Morphine
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Sore throat
Major Surgical or Invasive Procedure:
Needle aspiration of abscess
History of Present Illness:
38yo F p/w progressive sore throat for 4 days and fever. She
noted sore throat became worse on the left, and developed AS
otalgia. She's had progressive odynophagia, now w/ significantly
limited POs. Report fever to 104 at home. She usually gets 1
sore throat per year, but has never had a PTA. No difficulty
breathing. She was given dilaudid and Clindamyin in the ED.
Of note, she finished chemotherapy for breast cancer 2 months
ago.
Past Medical History:
Past Medical History:
Metastatic breast cancer with verterbral metastasis s/p XRT to
thoracic spine
HTN
Morbid Obesity
Depression
Anemia
Post partum cardiomyopathy- EF now improved to 45-50%
Social History:
Lives at home with husband and children. smoking [**1-16**] cigarettes
per day
Family History:
Aunt with [**Name2 (NI) 499**] cancer at 46. Grandmother had
leukemia. Mother: diabetes. [**Hospital 5772**] medical history unknown to
patient.
Physical Exam:
101.1 98.9 90 120/74 16 97%RA
NAD, no stridor, no work of breathing, appears uncomfortable
[**Name Prefix (Prefixes) **] - [**Last Name (Prefixes) **] without edema/erythema, TM intact without erythema
Nose - normal mucosa anteriorly bil, no drainage middle meatus
bil
OC - no trismus, tongue- no edema, soft FOM
OP - + erythema, 2+ tonsils thin exudate, uvula midline,
asymmetry of left anterior tonsillar fossa- which is displaced
toward midline inferiorly
Neck - + tender LAD on left, no stiffness
Fiberoptic exam: NP - no mass or drainage, patent ET bil, left
pharyngeal wall w/ significant edema narrowing OP by about 30%,
starting at inferior aspect of OP, partially obliterating left
vallecue, and extending into hypopharynx, left piriform sinus
partially obliterated by lateral pharyngeal wall edema, AE
folds- no edema, arytenoids- no edema, bil normal VC motion, VC
without edema, small amt pooled secretions in postcricoid space,
crisp epiglottis, normal R valleculae and piriform sinus
Pertinent Results:
[**2102-7-27**] 05:47AM BLOOD WBC-6.8 RBC-4.03* Hgb-11.6* Hct-34.9*
MCV-87 MCH-28.9 MCHC-33.3 RDW-14.2 Plt Ct-336
[**2102-7-27**] 05:47AM BLOOD Neuts-73.5* Lymphs-17.1* Monos-7.1
Eos-1.9 Baso-0.5
[**2102-7-27**] 05:47AM BLOOD Glucose-116* UreaN-17 Creat-0.8 Na-141
K-3.8 Cl-103 HCO3-27 AnGap-15
[**2102-7-28**] 06:30AM BLOOD Calcium-10.0 Phos-3.9 Mg-2.5
CT NECK W/CONTRAST
IMPRESSION:
1. A 1.7 cm rim enhancing collection in the left palatine
tonsil that
represents phlegmon or developing abscess.
2. New lytic lesions in the cervical spine are concerning for
progression of
known breast malignancy.
Brief Hospital Course:
Ms. [**Known lastname 3444**] was admitted to the MICU from the ER for continuous O2
sat monitoring, IV abx and steroids given the concern for
possible airway compromise. She was started on all of her home
medications. A repeat fiberoptic exam was done on the afternoon
of admission which showed a persistent mass/edema in the L
pharyngeal wall to within 1/2 cm from the epiglottis. An
attempt was made at aspiration of the peritonsillar area which
failed to return any purulent drainage. She was transferred out
of the MICU on HD 2 as she was clinically improving. She
received a total of 3 doses of steroids. On the floor she
continued to improve clinically. We suggested 24 hours
additional of IV antibiotics but the patient refused. Given her
refusal to stay and her clinical improvement we have decided on
a discharge plan including 10 days of high dose oral antibiotics
and close follow up. She will be seen on Wednesday in clinic
and was instructed to immediately return to the ER should she
experience any worsening symptoms.
Patient is being discharged: afebrile, tolerating regular diet
without nausea/vomiting, voiding, and ambulating well.
Medications on Admission:
Medications:
1. Lisinopril 40 mg daily
2. Metoprolol Succinate 50 mg daily
3. Hydrochlorothiazide 50 mg daily
4. Aspirin 325 mg daily
5. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H prn pain
6. Zofran 4 mg q8hr prn nausea
7. Ferrous Sulfate 325 mg daily
8. Docusate Sodium 100 mg [**Hospital1 **] prn
9. Senna 8.6 mg [**Hospital1 **] prn
10. Morphine 15 mg [**Hospital1 **] prn
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
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) as needed.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
8. Amoxicillin 250 mg Capsule Sig: One (1) Capsule PO twice a
day for 10 days: take in addition to Augmentin.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
peritonsillar phlegmon
Discharge Condition:
Stable
Discharge Instructions:
Seek immediate medical attention for fever >101.5, chills,
shortness of breath, change in your voice, chest pain or
anything else that is troubling you. Resume all home
medications. Call your surgeon to make follow up appointment.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 5773**]/Dr. [**Last Name (STitle) **] in ENT on Wednesday.
Call [**Telephone/Fax (1) **] on Monday to schedule an appointment
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1743
} | Medical Text: Admission Date: [**2179-10-22**] Discharge Date: [**2179-11-16**]
Date of Birth: [**2104-10-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / Lisinopril
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath/chest pain x 3.5 weeks
Major Surgical or Invasive Procedure:
[**2179-10-29**] Coronary artery bypass grafting x4: Left
internal mammary artery to the left anterior descending,
saphenous vein graft to the obtuse marginal, saphenous vein
graft to the posterior descending artery and saphenous vein
graft to the diagonal
.
[**2179-11-1**]
Exploratory laparotomy and liver biopsy
History of Present Illness:
75M with a history of atrial fibrillation, HTN, diastolic heart
failure, ESRD s/p renal transplant in [**2176**], CAD s/p 2-vessel
PCI/DESx2 in [**3-/2178**], possible new inferolateral reversible
defect on p-MIBI in [**12/2178**], worsening exertional CP/SOB over
the last month. He also complains of significant claudication
symptoms. He describes the chest pain as sub-sternal,
squeezing/sharp with radiation to his arms. He has been
pre-medicating himself with nitroglycerin prior to exertion. He
also complains of orthopnea, PND and cough productive of whitish
sputum. He has been experiencing abdominal pain for the past
month (RUQ) a/w mild nausea, no vomiting/diarrhea/constipation.
History of mild dilation of distal aorta. No recent long travel,
no recent surgeries. Came to ED today because granddaughter
called his cardiologist who recommended evaluation. He denies
fevers, chills, and diaphoresis.
In the ED, initial vitals were 99 75 155/70 18 95% RA. No new
EKG changes. Labs significant for TnT 0.05, CK:MB 135:3, BUN/Cr
35/2.2, proBNP 3083 and INR 1.1. The patient was totally chest
pain-free in the emergency department. Patient given aspirin
81mg x 4. Vitals on transfer were 58 110/85 24 96%.
On arrival to the floor, the patient is borderline tachypnic and
in mild respiratory distress. He is actively wheezing,
complaining of orthopnea and PND.
REVIEW OF SYSTEMS
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, hemoptysis, black stools
or red stools. He denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Cardiac review of systems is notable for absence syncope or
presyncope.
Past Medical History:
Coronary artery disease
Acute systolic heart failure
Atrial fibrillation
PMH:
Coronary Artery Disease
s/p stents to OM and LCx
Myocardial Infarction [**2167**] and [**2176**]
Hypertension
Hyperlipidemia
Atrial Fibrillation
Diastolic heart failure
ESRD, s/p renal transplant [**2176**]
Peripheral vascular disease
H/o CMV infection c/b pancytopenia
Dry eye syndrome
GERD
H/o Gastrointestinal bleed
Past Surgical History
S/p left brachiocephalic AV fistula
S/p L3-L4 spinal fusion
Social History:
Patient lives alone and is divorced. He has 2 children and 5
grandchildren. His granddaughter is frequently with him and
helps with his meds. He has a distant smoking history, quit
20yrs ago. Denies EtOH and illicits.
Family History:
Brother worked with tiles and passed from lung disease at age
59. Father died at age 79 of cancer. Mother died at 82 of old
age. Other siblings alive in their 80s and otherwise healthy. No
family history of early MI, arrhythmia, cardiomyopathy, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS- T= 97.4 BP= 161/77 HR= 62 RR= 20 O2 sat=96%
GENERAL- Mild respiratory distress. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with JVP of 14 cm.
CARDIAC- PMI located in 5th intercostal space, midclavicular
line. Irregular rhythm, normal S1, variably split S2. [**1-8**]
systolic murmur at RUSB. No thrills, lifts. No S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Diffuse wheezes. Fine
crackles 1/4 up lung fields.
ABDOMEN- Soft, NTND. No HSM. RUQ tenderness worse with
inspiration. Abd aorta not enlarged by palpation. No abdominial
bruits.
EXTREMITIES- No c/c/e. No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ECHOCARDIOGRAM
[**2179-10-23**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
inferior and inferolateral walls. The remaining segments
contract normally (LVEF = 45-50 %). Overall left ventricular
systolic function is mildly depressed. Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). 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. Physiologic mitral regurgitation is seen (within
normal limits). There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild regional systolic dysfunction
c/w CAD. Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of [**2177-1-30**],
regional wall motion abnormalities are new and systolic function
is not as vigorous.
.
[**2179-10-25**] Cardiac Cath:
1. LMCA and three vessel heavily calcified coronary artery
disease, progressed from [**2178-3-3**], with moderate in-stent
restenosis of the OM1 stent, mild in-stent restenosis of the AV
groove CX, and stable collateralized chronic totally occlusive
in-stent restenosis of the RCA.
2. Systemic systolic arterial hypertension.
3. Moderate-severe left ventricular diastolic heart failure in
the setting of known mild regional left ventricular systolic
dysfunction.
4. Routine post-TR Band care.
5. Reinforce secondary preventative measures against CAD,
hypertension, left ventricular systolic dysfunction and
diastolic
heart failure.
6. Suboptimal imaging due to body habitus.
7. Cardiac surgery evaluation for suitability for CABG,
although
distal targets are not ideal. There are no lesions appealing for
PCI, and presence of heavily calcified LMCA stenosis extending
past the origin of the LAD is strong relative contraindication
to
PCI.
8. Heparin infusion without bolus may be resumed in 6 hours as
clinically indicated.
.
[**2179-10-26**] Carotid Doppler:
Impression: Right ICA with<40% stenosis.
Left ICA with <40% stenosis.
[**2179-11-16**] 08:45AM BLOOD WBC-7.5 RBC-2.68* Hgb-8.2* Hct-26.5*
MCV-99* MCH-30.6 MCHC-30.9* RDW-20.1* Plt Ct-143*
[**2179-11-15**] 03:40PM BLOOD WBC-6.0 RBC-2.54* Hgb-8.0* Hct-24.7*
MCV-97 MCH-31.4 MCHC-32.3 RDW-20.1* Plt Ct-130*
[**2179-11-15**] 06:31AM BLOOD WBC-8.2 RBC-2.68* Hgb-8.1* Hct-25.8*
MCV-96 MCH-30.3 MCHC-31.5 RDW-19.6* Plt Ct-140*
[**2179-11-14**] 05:15AM BLOOD WBC-10.5 RBC-2.83* Hgb-8.8* Hct-27.8*
MCV-98 MCH-31.0 MCHC-31.5 RDW-20.0* Plt Ct-156
[**2179-11-16**] 08:45AM BLOOD PT-14.1* INR(PT)-1.3*
[**2179-11-15**] 03:40PM BLOOD PT-14.7* INR(PT)-1.4*
[**2179-11-14**] 05:15AM BLOOD PT-15.2* PTT-35.7 INR(PT)-1.4*
[**2179-11-16**] 08:45AM BLOOD Glucose-161* UreaN-46* Creat-5.4*#
Na-132* K-4.5 Cl-94* HCO3-24 AnGap-19
[**2179-11-15**] 03:40PM BLOOD Glucose-131* UreaN-32* Creat-4.2*# Na-135
K-3.8 Cl-97 HCO3-25 AnGap-17
[**2179-11-15**] 06:31AM BLOOD Glucose-160* UreaN-77* Creat-8.6*#
Na-131* K-4.7 Cl-93* HCO3-19* AnGap-24*
[**2179-11-14**] 05:15AM BLOOD Glucose-117* UreaN-62* Creat-7.5*# Na-135
K-4.6 Cl-93* HCO3-22 AnGap-25*
[**2179-11-13**] 05:20AM BLOOD Glucose-110* UreaN-47* Creat-6.0*# Na-133
K-4.5 Cl-96 HCO3-24 AnGap-18
Brief Hospital Course:
Mr. [**Known lastname **] is a 75 year old male with a history of atrial
fibrillation, diastolic heart failure, hypertension, and renal
transplant in [**2176**], CAD s/p 2-vessel PCI in [**3-/2178**], possible new
inferolateral reversible defect on p-MIBI in [**12/2178**], and
worsening exertional heart failure symptoms over the last month.
On catheterization he was found to have progression of three
vessel coronary artery disease and was scheduled for bypass
grafting. While his work-up was ensuing he was diuresed and his
heart failure symptoms began to abate. Renal saw him in consult
for end stage renal disease secondary to hypertensive
nephropathy. His baseline creatinine due to allograft
nephropathy was 2.3-2.7.
On [**11-1**] Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a coronary artery bypass grafting
times four (LIMA to LAD, SVG to PDA, SVG to OM, SVG to Diag).
Please see the operative note for details. He tolerated the
procedure well and was transferred in critical but stable
condition to the surgical intensive care unit. On the following
day he was extubated and neurologically intact. He [**Last Name (Titles) 1834**]
hemodialysis for hyperkalemia and fluid overload, and continued
to need periodic hemodialysis post-operatively. On
post-operative day three a lasix infusion was started for
oliguria and fluid overload but he did not respond sufficiently
to it, and by the following day he was reintubated with acute
acidosis. He [**Last Name (Titles) 1834**] a left chest tube placement for 1100mL
of serous drainage. He was also started on broad spectrum
antibiotics with a white blood cell count of 27 thousand. He
went into atrial fibrillation with a controlled ventricular
response and was given beta blockers. The transplant staff was
asked to consult given concern for mesenteric ischemia and an
exploratory laporatomy was performed [**2179-11-1**]. Please see the
operative note for details. This procedure revealed normal
intra-abdominal organs, although a liver biopsy was performed
intra-operatively later indicated acute hepatic ischemia. His
ex-lap wound healed poorly so a wound VAC was placed to aid
healing. He extubated successfully on post-operative day six.
He was thrombocytopenic and was found to be HIT positive.
Hematology was consulted as he was autoanticoagulated with an
INR in the mid twos. Hemodialysis was aborted after an
infiltration of his AV fistula. A temporary HD catheter was
placed and CVVHD was performed. A serotonin assay was performed
to assess for the need for anticoagulation. His SRA was negative
and subcutaneous Heparin was started for DVT prophylaxis. The
decision was made to not start Coumadin for chronic atrial
fibrillation, given that he was not on Coumadin preop and had a
history of GI bleed. His leukocytosis resolved and his
antibiotics were discontinued. He had a large amount of serous
drainage from his abdominal wound and this was opened by the
transplant team and VAC dressings were applied. By the time of
discharge on POD 18, he was tolerating a full oral diet with
some loose stools (C diff negative [**11-12**]), ambulating with
assistance and his wound was healing well with eschar at the
lower pole. His liver functiion tests continued to decrease.
Pravastatin was stopped due to elevated liver function tests and
this should be restarted once LFT's have normalized. Calcitriol
was also stopped due to an elevated phosporus by the renal
transplant team. Tacrolimus levels were stable and he is to
continue at his current dose of 1 mg in the AM and 0.5 mg Q HS
with tacrolimus levels to be followed. VAC dressing x 2 were
changed to the abdominal wound on [**2179-11-15**] and last HD was
[**2179-11-15**] through left arm fistula. It was felt that the patient
was safe for transfer to [**Hospital **] Rehab in [**Location (un) 86**] at this time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 80 mg PO DAILY
2. Allopurinol 100 mg PO BID
3. Tacrolimus 1 mg PO QAM
4. Tacrolimus 1 mg PO QPM
5. Metoprolol Succinate XL 100 mg PO BID
6. Arava *NF* (leflunomide) 20 mg Oral daily
7. Amlodipine 10 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Calcitriol 0.5 mcg PO DAILY
10. Aspirin 325 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
Discharge Medications:
1. Arava *NF* (leflunomide) 20 mg Oral daily Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
2. Aspirin EC 81 mg PO DAILY
3. Tacrolimus 1 mg PO QAM
4. Acetaminophen 650 mg PO Q4H:PRN fever, pain
5. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN
indigestion
6. Calcium Acetate 1334 mg PO QIDWMHS
7. Tacrolimus 0.5 mg PO QPM
8. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
9. Metoprolol Tartrate 25 mg PO TID
10. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
11. Nephrocaps 1 CAP PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Quetiapine Fumarate 25 mg PO HS:PRN sleep
14. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Coronary artery disease
Acute systolic heart failure
Atrial fibrillation
PMH:
Coronary Artery Disease
s/p stents to OM and LCx
Myocardial Infarction [**2167**] and [**2176**]
Hypertension
Hyperlipidemia
Atrial Fibrillation
Diastolic heart failure
ESRD, s/p renal transplant [**2176**]
Peripheral vascular disease
H/o CMV infection c/b pancytopenia
Dry eye syndrome
GERD
H/o Gastrointestinal bleed
Past Surgical History
S/p left brachiocephalic AV fistula
S/p L3-L4 spinal fusion
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with Tylenol
Sternal Incision - healing well, no erythema or drainage, eschar
at lower pole
VAC changes Q 72 hours to abdominal wound - last changed
[**2179-11-15**]
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 and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2179-12-7**] 1:30
Cardiologist Dr. [**Last Name (STitle) **] [**2179-12-23**] at 3:20pm [**Hospital Ward Name 23**] 7
Translant Surgeon:Provider: [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-11-24**] 9:15
Renal: Dr [**Last Name (STitle) **] [**2180-1-24**] @ 8:40 AM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 1576**],[**First Name3 (LF) 1575**] [**Telephone/Fax (1) 6662**] in [**4-8**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2179-11-16**]
ICD9 Codes: 0389, 5845, 4111, 2724, 4168, 4280, 412, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1744
} | Medical Text: Admission Date: [**2187-9-3**] Discharge Date: [**2187-9-9**]
Date of Birth: [**2124-7-31**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
Prostate Cancer
Major Surgical or Invasive Procedure:
Radical Prostatectomy with B/L lymph node dissection
History of Present Illness:
Increased PSA, [**3-24**] pos pr bxs, mod lower urinary symptoms,
decreased erectile fxn
Past Medical History:
HTN
Borderline Type II DM
Physical Exam:
PE: Gen - AAOx3 NAD
CV - S1 S2 RRR
Chest - CTA B/L
Abd - pos BS, soft, NT/ND, incisions C/D/I
GU - nml phallus
Extrem - no c/c/e, no edema
Pertinent Results:
[**2187-9-8**] 06:24AM BLOOD WBC-6.5 RBC-3.10* Hgb-9.4* Hct-26.8*
MCV-87 MCH-30.4 MCHC-35.1* RDW-13.2 Plt Ct-246
[**2187-9-7**] 05:03PM BLOOD Hct-26.4*
[**2187-9-7**] 06:10AM BLOOD WBC-6.4 RBC-2.90* Hgb-9.1* Hct-25.0*
MCV-86 MCH-31.4 MCHC-36.5* RDW-13.2 Plt Ct-167
[**2187-9-6**] 03:21AM BLOOD WBC-8.3 RBC-3.26* Hgb-9.6* Hct-28.3*
MCV-87 MCH-29.4 MCHC-34.0 RDW-13.9 Plt Ct-113*
[**2187-9-5**] 05:09PM BLOOD WBC-8.7 RBC-3.24* Hgb-9.7* Hct-26.9*
MCV-83 MCH-29.9 MCHC-35.9* RDW-13.9 Plt Ct-110*
[**2187-9-5**] 02:59AM BLOOD WBC-9.6 RBC-3.35* Hgb-10.0* Hct-28.2*
MCV-84 MCH-29.8 MCHC-35.5* RDW-14.1 Plt Ct-102*
[**2187-9-4**] 08:15AM BLOOD Hct-33.1*
[**2187-9-4**] 05:53AM BLOOD Hct-26.5*
[**2187-9-4**] 04:09AM BLOOD WBC-10.3 RBC-2.85* Hgb-8.5* Hct-24.0*
MCV-84 MCH-30.0 MCHC-35.6* RDW-13.6 Plt Ct-111*
[**2187-9-3**] 09:40PM BLOOD WBC-13.7* RBC-3.65* Hgb-11.0* Hct-31.9*
MCV-87 MCH-30.0 MCHC-34.4 RDW-13.9 Plt Ct-134*
[**2187-9-3**] 05:08PM BLOOD Hct-33.1*
[**2187-9-3**] 01:17PM BLOOD WBC-11.2*# RBC-3.68* Hgb-11.5*#
Hct-32.2*# MCV-88 MCH-31.2 MCHC-35.6* RDW-12.7 Plt Ct-135*
[**2187-9-5**] 02:59AM BLOOD PT-12.6 PTT-31.1 INR(PT)-1.0
[**2187-9-4**] 04:09AM BLOOD PT-12.8 PTT-33.0 INR(PT)-1.1
[**2187-9-3**] 09:40PM BLOOD PT-12.5 PTT-29.6 INR(PT)-1.0
[**2187-9-3**] 01:17PM BLOOD PT-13.9* PTT-32.4 INR(PT)-1.3
[**2187-9-8**] 06:24AM BLOOD Glucose-103 UreaN-11 Creat-1.0 Na-138
K-3.6 Cl-102 HCO3-25 AnGap-15
[**2187-9-7**] 06:10AM BLOOD Glucose-107* UreaN-13 Creat-0.8 Na-138
K-4.1 Cl-104 HCO3-24 AnGap-14
[**2187-9-7**] 01:47AM BLOOD Glucose-105 UreaN-13 Creat-0.9 Na-137
K-4.3 Cl-103 HCO3-24 AnGap-14
[**2187-9-6**] 03:21AM BLOOD Glucose-94 UreaN-11 Creat-0.8 Na-137
K-3.6 Cl-106 HCO3-23 AnGap-12
[**2187-9-4**] 04:09AM BLOOD Glucose-124* UreaN-11 Creat-1.3* Na-140
K-3.8 Cl-113* HCO3-21* AnGap-10
[**2187-9-3**] 09:40PM BLOOD Glucose-199* UreaN-12 Creat-1.5* Na-141
K-4.6 Cl-113* HCO3-20* AnGap-13
[**2187-9-3**] 01:17PM BLOOD Glucose-108* UreaN-10 Creat-0.9 Na-142
K-4.3 Cl-116* HCO3-18* AnGap-12
[**2187-9-4**] 05:05PM BLOOD CK(CPK)-2177*
[**2187-9-4**] 04:09AM BLOOD CK(CPK)-1170*
[**2187-9-3**] 09:40PM BLOOD CK(CPK)-1083*
[**2187-9-3**] 01:17PM BLOOD CK(CPK)-686*
[**2187-9-4**] 05:05PM BLOOD CK-MB-11* MB Indx-0.5 cTropnT-0.02*
[**2187-9-4**] 04:09AM BLOOD CK-MB-6 cTropnT-0.07*
[**2187-9-3**] 09:40PM BLOOD CK-MB-6 cTropnT-<0.01
[**2187-9-3**] 01:17PM BLOOD CK-MB-3 cTropnT-<0.01
[**2187-9-7**] 06:10AM BLOOD Calcium-7.2* Phos-2.7 Mg-2.2
[**2187-9-7**] 01:47AM BLOOD Calcium-7.4* Phos-2.8 Mg-2.3
[**2187-9-6**] 03:21AM BLOOD Calcium-7.0* Phos-2.6* Mg-2.0
[**2187-9-5**] 12:41PM BLOOD Calcium-7.0* Phos-2.7 Mg-2.3
[**2187-9-4**] 04:09AM BLOOD Calcium-7.2* Phos-3.0# Mg-1.7
[**2187-9-3**] 09:40PM BLOOD Calcium-7.9* Phos-5.0* Mg-2.3
[**2187-9-3**] 01:17PM BLOOD Calcium-7.8* Mg-1.2*
[**2187-9-6**] 03:35AM BLOOD Type-ART pO2-118* pCO2-41 pH-7.40
calHCO3-26 Base XS-0
[**2187-9-5**] 12:57PM BLOOD Type-ART pO2-149* pCO2-41 pH-7.41
calHCO3-27 Base XS-1
[**2187-9-5**] 11:46AM BLOOD Type-ART pO2-83* pCO2-38 pH-7.42
calHCO3-25 Base XS-0
[**2187-9-5**] 04:32AM BLOOD Type-ART pO2-86 pCO2-38 pH-7.40
calHCO3-24 Base XS-0
[**2187-9-5**] 03:34AM BLOOD Type-ART pO2-63* pCO2-44 pH-7.36
calHCO3-26 Base XS-0
[**2187-9-4**] 04:47AM BLOOD Type-ART pO2-118* pCO2-35 pH-7.36
calHCO3-21 Base XS--4
[**2187-9-3**] 11:50PM BLOOD Type-ART pO2-150* pCO2-43 pH-7.30*
calHCO3-22 Base XS--4
[**2187-9-3**] 10:26PM BLOOD Type-ART pO2-213* pCO2-44 pH-7.25*
calHCO3-20* Base XS--7
[**2187-9-3**] 06:11PM BLOOD Type-ART Temp-37.1 Rates-[**9-13**] Tidal V-750
FiO2-50 pO2-212* pCO2-46* pH-7.27* calHCO3-22 Base XS--5
Intubat-INTUBATED Vent-IMV
[**2187-9-3**] 01:48PM BLOOD Type-ART Temp-36.8 Tidal V-750 PEEP-5
FiO2-50 pO2-217* pCO2-46* pH-7.21* calHCO3-19* Base XS--9
Intubat-INTUBATED
[**2187-9-3**] 11:41AM BLOOD Type-ART pO2-223* pCO2-39 pH-7.27*
calHCO3-19* Base XS--8
[**2187-9-3**] 10:33AM BLOOD Type-ART Tidal V-700 pO2-236* pCO2-41
pH-7.31* calHCO3-22 Base XS--5
[**2187-9-6**] 03:35AM BLOOD Glucose-98
[**2187-9-5**] 12:57PM BLOOD Glucose-113*
[**2187-9-4**] 04:47AM BLOOD Glucose-110* Lactate-2.9*
[**2187-9-3**] 10:33AM BLOOD Lactate-3.3*
[**2187-9-3**] 10:15AM BLOOD Lactate-3.4*
[**2187-9-3**] 11:41AM BLOOD Hgb-10.0* calcHCT-30
[**2187-9-6**] 03:35AM BLOOD freeCa-1.07*
[**2187-9-5**] 12:57PM BLOOD freeCa-1.06*
[**2187-9-4**] 04:47AM BLOOD freeCa-1.02*
[**2187-9-3**] 10:33AM BLOOD freeCa-1.72*
[**2187-9-3**] 10:15AM BLOOD freeCa-1.00*
CXR [**9-5**]
HISTORY: Fever following radical prostatectomy.
IMPRESSION: AP chest compared to [**9-3**] at 2357 hours:
Lung volumes have improved slightly. There is relatively
symmetric perihilar
opacification accompanied by increased mediastinal venous
caliber, most likely
due to pulmonary edema and small pleural effusions. Endotracheal
tube and
right subclavian line are in standard placements and a
nasogastric tube loops
in the stomach.
Brief Hospital Course:
On [**9-3**] pt underwent RRP with B/L pelvic node dissection.
During the case he lost about 3200 cc of blood. He received
about 8 L of crystalloid and 4 U PRBC during the case and was on
neo intermittently. He was left intubated in the PACU and
required neo for BP control. He was Tx from the PACU to the
SICU for his hypotension. In SICU he had good pain control and
was weaned off of the vent and extubated on POD #2. He was
given Levophed to keep his BP at nml levels. His mental status
was good and he made adequate urine. on POD #3 he was
transferred to the floor. On the floor his diet was advanced as
tolerated, he had good pain control, and he ambulated well. His
JP tube was d/c'd on POD #4. He was in good condition and was
D/C'd home on POD #6.
Medications on Admission:
Benicar 40'
Tylenol for allergies
Nasal Spray
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day for
7 days.
Disp:*14 Capsule(s)* Refills:*0*
3. Medications
Please take pre admission medications at home
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day:
Start one day before you remove foley cath.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Gentiva/[**Location (un) 86**]
Discharge Diagnosis:
Prostate cancer
Discharge Condition:
Good
Discharge Instructions:
Can shower
Use cane if needed to move around
If you have a fever >101.4, pain, intractable nausea and
vomiting, discharge from wound or bleeding, or chest pain or
shortness of breath please return.
Start Levofloxacin one day before foley removal.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 4229**] ([**Telephone/Fax (1) 4230**]
ICD9 Codes: 4280, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1745
} | Medical Text: Admission Date: [**2161-6-17**] Discharge Date: [**2161-6-21**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
dyspnea, hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 year old Female with history of severe COPD on 2L Home
Oxygen, pulmonary hypertension, renal insufficiency and carotid
insufficiency was referred to the ED for hyponatremia and
dyspnea. Mrs. [**Known lastname **] was brought to the ED by EMS with dyspnea
x 2 days, recieving multiple nebulizer treatments in route to
the ED. Dyspnea started 2 days prior to admission, accompanied
with bilateral leg swelling. Denies any chest pain. No
palpitations. Says her urine output seems unchanged.
Symptoms started "when the weather got hot." She reports having
a poor apetite over the last few days and drinks very little. Of
note, Mrs. [**Known lastname **] was recently started on Lasix ([**6-3**]) for
symptom control of her cor pulmonale. Her sodium was noted to
decline gradually on subsequent with nadir of 122 on the morning
of referral to the emergency room. She has continued to take her
daily lasix, despite her PCP notifying her of her low sodium and
encouraging her to stop taking that med. Additionally, Mrs.
[**Known lastname **] was recently started on home O2, 2L, and is supposed to
wear it at all times, previously just at night. Her
granddaughter notes she often takes her oxygen off, particularly
while at her day program.
In the ED, initial vs were: T=98.1, HR=81, BP=121/76, RR=16
98%4LNC. Patient was given lasix, nitro gtt and BiPap, ASA 325,
for a presumed CHF exacerbation. Her CXR came back clear. She
was additionally treated for a COPD exacerbation with albuterol
and ipatropium nebs, azithromycin and solumedrol.
Past Medical History:
Pulmonary hypertension
COPD on 2L Home
carotid stenosis
Stage III CKD
Social History:
lives with family with good support, widowed, has VNA sevice.
past smoker, quit 50 yrs ago, smoked for about 20 years. Lost 2
children.
Family History:
Non-Contributory
Physical Exam:
Vitals: T: 95.1 BP: 129/57 P: 78 R: 18 O2: 97% on 4L by NC
General: Alert, oriented, appears tachypneic
HEENT: Sclera anicteric, MMM, oropharynx clear, pale
conjunctiva, dry mouth,d ry mucosa
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bases bilaterally, few expiratory wheezes.
CV: Regular rate and rhythm, systolic murmur at left sternal
border non radiating, no murmurs, rubs, gallops
Abdomen: soft, nt, nd, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: Foley in place to gravity
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. mild
pitting edema
Pertinent Results:
[**2161-6-21**] 06:30AM BLOOD WBC-10.8 RBC-4.76 Hgb-13.1 Hct-40.3
MCV-85 MCH-27.6 MCHC-32.6 RDW-13.6 Plt Ct-508*
[**2161-6-18**] 04:40AM BLOOD WBC-12.1* RBC-4.27 Hgb-11.6* Hct-34.8*
MCV-82 MCH-27.2 MCHC-33.4 RDW-13.6 Plt Ct-401
[**2161-6-16**] 10:30PM BLOOD WBC-11.1* RBC-4.92 Hgb-13.3 Hct-40.6
MCV-83 MCH-27.0 MCHC-32.7 RDW-14.0 Plt Ct-524*
[**2161-6-18**] 04:40AM BLOOD Neuts-86.6* Lymphs-7.8* Monos-5.4 Eos-0.1
Baso-0.1
[**2161-6-16**] 10:30PM BLOOD PT-11.5 PTT-25.6 INR(PT)-1.0
[**2161-6-21**] 06:30AM BLOOD Glucose-77 UreaN-18 Creat-1.2* Na-138
K-4.3 Cl-97 HCO3-35* AnGap-10
[**2161-6-18**] 01:33PM BLOOD Glucose-117* UreaN-27* Creat-1.3* Na-132*
K-5.5* Cl-97 HCO3-28 AnGap-13
[**2161-6-17**] 07:27PM BLOOD Glucose-121* UreaN-30* Creat-1.4* Na-122*
K-5.7* Cl-89* HCO3-26 AnGap-13
[**2161-6-17**] 05:54AM BLOOD Glucose-161* UreaN-35* Creat-1.7* Na-116*
K-5.6* Cl-83* HCO3-24 AnGap-15
[**2161-6-16**] 10:20AM BLOOD UreaN-33* Na-122* K-5.2* Cl-86* HCO3-24
AnGap-17
[**2161-6-17**] 05:54AM BLOOD CK(CPK)-140
[**2161-6-17**] 05:54AM BLOOD CK-MB-8 cTropnT-0.03*
[**2161-6-16**] 10:30PM BLOOD cTropnT-0.02*
[**2161-6-16**] 10:30PM BLOOD proBNP-2439*
[**2161-6-21**] 06:30AM BLOOD Calcium-10.1 Phos-3.5 Mg-2.1
[**2161-6-17**] 02:28PM BLOOD Calcium-9.1 Phos-4.0 Mg-2.1
[**2161-6-16**] 10:30PM BLOOD Calcium-9.8 Phos-4.1 Mg-2.4
[**2161-6-17**] 07:27PM BLOOD Osmolal-266*
[**2161-6-17**] 05:54AM BLOOD Osmolal-257*
[**2161-6-17**] 05:54AM BLOOD TSH-0.70
[**2161-6-17**] 09:40AM BLOOD Cortsol-95.6*
[**2161-6-16**] 10:30PM BLOOD Cortsol-39.0*
[**2161-6-17**] 01:24AM BLOOD Type-ART FiO2-100 O2 Flow-4 pO2-90
pCO2-43 pH-7.33* calTCO2-24 Base XS--3 AADO2-582 REQ O2-95
Intubat-NOT INTUBA
[**2161-6-16**] 10:43PM BLOOD Glucose-168* Lactate-1.8 Na-123* K-4.9
[**2161-6-18**] 01:33PM URINE Hours-RANDOM UreaN-207 Creat-17 Na-49
K-12 Cl-47 TotProt-<6
[**2161-6-18**] 08:13AM URINE Hours-RANDOM Creat-14 Na-46 K-8 Cl-39
[**2161-6-17**] 09:38PM URINE Hours-RANDOM Creat-30 Na-26 K-20 Cl-25
[**2161-6-17**] 05:54AM URINE Hours-RANDOM Creat-22 Na-59 K-25 Cl-73
[**2161-6-18**] 01:33PM URINE Osmolal-199
[**2161-6-18**] 08:13AM URINE Osmolal-172
[**2161-6-17**] 05:54AM URINE Osmolal-237
[**2161-6-17**] 4:05 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2161-6-19**]**
MRSA SCREEN (Final [**2161-6-19**]): No MRSA isolated.
Brief Hospital Course:
1. COPD with Acute Exacerbation:
- Pts dyspnea, hypoxemia, but normal CO2, was thought to be
secondary to Pulmonary HTN exacerbation in setting of low
intravascular volume. Patient had poor PO intake several days
prior to admission and continued her daily lasix which likely
volume depleted her. She had an echocardiogram which showed
severe pulmonary HTN but no sigificant changes from her [**2157**]
echo. She was given nasal canula O2 and weaned down to her home
dose of 2L. She was then given a steroid taper with prednisone
from [**6-17**] through [**6-21**] at the direction of the pulmonary
consultation team in concert with her primary pulmonologist Dr.
[**Last Name (STitle) 2168**].
2. Hyponatremia:
Found to have hypo-osmolar hyponatremia. Likely secondary to low
volume state after several days of poor PO intake and persistent
lasix with free water repletion. She was given lasix in ED as
patient was thought to initially present with CHF exacerbation.
Fluids were then repleted and Na levels normalized from
116-->138 over the admission. She was not restarted on
diuretics.
3. Pulmonary Hypertension:
- Unclear etiology as patient was known in OMR to have severe
pulmonary HTN but mild obstructive pattern on PFTs. Echo
revealed peristent severe pulmonary HTN with no signs of left or
right heart failure. Patient should meet with pulmonologist
outpatient to follow up.
4. Acute Renal Failure on Stage III CKD:
- Patient was pre-renal with low volume status. Cr peaked at 1.8
and baseline is 1.6. Gave IVF and Cr trended down to 1.3.
5. Hyperkalemia:
- Pt had hyperkalemia on admission. Cortisol level was 39 making
adrenal insuficiency unlikely. Losartan likely contributed to
hyperkalemia and was discontinued.
6. Benign Hypertension:
Her hypertension mends were all held while in the ICU. And her
beta-blocker and calcium channel blocker were restarted prior to
discharge on the floor.
DISPO: She was sent for short term rehabilitation for mobility
and strengthing, along with stability training while carrrying
her oxygen.
Medications on Admission:
Atneolol 50 mg [**Hospital1 **]
Cilostazol 100 mg qday
Advair 100/50 1 puff daily
Lasix 20 mg qday (stopped)
Nifedipine ER 60 mg qday
Ranitidine 150 mg [**Hospital1 **]
Spiriva 18 mcg daily
Valsartan 160 mg qday
Calcium
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheezing, SOB.
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
COPD With Acute Exacerbation
Hyponatremia
CKD Stage 4
Hyperkalemia
Pulmonary Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It is very important that you continue to wear your oxygen,
particularly when out and about, such as at your day program.
While at rehab, you should use your oxygen contininously
particularly when exercising. You should practice moving around
with your oxygen with the physical therapist.
We have made some changes to your medications as you had a very
low sodium, and we have stopped your furosemide (lasix). Dr.
[**Last Name (STitle) **] and [**Doctor Last Name 2168**] will address this after you return home.
Followup Instructions:
Please make an appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 133**]
when you are leaving the rehab.
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2161-8-5**] at 8:00 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 2761, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1746
} | Medical Text: Admission Date: [**2180-1-20**] Discharge Date: [**2180-1-25**]
Date of Birth: [**2113-4-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
OPCABx3(LIMA->LAD, SVG->Diag, PDA) [**1-21**]
History of Present Illness:
66 yo with recent symptoms while shoveling, EKG at well visit
with changes, cath with 3VD referred for surgery.
Past Medical History:
CAD s/p RCA stent [**2171**], HTN, lipids, DM, cataracts, T&A
Social History:
wine buyer
denies tobacco, etoh
Family History:
sister with heart problems in 70s
mother deceased from MI at 72
Physical Exam:
Admission exam unremarkable with the exception of bilateral
groin cath sites C/D/I.
Pertinent Results:
[**2180-1-24**] 08:00AM BLOOD WBC-7.7 RBC-2.60* Hgb-8.4* Hct-25.0*
MCV-96 MCH-32.5* MCHC-33.7 RDW-13.1 Plt Ct-212
[**2180-1-23**] 02:28AM BLOOD WBC-8.8 RBC-2.67* Hgb-8.7* Hct-25.1*
MCV-94 MCH-32.5* MCHC-34.7 RDW-13.0 Plt Ct-162
[**2180-1-24**] 08:00AM BLOOD Plt Ct-212
[**2180-1-21**] 11:49AM BLOOD PT-13.8* PTT-26.3 INR(PT)-1.2*
[**2180-1-24**] 08:00AM BLOOD Glucose-273* UreaN-20 Creat-1.1 Na-137
K-3.8 Cl-99 HCO3-30 AnGap-12
CHEST (PA & LAT) [**2180-1-25**] 10:05 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate effusion
HISTORY: Status post CABG.
FINDINGS: In comparison with the study of [**1-22**], the patient has
taken a better inspiration. Residual atelectatic changes persist
at the left base with blunting of the costophrenic angle.
No evidence of acute pneumonia.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 29375**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 29376**] (Complete)
Done [**2180-1-21**] at 8:57:54 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2113-4-30**]
Age (years): 66 M Hgt (in): 69
BP (mm Hg): 134/78 Wgt (lb): 169
HR (bpm): 72 BSA (m2): 1.92 m2
Indication: Intraoperative TEE for CABG procedure
ICD-9 Codes: 786.51, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2180-1-21**] at 08:57 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 #: 2008AW2-: Machine: [**Pager number 29377**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Small secundum ASD.
LEFT VENTRICLE: Normal regional LV systolic function. Mild
global LV hypokinesis. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Off pump CABG
1. A small secundum atrial septal defect is present.
2.Regional left ventricular wall motion is normal. There is mild
global left ventricular hypokinesis (LVEF = 45 %). Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7. Post revascularization inferior wall is moderately
hypokinetic. EF 40%
Brief Hospital Course:
He was transferred to cardiac surgery. On [**1-21**] he was taken to
the operating room on where he underwent an off pump CABG x 3.
He was transferred to the ICU in stable condition. He was
extubated later that same day. He was transferred to the floor
on POD#2. He did well postoperatively and was ready for
discharge home on POD #4.
Medications on Admission:
atenolol 100', norvac 2.5', benicar-hct 40-25, glipizide er 10',
lantus 25/25, byetta [**5-8**], metformin 1500/500, crestor 20, asa,
MVI, fish oil
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
Disp:*60 Tablet(s)* Refills:*0*
10. Metformin 500 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
Disp:*90 Tablet(s)* Refills:*0*
11. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*0*
13. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous twice a day.
Disp:*qs 1 month* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD now s/p CABG
Chronic systolic heart failure
CAD s/p RCA stent [**2171**], HTN, lipids, DM, cataracts, T&A
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 29378**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 5874**] 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2180-1-25**]
ICD9 Codes: 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1747
} | Medical Text: Admission Date: [**2197-11-18**] Discharge Date: [**2197-11-20**]
Date of Birth: [**2141-4-27**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 56-year-old male
with no previous medical history, who was out shoveling snow
on the day of admission. Five to 10 minutes into shoveling,
the patient experienced very heavy chest pressure associated
with shortness of breath, diaphoresis, and general weakness.
The patient has never experienced anything like this before.
The patient exercises regularly and has noticed that his
exercise tolerance has not changed recently. He jogs
approximately three miles every day and bikes regularly. The
patient immediately called 911 and was taken to the Emergency
Department, where he was found to have ST segment elevations
in leads II, III, and aVF as well as a Q wave in leads II,
III, and aVF.
PAST MEDICAL HISTORY: None.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: None.
SOCIAL HISTORY: The patient has a 30 pack year smoking
history, but quit three years ago. He drinks half a bottle
of wine everyday. He is employed and moved from Europe three
years ago with his wife due to her job. He is not currently
employed, but does fly planes.
FAMILY HISTORY: The patient's maternal grandfather had a
heart attack at age 60. Otherwise, his mother and father are
both alive with no coronary artery disease.
PHYSICAL EXAMINATION: Physical exam is notable for a heart
rate of 64 and a blood pressure of 99/60. His lungs are
clear. His heart is regular, rate, and rhythm with no
murmur. The remainder of his physical exam is unremarkable.
LABORATORIES ON ADMISSION: Notable for a CK of 64 and a
troponin of less than 0.01. The remainder of his
laboratories are all within normal limits.
EKG: Shows sinus bradycardia at a rate of 58. There are 2
mm ST segment elevations in leads II, III, and aVF. There
are also Q waves in leads II, III, and aVF. There is left
atrial enlargement and borderline left ventricular
hypertrophy.
HOSPITAL COURSE: The patient was admitted with a ST segment
elevation MI in the inferior leads. He was taken immediately
to cardiac catheterization, where he was found to have
complete occlusion of his right coronary artery. The artery
was stented. There was no evidence of stenosis in any of the
other arteries.
Following procedure, the patient became briefly hypotensive
and was started on a dopamine drip. He was admitted to the
CCU for close monitoring. The patient was quickly weaned off
dopamine with systolic blood pressures in the 90s to low
100s. The patient had several episodes of nonsustained VT,
which he spontaneously broke out of in the day following
cardiac catheterization. These episodes of NSVT most likely
represent reperfusion injury. Throughout the remainder of
the hospitalization, the patient experienced no further
episodes of chest pain, diaphoresis, shortness of breath,
nausea, or vomiting.
Post cardiac catheterization EKG showed resolution of ST
elevations. The patient was started on aspirin, Plavix, and
Lipitor. He was started on a low dose of a beta blocker
which he tolerated well. It was decided not to start ACE
inhibitor prior to discharge due to a borderline blood
pressure with a systolic blood pressure of 100. The patient
was advised to never take up smoking again, and was asked to
reduce his alcohol intake to a maximum of two drinks per day.
Patient was also advised not to fly planes at least until he
sees a cardiologist.
An echocardiogram was performed prior to discharge, which
showed a mildly depressed left ventricular ejection fraction
of 45-50% with marked inferior hypokinesis. There was also
1+ mitral regurgitation and a mildly dilated left atrium.
CONDITION ON DISCHARGE: Stable, chest pain free with no
shortness of breath, and ambulating well without assistance.
DISCHARGE STATUS: The patient is discharged to home without
any home services.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post ST segment elevation
myocardial infarction with stenting of the right coronary
artery.
2. Hypotension.
3. Hyperlipidemia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d. x3 months.
3. Lipitor 10 mg p.o. q.d.
4. Atenolol 25 mg p.o. q.d.
FOLLOW-UP PLANS:
1. The patient is asked to followup with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 53713**] on Friday, [**11-24**]. A phone
call was made to Dr. [**Last Name (STitle) 53713**] and a message was left
explaining the reason for hospitalization, and the
recommendation that the patient be started on an ACE
inhibitor if his blood pressure can tolerate it.
2. Patient is scheduled to followup with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] in
Cardiology on [**2197-12-15**] at 3 p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.12.222
Dictated By:[**Name8 (MD) 4993**]
MEDQUIST36
D: [**2197-11-20**] 13:45
T: [**2197-11-22**] 07:31
JOB#: [**Job Number 53714**]
ICD9 Codes: 4271, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1748
} | Medical Text: Admission Date: [**2116-4-29**] Discharge Date: [**2116-5-11**]
Date of Birth: [**2042-5-31**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Synchronous rectal cancer and sigmoid colon cancer
Major Surgical or Invasive Procedure:
Laparoscopic converted to open proctosigmoidectomy with partial
colectomy and end colostomy with takedown of splenic flexure and
prophylactic placement of Surgisis preperitoneal patch to
prevent parastomal hernia
History of Present Illness:
This is a 73 year-old male with locally advanced rectal cancer
with and biopsy-proven liver metastasis who presented electively
on [**2116-4-29**] for a laparoscopic converted to open
proctosigmoidectomy with partial colectomy and end colostomy,
takedown splenic flexure, and prophylactic placement of Surgisis
preperitoneal patch to prevent parastomal hernia.
Past Medical History:
PMH: locally advanced rectal cancer w/ liver mets, viral
cardiomyopathy EF 30%, A.fib on coumadin, multiple episdoes of
V.fib s/p ICD firing
PSH: Early stage urothelial carcinoma of the bladder status post
cystoscopic resection on [**2116-1-30**]
Social History:
Primarily Italian-speaking. He is married and lives at home with
his wife. His son and daughter are local and he is close to
them. He is originally from central [**Country 2559**] and tries to spend
time in [**Country 2559**] yearly. He smoked two packs per day for 40 years,
quitting in the past two years. He drinks two glasses of wine
per day and denies recreational substance use.
Family History:
Father: Died young of unknown causes.
Mother: Lived to 94 and was healthy with no known cancers.
Other: No other known cancer history in his family.
Physical Exam:
VITALS: T 98.2 HR 80 BP 133/64 RR 22 O2sat 99%RA
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2.
RESP: Clear to auscultation bilaterally without adventitious
sounds, minimally decreased breath sounds at bases bilaterally.
No wheezing, rhonchi or crackles.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs. Left sided colostomy
stoma is pink-purple, protuberant with mild friability and is
healing well with liquid-brown/green stool output and gas in his
ostomy appliance.
EXTR: 2+ peripheral pulses, without cyanosis, clubbing or edema.
INCISION/WOUND: Midline abdominal incision has mild erythema
extending 1-2 cm from the wound edge without fluctuance,
purulence or induration. [**4-17**] staples have been removed with
granulating tissue and minimally serosanginous drainage
underlying the exposed superficial fascia. The wound appears
clean.
Pertinent Results:
[**2116-5-10**] 06:00AM BLOOD WBC-9.2 RBC-3.58* Hgb-9.7* Hct-31.4*
MCV-88 MCH-27.1 MCHC-30.8* RDW-18.4* Plt Ct-650*#
[**2116-5-9**] 07:55AM BLOOD PT-13.2 PTT-24.7 INR(PT)-1.1
[**2116-5-10**] 06:00AM BLOOD PT-14.6* PTT-25.2 INR(PT)-1.3*
[**2116-5-11**] 03:50AM BLOOD PT-17.1* PTT-27.3 INR(PT)-1.5*
[**2116-5-10**] 06:00AM BLOOD Glucose-97 UreaN-21* Creat-1.2 Na-135
K-3.8 Cl-100 HCO3-27 AnGap-12
CXR ([**2116-5-5**]) - Stable postoperative findings indicative of
CHF. Fluid overload, as suggested in the requisition, may be a
cause of these findings provided other cardiogenic factors are
excluded.
LUE US ([**2116-5-2**]) - No evidence of left upper extremity deep
venous thrombus. Cephalic vein not visualized.
Pathology ([**2116-4-29**]) -
Rectum and sigmoid colon: Two synchronous colonic
adenocarcinomas. Thirty-five lymph nodes; no malignancy
identified.
Brief Hospital Course:
NEURO/PAIN: The patient was maintained on PCA/IV Morphine for
pain medication in the immediate post-operative period and
transitioned to PO narcotic medication with adequate pain
control on POD#[**6-19**]. The patient remained neurologically intact
and without change from baseline. The patient remained alert and
oriented to person, location and place.
CARDIOVASCULAR: The patient experienced a single episode of
what was suspected ventricular tachycardia and his AICD fired a
single time intra-operatively, as previously mentioned. The
event occurred soon after insufflation of the abdomen during
attempted laparoscopy. In light of the rhythm concerns, the
procedure was converted to an open approach. The procedure
progressed without further hemodynamic or arrhythmic issues and
he was transferred to ICU in stable condition, intubated. The
EP/cardiology service was consulted for further management, they
recommended continuing his outpatient anti-arryhthmic [**Doctor Last Name 360**]
(dofetilide) and initiating post-op beta-blockade with IV
metoprolol. Serial EKGs were closely monitored without issue. He
was transitioned to oral Metoprolol, continued his dofetilide,
and started Digoxin with resolve of cardiac issues by POD#4.
Vitals signs were closely monitored via telemetry. Lopressor
increased to provide better appropriate rate control.
RESPIRATORY: The patient was extubated POD# 1 successfully. The
patient had no episodes of desaturation. The patient denied
cough or respiratory symptoms. Pulse oximetry was monitored
closely and the patient maintained adequate oxygenations. serial
CXRs did reveal some evidence of atelectasis versus
consolidation, along with pleural effusions (improved with
diuresis) which was closely monitored. A sputum sample revealed
H. influenzae (non type-B) that was sensitive to Ampicillin.
Given diurnal temperature spikes and the respiratory source of
infection, empiric Vancomycin and Zosyn IV were started on
POD#2. He completed a course of Zosyn and his respiratory
status was stable.
GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#[**7-21**]. The
patient experienced no nausea or vomiting. His ostomy site began
functioning with liquid stool output and gas in the appliance on
POD# [**5-19**]. His stoma site appeared dusky and friable with some
edema that progressed post-op, but was cloesly monitored and
deemed clinically stable. The patient was transitioned to a
regular diet on POD#9 and IV fluids were discontinued once
adequate PO intake was established.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was
placed intra-operatively and removed on POD#6, at which time the
patient was able to successfully void without issue. The
patient's intake and output was closely monitored for > 30 mL
per hour output. The patient's creatinine was stable, his
baseline being above normal.
HEME: The patient remained hemodynamically stable and only
required transfusion of 2 units of packed red blood cells. The
patient's coagulation profile remained normal. The patient had
no evidence of bleeding from their incision.
ID: The patient was febrile immediately post-op and displayed a
nearly diurnal fever curve, the source likely being a sputum
sample which revealed H. influenzae (non type-B) that was
sensitive to Ampicillin. Given diurnal temperature spikes and
the respiratory source of infection, empiric Vancomycin and
Zosyn IV were started on POD#2. Their white count was stable
post-operatively and their incision was closely monitored for
any evidence of infection or erythema. Staples were removed from
the superior aspect of the incision on POD#5 given some
spreading peri-incisional erythema, and green-brown purulence
was expressed and cultured. Dry dressing were changed daily
following the staple removal. There was no induration,
fluctuance. Wound cultures demonstrated pan-sensitive
pseudomonas and he has been on oral ciprofloxacin, which will
continue until [**5-16**].
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op. The patient also had sequential compression
boot devices in place during immobilization to promote
circulation. GI prophylaxis was sustained with
Protonix/Famotidine. The patient was encouraged to utilize
incentive spirometry, ambulate early and was discharged in
stable condition.
Medications on Admission:
1. dofetilide 250 mcg Capsule Sig: Two (2) Capsule PO BID.
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pradaxa 150 mg Tablet Sig: One (1) Tablet, PO BID.
5. furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. metoprolol ER 50mg Tablet Sig: One (1) Tablet PO qday.
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Dose
to be adjusted based on INR.
8. colchicine 0.6mg Tablet Sig: One (1) Tablet PO DAILY.
9. simvastatin 40mg Tablet Sig: One (1) Tablet PO DAILY.
10. diovan 80mg Tablet Sig: One (1) Tablet PO DAILY.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
2. dofetilide 250 mcg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Dose
to be adjusted based on INR.
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days: Five more days of antibiotics - course to end on [**2116-5-16**].
9. oxycodone 5 mg Capsule Sig: [**2-16**] Capsules PO every 4-6 hours
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] at [**Location (un) 55**]
Discharge Diagnosis:
Synchronous sigmoid colon and rectal cancers
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a Laparoscopic converted
to open proctosigmoidectomy with partial colectomy and end
colostomy for surgical treatment of your colorectal cancer.
During this procedure a patch was also placed to prevent you
from developing a hernia near your colostomy site. You have
recovered from this procedure well and you are now ready to
return home. Samples from your colon were taken and this tissue
has been sent to the pathology department for analysis. You
developed pneumonia during your hospitalization and this has
been treated with broad spectrum antibiotics. You will continue
antibiotics by mouth as an outpatient for the wound on your
abdomen. This antibiotic is called Ciprofloxacin which will end
on [**2116-5-16**]. You have tolerated a regular diet, passing gas and
your pain is controlled with pain medications by mouth. You may
be discharge to a rehabiliation facility to finish your
recovery.
Monitor your bowel function closely, if you have any of the
following symptoms please call the office for advice or go to
the emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonges loose stool, or
constipation. You have a new colostomy. It is important to
monitor the output from this stoma. It is expected that the
stool from this ostomy will be solid to semi-solid and formed
similar to regular stool. You should have [**2-16**] bowel movements
daily. If you notice that you have not had any stool from your
stoma in [**2-16**] days, please call the office. You may take an over
the counter stool softener such as colace if you find that you
are becoming constipated from narcotic pain medications. Please
watch the appearance of the stoma, your stoma has become darker
purple/bluish/slightly yellow which is from some compromised
blood flow after your procedure, occationally this happens with
stomas and we watch the stoma for improvement which yours has
shown. The stoma will likely shed dead tissues which is ok, and
the tissue underneath should be beefy red/pink. This is expected
to happen however it is importnat that this is watched by the
wound/ostomy nurses and surgery team for improvements. The skin
around the ostomy site should be kept clean and intact. Monitor
the skin around the stoma for buldging or signs of infection
listed above. Please care for the ostomy as you have been
instructed by the wound/ostomy nurses. You will be able to make
an appointment with the ostomy nurse in the clinic 5-7 days
after discharge, You will have a visiting nurse at home for the
next few weeks helping to monitor your ostomy until you are
comfortable caring for it on your own.
You have a long vertical incision on your abdomen that is
partially closed with staples. The incision had a small area of
infection , and was opened at the bedside. This dressing must be
cared for by yourself and visiting nurses with wet to dry
dressing changes twice daily. It is important to monitor the
wound for signs of infection listed below. You will take
antibiotics that will help treat infection inthe area and allow
the wound to heal. The staples will stay in place until your
first post-operative visit at which time they can be removed in
the clinic, most likely by the office nurse. Please monitor the
incision for signs and symptoms of infection including:
increasing redness at the incision, opening of the incision,
increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line/ wound and
pat the area dry with a towel, do not rub. Reapply a new
dressing after showering.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
excersise Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1120**].
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please see Dr. [**Last Name (STitle) 1120**] in the Colorectal surgery office on
Tuesday, [**2116-5-26**] at 10am. The phone number is
[**Telephone/Fax (1) 160**].
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2116-12-2**]
3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2116-12-2**] 4:00
Please make an appointment with your primary care provider to
update them on your position.
ICD9 Codes: 5849, 486, 4254, 4280, 4271, 5180, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1749
} | Medical Text: Admission Date: [**2105-11-18**] Discharge Date: [**2105-12-1**]
Date of Birth: [**2033-3-4**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
pedestrian struck by car
Major Surgical or Invasive Procedure:
[**2105-11-20**]: s/p Bilateral open reduction internal fixation, tibial
plateaus
History of Present Illness:
72 year old male hit by car on [**2105-11-18**] resulting in bilateral
tibial plateau fractures requiring surgical management.
Past Medical History:
Atrial Fibrillation
COPD
CAD
T2DM
HTN
gout
chronic sinus infections
Social History:
Denies tobacco and drug use. Occ alcohol.
Family History:
n/a
Physical Exam:
On admission:
Temp:97.2 HR:102 BP:100/57 Resp:20 O(2)Sat:98
Constitutional: anxious, unable to follow commands
HEENT: hematoma R occiput
Chest: course BS with crackles, scattered
Cardiovascular: tachycardic, irregular
Abdominal: Soft, Nondistended
Extr/Back: lower extremity edema with ecchymosis around
bilateral malleoli, pulses palpable on L LE; non-dopplerable
PT on R, dopplerable DP on R, compartments soft, demarcation
distal R ankle; R posterior knee: ecchymosis with hematoma
and blistering; swelling along calf and posterior thigh
Neuro: unable to assess neurologic exam
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2105-11-18**] 12:09AM BLOOD freeCa-1.10*
[**2105-11-20**] 09:16AM BLOOD freeCa-1.10*
[**2105-11-20**] 10:49AM BLOOD freeCa-1.08*
[**2105-11-20**] 09:21PM BLOOD freeCa-1.14
[**2105-11-22**] 05:16PM BLOOD freeCa-1.09*
[**2105-11-18**] 12:09AM BLOOD Hgb-13.1* calcHCT-39
[**2105-11-20**] 09:16AM BLOOD Hgb-6.9* calcHCT-21 O2 Sat-83
[**2105-11-20**] 10:49AM BLOOD Hgb-8.1* calcHCT-24 O2 Sat-85
[**2105-11-20**] 09:21PM BLOOD O2 Sat-95
[**2105-11-21**] 05:56AM BLOOD O2 Sat-97
[**2105-11-18**] 12:04AM BLOOD Lactate-2.0 K-5.1
[**2105-11-18**] 12:09AM BLOOD Glucose-233* Lactate-1.9 Na-140 K-5.2
Cl-97*
[**2105-11-20**] 09:16AM BLOOD Glucose-77 Lactate-1.0 Na-140 K-4.1
Cl-99*
[**2105-11-20**] 10:49AM BLOOD Glucose-86 Lactate-1.8 Na-139 K-4.4
Cl-100 calHCO3-33*
[**2105-11-20**] 09:21PM BLOOD Lactate-1.3
[**2105-11-22**] 05:16PM BLOOD Lactate-1.6
[**2105-11-18**] 12:09AM BLOOD Type-ART pO2-73* pCO2-93* pH-7.19*
calTCO2-37* Base XS-4 Intubat-NOT INTUBA
[**2105-11-18**] 04:15AM BLOOD Type-ART Rates-/16 Tidal V-550 FiO2-100
pO2-362* pCO2-69* pH-7.29* calTCO2-35* Base XS-4 AADO2-318 REQ
O2-56 -ASSIST/CON Intubat-INTUBATED
[**2105-11-18**] 09:03PM BLOOD Type-ART Temp-36.4 Rates-22/ Tidal V-550
PEEP-5 FiO2-40 pO2-82* pCO2-52* pH-7.43 calTCO2-36* Base XS-8
-ASSIST/CON Intubat-INTUBATED
[**2105-11-20**] 09:16AM BLOOD Type-CENTRAL VE Tidal V-464 FiO2-54
pO2-53* pCO2-64* pH-7.36 calTCO2-38* Base XS-7 Intubat-INTUBATED
[**2105-11-20**] 09:21PM BLOOD Type-ART PEEP-5 FiO2-50 pO2-100 pCO2-76*
pH-7.29* calTCO2-38* Base XS-6 Intubat-INTUBATED
[**2105-11-20**] 11:55PM BLOOD Type-ART PEEP-5 FiO2-45 pO2-95 pCO2-58*
pH-7.37 calTCO2-35* Base XS-5 Intubat-INTUBATED Vent-SPONTANEOU
[**2105-11-21**] 05:56AM BLOOD Type-ART PEEP-5 FiO2-45 pO2-98 pCO2-58*
pH-7.37 calTCO2-35* Base XS-5
[**2105-11-21**] 09:27PM BLOOD Type-ART pO2-71* pCO2-59* pH-7.39
calTCO2-37* Base XS-7
[**2105-11-22**] 05:16PM BLOOD Type-ART Temp-37.8 Rates-/38 FiO2-50 O2
Flow-4 pO2-65* pCO2-58* pH-7.42 calTCO2-39* Base XS-10
Intubat-INTUBATED Comment-FACE TENT
[**2105-11-22**] 06:29PM BLOOD Type-ART Temp-37.8 Rates-/24 FiO2-40 O2
Flow-4 pO2-86 pCO2-57* pH-7.42 calTCO2-38* Base XS-9 Intubat-NOT
INTUBA Comment-FACE TENT
[**2105-11-17**] 11:00PM BLOOD Digoxin-2.5*
[**2105-11-22**] 02:01AM BLOOD Digoxin-0.8*
[**2105-11-17**] 11:00PM BLOOD Albumin-3.3*
[**2105-11-18**] 06:08AM BLOOD Albumin-2.9* Calcium-7.5* Phos-3.2 Mg-1.6
[**2105-11-18**] 04:50PM BLOOD Calcium-7.8* Phos-1.9* Mg-1.5*
[**2105-11-19**] 02:45AM BLOOD Calcium-7.9* Phos-1.8* Mg-1.5*
[**2105-11-20**] 01:12AM BLOOD Calcium-8.0* Phos-3.9# Mg-2.4
[**2105-11-20**] 04:27PM BLOOD Calcium-7.8* Phos-4.4 Mg-2.1
[**2105-11-21**] 09:06PM BLOOD Calcium-7.9* Phos-1.6*# Mg-2.3
[**2105-11-22**] 02:01AM BLOOD Calcium-7.9* Phos-1.7* Mg-2.4
[**2105-11-22**] 01:41PM BLOOD Phos-2.6*
[**2105-11-23**] 02:11AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.2*
Mg-2.0
[**2105-11-24**] 03:05AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.9
[**2105-11-17**] 11:00PM BLOOD cTropnT-<0.01 proBNP-1450*
[**2105-11-18**] 06:08AM BLOOD Lipase-705*
[**2105-11-19**] 02:45AM BLOOD Lipase-106*
[**2105-11-17**] 11:00PM BLOOD ALT-19 AST-33 LD(LDH)-338* AlkPhos-78
Amylase-585* TotBili-1.5
[**2105-11-18**] 06:08AM BLOOD ALT-20 AST-35 LD(LDH)-309* AlkPhos-67
Amylase-527* TotBili-2.1*
[**2105-11-19**] 02:45AM BLOOD ALT-20 AST-40 AlkPhos-56 Amylase-271*
TotBili-1.9*
[**2105-11-23**] 02:11AM BLOOD ALT-27 AST-54* AlkPhos-65
[**2105-11-17**] 11:00PM BLOOD Glucose-218* UreaN-26* Creat-1.9* Na-139
K-5.4* Cl-100 HCO3-31 AnGap-13
[**2105-11-18**] 04:50AM BLOOD Glucose-2275* UreaN-17 Creat-1.4* Na-74*
K-3.3 Cl-58* HCO3-16* AnGap-3*
[**2105-11-18**] 06:08AM BLOOD Glucose-344* UreaN-29* Creat-2.0* Na-135
K-5.6* Cl-97 HCO3-30 AnGap-14
[**2105-11-18**] 04:50PM BLOOD Glucose-157* UreaN-32* Creat-1.8* Na-142
K-4.2 Cl-102 HCO3-31 AnGap-13
[**2105-11-19**] 02:45AM BLOOD Glucose-80 UreaN-34* Creat-1.7* Na-138
K-3.9 Cl-99 HCO3-30 AnGap-13
[**2105-11-20**] 01:12AM BLOOD Glucose-80 UreaN-34* Creat-1.3* Na-141
K-4.5 Cl-104 HCO3-33* AnGap-9
[**2105-11-20**] 04:27PM BLOOD Glucose-106* UreaN-32* Creat-1.2 Na-144
K-4.5 Cl-106 HCO3-32 AnGap-11
[**2105-11-21**] 02:06AM BLOOD Glucose-66* UreaN-32* Creat-1.3* Na-143
K-4.3 Cl-105 HCO3-34* AnGap-8
[**2105-11-21**] 09:06PM BLOOD Glucose-146* UreaN-30* Creat-1.3* Na-145
K-3.8 Cl-106 HCO3-34* AnGap-9
[**2105-11-22**] 02:01AM BLOOD Glucose-44* UreaN-30* Creat-1.2 Na-142
K-3.5 Cl-105 HCO3-34* AnGap-7
[**2105-11-22**] 11:49AM BLOOD Glucose-144* Na-144 K-4.9 Cl-105
[**2105-11-22**] 01:41PM BLOOD Glucose-132* Na-142 K-4.9 Cl-103
[**2105-11-23**] 02:11AM BLOOD Glucose-116* UreaN-28* Creat-1.1 Na-140
K-4.4 Cl-103 HCO3-34* AnGap-7*
[**2105-11-24**] 03:05AM BLOOD Glucose-92 UreaN-29* Creat-1.0 Na-145
K-4.3 Cl-105 HCO3-34* AnGap-10
[**2105-11-25**] 04:40AM BLOOD Glucose-103* UreaN-34* Creat-1.3* Na-144
K-4.2 Cl-101 HCO3-36* AnGap-11
[**2105-11-26**] 04:46AM BLOOD Glucose-101* UreaN-37* Creat-1.3* Na-141
K-3.8 Cl-98 HCO3-37* AnGap-10
[**2105-11-17**] 11:00PM BLOOD PT-22.7* PTT-28.9 INR(PT)-2.1*
[**2105-11-17**] 11:00PM BLOOD Plt Smr-NORMAL Plt Ct-178
[**2105-11-18**] 04:50AM BLOOD PT-39.6* PTT-60.7* INR(PT)-4.1*
[**2105-11-18**] 04:50AM BLOOD Plt Smr-LOW Plt Ct-126*
[**2105-11-18**] 06:08AM BLOOD PT-22.6* PTT-30.5 INR(PT)-2.1*
[**2105-11-18**] 06:08AM BLOOD Plt Ct-128*
[**2105-11-18**] 04:50PM BLOOD PT-18.9* PTT-29.3 INR(PT)-1.7*
[**2105-11-18**] 04:50PM BLOOD Plt Ct-120*
[**2105-11-19**] 02:45AM BLOOD PT-16.3* PTT-29.0 INR(PT)-1.4*
[**2105-11-19**] 02:45AM BLOOD Plt Ct-127*
[**2105-11-20**] 01:12AM BLOOD Plt Ct-109*
[**2105-11-20**] 04:45AM BLOOD PT-13.2 PTT-27.4 INR(PT)-1.1
[**2105-11-20**] 04:27PM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0
[**2105-11-20**] 04:27PM BLOOD Plt Ct-142*
[**2105-11-20**] 04:27PM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0
[**2105-11-20**] 04:27PM BLOOD Plt Ct-142*
[**2105-11-21**] 02:06AM BLOOD Plt Ct-127*
[**2105-11-22**] 02:01AM BLOOD Plt Ct-106*
[**2105-11-22**] 05:05PM BLOOD Plt Ct-120*
[**2105-11-23**] 02:11AM BLOOD PT-14.5* PTT-31.6 INR(PT)-1.3*
[**2105-11-23**] 02:11AM BLOOD Plt Ct-119*
[**2105-11-24**] 03:05AM BLOOD Plt Ct-146*
[**2105-11-25**] 04:40AM BLOOD Plt Ct-222#
[**2105-11-26**] 04:46AM BLOOD Plt Ct-199
[**2105-11-17**] 11:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2105-11-17**] 11:00PM BLOOD Neuts-93* Bands-0 Lymphs-3* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2105-11-17**] 11:00PM BLOOD WBC-21.5* RBC-4.07* Hgb-12.9* Hct-39.2*
MCV-96 MCH-31.6 MCHC-32.9 RDW-16.1* Plt Ct-178
[**2105-11-18**] 01:17AM BLOOD Hgb-12.2* Hct-38.0*
[**2105-11-18**] 04:50AM BLOOD WBC-13.1* RBC-2.96*# Hgb-9.0*# Hct-32.5*
MCV-110*# MCH-30.5 MCHC-27.8*# RDW-16.2* Plt Ct-126*
[**2105-11-18**] 06:08AM BLOOD WBC-16.7* RBC-3.72*# Hgb-12.0*# Hct-35.4*
MCV-95# MCH-32.1* MCHC-33.7# RDW-16.4* Plt Ct-128*
[**2105-11-18**] 04:50PM BLOOD WBC-16.4* RBC-3.03* Hgb-9.5* Hct-28.6*
MCV-94 MCH-31.4 MCHC-33.4 RDW-16.3* Plt Ct-120*
[**2105-11-19**] 02:45AM BLOOD WBC-17.2* RBC-2.87* Hgb-9.1* Hct-27.4*
MCV-95 MCH-31.6 MCHC-33.2 RDW-16.5* Plt Ct-127*
[**2105-11-20**] 01:12AM BLOOD WBC-17.3* RBC-2.54* Hgb-8.1* Hct-24.3*
MCV-96 MCH-32.0 MCHC-33.4 RDW-16.7* Plt Ct-109*
[**2105-11-20**] 04:27PM BLOOD WBC-17.9* RBC-3.48*# Hgb-10.3*#
Hct-32.1*# MCV-92 MCH-29.5 MCHC-32.0 RDW-17.9* Plt Ct-142*
[**2105-11-21**] 02:06AM BLOOD WBC-14.4* RBC-3.17* Hgb-10.0* Hct-28.6*
MCV-90 MCH-31.4 MCHC-34.8 RDW-18.3* Plt Ct-127*
[**2105-11-22**] 02:01AM BLOOD WBC-8.8 RBC-2.55* Hgb-7.9* Hct-23.2*
MCV-91 MCH-31.2 MCHC-34.2 RDW-17.7* Plt Ct-106*
[**2105-11-22**] 05:05PM BLOOD WBC-13.1* RBC-3.33*# Hgb-10.4*#
Hct-30.2*# MCV-91 MCH-31.4 MCHC-34.6 RDW-17.2* Plt Ct-120*
[**2105-11-23**] 02:11AM BLOOD WBC-10.7 RBC-3.01* Hgb-9.7* Hct-27.5*
MCV-91 MCH-32.3* MCHC-35.3* RDW-17.1* Plt Ct-119*
[**2105-11-24**] 03:05AM BLOOD WBC-10.8 RBC-3.05* Hgb-9.6* Hct-28.3*
MCV-93 MCH-31.6 MCHC-34.1 RDW-16.9* Plt Ct-146*
[**2105-11-25**] 04:40AM BLOOD WBC-10.0 RBC-3.30* Hgb-10.3* Hct-31.5*
MCV-96 MCH-31.1 MCHC-32.6 RDW-16.4* Plt Ct-222#
[**2105-11-26**] 04:46AM BLOOD WBC-8.9 RBC-3.23* Hgb-10.2* Hct-30.5*
MCV-94 MCH-31.5 MCHC-33.4 RDW-16.9* Plt Ct-199
Brief Hospital Course:
Mr. [**Known lastname 1790**] was admitted to the General Trauma Surgery service
on [**2105-11-18**] after being hit by a car. In the ED he was
hypotensive and intubated for hypoxia then transferred to ICU.
The ICU team monitored him and replete his blood, fluid,
electrolytes and placed on pressors for hypotension. On
[**2105-11-20**] he underwent open reduction internal fixation of
bilateral tibial plateaus without complication. Post operatively
he was transferred back to the ICU. He was transfused for post
operative blood loss anemia and placed on sliding scales for his
electrolytes. On [**2105-11-20**] post operatively he went into AFib w/
RVR treated with Lopressor and digoxin. Then Dilt drip started
for AFib w/ RVR due to refractory to Lopressor and digoxin. On
[**2105-11-21**] he was extubated, c-spine cleared, diet advanced to
regular, weaned off dilt drip, started metoprolol 12.5mg. On
that evening he started sundowning. On [**2105-11-22**] he was
transfused 2U pRBC with Lasix in between for post operative
blood loss anemia. He became confused thus Haldol given. On
[**2105-11-23**] he aspirated and became agitated and delirious. The
chest xray did not show any interval change. On [**2105-11-23**] speech
and swallow test performed. On [**2105-11-24**] he was transferred out
of the ICU to the Orthopedic service. He remained confused
therefore the [**Female First Name (un) 1634**] service was consulted for post op delirium.
they recccomended for agigition use
Medications on Admission:
Home Medications:
coumadin,digoxin 250mcg daily, diovan 160mg daily, lasix 20mg
daily, lipitor 20mg daily, Toprol XL 200mg
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob, wheeze.
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
7. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*28 * Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
13. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Living
Discharge Diagnosis:
1. Bilateral tibial plateau fractures.
2. Hypercarbia.
3. Post operative Delirium.
4. Post operative blood loss anemia.
5. Fluid volume deficit
6. Hypotension
7. Hypoxia
8. Atrail Fib with rapid ventricular rate.
9. Aspiration
10. Hypoglycemia
11. Leukocytosis
12. Hypocalcemia.
13. Hypomagnesemia.
14. Hypophosphatemia.
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:
Wound Care:
-Keep Incisions dry.
-Do not soak the incisions in a bath or pool.
Activity:
-Continue to be non weight bearing on both legs.
-Keep the braces dry, they may come off while in bed, but need
to be on when up and transferring
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
If urethral bleeding worsens or it becomes difficult/painful to
urinate please come to the ED
Physical Therapy:
Activity: Out of bed
Right lower extremity: Non weight bearing
Left lower extremity: Non weight bearing
[**Doctor Last Name **] braces bilaterally unlocked, ROM knees as tolerated
Treatments Frequency:
remove staples 14 days from date of surgery
Followup Instructions:
2 weeks in the [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.
Please call [**Telephone/Fax (1) 1228**] to make this appointment.
...
Follow up with urology in 2 weeks. Please call ([**Telephone/Fax (1) 772**] to
set up an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2105-12-1**]
ICD9 Codes: 2762, 2851, 2930, 4589, 496, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1750
} | Medical Text: Admission Date: [**2153-6-12**] Discharge Date: [**2153-6-17**]
Date of Birth: [**2129-11-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Aortic insufficiency
Major Surgical or Invasive Procedure:
1. AVR (29mm CE pericardial)
History of Present Illness:
23M previously admitted [**Hospital3 1280**] for evaluation of migraines,
at which time a diastolic murmur was appreciated and subsequent
echocardiogram showed 4+ AI and a dilated aortic root.
Increasing DOE and chest pain. Referred for surgical repair.
Past Medical History:
1. Aortic insufficiency
2. + PPD
Social History:
Unremarkable
Family History:
Noncontributory
Physical Exam:
Unremarkable except for gr IV/VI diastolic murmur
Pertinent Results:
[**2153-6-14**] 05:05AM BLOOD WBC-14.0* RBC-3.29* Hgb-10.0* Hct-28.7*
MCV-87 MCH-30.4 MCHC-34.8 RDW-13.2 Plt Ct-110*
[**2153-6-14**] 05:05AM BLOOD Glucose-103 UreaN-21* Creat-0.8 Na-135
K-4.3 Cl-98 HCO3-31* AnGap-10
Brief Hospital Course:
To OR on [**2153-6-12**], underwent uneventful AVR (29mmCE). Post-op
transferred toCSRU on Neo for short period. Weaned from vent,
extubated the day of surgery. Transferred [**Last Name (un) 834**] ICU on POD # 1.
Began ambulation, pulm. toilet. Progressed well, chest tubes
and epicardial pacing wires removed on POD # 2. Has remained
stable, and is ready for discharge home today.
Medications on Admission:
TB meds for positive skin test (negative CXR)
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every
4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day for 5 days: then Q 8 hours prn pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Aortic insufficiency
2. Dilated aortic root
3. + PPD
Discharge Condition:
Good
Discharge Instructions:
1. Resume medications as directed.
2. Call office or go to ER if fever/chills, drainage from
incisions, chest pain, shortness of breath.
Followup Instructions:
PCP, 2 weeks, call for appointment.
Cardiologist, 2 weeks, call for appointment.
Dr[**Last Name (Prefixes) 4558**], 4 weeks, call for appointment.
Completed by:[**2153-6-15**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1751
} | Medical Text: Admission Date: [**2105-11-22**] Discharge Date: [**2106-1-8**]
Date of Birth: [**2048-12-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
56 year old Portuguese male with 1 day history of chest pain and
dizziness.
Major Surgical or Invasive Procedure:
AVR(27mm valve) Homograft/Ascending aorta tube graft [**2105-12-8**]
Tracheostomy
Percutaneous feeding tube placement
History of Present Illness:
56 y.o. male, Portugese speaking, with history of AS/AI who
presented to an OSH with CP and dizziness after walking up a
[**Doctor Last Name **]. Pt reports that he had been experiencing chest pain with
heavy exertion for quite some time. Pt presented to [**Hospital 8**]
Hospital for evaluation. Per OSH records, the pt described the
pain as substernal in nature with radiation to the shoulders
R>L. Pt had subjective palpitations and dizziness with the pain
but no fevers, chills, diaphoresis, nausea, or vomiting. On
arrival to the OSH, the pt's pain was relieved with tylenol.
However, he was found to have a fever of 101 so was admitted to
the ICU for further evaluation. On workup, pt's CXR was
significant for a sidened mediastinum with a tortuous aortic
shadow. CT with contrast revealed a ascending aortic aneurysm of
6.5 cm with a normal descending aorta. Pt was ruled out for MI.
Five sets of blood cultures were drawn. There was a concern for
endocarditis so the pt was started emperically on rocephin,
gentamicin, and nafcillin. The pt was then transferred to [**Hospital1 18**]
for CT surgical evaluation for repair of his aneurysm.
Past Medical History:
1. HTN
2. AS and AI- Seen on echo at [**Hospital 8**] Hospital on 08/[**2104**]. AV
area of 0.7 cm2 and a gradient of 77 mmGg. Moderate AI. LVEF of
75%.
3. Right VP shunt s/p trauma approximately 30 years ago
Social History:
Pt is married and lives with his wife and children. He works as
a mechanic. He is Portugese speaking. No tobacco, ETOH, or
drugs.
Family History:
[**Name (NI) 1094**] father had DM. No history of CAD or hypercholesterolemia.
Physical Exam:
Gen- Alert and oriented. NAD. Resting comfortably in bed.
HEENT- NC AT. PERRL. MMM.
Cardiac- Irregularly irregular. IV/VI harsh holosystomic murmur
radiating throughout precordium and up to carotids. No JVD
appreciated.
Pulm- CTAB.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Skin- Multiple cherry hemangiomas on abdomen and chest; no
stigmata of endocarditis
Extremities- Trace LE edema. 2+ DP pulses.
Neuro: CN 2-12 intact, sensation intact throughout, strength 5/5
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2106-1-7**] 06:36AM 6.6 3.82* 11.7* 35.7* 94 30.6 32.8 17.0*
463*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2106-1-7**] 06:36AM 463*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2106-1-7**] 06:36AM 20 0.7 4.1
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2106-1-6**] 02:46AM 1.7
Source: Line-Picc; GREEN TOP
Cardiology Report ECHO Study Date of [**2105-12-28**]
PATIENT/TEST INFORMATION:
Indication: Endocarditis. Evaluation for abscess. Prosthetic
valve function.
BP (mm Hg): 105/85
HR (bpm): 85
Status: Inpatient
Date/Time: [**2105-12-28**] at 11:20
Test: Portable TEE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2005W065-0:25
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 60% (nl >=55%)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2105-12-21**].
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the
body of the
LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast
in the body of the RA. No mass or thrombus in the RA or RAA. A
catheter or
pacing wire is seen in the RA and/or RV. No spontaneous echo
contrast in the
RAA. Normal interatrial septum.
LEFT VENTRICLE: Normal LV cavity size. Normal regional LV
systolic function.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Normal RV
systolic function.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR).
Normal AVR
leaflets. No masses or vegetations on aortic valve. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or
vegetation on
mitral valve. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or
vegetation on tricuspid valve.
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 monitored
by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient
was sedated for
the TEE. Medications and dosages are listed above (see Test
Information
section). Local anesthesia was provided by benzocaine topical
spray. No TEE
related complications. The rhythm appears to be atrial
fibrillation. Compared
with the findings of the prior study, there has been no
significant change.
Echocardiographic results were reviewed by telephone with the
houseofficer
caring for the patient.
Conclusions:
1.The left atrium is normal in size. No spontaneous echo
contrast is seen in
the body of the left atrium or right atria.
2. A pacing wire is visualized in the right atrium and is free
of masses or
vegetations.
3. The left ventricular cavity size is normal. Regional left
ventricular wall
motion is normal. Overall left ventricular systolic function is
normal
(LVEF>55%).
4. Right ventricular chamber size and wall motion are normal.
5.The ascending, transverse and descending thoracic aorta are
normal in
diameter and free of atherosclerotic plaque.
6. A bioprosthetic aortic valve prosthesis is present. The
prosthetic aortic
leaflets appear normal. No masses or vegetations are seen on the
aortic valve.
No aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. No mass or
vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
The tricuspid
valve has no masses or vegetations.
8.There is a trivial/physiologic pericardial effusion.
Compared with the prior study (tape reviewed) of [**2105-12-21**] there
is no
diagnostic change.
RADIOLOGY Final Report
CT HEAD W/ CONTRAST [**2105-12-27**] 2:53 PM
CT HEAD W/ CONTRAST; CT 100CC NON IONIC CONTRAST
Reason: needs IV contrast to identify signs of infection w/in
fronta
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
57M s/p AVR, with persistent sepsis & CNS fluid collections
REASON FOR THIS EXAMINATION:
needs IV contrast to identify signs of infection w/in frontal
collections. last noncontrast study was inadequate
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: Status-post aortic valve replacement with persistent
sepsis and CNS fluid collections.
COMPARISON: Same day approximately one (1) hour prior.
TECHNIQUE: Multiple axial images of the head were obtained
following the administration of 100 cc of Optiray.
CT HEAD W/IV CONTRAST: No enhancing intracranial collections
identified. Again seen, are bifrontal chronic subdural
collections, unchanged. There is a ventricular drainage catheter
via the right posterior approach, unchanged in position. There
is no shift of normally midline structures. No enhancing masses
are seen. There is no hydrocephalus.
IMPRESSION: Stable appearance of bifrontal chronic subdural
collections. No enhancing masses or enhancing collections
identified. Please note if meningeal infection is a concern, the
most sensitive test would be CSF analysis.
Brief Hospital Course:
The patient was admitted on [**2105-11-22**].On [**2105-11-23**], the pt was
also noted to be in new onset atrial fibrillation. He was loaded
with 200 mg of amiodarone and started on a heparin drip. On
arrival to [**Hospital1 18**], the pt was evaluated by CT [**Doctor First Name **] who delayed
valve repair until the patient was infection free. He was then
admitted to the CCU for further care. At that time, his
temperature was 102.9. Antibiotics were changed on admission to
gentamycin, vancomycin, and pen G. On the day following
admission ([**2105-11-23**]), it was found that all 10 bottles of
blood cultures from the OSH were growing gram positive cocci. ID
was consulted and the pt's antibiotics were changed to
vancomycin, gentamycin (until consistantly clean blood
cultures), and oxacillin. The pen G was discontinued. TTE was
significant for a LVEF of 30 to 35%; mild LA and RA enlargement;
severly dilated LV with diffuse hypokinesis; moderate dilation
of the aortic root; marked dilation fo the ascending aorta;
marked dilation of the aortic arch; severe AS; severe AR; mild
MR; mild TR; and mild PA systolic hypertension. TEE on
[**2105-11-24**] was negative for any vegitation or abcess suggestive
of endocarditis. At that time, ID felt that the infection was
most likely located [**Last Name (un) 7245**] in the aneurysm. By [**2105-11-25**], the
pt's fever curve was markedly decreased. He was transferred to
the [**Hospital Unit Name **] team for further care.
He grew out MSSA and the gentamycin was discontinued. He
developed fevers and an increased WBC again and was found to
have an abcess and vegitation on his aortic valve on TEE. He
blocked down and required temporary pacer placement. He was
restarted on Vanco and underwent cardiac cath prior to the OR.
On [**2105-12-8**] he underwent AVR homograft with a 27mm valve and
ascending aortic root replacement. He had purulent drainage
from his heart and aorta, and was transferred to the CSRU.
POD#1 he was on Epi and remained intubated. He was extremely
agitated and continued having high temps. He intermittently
required Neo and Vasopressin for profound hypotension. He was
closely followed by ID, Pulmonary, and EP. He was on Gent,
Vanco, Oxacillin, and Rifampin. He remained intubated and had
several TEEs which were all negative. Eventually his rhythm
recovered and the pacing wire was d/c'd. He had a negative LP
and head CT and was followed by neurology for agitation. All
cultures were negative. He was eventually started on
Casperfungin and POD #18 he defervesced and underwent a
tracheostomy on [**12-26**]. He continued to improve and the
Caspofungin was d/c'd. His antibiotics were eventually changed
to Rifampin and Oxacillin alone. He weaned quickly from the
vent., and failed a swallowing study, so he had a PEG placed on
[**1-5**]. On [**1-6**] he was transferred to the floor in stable
condition. He was discharged to acute rehab on POD#31 in stable
condition.
He needs to continue Oxacillin and Rifampin until [**1-22**]. He was
diagnosed with c. diff on [**1-3**] and should stay on Flagyl while
on abx.
Medications on Admission:
1. Amiodarone 200 mg QID
2. ASA 81 mg daily
3. Atorvastatin 20 mg daily
4. Docusate 100 mg [**Hospital1 **]
5. Gentamicin 100 mg IV Q8H
6. Weight based IV heparin
7. RISS
8. Oxacillin 2 gm IV Q4H
9. Pantoprazole 40 mg daily
10. Vancomycin 1000 mg IV Q12H
PRNs-
Tylenol
Bisacodyl
Ambien
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Acetaminophen 160 mg/5 mL Elixir Sig: Two (2) PO Q4-6H
(every 4 to 6 hours) as needed for temp>38.
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO PRN
(as needed) as needed for k < 4.4.
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): While on Oxacillin and Rifampin, pt. should stay
on Flagyl.
7. Rifampin 150 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours): D/C on [**2106-1-22**].
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
11. Oxacillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q4H (every 4 hours): D/C [**2106-1-22**].
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous twice a day.
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
Subcutaneous four times a day: SS: BS 110-150 2U
151-200 4U
201-250 6U
251-300 8U
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
MSSA endocarditis
Prolonged intubation
Aortic stenosis
Atrial fibrillation
HTN
s/p VP shunt 30 yrs ago
C. diff
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) **] when discharged from rehab.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Completed by:[**2106-1-8**]
ICD9 Codes: 9971, 5185, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1752
} | Medical Text: Admission Date: [**2132-10-26**] Discharge Date: [**2132-10-29**]
Date of Birth: [**2097-4-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
No major surgical or invasive procedures.
History of Present Illness:
35 yo M w/ h/o asthma only on albuterol prn though multiple
hospital admission, p/w SOB and asthma flare x 1d. Seen at
[**Hospital 1263**] Hospital 1 week ago, improved rapidly on iv steroids but
pt refused inpt admission. He did not fill his prednisone rx
after d/c but has been using advair inhaler x past week, stopped
recently. Previously seen here in [**1-21**] and d/c on prednisone
taper from ED also. Neice with URI which pt caught. In ED
received prednisone 60 mg po x 1, combivent neb x 9, MgSO4 4g
iv, and Terbutiline 0.5 mg SC x 1, placed on continuous nebs at
10 mg/h at 3A. Pt w/ unknown PF but in ED ranged 400-480 post
nebs. Sent to [**Hospital Unit Name 153**] for continuous nebs and further monitoring.
.
ROS: + chest tightness, + "breathing through a straw" sensation,
+ recent congestion, rhinorrhea. No cough, chest pain, abd pain,
n/v/d, LE edema, orthopnea. + weight gain of 30-40 lbs in past
couple years. Does not exercise due to DOE.
Past Medical History:
PMH:
- Asthma: no h/o intubations. Past 2 yrs has had only 1 other ED
visit for asthma flare prior to last week. Uses albuterol MDI
and nebs occasionally up to several times daily when trigger
encountered, occasionally not at all. 1 mo ago sister brought
another dog over which pt believes triggered sxs last week.
- Seasonal allergies
Social History:
SH: Truck driver. No tob or EtOH. Lives with 5 neices who he
raised. Has great [**Male First Name (un) **] dog x many years.
Family History:
FH: Mom and sister with asthma, DM
.
Physical Exam:
PE:
VS: T 100 HR 127 BP 128/51 RR 24 O2 sat 99% on continuous neb
Gen: Obese pleasant M sitting in bed speaking in mostly full
sentences
HEENT: PERRLA, EOMI, mildly dry mm
Neck: No LAD
CV: RRR tachy nl S1 S2 no m/r/g
Pulm: Bilateral diffuse wheezing on expiration with increased
expiratory time
Abd: Obese soft NT/ND
Extr: No c/c/e
Neuro: AAOx3, moves all extremities equally and spontaneously
Skin: Multiple extensive areas of tattoos
Pertinent Results:
[**2132-10-29**] 07:00AM BLOOD WBC-20.4* RBC-4.56* Hgb-14.3 Hct-42.7
MCV-94 MCH-31.5 MCHC-33.6 RDW-12.6 Plt Ct-242
[**2132-10-29**] 07:00AM BLOOD Glucose-98 UreaN-24* Creat-1.1 Na-141
K-3.7 Cl-108 HCO3-23 AnGap-14
[**2132-10-27**] 06:50AM BLOOD Glucose-211* UreaN-15 Creat-1.3* Na-143
K-3.9 Cl-106 HCO3-15* AnGap-26*
[**2132-10-29**] 07:00AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.3
[**2132-10-27**] 02:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2132-10-27**] 10:17PM BLOOD Acetone-NEGATIVE
[**2132-10-27**] 04:00PM BLOOD Type-ART pO2-78* pCO2-31* pH-7.38
calHCO3-19* Base XS--5
[**2132-10-27**] 04:00PM BLOOD Lactate-5.3*
[**2132-10-27**] 10:44PM BLOOD Lactate-1.7
[**10-26**] EKG: ST at 132, nl axis/int, no STE/depressions/TWI
concerning for ischemia, isolated small qs in III.
.
[**10-26**] CXR: Cardiac, mediastinal and hilar contours, pulmonary
vasculature wnl. Lungs clear, but left CPA cut off and overall
hazy likely d/t body habitus. No clear pleural effusions.
Brief Hospital Course:
35 yo M w/ asthma flare likely [**2-20**] URI admitted for increased
nebs and further monitoring.
.
1. Asthma flare: Though recently pt w/ 2 flares in past week, he
seems to usually not have flares. He also may have been
underreporting sxs and has high tolerance of sxs at baseline. On
arrival to the [**Hospital Unit Name 153**], he was switched to IV methylprednisolone,
which he received for two days, and then switched to po
prednisone (60-40-30-20-10) 10 day taper for continuation as
outpatient. He was placed on continuous neb treatments
initially, and then switched to albuterol q2 then albuterol q4.
By HOD3, he required no prn albuterol nebulizer treatments. He
was placed on an albuterol inhaler prn, as well as Advair [**Hospital1 **].
His peak flows improved to 600.
Patient is fairly noncompliant with his medications - states he
is unwilling to have regular follow-up with doctors. He would
ideally need a PCP and outpatient [**Name9 (PRE) 11149**], and minimizing of
environmental triggers (pt unlikely to be getting rid of dog,
however). His URI symptoms appeared viral, and did have
productive yellow cough. He remained afebrile in [**Hospital Unit Name 153**], but did
have a rising white count in the context of steroids. No
antibiotics were started.
2. Metabolic acidosis with gap and lactate 5.3, as well as
ketones in urine. Patient's acidosis was likely secondary to
lactic acidosis from acute asthma flare. Lactate down to 1.7
with fluids. Urinalysis shows glucose and ketones, but in the
context of poor po intake and poor glycemic control on steroids.
No sx of DKA. ABG c/w compensated metabolic acidosis. He may
need outpatient followup for FSBG.
.
3. FEN: He was on a regular diet.
4. Glucose: ISS.
5. Proph: PPI on steroids. Bowel regimen.
6. Code: DNR/I- confirmed with pt
7. Comm: with pt
Medications on Admission:
Albuterol inh prn
Advair x 1 week
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day
for 10 days: Four (4) tablets a day x 2 days, then two (2)
tablets a day x 3 days, then one (1) tablet a day x 3 days, then
half ([**1-20**]) tablet a day x 2 days. .
Disp:*18 Tablet(s)* Refills:*0*
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
Disp:*1 1* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Asthma Exacerbation
2. Lactic acidosis
3. Ketoacidosis
Discharge Condition:
Stable
Discharge Instructions:
If you experience shortness of breath, or wheezing, please
report to the emergency room immediately. Please take all of
your medications. Monitor your peak flows and record them.
Please follow up with your physicians (see information below.)
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] on Monday, [**2132-11-24**] at
2:00 p.m. The number of the clinic is [**Telephone/Fax (1) 250**].
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1753
} | Medical Text: Admission Date: [**2189-1-3**] Discharge Date: [**2189-1-16**]
Date of Birth: [**2120-10-4**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
endotracheal intubation
central venous line placement
History of Present Illness:
68yoM, nursing home resident, w/ pmh sig for Alzheimer's
dementia and hydrocephalus s/p shunt who was sent to the [**Hospital1 18**]
ED from the NH today because of five days of diarrhea, one day
of vomitting, and increased confusion/agitation. Found to have
partial SBO, aspiration pneumonia, now with blood cultures
positive for GPC. On CTX/azithro/vanco/Flagyl There have been no
recent fevers or chills, sob. He has had a dry cough today.
Per so, a stool sample was sent for c diff at the nursing home.
Son states that at baseline pt can be combative and agitated but
is also more verbal. There has been no blood in diarrhea or
melena.
.
ROS: No suggestion of back pain, headache, visual changes,
dysuria, hematuria.
.
In the ED he had a CT of the head, abd, as well as a cxr.
Neurosurg evaluated pt and noted milf increase in ventricular
size, but felt that shunt malfuntion or infection was unlikely.
In addition, the surgical team evaluated the patient out of
concern for partial sbo given vomitting and ct abd with ? of
sbo. Per surgical note, pt has likely partial sbo or ileus. An
NG tube was placed and the team recommended no surgery, but NG
tube, npo.
.
In the ED patient had a fever to 103, leukocytosis, no other
abnl vital signs, lactate > 2. A femoral line was placed and pt
was given CTX, azithromycin, flagyl.
Past Medical History:
Alzheimer's dementia, Bipolar disorder, PVD, DM2,
Hydrocephalus s/p VP shunt (son says it was placed 3-5 years ago
at [**Hospital3 **] with no revisions, unknown cause of
hydrocephalus), H/o subdural hemorrhages (unknown if before or
after shunt placed), Hearing loss with hearing aids, Cataracts,
Hypertension, Hypercholesterolemia, SIADH with fluid restriction
of 1L per day.
Social History:
Used to work as an accountant, 100 pack year smoking
history, supportive family
Family History:
NC
Physical Exam:
Vitals: Tm 102.6 HR 88 RR 18 BP 186/72 98%
General: Was asleep but easily arousable for exam. Screaming
in
Italian and throwing arms around. NG in place with bilious
output.
HEENT: No conjunctivitis or discharge, mucous membranes moist
and pink, neck supple, no LAD. Burr hole on the right with
shunt
traveling down behind ear to neck. Resevoir depressable with
refilling immediately.
CV: Normal S1 and S2, no murmurs
Pulm: Mild wheeze, decreased bs b/l, transmitted upper airway
sounds.
Abdomen: Soft, distended, nontender.
Extremities: Warm and well perfused
Mental status: Following some commands, awake and alert during
the examination.
Neuro: MAE, nl tone throughout
Pertinent Results:
[**2189-1-3**] 06:39PM LACTATE-2.3*
[**2189-1-3**] 02:55PM LACTATE-2.4*
[**2189-1-3**] 02:45PM GLUCOSE-173* UREA N-8 CREAT-0.4* SODIUM-132*
POTASSIUM-4.0 CHLORIDE-91* TOTAL CO2-31 ANION GAP-14
[**2189-1-3**] 02:45PM estGFR-Using this
[**2189-1-3**] 02:45PM ALT(SGPT)-16 AST(SGOT)-14 ALK PHOS-83
AMYLASE-49 TOT BILI-0.2
[**2189-1-3**] 02:45PM LIPASE-11
[**2189-1-3**] 02:45PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-1.4*
[**2189-1-3**] 02:45PM WBC-16.1*# RBC-5.23 HGB-14.1 HCT-42.2 MCV-81*
MCH-26.9* MCHC-33.4 RDW-13.9
[**2189-1-3**] 02:45PM NEUTS-86.6* LYMPHS-8.2* MONOS-4.7 EOS-0.3
BASOS-0.2
[**2189-1-3**] 02:45PM MICROCYT-1+
[**2189-1-3**] 02:45PM PLT COUNT-356
[**2189-1-3**] 02:10PM URINE HOURS-RANDOM
[**2189-1-3**] 02:10PM URINE GR HOLD-HOLD
[**2189-1-3**] 02:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2189-1-3**] 02:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2189-1-3**] 02:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
.
pCXR: 1. Nasogastric tube seen within the body of the stomach
and coursing off the imaged field of view.
2. Bilateral airspace disease reflecting evolving pneumonia or
asymmetric pulmonary edema.
.
CXR: Interval removal of nasogastric tube.
Patchy airspace opacities, unchanged. Diagnostic considerations
again include pneumonia and asymmetric pulmonary edema.
.
CT Abd/pelvis: 1. Air-filled dilated loops of small bowel, with
collapsed distal loops, suggesting partial small bowel
obstruction. No free air or free intraabdominal fluid is
identified.
2. Confluent consolidative opacities in the right middle and
lower lobes. Differential includes pneumonia versus aspiration.
.
CT head: 1. Compared to previous study dated [**2187-3-6**],
the ventricles appear slightly more dilated and therefore
recommend evaluation to rule out shunt malfunction .
2. Interval resolution of right subdural collection.
.
Video swallow: Fluoroscopic assistance was provided for the
speech/language pathology service with the radiologist present.
The patient swallowed barium of varying consistencies (thin
liquid, nectar-thick liquid, and pureed consistency barium). No
aspiration was seen throughout this examination. Bolus formation
with swallow initiation were appropriate with no premature
spillover or retention. No penetration or aspiration occurred.
The patient was able to cough throughout the examination and
expectorated thick clear sputum. No aspiration was noted prior
to and during the patient's coughing episodes.
.
CT Head: Stable prominence of lateral ventricles compared to
[**1-3**]. No acute intracranial abnormality including no
sign of hemorrhage.
.
CT Abd: 1. Resolved partial obstruction of small bowel. No free
air or free intra- abdominal fluid is noted.
2. Resolving right middle and lower lobe pneumonia or
aspiration.
3. Diffusely mild thickened bladder wall. This might be due to
cystitis.
.
TTE: The left atrium is moderately dilated. There is moderate
symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of
[**2187-3-6**], the pericardial effusion has resolved.
Brief Hospital Course:
1) HTN: Had severely elevated BP while in house even >200/100 at
times. He also complained of chest pain and headache at times
with this, so he was started on long acting medications due to
him refusing meds at times. On toprol, hydralazine, and
lisinopril his BP was much better controlled.
2) Partial SBO: Initially presented with n/v. CT showed partial
SBO, surgery was consulted. Resolved with bowel rest. CT abd
showed resolved pSBO. Now toleating diet and passing stool.
3) Diastolic CHF: Had slightly elevated cardiac enzymes, but no
ECG changes. TnT peaked at 0.24, although MB fraction negative:
likely demand ischemia in the setting of HTN. TTE showed
preserved EF and no wall motion abnormalities. Improved with
aggressive BP control. Cont. ASA/toprol/lisinopril/statin.
4) h/o SIADH: on salt tabs at home, but Na stable off them
in-house. Cont. fluid restriction.
5) Hypothyroidism: continued on levothyroxine
6) Type II DM: holding glyburide/metformin for now. Continue pm
NPH; RISS. Can restart oral meds at NH as needed.
7) Diarrhea: C. diff (-) X 3, no diarrhea.
8) Aspiration PNA: developed sudden respiratory arrest while
eating dinner. Thought to be aspiration. Pt. was intubated and
transferred to ICU and started on levofloxacin and flagyl.
Patient passed video swallow.
9) GPC bactermia [**1-15**] bcx [**1-8**] CNS; [**1-4**] also w/ CNS.
Surveillance Cx negative.
10) Candiduria: d/c Foley
11) Fe def anemia: SPEP hypogamma; check folate, low/nl vit B12,
hold iron pending completion of levo course
12) Full Code
13) Dispo: Back to NH
Medications on Admission:
Trileptal 300 mg [**Hospital1 **]
Glyburide 2.5 mg [**Hospital1 **]
Glucophage 1000 mg [**Hospital1 **]
Ursodiol 300 mg [**Hospital1 **]
NaCl 2 tabs tid
1L fluid restiction
senna
Levothyroxine 25 mcg daily
Abilify 10 mg daily
Colace 100 mg [**Hospital1 **]
Prilosec 20 mg daily
Ativan 0.25 mg prn
NPH 40 units sc q4pm
Regular Insulin Sliding scale [**Hospital1 **]
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
13. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed.
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Six (36) units Subcutaneous qdinner.
19. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale sliding scale Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Partial Small Bowel Obstruction
aspiration Pneumonia
Severe Hypertension
Diastolic CHF
CAD
Alzheimer's dementia
Discharge Condition:
stable
Discharge Instructions:
Please continue meds as listed. Please follow up with your PCP
in the next 2 weeks.
Followup Instructions:
1. Please follow up with your PCP in the next 2 weeks.
ICD9 Codes: 5070, 4280, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1754
} | Medical Text: Admission Date: [**2174-9-9**] Discharge Date: [**2174-10-7**]
Date of Birth: [**2152-3-29**] Sex: M
Service: MED
Allergies:
Benzocaine / Zosyn
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
fever and hypoxia, witnessed aspiration at rehabilitation
facility
Major Surgical or Invasive Procedure:
none
History of Present Illness:
22 y/o male w/ h/o [**First Name3 (LF) **]'s syndrome (DM, DI, optic atrophy,
deafness), presenting from [**Hospital3 **] after a witnessed
aspiration pna and 1 day of fevers. Pt also with central
hypoventilation requiring ventilation at night (now with trach,
peg for meds), h/o MRSA/pseudomonal pna's and persistent pulm
infitrates. Pt was on
Zosyn/caspofungin/amikacin/bactrim/linezolid at rehab (for 2 wk
course) and was scheduled to have CT at [**Hospital1 2025**] to evaluate
infiltrates. Pt also with intermittent agitation treated with
ativan/haldol prn. In ED, given versed, vanco, zosyn, put on
vent/PS.
Past Medical History:
[**Hospital1 **]'s (DIDMOAD) syndrome, Seizures [**12-27**] hypoglycemia, MRSA
pna, pseudomonas, trach collar, Hashimoto's thyroiditis,
anxiety/mdd, avnrt, central hypoventilation,
Social History:
Resident of [**Hospital3 **]; Full Code
Family History:
non-contributory
Physical Exam:
PE on admit to MICU:
Vitals: T 102.3, BP 110/50, HR 62, Vent settings: PS 20, PEEP 5,
Vt 590, RR 8, O2 97-100% O2
Gen: Sedated but in NAD
HEENT: non-icteric, mm dry
Chest: coarse BS bilat.
CV: RRR. no murmurs
Abd: Soft, NT/ND. PEG Tube
EXT: no c/c/e
Neuro: surgical pupils b/l; neuro exam difficult [**12-27**] sedation
Pertinent Results:
[**2174-9-9**] 08:01PM LACTATE-2.2*
[**2174-9-9**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2174-9-9**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2174-9-9**] 07:30PM GLUCOSE-250* UREA N-9 CREAT-0.8 SODIUM-132*
POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-23 ANION GAP-18
[**2174-9-9**] 07:30PM WBC-9.1 RBC-4.43*# HGB-13.7*# HCT-39.5*#
MCV-89 MCH-30.8 MCHC-34.6 RDW-15.3
[**2174-9-9**] 07:30PM NEUTS-85.3* LYMPHS-10.8* MONOS-2.8 EOS-1.0
BASOS-0.2
[**2174-9-9**] 07:30PM PLT COUNT-189#
[**2174-9-9**] 07:30PM PT-14.2* PTT-27.8 INR(PT)-1.3
[**9-9**] CXR: Bilateral pleural effusions, without definite focal
consolidation
[**9-15**] CTA-chest:
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusions with atelectasis and air
bronchograms in the lung bases.
3. Micronodular opacities are present in the right lung base,
consistent with pneumonia.
[**9-12**] Video Swallow Study:
The patient was unable to swallow the barium tablet with thin
liquid and demonstrated a moderate amount of thin liquid
aspiration during this attempt. There was no spontaneous cough,
and a cued cough was ineffective in clearing the
aspiration.
[**9-29**] Video Swallow Study:
Aspiration of thin and nectar thick barium. Penetration to the
vocal cords with pudding consistency barium. Prominence of the
cricopharyngeus muscle with episodes of apparent spasm.
Brief Hospital Course:
22 y/o M with h/o [**Month/Day (4) **]'s Disease (DIDMOAD), central
hypoventilation, recurrent PNA (h/o
MRSA/Pseudomonas/Klebsiella), presenting s/p witnessed
aspiration event, with intermittent fevers, afebrile since ABX
discontinued on [**9-16**].
1. Pneumonitis: Mr. [**Known lastname 37779**] was admitted on [**9-9**] following a
witnessed aspiration event at [**Hospital3 **]. He had recent
reported histoy of broad spectrum antibiotics over the last 2
weeks (Linezolid/Zosyn/Caspofungin/Bactrim/Amikacin). On
admission to [**Hospital1 18**] he was initially monitored in the ICU given
his central hypoventilation with ventilation dependence. Initial
CXR here was negative for infiltrate (reported as bilateral
atelectasis and small effusions). Sputum cultures grew
Pseudomonas/Klebsiella on two separate days. It was thought that
these organisms could represent colonization vs infection.
Given his persistent fever and bandemia, infection was suspected
and he was initially started on Vanco (D1=[**2174-9-11**]) and Zosyn.
Zosyn was changed to Merepenem (D1=[**2174-9-14**]) after final
sensitivies returned (Pseudomonas resistant to Zosyn and
Ceftaz). Given his persistent fevers, other etiologies of his
fever were pursued including PE and meds. CT-angio was performed
on [**9-15**] which demonstrated multi-nodular opacities in the right
lung base thought to be c/w pneumonia. No evidence of pulmonary
embolism. Non-pathologically enlarged lymph nodes were noted in
the mediastinum and hilar regions. However, repeat CXR's
continued to demonstrate no evidence of infiltrate. In addition,
the patient developed a rash that was thought to be consistent
with drug rash. All antibiotics were discontinued on [**9-16**] given
lack of clinical findings c/w pneumonia and given possible drug
rash/fever. He subsequently remained afebrile off antibiotics
for the next week. His rash subsequently resolved as well, with
suspected [**Last Name (un) **] to Zosyn (no respiratory compromise, no hives).
His respiratory status improved and he was able to maintain O2
sats >93% on 35% trach collar and off ventilation assistance
completely. Given his subsequent improvement without continued
antibiotics, the thought was that he was likely to have
pneumonitis rather than a new pneumonia.
His WBC count remained stable at 9-10 over the following week
off antibiotics. However, on [**9-28**], his WBC count increased to 18
with 3% bands. He remained afebrile, but he was noted to have
increased thick yellow sputum production. Repeat CXR
demonstrated evidence of a right lower lobe pna vs atelectasis.
Therefore he was re-started on antibiotics on [**9-28**] with Vanco
and Cefipime. However, he subsequently had resolution of his WBC
count the following day [**9-29**] (WBC =9, with 0 bands) and
antibiotics were discontinued. A new infection was thought to be
unlikely as he quickly recovered and remained afebrile and
clinically stable throughout the remainder of his course. On
discharge he is off all antibiotics and is afebrile with stable
respiratory status.
1a. Cricothyroid Muscle spasms: Given his recurrent aspirations
and secondary aspiration pnuemonitis/pneumonia he was evaluated
further by the speech and swallow service. Evaluation
demonstrated that he had paroxysmal cricothyroid muscle spasms
leading to aspiration. Spasm was noted to occur despite multiple
preceding normal swallows were documented. In addition he was
noted to have absent cough reflex. These spasms were thought to
be the likely etiology of his aspirations. In addition, GERD was
thought to be exacerbating his symptoms, with noted epiglottic
edema. Manometry [**9-27**] demonstrated no evidence of UES
dysfunction or spasm (over [**2-28**] swallows). However,there was
still concern over paroxysmal muscle spasm. Therefore he
underwent EGD w/dilatation of his UES on [**9-28**]. However, repeat
video swallow study on [**9-29**] demonstrated continued aspiration of
thin liquids with intermittent esophogeal spasms (please obtain
online medical record for full report). There was also noted
difficulty initating swallow. After consultation, we decided to
pursue conservative management of this problem. It is unclear
whether botox injections to his CM muscle would help at this
time. Therefore, we have resumed a diet of thickened liquids
with strict aspiration precautions, including maintaing the chin
down in postition while swallowing. He has tolerated thickened
liquids quite well and has had no evidence of pneumonia. If he
subsequently has reccurrent aspiration pneumonitis or pna, he
may follow-up with Dr. [**Last Name (STitle) 952**] for potential botox injection. He
has follow-up scheduled for [**2174-10-18**] for initial visit w/ Dr.
[**Last Name (STitle) 952**].
**He should have a repeat video swallow study to evaluate for
aspiration and potential advancement of diet.
2. Hyper/Hyponatremia: Over the course of his hospital stay,
Mr. [**Known lastname 37779**] had brittle sodium levels. His difficult sodium
balance was secondary to his central diabetes insipidus in the
setting of decreased PO intake (nutrition was given per tube
feeds). He does have an intact thirst reflex, however PO's were
initially held in the setting of his known aspiration risk. In
the ICU he developed hypernatremia with Na levels up to the
150's, treated with free water flushes. In addition he was
continued on his DDAVP (desmopressin) at 1.0mcg IV BID + and
additional mid-day dose at 0.5mcg. However, he subsequently
developed hyponatremia w/ Na down to 123. He remained
asymptomatic without seizure. His free water flushes were held
in addition to his DDAVP in setting of hyponatremia. He
persisted to have very brittle sodium control, with return of
sodium to 149. He was re-started on DDAVP at 1.0mcg IV BID. This
regimen lead to good sodium control. Of note, since he started
taking in PO's, he has been drinking thickened water,resulting
in sodium fall to 139. However, we do not want to discourage his
PO intake, so instead we have decreased his DDAVP dose. On
discharge we have him on 0.5mcg IV morning dose and 1.0mcg IV
evening dose.
3. Epilepsy: Continued on Dilantin with seizure precautions.
Dosed by levels. [**10-4**] dilantin level was 20.9, so we decreased
dilantin to 200mg [**Hospital1 **].
4. Hypothyroidism: Continued on Synthroid.
5. DMII- insulin dependent: Followed by [**Last Name (un) **] in the hospital.
He also was noted to have brittle diabetes with blood sugars
fluctuating from low's of 40's-50's with highs up to the 300's.
Eventually, he was able to be maintatined with good glycemic
control on the regimen as follows: NPH insulin 30qam/25qhs +
sliding scale humalog.
6. Anemia/Thrombocytopenia: Both stable, initially down from
admission. Concern for HIT/Zosyn-related low platelets. HIT
negative. Plts have since recovered; HCT stable.
7. FEN: Probalance Full strength via PEG. In addition, we would
recommend a calorie count if he continues to take in significant
PO's, since he may not need continued full strength tube feeds.
8. Allergic Derm Rxn: On [**9-11**] had fever,blanching erythematous
rash with non-blanching 1/2 mm papules. The rash abatted in
<2hrs after Benadryl IV. He was also given Albuterol Nebs, but
had no dyspnea. He has had resolution of his rash off of
antibiotics, with no current fever, so leading diagnosis is drug
rash/fever, likley secondary to Zosyn. Of note, he did not
develop rash on Cefipime.
9.Conjunctivitis: [**Month (only) 116**] be related to drug reaction. We do not
have high clinical suspicion that this is a bacterial
conjunctivitis, however have treated with erythromycin eye drops
for a 6 day total course. Clinically resolving.
10. Anxiety: On Ativan 2-4mg PO/IV q6h PRN. Paroxetine 30qday.
Trazadone prn at night.
Medications on Admission:
meds on tx from rehab: NPH 36 U qam/10qpm, DDAVP 1mcg IV BID,
0.5 mcg at 2pm, Zosyn 4.5gm IV q8 (day # 14),Caspofungin (day #
14), Amakacin 375mg IV q12, Dilantin 100mg PO BID, Mag Gluconate
1000mg TID, Protonix 40mg PO QD, Bactrim DS 1 tab po bid (day
#14), Linezolid 600mg PO BId, Synthroid 150 mcg PO Qday, haldol
5mg q 2-4 hours prn, Ativan 1-2 mg q 4-6 hrs prn, colace 100mg
PO TID
Discharge Medications:
1. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO QD
().
2. Phenytoin 100 mg/4 mL Suspension Sig: Two (2) PO twice a
day.
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Desmopressin Acetate 4 mcg/mL Solution Sig: One (1) mcg
Injection qpm.
12. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: One (1)
units Subcutaneous as scheduled: NPH 30 Units qam
NPH 25 Units qhs.
13. DDAVP 4 mcg/mL Solution Sig: 0.5 mcg Injection qam.
14. Lorazepam 1 mg Tablet Sig: 2-4 Tablets PO Q4-6H (every 4 to
6 hours) as needed for agitation.
15. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed.
16. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID
(4 times a day) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Aspiration pneumonitis
[**Location (un) **] (DIDMOAD) syndrome
Drug fever- secondary to Zosyn
Diabetes II-insulin requiring
Hyper/Hyponatremia
Discharge Condition:
Good. HD stable. Off vent dependence. Afebrile. No evidence of
pneumonia. Able to take in pre-thickened liquids while on strict
aspiration precautions.
Discharge Instructions:
Call your doctor if you experience fever greater than 100.4,
shaking chills, seizure, shortness of breath or worsening cough.
[**Hospital1 **]: Please do a repeat Video Swallow study to evaluate
for aspiration and potential advancement of diet. thank you.
Followup Instructions:
1. Pleae follow-up with Dr. [**Last Name (STitle) 952**] on [**2174-10-18**] at 1pm:
[**Hospital1 69**]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 170**]
2. If you would like to f/u with podiatry, you may call to
schedule an appt at [**Telephone/Fax (1) 543**]
ICD9 Codes: 5070, 2875, 2760, 2761, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1755
} | Medical Text: Admission Date: [**2175-10-30**] Discharge Date: [**2175-11-8**]
Date of Birth: [**2115-8-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
mental status change
Major Surgical or Invasive Procedure:
Incision and drainage of right groin abscess
History of Present Illness:
60 YO M w CHF, distant MI, VT s/p pacer/ICD/VT ablation who
presented with cloudy thinking and dizziness for 1 week in the
setting of polydypsia and polyuria.
.
Symptoms started about 1 week prior to presentation the [**Hospital1 18**],
with anorexia and sleeping constantly, followed by incontinence,
weakness, and dizziness. 2 days prior to admission, his wife
noted that he became disoriented, which persisted until the day
of admission, which was Monday evening [**10-30**], when the patient
requested to be taken to the hospital. He was transported by
Ambulance because he felt unable to make it down the stairs with
assistance only from his wife. [**Name (NI) **] never lost consiousness. Of
note, he did not take any of his medications the weekend prior
to admission because he dropped his pill box and his wife did
not know his usual regimen.
.
In the ED, he was noted to have a BS of >800, creat 2.8 (from
1.5) with a gap but no ketones. He was given levaquin and
admitted to the ICU for insulin gtt which was stopped within
24h. [**Last Name (un) **] was consulted and recommended starting lantus and
humalog. His BS decreased to 100s-200s but then his BS increased
to 300s on MICU day 2, [**11-1**], so his glargine was increased and
his humalog sliding scale was titrated up. His mental status
improved back to his baseline with improvement in his BS.
.
The patient has a known sacral decubitus ulcer, which he has had
for 3 weeks. He had no signs or symptoms of infection per his
wife - no fever, chills, cough, abdominal pain, diarrhea,
dysuria.
.
Never diagnosed with diabetes. Does not take diabetes
medications at home.
Past Medical History:
CAD s/p inferoposterior MI with PTCA [**2159**], [**2173**]
Dyslipidemia
Hypertension
Chronic Systolic Heart Failure, EF 25-30%.
Nonsustained ventricular tachycardia with ICD [**8-/2170**]
S/p VT ablation [**4-/2174**]
Hypertension
Hyperlipidemia
Obstructive sleep apnea
H/o vitamin B12 deficiency
Nephrolithiasis
Peripheral neuropathy
Remote history of peptic ulcer disease
GERD
Status post tonsillectomy and adenoidectomy.
Social History:
lives with wife, works part time in computer, quit smoking
couple months ago and uses an electronic tobacco relacement,
denies ETOH/IVDU
Family History:
Father - atrial fibrillation
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Otherwise non-contributory
Physical Exam:
VSS 98 74 97/54 25 96% 2L
GEN: Alert, oriented to person, place, but not time. Poor
attention - able to count 10 to 1, but not months of year.
HEENT: PERRLA. MMM. no LAD. neck supple.
Cards: Quiet heart sounds. Limited auscultory exam. Pulse
regular.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: Protuberant obese abdomen. NT, +BS. no rebound/guarding.
neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL.
*Sacral Decubitus Ulcer: Erythematous gluteal cleft with
erosions to subcutaneous tissue
*Groin Rashes: Right > Left crural rashes, with R > L edema and
warmth
Brief Hospital Course:
60-year-old male with hx of CHF (EF 40%), MI [**2159**], paroxysmal
ventricular tachyarrhythmia s/p pacemaker/ICD placement and VT
ablation in [**4-/2174**] presenting with altered mental status in
setting of severe hyperglycemia.
.
#Hyperosmolar hyperglycemic non-ketotic coma (HHNK):
Pt did not have diagnosis of DM on admission. Pt presented with
altered mental status and labs concerning for HHNK - blood
glucose [**Telephone/Fax (1) 62434**] glucose in UA, anion gap of 18, with absence
of ketones in urine favoring HHS over DKA. A1c on [**1-/2175**] was
6.5; A1c on admission was 13.3. The patient was placed on an
insulin drip for approximately 90 minutes. [**Last Name (un) **] Diabetes
Center was consulted and he was transitioned to a Lantus +
Humalog insulin sliding scale regimen and aggressively volume
resuscitated with 4L NS. Hyperglycemia rapidly improved and gap
closed. His lantus was gradually titrated to 30 units [**Hospital1 **] with
appropriate sliding scale with good glycemic control. In the
setting of WBC of 20 on admission, the trigger of the HHNK was
thought to be infectious with the source ultimately found to be
a right groin cellulitis as detailed below. Other infectious
etiologies were considered, but the work-up was negative, with
CXR showing no consolidation, and UA/UC negative.
.
#Right groin ulcer:
Right groin ulcer identified upon physical exam following
transfer from ICU. Evaluated by surgery who ultimately
performed I&D, recovering necrotic tissue that ultimately
cultured Staph Aureus and coagulase negative Staph sensitive to
Bactrim. Treated with IV Vancomycin and Zosyn for a total
course of 14 days and transitioned to Bactrim prior to
discharge.
.
#Hyponatremia:
Na 119 on admission due hyperglycemia. Normalized with treatment
of HHNK.
.
#Altered mental status:
Altered mental status was most likely secondary to HHNK. With
resolution of HHNK, mental status cleared markedly and pt was
oriented x 3 and answered questions appropriately once
transferred to the floor.
.
#Acute renal failure:
Cr was 2.8 on admission, up from 1.5 one month prior. Initially
acute renal failure was believed to be prerenal as pt appeared
severely volume depleted. Cr continued to rise, peaking at 3.6,
despite IV hydration. In setting of elevated CKs, acute renal
failure was attributed to rhabdomyolysis for which he was given
additional IV hydration, although this rise in CK was ultimately
attributed to a significant right groin abscess. Nephrotoxic
meds, including his home lasix, allopurinol, diovan and
spironolactone, were held during the majority of his hospital
course. As the patient recovered from his HHNK, his renal
function improved markedly to a creatinine of 1.8. He was
eventually restarted on his lasix and discharged on his home
regimen of allopurinol, diovan, and spironolactone.
.
#Anemia, guiac positive stool (OUTPATIENT FOLLOW-UP REQUIRED)
The patient had an initial Hgb of 14 and Hct of 40.1 on the day
of admission [**10-30**]. Over the next three days he developed a
slight anemia that remained stable at approximately Hgb 10 Hct
29 for the remaining five days of his administration. This was
attributed to anemia of inflammation. He did have one episode
of blood stained stool, and was guiac positive. Upon interview
the patient attributed this to a known history of hemorrhoids.
Given his age, however, outpatient colonoscopy is still
appropriate to work up his anemia and bloody stool. The patient
has otherwise been asymptomatic with regard to this anemia.
.
#Depression:
The patient has a history of depression, and his daughter
expressed concern near the end of his hospitalization that he
may try to harm himself. The patient denied suicidal ideation
and made no concerning statements during his hospital course.
He was seen by psychaitry, who cleared him for discharge and
confirmed no suicidal ideation.
.
#Chronic Systolic CHF, LV aneurysm, INR:
Pt with hx of systolic CHF with EF 40% on TTE. He required IV
hydration for both HHS and initial concern for rhabdomyolysis
but this was given judiciously given his reduced EF. TTE was
obtained that showed unchanged EF of 40% and mid inferior and
inferolateral akinesis which had previously been hypokinetic on
TTE from [**3-/2175**]; there was also an inferobasal left ventricular
aneurysm. Lasix was held due to acute renal failure until late
in his hospitalization but restarted several days prior to
discharge in the setting of dependent pitting edema. On
discharge, lungs were clear to auscultation and the patient was
clinically mildly hyper- to eu-volemic. Per OMR records, pt had
been started on coumadin after ablation for LV aneurysm. INR was
supratherapeutic 2 days prior to discharge in the setting of
antibiotics; coumadin was held for 1 day then restarted; the
patient was discharged on a lower dose than his prescribed 5mg
daily. **His INR will need to be followed-up and coumadin
redosed 2-3 days after discharge.**
.
#CAD:
Pt with extensive cardiac comorbidities, including CAD, CHF (EF
40%), prior MI, and paroxysmal ventricular tachyarrhythmia. MI
was considered as a possible etiology for his acute
hyperglycemic presentation. EKG was grossly unchanged with new
T wave inversions in V2-3. Troponin was elevated to 0.03 on
admission but this was in setting of acute renal failure. CK
was elevated to 600s on admission and increased to [**2165**] for
reasons discussed above. As TTE was grossly unremarkable,
suspicion for MI was low. He was continued on his aspirin;
statin was held due to elevated CKs in the setting of initial
concern for rhabdomyolysis and restarted on discharge.
.
#Paroxysmal Ventricular tachyarrhythmia:
Patient was s/p ablation and s/p pacer/ICD. Monitored on tele
for the duration of the hospitalization with no episodes of VT
or defibrillation.
.
#Hypothyroidism:
Pt had history of hypothyroidism and had been started on
levothyroxine as outpatient. He was treated with levothyroxine
and his TSH remained normal. He reported noncompliance with
levothyroxine. **[**Last Name (un) **] diabetes consult recommended thyroid
function tests as outpatient.**
.
Remained full code for the duration of the hospitalization.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
AMIODARONE - 200 mg Tablet - 2 Tablet(s) by mouth daily
CALCITRIOL - 0.25 mcg Capsule - one Capsule(s) by mouth every
other day
CARVEDILOL - 12.5 mg Tablet - 1 Tablet(s) by mouth twice a day
VITAMIN D 400 UNITS - - take 1 tablet by mouth twice a day
DULOXETINE [CYMBALTA] - 60 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth once a day
FUROSEMIDE - 40 mg Tablet - one and [**1-7**] Tablet(s) by mouth twice
a day
GABAPENTIN [NEURONTIN] - 300 mg Capsule - as directed Capsule(s)
by mouth 2 TID and 3 qhs
HYDROMORPHONE [DILAUDID] - 4 mg Tablet - 1 Tablet(s) by mouth
four times a day as needed for for pain
LORAZEPAM [ATIVAN] - 0.5 mg Tablet - [**1-7**] Tablet(s) by mouth at
bedtime
NIACIN [NIASPAN] - 500 mg Tablet Sustained Release - 1 Tablet(s)
by mouth once a day
NITROGLYCERIN - 0.3 mg Tablet, Sublingual - 1 Tablet(s)
sublingually q3 minutes as needed for chest pain
OXYCODONE - 5 mg Tablet - [**1-7**] Tablet(s) by mouth four times a
day
as needed for for nueropathy
PRAMIPEXOLE - 0.25 mg Tablet - 1 Tablet(s) by mouth once a day
ROSUVASTATIN [CRESTOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day
SPIRONOLACTONE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth
once a day
VALSARTAN [DIOVAN] - 40 mg Tablet - 1 Tablet(s) by mouth once a
day
WARFARIN - 5 mg Tablet - [**1-7**] Tablet(s) by mouth once a day as
[**Name8 (MD) **]
MD [**First Name (Titles) **] [**Last Name (Titles) 62435**]IN [JANTOVEN] - 2 mg Tablet - [**2-8**] Tablet(s) by mouth once
a
day
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
B COMPLEX VITAMINS [B-50] - Tablet - 1 Tablet(s) by mouth once
a day
CALCIUM CARBONATE - 500 mg (1,250 mg) Tablet - 1 Tablet(s) by
mouth twice a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
ERGOCALCIFEROL (VITAMIN D2) - 400 unit Capsule - 1 Capsule(s) by
mouth once a day
MAGNESIUM - (Prescribed by Other Provider) - 250 mg Tablet - one
Tablet(s) by mouth once a day
OMEGA-3 FATTY ACIDS-VITAMIN E [OMEGA-3 FISH OIL] - (Prescribed
by Other Provider) - 1,000 mg-5 unit Capsule - 1
SENNA - 8.6 mg Capsule - 1 Capsule(s) by mouth twice a day as
needed for constipation
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
4. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO three times
a day.
9. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
10. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for pain.
11. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime.
12. niacin 500 mg Tablet Sig: One (1) Tablet PO once a day.
13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
14. pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO daily ().
15. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
17. valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
21. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
22. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
23. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
24. ergocalciferol (vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
25. magnesium 250 mg Tablet Sig: One (1) Tablet PO once a day.
26. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1)
Capsule PO once a day.
27. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
28. insulin lispro 100 unit/mL Insulin Pen Sig: Two (2) units
Subcutaneous four times a day: According to scale.
Disp:*440 units* Refills:*2*
29. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Thirty
(30) units Subcutaneous twice a day: Before breakfast and before
bedtime.
Disp:*1800 units* Refills:*2*
30. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
31. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
Disp:*500 grams* Refills:*2*
32. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
33. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for itching.
Disp:*1 tube/unit* Refills:*0*
34. Kerlex Sig: One (1) Sterile dressing twice a day: Twice
daily dressing changes for right groin wound.
Disp:*60 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Diabetes Mellitus II
Hyperosmolar Hyperglycemic Non-Ketotic coma (HHNK)
Right groin abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
1. Be sure to attend your follow-up appointment with your
primary doctor Dr. [**Last Name (STitle) 4922**] on Tuesday [**2175-11-14**] at 10:45 AM.
You have some new medications and will need to make changes to
how you take care of yourself to prevent future episodes like
this, and your primary doctor will be the best person with which
to discuss these issues.
Location: [**State **] ([**Location (un) **], MA) [**Location (un) **]
2. Be sure to attend your appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9978**] at
the [**Last Name (un) **] Diabetes Center on Thursday, [**2175-11-9**] at 9 AM for
your continued diabetes care.
Location: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
3. Be sure to attend your appoint with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] at
[**Hospital1 **] Surgical Specialties for continued care of your right groin
wound on Monday, [**11-13**] at 3:30 PM.
Location: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
ICD9 Codes: 4280, 5859, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1756
} | Medical Text: Admission Date: [**2101-2-4**] Discharge Date: [**2101-3-12**]
Date of Birth: [**2101-2-4**] Sex: F
Service: NEONATAL
HISTORY: Baby Girl [**Known lastname 174**] is the 1445 gram product of a 33
week gestation born to a 32 year old Gravida 2, Para 0
mother. Serology was A positive, antibody positive (DAT
positive, antiwarm autoantibody). Hepatitis B surface
antigen negative. RPR nonreactive. Rubella immune. GBS
unknown.
Maternal history was significant for chronic hypertension
since [**15**] years of age maintained on Aldomet 500 mg p.o. four
times a day; asthma maintained on inhaler p.r.n.; pulmonic
stenosis, mitral valve prolapse requiring antibiotic
prophylaxis.
PAST SURGICAL HISTORY:
1. Breast reduction in [**2093**].
2. Tonsillectomy in [**2094**].
MATERNAL MEDICATIONS:
1. Aldomet.
2. Labetalol.
ALLERGIES: Maternal allergies include penicillin,
tetracycline, Vancomycin (red man's syndrome).
COMPLICATIONS: This pregnancy was complicated by underlying
chronic hypertension. On [**1-25**] she presented with
bloody spotting. Evaluation was benign.
She presented on day of delivery with increased hand and
pedal edema for past few days. No signs or symptoms or
laboratory evidence of pre-eclampsia.
Fetal biophysical profile was 8 out of 8, however, monitoring
also revealed possible intrauterine growth restriction with
an estimated weight in the 3rd percentile. In addition,
oligohydramnios with an AFI of 3.0, also nonreassuring fetal
heart rate pattern with fetal decelerations. Given noted
concerns infant delivered by cesarean section.
At delivery infant emerged with good color, tone and
spontaneous respirations. Dry bulb suctioned and stimulated
and provided brief blow-by O2. The infant responded well
with Apgar's of 9 and 9 and was transported to the Newborn
Intensive Care Unit for further management or prematurity.
PHYSICAL EXAMINATION: On admission, birth weight was 1455,
10th to 25th percentile. Length 38-3/4, 10th percentile.
Head circumference 28 centimeters, 10th percentile. Anterior
fontanel open and flat. Palate intact. General appearance:
Small for gestational age. Lungs with fair to good aeration,
equal but with fine crackles bilaterally. Normal S1, S2, no
audible murmur. Abdomen benign. No hepatosplenomegaly.
Three vessel cord. Normal external female genitalia
appropriate for gestational age. Hips stable. Spine intact.
Moves all extremities well.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: [**Known lastname 12536**] has remained stable on room air
throughout hospitalization. Had a brief period of apnea of
bradycardia with the most recent apnea spell on [**2101-3-2**]. She did not require any methylxanthine therapy. Her
most recent desaturation was associated with Nystatin oral
solution and it was self resolved. That was on [**2101-3-7**].
2. CARDIOVASCULAR: The infant has been cardiovascularly
stable throughout the hospital course. She was noted to have
an intermittent murmur which has since resolved. No further
issues.
3. Fluids, Electrolytes and Nutrition: Birth weight was
1445. Discharge weight is 2410 grams . The infant
was initially started on 80 cc. per kilo per day of D10W.
Enteral feedings started on day of life number one. The
infant achieved full enteral feedings by day of life number
three. Maximum enteral intake is 150 cc. per kilo per day of
PE30 with ProMod. The infant is currently ad lib feeding.
NeoSure 26 calories, concentrated by NeoSure concentrated to
24 calories per ounce and 2 calories per ounce of corn oil
added.
5. GASTROINTESTINAL: Her peak bilirubin was on day of life
three of 6.9/0.2. The infant received phototherapy for a
total of three days and the issue has resolved.
6. HEMATOLOGY: Hematocrit on admission was 51. The infant
has not required any blood transfusions and her most recent
hematocrit was 32.6 with a reticulocyte count of 4.9% on
[**3-3**]. The patient's blood type is A negative and Coombs
negative.
7. INFECTIOUS DISEASE: A CBC and blood culture was obtained
on admission. The CBC was benign. Blood cultures remained
negative and the infant did not receive any antibiotics
during this hospitalization. Urine for CMV was sent and the
result was negative. The infant received Nystatin oral
solution for a total of five days for oral thrush. Nystatin
was discontinued on [**2101-3-11**].
8. NEUROLOGICAL: The infant has been appropriate for
gestational age. On day of life ten, head ultrasound
demonstrated a small germinal matrix hemorrhage. Follow-up
at 30 days of age on [**2101-3-8**], demonstrated a resolving
germinal matrix with a recommended follow-up in two to four
weeks with another head ultrasound. The infant has been
appropriate for gestational age.
9. SENSORY: Audiology: Hearing screen was performed with
automated auditory brain stem responses and the infant passed
both ears.
10. OPHTHALMOLOGY: The patient has been most recently
examined on [**2101-3-7**], by Dr. [**Last Name (STitle) 36137**] from [**Hospital3 18242**] revealing mature retina bilaterally. Recommended
follow-up at eight months of age.
11. PSYCHOSOCIAL: A Social Worker has been involved with the
family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISPOSITION: To Home.
PRIMARY PEDIATRICIAN. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] from [**Location (un) 1468**].
Telephone number [**Telephone/Fax (1) 38385**].
MEDICATIONS:
1. Fer-In-[**Male First Name (un) **] Supplementation of 2 mg per kg per day.
Car seat position screening test was performed on the infant
State newborn screens have been sent for protocol and have
been within normal limits.
IMMUNIZATIONS: The patient infant received hepatitis B
vaccine on [**2101-2-1**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV Prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants that meet
any of the three criteria: 1) Born at less than 32 weeks; 2)
born between 32 and 35 weeks with plans for day care during
RSV season, with a smoker in the household, or with preschool
siblings or 3) with chronic lung disease.
FOLLOW-UP INSTRUCTIONS:
1. Recommend Ophthalmology with Dr. [**Last Name (STitle) 36137**] at [**Hospital3 18242**] at eight months of age for Ophthalmology follow-up.
2. Recommend head ultrasound in two to four weeks to follow
resolving germinal matrix bleed.
DISCHARGE DIAGNOSES:
1. Premature female born at 33 weeks gestation, corrected to
37-1/7 weeks gestation.
2. Status post rule out sepsis.
3. Status post mild apnea and bradycardia of prematurity.
4. Status post oral thrush.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (un) 48948**]
MEDQUIST36
D: [**2101-3-11**] 18:20
T: [**2101-3-11**] 21:07
JOB#: [**Job Number 48949**]
1
1
1
DR
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1757
} | Medical Text: Admission Date: [**2186-10-30**] Discharge Date: [**2187-11-8**]
Date of Birth: [**2187-10-30**] Sex: M
Service: NEONATOLOGY
HISTORY: [**Known lastname **] [**Known lastname 5395**] was born at 35 weeks gestation to a
35-year-old gravida II, para 0 now I woman by cesarean
section for breech presentation and pregnancy-induced
hypertension. The mother's prenatal screens were blood type
A positive, antibody negative, rubella immune, RPR
strep unknown. This pregnancy was complicated by gestational
diabetes diet controlled, and increased blood pressure
beginning at 26 weeks gestation. The mother was treated with
magnesium sulfate prior to delivery for worsening blood
pressures. The infant emerged with spontaneous respirations
and good cry. Apgars were 8 at one minute and 9 at five
minutes.
The infant's birth weight was 2500 grams, birth length 48 cm,
and birth head circumference 33 cm.
PHYSICAL EXAMINATION: Reveals a premature, non-dysmorphic
infant, anterior fontanel soft and flat, positive bilateral
red reflex, palate intact. Positive grunting, flaring and
retracting with scattered inspiratory crackles throughout the
lung fields. A Grade III/VI systolic ejection murmur at the
left lower sternal border, femoral and brachial pulses +2 and
equal, and a normal split S2. Soft abdomen, no
hepatosplenomegaly, testes descended bilaterally, patent
anus, intact spine, negative hip examination and a nonfocal
neurological examination.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant developed grunting, flaring and
retracting at about one-half hour of age, and so was admitted
to the Newborn Intensive Care Unit. He required
nasopharyngeal continuous positive airway pressure for the
first 48 hours of life, and then weaned to room air, where he
has remained. He does have some episodes of bradycardia and
desaturation with oral feedings, felt to be due to immature
suck, swallow and breathing reflex. On examination, his
respirations are comfortable. Lung sounds are clear and
equal.
2. Cardiovascular: At the time of admission, he did have a
Grade III/VI systolic murmur. He had a cardiac evaluation.
An electrocardiogram was within normal limits. He passed a
hyperoxia test, and the murmur was resolved by 24 hours of
age. He has remained normotensive throughout his Newborn
Intensive Care Unit stay, and there are no further
cardiovascular issues.
3. Fluids, electrolytes and nutrition: Enteral feeds were
begun on day of life number two, and advanced without
difficulty to full volume feeding by day of life five. The
infant is taking Enfamil 20 or breast milk and breast feeding
at total fluids of 150 cc/kg/day. He is requiring
approximately half of those feedings by gavage. He continues
to have incoordinated feedings. He initially required some
intravenous dextrose for some hypoglycemia, which resolved
within the first few hours after admission to the Newborn
Intensive Care Unit, and he has remained euglycemic since
that time.
4. Gastrointestinal: The infant never required any
phototherapy. His peak bilirubin occurred on day of life
number five, and was total 8.7, direct 0.2.
5. Genitourinary: The infant was circumcised on [**2187-11-7**]
without complications.
6. Hematology: The infant has never received any blood
product transfusions during his Newborn Intensive Care Unit
stay. His hematocrit at the time of admission was 46.2, and
the platelets were 103,000.
7. Infectious Disease: The infant was started on ampicillin
and gentamicin at the time of admission for sepsis risk
factors. The antibiotics were discontinued after 48 hours
when the infant was clinically well and the blood cultures
remained negative. He has received no further antibiotics.
8. Sensory: Audiology: Hearing screening was performed
with automated auditory brain stem responses, and the infant
passed in both ears.
9. Psychosocial: The parents have been visiting during his
Newborn Intensive Care Unit stay, and are very involved in
the infant's care. They are very pleased with the transfer
to a hospital closer to home.
CONDITION ON DISCHARGE: The infant is being discharged in
good condition.
DISCHARGE STATUS: The infant is being transferred to
[**Hospital3 **] Level II Nursery for continuing care.
PRIMARY PEDIATRIC CARE: Will be provided by [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 47323**],
M.D.
CARE RECOMMENDATIONS:
1. Feedings: Breast milk or Enfamil 20 calories/ounce at
150 cc/kg/day.
2. Medications: The infant is on no medications.
3. A car seat position screening test has not yet been done
and is recommended prior to discharge.
4. A state newborn screen was sent on [**2187-11-2**].
5. Immunizations received: The infant has received his
first hepatitis B vaccine on [**2187-11-6**].
6. Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation; (2) Born
between 32 and 35 weeks, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
Influenza immunization should be considered annually in the
fall for pre-term infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSIS:
1. Prematurity, 35 weeks
2. Status post transient tachypnea of the newborn due to
retained fetal lung fluid
3. Sepsis ruled out
4. Infant of a diabetic mother
5. Immature suck/swallow reflex
6. Status post circumcision, [**2187-11-7**]
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2187-11-8**] 03:28
T: [**2187-11-8**] 04:12
JOB#: [**Job Number 47324**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1758
} | Medical Text: Admission Date: [**2196-11-14**] Discharge Date: [**2196-11-19**]
Service: NEUROSURGERY
Allergies:
Sulfonamides / Epinephrine / Diltiazem / Pletal
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Depressed Mental status
Major Surgical or Invasive Procedure:
Left Craniotomy for SDH evacuation
History of Present Illness:
86 y/o female with history of afib on Coumadin. Ms [**Known lastname 97533**]
was with her son yesterday and fell getting bundles out of her
car. She hit her head on the pavement and did not have a loss of
consciousness. She was able to do her normal activities she went
to bed last night and her son attempted to arrouse her at 2am
for
which he stated "she did not fully awake" this morning when his
mother did not wake up he found her in her room and was able to
minimally arrouse her. She was brought by ambulance here.
Past Medical History:
Atrial fibrillation, Diabetes, HTN, Menieres Disease, S/P
multiple falls recent radius/humeral fractures.
Social History:
Retired nurse, lives with son, non [**Name2 (NI) 1818**], no alcohol
Family History:
NC
Physical Exam:
O: T: BP:169/78 HR:80 R17 O2Sats 100%
Gen: Seen prior to intubation, [**Name (NI) 91248**] respirations, no
commands
HEENT: Pupils: surgical bilateral 2mm
Neck: In collar
Neuro:
Does not follow commands
Does not open eyes
Extensor postures in upper extremities will slightly withdraw
legs left greater than right
Face symmetric
Toes mute
Normal tone
Difficult to obtain any reflexes most likely hyporeflexic and
symmetric
Pertinent Results:
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 97534**],[**Known firstname **] [**2109-12-5**] 86 Female [**-8/4553**]
[**Numeric Identifier 97535**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd
SPECIMEN SUBMITTED: left subdural hematoma, left subdural
hematoma.
Procedure date Tissue received Report Date Diagnosed
by
[**2196-11-14**] [**2196-11-14**] [**2196-11-17**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
Previous biopsies: [**Numeric Identifier 97536**] EGD (3).
[**Numeric Identifier 97537**] (Not on file)
DIAGNOSIS:
Left subdural hematoma:
Blood clot.
Clinical: Left subdural hematoma.
Gross:
The specimen is received fresh in a container labeled with the
patient's name, "[**Known lastname 97533**], [**Known firstname **]", and the medical record number
and additionally labeled "left subdural hematoma". It consists
of a blood clot measuring 6 x 2 x 0.2 cm. Representative
sections are submitted in cassette A.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Cardiology Report ECG Study Date of [**2196-11-14**] 9:15:36 AM
Sinus rhythm. Left atrial abnormality. Left ventricular
hypertrophy with
ST-T wave abnormalities. Since the previous tracing of [**2196-5-4**]
further
ST-T wave changes are present.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 180 78 [**Telephone/Fax (2) 97539**]0
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2196-11-14**]
9:22 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2196-11-14**] 9:22 AM
CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 97540**]
Reason: fx, dislocation
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall and ams
REASON FOR THIS EXAMINATION:
fx, dislocation
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: LLTc MON [**2196-11-14**] 10:47 AM
NO acute fx or malalignment.
Final Report
INDICATION: 86-year-old female status post fall with acute
mental status
changes.
TECHNIQUE: CT of the C-spine without IV contrast.
COMPARISON: MR of the C-spine available from [**2191-6-5**].
FINDINGS: There are no acute fractures or traumatic
malalignment. There is
mild straightening of lordosis, consistent with the presence of
cervical
collar. There are moderate to severe degenerative changes
throughout the
cervical spine, including severe facet arthropathy, and loss of
intervertebral disc space, most severely at C5 through T1. There
is grade 1 anterolisthesis of C4 over C5. Diffuse disc bulging
is present at C5-C6 and C6-C7, resulting in moderate spinal
canal stenosis, most severely at C5-C6.
There is no prevertebral hematoma or adjacent soft tissue
abnormalities.
Included views of the lungs demonstrate mild dependent
atelectasis
bilaterally. There are multiple nodules within the slightly
enlarged right
thyroid lobe.
IMPRESSION:
1. No acute fractures or traumatic malalignment.
2. Moderate-to-severe degenerative changes throughout the
cervical spine,
most severely at C5-C6, with associated moderate spinal canal
stenosis.
3. Multiple right thyroid nodules.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2196-11-14**]
9:22 AM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2196-11-14**] 9:22 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 97541**]
Reason: ICH
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall and AMS
REASON FOR THIS EXAMINATION:
ICH
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: LLTc MON [**2196-11-14**] 10:44 AM
Left subdural hematoma with mixed hyperdensity, concerning for
active bleed, tracking along the left convexivity and left
tentorium.
Rightward shift of midline structures up to 17 mm, with
significant
effacement of the left lateral ventricle. Dilated temporal [**Doctor Last Name 534**]
of right
lateral ventricle concerning for early hydrocephalus.
Rightward subfaclcine herniation. Early righward uncal
herniation.
Final Report
INDICATION: 86-year-old female status post fall and acute mental
status
changes.
TECHNIQUE: CT of the head without IV contrast.
COMPARISON: CT of the head available from [**2193-12-12**].
FINDINGS:
There is a large left cerebral subdural hematoma, measuring up
to 17 mm in
thickness, with blood tracking along the left tentorium. There
is significant neighboring mass effect on left cerebral sulci
and the left lateral ventricle with subfalcine herniation and
17-mm rightward shift of normally midline structures. The
hematoma has mixed hyper and hypoattenuating components,
consistent with an acute on chronic bleeding. There is slight
effacement of the suprasellar cistern, concerning for an early
rightward uncal herniation. Slight hyperattenuation along the
suprasellar cistern borders may represent trace subarachnoid
blood. The quadrigeminal cistern is preserved but slightly
asymmetric. The right lateral ventricle is slightly effaced, and
the temporal [**Doctor Last Name 534**] is slightly dilated in comparison to the prior
CT exam from [**2193-12-12**], concerning for possible early
hydrocephalus.
Again, there is significant hypoattenuation of the
periventricular white
matter, consistent with chronic microvascular ischemic disease.
There are no acute fractures. There is a large subgaleal
hematoma overlying the left parietal and occipital regions, with
a more focal hyperattenuating region representing a more focal
hematoma. The middle ear cavities and included portions of the
mastoid air cells and paranasal sinuses are clear. The orbits
are symmetrical and intact.
IMPRESSION: Large acute left subdural hematoma with associated
mass effect, subfalcine herniation and left uncal herniation.
Findings were communicated with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at 10:45 a.m.
on [**2196-11-14**].
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 97538**] F 86 [**2109-12-5**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2196-11-15**]
2:09 PM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2196-11-15**] 2:09 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) **]
Reason: 86 year old woman with SDH, on coumadin. Eval for
interval c
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
REASON FOR THIS EXAMINATION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Addendum
Dedicated imaging of the intracranial arteries can be considered
with MRA.
DR. [**First Name (STitle) 10627**] PERI
Approved: [**Doctor First Name **] [**2196-11-17**] 11:04 AM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2196-11-15**] 2:09 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) **]
Reason: 86 year old woman with SDH, on coumadin. Eval for
interval c
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
REASON FOR THIS EXAMINATION:
86 year old woman with SDH, on coumadin. Eval for interval
change. ***PLEASE
INCLUDE DWI***
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: 86-year-old woman with subdural hematoma on
Coumadin, status post
evacuation. Evaluate for interval change.
COMPARISON: Multiple head CTs most recent of [**2196-11-14**].
TECHNIQUE: Sagittal T1 and axial fat-saturated T2, FLAIR,
gradient echo, and diffusion-weighted images were obtained of
the head.
FINDINGS: Multiple areas of restricted diffusion are noted,
consistent with acute infarcts in the left anterior, middle, and
posterior cerebral artery vascular territories. In addition,
areas of acute infarct are noted in the right anterior and
posterior cerebral artery vascular territories, involving the
right thalamus. There is no evidence of hemorrhagic
transformation of these infarcts. There is persistent rightward
shift of midline structures which has improved since the
previous study, now measuring approximately 6 mm down from 10
mm. Previously noted pneumocephalus is resolving. Residual left
subdural hemorrhage and intraparenchymal hemorrhage are again
seen, unchanged. The ventricles remain unchanged in size. The
major vascular flow voids appear
patent.
IMPRESSION:
Acute multi vascular territorial infarcts most pronounced in the
left
hemisphere, as described above. While these can relate to
compression of the arteries from the extensive SDH and mass
effect, embolic etiology is also in the differential diagnosis.
Findings were discussed with Dr. [**Last Name (STitle) **] [**Name (STitle) **] shortly after
review on [**2196-11-15**].
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Ms. [**Known lastname 97533**] arrived to the ED intubated for airway protection.
She recieved Profiline 9 and several units of FFp to reverse her
coagulopathy and went emergently for a left sided craniotomy for
SDH evacuation. Post operatively she was left intubated and
transferred to the Surgical intensive care unit.
Her exam never improved. She was followed clinically for the
next few days. An MRI was performed for prognostics. She was
made CMO after a family meeting. She later expired.
Medications on Admission:
Medications prior to admission: Amiodarone 200 QD, Carvedilol
25mg [**Hospital1 **], Metformin 500mg tid, pravastatin 10 at HS, Januvia 100
QD, and Coumadin
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Left sided Acute on Chronic SDH
Hyperglycemia
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2196-11-28**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1759
} | Medical Text: Admission Date: [**2151-1-4**] Discharge Date: [**2151-1-14**]
Service:
ADMISSION DIAGNOSES:
1. Coronary artery disease.
2. Aortic stenosis.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Aortic stenosis.
3. Status post coronary artery bypass graft times one with
saphenous vein graft and left radial artery composite, atrial
valve replacement with 19 mm [**Last Name (un) 3843**]-[**Known firstname **] valve.
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
man with known coronary artery disease. He reports having
shortness of breath with exertion since [**2148**], but this has
gotten worse over the past month. He states that he has
dyspnea after climbing one flight of stairs, with carrying
ten pound trash barrels. He denies any chest pain. He
denies claudication, orthopnea, paroxysmal nocturnal dyspnea,
edema or lightheadedness. The patient is now referred for
cardiac catheterization. A previous cardiac catheterization
had shown a 70% apical LAD lesion, 90% circumflex lesion with
a subtotally occluding OM2, a 40-80% proximal RCA lesion and
a 60% MRCA lesion. The patient had stenting of the OM1,
distal circumflex/OM3 and PTCA of the small OM2.
Persantine/Myoview in [**2150-7-26**] was negative for angina
and an uninterpretable EKG. Negative for perfusion defects
with a calculated ejection fraction of 50-55%.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Nonhealing left foot ulcer.
3. Nephrolithiasis.
4. Small bowel obstruction.
5. Left superficial femoral artery to posterior tibial
bypass [**2149-4-1**].
6. Vein patch angioplasty of bypass [**2150-8-13**].
7. Laparoscopic cholecystectomy [**2145**].
MEDICATIONS:
1. Accupril 10 mg q. day.
2. Lopressor 25 mg b.i.d.
3. Glucophage 1000 mg b.i.d.
4. Aspirin 325 mg q. day.
5. Insulin NPH 52 units q. a.m., 22 units q. p.m.
6. Insulin regular 8 units q. a.m.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient is an elderly gentleman in
no acute distress. Vital signs are stable, afebrile. HEENT
is atraumatic, normocephalic. Extraocular movements intact.
Pupils equal, round and reactive to light. Anicteric.
Throat is clear. Neck is supple, midline with no masses or
lymphadenopathy. Chest is clear to auscultation bilaterally.
Cardiovascular is regular rate and rhythm without murmur, rub
or gallop. Abdomen is soft, non-tender, non-distended
without mass or organomegaly. Extremities are warm,
noncyanotic, nonedematous. There are venous stasis changes
in the legs. The patient also has scars consistent with his
left SFA to PT bypass grafts. Neuro is grossly intact.
LABS ON ADMISSION: CBC: 9.4/12.2/35.9/159. Chemistries:
142/4.6/104/27/22/0.9. INR 1.1.
HOSPITAL COURSE: The patient was admitted for cardiac
catheterization which revealed calculated ejection fraction
of approximately 50% and normal wall motion. Findings showed
codominant coronary artery system with severe two vessel
coronary artery disease and severe aortic valve stenosis.
There was also found to be biventricular diastolic
dysfunction and moderate pulmonary hypertension. The patient
was recommended for urgent revascularization surgery.
On [**2151-1-5**], the patient was taken to the Operating
Room for coronary artery bypass graft times one with
composite saphenous vein graft of the left radial artery to
the left posterior descending artery, he also had aortic
valve replacement performed with a 19 mm pericardial
[**Last Name (un) 3843**]-[**Known firstname **] valve. The patient tolerated the
procedure well with no complications. On postoperative day
zero, the patient was transfused two units of packed red
blood cells for an hematocrit of 21.7 in the CSRU. The
patient was also noted to have increased chest tube outputs
for which he was given protamine, four units packed red blood
cells and two units of platelets. The patient remained
intubated and had very thick secretions which were frequently
suctioned. The patient was extubated on postoperative day
one, but reintubated subsequent to difficulty with
respiration. The patient was again extubated on
postoperative day two and seemed to tolerate this well.
Levophed and dobutamine were both weaned off. On
postoperative day four, the patient was transferred to the
floor without further complication. He was noted to be quite
edematous and his remaining hospital course essentially dealt
with his diuresis. He was initially found to be poorly
responsive to Lasix and his Lasix dose was increased to 8 mg
b.i.d. He remained unresponsive to this with only slightly
negative I&O balance. Chest x-ray showed the patient was
moderately wet and a bedside echocardiogram revealed that
there was a high transaortic gradient but no wall motion
abnormalities. Mild mitral regurgitation was also detected
at that time. Lasix was increased to 120 mg b.i.d. on
postoperative day seven and a formal echocardiogram was
performed. Formal echocardiogram again showed a high
transaortic gradient as well as very mild global hypokinesis
of the left ventricle. No focal wall motion abnormalities.
Aggressive diuresis was continued at 120 mg of Lasix p.o.
b.i.d. The patient responded to this well and had
improvement in his clinical symptoms of extremity edema as
well as wheezing. The patient continued to work with
physical therapy and was ultimately discharged on
postoperative day nine tolerating a regular diet, adequate
pain control on p.o. pain medications and showing improvement
in his clinical symptoms of volume overload. The patient had
no further anginal symptoms during his hospital stay or at
the time of discharge.
PHYSICAL EXAMINATION ON DISCHARGE: General: No acute
distress. Vital signs are stable, afebrile. Chest clear to
auscultation bilaterally. Cardiovascular is regular rate and
rhythm with a 2/6 systolic ejection murmur. The patient's
abdomen is soft, non-tender, non-distended. The patient does
have 1+ peripheral edema. There is no sternal click or
sternal discharge. There is mild serosanguinous drainage
from the right lower extremity saphenous vein graft wound.
There is only minimal erythema.
CONDITION AT DISCHARGE: Good.
DISPOSITION: To home.
DIET: Cardiac and diabetic.
MEDICATIONS:
1. Lopressor 50 mg b.i.d.
2. Lasix 120 mg b.i.d. times ten days.
3. Keflex 500 mg b.i.d. times ten days (renal dose).
4. Potassium chloride 20 mEq b.i.d. times ten days.
5. Colace 100 mg b.i.d.
6. Aspirin 325 mg q. day.
7. Glucophage 500 mg b.i.d.
8. Percocet 5/325 one to two q. 4h. p.r.n.
9. Amiodarone 400 mg b.i.d.
10. Isosorbide mononitrate 60 mg q. day.
11. NPH insulin 15 units q. a.m. and 10 units q. p.m.
DISCHARGE INSTRUCTIONS: The patient is to continue elevating
his legs at rest and ambulating and incentive spirometry. He
is to follow up with Cardiology in one to two weeks' time and
address the need for continued diuresis as well as adjustment
of cardiac medications at that time. The patient should
follow up in four weeks with Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2151-1-14**] 16:28
T: [**2151-1-14**] 15:46
JOB#: [**Job Number 107068**]
ICD9 Codes: 4241, 4280, 4439, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1760
} | Medical Text: Admission Date: [**2136-12-26**] Discharge Date: [**2136-12-31**]
Date of Birth: [**2136-12-26**] Sex: F
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 36863**] was born at 34
4/7 weeks gestation by cesarean section to a 26 year old
Gravida 4, Para 1, now 3 woman. The mother's prenatal
screens are blood type 0 positive, antibody negative, Rubella
Group B Streptococcus unknown. The pregnancy was complicated
by preterm labor at 28 weeks gestation treated with magnesium
sulfate and Betamethasone. The mother has an intermittent
history of intravenous drug and crack Cocaine use during this
pregnancy. She has been in the [**First Name4 (NamePattern1) 36413**] [**Last Name (NamePattern1) **] Treatment
Program over the past few months. She presented on the day
of delivery in preterm labor and spontaneous decelerations of
The mother's medications during pregnancy were Synthroid and
Fluoxetine.
PHYSICAL EXAMINATION: This infant emerged with spontaneous
respirations and good cry. Apgars were 7 at one minute and 8
at five minutes. Birthweight is 1,990 gm, birth length 42
cm, and birth head circumference 30.25 cm.
Admission physical examination reveals a vigorous preterm
nondysmorphic infant, anterior fontanelle open and flat,
positive bilateral red reflex, intact palate, comfortable
respirations. Lungs have some inspiratory crackles and she
had some mild grunting, flaring and retracting. Normal S1
and S2 heartsound. No murmur. Pink and well perfused.
Abdomen is soft. Three vessel umbilical cord. Normal
external female genitalia, patent anus, intact spine.
Negative hip examination. Slightly decreased tone generally
but moving all extremities.
HOSPITAL COURSE: Respiratory status - The infant remained in
room air. Her respiratory distress resolved by approximately
two hours of age. She has never had any apnea or
bradycardia.
Cardiovascular status - She has been normotensive throughout
her Newborn Intensive Care Unit stay. She has a normal S1
and S2 heartsound, no murmur.
Fluids, electrolytes and nutrition status - Enteral feeds
were begun on day of life #1 and advanced without difficulty
to full volume. She is taking Enfamil 20 and breastfeeding
with a coordinated suck and swallow. She has been euglycemic
throughout her Newborn Intensive Care Unit stay.
Gastrointestinal status - Her bilirubin on day of life #3 was
total of 5.8, direct 0.2.
Hematological status - Her hematocrit at the time of
admission was 53.9 and platelets 335,000. She has received
no blood products during the Newborn Intensive Care Unit
stay.
Infectious disease status - The infant was started on
Ampicillin and Gentamicin at the time of admission for sepsis
risk factor. The antibiotics were discontinued after 48
hours when the blood cultures were negative and the infant
was clinically well.
Neurological status - She has not yet had an audiology
screen. Her neurological exam is normal.
Social status - The mother has been a resident of [**Name (NI) 36413**]
[**Last Name (NamePattern1) **] where she will remain until [**2137-9-24**]. She is
there with her 21 month old daughter and these two children
will go to stay with her there. She has been followed by
[**Hospital6 256**] social worker, [**Name (NI) 36130**]
[**Name (NI) 6861**].
CONDITION ON DISCHARGE: The infant is being transferred to
the Newborn Nursery. The infant is in good condition.
The mother has not yet identified a primary pediatric
provider but anticipates using the [**Hospital 12091**] Clinic.
CARE AND RECOMMENDATIONS:
1. Feedings at discharge - The infant is breastfeeding or
taking Enfamil 20 on an ad lib schedule.
2. Medications - The infant is discharged on no medications.
3. The infant will need a carseat position screening test
prior to discharge.
4. A newborn state screen was sent on [**2136-12-29**].
5. Due to the mother's hepatitis B vaccine, the infant
received her first hepatitis B vaccine in HBIG at the time of
admission to the Newborn Intensive Care Unit.
IMMUNIZATIONS RECOMMENDED:
1. Synagis respiratory syncytial virus prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria - I. Born at less than
32 weeks; II. Born between 32 and 35 weeks with plans for
daycare during respiratory syncytial virus season, with a
smoker in the household or with preschool siblings; III.
With chronic lung disease.
2. Influenza immunizations should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
DISCHARGE DIAGNOSIS:
1. Prematurity
2. Twin #1
3. Status post transitional respiratory distress
4. Sepsis, ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 36864**]
MEDQUIST36
D: [**2136-12-29**] 18:23
T: [**2136-12-29**] 19:26
JOB#: [**Job Number 36865**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1761
} | Medical Text: Admission Date: [**2172-10-19**] Discharge Date: [**2172-10-30**]
Service: MEDICINE
Allergies:
Vancomycin / Oxycodone / Lorazepam
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Failure to decanulate
Major Surgical or Invasive Procedure:
T-tube and Y-stent placement - [**10-19**]
T-tube and Y-stent removal - [**10-26**]
Trach tube placement - [**10-26**]
Bronchoscopy
Trach change to Portex # 7 after patient pulled out trach
balloon during agitation
History of Present Illness:
This is an 88 year old male with history of COPD and CHF
presenting for failure to decanulate tracheostomy tube at rehab
with need for T-tube placement, with anatomy such that the
distal end of the T-tube will be telescoped into the Y stent. He
had a stent trial in the past which was unsuccessful due to
mucous plugging. Two months ago he was also admitted to [**Hospital1 **] with respiratory failure and had a tracheostomy placed
at that time. He has been at the rehab since but have failed to
decannulate him. At baseline, he is on a 50% trach mask with
sats around 95%. He is now being admitted for changeover of
tracheostomy to a T-tube with placement of its distal end into a
Y stent. The procedure was accomplished this morning and he is
doing well on the floor. He has no complaints currently.
Review of systems negative for fevers, chills, dyspnea, cough,
nausea/vomiting, dysuria.
Past Medical History:
PMH:
Tracheobronchomalacia s/p stent [**9-5**] and multiple bronchs
GOLD stage III COPD
p-Afib
Prostate Ca
CLL
HTN
Hyperlipidemia
GERD
Depression
CAD s/p CABG and then stent within last 10 years
CKD (baseline creatinine 1.5-2.1)
Aortic Stenosis
Vit B12 defic
Arthritis
Ventral hernia
Hx of enterococcal urosepsis
CCY
.
PSH: Silicon wire stent placement in [**8-/2171**], s/p CABG and then
stent within last 10 years, CCY
Social History:
He lives alone in a senior's facility. His wife died 2 [**Name2 (NI) 23087**]
ago. He is retired and formerly was in airline sales and is
also a veteran. He smoked a pipe for 10 years and quit 35 years
ago. He has no known exposure to asbestos or tuberculosis, and
has no
pets.
Family History:
No family history of pulmonary disease
Physical Exam:
VS 97.6, 124/70, 84, 16, 92% 5 L (trach mask)
Gen: Sitting up in bed in no apparent distress
Cardiac: nl s1/s2 RRR
Pulm: clear bilaterally, trach sounds present
Abd: soft, nontender, ND
Ext: no edema noted
Pertinent Results:
I. Microbiology
A. [**2172-10-19**] 8:00 am BRONCHIAL WASHINGS RIGHT.
**FINAL REPORT [**2172-10-28**]**
GRAM STAIN (Final [**2172-10-19**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
CLUSTERS.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2172-10-28**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
~6OOO/ML Commensal Respiratory Flora.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION REQUESTED PER DR.[**First Name (STitle) **] B.#[**Numeric Identifier 31201**] [**2172-10-24**]
10:00AM.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVE TO Piperacillin/Tazobactam sensitivity
testing performed
by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.
10,000-100,000 ORGANISMS/ML..
CHLORAMPHENICOL <=8 MCG/ML SENSITIVE BY MICROSCAN.
TIMENTIN 32 MCG/ML INTERMEDIATE BY MICROSCAN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ESCHERICHIA COLI
| |
STENOTROPHOMONAS (XANTHOMON
| | |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R =>16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 2 S
LEVOFLOXACIN---------- =>8 R 1 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S =>16 R <=1 S
VANCOMYCIN------------ 1 S
B. Urine
[**2172-10-29**] 8:39 am URINE Source: Catheter.
**FINAL REPORT [**2172-10-30**]**
URINE CULTURE (Final [**2172-10-30**]):
GRAM NEGATIVE ROD #1. ~1000/ML.
C. Blood cultures x 2 - pending, no growth to date
II. Radiology
CXR [**2172-10-22**]:
FINDINGS: In comparison with the study of [**5-19**], the tracheal
stent is in
place. Continued low lung volumes with areas of atelectasis at
the bases. No evidence of pulmonary vascular congestion.
CXR [**2172-10-30**]
FINDINGS: In comparison with the study of [**10-29**], there is little
overall
change. Continued low lung volumes with mild prominence of
interstitial
markings and bibasilar atelectatic changes. Tracheostomy tube
remains in
place and the midline sternal wires are intact.
III. Labs
Admission Labs:
[**2172-10-19**] 04:15PM BLOOD WBC-7.1 RBC-2.92* Hgb-9.0* Hct-25.8*
MCV-88 MCH-31.0 MCHC-35.0 RDW-15.4 Plt Ct-185
[**2172-10-19**] 04:15PM BLOOD Glucose-141* UreaN-23* Creat-1.4* Na-139
K-4.4 Cl-102 HCO3-27 AnGap-14
[**2172-10-22**] 06:45AM BLOOD WBC-8.3 RBC-3.09* Hgb-9.4* Hct-28.6*
MCV-93 MCH-30.6 MCHC-33.0 RDW-15.8* Plt Ct-207
[**2172-10-22**] 06:45AM BLOOD Glucose-134* UreaN-27* Creat-1.5* Na-138
K-4.4 Cl-100 HCO3-27 AnGap-15
.
Discharge Labs:
WBC 7.1 Hgb 8.7 Hct 25.9 Plt 164 Glc 105 BUN 23 Cr 1.3 Na 141
K 3.7 Cl 103 HCO3 33 AG 9 Last ABG pO2 103 pCO2 50 pH 7.43 HCO3
34 ([**10-29**])
#### Pending studies - blood cultures x 2
Brief Hospital Course:
Medicine Floor Course [**Date range (1) **]:
The patient was admitted to the medicine service afer t-tube
placement on [**2172-10-19**]. On [**2172-10-20**] he was brought back to the
OR for repositioning of the t-tube. On [**2172-10-20**] he had
worsening of his secretions and was started on vancomycin and
levofloxacin. Bronchial washings came back with Staph aureus
coag+, E. Coli, and stenotrophomonas He is known to be a
colonizer with MRSA and Stenotrophomonas. His respiratory
status progressively worsened on [**2172-10-22**] and his antibiotics
were broadened to Vanc/Cefepime/Levo. He desatted occasionally
into the 80s with coughing and excessive secretions. He was
suctioned frequently. He was evaluated by IP who recommended
transferring him to the ICU for closer monitoring.
.
ICU Course 11-26-12/2:
88 year old male with tracheal stenosis, tracheobronchomalacia
s/p placement of Montogmery T-tube on [**10-19**] and revision on
[**10-20**] admitted to MICU with increased secretions and hypoxia
with coughing following procedure ([**2172-10-26**]) s/p Y-stent and
T-TUBE removal, mucous plugging s/p bronchoscopy and Portex
trach tube re-insertion ([**9-29**]) after patient agitated and
pulled out balloon. Hospital course complicated by delirium,
hypoxemia, and uncharacterized anemia.
# Tracheobronchomalacia with respiratory distress
On [**10-26**], the patient underwent removal of his T-tube and
Y-stent given minimal symptom improvement and hoarseness, and a
[**Last Name (un) 295**] # 7 trach was placed. Following the procedure, the
patient had an episode of respiratory distress, and he was
placed on pressure support ventilation. He was ultimately weaned
off pressure support ventilation, and placed on a TM, which he
tolerated well. The patient was evaluated by speech and swallow,
who cleared the patient for a full diet given previous concerns
about aspiration. On [**10-28**], he mucous plugged and turned ashen
acutely. IP did bronch and removed large plug with the patient
temporarily on [**4-6**] during this time then taken off vent.
Subsequently that evening, he became extremely agitated despite
zyprexa and haldol thought to be sundowning and pulled out the
balloon from his trach tube. This was replaced overnight with a
brief period of sedation with precedex. His [**Last Name (un) 295**] # 7 trach was
replaced with a perc portex # 7 trach. IP hopes to downsize the
trach in the future. There appears to be minimal options for
further treatment as he is not a stent candidate given he failed
trials and likely not an operative candidate. He will follow-up
with IP in [**11-30**] weeks after hospital discharge.
In the ICU, CPAP settings of 10 with FiO2 of 50 %
He was continued on xopenox and acetylcysteine nebs and will
need continued attention for secretion management.
#Tracheobronchitis:
Patient was thought to have teacheobronchitis given prominent
secretion component of symptoms with fever, leukocytosis, or
infiltrate on CXR. Patient's antibiotics were broadened from
cefepime to meropenem for E. coli EBSL and vancomycin was
switched to linezolid for history of vancomycin associated
ototoxicity. Levofloxacin was discontinued. *He is to continue
on meropenem and linezolid until [**2172-11-1**]*.
# Delirium
On [**10-28**], the patient appeared to have altered mental status,
believed to be consistent with delirium. This was attributed to
effect of medication, and specifically his benzodiazepenes,
codeine, and guiafenisen along with scolpamine patch were
stopped. He has a PARADOXICAL reaction to ativan causing
agitation, so ativan should be avoided. Guifenisen was also
discontinued. Infectious work-up including UA/UCx was negative.
He has both glasses and hearing aids that need to be utilized
with re-orientated. He is AAOx2 at baseline (person, place, time
only to year and does not know the month). He will continue on
olanzapine, avoid delirium-inducing drugs. He was responsive to
haldol during agitation episodes.
.
# Anemia
The patient's Hgb on admission was 9 with subsequent nadir to ~
7. He was transfused 1 unit of pRBC. There were no active signs
or symptoms of bleeding except some bloody secretions after a
procedure early in the hospital course. His stools were
hemoccult negative. Hemolysis labs in the setting of CLL were
not suggestive of hemolysis. Age appropriate cancer screening
and outpatient anemia work-up are advised.
# Abdominal distension
Pt noted to have distended abdominal, but no evidence of SBO or
ileus on KUB. He was disimpacted and placed on a bowel regimen.
# Atrial fibrillation
His coumadin is being held due to his recent procedures and can
likely be restarted once discharged and stable. He was continued
on amiodarone and metoprolol for his rate control.
#Chronic Kidney disease: The patient's Cr was stable at ~ 1.3 -
1.5.
# Hypertension: treated as above
# Hyperlipidemia: He was continued on atorvastatin at a
decreased dosage of 40 mg given concern of high dose statin with
amiodarone. Follow-up outpatient.
# Coronary Artery Disease: s/p CABG [**2156**]( LIMA->LAD,
SVG-diagonal, SVG-OM, SVG-LPL). On statin and BB, ASA.
# Aortic stenosis: Moderate with valve area of 1.0-1.2cm2.
# Depression: Continue olanzapine
# Vit B12 deficiency: Monthly injections as outpatient
# Access: peripherals, PICC (discontinue after antibiotic
course).
# Communication: Patient, HCP= [**Name (NI) **] [**Name (NI) 31202**] (son)
[**Telephone/Fax (1) 31203**]
# Mental status: Sometimes somnolent, usually AAOx 2 (to person,
place but not time - knows years but sometimes not month and
current date, can say months of year and days of week
backwards).
# GU - currently has foley in place.
# Code: DNR but ok to undergo short periods of ventilation via
tracheostomy if needed.
The patient's code status was re-adressed during his ICU stay
and his current status is DNR, but willing to undergo short
periods of ventilation via tracheostomy if needed.
Medications on Admission:
amiodarone 200 mg daily
Advair 50/250 1 puff twice a day
albuterol nebulizers,
Xopenex nebulizers every 4 hours
Lopressor 50 mg b.i.d.
Spiriva 1 capsule inhaled daily
Coumadin as directed
acetaminophen p.r.n.,
calcium and vitamin D.
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO twice a day.
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
5. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO qPM.
6. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation q 2 hr as needed for SOB.
7. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) mL Inhalation every six (6) hours.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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 for constipation.
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs
Miscellaneous [**Hospital1 **] (2 times a day).
15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
16. Meropenem 500 mg IV Q8H
17. Linezolid 600 mg IV Q12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis: Respiratory Failure, tracheobronchitis
Secondary Diagnosis: Tracheomalacia, Bronchitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for placement of a T-tube to
assist with your breathing. You were unable to tolerate this
T-tube, and it was ultimately removed. A tracheostomy tube was
inserted in its place. You tolerated this replacement tube well.
You were also started on antibiotics for an infection in your
airway. These antibiotics will be continued upon discharge from
the hospital through [**10-30**].
Medication changes:
CHANGE atorvastatin from 80 mg to 40 mg
START acetylcysteine nebs
START linezolid and meropenem for tracheobronchitis for an 8-day
total course. End DATE [**2172-11-1**]
START Xopenex nebs every 2 hours as needed and every 6 hours
standing
** Please talk to you doctor about re-starting warfarin after
your acute illness **
Followup Instructions:
Name: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Location: [**Hospital1 18**] - Division of Pulmonary Medicine
Phone: ([**Telephone/Fax (1) 17398**]
Appt: We are working on a follow up appt for you within the
next week. THe office will call you at home with an appt. If
you dont hear from them by tomorrow, please call them directly.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 5849, 2724, 4241, 5859, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1762
} | Medical Text: Admission Date: [**2146-5-12**] Discharge Date: [**2146-5-19**]
Date of Birth: [**2080-7-11**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
gentleman with worsening vision in the left eye over the past
year, was seen by an ophthalmologist who questioned glaucoma.
He was therefore followed up, had visual field deficit and
had an magnetic resonance imaging scan, magnetic resonance
angiography which showed a large aneurysm at the A1 junction.
He was then referred for angiogram today. He was noted to
have a large left ACA aneurysm on the angiogram and also a
left-sided headache on Monday but computerized tomography
scan was negative for subarachnoid.
PHYSICAL EXAMINATION: On physical examination his blood
pressure was 150/73. His heart rate was 70. Respiratory
rate was 18. Saturations were 88 to 99% on room air. He was
awake, alert and oriented times three with fluent speech.
Cranial nerves II/XII were intact. Extraocular movements
full. Face symmetric. Tongue was midline. Visual fields
full. No drift. Moving all extremities with 4+/5 strength.
Sensation intact to light touch. His reflexes were 1+
throughout. He had no [**Doctor Last Name 937**] and no clonus. Cardiac,
regular rate and rhythm. Lungs were clear to auscultation.
Abdomen was soft, nontender, nondistended. Good pedal
pulses.
HOSPITAL COURSE: He was admitted for observation to the
Intensive Care Unit and then underwent an angiogram which
showed a left A1 aneurysm which was partially coiled. The
patient then returned to the Intensive Care Unit for
observation. He remained neurologically stable. On
postoperative check he was awake, alert and oriented times
three, following commands. Pupils were equal and brisk. His
groin sheath was in place. He had no hematoma. On [**2146-5-14**], the patient had an episode. He became suddenly
confused and agitated, wanted to go home. On examination he
was alert and cooperative initially and then abruptly became
angered, repetitive, perseverating about staff not attending
to his needs, having tangential thoughts, becoming mild
distracted. The patient had a stat magnetic resonance
imaging scan which showed a small area of restricted
diffusion and he had a corpus callosum. It was suspected
the patient had an embolic event causing change in mental
status and word-finding difficulties. On [**2146-5-15**], the
patient was taken back to angiography where he underwent
additional coiling at the neck of his aneurysm without
complication. Post procedure the patient was awake, alert and had
some persistent word-finding difficulties with good repetition,
difficulty with naming, oriented to person but not place.
Cranial nerves were intact. His grasps were full. On [**5-16**], he was awake and alert and oriented times three, able to
name fingers. Repetition was intact. Extraocular movements
were full, face was symmetric. Grips were full.
Interphalangeals were full. He had no drift. His sheath was
therefore removed and his blood pressure continued to be elevated
. He was on intravenous Nipride for blood pressure
control. His blood pressure was under better control by
[**2146-5-18**], and he was transferred to the regular floor.
He has remained neurologically stable, awake, alert and
oriented times three with no word-finding difficulty. Speech
is fluent. Extraocular movements full, no drift, strength
5/5 in all objects. His memory is intact.
He will be discharged to home on [**2146-5-19**] in stable
condition with follow up with Dr. [**Last Name (STitle) 1132**] in two weeks and with
Dr. [**Last Name (STitle) 7356**] from [**Hospital 4415**], his
ophthalmologist in two weeks as well. His vital signs remain
stable. He has been afebrile.
MEDICATIONS ON DISCHARGE: His medications at the time of
discharge include Percocet 1 to 2 tablets p.o. q. 4 hours
prn, Aspirin 81 mg p.o. q. day for one week, Metoprolol XL
200 mg p.o. q. day, Hydrochlorothiazide 25 q. day, Valsartan
160 mg p.o. q. day.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2146-5-19**] 11:16
T: [**2146-5-19**] 11:41
JOB#: [**Job Number 109332**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1763
} | Medical Text: Admission Date: [**2136-6-7**] Discharge Date: [**2136-6-13**]
Date of Birth: [**2085-7-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall
Multiple pulmonary emboli
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 yo with extensive past medical history recently discharged on
[**2136-6-6**] from [**Hospital1 18**] after prolonged hospitalization for CHF. The
patient had a mechanical fall and is now readmitted on [**2136-6-7**].
The patient presented with worsening right sided chest pain and
new rib fractures and pulmonary emboli.
Past Medical History:
*low back pain - Patient has narcotic contract. Please refer to
letter dated [**2135-5-17**] for updated doses. He is followed by pain
management and orthopedics
*cryptogenic organizing pneumonitis s/p RML wedge resection
*depression and PTSD
*obstructive sleep apnea, reports compliance with CPAP but that
machine was recently taken away due to financial issues + being
hospitalized
*moderate diastolic CHF
*hypertension
*hyperlipidemia
*DMII
*obesity
*Squamous cell carcinoma on dorsum of right hand s/p Moh's
micrographic surgery
*alcohol abuse
*tobacco abuse
*5 GSWs in L leg, 4 GSWs in R leg, 1 GSW in buttocks
*multiple orthopedic surgeries
*? pericarditis with pericarial effusion requiring drainage at
[**Hospital1 **] (patient report)
Social History:
- On disability, but formerly worked in construction doing
wrecking.
He was a certified asbestos remover and had significant asbestos
exposure
20-30 years ago.
- Tobacco history: Smokes 2pk/day x30 years, "quit" 1 month ago
but has had 3 cigs over past month
- ETOH: Drinks a large amount of vodka and a few beers daily,
not able to quantify the vodka
- Illicit drugs: marijuana as a teenager, no other drug use
- Pt lives at home alone, and is minimally active.
- He has a girlfried who he sees on weekends.
- He is divorced, but close with his ex-wife. Two children, son
died last year in [**Name (NI) 8751**].
Family History:
- Brother with heart transplant for pericarditis
- no other family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory
- mother had melanoma and died of perforated peptic ulcer at 71
- father alive and well
- 3 brothers and 3 sisters alive and well
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Temp:98.8 HR:78 BP:100/49 Resp:17 O(2)Sat:82 ra low
Constitutional: Comfortable
HEENT: Extraocular muscles intact
Oropharynx within normal limits
Chest: coarse breath sounds
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: + pulses, + edema
Skin: ecchymosis to abdomen from heparin injections
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2136-6-7**] 12:25PM GLUCOSE-123* UREA N-30* CREAT-1.2 SODIUM-133
POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-28 ANION GAP-15
[**2136-6-7**] 12:25PM cTropnT-<0.01
[**2136-6-7**] 12:25PM proBNP-47
[**2136-6-7**] 12:25PM WBC-12.7* RBC-4.06* HGB-13.0* HCT-37.6*
MCV-93 MCH-32.0 MCHC-34.6 RDW-16.3*
[**2136-6-7**] 12:25PM NEUTS-80.3* LYMPHS-15.3* MONOS-3.7 EOS-0.3
BASOS-0.6
[**2136-6-7**] 12:25PM PLT COUNT-221
[**2136-6-6**] 03:25PM CREAT-1.3* POTASSIUM-4.4
[**2136-6-6**] 06:35AM WBC-14.7* RBC-4.01* HGB-12.7* HCT-37.5*
MCV-94 MCH-31.7 MCHC-33.9 RDW-15.8*
Imaging:
IMPRESSION:
5/6/10CT Chest & Abdomen
1. Pulmonary emboli within the right upper lobe segmental and
subsegmental pulmonary arteries, as well as the right
interlobar pulmonary artery, and segmental right lower lobe
pulmonary artery without evidence of right heart strain.
2. Unchanged bilateral ground-glass opacities most pronounced in
the upper lobes consistent with patient's history of cryptogenic
organizing pneumonia.
3. Superior endplate compression fracture of L2, new compared to
[**2136-5-5**]. New acute and subacute bilateral rib fractures.
Brief Hospital Course:
He was admitted to the Trauma Service for pulmonary care; pain
management and anticoagulation for his multiple pulmonary
emboli. He was immediately bolused and started on a Heparin
drip. His Coumadin was started on [**6-9**] at 5 mg and increased to
7.5 mg due to sub therapeutic INR; his last INR on [**6-13**] was 1.5.
Once INR goal range of [**3-7**] reached his Heparin drip can be
stopped.
Mr. [**Known lastname 20400**] has a long history with chronic pain requiring long
and short acting narcotics at home to manage this. With his rib
fractures his pain was very difficult to manage and the decision
was made to consult with the Pain Service. Both his long and
short acting medications were increased; it was noted however
that the Oxycodone increased breakthrough dose was not offering
much relief for his rib fracture pain. He had been receiving
intermittent IV Dilaudid for severe breakthrough pain and this
was stopped and he was changed to oral Dilaudid. It should be
noted that he is requiring larger than usual doses of this
medication 12-14 mg every 3-4 hours prn. His adjunct
medications, Neurontin and Topamax were increased. Tizanidine
was added as well. He is on an aggressive bowel regimen.
He was also evaluated by the Orthopedic Spine surgery service
for the L2 compression fracture; there was no operative
intervention indicated. Activity as tolerated was recommended.
His oxygen saturations have ranged in the low 90's and he has
made very slow progress with Physical therapy who are
recommending acute rehab after his hospital stay. He requires
frequent monitoring of his oxygen saturations and respiratory
status in general.
Medications on Admission:
Prednisone 40', Asa 81', Gabapentin 300''', Glargine 10HS,
Metformin 500', Albuterol nebs q6hprn, atrovent neb q6hprn,
oxycodone 40q4p, oxycontin 60''', Bactrim 800/160''', Lopressor
25'', Simvastatin 80', Citalopram 10', Topiramate 25'', Prazosin
1hs, Tramadol 50''''prn,Lisinopril 5', Ca+D, Betadine + adaptic
to R big toe daily, Spirinolactone 25', lasix 120'
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Prazosin 1 mg Capsule Sig: One (1) Capsule PO QHS (once a day
(at bedtime)).
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metformin 500 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. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF ([**Known lastname 766**]-Wednesday-[**Known lastname 2974**]).
16. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
18. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM: goal INR [**3-7**].
19. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
20. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
21. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
22. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
23. Topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
25. Tizanidine 6 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
26. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
27. Hydromorphone 4 mg Tablet Sig: [**4-4**] 1/2 Tablets PO Q3H (every
3 hours) as needed for breakthrough pain.
28. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1,950 units/hr Intravenous ASDIR (AS DIRECTED):
[**Month (only) 116**] discontinue Hep gtt once INR goal range of [**3-7**] reached.
29. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) Units
Subcutaneous at bedtime.
30. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for per sliding scale: see
attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
s/p Fall
1)Rib fractures
2)Pulmonary Emboli
3)L2 Fracture
Secondary diagnosis:
Heart failure
Chronic pain syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**] after
falling and breaking your ribs. You were also diagnosed with
pulmonary emboli. You were treated with medication for pain as
well as blood thining medication for the pulmonary emboli (blood
clots in your lung).
For your heart failure you should weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma for evaluation of
your rib fractures; call [**Telephone/Fax (1) 600**] for an appointment. You
will need a standing end expiratory chest xray for this
appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 1007**], orthoepdic spine for your
L2 fracture, call [**Telephone/Fax (1) 1228**] for an appointment.
The following appointments were made for you prior to your
hospital stay:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2136-6-27**] 2:40
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2136-6-27**] 3:00
Completed by:[**2136-6-13**]
ICD9 Codes: 2724, 4019, 311, 3051, 4280, 496, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1764
} | Medical Text: Admission Date: [**2142-11-18**] Discharge Date: [**2142-12-27**]
Date of Birth: [**2112-9-20**] Sex: F
Service: SURGERY
Allergies:
Vancocin Hcl
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
30 F s/p multiple gun shot wounds brought in by EMS in pulseless
electrical activity.
Major Surgical or Invasive Procedure:
1. Aortic arch and selective innominate, left carotid and left
subclavian arteriograms, inferior vena cava filter placement.
2. Median sternotomy and cervical incision for
exposure of upper thoracic and lower cervical spine.
Total vertebrectomy of C7 and T1.
3. Fusion C6-T2.
4. Anterior cage placement.
5. Repair of dural defect.
6. Autograft.
7. Flexible bronchoscopy and aspiration and lavage.
8. Percutaneous tracheostomy tube placement.
9. Percutaneous endoscopic gastrostomy tube placement.
History of Present Illness:
30 F who answered a knock on her door when she received multiple
gun shot wound including left leg, left clavicle, right
posterior trapezius. Found down in PEA, intubated in the field,
and sent to [**Hospital1 1474**] hosptial. Subsequently med-flighted to
[**Hospital1 18**] for further evaluuation. Hematocrit at outside hospital
=15, received 5 units PRBC on arrival to [**Hospital1 18**]. Initially no
dopplerable pedal pulses, decreased rectal tone, guiac postive.
Bilateral pulmonary contusions, C6-T1 burst fractures
Past Medical History:
No significant past medical history
Social History:
African american female with excellent family support.
No history of alcohol, tobacco, or drug abuse
Family History:
non-contributory
Physical Exam:
Neuro:Alert and oriented. Communicates when cuff down with
interrupted speach. Lip talks well.
Cardiac:RRR
Respiratory:Lungs clear bilaterally. Incision on neck and chest
clean and dry
Abdomen:soft nontender, obese, non-distended. G tube site clean.
Extremities:Moves right upper extremity only.
Pertinent Results:
Laboratories on Discharge
wbc:8.3
Hct: 28.9
Plts: 265
Sodium: 136
Potassium:3.7
Bun:21
Creatinine:0.3
Brief Hospital Course:
Ms [**Known lastname 12330**] was admitted to the trauma service after multiple
gunshot wounds. The one with consequence entered left neck and
exited right posterior neck causing spinal cord injury at
approximately c6 level leaving her quadraplegic with some
movement of right arm. Studies included arteriogram of neck
showing left vertebral disruption. Procedures included cervical
and superior thoracic spine fixation by anterior and posterior
approach, tracheostomy tube, gastrostomy tube, and ivc filter.
She is completely neurologically intact but has had little
improvement with her paralysis. Majority of her hospital course
has been due to fevers that go as high as 103. complete
infectios disease workup including CT of chest and abdomen,
wound checks, lumbar puncture have been negative. She has fevers
despite normal white count off antibiotics. Infectious disease
consultants have cleared her and she is being discharged to
rehabilitation alert and oriented, tolerating tube feeds,
comfortable, speaking with cuff down for short periods of time,
still with occasional fevers, and hemodynamically stable.
Medications on Admission:
None
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
units Injection TID (3 times a day).
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
5. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) 300 mg PO Q8H
(every 8 hours) as needed.
6. Gabapentin 250 mg/5 mL Solution Sig: One (1) 300 mg PO TID (3
times a day).
7. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) 150 mg PO BID (2
times a day).
8. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours): 25 mcg/hr. wean as tolerated.
9. Lorazepam 0.5 mg Tablet Sig: One (1) 0.5 mg PO TID (3 times a
day): wean as tolerated.
10. Lorazepam 1 mg Tablet Sig: One (1) 1 mg PO HS (at bedtime):
wean as tolerated.
11. Mirtazapine 15 mg Tablet Sig: One (1) 15 mg PO HS (at
bedtime).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection ASDIR (AS DIRECTED): Insulin regular
sliding scale.
13. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours).
15. Acetaminophen 160 mg/5 mL Solution Sig: One (1) 325 mg PO
Q4-6H (every 4 to 6 hours) as needed.
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
17. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
18. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
19. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
20. [**Location (un) **] Oil Oil Sig: One (1) Miscell. prn (): patient
taking own med. ([**Location (un) 2452**] oil).
21. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Multiple gun shot wounds
C6 spinal cord injury
Quadraplegia (with some movement of right arm)
Respiratory failure
Status post cervical spine fixation
Status post tracheostomy
Status post gastrostomy tube
Status post inferior vena cava filter placement
Discharge Condition:
Good.
Discharge Instructions:
Neuro: pain meds and ativan as required
Cardiac: Stable
Respiratory: Wean vent as tolerated. Routine trach care (#7
fenestrated cuffed)
GI: Goal tube feeds
ID: No antibiotics. Has fevers without source of infection. WBC
stable off antibiotics.
Renal: Foley. wean as tolerated
Prophylaxis: Ivc filter, heparin sq, tube feeds
Followup Instructions:
Trauma clinic 2-3 weeks at [**Hospital1 18**]. [**Numeric Identifier 50514**]
Completed by:[**0-0-0**]
ICD9 Codes: 5185, 5180, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1765
} | Medical Text: Admission Date: [**2163-6-21**] Discharge Date: [**2163-7-2**]
Date of Birth: [**2098-8-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
SOB, Fever
Major Surgical or Invasive Procedure:
Aline, central line
History of Present Illness:
Ms. [**Known lastname 108231**] is a 64 yo F w/ h/o pulm fibrosis after radiation
for Hodgkins, esophageal candidiasis, GERD, ? adrenal
insufficiency (orthostatic hypotension at PCP last wk when
dropped pred), esophageal HSV, SVT, unprovoked PE on coumadin
who presented to her PCP today [**Name Initial (PRE) **]/ 2D SOB and cough productive of
greenish brown sputum which is worse than her baseline. The
cough is assoc with left sided sharp 7/10 chest pain x1d. Pt
also reports nausea this am and vomiting mucus no blood after
albuterol. + chills, subj fevers, lightheaded, HA, weakness.
Recent PNA [**1-19**].
.
Has chronic SOB since [**1-19**] on pred taper. No hemoptysis.
.
In the ED, initial vs were: T 99.9 P 118 BP 120/49 R O2 sat
100%. Access 2 PIVs (18/20). Got 3 LNS, vanc 1gm, levo, aspirin,
tylenol. EKG diffuse ST depressions, improved since starting
fluids, initial troponin negative. CXR perimediastinal fibrosis
unchanged, incr linear opacities in apices bilat with nodular
opacities in RLL c/w multifocal PNA. CTA no PE, bilateral tree
and [**Male First Name (un) 239**] with RML consolidation. INR subtherapeutic 1.6.
.
Prior to transfer from the ED, vitals: T 99.5 P 110 BP 105/49 R
23 100% on BIPAP FIO2 100%, PEEP 5, PSV 8. Diffusely wheezy,
tachycardic. Pt waiting for a bed on [**Hospital Ward Name **] when HR rose to
140s, RR to 30, BP 120/80 and started BIPAP, got SL NTG, rpt CXR
without flash, started on ceftri as well (had already gotten
levo and vanco).
.
On arrival to the ICU, pt acknowledge feeling like she was
"drowning" in ED, but since starting BiPAP much improved.
Decreased SOB. Denies HA/CP/N/V/D/C.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-Reactive airways disease/Pulmonary Fibrosis
-Pneumonia [**2162-12-12**], CAP tx with levofloxacin. Cx's neg.
-Hodgkin's disease stage 2 in '[**22**] treated with total body
radiation
-Functional Asplenism s/p radiation treatment
-Radiation induced ovarian failure s/p total hysterectomy and
estradiol therapy
-Hypothyroidism
-Supraventricular tachycardia
-GERD
-?Coronary vasospasm
-Pulmonary emoblism in '[**54**] on longterm low-dose Coumadin
-Right chest lentigo
-H/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**]/HSV esophagitis in setting of being on steroids
-Outpatient question of adrenal insufficiency with
lightheadedness with decreasing steroids
Social History:
Patient is married and lives in [**Location 1514**], MA with her husband.
She works as an administrator at a private high school. She is
independent and performs ADLs without limitation. Physically,
she has difficulty climbing stairs and participating in sports
due to her radiation-induced lung fibrosis. She drink EtOH
socially on the weekendsremote tobacco history in college but
no current use, , no ilicit drug use.
Administrator in high school, rare alcohol, no tobacco, daily
cup caffeine
Family History:
No family history of lung or cardiac diseases.
Mother: [**Name (NI) 2481**]
Maternal GM: Uterine cancer
Physical Exam:
General Appearance: Well nourished, No acute distress, No(t)
Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
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:
Diminished: bases b/l)
Abdominal: Soft, Non-tender, b/l papular rash below both breasts
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
[**2163-6-21**] 08:12PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2163-6-21**] 08:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2163-6-21**] 08:12PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2163-6-21**] 04:07PM LACTATE-2.0
[**2163-6-21**] 04:00PM GLUCOSE-112* UREA N-27* CREAT-1.2* SODIUM-139
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
[**2163-6-21**] 04:00PM ALT(SGPT)-27 AST(SGOT)-32 CK(CPK)-41 ALK
PHOS-135* TOT BILI-0.6
[**2163-6-21**] 04:00PM LIPASE-17
[**2163-6-21**] 04:00PM CK-MB-NotDone cTropnT-<0.01
[**2163-6-21**] 04:00PM IRON-10*
[**2163-6-21**] 04:00PM calTIBC-308 FERRITIN-157* TRF-237
[**2163-6-21**] 04:00PM WBC-21.3*# RBC-3.37* HGB-10.4* HCT-30.1*
MCV-89 MCH-30.9 MCHC-34.6 RDW-14.5
[**2163-6-21**] 04:00PM NEUTS-85* BANDS-3 LYMPHS-2* MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2163-6-21**] 04:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2163-6-21**] 04:00PM PLT SMR-HIGH PLT COUNT-486*
[**2163-6-21**] 04:00PM PT-18.0* PTT-26.6 INR(PT)-1.6*
CTA CHEST: 1. No evidence of pulmonary embolism or aortic
dissection.
2. Tree-in-[**Male First Name (un) 239**] nodular opacities in both lungs, most pronounced
in the
superior segment of the right lower lobe, compatible with a
small airways
infectious or inflammatory process.
3. Partial collapse of the right middle lobe.
4. Paramediastinal fibrotic changes secondary to radiation, with
neighboring
traction bronchiectasis.
TTE [**2163-6-22**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with basl to mid septal
hypokinesis to akinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the report of the prior study (images unavailable
for review) of [**2155-12-16**], regional LV systolic dysfunciotn is
new.
Brief Hospital Course:
# Respiratory Failure - Mrs. [**Known lastname 108231**] was admitted to the ICU
due to hypoxia and tachypnea on presentation to the ED. PE was
ruled out by CTA, which also showed RLL pneumonia with tree [**First Name8 (NamePattern2) **]
[**Male First Name (un) 239**] opacities throughout lungs. In ED, she acutely worsened in
setting of tachycardia, thought likely secondary to flash
pulmonary edema. She was given diuretics, placed on BiPap with
some improvement, however ultimately required intubation for
hypoxic respiratory failure. She was admitted to the ICU. She
was treated for her pneumonia. She was intermittantly
hypotensive, requireing pressors. She was extubated after 24
hours with steady improvement in her oxygen requirement over the
course of her admission. Blood pressure was closely monitored
to avoid repeat flash pulmonary edema. On dishcarge, she was
breathing comfortably on room air.
# Pneumonia- Atypical distribution on CT with a RLL
consolidation. She was started on Vancomycin and Zosyn. ID was
consulted. While intubated, bronchoscopy was performed which
showed thick secretions, but no other pathology. Cultures were
taken and all were negative to date at time of discharge. Per
ID, antibiotic regimen was changed to Ceftriaxone given no
positive cultures. She was treated with Ceftriaxone for planned
10 day course. Oxygen requirement improved throughout
admission. Mrs. [**Known lastname 108231**] was discharged on a 2 day course of
Levoquin to complete a 10 day antibiotic course.
# Chest pain/NSTEMI - Mrs. [**Known lastname 108231**] presented with persistant,
pleuritic chest pain over lateral left chest in setting of
pneumonia on CT. EKG in the ED with SD depressions, first set
of cardiac enzymes were negative. Repeat enzymes in the ICU
were positive for troponin > 0.1 and she was started on
treatment for NSTEMI.
She was placed on high dose aspirin, beta-blocker, ace-inhibitor
and statin. Heparin was not given as she was
theapeutic/supratherapeutic on INR. Her EKG returned to
baseline. Cardiac catheterization was done after improvement in
acute infection. Catheterization showed diffuse coronary artery
disease; no internvention was done. Mrs.[**Known lastname 108232**]
[**Name (STitle) 10708**] was discontinued due to continued orthostatic
hypotension and restarting should be readdressed as an
outpatient. Aspirin, plavix, atorvostatin and metroprolol were
continued on discharge.
# Orthostatic Hypotension- Reportedly manifest as orthostasis
and lightheadedness over several weeks as patient tried to self
taper her prednisone that she has been on since last bout of PNA
in [**12-20**] - concern for adrenal insufficiency. She was given
stress dose steroids in the ICU and returned to outpatient dose
of prednisone (3 mg/day) after completion. Two days prior to
discharge, Mrs. [**Known lastname 108231**] experienced asymptommatic hypotension
in the morning that responded to small IV bolus. She continued
to hypotensive to systolic 80's the next two days. Cortisol
stimulation test was normal (however, patient was on prednisone
at the time). Patient was discharged on admission dose of
prednisone (3 mg). Salt in her diet was liberalized and patient
was discharged on Florinef with plans to follow-up with her PCP.
# Anemia - Anemia below baseline on admission, stable throughout
admission. Iron studies, B12 and folate normal. Transfused 1
unit PRBCs with no side effects.
# History of PE - Mrs. [**Known lastname 108231**] continues outpatient warfarin
for prophylaxis after PE approximately 10 years ago. She became
supratherapeutic during admission and this was held. Coumadin
was continued to be held in anticipation of cardiac
cathterization. After catheterization, coumadin was restarted.
After discharge, home VNA was arranged and INR checks will be
called into [**Hospital3 **] [**Hospital3 271**].
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs INH every four to six hours as needed for cough
ATENOLOL - 50 mg Tablet - 1 (One) Tablet(s) by mouth every day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 inhalation twice a day - RINSE MOUTH AFTER EACH
USE
LEVOTHYROXINE [SYNTHROID] - 112 mcg Tablet - 1 (One) Tablet(s)
by
mouth every day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
PREDNISONE - 2-3 mg daily
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth at bedtime
WARFARIN - 5 mg on Tuesday nights, 2.5 mg every other night.
CALCIUM CARBONATE-VITAMIN D3 500 mg (1,250 mg)-400 unit [**Hospital1 **]
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcium Carbonate-Vitamin D3 500 mg(1,250mg) -400 unit Tablet
Sig: One (1) Tablet PO once a day.
5. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO Once Daily at 4
PM: As directed by your PCP/coumadin clinic. Change dose as
instructed after coumadin/INR checks.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Hypotension
Respiratory Failure
Heart Attack - NSTEMI
Anemaia
Orthostatic Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
determined to have pneumonia. Due to your pneumonia and
difficulty breathing, you were briefly put on a machine to
breath for you. You also briefly required medications to
maintain your blood pressure. Antibiotics were continued
throughout your admission and you will need to take one dose of
antibiotics after discharge to complete the treatment for
pneumonia for which you were treated with an 11 day course. You
also suffered a small heart attack during your hospitalization.
You were started on medication for this and had a cardiac
cathterization that showed coronary artery disease, but no
intervention was required. Your blood pressure was low at times
and it is felt that you have orthostatic hypotension. You
recieved one blood transfusion to treat your low blood count.
You are being started on a medication to help your blood
pressure. It is important that you follow-up with the
specialist appointmnents arranged for you.
CHANGES IN MEDICATION:
START Metoprolol 12.5 mg twice a day
START Plavix 75 mg daily
START Atorvastatin 80 mg daily
START Aspirin 325 mg daily
START Fludrocortisone 0.1mg daily
START Levofloxacin 750mg daily
STOP Atenolol
Please continue all other medications as previously prescribed.
Followup Instructions:
The following appointments have been arranged for you:
Department: [**Hospital3 249**]
When: TUESDAY [**2163-7-12**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11917**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This is a follow up of your hospitalization. You will be
reconnected to your primary care physician after this visit.
Department: DIV OF ALLERGY AND INFLAM
When: TUESDAY [**2163-7-19**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: CARDIAC SERVICES
When: FRIDAY [**2163-7-22**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*We are working on a follow-up appointment for you in the
Pulmonary department. The office will contact you with an
appointment. If you do not hear from them or have questions,
please contact them at ([**Telephone/Fax (1) 3554**].
ICD9 Codes: 486, 5119, 4280, 2859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1766
} | Medical Text: Admission Date: [**2172-3-19**] Discharge Date: [**2172-3-24**]
Date of Birth: [**2089-12-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82M past medical history of renal failure on dialysis, stroke
with residual left-sided weakness, recent toe amputation with
vascular surgery, and atrial fibrillation on Coumadin, who
presents with several episodes of bright red blood per rectum
from his nursing home or rehabilitation. The patient reports no
sx, he reports taht he has been eating normally (ground food and
with a poor appetite at baseline) and has had no abdominal pain,
n/v/d/c. The patient has had a large decline in his baseline
health over the past month, beginning with vascular surgery in
which they did angioplasty on the posterior tibial artery and
they initiated [**First Name3 (LF) 4532**] at that time, [**2172-3-3**]. Since then, he has
been less mobile and more somnolent, with baseline fatigue and
decreased appetite. He is on warfarin for afib/flutter and on
Aspirin for his history of CVA. He reports that he had a fall in
which he hit his left shoulder and buttock, it is unclear the
situation surrounding this but he endorses pain in his left
shoulder and lidocaine patch is in place, he reports that this
has happened since his admission to [**Hospital1 18**] for surgery at the
beginning of [**Month (only) 956**].
.
When EMS arrived, he was observed to be "difficult to arouse."
In the ED, initial VS: 96.7 111 108/52 22 100% 2L Nasal Cannula.
In ED passed 700-800cc of BRPBR. Patient received Pantoprazole
bolus +ggt. CTA done and revealed no source of bleeding and
stool in the ascending bowel. IR aware for possible angio. VS
prior to transfer SBPs 99/50, with a baseline SBP 90-100. Access
established is 18g, triple lumen in groin. Received 1u FFP.
Received 10mg IV vitamin K. CXR with concern for PNA so started
on vanc, zosyn ordered. Missed HD today; last HD on Tuesday,
renal consult was obtained and they will not proceed with HD
today but do recommend DDAVP.
.
On arrival to the MICU, the patient is somnolent but responsive
and interactive. He had 100cc of bright red blood per rectum
with clots, no stool. He remains hemodynamically stable although
hypothermic with T 95, HR 80-90 and SBP 100-110/50s, which is
his baseline.
Past Medical History:
- ESRD on HD (Tu, Th, Sat)
- h/o CVA w R sided weakness
- DM
- Glaucoma
- Hypercholesteremia
- Atrial flutter
- PVD
- Gout
- Vit D Deficiency
Social History:
Patient lives with daughter but has recently been at rehab in
setting of amputation. Has wife who he did not live with. Has a
son also in the area.
- Tobacco: Former [**2-3**] ppd smoker, quit 10 years ago
- Alcohol: no recent EtOH
- Illicits: no illegal drug use
Family History:
Mother-deceased of "heart attack" in old age
Father-deceased of "leg wound" in 50s
Children-healthy
Physical Exam:
Vitals: T: 95 BP: 103/62 P: 93 R: 12 18 O2: 97% on 3L NC
General: somnolent but arousable. oriented to self, date but not
year and says "[**Hospital 882**] Hospital", no acute distress
HEENT: dry mucous membranes, oropharynx clear, poor dentition.
Pupils are non-reactive. Cloudy pupils
Neck: supple, JVP not elevated, no LAD
CV: irregular rate, rapid rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: poor air movement bilaterally. decreased breath sounds at
the bases. dyspneic with lying supine.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, dopplerable pulses. 2+ edema. Very swollen left UE.
LUE fistula with bruit. No large toe on left foot and there are
stitches in place. Wound on back of left leg.
Neuro: very limited neuro exam [**3-5**] cooperation, 3/5 strength
upper/lower extremities, grossly normal sensation, gait deferred
but ataxic and not ambulatory at baseline. Baseline weakness on
the left noted.
Pertinent Results:
Initial labs:
[**2172-3-19**] 01:30PM WBC-4.6 RBC-2.78* HGB-9.7* HCT-31.2* MCV-112*
MCH-34.9* MCHC-31.1 RDW-17.7*
[**2172-3-19**] 01:30PM NEUTS-86* BANDS-0 LYMPHS-3* MONOS-8 EOS-2
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2172-3-19**] 01:30PM PLT SMR-LOW PLT COUNT-80*
[**2172-3-19**] 12:35PM GLUCOSE-219* UREA N-40* CREAT-5.3* SODIUM-137
POTASSIUM-5.4* CHLORIDE-94* TOTAL CO2-33* ANION GAP-15
[**2172-3-19**] 12:35PM ALT(SGPT)-10 AST(SGOT)-31 ALK PHOS-240* TOT
BILI-1.2
[**2172-3-19**] 12:35PM LIPASE-40
[**2172-3-19**] 12:35PM ALBUMIN-3.0* CALCIUM-9.0 PHOSPHATE-6.3*#
MAGNESIUM-2.6
[**2172-3-19**] 12:10PM PT-40.0* PTT-42.9* INR(PT)-3.9*
[**2172-3-19**] 01:30PM TYPE-[**Last Name (un) **] PO2-57* PCO2-66* PH-7.30* TOTAL
CO2-34* BASE XS-3 COMMENTS-GREEN TOP
[**2172-3-19**] 01:30PM LACTATE-2.4*
[**2172-3-19**] 01:34PM HIV Ab-NEGATIVE
[**2172-3-19**] 03:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-300
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG
[**2172-3-19**] 03:10PM URINE RBC-57* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-<1
[**2172-3-19**] 03:10PM URINE HYALINE-10*
CT angiogram:
IMPRESSION:
1. Hyperdense fluid within the sigmoid colon consistent with
hemorrhage. No clear source for active bleeding on this
mesenteric CTA. No bowel wall
inflammation and diverticulosis.
2. Moderate nonhemorrhagic bilateral pleural effusions with
associated compressive atelectasis.
3. Moderate simple ascitic fluid, diffuse mesenteric edema and
subcutaneous edema consistent with anasarca.
CXR:
IMPRESSION: Findings suggesting mild-to-moderate pulmonary
vascular congestion with bilateral pleural effusions and
opacities at the lung bases likely due to associated
atelectasis.
Brief Hospital Course:
82 year old male with peripheral vascular disease on warfarin,
[**Last Name (LF) 4532**], [**First Name3 (LF) **] presenting with painless BRBPR, current hemodynamic
stability. In brief, he had GIB in the ICU requiring massive
transfusion protocol. Per ICU team, after discussion with family
the decision was made to transition him to CMO status and he was
managed with CMO protocol morphine gtt on the medical floor. He
passed away overnight on [**3-24**].
.
# BRBPR: Patient presenting with about 500cc of bright red blood
per rectum in the emergency room. It is painless and no
hemorrhoids have been visualized. The most likely etiology is
diverticular bleed. Also in the ddx is AVM, hemorrhoids,
ischemia, ulcer or other etiology of UGIB. Given bright red
blood while hemodynamically stable, it was suspected to be a
lower GI source. On admission INR 3.9, improved with FFP and
vitmain K. He was transfused 1 unit PRBC and one dose of DDAVP
20mcg over one hour given his uremia.
A CT angiogram was done that did not reveal a source of
bleeding. After reversal of his INR the bleeding slowed, and GI
held off on endoscopy. The patient then began passing clots per
rectum and was transfused several units, platelets, and FFP.
Despite all this, his hct and bp continued to drop. A left
femoral CVL was placed and he was started on pressors. A family
meeting was held and the decision to transition goals of care to
CMO was made. He was taken off pressors.
Pt was monitored for Si/Sx of pain, anxiety, discomfort; no
vitals, transfusions, hemodialysis, labs were pursued. Pt was
maintained on morphine gtt per Comfort Care Guidelines with prn
ativan for breakthrough pain or anxiety, with scopolamine patch
if necessary for use when suctioning airway. He passed away
overnight [**3-24**].
.
#Aflutter: patient had atrial fibrillation during his previous
hospitalization and was started on metoprolol for rate control
and warfarin. The patient was not a considered a candidate for
acute intervention but the patient is intolerant of high
ventricular rates. Warfarin and metoprolol were held in setting
of GIB.
.
#Peripheral vascular disease: complicated by bilateral gangrene
requiring admission at the beginning of [**2172-3-4**], s/p
Balloon angioplasty of left posterior tibial artery with
additional angioplasty and stenting of left posterior tibial
artery occlusion along with amputation of left great toe. He was
advised to continue [**Year (4 digits) **] for at least 30 days, until [**2172-4-6**].
His [**Month/Day/Year **] was held given GI bleed.
.
#ESRD: On dialysis qT-TH-SAT. Last HD tuesday ([**2171-3-18**]) with 3
Kg UF (post HD wt 80, EDW 76.5 kgs). Has working Lt UA AVF for
access. The patient has anasarca which is out of proportion of
missing one dialysis session. Continued nephrocaps and
sevelamer. Received dialysis [**2172-3-21**].
.
# Hypotension: the patient's systolic blood pressure is recorded
as baseline 90-110 systolic during previous admission. He did
have a requirement for pressors in the setting of afib during
his previous admission. Current blood pressure is 102/60, which
is baseline, but will monitor carefully, especially in the
setting of hypovolemia with GIB.
.
# Baseline Macrocytic Anemia: concern for liver disease although
hepatitis work up wsa negative. B12 and folate were high at the
beginning of [**Month (only) 956**]. MCV is 112.
.
#Hx CVA: Residual L-sided weakness. Requires assistance for
feeding.
- holding home [**Month (only) **] and warfarin
.
#Hx DM: insulin sliding scale. HgA1c of 6.0 in 01/[**2172**]. Was
on lantus 6 units at bedtime.
.
#Glaucoma:
- Continued on brimonidine, latanaprost, dorzolamide eyedrops
.
#Gout:
- Continued on allopurinol
Medications on Admission:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
10. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
14. midodrine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q 8H
(Every 8 Hours).
16. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Lantus 100 unit/mL Solution Sig: Six (6) Subcutaneous at
bedtime.
18. Warfarin dose is unclear
Discharge Medications:
none; pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
- Gastrointestinal bleed
- End Stage Renal Disease
- Diabetes
- Atrial flutter
- Peripheral vascular disease
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2172-3-24**]
ICD9 Codes: 5856, 2851, 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1767
} | Medical Text: Admission Date: [**2153-3-25**] Discharge Date: [**2153-4-4**]
Date of Birth: [**2067-11-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Shortness of breath. Transfer for NSTEMI/GIB/PNA
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
85yoM with no primary care for 25+ years presenting from [**Hospital 89271**]
Hospital with NSTEMI, PNA, and GI bleed.
.
The patient reports acute onset shortness of breath which began
last night which has been progressively worsening. He denies
chest pain, lightheadedness, dizziness, or pedal edema,
orthopnea, PND. He also reports 2-3 weeks of increasing dyspnea
on exertion and cough. He presented to [**Hospital3 **] and was
found to have an NSTEMI. He was given ASA 325 but reported
intermittent bloody bowel movements and was found to have gross
blood on rectal exam, and was not started on Heparin gtt. When
asked, the patient reported he has intermittent BRBPR for the
past 2 weeks. D-dimer was elevated. He underwent a CTA at
[**Location (un) **] which showed a question of b/l PNA and was given
Levofloxacin, negative for PE. He was transferred to [**Hospital1 18**] for
further management.
.
In the ED, initial vitals were: 97.9 105 133/74 18 97% 2L NC
ECG was significant for anterolateral ST depressions. Cardiology
was made aware. Troponin was 0.31. WBC was 21.9 and portable CXR
showed bilateral infiltrates. The patient had another rectal
exam which showed frank blood in the rectal vault. NG lavage was
negative. GI was made aware, and agreed the source of bleed is
likely lower source. Hct was 28.0. He was given Pantoprazole
80mg IV and type and screened. He was admitted for further
management.
Past Medical History:
none per patient
Social History:
35 pack years, recently less. 1 drink/week. Retired.
Family History:
non-contributory
Physical Exam:
On admission:
VS: 98, 111/58, 84, 20, 97%RA
GENERAL: alert, interactive, lying supine, NAD
HEENT: Sclerae anicteric. PERRL, EOMI. MMM.
NECK: Supple. JVP 3 cm above sternal angle at 30deg
CARDIAC: RRR, II/VI HSM heard best at apex. No S3 or S4. No
thrills, lifts.
LUNGS: Clear
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no C/C/E. Extremities warm and well perfused.
SKIN: No ulcers, scars, or xanthomas. Mild hyperpigmentation of
anterior shins
PULSES:
Right: Femoral 2+ Carotid 2+ Dopplerable DP/PT
[**Name (NI) 2325**]: Femoral 2+ Carotid 2+ Dopplerable DP/PT
On discharge: unchanged
Pertinent Results:
On admission:
[**2153-3-25**] 08:10PM BLOOD WBC-21.9* RBC-2.91* Hgb-9.6* Hct-28.0*
MCV-96 MCH-33.1* MCHC-34.4 RDW-14.2 Plt Ct-349
[**2153-3-25**] 08:10PM BLOOD Neuts-88.6* Lymphs-6.0* Monos-5.2 Eos-0.1
Baso-0.1
[**2153-3-25**] 08:10PM BLOOD PT-14.0* PTT-24.4 INR(PT)-1.2*
[**2153-3-25**] 08:10PM BLOOD Glucose-137* UreaN-40* Creat-1.3* Na-135
K-4.1 Cl-101 HCO3-21* AnGap-17
[**2153-3-25**] 08:10PM BLOOD CK(CPK)-330*
[**2153-3-26**] 06:30AM BLOOD ALT-19 AST-39 CK(CPK)-230 AlkPhos-70
TotBili-0.8
[**2153-3-26**] 06:30AM BLOOD Albumin-3.9 Calcium-8.8 Phos-4.0 Mg-1.9
Cholest-203*
[**2153-3-26**] 06:30AM BLOOD Triglyc-66 HDL-77 CHOL/HD-2.6 LDLcalc-113
[**2153-3-26**] 07:08AM BLOOD %HbA1c-6.1* eAG-128*
[**2153-3-26**] 03:04AM BLOOD Lactate-2.5*
Hematocrit and WBCs
[**2153-3-25**] 08:10PM BLOOD WBC-21.9* Hct-28.0*
[**2153-3-26**] 03:45PM BLOOD WBC-17.8* Hct-28.0*
[**2153-3-27**] 07:00PM BLOOD Hct-23.0*
[**2153-3-30**] 07:00AM BLOOD WBC-13.0* Hct-26.5*
[**2153-4-4**] 07:50AM BLOOD WBC-11.4* Hct-28.8*
Creatinine
[**2153-3-25**] 08:10PM BLOOD Creat-1.3*
[**2153-3-26**] 03:45PM BLOOD Creat-1.4*
[**2153-3-27**] 08:36PM BLOOD Creat-1.6*
[**2153-3-28**] 05:53PM BLOOD Creat-1.7*
[**2153-4-1**] 09:30AM BLOOD Creat-1.2
[**2153-4-4**] 07:50AM BLOOD Creat-1.3*
Cardiac enzymes
[**2153-3-25**] 08:10PM BLOOD CK-MB-32* MB Indx-9.7*
[**2153-3-25**] 08:10PM BLOOD cTropnT-0.31*
[**2153-3-25**] 08:10PM BLOOD CK(CPK)-330*
[**2153-3-26**] 02:11AM BLOOD CK-MB-21* MB Indx-8.0* cTropnT-0.36*
[**2153-3-26**] 02:11AM BLOOD CK(CPK)-262
[**2153-3-26**] 06:30AM BLOOD CK-MB-16* MB Indx-7.0* cTropnT-0.44*
[**2153-3-26**] 06:30AM BLOOD CK(CPK)-230
[**2153-3-28**] 03:43AM BLOOD CK-MB-4 cTropnT-0.54*
[**2153-3-28**] 03:43AM BLOOD CK(CPK)-107
MICROBIOLOGY
Blood, urine, sputum cultures - no growth
IMAGING
TTE ([**3-26**]): IMPRESSION: extensive inferior-posterior myocardial
infarct with secondary moderate-to-severe mitral regurgitation;
"severe" aortic stenosis (most likely with a component of low
flow/low gradient physiology); reduced stroke volume and cardiac
output
CXR: IMPRESSION: Acute pulmonary edema with underlying
centrilobular emphysema, an extensive pneumonia is a less likely
possibility.
CARDIAC CATH: 1. Selective coronary angiography in this right
dominant system demonstrated three vessel disease. The LMCA had
a 40-50% eccentric and calcified stenosis. The LAD had an 80%
calcified mid LAD stenosis with
100% distal occlusion. The LCx had a 100% ramus branch
occlusion, an 80% tubular OMB1 stenosis. There was an occluded
small OMB2. The RCA had a 60% diffuse stenosis which was
calcified and leading to a PDA. 2. Resting hemodynamics
demonstrated mildly elevated left sided filling pressures with
mean PCWP 21 mmHg. There is mild pulmonary artery systolic
hypertension with PASP of 42 mmHg. The cardiac index is
preserved at 2.52 L/min/m2 (using an assumed oxygen
consumption). There was moderate aortic stenosis with a
calculated aortic valve area of 1.19 cm2 (based on an assumed
VO2).
FINAL DIAGNOSIS:
1. Severe three vessel coronary artery disease.
2. Moderate to severe mitral regurgitation.
3. Moderate aortic stenosis.
4. Moderate pulmonary artery hypertension.
5. Mildly elevated pulmonary capillary wedge pressure.
CAROTID U/S: Right ICA 60-69% stenosis. A more severe [**Country **]
stenosis cannot be excluded due to the presence of
calcifiedplaque. Left ICA 40-59% stenosis. Right verterbral
artery appears occluded. L vertebral open.
SPIROMETRY: Impression: Severe obstructive ventilatory defect
with a moderate gas exchange defect. There are no prior studies
available for comparison.
TEE: IMPRESSION: Regional left ventricular systolic dysfunction.
Mild to moderate mitral regurgitation. Moderate thickened aortic
valve with significant aortic stenosis present (though not
quantified).
Brief Hospital Course:
85yoM with no primary care for 25+ years presenting from [**Hospital 89271**]
Hospital with posterior/inferior NSTEMI, PNA, and GI bleed.
.
ACTIVE ISSUES
.
# CORONARIES: The patient presented with acute onset dyspnea and
was found to have an NSTEMI with elevated CE's. He was started
on ASA 325, Atorvastatin 80mg, and Metoprolol. He was not
originally started on heparin or plavix given GIB (see below)
and was trasnfused 1U pRBCs to minimize cardiac demand ischemia.
After undergoing a flex sig, a cath was performed and showed
"LAD disease, with ramus occluded, diseased circ, 60% RCA, and
aortic valve area 1.1 without gradient". Given the extent of his
disease, the option of a CABG and valvular repair was offered.
However, cardiac surgery evaluated him and determined that he
would not be a good surgical candidate and should be medically
managed at this point. His valvular disease was not significant
enough to warrant mitral and aortic valve replacements, but
should be monitored. On discharge, he will begin taking the
follow medications for optimal medical management: aspirin 325
mg daily, Atorvastatin (Lipitor) 80mg daily, metoprolol 75mg
daily, and lisinopril 5mg.
.
# PUMP: On admission, he appeared euvolemic without evidence of
volume overload. An ECHO on [**3-26**] showed 3+ MR and severe aortic
stenosis with depressed EF35%. However after medical treatment
and diuresis, a repeat ECHO showed 2+ MR and a TEE confirmed
these findings. He will follow-up with Dr. [**Last Name (STitle) 1911**] as an
outpatient for repeat TTE and management of his heart failure
with the likely initiation of diuretic therapy.
.
# GI Bleed: The patient reported intermittent bloody bowel
movements in the past, BRBPR with stool. Likely lower source,
diverticulosis vs polyp vs AVM. GI was consulted. He was made
NPO and underwent a flexible sigmoidoscopy on [**3-27**] which showed
a polyp and bleeding hemorroids. His polyp was not removed given
the bleeding risk and recent MI and should be followed as an
outpatient with GI for this issue. He required 1 U pRBCs on [**3-27**]
but then stopped bleeding with stable hematocrit. He will need
a colonoscopy as an outpatient. His Plavix was held on
discharge and he should receive his colonoscopy before
restarting this. He will also be continued on omeprazole for
gastric protection while taking ASA.
.
# Community-acquired pneumonia: The patient reported cough and
shortness of breath for the past 2-3 weeks, and underwent CTA at
OSH which showed evidence of b/l PNA, and was given a dose of
Levofloxacin. He denied fevers and b/l lower lobe opacities are
more likely CHF exacerbation in the setting of NSTEMI given
infiltrates are bilateral and patient is not an aspiration risk.
However, given his elevated white count of 21.9, which may be
all or partially due to his NSTEMI and GI bleed, his
Levofloxacin was continued for 5 days.
.
TRANSITIONAL ISSUES
.
# Follow-up care: Mr. [**Known lastname 36413**] will be seeing Dr. [**Last Name (STitle) 1911**]
for outpatient Cardiology appointments. At this point, he will
be assisted in setting up an appointment with a primary care
physician, [**Name10 (NameIs) 1023**] will then be coordinating his care. Since he has
not been watched by the medical system for a while, he should be
encouraged to follow-up closely, given that he is on many new
medications and will new follow-up imaging to monitor his
valvular function.
.
# Health screening: He will likely need routine health
maintenance, most notably a colonoscopy, especially given his GI
bleeding and anemia. Follow-up with a new PCP will be essential
for him to follow his routine health care maintenance.
Medications on Admission:
No home medications
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule,
Delayed Release(E.C.)(s)
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
Please check chem-7 on Friday [**4-6**] with results to Dr.
[**Last Name (STitle) 1911**] at [**Telephone/Fax (1) 11767**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Non ST Elevation myocardial infarction
Aortic Stenosis, valve area 1.2
Moderate Mitral Valve Regurgitation
Acute systolic congestive heart failure
Acute Kidney Injury
Lower GI Bleed
Carotid Stenosis
Hyperlipidemia
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 had a cardiac catheterization that
revealed many blockages in your heart arteries. You have been
started on many medicines to help your heart function better and
recover from the heart attack. You were also found to have
blockages in the arteries in your neck that could lead to a
stroke if these blockages worsen. You had some bleeding from
your rectum that appeared to be due to internal hemorrhoids but
you absolutely need to have a colonoscopy to look at your whole
colon to make sure there are no other areas of bleeding or
polyps. You also were found to have emphysema or COPD due to
your smoking. It is extremely important that you do not start
smoking again. Your kidneys were not working well due to your
heart problems but now have almost returned to [**Location 213**] function.
Your heart is weak after the heart attack and you had some fluid
retention that was treated with diuretics. We are not sending
you home on diuretics now but you need to weigh yourself every
day in the morning and call Dr. [**Last Name (STitle) 1911**] if your weight
increases more than 3 pounds in 1 day or 5 pounds in 3 days.
.
We started you on the following medicines:
1. Start taking aspirin 325 mg daily to prevent another heart
attack
2. STart taking Atorvastatin (Lipitor) to prevent further
blockages in your arteries from cholesterol buildup
3. Start taking metoprolol to prevent another heart attack and
lower your heart rate
4. Start taking Lisinopril to lower your blood pressure and help
your heart pump better.
5. Start taking Omeprazole to protect your stomach from the
aspirin.
.
It is extremely important that you take all of your medicines
and follow up with your doctors.
Followup Instructions:
Department: CVI [**Location (un) **], [**Apartment Address(1) **]
When: WEDNESDAY [**2153-5-9**] at 2:00 PM
With: [**Last Name (un) 1918**] [**Doctor Last Name **] [**Telephone/Fax (1) 11767**]
Building: [**Location (un) 20588**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
**Please call Dr. [**Last Name (STitle) **] office on Monday [**4-9**] to
ask for names of Primary Care Physicians in the area that he
would recommend.**
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
ICD9 Codes: 486, 5849, 5990, 4280, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1768
} | Medical Text: Admission Date: [**2128-1-25**] Discharge Date: [**2128-2-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
slow responses, right sided weakness
Major Surgical or Invasive Procedure:
thoracentesis
nasogastric tube placement
History of Present Illness:
86yo right handed man with PMH significant for uncontrolled HTN
and hyperlipidemia who was in his USOH the night of presentation
when he walked to the restroom at 8:30pm. He then sat on the
couch but when his wife called to him to come to dinner, he was
slow to respond, stood but could not walk due to right-sided
weakness and his speech was slurred. She gave him a series of
commands which he performed but his response time was
significantly slowed and she had difficulty understanding his
speech. At this point, she called EMS. He is now transferred
here after CT of the head at OSH showed a 2.5cm x 2.4cm left
thalamic ICH with slight rupture into the ventricle. On
presentation to [**Location (un) 620**], he was hypertensive to 231/88 and he
was given lopressor, to lower his pressure to the current level
of 204/64.
Past Medical History:
anemia, w/u pending - referred by PCP to hematologist. Wife
brought in letter stating the belief that he has a problem with
"red cell production"
HTN x [**3-18**] yrs, often uncontrolled to 200's
hyperlipidemia
GERD
ankylosing spondylitis
L ICA carotid stenosis (complete occlusion)
h/o tuberculosis "in his neck", s/p multidrug treatment x 6mos
no MI, CAD, or stroke
Social History:
Lives with his wife, retired SBO. Quit smoking 8yrs ago after
20ppyr history. No other drug use.
Family History:
brother died of MI at age 70
Physical Exam:
Exam on discharge:
VS 98.5 204/64 16 98% 97
Gen Lying in bed in NAD
CV rrr
Pulm ctab
Abd soft
Ext L foot erythematous and swollen, warm to touch
NEURO
MS Lying in bed with eyes closed. Opens them to voice. Oriented
to hospital and city, states it is [**2128**]. Speech is very
dysarthric (from normal baseline) and slow but fluent and
without
apparent errors. Follows simple commands. Slow response time.
CN Pupils anisocoric (b/l cataracts) - L 1.5mm and R 2mm;
neither
reacts. VFF to confrontation. EOMI including upgaze. Facial
sensation intact. R NLF flat. Smile full. Hearing intact. Palate
rises symmetrically. Shrug [**4-17**]. Tongue midline
Motor normal bulk/tone. +R pronator drift
D B T WE FE FF IP Q H DF PF TE
Coord Decreased FFM/RAMs on right side, esp compared to
non-dominant left side
Reflexes 2+ throughout, except for 1+ at ankles. Toe up on R,
down on L
Sensory intact to all primary modalities throughout, no
extinction to LT
Gait deferred
Pertinent Results:
Admission labs:
CBC: WBC-3.5* RBC-3.28* Hgb-10.0* Hct-28.9* MCV-88 MCH-30.4
MCHC-34.5 RDW-19.0* Plt Ct-124*
Coags: PT-12.1 PTT-31.6 INR(PT)-1.0
Chem10: Glucose-130* UreaN-27* Creat-1.4* Na-133 K-3.9 Cl-102
HCO3-26 Calcium-7.8* Phos-3.8 Mg-2.0
LFTs: ALT-33 AST-38 CK(CPK)-44 AlkPhos-473* TotBili-0.5
Albumin-3.3* Lipase-54 GGT-321*
Cardiac enzymes negative x 3
Other labs:
proBNP-7299*
ABG: Type-ART pO2-100 pCO2-53* pH-7.34* calTCO2-30 Base XS-0
Repeat: Type-ART pO2-103 pCO2-49* pH-7.33* calTCO2-27 Base XS-0
Pleural fluid:
WBC-550* RBC-482* Polys-9* Lymphs-72* Monos-0 Meso-1* Macro-18*
TotProt-1.9 Glucose-127 LD(LDH)-89 Albumin-1.3 Cholest-37
GRAM STAIN-FINAL; FLUID CULTURE-PENDING; ANAEROBIC
CULTURE-PENDING; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PENDING
CXR: Right-sided volume loss and right apical pleural
thickening, unchanged. Increased opacity involving the right
lung may represent scarring versus atelectasis. Comparison with
previous radiographs would help to better assess for long-term
interval change.
Loculated left-sided pleural effusion. Increased air space
opacity involving the left mid and lower lung is less
conspicuous than seen previously. Diagnostic considerations
include asymmetric pulmonary edema and pneumonia.
Chest CT: Small right and moderate left pleural effusions,
probably not transudate, greater and maybe loculated in the left
side.
Peripheral consolidation in the right upper lobe, largely
scarring, but peribronchial thickening in the lower lobes, could
be chronic or subacute infection.
Fusiform aneurysmal dilatation of the suprarrenal abdominal
aorta.
Head CT [**1-25**]: The left thalamic hemorrhage is similar in size,
measuring 2.6 x 2.4 cm. There is interval increase in a small
amount of intraventricular hemorrhage. There is no new mass
effect, hydrocephalus, or major vascular territorial infarction.
Slight bulge of normally midline structures to the right is
noted. Surrounding osseous and soft tissue structures are again
noted. Mucosal thickening is seen in the sphenoid sinus.
Repeat [**1-27**]: The left thalamic hemorrhage has decreased in size.
There has been an increase in the amount of intraventricular
blood. Otherwise, no change.
L LENI: No evidence of intraluminal thrombus.
Abd u/s: 1. Normal gallbladder and no biliary ductal dilatation.
2. No hydronephrosis.
ECHO: The left atrium is mildly dilated. 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 athe sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is moderate pulmonary artery systolic hypertension. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade.
Brief Hospital Course:
Impression: 86yo man with PMH significant for HTN presents with
dysarthria and subtle right-sided weakness, along with delayed
response time cognitively, and was found to have left thalamic
bleed with slight extension into the ventricle, likely secondary
to hypertension. His hospital course was complicated by multiple
medical problems as detailed below. He was eventually
transferred to the MICU for hypercarbic respiratory failure,
made DNR/DNI and expired.
Hospital course:
1. hemorrhage - He was initially admitted to the stroke service
for management. His blood pressure was difficult to control (see
below). His exam remained unchanged with severe dysarthria,
slight right hemiparesis, and waxing and [**Doctor Last Name 688**] mental status
most likely secondary to metabolic encephalopathy (see medical
problems listed below).
2. hypertension - His blood pressure remained poorly controlled
initially: metoprolol was initiated but was ineffective.
Hydralazine was added and was initially successful at
controlling the blood pressure, but his blood pressure increased
again when the metoprolol was weaned. ACE inhibitor was not
started due to mild acute renal failure. His HCTZ was continued.
3. respiratory difficulties - Due to his bulbar weakness, the
patient was unable to clear his secretions. He was treated with
aggressive chest PT and deep suction (which was difficult due to
deviated trachea). A CXR on admission showed a loculated pleural
effusion on the left, which was not seen on previous x-rays. The
pulmonary service was consulted, and performed a diagnostic
thoracentesis, which was consistent with a transudative
effusion. ECHO was performed, which showed... Diuresis was
started. For wheezing, he was treated with albuterol and
atrovent. A chest CT showed emphysematous changes. He continued
to decline and developed hypercarbic respiratory failure
requiring transfer to the MICU. He was made comfort care and
expired.
4. elevated alkaline phos - His alk phos remained elevated
during his hospitalization. This may be secondary to his
ankylosing spondylitis, but was rather high for this
explanation. GGT was elevated, but abdominal ultrasound was
negative.
5. ?cellulitis - He was initially treated for concern for L foot
cellulitis with cefazolin. However, suspicion remained low and
the antibiotics were discontinued without effect. LENI was
negative.
6. renal failure - He was noted to have rising creatinine and
BUN during the beginning of his hospital stay, with low UOP at
times. FeNa was 0.22% and urine eosinophils were negative, no
hydronephrosis on abdominal ultrasound. He was initially treated
with IVF, and when UOP picked up and renal function stabilized,
diuresis was started.
7. FEN - He failed his speech and swallow. An NGT was placed by
IR on [**1-26**], and tube feeds started [**1-28**].
8. Code Status - Pt was made DNR/DNI by his family after
worsening neurologic deficits manifested in the setting of
respiratory failure. He expired at 11:45 pm on [**2128-2-3**].
Medications on Admission:
toprol
lipitor
protonix
iron sulfate
isosorbide
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure.
Stroke.
Renal failure.
Discharge Condition:
Expired.
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 431, 5849, 5119, 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1769
} | Medical Text: Admission Date: [**2174-2-8**] Discharge Date: [**2174-2-21**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Dizziness, vomiting, fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC:[**CC Contact Info 86781**]
HPI: 89 year old right handed man with type 2 diabetes mellitus,
peripheral vascular disease, atrial fibrillation, CAD, HLD, who
presented to [**Hospital **] after a fall. He was transferred
from [**Hospital **] this afternoon for surgical management of
his C2 fracture.
The history was recounted by his daughter-in-law [**Name (NI) **] [**Name (NI) 61454**]
(who is also his HCP). Mr [**Known lastname 68659**] had his supper last night, and
mentioned to his wife [**Name (NI) 440**] that he was not feeling well. His
wife
thought that he looked pale. He then vomited all of his food
that
he had just eaten, and complained of the room spinning to his
wife. [**Name (NI) **] did not complain of a headache, or any pain. His wife
helped him on to the couch, and she noticed that he was rigid,
and he was slouching to the right on the chair. She had to call
his caregiver [**Name (NI) **], to help him sit up. The caregiver thought
that he had a viral illness, and gave him a bath and put him to
bed.
The next morning, he woke up around 5 am. His wife had her back
turned when he fell, but he fell approximately 24 inches out of
the bed. She activated his medical alert button and he was taken
to [**Hospital3 17163**].
According to [**Doctor First Name 440**] and [**Doctor First Name **], Mr [**Known lastname 68659**] had become confused over a
period of 2 months. At the OSH a CT Cspine was done which showed
a C2 dens body fracture, and a CT Head showed no acute changes.
He is on Coumadin and at the OSH he was given 2 units of FFP and
10units of Vitamin K. His was 1.3 at the OSH, but instead due to
an attempt to reverse him given his status of taking Coumadin.
He was transferred to [**Hospital1 18**] for further management of his C2
fracture. When he was assessed by the neurosurgical team, and
they heard the history of the prior night, they suggested a
repeat head CT.
ROS: unobtainable from the patient. According to his wife, he
had
no tinnitus, no change in his speech, no facial droop, memory
impairment for several months, and symptoms described above. He
had no chest pain, palpitations, dyspnea, fever, new GI or GU
symptoms.
Past Medical History:
Type 2 diabetes mellitus
CAD
HLD
Peripheral vascular disease
A-Fib on Coumadin
Urinary incontinence after prostate surgery (?)
Social History:
Lives with his wife, who is his second wife of 22 years. He used
to smoke cigars, but his pack history is unknown. He drinks an
occasional beer. He never used recreational drugs. He uses a
rollator frame to walk. He has been incontinent of urine since
his prostate surgery.
PCP: [**Name10 (NameIs) **] [**Last Name (STitle) **] [**Last Name (NamePattern4) 69075**]-[**Last Name (un) **], [**Hospital **] Medical, [**University/College **]
Family History:
Mother and father died in their 60s, father died of an
MI. Unclear what his mother died of. The family are originally
from [**Country 6257**].
HCP [**Telephone/Fax (1) 86782**] ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 61454**])
Physical Exam:
O: T:97 BP: 165/85 HR:68 R:20 O2Sats:98%
Gen: cachectic, leaning to the left, he has a poor fitting hard
collar on obscuring the lower portion of his face.
HEENT: abrasion and ecchymosis on right frontal/pariteal region
His oral mucosae are dry.
Skin: R shin erythema noted
Peripheral pulses: no posterior tibial or dorsalis pedis
bilaterally, rest of the pulses are present. Feet are cold.
CVS: irregularly irregular heart sounds, with an ESM in the
aortic area [**1-29**], with radiation to the carotids.
Resp: fine crackles bilaterally
GI: soft, non-tender, no organomegaly, and normal bowel sounds.
Mental status
He is awake, oriented to self. Does not know the date or year.
He
is able to identify his wife but not his daughter-in-law. His
primary language is English, but he seemed to understand his
family speaking in Portuguese better than in English.
Cranial nerves
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Shuts his eyes to fundoscopic exam. Blinks to
threat
bilaterally, does not follow commands for extraocular movements.
His neck is immobilised so dolls head not attempted. Corneal
reflexes are in tact bilaterally. Facial symmetry is obscured
by
his hard collar. He is hard of hearing bilaterally. He has a gag
reflex, and his tongue is midline.
Motor: He has Geggenhalten bilaterally. He has marked wasting of
his legs L>R. He moves all extremities spontaneously strength
could not formally be assessed, but his legs are weaker than his
arms.
Sensation: he is too inattentive to do a reliable sensory exam
His reflexes are difficult to illicit throughout.
Toes are mute bilaterally
Rectal exam normal sphincter control (done by neurosurgery),
stool guaiac was negative.
Pertinent Results:
[**2174-2-8**] 03:00PM BLOOD WBC-9.9 RBC-3.76* Hgb-12.6* Hct-37.4*
MCV-100* MCH-33.6* MCHC-33.7 RDW-13.6 Plt Ct-230
[**2174-2-8**] 03:00PM BLOOD PT-14.9* PTT-24.0 INR(PT)-1.3*
[**2174-2-8**] 03:00PM BLOOD Glucose-278* UreaN-27* Creat-0.9 Na-142
K-3.9 Cl-101 HCO3-26 AnGap-19
[**2174-2-8**] 11:19PM BLOOD ALT-38 AST-30 CK(CPK)-103 AlkPhos-112
[**2174-2-8**] 03:00PM BLOOD cTropnT-0.01
[**2174-2-8**] 11:19PM BLOOD Calcium-9.1 Phos-3.2 Mg-1.7 Cholest-153
[**2174-2-10**] 01:34AM BLOOD %HbA1c-PND
[**2174-2-8**] 11:19PM BLOOD Triglyc-79 HDL-65 CHOL/HD-2.4 LDLcalc-72
[**2174-2-10**] 01:34AM BLOOD Osmolal-320*
[**2174-2-8**] 11:19PM BLOOD TSH-1.6
[**2174-2-8**] 11:19PM BLOOD Digoxin-0.6*
CT head [**2174-2-8**]
1. Right cerebellar hypodensity consistent with acute/subacute
infarct, more
conspicuous than on the prior exam. No intracranial hemorrhage.
2. Paranasal sinus disease, likely due to ongoing inflammation.
3. Right frontal scalp soft tissue swelling and hematoma.
CT c-spine [**2174-2-8**]
1. Transverse fracture through the base of the dens (Type 2),
although the
presence of sclerosis and degenerative changes of the fracture
fragments as
well as calcification of large posterior pannus suggests a more
chronic
nature. However, there is mild prevertebral soft tissue swelling
at this
level, measuring up to 7 mm.
2. Prominent posterior pannus at the level of C1-2, resulting in
marked canal
stenosis and deformity of the thecal sac. Additional thecal sac
deformity
results from degenerative changes between C3 and C7, most severe
at C6-C7. If
neurological symptoms are referable to these levels, MRI is
recommended for
further evaluation of the spinal cord.
3. Bilateral pleural effusions with interstitial pulmonary
edema.
4. Multilevel bilateral neural foraminal narrowing.
CT head [**2174-2-9**]
PFI: Right cerebellar hemisphere infarct with short-interval
increase of
edema, now with partial effacement of fourth ventricle and
ambient cisterns on
the right, compatible with slight upward transtentorial
herniation on the
right. No evidence of midline shift or tonsillar herniation. No
new vascular
territory infarct. No hemorrhagic transformation. Of note, a
right frontal
subgaleal hematoma appears increased in size and density since
the day prior.
Please correlate clinically.
CT head [**2174-2-10**]
No significant interval change.
Discharge labs:
139 | 100 | 28
---------------< 239
4.1 | 29 | 0.7
11.1
9.1 >------< 346
33.8
Brief Hospital Course:
Mr. [**Known lastname 68659**] is an 89 year old right handed man with type 2
diabetes mellitus, peripheral vascular disease, atrial
fibrillation on Coumadin with a subtherapeutic INR, CAD, HLD,
who presented to [**Hospital **] after a fall. He was
transferred
from [**Hospital **] this afternoon for surgical management of
his C2 fracture. Prior to transfer, he was given FFP and vitamin
K despite INR 1.3 at time of presentation. Prior to his fall,
the patient had vomiting and vertigo which was concerning for a
posterior circulation event. His memory has been gradually
becoming impaired over a period of 2 months.
.
Hospital course by problem;
.
Neurology; The patient was found to have a large right
cerebellar hypodensity on CT head consistent with stroke. It
was thought this was most likely cardioembolic in the setting of
subtherapeutic INR. Clinically, it appeared that the stroke
preceeded his fall and subsequent dens fracture. He was
admitted to the neurology ICU for q1h neurochecks. His coumadin
was resumed without a bridge and blood pressure was allowed to
autoregulate. He was continued on his home statin (LDL was 72),
and fingersticks covered with regular insulin sliding scale.
HbA1c was 7.9%. A repeat CT head was worrisome for partial
effacement of fourth ventricle and ambient cisterns on the
right, compatible with slight upward transtentorial herniation
on the right. He was started on mannitol at 1g/kg x1 then
0.5g/kg q6h. This was discontinued after serum osmolality
increased to 320. Mannitol was not given after that. The
patient's HCP, [**Name (NI) **] [**Name (NI) 61454**], confirmed the patient's DNR/DNI
status and wish against any surgical intervention if his
clinical situation worsened. Vessel imaging and echocardiogram
were not performed as it was unlikely that these studies would
change management. Exam on discharge was notable for
occasionally opening of eyes to voice, although he is not
following commands. Occasional mumbling, but no understandable
speech. Will have slight spontaneous movement of hands,
inconsistent retraction from pinch in upper extremities, none
observed in lower extremities.
The patient was found to have a type-2 dens fracture on CT
C-spine, likely from his fall out of bed. He was followed by
the neurosurgery service who recommended that he continue using
the cervical collar at all times for his C2 fracture. He can
follow up with Dr. [**Last Name (STitle) 739**] at [**Telephone/Fax (1) **] in 6 weeks
([**3-24**]) with a CT scan of the cervical spine with reconstruction.
.
ID; The patient had a T max of 101.5 [**2-9**] PM and mild
leukocytosis with WBC 11.2. A CXR showed a question of LLL
atelectasis vs. pneumonia. Blood cultures have been negative.
Urine cultures grew enterococcus, resistent to tetracycline, but
otherwise pan-sensitive, and on [**2-10**] he was started on Levoquin
and Clindamycin planned for a 10-day course. On [**2-14**] he spiked
a temperature of 101.4 and antibiotics were switched to Zosyn.
He continued to have temperature > 101 and vancomycin was added
[**2-15**] although stopped on [**2-16**]. He is being treated for presumed
aspiration pneumonia with Zosyn, which should continue through
[**2-23**]. He has been afebrile since [**2-16**]. Thus far, blood and
sputum cultures have been negative.
.
Respiratory; The patient continued to exhibit increased work of
breathing and an ABG on [**2-14**] was 7.52/39/81. He was transferred
to the intensive care unit. He remained on nasal cannula
overnight until 5 AM when he desaturated on 6L NC and a repeat
ABG was 7.49/44/55. He was started on humidified O2 at 15L/min.
His DNI status was confirmed with his HCP. BIPAP was
considered but this has been deferred for now. He has been
doing well on 40-50% humidified face mask, with intermittent
suctioning.
.
CV; The patient was continued on a beta-blocker and digoxin for
rate control and monitored on telemetry. Coumadin was initially
resumed with no bridge due to the size of the cerebellar infarct
and concern for hemorrhagic transformation with aggressive early
anticoagulation. Based on the increasing size of infarct,
Coumadin was discontinued, and he was instead placed on full
dose aspirin. He has a follow-up appointment scheduled with Dr.
[**Last Name (STitle) **] in Neurology on [**3-25**] - Phone [**Telephone/Fax (1) 44**] and the
possibility of switching back to Coumadin can be readdressed at
that time.
.
Abd/GI; The patient had a Dobhoff placed [**2-9**] for tube feeds.
Swallowing ability can be reassessed if mental status improves
further. A PEG was discussed, however given his overall tenuous
status, he was not considered a good candidate for placement at
this time. This can be readdressed if his condition improves.
.
Goals of care; The patient was transferred back to the step-down
unit on [**2-15**]. Multiple discussions have been had with the
patient's HCP and other family members in regards to goals of
care. Uniform agreement has been had in the patient's DNR/DNI
and no surgeries, however there has been some debate within the
family in regards to PEG tube. As per the HCP, the family does
not wish to make the patient CMO at this time but would not want
any aggressive measures to be done to prolong his life.
Medications on Admission:
- Coumadin 2 mg on Monday & Wednesday, and on 4 mg on all other
days
- Colace:
- Omeprazole:
- Meformin: 1000mg [**Hospital1 **]
- Metoprolol: 50mg [**Hospital1 **]
- Digoxin: 0.125mg QOD
- Potassium supplements: 10 meq qday
- Lasix: 40mg qday
- Lipitor: 10 mg Qday
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) tablet PO BID
(2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection ASDIR (AS DIRECTED): please follow attached sliding
scale.
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 gram Intravenous Q8H (every 8 hours) for 3 days.
12. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day) for
3 doses.
13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehabilitation hospital
Discharge Diagnosis:
Primary: Cerebellar stroke
Secondary: Atrial fibrillation
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Lethargic
Activity Status: Bedbound
Pupils equal and reactive. Will occasionally open eyes in
response to stimuli. Mumbles but has not produced decipherable
speech. Minimal response to painful stimuli in lower
extremities. Occasional slight spontaneous movement in hands.
Discharge Instructions:
You were admitted following a fall, with symptoms of dizziness.
You were found to have a very large cerebellar stroke. You also
have a cervical fracture which is being managed conservatively
with a hard C-collar
Medication changes:
-Stop taking Coumadin, switch to full-dose aspirin
If you notice any of the concerning symptoms listed below,
please call your doctor or come to the emergency department for
further evaluation.
Followup Instructions:
Neurology: Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2174-3-25**] 2:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 5070, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1770
} | Medical Text: Unit No: [**Numeric Identifier 107381**]
Admission Date: [**2181-9-25**] Discharge Date: [**2181-10-4**]
Date of Birth: Sex:
Service:
REASON FOR ADMISSION: Living related kidney transplant.
PROCEDURE PERFORMED: Renal transplant ultrasound and MR
contrast of the kidney.
HISTORY OF PRESENT ILLNESS: [**Known firstname 7232**] [**Known lastname 106665**] is a 69 year-old,
African-American female with end stage renal disease who has
been on [**Known lastname 2286**] for a long time. She underwent a
pretransplant evaluation and was found to be a suitable
candidate for organ transplantation. Her nephew presented as
a potential live donor and underwent evaluation and completed
his work-up.
HOSPITAL COURSE: On [**2181-9-25**], she underwent a left sided live
donor renal transplant. The kidney was somewhat slow to
reperfuse, taking about 20 to 25 minutes before it completely
pinked up but did not make urine in the operating room. Her
postoperative course was complicated by delayed graft
function, slow graft function, although she did not require
[**Date Range 2286**]. She did not make much urine. She underwent
ultrasound of the transplanted kidney on [**2181-9-25**], the day
after surgery, that demonstrated a normal flow and somewhat
reduced arterial wave forms. Ultrasound was repeated on
postoperative day number 3 which was also performed and
demonstrated a very small fluid collection around the kidney
but the resistive indices remained low. She completed her
induction immunosuppression which included 4 doses of
thymoglobulin and steroid injection, in conjunction with
Prograf and CellCept maintenance therapy. Steroids were
discontinued on postoperative day number 5. On [**2181-10-2**], she
underwent a MRA due to continued poor renal function. The MRA
demonstrated a 5 x 9 cm perinephric fluid collection. She
also demonstrated mild stenosis in the left common iliac and
no evidence of anastomotic stenoses in the renal artery. Ms.
[**Known lastname 106665**] was started on a liquid diet after surgery, which was
advanced over 3 days to a regular diet. She had no other
hospitalized complications. She eventually began making more
substantial quantities of urine 2 days prior to discharge and
was discharged home on [**2181-10-4**] with follow-up instructions
with the transplant office.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern4) 3433**]
MEDQUIST36
D: [**2181-12-12**] 15:18:12
T: [**2181-12-12**] 15:39:03
Job#: [**Job Number 107382**]
ICD9 Codes: 5856, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1771
} | Medical Text: Admission Date: [**2181-6-30**] Discharge Date: [**2181-7-26**]
Date of Birth: [**2120-4-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
ICH, SAH, depressed skull fracture s/p trauma
Major Surgical or Invasive Procedure:
1. 1.5 craniotomy for repair.
2. Elevation of displaced depressed skull fracture.
3. Reconstruction of displaced orbital rim.
4. Reconstruction of orbital roof and posterior wall.
5. Exenteration of frontal sinus with obliteration, packing and
sealing.
6. Ethmoidal sinus repair with packing and sealing.
7. Duraplasty.
8. Plastic cranioplasty.
History of Present Illness:
Pt is a 61 yo with unknown PMH who is admitted after being
hit by a [**Doctor Last Name **] while riding a bike without a helmet. He was
reportedly conscious, but confused at the scene. He went to an
OSH where he was following commands intermittently and answering
questions inappropriately. He was agitated and disoriented. He
was eventually intubated and transferred here after CT scans
showed multiple facial and skull fractures, a left frontal
depressed skull fracture, multiple IPHs and diffuse SAH, and
multiple spinal fractures. He was given triple antibiotics,
pepcid, and started on propofol. He also got morphine and
ativan.
Here, he was initially paralyzed, but when this wore off, he was
agitated and moving all extremities. He was also following
midline commands.
Past Medical History:
unknown
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
Exam upon admission:
Mental Status:Intubated and agitated, but opens eyes to command
off propofol.
HEENT:Depressed skull over left frontal lobe. No laceration
here.
No CSF leak seen currently. Left eye swollen shut and
proptotic.
CN:
Pupils: On right 3 to 2.5. Left swollen shut.
Nasal Tickle:
Gag/Cough:Present on tube.
Corneal Reflex:Present on right. None on left.
OCRs:Unable due to collar.
Motor:Moves all exts equally and strongly.
Toes:Mute bilaterally
Respiration:Pt is overbreathing ventilator.
Pertinent Results:
CT C spine [**6-29**]:
1. Right occipital condyle fracture and one-half vertebral body
posterior subluxation of the condyle on the C1 vertebral body.
2. Mild anterior widening of the C3/4 and C4/5 disc interspaces.
Ligamentous injury is suspected.
3. ? Fracture through the anterior inferior C7 vertebral body.
CTA [**6-29**]:
No evidence of carotid injury identified on CT angiography. No
evidence of dissection. No evidence of occlusion. Extensive
fractures and intracranial changes as on the previous CT head.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**6-29**]:
1. Depressed left frontal and parietal bone fractures with 14 mm
depression of the fracture fragments and extension through the
left frontal sinus, ethmoid air cells and sphenoid sinus on the
right. The fracture line extends through the right cavernous
carotid canal and CTA should be performed for further
evaluation.
2. Comminuted nasal bone fracture.
3. Right maxillary sinus fracture.
4. Right occipital condyle fracture. Please see CT C-spine
report for full characterization as well as description of
posterior subluxation of the occipital condyles on C1.
5. Extensive intraparenchymal, extraaxial and subarachnoid
hemorrhage is best described on CT head scan performed on the
same day.
[**6-29**] Head CT
1. Diffuse subarachnoid hemorrhage.
2. Left frontal, parietal and temporal subdural hematoma.
Subdural hematoma layers over the tentorium.
3. Left frontal extra-axial hemorrhage and intraparenchymal
hemorrhage and hemorrhagic contusions.
4. Right subfalcine herniation.
5. Depressed left frontal skull fracture with 14-mm depression
of the fracture fragments. Fracture line extends through the
right cavernous carotid canal. CTA is recommended to exclude
carotid injury. Other fractures are best described on CT
sinus/maxillofacial scan performed on the same day.
Brief Hospital Course:
Mr. [**Name13 (STitle) 42915**] was transferred from an OSH to [**Hospital1 18**] ER for
evaluation and treatment for a L depressed skull fracture, SAH,
and C1 occiput subluxation. The pt arrived in the ED intubated
and unresponsive. Neurosurgery as well as plastic surgery, ENT
and trauma were consulted for further care. An ICP monitor
(bolt) was placed in the ICU on admission, and ICPs were
monitored. He was started on vancomycin, gentamicin, and flagyl
for empirical coverage; he was also loaded and continued on
Dilantin for seizure prophylaxis. The patient was monitored
with serial CTs and neurological examinations. The patient was
kept in a hard collar; though no vessel dissection was noted,
and there was no acute surgical issue concerning the neck, it
was determined that further assessment would be made once acute
concerns had been resolved. The patient was taken to the trauma
ICU from the ER. The patient was prepared for surgical repair,
to go to the operating room on the 6th. On the fourth of
[**Month (only) 216**], the CT showed no change in SAH as well as the left
frontal contusion. There was an interval decrease of the acute
left frontal and parietal SDH, as well as significant decrease
of the subfalcine herniation. The patient went to the operating
room on the sixth for a craniotomy, elevation of dispaced
depressed skull fracture, reconstrution of a displaced orbital
rim, orbital roof and posterior wall, and exenteration of the
frontal sinus with obliteration, packing and sealing, ethmoidal
sinus repair with packing and sealing, duraplasty, and plastic
cranioplasty. The post operative CT was improved.
.
The patient was evaluated by physical and occupational therapy
as well as speech and swallow post-operatively.
.
Starting [**7-3**], the dexamethasone was weaned, the patient was in
stable condition. On [**7-5**], the patient was extubated, and doing
well post-extubation. The patient continued to require a sitter
for disorientation and inappropriate behavior. As the patient
had very poor oral intake, a Dobhoff tube was placed on [**7-7**],
which was pulled out twice by the patient. There was a question
of a pneumomediastinum (read as present, but immediately
resolved by one radiologist, and as never having been present by
another) following Dobhoff tube placement, though the patient
remained stable with no complaints. Repeat chest x-rays were
read as normal. Speech and swallow were later consulted for
evaluation recommending a regular diet of thin liquids and
regular solids. The patient was encouraged to eat, and his PO
intake increased. Endocrinology had also been consulted for
evaluation of hypernatremia, who felt that both the adrenal and
thyroid axis were intact, and that diabetes insipidus was not
the etiology; the patient's sodium was closely monitored, and it
normalized slowly not warranting further intervention.
.
On [**7-10**], the patient was transitioned to Keppra for seizure
prophylaxis, and his diet was changed to a regular one. The
patient was closely monitored, and received a chest x-ray to
evaluate for possible pneumomediastinum with the change in diet,
and questionable history of a pneumomediastinum. The patient
remained stable, though with waxing and [**Doctor Last Name 688**] orientation, and
no sign of pneumomediastinum.
.
The 14th and [**7-11**], the patient was possibly leaking
CSF [**Last Name (un) 834**] his nares. Nasal drippings were sent for laboratory
examination, confirming a CSF leak. The patient then went to
the operating room on [**7-12**] for lumbar drain placement for the
CSF leak; the patient was started on vancomycin for prophylaxis,
and tolerated the procedure well. The drain was removed on
[**7-15**], w/o renewed nasal CSF leakage.
Opthalmology was consulted for evaluation of the patient's
visual fields post-operatively.
.
The patient's family was also in discussion with the
neurosurgical team, social work, and case management regarding
disposition, as the patient had not been covered by insurance
for further rehabilitation as an out patient.
.
Multiple attempts were made over the coarse of [**7-11**] to
have the patient placed for rehabilitation, with an emphasis on
cognition. However, the patient required sitters to prevent him
from taking off the collar. With redirection or distraction he
was generally easily kept in line, and he probably does not need
full time one-on-one supervision once he is in a more active and
social environment such as rehab. He did frequently remove
collar despite all attempts to keep in place.
.
Throughout his stay on the floor, other than the cognitive
issues (impulsivity, no encoding in short term memory,
recalcitrant behavior probaly secondary to desinhibition,
disorientation in time), his general neurological exam was
stable, with PERRL, full eye movements (perhaps limited
mechanical restriction of the L eye), symmetric facial motor and
sensory systems, straight tongue protrusion, no motor deficits
nor pronator drift, intact sensory systems to touch, symmetric
reflexes with downgoing toes.
.
Psychiatry evaluated pt and felt significance of injuries
prevented pt from holding information and placed him at risk for
potentially self-neglectful and harmful behavior.
DIAGNOSES:
Neuro:
I - BRAIN: Diffuse subarachnoid hemorrhage. Left frontal,
parietal and temporal subdural hematoma. Subdural hematoma
layers over the tentorium. Left frontal extra-axial hemorrhage
and intraparenchymal hemorrhagic contusions.
II - SKULL/FACE : Depressed left frontal skull fracture with
14-mm depression, s/p repair. Comminuted nasal bone fracture.
Right maxillary sinus fracture
III - SPINE: Right occipital condyle fracture and one-half
vertebral body posterior subluxation of the condyle on the C1
vertebral body. Mild anterior widening of the C3/4 and C4/5 disc
interspaces. Questionable fracture through the anterior inferior
C7 vertebral body.
IV - Post-traumatic cognitive dysfunction, as outlined above
Endocrine:
Transient hypernatremia directly post-traumatic, likely related
to high doses of mannitol.
GI:
Questionable transient pneumomediastinum, unable to objectify,
no clinical consequences with negative F/U studies.
Medications on Admission:
unknown
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Comminuted displaced depressed frontal skull fracture with
orbital blow out
2. Frontal sinus fracture
3. Ethmoid sinus fracture
4. Frontal lobe contusions
5. c1 SUBLUXATION
6. C7 fracture
5. Left sided dural tear
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
YOU MUST WEAR CERVICAL COLLAR AT ALL TIMES.
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IF YOU EXPERIENCE ANY OF THE FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN [**5-4**] WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN and c-spine WITHOUT
CONTRAST
You will need to follow up at the endocrinology clinic (please
call ([**Telephone/Fax (1) 33582**] to make an appointment) in [**Month (only) **].
Completed by:[**2181-7-26**]
ICD9 Codes: 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1772
} | Medical Text: Admission Date: [**2165-12-20**] Discharge Date: [**2165-12-23**]
Date of Birth: Sex: F
Service:
ADMISSION NOTE: This is a 42-year-old woman who was status
post a craniotomy on [**2165-12-3**] for resection of a
right frontal hemorrhagic melanoma metastases. The patient
was diagnosed with melanoma initially in [**2149**]. She had been
doing well at home until this morning when her partner
noticed a facial droop and some difficulty with her speech.
The patient denies fever, chills, blurred vision, numbness or
tingling of extremities, or neck pain. She has a slight
headache at time of admission. She has a baseline
right-sided hemiparesis and has had some dysarthria on
discharge. Her speech appears the same as on discharge,
[**2165-12-5**], however, patient and partner stated it did improve
after discharge. Patient also has occipital and left
parietal lesions.
PAST MEDICAL HISTORY: Biopsy of the left foot for melanoma
in [**2149**] with node excision of the left groin with radiation
in [**2163-7-27**] with gluteal metastases in [**2165-6-25**] and
left frontal hemorrhage of melanoma in [**2165-11-25**].
MEDICATIONS AT TIME OF ADMISSION:
1. Decadron 2 mg b.i.d.
2. MS Contin 15 mg p.o. q.d.
3. Keppra 1500 mg b.i.d.
4. Pepcid 20 mg p.o. b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is a nonsmoker and nondrinker.
PHYSICAL EXAM: Temperature was 99.3, blood pressure was
129/85, heart rate was 89, respirations 16. She was 99%. On
physical exam, she was in no apparent distress. She was
awake, alert, and conversant. She had a well-healed
craniotomy scar. Pupils were equal, round, and reactive to
light and accommodation 4 to 3 bilaterally. EOMs were full.
Pulmonary showed lungs to be clear bilaterally. Heart showed
regular, rate, and rhythm, normal S1, S2. Abdomen was soft,
nondistended, bowel sounds positive. Extremities: Right
lower extremity showed some muscle wasting, but no clubbing
or edema. Neurologic exam: She was awake, alert, and
oriented times three, followed commands. Pupils are equal,
round, and reactive to light and accommodation 4 to 3. EOMs
were full. Visual fields were full to confrontation. Speech
showed some mild dysarthria. She has a slight right lower
facial droop. Tongue was midline. Complete paralysis on the
right. [**4-29**] motor strength in all muscle groups on the left.
Right toe was upgoing. Left toe was downgoing. Sensory exam
on the left was intact to light touch. Sensory exam on the
right was decreased. Unable to elicit reflexes throughout.
HOSPITAL COURSE: She was admitted to the Intensive Care Unit
under Dr. [**Last Name (STitle) 739**] for q.1h. neuro checks, blood
pressure be kept less than 140. Her decadron was increased
to 4 mg q.6h., and she was to have a repeat CAT scan on
[**12-21**].
Stable on [**12-21**]. She was neurologically stable, and
she remained in the Intensive Care Unit for observation on
steroids, and to have a repeat CAT scan.
On [**12-22**], she began to complain of some headache and
nausea, and over a short amount of time, she began to have
mental status changes and did not follow commands. Emergent
CAT scan of the head repeated did show increased intracranial
hemorrhage with a midline shift, and she was taken emergently
to the OR for evacuation. She underwent a left evacuation of
an intracerebral hematoma with an estimated blood loss of 400
cc.
Postoperatively, she did localize on the left. Pupils were 2
to 1.5, trace reactive bilaterally. She was started on
Dilantin until she was able to take p.o. Keppra, and the
decadron was continued at 4 mg q.6h.
On [**12-23**], she did show some right upper extremity
movement, but was not following commands. Discussion with
patient's family about her poor prognosis. She was made
comfort measures only, and on [**2165-12-23**] at 16:25, she
expired.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D. [**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 5996**]
MEDQUIST36
D: [**2166-5-5**] 12:13
T: [**2166-5-6**] 07:35
JOB#: [**Job Number 48463**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1773
} | Medical Text: Admission Date: [**2185-7-29**] Discharge Date: [**2185-8-4**]
Date of Birth: [**2124-8-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Visual field deficit
Major Surgical or Invasive Procedure:
Right subfrontal craniotomy for tumor resection
History of Present Illness:
60-year-old female who was recently seen in Brain [**Hospital 341**] Clinic,
with progressive visual loss and was found to have a growing
tuberculum sella meningioma. She was electively admitted on [**7-29**]
for resection of said mass.
Past Medical History:
Hypercholestrolemia
Social History:
from [**Country 4812**] and now lives in the U.S. with her daughter. She
has 7 children.
Family History:
non-contributory
Physical Exam:
On Discharge:
Oriented x 3 with interpreter.
Right eye has little sight but patient does she "shadows."
Left pupil is reactive to light. Right pupil is small but
unreactive.
Face symmetric, tongue midline.
Facial sensation symmetric.
No drift.
Full strength and sensation throughout all extremities.
Incision clean, dry, and intact.
Pertinent Results:
Labs on Admission:
[**2185-7-29**] 03:33PM BLOOD WBC-13.2*# RBC-4.24 Hgb-12.3 Hct-36.4
MCV-86 MCH-29.0 MCHC-33.8 RDW-14.5 Plt Ct-234#
[**2185-7-29**] 03:33PM BLOOD PT-12.5 PTT-19.2* INR(PT)-1.1
[**2185-7-29**] 03:33PM BLOOD Glucose-208* UreaN-7 Creat-0.8 Na-146*
K-3.9 Cl-112* HCO3-25 AnGap-13
[**2185-7-29**] 03:33PM BLOOD Calcium-8.7 Phos-5.3* Mg-2.0
Imaging:
MRI Head [**7-29**]:
LIMITED MRI OF THE BRAIN WITH CONTRAST:
There has been no significant interval change in the size or
appearance of the previously described enhancing mass along the
planum sphenoidale with dural tail, consistent with a
meningioma, which has suprasellar and intrasellar extension,
measuring approximately 23 x 35 mm on sagittal images with prior
measurement in [**2184**] of approximately 22 x 30 mm. Mass effect on
the chiasm and pre- chiasmatic optic nerves is stable. No
obvious vascular invasion is identified. No other abnormal
enhancing lesions are noted within the brain parenchyma.
Estimated tumor volume is approximately 8.96 cm3, slightly
increased from [**2184**] exam where it measured 7.3 cm3.
IMPRESSION:
Slight interval growth from [**2184**] of large planum sphenoidale
meningioma with stable adjacent mass effect.
CT Head [**7-30**]:
FINDINGS: Patient is status post right frontal subcraniotomy.
There has been interval removal of a suprasellar mass as seen on
most recent prior MRI. There is a 1.0 x 1.6 cm focus of high
attenuation located in the right frontal lobe (2A:7) that likely
represents focal intraparenchymal hemorrhage, not significantly
changed when compared to prior exam. High-attenuation material
tracking along the right frontal lobe convexity is unchanged.
There has been interval decrease in extensive pneumocephalus.
The [**Doctor Last Name 352**]-white matter differentiation is preserved. There is no
evidence of acute infarction or change in ventricular size and
configuration. There is no evidence of hydrocephalus. No new
hemorrhage is identified. The visualized paranasal sinuses are
clear.
IMPRESSION:
1. No significant change in right frontal intraparenchymal
hemorrhage and
right frontal hyperdensity seen layering along the dura.
2. Interval decrease in expected pneumocephalus
MRI Head [**7-30**]:
FINDINGS: Since the previous study, the patient has undergone
resection of
tuberculum sella and subfrontal meningioma. There is a right
frontal
craniotomy seen with a subdural collection in this region as
seen on the
recent CT. Small amount of blood products are seen in the
inferior frontal
region on the right secondary to the surgery. There is no
hydrocephalus or
midline shift is seen. No acute infarct seen on diffusion
images. Following gadolinium administration, no residual nodular
area of enhancement seen in the region of tuberculum sella or
the inferior frontal region. The suprasellar lesion seen on the
previous study has been resected. Difference in the signal
intensity of the intraorbital optic nerves is seen with the
right side being slightly had intense on T2-weighted images.
Slight hyperintensity of the right intraorbital or intracranial
optic nerve is also seen on diffusion images. It is unclear
whether this is secondary to edema or ischemia in the optic
nerve. Clinical correlation recommended.
IMPRESSION: Postoperative changes with resection of the
subfrontal tumor
without residual enhancing mass lesion identified. Slight
increased signal of the right optic nerve is seen on the T2 and
diffusion images. This could be secondary to edema from mass
effect. However, clinical correlation recommended. No acute
territorial infarct seen.
Brief Hospital Course:
Mrs. [**Known lastname 51216**] was admitted for an elective craniotomy for
resection of a supersellar meningeoma on [**2185-7-29**]. Her operative
course was uncomplicated and post- operatively the patient was
transferred directly to the intensive care unit. She was
monitored with close neurological observation she was found to
have decreased vision in the right eye with possible light
recognition. MRI showed postoperative changes with resection of
the subfrontal tumor without residual enhancing mass lesion
identified. Slight increased signal of the right optic nerve is
seen on the T2 and diffusion images, no infarct was seen. An
opthamology consult was obtained they felt there was little
change from pre-op and vision prognosis was uncertain. On [**8-1**]
she was transferred to neurological floor she was neurologically
intact except for her vision. She was evaluated by physical
therapy and occupational therapy and they recommended a second
day of therapy while in the hospital. Upon re-evaluation on [**8-4**]
she had improved significantly and they felt she was safe to be
discharged with home services. The patient was given one dose of
Na tablet due to Na of 130. She was neurologically much improved
compared to the prior few days. She was discharged on [**8-4**] with
services. Her family will be available to assist her at home as
well.
Medications on Admission:
ZOCOR 20MG DAILY
VITAMEN C 500MG TID (NON-COMPLIANT)
VITAMEN D 400UNITS DAILY
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: No driving while on this medication.
Disp:*50 Tablet(s)* Refills:*0*
8. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 doses: On [**8-5**] take 3mg [**Hospital1 **] x 3 days. On [**8-8**] take
2mg [**Hospital1 **] x 3 days. On [**8-11**] take 1mg [**Hospital1 **] x 3 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Supersellar meningioma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair only after sutures have been removed.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
??????Make sure to continue to use your incentive spirometer while at
home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????New onset of tremors or seizures.
??????Any confusion or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**7-29**] days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2185-8-22**]
@4pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your acute hospitalization.
You will also need formal visual field testing in approximately
8 weeks. Please call ([**Telephone/Fax (1) 5120**] to schedule this
appointment.
Completed by:[**2185-8-4**]
ICD9 Codes: 2760, 2768, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1774
} | Medical Text: Admission Date: [**2152-9-25**] Discharge Date: [**2152-9-28**]
Date of Birth: [**2074-10-20**] Sex: F
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Trauma
Major Surgical or Invasive Procedure:
IR embolization of internal iliac branches x2, unsuccesful
interventional neuroradiology treatment of ICA thrombosis.
History of Present Illness:
77F admitted with pelvic fractures, hemodynamically unstable
after being struck by a motor vehicle. Transferred from OSH for
further management
Past Medical History:
Breast cancer, GERD, HTN
Brief Hospital Course:
Pt admitted to SICU. She was doing well on HD 1 when she became
unresponsive. She was found to have a R ICA thrombosis with
minimal collateral flow from the MCA. Neurosurgery was unable to
dislodge the thrombus endovascularly. After discussion with the
patient's family, she was made DNR/DNI, then comfort measures
only, and she expired on [**2152-9-28**].
Discharge Disposition:
Expired
Discharge Diagnosis:
Stroke.
Discharge Condition:
Expired
ICD9 Codes: 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1775
} | Medical Text: Admission Date: [**2128-9-14**] Discharge Date: [**2128-9-21**]
Date of Birth: [**2070-5-11**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
PAD
Major Surgical or Invasive Procedure:
Aortobifemoral bypass with a 14 x 7 Dacron graft, right
profundoplasty and lysis of adhesions
History of Present Illness:
This 58-year-old lady has severe peripheral
vascular disease. She has previously had a left femoral-
popliteal bypass that was made by me. She has also had
bilateral iliac angioplasty and stenting. She has continued
to smoke and developed re-stenosis in her iliac arteries. She
was studied a couple of weeks ago and found to have extremely
narrowed and diseased iliac vessels on the left and occluded
external iliac artery on the right and a slightly aneurysmal
severely diseased infrarenal aorta. Because of this
combination of problems we decided to do an aortobifemoral
graft. She also has bilateral significant renal artery
stenosis
Past Medical History:
PMH: Hypertension, Hyperlipidemia, Borderline Diabetes (diet
controlled), PVD, CAD, s/p MI in [**2107**], Prior CVA ([**2124**] or [**2125**])
-occasional residual memory issues
PSH: Bilateral common iliac artery stenting, [**2126-3-1**] Left
fem-[**Doctor Last Name **] bypass, [**2112**]: Coronary stenting at the [**Hospital3 2358**],
Cholecystectomy, Hysterectomy, Tonsillectomy
Social History:
smoker
drinker
Family History:
n/c
Physical Exam:
a/o x3
nad
crackles at bases
rrr
abd benign
inc c/d/i
RLE dop pt
[**Name (NI) **] palp dp/pt
Pertinent Results:
[**2128-9-21**] 05:21AM BLOOD
WBC-9.3 RBC-3.37* Hgb-10.7* Hct-31.2* MCV-93 MCH-31.7 MCHC-34.2
RDW-14.0 Plt Ct-184
[**2128-9-20**] 02:19AM BLOOD
PT-12.4 PTT-26.3 INR(PT)-1.1
[**2128-9-21**] 05:21AM BLOOD
Glucose-92 UreaN-19 Creat-1.1 Na-133 K-3.4 Cl-100 HCO3-29
AnGap-7*
[**2128-9-21**] 05:21AM BLOOD
Calcium-8.1* Phos-3.8 Mg-2.2
[**2128-9-17**] 5:46 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2128-9-17**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH OROPHARYNGEAL FLORA.
CHEST (PORTABLE AP)
INDICATION: Status post line change.
A single AP view of the chest is obtained, AP upright portable
at 13:40 hours, and is compared with the prior study of [**2128-9-16**].
Patient has had placement of a right-sided IJ line with its tip
projecting over the right atrium on the current examination.
Small bilateral effusions are present, more marked on the left
side with bibasilar atelectasis.
IMPRESSION:
Bilateral pleural effusions, more marked on the left side.
Bibasilar atelectasis, more marked on the left side. Right IJ
line with tip likely in the right atrium.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.2 cm
Left Ventricle - Fractional Shortening: 0.42 >= 0.29
Aorta - Ascending: *3.5 cm <= 3.4 cm
Findings
58 years old female for infrarenal AAA. Has H/O MI and CHF in
the past. Depressed LV systolic function with an EF 40-45%.
There is apical hypokinesia and Basal portion of lateral wall
akinesia. Cardiac output before the clamp with continuity
equation is 3-3.5l/min. Prolong MPI 0.6. Vp before the clamp
48cm/sec. After the clamp it decreased to 20cm/sec and after the
clamp came off it stayed 40cm/sec. E/E' ratio [**9-24**]. No valvular
abnormalities.
LEFT ATRIUM: Normal LA size. All four pulmonary veins identified
and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mildly depressed LVEF. Transmitral
Doppler E>A and TDI E/e' <8 suggesting normal diastolic
function, and normal LV filling pressure (PCWP<12mmHg).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Mildly dilated descending aorta. Focal
calcifications in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
Conclusions
The left atrium is normal in size. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45 %). The
calculated myocardial performance index was 0.65 (MPI .
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. There are simple atheroma in the ascending
aorta. The descending thoracic aorta is mildly dilated. The
aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen.
Brief Hospital Course:
Mrs. [**Known lastname 44356**],[**Known firstname **] was admitted on [**2128-9-14**] with severe b/l
claudication. She agreed to have an elective surgery.
Pre-operatively, she was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preperations were
made.
It was decided that she would undergo a Aortobifemoral bypass
with a 14 x 7
Dacron graft, right profundoplasty and lysis of adhesions..
.
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring.
She was then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care. When stable she was
delined. Her diet was advanced. A PT consult was obtained. When
she was stabalized from the acute setting of post operative
care, she was transfered to floor status
In the VICU she was SOB / Inhalers were started. Pt worked with
PT. On DC her 02 SATS
were back to baseline.
On the floor, she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any incidents. She was discharged homw with VNA services
Medications on Admission:
[**Last Name (un) 1724**]: lopressor 50 ", Plavix 75, asa 81, simvastatin 80, MVI,
Lisiopril 20, Hctz 25, Nitroquick 0.4
Discharge Medications:
1. Medications
lopressor 50 ", Plavix 75, asa 81, simvastatin 80, MVI,
Lisiopril 20, Hctz 25, Nitroquick 0.4
2. Aspirin Sig: One (1) PO once a day.
3. Simvastatin Sig: One (1) PO once a day.
4. Lisinopril Sig: One (1) PO once a day.
5. Hydrochlorothiazide Sig: One (1) PO once a day.
6. Oxycodone Sig: [**12-16**] PO every six (6) hours as needed: prn.
Disp:*20 * Refills:*0*
7. Metoprolol Sig: One (1) PO three times a day.
8. multivitiamin Sig: One (1) once a day.
9. nitro quick Sig: One (1) three times a day: prn / if you
experience chest pain please call your PCP or come to the Er
immediatly.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Aortoiliac occlusive disease.
Hypertension, Hyperlipidemia, Borderline Diabetes (diet
controlled), PVD, CAD, s/p MI in [**2107**], Prior CVA ([**2124**] or [**2125**])
-occasional residual memory issues
Discharge Condition:
Good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-17**]
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:
Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 3121**], schedule an
appointment for one week
Completed by:[**2128-9-21**]
ICD9 Codes: 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1776
} | Medical Text: Admission Date: [**2140-3-3**] Discharge Date: [**2140-3-29**]
Date of Birth: [**2088-1-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
acute renal failure
Major Surgical or Invasive Procedure:
Hemodialysis
Removal of hemodialysis catheter
History of Present Illness:
In brief, pt is a 52 year old male with PMH of DM2, obesity,
obstructive sleep apnea, HLD, CAD s/p previous stent at [**Hospital1 3278**]
for possible MI, HTN, and neuropathy who is transferred from
[**Hospital3 **] for further management of rhabdomyolysis with
acute renal failure, severe metabolic acidosis, and
thrombocytopenia.
.
On [**2140-2-29**], at the outside hospital, he underwent an elective
lithotripsy of a right staghorn calculus, during which he was
held in the prone position for 8 hours. He eventually had to
have a percutaneous nephrostomy for stone removal. He had
metabolic acidosis postoperatively and evidence of high lactic
acid, and CK's >15,000 (assay not read higher than this) with
subsequent development of acute renal failure over the next [**12-31**]
days (Cr 0.79-->1.9-->6). He had a pH of 7.18 per anesthesia
records which was treated with a bicarbonate drip. He had an ABG
of 7.4/32/107 on transfer. He was also hyperkalemic to 5.0,
requiring frequent doses of kayaxelate. Of note, he was
hemodynamically stable during his stay without significant
respiratory distress or need for pressors. However, he did have
some runs of Vtach when turned, but responsive to metoprolol. He
was placed on noninvasive ventilation twice during his stay,
once for OSA and otherwise to attempt hyperventilation in
treatment of his metabolic acidosis. He has been oliguric with
dark urine. He also had a PICC line placed [**3-1**]. A nephrology
consult at the OSH thought that he would need hemodialysis, and
he was thus transferred here. His percutaneous nephrostomy tube
eventually dislodged requiring placement of a nephroureteral
stent through existing tract. Drainage was adequate per OSH
report, though the tube was clamped on transfer for unclear
reasons.
.
Course at OSH also c/b thrombocytopenia postoperatively with
platelet counts from 252 preop to 172 immediately postop to 29
morning prior to transfer to 56 after transfusion of 1 unit
platelets. The patient received 1 dose of enoxaparin on [**2140-3-1**].
His platelet was 56 after 1 trasnfusion. Labs on discharge were
significant for an ABG of 7.4/32/107.
.
In the MICU, his renal function has continued to worsen, with
increasing oliguria. Renal has been following, and no urgent
need for HD as of yet. PT has had significant lab abormalities
with AG 20, HCO3 14 today. Pt has been getting IVF and bicarb
per renal recs. Etiology of ARF attributed to rhabdo vs. ATN [**12-30**]
hypotension possibly during surgery, though noted at OSH to be
HD stable with no need for pressors. CK has been improving from
52,000 to 19,000 today. Urology has evaluated given nephrostomy
tube, and recomend keeping tube to gravity. He has also been
noted to have significant transaminitis, which has been
improving, but Tbili rising. Pt has also been hyponatremic.
Pt has also been having leg weakness, left>right since his
surgery at the OSH. Pt states that it hasn't gotten better or
worse. He describes it as a "numbness" but denies tingling. He
was evaluated at the OSH by neurology there, and had considered
CT and spine films, but were not done. Renal has recommended MRI
for possible dissection to explain weakness, LFT abnormalities.
This has not yet been pursued. Pt's thrombocytopenia has been
improving to 70 today. HIT Ab negative. PT has been on
pneumoboots and off heparin since admission. Unclear etiology
thus far.
did not get CT or L-spine films yesterday, exam here with
weakness L>R, but more impressive for decreased sensation rather
than weakness
.
Pt states that he mostly is very tired now. He also has pain in
his mid-lower back that he says has been there since surgery. He
says the numbness and weakness in his left leg as been unchanged
sicne admission. Vital signs prior to transfer were Temp 95.6 HR
78 BP 123/46 HR 78 RR 14 99%RA.
.
.
Review of systems: Positive as above.
Otherwise, denies fever, chills, night sweats. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Pt is unsure how much if any
urine he is making.
Past Medical History:
-Hypertension
-hyperlipidemia
-chronic kidney disease
-obesity
-OSA - does not tolerate CPAP
-diabetes mellitus type II
-CAD s/p stent placement at [**Hospital1 3278**]
-diverticulitis s/p surgical excision
-neuropathy
-right staghorn calculus
Social History:
- Tobacco: 1 pack per week for 16 years, quit 16 years ago
- Alcohol: none
- Illicits: none
Works as a courier. Married with 2 daughters.
Family History:
adopted without knowledge of family history
Physical Exam:
ADMISSION:
Vitals: 96.2 133/74 81 25 96%2LNC BG 145
General: Obese, Alert, oriented, looks fatigued, but NAD
HEENT: icteric sclera, EOMI, dry MM, oropharynx clear, swelling
an yellowing of left lateral aspect of tongue
Neck: supple, difficult to appreciate JVP given body habitus
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: Obes, soft, +BS, non-tender, non-distended
GU: foley in place, minimal urine in bag
Ext: warm, 1+ pitting edema to midshin bilaterally
Neuro: A&Ox3, EOMI, decreased sensation to light touch over left
shin and knee, left foot, pt minimally moving left leg, states
unable to move his left toes, distal strength 5/5 on right
DISCHARGE:
98.7 98.6 130/68 84 18 97%RA
24H 1800 PO / 4850 UOP
8H 380 PO / 1400 UOP
General: Obese, A&Ox3, NAD, eager for discharge
HEENT: EOMI, MMM, L tongue lesion appears well-healing without
drainage, stigmata of recent oozing but no active bleeding;
parotid firm, decreased size, non-erythematous, non-fluctuant,
no interior oozing, no TTP
Neck: supple, difficult to detect JVP 2/2 habitus
Lungs: good BS bilaterally anteriorly and posterolaterally. no
wheeze. no crackles.
CV: Distant sounds [**12-30**] habitus, RRR, nl S1 + S2, no m/r/g
Abdomen: Obese, soft, +BS, no referring pain, some diffuse
abdominal TTP but no r/g, no peritoneal signs. No RUQ pain to
palpation.
Ext: warm, bilat 1+ pitting edema, soft, NT. No asterixis. Faint
BUE tremor, improving.
Neuro: no sensory deficit across abd; [**3-31**] bilat hip and plantar
flexion strength, but unable to dorsiflex or extend L foot > R
foot. UE [**3-31**] bilat.
Pertinent Results:
ADMISSION LABS:
[**2140-3-3**] 09:26PM BLOOD WBC-7.8 RBC-3.43* Hgb-11.8* Hct-30.8*
MCV-90 MCH-34.4* MCHC-38.4* RDW-13.4 Plt Ct-67*
[**2140-3-3**] 09:26PM BLOOD Neuts-81.3* Lymphs-12.2* Monos-5.6
Eos-0.4 Baso-0.5
[**2140-3-4**] 04:01AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
[**2140-3-3**] 09:26PM BLOOD PT-13.3 PTT-23.0 INR(PT)-1.1
[**2140-3-7**] 01:00PM BLOOD Fibrino-1036*
[**2140-3-5**] 01:23AM BLOOD Ret Aut-2.0
[**2140-3-4**] 04:01AM BLOOD Ret Aut-2.3
[**2140-3-3**] 09:26PM BLOOD Glucose-162* UreaN-80* Creat-7.9* Na-131*
K-3.2* Cl-93* HCO3-20* AnGap-21*
[**2140-3-3**] 09:26PM BLOOD ALT-3437* AST-4532* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-196* TotBili-3.4* DirBili-2.7* IndBili-0.7
[**2140-3-4**] 04:01AM BLOOD Lipase-75*
[**2140-3-3**] 09:26PM BLOOD Albumin-2.7* Calcium-6.7* Phos-8.5*
Mg-1.9
[**2140-3-4**] 04:01AM BLOOD Hapto-<5*
[**2140-3-7**] 05:56AM BLOOD Hapto-16*
[**2140-3-8**] 04:28AM BLOOD calTIBC-139* Ferritn-5535* TRF-107*
[**2140-3-8**] 04:28AM BLOOD TSH-3.0
[**2140-3-8**] 04:28AM BLOOD T4-4.4*
[**2140-3-7**] 01:40PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2140-3-7**] 01:40PM BLOOD HCV Ab-NEGATIVE
[**2140-3-3**] 08:43PM BLOOD Type-ART pO2-79* pCO2-33* pH-7.42
calTCO2-22 Base XS--1
[**2140-3-6**] 08:56PM BLOOD Type-ART pO2-89 pCO2-30* pH-7.25*
calTCO2-14* Base XS--12 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2140-3-3**] 08:43PM BLOOD Lactate-1.4
[**2140-3-6**] 08:56PM BLOOD Glucose-125* Lactate-1.2 Na-126* K-4.1
Cl-98*
[**2140-3-3**] 08:43PM BLOOD Hgb-11.3* calcHCT-34
[**2140-3-3**] 08:43PM BLOOD freeCa-0.89*
.
.
DISCHARGE LABS:
Na 138 | Cl 101 | BUN 75 < Glu 95
K 5.0 | HCO3 27 | Cr 7.1
Ca: 9.5 Mg: 2.0 P: 6.0
WBC 6.3 > Hgb 8.0 / Hct 23.8 < Plt 433
.
STUDIES:
.
Images:
CXR [**2140-3-3**]: The left PICC line tip is at the level of the
cavoatrial junction/proximal right atrium and might be pulled
back for approximately 1 cm to secure its position in the low
SVC/cavoatrial junction. Heart size is normal. Mediastinum is
normal. Lungs are essentially clear except for right basal
opacity most likely representing atelectasis, but infectious
process is another possibility.
.
CXR [**2140-3-5**]:
The left PICC line tip is at the level of cavoatrial
junction/proximal right atrium. Cardiomediastinal silhouette is
stable. The right basal opacity is unchanged. No interval
development of interstitial edema or new consolidations has been
demonstrated.
Overall, no significant change noted since the prior study.
Continued attention to the right lower lung is recommended to
exclude the possibility of developing infectious process in this
location.
.
CTAP [**2140-3-5**]:
IMPRESSION:
1. No retroperitoneal hematoma.
2. Heterogeneously fatty liver.
3. Moderately distended gallbladder.
4. Large bowel dilatation extending to what appears to be a
surgical site within the deep pelvis, though evaluation of
surgical anatomy is limited without oral contrast or surgical
operative notes. Decompressed bowel distal to this anastomotic
site is suggestive of a partial or early large bowel
obstruction.
5. Bilateral perinephric stranding with well-positioned
right-sided
nephroureteral stent. Residual calculi noted in the right
kidney, largest measuring 1.1 cm.
6. Nonobstructing small bowel herniation through left abdominal
wall likely related to prior surgery.
7. Significant soft tissue stranding, likely representing
post-surgical change, is noted in the left-sided subcutaneous
tissue overlying the abdomen.
.
RUQ U/S [**2140-3-6**]:
IMPRESSION: Limited examination; however, no overt hepatic
venous or portal venous thrombus is seen. Normal directional
flow is demonstrated.
.
EKG [**2140-3-9**]: Normal sinus rhythm. Poor R wave progression in
leads V1-V3. Slight non-specific T wave changes. Consider
electrolyte abnormality. The poor R wave progression may be a
normal variant but consider prior anterior wall infarction. No
previous tracing available for comparison.
.
CXR [**2140-3-10**]: NG tube tip is out of view below the diaphragm.
Right IJ catheter tip remains in the right atrium. Left PICC tip
is in the mid SVC. There are low lung volumes. There is no
pneumothorax or large pleural effusions. Aside from bibasilar
atelectasis, the lungs are clear.
.
RUQ U/S [**2140-3-13**]: : Study limited by technique. The liver appears
echogenic, compatible with known history of cirrhosis. Trace
perihepatic fluid is noted. Portal vein appears patent. The
common bile duct measures 0.4 cm. The gallbladder appears normal
without evidence of gallstones. The limited visualization of the
head and body of the pancreas appears unremarkable. The tail is
not clearly visualized.
IMPRESSION:
1. Limited examination with echogenic liver, consistent with
known cirrhosis. Trace perihepatic fluid.
2. Partially visualized pancreas appears unremarkable.
.
EKG [**2140-3-14**]: Normal sinus rhythm. Poor R wave progression in
leads V1-V3. Non-specific ST-T wave abnormalities. Compared to
the previous tracing of [**2140-3-9**] no diagnostic change.
.
Renal U/S [**2140-3-15**]: The right kidney measures 14.0 cm. The left
kidney measures 14.5 cm. There is no hydronephrosis,
hydroureter, or evidence of residual renal calculi. The right
percutaneous nephrostomy tube is vaguely evident. Small amount
of perihepatic ascites is noted, but there is no perirenal
fluid. The bladder is not visualized, secondary to patient's
body habitus and bowel gas obscuration.
IMPRESSION: No hydroureteronephrosis. No residual renal stone
noted. Small perihepatic ascites.
.
MRI Thoracolumbar [**2140-3-16**]:
THORACIC SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of the thoracic spine were acquired.
FINDINGS: In the mid thoracic region at T7-8 a central disc
herniation identified moderately narrowing the spinal canal
indenting the spinal cord. At T8-9 there is a small central
disc herniation seen with mild narrowing of the spinal canal and
indentation on the spinal cord. Mild degenerative changes are
seen at other levels. There is no evidence of abnormal signal in
the thoracic spinal cord. In the visualized lower cervical
region at C7-T1 level there is a disc herniation or protrusion
identified on sagittal images which narrows the spinal canal and
indents the spinal cord. There is suspicion for increased signal
within the spinal cord at this level.
IMPRESSION:
1. Spinal canal narrowing in the lower cervical upper thoracic
region with indentation on the spinal cord by disc protrusion
seen on the sagittal images. Increased signal is also suspected
in the spinal cord at this level on the sagittal images. A
focussed study of the cervical spine would be helpful for
further assessment.
2. Disc protrusions at T7-8 and T8-9 levels indenting the spinal
cord with moderate spinal stenosis at T7-8 and mild spinal
stenosis at T8-9 levels. No abnormal signal in the thoracic
spinal cord. 3. Subtle increased signal within the posterior
muscles on the right side in the thoracic region could be due to
edema.
.
LUMBAR SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of the lumbar spine acquired.
FINDINGS: From T12-L1 to L3-4 no abnormalities are seen. At L4-5
disc bulging and a disc protrusion seen in the midline extending
to the left with moderate narrowing of the left subarticular
recess. At L5-S1 level no abnormalities are seen. Increased
signal is seen in both erector spinae muscles in the lumbar
region which could indicate edema. Soft tissue edema is also
seen in the subcutaneous fat in the lumbar region. Diffuse
decreased signal is visualized in the bony structures which
could be secondary to anemia or renal dysfunction. Clinical
correlation recommended.
IMPRESSION: Small disc protrusion at L4-5 level with moderate
narrowing of the left subarticular recess. No intraspinal fluid
collection or thecal sac compression. Increased signal within
the erector spinae muscles and soft tissues could indicate
edema.
.
Renal U/S [**2140-3-19**]: Transabdominal son[**Name (NI) 493**] images are limited
by body habitus but demonstrate normal-appearing kidneys without
hydronephrosis or stones. The left kidney measures 14.1 cm. The
right kidney measures 13.8 cm.
IMPRESSION: Normal renal ultrasound.
.
MICRO:
URINE CULTURE (Final [**2140-3-5**]): NO GROWTH.
MRSA SCREEN (Final [**2140-3-6**]): No MRSA isolated.
Blood Culture, Routine (Final [**2140-3-14**]): NO GROWTH.
URINE CULTURE (Final [**2140-3-10**]): YEAST. >100,000
ORGANISMS/ML.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final 04/13-15/11):
feces negative x3
URINE CULTURE (Final [**2140-3-11**]): NO GROWTH
LEFT PICC CATHETER TIP (Final [**2140-3-13**]): No significant
growth.
WOUND CULTURE (Final [**2140-3-15**]):
SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH. PAN-SENSITIVE
URINE CULTURE (Final [**2140-3-18**]): YEAST. 10,000-100,000
ORGANISMS/ML.
URINE CULTURE (Final [**2140-3-22**]): NO GROWTH.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2140-3-22**]): Feces
negative
OVA + PARASITES (Final [**2140-3-25**]): NO OVA AND PARASITES SEEN.
Brief Hospital Course:
Mr [**Known lastname 1968**] is a 52yo M with h/o HTN, HLD, CAD, DM2, and right
staghorn calculus who developed a likely rhadomyolysis-induced
acute renal failure following operative removal of his
nephrolith at [**Hospital3 **], transferred here with
nephroureteral stent. His hospital course at [**Hospital1 18**] was
complicated by worsening renal failure, thrombocytopenia and
transaminitis. He was transferred to the MICU for altered mental
status in setting of renal failure and needing to initiate
hemodialysis. He was called out from the MICU [**3-12**]. He was on
intermittent hemodialysis, but his renal function improved and
he has not needed hemodialysis since [**3-18**]. The hemodialysis
catheter was pulled [**3-24**]. Additionally, he has had left leg
weakness and numbness since the surgery at [**Hospital3 **]. He
has had no evidence of retroperitoneal bleed, but MRI showed
stenosis and disc herniation that may explain some of the pain
and sensory level findings. He may also have a lumbar plexopathy
from extended prone positioning or cord infarct due to
intraoperative ischemia from positioning. He was also treated
for parotitis. Below is a summary of each of his medical issues
in further detail.
.
*) RIGHT STAGHORN CALCULUS S/P OPERATIVE RETRIEVAL:
Laser lithotripsy was unsuccessful and pt had right percutaneous
nephrostomy and retrieval with later right percutaneous
nephroureteral stent placement after dislodged perc tube. [**3-15**]
renal ultrasound showed no residual stones and no hydronephrosis
bilaterally. Perc nephroureteral stent clamped [**3-17**] AM, UOP not
decreased, [**3-18**] subsequent renal ultrasound with no
hydronephrosis. However, urology recommends leaving tube open to
gravity/bag drainage until patient is seen in followup with his
urologist. Per urology, stent may be in place for 2-3 months
without problems. [**Name (NI) **] has been on allopurinol every other day for
stones, and has had pain control with PO oxycodone. Pain may
have a neuropathic component as below.
.
*) ACUTE KIDNEY INJURY with ANION GAP METABOLIC ACIDOSIS,
causing TOXIC METABOLIC ENCEPHALOPATHY:
Likely due to rhabdomyolysis after prolonged surgery while on
statin and gemfibrozil, causing acute tubular necrosis. Urine
sediment with not many muddy brown casts. His BUN/Cr continued
to rise despite downtrend in CK's initially, and despite much IV
resuscitation. He became increasingly oliguric and IV fluids
were discontinued. This all led to profound anion gap metabolic
acidosis and uremia causing a toxic metabolic encephalopathy. He
was transferred to the MICU and hemodialysis was initiated; the
AMGA and encephalopathy improved. In the workup for HD, his PPD
was negative; hepatitis panel was done and he received HBV
vaccine [**3-22**]. He received intermittent hemodialysis and his
renal function continued to improve. He made progressively more
urine and his BUN/Cr began to trend down spontaneously. He was
last dialyzed on [**2140-3-18**] and the dialysis catheter was removed
[**2140-3-25**]. At the time of discharge he had 5 consecutive days of
downward-trending BUN/Cr. He failed Foley removal twice and was
unable to urinate, so his Foley catheter remains in place. He
will continue on sevelamer until his followup with nephrology as
an outpatient. He will require daily Chem-10 to monitor renal
function and phosphorus.
.
*) DIARRHEA:
Patient has had multiple watery bowel movements since admission.
Negative c.diff [**3-11**], [**3-22**]. Flexiseal placed on admission,
discontinued [**3-21**]. His stool consistency and frequency has been
improving on loperamide prn.
.
*) LOWER EXTREMITY NUMBNESS/WEAKNESS and GENERALIZED PAIN
DIFFUSELY:
He has baseline neuropathy but notes numbness and weakness of
the lower extremity L>R since his surgery. Possible peripheral
nerve damage due to positioning at time of surgery but op notes
are unrevealing. He had no evidence of compartment syndrome or
retroperitoneal bleed either clinically or radiologically. Per
the neurology team, these symptoms are most likely due to cord
infarct/injury vs lumbar plexopathy L>R from surgical
positioning. He is is likely without risk of further injury and
is likely to improve slowly with neuropathic pain meds and
mobilization. MRI showed stenosis and disc herniation; however,
patient is largely asymptomatic from it and is without back
pain. Spine consultants recommended no surgical intervention
given that MRI findings are not likely to be clinically
significant. His pain was controlled on oxycodone and
gabapentin, renally dosed. Physical therapy followed him while
inpatient and he underwent EMG on [**3-28**] prior to discharge. He
will require aggressive physical and occupational therapy while
at rehab. He will need to follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] of
neurology 1-2 weeks after he is discharged from rehab.
.
*) PAROTITIS/TONGUE LACERATION:
He presented with a left-sided tongue laceration, presumably
from biting the tongue during surgery. This was stable and
well-healing although [**3-26**] it had a small, self-limited episode
of bleeding. It has not continued to bleed. For parotitis
diagnosed [**3-12**] he was started on Vancomycin and Unasyn, which
was narrowed to Unasyn and then Augmentin given cultures
negative for MRSA. He received a total of 10 days of
antibiotics. He is to continue warm packs as needed and [**Doctor Last Name **]
wedges three times daily with all meals to stimulate salivary
flow to the left parotid gland.
.
*) ANEMIA:
He has a normocytic anemia. His hematocrit was stable at ~30 for
several days since admission, and then following his onset of
renal failure it drifted downward and stabilized at 22-24 since
[**2140-3-13**]. He has had no evidence of bleeding and it is felt that
the anemia is most likely dilutional given volume overload from
acute renal failure; he is now autodiuresing.
.
*) RHABDOMYOLYSIS:
Initial elevated creatinine kinases to 52,000 (now normalized),
oliguria, dark urine, and acute renal failure were consistent
with acute rhabdomyolysis, possibly due to extended prone
position in the setting of morbid obesity while taking statin
and gemfibrozil. CK's were elevated on admission and trended to
normal. His statin and gemfibrozil continue to be held until his
renal failure completely resolves.
.
*) TROPONIN ELEVATION:
The patient complained of chest pressure [**3-14**] AM; it was in fact
epigastric abdominal pain at his prior baseline, no chest
pressure or pain. His troponin was borderline but his baseline
was unknown. His ECG was unchanged. His troponins were trended
and were overall stable, with a mild rise acceptable in the
setting of acute renal failure, rhabdo, and severe metabolic
derangement. He had no further chest pain so troponins were not
rechecked.
.
*) THROMBOCYTOPENIA:
He had a rather precipitous platelet drop at [**Hospital3 **]
from a pre-op 252 to a nadir of 29 prior to a platelet
transfusion at [**Hospital3 **]. HIT antibody came back negative.
Etiology of thrombocytopenia is still unclear; platelets trended
upward and have normalized since [**2140-3-8**].
.
*) ELEVATED TRANSAMINASES:
Most likely due to shock liver in setting of hypotension at
[**Hospital3 **]; continued to trend down and have normalized
since [**2140-3-19**]. His lipase was also elevated but trended down as
well.
.
*) DIABETES MELLITUS TYPE II:
His home metformin was held while he was inpatient; he was
placed on a lispro insulin sliding scale with evening glargine
dosing increased to 12 units at discharge. His blood sugars were
acceptable on this regimen.
.
*) HYPERTENSION:
His home metoprolol tartrate (50mg [**Hospital1 **]) was increased to TID on
[**2140-3-26**] given upward-trending BPs. This was transitioned to
metoprolol succinate 150mg daily upon discharge.
.
*) CORONARY ARTERY DISEASE/HYPERLIPIDEMIA:
He is s/p stent at [**Hospital1 3278**] for possible MI. He is not on aspirin
at home so this was started [**3-15**]. He was continued on home
metoprolol. His statin/gemfibrozil were held due to rhabdo and
may be restarted once his renal failure resolves.
.
*) OBSTRUCTIVE SLEEP APNEA:
Patient has not tolerated CPAP previously. O2 sats were normal
even at night.
.
*) Prophylaxis: pneumoboots and ASA
*) CONSULTS WHILE INPATIENT: Nephrology, Neurology, Spine,
Nutrition, PT, Social [**Name (NI) **]
*) Communication: Patient, wife [**Name (NI) 5321**] [**Telephone/Fax (1) 90071**]
TRANSITION OF CARE:
- Patient is full code
- Patient has EMG study results pending from [**2140-3-28**]; he will
follow up with neurology 1-2 weeks after discharge from rehab
(appointment will need to be scheduled)
- Patient will follow up with urology for nephroureteral stent
removal within 1-2 weeks after discharge from rehab (appointment
will need to be scheduled)
- Patient will follow up with nephrology on [**2140-5-11**] (appointment
scheduled with Dr. [**Last Name (STitle) 118**]/Dr. [**Last Name (STitle) **] per discharge planning)
- Patient will require weekly CBC for monitoring of anemia and
daily chem-10 until creatinine, phosphate stable
Medications on Admission:
Home meds:
gabapentin 100mg cap TID
gemfibrozil 600mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
toprol XL 100mg daily
pravastatin 80mg qhs
.
On transfer from OSH:
Metoprolol 50mg PO BID
Sodium bicarb at 3 oz/L of IV D5W infusing at 150cc/hr
Insulin at 10U qHS plus sliding scale insulin
hydromorphine 0.5-1mg IV q3hrs PRN pain
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. insulin lispro 100 unit/mL Solution Sig: Two (2)
Subcutaneous ASDIR (AS DIRECTED): 2 units for FS of > 150,
increase by 2 units for every 50 over 150.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
8. lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for for mouth pain: swish and
spit.
9. Outpatient Lab Work
Daily Chem 10.
Weekly CBC
10. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
11. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for loose stool.
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
14. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime: Or according to your doctor's
recommendation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Acute Kidney failure
Acute tubular necrosis
Rhabdomyolysis
.
Secondary:
Parotitis
Spinal stenosis
Disc herniation
Neuropathic pain
Left leg weakness
Type 2 diabetes
Hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr [**Known lastname 1968**],
It was a pleasure to care for you at [**Hospital1 827**]. You were hospitalized with acute renal failure
caused by rhabdomyolysis following your surgery from an outside
hospital. You were initiated on hemodialysis with slow recovery
of your kidney function and have not needed dialysis since [**3-18**]. Certain medications were stopped due to this issue. Please
follow up as indicated for restarting these. You were evaluated
by Renal and Urology specialists regarding the
nephroureterostomy stent you have in place. We tried twice to
remove your bladder catheter and both times you were unable to
void. To avoid damage to your bladder we have left the catheter
in place.
You briefly received tube feeds while hospitalized but were able
to tolerate a regular diet eventually. You had a rectal tube for
diarrhea, and this was eventually removed. There was no noted
infection in your stool.
You have completed a course of antibiotics for an infection in
your left parotid gland. You should continue to have [**Doctor Last Name **]
wedges with all meals to stimulate saliva flow.
You were evaluated by Neurology and Spine specialists regarding
left leg weakness and numbness and pain on your abdominal skin.
Although an MRI showed some herniation and stenosis of your
spine, it was determined that surgery was not necessary, and
that these findings do not necessarily correlate with your
symptoms. Your neuropathic pain improved with Neurontin, and
your weakness is improving with physical therapy and
mobilization. You had a nerve conduction study prior to
discharge and these results can be followed up as an outpatient.
Your medications were changed in the following ways:
STARTED baby aspirin for history of cardiovascular disease
STARTED allopurinol every other day - ask your primary care
physician how long to continue this
STARTED insulin sliding scale - follow up with your primary care
physician about blood sugar control
STARTED insulin glargine (Lantus) before bedtime
STARTED nephrocaps
STARTED sevelamer carbonate
STARTED heparin shots - while you are unable to get out of bed
STARTED lidocaine swish and spit for Parotitis
INCREASED metoprolol from 100mg to 150mg daily
INCREASED gabapentin - follow up dosing based on renal function
STOPPED gemfibrozil - follow up with physician about when to
restart
STOPPED metformin - follow up with physician about when to
restart
STOPPED pravastatin - follow up with physician about when to
restart
CHANGED percocet to oxycodone - attempt to wean yourself off
this medication
Continue the rest of your medications as prescribed.
Do not drive or operate heavy machinery while taking narcotics
or Neurontin (gabapentin).
You will need to follow up with your primary physician to follow
up your hospitalizations and medications.
You will need to follow up with your urologist to determine when
your nephroureterostomy stent should be removed.
You will need to follow up with the neurologist within 1-2 weeks
of being discharged from rehab.
Followup Instructions:
See your primary care physician within one week to follow up
your hospitalizations.
Follow up with your urologist within 1-2 weeks of being
discharged from rehab. If you wish to transfer your urologic
care to [**Hospital1 18**], you may call ([**Telephone/Fax (1) 8791**] to schedule this
appointment with Dr [**Last Name (STitle) 3748**] instead. If you are going to transfer
care to Dr [**Last Name (STitle) 3748**] please bring your [**Hospital3 **] urologic
records with you.
Follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] of neurology within 1-2 weeks of
being discharged from rehab. Please call ([**Telephone/Fax (1) 5088**] to
schedule this appointment.
You are to continue with daily lab draws to monitor your kidney
function and weekly lab draws to monitor your blood count.
Department: WEST [**Hospital 2002**] CLINIC (NEPHROLOGY)
When: WEDNESDAY [**2140-5-11**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**] (with Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **])
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2140-3-29**]
ICD9 Codes: 5845, 2762, 2761, 2875, 5859, 3572, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1777
} | Medical Text: Admission Date: [**2106-3-30**] Discharge Date: [**2106-4-15**]
Date of Birth: [**2062-5-17**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Reglan / Sulfa (Sulfonamides) / Morphine /
Tetracycline / Seroquel
Attending:[**First Name3 (LF) 10223**]
Chief Complaint:
[**First Name3 (LF) 10964**] overdose
Pyelonephritis
C.difficle colitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 43 year-old female with a complicated history of
multiple sclerosis with a resultant neurogenic bladder and
chronic pyelonephritis, who was transferred from an OSH for a
liver transplant consult s/p [**First Name3 (LF) 10964**] overdose. She has been
taking large amounts of [**First Name3 (LF) 10964**] (3.5-5gm/day) for the last two
years to help alleviate her chronic abdominal pain and flank
pain from pyelonephritis. She was in her usual state of health,
until approximately three weeks ago, when she presented to an
OSH with abdominal pain, flank pain, vomiting, hypoglycemia,
high wbc count, and dysphagia. Six days prior to admission at
[**Hospital1 18**], after spending two weeks at the OSH, she returned home
with the diagnosis of viral enteritis. Upon returning home, she
developed severe right upper quadrant pain at rest that was
rated a [**11-22**]. The pain was of similar quality to her previous
pain at the OSH, constant, sharp, non-radiating, and increasing
with palpation. She experienced N/V (no blood) and a decreased
appetite, but denied any shortness of breath, chest pain, bright
red blood per rectum, or melena. To alleviate her abdominal
pain, she increased her pain medication to 10 tabs of [**Month/Year (2) 10964**] (5
gm/day) and Percocet 2 tabs q3hr (16tab x .325 = 5.2gm). Two
days prior to admission, she took an additional 10 tablets of
Darvoset. Her boyfriend found her unresponsive at home, and
took her to the OSH.
.
At the OSH, patient??????s vital signs were temp 97, heart rate 74,
blood pressure 98/52, respiratory rate 15, and O2 sat 96% RA.
She was noted to be lethargic with slurred speech. Her serum
acetominophen level, measured approximately 6 hours after
overdose, was found to be 220mg/ml. There was no clear time of
last ingestion. She was started on acetylcysteine. For her
blood sugar of 21, she was given D50W. A nasogastric tube was
placed, which yielded heme positive coffee grounds followed by
bilious material. She was guaiac positive. A KUB showed
increased stool without obstruction.
.
Labs at OSH included: WBC 14.8 HCT 43, plt 226. NA 145, K 3.8,
Cl 112, HCO3 19, BUN 26, CR 1.0. Glucose 21. AST 1394 ALT
2995 LDH 4039 Ammonia 16. Urine toxicology screen was
positive for Benzo, THC, Prophoxypteme
.
One day prior to admission, the patient was transferred to the
[**Hospital1 18**] for a liver transplant consult. Her vital signs were
stable. In the [**Hospital1 18**] ED, she was given acetylcysteine @ 3.2 gm
q4h IV, D5W @75cc/hr, and then switched to D10W for a finger
stick blood glucose in the 50s. For her N/V, she was given
ativan 2mg IV and anzemet 12.5mg. Her abdominal pain was treated
with dilaudid 0.5 mg IV.
.
In the MICU, acetylcysteine was continued at @ 3.2 gm q4h IV,
ativan was continued at 1mg IV q4hours for nausea, and dilaudid
was given 0.5mg IV q3hours for abdominal pain. She was
maintained on D5NS 100cc/hr. During this time, she became
febrile to 101.2. Urine cultures grew E.coli, and she was
started on Ceftriaxone.
.
After 24 hours of observation in the MICU, she was transferred
to medicine. At the time of the interview, the patient
complained of RUQ and RLQ pain [**11-22**] which was dulled to an [**9-22**]
with dilaudid. In addition, she reported left flank pain that
developed one day prior to admission. She reports constipation,
+N/V, and a decreased appetite.
Past Medical History:
1. Chronic pyelonephritis. S/p right nephrectomy in [**2097**].
2. Recurrent UTIs, up to 12 over the last 12 months. Similar
microbiology patterns with resistance to many antibiotics, but
sensitive to cefotetan.
3. Multiple sclerosis leading to a neurogenic bladder. Patient
had a chronic suprapubic catheter in place, which was removed
due to the multiple UTIs. Currently, patient self-catheterizes
bladder.
4. Pituitary adenoma resected in [**2103**].
5. Cholecystectomy. Date unknown.
6. Bowel resection secondary to obstruction. Date unknown.
7. Anxiety and depression. Patient is seen by a psychiatrist
once a month.
Social History:
Patient was living with her 12 year-old daughter, who is now
staying with her ex-husband during this hospitalization.
Patient??????s boyfriend, [**Name (NI) **], is her main source of support. Her
father lives in the area and her mother, who is currently in
[**Name (NI) 108**] for the winter with her step-father, are also extremely
supportive. She used to work as a telephone operator, but
stopped after her diagnosis with a pituitary adenoma. She has a
19 pack-year smoking history, and denies any alcohol or
recreational/IV drug use.
Family History:
Mother has Type 2 Diabetes Mellitus. Aunt (on mother??????s side)
had pancreatic cancer. Father is healthy. No family history of
heart disease
Physical Exam:
Vitals: Tm 100.8, HR 66, BP 120/66, RR 12, O2 sat 100RA
Gen: Thin, frail woman lying in bed uncomfortable and in pain.
HEENT:Head: NC/AT
Eyes: PERRL 3.5mm-> 3mm sluggish response. EOMI, No scleral
icterus.
Ears: Hears finger rub at 3 inches.
Nose: septum midline, intact. Membranes normal; no polyps,
discharge, sinus tenderness
Mouth: lips and membranes unremarkable. Moist. Top dentures.
Tonsils present.
Neck: full ROM. Thyroid palpable. Trachea midline.
Nodes: no palpable cervical, supraclavicular adenopathy.
CV: No JVD.
RRR, normal S1/S2, no M/R/G. No carotids bruits
Resp: Thorax symmetrical; no increased AP diameter or use of
accessory muscles.
Normal to percussion.
CTAB, no rales, wheezing.
Abd: Scaphoid
+BS in all four quadrants, no aortic bruits.
Soft, nondistended. Liver percusses 8cm in midclavicular line;
3cm below 12th rib.
+ right upper and lower quadrant abdominal tenderness. Liver
tip is not palpable (area was too painful for deep palpation), +
rebounding, minimal guarding. + left CVA tenderness. No
hepatosplenomegaly or masses.
Ext: No clubbing/cyanosis/edema. Cool and dry. 2+ tibialis
anterior, posterior pedis, and radial pulses bilaterally
Rect: Guaiac positive
Skin: Right port-a-cath in place for approximately 1 month.
Neuro: No asterixes
MS: Awake and alert, oriented to ??????[**Known firstname **] [**Known lastname 61332**]??????, ??????hospital??????,
??????[**2106-3-16**]??????. Slow speech, comprehends. Registers [**4-15**],
recalls 0/3 at 5 mins. No hallucinations/delusions. No
suicidal ideations.
CN: EOMI without nystagmus, no ptosis. Sensation intact to LT,
masseters strong symmetrically. Face symmetric. Mild facial
motor weakness. Voice normal, palate symmetric. [**6-17**] SS
bilaterally. Tongue midline, no atrophy or fasciculation.
Motor:
D [**Hospital1 **] Tri IO Grip Q H [**Last Name (un) 938**] G
L 4+ 5 5 5 5 5 5 5 5
R 4 4 4 4 4 5 5 5 5
Reflexes:
[**Hospital1 **] Tri BR Pat Ach Plantar
L 2 2 2 2+ 2+ no response
R 2+ 2+ 2+ 2+ 2+ no response
[**Last Name (un) **]: intact to LT
Pertinent Results:
Admission labs
[**2106-3-30**] 05:24AM BLOOD WBC-13.4* RBC-4.51 Hgb-13.4 Hct-40.6
MCV-90 MCH-29.6 MCHC-32.9 RDW-17.5* Plt Ct-189
[**2106-3-30**] 05:24AM BLOOD Neuts-88.3* Bands-0 Lymphs-9.9*
Monos-0.4* Eos-1.2 Baso-0.2
[**2106-3-30**] 05:24AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-OCCASIONAL
Polychr-NORMAL Tear Dr[**Last Name (STitle) 833**]
[**2106-3-30**] 05:24AM BLOOD PT-16.2* PTT-26.4 INR(PT)-1.7
[**2106-3-30**] 05:24AM BLOOD Glucose-95 UreaN-21* Creat-0.8 Na-141
K-3.5 Cl-111* HCO3-19* AnGap-15
[**2106-3-30**] 05:24AM BLOOD ALT-2449* AST-1044* LD(LDH)-754*
AlkPhos-97 Amylase-62 TotBili-0.8
[**2106-3-30**] 05:24AM BLOOD Albumin-3.7 Calcium-9.0 Phos-2.1* Mg-1.8
[**2106-3-30**] 05:24AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-106.7*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2106-3-30**] 12:02PM BLOOD Type-ART pO2-92 pCO2-33* pH-7.35
calHCO3-19* Base XS--6
KUB:([**3-30**]):No evidence of bowel obstruction or perforation.
Nasogastric
tube in satisfactory position. Focal narrowing of gas column in
transverse
colon likely represents peristalsis, although clinical
correlation with
patient's history is recommended
Labs on transfer to floor
[**2106-3-31**] 05:07AM BLOOD WBC-7.6 RBC-3.62* Hgb-10.9* Hct-32.6*
MCV-90 MCH-30.0 MCHC-33.3 RDW-17.7* Plt Ct-154
[**2106-3-31**] 05:07AM BLOOD PT-15.4* PTT-28.0 INR(PT)-1.5
[**2106-3-31**] 05:07AM BLOOD Plt Ct-154
[**2106-3-31**] 05:07AM BLOOD Glucose-110* UreaN-10 Creat-0.7 Na-145
K-3.5 Cl-117* HCO3-22 AnGap-10
[**2106-3-31**] 05:07AM BLOOD ALT-1384* AST-195* AlkPhos-82 Amylase-82
TotBili-0.5
[**2106-3-31**] 05:07AM BLOOD Lipase-32
[**2106-3-31**] 05:07AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.5*
ALT/AST 1110/117; hct 33; PT 14 PTT 25 INR 1.4
Bld cx [**3-30**]
Urine cx [**3-30**] e coli >100,000
Brief Hospital Course:
Patient is a 43 year-old female with a complicated history of
multiple sclerosis with a resultant neurogenic bladder and
chronic pyelonephritis, who presented approximately 24 hours s/p
[**Month/Year (2) 10964**] overdose. Her hospitalization was complicated by
pyelonephritis, c.difficle colitis, and hypotension.
1. [**Month/Year (2) 10964**] Overdose/Liver failure. Patient reported that large
quantities of [**Month/Year (2) 10964**] were taken for pain control, with no
intent of hurting self. There is no clear time of patient??????s
last ingestion, and given her chronic use of [**Month/Year (2) 10964**] and recent
increase in acetominophen intake, the obtained concentration is
may not represent her peak concentration. Serum acetominophen
at 6 hours 220, 12 hours 107, 18 hours 24. During the hospital
course, the patient's liver function improved.
She was monitored by the hepatology team for the need of a liver
transplantation with [**Doctor Last Name 3728**] college criteria for liver
transplantation. No transplantation was needed. Liver enzymes
were measured q12 hours and steadily improved and NAC was
continued until her liver function tests normalized on hospital
day #5.
normalized within first week of hospitalization. Amylase and
lipase were also monitored, and although nml on admission,
reached peaks on [**4-11**] and have subsequently trended down.
PT/INR/PTT were measured q6h with no evidence of coagulopathy.
There were no signs of hepatic encephalopathy - no changes in MS
no signs of asterixes during admission.
2. UTI/Pyelonephritis: Pt with h/o recurrent UTIs likely [**3-17**]
neurogenic bladder. Pt has MS and, although + UOP, often must
straight cath herself at home. Patient developed a severe [**11-22**]
L flank on day 1 of hospitalization, which increased with
palpation and did not radiate. She spiked a fever to 101.2 and
complained of N/V. Given patient??????s history of chronic
pyelonephritis, self-catherization, and clinical findings, this
is most likely pyelonephritis. Urine culture + for E.coli and
Enterococcus. Patient was initially started on ceftriaxone 1 gm
IV q24hours. On day 4, the urine culture was + for E.coli.
Imipenum 500mg IV q6hours was started and ceftriaxone was
d/c'ed. On day 7, the urine culture was + enterococcus, and the
patient was started on Vancomycin 1000mg IV q12. Repeat urine
cx from [**4-10**] had no growth. Mr. [**Known lastname 61332**] complete 2 week course
of imipenem while in house. She was discharged on day 10 of
vancomycin, with home health arranged to administer last 4
doses. She had foley in during most of admission, but was making
good UOP after foley removed. Given neurogenic bladder, pt self
caths as needed at home.
3. Colitis/diffuse abdominal pain. Patient with diarrhea,
abdominal pain, leukocytosis occurring after antibiotic
administration. Pt has chronic abd pain and [**Month (only) **] peristalsis,
thought to be [**3-17**] autonomic dysfunction. Pt had NGT in place on
transfer to [**Hospital1 18**]. Given abd pain and large amount of drainage
suctioned on arrival, she had KUB/CT scan r/o obstrcution.
KUB/CT from [**3-31**] without evidence of obstruction. However, given
interval increase in pain of RUQ and RLQ repeat abd CT was done
on [**4-3**] with evidence of development of colonic wall thickening,
involving the transverse colon, splenic flexure, and descending
colon, findings that are consistent with colitis. Stool culture
+ for c. diff. Patient was maintained on 1000 ml NS continuous
at 150 ml/hr. On hospital day 5, Flagyl 500mg IV tid was started
and continued throught admission. Follow up CT on [**4-11**] with
diffuse mesenteric and subcutaneous edema. Unremarkable
appearance of small bowel and colon on this examination with no
wall thickening and apparent resolution of colitis. Pt continued
to have abd pain during admission which was managed to her
satisfaction with dilaudid. On [**4-14**] she noted inc distention of
abd/no BMX3 days and repeat KUB was done to r/u obstruction. KUB
significant only for small dilated loop of bowel in small int
which is attributed to her chronic poor gut
motility/peristalsis. Given that she was on broad spectrum IV
abx until day of discharge, 14 day course of PO flagyl was
started on discharge.
Please see nutrition section for more info, but briefly pt not
tolerating PO and inc secretions via NGT early during admission
- so TPN started on [**4-2**]. Attempted clamping of NGT periodically
but not tolerated until [**4-12**]. Finally, pt tolerating liquids and
soft custards and NGT pulled out on [**4-14**]. Pt continued on cycled
TPN, which was continued on discharge.
3. Anemia and upper GI bleed. On admission, patient's HCT had
dropped from 40.6-32.6 (In 24 hours). NG lavage at OSH showed
coffee ground particles and LBM tonight consisted of a scant amt
of dark red blood. Given [**Month/Day (2) **] o/d, differential for Upper GI
bleed at that time included gastritis, esophagitis,
[**Doctor First Name **]-[**Doctor Last Name **] tear (from vomiting), PUD, Dieulafoy??????s lesion.
Endoscopy was done at OSH. NGT aspirate and stools were guaiac
positive. Patient remained stable throughout hospital course
until evening of [**4-2**] when she experienced inc bloody aspirate
from NGT - hct remained stable but GI was consulted for further
management. Given stable hct and recent EGD at OSH, she was
managed conservatively with serial hct checks. Hct slowly
drifted down from 31.0 on [**4-2**] to 24.8 on [**4-6**] at which time she
was transfused 1 unit of PRBCs. Hct bumped appropriately and was
stable throughout remainder of admission. Will cont PPI on
discharge
4. Hypoglycemia. Resolved during hospitalziation. This was
most likely secondary from hepatic dysfunction -> decrease in
glucose production in setting of [**Month/Year (2) **] overdose.
6. N/V. Pt has had nausea for many years, but much increased
during this admisison. Likely multifactorial including decrease
gastric mobility from MS [**First Name (Titles) **] [**Last Name (Titles) 10964**] overdose vs pyelonephritis.
Has tried multiple antiemetics but has found that most relieving
regimen is phenergan with ativan prn.
7. Weight loss. Patient reports 81b weight loss over last 2
years, attributed to decreased appetite s/p pituitary resection.
Also concerning for neoplasm or eating disorders ?????? anorexia or
bulemia. Given inability to tolerate POs, PICC line was placed
on [**4-2**] and pt was started on TPN. Nutrition followed pt
throughout hospitalization. Pt tolerating PO liquid, but very
slow to tolerate soft diet. She has tolerated custards and
italian ice and jello and is slowly starting to tolerate soups.
Will continue to SLOWLY advance diet on discharge. Began
cycling TPN on [**4-13**] and she is now receiving TPN 12 hours
overnight. On discharge, she will continue overnight TPN cycling
for 12 hours. Heparin can be stopped as she is ambulatory. Will
have weekly labs drawn and sent to [**Hospital1 18**] nutrionist/TPN group
who will adjust TPN additives as necessary. Will also wean off
TPN as tolerated.
8. Hypotension: pt with baseline SBP in 100's but [**Month (only) **] to 80-90s
during admission; min response to fluid bolus - unclear etiology
- hct stable despite UGI bleed earlier during admit. Likely
multifactorial including her h/o autonomic dysfunction vs [**Month (only) **]
fluid volume from [**Month (only) **] PO intake/HGT suction vs SE of pain meds.
She was completely asymptomatic with SBPs in 90s.
9. Tobacco use. Patient has a 19 pack-year smoking history.
She was continued on Nicotine 14 mg TD daily. DIscussed smoking
cessation with pt who feels that this hospitalization may be the
beginning of her smoking cessation. WIll cont the patch on d/c
and discussed with pt that she cannot smoke while wearing the
patch.
Prior to discharge, discussed all of the above
events/complications with Ms. [**Known lastname 61333**] [**Last Name (Titles) 3390**]. [**Name10 (NameIs) **] will see her in
clinic the day after discharge and will follow her progress
closely.
Medications on Admission:
At home:
MVI I tab daily
Clonazepam (Klonopin) (dose unknown)
Venlafaxine (Effexor) (dose unknown)
Docusate (Colace) (dose unknown)
Folate (dose unknown)
Fentanyl patch 100mcg/hour
Acetominophen ([**Name10 (NameIs) 10964**]) 500mg PO q4-6hours
Percocet 2 tabs q3hr
.
Meds on transfer
Hydromorphone (Dilaudid) 0.5-1 mg IV Q3-4H:PRN
Ipratropium Bromide (Atrovent) MDI 2 PUFF IH Q4-6H:PRN
Acetylcysteine 20% 3200 mg IV Q4H
Lorazepam (Ativan) 0.5-2 mg PO/IV Q4H:PRN
Albuterol [**2-14**] PUFF IH Q6H:PRN
Nicotine 14 mg TD DAILY
Bisacodyl (Dulcolax) 10 mg PO/PR DAILY:PRN
Pantoprazole (Protonix) 40 mg IV Q24H
Ceftriaxone (Rocephin) 1 gm IV Q24H
Dolasetron Mesylate (Anzemet)25 mg IV Q8H:PRN
Discharge Medications:
1. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gm
Intravenous once a day for 4 days.
Disp:*4 gms* Refills:*0*
2. Outpatient Lab Work
Please check CBC, Chem-7, glucose, triglycerides, calcium,
magnesium, and phosphorus weekly from port-a-cath
Please fax results to [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 18971**] at [**Telephone/Fax (1) **]
3. Infusion pump
Infusion pump for TPN, 60/60
4. Catheter care
Catheter care per NEHT protocol
5. heparin flush
Heparin 100u/ml, 5mL flush SASH and prn, or QD for line
maintenance
6. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Transdermal
once a day.
Disp:*30 * Refills:*2*
7. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*2*
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
11. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
12. Clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
13. Promethazine HCl 25 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours) as needed for nausea.
Disp:*50 Suppository(s)* Refills:*1*
14. Promethazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea: please use if not
tolerating suppository.
Disp:*30 Tablet(s)* Refills:*1*
15. Ativan 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
16. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Chartwell Home therapies
Discharge Diagnosis:
Primary Diagnosis:
1. [**Telephone/Fax (1) 10964**] overdose
2. complicated UTI
3. Persistent Nausea/emesis requiring TPN
4. C. Diff Colitis
5. Pyelonephritis
Discharge Condition:
stable
Discharge Instructions:
Please call your [**Telephone/Fax (1) 3390**] or return to the emergency department if
you develop fevers, chills, worsening abdominal pain, nausea ,
vomiting, or other worrisome symptom.
Please follow up with your [**Telephone/Fax (1) 3390**] this [**Name9 (PRE) 2974**] [**2106-4-16**] as scheduled.
Please take all medications as prescribed.
You will continue to recieve TPN for 12 hours at night, but
continue to eat food by mouth as tolerated.
Followup Instructions:
Please follow up at Dr.[**Name (NI) 61334**] office this friday, [**2106-4-16**]
at 3:30 PM.
ICD9 Codes: 2765, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1778
} | Medical Text: Admission Date: [**2167-2-19**] Discharge Date: [**2167-3-12**]
Date of Birth: [**2098-3-27**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Betalactams / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 68 year-old female with CLL, HTN, CAD, CHF (EF
65% 1/08), hyperlipdemia, hypothyroid, CKD (baseline creatinine
1.3), DM2, anemia, and gout referred in by the oncologist from
[**Hospital1 **] for AMS. Per record, on arrival to onc clinic she was
obtunded, somnolent, drifting to sleep and snoring with BP
readings in the 90 to 105, which is unusually low for her.
Patient was recently diagnosed with a UTI and started on
macrodantin on [**2-17**] for culture positive UTI. She also was
started on oxycontin day prior to presentation for tooth pain.
She was also noted to have worsening renal failure with increase
in creatinine from 2 to 2.8, and worsening thrombocytopenia
requiring a bag of platelets.
In the ED patient had a head CT which was negative for
hemorrhage or mass effect and a CXR which was unremarkable. She
received 1 gram of Vancomycin and 400 mg of IV Cipro, one amp of
D50, and tylenol.
On arrival to the floor, patient is sleeping deeply and awakens,
startled, speaking in Spanish. She is initially disoriented but
is soon oriented to person, place, date, and time. She does not
know why she is here other than "[her] doctor wanted [her] to
come." With prompting from reviewing the record, she says that
she's been feeling tired for a couple days. Denies any pain,
recent diarrhea or constipation. Her only complaint is mouth
pain including her tongue and teeth.
Past Medical History:
-CLL: Dx in [**12-16**] by periph blood flow cytometry. CT scan showed
abdominal & cervical LAD, and large right pelvic mass.
Excisional biopsy of left supraclavicular node pathology and
immunohistochemistry c/w CLL. BM Bx [**12-16**] revealed extensive
infiltration, with 40% marrow cellularity. Pt was asympt &
deferred Tx until F/sweats in [**1-17**] & Tx was started
w/fludarabine ([**2164-1-24**]). Rituxan was added to 2nd cycle.
However her chemotherapy course was complicated by febrile
neutropenia. After two cycles of fludarabine this was changed to
single [**Doctor Last Name 360**] Rituxan, and she completed four weeks of
consolidation. Her post-chemotherapy course was complicated by
febrile neutropenia and pancytopenia. Her bone marrow was again
assessed in [**8-/2162**] and was consistent with treated CLL. She
remained thrombocytopenic following this without a response to
steroids and only minimal response to IVIG. Rituxan weekly was
given from [**2164-10-10**] through [**2164-11-2**] and platelets recovered
to about 30,000. Bone marrow biopsy on [**10/2164**] suggested a
sustained response to chemotherapy on the megakaryocytes. She
began maintenance Rituxan on [**4-/2165**], but her course was
complicated by diffuse arthralgias. Due to increasing painful
lymphadenopathy and IVC compression seen on CT, she was treated
with chlorambucil from [**2166-2-24**] through [**2166-4-3**]. This was
then stopped due to thrombocytopenia. Chlorambucil was restarted
at 4mg dose on [**2166-8-29**] when she progressed with painful
adenopathy. This was given concurrently with prednisone to treat
ITP. The chlorambucil was discontinued on [**2166-10-2**]. A second
course was again started on [**2166-11-20**].
- HTN with multiple admissions for hypertensive urgency. Most
recent admission with neurological complaints that resolved on
outpatient regimen
- CAD: diffuse multi-vessel disease. LAD stent [**12-17**]
- CHF
- High cholesterol
- Hypothyroid
- Chronic renal insufficiency with baseline Cr about 1.3
- Anemia
- gout
- DM 2
Social History:
From [**Male First Name (un) 1056**]. Married. Works as cashier. Denies T/A/D
Family History:
The patient notes a mother with a myocardial infarction at the
age of 71. A sister with a myocardial infarction at the age of
47. Otherwise, denies any further family history.
Physical Exam:
VS: T: 98.0 BP: 123/68 P: 90 RR: 22 O2 sat: 99% 2L
GEN: sleepy, NAD, + anasarca
HEENT: AT, NC, EOMI, no conjuctival injection, anicteric,
yellow-brown coating on tongue with foul odor, multiple
scattered petichial lesions on tongue, poor dentition, MMM, neck
supple,
CV: RRR, nl s1, s2, no m/r/g
PULM: Crackles [**1-15**] way up BL with good air movement throughout
ABD: soft, NT, ND, + BS, scattered eccymoses
EXT: warm, dry, distal pulses BL, no femoral bruits
NEURO: alert & oriented, CN II-XII grossly intact, limited
attention span, unable to recall [**3-16**] items, 5/5 strength
throughout. No sensory deficits to light touch appreciated. +
asterixis, no pronator drift, intact FNF
Pertinent Results:
LABS ON ADMISSION:
[**2167-2-19**] 03:29PM GLUCOSE-70 LACTATE-1.1
[**2167-2-19**] 03:30PM WBC-2.5*# RBC-2.59* HGB-7.9* HCT-24.2* MCV-93
MCH-30.5 MCHC-32.6 RDW-18.3*
[**2167-2-19**] 03:30PM CK-MB-NotDone cTropnT-0.03* proBNP-1678*
[**2167-2-19**] 03:30PM GLUCOSE-75 UREA N-113* CREAT-2.7* SODIUM-138
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-31 ANION GAP-13
[**2167-2-19**] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2167-3-4**] 10:06AM BLOOD TSH-3.9
[**2167-3-4**] 10:06AM BLOOD Free T4-1.5
.
LABS ON DISCHARGE:
[**2167-3-10**] 08:22AM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEG
[**2167-3-12**] 12:00AM BLOOD WBC-3.7* RBC-2.57* Hgb-8.0* Hct-23.6*
MCV-92 MCH-31.0 MCHC-33.8 RDW-18.1* Plt Ct-28*
[**2167-3-10**] 02:30PM BLOOD Neuts-25* Bands-0 Lymphs-63* Monos-8
Eos-1 Baso-0 Atyps-1* Metas-2* Myelos-0
[**2167-3-12**] 12:00AM BLOOD Glucose-145* UreaN-11 Creat-0.9 Na-141
K-3.5 Cl-99 HCO3-35* AnGap-11
.
[**2167-2-19**] HEAD CT: FINDINGS: There is no hemorrhage, edema, mass
effect, hydrocephalus or acute territorial infarct. Since the
previous study, the patient has been extubated. No soft tissue
abnormalities are appreciated. Visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION: No evidence of hemorrhage or mass effect.
.
[**2167-2-19**] CXR (AP PORT): IMPRESSION: No acute cardiopulmonary
process.
.
[**2167-2-19**] EKG: Atrial fibrillation with moderate ventricular
response. Modest inferolateral ST-T wave changes which are
non-specific. Compared to the previous tracing of [**2167-1-27**] there
is no significant diagnostic change.
.
[**2167-2-22**] LUE US: IMPRESSION: PICC line in the left brachial vein
without evidence of deep venous thrombosis in the left upper
extremity.
.
[**2167-2-23**] NECK US: IMPRESSION:
1. No evidence of internal jugular deep vein thrombosis.
2. No abscess.
3. Multiple enlarged lymph nodes consistent with history of CLL.
.
[**2167-2-23**] CXR (PA & LAT): IMPRESSION:
1. New vascular engorgement and perihilar haziness likely due to
fluid overload or CHF. Coexistent pulmonary infection cannot be
excluded.
2. Small bilateral pleural effusions.
.
[**2167-2-23**] Echo: The left atrium is dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild pulmonary artery systolic hypertension.
.
[**2167-3-1**] CXR (PORT): IMPRESSION: Worsening CHF with now moderate
pulmonary edema.
.
[**2167-3-2**] CXR: There has been continued worsening in pulmonary
edema with increased consolidation in the left upper lobe.
Cardiomegaly is unchanged. There is no pneumothorax. Small right
pleural effusion is stable.
.
[**2167-3-3**] CT HEAD: IMPRESSION: No evidence of hemorrhage, mass
effect, or significant interval change.
.
[**2167-3-5**] ECHO: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%) and regional function is normal.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue
velocity imaging are consistent with Grade II (moderate) LV
diastolic dysfunction. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
normal free wall contractility. The aortic valve leaflets (3)
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. There
is moderate pulmonary artery systolic hypertension. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade.
Compared with the prior study (images reviewed) of [**2167-2-23**],
findings are similar except patient now in sinur rhythm.
.
[**2167-3-6**] RUE US: IMPRESSION: No evidence of deep vein thrombosis
of the right upper extremity.
.
[**2167-3-6**] CXR (AP PORT): IMPRESSION: AP chest compared to
[**Month (only) 956**]. Predominantly perihilar consolidation in both lungs
with a smaller region of abnormality at the right base laterally
has worsened since [**3-4**], probably unchanged since the
21st. Severe cardiomegaly, mediastinal vascular engorgement are
other indications of cardiac decompensation. Left PIC catheter
tip projects over the junction of brachiocephalic veins.
Small-to-moderate right pleural effusion is stable. No
pneumothorax.
.
MICRO:
[**2167-2-19**] UCX neg
[**2167-2-19**] BCX neg x 2
[**2167-2-23**] BCX neg x 2
[**2167-2-23**] UCX: Ecoi
URINE CULTURE (Final [**2167-2-27**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
ESCHERICHIA COLI. ~8OOO/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 4 S =>32 R
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- R R
CEFTAZIDIME----------- R R
CEFTRIAXONE----------- =>64 R =>64 R
CEFUROXIME------------ =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S 2 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 64 I
PIPERACILLIN---------- =>128 R =>128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S 4 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
.
[**2167-3-3**] UCX neg
[**2167-3-4**] UCX: Ecoi
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2167-3-4**] BCX neg
[**2167-3-5**] BCX neg
Brief Hospital Course:
The patient is a 68 year-old female with PMH of CLL, HTN, CAD,
chronic stable diastolic CHF (EF >60%), hyperlipdemia,
hypothyroid, CKD (baseline creatinine 1.3), DM2, anemia, a-fib,
and gout admitted with AMS, UTI, and renal failure.
.
HOSPITAL COURSE BY PROBLEM:
.
#) AMS. Etiology was likely multifactorial. The patient p/w
known UTI and recent neutropenia, and was recently started on
oxycontin for pain. She was also on gabapentin while in acute on
chronic renal failure. Review of her meds show multiple sedating
agents. Head CT on admission was negative. Patient's mental
status returned to baseline shortly after admission; however,
she was noted to occasionally sundown. She responded well to
0.5mg haldol for this. Blood cultures were negative. She
received treatemnt for her UTI, as below. The patient should
avoid medications such as oxycontin, lorazepam, diphenhydramine,
gabapentin.
.
#) UTI. Patient was being treated for reported "pan-sensitive"
E. coli with nitrofurantoin at rehab. Per rehab, she also did
receive imipenem. On admission she was started on IV
ciprofloxacin for coverage, which was changed to Bactrim for
10-day course given sensitivities. This was again changed to
nitrofurantoin when cultures returned as bactrim-resistent
strain. 10 day course will be completed on [**2167-3-15**].
.
#) Febrile neutropenia: The patient had febrile neutropenia
(GRAN count 80 on [**2-20**])during admission without clear source. CXR
was negative for consolidation, blood cultures were negative.
Sites of previous biopsy showed no e/o abscess (though
+fluctuance on exam). Other possible sites included sacral wound
and tooth decay. The patient has lactam allergy and received
imipenem at rehab, which could also be considered a cause of her
neutropenia. The patient was started on broad antibiotic
coverage -- aztreonam for gram negatives, vanco for gram
positives, and clindamycin for anaerobes (mouth flora in
presence of oral sores) which was narrowed to flaygl (stomach
upset with clinda) for mouth flora and bactrim (changed to
nitrofurantoin based on sensitivities) for UTI. The patient
quickly defervesced and GRAN count increased steadily to 930 by
[**3-4**].
.
#) SOB/HYPOXIA: Had occasional O2 requirement this
hospitalization w/ significant SOB [**3-2**] overnight in setting of
transfusions. TRALI was considered, but the patient improved
quickly with diuresis and nebulizer treatments. On [**2167-3-4**], the
patient had an acute episode of hypoxia which necessitated ICU
transfer. The patient had SOB and hypoxia in setting of HTN and
tachycardia (afib with RVR) consistent with flash pulmonary
edema. CXR showed volume overload and echo showed mild diastolic
dysfunction with preserved EF. CEs were cycled frequently and
were negative. She was aggressively diuresed and continued on
nebs ATC, supplemental O2 PRN, and continued on rate control
with diltiazem and carvedilol. She was seen by the heart failure
team to titrate her regimen, and is scheduled for follow-up with
Dr. [**First Name (STitle) 437**] as an outpatient.
.
#) Atrial Fibrillation w/ RVR: Likely triggered by hypoxia in
setting of flash edema ([**2-14**] HTN). She was continued on
carvedilol and diltiazem with good rate control. Rhythm was
mostly in sinus for duration of hospital course. With cardiology
input, she was determined not to be a candidate for
anticoagulation secondary to chronic low platelets.
.
#) Hypertension: Patient has history of malignant hypertension
in prior admissions with symptoms of headache and
epigastric/left sided chest pain. Patient is now on a fairly
extensive med regimen including lisinopril, BB, nitrate,
clonidine patch, and diltiazem which should be continued as an
outpatient.
.
#) CAD: The patient was continued on ASA, beta-blocker,
ACE-inhibitor, nitrate. Cardiac enzymes are negative on
admisison, recycled [**3-2**]. ECG w/o new ST-T changes. The patient
did have significant chest pain with her rapid a-fib and
received nitroglycerin with good effect.
.
#) ARF: The patient had a creatinine of 2.8 from baseline ~ 1.3
This trended back to baseline with diuresis and antibiotics.
Creatinine on discharge was 0.9.
.
#) Pancytopenia. Patient has CLL and chronically has low counts;
however, her white count on admission was very low compared to
her usual baseline. Marrow infiltration vs. medication effect
were considered; however, recent bone marrow biopsy on [**12-20**] was
not suggestive of a clear explanation to account for
pancytopenia. Retic count inappropriately low. Smear not very
impressive but confirms pancytopenia, also some larger RBCs.
Etiology was most likely felt to be c/w medication-effect as the
patient did receive imipenem at rehab and has history of
leukopenia w/ beta-lactam antibiotics. Her ANC returned to
baseline but platelets remained low. She required a total of 3
platelet transfusions (on [**2-23**], -18, and -25) and 4 PRBC
transfusions ([**2-21**] x 2, -17, and -21) during her hospital course.
.
#) CLL. Further management per Dr. [**Last Name (STitle) **]. The patient will
follow-up with Dr. [**Last Name (STitle) **] in [**2-15**] weeks from discharge.
.
#) Thrush/dental pain: Continued nystatin swish, peridex. The
patient had panorex x-ray and was seen by the dental team who
recommended extraction when medically stable. The patient
completed a 10 day course of flagyl for mouth sores.
.
#) Yeast infection. The patient was started on 3 day course of
miconazole for yeast infection on [**3-12**].
.
#) Diabetes. on HISS in house with no acute issues.
.
#) Hypothyroidism. The patient was continued levothyroxine 75mcg
daily.
.
#) Communication. HCP son [**Name (NI) **] [**Telephone/Fax (1) 108998**]; [**Name2 (NI) 4906**] [**Name (NI) **]
[**Telephone/Fax (1) **]
.
#) Code Status. Full Code -- confirmed with patient and HCP, but
patient would not want "heroic measures".
.
#) The patient was discharged to rehab on [**3-12**] in good
condition, VSS, ambulating well with walker, with good O2
saturations on 2L NC.
Medications on Admission:
Per last d/c summary dated [**2167-2-2**]
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. Erythromycin 5 mg/g Ointment Sig: 1-2 drops Ophthalmic QID (4
times a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
9. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
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. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
15. Gabapentin 400 mg Tablet Sig: One (1) Tablet PO at bedtime.
16. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO Q
8H (Every 8 Hours).
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Maalox 200-200-20 mg/5 mL Suspension Sig: Fifteen (15) ML PO
TID (3 times a day) as needed for heartburn.
19. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
20. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for
wheezing.
21. Insulin
Humalog Insulin Sliding Scale
22. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for anxiety.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest Pain.
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
12. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
13. Carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
16. Miconazole Nitrate 200-2 mg-% (9 g) Combo Pack Sig: One (1)
Combo Pack Vaginal HS (at bedtime) for 3 days: day 1 = [**3-12**], to
complete 3 days.
17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
18. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
19. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 3 days: 10 day course to end
[**3-15**] .
20. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): hold for SBP < 100.
21. Humulog insulin sliding scale
Gluc Breakfast Lunch Dinner HS
0-50 mg/dL 4 oz. Juice 4 oz. Juice 4 oz. Juice 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
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Delirium
2. Urinary Tract Infection
3. Atrial Fibrillation with Rapid Ventricular Rate
4. Pulmonary Edema
5. Acute Diastolic Congestive Heart Failure
6. CLL
7. Hypertension
8. Coronary Artery Disease
9. Type 2 Diabetes Mellitus
.
SECONDARY DIAGNOSIS:
1. Hypercholesterolemia
2. Hypothyroidism
3. Chronic renal insufficiency with baseline Cr about 1.3
4. Anemia
5. Gout
Discharge Condition:
Stable. Patient can ambulate 80 feet of flat distance with
assistance, tolerates 2L of oxygen.
Discharge Instructions:
You were admitted to the hospital with confusion due to a
urinary tract infection and renal failure. While you were here,
you also developed very high blood pressure, rapid and irregular
heart rate, and difficulty breathing. These have all improved
significantly during treatment in the hospital.
.
We have treated your urinary tract infection with an antibiotic
called bactrim for seven days. We have also started you on
another antibiotic called nitrofurantoin, which should be
completed on [**2167-3-15**].
.
You also developed severe shortness of breath due to your rapid
and irregular heart rate, heart failure, and elevated blood
pressure. Your breathing improved significantly with duiretics
(water pills) and blood pressure medicines. It will be important
for you to follow-up with the heart failure doctor, Dr. [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) 437**].
.
Please continue to take your medications on the list provided.
(Please note that there have been several changes so you should
follow the updated list.)
.
If you experience any fevers > 100.5, chills, confusion,
shortness of breath, chest pain, palpitations, chest pain, or
any other concerning symptoms please call your PCP or go to the
ER for further evaluation.
Followup Instructions:
- Please follow-up with your cardiologist DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] at
your appointment on [**2167-3-16**] 10:30. If you need to reschedule,
please call his office at [**Telephone/Fax (1) 3512**].
.
- Please follow up with your Oncologist, Dr. [**Last Name (STitle) **], within [**2-15**]
weeks of discharge. We are trying to arrange an appointment for
you on Thursday [**2167-3-26**], but you should call the clinic to
confirm this. Phone: ([**Telephone/Fax (1) 15328**].
.
Please also follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within 2 weeks
of discharge. Phone [**Telephone/Fax (1) 14918**].
ICD9 Codes: 5849, 5990, 4280, 2449, 2724, 5859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1779
} | Medical Text: Admission Date: [**2118-9-7**] Discharge Date: [**2118-9-10**]
Date of Birth: [**2043-6-22**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
right lower extremity weakness and hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75yo female with a history of spinal stenosis s/p left
hemilaminectomy spinal surgery (L4-S1) on [**2118-8-22**] with a
post-operative course complicated by PE initially presented for
further evaluation of worsening right lower extremity numbness
and pain. While in the ED, patient developed hypotension and
syncope syncope and was transferred to MICU for further work-up
of hypotension.
.
Patient has a history of L4-S1 spinal stenosis and underwent a
left hemilanectomy on [**2118-8-22**] with significant improvement in
left lower extremity strength and pain; however she has had
persistent back pain. Then one day prior to admission she
noticed the sudden onset of [**9-7**] back pain that radiated to her
right thigh and foot with associated difficulty walking. She
initially presented to [**Hospital6 33**] for further
evaluation with vital signs of temp 99.3, HR 68, BP 115/57, RR
18, and pulse ox 99% on room air. She was transferred to [**Hospital1 18**]
for further MRI evaluation as MRI could not be performed at
[**Hospital6 33**]. She received ativan 1mg PO x 1 and
morphine 2mg x 1.
.
Upon arrival to [**Hospital1 18**] ED temp 99.2, HR 87, BP 85/50, RR 14, and
98% pulse ox. An MRI was performed which demonstrated residual
L5-S1 stenosis. Neurosurgery evaluated the patient and thought
her pain and numbness were likely secondary to residual canal
stenosis and she would benefit from a right hemilanectomy. While
in the ED, BP decreased to 68/26 and she had an episode of
syncope upon standing. She received 3L NS and zofran 4mg IV x 2
and toradol 15mg IV x 1. She reports that her blood pressure is
typically 90/70.
Past Medical History:
Spinal Stenosis - s/p left hemilaminectomy spinal surgery
(L4-S1) on [**2118-8-22**]
Pulmonary embolus - during post-operative course
Gallstones
Glaucoma
Hypothyroidism
Social History:
Home: caregiver for husband with COPD and sister with [**Name (NI) 11964**]
Tobacco: quit 30 years ago
EtOH: drinks [**11-30**] glasses of wine/day
Drugs: Denies
Family History:
noncontributory
Physical Exam:
T 97.9 / BP 103/49 / HR 64 / RR 18 / Pulse ox 100% 2L NC / Wt
73.9 kg
Gen: pleasant, speaking comfortably in full sentences, no acute
distress
HEENT: Clear OP, dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength throughout. trace patellar reflexes
bilateral and symmetric. Babinski sign absent bilaterally. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2118-9-7**] 09:16AM LACTATE-1.2
[**2118-9-7**] 09:00AM CK(CPK)-34
[**2118-9-7**] 09:00AM cTropnT-<0.01
[**2118-9-7**] 09:00AM CK-MB-NotDone
[**2118-9-7**] 09:00AM HCT-34.5*
[**2118-9-7**] 01:35AM GLUCOSE-101 UREA N-11 CREAT-0.7 SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-30 ANION GAP-11
[**2118-9-7**] 01:35AM CK(CPK)-23*
[**2118-9-7**] 01:35AM CK-MB-4 cTropnT-<0.01
[**2118-9-7**] 01:35AM WBC-8.2 RBC-3.76* HGB-12.3 HCT-35.7* MCV-95
MCH-32.7* MCHC-34.4 RDW-13.6
[**2118-9-7**] 01:35AM PT-23.4* PTT-48.4* INR(PT)-2.3*
------------------
[**2118-9-7**] - CXR - Findings at the left CP angle, which could
represent small pulmonary infarct with effusion in this patient
with apparently known pulmonary embolism.
--------------------
[**2118-9-7**] - MR L spine - CONCLUSION: Apparent residual stenosis
at the L4-5 operative site with cauda equina compression is seen
at this locale. There is extensive residual degenerative disease
of multiple lumbar intervertebral discs. Superimposed infection,
as also stated in the preliminary [**Location (un) 1131**] of Dr. [**Last Name (STitle) **], cannot
be excluded radiographically.
ADDENDUM: Also noted is moderately prominent degenerative
disease of the L4-5 and L5-S1 facet joint complexes.
[**2118-9-7**] - ECG - Sinus rhythm. First degree atrio-ventricular
conduction delay. Otherwise,
no significant abnormalities. No previous tracing available for
comparison.
[**2118-9-9**] - Echo - Normal global and regional biventricular
systolic function. No pulmonary hypertension seen.
Brief Hospital Course:
75 yo female with past medical history of spinal stenosis s/p
left hemilaminectomy was admitted for evaluation of hypotension
with an episode of syncope in the setting of recurrent back and
right lower extremity pain. Hospital course by problem below:
.
1. Hypotension
The patient was hypotensive in the ED with an episode of syncope
and she was admitted to the MICU initially for closer
monitoring. Differential diagnosis included decreased PO intake
and medication effects in the setting of increased narcotics.
Sepsis was thought much less likely given lack of
fever/leukocytosis and quick resolution of blood pressure with
IVF. Echo and [**Last Name (un) 104**] stim test were both unremarkable. While in
the MICU her SBP ranged from 70-90s, compared to her baseline
SBP 90. She was fluid resuscitated with improvement in her
blood pressure. Her pain regimen was modified from prn
narcotics to scheduled tylenol with prn NSAIDs. Her blood
pressure improved with these interventions and she was then
transferred to the floor. On the floor her blood pressure was
stable. She was advised to take only 5 mg of oxycodone every 5
hours.
.
2. Right Lower extremity weakness
The patient's right lower extremity and back pain was thought
most likely to be secondary to residual spinal stenosis. She
was evaluated by neurosurgery and they recommended right
hemi-laminectomy once her acute medical issues have resolved.
Neurosurgery evaluated her MRI and thought changes were most
consistent post-surgical change. Her pain improved
significantly shortly after admission with minimal medications
as above. Physical therapy assessed her and recommended home
physical therapy. She was advised to call Neurosurgery within
the next 2 weeks to discuss surgery.
.
3. Hypothyroidism
Stable. The patient continued levothyroxine 100mcg daily per
home regimen.
.
4. Pulmonary Embolus
She patient was recently diagnosed with PE on [**2118-8-30**] in the
post-operative course of recent neurosurgical procedure. Upon
admission, she was switched from coumadin to lovenox in
preparation for possible procedures. On discharge she was
subtherapeutic on coumadin and was discharged on lovenox as
bridging therapy. VNA will perform INR recheck 2 days after
discharge.
.
5. Anemia
She was found to have a normocytic anemia on admission. This
remained stable during her stay. PCP [**Name9 (PRE) 702**] was recommended.
Medications on Admission:
Coumadin 5mg PO qhs
Xalatan drops ou
Levothyroxine 100mcg PO daily
Oxycodone 5mg PO q4-6h prn
Valium
Colace
Senna
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Enoxaparin 80 mg/0.8 mL Syringe Sig: 0.7 ml Subcutaneous Q12H
(every 12 hours).
Disp:*12 syringes* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO three times a
day for 1 weeks.
11. Outpatient Lab Work
Draw PTT (INR) on Monday, [**9-12**]. Fax results to Dr.
[**Last Name (STitle) 32467**] at ([**Telephone/Fax (1) 32468**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
medication-induced hypotension
Spinal Stenosis
.
Pulmonary embolus
Anemia
Hypothyroidism
Discharge Condition:
stable, normotensive. able to ambulate with pain control.
Discharge Instructions:
You were hospitalized for low blood pressure and right-sided
back pain. You were seen by the surgeons, who feel that you
need a right-sided laminectomy in the future.
Please take all medications as directed. Your pain medications
were decreased while here. You will need to take Lovenox until
your INR is in the desired range.
Please seek immediate medical attention if you experience
dizziness, chest pain, shortness of breath, leg weakness or
numbness, or worsened back pain.
Followup Instructions:
You should follow-up with Dr. [**Last Name (STitle) 32467**] within the week. You will
need to have blood tests done on Monday to check your INR. Your
coumadin and Lovenox dosing may be adjusted accordingly.
Your blood count was low while in the hospital. You should
discuss this with Dr. [**Last Name (STitle) 32467**].
Please call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 88**] to arrange your back
surgery.
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1780
} | Medical Text: Admission Date: [**2108-8-5**] Discharge Date: [**2108-8-9**]
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
GI bleed transfer from OSH
Major Surgical or Invasive Procedure:
Upper GI Endoscopy
History of Present Illness:
81 year old with past medical history significant for Atrial
fibrillation, myelodysplasia, HTN, Bladder cancer, and [**Hospital **]
transferred from OSH to [**Hospital1 18**] for evaluation and further
treatment of GI bleed. Patient was seen at OSH on [**2108-8-2**] with
new-onset symptoms of dysphagia while trying to swallow pills.
Given patient's new-onset dysphagia, smoking history, and CT
findings of esophageal thickening, patient underwent upper GI
endoscopy with biopsy and dilatation of distal esophagus, which
demonstrated a normal-appearing esophagus. Upon returning home
s/p endoscopy, patient noted severe left lower sternal pain and
was then admitted to the hospital. On first day of admission,
patient had hematochezia and Hct dropped from ?? to 25. A second
endoscopy was performed which demonstrated a esophageal mucosal
tear and treated with epinephrine. Patient reports having had
third endoscopy on day of admission, which demonstrated no
further bleeding.
ROS: + weight loss x 10 pounds over one week, occurred in the
past month; + maroon stools
denies fatigue, night sweats, fevers, chills, chest pain, SOB,
nausea/vomiting, abdominal pain, change in urine, BRBPR
Past Medical History:
1. Myelodysplasia with anemia
2. Atrial Fibrillation
3. Lupus Anticoagulant
4. Polyclonal gammopathy
5. Hypertension
6. CAD s/p MI in [**2081**]
7. PVD s/p Aorto-femoral bypass
8. Bladder Cancer - [**2095**] - treated with BCG
Social History:
Patient lives with daughter and husband.
[**Name (NI) **] 4 children
Recently moved from [**State 108**] to live with her daughter
~60 year PPY smoking history, quit smoking in [**2081**] s/p MI
denies EtOH and drug use
Family History:
Asthma
Physical Exam:
T 98.1
BP 122/60
HR 72
RR 20
PO2 95% RA
Gen: alert, oriented, pleasant, appears stated age
HEENT: PERRL, no scleral injection, no nasal discharge, no oral
ulcers or sores
CV: irregularly irregular, no m/r/g, no JVP
Pulm: decreased breath sounds in left lower base
Abd: +BS, soft, nontender, no rebound, + bruit
Ext: no edema
Neuro: CN 2-12 intact and symmetric bilaterally; [**5-2**] UE and LE
strength symmetric bilaterally
Skin: multiple bruises on lower extremity, no rash
Pertinent Results:
[**2108-8-5**] 09:45PM GLUCOSE-88 UREA N-22* CREAT-0.7 SODIUM-137
POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-19* ANION GAP-14
[**2108-8-5**] 09:45PM ALBUMIN-2.8* CALCIUM-7.8* PHOSPHATE-2.0*
MAGNESIUM-1.5*
[**2108-8-5**] 09:45PM WBC-4.5 RBC-3.08* HGB-9.8* HCT-26.9* MCV-87
MCH-31.7 MCHC-36.2* RDW-17.1*
[**2108-8-5**] 09:45PM NEUTS-78* BANDS-0 LYMPHS-15* MONOS-5 EOS-1
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2108-8-5**] 09:45PM PLT SMR-LOW PLT COUNT-72*
[**2108-8-5**] 09:45PM PT-15.3* PTT-26.5 INR(PT)-1.4*
Brief Hospital Course:
This is a 82 yo female with pmhx significant for atrial
fibrillation, bladder cancer s/p BCG rx, CAD, HTN who presented
for further follow-up and treatment of esophageal bleed s/p
endoscopy and resulting esophageal tear on [**2108-8-2**].
.
1. Esophageal Bleed - Patient developed esophageal bleed s/p
upper GI endoscopy on [**2108-8-2**], although endoscopy on [**2108-8-5**] did
not demonstrate continued bleeding. On second day of admission,
patient continued to report maroon stools and had several
episodes of hemoptysis. Patient was transferred to MICU for
urgent upper GI endoscopy, which demonstrated an adherent clot
in the distal esophagus at 38cm without any active bleeding. A
repeat EGD on [**8-8**] demonstrated a large 2cm x 1cm esophageal
mucosal tear on the posterior wall with adherent clot at 38 cm
at the proximal end of the tear. The clot was removed and some
blood was seen at the base. [**Hospital1 **]-CAP Electrocautery was applied
for hemostasis successfully. She was maintained on IV PPI with
stable Hct checked q6 for the next 30 hours. Her Hct was stable
upon discharge, she was tolerating a regular diet and po pain
meds.
.
2. Mediastinal LAD - Patient's initial presentation of dysphagia
was most likely secondary to mediastinal LAD with unclear
etiology. Differential diagnosis includes lymphoma, primary lung
cancer, or recurrence of prior cancer. CT of the chest at [**Hospital1 18**]
demonstrated large LAD in the mediastinum and chest. It is not
clear to us if this a new process or an old process that has
been stable. We attempted to contact her PCP regarding this, but
were unsuccessful. In any case, she needs a follow-up CT of the
chest in [**3-2**] months. If there is any change in the
lymphadenopathy, she may need further work-up by biopsy or
bronchopscopy.
.
3. Atrial Fibrillation - Patient has a history of atrial
fibrillation. She was previously on coumadin but was
discontinued in [**2095**] after bladder cancer for unclear reasons.
Patient was maintained on telemetry, without any events. She was
not maintained on digoxin here as her rate was well controlled
with low-dose BB.
.
4. MDS w/ thrombocypenia: baseline plts in the 80s and has
remained stable, receives procrit as outpatient to maintain Hct.
She was given Procrit here prior to discharge and is to
follow-up with her PCP for outpatient dosing.
.
5. CAD s/p MI - Not on ASA at home given MDS as above. Continue
low-dose BB. Restart ACE-I as outpatient.
.
6. HTN - on low-dose BB. Holding Hyzaar, given recent acute
events. Plan to restart as outpatient.
.
7. COPD - continue nebs, no active issues
.
8. code- full, HCP [**Name (NI) 2048**] [**Name (NI) 68020**] [**Telephone/Fax (1) 68021**]
.
Medications on Admission:
1. Metoprolol
2. Hyzaar
3. Potassium
4. Digoxin
5. Pulmicort
6. Combivent
7. MVI
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-30**]
Puffs Inhalation Q6H (every 6 hours) as needed.
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary - esophageal tear s/p multiple EGD's with successful
stabilization
Seconday - MDS, A fib, CAD, PVD, HTN
Discharge Condition:
Stable Hct, no further bleeding
Discharge Instructions:
-continue with medications as prescribed
-please see your PCP [**Last Name (NamePattern4) **] [**1-30**] weeks for follow-up, call his office
to make an appointment
-you need follow-up re: lymph nodes in the chest, please speak
to your PCP regarding this
[**Name9 (PRE) 19288**] there any symptoms of swallowing difficulty, breathing
difficulty, vomiting blood, dizziness/lightheadedness, chest
pain, black stools/blood in stools or any other concerning
symptoms, please seek medical attention immediately
Followup Instructions:
Please see Dr. [**Last Name (STitle) 3373**] in [**1-30**] weeks for follow-up. Call
[**Telephone/Fax (1) 68022**] to schedule an appt for follow-up.
Completed by:[**2108-8-9**]
ICD9 Codes: 2859, 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1781
} | Medical Text: Admission Date: [**2200-5-22**] Discharge Date: [**2200-7-1**]
Date of Birth: [**2200-5-22**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 66673**] was an 1835 gram product of a 31-
[**2-25**] week gestation. She was born to a 24 year-old gravida I,
para 0 mother by spontaneous vaginal delivery after
preterm labor and vaginal bleeding. The pregnancy was
uncomplicated and she was admitted the day prior to delivery
after bleeding and cramping. Prenatal screens were as
follows: blood type O positive, hepatitis B surface antigen
negative, Rubella immune, RPR nonreactive, GBS unknown.
Ampicillin was given 12 hours prior to delivery. She received 1
dose of betamethasone and progressed quickly to spontaneous
vaginal delivery. Rupture of membranes occurred 3 hours prior to
delivery with clear fluid. The infant emerged vigorous and
crying, was suctioned, dried and stimulated. Apgars were 8
and 8 at one minute and five minutes, respectively. The baby
was [**Name2 (NI) **] and well-perfused without respiratory distress or
apnea. She was brought to the Neonatal Intensive Care Unit
for prematurity. On arrival in the Neonatal Intensive Care
Unit, she started to have some increased work of breathing
with grunting and tachypnea and poor aeration. CPAP was
started at 6. CBC and blood culture were done and ampicillin
and gentamicin were started.
PHYSICAL EXAMINATION ON ADMISSION: Weight 1835 grams, length
42.5 cm, head circumference 28 cm (All appropriate for
gestational age). She was alert, vigorous, crying on an open
warmer. Anterior fontanelle soft and flat. Palate intact,
nondysmorphic, Poor aeration was noted bilaterally with mild
retractions, tachypnea and grunting. Heart was regular rate and
rhythm without murmur. Pulses normal x4. Abdomen was soft,
nontender, nondistended with bowel sounds heard. No
hepatosplenomegaly was noted. Baby had normal premature appearing
female genitalia. Anus patent. Normal tone, strength,
responsiveness, and reflexes. Hips normal. Skin [**Name2 (NI) **],
well-perfused with a Mongolian spot on the sacrum.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: She was placed on CPAP of 6 initially and
remained on CPAP for 3 days. She has been in room air
since then. She did have some occasional desaturations
with feeding in late [**Month (only) 116**] which resolved. She
has been stable on room air with the exception of a couple
of choking episodes with feeding on [**2200-6-28**] and early
morning of [**2200-6-29**].
2. CARDIOVASCULAR: She has been cardiovascularly stable.
Echocardiogram was done on the [**6-18**], which was
reassuring with no PDA and good biventricular function.
This echocardiogram was done due to gross bloody stools. She
does have a soft murmur which radiates to the axilla,
consistent with pps.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Feeds were started on
day of life 3. Volume and calories were gradually
advanced. She is currently feeding ad lib Nutramigen
24 calories. Weight on [**7-1**] was 2.61 kilograms.
4. GASTROINTESTINAL: [**Known lastname **] developed gross bloody stools on
day of life 25. A KUB was done. It was reassuring. Blood
culture, CBC was sent. CBC was also reassuring. Blood
culture showed no growth. Ampicillin and gentamicin were
given for 48 hours. Her hematocrit was also stable at
35 on [**6-16**]. She was kept n.p.o. for about 5 days and
then was restarted on Nutramigen on day of life 29. She
is currently tolerating Nutramigen 24 kilocalories per ounce.
Stools have been guaiac negative to trace positive. She was
on phototherapy for about 6 to 7 days with
a maximum bilirubin of 10.9/0.4. Phototherapy was
discontinued on [**5-30**].
5. HEMATOLOGY: The baby's blood type is O positive. Coombs
was negative. Her last hematocrit was 35 on [**6-23**]. She
was on iron and multivitamins prior to the occurrence of
bloody stools. They have been held and will need to be
restarted once breastmilk is restarted.
6. INFECTIOUS DISEASE: She was on ampicillin and gentamicin
for about 48 hours at birth. Blood culture was negative
at that time. She was started on ampicillin and
gentamicin for about 48 hours again with the bloody
stools. Blood culture repeated was also negative.
7. NEUROLOGY: She has had 2 normal head ultrasounds on [**5-29**] and [**6-25**].
8. SENSORY:
a. Audiology: She passed the hearing screen.
b. Ophthalmology: Her initial eye examination on [**6-9**]
showed immature zone 3 bilaterally with follow-up
recommended at 3 weeks. Follow-up eye exam on [**6-30**] showed
mature retina.
DISPOSITION: Upon discharge, she is stable and feeding well.
She will be discharged to home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 4320**] [**Last Name (NamePattern1) **], phone #[**Telephone/Fax (1) 3581**] and
her fax is [**Telephone/Fax (1) 61285**].
CARE RECOMMENDATIONS:
1. Feeding: She will be discharged on Nutramigen 24
kilocalories/ounce. The plan is for her to remain on
Nutramigen 24 for about 3 to 4 weeks and breast milk should
be slowly reintroduced thereafter.
2. Medications: She will need to be restarted on iron and
multivitamins once she is restarted on breast milk.
3. Car seat: She passed the car seat test.
4. The State Newborn Screen was normal on [**6-7**].
5. Immunizations given: She received her hepatitis B
vaccine on [**6-10**].
6. Immunizations recommended:
a. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 3 criteria: 1) Born at less than 32 weeks;
2) Born between 32 and 35 weeks with 2 of the following:
day care during RSV season, a smoker in the household,
neuromuscular disease, airway anomalies or school age
siblings; or 3) With chronic lung disease.
b. 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:
1. PMD, Dr. [**First Name (STitle) 4320**] on [**2200-7-3**] at 6pm.
2. Needs to be scheduled for follow-up eye exam at about 9
months of age.
DISCHARGE DIAGNOSES:
1. Prematurity
2. Respiratory distress syndrome
3. Hyperbilirubinemia
4. Hematochezia, likely secondary to allergic colitis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Name8 (MD) 66674**]
MEDQUIST36
D: [**2200-6-27**] 16:42:56
T: [**2200-6-27**] 18:02:57
Job#: [**Job Number 66675**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1782
} | Medical Text: Admission Date: [**2192-9-13**] Discharge Date: [**2192-9-17**]
Date of Birth: [**2192-9-13**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] is the 3.45
kilogram product of a term gestation pregnancy born to a 36-
year-old gravida 6, para 2 woman.
PRENATAL SCREENS: Blood type B positive, antibody negative,
Rubella immune, hepatitis B surface antigen negative, group B
strep negative.
ANTEPARTUM COURSE: Remarkable for placenta previa and a
prenatal ultrasound on [**2192-9-5**] showing fetal brain
abnormality. The level II ultrasound shows fusion of the
frontal ventricular horns, bilateral ventriculomegaly, thin
or dysplastic corpus collasum, and absent cavum septum
pellucidum.
The baby was admitted for delivery by cesarean section due to
the known placenta previa. The baby emerged with a good cry
and tone. Apgar scores were 8 at 1 minute and 9 at 5
minutes. He was admitted to the Neonatal Intensive Care Unit
for observation and evaluation.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit weight was 3.45 kilograms. In general, a
well-appearing/nondysmorphic infant with normal vital signs.
Head, eyes, ears, nose, and throat examination revealed soft
anterior fontanel, normal faces, intact palate. Pupils were
equal and reactive to light. Present gag reflex. Mild
corneal opacity noted. Chest revealed no grunting, flaring,
or retracing. Clear breath sounds. Cardiovascular revealed
no murmurs. Present femoral pulses. The abdomen was flat,
soft, and nontender. No hepatosplenomegaly. Genitourinary
revealed normal phallus. Testes in normally pigmented
scrotum. Bilateral descended. Stable hips. Neurologically,
normal tone and activity.
HOSPITAL COURSE BY SYSTEM INCLUDING PERTINENT LABORATORY
DATA:
1. RESPIRATORY: The baby remained on room air, and there
were no respiratory issues.
2. CARDIOVASCULAR: The baby remained normotensive with heart
rates in the 120s to 160s. No murmurs were noted.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Initial blood glucose
was 45. The infant was fed Similac or breast fed ad lib.
Subsequent glucoses were 58 and 63.
4. ENDOCRINOLOGY: Due to the concern for panhypopituitarism,
extensive laboratory screening was sent on day of life
four ([**2192-9-17**]). Serum sodium was 143,
potassium was 4.9, chloride was 109, total carbon dioxide
was 19. A follicle-stimulating hormone level was 2.
Luteinizing hormone was 4.7. Thyroid stimulating hormone
was 2.1. T4 was 10.2. TBG was 0.93. Thyroid uptake was
1.08. T4 was 11. Free T4 was 2. Random cortisol level
was 11.4. Testosterone was 171 (normal range 280 to 800
for adults - but 171 within normal limits for a newborn).
A growth hormone level was obtained and sent to [**Hospital1 55707**] and remains pending at the time of discharge.
5. NEUROLOGICAL: At the request of the consulting
neurologist, an MRI was obtained on [**2192-9-15**].
The results were equivocal and difficult to interpret, and
the MRI will need to be repeated on an outpatient. A head
ultrasound was obtained on [**2192-9-17**]; confirming
the findings on the prenatal ultrasound of a thin corpus
callosum and absent cavum septum pellucidum. The baby has
maintained a normal neurological examination. Neurology
followup will be at the Neonatal Neurology Program at
[**Hospital3 1810**] within two months of discharge.
6. AUDIOLOGY: Hearing screening was performed with automated
auditory brain stem responses. The baby passed in both
ears.
7. OPHTHALMOLOGY: The baby had an ophthalmological
examination on [**2192-9-14**]. Except for some mild
retinal hemorrhages - consistent with birth - the
examination was within normal limits, and optic nerves
were present.
CONDITION ON TRANSFER: Good.
TRANSFER DISPOSITION: To the Newborn Nursery for continued
care.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 2921**] [**Location (un) **], [**University/College 56973**], [**Location (un) 86**], [**Numeric Identifier 56974**] (telephone number [**Telephone/Fax (1) 46358**]; fax [**Telephone/Fax (1) 50130**]).
CARE RECOMMENDATIONS:
1. Ad lib breast feeding.
2. No medications.
3. State newborn screen pending.
FOLLOW-UP APPOINTMENT:
1. Neonatal Neurology Program at [**Hospital3 1810**] - Dr.
[**First Name (STitle) **] du [**Doctor Last Name **] - [**Last Name (un) 9795**] 11, [**Hospital1 9796**], [**Location (un) 86**],
[**Numeric Identifier 6425**] (telephone number [**Telephone/Fax (1) 36468**]). The
administrative coordinator for the clinic will call the
parents to set up an appointment.
2. Endocrinology with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at two months of age
at [**Hospital3 1810**] (telephone number [**Telephone/Fax (1) 37116**]).
3. MRI as an outpatient to be arranged by the Neonatal
[**Hospital 878**] Clinic.
Dictated By:[**MD Number(1) 56975**]
MEDQUIST36
D: [**2192-9-17**] 20:04:05
T: [**2192-9-17**] 20:41:43
Job#: [**Job Number 56976**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1783
} | Medical Text: Admission Date: [**2178-5-15**] Discharge Date: [**2178-6-1**]
Service: CSU
HISTORY OF PRESENT ILLNESS: This is an 81 year old male
transferred from Bronkton for ST segment depression on stress
test and drop in his blood pressure. He was transferred to
the Medical Service and underwent a cardiac catheterization
which showed 30 percent ostial disease, 40 percent proximal
left anterior descending coronary artery and an right
coronary artery disease. His past medical history is
significant for hypertension, coronary artery disease, angina
and high cholesterol.
PAST SURGICAL HISTORY: Significant for an automatic
implantable cardiac defibrillator.
MEDICATIONS ON ADMISSION: Aspirin, Flomax, Plavix, Pepcid,
Lovenox and Atenolol.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: He was afebrile with stable vital
signs. His lungs were clear. His heart was regular. Abdomen
was soft, nontender, nondistended. Bowel sounds were
present. Extremities were warm and well perfused.
LABORATORY DATA: His laboratory studies were all within
normal limits.
HOSPITAL COURSE: The patient went to the Operating Room on
[**2178-5-21**], for a coronary artery bypass graft times two,
please see the operative report for further details.
Preoperatively he had a carotid study which showed no disease
of his carotids. The patient did well postoperatively and
was transferred to the Cardiac Surgery Recovery Unit. He was
continued on pressors to maintain his blood pressure, and was
kept intubated. He was weaned from the ventilator and
extubated by postoperative day #1. His pacemaker was
interrogated and because of the low index it was recalibrated
to a rate of 80. The patient continued to do well and his
chest tubes were kept in. His chest tubes were removed on
postoperative day #3, and he continued to do well. His blood
pressure was consistently low throughout the Intensive Care
Unit course. Chest x-ray was done and there were no
effusions. Physical therapy was consulted and it was found
that the patient had pretty significant orthostatic
hypotension, however, he was asymptomatic from this. He
continued to improve and was transferred to the floor. On
postoperative day #8, Electrophysiology Service was consulted
for management of pacemaker as well as for his hypotension.
It was decided the patient will be started on Florinef which
he started, his beta blocker was also stopped. All of his
cardiac medications were stopped at this time. He continued
to improve and continued to do well from a cardiac
standpoint. Physical therapy cleared the patient on
postoperative day #9, however, he was still having mild
orthostatic hypotension, therefore no [**5-31**], the patient was
seen again by physical therapy. His hypotension was greatly
improved and he was able to do stairs and it was decided that
the patient could be discharged home in a stable condition to
continue his Florinef.
DISCHARGE INSTRUCTIONS: The patient was discharged on [**2178-5-31**] in stable condition and instructed to follow up with
his primary care physician in one week, his cardiologist in
three to four weeks and with Dr. [**Last Name (STitle) 70**] in four to six
weeks. He was instructed to do no heavy lifting.
DISCHARGE MEDICATIONS: Home medications except for his beta
blocker and Atenolol and he was instructed to continue his
Aspirin and he was started on Florinef .1 mg p.o. q.d. The
patient was sent home with [**Hospital6 407**] in
order to have his blood pressure checked as well as his wound
monitored.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2178-5-31**] 11:10:02
T: [**2178-5-31**] 13:56:15
Job#: [**Job Number 55831**]
ICD9 Codes: 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1784
} | Medical Text: Admission Date: [**2125-6-8**] Discharge Date: [**2125-6-21**]
Date of Birth: [**2051-8-9**] Sex: F
Service: MEDICINE
Allergies:
Neosporin / Iodine; Iodine Containing / Ciprofloxacin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Hypoxia/Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation
Central Line Placement
Tracheostomy Tube Placement
History of Present Illness:
This is a 73 year old female who was D/Ced from [**Hospital1 **] two days
prior to presentation after a prolonged hospitalization for
dysphagia which resulted in a diagnosis of paraneoplastic
syndrome with an unknown primary (although lung suspected).
Ultimately a PEG tube was placed and the patient was discharged
home with VNA for further work-up as an outpatient. At home she
was gradually more short of breath. On the day of admit she
became acutely short of breath. EMS noted her sat to be 84 on
room air at home. There was a clinical concern for aspiration.
Her husband reported that it sounded like something was caught
in her throat.
.
In her last hospitalization she underwent an EGD (biopsy with
blunted villi and increased intraepithelial lymphocytes),
colonoscopy, transvaginal ultrasound, Mammogram, PEG placement,
and a bronchoscopy. No tumor was found. A neuro work up revealed
Anti-[**Doctor Last Name **] antibody was positive with a titer 1:640. She was
treated with IVIG for 5 days.
.
In the ED initial vitals were 98.6 110 101/80 24 89. Patient was
given ceftriaxone 1g, flagyl 500mg and azithromycin 500mg. 500cc
fluids. Her hct was noted to be 26.9, down from 31 a few days
prior (39-40 in early [**Month (only) **]). Her WBC count was 5.8 with 18%
bands. Her Na was 124 (recently diagnosed with a paraneoplastic
syndrome and has had hyponatremia for the last week). Cl was 87
and Cr 0.7. Her vitals on transfer to the MICU were 99, 96/54,
108, 25, 94% NRB.
.
In the MICU, she was tachycardic and subjectivly short of
breath. She did not endorse any chest pain, HA, N/V/C/D. No
peripheral edema, no rashes, no sick contacts, no myalgias.
Past Medical History:
- Hypothyroidism
- Uterine prolapse
- Cataracts
- Basal cell carcinoma treated 5-6 years ago
- Barrett's Esophagus
- Celiac disease ? (recently diagnosed, but not confirmed in
evaluation during recent hospitalization)
- s/p cholecystectomy
- s/p nephrectomy
- s/p appendectomy
Social History:
- Married 50 years, lives with husband
- [**Name (NI) 1139**]: Smoked 50 years, quit last year
- EtOH: Social
- Illicits: None
Family History:
Mother had malignant melanoma in 70s.
Physical Exam:
Physical Exam:
Vitals: T: 98 BP: 122/80 P: 98 R: 24 O2: 97% on 35%TM
General: laying in bed awake, in no respiratory distress, alert
HEENT: Sclera anicteric, MM dry, edentulous, NCAT, R eye patch
in place, L eye: EOMI, reactive to light
Neck: supple, JVP not elevated
Lungs: some rales at left base, rhonchi throughout bilateral
lung fields
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, PEG tube in
place w/ no surrounding erythema
GU: no foley
Ext: warm, well perfused, no C/C/E, 2+ PT pulses bilaterally
Pertinent Results:
[**2125-6-8**] 03:25PM BLOOD WBC-5.8 RBC-3.02* Hgb-9.9* Hct-26.9*
MCV-89 MCH-33.0* MCHC-37.0* RDW-14.7 Plt Ct-485*
.
[**2125-6-9**] 10:57AM BLOOD WBC-5.9 RBC-1.92* Hgb-6.5* Hct-17.8*
MCV-93 MCH-33.7* MCHC-36.4* RDW-14.9 Plt Ct-314
.
[**2125-6-11**] 04:33AM BLOOD WBC-12.9* RBC-2.66* Hgb-8.7* Hct-24.2*
MCV-91 MCH-32.7* MCHC-35.9* RDW-15.3 Plt Ct-364
[**2125-6-11**] 04:33AM BLOOD Neuts-92* Bands-1 Lymphs-3* Monos-0 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-2* NRBC-1*
.
[**2125-6-13**] 03:10AM BLOOD WBC-15.8* RBC-2.66* Hgb-8.7* Hct-23.8*
MCV-89 MCH-32.7* MCHC-36.6* RDW-15.0 Plt Ct-429
.
[**2125-6-19**] 05:10AM BLOOD WBC-14.8* RBC-2.02* Hgb-7.4* Hct-18.9*
MCV-94 MCH-36.4* MCHC-38.9* RDW-20.5* Plt Ct-721*
.
[**2125-6-21**] 06:09AM BLOOD WBC-13.0* RBC-3.08* Hgb-10.3* Hct-28.1*
MCV-91 MCH-33.5* MCHC-36.7* RDW-21.4* Plt Ct-663*
.
[**2125-6-21**] 11:57AM BLOOD Hct-31*
.
.
[**2125-6-8**] 03:25PM BLOOD PT-11.5 PTT-25.0 INR(PT)-1.0
[**2125-6-21**] 06:09AM BLOOD PT-12.2 PTT-56.5* INR(PT)-1.0
.
[**2125-6-8**] 03:25PM BLOOD Glucose-132* UreaN-20 Creat-0.7 Na-124*
K-5.8* Cl-87* HCO3-26 AnGap-17
[**2125-6-13**] 03:10AM BLOOD Glucose-147* UreaN-7 Creat-0.5 Na-131*
K-3.5 Cl-92* HCO3-28 AnGap-15
[**2125-6-21**] 06:09AM BLOOD Glucose-116* UreaN-25* Creat-0.6 Na-136
K-4.0 Cl-98 HCO3-32 AnGap-10
.
[**2125-6-8**] 03:25PM BLOOD ALT-128* AST-66* LD(LDH)-506* AlkPhos-74
TotBili-1.1
[**2125-6-21**] 06:09AM BLOOD ALT-132* AST-55* LD(LDH)-218 AlkPhos-77
TotBili-0.7
.
[**2125-6-8**] 03:25PM BLOOD cTropnT-<0.01
[**2125-6-9**] 03:18AM BLOOD CK-MB-1 cTropnT-<0.01
.
[**2125-6-9**] 03:18AM BLOOD Calcium-7.7* Phos-4.1 Mg-1.6
[**2125-6-21**] 06:09AM BLOOD Albumin-3.3* Calcium-8.9 Phos-4.7* Mg-2.2
.
[**2125-6-19**] 05:10AM BLOOD calTIBC-179* Hapto-268* Ferritn-1713*
TRF-138*
[**2125-6-19**] 05:10AM BLOOD Ret Aut-8.3*
[**2125-6-20**] 06:01AM BLOOD VitB12-1321* Folate-13.5
.
[**2125-6-9**] 10:57AM BLOOD Free T4-0.67*
[**2125-6-9**] 10:57AM BLOOD TSH-3.8
.
[**2125-6-9**] 03:18AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2125-6-9**] 03:18AM BLOOD HCV Ab-NEGATIVE
.
Blood gases
[**2125-6-8**] 06:44PM BLOOD Type-ART pO2-55* pCO2-35 pH-7.48*
calTCO2-27 Base XS-2
[**2125-6-16**] 06:13AM BLOOD Type-ART Temp-36.4 Rates-/18 FiO2-50
pO2-106* pCO2-39 pH-7.46* calTCO2-29 Base XS-3 Intubat-NOT
INTUBA
.
[**2125-6-8**] 04:10PM BLOOD Lactate-1.6 Na-127* K-4.9
[**2125-6-15**] 04:54AM BLOOD Lactate-0.6
.
Urine
[**2125-6-9**] 09:49AM URINE Hours-RANDOM UreaN-458 Creat-40 Na-105
K-65 Cl-126
[**2125-6-9**] 09:49AM URINE Osmolal-528
[**2125-6-9**] 03:18AM BLOOD Osmolal-262*
.
Microbiology
Legionella antigen ([**2125-6-9**] 9:49 am) - negative
Urine culture ([**2125-6-8**] 7:48 pm) - no growth
MRSA screen ([**2125-6-8**] 6:51 pm) - no MRSA identified
Sputum culture ([**2125-6-8**] 6:51 pm) - pan-sensitive Proteus
Mirabilis
Blood culture x 2 ([**2125-6-8**] 4:15 pm) - no growth
.
Imaging
Chest XR ([**2125-6-8**] 3:31 PM)
IMPRESSION:
Low lung volumes with bibasilar opacities. While findings could
represent prominent bibasilar atelectasis, aspiration or
infectious process is of concern.
.
Chest XR ([**2125-6-17**] 9:18 PM)
IMPRESSION:
The tracheostomy tip is relatively at the midline, 3.5 cm above
the carina. Cardiomediastinal silhouette is stable. Bibasilar
opacities are consistent with areas of atelectasis. Upper lungs
are essentially clear. No appreciable worsening since the prior
study has been demonstrated.
The right central venous line tip is at the level of low SVC.
Percutaneous gastrostomy is projecting over the left upper
quadrant.
Brief Hospital Course:
# Hypoxic Respiratory Failure: Likely [**1-9**] aspiration of
secretions from dysphagia/paraneoplastic disorder. During her
time in the ICU, she was treated for 8 days for hospital
acquired PNA with vancomycin and cefepime and ultimately
narrowed to CTX for proteus that grew out of her sputum. A
trial extubation occurred after treatment with antibiotics and
scopolamine to try to decrease secretions, but she became
acutely dyspenic almost immediately after extubation and
required re-intubation. She was trach'ed on [**2125-6-15**] by IP
without difficulty. It was felt that her upper airway collapse,
secondary to her paraneoplastic syndromes, was the cause of her
respiratory distress. She continued to require frequent
suctioning while on the floor and ultimately failed a Passy-Muir
valve trial due to her secretions. On discharge, she required
less frequent suctioning, her oxygen saturation has remained 99%
and above, and was breathing comfortably with the aid of a 35%
O2 trach mask.
.
# Anti-[**Doctor Last Name **] antibody syndrome and [**Location (un) **]-[**Location (un) **] myasthenic
syndrome: Neurology was consulted early in her hospital course,
as they have been following her previously. Anti-[**Doctor Last Name **] Ab and
voltage-gated calcium channel antibodies found to be positive.
As these syndromes usually indicate a primary small-cell lung
carcinoma, an in-depth work up for malignancy continued, but no
primary found thus far. Neurology continued to follow the
patient while in house and she was treated with 5 days of IVIg,
prednisone 60mg qd, and Mestinon 60mg PO for symptomatic relief
of her muscle weakness and oculobulbar symptoms (disconjugate
gaze and dysphagia). Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1206**] of Neurology discussed
numerous options for her future treatment course to manage her
symptoms. She will follow up with him for initiation of
treatments and to review her CT scan, currently scheduled for
[**7-3**] to further investigate a primary lung malignancy.
.
# Hematocrit drop: Her hematocrit started trending down while in
the MICU and she was transfused 1 unit of pRBCs with good
response. While on the general medicine floor, her hematocrit
hit a nadir of 18.9, but once again resolved with administration
of 2 units of packed RBCs to 28.2. Iron studies, hemolysis
labs, and guaiac testing revealed a likely anemia of chronic
disease (high ferritin, low TIBC, normocytic). B12 was found to
be slightly elevated, folate was within normal limits, and a
direct Coomb's test was negative. Though IVIg can be a cause of
hemolysis, laboratory testing did not show evidence of any
hemolysis. There was no evidence of an active bleed or
hemodynamic instability. Upon discharge, her hematocrit was
measured at 31.0.
.
# Hyponatremia: Her sodium levels were measured as low as 126,
thought to be secondary to her paraneoplastic disorders,
described above. Urine creatinine and electrolytes were
consistent with SIADH. Free water was restricted and sodium
eventually normalized.
.
#Thrombocytosis: Platelet elevation likely due to its role as an
acute phase reactant, as ferritin and haptoglobin have a similar
role and were also elevated.
Medications on Admission:
Docusate Sodium 50 mg/5 mL PO BID as needed for constipation.
Senna 8.6 mg PO BID
Erythromycin Ethylsuccinate 200 mg/5 mL PO Q 8H
Polyethylene Glycol 3350 17 gram/dose Powder PO DAILY prn
Metoclopramide 5mg PO TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] cambride
Discharge Diagnosis:
Hypoxic respiratory failure
Anti-[**Doctor Last Name **] antibody syndrome
[**Location (un) **]-[**Location (un) **] myasthenic syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure treating you at [**Hospital1 1170**]. You were admitted for your breathing and swallowing
difficulties and transferred to the Medical Intensive Care Unit.
In the MICU we had to place a breathing tube to assist your
breathing and a tracheostomy tube as well. We treated a
suspected pneumonia with antibiotics and it resolved. When you
were stable, you were transferred to a general medical floor
where we managed your tracheostomy tube, treated you for your
newly diagnosed anti-[**Doctor Last Name **] antibody syndrome and [**Location (un) **]-[**Location (un) **]
myasthenic syndrome with medications to help control your
symptoms.
Please note the following changes in your medications:
STARTED Pyridostigmine Bromide 60 mg Tablet, take One (1) Tablet
by NG tube every 6 hours
STARTED Prednisone 20 mg Tablet, take Three (3) Tablets by NG
tube DAILY (Daily) for 3 weeks.
STARTED Lorazepam 0.5 mg Tablet, take One (1) Tablet by NG tube
every 8 hours as needed for anxiety, respiratory distress
STARTED Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid, take
Three Hundred (300) mg by NG tube DAILY
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2125-7-3**] 11:30
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2125-7-3**] 4:00, located in [**Hospital Ward Name 23**] building, [**Location (un) **].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5070, 5180, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1785
} | Medical Text: Admission Date: [**2126-2-1**] Discharge Date: [**2126-5-14**]
Date of Birth: [**2100-2-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Multiple gunshot wounds of the abdomen and chest.
Major Surgical or Invasive Procedure:
[**2126-3-26**] Right AKA
[**2126-3-19**] PTSG
[**2126-3-15**] ORIF left elbow
[**2126-3-13**] flex sig - WNL
[**2126-2-21**] evac hematoma RLE
[**2126-2-19**] washout, sump drain out, perioduo [**Doctor Last Name 406**]
[**2126-2-15**] washout, duodenal repair, sump drain
[**2126-2-12**] washout, trach, partial abd closure
[**2126-2-10**] second look, washout, hemostasis, VAC replacement
[**2126-2-9**] duodenal repair/[**Location (un) **] patch, partial closure
[**2126-2-7**] washout, R colectomy, GJ tube, ortho closure except RLE
[**2126-2-5**] washout, CCY, dressing change
[**2126-2-2**] repair of R diaphragmatic laceration
[**2126-2-2**] repair of duodenal injury
[**2126-2-2**] repair of R renal vein injury
[**2126-2-2**] LUE decompressive fasciotomy
[**2126-2-2**] R ileofemoral thrombectomy, patch angioplasty of SFA
[**2126-2-1**]:
1. Exploratory laparotomy.
2. Small-bowel resection.
3. Resection of transverse colon.
4. Right femoral line arterial line placement.
History of Present Illness:
This man was brought to the emergency room with
multiple gunshot wounds to the chest and wounds in the back
as well. He was taken to the operating room emergently and
underwent a laparotomy first because his abdomen was
positive.
Past Medical History:
PMH: HTN
PSH: none
Social History:
married
Family History:
NC
Brief Hospital Course:
He was admitted to the Trauma service and taken immediately to
the operating room for exploratory laparotomy, small-bowel
resection, resection of transverse colon, and right femoral line
arterial line placement. He was transferred to the Trauma ICU
postoperatively sedated and vented. He was again taken back to
the operating room on [**2-2**] for repair of right diaphragmatic
laceration, repair of duodenal injury with lateral duodenostomy
and wide drainage, repair of right renal vein injury,
decompressive fasciotomies x4. On [**2-3**] he was noted with acute
ischemia of his right lower extremity and was taken back to the
operating room by Vascular surgery for ultrasound-guided
puncture of left common femoral artery, contralateral
second-order catheterization of right external iliac artery,
abdominal aortogram, right lower extremity angiogram,
iliofemoral thrombectomy on the right and vein patch angioplasty
of right common femoral artery into the superficial femoral
artery. He required multiple follow up procedures by orthopedics
for debridement of the bony injuries and VAC placement of his
right elbow injury. He underwent percutaneous tracheostomy on
[**2-9**] with partial closure of abdomen and application of open
abdominal dressing and again returned back to the operating room
on [**2-15**] for exploratory laparotomy with drainage of his
abdominal cavity. TPN was initiated early on.
He was eventually weaned from the ventilator and evaluated by
Speech for a Passy Muir valve. He would later be transferred to
the regular nursing unit where he continued to require extensive
nursing care.
During the week of [**3-11**] he was sent back to the ICU with concern
of sepsis. He was started on broad spectrum antibiotics
(linezolid/Meropenem) and fluid resuscitated. CT scan of his
torso demonstrated only small RLL opacity and 2 small
intraabdominal fluid collection consistent with his ongoing
leak. CT was otherwise unchanged. On [**3-13**] he underwent flex
sigmoidoscope which was within normal limits. A RUQ ultrasound
was done which demonstrated on biliary ductal dilation. He
improved quickly, cultures were sent off which did not grow out
anything. He then went back to the OR on [**3-15**] for planned ORIF
of his right elbow. At that time his wound VAC was changed
again and showing signs of improvement, although he still had
persistent duodenal leak and drainage from the distal
enterotomy. He was sent back to the floor several days later.
His TFs had to be stopped because he was leaking them into his
abdominal dressing. He was started back on TPN at that time.
On [**3-19**] he was taken back to OR and underwent skin grafting of
his entire abdomen using STSG from his non-functional RLE. A
wound VAC was placed over Xeroform and he was planned to be on
strict bedrest and lying flat for a total of 5 days in order to
allow the grafts to take. He continued TPN and remained NPO.
The VAC required multiple re-reinforcements during this week for
leakage however remained intact. Vascular surgery has also been
following and planned for RLE amputation.
On [**3-25**] the abdominal VAC was replaced and the skin graft was
assessed and appeared to be taking well especially on the left
side and remained well vitalized. On [**3-26**] patient underwent
right above knee amputation by vascular surgery. He tolerated
the procedure well. On [**3-27**] his trach and Foley were removed
and he was restarted on tube feeds. He continued to have leakage
of his tube feeds via his fistula requiring multiple dressings
changes throughout the day. He was evaluated by the wound/ostomy
nurses who became creative in devising an appliance to help
control the leakage and protect his skin.
He was evaluated early on by Physical and Occupational therapy
who worked with him on a regular schedule. He was eventually
fitted for a prosthesis and at time of discharge was independent
with wheelchair transfers and ambulation with assistive device.
Social work remained closely involved throughout his hospital
stay; multiple family/team meetings took place as there were
many patient and family issues. Prior to discharge it was
determined that there was a safe discharge plan in place when
patient was ready to leave the hospital.
At time of discharge he was on a regular diet, his TPN was
stopped and he was independent with his dressing changes and
activity of daily living. He was provided detailed instruction
for follow up.
Medications on Admission:
none
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q 8H
(Every 8 Hours): Dx: Chronic pain syndrome; s/p Above knee
amputation on right w/ phantom limb pain.
Disp:*qs Capsule(s)* Refills:*2*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-9**]
hours as needed for fever, pain.
4. Stump shrinker
Dx: s/p Right Above Knee Amputation
5. Standard wheelchair
Dx: s/p Right above knee amputation
6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for indigestion.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Multiple gunshot wounds
Right diaphragmatic laceration
Small bowel injury x3
Colon injury x1
Right renal vein laceration
Duodenal injury
Right elbow fracture
Respiratory failure
Sepsis
Enterocutaneous fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches, walker or cane).
Discharge Instructions:
You were hospitalized following multiple gunshot wound assault.
Your injuries were very extensive requiring mulitple operations.
Because of your injuries you have an abdominal wound that
continues to leak fluid due to a fistula; this will eventually
close as the others did. It is important that you continue to
eat a well balanced diet with adequate protein and calories to
facilitate in healing.
You will follow up with Dr. [**Last Name (STitle) **] in 2 weeks and at least every
2-4 weeks thereafter to monitor the progress of your wounds.
Plans for future surgery will be discussed over the next several
months. If you notice that the drainage output from the fistula
increases please contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 600**] or if at
night you should call the page operator and ask to have the
Acute Care service resident paged by calling [**Telephone/Fax (1) 13471**]. For
questions or concerns during the weekdays you may also contact
[**Name (NI) 17148**] [**Last Name (NamePattern1) 2819**], Nurse Practitioner for Trauma at [**Telephone/Fax (1) 67547**].
You were fitted with a shrinker for your stump in preparation
for being fitted for a prosthesis over the next 8 weeks or so.
You will require Physical therapy for training with the
prosthesis once you have this.
Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) **] for evaluation of your
abdominal wound/fistula. Call [**Telephone/Fax (1) 600**] for an appointment.
Follow up in 4 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP for Ortho Trauma
for your right elbow; call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 4 weeks with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], Vascular
Surgery for your right leg amputation site; call [**Telephone/Fax (1) 2625**]
for an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2126-9-23**]
ICD9 Codes: 5185, 5845, 5990, 2762, 2761, 2851, 2768, 2767, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1786
} | Medical Text: Admission Date: [**2186-6-24**] Discharge Date: [**2186-7-7**]
Date of Birth: [**2115-6-25**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 71-year-old gentleman
who presented to an outside hospital complaining of several
hours of substernal chest pain associated with shortness of
breath and orthopnea. He was initially diagnosed with a
chronic obstructive pulmonary disease exacerbation and
started on antibiotics, steroids, and Lasix. He ultimately
developed recurrent chest pain relieved by sublingual
nitroglycerin. His ECG revealed inferior T-wave inversions
and lateral ST segment depressions worse from previous. He
is transferred to the [**Hospital1 69**]
for further workup.
PAST MEDICAL HISTORY:
1. Gastric ulcers.
2. Varicose veins.
3. Appendicitis status post appendectomy.
4. Left inguinal hernia status post herniorrhaphy.
OUTSIDE MEDICATIONS: Zantac.
MEDICATIONS ON TRANSFER:
1. Heparin IV drip.
2. Integrilin IV drip.
3. Nitroglycerin IV drip.
ALLERGIES: He has no allergies.
EXAMINATION AT TIME OF ADMISSION: Temperature 97.8, heart
rate 78-89, blood pressure 91-118/53-64. Respiratory rate is
21, sating 96% on 4 liters nasal cannula. He is alert and
oriented times three. His neck was supple without bruit.
His heart had a regular, rate, and rhythm without murmurs.
His abdomen was soft, nontender, nondistended. Chest was
clear to auscultation bilaterally.
NOTABLE LABORATORIES: White count of 12.5, hematocrit of
33.8, platelets of 180. CKs at the outside hospital were
565, MBs were 53, and troponins were 12.4.
HOSPITAL COURSE: The patient was admitted to the Medicine
service and underwent a cardiac catheterization on the [**6-24**]. He had an intra-aortic balloon pump placed and the
results of the catheterization demonstrated three vessel
disease with an anomalous circumflex. His LAD had a proximal
lesion 90%, the D1 and D2 both had 90% ostial lesions. He
continued to be stabilized on the Cardiac Medicine service
without incident until he was brought to the operating room
on [**2186-6-27**], where he underwent a CABG x2 with a LIMA to
the LAD and a left radial artery to the ramus. He also
underwent an aortic valve replacement with 21 mm
[**Last Name (un) 3843**]-[**Doctor First Name **] valve.
His preoperative echocardiogram done in the OR demonstrated a
LV ejection fraction of 20%. Postoperatively, it was 25-30%
on significant inotropy medications. He was transferred to
the Cardiothoracic Surgery Recovery Unit, intubated on
milrinone at 0.4, Neo at 1.0, and nitroglycerin at 0.5.
On postoperative day one, he was extubated without
complication. His intra-aortic balloon pump was left in and
the Neo-Synephrine was weaned off. He had an extra unit of
blood for a hematocrit of 25.5. On postoperative day two,
the balloon was discontinued. He had an issue with multiple
PAC's and therefore, the patient was started on amio drip.
Postoperative day three, the balloon pump was out. He is on
milrinone at 0.4, amio at 0.5, and we restarted his Captopril
and Lasix. We continued to do a slow wean on his milrinone,
which unfortunately dropped his SPO2 down to
................, so it was restarted at 0.40. Over the next
several days in the Intensive Care Unit, we were able to wean
off the milrinone, increase his captopril, restart his Lasix.
He developed a bit of alkalosis for which he got a few doses
of Diamox which improved.
He continued to improve and was transferred out to the floor
on postoperative day eight. The remainder of his hospital
course was uneventful, and he was discharged to a rehab
facility on [**2186-7-7**].
EXAM AT THE TIME OF DISCHARGE: The patient's neck is supple,
no lymphadenopathy. No carotid bruits. Chest is clear.
Belly is soft, nontender, and nondistended. He had a regular
heart rhythm. Extremities still have a fair amount of edema.
MEDICATIONS AT TIME OF DISCHARGE:
1. Lasix 20 mg po q12 x5 days.
2. Potassium chloride 20 mEq po qid x5 days.
3. Colace 100 mg po bid.
4. EC-ASA 81 mg po q day.
5. Percocet 1-2 tablets po q4h prn pain.
6. Isosorbide mononitrate 60 mg po q day.
7. Amiodarone 400 mg po bid.
8. Captopril 100 mg po tid.
9. Digoxin 0.125 mg po q day.
10. Protonix 40 mg po q day.
11. Coumadin dose according to patient's INR.
12. Carvedilol 3.125 po bid.
DISCHARGE DIAGNOSIS: Coronary artery disease status post
coronary artery bypass graft x2.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 275**] 02-248
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2186-7-7**] 10:08
T: [**2186-7-7**] 10:08
JOB#: [**Job Number 48336**]
ICD9 Codes: 496, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1787
} | Medical Text: Admission Date: [**2145-8-11**] Discharge Date: [**2145-8-17**]
Date of Birth: [**2088-1-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
Paracentesis
Endoscopy (EGD)
History of Present Illness:
57 year old male with history of liver cirrhosis on [**First Name3 (LF) **]
list presents with weakness, vomiting, and confusion for several
days. Pt states he has been feeling weak for past 15d but felt
much worse yesterday. He had difficulty walking and became tired
going up stairs. No muscle pain. He felt as if he did not want
to get up from sofa. He had one episode of vomiting food,
non-bloody, non-bilious (unclear when this occurred). Pt also
noted that 15d ago, he had lower abdominal cramping which was
relieved by motrin. Pt states he has felt a little confused and
more forgetful over past few days. Denied f/c. Has diarrhea with
lactulose, no constipation. Currently without nausea.
In the ED, initial VS were: T 97.1 P 58 BP 99/81 R 18 O2 sat.
Noted to be jaundiced, with abdominal ascites and asterixis on
exam. Guaiac positive, brown stool. Abdominal ultrasound looks
stable. Head CT negative. Noted to have new acute renal failure,
ABG 7.32/25/152, lactate 2.7. Pt underwent ultrasound guided
paracentesis by radiology per liver recommendations. Got IVFs
with improvement in pressure to 123/84. Vitals on transfer HR
63, BP 142/111, RR 14, SaO2 100% RA.
On the floor, pt was alert and communicative.
Review of sytems:
(+) Per HPI; + recent weight loss (unclear how much over what
period)
(-) Denies fever, chills. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, shortness of breath.
Denied chest pain or tightness, palpitations. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
-End stage liver disease, with MELD 18, on [**First Name3 (LF) **] list
-alcoholic cirrhosis - decompensated in the past with ascites,
peripheral edema and hepatic encephalopathy.
-history of esophageal varices, never bled
-h/o hepatopulmonary syndrome
-HTN
Social History:
Smoke: quit 5y ago
EtOH: stopped [**2143-10-9**]; prior to that: 1 case/week
Drugs: never
Lives: with wife
[**Name (NI) **]: used to work for cable company; no longer working
Family History:
unknown, except
Mother - 90, alive
Father - deceased 5y ago
Physical Exam:
Physical Exam on admission [**2145-8-11**]:
Vitals: T: 97.5 BP: 111/64 P:65 R 14 SaO2: 100% RA
General: Alert, oriented, no acute distress, jaundiced
HEENT: Sclera icteric, MMM
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**12-8**] murmur at RUSB
non-radiating and LLSB, no rubs, gallops
Abdomen: no ascites, no fluid wave shift, no shifting dullness,
soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
Ext: 1+ pitting edema b/l, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: + asterixis, CN II-XII intact, 5/5 strength in UE and LE
b/l, sensation intact to light touch b/l
Pertinent Results:
[**2145-8-11**] 12:30PM BLOOD WBC-10.5 RBC-2.33* Hgb-8.7* Hct-26.7*
MCV-115* MCH-37.3* MCHC-32.6 RDW-15.7* Plt Ct-114*
[**2145-8-12**] 08:00AM BLOOD WBC-4.6# RBC-1.59*# Hgb-5.8*# Hct-18.2*#
MCV-114* MCH-36.1* MCHC-31.6 RDW-16.0* Plt Ct-71*
[**2145-8-12**] 03:30PM BLOOD WBC-4.4 RBC-1.76* Hgb-6.3* Hct-19.5*
MCV-111* MCH-35.7* MCHC-32.1 RDW-17.5* Plt Ct-58*
[**2145-8-12**] 11:40PM BLOOD WBC-4.7 RBC-2.38*# Hgb-8.3*# Hct-24.3*
MCV-102*# MCH-34.7* MCHC-34.1 RDW-19.9* Plt Ct-57*
[**2145-8-14**] 04:15PM BLOOD WBC-5.8 RBC-2.68* Hgb-9.3* Hct-27.4*
MCV-102* MCH-34.7* MCHC-34.0 RDW-21.1* Plt Ct-55*
[**2145-8-17**] 06:50AM BLOOD WBC-4.8 RBC-2.51* Hgb-8.8* Hct-25.2*
MCV-100* MCH-35.2* MCHC-35.1* RDW-19.5* Plt Ct-65*
[**2145-8-11**] 12:30PM BLOOD Neuts-62.2 Lymphs-27.3 Monos-5.8 Eos-3.8
Baso-1.0
[**2145-8-11**] 12:30PM BLOOD PT-20.2* PTT-39.6* INR(PT)-1.9*
[**2145-8-14**] 05:13AM BLOOD PT-21.9* PTT-41.9* INR(PT)-2.0*
[**2145-8-17**] 06:50AM BLOOD PT-24.0* PTT-45.4* INR(PT)-2.3*
[**2145-8-11**] 12:30PM BLOOD Glucose-142* UreaN-55* Creat-4.0*# Na-133
K-4.8 Cl-107 HCO3-14* AnGap-17
[**2145-8-13**] 05:48AM BLOOD Glucose-124* UreaN-35* Creat-1.9*# Na-139
K-4.2 Cl-112* HCO3-16* AnGap-15
[**2145-8-15**] 04:14AM BLOOD Glucose-133* UreaN-19 Creat-1.4* Na-136
K-3.9 Cl-110* HCO3-18* AnGap-12
[**2145-8-17**] 06:50AM BLOOD Glucose-97 UreaN-11 Creat-1.0 Na-137
K-4.7 Cl-108 HCO3-22 AnGap-12
[**2145-8-11**] 12:30PM BLOOD ALT-35 AST-61* AlkPhos-100 TotBili-4.5*
[**2145-8-13**] 05:48AM BLOOD ALT-25 AST-43* LD(LDH)-163 AlkPhos-66
TotBili-7.7* DirBili-1.6* IndBili-6.1
[**2145-8-14**] 05:13AM BLOOD ALT-24 AST-44* LD(LDH)-157 AlkPhos-66
TotBili-9.7*
[**2145-8-16**] 05:40AM BLOOD ALT-26 AST-43* AlkPhos-82 TotBili-5.8*
[**2145-8-17**] 06:50AM BLOOD TotBili-5.5*
[**2145-8-17**] 06:50AM BLOOD Calcium-8.4 Phos-1.7* Mg-1.9
[**2145-8-12**] 08:00AM BLOOD VitB12-1870* Folate-9.6 Hapto-30
[**2145-8-11**] 12:45PM BLOOD Ammonia-123*
[**2145-8-11**] 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2145-8-11**] 04:39PM BLOOD Lactate-2.7*
Micro:
[**2145-8-11**] BCx - pending
[**2145-8-11**] UCx - no growth
[**2145-8-11**] Peritoneal fluid cx - no growth
.
Images:
[**2145-8-11**] Abd US (PRELIM):
1. cirrhosis and moderate ascites.
2. Again no color flow seen in the left portal vein, likely
thrombus, but pulsed doppler may indicate a small amount of
reverse flow but could also be artifactual. Main portal vein
patent.
3. Cholelithasis without cholecystitis.
4. Splenomegaly.
Overall, not significantly changed since US study of [**2145-6-30**].
.
[**2145-8-11**] CXR
IMPRESSION: No evidence of acute cardiopulmonary process.
[**2145-8-11**] CT head
IMPRESSION: No hemorrhage, edema, or evidence for other acute
process.
[**2145-8-11**] US -
IMPRESSION:
1. Findings consistent with known cirrhosis. Moderate amount of
ascites and splenomegaly, sequelae of portal hypertension.
2. Again, no color flow identified within the left portal vein,
which may be due to thrombosis. Pulse Doppler demonstrates
possible flow although this may be reversed and slow or findings
could be artifactual.
3. Cholelithiasis.
4. Previously seen lesion within the pancreatic head cannot be
evaluated
today due to overlying bowel gas.
Diagnositic paracentsis via ultrasound
Fluid removed - 20ml
IMPRESSION: Successful ultrasound-guided diagnostic paracentesis
EGD:
Varices at the distal esophagus
Mosaic pattern in the diffuse compatible with chronic gastritis
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
57M with end stage liver disease on [**Month/Day/Year **] list presenting
with weakness found to be in acute renal failure.
# Anemia - pt with 10 point Hct drop on hosptial day 2 with
repeat Hct 17 down [**Last Name (un) 834**] 26. Anemia was macrocytic. Pt had
hypotension on the floor breifly with SBP in 70s, with no sx and
was asleep. He responeded to 1 liter. No evidence of active
bleeding during admission. But due to the recent EGD 1 month
prior showing grade II vaices, there was concern for a GI bleed
and the pt was transfered to the MICU. On exam the pt was guaiac
positive with brown stool. He had no abdominal pain. Had emesis
once in ER without blood. On HD2, pt received 4 units of blood
and 3 units FFP, with appropriate hct response to 27. He was
also given vitamin K 5mg PO for INR 2.3. Hemolysis labs and
smear were not consistent with hemolysis. Nadolol was stopped to
prevent masking of tachycardia in setting of anemia, but later
after the EGD was restarted. Pt was started on PPI IV and
received cipro 400mg IV for 5 days for empiric coverage during a
GI bleed (last day of cipro = [**2145-8-17**]). He had a bowel movement
on 2nd day of ICU stay which was guaiac negative. Pt was
evaluated by liver with EGD and found to have 4 cords Grade 2
varices with stigmata of recent bleed. Also had gastritis.
Banded x 4 (2 varices with 2 bands) without complication. As HCT
remained stable during ICU and no evidence of bleeding, pt was
called back out to floor. He was also started on carafate per
liver recs and kept on soft diet for evening post procedure.
Patient was transferred to the floor in stable condition, diet
advanced as tolerated and hematocrit remained stable.
Transitioned to PO PPI. Patient to follow-up in 1 week for
repeat EGD.
# Renal failure - Cr 4.0 on admission, 1.5 on [**2145-6-30**]. Pt had
albumin challenge on admission with improvement in Cr which
suggests he may be pre-renal, possibly from bleed prior to
admission. Fe urea 25% suggesting pre-renal. DDx also includes
hepato-renal syndrome, ATN, or infection elsewhere worsening
liver function. CXR negative. Paracentesis does not suggest SBP.
ATN less likely as Urine Eos negative. Diuretics held. Albumin
75 mg x 2 was given with improvement, therefore, was thought to
be prerenal. Cr improved throughout his hospital course and his
diuretics were restarted with lasix 20mg and aldactone 50mg on
[**2145-8-15**]. Patient was discharged on this dose of diuretics, renal
function stable, to follow-up in liver center for further
management.
# End stage liver disease: Due to alcoholic cirrhosis. Now with
MELD 33 due to increased Cr, on [**Date Range **] list. Diagnostic and
therapeutic paracentesis performed in ED by radiology. Pt has
h/o hepatic encephalopathy and non-bleeding esophageal varices.
Nadolol stopped initially and then later restarted. Continued
lactulose and xifaxan. Pt's home omeprazole changed to
pantoprazole 40mg IV BID then transitioned to pantoprazole 40 PO
qday on discharge. Was restarted on diuretics as discussed
above.
# Weakness - Most likely due to anemia as history suggests
fatigue or malaise rather than muscle weakness or DOE. Pt denies
muscle pain and with full strength during neuro exam. EKG
unremarkable.
# Metabolic acidosis: Pt with gap and non-gap acidosis on
admission (AG 12 but with albumin 2.8 so his normal gap is
approx 7.5). Gap acidosis most likely due to lactic acidosis and
uremia. Non-gap possibly due to normal saline received in ED or
diarrhea due to lactulose. On HD2, Pt with gap acidosis (AG 13
but albumin unknown after albumin challenge). Gap acidosis most
likely due to uremia. Gap later resolved with improvement of
renal function.
Medications on Admission:
per OMR list reviewed [**2145-7-15**], unable to confirm with pt as he
has no list and does not recall his meds
-clotrimazole 10mg Troche 5x/day
-furosemide 40mg PO qday - held on admission
-lactulose 10gm/15mL - 30cc QID
-nadolol 40mg PO daily
-xifaxan 400mg TID
-spironolactone 75mg PO BID - given once at admission, then held
-ferrous sulfate 300mg PO BID - changed to 325mg PO BID
-MVI daily
-Omeprazole E.C. Delayed Release 20mg PO BID
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
5X/DAY (5 Times a Day).
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): for [**2-3**] Bowel movements per day.
3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. 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*
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 doses.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
GI Bleed
Anemia
Cirrhosis
Encephalopathy
.
Discharge Condition:
Stable, not encephalopathic, ambulating independently,
Discharge Instructions:
You were admitted to the hospital for evaluation of bleeding.
It was found that you had varices in your esophagus. These are
dilated blood vessels that can bleed. You were treated with
blood transfusions, IV fluids, and banding of the varices to
prevent further bleeding. You were monitored in the ICU and
then subsequently on the floor. You required no further
interventions.
.
Please take all medications as directed. Please call your
doctor or return to the Emergency Room if you experience any
black stools, bright red blood per rectum, shortness of breath,
chest pain or any other symptoms concerning to you.
.
The following changes were made to your medications:
1. Furosemide dose was decreased to 20mg daily
2. Spironolactone dose was decreased to 50mg daily
3. Nadolol dose was decreased to 20mg daily
4. Ferrous Sulfate was changed to 325mg twice daily
.
Please follow-up as directed below, and call with any questions
or concerns.
Followup Instructions:
1. [**Last Name (LF) 1447**],[**First Name3 (LF) **] [**Telephone/Fax (1) 81526**], please call for an appointment
in the next 2 weeks.
.
2. Please present to the Gastroenterology Procedure Suite on
the [**Hospital Ward Name 516**] of [**Hospital3 **] Hospital for an Endoscopy on
[**2145-8-27**] at 8:30 AM. You should not eat after dinner
on the night prior to this procedure. You will receive
instructions regarding this procedure in the mail before the
appointment.
.
3. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] [**Name11 (NameIs) **] SOCIAL WORK
Date/Time:[**2145-9-29**] 10:00
.
4. Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2145-9-29**] 10:20
.
ICD9 Codes: 5849, 2851, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1788
} | Medical Text: Admission Date: [**2158-3-25**] Discharge Date: [**2158-3-27**]
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
transfer from rehab for management of CHF, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 82 year-old woman with a h/o CHF, CAD s/p MI
('[**32**]), Type 2 DM, and bilateral blindness who had a recent
admission to an OSH for dizziness with a fall and tibial fx, and
was then transferred to rehab. On [**3-9**], she was readmitted with
post-prandial abdominal pain, dyspnea with an O2sat of 76% on
RA, fevers to 104.0 and elevated WBC count. She was diagnosed
with worsening CHF (BNP has steadily risen since [**3-9**] and was
1100 at last measurement) and urosepsis. U/A and urine cultures
were negative, though Cipro had already been started at the time
that cultures were drawn. The etiology of her post-prandial
abdominal pain is still unclear, though CT scan shows extensive
calcification of the aorta and mesenteric vessels, and the
patient has newly diagnosed PAF and mesenteric ischemia from
emboli is also a possibility. Pt transferred to CCU team on
HD#1 for better management of CHF.
Past Medical History:
CHF
paroxysmal A-fib with RVR
CAD s/p MI '[**32**]
GERD
HTN
h/o GIB
venous stasis
s/p inguinal hernia repair '[**34**]
s/p TAH '[**25**]
s/p CCY '[**16**]
DM2
bilateral blindness
IBS
s/p tibial fx
Social History:
lives w/ daughter who works @ [**Hospital1 18**] as PA, denies smoking, EtOH
Family History:
non-contributory
Physical Exam:
Vitals: T 96.4 HR 71 BP 121/50 RR 22 O2 sat 100% on 100%NRB
General: lying in bed, moaning, using accessory muscles to
breathe
HEENT: anicteric, elevated JVD to carotid angle
CV: irregularly irregular, no m/r/g
Chest: diffuse crackles and wheezes bilaterally
Abd: soft, mildly tender to palpation in RUQ, ND, +BS
Ext: warm, no edema
Neuro: moaning, difficult to communicate with
Skin: decubitus ulcer on back, sacrum
Pertinent Results:
CXR: findings consistent with CHF, moderately sized R pleural
effusion, can not rule out PNA
EKG: atrial fibrillation, rate 71, nl axis, ST elevations in
V1-V3, aVR and downgoing ST segments in I, II, V5, and V6 which
were present on prior EKGs.
[**2158-3-26**] 05:00AM BLOOD CK(CPK)-72
[**2158-3-26**] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2158-3-26**] 12:33PM BLOOD Lactate-2.3*
[**2158-3-26**] 12:33AM BLOOD Type-ART pO2-84* pCO2-56* pH-7.37
calHCO3-34* Base XS-4
Brief Hospital Course:
Ms. [**Known lastname **] is a 82 y/o woman with MMP, most notably CHF,
ARF, and question of pneumonia/UTI. Her blood gas on admission
was 7.37/56/95 on 100% NRB, and continued to worsen despite
being on BIPAP and Natrecor. Her lactate rose to 3.3 and her
urine output remained nearly zero. Her primary medical team
communicated with her daughter throughout her hospital stay, and
respected her wishes to not intubate or resusitate given her
unfortunate prognosis. Ms. [**Known lastname **] died the morning after
admission from respiratory failure due to CHF in the setting of
renal failure.
Medications on Admission:
Amiodarone 200 mg qd
Atenolol 50 mg qd
Ciprofloxacin 400 mg IV q12h
Lanoxin 0.125 mg qd
Donnatal 5 mg a.c.
Furosemide 40 mg IV qd
Gabapentin 300 mg PO qd
RISS
Protonix 40 mg IV qd
Lisinopril 20 mg PO qd
Flagyl 500 mg IV q8h
Lomotil 1-2 tablets q6h prn diarrhea
Morphine sulfate 1 mg SC q1h prn pain
Zofran 4 mg IV q6h prn nausea
Zocor 20 mg qhs
Allergies: ? allergy to Levaquin
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
ICD9 Codes: 5849, 2765, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1789
} | Medical Text: Admission Date: [**2171-3-14**] Discharge Date: [**2171-3-20**]
Date of Birth: [**2111-9-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Pneumonia, Alcohol Withdrawal, Alcohol Dependence with Acute
Intoxication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59 year old male with a history of polysubstance abuse and
chronic pain, recently discharged from the medical service for
alcohol withdrawal and pneumonia, who was brought in by EMS
after he was found intoxicated at a T-stop. In the ED, the
patient sobered from his acute alcohol intoxication. However,
he then went into withdrawal. He began [**Doctor Last Name **] 22 on CIWA and
was given 3 doses of ativan.
Of note, the patients last admission one month prior to this
presentation was complicated by pneumonia, for which he was
discharged on amoxicillin/clavulonate. The patient continues to
note a persistent cough, although denies fever or chills. He
underwent chest X-ray in the ED was concerning for either a
recurrence of his pneumonia or a persistence of the prior
pneumonia.
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: + Dyspnea, + Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
Past Medical History:
- Benign Hypertension
- Alcohol abuse - 1qt vodka per day
- chronic pain on methadone
- h/o [**Doctor Last Name 8751**] with multiple traumatic injuries and subsequent
surgeries including splenectomy, fracture repairs, skin grafts
- h/o polysubstance abuse
-asplenia
Social History:
Currently homeless. Smokes 1ppd for the past 40 years. Drinks
about a pint of vodka daily with history of withdrawal. He
denies any IVDU.
Family History:
Parents were alcoholics. He notes a significant family history
of cancer in his mother and father as well as his siblings. He
thinks most were esophageal cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: 98.6, 166/94, 68, 20, 96%2L
GEN: Cachectic, Uncomfortable, Tremulous
Pain: [**3-5**]
HEENT: EOMI, MMM, - OP Lesions, + tongue fasiculations
PUL: coarse b/l rhonchi on all fields, EE Wheezes
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, course tremor, CN II-XII grossly normal
.
DISCHARGE PHYSICAL EXAM:
GEN: awake, alert, intermittently follows commands (has to be
reminded to take deep breaths during lung exam)
HEENT: EOMI, MMM, - OP Lesions
PUL: mild diminished BS on b/l lower lobes
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: AOx3, mild course tremor, CN II-XII grossly normal
Pertinent Results:
Admission Labs [**2171-3-15**] 06:45AM:
WBC-6.2 RBC-4.56* Hgb-14.5 Hct-47.0 MCV-103* MCH-31.7 MCHC-30.8*
RDW-14.2 Plt Ct-192
Neuts-51 Bands-0 Lymphs-34 Monos-10 Eos-5* Baso-0 Atyps-0
Metas-0 Myelos-0
PT-10.6 PTT-34.6 INR(PT)-1.0
Glucose-170* UreaN-9 Creat-0.6 Na-137 K-5.5* Cl-96 HCO3-31
AnGap-16
ALT-24 AST-25 LD(LDH)-198 CK(CPK)-105 AlkPhos-84 Amylase-920*
TotBili-0.3
Calcium-10.1 Phos-5.0* Mg-1.8
Discharge Labs:
WBC-4.6 RBC-4.26* Hgb-13.7* Hct-44.0 MCV-103* MCH-32.1*
MCHC-31.0 RDW-14.1 Plt Ct-242
Neuts-39* Bands-1 Lymphs-40 Monos-9 Eos-7* Baso-1 Atyps-3*
Metas-0 Myelos-0
PT-11.0 PTT-36.5 INR(PT)-1.0
Glucose-95 UreaN-13 Creat-0.6 Na-138 K-4.4 Cl-99 HCO3-32
AnGap-11
ALT-19 AST-23 LD(LDH)-199 AlkPhos-63 TotBili-0.3
Albumin-3.8 Calcium-9.4 Phos-3.5 Mg-1.8
Lactate-0.5
Micro:
Blood cultures 4/20, [**3-19**], [**3-20**] pending
CHEST (PA & LAT) Study Date of [**2171-3-14**] 9:29 PM
1. Continued right middle lobe opacification concerning for
pneumonia. As the findings appear similar when compared to prior
study, chest CT should be obtained to evaluate for the presence
of an obstructing central or endobronchial lesion.
2. Improved aeration of the left lower lobe with residual linear
opacities which may be reflective of atelectasis.
CT Chest non-con, [**3-16**]:
1. Right middle lobe collapse with bronchial obstruction. Right
lower lobe bronchus severely narrowed proximally with distal
reconstitution. In the setting of involvement of two adjacent
airways, lesion extrinsic to the airways is more likely than
endobronchial lesions, but evaluation is limited in the absence
of intravenous contrast. Repeat chest CT with intravenous
contrast could be performed for further evaluation.
Alternatively, direct visualization could be performed.
2. Prominent mediastinal and hilar lymph nodes.
3. Subcentimeter nodules and ground-glass opacity in the left
lower lobe, concerning for infection. In the presence of
centrilobular emphysema, close interval follow up is recommended
after treatment or within 3 months.
4. Mild anterior wedging of the T11 and T12 vertebral bodies.
5. Predominantly left-sided coronary artery calcifications.
CXR portable Study Date of [**2171-3-19**] 1:39 AM:
Mild-to-moderate bibasilar atelectasis has been present without
appreciable change since [**2-3**]. Previous small bilateral
pleural effusions have decreased. Upper lungs are clear. Heart
size is normal. There are no findings to suggest pneumonia
currently.
What appears to be a 5-cm long segment of catheter tubing
crosses the paramedian left hemithorax obliquely. In order to
clarify whether there is a retained catheter fragment, routine
chest radiograph should be obtained, and the radiologist
notified before the patient leaves the department.
Brief Hospital Course:
58 year old man with a history of polysubstance abuse, admitted
to the hospital with intoxication/withdrawal symptoms and
hypoxia; admission complicated by hypercarbic respiratory
failure.
# Hypercarbic and Hypoxic Respiratory failure: On admission,
the patient was noted to be hypoxic. He also has chronic CO2
retention related to baseline COPD. He underwent CT chest on
admission that showed RML collapse, likely by extrinsic
compression by mass. He was started on ceftriaxone and
azithromycin for CAP coveraged. He was evaluated by
interventional pulmonary with plan for bronchoscopy to further
evaluate bronchial obstruction. However, with the use of
benzodiazepines for alcohol withdrawal (described below), he
became somnolent and began to go into hypercarbic and hypoxic
respiratory failure. He was transferred to the MICU. In the
ICU, the patient was reversed with 4 doses of flumazenil. He
did not require invasive ventilation. The benzodiazepines
cleared from his system, and he awoke. He eloped from the
hospital prior to planned bronchoscopy. The patient should
follow up with interventional pulmonology for further evaluation
of his right middle lobe collapse.
# Alcohol Withdrawal, Alcohol Dependence with Acute
Intoxication: The patient presented to the emergency department
with alcohol intoxication, and was admitted to the hospital
floor as he started to withdraw. In the first 24 hours of his
hospital stay, he received >100mg valium. By hospital day 3
symptoms of withdrawal had improved, however, the patient became
increasingly somnolent. Respiratory drive was decreased by
cumulative effect of benzodiazepines, and the patient was
transferred to the MICU as above.
# Chronic Pain: Per prior notes and patient report, he takes
methadone 10mg TID for chronic pain after a motor vehicle
accident. On admission, he was continued on methadone 10mg TID.
This medication was held on admission to the ICU, as the patient
experienced increasing somnolence.
# Benign Hypertension: The patient was continued on home
Toprol-XL 25mg daily.
# Lung nodules: CT chest showed "Subcentimeter nodules and
ground-glass opacity in the left lower lobe, concerning for
infection. In the presence of centrilobular emphysema, close
interval follow up is recommended after treatment or within 3
months." The patient was recommended to follow up regarding
these findings in 3 months. No follow-up was arranged for him,
as he eloped from the ICU.
================================================
TRANSITIONAL ISSUES:
Patient with RML collapse likely secondary to extrinsic
compression, and left lower lobe lung nodules. Patient should
follow up with interventional pulmonology regarding these
findings and should undergo repeat CT scan chest in 3 months
Medications on Admission:
albuterol 90 mcg MDI 2 Puffs Q6H
methadone 10 mg PO TID
Toprol-XL 25 mg PO Daily
MVI Daily
Discharge Medications:
Patient eloped from the ICU prior to planned discharge
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Bacterial pneumonia
Lung [**Hospital3 45395**] failure
Discharge Condition:
patient eloped from the hospital while admitted to the ICU
Discharge Instructions:
Patient was admitted with alcohol withdrawal and shortness of
breath. He was found to have pneumonia and a mass in his lung.
Admission complicated by ICU transfer for somnolence in the
setting of benzodiazepines used to treat alcohol withdrawal.
Benzodiazepines cleared, and the patient returned to baseline
mental status. The patient insisted on leaving the hospital
against medical advice. Before the entire team had a chance to
speak with the patient about the full risks that he was facing,
he left the Unit without being observed.
During admission, patient was found to have lung nodules on a CT
scan of the chest. He will need to have another CT scan of the
chest in 3 months to follow these nodules.
Followup Instructions:
The patient left the ICU against medical advice and prior to
arranging followup for his outstanding problems.
ICD9 Codes: 5070, 5180, 3051, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1790
} | Medical Text: Admission Date: [**2177-3-5**] Discharge Date: [**2177-3-10**]
Date of Birth: [**2120-9-9**] Sex: F
Service: CCU
CHIEF COMPLAINT: Syncope.
HISTORY OF THE PRESENT ILLNESS: The patient was a
56-year-old woman who presented to the Emergency Department
on the morning of admission after experiencing five minutes
of loss of consciousness at home. The patient reportedly had
symptoms consistent with a urinary tract infection on the
morning prior to admission and was prescribed levofloxacin
and metronidazole. She subsequently experienced nausea,
vomiting, and coughing, and experienced loss of consciousness
after taking the above antibiotics. The patient's sister,
who was present during this episode of loss of consciousness,
stated that the patient fell to the ground with her arms
straightened and subsequently began drooling. There was no
postictal confusion. The patient reportedly denied fever,
chills, sweats, chest pain, palpitations, shortness of
breath, or diaphoresis. She reportedly had recently had an
upper respiratory tract infection. She also had epistaxis
lasting two to three minutes on the day prior to admission.
The patient was admitted to the Medicine Service on the day
of admission for evaluation of syncope versus seizure, but
subsequently had a cardiac arrest in the Emergency
Department. She was awaiting a bed on the Medicine floor
when she was found to be unresponsive, apneic, and pulseless.
Subsequent cardiac monitoring demonstrated ventricular
fibrillation. The patient was shocked four times, received
epinephrine three times, Atropine three times, and Amiodarone
once intravenously. She also was started on a lidocaine
drip, and subsequently reverted to normal sinus rhythm. She
was also found to be hypotensive, and was started on a
dopamine drip; this was changed to a phenylephrine drip given
tachycardia. She was then intubated and initially started on
assist control; the mode of ventilation was subsequently
changed to pressure support of 5 and PEEP of 5. The duration
of her arrest was at least 18 minutes.
PAST MEDICAL HISTORY:
1. Stage III-B cervical cancer, status post chemotherapy,
radiation therapy, and pelvic exenteration with an ileal
colonic urinary diversion and end-sigmoid colostomy.
2. Malignant melanoma, status post excision.
3. Anemia.
4. Thrombocytopenia in [**2175-9-13**].
5. History of bilateral hydronephrosis.
6. Status post right nephroureteral stent.
7. Cesarean section.
ALLERGIES: IV contrast, Bactrim, ciprofloxacin.
ADMISSION MEDICATIONS:
1. Metronidazole 500 mg p.o. b.i.d.
2. Levofloxacin.
3. Potassium supplements.
4. Diazepam 5 mg p.o. p.r.n.
5. Megestrol p.r.n.
SOCIAL HISTORY: The patient was a retired cardiac nurse.
She had no history of tobacco or alcohol abuse.
FAMILY HISTORY: The patient's father had bladder cancer.
Her mother had hypertension and an abdominal aortic aneurysm.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Heart rate
93, blood pressure 93/60, respiratory rate 16, oxygen
saturation 100% on the aforementioned mechanical ventilatory
settings. The patient was intubated. HEENT: Her pupils
were fixed and dilated, and she was noted to have several
broken teeth. Heart: Regular rate and rhythm, normal S1 and
S2 heart sounds, there were no murmurs, rubs, or gallops.
Lungs: Clear to auscultation bilaterally anteriorly.
Abdomen: Soft, nontender, normoactive bowel sounds. The
colostomy site was clean with soft stool at the ostomy site
and there was no splenomegaly. Extremities: She had faintly
palpable DP pulses bilaterally, warm extremities, and there
was no pitting edema. Neurologic: She had fixed pupils, as
noted above, no response to painful stimuli, 1+ biceps and
brachioradialis reflexes bilaterally, and no patellar or
ankle reflexes.
LABORATORY/RADIOLOGIC DATA: The patient's white blood cell
count was 7.2, hematocrit 35.8, platelet count 50,000.
Initial PT 14.5, PTT 30.3, INR 1.4. Her fibrinogen level was
221. Serum sodium initially was 140, potassium 4.2, chloride
106, bicarbonate 19, BUN 17, creatinine 1.3, glucose 136,
calcium 8.2, magnesium 1.8, phosphate 3.2. Her initial
urinalysis demonstrated positive nitrate, large blood,
greater than 300 protein, moderate leukocyte esterase, 0-2
red blood cells, 0-2 white blood cells, moderate bacteria, no
yeast, and no epithelial cells. Her LFTs prior to her
cardiac arrest were unremarkable.
Her initial ABG demonstrated pH of 7.23, PC02 28, P02 329 on
pressure support of 5, PEEP 5, and FI02 of 60%.
Initial chest x-ray done before her arrest demonstrated no
evidence of CHF, pneumonia, lymphadenopathy, or intrathoracic
metastases.
Subsequent chest radiographs obtained after the patient's
arrest demonstrated interval placement of an endotracheal
tube but otherwise confirmed the above findings.
An EKG done after the patient's arrest demonstrated sinus
rhythm, ventricular bigeminy with two ventricular foci, poor
R wave progression in leads V1 through V4 consistent with an
old anteroseptal myocardial infarction, and otherwise no new
findings. This ventricular bigeminy was no longer present on
repeat EKG done on the day of admission.
HOSPITAL COURSE: A repeat head CT scan done in route to the
CCU from the Emergency Department demonstrated no acute
intracranial hemorrhage, edema, or stroke. An echocardiogram
done on the day of admission demonstrated an elongated left
atrium, normal left ventricular cavity size, severely
depressed overall left ventricular systolic function with
global hypokinesis and septal hypokinesis, a dilated right
ventricle, and a very small pericardial effusion. Most
remarkably, however, much of the right ventricular cavity and
outflow tract was noted to be filled with an echodense mass
that was suspicious for tumor versus thrombus with a smaller
mobile mass prolapsing across the tricuspid valve into the
right atrium.
A chest MRI was done two days later that again demonstrated a
mass within the right ventricle that appeared to be adherent
to the septal wall. This mass was most likely felt to be
metastatic carcinoma versus metastatic melanoma versus a new
primary malignancy. The mass was felt to be the
arrhythmogenic focus that led to the patient's cardiac arrest
in the Emergency Department. Because the patient had
persistently fixed and dilated pupils in the face of
persistent unresponsiveness to painful, verbal, or tactile
stimuli, The patient's prognosis was deemed to be extremely
poor, and no intervention upon the right ventricular mass was
undertaken.
The patient was felt to likely have a significant anoxic
brain injury secondary to her prolonged cardiac arrest. Of
note, she had an MRI of the head done two days after
admission that demonstrated likely cortical infarctions
involving the temporal and posterior parietal lobes as well
as lacunar infarctions in the cerebellum.
By [**2177-3-8**], the patient's neurologic function
remained very poor and was essentially unchanged; she had
minimally reactive pupils bilaterally, scant response to
painful stimuli, and no response to the Babinski test with
evidence of new stroke as noted in the above MRI report. The
Neurology Service deemed her chance of any meaningful
neurologic recovery to be at best 5%.
A family meeting was held on the afternoon of [**2177-3-8**] with Dr. [**Last Name (STitle) **], members of the CCU house staff, the
patient's sister, and the patient's two daughters. During
this meeting, all family members clearly voiced the patient's
wishes to not undergo any further procedures given her
arduous medical journey to date. They wished to pursue
comfort measures pending the arrival of other close family
members and friends. The family understood that pursuing an
aggressive course would likely involve tracheostomy,
percutaneous feeding tube placement, and prolonged
rehabilitation with no guarantee that the patient's
underlying cardiac pathology, most likely a tumor versus
thrombus of the right ventricle, would not again cause
cardiac arrest. The patient's family clearly stated that the
patient would not want to pursue such a course.
Once the patient's friends and family members had arrived,
comfort measures were initiated, and the patient expired on
the morning of [**2177-3-10**]. The patient was pronounced
dead at 7:41 in the morning on [**2177-3-10**].
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2177-7-16**] 07:22
T: [**2177-7-20**] 08:40
JOB#: [**Job Number 32544**]
ICD9 Codes: 4275, 2875, 5990, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1791
} | Medical Text: Admission Date: [**2183-6-4**] Discharge Date: [**2183-6-9**]
Date of Birth: [**2183-6-4**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 1661**] [**Known lastname **], triplet #3, delivered at
34-6/7 weeks gestation with a birth weight of 2290 g and was
admitted to the Newborn Intensive Care Unit for management of
prematurity.
Mother is a 34-year-old gravida 1, para 0 now 3, woman with
estimated date of delivery [**2183-7-10**]. Prenatal screens
included blood type A+, antibody screen negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative, and group B strep unknown. Pregnancy was conceived
by in [**Last Name (un) 5153**] fertilization with donor sperm. Pregnancy was
complicated by triamniotic, trichorionic triplet gestation.
Pregnancy was essentially unremarkable until day of delivery
when mom presented at primary medical [**Name (NI) **] office with
elevated blood pressure and elevated pregnancy-induced
hypertension labs and decision was made to delivery. Delivery
was by cesarean section. Membranes were ruptured at delivery
for clear fluid. No maternal fever. No intrapartum
antibiotics. This infant emerged with a good cry and received
routine care. Apgar scores were 8 and 9 at 1 and 5 minutes,
respectively.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2290 g (45th
percentile), length 45 cm (35th percentile), head
circumference 32 cm (50th percentile). A nondysmorphic with
overall appearance consistently known gestational age,
anterior fontanel soft, open, flat, red reflex present
bilaterally, palate intact, grunting, flaring, retracting,
with a pectus, decreased breath sounds bilaterally,
symmetric, regular rate and rhythm, without murmur, 2+
peripheral and femoral pulses, abdomen benign without
hepatosplenomegaly or masses, normal male genitalia for
gestational age with testes descended bilaterally, normal
back and extremities with hips deferred, skin pink and well
perfused, appropriate tone and strength.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Was
placed on continuous positive airway pressure initially 25%
oxygen for respiratory distress. Weaned off CPAP around 12
hours of life to room air and has remained in room air since,
with comfortable work of breathing. Respiratory rate is in
the 30s-40s. No apnea of prematurity.
Cardiovascular: Has been hemodynamically stable throughout
hospitalization. No heart murmur.
Fluids, electrolytes, nutrition: Initially maintained with a
peripheral IV and D10W. Enteral feeds were started on day of
life 1 and IV fluids were stopped. Has advanced to 140 mL/kg
per day of breast milk with Similac 20. Is taking most feeds
by gavage with a little bit by bottle. Is voiding and
stooling appropriately. Discharge weight: 2090 up 35. atkign 24
cal feeds
GI: Bilirubin has been followed, and on day of life 3 the
bilirubin was total 9.7, direct 0.4, and phototherapy was
started. On day of life 4 the bilirubin had decreased to a
total of 7.4, direct 0.4, and the phototherapy was stopped. A
rebound bilirubin is pending from [**2183-6-9**] was 6.8/0.4.
Hematology: Hematocrit on admission 60%.
Infectious disease: Due to respiratory distress and
requirement for CPAP, a CBC and blood culture were done, and
the infant was placed on ampicillin and gentamicin. He
received 48 hours of ampicillin and gentamicin with a
negative blood culture and the CBC was benign.
Neurology: Exam is age appropriate.
Sensory: Hearing screening has not been performed yet.
Psychosocial: Parents are [**Known firstname **]
[**Known lastname **] and [**First Name4 (NamePattern1) **] [**Known lastname **]. The baby's last name will be
[**Name (NI) **].
CONDITION AT DISCHARGE: Stable 8 day old, former 34-6/7 week
pre-term triplet.
DISCHARGE DISPOSITION: Transferred to [**Hospital **] Hospital.
NAME OF PRIMARY PEDIATRICIAN: [**Last Name (un) **] [**Doctor Last Name 43313**] in [**Hospital1 3597**],
[**State 350**]. Telephone #: [**Telephone/Fax (1) 43314**].
CARE AND RECOMMENDATIONS:
1. Feeds: With breast milk or Similac 20. Plan to advance to
150 mL/kg per day and add calories if needed for growth.
2. Medications: Is not receiving any medications at this
time.
3. Car seat testing has not been performed.
4. State newborn screening was sent on [**2183-6-7**].
5. Has not received any immunizations.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age 34-6/7 week pre-term male.
2. Triplet #3.
3. Transient tachypnea of a newborn, resolved.
4. Perinatal sepsis ruled out.
5. Indirect hyperbilirubinemia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2183-6-8**] 14:49:40
T: [**2183-6-8**] 16:27:39
Job#: [**Job Number 61739**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1792
} | Medical Text: Admission Date: [**2147-8-30**] Discharge Date: [**2147-9-22**]
Date of Birth: [**2115-12-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
Exploratory laparotomy with Splenectomy [**2147-8-31**]
ORIF right distal tibia fracture with medial locking plate
[**2147-9-1**]
Mandible repair with wiring of jaw [**2147-9-2**]
History of Present Illness:
31 y/o male s/p car vs. tree at high rate of speed, confused and
c/o of chest pain. Unrestrained, +airbag deployment, heavy
front end damage.
Past Medical History:
Hep B
Hep C
Social History:
non-contributory
Family History:
Noncontributory
Physical Exam:
exam on arrival to ED:
140 70/P 14 99%RA
HEENT: multiple facial and head lacerations including forehead
lac and 4cm chin lac
Neck: +bleeding back of head and neck
Chest: CTAB, R chest ecchymosis
CV: RRR
ABD: soft, NT/ND FAST neg
Pelvis: Stable
GU: guiac neg, normal tone
Back: no step offs
Ext: RLE knee edema, defect in patella, pulses x2 LE's
Pertinent Results:
[**2147-8-30**] 10:16PM LACTATE-1.5
[**2147-8-30**] 09:16PM GLUCOSE-140* UREA N-10 CREAT-0.8 SODIUM-138
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-21* ANION GAP-16
[**2147-8-30**] 09:16PM ALT(SGPT)-315* AST(SGOT)-317* ALK PHOS-82
AMYLASE-426* TOT BILI-1.8*
[**2147-8-30**] 09:16PM CALCIUM-7.8* PHOSPHATE-2.9 MAGNESIUM-1.4*
[**2147-8-30**] 09:16PM WBC-29.7* RBC-4.78 HGB-15.4 HCT-43.5 MCV-91
MCH-32.2* MCHC-35.4* RDW-13.7
[**2147-8-30**] 09:16PM PLT COUNT-231
[**2147-8-30**] 09:16PM PT-15.2* PTT-30.7 INR(PT)-1.6
[**2147-8-30**] 09:16PM FIBRINOGE-192
MRI ABDOMEN W/O & W/CONTRAST [**2147-9-21**] 9:58 PM
MRI ABDOMEN W/O & W/CONTRAST; MR CONTRAST GADOLIN
Reason: second attempt visualize gall bladder--please call
before ex
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
31 year old man s/p MVC, rib fx's, mandible surgery to repair fx
with RUQ pain, inc alk phos, 9mm dilated GB duct on U/S, no
stones, no edema.
REASON FOR THIS EXAMINATION:
second attempt visualize gall bladder--please call before exam
today so that we may sedate pt. appropriately
INDICATION: Right upper quadrant pain, increased alk phos,
dilated common bile duct on ultrasound. Status post trauma, MVC.
COMPARISONS: CT abdomen [**2147-9-21**] and ultrasound [**9-20**], [**2146**].
TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained
of the abdomen. Dynamically acquired T1-weighted images were
obtained of the abdomen before, during and after administration
of intravenous gadolinium.
MRI OF THE ABDOMEN WITH AND WITHOUT CONTRAST: There is evidence
of central intrahepatic biliary dilatation. The common bile duct
is dilated measuring up to 12 mm. The common bile duct is
dilated down to the ampulla where it tapers and there is no
evidence of stones, strictures or masses. Post-gadolinium
administration, no abnormal masses are identified. The cause for
this common bile duct and intrahepatic biliary dilatation is not
identified. The pancreatic duct is normal. The pancreas is
normal without evidence of masses within the head. There is a
tiny, T2 bright lesion within the right lobe of the liver, which
does not enhance, is compatible with simple cysts. Otherwise,
the liver, gallbladder, adrenals, kidneys, and pancreas are
normal. The patient is status post splenectomy. Postsurgical
changes are identified within the midline. There are multiple
right-sided rib fractures as seen previously. There is no
abnormal lymphadenopathy. The patient is status post
splenectomy. There is minimal atelectasis at the lung bases.
IMPRESSION:
1. Mild-to-moderate central intrahepatic and common bile duct
dilatation as seen on previous studies. The cause for this
dilatation is not identified. There is no evidence of
strictures, stones or duodenal masses.
2. The patient is status post splenectomy with multiple
right-sided rib fractures.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2147-9-19**] 9:09 AM
CT SINUS/MANDIBLE/MAXILLOFACIA; CT RECONSTRUCTION
Reason: SP.MANDIBLE FX SURGICAL REPAIR ASSESSMENT OF ALIGNMENT
[**Hospital 93**] MEDICAL CONDITION:
31 year old man with s/p mandible fracture surgical repair
REASON FOR THIS EXAMINATION:
please perform 3d reconstruction of mandible for assesment of
alignment?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 31-year-old man, status post mandible fracture and
surgical repair. Followup evaluation.
TECHNIQUE: Axial, sagittal, and coronal images of the paranasal
sinuses and maxillofacial bones with 3D reconstructions.
FINDINGS: Comparison is made with [**2147-8-30**] exam. The
right comminuted mandibular ramus fracture is grossly unchanged
in appearance. The left mandibular ramus fracture is again seen
to be overriding and is grossly unchanged from prior exam. The
right paracentral mandibular body fracture is significantly
improved in alignment and now shows minimal displacement with
fixation hardware crossing the fracture lines. Fixation hardware
is also seen in the maxilla adjacent to the upper teeth and may
be connected to the lower teeth and mandible by non-opacified
material.
3D reformations revealed the presence of the above-mentioned
hardware as well as the previously described mandibular rami and
body fractures.
IMPRESSION:
1. Status post fixation of mandibular body fracture with
improved alignment.
2. Bilateral mandibular rami fractures, relatively unchanged
since the prior study.
TIB/FIB (AP & LAT) RIGHT [**2147-9-15**] 2:09 PM
TIB/FIB (AP & LAT) RIGHT
Reason: alignment. f/u surgery 2 weeks
[**Hospital 93**] MEDICAL CONDITION:
31 year old man with s/p MVA, R tib/fib ORIF. now 2 weeks out.
Needs 2 wk f/u films.
REASON FOR THIS EXAMINATION:
alignment. f/u surgery 2 weeks
INDICATION: ORIF patella and tibia.
COMPARISON: [**2147-8-30**].
FINDINGS: AP and lateral views of the tibia and fibula
demonstrate comminuted oblique fracture through the distal
tibia, transfixed by medial fixation plate and multiple
penetrating screws. Fracture lines are still visible. Also noted
is a transverse patellar fracture, transfixed by two K-wires and
cerclage wire. Incidental note is made of a spur along the
plantar fascia insertion of the calcaneus.
IMPRESSION: Interval ORIF distal tibia and patellar fractures.
Brief Hospital Course:
Upon arrival to the emergency dept. pt. was immediately
evaluated by the emergency medicine and trauma surgery teams. Pt
was sedated and intubated. Pt was imaged and revealed splenic
laceration, R tib/patella fractures, mandibular fractures with
tooth loss, R frontal brain contusion, bilateral rib fractures
including 1st rib, and inflammation of the superior pole of the
kidney. Pt was also noted to have multiple facial lacerations, a
large chin laceration, and gross hematuria of unknown origin.
Neurosurgery was consulted and stated nothing to do. Trauma took
pt. to OR for an exploratory laparotomy and performed a
splenectomy on [**2147-8-31**], after which he was admitted to the
TSICU. Orthopedics was consulted and took pt to OR for ORIF
right distal tibia fracture with medial locking plate on
[**2147-9-1**]. [**Date Range 40530**] was consulted and took pt. to OR for Mandible
repair with wiring of jaw on [**2147-9-2**]. Pt. was extubated without
incident. Pt. subsequently was requiring large amounts of pain
medication for injuries. Pt experienced an acute GI bleed while
in TSICU with associated tachycardia and hypotension to 60-70
systolic pressure. Pt. received transfusions of PRBC's, after
which his pressure and heart rate quickly normalized. GI was
consulted emergently during this event and pt's jaw wiring was
cut so as to perform emergent upper GI endoscopy. At that time
fresh blood was found in the stomach, but no point source was
found. On follow up endoscopy, a non-bleeding ulcer at the G-E
junction was identified and pt. was kept on tele and started on
an H-pylori eradication regimen. Pt. maintained his stability
and was subsequently transferred to the floor. Pt's jaw was
rubber banded by [**Name (NI) 40530**], pt. was instructed by nutrition on how to
follow a proper purreed diet, and pt. was advanced as tolerated
on PO's. Pt received PT & OT and was able to walk with walker.
Pt. continued to complain of constant [**9-25**] pain in chest and
abdomen, reproducible by palpation, no N/V, no diaphoresis, no
radiation. CXR and EKG were performed that were negative for any
changes. RUQ U/S, Abd CT and MRCP revealed a dilated CBD to 12mm
and mild to moderate hepatic duct dilitation without
stones/strictures/masses identified. GI ERCP fellow was
consulted and stated that there was nothing to do at this time
and that pt did not currently need to remain in the hospital for
this reason. Pt was evaluated by psychiatry and social work who
stated that pt. need strict boundries for pain medications and
that anxiety medications need to be increased, which they were
subsequently. Pt. was weened off IV pain medication and d/c'd on
PO pain meds as well as a low dose fentnyl patch for basal pain
coverage as taper from in hospital methadone coverage. Pt to
follow up with Trauma clinic, ortho-spine, [**Hospital **] clinic, [**Hospital 40530**], and
was given information about selecting a primary care physician
with whom to follow.
Medications on Admission:
Alprazolam
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
2. Chlorhexidine Gluconate 0.12 % Liquid Sig: Fifteen (15) ML
Mucous membrane QID (4 times a day).
Disp:*1800 ML(s)* Refills:*2*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal
QID (4 times a day) as needed.
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*500 ML(s)* Refills:*0*
8. Alprazolam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
9. 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*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
11. Amoxicillin 250 mg/5 mL Suspension for Reconstitution Sig:
One (1) 20ml PO BID (2 times a day) for 5 days.
Disp:*1 200ml* Refills:*0*
12. Clarithromycin 250 mg/5 mL Suspension for Reconstitution
Sig: One (1) 10ml PO Q12H (every 12 hours) for 5 days.
Disp:*1 100ml* Refills:*0*
13. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Transdermal
every seventy-two (72) hours as needed for pain.
Disp:*2 0* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p Motor Vehicle Crash
Splenic rupture and splenectomy
Right Tibia/fibula/patella fracture
Right frontal contusion
Mandibular fracture with tooth loss
Bilateral rib fractures including 1st rib
Gastrointestinal Bleeding
Right pulmonary contusion and pneumothorax
Dilated CBD at 12mm & mild intrahepatic duct dilitation
Discharge Condition:
Stable
Discharge Instructions:
-Take your medications as prescribed.
-Be sure to keep your schedule your follow up appointments.
-Return to emegency room if you develop fever, chills, abdominal
pain, nausea or vomiting.
-You will need to select a primary care physician, [**Name Initial (NameIs) 138**]
[**Telephone/Fax (1) 250**], [**Hospital6 733**]; [**Last Name (NamePattern4) 4113**] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] and
[**Last Name (NamePattern1) 54090**]are now accepting new patients.
Followup Instructions:
Follow up in 2 weeks in [**Hospital **] Clinic, call [**Telephone/Fax (1) 1228**] for
an appointment.
Follow up with Trauma Surgery in 3 weeks, call [**Telephone/Fax (1) 6439**] for
an aappointment.
Follow up with Dr. [**Last Name (STitle) 2866**], Oral Maxillo Facial Srgery in 1
week, call [**Telephone/Fax (1) 27823**].
Follow up with the [**Hospital **] clinic in 1 week regarding
your dilated common bile duct at: [**Telephone/Fax (1) 1954**] or [**Telephone/Fax (1) 1983**]
Follow up with a Primary care [**Name10 (NameIs) 63211**] [**Hospital **] to select your doctor: [**Telephone/Fax (1) 250**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 5185, 5789, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1793
} | Medical Text: Admission Date: [**2101-7-11**] Discharge Date: [**2101-7-15**]
Date of Birth: [**2045-10-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Left mainstem stent placement [**2101-7-11**] by Dr.[**First Name4 (NamePattern1) 1151**] [**Last Name (NamePattern1) 3373**]
History of Present Illness:
55 y/o male history of stage III non-small cell lung cancer,
consistent with squamous cell s/p chemotherapy and radiation
treatments as well as mutliple prior bronchoscopies with Dr.
[**Last Name (STitle) 3373**] for tumor debulking and stent placement to the left
mainstem bronchus who now presents with shortness of breath. The
patient lives in [**State 5111**], but receives his pulmonary care
here in [**Location (un) 86**]. He is in [**Location (un) 86**] for a stent placement however,
before a scheduled appointment with Dr. [**Last Name (STitle) 3373**] he presented this
morning with acute onset of shortness of breath and chest
tightness. EMS was called and found patient saturating 50% on RA
with intense tachypnia. Patient was placed on his home O2 of 3 L
which increased his saturations to about 70%. He was
transitioned to NRB with 90% saturations and transferred to
[**Hospital1 18**] ED.
In ED initial VS were HR 95, BP 123/73, RR 24, satting 99% on
NRB. US showed PTX on left side per ED report without evidence
of tension pneumothorax. A portable CXR showed collapse of the
left lung with tracheal deviation toward side of collapse. While
in the ER,had acute SOB/Tachypnea with drop in sats with NRB on
to 70's% which spontaneously returned to 100%. Labs were within
normal limits, except for a bicarbonate of 20. Patient's IP
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was conatacted in the ED and made aware of
the patient's admission.
Plan was for ICU admission with bronchoscopy/stenting of the
left mainstem later on this afternoon.
On arrival to the MICU, Pt. was sedated with propofol,
intubated, his VS were HR: 94, BP: 113/69, O2sat: 100% on
100FiO2 and vetilated, RR: 18 on the vent. Vent settings were
TV: 600cc, RR: 18, PEEP: 5, FiO2: 96%.
Review of systems: Unable to assess given sedation and
intubation.
Past Medical History:
NSCLC
HTN
DM
Hypothyroidism
s/p appendectomy age 17
s/p hemorrhoidectomy
s/p back surgery [**08**] years ago
Social History:
Lives with his wife [**Name (NI) 7346**] in [**State 5111**]. Has two children
occupation working as an oil refinery operator with reported
chemical exposures. Smoking history quit [**2090**] smoking [**12-13**] pack
per day since he was a teenager Alcohol since diagnosis
decreased from 12 pack per week
Family History:
Brother with history of melanoma
Physical Exam:
ADMISSION EXAM:
Vitals - HR: 95, BP: 123/73, RR: 24, satting 99% on NRB
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, 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: Foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Defer given sedation
DISCHARGE EXAM:
Vitals: T 98.1 BP 140/82 P 77 RR 18 O2 sat 96% RA
Gen: comfortable laying in bed in NAD
Neck: supple no JVD appreciated
Chest: distant heart sound. nl S1 S2 no mummurs, rubs, or
gallops
Lungs: rhonci b/l moving good air. No accessory muscle use
Abdomen: soft NTND, BS normoactive
Neuro: AOx3
Pertinent Results:
IMAGING:
CXR [**2101-7-11**] - Pre-operative
IMPRESSION: Near complete collapse of the left lung with
leftward mediastinal
shift. CT may be obtained to assess further for cause of lung
collapse.
CXR [**2101-7-11**] - Post-operative 1. ET tube 7.5 cm from the
carina.
2. Marked improvement of the aeration of the left lung with
possible small
left pleural effusion. No pneumothorax.
CXR [**2101-7-12**]- ET tube is 8.2 cm above the carina. A left
mainstem bronchus stent
is in place. Since the prior radiograph, there is no
significant change.
Small left pleural effusion is unchanged The right lung is
clear. There is no
focal consolidation, or pneumothorax. The bony structures are
intact.
CXR [**2101-7-13**]-FINDINGS: Portable AP chest radiograph is
obtained. Endotracheal tube is no longer visualized.
Cardiomediastinal contours are stable. Right lung remains
clear. Small left pleural effusion is again noted. Left lung is
better
aerated. No pneumothorax.
CT chest [**2101-7-14**]-IMPRESSION: 1. Unremarkable position of the
new stent in the left main bronchus. 2. Post-radiation
changes, stable. Mediastinal lymphoid tissue, unchanged.
Thickening of the trachea, unchanged 3. Interval decrease in
the size of the right lower lobe nodule, currently
cavitated.
ADMISSION LABS:
[**2101-7-11**] 10:07AM BLOOD WBC-8.8 RBC-4.60 Hgb-13.8* Hct-41.9
MCV-91 MCH-30.1 MCHC-33.0 RDW-13.7 Plt Ct-233
[**2101-7-11**] 10:07AM BLOOD Neuts-83.4* Lymphs-9.4* Monos-4.3 Eos-2.0
Baso-0.9
[**2101-7-11**] 10:07AM BLOOD Plt Ct-233
[**2101-7-11**] 10:07AM BLOOD PT-9.2* PTT-25.7 INR(PT)-0.8*
[**2101-7-11**] 10:07AM BLOOD Glucose-180* UreaN-16 Creat-1.2 Na-134
K-4.7 Cl-103 HCO3-20* AnGap-16
[**2101-7-11**] 04:04PM BLOOD Type-ART pO2-236* pCO2-77* pH-7.14*
calTCO2-28 Base XS--4
[**2101-7-11**] 07:53PM BLOOD Type-ART Temp-36.4 Rates-/18 Tidal V-540
PEEP-5 FiO2-100 pO2-283* pCO2-35 pH-7.40 calTCO2-22 Base XS--1
AADO2-391 REQ O2-69 -ASSIST/CON Intubat-INTUBATED
[**2101-7-11**] 04:04PM BLOOD Glucose-173* Lactate-0.3* Na-136 K-4.3
Cl-102
[**2101-7-11**] 04:04PM BLOOD Hgb-12.5* calcHCT-38 O2 Sat-99
RELEVENT LABS:
[**2101-7-12**] 03:52AM BLOOD WBC-10.3 RBC-3.71* Hgb-11.1* Hct-33.3*
MCV-90 MCH-30.0 MCHC-33.4 RDW-13.5 Plt Ct-194
[**2101-7-12**] 05:30AM BLOOD Hct-32.1*
[**2101-7-12**] 03:52AM BLOOD Plt Ct-194
[**2101-7-12**] 03:52AM BLOOD Glucose-160* UreaN-15 Creat-1.0 Na-136
K-4.0 Cl-106 HCO3-21* AnGap-13
[**2101-7-12**] 04:05AM BLOOD Type-ART Temp-36.4 Rates-/18 Tidal V-540
PEEP-5 FiO2-50 pO2-137* pCO2-35 pH-7.42 calTCO2-23 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2101-7-12**] 04:05AM BLOOD Lactate-1.0
DISCHARGE LABS:
[**2101-7-15**] 06:35AM BLOOD WBC-6.0 RBC-3.59* Hgb-10.9* Hct-32.6*
MCV-91 MCH-30.3 MCHC-33.4 RDW-13.9 Plt Ct-186
Brief Hospital Course:
55 yo male with non-small cell lung cancer with known left main
stem bronchus tumor burden presenting with acute worsening SOB.
#Left main bronchial obstruction/hypoxia/h/o NSCLC: The patient
presented to [**Hospital1 18**] with shortness of breath and hypoxia. He was
subsequently found to have near total collapse of his left lung
with mediastinal shift towards the collapsed lung on chest
X-ray. The patient has a known tumor in left mainstem region.
He has had 3 previous bronchial stents for left main bronchial
obstruction and hypoxia . He was intubated on admission and
admitted to the MICU. He underwent bronchoscopy by
interventional pulmonary who placed a metal stent in his left
mainstem bronchus. A repeat chest xray immediately following
the procedure showed reinflation of the upper lobe but
persistant collapse in the lower lobe. He was extubated on post
operative day one without respiratory distress, satting well on
50% face tent mask. He was transferred to the general medical
floors on hospital day 2. His supplemental O2 was weaned and he
was ultimately satting well on room air at discharge. The
patient was noted to have desaturations into the 80s on
ambulatory pulse ox, but remained asymptomatic with no shortness
of breath during these episodes. Final CXR prior to discharge
showed better aeration of the left lung. Per interventional
pulmonary he will need to have an official 6 min walk test and
be evaluated for pulmonary rehab when he returns home to
[**State 5111**]. He will have outpatient pulmonary follow up with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 90949**] of [**Last Name (LF) 11084**], [**First Name3 (LF) **] on [**2101-7-26**].
# Presumed Post Obstructive Pneumonia- During the bronchoscopy
the patient was noted to have several thick mucous plugs, and
per Interventional pulmonary was started on Levofloxacin for
presumptive post-obstructive pneumonia. His BAL cultures grew
oxacillin sensitive staph aureus which was also sensitive to
levofloxacin. He received one dose of IV vancomycin while the
sensitivities from the culture were pending. He also received
one dose of IV nafcilin. He was ultimately sent home on PO
levofloxacin and will have a 7 day course of antibiotics, ending
3 days after discharge.
#Anemia, NOS: During his stay in the MICU the patient was noted
to have a drop in hematocrit from 41.9 pre-operatively to 32.1
post-op day 1. He received 3.5 liters of normal saline during
his MICU stay and the drop was thought to possibly be dilution
versus peri-procedural bleeding. The patient maintained good
urine output with no signs of end organ damage such chest pain
or decreased urine output and no obvious sign of bleeding were
noted. His baseline Hct appears to be around 35. His hemoglobin
and hematocrit remained stable throughout the hospital course
and were 10.9/32.6 on discharge.
#Diabetes, type 2, controlled no complications: This is a
chronic stable issue. He is on metformin and Actos at home.
While in the hospital he was placed on a insulin sliding scale.
#HLD: This is a chronic stable issue. At home he is on
atorvastatin 40mg and Trilipix 135mg. He was continued on the
atorvastatin in the hospital. His Trilipix was held, as it is
not on formulary, but the patient who told to continue both
medications at discharge.
#HTN: This is a chronic stable issue. He is onolmesartan-HCTZ.
These medications were held as the patient's blood pressures
were stable but on the low side at SBP between 100-120. On
discharge his BP was 140/70 and it was recommended to the
patient to resume his home BP medications.
#Hypothyroid: This is a chronic stable issue. He was continued
on synthroid 200mcg each day
Transitional Issues:
- Will need to follow up with PCP to get an offical 6 minute
walk test and evaluation for pulmonary rehab
- Will establish outpatient pulmonary follow up with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 90949**] of [**Last Name (LF) 11084**], [**First Name3 (LF) **] on [**2101-7-26**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Pioglitazone 30 mg PO DAILY
2. Levothyroxine Sodium 200 mcg PO DAILY
3. fenofibrate *NF* 135 mg Oral QD
4. Atorvastatin 40 mg PO DAILY
5. MetFORMIN (Glucophage) 850 mg PO BID
6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
7. Albuterol Inhaler [**12-13**] PUFF IH Q6H:PRN SOB
8. Benicar HCT *NF* (olmesartan-hydrochlorothiazide) 20-12.5 mg
Oral QD
Discharge Medications:
1. Albuterol Inhaler [**12-13**] PUFF IH Q6H:PRN SOB
2. Atorvastatin 40 mg PO DAILY
3. Levothyroxine Sodium 200 mcg PO DAILY
4. Levofloxacin 750 mg PO DAILY
Day 1 [**2101-7-11**]
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
5. Benicar HCT *NF* (olmesartan-hydrochlorothiazide) 20-12.5 mg
Oral QD
6. fenofibrate *NF* 135 mg Oral QD
7. MetFORMIN (Glucophage) 850 mg PO BID
8. Pioglitazone 30 mg PO DAILY
9. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
Left main bronchus obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 62311**],
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted to the hospital because you were having difficutly
breathing. You were found to have near total collapse of your
left lung due to an obstruction of one of the main airways. You
had a bronschopy to relieve the obstruction. You were also
found to have a pneumonia and were started on antibiotics to
treat the infection.
Followup Instructions:
PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 699**]
Appt: [**2101-7-18**] @11:00 am
Phone number: [**Telephone/Fax (1) 90950**]
[**Street Address(2) 90951**].
[**Location (un) 90952**], [**Numeric Identifier 90953**]
-please make sure to get 6 min walk test and evaluate for
pulmonary rehab
DIVISION: PULMONARY
WITH: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 90949**]
WHEN: [**7-26**] 7:30am
PHONE: [**Telephone/Fax (1) 90954**]
WHERE: [**2088**] 6th Ave South,
[**Location (un) **]
[**Location (un) 11084**] [**Doctor Last Name **]
FAX: [**Telephone/Fax (1) 90955**]
.
ICD9 Codes: 4019, 2449, 2724, 2859, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1794
} | Medical Text: Admission Date: [**2122-5-4**] Discharge Date: [**2122-5-7**]
Date of Birth: [**2055-10-31**] Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66M with CAD s/p CABG, VF arrest s/p AICD, ischemic CMP (LVEF
20-25%), AF/flutter s/p ablation admitted with symptomatic
hypotension. Of note the pt was admitted from [**4-24**] through [**5-3**]
to [**Hospital1 1516**] for progressively worsening shortness of breath and
weight gain and found to have an acute systolic CHF
exacerbation. During the admission the pt denied chest pain,
Trop 0.14, CK-MB was 3, and EKG revealed non-specific findings.
BNP 2218. CXR with pulmonary edema. No clear preciptant was
identified though it was likely due dietary indiscretion and med
non-compliance. Pt was diuresed with lasix gtt and once daily
dosing of Diuril. Of note wt on admission was 221.7 lbs and was
diuresed to a wt of 178.2lbs (43.6 lbs change, below his dry
weight). On d/c Cr had increased from 1.1 to 2. The pt was
discharged on lasix 80mg [**Hospital1 **]. The pt was discharged yesterday.
Today the pt was seen by his VNA to whom he reported feeling
very lightheaded and tired. His BP was 60/30. He drank water and
repeat pressure with 72/40. She recommended he go to the ED and
he refused.
The VNA rechecked readings 60/30 sitting and 50/30 standing.
Patient got home last night. Also of note the pt had not filled
his bactrim or dabigitran. The pt's PCP then called the pt and
spoke to his granddaughter and instructed her to bring him to
the ED.
In the ED initial vitals 96.0 76 83/41 16 97% received 1.5L in
the 80s, starting to feeling better. 100% on 2L. Lactate. UA
negative. CXR clear. Little lightheadedness. ECG stable. Vitals
prior to transfer Afebrile, 90/48 7616 97%2:.
On arrival to the CCU (MICU 7 border) the pt denies
lightheadedness, chest pain, shortness of breath.
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. S/he denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Current 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. Severe CAD s/p 4vCABG [**2107**]
2. V-Fib arrest 4-days post-CABG s/p pacemaker/ICD [**2107**]
- Generator change and pocket revision in [**2120-1-14**] to right
side of chest secondary to pain
3. Ischemic cardiomypoathy / systolic CHF, EF 25%
4. Peripheral vascular disease s/p bilateral femoral-popliteal
bypass
5. multiple lower extremity catheterizations
6. Diabetes Type II - followed at [**Last Name (un) **]
7. Obstructive sleep apnea
8. Gout
9. Asthma
10. Mild sigmoid colonic thickening on recent CT-Abd/Plv,
colonoscopy showing sessile polyps, biopsy will have to happen
off plavix
11. Esophagitis, gastritis, peptic ulcer disease
12. Afib/flutter s/p TTE cardioversion [**1-/2121**], ablation.
Social History:
Married, lives at home with wife. Former 70 pack years tobacco
use but quit in [**2107**]. Denies alcohol or IVDA. Prior to his
admission to rehab he lived at home with his wife. [**Name (NI) **] walks with
a cane. He does not drink or smoke.
Family History:
Mother with kidney problems. Father died of unknown causes. One
sister died of stomach cancer, another sister also with stomach
cancer. Diabetes is prevalent throughout the family. There is no
family history of premature coronary artery disease or sudden
death.
Physical Exam:
Admission Exam
VS: Afebrile, 94/48 76 16 97%2L
GENERAL: comfortable-appearing, lying back in bed,
HEENT: NCAT, MMM, poor dentition
NECK: Supple with difficult to assess JVP
CARDIAC: Sustained PMI, RRR, normal S1 and S2, no m/r/g
LUNGS: Good airmovement bilaterally. No wheezes or rales.
ABDOMEN: surgical scars present, obese but soft, BS+, NT
EXTREMITIES: Trace pitting edema bilateral lower extremities.
SKIN: + Stasis dermatitis. No ulcers, scars, or xanthomas
Discharge exam
GENERAL: comfortable-appearing, NAD
HEENT: NCAT, MMM, poor dentition
NECK: Supple with difficult to assess JVP
CARDIAC: Sustained PMI, RRR, normal S1 and S2, no m/r/g
LUNGS: Good air movement bilaterally. Slight bibasilar rales
ABDOMEN: surgical scars present, obese but soft, BS+, NT
EXTREMITIES: Trace pitting edema bilateral lower extremities.
Distal pulses palpable and symmetric.
SKIN: + Stasis dermatitis. No ulcers, scars, or xanthomas
Pertinent Results:
CBC
[**2122-5-3**] WBC-9.6 RBC-4.11* Hgb-9.2* Hct-30.3* Plt Ct-348
[**2122-5-4**] WBC-9.7 RBC-3.78* Hgb-8.3* Hct-28.0* Plt Ct-298
[**2122-5-7**] WBC-9.3 RBC-4.00* Hgb-9.3* Hct-29.9* Plt Ct-327
Coags
[**2122-5-4**] PT-18.7* PTT-40.3* INR(PT)-1.7*
Chemistries
[**2122-5-3**] 06:54AM BLOOD Glucose-160* UreaN-38* Creat-2.0* Na-135
K-4.0 Cl-89* HCO3-35* AnGap-15
[**2122-5-7**] 04:20AM BLOOD Glucose-137* UreaN-50* Creat-2.2* Na-131*
K-4.9 Cl-95* HCO3-25 AnGap-16
cardiac enzymes
[**2122-5-5**] 12:08AM BLOOD CK(CPK)-83
[**2122-5-5**] 12:08AM BLOOD CK-MB-3 cTropnT-0.02*
[**2122-5-4**] 05:25PM BLOOD cTropnT-0.03*
[**2122-5-4**] 05:25PM BLOOD proBNP-2516*
[**2122-5-3**] 06:54AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.2
[**2122-5-7**] 04:20AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.4
[**2122-5-4**] 05:33PM BLOOD Lactate-2.7*
[**2122-5-5**] 12:07AM BLOOD Lactate-1.6
microbiology
blood cultures ([**5-4**]) - NGTD
urine culture ([**5-4**]) - NG
CXR [**5-4**]
PORTABLE UPRIGHT AP VIEW OF THE CHEST: A right-sided pacemaker
device is
noted with lead terminating in the right ventricle. Abandoned
left-sided
pacer leads are also noted. The patient is status post median
sternotomy and CABG. Mild cardiomegaly persists. The mediastinal
and hilar contours are stable. Pulmonary vascular congestion is
present without pleural effusions or pneumothorax. No focal
consolidation is present. There are no acute osseous findings.
Brief Hospital Course:
66 year old male with CAD s/p CABG, VF arrest s/p AICD, ischemic
CMP (EF 20-25%), AF/flutter s/p ablation with recent admission
for acute systolic CHF with aggressive diuresis admitted with
hypotension and [**Last Name (un) **].
1. Hypotension due to hypovolemia due to overdiuresis. Patient
was noted to be hypotensive at home by visiting RN. Admitted to
CCU. Hypotension resolved with one unit of PRBC and 500 cc of NS
bolus. Subsequently blood pressure remained stable throughout
hospital course.
2. Chronic Systolic heart failure: Compensated. Lasix 120 mg po
BID held on admission. Continued on metoprolol succinate 50 mg
po qdaily. Lisinopril 5 mg po qdaily held due to [**Last Name (un) **]. Was given
IV lasix 60 mg x 1 early morning of [**2122-5-6**] and = restarted
home lasix 120 mg po BID evening of [**2122-5-6**]. Pt was discharged
on above regimen with plans to follow up wtih cardiology
regarding the initiation of lisinopril.
3. Complicated Urinary Tract Infection: Urine analysis was
normal. Urine culture showed no growth. Bactrim was discontinued
due to [**Last Name (un) **] and did not require any antibiotics as patient was
asymptomatic.
4. CAD s/p 4V CABG: Currently chest pain free. ECG unchanged.
Cardiac enzymes negative. Continued on atorvastatin 40 mg PO
daily. Metoprolol succinate 50 mg po qdaily changed to
metoprolol tartrate 25 mg po BID. Lisinopril 5 mg po qdaily
held due to [**Last Name (un) **]. He was continued on aspirin 81 mg po qdaily.
5. Atrial Fibrillation/Flutter s/p Ablation: Currently with good
HR control on metoprolol 25 mg po BID. Anticoagulated with
dabigatran which was held on admission. Restarted dabigatran at
75 mg po BID on [**2122-5-6**].
6. Hypovolemic Hyponatremia: Resolved with volume repletion.
7. IDDM: A1c 7.6% on [**2122-4-10**]. FSG currently in mid-100s.
Continue home dose Lantus 30 units QAM. Continue Pregabalin 75
mg PO BID for neuropathy
8. Gout: Currently without a flare. Holding Allopurinol 600mg
daily and colchicine 0.6 mg po QOD with [**Last Name (un) **]. Restarted
allopurinol at 300 mg po daily given change in renal function.
9 Anemia: On admission pt had microcytic anemia with HCT of 25
and was transfused 1 unit PRBC responding appropriately and
remained stable.
Medications on Admission:
Bactrim 800-160mg PO BID for 13 more doses.
Dabigatran Etexilate 150mg PO BID
Atorvastatin 40mg PO Daily
Metoprolol Succinate 50 mg Tablet ER
Lisinopril 5mg (Has not started back yet)
Allopurinol 600mg Daily
Vicoden 5-500mg PO Q6H PRN PAIN
Colchicine 0.6 mg PO QOD
Pregabalin 75mg PO BID
Lantus 60 units QAM
Lasix 160mg PO BID
Humalog 100 unit/mL Solution Sig: ASDIR
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily). Tablet(s)
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. insulin glargine 100 unit/mL Solution Sig: One (1) 60
Subcutaneous once a day.
6. insulin lispro 100 unit/mL Solution Sig: [**11-16**] As directed
Subcutaneous four times a day.
7. furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
8. pregabalin 75 mg Capsule Sig: One (1) Capsule PO twice a day.
9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other
day.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis
- Hypotension secondary to overdiuresis
- Acute on Chronic Kidney Injury
- Chronic Systolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with lightheadedness. You were found
to have low blood pressure that was likely due to medications.
You were given IV fluids and had your medications adjusted.
.
Please note the following changes to your medications:
Please START taking:
1) Aspirin 81mg Daily
PLEASE NOTE THE FOLLOWING CHANGES TO THE DOSES OF YOUR
MEDICATIONS:
1) Dabigitran 75mg Please take twice daily (you were previously
prescribed 150mg twice daily)
2) Allopurinol 300mg Daily (you were previously taking 600mg
Daily)
3) Lasix 120mg twice daily (you were previously taking 300mg
Daily)
.
Please STOP taking:
1) Bactrim
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please set up appointments with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 7960**] and
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**] for Mr. [**Known lastname **] in the next week
.
Department: RHEUMATOLOGY
When: TUESDAY [**2122-6-9**] at 2:30 PM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2122-5-8**]
ICD9 Codes: 2720, 5849, 5990, 4280, 5859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1795
} | Medical Text: Admission Date: [**2112-5-30**] Discharge Date: [**2112-6-17**]
Date of Birth: [**2052-9-2**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Acute renal failure
Hepatitis C Cirrhosis, decompensated liver failure
Major Surgical or Invasive Procedure:
[**2112-6-2**]: Temporary right internal jugular double lumen dialysis
catheter
[**2112-6-6**]: [**Last Name (un) 1372**]-duodenal tube replacement
[**2112-6-10**]: OLT
History of Present Illness:
59 M with h/o hepC cirrhosis, s/p renal and pancreatic
transplant for DM, and recent admission for ARF (not thought to
be HRS, [**Date range (1) 34961**], admit creat 3.1 and d/c creat 2.3 on [**5-12**])
who presented for routine paracentesis on day of admission, and
was found to have elevated creatinine of 3.6. At Day Care
Clinic, pt had paracentesis removing 3 L of ascitic fluid which
was negative for SBP. Pt stayed hemodynamically stable
throughout the procedure with SBP in 90s-100s. Pt received 50
gm of albumin (concentrated) after paracentesis. Pt reports he
has not been eating or drinking much fluid due to abdominal
distension for the past several days. He reported intermittent
nausea and vomiting up food soon after eating. Denied any
hematemasis, melena, worsening diarrhea (has bm [**12-15**]/day),
hematochezia, decreased urinary stream or urine output (goes 3
times a day). Denied any cough, fevers, but reports chills all
the time. Denied sob, chest pain, abdominal pain, n/v, or
urinary symptoms. Denied any recent NSAIDS use. Stopped taking
ASA recently for easy bruising/bleeding. Has been getting tube
feeding at home at night and has been tolerating it well (60cc
goal).
Past Medical History:
1. Hepatitis C cirrhosis, genotype 1. s/p biopsy [**2-17**] (stage 2-3
fibrosis). HepC VL 965,000 [**2-17**]. +h/o SBP [**4-18**], +h/o
encephalopathy, EGD [**2-17**] no varices, +portal gastropathy. no
colonoscopy. +recurrent ascites on diuretics.
2. s/p cadaveric renal transplant in [**2107**] for presumed
diabetic nephropathy
3. s/p pancreas transplant in [**2108**] now with resolved diabetes
4. HTN
5. Asthma
6. Encephalopathy
Social History:
He lives at home with his wife. Ex-[**Name2 (NI) 1818**], quit 15 years ago. He
used to work as a cabinet maker in the past.
Family History:
Mother deceased MI [**69**], h/o kidney CA, dad alive at 87 yr old.
Otherwise NC.
Physical Exam:
VS: 98.3 98.3 116/54 88 18 97%RA
GEN: NAD, pleasant male.
HEENT: PERRLA, EOMI, sclera icteric, OP clear, MM dry, no LAD.
left side carotid radiation of murmur. 8cm JVP at 45
degrees.
CV: regular, nl s1, s2, 3/6 SEM radiating to carotids and
holosystolic murmur at base radiating to axilla, no r/g.
PULM: CTA B, no r/r/w.
ABD: soft, NT, +distended, + BS, + fluid wave, no HSM.
paracentesis dressing in LLQ c/d/i.
EXT: warm, 2+ dp/radial pulses BL. [**12-15**]+ edema to mid-calf L>R
(not new per pt).
NEURO: alert & oriented to place and [**2112-5-11**], CN II-XII grossly
intact. + mild L asterixis.
Pertinent Results:
On Admission: [**2112-5-30**]
WBC-5.0 RBC-3.58* Hgb-11.6* Hct-33.5* MCV-94# MCH-32.5*
MCHC-34.7 RDW-20.8* Plt Ct-181
PT-21.7* PTT-51.0* INR(PT)-2.1*
Glucose-90 UreaN-102* Creat-3.6*# Na-132* K-4.3 Cl-104 HCO3-16*
AnGap-16
ALT-46* AST-158* AlkPhos-134* Amylase-40 TotBili-8.4* Lipase-45
Calcium-8.4 Phos-5.7* Mg-2.9*
On discharge: [**2112-6-16**]
WBC-3.8* RBC-2.96* Hgb-9.5* Hct-28.4* MCV-96 MCH-32.0 MCHC-33.4
RDW-17.7* Plt Ct-116*
PT-11.8 PTT-29.1 INR(PT)-1.0
Glucose-130* UreaN-57* Creat-1.4* Na-135 K-3.1* Cl-102 HCO3-24
AnGap-12
ALT-223* AST-84* AlkPhos-114 Amylase-50 TotBili-1.4 Lipase-30
Albumin-2.7* Calcium-7.5* Phos-1.3* Mg-1.4*
[**2112-6-17**] 04:30AM BLOOD FK506-14.8
[**2112-6-15**] 04:25AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE >450
Brief Hospital Course:
59yo M with HCV cirrhosis, s/p renal/pancreas transplant a/w
ARF.
Initially admitted with ARF (Cr 3.3 today) s/p renal transplant
in [**2108**], creatinine rising from 0.8 one year ago, worsening over
the past year. This is likely hepatorenal syndrome. Transplant
renal U/S with lack of diastolic flow, a non-specific finding.
Started hemodialysis using temporary dialysis catheter
(Successful placement of temporary right internal jugular double
lumen dialysis catheter on [**2112-6-2**]).
It was felt that this was Hepatorenal syndrome and he was
started on midodrine, octreotide and albumin.
[**Date Range 13808**], awaiting transplant, EGD with no varices [**2112-3-2**]. Last
paracentesis [**2112-6-1**], no SBP, though has previous h/o SBP. He
was continued on lactulose, rifaxamin, ursodiol, levofloxacin
for SBP ppx.
In addition he continued his immunosuppression of tacrolimus and
prednisone as well as Bactrim. He has not required insulin since
his pancreas transplant in [**2108**].
He had a very poor nutritional status with low Na diet with
ensure, tube feeding for supplement, this was continued from
home. The [**Last Name (un) **]-intestinal tube was replaced on [**2112-6-6**].
Stress MIBI was performed on [**6-7**] in anticipation of liver
transplant, EF 67% Other blood serologies had been previously
reported.
On [**6-10**] the patient was able to undergo Orthotopic liver
transplant. Of note the patient was HBcAb positive, received
10,000 units HBIG intra-op in additon to routine induction
immunosuppression. He was started on Vanco and Zosyn for
presumed UTI (10-100,00 yeast in urine)
Please see the operative note for surgical details. OLT from
when the clamps were removed, there was excellent flow and good
thrill through the artery. The liver began making bile and its
color improved. There was a size discrepancy at the bile duct,
recipient bile duct was oversewn. He received CVVH while in the
OR
Patient followed pathway post-op, was extubated on POD 1 and
transferred to [**Hospital Ward Name 121**] 10 on POD 2.
He continued to make excellent progress, liver function tests
improved as did renal function. He did not require hemodialysis
following the transplant.
He received 5000 units HBIG daily for 5 days post op. HBsAb was
>450 daily.
He was continued on tube feeds, his ND tube was exchanged early
in the hospitalization. He will continue tube feeds at home,
having only a fair appetite.
He did have an insulin requirement while hospitalized, and will
go home on insulin at least in the short term. Seen by [**Last Name (un) **]
during the hospitalization.
He is ambulating using a walker.
Medications on Admission:
1. Gemfibrozil 600 mg [**Hospital1 **]
2. Hydroxyzine HCl 25 mg QHS
3. Tacrolimus 0.5 mg PO QDAILY at 8 PM
4. Prednisone 5 mg Daily
5. Trimethoprim-Sulfamethoxazole 80-400 mg DAILY (Daily).
7. Pantoprazole 40 mg Tablet PO Q24H
8. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
9. Hexavitamin 1 Tablet PO DAILY
10. Calcium Carbonate 500 mg PO TID
11. Cholecalciferol (Vitamin D3) 400 unit PO DAILY
12. Sodium Bicarbonate 650 mg Two (2) Tablet PO BID
13. Rifaximin 200 mg PO TID
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
15. Levofloxacin 250 mg Tablet PO Q24H
16. Simethacone 80mg po QID/PRN
17. Ursodiol 600mg [**Hospital1 **]
Discharge Medications:
1. Nutrition
Tubefeeding: Nutren 2.0 3/4 strength
Starting rate: 80 ml/hr; Do not advance rate
Goal rate: 80 ml/hr
Cycle start: 1800 Cycle end: 1000
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 30 ml water q6h
2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
11. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12)
Subcutaneous once a day.
12. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection four times a day.
13. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs inhaler* Refills:*2*
14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed.
Disp:*20 Tablet(s)* Refills:*0*
15. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
Medical Resources Home Health Corp
Discharge Diagnosis:
Acute renal failure: now resolved
[**Hospital1 13808**] s/p orthotopic liver transplant
Discharge Condition:
Good
Discharge Instructions:
Call the transplant office at [**Telephone/Fax (1) 673**] if you experience any
of the following symptoms: fever >101.4, chills, nausea,
vomiting, diarrhea, inability to eat, pain over the incision
site or liver, yellowing of the skin or eyes, an increase in
abdominal girth. Monitor incision for redness, drainage or
bleeding.
Do not drive if you are taking narcotics.
Take your medications exactly as directed.
Have labs drawn every Monday and Thursday and have them faxed to
[**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, Alk Phos, Albumin, T Bili
and trough Prograf Level
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-6-20**]
10:00AM
Completed by:[**2112-6-17**]
ICD9 Codes: 5715, 5849, 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1796
} | Medical Text: Admission Date: [**2151-7-2**] Discharge Date: [**2151-7-7**]
Date of Birth: [**2103-1-4**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 48 year old man with a history of hypertension,
hyperlipidemia and cognitive delay presenting from [**Hospital1 5979**] with a right temporal lobe hemorrhage detected after
patient presented with four days of headache and chest pain.
.
The patient reports that four days ago he suddenly developed a
[**9-1**] frontal headache as well as central, nonradiating chest
pain. The headache has been getting progressively worse. He
denies any recent head trauma or drug use, though last cocaine
use was 2 months ago. He admits to not exercising and eating
poorly recently. He presented to OSH with a systolic blood
pressure of 220. In our ED the patient had a blood pressure of
208/128 on presentation with improved headache and chest pain.
He was started on a nitroprusside drip.
.
ROS: reports "blurry vision", no focal weakness, numbess, loss
of balance, word finding. No fevers, weightloss, nausea,
vomiting, abd pain, cough, shortness of breath.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Obstructive sleep apnea
-Cognitive delay
Social History:
Single, no children, on disability. No tobacco, occasional ETOH,
Cocaine use as recent as 2 months prior. Contact is sister
[**Name (NI) 1787**] [**Name (NI) 3234**]: [**Telephone/Fax (1) 111883**].
Family History:
No strokes, seizure, bleeds.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T:97.6 BP:208 /128 -->127/60 HR:54 R18 O2Sats95% RA
Gen: sleepy but arousable and conversant, NAD
HEENT: Pupils: [**1-22**] bilaterally
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Obese, Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert but keeps eyes closed for most of
exam, cooperative with exam, normal affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3to2mm
bilaterally. Visual fields difficult to assess due to loss of
attention- possible deficit on left side.
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 [**3-27**] throughout though some giveway
on bilateral IPs. No pronator drift.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: 2+ patellar, bicep, tricep. 0 ankles
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
.
PHYSICAL EXAM ON DISCHARGE:
-Vitals: 98.1/97.9 117/86 [117-178/86-94] 69-88 [**10-15**] 92-99% RA
-General: obese HM in NAD, AAOx3, no longer appears somnolent
-Neuro: left superior quadrantanopia, more dense in left eye.
Otherwise, nonfocal exam.
Pertinent Results:
ADMISSION LABS:
-WBC-10.2 RBC-5.04 HGB-15.2 HCT-45.3 MCV-90 MCH-30.1 MCHC-33.5
RDW-12.4
-NEUTS-55.2 LYMPHS-35.3 MONOS-5.6 EOS-3.4 BASOS-0.6
-PT-11.4 PTT-26.2 INR(PT)-1.1
-cTropnT-<0.01 x2
-GLUCOSE-127* UREA N-16 CREAT-0.8 SODIUM-139 POTASSIUM-3.8
CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
.
MODIFIABLE STROKE RISK FACTOR LABS:
-%HbA1c-6.2* eAG-131*
-Triglyc-136 HDL-37 CHOL/HD-4.1 LDLcalc-87
-TSH-2.4
.
IMAGING:
CTA HEAD/NECK ([**7-2**]):
1. Interval mild-to-moderate increase in size of the large right
temporal parenchymal hemorrhage, with adjacent peri-hemorrhagic
edema, resulting in partial effacement of the adjacent sulci and
the right lateral ventricle, and 3-mm leftward shift of the
normally-midline structures, unchanged.
2. No new foci of acute intracranial hemorrhage. No
intraventricular extension.
3. No evidence of arteriovenous malformation, aneurysm or
cerebral venous thrombosis.
4. No CTA "spot sign" to portend rapid expansion of the
hematoma. Essentially normal CTA head and neck.
MRI HEAD ([**7-2**]): Slightly larger right temporal lobe hematoma,
with associated vasogenic edema and effacement of the
perimesencephalic cisterns as described above. There is no
evidence of abnormal enhancement or diffusion abnormalities.
NONCONTRAST HEAD CT ([**7-3**]): Limited study due to patient motion
demonstrates relatively stable appearance of right temporal lobe
hematoma with associated vasogenic edema, effacement of the
perimesencephalic cisterns, and 3 mm leftward shift of normally
midline structures.
LABS ON DISCHARGE:
-WBC-9.1 RBC-4.82 Hgb-14.6 Hct-44.3 MCV-92 MCH-30.3 MCHC-33.0
RDW-12.7 Plt Ct-305
-Glucose-115* UreaN-19 Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-29
AnGap-11
Brief Hospital Course:
Mr. [**Known lastname **] is a 48 year old right handed man with a history of
hypertension, hyperlipidemia and cognitive delay presenting from
[**Hospital3 **] with a right temporal lobe hemorrhage after
four days of headache and chest pain.
# NEURO: Mr. [**Known lastname **] was initially admitted to the neurosurgical
intensive care unit on the neurosurgery service. He was given
platelets as he was on aspirin at home. He was placed on a
nitroprusside drip for blood pressure control for a goal
systolic blood pressure of under 150. This was then changed to a
nicardipine drip with PO lisinopril 40mg PO and his home dose of
atenolol. A CTA of the brain was performed to rule out an
underlying vascular lesion that may have caused the bleed, which
was negative. He then underwent an MRI which ruled out an
underlying tumor, though given the amount of blood in the
temporal lobe, the MRI should be repeated in a few months to
confidently rule out a mass. The patient received mannitol to
reduce intracranial pressure and dilantin for seizure
prophylaxis. On [**7-3**] the patient was observed by the SICU staff
to be more somnolent, though arousable. A stat head CT was done
which was movement degraded but did not show any significant
increased size of bleed or edema. On transfer to the neurology
service, neurologic exam was largely intact although limited by
pt's alertness. His somnolence was likely explained by over 2
days of q1hour neurocheck and the resulting tiredness, as per
nursing, he had been intermittently quite awake, especially when
his family visited. 2 days after, patient was awake, alert, with
only defect on exam being left superior quadrantanopia. The
etiology of the bleed was most likely hypertensive despite the
lobar location. Other etiologies such as amyloidosis and
vascular malformations should be considered.
.
On HD #4, patient was transferred out of the ICU to the
neurology floor once he was no longer requiring IV medications
to keep his SBP<160. His dilantin prophylaxis was discontinued
as he was deemed at low risk for seizure. His antihypertensives
were uptitrated, and on discharge his med regimen was:
lisinopril 40mg PO daily, amlodipine 40mg PO daily,
hydrochlorothiazide 25mg PO daily, and metoprolol succinate
150mg PO daily. Given patient's cognitive delay and concern that
he had not been compliant with antihypertensive meds prior to
admission, he was connected with VNA services who will help with
med administration at home.
.
# Cardiac: The patient initially presented with chest pain of 4
days in duration. There were no ischemic changes on EKG and his
cardiac enzymes were cycled and remained flat. His blood
pressure was managed as above.
.
# Pulm: CPAP was ordered for OSA.
TRANSITIONS OF CARE:
-Patient will need MRI with contrast in 4 weeks to evaluate for
underlying mass/ vascular lesion (has been ordered, will be
followed by Dr. [**First Name (STitle) **].
Medications on Admission:
All:NKDA
Lisinopril 20mg daily
simvastatin 20mg daily
atenolol 100mg daily
Aspirin 81mg daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. Hydrochlorothiazide 25 mg PO DAILY
HOLD for SBP<110
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
4. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
5. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth once a day
Disp #*90 Tablet Refills:*1
6. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
ACUTE ISSUES:
1. Temporal lobe hemorrhage
CHRONIC ISSUES:
1. High blood pressure
2. Obesity
3. Developmental delay
4. Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a severe headache and
chest pain. You were found to have a hemorrhage (bleeding) in
your brain. This may have been caused by your poorly-controlled
high blood pressure, which puts you at risk for brain bleeding.
You were admitted to the ICU where you received IV medications
to reduce your blood pressure and prevent brain swelling. Your
oral blood pressure medications were also increased.
.
Please attend the outpatient appointment with Neurology (Dr.
[**First Name (STitle) **] listed below to follow up on your hospitalization.
.
You will need an MRI of your head as an outpatient to follow up
on your brain hemorrhage and make sure there were no other
underlying brain problems that caused the bleed. You should make
sure to have the MRI done BEFORE your appointment with Dr. [**First Name (STitle) **]
(see below for instructions on scheduling this appointment).
.
We made the following changes to your medications:
1. STARTED amlodipine 10mg by mouth daily
2. STARTED metoprolol succinate 150mg by mouth daily
3. STARTED hydrochlorothiazide 25mg by mouth daily
4. INCREASED lisinopril from 20mg by mouth daily to 40mg by
mouth daily
5. STOPPED amlodipine 100mg by mouth daily
Followup Instructions:
You will be called by the Radiology department to schedule an
outpatient MRI before your Neurology appointment. If you do not
hear from them within ONE week, please call ([**Telephone/Fax (1) 111884**] to
schedule this appointment.
Department: NEUROLOGY
When: MONDAY [**2151-9-6**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1797
} | Medical Text: Admission Date: [**2152-11-8**] Discharge Date: [**2152-11-15**]
Date of Birth: [**2079-5-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion and fatgue
Major Surgical or Invasive Procedure:
[**2152-11-8**] CABGx1 (LIMA->LAD), MVR (#29 pericardial)
History of Present Illness:
Mr. [**Last Name (Titles) 103416**] a 73 year old male with congestive heart failure.
He has at least a one year history of chest pain, dyspnea on
exertion and increasing fatigue. Cardiac catheterization in
[**2152-9-19**] showed two vessel coronary artery disease, severe
mitral regurgitation and normal ventricular function. Selective
coronary angiography of his right dominant system showd a 60%
lesion in the mid LAD and an 80% stenosis in PLV vessel of the
RCA. LV ventriculogram demonstrated preserved ejection fraction
with no LV focal wall abnormalities. Severe (4+) Mitral
regurgitation was noted. His severe MR and normal LV function
was confirmed by echocardiogram. Prior to cardiac surgical
intervention, he [**Year (4 digits) 1834**] sucdcessful stenting on his left
internal carotid artery in late [**2152-9-19**].
Past Medical History:
CHF - 3+ MR, EF 55%
Carotid Disease - s/p stenting of [**Doctor First Name 3098**]
HTN
DM2
LBP
elevated cholesterol
hyperparathyroidism
RCC s/p L partial nephrectomy, no chemo
AAA
BPH s/p turp
s/p ccy
kidney stones
Social History:
Married, Russian only speaking and lives with his wife who works
at [**Hospital3 328**] and translates for him. Has one daughter and two
granddaughters. His daughter will drive them to and from the
hospital.
Family History:
Noncontributory - no premature CAD
Physical Exam:
Vitals: BP 103/49, HR 70, RR 14,
General: elderly male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, transmitted murmur to carotid noted
Heart: regular rate, normal s1s2, [**1-23**] holosystolic murmur
Lungs: clear bilaterally
Abdomen: obese, soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 1+ distally
Neuro: alert and oriented, nonfocal
Pertinent Results:
[**2152-11-14**] 07:10AM BLOOD WBC-6.5 RBC-3.80* Hgb-11.1* Hct-31.6*
MCV-83 MCH-29.3 MCHC-35.2* RDW-16.8* Plt Ct-193
[**2152-11-14**] 07:10AM BLOOD Glucose-158* UreaN-20 Creat-1.4* Na-138
K-4.8 Cl-101 HCO3-30 AnGap-12
[**2152-11-15**] 07:55AM BLOOD Mg-1.5*
Brief Hospital Course:
On admission, Mr. [**Known lastname 41617**] [**Last Name (Titles) 1834**] a mitral valve replacement
and single vessel coronary artery bypass grafting by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1290**]. For surgical details, please see seperate operative
note. Following the operation, he was brought to the CSRU for
invasive monitoring. He initially required multiple blood
products for a postoperative coagulopathy. Once his bleeding
improved, he was weaned from sedation and awoke neurologically
intact. He was extubated without incident. He was initially kept
NPO and required an NG tube for abdominal distention. KUB at
that time was notable for large amounts of stool but no signs of
an ileus. With stool softeners, suppositories and ambulation,
his abdominal distention improved. His diet was slowly advanced
and NG tube was eventually removed without further complication.
While in the CSRU, he experienced intermittent agitation,
requiring Haldol. Over several days however, his neurological
status improved without further need on Haldol. He otherwise
maintained stable hemodynamics and eventually transferred to the
telemetry floor on postoperative day four. Beta blockade was
resumed and advanced as tolerated. He remained in a normal sinus
rhythm with first degree AV block. No atrial or ventricular
arrhtyhmias were noted. The [**Last Name (un) **] Center was consulted to
assist with the postoperative management of his diabetes
mellitus. With gentle diuresis, he continued to make clinical
improvements. Over several days, medical therapy was optimized
and he made steady progress with physical therapy. He was
cleared for discharge to home on postperative day seven. At
discharge, his BP was 120/60 with a HR of 75. His room air
saturations were 94% and his discharge chest x-ray was notable
for only small bilateral pleural effusions and a tiny, stable
left apical pneumothorax which was stable from several days
prior. His blood sugars were better controlled and all surgical
wounds were clean, dry and intact.
Medications on Admission:
Asa 81 qd, Lopressor 12.5 [**Hospital1 **], Lipitor 20 qd, Plavix 75 qd,
Lisinopril 30 qd, Lasix 80 [**Hospital1 **], Metformin 1000 [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
CAD/MR - s/p MVR/CABG
Tiny left apical PTX - stable
prostate CA
renal ca
HTN
hypercholesterolemia
DM
GERD
CHF
BPH
bladder stones
hperparathyroidism
incisional hernia
s/p TURP
s/p L partial nephrectomy
s/p chole
s/p cystoscopy
s/p lithotripsy
s/p prostate folgeration
s/p carotid stent
Discharge Condition:
Good.
Discharge Instructions:
Shower, no baths, no lotions, creams or powders. No lifting
morethan 10 pounds or driving.
Call with fever, change in incision, or weight gain more than 2
pounds in one day or five in one week
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Cardiologist 2 weeks
Completed by:[**2152-11-29**]
ICD9 Codes: 4240, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1798
} | Medical Text: Admission Date: [**2156-1-15**] Discharge Date: [**2156-1-26**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This is an 81 year-old female
who was admitted to the Cardiac Critical Care Unit as a
transfer from an outside hospital. She was intubated,
sedated and was being supported with an intra-aortic balloon
pump at that time. The HPI for this patient is ascertained
from transfer records only. By record it states that the
patient was experiencing approximately two days of increasing
shortness of breath and cough. Initially she was seen by her
primary care physician in the [**Name9 (PRE) 1474**] Emergency Room and he
evaluated and thought this was secondary to an asthma
exacerbation. Her additional complaints included chest
heaviness and an electrocardiogram was obtained, which showed
ST T wave changes. Therefore she was transferred to the
[**Hospital1 1474**] Coronary Care Unit and was treated with heparin,
aspirin and nitropaste. Subsequently she had an arterial
blood gases of 7.21 for a pH, 39 for a CO2 and a oxygen of 81
with progressive shortness of breath that ultimately led to
her intubation. She was transferred to the [**Hospital1 346**] for cardiac catheterization.
In the catheterization laboratory she was shown to have
significant three vessel coronary artery disease and 3+
mitral regurgitation. Therefore a cardiac thoracic surgery
consultation was obtained. At this time her pulmonary artery
pressures were 47/27 with a wedge of 28. Her cardiac output
was 8.1 with an index of 4.8 and a systemic vascular
resistance of 869. Her arteriole saturation was 73.
Additionally the left ventriculography showed apical and
inferior hypokinesis. She also had a 70% proximal right
coronary artery lesion and a 90% mid right coronary artery,
80% proximal left anterior descending coronary artery and 80%
mid left anterior descending coronary artery lesion
sequentially. She additionally had a 60% proximal left
circumflex and a 70% left circumflex lesion that was noticed.
She had an 80% oblique marginal one with an EF of 46%. She
was maintained on an anterior aortic balloon pump and was
being supported accordingly until cardiac surgery evaluated
the patient.
PAST MEDICAL HISTORY: Coronary artery disease status post
myocardial infarction in the past, asthma, chronic
obstructive pulmonary disease, type 2 diabetes,
gastroesophageal reflux disease, anxiety disorder, status
post right mastectomy, Parkinson's disease, osteoarthritis.
MEDICATIONS ON ADMISSION: Diltiazem CD 240 mg po q.d.,
Zantac 150 mg po b.i.d., Imdur 30 mg po q.d., Xanax .25 mg po
b.i.d., Captopril 25 mg po b.i.d., Sinemet 25/100 po q day,
[**Known lastname **] 60 mg po b.i.d., Insulin 70/30 14 units q.a.m. and an
unspecified amount q.p.m., Roxicet one tab po q 6 prn as well
as eye drops not otherwise specified for her glaucoma. Also
she was on Albuterol nebulizers MDI prn.
ALLERGIES: Vancomycin, sulfa, Clindamycin and possibly a
fourth [**Doctor Last Name 360**] not otherwise specified.
ADMISSION LABORATORY DATA: Hematocrit 30, BUN and creatinine
of 34 and 1.4, pH 7.21, 39 and 81 with repeat gas of 7.39, 29
and 127. Coagulations were PT/INR of 12.7 and 1.1 with a PTT
of 27.9. Admission chest films showed vascular engorgement
and bilateral pleural effusions consistent with questionable
failure. Electrocardiogram on admission showed mild ST
segment elevation with normal sinus rhythm at 99. She had 1
to 1.5 mm ST segment elevations from V1 to V3 as well as 1 mm
ST segment depressions in V5 and 6. She had no ST changes or
depressions over the other leads and this electrocardiogram
was markedly different then her [**2154-12-2**] electrocardiogram.
HO[**Last Name (STitle) **] COURSE: She was supported on aspirin, beta blockade
as well as transfused 3 units for a hematocrit of 23. She
was given Protonix and heparin for prophylaxis. She remained
intubated and cardiac surgery evaluated the patient and
deemed her an appropriate candidate and therefore took her to
the Operating Room on [**2156-1-16**] where Dr. [**Last Name (Prefixes) **]
performed the coronary artery bypass graft times five
including left internal mammary coronary artery to left
anterior descending coronary artery, right saphenous vein
graft to the right posterior descending artery and then to
the OM3 sequentiality as well as the right saphenous vein
graft to the OM1 and diagonal sequentially. This was done
under general anesthesia for unstable angina with slightly
decreased EF of 46. As stated the pericardium was left open,
arteriole line was in her right radial artery. She had a
right IJ Swan-Ganz catheter as well as an intra-aortic
balloon pump in the left femoral artery. She had two atrial
wires that were placed. Her chest tubes included two
mediastinal, one right pleural and one left pleural. The
type for the removal of the vein graft was an endoscopic vein
harvest performed on the right with a hybrid right calf
technique. Cardiopulmonary bypass and cross clamp times are
in the body of the dictated operative note.
She remained intubated and sedated with propofol. She was
being supported with Milrinone and neo at .3 and .75
respectively. She was in the Intensive Care Unit. On postop
day number one she was weaned to extubation. Her hematocrit
was 20. She was transfused for this value. Her BUN and
creatinine were 37 and 1.5. Neurologically she was intact.
Cardiovascular she was transfused 2 units of packed cells.
Respiratory wise, she was weaned to extubate and her
mediastinal chest tubes were removed. The pleural tubes were
kept for high output. Gastrointestinal, her diet was
advanced once she was extubated. Her milrinone and balloon
pumps and neo-synephrine were ultimately weaned off. By
postop day number two she was tachy to 109 sinus, 124/54
blood pressure. Gas was 7.37, 36, 174, 22, hematocrit 28.5,
her BUN and creatinine were 36 and 1.6 up from a baseline of
1.3. Her Milrinone was removed at midnight. She was started
on aspirin and Lopresor for blood pressure control. She was
given aggressive pulmonary toilet. She was tolerating a
cardiac diet. She was put on b.i.d. intravenous Lasix as
well as chest tubes were inadvertently discontinued at this
time.
By postop day number three she was noted to have low O2 sats
and high nasal cannula requirements. Chest x-ray showed
large bilateral pleural effusions. She was subsequently kept
NPO for the following morning when she underwent
bronchoscopy. This showed minimal secretions. As a
consequence it was felt that part of her respiratory
embarrassment may have been secondary to her pleural
effusions with the left being greater then right. She
subsequently received a left sided pleural chest tube on
postop day number four. This was achieved without any
difficulty. Placement of the tube was confirmed by chest
x-ray showing the tip to be in the posterosuperior region of
the left lung. Initially 200 cc of serosanguinous came out
of the thoracotomy site with another 250 aspirated
immediately into the jar collecting tube for the chest tube.
On postop day number [**Last Name (un) **] the patient was again continued on
respiratory therapy and pulmonary toilet. 29 was her
hematocrit, BUN and creatinine were 45 and 1.6, that was
decreasing. She was kept on Lasix for her diuresis due to
her swelling difficulties. She was evaluated by speech,
which determined that she was a high aspiration risk,
therefore a post bilateral nasoduodenal feeding tube was
subsequently placed.
The patient was started back on her oral regimen of home
medications including Sinemet. Because of her intermittent
atrial fibrillation and supraventricular tachycardia that she
began to experience at this time of her postoperative course
and she was given beta blockade and Amiodarone therapy. Over
the next couple of days her postoperative course was very
uncomplicated. She was walking with physical therapy. She
did have some low grade delirium that ultimately no
electrolytes or scenarios with the tube feeding became an
issue. She was placed on Nepro half strength at a goal rate
of 30 cc an hour, however, this was not achieved secondary to
the patient's intolerance and persistent diarrhea on the tube
feedings. Nutrition recommended to add fiber. She was
evaluated by swallow times two on postop day number seven and
nine. At both times the patient failed at bedside swallowing
evaluation. Both times it was recommended that she continue
to utilize the tube feed system.
On discharge she was afebrile with a temperature of 95.8, 60
in sinus, 154/70, blood pressure 18, respiratory rate 97% on
room air. She was incontinent of urine. Her hematocrit on
discharge was 31. BUN and creatinine were 51 and 1.4. Her
heart was regular. She had a stable sternum. No exudate.
Her extremities were unremarkable.
FO[**Last Name (STitle) 996**]P INSTRUCTIONS: She is to be seen by her
cardiologist or primary care physician in approximately three
to four weeks. She should see Dr. [**Last Name (Prefixes) **] in six weeks
from surgery. She will be maintained on tube feeds as
previously described with Nepro. Final nutrition
recommendations are pending at the time of this discharge
summary. She will work aggressively with physical therapy at
the rehabilitation facility. They anticipate that she should
return to her normal state. She has been accepted to the
[**Hospital3 245**] [**Location (un) 511**] Sanai for bed management care. She
will receive aggressive pulmonary and physical rehabilitation
at this facility.
DISCHARGE MEDICATIONS: Pilocarpine and D_________________
drops for her eyes b.i.d., Sinemet 25/100 po b.i.d.,
Ceftriaxone 1 gram intravenous q 24 to continue times six
days, Protonix 40 mg po q day, amiodarone 400 mg po b.i.d.,
Lopresor 75 mg po b.i.d., Hydralazine 15 mg intravenous q 6,
Lasix 20 mg po b.i.d., K-Dur 20 milliequivalents po q day as
well as Colace 100 mg po b.i.d.
It should be noted that this medication list is significantly
different from the patient's preoperative medication list.
She will be titrated back to her preoperative regimen once
she has follow up with her primary care physician.
On the day of discharge the patient is ambulating at a level
three with assistance with a nasoduodenal tube for feeding.
Strict aspiration precautions, head of bed to 40 degrees.
She is afebrile. Vital signs are stable. Sternum was stable
and unremarkable. She had decreased breath sounds throughout
particularly at the plunting at the bases bilaterally. She
will have the previously mentioned follow up.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft times five. MR
resolved thought to be secondary to ischemic papillary muscle
dysfunction.
2. Parkinson's disease.
3. Diabetes mellitus.
4. Gastroesophageal reflux disease.
5. Asthma.
6. Status post right mastectomy.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2156-1-26**] 12:31
T: [**2156-1-26**] 13:09
JOB#: [**Job Number 27840**]
ICD9 Codes: 4240, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1799
} | Medical Text: Admission Date: [**2163-9-25**] Discharge Date: [**2163-10-4**]
Date of Birth: [**2100-9-29**] Sex: F
Service: MEDICINE
Allergies:
Hydralazine Hcl / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
1. Jump graft replacement of arteriovenous graft with removal of
infected portion of arteriovenous graft ([**2163-9-26**])
2. Right internal jugular HD tunnelled line ([**2163-10-3**])
3. Right internal jugular temporary HD line ([**2163-9-27**])
History of Present Illness:
Briefly, Mrs. [**Known lastname 9037**] is a 62 year old female with a past
medical history significant for ESRD on MWF HD, DM 2, HTN, COPD,
carotid stenosis s/p PCI and PVD admitted for fever and found to
have MSSA bacteremia from an infected AV graft s/p AVG revision.
The patient underwent "jump graft" procedure on [**2163-9-26**] that was
complicated by edema and bleeding. In addition, her hospital
course has been complicated by a new O2 requirement felt to be
atelectasis versus volume overload.
Past Medical History:
-ESRD, secondary to HTN and DM, on HD M/W/F via left upper arm
AV graft created [**2162-11-30**], considering transplant with
extended criteria donor
-Type 2 DM, c/b nephropathy and retinopathy
-HTN
-Anemia
-PVD, s/p left extremity arteriography, left superficial femoral
artery, popliteal and anterior tibial angioplasty
-Hyperlipidemia
-COPD
-s/p PCI of carotid stenosis with stent to L ICA, on ASA and
plavix
-s/p cholecystectomy
-s/p C-section
-s/p surgery for retinopathy, cataracts
Social History:
Ms. [**Known lastname 9037**] is married and lives with her husband and daughter.
She is independent in ADLs and ambulatory with a cane. She
denies tobacco, alcohol, or illicit drugs.
Family History:
Significant DM, heart disease. Sister on HD.
Physical Exam:
VS: Tc 98.5, Tm 99.3, 142/44, 80, 18, 97%1L
GA: awake, NAD
HEENT: EOMI, PERRL, minimally reactive pupils, b/l lens
transplant, MMM, oropharynx clear without erythema or exudate,
no LAD, no JVD, neck supple, no conjunctival hemorrhage
CV: RRR, nl S1+S2, no M/R/G
Lung: CTAB, no wheezes, rales or rhonchi
Abd: soft, NT, ND, +BS, no rebound or guarding, no HSM
Extremities: W/WP, no C/C/E, 2+ DP/PT pulses bilaterally, LUE
with dressing w/serous drainage in place over AVG revision
Skin: warm, dry and intact with no rashes. L knee with
hypopigmented area from fall
Neuro/Psych: A+Ox3. CN II-XII grossly intact with no focal
deficit. Moving all extremities. Strength, sensation and
movement symmetric. Gait not observed.
Pertinent Results:
ADMISSION LABS:
[**2163-9-25**] 08:38PM LACTATE-1.7 K+-4.8
[**2163-9-25**] 08:25PM GLUCOSE-245* UREA N-55* CREAT-8.7*#
SODIUM-135 POTASSIUM-5.2* CHLORIDE-91* TOTAL CO2-27 ANION
GAP-22*
[**2163-9-25**] 08:25PM WBC-11.4*# RBC-4.02* HGB-12.0 HCT-34.9*
MCV-87 MCH-30.0 MCHC-34.5 RDW-15.4
[**2163-9-25**] 08:25PM NEUTS-85.8* LYMPHS-7.8* MONOS-4.3 EOS-1.6
BASOS-0.6
[**2163-9-25**] 08:25PM PLT COUNT-243
.
DISCHARGE LABS:
[**2163-10-4**] 07:54AM BLOOD WBC-11.8* RBC-3.34* Hgb-9.8* Hct-28.5*
MCV-85 MCH-29.2 MCHC-34.3 RDW-16.5* Plt Ct-292
[**2163-10-4**] 07:54AM BLOOD Glucose-100 UreaN-19 Creat-5.1*# Na-142
K-3.7 Cl-96 HCO3-35* AnGap-15
[**2163-10-4**] 07:54AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1
.
MICROBIOLOGY:
[**2163-9-25**] BLOOD CULTURES (4/4 bottles):
STAPH AUREUS COAG +
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 2 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
IMAGING:
[**2163-9-25**] CT Torso:
IMPRESSION: 1. Mild perinephric fat stranding bilaterally,
without hydronephrosis or
nephrolithiasis. Recommend correlation with urinalysis. 2. Small
right upper lobe pulmonary nodules. These may represent the
residual of consolidation which was previously present in that
location. Nevertheless, followup to exclude pulmonary nodules is
recommended with a dedicated CT scan of the chest in
approximately 6-12 months. 3. Unchanged partially calcified
nodularity of the right adrenal gland. 4. Uterine fibroids. 5.
Atherosclerotic disease.
.
[**2163-9-27**] TRANSTHORACIC ECHO:
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. The mitral valve leaflets are
mildly thickened. Trivial 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.
No vegetation seen (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2163-4-22**],
findings are similar.
.
[**2163-9-29**] TRANSESOPHAGEAL ECHO:
IMPRESSION: No evidence of endocarditis. Hyperdynamic left
ventricle with symmetric left ventricular hypertrophy.
.
[**10-1**] MR [**Name13 (STitle) 6452**]/THORACIC SPINE W/O CONT:
Non-enhanced examination, with: 1. No finding to suggest
thoracolumbar vertebral osteomyelitis, discitis or paraspinal,
or epidural fluid collection or abscess. 2. Transitional anatomy
at the lumbosacral junction, with numbering convention, as
described above.
3. Diffusely and uniformly hypointense vertebral bone marrow
signal, likely related to the ESRD on hemodialysis. 4. T8-9 and
T9-10 left paracentral and foraminal protrusions, respectively,
without spinal cord or exiting neural impingement. 5. Normal
thoracic spinal cord caliber and intrinsic signal intensity. 6.
L4-5: Disc degeneration with moderate bulging and bilateral
subarticular zone stenosis without definite neural impingement.
Brief Hospital Course:
# MSSA Bacteremia/AVG infection: Ms. [**Known lastname 9037**] was transferred to
the MICU shortly after admission for hypotension, fever and
altered mental status concerning for sepsis. Initially, she was
covered empirically with vancomycin and piperacillin/tazobactam.
Antibiotics were changed to nafcillin 2 g IV Q4 hours once
blood cultures returned MSSA. The source was felt to be an
infected AV graft in her left arm. On [**2163-9-26**] she was taken to
the OR and had placement of a jump graft in the left arm by the
transplant surgery service. On Tuesday [**2163-9-27**], she had a
hemodialysis session through a temporary HD line in the right
IJ. During this HD session, she felt unwell with abdominal pain
and developed a fever shortly thereafter. Blood cultures were
sent, as there was concern for a transient bacteremia. TTE from
[**2163-9-27**] and TEE from [**2163-9-29**] showed no evidence of endocarditis.
She intermittently complained of back and neck pain similar to
her previous arthritis pain, but an MRI of the thoracic and
lumbar spine showed no evidence of thoracolumbar vertebral
osteomyelitis, discitis, or paraspinal or epidural fluid
collection or abscess. The day prior to discharge the patient
was switched to cefazolin which will be dosed on dialysis days
for a total 6 week course.
# Bleeding/Anemia: Patient had ongoing oozing/bleeding from AVG
site. Hematocrit trended down but ultimately stabilized. She
likely has uremic platelets and requires aspirin and plavix for
[**Doctor First Name 3098**] disease s/p PCI. Received three total doses of DDAVP as
well as erythropoietin with hemodialysis.
# ESRD: Patient initially had a right internal jugular temporary
line but had repeated problems with clotting of the line. The AV
graft was accessed for dialysis occasionally. She had a RIJ HD
tunnelled line placed on [**10-3**]. She received nephrocaps and her
calcium acetate dose was increased to 1334mg TID with meals per
renal recommendations.
# HTN: Home antihypertensives were held during most of the
admission, but the patient began to have SBPs in the low 200s.
Her outpatient regimen was restarted prior to discharge.
# Hypoxia: Likely secondary to atelectasis. Patient performed
incentive spirometry and was weaned to room air. Denied any
shortness of breath on discharge.
# DM2: Patient's disease c/b nephropathy and retinopathy.
Continued humalog 75/25 12 units [**Hospital1 **].
# HLD: Continued on atorvastatin.
# CAD/PVD: Continued on aspirin, atorvastatin, and clopidogrel.
# COPD: Continued ipratropium-albuterol nebs as needed for
shortness of breath.
# Arthritis: Patient had intermittent neck and back pain and was
treated with tramadol 50 mg q6h prn.
#Prophylaxis: The patient received heparin products.
#Code: Full code
Medications on Admission:
ASA 325 mg daily
atorvastatin 80 mg daily
calcitriol .25 mg MWF
Ca Acetate 6667 TIDac
clopidogrel 75 mg qd
humalog 75/25 12 units [**Hospital1 **]
ipratropium-albuterol nebs prn SOB
labetalol 200 mg [**Hospital1 **]
lisionpril 20 mg [**Hospital1 **] (hold AM dose prior to HD)
loperamine 2 mg qid prn diarrhea
tramadol 50 mg [**Hospital1 **] prn
B complex-vit C-folate 1 cap daily
docusate, senna
amlodipine 10 mg daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF
(Monday-Wednesday-Friday).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Outpatient Lab Work
Weekly lab work (CBC, Bun, Cr, LFTs). All laboratory results
should be faxed to Infectious Disease R.Ns. at ([**Telephone/Fax (1) 1353**].
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
12. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
[**Telephone/Fax (1) **]:*180 Capsule(s)* Refills:*2*
14. Insulin Lispro Protam & Lispro 100 unit/mL (75-25)
Suspension Sig: Twelve (12) UNITS Subcutaneous twice a day.
15. Cefazolin 1 gram Recon Soln Sig: 2 grams QMon/Wed, 3 grams
QFri Intravenous QMWF: Dosed after HD. STOP AFTER [**2163-11-9**].
[**Month/Day/Year **]:*QS * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
Methicillin-sensitive staphylococcus aureus sepsis
Arteriovenous graft infection
End-stage renal disease
Secondary Diagnoses:
Hypertension
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. You were admitted for a fever and found to have an infection
in your blood from your infected A-V graft. This infected graft
was replaced and you were started on antibiotics. You will need
to complete a 6 week course of antibiotics and have weekly lab
work done.
- Ancef (cefazolin) 2g IV every Monday & Wednesday after
dialysis, 3g IV every Friday after dialysis (STOP AFTER [**11-9**])
- Weekly lab work (CBC, Bun, Cr, LFTs). All laboratory results
should be faxed to Infectious Disease R.Ns. at ([**Telephone/Fax (1) 1353**].
2. You had ongoing bleeding from the site of your A-V graft
revision and this was followed by the transplant surgeons. As a
result of this your red blood counts were low. You should follow
up your blood counts with your PCP.
3. It is very important that you take your medications as
prescribed.
4. It is very important that you keep all of your doctors
[**Name5 (PTitle) 4314**].
Followup Instructions:
Department: TRANSPLANT CENTER
When: MONDAY [**2163-10-10**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2163-10-24**] at 10:10 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 [**2163-11-14**] at 11:30 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
Completed by:[**2163-10-4**]
ICD9 Codes: 5856, 5180, 496, 2724 |
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