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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1800
} | Medical Text: Admission Date: [**2165-9-30**] Discharge Date: [**2165-10-18**]
Service: CARDIOTHOR
NOTE: THE PATIENT IS A SIGNIFICANT FALL RISK.
HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname **] is a [**Age over 90 **]-year-old
female, who had a history of aortic stenosis and developed
syncope. The patient underwent a scheduled cardiac
catheterization and was admitted to [**Hospital1 190**] on [**2165-9-30**]. The patient states that she had
been experiencing increasing chest pain and shortness of
breath on exertion, especially over the month prior to
admission. She subjectively feels that she had been getting
worse. Echocardiogram was performed on [**10/2164**], which had
shown a preserved EF of 65% with severe aortic stenosis with
peak gradient of 45 mmHg and estimated aortic valve area of
0.8 cm squared. Repeat echocardiogram done on [**2165-5-1**],
showed severe AS with a peak gradient of 52 mmHg with cross
sectional area of 0.6 cm squared, showing 2+ MR and 2+ TR.
Besides the symptoms of shortness of breath and chest pain,
the patient had episode of syncope, lightheadedness, and loss
of consciousness that had occurred during the months prior to
admission. Given the significant morbidity and mortality
noted to occur with patient's with AS and the above
complications of AS, she was scheduled for cardiac
catheterization to see if she was a possible valve-repair
candidate, as well as to find out if she had any clinically
significant cardiac disease. Cardiac catheterization on
[**2165-9-30**] showed left main coronary artery showing diffuse
plaque with approximately 30% lesion. The LAD had an ostial
stenosis of 40%. The left circumflex was patent. The right
coronary artery was moderately calcified with a mid 70%
stenosis and it was a right dominant system.
PAST MEDICAL HISTORY:
1. Breast cancer, status post radical left mastectomy and
left upper extremity lymphedema.
2. History of transient ischemic attacks.
3. Status post hysterectomy in the past.
4. Status post appendectomy in the past.
5. Aortic stenosis as mentioned above.
6. History of osteoarthritis in the bilateral hips, status
post left hip pinning in the past.
OUTPATIENT MEDICATIONS UPON ARRIVAL:
1. Aspirin 81 mg q.d.
2. Ultram as needed for pain.
3. Lotensin 10 mg PO q.d for hypertension.
SOCIAL HISTORY: History is significant for the patient being
married to [**First Name8 (NamePattern2) **] [**Known lastname **]. Home #: [**Telephone/Fax (1) 45383**]. She has a
huge fall risk. She uses a three-wheel chair and walker at
baseline and has a history of falls with hitting her head
secondary to unsteady gait, as well as syncope.
LABORATORY DATA: Labs on admission revealed the following:
Hematocrit 34.3, potassium 3.7, BUN and creatinine of 12 and
0.7. INR of 1.0. On telemetry, she had evidence of first
degree AV block, thought to be the result of the cardiac
catheterization on [**2165-9-30**], as noted diffuse plaque with
30% lesion in the left main coronary artery. LAD had an
ostial stenosis of 40%. The left circumflex artery was
patent. The right coronary artery was moderately calcified
with mid 70% stenosis. She had a high pulmonary capillary
wedge pressure of approximately 29. She had severe aortic
stenosis and moderate-to-severe mitral stenosis. She has
severe systolic-systolic arterial hypertension. Severe left
ventricular diastolic dysfunction. No obstructive
hypertrophy noted.
The patient had been transferred from an outside hospital for
the issue of syncope. The patient had the above cardiac
catheterization performed here at the outside hospital. She
had head CT performed secondary to head trauma sustained from
syncope, might be secondary to aortic stenosis. The head CT
showed no evidence of acute bleeding or infarction. It did
show diffuse atrophy and changes consistent with a
[**Age over 90 **]-year-old brain.
Chest x-ray on [**2165-9-28**] at the outside hospital showed
cardiomegaly, wide superior mediastinum, possible tortuous
innominate vessels and no evidence of CHF or focal
infiltrate, no effusion. Due to the nature of her fall and
the hip pain she complained of at the outside hospital, she
did have an x-ray on [**2165-9-28**]. There was markedly
demineralized bone, extensive degenerative arthritis, SI
joint was preserved, nailing of the old left hip fracture was
intact. Right hip showed possible fracture at the level of
the greater trochanter with follow up films negative.
PHYSICAL EXAMINATION: Admission was notable for vital signs
with a temperature of 96.6, blood pressure 184/80, pulse 78
and regular, respiratory rate 16 with saturation of 96% on
room air. GENERAL: The patient was awake and alert, more
actively interactive, intact mental status. HEENT:
Examination was notable for pain and clear oropharynx.
Mucous membranes moist. Tongue midline. Extraocular muscles
are intact. Pupils equal, round, and reactive bilaterally.
CARDIOVASCULAR: The patient was regular rate and rhythm.
She had a 3/6 systolic crescendo murmur throughout the
precordium. She had no carotid bruits. Chest examination
revealed good inspiratory effort, bilaterally, clear to
auscultation, no wheezes, rales, rhonchi. ABDOMEN: Good
bowel sounds, soft, nontender, nondistended, no guarding, no
hepatosplenomegaly. No ascites. EXTREMITIES: Warm.
Peripheral pulses palpable in the dorsalis pedis bilaterally.
No edema. No cyanosis. No calf tenderness. No tissue loss
or ulceration. SKIN: Right groin site, status post cardiac
catheterization; noted for no hematoma, no bruit, no oozing.
Due to the assessment and the critical AS and significant two
vessel coronary disease, consultation with the cardiac
surgical service was obtained with Dr. [**Last Name (STitle) 1537**]. The patient was
deemed a relatively high risk, but appropriate candidate for
valve replacement given her significant aortic stenosis.
Therefore, on [**2165-10-3**], the patient went to the operating
room. The patient underwent an AVR with 19 mm pericardial
valve, as well as a two-vessel coronary artery bypass graft
utilizing saphenous vein graft to the LAD, as well as
saphenous vein graft to the RPDA. This was done by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] as the attending surgeon, as well as having
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] in attendance and assistance, as well
as [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as a nurse practitioner as first assistant.
The pericardium was left open. She left the operating room
with right radial A line, right IG Swan-Ganz catheter. She
had two ventricular pacing wires, two atrial pacing wires,
two mediastinal chest tubes. Coronary pulmonary bypass was
132 minutes with cross-clamp time of 108 minutes. She left
the operating room with mean arterial pressure of 115, CVP 9,
PID pressure of 13, and a pulmonary artery mean pressure of
18. She was being A-V paced with underlying junctional
rhythm noted. Rate was 888 with the A-V pacing. She was on
epinephrine at 0.02 mcg per kilogram per minute. The patient
was on propofol for sedation at 20 mcg per kilogram per
minute. She was transferred to the CSRU for postoperative
care.
By postoperative day #1, she remained intubated. She
remained sleepy secondary to her sedation. She was on
insulin drip for blood glucose control. Nipride at 0.8 and
nitroglycerin 0.25 for adequate blood pressure management.
It was noted that the A-wires were inconsistently pacing.
The patient was placed on an A-demand setting. She seemed to
have an asystolic underlying rhythm at this time, therefore,
she was being paced accordingly. She was weaned off her
epinephrine overnight. Otherwise, she was hemodynamically
okay. She was afebrile at 98 with an accelerated junctional
rhythm postoperatively. She was on CPAP and pressure
supports with adequate tidal volumes, minimal support
overall. Gases showed good ventilation and oxygenation. She
was ultimately weaned to extubate. She was transfused a unit
of blood for postoperative hematocrit of 24.8. The BUN and
creatinine were 18 and 0.5. She was started on diuresis, on
the night of postoperative day #1 into postoperative day #2.
Swan-Ganz catheter was removed on postoperative day #2. She
was now noted to have a complete heart block underlying the
cardiac rhythm. She was being paced accordingly. She was
started on Captopril for afterload reduction. The diuresis
continued. EP consultation was obtained for incomplete heart
block, which was now new. The hematocrit was now 34.7 with a
BUN and creatinine of 35/0.7. The electrophysiology service
evaluated the patient. They agreed that she was likely in
complete heart block, but the rhythms progressed and over the
next several days they actually showed evidence of atrial
fibrillation and atrial flutter. She was, therefore, given
Amnio boluses and started on Amiodarone drip for a total of
24 therapy course and then switched to an oral Amiodarone
regimen. Additionally, she required titration of the
Captopril for afterload reduction. She was intermittently
quite hypertensive postoperatively, therefore, intermittently
she did require Nipride and nitroglycerin. She was never
started on Lopressor secondary to the intermittent heart
block and atrial fibrillation flutter.
By postoperative day #3, she as afebrile at 98 and A-V paced
with underlying heart rate. Heart: Complete heart block,
but again, intermittently in and out of atrial fibrillation
flutter. Blood pressure was in the 140s systolic. She was
breathing at a rate of 17. She was on 94% with a 6 liter
shovel mask. Hemodynamics were good with CVPs of 13, index
of 2.83, PA pressure of 36/16, SCRs of approximately 900,
hematocrit 32, with BUN and creatinine of 33 and 0.6. She
was making approximately 30 cc per hour urine. She was,
otherwise, alert and interactive, following commands. She
was noted to have markedly decreased breath sounds. She was
beginning to develop copious secretions. Plan at this time
was to continue with electrophysiology consultation, put her
on Lasix 20 IV b.i.d. for diuresis, use intermittent
Hydralazine and titrate the Captopril for pressure control
and to wean back the Nipride and nitroglycerin. She was
started on a diet. The Department of Physical Therapy had
been working with the patient at this time. Their assessment
immediately postoperative was that she certainly would
require, given her age and overall dysfunctionality,
postoperatively, a maximal physical therapy effort to get her
back to ambulation. Of noted, the pulmonary status did
impede her ability to completely participate in physical
therapy. Therefore, around-the-clock chest PT and suctioning
were engaged with the patient. There was a concern from the
nursing staff, based on [**2165-10-4**], that the patient likely
was aspirating some of her pills and she was not taking
adequate PO. She was evaluated by the Speech and Language
Pathology Service, who did bedside swallowing evaluation,
which showed gross aspiration and poor control of her
secretions, therefore, she was committed to being NPO. A
Dobbhoff tube was placed for the start of tube feedings and
medication administration. Shortly, thereafter, the
respiratory status began to deteriorate over the next several
days to the point of requiring her to have aggressive
pulmonary care toiletting. She was noted to be somewhat
confused and agitated postoperatively. This was thought to
be secondary to her possible hypercarbia, as well as
secondary to her age and medications, which had been
administered to her including as needed Percocets. All off
these medications were stopped. She was assurred that she
was not receiving any benzodiazepines, no anticholinergics,
narcotics were stopped. She was only utilizing Tylenol as
needed for pain. Ultimately, over the weekend of [**2165-10-11**],
the patient was noted to becoming recently lethargic and
requiring extensive pulmonary suctioning. She had copious
secretions to the point that by [**2165-10-13**], Dr. [**Last Name (STitle) **] did an
awake nonsedated bronchoscopy showing that she had thick
yellow plugging in her trachea. At approximately 8 cm
bronchioalveolar lavage was performed of the left lingula
with copious secretions throughout. All airways were patent.
There was no evidence of lobar collapse. Shortly,
thereafter, from the bronchoscopy, the patient had an ABG
drawn, which was significant for a PACO2 OF 92 and this was
consistent with her progressive somnolence and respiratory
distress. Therefore, she was re-intubated on [**2165-10-13**] for
airway secretion management and also for her hypercarbia and
respiratory failure.
On postoperative day #11, [**2165-10-14**], she had a fever of
101.0. She was started on Levaquin. Accordingly given
the fact that she had secretions for presumed
tracheobronchitis/left lower lobe pneumonia she was being
maintained on minimal respiratory support with CPAP and
pressure support. PEEP was 5 and the FIO2 was 40%. The
gases on that were notable for a pH of 7.43, PACO2 of 56 with
PAO2 of 156. She was, otherwise, balanced. The hematocrit
at this time was 27.6 with BUN and creatinine of 34 and 1.0.
It should be noted that during the postoperative course she
was initially started on heparin drip for several days
secondary to intermittent atrial fibrillation flutter, which
was treated with the Amiodarone as previously stated. This
was under the consultation of the Electrophysiology Service,
although given her meandering hematocrit, which had been
dropping from a value of 32 and down to as low as 24, as well
as some faintly guaiac-positive stools, it was decided that
anticoagulation would not be pursued. Heparin drip was,
therefore, stopped. She was being maintained on aspirin and
it was decided that at the time of discharge, whether it be
to a rehabilitation facility with vent support or otherwise,
she would be just maintained on aspirin and Plavix for
antiplatelet therapy and antithrombotic therapy. Given the
significant age and morbidities and fall risk, long-term
anticoagulation was not likely an appropriate for source of
therapy for this patient. It should be also stated that she
did have conversion to sinus rhythm with PACs and eventually
into sinus bradycardia with first degree AV block, which was
maintained over several days prior to discharge. Given the
re-intubation, it was deemed that she would ultimately need
tracheostomy and PEG. The upper-exchange tracheostomy tube
was placed on [**2165-10-16**] by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 952**] and then a
percutaneous enteral gastrostomy tube for eating was placed
on [**2165-10-17**]. Both of these procedures were uncomplicated.
It was agreed by the team that the patient likely would not
require much ventilatory support as she was oxygenating and
ventilating well, it was just an ensure adequate aiway
management in terms of her secretions. Therefore, pulmonary
hygiene would be critical to ultimately getting this patient
to breathe appropriately. She was maintaining
around-the-clock chest physical therapy, as well as
nebulizers as needed and aggressive pulmonary suctioning
care. Mental status did somewhat improved post tracheostomy.
She was awake, alert and following some commands given her
current clinical status with the tracheostomy and PEG status
post aortic valve replacement and CABG times two. The
patient was deemed an appropriate candidate to go to the
rehabilitation facility for further weaning and pulmonary
care hygiene.
MEDICATIONS ON DISCHARGE:
1. Captopril 15 mg PO t.i.d.
2. Amiodarone 600 mg q.d.
3. Albuterol and Atrovent 2 puffs q.4h. to 6h. around the
block.
4. Levaquin 500 mg q.d. to end on [**2165-10-26**].
5. Hydralazine 10 mg IV q.6. p.r.n. systolic pressures
greater than 150.
6. Tylenol 650 mg per PEG tube q.4h. to 6h.p.r.n.
7. Aspirin 325 mg per PEG q.day.
8. Plavix 75 mg per PEG q.day times one month and then to be
re-evaluated by Dr. [**Last Name (STitle) 1537**].
9. Lansoprazole 30 mg per PEG q.d.
10. Miconazole powder 2% one application topically b.i.d.
p.r.n.
11. Milk of Magnesia 15 cc to 30 cc per PEG q.i.d.p.r.n.
Additionally, the patient should receive Ultracal at 50 cc
per hour, provide her with 1400 K calories total calories, as
well as giving her 58 grams protein, which would meet her
assessed nutritional needs per the nutrition service, who had
been assisting us in the management of her tube feedings.
TREATMENT FREQUENCY: She should get all of her medications
per the PEG tube in a crush manner, as well as flushing the
PEG with approximately 15 cc to 30 cc water after medication
administration to ensure that soup does not become clogged.
She will require aggressive suctioning to attempt to provide
her with adequate pulmonary hygiene, as well as chest PT
around the clock. She will ultimately be transitioned to a
tracheostomy collar, as tolerated, to get her off the
ventilatory support. She should be out of bed ambulating
with physical therapy. The anticipated goal was to wean her
off the ventilator, change her to a tracheostomy collar and
provide her with adequate pulmonary hygiene, as well as a
giving her a guarded and watchful recovery. She should be
allowed to walk, but remember please that she is a
SIGNIFICANT FALL RISK, so accordingly many of these goals are
hypothetical. She should follow up with Dr. [**Last Name (STitle) 1537**] in
approximately two to three weeks. At the time of discharge,
appointment should be made at the time she is transferred to
her rehabilitation facility.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2165-10-17**] 11:13
T: [**2165-10-17**] 14:32
JOB#:
ICD9 Codes: 5185, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1801
} | Medical Text: Admission Date: [**2160-9-15**] Discharge Date: [**2160-10-2**]
Date of Birth: [**2118-12-13**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Trauma: assault:
Lt frontal & falx cerebri SDH
nasal bone fx
head lacs
Major Surgical or Invasive Procedure:
repair of facial laceration
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
transfer from OSH. Found with head injury, abrasions &
lacerations to face. Agitated at OSH. Intubated prior to
transfer for increased agitation. At OSH, head CT with SDH.
Per report, CT c-spine negativbe for fx.
PAST FAMILY AND SOCIAL HISTORY
Nursing triage/initial assessment reviewed and confirmed
Past Medical History: unknown
Medications: unknown
Allergies and Reactions: unknown
Family History: unknown
Social History: unknown
Past Medical History:
PHYSICAL EXAMINATION
Constitutional: intubated
HEENT: multiple lacerations to forehead, rt & left parietal
area, occipital area, midface stable
bleeding in oropharynx
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended, small abrasion
right abdomen, left flank
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: intubated, moves all extremities nonpurposefully,
does not follow commands
Psych: Normal mood
Social History:
unknown
Family History:
unknnow
Physical Exam:
PHYSICAL EXAMINATION upon admission
Constitutional: intubated
HEENT: multiple lacerations to forehead, rt & left parietal
area, occipital area, midface stable
bleeding in oropharynx
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended, small abrasion
right abdomen, left flank
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: intubated, moves all extremities nonpurposefully,
does not follow commands
Psych: Normal mood
Pertinent Results:
[**2160-9-26**] 01:00AM BLOOD WBC-15.7* RBC-2.76* Hgb-10.3* Hct-29.4*
MCV-107* MCH-37.2* MCHC-34.9 RDW-13.3 Plt Ct-576*
[**2160-9-25**] 01:13AM BLOOD WBC-11.8*# RBC-2.88* Hgb-10.6* Hct-30.2*
MCV-105* MCH-36.9* MCHC-35.2* RDW-13.0 Plt Ct-534*#
[**2160-9-22**] 01:24AM BLOOD WBC-7.2 RBC-2.40* Hgb-9.1* Hct-24.9*
MCV-104* MCH-38.1* MCHC-36.8* RDW-13.1 Plt Ct-329
[**2160-9-21**] 12:00AM BLOOD WBC-8.4 RBC-2.45* Hgb-9.3* Hct-25.6*
MCV-105* MCH-37.9* MCHC-36.2* RDW-12.7 Plt Ct-294
[**2160-9-15**] 08:25PM BLOOD WBC-10.0 RBC-3.13* Hgb-12.2* Hct-34.4*
MCV-110* MCH-39.0* MCHC-35.5* RDW-13.2 Plt Ct-152
[**2160-9-26**] 01:00AM BLOOD Plt Ct-576*
[**2160-9-25**] 01:13AM BLOOD Plt Ct-534*#
[**2160-9-26**] 01:00AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-135
K-4.2 Cl-100 HCO3-26 AnGap-13
[**2160-9-25**] 01:13AM BLOOD Glucose-144* UreaN-7 Creat-0.7 Na-135
K-3.8 Cl-99 HCO3-23 AnGap-17
[**2160-9-22**] 01:24AM BLOOD Glucose-228* UreaN-5* Creat-0.6 Na-139
K-4.7 Cl-108 HCO3-21* AnGap-15
[**2160-9-19**] 03:08AM BLOOD ALT-30 AST-29 LD(LDH)-266* AlkPhos-59
TotBili-0.9
[**2160-9-18**] 12:23AM BLOOD ALT-43* AST-52* LD(LDH)-305* AlkPhos-51
TotBili-0.7
[**2160-9-15**] 08:25PM BLOOD Lipase-43
[**2160-9-15**] 08:25PM BLOOD Lipase-51
[**2160-9-26**] 01:00AM BLOOD Calcium-9.8 Phos-4.7* Mg-1.9
[**2160-9-25**] 01:13AM BLOOD Calcium-9.8 Phos-4.6* Mg-1.7
[**2160-9-15**] 08:25PM BLOOD ASA-NEG Ethanol-112* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2160-9-15**] 08:25PM BLOOD ASA-NEG Ethanol-149* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2160-9-16**] 10:57AM BLOOD Type-ART pO2-173* pCO2-44 pH-7.37
calTCO2-26 Base XS-0 Intubat-INTUBATED
[**2160-9-15**] 09:42PM BLOOD Type-ART pO2-526* pCO2-43 pH-7.26*
calTCO2-20* Base XS--7
[**2160-9-15**] 09:00PM BLOOD Glucose-118* Lactate-1.9 Na-144 K-3.7
Cl-113* calHCO3-19*
[**2160-9-15**]: cat scan of head:
Wet Read: PBec MON [**2160-9-15**] 10:25 PM
1. previously noted l frontal lobe SDH and cerebral falx not as
well seen. 2. bilateral crescentric isodensities noted overlying
both convexities now seen - may represent redistribution of
prior SDH or more apparent chronic SDH.
3. linear focus of extra-axila hyperdensity at R frontal vertex,
appears vascular.
4. global atrophy.
5. nasal bone fx better eval on sinus CT.
[**2160-9-15**]: cat scan of abdomen and pelvis:
IMPRESSION:
1. No acute process or fracture identified.
2. Nasogastric tube with tip in the stomach and side port at
level of the GE
junction. Would recommend advancing approximately 5 cm.
3. Endotracheal tube with tip at the level of the clavicle.
4. Jejunojejunal intussception in the left abdomen without
evidence of
obstruction. In an adult patient, this finding is likely
transient.
[**2160-9-15**]: cat scan of sinus and mandible:
IMPRESSION: Bilateral nasal bone fractures and fracture of the
nasal spine of the maxilla
[**2160-9-16**]: cat scan of the head:
IMPRESSION:
1. Redistribution of small subdural hematomas along the
bilateral convexities and along the falx.
2. Stable single focus of subarachnoid hemorrhage in a right
frontal
paramedian sulcus.
3. Stable bifrontal hypodense subdural collections, which may
represent
subdural effusions.
4. Bilateral subgaleal hematomas, scalp lacerations, and
bilateral nasal bone fractures are again noted.
[**2160-9-17**]: chest x-ray:
FINDINGS: Interval removal of endotracheal tube and nasogastric
tube.
Cardiomediastinal contours are within normal limits for
technique, and lungs are grossly clear.
[**2160-9-25**]: ekg:
Sinus tachycardia. Other than rate, normal tracing. No previous
tracing
available for comparison.
[**2160-9-30**]: EKG:
Sinus tachycardia. Baseline artifact. Normal ST segments. Sinus
arrhythmia.
As on tracing #1, abnormal T waves are a known finding and are
not new.
TRACING #2
[**2160-9-16**]:
[**2160-9-16**] 9:36 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2160-9-22**]**
Blood Culture, Routine (Final [**2160-9-22**]): NO GROWTH.
[**2160-9-16**] 9:25 pm URINE Source: Catheter.
**FINAL REPORT [**2160-9-17**]**
URINE CULTURE (Final [**2160-9-17**]): NO GROWTH.
[**2160-9-22**] 1:23 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2160-9-24**]**
MRSA SCREEN (Final [**2160-9-24**]): No MRSA isolated.
repeat CBC [**2160-10-2**]: wbc=9.0, hct =30.0
Brief Hospital Course:
49 year old gentleman admitted to the acute care service after
he was assaulted. He was transferred from an OSH where he was
intubated for agitation. Upon arrival he was admitted to the
intensive care unit. He was made NPO, given intravenous fluids,
and underwent radiographic imaging. He was reported to have a
subdural hematoma, facial lacerations, and a nasal fracture.
Plastic surgery was consulted for his comminuted nasal fracture
which was minimally displaced. No surgical intervention was
necessary. He was followed by Neurosurgery who followed him
with head cat scans to assess any increase in his subdural
hematoma. His head cat scans remained stable. To prevent
seizures, he was placed on a keppra for 1 week.
He was extubated 24 hours after admission. His cervical and
thoracic spine was cleared and he was taken of log-roll
precautions. He was evaluated by speech and swallow who adviced
thickened liquids to decrease his risk of aspiration. During
this time, he became febrile and was cultured. His blood
cultures showed no growth. He began to exhibit signs of
alcohol withdrawal and required ativan and haldol to reduce his
anxiety. The agitation progressed to the point that he need to
be started on precedex. His precedex was weaned on on HD #5 and
his agitation was controlled with valium and haldol. Psychiatry
was consulted and recommended zyprexa and intermittent haldol
for his delirium and agitation. After his mental status
improved, he was evaluated by physical and occupational therapy.
He was transferred to the surgical floor on [**9-26**]. Psychiatry
continued to monitor his status and provided recommendations for
his care. At this point, he was off his benzodiazapines and
only on zyprexa. As his mental status cleared, he was
gradually re-introduced to a soft diet with progression to a
regular diet with no evidence of aspiration.
Upon discharge, he is oriented and cooperative. His vital
signs are stable and he is afebrile. His white blood cell count
is 9.0 and his hematocrit is stable. He is tolerating a regular
diet and ambulating without difficulty.
He was discharged to a shelter with recommendations to follow up
with the acute care service, and with Neurology in [**5-7**] week
where he will need a repeat non-contrast head cat scan to
evaluate his subdural hematoma. An appointment was set up in 1
week with Dr. [**Last Name (STitle) 91173**], who patient identified as his primary
care provider. [**Name10 (NameIs) **] importance of follow-up visits were
stressed.
Medications on Admission:
? klonopin
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: assault
Lt frontal & falx cerebri SDH
nasal bone fx
head lacs
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 after you were assaulted. You
sustained a small bleed in your head and a nasal bone fracture.
You are slowly recovering and you are now ready for discharge
home with the following instructions:
Please report/return to the emergency room if you experience:
*headache
*double vision or any other change in vision
*difficulty speaking
*weakness on one side of your body
*difficulty breathing
*change in your balance
*nausea/vomitting
*fever
*chills
Or any other symptoms that concern you
You will need to follow-up with the acute care service,
neurology, and your primary doctor. It is very important that
you keep these appointments.
Followup Instructions:
Please follow up your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 91173**], on
[**2160-10-8**] at 11am. His office is now at [**Hospital **] Medical Walk-in
[**Last Name (un) **]., [**Hospital1 487**], Mass. The telephone number is
[**Telephone/Fax (1) 72680**]
Follow up with acute care service in 2 weeks. The telephone
number is #[**Telephone/Fax (1) 600**].
Please follow -up with Neurosurgery, Dr. [**First Name (STitle) **] in [**5-7**] weeks.
Please let them know that you will need a non-contrast head cat
scan prior to your visit. The telephone number to schedule this
appointment is # [**Telephone/Fax (1) 1669**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2160-10-9**]
ICD9 Codes: 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1802
} | Medical Text: Admission Date: [**2160-4-28**] Discharge Date: [**2160-5-1**]
Date of Birth: [**2097-12-31**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 15427**] is a 62-year-old
woman who was transferred from [**Hospital6 3105**] for
shortness of breath over the last two days.
She is a 62-year-old woman with history of small cell lung
cancer, congestive heart failure, and chronic obstructive
pulmonary disease who was well until one week ago when she
began to develop a productive cough streaked with blood.
Over the last two days, she noticed worsening shortness of
breath with exertion particularly with stairs. She also
complained of pleurisy in her left back particularly when
taking in deep breaths. Because of the worsening breathing,
her husband brought her to the Emergency Department of
[**Hospital6 3105**].
At the outside hospital, she was noted to be pale, dry, and
with cool extremities. Blood pressure was 75-85 systolic.
O2 saturation was 85% and increased to 100% on
non-rebreather. A chest x-ray showed increased pleural
effusion. She was treated with fluids, Albuterol, and
Ceftriaxone, and subsequently transferred here.
The patient denied fever, chest pain, orthopnea (sleeps on
one pillow), and peripheral edema. There was no abdominal
pain, diarrhea, dysuria, or bloody stool. At baseline she is
able to walk a block but becomes short of breath with
inclines.
PAST MEDICAL HISTORY: The past medical history revealed
atrial fibrillation status post cardioversion on Sotalol,
last echocardiogram in 1/00 showed an ejection fraction
greater than 55% and normal systolic function; chronic
obstructive pulmonary disease with an FEV1/FVC of 68%; atrial
septal defect status post repair in [**2155**]; and small cell
carcinoma status post radiation and Cisplatin. A
transthoracic echocardiogram in [**2158-11-25**] showed an
ejection fraction of greater than 55%, mild right ventricular
dilatation and hypokinesis, mild to moderate mitral
regurgitation, and pulmonary hypertension. A MIBI in [**2159-11-26**] showed mild partial reversible defect in the vascular
portion of the inferior wall.
FAMILY HISTORY: Noncontributory.
MEDICATIONS: Prednisone 10 mg q. day, Lasix 20 mg q. day,
Singulair 10 mg q. day, Coumadin 5/7.5 mg q.h.s., Betapace 40
mg p.o. b.i.d., Xanax 5 mg p.o. q.d., Paxil 10 mg p.o. q.d.,
Motrin 400 mg p.o. b.i.d., Serevent inhaler 2 puffs b.i.d.,
Combivent inhaler 2 puffs b.i.d. p.r.n., Albuterol p.r.n.
SOCIAL HISTORY: The patient had smoked tobacco times 30
years with none in the last eight years. She drank three
glasses of wine per night. She had no IV drug abuse. She
lives with her husband and one son. She was born in [**Location (un) **]
but has lived here times 40 years.
PHYSICAL EXAMINATION: The patient was a pleasant 62-year-old
woman sitting upright in minimal distress. She was afebrile
with blood pressure of 112/90, pulse 84, saturation 91% on 4
liters nasal cannula and 80% on room air. On head and neck
examination, the fundi showed sharp discs. The pupils were
equal and reactive to light. The oropharynx was moist. The
chest showed coarse breath sounds bilaterally with wheezing
and crackles bibasilarly. There was a scar from her previous
ASD repair. The rate was regular with no murmurs. The
abdomen was soft and nontender with no edema. The
extremities were nontender.
LABORATORY DATA: White blood cell count was 11, hematocrit
35, platelets 277,000, MCV 97. Differential revealed
neutrophils 40, bands 43, lymphocytes 6, metamyelocytes 5,
occasional Dohle bodies. SMA-7 showed sodium 129, potassium
4.9, chloride 94, bicarbonate 28, BUN 34, creatinine 2.8,
glucose 122, CK 46.
EKG revealed normal sinus rhythm at 84-86. Axis was 90.
There was right bundle branch block, T wave inversions from
V2-V3, and ST depressions in V4 and V6 which were old.
Troponin was less than 0.03. INR was 4.3, PTT 44.
HOSPITAL COURSE: In brief, Mrs. [**Known lastname 15427**] is a 62-year-old
woman with a history of chronic obstructive pulmonary
disease, oat cell carcinoma, and congestive heart failure who
presented in respiratory distress with one week of productive
cough and hemoptysis. Her presentation was likely consistent
with COPD exacerbation secondary to bronchitis; however
pulmonary embolism could not be excluded based on her risk
factors such as cancer, immobility, and pleuritic pain.
Laboratory workup was also concerning for acute renal failure
and hyponatremia. Her hospital course can be summarized as
follows.
Cardiovascular: Electrocardiogram was concerning for
anterior subendocardial ischemia; however this was unchanged
from previously. She eventually ruled out for myocardial
infarction by CKs and as per Dr. [**Last Name (STitle) 1911**] we continued
Sotalol for her atrial fibrillation despite her COPD
exacerbation. The final [**Location (un) 1131**] on the EKG showed worsening
T wave inversions in leads III and aVF. Upon discussion with
Dr. [**Last Name (STitle) 1911**], he felt that her presentation was most
likely secondary to chronic obstructive pulmonary disease
exacerbation rather than an acute coronary syndrome. An
outpatient stress test was not recommended because of her
clinical presentation. She was continued on telemetry and
there were no further events.
Pulmonary: Chronic obstructive pulmonary disease
exacerbation secondary to bronchitis versus pneumonia. The
patient received pulse dose of steroids with Solu-Medrol 80
mg intravenously t.i.d. and this was transitioned to
Prednisone 60 mg p.o. q.a.m. for a tapered course over 14
days. Albuterol and Atrovent nebulizers were continued as
well as Flovent. She received empiric treatment of pneumonia
given her cough, hemoptysis, and bandemia with Levaquin.
Rule out pulmonary embolus: The PE test probability for
pulmonary embolus was low to moderate given her risk factors.
The D-dimer at [**Hospital6 3105**] was positive by
[**Doctor First Name **], therefore, it was not very useful. We could not
initiate CT angiogram given her renal failure nor VQ given
her effusions. LENIs were checked on hospital day #2 and
were negative for clots. She was already in part
anticoagulated for her atrial fibrillation and she came in
with an INR of 4.5.
As for her hemoptysis, this engaged a broad differential
including bronchitis, cancer, and pneumonia versus pulmonary
embolus. She had no further episodes of hemoptysis in
hospital.
Renal: Acute renal failure was likely secondary to prerenal
versus Motrin. A FENA was checked and this was 0.1% which
concurred with prerenal failure. She was hydrated with goal
intake and output positive one liter and her creatinine
subsequently climbed close to baseline on discharge. All her
medications were renally dosed. Urine electrolytes were
checked and revealed a FENA of 0.1%.
Hyponatremia was felt to be secondary to hypovolemia and
possibly a combination of syndrome of inappropriate diuretic
hormone. Cortisol was sent and was falsely elevated due to
her already being on steroids. The cortisol level was 53.
Urine osmolalities and urine electrolytes were also checked
and free water was restricted. TSH was normal.
Infectious disease: It was unclear where the source of her
bandemia originated. All blood cultures remained negative
and urine cultures as well. Followup bands obtained in the
hospital revealed a band level of 8 on admission and then 0
on hospital day #2. Levofloxacin was continued for presumed
pneumonia.
Gastrointestinal: There were no active issues and she ate
well.
Social: The patient was seen by physical therapy who felt
that she had no acute rehabilitation needs. Upon ambulation,
she desaturated to 88% on room air. Resting on room air, she
also improved and ranged from 88% to 92%. The patient was
reluctant to use oxygen at home but following review with
case management, this could be provided by her insurance and
she agreed to this.
DISCHARGE DIAGNOSES: Chronic obstructive pulmonary disease
exacerbation secondary to pneumonia; acute renal failure
secondary to dehydration.
DISCHARGE MEDICATIONS: Lasix 20 mg p.o. q.d., Singulair 10
mg p.o. q.d., Coumadin 5 mg alternating with 7.5 mg p.o.
q.h.s., Betapace 40 mg p.o. b.i.d., Xanax 0.5 mg p.o. q.d.,
Paxil 10 mg p.o. q.d., no Motrin, Combivent 2 puffs q.i.d.,
Albuterol p.r.n., Prednisone taper beginning with 50 mg to
taper over 10 days, Levaquin 500 mg p.o. q.d. for a total 10
day course to end on [**2160-5-8**], Zantac 150 mg p.o. b.i.d.
to end concurrent with the Prednisone taper.
DISCHARGE FOLLOWUP: The patient was to follow up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within a week. The patient will call to arrange
an appointment.
Outpatient pulmonary rehabilitation.
DISPOSITION: To home.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 19923**]
MEDQUIST36
D: [**2160-5-1**] 16:45
T: [**2160-5-1**] 18:16
JOB#: [**Job Number 21123**]
ICD9 Codes: 4280, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1803
} | Medical Text: Admission Date: [**2198-10-2**] Discharge Date: [**2198-10-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
[**Age over 90 **] yo male with known 3v CAD and multiple prior stents who has
previously refused CABG, SSS s/p PPM, and myelodysplasia who
transferred from [**Hospital1 18**]-[**Location (un) 620**] with chest pain.
He has known 3 vessel CAD with a tight LAD lesion found in [**5-31**]
for which stent placement was not thought possible and he
decline CABG. Since then he has had stable angina responsive to
SL NTG that he gets a few times per week. He typically gets
chest pain with exertion or if HCt drops which is frequent due
to MDS. This morning he had chest pain and pressure which was
relieved with SL NTG but recurred approximately 30 minutes
after. He ended up taking 4 SL NTG before presenting to
[**Hospital1 18**]-[**Location (un) 620**]. He reports that the character of his chest pain
is similar to his prior episodes of angina. He has a history of
NSTEMIs and angina in the setting of anemia. He missed his
epogen dose last week, received a dose yesterday. Per his son,
his baseline Hgb is 13.4 and had dropped to 11.4 upon
presentation to [**Location (un) 620**].
He denies any cough, PND, orthopnea. He does endorse peripheral
edema over the past 1 month for which he has been wearing
compression stockings.
At [**Location (un) 620**], his vitals were 66 149/70 18 97% on RA, 94% on RA.
He became chest pain free with a nitro gtt and Lasix. His
troponin was 0.22 which is his baseline. His CXR showed
pulmonary edema. He also recieved aspirin and Plavix. [**Location (un) 620**]
though he had a CHF exacerbation due to crackles on exam. He
was sent here for admission to cardiology and optimization of
his medications. In our ED, basic labs were sent and ECG looked
unchanged from prior (V-paced with TWI in V1-2). He continued
on a nitro gtt. On transfer to the floor, vitals were 98.5 65
153/66 14 100.
He also has new onset of hematuria today. He does not have a
history of recent foley placement. He has a h/o microscopic
hematuria in the past.
On review of systems, s/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. 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 of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
Macrocytic anemia- dropped Hgb from 10.8->8.5 due to interrupted
erthropoietin therapy
Myelodysplastic syndrome with macrocytic anemia and mild
thrombocytopenia
Right and left upper lobe nodules
Soft tissue density on the lateral left side of the bladder, ?
neoplasia
Parkinsonism
Hypertension
Psoriasis
S/P appendectomy
Glaucoma
Spinal stenosis
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
1. CAD, s/p stents x 3; s/p 2 Palmaz stents to the mid and
distal LCx in [**2185**], s/p Tristar stent to the mid PDA and PTCA to
distal PDA in [**2188**]; EF was 61%.
2. Sick sinus syndrome s/p DDD pacemaker
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: As above
-PACING/ICD: DDD pacemarker
Social History:
Patient lives with his wife of 67 years at home. His children
are very involved in his care, son is a radiologist. He is
retired from real estate business.
-Tobacco history: Remote, smoked x 7 years in the [**2128**]'s
-ETOH: None (occasional use)
-Illicit drugs: None
Family History:
Father died of MI at age 87. Brother and sister both died of
malignancies in middle age. Daughter currently has malignant
glioma, undergoing treatment. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: T 98.1 BP 154/78 HR 70 RR 20 96% RA
GENERAL: Awake, alert, 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 of 10cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. III/VI systolic murmur. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. With loud crackles
bilaterally and soft rhonchi L>R.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2198-10-2**] 04:15PM WBC-10.7 RBC-3.86*# HGB-13.7*# HCT-42.5#
MCV-110* MCH-35.5* MCHC-32.2 RDW-20.9*
[**2198-10-2**] 04:15PM PLT COUNT-168
[**2198-10-2**] 04:15PM PT-14.5* PTT-29.1 INR(PT)-1.3*
[**2198-10-2**] 04:15PM GLUCOSE-129* UREA N-34* CREAT-1.2 SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16
[**2198-10-2**] 04:15PM CK(CPK)-132
[**2198-10-2**] 04:15PM cTropnT-0.21*
Other Pertinent Labs:
[**2198-10-12**] 03:20PM BLOOD Thrombn-10.6
[**2198-10-10**] 03:32PM BLOOD Inh Scr-NEG
Studies:
ECG [**2198-10-2**]: Atrial sensed ventricular paced rhythm rate, 77.
There is no other diagnostic interim change.
Chest Xray [**2198-10-2**]: New interval haziness/blunting at the left
costophrenic angle, which could be due to left small pleural
effusion and adjacent small atelectasis at the left lung base;
however, cannot rule out pneumonia.
TTE [**2198-10-3**]:
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 hypokinesis of the
mid inferolateral and anterolateral walls, and distal anterior,
inferior and apical segments. The remaining segments contract
normally (LVEF = 45 %). No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened.
Trace 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 an anterior space which most likely represents a fat pad.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction suggestive of multivessel CAD. Moderate
pulmonary artery systolic hypertension. Mild mitral
regurgitation.
Chest Xray [**2198-10-4**]: There is interval development of bilateral
perihilar, right more than left, interstitial linear opacities
continuing toward the lung bases, including the bilateral
subpleural linear opacities as seen in particular in the right
lower lobe, findings that are consistent with interval
development of mild-to-moderate pulmonary edema. Cardiomegaly is
moderate and unchanged. There is no interval development of
mediastinal widening. There is no appreciable increase in
pleural effusion, although small amount of right pleural fluid
is most likely present.
Renal Ultrasound [**2198-10-5**]:
1. Normal-sized kidneys without signs of hydronephrosis. Small
nonobstructive right renal stone is noted.
2. Mucosal-based soft tissue nodule in the right posterolateral
bladder wall suggestive of urothelial neoplasm. Further
evaluation with cystoscopy or MRI would be indicated, when
clinical conditions warrant.
3. Enlarged prostate.
Cardiac cath report: Pending at the time of discharge. Patient
had intervention 2 drug eluting stents placed to proximal LAD
using tandem heart intra-procedure.
ECHO [**2198-10-15**]:
Conclusions
Left ventricular wall thicknesses are normal. There is severe
regional left ventricular systolic dysfunction with akinesis of
the inferolateral wall and severe hypokinesis of the mid to
distal anterior wall and septum. Right ventricular chamber size
and free wall motion are normal. Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2198-10-3**],
overall ejection fraction has decreased with worsened function
of the anterior wall, anterior septum and anterolateral wall.
Brief Hospital Course:
#. Angina: He presented with acceleration of his typical angina
symptoms and had unstable angina on admission. He has known 3
vessel CAD and he has declined CABG in the past. His medical
regimen was optimized on admission and included Plavix, full
dose ASA, Imdur SR 60 mg by mouth twice daily, metoprolol, and a
high dose statin. His cardiac enzymes fluctuated during this
admission, and he continued to have anginal symptoms
intermittently throughout the hospitalization. These episodes
were typically responsive to sublingual nitro. After many
discussions, the patient and family decided that his quality of
life is unacceptably poor with his current angina. They decided
to proceed with cardiac catheterization for stenting of his
proximal LAD lesion. He was taken to the cath lab and had a
tandem heart used to place 2 DES to his left main coronary
artery and LAD. He had a slight right groin hematoma after
catheterization that remained stable. He was chest pain free
after the procedure.
#. Pump: On admission, he had a history of 1 month of peripheral
edema and he appeared volume overloaded by chest xray at
[**Location (un) 620**]. He had received IV Lasix before transfer and appeared
relatively euvolemic on admission. He had a TTE after admission
which showed preserved systolic function. He had one episode of
hypoxia, shortness of breath, and increasing volume overload on
physical exam that was responsive to IV Lasix. He
intermittently required low doses of Lasix for pulmonary edema
diagnosed by physical exam and chest xray. During cardiac
catheterization, he had an echo that showed decreased LV
systolic function compared to previous with an LVEF of 20-25%.
He should have a repeat ECHO in [**2-26**] weeks now that he has been
revascularized to assess for improvement in function.
#. Anemia/Myelodysplasia: His hemoglobin remained in the
11.0-12.5 range during this admission. There was some concern
for anemia-induced angina, and his hematocrit was maintained
greater than 33. He was transfused a total of 4 units of blood
during and prior to his cardiac catheterization and continued
his outpatient Procrit injections. His anemia was decreased on
the day of discharge and he received an additional unit of prbcs
with resulting post-transfusion Hct of 31.9.
He should likely have a hematocrit drawn in two days to assess
for any continued drop. He had no change in his groin hematoma
and no evidence of retroperitoneal bleed at the time of
discharge.
#. Acute Renal Failure: His creatinine increased from 1.2 on
admission to 2.9 at its peak. The nephrology service was
consulted and his urine lytes were consistent with prerenal
etiology. It was felt that his acute renal failure was due to
poor forward flow in addition to light diuresis. Renal
ultrasound showed no hydronephrosis. He was given one small
fluid bolus (500cc) to improve his creatinine and 2 units of
blood for anemia. He had an additional 2 units during his
catheterization. His creatinine slowly improved prior to his
catheterization. His cardiac catheterization was delayed
somewhat in order for his renal function to improve. He was
given mucomyst and IV fluids prior to catheterization to prevent
contrast nephropathy. His creatinine was 2.1 on discharge. His
urine output should be followed as there is a risk of contrast
induced nephropathy approximately 2 to 3 days after his
catheterization.
#. Elevated PTT: He was started on subcutaneous heparin during
this hospitalization for DVT prophylaxis and his PTT increased
to approximately 70. The SQ heparin was stopped, and his PTT
remained elevated for approximately 5 days after stopping it.
He had a mixing study that was negative for a factor inhibitor
and his thrombin time was normal. The etiology of his elevated
PTT was not entirely clear, but it was not worked up further for
a specific factor deficiency. It continues to decrease at the
time of discharge.
#. Hematuria: He had hematuria on admission and was found to
have a mass in his bladder on renal ultrasound that was thought
to be the cause of his hematuria. The patient and family did
not want this worked up further.
#. Dysphagia: The patient experienced some dysphagia with his
pills and liquids during his hospitalization. This was thought
to be due to deconditioning and was not worked up further and he
was given Ensure Plus for nutritional supplementation. He was
able to tolerate PO and pills for the remainder of his
admission.
#. Code Status: During this hospitalization, his code status was
DNI but he wanted a trial of chest compressions/shocks but did
not want prolonged resuscitation. This was temporarily
suspended during his cardiac catheterization.
Medications on Admission:
Lisinopril 20mg po daily
Toprol XL 75mg po daily
Pravastatin 80mg po daily
ASA 325mg po daily
SL nitro 0.4mg once daily prn
Plavix 75mg po daily
Isosorbide mononitrate SR 60mg twice daily
Vit B Complex 1 tab po daily
Actonel 35mg po daily
Calcium 600 + D3 1 tab daily
Nascobal 500mcg/0.1mL Nasal Gel - 1 spray qweek
Timolol 2 drops twice daily
Cosopt 2%-0.5% Eye Drops - 1 drop at bedtime
Procrit 40,000 unit/mL injection
Colace 100mg
Zofran ODt prn
Flomax 0.4mg po daily
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
2. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest
pain/pressure: Can take every 5 minutes for 3 doses.
5. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Please take this dose for 1 month. Then take 1 tablet
(75mg) daily.
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
7. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
8. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week:
Please take this medication at the dose and frequency you were
prior to hospitalization.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**11-24**] Tablet,
Rapid Dissolves PO every 6-8 hours as needed for nausea.
12. Eye Drops Ophthalmic
13. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
14. Procrit 40,000 unit/mL Solution Sig: One (1) inj Injection
once a week.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Primary Diagnosis:
Coronary Artery Disease
Acute on chronic kidney disease
Secondary Diagnosis:
Anemia
Myelodysplasia
Hematuria
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to the hospital due to chest pain. You also
had acute renal failure while you were in the hospital that was
thought to be due to poor forward blood flow from your heart.
You were given both IV fluids and diuresis with IV Lasix
intermittently throughout your hospitalization. You also
received 4 units of blood due to anemia.
You underwent cardiac catheterization with Dr. [**Last Name (STitle) **] and had two
drug-eluting stents placed in your coronary arteries. You had a
hematoma (bruise) in your right groin after the procedure which
did not get bigger. You also worked with physical therapy after
this procedure.\
You were found to have a bladder mass on imaging during this
hospitalization that is likely the cause of your hematuria
(blood in your urine). At you and your family's request, we did
not work this up further. Please discuss this with your
outpatient primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **].
CHANGES to your medications:
-Increased Plavix to 150mg by mouth daily (you should take this
dose for one month and then go down to 75 mg daily; please
discuss this with your cardiologist at your next appointment).
-Stopped your lisinopril due to your low blood pressures and
renal failure. This should be restarted once your kidney
function returns to normal. Please discuss this with Dr. [**First Name (STitle) **]
and Dr. [**Last Name (STitle) 120**].
Please take all of your other medications as you were doing
prior to hospitalization.
Followup Instructions:
You should follow-up with your primary care doctor, Dr. [**First Name (STitle) **].
Please call [**Telephone/Fax (1) 95663**] to make an appointment.
In addition, you should follow-up with your cardiologist, Dr.
[**Last Name (STitle) 120**], in the next 2-3 weeks. Please call his office to
schedule an appointment.
ICD9 Codes: 5849, 4111, 5859, 2859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1804
} | Medical Text: Admission Date: [**2135-1-22**] Discharge Date: [**2135-1-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
dyspnea; transfer from OSH for possible AV repair
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]F with known severe AS (valve area 0.5cm^2 in [**10/2134**]) who was
transferred to [**Hospital1 18**] for evaluation for AV repair. She was
initially admitted to OSH when her daughter noticed her to be
short of breath at home. The daughter then [**Name2 (NI) 16690**] CPR (rescue
breaths) and called EMS. At the OSH, she was intially managed
on BiPAP but then reportedly had additional respiratory distress
on hospital day 2 +/- seizure activity. Shortly thereafter, she
had a PEA arrest, was intubated, and started on norepinephrine
for hypotension. She was also noted to have positive cardiac
enzymes (Troponin I 16.60, CK 427, MB 50.4, MBI 11.8) at this
time and was transferred to [**Hospital1 18**] for catheterization prior to
possible AV repair.
.
ROS: unable to answer due to intubation
Past Medical History:
Severe aortic stenosis (valve area 0.5cm^2 in [**10/2134**])
COPD (baseline PFTs unknown)
hypothyroidism
AAA s/p repair
restless leg syndrome
Social History:
Married, former smoker (quit), unable to say how much tobacco
use in past; denies EtOH/drug use.
Family History:
unable to obtain due to intubation
Physical Exam:
T 99.8 BP 90/70 HR 104 RR 12 Sat 100%
Vent: AC with tidal volume 500cc, PEEP 5
Gen: awake, intubated, NAD, following commands
HEENT: +OGT, +ETT
Neck: no carotid bruits, unable to assess JVP
Chest: bibasilar rales half way from bases with mild diffuse
wheezing
CV: IV/VI systolic murmur loudest at RUSB, tachycardic, regular
rhythm
Abd: mildly distended, NT, soft, normal BS
Extr: trace bipedal edema with 1+ PT pulses
Neuro: awake, able to follow verbal commands
Pertinent Results:
CT Chest/Abd/Pelvis ([**2135-1-24**]):
Markedly tortuous thoracic and abdominal aorta with an 8-cm
descending thoracic aortic aneurysm. The aorta becomes normal
in size as it enters the abdomen through the aortic hiatus.
There is moderate-to-severe atherosclerotic calcification of the
thoracic and abdominal aorta, coronary arteries, and branch
vessels of the aorta within the pelvis. There is
atherosclerotic calcification of the ostium of the celiac axis
and SMA. 6-mm right renal hyperdense lesion, not completely
characterized, comparison with prior studies is recommended. If
none are available, further evaluation with an ultrasound or MRI
is recommended. Small bilateral pleural effusions and bibasilar
compressive atelectasis. Severe degenerative changes of the
thoracic and lumbar spine.
.
TTE ([**2135-1-25**]):
Conclusions: The left atrium is mildly dilated. There is severe
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (area 0.4cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Severe aortic stenosis. Marked symmetric left
ventricular
hypertrophy with preserved global and regional biventricular
systolic
function. Pulmonary artery systolic hypertension. Moderate
mitral
regurgitation.
.
[**2135-1-22**] 09:00PM BLOOD WBC-15.2* RBC-3.46* Hgb-11.3* Hct-32.7*
MCV-94 MCH-32.7* MCHC-34.7 RDW-15.0 Plt Ct-238
[**2135-1-22**] 09:00PM BLOOD Glucose-182* UreaN-16 Creat-0.9 Na-136
K-4.0 Cl-97 HCO3-30 AnGap-13
[**2135-1-22**] 09:00PM BLOOD CK-MB-22* MB Indx-6.9* cTropnT-1.43*
[**2135-1-22**] 09:00PM BLOOD ALT-38 AST-84* LD(LDH)-398* CK(CPK)-321*
AlkPhos-61 TotBili-0.4
[**2135-1-22**] 09:00PM BLOOD Albumin-4.0 Calcium-9.5 Phos-3.2 Mg-2.4
[**2135-1-23**] 04:38AM BLOOD %HbA1c-6.3* [Hgb]-DONE [A1c]-DONE
[**2135-1-23**] 04:38AM BLOOD Triglyc-149 HDL-64 CHOL/HD-2.2 LDLcalc-48
Brief Hospital Course:
Ms. [**Known lastname 1274**] was intubated at an OSH for acute pulmonary edema in
the setting of a PEA arrest. Upon arrival, she was intubated
and stable on pressors. She was easily extubated the next
morning and pressors were gradually weaned off as it became
apparent that her peripheral NIBP was not indicative of her
central BP (presumably due to severe subclavian artery
stenoses). She was evaluated by CT surgery for possible AV
repair and was deemed to have an unacceptably high estimated
perioperative mortality given the degree of aortic and valvular
calcification, and particularly because of a massive 8cm
thoracic aortic aneurysm noted on chest CT. Once this was
determined and it was clear that she had a very poor short-term
prognosis due to the severity of her aneurysm, both the patient
and her family agreed that she should be made DNR/DNI. On the
morning of [**2135-1-27**], she had severe chest pain which required a
nitro drip and morphine drip to become pain free. ECGs showed
worsened ST depressions in her precordial leads and cardiac
enzymes were consistent with an NSTEMI (peak CK ~1100). Over
the next 24 hours, she had intermittent bouts of anginal chest
pain and was being evaluated for potential cardiac
catheterization on [**1-28**]. On the morning of [**1-28**], she became
acutely hypertensive, tachycardic, hypoxic, and dyspneic with
diffuse pulmonary wheezes. She was initally treated with IV
furosemide and metoprolol with minimal improvement. Her heart
rate acutely slowed and she had several [**1-8**] second asystolic
pauses before becoming spontaneously asystolic and stopped
breathing. Due to her previously determined DNR/DNI status,
further resuscitative efforts were not pursued and she was
declared deceased at 12:49PM. The attending notified her
daughter (her HCP) by phone.
Medications on Admission:
Meds on transfer:
aspirin 81mg daily
atenolol 12.5mg daily
levothyroxine 137 mcg
lorazepam prn
morphine prn
norepinephrine 18 mcg/kg
.
Home Meds:
Ultracet
Crestor 10mg
aspirin
atenolol (? dose)
Miralax
Colace
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnoses: severe aortic stenosis, 8cm thoracic aortic
aneurysm
Secondary diagnoses: coronary artery disease
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
n/a
ICD9 Codes: 4280, 4241, 496, 2449, 4168, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1805
} | Medical Text: Admission Date: [**2156-1-24**] Discharge Date: [**2156-3-30**]
Date of Birth: [**2156-1-24**] Sex: M
Service: NB
IDENTIFICATION: [**Known lastname 1104**] [**Known lastname 72488**] is a 66 day old former 26 [**5-6**] wk
twin (twin A) being transferred from [**Hospital1 18**] NICU to [**Hospital3 18242**] NICU with recurrent necrotizing enterocolitis and
feeding intolerance.
HISTORY: Baby [**Name (NI) **] [**Known lastname 1104**] [**Known lastname 72488**] was the 838 gm product of a
26-6/7 weeks gestation, born to a 19-year-old, G2, P0 now 2,
mother. Prenatal screens: A+, antibody negative, hepatitis
surface antigen negative, RPR nonreactive, rubella immune, GBS
unknown. This pregnancy was a spontaneous mono/di twins.
Maternal history unremarkable. Pregnancy was complicated by
cervical shortening and PTL, treated with bed-rest and
betamethasone at 25 weeks. On day of delivery, preterm labor
progressed, and infants were delivered by c-section. Twin A
emerged vigorous, with good cry. Apgars were 8 and 8.
He was intubated in the delivery room for respiratory distress
and admitted to the newborn intensive care unit.
HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: [**Known lastname 1104**] was admitted to the newborn intensive care
unit intubated. He was treated for significant RDS with 3 doses
of surfactant, requiring a brief period on high-frequency
ventilation and muscle relaxation before transitioning to
conventional ventilation. He weaned gradually to low conventional
ventilation settings, and was extubated to CPAP DOL #6. He
required reintubation on DOL #10 for increased apnea, and was
subsequently extubated on DOL #26. He then transitioned to CPAP
which he remained on for a total of 14 days, and transitioned to
room air on DOL #40, [**2156-3-4**]. He has required intermittent nasal
cannula since that time, including [**Date range (1) 25245**] with onset of
abdominal distension, but is in RA at time of transfer. Blood
gas on day of transfer showed pH 7.42, pCO2 56, and HCO3 38.
[**Known lastname 1104**] was also on caffeine citrate for management of apnea and
bradycardia of prematurity that was discontinued on [**2156-3-22**]. He still demonstrates occasional apnea spells.
CARDIOVASCULAR: [**Known lastname 1104**] demonstrated mild hypotension early in
life, requiring dopamine support for approximately 2 days. He
received one course of indomethacin for PDA, confirmed by ECHO.
F/U ECHO on DOL #5 showed small PDA, and repeat ECHO on DOL #34,
[**2156-2-27**], showed no PDA. Mild hypertension was also noted in first
week of life; renal function was adequate (see below), and
hypertension resolved. He has been hemodynamically stable since
that time, including during periods of illness involving
necrotizing enterocolitis. BPs at time of transfer are 80s/40s,
with HR 150s.
FLUID/ELECTROLYTES: Birth weight was 883 gm. Weight at time of
transfer is 2245 gm. Infant was initially maintained on
parenteral nutrition, with initiation of enteral feeds delayed
due to abdominal distension. Enteral feeds were introduced with
BM 20/SC 20 on DOL #11, and gradually advanced to full volume
feeds by DOL #19, [**2156-2-12**]. Within 48 hours, he developed
abdominal distension with pneumatosis, and began treatment for
presumed necrotizing enterocolitis. He received bowel rest and
antibiotics for 14 days, during which time a [**Known lastname 72489**] was placed
due to difficulty with access. He restarted enteral feeds with
[**Doctor Last Name **] special care 20 on DOL #35, but within 3 days, developed
abdominal distention requiring holding of feeds. Contrast enema
was performed at [**Hospital3 1810**] which was within normal
limits. Abdominal distension improved, and he restarted He
restarted SSC 20 formula, advancing gradually to 130 cc/kg/day by
DOL #46, [**2155-3-11**]. At that time, he developed bloody stools with
dilated intestinal loops. He was made NPO, and sepsis evaluation
was performed which was unremarkable. Following consultation
with surgery, he was kept NPO for 3 days and then started on
neocate formula on DOL #50. He advanced to full volume neocate
feedings by DOL #59, and then subsequently to 24 cals. On DOL
#65, [**2156-3-29**], he again developed grossly bloody stools,
pink/rusty in color with streaks of visible blood, with abdominal
distension. KUBs showed pneumatosis in RLQ, with dilated
intestinal loops. Initial WBC and platelet counts were normal,
although repeat WBC on [**3-30**] showed borderline neutropenia with WBC
6.5 with 15%N/3%B. Blood cx were sent. Infant was made NPO,
repogle was placed to suction, and zosyn was started. Surgery
was consulted, and transfer to [**Hospital1 **] was recommended fur
further surgical and GI evaluation and consideration of omegavan
therapy. Repeat KUB overnight showed improvement in pneumatosis
with less distension of loops, and abdominal exam remained
distended although less tense. Scant repogle output was noted.
Lytes on [**2156-3-29**] were 132/2.6/93/29. Repeat lytes on [**2156-3-30**]
showed 138/3.2/99/31.
GI: Infant was initially treated with phototherapy for
hyperbilirubinemia of prematurity, which resolved. Subsequently,
infant was noted to develop significant direct
hyperbilirubinemia, with bilirubin of 8.8/3.9 on DOL #48,
increasing to 13.9/8.4 on DOL #61, [**2156-3-25**]. LFTs were mildly
elevated at that time with AST 93, ALT 43. Abdominal ultrasound
was performed on [**3-26**], which showed several small stones in the
gall bladder but with normal liver parenchymea and no biliary
duct dilation. GI was consulted. Liver dysfunction was presumed
seconday PN cholestasis (infant had received PN for 55/65 days of
life), and actigall was begun on [**3-26**]. This was subsequently
held on [**3-29**] due to NPO status. Repeat labs on [**3-29**] showed Bili
11.8/7.9, AST 70, ALT 38, AP 666, Alb 3.1, and coags of PT 14.0
and PTT 40.3. Of note, bilateral inguinal hernias have been
noted, but are not present on current exam.
HEMATOLOGY: Infant's blood type is A+. He has received
approximately 7 PRBC transfusions, last on [**3-29**] for a Hct of
25.7; repeat Hct on [**3-30**] was 41.7. He experienced mild
thrombocytopenia in first week of life, not requiring platelet
transfusions, and platelet counts have been normal since,
including during episodes of illness. Platelets on [**3-29**] were 390
and on [**3-30**] were 285. PT and PTT on [**3-29**] were 14.0 and 40.3.
INFECTIOUS DISEASE: Initial CBC was negative. Blood cultures
were negative, but infant received 7 days of amp/cefotax after
birth due to significant clinical illness. He received 14 days
of zosyn from [**2-14**] to [**2-27**] for presumed NEC, and then 3 days of
zosyn from [**3-10**] to [**3-13**] for evaluation of colitis. Zosyn was
restarted on [**3-29**] for presumed recurrent NEC. Infant was
maintained on prophylactic amp or amoxicillin while not on other
antibiotics for hydronephrosis, until ultrasound on [**3-26**] showed
this issue to be resolved (see below). Multiple blood cultures
throughout hospital course were negative; most recent was sent on
[**3-29**] and is no-growth-to-date. Of note, a clean-catch urine
sample was sent for culture on [**3-26**] as part of evaluation for
direct hyperbilirubinemia; UA was negative but urine culture
subsequently grew Enterobacter cloacae, sensitive to piperacillin
and gentamicin. Repeat urine culture has not been performed.
GU: Renal ultrasound was performed on [**1-27**] due to mild
hypertension, and moderate bilateral hydronephrosis was noted.
No vascular thrombus was seen. Repeat ultrasound on [**2-12**] showed
mild right hydronephrosis, and repeat ultrasound on [**3-26**] showed
no hydronephrosis. Some echogenic debris was seen at the tips of
the renal medullary pyramids bilaterally as well as in the
bladder on this last ultrasound, likely insignificant, but f/u
renal ultrasound can be considered. Renal function has been
appropriate throughout, with several normal urinanalyses (last
[**3-26**]) and last BUN/Cr on [**3-10**] of 6/0.3.
NEURO: Infant has been appropriate for gestational age. Head
ultrasounds on day of life #2, #7, and #30, have all been
within normal limits.
OPHTHALMOLOGY: Infant received several eye exams without
evidence of retinopathy of prematurity. Last eye exam was on
[**3-29**], which showed immature retinas in zone III, with f/u
recommended in 2 weeks.
CONDITION AT DISCHARGE: Guarded.
EXAM AT DISCHARGE: WD premature infant on warmer, active with
exam. Mildly irritable but consolable. Skin warm, dry.
Fontanelles soft and flat. Chest moderately aerated, clear,
minimal retractions. Cardiac RRR, no murmur heard. Abdomen
distended, not tense, very quiet BS, no HSM, no mass, mildly
tender. Scrotal edema, no hernias felt. Anus patent. Tone and
activity grossly normal.
DISCHARGE DISPOSITION: To [**Hospital3 1810**]. Neonatologist on
7N ([**First Name8 (NamePattern2) 11705**] [**Last Name (NamePattern1) 10208**]) and surgery attending ([**First Name8 (NamePattern2) 11705**] [**Last Name (NamePattern1) 64492**]) aware
of transfer.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 30207**], [**First Name3 (LF) **], [**Telephone/Fax (1) 37875**].
MEDICATIONS: Zosyn 120 mg IV q.8.
RHCM: State newborn screens have been sent per protocol and have
been within normal limits.
IMMUNIZATIONS RECEIVED: [**Known lastname 1104**] has received hepatitis B
vaccine on [**2156-3-2**].
DISCHARGE DIAGNOSES:
Prematurity, born at 26-6/7 weeks gestation.
Twin gestation.
Respiratory distress syndrome.
Mild bronchopulmonary dysplasia.
Presumed sepsis.
Patent ductus arteriosus.
Necrotizing enterocolitis, recurrent.
Presumed allergic colitis.
Direct hyperbilirubinemia.
Apnea and bradycardia of prematurity.
Anemia of prematurity.
Inguinal hernias.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2156-3-30**] 00:43:26
T: [**2156-3-30**] 08:47:23
Job#: [**Job Number 72490**]
ICD9 Codes: 769, 7742, 4019, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1806
} | Medical Text: Admission Date: [**2201-3-6**] Discharge Date: [**2201-3-11**]
Date of Birth: [**2131-12-8**] Sex: M
Service: [**Hospital1 **]
HISTORY OF THE PRESENT ILLNESS: The patient is a 69-year-old
male with a history of CAD, hypertension, cervical diskectomy
on [**2201-2-16**], hospital course complicated by a left lower lobe
pneumonia treated with Azithromycin and Levaquin. He was
noted by the VNA to be tachycardiac on [**2201-3-5**] to the 120s
and referred to PCPs office where the PCPs EKG documented
sinus tachycardia at 130s and referred the patient to [**Hospital3 9683**] ED where a V/Q scan reportedly showed a pulmonary
embolus, questionable saddle-like on films but films were
unavailable upon transfer to [**Hospital6 2018**] Emergency Department for consideration of thrombectomy
given recent C spine surgery and contraindication [**First Name8 (NamePattern2) **] [**Hospital1 **]
surgeons by report to anticoagulation.
Upon admission, the patient had dyspnea on exertion but no
chest pain. The patient had a dry cough but no fevers or
chills and had some left leg swelling. The patient developed
a sharp burning left back pain and right back pain for the
past week also, pleuritic, sudden onset dyspnea as with
pneumonia and since in the ED, was transferred to the MICU
Service. The following was the MICU HPI.
PAST MEDICAL HISTORY:
1. Hyperlipidemia.
2. Hypertension.
3. CAD, status post angioplasty with stent two years ago.
4. Cervical diskectomy on [**2201-2-16**] at [**Hospital3 **].
5. Varicose veins.
6. DM2.
7. Seizure disorder four years ago.
8. No prior history of DVTs or PEs.
ADMISSION MEDICATIONS:
1. Lipitor.
2. Dilantin.
3. Lisinopril.
4. Timolol.
5. Amaryl.
SOCIAL HISTORY: No tobacco use.
FAMILY HISTORY: No DVT or PE in the family history.
PHYSICAL EXAMINATION ON ADMISSION TO MEDICAL INTENSIVE CARE
UNIT: Vital signs: Temperature 99, pulse 115, blood
pressure 121/77, respiratory rate 24, 02 saturation 97% on 2
liters nasal cannula. General: The patient was a pleasant
male with 30 inch soft cervical collar in place, nasal
cannula 02, speaking in full sentences, no major acute
distress. HEENT: PERRLA. Moist membrane mucosa. Neck:
Right anterior surgical site. No oozing. Steri-Stripped.
Prominent external jugular venous pulsations. Heart:
Tachycardiac, regular rhythm, S1 and S2 normal. No S3 or S4.
No rub. Lungs: Decreased breath sounds on the left, basilar
and also some crackles on the right basilar. Abdomen: Bowel
sounds present, scaphoid, nontender, nondistended, no
hepatosplenomegaly. Extremities: Increased edema in the
left leg. Trace pitting edema to the knee. No cords. No
calf tenderness. Pulses bilaterally present. Right leg
unremarkable. Neurologic: Alert and oriented times three.
Left upper extremity weakness, grossly intact sensation
throughout.
LABORATORY/RADIOLOGIC DATA: On admission, sodium 137,
potassium 4.5, chloride 103, bicarbonate 28, BUN 13,
creatinine 0.8, glucose 110, calcium 9.3, troponin 0.07, INR
1.2, PTT 23.6. White blood cell count 7.3, hematocrit 40.9,
platelets 427,000.
EKG at [**Hospital1 18**] showed sinus tachycardia at 106, normal axis,
normal intervals, and no RV strain, no S1, T3, had a positive
small Q in III but no ST changes or T wave inversions.
HOSPITAL COURSE: Since admitted, he was admitted to the MICU
and it was decided that instead of the thrombectomy to
actually go through anticoagulation with heparin. He
tolerated the heparin drip well and has become
hemodynamically stable and has been off the oxygen since and
the goal was once stable transfer to the floor. Her was
transferred to the floor without any new acute findings.
Homans sign negative. No calf tenderness since and has
become therapeutic on Coumadin after the third day on
admission to the [**Hospital1 139**] firm. The patient has done well
since on [**Hospital1 139**] firm and bridged to Coumadin to keep INR
level between 2 and 3. Have already discussed follow-up INRs
with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], over the phone. The patient will
follow-up with her tomorrow for INR checks and further
follow-up.
In terms of CAD, given that there is a possibility of
intervention, his aspirin was held to be restarted at the
PCPs office tomorrow. Already discussed with the PCP. [**Name10 (NameIs) **]
was continued on lisinopril, Lipitor meanwhile. Also, his
beta blockers were restarted on the day of discharge.
In terms of his diabetes, continue his Amaryl and he was
getting fingersticks while in the hospital and doing well,
and was well-controlled.
In terms of seizure disorder, he is asymptomatic. He had
Dilantin levels which were slightly subtherapeutic. To be
continued to be checked by PCP but continue with the Dilantin
while in the hospital.
The patient tolerated p.o. intake well and was doing well,
stable, and in very good condition, good spirits upon
leaving.
The only other added note is that since he has been here he
had emphasized that he had mood changes which were consistent
with some depressive episodes. He was started on Celexa
given that it will have less of an interaction in terms of
drug interactions with other drugs he has on board. The
start of Celexa was discussed with his PCP and is to be
continued at her discretion.
DISPOSITION: The patient was discharged to home. The
patient was noted to seek medical care if his symptoms worsen
or any new symptoms arise or any sign of bleeding from
anywhere.
FINAL DIAGNOSIS: Pulmonary embolus.
RECOMMENDED FOLLOW-UP: The patient has an appointment
tomorrow with Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 14214**], on [**2201-3-12**] at 2:45
p.m. He will have his INR followed-up over there. The goal
INR is [**12-30**] and consider also starting aspirin per PCPs input
and discretion.
MAJOR SURGICAL INVASIVE PROCEDURES: There were no procedures
done while the patient was in-house.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Docusate.
2. Phenytoin 200 mg b.i.d.
3. Atorvastatin 10 mg p.o. q.d.
4. Lisinopril 10 mg p.o. q.d.
5. Timolol maleate eyedrops 0.25% b.i.d.
6. Pantoprazole 40 mg q.d.
7. Citalopram 20 mg one-half tablet p.o. q.d.
8. Warfarin 6 mg p.o. q.h.s. with a goal INR of [**12-30**], to be
adjusted by PCP at her discretion.
9. Metoprolol 12.5 mg p.o. b.i.d. to be adjusted by PCP at
her discretion.
FOLLOW-UP: As discussed above.
The patient is to have liver function tests checked regularly
by PCP since on Citalopram.
[**First Name8 (NamePattern2) **] [**Doctor First Name **], M.D. [**MD Number(1) 19814**]
Dictated By:[**Name8 (MD) 6112**]
MEDQUIST36
D: [**2201-3-11**] 10:29
T: [**2201-3-12**] 19:49
JOB#: [**Job Number 54571**]
ICD9 Codes: 2724, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1807
} | Medical Text: Admission Date: [**2152-5-31**] Discharge Date: [**2152-6-5**]
Date of Birth: [**2087-2-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
coronary artery bypass graft x2 (LIMA-LAD, SVG to OM) [**2152-5-31**]
History of Present Illness:
65 yo M with PMH significant for
hypertension, hyperlipidemia, and known CAD s/p Cypher stent to
LCx in [**2148-3-9**]. The patient had an abnormal stress test as
part of routine follow up and is now referred for cardiac
catheterization. He states that he experiences chest pain and
shortness of breath with strenuous exercise which resolves with
rest. Cardiac cath showed 2VCAD and we are asked to consult for
surgical revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Coronary arterty disease s/p Cypher stent to LCx [**3-/2148**]
Chronic RLE pain on narcotics, f/b Dr. [**Last Name (STitle) 6598**] at RIH
Carotid artery disease
Social History:
Lives with:ex wife, [**Name (NI) **]
Occupation:Retired
Tobacco:denies
ETOH:denies
Family History:
Denies
Physical Exam:
Pulse:64 Resp:16 O2 sat: 99%RA
B/P Right:170/80 Left: 161/85
Height:5'6" Weight:93 kg (205 lbs)
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] No Murmur
Abdomen: Soft/non-distended/non-tender [x]
Extremities: Warm/well-perfused [x] Edema Varicosities: None []
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotids Right: (-) Left: (-)
Pertinent Results:
Intra-op Echo [**2152-5-31**]
Prebypass: The left atrium and right atrium are normal in cavity
size. No spontaneous echo contrast or thrombus is seen in the
body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size, and global systolic function are
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 (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
Post-bypass: The patient is receiving no inotropic support
post-CPB. Biventricular systolic function is preserved and all
findings are consistent with pre-bypass findings. The aorta is
intact post-decannulation. All findings communicated to the
surgeon intraoperatively.
[**2152-6-5**] 05:00AM BLOOD WBC-7.2 RBC-2.61* Hgb-8.1* Hct-24.0*
MCV-92 MCH-31.1 MCHC-33.9 RDW-13.4 Plt Ct-254
[**2152-6-4**] 05:30AM BLOOD WBC-9.2 RBC-2.60* Hgb-8.3* Hct-23.9*
MCV-92 MCH-31.8 MCHC-34.6 RDW-13.3 Plt Ct-238
[**2152-6-1**] 02:04AM BLOOD PT-13.0 PTT-29.4 INR(PT)-1.1
[**2152-6-5**] 05:00AM BLOOD Glucose-113* UreaN-23* Creat-1.0 Na-140
K-4.0 Cl-105 HCO3-26 AnGap-13
[**2152-6-4**] 05:30AM BLOOD Glucose-120* UreaN-27* Creat-1.1 Na-140
K-4.1 Cl-103 HCO3-28 AnGap-13
[**2152-6-5**] 05:00AM BLOOD Mg-2.2
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2152-5-31**] where the patient underwent CABG x 2
as detailed in the operative report. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Cefazolin was used for surgical antibiotic
prophylaxis. POD 1 found the patient extubated, alert and
oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight.
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. He
did develop a brief episode of rapid atrial fibrillation which
converted to sinus with amiodarone and titration of beta
blocker. He was discharged on Keflex for sternal drainage.
Mr [**Known lastname 10123**] was cleared for discharge to home on POD# 5 by Dr.
[**Last Name (STitle) **] in good condition with appropriate follow up
instructions.
Medications on Admission:
Zetia 10mg po daily
Metoprolol Tartrate 50mg po BID
Benicar HCT 40mg-25mg tablet, 1 tablet po daily
Oxycontin 10mg po BID
Percocet 1 tab po q 6hrs PRN leg pain
Lyrica 50mg po BID
Crestor 10mg po daily
ASA 325mg po daily
Plavix - last dose:600mg [**2152-5-11**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
4. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
8. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
400mg [**Hospital1 **] x 2 weeks, then 400mg daily x 1 week, then 200mg daily
until further instructed.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Hypertension, Hyperlipidemia, Coronary arterty disease s/p
Cypher stent to LCx [**3-/2148**], Chronic RLE pain on narcotics, f/b
Dr. [**Last Name (STitle) 6598**] at RIH, Carotid artery disease, s/p RLE trauma s/p
metal rod placement [**2148**], s/p appendectomy, s/p tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, serous drainage, no erythema
Leg Right - healing well, no erythema or drainage.
Edema +1 bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for 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
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2152-7-6**] 2:30
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-11**] weeks [**Telephone/Fax (1) 3183**]
Cardiologist Dr. [**Last Name (STitle) 7047**] in [**12-11**] weeks [**Telephone/Fax (1) 8725**]
**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:[**2152-6-5**]
ICD9 Codes: 4111, 5990, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1808
} | Medical Text: Admission Date: [**2158-6-24**] Discharge Date: [**2158-7-21**]
Date of Birth: [**2133-11-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Pt is s/p MVC with multiple facial fractures, left eye injury,
and evidence of small SAH and frontal contusion
Major Surgical or Invasive Procedure:
Left Globe exploration
Facial fracture fixation, with mandibular fixation
Peg and trach placement
History of Present Illness:
PT was involved in MVC and sustained multiple injuries to his
face, Left eye and brain
Physical Exam:
On discharge:
HEENT: Pt with swollen left orbit, arch bars in place, Head
lacerations well healed, Trach removed, dressing over stoma
C/D/I
Cardiac: RRR
Chest: CTAB
Abd:soft NT/ND +BS, PEG tube inplace and without
leakage/erythema or tenderness
Ext: +2 pulses throughout, no edema
Pertinent Results:
[**2158-6-24**] 06:20PM BLOOD WBC-21.6* RBC-4.39* Hgb-13.4* Hct-37.9*
MCV-86 MCH-30.5 MCHC-35.4* RDW-12.1 Plt Ct-130*
[**2158-6-24**] 06:20PM BLOOD PT-12.8 PTT-19.4* INR(PT)-1.1
[**2158-6-24**] 06:20PM BLOOD Plt Ct-130*
[**2158-6-24**] 10:00PM BLOOD Glucose-113* UreaN-15 Creat-1.0 Na-140
K-3.8 Cl-105 HCO3-26 AnGap-13
[**2158-6-24**] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2158-6-24**] 06:31PM BLOOD pO2-38* pCO2-62* pH-7.30* calHCO3-32*
Base XS-1 Comment-GREEN TOP
[**2158-6-24**] 10:07PM BLOOD Type-ART Temp-38.0 Rates-14/ Tidal V-600
PEEP-5 FiO2-70 pO2-331* pCO2-52* pH-7.34* calHCO3-29 Base XS-1
-ASSIST/CON Intubat-INTUBATED
[**2158-6-24**] 11:42PM BLOOD Type-ART Temp-38.0 Rates-18/ Tidal V-600
PEEP-5 FiO2-40 pO2-169* pCO2-41 pH-7.40 calHCO3-26 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2158-6-24**] 06:31PM BLOOD Hgb-14.0 calcHCT-42 O2 Sat-65
[**2158-6-28**] 05:03PM BLOOD Hgb-9.9* calcHCT-30
[**2158-6-29**] 01:14AM BLOOD Hgb-10.8* calcHCT-32
Brief Hospital Course:
Pt was admitted to Trauma surgery with multiple facial
fractures, as well as severe trauma to the left eye.
Neurosurgery, Opthomology and Plastics all contributed to the
patients care. The patient developed a CSF leak that was
followed by Neurosurgery that eventually subsided. Nuerosurgery
also followed the patient for a questionable C4-C6 ligamentous
injury for which he was put in a cervical collar. Opthomology
took the patient to the OR for Left globe exploration, they
found no globe rupture but significant corneal abrasion, [**Doctor First Name 2281**]
avulsion with intact lens, and retinal hemorrhages. Plastics
fixed the facial fractures and applied arch bars and was trached
and Peggged [**2158-6-28**]. Patient steadily improved over stay, he
developed some impulsiveness that slowly subsided, he was able
to maintain POs, and achieve daily caloric intake by d/c, and
was cleared by PT and OT for d/c to home with follow up.
Radiology reports:
Head CT showed:
1) Pneumocephalus from multiple facial bone fractures.
2) Subarachnoid versus subdural blood along anterior falx just
above crista
galli.
3) Likely left frontal contusion.
4) Multiple comminuted facial bone fractures. Please see the
dedicated CT
scan of the facial bones for more information.
Facial CT showed:
1. Comminuted fractures involving the outer and inner tables of
the frontal
sinuses with pneumocephalus.
2. Comminuted fractures involving the orbits and maxillary
sinuses
bilaterally. Comminuted fracture of the left zygoma.
3. Right mandibular fracture.
4. Significant subcutaneous emphysema involving the soft tissues
of the
scalp, the orbits and neck. Pansinus opacification.
MRI of spine showed:
Subtle increase in signal intensity adjacent to the spinous
processes of C4
through C6 may represent injury to the interspinous ligament.
CTA head:
IMPRESSION: 1) Slight decrease in prominence of subarachnoid
hemorrhage
anterior to the frontal lobes bilaterally, without evidence of
new mass effect
or new intracranial hemorrhage. Stable pneumocephalus associated
with
multiple comminuted skull fractures.
2) Stable appearance of extensive facial fractures.
3) No evidence of aneurysm or occlusion of the vessels of the
Circle of
[**Location (un) 431**] and its tributaries, or of the cervical portions of the
carotid and
vertebral arteries. Visualization of the small branches of the
external
carotid systems is limited, and if there is clinical interest
for evaluation
of these vessels, standard diagnostic angiography is
recommended. This
recommendation was conveyed to Dr. [**Last Name (STitle) **] at 5:00 p.m. on [**2158-6-25**].
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: One (1) drop Ophthalmic
QID (4 times a day): Administer to left eye.
Disp:*QS for 2wks drop* Refills:*2*
2. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day): Apply to Left eye.
Disp:*QS for 2wks * Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*400 ML(s)* Refills:*0*
4. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Boost Liquid Sig: One (1) PO three times a day.
Disp:*30 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple Facial Fractures, with CSF leak now resolved
Left eye injury: corneal abrasion, [**Doctor First Name 2281**] avulsion, retinal
hemorrhage
small anterior SAH, left frontal contusion
cervical ligamentous injury
Discharge Condition:
stable
Discharge Instructions:
Take medications as perscribed, be sure to follow up with
plastic surgery, opthomology, orthopaedics, and trauma surgery
clinic. Wear cervical collar at all times. Follow
recommendations of Occupational therapy.
Followup Instructions:
Plastic surgery will call you to arange arch bar removal, you
also have an appointment on [**2158-7-28**] at 1pm at the [**Hospital Ward Name 23**]
Building [**Location (un) 470**] surgical specialties department, cosmetic
clinic call [**Telephone/Fax (1) 274**] with questions
Opthomology: you have an appointment for evaluation on [**2158-7-25**] at
11:15am at the [**Hospital Ward Name 23**] Building [**Location (un) 442**], with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
call [**Telephone/Fax (1) 253**] with questions
Neurosurgery: call [**Telephone/Fax (1) 1272**] for appointment with Dr.
[**Last Name (STitle) 62075**] in 1-2weeks
Trauma Surgery: call [**Telephone/Fax (1) 6439**] to schedule an appointment in
2 weeks
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1809
} | Medical Text: Admission Date: [**2180-4-30**] [**Month/Day/Year **] Date: [**2180-5-11**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
failure to thrive
Major Surgical or Invasive Procedure:
[**5-1**] Exploratory lap; repair of anastomosis; repair of bladder;
loop ileostomy
History of Present Illness:
83 yo female with history of colon CA who underwent a resection
of a large right perforated right cecal tumor which infiltrated
the bladder, 12 days ago. She represented to the ED with signs
of sepsis and presumed leak on CT
scan. She was taken to the operating room for treatment of this.
Past Medical History:
1)Hypertension
2)Distant ovarian carcinoma-s/p THA BSO and ? brachy therapy
3)s/p cholecystectomy
4)s/p ORIF Le Fort I and II fracture [**1-3**] after fall
5)s/p ORIF L 4th MCP
6)RLE DVT on Coumadin
Social History:
Widowed for 30 yrs from husband who dies of bladder CA. Lives
with her daughters with good functional status. No smoking or
EtoH. Immigrated from [**Country 6171**] in [**2121**].
Family History:
Father and brother with HTN, no hx of breast, ovarian or colon
CA.
Pertinent Results:
Blood Urine CSF Other Fluid Microbiology
Recent
Last Day Last Week Last 30 Days All Results Hide Comments
From Date To Date
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2180-5-11**] 10:00AM 8.3 3.46* 9.7* 30.3* 88 28.0 32.0 16.7*
355
[**2180-5-11**] 05:45AM 6.4 3.02* 8.4* 26.5* 88 27.9 31.7 16.9*
302
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2180-4-30**] 11:52PM 95.5* 0 1.9* 2.5 0.1 0
[**2180-4-30**] 05:45PM 83* 8* 3* 6 0 0 0 0 0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Burr
[**2180-4-30**] 11:52PM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
[**2180-4-30**] 05:45PM NORMAL NORMAL 1+ NORMAL NORMAL 1+ 1+
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2180-5-11**] 10:00AM 355
[**2180-5-11**] 05:45AM 302
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2180-5-11**] 10:00AM 116* 10 0.5 143 3.9 115* 21* 11
[**2180-5-11**] 05:45AM 88 10 0.5 141 3.5 114* 21* 10
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2180-5-8**] 05:20AM Using this1
[**Numeric Identifier **] PICC W/O PORT [**2180-5-8**] 12:43 PM
Reason: please place PICC
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman with need for long term antibiotics
REASON FOR THIS EXAMINATION:
please place PICC
PICC LINE PLACEMENT
INDICATION: 83-year-old woman need for long term antibiotics.
The procedure was explained to the patient. A timeout was
performed.
RADIOLOGIST: Drs. [**First Name (STitle) 3175**] and [**Doctor Last Name **] Dr. [**First Name (STitle) 3175**] the attending
radiologist was present and supervising throughout.
TECHNIQUE: Using sterile technique and local anesthesia, the
left brachial vein was punctured under direct ultrasound
guidance using a micropuncture set. Hard copies of ultrasound
images were obtained before and immediately after establishing
intravenous access. A peel-away sheath was then placed over a
guidewire and a single lumen PICC line measuring 36 cm in length
was then placed through the peel-away sheath with its tip
positioned in the SVC under fluoroscopic guidance. Position of
the catheter was confirmed by a fluoroscopic spot film of the
chest.
The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile
dressing applied.
The patient tolerated the procedure well. There were no
immediate complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
single lumen PICC line placement via the left brachial venous
approach. Final internal length is 36 cm, with the tip
positioned in SVC. The line is ready to use.
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2180-5-11**] 10:00AM 6.6* 2.0* 2.2
[**2180-5-11**] 05:45AM 6.3* 2.1* 2.1
HEMATOLOGIC calTIBC Ferritn TRF
[**2180-5-8**] 05:20AM 108* 255* 83*
PITUITARY TSH
[**2180-5-2**] 01:25PM 2.5
LAB USE ONLY EDTA Ho HoldBLu RedHold
[**2180-5-2**] 01:25PM HOLD1
1 HOLD
DISCARD GREATER THAN 8 HOURS OLD
[**2180-5-2**] 01:25PM HOLD1
1 HOLD
DISCARD GREATER THAN 24 HRS OLD
Blood Gas
BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2 Intubat Comment
[**2180-5-4**] 02:37AM ART 100 38 7.44 27 1
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
[**2180-5-2**] 10:05AM 70
HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT
[**2180-5-1**] 09:42AM 7.5* 23
[**2180-5-1**] 08:24AM 8.0* 24
CALCIUM freeCa
[**2180-5-1**] 11:43AM 1.16
[**2180-5-1**] 09:42AM 1.19
[**2180-5-1**] 08:24AM 1.05*
CYSTOGRAM ([**Numeric Identifier 34386**], [**Numeric Identifier 34387**])
Reason: please evaluate for proper storage of urine, leak.Please
rep
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with invasion of colon Ca into bladder, s/p
partial cystectomy
REASON FOR THIS EXAMINATION:
please evaluate for proper storage of urine, leak.Please replace
foley under guidance
CLINICAL HISTORY: 82-year-old female with history of colon
cancer with invasion into the bladder status post partial
cystectomy. Evaluate for leak.
COMPARISON: None.
TECHNIQUE/FINDINGS: Scout view demonstrates multiple surgical
suture and clips projecting within the pelvis. A JP drain is
seen within the right hemipelvis.
650 cc of Cysto-Conray contrast was administered via Foley
catheter into the bladder under fluoroscopic guidance which
demonstrates extravasation of contrast along the right superior
aspect of the bladder. Contrast was noted to be draining from
patient's drain.
IMPRESSION: Extravasation of contrast along the right superior
aspect of the bladder. Findings were discussed with Dr.
[**Last Name (STitle) 34388**] at the time of dictation.
CHEST (PORTABLE AP)
Reason: eval for pna, chf
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with recent surgery, here with hypotension and
decreased UOP
REASON FOR THIS EXAMINATION:
eval for pna, chf
STUDY: Portable AP chest x-ray.
INDICATION: 82-year-old female with a recent surgery presenting
with hypotension and decreased urine output. Assess for
pneumonia/CHF.
COMPARISONS: None.
FINDINGS: The heart is normal in size. The mediastinal and hilar
contour is unremarkable. The lungs are clear. There are no
pleural effusions. The soft tissues and osseous structures are
grossly unremarkable aside from degenerative change of the
thoracic and upper lumbar spine.
IMPRESSION: No evidence of acute cardiopulmonary disease.
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: PO contrast ONLY (not IV)
Field of view: 35
[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with abd pain, elevated WBC.
REASON FOR THIS EXAMINATION:
PO contrast ONLY (not IV)
CONTRAINDICATIONS for IV CONTRAST: creat
INDICATION: 82-year-old woman with abdominal pain and elevated
white count, and renal failure. Status post ileo-right colectomy
and resection of part of the posterior bladder, now on postop
day #10.
COMPARISON: [**2180-4-15**].
TECHNIQUE: Contagious axial images were obtained from the lung
bases to the pubic symphysis. Multiplanar reformatted imaged
were obtained.
CONTRAST: Oral contrast only was administered. No intravenous
contrast administered secondary to poor renal function.
CT ABDOMEN: There is small bilateral pleural effusion at the
lung bases, with adjacent atelectasis.
There is a large amount of ascites. Additionally, in the right
upper quadrant, there is large air fluid level, and air within
the ascites. This region is abutting the right lobe of the
liver, and is centered around the anastomosis between the
transverse colon and the distal ileum. Oral contrast passes
through loops of small and large bowel, and can be seen
extending to the descending colon. There is a tiny focus of
dense material abutting the liver (series 2, image 35), which
cannot definitely be identified within a loop of bowel, and
likely represents a tiny focus of extravasated contrast. The
ascites extends around the spleen, and the descending colon, and
into the deep pelvis.
The bowel is not dilated, there is no evidence of obstruction.
There is limited evaluation of solid organs without intravenous
contrast; however, the liver, spleen, adrenal glands, kidneys,
and pancreas are unremarkable. There is no evidence of
hydronephrosis. No pathologic or retroperitoneum lymphadenopathy
is seen.
Subcutaneous air and post-surgical change can be seen within the
anterior abdominal wall from recent surgery. There is also soft
tissue anasarca.
CT OF THE PELVIS: A foley catheter seen within the bladder.
There is free fluid within the deep pelvis. Tiny foci of air can
be seen within the subcutaneous tissues in the left groin, and
along the left pelvic sidewall, which may be post-surgical, or
related to air in the right upper quadrant.
BONE WINDOWS: There is diffuse osteopenia, which is stable.
There is sclerosis along the anterior and superior aspects of
the sacroiliac joints, consistent with changes from osteitis
condensans ilii, which are stable.
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential
in delineating the anatomy and pathology.
IMPRESSION:
1. There is a large amount of ascites, with loculated appearing
air- containing pocket within the right upper quadrant
laterally, abutting the liver, and centered around the
anastomosis between the ileum and transverse colon.
Additionally, there is a small amount of oral contrast outside
of bowel. These findings are concerning for focal anastomotic
leak.
2. There is also a large amount of ascites remote from this
area, and by report, the patient has had bladder surgery. A
second source of ascitic fluid from a urine leak from the
bladder surgery cannot be excluded.
3. Anasarca.
4. Small bilateral pleural effusions.
5. Surgical changes in the anterior abdominal wall from recent
surgery.
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] C.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on SAT [**2180-5-6**]
7:26 PM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 34389**]
Service: Date: [**2180-5-1**]
Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(1) 34390**]
PREOPERATIVE DIAGNOSIS: Perforated viscus.
POSTOPERATIVE DIAGNOSES:
1. Perforated viscus.
2. Breakdown of bladder repair.
OPERATION:
1. Repair of perforated colon anastomosis.
2. Repair of bladder injury.
3. Loop ileostomy.
RESIDENT SURGEON: [**First Name8 (NamePattern2) **] [**Doctor Last Name **], INT
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3446**], RES
ANESTHESIA: General endotracheal.
HISTORY/INDICATIONS: The patient is an 82-year-old female
who underwent a resection of a large right perforated right
cecal tumor which infiltrated the bladder, 12 days ago. She
represented with signs of sepsis and presumed leak on CT
scan. She was taken to the operating room for treatment of
this.
PREPARATION: After the induction of adequate general
endotracheal anesthesia, the patient was identified and a
timeout was performed. The abdomen was prepped with Betadine
and draped sterilely in the usual fashion.
INCISION: The old incision was opened down to the fascia and
it was extended somewhat medially. The fascia was opened by
cutting the previous sutures.
FINDINGS: There was a lot of purulence and some gas in the
abdomen. There was a lot of free fluid, as well. The colonic
anastomosis had a 1 cm defect in the end. The reason why this
broke down was not immediately clear. The bladder had a 1 cm
defect in it, as well. We had instilled indigo [**Male First Name (un) **] and
this was leaking out of the bladder. Indigo [**Male First Name (un) **] into the
Foley catheter and this was leaking into the bladder.
PROCEDURE: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 34391**] retractor was placed. The anatomy was
clearly identified. The first priority was to deal with the
colonic anastomosis. The area where the perforation was, was
cleaned off and this was repaired with interrupted [**Last Name (un) 34392**]
sutures of 3-0 Nurolon with good supply. The omentum was
freed up and tied down over this anastomosis. Attention was
then directed to the bladder which had about 1/2 cm to 1 cm
defect. This was closed with interrupted 2-0 Vicryl full
thickness sutures and then reinforced with 2-0 Vicryl Lembert
sutures. The areas of contamination were widely irrigated and
the decision was to make a diverting ileostomy. This was
freed up such that there would be no excessive tension. This
was brought out through an opening in the abdominal wall on
the left side which had been previously identified. The loop
of the ileum was placed so that the proximal end was
superior. The ileum was attached to the fascia with 3-0
Vicryl sutures. This was then covered with a moist lap and
the abdomen was closed with #2 retention sutures to the
fascia but not through the skin and then the abdomen was
closed with a running #1 Prolene. The wound was packed with
Kerlix and covered. The ileostomy was opened in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 34393**]
fashion with the electrocautery, everted and sutured in place
with interrupted 3-0
Vicryl such that the distal side was flat and the proximal
side was everted. Ileostomy bag was placed over this and
dressings were placed on the wounds and the patient was
awakened, taken back to the intensive care unit intubated in
guarded condition.
ESTIMATED BLOOD LOSS: 200 cc.
COMPLICATIONS: Injury to the bladder from the sepsis and
right down to the ileocolic anastomosis.
SPECIMENS: Microbiology of the peritoneum.
SPONGE INSTRUMENT AND NEEDLE COUNT: Correct.
Brief Hospital Course:
Mrs. [**Last Name (STitle) 34394**] was admitted to the Surgical Intensive Care Unit
under the care of Dr. [**Last Name (STitle) **]. Following an initial CT scan of the
abdomen which demonstrated ascites and a likely leak at the site
of her ileo-colonic anastomosis, she was volume resuscitated and
antibiotic therapy was initiated. She was taken to the
operating room for exploratory laparotomy, and underwent repair
of an anastomosis leak at the site of her ileo-colonic
anastomosis, repair of a bladder perforation, and creation of a
diverting loop ileostomy (see Operative report for details).
She returned to the ICU post-operatively, was weaned from the
ventilator over the next 24 hours, and extubated successfully.
She initially required pressors for blood pressure support, but
these were weaned successfully as well. Her ileostomy began to
function early in her post-operative course, and her diet was
slowly advanced. Nutrition was consulted early on and she was
started on supplements. She was started on Meropenem and
Caspofungin per ID recommendations for gram negative & positive
organisms identified from abdominal wound culture. MRSA & VRE
were negative. The antibiotics will need to continue until [**5-18**].
She was transferred to the regular nursing unit, where she did
quite well. A wound VAC was placed on her abdominal wound. Her
ostomy output remained high and she was started on Loperamide,
her output remained high. The dose was subsequently increased to
10mg qid of Loperamide; this can be adjusted once her output
decreases. She is also on Metamucil wafers tid. Because of her
high output she has been given IV fluids for replacement; her
labs have been followed closely and her electrolytes have been
stable (see pertinent results). Wound ostomy nurse has followed
her closely throughout her hospital.
A wound VAC remains in place, as well as a JP drain. She will
need to follow up with Dr. [**Last Name (STitle) **] in 1 week in Surgery Clinic.
She will also require follow up with Dr. [**Last Name (STitle) **], Urology, in [**2-5**]
weeks because of her bladder perforation; the 22 Fr Foley will
remain in place until that time.
Physical and Occupational therapy were consulted and have
recommended rehab stay; her family would like to take her home
following her rehab stay.
[**Date Range **] Medications:
1. Miconazole Nitrate 2 % Powder [**Date Range **]: One (1) Appl Topical twice
a day: Apply to affected areas.
2. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: One (1) Tablet PO BID
(2 times a day): hold fro SBP <110; HR <60.
3. Amlodipine 5 mg Tablet [**Date Range **]: 0.5 Tablet PO DAILY (Daily): hold
for SBP<110.
4. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule [**Date Range **]: One
(1) Cap PO DAILY (Daily).
5. Cyanocobalamin 250 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
6. Quinidine Gluconate 324 mg Tablet Sustained Release [**Date Range **]: One
(1) Tablet Sustained Release PO DAILY (Daily).
7. Enoxaparin 60 mg/0.6 mL Syringe [**Date Range **]: 0.5 ML Subcutaneous Q12H
(every 12 hours).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Psyllium 1.7 g Wafer [**Last Name (STitle) **]: One (1) Wafer PO TID (3 times a
day).
10. Loperamide 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO four times a
day.
11. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: Five Hundred (500) mg
Intravenous every eight (8) hours for 7 days.
12. Caspofungin 50 mg Recon Soln [**Last Name (STitle) **]: Fifty (50) mg Intravenous
Q24H @ 1800 for 7 days.
[**Last Name (STitle) **] Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
[**Hospital6 **] Diagnosis:
Colon Cancer s/p colectomy
Anastomosis leak
Bladder perforation
[**Hospital6 **] Condition:
Stable
[**Hospital6 **] Instructions:
Your antibiotics will continue until [**5-18**].
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 1 week in Surgery Clinic, call
[**Telephone/Fax (1) 6439**] for an appointment.
Follow up with Dr. [**Last Name (STitle) **], Urology in [**2-5**] weeks, call [**Telephone/Fax (1) 164**]
for an appointment.
Follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab
(Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 133**]).
Completed by:[**2180-5-16**]
ICD9 Codes: 0389, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1810
} | Medical Text: Admission Date: [**2163-10-7**] Discharge Date: [**2163-10-21**]
Date of Birth: [**2097-1-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Vomiting
Diarrhea
Colon Cancer
Major Surgical or Invasive Procedure:
Exploratory lap, lysis of adhesions (3 hours),
resection of fistula, and closure of the enterotomy, low
anterior resection and colorectostomy, coloproctostomy,
takedown of colostomy, transverse colostomy and frozen
section biopsy
History of Present Illness:
66F with locally advanced rectosigmoid adenocarcinoma s/p
diverty colostomy and feeding jejunostomy [**5-21**]; s/p CT guided
abscess drainage [**2163-8-22**]. She just finished a course of
cemoradiation on [**2163-8-2**] (Capecitabine). Of note from her
previous hspitalization, the abscess drain was prematurely
removed and she was discharged home on Augmentin x 7 days. She
was schedule dto be admitted for resection of her rectal cancer,
but presents two days early with mild abdominal pain around
ostomy and peri-ostomy hernia with vomiting and increased ostomy
output x 1 day.
Past Medical History:
Obstructing Rectosigmoid Mass
Emphysema
PSH:
Colostomy/[**Doctor Last Name **]/Jejunostomy Tube [**2163-5-19**]
Open Cholecystectomy
Social History:
+ETOH (~2/day)
+tobacco (50+ pk/yr history)
No recreational drugs
Family History:
Mother died in late 70s of CVA
Father died in mid 60s of "hiatal hernia" (?strangulated hernia)
Physical Exam:
Admission Physical Exam: [**2163-10-7**]
98.2 114 88/60 20 99%RA
Neuro: AxOx3, NAD
HEENT: PERRL, EOMI
CVS: RRR, no m/c/r
Resp: CTAB, no w/r/r
Abd: soft/distended/tenderness to percussion around ostomy site
and peri-ostomy hernia/NABS
Ext: no c/c/e
Pertinent Results:
Admission Labs:
[**2163-10-7**] 02:00PM BLOOD WBC-21.7*# RBC-4.47 Hgb-12.9# Hct-40.7
MCV-91 MCH-28.8 MCHC-31.6 RDW-17.6* Plt Ct-851*
[**2163-10-7**] 02:00PM BLOOD Neuts-85* Bands-8* Lymphs-3* Monos-2
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2163-10-7**] 02:00PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Target-OCCASIONAL Schisto-1+ Burr-2+
[**2163-10-7**] 02:00PM BLOOD Plt Ct-851*
[**2163-10-7**] 10:00PM BLOOD PT-11.8 PTT-24.3 INR(PT)-1.0
[**2163-10-7**] 02:00PM BLOOD Glucose-131* UreaN-30* Creat-0.8 Na-136
K-4.7 Cl-98 HCO3-21* AnGap-22*
[**2163-10-7**] 02:00PM BLOOD ALT-10 AST-27 AlkPhos-79 Amylase-29
TotBili-0.4
[**2163-10-8**] 06:40AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.3*
[**2163-10-7**] 02:00PM BLOOD Albumin-4.2 Calcium-10.2 Mg-1.9
[**2163-10-7**] 05:40PM BLOOD Lactate-1.8
Discharge Labs:
[**2163-10-20**] 05:07AM BLOOD WBC-15.0* RBC-3.36* Hgb-10.1* Hct-29.8*
MCV-89 MCH-30.1 MCHC-33.9 RDW-16.8* Plt Ct-707*
[**2163-10-20**] 05:07AM BLOOD Glucose-109* UreaN-13 Creat-0.4 Na-137
K-4.7 Cl-103 HCO3-27 AnGap-12
[**2163-10-20**] 05:07AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0
----------NUTRITION LABS----------
Date-----Alb-----Fe-----TIBC-----[**Last Name (un) **]-----TRF
*[**10-7**]-----4.4
*[**10-10**]-----2.8-----26-----[**Telephone/Fax (3) 66698**]
*[**10-17**]-----2.9-----38-----172-----280-----132
CT OF THE ABDOMEN WITH IV CONTRAST:
There are new diffuse, but patchy, tree- in-[**Male First Name (un) 239**] and ground-glass
opacities in the right middle, right lower, and left lower lobes
with sparing of the lingula, most consistent with pneumonia.
The liver appears normal. The patient is status post
cholecystectomy. There are splenic arterial calcifications. The
pancreas, adrenal glands and kidneys are within normal limits.
The stomach appears normal. There is a jejunostomy tube
overlying the left upper quadrant in suitable position. Enteric
contrast has been administered via that tube for this study.
There is marked dilatation of the proximal small bowel, to a
greater extent than on the prior study. A segment of jejunum in
the left upper quadrant measures 4 cm in diameter. More distally
there are several segments of irregular narrowing, accompanied
by wall thickening of the small bowel. These abnormal segments
are mostly within or immediately above the pelvis, particularly
near the residual rectum.
More distally the terminal ileum is normal in caliber. Contrast
passes freely into the cecum. The proximal residual colon is
only mildly distended, and more distally, is almost collapsed
near the colostomy site. Although contrast passes freely
throughout, the appearance of proximal small bowel dilatation,
worse than before, suggests either a low- grade obstruction,
perhaps related to segments of abnormally thickened distal small
bowel, or an ileus.
There are multiple enlarged retroperitoneal and mesenteric lymph
nodes, which are unchanged. As none of these is over 12 cm in
shortest dimension, however, these may be reactive, but
metastatic disease is also possible. There are vascular
calcifications in the aorta with mild distal fusiform dilatation
up to 2.9 cm at the aortic bifurcation. There is no free air.
CT OF THE PELVIS WITH IV CONTRAST: There is a persistent
collection of fluid in the presacral space of intermediate
density with a smooth enhancing wall. It is only somewhat
smaller than before and measures 1.9 x 2.5 cm in axial
dimensions. The collection contains air, which suggests a
fistulous connection to adjacent bowel or may be due to abscess
formation.
The rectal stump also contains air and fluid. More proximally
the residual rectum is markedly thickened throughout, suggesting
persistent tumor. There is also enteric contrast which has
passed into the residual rectum, which outlines the convex
contour of an apparent endoluminal mass more distally. There is
no pelvic or inguinal lymphadenopathy or free fluid.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. Increased dilatation of the proximal small bowel, with areas
of narrowing and wall thickening in the more distal small bowel.
This appearance may relate to radiation change or involvement
with tumor. Proximal dilatation may be due to an ileus or
low-grade obstruction, although contrast passes freely
throughout.
2. Residual rectum with an overall similar appearance, including
marked thickening and apparently an endoluminal mass. The
residual rectum contains contrast proximally, implying a
fistulous connection to the small bowel. There is also air and
fluid more distally.
3. Persistent presacral fluid collection with enhancing rim. The
presence of air within the collection also suggests fistulous
connection to adjacent bowel, or may be due to abscess
formation.
4. Mild lymphadenopathy, which could be either metastatic or
reactive.
Operative Note:
PREOPERATIVE DIAGNOSIS: Carcinoma of the rectosigmoid with a
question of an enterorectal fistula.
POSTOPERATIVE DIAGNOSIS: Enterorectal fistula, question
carcinoma of the rectosigmoid.
INDICATIONS: The patient presented with massive weight loss
and total obstruction of her rectum which may have been due
to a pelvic abscess which was not seen early on. We could not
get a histologic diagnosis and at the first operation I did
not think that I could extirpate the rectum very well, and so
we did an end sigmoid colostomy and treated her with
radiation and chemotherapy. We then brought her back. She had
2 recurrent pelvic abscess which we believed probably was the
result of an enterorectal fistula. At the time of surgery, we
were able to take down the enterorectal fistula and close the
enterotomy and then do a low anterior resection, takedown the
colostomy and resect it and then do an anastomosis and then
because of the situation with the previous radiation then do
a protected colostomy. The following procedure was carried
out.
OPERATIONS: Exploratory lap, lysis of adhesions (3 hours),
resection of fistula, and closure of the enterotomy, low
anterior resection and colorectostomy, coloproctostomy,
takedown of colostomy, transverse colostomy and frozen
section biopsy.
ASSISTANT: Dr. [**Last Name (STitle) 66699**]
[**Name (STitle) **] [**Name8 (MD) **], MD (RES)
Dr [**Last Name (STitle) **].
PROCEDURE: Under satisfactory general anesthesia, the
patient was placed supine and prepped and draped in the usual
manner. We excised the old incision and actually carried this
higher on the abdominal wall, entering the abdomen cleanly.
The liver had no disease. There were a number of adhesions.
The principal adhesion, however, was to a loop of bowel which
went down on the right side to the rectum and clearly was an
enterorectal fistula. This was taken down and the opening in
the small bowel was closed in 2 layers with 4-0 silk
transversely and interrupted 4-0 Prolene. Attention was then
turned to lysing all of the adhesions in the small bowel
until we actually had a totally free small bowel and this was
carried out without difficulty.
We then started dissecting the rectum which we did by
grasping the rectum with 3-0 silk sutures, getting behind it,
freeing it up from the left ureter which was clearly seen and
was intact and there was no hematuria and then gradually
working our way down and doing a total mesenteric excision,
getting below the entrance of the fistula into the rectum and
then finally well below the sacral curve. Irrigation of the
rectum revealed that it was entirely open at this point up
into the point of the obstruction which the area of radiation
at the bottom of which was the enterorectal fistula, the most
distal. After we saw that we could get a reasonable length of
rectum up to do the anastomosis, we took down the colostomy
which had a pericolostomy hernia and then transected it with
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] stapler and then anastomosed it with 2 layers of 4-0
silk, initially by using the rectum as a handle, but then
dealing with the front and taking it off and then getting a
very nice 2-layer 4-0 silk interrupted anastomosis.
We then irrigated the pelvis copiously. We were happy with
the anastomosis. The rectal tube had been removed and we then
changed gowns and gloves and closed the site of the colostomy
which had a pericolostomy hernia and then prepared the
transverse colostomy by getting a quarter inch Penrose drain
under the transverse colon. We then changed gowns and gloves
to closure kit and closed the peritoneum, put the Penrose
drain which had a tie around it in the peritoneum, irrigated
the peritoneum, checked for the nasogastric tube, checked for
bleeding which there was very little and then closed the
peritoneum with #1 chromic catgut. The paramedian incision
was then closed as a lateral paramedian incision taking the
freed up muscle and placing it in the midline and then #1
Vicryl on the fascia. After the fascia was closed, we then
made a transverse incision over the right rectus, split the
rectus and then brought up a loop of colon through the
previous identified colon through and put a bridge
underneath. This was subsequently matured at the end of the
procedure by dividing the anterior wall. The closure was
completed. We had previously closed the area of the colostomy
with #1 Vicryl. The subcutaneous tissue of the incision was
closed with 3-0 Vicryl and with 4-0 Monocryl and the same
with the area of the previous transverse colostomy.
Estimated blood loss was 600 cc. The patient tolerated the
procedure well. She was slightly acidotic so she was left on
the ventilator. Two sponge counts, needle counts and
instrument counts were reported as correct by the nursing in
charge. The patient tolerated the procedure well and was
returned to the PACU and will likely go to the ICU.
Brief Hospital Course:
[**Known firstname 1743**] [**Known lastname 54371**] presented to the emergency department at [**Hospital1 18**]
on [**2163-10-7**]. Her WBC was found to be elevated at 21.7. An
abdominal/pelvic CT scan showed increased dilatation of the
proximal small bowel, with areas of narrowing and wall
thickening in the more distal small bowel; residual rectum with
intraluminal mass; implied fistulous connection from residual
rectum to the small bowel; persistent presacral fluid collection
with enhancing rim; and mild lymphadenopathy (see pertinent
results). A chest xray was obtained which was negative for acute
process or effusion(see pertinent results).
She was admitted to the surgery service under the care of Dr.
[**Last Name (STitle) 957**] for questionable obstructive process and presacral fluid
collection. She was placed NPO; tube feeds were held; and a
foley catheter was inserted. Vancomycin/Levofloxacin/Flagyl were
started for empiric coverage. At HD 2 a PICC line was placed;
TPN was started. Her j-tube was placed to gravity. She was
taken to interventional radiology for CT-guided aspiration of
the presacral fluid collection which revealed 30-40ml of
purulent, then serosanguinous drainage. A pigtail catheter was
placed. A sample of the drainage was sent for culture.
At HD 5 her abdomen remained distended with question of
continued obstructive process. She denied pain or vomiting. She
remained NPO and continued nutrition via TPN. At HD 6
Hibiclens washes and Neomycin/Erythromycin were provided. On HD
7 she was taken to the operating room where she underwent an
exploratory lap, lysis of adhesions, resection of fistula, and
closure of the enterotomy, low anterior resection and
colorectostomy, coloproctostomy,takedown of colostomy,
transverse colostomy and frozen section biopsy. She tolerated
the procedure well. Estimated blood loss was 600ml and she
received 2 units of PRBCs and 500ml albumin. She remained
intubated after surgery and was taken to the ICU for further
care.
By POD 1 the presacral fluid culture grew staph aureus
susceptible to Vancomycin and her Levo/Flagyl were discontinued.
Blood cultures from the emergency department were negative.
She was doing well. Urine output and vital signs were stable.
She was extubated without complication.
At POD 3 narcotic pain control was weaned and she was receiving
tylenol with good control. Her colostomy was functioning well
with good output. 1/2 strength tube feeds were started and TPN
was continued. Her WBC count was elevated at 20.2 and a repeat
abscess culture was sent from the pigtail. Vancomycin was
continued. Levofloxacin/Flagyl were restarted. Her diet was
advanced to sips, and she was deemed stable for transfer to the
floor.
On POD 4, she was transferred to a regular floor. She continued
to be afebrile. Her tube feeds were advanced to 30cc/hr and her
TPN was continued. She ctoninued to has gas and stool from her
ostomy an her pigtail continued to drain 25 cc of serosanguinous
fluid. She was continued on her vancomycin.
On POD 5, she continued to be afebrile and stable. Her tube
feeds were advanced to 40 cc/hr, which she tolerated well. She
was advanced to sips and her TPN was continued. Her antibiotics
were continued and her pigtail continued to have minimal output.
On POD 6, she continued to do well and be afebrile. She was
advanced to a soft diet and her TF were advanced to 50 cc/hr
cycled overnight. Her pigtail continued to have minimal
output of 10cc and her TPN was discontinued. Her metoprolol was
increased for an elevated heart rate.
On POD 7, she was deemed stable for discharge home. She
remained afebrile and her tube feeds advanced to 70 cc/hr cycled
overnight with non-generic imodium.
On POD 8, she continued to do well, tolerating a soft diet. Her
pigtail was discontinued. She was discharged home with nursing
services for her tube feeds and IV antibiotics.
Medications on Admission:
Megace 40mg QID
Metoprolol 25mg 1.5 [**Hospital1 **]
ASA 81mg daily
Discharge Medications:
1. Ampicillin Sodium 1 g Piggyback Sig: One (1) Intravenous
every six (6) hours for 7 days.
Disp:*4 4* Refills:*24*
2. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous every eight (8) hours for 7 days.
Disp:*3 3* Refills:*18*
3. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
5. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) ml PO Q
8H (Every 8 Hours) for 10 days: Please flush down J-tube.
Disp:*QS QS* Refills:*0*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Imodium A-D 1 mg/5 mL Liquid Sig: Two (2) mg PO twice a day:
Give 10ml liquid down J-tube twice daily.
Disp:*qs qs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapies
Discharge Diagnosis:
Enterorectal fistula, question carcinoma of the rectosigmoid.
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101.5,
nausea/vomiting, inability to eat, wound
redness/warmth/swelling/foul smelling drainage, abdominal pain
not controlled by pain medications or any other concerns.
Please take medications as prescribed.
Please follow-up as directed.
No heavy lifting (anything that makes you strain) for 4-6 weeks
or until directed otherwise. Please leave water proof dressing
on until follow-up with Dr. [**Last Name (STitle) 957**].
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 957**] in [**1-17**] weeks. Please call his
office at ([**Telephone/Fax (1) 376**] to schedule an appointment.
Completed by:[**2163-10-24**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1811
} | Medical Text: Admission Date: [**2175-10-12**] Discharge Date: [**2175-10-16**]
Date of Birth: [**2128-2-22**] Sex: M
Service: SURGERY
Allergies:
Vitamin K
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Leakage of clear fluid from umbilicus.
Major Surgical or Invasive Procedure:
No repair to hernia
Resuscitation with intubation [**2175-10-13**]
History of Present Illness:
47M with h/o ESRD on HD, ESLD [**2-17**] hepatitis C, alcoholic
cirrhosis, encephalopathy who presents with leakage of clear
fluid from his umbilicus. This was first noticed last evening
([**10-11**]). The leakage soaked his clothes and
bed by his report. He spoke with his PCP, [**Name10 (NameIs) 1023**] recommended he go
to the ED to be evaluated, which he did not do until today. He
is seen now in dialysis. The leakage has decreased throughout
today. He notes that this could be secondary to his belt
frequently rubbing on his large umbilical hernia. He denies
F/C/N/V/C/D. He reports feeling generally well recently, with
the exception of
this new complaint.
Past Medical History:
# Cirrhosis
- hep C + EtOH abuse
- c/b esophageal varices s/p banding in [**12-26**]
- EGD [**2175-4-28**]: 4 cords of grade II varices, nonbleeding GE jctn
ulcer
- has not been treated for hepatitis C
- has nodular lesions on US -> no MRI to eval for HCC, AFP 4.3
- h/o SBP in [**9-21**], ? SBP during last hospitalization (empiric)
# ESRD on HD T/Th/Sat
# Anemia of chronic disease
# Left Lower extremity wound
# h/o major depression
# schizotypal personality disorder
Social History:
Lives with wife. Denies tobacco, ETOH, or drug use currently.
Heavy ETOH use in the past, prior IV drug use in early 80s (last
[**4-21**]).
Family History:
Maternal aunt with DM
Physical Exam:
T: 96.6 88 119/67 28
GEN: NAD. Awake and alert. Pleasant.
HEENT: Icteric sclera. MMM. OP clear.
NECK: Supple, JVP ~ 10 cm H2O.
CV: RRR. nl S1, S2. No MRG
LUNGS: Diminished BS at bases bilaterally. No rales or rhonchi.
ABD: + Accessory muscle use. Mild work of breathing. ABD: Softly
distended. Large umbilical hernia. Very small drops of serous
fluid on superior aspect of umbilical hernia. There is no
obvious
skin defect where the leak was coming form. Hernia easily
reeducible. Abdomen is nontender. Dullness to percussion on
dependent flanks. Hypoactive BS. Otherwise soft. No rigidity.
EXT: Warm. 1+ LE edema.
SKIN: Mild jaundice. No spider angiomas. R chest ecchymosis.
NEURO: Oriented x3.
Pertinent Results:
On Admission: [**2175-10-12**]
WBC-11.3* RBC-2.97* Hgb-10.6* Hct-33.7* MCV-114* MCH-35.6*
MCHC-31.4 RDW-19.3* Plt Ct-100*
PT-19.2* PTT-41.9* INR(PT)-1.8*
Glucose-90 UreaN-56* Creat-7.6* Na-134 K-5.2* Cl-99 HCO3-27
AnGap-13
ALT-28 AST-60* LD(LDH)-418* AlkPhos-157* Amylase-92 TotBili-4.0*
Lipase-95* Albumin-2.7*
Calcium-8.3* Phos-2.9 Mg-2.5
Ammonia-65*
Brief Hospital Course:
Initial plan for patient was to go to OR for repair of the
umbilical hernia. He has a new onset of ascites and there is
concern for erosion of hernia and/or infection. He was admitted
following hemodialysis.
On the morning of the intended surgery, his INR was 1.8 and PTT
42. Plan was to give Vitamin K pre-op and have FFP on call to
OR. During the infusion of the Vitamin K the patient suffered an
apparent anaphylactic reaction to the IV Vitamin K and he
required resuscitation to include intubation.
He was transferred to the ICU where he was stablized, and
ultimately extubated.
He was transferred back to the surgical floor. However it was
felt that the risk of the operative procedure would outweight
the benefit of fixing the hernia, so it was determined to send
the patient home without the hernia repair.
He is to wear an abdominal binder at all times, one was provided
to the patient prior to discharge.
He will continue on his usual home medications and be followed
by the liver team as he has been prior to this admission. He
will also continue his hemodialysis per outpatient schedule.
Medications on Admission:
Rifaximin 400 mg PO TID, Nadolol 20 mg DAILY, Lactulose 45) ML
PO QID, Thiamine 100 mg DAILY, Folic Acid 1 mg DAILY, Protonix
40 mg once a day, Sevelamer 1600 mg TID
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO QID (4
times a day).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Umbilical hernia with fluid leakage: stable
Discharge Condition:
Fair
Discharge Instructions:
Please call Dr [**Last Name (STitle) 56228**] office at [**Telephone/Fax (1) 2422**] if you experience
increased abdominal pain, fevers > 101, nausea, vomiting, or
other concerning symptoms.
Continue medications as prescribed
Wear the abdominal binder at all times.
Please call Dr [**Last Name (STitle) 10285**] if you feel you need to be seen sooner
than your previously scheduled appointment
Continue Hemodialysis schedule per your outpatient clinic
schedule
PLease call [**Telephone/Fax (1) 673**] and ask for [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] to help with
discussion about dialysis access
Other dialysis clinics: fresenius, Dialysis Care Incorporated
Followup Instructions:
[**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2176-2-29**] 11:30
Completed by:[**2175-10-16**]
ICD9 Codes: 4275, 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1812
} | Medical Text: Admission Date: [**2113-3-3**] Discharge Date: [**2113-3-8**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Aortic valve stenosis and CAD
Major Surgical or Invasive Procedure:
Endoscopy
Colonoscopy
Capsule Study
History of Present Illness:
83F with aortic stenosis ([**Location (un) 109**] .8cm2) and CAD. Presented
initially with SOB, ST depression and anemia. Cath showed 30%
stenosis of
left main, clean LAD, 30% Lcx, and 60-70% prox RCA. Scheduled
for elective AVR/CABG on [**3-3**].
Past Medical History:
PAST MEDICAL HISTORY:
# Deaf, communicates well & reads lips well
# HTN
# H/O TIA
# COPD (emphysema) - on albuterol
# Hysterectomy
# Appendectomy
Social History:
Cardiac Risk Factors: Hypertension, tobacco
Family History:
NC
Physical Exam:
Tm 99.5, Tc 99.3, HR 94, BP 145/70, RR 18, O2sat 97RA
Genl: NAD
CV: RRR
Resp: rales at bases, unlabored resps
Abd: s/nt/nd, no pulsatile mass
Extr:
RLE fem/[**Doctor Last Name **]/DP/PT: 2+/1+/[**Hospital1 **]/[**Hospital1 **]
LLE fem/[**Doctor Last Name **]/DP/PT: 2+/1+/[**Hospital1 **]/[**Hospital1 **]
Pertinent Results:
[**2113-3-3**] 08:54AM HGB-5.0* calcHCT-15
[**2113-3-3**] 09:09AM WBC-16.7*# RBC-2.02*# HGB-4.7*# HCT-17.1*#
MCV-85 MCH-23.3* MCHC-27.6*# RDW-21.3*
[**2113-3-3**] 09:30AM PT-13.4 PTT-37.7* INR(PT)-1.1
[**2113-3-3**] 09:30AM calTIBC-289 VIT B12-363 HAPTOGLOB-102
FERRITIN-14 TRF-222
[**2113-3-3**] 09:30AM IRON-14*
[**2113-3-3**] 10:48AM WBC-16.0* RBC-2.91*# HGB-7.5*# HCT-24.8*#
MCV-85 MCH-25.6* MCHC-30.1* RDW-18.4*
[**2113-3-3**] 08:57PM BLOOD Hct-30.6*
[**2113-3-4**] 10:25AM BLOOD Hct-31.5*
[**2113-3-5**] 11:54AM BLOOD Hct-32.5*
[**2113-3-7**] 05:15AM BLOOD WBC-10.6 RBC-3.85* Hgb-10.2* Hct-32.2*
MCV-84 MCH-26.5* MCHC-31.7 RDW-17.8* Plt Ct-452*
GI Report
Blood was seen in 3rd portion of duodenum. Careful inspection of
the area with endoscopy, side viewing ERCP scope, and
colonoscope ultimately revealed an irregular appearing ulcer in
the distal 2nd to 3rd portion of duodenum (post-ampullary).
There was no active bleeding when these areas were inspected,
even with provocation with the tip of the endoscope. Distal to
this was an erythematous area on top of a protruding/pulsatile
submucosal mass which took up almost [**12-8**] of the lumen. Cytology
sent.
Brief Hospital Course:
Ms. [**Known lastname **] is a 83 year old female who was recently found
to have severe cardiac disease requiring a CABG/AVR. She was
scheduled for elective repair on [**3-3**] but was found to have a
Hct of 17. Her
surgery was cancelled. GI was consulted for workup of a GI
bleed.
On endoscopy, she was noted to have a duodenal ulcer that was
not actively bleeding. Additionally there was noted to be a
duodenal pulsatile bulge which was confirmed to be a 3cm
abdominal aortic aneursym on subsequent
CT scan. Pt was extubated and after 48 hrs of stable hcts was
transferred to the floor. She underwent bowel prep and
colonoscopy on [**3-7**] which was normal. Capsule endoscopy was
performed on [**3-8**]. She was discharged home with GI followup, and
follow up with Dr. [**First Name (STitle) **] after her repeat endoscopy.
Medications on Admission:
simvastatin 10', metoprolol 37.5'', asa 81', ferrous sulf 325',
alb prn, prevacid 40'.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 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. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Caretenders
Discharge Diagnosis:
anemia
GI bleed
3cm AAA
CAD (LM 30%, LCx 30%, RCA 60%)
AS
htn
COPD
prior TIA
deafness
appy
hysterectomy
Discharge Condition:
Stable.
Discharge Instructions:
Do not take Aleve (Naproxen), Motrin/Advil (Ibuprofen) or
Aspirin.
Stop taking Iron on [**3-23**] (1 week prior to endoscopy).
Do not eat or drink anything after midnight before your
endoscopy.
If you have any nausea or vomiting please call GI at
[**Telephone/Fax (1) 65629**].
Followup Instructions:
Dr. [**First Name (STitle) 908**]/Dr. [**Last Name (STitle) **] for repeat endoscopy: Scheduled for
Thursday [**3-30**] at 10 am, arrive at 9 am to the [**Location (un) **] of the
[**Hospital Ward Name 1950**] Building on the [**Hospital Ward Name 516**].
Dr. [**First Name (STitle) **] 1-2 weeks
Dr. [**Last Name (STitle) 1391**] with repeat CT scan in 6 months for follow up of
AAA.
Dr. [**First Name (STitle) **] after repeat endoscopy, [**Telephone/Fax (1) 170**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2113-3-8**]
ICD9 Codes: 4241, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1813
} | Medical Text: Admission Date: [**2108-11-26**] Discharge Date: [**2108-12-4**]
Service: CARDIOTHORACIC
Allergies:
Ambien
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
aortic valve replacement (19mm [**Company 1543**] Mosaic Ultra Porcine)
tricuspid valve repair (28mm [**Last Name (un) 3843**]-[**Doctor Last Name **] MC-3 ring)
closure of patent foramen ovale
History of Present Illness:
The patient is an 84 year old white female with history as noted
who has developed dyspnea on exertion over the past several
months. Echo revealed critical aortic stenosis, moderate to
severe mitral regurgitation, and tricuspid regurgitation with
preserved ejection fraction. She was referred for cardiac
surgery.
Past Medical History:
coronary artery disease
aortic stenosis
cerebral vascular disease, s/p cerebral vascular accident with
residual left lower extremity weakness
sick sinus syndrome s/p permanent pacemaker
hypertension
hyperlipidemia
peripheral vascular disease
paroxysmal atrial fibrillation
insulin dependent diabetes mellitus
s/p stent to the left anterior descending coronary artery
angioplasty/stent to popliteal artery [**2104**]
s/p right carotid endarterectomy
Social History:
lives with daughter
tobacco: quit 20 yrs. ago, [**2-12**] PPD x 40 years
alcohol: denies
Family History:
non-contributory
Physical Exam:
VS: 97.5, 153/71, 74paced, 18, 98% 2L
Gen: NAD, WG, WN, WF
Chest: LCTAB
CV: RRR, no murmur or rub
Abd: soft, non-tender, non-distended, NABS
Ext: 1+edema lower extremities (ankles)
sternal incision: c/d/i, no erythema or drainage
Pertinent Results:
[**2108-12-3**] 06:10AM BLOOD WBC-9.9 RBC-3.59* Hgb-10.4* Hct-30.6*
MCV-85 MCH-28.9 MCHC-33.9 RDW-15.8* Plt Ct-217
[**2108-12-4**] 05:56AM BLOOD PT-14.7* PTT-26.5 INR(PT)-1.3*
[**2108-12-3**] 06:10AM BLOOD Glucose-84 UreaN-22* Creat-0.7 Na-142
K-3.2* Cl-101 HCO3-33* AnGap-11
[**2108-12-3**] 06:10AM BLOOD Mg-2.0
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 79740**], [**Known firstname 2671**] [**Hospital1 18**] [**Numeric Identifier 79741**]
(Complete) Done [**2108-11-28**] at 11:35:19 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2023-11-3**]
Age (years): 85 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for AVR, TVR, ?MVR
ICD-9 Codes: 440.0, 424.1, 394.2, 745.5, 424.2
Test Information
Date/Time: [**2108-11-28**] at 11:35 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: 1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.4 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 65% >= 55%
Aorta - Sinus Level: 2.7 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aortic Valve - Peak Gradient: *37 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 21 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 0.8 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - MVA (P [**1-11**] T): 1.9 cm2
Findings
LEFT ATRIUM: Moderate LA enlargement. Elongated LA. Mild
spontaneous echo contrast in the body of the LA. No
mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection
velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV. PFO
is present. Left-to-right shunt across the interatrial septum at
rest.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Moderate symmetric LVH. Normal LV
cavity size. Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic function.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Simple atheroma in ascending aorta. Normal
aortic arch diameter. Complex (>4mm) atheroma in the aortic
arch. Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Trace AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
No MVP. Severe mitral annular calcification. Severe thickening
of mitral valve chordae. Mild valvular MS (MVA 1.5-2.0cm2).
Moderate to severe (3+) MR. [**First Name (Titles) **] vena contracta is >=0.7cm
TRICUSPID VALVE: Tricuspid valve not well visualized. Moderate
to severe [3+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be A-V paced. Results were personally reviewed with the MD
caring for the patient.
Conclusions
PRE BYPASS The left atrium is moderately dilated. The left
atrium is elongated. Mild spontaneous echo contrast is seen in
the body of the left atrium. No mass/thrombus is seen in the
left atrium or left atrial appendage. The left atrial appendage
emptying velocity is > 20 cm/s. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. 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 is normal. with borderline normal free
wall function. There are simple atheroma in the ascending aorta.
There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. There
are three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. The non-coronary cusp is
immobilized. There is severe aortic valve stenosis (area
<0.8cm2). Trace aortic regurgitation is seen. Trace aortic
regurgitation is seen. The posterior mitral valve leaflet is
severely thickened, calcified, and immobilized. The anterior
mitral valve leaflet is moderately thickened. There is no mitral
valve prolapse. There is severe mitral annular calcification.
There is thickening of the mitral valve chordae. There is mild
valvular mitral stenosis (area 1.5-2.0cm2). Moderate to severe
(3+) mitral regurgitation is seen. The mitral regurgitation vena
contracta is >=0.7cm. Moderate to severe [3+] tricuspid
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results in the operating
room at the time of the study.
POST CPB Normal biventricular systolic function. There is a
bioprosthesis in the aortic position. It is well seated. The
leaflets are not seen. There is trace aortic regurgitation the
source of which can not be determined. The mean pressure
gradient across the aortic valve is about 20 mm Hg with a
maximum gradient of about 30 mm Hg. A tricuspid valve
annuloplasty ring is in situ but not well seen. There is trace
tricuspid regurgitation. There is some improvement in the mitral
regurgitation, now moderate. The thoracic aorta appears intact.
The PFO remains visible with left to right flow.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2108-11-28**] 15:25
?????? [**2103**] CareGroup IS. All rights reserved.
Brief Hospital Course:
The patient was admitted on [**2108-11-26**] for further management of
her valvular heart disease. The patient had been taking
coumadin for paroxysmal atrial fibrillation. Heparin drip was
started, and PT/INR were reversed with vitamin K. After a
discussion of the risks, benefits and alternatives to cardiac
surgery, the patient was brought to the operating room on
[**2108-11-28**], where she underwent AVR, TVrepair and closure of
PFO. Vancomycin was administered perioperatively given the
patient's preoperative length of stay of more than 24hours.
Please see operative report for full details. Overall the
patient tolerated the procedure well, and post-operatively was
tranferred to the CVICU in good condition for further monitoring
and recovery. Hemodynamics were supported with epinephrine,
packed red blood cells and neosynephrine. By POD 2 the patient
was extubated and breathing comfortably. The patient was given
Ambien for insomnia on the evening of POD 2. On POD 3, she was
very lethargic. Lethargy cleared, and the patient was
transferred to the floor on POD 3. Permanent pacemaker was
interrogated. Chest tubes and pacing wires were discontinued
without complication. She was gently diuresed toward her
preoperative weight. Amiodarone and coumadin were resumed for
preoperative paroxysmal atrial fibrillation. The patient made
good progress on the floor, and was discharged to rehab on POD
6.
Medications on Admission:
asa 81'
amiodarone 200'
diltiazem CD 240'
lopressor ER 100'
lisinopril 10'
lipitor 10'
glipizide 10'
novolin 70/30 [**10-24**] unit/day
MVI
protonix 40'
citalopram 20'
temazepam 15'
coumadin 2'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic qhs ().
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
14. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
15. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
16. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
18. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: MD to dose daily for goal INR [**2-12**] (paroxysmal A-fib).
19. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
20. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Tab
Sust.Rel. Particle/Crystal(s)
22. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
23. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): see attached sliding scale.
24. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
25. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
critical aortic stenosis
mitral regugitation
pulmonic regurgitation
pulmonary hypertension
s/p permanent pacemaker
sick sinus syndrome
h/o stroke
insulin dependent diabetes mellitus
hypertension
coronary artery disease
s/p coronary angioplasty
s/p right carotid endarterectomy
paroxysmal atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any drainage from, or redness of incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 77498**] in 2 weeks ([**Telephone/Fax (1) 8058**])
wound clinic in 2 weeks
Please call for appointments
Completed by:[**2108-12-4**]
ICD9 Codes: 4019, 2724, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1814
} | Medical Text: Admission Date: [**2129-2-19**] Discharge Date: [**2129-2-21**]
Date of Birth: [**2056-5-15**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Acute onset aphasia.
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
The pt is a 72 year-old woman with a history of hypertension,
leukemia, breast and colon cancer, who was last seen well at 6pm
on [**2-18**]. At ~6:30pm, one of her granddaughters went to her home
to help her make dinner, and noticed that "she wasn't speaking
right". Pt replied "Yes I know" to every question. Did not seem
to be understanding what people were saying. No known headache,
but Pt held her hand over her forehead. Concerned that this
could be related to her diabetes (?low blood sugar), she was
given juice. No improvement, EMS called at 7pm. Upon arrival to
[**Hospital3 **] [**Name (NI) **], Pt vomited and had a seizure (?focal onset
with head turn). Right sided weakness was noted after the
seizure. She was loaded with Dilantin and intubated. Head CT
revealed a large L parieto-occipital hemorrhage with surrounding
edema. Pt received Decadron 10mg IV x1 and was transferred to
[**Hospital1 18**] for neurosurgical evaluation.
Past Medical History:
-HTN - baseline SBP 140s, developed HTN at least 20 years ago
-Leukemia - diagnosed 4 1/2 years ago
-Colon CA - s/p resection
-Breast CA - s/p mastectomy
-NIDDM
-s/p cholecystectomy
Social History:
Lives alone, is independent with ADLs. Family members live
upstairs. No tobacco, EtOH, or illicit drug use.
Family History:
Noncontributory.
Physical Exam:
Afebrile HR 93 BP 129/38, 142/77 RR 16 O2sat 100%
GEN Lying in bed, intubated, sedated
HEENT NCAT, MMM, OP clear
Chest CTAB
CVS RRR, I/VI systolic murmur loudest @ LLSB
ABD soft, NT, ND, +BS
EXT no c/c/e, 2+ distal pulses, +venous stasis changes over LE
Neuro
MS: Sedated with propofol. Grimaces to sternal rub and moves L
arm, but does not localize. Not following commands. No
spontaneous eye opening.
CN: PERRL 3 to 2mm bilaterally, does not blink to threat,
+doll's eye reflex, +corneal reflexes bilaterally. +grimace to
nasal tickle bilaterally. +gag, cough.
Motor: normal bulk and tone; moves all extremities spontaneously
L>R.
Reflexes:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 2 | 2 | 2 | 2 | 2 | dn |
R | 2 | 2 | 2 | 2 | 2 | dn |
[**Last Name (un) **]: Withdraws to noxious stim in all four extremities.
Pertinent Results:
[**2129-2-18**] 09:00PM BLOOD WBC-2.0* RBC-2.64* Hgb-11.3* Hct-31.3*
MCV-119* MCH-42.6* MCHC-36.0* RDW-20.2* Plt Ct-314
[**2129-2-18**] 09:00PM BLOOD Neuts-74* Bands-0 Lymphs-21 Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2129-2-18**] 09:00PM BLOOD PT-14.0* PTT-21.1* INR(PT)-1.2*
[**2129-2-18**] 09:00PM BLOOD Glucose-259* UreaN-57* Creat-1.5* Na-138
K-3.6 Cl-99 HCO3-23 AnGap-20
[**2129-2-19**] 01:56AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.9
[**2129-2-19**] 01:56AM BLOOD Phenyto-17.2
[**2129-2-18**] 10:11PM BLOOD Type-ART Rates-10/ Tidal V-600 FiO2-100
pO2-466* pCO2-39 pH-7.43 calHCO3-27 Base XS-2 AADO2-222 REQ
O2-44 Intubat-INTUBATED
CT head ([**2129-2-18**]):
Significant worsening compared to the outside hospital CT; while
the left parietal hemorrhage appears roughly similar in size,
the prominent hyperdense left subdural is new, and the amount of
midline shift is much worse. Additionally, there is progression
of the blurring of [**Doctor Last Name 352**]-white matter differentiation throughout
the left hemisphere suggesting diffuse edema. Subfalcian
herniation, and possible early uncal herniation.
CT head ([**2129-2-19**]):
Large left-sided intraparenchymal and extra-axial hemorrhage.
Slightly increased degree of subfalcine and uncal herniation
Brief Hospital Course:
The patient was admitted to the neurology ICU. Neurosurgical
consultation was obtained and she was deemed not to be a
candidate for operative management. Serial CT scans of the head
demonstrated worsening in terms of edema and herniation.
Clinically, she steadily declined. A family meeting was held
with the patient's next of [**Doctor First Name **]. It was decided by the patient's
family that given the patient's poor prognosis, the focus of
care should be her comfort. All medical interventions were
discontinued except sedation and analgesia. The patient passed
away at 5am on [**2129-2-21**].
Medications on Admission:
Verapamil 240mg [**Hospital1 **]
Hydroxyurea 500mg QD
Lasix 80mg [**Hospital1 **]
Glyburide 7.5mg QD
KCL 10mEq QD
Lisinopril 20mg QD
Colchicine 0.6mg QD
Iron QD
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracranial hemorrhage
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1815
} | Medical Text: Admission Date: [**2109-4-18**] Discharge Date: [**2109-4-20**]
Date of Birth: [**2041-10-3**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: [**Known firstname **] [**Known lastname 3123**] is a 67-year-old right-handed man who had a
left parietal hemorrhage (4.2X2.7 cm) on [**2109-4-1**], who
presents
with a seizure today. According to his wife [**Name (NI) 2048**], he was in
his usual state of health and was having physiotherapy at home.
At around 11:30 am when his daughter [**Name (NI) **] got there, he was
complaining of right arm muscle spasm and so he applied an ice
pack. Around 12:30 pm, the therapist called his wife stating
that
he was having a seizure. The duration is unclear, and his wife
thinks that it might have been as long as 15 minutes, because he
was still having the episode when she arrived. She said that his
face looked blue, he was frothing at the mouth, was not moving
his right side, and she was not sure what he was doing with his
left side. He did not bite his tongue and did not have urinary
incontinence, however, he did fall to the floor when he had the
event. His BP at the beginning of the PT session was 140/86 and
during the event it was 160/96. He was brought to [**Hospital1 18**] by the
EMS.
Please refer to Dr [**Last Name (STitle) 911**] and Dr [**Last Name (STitle) 11903**] note from [**2109-4-1**] which
describes the prior event.
ROS: currently unobtainable from the patient as he has just
received 1 mg IV Ativan.
Past Medical History:
HTN
Hyperlipidemia
Small MI in [**2085**]
question of a TIA [**2078**]
Social History:
Married, lives with his second wife.
-Alcohol: occasionally
-tobacco: quit smoking 10 years ago. Prior to that he smoked 1.5
packs per day for most of his life, as per family
-drugs: no IV drugs
- Marital status: divorced and remarried
Wife: [**Name (NI) 2048**]/HCP [**Telephone/Fax (1) 44882**]
PCP: [**Name10 (NameIs) **] [**Last Name (STitle) **] ([**Location (un) 1411**]) Atrius patient
Family History:
-mother: heart attack and stroke. Mat GM with heart attack
-father: passed away after heart attack ~68yo. No CA, no
migraines; no epilepsy.
Physical Exam:
Vitals: T:afebrile P:76-88 BP 106/62-131/73 RR 19-25 SpO2 87
(not
on O2)-97% (on a rebreather)
General: Drowsy, just received ativan
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: Oriented to self, but not place or date, but he
has received 1 mg Ativan. Waxing and [**Doctor Last Name 688**] mental status. He
could follow one step commands.
-Cranial nerves (he was able to obey this part of the exam)
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Fundoscopy is normal. Visual fields are full to
confrontation. Extraocular movements intact bilaterally, no
nystagmus. Sensation intact V1-V3. Facial movement symmetric.
Hearing intact to finger rub bilaterally. Palate elevation
symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact
- Motor & Sensory (he became drowsy at this point and unable to
follow any commands). He was moving his right arm and leg less
readily than his left side, but he was antigravity throughout.
He
was withdrawing all 4 limbs away from noxious stimuli.
- Reflexes were 2s throughout with up going toes bilaterally
Pertinent Results:
U/A shows protein
Utox is negative
[**2109-4-18**]
1:40p
Trop-T: <0.01
140 102 23 AGap=29
------------< 134
3.5 13 1.3
CK: 101 MB: 3
Ca: 9.3 Mg: 2.3 P: 4.4
ALT: 23 AP: 68 Tbili: 0.9 Alb: 4.6
AST: 24 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Serum tox is negative
88
9.1 14.9 255
42.0
N:59.2 L:32.3 M:5.0 E:2.8 Bas:0.7
PT: 12.9 PTT: 20.2 INR: 1.1
Radiologic Data:
CT head
Significantly increased vasogenic edema surrounding left
parieto-occipital hematoma. No expansion of hematoma. No new
hemorrhage.
MRI +/-
Expected evolution of a left parietal hematoma, with an increase
in the
surrounding vasogenic edema since the prior MRI. There is no
definite
underlying lesion, although an underlying mass can be obscured
by the
hematoma. A repeat MRI could be considered once the hematoma has
resolved.
CT chest +/-
(prelim report)
No lung mass. Mild atelectasis. Large liver cyst and second
hypodensity too small to characterize, may be cyst however.
CT abd/pelvis +/-
1. Liver hypodensities, the largest representing a cyst, and the
smallest too
small to accurately characterize.
2. 8-mm subtle hypodensity in the mid left kidney arising from
the cortex is
too small to accurately characterize but does not have
appearance of a simple
cyst. Renal ultrasound may be performed to determine whether
this represents
a hyperdense cyst.
3. Small hiatal hernia. Sigmoid diverticula, without evidence of
diverticulitis.
4. Gas within the urinary bladder, ? recent history of
instrumentation.
Urinary bladder with thickened wall, but this could be due to
underdistension.
5. Prostate enlargement.
6. Osteoarthritis of the hips.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 3123**] is a 67-year-old right-handed man who presented
to the ED after a seizure with considerable vasogenic edema
surrounding his prior left parietal hemorrhage ([**2109-4-1**]). The
etiology of his hemorrhage was considered to be secondary to AVM
vs. underlying mass, vs. (less likely) amyloid angiopathy. The
cortical irritability of his IPH with edema was the likely cause
of his seizure. The patient was admitted to the neuro ICU for
further care.
.
Hospital course;
.
Neuro; The patient was loaded with phenytoin in the emergency
department and received ativan, and admitted to the neuro ICU
for monitoring. He was started on keppra 1000 mg [**Hospital1 **] the
following morning and his examination was back to baseline and
nonfocal. He was started on dexamethasone but this was
discontinued on hospital day #2. He underwent MRI brain with
and without contrast which showed expected evolution of a left
parietal hematoma, with an increase in the surrounding vasogenic
edema since the prior MRI. There is no definite underlying
lesion, although an underlying mass can be obscured by the
hematoma. A CT torso was also performed which showed no
evidence of a primary malignancy. He will increase his keppra
to 1500 mg [**Hospital1 **] on [**4-21**], undergo an MRI brain with and without
contrast in two months as well as a conventional angiogram at
that time for further evaluation of his lesion. He will follow
up with neurology upon completion of these tests.
Medications on Admission:
Simvastatin 10 mg
Amlodipine 5 mg
Motrin PRN
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Zocor 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Keppra 1,000 mg Tablet Sig: 1.5 Tablets PO twice a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Intraparenchymal hemorrhage
Seizure
Discharge Condition:
No focal deficits.
Discharge Instructions:
You were admitted after having a seizure. This was likely due
to your cerebral hemorrhage. You were started on a medication
called Keppra to decrease the chance you will have a recurrent
seizure and you temporarily received a steroid called
dexamethasone to reduce swelling in your brain. You cannot
drive for at least six months and please avoid any activities
that would put yourself or others in danger should you have
another seizure. You will also need to have further tests in
[**7-2**] weeks to evaluate why you had your cerebral bleed. These
include a cerebral angiogram (you will first have an appointment
with a neurosurgeon, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]) as well as a repeat MRI
with and without contrast of your brain.
Please return to the Emergency Department for recurrent seizure,
new headache, visual changes, new weakness, sensory changes,
chest pain, or shortness of breath.
Followup Instructions:
You have an appointment with [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD (neurosurgery)
Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2109-6-20**] 11:15. His office is in
[**Hospital Ward Name **] Bldg [**Location (un) 470**] Suite B and he will consent you for an
angiogram at that time.
Please have a repeat MRI brain with and without contrast in [**7-2**]
weeks. An order has been placed for this study but you may call
[**Telephone/Fax (1) 327**] to schedule the test. This study should occur in
mid-[**2109-5-25**].
You originally had a neurology appointment set with a
neurologist through Atrius which was missed due to your
hospitalization. Please discuss with your primary care
physcician, Dr. [**Last Name (STitle) **], regarding neurology follow-up at [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] with Dr. [**Last Name (STitle) **] to occur within
the next few weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1816
} | Medical Text: Admission Date: [**2133-5-6**] Discharge Date: [**2133-5-9**]
Date of Birth: [**2052-8-12**] Sex: F
Service: SURGERY
Allergies:
Adhesive Tape
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Enlarging AAA
Major Surgical or Invasive Procedure:
[**5-6**]:
Endovascular repair of abdominal aortic aneurysm
with modular endograft, angioplasty and stenting of the right
renal artery, right common femoral endarterectomy and
saphenous vein patch angioplasty.
History of Present Illness:
This 81-year-old lady with severe COPD on
steroids has an abdominal aortic aneurysm which has been
enlarging slowly, now about 4.8 cm in maximum diameter. CT
angiography showed a somewhat marginal situation for
endovascular repair due to small caliber iliac arteries
mostly but we decided to proceed since she was a high risk
for open surgery.
Past Medical History:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
HYPERTENSION
HYPERLIPIDEMIA
FORMER SMOKER
CATARACTS
OSTEOPOROSIS
GI intolerance
POOR NUTRITION
POLYMYALGIA RHEUMATICA [**2127**]
ABNORMAL MAMMOGRAM [**2130-7-15**]
right breast calcifications six month follow up recommended
DIVERTICULOSIS
colonoscopy2002
DYSPHAGIA
EGD [**5-/2130**] with esophagitis
ABDOMINAL AORTIC ANEURYSM now s/p EVAR
Social History:
[**2-17**] drinks/week. She is a former heavy smoker but quit about 10
years ago. She is not Oxygen dependent
Family History:
nc
Physical Exam:
98.4, 67, 89/42, 16, 96%
comfortable, NAD
RRR
CTA B
s/NT/ND
R groin wound C/D/I
L groin appears normal
doppler exam:
DP PT
R p p
L p p
Pertinent Results:
[**2133-5-6**] 06:13PM WBC-6.1 RBC-3.09*# HGB-9.6*# HCT-28.1*#
MCV-91 MCH-31.0 MCHC-34.0 RDW-13.8
[**2133-5-6**] 06:13PM CALCIUM-7.6* PHOSPHATE-3.7 MAGNESIUM-1.3*
[**2133-5-6**] 06:13PM GLUCOSE-141* UREA N-11 CREAT-0.5 SODIUM-137
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-23 ANION GAP-10
Brief Hospital Course:
Pt was admitted to pre-op holding in anticipation of an EVAR for
an enlarging AAA. She underwent endovascular repair of abdominal
aortic aneurysm with modular endograft, but her operative course
was complicated by partial covering of the origin of the right
renal artery requiring renal angioplasty and stenting,
dissection of the right common femoral artery with occlusionas a
result of percutaneous access requiring groin exploration,
endarterectomy and vein patch repair. She tolerated the
procedure well, though given her complicated operative course,
she remained intubated overnight in the CVICU. She was extubated
without difficulty the following morning, and transferred to the
VICU later that day. On POD 2, her hct had dropped to 24, and
she was given 1u PRBCs. Her hct responded nicely to above 30.
Her A-line was removed and she was getting out of bed. The
remainder of her post-operative course of unremarkable, and she
was deemed ready for discharge on POD 3. She will follow up with
Dr. [**Last Name (STitle) **] in 3 weeks, with a CTA to be done beforehand.
Medications on Admission:
ATENOLOL - 25 mg daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk 1 puff [**Hospital1 **] IBANDRONATE [BONIVA] - 150 mg Tablet monthly
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 103 mcg (90 mcg)-18
mcg/Actuation Aerosol - 2 puff [**Hospital1 **] to tid
LEVOTHYROXINE - 50 mcg Tablet - 1 Tablet(s) by mouth once a day
LOVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
NYSTATIN - 100,000 unit/mL Suspension - 1 tsp by mouth swish and
spit qid for 10 days
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
TRANDOLAPRIL - 4 mg Tablet - 2 Tablet(s) by mouth daily
TRAZODONE - 150 mg Tablet - 1 Tablet(s) by mouth at hs
Medications - OTC
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
CALCIUM CARBONATE [CALTRATE 600] - 1.5 gram Tablet - 1 Tablet(s)
by mouth twice a day
CYANOCOBALAMIN [VITAMIN B-12] - 500 mcg Tablet - 1 Tablet(s) by
mouth once a day
GUAIFENESIN [MUCINEX] - 600 mg Tablet Sustained Release - 1
Tablet(s) by mouth once a day
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H:PRN as needed: please do not drive on this medication.
Disp:*30 Tablet(s)* Refills:*0*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for mild pain.
14. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Aspirin 325 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:*2*
17. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Aortic Aneurysm
Post-op blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-17**]
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
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-20**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Please call
([**Telephone/Fax (1) 18181**] to make that appointment. You will need to
schedule a CTA of your abdomen and pelvis, so please be sure to
have this arranged before your follow-up appointment. Dr. [**Name (NI) 19759**] office will help you coordinate this.
Completed by:[**2133-5-9**]
ICD9 Codes: 2851, 496, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1817
} | Medical Text: Admission Date: [**2123-7-21**] Discharge Date: [**2123-7-26**]
Date of Birth: [**2060-6-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2123-7-22**] AVR(21 [**Doctor Last Name **] Pericardial)/Septal myomectomy
History of Present Illness:
62 year old female with known bicuspid aortic valve and
aortic stenosis. She has a history of a coarctation of the aorta
repair by way of an end to end anastomosis at the age of 12.
Over
the past couple years, she has been followed by serial
echocardiograms which have shown progression of her aortic
stenosis. Over the last 6 months, she has noted mild dyspnea on
exertion. She denies chest pain, syncope, pre-syncope,
orthopnea,
PND and pedal edema. Given her most recent echocardiogram
findings, she has been referred for cardiac surgical evaluation.
Past Medical History:
Past Medical History:
- Bicuspid aortic valve, Aortic stenosis
- Dyslipidemia
Past Surgical History:
- Coarctation repair at age 12 via left thoracotomy
- Tonsillectomy
Past Cardiac Procedures:
- Coarctation repair at age 12 via left thoracotomy at [**Hospital1 1872**]
in [**Location (un) 6482**]
Social History:
Race: Caucasian
Last Dental Exam: Every 6 months
Lives: In [**Location (un) 17566**] with brother who is somewhat dependent,
has social supports/friends in area
Occupation: Teacher
Cigarettes: Very rarely, in distant past
ETOH: Rare
Illicit drug use: Denies
Family History:
Denies premature coronary artery disease
Physical Exam:
Admission:
Vital Signs
BP: 152/82 Heart Rate: 84 Resp. Rate: 16
O2 Saturation%: 100.
Height: 5'2" Weight: 133 lbs
General: WDWN in NAD
Skin: Warm, Dry and intact
HEENT: NCAT, PERRLA, EOMI, sclera anciteric, OP benign. Teeth in
good repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, IV/VI SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] +BS [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:1
Radial Right:2 Left:2
Carotid Bruit - Transmitted vs. Bruit
Discharge:
VS T 98.2 HR 84 BP 97/62 RR 18 O2sat 97%-RA
Gen: NAD
Neuro: A&O x3, MAE. nonfocal exam
CV: RRR, no M/R/G. Sternum stable-incision CDI
Pulm: CTA-bilat
Abdm: soft, NT/ND/+BS
Ext: warm, well perfused. trace edema bilat
Pertinent Results:
Admission labs:
[**2123-7-21**] 12:38PM PT-12.8* INR(PT)-1.2*
[**2123-7-21**] 12:38PM PLT COUNT-208
[**2123-7-21**] 12:38PM NEUTS-65.7 LYMPHS-30.2 MONOS-3.7 EOS-0.2
BASOS-0.3
[**2123-7-21**] 12:38PM WBC-6.6 RBC-3.58* HGB-11.9* HCT-35.4* MCV-99*
MCH-33.2* MCHC-33.6 RDW-12.5
[**2123-7-21**] 12:38PM TRIGLYCER-29 HDL CHOL-60 CHOL/HDL-2.7
LDL(CALC)-97
[**2123-7-21**] 12:38PM %HbA1c-5.5 eAG-111
[**2123-7-21**] 12:38PM VIT B12-551
[**2123-7-21**] 12:38PM ALBUMIN-3.7 CHOLEST-163
[**2123-7-21**] 12:38PM ALT(SGPT)-14 AST(SGOT)-17 ALK PHOS-58
AMYLASE-19 TOT BILI-0.4
[**2123-7-21**] 12:38PM GLUCOSE-85 UREA N-15 CREAT-0.5 SODIUM-138
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
Discharge labs:
[**2123-7-26**] 05:50AM BLOOD WBC-6.2 RBC-2.86* Hgb-9.4* Hct-28.5*
MCV-100* MCH-32.9* MCHC-33.0 RDW-12.6 Plt Ct-117*
[**2123-7-26**] 05:50AM BLOOD Plt Ct-117*
[**2123-7-22**] 11:50AM BLOOD PT-13.8* PTT-30.8 INR(PT)-1.3*
[**2123-7-26**] 05:50AM BLOOD Na-141 K-4.0 Cl-103
Radiology Report CHEST (PA & LAT) Study Date of [**2123-7-25**] 11:21
AM
Final Report: In comparison with the study of [**7-24**], there is
continued
opacification in the retrocardiac region and obscuring the
costophrenic sulcus on the left. Again, this is consistent with
pleural effusion and substantial volume loss in the left lower
lobe. A small apical pneumothorax on the right is again seen.
IMPRESSION: Little overall change.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Indication: Aortic valve disease. Congenital heart disease. Left
ventricular function. Prosthetic valve function. Right
ventricular function. Valvular heart disease.
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Gradient: *51 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 36 mm Hg
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins not identified.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD or PFO
by 2D, color Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Normal LV cavity
size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Severe AS (area 0.8-1.0cm2).
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. There is mild 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. There
is severe aortic valve stenosis (valve area 0.8-1.0cm2). The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
POST CPB:
1. Preserved biventricular systolci function
2. Bioproshtetic valve in aortic position. Well seated and good
leaflet excursion.
3. No AI, Peak Gradient = 30 mm Hg,
4. Intact aorta and no other change
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2123-7-22**] 10:21
Brief Hospital Course:
Ms [**Known lastname **] was admitted one day prior to scheduled surgery for
cardiac catheterization. the catheterization revealed: no
angiographically-apparent flow-limiting stenoses.
She was brought to the operating room on [**7-22**] for planned heart
suregry, please see operative report for details in summary she
had: Aortic Valve Replacement with 21 [**Doctor Last Name **] Pericardial and
Septal myomectomy. Her bypass time was 63 minutes with a
crossclamp time of 49 minutes. She tolerated the operation well
and post operatively was transferred to the cardiac surgery ICU
in stable condition. She remained stable in the immedicate
post-op period and within hours of leaving the OR woke
neurologically intact was weaned from the ventilator and
extubated. She weaned off all pressors over the next 12 hours
and on POD1 was transferred to the stepdown floor for continued
care and recovery. All tubes lines and drains were removed per
cardiac surgery protocol. She worked with nursing and PT to
increase strength and endurance.
The remainder of her hospital course was uneventful. On POD 4
she was discharged home with visiting nurses. She is to folllow
up in wound clinic in 1 week and with Dr [**Last Name (STitle) **] in 1 month.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 81 mg PO DAILY
2. biotin *NF* 1 mg Oral daily
3. Glucosamine-Chondroitin Complx *NF*
(gluc-[**Doctor Last Name 2871**]-msm#1-C-[**Last Name (un) **]-bos-bor;<br>glucosam-chondroitin-vit
C-Mn;<br>glucosamine-chondroit-vit C-Mn) Oral daily
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Acetaminophen 650 mg PO Q4H:PRN pain
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY Duration: 10 Days
5. Ibuprofen 400 mg PO Q8H:PRN pain
6. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
7. Oxycodone-Acetaminophen (5mg-325mg) [**11-16**] TAB PO Q4H:PRN pain
8. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
9. biotin *NF* 1 mg Oral daily
10. Glucosamine-Chondroitin Complx *NF*
(gluc-[**Doctor Last Name 2871**]-msm#1-C-[**Last Name (un) **]-bos-bor;<br>glucosam-chondroitin-vit
C-Mn;<br>glucosamine-chondroit-vit C-Mn) 0 ORAL DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
s/p AVR(21 [**Doctor Last Name **] Pericardial)/Septal myomectomy [**2123-7-22**]
PMH:
Bicuspid aortic valve
Aortic stenosis
Dyslipidemia
Coarctation repair at age 12 via left thoracotomy [**Hospital1 13696**]([**Location (un) 6482**])
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema- trace bilat
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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:
Wound check: [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2123-8-3**] @10:30
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time: [**2123-8-18**] 1:15
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2123-9-11**] @10:50AM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 85715**],[**Last Name (un) **] F. [**Telephone/Fax (1) 85716**] in [**2-18**] 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:[**2123-7-26**]
ICD9 Codes: 4241, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1818
} | Medical Text: Admission Date: [**2110-4-1**] Discharge Date: [**2110-4-25**]
Date of Birth: [**2055-1-15**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Codeine
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
transfer from [**Hospital 1474**] Hospital, fever to 108 and hypotension.
Major Surgical or Invasive Procedure:
endotracheal intubation.
History of Present Illness:
55F s/p lap appy (perforated retrocecal appendix) converted to
open [**3-31**] who had fever to 102 after procedure yesterday and was
tachycardic, received 1 dose unasyn and then was febrile to 108
this am with altered mental status. Pt was intubated for signs
of respiratory distress and was placed on a cooling blanket and
received cold gastric lavage. Unasyn was d/c'd and Zosyn and
Vanc were started and central line placed. CT head, chest, abd
neg for acute processes. Pt was paralyzed and sedated for
presumed seratonin syndrome. Cryptoheptadine was administered.
Prozac was d/c'd (last dose [**2110-4-1**] 1am). At 8:30pm [**4-1**] pt
became hypotensive to SBP <80 mmHg and Levophed started prior to
transfer to [**Hospital1 18**]. During transfer Neosinephrine was addeded for
additional support.
Past Medical History:
Depression
Scoliosis
Ventral hernia
Endometriosis
Migraines
Chronic anemia
s/p back surgery
s/p hernia repair
s/p ex lap
hx uveitis
Social History:
lives alone, never married, works as a data programmer. No EtOH,
remote tob hx, quit 5 yrs ago.
Family History:
non-contributory.
Physical Exam:
VS: T 101.6 BP 123/78 HR 83 AC 500 X 14 P 10 FiO2 50%
Gen: NAD, intubated, not responsive, flaccid
HEENT: EOMI, PERRL (3 mm)
Neck: no LAD
Chest: CTAB
CV: RRR nl s1 s2 no mrg appreciated
Abd: soft, NT, mildly distended + BS, 5 cm horizontal incision
near umbilicus, CDI with staples. 15 cm horizontal incision R
abdomen CDI with staples.
Ext: obese, non-pitting edema
Neuro: flaccid, likely still paralyzed from cisatracurium given
at OSH. PERRL. tracking with eyes.
Skin: no rash
Pertinent Results:
CXR [**4-2**]: Mild cardiomegaly accompanied by moderate distention
of the mediastinal vasculature. Mild pulmonary edema and small
right pleural effusion suggest cardiac decompensation and/or
volume overload. There is no pneumothorax. Tip of the
endotracheal tube ends above the clavicles, at least 5.5 cm
above the carina, probably 2-3 cm above optimal placement.
Nasogastric tube passes to the distal stomach and out of view.
Tip of the right jugular central line projects over the course
of the right brachiocephalic vein. No pneumothorax.
.
TTE [**4-2**]: There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen (probably mildly thickened
leaflets). There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no pericardial effusion.
.
CT abd/pelvis [**4-5**]: 1. Complex cystic focus in the left adnexa
with apparent enlargement of the left ovary. This is worrisome
for an ovarian malignancy. Tuboovarian abscess is considered
less likely as there is no inflammatory reaction surrounding the
ovary. Further evaluation could be obtained with ultrasound. 2.
No fluid collection is identified in the retrocecal space. 3.
Sigmoid diverticulosis. 4. No acute hepatobiliary or pancreatic
abnormalities identified. 5. Small bilateral pleural effusions.
Brief Hospital Course:
A/P: 55yoF s/p appendectomy for ruptured retrocecal appy, still
febrile on Abx.
.
1. Sepsis:
The patient was transferred to [**Hospital1 18**] with sepsis syndrome from
OSH, was hypotensive and with high fevers. Soon after transfer
she was hemodynamically stable. She was continued on broad
spectrum antibiotics. There was no pathogen identified, although
she was treated for a presumed PNA as well as a possible GI
source given the history of appendectomy at the OSH. There was
an initial concern for a Gyn source of infection, possible L
[**Last Name (un) **], Gynecology was consulted, and this was found to be less
likely. The infection resolved with empiric antibiotics
.
2. Altered MS/seizures:
After the sepsis was resolving, the pt was noted to have
persistent coma. She remained unarousable, with flaccid limbs
not withdrawing to pain. Neurology was consulted. She was noted
at one point to have jerking movements suggestive of seizure
activity, initial ECG was negative for epileptogenic activity.
In order to rule out meningitis, LP was attempted by radiology
under fluoro although was unsuccessful. She was treated for
possible HSV and bacterial meningitis empirically. There was
high clinical suspicion for status epilepticus, continuous EEG
monitoring was done and confirmed seizure activity. The patient
was started on depakote for seizure prophylaxis. The etiology of
the initial CNS insult was assessed as likely sustained when
hypotensive and febrile to 108. Over the course of the
hospitalization, the patient's mental status showed minimal
improvement. She was able to interact and follow commands
limited to movements of her eyes and tongue. She demonstrated
extremely limited ability to perform movements below the neck.
She remained quadraplegic She had no gag reflex and could not
breathe off of the ventilator.
.
3. Withdrawal of Life Support:
Extensive discussions were held with the patient as well as
members of her immediate family with the attending physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as well as other members of the medical team. It was
explained to the patient and family that in her current state,
she could not live without life support from the venitalor since
she was not able to breathe on her own. They were explained the
option to have a tracheotomy for ventilation at rehab where she
would have an opportunity for a longer-term recovery, although
there was no guarantee that she would be able to come off of the
ventilator. Whether the patient would make any meaningful
neurological recovery was also uncertain. The patient and
family expressed a clear decision that the patient did not want
to remain on the ventilator and that she wanted to be off of
life support. She indicated that she understood the
implications. The patient was extubated and passed away shortly
therafter with family and friends present.
.
4. Respiratory failure:
The patient remained ventilator dependent during the hospital
stay as noted above,
.
5. Pancreatitis:
There was an isolated elevation of pancreatic enzymes in the
abscence of symptoms. She received a post-pyloric tube for
feeding. After several days, this was trending down and tube
feeds were done through an NG tube.
.
6. Anemia:
Hct remained 25 range stable.
.
7. Trop leak:
trop peak to 0.55 on [**4-3**], elevated CK [**1-16**] rhabdo. Likely demand
ischemia in setting of septic shock.
.
8. Rhabdomyolisis:
CK peaked [**Numeric Identifier 43631**] on [**4-6**], and later resolved. Her renal funtion
remained intact.
# Thrombocytosis:
most likely reactive [**1-16**] infection, trending down.
.
# s/p appy on [**4-1**]: appreciate surgery recs, no active issues.
.
# FEN: continue TFs, new OG tube placed [**4-17**]. electrolyte
repletion as needed.
.
# Ppx: PPI, pneumoboots, heparin SC, bowel regimen.
# Code: Full initially, but then later in the hospitialization
converted to DNR/DNI.
# Access: 20g PIV x 2, RtF A-line [**4-11**]
# Comm: Sister [**Name (NI) 382**] [**Name (NI) 1258**] [**Name (NI) **] [**Telephone/Fax (1) 43632**] or cell
[**Telephone/Fax (1) 43633**].
Medications on Admission:
prozac 20 qhs
premarin 0.625 mg [**Hospital1 **]
Trazodone 100 mg po qd
Atenolol 100 mg po qd
Albuterol prn
Rhinocort
[**Doctor First Name 130**]
flexeril
.
Meds on transfer:
vanc 1 gm
Zosyn
cryptoheptadine 12 mg
tylenol 650 mg
Motrin 600 mg
Versed 5 mg
Nimbex gtt
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
not applicable
Discharge Condition:
deceased
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 0389, 5185, 5849, 486, 5119, 2875, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1819
} | Medical Text: Admission Date: [**2127-12-15**] Discharge Date: [**2128-1-8**]
Service: MEDICINE
Allergies:
Ampicillin / Codeine / Tetracyclines
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Cough, fever
Major Surgical or Invasive Procedure:
Bronchoscopy x 2
Intubation/extubation, mechanical ventilation
History of Present Illness:
The pt is an 85-yo woman w/ hypertension, hyperchol,
hypothyroid, GERD, anemia, and stage IV CKD (bl Cr 3.2-3.5) who
presents with 1.5 weeks of left side pain and cough. She notes
constant left side and back pain, and feeling weak. She has had
chest congestion with an intermittent cough, productive of a
white sputum. Denies SOB, or chest or abdominal pain. She has
not been eating well, [**12-30**] no appetite. No LH, dizziness, N/V,
diarrhea, or dysuria. She has been taking [**Doctor Last Name 1819**] Aspirin 325mg x2
three times daily for pain. Additionally, she has not gotten out
of bed because of the weakness, and has not been able to care
for herself, needing help getting to the bathroom.
.
In the ED, VS - Temp 99.2F, HR 76, BP 151/80, R 24, SaO2 96% 4L
NC. Labs significant for WBC 10.2 (85.6% PMNs), Cr elevation to
4.5, trop 0.05, and negative UA. ECG was unremarkable. CXR
showed RLL atelectasis and LLL consolidation vs effusion; CT-A/P
confirmed LLL pulm consolidation and RLL atelectasis, as well as
diverticulosis w/o diverticulitis, and stable atrophic kidneys.
She got 1L NS IVF, and Ceftriaxone 1gram IV + Azithromycin 500mg
PO for pneumonia.
.
Prior to transfer to the ICU, patient was treated for CAP with 5
days azithromycin and 14 days ceftriaxone. On [**12-19**] she was
transferred to the MICU and bronched for mucus plugging and
another bronch on [**12-22**] for same reason. She was called out to
the floor on [**12-24**] and had been doing well from a respiratory
standpoint until this morning when she desaturated. Currently,
the patient's breathing is much more comfortable. She was
transitioned to nasal cannula and Venturi mask. She states her
dyspnea is stable. She denies any chest pain, nausea, vomiting,
abdominal pain, or diarrhea.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Hypertension
AAA s/p intravascular repair in [**2119-2-26**]
s/p CVA in [**2120-1-26**], lacunar infart with no residual deficits
Hypercholesterolemia
Chronic back pain
Hypothyroidism
Osteoarthritis
GERD
Bilateral parotid gland masses
Diverticulitis
Chronic bronchitis
Anemia with baseline hematocrit 31 to 34 (likely secondary to
renal disease)
Stage IV Chronic Kidney Disease with baseline creatinine 3.2-3.5
Social History:
Widowed since [**2111**]. Has three grown sons. Lives with one of her
sons. Continues to smoke [**11-29**] pack per day x 70 years. No alcohol
or recreational drugs.
Family History:
No family history of gastrointestinal bleeding
Physical Exam:
Physical Exam:
VS: Temp 97.3F, BP 159/77, HR 75, R 22, SaO2 92% 2L NC
General: frail elderly woman in mild respiratory distress
HEENT: NC/AT, sclera anicteric, dry MM
Neck: supple, no LAD, no JVD
Lungs: diffuse rhonchi, occasional wheeze, no crackles
Heart: RRR, nl S1-S2, +[**1-3**] HSM @ LLSB w/o radiation
Abdomen: +BS, soft/NT, mild upper abd distension, no r/g, no HSM
Extrem: WWP, no c/c/e, 1+ pedal pulses
Neuro: awake, A&Ox3, CNs [**2-6**] grossly intact, muscle strength
full and sensation to light touch grossly intact throughout
Pertinent Results:
ADMISSION LABS
[**2127-12-15**] 04:15PM BLOOD WBC-10.2 RBC-4.02* Hgb-10.7* Hct-33.5*
MCV-83 MCH-26.6* MCHC-31.9 RDW-17.4* Plt Ct-390
[**2127-12-15**] 04:15PM BLOOD Neuts-85.6* Lymphs-10.8* Monos-2.8
Eos-0.3 Baso-0.5
[**2127-12-15**] 04:15PM BLOOD PT-11.3 PTT-24.8 INR(PT)-0.9
[**2127-12-15**] 04:15PM BLOOD Glucose-101* UreaN-58* Creat-4.5* Na-138
K-3.9 Cl-108 HCO3-16* AnGap-18
[**2127-12-15**] 04:15PM BLOOD cTropnT-0.05*
[**2127-12-16**] 07:00AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.1
[**2127-12-16**] 08:21AM BLOOD Type-ART pO2-66* pCO2-28* pH-7.35
calTCO2-16* Base XS--8
[**2127-12-15**] 04:28PM BLOOD Lactate-1.2 K-3.5
[**2127-12-16**] 08:21AM BLOOD freeCa-1.11*
MICROBIOLOGY
BLOOD CULTURE: (1//18/[**2127**]) NO GROWTH
URINE CULTURE (Final [**2127-12-16**]): BETA STREPTOCOCCUS GROUP B.
10,000-100,000 ORGANISMS/ML..
SPUTUM
GRAM STAIN (Final [**2127-12-17**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2127-12-19**]):
RARE GROWTH Commensal Respiratory Flora.
BRONCHOALVEOLAR LAVAGE
[**2127-12-22**] 5:41 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final [**2127-12-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
CT ABDOMEN:
IMPRESSION:
1. Left lower lobe pulmonary consolidation, concerning for
pneumonia.
Additional right lower lobe patchy opacities could reflect
atelectasis.
2. Bilateral renal hypodensities, which are incompletely
characterized, but stable, and may reflect cysts.
3. Aortoiliac stent, incompletely assessed without IV contrast.
4. Severe diverticulosis without evidence of diverticulitis.
5. Stable retroperitoneal lymphadenopathy.
CHEST X-RAY ([**2127-12-15**])
Left lower lobe consolidation, better assessed on the
subsequently performed CT abdomen and pelvis.
CHEST X-RAY ([**2127-12-20**])
There is complete consolidation and opacification of the left
lung with mild mediastinal shift to the left. The right lung is
relatively [**Name (NI) **], and there is minimal atelectasis at
the right lung base. There is a stent in the upper abdomen.
.
[**2127-12-19**] CXR:
new opacification of the LEFT hemithorax. mediastinal shift
indicates left lung collapse. truncation of left main bronchus -
likely due to mucus plug or aspiration. d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] 8:45am
[**2127-12-19**].
.
ECHO: The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Right ventricular chamber size and free wall
motion are normal. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. Mild to
moderate ([**11-29**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2125-1-19**], the aortic stenosis may be slightly worse
(but still only mild).
.
CT chest: 1. Partial atelectasis of the lingula and complete
collapse of left lowerlobe is likely due to mucous impaction,
but a mass cannot be excluded due to absence of contrast
administration.
2. Several pulmonary nodules are predominantly stable. Several
new right
lung lobe nodules are likely inflammatory and can followed by CT
to ensure
stability in 6 months if warranted clinically.
3. Findings suggestive of pulmonary artery hypertension.
4. Enlarged mediastinal lymph nodes are similar to [**2121-10-30**].
.
Chest Xray ([**2128-1-6**]): As compared to the previous examination,
there is a complete
collapse of the left lung. As a consequence, there is an
extensive shift of
the mediastinum and the heart to the left. In the right lung,
the parenchyma
shows minimally improved ventilation. No evidence of interval
occurrence of
focal parenchymal opacities on the right.
Brief Hospital Course:
85 yo female with HTN, HLP, CKD stage 4, admitted with cough and
pleuritic CP, found to have LLL pneumonia,
.
# Hypoxia/respiratory distress/ Community acquired pneumonia:
Patient initially admitted with CAP involving the left lower
lobe and with 3-4L Oxygen requirement (PORT Score 135, Risk
class V, 26.7% Mortality). Patient was admitted to the medical
floor where she developed acute respiratory distress and
hypoxia, requiring transfer to the MICU. Patient cleared a large
mucous plug with immediate improvement in respiratory status and
underwent urgent bronchoscopy which confirmed large amount of
mucous. Patient required repeat bronchoscopy which was
successful in removal of a large mucous plug. She became
progressively more dyspneic and hypoxemic in the MICU and
required intubation with mechanical ventilation. Repeat
bronchoscopy at that time showed complete collapse of her left
lower lungs with thick mucus plugging and secretions that were
very difficult to suction out. Patient was started on Mucomyst,
aggressive chest PT and frequent deep suctioning. Her collapsed
left lung slowly re-expanded on mechanical ventilation. There
was difficulty weaning patient off the ventilator; when propofol
was turned off, she would wake up minimally. CT head showed no
acute processes, however, and ultimately, patient self-extubated
one morning with family at her bedside. She made it explicitly
clear that she did not wish to be intubated again. In
discussions with her and her sons, the patient was made DNR/DNI.
In the following two days, patient became progressively anxious
and delirious, as well as refusing chest PT, deep suctioning and
face mask. She would intermittently desaturate to the 70-80s.
Palliative Care was consulted and in further discussions with
her family, the goal was for comfort measures. Patient was
started on Morphine 1-3mg every hour for symptomatic relief of
air hunger. No more labs were drawn, lines were pulled. Final
chest xray two days prior to expiration showed recollapse of her
entire left lung, which the family understood could not be
reinflated with bronchoscopy with likely re-intubation, which
was not in keeping with patient's desires. Patient was
ultimately transferred to the regular Medicine floor where she
passed away on [**1-8**] in the early morning.
.
Pneumonia was treated with Ceftriaxone x 7 days and 5 day course
of azithromycin. Agressive chest physical therapy, flutter
valve, decongestants and nebulizer treatments were given.
#. Acute on Chronic renal insufficiency: Patient with Stage IV
CKD at baseline, at time of admission with Cr up to 4.5, with
muddy brown casts suggestive of ATN, most likely ischemic from
prerenal failure vs NSAID induced ischemia. ASA, NSAIDs,
nephrotoxins avoided, patient volume resuscitated and creatinine
improved to 3.2 by day of expiration.
.
# Metabolic Acidosis: During acute decompensation, likely due to
Acute Kidney Injury. Delta/delta was suggestive of combination
of anion-gap and nonanion-gap metabolic acidosis. This however
resolved during hospitalization.
.
#. Hypertension - Somewhat better controlled. Patient was
continued on Diltiazem 60mg PO four times daily.
.
#. Weakness -Elderly female with acute illness now in addition
to baseline deconditioning. Patient was evaluated by Physical
Therapy who recommended rehabilitation facility.
#. Hypothyroidism - Continued home levothyroxine
.
#. Hyperlipidemia - Continued home statin
.
#. Anemia - Likely anemia of chronic disease. Given patient's
resistance to hemodialysis, it was never initiated and she was
never started on Epogen.
Medications on Admission:
Diltiazem SR 120mg daily
Doxercalciferol 0.5 mcg daily
Levothyroxine 150 mcg daily
Oxybutynin 5 mg daily -- pt denies
Simvastatin 40 mg daily
Discharge Medications:
Expired
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 5849, 5180, 5990, 2762, 2720, 2449, 5070, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1820
} | Medical Text: Admission Date: [**2123-4-8**] Discharge Date: [**2123-4-14**]
Date of Birth: [**2060-10-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
acute renal failure
Major Surgical or Invasive Procedure:
Intubation/extubation
Debridement of right hallux necrotic tissue/infection
History of Present Illness:
52 year old male who presented to an OSH with SOB that had
started about 2 weeks ago and gradually worsened, constant in
nature. This occurred in the setting of severe right hallux
pain from an ulcer related to his Buerger's disease; he had
treated himself with up to 15 tablets of ibuprofen per day for
approximately 1-2 weeks when he went to see his podiatrist who
felt he was quite ill and advised him to report to the ED. He
had also been having 20 BMs/day for several days, and was
lightheaeded.
At the OSH, he was found to be hypotensive, hypoxic, profoundly
acidemic (ph 6.9), and in acute renal failure. He was intubated
and transferred to [**Hospital1 18**] where he was sent to the MICU and given
agressive hydration with bicarbonate. He responded rapidly and
well with a dramatic improvement in his renal function and
acid/base status.
Past Medical History:
1.)Gout
2.)GERD
3.)[**Doctor Last Name 35251**] disease
4.)Hypertension
Social History:
The patient lives with his wife and youngest son. [**Name (NI) **] has a
heavy smoking history but recently quit (about 1 month prior to
admission).
Family History:
Non-contributory
Physical Exam:
PE at OSH: T 96 P 83 BP 119/60 R 26 O2 100% on 2L, tachypnea,
abd is soft, A+ O x 3, warm and dry
[**Hospital1 18**]:
t 99.2, bp 128/74, hr 72, rr 16, spo2 97%ra
gen- awake, pleasant, obese male in nad
heent- anicteric sclera, op clear with mmm
cv- rrr, s1s2, no m/r/g
pul- moves air well, occasional rhonchi, no wheezes/rales
abd- soft, nt, nabs
extrm- no cyanosis/edema, right hallux with large ulcer with
necrotic debris
neuro- a&ox3, cn 2-12 intact, no focal motor/sensory deficits
Pertinent Results:
Lab at OSH:
plt 1506, hct 39.8 Wbc 34.3( 88 seg 5 lymph 5 bans) , NA 137 K
4.8 Cl 97 Hco 3, BUn 167 Creat 9.2, BNP 310, ALT 48, AST 34, Alk
Phos 110, T bili <0.5, CK 166, CK-MB 14.2 ** MB index 8.6** Trop
0.1, PT 13.2 INR 1.2 PTT 33
..
ABG on RA: 6.91/13/130
ABG repeat 6.99/18/130
lactate 3.2
acteminophen <2, salicylate
U/A: tr ketone, 4+ bld, tr LE, [**11-4**] WBC, 1+ bact, packed RBC..
..
Renal U/S (prelim read): No acute abnormality. Possible small R
nonobstructing nephrolithiasis. NO hydronephrosis. R keidney
12.2 cm. L kidney 13.3 in length. cortical thickness 2 cm.
..
EKG (OSH): NST 80, nl axis, no ischemic ST changes
CXR (here): ETT in good position, L subclavian in good position,
OGT, no infiltrate, no edema, no PTX
[**2123-4-8**] 11:28PM BLOOD WBC-30.3* RBC-3.87* Hgb-11.5* Hct-33.6*
MCV-87 MCH-29.7 MCHC-34.1 RDW-15.0 Plt Ct-892*
[**2123-4-10**] 12:38PM BLOOD WBC-12.6* RBC-3.54* Hgb-10.4* Hct-29.1*
MCV-82 MCH-29.4 MCHC-35.8* RDW-14.8 Plt Ct-641*
[**2123-4-14**] 05:19AM BLOOD WBC-12.1* Hct-31.5* Plt Ct-532*
[**2123-4-8**] 11:28PM BLOOD Glucose-189* UreaN-157* Creat-7.6* Na-137
K-4.6 Cl-101 HCO3-6* AnGap-35*
[**2123-4-10**] 12:38PM BLOOD Glucose-119* UreaN-115* Creat-2.1*#
Na-143 K-3.1* Cl-111* HCO3-20* AnGap-15
[**2123-4-14**] 05:19AM BLOOD Glucose-96 UreaN-20 Creat-1.0 Na-143
K-3.7 Cl-109* HCO3-25 AnGap-13
[**2123-4-9**] 04:40AM BLOOD calTIBC-157* Ferritn-697* TRF-121*
[**2123-4-8**] 11:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2123-4-9**] 01:48AM BLOOD Type-MIX pO2-129* pCO2-24* pH-7.09*
calHCO3-8* Base XS--21
[**2123-4-10**] 01:14PM BLOOD Type-ART Temp-36.7 O2 Flow-2 pO2-132*
pCO2-28* pH-7.44 calHCO3-20* Base XS--3 Intubat-NOT INTUBA
[**2123-4-9**] 01:48AM BLOOD Lactate-1.1
Brief Hospital Course:
A/P: 62 year old gentleman, HTN, gout, PCV, presents with acute
renal failure with significant acidemia.
1.)Acute renal failure -- In reviewing the clinical history,
urine sediment, FeNa, and rapid response to fluid hydration, Mr.
[**Known lastname 3527**] acute renal failure was most likely from severe
volume depletion and NSAID abuse. The possibility of ATN was
entertained, given the severity of the renal function decrement
and exorbitant NSAID use, but given the rapid response to
fluids, this appeared less likely. As previously mentioned, Mr.
[**Known lastname 3527**] renal function rapidly improved to baseline function
within the first forty-eight hours of admission in response to
aggresive fluid hydration and remained there throughout the
remainder of his hospital stay.
2.)Anion gap metabolic acidosis -- With his highly elevated BUN
and Cr, this was felt to be a uremic acidosis. Other
possibilities included lactic, alcholic, starvation, or toxic
ingestion, yet these all proved incorrect. His acid-base status
quickly normalized with IV bicarbonate and improving renal
function and remained as such for the ensuing few days of his
admission.
3.)Hypotension -- Without an elevated lactate, fever,
tachycardia, ECG changes, or
persistently elevated cardiac enzymes, Mr. [**Known lastname 3527**]
hypotension was attributed to severe volume depletion,
corroborated by his excellent reponse to hydration. He remained
normotensive off all pressors beginning twenty-four hours into
his stay.
4.)Leukocytosis -- With an otherwise negative ID work-up, this
lab finding was felt to be due to both severe hemoconcentration
and, potentially, a C. difficile infection, as described below.
He was treated for this, with a WBC that normalized
and remained stable 72 hours prior to discharge. Urine, blood,
and sputum cx's remained negative, as did C. diff toxin assay.
5.)Thrombocytosis -- In discussion with the PCP, [**Last Name (NamePattern4) **]. [**Known lastname 3517**]
has a history of essential thrombocytosis and has been
intermittently followed by a hematologist as an outpatient. The
acute elevation, up to 1000, was probably due to an acute phase
reaction; once this resolved, his platelet count declined but
still remained slightly elevated. This was discussed with his
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1159**], who said that he would arrange for Mr. [**Known lastname 3517**]
to again be seen by hematology.
6.)Right Hallux -- During the admission, after his acute issues
had resolved, Mr. [**Known lastname 3517**] continued to note right toe pain.
Podiatry was evaluated for a possible paronychial infection,
which they agreed with; they debrided the ulcer and drained the
pus from around the nail, providing significant relief. Mr.
[**Known lastname 3517**] will see his podiatrist in one to two weeks.
Medications on Admission:
Ibuprofen
Lisinorpil/hctz 10/12.5 mg daily
Allopurinol 100mg [**Hospital1 **]
Amlodipine 5
Omeprazole 20mg [**Hospital1 **]
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 20 days.
Disp:*60 Tablet(s)* Refills:*0*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-17**]
Puffs Inhalation Q6H (every 6 hours).
Disp:*2 inhalers* Refills:*2*
7. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute renal failure
Metabolic acidosis
Paronychial infection
Hypotension
Diarrhea
Secondary:
Buerger's disease
Hypertension
Gout
GERD
Discharge Condition:
Good, with improved renal function, acid/base status, and right
toe pain.
Discharge Instructions:
Please return to the emergency department for
fevers/chills/drenching sweats, shortness of breath, chest pain,
worsening pain or redness in your toe/foot, or other concerning
symptoms.
Follow-up as below.
Take medications as prescribed. Please try to avoid taking
medications such as ibuprofen (Advil, Motrin) in anything
greater than the recommended dosage.
Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1159**], in the next week.
Please see you podiatrist in the next two weeks.
If you would like to be seen at [**University/College 60388**] Dental School, you can
call at ([**Telephone/Fax (1) 37579**].
ICD9 Codes: 0389, 5849, 486, 2749, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1821
} | Medical Text: Admission Date: [**2131-1-6**] Discharge Date: [**2131-1-21**]
Date of Birth: [**2093-10-20**] Sex: F
Service:
CHIEF COMPLAINT: Hypercarbic respiratory failure secondary
to bronchiectasis and likely pneumonia.
HISTORY OF PRESENT ILLNESS: This is a 37 year-old year-old
woman with a complicated past medical history including
respiratory distress syndrome, aspergillus and tuberculosis
leading to left pneumonectomy, bronchiectasis, congestive
heart failure and dilated cardiomyopathy. The patient was in
her usual state of health until approximately two days prior
to admission when she noticed an increase in her baseline
shortness of breath, increased sinus drainage and secretions,
increased coughing, which was productive of green sputum.
over the last week and upon contacting Dr.[**Name (NI) 21360**]
nurse [**First Name (Titles) **] [**Last Name (Titles) 2875**] Amoxicillin yesterday for symptoms she
attributed to sinusitis. There was no improvement in her
symptoms for the past day. Her temperature was 99.4 at home.
There were no chills or rigors. No chest pain. No pleuritic
pain. No increase in orthopnea of three pillows baseline.
No change in lower extremity edema. No headache, nausea,
vomiting, visual changes, abdominal pain, urinary or bowel
changes. She noted decreased po intake and decreased
appetite recently. She had also used her BiPAP overnight the
day prior to admission, which she does not always use unless
she is not feeling well. Her mother also gave her chest
physical therapy yesterday.
In the Emergency Department O2 sat 92% on 2 liters increased
to 100% on 2 liters after nebulization. PCO2 was 51,
received .5 mg of Ativan and started on BiPAP, received 1
gram of Ceftriaxone 10 units of insulin, 1 amp of D50, 1 amp
of calcium gluconate for K of 6.4.
PHYSICAL EXAMINATION: Temperature 97.2. Blood pressure
98/43. Heart rate 118. Oxygen saturation 99% on 25% FIO2
BiPAP. General, thin young female in moderate distress with
accessory muscle usage. HEENT extraocular movements intact.
Pupils are equal, round and reactive to light. Slightly dry
mucous membranes. Neck, no JVD, supple. No lymphadenopathy.
Chest, rhonchi on right. No rales or wheezes. No breath
sounds on the left. Status post pneumonectomy. Heart
tachycardic, normal S1 and S2, present S3. Abdomen positive
bowel sounds, nontender, nondistended. G tube in place with
some erythema and induration. Extremities 2+ pitting edema
bilaterally, purplish color bilaterally. Neurological
sedated after Ativan and on BiPAP, later responded
appropriately to questions and moved all extremities.
LABORATORY: Chem 7 138, 6.4, 88, 50, 37, 0.6, 145. Calcium,
magnesium, phos 9.4, 2.0, 4.3. CBC 9.4, 40.8, 267.
Differential 68 neutrophils, 16% bands, 3% lymphocytes, 10%
monocytes, 0 eosinophils, 1 baso, 1 atypical, 1 meta. PT
11.6, PTT 38.7, INR 0.9, arterial blood gases 1:30 p.m.,
7.15/151/294, at 2:25 p.m., 7.19/142/87 on 40% O2 with
lactate of 1.0. Chest x-ray, possible early pneumonia at
right lung base, patchy increased density, some right pleural
thickening versus small effusion, status post left
pneumonectomy. Electrocardiogram sinus tachycardia rate at
113, right axis deviation. No peaked T waves. Normal
intervals, down sloping ST in lead 3. No change compared to
old electrocardiogram. Spirometry FEV1 equals 0.41, 13% of
predicted, FVC equals 0.6, 15% of predicted, FEV1/FVC equals
68 87% of predicted.
HOSPITAL COURSE: 1. Respiratory: The patient has a
baseline elevated CO2 likely due to bronchiectasis with VQ
mismatch as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12794**] effect and decreased
respiratory drive. The CO2 is now elevated above baseline
likely secondary to infection. The patient was treated with
Ceftazidime and Levofloxacin. She received BiPAP as
tolerated during the day as well and Albuterol and Atrovent
nebulizers and chest physical therapy and frequent
suctioning. Sputum cultures grew Xanthemonas. The patient
was not treated with steroids. The patient was initially
treated with intubation and mechanical ventilation, but was
successfully extubated on [**2131-1-16**]. On the [**7-17**] the
patient's blood gas was 7.40/62/181 and it was felt the
patient had improved significantly enough to transfer to
pulmonary rehabilitation or the floor service. The patient
was transferred to the floor, but returned to the Intensive
Care Unit on [**1-18**], with hypercarbic respiratory failure
likely secondary to decreased ability to suction the patient,
provide chest physical therapy and respiratory treatment on
the floor. She continued on BiPAP at night and received 2
liter transtracheal oxygen with saturations in the 100%
range. After intensive suctioning and chest physical therapy
the patient could tolerate even 1 liter transtracheal O2 with
an oxygen saturation on 100% Subacute decline necessitated
reintubation [**2131-1-21**], and eventually patient underwent bedside
percutaneous tracheostomy placement to facilitate ventilation
and allow adequate suctioning. Plan was to work towards
eventual liberation from mechanical ventilation if tolerated..
She is to be screened for and admitted to a pulmonary rehab
facility.
2. Cardiovascular: The patient had no signs of pulmonary
edema on chest film. There was no increase in lower
extremity edema or rales or JVD on admission. However, over
time it was felt that she was gaining weight above her
baseline of approximately 112 to 114 pounds and should be
diuresed especially given the development of crackles in the
right lower lung base. When she returned from the unit to
the floor she received a Lasix drip, which resulted in
greater then 1 liter fluid extraction. She was started on a
po regimen of Lasix, which she could continue as an
outpatient.
3. Infectious disease: The patient was given Ceftazidime
and Levo empirically for coverage of gram negative,
Pseudomonas and pulmonary gram positive and atypical
pathogens. She completed a fourteen day course, but appeared
to have some increasing patchiness in her right lower lobe on
chest film of [**2131-1-18**] and was restarted on Levo and Ceptaz
after a fourteen day course had just completed. In addition
her sputum grew out Stenotrophomonas from the culture and was
sensitive to Bactrim. However, she has a sulfa allergy and a
repeat culture was sent to determine the sensitivity as the
initial plate had been discarded by the laboratory. On
[**1-21**] she remained afebrile with temperature of 98.6.
4. Gastrointestinal: The patient tolerated tube feeds well
and was given Zantac for prophylaxis. She intermittently
took food by mouth having more difficulty with solids then
liquids. However, there were no witnesses of this episode of
severe aspiration.
5. FEN: The patient was initially thought not to be fluid
overloaded, but over time it was noticed that her weight was
increased and a goal was established to diurese her back to
approximately her normal outpatient weight of 114 pounds.
For this reason she was starred on a Lasix drip and titrated
after which she was started on a po Lasix regimen and the
Foley was removed.
6. Psychiatric: The patient expressed significant grief of
the difficulty she is faced due to her medical issues and the
desire for her to go home and refuse care. She was seen by
psychiatry consult who found her to be in acute delirium and
having both passive and active suicidal ideation with plan to
drown herself in the bathtub at times. Psychiatry
recommended her to be started on 15 mg of Remeron q.h.s. to
be initially used for sedation at night, while weaning her
off 1 mg of Ativan she has usually been taking in house, but
then the Remeron could be increased to give as an
anti-depressant dose as an outpatient. An outpatient
psychiatry appointment will be set up before the patient's
discharge so that this issue can be addressed thoroughly.
7. Code: Full.
8. Communication: [**Name (NI) 1356**], mother, sister, Dr. [**Last Name (STitle) 217**].
DISPOSITION: To pulmonary rehabilitation facility, pending.
A discharge summary addendum will be added to this discharge
summary upon the patient's discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (STitle) 18486**]
MEDQUIST36
D: [**2131-1-21**] 14:02
T: [**2131-1-24**] 12:10
JOB#: [**Job Number **]
ICD9 Codes: 5185, 4254, 4589, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1822
} | Medical Text: Admission Date: [**2142-3-1**] Discharge Date: [**2142-3-7**]
Date of Birth: [**2083-10-25**] Sex: M
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old white
male with complicated past medical history including diabetes
mellitus type 1, complicated by retinopathy, nephropathy,
neuropathy, end-stage renal disease status post living
related kidney transplant in [**2130**] now with evidence of
chronic rejection, now on hemodialysis, status post
peritoneal dialysis catheter placement in [**2141-12-9**],
status post recent hospitalizations in [**2142-1-8**] for
choledocholithiasis, and cholecystitis status post ERCP and
cholecystectomy, presented on [**2142-3-1**] with complaints of
abdominal pain, nausea, vomiting, diarrhea, and elevated
systolic blood pressure.
Patient reported that earlier on the day of admission, he had
undergone a session of hemodialysis. While at hemodialysis,
his blood pressures elevated to a systolic blood pressure to
the 220s. Per the patient, his baseline systolic blood
pressure is closer to 150. After hemodialysis, later that
evening, he had the onset of nonbloody, nonbilious emesis,
and diffuse, generalized abdominal pain. At that time, he
had also noted a fever of 102.9 associated with shaking
chills.
REVIEW OF SYSTEMS: Upon admission was negative for chest
pain, shortness of breath, cough, sputum, sick contacts,
rash, medication changes, dysuria, or increased urinary
frequency. Of note, the patient has a history of chronic
loose stools secondary to autonomic insufficiency caused by
his diabetes. He also reports intermittent fevers of unclear
etiology dating back to his open cholecystectomy on [**2142-2-7**].
While in the Emergency Department, he was noted to have a
temperature of 102.0, blood pressure of 227/101, heart rate
of 95, respiratory rate of 22, oxygen saturation of 98% on
room air. While in the Emergency Department, he received
total hydralazine of 10 mg IV x2, Phenergan 25 mg IV x2, and
levofloxacin 500 mg IV x1. He also received Tylenol 650 mg
en route to the Emergency Department.
CT scan of the abdomen and pelvis was performed on [**2142-3-1**],
which noted two postoperative fluid collections with internal
air bubbles, one in the gallbladder fossa, and the other in
the subcutaneous tissue incision line. Per the [**Location (un) 1131**],
could not exclude abscess formation. There is stable
appearance of a transhepatic kidney with one large cyst. Per
Transplant Surgery, the CT findings were consistent with
postoperative changes. However, in light of these findings,
the patient was admitted to the Transplant Surgery service,
and was started on linezolid and levofloxacin for antibiotic
coverage.
During the admission, Surgical staff also noted trauma to the
right great toe. He was seen by Podiatry. Foot x-rays
demonstrated evidence of heavy calcification, but there was
no evidence of acute fracture in the region of the right
great toe. There was noted an old healed fracture of the
fourth metatarsal bone.
While on the Surgical service, he continued to spike
temperatures to 101.3 and 101.5 while on linezolid and
levofloxacin. He also had irregularities in his blood sugar,
for which he is followed by the [**Last Name (un) **] Diabetes consult
service for better blood sugar control. In light of his
complicated medical history and hospital course, he was
transferred from the Transplant Surgical service to the
Medicine service on [**2142-3-5**].
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 1, diagnosed at age 28, complicated
by nephropathy, autonomic insufficiency causing orthostatic
hypotension and gastroparesis, sensomotor neuropathy and
retinopathy resulting in blindness. Last hemoglobin A1C was
on [**2141-12-5**] 7.3.
2. End-stage renal disease on hemodialysis since [**2140-1-9**] via right tunneled Permacath.
3. Status post living related kidney transplant in [**2130**], with
[**Year (4 digits) **] in [**2140**] showing chronic inflammation consistent with
rejection.
4. Status post peritoneal dialysis catheter placement in
[**2141-12-26**].
5. Status post recent hospitalization on [**1-/2142**] for
choledocholithiasis complicated by cholecystitis status post
ERCP and sphincterotomy, status post cholecystectomy in
[**2142-2-7**] complicated by postoperative fevers, treated with
Vancomycin and Zosyn. He was transferred to the Surgical ICU
after a period of unresponsiveness. Workup failed to reveal
etiology of fevers. He was discharged to rehabilitation
facility with one week of Augmentin therapy.
6. Recurrent presumed aspiration pneumonia with history of
hypoxic respiratory failure requiring intubation in [**2141-12-9**], bronchoalveolar lavage negative for organism.
Transbronchial [**Year (4 digits) **] in [**12/2141**] with patchy interstitial
fibrosis, status post VATS with right lower lobe wedge [**Year (4 digits) **]
with patchy acute and organizing pneumonia.
7. Multiple pulmonary nodules.
8. MGUS with SPEP significant for monoclonal IgG spikes,
status post bone marrow [**Year (4 digits) **] in [**2140-2-9**]. In [**2140-9-8**] with increased plasma cells.
9. Obstructive-sleep apnea.
10. Anemia of chronic disease secondary to renal disease.
11. History of left lower extremity DVT.
12. Coronary artery disease status post non-ST-elevation
myocardial infarction in [**2140-3-11**], status post PTCA
and stent to distal LAD [**7-10**]. Catheterization at that time
also with mild diffuse disease of the right coronary artery
and left circumflex artery. Persantine MIBI in [**2142-1-11**]
showed fixed severe apical perfusion defects with moderate
size partially reversible defects in the inferior wall and
septum. Unchanged from prior study of [**2141-2-8**].
13. CHF with echocardiogram in [**2141-8-8**] with an ejection
fraction of 40%.
14. History of right pontine lacunar infarction.
15. Gastroesophageal reflux disease with history of Barrett's
esophagitis.
16. Diverticulosis.
17. History of Clostridium difficile infection.
18. History of methicillin-resistant Staphylococcus aureus
bacteremia complicated by septic pulmonary emboli and
empyema.
19. History of hypoglycemic coma in [**2141-5-9**] and
[**2141-12-9**].
20. Hypertension.
21. History of nasopharyngeal swab positive for MRSA in
[**2141-12-9**].
22. Hypothyroidism.
MEDICATIONS PRIOR TO ADMISSION:
1. Midodrine 5 mg p.o. t.i.d.
2. Prednisone 5 mg p.o. q.d.
3. Levoxyl 25 mcg p.o. q.d.
4. Nephrocaps.
5. Calcium carbonate 500 mg p.o. b.i.d.
6. Calcitriol 0.25 mcg p.o. q.d.
7. Protonix 40 mg p.o. q.d.
8. Nifedipine SR 60 mg p.o. q.d.
9. Calcium acetate 1334 mg p.o. t.i.d.
10. Isosorbide sustained release 90 mg p.o. q.d.
11. Colace 100 mg p.o. b.i.d.
12. Neurontin 300 mg p.o. b.i.d.
13. Pravastatin 40 mg p.o. q.d.
14. Atenolol 200 mg p.o. q.d.
15. Lantus 30 units subcutaneous q.h.s.
16. Epogen 20,000 units subcutaneous twice a week.
17. Insulin Lispro q.i.d. with meals.
18. Sublingual nitroglycerin 0.3 nanograms sublingual prn
chest pain.
ALLERGIES: Patient reports allergies to Compazine and
dicloxacillin resulting in nausea and vomiting.
SOCIAL HISTORY: The patient lives with his wife and
daughter. [**Name (NI) **] is a former military officer. He reports a 20
pack year tobacco history, but quit approximately 20 years
ago. He denies any alcohol or IV drug use. He has a distant
history of [**Doctor Last Name 360**] [**Location (un) 2452**] exposure.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM UPON ADMISSION: T max 100.7, blood pressure
160/84, heart rate 82, respiratory rate 18-20, and oxygen
saturation 100% on room air. Fingerstick blood glucose 189.
General appearance: Well-developed and well-nourished white
male, comfortable in no acute distress. HEENT:
Normocephalic, atraumatic. Right eye with cataract and
ptosis. Left pupil with post surgical changes. Sclerae are
anicteric. Mucous membranes moist. Oropharynx clear. Neck:
Supple, no masses, or lymphadenopathy. No jugular venous
distention. No carotid bruits. Lungs: Fair inspiratory
effort. Clear to auscultation bilaterally, no rhonchi,
rales, wheezes. Cardiac: Regular rate and rhythm, normal
S1, S2 heart sounds auscultated. Grade [**3-16**] holosystolic
murmur heard best at apex with radiation to axilla. No rubs
or gallops. Abdomen: Soft, nontender, nondistended,
positive normoactive bowel sounds, peritoneal catheter in
place with no erythema, edema, or exudates. Positive post
surgical/post cholecystectomy wound in the right upper
quadrant with overlying bandage clean, dry, and intact.
Extremities: No clubbing or cyanosis, trace pretibial edema.
Multiple healed lesions on shins and toes. Left ankle
indicative of Charcot joint. Extremities warm with good
capillary refill. Two plus dorsalis pedis pulses. Right
great toe bandage clean, dry, and intact. Neurologic: Alert
and oriented times three. No evidence of asterixis.
PERTINENT LABORATORIES, X-RAYS, AND OTHER STUDIES: Complete
blood count on transfer showed a WBC of 7.9, hematocrit 25.4,
platelets 215. Serum chemistry demonstrated a sodium of 136,
potassium 3.7, chloride 98, bicarbonate 25, BUN 48,
creatinine 6.6, glucose 211. Liver function tests showed ALT
11, AST 19, alkaline phosphatase 108, total bilirubin 0.4.
[**Month/Day (4) **] studies were pending at the time of this dictation.
Microbiological data demonstrated serial blood cultures from
[**2142-3-1**], [**2142-3-2**], [**2142-3-3**], and [**2142-3-5**] demonstrating no
growth to date. Urine culture from [**2142-3-2**] was negative. A
wound swab of his right hallux ulcer demonstrated no
polymorphonuclear cells, no microorganisms. Culture had
evidence of rare coagulase positive Staphylococcus aureus.
Peritoneal dialysis fluid sample from [**2142-2-21**] demonstrated
one sample with 2+ polymorphonuclear, 2+ gram-positive cocci
in pairs, chains, clusters with culture demonstrating
coag-positive Staphylococcus aureus, oxacillin sensitive.
Second culture from [**2142-2-21**] demonstrated 3+
polymorphonuclear cells with sparse Enterococcus species
faecium, sensitive to Synercid, minocycline, and linezolid.
Followup peritoneal dialysis fluid culture on [**2142-3-3**]
demonstrated no polymorphonuclear cells, no microorganisms,
and fluid culture with no growth.
PA and lateral chest x-ray from [**2142-3-1**] demonstrated the
heart size and mediastinal contours were normal. Central
venous line terminated within the mid right atrium. The
pulmonary vascularity was normal with no evidence of failure.
There was scarring at the right lung base with old rib
fractures in the right that appeared unchanged compared with
prior radiographs. There was atelectasis noted at the left
lung base. There was no evidence of pneumothorax or pleural
effusion. The osseous structures were unremarkable aside
from the old right healed rib fractures. There was a
pulmonary parenchymal opacity at both lung bases that was
likely consistent with atelectasis.
CT scan of the abdomen and pelvis from [**2142-3-1**] noted two
postoperative fluid collections with internal air bubbles,
one in the gallbladder fossa, and the other in the
subcutaneous incision line. [**Location (un) **] could not exclude
abscess formation. There is stable appearance of a
transplanted kidney with one large cyst.
EKG demonstrated sinus rhythm at 90 beats per minute with
normal intervals. The axis leftward deviated. There was
evidence of left atrial enlargement and borderline left
ventricular hypertrophy with T-wave inversions in I, aVL, V5
through V6 with [**Street Address(2) 4793**] depressions in V6. There was [**Street Address(2) 4793**]
elevations in leads V1 through V3, however, these were not
significantly changed from an [**2141-12-30**] study.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. Fevers: Patient had multiple sources for infection
including tunneled hemodialysis catheter, peritoneal
catheter, his wound infection status post cholecystectomy,
possibility of intraabdominal abscess status post
cholecystectomy, and the traumatic wound to his right great
toe. However, it also felt that fever could be noninfectious
secondary to progression of his MGUS or due to another
malignancy or could be due to worsening rejection of his
transplanted kidney.
However, in light of the clinical history of abdominal pain,
nausea, and vomiting and associated fevers, it was felt
initially the most likely source appeared to be the
peritoneal dialysis catheter. This was also reinforced by
the fact that his peritoneal dialysis catheter was not
functioning well and was not flushing easily. Although prior
to this admission, the peritoneal dialysis catheter had not
been accessed for peritoneal exchange. Decision was made to
attempt to use a catheter in order to attempt to obtain
further culture data as well as to assess its overall
function.
Another confusing factor was that the patient's temperature
spikes seemed to occur after his hemodialysis sessions. This
led to the speculation that perhaps his hemodialysis catheter
was infected, and this could be the culprit of his recurrent
fevers. However, culture data from both his peritoneal
dialysis catheter and his hemodialysis catheter had failed to
reveal any significant causative organism.
While he was on the Surgical service from [**2142-3-1**] to
[**2142-3-5**], the patient was receiving linezolid and Levaquin.
However, as it was not clear what organisms were being
covered with these antibiotics nor was it clear via our
culture data what his source of infection was, decision was
made to discontinue these antibiotics. Infectious Disease
consultation was obtained on [**2142-3-6**]. The Infectious
Disease consultants agreed withholding antibiotics until
further culture data can be obtained.
As the patient was followed by the Renal team, there were
discussions in terms of whether discontinuation of his
peritoneal and hemodialysis catheters would be necessary in
order to remove the multiple lines that could be nidus sites
for infection. At the time of this dictation, that
discussion was still ongoing.
Of note, in addition to the linezolid and Levaquin, the
patient did receive one dose of cefazolin through the
peritoneal dialysis catheter as ordered by the Renal team.
He also had a chest x-ray which ruled out any evidence of
infiltrative process or pneumonia. At the time of dictation,
multiple culture data sets were will pending. His culture
data will be followed while he is the patient in the MICU and
antibiotic coverage adjusted appropriately.
2. Diabetes mellitus type 1: The patient was continued on
diabetic diet with Humalog insulin-sliding scale and glargine
insulin q.h.s. He was followed closely by the [**Last Name (un) **]
Diabetes Center consultation service, and their
recommendations were taken in consideration and implemented.
3. End-stage renal disease on hemodialysis: Patient was
continued on his outpatient prednisone dose for
immunosuppression status post his renal transplant. He was
dialyzed via hemodialysis on a scheduled by the Renal team.
He was continued on Nephrocaps, calcium acetate, and a renal
diet. His peritoneal dialysis catheter was accessed as per
Renal's recommendations with multiple culture samples sent
for evaluation of the peritoneal dialysis catheter as his
source of infection.
4. Coronary artery disease: On initial presentation, there
was no clinical history suggest active coronary artery
disease. Patient was initially continued on nifedipine,
Imdur, atenolol, Pravastatin, and aspirin. His amlodipine
was discontinued in order to streamline his medication
regimen somewhat.
However, on the evening of [**2142-3-6**], the patient experienced
an episode of hypoxia in which he dropped his oxygen
saturation level to the mid 80s on room air. He was
therefore transferred to the Medical Intensive Care Unit for
evaluation of his hypoxemia with a differential that was
related to volume overload versus transfusion reaction versus
possible coronary ischemic event. At the time of this
dictation, the determination of that is still being
evaluated.
5. Neuropathy: Patient was continued on Neurontin. The
Podiatry service followed him for his right great toe injury
and felt that there was no evidence of any underlying
infection or fracture. They made recommendations as to wound
changes which were appreciated.
6. Hypertension: Patient is continued on atenolol, Imdur,
nifedipine. These medications were to be titrated up for
better blood pressure control. As he also has a history of
severe orthostasis, he was continued on midodrine in light of
history of autonomic insufficiency. As stated above,
amlodipine was discontinued from his medication regimen
during this hospitalization.
7. Hypothyroidism: Patient was continued on his outpatient
dose of Levoxyl.
8. Anemia: Patient continues to receive Epogen twice weekly
at hemodialysis. As there was a slow downward trend of his
hematocrit on [**2142-3-6**], he underwent transfusion of 1 unit of
packed red blood cells. Chest x-ray prior to this did not
demonstrate any evidence of fluid overload. However, during
the transfusion, the patient had an episode of hypoxemia as
well as elevated systolic hypertension. Transfusion was
discontinued at that time. He was transferred to the Medical
Intensive Care Unit for further evaluation and treatment.
The results of that portion of his hospital course will be
dictated as a separate addendum to this report.
9. Fluids, electrolytes, and nutrition: Patient was
maintained on a diabetic and renal diet. Electrolytes were
followed and repleted as needed.
10. Prophylaxis: Patient was maintained on a bowel regimen,
Tylenol, subQ Heparin for DVT prophylaxis, and Ambien for
sleep.
11. Code status: Patient is full code.
12. Disposition: As outlined above, the patient had an
episode of hypoxemia and elevated systolic blood pressure on
[**2142-3-6**]. As they was concern for possible transfusion
related reaction versus fluid overload resulting in
congestive heart failure, the patient was transferred to the
Medical Intensive Care Unit. The results of that portion of
his hospitalization will be dictated as a separate addendum
to this report.
In addition, a separate addendum will be dictated denoting
the remainder of his hospital course, post discharge
medications, and follow-up plans.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D. [**MD Number(1) 11866**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2142-3-7**] 16:43
T: [**2142-3-8**] 06:53
JOB#: [**Job Number 20636**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1823
} | Medical Text: Admission Date: [**2177-9-27**] Discharge Date: [**2177-10-8**]
Date of Birth: [**2177-9-27**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname **] was born at 35-0/7 weeks gestation to
a 33-year-old G2, P1, now 2 mother with prenatal screen of
blood type O positive, antibody negative, HBsAg negative, RPR
nonreactive. Past obstetric history was maternal pregnancy-
induced hypertension at term. This pregnancy was unremarkable
until recent development of PIH. Mother was admitted for
induction on magnesium sulfate. She had rupture of membranes
2 hours prior to delivery, received intrapartum antibiotics
14 hours prior to delivery, had no maternal fever, was a
normal spontaneous vaginal delivery with Apgars of 8 and 9 at
1 and 5 minutes.
PHYSICAL EXAMINATION ON ADMISSION: Weight was 2370 g, which
is 50th percentile, length of 45.5 cm which is 25th-50th
percentile, head circumference of 23.5 cm, which is 50th
percentile. Exam showed a well-appearing preterm infant in no
respiratory distress with normal vital signs, pink and well
perfused, normal facies. Anterior fontanelle was soft and
flat. Intact palate. No neck masses. No grunting, flaring or
retracting, clear and equal breath sounds, no murmur, present
femoral pulses, flat, soft and nontender abdomen with no
hepatosplenomegaly, stable hips, normal perfusion, normal
tone and activity.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The
infant has remained on room air since birth and has required
no oxygen therapy, although the infant did develop some
desaturations with oral feedings, none requiring
methylxanthine therapy. The infant has not had any
desaturations with feeding for 5 days as of [**2177-10-8**].
CARDIOVASCULAR: The infant has maintained a normal
hemodynamic status with no murmurs audible, normal heart rate
and rhythm, normal blood pressure, pink and well perfused.
FLUIDS, ELECTROLYTES AND NUTRITION: The infant was started on
ad lib feedings on the newborn day and has been feeding p.o.,
PG initially and then started to p.o. feed well and has been
ad lib demand feeding now for over a week and is just about
at birth weight at this point. Today's weight is 2370 gm.
GI: The infant has had very mild hyperbilirubinemia, not
requiring any phototherapy, with a peak bilirubin level of
7.9/0.3.
HEMATOLOGY: No blood typing has been done on this infant. No
CBCs have been measured. No blood product transfusions have
been administered.
INFECTIOUS DISEASE: CBCs and blood cultures were not done.
There have been no infectious issues.
NEUROLOGY: The infant has maintained a normal neurologic exam
for gestational age.
SENSORY: A hearing screen was performed prior to discharge:
both ears passed
PSYCHOSOCIAL: [**Hospital1 18**] social worker has been in contact with
the family. There are no active ongoing psychosocial issues
at this time. If the [**Hospital1 18**] social worker needs to be reached,
the telephone number is [**Telephone/Fax (1) 8717**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the family.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **] from [**Hospital **] Pediatrics,
telephone number [**Telephone/Fax (1) 49828**].
CARE RECOMMENDATIONS: Ad lib p.o. feedings of breast milk or
breastfeeding, supplementation as needed.
MEDICATIONS: None.
CAR SEAT SCREENING: Passed prior to discharge.
IMMUNIZATIONS RECEIVED: The hepatitis B vaccine was given on
[**2177-10-1**].
STATE NEWBORN SCREEN: Sent on day of life 3 and the results
are pending.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria:
1. Born at less than 32 weeks gestation.
2. Born between 32 and 35 weeks gestation with 2 of the
following - day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings.
3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP: Follow-up appointment is recommended with the
pediatrician within 48 hours of discharge from the NICU.
DISCHARGE DIAGNOSES: Prematurity, mild hyperbilirubinemia,
resolved, feeding discoordination, resolved.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2177-10-7**] 22:17:31
T: [**2177-10-8**] 04:58:40
Job#: [**Job Number 68542**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1824
} | Medical Text: Admission Date: [**2145-10-19**] Discharge Date: [**2145-10-26**]
Date of Birth: [**2064-4-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Fall, possible syncope, altered mental status
Major Surgical or Invasive Procedure:
Intubation
Extubation
History of Present Illness:
Mr. [**Known lastname 87545**] is an 81 yo M with PMH CAD s/p CABG in [**2125**], ICD
placed in [**2142**] for ischemic cardiomyopathy, recently admitted in
[**7-/2145**] for fascicular VT s/p lidocaine and sent home on
amiodarone, who presents with syncope, fall, and AMS. Pt's
family notes that patient has been falling lately, thought to be
secondary to leg weakness. Has been acting "out-of-it" lately
and almost "drunk-like". Yesterday he fell and hurt his arm but
did not seek medical care. Today, he was "out-of-it" in presence
of daughter, who helped him sit down and then called EMS. There
was no observed LOC. Pt was intubated at [**Hospital1 **] [**Location (un) 620**] for
obtundation and transfered to [**Hospital1 18**]. During transport, pt had
what looked like VT in ambulance (no strip available), he was
given 100mg Lidocaine IV, and Kayexalate 30mg for K+ 6.5. He is
currently AV paced at 60 BPM.
Head and torso CT done at [**Location (un) 620**] showed no pathology, L arm
noted to be significantly bruised (on plavix). In ED, vitals
were HR 60, BP 106/47, CMV asst mode, afebrile. Pt had neg CXR
and UA. K+ was 5.4 and Cr increased from 0.9 baseline to 2.0.
For hyperkalemia, pt received 8 units of insulin, amp of d50,
and 1 amp of calcium gluconate. Trop was elevated at 0.09, CK
107, MB 6- elevated trop was attributed to his renal
insuficiency. He was given rectal ASA. An Xray of left arm
eccymosis showed contrast extravasation into hand on left side
(from IV site). Plastics saw pt in ED and recommended ace
bandage. Pt has a right femoral a-line in place.
Past Medical History:
Dyslipidemia, Hypertension
CABG: x3 in [**2125**] - unknown anatomy
PACING/ICD: ICD placed in [**2142**] due to results of holter monitor.
VT episode in 8/[**2144**].
Prostate cancer s/p radiation [**2126**], cryosurgery [**2130**]
IBS
Gastro-esophageal spasms
Osteoarthritis
COPD
Total knee replacement
Fractured vertebrae [**4-/2145**]
Social History:
-Tobacco history: quit smoking 33 years ago, smoked 3-4ppd for
34 yrs
-ETOH: sober for 47 years
-Illicit drugs: denies
Family History:
Mother passed at 79 from CHF, father passed at 65 with lung
cancer.
Physical Exam:
Vitals: T:99.2 BP:94 P:61 (v-paced) R:25 O2: 98%/2L
General: sleepy, responsive, AAOx2
HEENT: Sclera anicteric, mucous membranes tacky, oropharynx
clear
Neck: supple, JVP not assessed, no LAD
Lungs: ronchorous bilaterally, likely transmitted upper airway
sounds
CV: difficult to assess
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, thready peripheral pulses, no
clubbing, cyanosis or edema
Skin: multiple bruises over all extremeties
Neuro: AAOx2, registers [**2-24**], recalls [**1-27**] @ 10 min, cannot
perform days of the week backwards. Rest of mental status exam
deferred.
Pertinent Results:
Admission labs:
[**2145-10-19**] 08:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
[**2145-10-19**] 08:45PM URINE RBC-21-50* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2145-10-19**] 08:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2145-10-19**] 08:45PM PT-13.9* PTT-24.0 INR(PT)-1.2*
[**2145-10-19**] 08:45PM WBC-7.9 RBC-3.53* HGB-9.9* HCT-31.5* MCV-89
MCH-28.1 MCHC-31.4 RDW-14.7
[**2145-10-19**] 08:45PM NEUTS-78.8* LYMPHS-11.0* MONOS-8.8 EOS-0.8
BASOS-0.6
[**2145-10-19**] 08:45PM CALCIUM-9.6 PHOSPHATE-3.3 MAGNESIUM-2.4
[**2145-10-19**] 08:45PM cTropnT-0.09*
[**2145-10-19**] 08:45PM CK-MB-6
[**2145-10-19**] 08:45PM LIPASE-18
[**2145-10-19**] 08:45PM ALT(SGPT)-40 AST(SGOT)-104* CK(CPK)-107 ALK
PHOS-62 TOT BILI-0.8
Imaging:
Left humerus X-ray
These two exams consist of AP and oblique views of left humerus
and left
forearm. Extensive changes in the soft tissues, probably relate
to overlying bandage with suboptimal assessment. Marked
generalized demineralization. No fracture identified although
this assessment not ideal and I have no localizing history.
Carpus is inadequately assessed with apparent irregularity of
the carpal navicular bone. Incidental pulse generator in the
partially visualized tissues of the left hemithorax. The
acromiohumeral soft tissues are probably diminished consistent
with rotator cuff attenuation.
IMPRESSION: No fracture.
Knee X-ray
AP and lateral cross-table views left knee. There is
satisfactorily
positioned three-part total knee prosthesis without evidence of
loosening (no comparison radiographs at this facility). There is
considerable soft tissue swelling about the knee particularly
anteriorly in relationship to the patellar tendon. No fracture
or bone destruction. A small suprapatellar effusion is present
(I doubt the presence of fat-fluid level although this is
suboptimally assessed). Vascular calcifications.
IMPRESSION: No fracture identified.
Chest X-ray
IMPRESSION: Mild pulmonary edema with small left pleural
effusion.
Retrocardiac opacity likely reflects atelectasis, but developing
infection
cannot be excluded. Endotracheal tube and nasogastric tubes in
standard
positions.
Echo:
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD (PDA distribution). Moderate mitral regurgitation. Pulmonary
artery hypertension. Compared with the prior report (images
unavailable for review) of [**2145-8-9**], the findings are similar.
CT Head:
IMPRESSION:
1. No evidence of acute intracranial process.
2. No CT evidence of incracranial mass. Note MRI with gadolinium
is more
sensitive for small mass if not contraindicated.
3. Age-related involution and mild, if any underlying small
vessel ischemic
disease.
CT Chest:
IMPRESSION:
1. Bilateral small-to-moderate loculated pleural effusions, with
adjacent
atelectasis. Cannot exclude superimposed infectious process.
2. No lung masses. No mediastinal, hilar or axillary
lymphadenopathy.
3. Marked cardiomegaly. Dual chamber ICD. No significant
pericardial
effusion.
4. Markedly tortuous and moderately calcified descending aorta.
Significant
coronary artery disease
Discharge Labs:
Brief Hospital Course:
81 y.o. M history of CAD, CHF with AICD placed, recent admission
for VT s/p home amiodarone therapy, who is admitted for
possible syncopal episode, altered mental status, and acute
renal failure.
#. RHYTHM: Given recent hospitalization for VT, there was
initial concern that his event was secondary to an underlying
arrhtymia. Pt came to [**Hospital1 18**] intubated and was transfered to the
CCU. EP consult interrogated pacer and found that patient had
not been in V. Tach and was unlikely the source of his
presenting symptoms. He was continued on his home daily
amiodarone medication while inpatient. On the morning of
[**2145-10-25**], he had a 15-beat run of tachyarrhythmia that resolved
spontaneously. Mr. [**Known lastname 87545**] was asymptomatic throughout the
episode. His metroprolol was increased from 25mg [**Hospital1 **] to 25mg TID
for better rhythm control.
.
#. Syncope/Fall/AMS: Unclear if this episode involved any LOC.
Per family, pt has been in his usual state of health ([**Location (un) 1131**] 3
newspapers a day, lucid, no memory impairment) and around 1 week
prior to admission has been acting different. Further discussion
with his son [**Name (NI) 87546**] that he has had prior issues with self
medication management and it is unclear if he has been using
narcotic pain medicine for back pain. Infectious etiology workup
was unrevealing, urine and blood cx negative. PPD was negative.
Home gabapentin therpay was held while inpatient. Geriatricas
was consulted and they agreed that polypharmacy was a possible
eitology of his AMS . A Urine drug tox was negative. The most
likely etiology of his AMS is benadryl abuse. The patient and
family were educated about the risk of benadryl. Pts mental
status returned to baseline by [**2145-10-25**], and per family even
better than baseline.
.
#. Acute kidney injury: Baseline Cr 0.9 --> increased to 2.0 on
this admission. Etiology secondary to CHF and poor forward flow
since Cr improved with lasix.
On discharge Cr had returned to [**Location 213**].
.
# CORONARIES: Patient with known coronary disease, s/p CABG
with triple bypass in [**2125**]. Reports a diagnosis of Prinzmetals
angina, responsive to sublingual nitro. Cardiac biomarkers
mildly elevated at 0.09-0.10 on admission and then peaked up to
0.73 in the setting of an elevated CK-MB. No EKG changes or
chest pain, likely demand ischemia event. Trop continued to
trend upwards without chest pain or findings on ECG. CK-MB
remained flat indicating that pt was not having a repeat even.
BB was adjusted from metoprolol succinate 75mg [**Hospital1 **] to Metoprolol
tartate 50mg [**Hospital1 **] secondary to low blood pressures. His pressures
improved and was ultimatly discharged home on metoprolol
tartrate 25mg TID.
CCU team feels that Pt would benefit from outpatient stress and
possible cath as an outpt. Currently pt is on the appropriate
medical regimen. Ace inhibitor would be appropriate though at
the current time pts BP does not allow for it. This medication
should be started as an outpt.
.
# PUMP: New Echo on this admission had similar findings to Echo
on [**8-9**]. LVEF 30-35%. BNP elevated at 18,000 on this admission.
Pt found to have CHF exacerbation resulting in poor forward flow
and ARF. Pt was diuresed with lasix and renal function improved.
Spironolactone was held on admission due to K=5.4. Pt also takes
Lisinopril 2.5mg at home which was also held. He was discharged
home on his home medications.
.
#: Resp: The patient was intubated and vented for AMS and airway
protection. By the morning of [**10-20**] (around 12 hrs after
admission), the patient had been successfully extubated. He had
no additional respiratory distress for the remainder of his ICU
stay. On the floor pt continued to well with an episode of
wheezing c/w asthma flare at baseline. Tx with home regimen plus
albuterol neb.
.
Discharged to [**Hospital 745**] [**Hospital **] Rehab.
Medications on Admission:
1. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
HOLD
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take two times a day for 1 month. Then take one times a
day.Disp:*120 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO BID (2 times a day).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) capsule Inhalation once a day.
Discharge Medications:
1. gabapentin 100 mg Capsule Sig: One (1) Capsule PO twice a
day.
2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO bid.
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1196**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary: Altered mental status, acute renal failure
Secondary: acute systolic heart failure, asthma
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 seen and treated at [**Hospital1 18**] for altered mental status,
congestive heart failure and renal failure. You were initially
treated in the ICU and then transferred to medical floor. While
in the ICU you were found to have strain on your heart likely
from your congestive heart failure. This improved during your
stay. Your kidney failure was treated with medications and
fluids and improved back to normal. Your mental status changes
were likely due to overuse of benadryl. You were seen by a
gerontologist and you and your family were educated on the
dangers of this medication in the elderly.
We made oone change to your medications:
1) we changed your metoprolol dose to metoprolol 25mg three
times a day.
Please continue your other home medications as prescribed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with your PCP within one week of discharge from
rehab.
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Address: [**Street Address(2) 12840**],[**Apartment Address(1) 12841**], [**Location (un) **],[**Numeric Identifier 53683**]
Phone: [**Telephone/Fax (1) 10813**]
Completed by:[**2145-10-27**]
ICD9 Codes: 5849, 2724, 4019, 4280, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1825
} | Medical Text: Admission Date: [**2121-4-26**] Discharge Date: [**2121-5-2**]
Date of Birth: [**2048-5-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
weakness, abdominal pain
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] with stent placement
History of Present Illness:
Pt is a 72 y.o female with h.o metastatic [**First Name3 (LF) 499**] cancer to the
liver s/p colostomy and urostomy ~6 years ago, no longer on
chemo, who presented from home with 3 days of generalized
weakness, fatigue, anorexia and [**8-1**] throbbing RUQ abdominal
pain. Pt reports she has not eaten for 3 days due to fear of
nausea and abdominal pain. Denies change in stool in ostomy
(increase or decrease or blood/black), constipation, dysuria,
but does report urine has appeared darker than usual. Otherwise,
denies fever, chills, weight gain/loss, ST, URI, cough, cp,
palpitations, rash, joint pain, paresthesias, weakness,
headaches, dizziness.
.
Pt's daugther reports that pt has had recurrent
choledocholithiasis with [**Month/Year (2) **] and stent at [**Last Name (un) 1724**]. Last [**Last Name (un) **] 1
month ago with stent extraction per pt's dtr. Pt was told she
would need a CCY to prevent future recurrences.
.
In the ED, INnitial vitals
T98.2, BP 114/79, HR 80, RR 16, sat 97% on RA
recent T 99, BP 132/68, HR 110-113, RR 18-20 sat 96-100%
Pt underwent an u/s that showed biliary dilation. Pt was given
IV vanco and flagyl and PO keppra.
Past Medical History:
-metastatic [**Last Name (un) 499**] cancer with metastatis to the liver, off chemo
for at least 6 months. S/p surgery resection colostomy and
urostomy
-recurrent choledocholithiasis
-seizure disorder
-depression/anxiety
-recurrent UTI
Social History:
Pt lives alone. Dtrs nearby and helpful to pt. Denies ever
smoking. Denies ETOH, drug use
Family History:
[**Name (NI) 1094**] mother with [**Name2 (NI) 499**] and breast ca
pt's dtr with breast ca
Physical Exam:
GEN:
NAD, lying in bed, appears nervous
vitals: T98.8, Bp 114/68, HR 110, RR 20 sat 99% on RA
HEENT: ncat +icterus, MMM
neck: supple, no LAD, no JVD
chest: b/l ae no w/c/r
heart: s1s2 rr no m/r/g
abd: +bs, soft, NT, ND, no guarding or rebound, +ostomy with
brown stool. Urostomy with [**Location (un) 2452**] urine
back: non tender
ext: no c/c/e 2+pulses
neuro: AAOx3, CN2-12 intact, motor [**4-26**] x4, sensation intact to
LT, slight oral and L.hand pill rolling tremor
psych: slightly anxious, cooperative
skin: jaundiced
Pertinent Results:
Labs at [**Last Name (un) 1724**] [**1-/2121**]
tbilo 0.6, alt 25, ast 15, CEA 7.6
.
[**2121-4-26**] 12:16PM GLUCOSE-130* UREA N-18 CREAT-0.9 SODIUM-130*
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-17* ANION GAP-17
[**2121-4-26**] 12:16PM estGFR-Using this
[**2121-4-26**] 12:16PM ALT(SGPT)-148* AST(SGOT)-116* ALK PHOS-892*
TOT BILI-7.4*
[**2121-4-26**] 12:16PM LIPASE-14
[**2121-4-26**] 12:16PM ALBUMIN-3.4* CALCIUM-9.1 PHOSPHATE-1.7*
MAGNESIUM-1.8
[**2121-4-26**] 12:16PM WBC-13.4* RBC-3.76* HGB-10.3* HCT-34.5*
MCV-92 MCH-27.4 MCHC-29.9* RDW-14.0
[**2121-4-26**] 12:16PM NEUTS-91.8* LYMPHS-4.4* MONOS-3.5 EOS-0.3
BASOS-0.1
[**2121-4-26**] 12:16PM PLT COUNT-307
[**2121-4-26**] 12:16PM PT-17.0* PTT-74.4* INR(PT)-1.6*
[**2121-4-26**] 12:14PM LACTATE-1.7
[**2121-4-26**] 12:10PM URINE HOURS-RANDOM
[**2121-4-26**] 12:10PM URINE UHOLD-HOLD
[**2121-4-26**] 12:10PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.007
[**2121-4-26**] 12:10PM URINE BLOOD-TR NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-6.5
LEUK-SM
[**2121-4-26**] 12:10PM URINE RBC-2 WBC-24* BACTERIA-MOD YEAST-NONE
EPI-0
[**2121-4-26**] 12:10PM URINE AMORPH-FEW
.
RUQ u/s:
IMPRESSION:
1. Intra- and extra-hepatic biliary ductal dilatation and some
gallbladder wall sludge. The biliary stent is visualized in the
distal duct. Based on this patient's clinical symptoms
consistent with cholangitis and prior history
of cholelithiasis, [**Year/Month/Day **] would be most beneficial for further
evaluation.
2. Multiple hepatic masses consistent with known metastatic
[**Year/Month/Day 499**] cancer.
.
[**Year/Month/Day **] [**3-27**]:
Impression:
1. Successful balloon sweep of the extrahepatic biliary
ducts.
2. Removal of the double pigtail biliary stent and a
calculus
from the common bile duct.
.
CXR-There are new bilateral consolidations and bilateral pleural
effusions, not seen on the limited view of the CT abdomen. In
addition, there is potentially present left mid lung
consolidation and right apical consolidation. Patient has azygos
lobe, anatomical variant. Heart size is normal. Mediastinal
contours are unremarkable. Port-A-Cath catheter tip is at the
level of mid SVC. Overall, the findings might be consistent with
bilateral effusions and bibasal consolidations reflecting
pneumonia, although atelectasis is another possibility.
Port-A-Cath placement is unremarkable with the tip in the
appropriate
location. Biliary stent is projecting over the right upper
abdomen.
.
Echo:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The 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 structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: No endocarditis, abscess or significant valvular
regurgitation seen. Normal regional and global biventricular
systolic function.
.
MRCP
IMPRESSION:
1. Examination is severely limited and had to be terminated due
to
combination of factors including multiple artifacts noted in the
upper abdomen related to prior surgery and metallic hardware in
the lower abdomen, inability of patient to breath-hold and lack
of peripheral IV line.
2. There are new bilateral pleural effusions and atelectasis in
the lower
lobes bilaterally.
3. Extensive metastatic disease within the left lobe of the
liver with
complex cystic lesion also noted within segment II, which is
more impressive when compared to outside hospital CT from [**Month (only) 958**]
[**2120**].Overall, the size of both the right and left lobes of the
liver have increased by 1 cm (measured craniocaudially)
4. There has been interval decompression of the right
intrahepatic biliary tree when compared to prior outside
hospital imaging. A pigtail stent is noted in the distal common
bile duct with marked decompression compared to prior CT. Sludge
and gallstones are noted dependently within the gallbladder
without evidence for acute cholecystitis. The common bile duct
cannot be assessed in full due to due to artifacts in the upper
abdomen and presence of a double-pigtail stent. However, 3
stones are noted in the distal CBD.
5.The left-sided bile ducts are filled with likely sludge or
even tumor de ris. Tumor is seen surrounding the left
intra-hepatic biliary tree.
:
.
[**2121-4-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2121-4-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2121-4-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2121-4-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2121-4-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2121-4-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2121-4-27**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2121-4-27**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {ENTEROCOCCUS FAECIUM}; Anaerobic Bottle
Gram Stain-FINAL INPATIENT
[**2121-4-27**] 7:15 pm BLOOD CULTURE Source: Line-POC.
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
SENSITIVE TO Daptomycin MIC = 3.0MCG/ML, Sensitivity
testing
performed by Etest.
HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
gentamicin. Screen predicts NO synergy with penicillins
or
vancomycin. Consult ID for treatment options.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
[**Year/Month/Day **]------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
[**2121-4-27**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2121-4-27**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2121-4-26**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2121-4-26**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {VIRIDANS STREPTOCOCCI}; Anaerobic Bottle
Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2121-4-26**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2121-5-2**] 05:45AM BLOOD WBC-6.4 RBC-2.65* Hgb-7.4* Hct-24.3*
MCV-91 MCH-27.9 MCHC-30.5* RDW-15.0 Plt Ct-295
[**2121-5-1**] 05:30AM BLOOD WBC-6.0 RBC-2.75* Hgb-7.4* Hct-24.9*
MCV-90 MCH-27.0 MCHC-29.8* RDW-14.3 Plt Ct-291
[**2121-4-30**] 06:11AM BLOOD WBC-4.5 RBC-2.68* Hgb-7.3* Hct-24.0*
MCV-90 MCH-27.2 MCHC-30.3* RDW-14.2 Plt Ct-292
[**2121-4-29**] 03:04PM BLOOD Hct-26.6*
[**2121-4-29**] 12:50AM BLOOD WBC-6.2 RBC-2.63* Hgb-7.2* Hct-23.6*
MCV-90 MCH-27.4 MCHC-30.5* RDW-14.2 Plt Ct-230
[**2121-4-28**] 02:06PM BLOOD WBC-7.4 RBC-2.77* Hgb-7.6* Hct-25.1*
MCV-91 MCH-27.4 MCHC-30.2* RDW-14.3 Plt Ct-252
[**2121-4-28**] 03:30AM BLOOD WBC-7.2 RBC-2.63* Hgb-7.3* Hct-24.1*
MCV-92 MCH-27.7 MCHC-30.2* RDW-14.0 Plt Ct-224
[**2121-4-27**] 10:39PM BLOOD WBC-7.9 RBC-2.57* Hgb-7.2* Hct-23.5*
MCV-92 MCH-28.0 MCHC-30.5* RDW-14.9 Plt Ct-184
[**2121-4-27**] 07:15PM BLOOD Hct-24.5*
[**2121-4-27**] 03:00PM BLOOD Hct-24.6*
[**2121-4-27**] 05:33AM BLOOD WBC-12.9* RBC-3.03* Hgb-8.5* Hct-27.2*
MCV-90 MCH-28.0 MCHC-31.2 RDW-13.9 Plt Ct-246
[**2121-4-26**] 12:16PM BLOOD WBC-13.4* RBC-3.76* Hgb-10.3* Hct-34.5*
MCV-92 MCH-27.4 MCHC-29.9* RDW-14.0 Plt Ct-307
[**2121-4-28**] 03:30AM BLOOD Neuts-81* Bands-5 Lymphs-7* Monos-3 Eos-2
Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2121-4-28**] 03:30AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
[**2121-4-28**] 03:30AM BLOOD PT-13.8* PTT-29.5 INR(PT)-1.3*
[**2121-5-2**] 05:45AM BLOOD Glucose-90 UreaN-7 Creat-0.7 Na-137 K-4.4
Cl-111* HCO3-23 AnGap-7*
[**2121-5-1**] 05:30AM BLOOD Glucose-89 UreaN-3* Creat-0.6 Na-139
K-3.7 Cl-110* HCO3-23 AnGap-10
[**2121-4-30**] 06:11AM BLOOD Glucose-97 UreaN-5* Creat-0.6 Na-139
K-3.9 Cl-111* HCO3-23 AnGap-9
[**2121-4-29**] 12:50AM BLOOD Glucose-119* UreaN-6 Creat-0.7 Na-135
K-3.6 Cl-111* HCO3-21* AnGap-7*
[**2121-4-28**] 02:06PM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-138 K-4.1
Cl-112* HCO3-20* AnGap-10
[**2121-4-28**] 03:30AM BLOOD Glucose-66* UreaN-9 Creat-0.6 Na-141
K-4.1 Cl-116* HCO3-19* AnGap-10
[**2121-4-27**] 07:15PM BLOOD Glucose-82 UreaN-9 Creat-0.7 Na-142 K-4.4
Cl-117* HCO3-19* AnGap-10
[**2121-4-27**] 05:33AM BLOOD Glucose-113* UreaN-10 Creat-0.8 Na-135
K-3.0* Cl-108 HCO3-19* AnGap-11
[**2121-4-26**] 12:16PM BLOOD Glucose-130* UreaN-18 Creat-0.9 Na-130*
K-3.6 Cl-100 HCO3-17* AnGap-17
[**2121-5-2**] 05:45AM BLOOD ALT-25 AST-23 AlkPhos-556* TotBili-1.7*
[**2121-5-1**] 05:30AM BLOOD ALT-31 AST-25 AlkPhos-530* TotBili-1.9*
[**2121-4-30**] 06:11AM BLOOD ALT-37 AST-25 AlkPhos-482* TotBili-2.1*
[**2121-4-29**] 12:50AM BLOOD ALT-46* AST-28 CK(CPK)-33 AlkPhos-440*
TotBili-2.2*
[**2121-4-28**] 03:30AM BLOOD ALT-55* AST-32 LD(LDH)-179 AlkPhos-437*
TotBili-3.1*
[**2121-4-27**] 05:33AM BLOOD ALT-99* AST-63* AlkPhos-657* TotBili-6.0*
[**2121-4-26**] 12:16PM BLOOD ALT-148* AST-116* AlkPhos-892*
TotBili-7.4*
[**2121-4-26**] 12:16PM BLOOD Lipase-14
[**2121-5-2**] 05:45AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.8
[**2121-5-1**] 05:30AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.0
[**2121-4-30**] 06:11AM BLOOD Calcium-7.5* Phos-2.7 Mg-2.3
[**2121-4-29**] 12:50AM BLOOD Calcium-7.0* Phos-2.6* Mg-1.9
[**2121-4-28**] 02:06PM BLOOD Calcium-7.8* Phos-2.5* Mg-2.3
[**2121-4-27**] 07:15PM BLOOD Calcium-7.9* Phos-2.8 Mg-1.5*
[**2121-4-27**] 05:33AM BLOOD Calcium-7.3* Phos-3.2 Mg-1.6
[**2121-4-26**] 12:16PM BLOOD Albumin-3.4* Calcium-9.1 Phos-1.7* Mg-1.8
[**2121-4-30**] 06:11AM BLOOD CEA-7.3* AFP-2.0
[**2121-4-27**] 07:20PM BLOOD Lactate-0.8
[**2121-4-26**] 12:14PM BLOOD Lactate-1.7
[**2121-4-30**] 06:33AM BLOOD CA [**27**]-9 -PND
Brief Hospital Course:
Assessment/Plan:
Pt is a 72 y.o female with h.o metastatic [**Year (2 digits) 499**] cancer with
known metastasis to the liver, depression, who presented with
weakness and was found to have cholangitis and enterococcal and
strep viridans sepsis.
.
#Sepsis-due to polymicrobial bacteremia (VRE, strep viridans)
and due to cholangitis/biliary obstruction. Pt was found to have
fever, RUQ pain, transaminitis and bile duct obstruction. She
was started on cipro and flagyl upon admission as well as IV
vanco given her recent instrumentation/[**Year (2 digits) **] at OSH 1 month ago
with stent pull. Pt underwent an [**Year (2 digits) **] on [**4-27**] finding biliary pus
and a large obstructing stone that could not be removed. A
plastic stent was placed. Pt will need a repeat [**Month/Day (4) **] in 1 month
at [**Hospital6 1597**] for stent extraction. The day of pt's
[**Hospital6 **], she developed severe sepsis and required many liters of
IVF. She was transferred to the ICU after the [**Hospital6 **] for further
monitoring. In the ICU, pt received continued aggressive IVFs.
Her BP improved and she was then transferred back to the medical
floor. Initial BCX from the periphery grew strep viridans and
another BCX in the setting of hypotension grew VRE from the port
sample. AFter this, the ID service was consulted. The final ID
recommendation was to place pt on IV daptomycin during admission
and switch to [**Hospital6 11958**] to complete a 2 week total course for
bacteremia (600mg [**Hospital6 11958**] [**Hospital1 **]), 11 more days after discharge.
Port/line infection was considered. However, only 1 blood
culture from the line was positive with subsequent cultures
negative and prior cx's negative. It was not recommended that
the patient have her line/port removed at this time unless
subsequent cultures return positive. Pt will be treated with
cipro/flagyl for 10 days for cholangitis. TTE did not show
endocarditis. LFTs improved as did jaundice.
-would recommend weekly cbc, lfts, chem 7 while on [**Hospital1 11958**] and
given recent cholangits.
MONITOR CLOSELY FOR SEROTONIN SYNDROME WHILE PT IS ON [**Name (NI) **]
AND SSRI
.
#biliary obstruction/obstructive jaundice/transaminitis-Pt with
known liver mets and history of cholangitis/cholelithiasis. Pt
presented this admission with sepsis and cholangitis. The
physicians at [**Last Name (un) 1724**] had been recommending that the patient undergo
consultation with Dr. [**Last Name (STitle) 7504**] at [**Hospital1 18**] for consideration of CCY
and ?hepatic metastasis resection. MRCP was performed showing
progression of hepatic metastasis as well as cholelithiasis and
biliary sludge. The patient was discussed at hepatobiliary
surgical conference. The team will likely be performing a CCY in
the outpatient setting after treatment for
cholangitis/bacteremia. The appointment has been set up with Dr.
[**MD Number(4) 110191**] below. Pt will need a repeat [**MD Number(4) **] in 1 month's time
for stent extraction at [**Hospital6 2561**].
.
#metastatic [**Hospital6 499**] cancer-s/p resection, urostomy, ileostomy-Pt
is no longer on chemo x 6 months. MRCP and U/S revealed the
presence of hepatic metastasis. Pt should follow up with her
outpatient oncologist for further care.
.
#Urinary tract infection-Pt treated with ciprofloxacin.
.
#non-gap metabolic acidosis-resolved
.
#anemia, normocytic-no current suggestion of active bleeding.
Anemia worsened after agressive IVF. HCT upon discharge 24.3. No
signs of active bleeding during admission.
.
#seizure d/o-continued keppra.
.
#depression/anxiety-continued venlafaxine/clonazepam. Social
work was consulted.
PLEASE MONITOR FOR SEROTONIN SYNDROME WHILE PT IS ON AN SSRI
.
#FEN-regular low fat
.
#ppx-hep SC TID
.
#access-PIV
.
#communication-letter sent to PCP, [**Name10 (NameIs) **] Team
HCP [**Name (NI) **] [**Telephone/Fax (1) 110192**]
.
#code-full, discussed with pt and HCP
Medications on Admission:
clonazepam 0.5mg [**Hospital1 **]
ciprofloxacin 500mg [**Hospital1 **]
levetiracetam 500mg [**Hospital1 **]
venlafaxine ER 75mg daily
cyanocobalamin 500mcg, 2 tabs daily
ferrous sulfate 325mg daily
prochlorperazine 10mg suppository daily
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
4. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
once a day.
7. [**Hospital1 11958**] 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 11 days: MONITOR FOR SEROTONIN SYNDROME.
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
12. heparin lock flush (porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
13. Outpatient Lab Work
WEEKLY CBC, LFTS, CHEM 7 WHILE ON [**Hospital1 **] THERAPY
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **] - [**Location (un) 3786**]
Discharge Diagnosis:
-sepsis due to cholangitis and Strep viridans, enteroccal
bacteremia
-bile duct obstruction/obstructive jaundice
-urinary tract infection
.
Chronic
-metastatic [**Location (un) 499**] cancer with hepatic metastasis, s/p urostomy,
ileostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with a severe infection in your bile ducts and
blood stream. For this, you were given antibiotics, aggressive
IV fluids and underwent an [**Location (un) **]. The [**Location (un) **] confirmed infection in
your bile ducts and also found a large stone. You had a stent
placed and will need to have a repeat [**Location (un) **] done in 1 month's
time for stent removal at [**Hospital3 **].
.
You will need to continue your antibiotics upon discharge.
.
medication changes:
1.start PO [**Hospital3 **] 600mg twice a day for 11 more days
2.cipro/flagyl for 4 more days
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
PCP-[**Name10 (NameIs) **] have your rehab facility call to make an appointment
with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6099**] at [**Telephone/Fax (1) 56399**] upon discharge.
.
GI-please be sure to follow up with Dr. [**Last Name (STitle) 73382**] at [**Hospital3 **]
for a repeat [**Hospital3 **] within 1 month for stent removal.
.
Department: TRANSPLANT CENTER-surgery
When: THURSDAY [**2121-5-15**] at 3:45 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Please also be sure to follow up with your primary oncologist
upon discharge.
ICD9 Codes: 5990, 2761, 2762, 2930, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1826
} | Medical Text: Admission Date: [**2128-12-3**] Discharge Date: [**2128-12-6**]
Date of Birth: [**2076-8-14**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Penicillins / Codeine / Bactrim Ds / Egg /
Shellfish Derived / Lisinopril / Ace Inhibitors / Valsartan
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
CC:[**CC Contact Info 104586**]
Major Surgical or Invasive Procedure:
endotracheal intubation
Nasogastric tube
History of Present Illness:
HPI: 52 y/o lady with hyptension presented to the Emergency
Department with swollen tongue and funny feeling in her tongue.
Patient is sedated at this time and history was obtained from
the medical records. Patient denied any difficulty breathing,
palpitations, nausea, vomitting or diarrhea. No new food
exposure. Vitals in ED were T 98.3 BP 161/117 HR 94 RR 12
100% RA. Her swelling was worsening in ED and was she was
intubated for airway protection. She recieved solumedrol 125 mg
IV, benadryl 30 mg IV, pepcid 20 mg IV, fentanyl 100 mcg IV x2
and versed 2 mg IV x 2.
On arrival to the floor her vitals were T 96.3 HR 79 BP 153/98
RR 14 100% FiO2. CMV/AC FiO2 100% TV 550 PEEP 5. Patient is
heavily sedated and unable to give any history.
Past Medical History:
PMHx:
Hypertension
Asthma
Menorrhagia secondary to fibroid uterus
Seasonal Allergies
Social History:
Social History: (obtained from OMR notes)
She is single, currently not in a relationship. She has two
grown sons. in their 20s, a boy and girl. She use to work at
[**Hospital1 18**].
Family History:
Unable to obtain any significant history.
.
Physical Exam:
Vitals: T 96.3 HR 79 BP 153/98 RR 14 100% FiO2. CMV/AC
FiO2 100% TV 550 PEEP 5.
Gen: Medically sedated. Not responding to verbal stimuli.
HEENT: Swollen lips. asymetric swelling of the cheeks right
greater than left. Unable to properly assess oropharynx given
swollen lips and OT tube.
Heart: S1S2 RRR, no MRG
Lungs: CTAB in ant lung fields, no wheezes or crackles
Abdomen: Obese, BS present, soft NTND, no appreciable
mass/organomegaly
Ext: WWP, DP 2+, no edema
Neuro: Limited due to sedation. Pinpoint pupils.
Pertinent Results:
[**2128-12-3**] 09:40AM BLOOD WBC-5.0 RBC-4.22 Hgb-11.3* Hct-34.6*
MCV-82 MCH-26.9* MCHC-32.8 RDW-14.2 Plt Ct-199
[**2128-12-6**] 06:25AM BLOOD WBC-14.3* RBC-4.09* Hgb-10.7* Hct-33.3*
MCV-81* MCH-26.2* MCHC-32.1 RDW-13.6 Plt Ct-200
[**2128-12-3**] 09:40AM BLOOD Neuts-60.0 Lymphs-32.3 Monos-3.8 Eos-3.1
Baso-0.7
[**2128-12-4**] 06:00AM BLOOD Neuts-91.4* Lymphs-7.8* Monos-0.5*
Eos-0.2 Baso-0
[**2128-12-4**] 06:00AM BLOOD PT-13.5* PTT-26.2 INR(PT)-1.2*
[**2128-12-4**] 06:00AM BLOOD ESR-20
[**2128-12-3**] 09:40AM BLOOD Glucose-97 UreaN-12 Creat-0.6 Na-139
K-3.5 Cl-107 HCO3-24 AnGap-12
[**2128-12-6**] 06:25AM BLOOD Glucose-93 UreaN-13 Creat-0.6 Na-138
K-4.0 Cl-102 HCO3-29 AnGap-11
[**2128-12-5**] 06:33AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.7*
[**2128-12-4**] 06:00AM BLOOD TSH-0.23*
[**2128-12-3**] 05:15PM BLOOD C1 ESTERASE INHIBITOR, FUNCTIONAL
ASSAY-PND
[**2128-12-4**] 06:00AM BLOOD C4-PND
.
CXR [**12-3**]: FINDINGS: The patient is status post endotracheal
tube placement with the tip lying 3.0 cm above the level of the
carina. There are right base atelectatic changes. There are low
lung volumes. The lungs are clear with no evidence of pneumonia
or congestive heart failure. There is no evidence of pleural
effusions or pneumothorax. The cardiac and mediastinal contours
are normal in appearance. The visualized osseous structures are
unremarkable. There are high-density ovoid structures projecting
over the right upper quadrant of the abdomen that could either
represent gallstones or may be extrinsic to the patient. Please
correlate clinically. IMPRESSION: 1. ET tube 3 cm above the
level of the carina. 2. Possible calcified gallstones.
.
CXR ([**2128-12-4**]): Tubes and lines in good position. Nasogastric
tube coils in the stomach. Atelectasis in the left lower lobe.
Brief Hospital Course:
The patient presented with lip and tongue swelling consistent
with angioedema in setting of ACEi use. She was intubated for
airway protection in the ED. Upon admission to the ICU, the
patient was started on pulse dose steroids, antihistamines and
H2 blockers around the clock. Her swelling rapidly improved and
she was successfully extubated within 48 hours. She was
evaluated by the allergy consult service who recommended C4 and
C1 esterase inhibitor levels which are pending at the time of
discharge. The patient was discharged on an oral prednisone
taper. She was transitioned off of her home ACEi in favor of
amlodipine for blood pressure control. She was also [**Month/Day/Year 1988**]
for outpatient allergy follow-up. The patient should avoid all
ACEi and [**Last Name (un) **] use in the future.
The patient was incidentally noted to have hilar lymphadenopathy
on CXR. Outpatient CT is recommended for further evaluation of
this finding.
She continues on albuertol for astham and oral contraceptives
for chronic uterine bleeding.
Medications on Admission:
Home Medications:
Lisinopril 10 mg daily
Albuterol 2 puffs prn
Flovent [**12-24**] inh [**Hospital1 **]
Nasonex 50 mcg 2 sprays daily
Norethindrone-Ethin (Necon 1/35) once a day
.
Allergies:
Erythromycin causes rash and itching. Penicillin causes throat
swelling and anaphylaxis type reaction. Allergy to codeine,
which causes anaphylaxis. Bactrim causes rash. Egg causes
hives.
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: Per schedule Tablet PO DAILY
(Daily): 2 pills for 2 days, 1 pill for 2 days and then 0.5
pills for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
3. Flovent HFA 110 mcg/Actuation Aerosol Sig: [**12-24**] Inhalation
twice a day.
4. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2)
Nasal once a day.
5. Necon 1/35 (28) 1-35 mg-mcg Tablet Sig: One (1) Tablet PO
once a day.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Angioedema
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with swelling of the lips and tongue. This was
almost certainly due to an allergic reaction to the medication
lisinopril. Avoid this medication in the future and all other
medications of this class, called ACE inhibitors or angiotensin
converting enzyme inhibitors.Please complete a course of
prednisone as treatment for this problem. Follow-up in your
primary care doctors office as [**Name5 (PTitle) 1988**]. Also follow-up with
Dr. [**Last Name (STitle) 2603**] of allergy medicine as [**Last Name (STitle) 1988**].
Take all medications as prescribed. Take amlodipine for blood
pressure control.
Call your doctor or return to the ED for any new or worsening
swelling of the lips or tongue, shortness of breath, chest pain
or any other concerning symptoms.
Followup Instructions:
Primary care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**] [**2128-12-14**]
8:00
Allergy: Dr. [**Last Name (STitle) 2603**] ([**Telephone/Fax (1) **]) Tuesday [**2128-2-8**]
9:00AM
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1827
} | Medical Text: Admission Date: [**2177-12-16**] Discharge Date: [**2178-1-8**]
Date of Birth: [**2106-8-2**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Heparin Agents / Morphine / Tylenol
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
CC: pain control, [**First Name3 (LF) **] hypotension
Major Surgical or Invasive Procedure:
right IJ CVL placement
PICC placement
History of Present Illness:
71 y.o. female with left tib/fib fracture recently admitted to
MICU Green for pain control in the setting of hypotension
necessitating Dopamine, later found to have an Enterobacter UTI
treated with Meropenem and subsequently called out to the floor
upon resolution of hypotension who is now being transferred back
for an acute change in mental status.
.
Patient had been doing well after being called out until
yesterday when she triggered for being nonresponsive. Of note,
she had gotten Dilaudid in the AM for pain control and had
undergone regularly scheduled dialysis with no complications. At
the time of the acute change in mental status, a head CT was
performed which was normal. An ABG was also performed -
7.37/53/71 (previous ABGs dating back as far as [**2176**] have shown
normal CO2 values). She became more responsive after the ABG was
performed, interacting appropriately and responding to verbal
stimuli, however her mental status continued to wax and wane and
a MICU evaluation was requested.
.
In the ED, vitals were notable for a RR of 10 during most of the
day, but otherwise vitals were stable. She was awake, alert and
oriented to person and place. She correctly identified the
month, but not the date or year. She was able to follow simple
commands. Asterixis was noted on exam, despite taking Lactulose,
recently increased from 30 mL TID to QID and Rifaximin. Given
underlying acid-base disturbance in the setting of mental status
changes, she was transferred to the ICU for further management.
.
In the MICU, she continued to be hypotensive, CTA negative for
PE, Urine + enterococcus and started on Meropenem. Mental status
improved once agreed to take Lactulose. She also failed her [**Last Name (un) 104**]
stim so was started on steroids. Her BP stabilized and she was
off pressors and back to the floor. BP was stable during second
ICU admission. She did have a hct drop (see below) but heme/onc
felt this was not hemolysis and there was no active bleeding but
hemoccult + stools.
.
Currently, patient reports some leg pain at fracture site but
otherwise feeling well. She denies f/c, no dizzyness, no
dysphagia, no chest pain, no SOB, no cough, no [**Last Name (un) 103**] pain, [**Last Name (un) 103**]
girth slightly increased, no dysuria, no hematuria. She has
loose stool with copper tinge, no melena, no nausea/vomiting.
Past Medical History:
- VRE UTI (IV Daptomycin) [**2177-12-6**]
- admission [**Date range (1) 40794**]/07 for altered ms [**First Name (Titles) **] [**Last Name (Titles) **]
hypotension
- Hepatic encephalopathy: multiple episodes s/p lactulose
non-compliance
- Portal vein thrombosis [**5-10**] but not anticoag for h/o GIB
- Type 2 diabetes.
- End-stage renal disease, on hemodialysis M/W/F
- Cirrhosis [**3-7**] NASH and acetaminophen toxicity.
- Gastric angioectasia with h/o GI bleeding in 4/[**2177**].
- Diastolic CHF. EF>55% by echocardiogram in 7/[**2176**]. Mod MR and
long mitral deceleration time
- ?right sided pleural effusion: diagnosed on U/S [**11/2176**], CXR
showed a small effusion - stayed stable in subsequent imaging.
- Heparin-induced thrombocytopenia, Ab+ in 1/[**2176**].
- History of seizure disorder, on [**Year (4 digits) 13401**].
- History of infection in the left knee.
- History of MRSA and Clostridium difficile and VRE.
- History of gram-positive rod bacteremia in 4/[**2177**].
- Status post ORIF of the left distal femur fracture in
12/[**2175**].
Social History:
She lives at home. Her daughter is involved in her care. The
patient currently denies alcohol use, tobacco use, and illicit
drugs.
Family History:
Noncontributory.
Physical Exam:
PHYSICAL EXAM:
VS: 98.3 HR 54 RR 16 90/29 98% RA
GEN: comfortable, obese, jaundiced, NAD
NEURO: pos asterixis. alert to person, place, month, situation.
- CN II-XII intact, pupils are 2mm and minimally reactive. left
buccal fold slightly lower than right
- Motor: [**6-7**] bilat upper prox/distal. [**6-7**] right lower
prox/distal. left lower not assessed
- [**Last Name (un) 36**]: intact to light touch throughout
- reflexes: 2+ brachiorad bilat, 1+ knee/ankle on right. toes
equiv on right. left lower ex not able to examine
[**Last Name (un) 4459**]: jaundiced. Subconjunctival hemorrhage on left lateral
eye. MM dry. JVP flat
CARDS: III/VI systolic M w radiation to axilla. RRR, no heave
LUNGS: decreased BS at right base, otherwise clear, no wheeze
ABD: obese, no caput, BS+ NT ND soft, no rebound. no obvious
fluid wave. no shifting dullness
SKIN: erythematous plaques under left breast and panus.
ecchymotic lesions on right and left upper ex. left lower ex
bandaged.
EXTREMITIES: LUE AV fistula w thrill. DP right dopplerable. [**Last Name (un) 36**]
intact left toes.
GUAIAC: NEG brown stool
Pertinent Results:
EKG: sinus brady, rate 50, left anterior fasc block, RBBB
pattern, QTc 535, TW flattening diffusely, no other ST-T
changes. c/w prior.
.
CXR: Stable right pleural effusion and a lower lobe opacity
which may
reflect effusion/atelectasis
.
Pelvis and ankle: no fracture
.
Left Leg: Acute fracture involving the proximal tibia and fibula
metaphysis with approximately 6 mm medial displacement of the
distal fracture fragment
.
RUQ U/S
Note is made that this is a difficult study due to the patient's
body habitus. The liver has a coarse echotexture appearance, but
there are no lesions identified. There is no biliary dilatation
and the common duct measures 0.5 cm. There is a partially
shadowing echogenic structure within the gallbladder, which
appears to be sludge with developing gallstone. There is no
ascites identified. The spleen was not identified on this exam.
.
CXR: There has been removal of right IJ central venous catheter.
A right PICC is seen with its tip terminating in the mid
subclavian vein. There is interval resolution of pulmonary
congestion and improvement in right pleural effusion which is
now small-to-moderate. Right lower lung opacities persist likely
representing atelectasis. Streaky atelectasis persists in the
left mid and lower lung. Otherwise no new pulmonary infiltrates
are identified. The heart size remains enlarged. No pneumothorax
is identified.
.
Ammonia: 35
138 101 19
--------------< 137
3.7 25 4.3
Ca: 9.1 Mg: 2.0 P: 3.3
Trop-T: 0.10
CK: 52 MB: Notdone
.
WBC: 6.3
HCT: 29.9
PLT: 77
N:80.2 L:9.8 M:5.2 E:4.4 Bas:0.3
.
PT: 16.7
PTT: 36.1
INR: 1.5 (baseline: 1.5-1.8)
.
Echo [**8-8**]: mod symmetric LVH, EF 60-70%, [**2-4**]+MR
.
CBC
[**2177-12-16**] 05:00PM BLOOD WBC-6.3# RBC-2.64* Hgb-9.4* Hct-29.9*
MCV-113* MCH-35.5* MCHC-31.3 RDW-19.5* Plt Ct-77*#
[**2177-12-18**] 03:11AM BLOOD WBC-10.7# RBC-2.52* Hgb-8.8* Hct-26.5*
MCV-105*# MCH-34.9* MCHC-33.2 RDW-20.1* Plt Ct-68*
[**2177-12-19**] 04:04AM BLOOD WBC-16.7*# RBC-2.40* Hgb-8.7* Hct-25.7*
MCV-107* MCH-36.3* MCHC-33.9 RDW-20.2* Plt Ct-62*
[**2177-12-20**] 03:40AM BLOOD WBC-7.5# RBC-2.24* Hgb-7.9* Hct-23.4*
MCV-105* MCH-35.3* MCHC-33.7 RDW-20.7* Plt Ct-38*
[**2177-12-20**] 04:51PM BLOOD WBC-5.3 RBC-2.34* Hgb-7.9* Hct-23.5*
MCV-101* MCH-33.7* MCHC-33.5 RDW-21.5* Plt Ct-27*
[**2177-12-21**] 05:01PM BLOOD WBC-5.0 RBC-2.52* Hgb-8.7* Hct-25.9*
MCV-103* MCH-34.5* MCHC-33.6 RDW-21.5* Plt Ct-30*
[**2178-1-5**] 06:02AM BLOOD WBC-5.2 RBC-2.23* Hgb-7.6* Hct-24.2*
MCV-108* MCH-34.2* MCHC-31.6 RDW-21.2* Plt Ct-50*
[**2178-1-7**] 05:10AM BLOOD WBC-4.4 RBC-2.53* Hgb-8.7* Hct-26.0*
MCV-102* MCH-34.2* MCHC-33.4 RDW-20.9* Plt Ct-34*
.
ABG
[**2177-12-24**] 02:31PM BLOOD Type-[**Last Name (un) **] pO2-319* pCO2-53* pH-7.35
calTCO2-30 Base XS-2
[**2177-12-24**] 05:15PM BLOOD Type-ART pO2-71* pCO2-53* pH-7.37
calTCO2-32* Base XS-3
[**2177-12-25**] 07:41AM BLOOD Type-ART pO2-80* pCO2-45 pH-7.44
calTCO2-32* Base XS-5
.
Lactate:
[**2177-12-18**] 03:57PM BLOOD Lactate-3.1*
[**2177-12-24**] 05:15PM BLOOD Lactate-2.3*
.
Misc
[**2177-12-18**] 12:26PM BLOOD Cortsol-43.5*
[**2177-12-31**] 03:32PM BLOOD PTH-161*
[**2177-12-24**] 02:12PM BLOOD Ammonia-31
[**2177-12-20**] 03:40AM BLOOD VitB12-[**2095**]* Folate-9.0
[**2178-1-7**] 05:10AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.8
[**2177-12-22**] 03:06AM BLOOD ALT-14 AST-21 LD(LDH)-220 AlkPhos-92
TotBili-5.1*
[**2177-12-21**] 04:18AM BLOOD ALT-15 AST-20 AlkPhos-92 TotBili-6.5*
DirBili-4.1* IndBili-2.4
.
Chem 7
[**2177-12-16**] 05:00PM BLOOD Glucose-137* UreaN-19 Creat-4.3* Na-138
K-3.7 Cl-101 HCO3-25 AnGap-16
[**2177-12-19**] 04:04AM BLOOD Glucose-192* UreaN-35* Creat-5.5* Na-136
K-4.4 Cl-105 HCO3-21* AnGap-14
[**2177-12-23**] 11:09AM BLOOD Glucose-233* UreaN-25* Creat-3.8* Na-136
K-3.8 Cl-101 HCO3-26 AnGap-13
[**2177-12-27**] 05:58AM BLOOD Glucose-169* UreaN-24* Creat-3.1* Na-138
K-4.0 Cl-101 HCO3-27 AnGap-14
[**2178-1-4**] 06:08AM BLOOD Glucose-111* UreaN-24* Creat-3.3* Na-139
K-4.4 Cl-104 HCO3-31 AnGap-8
[**2178-1-5**] 06:02AM BLOOD Glucose-118* UreaN-29* Creat-3.8* Na-140
K-4.9 Cl-105 HCO3-30 AnGap-10
[**2178-1-7**] 05:10AM BLOOD Glucose-101 UreaN-24* Creat-3.3* Na-139
K-4.9 Cl-103 HCO3-31 AnGap-10
Brief Hospital Course:
71 y.o. female with multiple medical problems, namely cirrhosis
and current ESBL UTI who was transferred to the MICU for change
in mental status.
.
Hosp course by problem:
.
MS: delirium intermittently thought initially [**3-7**] hepatic
encephalopathy vs infection vs medications. In the ICU, she was
hypotensive requiring pressors (see below). She also developed
a UTI which was treated. She initially refused lactulose but
once she took it, started having BMs and improved MS. She was
transferred from MICU to the floor and was stable for several
days. She then was found to be hypoventilating after having
received dilaudid. Trigger called and she was transferred back
to the unit. ABG revealed mild hypercapnea but her sx improved
rapidly without much intervention. We felt this was [**3-7**]
dilaudid in setting of pt with poor baseline ms (hepatic enceph)
as well as urosepsis. Her mental status was stable at
discharge.
.
Hypotension: Baseline SBP 90s-100s. Initially in the MICU, she
was at baseline but then she trended downward. She required
urgent line placement and aggressive IVF repletion. HD was held
for several days and she even required pressors and aggressive
IV fluids. She had enterobacter UTI and was treated with
meropenem for plan for 10-14d of therapy. She also failed her
[**Last Name (un) 104**] stim so was started on steroids. Her BP stabilized and she
was off pressors and back to the floor. BP was stable during
second ICU admission. Incidentally, CTA neg for PE. She did
have a hct drop (see below) but heme/onc felt this was not
hemolysis and there was no active bleeding. She continued to
have BP's in the 80-90's while on the floor, but was
asymptomatic with stable HCT's. Her slightly low BP was
attributed to diarrhea and the patient responded to gentle IVF
boluses.
.
HEME POSITIVE STOOLS: The patient has history of upper GI bleeds
and has known gastric angioectasia and grade I varices of
esophagus. She continued to have maroon-colored stools this
hospitalization but she remained asymptomatic and her hematocrit
was stable. She continued her PPI and was restarted on
propranolol once her BP normalized. Her propranolol has been
held due to low blood pressures.
.
Cirrhosis: Patient appeared encephalopathic on presentation but
improved throught her stay and was oriented and interactive. She
was compliant with Lactulose and Rifaximin but has been known to
stop taking her lactulose. Liver service followed patient and
will see her in clinic.
.
UTI: Patient received Meropenem, based on sensitivity profile,
started on [**12-21**] with 10-day total course.
.
ESRD: on HD, seen by renal during her stay.
.
Tib/Fib Fracture: S/P set in Breslow Brace. Patient will f/u
with orthopedics in 4 weeks with Dr. [**Last Name (STitle) **]. Cautious pain
control was initiated given h/o AMS.
.
Adrenal Insufficiency: Patient mildly abnormal stim test while
hypotensive and received steroids which were rapidly tapered.
.
CHF: History of diastolic dysfunction with significant edema on
exam after aggressive hydration. She will continue to have
fluid removed by HD.
.
Diarrhea: The patient had multiple episodes of diarrhea with
slightly low BP. Her diarrhea was mostly likely secondary to
lactulose and her dose was decreased, with decreasing bowel
movements. C.diff was sent, neg x1.
.
DM: she was continued on ISS
.
PPx
- PPI
- Lactulose/Rifaximin
- Seizure PPx with [**Last Name (STitle) 13401**] given seizure history
- No anticoagulation given HIT and previous GIB; Pneumoboots
Medications on Admission:
MEDICATIONS; confirmed verbally w daughter:
Lasix 40mg nondialysis days
Lactulose 30ml TID
Levetiracetam 500 mg daily
Rifaximin 400 mg Tablet PO TID (not taking at home)
Pantoprazole 40 mg Tablet daily
Ursodiol 300 mg Capsule PO BID
Sevelamer 800 mg Tablet TID w meals
Glargine 12u qhs
Lispro sliding scale
Propranolol 10 mg PO BID
.
ALLERGIES:
ASA
Heparin (HIT)
Morphine
Tylenol
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day). Hold for diarrhea.
7. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor - [**Location (un) **]
Discharge Diagnosis:
Primary:
Enterobacter UTI with sepsis
Proximal left tibial fracture
Hepatic encephalopathy
Secondary:
Diastolic Heart Failure.
Reversible inferior wall myocardial perfusion defect
Seizure Disorder.
Cirrhosis secondary to non-alcoholic steatohepatits
Hepatic encephalopathy
Gastric angioectasia
Chronic renal failure Stage V on Hemodialysis.
Pancytopenia.
Diabetes Mellitus Type II.
HIT antibody positive.
Portal vein thrombosis
Gallstone pancreatitis
MRSA/Clostridium difficile.
S/P ORIF of the left distal femur fracture c/b septic knee
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a leg fracture. You then developed a
urinary tract infection with sepsis, which as now resolved. Do
not but weight on your left leg or walk on your own. If you have
fevers or chills, please return to the emergency room.
Followup Instructions:
1. Please make an appointment to see your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **]
[**Name Initial (NameIs) **]. [**Telephone/Fax (1) 40793**] for follow-up.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2178-2-5**] 11:00
3. Please call to make a follow-up appointment with the Liver
clinic. The phone number is: [**Telephone/Fax (1) 2422**]
ICD9 Codes: 4280, 5180, 2851, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1828
} | Medical Text: Admission Date: [**2175-6-10**] Discharge Date: [**2175-6-20**]
Date of Birth: [**2100-10-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Trauma admission s/p motor vehicle accident.
Major Surgical or Invasive Procedure:
None, pelvic fractures were deemed non-operative by orthopedic
surgery, as were diffuse subarachnoid hemorrhage by neurosurgery
History of Present Illness:
75 year old male admitted to trauma SICU after motor vehicle
accident in which he was the driver and was t-boned by another
vehicle. Had positive loss of consciousness at the scene, airbag
had deployed, and had prolonged extraction. Was intubated in the
ED for combative behavior.
Past Medical History:
Atrial fibrillation, hypertension, diabetes, gout, chronic
kidney disease Stage IV, peripheral vascular disease
Social History:
Widowed, good family support, has children in the area
Family History:
Non-contributory
Physical Exam:
At admission:
Gen: Intubated and sedated
CV: Atrial fibrillation
Resp: Clear to ausculation bilaterally
Abd: Soft, non-distended, unable to assess pain due to sedation
Pertinent Results:
[**2175-6-10**] 11:22PM TYPE-ART TEMP-37.1 RATES-/16 TIDAL VOL-600
PEEP-5 O2-50 PO2-188* PCO2-43 PH-7.39 TOTAL CO2-27 BASE XS-1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2175-6-10**] 11:22PM LACTATE-2.1* K+-3.6
[**2175-6-10**] 11:22PM freeCa-1.17
[**2175-6-10**] 11:09PM GLUCOSE-247* UREA N-27* CREAT-1.3* SODIUM-141
POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-23 ANION GAP-11
[**2175-6-10**] 11:09PM LD(LDH)-356* CK(CPK)-739*
[**2175-6-10**] 11:09PM CK-MB-12* MB INDX-1.6 cTropnT-0.03*
[**2175-6-10**] 11:09PM CALCIUM-8.3* PHOSPHATE-2.3* MAGNESIUM-1.6
[**2175-6-10**] 11:09PM WBC-13.9* RBC-3.40* HGB-9.4* HCT-26.9*
MCV-79* MCH-27.6 MCHC-35.0 RDW-16.0*
[**2175-6-10**] 11:09PM PT-16.0* PTT-33.3 INR(PT)-1.4*
[**2175-6-10**] 04:29PM TYPE-ART PO2-361* PCO2-39 PH-7.37 TOTAL
CO2-23 BASE XS--2
[**2175-6-10**] 04:29PM LACTATE-3.3*
[**2175-6-10**] 04:15PM GLUCOSE-475* UREA N-31* CREAT-1.4* SODIUM-139
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-21* ANION GAP-13
[**2175-6-10**] 04:15PM CK(CPK)-372*
[**2175-6-10**] 04:15PM CK-MB-8 cTropnT-0.01
[**2175-6-10**] 04:15PM CALCIUM-7.5* PHOSPHATE-3.4 MAGNESIUM-1.4*
[**2175-6-10**] 04:15PM TRIGLYCER-140
[**2175-6-10**] 04:15PM WBC-16.7* RBC-3.02*# HGB-8.0*# HCT-24.0*#
MCV-79* MCH-26.3* MCHC-33.2 RDW-15.2
[**2175-6-10**] 04:15PM NEUTS-91.3* BANDS-0 LYMPHS-5.9* MONOS-2.5
EOS-0.1 BASOS-0.1
[**2175-6-10**] 04:15PM PT-18.8* PTT-36.0* INR(PT)-1.7*
[**2175-6-10**] 04:15PM PLT SMR-LOW PLT COUNT-78*#
[**2175-6-10**] 02:14PM PH-7.62*
[**2175-6-10**] 02:14PM GLUCOSE-402* LACTATE-4.0* NA+-154* K+-4.9
CL--103
[**2175-6-10**] 02:14PM freeCa-0.80*
[**2175-6-10**] 02:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2175-6-10**] 02:10PM URINE COLOR-Red APPEAR-Hazy SP [**Last Name (un) 155**]-1.012
[**2175-6-10**] 02:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2175-6-10**] 02:10PM URINE RBC->50 WBC-[**5-2**]* BACTERIA-NONE
YEAST-NONE EPI-[**5-2**]
[**2175-6-10**] 02:10PM URINE AMORPH-RARE
[**2175-6-10**] 01:50PM UREA N-33* CREAT-1.7*
[**2175-6-10**] 01:50PM estGFR-Using this
[**2175-6-10**] 01:50PM AMYLASE-66
[**2175-6-10**] 01:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2175-6-10**] 01:50PM WBC-18.0* RBC-4.53* HGB-11.7* HCT-36.1*
MCV-80* MCH-25.9* MCHC-32.5 RDW-15.0
[**2175-6-10**] 01:50PM PT-21.9* PTT-32.8 INR(PT)-2.1*
[**2175-6-10**] 01:50PM PLT COUNT-169
[**2175-6-10**] 01:50PM FIBRINOGE-316
Imaging:
[**6-10**] Head CT: diffuse SAH
[**6-10**] C-spine CT: no fractures
[**6-10**] CT torso: Left pubic rami, sacral ala, and acetabular fx
with associated hematoma in the pelvis. Rounded hyperenhancing
structure in the spleen with small amount of perisplenic blood,
suspicious for post-traumatic pseudoaneurysm.
7/19 L femur film: no fx
7/19 L hand film: no fx, ?FB
[**6-10**] CT Head and CTA Head: No obvious aneurysm. Stable SAH.
[**6-10**] repeat Abd CT: Stable splenic injury
[**6-11**] MRA/MRI brain: Diffuse vasospasm of L>R MCA Abnl restricted
diffusion of cortex - R sylvian fissure concerning for acute
infarction
[**6-12**] ECHO: poor quality - LVEF 60%, no effusion, can't r/o wall
motion abnormality
Brief Hospital Course:
[**6-10**]: Patient was admitted to TSICU with diagnoses of pelvic
fractures and subarachnoid hemorrhage. He was intubated and
sedated at the time. He was given IV fluids for resuscitation
and had a Foley catheter in place. Dilantin was given for
seizure prophylaxis, and a phenylephrine drip was initiated to
keep SBP above 110. Electrolytes were repleted as necessary
(magnesium, potassium, calcium). Blood gases were followed.
[**6-11**]: He was transfused 4 units PRBCs after labs revealed a
following hematocrit and acute anemia related to blood loss.
Isotonic fluid administration was continued as was mechanical
ventilation. Serial hematocrit checks were followed.
MRA/MRI of brain were obtained which revealed diffuse vasospasm
and abnormal restriction of cortex concerning for acute
infarction. Sodium bicarbonate was administered.
[**2089-6-10**]: Lasix was begun for diuresis. Vancomycin, Zosyn, and
ciprofloxacin were started after pt developed a fever. Blood
cultures were sent; bronchioalveolar lavage was performed and
sputum sample was sent for culture. Arterial line was removed
and tip was sent for culture. Blood gases were followed.
[**2094-6-12**]: Tube feeds were initiated via NG tube. Antibiotics were
discontinued after cultures came back negative. Source of fever
was thought to be either active gout or central (related to
brain infarct).
[**6-19**]: After 10 days on ventilator and in light of brain infarct
and patient's complete lack of responsiveness to stimulation
when off all sedating medications, decision was made by family
to discontinue life support. Patient's respiratory rate
gradually declined and heart rate rose throughout the night and
into the next day.
[**6-20**]: Pt expired with family at bedside.
Medications on Admission:
Coumadin, Lasix, glyburide, lopressor, aspirin, allopurinol,
digoxin, lipitor, amitriptyline, verapamil, prilosec, levemir
Discharge Medications:
Pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Diffuse subarachnoid hemorrhage and subsquent brain infarction
secondary to motor vehicle accident, pelvic fractures with
associated pelvic hematoma, small stable splenic injury
Discontinuation of ventilatory support at family's request
leading to respiratory arrest and death.
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 2851, 2724, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1829
} | Medical Text: Admission Date: [**2125-10-6**] Discharge Date: [**2125-10-31**]
Date of Birth: [**2073-2-10**] Sex: F
Service:
NOTE: This discharge summary is being dictated by a
physician who was not the admitting physician for this
patient. The initial admitting notes are not available. The
chart has been thinned. The location of the admitting notes
is not clear at present; however, it has been signed out to
this physician.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
Jamaican female with a history of lymphocytic pleocytosis of
unknown etiology, a seizure disorder, a history of herpes
encephalitis that was treated empirically (although never
diagnosed as herpes encephalitis), hypertension and a
suprasellar mass noted on CT scan in [**2125-9-15**]. She
presented with a one week history of nausea and vomiting on
[**2125-10-6**] as well as a three day history of atypical chest
pain. Further details are noted, although at this time the
chart has been thinned and the whereabouts of the admitting
notes are not clear.
PAST MEDICAL HISTORY: The patient's past medical history, as
stated above, included lymphocytic pleocytosis, a seizure
disorder, hypertension and a suprasellar mass.
MEDICATIONS ON ADMISSION: The patient's medications on
admission are not known to this physician at this time.
PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile
and vital signs were stable. In general, she was an obese
African American female lying in bed in no apparent distress.
She seemed slightly confused. On HEENT examination, the head
was normocephalic and atraumatic. The pupils were equal,
round and reactive to light. The extraocular muscles were
intact.
The pulmonary examination was clear to auscultation
bilaterally with no wheezes, rales or rhonchi. The cardiac
examination revealed a regular rate and rhythm with a normal
S1 and S2 and no murmurs, rubs or gallops. The abdomen was
soft, nontender and nondistended with no rebound or guarding
and no hepatosplenomegaly. The extremities had 2+ pulses
times four with no clubbing, cyanosis or edema. On
neurological examination, the patient seemed confused, as
stated above, but was otherwise grossly intact.
LABORATORY VALUES ON ADMISSION: The patient had a white
blood cell count of 5700, hemoglobin of 12.9, hematocrit of
36.8 and platelet count of 294,000. Urine specific gravity
was 1.003. There was a serum sodium of 141, potassium of
3.4, chloride of 103, bicarbonate of 27, BUN of 4, creatinine
of 1.0 and glucose of 109. CKs were flat at 200 and 166 on
the day of admission. Troponin was less than 0.3. Calcium
was 10.4, magnesium was 2.1 and phosphorus was 1.7. Dilantin
level was 14.9.
CARDIAC STUDIES: The electrocardiogram on admission showed T
wave inversions in I through III, aVF and V2 through V6 with
early R wave progression. Compared to the previous tracing
of [**2124-8-15**], the widespread T wave inversions were new.
Myocardial ischemia was considered, but ruled out by enzymes.
A stress test thereafter showed no angina with an
uninterpretable electrocardiogram. The nuclear report for
the stress test was normal. The patient was unable to
achieve maximal exercise tolerance, however.
RADIOLOGY DATA: An MRI of the head showed the base of the
third ventricle a suprasellar mass with associated foci of
increased intensity on the flare sequences within both
cerebral hemispheres, primarily in the periventricular
location, possibly consistent with sarcoidosis and probably
not consistent with herpes encephalitis.
HOSPITAL COURSE: The patient was admitted to the internal
medicine service, [**Hospital1 139**] firm. She continued to complain of
nausea and vomiting on day #2. On day #3, the Persantine
MIBI results, which were reported above, were found to be
negative. The neurosurgery service was consulted for
possible biopsy of the mass and the leptomeninges.
On [**2125-10-9**], an esophagogastroduodenoscopy was performed for
nausea and vomiting; this test was negative. On [**2125-10-11**], a
lumbar puncture was performed and cytology was sent. The
white blood cell count was noted to be 233 with a glucose of
181 and a protein of 41. Cytology from this lumbar puncture
was negative. The patient was treated for a urinary tract
infection with ciprofloxacin during this admission from
[**2125-10-12**] to [**2125-10-14**].
The patient continued to complain of headache; however, her
neurological examination was nonfocal. She was started on
hydrocortisone intravenously for her headache. The endocrine
service was consulted for a diagnosis of panhypopituitarism
and recommended Synthroid 50 mcg q.d. with checking of
thyroid functions in two to three weeks and DDAVP 10 mcg h.s.
for a sodium greater than 140. The patient's cardiovascular
regimen was continued. This regimen consisted of Lipitor 20
mg p.o. h.s. and Lopressor 25 mg p.o. q.d. On the steroids,
the patient's nausea and vomiting were noted to be improving.
The dose of hydrocortisone was 50 mg intravenously every
eight hours. DDAVP was continued until discharge for sodium
greater than 140 to 145 and a urine output of greater than
300 to 400 cc per hour.
The patient was initially scheduled for discharge on
[**2125-10-15**]. However, she remained in the hospital because of
continued concern about her diabetes insipidus. She
continued to require DDAVP for high urine outputs and high
sodium levels.
A biopsy of the patient's suprasellar mass was scheduled for
[**2125-10-18**]. The patient was given fresh frozen plasma for an
INR of 1.4 before that time. The biopsy was performed on
[**2125-10-18**]. The patient tolerated the procedure well. She
was transferred back to the internal medicine service on
[**2125-10-25**]. The histology of the biopsy suggested a
diagnosis of neurosarcoidosis. There were noncaseating
granulomas. However, this diagnosis was not 100% sure and a
PPD was placed. The PPD was read as 10 mm, which was
unchanged from the PPD that had been placed in [**2125-1-15**].
No treatment for tuberculosis was indicated at that point.
The patient received pulse steroids with 1 gm of Solu-Medrol
each day for three days beginning on [**2125-10-27**] for treatment
of her neurosarcoidosis. She described improvement in her
headache and nausea after the administration of the
Solu-Medrol. She is now being tapered on oral prednisone.
The patient continues to require DDAVP.
The patient is being discharged to a rehabilitation facility
on [**2125-10-31**]. It is felt that she will benefit from
rehabilitation, in addition to monitoring her fingersticks
while on steroids, as she has been receiving regular insulin
sliding scale and NPH insulin for the steroid induced
hyperglycemia.
DISCHARGE MEDICATIONS:
DDAVP 10 mcg spray q.d. p.r.n. for sodium of greater than 145
or urine output of greater than 300 to 400 cc per hour.
Levothyroxine 100 mcg p.o. q.d.
Zofran 4 mg p.o. every six hours p.r.n.; the patient was
started on this medication relatively early in her hospital
course.
Compazine 10 mg p.o. every six hours p.r.n. for relief of
nausea.
Serax 15 to 30 mg p.o. h.s. p.r.n. for insomnia.
Lipitor 20 mg p.o. h.s. for hyperlipidemia.
Lopressor 25 mg p.o. b.i.d. for hypertension.
Tylenol 650 mg p.o. every four to six hours p.r.n. for pain.
Nitroglycerin 0.4 mg sublingual every five minutes times
three p.r.n. for chest pain and call medical doctor; the
patient has not required any nitroglycerin during this
admission.
Dilantin 400 mg p.o. q.o.d. on odd numbered days.
Dilantin 300 mg p.o. q.o.d. on even numbered days.
Colace 100 mg p.o. b.i.d.
Maalox 30 cc p.o. t.i.d. p.r.n.
Zantac 150 mg p.o. b.i.d., which was started when the patient
was started on steroids.
Prednisone taper with the following scheduled: 80 mg p.o.
q.d. on [**2125-10-31**] and [**2125-11-1**], 60 mg p.o. q.d. on
[**2125-11-2**] through [**2125-11-4**], 40 mg p.o. q.d. on [**2125-11-5**]
through [**2125-11-7**], 20 mg p.o. q.d. on [**2125-11-8**] through
[**2125-11-10**] then 10 mg p.o. q.d. as baseline dose after
[**2125-11-10**].
NPH insulin 6 units subcutaneous q.a.m. and 4 units
subcutaneous h.s.
Regular insulin sliding scale: for glucose of 0 to 60, give
[**Location (un) 2452**] juice and 0 units; for 61 to 200, 0 units, for 201 to
250, three units subcutaneous; for 251 to 300, six units
subcutaneous; for 301 to 350, nine units subcutaneous; and,
for 351 and greater, 12 units subcutaneous; the patient has
required this insulin for glucose intolerance from her
steroids.
DISCHARGE DIAGNOSES:
1. Neurosarcoidosis.
2. Panhypopituitarism.
3. Diabetes insipidus.
4. Steroid induced diabetes mellitus.
5. Seizure disorder.
6. Nausea and vomiting secondary to suprasellar mass.
7. Hypertension.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 6754**] on
[**2125-11-8**] at 8 a.m. in the [**Hospital 23**] Clinic on the [**Location (un) 436**]
for endocrinology. She should also follow up with Dr.
[**Last Name (STitle) **], her primary care physician, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] regular appointment
in one to two weeks. The patient has been seen by the
neurology service before with Dr. [**Last Name (STitle) 6755**] and Dr. [**Last Name (STitle) **];
she should follow up with these physicians as needed. The
patient will also require follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] of
neuro-oncology for treatment of her neurosarcoidosis. The
patient has been seen by the infectious disease service in
the hospital.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6756**], M.D. [**MD Number(1) 6757**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2125-10-31**] 13:17
T: [**2125-10-31**] 13:40
JOB#: [**Job Number 6758**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1830
} | Medical Text: Admission Date: [**2133-6-5**] Discharge Date: [**2133-6-9**]
Date of Birth: [**2089-11-25**] Sex: M
Service: MEDICINE
Allergies:
Haloperidol / Prochlorperazine
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 y/o male with suicidal ideation in the past, h/o depression
presents with altered mental status. Apparently he stated on
that presentation that he was given a prescription for 55 pills
of clonazepam two days prior to admission. Patient endorsed
taking more than he should have, and was found with only 4 left,
but can't recall how many he took during this event. He states
that he was trying to get high, and not trying to kill himself,
and says he did not take anything else.
.
In the ED, initial VS were T 97.1 P 95 BP 110/82 Sat 94% ra.
Patient was found to be bradypneic to 6 and hypoxic to the 80's
soon after arrival. He was given a dose of narcan, and perked up
a little in bed. Tylenol level was 29 and ethanol 14, and serum
tox was negative, urine tox pending. Toxicology was consulted
and recommended supportive care and continouous O2. ABG was
performed and was 7.32/48/106/26, with a lactate of 2.9. Before
transfer, patient was noted to be somewhat conversant, but then
was found to be less responsive. Vital signs prior to transfer
were P 104 BP 139/66 R 24 Sat 100%RA.
.
On the floor, patient denies taking clonazepam, and states that
he got the bottle from a friend, who was supposedly attempting
to overdose on the medication, and he took it from her. The
clonazepam bottle does have the name of another person on it. He
states that he has been taking medication for his kidney stone
pain, but can't identify what this is or what quantity he took.
He cannot recall if he drank alcohol prior to presentation. He
does not recall the events that happened prior to coming to the
ED in an ambulance.
.
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:
PSYCHIATRIC HISTORY:
--Over 20 psychiatric hospitalizations over the past 5 years
most recently in [**9-/2131**] at [**Hospital1 18**]).
--Depression first started in [**2127**] when his daughter was in a
coma for 9 days.
--ECT courses x 3 (most recently [**9-/2131**] with 4 bilateral and 3
unilateral treatments).
--DBT treatment at MMHC since [**10/2131**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
resident, and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18741**], attending, are his
treaters).
--Patient reports dx'es that range from MDD to bipolar to
borderline personality disorder depending on the inpatient
facility (he denies symptoms of mania).
--Denies history of violence or SIB.
--States his only suicide attempt was in 9/[**2131**].
.
PAST MEDICAL HISTORY:
--PUD
--Migraines (every 3-4 years): he's taken Fiorinal, Fiorocet,
Imitrex, and a beta blocker in the past; Fiorinal has been most
effective
--s/p Gastric bypass
--s/p Hernia repair
--hypothyroidism
Social History:
Pt born/raised in [**Location (un) 620**], MA. Parents divorced. Denies
childhood abuse. Completed law school at NE School of Law. "Gave
up" his license in [**2130**] [**2-11**] malpractice/not being able to "keep
mind straight." Reports being addicted to fentanyl in [**2128**]; went
to detox and then was on Suboxone for 6 months. Divorced.
Daughter is 6 y/o. He is unemployed.
Family History:
Mother and brother have EtOH dependence and depression.
Physical Exam:
ICU Admission Physical Exam
Vitals: T: 98.3 BP: 120/98 P: 70 R: 16 O2: 98%
General: Somnolent, oriented x 2, not to date, no acute
distress, cooperative
HEENT: NCAT, sclera anicteric, pupils bilaterally at 2 mm, MMM,
oropharynx clear with no lesions noted
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, with no wheezes,
rales, rhonchi audible
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Back: + right CVA tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2133-6-5**] 05:30PM BLOOD WBC-6.3 RBC-4.36* Hgb-12.6* Hct-36.4*
MCV-84 MCH-28.9 MCHC-34.7 RDW-16.5* Plt Ct-234
[**2133-6-6**] 05:23AM BLOOD WBC-4.1 RBC-3.78* Hgb-10.7* Hct-32.0*
MCV-85 MCH-28.4 MCHC-33.5 RDW-16.8* Plt Ct-172
[**2133-6-5**] 05:30PM BLOOD Neuts-70.6* Lymphs-19.9 Monos-3.6
Eos-4.5* Baso-1.4
[**2133-6-5**] 05:30PM BLOOD PT-12.6 PTT-21.5* INR(PT)-1.1
[**2133-6-5**] 05:30PM BLOOD Plt Ct-234
[**2133-6-6**] 05:23AM BLOOD Plt Ct-172
[**2133-6-5**] 05:30PM BLOOD Glucose-93 UreaN-17 Creat-1.6* Na-145
K-4.2 Cl-110* HCO3-22 AnGap-17
[**2133-6-6**] 05:23AM BLOOD Glucose-85 UreaN-13 Creat-0.9 Na-145
K-3.9 Cl-114* HCO3-24 AnGap-11
[**2133-6-6**] 05:23AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.1
[**2133-6-5**] 05:30PM BLOOD calTIBC-449 VitB12-810 Folate-15.5
Ferritn-29* TRF-345
[**2133-6-5**] 05:30PM BLOOD TSH-5.2*
[**2133-6-5**] 05:30PM BLOOD ASA-NEG Ethanol-14* Acetmnp-29
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2133-6-5**] 05:50PM BLOOD Glucose-76 Lactate-2.9* Na-146 K-4.2
Cl-110 calHCO3-23
[**2133-6-5**] 05:50PM BLOOD Hgb-13.2* calcHCT-40
Tox Screen
Benzodiazepine Screen, Urine POS
Barbiturate Screen, Urine POS
Opiate Screen, Urine POS
OPIATE IMMUNOASSAY SCREEN DOES NOT DETECT SYNTHETIC
OPIOIDS;SUCH AS METHADONE, OXYCODONE, FENTANYL, BUPRENORPHINE,
TRAMADOL,;NALOXONE, MEPERIDINE. SEE ONLINE LAB MANUAL FOR
DETAILS
Cocaine, Urine NEG
Amphetamine Screen, Urine NEG
TRAZODONE METABOLITE [**Month (only) **] CAUSE FALSE POSITIVE AMPHETAMINE
RESULT
Methadone, Urine NEG
METHADONE ASSAY DETECTS ONLY METHADONE (NOT OTHER
OPIATES/OPIOIDS)
Blood Tox
Salicylate NEG 2 - 25 mg/dL
Ethanol 14* 10 - 10 mg/dL
80 (THESE UNITS) = 0.08 (% BY WEIGHT)
Acetaminophen 29 10 - 30 ug/mL
Benzodiazepine Screen NEG
Barbiturate Screen NEG
Tricyclic Antidepressant Screen NEG
CHEST (PORTABLE AP) Study Date of [**2133-6-5**] 5:42 PM
SEMI-UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette
remains mildly
enlarged. The mediastinal and hilar contours are relatively
stable. Lungs
are clear. No focal consolidation, pleural effusion or
pneumothorax is
identified. No acute osseous findings are seen.
IMPRESSION: No acute cardiopulmonary abnormality.
Brief Hospital Course:
43 y/o male with suicidal ideation in the past, h/o depression
presents with altered mental status after ingesting undetermined
amount of clonazepam.
.
# Toxidrome/toxic-metabolic encephalopathy: Presentation was
consistent with benzodiazepine toxicity given generally normal
vital signs with CNS depression. Patient inconsistent in his
report of what he took, amount of drinking, etc. Ethanol level
was 14, slightly elevated, which could raise some concern for
respiratory depression. Urine tox was positive for benzos,
barbiturates, and opiates. Patient only slightly responded to
Narcan dosing in the ED. Flumazenil was not indicated given that
patient already takes bupropion which lowers seizure threshold.
Patient with slight anion gap, likely due to elevated lactate.
Pt's was closely monitored in ICU, did not require intubation
and mental status gradually improved. Pt was seen by psych who
sectioned pt. Pt placed on suicide precautions and called out to
floor given clinical improvement. He recovered to baseline,
there was no evidence of any intoxication as of [**2133-6-8**]. He was
accepted for inpatient psychiatry admisssion on discharge.
.
# Acute kidney injury: The patient presented with acute renal
failure. After IVFs, Cr improved from 1.6 to 0.9 by AM.
.
# Anemia: iron studies and vitamin B12/folate last checked in
[**2131**], hematocrit appears to be at baseline. He had normal B12
and folate levels on this admission.
.
# Depression: The patient was restarted on his home medication
regimen after he was able to give a reliable medication list.
.
# Hypothyroidism: The patient was continued on his home
levothyroxine.
.
# History of kidney stones. The patient has a history of kidney
stones and is undergoing definitive therapy in the urology
clinics. He asked multiple times for continuation of narcotic
pain medications that he takes at home and it was confirmed that
he received small volume (20 pills) of oxycodone on [**2133-5-19**] and
vicodin on [**2133-6-3**]. He had no objective source for pain that
would require narcotic pain medications and given his history of
suicidality with intentional overdose it seemed appropriate to
try non-narcotic pain control.
Medications on Admission:
Confirmed by phone with [**Company 4916**] pharmacy:
Fioricet
Oxycodone 5mg from [**2133-5-19**] - prescribed by Dr. [**First Name (STitle) 24425**] for 5 day
supply
Gabapentin 800mg TID
Omeprazole 20mg [**Hospital1 **]
Mirtazapine 15mg Daily
MVI
Levothyroxine 0.175mg Daily
Sertraline 150mg Daily
Hydroxyzine
Buproprion XR 200mg Daily
Vicodin 7.5/750mg Q6h from [**2133-5-29**] - prescribed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 6382**]
Discharge Medications:
1. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID (2 times a day).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain or fever.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis
- Benzodiazepine Overdose
- Polysubstance Abuse
- Depression
- Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were brought to the emergency department after you were
found to be confused and sedated. Your lab work was positive for
alcohol, tylenol, and several other medications. Given your
level of sedation, you were admitted to the ICU for close
respiratory monitoring. You improved overnight and were
evaluated by the psychiatry service. You are now being
discharged to an inpatient psychiatry facility for further
treatment.
There were no changes to your medications during this
hospitalization.
Followup Instructions:
You should follow up with your primary care physician and your
psychiatrist within the next 2 days.
ICD9 Codes: 5849, 2859, 311, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1831
} | Medical Text: Admission Date: [**2183-3-2**] Discharge Date: [**2183-3-5**]
Service: MEDICINE
Allergies:
Codeine / Sulfonamides / Penicillins / Vicodin / Quinine Sulfate
/ Nsaids / Ephedrine / Ambien / Trazodone / Remeron
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
painful foot
Major Surgical or Invasive Procedure:
peripheral catheterization x 2
History of Present Illness:
[**Age over 90 **] year old female with severe PVD s/p multiple interventions,
CKD and DM presents to ED with bilateral leg pain worse on left.
Patient states the onset was acute on the day of admission. In
the ED, her left lower extremity was noted to be cold and
pulseless for whcih she was started on Heparin gtt.
As per [**Hospital Unit Name 196**] admission note: Pt last admited 3 months prior for
similar symptoms; she was taken urgently to cath lab where she
was found to have TO of proximal LSFA. Thrombectomy of LSFA
without restoration of flow so TPT and peroneal were
subsequently stented. However, several days later she
complained of episodes of worsened left leg and foot pain.
Intervention at that time included angioplasty to TPT plaque and
thrombectomy of the SFA. Final angiography demonstrated
improved flow, with 10-20% residual stenosis in the SFA and
TPT. The patient was asymptomatic at the time of discharge with
good blood flow to her LLE evident on exam.
.
As documented in our prior admit note, pt has been doing well
since discharge. Morning of admission while standing doing
chores had abrupt unset bilateral LE pain up to her knees. It
lasted several hours and slowly resolved on its own. Has not
had pain like this in the past. Denied any chest pain,
palpitations or dyspnea. Believes her left foot might be a bit
colder then normal. States that her son looked at her legs a few
days prior and said they looked good. Denies any parathesia or
anesthesia. At baseline, able to ambulate around the apt without
much difficulty. Denies classic caludication symptoms but states
that her legs get tired with walking and then get better with
rest. Able to lie flat at night without SOB or leg pain. Pt
denies any ankle edema, palpitations, syncope or presyncope.
.
On review of symptoms, she denied any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She did have extensive echymosis with her last
infuison of heparin. She denies recent fevers, chills or
rigors. All of the other review of systems were negative as not
mentioned above.
.
Admitted to [**Wardname 5010**] Service and underwent LE angiography in AM
which showed Left lower extremity - CFA was normal. The SFA
(left) occluded at the level of stents. The distal vessel has a
PA and distal PT at the foot. The AT was occluded. The distal
vessel was crossed into the PA and baloon angioplasty of the PA
was done. The flow in the PA was improved with the SFA still
ocludded with noted thormbus.
Past Medical History:
# Peripheral Vascular Disease-
[**4-/2181**] occluded stents in the LSFA, occluded trifurcation. The
LSFA stented. PTCA was performed on the L PT and the L lateral
tarsal at that time.
[**1-28**] occluded left SFA + occluded [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 101149**], pt underwent
successful PTCA/PCI of L SFA.
[**9-27**]: LSFA stenting of instent restenosis
[**10-28**]: RSFA stenting
[**11-27**]: thrombectomy of LSFA without restoration of flow. TPT and
peroneal stented. Repeat angiography with angioplasty to TPT
plaque and thrombectomy of the SFA. Final angiography
demonstrated improved flow, with 10-20% residual stenosis in the
SFA and TPT.
# Atrial Fibrillation: s/p AVJ ablation and pacemaker placement
#
# Chronic Kidney Disease: baseline Cr 2.5-3.0
# CHF: followed by [**Doctor Last Name **], mostly LE edema but sometimes also
gets pl effusions and pulm edema, EF [[**2179**]] was 70%; mild LVH,
mild AR, MR and mild pulm HTN, Goal wt around 125
# Diabetes Mellitus: diet controlled
# Glaucoma
# h/o lung nodules unclear Hx not being w/u
# h/o falls: lumbar and cervical spinal stenosis, poor vision
# h/o voice hoarseness
Social History:
Social History:
Patient lives by herself. Daughter is a nurse and one son is a
physician (radiologist). Quit tobacco 45 years ago. No EtOH or
other drug use. Has VNA 5 days per week and help with cleaning
for 3 hours once per week.
Family History:
Family History:
Heart disease, diabetes in her mother and 2 female siblings.
Physical Exam:
VS: BP 137/46 HR 74 T 94.9 RR 14 Sats 94%
.
GENERAL: thin and elderly but comfortable in NAD.
HEENT: Pupiles equal and reactive to light. No JVD appreciated.
CHEST: clear to ausculation anteriorly
CARDIAC: Nondispalced PMI. regular rate and rhythm, [**1-28**]
holosistolic murmur best heard There was a [**1-28**] holosystolic
murmur best at the apex
ABD: BS+, soft, non tender non distended. No hepatomegaly
appreciated.
EXT: Right groin line present. Mild oozing.
Left leg cool, decreased sensation medial aspect of the sole
bilaterally.
Cyanosis and delayed cap refill evident LLE.
.
Pulses:
Right: Carotid 2+ Femoral 1+ Popliteal non DP non PT non
Left: Carotid 2+ Femoral 1+ Popliteal dop DP non PT non
Pertinent Results:
[**2183-3-2**] 12:10PM PT-12.3 PTT-28.0 INR(PT)-1.1
[**2183-3-2**] 12:10PM PLT COUNT-295
[**2183-3-2**] 12:10PM ANISOCYT-1+ MICROCYT-1+
[**2183-3-2**] 12:10PM NEUTS-80.9* LYMPHS-11.8* MONOS-5.1 EOS-1.5
BASOS-0.6
[**2183-3-2**] 12:10PM WBC-9.6 RBC-4.66 HGB-13.4 HCT-39.6 MCV-85
MCH-28.7 MCHC-33.8 RDW-17.2*
[**2183-3-2**] 12:10PM CALCIUM-10.1 PHOSPHATE-4.6* MAGNESIUM-2.5
[**2183-3-2**] 12:10PM estGFR-Using this
[**2183-3-2**] 12:10PM GLUCOSE-137* UREA N-63* CREAT-2.9* SODIUM-142
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-20* ANION GAP-19
[**2183-3-2**] 08:55PM PT-13.1 PTT-133.2* INR(PT)-1.1
.
[**3-3**] CT Head
IMPRESSION: No evidence of acute intracranial pathology,
including no intracranial hemorrhage
.
[**3-3**] Cath
FINAL DIAGNOSIS:
1. Occluded LSFA stents
2. Diffuse below knee disease
3. Likely large thrombotic burden.
4. LLE thromobolysis using TPA
.
[**3-3**] Cath
FINAL DIAGNOSIS:
1. Significant restoration of flow after thrombolysis
2. diffuse, critical LSFA and below knee disease.
3. Successful PTA of the L PT (distal and proximal)
4. Successful stenting of the mid LSFA instent restenosis
5. Successful stenting of the proximal LSFA lesion
6. Successful PTA of the L popliteal
.
[**3-4**] CT Abd/Pelvis
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Large right groin hematoma extending into the medial aspect
of the right thigh.
3. Large right-sided pleural effusion. Moderate left pleural
effusion. These measure relatively high attenuation, and
hemorrhage cannot be excluded. Associated atelectasis, with near
complete collapse of the right lower lobe noted.
4. Nodular opacities are seen at the lung bases. Followup
imaging recommended to document resolution or stability.
5. Single posterior mid-right renal lesion does not meet CT
criteria for simple cyst.
.
[**3-4**]
IMPRESSION: Moderate to large right pleural effusion, possibly
representing hemothorax given history, although moderate
effusion has been present since [**2182-11-22**] CT. Pulmonary
edema.
.
Brief Hospital Course:
The patient was admitted with an ischemic left foot and was
brought to the cath lab for intervention. She underwent
angioplasty and received tPA and stenting with transient
improvement in flow. However, her foot again became pulseless
and ischemic, and she became hypotensive requiring pressers.
Her family (daughter and son) wanted the patient made
comfortable, and expressed that the patient would not wish to
live without her foot. Subsequently the patient's goal of care
was changed to comfort and she was started on a Morphine drip.
She died shortly after this.
Medications on Admission:
Aspirin 325 mg per day
Plavix 75 mg perday.
Toprol 50
Vitamin B12 1000 mcg IM monthly
Lasix 20 mg p.o. daily
multivitamin one tab daily
pilocarpine eyedrops
timolol eyedrops
Trusopt eyedrops
Protonix 40 mg p.o. every morning
Prevacid 15 mg p.o. nightly
Tylenol 500 mg two tabs as needed for pain.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 4280, 5119, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1832
} | Medical Text: Admission Date: [**2145-2-19**] Discharge Date: [**2119-4-17**]
Date of Birth: [**2083-5-2**] Sex: M
Service: GEN [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
man, recently discharged from [**Hospital1 188**] on [**2145-1-22**], who had an episodic asymptomatic
hypoglycemia that was incidentally discovered in [**Month (only) 547**]. The
patient suffered a cerebrovascular accident on [**2144-6-13**] with
right hemiparesis. He was told he suffered from diabetes,
but no glucose levels or hemoglobin A1c values were
available. The patient was evaluated for a stroke on [**2144-7-20**]. During the hospital stay, his hemoglobin A1c was 6.4%
(normal is less than 5). The patient began checking finger
sticks at home, which were normal early in the morning, and
usually they were in the 40s by the late morning. He was
always asymptomatic during these episodes. The patient
reports a weight loss of approximately 15 pounds since [**2144-5-17**].
On [**2144-10-3**], his serum glucose was 56, C-peptide 3.1,
and insulin 36, hemoglobin A1c of 5.6%. On [**1-5**], the
patient's wife found him sitting in front of his lunch,
staring ahead, unresponsive to verbal stimuli. The patient
was taken to [**Hospital3 1280**] Emergency Department and was found to
have a [**Hospital3 **] sugar of 16. Further workup revealed a glucose
of 93, an insulin of 17, and pro-insulin of 4.2. He was
negative for insulin antibodies. Prolactin level was 9.7.
Urine panel was negative. Chest x-ray was normal.
The patient had a CT done on [**2-4**] that showed a 1.3 x
1.4 cm pancreatic mass at the tail, hypervascular lesion.
There were no metastases.
PAST MEDICAL HISTORY: Hypertension, dyslipidemia, left
middle artery division stroke/left basal ganglion internal
capsule with residual right hemiparesis in [**2144-5-17**].
MEDICATIONS: Aspirin 325 mg once daily, Norvasc 5 mg once
daily, Lipitor 10 mg once daily, folate 1 mg by mouth once
daily, Trazodone 25 mg by mouth daily at bedtime, Detrol LA 4
mg by mouth once daily.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Pulse 92, [**Year (4 digits) **] pressure 164/78. The
chest was clear to auscultation, with decreased breath sounds
at the bases. Cardiac was regular rate and rhythm, S1, S2.
He was obese, soft, nontender, positive bowel sounds, no
bruit. The right lower extremity was in a brace. The
dorsalis pedis pulses were palpable bilaterally.
HOSPITAL COURSE: The patient was found to have insulinoma
and underwent a distal pancreatectomy and splenectomy with
intraoperative ultrasound on [**2145-2-19**], by Dr. [**Last Name (STitle) 1305**]
and Dr. [**Last Name (STitle) 22214**]. Please see operative note for further
details. Postoperatively, the patient went without
complications. Postoperative hematocrit was 40.4. Sodium
was 138, potassium 3.9. The patient's finger sticks were
within normal limits throughout the hospital stay.
Urinalysis on postoperative day two revealed trace glucose,
15 ketones. The patient was treated for pain with epidural.
On postoperative day three, the patient was started on
clears, had bowel sounds. The nasogastric tube was removed.
He was advanced on diet as tolerated. The patient started
oral intake, and was switched to oral pain medications. The
epidural was clamped on [**2-23**], postoperative day four.
The patient tolerated clears. The epidural was removed. The
[**Location (un) 1661**]-[**Location (un) 1662**] drain remained serosanguinous. The Foley was
discontinued, and he was able to void. He was taking a
regular diet. The [**Location (un) 1661**]-[**Location (un) 1662**] amylase was 210.
The patient is to be discharged to rehabilitation, given his
cerebrovascular accident, difficulty ambulating and
difficulty with care of self. Date of discharge and
rehabilitation placement are pending. The patient received
his H. influenza and pneumococcal vaccines on [**2145-2-23**]. The patient, in hospital, was on heparin 5000
subcutaneously twice a day, Zantac 50 intravenously every
eight hours, insulin sliding scale, and percocet for pain.
The rest of this dictation is pending rehabilitation
placement.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**]
Dictated By:[**Name8 (MD) 6908**]
MEDQUIST36
D: [**2145-2-23**] 23:43
T: [**2145-2-24**] 00:30
JOB#: [**Job Number 33381**]
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1833
} | Medical Text: Admission Date: [**2119-10-25**] Discharge Date: [**2119-11-1**]
Date of Birth: [**2059-5-16**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Sudden onset right hemiparesis with a facial droop, Code Stroke
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
The pt is a 60 year-old right-handed man with a PMH of tobacco
use who was transferred from [**Hospital **] Hospital this evening after
presenting with R sided weakness.
Mr. [**Known lastname 80445**] was in his USOH this evening when around 6pm he
developed R hand numbness and weakness. He shook his hand and
the symptom resolved over a couple of minutes. Then around 8:30
pm he developed R arm and leg weakness over about 2 minutes. He
went to find his wife and she called 911. He had a R facial
droop as well as R sided weakness.
He was taken to [**Hospital 19135**] hospital and his Bp there was 212/120 and
the BS was 144. His labs were remarkable for a Cr of 1.2 and
negative CE. His INR was 0.88. His NIHSS was 9, for a R facial
droop, R arm and leg weakness and dysarthria.
ROS: per HPI
Past Medical History:
None
Social History:
-married
-1 ppd for "whole life"
-denies drug use
-Social EtOh
Family History:
Non-contributory
Physical Exam:
Physical Exam:
NIHSS= 9 ( 3 for arm and leg weakness; 2 for facial droop; 1 for
dysarthria
Vitals: T: 97.6 P: 65 R: 16 BP: 237/124 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No LE edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent but with
significant dysarthria. He has intact repetition and
comprehension. Normal prosody. There was one paraphasic errors,
called a cactus a cacus. Pt. was able to name both high and low
frequency objects otherwise. Able to read without difficulty.
Able to follow both midline and appendicular commands. There was
no evidence of apraxia or neglect.
CN
I: not tested
II,III: VFF to confrontation, Pupils 4mm->3mm bilaterally, fundi
normal
III,IV,V: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: L facial droop
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**5-15**] bilaterally
XII: tongue protrudes midline, + dysarthria
Motor: Normal bulk and tone; no asterixis or myoclonus. No
pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 5 5 5 5 5 5
R 0--------------------
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 0--------------------
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 2 Flexor
R 2 2 2 2 2 Flexor
-Sensory: No deficits to light touch, pinprick. No extinction to
DSS.
-Coordination: No dysmetria on FNF or HKS bilaterally on R. L
sided is plegic
-Gait: deferred
Pertinent Results:
LABS:
ADMISSION:
14.9 90
8.7>--------<183
42.6
N:70.0 L:21.4 M:6.4 E:1.9 Bas:0.2
PT: 12.3 PTT: 29.4 INR: 1.0
%HbA1c: 5.9
140 105 15 102
-------------<
4.1 25 1.0
Ca: 9.2 Mg: 2.1 P: 3.9
CK: 93->97->168 Trop-T: <0.01 x3
ALT: 26 AP: 69 Tbili: 0.4
AST: 21
Cholesterol:190
Triglyc: 69
HDL: 51
CHOL/HD: 3.7
LDLcalc: 125
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Urine Tox: Negative
DISCHARGE:
138 104 22 90
-------------<
4.2 27 1.0
Ca: 9.0 Mg: 2.2 P: 4.5
13.6 92
6.4>---------<205
40.5
PT: 12.8 PTT: 61.8 INR: 1.1
IMAGING:
[**2119-10-25**] ECG
Normal sinus rhythm. Probable voltage criteria for left
ventricular
hypertrophy with secondary ST-T wave abnormalities. No previous
tracing
available for comparison.
[**2119-10-25**] CXR
The cardiomegaly is moderate to severe. Mediastinal contours are
grossly
unremarkable. The lung volumes are preserved. Small right
pleural effusion
is demonstrated but no overt failure is present although
vascular engorgement is seen. No pneumothorax is demonstrated.
Overall the study is technically limited.
[**2119-10-25**] CTA head/neck
1. No acute intracranial hemorrhage.
2. Atherosclerotic disease without significant stenosis of the
internal
carotid or vertebral arteries.
[**2119-10-25**] MRhead/MRA brain
1. MRI of the brain is limited to diffusion-weighted imaging,
ADC map, and
fractional anisotropy, as the patient declined further imaging.
2. Acute infarcts within junction of the left thalamus and
internal capsule and bilateral frontal lobes. Multifocality
suggests a central embolic source.
3. Unremarkable MRA of the brain.
[**2119-10-26**] TTE
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
0-5 mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 70%).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I (mild) LV diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The aortic 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. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
[**2119-10-28**] CT chest/abdomen/pelvis
IMPRESSION: Extensive arterial vascular calcifications,
including among the coronary arteries, but no findings
suspicious for malignancy by CT.
[**2119-10-30**] EEG
(Prelim): No electrographic seizures
[**2119-10-31**] TEE
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 very small patent foramen ovale
is present but there is no passage of agitated saline from right
atrium to left atrium with bubble study. Overall left
ventricular systolic function is normal (LVEF>55%). There are
complex (>4mm) non-mobile atheroma in the aortic arch. There are
complex (> 4 mm and mobile) atheroma in the descending aorta.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Diffuse aortic atherosclerosis with complex (>4 mm)
highly-mobile atheroma in the descending aorta and complex (>4
mm) non-mobile atheroma in the aortic arch. Very small patent
foramen ovale with no evidence of right to left shunting.
Brief Hospital Course:
1. Embolic stroke. The patient is a 60 year-old right handed man
with a PMH of tobacco use who was transferred from an OSH 6
hours after the onset of R face, arm, and leg weakness. His exam
was remarkable for a R facial droop with dysarthria and a dense
R hemiplegia. CTA head/neck showed atherosclerotic disease
without significant stenosis of the internal carotid or
vertebral arteries. MRI/A Head showed acute infarcts within
junction of the left thalamus and internal capsule and bilateral
frontal lobes, multifocality suggests a central embolic source.
Unremarkable MRA of the brain. CT chest/abdomen/pelvis showed
extensive arterial vascular calcifications, including among the
coronary arteries, but no findings suspicious for malignancy by
CT. TTE showed no ASD or PFO, LVEF 70% with moderate symmetric
LVH and grade I (mild) LV diastolic dysfunction. TEE showed
diffuse aortic atherosclerosis with complex (>4 mm)
highly-mobile atheroma in the descending aorta and complex (>4
mm) non-mobile atheroma in the aortic arch, very small patent
foramen ovale with no evidence of right to left shunting. Given
the TEE findings, the patient initially was started on heparin
gtt and Coumadin 5 mg daily; however, he then decided he does
not want to be on Coumadin. Therefore he was continued on ASA
325 daily. Lipids: Cholest 190, Triglyc 69, HDL 51, LDL 125. He
was started on Atorvastatin 20 daily. HgA1c: 5.9%. Trop T
negative x3. He had a routine EEG on [**10-30**] as he was having
right arm and leg spasms s/p stroke, prelim read showed L>R
temporal slowing. He will follow up with Dr. [**First Name (STitle) **] in Neurology
as an outpatient.
2. Hypertension: On [**10-25**], he developed hypertension to 206/105
with chest tightness. His bp was not able to be controlled with
IV lopressor and IV hydralazine on the floor, so he was briefly
transferred to NeuroICU for Labetalol gtt. He was discharged on
Amlodipine 10 mg daily and Lisinopril 10 mg daily.
3. Elevated Cr: His Cr on admission was 1.2, but increased to
1.3. This was thought to likely be obstructive, and he was
started on Flomax 0.4 mg PO qhs. His Cr was 1.0 at the time of
discharge.
4. Arm Cellulitis: He developed arm cellulitis around the site
of a peripheral IV, and was traeted with Cephalexin 500 mg PO q6
hr to complete a 7 day course.
5. Contact: [**Name (NI) **] (daughter) [**Telephone/Fax (1) 80446**]
Medications on Admission:
None
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Medications
Humalog Insulin Sliding Scale
5. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
PRIMARY:
Stroke - Acute infarcts within junction of the left thalamus and
internal capsule and bilateral frontal lobes, likely embolic
Hypertension
Hypercholesterolemia
Arm Cellulitis
Discharge Condition:
Right hemiparesis with a right facial droop
Discharge Instructions:
You presented with right sided body weakness and slurred speech,
and were found to have multiple strokes. You had high blood
pressure during the hospitalization, requiring you to briefly go
to the MICU. You had a trans-esophageal echocardiogram which
showed 2 large atheroma in your aorta. You elected not to be
started on Coumadin, so you should continue taking Aspirin 325
mg daily. You should discontinue smoking.
You were started on Aspirin, Atorvastatin, Amlodipine,
Lisinopril, Tamsulosin, Albuterol as needed, and Ipratropium as
needed while in the hospital. You should take Keflex for 2 mores
days for your arm cellulitis.
If you develop weakness or numbness, double vision or blurry
vision, difficulty speaking or swallowing, chest pain,
fevers/chills, or any other symptoms that concern you, call your
PCP or return to the ED.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in
Neurology([**Telephone/Fax (1) 2574**]) on [**2119-12-15**] at 10:00 am in the [**Hospital Ward Name 23**]
Building [**Location (un) 858**]. You will need to call the office before the
appointment in order to complete your registration, and will
need a referral from your PCP.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1834
} | Medical Text: Admission Date: [**2174-12-5**] Discharge Date: [**2174-12-10**]
Date of Birth: [**2104-10-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
[**2174-12-5**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to
OM1, SVG to OM2, SVG to PDA)
History of Present Illness:
70 y/o male with exertional angina and abnormal ETT. Underwent
cath and was found to have severe three vessel coronary artery
disease. Referred for surgical revascularization.
Past Medical History:
Hypertension, Hypercholesterolemia, Diabetes Mellitus, Glaucoma,
Macular degeneration, Renal Colic, Erectile dysfunction, s/p
Appendectomy
Social History:
Retired. Quit smoking 30 yrs ago. Social ETOH use.
Family History:
Brother died from MI at age 49.
Physical Exam:
Admission Wt 96.6K
Gen: WDWN male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused -JVD
Neuro: A&O x 3, MAE, non-focal
Discharge
VS T 98 BP 113/62 HR 97SR RR 20 O2sat 94%-RA Wt 89.5K
Gen NAD
Neuro Alert, nonfocal. Spanish speaking
Pulm course BS-diminished at bases
CV RRR, no murmur. Sternum stable, incision CDI.
Abdm Soft, NT/+BS
Ext warm, trace edema bilat. EVH site CDI
Pertinent Results:
[**12-5**] Echo: PRE BYPASS: The left atrium and right atrium are
normal in cavity size. A small secundum atrial septal defect is
present. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). 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. There are three aortic valve leaflets. 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. No mitral
regurgitation is seen. There is no pericardial effusion.
POST BYPASS: On infusion of phenylephrine. Preserved lv systolic
function. Mild AI, MR. Aorta is intact post decannulation.
[**2174-12-5**] 06:45PM GLUCOSE-170* NA+-136 K+-4.3
[**2174-12-5**] 06:28PM UREA N-12 CREAT-1.0 CHLORIDE-108 TOTAL CO2-24
[**2174-12-5**] 06:28PM WBC-15.3* RBC-3.57* HGB-10.9* HCT-31.3*
MCV-88 MCH-30.4 MCHC-34.7 RDW-12.6
[**2174-12-5**] 06:28PM PLT COUNT-190
[**2174-12-5**] 06:28PM PT-14.7* PTT-33.0 INR(PT)-1.3*
[**2174-12-8**] 05:30AM BLOOD WBC-10.6 RBC-2.96* Hgb-9.2* Hct-26.4*
MCV-90 MCH-31.1 MCHC-34.7 RDW-12.8 Plt Ct-187
[**2174-12-7**] 05:55AM BLOOD Plt Ct-187
[**2174-12-9**] 05:00AM BLOOD Glucose-156* UreaN-17 Creat-1.1 Na-136
K-4.2 Cl-103 HCO3-29 AnGap-8
DIABETES MONITORING %HbA1c
[**2174-11-30**] 01:50PM 6.3*1
Radiology Report CHEST (PORTABLE AP) Study Date of [**2174-12-8**] 8:13
AM
[**Hospital 93**] MEDICAL CONDITION:
70 year old man s/p CABG
REASON FOR THIS EXAMINATION:
atelectasis
Preliminary Report !! PFI !!
Bilateral basilar atelectases, unchanged. There is a stable
small right
apical pneumothorax.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Brief Hospital Course:
Mr. [**Known lastname 6633**] [**Known lastname 79739**] was a same day admit after undergoing
pre-operative work-up as an outpatient. On day of admission he
was brought directly to the operating room where he underwent a
coronary artery bypass graft x 4. Please see operative report
for surgical details. In summary he had CABGx4 with LIMA-LAD,
SVG-OM1, SVG-OM2, SVG-PDA, his bypass time was 96 minutes with a
crossclamp of 77 minutes. He tolerated the operation well and
following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. He remained hemodynamically
stable in the immediate post-op period and was weaned from
sedation, awoke neurologically intact and was extubated. On
post-op day one he was started on beta blockers and diuretics
and gently diuresed towards his pre-op weight. Also on this day
he was transferred to the telemetry floor for further care.
Once transferred to the floors his hospitalization was largely
uneventful. On post-op day two his chest tubes were removed and
post-op chest x-ray revealed small apical pneumothorax, which
remained stable throughout his stay. On post-op day three his
epicardial pacing wires were removed. His activity level was
advance dand on POD 4 he was discharged home with visiting
nurses.
Medications on Admission:
Aspirin 325mg qd, Enalapril 20mg qd, Lopressor 25mg [**Hospital1 **],
Amlodipine 10mg qd, Simvastatin 20mg qd, Loratadine 10mg qd
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6011**] Care
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: Hypertension, Hypercholesterolemia, Diabetes Mellitus,
Glaucoma, Macular degeneration, Renal Colic, Erectile
dysfunction, s/p Appendectomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 6 weeks or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) **] in [**3-13**] weeks
Dr. [**Last Name (STitle) 13983**] in [**2-9**] weeks
Completed by:[**2174-12-9**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1835
} | Medical Text: Admission Date: [**2147-12-8**] Discharge Date: [**2147-12-27**]
Date of Birth: [**2093-8-14**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
R IPH, LOC
Major Surgical or Invasive Procedure:
[**2147-12-8**]: Right Craniectomy, embolization of AVM, and evacuation
of right IPH
History of Present Illness:
This is a 54 year old female who was in her usual state of
health until she was
found by upstairs neighbors after they heard a loud noise. The
patient reported that she had run into the door, which caused
her left eye ecchymosis the day prior. EMS transported patient
from home to [**Hospital1 18**] ER. Upon arrival she was quite somnolent and
was intubated post-CT scan.
Past Medical History:
HTN, AVM(known hx), XRT for cervical CA, OP, s/p MVA 2yrs ago.
Social History:
Possible history of domestic abuse, lives alone, works at
funeral home, has two daughters ages 30 and 21
Family History:
family history of aneurysms
Physical Exam:
On admssion:
O: T: 97.0 BP: 105/89 HR: 74 R 18 O2Sats 100%
Gen: Somnolent; cervical hard collar in place
HEENT: Normocephalic. Ecchymosis to left eye
Neck: Hard cervical collar in place
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and somnolent, cooperative with exam,
normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus, left sided neglect.
V, VII: Right facial droop
VIII: Hearing intact to voice.
IX, X: not tested
[**Doctor First Name 81**]: not tested
XII: Tongue midline without fasciculations.
Motor: RUE and RLE [**3-27**]. LUE and LLE was antigravity but no
initiation of movement on that side- apparent left sided
neglect.
On discharge: ****
Pertinent Results:
CT Head [**2147-12-13**]:
Stable size and appearance of intraparenchymal and
interventricular
hemorrhage, pneumocephalus, post-surgical changes and frontal
hematoma.
Midline shift measures 12 mm today vs 10 mm today likely due to
inter-scan
variability given stable size of intracranial hemorrhage and
edema.
CT Head [**2147-12-11**]:
1. Postoperative changes of the right frontoparietal lobe as
described.
Increase in the amount of hypodensity within the surgical bed,
concerning for evolving infarct with edema.
2. Unchanged 8-9mm leftward shift of midline structures, mass
effect on the right lateral ventricle and adjacent sturctures
including thalami, subthalamic regions and upper midbrain.
3. Slight interval enlargement of the lateral and third
ventricles concerning for developing hydrocephalus. Unchanged
intraventricular hemorrhage.
MR [**Name13 (STitle) **] [**2147-12-9**]:
1. Straightening and reversal of the cervical lordosis.
2. There is no evidence of focal or diffuse lesions within the
cervical
spinal cord.
3. Multilevel disc degenerative changes throughout the cervical
spine as
described in detail above, more significant from C4/C5 through
C6/C7 levels.
No diffusion abnormalities are detected to suggest acute
ischemic changes.
MRA of Brain [**2147-12-9**]:
There is no evidence of significant flow stenotic lesions, mild
deviation of the vessels on the right, likely consistent with
mass effect from the previously drained parenchymal hematoma.
MRA of Neck [**2147-12-9**]:
Patency of the carotid arteries and vertebral arteries with mild
decreased signal at the origin of the left common carotid
artery, possibly
artifactual in nature.
CT Head [**2147-12-9**]:
1. Expected postoperative changes in the right frontoparietal
lobe as
described above. Persistent shift of normally midline structures
towards the left by approximately 10 mm, unchanged.
2. No significant change in intraventricular hemorrhage as
described above. Small amount of hemorrhagic products again
identified within the surgical bed, similar in appearance.
CT Head [**2147-12-8**]:
5 cm right intraparenchymal hemorrhage in right temporal and
parietal lobe
with extension into right lateral ventricle. Midline shift of 14
mm, slight effacement of basal cisterns suggest early or
impending central herniation.
CT C-spine [**2147-12-8**]:
Linear lucency through the right C4 transverse foramen. This
would be unusual for an isolated injury; however, a
non-displaced fx cannot be excluded. A CTA is recommended for
assessment of [**Month/Day/Year 1106**] injury.
CTA Head and Neck [**2147-12-8**]:
1. Arteriovenous malformation in the posterior right temporal
lobe, supplied by branches of the distal right MCA and draining
into the cortical veins and eventually into the superior
sagittal sinus.
2. Similar size and appearance of large parenchymal hematoma and
intraventricular hemorrhage as estimated on the
contrast-enhanced study, and similar degree of mass effect,
midline shift and central herniation.
Brief Hospital Course:
Ms. [**Known lastname 101911**] was admitted to the Neurosurgery service on
[**2147-12-8**]. She was started on Dilantin. Following an acute
decompensation and posturing in the ED, she was emergently taken
to the OR on [**2147-12-8**] initially for a right craniectomy, followed
by cerebral angiography and onyx embolization of rt parietal
AVM. Immediately after, she was taken back to the OR where blood
products and AVM nidus were resected-followed by cranioplasty.
She was transferred to the ICU from the OR. While in the ICU
she was closely monitored with q1hour neuro checks. On [**2147-12-9**],
she had a NCHCT which showed expected post-operative changes,
with persistent 10mm of midline shift. She also had an MRI/MRA
of the head and neck [**2147-12-9**].
On [**2147-12-11**], she was noted to have a fixed and dilated right
pupil. She was treated with mannitol bolus and hyperventilation
to PCO2 to 35. She improved with this intervention. With this
event, she underwent a Head CT which showed Slight interval
enlargement of the lateral and third ventricles but was
otherwise unchanged from previous studies.
On [**2147-12-12**] her exam improved with her eyes opening to voice,
following commands in the Right Upper and Right Lower
extremities as well as the Left Upper extremity. She had brisk
withdrawal on the Left Lower Extremity. Her pupils were equal
round and reactive to light with hippus.
On [**2147-12-13**] her mannitol dosing was decreased from 50mg q4hours
to 50mg q6hours, and her exam remained stable, however she
appeared to be more interactive. In the late am, she had a
bronchospastic event(thought to be caused by carinal
irritation), requiring Propofol for additional sedation,
albuterol and racemic epinephrine. Her neuro exam remained
stable despite this. She was further weaned of her ventilator
requirements for goals of extubation.
On [**2147-12-14**] she developed a fever to 104 overnight and was
subsequently pancultured. On exam she was found to be less
interactive, with eye opening to voice with light stimulation,
but was not following commands otherwise, and withdrew to
noxious stimuli in all 4 extremities. A STAT Head CT was
obtained which was stable when compared to the prior study done
on [**2147-12-13**]. Her mannitol was then decreased to 25g q6 hours with
the intent to wean.
On [**2147-12-15**] the patient's HCT was 21 and she received 1 unit of
RBCs. Her exam was improved and she was following commands with
the right side. Her mannitol was decreased to 12.5 Q6 hours.
On [**2147-12-16**] her sputum culture grew coag + staph aureus so she
was changed to Cipro. The patient's mannitol was decreased
again and her exam remained stable. Her steroids were also
weaned down.
On [**2147-12-17**] the patient was noted to have bilateral vesicular
lesions in the sacral region so antivirals were started
empirically. ID was consulted for assistance in managing the
pneumonia and the skin infection. Eventual cultures were
negative for HSV but positive serum HSV for which she was
treated for 7 days with Acyclovir. Mannitol was weaned to off.
Her hematocrit was trended during her hospital course. No source
of bleed was found for her initial drop in hct, however at that
time the patient was receiving multiple amounts of IV fluids and
it was thought to be dilutional. On discharge her hct was 24.8.
She is being treated for a VAP pneumonia (dx [**12-16**]) a bronch
showed Coag + staph for which she is being treated with IV
Naficillin until [**1-8**] for a RLL pneumoia. Follow up CXR showed
on [**12-25**] showed much improved pneumonia. All blood have been
negative to date. She was treated for a UTI on [**12-8**]. She has
been afebrile since [**12-23**] and had a PICC line placed for IV
Naficilin on [**12-25**].
Social work has been involved due to question of abuse. A family
member has brought this concern to a detective in the [**Location (un) 86**]
Police Department.
On [**2147-12-19**] she was transferred to the Step Down Unit. HSV
culture was finalized on [**2147-12-20**] which was positive for HSV,
negative shingles; Acyclovir for 7 days for treatment.
She remained febrile and on [**12-21**] LENIS was done to rule a
thrombus in the tibial vein, [**Month/Year (2) 1106**] surgery was consulted
regarding question of treatment and need for IVC filter. Follow
up ultrasound on [**12-25**] did not show any progression of the clot.
They recommended following up in 2 weeks that appointment has
been made.
On [**12-25**] she had a transient increase in LFTs for which her
Naficllin was changed to Vancomycin and a ultrasound of her
liver showed a grossly normal son[**Name (NI) 493**] assessment of the
abdomen with incidental note of hepatic cyst. Her LFTs returned
to normal on [**12-26**]. Her hepatitis panel was negative.
On discharge she was awake, alert and orientated X3 with no
cranial nerve findings. She has some minimal left sided weakness
noted. She was tolerating a regular diet and voiding without
difficulty, final ua was negative.
Medications on Admission:
Unknown HTN, Unknown OP
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing/SOB.
9. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheeze.
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
13. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q4H
(every 4 hours) as needed for SBP>160.
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
15. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. Vancomycin 500 mg Recon Soln Sig: 2.5 Recon Solns
Intravenous Q 12H (Every 12 Hours) for 12 days: End [**1-8**].
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Right intraparenchymal hemorrhage
Right AVM
Respiratory Failure
Hypertension
Staph aureus pneumonia
Urinary Tract Infection
Bronchospasm
Left lower extremity deep vein thrombus (posterior tibial vein)
small pericardial effusion
Left hemi neglect
Left visual field cut
HSV +
Discharge Condition:
Neurologically Stable
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
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 as normal as your staples are removed
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain
YOU WILL NEED TO SEE YOUR PRIMARY CARE PHYSICIAN WITHIN TWO
WEEKS OF YOUR DISCHARGE
PLEASE CALL [**Telephone/Fax (1) **] FOR AN APPOINTMENT TO SEE DR. [**Last Name (STitle) **] /
[**Hospital **] CLINIC / FOR FURTHER TREATMENT AND WORK UP OF YOUR DEEP
VEIN THROMBOSIS (CLOT)....AN APPOINTMENT HAS BEEN MADE FOR YOU
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2148-1-5**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2148-1-5**] 10:45
YOU WILL NOT NEED TO FOLLOW UP IN THE INFECTIOUS DISEASE CLINIC.
Completed by:[**2147-12-27**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1836
} | Medical Text: Admission Date: [**2189-11-3**] Discharge Date: [**2189-11-7**]
Date of Birth: [**2148-12-1**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Bronchoscopy with broncheoalveolar lavage
History of Present Illness:
Mr. [**Known lastname 7749**] is a 40 year old laborer with AIDS and a CD4 count of
12, as well as genotype 1b Hepatitis C, with recent occupational
exposure to sewage and recent crack cocaine and marijuana use,
who presents with 3 weeks of progressive dyspnea.
.
About 1.5 months ago, Mr. [**Known lastname 7749**], [**First Name3 (LF) **] unemployed [**Hospital1 **]-afilliated
laborer, took a brief job helping clean sections of
sewage-coated areas of the Deer Island Sewage Treatment Plant,
in which he used a large vacuum cleaner to clean sewage, ripe
with the smell of feces, out of trough-like areas of the plant.
He found this to be very physically demanding work, one of the
hardest jobs he's ever had in a work history marked mainly by
laborer and demolition work in construction, but he did not lose
his energy and additionally, he had [**Last Name **] problem bicycling to
work. When the job ended, about 3-4 weeks ago apparently
(although his timeline is not entirely consistent), he had a
large amount of cash on hand and used it to binge on crack
cocaine and Klonopins, the former being a frequent past drug of
choice for him, and the latter being a more unusual variation.
This run of drug use lasted about a week.
.
Apparently around the time this week ended he got what he
describes as "a cold" with some runny nose and cough; he says
that everyone in his rooming house got a cold, but he was the
only one not to get over it. 2 weeks ago he quit smoking. His
respiratory status gradually worsened, with more and more
difficulty breathing. Over the last week he has had little
appetite, even despite some efforts to smoke marijuana to
stimulate it; and he believes that he has lost weight. He has
had subjective fever symptoms of feeling cold and getting sweats
for several weeks.
.
He reports that earlier today he tried to take a shower, shave,
and brush his teeth; this required frequent stops to get his
breath and all told took about an hour and a half.
.
He has already been seen for cough and SOB with exertion. He was
seen by his primary care and HIV physician, [**Known firstname **] [**Last Name (NamePattern1) 2148**], on
[**10-26**]; he was prescribed an azithromycin z-pack and given the
regular flu vaccine. He also restarted his prior [**Month/Year (2) 2775**] regimen,
of ritonavir-boosted atazanavir and emtricitabine-tenofovir, at
this time.
.
He was seen in the emergency department on [**10-30**], at which time
he had not started his z-pack, where he complained of productive
cough with yellow-green sputum, but without shortness of breath
or chest pain. He started his azithromycin then, after the ED
visit, and had continued to take it up until his admission on
[**11-3**]. He returned with still worse cough, shortness of breath,
and dyspnea with exertion.
.
In the ED, initial vs were: T 100.3; P 122 BP 114/80 R 30 O2 sat
88%RA. Patient was given:
Levofloxacin 750 mg IVx1
Vancomycin 1gm IV x1
Primaquine 30 mg PO x1
Clindamycin 600 mg IV x1
.
When arriving in the [**Hospital Unit Name 153**], Mr. [**Known lastname 7749**] was conversing easily while
wearing a face mask. He complained of cold temperature in
cool-to-normal room. He had his [**Known lastname 2775**] medicines with him and
planned to take them while he was here and emphasized that he
was now taking them faithfully. He did discuss some instances in
which he was found to have HIV in prior group houses and this
created problems for him, and he does not let his fellow rooming
house residents know that he has HIV; he denies that this is now
a barrier to adherence.
.
Past Medical History:
HIV/AIDS - exposure assumed to be IVDU (injected cocaine)
.
Hepatitis C, genotype 1b; was on interferon for 4 shots until
becoming paranoid and earning a [**Hospital1 **] 4 admission
.
Denies any asthma history or other childhood illnesses
Social History:
Occupation: Laborer, local 233; unemployed for last 6 months;
Occupational exposures: demolition work; asbestos exposure in
younger years of adulthood; sewage as described above. Cat at
home owned by other people with rooms in the house, he does not
change cat litter. Denies exposure to horses.
Drugs: cocaine, klonopin; past but not recent IVDU
Tobacco: 25+ years of 1ppd
Alcohol: not recently
Other: Sexually active w girlfriend of 12 years (though this
contradicts info in some past outpt notes); uses condoms
Family History:
Father with alcoholism
Physical Exam:
T: 35.8 ??????C (96.5 ??????F)
HR: 76 (75 - 76) bpm
Heart rhythm: SR (Sinus Rhythm)
BP: 118/64(78)
RR: 17 (16 - 17) insp/min
O2 Delivery Device: Non-rebreather
SpO2: 95%
.
General Appearance: Thin, Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, dry mouth; no thrush
seen in anterior OP
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : at base, Wheezes : slight insp/exp wheezes,
Diminished: poor air movement throughout w shallow breathing;
less air movement on left lower lung field)
Abdominal: Soft, Non-tender, Bowel sounds present, no
splenomegaly
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis
Musculoskeletal: No(t) Muscle wasting
Skin: Warm, No(t) Rash: , Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): situation, place, person,
Movement: Purposeful, Tone: Normal
Pertinent Results:
[**2189-11-3**] 07:23PM WBC-8.3# RBC-5.44 HGB-14.9 HCT-44.2 MCV-81*
MCH-27.3 MCHC-33.6 RDW-13.2
[**2189-11-3**] 07:23PM NEUTS-81.0* LYMPHS-12.1* MONOS-4.9 EOS-1.5
BASOS-0.5
[**2189-11-3**] 07:23PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL BURR-OCCASIONAL
[**2189-11-3**] 07:23PM PT-13.4 PTT-29.9 INR(PT)-1.1
[**2189-11-3**] 07:23PM PLT COUNT-178#
[**2189-11-3**] 07:23PM RET AUT-0.7*
.
[**2189-11-3**] 07:23PM ALT(SGPT)-42* AST(SGOT)-46* LD(LDH)-344*
CK(CPK)-47 ALK PHOS-63 TOT BILI-6.0* DIR BILI-0.3 INDIR BIL-5.7
.
[**2189-11-3**] 07:23PM cTropnT-<0.01
[**2189-11-3**] 07:23PM CK-MB-NotDone
.
[**2189-11-3**] 07:23PM GLUCOSE-100 UREA N-14 CREAT-0.9 SODIUM-136
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13
[**2189-11-3**] 07:29PM LACTATE-1.4
.
Urine and serum tox screens were negative.
.
CT SCAN [**2189-11-3**]
INDICATION: 40-year-old man with HIV, with shortness of breath
and recent
course of antibiotics.
COMPARISON: No prior chest CT for comparison.
TECHNIQUE: MDCT-acquired axial images were obtained through the
chest
following administration of intravenous contrast material.
Multiplanar
reformatted images were generated.
CT CHEST WITH IV CONTRAST: The pulmonary arterial tree is well
opacified, and there is no pulmonary embolus. The aorta is
normal without acute abnormality. Great vessels are
unremarkable. The heart is normal in size, without pericardial
effusion.
.
There are small left hilar lymph nodes, but no hilar or
mediastinal lymphadenopathy by size criteria. There is no
axillary lymphadenopathy.
.
Lungs demonstrate multifocal ground-glass opacities in an
asymmetric distribution, greater throughout the left lung than
the right. Ground glass attenuation becomes more confluent in
the lower left lung. In the central lower portion of the left
lower lobe, there is a focal region of consolidation, and a 2.4
x 2.7 cm area of cavitation. The cavitary lesion demonstrates a
thick wall, and does not contain fluid. The region of cavitation
abuts the major fissure and possibly the pericardium.
Posteriorly in the right lower lobe (2:84), there is a 4-mm
nodule. There is no pleural effusion. The tracheobronchial tree
is patent to subsegmental levels.
.
While this exam is not optimized for evaluation of the abdomen,
there are no gross abnormalities of the upper abdomen.
.
OSSEOUS STRUCTURES: There is no fracture or worrisome bony
lesion.
.
IMPRESSION:
1. Multifocal ground-glass opacities in an asymmetric
distribution (left greater than right), with a small focus of
consolidation in the left lower lobe, and a 2.7 cm, thick-walled
cavitary lesion. Findings are compatible with a cavitary
pneumonia, which may be bacterial in etiology, but atypical
organisms including N. asteriodes, R. equi, and fungal
processes, should be considered given the patient's immune
status.
2. No pulmonary embolus or acute aortic abnormality.
.
Brief Hospital Course:
Mr. [**Known lastname 7749**] is a 40 year old man with AIDS and a CD4 count of 12,
as well as genotype 1b Hepatitis C, recently restarting [**Known lastname 2775**],
who presented with dyspnea, worse with exertion; and hypoxia
observed in the emergency department. He was transferred to the
[**Hospital Ward Name 332**] ICU for further management and observation.
.
HYPOXIA SECONDARY TO PNEUMONIA
In the setting of AIDS, the differential for pulmonary
inflammation was broad. He was initially covered for PCP
[**Name Initial (PRE) 1064**] (with clindamycin and primaquine, given reported sulfa
allergy), as well as piperacillin-tazobactam and vancomycin for
broad coverage of bacterial etiology. His azithromycin was
continued to finish out his possible treatment for atypical
pneumonia. He rapidly improved in the first half-day that he was
in the [**Hospital Ward Name 332**] ICU, to the point that it inspired some skepticism
about the diagnosis of PCP given the rapidity of improvement.
The cavitary lesion seen on CT could be consistent with PCP, [**Name10 (NameIs) **]
also raised concern for other organisms--especially anaerobic
organisms, given the location and the history of a binge on
benzodiazepines and crack cocaine and possible risk for
aspiration. The exposure history to dried raw sewage also
provoked a question of unusual organisms but PCP or more typical
anaerobic commensals were more likely culprits.
.
He did initially desaturate with ambulation and felt
subjectively dyspneic with minor activity prior to admission.
However, this improved considerably and rapidly during his
admission, with his O2 sats improving within the first day and
desaturation with activity improving within two days. He
ultimately underwent a bronchoscopy. The appearance of his
airways and of the fluid on BAL on visualization actually
appeared benign. However, pneumocystis was found and beta-glucan
was elevated, along with an elevated LDH, all consistent with
pneumocystis infection.
.
Given the rapidity of his improvement once hospitalized, it was
difficult to explain the course of worsening and then rapid
improvement by a story of worsening PCP infection alone. One
possibility is that this was an atypical infection which simply
had a delayed but adequate response to his outpatient
azithromycin. It is also possible that his acute inflammatory
and hypoxic state was in fact the result of immune
reconstitution inflammatory syndrome ([**Doctor First Name **]) in the setting of
ongoing previously sub-clinical pneumocystis infection and
recent resumption of [**Doctor First Name 2775**] on [**10-26**]. If this is the case, it is
possible that an unrelated URI actually brought him into care;
and then that [**Doctor First Name **] related to Pneumocystis produced a subsequent
unrelated inflammation when he restarted [**Doctor First Name 2775**]. He needs close
follow-up for future inflammatory symptoms, particularly as he
tapers down his steroids.
.
For the PCP, 21 day treatment plan per usual protocol (with
steroid taper and ongoing primaquine and clindamycin, with
hospital days included) was planned, and discharge was
originally planned for [**2189-11-6**]. However, the pharmacy near the
hospital did not have primaquine available and given his past
problems with obtaining and adhering to medications, discharge
was delayed to ensure that he would be able to obtain primaquine
immediately after discharge, rather than requiring him to return
to [**Hospital1 1426**] from his [**Hospital1 3494**] residence to obtain it.
.
HIV/AIDS (CD4=12)
Mr. [**Known lastname 7749**] is a long-term survivor of HIV infection, likely for
greater than 20 years per his story, including a good deal of
time in the pre-[**Known lastname 2775**] era. Unfortunately, his HIV disease has
now become advanced AIDS, as shown by his last CD4 count and his
pneumocystis infection. He has recently restarted [**Known lastname 2775**], and as
above, is at risk for [**Doctor First Name **]. His [**Doctor First Name 2775**] regimen (atazanavir
boosted by ritonavir with emtricitabine and tenofovir) is a
prior regimen which he took for some time earlier; it is
possible that he has resistance to this regimen but his
outpatient physician, [**Last Name (NamePattern4) **]. [**Known firstname **] [**Last Name (NamePattern1) 2148**], notes that he will have
reverted to wild type during his time off of [**Last Name (LF) 2775**], [**First Name3 (LF) **]
resistance will only reveal itself if this regimen fails and
viral load continues despite adherence.
.
Given his low CD4 count, he will also need prophylaxis; PCP
prophylaxis of dapsone can be resumed once his treatment regimen
is completed, and [**Doctor First Name **] prophylaxis of weekly azithromycin 1200 mg
should be started on discharge.
.
ADHERENCE TO MEDICATIONS
Adherence has been a particular issue with Mr. [**Known lastname 7749**], not only
in the setting of his substance abuse, but also with an
apparently diminished ability to perceive amd understand the
danger which his HIV infection presents to him. On discharge,
Mr. [**Known lastname 7749**] claims to have found his new circumstances to be both
literally and figuratively sobering, and stated his intent to
abstain from drug use and to better adhere to his medication
regimens.
.
As above, we delayed discharge to ensure that he could get his
full medication regimen. We also set up a close follow-up
appointment with Dr. [**Last Name (STitle) 2148**] and emailed the social worker in
Dr.[**Name (NI) 7750**] practice to let her know that Mr. [**Known lastname 7749**] may need
extra support. We offered him VNA support to assist with
medication adherence. Confidentiality in his rooming house
situation appears to be a particular concern for Mr. [**Known lastname 7749**]. This
housing situation--in which there was apparently a house meeting
based on concern about his landlord and neighbors finding HIV
medications for Mr. [**Known lastname 7749**], and in which Mr. [**Known lastname 7749**] claimed his
medications were only for hepatitis--suggests an ongoing need
for secrecy which may impair his adherence.
.
He also says that his girlfriend of a number of years is aware
of his medical circumstances but that she is not a source of
support for adherence; he does not have anyone else in his life
who can regularly monitor and support his adherence to
medications. This will be an ongoing issue which will require
check-in and support as Mr. [**Known lastname 7749**] allows. He has never had
ongoing participation in 12-step groups or other forms of group
support previously; if he becomes open to group support it might
be useful for him.
.
Because primaquine was only available at the [**Location (un) 535**] in
[**Location (un) 5069**], Mr. [**Known lastname 7749**] was given a cab voucher to get to the
pharmacy, and prescriptions were both called in and given to Mr.
[**Known lastname 7749**].
.
POLYSUBSTANCE ABUSE
See above HPI in regards to recent past substance abuse. His tox
screen on admission was negative. He declined further assistance
with this. He stated his intention to abstain from drug use in
the future.
.
Medications on Admission:
Adherence has been spotty, and on [**10-26**] visited doctor and said
he had not been taking current regimen regularly, but restarted
it; current regimen is:
atazanavir, with ritonavir boosting
Truvada (emtricitabine/tenofovir)
dapsone (PCP [**Name Initial (PRE) **])
azithromycin (recently prescribed)
Discharge Medications:
1. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) for 3 days: Take this dose of prednisone first. When you
finish this, take 2 tabs once daily for 5 days; then 1 tab once
daily for 11 days.
Disp:*12 Tablet(s)* Refills:*0*
5. Primaquine 26.3 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*19 Tablet(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
5 days: take for five days after finishing the 40 mg twice a
day.
Disp:*10 Tablet(s)* Refills:*0*
7. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO four
times a day for 19 days.
Disp:*152 Capsule(s)* Refills:*0*
8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
11 days: take after finishing the 40 mg once a day. .
Disp:*11 Tablet(s)* Refills:*0*
9. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO once a
week.
Disp:*24 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pneumocystis jirovecii pneumonia (also known as Pneumocystis
carinii pneumonia)
AIDS
.
Secondary diagnosis:
Hepatitis C
Discharge Condition:
Good
Discharge Instructions:
You were very short of breath when you came to the hospital, and
a CT scan showed that you most likely had pneumonia. A number of
tests were done to find out what kind of pneumonia you had,
including a bronchoscopy (a camera and tools put down into the
pipes of your lungs); and blood tests.
These tests eventually showed that you have Pneumocystis
pneumonia. This is a type of pneumonia that is common in people
with damaged immune systems. It can be very serious.
Fortunately, your pneumonia has gotten better--but it's very
important that you complete your treatment, all of your
treatment, no matter how good you feel later. Otherwise, this
pneumonia may come back and be worse the second time.
You will have three medicines to take in addition to your
regular medicines that you already take. These are:
.
PREDNISONE. This lowers the inflammation that happens when you
treat your pneumonia. The dose for this medicine will change
over the next three weeks, so read the instructions very
carefully:
For the first three days you take 40 mg (2 tablets) twice a day.
Then for the next five days you take 40 mg (2 tablets) once a
day.
Then for the eleven days after that, you take 20 mg (1 tablet)
once a day.
.
CLINDAMYCIN. This is a FOUR TIMES A DAY medicine; it must be
taken regularly. We realize this is a more difficult schedule
than some of your previous medicines. However, this medicine
MUST be taken FOUR TIMES A DAY. This is one of the most
important medicines you are taking--don't miss doses.
.
PRIMAQUINE. This is another medicine for your pneumocystis
pneumonia. It is also very important to take twice every day as
scheduled.
.
Be sure to use all the resources and help you can to help you
with sticking to your medications. Your life depends on your
ability to continue these medications successfully. Dr. [**Last Name (STitle) 2148**]
and all of the [**Hospital1 18**] nurses, doctors, and social workers are
eager to help get you through this and back to good health--but
only you can manage your own health. Get all the help you need
to stick to your medications, and if you need more help, ask.
Followup Instructions:
We have made an appointment for you with Dr. [**Known firstname **] [**Last Name (NamePattern1) 2148**]:
Thursday, [**2189-11-12**], at 11:00 am
The number to call his office is [**Telephone/Fax (1) 457**]. You should also
call this number to get in touch with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. You should
check in with her about getting help with services that may help
you in the coming months as you work to regain your health.
.
Please work with the visiting nurse who will come visit you to
check your oxygen saturation and make sure you're doing OK. The
visiting nurse will also review your medications with you to
make sure this is going well.
Completed by:[**2189-11-7**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1837
} | Medical Text: Admission Date: [**2153-8-19**] Discharge Date: [**2153-8-22**]
Date of Birth: [**2089-5-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
variceal bleed
Major Surgical or Invasive Procedure:
Endotracheal intubation
Upper GI endoscopy with variceal banding
Femoral central venous catheter placement
History of Present Illness:
Mr. [**Known lastname **] is a 64 year old man with hx of known cirrhosis,
complicated by esophageal varices and HCC, recently placed on
home hospice, presenting today for hematemesis. He was
reportedly feeling tired and nauseated all day and had 3 small
episodes of bloody and black hematemesis. Reported feeling
significantly worse later during the day, experienced large
volume hematemesis at home, after which he called EMS himself.
SBP was reportedly 80/palp in the field.
.
In the ED, lowest SBP was in 90s. He had another episode of
hematemesis 800cc bright red with black clots in the ED. He was
noted to be just mildly encephalopathic, but mentating well
enough to confirm that he would want intubation in the temporary
setting to protect his airway for upper endoscopy. When
preparing to do an IJ, pt had another large volume hematemesis.
Pt was intubated with racuronium and etomidate; racuronium was
used in the setting of elevated K to 6.8. A PIV was placed in
hand and sterile Right Femoral Cordis placed as well. Patient
received 3u pRBCs as well as 1300cc total NS in EMS and ED. He
was started on octreotide bolus + gtt as well as pantoprazole
bolus + gtt. He is on fentanyl and versed for sedation. Vitals
in the ED prior to transfer to MICU were as follows: 76 145/76
FiO2 100% PEEP 5 Vt 500 RR 14.
Past Medical History:
Onc Hx:
-[**2150-11-19**]: resection of 4x4x3.8cm liver lesion in segment 5.
Pathology consistent with HCC. No lymphovascular invasion
-[**2151-5-20**]: resection of 1.8cm lesion in segment 5
-[**2152-2-14**]: chemoembolization of a branch of right hepatic artery
with taxotere and embospheres for two right lobe lesions
measuring 1.5 and 0.5 cm along with microwave ablation of the
1.5cm lesion
-had been on transplant list when MRI [**2152-8-11**] showed 2.4 x 4.3cm
lesion in segment 8 and thrombosis of a portal vein branch.
Underwent biopsy of the lesion which revealed a moderately
differentiated hepatocellular carcinoma with tumor embolus in
the portal vein branch. AFP started rising, 232ng/mL. Delisted
from transplant list.
-attempt to enroll in SEARCH trial. However, pt had anemia
(despite d/c-ing internferon and ribavarin), making him
ineligible from study
-began radiation in [**11/2152**] and finished 01/[**2153**]. Since [**2153-1-22**]
he has been on sorafenib 400mg [**Hospital1 **]. AFP steadily increasing over
last 5 months to 3000s.
-required large volume paracentesis twice [**2-/2153**] (7.6L and
7.8L). Episodes of anemia secondary to GI bleeding. EGD and
colonoscopy performed, revealing esophageal varices, hemorrhoids
and mild portal gastropathy.
-hospital admission [**2153-3-5**] for drop in Hct for which he
received PRBCs. No site of bleeding identified.
.
Other Past Medical History:
- HTN
- ? CHF
- Hepatitis C as above, felt to be obtained on the job due to
numerous episodes of bleeding and other injury.
- h/o back spasms for which he takes narcotics.
.
Past surgical history:
- s/p cholecystectomy.
- s/p appendectomy.
- s/p tonsillectomy.
- s/p procedure for shoulder dislocation
Social History:
Recently moved from [**State 531**] to [**Location (un) 86**] to be near his son. Lives
alone but son lives ten minutes away. Worked in the past as
sheet metal worker but now retired. Denies hx of smoking, EtOH
or illicit drug use, including IV drugs.
Family History:
Father: Cirrhosis, EtOH.
Physical Exam:
Admission:
Vitals: T: BP: 115/59 P: 76 R: 15 O2: 100% on AC FI02 100%
General: Intubated and sedated; general wasting
HEENT: Sclera icteric; OG tube in place
Neck: JVP not elevated, no LAD
Lungs: Vented breath sounds with transmitted upper airway noises
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: tensely distended; tympanic to percussion; normoactive
bowel sounds present; anus with erythematous, bulging
hemorrhoids. Skin surrounding anus with small amount of dried
red blood.
GU: foley in place
Skin: Jaundiced
Ext: cool, doughy; 1+ DP and PT pulses
.
Transfer to the floor from the MICU
Vitals: R [**10-26**]
General: Extubated; general wasting
HEENT: Sclera icteric; MM dry
Neck: JVP not elevated, no LAD
Lungs: CTAB with transmitted upper airway noises
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: tensely distended; tympanic to percussion; +BS
GU: foley in place
Skin: Jaundiced
Ext: cool, no edema
Pertinent Results:
ADMISSION
[**2153-8-19**] 09:38PM GLUCOSE-81 UREA N-44* CREAT-2.0* SODIUM-132*
POTASSIUM-6.8* CHLORIDE-104 TOTAL CO2-13* ANION GAP-22*
[**2153-8-19**] 09:38PM ALT(SGPT)-52* AST(SGOT)-89* ALK PHOS-194* TOT
BILI-10.1*
[**2153-8-19**] 09:38PM LIPASE-16
[**2153-8-19**] 09:38PM ALBUMIN-2.2* CALCIUM-8.5 PHOSPHATE-6.0*#
MAGNESIUM-1.9
[**2153-8-19**] 09:38PM WBC-12.2*# RBC-2.53* HGB-9.0* HCT-27.2*
MCV-108* MCH-35.7* MCHC-33.2 RDW-23.4*
[**2153-8-19**] 09:38PM NEUTS-83.9* LYMPHS-9.3* MONOS-6.4 EOS-0.1
BASOS-0.3
[**2153-8-19**] 09:38PM PLT COUNT-153
[**2153-8-19**] 09:38PM PT-22.8* PTT-37.1* INR(PT)-2.1*
[**2153-8-19**] 09:17PM PH-7.35
[**2153-8-19**] 09:17PM GLUCOSE-65* LACTATE-6.5* NA+-131* K+-6.3*
CL--109 TCO2-13*
[**2153-8-19**] 09:17PM HGB-7.8* calcHCT-23 O2 SAT-95
.
LAST LABS
[**2153-8-20**] 12:00AM BLOOD WBC-11.1* RBC-3.35*# Hgb-11.5*# Hct-34.0*
MCV-102* MCH-34.4* MCHC-33.8 RDW-23.2* Plt Ct-107*
[**2153-8-20**] 12:00AM BLOOD Glucose-97 UreaN-45* Creat-2.0* Na-129*
K-6.5* Cl-101 HCO3-14* AnGap-21*
[**2153-8-20**] 12:00AM BLOOD Calcium-8.4 Phos-6.0* Mg-2.0
[**2153-8-20**] 12:30AM BLOOD Lactate-5.4* K-6.4*
[**2153-8-20**] 12:30AM BLOOD freeCa-1.09*
Brief Hospital Course:
64M with known history of cirrhosis, complicated by HCC and
esophageal varices, recently placed on Hospice, presenting with
large volume variceal bleed.
.
# Goals of Care
Patient was admitted with hematemesis due to an upper
gastrointestinal bleed secondary to bleeding varicies status
post variceal banding. Discussion with family led to a decision
of transitioning goals of care to comfort measures only. Patient
was then transferred from the MICU to the floor and the patient
was kept comfortable with morphine and scopolamine. Patient
passed away about 48 hours after transfer to the floor. Family
was notified and came to the hospital shortly thereafter.
.
# Variceal Bleed
Pt was admitted with hematemesis secondary to variceal bleed and
underwent emergent upper endoscopy with variceal banding while
in the ICU. He received a total of four units of red cells, and
was started on pantoprazole and octreotide drips. Patient with
known history of HCV cirrhosis, complicated by variceal bleeding
in the past, and last banded in [**11/2152**], per son. Previously
received medical care in [**State 531**]. Further observation and
treatment were held as the patient was made CMO.
.
# Hyperkalemia
Likely due to constipation, and also likely due to acute kidney
injury. No significant acidemia on VBG. No EKG changes.
Kayexelate was offered, but the family declined as the patient
was made CMO.
.
# Acute Renal Failure
Likely prerenal etiology in setting of large volume upper GI
bleed. However, as patient has elevated lactate, hypoperfusion
may have been severe enough for acute kidney injury to be due
acute tubular necrosis. His creatinine was 2.0 upon transfer,
but further treatment was held.
.
# Anion gap metabolic acidosis
Likely due to lactic acidosis, though etiology unclear.
Possibly due to hypoperfusion from gastrointestinal bleed.
However, as patient has elevated WBC count, sepsis also
possible. Per son, patient may also have GI obstruction
evidenced by constipation. Lactate peaked at 7 but fell to 5.4
when his last set of labs were checked. No further treatment as
patient was made CMO.
.
#Hyponatremia - Likely hypovolemic hyponatremia in the setting
of hypoperfusion/decreased effective circulating volume.
Baseline in the mid 130s. This was monitored and was stable at
129 upon transfer.
.
#HCV Cirrhosis
Patient has a history of HCV cirrhosis with multifocal
hepatocellular carcinoma, complicated by portal vein thrombosis,
esophageal varices, and hepatic encephalopathy. Prior to
intubation, patient mildly encephalopathic and reportedly had
not stooled for 36 hours prior to admission. Lactulose was
stopped as patient was made CMO.
.
#Leukocytosis
Infectious etiology broad in this patient with HCV cirrhosis
with variceal bleed, and status post intubation. Patient has
been afebrile and hemodynamically stable since admission. He
may have had a primary pneumonia, or may have had an aspiration
event. Must also consider SBP in this patient. Urinalysis
negative for UTI. As concern for intestinal obstruction, may
consider infectious GI complication or perforation, but no
evidence of sepsis. As patient afebrile, leukocytosis may also
be reactive. White counts were trending down when his last set
of labs were checked. No further treatment or evaluation as the
patient was made CMO.
Medications on Admission:
1. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxycodone 10 mg Tablet Extended Release 12 hr Sig: Two (2)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for back spasm.
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Take [**1-15**] doses daily with a goal of 3 bowel
movements per day.
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Intubation
Right Femoral Central Venous Catheter Insertion
Upper Endoscopy status post Variceal Banding x4
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Completed by:[**2153-8-26**]
ICD9 Codes: 5849, 2762, 2761, 5715, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1838
} | Medical Text: Admission Date: [**2117-10-2**] Discharge Date: [**2117-10-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Transferred from [**Hospital3 **] for sepsis and cancer work-up
Major Surgical or Invasive Procedure:
Intubation.
Placement of cental venous catheter and arterial line.
Chest tube Placement
PICC placement and removal
History of Present Illness:
[**Age over 90 **] yo F with CAD s/p CABG in [**2096**] and [**Hospital 41538**] transfered from [**Hospital1 **]
for sepsis and cancer work-up. The patient reported that she was
treated for pneumonia with abx and then thoracentesis two weeks
prior to admission. Since then patient noted she has had
problems with dysuria. She saw a "kidney doctor" however
details are unclear. She stateed that she was prescribed several
pills by her kidney doctor, but this morning the "white pill"
did not help. She noted one day prior to admission that she had
been unable to urinate with suprapubic pain. She called her PCP
who recommended that she go to [**Hospital3 4107**].
While there, the patient was noted to be in ARF with Cr of 2.5.
She was also noted to have leukocytosis with WBC of 11.9 and 82%
PMNs. She was given 2mg of Hydromorhone and Zofran. CT abdomen
was performed and was notable for ascites and diffuse nodular
changes in peritoneal cavity and on omentum suggesting
carcinomatosis. The stomach herniated into chest cavity. Left
kideny had 1.5 mm lower pole and 5.5 exophytic cyst as well as
1mm nonobtracting calculus. Right kidney had no evidence of
obstruction. CT of lungs was significant for collapsed left lung
with left chest cavity filled with fluid, significant
compression and collapse of the right lower lobe with large
right pleural effusion. She was also noted to be hypotensive
with BP of 80/50 after CT scan and was bolused with fluids. The
patient was started on Vancomycin and Piperacillin-Tazobactam
for presumed sepsis and transferred to [**Hospital1 18**] for further care.
On admission patient denied dizziness, CP or abdominal pain.
She endorsed mild SOB with slight sputum production. No fever,
no chills.
In the emergency department, initial vitals were HR 67 BP 79/60
RR 23 and O2 sat: 97% on 3L NC. 15 minutes later BP decreased
further to SBP of 68 and Levophed was given. The patient was
mentating and responding appropriately, and appeared
comfortable. The patient also received a right femoral line.
Troponins 0.04 x 1. The patient was admitted to [**Hospital Unit Name 153**] for likely
sepsis. On transfer, vitals were T98.0 HR 72 BP 101/68 RR 30 93%
3L.
Past Medical History:
-Hypertension
-Hyperlipidemia
-CAD s/p CABG
-PPM placement
Social History:
Quit smoking at the age of 30. Denies EtOH history. Lives alone
in [**Hospital3 **]. 13 children, 8 of whom are living. >50
grandchildren.
Family History:
Non-contibutory
Physical Exam:
Exam on Admission:
GENERAL: Pleasant, elderly F, slightly tachypneic, but in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. [**1-1**]
systolic murmur at LUSB.
LUNGS: CTAB, decreased breaths sounds bilaterally, RLL worse
than LLL.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Alert, oriented and appropriate. Speech fluent. Moves all
extremities.
Pertinent Results:
******************
CBC
******************
[**2117-10-2**] 08:38PM BLOOD WBC-14.5* RBC-4.17* Hgb-10.8* Hct-34.8*
MCV-84 MCH-25.9* MCHC-31.0 RDW-17.0* Plt Ct-444*
[**2117-10-12**] 04:37AM BLOOD WBC-12.9* RBC-3.81* Hgb-10.0* Hct-32.8*
MCV-86 MCH-26.2* MCHC-30.4* RDW-18.8* Plt Ct-573*
******************
DIFFERENTIAL
******************
[**2117-10-2**] 08:38PM BLOOD Neuts-88.0* Lymphs-8.0* Monos-3.7 Eos-0.2
Baso-0.2
[**2117-10-12**] 04:37AM BLOOD Neuts-73.8* Lymphs-17.7* Monos-5.9
Eos-2.4 Baso-0.2
******************
ELECTROLYTES
******************
[**2117-10-2**] 08:38PM BLOOD Glucose-120* UreaN-63* Creat-2.9* Na-141
K-4.1 Cl-95* HCO3-32 AnGap-18
[**2117-10-3**] 04:06AM BLOOD Glucose-122* UreaN-62* Creat-2.5* Na-140
K-4.0 Cl-100 HCO3-32 AnGap-12
[**2117-10-6**] 04:20AM BLOOD Glucose-102 UreaN-40* Creat-1.2* Na-139
K-3.9 Cl-110* HCO3-19* AnGap-14
[**2117-10-10**] 06:50AM BLOOD Glucose-74 UreaN-24* Creat-1.0 Na-148*
K-3.8 Cl-114* HCO3-23 AnGap-15
[**2117-10-12**] 04:37AM BLOOD Glucose-66* UreaN-21* Creat-0.8 Na-146*
K-4.3 Cl-112* HCO3-24 AnGap-14
******************
LFTS
******************
[**2117-10-2**] 08:38PM BLOOD ALT-16 AST-27 CK(CPK)-20* AlkPhos-80
TotBili-0.4
[**2117-10-4**] 04:54AM BLOOD ALT-14 AST-20 LD(LDH)-192 AlkPhos-67
TotBili-0.3
[**2117-10-7**] 03:51AM BLOOD ALT-27 AST-28 LD(LDH)-300* AlkPhos-64
TotBili-0.4
[**2117-10-8**] 03:07AM BLOOD ALT-24 AST-27 AlkPhos-61 TotBili-0.5
[**2117-10-2**] 08:38PM BLOOD Lipase-19
******************
CARDIAC
******************
[**2117-10-2**] 08:20PM BLOOD cTropnT-0.04*
[**2117-10-2**] 08:38PM BLOOD CK-MB-4
EKG ([**2117-10-2**]): Sinus rhythm. Ventricular paced rhythm. No
previous tracing available for comparison.
******************
TUMOR MARKERS
******************
[**2117-10-3**] 04:06AM BLOOD CEA-4.1* CA125-2477*
******************
IMAGING & STUDIES
******************
[**2117-10-2**] Chest Xray:
Complete opacification of the left hemithorax may represent
pleural
effusion- atelectasis. Underlying pneumonia - aspiration is not
excluded.
Right small pleural effusion with adjacent atelectasis.
[**2117-10-3**] CT Abd/Pelvis:
1. Large left pleural effusion, with near complete collapse and
consolidation of the left lung.
2. Moderate-to-large right pleural effusion.
3. Ascites, with diffuse nodularity of the peritoneum,
suspicious for
peritoneal carcinomatosis.
4. Mesenteric lymphadenopathy.
5. Ill-defined lesion within the left lower pelvis, in the
expected location of the uterus and adnexa, with calcifications
seen. The origin and etiology of this lesion is unclear without
intravenous contrast, and could reflect a uterine fibroid, or
adnexal lesion. This can be correlated by ultrasound if
clinically indicated.
6. Prominence of the cecal and sigmoid colonic walls. Correlate
with
colonoscopy findings.
[**2117-10-3**] Pleural Fluid Analysis:
ATYPICAL. Rare clusters of atypical but degenerated epithelioid
cells.
[**2117-10-4**] Pleural Fluid Cell Block:
Rare epithelioid cells, too few to further categorize, and
inflammatory cells.
[**2117-10-4**] ECHO:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. The aortic root
is moderately dilated at the sinus level. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. There is no pericardial effusion.
[**2117-10-6**] Pleural Fluid Analysis:
ATYPICAL; Rare atypical but degnerated epithelioid cells in a
background of mesothelial cells and inflammatory cells.
[**2117-10-7**] Pleural Fluid Cell Block:
Highly atypical epithelioid cells, consistent with metastatic
carcinoma.
[**2117-10-12**] Chest Xray:
Interval removal of the left pigtail drain. No PTX. Worse right
pleural
effusion. Left hemithorax unchanged. PICC tip now in the left
IJ.
[**2117-10-13**] Right Upper Arm US:
1. Occlusive thrombus in right basilic vein.
2. PICC line within left subclavian with normal flow and normal
waveform
noted.
[**2117-10-14**] Chest Xray:
No significant change in bilateral moderate-to-large pleural
effusions and associated atelectasis.
Brief Hospital Course:
The patient is a [**Age over 90 **] yo F with CAD s/p CABG in [**2096**] and [**Hospital 41538**]
transfered from [**Hospital1 **] for hypotension, renal failure and cancer
work-up found to have metastatic cancer likely primary ovarian.
Each of the problems addressed during this hospitalization are
described in detail below.
* Hypotension:
The patient was hypotensive on admission, requiring pressors and
large volumes of IVF. This was believed to be secondary to
distrubutive shock, likely sepsis of unknown source. Infectious
sources may have been from a GI source given carcinomatosis as
well as pulmonary given recently diagnosed PNA. Pericardial
effusion was unlikely given low voltage EKG and no JVD, no
effusion on CT chest. Furthermore, TTE was performed which
showed no pericardial effusion. The patient was immediately
started on Vanc and Piperacillin-Tazobactam. Given poor renal
function, Vanc was initially dosed by level. Outpatient
antihypertensives and Lasix were held. Levophed and Vasopressin
were given as needed to keep MAP>65. IVF boluses were given as
necessary to keep blood pressure up, however excessive IV
boluses were avoided in order to prevent reaccumulation of
fluid. At the time of transfer from [**Hospital Unit Name 153**], the patient was
normotensive without requirement of pressors or fluid
resuscitation and was on day 6 of a 7 day course of vanc and
piperacillin-tazobactam. Blood cultures from [**Hospital1 18**] as well as
[**Hospital1 **] were negative.
On the floor patient's antibiotics were continued for a full 7
day course and then stopped. She was normotensive and did not
require any fluid resuscitation.
* Hypoxia:
Several hours after admission to [**Hospital Unit Name 153**], the patient had
significantly increased work of breathing, was getting
progressively more tachypneic with increasing oxygen
requirements. She was intubated for hypoxic respiratory
failure. CT of the chest was performed and revealed large left
pleural effusion, with near complete collapse and consolidation
of the left lung. Chest tube was placed on the left side of the
chest and drained 2300 cc pleural fluid. It was placed on water
seal. Following drainage of fluid, the patient was successfully
extubated on [**2117-10-5**]. The chest tube continued to produce a
significant amount of pleural fluid while in the [**Hospital Unit Name 153**]. At the
time of transfer from [**Hospital Unit Name 153**], the patient's respiratory status had
improved and she was breathing comfortably and satting >95% on
3-4L NC.
On the floor the chest tube drainage decreased and the chest
tube was removed. Repeat xray showed no interval worsening of
the pleural effusions and patient remained stable saturing at
>95% on 2-3L of oxygen by NC. Patient denied shortness of
breath.
* Oliguric renal failure:
On admission, the patient was noted to have Creatinine of 2.9,
with bland sediment and minimal urine output. Renal failure was
suspected to be secondary to hypotension. There was no evidence
of hydronephrosis or vascular impairment on CT. Urine lytes were
consistent with a pre-renal cause of ARF. Antihypertensive
medications, diuretics were held and nephrotoxins were avoided.
IV fluids and pressors were given as needed to keep MAP > 65.
Over the course of the next several days, the patient's renal
function recovered close to baseline (Cr 0.9 at the time of
callout from [**Hospital Unit Name 153**]). Medication doses were adjusted accordingly.
On the floor the patient's renal function remained wnl. She was
not restarted on any of her home blood pressure medications
except for furosemide.
* Metastatic Ovarn Cancer:
The patient was noted to have evidence of carcinomatosis on scan
from OSH. CEA and CA125 were elevated. CT scan performed here
confirmed carcinomatosis and also revealed an ill-defined lesion
within the left lower pelvis, in the expected location of the
uterus and adnexa, with calcifications. Cytology from her
pleural effusion showed atypical epithelial cells consistent
with metastatic disease, however a primary source was not
identified. Gyn/Onc felt that patient's presentation and
elevated CEA/CA125 were most consistent with a stage IV ovarian
cancer. The diagnosis was discussed with the patient and the
family who decided that they did not want to pursue disease
specific therapy and wanted to focus their goals on keeping her
comfortable.
* Anasarca
On transfer from the ICU, the patient was hypervolemic with
total body overload including lower extremity and sacral edema
with crackles bilaterally on chest auscultation. As she was
normotensive on the floor she was given lasix 20mg IV x 2 days
and then transitioned po lasix with dramatic improvement in her
anasarca.
* Raynaud's Syndrome
On patient's 7th day in the hospital she developed cyanosis of
the fingertips in her right hand. Patient and family do not
remember this ever happening in the past. An US of patient's
right upper extremity showed a clot in the superficial basilic
vein (unlikely to account for these symptoms). Patient was
started on amlodipine 10mg QD and encouraged to keep her hands
warm with mittens and heat packs. Her symptoms improved
moderately with these interventions. A literature search was
done and it was found that approximately 2.7% of individuals
with ovarian cancer develop cutaneous manifestations, which can
include Raynauds.
* Rash/Decubitus Ulcer
During her stay in the hospital the patient developed perineal
erythema. It was treated with miconzole powder which she should
continue as an outpatient. She also developed a stage II
decubitus ulcer which should be cleaned daily and dressed. She
should be repositied every 2 hours.
* Diarrhea
Patient complated of diarrhea on the floor. She was tested for
cdiff twice, once on the [**10-6**] and once on [**10-9**] and both times
was negative. She was started on low dose loperamide which
improved her symptoms dramatically. She will be discharged on
loperamide with instructions to re-evaluate weekly her need to
continue this medication.
* History of CAD s/p CABG [**37**] years ago:
Patient was continued on outpatient Aspirin. Given her goals of
care her statin was discontinued. Beta Blocker was held given
hypotension in the [**Hospital Unit Name 153**] and not restarted on the floor given
that she was normotensive.
* Anxiety/Depression
Patient was started on mirtazepine 15mg po with good effect for
depression and to promote appetite.
The patient was on SC heparin for DVT prophylaxis. After
discussion with her family and the patient in the context of the
decision to not pursue disease specific therapy she was made
DNR/DNI.
Medications on Admission:
Aspirin 81mg daily
Atorvastatin 10mg daily
Metoprolol tartate 25mg [**Hospital1 **]
Lasix 40mg daily
Tylenol
Colase
Milk of magnesia
Discharge Medications:
1. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-27**] Sprays Nasal
QID (4 times a day) as needed for nasal dryness.
2. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea: Please re-evaluate need to
continue this on a weekly basis.
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Morphine 15 mg Tablet Sig: 0.5-1 tabs Tablet PO Q4H (every 4
hours) as needed for pain.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis
Presumed Ovarian Cancer - Stage IV
Secondary Diagnosis
Pneumonia
Raynaud's
Discharge Condition:
Stable on 2-3L of oxygen.
Discharge Instructions:
You came to the [**Hospital3 **] Hospital from [**Hospital3 **] where
you were found to have a low blood pressure, poor kidney
function and imaging that showed fluid in your lungs and nodules
in your abdomen. Here at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] you were found to have a
pneumonia and were treated with antibiotics. You were also
found to have elevated tumor markers and atypical cells in the
fluid in your lungs, suggestive of cancer, and most consistent
with ovarian cancer. A chest tube was used to drain the fluid
from your lungs and was removed after a few days. You and your
family decided that you did not want to pursue chemotherapy
against the cancer and would instead focus on your comfort.
You also developed cyanosis of your left fingertips consistent
with Raynaud's. We did an ultrasound of your arm that showed a
small clot in a superficial vein, this is very unlikely to be
the cause of your symptoms. We started you on a drug called
amlodipine that will help with this condition and we recommend
that you continue to take it. We also recommend that you keep
your hands warm: wear mittens, use heating pads, keep your hands
covered.
You should apply miconazole powder to the erythematous areas in
your perineum and you should have the dressing changed daily on
the ulcer on your lower back. You should be repositioned every
two hours.
Should you develop shortness of breath we recommend that you
contact Dr. [**Last Name (STitle) 4149**] to discuss following up with the lung doctors
about [**Name5 (PTitle) 20483**] a chest radiograph and perhaps a more permanent
catheter.
For your diarrhea you can continue to take loperamide, however
we do not recommend that you take this over the long term, and
you should attempt to stop the loperamide every few days and
re-evaluate whether you require it. Your hospice nurse can help
you with this.
Your hospice should be able to help you address any symptoms you
develop and alleviate any discomfort you may have. You can of
course come back to the hospital at any time if you so desire.
Followup Instructions:
ONCOLOGY/PALLIATIVE CARE
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**] Phone
[**2117-10-25**] 10:00
[**Hospital Ward Name 23**] Center, [**Location (un) **]
[**Telephone/Fax (1) 22**]
ICD9 Codes: 0389, 486, 5849, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1839
} | Medical Text: Admission Date: [**2143-12-31**] Discharge Date: [**2144-1-6**]
Date of Birth: [**2063-7-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
AVR (23mm St. [**Male First Name (un) 923**] porcine), CABG x 1 SVG-PDA)
History of Present Illness:
80yo M w h/o known aortic stenosis, followed by echo. Has
noticed increasing dyspnea on exertion. Previously could walk 1
mile, now becomes short of breath around half of a mile. Also
notes some chest tightening with exertion. Cardiac cath reveals
two vessel disease in addition to known aortic stenosis. He
presents for surgical opinion.
Past Medical History:
paroxysmal a-fib- since [**2131**] (on coumadin)
aortic stenosis
hyperlipidemia
hypertension
TIA, 10 yrs ago
tachy-brady syndrome, s/p PPM [**2140**] ([**Company 1543**])
hemorrhoids/hematochezia (hospitalized [**2143-5-16**]- did not
require
transfusion)
diverticulosis
Social History:
Race: Caucasian
Last Dental Exam: 3 months ago
Lives with: wife
Occupation: retired from [**Name (NI) 90314**] and NE telephone
Tobacco: quit 25yrs ago
ETOH: rare
Family History:
Family History:
mother died of MI 83yo
Physical Exam:
Pulse: 60 (AV paced) Resp: 18 O2 sat: 98%
B/P Right: 132/70 Left:
Height: 5'7" Weight: 179lb
General:
Skin: Dry [x] [**Name (NI) 5235**] [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [x]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None
[x]
Neuro: Grossly [**Name (NI) 5235**]
Pulses:
Femoral Right: p Left: p
DP Right: p Left: p
PT [**Name (NI) 167**]: p Left: p
Radial Right: p Left: p
Carotid Bruit Right: p Left: p
Pertinent Results:
[**2144-1-4**] 07:00AM BLOOD
WBC-12.2*# RBC-3.28*# Hgb-10.0*# Hct-29.3* MCV-89 MCH-30.6
MCHC-34.2 RDW-14.1 Plt Ct-81*
[**2144-1-4**] 07:00AM BLOOD
PT-13.1 INR(PT)-1.1
[**2144-1-4**] 07:00AM BLOOD
Glucose-114* UreaN-22* Creat-1.0 Na-137 K-3.5 Cl-98 HCO3-29
AnGap-14
[**2144-1-3**] 04:25AM BLOOD
Calcium-7.9* Phos-2.8 Mg-2.2
[**2143-12-31**] 05:58PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
CXR:
FINDINGS:
Dual lead pacemaker in situ, unchanged in position. Previous
median
sternotomy noted. Compared to the prior study, there has been
interval
widening of the superior mediastinum. There is a persistent
pneumopericardium, most evident along the left heart border.
Bilateral lower lobe airspace opacities likely reflect
atelectasis. Possible small bilateral pleural effusions. On the
lateral view, there is a loculated air collection seen
anteriorly, although distant from the sternum. This could
represent loculated air within the pericardium.
ECHO:
Pre-CPB:
Mild spontaneous echo contrast is present in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
with normal free wall contractility.
There are simple atheroma in the descending thoracic [**Last Name (un) 5236**].
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Trivial
mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB #1:
There is a significant paravalvular leak at the right end of the
left cusp. Re-clamped and opened for repair.
Post-CPB #2:
The patient is AV-Paced, on epinephrine.
Preserved biventricular systolic fxn.
The paravalvular leak is now insignificant.
The prosthetic aortic valve is competent and well-seated.
The residual mean gradient is 15 mmHg.
Trace MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**].
The tip of the SGC is in the right PA just beyond the
bifurcation.
EKG:
Atrial paced rhythm. Intraventricular conduction delay may be
right
ventricular conduction delay. Consider prior inferior myocardial
infarction, although it is non-diagnostic. QTc interval appears
prolonged but it is difficult to measure. Clinical correlation
is suggested. Since the previous tracing of [**2143-12-31**] no
significant change.
Brief Hospital Course:
The patient was brought to the operating room on [**12-31**] where he
underwent AVR (23mm St. [**Male First Name (un) 923**] porcine), CABG x 1 SVG-PDA).
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 [**Male First Name (un) 5235**]
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. 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 a rehab in good condition with
appropriate follow up instructions.
Coumadin was restarted for atrial fibrillation after the
temporary pacing wires were removed. His PCP should [**Name9 (PRE) **] his
INR on discharge from rehab. He was discharged on
post-operative day five to [**Hospital **] Rehab in [**Location (un) 1110**].
Medications on Admission:
warfarin 4mg as directed, flecainide 150", atenolol 25', lipitor
40', diovan 40'
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. flecainide 50 mg Tablet Sig: Three (3) Tablet PO Q12H (every
12 hours).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation .
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO twice a day for 10 days.
Disp:*20 Capsule, Extended Release(s)* Refills:*0*
13. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day:
please follow INR for goal of [**12-19**] for afib. First INR to be
drawn on [**2144-1-7**].
Disp:*30 Tablet(s)* Refills:*2*
14. Insulin
Insulin SC (per Insulin Flowsheet)
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 2 Units
160-199 mg/dL 4 Units 4 Units 4 Units 4 Units
200-239 mg/dL 6 Units 6 Units 6 Units 6 Units
240-279 mg/dL 8 Units 8 Units 8 Units 8 Units
> 280 mg/dL Notify M.D.
15. furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
twice a day for 10 days.
Disp:*qs * Refills:*0*
16. Tele
Please place patient on telemetry secondary to s/p AVR/CABG
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Dyspnea on exertion, CAD, aortic stenosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2144-1-23**] 2:30
Please call to schedule the following:
Cardiologist Dr. [**Last Name (STitle) 20222**], schedule an appointment for 2 weeks
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) 412**] A. in [**2-18**] weeks
Phone: [**Telephone/Fax (1) 20221**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
On Coumadin for Afib, goal INR [**12-19**]. First INR draw should be on
[**2144-1-7**].
Completed by:[**2144-1-6**]
ICD9 Codes: 4241, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1840
} | Medical Text: Admission Date: [**2144-12-31**] Discharge Date: [**2145-1-7**]
Date of Birth: [**2079-12-25**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vicodin
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Cough/hypoxia/fever.
Major Surgical or Invasive Procedure:
[**2145-1-5**] G-tube to J-tube conversion.
History of Present Illness:
65 M with renal cell CA (dx in [**8-/2143**]) with mets to the brain
sp cyberknife and avastin, g-tube placement in [**8-/2144**] when pt
had difficulty swalling in setting of muscle weakness, recent
discharged from [**Hospital1 18**] pna and C diff then sent to rehab who now
presents with cough and SOB.
.
Pt was admitted [**Date range (1) 87959**] for pna treated with levoflox x 5 days
as well as C diff found to have pancolitis treated with oral
vancomycin. Pt has been at nursing home past 2 weeks for
deconditioning. Pt was doing well, according to wife, and looked
"the best she had seen him in years" last night. However, at
midnight last night pt reported ?aspiration event with his tube
feeds where he had regurgitation and coughing. He has been
coughing since then. Now notes a productive cough. This morning
cough worsening productive of purulent colored sputum and
developed hypoxia with new O2 requriment, saturating 89% on RA,
required 4L. Also became febrile to 101.9 at rehab. Sent to the
ED for further evaluation.
.
In the ED, vitals: T 99.0 BP 90/60 (baseline SBP 100-110) HR 120
18 90%.
Patient denied chest pain, hemoptysis, worsening dyspnea, denies
nausea vomiting. He has chronic diarrhea related to tube feeds
but has not acutely changed (2 loose stools a day). Nursing home
notes also report change in mental status as well. No
lightheadedness, no syncope or pre-syncopal episodes, no
headaches or vision changes, no stiffneck.
ED felt this was likely a pna, aspiration vs HCAP. Lactate
5.7-->4.1->3.7 after 2 L NS. BP also improved to 100 after 2 L.
Stopped fluids because he started to desat. Has 2 peripherals,
no central. EKG: unchanged from prior. Was given vanco 1g, zosyn
4.5mg IV, and flagyl 500mg via Gtube.
Vitals on transfer: BP 103/86, HR 122, RR 22, 90%4L
.
On arrival to the ICU, pt is comfortable, has a productive cough
with purulent white sputum. Denies any urinary symptoms, no new
diarrhea. Dose have known loose stool 2/day from tube feeds but
this is markedly improved from prior.
Past Medical History:
# Mestatastic clear cell renal CA s/p R nephrectomy 3 yrs ago
# Prostate CA s/p prostatectomy
# HTN
# DM
# HL
# Anxiety
# GERD
# Gout
.
Summary of Past Oncologic Treatment:
1. [**2141-8-23**] - A renal ultrasound obtained as part of an
investigation into the etiology of his elevated creatinine
showed
a right renal mass for which the patient underwent a
nephrectomy.
2. [**2142-2-21**] - Prostatectomy for prostate carcinoma.
3. [**2143-10-23**] - The patient developed confusion and was
found to have a left frontal lobe metastasis. A stereotactic
biopsy was done that showed metastatic renal cell carcinoma.
4. [**2143-12-24**] - CyberKnife treatment to the brain
metastasis.
5. Brief admission for recent onset seizures.
6. [**2144-5-22**] - Avastin treatment begun because of persistent
symptomatic vasogenic edema surrounding the treated brain
metastasis and because of steroid myopathy. This allowed Mr.
[**Known lastname 4587**] to be weaned from decadron.
Social History:
Married. Lives with his wife. [**Name (NI) **] is a retired insurance [**Doctor Last Name 360**].
He never smoked. No alcohol since [**2140**]. No drugs.
Family History:
He has two daughtres and one son, all healthy. His father died
at age 49 after returning from WWII, cause unclear. His mother
died at age 85. He has no siblings.
Physical Exam:
ADMISSION EXAM:
Vitals: HR 89, 106/70, 97%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles in bilateral bases R>L
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, 2+ pulses, no clubbing, cyanosis or edema
Pertinent Results:
ADMISSION LABS:
[**2144-12-31**] 12:10PM BLOOD WBC-10.1# RBC-4.32*# Hgb-13.2*# Hct-38.3*
MCV-89 MCH-30.6 MCHC-34.5 RDW-15.7* Plt Ct-164#
[**2144-12-31**] 12:10PM BLOOD Neuts-60 Bands-23* Lymphs-5* Monos-10
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2144-12-31**] 12:10PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-OCCASIONAL
[**2145-1-1**] 04:00AM BLOOD PT-13.8* PTT-31.2 INR(PT)-1.3*
[**2144-12-31**] 12:10PM BLOOD Glucose-178* UreaN-17 Creat-0.9 Na-134
K-3.7 Cl-96 HCO3-22 AnGap-20
[**2145-1-1**] 04:00AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.3*
[**2144-12-31**] 08:00PM BLOOD Type-ART pO2-82* pCO2-33* pH-7.49*
calTCO2-26 Base XS-2
[**2144-12-31**] 01:06PM BLOOD Lactate-5.7*
[**2144-12-31**] 03:04PM BLOOD Lactate-4.1*
[**2144-12-31**] 05:15PM BLOOD Lactate-3.7*
[**2144-12-31**] 08:00PM BLOOD Lactate-2.7*
[**2145-1-2**] 02:33AM BLOOD Lactate-1.0
[**2144-12-31**] 12:10PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.025
[**2144-12-31**] 12:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2144-12-31**] 12:10PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2144-12-31**] 12:10PM URINE Mucous-RARE
.
Micro:
[**2144-12-31**] 12:30 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2145-1-1**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**Doctor Last Name 1955**] [**Doctor Last Name **] AT 6:40PM ON
[**2145-1-1**].
.
[**2144-12-31**] 12:10 pm URINE OLD S# [**Serial Number 87960**]B.
Legionella Urinary Antigen (Final [**2145-1-1**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
[**2145-1-1**] 2:09 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2145-1-1**]):
[**9-16**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Preliminary):
SPARSE GROWTH Commensal Respiratory Flora.
.
[**2145-1-1**] 6:52 am STOOL
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2145-1-1**]):
Reported to and read back by DR. [**Last Name (STitle) **]. [**Doctor Last Name **] ON [**2145-1-1**] AT
2250.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2144-12-10**] VIDEO SWALLOW: IMPRESSION: Aspiration with thin and
nectar liquids. Penetration with puree. Cervical osteophytes
causing narrowing of the hypopharynx.
.
[**2144-12-31**] CXR: IMPRESSION: Findings suggesting mild vascular
congestion.
.
[**2145-1-1**] CXR: IMPRESSION: Opacities in the right upper and lower
lung zone and left mid lung zone concerning for pneumonia. Given
their nodular appearance septic emboli should also be
considered.
.
[**2145-1-2**] CXR: IMPRESSION: Large areas of pneumonia in the right
upper and left perihilar lung are stable. There may be new
pneumonia in the right lower lung projected over the lower pole
of the hilus. Moderate cardiomegaly is slightly larger and there
is pulmonary vascular and mediastinal vascular engorgement but
no edema. Pleural effusions are small if any.
.
DISCHARGE LABS:
[**2145-1-6**] 06:30AM BLOOD WBC-7.5 RBC-3.29* Hgb-9.8* Hct-29.0*
MCV-88 MCH-29.9 MCHC-33.9 RDW-16.1* Plt Ct-148*#
[**2145-1-7**] 06:25AM BLOOD WBC-6.1 RBC-3.18* Hgb-9.7* Hct-28.2*
MCV-89 MCH-30.5 MCHC-34.3 RDW-16.2* Plt Ct-UNABLE TO
[**2145-1-2**] 02:06AM BLOOD Neuts-83.1* Bands-0 Lymphs-12.3*
Monos-3.8 Eos-0.6 Baso-0.1
[**2145-1-1**] 04:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Spheroc-1+
Ovalocy-1+ Schisto-1+
[**2145-1-6**] 06:30AM BLOOD PT-12.8* INR(PT)-1.2*
[**2145-1-3**] 07:20AM BLOOD Ret Aut-2.7
[**2145-1-7**] 06:25AM BLOOD Glucose-157* UreaN-9 Creat-0.7 Na-138
K-3.4 Cl-105 HCO3-24 AnGap-12
[**2145-1-7**] 06:25AM BLOOD Calcium-8.3* Phos-2.0* Mg-1.5*
[**2145-1-4**] 07:21AM BLOOD ALT-9 AST-17 AlkPhos-56 TotBili-0.2
[**2145-1-2**] 12:16PM BLOOD Albumin-2.8* Calcium-8.2* Phos-2.4*
Mg-1.9
[**2145-1-3**] 07:20AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.7 Iron-59
[**2145-1-3**] 07:20AM BLOOD calTIBC-185* VitB12-1386* Folate-18.8
Ferritn-880* TRF-142*
[**2145-1-4**] 07:21AM BLOOD TSH-3.3
[**2145-1-4**] 07:21AM BLOOD T3-86 Free T4-1.2
[**2144-12-31**] 01:06PM BLOOD Lactate-5.7*
[**2145-1-2**] 02:33AM BLOOD Lactate-1.0
Brief Hospital Course:
65 M with metastatic renal cell CA (dx in [**8-/2143**]), history of
difficulty swallowing 65yo man with metastatic renal clear cell
CA admitted for pneumonia/sepsis and hypotension. Witnessed
aspiration. Vanco, metronidazole, pip/tazo started. Pip/tazo
changed to cefepime. Hypotension improved with IV fluids.
.
# Aspiration pneumonia/sepsis: Coag-negative Staph in blood
(possible contaminant). Recurrent aspiration due to cyberknife
complication. Stopped vancomycin [**2145-1-4**] due to worsening
thrombocytopenia. Changed G-tube to J-tube [**2145-1-5**] to prevent
future aspiration considering he reported tube feed refluxing.
Cefepime x7d finished [**2145-1-7**].
- Follow-up cultures.
.
# Hypotension: Due to sepsis. Improved with IV fluids.
.
# C. difficile colitis: Continued metronidazole and vancomycin
per PEG x2 additional weeks.
.
# Chronic diarrhea: Diarrhea began when he started tube feeds,
prior to C. diff colitis. Added banana flakes to tube feeds.
.
# Metastatic renal CA: Continuing with bevacizumab as
outpatient.
.
# Seizure disorder: Due to brain mets. Continued valproate and
dexamethasone.
.
# Anemia: Iron studies reflecting anemia of inflammation.
Normal B12 and folate. Coags unremarkable. Retic 2.7.
.
# Thrombocytopenia: Improved after stopping vancomycin (also
stopped SC heparin); history of platelet clumping (checking with
citrate yellow-top tube). Coags unremarkable. Stopped
vancomycin and SC heparin [**2145-1-4**] even though T4 score was
low-intermediate (4). Therefore, held off ordering HIT Ab.
.
# Hypogammaglobulinemia: Consider IVIG if infections
recur/persist.
.
# Hypothyroidism: Abnormal TSH corrected without treatment.
.
# DM: Continued insulin glargine and cover with insulin sliding
scale.
.
# Gout: Continued allopurinol.
.
# Depression: Continued sertraline.
.
# Pain (abdomen): Acetaminophen PRN.
.
# FEN: NPO due to aspiration. Tube feeds through J-tube, to
initiate overnight cycling at home. Repleted hypophosphatemia,
hypomagnesemia, and hypokalemia.
.
# GI PPx: PPI. No bowel regimen with diarrhea.
.
# DVT PPx: Changed heparin SC to venodynes due to
thrombocytopenia.
.
# IV access: Peripheral.
.
# Precautions: Contact (C. diff), aspiration.
.
# Code status: Full.
Medications on Admission:
MOM prn
bisacodyl PRN
tylenol650 q 4hr prn
mylanta qid prn
allopurinol 100mg daily via g tube
lansoprazole 30mg rapid dissolve
sertraline 50mg
alprazolam 0.25mg [**Hospital1 **]
dexamethasone 4mg daily
lantus 28 U qAM
valprioc acid 250mg - give 15mL [**Hospital1 **]
Vital 100ml 7pm-7am for total 1200ml at 100/hr
flush G tube with 200cc water q 4hrs
Discharge Medications:
1. acetaminophen 325-650mg PO Q6H PRN headache/ pain.
2. allopurinol 100 mg PO DAILY: Per J-tube.
3. lansoprazole 30 mg Rapid Dissolve PO DAILY.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
4. sertraline 50 mg PO DAILY: Per J-tube.
5. dexamethasone 4 mg PO DAILY.
6. insulin glargine 100 unit/mL Cartridge [**Hospital1 **]: 20 Units SC once
a day.
7. valproic acid (as sodium salt) 250mg/5mL [**Hospital1 **]: 15 mL PO Q12H.
8. vancomycin 125 mg PO Q6H x2 weeks.
Disp:*56 Capsule(s)* Refills:*0*
9. potassium & sodium phosphates 280-160-250 mg Powder in Packet
[**Hospital1 **]: 1 Packet PO BID x7 days: Per J-tube.
Disp:*14 Powder in Packet(s)* Refills:*0*
10. insulin regular human 100 unit/mL As directed SC QID: Per
sliding scale.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
1. Aspiration pneumonia.
2. Sepsis (severe blood stream infection).
3. Hypotension (low blood pressure).
4. Clostridium difficile colitis (bowel infection).
5. Metastatic kidney cancer.
6. Diabetes.
7. Chronic diarrhea.
8. Anemia (low red blood cell count).
9. Thrombocytopenia (low platelet count).
10. Hypophosphatemia (low phosphorous level).
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for aspiration pneumonia
requiring a stay in the Intensive Care Unit (ICU). This
improved with IV antibiotics and low blood pressure
(hypotension) responded to IV fluids. Because of recurrent
aspirations and reflux from tube feeds, your G-tube was changed
to a J-tube, so it is lower down in the bowel. You have also
been treated for C. difficile colitis, a bowel infection, and
will need to continue antibiotics for this at home.
.
MEDICATION CHANGES:
1. Vancomycin x2 weeks.
2. Phosphorous 2x a day for one week.
3. Stop alprazolam.
4. Decrease insulin glargine (Lantus) to 20 units daily.
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Please call the office number listed below to schedule a
follow up hospital visit for 4-8 days after your discharge.
Location: INTERNAL MEDICINE AT [**Location (un) **]
Address: [**Location (un) 87961**], [**Location (un) **],[**Numeric Identifier 36782**]
Phone: [**Telephone/Fax (1) 87962**]
.
Department: Hematology/ Oncology
Name: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: We are working on a follow up plan with Dr.[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and
[**Doctor Last Name **] in the next 9-15 days. You will be called by the office
at home with the appointment. If you have not heard for have
questions please call [**Telephone/Fax (1) 87963**]
Location: [**Hospital1 18**] [**Hospital Ward Name 23**] Bldg [**Location (un) 24**]
Address: 330 [**Location (un) **], Ave. [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 87964**]
ICD9 Codes: 0389, 5070, 4019, 2724, 2749, 2767, 311, 2449, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1841
} | Medical Text: Admission Date: [**2185-12-4**] Discharge Date: [**2185-12-6**]
Date of Birth: [**2185-12-4**] Sex: M
Service: NEONATOLOGY
HISTORY: Eamonn [**Known lastname 4027**] is the former 1.015 kg product of a
27 [**3-17**] week gestation twin pregnancy, born to a 36-year-old
GIII PI woman. Prenatal screens: Blood type A positive,
antibody negative, rubella non-immune, RPR nonreactive,
hepatitis B surface antigen negative, group beta strep status
chlamydia and GC negative. There was a maternal history of
hypothyroidism. This pregnancy was notable for spontaneous
dichorionic diamniotic twins. Pregnancy was complicated by
pre-term labor and cervical shortening noted during routine
examination at 23 5/7 weeks. The mother was admitted to [**Hospital1 1444**], where she was placed on bed
rest and magnesium sulfate. She was betamethasone complete
active labor despite high doses of magnesium. Delivery was
by cesarean section due to the breech presentation of this
twin number one. This twin emerged breech, floppy, without
spontaneous respiratory effort. He received bag mask
ventilation, and was intubated in the delivery room. Apgar
scores were 2 at one minute, 4 at five minutes, and 6 at ten
minutes. The infant was shown to the parents, and admitted
to the Neonatal Intensive Care Unit for treatment of
prematurity.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, weight 1.015 kg, length 37.5 cm, head
circumference 26.5 cm. General: Some activity, with
irritation yet overall floppy. Head, eyes, ears, nose and
throat: Positive molding, anterior fontanel open and flat,
palate intact, ears normally set, neck supple. Chest: Lungs
with poor aeration, bilateral crackles, significant
retractions. Cardiovascular: Regular rate and rhythm, no
murmur, 1+ pulses. Abdomen: Loopy, hypoactive bowel sounds,
soft. Genitourinary: Normal pre-term male phallus, testes
non-descended, patent anus. Spine and extremities: No
sacral anomalies, hips stable though lax, moves all. Skin:
Ruddy, poor overall perfusion, bruised extensively,
especially the extremities and groin area.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant was treated with surfactant for
a total of three doses. He was initially on a conventional
ventilator at settings of 22 peak inspiratory pressure over 5
of PEEP, intermittent mandatory ventilatory rate of up to 27.
On [**2185-12-6**], at approximately 2 P.M., the infant had an
episode of profound pulmonary hemorrhage with large amounts
of fresh blood evacuated from the endotracheal tube. He had
concurrent poor perfusion. At that time, he was changed over
to the high-frequency oscillatory ventilator but was unable
to maintain adequate ventilation. His last blood gas was pH
6.96, PCO2 86, PO2 30. After several hours, the oxygen
saturations were only 50 to 70%. After discussions with the
family, further medical management was deemed futile, and
care was redirected to the maximal relief of pain and
discomfort.
2. Cardiovascular: The infant required normal saline
boluses and treatment with dopamine for hypotension. His
maximum dopamine requirement was 10 mcg/kg/minute. He was
able to wean off the dopamine by 8 A.M. on [**2185-12-6**]. No
murmurs were noted until the episode of pulmonary hemorrhage,
when a loud murmur was present. The infant had umbilical,
arterial and percutaneously-placed central venous catheters.
3. Fluids, electrolytes and nutrition: The infant was
nothing by mouth. He was treated with intravenous fluids and
total parenteral nutrition. Serum electrolytes were normal.
4. Infectious Disease: Due to his prematurity and lung
disease, this infant was evaluated for sepsis. A total white
blood count was 10,400, with a differential of 35% polys, 0%
bands, 57% lymphs. A blood culture was obtained prior to
initiating antibiotic therapy. He was treated with
ampicillin and gentamicin during his hospital course.
5. Hematology: Hematocrit at birth was 50.3%. At the time
that the pulmonary hemorrhage was noted, a hematocrit was
29.7, reflecting a 20% drop. He was treated with multiple
infusions of fresh frozen plasma and packed red blood cells.
6. Gastrointestinal: Serum bilirubin at 12 hours of life
was a total of 3.4/0.2 direct. On day of life two, the
bilirubin was 4.6 total/0.3 direct, and phototherapy was
initiated.
7. Neurology: The infant was never very vigorous, with
decreased tone. At the time of the pulmonary hemorrhage,
there was a significant change in the anterior fontanel,
which became bulging. We speculated that there was an
intraventricular hemorrhage occurring at the same time as the
pulmonary hemorrhage. No head ultrasounds were performed.
8. Social: The parents were present through the afternoon
of [**2185-12-6**]. They concurred with the primary care team that
continued aggressive treatment would not be in Eamonn's best
interest. The infant was extubated and held by the parents.
He was pronounced dead by Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 6174**] at 8 P.M. on
[**2185-12-6**].
CONDITION AT DISCHARGE: Expired.
DISCHARGE DISPOSITION: Parents consented to a post-mortem
examination, but the results of this are not avaiable at the time
of this dictation.
DISCHARGE DIAGNOSIS:
1. Prematurity at 27 3/7 weeks gestation
2. Twin number one of twin gestation
3. Respiratory distress syndrome
4. Suspicion for sepsis
5. Hypotension
6. Pulmonary hemorrhage
7. Presumed intraventricular hemorrhage
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (Titles) 37585**]
MEDQUIST36
D: [**2185-12-6**] 23:10
T: [**2185-12-7**] 00:31
JOB#: [**Job Number 47461**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1842
} | Medical Text: Admission Date: [**2194-2-15**] Discharge Date: [**2194-2-20**]
Service: CARDIOLOGY
HISTORY OF PRESENT ILLNESS: An 83-year-old female, with a
past medical history of hypertension, but no other cardiac
history, went to [**Last Name (un) 4068**] Emergency Department with 30 minutes
of substernal chest pain that was associated with nausea,
shortness of breath and diaphoresis. EKG at that time showed
ST elevation in the anterior and high lateral leads, and ST
depression inferiorly. She was started on Integrilin,
heparin, Nitroglycerin drip and IV Lopressor. She was
transferred to [**Hospital1 18**] for cardiac catheterization.
In the cardiac catheterization laboratory she was found to
have three-vessel disease with 100% proximal LAD lesion which
was stented, a 60% mid left circumflex lesion, and a 60% mid
right coronary artery occlusion. Her pressures were right
atrium 12, PA 40/23, and PCW 24. Her procedure was
complicated by a right groin hematoma.
PAST MEDICAL HISTORY: Hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS: Lisinopril.
SOCIAL HISTORY: The patient lives alone. She has no family.
She is very active in her church and has a lot of social
support through them. She does not cook her own meals, and
usually eats out for her meals. She exercises daily by
walking. She does not have a history of smoking, alcohol, or
drug use.
PHYSICAL EXAM: Blood pressure 101/53, pulse 52, respirations
16, 98% on 4 liters nasal cannula. Exam significant for
elderly female in no acute distress. Moist mucous membranes.
A 12 cm JVP. Lungs clear to auscultation. Normal S1, S2
with a II/VI systolic ejection murmur at the apex. Abdomen
benign. Extremities warm without any peripheral edema. 1+
dorsalis pedis and posterior tibial pulses bilaterally.
Circumscribed tender and firm hematoma in the right groin
that was nonexpanding.
EKG PRECATH: Normal sinus rhythm at 88, normal axis and
intervals, ST elevations in I, L, V2 through V4. ST
depressions in III.
POSTCATH EKG: Normal sinus rhythm at 62, normal axis and
normal intervals. Q waves in V1 through V3. T wave
inversions with low voltage laterally.
LABS: Hematocrit 39.8, platelets 333, creatinine 0.8, CPK
4477, CK-MB greater than assay.
HOSPITAL COURSE: An 83-year-old female, with history of
hypertension, admitted with anterior ST elevation MI
requiring cardiac catheterization and stent placement to her
proximal LAD. Cardiac catheterization complicated by right
groin hematoma. The patient developed postinfarct atrial
fibrillation.
1) CAD: She had an ST elevation MI in the anterior region.
Her peak CPK was 4477. She was started on Plavix, aspirin, a
statin, a beta blocker and an ACE inhibitor. She had an
echocardiogram that showed an ejection fraction of 20-25%,
elongated left atrium, apical akinesis, severe hypokinesis of
the anterior septum and anterior wall, mildly dilated
ascending aorta, 1+ MR. She did not have pulmonary artery
systolic hypertension, or pericardial effusion.
The patient's primary team spoke with electrophysiology who
performed a risk stratification. The patient had a
signal-weighted EKG that did not show late potentials. She
will follow-up for a cardiac MRI to look for scar and
function in one month's time. Her cardiologist will set-up
this appointment. In addition, she will have a P-MIBI stress
test with T-wave alternans in four week's time. The patient
may need an intervention on her other coronary arteries at
that time. She was started on anticoagulation with Coumadin,
with Lovenox bridge. Her goal INR is [**12-24**]. She was started
on anticoagulation because of her severe anterior hypokinesis
and low ejection fraction in the setting of an acute MI. Her
INRs will be followed as an outpatient, and her Coumadin
adjusted accordingly. She will follow-up with Dr. [**Last Name (STitle) 3321**]
in 2 week's time. At that time, she will be evaluated to
increase her ACE inhibitor, and to increase her statin as
needed. Prior to starting amiodarone, the patient received
baseline PFTs, a TSH, and LFTs.
2) ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE: The
patient had persistent, intermittent, asymptomatic atrial
fibrillation with heart rates into the 150s. She was started
on beta blocker for rate control. In addition, she received
a loading dose of digoxin. However, prior to discharge the
digoxin was discontinued, and she was started on amiodarone
200 mg tid for 1 week. Her amiodarone dose will be decreased
to 200 qd after her 1 week loading period. This was done to
better control her atrial fibrillation. The patient is
anticoagulated on Coumadin.
3) ELEVATED LFTs: The patient had elevated LFTs on
admission: ALT 69, AST 344, with a normal alk phos and total
bili. Her higher elevation of AST versus ALT is likely due
to cardiac damage. She will need follow-up of her LFTs
within approximately 4-6 weeks after starting her statin.
4) HYPERCHOLESTEROLEMIA: Total cholesterol 211, triglyceride
191, HDL 41, LDL calculated at 132, fasting. She was started
on a statin, and this will be titrated up as an outpatient.
Goal LDL is less than 100. The patient is being discharged
to an advanced telemetry monitored rehabilitation center.
5) RIGHT GROIN HEMATOMA: The patient's initial groin
hematoma was large and; therefore, a CT scan was done of her
abdomen to evaluate for retroperitoneal bleed. CT scan did
not show a retroperitoneal bleed. She does have
cholelithiasis and diverticulosis. The groin hematoma
resolved during hospitalization.
DISCHARGE CONDITION: Good, in atrial fibrillation,
tolerating a PO diet, ambulating chest pain-free.
DISCHARGE DIAGNOSES:
1. Anterior wall myocardial infarction with low ejection
fraction.
2. Post myocardial infarction atrial fibrillation.
3. Groin hematoma from cardiac catheterization.
4. Elevated liver function tests.
5. Hypercholesterolemia.
RECOMMENDED FOLLOW-UP:
1. The patient to follow-up with Dr. [**Last Name (STitle) 3321**] at [**Hospital1 18**],
[**Location (un) 620**], ([**Telephone/Fax (1) 8937**] within 2 week's time. Rehab will
call to make an appointment. At that time, the patient's ACE
inhibitor and statin may both be increased.
Dr. [**Last Name (STitle) 3321**] to set-up follow-up cardiac MRI within 4
week's time. The patient to have a Persantine MIBI stress
test in approximately 4 week's time at [**Hospital1 18**], [**Location (un) 86**], with a
T-wave alternans on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 55001**] machine. This appointment
has not been set-up, but will hopefully be set-up prior to
her discharge.
2. The patient to follow-up with PCP within the next 2 weeks.
DISCHARGE MEDICATIONS:
1. Aspirin 325 qd.
2. Plavix 75 qd.
3. Colace 100 mg [**Hospital1 **].
4. Senna 1 tab po q hs.
5. Atorvastatin 20 mg qd.
6. Lasix 20 mg qd.
7. Coumadin 5 mg po q hs with a goal INR of [**12-24**].
8. Toprol XL 25 mg po qd.
9. Amiodarone 200 mg po tid for 1 week, and then 200 mg po
qd.
10.Enoxaparin 60 mg injection subcu q 12 h as a bridging
until INR is in its goal range of [**12-24**] for approximately 3
days.
11.Lisinopril 2.5 mg po qd.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Last Name (NamePattern1) 17526**]
MEDQUIST36
D: [**2194-2-19**] 12:23
T: [**2194-2-19**] 13:13
JOB#: [**Job Number 55002**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1843
} | Medical Text: Admission Date: [**2201-12-3**] Discharge Date: [**2201-12-18**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Ischemic rest pain of the left foot
Major Surgical or Invasive Procedure:
Left femoral-femoral bypass graft to below-knee popliteal artery
bypass with nonreversed saphenous vein and angioscopy.
History of Present Illness:
Mr. [**Known lastname **] is a 86-year-old man with ischemic rest pain and severe
flow deficit to his left leg. He has previously had an
aortobifemoral bypass and a left-to-right femoral-femoral bypass
for occlusion of the right limb of the graft. He has extensive
profunda femoral artery disease and a total occlusion of his
superficial femoral and above-knee popliteal arteries. He
reconstitutes a below-knee popliteal artery with runoff via the
anterior tibial artery which was poorly visualized on his
preoperative arteriogram. He is not a candidate for a
catheter-based intervention and was advised to have a bypass
graft. Vein mapping showed suitable vein.
Past Medical History:
PMH: Dyslipidemia, HTN, CAD (h/o STEMI complicated by VT arrest,
PVD, Increasing RLE claudication, Renal Cell Carcinoma
PSH: s/p distal RCA stent ([**2193**]), [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] of RCA
bifurcation ([**2197**]), [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] in left main ([**2198**]).
Aortobifemoral bypass and
left-to-right fem fem bypass.s/p R nephrectomy in [**2176**], [**2195**]
bowel resection and ileostomy for gangrene of the bowel, s/p
hernia repair ([**2176**]), s/p prostatectomy ([**2172**])
Social History:
Married, lives with wife. + Tobacco use in the past, no current
use. 4-5 drinks EtOH per day. No hx of withdrawal. No street
drugs.
Family History:
non-contributory
Physical Exam:
PE
Blood pressure is 114/60. Pulse is 73. Respirations are 18.
NAD AAOx3
RRR
CTAB
Abd soft NT/ND
He has palpable femoral pulses bilaterally, but no distal
pulses. His feet show some rubor and some cyanosis while the
capillary refill, while
diminished, is unchanged. There are no ischemic lesions.
Pertinent Results:
11/12/9:
Hct: 28
PLT: 245
129 98 48
------------- 133 AGap=14
4.9 22 1.8
MB: 7 Trop-T: 0.03
Vein mapping [**2201-11-25**]:
The greater and lesser saphenous veins are patent bilaterally.
Brief Hospital Course:
The patient was admitted to the [**Month/Day/Year 1106**] surgery service for
evaluation and treatment of his severe left lower extremity
ischemia. On [**2201-12-3**] he was taken to the OR for a left fem-BK
[**Doctor Last Name **] bypass with NRGSV. He tolerated the procedure well and was
taken to the PACU postop. He was managed then in the VICU. On
POD1 patient was feeling well and diet was advanced to regular
with adequate po intake and discontinuing his IV fluids. On POD2
(11/14/9) patient coded in the VICU while seated in chair
attempting to ambulate to bed new RBBB. CPR was performed after
V. Tach and PEA arrest and patient cardiopulmonary status came
back. Immediately after that he was transferred to the CVICU.
Heparin gtt initiated empirically. No AA gradient. Could not
obtain CTA [**2-23**] ARF (Cr 1.5 improved from 2.0 on day of surgery).
Cardiology consulted. Echo with mod/severe LV dysfunction w
inferior/infero-lateral akinesis. Hemodynamically stable. CEs
cycled. Trop peaked .34. Cardiology did not think represented
a primary cardiac event. Extubated following day. Course in
CVICU uncomplicated. C/O rib tenderness anterior/inferior left
chest. IS encouraged. CXR with chronic fibrotic scarring. On
POD 5 ([**2201-12-8**]) he was transferred back to VICU from CVICU. As
the etiology of the arrest was not clear and there was a
question of weather a thromboembolic event was the source, LE
u/s was performed and no evidence of DVT was shown. Heparin drip
was discontinued. On SQH. LLE edema, slowly improving. Diuresis
as tolerated. He also developed some Hyponatremia down to 129
that did resolve over the course of his stay with appropriate
free water fluid restrictions. On POD6 he developed Afib with
RVR, converted with amio. We consulted cardiology again and we
started on standing doses of amio and b/blockers. After that he
had some new episodes of Afib all converted with amio. On POD7
with desat responsive to O2. CXR with question of LLL new
infiltrate. Lot of sputum production. Abx started for PNA.
SCx with respiratory flora. Pulmonary status improved but still
with large amount of sputum production. Undergoing chest
Physiotherapy by nursing staff. His foley was removed. He
developed some mild erythema of inferior portion of wound, that
improved during his hospital stay. Having significant edema of
his LLE, we ordered another LE u/s, which showed no evidence of
deep vein thrombosis in the left leg, but persistent complex
fluid collection extending from the left popliteal fossa medial
and posterior along the left calf that was stable from before.
He was diuresed with lasix until balance was daily negative. Hi
LLE looked better and patient was able to ambulate with nursing
staff and physical therapy. Decision was made to send him to a
rehab based on his level of activity. At the time of discharge,
the patient was doing well, afebrile with stable vital signs.
The patient was tolerating a regular diet, ambulating, voiding
with some assistance, and pain was well controlled.
Medications on Admission:
[**Last Name (un) 1724**]: Albuterol prn, Cilostazol 50'', Plavix 75', Folic Acid 1',
Lisinopril 20'', Lopressor 50'', Rosuvastatin 20', Vit C 500',
[**Last Name (un) **] 81', Vit E 400', MVI, bumex 2mg qm/w/f, spironalactone 25'
(meds confirmed with family)
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
7. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for pain.
Disp:*20 Lozenge(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze.
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) for 10 days.
16. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Ischemic rest pain of the left foot with left superficial
femoral artery occlusion.
Discharge Condition:
Stable
Discharge Instructions:
Division of [**Hospital6 **] 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 [**2-24**] 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
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2201-12-31**] 3:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2201-12-31**] 4:20
Completed by:[**2201-12-18**]
ICD9 Codes: 4275, 486, 5849, 4271, 2761, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1844
} | Medical Text: Unit No: [**Numeric Identifier 65192**]
Admission Date: [**2155-1-13**]
Discharge Date: [**2155-2-6**]
Date of Birth: [**2155-1-13**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname 8125**] [**Known lastname 65193**] is the former 1.88-
kilogram product of a 36-2/7 week gestation pregnancy born to
a 38-year-old G2, P1 now 2 woman. Prenatal screens: Blood
type O-positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group B
Strep status unknown. This pregnancy was followed closely for
intrauterine growth restriction. The mother's previous
pregnancy also was notable for mild intrauterine growth
restriction with the child now healthy. Delivery was by
repeat C-section after the mother presented in labor and the
fetal heart rate was noted to be high with variable
decelerations followed by late decelerations. Infant's Apgars
were 7 at 1 minute, 8 at 5 minutes, and 8 at 10 minutes. He
was initially noted to have some mild grunting and
retracting. He was admitted to the neonatal intensive care
unit because of his small size and an initial blood glucose
of 7.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 1.88 kilograms (10th percentile), length 42.5
cm (10th percentile), head circumference 31.5 cm (25th
percentile). General: Well appearing, small for gestational
age 36-week infant. Head, eyes, ears, nose, and throat:
Anterior fontanel soft and flat. Eyes: Normal. Palate:
Intact. Chest: Breath sounds clear and equal, good
respiratory effort. Cardiovascular: Normal S1, S2 with normal
intensity, no murmur, well perfused, pulses normal. Abdomen:
Soft with no organomegaly. GU: Normal male external
genitalia, mild hypoplasia of the distal foreskin. Urethral
opening: Normally placed. Musculoskeletal: Sacral dimple
noted. Base of dimple appears to be visible. No abnormal hair
growth. Musculoskeletal: Hips stable. Neuro: Tone normal.
Symmetrical exam, no clonus.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: [**Known lastname 8125**] was in room air upon admission to the
neonatal intensive care unit. Oxygen saturations were 98-
100%. He did not have any respiratory distress. He
remained in room air for his entire neonatal intensive
care unit admission. He did not have any episodes of
spontaneous apnea or bradycardia.
2. Cardiovascular: A soft murmur was noted on day of life
#17. An electrocardiogram was within normal limits. A
chest x-ray showed normal situs and heart size. Four limb
blood pressures were within normal limits. No further
workup was felt indicated at this time. At the time of
discharge, he has a baseline heart rate of 130-160 beats
per minute with a recent blood pressure of 75/39 with a
mean of 50.
3. Fluid, electrolytes, and nutrition: [**Known lastname 8125**] had significant
issues with hypoglycemia. As noted, initial blood glucose
was 7. He required multiple dextrose boluses and
continuous infusion of 12.5% dextrose. An umbilical
venous catheter was placed for administration and weaning
of the intravenous glucose. Enteral feeds were started on
the day of birth and have been well tolerated. The
intravenous glucose was finally discontinued on day of
life 12. [**Known lastname 8125**] has been closely followed for hypoglycemia.
At the time of discharge, the plan developed with his mother
is for breastfeeding every 4 hours breast-feeding for 10
minutes, then offering a bottle of breast milk fortified to 30
calories per ounce, 6 calories by EnfaCare powder and 4 calories
of corn oil. Glucoses checked prior to feedings at the 4-
hour mark has consistently been over 50. Weight on the
day of discharge is 2.485 kilograms with a head
circumference of 34 cm and a length of 47 cm.
4. Infectious disease: Due to the unknown group B Strep
status and the profound hypoglycemia noted at birth, [**Known lastname 8125**]
was evaluated for sepsis upon admission to the neonatal
intensive care unit. A complete blood count had a white
blood cell count of 13,900 with 27% polymorphonuclear
cells, 4% band neutrophils. A blood culture was sent and
was no growth at 48 hours. With the late placement of the
umbilical venous catheter on day of life #3, [**Known lastname 8125**] was
given oxacillin for coverage. A repeat blood culture was
sent on day of life #4, and he was presumptively started
on ampicillin and gentamicin. Due to concerns for sepsis,
he received a 7-day course of ampicillin and gentamicin.
The 2nd blood culture was also no growth. Due to the
growth restriction, low platelets, and evolving liver
compromise, [**Known lastname 8125**] was evaluated for suspicion for
cytomegalovirus perinatal infection. A CMV urine antigen
was positive prompting further investigation. A serum CMV
PCR was sent and was negative. A lumbar puncture was
performed with normal cell count, glucose, and protein. A
CSF CMV PCR was negative. A serum CMV viral load was 0.
There was continued concern initially when [**Known lastname 8125**] did not
pass hearing screening on the left side. Infectious
disease consultation from [**Hospital3 1810**] was
involved and treatment with ganciclovir was considered,
but as there was no evidence for central nervous system
involvement, this was deemed unnecessary. Subsequently,
[**Known lastname 8125**] was rescreened and passed the hearing screen on the
left side. He then had a full diagnostic frequency specific
ABR performed on the day of discharge at [**Hospital3 1810**] by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 65194**] which was normal in both ears. At this point
gancyclovir is not recommended.
5. Hematological: Hematocrit at birth was 46.3%. By day of
life #3, his hematocrit had risen to 63% with a
reticulocyte count of 3.8%. Platelets initially were
103,000 and fell by day of life #4 to 47,000. He received
3 platelet transfusions over the 1st week of life. His
platelets finally stabilized on day of life #9 at
244,000. Most recent platelet count was on [**2155-1-31**] and was 277,000. Hematocrit at that time was 42.1%.
The polycythemia and the thrombocytopenia are felt to be
related to his intrauterine growth restriction.
6. Gastrointestinal: [**Known lastname 65195**] initial bilirubin at 12 hours of
life was a total of 6.1/0.6 mg per deciliter direct.
Through the 1st week of life, his direct bilirubin was
noted to rise slowly and on day of life #10, the direct
bilirubin was 2 mg per deciliter. An ammonia obtained at
that time was normal at 57. His direct bilirubin peaked
on day of life #24 at 2.7 mg per deciliter, total bili of
4.6/ 1.9 indirect. Follow up liver
function tests have been sent on 3 occasions and remained
slightly elevated. Most recent set of values are from
[**2155-1-31**] with an AST of 100, an ALT of 35.
Coagulation studies were sent and had a PT of 11.3, a PTT
of 28.8, and alkaline phosphatase of 420, and an albumin
of 3.4. [**Known lastname 8125**] had an abdominal ultrasound performed on
[**2155-1-29**]. The liver appeared normal, but the
ultrasonographer was unable to visualize the gallbladder. A
repeat abdominal ultrasound was performed on [**2155-2-5**]
and in the region of the gallbladder [**Last Name (LF) 38438**], [**First Name3 (LF) **] echogenic
band was seen which may represent a collapsed
gallbladder. Stools have been yellow in color. [**Known lastname 8125**] will be
followed by Dr. [**First Name8 (NamePattern2) 2795**] [**Last Name (NamePattern1) 65196**] of
the Gastroenterology service from [**Hospital3 1810**].
Follow-up appointment to be scheduled 2 weeks after
discharge.
7. Neurology: As part of the workup for CMV, [**Known lastname 8125**] had a head
CT scan which was normal. He also had a spine ultrasound
performed for the sacral dimple which was normal. He has
maintained a normal neurological exam during admission
and there were no neurological concerns at the time of
discharge.
8. Sensory: 1. Audiology: As previously mentioned, [**Known lastname 8125**]
referred in the left ear with his initial hearing
screening. The hearing screening was repeated on [**2-5**], [**2154**] and [**Known lastname 8125**] passed in both ears. Due to the concern
of the possible CMV infection, an audiology evaluation
was performed at CH on the day of discharge as noted above
with a full frequency specific ABR and was normal. FU is
recommended in 4 months time.
2. Ophthalmology: As
part of the CMV workup, [**Known lastname 65195**] eyes were examined for any
evidence of retinitis. His eyes were normal on exam.
9. Psychosocial: [**Known lastname 65195**] surname after discharge will be
Hasanaj.
Condition at discharge is good.
Discharge disposition is home with the parents.
The primary pediatrician is Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **], [**Street Address(2) 61182**], [**Location (un) 538**], [**Numeric Identifier 18788**], phone number ([**Telephone/Fax (1) 65197**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: Breast-feeding for 10 minutes followed by ad-lib
amounts of expressed breast milk fortified to 30 calories
per ounce, 6 calories by EnfaCare powder and 4 calories
corn oil.
2. Medications: Multivitamin supplement 1 mL p.o. once
daily, ferrous sulfate 25 mg per mL dilution 0.3 mL p.o.
once daily.
3. Car seat position screening was performed. [**Known lastname 8125**] was
evaluated in his car seat for 90 minutes without any
episodes of oxygen desaturations or bradycardia.
4. State newborn screens were sent on [**1-16**] and [**1-27**], [**2154**] with no abnormal results noted.
5. Immunizations: Hepatitis B vaccine was administered on
[**2155-2-5**].
6. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: 1. Born at less
than 32 weeks; 2. Born between 32 and 35 weeks with 2 of
the following: Daycare during the RSV season, a smoker in
the household, neuromuscular disease, airway
abnormalities, or school-age siblings; or 3. With chronic
lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW-UP APPOINTMENTS:
1. Appointment with Dr. [**Last Name (STitle) **], primary pediatrician within
3 days of discharge.
2. Dr. [**First Name8 (NamePattern2) 2795**] [**Last Name (NamePattern1) 65196**], [**Hospital3 1810**] gastroenterology.
[**Hospital3 1810**] beeper #[**Pager number **]. Appointment [**2161-2-23**]:00
noon phone number ([**Telephone/Fax (1) 56623**].
3. Audiology evaluation with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 65194**] in 4 months at CH.
DISCHARGE DIAGNOSES:
1. Prematurity at 36-2/7 weeks gestation.
2. Hypoglycemia.
3. Suspicion for bacterial sepsis ruled out.
4. Sacral dimple.
5. Small for gestational age with heard sparing intrauterine
growth restriction.
6. Thrombocytopenia.
7. Rule out congenital cytomegalovirus infection.
8. Cardiac murmur.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2155-2-6**] 02:33:08
T: [**2155-2-6**] 04:48:16
Job#: [**Job Number 62255**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1845
} | Medical Text: Admission Date: [**2186-7-25**] Discharge Date: [**2186-7-27**]
Date of Birth: [**2122-12-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy with placement of 4 cecal clips [**2186-7-26**]
History of Present Illness:
63F with a history of HTN, HLD, and DCIS s/p bilateral
mastectomy who presents with hematochezia x 12 hours, DOE, and
significant malaise. She underwent a screening colonoscopy on
[**2186-7-18**] where she was found to have a 5mm x 10mm sessile polyp
in the cecum, 1 x 2mm sessile polyp in the cecum, and a 4mm
sessile polyp in the sigmoid colon as well as several small
AVMs, mild diverticulosis, and internal hemorrhoids. For a few
days after her colonoscopy she was feeling somewhat unwell but
denies abdominal pain or cramping, hematochezia, dark stool,
maroon stool, DOE, or orthostatic symptoms. She fully recovered
and felt fine for a week. The evening prior to admission she
suddenly developed crampy lower abdominal pain and an urge to go
to the bathroom. She have 4 bouts of diarrhea of brown stool as
well as bright red blood. She denies blood clots or maroon
stool. She felt weak after the BMs and could barely walk back to
her office. A colleague drove her home. That evening she had DOE
walking in the yard with her dog. She called the on call service
at [**Location (un) 2274**] and was advised to stay well hydrated and consider
coming to the ED, but refused. The following morning she
conitnued to feel tired and weak. her abdominal cramps returned
and she had 4 more bouts of diarrhea with bright red blood. She
felt so weak she could barely stand and was dizzy with sitting
up. Her son called 911 and she was transported to the ED for
further management.
.
In the ED initial vital signs were 97.9 72 140/90 20 100% on RA.
Initial labs were notable for a H/H of 9.8/28.9 from a baseline
of 14.5/42.8 in 11/[**2184**]. Two 18G PIVs were placed and an ECG
showed no ischemic changed. She received NS 2000mL and was seen
by GI who recommended ICU admission and a PPI. She was
transfered to the ICU for further management.
.
In the [**Hospital Unit Name 153**] she is tired but denies and CP, chest pressure, SOB,
palpitations, or HA. She reports dizziness when she sits up and
some stomach grumbling, but no cramps. She denies any history of
bleeding problems, GIB bleeding, clotting problems, GERD, heart
burn, or jaundice.
.
She was consented for ICU care.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denied nausea, vomiting.
No recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. No feelings of depression or
anxiety. All other review of systems negative.
Past Medical History:
- DCIS s/p mastectomy
- Osteopenia
- Hypercholesterolemia
- Vulvodynia
- Hx of BCC and SCC
- Rhinitis
- Constipation
- Sciatica
- Cervicalgia
- HTN
- Osteoarthritis
- Blistering dermatitis NOS
Social History:
- Tobacco: Denies
- etOH: Social
- Illicits: Distant marijuana, no IVDU or other illicits
Family History:
- Mother: [**Name (NI) 2481**] dementia
- Father: CAD s/p CABG, melanoma
- Sister: Breast cancer
Physical Exam:
GEN: NAD, pale
VS: 97.0 87 supine: 153/93 sitting 133/88 17 99% on RA
HEENT: MMM, no OP lesions, JVP below the clavicle, neck is
supple, no cervical, supraclavicular, or axillary LAD, normal
geographic tongue
CV: RR, NL S1S2 no S3S4, II/VI low systolic murmur at the LUSB
PULM: CTAB
ABD: BS++, soft, nondistended, liver tender and palpable 3cm
below the costal margin in the mid clavicular line, no stigmata
of chronic liver disease
LIMBS: No LE edema, no tremors or asterixis, no clubbing, no
koilonychia
SKIN: No rashes or skin breakdown
NEURO: Strength 5/5 of the upper and lower extremities, reflexes
2+ of the upper and lower extremities
Pertinent Results:
Labs on Admission:
[**2186-7-25**] 11:51PM GLUCOSE-95 UREA N-11 CREAT-0.7 SODIUM-145
POTASSIUM-3.5 CHLORIDE-114* TOTAL CO2-22 ANION GAP-13
[**2186-7-25**] 11:51PM CALCIUM-7.9* PHOSPHATE-2.1* MAGNESIUM-2.3
[**2186-7-25**] 11:51PM WBC-6.6 RBC-2.48* HGB-7.9* HCT-22.8* MCV-92
MCH-31.8 MCHC-34.6 RDW-12.8
[**2186-7-25**] 11:51PM PLT COUNT-216
[**2186-7-25**] 05:01PM WBC-8.2 RBC-3.19* HGB-9.9* HCT-29.5* MCV-93
MCH-31.2 MCHC-33.7 RDW-11.9
[**2186-7-25**] 05:01PM PLT COUNT-277
[**2186-7-25**] 02:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2186-7-25**] 02:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2186-7-25**] 02:40PM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2186-7-25**] 12:30PM GLUCOSE-145* UREA N-23* CREAT-0.8 SODIUM-134
POTASSIUM-3.1* CHLORIDE-99 TOTAL CO2-26 ANION GAP-12
[**2186-7-25**] 12:30PM ALT(SGPT)-21 AST(SGOT)-30 LD(LDH)-222 ALK
PHOS-52 TOT BILI-0.4
[**2186-7-25**] 12:30PM ALBUMIN-3.8 CALCIUM-8.8 PHOSPHATE-2.9
MAGNESIUM-1.8 IRON-73
[**2186-7-25**] 12:30PM calTIBC-272 VIT B12-513 FOLATE-10.3
FERRITIN-72 TRF-209
[**2186-7-25**] 12:30PM WBC-7.6 RBC-3.23* HGB-9.8* HCT-28.9* MCV-90
MCH-30.4 MCHC-34.0 RDW-12.7
[**2186-7-25**] 12:30PM NEUTS-79.0* LYMPHS-17.1* MONOS-3.3 EOS-0.5
BASOS-0.2
[**2186-7-25**] 12:30PM PLT COUNT-249
[**2186-7-25**] 12:03PM GLUCOSE-167* UREA N-22* CREAT-0.8 SODIUM-133
POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-25 ANION GAP-13
[**2186-7-25**] 12:03PM estGFR-Using this
CTA-Ab [**2186-7-26**]:
No acute intra-abd or pelvic abnl. Patent mesenteric vasculature
and no e/o
active extravasation.
.
Ab US [**2186-7-25**]
1.3-cm predominantly hypoechoic lesion of the pancreas.
Though likely benign and possibly sequellae of processes such as
pancreatitis,
dedicated MRCP (on a nonemergent basis) of the pancreas
recommended for
further evaluation.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
# Lower GI Bleed: Admitted with a Hct of 29 from baseline 43 and
orthostatic by vital signs. She was aggressively volume
resuscitated with 5 L of crystalloid and transfused 2 units of
PRBCs after continuning to pass dilute blood with a Golytely
prep, which was then held the first night of the hospitalization
after completing half of the prep. On hospital day 2, she
underwent colonoscopy, which was remarkable for bleeding in the
cecum, the site of 2 of her polypectomies 9 days prior to
admission; 4 clips were placed with adequate hemostasis. Her
volume and hematocrit subsequently remained stable. She was
discharged home in stable condition.
# Tender hepatomegaly: The patient's liver was slightly tender
to palpation on admission, which prompted and abdominal
ultrasound, which subsequently showed that the liver was normal.
# Pancreatic cyst on US: On abdominal ultrasound a pancreatic
cyst was found incidentally described as a 1.3 x 0.6 x 0.6 cm
predominantly hypoechoic lesion in the pancreatic head/neck; it
is likely benign. This will be further evaluated on an
outpatient basis after discharge with an MRCP.
Medications on Admission:
- Simvastatin 60mg PO HS
- HCTZ 12.5mg PO HS
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: Three (3) Tablet PO at bedtime.
Tablet(s)
2. STOPPED: Hydrochlorothiazide 12.5 mg Capsule Sig: One (1)
Capsule PO once a day: Take in mornings; Restart in a week
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed from cecal polypectomy site
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a privilege to take care of you in the hospital.
.
You were hospitalized for a bleed in your colon caused by the
re-bleeding of one of your polypectomy sites in your cecum. You
were admitted to the ICU with a low blood count and low blood
pressures when sitting up and standing. We resuscitated your
volume and blood coutns with IV fluids and 2 units of packed red
blood cells. A CT of yoru abdomen did not show the bleeding
source, but a colonoscopy revealed the source, which was stopped
with clips. You also underwent an abdominal ultrasound because
your liver was slightly tender on admission, which showed a
normal liver but an incidental finding of a pancreatic cyst. We
recommend that you have this finding evaluated further as an
outpatient.
.
No changes were made to your home medications.
Followup Instructions:
Please schedule an appointment with Gastroenterology for
evaluation of your pancreas
ICD9 Codes: 2851, 2768, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1846
} | Medical Text: Admission Date: [**2108-11-22**] Discharge Date: [**2108-11-26**]
Date of Birth: [**2034-6-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Fatigue and abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
74 yoM w/ a h/o ETOH related cirrhosis presents with coffee
ground emesis (few episodes) and black stools x 3 weeks. He had
been taking 6 ASA per day for a few weeks. He also has not been
taking his nexium for the past 3 weeks. The patient went to
[**Hospital6 12112**] where his hct was found to be 18, he
was then transferred to [**Hospital1 18**]. Prior to transfer he was given
Protonix 40 mg IVx1, and morphine 2 mg IVx1. In addition the
patient complains of fatigue, nausea, and abdominal pain for the
past 2-3 weeks.
In the ED, initial VS: T 96.9 HR 95 BP 125/67 RR 22 O2 sat:
96% on RA. He rec'd 1 uPRBC in the ER. He was guaiac +, dark
stool. NG lavage negative. He rec'd 2 liters of fluid. He was
given 40mg IV protonix (in addition to the 40mg IV protonix).
He was started on an octreotide drip after a bolus.
BP 122/56 HR 93 100% on 3L RR 12.
Past Medical History:
COPD
Cirrhosis (GI f/u @ [**Last Name (un) 4199**])
Gastric PUD 10 years ago
Variceal bleed in past (10 years ago)
h/o GI bleed
HTN
ETOH abuse
COPD
DM c/b neuropathy
DJD
OA
anemia
Social History:
h/o ETOH abuse. No ETOH recently (x10 years) w/ the exception
of "sneaking" some ETOH recently.
Family History:
Non contributory
Physical Exam:
Vitals - T: 96.6 BP: 122/57 HR: 96 RR: 12 02 sat: 96% 2L
GENERAL: Oriented x1, Sleeping but arousable
HEENT: PERRL, no scleral icterus, dry MM
CARDIAC: tachy, regular, no murmurs rubs or gallops
LUNG: Clear bilaterally
ABDOMEN: + BS, soft, nt, no hsm, dull to percussion bilaterally
in flanks
EXT: WWP, 1+ pedal edema, no c/c
NEURO: No asterxis
Pertinent Results:
[**2108-11-23**] 09:24AM BLOOD Hct-23.7*
[**2108-11-23**] 02:47AM BLOOD WBC-5.7 RBC-2.58* Hgb-7.8*# Hct-24.0*
MCV-93 MCH-30.2 MCHC-32.4 RDW-18.1* Plt Ct-213
[**2108-11-22**] 12:53PM BLOOD WBC-7.0 RBC-2.08*# Hgb-6.1*# Hct-20.1*#
MCV-97# MCH-29.1 MCHC-30.2* RDW-18.9* Plt Ct-201
[**2108-11-23**] 02:47AM BLOOD Neuts-83.3* Bands-0 Lymphs-8.9* Monos-6.7
Eos-0.7 Baso-0.5
[**2108-11-23**] 02:47AM BLOOD PT-17.3* PTT-32.9 INR(PT)-1.5*
[**2108-11-22**] 12:53PM BLOOD PT-17.4* PTT-32.0 INR(PT)-1.6*
[**2108-11-23**] 02:47AM BLOOD Glucose-42* UreaN-28* Creat-0.8 Na-145
K-3.4 Cl-112* HCO3-20* AnGap-16
[**2108-11-22**] 12:53PM BLOOD Glucose-147* UreaN-33* Creat-0.9 Na-143
K-3.9 Cl-106 HCO3-23 AnGap-18
[**2108-11-23**] 02:47AM BLOOD ALT-82* AST-175* AlkPhos-103 TotBili-3.1*
DirBili-1.2* IndBili-1.9
[**2108-11-22**] 12:53PM BLOOD ALT-100* AST-248* AlkPhos-121*
TotBili-1.4
[**2108-11-23**] 02:47AM BLOOD Albumin-2.6* Calcium-7.6* Phos-2.2*
Mg-1.6
[**2108-11-22**] 12:53PM BLOOD Albumin-2.9* Calcium-8.7 Phos-2.7 Mg-1.8
[**2108-11-22**] 12:53PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2108-11-22**] 12:53PM BLOOD AFP-153.2*
[**2108-11-22**] 12:53PM BLOOD Lipase-24 GGT-550*
[**2108-11-22**] 12:53PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE
[**2108-11-22**] 12:53PM BLOOD tTG-IgA-21*
[**2108-11-22**] 12:53PM BLOOD HCV Ab-POSITIVE*
[**2108-11-26**] 05:30AM BLOOD WBC-3.4* RBC-3.11* Hgb-9.2* Hct-29.0*
MCV-93 MCH-29.4 MCHC-31.5 RDW-18.0* Plt Ct-213
[**2108-11-26**] 05:30AM BLOOD Glucose-110* UreaN-22* Creat-0.8 Na-141
K-4.0 Cl-108 HCO3-22 AnGap-15
[**2108-11-25**] 06:55AM BLOOD Ret Aut-1.9
[**2108-11-26**] 05:30AM BLOOD Glucose-110* UreaN-22* Creat-0.8 Na-141
K-4.0 Cl-108 HCO3-22 AnGap-15
[**2108-11-26**] 05:30AM BLOOD ALT-55* AST-84* AlkPhos-97 TotBili-2.6*
[**2108-11-26**] 05:30AM BLOOD Albumin-2.9* Calcium-8.2* Phos-2.4*
Mg-1.8
EGD [**2108-11-22**]:
Varices at the lower third of the esophagus and gastroesophageal
junction
Ulcers in the antrum
Three non bleeding AVM's found in the stomach
Erythema, congestion, abnormal vascularity and mosaic appearance
in the whole stomach compatible with portal hypertensive
gastropathy
Villous blunting noting diffusely in first and second portion of
the duodenum
Varices at the fundus
Otherwise normal EGD to second part of the duodenum
[**2108-11-22**] RUQ ULTRASOUND:
1. Cirrhotic shrunken liver, with a mass in the right lobe,
which is
worrisome for the presence of HCC. Recommend a multi-phasic CT
or MRI of the liver to further evaluate the mass in the right
lobe.
2. The main portal vein, right and left portal vein are patent
with
hepatopetal flow.
3. There is extensive ascites and splenomegaly in keeping with
portal
hypertension.
4. The right hepatic vein is not visualized.
Brief Hospital Course:
UPPER GI BLEED: Given his symptoms of coffee ground emesis, dark
stool and low hematocrit, the patient was assumed to have
suffered an upper GI [**Last Name (un) **]. He underwent an upper endoscopy in
the medical ICU which revealed no active bleeding but multiple
sources including grade II varicies, AVMs and peptic ulcer
disease. The patient was started on an octreotide and protonix
drip initially; eventually the octreotide was discontinued and
the protonix changed to oral dosing. The patient was instructed
to avoid NSAIDs, ASA, and ETOH. He was transfused 2 units of
pRBCs and his hematocrit rose to the upper 20s and was stable.
LIVER CIRRHOSIS: The patient has known alcoholic cirrhosis as
per HPI. During this admission, he was started on
spironolactone, lactulose, and nadolol for his
cirrhosis/varices, ciprofloxacin for SBP prophylaxis, and folic
acid and thiamine for nutritional deficits, but he refused to
take most of these medications during his stay. After discussion
with his wife, we will prescribe these medications at transfer
with the intent for patient to take prescriptions with him when
departing rehab. His wife understands the the priority order (if
patient wishes to limit number of medications) is lactulose >
nadolol > spironolactone > cipro/folic acid/thiamine. He will
continue to take Nexium as before.
HEPATIC MASS: This is likely HCC based on ultrasound findings,
and his AFP was markedly elevated. This finding was discussed at
length with Dr. [**Last Name (STitle) 497**] (hepatology attending), the patient and
his wife, and a decision was reached to pursue no further
work-up or treatment for this mass. In addition, the patient has
elected to change his code status to DNR/DNI.
PAIN CONTROL: The patient was reportedly taking [**4-30**] aspiring per
day prior to admission, which may have caused or exacerbated his
upper GI bleed. He has been on tramadol 50 mg PO TID at home as
well as percocet, which seem effective for his pain and are
safer than NSAIDs or aspirin. His total acetominophen intake
should be limited to 2 g daily given his liver disease.
Additional narcotic medication may be required in this patient
with likely cancer in the future.
DIABETES MELLITUS: Per the patient's wife, he was taken off of
insulin in [**Month (only) 547**] of this year, and since then has largely
refused to allow her to check his fingersticks. During this
admission, he was placed on a humalog sliding scale with blood
sugars ranging in the 100s (range 145-202 on the day prior to
discharge). Given the relatively low sugars and the patient's
preference to stay off of insulin, we are not continuing his
fingersticks or humalog sliding scale at discharge.
OTHER CARE: Also, patient was discharged with foley catheter in
place. As soon as possible, please remove foley and do voiding
trial.
Medications on Admission:
Nexium 40 mg PO daily
Percocet PRN (patient has taken 9 tabs since [**Month (only) 359**])
Tramadol 50 mg PO TID PRN (patient typically takes TID)
Ambien 10 mg PO QHS PRN insomnia
ASA PRN (up to 6-8 tablets per day, per his wife)
[**Name (NI) **] supplement
Discharge Medications:
1. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
2. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 4 days.
3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Hold for > 3 bowel movements per day.
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: OK for patient to take this medication
3 times daily at times of his choice.
8. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
11. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain: Please do not drive or
operate machinery while taking this medication. Please keep your
total daily acetominophen use to less than [**2098**] mg daily (325 mg
per Percocet tablet).
13. [**Year (4 digits) **] (Ferrous Sulfate) 325 mg (65 mg [**Year (4 digits) **]) Tablet Sig: One
(1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
Primary:
- Upper gastrointestinal bleed (source unknown - esophageal
varices vs. ulcer vs. AVM)
- Alcoholic cirrhosis of the liver
- Liver mass (probable hepatocellular carcinoma)
- Esophageal varices
- Ulcers in antrum
Secondary:
- Diabetes mellitus type II (diet-controlled)
- COPD
Discharge Condition:
Mental Status:Confused - sometimes (at the time of discharge,
patient is coherent, but had episodes of confusion throughout
this admission)
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane) - this is his baseline; he is currently deconditioned
and only able to walk very short distances
Discharge Instructions:
You were transferred to [**Hospital1 69**]
with weakness, fatigue, dark stool, and a low hematocrit (red
blood level). You were admitted to the intensive care unit and
you underwent an upper endoscopy procedure. This showed
esophageal varices (distended veins), ulcers in the stomach, and
some arteriovenous (vascular) malformations, but there was no
active bleeding seen. You received 2 units of packed red blood
cells and your hematocrit (blood level) improved and remained
stable. You were re-introduced to a regular diet, and you
appeared much improved. However, because you are still very weak
and it will be difficult for your wife to care for you alone at
home, you will be discharged to a rehab facility where you can
focus on re-gaining your strength.
While you were here, an imaging study of your liver showed a new
liver mass. This most likely represents a type of liver cancer
called hepatocellular carcinoma. You discussed this finding with
Dr. [**Last Name (STitle) 497**] and your wife, and a decision was made not to pursue
further work-up or treatment for the mass at this time.
We have made the following changes to your medication regimen:
- STOP TAKING aspirin and do not take any other over-the-counter
NSAIDs (non-steroidal anti-inflammatory drugs, such as ibuprofen
or naproxen). These medications could cause a life-threatening
bleed given the findings on your endoscopy study.
- CONTINUE TAKING Percocet as needed for pain. Please keep your
total acetominophen (Tylenol) level to < [**2098**] mg (2 g) per day.
Each Percocet contains 325 mg of acetominophen.
- BEGIN TAKING acetaminophen (Tylenol) for pain not controlled
by the tramadol and Percocet you already use, up to [**2098**] mg (2
g) a day as above. Note that each Percocet tablet contains 325
mg of acetaminophen that must be counted toward the total daily
dose. It is important that you not take more acetominophen than
this as it may worsen your liver disease.
- BEGIN TAKING Lactulose 30 ml by mouth three times daily
(unless having more than 3 bowel movements daily; then scale
back). This medication will help to keep your mind clear by
preventing confusion caused by liver disease. This is the MOST
IMPORTANT medication for you to take as prescribed.
- BEGIN TAKING nadolol 40 mg by mouth daily. This medication
will help to prevent bleeding complications from esophageal
varices. This is the SECOND MOST IMPORTANT medication for you to
take as prescribed.
- BEGIN TAKING spironolactone 100 mg by mouth daily. This
medication will prevent complications from fluid build-up caused
by your liver disease. This is the THIRD MOST IMPORTANT
medication for you to take as prescribed.
- BEGIN TAKING ciprofloxacin 500 mg by mouth daily. This
medication will help to prevent abdominal infections caused by
your liver disease.
- BEGIN TAKING folic acid 1 mg by mouth daily
- BEGIN TAKING thiamine 100 mg by mouth daily
If you have to prioritize your medications, the most important
ones by order are 1. lactulose 2. nadolol 3. spironolactone
Followup Instructions:
Please follow up with your primary care doctor as below. You do
not require specific liver clinic follow up at this time. If you
are unwilling or unable to make these appointments, please call
ahead to cancel.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:
Tuesday [**2108-12-11**] 11:00 AM
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2109-2-19**] 10:00 AM
Completed by:[**2108-11-26**]
ICD9 Codes: 5789, 4019, 3572, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1847
} | Medical Text: Admission Date: [**2189-8-26**] Discharge Date: [**2189-9-23**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Nausea
Vomitting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 86 year old male w/ MMP, h/o ileocecectomy for Stage I
CR CA-
subsequently developed high grade dysplasia and ~ 2weeks ago
underwent a transverse colectomy (has an ileo-dscending
colostomy). He was transfered here from a [**Hospital 760**] Hospital
after persistent nausea and vomitting and inability to take a
regular diet.
Studies:
[**8-24**] CT showed some free air in the left hemidiaphram.
[**8-24**] Gastograffin enema - no obstruction or leak
[**8-25**] UGI - delayed gastric emptying
Past Medical History:
PMH: Afib, DM2, CAD, PUD, HTN, BPH, depression
PSH: B2 (antecolic j-j)~ 25 years ago, ileocecectomy ~ 20 years
ago, CABG, pacer, open Chole.
Social History:
Patient born and raised in [**Month/Year (2) 36978**]. [**Hospital1 **]. WWII survivor. Met
wife in [**Name (NI) 36978**]. Patient and wife coauthored book about life in
[**Name (NI) 36978**] during WWII. Patient has authored several other
publications about the holocaust.
Immigrated to U.S. 35 [**Last Name (un) **]. Patient moved here to escape
communism,
Physical Exam:
PE: 97.3 77 167/84 22 99RA
GEN: comfortable at rest
HEENT: NCAT, anicteric
CV: RRR, pacemaker in place
Pulm: CTAB
Abd: soft, NT, minimally distended, vertical midline incision
healing well, no erythema, no induration
Ext: no LE edema
Pertinent Results:
Cardiology Report ECG Study Date of [**2189-8-26**] 10:38:38 AM
Atrial sensed ventricular paced
No previous tracing available for comparison
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 0 130 466/466 0 -44 126
CHEST (PA & LAT) [**2189-8-27**] 9:38 AM
CHEST (PA & LAT)
Reason: 86 year old man with ? of obstrxn / p/op leak
[**Hospital 93**] MEDICAL CONDITION:
86 year old man with ? of obstrxn / p/op leak
REASON FOR THIS EXAMINATION:
86 year old man with ? of obstrxn / p/op leak
CHEST RADIOGRAPH
INDICATION: 86-year-old man with history of colorectal carcinoma
and colectomy.
No prior studies are available for comparison.
FINDINGS: Left-sided dual chamber pacemaker is identified. There
is a free lead that probably corresponds to prior advise.
Bibasilar opacities are seen consistent with pleural effusions.
The cardiac silhouette is obscured by these opacities and cannot
be evaluated. The aorta appears tortuous. _____ vascular
calcifications are identified. The upper lung zones appear
clear.
IMPRESSION: Bilateral pleural effusions. Surgical clips are seen
overlying the right upper quadrant and the mid abdomen
Cardiology Report ECG Study Date of [**2189-8-28**] 3:27:52 PM
Ventricularly paced rhythm, rate 60. Probable underlying atrial
fibrillation.
Compared to the previous tracing of [**2189-8-28**] no diagnostic
change.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
59 258 142 492/489.72 28 -38 51
CT ABDOMEN W/CONTRAST [**2189-8-30**] 1:30 PM
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
Reason: please eval for collection, obstruction. please give
gastro
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
86 year old man s/p transverse colectomy, now w/ vomiting, fever
REASON FOR THIS EXAMINATION:
please eval for collection, obstruction. please give
gastrograffin (pt had ? of leak on outside hospital scan--we
could not see evidence of such on studies). page [**Numeric Identifier **] w/
questions.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 86-year-old man status post transverse colectomy,
now with vomiting and fever. Evaluate for collection or
obstruction. Please administer Gastrografin.
TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis
were performed with IV contrast.
CT ABDOMEN WITH IV CONTRAST: There is a large right pleural
effusion with associated atelectasis and a small-to-moderate
size left effusion. The liver, pancreas, spleen, adrenal glands,
kidneys are unremarkable with the exception of a left large
simple renal cyst. There are no pathologically enlarged lymph
nodes within the retroperitoneum or mesentery. There is a small
amount of free air within the abdomen and subcutaneous tissue
adjacent to incision site. Surrounding site of anastomosis in
the region of the hepatic flexure, there is a moderate amount of
fat stranding with no definite fluid collection identified.
These findings could represent sequelae of the prior anastomosis
from 10 days ago.
CT PELVIS WITH IV CONTRAST: The urinary bladder, rectum, and
sigmoid colon are unremarkable. The prostate is slightly
enlarged.
BONE WINDOWS: No suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. Large right and small-to-moderate left pleural effusions.
2. Small amount of free air within the abdomen and subcutaneous
tissues adjacent to incision site, likely postoperative
sequelae.
3. Small amount of fat stranding surrounding anastomotic site,
consistent with postoperative sequelae. No focal fluid
collection is identified. Contrast is seen passing this site.
4. No evidence of bowel leak or obstruction.
BILAT LOWER EXT VEINS [**2189-8-31**] 12:03 PM
BILAT LOWER EXT VEINS
Reason: eval for dvt
[**Hospital 93**] MEDICAL CONDITION:
86 year old man with fevers, increasing WBC, with bilat pitting
edema & [**Last Name (un) **] signs
REASON FOR THIS EXAMINATION:
eval for dvt
INDICATION: An 86-year-old male with fevers and increasing white
blood cell count and bilateral pitting edema. Evaluate for DVT.
BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND:
[**Doctor Last Name **] scale and Doppler son[**Name (NI) 1417**] of the right and left common
femoral, superficial femoral, and popliteal veins were
performed. Normal compressibility, augmentation, flow, and
waveforms are demonstrated. There is no evidence of intraluminal
thrombus.
IMPRESSION:
No evidence of DVT bilaterally.
PORTABLE ABDOMEN [**2189-9-1**] 4:50 PM
PORTABLE ABDOMEN; FOLLOW-UP,REQUEST BY RAD.
Reason: CHK FOR GASTRIC EMPTYING POST UGI
INDICATION: Check for gastric emptying status post upper GI.
Note is made of the GI/small bowel follow through of [**9-1**], [**2188**].
SUPINE ABDOMINAL RADIOGRAPH: Clips are seen in the right upper
quadrant. Contrast is seen within the stomach as well as within
loops of small and large bowel. Staples are seen over the mid
abdomen. There is no evidence of obstruction.
IMPRESSION:
1. Contrast remains within the stomach. No evidence of
obstruction.
BAS/UGI AIR/SBFT [**2189-9-1**] 2:21 PM
BAS/UGI AIR/SBFT
Reason: eval gastric emptying... directed consult to dr [**Last Name (STitle) **].
pls
[**Hospital 93**] MEDICAL CONDITION:
86M s/p distant B2 with gastric bezoar (but no strciture on EGD)
& N/V after transverse colectmoy
REASON FOR THIS EXAMINATION:
eval gastric emptying... directed consult to dr [**Last Name (STitle) **]. pls call
with questions
INDICATION: A distant history of gastric bezoar with nausea and
vomiting after transverse colectomy. Please evaluate gastric
emptying.
COMPARISON: None.
FINDINGS: A focussed fluoroscopic study of the stomach was
performed. Patient was orally administered a thin barium, which
demonstrated free passage through the esophagus into the
stomach. There is no evidence for hiatal hernia. There was
significant reflux with a large column of contrast refluxing
into the esophagus to the upper mediastinum. This was
accompanied by dysfunctional tertiary peristaltic waves.
Esophageal lumen is featureless with a small diverticulum noted
in the mid portion of the esophagus. The patient was kept in the
fluoroscopic suite for 20 minutes without opacification of the
stomach antrum. Given a large column of reflux of contrast, a
decision was made not to administer fizzies for stomach
dilation. Study will be continued on the floor with subsequent
portable abdominal radiograph to assess gastric emptying.
Three-lead pacemaker is noted with leads coursing their
anticipated paths. Surgical clips are present in the right upper
quadrant, midline, as well as skin staples present along the
midline. Contrast is present within the colon from a previous
contrast study.
Abdominal supine portable radiograph performed one hour after
thin barium administration demonstrates unchanged appearance of
contrast in the stomach. Contrast in the colon is from a prior
study.
Abdominal supine portable radiographs performed two hours after
thin barium administration demonstrates contrast opacification
of non-distended stomach. Contrast has progressed into the
duodenum and proximal jejunum.
IMPRESSION:
1. Marked esopphageal reflux with large column of barium
persisting in esophagus to the upper mediastinum (exam performed
in near upright position). Patient is at risk for aspiration.
Small mid-esophageal diverticulum.
2. Contrast passage through non-dilated normal-appearing stomach
demonstrated two hours post contrast administration.
CHEST (PA & LAT) [**2189-9-2**] 1:29 PM
CHEST (PA & LAT)
Reason: eval for passage of contrast
[**Hospital 93**] MEDICAL CONDITION:
86 year old man with nausea, vomiting, fever. s/p transverse
colectomy
REASON FOR THIS EXAMINATION:
eval for passage of contrast
PELVIC ULTRASOUND.
INDICATION: Nausea, vomiting, and fever, status post transverse
colectomy.
COMPARISON: [**2189-8-31**].
Since the prior examination, there has been interval removal of
the enteric tube. Stable appearance of the left-sided central
venous catheter with its tip projecting over the SVC. Slight
increased opacity in the right lung base may represent a
possible consolidation. Stable appearance of the left lower lobe
opacification. Left-sided dual chamber pacemaker is unchanged
with the presence of an abandoned lead from prior device. The
upper abdomen demonstrates gas fluid level and barium layering
in a slight dilated stomach. Some of the contrast exited the
stomach, but cannot be assessed.
IMPRESSION: Possible consolidation in both lung bases,
particularly in the right. Interval removal of the enteric tube.
Large amount of residual contrast layering in the stomach with
at least some in the small bowel
Cardiology Report ECG Study Date of [**2189-9-8**] 10:19:16 AM
Ventricularly paced rhythm at 60 beats per minute with probable
underlying
atrial fibrillation. Compared to the previous tracing of [**2189-9-3**]
the
ventricular pacing is new.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
59 0 128 440/437.72 0 -45 92
([**-5/4869**])
RADIOLOGY Final Report
[**Last Name (un) **]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [**2189-9-16**] 3:43 PM
[**Last Name (un) **]-INTESTINAL TUBE PLACEMENT
Reason: Please change over a wire and replace NJ tube.*[**Numeric Identifier 111429**]
[**Doctor First Name 13291**]
[**Hospital 93**] MEDICAL CONDITION:
86 year old man with [**Last Name (un) 1372**]-jejunal tube that is clogged.
REASON FOR THIS EXAMINATION:
Please change over a wire and replace NJ tube.*[**Numeric Identifier 111429**] [**Doctor First Name 13291**]
INDICATIONS: 86-year-old man with clogged nasojejunal tube.
TECHNIQUE: Placement of feeding tube under fluoroscopy.
FINDINGS: A 14 French [**Doctor First Name 1557**]-[**Location (un) 2174**] nasointestinal feeding
tube was passed into the stomach without difficulty, and the
existing tube removed. However, attempts to pass the tube beyond
the stomach were not successful. A redundant segment was left in
the stomach in order to potentially facilitate distal passage.
Persistent debris in the fundus of the stomach is noted.
IMPRESSION:
1. Placement of feeding tube within the stomach. The tube could
not be advanced into the jejunum (the patient is s/p BillrothII)
. It could be helpful to acquire an abdominal radiograph in the
morning, and if the tube does not spontaneously pass into the
jejunum by that time, the patient could be returned to the
fluoroscopy suite for repositioning.
2. Persistent debris within the fundus of the stomach.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: [**Doctor First Name **] [**2189-9-17**] 5:06 PM
RADIOLOGY Final Report
CATHETER, DRAINAGE [**2189-9-17**] 2:32 PM
Reason: please place GJ tube tube with G port to vent stomach &
J po
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
86M s/p bilroth 2, with delayed gastric emptying & need for
feeding tube.
REASON FOR THIS EXAMINATION:
please place GJ tube tube with G port to vent stomach & J port
into efferent jejnual limb for tube feedings...
HISTORY: Gastric outlet obstruction in a patient with a Billroth
II procedure. Please place GJ tube.
TECHNIQUE/FINDINGS: After informed consent was obtained, the
patient's anterior abdominal wall was prepped and draped in a
sterile fashion. Insufflation of the patient's current NG tube
was performed in conjunction with review of a recent CT scan.
This demonstrated the gastric remnant to be of decent size and
directly below the anterior abdominal wall. Hence, after
insufflation, two T-fasteners were placed along the greater
curvature of the stomach, after which the Seldinger technique
was used to place a 5 French sheath within the gastric remnant
lumen. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire and Kumpe catheter were used to manipulate
into the patient's efferent loop. This loop was confirmed both
with contrast and passage of a 150-cm wire. The catheter-wire
combination were manipulated approximately 100 cm into the
efferent limb, after which the wire was exchanged for an Amplatz
wire. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12056**]-Coons gastrojejunostomy tube was shortened
(regularly 100 cm, shortened to approximately 80 cm) with
additional sideholes placed and then advanced into the efferent
limb after tract dilatation. The proximal port which is for
gastric aspiration, was left within the gastric remnant, the
distal port, 80 cm in the efferent limb for tube feeding. The
tube was sutured in place with 0-Prolene. As well, it contains a
mushroom tip for internal anchoring.
IMPRESSION: Placement of a double-lumen gastrojejunostomy tube
via this patient's gastric remnant, proximal port within the
remnant, distal port approximately 80 cm within the efferent
limb in this patient who is status post a Billroth II procedure.
No complications.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Approved: TUE [**2189-9-22**] 9:22 AM
RADIOLOGY Final Report
[**Numeric Identifier 4176**] PERC PLCMT GASTROMY TUBE [**2189-9-17**] 2:32 PM
Reason: please place GJ tube tube with G port to vent stomach &
J po
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
86M s/p bilroth 2, with delayed gastric emptying & need for
feeding tube.
REASON FOR THIS EXAMINATION:
please place GJ tube tube with G port to vent stomach & J port
into efferent jejnual limb for tube feedings...
HISTORY: Gastric outlet obstruction in a patient with a Billroth
II procedure. Please place GJ tube.
TECHNIQUE/FINDINGS: After informed consent was obtained, the
patient's anterior abdominal wall was prepped and draped in a
sterile fashion. Insufflation of the patient's current NG tube
was performed in conjunction with review of a recent CT scan.
This demonstrated the gastric remnant to be of decent size and
directly below the anterior abdominal wall. Hence, after
insufflation, two T-fasteners were placed along the greater
curvature of the stomach, after which the Seldinger technique
was used to place a 5 French sheath within the gastric remnant
lumen. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire and Kumpe catheter were used to manipulate
into the patient's efferent loop. This loop was confirmed both
with contrast and passage of a 150-cm wire. The catheter-wire
combination were manipulated approximately 100 cm into the
efferent limb, after which the wire was exchanged for an Amplatz
wire. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 12056**]-Coons gastrojejunostomy tube was shortened
(regularly 100 cm, shortened to approximately 80 cm) with
additional sideholes placed and then advanced into the efferent
limb after tract dilatation. The proximal port which is for
gastric aspiration, was left within the gastric remnant, the
distal port, 80 cm in the efferent limb for tube feeding. The
tube was sutured in place with 0-Prolene. As well, it contains a
mushroom tip for internal anchoring.
IMPRESSION: Placement of a double-lumen gastrojejunostomy tube
via this patient's gastric remnant, proximal port within the
remnant, distal port approximately 80 cm within the efferent
limb in this patient who is status post a Billroth II procedure.
No complications.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Approved: TUE [**2189-9-22**] 9:22 AM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2189-9-22**] 9:26 AM
CHEST (PORTABLE AP)
Reason: resp distress
[**Hospital 93**] MEDICAL CONDITION:
86 year old man with nausea, vomiting, fever. s/p transverse
colectomy
REASON FOR THIS EXAMINATION:
resp distress
AP CHEST 9:40 A.M. [**9-22**].
HISTORY: Nausea, vomiting and fever following transverse
colectomy. Respiratory distress.
IMPRESSION: AP chest compared to [**8-31**] through [**9-21**]:
Moderate pulmonary edema best demonstrated in the perihilar left
lung has developed since [**9-21**]. There is consolidation in
both lower lungs, particularly the right, strongly suggestive of
concurrent pneumonia. Accompanying small-to-moderate right
pleural effusion could be related to either development. Heart
is at least moderately enlarged partially obscured by
right-sided consolidation. There is no pneumothorax.
Two transvenous right ventricular and one right atrial pacer
lead are unchanged in their respective positions originating in
the left axillary pacemaker. A right central line probably a
PICC can be traced as far as the junction of the brachiocephalic
veins.
Findings were discussed by telephone with Dr. [**Last Name (STitle) 3446**] at the
time of dictation.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: TUE [**2189-9-22**] 9:27 PM
Brief Hospital Course:
He was admitted to [**Hospital1 18**] on [**2189-8-26**] for nausea and vomitting
since recent surgery. He has been unable to take a regular diet
since that time.
He continued to be nausea. A PICC line was put in and TPN
started. He subsequently developed a fever and increased WBC.
The PICC was then removed. Blood cultures from [**8-30**] grew Staph
form one bottle only. He was started on Vancomycin, but then
this was D/C'd on [**9-1**] when other cultures did not reveal any
growth.
GI: A NGT was placed on [**8-30**]. Very foul smelling output from NG
(only 75-100 cc). It was thought that the efferent limb of
billroth is twisted due to recent surgery.
CT showed oral contrast going down ok. An EGD, down 20-30 cm in
efferent limb, showed no stricture or obstruction. A SBFT showed
marked esophageal reflux with large column of barium persisting
in esophagus to the upper mediastinum (exam performed in near
upright position). Regland was started. An EGD on [**2189-9-7**] was
performed with dilation, injection, NJ feeding tube placement.
He was then started on tube feedings. The tube became clogged
and it was then decided to place a GJ tube for nutritional
support. His tubefeedings were slowly advanced to goal over the
next few days.
Geriatrics: [**Female First Name (un) 1634**] was consulted to help manage the care of this
86 year old gentleman. He was depressed and discouraged. He was
started back on his home med of Zoloft. Other recommmendations
were to D/C Ibuprofen and give Tylenol.
Psych: Psych was consulted for his obvious depression and for
thought of harming himself. He was switched from Zoloft to
Celexa. His mood improved after be able to provide nutrition.
Endo: [**Last Name (un) **] was consulted for elevated blood sugars. He needed
15 Units Humalog for a blood sugar on 430 on [**2189-9-4**]. His
sliding scale was adjusted and his sugars were in better
control.
Renal: He was ordered for Lasix 40 mg IV BID for LE edema and
pleural effusion.
Cardiology: He was noted to have A fib on routine ECG. His pacer
was interrogation and shows A fib since early this month. He was
on his beta blocker. All cardiac enzymes tested were negative.
Musculoskeletal: He complained of joint pain and aches. He was
ordered for Tylenol and put back on his Allopurinol and
Colchicine.
Resp: On [**2189-9-22**], the patient was found by the nurses to be
conscious, but not responding. His O2 sats were in the 70's, he
was tachypenic, his lungs sounds were wet. It was thought that
due to development of pneumonia, his respiratory status was
compromised and he most likely aspirated. Secretions were
suctioned from his oralpharynx and a NGT was placed to relieve
any gastric content. He vommited a small amount of foul smelling
brownish gastric contents. He was transfered to the SICU and
placed on BIPAP support. He was DNR/DNI and so was not
intubated. His family was notified and he was made CMO. He
expired on [**2189-9-23**].
Radiology:
[**8-27**] Abd Xray - No evidence of obstruction.
[**8-27**] Chest Xray - Bilateral pleural effusions
[**8-30**] Abd CT - Large right and small-to-moderate left pleural
effusions, small amount of free air within the abdomen and
subcutaneous tissues adjacent to incision site, likely
postoperative sequelae, small amount of fat stranding
surrounding anastomotic site, consistent with postoperative
sequelae. No focal fluid collection is identified. Contrast is
seen passing this site, no evidence of bowel leak or
obstruction.
[**8-31**] US Lower Ext - No evidence of DVT bilaterally.
[**9-1**] Abd X-ray - Contrast remains within the stomach. No
evidence of obstruction
[**9-2**] Chest Xray - Possible consolidation in both lung bases,
particularly in the right. Interval removal of the enteric tube.
Large amount of residual contrast layering in the stomach with
at least some in the small bowel
[**9-6**] CXR - Bilateral loculated effusions, right much larger than
left.
Medications on Admission:
Glipizide 5", Zoloft 100', Atenolol 25', ASA 81mg', Lasix 40',
Colchicine 0.6', Doxazosin 4', Glucosamine/chondroitin', [**Last Name (un) **]
400', allopurinol 100'
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Delayed Gastric Emptying
Discharge Condition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2189-9-24**]
ICD9 Codes: 5070, 5119, 4280, 5859, 2749, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1848
} | Medical Text: Admission Date: [**2181-9-8**] Discharge Date: [**2181-9-26**]
Date of Birth: [**2119-11-6**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
productive cough, shortness of breath
Major Surgical or Invasive Procedure:
Placement of PICC line
History of Present Illness:
61 y/o male with history of right lung Non Small Cell Cancer,
s/p right upper lobe lobectomy, severe COPD, and a history of
MRSA and psuedomanous PNA who presents from ED to ICU with
hypoxia and possible PNA. He recently had a 3 week
hospitalization for COPD exacerbation and treated for a
pneumonia with Bactrim (for MRSA) and levaquin (for
pseudomonas). He was discharged on [**8-6**] but continued to feel
SOB and was readmitted several days later where he grew out
pseudomonas Resistant to ciprofloxacin. Workup also included a
CXR which showed a question of interstitial process and CTA was
negative for PE but did reveal bilateral patchy infiltrates in
middle and lower lobes bilaterally c/w pneumonia. Pt was treated
with vancomycin and ceftaz during this hospital course, and was
discharged on prednisone taper.
.
He was doing well at home until 1 week PTA when he reports onset
of fevers to 101, weakness, SOB, pleuritic CP, cough. Denies any
arm or jaw pain, diaphoresis, nausea, palpitations. ROS + for
photophobia, dizziness with some balance loss, but no loss of
consciousness over this time period as well.
Pt therefore presented to [**Hospital **] hospital. He remained clinically
stable throughout his course at MVH - afebrile, BP
110s-130s/60s-70s, HR 60s-80s, RR 18-24 and sats of 93% on 3L ->
93% on 2L. His pulmonologist (Dr. [**Last Name (STitle) 14069**] was contact[**Name (NI) **] and
recommended transfer to [**Hospital1 18**] for possible bronchoscopy to
figure out why he is having recurrent COPD flares.
On arrival here, he states that his breathing feels comfortable.
Past Medical History:
1. Non-small cell lung cancer, s/p R upper lobectomy, partial R
fifth rib resection c/b chronic pain. No chemo or radiation.
2. COPD w/ severely reduced DLCO, FEV1, and FEV1/FVC ratio
3. h/o MRSA and pseudomonas PNA
4 UC - s/p multiple surgeries, most recently in late 80s. S/P
total colectomy and ileostomy
5. Steroid induced hyperglycemia
6. PFO
7. h/o cardiomegaly
8. h/o depression
Social History:
Married, 2 daughters, lives on the [**Name (NI) **]. Not current
smoker, quit in [**2177**] w/ dx of lung cancer, 40 pack-yr history.
Occasional EtOH use. Worked as a paiting contractor, retired
after lung cancer surgery.
Family History:
F died of lung cancer; M died of Alzheimer's. Has 3 sisters, all
older than him, healthy
Physical Exam:
Vitals - T 95.9, HR 95, BP 107/58, RR 20, O2 97% on high flow
face mask
General - awake alert, sitting up in bed, mask on, NAD
HEENT - PERRL, EOMI, dry MM
CVS - slightly tachycardic, no noted m/r/g
Lungs - diffuse insp and exp wheezes, scattered coarse rhonci at
bases, bronchial breath sounds on right middle airfield
Abd - tense, non-tender, ileostomy in place
Ext - no LE edema b/l
Pertinent Results:
ADMISSION LABS:
[**2181-9-8**] 10:15PM BLOOD WBC-9.3 RBC-3.40* Hgb-10.0* Hct-28.8*
MCV-85 MCH-29.4 MCHC-34.6 RDW-15.4 Plt Ct-280#
[**2181-9-8**] 10:15PM BLOOD Neuts-80* Bands-10* Lymphs-3* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-1*
[**2181-9-8**] 10:15PM BLOOD PT-16.1* PTT-31.4 INR(PT)-1.5*
[**2181-9-8**] 10:15PM BLOOD Glucose-262* UreaN-65* Creat-2.8*#
Na-129* K-4.1 Cl-87* HCO3-24 AnGap-22*
[**2181-9-9**] 05:39AM BLOOD ALT-122* AST-155* LD(LDH)-347*
AlkPhos-118* Amylase-64 TotBili-0.5
[**2181-9-10**] 05:10AM BLOOD ALT-79* AST-52* LD(LDH)-311* AlkPhos-115
TotBili-0.4
[**2181-9-13**] 04:14AM BLOOD ALT-14 AST-1 LD(LDH)-255* AlkPhos-108
TotBili-0.3
[**2181-9-9**] 05:39AM BLOOD Lipase-12
[**2181-9-10**] 05:10AM BLOOD Lipase-13
[**2181-9-9**] 05:39AM BLOOD Albumin-2.5* Calcium-7.7* Phos-6.6*#
Mg-2.1
[**2181-9-13**] 04:14AM BLOOD calTIBC-160* Ferritn-1317* TRF-123*
[**2181-9-9**] 08:26AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
[**2181-9-9**] 08:26AM BLOOD HCV Ab-NEGATIVE
[**2181-9-9**] 01:59AM BLOOD Type-ART pO2-110* pCO2-40 pH-7.38
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2181-9-8**] 10:31PM BLOOD Lactate-2.4*
Pertinent Labs/Studies:
.
CHEST (PORTABLE AP) [**2181-9-8**] 10:10 PM
IMPRESSION:
1. New right middle lung opacification most consistent with
newly developing pneumonia given acuity of onset (1 month).
2. Underlying chronic obstructive pulmonary disease, status post
right thoracotomy.
.
[**2181-9-24**]: Portable CXR -
IMPRESSION:
Minimal worsening of right pneumonia, superimposed upon severe
emphysema. It is difficult to exclude a component of
necrotizing infection.
Persistent air collection at right apex, likely due to a
postoperative
pneumothorax, unchanged since recent radiograph, but worse when
compared to older studies from [**2181-7-20**].
.
[**2181-9-11**]: Echocardiogram
Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function cannot be reliably assessed.
2. The mitral valve leaflets are mildly thickened. The mitral
valve is not well seen.
3. There is no obvious vegetations seen, but the cardiac valves
are not well seen.
.
.
MICROBIOLOGY:
[**2181-9-9**] SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2181-9-9**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final [**2181-9-13**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG + MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S =>16 R
IMIPENEM-------------- 8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 8 I
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ =>16 R
VANCOMYCIN------------ <=1 S
.
Blood cultures:
[**2181-9-8**] to [**2181-9-15**]: No growth
.
Urine:
[**2181-9-9**]: No growth
[**2181-9-20**]: No growth
.
Stool:
[**2181-9-24**]: C. Diff - negative
Discharge Labs:
.
[**2181-9-26**] 05:25AM BLOOD WBC-8.2 RBC-3.03* Hgb-9.5* Hct-25.7*
MCV-85 MCH-31.4 MCHC-37.1* RDW-16.6* Plt Ct-179
[**2181-9-26**] 05:25AM BLOOD Glucose-118* UreaN-22* Creat-0.7 Na-134
K-3.6 Cl-95* HCO3-30 AnGap-13
[**2181-9-26**] 05:25AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.6
Brief Hospital Course:
61 y/o M w/ h/o NSCLC s/p RUL lobectomy, severe COPD, recurrent
pna over past couple months, with righ sided PNA
(MRSA/Pseudomonas) and severe hypoxia requiring significant O2
suppplementation.
.
1. PNA with Severe Hypoxia: Had right multilobar PNA with
MRSA/Pseudomonas growing from sputum, with WBC count of 9,000
and bandemia as high as 22%, elevated anion gap, and elevated
lactate to 2.4. Also has poor underlying lung function from COPD
(FEV 1.2L in [**2181-7-20**]) and h/o right upper lobe lobectomy.
Patient was initially treated with high flow face mask of 15 L
at 40% with additional NC with saturations varying from 88 to
98%, but with continued frequent coughing which causes
desaturations. The patient has since decreased his oxygen
requirement to Venti amsk at 12 lpm with O2 sats rangin 89 to
97%. The patient continues to cough and is draining sputum well
with transition from dark brown thick sputum to thinner
grey/clear sputum. The patient had one episode small volume
blood tinged sputum on [**2181-9-24**] attributed to inflammation from
underlying PNA. The patient is currently being treated with
Linezolid for a planned 21 day course for MRSA as well as
Ceftazidime, again for a planned 21 day course for Pseudomonas.
Amikacin was added for syndergy and to avoid resistance with a
planned 14 day course (ending dates specified on discharge
meds). The patient will be discharged with need for continued
O2 suppplementation to keep sats >90% and <94% with O2 weaning
as possible. The patient will continue to require ongoing Chest
PT and physical therapy as well.
.
2. COPD: Has h/o COPD on montelukast, spiriva, advair, flovent,
prednisone 10mg at home with PFT's showing FEV of 1.2 L (42%
predicted), FEV1/FVC ratio of 42 (59% predicted), 6 L TLC, and
elevated Residual Volume (193% predicited). He was given Advair,
Monteleukast, Prednisone 60 mg DAily tapered down to 30 mg Daily
as well as Atrovent nebulizers. The patient is followed by Dr.
[**Last Name (STitle) 14069**], his outpatient pulmonolgist with whom he should continue
to be followed after discharge.
.
3. Anxiety: Patient was experiencing a significant amount fo
anxiety during this admission, likely at least partly
attributable to his air hunger. The patient was maintained on
Clonopin with hold parameters with Ativan rescues as needed.
.
4. Acute renal failure: Patient presented with ARF with Cr to
2.8 which resolved rapidly with fluids down to baseline of 0.7.
.
5. Chest Pain: Had right sided chest pain, which is diffuse and
pleuritic, likely due to PNA. Treated with MSSR 45 mg [**Hospital1 **] and IV
morphine for breakthrough pain.
.
6. Abdominal pain: Patient has been experiencing ongoing
abdominal pain for a few days. A KUB showed a non-obstructive
bowel gas patterns and the patient's ostomy continues to drain
well. The patient has good appetite without Nausea/vomiting. C.
Diff was negative x 1. The patient did have an elevated
amylase/lipase, now trending down. Pain did not radiate to back
and again patient was tolerating PO well without any
exacerbation of pain. The patient's symptoms are exacerbated
with coughing and are likely secondary to musculoskeletal strain
from frequent coughing. Treating pain as above with MS SR 45 [**Hospital1 **]
with rescue doses.
.
6. Transaminitis: Presented with elevated liver enxymes which
trended down to normal. Hepatitis panel negative for Hep B or C.
.
7. H/o LLL nodule and several other areas of focal scarring:
should be followed with serial CT scans in the future by
outpatient providers.
.
8. H/o right upper lobe lung ca: Not active currently. Sputum
for cytology was negative for malignant cells. No history of
chemo or radiation.
.
9. H/o thrush: Likely related to inhaled staeroids. Continued
his outpt nystatin.
.
10. Steroid Induced Hyperglycemia: Treated with 70/30 insulin
[**Hospital1 **] at AM dose of 40 and PM dose of 22.
.
11. Anemia: Labs consistant with Anemia of chronic disease. Also
was guaiac positive. Needs to be followed in the future. He is
s/p colectomy for Ulcerative colitis.
.
12. Ulcerative colitis: S/P colectomy and ileostomy. Not on any
medications for UC.
.
Code: Full
.
Communication: wife [**Name (NI) **] (h) [**Telephone/Fax (1) 56560**] (c) [**Telephone/Fax (1) 56561**],
daughter [**Name (NI) **] [**Name (NI) 56562**] ([**Telephone/Fax (1) 56563**]
Medications on Admission:
Montelukast 10 mg PO DAILY
Tiotropium Bromide 18 mcg DAILY
Flovent 110 2 puffs [**Hospital1 **]
Prednisone 10mg daily
mucinex 600mg tid
Multivitamin PO DAILY
Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **]
Benzonatate 100 mg PO TID
Senna 8.6 mg PO BID PRN
Docusate Sodium 100 mg PO BID PRN
Nexium 40 mg twice a day.
Morphine 30 mg Tablet Sustained Release PO Q12H
morphine 15mg IR PO q8hr PRN
Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Nystatin 100,000 unit/mL Suspension Sig: 100,000 MLs PO QID
(4 times a day).
4. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed.
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-20**] Sprays Nasal
TID (3 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for anxiety.
8. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): Continue until patient is
regularly ambulatory, than may D/C.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q4H (every 4 hours) as needed.
15. Clonazepam 0.25 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO three times a day: Hold for RR < 16.
16. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
17. Morphine 15 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO Q12H (every 12 hours).
18. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous Q12H (every 12 hours) for 5 days: First
dose: [**2181-9-10**]
Continue for total of 21 day course
Last dose: [**2181-9-30**].
19. Ceftazidime-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) grams Intravenous Q8H (every 8 hours) for 7 days: First
dose: [**2181-9-12**]
Continue for total of 21 day course
Last dose: [**2181-10-2**].
20. Amikacin 250 mg/mL Solution Sig: One (1) gram Injection Q24H
(every 24 hours) for 3 days: First dose: [**2181-9-15**]
Continue for total 14 day course
last dose: [**2181-9-28**].
21. Dolasetron 12.5 mg/0.625 mL Solution Sig: 12.5 mg
Intravenous Q8H (every 8 hours) as needed for nausea /vomiting.
22. Morphine 2 mg/mL Syringe Sig: Two (2) mg Injection Q4H
(every 4 hours) as needed for breakthrough pain.
23. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Continue for 1 week. Wean as possible over following 2
to 3 weeks to 10mg daily as possible.
24. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: see instructions units Subcutaneous once a day: Please
provide 40 units qam
22 units qhs.
25. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
unit Subcutaneous four times a day: Please provide Humalog
sliding scale with meals and at bedtime per provided sliding
scale in addition to standing Insulin 70/30 .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
MRSA/Pseudomonas Pneumonia
COPD exacerbation
Abdominal Pain
Steroid induced hyperglycemia
Anxiety
.
Secondary:
History of Non small cell Lung Ca s/p pneumonectomy
Ulcerative Colitis
Anemia
Discharge Condition:
Fair. Patient with ongoing O2 requirement above baseline.
Symptomatically improved, hemodynamically stable.
Discharge Instructions:
1. Please take all medications as prescribed
.
2. please keep all outpatient appointments
.
3. Please return to the hospital for symptoms fevers/chills,
worsening respiratory status, shortness of breath, chest pain,
or any other concerning symptoms
Followup Instructions:
1. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on discharge. Please
call his office at [**Telephone/Fax (1) 36558**] to make an appointment
.
2. Please follow up with your Pulmonologist within one week of
discharge from your rehab facility. Please call his office to
schedule an appointment.
ICD9 Codes: 5849, 7907, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1849
} | Medical Text: Admission Date: [**2183-5-28**] Discharge Date: [**2183-6-4**]
Date of Birth: [**2103-6-1**] Sex: F
Service: MEDICINE
Allergies:
ceftriaxone
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Saddle pulmonary embolus
Major Surgical or Invasive Procedure:
IVC filter placement by interventional radiology [**2183-5-30**]
History of Present Illness:
Pt is a 79 y/o F with unknown PMHx, who presented to the ED with
generalized weakness and DOE for the past week. She presented
earlier this week to her PCP, [**Name10 (NameIs) 1023**] was planning ot see her in
follow-up on Friday. However, her symptoms progressed, and she
ultimately presented to an OSH ED today, where she was found to
have a large saddle pulmonary embolus. While at the OSH, she
received 100 mg tpa. She was hypoxic to the 80's on NC and was
placed on NRB.
On arrival to the [**Hospital1 18**] ED, she was started on a heparin gtt
after her tpa was completed. Labs were significant for troponin
0.11, BNP 3456, lactate 4.8. Per report, K was low at OSH;
repeat here was 5.2 but was hemolyzed. WBC 18.7. CXR was
unremarkable. Bedside ultrasound was performed and "generous" RV
with some septal bowing during systole. ECG showed TWI in V1-V4.
BP's were borderline in the ED; she received a total of 1 L NS.
VS prior to transfer BP 98/50, HR 75, 100% on NC.
On arrival to the MICU, the patient endorsed some mild SSCP that
was non-radiating. She reports chronic BLE swelling and
tightness, which has been worse recently (R>L). No other
complaints.
Past Medical History:
- lower extremity edema
- HTN
- "phlebitis" vs. DVT during her pregnancies
- GERD
- insomnia
Social History:
Tobacco: Denies. Alcohol: Denies. Illicits: Denies. Lives alone
in a senior complex. Son recently died [**1-23**] EtOH; daughter
attempted suicide as a result.
Family History:
Many family members with depression. Mother with ovarian cancer
(at 35) and colon cancer (at 75). Father with throat cancer,
Alzheimer's. 2 brothers with skin cancer, one with ?lymphoma.
Physical Exam:
Admission:
Vitals: T: 99.1 BP: 136/68 P: 74 R: 16 O2: 995 NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, BLE edema, increased warmth erythema
of medial distal RLE
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
DISCHARGE:
VS: 98.4 116/57 79 18 99% RA
Skin: back, buttocks and thighs with pruritic maculopapular
rashes. no ulcerations or skin openings.
otherwise essentially unchanged.
Pertinent Results:
ADMISSION LABS:
[**2183-5-28**] 05:30PM cTropnT-0.11*
[**2183-5-28**] 05:30PM proBNP-3456*
[**2183-5-28**] 05:33PM LACTATE-4.8*
[**2183-5-28**] 05:30PM GLUCOSE-132* UREA N-32* CREAT-1.2* SODIUM-137
POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-20* ANION GAP-18
[**2183-5-28**] 05:30PM WBC-18.7* RBC-4.26 HGB-12.9 HCT-38.2 MCV-90
MCH-30.3 MCHC-33.8 RDW-13.6
DISCHARGE LABS:
[**2183-6-2**] 06:10AM BLOOD WBC-7.6 RBC-3.87* Hgb-11.6* Hct-34.9*
MCV-90 MCH-29.9 MCHC-33.2 RDW-14.2 Plt Ct-222
[**2183-6-2**] 06:10AM BLOOD PT-18.7* PTT-110.4* INR(PT)-1.8*
[**2183-6-2**] 06:10AM BLOOD Glucose-98 UreaN-10 Creat-0.7 Na-143
K-4.5 Cl-108 HCO3-29 AnGap-11
[**2183-6-2**] 06:10AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.3
CHEST X-RAY ([**2183-5-28**]): Single AP portable chest radiograph was
provided. Subtle hazy opacity at the right base which may
represent atelectasis; however, early infection cannot be
excluded. The lungs are otherwise clear. There is no pleural
effusion or pneumothorax. Heart size is top normal; however,
this may be due to AP projection. There are no acute skeletal
abnormalities. IMPRESSION: Subtle hazy opacity right base is
most likely atelectasis but cannot exclude early infectious
process.
LOWER EXTREMITY DOPPLER [**2183-5-29**]:
IMPRESSION:
1. Deep venous thrombosis involving the right mid femoral vein
extending into the popliteal vein. No evidence of below-knee
DVT on the right side.
2. On the left side there is non-occlusive thrombus in the
popliteal vein
extending into the left peroneal vein.
ECHOCARDIOGRAM [**2183-5-30**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 65%). The right ventricular free wall is hypertrophied.
The right ventricular cavity is mildly dilated with depressed
free wall contractility. There are focal calcifications in the
aortic arch. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. There
is no pericardial effusion.
IVC FILTER PLACEMENT [**2183-5-30**]:
IMPRESSION:
1. Placement of a Bard Eclipse IVC filter into the infrarenal
inferior vena cava via a femoral approach.
2. No evidence of IVC thrombus or IVC duplication anomalies on
IVC venogram which preceded IVC filter placement.
MICROBIOLOGY:
UCx [**2183-5-31**]:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
2ND MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 128 R <=16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
TRANSITIONAL ISSUES:
[ ] Restarting home antihypertensives as patient's clinical
status stabilizes. Pt was restarted on 5 mg of lisinopril (20 mg
daily at home). Her metoprolol was held as we did not want to
interfere with compensatory tachycardia if pt needed it (home
dose 50 mg metoprolol succinate daily). She had recently been
started on diltiazem, which was stopped.
[ ] Lasix was also held as we did not want to decrease her
preload, and the recently increased swelling were thought to be
due to DVT. It can be restarted in the future if lower extremity
swelling does not improve with treatment of DVT.
[ ] Patient will need to make sure that her cancer screening is
up to date as an outpatient to rule out hypercoagulable state.
Hypercoagulable work up is not recommended during this acute
episode of clot, but can be considered in the future.
[ ] Patient will also need an appointment with interventional
radiology to remove the retrievable IVC filter in about [**3-28**]
weeks. IR is aware and will be contacting the patient to make
the appointment.
============================
79 yo F with PMH of chronic lower extremity swelling and HTN who
presented to the ED with generalized weakness and DOE for the
past week, found to have saddle PE and bilateral DVT, now s/p
TPA and on heparin gtt/coumadin. Pt also had troponin leak to
0.11 and evidence of right heart strain on bedside
echocardiogram so underwent IVC filter placement to prevent
further clot burden. She was continued on heparin gtt/coumadin
until her INR was therapeutic.
# PE/bilateral DVT: Pt is now s/p TPA and on heparin
gtt/coumadin. Given a bedside echo with reported evidence of
right heart strain and troponin leak to 0.11, underwent
placement of IVC filter. Patient Stable in terms of respiratory
status. Unclear etiology for pt's PE, ?history of "phlebitis"
with her 9 pregnancies, but no obvious clotting history. Patient
also reports normal mammogram 1 year ago, and had colonoscopy 5
years ago but does not know the result, as she did not follow
up.
Patient received 100 mg TPA at OSH prior to admission to the
[**Hospital1 18**] MICU. Bedside ultrasound showed large RV with some septal
bowing during systole. ECG showed TWI in V1-V4. The patient's
respiratory status improved and the patient was weaned from NRB
to NC. She was put on a heparin gtt and LENIs showed bilateral
DVTs (RLE femoral to popliteal occlusive thrombus, LLE popliteal
nonocclusive thrombus).
She had IVC filter placed given the extent of her saddle emboli
and bilateral DVT. It was thought that risk of further clot
burden would be of significance. After the IVC filter was
placed, she was started on coumadin with goal INR of [**1-24**].
Echocardiogram was also obtained to evaluate for evidence of
right heart strain, given the report of septal bowing seen on
bedside echocardiogram in the ICU. The formal echocardiogram
showed mild RV dilation but no bowing or other evidence of
strain/failure. Patient was seen by PT and was recommended
discharge to rehab for conditioning/strengthening.
# Hypertension: Patient's antihypertensives were held initially
given that her BP was borderline low on admission. As her
treatment for PE continued, her blood pressure improved, likely
due to decreased strain on RV. As we did not want to beta-block
the patient to allow her compensatory tachycardia if needed, she
was started on low dose lisinopril only and her blood pressure
remained within normotensive range. Her metoprolol was not
restarted on discharge, but can be restarted as an outpatient if
needed.
# Insomnia/anxiety: patient with anxiety over her PE/DVT and IVC
filter placement. She also has had recent loss of her son,
suicide of her son's GF and overdose of her daughter. Social
work and pastoral care were consulted and patient appreciated
their care.
# [**Last Name (un) **]: Unclear baseline. With treatment of her PE, her
creatinine improved.
# UTI: patient had fevers, found to have urinary tract
infection. She was treated with IV ceftriaxone for 3 days.
Patient developed rash that was thought to be due to allergic
reaction to ceftriaxone, so it was stopped.
Medications on Admission:
Lisinopril 20 mg 1 tab QD
Toprol XL 50 mg 24 hr, 1 tab QD
Lasix 20 mg 1 tab QD
Zolpidem 10 mg 1 tab QD
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
5. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for itching for 5 days.
7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Itching.
8. diphenhydramine HCl 12.5 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q6H (every 6 hours) as needed for
itching/pruritus.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Nursing and Rehab Centre
Discharge Diagnosis:
Primary Diagnosis: Saddle pulmonary embolus, deep vein
thrombosis
Secondary Diagnosis: Hypertension, lower extremity swelling,
drug rash
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 28331**],
Thank you for allowing us to participate in your care at [**Hospital1 1535**]. You were admitted because you
had large blood clots in your lungs (saddle pulmonary embolus).
We also found that you had blood clots in your legs, and we
treated the blood clots in your lungs and legs with a blood
thinner called heparin. You will also have placement of a filter
(IVC filter) in one of your blood vessels to help prevent future
clots in your lungs.
These CHANGES were made to your medications:
STOP diltiazem
STOP lasix for now, this can be restarted in the future if you
have worsening lower extremity swelling
DECREASE lisinopril to 5 mg daily
DECREASE ambien to 5 mg at bedtime as needed for sleep. Given
your age, it is recommended that you take the smaller dose.
START warfarin 2 mg daily (please follow directions from your
facility and from your PCP to change the warfarin doses)
START colace/senna twice daily for constipation
START acetaminophen (tylenol) 325-650 mg every 6 hours as needed
for pain/fever. Do not take more than 3000 mg daily.
START hydrocortisone 0.5 % Cream. apply to skin twice a day as
needed for itching/rashes for up to 5 days. Please avoid
face/armpit/groin areas.
START camphor-menthol (sarna) lotion. apply to skin up to 4
times a day as needed for itching/rashes.
START diphenhydramine (benadryl) 12.5 mg every 6 hours as needed
for itching/pruritus.
Followup Instructions:
Please call and make an appointment with your primary care
physician once you are discharged from the long term acute care
facility. Please follow up with your doctor regarding your
cancer screening.
Interventional radiologists will be calling you to schedule a
removal of your IVC filter. Please make this appointment in
about 4-6 weeks from [**2183-5-30**].
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1850
} | Medical Text: Admission Date: [**2184-9-27**] Discharge Date: [**2184-10-8**]
Date of Birth: [**2117-8-20**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vasotec / Ranitidine
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Abdominal Pain
Fever
Major Surgical or Invasive Procedure:
Cardiac catheterization
Intubation and mechanical ventilation
Abdominal fluid drainage
History of Present Illness:
67-year-old male with history of stroke s/p gastrostomy, CAD s/p
CABG ([**2169**]),HTN,DM II presented to ED w/ fever associated with
left upper quadrant abdominal pain. All history was obtained
through wife as pt was intubated when he arrived to the unit.
[**Name (NI) 1094**] wife reported that pt began feeling unwell ~1 week ago,
with increasing weakness and gait instability. Over the course
of the past week, pt has complained of increasing LUQ pain,
worse with inspiration, no association with food. Pain was
described as sharp, only lasting for short period of time. Wife
denied any nausea, vomiting or diarrhea; he has been constipated
with last bowel movement about 3 days ago. His wife also notes
increasing urinary accidents over the past week and she was
concerned that he had a urinary tract infection. He was also
noted to have a cough, but no chest pain, no shortness of
breath. Of note, wife also reports that pt had dental work done
on Wednesday, routine cleaning, for which he took prophylactic
antibiotics.
Initial work-up in the ED included unremarkable CT abd and
normal CXR. Pt had a fever of 101 and was given 2L NS and
started on vanc/zosyn.
PT began suddenly dyspneic in ED. He was tachypnea to 40 87% RA,
and received 2 L. Bradycardic to 37 x 1 min, Then improved
spontaneously. Event was associated with a BM. Pt placed on NRB
O2 sat 99%. was a=ox3 at this point. On exam he was rhonchorous
and and had b/l crackles. Repeat CXR notable for pulmonary
edema. Pt continued to be tachypneic to 40 r/min and was
intubated. An EKG at this time showed EKG showed elevations III,
avR, diffuse ischemia - in setting of hypoxemic to 80s,
tachycardic to 100s. Trop was .15. He was started on hep ggt,
given asa 625, and admitted to CCU. Pt was not started on
clopidogril as he has a known mutation preventing
metabolization. He is not a candidate for prasugrel with prev
stroke. On transfer, he is febrile to 102.8.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia (LDL 52
HDL 33 [**12-10**]), (+)Hypertension
2. CARDIAC HISTORY:
-CABG: CAD s/p CABG in [**2169**] (SVG--->large bifurcating ramus,
SVG--->
first diagonal, SVG--> posterior descending, LIMA---> left
anterior descending)
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
DMII with A1C of 6.5 however microalbuminuria
CKDIII due to DMII and HTN
PVD s/p R and L SFA stent [**11-5**]
OSA - non-compliant with CPAP
s/p R knee replacement
Psoriasis
HPL
HTN
Social History:
He owned and ran several companies including a party store and a
shoe store. His wife is now trying to [**Last Name (un) **] these off. He lives
in
[**Location (un) 3146**] with his wife. [**Name (NI) **] smoked until the 80s and
then quit. He occassionally drinks but not to excess and does
not use illegal drugs. Does not restrict his diet.
Family History:
His father died at 72 from coronary artery diseas, his mother at
83 from CAD and cancer (type unknown). He has 2 sisters, 1 of
whom has issues related to diabetes and blood pressure. He has
children who are healthy.
Physical Exam:
Admission Exam:
Tm/Tc:98/98 HR:56-60 BP:124-161/57-86 RR:18 02 sat: 96% 2L
GENERAL: Pt indtubated and sedated
HEENT: NCAT. Sclera anicteric. L pupil >R, equally reactive.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP appreciated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Diffuse
rhonchi with scattered wheezing. Crackles b/l.
ABDOMEN: Soft, NT,ND. No HSM or tenderness. No abdominial
bruits.
EXTREMITIES: 1+ b/l tibial edema. Tibial skin shiny, without
hair. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
DISCHARGE EXAM:
97.1 50-57 18 110-151/56-72
GENERAL: WDWN Male, sitting up in chair NAD
HEENT: NCAT. Sclera anicteric. L pupil >R, equally reactive.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP WNL
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Diffuse
rhonchi with scattered wheezing. Decreased breath sounds b/l.
ABDOMEN: Soft, NT,ND. No HSM or tenderness. No abdominial
bruits.
EXTREMITIES: 1+ b/l tibial edema. Tibial skin shiny, without
hair. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Pertinent Results:
Admission Labs:
[**2184-9-26**] 07:20PM PLT COUNT-259
[**2184-9-26**] 07:20PM NEUTS-79.3* LYMPHS-12.8* MONOS-6.2 EOS-1.5
BASOS-0.2
[**2184-9-26**] 07:20PM WBC-10.6 RBC-3.94* HGB-10.4* HCT-33.0* MCV-84
MCH-26.3* MCHC-31.4 RDW-14.3
[**2184-9-26**] 07:20PM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-2.8
MAGNESIUM-1.8
[**2184-9-26**] 07:20PM proBNP-1698*
[**2184-9-26**] 07:20PM cTropnT-0.15*
[**2184-9-26**] 07:20PM LIPASE-48
[**2184-9-26**] 07:20PM ALT(SGPT)-26 AST(SGOT)-26 ALK PHOS-86 TOT
BILI-0.4
[**2184-9-26**] 07:20PM estGFR-Using this
[**2184-9-26**] 07:20PM GLUCOSE-149* UREA N-22* CREAT-1.2 SODIUM-139
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
[**2184-9-26**] 07:25PM LACTATE-1.3
[**2184-9-26**] 09:15PM URINE MUCOUS-RARE
[**2184-9-26**] 09:15PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
[**2184-9-26**] 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2184-9-26**] 09:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2184-9-27**] 02:05AM CK-MB-3 proBNP-1765*
[**2184-9-27**] 02:05AM cTropnT-0.08*
[**2184-9-27**] 02:05AM CK(CPK)-102
[**2184-9-27**] 02:09AM LACTATE-2.0
[**2184-9-27**] 03:00AM TYPE-ART TEMP-39.3 RATES-18/ TIDAL VOL-450
PEEP-5 O2-60 PO2-97 PCO2-47* PH-7.34* TOTAL CO2-26 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED VENT-SPONTANEOU
[**2184-9-27**] 04:44AM O2 SAT-96
[**2184-9-27**] 04:44AM TYPE-ART TEMP-37.8 RATES-18/ TIDAL VOL-450
PEEP-5 O2-50 PO2-97 PCO2-51* PH-7.33* TOTAL CO2-28 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED
[**2184-9-27**] 05:04AM PT-19.4* PTT-62.7* INR(PT)-1.8*
[**2184-9-27**] 05:04AM PLT COUNT-252
[**2184-9-27**] 05:04AM WBC-12.6* RBC-3.64* HGB-9.6* HCT-30.5* MCV-84
MCH-26.3* MCHC-31.3 RDW-14.5
[**2184-9-27**] 05:04AM ALBUMIN-3.1* CALCIUM-7.7* PHOSPHATE-2.8
MAGNESIUM-1.7
[**2184-9-27**] 05:04AM CK-MB-7 cTropnT-0.24*
[**2184-9-27**] 05:04AM ALT(SGPT)-24 AST(SGOT)-30 LD(LDH)-230
CK(CPK)-128 ALK PHOS-76 TOT BILI-0.6
[**2184-9-27**] 05:04AM GLUCOSE-235* UREA N-20 CREAT-1.1 SODIUM-136
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
[**2184-9-27**] 09:01AM O2 SAT-97
[**2184-9-27**] 09:01AM TYPE-ART TEMP-37.8 RATES-20/ TIDAL VOL-550
PEEP-5 O2-50 PO2-131* PCO2-37 PH-7.46* TOTAL CO2-27 BASE XS-3
-ASSIST/CON INTUBATED-INTUBATED
[**2184-9-27**] 12:30PM CK-MB-19* MB INDX-8.7* cTropnT-0.60*
[**2184-9-27**] 12:30PM CK(CPK)-218
[**2184-9-27**] 03:00PM PTT-57.8*
[**2184-9-27**] 06:18PM HGB-8.7* calcHCT-26 O2 SAT-98
[**2184-9-27**] 06:18PM GLUCOSE-145* K+-3.7
[**2184-9-27**] 06:18PM TYPE-ART RATES-/16 PO2-270* PCO2-36 PH-7.48*
TOTAL CO2-28 BASE XS-4 -ASSIST/CON INTUBATED-INTUBATED
[**2184-9-27**] 07:00PM MAGNESIUM-1.7
[**2184-9-27**] 07:00PM CK-MB-12* MB INDX-6.9* cTropnT-0.60*
[**2184-9-27**] 07:00PM CK(CPK)-173
[**2184-9-27**] 07:00PM UREA N-21* CREAT-1.2 SODIUM-139 POTASSIUM-3.9
CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
.
Cardiac Catheterization [**2184-9-27**]:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated
multi-vessel disease. The LMCA was patent with mild plaquing.
The LCx
was a small (2.0-2.25 mm) vessel that was heavily calcified,
tortuous,
and severely diffusely diseased from origin to distal. It was
supplied
by collaterals to the distal RCA breanches. The RI had a 100%
CTO
proximally with delayed filling and possible appearance of
competitive
flow versus scissoring of its proximal vessel. The RCA had a
100% CTO
proximally with minimal R to R collaterals.
2. Venous conduit angiography revealed the SVG-RCA, SVG-RI, and
SVG-diagonal grafts to be flush occluded.
3. Arterial conduit angiogrpahy revealed the LIMA-LAD graft to
be patent
and the distal LAD to be severely diffusely diseased with total
occlusion distal to the anastamosis.
4. Supravalvular aortography was performed and confirmed no
filling of
the vein grafts.
5. Resting hemodynamics revealed markedly elevated left and
right-sided
filling pressures consistent with severe diastolic dysfunction.
There
was moderately elevated pulmonary arterial pressure. Preserved
cardiac
output and index.
FINAL DIAGNOSIS:
1. Severe native three-vessel coronary artery disease.
2. Occlusion of the three vein grafts.
3. Patent LIMA with severe post-anastamosis LAD disease.
4. Markedly elevated left and right-sided filling pressures.
5. Moderate pulmonary hypertension.
6. Preserved cardiac output and cardiac index.
.
Admission EKG:
Sinus rhythm @94bpm w/ STE in II, III, aVF, Q waves in inferior
leads, ST depression in I, aVL, LVH
Brief Hospital Course:
67-year-old male with history of stroke, s/p
gastrostomy/traumatic gastrostomy tube removal requiring
surgical repair, CAD s/p CABG ([**2169**]), HTN, DM II presented to ED
w/ fever associated with LUQ pain. ED course complicated by
acute respiratory distress and intubation. Additional workup
showed (+) trop and inferior lead ST elevation.
.
# Respiratory Distress: Most likely secondary to flash pulomary
edema in setting of interval change in CXR and acute
decompensation after fluid was given in the ED. Most likely not
[**3-4**] PNA in setting of clear admission CXR. PE also considered
but pt has low [**Doctor Last Name 3012**] criteria. Patient was diuresed with IV
Lasix, and pulmonary edema resolved. He was extubated on
[**2184-9-28**] and remained on Lasix drip and supplemental O2
initially, both of which were eventually weaned, as his
respiratory status improved.
.
# ECG changes: ECG changes and elevated troponin were likely
secondary to demand ischemia in the setting of respiratory
distress. Pt does have baseline ST elevatations in inferiors
leads secondary to old infart. On admission, diffuse ST
depressions in lateral leads more consistent with demand
ischemia. Pt was a poor candidate for stent with inability to
take Plavix due to known mutation preventing metabolization and
with inability to take prasugrel due to previous stroke. Echo
showed Mild symmetric left ventricular hypertrophy with regional
systolic function c/w CAD (proximal RCA distribution). Right
venticular free wall hypokinesis. Mild-moderate mitral
regurgitation with probable papillary muscle dysfunction.
Compared with the prior study from [**2183-7-1**], the left
ventricular dysfunction is more extensive, right ventricular
dysfunction and mitral regurgitation are new c/w interim
ischemia/infarction. Cardiac catheterization showed 3-vessel
disease with no lesions amenable to revascularization. He was
treated medically. He was initially placed on heparin drip, but
this was stopped on [**9-28**] when cardiac enzymes were trending
down. He was initially put on ticagrelor, aspirin, and initally
labetolol and later metoprolol. Given history of large
hemorrhagic stroke on dual antiplatelets, Ticagrelor was
discontinued. He was d/c on Aspirin 325mg daily.
.
# Intraabdominal abscess: Pt previously (on past admission) had
PEG but removed it when delirious and had secondary sepsis and
abd infection requiring gastrectomy. On this admission, he
continued to have abdominal pain, and on [**9-30**], GI was consulted.
Repeat CT showed two fluid collections in the anterior abdomen
adjacent to the stomach and a left subphrenic abscess. The
subphrenic abscess was drained by IR with CT-guided drainage of
20cc of pus. The anterior abdominal collection which was
thought to be a hematoma had resolved by the time of the
drainage. The abscess drainage was sent for culture and will be
followed up upon discharge. We will d/c with zosyn to complete
a 14 day course. If the culture shows bacteria not optimally
treated with zosyn we will call rehab and recommend changing
antibiotics. Patient to be seen by ID as an outpatient.
.
# Unsteady gait: Per wife, patient has had increasing weakness
and gait instability worse than baseline over the last several
days. On exam, pt's pupils are not symmetric, which, according
to the report of the patient and his wife, has been present
since his stroke 14 months ago. The weakness and gait
instability were consistent with the patient's deficits
following his stroke. These improved udirng his hospital stay.
He likely had unmasking of prior deficts in the setting of
systemic illness that resolved with the resolution of the
systemic illness.
.
# DM II: Patient well controlled on metformin at home with
recent A1c of 6.3. Home meds held during admission in favor of
ISS.
.
# CKD: Baseline Cr around 1 with microalbuminuria in past, most
likely secondary to DMII. Hi creatinine bumped to 1.4 2 days
after his cardiac catheterization. We avoided nephrotoxins. On
discharge, his creatinine was 1.3.
.
#HTN: Treated with losartan and amlodipine at home. We initially
held antihypertensives as pt was normotensive and sedated with
concern for underlying infection. Once stabilized, losartan was
re-initiated. Amlodipine 10mg daily. In addition, he was d/c
with carvedilol 25mg PO BID and furosemide 60mg daily.
.
#HLD: We continued home atorvastatin.
.
## Transitional Issues:
- Asymmetric bladder wall thickening. Consider outpatient urine
cytology and consider cystoscopy
- Left Adrenal Nodule: There is a 2.1 x 2.4 cm heterogeneously
enhancing nodule
within the left adrenal gland with indeterminate attenuation
characteristics
([**Doctor Last Name **]:60). The nodule has increased in size since the prior
examination when it
measured 1.7 x 1.8 cm. Though this nodule was previously
characterized as an
adenoma, the increasing size and heterogenous enhancement
pattern are
concerning. Further evaluation with MR of the abdomen is
recommended for
further characterization (2:17).
.
- CODE: Full Code
- EMERGENCY CONTACT: wife [**Name (NI) **] [**Telephone/Fax (1) 106913**]
Medications on Admission:
1. Losartan Potassium 100 mg PO DAILY
2. Labetalol 200 mg PO BID
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Amlodipine 10 mg PO DAILY
7. Atorvastatin 80 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. sildenafil *NF* 100 mg Oral prn ed
10. Omeprazole 20 mg PO DAILY
11. Potassium Chloride 10 mEq PO TID Duration: 24 Hours
Hold for K >
12. Aspirin 325 mg PO DAILY
13. Cetirizine *NF* 10 mg Oral daily
14. Citalopram 20 mg PO DAILY
15. traZODONE 50 mg PO HS:PRN insomnia
16. Ascorbic Acid 500 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Furosemide 60 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. traZODONE 100 mg PO HS insomnia
7. Acetaminophen 325-650 mg PO/PR Q6H:PRN fever
8. Carvedilol 25 mg PO BID
Hold for sbp < 100, hr < 60
9. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
10. Polyethylene Glycol 17 g PO BID
hold for loose stools
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Cetirizine *NF* 10 mg Oral daily
13. Citalopram 20 mg PO DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
15. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
16. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation Center - [**Location (un) 3915**]
Discharge Diagnosis:
PRIMARY
- Intra peritoneal phlegmon/abscess
- Non ST elevation myocardial infarction
- Diabetes Type 2
- Hemorrhagic stroke history
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:
Mr. [**Known lastname **],
Thank you for chosing [**Hospital1 18**]. You were admitted for abdominal
pain and a fever. You had difficlty breathing which required
intubation and support from a breathing machine. You also had
decreased blood flow to your heart resulting in a mild heart
attack. Imaging of your abdomen showed a fluid collection which
is the likely cause of your abdominal pain and fever. You were
given antibiotics and the radiology doctors performed a
procedure that drained the fluid collection. The fluid is being
tested to determine the type of bacteria present and this will
help us determine what antibiotics you need to continue.
.
It is very important that your weigh yourself every day at home
in the morning before breakfast and call Dr. [**Last Name (STitle) **] if your
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days. You may need to go up on your furosemide if this is the
case.
Followup Instructions:
needs ID and CV follow up.
.
Department: [**Hospital1 **] [**Location (un) 2352**] SUITE B
When: THURSDAY [**2184-10-21**] at 4:30 PM
With: [**Doctor First Name 275**] [**Last Name (LF) **], [**First Name3 (LF) 3947**], DPM [**Telephone/Fax (1) 21928**]
[**Name2 (NI) **]g: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: NEUROLOGY
When: TUESDAY [**2184-11-9**] at 3:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: TUESDAY [**2184-12-21**] at 2:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2724, 4439, 4168, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1851
} | Medical Text: Admission Date: [**2182-6-11**] Discharge Date: [**2182-6-17**]
Date of Birth: [**2104-9-2**] Sex: F
Service: MED
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Patient is a 77 year old female with COPD, ESRD on HD, CAD, MVR,
who was tranferred from an outside hospital ED already intubated
for respiratory failure. Also with hyperkalemia. She was
afebrile ane hemodynamically stable.
According to family, the patient had progressive SOB
yesterday,despite increasing chronic home O2 from 2L to 4+L. No
cough/fever/chills/CP. Of note, she has a h/o intubations for
COPD flares. She was also due for HD.
Patient was treated for recent bronchitis 4 weeks ago with
Z-Pack. She reports being well until [**Month (only) **] of last year when
she was first hospitalized for COPD exacerbation and was
intubated. Since then she has been intubated 3 times. She
reports that she has been on dialysis since [**11-29**].
Patient was admitted from the ED to the MICU. She received
kayexalate, insulin, D5 and calcium carbonate for high
potassium. She was kept on solumedrol for 24 hours. She was
started on Levofloxacin. She was extubated on [**6-13**].
Past Medical History:
1. COPD on chronic O2 (most recent intubation x 1yr ago)
2. ESRD on HD (T, TH, Sat) thought to be secondary to XRT for
uterine ca
3. Uterine ca x 16 yrs ago s/p chemo/xrt
4. CAD s/p CABG x 3 [**10-30**]
5. MVR on coumadin (PCP believes this is porcine and goal INR is
1.5-2.5; no valve seen on CXR)
6. s/p cholecystectomy
7. anxiety
8. GERD
9. restless legs.
Social History:
Lives with supportive husband. [**Name (NI) **] 5 children. Ambulatory. Uses
2L oxygen at home when active. Quit smoking one year ago. Prior
to that smoked 1 pack every two days. Does not drink alcohol.
Family History:
Non contributory
Physical Exam:
VS: T 97.8 HR 68 BP 151/60-184/77 RR 24
EDW: 58 kg
GEN: Elderly female seen at dialysis, in NAD.
HEENT: Anicteric sclera. EOMI. Moist mucous membranes. No
erythema or edema of oropharynx.
LUNGS: Crackles bilaterally R>L [**12-28**] way up. No wheezes.
CV: Regular. [**3-2**] holosystolic murmur at apex.
ABD: Soft, non tender, non distended, active bowel sounds.
EXT: No clubbing, or edema. Blue discoloration of toes with some
healed sores. 1+ posterior tibialis pulses bilaterally. AVF of
left arm with palpable thrill and good bruit.
NEURO: Alert and oriented x 3. CN II-XII intact and symmetric
bilaterally. Strength is [**5-1**] in upper and lower extremities
bilaterally.
Labs: 8.7>32.1<191 143| 95 | 54
3.2| 30 | 6.3 Glucose 78
Ca 7.9 Mg 2.1 P 8.3 INR 1.5 PTT 69.4
Blood culture negative.
Sputum gram stain: 3+ gram positive cocci in
pairs/chains/cluters
2+ gram negatvie rods
Sputum culture: moderate orophayngeal flora with sparse
pseudomonas
Pertinent Results:
ECG: Normal sinus rhythm. First degree AV block. Probable
anterior infarct - age undetermined. Lateral ST-T changes offer
additional evidence of ischemia. Repolarization changes may be
partly due to rate. Clinical correlation is suggested
No previous tracing. Rate: 120. Intervals: PR 0 QRS 72 QT/QTc
330/401.42 Axis: P 0 QRS 0 T 113
CXR: The heart is enlarged. There are increased interstitial
markings and perihilar haziness, consistent with congestive
heart failure. Small left pleural effusion is also likely
present. The patient is post median sternotomy and mitral valve
replacement. An endotracheal tube terminates just proximal to
the carina. An NG tube is seen coarsing below the diaphragm into
the proximal stomach.
IMPRESSION: Cardiomegaly with congestive heart failure. Low
lying endotracheal
tube which could be pulled back several centiimeters.
CXR: The heart shows slight left ventricular enlargement.
There is evidence of a prosthetic valve and prior CABG surgery.
The pulmonary
vessels are slightly prominent and appear slightly blurred.
Slight left heart
failure may be present. There is also evidence of patchy
atelectasis at the
left lung base behind the heart and some minor atelectasis is
also noted in
the right lower lobe. Interstitial changes are present in both
lungs, mainly
in the mid and upper zones. The endotracheal tube, the right IJ
central line,
and the NG line are in good position.
IMPRESSION: Findings are consistent with slightly improving left
heart
failure. Bibasilar atelectasis is noted. Background CABG and
prosthetic valve
surgery.
Brief Hospital Course:
Assessment and Plan:
77 year old woman with ESRD, COPD, CAD, MVR admitted with COPD
exacerbation/CHF, initially intubated. Now extubated, afebrile
and hemodynamically stable.
1. Respiratory failure: Likely COPD flare with possible
component of CHF. Patient was extubated with no event after 48
hours and maintained on 4L O2. She was given solumedrol for 24
hours and then transitioned to prednisone taper, serevent,
flovent, albuterol and atrovent. She was started on levofloxacin
for COPD flare as she had bronchitis recently and was treated
with azithromycin and did not improve. Sputum culture was
obtained and showed sparse growth of pseudomonas aeruginosa
thought to be a colonizer. As the patient was not febrile and
not producing much sputum she was not started on antibiotics.
After hemodialysis with fluid removal patient was euvolemic. She
was continued on ACE I for afterload reduction.
2. ESRD: Patient received dialysis Tuesday, Thursday, Saturday
and Monday. To have next session Thursday at [**Location (un) 4265**] [**Location (un) 3786**]. She
was dialyzed to her 59 kg on day of discharge. On Tuesday 1.9 kg
was removed, on Thursday 2.8 kg was removed, on Saturday 3.3 kg
was removed adn on Monday 2.9 kg was removed.
3. MVR: Patient was maintained on coumadin.
4. CAD: Patient was contined on lipitor, beta blocker and Ace
inhibitor.
5. Hyperkalemia: Resolved with insulin, D5, kayexalate. Now on
dialysis.
6. FEN: Heart friendly diet, 2 gm sodium, 1 liter fluid
restriciton. No elevation of blood glucose while on prednisone.
7. Lines: Right internal jugular central line placed in
intensive unit and removed on the floor.
8. family: Husband is health care proxy.
10. code status: full code.
Medications on Admission:
Coumadin 3 mg PO qhs
Lisinopril 5 po qd
Coreg 12.5 po bid
lipitor 10 po qd
folate 1 po qd
zinc
advair
albuterol ativan prn
2L oxygen via NC
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
4. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day
for 9 days: 3 tablets PO for 3 days, 2 tablets po for 3 days, 1
tablet PO for three days.
Disp:*18 Tablet(s)* Refills:*0*
5. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) inh
Inhalation every six (6) hours.
Disp:*2 cannisters* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Coreg 12.5 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
10. Advair Diskus 250-50 mcg/DOSE Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
11. oxygen 2L oxygen by nasal cannula
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Chronic obstructive pulmonary disease exacerbation
Congestive heart failure
Discharge Condition:
Stable with improved oxygen saturation and improved clinical
exam.
Discharge Instructions:
Take your medications as prescribed. Call your primary care
physician if you experience shortness of breath, cough, chest
pain or wheezing.
Take the same medications that you were taking before this
hospitalization. You are also now taking prednisone for the next
18 days and combivent four times a day every day.
Followup Instructions:
Follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
in one week. Call [**Telephone/Fax (1) 55519**] for an appointment. Patient will
have INR checked by VNA on Tuesday, [**2182-6-18**] and called
into [**Location (un) 4265**] [**Location (un) 3786**] Dialysis center at [**Telephone/Fax (1) 55520**].
ICD9 Codes: 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1852
} | Medical Text: Admission Date: [**2192-10-24**] Discharge Date: [**2192-10-31**]
Date of Birth: [**2121-6-24**] Sex: F
Service:
This is a 71-year-old female with a history of coronary
artery disease who had a coronary artery bypass graft in the
past 18 years ago who had congestive heart failure and was
hospitalized for an exacerbation. Experienced chest pain the
night before and relieved with nitroglycerin, and she
presented for cardiac catheterization.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, unstable angina, status post coronary artery bypass
graft 18 years ago, high cholesterol, hypothyroidism, status
post TAH/BSO, and hypertension.
ALLERGIES: She has allergies to sulfa.
MEDICATIONS ON ADMISSION: Synthroid 0.625 mg po q day,
Norvasc and sublingual nitroglycerin prn.
PHYSICAL EXAMINATION: On physical exam, she was afebrile and
vital signs were stable. She was in no apparent distress.
She had no jugular venous distention. Her neck was supple.
She had a murmur in her carotids. She has regular, rate, and
rhythm, normal S1, S2. She had 2/6 systolic ejection murmur
radiating to the carotids. Lungs were clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended, bowel
sounds present. Extremities were no clubbing, cyanosis, or
edema. She is warm and well perfused. She has bilateral 2+
dorsalis pedis pulses.
On admission her white count was 10.4, hematocrit 33.0,
platelets of 278,000. Chem-7: Sodium is 137, potassium 3.7,
chloride 103, bicarb 25, BUN 15, creatinine 0.7, blood
glucose 193, INR was 1.2.
She was taken to the cardiac catheterization laboratory which
showed multi-vessel disease. CT Surgery was consulted at
that time. She was taken to the operating room on [**2192-10-25**]
where a redo coronary artery bypass graft x4 was performed.
Patient was transferred to the CSRU, where she did well. She
was able to be weaned from her ventilator and extubated and
had great O2 saturations on 4 liters nasal cannula. She had
good urine output and was started on a clear liquid diet.
Chest tubes remained in at that time due to high output.
Patient continued to do well and hematocrit was stable. She
was transferred to the floor on postoperative day #1 and just
prior to transfer to the floor, she had an episode of rapid
atrial fibrillation which was converted with IV Lopressor.
On arriving to the floor, she had another episode of rapid
atrial fibrillation which required again IV Lopressor as well
as amiodarone bolus. The patient converted and was rate
controlled.
At that time however, she converted to sinus rhythm after
that. Her Foley was removed and she did well. Physical
therapy was consulted to assess her ambulation and mobility.
She did well with physical therapy and they felt that she
would benefit most from cardiac rehabilitation.
On postoperative day #3 her chest tubes were removed and she
was converted to sinus rhythm at that time. Continued on her
amiodarone was changed to 400 mg po q day for dosing. Her
wires were removed postoperatively, and she continued to
improve. She began complaining of some right arm weakness,
but she said it continued from postoperatively and on
examination, she had diffuse right arm weakness, unable to
move whatsoever, but sensation was intact at that time, and
Neurology was consulted, who suggested a head CT scan.
Head CT scan was done which showed a small stroke in the left
internal capsular region. Her right arm function began to
improve after that time and she continued to improve her
strength and reflexes. Neurology continued to follow along
and patient did well. Patient is continuing to be slightly
hypertensive and started on Captopril at this time. At time
of dictation, the patient is being transferred for
rehabilitation, discharge date pending. Please see addendum.
Her discharge medications currently include Lasix 20 mg po
bid, Lopressor 25 mg po bid, Synthroid 162.5 mcg po q day,
Percocet 1-2 tablets po q4 hours, amiodarone 400 mg po q day,
EC-ASA 325 mg po q day, Colace 100 mg po bid, [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq
po bid, Zantac 150 mg po bid, Motrin 400 mg po q6 hours prn.
She is discharged to rehab facility in stable condition.
Instructed to followup with Dr. [**Last Name (STitle) 1537**] in [**5-19**] weeks and with
her primary care physician [**Last Name (NamePattern4) **] [**2-15**] weeks.
DISCHARGE DIAGNOSES: Coronary artery disease status post
redo coronary artery bypass graft x4, high cholesterol,
hypothyroidism, status post total abdominal hysterectomy and
bilateral salpingo-oophorectomy, hypertension.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2192-10-31**] 10:38
T: [**2192-10-31**] 10:51
JOB#: [**Job Number 23114**]
ICD9 Codes: 4280, 4111, 2449, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1853
} | Medical Text: Admission Date: [**2140-9-21**] Discharge Date: [**2140-10-11**]
Date of Birth: [**2098-4-4**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
central line placement
PICC Line placement ([**10-11**])
History of Present Illness:
(Pt is intubated and sedated on arrival to the [**Last Name (LF) 153**], [**First Name3 (LF) **] the
history is provided by his significant other, [**Name (NI) 401**]). Mr. [**Known lastname **]
is a 42 year-old male with a history of HIV infection and Lyme
disease who presents w/ a diffuse erythematous rash which
started today at 11am. The rash was first noticed last week. He
went to his PCP's office on [**2140-9-15**] when he first noted the
rash. It was described as a generalized, macular papular rash on
his torso and extremities. It was thought to be due to dapsone
(which was being used for PCP [**Name Initial (PRE) 1102**]) and it was
recommended that he d/c dapsone. He had been on dapsone since
mid-[**Month (only) 216**]. For PCP prophylaxis, he was then given inhaled
pentamidine (on [**9-15**]) without any problems. The patient was
advised to use benadryl for symptom relief. The following
weekend ([**Date range (1) 9879**]), the patient continued to have what his
partner described as an erythematous, "spotty" rash all over his
body. It was not itchy, but the patient took benadryl and
claritin RTC to help with the rash, without much improvement. He
also stopped taking Atripla (his previous HAART medication) and
began taking Kaletra and Truvada (the new HAART regimen which
had been prescribed by his PCP [**Last Name (NamePattern4) **] [**2140-9-8**]). He was noted to have
intermittent fevers to 101 and "heart palpitations". His partner
denied any symptoms of night sweats, chills, SOB, chest pain,
cough, URI sx, nausea, vomiting, abdominal pain, diarrhea. He
was noted to be fatigued and his partner states that the patient
"slept for the last 3 days". By Tuesday ([**9-20**]), the patient's
rash had resolved and he went to work without any complaints. He
was noted to have more energy that evening and slept well.
However, upon waking on [**2140-9-21**], he noted to his partner that he
felt poorly but tried to go to work. He also told his partner
that he was beginning a new medication today for pneumonia but
it was unclear what medication this was. The patient then
presented to the ER for further evaluation.
.
In the ER, initial VS were T 98.6, BP 103/51, HR 110, RR 18,
sats of 99% on RA. His initial complaint was of an allergic
reaction at work -he noted that his skin was warm, dry, flushed
and his eyes were red and itchy. He quickly then dropped his BP
to 74/41. He was bolused w/ IVF and started on vancomycin. His
temp started to rise and he was given ibuprofen. IVF were
continually bolused and CTX was given. His SBP remained in the
70s so he was put on dopamine through a peripheral IV while a
central line was placed. He was then switched to levophed. He
then became hypoxic with increasing O2 requirement and was
intubated in the ER using etomidate/succinylcholine. He received
a total of 5.5L of NS and had 80cc UOP (a foley had been
placed). Dermatology was consulted in the ER and had a ddx of
drug hypersensitivity, viral exanthem, or infection. They did
not feel that this was SJS.
.
Per the PCP notes at [**Name9 (PRE) 778**], the patient had stopped Atripla on
[**9-10**] due to a rash and had begun on Kaletra/Truvada on [**9-11**]. The
rash was felt to be self-limited as it resolved with
discontinuation of Atripla. He also noted that he had continued
on the dapsone up until [**2140-9-17**]. He commented on resolution of
the rash, but did note a HA over the weekend that was [**8-26**].
Given pt's intubated status and conflicting story from his
partner, it is unclear what meds the patient was receiving and
when he had discontinued others.
.
Of note, the patient was admitted with a similar chief complaint
in [**3-23**]. He presented with fever, acute renal failure, anemia
and joint pain. He was diagnosed with acute HIV infection (VL
>100,000K, CD4 of 180) and the remainder of the infectious w/u
was negative. ASO titer was positive and complement levels were
negative, but the patient was treated with a full course of
augmentin anyways. Anemia was felt to be due to iron deficiency
and outpatient workup was recommended. He then presented 2 days
after discharge with fever to 103.8, "red eyes", and rash. He
had a lactate of 2.8 at the time. He was initially treated with
CTX, vanco and acyclovir, had an LP (neg for meningitis), head
CT (neg for bleed), and CXR (no infiltrate). His abx were
initially switched to CTX and azithromycin. Lyme antibody was
positive so his antibiotics were switched to doxycycline for a
30 day course. He was discharged on cipro eye drops and
atovaquone for PCP [**Name Initial (PRE) 1102**].
Past Medical History:
1. Anal fissure
2. Adjustment disorder
3. Urethritis NOS [**2133**]
4. Depression/Anxiety
5. Pharyngeal gonococcal infection
6. Anal gonococcal infection
7. New diagnosis of HIV, VL > 100K, CD 4 pending; per his report
had negative HIV test in [**2139-12-18**]
Social History:
Pt is involved with a monogamous partner, with whom he lives
([**Name (NI) 449**]). He works as a social worker for the [**Location (un) **] of
Mass. He reports no recent sexual contact (>6 weeks [**2-19**]
decreased libido). His partner is monogamous per his report.
He drinks [**3-21**] glasses of wine on weekends. He denies tobacco
use. He does not use heroin or cocaine, but does admit to rare
marijuana use.
Family History:
Glaucoma (father, [**Name (NI) 9876**]. Sister and GM with DM.
Physical Exam:
VS - T 101.8, Tmax 102.8, BP 98/62, HR 129, RR 20, sats 96%
AC 500x20, PEEP 10, FiO2 100%
weight - 75kg pre-IVF; 83kg on admit
GEN: WDWN middle aged male intubated and sedated. .
HEENT: Sclera injected but anicteric. PERRL (3->2mm
bilaterally). OP clear around mouth (could not assess posterior
pharynx as pt intubated, OGT in place, pt not opening mouth). No
JVD but prominent visible carotid pulsations.
CV: Hyperdynamic precordium, prominent PMI in mid L clavicular
line. Tachycardic, regular. Normal S1, S2. No m/r/g.
LUNGS: Clear anteriorly at apices. Rhonchorous, vented breath
sounds throughout remainder anterior lung fields.
ABD: Firm, distended. Minimal BS. No rebound or guarding.
EXT: Warm, erythematous, 2+ PT, DP, radial pulses bilaterally. R
IJ. R art line.
GU: Penis w/o any lesions. Rectal exam in ED guaiac negative.
NEURO: Pt intermittently sedated and awake. When awake, follows
commands and answers questions appropriately. Can respond by
shaking head, writing. Using all 4 extremities spontaneously.
Downgoing toes bilaterally.
SKIN: Diffuse, erythematous, fine, maculopapular confluent,
blanching rash that is extensive over his face, neck, torso,
extremities (upper and lower bilaterally) and palms, but spares
his soles. Not pruritic, no excoriations, no skin lesions, no
bullae or vesicles.
Pertinent Results:
CT CHEST/ABDOMEN/PELVIS W/CONTRAST [**2140-10-10**] 10:23 AM
CT CHEST WITH INTRAVENOUS CONTRAST: There is dramatic
improvement in the bilateral effusions with minimal residual
bilateral atelectasis when compared to the previous study. The
central airways are patent to segmental levels bilaterally.
There is a small hyper attenuated lesion in the right middle
lobe of the lung, which is likely a tiny calcified granuloma.
There are small axillary lymph nodes under 1.5 cm as seen in the
previous study. There are no pathologically enlarged mediastinal
lymph nodes. There is no pericardial effusion.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, spleen,
adrenal glands, pancreas, abdominal loops of small bowel are
unremarkable. There is resolved ascites when compared to the
last study. There is minimal gallbladder wall thickening likely
due to third spacing. Tiny paraortic lymph nodes noted, not
significantly enlarged by strict CT criteria.
PELVIS: Mild thickening of the right colonic wall, likely due to
third spacing. A comparison with a prior examination is
difficult due to the lack of contrast filling in the previous
study. Lower left ureter dilation with no evidence of
obstruction as seen in the previous study. No mass is identified
in and around the bladder. No significant lymphadenopathy within
the pelvis.
IMPRESSION:
1. Improvement of effusion and ascites when compared to previous
CT.
2. No abscess or fluid collection seen.
3. Mild right colonic wall thickening, possibly due to third
spacing. A comparison with a previous exam is difficult due to
the lack of opacification from oral contrast in the previous
study.
4. Dilated left lower ureter seen previously, possibly due to
reflux or ureterocele
<br>
CD4 Count ([**10-9**]) - 250.
ESR ([**10-9**])- 58
CRP ([**10-9**])- 20
<br>
<b>Micro Data:</b>
Blood Cx ([**10-1**]) - Coag negative staph x 2 bottles
All other blood/urine cultures negative
Throat strep culture ([**10-8**]) - negative
Toxo Culture ([**10-9**]) - negative
Pending Cultures/serology: blood ([**10-10**], [**10-9**], [**10-7**] x 2), fungal
([**10-6**]), paracoccidio ([**10-10**]), histo ([**10-10**])
<br>
[**2140-10-1**] EEG: "This is an abnormal portable EEG due to the
presence of
frontally predominant generalized delta frequency slowing
suggestive of
deep midline or subcortical dysfunction. No clear epileptiform
features
were seen."
[**2140-9-30**] Head MRI: "Area of encephalomalacia in the right
inferior frontal lobe. No abnormal enhancement, mass effect, or
hydrocephalus. No evidence of slow diffusion to indicate acute
infarct or signs of encephalitis."
[**2140-9-29**] Head CT: "No acute intracranial process. Specifically,
no evidence of hemorrhage, mass, or abnormal enhancement."
[**2140-9-21**] 12:00PM PLT SMR-NORMAL PLT COUNT-335
[**2140-9-21**] 12:00PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
[**2140-9-21**] 12:00PM NEUTS-38* BANDS-39* LYMPHS-17* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2140-9-21**] 12:00PM WBC-1.5* RBC-3.26* HGB-11.0* HCT-32.0* MCV-98
MCH-33.8* MCHC-34.4 RDW-16.0*
[**2140-9-21**] 12:00PM estGFR-Using this
[**2140-9-21**] 12:00PM GLUCOSE-96 UREA N-17 CREAT-1.4* SODIUM-139
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
[**2140-9-21**] 12:37PM LACTATE-2.8* K+-3.9
[**2140-9-21**] 12:37PM COMMENTS-GREEN TOP
[**2140-9-21**] 01:44PM HGB-9.1* calcHCT-27 O2 SAT-78 CARBOXYHB-1 MET
HGB-3*
[**2140-9-21**] 04:30PM URINE HYALINE-0-2
[**2140-9-21**] 04:30PM URINE RBC-0-2 WBC-[**3-21**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2140-9-21**] 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2140-9-21**] 04:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2140-9-21**] 04:30PM URINE UHOLD-HOLD
[**2140-9-21**] 04:30PM URINE HOURS-RANDOM
[**2140-9-21**] 08:54PM O2 SAT-94
[**2140-9-21**] 08:54PM LACTATE-2.5*
[**2140-9-21**] 08:54PM TYPE-ART TEMP-38.8 RATES-20/6 TIDAL VOL-500
PEEP-10 O2-90 PO2-315* PCO2-43 PH-7.30* TOTAL CO2-22 BASE XS--4
AADO2-302 REQ O2-55 INTUBATED-INTUBATED
[**2140-9-21**] 09:08PM PLT SMR-NORMAL PLT COUNT-301
[**2140-9-21**] 09:08PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2140-9-21**] 09:08PM NEUTS-87* BANDS-12* LYMPHS-0 MONOS-0 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2140-9-21**] 09:08PM WBC-4.8# RBC-2.73* HGB-9.4* HCT-26.9* MCV-99*
MCH-34.6* MCHC-35.0 RDW-15.4
[**2140-9-21**] 09:08PM CALCIUM-6.2* PHOSPHATE-2.1* MAGNESIUM-1.2*
[**2140-9-21**] 09:08PM ALT(SGPT)-75* AST(SGOT)-77* LD(LDH)-426* ALK
PHOS-54 TOT BILI-0.4
[**2140-9-21**] 09:08PM GLUCOSE-98 UREA N-18 CREAT-1.4* SODIUM-139
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-19* ANION GAP-14
[**2140-9-21**] 09:16PM PT-14.9* PTT-35.8* INR(PT)-1.3*
[**2140-9-21**] 09:16PM PLT COUNT-319
[**2140-9-21**] 09:16PM WBC-6.4 RBC-2.58* HGB-8.8* HCT-25.7* MCV-100*
MCH-33.9* MCHC-34.1 RDW-15.2
[**2140-9-21**] 09:16PM CALCIUM-6.3* PHOSPHATE-2.8 MAGNESIUM-2.4
[**2140-9-21**] 09:16PM ALT(SGPT)-99* AST(SGOT)-106* LD(LDH)-458* ALK
PHOS-46 TOT BILI-0.4
[**2140-9-21**] 09:16PM GLUCOSE-140* UREA N-23* CREAT-1.9* SODIUM-136
POTASSIUM-5.3* CHLORIDE-112* TOTAL CO2-15* ANION GAP-14
[**2140-9-21**] 09:18PM WBC-6.3 LYMPH-6* ABS LYMPH-378 CD3-69 ABS
CD3-263* CD4-21 ABS CD4-79* CD8-47 ABS CD8-179* CD4/CD8-0.4*
[**2140-9-21**] 09:18PM FIBRINOGE-298 D-DIMER-4843*
[**2140-9-21**] 09:18PM FDP-10-40
[**2140-9-21**] 09:18PM PT-13.1 PTT-28.6 INR(PT)-1.1
[**2140-9-21**] 09:18PM PLT COUNT-363
[**2140-9-21**] 09:18PM WBC-6.3 RBC-2.84* HGB-9.7* HCT-28.6* MCV-101*
MCH-34.3* MCHC-34.0 RDW-15.7*
[**2140-9-21**] 09:18PM CORTISOL-17.0
[**2140-9-21**] 09:18PM CALCIUM-6.7* PHOSPHATE-2.8 MAGNESIUM-1.4*
[**2140-9-21**] 09:18PM ALT(SGPT)-87* AST(SGOT)-90* LD(LDH)-503* ALK
PHOS-62 TOT BILI-0.4
[**2140-9-21**] 09:18PM GLUCOSE-118* UREA N-20 CREAT-1.6* SODIUM-138
POTASSIUM-5.2* CHLORIDE-108 TOTAL CO2-20* ANION GAP-15
[**2140-9-21**] 09:19PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2140-9-21**] 09:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2140-9-21**] 09:56PM O2 SAT-76
[**2140-9-21**] 09:56PM TYPE-[**Last Name (un) **] TEMP-38.8 RATES-20/8 TIDAL VOL-500
PEEP-10 O2-60 PO2-61* PCO2-64* PH-7.15* TOTAL CO2-24 BASE XS--7
-ASSIST/CON INTUBATED-INTUBATED
[**2140-9-21**] 10:36PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2140-9-21**] 10:36PM URINE OSMOLAL-350
[**2140-9-21**] 10:36PM URINE HOURS-RANDOM UREA N-196 CREAT-117
SODIUM-91
[**2140-9-21**] 10:36PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-9-21**] 10:36PM CORTISOL-16.3
[**2140-9-21**] 10:36PM ALBUMIN-2.6*
[**2140-9-21**] 10:36PM LIPASE-20
[**2140-9-21**] 11:19PM O2 SAT-94
[**2140-9-21**] 11:19PM O2 SAT-94
[**2140-9-21**] 11:19PM LACTATE-1.6
[**2140-9-21**] 11:19PM TYPE-ART TEMP-39.7 RATES-20/6 TIDAL VOL-500
PEEP-10 O2-60 PO2-193* PCO2-54* PH-7.17* TOTAL CO2-21 BASE XS--9
-ASSIST/CON INTUBATED-INTUBATED
<br>
<b>Discharge Labs:</b>
[**2140-10-11**]
Chem Panel:
Na-141 Cl-100 BUn-13 Gluc-111 AGap=15
K-3.8 HCO3-30 Cr-1.1
Ca: 9.2 Mg: 1.8 P: 2.6
ALT: 52 AP: 81 Tbili: 0.3 Alb: 4.1
AST: 29
MCV:99
WBC-4.5 Hb-11.3 Plt-260 Hct-33.4
N:60.3 L:32.2 M:3.8 E:3.2 Bas:0.5
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 42-year-old male newly diagnosed with HIV in
[**2140-3-17**] who presented to the [**Hospital1 **] ED on [**2140-9-21**] with fever,
nausea, headache, and a whole body erythematous skin rash that
had started earlier in the day. In the ED, his skin was noted
to be warm, dry, and flushed. His blood pressure, initially
103/51, dropped to 74/41. Fluid boluses failed to improve his
blood pressure and so pressors were started. When he became
hypoxic, he was intubated using etomidate and succinylcholine.
One dose of Ceftriaxone and one dose of Vancomycin were given in
the ED. He was admitted to [**Hospital Unit Name 153**] with a diagnosis of
distributive shock of unknown etiology and started on Zosyn,
Vanco, and Clindamycin.
.
Mr. [**Known lastname **] continued to be hypotensive in the ICU. He
received large amounts of IV fluid and was placed on three
pressors, dopamine, levophed, and epinephrine, and still
remained hypotensive. When [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim test showed adrenal
insufficiency, hydrocortisone was added as well. Over the next
few days, pressors were slowly weaned as his blood pressure
recovered. Urine, stool, sputum, throat, eye, and blood
cultures all failed to grow significant pathogens. A nares
Staph aureus swab was negative as well. HIV viral load measured
to be fairly low at 17,000 copies/ml, making acute HIV
superinfection/exacerbation unlikely. A 2D echo on [**9-22**] showed
normal ventricular function. It was felt that the patient had
distributive shock from one of the following three etiologies:
.
1. Dapsone Hypersensitivity Syndrome: Consistent in that the
patient had recent use of dapsone, elevated methemoglobin,
fever, erythematous rash with subsequent exfoliative rash, and
elevated liver enzymes. Inconsistent in that the patient had no
jaundice or eosinophilia. "Sulfa/Sulfone" drugs, including
Lasix, were avoided during the patient's stay to avoid the risk
of re-inciting a hypersensitivity reaction. The patient was
given stress doses of hydrocortisone.
.
2. Toxic Shock Syndrome: Consistent in that patient had fever,
hypotension, intense erythoderma, blanching, conjunctival
injection, and elevated liver enzymes. Inconsistent in that the
patient had no significant renal involvement, thrombocytopenia,
convincing desquamative rash, or known source of bacterial
infection. The patient was examined and cultured extensively
(including throat, eyes, and nose) for Streptococcus or Staph
aureus, but no source was identified. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**] Spotty
Fever and Leptospira antibodies were sent as they are in the
differential of TSS. The patient was maintained intially on
broad spectrum antibiotics.
.
3. Bacterial Sepsis: Consistent with the patient's presentation
of 39% bandemia, but inconsistent in that no source of infection
was ever identified. As noted above, extensive culturing
offered no source of bacterial infection. The patient was
maintained initially on broad spectrum antibiotics.
.
Of note, the patient required heavy sedation with fentanyl and
midazolam drips to keep him sedated while intubated. Pressure
support trials were initially unsuccessful as the patient had
prolonged periods of apnea. The trials improved and he was
ultimately extubated on [**9-28**] successfully.
.
Following extubation, the patient initially appeared to be his
normal self. The next day, however, he began to appear agitated
and confused. After being given a dose of Haldol, he displayed
symptoms consistent with antipsychotic-induced dystonia
(lip/tongue smacking, grimacing, etc.). Haldol was discontinued
and Benadryl/Cogentin given. The following morning, while still
agitated and confused, he had a tonic clonic seizure lasting
less than one minute followed by lethargy/confusion interspersed
with 3 or 4 short moments of terror and accompanying screams.
He calmed with 2 mg of IV Ativan.
.
The seizure was felt to be due to benzo withdrawal as the
patient had a long standing history of benzo use and had been on
large doses of midazolam while sedated. While he was being
maintained on 1 mg Ativan [**Hospital1 **] for anxiety prior to the seizure,
this may not have been sufficient. Other etiologies that could
not be ruled out included Levofloxacin reaction, neurological
HIV, and infectious meningitis or encephalitis. The patient
never exhibited autonomic lability, however, as would be
expected with a benzo withdrawal. A head CT with contrast
immediately after the seizure failed to show any acute
pathology.
.
The patient remained agitated, confused, and confrontational.
In order to obtain the appropriate tests for his mental status
change, he was again sedated and intubated on [**9-30**]. A head MRI
showed "encephalomalacia in the right inferior frontal lobe,"
but no acute process. CSF fluid from LP was sent for the
following tests: protein, glucose, cytology, gram stain, HSV,
HIV viral load, [**Male First Name (un) 2326**] virus, cryptococcus, EBV, Lyme disease,
Toxoplasma, Varicella, VDRL, WNV, and cultures. His serum was
tested for toxoplasma, RPR, cryptococcus, B12, folate, and urea.
An EEG was done on [**10-1**].
.
Following the completion of tests on [**10-1**], the patient was
weaned from sedation and extubated. He was placed on standing
doses of Ativan (2mg TID) and Zyprexa for agitation and
prevention of opioid withdrawal. He remained much calmer than
previously and his mental status returned to [**Location 213**]. On [**10-2**],
he was discharged to the floor. No PCP prophylaxis was given
during his [**Hospital Unit Name 153**] stay because he had received Pentamidine
nebulizer treatment on [**2140-9-15**] (dosed every 30 days).
.
On arrival to the floor, the patient was noted to be calm and in
no respiratory distress. He was afebrile and hemodynamically
stable. He was increasingly ambulatory, and was eating and
drinking well. He did not need any prn zyprexa for sedation, so
this was discontinued. He did not require insulin, so this was
discontinued. He was ambulatory on the floor, so subcutaneous
heparin was discontinued. He continued to have low grade fevers
in the 99 degree range, and blood cultures off of his central
line drawn on [**10-1**] showed 2/2 bottles from the line positive for
coagulase-negative, staph. aureus. Peripheral cultures drawn at
the same time showed no growth of bacteria. The catheter tip
culture was negative. Surveillance cultures were drawn. He
continued to look and feel clinically well, and had no
subjective complaints. However, he subsequently had
intermittent fevers. He was restarted on Vancomycin on [**10-6**].
Fevers on [**10-8**] and [**10-9**] were as high as 102.5. On [**10-10**], he had
a fever of 101. On [**10-11**], Tmax was 100.6. All cultures were
ngative except culture from [**10-1**]. Preference was to have
patient monitored until he was consistently without fevers,
however patient reported increased anxiety with staying in
hospital and very strong desire to leave. Given no other clear
souce, pt is being discharged to complete 2-week course of
antibiotics (Vancomycin) for possible line infection.
.
ID team was following him in the hospital, recommended holding
antiretroviral therapy during this hospitalization until
outpatient ID care arranged and acute illness resolved. This
discharge, CD4 count was in 250s, so HAART and prophylaxis not
acutely restarted. Pt can f/u as outpatient for consideration
of these therapies.
.
Psychiatry was also following along and recommended institution
of celexa and taper of benzodiazepines at 25% per day. This was
completed. He was discharged on Celexa 20mg (had briefly been
on 60mg which was home dose, but this was thought to be too high
for him given that he had been off this dose for some time).
.
At the time of discharge, he was culture negative with the
exception of studies off of central line as mentioned above, and
the following studies are outstanding and will need to be
followed up on by his Primary Care Doctor and or his ID
physicians.
.
Pending Studies:
Blood Cultures ([**10-10**], [**10-9**], [**10-7**] x 2)
Fungal Culture ([**10-6**])
Histo Serology ([**10-10**])
Paracoccidio Serology ([**10-10**])
Medications on Admission:
MEDS: (per [**Hospital1 778**] records)
Celexa 60mg PO QHS
Acyclovir (? prolonged course)
Kaletra 200-50 2tabs PO Q12 (lopinavir-ritonavir)
Truvada 200-300mg 1 tab PO QD (emtricitabine-tenofovir)
pentamidine inhaled - first dose on [**2140-9-15**]
.
MEDS that patient had available to him:
Seroquel 50mg PO QHS prn insomnia
Truvada 1 tab PO QD - filled [**2140-9-8**]
Atripla 1 tab PO QD - filled [**2140-9-6**]
SMZ-TMP 400-800mg PO QD (also has DS tabs 2tabs PO BID [**12-21**])
Dapsone 100mg PO QD - filled [**2140-9-2**]
Acyclovir 800mg PO TID x10d - filled [**2140-9-2**]
Celexa 60mg PO QHS
Fluoxetine 20mg PO QD
Kaletra 50-200mg 2tabs PO BID - filled [**2140-9-7**]
Clonazepam 1mg PO QHS - filled [**2140-7-26**]
Fluconazole 100mg PO QD x7d - filled [**2140-9-2**]
Ambien 10mg PO QHS
Triamcin/Orabas 0.1% apply to affected area [**Hospital1 **]
.
MEDS identified by pharmacy as free pills pt had in bag:
Ibuprofen
Acyclovir
Vicodin
Hydrocodone
Percocet
Vicoprofen
Diazepam
Clonazepam
Lorazepam
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
twice a day for 9 days: Last dose on [**10-20**].
Disp:*18 solution bags* Refills:*0*
3. PICC Line Care Sig: As directed as directed: PICC Line
Care per protocol.
Disp:*qs PICC Care* Refills:*0*
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*600 ML(s)* Refills:*2*
7. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary:
shock, circulatory (sepsis vs. anaphylactic)
dapsone hypersensitivity syndrome
acute renal failure
Coag negative staph infection
Thrush
Secondary:
HIV/AIDS
Discharge Condition:
T-100.6. Vital signs otherwise stable. No complaints.
Discharge Instructions:
Take all medications as prescribed. You will need to take
Vancomycin for 9 more days to complete a 2-week course (last
dose on [**10-20**]). Follow up appointments as indicated below. You
were advised to remain in hospital for further monitoring of
your temperature, however since you insisted on leaving, you are
asked to monitor your temperature at home (ideally every [**4-22**]
hours).
.
Return to the emergency room or call your doctor for:
Temperature of 101 or more
Shortness of breath
Worsening headaches
Followup Instructions:
NEW PCP:
[**Name Initial (NameIs) 2169**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2140-10-13**] 2:00
NEW ID SPECIALIST:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] BLOOD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2140-10-17**]
3:30
PSYCHIATRIST:
Triangle Program. [**10-14**] 9AM. [**Street Address(2) 9881**].
[**Location (un) **], MA.
You are also welcome to continue primary care with Dr. [**Last Name (STitle) 2392**]
at the [**Hospital6 **] Center (I have discussed this
with him). Call him to arrange an appointment with him for
within two weeks of leaving the hospital should you elect to
continue your primary care with him.
ICD9 Codes: 486, 0389, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1854
} | Medical Text: Admission Date: [**2165-4-23**] Discharge Date: [**2165-4-28**]
Date of Birth: [**2094-7-13**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer from [**Hospital3 **] for VT ablation
Major Surgical or Invasive Procedure:
EP study
VT ablation
Aortic catheterization with abdominal aortogram
and pelvic runoff, right common iliac artery stent, right
external iliac artery stent followed by groin closure with
Perclose.
History of Present Illness:
Patient is a 70 y/o with a history of CAD, CHF, prostate CA,
hyperlipidemia, DM, atrial fibrillation who presented to [**Hospital1 **] on [**2165-4-21**] after feeling dizzy and not himself after
dinner. His friends reported that he also looked very pale, and
activated EMS. He said he has felt like this in the past, but
usually after pacer firing. He was waiting in the ED at Sturdy
at rest, and his pacer fired. He was admitted and taking up to a
room. at around 1am as he stood up from lying down. This
discharges were for ventricular tachycardia. According to the
discharge summary, he had approx 5 runs of VT while on telemetry
and his ICD fired once.
denied CP, dyspnea, nausea or diaphoresis; pt did feel his
"typical funny" palpatations and "a bit dizzy" as per prior
events that trigger his ICD.
pt was recently discharged from [**Hospital3 **] for treatment of
RAF following 7 recorded ICD discharges on [**4-12**]; dofetilide was
added to a regimen of digoxin and increased toprol with
subsequent conversion to sinus rhythm. Pt was discharged home on
dofetilide 250 mg, and had been well controlled until [**4-17**]
episode.
Patient has had 4 difference pacers placed since [**2159**]. The first
was replaced for infection 2 weeks after placement. The second
and third were removed for abnormal firing.
[**2164-4-19**]: Upgrade of an ICD to a [**Company 1543**] Concerto biventricular
ICD, Successful ablation of the AV junction with resultant
complete heart block
[**2162-1-19**]: VT and flutter ablation
Past Medical History:
Known AAA
PVD
CHF
Prostate CA
CAD s/p PCI with angioplasty
s/o pacer placement x4
GERd
Hyperlipidemia
HTN
Sciatica Hyperthyroidism
Atrial Fibrillation
Diabetes mellitus II
Social History:
- quit smoking in [**2158**], 10 pack here smoking history,
occassional ETOH use, no other drug use. Never married. Lives in
monastery.
Family History:
- Brother died of MI age 46, sister died of MI age 59, also had
thyroid problems
Physical Exam:
VS T 97.2 BP 116/80 P 77 o2 sat 98%.
Gen: NAD. Oriented x3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, 8cm JVP
CV: irregular, occassional s3
Chest: CTA b/l
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2165-4-24**] ART DUP EXT LOW/BILAT C
IMPRESSION: Peak systolic velocities do not show evidence of
significant
proximal femoral artery stenosis on either side.
A more comprehensive assessment may be obtained with pulse
volume recordings and segmental blood pressure measurements, if
clinically indicated.
[**2165-4-24**] Carotid dopplers
IMPRESSION:
1. There is 40-59% stenosis within the right internal carotid
artery.
2. There is 70-79% stenosis within the left internal carotid
artery.
[**2165-4-24**] US aorta and branches
IMPRESSION: Fusiform abdominal aortic aneurysm measuring up to 4
cm in
greatest dimension.
[**2165-4-25**] ECHO
Left ventricular wall thicknesses are normal. The left
ventricular cavity is dilated. No masses or thrombi are seen in
the left ventricle. Overall left ventricular systolic function
is severely depressed (LVEF= 20 %). with focal hypokinesis of
the apical free wall. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened.
[**2165-4-26**] ECHO
The left atrium is mildly dilated. There is severe regional left
ventricular systolic dysfunction with akinesis of the anterior
wall, anterior septum, inferolateral wall, and apex. There is
mild hypokinesis of the remaining segments. Quantitative
(biplane) LVEF = 22%. No masses or thrombi are seen in the left
ventricle. Transmitral Doppler and tissue velocity imaging are
consistent with Grade II (moderate) LV diastolic dysfunction.
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w multivessel CAD. Mild mitral regurgitation. No
pericardial effusion.
[**2165-4-27**] CT abd/pelvis with contrast
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Aneurysmal dilatation of the infrarenal aorta measuring up to
3.4 cm in
greatest axial dimension.
3. Right iliac stent.
Brief Hospital Course:
Patient is a 70 y/o with hx of CAD, CHF, VT with pacer placement
and multiple ablations here for VT and pacer firing, transferred
here for EP study and ablation
.
Ventricular Tachycardia: The patient presented to [**Hospital 8125**] hospital
after feeling lightheaded and will. There, he had 5 episodes of
ventricular tachycardia on tele, and his ICD fired once while in
the waiting room. The patient had been on digoxin and
transferred on amiodarone gtt. He had had multiple ablations in
the past and on admission had a dual chamber ICD. He has had
thyroid and liver abnormalites from amiodarone in the past, and
so the amiodarone was discontinued on admission, but he recieved
800mg PO x2 prior to procedure. On [**2165-4-25**] he had a VT ablation.
He had ablation of inducible ventricular tachycardia (RBBB
superior axis CL 400. He had mechanical bump termination of the
tachycardia in apical septum which caused noninducibility. The
ablation was guided b the site of termination and pacemapping.
Nonspecific endpoint on noninducibility given noninducibility
prior to ablations. His device was reprogrammed. Prior to the
procedure he was on heparin until INR. Post procedure he was on
heparin bridge to coumadin.
During the procedure he was noticed to have a cold leg. He was
transferred to the CCU:
CCU COURSE:
The patient was admitted to the CCU following a VT ablation when
it was noted that his right leg was cool and mottled. His right
common iliac artery was dissected. Vascuar surgery consult was
called. This was repaired with stent. His pulses returned. He
was transfered to the CCU for monitoring, and did well. His feet
remained warm and well perfused. There was no recurrence of VT.
He was trasnfered back to the [**Hospital1 1516**] service in good condition,
continued on heprain, aspirin, and plavix as well as coumadin.
His INR on transfer was 1.7.
- Also of note, he was had a pre and post ablation ECHO. He was
monitored on telemetry throughout the admission and did not have
recurrance ventricular tachycardia. He was continue metoprolol
50mg [**Hospital1 **], digoxin. LFTs WNL, checking baseline while on
amiodarone. TSH: 3.8. He also had ultrasounds of carotids,
femoral arteries and AAA for history of AAA, carotid bruit.
.
Atrial fibrillation: on coumadin, beta blocker, digoxin. He was
on heparin after procedure as bridge back to coumadin.
.
CAD: s/p MI, and PCI.
- continue plavix, metoprolol, aspirin, atorvastatin 80mg
.
Chronic Systolic Heart Failure: EF 20% in [**2160**].
- continue metoprolol 50mg, Lisinopril 10mg, lasix 40mg daily,
digoxin .125 mcg daily.
.
HTN: currently normotensive. continue metoprolol and lisinopril.
.
Diabetes Mellitus type II: continue insulin 70/30 10units qAM
and insulin sliding scale while here
.
Chronic kidney disease: baseline 1.5-1.8 this admission and
last, currently at baseline
- renally dose meds.
.
GERD: continue ranitadine.
Medications on Admission:
Lipitor 80mg daily
Aspirin 81mg daily
Plavix 7mg daily
Lisinopril 10mg daily
Metoprolol 50mg [**Hospital1 **]
Digoxin 0.125 daily
Ranitadine 150mg [**Hospital1 **]
Flomax 0.4 HS
Coumadin 2-3mg nightly
Insulin 70/30 10units qAM
Lasix 40mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Ten (10) units Subcutaneous qAM.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Ventricular Tachycardia
Common Iliac Artery Dissection
CAD
HTN
atrial fibrillation
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital after feeling lightheaded. You
intially went to another hospital and your pacer fired 2 times.
You had an ablation and developed a complication of dissection
of one of the arteries that supplies your leg. You had a
vascular procedure and the surgeons placed stents in that
artery. Your pacer did not fire while you were here.
Please have your coumadin level (INR) checked on Tuesday.
Please call your doctor if you have lightheadedness, if your
pacer fires, chest pain or any other concerning symptoms.
Followup Instructions:
Please f/u with Dr. [**Last Name (STitle) 3407**], the Vascular surgeon in 1 month for
an ultrasound of your leg and abdomen. PLease call [**Telephone/Fax (1) 1721**].
Please f/u with your cardiologist in 1 week.
Please have your coumadin level (INR) checked on Tuesday.
Completed by:[**2165-5-24**]
ICD9 Codes: 4271, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1855
} | Medical Text: Admission Date: [**2139-3-21**] Discharge Date: [**2139-3-23**]
Service: MEDICINE
Allergies:
Amiodarone / Zithromax
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
IR guided attempted embolization
History of Present Illness:
88M with CAD s/p CABG, hyperlipidemia, colonic diverticuli and
recent admission [**Date range (3) 61062**] for LGIB and BRBPR now
presenting with recurrent BRBPR. During his recent
hospitalization, he was transfused a total of 12 units PRBCs and
had nadir HCT 22.9. At this time, they were unable to localize
source and had negative angio and colonoscopy with
diverticulosis but no active bleeding. Surgery and GI were
following. He was discharged home on ASA 81mg.
.
This evening at 530 pm, he passed BRBPR described as large
bloody BM at home. He felt lightheaded with this and called 911
and he was brought to [**Hospital1 18**] ED.
In ED, he had two more episodes of BRBPR. NGL was negative. GI
and surgery were consulted. CTA was performed and localized
bleeding to proximal sigmoid colon. HCT which was 32 on
discharge dropped from 37.2 on arrival to ED to 28.6 over 3
hours. 18 and 16g PIV placed. IR was called and he is currently
in IR undergoing embolization. He received 2 units PRBCs. He was
never tachycardic or hypotensive in ED. VS prior to transfer: 87
135/65 20 99%RA.
.
In IR suite, he denied any complaints including lightheadedness,
dizziness, palpitations, SOB, CP, abdominal pain or further
bleeding.
Past Medical History:
CAD s/p CABG (LIMA/LAD, SVG/OM1, SVG/RCA) in [**4-11**], recent
P-MIBI [**12-13**] with normal EF of 66% no perfusion defects
LGIB - discharged [**3-19**] after mesenteric angiography did not show
any acute bleeding
Hypercholesterolemia
Esophageal stricture s/p dilatation
s/p bilateral knee replacements
Social History:
The patient lives with his daughter in [**Name (NI) 392**]. Wife passed away
2 days ago after suffering stroke. He does not smoke
cigarettes. He drinks EtOH rarely. He was previously a
construction worker and WWII vet. He is reportedly very active
at home and is able to perform all of his ADLs.
Family History:
Mother died at 88. Father died at 93 from head trauma after
fall. His father had [**Name (NI) 5895**] disease. No premature CAD. No
sudden cardiac death.
Physical Exam:
GEN: pleasant, comfortable, NAD, speaking in full sentences
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits
RESP: CTA b/l with good air movement throughout anteriorly
CV: RR, S1 and S2 wnl, [**3-15**] systolci murmru LLSB, no r/g
ABD: nd, hyperacive bs, soft, nt, no masses or
hepatosplenomegaly
EXT: no c/c. 2+ edema B/L
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.
RECTAL: Per ED,
Pertinent Results:
Admission Labs:
[**2139-3-21**]
WBC-6.3 RBC-4.09* Hgb-12.8* Hct-37.2* MCV-91 MCH-31.4 MCHC-34.5
RDW-15.8* Plt Ct-222
Neuts-61.8 Lymphs-24.2 Monos-8.4 Eos-5.0* Baso-0.6
PT-12.9 PTT-26.2 INR(PT)-1.1
Glucose-110* UreaN-24* Creat-1.0 Na-142 K-4.4 Cl-104 HCO3-27
AnGap-15
Discharge Labs:
[**2139-3-23**]
WBC-7.2 RBC-4.05* Hgb-12.2* Hct-35.9* MCV-89 MCH-30.0 MCHC-34.0
RDW-15.9* Plt Ct-151
Glucose-85 UreaN-24* Creat-0.9 Na-138 K-4.1 Cl-106 HCO3-25
AnGap-11 Calcium-8.1* Phos-3.1 Mg-2.2
CTA abdomen pelvis:
1. Two small areas of active extravasation most consistent with
bleeding
within the region of the proximal sigmoid colon.
2. Mild narrowing of the origin of the inferior mesenteric
artery secondary to calcific and non-calcific plaque.
3. Prostatic enlargement, correlate with serum PSA.
Mesenteric Angiogram:
No acute source of bleeding identified.
Brief Hospital Course:
- Sigmoid Diverticular Bleed: CTA pelvis in ED showed active
sigmoid bleed and he was transfused 2 units PRBCs. Two large
bore IVs were placed and he was made NPO. He was transferred
directly to the IR suite where a mesenteric angiogram showed no
active bleeding and no intervention was performed. After
transfusion his hematocrit remained stable at ~35. He
experienced no further BRBPR and his diet was advanced. Plan
per general surgery was elective sigmoid resection, outpatient
follow up was arranged within one week. Aspirin was held on
discharge given planned surgery and followup was arranged with
his cardiologist Dr. [**Last Name (STitle) 911**]. If he re-bleeds he will likely need
surgery.
- CAD s/p CABG: Aspirin was held in the setting on active GI
bleed. Also held on discharge given need for surgery. Follow
up was arranged with Dr. [**Last Name (STitle) 911**].
- Hyperlipidemia: Pravastatin held initially given NPO status.
He was restarted on pravastatin on discharge.
Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours)
(unable to fill prescription on discharge so not taking).
5. Glucosamine-Chondroitin Complx 500-400 mg Capsule Sig: One
(1) Capsule PO twice a day.
Discharge Medications:
1. pantoprazole 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:*2*
2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for bleeding from your bowel.
We tried to find where the bleeding was from in the
interventional angiography suite, but we were not able to
intervene in any way. You stopped bleeding and your blood count
was stable.
There is a high probability that your bowels will start to bleed
again. We asked the surgeons to see you and they think you
might benefit from an outpatient surgery to remove the portion
of your bowel that bleeds.
We made the following changes to your medications:
Please STOP taking aspirin
Continue all other medications as you were taking before.
Please come back to the hospital if you have any more bleeding,
dizziness, fainting or other concerns.
Followup Instructions:
Please follow up with:
** Please note your appointment with Dr. [**Last Name (STitle) 47377**] [**Name (STitle) **] for
[**3-25**] has been cancelled.**
PCP [**Name Initial (PRE) 648**]: Tuesday, [**3-31**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Location: [**Hospital3 **] MEDICAL ASSOCIATES
Address: [**Street Address(2) 17502**], [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 17503**]
This appointment is with a member of Dr. [**Last Name (STitle) **]. Singhs team as part
of your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care provider.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2139-4-1**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2139-4-7**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2139-3-24**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1856
} | Medical Text: Admission Date: [**2194-5-28**] Discharge Date: [**2194-6-8**]
Date of Birth: [**2141-12-19**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 60939**] is a 52-year-old
gentleman with a history of aortic valve endocarditis, and he
was hospitalized approximately 6 weeks. The cause was
unknown, and the organism was unknown, but he had recovered
well until about 7 to 8 months ago. He had been starting to
experience worsening shortness of breath and dyspnea on
exertion. Echocardiography showed LVH, an ejection fraction
of 55% to 60%, a calcified aortic valve with aortic stenosis
and aortic insufficiency. He was referred to Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **].
[**Last Name (NamePattern1) **] for aortic valve replacement.
PAST MEDICAL HISTORY:
1. Diverticulosis.
2. Status post colon resection in [**2179**] due to diverticulitis.
3. Hypertension.
4. Psoriasis on his lower extremities.
5. Aortic valve endocarditis.
ALLERGIES: He had no known allergies.
MEDICATIONS ON ADMISSION: Enalapril 20 mg p.o. once a day,
aspirin 81 mg p.o. once a day, Afrin nasal spray p.r.n., and
over-the-counter medication for psoriasis.
RADIOLOGIC AND OTHER STUDIES: Preoperative carotid studies
showed a 30% to 49% right internal carotid stenosis and less
than 30% on the left.
A preoperative chest x-ray showed no evidence of any acute
cardiopulmonary abnormality. Please refer to the official
report dated [**2194-5-28**].
A preoperative EKG showed a sinus rhythm at 83 with some LVH
and secondary ST-T changes. Please refer to the official
report dated [**2194-5-28**].
A preoperative cardiac catheterization report was not
available at the time of this dictation. Per the patient, he
had right coronary artery disease.
PREOPERATIVE LABORATORY DATA: White count was 8.1,
hematocrit was 34.9, and platelet count was 348.000. PT was
13.4, PTT was 28.7, and INR was 1.1. Urinalysis was negative.
Sodium was 140, K was 4.6, chloride was 106, bicarbonate was
30, BUN was 17, creatinine was 1.1, with a blood sugar of
112. ALT was 42, AST was 20, alkaline phosphatase was 63,
amylase was 53, total bilirubin was 0.4, lipase was 30.
Magnesium was 2.0. HbA1C was 5.6%. Urine culture was also
negative.
HABITS: He denied any tobacco use and rare use of alcohol.
His last dental visit was approximately 1 year prior with no
problems.
PHYSICAL EXAMINATION ON ADMISSION: He was in sinus
tachycardia at 105, with a temperature of 99.2, a blood
pressure of 132/74, a respiratory rate of 18, and saturating
94 percent on room air. He was awake, and anxious, and
oriented x 3. He had a grossly nonfocal neurologic exam. His
heart was regular in rate and rhythm with a harsh grade 4/6
systolic ejection murmur that radiated to his carotids. His
lungs were clear with faint wheezes. He had positive bowel
sounds. His abdomen was soft, nontender, and nondistended,
and obese, with a well-healed surgical scar from his
colectomy. His extremities had 1+ edema with right lower
extremity psoriatic plaques. He had 2+ femoral pulses
bilaterally without any bruits heard on his right side, 2+
popliteal, 2+ DP and PT and radial pulses on the right, and
1+ DP and PT pulses on the left, with 2+ radial on the left.
On exam later in the day he was noted to have mild bilateral
rales as well as the elevated blood sugar that Dr. [**Last Name (STitle) **]
deemed to be undiagnosed diabetes.
HOSPITAL COURSE: He was admitted for management of his
congestive heart failure with a plan to do surgery the
following morning. On [**5-29**], he underwent aortic valve
replacement with Dr. [**Last Name (STitle) **] with a 25-mm St. [**Male First Name (un) 923**] mechanical
valve. The right coronary artery was nondominant and unable
to be grafted. Postoperative TEE showed an ejection fraction
of 50%, no AI, and 1+ MR. [**Name13 (STitle) **] did go to the cardiothoracic ICU
on a nitroglycerin drip at 0.2 mcg/kg per minute, a propofol
drip at 15 mcg/kg per minute, and an insulin drip at 2 units
per hour. He was AV paced at the time.
On postoperative day 1, he had a cardiac index of 2.7, in
sinus rhythm at 93, with a blood pressure of 124/76. He was
alert and oriented. He had been extubated. His Swan was
removed. His chest tubes were removed. His Lopressor beta
blockade was begun. He remained on an insulin drip as well as
nitroglycerin at 1.25.
On postoperative day 2, the patient showed third-degree AV
block. His Lopressor was stopped. He continued to be
hemodynamically stable. He was started on captopril at 12.5
and began Lasix diuresis. The electrophysiology service was
consulted. He had an underlying sinus rhythm with junctional
rate also. He alternated between sinus and a junctional rate
at approximately 40 beats per minute.
On postoperative day 4, his Lasix was increased. His Foley
catheter was discontinued. He started a heparin drip. His
Coumadin was held pending his EP consult in case it was
determined that he would need a pacemaker, and he was
transferred out to the floor to begin working with nurses and
the physical therapist. EP evaluated him and determined that
his third-degree heart block and junctional rhythm would
require a pacemaker. His heparin was turned off on the
morning on postoperative day 5. He continued on captopril and
continued with aspirin and Imdur. His exam was unremarkable,
and he continued to have a temporary pacemaker prior to his
pacemaker placement on the 25th in the catheterization
laboratory which he had done successfully.
On postoperative day 6, he seemed to have tolerated his
pacemaker well. His temporary pacing wires were removed. He
was restarted on his heparin as well as Lopressor. He was
seen by case management and continued to work with the nurse
and physical therapist on increasing his exercise tolerance
and ambulating activity. The pacemaker was checked and
interrogated by the EP service with a confirmatory chest x-
ray also. He was receiving Percocet for sternal incisional
pain. His heparin was increased on postoperative day 6. He
received his first dose of Coumadin on [**6-4**]. He continued
with beta blockade with metoprolol 25 twice a day, and his
creatinine was stable at 0.9. His baseline INR was 1.1 prior
to his first dose of Coumadin. His sternum was stable. The
incisions were clean, dry, and intact. His pacer incision was
clean, dry, and intact. He had no extremity edema. He was
encouraged to increase his activity level with physical
therapy and that he would be able to be discharged to home
with VNA services as soon as his INR was therapeutic. Over
the course of the next several days he continued his
ambulation and continued to improve. He was dosed with
Coumadin every evening.
On postoperative day 8, his INR rose to 1.2. His Imdur was
discontinued as well as captopril being changed over to
lisinopril. His heparin was increased to 1400 units per hour
when his INR only rose from 1.1 to 1.2.
On postoperative day 9 and postoperative day 4 from his
pacemaker, he did a level V and was cleared by physical
therapy. He had a short run of a question of SVT versus AFib
which self terminated. He had scattered rhonchi and a sharp
click from his mechanical valve. His pacer site had no
hematoma. His Coumadin was increased to 7.5 mg that evening.
His enalapril was increased to 10 mg. On the 1st, Dr. [**Last Name (STitle) **]
determined that once his INR reached 1.8 he could be
discharged home on his Coumadin with followup with his
primary care physician. [**Name10 (NameIs) **] postoperative day 9, his INR rose
to 1.7.
On [**6-8**], on the day of discharge, his PT rose to 16.7 with
an INR of 1.8; and it was determined that he could be
discharged to home with VNA services with follow-up blood
draws at [**Hospital3 35813**] Center in [**Location (un) 37361**], [**Doctor Last Name **],
his home town, the following Monday.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement with a 25-mm St. [**Male First Name (un) 923**]
mechanical valve.
2. Status post pacemaker placement.
3. Diverticulosis.
4. Status post colectomy in [**2179**].
5. Hypertension.
6. Lower extremity psoriasis.
MEDICATIONS ON DISCHARGE:
1. Percocet 5/325 1 to 2 tablets p.o. q.4h. p.r.n. (for
pain).
2. Enteric coated aspirin 81 mg p.o. once daily.
3. Colace 100 mg p.o. twice a day.
4. Lasix 40 mg p.o. once daily (for 7 days).
5. Metoprolol 50 mg p.o. twice a day.
6. Enalapril 20 mg p.o. once a day.
7. Coumadin 7.5 mg on the evening of discharge only and then
following doses to be taken as directed by Dr. [**Last Name (STitle) 60940**] for
an INR goal of 2 up to 3.5. The patient was instructed to
follow up with Dr. [**Last Name (STitle) 60940**] and have his lab work drawn the
following Monday at [**Hospital3 35813**] Center in [**Doctor Last Name **]
Island.
8. Zantac 150 mg p.o. twice a day.
9. Potassium chloride 20 mEq p.o. once a day (for 7 days).
DISCHARGE INSTRUCTIONS: The patient was also instructed to
have a follow-up appointment with Dr. [**Last Name (STitle) 60940**] in 1 to 2 weeks
post discharge and to make an appointment with Dr. [**Last Name (STitle) **],
his surgeon, for a postoperative visit in the office in 4
weeks.
DISCHARGE DISPOSITION: He was discharged to home with VNA
services on [**2194-6-8**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2194-7-10**] 09:15:37
T: [**2194-7-11**] 10:23:29
Job#: [**Job Number 60941**]
ICD9 Codes: 4241, 4280, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1857
} | Medical Text: Admission Date: [**2105-12-7**] Discharge Date: [**2105-12-30**]
Date of Birth: [**2042-8-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Pulmonary Embolus
Major Surgical or Invasive Procedure:
EGD
CVC insertion
Intubation
IVC filter placement
History of Present Illness:
Mr. [**Known lastname 31624**] is a 63 yo man w/hx of esophageal CA, who presents
to the MICU now with hypotension, unresponsive requiring
intubation on the medicine floors and melena. Pt was found to be
slightly confused per nursing, nightfloat was called to the room
and pt shortly thereafter became unresponsive and was found to
have a BP of 60's/palp. He maintained a pulse but was intubated
for airway protection. He was noted to have dark red blood from
his G-tube. He also had melena noted in the bed. He was then
transferred to the MICU for further care and monitoring. He
presented to medicine on [**12-7**] with complaints of SOB and was
found to have PE on CTA Pt is a 63 yo man w/hx of esophageal CA
in the 90's, s/p J-tube on [**2105-10-7**]. Pt presents with 3 days of
shaking chills w/SOB; he denies having a fever but noted that
the shaking chills would come on at various times during the
day. He has chronic abd and back pain but htis had not changed
in character. No CP, cough or syncope. He presented to his PCP
who was worried about a possible PE. A CTA was obtained which
showed segmental and subsegmental pulmonary emboli in superior
segment of right upper lobe and right middle lobe. He was
started on a heparin gtt, and LENI's from [**12-9**] showed no DVT.
Of note, he had a guaiac positive stool on initial presentation
to the ED, but no s/s bleeding on the medicine floors. He had
noted low-grade fevers to 100.1 on [**12-8**], but no fevers in
previous 24hrs.
ROS as above. Unable to obtain complete ROS given unresponsive.
On the floor, pt was intubated, with initial settings of CMV/A
Vt 600, RR 14, PEEP 5, FiO2 100%. He received one unit of blood
overnight, and the second was transfusing on transfer. There was
gross melena in the bed.
Past Medical History:
Esophageal Cancer, bowel obstruction, TEF, Left vocal cord
paralysis, Depression s/p ECT (following [**2091**] surgery), Anxiety
Past Surgical History: Esophagectomy at [**Hospital1 112**] in [**2091**] complicated
by stricture and tracheal esophageal fistula s/p dilation x2 and
Y-stent for the TEF on [**6-23**], exploratory laparotomy/LOA/biliary
diversion with G and J Tube placement [**2103-7-9**], Repair of TE
fistula w/intercostal flap [**8-19**], Roux-n-Y gastrojejunostomy
(esophageal conduit) with intra-thoracic anastomosis, small
bowel
resection, J-tube on [**10-7**]
Social History:
General Surgeon, lives w/ wife and 2 small children ages 5 and
7.
non-smoker
Family History:
non-contributory
Physical Exam:
ON Arrival to MICU from floors: On ventilator: CMV/A Vt 600, RR
14, PEEP 5, FiO2 100%
General: unresponsive, intubated, in distress
HEENT: Sclera anicteric, MMM
Neck: supple, JVP difficult to assess given use of accessory mm
of breathing
Lungs: using accessory mm to breath, intubated, breath sounds
present bilaterally anteriorly, no wheezes or crackles
appreciated in anterior lung fields
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-distended, bowel sounds present, using
abdominal mm to breath, gross melena in bed
GU: no foley
Ext: warm, 2+ DP pulses, slight mottling of lower extremities
Neuro: unresponsive, not following commands, sedated
.
On Discharge:
General Appearance: No(t) Well nourished, No acute distress,
No(t) Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic
Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t)
Conjunctiva pale, No(t) Sclera edema
Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition,
No(t) Endotracheal tube, No(t) NG tube, No(t) OG tube
Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (PMI No(t) Normal, No(t) Hyperdynamic), (S1:
Normal, No(t) Absent), (S2: Normal, No(t) Distant, No(t) Loud,
No(t) Widely split , No(t) Fixed), No(t) S3, S4, No(t) Rub,
(Murmur: Systolic, No(t) Diastolic), [**1-21**] holosyst m
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Not assessed)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness
: ), (Breath Sounds: No(t) Clear : , Crackles : rare, No(t)
Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent
: , No(t) Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender: , No(t) Obese
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing
Musculoskeletal: Muscle wasting, Unable to stand
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, No(t)
Sedated, No(t) Paralyzed, Tone: Not assessed
Pertinent Results:
ADMISSION LABS:
---------------
[**2105-12-7**] 10:45PM PTT-45.8*
[**2105-12-7**] 03:40PM GLUCOSE-111* UREA N-30* CREAT-1.1 SODIUM-136
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
[**2105-12-7**] 03:40PM estGFR-Using this
[**2105-12-7**] 03:40PM D-DIMER-1116*
[**2105-12-7**] 03:40PM WBC-6.6 RBC-3.86* HGB-10.1* HCT-30.9*
MCV-80*# MCH-26.1*# MCHC-32.5 RDW-14.6
[**2105-12-7**] 03:40PM NEUTS-78.0* LYMPHS-12.0* MONOS-8.2 EOS-1.1
BASOS-0.7
[**2105-12-7**] 03:40PM PLT COUNT-338
.
DISCHARGE LABS:
----------------
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
8.6 4.54* 12.2* 37.4* 82 27.0 32.8 16.2* 442*
Glucose UreaN Creat Na K Cl HCO3 AnGap
139*1 65* 2.0* 133 4.5 95* 26 17
.
MICROBIOLOGY:
-------------
[**2105-12-25**] 4:02 pm BLOOD CULTURE Source: Line-piv.
Blood Culture, Routine (Preliminary):
GRAM POSITIVE RODS. CONSISTENT WITH CLOSTRIDIUM OR BACILLUS
SPECIES.
.
Blood Culture, Routine (Final [**2105-12-30**]):
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
.
[**2105-12-10**]: [**Female First Name (un) 564**]
.
IMAGING:
--------
CT chest w/o [**12-7**]:
IMPRESSION:
1. Segmental and subsegmental pulmonary emboli in superior
segment of right upper lobe and right middle lobe.
2. Right lower lobe consolidation/aspiration, less likely
pulmonary infarct.
3. Stable right upper lobe peripheral tree-in-[**Male First Name (un) 239**] opacities and
calcified granulomas as compared to [**2105-8-26**].
4. Stable post-surgical changes of esophagectomy and
neoesophageal
reconstruction.
.
Emergent EGD after large-volume bleed ([**12-10**]): Sp Esophagectomy
with neoesophagus and gastrojejunostomy (Roux-n-Y) Large ulcer
with visible vessel seen at the gastrojejunostomy site. No
active bleeding. Diverticulum in the upper third of the
esophagus Otherwise normal EGD to jejunum.
.
2nd EGD done [**12-11**] (day after bleed):One endoclip was
successfully applied for the purpose of radiographic marker. It
was placed at the distal end of the ulcer bed.
.
Head CT [**12-12**]: Atypical appearing hypodense lesions, largest
involving left periatrial parieto-occipital lobe, and smaller
lesions involving bilateral centrum semiovale and possibly also
right frontal lobe and left cerebellum. These are incompletely
evaluated, but concerning for infection or embolic process in a
patient with fungemia, less likely neoplastic. Recommend further
evaluation by MRI if not contraindicated. Coiling of feeding
tube within the oronasopharynx. Recommend repositioning.
.
Echo [**12-16**]: The left atrium is mildly dilated. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast with maneuvers. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is moderately dilated with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Moderate to severe (3+)
mitral regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2105-12-12**],
the degrees of mitral and tricuspid regurgitation and of
pulmonary hypertension have all worsened. The right ventricle is
dilated and moderately hypokinetic on the current study. It was
described as normal in size on the prior echo but image quality
was suboptimal. It appears to be more hypokinetic. LV systolic
function is similar. Negative bubble study on the current exam
.
RUQ U/S [**12-18**]:Small stones with [**Doctor Last Name 5691**] and sludge seen within the
gallbladder. No signs of cholecystitis. No biliary dilatation
identified.
.
Brief Hospital Course:
Hypotension: Patient was hypotensive and unresponsive during
episode that brought him to the MICU. This was in the setting
of large-volme GI bleed, so hypotension was the most likely
source. However, the patient had also had low-grade fevers
before transfer to the MICU and had prfound enough hypotension
to require vasopressors, so was started on broad-spectrum
antibiotics for potential septic component. He was transfused
with 5 units within the first 48 hours, and recovered
hemodynamic stability within the first several hours of
resuscitation and was weaned from pressors.
.
GI bleed: Large volume GIB which required intubation for airway
protection. Patient required 5 UpRBCs in first 48 hours in ICU.
EGD showed large ulcer with large pulsatile vessel lying
underneath in the area of patient's esophageal anastomosis.
Discussion with thoracic team revealed that d/t esophagectomy
with revision, only one vessel (gastroepiploic) supplies this
portion of the anastomosis. Decision was made not to attemt
endoscopic manipulation of the pulsatile vessel d/t concern for
interruption of vascular supply to the entire anatomic
esophagus. The patient was monitored in the ensuing weeks in
the ICU, and despite a few episodes of maroon stool a week after
the initial bleed, the h/h remained stable and there was no
other evidence of repeat bleed. GI receommended an outpt EGD in
6 weeks from time of discharge. This will need to be scheduled.
.
Fungemia: While in the ICU, patient intermittently spiked
fevers. Surveillance cultures showed candidemia out of the
a-line and a peripheral. Micafungin was started initially and
then changed to ambisome at a concentration sufficient to treat
CNS infection, with a target course that will end [**12-26**] and then
change to fluconazole until [**1-9**]. All lines were resited or
d/ced after the fungemia, and patient defervesced.
.
Watershed Infarct: Patient was intubated and sedated upon
initial arrival to ICU. Upon sedation wean, patient was poorly
responsive to verbal and tactile stimuli, with residual
hemiparesis. Head CT showed hypodensities in the white matter,
with a differential of seeding of fungi vs. lacunar infarcts.
Patient could not get an MRI due to his tenuous hemodynamics and
the fact that a metal clip had been placed during EGD to mark
the bleeding vessel for potential IR embolization. Repeat head
CT showed similar findings, and given the time course and
appearance, these hypodensities were thought to represent
lacunar watershed infarcts rather than infectious seeding. The
patient initiated physical therapy, occupational therapy, and
speech therapy in the ICU. At time of discharge he was alert and
orientedx 3 and following simple commands.
.
Myocardial event: patient with EKG changes on presentation and
elevated troponin which peaked. This was attributed to demain
ischemia. Given patient's GI bleed and tenuous status, he was
not a candidate for PCI or for heparinization. Echocardiograms
demonstrated impaired function after initial event, and valvular
dysfunction that was worsening over time. ECHO on [**12-16**] showed EF
50-55% with severe MR [**First Name (Titles) **] [**Last Name (Titles) **]. Clinically, MR improved with
diuresis and pt euvolemic at time of discharge. He will require
outpt cardiology follow up.
.
Pulmonary Embolism: patient presented to hospital with
subsegmental PE, was on heparin before transfer to ICU with GIB.
Has hx of PE and bleeds after anticoag. previously in [**2103**], and
has SVC filter from that time. In MICU, heparin was held and
LENIs tracing to the iliacs did not demonstrate any lower ext.
clot, so no IVC was placed. Patient was put on pneumoboots for
first week in unit until GIB was stable, and then switched to
heparin. The patient had an IVC filter placed by vascular
surgery.
.
Atrial fibrillation: Patient intermittently in afib with RVR
while in ICU. Was initially managed with fluids and metoprolol,
but borderline pressures prevented metoprolol as the standing
treatment. As a result patient was loaded with 10g amiodarone
via drip and then placed on PO amio. Intermittently had
afib/rvr despite amio, and vagal maneuvers and/or small iv
metoprolol were sufficient to break episodes into NSR.
Cardiology was consulted, and recommended focus on afterload
reduction in addition to rate/rhythm control. The patient was
ultimately placed on metoprolol, amiodarone, isosorbide, and
hydralazine as per discharge medication list. Amiodarone should
be 400mg daily through [**1-20**] at which time decrease
amiodarone to 200mg daily. Pt should follow up with Atrius
cardiology in [**4-21**] weeks. An appt will need to be made.
.
Volume Overload: Pt determined to be fluid overloaded towards
the end of his MICU course. Likely related to initial
resucitation. He was diuresed aggressively with a lasix gtt and
then IV lasix boluses and is euvolemic at time of discharge.
Creatinine was elevated briefly in setting of aggressive
diuresis and improved to normal baseline when diuresis stopped
and pt given some volume back. We suspect he will require
diuresis in the future given a dilated and mildly hypokinetic
RV. Would suggest monitoring volume status closely and if he
does appear to be developing LE edema or gaining weight starting
lasix 20mg PO daily.
.
Bacteremia: Patient with staph aureus in [**2-19**] blood cultures
assoc w/ fever and leukocytosis. Patient started on vancomycin
on [**2105-12-25**]. Surveillance cultures have been negative. Patient
will need to be continued on vancomycin through [**2106-1-8**] for
full 2 week course. Dose was changed to vancomycin 750mg Q24 to
start on [**2105-12-31**] based on renal failure and level of 24.9 on
[**2105-12-30**]. A vancomycin level will need to be checked on [**2106-1-3**]
before the fourth dose.
.
Anxiety/Depression: Pt has known history of anxiety and
depression. Prior to admission he was taking clonazepam for
anxiety. Clonazepam was stopped in setting of his critical
illness and he was treated with diazepam for withdrawl symptoms.
Patient seen by psychiatry who suggested [**Last Name (un) **] starting
antidepressant at this time. They did suggest using low dose
quetiapine 12.5-25 mg for anxiety-this was not trialed during
his inpt stay. Psychiatry has also recommeded having patient
followed by psychiatry when he goes to rehab. He has an outpt
psychiatrist who he should follow with at time of discharge.
.
Acute Renal Failure: Patient now has new baseline Cr around
1.6-2.0, which was 2.0 on discharge. This is felt to be due to
combination of ATN while hypotensive in setting of GI bleed and
also with some component of poor forward flow from volume
overload. Creatinine stable at time of discharge.
.
Transamitis: Patient w/ elevated transaminases in setting of
hypotension, now trended down to ALT 47, AST 38.
Medications on Admission:
clonazepam 1mg 4 times per day--> pt state usually takes ~12 per
day
percocet 1-2tabs by mouth q4hr;prn
levothyroxine 50mg daily
trazadone 150mg qhs
colace
senna
Discharge Medications:
1. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Last Name (un) **]: One
(1) Appl Ophthalmic TID (3 times a day).
2. fentanyl 25 mcg/hr Patch 72 hr [**Last Name (un) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. fluconazole 200 mg Tablet [**Last Name (un) **]: Two (2) Tablet PO once a day:
Start date: [**12-28**]
End date: [**1-9**] .
4. metoprolol tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QAM
(once a day (in the morning)).
5. metoprolol tartrate 25 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO QPM (once
a day (in the evening)).
6. hydralazine 10 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO Q8H (every
8 hours).
7. amiodarone 200 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily): 400mg daily through [**2105-1-20**] then decrease to 200mg
daily.
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Seroquel 25 mg Tablet [**Last Name (STitle) **]: 0.5-1 Tablet PO once a day as
needed for agitation/anxiety/insomnia.
10. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1)
PO DAILY (Daily).
11. isosorbide dinitrate 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
13. vancomycin 750 mg Recon Soln [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y (750)
mg Intravenous once a day: check level before dose on [**1-3**],
last day is [**1-8**].
14. Synthroid 50 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Pulmonary embolism, gastrointestinal bleed secondary to
ulcer, atrial fibrillation, acute renal failure, transaminitis,
respiratory failure, [**Female First Name (un) **] fungemia, stroke, coag negative
staphylococcus bacteremia
Secondary: esophageal cancer, anxiety, depression
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were initially admitted for a pulmonary embolism (blood clot
in the lung) with a resultant gastrointestinal bleed from
anticoagulation. Your hospital course was complicated by
respiratory failure, stroke, atrial fibrillation/flutter (fast
heart rate) and blood infections.
.
Medication changes:
START fluconazole 400mg daily through [**1-9**]
START fentanyl patch 25 mcg/hr
START artificial tears
START lansoprazole
START metoprolol 25mg in the morning and 12.5mg at night
START amiodarone 400mg daily through [**2105-1-20**] and then 200mg daily
thereafter
START miralax
START seroquel for anxiety/agitation/insomnia
START vancomycin 750mg IV every 24 hours through [**2106-1-8**]
STOP clonazepam
STOP percocet
STOP trazodone
Followup Instructions:
You will need to follow up with a cardiologist at Atrius/[**Hospital1 2292**] in [**4-21**] weeks. Please call [**Telephone/Fax (1) **].
.
You will need to follow up with your primary care physician 1
weekk after you are discharged from rehab.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5845, 7907, 2851, 2762, 2760, 4240, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1858
} | Medical Text: Admission Date: [**2104-10-2**] Discharge Date: [**2104-10-6**]
Date of Birth: [**2027-5-24**] Sex: M
Service:
Briefly, this is a 77-year-old male who was very active, had
progressive exertional dyspnea, short of breath while walking
on the treadmill and on tennis court became lightheaded and
with change of position. Echo was done which showed aortic
valve gradient and concentric left ventricular hypertrophy
with mild MR. [**Name13 (STitle) **] had stress test which was positive with ST
depressions and was referred for cardiac catheterization for
coronary anatomy and aortic valve replacement.
PAST MEDICAL HISTORY: High cholesterol.
PAST SURGICAL HISTORY: Hernia repair times two.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Lipitor 5 mg p.o. q day.
2. Vitamin E q day.
He underwent a cardiac catheterization where multiple vessel
coronary artery disease was found. He was taken to the
operating room on [**2104-10-2**] for an AVR with pericardial valve
and coronary artery bypass graft times three, Left internal
mammary artery to left anterior descending, Supraventricular
tachycardia to Patent ductus arteriosus and SVG to OM was
done. The patient was taken to the CSRU postoperatively and
was weaned. Able to be extubated on that same day. Urine
output was good. The patient was comfortable. The patient's
diet was advanced and he had adequate urine output and his
chest tube remained in due to high output. He was transfused
one unit for a low hematocrit. Pain was controlled on
Percocet and he was started on Zantac.
The patient was transferred to the floor on postoperative day
1 and physical therapy was consulted for ambulation. He did
well with ambulation and physical therapy felt he was capable
of being discharged home with follow-up as an outpatient.
Chest tubes remained due to high output and were slowly
pulled one at a time. On postop day #4 the last of his chest
tubes was removed, his wires were also removed and that time
and the patient continued to improve. His primary care
physician was in and discussed with him as well as the team
his future plans.
The patient and primary care physician was instructed on the
care of the patient and follow-up issues. The patient is
discharged home in stable condition.
DISCHARGE MEDICATIONS:
1. Lipitor 5 mg p.o. q day.
2. Vicodin 1 to 2 tabs p.o. q 4 to 6 hours p.r.n.
3. Ecasa 325 mg p.o. q day.
4. Zantac 150 mg p.o. b.i.d.
5. Colace 100 mg p.o. b.i.d.
6. KCL 20 mEq p.o. b.i.d.
7. Lasix 20 mg p.o. b.i.d.
8. Lopressor 25 mg p.o. b.i.d.
The patient is discharged home in stable condition.
Instructed to follow-up with Dr. [**Last Name (STitle) 70**] in four weeks as
well as with his primary care physician in one to two weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 23403**]
MEDQUIST36
D: [**2104-10-6**] 17:32
T: [**2104-10-6**] 19:00
JOB#: [**Job Number 42682**]
ICD9 Codes: 4111, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1859
} | Medical Text: Admission Date: [**2161-11-3**] Discharge Date: [**2161-11-16**]
Service: VASCULAR SURGERY
CHIEF COMPLAINT: 5.6 cm infrarenal abdominal aortic
aneurysm.
HISTORY OF PRESENT ILLNESS: [**Known firstname 4115**] [**Known lastname 17147**] is a 77 year-old
white female with a past medical history significant for
colon carcinoma status post sigmoidectomy in [**2158-3-5**]
who presents with a 5.6 cm infrarenal abdominal aortic
aneurysm found on workup for her colon cancer. Her initial
CAT scan in [**2158**] revealed her aneurysm to be approximately 4
cm in diameter with subsequent CT scanning this year
revealing a significant enlargement to 5.6 cm. She had a
full course of chemotherapy and radiation therapy and her
last colonoscopy revealed no recurrent cancerous lesions.
Her hepatic workup was negative for any liver involvement.
She is a fairly active individual and was referred for the
repair of the abdominal aortic aneurysm. She has a history
of known coronary artery disease, which has been managed
conservatively. She has a 60% right CA and 90% mid
circumflex lesion. She does admit to shortness of breath,
but no angina and denied any history of coronary artery
disease.
She was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for evaluation of her
preoperative coronary artery disease. He decided that she
had no previous angiographic evidence of progression of her
coronary artery disease and in view of her mild stable
symptoms and it was reasonable to proceed with her aneurysm
surgery with the usual perioperative precautions without any
intervention at that time. She was noted to have a 58%
ejection fraction on cardiac catheterization. She was
evaluated for a endoluminal stent graft, however, was not a
candidate possibly due to her femoral and iliac disease.
PAST MEDICAL HISTORY: Significant for sigmoid and colon
cancer managed with surgery, chemotherapy and x-ray therapy.
Hypertension, coronary artery disease, nicotine abuse in the
past that had ceased since [**2158**], as well as hyperlipidemia.
PAST SURGICAL HISTORY: Colon resection, appendectomy, left
salpingo-oophorectomy and splenectomy.
PREOPERATIVE LABORATORIES: CAT scan with a 5.5 cm abdominal
aortic aneurysm starting just below the renal arteries and
ending at the iliac bifurcation. Her iliac arteries appeared
to be heavily calcified. Cardiac catheterization revealed
58% ejection fraction, normal left main coronary artery, mild
narrowing of approximately 50% stenosis at the ostium of the
left anterior descending coronary artery, left circumflex
artery with a 60% stenosis before the origin of the first
major marginal. The right coronary artery had an osteal
lesion at approximately 68% and a sequential 80% lesion in
the mid vessel at the site where the vessel is calcified and
tortuous. There was slight prolapse of the posterior mitral
valve leaflet without evidence of regurgitation. Chest x-ray
revealed slight ventricular enlargement without evidence of
heart failure. Electrocardiogram revealed nonspecific
lateral ST segment changes, but otherwise normal sinus
rhythm. Her white blood cell count was 10.1 with a
hemoglobin of 13.2, hematocrit 42.1, platelet count 341.
Potassium blood sugar was 85. BUN 18, creatinine 0.6,
potassium 4.6. Other electrolytes were within normal limits.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] where she underwent open repair of
her abdominal aortic aneurysm with an aortobifemoral bypass.
Details of this procedure are dictated in a separate
operative note. The patient was subsequently transferred up
to Far Nine in the Vascular Intensive Care Unit where she was
monitored for any hemodynamic changes, drop in urine output,
and cardiac events. She did well until postoperative day
number three when it was noted that she had an elevated white
blood cell count to be approximately 20.2. Her hemoglobin
and hematocrit had also dropped from 33 to 29.6 and a rectal
examination was performed due to her history of colon CA,
which was guaiac negative. She was essentially asymptomatic
and denied any history of fevers or chills, nausea, vomiting
or abdominal pain. She did have a low grade fever of
approximately 100.7. A stool was sent for C-difficile.
On postoperative day number four her white count did drop to
15.5 and she continued to do well. She was afebrile at that
time and no active issues were going on. She was evaluated
by physical therapy and got out of bed and the Swan-Ganz
catheter was discontinued. On postoperative day number four
at approximately 1:00 in the morning she went into a rapid
atrial fibrillation and dropped her blood pressure. She was
somewhat nauseated at the time and feeling lightheaded. She
responded rather well with beta blockade and with Cardizem 25
mg intravenous bolus. She then dropped her rate severely
down into the 40s and was prepared for pacing. She did
respond spontaneously though without need for pacing. She
was seen by cardiology who started her on a Cardizem drip at
5 cc per ml to be titrated slowly. They were advised not to
give any bolus of Cardizem after that. She ruled out for a
myocardial infarction as per enzyme criteria. Her blood
pressure did remain somewhat low being less then 100 and one
unit of packed red blood cells was transfused. She responded
very well to this. She did remain in atrial fibrillation for
the next several days going in and out of normal sinus
rhythm. She was started on a heparin drip with PTT being
monitored anywhere between 50 and 60. It was noted though
after three days of anticoagulation that she begin to have
epistaxis and hematuria. The heparin was subsequently
discontinued after an echocardiogram. The echocardiogram
failed to reveal any kind of mural thrombus present and it
was decided by cardiology that she could be maintained on
oral aspirin rather then chronic anticoagulation.
She continued to do well and remained in normal sinus rhythm.
She was transferred out to the floor and off monitor. She
was evaluated by physical therapy and due to the events was
thought to need rehabilitation. On postoperative day number
nine, the patient again had a fever of 100.1 and an elevated
blood cell count to 15.6. It was noted by the nurse that the
urine was quite cloudy and slightly foul smelling. A
urinalysis and urine culture were obtained, which grew out
E-Coli. This was susceptible to Bactrim and she was
subsequently started on this twice a daily. It should also
be noted she was discontinued off her cardizem drip and
advised by cardiology to remain on her Atenolol. She was
then evaluated by Dr. [**Last Name (STitle) **] who was concerned about an
intra-abdominal process due to her history of the colon
cancer as well as her new aortic graft. A repeat CBC was
obtained that morning and revealed the white blood cell count
to have risen to 20.5. A CAT scan with contrast was then
performed who ruled out an intra-abdominal abscess. This was
negative for any kind of abscess or perforation and only
revealed gallstones without evidence of gallbladder wall
thickening as well as a left flank hematoma beneath her
kidney, which was expected secondary to her aortic surgery
and the retroperitoneal incision. Her Bactrim was
discontinued and she was started on Levaquin and Flagyl to
cover for any kind of occult infection or C-diff. She
continued to do well over the weekend and her white count
dame down and she is currently afebrile.
At this time the patient is doing quite well and is feeling
much better. She has had three bowel movements over the
weekend, which she feels has resolved some of her discomfort
and she is able to ambulate without difficulty at this time.
She has been cleared by physical therapy to go home. She no
longer has any urinary symptoms and her urine has come back
clean. She has been discontinued from her antibiotics and
will go home with visiting nurse this evening.
DISCHARGE MEDICATIONS: Ambien 5 mg po q.h.s., Colace 100 mg
po q.d., Dulcolax 10 mg per rectum prn, Senokot two tabs po
q.d., Atenolol 50 mg po b.i.d., Zantac 150 mg po b.i.d.,
Norvasc 2.5 mg po q.d., Ecotrin 325 mg po q.d., potassium
chloride 40 milliequivalents po prn and she will be sent home
on Percocet one to two tabs q 4 to 6 hours prn pain.
CONDITION ON DISCHARGE: Stable and progressing well.
DISCHARGE DIAGNOSES:
1. Abdominal aortic aneurysm with need for repair.
2. Proximal atrial fibrillation currently resolved and in
sinus rhythm.
3. Elevated temperature and white blood cell count secondary
to urinary tract infection.
4. Hypertension.
5. Colon cancer.
6. Anemia with the need for blood transfusion currently
resolved.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Doctor First Name 22875**]
MEDQUIST36
D: [**2161-11-16**] 09:50
T: [**2161-11-16**] 10:17
JOB#: [**Job Number 25012**]
ICD9 Codes: 9971, 5990, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1860
} | Medical Text: Admission Date: [**2159-2-8**] Discharge Date: [**2159-2-10**]
Date of Birth: [**2075-5-3**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
Bladder tumor
Major Surgical or Invasive Procedure:
Cystoscopy, TURBT [**2159-2-8**] - Dr. [**Last Name (STitle) 9125**]
History of Present Illness:
83yoM hx htn, dm, chf, presented for anesthesia assisted,
urological transurethreal resection of presumed bladder cancer,
admitted to [**Hospital Unit Name 153**] for post-procedure monitoring given significant
[**Hospital Unit Name 1106**] disease.
Over previous 2 months, pt has had hematuria, in addition to
multiple UTIs, without resolution with abx. Dr. [**Last Name (STitle) 9125**] from
urology performed outpt cystoscopy, showing bladder tumors, c/w
bladder CA; was scheduled for transurethral bx and removal of
tumors with anesthesia assitance, given past hx of [**Last Name (STitle) 1106**] cva.
On day of admit to [**Hospital1 18**], pt underwent transurethral resection
of tumour, 45min procedure, stable hemodynamics throughout
procedure. SBP prior to procedure 180, kept on peripheral
phenylephrine throughout procedure to maintain MAPs (unclear if
BPs dropped throughout procedure). Patient was transferred to
PACU with pressor off and stable hemodynamics then transferred
to [**Hospital Unit Name 153**] in stable condition.
Past Medical History:
PMH:
CRI, baseline 2.5-3.5
NIDDM
[**11/2139**] AMI
PVD: s/p RLE bypass [**7-/2143**], [**5-/2148**] left Fem [**Doctor Last Name **] bypass, [**2-4**]
angioplasty of left Fem-AT bypass stenosis
Hyperlipidemia
Gallstones s/p [**2156-1-2**] ERCP w/ CBD [**Month/Day/Year **] placement needs
[**Month/Day/Year 100581**]
AAA (3cm stable sine [**2145**])
Elevated Alk Phos
[**9-/2147**] embolic CVA, seven CVA's since most recently in [**10-8**].
Afib/flutter s/p Ablation [**11-6**], EPS [**11-8**]
Syncope
HTN
renal arteries no stenosis by cath [**2154-5-17**]
[**5-9**] s/p TTE w/ EF to be newly depressed at 30-35% with left
ventricular hypertrophy and [**12-8**]+MR. [**Name14 (STitle) **] w/ reversible defect
PSH:
[**2142**] R Fem [**Doctor Last Name **] in situ
[**2147**] L Fem [**Doctor Last Name **] in situ
[**2150**] vein angioplasty L Fem artery
Social History:
Married for 53 years with three sons. They have assistance with
cleaning and cooking at home through elderly affairs assistance.
His son manages all their bills and mail and lives upstairs.
Wife is legally blind and is a care taker for Mr. [**Known lastname 100582**]. The
patient walks unassisted now. He is very hard of hearing. +80
ppy history, quit [**2145**]. No EtOH or illicits.
Family History:
NC
Physical Exam:
97.1, 57, 142/51, 13, 100%RA
PHYSICAL EXAM
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=flat
LUNGS: mild exp wheezes
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact.
PSYCH: Listens and responds to questions appropriately, pleasant
Brief Hospital Course:
83yoM hx htn, dm, chf, presented for anesthesia assisted,
urological transurethreal resection of presumed bladder cancer,
admitted to [**Hospital Unit Name 153**] for post-procedure monitoring given significant
[**Hospital Unit Name 1106**] disease. In [**Hospital Unit Name 153**], he was found to possibly have OSA,
monitored on continous O2 and telemetry, no events. He was
transferred out of ICU POD1. Urine clear off CBI POD2 and foley
removed. He passed voiding trial and discharged home in stable
condition. He will follow-up with Dr. [**Last Name (STitle) **] of sleep clinic
for OSA work-up, per ICU team and respiratory.
Medications on Admission:
Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Discharge Medications:
1. Pyridium 100 mg Tablet Sig: One (1) Tablet PO twice a day for
3 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bladder tumor
Discharge Condition:
Stable
Discharge Instructions:
--Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
--The operation you have experienced is a "scraping" operation;
that is to say, the bladder tumor or biopsy sample was "scraped"
off the bladder wall. Bleeding was controlled with
electrocautery which will produce a "scab" in the inside bladder
wall. About 1-2 weeks after the operation, pieces of the scab
will fall off and come out with the urine. As this occurs,
bleeding may be noted which is normal. You should not worry
about this. Simply lie down and increase your fluid intake for a
few hours. In most cases, the urine will clear. Because of this
tendency for bleeding, aspirin (or Advil) must be avoided for 2
weeks following your operation (Tylenol is okay). If bleeding
occurs or persists for more than 12 hours or if clots appear
impairing your stream, call your urologist.
If you develop a fever over 101??????, or have chills, call your
urologist. Although not common, this may indicate infection that
has developed beyond the control of the antibiotics that you
have taken.
It will take 6 weeks from the date of surgery to fully recover
from your operation. This can be divided into two parts -- the
first 2 weeks and the last 4 weeks. During the first 2 weeks
from the date of your surgery, it is important to be "a person
of leisure". You should avoid lifting and straining, which also
means that you should avoid constipation. This can be done by
any of 3 ways: 1) modify your diet, 2) use stool softeners which
have been prescribed for you, and 3) use gentle laxatives such
as Milk of Magnesia which can be purchased at your local drug
store. It is important for you to avoid prolonged sitting. You
should avoid sexual activity during this time. Also, avoid
driving. The danger is not so much the driving, but it may delay
you from urinating if you have the urge; and, "holding" urine
may cause bleeding. If you return to work before 2 weeks, you
may feel fatigued and require a decreased work load.
During the second 4 week period of your recovery, you may begin
regular activity, but only on a graduated basis. For example,
you may feel well enough to return to work, but you may find it
easier to begin on a half-day basis. It is common to become
quite tired in the afternoon, and if such occurs, it is best to
take a nap! Also, you may begin to drive as well as lift objects
such as a briefcase, etc. If you are a golfer, you may begin to
swing a golf club at this time. Sexual activity may be resumed
during this time, but only on a limited basis. In general, your
overall activity may be escalated to normal as you progress
through this second time period, such that by 6-8 weeks
following the date of surgery, you should be back to normal
activity. If you take aspirin as a regular medication, it may be
resumed at this time.
Finally, call your urologist in one week after your surgery for
the results of your biopsy and your next appointment
Followup Instructions:
Please call Dr. [**Last Name (STitle) 9125**] for a f/u appointment.
Call [**Telephone/Fax (1) 55570**] Sleep Medicine for work-up of sleep apnea, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
ICD9 Codes: 4280, 412, 4439, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1861
} | Medical Text: Admission Date: [**2133-11-20**] Discharge Date: [**2133-12-29**]
Date of Birth: [**2063-12-22**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old
female with an extensive history of coronary artery disease,
status post coronary artery bypass graft in [**2130**]. [**Doctor First Name 4796**] to
left anterior descending, saphenous vein graft to obtuse
marginal one, saphenous vein graft to obtuse marginal two,
saphenous vein graft to posterior descending artery.
Multiple percutaneous coronary interventions. Status post
NST EMI on [**8-30**], requiring CCU admission after stents to
obtuse marginal two, LMCA, left circumflex and rescue jailed
left anterior descending. Hospital course was complicated by
gallstone pancreatitis, status post recent admission on [**11-9**]
for recurrent substernal chest pain. Repeat catheterization
on [**11-9**] revealed saphenous vein graft to obtuse marginal
stent; relook catheterization on [**2133-11-12**] with no
intervention.
She presented today to [**Hospital3 417**] Hospital with
substernal chest pain. Reports feeling in her usual state of
health after discharge from [**Hospital1 188**] on [**11-13**]. Also, history of chest tightening,
intermittent throughout the day, occurring at rest. This
a.m., she was lying in bed at around 7:30 a.m. when she had
the onset of eight out of ten chest pain, substernal anginal
equivalent while at rest. She took sublingual nitroglycerin
which decreased pain to four to five out of ten and then
changed to jaw pain. Jaw pain resolved after 5 to 10
minutes. This recurred at 11 a.m., again with mild decrease
in pain with subinguinal nitroglycerin times two. She was
not admitted with any nausea, vomiting, diaphoresis,
shortness of breath, palpitations, dizziness, weakness or
syncope. When pain recurred, she called Dr. [**Last Name (STitle) **], her
cardiologist, who advised her to come to the Emergency
Department. She went to [**Hospital3 417**] via EMS. She
received aspirin 325 mg en route.
On arrival to [**Hospital3 417**], she had a heart rate of 58;
blood pressure of 92/47. There, she became chest pain free
after sublingual nitroglycerin, Morphine sulfate 2 mg, 50 cc
bolus and started nitroglycerin drip. Transferred to [**Hospital1 1444**] for emergent cardiac
catheterization. Of note, electrocardiogram at [**Hospital3 418**] with primary AV block; one to two mm ST elevations
inferiorly with no change from [**2133-9-6**] electrocardiogram.
Borderline AV block noted on electrocardiograms from [**11-9**] to
[**11-13**], all three admissions. Of note, the patient was also
restarted on Atenolol during the last admission.
The patient went for cardiac catheterization. Hemodynamics
of cardiac output were 4.88; cardiac index of 2.49; pulmonary
capillary wedge 22; right atrial pressure of 20; aortic
pressure of 80 over 31. Pulmonary artery 46 over 22. Mean
of 31. Right ventricle 46/12; end diastolic of 22.
Angiography showed right dominant system with stent; left
LMCA normal; Left anterior descending with 70% ostial
stenosis; mid occluded; known to fill via patent left
internal mammary artery. Left circumflex without instant
narrowing; normal except for occluded grafted obtuse
marginal, unchanged. Right coronary artery: Known occluded.
Distal vessel fills via saphenous vein graft. Unchanged
severe distal disease. Saphenous vein graft to RPDA normal;
left internal mammary artery to left anterior descending not
injected; known normal [**11-14**]. Saphenous vein graft to obtuse
marginal one normal. Minimal instant disease. Severe
disease in obtuse marginal, distal to graft.
In light of the patient's decreased pressure and elevated
right heart pressures with preserved cardiac output,
cardiology was concerned for sepsis. The patient was
transferred to Medical Intensive Care Unit with PA catheter
in place for monitoring. She was started on Levaquin with in
catheterization laboratory to increase blood pressure. On
arrival, the patient denies fevers, myalgia, chest pain,
shortness of breath, palpitations, history of cough, sputum
or hemoptysis. No nausea, vomiting, diarrhea, chills, but
several formed bowel movements times four on [**2133-11-18**]. No
sick contacts, no headaches, no visual changes, no neck
stiffness. No dysuria. Increased frequency. No abdominal
pain or tenderness. No skin rashes or lesions. Positive
chills yesterday.
PAST MEDICAL HISTORY: 1.) Coronary artery disease status
post coronary artery bypass graft in [**2130**]; with saphenous
vein graft to obtuse marginal one; saphenous vein graft to
obtuse marginal two; saphenous vein graft to posterior
descending artery; left internal mammary artery to left
anterior descending. Status post myocardial infarction in
[**8-30**]. NSTMI. Status post multiple pulmonary cardiac
interventions. [**6-29**] stent to saphenous vein graft and left
circumflex; [**10-29**] left circumflex LMCA; [**1-30**] percutaneous
transluminal coronary angioplasty of the left circumflex.
Status post repeat catheterization on [**11-9**] with saphenous
vein graft to obtuse marginal stent. Status post relocation
of catheterization on [**11-12**] with no interventions. Stents in
LM; obtuse marginal two patent. Left anterior descending
with proximal 60% stenosis and totally occluded. Left
circumflex was widely patent. Totally occluded obtuse
marginal one. Right coronary artery totally occluded.
Saphenous vein graft to obtuse marginal one patent.
Saphenous vein graft to posterior descending artery patent.
Left internal mammary artery to left anterior descending
patent.
2.) End stage renal disease on peritoneal dialysis. 3.)
Diabetes mellitus, type II on insulin. 4.) Hypertension.
5.) Hyperlipidemia. 6.) Hypothyroidism. 7.) Paroxysmal
atrial fibrillation. 8.) Peripheral vascular disease. 9.)
Anemia. 10.) History of gallstone pancreatitis.
ALLERGIES: Prevacid, gets nauseous.
SOCIAL HISTORY: Married, retired; lives with husband in own
housing. Grown kids live in area. Remote tobacco history.
No intravenous drug abuse. No alcohol.
FAMILY HISTORY: Brother died of myocardial infarction at the
age of 44.
MEDICATIONS ON DISCHARGE: On [**2133-11-13**], the patient was on
the following medications:
Prilosec 30 mg q. day.
Levoxyl 130 mg q. day.
Lipitor 40 mg q h.s.
Amiodarone 200 mg q. day.
Vitamin E 400 units q. day.
Plavix 75 mg q. day.
Savalimir 800 mg three times a day.
Iron 325 mg four times a day.
Epogen [**2130**] units subcutaneous five times a week.
Colace 100 mg twice a day.
Nitroglycerin sublingual prn.
Glipizide 10 mg q. day.
Folic acid/vitamin B capsules/Vitamin C capsules.
Neurontin 100 mg h.s.
Lente 60 units.
Novolin L 54 units subcutaneous.
Imdur 60 units q. a.m.
Aspirin 81 mg q. day.
Coumadin 5 mg q. day.
Docsercalciferol 2.5 mcg three times per week.
PHYSICAL EXAMINATION: Temperature 95.5; heart rate of 52;
blood pressure 111/50; respirations 18; oxygen saturation 90%
on room air. Swan catheter readings: PA of 63 over 42;
pulmonary artery pressure mean of 50. General: Well
developed, obese female, pleasant, supine, eating crackers in
no acute distress. HEAD, EYES, EARS, NOSE AND THROAT:
Normal cephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
intact. Mucous membranes moist. Neck: Thick, supple.
Normal left anterior descending. 1+ carotids. No bruits.
Lungs: Clear to auscultation anteriorly. Cardiovascular:
Heart sounds distant; S1 and S2; no S3 or S4; 2/6 systolic
ejection murmur at the left sternal border. Abdomen: Soft,
obese, distended, nontender. Positive bowel sounds.
Peritoneal dialysis catheter site in the left lower quadrant,
no erythema, no tenderness, no induration. Extremities: No
cyanosis, clubbing or edema. Positive onychomycosis of
toenails. Skin: No rashes, no lesions. Groin: Arterial
sheath in place, no ooze.
LABORATORY DATA: Laboratory studies from [**Hospital3 417**]
Hospital revealed the following: White blood cell count of
7.6; hematocrit of 34.8; platelets 293. Sodium of 131;
potassium of 3.9; chloride of 91; bicarbonate of 29; BUN 27;
creatinine of 6.4; glucose 182. CK 19; CK MB less than 0.1;
troponin level of 0.06. PT of 15.1; PTT of 24; INR of 1.6.
Electrocardiogram: Sinus rhythm 53 with primary AV block.
ST elevations in 2, 3 and AVF, less than 1 mm.
HOSPITAL COURSE: Cardiovascular: On [**11-20**], the patient was
admitted to the cardiac catheterization laboratory for
possible intervention. On catheterization, the following
results were noted: LMCA normal; Left anterior descending
70% ostial mid occlusion; known to fill via patent left
internal mammary artery; left circumflex, no instant
narrowing; normal except for occluded graft at obtuse
marginal. Right coronary artery, known occluded. Distal
vessel fills via saphenous vein graft. Unchanged severe
distal disease. Saphenous vein graft to RPDA, normal. Left
internal mammary artery to left anterior descending, not
injected; known normal [**11-14**]. Hypotension and elevated right
heart pressures with preserved cardiac output brought about
BIDF, possible sepsis.
With this in mind, the patient was transferred to the
Intensive Care Unit with PA catheter in place.
Catheterization showed that her grafts were unchanged. Flat
CK's and minimal changes on electrocardiogram did not support
the hypothesis of a myocardial infarction to explain the
patient's hypotension during the patient's procedure.
Hospital course was long protracted course of chest pain,
unrelieved by sublingual nitroglycerin. It was the
consensus of the team at that time, caring for the patient,
that a MIBI should be done to further evaluate any ischemic
areas occurring secondary to possible coronary graft
occlusions. P-MIBI was done and showed no perfusion defects.
The team, at that time, then decided to take the patient to
the catheterization laboratory again to check obtuse marginal
two vessel and decide upon further intervention. Second
catheterization was done and was complicated by nausea and
hypotension, necessitating pressors and IAPB for blood
pressure support. The patient became unresponsive requiring
intubation with mechanical ventilation for airway protection.
Despite high dose pressors, the patient remained hypotensive.
CT of the abdomen was done which showed a large,
retroperitoneal hematoma with active extravasation of
contrast during the study. Etiology for this hematoma was
probably injury to a side branch of the common femoral
external iliac arteries or a punctate laceration of the
artery that tracked up to the right flank in the
retroperitoneum. Vascular surgery was consulted and the
patient was transferred to the CCU for further stabilization.
Once the patient's hypotensive and retroperitoneal bleed was
stabilized, the patient was medically managed and stabilized
on aspirin, Atenolol q. day and Atorvastatin 10 mg q. day
with reinstitution of Coumadin two to three days prior to
discharge for management of her coronary artery disease.
Pump: When the patient was transferred to the Neonatal
Intensive Care Unit, after the first cardiac catheterization,
there was a question as to whether the patient had a septic
shock or cardiogenic shock picture. The patient was then
infused with many liters of normal saline for blood pressure
support. Septic work-up was unrevealing. Thus, the
prevailing theory was that the patient had a possible
cardiogenic shock. However, subsequent thought was that the
patient's hypotensive episode was more or less caused by
medications versus chronic low blood pressure. The patient
was placed on Levophed and then subsequently weaned off
successfully after several days.
Hemodialysis was instituted which helped the patient over the
course of the hospital stay with the patient's volume issues
as she was grossly volume over loaded. Hemodialysis was done
almost every day for over a course of two weeks to remove the
excess fluid and help the patient's cardiac function. The
patient had an echo done which showed an ejection fraction of
50 to 55%.
Rhythm: Amiodarone was continued throughout the course. The
patient was noted to be persistently in atrial fibrillation
throughout most of the hospital course and up until
discharge. As her blood pressure improved and became more
stable, the twice a day betablocker was instituted for rate
control. This was with once a day dosing of Atenolol 100 mg
q. day. Coumadin was restarted a couple of days prior to
discharge, achieving a therapeutic INR between 2 to 3.0.
Pulmonary: The patient was intubated on [**2133-12-8**] on the
table immediately after cardiac catheterization as she became
hypotensive and unresponsive. She remained intubated for 11
days and was successfully extubated on [**2133-12-19**]. The patient
continued to be tachypneic throughout her stay, up to
respiratory rates of 30's with saturation 95 to 100% on two
liters nasal cannula. In light of the patient's hypotensive
episode, and her end stage renal disease, the patient was
infused with liters upon liters of normal saline to maintain
blood pressure support. In that process, the patient became
very volume over loaded with much of her fluid third spacing
and going into her lungs. As hemodialysis continued
throughout her hospital course, her volume status decreased
with improvement in oxygenation and facilitation of weaning
her off of the vent. Hemodialysis was continued post
extubation with notable improvement in her oxygen
saturations.
While on mechanical ventilation, the patient developed
Klebsiella pneumonia which was treated for 14 day course of
Zosyn. The patient was successfully treated. White blood
cell count decreased back to normal and the patient became
afebrile.
Renal: The patient has known end stage renal disease
secondary to diabetic nephropathy. The patient was initially
instituted on dialysis with peritoneal dialysis catheter;
however, she was switched to a hemodialysis catheter
secondary to peritoneal dialysis catheter clotting. The
patient was placed on the hemodialysis schedule and slowly
brought to a dry weight of 90 kilograms. The patient's
respiratory status improved with better volume control. The
patient was placed on Sivelamir for her increased phosphorus.
The patient is to follow-up after rehabilitation for
transplant for a peritoneal dialysis catheter placement.
Endocrine: The patient's Synthroid dose was changed to 150
mcg per day. The patient was taken off of oral hypoglycemics
and placed on Reglan sliding scale in fixed doses from home.
However, the blood pressure control was suboptimal and
continued to be labile in the setting of stress, and
infection. When transferred to the unit, the patient was
placed on an insulin drip for optimal blood sugar control.
Subsequently, she was changed back to regular insulin sliding
scale and was transferred to the floor. Blood sugar was still
elevated. Regular insulin sliding scale was started and
adjusted; starting the patient on NPH of 24 units q. a.m. and
9 units q. p.m. for better blood pressure control.
Infectious disease: Urine culture showed Klebsiella. She
was treated initially with Levaquin and then changed to
Tetracycline for seven days; however, infectious disease was
consulted and their impression was that the patient had
asymptomatic bacteruria and urine colonization. Their
recommendation was not to treat at that point in time.
Initial thought for hypotension was sepsis but work-up was
completely negative. No growth in blood cultures. The
patient was subsequently found to have a Klebsiella pneumonia
which was treated with a 14 day course of Zosyn. The patient
became afebrile and white blood counts came back to normal
after days of initial treatment. She remained afebrile
throughout the remainder of her hospital course.
Hematology: The patient was admitted to the cardiac
Intensive Care Unit secondary to a large retroperitoneal
bleed. The patient's coagulation studies, hematocrit and
platelets were monitored q. 2 hours initially for the first
day. Goal hematocrit parameters were hematocrit of above 30;
INR of less than or equal to 1.5; platelet above 80,000. The
patient received a total of 20 packed red blood cells, 20
platelets, 10 FFP, one cryoprecipitate. Vascular was
consulted and had repair of the right common femoral artery.
Base parameters remained stable. The patient is to follow-up
with vascular after rehabilitation for staple removal.
Neurology: The patient's mental status waxed and waned. WE
had an EEG done that was consistent with toxo metabolic
state, likely due to the patient's Klebsiella infection at
that time and uremia. As pneumonia resolved and hemodialysis
was reinstituted, the patient's mental status improved. Post
extubation, the patient's mental status continued to
progress. The patient went from speaking one word to forming
complete sentences. However, the patient's ability to speak
in sentences takes effort and needs to be elicited. The
patient was oriented times one, often times to times three.
As time progressed, the patient's orientation was more
consistent and stable at two to three. The patient was
oriented to person, place and problem.
Cerebral angiography was deferred due to high risk procedure
and Transesophageal echocardiogram was not done because of a
low probability of endocarditis causing her mental status
changes. MRI/MRA of the brain was done and there was the
impression that there was no evidence of acute cerebral
infarct on images. MRA demonstrated normal flow signal. The
artery was anterior and posterior circulation. Hence, no
significant abnormalities were detected on the MRA of the
head.
Ultimately, her mental status changes were attributed to the
infection and uremia.
Gastrointestinal: The patient was unable to take p.o. since
extubation. She had been fed via nasogastric tube and then
switched to Dobbhoff, secondary to the patient pulling
nasogastric tube. It was thought that Dobbhoff tube would be
more comfortable and would cause less trauma as well. Speech
and swallow came by to evaluate the patient on three
occasions. The patient failed the first two and the third
evaluation was a video swallow that was aborted due to the
patient's fatigue after hemodialysis. Percutaneous
endoscopic gastrostomy tube was recommended for long term if
the patient failed another trial.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation.
DISCHARGE DIAGNOSES:
Systolic end diastolic congestive heart failure.
Coronary artery disease.
Percutaneous coronary intervention.
Diabetes, type II.
Atrial fibrillation.
Chronic ischemic heart disease.
Post procedure hemorrhage.
DISCHARGE MEDICATIONS:
Epoetin alpha 10,000 units per ml one injection two times per
week, Monday and Friday.
Lansoprazole 30 mg capsule, one capsule q. day.
Levothyroxine 350 mg tablets, one tablet p.o. q. day.
Aspirin 325 mg p.o. one tablet p.o. q. day.
Amiodarone 200 mg tablets one q. day.
Wolfram 5 mg tablet one tablet p.o. q h.s.
Atenolol 100 mg tablet one tablet p.o. q. day.
Atorvastatin 10 mg tablet one tablet p.o. q. day.
Sulviramir 800 mg tablet, two tablets p.o. three times a day
with meals.
Th patient is to restart her home insulin regimen.
FOLLOW-UP PLANS: The patient is to follow-up with Dr.
[**Last Name (STitle) 1391**] of vascular surgery in one week. He will remove the
staples during this visit.
The patient is to continue with hemodialysis schedule.
The patient is to follow-up with transplant surgery,
considering peritoneal dialysis catheter.
The patient is to follow-up with primary care physician
within one to two weeks, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient is to
call and schedule an appointment at [**Telephone/Fax (1) 3183**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**First Name3 (LF) 2551**]
MEDQUIST36
D: [**2133-12-29**] 02:18
T: [**2133-12-29**] 05:24
JOB#: [**Job Number 33485**]
ICD9 Codes: 4111, 5990, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1862
} | Medical Text: Admission Date: [**2122-7-24**] Discharge Date: [**2122-9-1**]
Date of Birth: [**2122-7-24**] Sex: M
Service: Neonatology
Baby [**Name (NI) **] [**Known lastname 43514**] [**Known lastname 5749**] was born at 31-1/7 weeks gestation to a
30-year-old gravida 3, para 1 now 1 woman. Her prenatal
rubella immune, RPR nonreactive, hepatitis surface antigen
increasing maternal white blood cell count concerns for
chorioamnionitis prompted a repeat cesarean section (Mother
had a previous classical incision).
Previous obstetrical history is remarkable for an infant born
This pregnancy was complicated by preterm labor beginning on
[**2122-6-28**] at which time the mother was diagnosed with
sulfate. She was sent home on bed rest.
Infant emerged with good tone. Apgars were seven at one
minute and eight at five minutes.
Birth weight was 1,610 grams, 75th percentile, birth length
was 42.5 cm, 50th-70th percentile for gestational age, and
head circumference 28 cm in the 50th percentile for
gestational age.
Admission physical examination reveals a premature active,
nondysmorphic infant. Anterior fontanelle is soft and flat.
Intact palate. Mild nasal flaring, no retractions, good
breath sounds bilaterally. Regular, rate, and rhythm of
heart. No murmur. Pink and well perfused. Abdomen is soft,
nondistended, no organomegaly. Three vessel umbilical cord,
patent anus, normal male genitalia, testes descended
bilaterally, and alert and active preterm infant.
HOSPITAL COURSE BY SYSTEMS:
Respiratory status: Infant never required any supplemental
oxygen during the NICU stay. He was treated with caffeine
for apnea of prematurity from day of life three to day of
life 15. His last episode of bradycardia occurred on
[**2122-8-27**].
Cardiovascular status: The infant has remained normotensive
throughout his NICU stay. He has had an intermittent grade
1/6 systolic ejection murmur consistent with a flow murmur.
Fluids, electrolytes, and nutrition status: Enteral feeds
were begun on day of life #1 and advanced to full volume feeds
by day of life #7. He was then advanced to a maximum
calorie-enhanced formula of 28 calories per ounce At the
time of discharge, he is eating 24 calories/ounce of Enfamil
on an ad lib schedule. At discharge, his weight is 2,825
grams, his length is 45.5 cm, and his head circumference is
34 cm.
Gastrointestinal status: He was treated with phototherapy
for hyperbilirubinemia of prematurity on day of life #1 until
day of life #4. His peak bilirubin occurred on day of life
#3 and was total 8.8, direct 0.3. Small umbilical hernia noted
prior to discharge.
Hematology status: Infant has received no blood product
transfusions during his NICU stay. His last hematocrit on
[**2122-8-14**] was 34.2. His reticulocyte count on [**2122-8-12**] was
4.0%.
Infectious disease status: The infant was started on
ampicillin and gentamicin at the time of admission for sepsis
risk factors. Antibiotics were discontinued after 48 hours
when the blood cultures were negative and the infant was
clinically well.
Day of life #22, the infant developed a firm nodule on his
neck. An ultrasound showed a well-defined solid
submandibular mass 1-1.5 cm in measurement, question of being
a gland versus a node. There was no laboratory evidence of
infection. No antibiotics were started, the mass
was no longer palpable by day of life #25 and the infant remained
clinically well.
Neurological status: Head ultrasounds on [**7-31**] and [**2122-8-25**]
were within normal limits.
Audiology: Hearing screen was performed with automated
auditory brain stem responses and the infant passed in both
ears.
Ophthalmology: Eyes were examined most recently on [**2122-8-12**]
revealing mature retinal vessels bilaterally. A follow-up
exam is recommended in six to eight months.
Psychosocial: The parents have been very involved in the
infant's care during this NICU stay. The infant last name
after discharge will be [**Doctor Last Name 4318**]. His first name is [**Name (NI) 43515**].
Infant is being discharged in good condition. He is being
discharged home with his parents.
Primary pediatric care will be provided by Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **] at
[**Hospital **] Hospital in [**Hospital1 6687**], telephone number [**Telephone/Fax (1) 38070**].
Interim care for the next 2 weeks while the family stays in [**Location (un) 34973**] will be provided by Dr [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 43516**], telephone number
[**Telephone/Fax (1) 43517**].
Car seat position screen test was done on the
day of discharge and the patient passed.
State newborn screen was last done on [**2122-8-10**].
The infant has received the following immunizations:
1. Hepatitis B vaccine on [**2122-8-19**].
2. Synagis on [**2122-9-1**].
RECOMMENDED IMMUNIZATIONS:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the three criteria:
(a) Born less than 32 weeks.
(b) Born between 32 and 35 weeks with plans for day care
during the RSV season, with a smoker in the household, or
with preschool siblings, or
(c) 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, family and
other care-givers should be considered for immunization
against influenza to protect the infant.
The family has a pediatrician appointment with Dr [**Last Name (STitle) 43518**] for
Thursday, [**2122-9-3**].
DISCHARGE DIAGNOSES:
1. Status post prematurity at 31-1/7 weeks.
2. Sepsis ruled out.
3. Status post hyperbilirubinemia of prematurity.
4. Status post apnea of prematurity.
5. Resolved submandibular mass: Gland versus lymph node.
6. Anemia of prematurity.
7. Umbilical hernia.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 36532**]
Dictated By:[**Last Name (NamePattern1) 43006**]
MEDQUIST36
D: [**2122-9-1**] 03:19
T: [**2122-9-1**] 04:02
JOB#: [**Job Number 43519**]
ICD9 Codes: V290, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1863
} | Medical Text: Admission Date: [**2200-5-14**] Discharge Date: [**2200-5-19**]
Date of Birth: [**2154-5-21**] Sex: F
Service: [**Hospital Ward Name **] ICU
HISTORY OF PRESENT ILLNESS: The patient is a 45 year-old
female with a past medical history significant for metastatic
melanoma to the lung, liver, pancreas and bone who presents
from [**Hospital **] Rehab with dyspnea. She had a pleural tap one
and a half weeks prior to this admission at [**Hospital3 2576**]
[**Hospital3 **] when 650 cc of fluid was removed. On admission here
the patient denies fever. However, she did admit to
increased dyspnea over the past week. She had also been
complaining of severe baseline constipation for which she
uses Fleet enemas every other day. Her last bowel movement
was two days ago. She stated that her abdomen yesterday was
not as distended as usual. She admits to fevers, shaking
chills, which started at 4:00 p.m. on the day of admission.
She felt that the right side of her chest was tender to
palpation and that it was difficult to take in a deep breath.
The patient arrived to [**Hospital1 69**]
Emergency Room on the morning of admission when she had a
chest x-ray showing a large right sided pleural effusion.
Her initial vital signs in the Emergency Room were
temperature 99, blood pressure 104/30, heart rate 125,
respiratory rate 21, oxygen saturation 95% on 6 liters nasal
cannula. A pleurocentesis was performed in the Emergency
Room, yielding 1000 cc of bloody fluid, with a post procedure
chest x-ray showing decreased size in the effusion and no
pneumothorax. The patient was then transferred to the floor
on the Oncology Service for further monitoring. At about
3:30 p.m. on the day of admission the Intensive Care Unit
team was called to see the patient secondary to decreased
oxygen saturations. (On arrival to the floor the patient was
sating 96% on 6 liters after which she proceeded to have
undetectable oxygen saturations). Her blood pressure was
undetectable, whereas on arrival to the floor her blood
pressure is 110/62. She had increased work of breathing with
shallow breaths. The patient was mentating sufficiently to
answer questions. Anesthesia was called and the patient was
electively intubated for airway protection. An arterial
blood gas performed prior to intubation with dagging was pH
7.22, PCO2 54, oxygen saturation PAO2 465. A neo-synephrine
drip was started with an increase in her blood pressure to
systolic in the 70s. An echocardiogram done at the bedside
prior to transfer to the unit showed right ventricular
dilatation with mild to moderate right ventricular free wall
hypokinesis. The patient was subsequently transferred to the
[**Hospital Ward Name 332**] Intensive Care Unit for further monitoring.
On transfer to the Intensive Care Unit the patient had been
intubated and on a neo-synephrine drip with intravenous
normal saline running wide open through a femoral line and a
PICC line. The patient remained hypotensive despite
titrating up the neo-synephrine to 2.45 micrograms per
kilogram per minute. An arterial blood gas done after
intubation on assist control with tidal volume 400,
respiratory rate of 20, FIO2 of 100% was pH 7.38, PCO2 33,
PAO2 410. A hematocrit done on the arterial blood gas was
18, with a repeat CBC showing a hematocrit of 14 with an INR
of 1.3. Her anemia was thought to be secondary to her
hemothorax given the increased effusion on her chest x-ray
and recent intervention. Cardiothoracic surgery was
consulted and a right sided chest tube was placed, which
drain 2 liters of dark bloody fluid. The patient persisted
to be hypotensive. During the initial part of her Intensive
Care Unit stay she received a total of 10 units of packed red
blood cells, 11 liters of intravenous normal saline.
On her laboratory examinations she was noted to be slightly
more coagulopathic with her INR rising from 1.3 to 1.9, PTT
increasing from 27 to 35 and fibrinogen of 93 with a D-dimer
greater than [**2196**]. The patient was felt to be in DIC
secondary to a consumptive coagulopathy secondary to
the large collection of blood in her pleural space as well as a
dilutional coagulopathy secondary to intravenous fluid
resuscitation with large amounts of intravenous normal
saline. The patient subsequently received four bags of fresh
frozen platelets and two bags of platelets. A repeat
arterial blood gas after resuscitation with fluid and blood
products was pH 6.96, PCO2 68, PO2 124. She was thought to
have a respiratory acidosis and a dilutional anion gap
metabolic acidosis secondary to large amounts of intravenous
normal saline.
Her ventilator settings were changed to increase her
respiratory rate to 34 to allow increased ventilation after
which her arterial blood gas improved to a pH of 7.1, PCO2 of
37, PO2 of 194. The patient was given two amps of sodium
bicarb after which her pH increased to 7.27 and then 7.33.
After receiving 10 units of packed red blood cells, her
hematocrit increased to 36. Her blood pressure then improved
to systolics between 120 and 140. Her peak inspiratory
pressures increased to 50 with a plateau pressure of 40 and
auto PEEP of 12. A bronchoscopy was performed on the day of
transfer to the MICU showing some degree of airway edema,
erythematous and hemorrhagic mucosa. Her systolic blood
pressure subsequently increased to 200. Her sedation was
subsequently increased along with her paralytics with a
slight decrease in her blood pressure and peak inspiratory
pressures. Lasix 20 mg intravenous was given after which the
patient diuresed 1 liter and her peak inspiratory pressures
decreased to 35 to 40 and her systolic blood pressure
decreased to high 90s.
PAST MEDICAL HISTORY:
1. Melanoma diagnosed in [**2188**]. Her melanoma was initially
located on her left scapula. In [**2199-12-1**] she had
hemoptysis. In [**2200-3-1**] a PET scan showed metastasis to
the lung, sternum, left humerus, three lumbar vertebra, left
proximal femur, liver and nodal metastasis. A chest CT
performed in [**2200-3-1**] showed a region in the right hilum
with associated adenopathy. On [**2200-3-19**] bronchoscopy
with biopsy revealed malignant melanoma. On [**2200-3-20**]
the patient was started on palliative radiation therapy to
her spine.
2. L3 compression fracture.
3. Allergic rhinitis.
4. Asthma.
5. Malignant hypercalcemia treated with Pamidronate.
MEDICATIONS ON ADMISSION:
1. Heparin 5000 units subq b.i.d.
2. Albuterol and Atrovent meter dose inhalers q.i.d.
3. Flovent 110 micrograms two puffs q.d.
4. Serevent 25 micrograms two puffs b.i.d.
5. Fentanyl patch 125 micrograms q 72 hours.
6. Lactulose 30 cc po q.i.d.
7. Prevacid 15 mg po q.d.
8. Levofloxacin 500 mg po q.d.
9. Reglan 10 mg intravenous q.i.d.
10. Vioxx 25 mg po q.d.
11. Morphine PCA.
12. Scopolamine patch.
13. Ambien prn.
14. Dilaudid 1 to 4 mg intravenous q 3 to 4 hours prn.
15. Oxycodone 5 to 20 mg po q 3 hours.
16. Ibuprofen 600 mg q 8 hours prn.
ALLERGIES: Sulfa and Penicillin cause a rash.
FAMILY HISTORY: Father had prostate cancer. Uncle had a
thoracic malignancy.
SOCIAL HISTORY: The patient is married and has two twin
children. One son is autistic. She is a dietitian in
[**Hospital1 1474**]. She denies tobacco use.
PHYSICAL EXAMINATION ON TRANSFER TO THE INTENSIVE CARE UNIT:
Temperature 98. Blood pressure 111/85. Heart rate 110.
Respiratory rate 24. Oxygen saturation 100% on AC with tidal
volume of 400, respiratory rate of 20, PEEP of 5, FIO2 of
100%. General, the patient was intubated and awake
responding to questions with nodding and shaking her head.
Head and neck examination pupils are equal, round and
reactive to light. Sclera anicteric. Oropharynx is clear.
Cardiac examination normal S1 and S2. Tachycardic. No
murmurs, rubs or gallops. Lungs decreased breath sounds
throughout the right lung anteriorly, left lung was clear to
auscultation. Abdomen slightly tense and distended with mild
left lower quadrant tenderness. There were decreased breath
sounds throughout. Extremities 2+ edema bilaterally to the
knees. Neurological examination full range of motion in all
four extremities.
LABORATORY EXAMINATIONS ON ADMISSION: White blood cell count
4, hematocrit 29.4, platelets 82, sodium 127, potassium 4.1,
chloride 94, bicarbonate 23, BUN 12, creatinine 0.4, glucose
110. PT 14.1, PTT 27.1, INR 1.3, calcium 7.4, magnesium 1.5,
phosphorus 1.8, erythrocyte sedimentation rate 61, ALT 95,
AST 160, LD 1220, alkaline phosphatase 556, amylase 16,
lipase 16, pleural fluid with 325 white blood cells, 737,500
red blood cells, 65% polys, 3% bands, 21% lymphocytes, 4.1
protein, glucose 52 and LD 805. Gram stain of pleural fluid
without any polys or microorganisms. Fluid culture pending.
Arterial blood gas on the above ventilator settings were pH
7.22, PCO2 54, O2 465.
IMAGING: Chest x-ray on transfer to the Intensive Care Unit
showing interval enlargement of right pleural effusion with
only a small amount of residual aerated right lung.
Endotracheal tube was at the level of the carina. There was
interval improvement in aeration in the left lower lung.
There were left lower lung nodules consistent with metastatic
disease. Electrocardiogram showing sinus tachycardia at 120
beats per minute, normal axis and intervals, T wave
flattening in 3, AVL and V2.
HOSPITAL COURSE: This is a 45 year-old female with a history
of metastatic melanoma to the spine, lungs, liver, pancrease,
presenting with increased dyspnea from [**Hospital3 **]. She
was found to have a recurrent large right pleural effusion
status post pleurocentesis with removal of 2 liters of fluid
about one and a half weeks ago. She is status post recurrent
pleurocentesis today with removal of 1 liter of bloody fluid.
The patient was found to be hemodynamically unstable several
hours after her pleurocentesis with hypotension, shallow and
labored breathing. A repeat chest x-ray showed increased
size of her pleural effusion after her tap, a 14 point drop
in her hematocrit. Her hypotension and respiratory distress
were likely secondary to blood loss. The patient was also found
to be increasing coagulopathic likely secondary to consumption
of her coagulation factors by large collection of blood in
her thorax as well as a dilutional coagulopathy secondary to
resuscitation with large amounts of bicarbonate free fluid.
After stabilization in the Intensive Care Unit, the patient
was hemodynamically stable after chest tube placement and
resuscitation with blood products and intravenous fluids.
1. Hypotension: The patient was initially hypotensive
secondary to massive blood loss likely secondary to
distributive shock. However, septic shock was also a
contributing factor, given that the patient was
immunocompromised and reported rigors and chills with fevers
on admission. The patient was resuscitated with 10 units of
packed red blood cells and 11 liters of intravenous normal
saline. She was initially placed on a neo-synephrine drip,
which was quickly titrated off and the patient subsequently
never needed pressors during her Intensive Care Unit stay.
She was also placed on broad spectrum antibiotics with
intravenous Levaquin, Flagyl and Vancomycin to cover for the
possibility of septic shock. The patient had intermittent
episodes of hypotension with systolic blood pressures into
the 70s, which responded well to intravenous fluid boluses.
Toward the end of her Intensive Care Unit stay it was decided
not to administer any more intravenous fluid boluses as the
patient was becoming increasingly edematous, which was
decreasing her chest wall compliance and impairing
ventilation.
2. Respiratory failure: The patient was initially
hypercarbic respiratory failure. She was placed on AC
ventilation initially with intermittent increased CO2 levels,
which corrected with increasing respiratory rate on the
ventilator settings. During her hospital stay the patient
was noted to have increased peak inspiratory pressures. A
transesophageal balloon was transduced revealing that her
increased peak inspiratory pressures were likely secondary to
extrinsic compression secondary to her increased abdominal
distention and decreased chest wall compliance secondary to
chest wall edema from massive fluid resuscitation. Her PEEP
was increased to 20 to allow for increased alveolar
recruitment. On increasing her PEEP to 25 her systolic blood
pressure dropped into the 60s. Therefore her positive end
expiratory pressure was maintained at 20. The patient was
not sent down for a CT angiogram to evaluate for a pulmonary
embolism as she was deemed to be too unstable to go to the CT
scanner. Her FIO2 was weaned from 100% to 40% with stable
oxygenation. It was decided not to treat her with Lasix for
her total body volume overload as she was felt to have leaky
capillary secondary to an inflammatory response. She was
allowed to autodiurese. Toward the end of her hospital stay
she started stooling with decreased abdominal distention.
The patient was finally tried on pressure support of 15 with
a PEEP of 5 and failed. She was then changed back to assist
control ventilation. On [**5-19**] the patient's ventilator
alarm secondary to high pressures. Her airways were
suctioned with removal of blood from her airway. She was
bagged without success. Her vital signs rapidly deteriorated
over the next one to two minutes. A respiratory therapist
was unable to ventilate the patient. She subsequently became
asystolic on monitor with no pulse. She passed away at 12:32
a.m. on [**5-19**].
3. Renal: The patient had stable renal function with good
urine output throughout her Intensive Care Unit stay.
4. Infectious disease: The patient reported fevers and
chills at rehab with a bandemia on admission. She
subsequently had decreased white blood cell count suggestive
of sepsis versus dilutional secondary to massive fluid
resuscitation. She grew out one out of two bottles positive
for gram positive cocci in pairs and clusters. Possible
sources for sepsis included her pleural effusion, a hidden
infiltrate or pneumonia under her effusion, versus an
abdominal source given her obstipation and potential feeding
of bowel. An abdominal ultrasound was done, which showed no
ascites. The patient was covered broadly with antibiotics
with Vancomycin, Levaquin and Flagyl. She was followed
closely for emerging sources of infection. Toward the end of
her hospital stay she spiked high temperatures to 103 and
104. Potential sources were thought to be her left femoral
line, which was removed. It was decided to not further
broaden her antibiotic coverage and to follow surveillance
culture results and treat accordingly. She was given Tylenol
prn for her fevers.
5. Gastrointestinal: The patient had abdominal distention
and tenderness on admission. She had no bowel movements in
two days. An initial KUB showed a nonspecific bowel gas
pattern. She could not be sent for an abdominal CT as she
was thought to be too unstable. She was broadly covered with
Vanco, Levo and Flagyl to cover a possible abdominal sources
for sepsis. She was started on a bowel regimen and
eventually started stooling toward the end of her Intensive
Care Unit stay. She was placed on an nasogastric tube to
suction.
6. Hematology: The patient was initial anemic secondary to
blood loss and coagulopathic secondary to consumption by
large amount of sequestered blood in her thorax as well as
dilution secondary to massive fluid resuscitation. The
decrease in her white blood cell count was also thought to be
secondary to sepsis versus dilutional. The patient's
hematocrit remained stable after initial resuscitation with
blood products. Her coagulopathy improved, but persisted.
The patient transferred her oncology care from [**Hospital1 2025**] to [**Hospital1 1444**] secondary to dissatisfaction
with care. Her current oncologist was Dr. [**Last Name (STitle) **] at the [**Hospital1 1444**] who frequently came to visit
the patient during her Intensive Care Unit stay.
7. Endocrine: A.M. Cortisol level was checked and was 29
ruling out adrenal insufficiency as a cause of her
hypotension.
8. Fluids, electrolytes and nutrition: A Swan-Ganz catheter
was placed to assess hemodynamics revealing increased
pulmonary artery pressures to 50/30, pulmonary capillary
wedge pressure of 22, with a cardiac output of 6 and cardiac
index of 3 and SVR of 665 indicating that the patient was
retaining sufficient fluid in her intravascular space, but
was still demonstrating septic physiology secondary to
a systemic inflammatory response. She initially had a
nonanion gap metabolic acidosis, which was likely dilutional.
Her acidosis subsequently improved. She was initially
treated with 2 amps of sodium bicarbonate. She was also
hypocalcemic initially secondary to massive resuscitation
with blood products. Her electrolytes were repleted as
needed.
9. Code status: The patient was initially a full code.
Frequent family discussions were held with the family, and
they continued to understand the grave prognosis of the
patient. However, they maintained that they wanted at all
times everything possible to be done for her. Furthermore
they suggested that they wished for things to take their
natural course as well. Toward the end of her hospital stay
they decided that they did not want any pressors, CPR or
defibrillation or ventilator changes. The patient passed
away on [**2200-5-19**].
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2691**]
Dictated By:[**Name8 (MD) 2692**]
MEDQUIST36
D: [**2200-9-3**] 06:30
T: [**2200-9-4**] 10:28
JOB#: [**Job Number 48850**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1864
} | Medical Text: Admission Date: [**2188-5-10**] Discharge Date: [**2188-5-12**]
Date of Birth: [**2129-2-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 59 yo male with liver mets (?colon primary) s/p
Xeloda/Oxaliplatin/Avastin started [**2188-4-24**], who presents with
diarrhea.
He began treatment [**4-24**] with oxaliplatin and Xeloda 1500 mg
b.i.d. for two out of three weeks and Avastin 15 mg/kg every
three weeks. He had diarrhea the first 2 days which improved. At
a routine follow up visit, the patient was noted to be
hyperkalemic. This was felt to be [**3-12**] to aldactone so it was
stopped [**5-6**]. He was also given IVFs in the office and sent home
with one dose of kayexylate. After the kayexylate, the patient
developed diarrhea - small volumes every 30 minutes -1 hour. He
describes the stool as brown, but mixed with blood (chronically
mixed with blood [**3-12**] hemorrhoids). He took Immodium as directed
without relief, then changed to lomotil He continues to have
frequent episodes of diarrhea. He has had decreased fluid
intake, despite being thirsty. His wife also notes that he has
been breathing fast. He denies fevers/chills/sweats. He denies
nausea /vomiting and notes stable RUQ pain [**5-18**] without
radiation. He also notes stable chronic shortness of breath but
denies chest pain/palpations/diaphoresis/lightheadedness. He
denies lower extemity edema.
ROS: no melena/hematochezia. no new ecchymoses/gingival
bleeding. no dysuria. no new numbness/tingling.
Past Medical History:
Past Onc History:
Mr. [**Known lastname **] is a 59-year-old gentleman with recently discovered
liver masses. He had an EGD ~2 months ago for right sided
abdominal pain which was notable for Barrett's esophagus. Biopsy
of this showedmild active esophagitis. He then underwent an MRI
on [**2188-3-13**] that demonstrated multiple masses throughout
the liver, largest being about 8 cm with some central necrosis.
Periportal, pancreatic and periceliac node were also enlarged.
Biopsy was performed on [**2188-3-17**], and this showed poorly
differentiated carcinoma with focal squamous differentiation.
The cells were CK20+, CK7-. An endoscopic ultrasound and an
upper GI showed no evidence of any tumor. On [**4-24**], he started
treatment with oxaliplatin 135 mg per meters squared every three
weeks along with Xeloda 1500 mg b.i.d. for two out of three
weeks and Avastin 15 mg/kg every three weeks. He had diarrhea
the first 2 days which improved.
Past Medical History:
Hypercholesterolemia
Hemorroids
Social History:
He is married. He lives with his wife in [**Name (NI) 701**].
He Drinks one glass of wine a week. He has no history of tobacco
use.
Family History:
Sister - breast cancer-age 40
Physical Exam:
GENERAL: jaundiced, thin, NAD
VITAL SIGNS: blood pressure 110/70, pulse 105, O2 sat 98% RA,
RR 24 and
temperature 97.
HEENT: PERRL, EOMI. (+) scleral icterus. Oropharynx
without lesions or erythema. (+)dry mucus membranes
LYMPHATICS: No cervical, supraclavicular, axillary, or inguinal
adenopathy.
NECK: Supple, flat neck veins, no thyromegaly.
LUNGS: Clear to auscultation bilaterally.
BACK: No spinal tenderness.
CV: Regular rate and rhythm. Nl S1, S2. (+) 3-4/6 holosystolic
murmur -loudest at apex. PMI nondisplaced.
ABDOMEN: Soft, nontender, nondistended. liver edge palpable ~10
cm below the
costal margin. No rebound/guarding.
EXTREMITIES: No clubbing/cyanosis/ edema. Bottoms of feet dry,
red. Left lateral foot, (+)hypopigmented lesions with brown
rings.
SKIN: jaundiced.
Pertinent Results:
[**2188-5-10**] 06:45AM WBC-8.8# RBC-4.22* HGB-11.7* HCT-37.3* MCV-88
MCH-27.6 MCHC-31.3 RDW-25.8*
[**2188-5-10**] 06:45AM NEUTS-40* BANDS-30* LYMPHS-16* MONOS-9 EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-1* NUC RBCS-3*
[**2188-5-10**] 06:45AM PLT COUNT-527*
[**2188-5-10**] 06:45AM PT-19.6* PTT-39.0* INR(PT)-2.4
[**2188-5-10**] 06:45AM GLUCOSE-99 UREA N-76* CREAT-1.5* SODIUM-133
POTASSIUM-5.6* CHLORIDE-93* TOTAL CO2-12* ANION GAP-34*
[**2188-5-10**] 06:45AM ALBUMIN-2.8* CALCIUM-11.2* PHOSPHATE-4.6*
MAGNESIUM-2.9*
[**2188-5-10**] 06:45AM ALT(SGPT)-49* AST(SGOT)-81* LD(LDH)-230
CK(CPK)-106 ALK PHOS-571* AMYLASE-33 TOT BILI-26.4*
[**2188-5-10**] 06:45AM CK-MB-24* MB INDX-22.6*
[**2188-5-10**] 06:45AM cTropnT-<0.01
[**2188-5-10**] 03:00PM CK(CPK)-93 TOT BILI-22.1* DIR BILI-17.0*
INDIR BIL-5.1
[**2188-5-10**] 03:00PM CK-MB-20* MB INDX-21.5* cTropnT-<0.01
[**2189-5-10**]:
Abdominal US:
1) No evidence of intra or extrahepatic biliary ductal
dilatation.
2) Slight possible gallbladder wall thickening, which is
nonspecific, but contracted gallbladder.
3) Major hepatic arteries and veins and main portal vein and its
major branches, with appropriate directional flow.
4) Extensive involvement of the liver with metastases
Brief Hospital Course:
59 yo M with newly diagnosed liver masses (primary vs mets from
unknown primary (?colon)) s/p xeloda, avastin, oxaliplatin who
present with diarrhea, hyperkalemia, hypercalcemia, and an anion
gap acidosis.
#Diarrhea - etiology includes c.diff (recent course of augmentin
for elevated wbc), infectious diarrhea, malabsorptive diarrhea,
chemo related. The patient was started on flagyl empirically for
c. diff. He was also started on octreotide/cholestyramine for a
question of malabsorptive/chemo related diarrhea that was
resistant to immodium. His diarrhea improved with these
interventions.
#Anion Gap Acidosis - On admission the patient was found to have
a primary gap acidosis with an insignificant delta-delta. His
lactate on admission was 10.7 and did not improve despite
aggressive IVF hydration. He was started on IVFs with bicarb for
his bicarb of 13 and shortness of breath associated with the
acidosis. His lactic acidosis was thought to be secondary to
infection vs extensive tumor burden vs possible bowel ischemia.
He was continued on IVFs and treated empirically with vanco,
levo, flagyl. His lactate was stable with these interventions.
#Hypotension - On admission the patient's blood pressure was
110/70. His blood pressures remained stable with IVF hydration
for the first 12 hours. It then transiently decreased to 80/40
but responded to 1 L NS bolus. He continued to be tachycardic
100-120 so he was bolused again. His blood pressures remained
stable for 2-3 hours then decreased to 84/60 again. This time
his blood pressures did not improve with IVF bolus so he was
transferred to the ICU for closer monitoring. Blood cultures
were sent and he was started on empiric broad spectrum
antibiotics. Vanco/Levo was started for a question of SBE in the
setting of a new holosystolic murmur and flagyl was started for
a question of c. diff. A cortisol was sent which was
appropriate. His blood pressures improved with IVFs and
antibiotics.
#Acute Renal Failure - BUN/Creatinine ratio and history were
consistent with prerenal etiology. UA was notable for granular
casts. It was felt his diarrhea had led to hypovolemia and this
in combination with his hypotension had caused ATN and acute
renal failure. IVFs were instituted for supportive care.
#Liver Failure/Hyperbilirubinemia - The patient had an elevated
INR and low albumin. The rest of his labs were not consistent
with DIC, thus both his coagulopathy and hyperbilirubinemia were
felt to be [**3-12**] extensive tumor burden of his liver.
#Hospital Course - In the setting of his recent diagnosis, the
patient was originally full code on admission. A family meeting
was held on the day of admission and both the patient and his
family agreed that they wanted everything done in the case of a
code. He was transferred to the unit for a central line and
possible pressors in the setting of his repeated hypotension. As
the patient became increasingly short of breath, acidemic, and
uncomfortable, his views on code status changed. On hospital day
2, another family meeting was held and it was decided that the
patient would be treated with best supportive measures and
comfort care. He was seen by social work and palliative care. He
was started on a morphine drip and transferred to the floor. He
expired on [**2188-5-12**] at 23:45.
Medications on Admission:
oxycodone
priolosec
lomotil
Discharge Medications:
Deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
ICD9 Codes: 5849, 2765, 2762, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1865
} | Medical Text: Admission Date: [**2168-9-16**] Discharge Date: [**2168-9-19**]
Service: MEDICINE
Allergies:
Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol /
Lisinopril / Diovan
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea, hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 year old female with history of poorly controlled
hypertension, CHF, CAD presents with dyspnea of sudden onset the
morning of admission. She reports strict adherence to
medications and diet restrictions (no salt, no sugar, limits
fluid intake). In the ED, she was found to have a RR of 30, O2
= 77%, BP of 220/P and placed on BiPAP. On exam, she had
wheezing and crackles, lower extremity edema. CXR showed fluffy
infiltrates. Patient also noted to have cellulitis on left
lower leg. She recieved one dose of levofloxacin, aspirin,
lasix and started on a nitroglycerin gtt. She was afebrile,
transfer vitals 98 73 175.67 24 100% on bipap. She continued to
be dyspneic although her blood pressure did improve on the nitro
gtt.
.
Of note, she was recently admitted in [**Month (only) 116**], acutely dyspneic with
hypertension in the setting of a CHF exacerbation.
.
On the floor, she appeared to be comfortable but frustrated. Per
report, her SBP was 170 yesterday.
.
Review of systems:
(+) Per HPI
Past Medical History:
1. Coronary artery disease status post inferior myocardial
infarction in [**2157**], treated with balloon angioplasty of the RCA.
Complicated by an RCA dissection.
2. Recent cardiac catheterization in [**1-19**] for resting
angina associated with positive troponins and anterior lateral
ST depression. Study noted a heavily calcified LAD with diffuse
disease throughout as well as a left circ with diffusely
diseased small OM1 and small OM2 with 50% stenosis at the origin
as well as diffuse disease through the AV groove into OM3 side
branch with 70% stenosis in the lower pole, all of which was
unfavorable to PCI.
3. Combined diastolic and systolic heart failure. Most recent
EF: 40% per cards note.
4. Peripheral arterial disease with a left superior femoral
artery angioplasty complicated by dissection requiring stent in
[**6-18**] as well as left common iliac and external iliac artery
stenting in [**Month (only) 547**] of 06.
5. Hypertension
6. Dyslipidemia
7. Diabetes
8. Baseline chronic kidney disease with a recent episode of
acute renal failure secondary to treatment with an ACE inhibitor
for which she was hospitalized in early [**Month (only) 547**].
Social History:
The patient currently lives in [**Location 745**] with her [**Age over 90 **] year old
husband. She has 1 son who lives in [**Name (NI) 701**]. At baseline she
walks with a cane, she is otherwise independent in all ADLs.
Tobacco: None
ETOH: None
Illicits: None
Family History:
-Father: heart problems, DM
-Mother: heart problems
-4 brothers: CAD, one with stroke
Physical Exam:
Vitals: T: 98 BP:180/60 P:67 R: 18 O2: 100 on CPAP
General: Alert, oriented, mild/moderate respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple.
Lungs: +wheezes, +rhales, occ rhonchi, decreased BS at bases.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, LLE has erythematous
leision that is covered, dressing CDI (s/p trauma).
Neuro: CN II- XII intact.
GU: foley
Pertinent Results:
[**2168-9-16**] 05:30PM GLUCOSE-169* UREA N-61* CREAT-1.4* SODIUM-139
POTASSIUM-5.2* CHLORIDE-107 TOTAL CO2-22 ANION GAP-15
[**2168-9-16**] 05:30PM CK(CPK)-75
[**2168-9-16**] 05:30PM CK-MB-6 cTropnT-0.11*
[**2168-9-16**] 05:30PM WBC-6.6 RBC-2.79* HGB-9.2* HCT-26.9* MCV-96
MCH-32.9* MCHC-34.2 RDW-15.0
[**2168-9-16**] 05:30PM PLT COUNT-205
[**2168-9-16**] 05:30PM PT-13.9* PTT-27.2 INR(PT)-1.2*
[**2168-9-16**] 06:50AM URINE BLOOD-SM NITRITE-POS PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2168-9-16**] 06:16AM LACTATE-0.7
[**2168-9-16**] 06:15AM CK(CPK)-85
[**2168-9-16**] 06:15AM cTropnT-0.10* proBNP-[**Numeric Identifier 16043**]*
[**2168-9-16**] 06:15AM CK-MB-7
Imaging:
CXR [**2168-9-16**]: Fine detail is obscurred by motion artifact.
Within this limitation, perihilar haziness, cardiomegaly and
cephalization of the pulmonary vessels are similar to prior. No
new focal consolidation. Atherosclerotic calcification of the
aortic arch is noted. The mediastinal silhouette is otherwise
unremarkable. No appreciable pleural effusion or pneumothorax.
.
TTE [**2168-9-16**]: The left atrium is mildly dilated. The estimated
right atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with mid to
distal anteroseptal and inferior hypokinesis. Overall left
ventricular systolic function is mildly depressed (LVEF= 40 %).
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. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is a
trivial/physiologic pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2168-6-16**], the
severity of mitral regurgitation has decreased, the other
findings are similar.
Brief Hospital Course:
# Hypertension: Admitted to MICU on nitro gtt, able to wean from
drip over the first hospital day. Transitioned to home BP meds
on HD #1. One episode of HTN systolics in 180s, given
hydralazine 10mg and lasix 20mg with return to SBP 140s. On HD
#2 isosorbide mononitrate increased to 30mg [**Hospital1 **]. After some
clarification over her home dosing, written to increase to 30mg
tid (her home dose is 90mg ER q day.) BP stable on increased
regimen, but continues to be difficult to control and should be
followed up closely.
# Dyspnea/CHF Excerbation/Pulmonary edema: Responded well to
lasix bolus with no evidence of fluid overload on HD #2. There
was some confusion over her home lasix dosing, initially she
received 40mg but was then transitioned to 20mg q day. Patient
has underlying COPD for which her home nebs were required.
# h/o NSTEMI: Patient was continued on aspirin 325mg, plavix
75mg and statin. ECHO showed no change from prior. She was
ruled out for MI with serial cardiac enzymes and repeat ECG.
# Cellulitis LLE: Initially started on
Trimethoprim-sulfamethoxazole + Amoxicillin-clavulanate but Cre
increased. Bactrim was discontinued and patient was switched
from Augmentin to doxycycline. She is discharged on
doxycycline.
# DIABETES: Patient's ALF medications were different from what
was listed in OMR so her initial home insulin regimen was
incorrect. She was placed on sliding scale until her home
dosing was clarified through [**Last Name (un) **]. She is now written for NPH
16 units q am with sliding scale at meals.
# Right Shoulder Pain: The patient has chronic right shoulder
pain due to known torn rotator cuff. Received home lidoderm
patch and continued to have significant pain for which she is
discharged on oxycodone. Please follow-up pain control.
# Bacteriuria: The patient had a positive urine culture without
symptoms (no dysuria, no increased urinary frequency). As she
was asymptomatic, she did not receive treatment. However, it
should be noted she received a full course of antibiotics as
described above for cellulitis.
# Pending Blood Culture: The patient has one pending blood
culture from the ED on [**2168-9-16**] which has shown NGTD, but should
be followed-up.
# Full Code.
Medications on Admission:
- Amlodipine 10 mg daily
- Acetaminophen 325-650 mg PO Q6H prn pain
- Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
- Clopidogrel 75 mg Tablet PO DAILY
- Fluticasone-Salmeterol 250-50 mcg/Dose Disk Inhalation [**Hospital1 **]
- Furosemide 40 mg PO once a day
- Hydralazine 25 mg PO TID
- Isosorbide Mononitrate ER 90 mg Tablet PO daily
- Simvastatin 20 mg PO once a day
- ISS (NPH 16 U, Sliding scale)
- Docusate Sodium 100 mg PO BID
- Senna 8.6 mg [**2-13**] PO HS
- Ipratropium-Albuterol 18 mcg-103 mcg 1-2 Puffs IH Q6H PRN SOB
- Cholecalciferol (Vitamin D3) 1,000 unit PO once a day.
- Nitroglycerin 0.4 mg/dose Spray Q5min X 3 PRN Chest pain
- Multivitamin PO DAILY
- Lidocaine 5 %(700 mg/patch) appl DAILY
- Ascorbic acid 500mg DAILY
- Aspirin 81 mg PO DAILY
- Calcium Carbonate 500 mg 2 Tablet PO QID with meals.
- Cholecalciferol (Vitamin D3) 1,000 unit Tablet PO once a day
- Cyanocobalamin 1,000 mcg PO once a day.
- Trazodone 25 mg PO HS PRN for insomnia.
- Ranitidine HCl 150 mg PO once a day.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
4. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: Two (2)
Tablet PO four times a day.
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to Right shoulder for pain.
10. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Isosorbide Mononitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Puff Inhalation [**Hospital1 **] (2 times a day).
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
Disp:*8 Capsule(s)* Refills:*0*
19. Cyanocobalamin (Vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
20. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
21. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
22. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-13**]
puffs Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
23. Nitroglycerin 0.4 mg/Dose Aerosol Sig: One (1) Spray
Translingual three times a day as needed for chest pain: Please
take one spray every five minutes up to 3 times over 15 minutes
for chest pain.
24. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
25. Insulin Lispro 100 unit/mL Cartridge Sig: as directed as
directed Subcutaneous four times a day: Please administer per
insulin sliding scale qachs.
26. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain for 1 days.
Disp:*3 Tablet(s)* Refills:*0*
27. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Sixteen
(16) units Subcutaneous once a day: Please take in morning with
breakfast.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis: Respiratory Distress, Hypertension,
Cellulitis
Secondary Diagnoses: Coronary Artery Disease, Heart Failure,
Dyslipidemia, Diabetes, Chronic Kidney Disease.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for difficulty breathing
caused by too much fluid around your lungs, as well as poorly
controlled hypertension, and a skin infection on your left shin.
For your difficulty breathing you were given a water pill to
help remove your extra fluid. Your blood pressure was initially
controlled with IV medications and you were swtiched to
medications to take by mouth. You were given antibiotics for
your skin infection which you should continue after you are
discharged. You were also given medicine for your chronic
shoulder pain.
.
The following changes were made to your medications:
Your furosemide dose was DECREASED to 20 mg by mouth per day.
Doxycycline was started for treatment of your cellulitis for
four more days on discharge.
.
It was unclear what your Insulin regimen was when you were
admitted. You are discharged on 16 Units NPH in the morning
with breakfast as well as a humalog Insulin Sliding Scale.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2168-9-21**] 11:30
.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **]
Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2168-10-13**] 2:30.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D.
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2168-10-18**] 3:40
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5849, 4280, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1866
} | Medical Text: Admission Date: [**2178-12-5**] Discharge Date: [**2178-12-17**]
Date of Birth: [**2108-3-4**] Sex: M
Service: SURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
ruptured abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
1) Open repair of AAA, right external iliac stent, left CIA and
EIA stents ([**2178-12-5**])
2) Exploratory laparotomy, removal of Silastic sheeting and
temporary abdominal closure ([**12-12**])
3) Repair of incisional/ventral hernia with mesh closure,
placement of vacuum-assisted closure dressing ([**12-15**])
History of Present Illness:
The patient is a 70 year old male who presneted to an OSH on
[**2178-12-4**] with back pain, syncope, and hematemesis x2. He also
had oliguria. A workup at that institution revealed a 7.5 cm
AAA with an associated hematoma. he was also in acute renal
failure with a createnine of 3.3. He was hemodynamically stable
and was transferred to [**Hospital1 **] for emergent surgery on [**2178-12-5**].
Past Medical History:
Tonsillectomy
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
VS- pulse 73, BP 125/75, RR 19, O2 96% RA
Gen- NAD, drowsy
HEENT- anicteric, EOMI
Heart- RRR
Lungs- CTA b/l
Abdomen- distended, form, tympanitic, hypoactive bowel sounds,
unable to palpate aneurysm
Pulses- 2+ femoral b/l, 2+ radial b/l, foot pulses nonpalpable,
feet clammy, moving all 4 extremities
Pertinent Results:
[**2178-12-5**] 07:50PM BLOOD WBC-15.2* RBC-3.46* Hgb-10.5* Hct-31.0*
MCV-90 MCH-30.2 MCHC-33.7 RDW-14.8 Plt Ct-149*
[**2178-12-6**] 03:10AM BLOOD WBC-10.0 RBC-3.01* Hgb-9.3* Hct-25.6*
MCV-85 MCH-30.8 MCHC-36.2* RDW-15.1 Plt Ct-100*
[**2178-12-15**] 05:18PM BLOOD WBC-31.1* RBC-3.27* Hgb-9.5* Hct-29.8*
MCV-91 MCH-29.2 MCHC-32.0 RDW-15.8* Plt Ct-368#
[**2178-12-17**] 04:02AM BLOOD WBC-36.4* RBC-2.20* Hgb-6.5* Hct-19.6*
MCV-89 MCH-29.7 MCHC-33.3 RDW-16.1* Plt Ct-288
[**2178-12-5**] 07:50PM BLOOD PT-15.2* PTT-43.7* INR(PT)-1.3*
[**2178-12-7**] 03:11AM BLOOD Fibrino-505*
[**2178-12-5**] 09:24PM BLOOD Glucose-112* UreaN-35* Creat-3.3* Na-140
K-6.6* Cl-116* HCO3-16* AnGap-15
[**2178-12-8**] 04:44PM BLOOD Glucose-93 UreaN-51* Creat-6.6* Na-144
K-4.8 Cl-108 HCO3-23 AnGap-18
[**2178-12-17**] 04:02AM BLOOD UreaN-53* Creat-3.0* Na-132* Cl-98
HCO3-24
[**2178-12-5**] 09:24PM BLOOD CK(CPK)-187*
[**2178-12-7**] 03:11AM BLOOD CK(CPK)-[**Numeric Identifier 20476**]*
[**2178-12-8**] 04:44PM BLOOD ALT-82* AST-382* CK(CPK)-7708* AlkPhos-49
Amylase-242* TotBili-0.8
[**2178-12-10**] 02:44AM BLOOD CK(CPK)-[**Numeric Identifier 76453**]*
[**2178-12-10**] 02:54PM BLOOD CK(CPK)-[**Numeric Identifier 76454**]*
[**2178-12-16**] 12:57AM BLOOD CK(CPK)-1243*
[**2178-12-5**] 09:24PM BLOOD CK-MB-10 MB Indx-5.3 cTropnT-0.05*
[**2178-12-6**] 11:07AM BLOOD CK-MB-140* MB Indx-1.3 cTropnT-0.45*
[**2178-12-13**] 01:22AM BLOOD CK-MB-16* MB Indx-0.4 cTropnT-1.62*
[**2178-12-5**] 09:24PM BLOOD Calcium-7.2* Phos-6.5* Mg-1.8
[**2178-12-5**] 04:47PM BLOOD Type-ART Tidal V-600 FiO2-50 pO2-199*
pCO2-45 pH-7.18* calTCO2-18* Base XS--11 -ASSIST/CON
Intubat-INTUBATED
[**2178-12-5**] 06:28PM BLOOD Type-ART Rates-/10 Tidal V-700 FiO2-100
O2 Flow-2 pO2-315* pCO2-46* pH-7.13* calTCO2-16* Base XS--13
AADO2-364 REQ O2-64 -ASSIST/CON Intubat-INTUBATED
[**2178-12-5**] 10:42PM BLOOD Type-ART pO2-119* pCO2-44 pH-7.28*
calTCO2-22 Base XS--5 Intubat-INTUBATED
[**2178-12-15**] 08:08PM BLOOD Type-ART pO2-80* pCO2-46* pH-7.33*
calTCO2-25 Base XS--1
[**2178-12-17**] 12:49PM BLOOD Type-ART pO2-82* pCO2-39 pH-7.42
calTCO2-26 Base XS-0
Brief Hospital Course:
The patient was admitted on [**2178-12-5**] and taken emergently to the
OR for repair of a ruptured AAA. Please see operative note for
details. Estimated blood loss was 2 liters. He got 4 liters of
IV fluid, 2 units of FFP, 6 units of RBC, 1 of platlets, and 250
of cell [**Doctor Last Name 10105**]. He was transferred to the ICU post operatively.
He was intubated and sedated. Foot pulses were not dopplerable
on the right but they were on the left. Urine output was
adequate. He was on Vancomycin and Zosyn empirically. On POD
1, he was given 1 unit of RBC for post operative blood loss
anemia. Foot pulses became dopplerable bilaterally. On POD 2,
he was paralyzed to aid in his ventillation. His CPK level rose
to [**Numeric Identifier 4731**] and a bicarbonate drip was started. Renal was
consulted and they agreed to start CVVHD in the morning.
General surgery was consulted to close the abdomen when he was
more stable. On POD 3, he was taken to the OR by general
surgery for a washout and placement of [**State 19827**] patch. TPN was
started. On POD [**3-22**], he was on Vanco, Ciprofloxacin, and
Flagyl. On POD [**4-22**], he was kept negative by the CVVHD and his
BUN and createnine began to trend down. On POD [**6-24**], he was
taken back to the OR by general surgery for an exploratory
laparotomy, removal of silastic sheeting and temporary abdominal
closure, after a teal was noted in the Silastic sheet. He
continued to require CVVHD. On POD [**7-26**], he was noted to have an
incrasing oxygen requirement. A chest X-ray demonstrated a
likely anterior pneumothorax. A chest tube was placed at the
bedside and a continuous air leak was noted. On POD [**8-27**],
thoracic surgery was consutlet and they felt that he had
ruptured a bleb and that there was nothing to do. He went into
rapid atrial fibrillation and became hypotensive and was started
on an amiodarone drip and neosynpherine. Gradually, he
converted into sinus and was weaned off the neosynepherine. On
POD [**9-27**], his abdomen was noted to have purulent fluid
underneatht he dressing. He was spiking fevers and requring
Neosynepherine co maintain his blood pressure. He was taken
back to the OR by general surgery for repair of incisional/
ventral hernia with mesh closure and placement of
vacuum-assisted closure dressing. Purulent fliud was washed out
of his abdomen. He was then transferred back to the ICU. He
was hypotensive and tachycardic and requiring increasing oxygen
to maintain his saturations. He was maintained on broad
spectrum antibiotics, although no cultures came back positive.
A chest X-ray demonstrated right upper lobe consolidation. A
bronchoscopy was performed and copiuos mucus was suctioned from
his right upper lobe. A post-bronchoscopy X-ray demonstrated
re-inflation of his right lung. Over the next 2 days, he
continued to require sedation and paralysis. His heart rate and
blood pressure were stabilized on amiodarone and he was
intermittently on and off of pressors. He continued to have a
continuous air leak, although we were able to wean his FiO2 down
from 85% to 50%. He continued to tolerate tube feeds at goal.
He continued to require CVVHD to keep him even or negative. His
hematocrit did fluctuate due to a liekly GI bleed (his NG tube
output was bloody at times). He requried an insulin drip for
glucose control. On POD 13/10/6, his dismal prognosis was
discussed at length with his family. They understood that he
had multiple failing organ systems and that his chance of
recovery and meaningful quality of life were quite slim. he was
therefore made comfort measures only and he died later that
night.
Medications on Admission:
Tylenol
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
ruptured abdominal aortic aneurysm, atrial fibrillation,
pneumothorax, intra-abdominal sepsis, acute renal failure
requiring CVVHD
Discharge Condition:
dead
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2178-12-18**]
ICD9 Codes: 5849, 2851, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1867
} | Medical Text: Admission Date: [**2132-2-9**] Discharge Date: [**2132-2-13**]
Date of Birth: [**2057-5-9**] Sex: F
Service: GEN [**Doctor First Name 147**]
CHIEF COMPLAINT: Mental status changes.
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old
female with metastatic ovarian carcinoma status post total
abdominal hysterectomy/bilateral salpingo-oophorectomy,
omentectomy, ileus cecectomy on [**2131-10-18**], by Dr. [**Last Name (STitle) 2093**],
complicated by perforation of anastomosis on [**2132-1-19**],
requiring an exploratory laparotomy, lysis of adhesions,
resection of anastomosis, ileostomy and mucous fistula. Her
hospital course during that time had been complicated by
prolonged intubation, acute renal failure, hypotension. She
had been discharged to rehabilitation on [**2132-2-4**].
She returns now with mental status changes. No fever. She
is still tolerating her tube feeds.
PAST MEDICAL HISTORY:
1. Status post cholecystectomy.
2. Status post total abdominal hysterectomy/bilateral
salpingo-oophorectomy/omentectomy/ileus cecectomy
[**2131-10-18**].
3. Status post exploratory laparotomy, lysis of adhesions,
resection of anastomosis and ileostomy and mucous fistula
by Dr. [**Last Name (STitle) **], [**2132-1-19**].
4. Metastatic ovarian carcinoma.
5. Status post dilatation and curettage.
6. Status post cesarean section.
7. Diabetes mellitus.
8. Paranoid schizophrenia.
9. Depression.
ALLERGIES: Penicillin.
MEDICATIONS ON ADMISSION:
1. Epogen 40,000 units subcutaneously twice a week, Mondays
and Thursdays.
2. Heparin subcutaneously 5,000 twice a day.
3. Lacrilube to eyes.
4. Lopressor 100 mg via G-tube twice a day.
5. Hydralazine 10 mg via G-tube q. six hours.
6. Sliding scale insulin.
7. Glyburide 10 units q. a.m.
8. Risperdal 0.5 mg q. a.m. per G-tube, 1.5 mg q. p.m. per
G-tube.
9. Tube feeds, ProMod with fiber at 60 cc an hour, free
water boluses 250 cc q. four hours.
PHYSICAL EXAMINATION: On admission, temperature 98.0 F.;
pulse 109; blood pressure 162/61; respiratory rate 27;
saturation 100% on room air. She was catatonic, following
simple commands. Lungs decreased breath sounds both bases.
Heart regular. Abdomen soft, nontender, nondistended, and
ileostomy plus mucous fistula pink and patent. Incisions
clean, dry and intact. Extremities warm. Rectal examination
revealed a 5 cm left perirectal collection with minimum
erythema. On rectal examination no mass, no stool.
LABORATORY: On admission, white count 10.6, hematocrit 33,
platelets 306,000. Chem-7, sodium 139, potassium 5.3,
chloride 101, CO2 26, BUN 46, creatinine 1.6. Glucose 208,
magnesium 1.5.
Urinalysis negative. Chest x-ray negative. ALT 19, AST 27,
alkaline phosphatase 224, amylase 129, lipase 415, total
bilirubin 0.3, INR 1.1, PT 12.3, PTT 22.2.
Abdominal CT scan revealed a 5 by 6 cm left perirectal
collection, and a 6 by 3 cm perihepatic fluid collection.
HOSPITAL COURSE: The patient was admitted under the General
Surgery service. Her perirectal abscess was drained in the
Emergency Department and 200 cc of pus was aspirated. She
was started on intravenous Levo and Flagyl. Her tube feeds
were held. On [**2132-2-9**], the day of admission, she
underwent a CT guided drain placement of a #8 French catheter
into the inferior hepatic fluid collection; 10 cc of
serosanguinous fluid were withdrawn and sent for culture.
She tolerated this well.
Over the next few days, her mental status improved and she
was alert and oriented times three. On [**2-11**], she underwent
a repeat CT scan and readjustment of the drain. She also
underwent a swallow study which she failed as she aspirated
the thick and thin liquid. She was started on Vancomycin
after culture results from the drain.
She continues to do well and is being discharged to
rehabilitation with plans to leave the drain in for a week
and re-scan. She will also be evaluated for a swallow study
in three weeks' time.
MEDICATIONS ON DISCHARGE:
1. Vancomycin 500 mg intravenously q. 24 hours times three
weeks.
2. Epogen 40,000 units subcutaneously two times a week,
Mondays and Thursdays.
3. Glyburide 10 mg q. day per NG tube.
4. Heparin 5000 units subcutaneously twice a day.
5. Hydralazine 10 mg q. six hours per NG tube.
6. Regular insulin sliding scale.
7. Lacrilube Ointment four times a day.
8. Metoprolol 100 mg twice a day per NG tube.
9. Zantac 150 mg per NG tube q. day.
10. Risperidone 0.5 mg q. a.m. and 1.5 mg q. p.m. per NG
tube.
DISCHARGE INSTRUCTIONS:
1. Treatment twice a day wet-to-dry dressing changes to the
perirectal abscess.
2. Flush drain as recommended.
3. Re-scan in one week.
4. Repeat swallow study in three weeks.
5. Fingerstick q. six hours.
6. Diet is ProMod with fiber, 60 cc an hour via NG tube, 250
cc free water q. six hours via NG tube.
CONDITION AT DISCHARGE: Stable.
FOLLOW-UP INSTRUCTIONS: Follow-up with Dr. [**Last Name (STitle) **].
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2132-2-13**] 11:09
T: [**2132-2-13**] 11:35
JOB#: [**Job Number 35754**]
ICD9 Codes: 5849, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1868
} | Medical Text: Admission Date: [**2169-3-6**] Discharge Date: [**2169-3-11**]
Service: MEDICINE
Allergies:
Penicillins / Hydrochlorothiazide / Codeine / Fluvastatin /
Metrolotion
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Change in mental status, hypoxia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname 97172**] is a [**Age over 90 **] year old female with history of CAD s/p MI,
CHF (EF 50%), aortic stenosis (area 0.8cm2), dementia, MDS who
was admitted on the afternoon of [**3-6**] from [**Hospital 100**] Rehab with
change in mental status. In the ED, vitals were Tmax 102, BP
110/67, HR 124, 95% on 4L NC. Cardiac enzymes were sent from
the ED and she ruled in for NSTEMI (troponin 0.47, CK 81). BNP
on admission was [**Numeric Identifier 97173**], lactate 2.4. EKG on admission with
sinus tachycardia, RBBB, no ST or TW changes. She was not
started on heparin at that time but was given ASA 325mg in the
ED. There was question of a pneumonia on CXR and Vanc/Levo were
started empirically.
.
Overnight on [**3-7**], nursing became concerned due to increased
ectopy on telemetry. Check of vital signs at the time revealed
hypoxia to 88% on 6L NC. She was placed on a NRB improvement to
98% O2 sat. She denied any chest pain, shortness of breath,
palpitations, lightheadedness, or dizziness. Her only complaint
was back pain which had been present since admission. CE
trending up from those in ED (CK 158, trop 1.14). CXR showed
worsening pulmonary edema bilaterally with bilateral pleural
effusions. Repeat EKG showed normal sinus rhythm, rate of 94,
STE in V1-V3 and TWI in V4-V6, I, II, aVF, aVL. She was given
Lasix 40mg x1, morphine 1mg, and 1 inch nitropaste was applied.
Plan to transfer to CCU for closer monitoring and noninvasive
ventilation.
.
On arrival to the CCU she is asking for water. She notes right
sided back pain which is stable from prior. She denies chest
pain, shortness of breath, palpitations, nausea or diaphoresis.
Noninvasive ventilation was tried on arrival to ICU but patient
would not tolerate the mask.
.
Of note, her home dose of lasix had been held for one week due
to a recent gastroenteritis and dehydration. She was treated
with IVF. Her metoprolol had also been decreased from
Metoprolol 12.5mg [**Hospital1 **] to toprol 12.5mg daily.
.
Review of symptoms is limited by patient's dementia. She denies
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
cough, hemoptysis, black stools or red stools.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
Past Medical History:
- Diverticulitis s/p colectomy
- h/o c diff colitis
- depression
- myelodysplastic d/o
- chf, EF 50%: Echocardiogram done on [**2164-9-3**] revealing ejection
fraction of 45 to 50%, mild global hypokinesis, more pronounced
on the
inferior and posterior segments. Mild AS and aortic valve
calcification with an aortic valve area of 1 to 2 cm square.
Mild to moderate MR.
- aortic stenosis, per report valve area of 0.8cm2
- h/o falls
- CAD h/o MI
- dementia
- hyponatremia
- Paroxysmal Afib
Social History:
In nursing homes/rehab since colectomy in 3/[**2168**]. denies
tob/alc/etoh
Family History:
nc
Physical Exam:
VS: T 96.4, BP 115/60, HR 95, RR 40, O2 96 % on NRB
Gen: Elderly female, tachypneic, using accessory muscles.
Responding appropriately to questions, asking for water.
HEENT: NCAT. Sclera anicteric. Left eye with yellow discharge.
PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
Neck: Supple with JVP of 10cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Tachycardic, normal S1, S2. No S4, no S3. Systolic ejection
murmur heard best at upper sternal borders. Difficult to
characterize secondary to breath sounds.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were labored. Bibasilar crackles halfway up, +wheeze, no
rhonchi.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: Trace LE edema bilaterally. No femoral bruits.
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:
[**2169-3-6**] 11:45AM BLOOD WBC-12.9*# RBC-3.45* Hgb-10.4* Hct-31.8*
MCV-92 MCH-30.1 MCHC-32.7 RDW-15.7* Plt Ct-268
[**2169-3-7**] 12:38PM BLOOD WBC-11.8* RBC-3.06* Hgb-9.0* Hct-28.6*
MCV-93 MCH-29.4 MCHC-31.5 RDW-16.0* Plt Ct-318
[**2169-3-9**] 03:02AM BLOOD WBC-5.7 RBC-2.72* Hgb-8.0* Hct-25.0*
MCV-92 MCH-29.4 MCHC-32.0 RDW-17.1* Plt Ct-279
[**2169-3-9**] 03:02AM BLOOD PT-13.5* PTT-44.4* INR(PT)-1.2*
[**2169-3-6**] 11:45AM BLOOD Glucose-140* UreaN-29* Creat-1.0 Na-136
K-5.3* Cl-104 HCO3-19* AnGap-18
[**2169-3-9**] 03:02AM BLOOD Glucose-100 UreaN-62* Creat-1.9* Na-135
K-4.1 Cl-104 HCO3-20* AnGap-15
[**2169-3-9**] 03:02AM BLOOD ALT-11 AST-22 AlkPhos-100 TotBili-0.8
[**2169-3-6**] 11:45AM BLOOD cTropnT-0.47*
[**2169-3-6**] 11:45AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 97173**]*
[**2169-3-6**] 09:21PM BLOOD CK-MB-40* MB Indx-25.3* cTropnT-1.14*
[**2169-3-7**] 07:10AM BLOOD CK-MB-NotDone cTropnT-1.14*
[**2169-3-7**] 09:08PM BLOOD CK-MB-NotDone cTropnT-0.98*
[**2169-3-7**] 07:10AM BLOOD Calcium-9.6 Phos-4.3 Mg-1.9
[**2169-3-7**] 08:57AM BLOOD Type-ART FiO2-95 pO2-83* pCO2-27* pH-7.40
calTCO2-17* Base XS--5 AADO2-582 REQ O2-94 Intubat-NOT INTUBA
Comment-HIFLOW
[**2169-3-7**] 12:29PM BLOOD Type-ART pO2-128* pCO2-31* pH-7.42
calTCO2-21 Base XS--2 Intubat-NOT INTUBA
[**2169-3-6**] 11:51AM BLOOD Lactate-2.4*
[**2169-3-7**] 12:29PM BLOOD Lactate-1.5
CXR:
This is a study limited by patient motion and nonvisualization
of the left costophrenic junction. There is prominence of the
pulmonary hila with central congestion, more apparent on the
left. There is no large pleural effusion or pneumothorax.
IMPRESSION:
1. Central pulmonary vascular congestion.
TTE:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with inferior and
inferolateral akinesis along with anterior and anterolateral
hypokinesis. Overall left ventricular systolic function is
moderately depressed (LVEF= 30-35%). The aortic valve leaflets
are severely thickened/deformed. There is severe aortic valve
stenosis (area 0.7 cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate left ventricular systolic dysfunction with
severe aortic stenosis. Moderate pulmonary artery systolic
hypertension
Brief Hospital Course:
[**Age over 90 **] year old female with history of CAD s/p MI, CHF w/ EF 45-50%,
[**Hospital 90129**] transferred to CCU with respiratory distress, elevated
troponins and ?STEMI vs. LV strain pattern with plan for medical
management as patient is too high risk for catheterization.
.
1) Respiratory Distress: New oxygen requirement on presentation
and increasing pulmonary edema on CXR. EKG showed ST elevations
in anterior leads. These changes may be related to LV strain
given likely LVH vs ischemic. ABG done on NRB showed pH
7.4/27/83. Patient was tachypneic on exam, question if there is
some component of anxiety contributing to tachypnea. Given EKG
changes, CXR and elevated BNP on admission, patient is likely in
decompensated heart failure due to infection +/- recent d/c of
lasix and metoprolol. Now appears to be dry by labs and exam so
respiratory distress was likely a flash pulmonary edema but not
total body volume up. O2 requirement falling but still present.
Pulmonary edema resolved on CXR
- Surface echocardiogram->EF 30-35% with inferior and
anterolateral hypo/akinesis.
- Temporarily on heparin drip for ischemia, now off.
- On plavix, aspirin
- Lasix resumed at discharge.
- Initial "pneumonia" seen on CXR may have been pulmonary edema,
however MRSA growing in [**3-7**] sputum but not present on repeat
sputum gram stain, likely colonization given absence of fever
elevated WBC and or clear infiltrate on CXR. Antibiotics were
held. No signs of infection.
.
2) CAD/Ischemia: Developed ST elevations initially, possibly
related to strain from tachycardia. Given age and
comorbidities, patient was too high risk for catheterization.
Medical management of cardiac issues.
- On Aspirin, plavix, Toprol XL 25mg ; need to be continued.
.
3) Rhythm: Originally sinus tach, likely compensation decrease
CO. Then had episode of a.fib with RVR and hypotension at 8pm
[**2169-3-7**]. Converted to NSR with amio bolus and drip. Now in NSR at
60's to 70's.
- Continue PO amio 200mg [**Hospital1 **] x 1month (until [**2169-4-10**])then daily
- On Toprol XL 25mg daily
.
4) Valves: Aortic stenosis, per report last AV area was 0.8cm2.
Read as 0.7cm2 on repeat echo. No surgery or valvuloplasty
.
5) MDS: Receives frequent transfusions. HCT has been trending
down during admission. Guaic negative. Responded appropriately
to transfusion [**2169-3-9**].
- hemolysis labs->negative
- Epo injections
Medications on Admission:
- Nitroglycerine 0.3mg sl prn
- mirtazapine 7.5mg PO qhs
- tylenol 650 po prn
- cholecalciferol 1000units daily
- ammonium lactate topical qhs
- aranesp 40 mcg sc Thurs at [**2161**]
- iron 325 mlg po daily
- lopressor 12.5mg daily
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
2. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever / pain.
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
5. Ammonium Lactate 12 % Lotion Sig: One (1) Topical qHS ().
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for prn wheezing.
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Aranesp 40 mcg sc Thurs
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary diagnosis:
NSTEMI
Atrial fibrillation
Diastolic CHF
Secondary diagnosis:
Dementia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted with confusion. During your stay in the
hospital you developed difficulty breathing. You also had signs
of cardiac ischemia. You were briefly in the intensive care
unit. You were medically managed.
Please continue medication as prescribed. Please follow up as
below.
Followup Instructions:
You should should follow up with your doctors as recommended by
[**Hospital 100**] Rehab facility.
You have been started on Amiodarone for atrial fibrillation.
You will need Pulmonary function tests and ophthalmology follow
up.
Completed by:[**2169-3-11**]
ICD9 Codes: 5849, 4280, 412, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1869
} | Medical Text: Admission Date: [**2141-11-26**] Discharge Date: [**2141-11-27**]
Date of Birth: [**2059-5-6**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
found unresponsive
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The pt is an 82 year-old R-handed man with PMHx of mild
dementia, mild HTN, hemochromatosis, and esophageal cancer
treated with radiation 25 yrs ago who presents with a large IPH.
Per report, patient was last known well this morning, but had
been left alone at home all day. He was found at around 7pm by
one of his children in the shower, having fallen onto his left
side. It is unclear how long he had been in the shower, but per
his usual routine of when he showers the estimate was for about
20-30 mins. EMS was called and when they arrived pt had
spontaneous eye mvmts and withdrawal to pain, but was otherwise
unresponsive. His BP was in the 230's. When he arrived a stat
head CT was done which showed a large (9.5x6.1cm) right
intraparenchymal hematoma, likely arising from the basal
ganglia, with leftward subfalcine and uncal herniation, and
obstructive hydrocephalus at the level of the third ventricle.
He was intubated in the ED, and because of his poor prognosis
was made CMO by his family. They requested that he remain
intubated until more family members and a priest could arrive,
then they planned to terminally extubate the pt.
.
Pt unable to give ROS as was unresponsive.
Past Medical History:
- Knee surgery
- mild dementia (was on aricept in past)
- spinal fusion (?lumbar)
- Left scaphoid fracture
- Hemochromotosis (phlebotomy)
- Esophageal cancer tx w/ radiation > 25 yrs ago
- Macular degeneration
- Hearing loss (totally on Right, 70% on Left)
- Osteoarthritis in feet
- recent MVA in [**Month (only) 359**], then another MVA shortly therafter,
with resultant C2-C5 spinous process fc
- HTN diagnosed on [**Month (only) 359**] admission (Rx'd lopressor)
Social History:
ETOH - hasn't in 20 years, used to have alcohol addiction
problem
Smoking - used to smoke, quit over 30 yrs ago
Drugs - none
Lives with wife in an [**Hospital3 **] facility
Family History:
no FHx of aneurysms or bleeding strokes
Physical Exam:
Physical Exam on Admission:
Vitals: T:98.2 P: 73 R: 16 BP: 159/72 SaO2: intubated, 97% on
ETT
General: intubated, not sedated, unresponsive.
HEENT: ETT in place
Neck: 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: cuts and scrapes on bilateral arms and legs
.
Neurologic:
.
-Mental Status: intubated, unresponsive
.
-Cranial Nerves:
I: Olfaction not tested.
II: pupils fixed and dilated bilaterally, corneals absent
bilaterally
III, IV, VI: gaze midline, negative Doll's maneuver
V: unable to test
VII: ETT in place, unable to assess
VIII: unable to assess
IX, X: per report gag intact
[**Doctor First Name 81**]: unable to test
XII: ETT in place, unable to assess
.
-Motor: Withdrew in all 4 ext to pain with extensor posturing in
RUE and flexion in LUE as well as triple flexion in bilateral
lower extremities.
.
-Sensory: withdrawal to noxious as above
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
.
Plantar response was extensor bilaterally.
.
-Coordination: unable to assess
.
-Gait: unable to assess, pt intubated
Physical Exam on Discharge:
Patient expired
Pertinent Results:
[**2141-11-26**] 08:44PM TYPE-ART O2 FLOW-100 PO2-512* PCO2-38
PH-7.47* TOTAL CO2-28 BASE XS-4 INTUBATED-INTUBATED
[**2141-11-26**] 08:09PM GLUCOSE-160* LACTATE-1.9 K+-4.3
[**2141-11-26**] 08:00PM GLUCOSE-169* UREA N-13 CREAT-0.9 SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
[**2141-11-26**] 08:00PM estGFR-Using this
[**2141-11-26**] 08:00PM cTropnT-0.04*
[**2141-11-26**] 08:00PM WBC-11.5* RBC-4.42* HGB-12.7* HCT-38.3*
MCV-87 MCH-28.7 MCHC-33.1 RDW-13.5
[**2141-11-26**] 08:00PM NEUTS-84.5* LYMPHS-10.8* MONOS-2.5 EOS-1.7
BASOS-0.5
[**2141-11-26**] 08:00PM PT-12.8* PTT-31.2 INR(PT)-1.2*
[**2141-11-26**] 08:00PM PLT COUNT-313
CT head:
1. Massive right intraparenchymal hematoma, likely arising from
the basal
ganglia, with leftward subfalcine and uncal herniation, and
obstructive
hydrocephalus at the level of the third ventricle.
2. Intraventricular extension of acute hemorrhage.
CT C spine:
1. Findings consistent with an anterior inferior T2 vertebral
body fracture.
2. Mild superior endplate deformity at T1 of unknown chronicity.
3. Chronic C6 wedge compression deformity and old C3 through C6
spinous
processes fractures.
4. Severe apical emphysema.
CXR:
1. Satisfactory positioning of endotracheal tube.
2. Questionable small nodular densities projecting over the left
mid lung. Short-term repeat radiographs are recommended to see
whether these may persist.
3. Cholelithiasis.
Brief Hospital Course:
82 year-old R-handed man with PMHx of mild dementia, mild HTN,
hemochromatosis, and esophageal cancer treated with radiation 25
yrs ago who presented to the ED after being found down at home.
CT head showed a large (9.5x6.1cm) R IPH, likely arising from
the basal ganglia, with leftward subfalcine and uncal
herniation, and obstructive hydrocephalus at the level of the
third ventricle. He was intubated in the ED and subsequently
made CMO at the request of his family.
He was admitted to the neuro ICU and extubated overnight. He was
started on a morphine drip for comfort. He passed away
comfortably at 3:20pm on [**2141-11-27**]. Family were present and
declined autopsy.
Medications on Admission:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours).
Disp:*60 Tablet(s)* Refills:*2*
5. Alphagan P 0.1 % Drops Sig: One (1) drop to right eye
Ophthalmic three times a day.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Massive right intraparenchymal hematoma, likely arising from the
basal ganglia, with leftward subfalcine and uncal herniation,
and obstructive hydrocephalus at the level of the third
ventricle
Discharge Condition:
Expired
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 69**] on
[**2141-11-26**] after being found unresponsive at home. A CT scan of
your head showed a large hemorrhage in your brain. Per
discussion with your family the decision was made to pursue
comfort measures only. You passed away comfortably at 3:20pm on
[**2141-11-27**].
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1870
} | Medical Text: Admission Date: [**2138-9-17**] Discharge Date: [**2138-10-28**]
Date of Birth: [**2068-3-23**] Sex: F
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Bright Red Blood per rectum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
70 yo female with myelodysplastic syndrome, chronic renal
insufficiency secondary to cyclosporine, extensive GI bleeding
over the past several years, presenting with multiple episodes
of BRBPR starting on the morning of admission. Pt was initially
admitted to the OMED service with a hct drop of 4 points and was
transfused 2U PRBC and 3U pf HLA matched platelets for a
platelet count of 14. She was also given DDAVP for presumed
dysfunctional platelets. She was hemodynamically stable. Last
night she was also found to be febrile and was started on
Cefepime and Flagyl and then changed over to Zosyn as she
complained of severe nausea on Flagyl.
This am the patient developed worsening BRBPR and again had one
bloody stool with associated abdominal pain as well as
hypotension with a systolic BP of 90 and tachycardia. She was
transfused another 3U PRBC and her BP and HR normalized again.
The patient then went to nuclear medicine and subsequently was
transferred to the ICU for closer monitoring.
.
ROS: negative for lightheadedness, chest pain, palpitations,
SOB, dysuria or altered mental status. She reports fatigue, mild
cramping abdominal pain, and increased number of echymoses
across her abdomen, arms, and legs.
Past Medical History:
1) Aplastic anemia/Hypocellular myelodysplastic syndrome with
trisomy 8 and 21. s/p high dose prednisone and gamma globulin,
s/p Anti-thymocyte globulin therapy [**2126**], on cyclosporine since
with renal insufficiency; started IVIG q3 weeks [**2138-7-10**]
2) s/p terminal ileum resection [**3-26**] for multiple bleeding
ulcers
3) h/o candidemia with [**Female First Name (un) 564**] parapsilosis
4) Renal insufficiency (recent baseline Cr 1.2 - 1.6)
5) Hypertension
6) h/o hypercholesterolemia
Past Surgical History:
- TAH/BSO [**2-21**] fibroids
- Appendectomy
- Venous stripping LLE
Social History:
Married, 5 children. Does not smoke, drink alcohol or coffee
Family History:
Mother died of scleroderma, father died of CAD
Physical Exam:
Vital signs: T:100.4, HR 80, RR 20, Sats 94% ra
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI, no scleral icterus noted, MMM, white
patches on oropharynx consistent with thrush.
Neck: supple, no JVD no lymphadenopathy
Pulmonary: Lungs CTA bilaterally, no crackles or wheezes. equal
aeration bilaterally.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. purpura across her abdomen
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: purpura and echymoses across arms, legs and abdomen.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor
-DTRs: Plantar response was flexor bilaterally.
Pertinent Results:
[**2138-9-17**] 09:31PM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.018
[**2138-9-17**] 09:31PM URINE BLOOD-SM NITRITE-POS PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2138-9-17**] 09:31PM URINE RBC-2 WBC-6* BACTERIA-MOD YEAST-NONE
EPI-3
[**2138-9-17**] 07:31PM WBC-2.1* RBC-2.68* HGB-9.5* HCT-26.9*
MCV-101* MCH-35.3* MCHC-35.1* RDW-21.0*
[**2138-9-17**] 07:31PM PLT COUNT-19*
[**2138-9-17**] 02:05PM PLT COUNT-36*#
[**2138-9-17**] 11:50AM GLUCOSE-129* UREA N-42* CREAT-1.7*
SODIUM-131* POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-21* ANION
GAP-13
[**2138-9-17**] 11:50AM ALT(SGPT)-81* AST(SGOT)-39 LD(LDH)-265* ALK
PHOS-38* TOT BILI-1.0 DIR BILI-0.5* INDIR BIL-0.5
[**2138-9-17**] 11:50AM ALBUMIN-3.1* CALCIUM-8.0* PHOSPHATE-2.2*
MAGNESIUM-1.5*
[**2138-9-17**] 11:50AM WBC-2.5*# RBC-2.35* HGB-8.4* HCT-24.8*
MCV-105* MCH-35.7* MCHC-33.9 RDW-20.3*
[**2138-9-17**] 11:50AM NEUTS-93* BANDS-0 LYMPHS-4* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2138-9-17**] 11:50AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2138-9-17**] 11:50AM PLT SMR-RARE PLT COUNT-14*#
[**2138-9-17**] 11:50AM PT-11.6 PTT-20.6* INR(PT)-1.0
[**2138-9-17**] 11:50AM GRAN CT-2325
.
Imaging:
CXR: Single AP view of the chest reveals the tip of a port line
in the SVC in satisfactory position. The mediastinum is
midline. There is peribronchial thickening and increased
markings in both lung bases without gross consolidation however
early pneumonitis in the left lower lobe cannot be excluded.
.
Nuclear bleeding scan: negative per oral report
CHEST (PORTABLE AP)
Reason: progression of opacities, likely PCP [**Name Initial (PRE) 1064**]
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman with myelodysplastic syndrome, with fever and
neutropenia, with decreased o2 sats and SOB.
REASON FOR THIS EXAMINATION:
progression of opacities, likely PCP pneumonia
HISTORY: Fever. Shortness of breath.
Single portable radiograph of the chest demonstrates similar
cardiomediastinal contour to that seen on [**2138-10-15**]. Right-sided
Port-A-Cath remains unchanged. Increased opacity involving the
bilateral lungs remains similar in appearance. There is very
mild blunting of the bilateral costophrenic angles. Trachea is
midline.
IMPRESSION:
No interval change.
CT CHEST W/O CONTRAST [**2138-9-28**] 3:47 PM
CT CHEST W/O CONTRAST
Reason: please evaluate for infiltrates
[**Hospital 93**] MEDICAL CONDITION:
70 year old woman with MDS fevers, acute hypoxia
REASON FOR THIS EXAMINATION:
please evaluate for infiltrates
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: CT of the chest without contrast.
INDICATION: 70-year-old female with history of myelodysplastic
syndrome presenting with fevers, acute hypoxia. Assess for
infiltrates.
COMPARISONS: [**2138-9-24**].
TECHNIQUE: MDCT axial images of the lungs are acquired. Coronal
and sagittal reformatted images were then obtained.
CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: There are several,
subcentimeter mediastinal lymph nodes. No pathologically
enlarged axillary or hilar lymph nodes are present. A small
pericardial effusion is relatively unchanged in size compared to
the examination four days prior. A moderate- to large-sized
hiatal hernia is also again noted.
Lung windows demonstrate dramatic interval change with diffuse,
ground-glass opacities present throughout both lungs, mostly new
compared to the previous examination. A few pulmonary nodules
within the right lung are again noted and unchanged compared to
the previous examination. Incidental note is also made of
bibasilar atelectasis.
No lytic or blastic lesions within the osseous structures are
noted. Limited views of the upper abdomen are unremarkable.
IMPRESSION: Multifocal air-space process throughout both lungs
dramatically new compared to examination from four days prior.
Given the non-pathologic but prominent mediastinal
lymphadenopathy, infectious etiologies including atypical
infections if the patient is immunocompromised should be
considered. ARDS given the timing of these findings is also a
diagnostic consideration. Clinical correlation is advised. No
pleural effusion.
Findings were discussed with Dr. [**Last Name (STitle) **] at 4:55 pm by Dr.
[**First Name (STitle) 7747**] over the telephone on [**2138-9-28**].
[**2138-10-28**]
HCT 28.8
platelet 67
wbc 3.5
Na 130
creat 1.9
BUN 25
K 4.5
Brief Hospital Course:
A/P: 70 y.o. woman with myelodysplastic syndrome and resultant
pancytopenia and recurrent GIB associated with ulcerations in
her small intestine.
.
# GI Bleeding: Likely due from previously discovered small
intestinal ulcerations, with increased propensity for bleeding
given thrombocytopenia. No evidence of UGIB. Baseline hct 32,
was 22 on admission. On the second day of hospitalization the
patient had further bleeding per rectum, became hypotensive, and
had sinus tachycardia to 140. She was soon transferred to the
MICU. While in the ICU, Angiography did not show active bleed,
although unable to catheterize the [**Female First Name (un) 899**]. Tagged RBC study also
did not show site of bleed. At present, there are no surgical
or endoscopic options, so will continue with supportive care.
NG lavage was negative. The patient received numerous PRBC
transfusions. Platelets remain above 50 after many platelent
transufsions. After stabilization, the patient was transferred
to the floor where she remained hemodynamically stable for the
remainder of her hospitalization. She did have occasional
BRBPR, and always remained guaiac positive. She continued to
receive prbc's nearly every other day to maintain a stable
hematocrit, and she received HLA matched platelets on nearly a
daily basis to maintain her platelet count over 50.
.
# Neutropenic fever: The patient finished her 5th day of
decitabine for MDS treatment on [**9-12**]. Previous to decitabine
therapy the patient had adequate cell counts, and after
decitabine the patient became progressively neutropenic. On
return to the floor form the MICU the patient proceeded to spike
daily fevers as high as 103.0, with associated rigors. The
source of fever was not identified. Daily blood cultures were
negative. stool was C.Diff negative. The patient placed on
several antibiotics, including vancomycin, Zosyn, Flagyl, and
fluconazole, and continued to spike. CT chest/Abdomen/Pelvis on
[**9-24**] did not reveal a source of fevers. CT Pelvis
revealed fat stranding and questionable external iliac [**Last Name (un) **]
thrombus, followup MRI showed fat stranding but no thrombus.
Antibiotics eventually switched to Vanc/Cefepime/Flagyl
(cefepime was discontinued secondary to drug rash), to
Vanc/Aztreonam/Caspofungin. The patient desaturated on [**9-28**] to
78%, and CT chest showed extensive infiltrates. Clinical
suspicion for PCP was high, and after consulting ID, the patient
was maintained on Vanc/Caspo/Meropenem, and the patient was
begun on Bactrim and steroids empirically, unable to perform
bronchoscopy with the high likelihood of being unable to
extubate her. Soon after Bactrim administration her fevers
stopped. She was continued with a full 14 day course of IV
Bactrim. After completing this course she was transitioned to
Bactrim DS 3 times weekly.
.
#O2 desaturation-Patient began to desat on [**9-26**]. Thought
initially to be due to fluid overload in setting of increased
platelet and prbc transfusions, and CT on [**9-24**] showing bibasilar
atelectasis. Oxygen improved with lasix on [**9-26**] and [**9-27**], and
patient was saturating at 94% on room air on [**9-27**]. Patient
desaturated to 78% on [**9-28**]. CT chest showed extensive
infiltrates. ID reccomended broad antibiotic coverage, and
biggest concern was for PCP in the setting of an
immunocompromised patient. She was subsequently begun on
Bactrim and steroids. Soon after bactrim administration the
patient stopped spiking fevers, however she persisted with low
oxygen saturation and required 6L O2 by nasal cannula. The
patient's O2 saturation ranged from 89-94%, and appeared to
improve with lasix administration. She occasionally required
masked ventilation to maintain O2 saturation over 90%. After
six days of bactrim therapy, her bactrim was discontinued out of
concern that it was contributing to the patient's neutropenia.
Primaquine and clindamycin were begun instead. Her neutrophil
count slowly increased over a period of four days from 40 to
170, she remained afebrile, but her oxygenation did not improve.
On [**10-12**] the patient was transferred back to the ICU after
having another acute oxygen desaturation of 78% on 6LNC. Patient
was stabilized and transeferred back to the floor on NRB 100%,
she continued on IV antibiotic regimen of meropenem and Bactrim.
She remained afebrile and was continued on Bactrim and
voriconazole. She was able to be weaned to 99% on 3L nasal
cannula prior to discharge. Her prednisone dose was tapered, she
was discharge on Prednisone 30mg AM, 10mg PM per Dr. [**First Name (STitle) 1557**] who
will follow her at the rehabilitation facility. Given her risk
of GIB it was very important to taper her steroid dose.
# MDS: The patient is s/p decitabine treatment from [**9-12**], and
gradually became neutropenic. While in the hospital her
cyclosporine was discontinued. She was administered neupogen
and her counts eventually recovered slowly. Her last ANC on the
day of discharge was 3100. Further treatment for underlying
disease at Dr.[**Name (NI) 6168**] discretion.
# Hyponatremia: Urine electrolytes consistent with SIADH, likely
from the pulmonary process. She was fluid restricted to 1L, it
was diffucult to mantain this restriction given the IV
medications. Once she was taken off the IV meds her sodium level
rose, 130 upon dishcharge. She was continued on salt tabs.
#Sundowning: Her mental status would wax and wane at nighttime,
multifactorial etiology of undrlying infection, hypoxia,
hyponatremia and medications. Her medication list was reviewed
and with treatment of her underlying disease her mental status
improved. She was alert and oriented at discharge.
Medications on Admission:
Home Medications:
1. Cyclosporine 50 mg twice daily
2. IVIG finished 9 week therapy 3 weeks ago.
3. Prednisone 20 mg daily, 15mg qam, 5mg qpm
4. Decitabine c1 [**Date range (3) 51772**]
5. Metoprolol 50mg twice daily
6. Aranesp PRN
7. Vitamin B6
8. Folic Acid
9. Danazol 200g Daily
10. Protonix 40mg Daily
11. Potassium 20mEq twice daily
12. Mg supplements.
.
Medications on transfer:
Meperidine 25-50 mg IV Q6H:PRN
Acetaminophen 325-650 mg PO Q6H:PRN
Nystatin Oral Suspension 5 ml PO QID:PRN
CycloSPORINE (Sandimmune) 50 mg PO Q12H
Pantoprazole 40 mg PO Q12H
Danazol 200 mg PO QD
DiphenhydrAMINE 25 mg PO Q6H:PRN
FoLIC Acid 1 mg PO DAILY
HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN pain
Zolpidem Tartrate 10 mg PO HS:PRN
Hydrocortisone Na Succ. 100 mg IV Q8H
Lorazepam 0.5 mg PO Q8H:PRN
Zosyn 2.25mg Q6h
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q2H (every 2 hours) as needed for wheezing.
3. Danazol 200 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
14. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-21**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for dry nose.
16. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO BID (2
times a day) as needed for hyponatremia.
17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
19. Prednisone 20 mg Tablet Sig: 0.5 Tablet PO QPM for 5 days.
20. Prednisone 20 mg Tablet Sig: 1.5 Tablets PO QAM for 5 days.
Discharge Disposition:
Extended Care
Facility:
NE [**Hospital1 41724**]
Discharge Diagnosis:
Primary:Aplastic anemia/Hypocellular myelodysplastic syndrome
with trisomy 8 and 21. s/p high dose prednisone and gamma
globulin, s/p Anti-thymocyte globulin therapy [**2126**], on
cyclosporine since with renal insufficiency; started IVIG q3
weeks [**2138-7-10**]
Empiric tx for PCP [**Name Initial (PRE) 1064**]
s/p terminal ileum resection [**3-26**] for multiple bleeding
ulcers
h/o candidemia with [**Female First Name (un) 564**] parapsilosis
Renal insufficiency (recent baseline Cr 1.2 - 1.6)
Hypertension
h/o hypercholesterolemia
Past Surgical History:
- TAH/BSO [**2-21**] fibroids
- Appendectomy
- Venous stripping LLE
Discharge Condition:
Stable, ambulating with assistance, alert and oriented
Discharge Instructions:
You were admitted with GI bleeding, you were in the ICU and
transfused. Your hospital course was further complicated by
hypoxia which was treated as PCP [**Name Initial (PRE) 1064**]. This led to 2
transfers to the ICU for problems [**Name (NI) 51773**] your oxygen status.
You completed treatment for PCP pneumonia and your oxygen was
weaned to 3 liter by nasal canula. You have an appointment with
Dr. [**First Name (STitle) 1557**] on [**2138-10-31**] at 11 am for follow up. Take all of your
medications as prescribed.
Followup Instructions:
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2138-11-28**] 12:30
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2138-10-31**] 11:00
ICD9 Codes: 5856, 5990, 7907, 4589, 2720, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1871
} | Medical Text: Admission Date: [**2154-10-17**] Discharge Date: [**2154-10-19**]
Date of Birth: [**2105-7-28**] Sex: F
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:
None
History of Present Illness:
49 year old female with hx metastatic renal cell carcinoma on
sutent s/p gemzar chemotherapy on [**10-14**] presented to clinic with
dizziness and malaise. She was found to be hypotensive to the
80s, and tachycardic at 112, pale but mildly jaundiced which was
an acute change. She was also initially hypothermic at 94. She
was then brought to the ED were rectal temp was 98, BP 100/60s,
and tachy 100-110s. Received IVF. Denied pain. Found to be in
acute liver failure. A CTA was performed which showed no PE but
with increased vascular resistance in the R M/L lobes, known R
mediastinal mass with mass effect on SVC, worsening collapse of
entire R lung and finally R pleural effusion. Recently she has
been admitted for a presumptive pna on levo/flagyl dc'd on [**9-16**]
with completion of her antibiotics on [**2154-9-21**]. She denied
further symptoms at that time. C/o increased WOB and fever for
last 2 days, that has worsened to dyspnea at rest. Increasingly
weak for last 7 days and cannot ambulate for more than a few
feet, eating fatigues her. Denies any other localizing symptoms
- no cough, chest pain, fever, abdominal pain, diarrhea, rashes
or headaches. Confirms poor food intake for last several days.
Past Medical History:
Depression
Renal Clear Cell Carcinoma, [**Last Name (un) 19076**] grade [**2-3**] s/p right radical
nephrectomy with venacavotomy, with pulmonary metastases, s/p
multiple chemotherapeutic regimens most recently C3D1 of
gemzar/sutent on [**10-14**]
Peridontal disease
Bartholin cysts
Social History:
Divorced, 2 adult kids, quit tobacco at age 30 after 1ppd x 10
years, social EtOH, lives in [**State 1727**]. Sister lives in [**Name (NI) 86**]
area. Son, [**Name (NI) 916**] lives in [**Location 86**]. Daughter lives in [**Location **].
Family History:
colon ca mother age 80, [**Name2 (NI) 3685**] in maternal aunts, older age
Physical Exam:
96.8 79/61 HR 90 RR 36 SpO2 50% on nonrebreather
Gen: obvious increased work of breathing, speaking in short
sentences
HEENT: periocular pallor, perioral cyanosis, MM dry, open mouth
breathing
CV: tachycardic, regular rhythm, no m/g/r
Pulm: no breath sounds right side, left side with good air
movement, no wheeze/rale/rhonchi
Abd: +BT, soft, nontender
Ext: Cool, poorly perfused with mild cyanosis
Pertinent Results:
[**2154-10-17**] 04:20PM TYPE-ART O2 FLOW-4 PO2-23* PCO2-37 PH-7.15*
TOTAL CO2-14* BASE XS--17 INTUBATED-NOT INTUBA COMMENTS-NASAL
[**Last Name (un) 154**]
.
[**2154-10-17**] 12:05PM
WBC-9.8# RBC-3.75* HGB-11.7* HCT-37.9 MCV-101*# MCH-31.3
MCHC-30.9* RDW-16.9* NEUTS-90.0* BANDS-0 LYMPHS-8.9* MONOS-0.7*
EOS-0.3 BASOS-0.2
HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-2+
MICROCYT-NORMAL POLYCHROM-OCCASIONAL
.
[**2154-10-17**] 12:05PM
ALT(SGPT)-150* AST(SGOT)-511* LD(LDH)-674* ALK PHOS-166* TOT
BILI-4.5* DIR BILI-2.7* INDIR BIL-1.8
.
[**2154-10-17**] 12:05PM UREA N-31* CREAT-1.2* SODIUM-138
POTASSIUM-6.2* CHLORIDE-96 TOTAL CO2-13* ANION GAP-35*
.
[**2154-10-17**] 01:30PM URINE
COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021 BLOOD-LG NITRITE-NEG
PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-8*
PH-5.0 LEUK-NEG
RBC-[**11-19**]* WBC-[**3-4**] BACTERIA-FEW YEAST-NONE EPI-[**3-4**] GRANULAR-[**3-4**]*
HYALINE-21-50*
.
[**10-17**] CTA - IMPRESSION:
1. No evidence of aortic dissection or central/segmental
pulmonary emboli. Subsegmental branches within the right middle
and right lower lobe are incompletely opacified due to increased
vascular resistance.
2. No significant interval change since prior exam of the known
large
invasive right mediastinal mass, adjacent mass effect on the
SVC, and
development of collateralization.
3. Moderate increase in size to a loculated right pleural
effusion with fissural component. New small left pleural
effusion. Mild amount of adjacent linear and dependent
atelectasis.
.
[**9-9**] CT Abd/Pelvis
IMPRESSION:
1. Increased size and mass effect of metastatic lesion in the
mediastinum/right hilum which now almost completely occludes the
SVC with increased collateralization. The right main pulmonary
artery is also significantly compressed.
2. Increased right pleural effusion, partly loculated.
3. Other pulmonary lesions have increased in size.
Brief Hospital Course:
49 F with met RCC presents with SOB found to have near total
collapse/occulusion of her right lung [**2-1**] tumor progression.
Have discussed futility of care, and she's confirmed a CMO
status.
.
# SOB - No PE evident on CTA, CT with evidence of tumor
progression and collapse of most of right lung with minimal
perfusion and pleural effusions. Initially began antibiotics and
fluid resuscitation. Discussed ultimate poor outcome with
patient, and that if intubated it is unlikely she would be
successfully extubated. And that intubation needed to be soon
given her poor oxygenation. Pt chose to be CMO at this point and
requested we contact her family to come in, which we did. Was
started on a morphine gtt which helped with her dyspnea. Her
family arrived and she was continued on CMO status until her
death on [**2154-10-19**].
.
# Acid/base- Metabolic Acidosis- 31 Gap acidosis, with Elevated
lactate, also with inappropriate respiratory compensation, thus
likely respiratory alkalosis, with mixed metabolic alkalosis
given the anion gap difference is 20, and change in bicarb is
17. Given D5 3amps bicarbonate. Patient then decided to be CMO,
so stopped attempted to aggressively treat her acid-base
abnormalities. No labs were drawn the last day of her life
given her CMO status.
.
# ARF - Likely prerenal in the setting of hypotension, low fluid
intake. Bolused with IVF, then transitioned to CMO. Was not
treated with further IV fluids. Expired [**2154-10-19**].
.
# Increased LFTs- New lab abnormality, no evidence of malignancy
on recent CT, likely associated with worsening SVC syndrome,
hepatic congestion, or possible new metastases. Did not pursue
further work-up on admit given CMO status.
.
# Hypothyroidism- Held synthroid given CMO status. Expired
[**2154-10-19**].
.
Expired [**2154-10-19**] due to cardiopulmonary arrest in the setting of
widely metastatic lung cancer.
Medications on Admission:
Venlafaxine 150 mg Daily
Levothyroxine 75 mcg Daily
Docusate Sodium 100 [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Prilosec 20 mg QD
Albuterol 90 mcg q6h
Ipratropium Bromide 17 mcg Inhaler
Discharge Medications:
Expired [**2154-10-19**]
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic Lung Cancer
Discharge Condition:
Expired [**2154-10-19**]
Discharge Instructions:
Expired [**2154-10-19**]
Followup Instructions:
Expired [**2154-10-19**]
ICD9 Codes: 5180, 5849, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1872
} | Medical Text: Admission Date: [**2162-6-23**] Discharge Date: [**2162-6-28**]
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Fever
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo female with history of dementia presented with altered
mental status, fever, vomiting and lethargy.
In the ED, initial vitals were 101 95 192/65 18 98% 3L.
-PE: loud diffuse systolic ejection murmur. AAOX self and
location. Follows commands selectively. Non focal neurological
exam.
-Labs notable for leukocytosis w/ left shift, Transaminitis w/
bilirubinemia.
-CXR was done
-CT a/p was done for elevated LFTs/tbili
-She was given flagyl, vanco, and levaquin
-Full Code per graddaughter. She will bring living will in AM
Most Recent Vitals: 98.4 94 18 118/46 97% 2l.
Spoke to patient's daughter who reports patient's memory is poor
but she can hold a conversation. She recognizes most people
unless she hasn't seen family memebers in a long time. She
feeds herself, is mobile and goes down to dining room herself.
On arrival to the MICU, she is comfortable and reports achy
bilateral hip pain. She reports chronic abdominal and back pain
unchanged from prior.
Past Medical History:
- Dementia
- Arthritis
- Sjogrens
- Cataracts
- Bleeding ulcer
- Narrow complex tachycardia: [**1-29**], reverted to sinus, on
toprol.
- L2-L3 compression fractures
- Anterior abdominal wall fat-containing hernia and right
inguinal hernia
Social History:
Lives in [**Hospital3 **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] facility and ambulates with
walker. All of her cooking and cleaning are done for her. She
has help in shower three times per week. Previously interior
decorator, has 3 children, widowed, family very involved. Drinks
alcohol only on holidays, no smoking.
Family History:
Mother/Father with CAD.
Physical Exam:
Admission:
Vitals: 98.2 76 100/34 17 97% on 2L
General: Alert, oriented to self and hospital, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, 3/6 SEM best heard over RUWB
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: +BS, soft, non-distended, tender over epigastrium and
umbilicus, pain with attempt at reduction of umbilical hernia,
no peritoneal signs
GU: +foley
Ext: wwp, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Discharge:
Vitals: T: 97.7 BP: 144/70 P: 70 R: 18 O2: 97% on RA
General: Alert, oriented to self, comfortable, no acute
distress, sleeping
HEENT: Sclera anicteric, MMM
Neck: Supple. No LAD.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic
ejection murmur heard best at RUSB, no rubs, gallops
Abdomen: Soft, protuberant, non-distended, nontender, bowel
sounds present
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2162-6-23**] 10:30PM BLOOD WBC-18.6*# RBC-4.54 Hgb-11.8* Hct-36.2
MCV-80* MCH-25.9* MCHC-32.5 RDW-16.8* Plt Ct-461*
[**2162-6-23**] 10:30PM BLOOD Neuts-93.7* Lymphs-2.9* Monos-3.1 Eos-0.2
Baso-0.1
[**2162-6-24**] 05:49AM BLOOD PT-14.3* PTT-31.3 INR(PT)-1.3*
[**2162-6-23**] 09:15PM BLOOD Glucose-124* UreaN-13 Creat-0.6 Na-133
K-3.7 Cl-96 HCO3-22 AnGap-19
[**2162-6-23**] 09:15PM BLOOD ALT-599* AST-788* AlkPhos-209*
TotBili-2.6*
[**2162-6-23**] 10:30PM BLOOD DirBili-1.1*
[**2162-6-23**] 09:15PM BLOOD Lipase-3582*
[**2162-6-24**] 05:49AM BLOOD Lipase-1236*
[**2162-6-23**] 09:15PM BLOOD proBNP-1234*
[**2162-6-23**] 09:15PM BLOOD Albumin-4.0 Calcium-9.5 Phos-3.2 Mg-2.0
[**2162-6-24**] 05:49AM BLOOD Triglyc-65 HDL-51 CHOL/HD-2.7 LDLcalc-72
[**2162-6-23**] 10:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2162-6-23**] 08:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2162-6-23**] 08:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2162-6-23**] 08:15PM URINE RBC-3* WBC-2 Bacteri-MOD Yeast-NONE Epi-0
[**2162-6-23**] 08:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS:
[**2162-6-28**] 05:55AM BLOOD WBC-12.3* RBC-4.65 Hgb-12.0 Hct-36.7
MCV-79* MCH-25.9* MCHC-32.8 RDW-17.2* Plt Ct-500*
[**2162-6-28**] 05:55AM BLOOD Neuts-68.8 Lymphs-17.4* Monos-9.9 Eos-3.6
Baso-0.2
[**2162-6-28**] 05:55AM BLOOD Plt Ct-500*
[**2162-6-25**] 04:14AM BLOOD PT-14.3* PTT-48.6* INR(PT)-1.3*
[**2162-6-28**] 05:55AM BLOOD Glucose-130* UreaN-9 Creat-0.4 Na-135
K-3.9 Cl-101 HCO3-24 AnGap-14
[**2162-6-28**] 05:55AM BLOOD ALT-92* AST-26 AlkPhos-108* TotBili-0.5
[**2162-6-28**] 05:55AM BLOOD Lipase-425*
[**2162-6-28**] 05:55AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8
[**2162-6-24**] 05:49AM BLOOD Triglyc-65 HDL-51 CHOL/HD-2.7 LDLcalc-72
MICRO:
[**2162-6-23**] 8:15 pm URINE
**FINAL REPORT [**2162-6-25**]**
URINE CULTURE (Final [**2162-6-25**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2162-6-23**] 9:00 pm BLOOD CULTURE #1.
**FINAL REPORT [**2162-6-27**]**
Blood Culture, Routine (Final [**2162-6-26**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ESCHERICHIA COLI. SECOND STRAIN. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ 8 S 8 S
AMPICILLIN/SULBACTAM-- 4 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Aerobic Bottle Gram Stain (Final [**2162-6-24**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 43649**] [**2162-6-24**] 9:30AM.
Anaerobic Bottle Gram Stain (Final [**2162-6-24**]): GRAM
NEGATIVE ROD(S).
[**2162-6-23**] 9:15 pm BLOOD CULTURE #2.
**FINAL REPORT [**2162-6-26**]**
Blood Culture, Routine (Final [**2162-6-26**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
350-1181H
[**2162-6-23**].
Aerobic Bottle Gram Stain (Final [**2162-6-24**]): GRAM NEGATIVE
ROD(S).
Anaerobic Bottle Gram Stain (Final [**2162-6-24**]): GRAM
NEGATIVE ROD(S).
Blood cultures [**2162-6-25**] and [**2162-6-26**]: Pending (NGTD).
MRSA SCREEN (Final [**2162-6-26**]): No MRSA isolated.
CT A/P:
1. Prominent common bile duct measuring up to 1 cm, similar
from prior.
Mildly increased intrahepatic biliary ductal dilatation. No
clear distal
obstructing lesion is identified.
2. No intra-abdominal fluid collection to suggest abscess
formation. No
ascites.
3. Appendix not clearly visualized; however, no secondary signs
of acute
appendicitis.
4. Sigmoid diverticulosis without signs of acute
diverticulitis.
5. Cecum containing right inguinal hernia without evidence of
obstruction, unchanged from prior.
6. Stable severe compression deformities of the L2 and L3
vertebral bodies.
CXR: 1. Bibasilar opacities concerning for pneumonia in this
patient with fever and altered mental status, though atelectasis
is also possible.
2. Probable small left pleural effusion.
RUQ u/s [**2162-6-27**]: FINDINGS: There are no focal hepatic lesions.
There is no intra- or extra-hepatic biliary dilation with the
common bile duct measuring between 6 and 8 mm. There is no
evidence of obstruction, stones or masses in the CBD.
Gallbladder is normal without stones.
Spleen is normal in size measuring 7 cm. The left kidney
measures 10.3, the right kidney measures 10.2 cm without
evidence of hydronephrosis, stones, or masses. The portal vein
is patent with normal hepatopetal flow. The abdominal aorta and
IVC are normal.
IMPRESSION: Normal CBD and no evidence of gallstones.
Brief Hospital Course:
[**Age over 90 **] yo female with history of dementia who reportedly had fever
and altered mental status at her nursing home found to have pan
sensitive E. Coli septicemia likely from a biliary source.
# E. Coli Septicemia likely secondary to Cholangitis: Patient
noted on initial blood cultures to have pan-sensitive E coli.
She was initially started on Unasyn to cover likely biliary
source, transitioned to ceftriaxone and then PO cefpodoxime with
plan for total 14 day course (on day 5 of 14 on day of
discharge). Likely biliary source of bacteria; initial concern
for urinary source given GNR in urine, but later grew out
pan-sensitive Klebsiella in urine. Most likely source of
septicemia is cholangitis given initial intrahepatic ductal
dilitation and CBD dilitation on CT; resolved by day prior to
discharge per RUQ ultrasound. No evidence of stones in the
gallbladder on day prior to discharge; no evidence of
obstructive mass on imaging, and given the resolution of the
symptoms, she likely had a transient obstruction from a stone
that has since passed. The patient improved clinically and her
LFTs and white count trended down, with WBC 12 on day of
discharge.
.
# Pancreatitis: Patient with abdominal pain, elevated lipase,
and dusky stranding around pancreas on CT scan on admission.
Bisap score was 3 given age, SIRS criteria (fever and
leukocytosis), and pleural effusion. She was mildly
hemoconcentrated with elevated hct and dry on exam. Most likely
cause of pancreatitis is gallstones given prominent CBD
(although size normal for age) and intrahepatic ductal
dilatation, though CBD diameter stable from previous imaging and
resolved on RUQ u/s on day prior to discharge. No clear inciting
medications, normal TG, and no EtOH. No evidence of malignancy
causing obstruction based on CT scan, and symptoms resolved
without intervention making persistant obstruction unlikely.
Considered ERCP but felt risk outweighed potential benefit given
rapid improvement with antibiotics and conservative management.
She was initially managed conservatively with NPO, IVF, and diet
was advanced which she tolerated. On day of discharge, abdominal
pain resolved and all labs trending towards normal.
.
# HTN: The patient's SBP was quite labile, ranging from 100 on
admission to 190 on the floor. Had been on metoprolol succinate
12.5 mg daily which was held in the ICU given septicemia.
Restarted on metoprolol succinate 25 mg daily on discharge.
.
# Bacteruria: Patient's urine grew pan-sensitive Klebsiella. No
urinary symptoms. Likely asymptomatic bacturia, not source of
septicemia; covered by cefpodoxime.
.
# Umbilical hernia: Mildly tender but reducible. No signs of
obstruction, strangulation, or incarceration. Initially elevated
lactate, now trended down and within normal limits on discharge.
.
# Dementia: Granddaughters report she is at her baseline.
Initially held donepizil, then later restarted.
.
# Sjogrens: Stable. Continued artificial tears.
.
# Code status: Per extensive discussion with granddaughter,
patient now DNR/DNI.
# Transitions:
1) Blood cultures pending from [**2162-6-25**] and [**2162-6-26**]
2) Finish 14-day course of cefpodoxime 400 mg [**Hospital1 **], to be
completed [**2162-7-7**]
3) Monitor blood pressure, may benefit from different
antihypertensive medications given labile blood pressure
4) Consider RUQ ultrasound or MRCP as outpatient if develops
abdominal pain in the future
Medications on Admission:
1. Vitamin D 1,000 unit Capsule daily
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) daily
4. Metoprolol succinate 25 mg Tablet Sig: 0.5 Tablet PO daily
5. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
6. Oxycodone 5 mg Capsule Sig: 2 Capsules PO BID
7. Calcium carbonate-vit D3-min 600 mg calcium- 400 unit Tablet
[**Hospital1 **]
8. Glucosamine-chondroitin 500-400 mg Tablet (2) Tablet [**Hospital1 **]
10. Alendronate 70 mg Tablet Sig: One (1) Tablet PO every Monday
11. Miralax 17 gram/dose Powder Sig: One (1) packet PO tid
12. Artificial Tears Drops Sig: 1-2 drop Ophthalmic tid prn
13. Cranberry 1 tab daily
Discharge Medications:
1. Artificial Tears 1-2 DROP BOTH EYES PRN irritation
2. Donepezil 10 mg PO HS
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Polyethylene Glycol 17 g PO TID:PRN constipation
7. Vitamin D 1000 UNIT PO DAILY
8. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 9 Days
Last Day [**2162-7-7**]
RX *cefpodoxime 200 mg 2 Tablet(s) by mouth twice a day Disp
#*36 Tablet Refills:*0
9. Miconazole Powder 2% 1 Appl TP PRN rash
RX *Anti-Fungal 2 % Please apply to rash Four times a day Disp
#*1 Bottle Refills:*0
10. Alendronate Sodium 70 mg PO QMON
11. calcium carbonate-vitamin D3 *NF* 600 mg calcium- 200 unit
Oral [**Hospital1 **]
12. glucosamine-chondroitin *NF* 500-400 mg Oral [**Hospital1 **]
13. OxycoDONE (Immediate Release) 5-10 mg PO BID:PRN pain
This medication was held during hospitalization
14. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 8463**] [**Last Name (NamePattern1) **] Place
Discharge Diagnosis:
Acute Cholangitis
Septicemia (blood stream infection)
Pancreatitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted for abdominal pain and fever. You were found to have a
bacteria called E. coli in your blood, originally from an
infection of your gall bladder and bile ducts. You will continue
an antibiotic called cefpodoxime for a total duration of 14
days.
See attached for any medication changes.
Followup Instructions:
You will have a follow-up appointment scheduled with your rehab.
ICD9 Codes: 5990, 2761, 2768, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1873
} | Medical Text: Admission Date: [**2195-5-17**] Discharge Date: [**2195-5-24**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
left sidedweakness, confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:89 yo RHF with ho of uncontrolled HTN and severe peripheral
neuropathy who presents with confusion, dysarthia and left
face/arm weakness and CT findings showing right thalamic
hemorrhage with ventricular extension. Patient was in her usual
state of health until appx 7:30 pm last night when she was noted
to be calling a well known dinner guest by her daughter's name.
The patient persistently made this error and it was later noted
she was clumsy with the left hand. She required more assistance
with transfers from her wheelchair later in the evening and then
left arm noted to have weakness. She was taken to OSH where VSS
showed SBP 200-230s. She had CT head which showed 2.6 cm
hemorrhage in right thalmus with intraventricular hemorrhage, no
hydrocephalus. The patient was transferred to [**Hospital1 18**] for further
care.
Past Medical History:
PMHx:
-HTN-uncontrolled for at least 5 years
-idiopathic peripheral neuropathy-wheelchair bound
-hyponatremia/hypokalemia
-h/o left breast cancer dx [**2177**] (s/p lumpectomy and XRT)
-Lumbar fractures after MVC at age 40 y
-Pelvic fracture after fall in [**2180**]
-h/o of seizures while in 40s thought to be secondary to benzene
exposure
-cataract surgery bilat
Social History:
Social Hx: lives with daughter; nonsmoker/nondrinker.
Family History:
Family Hx:Mother died of stroke at age 70y, no bleeding
dyscrasias in family. 2 younger sisters with peripheral
neuropathy
Physical Exam:
PHYSICAL EXAM:
O: T: AF BP:107-157/39-69 HR: 60-66 R [**12-18**] O2Sats
96-100% 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: irreg, reactive to light 4 mm-> 3mm
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.Murmur present
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect, talkative.
Orientation: Oriented to person and date.
Recall: [**1-7**] objects at 5 minutes.
Language: Speech dysarthic with good comprehension and
repetition.
Naming intact [**2-7**] lo freqhency objects.
Cranial Nerves:
I: Not tested
II: Pupils equally irreg and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: left facial droop
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.
D B T WE WF FF FE
R 5 5 5 5 5 5 5
L 4 5 4 4- 5- 4+ 3+
IP Q H DF PF [**Last Name (un) 938**]
R 5- 5- 5- 5 5 5
L 5- 5- 5- 5- 5 5
Sensation: Intact to light touch. Decreased vibration in toes
bilat.
Reflexes: B T Br Pa Ac
Right 1 1 1 1 0
Left 1 1 1 1 0
Toes upgoing bilaterally.
Coordination: slightly dysmetric FNF bilat.
Pertinent Results:
[**2195-5-22**] 06:30AM BLOOD WBC-9.6 RBC-2.82* Hgb-8.7* Hct-26.0*
MCV-92 MCH-30.9 MCHC-33.5 RDW-19.9* Plt Ct-378
[**2195-5-17**] 08:04AM BLOOD Neuts-66.2 Lymphs-23.4 Monos-7.0 Eos-3.0
Baso-0.5
[**2195-5-22**] 06:30AM BLOOD Glucose-104 UreaN-19 Creat-0.5 Na-134
K-3.8 Cl-100 HCO3-27 AnGap-11
[**2195-5-22**] 06:30AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.2
CT head [**2195-5-17**]:
No significant change in the appearance of the right thalamic
intraparenchymal hemorrhage with 6 mm right to left midline
shift, obliteration of the left ventricle and dissection into
the left lateral ventricle. No change in the amount of blood in
the occipital [**Doctor Last Name 534**] of the left lateral ventricle, cerebral
aqueduct and fourth ventricle.
CT head [**2195-5-19**]:
Since the prior examination of [**2195-5-17**], there has been no
change in the right thalamic hemorrhage. There are unchanged
amounts of intraventricular blood present. The size of the
ventricular system is enlarged consistent with worsening
communicating hydrocephalus. The mass effect and minimal
leftward midline shift are also unchanged. No new intracranial
hemorrhage is noted. On today's exam, the blood in the fourth
ventricle is no longer apparent.
Unchanged amounts of chronic microvascular ischemic change are
again identified. There is no evidence of herniation.
Brief Hospital Course:
Neurology: Patient admitted to ICU under Neurology for
hypertensive associated intracranial hemorrhage of the left
thalamus. Patient received Neurosurgical consultation but no
surgical intervention needed as she had no evidence of clinical
decline of neurological status. In ICU, blood pressures were
controlled with metaprolol. She was transferred to the floor and
monitored in the step down unit for 24 hours because of CT scan
on [**2195-5-19**] showing increased non-communicating hydrocephalus.
Patient continued to show no evidence of decline in neurological
status and remained stable on floor. She had episodes of HTN
noted with SBP 170-180s so Metaprolol increased to 37.5 mg po
tid and Lisinopril 20 mg po qday added. This improved SBP to
goal of SBP > 90 and less than 160. Her discharge exam shows Ax
0 x 2 (forgets month and date), alert, occassional paraphasic
errors, mild dysarthia, left facial weakness, left wrist
extensors [**4-9**] and left finger extensor [**4-9**] and triceps 5-/5. She
passed a swallow study and tolerated regular diet. She was
treated for 3 days with for UTI found on admission
(ENTEROBACTERIACEAE species sensitive to Ciprofloxacin). She
refused to urinate in bedside commode and foley had to be
replaced. Was recommended for STR to which she agreed. Was
transferred [**5-24**] t SKRH.
Prior to d/c she was restarted on cipro for recurrent UTI.
Please repeat UA at rehab, and adjust treatment if indicated.
Medications on Admission:
Medications prior to admission:
1.demeclocycline 300mg [**Hospital1 **]
2. hydralazine 25 qam/ 50mg qpm;
3. sertraline 25mg qam
4. synthroid 175mcg qam
5. toprol XL 50mg qam
6. PRNs: colace #1 tid; tylenol 325mg tid.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Demeclocycline 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): hold for SBP <120.
11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: starting date was [**5-24**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
left thalamic hemorrhage
UTI
Discharge Condition:
left lower facial weakness, mild dysarthia, left wrist ext
weakness 4/5 and finger ext weakness 4/5 and triceps 5-/5.
Discharge Instructions:
Follow-up as instructed
Followup Instructions:
Stroke Neurology: [**Hospital1 18**] [**Hospital Ward Name 23**] bldng [**Location (un) **]. Provider:
[**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2195-6-22**] 3:00 pm
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2195-5-24**]
ICD9 Codes: 431, 5990, 2761, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1874
} | Medical Text: Admission Date: [**2137-6-9**] Discharge Date: [**2137-6-14**]
Date of Birth: [**2057-5-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Bactrim / Nsaids
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
The patient reports that she has increased shortness of breath
both at rest and with activity in the past 24 hours with
associated yellow sputum production. She notes fevers and sweats
at home. She denies any new lower extremity edema, weight gain
or orthopnea. Her son corroborates that she had worsening,
labored breathing in the past 24 hours precipitating her to
admission through the ED.
.
In the ED, 102.2 80 138/61 40 84% 2L improved to 98% on 15L face
mask. She received 1L NS, albuterol, ipratropium, acetaminophen,
levofloxacin 750mg IV and cefepime 2g IV.
Past Medical History:
1. CAD - Cath ([**3-/2134**]) - LMCA and LCx, no disease; LAD: proximal
and mid vessel 30% stenoses; RCA - mild luminal irregularities
- Pacemaker/ICD ([**Company 1543**] Sigma SDR303 B pacemaker), in [**1-/2132**]
2. Atrial fibrillation, status post AVJ ablation and DDD pacer
3. Congestive heart failure (EF 20% in [**2134-2-16**])
4. MVR and TVR ([**4-/2132**])
5. Bronchiectasis with presumed pseudomonal colonization
([**Month (only) 404**]
[**2135**] and treated with ceftazidime and azithromycin): Previously
suffered exacerbations in [**Month (only) **] and [**2135-8-19**] that were
treated with meropenem/cipro and ceftaz as outpatient
6. Depression
Social History:
Lives in [**Location (un) 55**]. She worked as a lecturer on Egyptology
at the MFA in [**Location (un) 86**]. Husband is deceased. She lives with her
son and has an aid most days of the week. Has three sons, [**Name (NI) **],
[**Name (NI) **] and [**Name (NI) **]. Quit smoking 30 years ago, had a 5 pack year
history. Previously, she drank one drink/day but no ETOH now
for many years.
Family History:
Her father and mother are both deceased. Her father had HTN. Her
mother had [**Name (NI) 19917**] disease and died as an elderly woman. There
is a negative family history of colon cancer, breast cancer,
diabetes, and premature coronary artery disease. She has three
natural children who are alive and well and one brother who is
alive and well.
Physical Exam:
Gen: Elderly woman in facemask. Pleasant. In mild respiratory
distress. Speaking in full sentences.
HEENT: PERRL.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Tachypneic, using accessory muscles for breathing. Diffuse
harsh crackles in all lung fields worse on the left.
Abd: Soft, nontender, nondistended. No organomegaly.
Ext: No edema.
Pertinent Results:
[**2137-6-9**] 05:30PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-756*
[**2137-6-9**] 10:00PM BLOOD CK-MB-2 cTropnT-<0.01
[**2137-6-10**] 04:48AM BLOOD CK-MB-3 cTropnT-<0.01
*Negative trop x 3
[**2137-6-11**] 04:40AM BLOOD WBC-8.0 RBC-4.18* Hgb-12.0 Hct-36.3
MCV-87 MCH-28.7 MCHC-33.0 RDW-13.5 Plt Ct-220
[**2137-6-11**] 04:40AM BLOOD Glucose-93 UreaN-19 Creat-0.7 Na-135
K-3.7 Cl-100 HCO3-30 AnGap-9
==========
[**2137-6-9**]
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are no
filling defects
present within the pulmonary arterial vasculature. The heart is
top-normal in
size. There is no pericardial effusion. The aorta is normal in
caliber and
contour. Scattered vascular calcifications are noted. A
precarinal lymph
node measures 1.5 cm in short-axis diameter (3:46). A right
hilar lymph node
measures 1.8 cm in short-axis diameter (3:51). No pathologically
enlarged
left hilar or axillary lymph nodes are noted. A spiculated
opacity is
present in the left lung apex that is stable compared to
[**2135-5-3**]. A
spiculated opacity located in the right upper lobe is also
stable compared to
the previous chest CT (3:41). Overall, there has been interval
improvement in
scattered areas of peripheral parenchymal opacity. Diffuse areas
of tree-in-
[**Male First Name (un) 239**] opacities; however, are essentially stable compared to the
previous
examination. There is extensive bronchiectasis within both lungs
and several
areas of mucus plugging, most notable at the left lung base. The
imaged
portion of the upper abdomen is unremarkable.
BONE WINDOWS: Demonstrate no suspicious lytic or blastic
lesions.
IMPRESSION:
1. No pulmonary embolism or thoracic aortic dissection.
2. Stable appearance of bronchiectasis involving both lungs with
mucoid
impaction predominately affecting the left lung base.
3. Enlarged mediastinal and right hilar lymphadenopathy and
persistent tree-
in-[**Male First Name (un) 239**] opacities are relatively stable compared to the previous
examination,
likely representing chronic mycobacterial infection.
Brief Hospital Course:
Patient was admitted to [**Hospital Unit Name 153**] from ED due to worsening shortness
of breath. She was placed on a non-rebreather mask initially
and placed on single [**Doctor Last Name 360**] meropenem based on her history of
Bronchiectasis and fear of pulmonary infection. Numerous prior
bronchiectasis flares associated with pseudomonal and
non-fermenter, non-pseudomonal infections sensitive to
meropenem. Second day, patient was weaned to 5L NC (baseline
2.5L NC at home). CXR showed some increased pulmonary
vasculature thought due to fluid overload, goal to keep her
negative and start on spironolactone due to history of CHF --
however, patient was in good condition and was able to ambulate;
as a result patient was transferred to the floor.
A PICC line was placed, and after consultation with Infectious
Diseases and Pulmonary, the patient was planned to complete a
total of 14 days of therapy with meropenem. On discharge, the
patient was at her baseline oxygen requirement and baseline
exercise tolerance, without fevers or leukocytosis.
Medications on Admission:
Albuterol 90mcg 2 puffs q4-6h as needed
Alendronate 70mg weekly
Ciprofloxacin 250mg twice a day x3 days (06.16-19.08)
Citalopram 20mg Daily
Fluticasone-Salmeterol 500/50mcg 1 puff twice daily
Furosemide 10mg Daily
Lisinopril 2.5mg Daily
Lorazepam PRN
Omeprazole 20mg Daily
Simvastatin 20mg daily
Spironolactone 12.5 Daily
Tiotropium 18mcg inh Daily
Warfarin 1mg Daily
Ca-Citrate-Vit D3 315/200 3 pills Daily
Guaifenesin 1200mg twice daily as needed
MVI
Discharge Medications:
1. Meropenem 1 gram Recon Soln Sig: 1000 (1000) mg Intravenous
Q8H (every 8 hours) for 10 days: End date [**2137-6-24**].
Disp:*QS * Refills:*0*
2. PICC line care
PICC line care per Critical Care Systems routine. Normal saline
[**4-27**] mL flush prn and heparin 10 units/mL [**2-20**] mL prn.
3. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Remain upright for 30 minutes after taking dose.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
13. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q12H (every 12 hours) as needed.
14. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
15. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Three (3)
Tablet PO DAILY (Daily).
16. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
17. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
1. Bronchiectasis flare
2. Acute on chronic systolic congestive heart failure
3. Primary hyperparathyroidism
4. Osteoporosis
5. Atrial fibrillation s/p ablation and pacemaker
6. Depression
Discharge Condition:
Fair
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Please contast your primary care physician or pulmonologist if
you develop fevers, sweats, chills, or worsening shortness of
breath.
Followup Instructions:
Provider: [**Name (NI) **] [**Name (NI) **], PT Phone:[**Telephone/Fax (1) 2484**]
Date/Time:[**2137-6-14**] 3:10
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2137-6-17**] 11:15
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4506**] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2137-6-17**] 11:15
ICD9 Codes: 4280, 311, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1875
} | Medical Text: Admission Date: [**2170-2-12**] Discharge Date: [**2170-2-19**]
Date of Birth: [**2102-6-17**] Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Nausea, abdominal distention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67 yo M with history of SBO of unknown etiology presents from
home with increased lethargy today, found covered in emesis and
stool. Patient without acute complaints and states that he is
here because he "has a cold". Attempted to corraborate history
with [**Hospital 228**] health care proxy; however, HCP did not know
details of acute presentation. He was able to state that patient
is a minimizer with a high pain tolerance. [**Name (NI) **] HCP noted
that patient has severe lack of insight regarding his physical
state. The patient has reportedly gotten very sick in the past
and presented to healthcare late given minimal complaints about
physical state. He is otherwise noted to be intelligent and
fluidly conversant and typically fully oriented.
Upon presentation to the ED vitals were: T 97.7, HR 60, BP
108/71, RR 18, O2Sat 99% 3L NC. Physical exam with reported
abdominal distension, though no abdominal pain. Guaiac negative
in ED. Received 500 mL NS bolus after a brief drop in BP and was
fluid response. Following that he received an additional 3.5 L
NS prior to transfer to the ICU. Patient was started on Zosyn
and Flagyl. CT abdomen showed gaseous distension and dilation of
bowel without evidence of bowel obstruction, most consistent
with Ogilvies syndrome. A surgical consult was called and NG
tube was placed to suction. Prior to transfer to MICU vitals
were: HR 64, BP 138/79, RR 20, O2Sat 97% RA.
Past Medical History:
Bipolar disorder
SBO with colostomy and reversal in [**2162**]
HTN
Social History:
Patient lives alone at [**Location (un) 6107**] park apartments in [**Location (un) **] and
has a daily caretaker visit from [**Hospital1 **] Family and Children
Services. Denies difficulty with ADLs. He reportedly nas no
family members [**Name (NI) 95267**] in his care. Denies Tob, EtOH,
recreational drug use
Family History:
Not relevant
Physical Exam:
ON ADMISSION:
VS: T 97.8, HR 57, BP 145/79, RR 22, O2Sat 96% RA
GEN: NAD
HEENT: PERRL, EOMI, corrective lenses, NG tube in place,
NECK: Supple, no [**Doctor First Name **], no JVP elevation
PULM: Crackles at bilateral bases anteriorly, otherwise CTAB
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS hyperactive, soft, diffusely tender without rebound or
guarding, markedly distended and tympanic to percussion
EXT: no C/C/E
SKIN: no rashes
NEURO: Oriented x 3 though much prompting required for patient
to report date
PSYCH: Flat affect, conversation is strained, answers yes/no to
open-ended questions, lack of insight into reason for hospital
presentation and admission
Pertinent Results:
ADMISSION LABS:
[**2170-2-12**] 11:20AM BLOOD WBC-13.8*# RBC-4.38* Hgb-12.9* Hct-37.0*
MCV-84 MCH-29.3 MCHC-34.8 RDW-13.9 Plt Ct-264
[**2170-2-12**] 11:20AM BLOOD Neuts-85.3* Lymphs-8.0* Monos-6.4 Eos-0.1
Baso-0.2
[**2170-2-12**] 11:20AM BLOOD PT-13.3 PTT-28.4 INR(PT)-1.1
[**2170-2-12**] 11:20AM BLOOD Glucose-147* UreaN-34* Creat-2.1*# Na-136
K-4.0 Cl-93* HCO3-28 AnGap-19
[**2170-2-12**] 10:05PM BLOOD ALT-20 AST-45* LD(LDH)-268* AlkPhos-56
TotBili-0.6
[**2170-2-12**] 10:05PM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.4 Mg-2.1
[**2170-2-12**] 11:18AM BLOOD Glucose-144* Lactate-3.7* Na-137 K-3.9
Cl-90*
DISCHARGE LABS:
[**2170-2-19**] 07:44AM BLOOD WBC-6.7 RBC-3.98* Hgb-11.9* Hct-34.5*
MCV-87 MCH-29.9 MCHC-34.5 RDW-13.7 Plt Ct-255
[**2170-2-19**] 07:44AM BLOOD Glucose-89 UreaN-18 Creat-0.9 Na-140
K-4.5 Cl-105 HCO3-27 AnGap-13
[**2170-2-19**] 07:44AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.8
CT ABDOMEN/PELVIS [**2170-2-12**]:
LUNG BASES: There are bibasilar areas of atelectasis with trace
bilateral
pleural effusions. There is a coronary artery calcification
noted with a
small pericardial effusion. The NG tube courses into the
proximal stomach.
ABDOMEN: There is extensive gas-filled small and large bowel
without definite signs of free air or pneumatosis. The liver is
small which may be secondary to left lobe resection, and no
focal lesions on this non-contrast study are seen. The spleen is
unremarkable. Both adrenal glands appear normal in size and
configuration. The pancreas is difficult to assess and appears
quite atrophic. The kidneys bilaterally appear normal. An IVC
filter is seen within the IVC, infrarenal. Aorta is normal in
caliber, somewhat tortuous course with scattered areas of
atherosclerotic calcification.
The stomach is mostly decompressed. The duodenum is
unremarkable.
PELVIS: Loops of small bowel contain air-fluid levels and are
mildly dilated. There is no point of obstruction/transition. The
large bowel is markedly distended and dilated along its distal
extent with no transition point. A fluid at the level of the
rectosigmoid is noted, and overall findings are most suggestive
of [**First Name8 (NamePattern2) **] [**Last Name (un) 3696**]/pseudo-obstruction. No free fluid in the pelvis.
Urinary bladder is only partially distended.
BONES: No suspicious bony lesions. Old left posterior rib
fractures noted.
Bones are somewhat demineralized. Degenerative changes at the
lumbosacral
junction. Lumbarization of S1 noted.
IMPRESSION:
1. Dilated large bowel and small bowel without transition point
with an
overall configuration most compatible with [**Last Name (un) 3696**]
pseudo-obstruction.
2. Trace bilateral pleural effusions with areas of bibasilar
atelectasis,
left greater than right.
KUB [**2-17**]:
One upright and one supine view of the abdomen are compared to a
series of the abdominal radiographs since [**2-12**]. Today's
study shows
generalized distention of the bowel, primarily the colon, that
is not as
severe as it was on the first study in this series on [**2-12**]. The
rectosigmoid, currently 163 mm wide, was 186 mm and the cecum
which is 8 cm
today, was 10 cm. Nevertheless, there is substantial volume of
dilated colon. The transverse contains air and fluid and is
greater caliber, 8 cm than it has been before. Nasogastric tube
ends in the stomach which is not distended. I do not see gas in
the wall of any bowel, nor free intraperitoneal gas. Caval
umbrella filter has not migrated.
Brief Hospital Course:
67M admitted for vomiting and diarrhea, found to have [**Last Name (un) **]
syndrome of uncertain etiolgy.
# [**Last Name (un) 3696**] syndrome: Pt found at home lethargic covered in
stool and emesis. He was admitted to the MICU at [**Hospital1 18**] where
abdominal imaging showing multiple air-filled distended bowel
loops without obvious transition point on CT consistent with
[**Last Name (un) **] syndrome. The exact cause is unclear. Pt was noted
to have significant electrolyte disturbances throughout
admission which could likely have been a cause, but also could
have been a result of his vomiting and diarrhea. Medications,
infectious, or metabolic causes could also be possible. Zosyn
was started emperically in the MICU for possible intraabdominal
infection. NG tube placed to suction on arrival, and GI was
consulted who recommended placing a rectal tube. Serial KUBs
were followed and patient's bowels decompressed significantly.
Thus NGT and rectal tube were removed without need for further
bowel decompression. As cultures were negative for 48 hours,
Zosyn was discontinued. C. diff also negative. On [**2-19**]
and [**2-19**] the patient tolerated good PO intake and had daily
bowel movements. His abdomen remained mildly distended but soft
and non-tender. He was discharged with instructions for GI
follow up.
# Hypotension: Patient was initially hypotensive in the ED
which responded to fluid boluses. He haad initially been on
Zosyn, though as blood cultures were negative for 2 days, Zosyn
was discontinued on morning of [**2-14**]. His presenting lactate was
3.7, which resolved to 1.3 on morning of [**2-13**] with fluid
resuscitation. Initially his BP meds were held but amlodipine
restarted at home dose of 5mg daily after BPs stabilized. On
[**2-17**] he was noted to be hypertensive so home Atenolol was
restarted. He continued to be hypertensive throughout the day so
his amlodipine was increased from 5mg to 10mg po daily with good
response. Of note his home chlorthalidone was not due to
electrolyte disturbances throughout admission.
# Electrolyte disturbances: Pt noted to be significantly
hyopkalemic and hypophosphatemic throughout most of admission
requiring aggressive repletion. This may have contributed to
the etiology of the [**Last Name (un) 3696**] syndrome, compounded by vomitting
and diarrhea. With improvement of his distension, his
electrolytes normalized and he had no abnormalities by
discharge.
# Acute Kidney Injury: Peak Cr of 2.1 at presentation. History
most consistent with pre-renal azotemia and this confirmed with
rapid correction in Cr to 1.1 after fluid resusciation.
# Bipolar disorder: Home ziprasidone and seroquel were intially
held while NPO, then restarted once he tolerated a diet.
#. BPH: Held patient's home tamsulosin while peri-hypotensive
period, then restarted tamsulosin prior to foley
discontinuation.
Medications on Admission:
1) Geodon 60 mg [**Hospital1 **]
2) Tamsulosin 0.4 mg each morning
3) Amlodipine 5 mg each morning
4) Chlorthalidone 25 mg each morning
5) Atenolol 25 mg each morning
6) Seroquel 100 mg QHS
7) Calcium supplement
8) Vitamin E supplement
Discharge Medications:
1. ziprasidone HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
3. quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. calcium Oral
5. vitamin E Oral
6. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Olgivie's syndrome
Hypotension
Bipolar
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 diarrhea and vomitting
with a distended abdomen. This is a condition called Olgivie's
syndrome. It was unclear exactly what caused this, but may have
been related to your low blood electrolyte levels. We
decompressed your GI tract with a suction tube in your stomach,
and you improved. We closely monitored your electrolytes which
improved as well. You also had low blood pressure on admission
so you went to the ICU for fluids and your blood pressure
improved
You should make appointments to follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **],
as well as our GI department (see below).
We have made the following changes to your medications:
Increased AMlodipine to 10mg po daily
STOPPED: Chlorthalidone because your electrolytes were abnormal
All other medications remain the same
Followup Instructions:
Please make an appointment to follow up with your PCP within the
next 1-2 weeks:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Please call our gastroenterology department to make a follow up
appointment within 2 weeks at [**Telephone/Fax (1) 463**]
ICD9 Codes: 5849, 2768, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1876
} | Medical Text: Admission Date: [**2189-11-2**] Discharge Date: [**2189-11-9**]
Date of Birth: [**2113-2-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
bile leak
Major Surgical or Invasive Procedure:
sp ERCP/stent [**11-2**]
History of Present Illness:
76M sp lap chole and intra op cholangiogram [**10-28**] @ an OSH sp
ERCP/stent showing active extravasation; ? R hepatic duct
ligation vs cystic duct sump leak.
Past Medical History:
Chronic AFib, mild CHF, h/o GI bleed/ulcers
Family History:
NC
Physical Exam:
NAD, mild jaundice
A&O X 3
CN II-XII intact
icteric sclera
AF, RR
CTAB
obese, mild distention, NT
Bilious fluid draining out of R port site, otherwise lap sites
C/D/I
+ 1 E, No C/C
Pertinent Results:
[**2189-11-2**] 10:35PM ALT(SGPT)-17 AST(SGOT)-21 ALK PHOS-178*
AMYLASE-101* TOT BILI-5.0* DIR BILI-3.6* INDIR BIL-1.4
[**2189-11-2**] 10:35PM LIPASE-1574*
[**2189-11-2**] 10:35PM GLUCOSE-100 UREA N-11 CREAT-0.6 SODIUM-133
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-30* ANION GAP-13
[**2189-11-2**] 10:35PM ALBUMIN-3.0* CALCIUM-8.9 PHOSPHATE-2.2*
MAGNESIUM-2.0
[**2189-11-2**] 10:35PM WBC-11.1* RBC-3.47* HGB-11.3* HCT-33.2*
MCV-96 MCH-32.5* MCHC-34.0 RDW-14.0
[**2189-11-2**] 10:35PM PLT COUNT-326
[**2189-11-2**] 10:35PM PT-14.3* PTT-24.6 INR(PT)-1.3
[**2189-11-2**] 09:00AM BLOOD WBC-9.4 RBC-3.54* Hgb-11.4* Hct-33.9*
MCV-96 MCH-32.3* MCHC-33.7 RDW-14.5 Plt Ct-321
[**2189-11-6**] 06:00AM BLOOD WBC-11.4* RBC-3.58* Hgb-11.3* Hct-33.1*
MCV-92 MCH-31.5 MCHC-34.1 RDW-13.7 Plt Ct-433
[**2189-11-9**] 05:57AM BLOOD PT-16.4* PTT-34.4 INR(PT)-1.7
[**2189-11-8**] 09:00AM BLOOD PT-14.9* INR(PT)-1.4
[**2189-11-9**] 05:57AM BLOOD Glucose-89 UreaN-8 Creat-0.7 Na-137 K-4.0
Cl-99 HCO3-30* AnGap-12
[**2189-11-3**] 06:39AM BLOOD ALT-15 AST-22 AlkPhos-168* Amylase-88
TotBili-3.6* DirBili-2.4* IndBili-1.2
[**2189-11-4**] 06:30AM BLOOD ALT-15 AST-21 AlkPhos-163* Amylase-16
TotBili-2.6*
[**2189-11-5**] 06:37AM BLOOD ALT-29 AST-47* AlkPhos-189* Amylase-9
TotBili-2.2*
[**2189-11-6**] 06:00AM BLOOD ALT-34 AST-49* AlkPhos-179* TotBili-1.9*
[**2189-11-7**] 06:45AM BLOOD ALT-48* AST-59* AlkPhos-182* TotBili-1.9*
[**2189-11-8**] 06:14AM BLOOD ALT-38 AST-37 AlkPhos-156* TotBili-1.3
[**2189-11-9**] 05:57AM BLOOD ALT-37 AST-34 AlkPhos-155* TotBili-1.2
Brief Hospital Course:
The pt was admitted and started on IV AUnasyn, NPO, IVF. A CT
abdomen was performed to R/O biloma fromation which showed the
following:
No drainable fluid collections. Post surgical changes in the
gallbladder fossa. Calcified densities in the posterior liver,
below the level of the diaphragm/? calcified granulomas,
Prostatic enlargement, and small bilateral pleural effusions.
A HIDA scan was obtained on HD #2 which showed no evidence of
extravasation. The ostomy bag draining bilious fluid over the R
post site steadily decreased throughout the [**Hospital **] hospital stay.
TB of the fluid was measured at the beginning and at the end of
the hospital course measuring 6.9 and 2.1 respectiveley. The
pt's LFT's and PE were monitored throughout his stay and his
LFT's steadily improved throughout his hospital stay. (see lab
result section). With the pt's clinical improvement post
stenting and review of his cholab=ngiogram, it was thought that
the leak was most likely from the cystic duct stump.
The [**Hospital **] hospital course was remarkable for diarrhea. CDIFF was
sent and was negative X 3.
The pt tolerated a regular diet, was voiding on his own,
abulating without difficulty, and had stable VS and an
unremarkable PE upon discharge. The pt was cleared by physicial
therapy and was DC'd on prophalyctic antibiotics
(ciprofloxacin)and with VNA for drain care. The pt preferred to
have his follow up care done through the VA system but was to
return for a repeat ERCP in approximately 10 days.
Medications on Admission:
Protonix 40', digoxin 0.125', lopressor 50", albuterol MDI/neb
prn, lasix 20', quinine, coumadin 7.5'
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
6. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Discharge Disposition:
Home With Service
Facility:
CAPECOD VNA
Discharge Diagnosis:
bile leak
Discharge Condition:
stable
Discharge Instructions:
Please call your physician if experiencing fevers/chills,
nausea/vomiting, shortness of breath or chest pain.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] for a repeat ERCP in [**10-8**]
days; appointment to be set up by Hepatobiliary NP.
Follow up with Dr. [**Last Name (STitle) **] after ERCP. Appointment to be set up
by Hepatobiliary NP.
Follow up for coumadin dosing/INR checks with PCP.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2189-11-12**]
ICD9 Codes: 4280, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1877
} | Medical Text: Admission Date: [**2172-8-8**] Discharge Date: [**2172-8-17**]
Date of Birth: [**2172-8-8**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Nevaeh [**Known lastname 10528**] was born at 32
and 2/7 weeks gestation by cesarean birth for a nonreassuring
fetal heart rate. The mother is a 32-year-old gravida 8, para
5, now 6 woman whose prenatal screens are blood type O
positive, antibody negative, rubella immune, RPR nonreactive,
hepatitis surface antigen negative, and group B strep
unknown. This pregnancy was complicated by Insulin dependent
diabetes and chronic hypertension. The mother presented to
[**Name (NI) 86**] hospital on the day of delivery with fetal
deceleration, a good biophysical profile of [**7-14**]. At that time
she was given a dose of betamethasone.
The infant emerged vigorous. Apgars were 8 at 1 minute and 8
at 5 minutes.
The birth weight was 1750 grams, birth length was 44 cm, and
birth head circumference was 30 cm.
PHYSICAL EXAMINATION: The admission physical examination
reveals a vigorous preterm infant, anterior fontanel soft and
flat, nondysmorphic. Neck supple with intact clavicles. Lungs
clear. Mild subcostal retractions. Heart with regular rate
and rhythm. No murmurs. Femoral pulses present. Abdomen soft.
Positive bowel sounds. Normal genitalia. Patent anus. No
sacral or back anomalies. Well perfused. Stable hips and
normal tone and activity.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: She had
some initial transitional respiratory distress which resolved
within few hours of life. She has always remained in room
air. She has had no apnea or bradycardia. On examination her
respirations are comfortable with minimal subcostal
retractions. Lung sounds are clear and equal.
CARDIOVASCULAR: She has remained normotensive throughout her
NICU stay. There was no cardiovascular issues.
FLUIDS, ELECTROLYTES AND NUTRITION: At the time of discharge
her weight is 1620 grams. Enteral feeds were begun on day of
life 1 and were advanced without difficulty to full volume
feedings. She is curently NPO since [**2172-8-16**], with working
diagnosis of Hisrchprung.
GASTROINTESTINAL: She was treated with phototherapy for
hyperbilirubinemia from day of life 3 until day of life 6.
Her repeat bilirubin occurred on day of life 3 and was total
9.8, direct 0.3. Her rebound bilirubin on [**2172-8-15**],
was total 5.3, direct 0.2. Of note one of the infant's
siblings did have Hirschsprung's disease and had a bowel pull
through done at 1-year of age. This infant has had one
spontaneous bowel movement and one with a glycerine
suppository. On [**2172-8-16**], she was kept NPO due to abdominal
distension with multiple KUB showing no pneumatosis, presence of
dilated bowel loop specially the transverse colon.
Brium enema on [**2172-8-17**] showed rectum narrower than sigmoid which
is suggestive of Hirschprung.
HEMATOLOGY: She has had no blood product transfusions during
her NICU stay. At the time of admission her hematocrit was
46.5 and platelets 330,000.
INFECTIOUS DISEASE: She was started on ampicillin and
gentamycin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours and the
blood cultures were negative and the infant was clinically
well. At the time of admission her white count of 9000 with a
differential of 46 poly's and 0 bands. At the time of abdominal
distention, she had sepsis evaluation and showed marked left
shift. She is currently on triple antibitherapy with ampicilli,
gentamicn, and clindamycin. She need LP since the attempt on
[**2172-8-17**] is unsuccessful.
SENSORY: Audiology - Hearing screening has not yet been
performed and is recommended prior to discharge.
PSYCHOSOCIAL: Mom has been involved in the infant's care
throughout her NICU stay.
The infant is transferred to [**Hospital1 1926**] in good condition.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] in [**Hospital1 1474**],
[**State 350**].
CDISCHARGE DIAGNOSIS:
1. Prematurity at 32 and 2/7 weeks gestation.
2. Sepsis ruled out.
3. Status post transitional respiratory distress.
4. Status post hyperbilirubinemia of prematurity.
5. working disagnosis of Hirschprung
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2172-8-16**] 00:45:07
T: [**2172-8-16**] 03:18:25
Job#: [**Job Number 69132**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1878
} | Medical Text: Admission Date: [**2183-7-18**] Discharge Date: [**2183-8-11**]
Date of Birth: [**2109-8-31**] Sex: M
Service:
CHIEF COMPLAINT: Dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: This is a 73 year old male with
a history of aortic valve replacement in [**2180**], abdominal
aortic aneurysm, hypertension who was transferred from an
outside hospital with one week of dyspnea on exertion,
shortness of breath, fever and violent chills. The patient
denied a history of recent travel, sick exposure, cough,
sputum production, nasal congestion, abdominal pain or skin
infection.
On admission the patient's temperature was 100.8. Three
blood cultures were drawn and he was started on Vancomycin
and Gentamicin. The initial chest x-ray showed negative
pleural effusions or evidence of congestive heart failure.
Transesophageal echocardiogram showed an left ventricular
ejection fraction of 65% with thickened mitral valve with
mild regurgitation, large echodense objects, suggestion of
vegetation, and tricuspid regurgitation. The initial
transesophageal echocardiogram done at [**Hospital6 649**] showed dehiscence of the porcine arteriovenous
graft and a positive abscess. He was admitted for evaluation
and consideration for surgery.
PAST MEDICAL HISTORY: Significant for aortic valve
replacement with porcine valve. The patient unclear reason
for aortic valve replacement, abdominal aortic aneurysm and
hypertension. Hypercholesterolemia, chronic anemia,
infrarenal abdominal aortic aneurysm, and chronic renal
insufficiency.
PAST SURGICAL HISTORY: Aortic valve replacement with porcine
valve.
MEDICATIONS:
1. Lipitor 10 mg p.o. b.i.d.
2. Vitamin B12
3. Lopressor 25 mg b.i.d.
4. Vancomycin started at outside hospital
5. Gentamicin started at the outside hospital
PHYSICAL EXAMINATION: Temperature was 98.4, heartrate 64,
blood pressure 120/70, respiratory rate 20 and saturations
97% on room air. General: He was alert, awake and in no
acute distress, resting comfortably. Head, eyes, ears, nose
and throat: Pupils are equal, round, and reactive to light,
extraocular muscles intact, no lymphadenopathy. Neck was
supple, negative left axis deviation, negative masses,
jugulovenous distension of 14 cm, negative bruits. Trachea
aortic murmur, 2 to 3 tricuspid murmur. Pulmonary clear to
auscultation bilaterally. Abdomen was soft, nontender,
nondistended, positive bowel sounds. Abdominal had no bruits
and no hepatosplenomegaly. Extremities: +2 dorsalis pedis
pulses bilaterally, negative edema. Skin was negative for
dermatitis, ecchymosis, negative splinter hemorrhages or
axillary nodes.
LABORATORY DATA: Initial labs included a white blood cell
count of 6, hemoglobin 11, hematocrit 34.8 and platelets 168.
Chem-7 included sodium 131, potassium 3.3, chloride 102,
carbon dioxide 21, BUN 14, creatinine 1.4, and 98% glucose.
Calcium was 8.6, phosphate was 3.9 and magnesium was 1.8. He
showed dehiscence of the AV.
ALLERGIES: No known drug allergies
HOSPITAL COURSE: After admission the patient was continued
on intravenous Vancomycin and Gentamicin. Infectious Disease
was also consulted. The patient was transferred to the
Coronary Care Unit.
On [**7-21**], the patient was taken to the Operating Room for
an indication of infected aortic valve replacement and
endocarditis. Procedure was a redo sternotomy aortic valve
replacement with homograft 29 mm. The patient tolerated the
procedure well and was sent to the Coronary Intensive Care
Unit. On [**7-22**], Neurology was consulted for an altered
mental status. Their impression was that decreased alertness
could be due to several factors including culture-negative
endocarditis, recent Propofol use and Morphine. [**7-22**],
Infectious Disease reassessed the situation and decided to
continue the intravenous Ceftriaxone, Vancomycin and
Rifampin. On [**7-25**], Renal was consulted for acute renal
failure in which their assessment of the situation was acute
renal failure but there was no indication for dialysis and
that they would follow. The patient continued to course in
the Intensive Care Unit with close monitoring and broad
spectrum antibiotics, including Ceftriaxone, Vancomycin, and
Rifampin. During the course of the Intensive Care Unit stay
Cardiology had recommended placement of a pacemaker. On [**8-1**], the patient was brought back to the Operating Room for
placement of a [**Company 1543**] lead pacemaker. The patient
tolerated the procedure well. Neurology was consulted and
the patient was started on Dilaudid 200 mg. There were no
complications. The patient continued his stay in the
Intensive Care Unit until [**8-5**], at which time he was
transferred to the floor. During the Intensive Care Unit stay
the patient had signs and symptoms of what possibly could
have been a seizure.
On [**8-6**], the patient was assessed for placement of a
percutaneous endoscopic gastrostomy tube due to a 24 hour
caloric count well below [**2182**] calories. On [**8-8**], the
patient was brought back to the Operating Room with placement
of the percutaneous endoscopic gastrostomy tube. The patient
tolerated the procedure well and was discharged back to the
Surgical Floor. Also on [**8-8**], the patient was assessed
for rehabilitation placement.
On [**8-10**], the patient was doing well and tolerating tube
feeds without abdominal pain, nausea or vomiting.
The discharge physical showed vital signs 98.6 temperature,
60 heartrate, 130/70, blood pressure was 105/58, 18
respiratory rate, and 96% on 2 liters. General: He was
alert and oriented in no acute distress. Cardiovascularly,
he was regular rate and rhythm with no murmurs or rubs.
Respiratory rate was clear to auscultation bilaterally.
Abdomen was soft, nontender, nondistended with positive bowel
sounds, positive percutaneous endoscopic gastrostomy
placement. Extremities, negative peripheral edema. Incision
was intact. Physical therapy level was 1 out of 5.
Complications and significant events included acute renal
failure treated without dialysis, pacemaker placement and
percutaneous endoscopic gastrostomy placement.
Discharge laboratory data included a white blood cell count
of 4.7, hemoglobin 10.1, hematocrit 30 on [**8-8**] and a
sodium of 141, potassium 4.0, chloride 109, carbon dioxide of
22, BUN 19 and creatinine of 1.9 and glucose of 94. Dilantin
was 3.5 with a free Dilantin of 1.1 on [**8-9**].
DISCHARGE MEDICATIONS:
1. Hydralazine 50 mg p.o. q. 4 hours
2. Rifampin 600 mg p.o. q.d.
3. Ceftriaxone 2 mg intravenously q. 24
4. Vancomycin 1 gm intravenously q.d.
5. Dilantin 250 mg b.i.d., hold to repeat 30 minutes prior
and 30 minutes after administration of Dilantin
6. Docusate 100 mg p.o. b.i.d.
7. Heparin 5000 units subcutaneous b.i.d.
8. Vitamin C 500 mg p.o. b.i.d.
9. ZnSO4 220 mg p.o. q.d.
10. Amiodarone 400 mg p.o. q.d.
11. Norvasc 10 mg p.o. q.d.
12. Nephrocaps times one p.o. q.d.
13. Nystatin powder to the groin b.i.d. prn
14. UltraCal 80 cc/hr, hold 30 minutes prior and after
administration or administration of Dilantin
15. Ibuprofen 400-600 mg p.o. q. 6 hours
16. Milk of Magnesia 30 ml p.o. prn
17. Tylenol 650 mg p.o. q. 4 hours
PRIMARY DISCHARGE DIAGNOSIS:
1. Status post redo sternotomy and aortic valve replacement
with homograft
SECONDARY DIAGNOSIS:
1. Chronic renal insufficiency
2. Hypertension
3. Hypercholesterolemia
4. Chronic anemia
5. Infrarenal abdominal aortic aneurysm
DISPOSITION: [**Hospital **] hospital, [**Hospital3 672**]
Hospital & Rehabilitation Center. #[**Telephone/Fax (1) 35784**], Fax
[**Telephone/Fax (1) 35785**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] R. 02-358
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2183-8-10**] 19:49
T: [**2183-8-10**] 21:24
JOB#: [**Job Number 35786**]
ICD9 Codes: 4241, 5849, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1879
} | Medical Text: Admission Date: [**2203-11-3**] Discharge Date: [**2203-11-12**]
Date of Birth: [**2161-11-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath, chest pain
Major Surgical or Invasive Procedure:
Pericardiocentesis
EGD with biopsy
History of Present Illness:
41 y/o M w/ h/o HIV/AIDS (HIV dx 83, AIDS 92, last CD4 132, VL
>100K [**10/2203**], RF IVDU), not currently on HAART, previous right
sided bacterial endocarditis with residual 4+ TR, h/o prior MI
in [**2193**], who presents from [**Hospital **] Hospital for emergent
evaluation of pericardial tamponade.
Patient was recently hospitalized at [**Hospital1 18**] for osteomyelitis of
his L-ankle s/p prior fall. Presented to ED with fevers and
ankle pain. Taken to OR by ortho and found to have neg
brefringent crystals c/w gout. Tissue/Bone cultures grew MSSA.
Patient started on cefazolin. F/U MRI could not rule out
osteomyelitis and the patient was discharged to [**Hospital **]
hospital for 6 weeks of IV cefazolin (to end [**2203-12-5**]).
While at [**Hospital1 **], patient had uneventful course until night
prior to admission when he developed low grade temp to 100.2.
The morning of admission patient felt short of breath, lethargic
with some chest pain. Noted to be tachycardic by vitals, and
with decreased O2 sat to 90% on RA -> 96% 2L NC. Chest CT
performed showing massively enlarged cardiac silhouette.
Transfered to [**Hospital1 18**] for emergent pericardiocentesis.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
In the ED, T98.8, HR 122, BP 147/87, RR 19, O2 97%. Patient
noted to be uncomfortable, and w/ rub on exam. Pulsus not
performed. Otherwise exam unremarkable. Transferred to cath lab
for emergent peridcardiocentesis.
In cath lab, pericardial pressure 35, RA and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1934**] each
30, RV systolic 55. 1.2 L of sanguinous fluid drained from the
pericardium. Pericardial pressure decreased to 5mm Hg, and RA to
18mm Hg s/p drain. Patient admitted to CCU for further
management.
Past Medical History:
- HIV/AIDS: HIV dignosed in '[**79**], AIDS diagnosed in '[**88**], last CD4
count 132, VL 100K [**2202-7-26**]. Perscribed HAART but pt reports
noncompliance for past 5 months (followed by Dr [**Last Name (STitle) 2219**] at [**Hospital1 2177**]
and NP [**Doctor Last Name **] [**Telephone/Fax (1) 2218**]) -- ONLY FATHER KNOWS DIAGNOSIS.
- Hep C
- Hep B cleared
- Myocardial infarction in [**2193**]
- h/o endocarditits with grade 4 TR - approximately 12 years ago
- Recurrent epididimitis
- h/o IVDU on methadone 80 mg QD (followed at Baycove
[**Telephone/Fax (1) 2217**])
- Asthma
- osteomyelitis (MSSA) on cefazolin
Social History:
Pt was most recently living at [**Hospital1 **]. He has a girlfriend.
[**Name (NI) **] denies tobacco, EtOH, and current drug use/abuse. He is in a
methadone program because of past IVDU.
Family History:
NC
Physical Exam:
ON ADMISSION:
VS: T 99.3, BP 132/72 , HR 105 , RR 20, O2 99% 2l NC
Gen: Caucasion male w/ mild bitemporal wasting resting
comfortably in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple. Unable to appreciate JVD as prominent carotid
pulses b/l.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. +2/6 SEM at LUSB.
Chest: Pericardial drain in place, clean, dry, intact, No
scoliosis or kyphosis. Resp were unlabored, no accessory muscle
use. Sparse basilar crackles right > left.
Abd: +BS, softly distended, non-tender, liver edge palpable
below the costal margin. No abdominial bruits.
Ext: R-AKA. Left ankle in cast, 2+ DP pulse. No c/c/e. No
femoral bruits. +line in L-groin, no bleeding, no hematoma.
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
ON DISCHARGE:
VS: 98.1 117/89 118 20 95% RA
Exam was largely unchanged. Abdomen was mildly distended, not
tender, normoactive bowel sounds. His cardiac exam was
unchanged, the pericardial drain was pulled on day 2 of
admission. Lungs were clear to auscultation bilaterally. Wound
vac was in place, with minimal drainage.
Pertinent Results:
[**2203-11-3**] 05:00PM OTHER BODY FLUID TOT PROT-6.1 GLUCOSE-69
LD(LDH)-650 AMYLASE-56 ALBUMIN-1.9
[**2203-11-3**] 05:00PM OTHER BODY FLUID WBC-2122* HCT-11* POLYS-56*
LYMPHS-27* MONOS-13* EOS-2* METAS-2*
[**2203-11-3**] 03:58PM LACTATE-3.2*
[**2203-11-3**] 03:50PM GLUCOSE-126* UREA N-38* CREAT-1.8*
SODIUM-132* POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-14
[**2203-11-3**] 03:50PM estGFR-Using this
[**2203-11-3**] 03:50PM CK(CPK)-29*
[**2203-11-3**] 03:50PM cTropnT-<0.01
[**2203-11-3**] 03:50PM CK-MB-NotDone
[**2203-11-3**] 03:50PM WBC-6.2 RBC-3.09* HGB-9.2* HCT-28.6* MCV-93
MCH-29.6 MCHC-32.0 RDW-19.5*
[**2203-11-3**] 03:50PM NEUTS-77.3* LYMPHS-17.1* MONOS-5.3 EOS-0.1
BASOS-0.2
[**2203-11-3**] 03:50PM PLT COUNT-295#
[**2203-11-3**] 03:50PM PT-15.1* PTT-38.2* INR(PT)-1.4*
Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS.
.
ECHO ([**2203-11-3**]) Pre-pericardiocentesis: The left atrium is
elongated. The estimated right atrial pressure is >20 mmHg. The
left ventricular cavity is unusually small. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). The right ventricular cavity
is moderately dilated. There is a large circumferential
pericardial effusion. Stranding is visualized within the
pericardial space c/w some organization. There is left atrial
diastolic collapse. There is right ventricular diastolic
collapse, consistent with impaired fillling/tamponade
physiology. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, consistent with
impaired ventricular filling.
Compared with the prior study (images reviewed) of [**2203-10-20**],
large pericardial effusion with echocardiographic signs of
tamponade is new.
.
ECHO ([**2203-11-3**]) Post pericardiocentesis: The left atrium is
elongated. The right atrium is markedly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (LVEF>55%). The right ventricular cavity
is markedly dilated. Right ventricular systolic function is
normal. [Intrinsic right ventricular systolic function is likely
more depressed given the severity of tricuspid regurgitation.]
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. There is no aortic valve
stenosis. The mitral valve leaflets are mildly thickened. There
is partial flail of a tricuspid valve leaflet. The tricuspid
valve leaflets fail to fully coapt. Severe [4+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2203-11-3**],
the residue pericardial effusion is minimal.
.
Cardiac catherization ([**2203-11-3**]):
1. Large circumferential pericardial effusion with tamponade
physiology.
2. Successful pericardiocentesis with drainage of 1500mls of
blood
stained fluid. Patient left cathlab in stable condition
FINAL DIAGNOSIS:
1. Severe pericardial tamponade.
2. Mild primary pulmonary hypertension.
3. Successful pericardiocentesis with drainage of 1500ml of
blood
stained fluid.
.
ECHO ([**2203-11-4**]): The left atrium is mildly dilated. The right
atrium is markedly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral and
tissue Doppler imaging suggests normal diastolic function, and a
normal left ventricular filling pressure (PCWP<12mmHg). The
right ventricular cavity is moderately dilated. Right
ventricular systolic function is borderline normal [intrinsic
function is likely depressed given the severity of tricuspid
regurgitation.]. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The tricuspid valve leaflets are
mildly thickened and appear shortened/remnants that do not fully
coapt. A small echodensity is seen on the right atrial side of
the septal leaflet - ?vegetation ?old vs. partial flail of
leaflet segment. Severe [4+] tricuspid regurgitation is seen.
There is a small (<1cm), circumferential, partially echo filled
pericardial effusion without evidence of hemodynamic compromise.
Compared with the prior study (post-pericardiocentesis, images
reviewed) of [**2203-11-3**], the findings are similar.
.
ECHO ([**2203-11-5**]): The left atrium is mildly dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). The right ventricular cavity is moderately
dilated. Right ventricular systolic function is borderline
normal. The mitral valve appears structurally normal with
trivial mitral regurgitation. The tricuspid valve leaflets are
mildly thickened and appear shortened/remnants and fail to fully
coapt. A small echodensity is again seen on the right atrial
side of the septal leaflet which could be either a vegeateion or
a partial leaflet segment. Severe [4+] tricuspid regurgitation
is seen. There is a small pericardial effusion. The effusion is
echo dense, consistent with blood, inflammation or other
cellular elements. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2203-11-4**],
the pericardial effusion is slightly smaller and may be more
echo dense. The left ventricular cavity size is probably
slightly larger (reflecting better filling). The small
echodensity on the tricuspid leaflet has not changed in size.
.
ECHO ([**2203-11-8**]): The left atrium is mildly dilated. The right
atrium is dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). The
right ventricular cavity is dilated. Right ventricular systolic
function is normal. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets fail to fully coapt.
Severe [4+] tricuspid regurgitation is seen. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2203-11-5**],
pericardial effusion now appears slightly smaller.
.
ECHO ([**2203-11-11**]):
The right atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
systolic function (LVEF>55%). The right ventricular cavity is
moderately dilated. Right ventricular systolic function is
borderline normal. The mitral valve leaflets are structurally
normal. The tricuspid valve leaflets are mildly thickened. The
tricuspid valve leaflets fail to fully coapt. There is a very
small, partially echo filled pericardial effusion.
Compared with the prior study (images reviewed) of [**2203-11-8**],
the findings are similar.
Brief Hospital Course:
41 year old male with HIV/AIDS, previous R-sided endocarditis
and severe TR, presented in cardiac tamponade from
rehabilitation.
CARDIAC TAMPONADE: On admission, he was transferred to the
cardiac catherization lab, where over one liter of fluid was
drained from his pericardial space. The fluid was sent for gram
stain, culture, AFB, [**Doctor First Name **], TB PCR as well as viral studies and
cytology. A pericardial drain was initially left in place, but
given minimal drainage over 24 hours, was pulled prior to his
transfer to the floor. The etiology of the pericardial effusion
is unknown. He was followed by Cardiology on the floor and the
initial plan was for a pericardial window, for both tissue and
to prevent reaccumulation of fluid. The patient refused the
procedure at this time. He will follow up as an outpatient to
re-evaluate for the procedure. The effusion was followed by
serial ECHO while the patient was in the hospital. There was no
evidence of re-accumulation. He is scheduled for an outpatient
ECHO in several weeks to evaluate the pericardial space for
reaccumlation of effusion.
ATRIAL FIBRILLATION/FLUTTER: Per multiple EKGs, the patient
appears to have developed new a fib/flutter. Given his guaiac
positive stools, it is not advisable to start anticoagulation at
this time. The patient is being rate controlled on a low dose
of beta-blocker, which appears to be effective. He will be
followed by outpatient Cardiology.
ANEMIA: The patient had a hematocrit drop during this admission.
His lab studies are consistent with anemia of chronic disease,
however, the patient was found to have guaiac positive stools.
GI was consulted and recommeded colonoscopy and EGD. The
patient was unable to tolerate the prep and thus the colonoscopy
was cancelled. His EGD demonstrated gastritis and thrush. He
was started on fluconazole to treat the thrush. He was also
transfused two units of packed red blood cells with an
appropriate hematocrit response.
HIV/AIDS: The patient had a CD4 count checked during his last
admission, it was found to be 132 with a viral load >100K.
Given his past noncompliance with HAART therapy and the risk of
developing drug resistant HIV, HAART was not restarted. Pt is
willing to restart HARRT, and the plan remains to restart
medications at rehabilitation. Bactrim was continued for PCP
[**Name Initial (PRE) 1102**].
OSTEOMYELITIS: The patient was previously admitted for left
ankle pain. He was followed previously by both the orthopedic
and ID services. Both services continued to follow the patient
on this admission. The patient was continued on 6 weeks of IV
antibiotics (last day of cefazolin [**2203-12-5**]), although the dose
was decreased to 1g q6 because of a low white blood count.
SEVERE TRICUSPID REGURGITATION: Pt with known grade 4 TR and
flail leaflet which he deveoped after acute bacterial
endocarditis roughly 10 years ago. We restarted his lasix and
spironolactone on this admission.
HCV: HCV viral load checked, and found to be 1.5 million. No
further therapy initiated.
ANXIETY: Pt with history of anxiety and on Klonapin at home.
His home regimen was continued.
ESOPHAGEAL CANDIDIASIS: Patient was found to have thrush on EGD.
He was started on a course of fluconazole given his
immunosupressed state. He is being discharged to complete a two
week course of anti-fungal medication.
Medications on Admission:
cefazolin 2g IV q8
methadone 80mg PO qd (confirmed on prior admit)
prednisone 10mg qd
lovenox 40mg SQ
prilosec 20mg PO qd
ASA 81mg PO daily
colace 100mg PO daily
clonazepam 1mg qAM, 1mg qNoon, 2mg qhs prn
sennekot 2 tabs PO BID PRN
morphine sulfate IR 15mg PO q4 PRN
promethazine 12.5mg PO q4h PRN
Discharge Medications:
1. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble
PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q 12 NOON ().
7. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)) as needed for anxiety.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 14 days.
17. 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.
18. Cefazolin 1 gram Recon Soln Sig: One (1) Intravenous every
six (6) hours for until [**2203-12-5**] weeks: please continue until
[**2203-12-5**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnosis:
Cardiac tamponade
GI Bleeding
Atrial flutter
[**Female First Name (un) 564**] esophagitis
Secondary diagnosis:
Pancytopenia
HIV/AIDS
Hepatitis B and C
Endocarditits with flail tricuspic valve
Right heart failure.
Recurrent epididymitis
IVDU on methadone 80 mg QD (followed at Baycove [**Telephone/Fax (1) 2217**])
?Myocardial infarction in [**2193**]
Asthma
LLE medial MSSA foot abscess/osteomyelitis.
Gout
Traumatic Right AKA
PCP
Anxiety and depression.
PPD (+) treated with 6 months INH
Discharge Condition:
Stable without fluid reaccumulation per ECHO
Discharge Instructions:
You were admitted with shortness of breath. You were
found to have fluid around your heart. The fluid was removed
but no specific cause was identified. If you have any chest
pain or shortness of breath, please alert your doctors
[**Name5 (PTitle) 2227**].
You will need weekly labs (specifically CBC, LFTs, BUN, and
Cr) faxed to Dr. [**Known firstname **] [**Last Name (NamePattern1) 1075**] in the Infectious [**Hospital 2228**] clinic at
[**Hospital1 18**] (fax [**Telephone/Fax (1) 432**]).
You have a wound VAC on your ankle to help with healing of the
tissue. This should be changed every 3 days by the nurses at
your facility. You will need to be seen in the [**Hospital 1957**] clinic to
determine how long you will need to have this in place.
If you have any symptoms of worsening foot pain, foot redness,
fevers, chest pain, nausea, vomiting, or any other concerning
symptoms you are to go to the emergency room.
Medication changes:
1. Lasix and spironalactone were restarted during this
admission.
2. You HAART medication was held during this admission. These
can be restarted by your ID doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) **] are at rehab.
3. You are being treated with an antibiotics called cefazolin.
You need to continue this medication until [**2203-12-5**].
Followup Instructions:
Please arrive at ORTHO XRAY (SCC 2) on [**2203-11-15**] at 7:40 AM for
x-ray *(Phone:[**Telephone/Fax (1) 1228**]).
.
Please follow up with your orthopedic doctor, [**Name6 (MD) **] [**Name8 (MD) 2229**], MD on [**2203-11-15**] at 8:00 AM (Phone:[**Telephone/Fax (1) 1228**])
.
Please follow up with [**Known firstname **] [**Name8 (MD) **], MD on [**2203-11-25**] 11:00AM
(Phone:[**Telephone/Fax (1) 457**])
.
You are scheduled for an ECHO on [**2203-11-21**] at 8 AM.
Please come to the [**Hospital Ward Name 23**] building, [**Location (un) 436**] for your
appointment.
Please follow up with Dr. [**Last Name (STitle) 2230**], CT surgery on Monday, [**11-21**] at 1:15 pm. This appointment is at [**Hospital Unit Name 2231**].
You are also scheduled for a Cardiology appointment with Dr.
[**Last Name (STitle) 2232**] on Monday, [**2203-11-28**] at 9:40 AM. This appointment
is in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**].
Please follow up with the gastroenterologists for a colonoscopy.
You can call to schedule the appointment at ([**Telephone/Fax (1) 2233**].
ICD9 Codes: 2749, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1880
} | Medical Text: Admission Date: [**2125-9-18**] Discharge Date: [**2125-9-22**]
Date of Birth: [**2052-12-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
72 year old male with history of cholangiocarcinoma is having
fever and worsening mental status changes.
Major Surgical or Invasive Procedure:
[**2125-9-18**]: ERCP with stent placment
[**2125-9-18**]: Central line placement
History of Present Illness:
72 yo male with a history of metastatic cholangiocarcinoma
called from home because he was having increased jaundice,
abdominal pain, fever and confusion. He was advised to go into
the hospital for evaluation. In the ED he was found to have
worsening LFTs and a fever with elevated lactate.
Past Medical History:
Diabetes, peripheral vascular disease,
bilateral hip replacements, and back surgery x6.
Social History:
used to work as school custodian. has 2 daughters and 2 sons.
wife died in [**2108**]. has not smoked for 25 years, and he doesn't
drink.
Family History:
mother had [**Name2 (NI) 499**] ca, s/p colectomy
Physical Exam:
VS: Temp 97.0, BP 118/46, Pulse 62, RR 19, 99% on Cool neb mask,
pain currently 0/10
Gen: alert, oriented, jaundiced male currently doing well on
cool
neb mask
HEENT: sclera icteric, MMM, OP clear
Neck: no lymphadenopathy, no thyromegally
CV: RRR, nl S1S2, no murmers
Lungs: slight crackles at bases
Lymphatics: no axillary or inguinal lymphadenopathy
Abd: mild tenderness in LUQ, no rebound or guarding, positive BS
Ext: 2+ edema below pneumoboots
Neuro: alert and oriented, moving all extremities, sensation
intact.
Pertinent Results:
On Admission: [**2125-9-18**]
WBC-14.8* RBC-3.24* Hgb-10.5* Hct-28.9* MCV-89 MCH-32.5*
MCHC-36.5* RDW-14.2 Plt Ct-357 Neuts-94.3* Bands-0 Lymphs-4.3*
Monos-1.2* Eos-0 Baso-0.2
PT-16.2* PTT-30.0 INR(PT)-1.5*
Glucose-239* UreaN-45* Creat-1.2 Na-128* K-2.7* Cl-88* HCO3-22
AnGap-21*
ALT-67* AST-83* AlkPhos-352* Amylase-50 TotBili-12.2* Lipase-61*
Calcium-8.2* Phos-3.5 Mg-1.9
Albumin-2.6*
CRP-153.6*
Lactate-5.6*
Brief Hospital Course:
Patient having fever and mental status changes at home. In the
ED he was found to have worsening LFTs and a fever with elevated
lactate. He received Vancomycin and Cefepime in the ED.
An ERCP was performed on day of admission ([**2125-9-18**]) which showed
-The common bile duct demonstrated a filling defect in the upper
portion with no filling of the left intrahepatic duct. Per
endoscopy report, a balloon sweep was performed with sludge and
purulent drainage noted.
In addition, a CT of abdomen was performed on [**2125-9-18**], this
showed:
- Stable examination of the abdomen and pelvis without change in
the multiple lobar infiltrative cholangiocarcinoma with
left-sided biliary dilatation and decompression of the right
biliary tree, via a metallic stent, which is unchanged in
position.
-Worsening bibasilar atelectasis.
Due to the apparent cholangitis, he was initially admitted to
the SICU for close observation. He was trasnferred to [**Hospital Ward Name 121**] 10
once the fever defervesced and his blood pressure was more
stable.
He was changed to Meropenem for a 3 day course and then switched
to PO Cipro to discharge home. His blood cultures were no
growth, however his bile culture grew out Pseudomonas. He will
continue on the Cipro at home.
Medications on Admission:
finasteride 5 mg daily, folic acid 1 mg daily, gabapentin 300 mg
at bedtime, oxycodone 5 mg 1 to 2 q.4h., Colace 100 mg b.i.d.,
ursodiol 300 mg t.i.d., Lasix 80 mg daily, potassium chloride 20
mEq daily, metformin 500 mg twice a day, fexofenadine 60 mg
twice a day, Zeloda 1500mg [**Hospital1 **]. (held during hospitalization)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache/pain.
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
cholangitis
Discharge Condition:
good
Discharge Instructions:
please call the transplant office @ [**Telephone/Fax (1) 72722**] for fevers >
101.5, severe nausea, vomitting, pain, change in mental status
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2125-10-1**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-10-1**] 1:10
Please f/u with ERCP / GI team. call ([**Telephone/Fax (1) 2360**] for an
appointment
Completed by:[**2125-9-27**]
ICD9 Codes: 0389, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1881
} | Medical Text: Admission Date: [**2155-9-3**] Discharge Date: [**2155-9-10**]
Date of Birth: [**2090-5-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Nausea, vomiting and hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 65F with DMI on an insulin pump, HTN p/w nausea vomiting
and SBP to 200s. Pt states that symptoms started the night
before admission with nausea and inability to keep down POs.
sugars at the time was in the 120s. Patient woke up from sleep
the morning of admission with nausea and vomiting
(non-bloody/non-bilious). Blood sugar noted to be 440. Patient
called EMS and on arrival blood sugar 381. She had a similar
presentation just over a year ago and nausea/vomiting attributed
to gastroparesis vs gastritis and esophagitis (seen on EGD). Per
patient and husband, she has been told that she has
gastroparesis [**1-3**] DM.
.
ED: bp 190/72 on arrival. Given anti-emetics and labetalol prn.
BP later 170 systolic. Given pr aspirin. iv fluids given. EKG
without change. 1st set CEs negative. Lack of iv access, so
femoral line attempted x 2 without success (one femoral arterial
stick). Patient was chest pain free. 2 peripheral ivs were
placed. ABG performed: 7.57/25/101.
Past Medical History:
1. Sciatica with h/o laminectomy.
2. DM1 for 36 years, on insulin pump
3. Hypercholesterolemia
4. h/o CP in [**2137**], cardiac cath clean - sx's felt to be ?spasms.
5. HTN
6. Hiatal hernia
7. s/p hysterectomy
Social History:
Married, lives with husband, has 4 children, smokes 10 cig/day,
occassional EtOH, no illicit drug use.
Family History:
Mother MI [**97**]'s
Father MI [**07**]'s
Physical Exam:
Vitals: T: 97.5 P: 72 BP: 132/72 R: 16 SaO2: 98% RA.
General: alert and oriented x 3, NAD
HEENT: NC/AT, PERRL, EOMI without nystagmus, anicteric sclera,
dry mucous membranes, top dentures ill fitting but no OP lesions
Neck: supple, no JVD
Pulmonary: Lungs CTA bilaterally although air movement somewhat
limited
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, nondistended, nontender, no rebound or guarding
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted, skin tanned.
Pertinent Results:
[**2155-9-3**] 12:05PM freeCa-1.09*
[**2155-9-3**] 12:05PM GLUCOSE-260* LACTATE-2.0 NA+-136 K+-4.0
CL--97*
[**2155-9-3**] 12:05PM TYPE-ART PO2-101 PCO2-25* PH-7.57* TOTAL
CO2-24 BASE XS-2
[**2155-9-3**] 01:40PM PT-12.1 PTT-26.5 INR(PT)-1.0
[**2155-9-3**] 01:40PM PLT COUNT-244
[**2155-9-3**] 01:40PM NEUTS-85.0* LYMPHS-10.4* MONOS-3.8 EOS-0.5
BASOS-0.3
[**2155-9-3**] 01:40PM WBC-8.8 RBC-4.37 HGB-14.1 HCT-40.9 MCV-94
MCH-32.2* MCHC-34.4 RDW-13.6
[**2155-9-3**] 01:40PM ALBUMIN-4.4 CALCIUM-10.2 PHOSPHATE-1.5*#
MAGNESIUM-1.9
[**2155-9-3**] 01:40PM CK-MB-NotDone
[**2155-9-3**] 01:40PM ALT(SGPT)-31 AST(SGOT)-34 CK(CPK)-99 ALK
PHOS-102 AMYLASE-46
[**2155-9-3**] 01:40PM estGFR-Using this
[**2155-9-3**] 01:40PM GLUCOSE-227* UREA N-40* CREAT-1.5* SODIUM-135
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-20* ANION GAP-20
[**2155-9-3**] 01:56PM LACTATE-2.4*
[**2155-9-3**] 02:00PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2155-9-3**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2155-9-3**] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2155-9-3**] 02:00PM URINE GR HOLD-HOLD
[**2155-9-3**] 02:00PM URINE HOURS-RANDOM
[**2155-9-3**] 07:20PM PLT COUNT-221
[**2155-9-3**] 07:20PM WBC-8.5 RBC-3.77* HGB-12.4 HCT-37.2 MCV-99*
MCH-32.9* MCHC-33.3 RDW-13.1
[**2155-9-3**] 07:20PM CALCIUM-8.1* PHOSPHATE-3.1# MAGNESIUM-1.6
[**2155-9-3**] 07:20PM CK-MB-5 cTropnT-<0.01
[**2155-9-3**] 07:20PM CK(CPK)-93
[**2155-9-3**] 07:20PM GLUCOSE-222* UREA N-30* CREAT-1.1 SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-19
Brief Hospital Course:
In [**Hospital Unit Name 153**]: pt was kept NPO due to persistent nausea and vomiting.
she was started on iv reglan as well as other antiemetics. her
symptoms are improving but not yet resolved. her blood pressure
was better controlled with a combination of captopril, clonidine
and labetalol iv. will need to further titrate dose as well as
consolidate and switch to po when tolerating. pt's dm was
aggressively managed with iv rehydration and insulin. her gap
has since closed and sugar came down. [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recommendation, her insulin pump's d'ced while she's not able to
tolerate po. she's currently on glargin baseline and sliding
scale. she's to restart insulin pump once tolerating po.
.
#) Nausea/vomiting - felt due to gastroparesis. Improved with
IV antiemetics. Was ultimately controlled with oral reglan. By
discharge, this had resolved.
.
#) HTN - no evidence of end organ damage seen. Initially
treated with IV labetolol, and this was changed to oral
formulation by discharge. Her ace inhibitor was continued.
Clonidine patch was started. BP was well controlled at
discharge.
.
#) DMI - on insulin pump at home. Presented with ketones in
urine and AG = 16 suggestive of mild DKA. Started on IVF
resuscitation and insulin gtt for improved control - gap
resolved and BG controlled. Transitioned to lantus and lispro
(HS and sliding scale) and pump turned off. [**Last Name (un) **] consulted.
Agreed with this plan. Plan to leave pump of indefinately.
.
#) Sciatica - [**Last Name (un) 16604**] and oxycodone held in hospital as pt.
was slightly confused on presentation. This was not restarted,
and she did not experience overt opiate withdrawal. At the time
of discharge, she was not complaining of back pain, so the
opiates were not restarted/continued.
.
Pneumococcal vaccine status confirmed (last [**2152**]); gave
influenza vaccine.
Medications on Admission:
albuterol inh prn
?aspirin 325mg daily
calcitriol 0.5mcg po daily
citalopram 40mg daily
Humalog pump
lisinopril 30mg daily
lorazepam 0.5mg daily prn
neurontin 800mg po qam, qpm, 1600mg qhs
[**Year (4 digits) 16604**] 40mg qam and 10mg qhs
oxycodone 5mg po q6hrs prn
ranitidine 300mg po qday
reglan 10mg po qid
zocor 40mg daily
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
2. Gabapentin 400 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
Disp:*120 Capsule(s)* Refills:*2*
3. 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*
4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety or insomnia.
Disp:*30 Tablet(s)* Refills:*0*
7. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
10. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSAT (every Saturday).
Disp:*4 Patch Weekly(s)* Refills:*2*
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28)
Units, insulin Subcutaneous at bedtime.
Disp:*10 mL* Refills:*2*
14. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale (attached) Units, insulin Subcutaneous QACHS insulin.
Disp:*6 mL* Refills:*2*
15. Syringe Misc Sig: One Hundred (100) syringes, insulin
Miscellaneous as directed.
Disp:*100 syringes, insulin* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperglycemia and hypertensive crisis
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Return to the Emergency Department at [**Hospital1 18**] for:
Lightheadedness, nausea, vomiting, uncontrolled high blood
pressure or blood sugar, headache, changes in vision
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2155-9-15**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2155-10-1**] 10:40
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2155-12-18**] 7:50
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1882
} | Medical Text: Admission Date: [**2152-6-29**] Discharge Date: [**2152-7-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypertensive emergency with AMS
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 96278**] is a [**Age over 90 **] year old female with history of poorly
controlled hypertension (reported baseline SBP of 170),
dementia; admit with HTN emergency and mental status changes.
Patient had emesis x3, blood-tinged with last episode, at [**Hospital1 1501**]
this morning. She was hypertensive to SBP 190-240/70-90 there
without significant improvement after her morning meds.
In the ED, SBP 270/80, HR 76, afebrile. Had emesis x1; NGL done
with some guaiac positive return (coffee ground appearing). NGT
kept in place, 200 cc total returned to suction. GI consulted,
felt likely [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear; would EGD only if continued
hematemesis and BP more stable. BP wise, brought down to goal
~190 with labetalol gtt. EKG with isolated TWI in V6, 1st set
enzymes negative. There was concern for mental status changes
(at baseline "pleasantly confused", per last d/c summary vaguely
oriented to time/place); in ED patient oriented to self and
agitated requiring restraints to keep patient from pulling out
NGT. Had head CT with no brain pathology but concern for
intraocular hemorrhage on initial read. Other workup included
lactate 2.2, CXR and U/A unremarkable.
Past Medical History:
PAST MEDICAL HISTORY
- Hypertension, difficult to control per PCP; baseline
reportedly 170s
- Congestive heart failure, EF unknown
- Borderline DM2
- Chronic kidney disease stage IV (baseline Cre 1.6-1.8)
- Osteoarthritis s/p L THR
- Dementia
- Hypothyroidism, recently started on levothyroxine (last month)
Social History:
Lives at [**Hospital3 2558**]. Power of Attorney is brother [**Name (NI) **]
[**Name (NI) 102210**]. Denies tobacco, EtOH.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 97.8F, BP 151/50 (range 131/46 - 179/63 since arrival
to ICU) P 75, RR 19, 98% SaO2 on 2 L NC
General: NAD, well nourished elderly female
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: supple, no nuchal rigidity, bilateral carotid bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MRG
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated
Skin: no rashes
Neurologic Examination:
Mental Status:
Awake and alert, but poor attention; follows simple commands
only intermittently
Oriented to person but cannot/will not state time or place.
Language: perseverative; to question of name, answered "[**Known firstname 102211**]
[**Last Name (NamePattern1) 102212**]..." and when asked to repeat, "No ifs ands or
buts," said, "No and ifs and ifs and buts and buts and..."
Calculation: not tested
Fund of knowledge: unable to assess
Memory: registration: [**2-7**] items, recall [**2-7**] items at 3 minutes
No evidence of apraxia or neglect
Cranial Nerves:
Blinks to threat. Pupils equally round and reactive to light, 4
to 3 mm bilaterally.
Extraocular movements intact, no nystagmus. Facial sensation
intact bilaterally. Facial movement normal and symmetric.
Hearing intact to finger rub bilaterally. Palate elevates
midline. Tongue protrudes midline, no fasciculations. Trapezii
full strength bilaterally.
Motor:
Normal bulk and tone throughout. No tremor or asterixis.
Able to lift all extremities off the bed but unable to cooperate
with detailed testing. According to nursing staff, she was
pulling at tubes overnight with full strength in both arms.
Sensation: No deficits to light touch and pin-prick.
Reflexes: B T Br Pa Pl
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes were downgoing bilaterally.
Coordination: No intention tremor.
Gait: Unable to assess
Pertinent Results:
ADMISSION LABS:
[**2152-6-29**] 11:51AM BLOOD WBC-15.9*# RBC-5.26 Hgb-14.7 Hct-43.2
MCV-82 MCH-27.9 MCHC-34.0 RDW-13.1 Plt Ct-272
[**2152-6-29**] 11:51AM BLOOD Neuts-94.2* Bands-0 Lymphs-3.9*
Monos-1.2* Eos-0.3 Baso-0.5
[**2152-6-29**] 11:51AM BLOOD Glucose-223* UreaN-26* Creat-1.3* Na-138
K-4.0 Cl-101 HCO3-22 AnGap-19
[**2152-6-29**] 11:51AM BLOOD cTropnT-<0.01
[**2152-6-29**] 11:51AM BLOOD ALT-10 AST-15 CK(CPK)-43 AlkPhos-76
TotBili-0.6
[**2152-6-29**] 08:32PM BLOOD TSH-0.29
[**2152-6-29**] 08:32PM BLOOD Free T4-2.3*
[**2152-6-29**] 12:11PM BLOOD Lactate-2.2*
[**2152-6-29**] 10:17PM BLOOD Lactate-3.8*
[**2152-6-30**] 04:31AM BLOOD Lactate-2.0
NOTABLE DISCHARGE LABS:
Cr 1.2, BUN 19
WBC 14.1
HCT 38.8
INR 1.6
MICROBIOLOGY:
[**6-29**], [**2152-7-2**] Urine Cultures: negative
[**2152-7-7**] Urine Cultures: NGTD
[**2152-7-2**] Urine Legionella: negative
[**6-29**], [**7-2**], [**2152-7-6**] Blood Cultures: negative
[**2152-7-6**] Stool C. diff toxins A & B: negative
CT HEAD W/O CONTRAST Study Date of [**2152-6-29**] 11:56 AM
HISTORY: Altered mental status, systolic blood pressure 200's,
nausea and
vomiting. Rule out intracranial bleed.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT.
CT OF THE HEAD WITHOUT CONTRAST: There is no evidence of masses,
hydrocephalus, shift of normally midline structures, infarction,
or hemorrhage. Bilateral basal ganglia calcifications are seen.
The ventricles and sulci are prominent consistent with
age-related atrophy. Vascular calcifications are seen. Confluent
hypodensities within the periventricular white matter likely
represent chronic microvascular ischemia. The osseous structures
demonstrate hyperostosis frontalis interna. The surrounding soft
tissues are unremarkable. The visualized paranasal sinuses are
clear. Partial opacification of the mastoid air cells
bilaterally is noted. A right scleral band is seen around the
right globe.
IMPRESSION: No intracranial hemorrhage.
CT ABDOMEN W/CONTRAST Study Date of [**2152-6-29**] 2:53 PM
INDICATION: [**Age over 90 **]-year-old female with vomiting and abdominal pain.
COMPARISON: Abdominal radiographs from same day.
TECHNIQUE: MDCT-acquired axial imaging of the abdomen and pelvis
was performed following administration of oral and intravenous
contrast. Multiplanar reformatted images were obtained and
reviewed.
CT ABDOMEN: There is mild dependent bibasilar atelectasis. Liver
is
unremarkable. There is a thin crescent of hyperdensity layering
in the
gallbladder fundus, which may represent a tiny amount of [**Doctor Last Name 5691**]
versus a small focus of adenomyomatosis. Gallbladder is
otherwise unremarkable. Pancreas is atrophic and fatty replaced.
Spleen is unremarkable. Adrenal glands and kidneys are
unremarkable. There is no hydronephrosis. Stomach and
intra-abdominal loops of bowel are unremarkable. Nasogastric
tube is in place, tip in the gastric body. There is a moderate
axial hiatal hernia and a small fat-containing ventral hernia.
There is no free air, free fluid, or abnormal intra- abdominal
lymphadenopathy. There is mild atherosclerotic calcified and
noncalcified plaque throughout the abdominal vasculature.
CT PELVIS: Pelvic loops of large and small bowel are
unremarkable, except to note sigmoid diverticulosis. Evaluation
of the deep pelvic structures is limited by streak artifact from
bilateral hip replacements. There is no definite free pelvic
fluid. There is no abnormal pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: There is no osseous lesion suspicious for
malignancy.
Multilevel degenerative changes in the thoracolumbar spine are
noted, with
moderate dextroconvex thoracolumbar scoliosis.
IMPRESSION:
1. No specific CT finding to explain hematemesis and abdominal
pain.
2. Moderate axial hiatal hernia.
3. Diverticulosis, without evidence of diverticulitis.
4. Small fat-containing ventral hernia.
ECHO [**2152-6-30**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). A mild apical intracavitary gradient is identified.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: hypertrophic, hyperdynamic left ventricle
Chest X-ray, PA and Laterl [**2152-7-2**]:
The lungs are hyperinflated and the diaphragms are flattened,
consistent with COPD. There are low inspiratory volumes.
Allowing for this, there is
probable moderate cardiomegaly and mild unfolding of the aorta.
The ascending aorta is prominent, consistent with chronic
hypertension. There is upper zone re-distribution, but I doubt
overt CHF. There is a small right pleural effusion posteriorly.
There is also minimal blunting of both costophrenic angles. No
focal infiltrate is identified.
Sinus rhythm with supraventricular premature depolarizations.
Marked
lateral ST segment depressions. Compared to the previous tracing
sinus rhythm
is now present with overall reduced ventricular rate and
diminished ischemic
ST segment depression.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 142 96 444/463 86 64 169
ECG - [**2152-7-4**] - Ectopic atrial rhythm with ventricular premature
depolarizations. Inferior myocardial infarction. Short P-R
interval with abnormal P wave axis raising consideration of
ectopic atrial rhythm. Diffuse non-diagnostic repolarization
abnormalities. Compared to the previous tracing of [**2152-7-3**] an
ectopic atrial rhythm is now present with inferior myocardial
infarction pattern.
Shoulder XR [**2152-7-4**] - IMPRESSION: No acute fracture detected
involving the proximal humerus or
shoulder girdle. Possible old healed proximal humeral fracture.
Probable
chronic rotator cuff tear. Superior and anterior subluxation of
humeral head
with respect to glenoid, but no frank dislocation.
CXR [**2152-7-4**] - Lung volumes are low, particularly elevation of
the left lung base, new. Some of this may be due to left lower
lobe atelectasis. Heart size top normal, unchanged. No pulmonary
edema or vascular redistribution to suggest heart failure. No
appreciable pleural effusion. This examination is not designed
for detection of rib fractures which are easily missed.
ECG - [**2152-7-6**] - 7AM - Atrial fibrillation, mean ventricular rate
128. Compared to the previous tracing no major change.Rate
PR QRS QT/QTc P QRS T
128 0.86 312/431 0 -9 -155
Brief Hospital Course:
HYPERTENSION, HYPERTENSIVE EMERGENCY, ALTERED MENTAL STATUS:
Ms. [**Known lastname 96278**] was initially admitted to the MICU after coming from
the ED on a labetolol drip for her hypertension. Once in the
MICU, neurology was consulted for altered mental status,
non-fluent aphasia and possible left-sided neglect. Neurology
ultimately felt her presentation was consistent with transient
worsening of her dementia from relative
hypotension/hypoperfusion in the setting of aggressive blood
pressure reduction. SBP was at one point 110 - 120 while on the
beta-blocker drip. Neurology recommended maintaining SBP within
the 160 - 180 range, which was attained off medicines. After 24
hours of blood pressures in this range, mental status and speech
returned to baseline. She had no residual deficits and was at
her baseline dementia. Head CT showed no evidence of bleed.
Since she recovered to baseline, further MRI studies were not
deemed necessary. At discharge she was conversant, pleasant and
was able to follow multistep commands. She had registration but
significantly impaired recall at 5 minutes, with no improvement
with prompting or lists.
Two days after being called out to the floor from the MICU, her
blood pressure began to increase and she was restarted on
lisinopril 40mg, HCTZ 25m, with PRN hydralazine. On [**2152-7-2**],
she then dropped her systolic BP to the 70's when her rhythm
changed from sinus to atrial fibrillation with RVR. She was
noted to have ST segment depressions in I, II, AVL, V3, V4, V5,
V6 and ST elevation in III, AVR, VI. She did not respond to IV
metoprolol, and as pacer pads were being placed she developed
ventricular fibrillation. She became pulseless for which chest
compressions were initiated and the patient was given 1 shock.
NSR was reattained and patient regained consciousness. Repeat
EKG showed NSR, but continued, however to show lessened ST
changes as above. A right femoral central line placed, heparin
bolus and gtt initiated for a STEMI.
She was transferred to the CCU conversant and, on [**7-3**], was
started on 20 mg LISINOPRIL, 25 mg METOPROLOL [**Hospital1 **], and NORVASC 5
mg daily for a low SBP goal of 160 based on the patient's
longstanding hypertension in the 170's. Her IV heparin was
discontinued, and SC heparin started due to the risk of
bleeding. Her troponins were elevated (max 5.3) and trended
down with medical managment of her ischemia, thought to be [**1-8**]
demand during the afib episodes. She was started on ASA,
continued on beta blocker, ACEI and high dose statin. She was
continued on these medications throughout the hospitalization.
GIbIIa inhibitor was not started due to concern for acute
bleeding.
ATRIAL FIBRILLATION:
Once patient was hemodynamically stable, she was transferred
back to the floor on [**7-4**], where she continued to have episodes
of atrial fibrillation with RVR. She was difficult to controll
with IV beta blockade and responded transiently to cardizem IV.
She was started on cardizem PO 60mg qid, with marginal control
of HR (90s - 100s) with frequent reversions to fibrillation. On
[**7-5**], patient was started on amoiodarone loading dose of 400mg
QD. She converted to sinus rhythm of ~ 50 - 60. She had
occasional reversions to atrial fibrillation on [**7-5**] - [**7-6**],
which were converted to sinus rhythm with 20mg IV doses of
cardizem. Her rhythm was controlled for over 24 hours prior to
discharge. Patient was also noted to have 2 asymptomatic
pauses of 3 - 5 seconds each. She was evaluated by EP and
ordered a 30 day heart monitor to be triggered for HR < 40 or >
100. She has a follow up appointment with Dr. [**Last Name (STitle) **]
regarding atrial fibrillation control and suspected tachy-brady
syndrome.
Because of frequent conversions from atrial fibrillatin to sinus
rhythm, her age and her history of hypertension and diabetes,
patient was deemed a candidate for anticoagulation. She was
started on coumadin 2mg PO daily on [**2152-7-5**], which was increased
subsequently to 4mg PO daily on [**2152-7-6**]. Her INR on [**2152-7-7**] was
1.6. She should have her INR measured daily and warfarin dosing
adjusted to goal of INR 2 - 3.
LEUKOCYTOSIS:
She was noted to have leukocytosis on admission. The workup for
this has remained negative throughout hospitalization, and may
have been a stress response although blood cultures were pending
at discharge (multiple earlier sets were negative). Her urine
cultures, C.diff and legionella were negative. She was afebrile
throughout and was never on antibiotics while in-house.
UPPER GI BLEED:
The day of admission, Ms. [**Known lastname 96278**] has several episodes of emesis
thought to be from GI upset in the setting of the severe
hypertension. The last episode of emesis was coffee-grounds and
guaiac positive. The GI service was consulted and felt this was
due to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear, and she was never scoped. Her
bleeding appeared to resolve as her Hct was stable throughout
the admission and she had no further episodes of emesis. She
was placed on PO protonix. She did test positive for H.Pylori
by EIA, but was not treated due to no signs of acute bleeding
and the risks associated with long term antibiotic treatment in
a geriatric patient.
On [**7-4**] patient was noted to have right sided abdominal pain on
deep palpation. Negative [**Doctor Last Name **], no signs of acute abdomen
were noted on exam. Pt. has a ventral hernia on CT from [**6-29**],
but no other abdominal process to explain the pain. Her lactate
was 1.3. LFTs normalized by [**2152-7-6**]. Pain was well controlled
with APAP. She should be reevaluated with serial abdominal
exams for follow up.
LEFT SHOULDER PAIN:
Left shoulder and chest wall pain were also noted on [**7-4**].
These were reproducible w/ palpation, and with shoulder ROM
manipulation. Patient also had supraspinatus tenderness, no
apprehension sign. Given recent chest compressions when she was
coded, there was concern for fractures. X-ray did not show
fractures of the ribs or shoulder/humerus. Shoulder x-ray
showed probable rotator cuff tear. She was treated by physical
therapy and acetaminophen around the clock.
HYPOTHYROIDISM:
The patient has a history of hypothyroidism and her synthroid
had been recently increased from 50 to 225 mcg in the course of
1 month, and while at [**Hospital1 18**], she has been given 50 mg given
concern for overmedication causing AFib.
CHRONIC KIDNEY DISEASE:
At baseline, patient has CKD with likely etiology being HTN.
Baseline reportedly 1.6-1.8. Cr improved to 1.2 with 250 - 500
NS boluses daily and remained stable stable [**7-4**] - [**7-7**]. Patient
will require renal dosing of medications.
SCLERAL BUCKLE:
Opthalmology also consulted for a possible intraocular
hemorrhage that was seen on CT on admission. Ophthalmology
thought the scleral buckle was secondary to prior repair of
retinal detachment.
CODE STATUS, COMMUNICATION:
The patient is a poor candidate for invasive procedures given
her age and baseline dementia. Her brother, [**Name (NI) **] [**Name (NI) 102210**] is
her health care proxy and her current status is DNR/DNI. He can
be reached at ([**Telephone/Fax (1) 102213**] or [**Telephone/Fax (1) 102214**].
PENDING ISSUES FOR FOLLOW-UP:
1. Patient is on coumadin and will require daily measurements of
PT/INR and adjustment of her coumadin dose to achieve goal INR
of 2 - 3.
2. Patient was started on amiodarone for atrial fibrillation
with rapid ventricular response. She should be continued on
this medication at a dose of 400mg daily for another 10 days,
then on 200mg daily for another 14 days, followed by maintenance
dose. Her liver and kidney function tests should be checked
weekly and electrolytes every other day until stabilized.
3. Heart failure - patient has documented heart failure of
likely diastolic dysfunction. EF ~ 70%. She is on metoprolol
and lisinopril. Her diet is restricted as below and she has no
fluid restriction. Activity level is as per PT recommendations.
Patient should be weighed daily and monitored for symptoms of
heart failure: shortness of breath, leg edema, orthopnea. She
will be follow up by cardiology and primary care physician.
Medications on Admission:
MEDICATIONS AT HOME
Norvasc 5 mg daily (increased yesterday)
Synthroid 225 mcg daily (appears recent increase)
Lisinopril 20 mg daily
Atenolol 50 mg daily
Colace 100 mg [**Hospital1 **]
APAP 650 TID
bisacodyl prn
MOM prn
[**Name2 (NI) **]
senna [**Hospital1 **] prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous ASDIR (AS DIRECTED): As per [**Hospital1 18**] inpatient sliding
scale.
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 10 days: Then can be changed to 200mg daily for
additional 14 days, followed by maintenance dose.
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Q
1700.
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Myocardial infarction, Hypertensive emergency
Secondary: Hypertension, Atrial fibrillation, Diabetes mellitus,
Chronic kidney disease
Discharge Condition:
Hemodynamically stable
At discharge she was conversant, pleasant and was able to follow
multistep commands. She had registration but significantly
impaired recall at 5 minutes, with no improvement with prompting
or lists.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with significantly elevated blood
pressure. As you were treated for this, you had changes in your
mental state. You then developed a new arrhythmia, following
which you had a heart attack. These were thought to be due to
elevated thyroid hormones.
.
You were treated for all these complications and required
intensive care unit management. You were able to recover to
your mental state baseline. Your arrhythmias were finally
controlled with medications (see medication list below).
Finally, because of your arrhythmia (atrial fibrillation) you
were started on a medication (coumadin) to help prevent a
stroke.
You were discharged to your nursing facility in a
hemodynamically stable condition, with your heart rate
controlled.
During your hospitalization, through discussion with your health
care proxy and the medical staff, you resuscitation status was
changed to Do not resuscitate, do not intubate.
Should you experience new chest pain, shorness of breath,
difficulty speaking, dizzyness, palpitations, fever, cough, new
pain or any other symptom concerning to you, please contact your
health care provider at the rehabilitation facility or go to the
nearest emergency room.
Followup Instructions:
Please follow up with the following appointments:
You will be seen at your facility by your primary care doctor:
Dr. [**First Name (STitle) 807**].
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Hospital1 18**], [**Hospital Ward Name 23**] 7, on [**2152-8-4**] at 2pm.
[**Telephone/Fax (1) 102215**].
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2152-7-17**] 9:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2152-8-4**] 2:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1883
} | Medical Text: Admission Date: [**2176-2-8**] Discharge Date: [**2176-2-14**]
Date of Birth: [**2098-10-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right upper lobe lung cancer.
Major Surgical or Invasive Procedure:
[**2176-2-8**] Video-assisted thoracic surgery right
upper lobectomy, video-assisted thoracic surgery right lower
lobe superior segmentectomy, mediastinal lymph node
dissection and flexible bronchoscopy.
[**2176-2-9**] Flexible Bronchoscopy
History of Present Illness:
76F who is a former smoker had a history of dry cough for the
past year. She saw her physician and had [**Name Initial (PRE) **] CXR, which showed a
RUL infiltrate. She was treated with antibiotics without
improvement. She then underwent a chest CT [**2175-5-4**], which
demonstrated a 5x3cm spiculated ilfiltrate in the RUL. She was
treated with another course of levo and had a repeat CT scan
[**2175-6-7**]. This scan showed an increase in size in the RUL
consolidation with some new fullness in the R hilum. PET-CT was
done on [**2175-9-9**], revealing intense FDG activity in the R lung
consistent with malignancy. There was also an FDG-avid area in
the proximal descending colon. The patient underwent a flex
bronch [**2175-10-19**], and the brushings and washings were negative. No
lymph nodes were biopsied. She then underwent a CT guided biopsy
of the mass which revealed NSCLC most consistent with poorly
differentiated adenocarcinoma.
Past Medical History:
Cardiomyopathy
Macular degeneration
Detached retina
Spinal Stenosis
Asthma w h/o intubation,
Arthritis
osteoporosis
Open cholecystectomy in the [**2135**].
Cataract extraction bilateral
Social History:
Lives with family. 25 pack-year quit 12 years ago. ETOH
occasional
Family History:
Siblings - sister w pancreas ca, brother w [**Name2 (NI) 500**] cancer
Physical Exam:
VS: T: 98.8 HR 94 SR BP: 108/60 Sats: 96% 3L
General: no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds on right with scattered rhonchi
GI: benign
Extr: warm no edema
Incision: Right VATs site clean dry intact no erythema
Neuro: non-focal
Pertinent Results:
[**2176-2-14**] WBC-9.6 RBC-2.88* Hgb-9.0* Hct-27.5 Plt Ct-433
[**2176-2-13**] WBC-7.5 RBC-3.15* Hgb-9.6* Hct-29.4 Plt Ct-396
[**2176-2-11**] WBC-11.2* RBC-2.95* Hgb-9.2* Hct 30 Plt Ct-290
[**2176-2-9**] WBC-13.5* RBC-3.26* Hgb-10.5* Hct-31.0* Plt Ct-354
[**2176-2-8**] WBC-18.6*# RBC-3.97* Hgb-12.6 Hct-37.6 Plt Ct-413
[**2176-2-8**] WBC-6.9 RBC-3.84* Hgb-11.7* Hct-35.2* Plt Ct-377
[**2176-2-14**] Glucose-110* UreaN-10 Creat-0.8 Na-135 K-4.4 Cl-100
HCO3-27
[**2176-2-13**] Glucose-102* UreaN-9 Creat-0.8 Na-137 K-3.9 Cl-100
HCO3-27
[**2176-2-9**] Glucose-132* UreaN-16 Creat-1.3* Na-137 K-4.1 Cl-104
HCO3-26
[**2176-2-9**] Glucose-192* UreaN-19 Creat-1.9* Na-137 K-4.8 Cl-101
HCO3-26
[**2176-2-8**] Glucose-227* UreaN-17 Creat-1.5* Na-139 K-4.8 Cl-100
HCO3-26
[**2176-2-8**] Glucose-158* UreaN-14 Creat-1.2* Na-140 K-4.2 Cl-105
HCO3-24
[**2176-2-9**] CK(CPK)-245* [**2176-2-9**] CK(CPK)-349*
[**2176-2-14**] Calcium-9.0 Phos-2.9 Mg-1.9
[**2176-2-13**] Calcium-8.8 Phos-2.9 Mg-2.3
[**2176-2-9**] pO2-172* pCO2-64* pH-7.22* calTCO2-28 Base XS--2
NON-REBREA
[**2176-2-10**] Type-ART pO2-111* pCO2-52* pH-7.32* calTCO2-28 Base
XS-0
[**2176-2-10**] Type-ART pO2-102 pCO2-48* pH-7.34* calTCO2-27 Base XS-0
[**2176-2-11**] ART pO2-131* pCO2-37 pH-7.41 calTCO2-24 Base XS-0
CXR:
[**2176-2-13**] FINDINGS: In comparison with the study of [**2-12**], the
postoperative changes are again seen in the right hemithorax.
This includes the mediastinal and tracheal displacement as well
as distortion of the right hilus. The left lung remains
essentially clear except for some atelectatic streaks at the
base. There appears to be a hiatal hernia in the retrocardiac
region on the lateral projection.
[**2176-2-11**] Tiny loculated right apical pneumothorax unchanged,
small to moderate right pleural effusion probably decreasing,
pleural tubes still in place. Mild cardiomegaly stable. Hiatus
hernia noted. Left upper lung clear.
[**2176-2-9**]: In comparison with the study of [**2-8**], right chest tube
again
extends to the apex and descends inferiorly to terminate at the
level of the hemidiaphragm. The small to moderate right apical
pneumothorax is again seen, though quite subtle. Right perihilar
opacity persists, most likely representing a combination of
atelectasis and contusion in this recently postoperative
patient. Left lung remains essentially clear.
Micro: BC x 2 no growth to date, Ucx negative, sputum rare
yeast
Brief Hospital Course:
Mrs. [**Known lastname 25780**] was admitted on [**2176-2-8**] for Video-assisted
thoracic surgery right
upper lobectomy, video-assisted thoracic surgery right lower
lobe superior segmentectomy, mediastinal lymph node dissection
and flexible bronchoscopy. She was extubated in the operating
room and monitored in the PACU prior transfer to the floor.
Overnight she developed respiratory distress and was
re-intubated and transferred to the SICU for respiratory
failure. Aggressive pulmonary toilet, mucolytic nebs were
administered.
Respiratory: Respiratory failure [**2176-2-9**] re-intubated on a
vent, sedated, unable to to protect her airway and manage
secretions. Aggressive pulmonary toilet, mucolytic nebs were
administered. Followed by serial ABGs (see above). On [**2176-2-10**]
she was extubated with oxygen saturations in the 94-98% with
occasional desaturations to low 90's on 50% shovel mask.
Aggressive chest PT was administered her oxygen saturations
improved 94-97% on 4 Liters nasal cannula. She transferred to
the floor on [**2176-2-12**]. Oxygen saturations remained > 93% at rest
on 3Liters of nasal cannula with desaturations to 88% with
acitivity. She required home oxygen to maintain oxygen
saturations > 93%.
Flexible bronchoscopy was performed on [**2176-2-10**] which showed
slight effacement of right middle lobe medial segment.
[**Doctor Last Name 406**] drain: right was removed on [**2176-2-10**]. She was followed by
serial chest films which showed atelectasis and stable right
apical space.
Cardiac: she remained hemodynamically stable in sinus rhythm.
GI: prophylactis PPIs and bowel regime were administered
Nutrition: She tolerated a regular diet.
Speech: Speech and swallow consulted for a weak voice. Vocal
cord paralysis since [**2164**] no signs of aspiration. Continue with
regular diet, thin liquids, medications whole. F/U with voice
therapy as an outpatient.
Renal: ATN with peak CRE 1.9 base 1.1-1.3. She was hydrated
with CRE return to baseline. On [**2176-2-12**] she was gently diuresed
with IV lasix with good Urine output.
On [**2176-2-13**] she restarted her home lasix dose. Electrolytes were
repleted as needed.
Pain: Acute on chronic pain. history of spinal stenosis takes
home oxycodone. She was started with a Dilaudid PCA titrated to
comfort. Once extubated she was converted to PO oxycodone with
good pain control.
Disposition: Physical therapy recommended Short term rehab. She
was discharged [**2176-2-14**] to [**Hospital1 **] in [**Location (un) 701**].
Medications on Admission:
Furosemide 20 mg a day, amlodipine 5 mg a day, Nexium 40 mg a
day, Cymbalta 60 mg a day, Lipitor 10 mg daily, aspirin 81 mg
daily, meclizine 25 mg three times a day as needed, oxycodone
one tablet five times a day, Flovent two puffs
twice a day, albuterol as needed, Actonel 150 mg once a month,
multivitamin one tablet a day, vitamin C 500 mg daily, calcium
plus D 600 mg two tablets per day, vitamin E 400 international
units per day, flaxseed oil 1000 mg, and omega-3 tablets three
times a day, Ocuvite one drop per day.
Discharge Medications:
1. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
10. Meclizine 25 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for vertigo.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Right upper lobe nodule
Cardiomyopathy
Macular degeneration
Detached retina
Spinal Stenosis
Asthma w h/o intubation,
Arthritis
Osteoporosis
Open cholecystectomy in the [**2135**].
Cataract extraction bilateral
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Call Dr.[**Name (NI) 25781**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills
-Increased shortness of breath cough or sputum production
-Chest pain
-Incision develops drainage
-You may shower no tub bathing or swimming for 3 weeks
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2176-2-29**]
2:30
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**].
Chest X-Ray 2:00pm before your appointment on the [**Location (un) 861**]
Radiology Department
Completed by:[**2176-2-16**]
ICD9 Codes: 4254, 5180, 5845, 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1884
} | Medical Text: Admission Date: [**2128-12-29**] Discharge Date: [**2129-1-3**]
Service: MEDICINE
Allergies:
Feldene / Ceftriaxone / Augmentin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo [**Age over 90 **] speaking female with severe Parkinson's, CRI,
recurrent UTI's, diastolic CHF, afib, dementia, ppm for
bradycardia who presented from NH for ? PNA and dehydration,
found to be persistently hypotensive in ED and transferred to
MICU for possible sepsis. History is obtained from daughter, as
patient is noncommuncative currently. Per daughter, patient was
in USOH (baseline includes some eating, drinking, wathcing tv,
looking at pictures, and somewhat verbal to daughter) until
[**Name (NI) 2974**] when appetite declined. Labs sent with nothing revealing.
On Sunday patient stopped eating and began sleeping all of the
time. Tues CXR done which demonstrated possible PNA vs CHF. No
cough, fever. Levofloxacin x 1 given. Sent to ED for possible
PNA and dehydration.
.
Vitals were initially stable in ED until pt became hypotensive
to systolic of 70's. Pancultured and given ceftriaxone (has true
allergy to this), vancomycin 1000mg x 1, flagyl 500 mg x 1, and
dexamethasone 10 mg IV x 1. Central line placed (unable to get
in touch with daughter to get permission for this) and started
on levophed. Also guaic positive in ED.
.
Of note the patient has been admitted in the past ([**2128-7-10**])
for urosepsis treated with Augmentin after patient got AIN s/p
Ceftriaxone, then again in [**2128-8-10**] with change in mental
status & possible urosepsis but cultures negative. Most recent
admission in [**Month (only) 359**] for UTI with possible urosepsis (E. coli in
urine, MSSA in blood, treated with meropenem), PNA,
hypernatremia.
.
ROS: Unable to obtain from patient. Per daughter, afebrile, more
sleepy, no SOB, cough, URI sxs, CP, abd pain, diarrhea,
constipation. Lives in [**Location **] so +sick contacts.
Past Medical History:
#Recurrent urinary tract infections
#Congestive heart failure with a normal EF, 4+ MR. [**First Name (Titles) **] [**Last Name (Titles) 113**]
[**2121**]
#Bipolar disorder
#Parkinson's disease
#Asthma
#OA
#s/p DDD pacer in [**2121**] for bradycardia.
Social History:
Lives [**Hospital3 **]. Daughter is [**First Name5 (NamePattern1) 335**] [**Last Name (NamePattern1) 111445**] who is on
staff at [**Hospital1 18**] as [**Hospital1 595**] interpreter (beeper [**Numeric Identifier 111446**])
Family History:
Non contributory
Physical Exam:
per admitting resident:
Vitals: 97.1, 91, 84/58 (MAP 62), 22, 100% on 2L
HEENT: PERRL, left eye closed, unable to assess EOM, anicteric
sclera, MMM, OP clear
Neck: supple, no LAD, no thyromegaly
Cardiac: RRR, NL S1 and S2, no MRGs
Lungs: crackle at right base, o/w CTAB
Abd: soft, NTND, NABS, no HSM, no rebound or guarding
Ext: contracted, warm, 2+DP
Neuro: unable to fully assess d/t patient
noncompliance/unresponsiveness. CN III intact, will not squeeze
hands or follow commands
Pertinent Results:
Labs:
[**12-29**] INR 7.5 (NH)
Na 158(from 157 day prior) , K 5.7, Cl 121, HCO317, BUN 77, Cr
6.7 (from 6.9 day prior)
.
Studies:
UA: tr leuks, neg nit, [**3-14**] WBC, few bact, tr ket, sm bili
.
CXR:
Dual chamber pacer in place. Left lower lobe with consolidation
and possibly a left pleural effusion.
.
EKG: NSR, LAD, poor R wave progression, Q wave in III and V1,
0.[**Street Address(2) 1755**] depressions in V4-V6.
.
CT Head: Moderate size bilateral occipital lobe low density
zones- consider vertebrobasilar infarction. Involvement of
cortex argues against infection. Hypertensive encephalopathy is
possible, but requires clinical correlation.
.
[**Street Address(2) **] [**2128-11-9**]:
Mild LVF. EF nml (>55%). RV nml. Mild AR. Trivial MR.
.
Brief Hospital Course:
[**Age over 90 **] yo [**Age over 90 **] speaking female with severe Parkinson's, CRI,
recurrent UTI's, diastolic CHF, afib, dementia, ppm for
bradycardia who presented with a possible PNA and dehydration,
found to be persistently hypotensive in emergency department and
transferred to MICU for possible sepsis. Patient had a history
of multiple recent previous admissions. The patient presented
hypotensive and somnolent. She was given IV fluid resuscitation
and broad antbiotic coverage, she also was started on pressors.
Her head CT showed changes consistent with vertebrobasilar
infarction rather than infection.
The patient's condition did not improve with maximal care, and
given her poor prognosis, the family decided to pursue comfort
measures only. The patient passed away in presence of her family
on [**2129-1-3**]
Medications on Admission:
D5 1/2 NS at 80cc/hr
Roxanol 2.5 mg SL Q4H prn
Procrit 2,000 SQ MWF
MVI
Seroquel 25 mg PO BID
Seroquel 12.5 mg PO Q4H prn
Metoprolol 50 mg PO TID
Hydralazine 10 mg PO Q6H
Sinemet 25/100 TID
Oxycodone 2.5 mg PO Q 8H prn
Acet prn
Warfarin 5 mg PO QD
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 0389, 5849, 5859, 486, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1885
} | Medical Text: Admission Date: [**2170-12-10**] Discharge Date: [**2170-12-14**]
Date of Birth: [**2099-10-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
AVR (25mm mosaic porcine) [**12-10**]
History of Present Illness:
71 yo F who was noted to have a mheart murmur on physical exam.
An echo on [**2170-9-27**] showed AS.
Past Medical History:
AS, Hysterectomy, Appendectomy [**2151**], RT tib/fib fx from MVC,
Anxiety
Social History:
retired
lives with husband
rare etoh
1 ppd tob x 50 years
Family History:
mother deceased from MI in 60s
Physical Exam:
WDWN elderly F in NAD HR70 RR 16
Pertinent Results:
[**2170-12-14**] 07:17AM BLOOD WBC-8.0 RBC-2.98* Hgb-9.7* Hct-28.1*
MCV-94 MCH-32.5* MCHC-34.4 RDW-13.9 Plt Ct-175
[**2170-12-14**] 07:17AM BLOOD Plt Ct-175
[**2170-12-13**] 08:10AM BLOOD Glucose-96 UreaN-10 Creat-0.5 Na-138
K-3.7 Cl-100 HCO3-29 AnGap-13
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *70 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Normal LV cavity
size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Mildly dilated
ascending aorta. Focal calcifications in ascending aorta. Simple
atheroma in aortic arch. Focal calcifications in aortic arch.
Mildly dilated descending aorta. Simple atheroma in descending
aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Calcified tips of papillary
muscles. Mild (1+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. Frequent ventricular premature beats. Results were
Conclusions
PRE-BYPASS:
1. No spontaneous echo contrast or thrombus is seen in the body
of the left atrium or left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending aorta is mildly dilated. There are simple
atheroma in the aortic arch. There are focal calcifications in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta.
6. The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (area = 0.8cm2). Trace aortic
regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
POST-BYPASS:
Patient removed from cardiopulmonary bypass on phenylephrine
infusion and atrially paced.
1. There is a bioprosthesis in the aortic position. The valve is
well seated. The leaflets are only poorly seen but do appear to
be working. There appaers to be a trace perivalvular leak seen
in the deep transgastric views. No valvular aortic regurgitation
is seen. The peak gradient across the valve is 17.8mmHg.
2. Biventricular function is maintained; LVEF>55%.
3. The degree of mitral regurgitation has decreased to trace.
4. Aortic contours are intact post-decannulation.
Brief Hospital Course:
Admitted on [**2170-12-10**], taken to the OR and underwent AVR (25mm
mosaic porcine). Post-operatively, she was taken to the CVICU
in stable condition. She was weaned from mechanical ventilation
and extubated. She was started on Lasix & beta blocker, chest
tubes were removed, and was transferred to the telemetry floor
on POD # 1. Early am on POD # 3, she had rapid AFib, and was
treated with increased lopressor, and amiodarone. She
subsequently went in to junctional rhythm, with stable
hemodynamics, and her lopressor & amiodarone were decreased.
Her rhythm has returned to NSR today, and she is ready for
discharge home.
Medications on Admission:
Lorazepam 0.5"
Toprol XL 12.5'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Toprol XL 25 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*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
AS now s/p AVR
Hysterectomy, Appendectomy [**2151**], RT tib/fib fx from MVC, Anxiety
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 incision.
No lifting more than 2 pounds or driving until follow up with
surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 7047**] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2170-12-14**]
ICD9 Codes: 4241, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1886
} | Medical Text: Admission Date: [**2135-9-27**] Discharge Date: [**2135-10-7**]
Date of Birth: [**2104-8-11**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Fever, tachycardia
Major Surgical or Invasive Procedure:
Temporary hemodialysis catheter placement
Tunnelled hemodialysis catheter placement
[**Last Name (un) 1372**] intestinal tube placement
History of Present Illness:
This is a 31 yo male with biliary atresia s/p liver [**Last Name (un) **]
in [**2110**], s/p small bowel resection [**8-/2135**], recent staph
bacteremia [**12-27**] infected HD line who was transferred from OSH for
fevers and tachycardia. At home, patient complained of two weeks
of fatigue, productive cough, progressive lower extremity edema,
and fevers/chills. At a VNA visit he was noted to be
tachycardic and taken to an OSH.
.
At OSH, he was febrile and noted to be in SVT, which broke with
adenosine. He was started on levofloxacin for suspected LLL PNA
on CXR. This was broadened empirically to vanc/pip-tazo given
concern for SBP, as well. Patient was transferred to [**Hospital1 18**] ICU.
.
In the ICU, all cell lines of his CBC were trending down, hct
drop from 27 to 19, given 2U PRBC with appropriate increase to
26. No clear source of blood loss. He also c/o
myalgias/arthralgias, with multiple sick contacts, so flu swab
was sent. This came back positive, so he was started on
oseltamivir. Diagnostic para was negative for SBP and CXR did
not show PNA, so vanc/pip-tazo were stopped. His vitals have
shown mild tachycardia from the 90s to low 100s, current BP
136/90.
.
Currently, patient c/o fevers, chills, night sweats, myalgias,
arthralgias, dyspnea, cough productive of greenish sputum, and
hematuria. He denies CP, sore throat, n/v/d, abd pain, melena,
hematochezia, dysuria, frequency, urgency.
Past Medical History:
-biliary Atresia s/p liver [**Hospital1 **] at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
-small bowel resection
Social History:
denies any tobacco, EtOH or illict drug use. Lives at home with
parents, engaged. Has one child with a prior girlfriend. Does
not work.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
Vitals - T: 101.1 (current) BP: 136/92 HR: 110 RR: 22 02 sat:
94% 3L
GENERAL: Tachypneic, diaphoretic, mild resp distress, alert and
cooperative
HEENT: NCAT, no scleral icterus, MM dry, no JVD
CARDIAC: +S1/S2, no M/R/G, slightly tachycardic, regular rhythm
LUNG: Rhonchi throughout right lung, exp wheezing on left, good
air mvmt
ABDOMEN: NABS, several abdominal scars, soft, distended, no TTP.
Dependent flank edema.
EXT: 2+ LE edema, WWP.
Pertinent Results:
*** CBC
[**2135-9-27**] WBC-7.8 RBC-2.99* Hgb-9.1* Hct-26.9* MCV-90 MCH-30.3
MCHC-33.8 RDW-16.6* Plt Ct-169#
[**2135-10-7**] WBC-9.6 RBC-3.40* Hgb-9.8* Hct-29.5* MCV-87 MCH-28.9
MCHC-33.2 RDW-16.7* Plt Ct-187
[**2135-9-27**] Neuts-84.2* Lymphs-7.2* Monos-3.4 Eos-4.8* Baso-0.4
[**2135-9-27**] PT-16.0* PTT-35.2* INR(PT)-1.4*
.
*** Chemistries
[**2135-9-27**] Glucose-87 UreaN-23* Creat-2.5* Na-137 K-4.2 Cl-109*
HCO3-21* AnGap-11
[**2135-9-28**] Glucose-105 UreaN-24* Creat-2.5* Na-136 K-4.0 Cl-110*
HCO3-19* AnGap-11
[**2135-9-28**] Glucose-98 UreaN-28* Creat-2.6* Na-136 K-4.1 Cl-110*
HCO3-20* AnGap-10
[**2135-9-29**] Glucose-80 UreaN-30* Creat-2.8* Na-138 K-4.1 Cl-112*
HCO3-20* AnGap-10
[**2135-9-30**] Glucose-78 UreaN-38* Creat-3.6* Na-137 K-3.8 Cl-111*
HCO3-17* AnGap-13
[**2135-10-1**] Glucose-95 UreaN-45* Creat-4.2* Na-137 K-3.8 Cl-110*
HCO3-17* AnGap-14
[**2135-10-2**] Glucose-82 UreaN-52* Creat-5.5*# Na-135 K-3.9 Cl-110*
HCO3-16* AnGap-13
[**2135-10-3**] Glucose-80 UreaN-57* Creat-6.6*# Na-138 K-4.3 Cl-110*
HCO3-15* AnGap-17
[**2135-10-4**] Glucose-83 UreaN-66* Creat-7.6* Na-139 K-4.6 Cl-111*
HCO3-15* AnGap-18
[**2135-10-5**] Glucose-92 UreaN-51* Creat-6.9* Na-140 K-3.8 Cl-108
HCO3-20* AnGap-16
[**2135-10-6**] Glucose-98 UreaN-35* Creat-5.7*# Na-141 K-3.7 Cl-107
HCO3-26 AnGap-12
[**2135-10-7**] Glucose-139* UreaN-22* Creat-4.3*# Na-140 K-3.8 Cl-105
HCO3-28 AnGap-11
.
*** Liver Function Tests:
[**2135-9-27**] ALT-33 AST-79* LD(LDH)-399* CK(CPK)-310* AlkPhos-371*
TotBili-0.4
[**2135-9-28**] ALT-25 AST-63* LD(LDH)-319* CK(CPK)-305* AlkPhos-265*
TotBili-0.6
[**2135-9-28**] LD(LDH)-364*
[**2135-9-29**] ALT-20 AST-62* LD(LDH)-403* AlkPhos-267* TotBili-1.0
[**2135-9-30**] ALT-18 AST-68* LD(LDH)-504* AlkPhos-336* TotBili-0.5
[**2135-9-30**] CK(CPK)-387*
[**2135-10-1**] ALT-15 AST-56* LD(LDH)-442* AlkPhos-329* TotBili-0.6
[**2135-10-2**] ALT-14 AST-56* LD(LDH)-469* AlkPhos-321* TotBili-0.5
[**2135-10-4**] ALT-12 AST-48* AlkPhos-310* TotBili-0.5
[**2135-10-5**] ALT-13 AST-39 AlkPhos-275* TotBili-0.5
[**2135-10-6**] ALT-10 AST-40 AlkPhos-301* TotBili-0.5
[**2135-10-7**] ALT-14 AST-48* AlkPhos-327* TotBili-0.4
[**2135-9-30**] Lipase-119*
.
*** Albumin, Calcium, Phosphorus, Magnesium
[**2135-9-27**] Albumin-1.1* Calcium-6.3* Phos-3.2 Mg-0.8*
[**2135-9-28**] Calcium-6.0* Phos-3.2 Mg-1.4*
[**2135-9-28**] Calcium-6.5* Phos-3.7 Mg-1.8
[**2135-9-29**] Calcium-6.7* Phos-4.3 Mg-1.8
[**2135-9-30**] Albumin-1.5* Calcium-6.8* Phos-4.3 Mg-1.7
[**2135-10-1**] Calcium-7.3* Phos-4.4 Mg-1.7
[**2135-10-2**] Calcium-7.4* Phos-4.4 Mg-1.7
[**2135-10-3**] Calcium-7.3* Phos-4.6* Mg-1.8
[**2135-10-4**] Albumin-1.2* Calcium-7.2* Phos-5.0* Mg-1.9
[**2135-10-5**] Calcium-7.2* Phos-4.4 Mg-1.8
[**2135-10-6**] Albumin-1.1* Calcium-7.0* Phos-4.0 Mg-1.7 Iron-22*
[**2135-10-7**] Calcium-6.9* Phos-3.1 Mg-1.7
.
*** Other Lab Tests:
[**2135-10-6**] calTIBC-55* Ferritn-1367* TRF-42*
[**2135-9-28**] TSH-0.18*
[**2135-9-30**] Free T4-0.48*
[**2135-10-4**] T3-50*
[**2135-10-7**] C3-70* C4-26
[**2135-10-6**] Vanco-21.5*
.
*** Serum tacrolimus level:
[**2135-9-28**] tacroFK-2.2*
[**2135-9-29**] tacroFK-3.5*
[**2135-9-30**] tacroFK-5.5
[**2135-10-1**] tacroFK-11.5
[**2135-10-2**] tacroFK-8.6
[**2135-10-3**] tacroFK-10.2
[**2135-10-4**] tacroFK-8.7
[**2135-10-5**] tacroFK-6.9
[**2135-10-6**] tacroFK-8.8
[**2135-10-7**] tacroFK-5.0
.
*** Urine
[**2135-9-28**] 11:44AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2135-9-28**] 11:44AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2135-9-28**] 11:44AM URINE RBC->50 WBC-[**10-14**]* Bacteri-FEW [**Month/Year (2) **]-MANY
Epi-0
[**2135-9-28**] 11:44AM URINE Hours-RANDOM UreaN-339 Creat-73 Na-58
URINE CULTURE (Final [**2135-9-29**]): NO GROWTH.
.
[**2135-10-2**] 11:10AM URINE Color-Brown Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2135-10-2**] 11:10AM URINE Blood-LG Nitrite-NEG Protein->300
Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-0.2 pH-5.5 Leuks-NEG
[**2135-10-2**] 11:10AM URINE RBC->50 WBC-[**1-27**] Bacteri-MANY [**Month/Day (1) **]-NONE
Epi-[**1-27**]
[**2135-10-2**] 11:10AM URINE Hours-RANDOM UreaN-195 Creat-157 Na-32
K-63
[**2135-10-2**] 11:10AM URINE Osmolal-295
URINE CULTURE (Final [**2135-10-2**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
*** Peritoneal Fluid.
[**2135-9-28**] 08:10AM ASCITES WBC-25* RBC-50* Polys-1* Lymphs-7*
Monos-0 Eos-3* Macroph-89*
GRAM STAIN (Final [**2135-9-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2135-10-1**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2135-10-4**]): NO GROWTH.
Transthoracic Echcardiogram:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
No vegetation identified (but cannot exclude).
.
Abdominal Ultrasound:
INDINGS: Postsurgical anatomy and inability of patient to
cooperate with
breathing instructions limits this examination.
No evidence of focal lesions. Echogenic linear structures are
seen in the
liver, likely due to pneumobilia. Limited views of the pancreas,
due to
overlapping bowel gas. Gallbladder not seen, likely surgically
absent. There
is no intrahepatic biliary duct dilatation.
IVC, right main and left hepatic vein are patent.
The main portal vein and right portal vein are patent and show
normal
hepatopetal flow. Flow was seen in the splenic veins, however,
difficult to
obtain splenic vein waveform. The SMV was not imaged. The left
portal vein
is not definitely identified.
The right hepatic artery, main hepatic artery, are patent with
normal
waveforms. The left hepatic artery was not seen.
Ascites is seen in the left lower quadrant.
IMPRESSION:
1. Main and right portal veins have appropriate flow and
directionality; the
left portal vein difficult to visualize, and unable to assess.
2. Left hepatic artery not clearly visualized; remainder of the
arteries and
veins of the liver appear patent.
3. Gallbladder not seen, likely surgically removed.
4. Trace ascites.
.
Renal U/S:
Both kidneys are echogenic throughout with poor corticomedullary
differentiation. They are of a good size, measuring 11.3 cm
longitudinally on
the left, and 11.7 cm longitudinally on the right. No
hydronephrosis or focal
abnormality is seen in relation to either kidney.
Both main renal veins and main renal arteries are patent. There
are normal
resistive indices on both sides varying from 0.59 to 0.66.
Views of the urinary bladder are unremarkable.
Incidental note is made of a small amount of ascites.
CONCLUSION:. The kidneys are of increased echogenicity
bilaterally with poor
corticomedullary differentiation, in keeping with chronic renal
disease, from
the patient's known post-infectious glomerulonephritis. There is
no
hydronephrosis. There is good perfusion of the kidneys.
Brief Hospital Course:
#. Multifocal Pneumonia. On arrival to the floor, patient had
significant rhonchi bilaterally, and had an oxygen saturation of
94% on 3L of oxygen by nasal cannula. Serial blood cultures
were negative and an echocardiogram demonstrated no vegetations
suggestive of endocarditis. A repeat chest x-ray was obtained
which demonstrated multifocal opacities sugeestive f pneumonia.
He was restarted in IV vancomycin, piperacillin-tazobactam, and
levofloxacin for treatment of multifocal pneumonia in the
setting of influenza, in a immunosupressed patient. Antibiotics
were dosed renally and adjusted to match his changing renal
function. His respiratory symptoms and pulmonary exam improved
with treatment and he was successfully weaned from supplemental
oxygen. Per the recommendation of infectious disease, he was
treated for a total of 8 days of antibiotics with complete
resolution of symptoms.
.
#. H1N1 Influenza. On admission, his influenza swab tested
positive for H1N1 swine like influenza. He was treated with
five days of oseltamivir 150mg PO bid and kept on droplet
precautions. He defervesced on hospital day 4, and droplet
precautions were removed, and droplet precautions were removed
24 hours later, with the completion of antiviral therapy.
.
#. Acute on Chronic Renal Failure. On admission, serum
creatinine was 2.5, which was increased over his baseline of 1.9
at his last discharge. Urinalysis was X, and FeNa was 1.46%.
He was given IV fluid boluses and his creatinine did not
decrease. He later was treated with IV albumin, with no
improvement of his renal function. His serum creatinine
subsequently began to increase to a peak of 7.6, with a
concomitant decrease in urine output. [**Month/Day/Year 1326**] nephrology
was consulted, and a urinalysis, urine chemistries were
repeated. Urinalysis was significant for muddy brown casts, and
acute tubular necrosis was diagnosed. A temporary hemodialysis
catheter was placed on [**2135-10-3**], and hemodialysis was initiated
on [**2135-10-4**]. The temporary catheter was exchanged for a
tunneled catheter on [**2135-10-6**]. By discharge, serum creatinine
had improved to 4.3, but he was still oliguric with under 100cc
of urine output per day. He was relisted for kidney [**Date Range **],
and follow-up will be arranged with [**Date Range **] nephrology.
Infectious disease was consulted regarding infectious causes of
renal failure, and recommended CMV, HIV, BK virus, HBV and HCV
viral load tests, which were pending at the time of discharge.
.
#. Chronic liver disease s/p liver [**Date Range **]. On admission,
patient had a mild transamititis with an ALT and AST of 33 and
79, an elevated alkaline phosphatase of 371, low albumin of 1.1
and an INR of 1.4, all of which were at his baseline. An
ultrasound guided paracentesis was performed, revealing mild
ascites, but paratoneal fluid analysis demonstrated no SBP.
Patient was continued on his home doses of tacrolimus 0.5mg PO
bid and lactulose 30ml PO tid. Daily serum tacrolimus levels
were drawn, and doses were held as his renal function worsened.
On the day of discharge, his serum tacrolimus level had
decreased to 5.0, and he was restarted on tacrolimus 0.5mg
daily. Serum tacro levels will be drawn at [**Date Range 2286**] on [**2135-10-11**]
and faxed to the liver [**Date Range **] center. MELD on discharge was
23. Follow-up was arranged with the liver [**Date Range **] center on
[**2135-10-19**].
.
#. Hyperthyroidism. On admission, serum TSH was low at 0.18.
Free T4 was low at 0.4 and T3 low at 50. This was thought to be
due to sick euthyroid and was on uncertain significance in a
patient with acute illness. Repeat TSH levels are recommended
4-6 weeks after discharge.
Medications on Admission:
OxycoDONE 2.5 mg Q4H:PRN pain
Oseltamivir Phosphate 75 mg PO BID
Sarna Lotion 1 Appl TP TID:PRN itching
DiphenhydrAMINE 25 mg Q6H:PRN itching
Ipratropium Bromide 1 NEB IH Q6H SOB
Ondansetron 4 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/NG Q6H:PRN fevers, pain
Tacrolimus 0.5 mg PO Q12H
Pantoprazole 40 mg PO Q24H
Lactulose 30 mL PO/NG TID
Discharge Medications:
1. 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*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*1 bottle* Refills:*2*
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1 bottle* Refills:*2*
5. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO once a day.
6. Outpatient Lab Work
Please draw serum tacrolimus level with [**Date Range 2286**] next tuesday
[**2135-10-11**] and fax the result to Dr. [**Last Name (STitle) 497**] at the liver [**Last Name (STitle) **]
center.
Discharge Disposition:
Home With Service
Facility:
vna southeastern [**State **]
Discharge Diagnosis:
Acute on Chronic Renal Failure
H1N1 Influenza
Multifocal Pneumonia
s/p liver [**State **]
Discharge Condition:
Stable, alert and oriented to person, place and time.
Discharge Instructions:
You were admitted for high heart rate and fevers. Laboratory
testing revealed you had H1N1 swine like influenza. A chest
x-ray showed pneumonia. Fluid was taken from your abdomen and
demonstrated no infection. You were treated with antiviral
medications for your flu. You were treated with intravenous
antibiotics for your pneumonia. Your kidney function
deteriorated and hemodialysis was initiated. With hemodialysis,
your laboratory values improved. While here your blood level of
thyroid stimulating hormone (TSH) was low. This is not
surprising in the case of an acute illness, but your primary
doctor may want to recheck you TSH valcue is 4-6 weeks.
Please make the following changes in your medications:
Please CHANGE your dose of tacrolimus to 0.5mg by mouth daily
Please STOP taking lasix
Please START Pantoprazole 40mg by mouth daily
You will require hemodialysis for the forseeable future. Your
first hemodialysis session will be on [**2135-10-8**].
Please adhere to your follow-up appointments. They are important
for managing your long-term health.
.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Please follow up with the following appointments:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2135-10-8**]
7:30
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2135-10-19**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],[**MD Number(3) 13795**]:[**Telephone/Fax (1) 37766**]
Date/Time:[**2135-10-26**] 9:00
Please make an appointment with your primary care doctor within
the next two weeks.
ICD9 Codes: 5849, 486, 5119, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1887
} | Medical Text: Admission Date: [**2199-11-18**] Discharge Date: [**2199-12-16**]
Date of Birth: [**2199-11-18**] Sex: M
Service:NEONATOLOGY
HISTORY: [**Known lastname 17766**] is a former 31-week infant born via normal
spontaneous vaginal delivery to a 32-year-old gravida 3, para
[**11-28**] mother. The pregnancy was complicated by premature
prolonged rupture of membranes at 25 weeks of gestation and
the mother was on bedrest for six weeks until delivery. She
well-controlled gestational diabetes mellitus; otherwise was
a healthy woman with no major antenatal issues. Her
pregnancy was complicated by a motor vehicle accident in
[**Month (only) **], however this did not affect the remainder of her
pregnancy course.
Maternal laboratory studies were A+, hepatitis B surface
PERINATAL HISTORY: The mother progressed to spontaneous
vaginal delivery secondary to preterm labor in the setting of
concerns over the possibility of chorioamnionitis. The
infant was born at 31 weeks gestation. The infant emerged
with decreased tone, initially some mild respiratory efforts,
heart rate of 100, but then required some bag mask
ventilation in order to maintain sufficient respiratory
effort. The patient responded well to these attempts and was
taken to the Neonatal Intensive Care Unit for further
management. Apgar scores were 6 at one minute and 8 at five
minutes.
PHYSICAL EXAMINATION: On admission this was a pink,
nondysmorphic infant, blow-by oxygen, well perfused and
saturated. There was a flat anterior fontanel with the
exception of the presence of some alopecia on the right
temporal region. There was no skull defect. The skin was
intact. No other lesions were noted. The clavicles were
intact. The cardiac examination revealed normal S1 and S2
without murmurs. The lungs had fair and equal air entry
bilaterally. The abdomen was benign. There was no
hepatosplenomegaly or organomegaly. There was normal
genitalia in this infant with well-descended left testis,
unable to palpate the right. Hips were normal. The spine
was intact and the neurological examination was nonfocal with
appropriate tone and reflexes for age.
MEASUREMENTS: Birth weight was 1,830 grams (75th
percentile). Length was 42 cm (around the 55th percentile).
Head circumference was 26.8 cm which was then repeated around
29 cm putting him between the 25th and 50th percentile for
gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory:
[**Known lastname 17766**] had some retracting and increased work of breathing
after delivery and was briefly on CPAP and then weaned over
24 hours to room air, and has remained on room air for the
remainder of his hospital stay. He did have some evidence of
respiratory immaturity consistent with gestational age. He
was briefly on caffeine. This was discontinued on the 11th
day of life. He has had minimal apnea since then and has
been free of apnea for over a week prior to discharge.
2. Cardiovascular: The patient has a murmur which was
initially quite loud and now has become softer consistent
with peripheral pulmonic stenosis and confirmed by
echocardiogram. His examination reveals a pink, warm and
well-perfused infant. His last hematocrit was 30 on [**12-7**], and there have been no other concerns from a
cardiovascular standpoint.
3. Fluids, electrolytes and nutrition: His weight today is
2,645 grams. Head circumference is 32 cm. He is taking
50-70 cc of Enfamil 24 calorie or breast milk supplemented to
24 calories ad lib, and he is achieving at least 130 cc per
kg per day of intake on an ad lib basis. Over the last 24
hours he took about 160 cc per kg per day. By himself he is
waking up to feed. He has had no other concerns for fluid
and electrolyte issues.
4. Dermatologic: He does have a sebaceous nevus on his
scalp. He has had a consultation with dermatology for
cosmetic purposes. This area can be surgically removed when
he gets closer toward childhood but it is not any source for
concern at the present time.
5. Neurological: He had normal head ultrasounds early in
life and he needs a 30-day ultrasound which can be scheduled
as an outpatient.
6. [**Last Name (STitle) **]almologic: His most recent examination showed
immature retina but normal vascularization out to zone 3 in
both eyes. He needs a follow up in two weeks with Dr. [**Last Name (STitle) 47288**] [**Last Name (Prefixes) **] at [**Hospital3 1810**].
7. Gastrointestinal: He has some neonatal jaundice with a
peak bilirubin of 9.1 on day of life three. He received
about 3-4 days of phototherapy and has not been on
phototherapy since then. This was discontinued around day of
life six to seven. He has had no other major problems of
feeding intolerance.
8. Infection: He had a seven-day course of antibiotics due
to concerns of maternal chorioamnionitis. Blood and
cerebrospinal fluid remained unremarkable and the antibiotics
were discontinued after seven days. Approximately one week
prior to discharge he had an episode where he had increased
periodic breathing and a concern for possible sepsis and
received a short course of antibiotics. Work-up was also
negative and he has been clinically well since that time with
no other concern for sepsis.
9. [**Last Name (STitle) 47289**]ry:
A. Audiology: A hearing screen was performed with
automated auditory brainstem responses.
B. Ophthalmology: The infant's eyes were examined as
mentioned above and were found to be immature but at zone 3.
Follow up in two weeks should be with Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) **] at
[**Hospital3 1810**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47290**] with [**Hospital **]
Pediatrics, phone #[**Telephone/Fax (1) 47291**]. She has been informed. She
is looking after this baby's older sibling and follow up can
be arranged for tomorrow or the day after.
CARE RECOMMENDATIONS:
1. Feeds at discharge: Enfamil supplemented to 24 calories
per ounce or mother's mild supplemented with Enfamil powder
at 24 calories per ounce given on an ad lib basis.
2. Medications: Fer-In-[**Male First Name (un) **] 0.2 cc daily.
3. Car seat position screening is being done.
4. State newborn screening status: Immunizations received -
the infant is getting Synagis and hepatitis B vaccine.
Immunizations recommended - Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: 1. Born at less than 32
weeks gestation. 2. Born between 32 and 35 weeks with plans
for day care during the RSV season, smoker in the
household or with preschool siblings. 3. With chronic lung
disease. Influenza immunization should be considered
annually in the fall for preterm infants with chronic lung
disease once they reach six months of age. Before this age
the family and other caregivers should be considered for
immunization against influenza to protect the infant.
FOL[**Last Name (STitle) **]P APPOINTMENTS SCHEDULED AND RECOMMENDED:
1. Follow up with Dr. [**Last Name (STitle) 47290**] tomorrow or the day after
discharge.
2. Visiting nurse is to be arranged for two days following
discharge for a weight check.
3. Follow up with dermatology regarding nevus sebaceous on a
p.r.n. basis.
4. Follow up with Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) **] at [**Hospital3 1810**] in
two weeks for repeat eye examination.
5. Follow up this week at [**Hospital3 1810**] as an
outpatient for head ultrasound.
DISCHARGE DIAGNOSES:
1. Former 31-week premature infant now corrected to 35 weeks
gestation.
2. History of mild respiratory distress resolved.
3. History of neonatal jaundice resolved.
4. Sepsis evaluation completed.
5. Nevus sebaceous.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 37234**]
MEDQUIST36
D: [**2199-12-16**] 11:57
T: [**2199-12-16**] 12:08
JOB#: [**Job Number 47292**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1888
} | Medical Text: Admission Date: [**2197-8-24**] Discharge Date: [**2197-8-31**]
Date of Birth: [**2142-5-31**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Demerol
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
headache, nausea, left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55yo woman with PMH significant for stroke with right
hemiparesis and language difficulties, breast cancer,
hypertension, s/p R CEA who presents as a transfer from an OSH
with headache, nausea, and left hemiparesis. History is limited,
as the OSH reports are brief and do not include old records or
new reports, the patient will only comply with some history and
examination due to pain, and her family cannot be reached
(husband [**Name (NI) **] [**Telephone/Fax (1) 75253**] was called without any answer,
daughter reportedly on the way). The patient reports symptoms of
right sided headache and nausea with vomiting beginning around 3
or 4pm. She says the left sided weakness occurred sometime
around the same time. She presented to [**Hospital 8641**] Hospital, where
she was noted to have "decreased LOC," "L facial," and "L
weakness." A neurology consult was called - notes are "dictated"
but not
provided. A brief neurology note reports left neglect, left
hemiparesis, and old right hypesthesia. She was given morphine
2mg IV x 1, 4mg IV x 1, zofran 4mg x 1, and dilaudid 0.5mg x 1
(2205). She had a head CT, which was reported as "negative" to
the accepting ED attending, though did not come with a report.
She was then transferred to [**Hospital1 18**].
She reports that her prior stroke caused right sided weakness
and numbness of the face, arm, and leg, as well as speech
difficulties (unclear if dysarthria or aphasia). She reports
these have improved or resolved, and that this speech is not as
bad as her prior stroke. She feels her headache is improved
after treatment at [**Location (un) 8641**] (though severely worsened after
movement in the CT scanner). She reports history of migraines,
which are different from this in both severity and diffuseness.
Past Medical History:
hypertension
stroke x 2 as above
s/p right carotid endarterectomy
breast cancer 4yrs ago, s/p surgery and XRT, not active per pt
chronic low back pain
Social History:
married, has at least one daughter. [**Name (NI) **] EtOH, smoked x 1yr, quit
2wks ago by report
Family History:
noncontributory
Physical Exam:
VS: T 98.3, HR 53, BP 165/63, RR 14, SaO2 100%
Gen: appears uncomfortable
HEENT: NCAT, MMM, OP clear
Neck: R scar, but no bruits appreciated
CV: RRR, nl S1, S2, II/VI systolic murmur
Chest: CTAB
Abd: soft, NTND, BS+
Ext: warm and dry
Neurologic examination:
Mental status: Awake and alert, cooperative with exam at first,
but then after CT reports severe headache and will not fully
cooperate. Oriented to name, though slow in saying first name
(says last name when asked name). Says year is "200...4", does
not say month. However, able to tell some history of current
symptoms and past events. Speech is nonfluent with repetition
and naming affected. +dysarthria. No right-left confusion.
Cranial Nerves: Pupils equally round and reactive to light, 5 to
3mm bilaterally. No RAPD. blinks to threat bilaterally, L>R.
Extraocular movements intact bilaterally without nystagmus.
Sensation absent V2-V3 and right V1, feels it slightly in left
V1. Facial asymmetry, with right side of mouth open and left
closed, but right moving more and left not moving much at all;
forehead moves bilaterally. Hearing intact bilaterally. Palate
cannot be visualized. No gag, +cough. When asked to put out
tongue, puts it deviated far left, but able to move it to the
right easily.
Motor: Flaccid left arm and leg, left leg externally rotated. No
observed myoclonus, asterixis, or tremor. RUE and RLE full
strength, LUE and LLE 0/5.
Sensation: Reports decreased sensation on the right, and absent
to noxious (nailbed pressure) on the left.
Reflexes: 2 and symmetric throughout (?R>L). Toe downgoing on
right, mute on left.
Coordination and gait: not tested
Discharge exam:
MS- alert and oriented x3. Speech fluent.
CN- functional left facial droop, disappears with distraction or
complex phonemic speech. PERRL. EOM's full. tongue at midline.
Motor- left hemiparesis resolving. + [**Doctor Last Name 60437**] sign. Protects
face with left arm drop.
Reflexes- normal, symmetric throughout.
Pertinent Results:
[**2197-8-24**] 01:00AM BLOOD WBC-7.1 RBC-4.43 Hgb-14.4 Hct-41.3 MCV-93
MCH-32.4* MCHC-34.8 RDW-14.0 Plt Ct-294
[**2197-8-24**] 01:00AM BLOOD Neuts-78.4* Lymphs-18.5 Monos-3.0 Eos-0.1
Baso-0.1
[**2197-8-26**] 07:50AM BLOOD PT-11.8 PTT-27.0 INR(PT)-1.0
[**2197-8-26**] 07:50AM BLOOD Glucose-67* UreaN-13 Creat-0.8 Na-144
K-4.1 Cl-109* HCO3-26 AnGap-13
[**2197-8-24**] 01:00AM BLOOD ALT-24 AST-27 CK(CPK)-150* AlkPhos-179*
Amylase-51 TotBili-0.5
[**2197-8-24**] 02:07PM BLOOD CK-MB-5 cTropnT-0.05*
[**2197-8-26**] 07:50AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.3
[**2197-8-24**] 02:07PM BLOOD %HbA1c-5.9
[**2197-8-24**] 02:07PM BLOOD Triglyc-120 HDL-38 CHOL/HD-3.1 LDLcalc-56
[**2197-8-24**] 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2197-8-24**] 02:05PM BLOOD FACTOR V LEIDEN-PND
IMAGING:
CT HEAD W/O CONTRAST [**2197-8-26**] 11:37 AM
FINDINGS: A small amount of subarachnoid blood in the left
frontal sulci is resolving. There are no new areas of
subarachnoid hemorrhage. There is no shift of the normally
midline structures or major vascular territorial infarct. There
is no hydrocephalus. Osseous structures and paranasal sinuses
are unchanged.
IMPRESSION:
1. Resolving left frontal subarachnoid hemorrhage.
CT HEAD W/O CONTRAST [**2197-8-24**] 1:28 AM
No prior comparison studies are available. There is a small
amount of subarachnoid blood in left superior frontal sulci
(2:24). There is a second focus of small amount of hemorrhage
overlying a left frontal gyrus (2:19). No mass effect or shift
of normally midline structures. Ventricles and cisterns are
normal in size. No evidence of major vascular territorial
infarct.
Partially visualized is an interrupted tooth projecting into the
left maxillary sinus. The sinus and mastoid air cells are clear.
Bony structures and surrounding soft tissue structures are
unremarkable.
IMPRESSION:
1. Small amount of subarachnoid hemorrhage in the superior left
frontal region.
2. Small amount of acute hemorrhage overlying a left frontal
gyrus, most likely also representing subarachnoid hemorrhage.
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers (images after cough and Valsalva
maneuver are technically uboptimal). Left ventricular wall
thickness, cavity size and egional/global systolic function are
normal (LVEF >55%) No masses or thrombi are seen in the left
ventricle. Right ventricular chamber size and free wall motion
are normal. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No cardiac source of embolism identified. Normal
global and
regional biventricular systolic function.
MR HEAD W/O CONTRAST [**2197-8-24**] 5:53 PM
FINDINGS: Small linear foci of T2 and FLAIR prolongation in the
sulci of the left frontal lobe correspond with the known area of
subarachnoid hemorrhage on the CT scan of [**2197-8-24**], and
represent a small amount of chronic subarachnoid blood. No new
areas of hemorrhage are identified. No masses or mass effect are
seen. Ventricles and sulci are normal in configuration.
MR angiography and MR venography were also performed, and show
no aneurysms or vascular malformations.
There is no evidence of infarction.
IMPRESSION: Small amount of linear high T2 signal in the left
frontal lobe corresponding with the known area of subarachnoid
hemorrhage. No aneurysms or other vascular malformation. No
evidence of infarction.
Speech and Swallow Consultation:
Mrs. [**Known lastname **] presented with a moderate oral dysphagia and a mild
to moderate delay in swallow initiation. However once the
pharyngeal swallow was started, it was functional and no residue
was seen. The pt did not aspirate today, but the pyriform
sinuses filled completely before the swallow [**2-3**] swallow delay
and it is therefore recommended she use a chin tuck with the
thin liquids. She was able to manage moist, ground solids, but
did not feel comfortable and is requesting pureed solids at this
time. Pill should be crushed and given with purees.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 4, mild-moderate dysphagia with
consistencies restricted because of retention in the oral
cavity.
RECOMMENDATIONS:
1. Suggest a PO diet of thin liquids and pureed consistency
solids.
2. Use a chin tuck when drinking liquids.
3. No straws.
4. Place solid food on the right side of your mouth.
5. Alternate between bites and sips as needed.
6. All pills crushed with purees or in liquid form.
Brief Hospital Course:
55yo woman with history of stroke (with right
weakness/numbness), R CEA, HTN, breast cancer 4yrs ago, who
presents as a transfer from an OSH with right-sided headache,
nausea, vomiting, dysarthria, and left hemiparesis. On
presentation to this hospital, she was disoriented, with a
nonfluent aphasia including difficulty with repetition,
dysarthria, decreased bilateral facial sensation, an unclear
facial asymmetry, no gag (but cough present), left tongue
protrusion, left hemiparesis, and left hemisensory loss. Head CT
revealed a left parietal subarachnoid hemorrhage.
Her neurologic exam was difficult to localize, as her
examination was not entirely consistent. Is it was odd to have
left sided symptoms and a left sided lesion. MRI/MRA was
obtained to rule out possibility of venous sinus thrombosis or
multiple emboli to explain her symptoms. MRA did not reveal
aneurysm to explain her subarachnoid hemorrhage. Her daily
aspirin therapy was held. She was covered on an insulin sliding
scale for tight glycemic control.
The patient had an acute "thunderclap" headache over the weekend
resulting in repeat CT evaluation. There were no acute changes
by head CT. Her headache was intially treated with dilaudid IV,
then tapered to her chronic dose of methadone.
Further examination and history revealed the patient has
significant psychosocial stressors with history of interpartner
violence/abuse. The patient had an event prior to discharge
consisting of violent shaking movements with her eyes closed and
bilateral arms thrashing. This is strongly suggestive of a
pseudoseizure or behavioral event given 90% of seizures occur
with eyes open and deviation to one side. Furthermore the event
demonstrated complete resolution of her prior left sided
hemiparesis, garnering further support for conversion. A repeat
Head CT was without any changes to suggest new neuropathology.
Her prior subarachnoid hemorrhage seen on admission has nearly
completely resorbed. Further physical therapy will greatly
benefit her expected continued recovery for her deficits. She
will follow up with Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 877**] in the neurology
department at [**Hospital1 18**] once discharged from rehab.
Medications on Admission:
methadone 20mg qid prn pain
lipitor 40mg daily
ASA 81mg daily
plavix 75mg daily
doxycycline 100mg [**Hospital1 **] (for acne)
lunesta 3mg qhs
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. Methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Insulin Regular Human 100 unit/mL Solution Sig: dose per
sliding scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 17921**] Center - [**Location (un) 5450**], NH
Discharge Diagnosis:
Left Frontal Subarachnoid Hemorrhage
Conversion Disorder
Discharge Condition:
Stable. Resolving left hemiparesis- antigravity at discharge.
Resolving left facial droop. Positive [**Doctor Last Name 60437**] Sign. Protects
face with left arm drop.
Discharge Instructions:
You were admitted and found to have a subarachnoid hemorrhage
and left sided weakness. The bleeding in your brain was small
and stable by repeat CT scans. You should expect your deficits
to resolve very rapidly.
Please contiue to take all medications as prescribed.
Call your doctor or 911 if you experience any symptoms of chest
pain, shortness of breath, new weakness, numbness or tingling.
Followup Instructions:
Please seek the guidance of a psychiatrist or other mental
health professional for further support with your life stresses.
Please call [**Telephone/Fax (1) 2574**] to schedule a follow up appointment
with Dr. [**Last Name (STitle) 877**] and Dr. [**First Name (STitle) **] on the Neurology service at
[**Hospital1 18**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1889
} | Medical Text: Admission Date: [**2157-1-10**] Discharge Date: [**2157-2-1**]
Date of Birth: [**2090-12-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2157-1-24**] Aortic valve replacement (23mm St. [**Male First Name (un) 923**] mechanical) and
coronary artery bypass grafting x3 (LIMA-LAD, SVG-OM1-OM2)
[**2157-1-24**]
Left heart catheterization, coronary angiography [**1-18**]
History of Present Illness:
Mr. [**Known lastname 33733**] is a 66 year old gentleman who was admitted with a
non-healing ulcer on his heel. He subsequently underwent a
right below the knee amputation ([**8-30**]) with a prolonged
post-operative course. He was readmitted now with CHF and
catheterization was done to demonstrate left main and diffuse
three vessel disease. Echocardiography has demonstrated
critical AS as well. he was referred for surgical evaluation for
AVR/CABG.
Past Medical History:
insulin dependent diabetes mellitus
coronary artery disease -s/p MI
chroinc systolic CHF
atrial fibrillation
polyarthritis rheumatica,predisone dependent
peripheral vascular disease
s/p right BKA
s/p AICD implant
Social History:
Pt and wife live at home in [**Name (NI) 8117**], [**Name (NI) **]. Pt retired in [**11-28**]
from
his work as a manager in auto sales. He states he hopes to
return to his previous work part-time in the future. He has a
close family.
ETOH:denies
Tobacco: former use
Family History:
N/C
Physical Exam:
Admission:
VS: 96.2 68 137/67 18 99RA
Gen: NAD, pleasant
HEENT: EOMI, pupils reactive to light, R pupil slightly larger
than the left
CV: irreg irreg, no m/g/r
Pulm: CTA in upper fields b/l, crackles in bases
Abd: +BS, nt/nd, obese
Ext: R BKA; L foot digits [**12-26**] with dry gangrene on distal joints
top part of toes, similar ulcer on right heal.
Pulses
Rad Fem [**Doctor Last Name **] PT DP
R P P dop
L P P dop dop dop
Pertinent Results:
TTE (Complete) Done [**2157-1-12**] at 9:32:13 AM FINAL
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (LVEF = 20 %). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricle has moderate
global free wall hypokinesis. There is severe aortic valve
stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Carotid U/S - [**2157-1-18**]
IMPRESSION:
1. Antegrade flow in both vertebral arteries.
2. Occluded left ICA.
Cardiac Cath - [**2157-1-20**]
FINAL DIAGNOSIS:
1. Moderate left main and diffuse three vessel coronary artery
disease.
2. Moderate to severe aortic stenosis.
3. Low cardiac output/index.
4. Left ventricular systolic and diastolic dysfunction.
5. Severe pulmonary hypertension.
[**2157-1-31**] 04:03AM BLOOD WBC-13.3* RBC-2.86* Hgb-8.5*
[**Known lastname **],[**Known firstname **] [**Initial (NamePattern1) **] [**Known lastname **]. [**Age over 90 95331**] M 66 [**2090-12-8**]
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2157-2-1**] 10:52 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2157-2-1**] 10:52 AM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip #
[**Clip Number (Radiology) 95332**]
Reason: r/o cva
[**Hospital 93**] MEDICAL CONDITION:
66 year old man with ? L visual field cut.
REASON FOR THIS EXAMINATION:
r/o cva
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: DBH TUE [**2157-2-1**] 3:14 PM
PFI: 1. Left posterior temporal lesion likely old ischemia.
2. Left internal carotid artery completely occluded at its
origin.
Preliminary Report !! PFI !!
PFI: 1. Left posterior temporal lesion likely old ischemia.
2. Left internal carotid artery completely occluded at its
origin.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
PFI entered: TUE [**2157-2-1**] 3:14 PM
Imaging Lab
Hct-26.4* MCV-92 MCH-29.6 MCHC-32.1 RDW-16.8* Plt Ct-336
[**2157-1-31**] 04:03AM BLOOD Glucose-51* UreaN-21* Creat-0.8 Na-136
K-4.0 Cl-101 HCO3-33* AnGap-6*
Brief Hospital Course:
Mr [**Known lastname 33733**] is a 66 year old male with known severe PVD, DM,
severe AS, CHF, who was admitted with LLE gangrene. He
underwent a right below the knee amputation. During this
admission the patient developed acute CHF and ARF. He was found
to have severe AS and multivessel CAD and on [**2157-1-24**] he underwent
an aortic valve replacement (#23mm St.[**Male First Name (un) 923**] Mechanical) and
coronary artery bypass grafting times three
(Lima->LAD/SVG->OM1-OM2sequential). Please refer to Dr. [**Doctor Last Name 95333**] operative report for further details. He
tolerated the procedure well and was transferred in critical but
stable condition to the surgical intensive care unit. He awoke
neurologically intact, pressors were weaned and he was extubated
on post-operative day one. Mr.[**Known lastname 33733**] was placed on stress dose
steroids for his polymyalgia rheumatica and was seen in
consultation by [**Last Name (un) **] for elevated blood sugars. He required
aggressive diuresis with a lasix drip. Electrophysiology
interrogated his internal pacemaker and his epicardial wires
were removed. Coumadin and heparin were started for the
mechanical aortic valve and atrial fibrillation. On POD#4
Mr.[**Known lastname 33733**] was transferred to the surgical step down floor. The
lasix drip was weaned to off. [**1-30**] Mr.[**Known lastname 33733**] complained of poor
visual focus in the mornings. An Ophthalmology consult was done
and he was found to have a normal exam. Neurology was also
consulted and felt it was likely due to fluctuating blood
sugars. [**2-1**] a Head CTA was done which confirmed a previous
ischemic event. No new changes.Neurology cleared Mr.[**Known lastname 33733**] for
discharge to rehab. He also experienced diarrhea toward the end
of his stay and tested positive for clostridium difficile. He
was placed on flagyl. The steroid taper was completed and he
was placed on his home maintenance dose of hydrocortisone. By
post operative day #8, [**2-1**] he was ready for transfer to a rehab
facility for increase in strength, endurance and daily
activities.All follow up appointments were advised.
Medications on Admission:
#. Warfarin stopped on [**2157-1-7**], unclear reason
#. Carvedilol 12.5'
#. Spironolactone 12.5'
#. Captopril 12.5"
#. Rosuvastatin 5'
#. Furosmide 80'
#. Digoxin 0.125mg QOD
#. K-DUR 20'
#. Magnesium oxide
#. Hydrocortisone 10' for PMR,
#. Insulin glargine 32 QHS
#. Novolog SS
#. Citalopram 20'
#. Pantoprazole 40"
#. Oxycodone
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
9. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Hydrocortisone 10 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
16. Warfarin 1 mg Tablet Sig: 7.5 Tablets PO DAILY (Daily):
titrate for an INR goal of 2.5-3.5 for an aortic mechanical
valve.
17. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous at bedtime.
Disp:*qs units* Refills:*2*
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
Subcutaneous four times a day: per sliding scale.
19. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days: dc on [**2-8**].
22. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
x 1 week.
23. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
24. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
s/p aortic valve replacement & coronary artery bypass grafts
coronary artery disease
peripheral vascular disease
Acute on chronic heart failure- LVEF 20%
Severe Aortic stenosis
Mitral regurgitation
Tricuspid regurgitation
history of perpherial vascular disease with left foot gangrenous
changes,s/p rt. BKA
s/p AICD [**11/2156**] ([**Company 2267**])
insulin dependent diabetes mellitus
atrial fibrillatiion
h/o polymyalgia rheumatica- prednisone dependent
clostridium difficile colitis
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 100.5
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for one month and off all narcotics
No lifting more than 10 pounds for 10 weeks
take all medications as directed
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] ([**Telephone/Fax (1) 14585**] for left lower extremity
vasculature in 1 month.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 95334**] PCP ([**Telephone/Fax (1) 95335**] in [**12-24**] weeks.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14715**] Cardiology([**Telephone/Fax (1) 95336**] in [**12-24**] weeks.
Dr. [**Last Name (STitle) **] Cardiac Surgeon([**Telephone/Fax (1) 11763**] in [**3-28**] weeks.
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2157-2-1**]
ICD9 Codes: 4241, 5849, 2761, 4280, 4240, 2724, 3572, 2859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1890
} | Medical Text: Admission Date: [**2119-1-25**] Discharge Date: [**2119-1-27**]
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old woman who
fell out of bed at rehabilitation and struck the left side of
her head. No loss of consciousness. She complains of a
left-sided headache with left shoulder pain.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Cerebrovascular accident (times three); no residual
deficits.
3. Hernia.
4. Hypothyroidism.
5. Depression.
6. Seizure disorder.
7. Hard of hearing.
8. Odontoid fracture in [**2114**].
ALLERGIES: The patient is allergic to AMOXICILLIN.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
normal sinus rhythm in the 60s, blood pressure was 236/50,
respiratory rate was 17. The patient was awake and alert.
She appeared in no acute distress. The lungs were clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. The abdomen was soft,
nontender, and nondistended. Extremities were warm and dry.
Back and neck were nontender. Neurologically, the patient
followed commands. Pupils were equal, round, and reactive to
light and accommodation. Extraocular movements were intact.
Left periorbital ecchymosis and swelling were noted.
Strength was full with no deficits.
RADIOLOGY/IMAGING: A head computed tomography revealed right
temporoparietal subarachnoid hemorrhage with no shift.
A computed tomography of the cervical spine revealed odontoid
fracture (type 2) with 4-mm to 8-mm displacement; similar to
findings reported in [**2114**].
Shoulder films showed no fracture or dislocation.
HOSPITAL COURSE: The patient was admitted for blood pressure
control with conservative management. The patient was placed
in a hard collar. There were no complications throughout her
stay.
MEDICATIONS ON DISCHARGE: (Medications at the time of
discharge included)
1. Docusate 100 mg p.o. b.i.d.
2. Senna one tablet p.o. q.d.
3. Venlafaxine 25 mg p.o. b.i.d.
4. Phenytoin 150 mg p.o. b.i.d.
5. Levothyroxine 100 mcg p.o. q.d.
6. Pantoprazole 40 mg p.o. q.24h.
7. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed.
DISCHARGE DISPOSITION: The patient was discharged back to
rehabilitation.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**Last Name (STitle) 1327**] in two
weeks.
2. The patient was to be discharged with an Aspen collar.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2119-1-27**] 09:03
T: [**2119-1-27**] 09:04
JOB#: [**Job Number 43955**]
ICD9 Codes: 4019, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1891
} | Medical Text: Admission Date: [**2196-1-28**] Discharge Date: [**2196-2-3**]
Date of Birth: [**2143-6-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
Mr. [**Known lastname 10794**] is a 52yo male with a past medical history of
non-ischemic cardiomyopathy (LVEF 30%-35%), insulin-dependent
diabetes mellitus, hepatitis C infection, HTN, HLD,
schizophrenia and depression who is presenting in acute
respiratory distress after recent admission to the MICU/Gen med
([**Date range (1) 63644**]) for similar presentation. The patient reports that he
was smoking crack cocaine earlier 2 days ago began to have chest
pain and progressive shortness of breath over the past 2 days.
He also reports worsening of productive cough (white sputum)
which has been present since his discharge from the hospital on
[**1-21**]. He says that he felt that he never truly returned to his
baseline after his last hospitalization. He says that he has had
worsening orthopnea, with use of 3 pillows instead of his usual
2 last night. He denies edema, PND. He denies fevers/chills or
other URI sx, chest pain/pressure, pleuritic pain. He has had a
VNA and reports that his weight has decreased from 183 to 180,
he has avoided salt in his diet and he has been fully compliant
with this medications. He does think that the crack that he
smoked 2 days ago had "less baking soda in it." The patient also
does have a past medical history of MRSA pna requiring
tracheostomy.
.
He also had admission from [**2112-12-8**] in which he was intubated
and CT showed multifocal pneumonia. Because the radiographic
evidence of this pneumonia cleared quickly within 2 weeks, it
was felt that this was crack lung as opposed to infectious. He
was treated with broad spectrum abx and his respiratory status
returned to baseline. During his admission [**Date range (1) 63644**], the patient
was felt to have crack lung/hypersensitivity pneumonitis given
parenchymal abnormality seen on chest CT, he was treated with
one dose of methylprednisone 125mg but had hyperglycemia
requiring insulin gtt and was thus not treated with steroids. He
did not receive antibiotics. There may have been a component of
CHF during this presentation and the patient was treated with
lasix gtt during this prior admission.
.
In the ED, initial VS were: RR 40s, O2 Sat: 75% on NRB. The
patient received nitro gtt, was placed on BiPap with dramatic
improvement. The patient was also treated with levofloxacin and
vancomycin. He received lasix 40mg IV x1, aspirin and tylenol
1000mg po. Blood cultures were obtained.
.
On arrival to the MICU, the patient is still tachypneic but
completing full sentences. He is alert, oriented and does not
appear in acute distress.
.
Review of systems:
(+) Per HPI. Endorses headaches. Endorses diarrhea which
resolved 2 days ago.
(-) Denies fever, chills, night sweats, recent weight gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
1. CARDIAC RISK FACTORS: Type II Diabetes, Hyperlipidemia, HTN
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
- Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 20%, LVD
6.4cm, mild RV dilation, borderline function, 1+ MR)
- hepatitis C antibody positive
- MRSA pneumonia (requiring trach)
- COPD
- Substance abuse (cocaine)
- Tobacco abuse
- schizophrenia
Social History:
- history of multiple incarcerations (>6 months in [**2193**])
- lives with sister
- walks w/ cane due to right sided foot drop
- Tobacco history: current smoker, 1 cig per day
- ETOH: denies
- Illicit drugs: crack cocaine three days ago
Family History:
- Father: pacemaker, deceased
Physical Exam:
ADMISSION EXAM:
.
Vitals: T: 98.6 BP: 98/61 P:95 R: 31 18 O2: 100% CPAP with FiO2
100% and PEEP of 5
General: Alert, oriented, no acute distress with CPAP on
HEENT: Sclera anicteric, MMM, poor dentition, EOMI, PERRL
Neck: supple, JVP not able to be assessed, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Lungs: diffuse dry crackles, no wheezes. Air movement
throughout. No use of accessory muscles with CPAP in place.
Abdomen: soft, minimal diffuse tenderness, mild distended, bowel
sounds present, obese
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
.
VITALS: 98.8 98.7 115/68 100 20 94% 1L NC BG: 77-239 mg/dL
I/Os: 1300 | 1000 + BRP (-0.5L LOS)
GENERAL: Appears in no acute distress. Alert and interactive.
Able to speak in full sentences.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD just above clavicle at
90-degrees.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Faint breath sounds bilaterally with inspiratory crackles
at bases; rhonchi in upper airways bilaterally. No wheezing.
Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; no peripheral edema, 2+ peripheral
pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
Pertinent Results:
ADMISSION LABS:
.
[**2196-1-28**] 09:30PM BLOOD WBC-13.6* RBC-4.20* Hgb-11.1* Hct-35.4*
MCV-84 MCH-26.4* MCHC-31.4 RDW-15.3 Plt Ct-333
[**2196-1-28**] 09:30PM BLOOD Neuts-74.1* Lymphs-18.8 Monos-2.5
Eos-4.2* Baso-0.4
[**2196-1-28**] 09:55PM BLOOD PT-11.4 PTT-35.1 INR(PT)-1.1
[**2196-1-28**] 09:30PM BLOOD Glucose-127* UreaN-12 Creat-0.9 Na-144
K-4.0 Cl-108 HCO3-26 AnGap-14
[**2196-1-29**] 03:06AM BLOOD ALT-19 AST-23 LD(LDH)-360* CK(CPK)-98
AlkPhos-65 TotBili-0.4
[**2196-1-29**] 03:06AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.9 Mg-1.4*
[**2196-1-28**] 09:30PM BLOOD ASA-NEG Ethanol-17* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-1-28**] 09:31PM BLOOD Lactate-2.2*
[**2196-1-28**] 10:35PM BLOOD Lactate-1.2
[**2196-1-29**] 05:07AM URINE cocaine-POS
.
DISCHARGE LABS:
.
[**2196-2-1**] 07:25AM BLOOD WBC-6.4 RBC-3.55* Hgb-9.2* Hct-30.1*
MCV-85 MCH-26.0* MCHC-30.7* RDW-15.1 Plt Ct-335
[**2196-1-29**] 03:06AM BLOOD PT-12.6* PTT-32.4 INR(PT)-1.2*
[**2196-2-3**] 06:55AM BLOOD Glucose-112* UreaN-9 Creat-0.8 Na-143
K-4.3 Cl-108 HCO3-29 AnGap-10
[**2196-2-3**] 06:55AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8
.
MICROBIOLOGY DATA:
[**2196-1-28**] Blood culture (x 2) - pending
[**2196-1-29**] MRSA screen - negative
[**2196-1-29**] Urine legionella - negative
.
IMAGING:
[**2196-1-30**] CHEST (PORTABLE AP) - In addition to a severe
infiltrative abnormality, with probable confluence in the lung
bases, there are many small discrete nodular opacities, which
have grown appreciably since [**1-28**], probably entirely new
since [**1-18**]. Pattern strongly suggests widespread
infection, possibly septic emboli. Heart is moderately enlarged,
unchanged. At least small bilateral pleural
effusions are presumed.
Brief Hospital Course:
IMPRESSION: 52M with a PMH significant for non-ischemic
cardiomyopathy (LVEF 30%-35%), insulin-dependent diabetes
mellitus, hepatitis C infection, HTN, HLD, schizophrenia and
depression with recent hospitalization for crack lung, who
presented with acute hypoxic respiratory distress found to have
bilaterally diffuse airspace opacification with suspected
component of CHF exacerbation, in the setting of recent illicit
substance use.
.
# DIFFUSE, BILATERAL LUNG OPACIFICATION AND ACUTE RESPIRATORY
DECOMPENSATION - Consistent with his prior hospitalizations, Mr.
[**Known lastname 10794**] was admitted with acute hypoxic respiratory failure
requiring NIPPV in the setting of recent crack cocaine use,
attributed to acute crack inhalation lung injury. In [**Month (only) 1096**]
[**2194**], he presented with a picture concerning for multifocal
pneumonia, although his rapid resolution of symptoms without
antibiotics was more consistent with hypersensitivity
pneumonitis or crack lung. Three days preceding admission, he
notes crack cocaine use. He was admitted to the MICU for
respiratory monitoring and required a period of BiPAP use with
improvement with symptomatic treatment, namely nebulizers and
agressive respiratory therapy. He was not intubated during this
admission. While he received a single dose of IV Vancomycin in
the ED, these were discontinued, and steroids were deferred
given his similar presentation with rapid improvement in the
past despite minimal intervention. His admitting CXR showed
bilateral opacifications, despite a normal WBC and no fevers. A
chest CT on prior admission showed marked diffuse bilateral
airspace opacities, ground-glass in appearance, with confluent
consolidation -- but subsequent CXRs noted rapid improvement
despite limited therapy, supporting a crack lung or
hypersensitivity etiology. Over several days, his supplemental
oxygen was weaned and he ambulated 100 feet without
destaurations, maintaining his oxygen saturations in the 92-94%
range on room air (which is his baseline). He had no cough or
respiratory symptoms and he resumed all of his home medications.
.
# INSULIN-DEPENDENT DIABETES MELLITUS - Patient previously
managed with Lantus dosing (taking 40 units at home) -
intermittently checks his glucose at home, has been under the
200 mg/dL range per the patient. Last HbA1c 7.4% in 11/[**2194**]. No
evidence of retinopathy, renal failure (baseline creatinine
0.9-1.1) or neuropathy. We titrated his Lantus to 50 units SC at
nighttime for tighter glucose control.
.
# NON-ISCHEMIC CARDIOMYOPATHY / CHRONIC SYSTOLIC HEART FAILURE -
Patient with known moderate global left ventricular hypokinesis
(LVEF = 30-35%), LVD 6.4-cm, mild RV dilation, borderline
function, 1+ MR on 2D-Echo from 12/[**2194**]. His respiratory
decompensation was attributed to a pulmonary source
predominantly. He was tolerating his home PO Lasix, and returned
to room air with adequate oxygen saturations prior to discharge.
We continued his Lisinopril 10 mg PO daily, Metoprolol succinate
XL 100 mg PO daily, maintained his home dose of Furosemide 40 mg
PO daily and kept him on a fluid restriction of 1500 mL daily.
He was monitored with daily weights, monitored I/Os, and his
goal for diuresis was 0.5-1L daily.
.
# HYPERTENSION - Managed as an outpatient with ACEI,
beta-blocker. Discharged on home regimen without changes.
.
# HYPERLIPIDEMIA - We continued Atorvastatin 20 mg PO QHS.
.
# SUBSTANCE, TOBACCO ABUSE HISTORY - He has multiple prior
episodes of relapse with resulting hospitalizations; patient
notes mostly crack-cocaine use (2-3 days prior to admission) in
lieu of alcohol use. Lives with sister who is supportive and is
a probation officer. We offered him a nicotine patch for tobacco
use and provided smoking cessation counseling. Social work
consultation was provided and motivational support was offered;
he may benefit from outpatient addiction program assistance,
which he is strongly considering. He does not qualify for dual
diagnosis admission since his psychiatric illness is
compensated.
.
# HEPATITIS C INFECTION - He has a history of positive HCV
antibody documented in [**2188**]. No evidence of sequelae of chronic
liver disease. Liver synthetic function appears maintained (plt
424, albumin 2.8). LFTs: AST 29 and ALT 13 with T-bili 0.4 from
prior lab studies. HIV negative, AMA and smooth negative in
[**2190**]. Abdominal U/S in [**2189**] was normal. HCV viral load
20,101,696 IU/mL in 11/[**2194**]. Will need follow-up as outpatient
for AFP, serial ultrasounds, candidacy for possible anti-viral
therapy
(likely poor candidate) given his hepatitis C infection.
.
TRANSITION OF CARE ISSUES:
1. Social work consultation was provided and motivational
support was offered; he may benefit from outpatient addiction
program assistance given his substance abuse history.
2. Has outpatient follow-up with primary care physician and
Pulmonology scheduled.
3. Will need follow-up as outpatient for AFP, serial
ultrasounds, candidacy for possible anti-viral therapy (likely
poor candidate) given his hepatitis C infection.
4. Will also need outpatient PFTs and Pulmonology follow-up to
evaluate for other underlying lung disease.
Medications on Admission:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. insulin lispro 100 unit/mL Solution Sig: [**12-21**] units
Subcutaneous per sliding scale.
6. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
7. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. sertraline 50 mg Tablet Sig: 0.5 Tablet PO once a day.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
14. codeine sulfate 30 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for pain.
15. Seroquel 100 mg Tablet Sig: 0.5-1 Tablet PO at bedtime.
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Novolog 100 unit/mL Solution Sig: [**12-21**] units Subcutaneous once
a day: per insulin sliding scale.
6. Lantus 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
7. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. codeine sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. quetiapine 100 mg Tablet Sig: 0.5-1 Tablet PO HS (at
bedtime).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnoses:
1. Acute pulmonary syndrome (presumably related to crack-cocaine
use)
2. Acute on chronic exacerbation of non-ischemic cardiomyopathy
.
Secondary Diagnoses:
1. History of polysubstance abuse
2. Insulin-dependent diabetes mellitus
3. Hypertension
4. Hyperlipidemia
5. Positive Hepatitis C antibody
6. Chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of
your acute respiratory issues. You were first admitted to the
medical intensive care unit given concern for worsening heart
failure in the setting of your illicit substance use, but this
resolved with supportive therapy. You should AVOID ALL ILLICIT
SUBSTANCE USE in the future and take all necessary steps to
obtain motivational assistance and substance abuse program
assistance to promote healthy living.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED: NONE
.
* Upon admission, we CHANGED:
We CHANGED: Lantus from 40 to 50 units subcutaneously in the
evenings for better glucose control
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2196-2-11**] at 9:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2196-2-11**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PFT
When: THURSDAY [**2196-2-11**] at 9:30 AM
** Please contact our registration department at [**Telephone/Fax (1) 10676**] to
update your information.**
.
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: FRIDAY [**2196-2-12**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63642**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
ICD9 Codes: 4254, 3051, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1892
} | Medical Text: Admission Date: [**2200-10-24**] Discharge Date: [**2200-11-11**]
Date of Birth: [**2119-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Vicodin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath, exertional dyspnea
Major Surgical or Invasive Procedure:
[**2200-10-27**] Mitral Valve Replacement (33mm St. [**Male First Name (un) 923**] tissue)/
Coronary artery bypass grafts x 4 (LIMA-LAD, SVG-OM, SVG-Dg,
SVG-PDA)
[**2200-10-24**] Left and right heart catheterization, coronary
angiography
History of Present Illness:
80M with history of coaornary disease who was in usual health
until two weeks ago when he noted progressively worsening
dyspnea and orthopnea. His symptoms progressively worsened and
he presented to [**Hospital3 3583**] on [**10-23**] and was found to be in
heart failre with a BNP of 2351 and a borderline troponin of
0.15. An ECHO was performed and showed LVEF of 25%. He was
diuresed with IV lasix and was oxygenating well on 2L NC but
still had dyspnea. Of note, the patient's last stress test was
in [**2199**] and was unremarkable with preserved LVEF. He received
metformin and lovenox on morning of transfer and was not given
plavix. He was transferred to [**Hospital1 18**] for catheterization.
At cath, he was found to have severe three vessel coronary
artery disease, moderate to severely elevated right and left
sided filling pressures and depressed cardiac index and
ejection fraction with diffusely hypokinetic left ventricle.
He was referred for surgical revascularization.
Past Medical History:
osteoporosis
spinal stenosis
hx of asbestos exposure
kidney stones- s/p lithotripsy colon polyps
hyperlipidemia
glaucoma
peripheral vascular disease.
diverticulosis
colonic polyps
Hypertension
diabetes
Social History:
Quit smoking 44 years ago, previously had a 15 pack-year
history. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father died of CVA. No other known FH of CVD.
Pertinent Results:
[**2200-10-24**] Cardiac Cath:
1. Coronary angiography of this right dominant system revealed
severe, calcific three vessel coronary artery disease. The LMCA
did not have focal stenoses. The LAD had a 90% stenosis in the
mid-vessel. The proximal portion of the major diagonal branch
had a 70% stenosis. The LCx had a 99% stenosis at the origin,
with left to left collaterals. The RCA was totally occluded
proximally, with left to right collaterals.
2. Resting hemodynamics revealed moderate to severely elevated
right and left sided filling pressures (RVEDP 19 mm Hg, LVEDP 25
mm Hg, respectively). The PCWP mean was elevated at 28 mm Hg.
There was moderate pulmonary artery hypertension (PASP 59 mm
Hg). The systemic arterial blood pressure was low-normal (SBP
105 mm Hg). The cardiac index was depressed at 1.7 L/min/m2. The
systemic and pulmonary vascular resistances were mildly elevated
at 1697 dynes-sec/cm5 and 315 dynes-sec/cm5, respectively.
3. Left ventriculography demonstrated a dilated left ventricle
with global, severe hypokinesis to akinesis, with estimated
ejection fraction of 25%. There was moderate to severe mitral
regurgitation.
[**2200-10-25**] ECHO:
The left atrium is dilated. The right atrium is markedly
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is moderate to
severe regional left ventricular systolic dysfunction with
inferior/inferolateral and inferoseptal akinesis. Overall left
ventricular systolic function is moderately depressed (LVEF= 30
%). [Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] with
borderline normal free wall function. 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. An eccentric, medially directed jet of at
least moderate (2+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname **] was found to have triple vessel disease on
catheterization, with right heart pressure elevated and mitral
regurgitation. He was taken to the operating room on [**10-27**] where
coronary bypass grafting and mitral valve replacement were
performed. See operative note for details. He weaned from
bypass on Milrinone,epinephrine and neosynephrine.
Postoperatively he was relatively stable and was extubated on
[**Name (NI) 80108**]. His epinephrine was weaned and discontinued as was his
neosynephrine by POD 2. The Milrinone was then slowly weaned
and he remained stable.
He was gently diuresed, however, he became hypotensive each time
he received a Lasix bolus. A Lasix drip was instituted with a
good diuresis and stable blood pressure. Consult was obtained
from the CHF service-- we appreciate their recommendations. The
patient was transitioned from the lasix gtt to bolus treatment,
which he tolerated well.
He made good progress with physical therapy before discharge.
By the time of discharge, the patient was ambulating with
assistance, the pain was controlled with oral analgesics, and
the woundf was healing. He was discharged on POD 15 to The
Rehab of [**Location (un) **] and Islands for further recovery.
Medications on Admission:
Prilosec 20 qd
Altace 10 qd
Metformin 1000 qam, 500 qpm
Crestor 10 qd
ASA 81
MVI
Ca Vit D
Actonel 35 qFriday
Lasix
Timolol 0.5% to L eye [**Hospital1 **]
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Captopril 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
5. Furosemide 10 mg/mL Solution Sig: Four (4) Injection [**Hospital1 **] (2
times a day).
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day).
12. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
17. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
congestive heart failure
coronary artery disease
Diabetes Mellitus
Dyslipidemia
Hypertension
peripheral vascular disease
h/o nephrolithiasis
chronic anemia
spinal stenosis
glaucoma
osteoporosis
diverticulosis
colonic polyps
Discharge Condition:
good
Discharge Instructions:
No lifting more than 10 pounds for 10 weeks
no driving for 4 weeks and off all narcotics
report any temperature greater than 100.5
report any redness or drainage from incisions
shower daily, no baths or swimming
take all medications as directed
no lotions, powders or creams to incisions
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 58201**] in 2 weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] in [**3-2**] weeks
Completed by:[**2200-11-11**]
ICD9 Codes: 2761, 4240, 4280, 4019, 2859, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1893
} | Medical Text: Admission Date: [**2154-6-13**] Discharge Date: [**2154-6-15**]
Date of Birth: [**2100-4-27**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12657**]
Chief Complaint:
CSF leak, AD otorrhea
Major Surgical or Invasive Procedure:
[**2154-6-13**] repair of CSF leak
History of Present Illness:
54 yo M with chronic CSF leak
Past Medical History:
HTN, CAD s/p NSTEMI, and stents x 2
Social History:
+tobacco, +etoh
Physical Exam:
Afebrile VSS
AD dressing changed. Would flat, no otorrhea
Facial function intact and symmetric
Pertinent Results:
[**2154-6-14**] 02:00AM BLOOD WBC-13.0* RBC-4.44* Hgb-13.4* Hct-37.6*
MCV-85 MCH-30.2 MCHC-35.6* RDW-13.8 Plt Ct-291
[**2154-6-14**] 02:00AM BLOOD Plt Ct-291
[**2154-6-14**] 02:00AM BLOOD Glucose-247* UreaN-14 Creat-0.8 Na-139
K-4.2 Cl-105 HCO3-23 AnGap-15
[**2154-6-14**] 02:00AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.9
Brief Hospital Course:
Initially monitored in ICU setting. Vitals remained stable.
ECG was normal. Transferred to floor on POD 1. Ambulated and
tolerated PO's. No clear fluid drainage or swelling of incision
site. Received IV ceftriaxone while an inpatient. Lovenox held
for 48 hours, and restarted on POD 2.
Medications on Admission:
Metoprolol, Aspirin, Valsartan, ativan, lovenox, omeprazole,
zocor
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain. Tablet(s)
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate Oral
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Lovenox 1.5 mg/kg SC QD
8. Keflex 500 mg Po QID x 7 days
Discharge Disposition:
Home
Discharge Diagnosis:
CSF leak
Discharge Condition:
Good
Discharge Instructions:
Light activity, no straining or bending over. Call the office
if develop neck stiffness, light bothering eyes, or high fevers.
Followup Instructions:
Dr. [**Last Name (STitle) 3878**], 1 week-call office to schedule
Completed by:[**2154-6-15**]
ICD9 Codes: 4019, 412, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1894
} | Medical Text: Admission Date: [**2150-12-26**] Discharge Date: [**2151-1-7**]
Service: NEUROSURGERY
Allergies:
Cosopt / Lisinopril
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Left arm weakness
Major Surgical or Invasive Procedure:
[**12-26**] Right Burr Holes and SDH evacuation
[**12-30**] Placement of Subdural Drain
History of Present Illness:
88yo woman s/p mechanical [**2150**]. She sustained an
acute SDH at that time as well as a fractured him. She had
prolonged hospital course and was just discharged to rehab on
[**12-23**]. Pt returns from rehab today with complaint of worsening
left sided weakness and lethargy.
Past Medical History:
-CAD
-HTN
-NIDDM
-b/l cataract surgery
-cholecystectomy
-polyp removal from uterus
- hip ORIF
Social History:
No ETOH
No tobacco
lives with husband who is hospitalized, children very involved
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
O: T:98.1 BP: 162/68 HR:72 R 18 O2Sats97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL 4-3mm EOMs- unable to look left past
midline bilaterally.
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech slow
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally.
III, IV, VI: Extraocular movements are limited to the left
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. full strengths on right
UE and LE. Left neglect but able to lift UE and LE antigravity.
Sensation: Intact to light touch
DISCHARGE EXAM:
As above - A&0 x 2
Pertinent Results:
[**12-26**] CT head: IMPRESSION:
1. Interval decrease in density but increase in size of the
right hemispheric subdural collection which may represent
subdural hygroma, now with increased mass effect on the right
hemisphere and increased midline shift to the left, as above,
now 13 mm.
2. Evolving small left parietal subdural hematoma, not
increased.
[**12-26**] CT head: IMPRESSION:
1. Stable evolving right hemispheric subdural collection with
stable mass
effect on the right hemisphere and 11 mm shift of normally
midline structures to the left, previously 13 mm shift.
2. Stable left parietal subdural hematoma.
3. Interval burr hole evacuation with intracranial foci of
pneumocephalus;
largest focus along the right frontal hemisphere, other
scattered foci in the right cerebral hemisphere.
[**12-27**] CT head: IMPRESSION:
1. Stable large right subdural hematoma with chronic and acute
components
with stable mass effect on the right hemisphere. 13 mm leftward
shift of
midline structures is also stable.
2. Stable left parietal subdural hematoma measuring up to 4 mm
in maximum
thickness. No new areas of acute hemorrhage.
[**12-29**] CT Head:
1. Large right subdural hematoma, increased in size due to
increased
nondependent fluid, with a new septation. Expected evolution of
dependent
blood within this colleciton, without evidence of new
hemorrhage.
2. Increased leftward midline shift. Increased prominence of the
left
temporal [**Doctor Last Name 534**], consistent with increased trapping of the left
lateral
ventricle due to compression of the third ventricle.
3. Persistent right uncal herniation.
[**12-30**]/ CT HEad:
Interval evacuation of large right subdural collection, much of
which is now replaced by moderate pneumocephalus anteriorly,
with mild
improvement of leftward shift but similar configuration of mass
effect on the right frontal lobe, which may not be immediately
relieved. Right transcranial catheter with tip in the right
frontal region. No new focal hemorrhage.
[**1-1**] CT head:
1. Subdural catheter with tip in the right frontal subdural
collection.
2. Right frontoparietal subdural hemorrhage, smaller in size but
still 11 mm in greatest thickness.
3. Improvement in pneumocephalus which is now bifrontal.
4. Improvement in shift of normally midline structures from 12
to 6 mm.
5. Resolution of right uncal herniation
[**1-6**] R Knee XRay
No previous images. Generalized demineralization of the bony
elements. No evidence of acute fracture or dislocation or joint
effusion.
There is some meniscal calcification, especially in the lateral
aspect. Some vascular calcification is noted posteriorly
Brief Hospital Course:
Patient was admitted from the Emergency Department to the
Neurosurgical service and taken to the operating room for burr
holes (2) and evacuation of subdural hematoma. Surgery was
without complication and the patient tolerated it well. She was
extubated and transferred to the PACU where she remained
overnight. Post operative head CT revealed stable post op
changes. Left neglect was improving compared to preop.
On POD#1 she was transferred to the floor. She was started on
cipro for a UTI. Pt remained lethargic and was not taking PO's,
therefore IVF was continued.
On POD#2 her exam was again stable, but she remained lethargic.
Speech and Swallow were consulted to eval whether PO intake was
safe. PT and OT were consulted for assistance with discharge
planning.
On POD#3 pt continued to be lethargic and mental status was
declined in comparison to immediate post op. A head CT was
obtained which revealed resolving pneumocephalus but expanding
fluid collection. CXR was obtained which revealed pleural
effusion. She was started on lasix.
ON POD#4 MS [**First Name (Titles) **] [**Last Name (Titles) 1506**] therefore a dobhoff was placed. KUB
confirmed placement in the proximal duodenum. It was decided
that the SDH needed to be drained therefore she was taken to the
operating room. In the OR the subdural collection was drained
and a subdural drain was placed. She remained intubated and was
trasnferred to the PACU where she remained overnight. On [**12-31**]
she was still intubated but interacting on exam slightly more
than she was pre-operatively. Her hematocrit was 22 so she
recieved a unit of red cells. On [**1-1**] she had a CT which was
improved and as a result she was extubated and tolerated it well
while on nasal cannula. She was trasnferred to the floor and
tube feeds were started on [**1-1**] as well and she remained stable
there into [**1-2**]. On [**1-2**] she was stable however developed
hypertension and decreased urine output. She was placed on
antihypertensive medications in addition to her prior agents and
bolused fluid and her UOP improved. On [**1-3**] she had a CXR which
showed pulmonary venous congestion and she was given lasix. Her
BNO was found to be elevated and the team had difficulty
controllign her blood pressures. At this time her subdural
drain was also pulled. The medicine team was consulted to
comment on her hypertension and fluid overload and they felt
althoguh she had a history of CHF she was not currently in it.
Recommendations were made and carried out with improvement in
her medical status. On [**1-4**] her exam continued to improve, her
blood pressure was under control, and she was progressing
towards discharge to rehab.
She pulled her NG Tube on [**1-5**], however, a PO diet was initiated
and she did quite well. 3 days of calorie counts were obtained
by nutrition, who determined that she adequately met her calorie
requirements with oral intake. She complained of R knee pain on
[**1-6**], and an XRay revealed no acute fracture but a small
effusion. She was OOB with PT and standing with assistance.
She was discharged to rehab on [**2151-1-7**].
Medications on Admission:
tylenol
tums 500"
colace
flonase "
keppra 500"
metformin 500"
metoprolol 75 "'
timolol "
vit d 1000
senna
miconazole "
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
6. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
7. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
9. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
13. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] @ [**Hospital1 189**]
Discharge Diagnosis:
Subdural Hematoma s/p evacuation
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, do not
resume taking these until cleared by your surgeon.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2151-1-7**]
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1895
} | Medical Text: Admission Date: [**2100-12-28**] Discharge Date: [**2101-1-6**]
Date of Birth: [**2039-6-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 61 year old man
with known three vessel coronary artery disease and
congestive heart failure with an ejection fraction of 25 to
30% who had a planned coronary artery bypass grafting
scheduled for the morning of admission when he was noted to
be acutely short of breath while undressing in the
Preoperative Holding Area. States this is more severe than
his usual and did not resolve with rest. He had no
associated chest pain. He received 40 mg of intravenous
Lasix, Captopril, Lopressor and was started on Nitroglycerin
drip. He subsequently diuresed 1100 cc and had symptomatic
improvement. Over that day he was weaned off of his
Nitroglycerin drip and was seen to have improvement in his
symptoms. He had noted one month history of increasing
dyspnea on exertion and orthopnea and had been admitted to
[**Hospital 882**] Hospital in early [**Month (only) 1096**] with similar symptoms.
An echocardiogram at that time revealed an ejection fraction
of 40% with global hypokinesis and a catheterization
reportedly showed three vessel disease for which he was then
transferred to the [**Hospital6 256**] on
[**2100-12-2**]. His initial workup showed troponin of .56
and a chest x-ray with bilateral effusion and a left upper
lobe infiltrate. He was started on beta blocker, ACE
inhibitor and heparin and received Levaquin for a urinary
tract infection plus a possible pneumonia. Due to his
infection, his coronary artery bypass graft was subsequently
deferred at that time and since he had a history of stable
angina he was discharged to home at that time to return for
elective surgery.
PAST MEDICAL HISTORY: Coronary artery disease, congestive
heart failure with an ejection fraction of 25 to 30% by
echocardiogram on [**2100-12-1**], borderline hypertension,
recent urinary tract infection on last admission and recent
pneumonia on last admission.
SOCIAL HISTORY: He was born in [**Country 4754**] and now lives in
[**Location 2312**]. He is not married and has no children. His
tobacco history reveals he smoked 1 1/2 packs per day for 15
years and quit 25 years ago. He does drink occasional
alcohol and does not use intravenous drugs.
ALLERGIES: No known drug allergies.
MEDICATIONS: His medications at home include Captopril 12.5
mg p.o. b.i.d., Lopressor 15 mg p.o. t.i.d., Aspirin 325 mg
p.o. q.d., Zocor 20 mg p.o. q.d.
REVIEW OF SYSTEMS: Significant for positive dyspnea on
exertion, positive orthopnea, positive dry cough, no fevers
or chills or urinary frequency and no dysuria.
PHYSICAL EXAMINATION: On physical examination he is a
pleasant well nourished, well developed male in no apparent
distress. His vital signs showed a temperature of 97,
heart rate 91, blood pressure 114/62, respirations 22, and
oxygen saturations of 92% on 76% face mask. His head, eyes,
ears, nose and throat showed pupils equal, round and reactive
to light, extraocular movements intact, and oropharynx is
clear. His neck has jugulovenous pressure to about 9 to 10
cm. He has no bruits. Carotid pulses are 2+ bilaterally.
His lungs are clear to auscultation bilaterally and heart is
regular rate and rhythm with a normal S1 and S2 with no
murmur, rub or gallop. His abdomen is soft, nontender,
nondistended with positive bowel sounds. His extremities
showed 2+ pitting edema to the mid calf with 2+ dorsalis
pedis and 2+ posterior tibialis pulses. His neurological
examination shows him to be alert and oriented and grossly
intact.
LABORATORY DATA: His laboratory data on admission include a
white count of 19.1, hematocrit 45.5%, platelet count of
368,000 and sodium of 41, potassium 3.1, chloride 106, carbon
dioxide 22, BUN 16, creatinine 1.1 and blood glucose is 186.
His electrocardiogram showed sinus tachycardia at 119
beats/minute with T wave inversions in V5 and V6 which were
old and [**Street Address(2) 4793**] depressions in V1. His chest x-ray showed
low lung volumes, positive for mild congestive heart failure
and positive for bilateral effusions.
HOSPITAL COURSE: The patient was then admitted and brought
to the Coronary Care Unit where he was diuresed, treated and
stabilized. He was then later that date transferred to the
floor where he continued to be diuresed. On the evening of
admission he was noted to have a brief run of nonsustained
ventricular tachycardia consisting of five beats during which
he was stable and asymptomatic. His enzymes were checked
over the day and his troponin peaked at .21. On [**2100-12-30**], he had transthoracic cardiac echocardiogram which
showed 1 to 2+ mitral regurgitation which was unchanged from
previous echocardiogram and an ejection fraction of about
25%. Later that night he was noted to have a ten beat run
and nonsustained ventricular tachycardia during which he was
asymptomatic with stable vital signs. On [**12-31**], he was
thought to be stable and he was brought to the Operating Room
for coronary artery bypass grafting times four with the left
internal mammary artery to the left anterior descending
coronary artery, saphenous vein graft to the obtuse marginal
sequential to the ramus and a saphenous vein graft to the
right coronary artery. This surgery was performed by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The surgery was performed under general
endotracheal anesthesia with a cardiopulmonary bypass time of
123 minutes and a cross-clamp time of 91 minutes. The
patient was transferred to the Surgical Intensive Care Unit
in stable but critical condition on Levophed, Milrinone and
Propofol drips. He pulled from anesthesia well, followed
commands and was extubated later that evening. He also was
started on an insulin drip for blood sugars greater than 120.
By postoperative day #1, his Milrinone was weaned off and he
was started on Amiodarone drip for brief runs of nonsustained
ventricular tachycardia. By postoperative day #2, he
continued on his Amiodarone drip to help prevent further
ectopy and required Levophed for blood pressure support. He
had his chest tubes discontinued without incident on
postoperative day #3 and was transfused 1 unit of packed red
blood cells on this date. On postoperative day #3 he was
transferred from the Unit to the Surgical Floor and was
started on cardiac rehabilitation physical therapy. Chest
x-ray performed on postoperative day #4 showed mild to
moderate left pleural effusion. He continued with diuresis
and repeat chest x-ray on postoperative day #5 showed slight
improvement in this effusion and it was felt that the patient
was ready to be discharged to home with the [**Hospital6 1587**] services.
His discharge examination revealed vital signs stable with a
temperature of 98.8, heart rate 78, blood pressure 100/67,
respirations 20 and oxygen saturations 93% on room air. His
lungs were clear to auscultation. His heart was regular rate
and rhythm. His abdomen was soft, nontender, nondistended
with positive bowel sounds. His incisions are clean, dry and
intact.
His discharge laboratory data included white count of 12.6,
hematocrit 27.7%, platelet count of 273,000, sodium 137,
potassium 4.0, chloride 101, carbon dioxide 30, BUN 17,
creatinine 1.1 and blood glucose of 93.
DISCHARGE DISPOSITION/CONDITION: He will be discharged to
home with [**Hospital6 407**] services in good
condition.
DISCHARGE MEDICATIONS:
Lipitor 10 mg p.o. q.d.
Aspirin enteric coated 325 mg p.o. q.d.
Colace 100 mg p.o. b.i.d. prn.
Isordil 30 mg p.o. q.d., this is due to poor targets for
bypass grafts.
Plavix 75 mg p.o. q.d., also due to poor targets for his
bypass graft.
Amiodarone 400 mg p.o. b.i.d. times seven days and then 400
mg p.o. q.d. times seven days and then 1 tablet p.o. q.d. and
the need for this medication is to be reassessed by the
patient's cardiologist in one month's time.
Amantadine Hydrochloride 10 cc p.o. b.i.d. for four days as
the patient was exposed to a patient who tested positive for
influenza.
Lasix 60 mg p.o. t.i.d. times seven days, then 60 mg p.o.
b.i.d. times five days.
Potassium chloride 20 mEq p.o. b.i.d. times 12 days.
Percocet 1 to 2 tablets p.o. q. 4 hours prn pain.
FOLLOW UP: The patient should follow up with Dr. [**Last Name (STitle) 53443**] in
one to two weeks, with his cardiologist in two to three weeks
and with Dr. [**Last Name (STitle) **] in four weeks.
PRIMARY PROCEDURE: Coronary artery bypass grafting times
four with left internal mammary artery to the left anterior
descending coronary artery, saphenous vein graft to the
obtuse marginal with a sequential graft to the ramus and a
saphenous vein graft to the right coronary artery.
PRIMARY DIAGNOSIS:
Coronary artery disease.
Congestive heart failure.
Hypertension.
Pneumonia.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 31272**]
MEDQUIST36
D: [**2101-1-6**] 16:13
T: [**2101-1-6**] 18:51
JOB#: [**Job Number 53444**]
ICD9 Codes: 4280, 4271, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1896
} | Medical Text: Admission Date: [**2158-1-3**] Discharge Date: [**2158-1-8**]
Date of Birth: [**2096-5-3**] Sex: M
Service: MEDICINE
Allergies:
A.C.E Inhibitors / Insulins
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Dyspnea, LE edema
Major Surgical or Invasive Procedure:
Cardiac catheterization- no intervention
History of Present Illness:
61 year old primarily Italian speaking male with known coronary
artery disease (s/p 3 vessel CABG in [**5-25**], and multiple PCI's on
both native and grafts), status-post re-PCI of SVG=>D2 in-stent
restenosis via Cypher DES on 12/[**2156**]. Also, has history of PVD,
HTN, DM, HLP, smoking history. Recently admitted
[**11/2157**]/6/[**2157**] for acute decompensated heart failure in the
setting of a non-ST elevation myocardial infarction. Peak CK
2200, and troponin T 5.21 (baseline Cr 1.5), with troponin on
discharge 3.21. Patient had post-procedure echocardiogram on
[**2157-12-27**], which demonstrated no new MR with LV ejection fraction
35% (depressed from [**5-29**] EF 45%).
Since discharge on [**2157-12-30**], he has had intermittent dyspnea at
home, unclear if this was exertional or rest, which has been
increasing over the past 2 days. Associated with this SOB is
chest heaviness, no other symptoms (including no fevers, chills,
nausea, vomiting, diaphoresis, palpitations, ligtheadedness,
syncope, worsening LE edema).
He presented to [**Hospital 8050**] hospital on [**1-3**] in heart failure, and
was given 80 mg 80 IV lasix, morphine. He was started on heparin
drip for elevated cardiac enzymes (though decreaed since last
admission at [**Hospital1 18**]), and transferred to [**Hospital1 18**] for invasive
management. Here, heparin drip was discontinued (as cardiac
enzymes were decreased from prior) and he was given another 80
mg IV lasix and placed on nitroglycerin drip transiently for
pulmonary edema. Chest x-ray here was consistent with heart
failure. He was chest pain free on admission.
Past Medical History:
1. DMII - on humalog
2. HTN
3. hyperchol
4. CAD:
- [**2146**] - first IMI c/b VT, stent to an 80% RCA lesion.
- [**2152**] - CABG: SVG -> OM, SVG-> D1 & SVG-> D2
- [**2153**] - PTCA to SVG->D1 in [**5-26**], PTCA w/ brachy therapy to
SVG->D2 in [**10-26**]
- [**5-29**] - PTCA to SVG-D1 with 4 Cypher DES
- [**4-28**] - PTCA showed LAD had a 80% distal lesion. The LCX was
totally
occluded proximally. Distal LAD stented.
- [**11-28**] - stenting of the ISR of SVG to the D2
.
5. Severe symptomatic PVD s/p mult peripheral stents
- [**2155**] - 3 left SFA Dynalink stents to the left superficial
femoral artery
- [**4-28**] - Successful Atherectomy to the right EIA, CFA and SFA
- [**5-/2157**] - Successful atherectomy of the [**Female First Name (un) 7195**] and CFA.
Atherectomy of the LSFA complicated by distal embolization to
the AT and PT
- [**9-28**] - Successful atherectomy of the right SFA and CFA.
Successful stenting of the right EIA. Successful stenting of the
left CIA and EIA.
5. Systolic dysfunction: TEE in [**5-29**] showed no masses,
vegatatation. TTE in [**5-29**] showed EF 45%, Mild global LV
hypokinesis, trivial MR
6. Depression
7. AFib
8. Nephropathy
9. Hematuria
10. GERD
11. chronic LBP
12. colon polyps
13. PUD
Social History:
Married, speaks Italian, + smoker, quit two years ago but
restarted recently approximately 2 cigarettes per day (120 pk-yr
history). Denies alcohol or other drug use
Family History:
No family history of CAD
Physical Exam:
Admit PE:
vitals- T 99.4, BP 104/52, HR 85, RR 24, 97% on 2L o2; Wt 94 kg
gen- lying in bed, 45 degrees, 2 pillows, NAD
heent- EOMI. OP CLEAR. PERRLA.
neck- diffuse jvp at 8cms
pulm- bibasilar rales. upper lung fields clear. no wheezes
cv- RRR. normal s1/s2. +s3. no murmurs
abd- obese. nt/nd. NABS
ext- no edema
neuro- alert and oriented x 3. speaks limited english. motor fn
[**4-28**] UE/LE.
Pertinent Results:
DATA: EKG- sinus at 92 bpm, QRS axis 70, normal intervals; ST
depression V4 2mm; V5 1mm; V6 1mm -> new compared to prior
.
Labs: Na 141, K 4.5 (from 5.5) , Cl 103, Co2 24, BUN 68, Creat
1.9 (from 2.0) Ca 8.4, Mag 2.0, WBC 11.0, Hct 28.8, Plt 226
.
[**2158-1-4**] 7:30 am CK 165 Trop 2.33
[**2158-1-4**] 7:40 pm CK 210 Trop 2.42
[**2158-1-5**] 07:15AM CK(CPK)-143 CK-MB-3
.
Max CK 2225 ([**2157-12-26**]), Max Trop 5.21 ([**2157-12-25**])
[**2158-1-3**] pBNP: [**Numeric Identifier 47373**]
.
CXR [**2157-1-3**]: Small bilateral pleural effusions with prominence
of the pulmonary vasculature, consistent with mild pulmonary
edema. Scattered bibasilar atelectasis is noted
.
Cardiac Catheterization:
PROCEDURE DATE: [**2158-1-5**]
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease. Congestive heart failure. Dyspnea.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease with occluded
SVG-OM and
SVG-D.
2. Severe biventricular diastolic dysfunction.
3. Preserved cardiac output / index.
COMMENTS: 1. Selective coronary angiography demonstrated native
three vessel coronary artery disease in this right dominant
circulation.
The LMCA was without angiographically apprarent flow limiting
disease.
The LAD had moderate diffuse disease in the proximal and mid
vessel
without flow limitation. The diagonal branches were not
visualized. The
LCX was a small vessel with a mid-segment occlusion. The OM
branches
were not visualized. The RCA was a dominant vessel with a
proximal total
occlusion.
2. Graft angiography demonstrated that the SVG-D2 was occluded
distally
at the previously placed stent. The SVG-OM was occluded
proximally.
3. Right and left heart catheterization demonstrated elevated
right and
left sided filling pressures (RVEDP=15mmHG, mean PCWP=35mmHg,
LVEDP=35mmHg). Severe pulmonary arterial hypertension was
present.
Cardiac output and index were 4.5 L/min and 2.2/ L/min/m2
respectively. No transaortic gradient seen from catheter
pullback from
LV to ascending aorta.
4. Left ventriculography was not performed to reduce contrast
volume
Brief Hospital Course:
61 y/o M w/ h/o CAD, CABG, CHF, CRI, PAF p/w CHF exacerbation
.
1. CHF: Unclear precipitator, although he had a recent
pneumonia. His cardiac enzymes were elevated but down-trending
from previous admission. Unlear whether dietary indiscretion or
medical noncompliance were an issue, as patient did not know
what mediacations he [**Last Name (un) **] on. He came in with dyspnea and LE
edema. Had cardiac catheterization showing elevated right and
left sided pressures with PCWP of 35. His cardiomyopathy is
ischemic judging by wall motion abnormalities and his EF is 35%
by echo this admission. He did not have any intervention. He was
transfered to the CCU for tailored diuresis, where he diuresed
well with IV lasix. He self removed his femoral pressure
monitoring line, but not before two readings of PCWP around 20
were recorded. He diuresed over 2800 cc in two days in the CCU
and was transferred back to the floor for continued diuresis.
His IV lasix was changed to PO and he continued to diurese
appropriately. He was dicharged without LE edma, crackles, or
SOB.
.
2. CRI: He has elevated Cr in the past. His Cr was Cr 2.0 on
admission and 1.7 on discharge. It is thought to be due to CHF
on CRI, but there could be some component of dye induced
nephropathy. He will need his Cr checked on his next office
visit to see if he is trending down.
.
3. CXR infiltrate: He had recently completed course of levoflox
for PNA. During his stay he had no fever or productive cough to
support pneumonia. He did have a mild leukocytosis but it was
down trending. Suspected to be atelectasis vs delayed
radiographic resolution of pna. he did not receive antibiotics.
.
4. Hyperkalemia: In setting of renal insufficiency. He was given
Kayexalate and Insulin and it normalized.
.
5. DM insulin dependent: He was continued on his home insulin
regimen of 50 units of 75/25 qam and qpm. He recieved RISS for
breakthrough coverage and was given a diabetic diet.
.
6. CAD: He was chest pain free throughout his admission. He was
treated with aspirin, plavix, toprol and imdur.
.
7. AFib: He has a history of afib but has not been in it for his
last two admissions. He presented without anticoagulation,
though it is not clear why. He does carry a diagnosis of PUD and
colonic polys, but it is unclear if these are the reasons he is
not anticoagulated. We will defer to outpatient cardiologist,
Dr. [**First Name (STitle) **], and PCP as he was not anticoagulated prior to
admission and this diagnosis is old.
Medications on Admission:
Clopidogrel 75 mg qday
Aspirin 325 mg qday
Valsartan 80 mg qday
Alprazolam 0.5 mg po qhs prn
Furosemide 40 mg po bid
Levofloxacin 250 mg po qday to continue until [**2158-1-3**]
Isosorbide Mononitrate 120 qday
Nitroglycerin 0.3 mg Tablet, Sublingual prn
Pantoprazole 40 mg qday
Toprol XL 200 mg qday
Lipitor 80 mg qday
Insulin Lisp & Lisp Prot (Hum) 75-25 unit/mL 80 units sc twice a
day.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
10. Insulin Lisp & Lisp Prot (Hum) 75-25 unit/mL Suspension Sig:
as outlined below Subcutaneous twice a day: 80 units SC BID as
previously taking.
11. Outpatient Lab Work
Please have a "Chem 7" drawn within the week, and have results
sent to Dr. [**Last Name (STitle) **] at ph [**Telephone/Fax (1) 1144**] or fax [**Telephone/Fax (1) 6443**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CHF
CAD
Acute Renal Failure
Discharge Condition:
stable.
Discharge Instructions:
Please call your doctor if you have worsening shortness of
breath or leg swelling. Please come directly to the emergency
room if you have any concerning chest pain.
Please take all your medications as prescribed. Please weigh
yourself daily. If your weight increases by three pounds, please
call your doctor.
Followup Instructions:
In addition to the appointments below, please follow-up with
your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1144**] within the month. Follow-up
with Dr. [**First Name (STitle) **] as scheduled.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2158-1-13**]
9:30
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2158-2-7**]
3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2158-2-7**] 4:30
Completed by:[**2158-1-11**]
ICD9 Codes: 4280, 5849, 2767, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1897
} | Medical Text: Admission Date: [**2147-12-27**] Discharge Date: [**2148-1-1**]
Date of Birth: [**2081-2-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
[**2147-12-29**] ERCP performed, stent placed, stones extracted
[**2147-12-28**] Perc drain placed
History of Present Illness:
This is a 66 year-old male with a distant history of a Bilroth
II procedure and recently diagnosed cholelithiasis who presents
with acute cholecystitis and possible choledocholithiasis who is
being transferred from [**Hospital6 19155**] for ERCP.
Frequent upper abdominal pains recently. Recent ER visit with US
showing cholelithiasis and thickened GB wall with slight dilated
CBD and dilated PD. LFTs showed t bili of 3.1 with direct 1.4
but no fever, chills, jaundice or bloody stools prior to
admission at OSH. At OSH had fevers and chills and brief
diarrhea but no nasuea or vomiting. Last bowel movement he
recalls was last Saturday (5 days ago). He thinks he has passed
small amounts of flatus but he is not sure.
.
Admitted [**12-23**] to OSH. LFTs trended down and he was scheduled for
cholecystectomy. Laparoscopic cholecystectomy performed [**2146-12-26**]
which was "challenging with empyema of the gallbladder
encountered with both acute and chronic cholecystitis".
Intraoperative cholangiogram performed which showed markedly
dilated CBD and intrahepatic duct with 6-7 2-3mm gallstones in
the distal CBD which did not flush. Duct ligated and gallbladder
removed.
.
Post operatively he developed wheezing and a CXR showed probably
RLL infiltrate c/w possible aspiration PNA. He was started on
DuoNebs with good affect. Overnight he became more confused and
had worsening abdominal pain which they treated with Demoral
without good affect but which responded to ativan. The next
morning (the morning of transfer) a CXR showed ongoing RLL
infiltrate with possible cephalization and so he was diuresed
with almost 2L output.
.
On arrival in the [**Hospital Unit Name 153**] he was in visible discomfort, tachypneic,
and complaining of RUQ pain which was worth with deep breathing.
VSS and as noted below.
.
ROS:
(+) +RUQ pain worse with inspiration, +R shoulder pain, +mild
SOB x2 days, +mild cough x 2 days, +diarrhea (brief, nonbloody,
resolved, last episode ~5 days ago), +no bowel movement x5 days
(-) The patient denies any nausea, vomiting, current diarrhea,
melena, hematochezia, chest pain, orthopnea, PND, lower
extremity edema, dysuria.
Past Medical History:
Cholelithiasis
DMII
HTN
h/o Billroth II surgery [**66**] years ago
hyperlipidemia
Social History:
Retired, lives with wife, former [**Name2 (NI) 1818**], no alcohol in 40 years,
no illicits
Family History:
Non-contributory
Physical Exam:
On Admission
Vitals: T 99.2 BP 149/79 HR 105 RR 26 O2Sat 94/6L
GEN: well-nourished, mild respiratory distress
HEENT: EOMI, PERRL, dry MM
NECK: unable to appreciate any JVD
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: diffuse wheeze anteriorly, crackles at right lower base
ABD: distended, tense, +RUQ tenderness, no rebound or guarding,
chole drain draining yellow fluid, hypoactive bowel sounds
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. Moves all 4
extremities.
SKIN: jaundiced, no cyanosis
Pertinent Results:
[**2147-12-31**] 08:10AM BLOOD WBC-8.0 RBC-4.06* Hgb-13.2* Hct-37.3*
MCV-92 MCH-32.6* MCHC-35.5* RDW-12.9 Plt Ct-401
[**2147-12-27**] 04:49PM BLOOD WBC-11.5* RBC-4.46* Hgb-14.4 Hct-41.8
MCV-94 MCH-32.2* MCHC-34.3 RDW-12.8 Plt Ct-299
[**2147-12-31**] 08:10AM BLOOD Glucose-91 UreaN-9 Creat-0.5 Na-137 K-4.6
Cl-99 HCO3-30 AnGap-13
[**2147-12-27**] 04:49PM BLOOD Glucose-200* UreaN-11 Creat-0.7 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
[**2147-12-31**] 08:10AM BLOOD ALT-46* AST-33 AlkPhos-114 TotBili-1.8*
[**2147-12-27**] 04:49PM BLOOD ALT-75* AST-34 AlkPhos-135* TotBili-2.7*
.
Micro:
[**2147-12-28**] 5:00 pm FLUID,OTHER
Source: fluid collection around the liver.
GRAM STAIN (Final [**2147-12-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
Blood cx: NGTD
.
Urine cx: No growth
.
MRSA SCREEN (Final [**2147-12-30**]): No MRSA isolated.
Imaging:
CT Abd-Pelvis
IMPRESSION:
1. Heterogeneous predominantly fluid collection in the
gallbladder fossa
measuring 9.3 x 5 x 6.9 cm. The JP drain has displaced and is no
longer
draining this collection.
2. Subcapsular hepatic fluid.
3. Small bilateral pleural effusions with compressive
atelectasis.
4. Possible high-density material seen in the distal CBD
consistent with
stones. Recommended correlation with ERCP.
5. Calcification of the aorta and coronary arteries.
.
TTE
IMPRESSION: Normal global and regional biventricular systolic
function. Probable mild diastolic dysfunction. Mild mitral
regurgitation. Trivial pericardial effusion without echo
evidence of tamponade.
.
CXR [**12-30**]
CHEST RADIOGRAPH
INDICATION: Status post ERCP. Evaluation for interval changes.
COMPARISON: [**2147-12-28**].
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Minimal interstitial pulmonary edema, associated with a
minimal right
pleural effusion and a mild degree of left and right basal areas
of
atelectasis. Unchanged size of the cardiac silhouette. No newly
appeared
focal parenchymal opacities suggesting pneumonia.
Brief Hospital Course:
The patient was initially admitted to the medicine service on
[**2147-12-27**]. He underwent a CT scan that showed a 9x5cm biloma and
perihepatic fluid c/w bile leak. He was started on broad
spectrum atbx with vanc/zosyn. On [**12-28**], the patient underwent
percutaneous drainage of his biloma and drain was left in place.
His lab values were improving and his LFTs began to trend down.
On [**12-29**], patient underwent ERCP with sphincterotomy and
extraction of stones from the CBD. A pancreatic stent was
placed. The patient tolerated the procedure well. The patient's
diet was then changed to clears, and advanced as tolerated to
regular diet. The patient was transferred to the floor on HD 4.
His pain was much improved and he was tolerating regular diet.
His foley was dc'd on HD4, and patient voided without problem.
His [**Name2 (NI) **] continued to trend down and all cultures were negative.
He was transitioned to po pain meds, and restarted on his home
medications as well. Vanc/zosyn were discontinued and patient
was switched to unasyn on [**2147-12-30**]. He will be sent home with 3
days of augmentin to complete a 1wk course of atbx. On day of
discharge, patient's JP drain was removed, but new pigtail drain
was left in place. Of note, the patient did have increased work
of breathing upon admission with SOB/dyspnea. Crackles and
diffuse wheeze were heard in the RLL and CXR showed some
consolidation in that area. Patient was started on nebulizer
treatments and adequate pain control was started to minimize
splinting. ECHO was performed to rule out heart failure, and
this study was normal. Patient's breathing continued to improve
during his stay, and he was saturating well on RA at time of
discharge with no complaints of dyspnea.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Home Medications:
Alprazolam 0.5mg Q8H
Simvastatin 10mg daily
Lisinopril 10mg daily
Metformin 1000mg [**Hospital1 **]
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
3. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
4. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 **] [**Hospital1 **]
Discharge Diagnosis:
Bile leak s/p lap chole, CBD stones
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-16**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
You will be contact[**Name (NI) **] by the by the ERCP department regarding
followup.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2148-1-26**] 10:45
Completed by:[**2148-1-1**]
ICD9 Codes: 5070, 2930, 2859, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1898
} | Medical Text: Admission Date: [**2189-5-20**] Discharge Date: [**2189-5-30**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4854**]
Chief Complaint:
fever, hypotension, afib with RVR
Major Surgical or Invasive Procedure:
redo LUE AV fistula & replacement R SCV tunneled HD
History of Present Illness:
56 yo male, h/o ESRD [**2-5**] anti-GBM disease, on HD, DM2, HTN, p/w
fevers s/p HD session. Pt was reportedly dialyzed today; HD was
almost completed but had to be stopped early secondary to
clotting in the fistula. Pt/wife stated that he had felt unwell
since dialysis session on Monday (2 days prior to admission).
At this time, he was having some bilateral shaking of his arms.
He also reports some pain in his right shoulder, above the site
of his HD catheter. He states that this was worse with
movement. He had 1 episode of loose stools 1 day PTA. He
denies any URI symptoms, no CP/SOB/abdominal pain. After HD
session on day of admission, he felt unwell/lethargic at home.
He had some more episodes of shaking/rigors. He took a nap, and
after awaking from this, had a fever to 104. At this time, his
wife brought him to the [**Name (NI) **].
.
On presentation to the ED, he was febrile to 103.9; HR was
initially in the 90s with SBP=130. He subsequently went into
afib with a ventricular response 150-170s, with SBPs as low as
40-50. In the ED, he received 3 L NS (CVP from [**9-18**]; max). He
was seen by renal who felt that this was likely septic shock,
recommended vanco/gent. Renal stated that HD catheter (right
SC) should be used for fluids/pressors/abx (pt has history of
difficult access, ?saving femoral sites for future HD
catheters). As his SBP did not significantly improve with IVF,
he was started on dopa gtt with some improvement in SBP but
?exacerbation of tachycardia. Bedside TTE showed no pericardial
effusion or signs of tamponade. He was reportedly mentating
well throughout ED course. Other ED events include treatment of
hyperkalemia (7.1 to 4.6) with bicarb, D50. On presentation to
the ICU, he remained hypotensive, in afib with RVR, was
mentating adequately. He had no specific complaints but did
state that he was having pain in right shoulder at site of HD
catheter.
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-7**]
2. DM2: dx [**2177**]
3. HTN
4. Chronic low back pain [**2-5**] herniated discs
5. CHF
6. Peripheral neuropathy
7. Anemia
8. h/o nephrolithiasis
9. s/p cervical laminectomy; ?osteo in past
10. h/o depression
11. h/o MSSA bacteremia ([**3-9**]-infected HD catheter), E. coli
bacteremia
12. s/p L AV graft: [**7-7**]
13. h/o [**12-7**] of L4-5 diskitis, osteo, epidural abscess
Social History:
Lives w/ wife, son, daughter-in-law, and three grandchildren in
[**Name (NI) 86**] area, has been unemployed [**2-5**] disability, smokes tobacco
1 ppd x45 years, past alcohol, no recreational drug use.
Family History:
1. DM
2. Renal failure
Physical Exam:
Gen: pleasant male, sitting in bed, A&Ox3 ("[**Hospital3 **],"
"[**2189**]," "[**5-20**]," "[**Last Name (un) 2450**]")
HEENT: PERRL, OP clear
Lungs: CTA bilat, no w/r/r
CV: tachy s1/s2, no m/r/g appreciated
ABd: soft, nt/nd, nabs
Extr: no c/c/e, DP 1+ bilat
Skin: with right SC HD catheter; some tenderness superior to
this area, some firm areas around site
Pertinent Results:
[**2189-5-20**] 04:50PM BLOOD WBC-12.2*# RBC-3.86*# Hgb-11.5*#
Hct-35.9*# MCV-93 MCH-29.7 MCHC-31.9 RDW-18.4*
[**2189-5-22**] 04:08AM BLOOD WBC-7.9 RBC-2.98* Hgb-8.6* Hct-27.9*
MCV-94 MCH-28.8 MCHC-30.8* RDW-18.6* Plt Ct-275
[**2189-5-25**] 06:00AM BLOOD WBC-5.2 RBC-2.52* Hgb-7.3* Hct-23.6*
MCV-94 MCH-28.8 MCHC-30.8* RDW-18.9* Plt Ct-353
[**2189-5-29**] 04:55AM BLOOD WBC-7.1 RBC-3.13* Hgb-8.9* Hct-28.6*
MCV-92 MCH-28.4 MCHC-31.1 RDW-18.6* Plt Ct-550*
[**2189-5-20**] 04:50PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-3 Eos-0
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2189-5-20**] 11:20PM BLOOD PT-16.6* PTT-33.4 INR(PT)-1.5*
[**2189-5-24**] 12:00AM BLOOD PT-19.3* PTT-42.1* INR(PT)-1.8*
[**2189-5-29**] 12:41PM BLOOD PT-14.2* PTT-48.9* INR(PT)-1.3*
[**2189-5-20**] 04:50PM BLOOD Glucose-109* UreaN-31* Creat-9.6* Na-131*
K-7.1* Cl-93* HCO3-21* AnGap-24*
[**2189-5-22**] 04:08AM BLOOD Glucose-74 UreaN-40* Creat-9.3* Na-138
K-4.6 Cl-101 HCO3-22 AnGap-20
[**2189-5-24**] 05:58PM BLOOD Glucose-113* UreaN-26* Creat-6.4*# Na-137
K-4.2 Cl-100 HCO3-23 AnGap-18
[**2189-5-28**] 06:05AM BLOOD Glucose-62* UreaN-8 Creat-4.7* Na-143
K-4.1 Cl-105 HCO3-28 AnGap-14
[**2189-5-29**] 12:41PM BLOOD Glucose-71 UreaN-12 Creat-6.6* Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
[**2189-5-21**] 03:34AM BLOOD ALT-4 AST-12 LD(LDH)-176 CK(CPK)-271*
AlkPhos-101 Amylase-25 TotBili-0.4
[**2189-5-20**] 04:50PM BLOOD CK-MB-2 cTropnT-0.39*
[**2189-5-20**] 11:20PM BLOOD CK-MB-3 cTropnT-0.37*
[**2189-5-21**] 03:34AM BLOOD CK-MB-2 cTropnT-0.34*
[**2189-5-20**] 11:20PM BLOOD Calcium-7.9* Phos-5.2* Mg-1.5*
[**2189-5-22**] 04:08AM BLOOD Calcium-7.9* Phos-5.4* Mg-2.3
[**2189-5-29**] 12:41PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8
[**2189-5-28**] 06:05AM BLOOD TSH-5.9*
[**2189-5-28**] 06:05AM BLOOD Free T4-1.0
[**2189-5-21**] 03:34AM BLOOD Genta-1.5* Vanco-10.9*
[**2189-5-26**] 04:00AM BLOOD Vanco-19.9*
[**2189-5-29**] 03:45PM BLOOD Vanco-17.1*
Time Taken Not Noted Log-In Date/Time: [**2189-5-20**] 10:19 pm
BLOOD CULTURE
**FINAL REPORT [**2189-5-23**]**
AEROBIC BOTTLE (Final [**2189-5-23**]):
REPORTED BY PHONE TO [**Doctor Last Name **] [**Doctor Last Name **] AT 11:55AM ON [**2189-5-21**]
- CC6D.
STAPH AUREUS COAG +.
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.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2189-5-23**]):
STAPH AUREUS COAG +.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
Time Taken Not Noted Log-In Date/Time: [**2189-5-20**] 10:20 pm
BLOOD CULTURE
**FINAL REPORT [**2189-5-23**]**
AEROBIC BOTTLE (Final [**2189-5-23**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 103963**] [**2189-5-20**].
ANAEROBIC BOTTLE (Final [**2189-5-23**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 103963**] [**2189-5-20**].
[**2189-5-22**] 1:00 pm CATHETER TIP-IV RIGHT TUNNELLED DIALYSIS.
**FINAL REPORT [**2189-5-25**]**
WOUND CULTURE (Final [**2189-5-25**]):
STAPH AUREUS COAG +. >15 colonies.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
[**2189-5-23**] 5:33 pm BLOOD CULTURE
**FINAL REPORT [**2189-5-29**]**
AEROBIC BOTTLE (Final [**2189-5-29**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2189-5-29**]): NO GROWTH.
Cardiology Report ECG Study Date of [**2189-5-20**] 4:40:10 PM
Atrial fibrillation with rapid ventricular response
Ventricular premature complex
Indeterminate QRS axis
Late precordial QRS transition
Prominent/modestly peaked T waves - possible hyperkalemia
Consider also chronic pulmonary disease
Clinical correlation is suggested
Since previous tracing of [**2189-4-6**], findings as outlined now
present
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
147 0 80 258/342.57 0 90 10
[**First Name3 (LF) 706**] Final Report
US EXTREMITY NONVASCULAR LEFT [**2189-5-23**] 2:32 PM
US EXTREMITY NONVASCULAR LEFT
Reason: rule out fluid collection around LUE graft
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with tunneled HD catheter in R SC, ESRD, with L
AV graft
REASON FOR THIS EXAMINATION:
rule out fluid collection around LUE graft
INDICATION: 56-year-old man with tunneled hemodialysis catheter
in right subclavian vein, end-stage renal disease and left AV
graft. Evaluate for fluid collection surrounding the left upper
extremity graft.
LEFT UPPER EXTREMITY ULTRASOUND: The patient's left upper
extremity arteriovenous graft is again seen, without evidence of
intraluminal flow, and multiple internal echos suggesting
thrombosis. No fluid collections are seen surrounding the graft.
The fat, muscle, and fascial planes are preserved.
IMPRESSION:
1. No fluid collections surrounding the patient's left upper
extremity AV graft.
2. Graft thrombosis.
[**Hospital 706**] Final Report
MR L SPINE SCAN [**2189-5-23**] 8:02 AM
MR L SPINE SCAN; -52 REDUCED SERVICES
Reason: epidural abscess? discitis?
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with h/o discitis and increasing pain
REASON FOR THIS EXAMINATION:
epidural abscess? discitis?
EXAM: MRI of the lumbar spine.
CLINICAL INFORMATION: Patient with history of discitis and
increasing pain. Rule out epidural abscess.
TECHNIQUE: T2 sagittal images were acquired. The examination is
limited as patient was unable to continue.
FINDINGS: Compared to the previous MRI of [**2188-1-24**], again noted
is endplate changes at L4-5 level with anterior displacement of
L4 over L5 secondary to spondylolisthesis. Since the previous
study, the high-grade narrowing of the spinal canal has resolved
which could be secondary to laminectomy at this level. No
evidence of spinal stenosis seen at other levels. Bilateral
severe narrowing of the neural foramina is noted. Disc bulging
is seen at L5-S1 level as before.
IMPRESSION: Limited study demonstrating chronic changes of
discitis and osteomyelitis at L4-5 level. For better assessment
a repeat study with gadolinium is recommended if clinically
indicated.
Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Left
ventricular
systolic function is hyperdynamic (EF 70-80%). No masses or
thrombi are seen
in the left ventricle. There is no ventricular septal defect.
Right
ventricular chamber size and free wall motion are normal. The
aortic root is
moderately dilated. The number of aortic valve leaflets cannot
be determined.
The aortic valve leaflets are mildly thickened; there is focal
thickening of
the right cusp that could represent a vegetation. There is no
aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2187-11-19**], the aortic and tricuspid valve abnormalities are new, and
are highly
suggestive of endocarditis.
Cardiology Report ECG Study Date of [**2189-5-23**] 4:29:46 PM
Baseline artifact. Sinus rhythm. First degree A-V block.
Non-diagnostic poor
R wave progression. Compared to the previous tracing of [**2189-5-21**]
sinus rhythm
has replaced atrial fibrillation. Clinical correlation is
suggested.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 204 96 428/459.57 31 27 17
[**Last Name (NamePattern1) 706**] Final Report
CHEST (SINGLE VIEW) [**2189-5-29**] 12:50 PM
CHEST (SINGLE VIEW); CHEST FLUORO WITHOUT RADIOLOGI
Reason: H/O RENAL FIALURE, NOW INSERTIUON OF CATHETER FOR
DIALYSIS
CHEST 7:49 a.m. [**5-29**]:
HISTORY: Catheter insertion for dialysis.
IMPRESSION: A single frontal spot film of the chest centered
over the right lower lobe was provided for documentation of a
fluoroscopic guided procedure without a radiologist in
attendance. It shows a dual channel central venous line, tip
projecting over the right atrium.
Brief Hospital Course:
# MRSA Bacteremia and sepsis: Patient presented to the ED with
fevers/chills after partial HD session on [**5-20**] (stopped early
due to fistula clotting), he was admitted to the MICU in afib
with RVR and subsequent hypotension, found to have sepsis, MRSA
bacteremia. He responded to fluids and pressors, and vancomycin
and gentamicin. His subclavian line was changed over a wire and
the catheter tip also grew out MRSA. He was loaded on amio for
afib with good result (PR increased to 212 after amio started).
TTE showed no pericardial effusion or evidence of tamponade, but
was concerning for endocarditis given valve thickening. A TEE
was attempted but was unsuccessful due to inability to pass the
U/S scope. He was weaned from pressors on [**5-23**] but remained in
the MICU for until [**5-25**] for CVVH. He remained hemodynamically
stable, restarted hemodialysis without difficulty. All
surveillance blood cultures had no growth. For further ID work
up patient will need an outpatient MRI with gadolinium (to
further assess chronic changes of discitis and osteomyelitis at
L4-5) and TEE for more accurate assessment of endocarditis.
Patient will continue vancomycin for 6 weeks and will follow up
in the [**Hospital **] clinic on [**6-15**] at 2pm
.
# ESRD: Patient was continued on CVVH while in the MICU via a
new subclavian line changed over wire. He was transitioned back
to HD without difficulty once out of the MICU. ID recommended
removing the line altogether and resiting it to L subclavian.
However given L subclavian is a future site for dialysis access
via fistulas in his L arm. ON [**5-29**] LUE AV fistula was redone by
transplant surgery & replacement R SCV tunneled HD was placed.
.
# Afib with RVR: Patient was loaded on IV amiodarone while in
the MICU and then continued on PO amiodarone 400 po bid x 14
days. He will need oupatient follow up of his TFTs, LFTs, and
PFTs by his PCP. [**Name10 (NameIs) **] will need to restart anticoagulation once
cleared by surgery, that no further procedures are required.
.
# Chronic Pain: Patient was continued on methadone, oxycodone,
and neurontin per home regimen
.
# Anemia: Remained stable at baseline 26-30, attributed to ACD
and ESRD. Continued Epo and transfusions as needed with
dialysis.
.
# HTN: BP remained stable after MICU stay. Continued PO
amiodarone and BB. Consider restarting amlodipine and
lisinopril as BP allows as outpatient.
.
# CAD: Pt's elevated troponins attributed to end stage renal
disease. He was continued on BB and aspirin.
.
# Diabetes - Continued diabetic diet, SSI with FS QID.
.
# Depression - Continued paxil, remeron, and seroquel.
Medications on Admission:
Meds at home:
Oxycodone PRN
Colace
Amlodipine 10 mg
Paxil 20 mg
Protonix 40 mg
Seroquel 25 mg
Remeron 30 mg
Neurontin 200 mg QHD
Lisinopril 40 mg (recently held)
Methadone 10 mg q4h
Lopressor 100 mg TID, recently decreased to 50 mg TID
Coumadin 5 mg
Sevalemer 400 mg TID
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. 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*
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
6. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for back or surgical pain.
Disp:*30 Tablet(s)* Refills:*0*
16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
DIALYSIS for 5 weeks: TO BE DOSED AND GIVEN AT DIALYSIS.
Disp:*0 0* Refills:*0*
17. Outpatient Lab Work
PATIENT NEEDS CBC DRAWN ONCE A WEEK
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
HD catheter sepsis
Discharge Condition:
good
Discharge Instructions:
please seek medical attention if you experience fevere > 101.5,
severe nausea, vomitting, pain
please take medications as instructed
no driving while taking narcotic pain meds
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-6-4**]
9:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. Date/Time:[**2189-6-12**] 11:30
INFECTIOUS DISEASE CLINIC [**6-15**] AT 2PM
[**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**] MD, [**MD Number(3) 4858**]
Completed by:[**2189-5-31**]
ICD9 Codes: 2767, 5856, 4280, 4589, 3572, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1899
} | Medical Text: Admission Date: [**2109-8-21**] Discharge Date: [**2109-8-23**]
Date of Birth: [**2049-8-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy [**2109-8-22**]
History of Present Illness:
The patient is a 59M with minimal past medical history who
underwent colonscopy yesterday ([**First Name4 (NamePattern1) 12536**] [**Last Name (NamePattern1) **]) with removal of
2 polyps on right side of the colon now with BRBPR. Tolerated
the procedure well without bleeding. After no issues, went to
work the next day and then had 2 episodes of BRBPR. Initially
associated with mild abdominal cramping but this subsequently
resolved. Denies syncope, dizziness, palpitations.
.
Went to [**Hospital3 **]where VS: 98.2 112 163/103, found to
have HCT of 38.6 (baseline 41). Dark maroon, guiaic positive
stool on rectal. Continued to have episodes of bloody stools +
clots but he felt were improving. Got 1L NS.
.
In the [**Hospital1 18**] ED, initial vs were 98.7 106 140/98 16 100. Rectal
revealed bright red blood. HCT of 30.7 down from 38.6 at OSH
(baseline of 41). Typed and crossed for 2U. 2 large bore IV for
access. Talked w/ GI plan to start Golytely prep tonight for
scope tomorrow. Got 1L of fluid. vitals on transfer: 98.6 98
114/85 98%RA.
.
On the floor, no complaints. With colonoscopy prep had episode
of bloody bowel movement. Ambulating to commode without sx.
Past Medical History:
Borderline hypertension
Social History:
- married, 2 children, 5 grandchildren
- works as maintenance supervisor
- tobacco abuse, trying to quit
- minimal ETOH
Family History:
- no family history of colon or prostate cancer
Physical Exam:
Vitals: 110 137/88 18 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: S1, S2 Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Lab Results:
[**2109-8-21**] 09:10PM BLOOD WBC-7.4 RBC-3.05* Hgb-10.8* Hct-30.7*
MCV-101* MCH-35.2* MCHC-35.0 RDW-13.3 Plt Ct-219
[**2109-8-21**] 09:10PM BLOOD Neuts-83.7* Lymphs-11.9* Monos-3.1
Eos-0.9 Baso-0.4
[**2109-8-21**] 09:10PM BLOOD PT-12.9 PTT-26.7 INR(PT)-1.1
[**2109-8-21**] 09:10PM BLOOD Glucose-124* UreaN-10 Creat-0.7 Na-137
K-4.4 Cl-104 HCO3-23 AnGap-14
[**2109-8-22**] 02:33AM BLOOD WBC-6.2 RBC-2.53* Hgb-8.9* Hct-25.9*
MCV-102* MCH-35.1* MCHC-34.3 RDW-13.1 Plt Ct-228
[**2109-8-22**] 07:26AM BLOOD Hct-25.9*
[**2109-8-22**] 10:54AM BLOOD Hct-37.5*#
[**2109-8-22**] 04:07PM BLOOD Hct-35.9*
[**2109-8-22**] 10:08PM BLOOD Hct-35.9*
[**2109-8-23**] 04:07AM BLOOD WBC-4.6 RBC-3.59*# Hgb-11.9*# Hct-34.2*
MCV-95# MCH-33.3* MCHC-34.9 RDW-15.6* Plt Ct-145*
[**2109-8-23**] 02:27PM BLOOD Hct-35.6*
.
CXR [**2109-8-22**]:
Relatively large lung volumes without marked diaphragmatic
depression. Moderately air-filled colonic segments seen in the
right upper
quadrant. No evidence of free subdiaphragmatic air. No focal
parenchymal
opacity suggesting pneumonia. Normal size of the cardiac
silhouette without evidence of pulmonary edema.
.
Colonoscopy [**2109-8-22**]:
At the distal post-polypectomy site there was an overlying
eschar suggestive of recent bleeding. There was no visible
vessel to clip. There was no active bleeding. There were two
sigmoid polyps. The procedure was aborted secondary to
hemodynamic instability (BP dropped to the 60s and he required
IVF boluses). The patient was interactive during this time.
Impression: At the distal post-polypectomy site there was an
overlying eschar suggestive of recent bleeding. There was no
visible vessel to clip. There was no active bleeding. There were
two sigmoid polyps. The procedure was aborted secondary to
hemodynamic instability (BP dropped to the 60s and he required
IVF boluses). The patient was interactive during this time.
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
The patient was admitted to the MICU for active bleeding. He
required a total of 5 units of PRBCs for his bleeding and
anemia. He underwent coloscopy by GI who saw the site of
polypectomy but no active bleeding. During the procedure, he
had an episode of hypotension with systolic blood pressures in
the 60s, and then developed a brief rash which resolved over the
next couple of hours. This may have been due to the Fentanyl
and Versed that he received for the colonoscopy. He received
normal saline boluses and blood for his hypotension and this
resolved. His hematocrit remained stable. Follow-up will be
arranged with a colorectal surgeon (Dr. [**Last Name (STitle) 85321**] for removal of
the remaining polyps and he will be called with this
appointment. He stayed in the ICU until his hematocrit was
stable and then was discharged. He was told to go emergently to
an ER if he started to bleed again.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Lower GI bleed after colonoscopy
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 bleeding after a
colonoscopy. You underwent repeat colonoscopy which looked at
the site of bleeding but you were no longer actively bleeding.
You received blood transfusions and were monitored closely in
the intensive care unit. You still have polyps which were not
completely removed from the colon and you need to see a
colorectal surgeon to address this. The gastroenterology
doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 138**] [**Name5 (PTitle) **] to set this up. If you do not here from
them in 1 week, you should call Dr. [**Last Name (STitle) 85321**] (colorectal surgeon)
to schedule an appointment to remove the remaining polyps. His
office number is [**Telephone/Fax (1) 2296**].
No medications were added or changed.
You should follow-up with your primary care doctor in 1 week for
repeat blood counts.
If you have any further episodes of bleeding from your rectum,
dark or black stools, lightheadedness, weakness, dizziness or
other symptoms that concern you, you should go to an emergency
room immediately.
Followup Instructions:
Please see your primary care doctor in 1 week to check your
hematocrit.
You will be contact to schedule surgery to remove the remaining
polyps. If you do not here from the surgeon in 1 week, you
should call Dr. [**Last Name (STitle) 85321**] (colorectal surgeon) to schedule an
appointment to remove the remaining polyps. His office number
is [**Telephone/Fax (1) 2296**].
ICD9 Codes: 2851, 4019, 3051 |
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