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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1900
} | Medical Text: Admission Date: [**2129-2-19**] Discharge Date: [**2129-2-23**]
Date of Birth: [**2051-4-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Left arm pain
Major Surgical or Invasive Procedure:
placement of intraaortic balloon pump
[**2129-2-20**] cardiac catheterization with 2 Cypher overlapping stents
to the left circumflex artery and second obtuse marginal artery
History of Present Illness:
The patient is a 77 year old Spanish-only speaking female with a
history of CAD s/p MI in [**March 2125**] s/p CABG (LIMA->LAD,
SVG->OM1, SVG->D1, SVG->rPDA) complicated by sternal wound
infection with subsequent debridement, chronic rest angina, DMII
and HTN who presented to [**Hospital3 417**] Hospital on [**2129-2-19**] with
the chief complaint of worsening left arm pain at rest. The
history was obtained by the patient's daughter [**Name (NI) 26681**] as the
patient does not speak English
The patient described to her daughter's a history of daily
angina that occurs with rest that is substernal in origin and
radiates to her left arm. She did have a prior MI but cannot
recall her symptoms at the time as she was unconscious. In the
past week, she described increasing shortness of breath with
intermittent left arm pain. On Friday [**2129-2-18**], she described more
intense left arm pain at rest that was associated with shortness
of breath and mild chest tightness that resolved spontaneously
(the patient does not have nitro at home). On Saturday morning
[**2129-2-19**], the patient again experienced left arm pain and
substernal chest pain that lasted for hours. She still complains
of some chest pain upon transfer on a nitro gtt.
At [**Hospital3 417**] hospital, she went into vfib arrest and was
shocked once with 200 joules and was given a push of 150 mg
amiodarone IV with SBP 187/119. She was then placed on an
amiodarone gtt and nitro gtt. By report, she was went into
torsades at [**Hospital3 417**] and was given magnesium 2 gm IV x 1.
Before being transported to [**Hospital1 18**], the patient then again had a
vfib arrest and was shocked once again with 200 joules into
sinus rhythm. Her troponin and CK at [**Hospital3 **] was negative.
She arrived to the CCU with some chest pain on nitro and
persistent left arm pain. Her EKG showed old TWI in I and avL
and new [**Street Address(2) 4793**] depressions in V2-V3.
At baseline, the patient sleeps with her head elevated but notes
no increased peripheral edema or weight gain. Her daughters say
she has been compliant with all her medications.
Past Medical History:
DMII
CAD s/p MI 4'[**24**] with CABG
HTN
Social History:
The patient lives alone.
Family History:
Noncontributory.
Physical Exam:
P=60 BP=142/58 RR=22 97% on 10 liters NRB
Gen - NAD, Spanish-speaking
Heart - RRR, no M/R/G
Lungs - CTAB (anteriorly)
Abdomen - soft, NT, ND + BS
Ext - no C/C/E, + 2 d. pedis, left arm pain reproducible with
palpation
Pertinent Results:
[**2129-2-19**] 09:00PM GLUCOSE-279* UREA N-31* CREAT-1.1 SODIUM-138
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
[**2129-2-19**] 09:00PM ALT(SGPT)-22 AST(SGOT)-44* LD(LDH)-217
CK(CPK)-306* ALK PHOS-78 AMYLASE-98 TOT BILI-0.5
[**2129-2-19**] 09:00PM LIPASE-24
[**2129-2-19**] 09:00PM CK-MB-25* MB INDX-8.2* cTropnT-0.15*
[**2129-2-19**] 09:00PM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-3.6
MAGNESIUM-2.7*
[**2129-2-19**] 09:00PM WBC-13.2*# RBC-4.39 HGB-13.7# HCT-38.9 MCV-89
MCH-31.2 MCHC-35.2* RDW-12.7
[**2129-2-19**] 09:00PM PLT COUNT-254
[**2129-2-19**] 09:00PM PT-15.5* PTT-130.1* INR(PT)-1.5
CHEST (PORTABLE AP) [**2129-2-22**] 7:14 AM
IMPRESSION:
Interval improvement in the magnitude of bilateral lower lobes
partial atelectasis with some residual right lower lobe partial
atelectasis present. Mild degree of segmental atelectasis in the
posterior segment of the left lower lobe.
ECHO Study Date of [**2129-2-21**]
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional
left ventricular wall motion is normal. There is no left
ventricular outflow
obstruction at rest or with Valsalva. Right ventricular chamber
size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
The pulmonary
artery systolic pressure could not be determined. There is no
pericardial
effusion.
C.CATH Study Date of [**2129-2-20**]
COMMENTS: 1. Selective coronary angiography of this right
dominant
system revealed mutli vessel disease. The LMCA contained mild
disease.
The LAD was totally occluded after the first diagonal branch.
The
distal LAD filled well from the LIMA. The LCX had severe,
diffuse
disease throughout. OM1 had a totally occlusion but filled via
a patent
SVG. OM2 was a large vessel witha n 80% proximal stenosis
before
bifurcating into two large poles. The RCA was diffusely
diseased up to
50% in the PDA and 60% is the RPL.
2. Graft angiography revealed an occluded SVG-PDA, a patient
SVG-OM-D1,
and a patent LIMA-LAD.
3. Limited resting hemodynamics revealed a normal central
aortic
pressure of 111/39.
4. Successful PTCA and stenting of the LCX into OM2 with 2
overlapping
2.5 x 28 mm Cypher DES. The LCX portion of the proximal stent
was
dilated to 3.0 mm. Final angiography revealed no residual
stenosis, no
apparent dissection, and normal flow (see PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Occluded SVG-PDA
3. Patent SVG-OM-D1 and LIMA-LAD
4. Successful placement of 2 drug-eluting stents in the LCX and
OM2.
ECG Study Date of [**2129-2-21**] 8:10:40 AM
Sinus rhythm
Left anterior fascicular block
Diffuse ST-T wave abnormalities with prolonged Q-Tc interval -
Clinical correlation is suggested for possible metavolic/drug
effect and/or
ischemia
Since previous tracing of, [**2129-2-20**], further ST-T wave changes
present
Brief Hospital Course:
The patient is a 77 year old Spanish-speaking female with a
history of DMII, HTN, CAD s/p CABG '[**24**] (LIMA->LAD, SVG->OM1, D1,
rPDA) who presents with persistent left arm and chest pain not
relieved by nitro gtt with [**Street Address(2) 4793**] depressions in V2-V3 with old
TWI in I and avL.
1. CAD
- The patient was continued on a nitro drip, heparin drip,
statin and aspirin, holding her beta-blocker initially given her
history of ?bradycardia in ambulance.
- Her EKG initially showed mild ST depressions anteriorly with
no ST elevations, acute ischemic changes and her left shoulder
pain was reproducible on exam. However her polymorphic VT may
have been precipitated by an acute coronary syndrome and her
unstable angina. Her first troponin was negative. Her case was
reviewed and it was decided to maintain medical management
overnight. During this time, the patient's peak troponin hit
near 6 up from 0.15 on admission and her peak CK was 1570 up
from 306.
- She was taken to the cath lab the following day where she was
found to have an occluded SVG->PDA, patent SVG->OM1,D1 and
patent LIMA->LAD. The OM2 had a proximal 80% stenosis which was
subsequently stented into the LCX via 2 overlapping Cypher
stents. Her left arm pain resolved post-procedure and was felt
to be her likely anginal equivalent.
- She was ultimately titrated up to Lisinopril 10 mg and
Metoprolol 25 mg [**Hospital1 **] and maintained thereafter on plavix in
addition to her regimen above.
- Lastly, the patient had an echocardiogram which showed an EF
of 60% with no gross wall motion abnormalities.
2. HTN
- Her HR was originally 55 without beta-blockade. We were able
to successfully titrate up to Lisinopril 10 mg and Metoprolol 25
mg [**Hospital1 **] without difficulty.
3. DMII
- The patient does take insulin at home in the am ?NPH 45 units
and metformin 1 gm [**Hospital1 **]. For now, we initially held her metformin
as she went to cath. This was restarted prior to discharge. The
patient was not instructed to follow up with [**Last Name (un) **] as she does
not get her medical care in this area.
4. Polymorphic VT
- The patient was loaded on amiodarone 150 mg IV at the outside
hospital. We continued the patient on an amiodarone gtt at 1 mg
prior to cath. After her intervention, she experienced no more
significant arrhythmias.
- EP was consulted and agreed that her polymorphic VT was most
likely secondary to ischemia. She was discontinued from
amiodarone and secondary to her good EF, did not require further
intervention.
Medications on Admission:
Lasix 20 mg PO BID
Lescol 40 mg PO QD
Metformin 1 gm [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*9*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Metformin HCl 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
good
Discharge Instructions:
Please return to the ER or call 911 if you experience any more
chest or left arm pain.
You MUST take Plavix every day for 9 months along with your
aspirin. Failure to do so may result in another heart attack or
even death.
Followup Instructions:
Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**], to
schedule an appointment in [**12-19**] weeks. At this time, you should
discuss which local cardiologist you may follow up with after
your heart attack. You will need to see a cardiologist in 4
weeks.
ICD9 Codes: 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1901
} | Medical Text: Admission Date: [**2184-5-12**] Discharge Date: [**2184-5-18**]
Date of Birth: [**2127-1-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Progressive angina
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 1 [**2184-5-14**].
History of Present Illness:
This is a 57 yo male pt with history CABGs in [**2160**] and [**2172**] and
multiple stents since. He reports recent increase in anginal
symptoms with minimal exertion. Referred for cath showing known
3VD with patent RIMA to PDA, LCX (known) 100% with SVG to OM 90%
stenosis.
Past Medical History:
IWMI.
CAD/multiple PCIs.
OA.
Hiatal hernia.
Right rotator cuff tear.
S/P CABG [**2160**].
S/P CABG with RIMA to PDA, SVG to Ramus.
Social History:
Lives in [**Location **] with wife and 20 year old son. Does not work
-- disabled. Tob: quit 27 years ago -- 30 pack year history.
ETOH: 1 drink per week.
Family History:
Mother deceased with MI in 70s.
Pertinent Results:
[**2184-5-16**] 03:22AM BLOOD WBC-16.1* RBC-3.15* Hgb-10.1* Hct-28.4*
MCV-90 MCH-32.2* MCHC-35.7* RDW-13.2 Plt Ct-117*
[**2184-5-16**] 03:22AM BLOOD Plt Ct-117*
[**2184-5-16**] 11:57PM BLOOD Glucose-137* UreaN-24* Creat-1.1 Na-128*
K-4.2 Cl-98 HCO3-26 AnGap-8
[**2184-5-16**] 11:57PM BLOOD Calcium-8.7 Phos-3.7 Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname 2643**] was admitted on [**2184-5-12**] for cardiac cath showing known
3 VD with occluded SVG to OM and 100% occluded LCx. Referred
for 1 one vessel CABG s/p multiple previous attempts at failed
stents.
On [**2184-5-14**] he proceeded to the OR and underwent a CABG x 1 with
LIMA to the ramus with Dr. [**Last Name (STitle) **]. He was successfully weened
and extubated on his operative day and was transferred pou of
the CSRU on POD 2.
On PODs two and three he experienced some bursts of afib and SVT
to the 140s, broken with IV diltiazem and increase in PO
lopressor. Patie3nt has experienced no further episodes of SVT.
On POD four he was cleared by the physical therapy team and it
was decided that he was safe for discharge home.
Medications on Admission:
Aspirin 325 daily.
Nexium 40 daily.
Lopressor 50 [**Hospital1 **].
Plavix 75 daily.
Folic acid 1 daily.
Zetia 10 daily.
Lopid 600 [**Hospital1 **].
Lisinopril 10 daily.
Hytrin 2 daily.
Nitro patch 0.1 mg/hour -- three patches during daytime hours.
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:*0*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO q6h PRN.
Disp:*120 Tablet(s)* Refills:*0*
6. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO q6h PRN as
needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Coronary artery disease.
Discharge Condition:
Stable.
Discharge Instructions:
Shower daily nad [**Last Name (un) 24097**] incisions with soap and water -- rinse
well. Do not apply any creams, lotions, powders, or lotions.
No swimming or tub bathing.
No lifting greater than 10 pounds.
Schedule follow-up appointments as scheduled.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks.
Follow-up with Dr. [**Last Name (STitle) **] in [**4-2**] weeke.
Follow-up with Dr. [**Last Name (STitle) 11493**] in [**2-1**] weeks.
Completed by:[**2184-5-18**]
ICD9 Codes: 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1902
} | Medical Text: Admission Date: [**2104-2-3**] Discharge Date: [**2104-2-11**]
Date of Birth: [**2104-2-3**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Doctor First Name **] is a 1195 gram, 28 and 2/7
weeks, twin number one, admitted secondary to prematurity and
respiratory distress. She was born to a 35 year-old, Gravida
I, Para 0 to 2, white female, with prenatal screens
remarkable for A positive, antibody negative, RPR
nonreactive, Rubella immune, hepatitis B surface antigen
negative, GBS unknown. Mother did have a history of [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 4585**] and cervical dysplasia with previous laser therapy.
This was an in-[**Last Name (un) 5153**] fertilization pregnancy with di/di
twins. Ultrasound with Twin A with intra-cardiac echogenic
focus, nuchal translucency, no amniocentesis was done. She
was admitted at 25 weeks with cervical shortening and was
beta complete. Good interval growth. On magnesium sulfate
since about 26 weeks with expectant management. On day of
delivery, she progressed to advanced cervical dilatation with
bulging bag of membranes. A Cesarean section was performed
under spinal anesthesia. Rupture of membranes was at the
time of delivery. This twin was vertex, given facial CPAP.
Apgars were 7 at one minute and 8 at five minutes of life.
The patient was brought to the Neonatal Intensive Care Unit
with blow-by oxygen.
PHYSICAL EXAMINATION: On examination on admission, in
general, this is a premature infant, orally intubated, pink
and retracting. Temperature of 97.5. Pulse of 155,
respiratory rate of 40, blood pressure 53/26 with a mean of
35. Oxygen saturation of 91 percent. Weight 1195 grams
which was the 50th to 75th percentile, length of 35.5 cm,
which was 50th to 75th percentile, head circumference of 27
cm which was the 50th to 75th percentile. Anterior fontanel
is soft and flat. She is non dysmorphic. Orally intubated
with good aeration, although there were some coarse breath
sounds. No murmur noted. Normal pulses. She had a soft
abdomen with three vessel cord. No hepatosplenomegaly.
Normal female genitalia and a patent anus. No hip click. No
sacral dimple. Tone was normal for age.
HOSPITAL COURSE:
1. Cardiovascular: Patient developed a murmur on day of life
number four and was treated with Indomethacin. The
patient has had no murmur since completing a course of
Indomethacin and has been hemodynamically stable.
2. Respiratory: The patient was initially intubated. She was
weaned to CPAP on day of life number two and weaned to
room air on day of life four. She has 3 to 4 apnea or
bradycardia episodes related to apnea of prematurity every 24
hours. She is currently on caffeine.
3. FEN: The patient was initially n.p.o. on total fluids of
80 cc per kg per day. She was started on trophic feeds
and then made n.p.o. again when a PDA was noted and she
was started on Indocin. She restarted feeds on day of
life number six and is currently on 30 cc/kg per day and
working up 10 cc per kg per day, twice a day. Total
fluids are at 150 cc/kg per day with the remainder being
P.N. She currently has a UVC in for access.
4. Gastrointestinal: The patient was started on phototherapy
on day of life number two for a bilirubin of 5.9 over 0.3.
Next bilirubin of 7.2 over 0.4. Phototherapy was
discontinued on day of life number 8 with a bilirubin of
4.0 over 0.3 with a rebound plan for tomorrow.
5. Infectious disease: The patient was started on Ampicillin
and Gentamycin for a planned 48 hour rule-out. CBC was
obtained which was benign. Blood culture was no growth
and, therefore, after 48 hours, Ampicillin and Gentamycin
were discontinued.
6. Hematology: The patient had a normal hematocrit
throughout her stay. Hematocrit on day of life 7 was 43.
7. Neuro: The patient had a normal head ultrasound on day of
life number five. Plan is for repeat head ultrasound
tomorrow.
CONDITION ON DISCHARGE: Good.
CARE RECOMMENDATIONS:
1. Feeds to continue to go up by 10 cc per kg twice a day of
breast milk, total fluids of 150 cc per kg per day.
2. Medications: The patient is currently on caffeine for
apnea of prematurity.
3. Immunizations: None have been given as of yet.
DISCHARGE DIAGNOSES:
1. Prematurity at 28 and 2/7 weeks.
2. Twin gestation.
3. PDA, status post Indomethacin.
4. Hyperbilirubinemia status post phototherapy.
5. Rule out sepsis, status post 48 hour antibiotics.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 58671**]
MEDQUIST36
D: [**2104-2-11**] 17:08:17
T: [**2104-2-11**] 17:47:26
Job#: [**Job Number 60443**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1903
} | Medical Text: Admission Date: [**2108-6-29**] Discharge Date: [**2108-7-3**]
Date of Birth: [**2049-3-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Atenolol / Metoprolol
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2108-6-29**] Coronary bypass grafting x 5: Left internal mammary
artery to left anterior descending coronary artery; reverse
saphenous vein single graft from aorta to first obtuse marginal
coronary; reverse saphenous vein single graft from aorta to the
second obtuse marginal coronary artery; as well as reverse
saphenous vein double sequential graft from aorta to the
posterior descending coronary artery and posterior left
ventricular coronary artery
History of Present Illness:
59 year old male in [**2106-2-11**] underwent a coronary CT as
part of a research protocol which revealed a significant Left
Circumflex stenosis. Follow up stress testing did not reveal any
perfusion defects. On [**2106-2-16**] he underwent cardiac
catheterization where he was found to have an 80% OM2. The RCA
was patent and the LAD had a 50% stenosis in the proximal
portion. An attempt to open the OM2 was made, although was
unsuccessful as the lesion was calcified.
The patient reports that about two months ago he developed new
onset angina. He describes mid and upper left sided chest
tightness associated with pain in the neck and left arm. This
only occurs with exertion, ie. Two flights of stairs. In
addition, he has noticed new dyspnea on exertion. These symptoms
typically resolve with rest or SL nitroglycerin. Recent stress
testing has revealed inferoseptal and posteroseptal ischemia. He
was referred for cardiac catheterization. Cardiac catherization
revealed multivessel coronary artery disease.
Past Medical History:
Coronary artery disease s/p failed OM2 PCI in [**2106**]
HIV
Trigeminal neuritis
[**2104**] resection of basal cell cancer
Asthma/seasonal allergies
Hepatitis
Anxiety
Depression
Tonsillectomy
resection of pilonidal cyst
Social History:
Lives with: partner
Occupation: unemployed dental ceramist
ETOH: 2 glasses of wine per week
+tobacco [**5-17**] cigs/day x 43 yr
Family History:
Father died of an MI at age 74 + MI
Physical Exam:
Pulse:67 Resp: 12, O2 sat: 100%
B/P 144/
Height: 5'[**10**] in Weight:162Lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit none Right: 2+ Left:2+
Pertinent Results:
[**2108-6-29**] Echo: The left atrium and right atrium are normal in
cavity size. No spontaneous echo contrast is seen in the left
atrial appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal for the patient's body
size. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. There
is no aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. There is no pericardial effusion.
Post Bypass: Patient is in sinus rhythm on phenylepherine
infusion. Preserved biventricular function, LVEF >55%. Mitral
regurgitation is now [**1-13**]+. Aortic contours are intact. Remaining
exam is unchanged. All findings discussed with surgeons at the
time of the exam.
[**7-2**] CXR: In comparison with the study of [**6-29**], the various
monitoring and support devices have been removed. Specifically,
there is no evidence of pneumothorax. There has been an increase
in opacification at the left base with silhouetting of the
hemidiaphragm, consistent with atelectasis and pleural effusion.
Less prominent atelectatic changes seen at the right base. The
upper lungs remain clear.
[**2108-6-29**] 04:50PM BLOOD WBC-13.6*# RBC-2.59* Hgb-10.2* Hct-28.7*
MCV-111* MCH-39.5* MCHC-35.5* RDW-14.1 Plt Ct-153
[**2108-7-2**] 06:00AM BLOOD WBC-10.5 RBC-2.62* Hgb-10.0* Hct-29.6*
MCV-113* MCH-38.0* MCHC-33.7 RDW-14.1 Plt Ct-130*
[**2108-6-29**] 04:50PM BLOOD PT-16.4* PTT-30.6 INR(PT)-1.5*
[**2108-6-29**] 06:47PM BLOOD PT-14.4* PTT-32.8 INR(PT)-1.2*
[**2108-6-29**] 06:47PM BLOOD UreaN-10 Creat-0.9 Cl-108 HCO3-25
[**2108-7-2**] 06:00AM BLOOD Glucose-112* UreaN-10 Creat-1.3* Na-136
K-4.8 Cl-105 HCO3-26 AnGap-10
[**2108-7-3**] 06:00AM BLOOD UreaN-11 Creat-1.1 K-4.2
[**2108-7-1**] 05:01AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.4
Brief Hospital Course:
Mr. [**Known lastname 9624**] was a same day admit and brought to the operating
room on [**6-29**] where he underwent a coronary artery bypass graft
surgery. See operative report for further details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. In the first twenty four hours he was
weaned from sedation, awoke neurologically intact, and extubated
without complications. He continued to progress but remained in
the intensive care unit on Neo-Synephrine for blood pressure
management. He was eventually weaned off and transferred to the
telemetry floor on post operative day two. Chest tubes and
epicardial pacing wires were removed per protocol. Physical
therapy worked with him on strength and mobility. He continued
to progress well and was ready for discharge with VNA services
and the appropriate follow-up appointments on post operative day
four.
Medications on Admission:
Trizivir 300mg-150mg-300mg one tablet twice a day
Bupropion HCL 75mg two tablets every morning, one tablet every
evening
Pravastatin 10mg daily
Viread 300mg daily
Trazodone 150mg daily at bedtime
Aspirin 325mg daily
Coenzyme Q10 200mg daily
Flaxseed Oil daily
Efudex 5% cream as needed
Hydrocortisone 2.5% cream as needed
Anusol Suppository as needed
Nitroglycerin .3mg SL prn
Discharge Medications:
1. Trizivir 300-150-300 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
2. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. 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:*1*
5. Viread 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) as needed for q AM: 150 mg in am and 75 mg in pm .
Disp:*60 Tablet(s)* Refills:*0*
7. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): 150 mg in am and 75 mg in pm .
Disp:*30 Tablet(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for PAIN.
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 5
HIV
Trigeminal neuritis
[**2104**] resection of basal cell cancer
Asthma/seasonal allergies
Hepatitis A
Anxiety
Depression
s/p Tonsillectomy
s/p Resection of Plonidal cyst
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 9625**] in 1 week ([**Telephone/Fax (1) 798**]) please call for appointment
Dr [**Last Name (STitle) **] in [**2-14**] weeks - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2108-7-3**]
ICD9 Codes: 2724, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1904
} | Medical Text: Admission Date: [**2195-12-13**] Discharge Date: [**2195-12-20**]
Date of Birth: [**2123-1-12**] Sex: F
Service: SURGERY
Allergies:
Codeine / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72 yo F presents BIBA from OSH s/p fall down [**1-3**] steps. X-rays
at OSH showed posterior left rib fractures, and a left clavicle
fracture. No LOC. Tetanus given 1 week ago. At OSH, glucose
450, WBC 16.3, ceftriaxone x1 dose, 10 units of insulin.
Past Medical History:
1. IDDM
2. s/p AAA repair
3. ureteral stent with atrophic R kidney
4. s/p TAH/BSO
Social History:
lives at home with her husband, [**Name (NI) **] [**Name (NI) 28211**], [**Telephone/Fax (1) 76452**].
Family History:
non-contributory
Physical Exam:
on admission:
101.4 F (rectal) 110 140/90 24 97%
General: NAD, appears mildly confused
Eyes: 3-->2 bilaterally
ENT: airway patent
Neck: c-collar in place, trachea midline
Respiratory: CTAB
CV: nl rate, regular rhythm
Chest: left amteropr cjest wa;; temder to palpation
GI: soft, NTND, guaiac negative, good rectal tone
Foley in place, no gross blood
Spine: non-tender
Neuro: A&O x2, following commands, MAEW
Pertinent Results:
admission labs:
[**2195-12-13**] 04:51PM GLUCOSE-241* LACTATE-2.5* NA+-143 K+-4.3
CL--104 TCO2-24
[**2195-12-13**] 04:15PM CK(CPK)-483* AMYLASE-19
[**2195-12-13**] 04:15PM CK-MB-7 cTropnT-<0.01
[**2195-12-13**] 04:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2195-12-13**] 04:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2195-12-13**] 04:15PM WBC-16.4* RBC-4.30 HGB-12.7 HCT-36.5 MCV-85
MCH-29.6 MCHC-34.8 RDW-17.5*
[**2195-12-13**] 04:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2195-12-13**] 04:15PM URINE RBC-[**10-20**]* WBC-[**10-20**]* BACTERIA-FEW
YEAST-MOD EPI-0-2
pertinent imaging:
[**12-13**] CT head (OSH): large left hematoma soft tissue. No SAH or
SDH, no fracture, sinuses clear, no acute intracranial process.
[**12-13**]: CT chest: L lateral ribs 3->6 rib fx's. posterior [**1-4**] rib
fx's
[**12-13**]: CT c-spine: degenerative changes, no fx or dislocation
[**12-13**]: CT torso: neg for acute intra-abdominal process, s/p AAA
repair. R adrenal mass 3.6x1.8cm c/w adenoma. R ureteral stent
with atrophic R kidney. s/p TAH/BSO.
[**12-14**]: CXR: As compared to [**2195-12-13**], slight left
suprabasal
atelectasis has developed. Small left-sided pleural effusion,
no
pneumothorax. Rib fractures and clavicular fracture are
unchanged.
[**12-17**]: CXR: (prelim) Moderate left pleural effusion, slightly
increased. Adjacent L retrocardiac opacity likely represents
atelectasis but coexisting infxn is not excluded. No definite
pneumonia.
Brief Hospital Course:
Upon arrival to the [**Hospital1 18**] ED, a trauma basic was called. The
patient had multiple radiographic studies, as detailed above.
The patient was admitted to the TICU, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
attending. Her pain was controlled with dilaudid, and she was
placed on insulin sliding scale for her high glucose. She was
additionally started on ciprofloxacin for her UTI. Her
pulmonary function was closely monitored because of her multiple
rib fractures. Incentive spirometry was encouraged. She was
seen by the inpatient geriatrics service, and the physical
therapy and occupational therapy services. It was felt that she
would be best served in a rehab facility upon discharge. The
Acute Pain Service was contact[**Name (NI) **] regarding placement of an
epidural, and an epidural was placed on HD 3. The patient was
transferred to the floor, and continued to work with physical
therapy. She tolerated a regular home diet, and continued on
her home medications. The patient continued to improve, and her
epidural was removed on HD 6.
She was placed on an insulin sliding scale in addition to her
home oral diabetic medications, and this was titrated as needed
for improved blood sugar control. She will continue her diabetic
medications and insulin sliding scale at her Rehab facility. On
HD 6, a Foley was placed for urinary retention, and 1250 cc were
emptied. Her Foley was d/c'd the next day, and she failed a
voiding trial, so it was replaced. It was then d/c'd, and she
was voiding, though incontinent at times. She was bladder
scanned for only 66cc - negative for overflow incontinence.
Early in her hospital course, the urology service was consulted
regarding her UTI given her stent and renal issues - per their
recommendations, the stent was left in place ,and she completed
her 7 day course of ciprofloxacin for complicated UTI on HD 7.
Medications on Admission:
advair
oxycontin
albuterol/ventolin HFA 90 mcg
lorazepam 1 [**Hospital1 **]
buproprion (wellbutrin xl) 150 qhs
trazodone 300 qhs
gemfibrozil 600
glyburide 5 [**Hospital1 **]
ibuprofen 800 [**Hospital1 **]
atenolol 100
premarin 0.625
lipitor 40 mg
effexor 150 mg
detrol 4 mg qhs
aspirin 325 mg qd
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain: Hold for sedation or RR <12.
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for breakthrough pain: Hold for sedation or RR
<12.
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
17. Insulin Sliding Scale
Please keep patient on a tight Humalog insulin sliding scale.
Titrate as needed to keep blood sugars between 120 and 140 if
possible.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
1.s/p fall
2. Left lateral ribs 3->6 rib fractures. Posterior [**1-4**] rib
fractures
Discharge Condition:
stable
Discharge Instructions:
You have been admitted to [**Hospital1 69**]
after a fall. You have been cared for by the trauma team. The
acute pain service has also followed you.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Redness around your wounds or drainage from your wounds.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in trauma clinic in [**12-2**] weeks.
Please call [**Telephone/Fax (1) 6429**] to make an appointment.
Please call your primary care physician to schedule an
appointment in 1 week for monitoring of blood sugar management.
Please call your Urologist to schedule an appointment for 1 week
for f/u of complicated UTI and renal f/u.
ICD9 Codes: 5990, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1905
} | Medical Text: Admission Date: [**2134-7-13**] Discharge Date: [**2134-7-16**]
Date of Birth: [**2071-4-28**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Dicloxacillin / Levofloxacin
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Chronic, cough, fever
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
Ms. [**Known lastname 52**] is a 63 year-old female with Burkitt's lymphoma
(last chemo [**2134-4-29**]) with recent parainfluenza pneumonia who
presented on transfer with sepsis.
Over past three weeks has had cough. Seen by Dr. [**Last Name (STitle) **] on
[**6-29**] and felt to be consistent with postviral irritative
bronchitis; at that time had had no fever. She was given a
brief course of steroids followed by inhaled steroids.
Then presented to an OSH with continued cough and fever to 103.
Found to have a RLL and RML PNA on CXR and was given 2 L NS and
azithromycin/ceftriaxone and transferred to [**Hospital1 18**] as she
receives all of her oncologic care here. Enroute in the
ambulance, she developed hypotension.
In the [**Hospital1 18**] ED, initial vitals included P 106 BP 78/45. She
was fluid resusicated with 5 L NS, however remained hypotensive
with SBPs in the 80's-90's. She was treated with vancomycin and
cefepime and admitted to the ICU. A CTA was done which showed
no PE, but did show opacification in the RML concerning for
infection.
ROS:
(+) fever per HPI
(+) 60 point weight loss since [**Doctor Last Name 11579**] diagnosis
(+) alopecia with chemo
(-) chest pain, palpatations
(+) cough per HPI
(-) abdominal pain, diarrhea, constipation
(-) rash
(+) right shoulder pain
(-) dysuria, frequency, hematuria
(-) weakness
Past Medical History:
ONCOLOGIC HISTORY:
1. Burkitt's lymphoma
- Diagnosed in [**2133-11-27**], s/p multiple chemo regimens.
- Most recent cycle (IVAC) was on [**2134-4-29**] with complications of
admission for profound neutropenia, fever, parainfluenza
infection, and bacteremia.
2. Hypothyroidism.
3. Hyperlipidemia.
4. Hx of Pseudomonas bacteremia.
5. Hx of Coag-neg staph bacteremia.
6. Hx of Enterobacter bacteremia.
7. Hx of Parainfluenza and pneumonia
Social History:
Her husband has COPD and has required frequent hospitalizations.
One of her sons and daughter-in-law live downstairs with their
three children. She worked as a system analysis at NHIC, but is
currently retired. Denies tobacco or alcohol use.
Family History:
There is no family history of lymphoma or other malignancies
within the family. Her sister has a history of cirrhosis. Her
brother has diabetes and anterograde amnesia.
Physical Exam:
Vitals -
General - well appearing, sitting in a chair at the bedside
HEENT - no icterus; no pallor; no thrush
CV - regular; split S2; no murmurs
pulm - bilateral crackles without clear focus; no wheeze
abd - soft; non-tender; lower abdominal scar from prior
c-section
ext - warm; 1+ edema
neuro - alert; in good spirits; able to provide clear history
Pertinent Results:
WBC: 6.6 -> 6.1; 36% bands
at discharge, WBC 2.3
HCT: 32 -> 28 -> 30.2
PLT: 129 -> 103
INR: 1.5
Cr: 0.4
Lactate: 1.2
LDH: 175
ALT: 62
AST: 53
Alb: 3.4
UA: negative
[**7-13**] CXR: IMPRESSION:
1. Right perihilar opacification is new since [**2134-6-17**] and
may represent early infectious process versus nodule. Correlate
clinically. Recommend follow up imaging post treatment or
dedicated CT chest for further evaluation.
2. Right-sided pleural effusion is resolved compared to the
prior chest x-ray.
3. Minimal right basilar atelectasis is noted.
[**7-13**] CTPA:IMPRESSION:
1. No evidence of pulmonary embolism.
2. Focal nodular opacity in the right middle lobe measuring up
to 2.4 cm in cross-section with surrounding ground-glass halo,
new from prior study from three weeks ago, likely represents
pneumonia.
3. Tree-in-[**Male First Name (un) 239**] micronodularity in the lower lobes most likely
related to
aspiration or pneumonia. Please note the presence of mild
bronchial wall
thickening in the lower lobes and right middle lobe could also
indicate
chronic aspiration, though airways disease/bronchitis is also
considered.
Brief Hospital Course:
1. Pneumonia / Septic shock: Presented with fever and
hypotension and imaging showing infiltrate. Bronchoscopy with
BAL showed 1+ GNR, 1+ GPR and yeast. Initially treated with
vancomycin and cefepime with marked improvement. After 48+
hours afebrile and stable, transitioned to oral regimen. Given
no GPC on BAL, did not cover staph auerus (MRSA). Given allergy
to levofloxacin, oral options were more limited; as there had
been improvement without coverage for atypicals, switched to
cefpodoxime alone. Plan was for 14 days total with follow-up
three days post-discharge.
2. Burkitt's lymphoma: Felt to be in remission; WBC trended
down during stay with resolved bandemia; LDH was normal.
Medications on Admission:
Levothyroxine 100 mcg Tablet po daily
Acyclovir 400 mg Tablet po q8h
Clonazepam 0.5 mg Tablet po tid prn
Oxycodone 5 mg Tablet po q4h prn
Lidocaine patch prn shoulder pain
Pyridoxine 50 mg Tablet po daily
Sennosides 8.6 mg Tablet 1-2 Tablets [**Hospital1 **] prn
Docusate Sodium 100 mg Capsule po bid
Vancomycin 125 mg PO QID
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for prn shoulder pain.
6. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Sennosides 8.6 mg Capsule Sig: [**11-28**] Capsules PO twice a day as
needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
10. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Health care associated pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with pneumonia. Please be sure to complete a
course of antibiotics, as prescrubed.
If you experience ANY fevers/chills, shortness of breath,
worsening fatigue or have any concerns, please seek medical
attention right away.
Followup Instructions:
Department: HEMATOLOGY/[**Month/Day (2) 3242**]
When: MONDAY [**2134-7-19**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Last Name (NamePattern1) 280**] [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 0389, 486, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1906
} | Medical Text: Admission Date: [**2170-8-7**] Discharge Date: [**2170-8-16**]
Date of Birth: [**2112-2-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
VF arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Placement of ICD
History of Present Illness:
Mr. [**Known lastname 79807**] is a 58 year-old man who suffered a VF arrest while
jogging in a park in [**Location (un) 745**]. There were other joggers nearby
during the arrest who administered immediate CPR. At the time
of EMS arrival, he was noted to be in VF arrest (9:43 AM); he
received a shock at 200 J and was given amiodorone 300 mg; at
that time he was found to be in asystole and CPR was continued.
A pulse was first noted at 9:49 AM; he was in sinus rhythm. He
was intubated and cooled with ice packs in the field.
.
In the ED, he was found to be hypotensive and was given IVF
without response; he was started on neosynephrine and given ASA
325. He was cooled to 35 degrees C and sedated on versed and
fentanyl. He received vecuronium as muscle paralytic to prevent
shivering.
.
His ECG in the ED showed sinus bradycardia to 52 with normal
axis and LVH by voltage criteria; there were TWI in leads I and
aVL, V1-V2, a right bundaloid pattern, and a prolonged QTc to
500.
Past Medical History:
# AORTIC INSUFFICIENCY for many years. He is followed by Dr.
[**Last Name (STitle) 32963**] in cardiology at [**Hospital1 112**]. Valve replacement was
recommended in the past and he has been considering this. OSH
TTE shows 2+ AI. For several months, he has had chest pressure
and dyspnea sensation while running and has been concerned about
cardiac trouble since then.
.
# GASTROESOPHAGEAL REFLUX DISEASE
Social History:
Nonsmoker, rare EtOH, no drug use. Married with 2 children.
Residence in [**Location (un) 745**]. Jogs for exercise on average 4-5x/wk for
total 20 mi/wk. Works in marketing for [**Company 22916**]; job requires
frequent travel.
Family History:
Family history significant for mother with CAD and MI age 64,
father with CAD with CABG in 70s, sister with MI at age 62.
Physical Exam:
PHYSICAL EXAM AT ADMISSION:
Vitals: T94.8, HR 57, 117/59, R16, 100% on AC 0.5, 550 x 14,
PEEP 5
General: Intubated, sedated.
HEENT: NC/AT. Pupils 2 mm, minimally responsive, equal. Sclera
anicteric. MMM, ETT and NGT in place.
Neck: Supple, no adenopathy, no JVP elevation appreciated.
Chest: CTA bilat on vent
Heart: RRR, S1 S2, soft SM at apex, ?diastolic murmur at RUSB
Abdomen: +BS soft NT/ND
Extrem: +shivering, no edema, 2+ distal pulses bilaterally.
Neuro: Sedated. No spontaneous movement or response to pain
(?[**12-30**] residual paralytics).
..
PHYSICAL EXAM AT DISCHARGE:
Tm 99.1, BP 132/74, HR 68, RR 20, 95% on RA
He is alert and oriented, in no acute distress. Memory,
cognition, judgment, language and other neurological function is
back to baseline from before cardiac arrest. Heart exam shows
RRR. [**2-1**] blowing diastolic murmur is heard loudest at base.
Dressing is in place over left upper chest at site of ICD
placement. Non-erythematous, non-edematous, appropriately
tender. There is mild tenderness to palpation over precordium
where he received chest compressions. Lungs are clear. Abdomen
is non-tender and non-distended. There is no lower extremity
edema.
Pertinent Results:
LABS FROM ADMISSION:
.
[**2170-8-7**] 10:02PM GLUCOSE-114* UREA N-14 CREAT-0.8 SODIUM-140
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-28 ANION GAP-11
[**2170-8-7**] 10:02PM CK(CPK)-553*
[**2170-8-7**] 10:02PM CK-MB-22* MB INDX-4.0 cTropnT-0.19*
[**2170-8-7**] 10:02PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.0
[**2170-8-7**] 06:09PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2170-8-7**] 06:09PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.050*
[**2170-8-7**] 06:09PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2170-8-7**] 06:09PM URINE RBC-18* WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2170-8-7**] 02:10PM WBC-17.8*# RBC-4.75 HGB-14.8 HCT-43.0 MCV-90
MCH-31.2 MCHC-34.5 RDW-13.0
[**2170-8-7**] 10:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-8-7**] 10:15AM PT-14.3* PTT-32.3 INR(PT)-1.2*
..
EKG: sinus bradycardia to 52, normal axis, LVH by voltage
criteria, TWI in I and aVL, V1-V2, right bundaloid pattern,
prolonged QTc at 500
..
CORONARY CATHETERIZATION ([**2170-8-7**]):
1. Selective coronary angiography of this right-dominant system
demonstrated single-vessel coronary artery disease. The LMCA,
LCX, and
RCA were all without angiographically-apparent flow-limiting
stenoses.
The LAD had a proximal 80% stenosis that improved to 30% after
direct
intracoronary infusion of nitroglycerine.
2. Aortography demonstrated severe aortic regurgitation and
mild
dilatation of the ascending aorta without evidence of
dissection.
FINAL DIAGNOSIS:
1. Single-vessel coronary artery disease.
2. Aortic regurgitation.
..
TTE ([**2170-8-7**]):
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. There is normal
regional and global biventricular systolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve is bicuspid.
The aortic valve leaflets are mildly thickened. The study is
inadequate to exclude significant aortic valve stenosis. Severe
(4+) aortic regurgitation is seen. The aortic regurgitation jet
is eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mildly thickened bicuspid aortic valve with severe
eccentric aortic regurgitation directed toward the anterior
mitral leaflet. Mild symmetric left ventricular hypertrophy with
dilated left ventricular and preserved regional/global systolic
function. Moderately dilated aortic root. Borderline pulmonary
hypertension.
.
TEE ([**2170-8-9**]):
No mass/thrombus is seen in the left atrium or left atrial
appendage. No mass or thrombus is seen in the right atrium or
right atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The ascending aorta is mildly dilated. The aortic valve has
three leaflets but is functionally bileaflet. Leaflets are
thickened and deformed. No masses or vegetations are seen on the
aortic valve. An eccentric jet of moderate to severe (3+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Trivial mitral regurgitation is seen.
IMPRESSION: No vegetations seen. Functionally bicuspid aortic
valve with thickened leaflets and eccentric, moderate to severe
aortic regurgitation. Mildly dilated thoracic aorta.
..
CT HEAD ([**2170-8-7**]):
FINDINGS: There is no intra-axial or extra-axial hemorrhage,
mass effect, shift of normally midline structures, or
hydrocephalus. [**Doctor Last Name **]-white matter differentiation is preserved.
Ventricles, sulci and basal cisterns are unremarkable.
Structures within the posterior fossa are unremarkable. No
suspicious lytic or blastic osseous lesion is identified. There
is scattered opacification of ethmoid air cells, and thickening
of the posterior aspect of the left maxillary sinus. Visualized
paranasal sinuses and mastoid air cells are otherwise well
aerated.
IMPRESSION: No acute intracranial abnormality identified.
..
CXR ([**2170-8-14**]):
FINDINGS: There is a single chamber pacer/AICD in place with
lead terminating in the region of the right ventricle. There is
no pneumothorax.
There is significant interval increase in right lung base
opacity. This
appears to be progressive since [**2170-8-9**]. There is
blunting of the right costophrenic angle. These findings likely
represent a right pleural effusion and given the chronicity of
findings adjacent right lung base pneumonia. The left lung is
unchanged from past studies. There is a large cardiac
silhouette, and mediastinal contours are unremarkable.
IMPRESSION:
1. Interval progression of right lung base opacity, likely
pneumonia.
2. Interval placement of single chamber pacer/AICD with lead in
good
position.
Brief Hospital Course:
In summary, this is a 58 year-old man presenting s/p ventricular
fibrillation arrest, now intubated, sedated and paralyzed on
cooling protocol, back in normal sinus rhythm. The period
between onset of cardiac arrest and restoration of sinus pulse
was approximately 6 minutes, per EMS report.
..
# RHYTHM / VF ARREST:
Shortly after presentation to the emergency room he went to the
cath lab where there was evidence of coronary vasospasm of the
LAD; there were no fixed lesions requiring stenting, only a 30%
fixed stenosis of the LAD (see full catheterization report
above). Urine toxicology was negative. Echo showed severe
aortic regurgitation and mild symmetric LVH with preserved
global systolic function. He was started on a nitro drip for
vasospasm and afterload reduction in the setting of known AI.
He was cooled per neuroprotective protocol post cardiac arrest
and maintained in a hypothermic state for 24 hours. He was
sedated throughout with Fentanyl and midazolam and paralyzed
with vecuronium to minimize shivering.
.
Twenty-four hours after beginning cooling, his core body
temperature was slowly warmed. He became increasingly agitated
overnight and on the morning of HD 2, his sedation was weaned
and he was extubated. Telemetry showed no further episodes of
ventricular dysrhythmia. The presumed cause for his VF arrest
is coronary artery vasospasm. It is unclear at this time
whether the (exertional) anginal-type symptoms he describes in
the weeks leading up to this event are also due to vasospasm.
.
During the hospital course, his nitro drip was switched over to
long acting nitro and calcium channel blocker. An ICD was
placed several days prior to discharge. He will have follow-up
with his cardiologist at [**Hospital1 112**] as well as follow-up in the [**Hospital **]
clinic at [**Hospital1 18**].
..
# PUMP / VALVES:
An echocardiogram performed in the ED showed normal EF with
severe AI and moderate LV dilation. Although he was initially
hypotensive in the ED requiring neosynephrine he became
hypertensive in cath lab and his pressor was discontinued. As
above, there was no significant coronary artery disease and no
regional wall motion abnormalities. A repeat TTE performed two
days after admission showed normal LV function with EF of >55%
and an aortic valve with three leaflets but functionally
bileaflet; AR was 3+. It is unclear at this time whether his
aortic insufficiency is at all related to his VF arrest.
.
As above, he was continued on afterload reducing agents. He
will follow-up at [**Hospital1 112**] with Dr. [**Last Name (STitle) 32963**]. Aortic valve
replacement is being considered.
..
# ISCHEMIA / CAD:
As above, coronary angiography showed a 30% fixed stenosis of
his proximal LAD. LCx and RCA were unremarkable. The LAD
coronary vasospasm that likely caused his cardiac arrest was
treated with Imdur and amlodipine. We continued his home dose
of aspirin 81 mg qday.
.
# RESPIRATORY STATUS / PNEUMONIA:
He was intubated in the field secondary to his cardiac arrest
and continued on ventilation throughout the cooling and
rewarming period. On HD 2, sedation was weaned and he was
extubated on the morning of HD 3.
.
The night before extubation, he spiked a fever. Differential at
that time included VAP, aspiration pna, pulmonary embolus, and
endocarditis (given his known valvular disease). [**12-1**] blood
cultures grew gram positive cocci (later speciated as coag neg
staph), and he was started empirically on IV vanco. A
tranesophageal echo was done while he was still intubated that
was negative for valvular vegetations. CXR came back showing
bibasilar consolidations c/w aspiration pna. We started him
empirically on Zosyn and continued the vanco. When blood
culture speciation returned and he began tolerating PO, IV vanco
and Zosyn were stopped and he was started on levo and flagyl to
complete a seven day course of antibiotics.
.
Unfortunately, on day 7 of his antibiotic course he spiked a
low-grade fever to 100.6, then on day 8 to 101.1. Repeat CXR,
PA and lateral, showed worsening RLL pneumonia. Blood and urine
cultures were negative. Infectious disease consultation
recommended increasing dose of levo to 750 QDAY. We made this
change and decided to treat for an additional 7 days for
presumptive hospital acquired pneiumonia. He had no more fever
over the next 24 hours. O2 sats were excellent on RA and there
was no cough or sputum production. He is discharged with five
days of PO levo remaining to complete a seven day course.
..
# PLEURITIC CHEST PAIN / STATUS POST CHEST COMPRESSIONS:
Chest pain was treated with IV morphine, switched over to
oxycodone post-extubation. This was suppplemented by a lidocaine
patch. At time of discharge, he is taking vicodin, lidocaine
patch, and NSAIDs with adequate pain control. Narcotic-related
constipation is treated with senna and docusate.
..
# MENTAL STATUS:
There was concern after extubation that he may have memory
deficits s/p arrest. CT-head was ordered at admission and
negative for acute intracranial process. Over the course of the
hospitalization, he became increasingly alert and oriented. His
MS at time of discharge is fully recovered and back to baseline
pre-arrest.
..
# ANEMIA:
During hospital course, he had hematocrit in mid twenties that
rose to 30 at time of discharge. Kidney function was normal;
iron studies WNL and hemolysis labs negative. Unclear why this
otherwise healthy man who runs 20 mi/wk should have anemia,
other than possibly d/t marrow suppression in the setting of
acute illness. This will need follow-up as outpatient.
..
# After extubation, he was started on a regular diet. DVT
prophylaxis with subcutaneous heparin. GI ulcer prophylaxis
with an H2 blocker while intubated which was stopped after
extubation. Code status was full throughout.
Medications on Admission:
# ASA 325 mg daily
# MVI
# Vitamin C 1000 mg daily
# Vitamin D 400 mg daily
# Licorice enzyme supplements
# Free amino acids
# DHEA supplement
# EPA/DHA (Opti-EPA) supplement
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*1*
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical every twenty-four(24)
hours: Please apply for 12 hours then 12 hours off. .
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PRIMARY DIAGNOSES
VF arrest with ICD placement
Coronary vasospasm
..
SECONDARY DIAGNOSIS
Aspiration pneumonia
Aortic insufficiency
Discharge Condition:
Vital signs stable. Afebrile.
Discharge Instructions:
You had a cardiac arrhythmia called ventricular fibrillation
while you were jogging. It was thought that you had some
coronary spasm in the artery that feeds blood to the heart. You
also may need to have aortic valve surgery in the next few
months.
.
You had an internal defibrillator placed that will shock your
heart out of an abnormal rhythm. You need to be seen in the
device clinic in 1 week to check this ICD and be followed by a
cardiologist that specializes in heart rhythms such as Dr.
[**Last Name (STitle) **] or similar doctor [**First Name (Titles) **] [**Last Name (Titles) 112**]. Your ICD has not been
tested, this needs to be done in about 2 months.
.
Also, you had a pneumonia for which we prescribed an antibiotic
called levofloxacin (Levaquin). Take this medication for 5 more
days, and call your doctor right away if you have any chills,
fevers, or cough.
.
You have also been given information for an interventional
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who you know from your hospital
stay and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2689**] who you may choose as your primary care
provider.
.
No lifting more than 5 pounds for 6 weeks. No lifting your left
arm over your head or tucking in your shirt 6-8 weeks. No shower
for one week, you may take a bath but the dressing/incision
should remain dry.
.
Please call your cardiologist if you experience any swelling,
redness, fevers, increasing chest pain, trouble breathing or if
you have any shocks from the ICD firing.
.
Please call [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) 69336**], [**MD Number(3) 79808**] have any questions
about this discharge. [**Telephone/Fax (1) 79809**].
.
If you want a copy of your medical records, please contact
Information Resources on the ground floor of the [**Hospital Ward Name 23**] center
at ([**Telephone/Fax (1) 39110**].
Followup Instructions:
Device clinic: [**Hospital Ward Name 23**] clinical center on [**Hospital Ward Name **], [**Location (un) **].
Tuesday, [**8-21**] at 9am.
.
Cardiology:
Dr. [**Last Name (STitle) 13179**] within next 2 weeks.
Electrophysiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**]
DFT testing needs to be done in approx 2 months
.
Primary Care:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2689**] Phone: [**Telephone/Fax (1) 250**] for an appt in [**1-30**] weeks.
Completed by:[**2170-8-16**]
ICD9 Codes: 5070, 486, 4275, 4241, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1907
} | Medical Text: Unit No: [**Numeric Identifier 61567**]
Admission Date: [**2165-5-14**]
Discharge Date: [**2165-5-20**]
Date of Birth: [**2165-5-14**]
Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 1692**]-[**Known lastname **] is the 4.165 kg product of
a 39-4/7 week gestation born to a 34 year old G2 P1, now 2
mother. Prenatal [**Name2 (NI) **] include blood type A positive, antibody
negative, hepatitis surface antigen negative, RPR
nonreactive, Rubella immune and GBS negative. The pregnancy
was reportedly unremarkable. The antepartum period was
notable for ruptured membranes 2 hours prior to delivery, no
maternal fever, no other identified sepsis risk factors for
sepsis and no intrapartum antibiotic prophylaxis. The infant
was born vaginally with Apgar of 8 and 9.
PHYSICAL EXAM ON ADMISSION: Weight was 4.165 kg,
intermittent respiratory distress with tachypnea, flaring and
grunting increased with activity. Skin was warm, dry, no
rash. Fontanelle was soft and flat. Palate was intact.
Coarse, moderately aerated breath sounds. Intermittent
grunting, flaring, retracting. Regular rate and rhythm, no
murmurs. Soft, no hepatosplenomegaly, no masses, active bowel
sounds. Normal external male genitalia. Femoral pulses are
2+. Patent anus. Brisk capillary refill. Interactive with
exam. Vigorous intact Moro grasp and suck.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
infant continued to be tachypneic. Chest x-ray demonstrated
fluid in the fissure. The infant remained in room air
throughout hospital course and the tachypnea resolved around
day 2 of life.
Cardiovascular: No issues.
Fluids and Electrolytes: Birth weight was 4.165. Discharge
weight was 4.060. The infant is ad lib feeding breast milk or
Similac 20 calorie, taking in adequate amounts.
GI/GU: Peak bilirubin was 7.6/0.2 on day of life 3 and did
not require any intervention.
Hematology: Hematocrit on admission was 50.3 and he did not
require any blood products during admission.
Infectious Disease: A CBC and blood culture was obtained on
admission. CBC was benign, but with persistence of tachypnea,
ampicillin and gentamicin were started. Repeat chest x-ray on
day of life 1 was concerning or suggestive of pneumonia. At
that time, decision was made to treat infant for 7 days of
antibiotics. A lumbar puncture was performed and was within
normal limits. Infant has been appropriate for gestational
age.
Sensory: Audiology - hearing has been performed with
automated auditory brainstem responses and the infant passed
both ears.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To the newborn nursery.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], telephone
number [**Telephone/Fax (1) 61251**].
CARE RECOMMENDATIONS: Continue ad lib feeding of breast milk
or Similac 20 calorie.
DISCHARGE MEDICATIONS: Continue ampicillin and gentamicin
for a total of 7 days.
Car seat position screening is not applicable. State newborn
screens were sent as per protocol and had been within normal
limits. The infant received hepatitis B vaccine on [**2165-5-16**].
DISCHARGE DIAGNOSIS: Pneumonia.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2165-5-20**] 21:13:55
T: [**2165-5-20**] 21:51:26
Job#: [**Job Number 61568**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1908
} | Medical Text: Admission Date: [**2201-3-28**] Discharge Date: [**2201-3-31**]
Service: MEDICINE
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Hypothermia, hypotension, bradycardia
Major Surgical or Invasive Procedure:
central venous catheter placement
History of Present Illness:
[**Age over 90 **] yo female with PMH of afib on coumadin, htn, and dementia,
was found at home yesterday [**3-28**] being brady to 40s and
hypothermic 86.7F and hypotensive 60/dop in field. Patient was
given atropine and external paced by EMS. She was brought to ED,
and admitted to MICU. Within an hour after MICU admission, she
was normothermic on Bair hugger and with warmed IVF, and off
pressors (levophed). HR improved as well.
.
She had garbled speech in the ED, code stroke was called.
Neurology recommended MRI and felt her symptoms were likely
unrelated to an acute stroke. Garbled speech is her baseline.
It appears that patient has been having increasing agitation at
home recently, and was started on seroquel and had a recent
fall. CTA of brain was negative.
.
Patient was given vanc/zosyn in the ED, which were continued
overnight last night in the MICU, and discontinued this morning.
Infectious workup is negative so far. Thyroid function was
normal, and tox screen was negative. She was found to have INR
of 12, got 10 of IV vitamin K. On transfer to medicine floor,
her BP, HR and body temperature all returned normal.
.
On arrival to the medicine floor, pt was very drowsy. Her eyes
were closed despite sternal rubs, but she does withdraw to
painful stimuli. She is not requiring oxygen, and her vital
signs are stable. She moaned and grimaced when her abdomen was
palpated.
Past Medical History:
- Alzheimer and [**Last Name (un) 309**] Body Dementia (Dr. [**First Name (STitle) **] neurologist)
Hypertension
- Atrial fibrillation, on coumadin
- Urinary incontinence - detrusor instability
- Diastolic CHF
- Degenerative joint disease/osteoarthritis
- Right hip fracture
- Bilateral knee replacements
- Ventral hernia
- Depression/post-traumatic stress disorder
- Left sided carotid bruit
- Cervical spondylosis, spinal stenosis
Social History:
Lives alone with home health care aide who visits. Recent fall
on [**3-19**] and prior pneumonia in [**Month (only) 404**] caused decline in her
ADLs - unable to feed self anymore and unsteady on feet,
requiring assistance to getting to her walker. Since her fall,
patient has become increasingly agitated and incoherent; was
recently started on Seroquel.
Family History:
Diabetes, arthritis
Physical Exam:
Vitals - T:98.5 BP:107/57 HR:50-68 RR:16 02 sat:100% on room air
GENERAL: not responsive to commands, eyes closed despite sternal
rubs. moans to pain stimuli.
HEENT: RIJ in place. Eyes closed. when opened, PERRL. No LAD.
CARDIAC: bradycardic, irregularly irregular, normal s1, s2, no
m/r/g
LUNG: clear from anterior
ABDOMEN: normoactive BS, soft, nondistended. Pt moans and
grimaces when abdomen was palpated.
EXT: No LE edema, no cyanosis, no clubbing.
NEURO: Not responsive to commands. PERRL. moans to pain
stimuli. moves all 4 extremities.
DERM: No skin rash.
On discharge:
Pt opens eyes, awake able to make requests. Able to follow some
commands.
Abdomen no longer tender.
Otherwise exam unchanged.
Pertinent Results:
[**2201-3-28**]
WBC-4.6 RBC-3.47* Hgb-9.9* Hct-30.7* MCV-88 MCH-28.5 MCHC-32.3
RDW-16.1* Plt Ct-104*
Glucose-124* UreaN-64* Creat-2.0* Na-147* K-4.4 Cl-107 HCO3-30
AnGap-14
ALT-69* AST-55* LD(LDH)-679* CK(CPK)-81 AlkPhos-70 TotBili-0.2
Lipase-66*
cTropnT-0.02*
Calcium-8.8 Phos-4.3 Mg-2.5
Hapto-143
TSH-4.2 T4-7.0 T3-73*
Lactate-2.0
FIBRINOGE-507*
PT-97.1* PTT-88.7* INR(PT)-12.0*
[**2201-3-30**]
WBC-6.5 RBC-3.19* Hgb-8.9* Hct-28.1* Plt Ct-94*
PT-17.5* PTT-38.9* INR(PT)-1.6*
Glucose-88 UreaN-29* Creat-1.4* Na-147* K-3.5 Cl-116* HCO3-26
AnGap-9
ALT-55* AST-46* CK(CPK)-64 AlkPhos-56 TotBili-0.3
Calcium-8.4 Phos-2.5* Mg-2.2
FDP-0-10
CT Brain Perfusion/ CTA Neck:
1. No acute hemorrhage or evidence of acute territorial
infarction, with no evidence of asymmetric perfusion.
2. Central and cortical involutional changes as expected for the
patient's
age of [**Age over 90 **] years.
3. Approximately 40% narrowing of the left internal carotid
artery origin by NASCET criteria. The remaining intra- and
extra-cranial arterial vasculature demonstrates no evidence of
flow-limiting stenosis.
4. Infundibulum at the junction of the A1 segment of the right
ACA and the
ACom vessel.
5. Chronic microvascular ischemic white matter disease.
CXR: Cardiomegaly, mild central congestion. Left basilar
atelectasis.
Limited exam.
CT Head: No evidence of hemorrhage or infarction. No evidence
of change
since a head CT of [**2201-3-28**].
Brief Hospital Course:
[**Age over 90 **] yof w hypertension, atrial fib, Alzheimer's and [**Last Name (un) 309**] Body
dementia who hypothermia, hypotension, bradycardia, and AMS.
.
#AMS - Ddx includes poor cerebral perfusion, oversedating
medications (seroquel), infection on underlying dementia. There
was no evidence of infection and no history of any toxin
ingestion. CTA of the head/neck could not explain her
somnolence. She is having some episodes of improvement at time
of discharge when she was she was alert and able to make
requests.
.
# Hypothermia: Resolved. Working differential includes sespis,
neurogenic hypothermia, ingestion. Less likely is adrenal
insufficiency, thiamine deficiency, hypoglycemia,
hypothyroidism. No evidence of infection. Monitoring on
telemetry was unremarkable.
.
# Coagulopathy: Patient presented with INR 12.0, which corrected
by time of discharge. Her PT/PTT also elevated also elevated.
She was given 10mg IV vitamin K. Thorough evaluation of
coagulation abnormalities was not evaluated further given pt's
overall poor prognosis as it was unlikley to change managemnet.
Pt's family expressly does not want pt to receive blood
transfusion.
# Hypotension: Resolved after rewarming. No evidence after
broad workup for infection, as stated above.
.
# Bradycardia: Resolved. Patient received atropine received in
the field. Her heart rate normalized, although she generally
remains slow. HR drops to high 30s during sleep and she
otherwise asymptomatic. Pt not to be paced if becomes
bradycardic, may receive atropine if necessary.
# Hypernatremia: Pt was hypernatremic on admission, improved
with free water boluses.
.
# Acute renal failure: improving with IVF. Likely pre-renal (on
lasix as outpt). Pt was discharged with prn lasix for signs of
volume overload such as increasing oxygen requirement,
respiratory distress, or lower extremity edema.
# Abd discomfort: Pt presented with abdominal discomfort. KUB
shows non obstructive gas pattern, but consistent with
constipation. She was initiated on a bowel regimen.
.
# Thrombocytopenia: Since hospitalization plt count 80-90s. DIC
workup in ICU negative. Platelets remained low but stable.
.
# Atrial fibrillation: Pt is afib with slow ventricular response
on tele. Coumadin was discontinued on this admission due to
high maintenance required with this medication. This is
consistent with the overall plan to focus on comfort care.
.
# Alzheimer and [**Last Name (un) 309**] Body Dementia: Pt was admitted on Aricept
which was discontinued to reduce unnecessary medications.
.
# Hypertension: Pt's blood pressure was low on admission. All
BP meds were held. They were discontinued prior to discharge to
reduce medications that are not directed towards comfort care.
.
# Diastolic CHF: Compensated currently. Cardiac medications
minimized to prn lasix.
.
# Degenerative joint disease/osteoarthritis: Tylenol and
Mortrin prn for pain control.
# Goals of care: Pt is DNR/DNI, with the understanding that pt
does not want advancement of care. Treatment should be focused
on comfort based care. Family would not want rehospitalization
without communication with health care proxy.
# Code: DNR/DNI
# Communication:
Daughter [**Name (NI) **] HCP [**Telephone/Fax (1) 96812**]
Son [**Name (NI) 18330**]: [**Telephone/Fax (1) 96813**]
[**Name2 (NI) **]-Daughter [**Name (NI) **]: [**Telephone/Fax (1) 96814**]
Medications on Admission:
* Coumadin 2.5mg Sat/Sun/Tues/Th, 5mg M/W/F
* Alendronate 35 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
* Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
* Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
* Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
* Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime))
* Detrol LA 2 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
* Trandolapril 4 mg Tablet Sig: One (1) Tablet PO twice a day.
* Multivitamin DAILY
* Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day)
* Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day
* Zinc Sulfate 220mg daily
* Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath.
* Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed
for agitation.
6. Motrin 400 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain.
7. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day as
needed for volume overload: please base on symptoms, physical
exam, and daily weights.
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) unit Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] healthcare
Discharge Diagnosis:
Primary:
hypothermia
hypotension
bradycardia
[**Last Name (un) **] body dementia
Secondary:
- Alzheimer and [**Last Name (un) 309**] Body Dementia (Dr. [**First Name (STitle) **] neurologist)
Hypertension
- Atrial fibrillation, on coumadin
- Urinary incontinence - detrusor instability
- Diastolic CHF
- Degenerative joint disease/osteoarthritis
- Right hip fracture
- Bilateral knee replacements
- Ventral hernia
- Depression/post-traumatic stress disorder
- Left sided carotid bruit
- Cervical spondylosis, spinal stenosis
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Lethargic but arousable
Discharge Instructions:
You were seen at [**Hospital1 18**] for low temperature. You were also noted
to have low blood pressure, and slow heart rate. No reason for
these was found, but you improved spontaneously. Your mental
status was initially quite poor, though improved on the day of
your discharge. Because of your recent worsening, your family
made a decision to focus on comfort.
You are going to a skilled nursing facility.
Followup Instructions:
please schedule an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] at [**Telephone/Fax (1) 250**]
in the next 2-3 weeks.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2201-4-27**] 10:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2201-7-22**] 10:50
Completed by:[**2201-4-1**]
ICD9 Codes: 5849, 2760, 4589, 4280, 311, 4019, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1909
} | Medical Text: Admission Date: [**2147-12-18**] Discharge Date: [**2147-12-29**]
Date of Birth: [**2094-1-28**] Sex: F
Service: MEDICINE
Allergies:
Oxaliplatin / Iodine Containing Agents Classifier /
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
nausea and emesis
Major Surgical or Invasive Procedure:
Bilateral Nephrostomy Tube Placement [**2147-12-19**]
History of Present Illness:
53 yo f with hx of metastatic colon CA, Spanish speaking, who
presented with n/v/d and was sent to ER for evaluation from her
oncologist. She has not been eating or drinking for last 5 days
due to n/v after returning from a trip to [**Country 7192**]. She has
been having abdominal pain, but does not like to take her
narcotics.
.
On the floor (interview not with interpreter at this time, so
limited) pt complains of pain in her abdomen, worse with
sitting. Some right sided chest dicomfort. States she has had
swelling her LLE for about 1 month, but no pain in her leg. She
is not currently having nausea, but had some this AM. She
reports urinating today with no pain, but a small amount of
blood.
.
VS on arrival were 97.4 101 181/104 18. Pt was found to have ARF
with Cr from 0.8 to 6.7 and hyperkalemic to 7.2. She has a known
mass compressing left ureter and now with a new compression of
the right ureter on CT scan. Urology was consulted and
recommended IR to place a percut nephrostomy tube. Pt was tx
with D50 and insulin, and kayexalate 30. Hypoglycemia ensued
after tx and she was given a [**11-26**] amp D50 with improvment of BS
to 105. K down to 5.5. IVF x 2 liters were given. Pt also had a
neg head CT. Right sided CP, negative LENI, concern for PE, pt
not anticoagulated in ER. No CTA due to Cr. PNA present on CT.
She was given ceft and azithro. VS at trasfer HR-106, SBP-142
16, 100% RA, BS 105.
.
Past Medical History:
- adenocarcinoma of distal sigmoid colon [**1-1**], s/p sigmoid
colectomy by Dr. [**Last Name (STitle) 1120**] on [**2144-2-17**]. T3 lesion measuring 7 cm x
6 cm x 4 cm,
low-grade, [**2-4**] lymph nodes were involved with cancer
- completed adjuvant chemotherapy with FOLFOX in 10/[**2143**]. CEA
continued to slowly rise from 7 in [**12/2145**] to 9.5 in [**2-/2146**]
to 18 in 08/[**2145**]. CT imaging demonstrated new left
hydronephrosis with a 10.4 cm prevertebral mass at the point of
the ureteral obstruction. PET scan in [**7-/2146**] confirmed disease
recurrence near the sigmoid anastomosis causing the ureteral
obstruction. She additionally had evidence of metastatic
disease to the mesentery and mesenteric nodes. She underwent
percutaneous nephrostomy tube placement on [**2146-12-8**]. [**Known firstname **]
completed two cycles of FOLFIRI and on CT [**2147-4-14**]
she had disease progression involving the known omental
metastases and innumerable pulmonary metastasis.
- admission for PE [**2147-4-17**] for inpatient anticoagulation.
- [**2147-6-20**]: Discussion for participation to a clinical trial
with Cisplatin / V1 inhibitor
- [**2147-7-21**]: left sided nephrostomy tube replacement
- [**7-/2147**]: nephrostomy tube removal
- [**2147-8-23**]: Start on Capecitabine
- Left hydronephrosis with 2.4 cm prevertebral mass at the point
of apparent ureteral obstruction in pelvis. Failed ureter stent
.
Social History:
She is married. She has two children. She used to work as a
cleaning person. She does not presently smoke cigarettes but did
smoke about two cigarettes per day for 20 years and quit three
yrs ago just prior to her surgery. She does not drink alcohol
Family History:
There is no family history of breast, ovarian or colon cancer.
Her mother died at age 75 of hypertension and cardiovascular
disease. Her father died at age 82 of a hemorrhagic stroke.
She has two brothers and five sisters. Two of those had uterine
cancer at the age of 49 and 40.
Physical Exam:
ON ADMISSION
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM,
RESP: CTA b/l with good air movement throughout
CV: tachy, S1 and S2 wnl, no m/r/g
ABD: distend, firm, tender to palpation, +BS
BACK: mild CVA tenderness
EXT: no c/c, 1+ pitting edema in LLE
SKIN: no rashes/no jaundice
NEURO: Moving all extremites, able to ambulate to commode.
.
ON DISCHARGE
Vitals 98.7 140/86 105 16 98%RA
I/O: R nephrostomy 500o/n, 950cc day prior, bathroom unrecorded
GEN: NAD, AOx3
HEENT: MMM, OP clear
CV: tachy, RR, nl S1S2 no MRG
PULM: CTA b/l
ABS: BS+, mildly tender to palpation, multiple masses palpated
throughout abdomen
BACK: Nephrostomies are c/d/i
EXT: 2+ DP/PT/radial pulses, no c/c/e
Pertinent Results:
Blood Counts
[**2147-12-18**] 11:23AM BLOOD WBC-11.2* RBC-3.73* Hgb-9.5* Hct-29.4*
MCV-79* MCH-25.5* MCHC-32.4 RDW-17.1* Plt Ct-424
[**2147-12-20**] 04:08AM BLOOD WBC-20.0* RBC-3.13* Hgb-8.1* Hct-24.9*
MCV-80* MCH-25.8* MCHC-32.4 RDW-17.9* Plt Ct-380
[**2147-12-26**] 05:25AM BLOOD WBC-12.4* RBC-3.64* Hgb-9.5* Hct-29.5*
MCV-81* MCH-26.2* MCHC-32.3 RDW-16.6* Plt Ct-415
.
Coags
[**2147-12-24**] 06:30AM BLOOD PT-13.2 PTT-24.0 INR(PT)-1.1
.
Chemistry
[**2147-12-18**] 11:23AM BLOOD UreaN-63* Creat-6.8*# Na-133 K-7.2*
Cl-95* HCO3-26 AnGap-19
[**2147-12-22**] 05:23PM BLOOD Glucose-114* UreaN-20 Creat-2.3* Na-144
K-2.5* Cl-106 HCO3-27 AnGap-14
[**2147-12-25**] 02:30PM BLOOD Glucose-94 UreaN-17 Creat-1.1 Na-137
K-3.9 Cl-102 HCO3-26 AnGap-13
[**2147-12-26**] 05:25AM BLOOD Glucose-95 UreaN-19 Creat-1.3* Na-135
K-4.1 Cl-101 HCO3-25 AnGap-13
.
Imaging
[**2147-12-18**] CXR
1. New small right pleural effusion, with right lower lobe
atelectasis or
consolidation.
2. Diffuse pulmonary nodular metastases.
.
[**2147-12-19**] CT Abd
1. Right lower lobe pneumonia and trace effusion.
2. Apparent increase in size and number of metastatic pulmonary
nodules at
the lung bases.
3. New heterogeneously hypodense liver. This could represent
fatty
infiltration, but congestive edema and/or diffuse metastases are
not excluded.
4. New mild-to-moderate right hydronephrosis, with incompletely
visualized transition point in mid right ureter, suggestive of
obstruction by peritoneal metastasis.
5. Chronic left moderate-to-severe hydronephrosis and atrophy,
secondary to obstruction by left L5 paravertebral mass.
6. Multiple prominent fluid-filled small bowel loops, suggestive
of ileus or partial obstruction secondary to increasing
mesenteric adhesions.
7. Diffuse omental and peritoneal implants.
8. Cholelithiasis.
9. Fibroid uterus.
.
[**2147-12-22**] Nephrostomy Tubes Placement
Bilateral ureteric stenoses, more prominent on the left side.
Satisfactory placement of bilateral nephroureteric stents (8
French x 24 cm). Patient would require routine stent change in
three months.
Brief Hospital Course:
HOSPITAL COURSE
53yo female with w metastatic colon cancer admitted with acute
ureteral obstruction secondary to metastasis, now status-post
bilateral percutaneous nephrostomy tube placement, hospital
course complicated by pyelonephritis and community acquired
pneumonia, treated with antibiotics, made comfort measures only,
discharged to home with hospice care
.
ACTIVE
# Acute Kidney Injury: Patient was admitted with a creatinine of
7.2 secondary to obstructive uropathy from compression by
peritoneal metastases. Patient underwent placement of bilateral
percutaneous nephrostomy tubes by IR [**2147-12-19**], and
nephrouretheral stents on [**2147-12-22**], after which the patient's
Cr trended down to 1.3. The patient had good UOP from right
urostomy, but poor output from L nephrostomy tube (<100cc/day)
which was thought to be secondary to known chronic
hydronephrosis. Urine cultures from L nephrostomy tube grew
MSSA, prompting antibiotic treatment with 5d augmentin and 14d
doxycycline. After 1wk abx, repeat culture was negative and the
L tube was capped. The R tube was not capped, given continued
high output from the R nephrostomy tube, thought to be secondary
to known compression of the bladder by peritoneal metastases.
.
# Community Acquired Pneumonia: Admission CXR demonstrated RLL
consolidation, for which the patient received 5d augmentin, 14d
doxycycline. At discharge patient was given script for
remainder of doxy course.
.
# Metastatic Colon Cancer: Primary issue during hospitalization
became pain [**12-27**] multiple metastases. Given poor prognosis,
patient decided to be made comfort measures only. With
palliative input, pain regimen of dilaudid and fentanyl patch
was started. Patient was discharged home with hospice care.
.
TRANSITIONAL
1. Code status: Patient was DNR/DNI for the duration of this
admission, and was converted to comfort measures only several
days prior to discharge
2. Pending: No labs pending at time of discharge
3. Transition of Care: Patient was scheduled for follow-up with
Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **] for [**1-22**]. Instructions for
nephrostomy tube maintenance were sent home with patient. IR
requested follow-up visit in 6-12weeks, decision regarding
scheduling necessity was deferred to outpatient oncologist.
Patient was discharged home with hospice care.
Medications on Admission:
-Docusate Sodium 100 mg PO BID
-Ondansetron 4 mg IV Q8H:PRN nausea
-Fentanyl Patch 25 mcg/hr TP Q72H
-Oxycodone SR (OxyconTIN) 30 mg PO Q12H
-Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
-Senna 1 TAB PO/NG [**Hospital1 **]:PRN constiapation
-HYDROmorphone (Dilaudid) 0.5 -1 mg IV Q2H:PRN pain
-Heparin 5000 UNIT SC TID
Discharge Medications:
1. Hospital Bed
Semi-electric hospital bed
Patient has a medical condition, which requires positioning of
the body, which is not feasible in an ordinary bed to alleviate
pain
Diagnosis: Peritoneal Carcinomatosis (ICD-9 158.8 Malignant
neoplasm of specified parts of peritoneum)
2. Bedside Comode
Patient is confined to a single room
Dx: ICD 9 code 158.8
3. Normal Saline Flush 0.9 % Syringe Sig: Two (2) flush
Injection once a day: for nephrostomy tube flushes.
Disp:*60 flushes* Refills:*3*
4. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
5. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*90 Tablet(s)* Refills:*2*
7. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 4 days.
Disp:*8 Capsule(s)* Refills:*0*
8. hydromorphone 4 mg Tablet Sig: 1.5 Tablets PO every 2 hours
as needed for pain.
Disp:*500 Tablet(s)* Refills:*0*
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
10. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
11. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for
insomnia.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
12. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
13. Reglan 10 mg Tablet Sig: One (1) Tablet PO QID with meals
and before bed.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY
Metastatic Colon Cancer
SECONDARY
Acute Kidney Injury Secondary to Obstruction status-post
Bilateral Nephrostomy Tube Placement
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:
Ms. [**Known lastname **]:
.
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for treatment of kidney
failure. This was caused by tumors blocking your urine from
leaving your kidneys. You had nephrostomy tubes placed to drain
the urine, and then had stents placed to help prevent blockage
of your kidneys. You are now stable and being discharged home
to be with your family. You will have visiting nurses to help
care for you.
.
During this hospitalization, you decided to focus on treating
your pain, so WE STOPPED ALL PREVIOUS MEDICATIONS, and started
the following medications:
- Colace for constipation
- Senna for constipation
- Fentanyl for pain
- Dilaudid for pain
- Compazine for nausea
- Zofran for nausea
- Reglan for nausea
- Ativan for sleep
- Olanzapine for sleep
- Doxycycline (for 4 days) for infection
.
Please see below for your recommended follow-up appointments
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2148-1-22**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
ICD9 Codes: 486, 5849, 2760, 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1910
} | Medical Text: Admission Date: [**2112-3-14**] Discharge Date: [**2112-3-31**]
Date of Birth: [**2057-8-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
lightheadedness, chest discomfort
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting (CABGx3)[**3-16**]
History of Present Illness:
54 yoM w/ a h/o CAD s/p stent->LAD in [**2102**], htn, hyperlipidemia,
and strong family history of CAD who p/w 48 hours of
lightheadedness and chest discomfort. Given these symptoms, his
wife brought him to [**Name (NI) 2079**] [**Name (NI) **]. At [**Name (NI) 2079**], ECG showed TW
inversions in ant leads and bradycardia in the 40s. Cardiac
enzyme were elevated w/ trop 0.29, CK 725, MB 71. Transfer was
arranged to [**Hospital1 18**] for potential cath.
Past Medical History:
Dyslipidemia, Hypertension, Percutaneous coronary intervention,
in [**2102**] w/ stent to LAD at [**Hospital6 **].
Social History:
Denies any tobacco, EtOH or illicit drug use. Works as a nurse
for an insurance company for the last year.
Family History:
His father and brother both died of MIs at age 48.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 97.3, BP 100/57, HR 60, RR 25, O2 95% on 2LNC
Gen: middle aged male in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL, EOMI. no pallor or cyanosis of
the oral mucosa.
Neck: Supple no JVd
CV: RR, normal S1, S2. No S4, no S3.
Chest:CTA
Abd: +BS, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without
bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Discharge
VST 99 HR 84 BP 124/70 RR 20 02sat 94%RA
Gen NAD
Neuro A&Ox3, nonfocal exam
CV RRR no M/R/G
Pulm CTA-bilat
Abdm soft, NT/+BS
Ext warm palpable pulses. Trace edema-bilat
Pertinent Results:
ADMISSION LABS:
[**2112-3-14**] 08:35PM BLOOD WBC-10.2 RBC-4.44* Hgb-14.6 Hct-41.5
MCV-93 MCH-32.8* MCHC-35.1* RDW-13.0 Plt Ct-227
[**2112-3-14**] 08:35PM BLOOD Neuts-76.2* Lymphs-17.1* Monos-5.6
Eos-0.7 Baso-0.4
[**2112-3-14**] 08:35PM BLOOD PT-14.3* PTT-137.7* INR(PT)-1.2*
[**2112-3-14**] 08:35PM BLOOD Plt Ct-227
[**2112-3-14**] 08:35PM BLOOD Glucose-109* UreaN-15 Creat-1.0 Na-143
K-5.0 Cl-110* HCO3-22 AnGap-16
[**2112-3-14**] 08:35PM BLOOD CK(CPK)-1145*
[**2112-3-14**] 08:35PM BLOOD CK-MB-147* MB Indx-12.8*
[**2112-3-14**] 08:35PM BLOOD cTropnT-0.84*
[**2112-3-15**] 03:54AM BLOOD Calcium-7.2* Phos-3.9 Mg-1.7 Cholest-92
[**2112-3-15**] 03:54AM BLOOD Triglyc-48 HDL-31 CHOL/HD-3.0 LDLcalc-51
[**2112-3-15**] 09:35AM BLOOD Type-ART pO2-80* pCO2-30* pH-7.46*
calTCO2-22 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
CXR: No acute cardiopulmonary process
[**2112-3-15**] TTE:
The left ventricular cavity is mildly dilated. LV systolic
function appears depressed with inferior, inferolateral and
apical hypokinesis/?akinesis (however views suboptimal;
estimated ejection fraction ?35-40). Right ventricular chamber
size is normal. with normal free wall contractility. The aortic
valve leaflets are mildly thickened. The aortic valve is not
well seen. There is no aortic valve stenosis. No aortic
regurgitation is seen. No mitral regurgitation is seen. There is
no pericardial effusion.
[**2112-3-15**] Cardiac Catheterization:
1. Coronary angiography of this right dominant system revealed
3 vessel
coronary artery disease. The LMCA had a 60% distal ulcerated
lesion.
The LAD had a widely patent previously placed stent. The origin
of the
LCx had an 80% stenosis. The proximal RCA was 90% stenosed,
with a 100%
distal RCA occlusion and left to right collaterals.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures, with RVEDP and LVEDP of 20 and 27 mm Hg,
respectively. Mean
PCWP was elevated at 19 mm Hg. Systemic arterial pressures were
low
with aortic systolic pressure of 92 mm Hg and mean arterial
pressure of
64 mm Hg. Cardiac index was 3.07 l/min/m2.
3. Left ventriculography revealed no mitral regurgitation and a
large
area of anteroapical and inferoapical dyskinesis. Estimated
left ventricular ejection fraction was 35%.
4. 40 cc IABP was placed in the setting of extensive myocardial
infarction, hypotension, and impending CABG.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2112-3-27**] 1:30 PM
CHEST (PORTABLE AP)
Reason: ?pneumonia
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with altered mental status, wbc 14.4 (?
infiltrate)
REASON FOR THIS EXAMINATION:
?pneumonia
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Elevated white blood count and altered mental
status.
Comparison is made with prior study [**2112-3-22**].
Mild cardiomegaly is accentuated by low lung volumes, unchanged
from prior study. The patient has been extubated. There is no
pneumothorax. The right lung is clear. There is a small left
pleural effusion. Ill-defined opacity in the left base is
persistent, could be atelectasis or pneumonia. Patient is post
median sternotomy and CABG.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
MC [**Last Name (LF) **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 100119**]
(Complete) Done [**2112-3-16**] at 12:08:58 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2057-8-27**]
Age (years): 54 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG with IABP
ICD-9 Codes: 410.92, 440.0, 424.0, 424.2
Test Information
Date/Time: [**2112-3-16**] at 12:08 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: Suboptimal
Tape #: 2008AW4-: Machine: B-[**Numeric Identifier **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - LVOT diam: 2.4 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. All four pulmonary veins identified and
enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV cavity size. Mild-moderate
regional LV systolic dysfunction. Moderately depressed LVEF.
RIGHT VENTRICLE: Focal apical hypokinesis of RV free wall.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Simple
atheroma in aortic arch. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. The patient appears to be in sinus rhythm. Results were
Conclusions
PRE CPB No spontaneous echo contrast or thrombus is seen in the
body of the left atrium/left atrial appendage or the body of the
right atrium/right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. The left ventricular cavity size is
normal. There is mild to moderate regional left ventricular
systolic dysfunction with apical severe hypokinesis/akinesis. No
apical thrombus is seen. Overall left ventricular systolic
function is mildly to moderately depressed (LVEF= 40 %). The
right ventricle displays normal mid and basal function with mild
to moderate focal hypokinesis of the apical free wall. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion. An intra-aortic balloon pump is seen in
the descending aorta with its tip 2 cm below the distal aortic
arch.
POST-CPB The focal wall abnormalities noted in the pre-bypass
study are unchanged. The mitral regurgitation may be slightly
improved. No other significant changes.
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) **] [**2112-3-16**] 15:29
[**2112-3-29**] 06:30AM BLOOD WBC-14.8* RBC-3.45* Hgb-10.5* Hct-30.3*
MCV-88 MCH-30.4 MCHC-34.6 RDW-14.4 Plt Ct-846*
[**2112-3-29**] 06:30AM BLOOD Plt Ct-846*
[**2112-3-27**] 03:10AM BLOOD PT-15.8* PTT-22.9 INR(PT)-1.4*
[**2112-3-29**] 06:30AM BLOOD Glucose-102 UreaN-22* Creat-0.8 Na-137
K-4.0 Cl-103 HCO3-22 AnGap-16
Brief Hospital Course:
Admitted as transfer from [**Hospital6 33**] with acute MI on
[**3-14**]. Brought to cath lab on [**3-15**] found to have left main and
2VD/EF 35%. Intra Aortic Ballon Pump placed at that time. CT
surgery consulted and patient brought to operating room on [**3-16**]
for coronary artery bypass grafts. Patient tolerated the surgery
well and [**Hospital 19692**] transferred to the cardiac surgery ICU in stable
condition. He remained intubated and hemodynamically stable on
the day of surgery. On POD1 the IABP was weaned and removed,
after which his sedation was stopped. An attempt to wean from
ventilator was unsuccessful. On POD2 he was again weaned and
extubated however required reintubation because of agitation.
Neurology and psychiatry were consulted. The patient had ahead
CT that was negative as well as an MRI and Lumbar puncture that
were also negative. Over the next several days his neuro status
cleared and he was successfully extubated. He did remain
delerious for several additional days but was ultimately
transferred to the stepdown floor on POD 12. The patient also
experienced a Gout flare during this time, rheumatology was
consulted and he was started on Colchicine and Indocin. Over the
next several days he continued to make slow progress in his ADL
and ambulation and on POD 15 it was decided he was stable and
ready for discharge to [**Hospital 38**] Rehab. He will followup with Dr
[**Last Name (STitle) **] in 4 weeks
Medications on Admission:
atenolol 50 mg daily
lisinopril 20 mg daily
lipitor 10 mg daily
aspirin 325 mg daily
niacin 500 mg daily
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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) as needed.
10. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
s/p CABGx3(LIMA-LAD, SVG-OM, SVG-RCA)[**3-16**]. Post-op delerium
PMH: CAD s/p MI-stent LAD w/IABP, HTN, ^chol, Piloneal cyst
removal,Tonsillectomy
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
wound check in 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks
Dr [**First Name (STitle) 5936**] in [**4-12**] weeks
Completed by:[**2112-3-31**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1911
} | Medical Text: Unit No: [**Numeric Identifier 76206**]
Admission Date: [**2105-11-25**]
Discharge Date: [**2105-11-27**]
Date of Birth: [**2105-11-25**]
Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname **] is twin #2, born at 2315 gm, the
product of a 36-1/7 week pregnancy, born to a 35-year-old G1,
P0, now 2 mother, with prenatal screen, blood type O+,
antibody negative, RPR nonreactive, rubella immune, HBSAG
negative, GBS unknown. This pregnancy was complicated by twin-
to-twin transfusion with this twin being the recipient twin.
There was oligohydramnios in Twin A. Mom has a history of
depression. Labor was otherwise uncomplicated. There was no
fever. Rupture of membranes was at delivery with clear fluid
and no increased fetal heart rate. This infant was born by C-
section because of oligohydramnios. This infant emerged
active, vigorous, and crying, was dried, bulb suctioned, and
was given blow-by O2 in the delivery room. He was noted to be
persistently cyanotic and transported to the NICU on oxygen.
Apgar scores were 8 and 5 at 1 and 5 minutes. Weight at birth
was 2315 gm, which is 25th percentile. Head circumference was
32.5 cm, which is 25th-50th percentile. Length 46 cm, which
was 25th to 50th percentile.
PHYSICAL EXAMINATION: HEENT: Normocephalic. Anterior
fontanelle open and flat. Intact red reflex bilaterally.
Lungs clear and equal with slight retraction. CV: Regular
rate and rhythm. No murmur. Femoral pulses 2+ bilaterally.
Abdomen: Soft with active bowel sounds. No masses or
distention. GU: Normal male with testes descended
bilaterally. Spine midline, no sacral dimple. Hips stable.
Clavicles intact. Anus patent. Neurological: Good tone. Moves
all extremities equally and well. Extremities warm and well
perfused, pink with good capillary refill. Reflexes intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: The infant has remained on room air since
admission to the NICU and had brief transitional
grunting, flaring, and retracting which resolved on the
newborn day.
2. Cardiovascular: The infant has maintained cardiovascular
stability while in the NICU, and is ruddy and well
perfused with normal heart rates and blood pressures,
and no murmur present.
3. Fluid, electrolytes, and nutrition: The infant was
started on IV fluids on admission to the NICU due to
transitional respiratory issues. The D-stick initially
was 46. A follow up 2 hour later was 34. Due to the D-
stick of 34 and the hypoglycemia, the infant was started
on VI fluids at that time and given a D10W bolus. D-
sticks have been stable since. The infant was started on
enteral feedings on day 1 of IV fluids. There were 2
borderline ACD sticks. The ACD sticks were resolved and
within normal limits prior to the infant being
transferred to the newborn nursery. The infant is
presently ad lib p.o. feeding, Enfamil 20 calories per
ounce, or breastfeeding. Most recent weight is 2315 gm
on [**2105-11-26**]. No electrolytes have been measured
on this baby.
4. GU: bilirubin was done on [**2105-11-27**]. Result is
12.6
5. Hematology: No blood typing has been done on this
infant. Hematocrit at birth was 57 with a platelet count
of 186,000. No further hematocrits or platelets have
been measured.
6. Infectious disease: The CBC and blood culture were
screened on to the NICU due to the transitional
respiratory distress. The CBC was benign with no left
shift. Blood cultures remains to date. The infant was
not started on any antibiotic therapy.
7. Neurologic: The infant has maintained a neurologic exam
for gestational age.
8. Sensory: Audiology, a hearing screen will need to be
performed with automated auditory brainstem responses
prior to discharge from the hospital. It has not been
done thus far.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to the newborn nursery.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 2429**] [**Name (STitle) 4135**]
CARE RECOMMENDATIONS: Ad lib p.o. feedings of Enfamil 20
calories per ounce or breastfeeding.
MEDICATIONS: None.
IRON AND VITAMIN D SUPPLEMENTATION:
1. Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age.
2. All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 International units,
which may be provided as multivitamin preparation daily
until 12 months' corrected age.
Car seat position screening is recommended prior to discharge
from the hospital due to gestational age of 36-1/7 weeks at
birth.
IMMUNIZATIONS RECEIVED: The infant has not received any
immunizations thus far.
IMMUNIZATIONS RECOMMENDED:
1. Synergis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria: (1) Born at less than 32 weeks'
gestation; (2) Born between 32 and 35 weeks with 2 of
the following: Either day care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school siblings; (3) Chronic lung
disease; or (4) Hemodynamically significant congenital
heart defect.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
3. This infant has not received the Rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following discharge
from the hospital if they are clinically stable and at
least 6 weeks but fewer than 12 weeks of age.
Follow-up appointment is recommended with the pediatrician
after discharge from the hospital.
DISCHARGE DIAGNOSES:
1. Prematurity, born at 36-1/2 weeks gestation.
2. Twin gestation.
3. Twin-to-twin transfusion syndrome.
4. Sepsis ruled out.
5. Transitional respiratory distress, resolved.
6. Hypoglycemia, resolved.
[**First Name8 (NamePattern2) 73452**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 73453**]
Dictated By:[**First Name3 (LF) 76207**]
MEDQUIST36
D: [**2105-11-26**] 20:05:05
T: [**2105-11-26**] 20:52:19
Job#: [**Job Number 29568**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1912
} | Medical Text: Admission Date: [**2115-11-17**] Discharge Date: [**2115-11-24**]
Date of Birth: [**2073-6-1**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Latex
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
GIB, hematemesis
Major Surgical or Invasive Procedure:
EGD with esophageal varices sclerosis
History of Present Illness:
42 year old female with h/o cholangiocarcinoma dx in [**2112**] s/p
resection, with recent CT showing met cholangiocarcinoma in
9/[**2115**]. Pt was recently admitted for fever due to cholangitis on
[**11-8**] and had chemo (CDDP and Gemcitabine) on Monday, [**11-11**].
Since chemo pt has intermittent nausea adequately controlled by
zofran and compazine. Pt was doing well till night of admission
when she developed nausea/ vomitting and sizable amount of
hemoptysis and clots. Has low grade fever since chemo but
otherwise ROS was neg for shaking chills, chest pain, SOB,
coughing, constipation, diarrhea, tarry stools, abd pain. Pt
has reported gaining 30lbs since [**9-21**] due to ascites.
In ED: vitals: T98.8 P98 BP136/68 R29 Sat 98% RAPt had NG lavage
which evantually cleared up, also was transfused 1U PRBC, GI
consult called, also got zofran and iv protonix.
Past Medical History:
1. Ca Hx-Klatskin tumor originally diagnosed [**9-/2112**] after
presenting with painless jaundice. [**2112-10-21**] pt underwent ex. lap
with en bloc resection of L liver lobe, biliary tree, and portal
vein. Reconstructed portal vein followed by Roux-en-Y
hepaticojejunostomy. Per notes, pathology demonstrated biliary
ductal adenocarcinoma
(T3N0M0) stage [**Doctor First Name **]. Since presentation, patient had multiple
episodes of cholangitis([**8-27**] in past 3 years with last on
[**11-8**]), always short lived and treated with antimicrobial
therapy. She has been on
ciprofloxacin proph for about 1 year. Followed with yearly
abdominal CT without radiographic progression. CAT scan was
performed on [**2115-10-11**] at [**Hospital3 2358**], which revealed that she
had a recurrence of the tumor with occlusion of her portal vein
occluding bile ducts, hepatic artery nearly completely occluded,
and much ascites and was started on diuretics. She was was seen
at [**Hospital1 18**] heme/on clinic [**10-30**] and had repeat CT scan which
revealed metastatic
cholangiocarcinoma with mets to the ovaries, with tremendous
increase in metastatic disease. There was there was obstructive
uropathy on the right side, as well as questionable gastric
outlet obstruction and peritoneal carcinomatosis.
2. cholecystectomy at age 25
3. MVA-multiple orthopedic procedures
4. Strabismus
Social History:
She is a nurse [**First Name (Titles) **] [**Hospital6 204**]. She
denies any alcohol, drugs or tobacco. She lives in [**Hospital1 487**] with
her mom. She is single, no children.
Family History:
Her maternal grandmother had breast cancer in
her 80s and her dad's grandmother had stomach cancer and died in
her 50s. On her mom's side is an extensive family cardiac
history.
Physical Exam:
VITAL: afebrile, 96, 108/51, O2sat99%RA
GENERAL: pleasant female in no apparent distress, jaundiced
skin.
HEENT: sclera icteric, OP clear, EOMI, PERRL.
NECK: Supple.
NODES: No supraclavicular, submandibular, axillary or inguinal
lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate, s1 s2 .
ABDOMEN: soft and distended, but no actual tenderness. Guaiac
neg by ED
BACK: No CVA tenderness.
EXTREMITIES: No clubbing, cyanosis, but +edema.
Pertinent Results:
[**2115-11-17**] 01:30AM GLUCOSE-112* UREA N-14 CREAT-0.8 SODIUM-133
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17
[**2115-11-17**] 01:30AM ALT(SGPT)-149* AST(SGOT)-83* ALK PHOS-663*
AMYLASE-37 TOT BILI-8.2*
[**2115-11-17**] 01:30AM LIPASE-42
[**2115-11-17**] 01:30AM IRON-52
[**2115-11-17**] 01:30AM calTIBC-230* FERRITIN-197* TRF-177*
[**2115-11-17**] 01:30AM WBC-3.0* RBC-2.25* HGB-7.2* HCT-20.9* MCV-93
MCH-31.8 MCHC-34.3 RDW-14.7
[**2115-11-17**] 01:30AM NEUTS-79.7* BANDS-0 LYMPHS-13.3* MONOS-4.6
EOS-2.2 BASOS-0.2
[**2115-11-17**] 01:30AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2115-11-17**] 01:30AM PLT COUNT-88*
[**2115-11-17**] 01:30AM PT-13.4 PTT-25.9 INR(PT)-1.1
[**2115-11-17**] 01:30AM RET AUT-0.3*
[**2115-11-17**] 01:30AM URINE COLOR-Amber APPEAR-SlHazy SP [**Last Name (un) 155**]-1.025
[**2115-11-17**] 01:30AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-LG UROBILNGN-0.2 PH-5.5 LEUK-NEG
[**2115-11-17**] 01:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-[**3-22**] RENAL EPI-0-2
[**2115-11-17**] 01:30AM URINE HYALINE-0-2
CT abd on [**2115-11-7**] showed: 1. Recurrent cholangiocarcinoma, with
intrahepatic bile duct dilatation and gastric outlet
obstruction; exact extent of disease is unclear, but likely
extensive. No evidence of portal hypertension is seen. 2. Large,
cystic, multiseptated mass arising from the adnexa, worrisome
for second primary malignancy.
3. Ascites, and intraperitoneal carcinomatosis, which can arise
from either of the two processes described above. 4. Hiatal
hernia.
[**2115-11-24**] 07:30AM BLOOD WBC-2.2* RBC-3.09* Hgb-9.6* Hct-28.7*
MCV-93 MCH-31.2 MCHC-33.6 RDW-17.0* Plt Ct-89*
[**2115-11-21**] 06:00AM BLOOD Neuts-89.7* Bands-0 Lymphs-6.9* Monos-2.6
Eos-0.2 Baso-0.7
[**2115-11-24**] 07:30AM BLOOD PT-15.2* PTT-29.7 INR(PT)-1.5
[**2115-11-24**] 07:30AM BLOOD Glucose-117* UreaN-11 Creat-0.9 Na-135
K-3.5 Cl-97 HCO3-28 AnGap-14
[**2115-11-24**] 07:30AM BLOOD AlkPhos-431* TotBili-7.8*
[**2115-11-24**] 07:30AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9
[**2115-11-17**] 01:30AM BLOOD calTIBC-230* Ferritn-197* TRF-177*
Brief Hospital Course:
1) GI - In the [**Name (NI) **] pt had Hct of 20 and bloody NG lavage which
did not clear. She was transfused 1U PRBC, GI consult called,
also got zofran and iv protonix and admitted to the [**Hospital Unit Name 153**]. On
arrival to unit pt had EGD which revealed grade III esophageal
varices with signs of old bleeding. She was started on
octreotide and nadolol to control portal htn. Pt was stable
and had appropriate Hct bump to 25 after 2U PRBC's.
She also had climbing bilirubin and low grade temp and was
started on Zosyn for suspected biliary obstruction and ascending
cholangitis coverage. She was rescoped on [**11-18**] and varices were
sclerosed(no banding due to latex allergy) and diuretics of
lasix and aldactone were readded for ascites since BP stable.
[**11-19**] she was transfused another 3U PRBC's with hct bump to 31.9
and antibiotic coverage broadend to Unasyn, Ceftriaxone, Flagyl
because she continued to spike, and for SBP prophylaxis.
Preprocedure of PTC on [**11-20**] she was transfused 1 unit PRBC's, 2
platelets and 2U FFP and procedure went without complication.
ON transfer to the floor she remained hemodynamically stable
with stable Hct and declining bilirubin. She remained afebrile
so on [**11-23**] antibiotic regimen was weaned to only levofloxacin.
Liver teams recommended to repeat EGD with non latex banding in
[**7-27**] days. She also went home on naldolol 20mg qd for portal
htn, and her home doses of diuretics to control her ascites.
2. US finding- Pt was incidentally found to have R
hydronephrosis and a R adenexal mass on her US. The
hydronephrosis was likely caused by blockage by her tumor.
Given her disease prognosis and the fact that her other kidney
is functioning well, no intervention was done. Also the
adenexal mass may represent a second primary maligancy. This
was seen on a prior CT scan and her [**Date Range 5564**] is aware. Again
given the patient's poor disease prognosis, there was no
intervention made at this time.
Medications on Admission:
MEDICATIONS: She is on Lasix 40 mg p.o. b.i.d., Aldactone 25 mg
p.o. b.i.d., Prilosec 20 mg p.o. daily, ciprofloxacin 250 mg
p.o.
daily, this is for prophylaxis for cholangitis and iron.
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
6. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO four
times a day: Swish and swallow.
Disp:*qs mL* Refills:*2*
8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please have CBC and alkaline phosphatase and total bilirubin
checked on Monday [**11-25**]
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital1 487**]
Discharge Diagnosis:
Cholangiocarcinoma
Biliary obstruction
Grade III esophageal varices
Discharge Condition:
Stable.
Discharge Instructions:
Call your primary care doctor, [**Hospital1 5564**], or return to the
Emergency Room if you have increasing nausea, vomiting, leg
swelling, confusion, or pain.
Followup Instructions:
Please follow up at all scheduled appointments including
Wednesday in [**Hospital **] clinic. Call the [**Hospital **] clinic on Monday to confirm
your appointment: [**Telephone/Fax (1) 53981**]. Ask to speak with [**Month (only) 116**] [**Doctor Last Name **], PA.
Call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 5564**] for follow up
appointments. You will have a banding procedure in 9 days.
Please call the [**Hospital **] clinic and arrange to see Dr. [**Last Name (STitle) 2161**] for an
appointment: [**Telephone/Fax (1) 1954**].
ICD9 Codes: 2851, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1913
} | Medical Text: Admission Date: [**2123-9-13**] Discharge Date: [**2123-9-20**]
Date of Birth: [**2071-4-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2123-9-13**] - CABGx2 (Left internal mammary artery to the left
anterior descending artery, vein graft to the obtuse marginal
artery); Mitral Valve Replacement (27mm [**Company 1543**] Mosaic Tissue
Valve); Diagnostic Cardiac Catheterization
History of Present Illness:
52 year old female with IDDM and CAD who ruled in for an MI in
[**2123-5-25**]. Work-up revealed severe left main and three vessel
disease. An echo showed moderate mitral valve regurgitation. Her
surgery was originally delayed due to uterine bleeding which was
caused by endometriosis. She now presents for surgical
management of her coronary arerty disease.
Past Medical History:
IDDM
Hyperlipidemia
HTN
PVD s/p Right Fem-[**Doctor Last Name **] Bypass
CAD
MI
Uternine bleeding d/t endometriosis s/p Endometrial ablation.
Depression
Social History:
Married and lives in [**State 108**]. 25 pack year smoking hostory
quitting in [**2123-2-25**]. Denies alcohol use.
Family History:
Noncontributory
Physical Exam:
PE: middle aged female, chronic-ill appearing. lying in bed. NAD
T Afeb BP 112/62 P 68
skin: Warm, dry, No C/C/E
lymph: not palpable at cervical region
HEENT: oral mucosa dry
neck: supple, no JVD, no thymomegaly
chest: lungs CTAB
CVS: RRR, quiet late systolic I/VI murmur
abd: soft, NT, BS normal
ext: No edema bilaterally, distal pulses decreased bilaterally.
Right GSV harvaest. Left appears suitable.
neuro: nonfocal
Pertinent Results:
[**2123-9-13**] ECHO
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are mildly
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Moderate to severe (3+)
mitral regurgitation is seen. The MR jet is directed
posteriorly. Moderate [2+] tricuspid regurgitation is seen.
There is no pericardial effusion.
Post-CPB: Patient is on phenylephrine gtt. A well-seated and
functional mitral prosthesis is seen with no MR [**First Name (Titles) **] [**Last Name (Titles) **]-valvular
leak. Good RV systolic fxn. Moderate LV depression, with EF35 -
40%. Aorta intact. Other parameters as pre-bypass.
[**2123-9-16**] CXR
Small bilateral pleural effusions, greater on the left side, are
unchanged. Left lower lobe retrocardiac opacity consistent with
atelectasis is persistent. There has been mild increase in right
lower lobe opacity consistent with atelectasis. Postoperative
cardiomediastinal silhouette is unchanged. There is no
pneumothorax. Right IJ line and chest tubes have been removed.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2123-9-13**] for surgical
management of her coronary artery disease. She was taken
directly to the operating room where she underwent a cardiac
catheterization followed by coronary artery bypass grafting to
two vessels and a mitral valve replacement using a 27mm
[**Company 1543**] Mosaic Tissue Valve. Postoperatively she was
transferred to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Mrs. [**Known lastname **] awoke
neurologically intact and was extubated. She was transfused a
unit of red blood cells for postoperative anemia. She was slow
to wean from pressors. Eventually she was resumed on her beta
blockade and a statin. On postoperative day three, she was
transferred to the step down unit for further recovery. Mrs.
[**Known lastname **] was gently diuresed towards her preoperative weight. Her
blood sugars were difficult to control and the [**Last Name (un) 387**] diabetes
service was consulted for assistance in her care. Appropriate
changes were made to her insulin regimen. The physical therapy
service was consulted for assistance with her postoperative
strength and mobility. Mrs. [**Known lastname **] had episodes of confusion
postoperatively which slowly resolved during her postoperative
course. Haldol was used as needed with good effect. The [**Last Name (un) **]
diabetes service continued to aggressively manage her blood
sugars as they were labile. Mrs. [**Known lastname **] continued to make steady
progress and was discharged home on postoperative day seven. She
will follow-up with Dr. [**Last Name (STitle) 1290**], her cardiologist and her
primary care physician as an outpatient.
Medications on Admission:
Lantus 40units Qday
humalog s/s
Lipitor 40mg one tablet daily
Capoten 25mg 1 tablet twice a day for hypertension
Paxil 40mg
Neurontin 100mg
Trazodone 100mg 3 po qhs
Klonopin 1mg 1 [**1-26**] po qhs
Aspirin 81mg
Iron once daily
Zetia 10mg one daily
Norethindrone Acetate 5mg one daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Paroxetine HCl 10 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily). Tablet(s)
5. Insulin Glargine 100 unit/mL Solution Sig: as dir
Subcutaneous at bedtime.
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Toprol XL 100 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:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
10 days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
14. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Greater [**Hospital1 189**]
Discharge Diagnosis:
CAD s/p CABG
IDDM
PVD s/p Right Fem-[**Doctor Last Name **] Bypass
HTN
Hyperlipidemia
Uterine bleeding
Hypothyroid
MI
MR
[**Name13 (STitle) 19458**] disease
Discharge Condition:
Good.
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-26**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 19459**] in 2 weeks. [**Telephone/Fax (1) 19460**]
[**Hospital Ward Name 121**] 2 wound clinic as instructed.
Please call all providers for appointments.
Completed by:[**2123-9-20**]
ICD9 Codes: 4240, 3572, 4019, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1914
} | Medical Text: Admission Date: [**2126-8-3**] Discharge Date: [**2126-8-29**]
Date of Birth: [**2126-7-29**] Sex: F
Service: Neonatology
ID: [**Known firstname 37958**] Girl [**Known lastname **] is a 1 month old former 36 [**5-23**] wk twin with a
history of intraventricular hemorrhage and seizures who is being
discharged from the [**Hospital1 18**] NICU.
HISTORY: [**Known firstname 37958**] Girl [**Known lastname **] was born on [**2126-7-29**] at [**Hospital6 **] as the 1860 gram product of a 36 and [**5-23**] week twin
gestation to a 39 year-old, G1 P0 to 2 mother. Maternal prenatal
screens: Blood type B negative, antibody negative, hepatitis
surface antigen negative, Rubella immune, RPR nonreactive, and
GBS negative. Pregnancy complicated by IVF dichorionic,
diamniotic twin gestation, and was also notable for advanced
maternal age and gestational diabetes which was diet
controlled. Mother presented on date of delivery with
spontaneous rupture of membranes of twin A. Twin B was
breech presentation, which prompted Cesarean section
delivery. Rupture of membranes of twin B was at delivery. In
the delivery room, twin B was noted to be hypotonic with
respiratory distress. Blow-by oxygen and stimulation was
provided and Apgars were assigned of 7 and 8.
HISTORY OF HOSPITAL COURSE AT [**Hospital6 **]:
Initial hospital course at [**Hospital **] Hospital was notable for:
- Discordant twin size, with this twin growth restricted at less
than 10th percentile and other twin appropriate size for
gestational age;
- Mild respiratory distress and oxygen requirement that resolved
over first 12 hours of life, most consistent with TTN;
- Initial hypoglycemia, treated with intravenous glucose with a
maximum of D-15 concentration;
- Polycythemia with variable hematocrit values, with initial
hematocrit of 64% and reaching 73% by day of life 3, prompting
partial exchange transfusion;
- Mild thrombocytopenia with platelet counts 70-80s, diminishing
to 50s following exchange transfusion;
- Sepsis evaluation on two occasions, with initial treatment with
ampicillin and gentamicin and subsequent reinitation of
ampicillin and cefotaxime, with both blood cultures negative;
- Mild hypocalcemia, which resolved;
- Mild hyperbilirubinemia which treated with phototherapy (infant
blood type B-, coombs -).
On day of life 5, infant was noted to have generalized tonic
clonic seizure activity. She was loaded with phenobarbital, and
transferred to the [**Hospital1 18**] NICU. Head CT performed shortly after
admission to [**Hospital1 **] revealed a large right intraventricular
hemorrhage with parenchymal involvement.
PHYSICAL EXAMINATION: On admission to [**Hospital1 190**], physical examination revealed the following:
General: SGA white female, quiet, asleep but responsive with
good tone. Well perfused but pale pink, mild jaundice.
Normal caput. Anterior fontanel soft, flat, sutures not
split. Eyes with moderate dilatation of pupils but reactive
to light. Red reflex present bilaterally. Good facial
muscular tone. Ears, nose, mouth appear within normal
limits. Neck within normal limits. Chest: Clear breath
sounds, regular respirations with good respiratory effort.
Cardiovascular: S1 and S2, within normal limits. No murmur.
Pulses within normal limits in all extremities. Abdomen
soft, nontender. Right upper quadrant mass, distinct from
liver, egg-shaped, palpable, no apparent hepatosplenomegaly.
Full abdomen, non tense. Normal female genitalia with
edematous labia. Anus patent. Back within normal limits.
Skin: No apparent petechiae, bruising, purpura on
examination, except evidence of site of multiple needle
sticks, no apparent bleeding. Neurologic examination on
admission: Sleepy, quiet, status post loading dose of
Phenobarbital but very responsive to examination. Good tone.
Normal reflexes. Normal posture.
HISTORY OF HOSPITAL COURSE AT [**Hospital3 **]:
1. Respiratory: The infant was stable throughout admission,
breathing comfortably in room air without apnea or desaturation
episodes.
2. Cardiovascular: The infant was stable throughout admission,
without evidence of hemodynamic instability.
3. Fluids, electrolytes and nutrition: Birth weight was 1860
grams. Admission weight to the [**Hospital1 188**] was [**2116**] grams. Her discharge weight is 2395 grams. On
admission to [**Hospital1 69**], the infant was
initially maintained NPO and on IVF. Serum chemistries including
calcium and magnesium were within normal limits. Enteral
feedings were started on [**8-6**] via gavage tube. Advancement
of feedings was limited by frequent vomiting. As described
below, the infant underwent evaluation for the abdominal mass
palpated on admission, thought to be most consistent with
duplication cyst. Evaluation included an upper GI study which
did not suggest obstruction. Feedings were continued, and
eventually tolerance improved and infant was able to be given
full volume feeds. Caloric density was increased to max 26
calories per ounce to aid weight gain. As infant's overall
status improved, oral feedings were introduced, with eventual
transition to full oral feeds. By the time of discharge, the
infant has been feeding PO ad lib Neosure 26 calorie/oz formula
for greater than three days, taking over 140 cc/kg/day. Urine
and stool output have been normal.
4. Gastrointestinal/Genitourinary: Abdominal mass palpated
on admission. Ultrasound was performed on [**8-5**], demonstrating
a cystic mass in the mid upper abdominal region to the right of
the midline measuring 3 x 3 x 3.5 cm, separate from the liver and
adjacent to the gallbladder. Differential
diagnoses included duplication cyst, mesenteric cyst, and less
likely a choledochal cyst or macrocystic lymphatic mass. Surgery
from [**Hospital3 1810**] (Dr. [**Last Name (STitle) 37080**] was consulted. The mass
was followed clinically at first, but due to issues with vomiting
with introduction of enteral feeds, further evaluation was
performed with repeat ultrasound and upper GI study, performed on
[**2126-8-14**] at [**Hospital3 1810**]. Repeat ultrasound suggested the
mass was most consistent with duplication cyst, and upper GI
study showed displacement of the duodenal loop but no evidence of
obstruction of flow. Feedings were resumed following the
studies, and were gradually able to be well tolerated. Plan at
the time of discharge is for follow-up with surgery at [**Hospital1 **]
as an outpatient, with elective excision of the mass in the
future.
She required treatement for hyperbilirubinemia with phototherapy
for several days after transfer.
5. Hematology: Blood type is B negative, Coombs negative.
Initial hematocrit on admission to [**Hospital1 190**] was 56, and remained stable in follow-up. Last Hct
on [**8-29**] was 33.4. In light of IVH, coagulation studies were
performed and were basically within normal limits. Initial PT
was mildly elevated, although normal on repeat, and a factor 7
level was sent and that was normal. Hematology was consulted and
considered the coagulation studies to be overall reassuring.
On admission to the [**Hospital1 69**], she
had a platelet count of 43 and was given a platelet transfusion.
Platelet count post-transfusion was 143, and then remained
stable, with last count of 272 on [**8-9**].
6. Infectious disease: In light of the seizure activity,
acyclovir was added to the ampicillin and cefotaxime the infant
had been on at the time of transfer. An LP was performed which
was noted to be bloody. CSF PCR was sent and results were
negative. Blood cultures remained negative. Antibiotics were
discontinued on [**8-6**] and the Acyclovir was discontinued on
[**8-8**].
7. Neurology: As noted above, infant was loaded with
phenobarbital following seizure activity at [**Hospital **] Hospital.
Head CT was performed on [**8-3**], demonstrating bilateral
germinal matrix bleed with extension into the ventricular and
peri-ventricular matter on the right side. There was no
ventricular dilatation. An additional clinical seizure was seen
on [**8-3**], and EEG performed on [**8-4**] and 20 suggested ongoing
subclinical seizure activity, prompting additional doses of
phenobarbital with an eventual level of 36. Clinical seizures
resolved, and EEG on [**8-8**] demonstrated no seizure activity.
Neurology from [**Hospital1 **] was consulted and has been actively
involved in this case.
Multiple head ultrasounds showed expected evolution of the
right-sided intraventricular hemorrhage, with gradual cystic
changes noted in the periventricular areas bilaterally. Mild
ventricumegaly was seen, but was stable. Head circumferences
were followed daily, and remained stable, increasing
appropriately from 31 cm to 33 cm. Head MRI was performed on
[**8-28**], and revealed bilateral right greater than left
multicystic encephalomalacia, primarily in the periventricular
areas but also extending slightly beyond. Hemorrhagic changes
were seen within the damaged white matter areas, with a large
subependymal hemorrhage in the right lateral ventricle. Overall
these findings were thought to be most consistent with a prior
hypoxic ischemic injury, with secondary hemorrhage.
Clinically, infant showed very gradually improving activity and
mental status over course of hospitalization. With no further
seizure activity seen and slow improvement in activity level,
target phenobarbital level was reduced to 25-30, and
phenobarbital dose was reduced accordingly. Last two
phenobarbital levels were 21, last on [**8-29**], and dose was
increased to 12 mg per day. Repeat EEG was also performed on
[**8-23**], secondary to persistent limited PO feeding, and revealed a
generally normal background without seizure activity. Infant did
begin to demonstrate more rapid improvement in activity level and
PO feeding after that time, and by the time of discharge, infant
is appropriately active and vigorous with exam.
Occupational therapy has been following the infant throughout,
and has noted increased tone diffusely. Stretching exercises
have been performed regularly, and taught to the parents, with
some improvement in tone seen.
8. Psychosocial: This family is invested and involved and has
been working with the social worker who can be contact[**Name (NI) **] at
[**Telephone/Fax (1) 8717**]. The social worker is [**Name (NI) 4457**] [**Name (NI) 36244**].
CONDITION ON DISCHARGE: Stable. Weight 2395 grams.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 56527**], [**Hospital 17566**] Pediatrics,
[**Telephone/Fax (1) 52275**].
CARE RECOMMENDATIONS:
1. Diet: Neosure 26 cals/oz made by concentration.
2. Medications: Phenobarbital 12 mg (3 mL) PO daily.
3. Car seat position screening: passed on [**2126-8-27**].
4. State newborn screen: last sent on [**8-13**], results all WNL.
5. Immunizations received: received Hepatitis B vaccine # 1 on
[**2126-8-28**]. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
FOLLOW-UP APPOINTMENTS AND RECOMMENDATIONS:
- Dr. [**Last Name (STitle) 56527**] (PMD) in 1 day; VNA in 2 days.
- Dr. [**Last Name (STitle) 37080**], General Surgery, [**Hospital3 1810**] ([**Last Name (un) 9795**] 3),
[**9-18**], 9:15 am.
- Neonatal Neurology Program, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital3 18242**], 2-3 months after discharge (referral made).
- Early intervention (referral made to Criterion-[**Location (un) 270**] Child
Development.
DISCHARGE DIAGNOSES:
1. Hypoxic-ischemic brain injury.
2. Intraventricular hemorrhage.
3. Seizures.
4 Rule out sepsis with antibiotics.
5. Abdominal mass, likely duplication cyst.
6. Thrombocytopenia.
7. Polycythemia.
8. Hyperbilirubinemia.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2126-8-14**] 00:07:12
T: [**2126-8-14**] 05:07:07
Job#: [**Job Number 63567**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1915
} | Medical Text: Admission Date: [**2135-6-15**] Discharge Date: [**2135-7-22**]
Date of Birth: [**2073-8-16**] Sex: M
Service: MEDICINE
Allergies:
Cortisone
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Back wound
Major Surgical or Invasive Procedure:
Debridement of back wound by Neurosurgery and Plastic Surgery
Flap placement and closure by Plastic Surgery
Flap revision by Plastic Surgery
multpile PICC line placements
History of Present Illness:
61 yo male w/o significant past medical history
transferred from [**Hospital 3844**] hosp for wound evaluation. Pt has
large back wound, which he has never actually seen, but has
noticed over past 1-2mo draining fluid. Pt states that he fell
backwards ten feet into the foundation of a home in [**9-15**] and
developed a wound in the back. Since his fall, he has been
packing the wound w/ a cut out square of a T shirt, paper
towels, and Neosporin. He has noticed pus dripping from the
wound for the last month. He decided to go the
hospital today in NH when it started to smell bad. Given the
complexity of the wound and exposure of spinous processes, he
was brought to [**Hospital1 18**] for further management.
.
In [**Name (NI) **], pt febrile to 101.8 w/ "labile" BP w/ SBP in the 80's.
Code sepsis initiated. Pt given 5L IVF, central line (R IJ
placed) and pressors started. Plastics & spine consults were
obtained. Given vanco/zosyn. Admitted to the MICU for HD
monitoring & stabilization.
.
In the MICU, the patient was maintained on empiric abx and
aggressive IVF repletion. Plastics and spine still following.
Once hemodynamically stable and afebrile, the patient was
transferred out to the floor.
.
Currently, the patient denies pain (although visibly in distress
when laying back in bed), and denies f/c/n/v/dizziness.
.
On ROS, the patient denies parasthesias/weakness in his
extremities, no changes in bowel or bladder function. He admits
to a 20lb weight loss over 1 year but attributes this to new
retirement. He denies any other B symptoms. He denies
diarrhea/nightsweats/palpitations.
Past Medical History:
pt has not seen a physician [**Name Initial (PRE) 14169**] [**2098**]
Social History:
Worked as a electrician, retired one year ago.
Lives alone, estranged from family. Has two children who moved
away with mother. [**Name (NI) **] brother nearby, but not in close contact
with him. Remote history of tobacco/ETOH.
Family History:
mom - cancer of unclear etiology
Physical Exam:
Vitals: T 98.5; BP 81/39; P 82; RR 18; 98% RA
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple, no carotid bruit
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Skin: ulcerating skin wound from ~ C7-T6 eroded through
paraspinal muscles and exposes necrotic spinous processes. 22 cm
at greatest width.
Extremities: no c/c/e.
Neuro: CNII-XII in tact, strength in tact UE/LE equal
bilaterally, sensation in tact. No clonus, DTR's 2+, Babinski
down b/l.
Pertinent Results:
[**2135-6-15**] 07:00PM WBC-11.7* RBC-3.74* HGB-9.6* HCT-28.1*
MCV-75* MCH-25.5* MCHC-34.0 RDW-14.8
[**2135-6-15**] 07:00PM NEUTS-79.7* LYMPHS-14.4* MONOS-5.4 EOS-0.4
BASOS-0.1
[**2135-6-15**] 07:00PM PLT COUNT-715*
[**2135-6-15**] 07:00PM GLUCOSE-102 UREA N-16 CREAT-0.8 SODIUM-127*
POTASSIUM-5.9* CHLORIDE-97 TOTAL CO2-19* ANION GAP-17
[**2135-6-15**] 07:18PM LACTATE-1.3
.
[**2135-6-16**]: CXR: IMPRESSION: 1. Standard position of the right
internal jugular line with no evidence of complications. 2. New
large left lower lobe consolidation might be accompanied by
pleural effusion. Given its fast appearance, it might represent
aspiration. 3. Questionable left upper lobe nodule. Repeated PA
and lateral chest radiographs are recommended for precise
evaluation of these findings.
.
[**2135-6-16**]: TTE: Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Left
ventricular systolic
function is hyperdynamic (EF 80%). Tissue Doppler imaging
suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no
ventricular septal defect. The right ventricular cavity is
dilated. Right
ventricular systolic function is 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 appears
structurally normal
with trivial mitral regurgitation. There is no mitral valve
prolapse. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2135-6-16**]: CT abd/pelvis: IMPRESSION:
1. Multiple lung nodules, which may represent metastases or
infection. However, no definite primary cancer identified.
2. Open wound in left upper back and over the thoracic spine.
However, no drainable collection identified.
3. Bilateral pleural effusions, left greater than right and left
loculated.
4. Ascites.
5. No suspicious sclerotic lesions seen in the bones. However,
CT is not specific for evaluating bony metastases.
.
[**2135-6-17**]: CT Head: IMPRESSION: No evidence of intracranial
metastatic disease.
.
[**2135-6-17**]: MR [**Name13 (STitle) 2854**] - FINDINGS: There are extensive signal
intensity abnormalities of all of the visualized vertebral
bodies. This finding is most strongly suggestive of diffuse
metastatic disease. There is no definite evidence of rupture of
tumor through the cortex. However, as noted below, there are
areas where it is difficult to distinguish tumor from the
infection.
There is a large defect in the skin and musculature posterior to
the spine. The superior extent of this defect appears to be
located at approximately T1. This appears to extend to
approximately T11. At the greatest depth of the defect, it
appears to extend to the spinous processes and lamina. There is
extensive soft tissue abnormality, with enhancement, surrounding
the thecal sac, most prominent from approximately T2 to T6.
Throughout these levels, there also appears to be abnormal
enhancement of the vertebral bodies themselves. The spinous
processes and lamina at T2 through T4 appear markedly
hypointense on the MR images suggesting sclerosis due to chronic
osteomyelitis.
There are large bilateral pleural effusions, larger on the left
than right. A right lung nodule is identified in the limited
views of the lung included in this study.
There is a protrusion of the T7-8 intervertebral disc with
indentation on the spinal cord. This is incompletely visualized
on these images.
The findings described above suggest both infectious and
neoplastic pathology with the diffuse vertebral body signal
intensity abnormalities, and the right lung nodule,
characteristic of metastatic disease. The large ulceration of
the posterior soft tissues and the enhancement surrounding the
thecal sac presumably represent infection. However, this
intraspinal soft tissue may also contain tumor. There may well
be an intraspinal epidural abscess or phlegmon. No drainable
fluid collection is noted within the spinal canal.
CONCLUSION: Findings suggesting both metastatic disease and
chronic infection with intraspinal enhancement most suspicious
for epidural abscess or phlegmon.
Right lung nodule.
Bilateral pleural effusions.
T7-8 disc protrusion.
.
[**2135-6-19**]: MR L/C spine:
IMPRESSION:
1. Epidural abnormality which could represent phlegmon or early
abscess, from the T3 through T5 level. At the T4-T5 level, this
deforms the dorsal surface of the thecal sac.
2. Foci of increased signal on the T1 post-gadolinium sequence
at the T3-T4 level within the thecal sac which could represent
enhancing nerve roots, vessels, or artifact. It is unlikely to
be intrathecal extension of infection.
3. Erosion of the spinous processes of T2 through T8 with
extensive posterior soft tissue phlegmon and inflammation. At
T3-T4, T4-T5 and T5-T6, this soft tissue extends into the neural
foramina, and into the epidural space.
4. No cervical or lumbar epidural abnormalities, and no cervical
or lumbar cord signal abnormalities.
5. Bilateral pleural effusions and multiple lung nodules, which
are better assessed on the recent CT of the torso.
6. Multifocal signal changes within vertebral bodies in the
cervical, thoracic and lumbar spine are most suggestive of
multifocal osseous metastatic disease.
Overall, the study of the thoracic spine does not demonstrate
significant change since [**2135-6-17**].
.
[**2135-6-20**]- pathology report:
SPECIMEN SUBMITTED: SPINOUS PROCESS (BONE) (1).
Procedure date Tissue received Report Date Diagnosed
by
[**2135-6-20**] [**2135-6-21**] [**2135-6-29**] DR. [**Last Name (STitle) **]. LOMO/lxl??????
DIAGNOSIS:
Spinous process bone:
.
Metastatic carcinoma with squamous features (see Note).
.
Acute osteomyelitis with necrosis.
.
Note: Immunostains will be performed and the results reported in
an addendum.
.
[**2135-6-20**]: EKG: Sinus rhythm. Left atrial abnormality. No previous
tracing available for comparison.
.
[**2135-6-21**]: Pleural Fluid Cytology: Pleural fluid: NEGATIVE FOR
MALIGNANT CELLS.
.
SWAB THORAC BACK.
.
**FINAL REPORT [**2135-6-22**]**
.
GRAM STAIN (Final [**2135-6-15**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
.
WOUND CULTURE (Final [**2135-6-19**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
STAPH AUREUS COAG +. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND STRAIN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| | PSEUDOMONAS
AERUGINOSA
| | |
CEFEPIME-------------- 4 S 2 S
CEFTAZIDIME----------- 4 S <=1 S
CIPROFLOXACIN--------- 0.5 S <=0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S 4 S <=1 S
IMIPENEM-------------- <=1 S <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM------------- <=0.25 S <=0.25 S
OXACILLIN-------------<=0.25 S
PIPERACILLIN---------- 8 S <=4 S
PIPERACILLIN/TAZO----- 8 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- S
ANAEROBIC CULTURE (Final [**2135-6-22**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
.
[**2135-6-20**] 6:00 pm TISSUE LUMBAR INFECTION.
**FINAL REPORT [**2135-6-26**]**
GRAM STAIN (Final [**2135-6-20**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
TISSUE (Final [**2135-6-26**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 72682**] ([**6-23**]).
STAPH AUREUS COAG +. RARE GROWTH.
Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- <=0.5 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 4 R
MEROPENEM------------- S
OXACILLIN------------- 0.5 S
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 64 S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- S
ANAEROBIC CULTURE (Final [**2135-6-24**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
61yo M estranged from medical care for >35yr who presents w/
extensive back wound, pentrating to spinous processes, and
smaller L back/axillary wound. Pt septic on admission.
.
# Sepsis: When the patient was initially admitted, he was
hypotensive with the obvious source being the large infected
back wound with associated chronic vertebral osteomyelitis and
possible epidural abscess. Additionally, blood cultures from
OSH grew pseudomonas, though blood cultures here were without
growth (except for cornybacterium, which is presumed
contamination). The patient was started on broad antibiotic
coverage with vancomycin and zosyn. He was aggressively fluid
resuscitated (>12L) and required pressors for approximately
24hrs. Thereafter, he was hemodynamically stable and afebrile.
Workup of his hypotension was unrevealing for adrenal
insufficiency or cardiogenic source (EF>80%). Likewise, TTE
showed no gross evidence of endocarditis. His wound swab
ultimately grew MSSA and pseudomonas. Antibiotics were changed
to naficillin/cipro/flagyl given sensitivities of cultures. Pt
was changed to high-dose Levaquin and Flagyl to complete 6 week
course. Stop date [**2135-8-18**].
.
# Back wounds: wound culture grew MSSA and pan-sensitive
pseudomonas. Patient was treated initially in the MICU with
vancomycin & zosyn, and ultimately tailored to nafcillin, cipro,
flagyl on the floor. Plastic surgery and neurosurgery took the
patient to the OR together on [**2135-6-20**] for initial debridement
and was thereafter followed by plastic surgery who took him back
to the OR on [**6-27**] for flap closure. He was kept on a wound vac.
It was taken down on [**2135-7-2**], and because the flap didn't take,
he needed to be taken back to the OR on [**7-6**] for a wound
wash-out and another vac dressing. Plastic surgery recommending
that patient is able to be d/c'ed with [**Hospital1 **] dressing changes and
outpatient follow-up, with plan to consider another skin graft
in the future.
.
# Osteomyelitis: because the wound had exposed vertebral
processes (by definition osteomyelitis), ID recommended several
weeks of IV antibiotics. Pt received IV naficillin until
discharge. Medication changed to high-dose Levaquin and Flagyl
on discharge to complete 6 week course on [**2135-8-18**]. Acute care as
outlined above.
.
# Question of malignancy: MRI revealed extensive vertebral body
changes throughout the thoracic spine that were suggestive of
malignancy/metastatic disease. The patient has no known prior
malignancy, although he did not have any medical care for over 3
decades. Pan-CT scan notable for multiple lung nodules as well
as left sided pleural effusion. This effusion was tapped by
Interventional Pulmonary, which showed predominant lymphocytosis
with cytology negative for evidence of malignancy. A specimen of
the spinous process was sent to pathology and under special
staining revealed likely non-small cell lung cancer, stage IV.
Hematology/oncology was consulted who felt that the prognosis
was likely poor with an estimated lifespan of 8 months; they
offered the patient palliative chemotherapy (which would not be
able to be initiated until the ulcers healed) and the patient
has initially refused but will arrange follow up in New
[**Location (un) **] if patient is amenable.
.
# ARF: On presentation, the patient had a slight bump in his
creatinine, thought to be prerenal azotemia versus contrast
nephropathy versus ATN secondary to either medication or
hypovolemic insult during sepsis and then again with second
hypotensive episode following incomplete fluid resuscitation in
the PACU following his second surgery. Urine electrolytes
indicated a FENa of 2.2, which indicates a more likely intrinsic
mechanism for renal failure, such as ATN. He was treated with
IVF and all medications were renally dosed. Subsequent to these
events, the patients renal funtion returned to [**Location 213**] and has
remained normal through discharge.
.
# FEN: tolerates a regular diet, although has refused most meals
since [**7-4**] since complaining that his pills (specifically
cipro/flagyl) were altering his sensation of taste. Cipro and
flagyl were switched to IV, but the patients po intake continues
to be poor so medications were restarted po. Pt. only accepted
cans of Ensure.
.
# Access: pt initially had R IJ, then PICC placed on [**2135-6-19**] for
long-term access.PICC DC'd prior to discharge.
.
# However, despite multiple attempts by PT to encourage exercise
and OOB activity, he has become deconditioned and at this point
will need PT services at home.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Bismuth Subsalicylate 262 mg/15 mL Suspension Sig: Fifteen
(15) ML PO TID (3 times a day).
3. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
27 days.
Disp:*27 Tablet(s)* Refills:*0*
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 27 days.
Disp:*81 Tablet(s)* Refills:*0*
5. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health and Hospice
Discharge Diagnosis:
Primary:
1. Stage IV Non-small cell lung cancer.
2. Metastasis and osteomyelitis of thoracic spine.
3. Malignant back ulcer with superinfection - MSSA, Pseudomonas
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a large back ulcer that involved the
bones of your spine. You were initially taken to the ICU, as
bacteria had entered your bloodstream, and you were taken to the
operating room three times, first by neurosurgery and
subsequently, by plastic surgery, to clean and then close the
wound. You were maintained on intravenous antibiotics throughout
the admission.
.
Additionally, on imaging it was noted that you had evidence of
malignancy in the bones of your spine. A sample of bone was
taken for analysis during surgery, which came back as non-small
cell lung cancer metastasized to the bone. Hematology/Oncology
has offered palliative chemotherapy and will arrange follow up
for you in [**Location (un) 3844**] if you are amenable.
.
You have been accepted as a patient at the [**Location (un) **] Family
Practice. Please follow-up with your PCP after your discharge
from the hospital.
Followup Instructions:
It is recommended that you be followed by hematology/oncology,
infectious diseases and plastic surgery upon discharge. Your PCP
can arrange appointments with these specialty services for you.
ICD9 Codes: 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1916
} | Medical Text: Admission Date: [**2174-6-21**] Discharge Date: [**2174-6-29**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Failure to thrive, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 75001**] is an 87M with a history of CVAs, HTN, CKD and
hypothyroidism who was brought in by his daughter on [**6-21**] for
failure to thrive and difficulty taking care of him at home.
This is all occurring in the setting of a recent disruption in
home VNA and PT services. Since these services stopped, the
patient has been needing 24/7 help with all ADLs. On the
morning of admission the patient was found down presumably after
falling off of the couch. There was no loss of consciousness or
head trauma. His ROS is only notable for decreased PO intake at
home with minimal weight loss. He has not had any other
symptoms at home, she denies any fevers, cough, SOB, abdominal
pain, nausea, vomiting or diarrhea.
.
In the emergency department he had a fever to 102F rectally, and
elevated CK to 2100 with a troponin of 0.17. Otherwise his
vital signs were stable. An EKG was difficult to interperet in
the setting of a LBBB and a V-paced rhythm. CT head and C-spine
were negative. A UA was negative. He was given Vancomycin,
levofloxacin and IVF; and sent to the ICU.
.
In the ICU, a cardiology consult did not feel the patient had an
acute MI. An infectious work-up revealed blood cultures 4/4
bottles positive for GPC's in pairs, clusters, and chains. A CT
of the chest showed multiple bronchial, calcified and
noncalcified pulmonary nodules associated with bronchiectasis
and bronchial impaction concentrated in the upper lobes,
suggesting nonacute nontuberculous mycobacterial infection or
[**Doctor First Name **]. The patient was placed on vancomycin and on respiratory
isolation. The team was unable to obtain sputum for AFB smear.
He was transferred to the floor for further work up.
Past Medical History:
1. Recent temporal lobe CVA [**9-18**]
2. h/o right PICA stroke
3. h/o TIA in [**5-15**] (left weakness, slurred speech)
4. Hypertension
5. Hyperlipidemia (LDL 58, HDL 100 [**3-18**])
6. Hypothyroidism: h/o [**Doctor Last Name 933**], now hypothyroid
7. Chronic kindey disease (baseline mid 2s)
8. Anemia (baseline mid-high 30s): Normal iron studies in [**3-18**]
9. Diverticulosis and internal hemorrhoids
Social History:
Previously took care of his wife, who is severely demented. No
history of tobacco, alcohol or drug use.
Family History:
Non-contributory.
Physical Exam:
Tmax: 96.4 Tcurrent: 95 BP: 97-127/54-77... HR:65-89...
96-100% RA
UOP: 25-40cc/hr
GENERAL: This is a cachectic elderly caucasian male, responsive
to verbal stimuli, minimally responsive to sternal rub
CARDIAC: rrr no murmurs
LUNGS: decreased breath sounds diffusely, RR ~10
ABDOMEN: Scaphoid, NABS, NTTP, soft
HEENT: NC, erythmatous area over righ eyebrow with a small
scrape. No bleeding or oozing.
NEURO: limited, will respond to verbal stimuli but will not
follow commands such as "open your eyes", seems to be refusing
to respond, not unresponsive. Bilateral ankle clonus. Upgoing
toe on the right, down going on the left. able to squeeze
fingers bilaterally, weak, [**3-16**]. Unable to move upper or lower
extremities on command. Pupils are reactive bilaterally.
Pertinent Results:
CT CHEST
1. No acute pulmonary process. Multiple bronchial, calcified,
noncalcified pulmonary nodules associated with bronchiectasis
and bronchial impaction concentrated in the upper lobes suggest
nonacute nontuberculous mycobacterial infection or [**Doctor First Name **]. If
clinically indicated, a followup can be performed in one year.
2. Extensive coronary artery calcifications.
.
CT spine
1. No acute fractures or alignment abnormalities.
.
CT head
1. No acute intracranial process.
2. Left temporal lobe encephalomalacia, likely sequela of an old
infarct.
.
US abdomen
1. Trace amount of pericholecystic fluid with gallbladder
"sludge ball."
2. Large right and small left pleural effusions with trace
amount of free
fluid in the right lower quadrant.
3. 6-mm saccular outpouching from the posterior aspect of the
infrarenal
abdominal aorta which may represent a small saccular aneurysm;
in the setting of known enterococcal bacteremia, endovascular
infection with mycotic aneurysm cannot be excluded.
4. Left hydroureteronephrosis with increased echogenicity of
bilateral renal cortex, suggesting chronic "medical renal
disease" consistent with patient's renal insufficiency.
.
Echocardiogram
Probable small aortic valve vegetation. Mild aortic
regurgitation. Severe global left ventricular systolic
dysfunction. Compared with the prior study (images reviewed) of
[**2173-9-2**], aortic valve abnormality is new. Left ventricular
systolic function has significantly deteriorated.
Brief Hospital Course:
HOSPITAL COURSE BY PROBLEM
.
1. Bacteremia: The patient was found to have persistent
Enterococcal and staphylococcal bacteremia despite broad
spectrum coverage with vancomycin. Abdominal ultrasound was
obtained on [**6-23**] which showed a saccular aneurysm on the
infrarenal aorta, which is concerning for a mycotic aneurysm as
a possible source. Echocardiogram obtained on [**6-24**] showed a
vegetation on the aortic valve. The patient was not likely to
be a good candidate for vascular surgery, given his poor
prognosis and functional capacity. He continued to be
hypothermic and bacteremic on surveillance cultures despite
broad spectrum coverage. The desicion was made by the family to
make him CMO.
.
2. Altered mental status: Likely a result of high grade
bacteremia, we were unable to image with MRI or CT with contrast
as the patient has a pacer and CKD
.
3. Findings on CT chest: The patient was ruled out for pulmonary
TB with three negative AFB smears and taken off of precautions.
.
4. Aspiration risk: The patient was evaluated by speech and
swallow as we had high suspicion for aspiration risk. They
deemed him a high risk and the patient was NPO for several days.
An attempt at an NG tube was unsuccessful, as the patient
refused it and pulled it out. The family was presented with the
options of a percutaneous feeding tube, as TPN was not an option
in the setting of high grade bacteremia. They did not feel that
this was a good option given his prognosis and decided to make
him CMO
Medications on Admission:
ASA 81 mg daily
Levothyroxine 150 mcg daily
Zydis 5 mg [**Hospital1 **]
Acetaminophen 325 mg q4h prn
Simvastatin 20 mg daily
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1H
(every hour) as needed for pain.
4. Lorazepam 0.5 mg IV Q4H:PRN agitation
5. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]
Discharge Diagnosis:
Enterococcal and staphylococcal bacteremia
Endocarditis
Aneurysm (possibly mycotic)
Failure to thrive
Discharge Condition:
Comfort measures only
Discharge Instructions:
You were admitted with fevers and confusion, and we found you to
have a very severe bloodstream infection. We held a family
meeting to discuss the likelihood of recovery, and the decision
was made to maximize your comfort only, and stop invasive
measures. You will transferred to a facility that focuses on
comfort measures.
Followup Instructions:
None
ICD9 Codes: 7907, 5859, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1917
} | Medical Text: Admission Date: [**2196-4-2**] Discharge Date: [**2196-4-4**]
Service: MEDICINE
Allergies:
Clozapine / Propranolol
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
sent from rehab for hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
86 y/o F w/severe dementia, recent femur fx [**1-31**], who earlier on
[**2196-4-1**] was reportedly witnessed aspirating jello. She was then
noted to be febrile to 103, tachycardic in the 120s. She was
begun on ceftriaxone and flagyl for presumed aspiration
pneumonia, and a PICC line was placed. She was hydrated with NS
at 125 cc/hr. Over the course of the day, she became more
hypotensive to 90/46 and then to 80/40 (after having been 156/60
earlier in the day). Her o2 saturation was 88% on 3L NC. Of
note, in a progress note from the day prior ([**2196-3-31**]), it states
she had been having diarrhea and loose stools which was
concerning to her caretakers at [**Hospital 100**] Rehab given their
[**Name (NI) **] outbreak.
.
In our ED, her vitals were 100.6, 84/42, 100, 28, and 88% on 6L
NC (improved to 98% on a NRB). She was begun on levophed, and
her pressure dropped as low as 69/31. She was given vancomycin
and zosyn. After discussion with her legal guardian, it was
decided she would not want any invasive lines but would want
pressors and antibiotics. She was admitted to the MICU.
Past Medical History:
PMHX:
Schizophrenia, tardive dyskinesia
HTN
DVT [**3-29**] in LLE
Iron def anemia
OA
Dysphagia, on pureed solids and nectar-thickened liquid diet
Hypothyroid
R eye blindness
CHF, unknown LVEF, hypoalbuminemia (2.2)
?PAF - in one note from rehab, though not listed in PMH
CVA
Osteoporosis
Obesity
Hyperlipidemia
COPD
h/o PPD(+), s/p 6mth course of tx
L ischium decub ulcer, Stage 2
Social History:
DNR/DNI with form from Heb Reheb; Legal Guardian [**Name (NI) **] [**Name (NI) 29768**]
[**Telephone/Fax (1) 29769**](h), [**Telephone/Fax (1) 29770**](c). Unknown etoh, tob, drug
history.
Family History:
NC
Physical Exam:
T: 99.6 BP: 80/40 P: 84 R: 20 O2 sat: 100% on NRB
Gen: yelling incoherently, does not respond to questions,
gurgling secretions
HEENT: MM very dry
Lungs: rhonchorous although difficult to hear over yelling
CV: RRR, II/VI SEM at RUSB
Abd: soft, nt/nd, +bs
Ext: left leg in immobilizer, left foot with 3+ edema, no edema
on right, 1+ dp pulses bilaterally
Skin: erythema over left ischium without open ulceration
Pertinent Results:
Chest X-ray on [**2196-4-2**]:
IMPRESSION:
1. Improved interstitial edema.
2. Bibasilar effusions, worse on the left. Adjacent left
basilar opacity may represent atelectasis or pneumonia.
[**2196-4-4**] 05:36AM BLOOD WBC-16.5* RBC-3.27* Hgb-9.1* Hct-29.4*
MCV-90 MCH-28.0 MCHC-31.2 RDW-17.6* Plt Ct-206
[**2196-4-3**] 06:10AM BLOOD WBC-21.7* RBC-3.39* Hgb-9.4* Hct-30.0*
MCV-89 MCH-27.6 MCHC-31.2 RDW-17.8* Plt Ct-196
[**2196-4-2**] 04:30AM BLOOD WBC-28.0*# RBC-3.78* Hgb-10.5* Hct-33.3*
MCV-88 MCH-27.8 MCHC-31.6 RDW-17.7* Plt Ct-227#
[**2196-4-2**] 04:30AM BLOOD Plt Ct-227#
[**2196-4-3**] 06:10AM BLOOD PT-18.8* PTT-36.8* INR(PT)-1.8*
[**2196-4-3**] 06:10AM BLOOD Plt Smr-NORMAL Plt Ct-196
[**2196-4-4**] 05:36AM BLOOD PT-18.9* PTT-32.8 INR(PT)-1.8*
[**2196-4-2**] 04:30AM BLOOD Glucose-70 UreaN-46* Creat-2.0*# Na-146*
K-5.5* Cl-111* HCO3-23 AnGap-18
[**2196-4-2**] 08:36AM BLOOD K-5.0
[**2196-4-2**] 09:59AM BLOOD K-5.0
[**2196-4-2**] 05:17PM BLOOD Glucose-111* UreaN-39* Creat-1.1 Na-148*
K-4.8 Cl-114* HCO3-24 AnGap-15
[**2196-4-3**] 06:10AM BLOOD Glucose-65* UreaN-37* Creat-0.9 Na-149*
K-4.2 Cl-116* HCO3-25 AnGap-12
[**2196-4-4**] 05:36AM BLOOD Glucose-59* UreaN-31* Creat-0.5 Na-152*
K-4.4 Cl-119* HCO3-26 AnGap-11
[**2196-4-2**] 08:36AM BLOOD Cortsol-22.2*
Brief Hospital Course:
86 year-old female with dementia and femur fracture who
presented with hypotension, fever, tachycardia, likely urosepsis
vs aspiration pneumonia.
.
# Septic shock: Urine appears grossly infected although UA not
remarkable. Obviously given witnessed aspiration, pneumonia is
also a likely contributor. GNR bactaremia per [**Hospital 100**] rehab [**4-27**]
bottles. Has had vomiting and diarrhea, most likely [**Location (un) 27292**]
given where she came from, but could also have C. Diff. [**Month (only) 116**]
potentially become hypovolemic, became more confused, then
aspirated. Another source of infection is her decubitis ulcer
although it appears intact. Currently appears severely volume
depleted by exam, labs, and poor urine output. Responded to IV
fluid hydration and was successfully weaned off of pressors.
Initially started on meropenem for broad-spectrum antibiotic
coverage but narrowed to ciprofloxacin prior to discharge, to
complete a 2 week course on [**2196-4-15**]. [**Month (only) 116**] need to adjust
antibiotics based on further sensitivities.
.
# Acute renal failure: Creatinine was 2.0 on admission. Most
likely pre-renal azotemia from volume depletion as creatinine
normalied with IV fluids. Urine negative for eosinophils.
.
# Hypoxia: Was hypoxic to 88% on 6L NC. Most likely due to
aspiration pneumonia/pneumonitis given hx. Currently saturating
well on a face tent. Wean O2 as tolerated.
.
# Elevated troponin: Unclear the significance of this. No ECG
changes, ck/mb are flat, and has an elevated creatinine. Likely
combination of renal failure and demand ishcemia in the setting
of sepsis, no need for heparin.
.
# Status-post femur fracture: continue knee immobilizer. On
tylenol for pain and PRN morphine.
.
# Schizophrenia/dementia: Hold po meds for now as patient unable
to take po's. Will continue home meds if appropriate with MS at
future date.
.
# COPD: cont albuterol/atrovent nebs
.
# Hx DVT: It appears patient had DVT in [**2195-3-25**], so it has
been 12 months since the DVT. We have held warfarin for this
reason, but can be decided whether patient needs to continue for
prophylaxis at Rehab, given history of femur fracture.
.
# Hypothyroidism: Can resume synthroid once patient is
tolerating POs.
.
# FEN: Aggressive IVF resuscitation. Hypernatremia likely
related to volume depletion and lack of access to free water.
Continue IVF of LR. Currently strict NPO given aspiration, but
can resume PO if tolerating later.
.
# Ppx: PPI, sub-cutaneous heparin while warfarin is being held.
Can discontinue heparin SC and restart warfarin if appropriate,
as above.
.
# Communication: Legal Guardian [**Name (NI) **] [**Name (NI) 29768**] [**Telephone/Fax (1) 29769**](h),
[**Telephone/Fax (1) 29770**](c).
.
# Code: DNR/DNI, no invasive procedures, no NG tubes, no
arterial lines. Discuss utility of future inpatient
hospitalizations with guardian.
Medications on Admission:
Tylenol q6h
Duoneb prn
Norvasc 10 mg daily
Abilify 20 mg daily
Divalproex 250 mg qam, 375 mg qpm
Ferrous sulfate 325 mg daily
Lasix
Lisinopril 20 mg hs
Levothyroxine 100 micrograms daily
Losartan 50 mg qam
Roxanol
Sorbitol
Coumadin
Zeasorb
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP < 100.
5. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO qam.
6. Divalproex 125 mg Capsule, Sprinkle Sig: Three (3) Capsule,
Sprinkle PO qpm.
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day. Tablet(s)
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO at bedtime:
Hold for SBP < 100.
9. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP < 100.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP < 100.
12. Roxanol Concentrate 20 mg/mL Solution Sig: As per outpatient
regimen. PO As directed.
13. Zeasorb 0.1 % Powder Topical
14. Sorbitol Miscellaneous
15. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN Sig:
As directed as directed: 10 ml NS followed by 2 ml of 100
Units/ml heparin (200 units heparin) each lumen Daily and PRN.
Inspect site every shift. .
16. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1) dose
Intravenous Q12H (every 12 hours) for 14 days: to complete
course on [**2196-4-15**].
17. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis:
Sepsis
Femur fracture
Secondary diagnoses
1. Schizophrenia, tardive dyskinesia
2. Hypertension
3. Deep venous thrombosis
4. Iron deficiency anemia
5. Osteoarthritis
6. Dysphagia, on pureed solids and nectar-thickened liquid diet
7. Hypothyroidism
8. R eye blindness
9. Congestive heart failure, unknown LVEF
10. CVA
[**00**]. Osteoporosis
12. Obesity
13. Hyperlipidemia
14. Chronic obstructive pulmonary disease
15. h/o PPD(+), s/p 6mth course of tx
16. L ischium decub ulcer, Stage 2
Discharge Condition:
Blood pressure stable, off of pressors, afebrile.
Discharge Instructions:
You were admitted for hypotension, hypoxia. You were treated
for sepsis with antiobiotics. Please complete the 14 day course
of antibiotics as listed below.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**1-26**] weeks.
Completed by:[**2196-4-4**]
ICD9 Codes: 0389, 496, 5849, 4280, 5070, 2449, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1918
} | Medical Text: Admission Date: [**2190-9-10**] Discharge Date: [**2190-9-10**]
Date of Birth: [**2124-2-1**] Sex: F
Service: MEDICINE
Allergies:
Tetracyclines / Zinc
Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 year-old F with Castelman's syndrome, recurrent aspiration
PNA, HTN who presents s/p fall. She fell yesterday while trying
to get up from bed and was put back to bed by her Home Health
Aid; today she fell again and her aid 'dragged' her to bed and
called EMS. Some head and L hip trauma (no LOC).
.
In the ED she received MSO4 2 mg IV for pain. Her C-spine was
cleared. Head CT and hip films were negative. Fall was thought
to be mechanical and social work was consulted re question of
elder abuse/neglect. At midnight pt spiked to 102 rectal,
received tylenol. CXR and UA negative. She was admitted for
observation and placement.
.
Of note, pt was recently discharged from [**Hospital1 **] on [**2190-8-27**] for
Pseudomonas PNA.
.
ROS: Pt is poor historian. She c/o L hip pain. She [**Date Range **] fever/
chills/ sweats. Denied headache, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness. Denied nausea, vomiting, diarrhea, or constipation.
No dysuria or rash.
Past Medical History:
Past Medical History:
1. Castleman's disease (unicentric) s/p splenectomy in [**2176**].
Lymph node bx revealed reactive lymph tissue; followed in
Heme/Onc by Dr. [**Last Name (STitle) 410**]
2. H/O anaplastic thyroid cancer s/p radical neck dissection;
age 15
3. Esophageal webs and esophageal dysmotility s/p multiple
dilatations
4. Recurrent aspiration pneumonias s/p PEG (sputum with
klebsiella sensitive to Meropenem, MRSA, strep pneumo, [**Last Name (STitle) **])
5. Chronic Respiratory Disease; bronchiectasis, [**Last Name (STitle) 1570**]'s revealed
Restrictive physiology, ?interstitial lung disease. On 2L home
O2 at baseline
6. MRSA osteomyelitis of olecranan s/p multiple debridements
7. Bipolar d/o
8. GERD
9. ?Seizure d/o (may be in setting of hypoglycemia)
10. Hx Grave's disease
11. Osteoporosis: has broken both hips, left in [**11-7**], right
with failed ORIF and redo at [**Hospital1 2025**]; s/p short gamma nail fixation
of a left hip basicervical fracture [**9-7**]
12. h/o zoster
13. HTN
Social History:
Social History:
Used to work as a social worker at the VA. Was at [**Hospital1 **] until
[**6-9**] when she was discharged to home. Home health aide 24
hrs/day. No tobacco or EtOH.
Family History:
NC
Physical Exam:
Vitals: T: 98.9 ax P: 80 BP: 128/72 RR: 18 SaO2: 100% 2L NC
General: very thin, chronically-ill appearing female, lying in
bed with hyperextended neck, awake, in NAD.
HEENT: NC/AT, PERRL + L cataract, EOMI. MMM, OP without lesions.
Neck: able to rotate and flex neck.
Pulm: diffuse fine crackles, no rhonchi or wheezes
Cardiac: RRR, nl S1/S2, 2/6 SEM
Abdomen: soft, NT/ND, + BS. PEG in place, site c/d/i.
Ext: No edema b/t, L hip without ecchymosis
Skin: multiple areas of bruises in various stages of healing
Pertinent Results:
[**2190-9-10**] 01:20AM WBC-21.6 Hct-29.1 MCV-90 RDW-16.3 Plt Ct-211
.
[**2190-9-9**] 06:45PM PT-12.8 PTT-26.2 INR(PT)-1.1
.
[**2190-9-10**] 05:05AM Glucose-102 UreaN-34 Creat-1.7* Na-138 K-4.7
Cl-104 HCO3-27 AnGap-12
[**2190-9-9**] 06:45PM CK-MB-4 cTropnT-0.02* proBNP-225
.
[**2190-9-10**] 01:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2190-9-10**] 01:20AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
Brief Hospital Course:
66 yo F with Castleman's syndrome, recurrent aspiration PNA, HTN
who presents s/p fall with concern for elderly neglect, and
fever.
.
* s/p fall: mechanical in nature. Neg head CT, hip films,
C-spine imaging. No infection on CXR or UA. EKG unremarkable.
She ruled out for MI with two sets of negative troponins. She
was continued on her home pain regimen. She denied abuse by her
caretaker.
.
* Fever: leukocytosis with left shift. no localizing si/sx. CXR
and UA negative for infection. nl lactate. given recent Abx for
PNA, there is concern for CDiff. In looking back, her white
count is normal and likely secondary to her lymphoproliferative
disorder. She was not given antibiotics.
.
* Recurrent aspiration PNA: Had speech and swallow eval on last
admission recommending no POs, but she continues to eat. No
clinical evidence of PNA.
.
* Restrictive Lung Dz: unclear etiology. on 2L home O2.
Continued on O2 by NC. Continued ipratropium and albuterol nebs.
.
* Hypothyrodism: post thyroid Ca tx. Continued home
levothyroxine.
.
* ARF: Cr of 1.7 on admission, up from baseline of 1.3. likely
prerenal. s/p 1L IVF in ED. came back to baseline.
.
* HTN: cont metoprolol
.
Medications on Admission:
1. Acetaminophen 650 mg Suppository Rectal Q4-6H as needed.
2. Cholecalciferol 800 unit PO DAILY (Daily).
3. Levothyroxine 100 mcg PO DAILY
4. Ipratropium Bromide 0.02 % Inhalation Q6H (every 6 hours).
5. Albuterol Sulfate 0.083 % Inhalation Q6H as needed.
6. Gabapentin 400 mg PO HS
7. Ferrous Sulfate 325 (65) mg Tablet PO DAILY (Daily).
8. Lamotrigine 100 mg Tablet PO DAILY
9. Lansoprazole 30 mg Susp,One PO DAILY (Daily).
10. Metoclopramide 10 mg Tablet PO QIDACHS
11. Quetiapine 200 mg PO HS as needed.
12. Sodium Polystyrene Sulfonate 15 g/60mL Suspension PO DAILY
13. Prochlorperazine 5 mg PO Q6H as needed.
15. Oxycodone 10 mg PO Q4-6H as needed.
16. Venlafaxine XR 150 QD
17. Lorazepam 2 mg PO QID
18. Alendronate 70 mg PO QSAT
19. Metoprolol Tartrate 12.5mg PO BID
21. Polyvinyl Alcohol 1.4 % Drops 1-2 Drops Ophthalmic PRN
22. Fentanyl 50 mcg/hr Patch 72HR
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day/Year **]: One (1)
Tablet PO BID (2 times a day).
3. Levothyroxine 100 mcg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2)
Puff Inhalation QID (4 times a day).
5. Albuterol Sulfate 0.083 % Solution [**Month/Day/Year **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Day/Year **]: One (1) PO DAILY
(Daily).
7. Lamotrigine 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
8. Lansoprazole 30 mg Susp,Delayed Release for Recon [**Month/Day/Year **]: One
(1) PO DAILY (Daily).
9. Metoclopramide 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
10. Quetiapine 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
11. Sodium Polystyrene Sulfonate 15 g/60mL Suspension [**Month/Day/Year **]: One
(1) PO DAILY (Daily).
12. Prochlorperazine 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
13. Oxycodone 5 mg/5 mL Solution [**Month/Day/Year **]: Two (2) PO Q4-6H (every 4
to 6 hours) as needed.
14. Venlafaxine 75 mg Capsule, Sust. Release 24HR [**Month/Day/Year **]: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
15. Lorazepam 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QID (4 times a
day).
16. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO BID (2
times a day).
17. Polyvinyl Alcohol 1.4 % Drops [**Month/Day/Year **]: 1-2 Drops Ophthalmic PRN
(as needed).
18. Fentanyl 50 mcg/hr Patch 72HR [**Month/Day/Year **]: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
19. Alendronate 70 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a week:
Saturday.
20. Gabapentin 400 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO at
bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
s/p fall x 2
Castleman's syndrome s/p splenectomy [**2176**]. followed by Dr
[**Last Name (STitle) 410**].
recurrent aspiration PNA - s/p PEG (sputum with pseudomonas,
klebsiella sensitive to Meropenem, MRSA, strep pneumo, [**Last Name (STitle) **])
anaplastic thyroid Ca s/p radical neck dissection - 50 yrs ago
bipolar disorder
OA
HTN
esophageal webs and esophageal dysmotility s/p multiple
dilatations
chronic Respiratory Disease; bronchiectasis, [**Last Name (STitle) 1570**]'s revealed
Restrictive physiology, ?interstitial lung disease. On 2L home
O2 at baseline
h/o MRSA osteomyelitis of olecranan s/p multiple debridements
?Seizure d/o (may be in setting of hypoglycemia)
H/o Grave's disease
Osteoporosis: has broken both hips, left in [**11-7**], right with
failed ORIF and redo at [**Hospital1 2025**]; s/p short gamma nail fixation of a
left hip basicervical fracture [**9-7**]
h/o zoster
Discharge Condition:
fair
Discharge Instructions:
Continue your home medications. You need to seriously consider
rehab since you are likely to fall at home again soon.
Followup Instructions:
Please schedule an appointment in the next 2 weeks: PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2936**].
ICD9 Codes: 5070, 5849, 5990, 5859, 4280, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1919
} | Medical Text: Admission Date: [**2151-12-13**] Discharge Date: [**2151-12-20**]
Date of Birth: [**2104-4-9**] Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
increasing DOE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 47 yo female with h/o HTN, osteoporosis, sleep
apnea and severe COPD with FEV1 of 13 % who orginally presented
on [**12-13**] with 2-3 weeks of increasing dyspnea that has limited
her ability to the point she had difficulty ambulating even a
few steps and had increased her home 02 from 2-4L in this [**3-19**]
week period. The day prior to admission she had some rhinorrhea
and cold sx. She was admitted to the ICU due to increased work
of breathing. She was briefly on CPAP, but was quickly weaned to
NC and was stable. Previous symptoms suggestive of URI and
possible COPD exacerbation. Ruled out for flu by nasal aspirate.
Given stressed dosed steroids and started on Levofloxacin to
complete a 7 day course. Pt ruled out for PE with CTA and MI by
cardiac enzymes. For remainder of her ICU stay she was on 5 L of
NC as per her new baseline. in addition, she has chronic
tachycardia and was started on diltiazem.
.
On transfer from the ICU, she reports that her breathing seems
to be at baseline. She was able to get up and walk about 50 feet
with PT. Denies CP, worsened SOB, palpitations, headache, N/V.
She has her chronic back pain. She does report some abdmiinal
fullness and crampimg which has improved today after a BM with
bowel regimen
.
ROS: Positive as above and also for occasional feeling of
lightheadedness on standing, occasional sharp substernal chest
pain (isolated episodes, 2-3 times in the last several weeks)
now resolved. Otherwise she has no symptoms of vomiting,
headache, dysuria, abdominal pain, cough, change in sputum
(always yellow), passing out.
.
In the ED: patient's intial vitals were HR 140, BP 110/80, RR
30, 02 sat 100% RA. She received Xoponex, Combivent neb x 1,
Ativan, Methylprednisolone, 1 L NS, magnesium. Additionally
blood cultures were sent. Patient had increasing work to breathe
and then required CPAP.
.
On admission to the ICU, the patient required CPAP, but was able
to answer questions appropriately and did not have any acute
symptoms of pain or dyspnea. She was quickly weaned to nasal
canula and felt that her breathing had improved.
Past Medical History:
1. COPD, PFTs in [**9-19**] with FEV1 0.30 (13%), FVC 1.02 (34%) and
FVC/FEV1 38% - on Home O2 at 3L NC, on chronic steroids, hx of
prolonged intubation requiring trach for resp failure in [**1-15**],
[**3-21**]. She was recently taken off the lung transplant list at the
[**Hospital6 1708**] due to compression fractures. Has
previous history of asthma per OMR
2. Hypertension
3. Anxiety
4. Leukocytosis of unknown etiology with negative BMBx.
5. Osteoporosis with compression fractures
6. Shoulder pain
7. History of positive PPD s/p 6mos of isoniazid
8. Mitral valve prolapse
9. Obstructive sleep apnea on BiPAP (15/12 every night)
Social History:
Single, quit smoking one year ago. Prior to that, she used to
smoke less than a pack a day since the age of 16. She has no
alcohol consumption, and lives with her mother and has one
child.
Family History:
Great uncle had MI in 50s, Maternal & Paternal GMs had CVAs in
50s.
Physical Exam:
Vitals: T 96.5 HR 124 BP107/58 P104 R17 O2 100% CPAP
Gen: Well-appearing woman in NAD.
HEENT: NC/AT. MMM no erythema/exudate. JVP not seen. Neck supple
w/o LAD.
Pulm: Faint crackles B bases.
CV: Distant heart sounds.
Abd: Soft, tender to palpation diffusely especially on RUQ, no
rebound or guarding. Bowel sounds are hypoactive. No
organomegaly
Ext: 2+ dorsalis pedis/radial pulses; no edema, clubbing, or
cyanosis.
Neuro: AAOx3. CNII-XII grossly intact. 5/5 strength throughout
Pertinent Results:
[**2151-12-13**] 01:00PM BLOOD WBC-18.3* RBC-3.88* Hgb-11.3* Hct-33.3*
MCV-86 MCH-29.1 MCHC-33.9 RDW-14.1 Plt Ct-485*
[**2151-12-13**] 01:00PM BLOOD Neuts-94.1* Bands-0 Lymphs-4.1*
Monos-1.6* Eos-0.2 Baso-0.1
[**2151-12-13**] 01:00PM BLOOD Glucose-160* UreaN-15 Creat-0.8 Na-137
K-4.5 Cl-92* HCO3-38* AnGap-12
[**2151-12-13**] 01:00PM BLOOD ALT-22 AST-28 LD(LDH)-228 AlkPhos-127*
Amylase-50 TotBili-0.1
[**2151-12-13**] 01:00PM BLOOD Lipase-16
[**2151-12-13**] 05:41PM BLOOD CK-MB-8 cTropnT-0.04*
[**2151-12-13**] 01:00PM BLOOD Calcium-9.6 Phos-3.2# Mg-2.0
[**2151-12-13**] 05:41PM BLOOD TSH-0.23*
[**2151-12-14**] 04:10AM BLOOD Free T4-1.0
[**2151-12-20**] 09:10AM BLOOD WBC-19.0* RBC-3.62* Hgb-10.1* Hct-31.7*
MCV-87 MCH-27.9 MCHC-32.0 RDW-14.5 Plt Ct-374
[**2151-12-17**] 04:25AM BLOOD PT-12.5 PTT-27.0 INR(PT)-1.1
[**2151-12-20**] 09:10AM BLOOD Glucose-109* UreaN-12 Creat-0.8 Na-136
K-3.8 Cl-89* HCO3-41* AnGap-10
[**2151-12-20**] 09:10AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.8
.
CTA CHEST W&W/O C &RECONS [**2151-12-13**] 11:55 PM
INDICATION: 37-year-old woman with COPD and increasing dyspnea
on exertion in the setting of chest pain. Evaluate for pulmonary
embolism.
CTA OF THE CHEST: No filling defects or pulmonary emboli are
identified within the pulmonary arteries to the level of the
segmental branches. Scattered aortic calcifications are seen,
however the aorta is within normal caliber and contour
throughout its course.
CT OF THE CHEST WITH IV CONTRAST: Soft tissue window images
demonstrate no pathologically-enlarged mediastinal, hilar, or
axillary lymphadenopathy. The heart and pericardium are normal
in appearance. No pleural or pericardial effusions are seen.
Lung window images demonstrate no pulmonary nodules or
parenchymal consolidation. Scattered emphysematous changes are
seen diffusely throughout the lungs.
Limited images of the superior portion of the abdomen
demonstrate a cyst with calcification within the superior pole
of the left kidney. The visualized parts of the liver, spleen,
right kidney, adrenal glands, and pancreas are within normal
limits.
BONE WINDOWS: Compression deformities are seen within several
mid thoracic vertebral bodies, of indeterminate age.
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential
in delineating the anatomy and pathology.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Extensive emphysematous changes are seen bilaterally.
3. Hypodensity within the superior pole of the left kidney with
wall calcification likely represents a complex cyst.
4. Multiple compression farctures of the thoracic vertebrae.
.
CHEST (PORTABLE AP) [**2151-12-13**] 12:46 PM
INDICATION: Shortness of breath.
FINDINGS: Allowing for apical lordotic projection,
cardiomediastinal contours are within normal limits. There are
no focal areas of consolidation within the lungs, and no pleural
effusions are identified on this single projection. Attenuation
of the upper lobe vasculature is suggestive of underlying
emphysema.
IMPRESSION: Emphysema. No pneumonia.
Brief Hospital Course:
A/P: 47 yo with COPD admitted with increasing respiratory
disress now stable at baseline and transferred to floor.
.
# Respiratory distress- As the patient has severe disease and
has a history of intubation and severe decompensation, the
patient was felt to require MICU care but rapidly improved. The
cause for her decompensation is likely a viral infection given
her recent fatigue and shortness of breath coupled with her
occasional rhinorrhea. Already r/o flu and r/o MI. (Of note,
bronchial washing in OMR were logged incorrectly and are not
from this patient) Will continue to treat for COPD
- prednisone 40mg; plan [**Month/Day/Year 15123**] back to prednisone 20mg over the
next 3 days
- completed 7 days Levofloxacin for COPD exacerbation
- Ipratroprium, atrovent q6h prn
- continue home pulm meds: montelukast, advair 500-50,
tiotropium 18mcg daily
- viral cultures negative
- RISS while on steroids
.
# Tachycardia: Patient with chronic history of sinus
tachycardia. Cause unclear. Fluid resuscitated. TFTs checked.
- Continue dilt
.
# Osteoporosis: Patient with history of persistent fractures as
a result of persistent steroid administration.
- Continue Forteo as per outpatient regimen
- Con't Vitamin D and calcium
.
# Hypertension- Currently normotensive, will continue on home
regimen
.
# Leukocytosis- Infectious causes ruled out and afebrile. Likely
[**3-18**] steroids
- Con't to monitor
.
# Abdominal discomfort: Likely [**3-18**] constipation as improved with
bowel movement and LFT unremarkable.
- continue bowel regimen
.
# Anxiety: Continue outpatient medications.
.
# Sleep apnea: continued nightly CPAP.
.
# Pain control: Likely due to chronic fractures. Will continue
oxycodone SR and IR for pain control as per outpatient regimen.
.
# FEN- [**Doctor First Name **] diet, has elevated HCO3 due to chronic CO2 retention
at baseline, monitor lytes.
Medications on Admission:
1. Prednisone 20 mg (finished [**Doctor First Name 15123**] 2 weeks ago)
2. Furosemide 80 mg PO DAILY
3. Advair Diskus 500-50 mcg/Dose Disk with Device 1 Inh [**Hospital1 **]
4. Montelukast 10 mg PO QHS
5. Verapamil 80 mg PO Q8H
6. Nexium 40 mg PO BID
7. Tiotropium Bromide 18 mcg Capsule Inh DAILY
8. Quetiapine 25 mg PO BID
9. Mirtazapine 15 mg PO once a day
10. Gabapentin 600 mg PO HS
11. Oxybutynin Chloride 5 mg PO BID
12. Citracal Plus 2 tabs qam, 1 tab qhs
13. Cholecalciferol (Vitamin D3) [**Numeric Identifier 1871**] unit PO 2x weekly
14. Dulcolax QHS PRN
15. Clonazepam 1 mg PO QHS
16. Clonazepam 0.5 mg PO QAM
17. Sertraline 50 mg PO DAILY
18. Potassium 20 mEq PO BID
19. MVI PO Daily
20. Lisinopril 5 mg po daily
21. Senna QHS PRN
22. Potassium 20 mEq QD
23. Baclofen 10 mg TID
24. Oxycodone SR 10 mg [**Hospital1 **]
25. Forteo QD
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
Two (2) pufss Inhalation twice a day.
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 7 days: two tabs (=40mg) daily on [**12-21**] and [**12-22**], then 20mg
daily ([**Month/Day (4) 15123**] back to home dose).
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for anxiety.
9. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed for
constipation.
11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
14. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 2X/WEEK (MO,FR).
15. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
16. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
17. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Insulin Lispro (Human) 100 unit/mL Solution Sig: Two (2)
units Subcutaneous ASDIR (AS DIRECTED): 2 units for FSBG
151-200, 4 units for FSBG 201-250, 6 units for FSBG 251-300, 8
units for FSBG 301-350, 10 units for FSBG 351-400.
19. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
20. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
21. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
22. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
24. Teriparatide 750 mcg/3 mL Pen Injector Sig: Three (3) ML
Subcutaneous daily () as needed for osteoporosis.
25. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
26. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
27. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every 4-6 hours as needed for dyspnea.
28. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: [**2-15**] puff
Inhalation every 4-6 hours as needed for dyspnea.
29. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day: 1 packet = 20 mEq.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
1. COPD, PFTs in [**9-19**] with FEV1 0.30 (13%), FVC 1.02 (34%) and
FVC/FEV1 38% - on Home O2 at 4L NC, on chronic steroids, hx of
prolonged intubation requiring trach for resp failure in [**1-15**],
[**3-21**]. She was recently taken off the lung transplant list at the
[**Hospital6 1708**] due to compression fractures. Has
previous history of asthma per OMR
2. Hypertension
3. Anxiety
4. Leukocytosis of unknown etiology with negative BMBx.
5. Osteoporosis with compression fractures
6. Shoulder pain
7. History of positive PPD s/p 6mos of isoniazid
8. Mitral valve prolapse
9. Obstructive sleep apnea on BiPAP (15/12 every night)
Discharge Condition:
Stable. Requires 4 liters oxygen by nasal cannula.
Discharge Instructions:
Call your doctor for increasing shortness of breath or
increasing oxygen needs or anything that is medically concerning
to you.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-12-23**] 2:25
Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-12-23**] 2:45
Call Dr [**Last Name (STitle) **] for an appointment within the next month.
[**Telephone/Fax (1) 250**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
ICD9 Codes: 4019, 4240, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1920
} | Medical Text: Admission Date: [**2133-8-20**] Discharge Date: [**2133-8-25**]
Service: MEDICINE
Allergies:
Flagyl / Proton Pump Inhibitors (Benzimidazole)
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 85 year old male with history of diastolic heart
failure, copmlete heart block (now s/p PPM [**6-7**]) ESRD on HDHD,
h/o MRSA bacteremia and thrombocytopenia, likely secondary to
drug reaction (PPI?) who presents from [**Hospital 100**] rehab with
dyspnea. Patient reports SOB x 1 day. He denies any chest
pain, palpitations, N/V, abdominal pain, diarrhea, fevers,
chills or recent cough. Patient states he was walking with
PT/OT and became SOB and dizzy. Per ED report patient felt
better after HD yesterday, but continued with SOB today along
with AMS. ABG done at [**Hospital 100**] Rehab which showed increased CO2
and decreased PaO2 from baseline so he was transferred to [**Hospital1 18**]
for further care.
In the ED: Temp 97, HR 71, BP 122/53, RR 15 88% on RA 99%
on NRB and then on CPAP. CXR done which showed worsening
bilateral pleural effusions. He was given CTX 1gm x 1, Levaquin
500mg IV x 1, Vanco 1gm IV x 1 and was transferred to MICU.
On arrival, patient stated he was feeling well. +mild SOB.
CPAP was removed and patient was with 98% O2 saturation on 2LNC.
ABG: 7.21 // 77 // 149 // 32
Past Medical History:
Diastolic Congestive Heart Failure: ECHO [**3-7**] EF of 50% &
severe LVH
Atrial fibrillation previously on Coumadin (until GI bleed
[**6-7**]), failed cardioversion
s/p Pacemaker placement [**6-7**] for complete heart block
Peripheral vascular disease s/p right lower extremity bypass
Hiatal hernia with intrathoracic stomach (confirmed by [**2133-6-16**]
CT)
Hypertension
Gout
?Prostate followed by Urology (denies symptoms of BPH)
Chronic Kidney Disease on HD
Social History:
Patient has an insurance business and worked daily until recent
sicknesses. No current tobacco use. There is no history of
alcohol abuse.
Occupation: Owns Insurance business
Drugs: None
Tobacco: None
Alcohol: None
Other:
Family History:
There is no family history of premature coronary artery disease
or sudden death. Patient's daughter had "kidney disease" and is
now s/p renal transplant. 2 sons and 1 daughter.
Physical Exam:
Tmax: 36.8 ??????C (98.2 ??????F)
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 70 (70 - 76) bpm
BP: 107/53(64) {82/16(37) - 112/93(97)} mmHg
RR: 27 (14 - 27) insp/min
SpO2: 100%
Heart rhythm: AV Paced
Height: 65 Inch
General Appearance: Well nourished, No acute distress,
Overweight / Obese, No(t) Thin, 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
Lymphatic: Cervical WNL, Supraclavicular WNL, No(t) Cervical
adenopathy
Cardiovascular: (PMI 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, No(t) S4, No(t) Rub,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),
(Percussion: No(t) Resonant : , No(t) Hyperresonant: ), (Breath
Sounds: No(t) Clear : , Crackles : midway up posterior lung
fields, No(t) Bronchial: , No(t) Wheezes : , Diminished:
bilateral bases)
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender: , No(t) Obese
Extremities: Right: 2+, Left: 2+, to ankles bilaterally
Musculoskeletal: No(t) Muscle wasting
Skin: Not assessed, Rash:
Neurologic: Follows simple commands, Responds to: Not assessed,
Oriented (to): person, place, time, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
[**2133-8-20**] 01:21PM PT-14.5* PTT-31.3 INR(PT)-1.3*
[**2133-8-20**] 01:21PM PLT SMR-VERY LOW PLT COUNT-61*
[**2133-8-20**] 01:21PM NEUTS-68 BANDS-0 LYMPHS-13* MONOS-9 EOS-10*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2133-8-20**] 01:21PM WBC-6.9 RBC-3.30*# HGB-10.8* HCT-36.9*#
MCV-112* MCH-32.7* MCHC-29.2* RDW-17.3*
[**2133-8-20**] 01:21PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.4
[**2133-8-20**] 01:21PM CK(CPK)-28*
[**2133-8-20**] 01:21PM GLUCOSE-106* UREA N-20 CREAT-3.8*# SODIUM-140
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-31 ANION GAP-14
[**2133-8-20**] 01:30PM cTropnT-0.23*
[**2133-8-20**] 01:31PM LACTATE-0.9
[**2133-8-20**] 01:31PM TYPE-ART PO2-149* PCO2-77* PH-7.21* TOTAL
CO2-32* BASE XS-0 INTUBATED-NOT INTUBA
[**2133-8-20**] 03:59PM TYPE-ART PO2-95 PCO2-58* PH-7.30* TOTAL
CO2-30 BASE XS-0
Brief Hospital Course:
Pt is an 85 year old male with history of diastolic heart
failure, copmlete heart block (s/p PPM [**6-7**]) ESRD on HDHD, h/o
MRSA bacteremia and thrombocytopenia, likely secondary to drug
reaction (PPI?) who presented from [**Hospital 100**] rehab with dyspnea.
Initially admitted to MICU with dyspnea and ? CO2 retention
requiring BiPAP. Pt was called out to the floor and did well for
several days. He was then noted to be hypoxic at dialysis. he
also underwent therapeutic thoracentesis on right side with good
relief. The following morning, he was found to be somnolent
with myoclonic jerking. ABG demonstrated 7.24/70/89 on 3 L/min.
He was transferred back to the MICU for ? bipap. He was noted
to be continually hypercarbic throughout his admission.
Pt's BPs continued to drop and he became unable to tolerate HD.
On the day prior to death, dialysis had to be stopped
prematurely (removed 2.2L) due to hypoxia and hypotension. The
morning of his death, he was noted to be acutely hypoxic and
hypercarbic. CXR revealed a collapsed left lung and increase in
right sided pleural effusion. Discussed situation with family
and it was decided to not escalate care (had been decided upon
to make him DNR/DNI the night before). Over the course of the
day, he became increasinly hypoxic, hypercarbic, acidotic, and
hypotensive. He was pronounced deat at 17:25 on [**2133-8-25**].
Family was present and declined autopsy.
.
#. Dyspnea: Patient presented from rehab with acute dyspnea
and SOB with walking the day of admission likley from increasing
pleural effusions. Patient had been afebrile, without
leukocytosis, bandemia or cough making PNA very unlikely. Given
that CTX/Levaquin/Vanco started in the ED were D/Ced. Nephrology
was notified that the patient was admitted and Pt was sent to HD
for ultrafiltration on the day of transfer off of the MICU. CEs
were negative.
#. End Stage Renal Disease: Patient on MWF HD treatments. Pt
continued HD as an in patient with removal of excess fluid.
#. C Diff colitis: Patient with (+) C diff tox x 3 during
admission in [**Month (only) 205**]. On Vanco at [**Hospital 100**] rehab until [**2133-8-24**].
Vanco 250mg PO QID was continued as an in patient.
#. Diastolic heart failure: Last ECHO [**2133-7-17**] with EF >55% and
mild mitral regurgitation. HD was done as above.
#. Atrial Fibrillation: Patient is currently V-paced. We
continued outpatient amiodarone. Anticoagulation was held given
recent history of GI bleed.
#. Thrombocytopenia: Thought to be [**1-31**] to drug reaction one
month ago (PPI), currently at 61, down from 113 at last
admisstion. This suggests the possibility of MDS. Follow up with
a hematologist may be indicate in the future as an outpatient,
but since the remainder of his counts are WNL no H/O consult was
called.
Medications on Admission:
Amiodarone 200mg daily
Calcium Gluconate 650mg TID
Midodrine 5mg TID
Simethicone 80mg [**Hospital1 **]
Vanco 250mg PO QID
Vit B/Vit C/Folic Acid
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2133-8-25**]
ICD9 Codes: 5856, 5180, 2762, 4280, 4439, 2749, 4589, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1921
} | Medical Text: Admission Date: [**2195-9-14**] Discharge Date: [**2195-9-14**]
Date of Birth: [**2121-1-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
consulted for SDH found on CT at OSH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 year old male on coumadin for ICD was not feeling well
around 8 pm last night and he went to sleep at that time. This
morning at 5:30 am his wife noticed that he had not moved
positions since he went to bed and one of his legs was hanging
over the side of the bed. She was unable to arouse him and he
went to an OSH. He was intubated and had a head CT which
revealed
a large right SDH with midline shift. The patient was given
cerebryx and 50 mg of mannitol and sent to [**Hospital1 18**]. When
neurosurgery was called the patient the ER had ordered another
50
mg of mannitol to be given as well as vitamin K and Profiline
Past Medical History:
Has ICD - on coumadin
adenocarcinoma of the prostate - s/p brachytherapy
Social History:
lives with wife, has a daughter, son, and
daughter-in-law who are here in the ER with him
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM upon admission:
T:99.8 BP:109/56 HR:74 RR:16 O2Sats:100% vented
Gen: intubated and sedated
HEENT: Pupils:5mm, unreactive bilaterally EOMs-unable
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Unresponsive.
Cranial Nerves:
I: Not tested
II: Pupils 5 mm, unreactive bilaterally.
III-XII: unable to test
Motor: Upper extremities extending to pain. Lower extremities
withdrawing to pain.
Toes upgoing bilaterally
Pertinent Results:
CT Head from OSH [**2195-9-14**]:
The patient had a very large right SDH with midline shift and
herniation. Formal read is unavailable at this time.
Brief Hospital Course:
The patient was admitted to the ICU after the decision was made
to keep him comfortable since he had a devasting hemorrhage with
herniation. He was extubated several hours later after the
family had a chance to see him and spend some time with him. The
patient expired about 1 [**1-23**] after extubation.
Medications on Admission:
Vytorin 10-80 mg PO QHS
HCTZ 25 mg PO daily
Lopressor 200 mg PO BID
KCL 20 mEq PO daily
Diovan 320 mg PO daily
Coumadin dose changes
Tylenol 80-160 mg PO PRN pain
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right SDH with mass effect and herniation
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2195-9-14**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1922
} | Medical Text: Admission Date: [**2162-1-25**] Discharge Date: [**2162-1-30**]
Service: GENERAL SURGERY
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname 2470**] is a 78-year-old
female who is status post open cholecystectomy for acalculous
cholecystitis on [**2162-1-2**]. She was admitted for that
procedure for 5 days and was doing well
postoperatively and in follow up.
She came to the Emergency Room at [**Hospital6 2018**] on [**2162-1-24**] for complaints of nausea, vomiting,
and fever for two days. There was mild abdominal pain. There
were no sick contacts. She also complains of anorexia for one day
duration, fever to 100.9 at home. There was no jaundice. No
chest pain. No diarrhea. No constipation. No dysuria or
pyuria. She had also complained of some slight cough.
PAST MEDICAL HISTORY:
1. History of hypertension
2. Perforated Diverticulitis
3. History of palpitations
4. History of hysterectomy
5. History of appendectomy
6. History of colon resection/Diverting Colostomy
7> Colostomy Takedown
HOME MEDICATIONS:
1. Lipitor 10 mg per day.
2. Zestril 10 mg q.d.
3. Klonopin 0.5 b.i.d.
4. Metoprolol 25 b.i.d.
ALLERGIES: The patient is allergic to penicillin.
SOCIAL HISTORY: The patient denied a history of alcohol or
tobacco use.
PHYSICAL EXAMINATION ON ADMISSION: The patient was an
elderly female in no acute distress. Her temperature was
101.1, heart rate 126, blood pressure 151/65, breathing at 18
times per minute on room air, 02 saturation at 100%. Her
extraocular movements were intact. The pupils were equal and
reactive to light. There was no JVD. The chest was clear to
auscultation bilaterally. The heart revealed a regular rate
and rhythm. Normal heart sounds with no murmurs. The
abdominal examination showed a soft nondistended abdomen with
surgical scars healing, no drainage, no erythema, moderately
tender in midgastric regions. The extremities had no edema.
LABORATORY DATA ON ADMISSION: White blood cell count 15.6,
hematocrit 31.2%, platelets 436,000. Sodium 135, potassium
1.9, chloride 97, bicarbonate 22, BUN 29, and creatinine 0.8.
The blood sugar level was 144. ALT 352, AST 177, alkaline
phosphatase 1,991, total bilirubin 2.0, amylase 8, lipase 8.
A urinalysis was negative.
The patient was admitted and an ultrasound showed a [**4-20**] x 5
cm fluid collection in the gallbladder fossa likely to be a
hematoma, biloma or abscess. A CT scan performed confirmed this
collection and it had enhancing features consistent with an
abscess.
The chest x-ray was negative.
HOSPITAL COURSE: The patient was admitted to the hospital
for a subhepatic abscess in the gallbladder fossa and she needed
underwent ultrasound guided percutaneous drainage and antibiotic
treatment on [**2162-1-25**]. She was transferred to the
Surgical Intensive Care Unit after the drainage for management of
fluid status and hypotension. She was hydrated in the SICU with
close monitoring. She received 1 unit of packed red blood cells.
She subsequently recovered very well. She was treated
prophylactically with vancomycin, gentamicin, and clindamycin
until her microbiology results came back which showed a pan
sensitive Klebsiella pneumoniae
She was subsequently treated with Ciprofloxacin 500 mg b.i.d.
Initially, her drain put out a approximately 500cc of bile and
purulent drainage which subsequently diminished over the course
the next 2-3 days [**2162-1-29**]. The drain stopped putting
out fluid and an MRCP was also obtained to evaluate for an
undrained fluid collections or common bile duct stones or sludge.
There was no final report yet as of the time of her discharge. A
brief review of the film showed no obvious fluid collection and
there does not appear to be any common bile duct obstruction
as well.
The patient did very well on pain control with oral pain meds and
she is discharged to home with VNA Service for drain
management. She will resume her outpatient medications in
addition to Percocet for pain control, Colace, and
ciprofloxacin 500 mg b.i.d. She will follow-up with Dr. [**First Name (STitle) 2819**]
in approximately ten days.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSIS:
1. Right upper quadrant abscess, status post ultrasound guided
drainage and pigtail catheter placement
2. Hypovolemia and sepsis requring 48 hour ICU stay
3. Anemia requiring blood transfusion
DISCHARGE STATUS: To home with VNA services for drain care
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**]
Dictated By:[**Name8 (MD) 6276**]
MEDQUIST36
D: [**2162-1-30**] 11:09
T: [**2162-1-30**] 11:20
JOB#: [**Job Number 100621**]
ICD9 Codes: 2765, 0389, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1923
} | Medical Text: Admission Date: [**2144-9-26**] Discharge Date: [**2144-10-3**]
Date of Birth: [**2066-9-8**] Sex: M
Service: MEDICINE
Allergies:
Triaminic
Attending:[**Doctor First Name 1402**]
Chief Complaint:
transfer from [**Hospital3 3583**] with temporary pacing wire for
complete heart block in order to get pacemaker and possible
implanted defibrillator
Major Surgical or Invasive Procedure:
Insertion of Cardiac Pacemaker
History of Present Illness:
This is a 78 y/o male with HTN, Hypercholesterolemia, S/P AVR
(St. [**Male First Name (un) 923**], [**2132**], on coumadin) who was transferred from [**Hospital1 **](after presenting with dizziness) for AV conduction
defect, likely complete heart block. At [**Hospital3 3583**] he was
found to have heart rate in the 30's with markedly long PR
intervals witha baseline left bundle branch block. He was
asymptomatic and hymodynamically stable. He had a noraml CXR,
was ruled out for MI by cardiac enzymes. He had a temporary
pacing wire placed in Right IJ with rate 60, MA of 10 and
Sensitivity of 0.5.
.
He denies CP, SOB, N/V, diaphoresis with these episodes. He has
had stable anginal pain in past but has not had it during these
episodes. He has two pillow orthopnea. He denies PND. He reports
nocturia.
He has not started any new medications or chnged an y of his
medications. He has been on atenolol and stable for some time.
.
ROS: no history of lung disease, no cough, has GERD symptomes,
no abdominal pain, no nausea, no vomiting, no constipation, no
diarrhea, no bleeding (melena, hematochezia), no h/o liver
disease, has history of joint pain/arthritis, no claudication.
Past Medical History:
HTN
AVR ([**2130**], St. [**Male First Name (un) 923**] Mechanical Valve on COumadin at home)
Left Bundle Branch Block
Prostate Ca treated with Radiation and Turp
Social History:
Lives with wife in [**Name (NI) 3320**]. No children. Former Surveyor.
Smoked for 40 years 1.5 ppd. No alcohol use. No drug use.
Family History:
Father lived to [**Age over 90 **] years old of diabetes complications. Mother
lived to [**Age over 90 **] years old. Died of CVA.
Physical Exam:
VITALS: T 97.8 HR 60 BP 189/56 RR 20 Sat 96 Pain 0/10
GENERAL: well developed, older male in NAD. Pleasant, very
talkative.
GAIT: not assessed for risk of fall.
SKIN: chronic venous stasis changes of lower legs
HEAD: NC/AT
EARS: Normal external structure
EYES: EOMI, Anicteric, PERRL
NOSE: Non deviated septum
THROAT: tongue midline, upper dentures
NECK: No stiffness, No masses, No LAD, Palpable carotid pulses,
soft left bruits, no tracheal deviation
CHEST: no supraclavicular or axillary LAD, Lungs Clear to
Asculation, No Wheezes/Rhonchi/Crackles
HEART: RRR, No Murmurs/Gallops/Rubs
ABDOMEN: Mildly Obese, No scars, NABS, mildly Distended, Soft,
No organomegaly, No masses, No guarding, No rebound
EXT: No clubbing/cyanosis/edema. 2+ Pulses right DP, Decreased
pulse in left DP.
NEURO:
MS oriented to person, place, time
CN II-XII intact
Muscle Strength RUE [**5-28**] LUE [**5-28**] LLE [**5-28**] RLE [**5-28**]
Coord intact FTN nl HTS nl
Pertinent Results:
Labs From [**Hospital 63139**] Hospital [**2144-9-26**]
141 108 23 136 AGap 10
5.0 23 1.4
Ca: 9.2 Mg: 1.9 P: 3.9
.
.....13.3..92
7.6>-----< 180
.....39.4
.
PT: 23.5 PTT: 35.9 INR: 2.22
CPK 130->102->78
cTropI <0.038 x 2
.
Labs on Admission at [**Hospital1 18**] [**2144-9-26**]
5:49p
142 110 22 105 AGap 10
4.6 22 1.2
Ca: 9.5 Mg: 1.9 P: 3.7
.
....13.4..91
10.3>---< 160
....38.0
.
PT: 18.4 PTT: 30.7 INR: 2.3
.
EKG: V Paced at 60 bpm. Left bundle branch block.
.
Echo [**2144-9-27**]:
Conclusions:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with septal, anterior and
apical hypokinesis. The inferior wall also appears mildly
hypokinetic. The lateral wall moves best. No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
and free wall motion are normal. A mechanical aortic valve
prosthesis is present. The prosthetic aortic valve leaflets are
thickened. The transaortic gradient is normal for this
prosthesis. A paravalvular aortic valve leak is probably
present. Mild (1+) aortic regurgitation is seen. No valvular
vegetations seen but cannot exclude opn the basis of this study.
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.]
There is no pericardial effusion.
IMPRESSION: Moderate to severe regional LV systolic dysfunction
c/w CAD.
Mechanical aortic prosthesis with normal gradients but mild
paravalvular
regurgitation.
.
Echo [**2144-9-29**]:
Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. The interatrial septum is aneurysmal, but no atrial
septal defect is seen by 2D or color Doppler. There are complex
(>4mm, non-mobile) atheroma in the descending thoracic aorta and
simple atheroma in the ascending aorta. A bileaflet aortic valve
prosthesis is present. The aortic prosthesis leaflets appear to
move normally. No masses or vegetations are seen on the aortic
valve. No aortic valve abscess is seen. Mild (1+) aortic
regurgitation is seen. [The amount of regurgitation present is
normal for this prosthetic aortic valve.] The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
IMPESSION: Well seated, normal functioning aortic bileaflet
prosthesis.
Interatrial septal aneurysm. No vegetations or abscess
identified.
Brief Hospital Course:
78 y/o male with HTN, Hypercholesterolemia, S/P AVR (St. [**Male First Name (un) 923**]
Mechanical Valve, [**2132**], on coumadin) presented with
dizziness/lightheadedness to [**Hospital3 3583**] and found to have
complete heart block. Had temporary pacing wire placed and then
transferred for pacememker and possible defibrilator.
1. Complete heart block: He was admitted with temporary pacing
wire and had pacemaker placed. His heart rhythm was continusly
monitored by telemetry. His atenolol was held on admission and
restarted after the pacer was placed. He was started on a
heparin drip as his coumadin was being held for procedure and
heparin and coumadin werelater restarted. He was followed by Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 63140**] of EP. He was transfered from CCU
to step down floor after pacer implanted.
.
2. CAD: EF of 38% from nuclear study in [**8-28**]. He was not cathed
at [**Hospital1 18**]. He has a history of anginal symptomes and is followed
by Dr. [**Last Name (STitle) 47696**] at [**Hospital3 3583**]. We started him on aspirin
during his stay. Up titrated his isordil and increased his dose
of BB at time of discharged.
.
3. AVR: S/P AVR with mechanical St. Jude valve in [**2132**]. He was
on coumadin at home. We held his coumadin for the procedure and
start heparin drip for anticoagulation. He was discharged with
therapeutic range INR on coumadin.
.
4. HTN: His blood pressure was elevated at times during his
hospital stay. We added Lisinopril and HCTZ and increased his
dose of isordil and BB.
.
5. Hypercholesterolemia: We continued him on his home dose of
atorvaststin.
.
6. GERD: We gave him protonix for his GERD history.
.
7. Left lower extremity pain: Pt notes increased left "calf"
pain when he walks. Palpable L PT and warm, so not at risk for
limb-threatening ischemia. Would benefit from formal ABI's as
outpt and treatment based on these studies.
Medications on Admission:
HOME MEDS:
Lipitor 5mg QD
Isordil 20 mg TID
Lisinopril 2.5 mg TID
Coumadin 3 mg QD
Terazosin 3 caps QD
Atenolol 12.5 mg QD
Omeprazole 40mg QD
.
TRANSFER MEDS:
Lipitor 5mg QD
Pantoprazole 40 QD
Reglan PRN
Anzimet PRN
Atropine PRN
.
ALLERGIES:
Triaminic (unable to void when he took it)
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Complete Heart Block
Secondary: Stable chronic angina
Discharge Condition:
Good, without dizziness.
Discharge Instructions:
Please call your cardiologist, Dr. [**Last Name (STitle) 5310**], FIRST THING on
Monday. You need to be seen by him on Monday for 3 reasons:
1) Interrogation of pacemaker
2) Inspection of pacemaker pouch
3) Labs as follows: HCT, INR, Creatinine.
IF Dr. [**Last Name (STitle) 5310**] can't see you on Monday, or cannot
interrogate the pacemaker, Please follow up at the [**Hospital1 18**] Device
Clinic on Monday [**2144-10-5**] at the [**Hospital Ward Name 23**] center at [**Hospital1 18**] at 2PM
so that the Cardiologists can check on your pacemaker.
PLEASE have Dr. [**Last Name (STitle) 5310**] contact [**Hospital1 18**] with the results of
his examinations on Monday. He can call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
([**Telephone/Fax (1) 63141**]. Or email [**University/College 63142**]
Please follow up with the coumadin clininc in [**Location (un) 3320**] to have
your blood checked frequently while on coumadin.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2144-10-5**] 2:00
ICD9 Codes: 4240, 4254, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1924
} | Medical Text: Admission Date: [**2169-7-7**] Discharge Date: [**2169-7-19**]
Date of Birth: [**2111-10-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Tetracycline / Sulfa (Sulfonamides) / Morphine /
Codeine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Severe diffuse tracheobronchomalacia.
Major Surgical or Invasive Procedure:
[**2169-7-7**]: Right thoracotomy and tracheoplasty with mesh, right
main stem bronchus/bronchus intermedius bronchoplasty with mesh,
left main stem bronchus bronchoplasty with mesh, bronchoscopy
with bronchoalveolar lavage.
[**2169-7-10**]: Flexible Bronchoscopy
[**2169-7-16**]: Trach changed to 6.0 Portex Trach cuff deflated
History of Present Illness:
Mrs. [**Known lastname 42611**] is a 57 y/o, female with severe TBM with previous
silicone-Y-stent and tracheostomny tube that resulted in
symptomatic improvement but the patient was hesitant to undergo
a TBP at that time. She developed another episode of respiratory
failure with septic shock 2 months ago in the setting of
pneumonia which required another silicone-Y-stent and
tracheostomy tube and then later on, had the silicone-Y-stent
removed secondary to granulation tissue. The patient was
discharged to [**Hospital1 **] Rehab where she was weaned off
mechanical ventilation and has been tolerating continuous red
capping for the last few weeks. She has been participating in
physical therapy and reports being "active" while she denies any
dyspnea, chest pain, neck pain, cough, hemoptysis, wheezing,
feve, chills, night sweats. She has been tolerating oral feeding
and denies any dysphagia. She is being admitted following her
trachealplasty.
Past Medical History:
# tracheobronchial malacia: s/p stent placement in [**2167-11-14**] then
removal in [**2168-11-13**] due to persistent secretions
# obesity
# GERD
# avascular necrosis of the L hip s/p L hip replacement in [**2161**]
# alcohol abuse
# RUE DVT in [**2167-10-14**]
# COPD
# granulomas in L lung
# s/p TAH
# s/p appendectomy
Social History:
Ms. [**Known lastname 42611**] had been a regional manager at insurance company.
She lived with boyfriend > 10 years. She had not been in contact
with her brother in ~1 year, however, brother has visited her
frequently while in the hospital and he is from [**State **] area and
lives at a distance. Patient has history of significant
alcoholism. Former smoker
Family History:
Noncontributory
Physical Exam:
VS: T 96.5 HR: 93 SR BP: 110/70 Sats: 93% TM 50%
General: 57 year-old sitting in chair in no apparent distress
HEENT: mucus membranes moist
Neck: trach in place. Site clean
Card: RRR
Resp; decreased breath sounds with scattered crackles
GI: benign. PEG in place
Extr: warm no edema
Incision: Right thoracotomy site clean, margins well
approximated
Neuro: awake, alert, responds appropriately
Pertinent Results:
[**2169-7-18**] WBC-6.4 RBC-3.17* Hgb-8.3* Hct-26.5 Plt Ct-303
[**2169-7-16**] WBC-8.2 RBC-3.11* Hgb-8.1* Hct-26.3 Plt Ct-238
[**2169-7-18**] Glucose-111* UreaN-19 Creat-0.7 Na-146* K-4.2 Cl-105
HCO3-35
[**2169-7-16**] Glucose-105* UreaN-18 Creat-0.8 Na-145 K-4.0 Cl-105
HCO3-33
[**2169-7-12**] Glucose-135* UreaN-11 Creat-1.1 Na-145 K-4.0 Cl-105
HCO3-34
[**2169-7-7**] Glucose-200* UreaN-19 Creat-0.8 Na-143 K-3.8 Cl-108
HCO3-27
Cultures: [**2169-7-8**] SPUTUM Endotracheal.
GRAM STAIN (Final [**2169-7-8**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2169-7-10**]):
MODERATE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
CXR:
[**2169-7-18**] FINDINGS: The tracheostomy tip is 4 cm above the
carina. The heart size is at the upper limits of normal. The
mediastinal contours appear mildly widened but unchanged from
prior study. The lung volumes are low. Bibasilar opacities may
represent atelectasis, although underlying infectious process
cannot be ruled out. Blunting of the costophrenic angles
bilaterally is consistent with small pleural effusions. A coiled
tube projecting over the epigastrium is most consistent with a
percutaneous feeding tube. The osseous structures demonstrate
mild scoliosis.
[**2169-7-17**]: continued low lung volumes with some elevation of the
right hemidiaphragmatic contour. Although
bibasilar opacifications persist, there appears to be some
increased aeration on the left. This most likely represents some
effusion and atelectasis, though superimposed pneumonia must be
considered if there are appropriate clinical symptoms.
[**2169-7-13**]: : In comparison with the study of [**7-13**], there are
continued low lung volumes in a patient with tracheostomy tube.
Bibasilar opacification is consistent with atelectasis and
effusions. In the appropriate clinical
setting, the possibility of supervening pneumonia could not be
excluded.
[**2169-7-7**]: Right basal chest tube is in place. There is no
evident pneumothorax. There are low lung volumes. Bibasilar
opacities are likely atelectases, right greater than left. There
is mild right subcutaneous emphysema. Tracheostomy tube is in
standard position. Cardiac silhouette is obscured by lung
abnormality. Catheter projects over the upper abdomen.
Brief Hospital Course:
Ms. [**Known lastname 42611**] was admitted to the Thoracic surgery service at [**Hospital1 18**]
on [**2169-7-7**] after she was taken to the operating room on [**2169-7-7**]
for tracheoplasty by Dr. [**Last Name (STitle) **]. Please see operative
report for full details. She remained ventilated with Trach mask
trials until [**2169-7-17**] when she tolerated Trach mask x 24 hours
with oxygen saturations stable at 93-95% on 50% humidified
oxygen.
Neuro: Awake alert with episodes of anxiety which responded to
Seroquel.
Pulmonary: The patient required aggressive pulmonary toilet,
mucolytic nebs, chest PT and ambulation. She continued to do
well on Trach collar. Her Trach was downsized to a 6.0 Portex
w/o inner cannula, cuff (deflated) from #7 [**Last Name (un) 295**]. She
tolerated this well. Oxygen saturations with 50% humidified air
were 93-95%.
CV: The patient was maintained on TID diltiazem in SR 80-90.
Hemodynamic stable with blood pressures 110-140.
GI: Her bowel function returned with bowel regime in place.
Nutrition: She was seen by nutrition who recommended Replete
with fiber to a Goal of 70 mL/hr. Strict NPO. Sit upright when
receiving tube feeds.
Speech: She was seen by Speech for PMV evaluation initially but
was unable to tolerate [**2-14**] edema. Repeat swallow evaluation on
[**2169-7-18**] her oxygen saturations decreased. Vocal quality is
strained likely [**2-14**] irritation and swelling, but she can wear it
for trials throughout the day. Her vocal quality is improved
with
cues to "have an easy onset" to speech.She was taken for a
video-swallow on [**2169-7-19**] which showed aspiration. She should
remain NPO including all medications. Initiate swallow therapy
to improve oral and pharyngeal strength.
Renal: renal function within normal range with good urine
output. Electrolytes were replete as needed.
ID: Bronchoscopy x 2 for mucus plug with BAL GNR consistent with
normal flora. She completed a 7 Day course of Levofloxacin.
Heme: HCT stable at baseline 26.0-30. Anticoagulation was not
restarted since she completed her treatment for Right cephalic
thrombus.
Endocrine: blood sugars were 88-140's requiring occasional
insulin sliding scale coverage immediately postoperatively.
Pain: Epidural Bupivacaine and Dilaudid was managed by the Acute
pain service, once removed she was converted to PO pain
medications via PEG, and Lidocaine patch placed on either side
of the right thoracotomy site.
Disposition: She was followed by physical therapy. She continue
to make steady progress but continued need for aggressive
physical and speech therapy is required.
She was discharged to [**Hospital1 700**] in [**Location (un) 701**]
[**2169-7-19**].
Medications on Admission:
Polyethylene Glycol
Senna
Docusate Sodium
Folic Acid
Sucralfate 1 g. PO QID
Tiotropium Bromide one inhalation daily
Diltiazem HCL 360 mg PO daily
Artificial Tears
Miconazole
Acetaminophen
Albuterol Sulfate nebulized solution Q6Hrs. PRN
Ipratropium Bromide nebulized solution Q6Hrs. PRN
Magnesium Hydroxide
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for SOB.
3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Diltiazem HCl 60 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day): give via PEG.
5. Quetiapine 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day): give via PEG.
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): cut in
[**1-14**] on either side of right thorocotomy incision.
7. Acetylcysteine 20 % (200 mg/mL) Solution [**Street Address(2) **]: Three (3) ML
Miscellaneous Q12H (every 12 hours) as needed for thick
secretions: mix with albuterol to prevent bronchospasm.
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Street Address(2) **]: [**5-22**] mL
PO every 4-6 hours as needed for pain: via PEG.
9. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
10. Acetaminophen 325 mg/10.15 mL Suspension [**Last Name (STitle) **]: Ten (10) mL PO
every six (6) hours as needed for pain.
11. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO twice
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
-Tracheobronchomalacia s/p tracheoplasty
-Atrial fibrillation- new [**3-/2169**] controlled with diltiazem
-TBM
-avascular necrosis of the L hip s/p L hip replacement in [**2161**]
-alcohol abuse
-R Cephalic DVT in [**2167-10-14**]
-COPD
-granulomas in L lung
-s/p TAH
-s/p appendectomy
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:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Trach concerns.
-Incision develops drainage
-You may shower. No tub bathing or swimming
-Strict NPO
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3020**] Date/Time:[**2169-8-8**]
9:30 in the [**Hospital Ward Name 121**] Building Chest Disease Center [**Hospital1 **] I
Chest X-Ray [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology 30
minutes prior your appointment
Completed by:[**2169-7-24**]
ICD9 Codes: 5180, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1925
} | Medical Text: Admission Date: [**2135-12-26**] Discharge Date: [**2135-12-31**]
Date of Birth: [**2071-11-22**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
female with approximately a 6-month history of progressive
leg weakness and burning sensation below the waist, as well
as tingling sensation in her feet and fingers. The patient
is status post multiple laminectomies and presents with
approximately a 15-month long history of progressive leg
weakness and burning sensation and tingling in her feet and
fingers.
PAST MEDICAL HISTORY: She has a past medical history of
hypertension, dyspnea on exertion secondary to obesity,
depression, hypothyroidism, lower extremity edema, a 70-pound
weight loss with diet and fluid loss. The patient has had a
normal MIBI scan in [**2133**] with left ventricular ejection
fraction of 66%.
ALLERGIES: She has an allergy to DEMEROL.
PHYSICAL EXAMINATION ON PRESENTATION: On examination her
blood pressure was 115/50, heart rate 66. On physical
examination head, ears, nose, eyes and throat revealed
normocephalic and atraumatic. Thyroid was enlarged,
fluctuant limited neck motion. Her chest was clear to
auscultation bilaterally. Cardiovascular revealed first
heart sound and second heart sound. No murmurs, rubs or
gallops. The abdomen was soft and nontender, positive bowel
sounds. Extremities were warm. No edema. Positive
peripheral pulses.
HOSPITAL COURSE: The patient was admitted status post a
transthoracic T7-T8 discectomy under general anesthesia which
was tolerated well. Two chest tubes were in place and placed
on low-wall suction. The patient was transferred intubated
and ventilated to the Surgical Intensive Care Unit where she
remained intubated overnight.
She was extubated on postoperative day one after remaining
stable that day. The patient had no radiographic evidence of
pneumothorax. The patient was transferred to the floor.
Chest tubes were put to water seal on postoperative day two.
Chest x-rays continued to show no evidence of pneumothorax.
her chest tube were removed on [**2135-12-29**]. The patient
continued to do well, and her pain was well controlled with
morphine and Dilaudid orally.
DISCHARGE DISPOSITION: Her postoperative course was
uneventful, and the patient was transferred to rehabilitation
in stable condition on [**2135-12-31**].
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) 1327**] on [**1-10**] for staple removal.
MEDICATIONS ON DISCHARGE:
1. MS Contin 15 mg p.o. q.4-6h. p.r.n.
2. Dilaudid 2 mg to 6 mg p.o. q.4-6h. p.r.n.
3. Tylenol 650 mg p.o. q.6h. p.r.n.
4. Ativan 1 mg p.o. q.h.s. p.r.n.
5. Zoloft 50 mg p.o. q.h.s.
6. Lasix 50 mg p.o. in the morning and 40 mg p.o. in the
evening.
7. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. q.d.
8. Levoxyl 1.75 mg p.o. q.d.
CONDITION AT DISCHARGE: The patient was in stable condition
at the time of discharge.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2136-1-2**] 11:47
T: [**2136-1-4**] 09:38
JOB#: [**Job Number 104361**]
ICD9 Codes: 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1926
} | Medical Text: Admission Date: [**2138-5-5**] Discharge Date: [**2138-5-15**]
Date of Birth: [**2070-2-18**] Sex: M
Service: VSU
CHIEF COMPLAINT: Left ankle-foot nonhealing ulceration.
HISTORY OF PRESENT ILLNESS: This patient was hospitalized
from [**2138-4-9**] to [**2138-4-11**], for his nonhealing
ulceration. He underwent a diagnostic lower extremity
angiogram. Patient was determined to be a surgical candidate.
He now returns for elective revascularization.
PAST MEDICAL HISTORY: Type 2 diabetes with triopathy, end-
stage renal disease, hemodialysis Monday, Wednesday, Friday,
history of coronary artery disease with cardiomyopathy,
history of systolic congestive heart failure, pulmonary edema
compensated, status post coronary artery bypasses x2 with
vein complicated by respiratory failure requiring a
tracheostomy, history of pneumonia, history of catheter
sepsis, MRSA; history of atrial fibrillation, history of
bilateral DVTs with pulmonary embolus anticoagulated, history
of depression, history of hypertension, history of GERD,
history of gastroparesis, history of morbid obesity.
SOCIAL HISTORY: Patient lives at rehab. He does not smoke or
drink.
PHYSICAL EXAM: Patient was in no acute distress, oriented
x3. He had an irregularly, irregular rhythm without murmur,
gallop, or rub. Lungs were clear to auscultation bilaterally.
Abdominal exam was unremarkable except for obese,
protuberant, soft, nontender belly. The left ankle had a 2.5-
cm nonhealing ulceration with purulence. There was dry eschar
with an erythematous rim. The pulse exam showed palpable DP
and PTs bilaterally.
MEDICATIONS ON ADMISSION: Bupropion 100 mg daily, donepezil
5 mg at bedtime, lactulose 10 grams in 15 cc, 30 cc Tuesdays,
Sundays, and Thursdays, Reglan 5 mg b.i.d., calcium acetate
tablets, atorvastatin 20 mg at bedtime, Nephrocaps daily,
mirtazapine 45 mg at bedtime, niacin 500 mg at bedtime,
levothyroxine 50 mcg daily, Prozac 20 mg daily, fluconazole
110 mcg inhaler puffs 2 b.i.d., sublingual nitroglycerin 0.04
p.r.n.
HOSPITAL COURSE: Patient was admitted to the vascular
service. Vancomycin, ciprofloxacin, and Flagyl were
instituted. The patient was prepared for surgery and prior to
surgery, underwent dialysis. Patient proceeded to surgery on
[**2138-5-6**]. He had a redo left mid SFA to BK-[**Doctor Last Name **] bypass with
nonreverse saphenous vein left, angioscopy and valve lysis.
Urology was consulted intraoperatively to place a Foley. The
patient underwent a cystoscopy which showed slight narrowing
at the bulbar urethra. Patient was dilated, and a Foley
catheter was placed. This remained in for 7 days
postoperatively.
Patient was transferred to the PACU in stable condition.
Postoperative day 1, there were no acute events.
Postoperative day 2, patient's T. max was 101. Blood cultures
were obtained which were no growth. The patient remained in
the VICU. On physical exam, he had a left Dopplerable DP and
PT. Potassium was 7.2. Patient went to dialysis.
Wound care service was requested to see the patient for a
type stage I pressure ulceration on the sacrum.
Recommendations were turn frequently. Keep heels off of bed
surface at all times and apply protective ointment to the
area after cleaning the area carefully.
Postoperative day 3, patient's T. max was 98.0. His potassium
improved postdialysis. He was sent to the regular nursing
floor for continued care. Patient had very poor venous
access, and a PICC was recommended. It was determined at this
time that his antibiotics will be converted to oral agents,
and the vancomycin would be dosed at dialysis.
Postoperative day 5, patient continued to progress. He
remained afebrile and ambulation to chair was begun.
Postoperative day 6, the patient was afebrile. He complained
of mild dyspnea with desaturation which responded to face
mask. The chest x-ray demonstrated near white of the left
chest. The CT was considered. CT scan was done which showed
collapse of the left lung. Patient was transferred to the
ICU, where he underwent a bronchoscopy. Was intubated and
ventilator support overnight.
Postoperative day 7, patient remained in the unit, intubated,
and bronchoscopy was repeated with improvement in left lung
aeration. At this point, they felt the patient, from
pulmonary standpoint, had improved enough to be extubated and
transferred back to the regular nursing floor. Patient did
require transfusion for a hematocrit of 23.7.
Pulmonary was consulted on postoperative day 9 for continued
left lower lobe changes, concerns for pneumonia and
appropriate treatment. Their recommendations were to continue
aggressive pulmonary PT. Discontinue the Mucomyst as this can
increase secretion thickness. Discontinue the Tylenol since
it may be hiding a fever. Recommend fluid removal at dialysis
if blood pressure will tolerate. Will avoid sedating
medications. Begin albuterol nebulizers q.4 hours standing
and q.2 hours p.r.n. with Atrovent nebulizers q.6 hours. Felt
he did not need to be rebronched at this time to consider
starting CPAP for possible OSA at night. Continue his
antibiotics, vancomycin and levofloxacin. Add cefepime for
concerns for hospital-acquired pneumonia. Maintain
saturations greater than 91%. Keep patient on right side as
much as possible for postural drainage. Continue to monitor
pulmonary status by daily x-rays.
Sputum culture was obtained which showed no microorganisms on
Gram stain and it was finalized of rare growth of
oropharyngeal flora. This cefepime was discontinued. The
patient will be continued on vancomycin and levofloxacin for
total of 7 more days. The vancomycin will be given at
hemodialysis when the level is less than 15. Vancomycin will
be orally. Patient was made n.p.o. for potential rebronch on
[**2138-5-15**]. Patient will return to his nursing home once
patient is medically stable.
DISCHARGE INSTRUCTIONS: Patient may ambulate essential
distances. Please elevate the leg when patient is sitting in
a chair. Please call us if he develops a fever greater than
101.5 or the leg wounds become erythematous, drain, or he has
groin swelling. The patient may shower, but no tub baths.
Please continue all medications as ordered. Random levels on
a daily basis to determine when to dose at dialysis of
vancomycin. Sacral decubitus care should be continued with
adequate cleansing and protective ointment to the skin.
DISCHARGE MEDICATIONS: Miconazole powder to effected area
p.r.n., senna tablets 8.6 mg tablets 1 b.i.d., fluconazole
110 mcg actuation aerosol +2 b.i.d., paroxetine 20 mg daily,
niacin 500 mg daily, levothyroxine 50 mcg daily, mirtazapine
15 mg tablets 3 at bedtime, calcium acetate 667 mg capsules 1
t.i.d. with meals, donepezil 5 mg at bedtime, B complex,
vitamin C, folic acid, capsule 1 mg daily, lactulose 30 cc
daily, atorvastatin 20 mg daily, Reglan 5 mg a.c. and at
bedtime, bupropion 100 mg sustained release q.a.m.,
amiodarone 200 mg daily, lansoprazole 30 mg daily, Colace 50
mg in 5 cc b.i.d., metoprolol 25 mg b.i.d., albuterol sulfate
0.083% solution inhalation q.2 hours, ipratropium bromide
0.02% solution inhalation q.6 hours, levofloxacin 500 mg q.48
hours for a total of 7 days, acetaminophen 325 mg tablets [**1-7**]
q.4-6 hours p.r.n., vancomycin 1 gram at dialysis when random
level is less than 15 for a total of 7 days, glargine U100
eight units subcutaneously daily at breakfast. Humalog
sliding scale before meals: Glucoses less than 150: No
insulin, 151-200: 1 unit, 201-250: 2 units, 251-300: 3 units,
301-350: 4 units, 351-400: 5 units, greater than 400: Notify
physician. [**Name10 (NameIs) **] bedtime sliding scale glucoses less than 250:
No insulin, 251-300: 2 units; 351-400: 3 units; glucoses
greater than 400: Notify physician.
DISCHARGE DIAGNOSES: Ischemic left foot ulceration,
nonhealing; peripheral vascular disease status post
diagnostic arteriogram on [**2138-4-10**], history of type 2
diabetes with triopathy, controlled; history of end-stage
renal disease on hemodialysis Monday, Wednesday, Friday,
history of coronary artery disease with cardiomyopathy,
status post coronary artery bypass graft x2 complicated by
congestive heart failure, systolic; respiratory failure,
pneumonia, status post tracheostomy, history of methicillin-
resistant Staphylococcus aureus catheter sepsis, history of
pneumonia, history of atrial fibrillation, history of
pulmonary embolus secondary to deep venous thrombosis,
anticoagulated, history of depression, history of
hypertension, history of gastroparesis, history of gastric
reflux, history of morbid obesity, urethral stenosis status
post cystoscopy with dilatation and Foley placement on [**5-6**],
postoperative blood loss anemia, transfused; postoperative
left lower lobe collapse secondary to bronchial mucus
plugging, status post bronchoscopy x2.
MAJOR SURGICAL PROCEDURES: Cystoscopy with urethral
dilatation and Foley placement on [**2138-5-6**], redo left mid
SFA BK-[**Doctor Last Name **] with nonreverse saphenous vein, left angioscopy
and valve lysis, [**2138-5-6**], status post bronchoscopy x2 [**5-13**] and [**5-14**].
FOLLOW UP: Patient should follow up with Dr. [**Last Name (STitle) 1391**] in 2
weeks' time. He should call for an appointment at ([**Telephone/Fax (1) 72527**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2138-5-15**] 09:50:29
T: [**2138-5-15**] 10:33:22
Job#: [**Job Number 72528**]
ICD9 Codes: 311, 5180, 486, 4254, 5856, 4280, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1927
} | Medical Text: Admission Date: [**2166-7-13**] Discharge Date: [**2166-7-18**]
Date of Birth: [**2092-7-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Neck swelling
Major Surgical or Invasive Procedure:
[**2166-7-14**]: Removal of packing. Mediastinoscopy. Flexible
bronchoscopy and bronchoalveolar lavage (BAL).
[**2166-7-13**]: Redo mediastinoscopy. Packing of wound.
History of Present Illness:
73 y/o M with COPD found to have new RUL mass who is s/p
mediastinoscopy on [**2166-7-9**] presents with acute onset neck
swelling. The neck swelling began this morning and he is
complaining of dysphagia and difficulty breathing. He did not
some chest discomfort and took his home SL nitro with no change.
He has extensive cardiac history and is on Coumadin for AFib.
The coumadin was held 1 week prior to the medistinoscopy and he
was to be discharged home on coumadin with lovenox bridge.
According to the patient he did not take his home coumadin and
has been on the Lovenox only. He denies any fevers/chills, N/V,
abd pain, hematochezia/melena.
Past Medical History:
Bilateral pulmonary nodules
Hypothyroidism
DM II
Hypertension
Hyperlipidemia
CAD s/p DEstents in [**2159**] to LAD, RCA, PLV,
Atrial fibrillation on warfarin
Gastritis
COPD
Anemia
Hyponatremia
Cerebral aneurysm
CKD
PVD
Social History:
Married lives with family. Tobacco: 40 pack-year. Quit 40 years
ago. ETOH none
Occupation: bartender
Family History:
non-contributory
Physical Exam:
VS: T: 96.0 HR: 82-86 SR BP: 150-160/70-80 Sats: 96% RA
General: 74 year-old male sitting in chair in no distress
HEENT: normocephalic, mucus membranes moist
NEck: mild anterior neck swelling, incision site w/steri-strips
no erythema mild dark heme drainage
Card: RRR
Resp: decreased breath sounds on left otherwise clear
GI: benign
Extr: warm no edema
Neuro: awake, alert oriented
Pertinent Results:
[**2166-7-18**] WBC-16.9* RBC-3.98* Hgb-12.6* Hct-36.9* MCV-93 MCH-31.8
MCHC-34.3 RDW-15.2 Plt Ct-260
[**2166-7-17**] WBC-17.3* RBC-4.25* Hgb-13.0* Hct-38.4* MCV-91 MCH-30.6
MCHC-33.9 RDW-15.7* Plt Ct-223
[**2166-7-13**] WBC-11.2* RBC-2.75* Hgb-8.2* Hct-25.1* MCV-92 MCH-30.0
MCHC-32.8 RDW-16.6* Plt Ct-271
[**2166-7-18**] Glucose-182* UreaN-26* Creat-0.8 Na-133 K-4.0 Cl-94*
HCO3-24
[**2166-7-17**] Glucose-250* UreaN-27* Creat-0.8 Na-129* K-4.1 Cl-94*
HCO3-26
[**2166-7-13**] Glucose-322* UreaN-20 Creat-1.0 Na-121* K-4.6 Cl-87*
HCO3-22
[**2166-7-17**] Albumin-3.4* Calcium-8.7 Phos-1.7* Mg-2.2
CXR:
[**2166-7-16**]: The lungs show an unchanged right apical pneumothorax
with confluent lower lobe opacities, and mild edema unchanged. A
right lung mass is unchanged as well. A moderate left effusion
is unchanged as well. An NG tube terminating in the stomach is
unchanged.
[**2166-7-13**]: Lungs are low in volume. The cardiac silhouette is
mildly enlarged. The mediastinal silhouette is mildly prominent,
which may be post-procedural, or partially due to low lung
volumes. Bilateral lower lobe opacities are new. The hilar
contours are unremarkable. Previously noted pulmonary vascular
engorgement has resolved. Known nodular opacities in the right
upper lobe and lingular are stable. There are small bilateral
effusions. No pneumomediastinum or pneumothorax identified.
MICRO: all cultures were negative.
Brief Hospital Course:
Mr. [**Known lastname 89251**] was admitted [**2166-7-13**] for neck swelling secondary to
bleed after restarting Lovenox following cervical
mediastinoscopy on [**2166-7-9**]. He was taken to the operating room
for Redo mediastinoscopy with Packing of wound. No source of
bleeding was found. He was transfer to the TSICU intubated,
hypovolemic SBP 70's, Transfused 2 Unit of PRBC, CXR with Right
pleural effusion, CT placed with 600 mL serosanguinous drainage.
On [**2166-7-14**] he was taken back to the OR for Mediastinoscopy
Flexible bronchoscopy and bronchoalveolar lavage (BAL) and
packing removal.
Transferred back to TICU intubated and successfully extubated.
His oxygenation improved, titrated off oxygen with saturations
96% on room air.
Heme: Transfused 3 units of PRBC in OR & ED and 2 units while in
the SICU for HCT 25. Serial HCTs where followed and he remained
stable in the high 30.s
Hypertension: hypertensive SBP 180-200 requiring Labatelol drip
until taking PO's. His SBP improved 150's baseline 140's. His
home medications were restarted Lisinopril, felodipine.
Atrial Fibrillation: rate controlled with metropolol.
Anticoagulation: Warfarin was held. Aspirin restarted. Spoke
with his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 487**] whom agreed with Warfarin 3 mg with No
lovenox bridge.
Nutrition: Seen by speech and swallow for laryngeal edema on
[**7-15**]. He remained NPO for signs & symptoms of aspiration. An
NGT was placed and Tube feeds were started.
Speech continued to follow him. [**2166-7-16**] his laryngeal edema
improved the NGT was removed, a puree nectar thick liquid was
started. Video-swallow on [**2166-7-17**] showed improved pharyngeal
edema. He was transition to a soft mechanical diet with thin
liquids and aspiration precautions.
Endocrine: insulin sliding scale to maintain BS < 150. His home
dose Prandin was restarted when taking PO. Levothyroxine
restarted to once taking PO.
Hypervolemia: IV Lasix was given to Goal negative > 1. Liter
with good results. His home PO dose was restarted.
Electrolytes were replete as needed.
Pleural: small left pleural effusion. Ultrasound by
interventional pulmonology of left pleural effusion showed
approximately 300 mL. No thoracentesis was performed.
Disposition: He continue to make steady progress. Was seen by
physical therapy who recommended home with PT. He was
discharged on [**2166-7-18**].
Medications on Admission:
Tiotropium Bromide 18 mcg', Esomeprazole 40 mg', Albuterol
2puffs q4-6H, Furosemide 40 mg daily, Simvastatin 80 qhs,
Ferrous sulfat 325 mg daily, Coumadin, Cholecalciferol, Vitamin
D, Lisinopril 40 mg daily, Prandin 0.5 prior to meals, atenolol
100 mg daily, levotyroxine 75 mcg daily, felodipine 5 mg daily,
NTG, MVI
Discharge Medications:
1. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. felodipine 5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. repaglinide 0.5 mg Tablet Sig: One (1) Tablet PO TIDAC (3
times a day (before meals)).
10. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO every four (4) hours.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Cervical mediastinoscopy [**2166-7-9**] complicated by bleed s/p Redo
mediastinoscopy, Packing of wound [**2166-7-13**]
Bilateral pulmonary nodules
Hypothyroidism
DM II
Hypertension
Hyperlipidemia
CAD s/p DEstents in [**2159**] to LAD, RCA, PLV,
Atrial fibrillation on warfarin
Gastritis
COPD
Anemia
Hyponatremia
Cerebral aneurysm
CKD
PVD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Difficulty breathing, swallowing or new hoarsness
-Increased bleeding for neck incision
Neck incision
-Cover with a clean dry dressing as needed. It will ooze for a
few days. Please call if there is a large amount of discharge
from the site.
-Steri-strips remove in 10 days or sooner should they start to
come off
Pain:
-Acetaminophen 650 mg every 6 hours as needed for pain
-Oxycodone 5 mg every 4-6 hours as needed for pain
-Take stool softners with narcotics
Activity
-Shower daily. Wash incisions with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-Do Not apply any lotions or creams to incisions
Warfarin
-Restart you standing dose on Sunday night. Take 3 mg Sunday and
Monday evening.
-Follow-up with your PCP on Tuesday for further warfarin
instructions.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2166-7-29**] 11:30 on
the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Follow-up with Dr.[**First Name (STitle) 487**] [**Telephone/Fax (1) 68410**] for warfarin managenment
on Tuesday.
Completed by:[**2166-7-18**]
ICD9 Codes: 5119, 4589, 2761, 496, 2449, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1928
} | Medical Text: Admission Date: [**2174-2-23**] Discharge Date: [**2174-3-4**]
Service: CARDIOTHORACIC
Allergies:
Protamine Sulfate / Gluten / Milk / Wheat Flour
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath, atrial fibrillation s/p MVR ( 25 Mosaic
procine), Maze, ligation of left atrial appendage [**2174-2-8**]
Major Surgical or Invasive Procedure:
Re-do sternotomy, evacuation of pericardial and pleural
effusions [**2174-2-24**]
MVR (25 Mosaic, porcine), MAZE, Ligation of left atrial
appendage
History of Present Illness:
85 year old female s/p MVR (25 Mosaic porcine),Maze, ligation of
left atrial appendage [**2174-2-8**]. Readmitted from rehab with
shortness of breath, atrial fibrillation.
Past Medical History:
Paroxysmal atrial fibrillation
Rheumatic heart disease
Moderate-to-severe mitral stenosis
Hypertension
Hypothyroidism
Glaucoma
Osteoporosis
Social History:
She currently lives alone but has a daughter
Retired
[**Name2 (NI) 1139**] denies
ETOH denies
Family History:
non contributory
Physical Exam:
admit history and physical
vs: 99.2, 94/55, 66, 18, 96% on 2 liters
neuro: alert and oriented x3, non-focal
resp: lings CTA bilat,-decreased at the bases, no rhonchi or
wheezing.
cardiac RRR S1, S2, no murmur
GI: soft, tender bilat lower quadrants, non-distended, +BS
Extrem: upper extremities: warm, pulses +2, no edema. lower
extremities: Cool, Pulses +1, +1 edema.
Skin: Sternal incision- healing, no erythema, no drainage,
stable
Pertinent Results:
[**3-4**]: WBC 7.9 *Hgb 11.4* HCT 35.0* Plt 319
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 77013**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77015**]Portable TTE
(Complete) Done [**2174-2-23**] at 4:37:43 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2088-7-7**]
Age (years): 85 F Hgt (in): 64
BP (mm Hg): / Wgt (lb): 119
HR (bpm): 66 BSA (m2): 1.57 m2
Indication: H/O cardiac surgery. Pericardial effusion.
ICD-9 Codes: 423.3, V42.2
Test Information
Date/Time: [**2174-2-23**] at 16:37 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2009W0-0:00 Machine: Vivid [**6-6**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 1.0 m/s
Right Atrium - Four Chamber Length: *5.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.3 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 1.9 cm
Left Ventricle - Fractional Shortening: 0.42 >= 0.29
Left Ventricle - Ejection Fraction: 65% to 75% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Arch: 2.8 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Mitral Valve - Mean Gradient: 2 mm Hg
Mitral Valve - Pressure Half Time: 91 ms
Mitral Valve - MVA (P [**12-3**] T): 2.4 cm2
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.56
Mitral Valve - E Wave deceleration time: *270 ms 140-250 ms
TR Gradient (+ RA = PASP): *29 mm Hg <= 25 mm Hg
Pericardium - Effusion Size: 2.2 cm
Findings
Left pleural effusion
This study was compared to the prior study of [**2174-2-11**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Normal
regional LV systolic function. Overall normal LVEF (>55%). No
resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Borderline normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Normal aortic arch diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR
well seated, with normal leaflet/disc motion and transvalvular
gradients. No MR.
TRICUSPID VALVE: Moderate to severe [3+] TR. Mild PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: Large pericardial effusion. Effusion
circumferential. Stranding is visualized within the pericardial
space c/w organization. No echocardiographic signs of tamponade.
No RV diastolic collapse.
Conclusions
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is no
ventricular septal defect. with borderline normal free wall
function. 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. A
bioprosthetic mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. No mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is a large
pericardial effusion. The effusion appears circumferential.
Stranding is visualized within the pericardial space c/w
organization. No right ventricular diastolic collapse is seen,
however there are indirect signs of elevated intrapericardial
pressure (RV free wall diastolic flattening)
Compared with the prior study (images reviewed) of [**2174-2-11**],
the large pericardial effuison is new.
IMPRESSION: Large circumfirential pericardial effusion with
early organization. No overt tamponade.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2174-2-23**] 17:04
Brief Hospital Course:
Pt was admitted to intially to the cardiac surgical floor then
had an ECHO which revealed pericardial effusion and was
transferred to the cardiac ICU to monitor for tamponade. Of
note, Ms. [**Name14 (STitle) 77017**] was c-diff positive at rehab abd was being
treated with flagyl. Her urine was also positive for gram neg
rods and was treated with cipro. Ms. [**First Name (Titles) 77017**] [**Last Name (Titles) 1834**] aggressive
diuresis. On HD #2 Ms. [**Known lastname **] was taken to the OR with Dr.
[**First Name (STitle) **] for pericardial window for drainage of pericardial
effusion and bilat pleural effsuions (left 1 liter and right
500cc). She was treated with periop vanco. She was readmitted to
the ICU post operatively intubated and on neosynephrine. She
weaned from the vent and pressors and was extubated. She was
seen by electrophysiology and her dofetilide was maintained and
VERY LOW DOSE COUMADIN was recommended when stable. She was
transferred from the ICU to the floor. Bilateral chest tubes
remained in place to suction for drainge. when chest tubes were
placed to water seal, she developed pneumothoracies and was
placed back to suction. Chest tubes were later removed and Ms.
[**Name14 (STitle) 77018**] CXR showed stable bilateral 20% pneumothoracies. She
was evaluated by physical therapy and reab was recommended.
On POD#8 she was discharged to rehab.
SHE WILL NEED HER INR CHECKED DAILY AND RECIEVE ONLY LOW DOSE
COUMADIN- 1MG DAILY. SHE WILL ALSO NEED HER RENAL AND LIVER
FUNCTION MONITORED CLOSELY WHILE ON DOFETILIDE. SHE WILL HAVE
CLOSE FOLLOW UP WITH DR. [**Last Name (STitle) **]- APPOINTMENT IS SCHEDULED.
Medications on Admission:
Coumadin held since [**2-21**], ASA, Levoxyl 75/D, Effexor XR 75/D,
Vanco po for cdiff
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
17. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 1 months.
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
19. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
20. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
pericardial and pleural effusion after MVR (25 Mosaic, porcine),
MAZE, Left atrial appendage ligation
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
DAILY INR CHECKS- VERY LOW COUMADIN FOR AFIB.
CLOSE MONITORING OF LIVER FUNCTION AND RENAL TESTS WHILE ON
DOFETILIDE.
Followup Instructions:
Make the following appointments:
Dr. [**Last Name (STitle) 17863**] (primary care)UPON DISCHRAGE FROM REHAB
You have the following appointments:
DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-3-10**]
11:40
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2174-3-14**]
1:00
DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-5-19**]
10:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2174-3-4**]
ICD9 Codes: 5119, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1929
} | Medical Text: Admission Date: [**2163-11-7**] Discharge Date: [**2163-11-11**]
Date of Birth: [**2088-8-8**] Sex: F
Service: MEDICINE
Allergies:
Vitamin K (intravenous formulation)
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Shortness of breath, Pericardial Effusion
Major Surgical or Invasive Procedure:
Pericardiocentesis with drain placement
Removal of pacemaker
History of Present Illness:
75-year-old female with a past medical history of CHF, afib,
COPD, HTN pacer placement approximately 7 days prior on Coumadin
who presented to an outside hospital with worsening SOB since
yesterday morning with exertion. As per patient's HCP, since
being discharged from the hospital pt was doing well and
developed dyspnea after breakfast yesterday morning. An echo
showed a moderate-large pericardial effusion with possible RV
diastolic collapse, INR was 4, she was given 5 VitK, and sent to
[**Hospital1 18**] for further eval. At [**Hospital1 18**], initial vitals were 98.0 63
129/63 18 99% 2L Nasal Cannula. Bedside TTE showed a moderate
pericardial effusion with some RV/RA diastolic collapse. Pulsus
[**10-19**] with JVP 10. INR was 6.9, BNP 5705, Trop .62. She was
given 2 units FFP, 5 VitK, and admitted to the CCU. On
transfer, vitals 98.2 57 115/62 18 100% on 3L.
.
On transfer to the floor, the patient was found to been in
respiratory distress, with stridorous breath sounds throughout
lungs fields; had hives on back, as well as chest. Patient was
tachypneic, with labored respirations. Given IV epinephrine
followed by subQ doses, solumedrol IV push, famotidine,
diphenhydramine and taken to cath lab for intubation and
pericardial drainage.
.
Cath Lab Course: Pt taken to cath lab, intubated without
complications, and found to have perforation of RV by pacer lead
which was found to be within the pericardial space. Pericardial
drain placed with drainage of ~350cc's of bloody fluid.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY: Notable for CAD, recent NSTEMI, Sick sinus
syndrome causing cardiogenic syncope, atrial fibrillation on
coumadin
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD: Single lead pacer placed c/b perforation of RA,
RV, LV
3. OTHER PAST MEDICAL HISTORY:
-Atrial fibrillation on coumadin
-CHF
-Insomnia
-Anxiety
-GERD
-Osteoporosis
-Ostearthritis
-Transaminitis (unknown etiology)
Social History:
- Tobacco history: None
- ETOH: None
- Illicit drugs: None
Family History:
- Positive for CAD and pacemaker
Physical Exam:
ADMISSION EXAM:
GENERAL: disheveled, elderly woman, sitting up in bed,
tachypneic, labored breathing, audible stridor.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP of [**10-19**]
CARDIAC: Rapid rate, regular rhythm, no murmurs/rubs/gallops
LUNGS: stridor throughout lung fields
ABDOMEN: Soft, NTND, +BS
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: +hives on back and chest
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE EXAM:
Vitals: T36.6 ??????C (97.9 ??????F), HR: 89 (77 - 110) bpm, BP: 93/54(65)
{84/45(58) - 117/73(86)} mmHg, RR: 18 (15 - 25) insp/min, SpO2:
97%, Heart rhythm: AF (Atrial Fibrillation) Wgt (current): 64.8
kg (admission): 69 kg
GENERAL: elderly woman, NAD, sitting up comfortably in bed
HEENT: NCAT. Sclera anicteric.
NECK: Supple, JVP to edge of mandible
CARDIAC: Rapid rate, irregular rhythm, no murmurs/rubs/gallops
LUNGS: fine inspiratory crackles halfway up the lung fields b/l
CHEST: site of pericardial drainage, dressing clean/dry/intact
ABDOMEN: Soft, NTND, +BS
EXTREMITIES: warm, well perfused, trace pedal edema b/l, trace
UE edema b/l, L arm with bruising
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2163-11-7**] 03:23AM WBC-16.7* RBC-3.26* HGB-10.8* HCT-33.4*
MCV-103* MCH-33.2* MCHC-32.4 RDW-13.1
[**2163-11-7**] 03:23AM NEUTS-90.6* LYMPHS-5.8* MONOS-3.2 EOS-0.3
BASOS-0.2
[**2163-11-7**] 03:23AM PLT COUNT-460*
[**2163-11-7**] 03:23AM PT-62.3* PTT-36.2* INR(PT)-6.9*
[**2163-11-7**] 03:23AM GLUCOSE-136* UREA N-24* CREAT-0.8 SODIUM-138
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
[**2163-11-7**] 03:23AM ALT(SGPT)-25 AST(SGOT)-34 CK(CPK)-24* ALK
PHOS-76 TOT BILI-0.5
.
PERTINENT LABS:
[**2163-11-7**] 02:07PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2163-11-7**] 02:07PM URINE RBC-23* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-2
[**2163-11-7**] 03:23AM BLOOD CK-MB-2 proBNP-5705*
[**2163-11-7**] 03:23AM BLOOD cTropnT-0.62*
[**2163-11-7**] 11:10PM BLOOD CK-MB-4 cTropnT-0.57*
[**2163-11-7**] 07:32AM BLOOD Lactate-5.4*
[**2163-11-7**] 06:33PM BLOOD Lactate-1.5
[**2163-11-9**] 04:38AM BLOOD Lactate-1.3
.
DISCHARGE LABS:
[**2163-11-11**] 04:41AM BLOOD WBC-13.2* RBC-3.89* Hgb-12.8 Hct-39.9
MCV-103* MCH-33.0* MCHC-32.2 RDW-14.3 Plt Ct-401
[**2163-11-11**] 04:41AM BLOOD Glucose-93 UreaN-37* Creat-0.9 Na-144
K-4.2 Cl-101 HCO3-33* AnGap-14
[**2163-11-9**] 02:24PM BLOOD Type-ART Temp-36.9 pO2-86 pCO2-39
pH-7.46* calTCO2-29 Base XS-3
.
ECHO [**2163-11-7**]
The left atrium is elongated. The estimated right atrial
pressure is 5-10 mmHg. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). with
normal free wall contractility. The aortic valve is not well
seen. Trace aortic regurgitation is seen. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a moderate sized pericardial effusion. The effusion
appears circumferential. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. No right
ventricular diastolic collapse is seen.
IMPRESSION: Moderate pericardial effusion. Elevated
intrapericardial pressure without overt tamponade.
.
ECHO [**2163-11-9**]
FOCUSED STUDY FOR PERICARDIAL EFFUSION: The left atrium is
dilated. The right atrium is dilated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
dilated with depressed free wall contractility. The mitral valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. 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 [**2163-11-8**],
the pericardial effusion is similar in size.
PERICARDIOCENTESIS [**2163-11-7**]
COMMENTS:
Using the sharp-tip needle, we performed pericardiocentesis via
the
subxyphoid approach. There was inadvertent needle puncture of
the RA, RV
and LA before appropriate needle position was obtained in the
pericardial space. A wire was advanced, the tract was dilated,
and the
pericardial drain was inserted into the pericardial space. 370
cc of
bloody fluid was removed and echocardiography confirmed minimal
residual
effusion. Because of respiratory acidosis, she was intubated at
the
conclusion of the procedure. The pericardial drain was sutured
into
place.
.
EKG [**2163-11-10**]
Atrial fibrillation. Non-specific anterior T wave changes. Low
voltage in the limb leads. There is non-specific T wave
flattening in leads V5-V6. Compared to the previous tracing of
[**2163-11-7**] there is now atrial fibrillation and non-specific T
wave flattening. Clinical correlation is suggested.
.
CXR [**2163-11-9**]
PORTABLE AP CHEST: The endotracheal tube, orogastric tube, and
left chest
wall pacer and associated leads have been removed. A small-bore
catheter
projecting over the heart could represent a pericardial drain.
Cardiac silhouette remains markedly enlarged. There is decreased
vascular
congestion and edema. Moderate right and likely left pleural
effusions
persist. No new opacity concerning for pneumonia.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
75 year-old female with a recent s/p NSTEMI at OSH and pacemaker
placement 7 days ago on coumadin presenting with new pericardial
effusion.
.
ACTIVE ISSUES:
# Pericardial effusion: From recent pacemaker placement with
inadvertent perforation of myocardium in setting of
supratherapeutic INR. Pericardiocentesis was performed, however
this was complicated by inadvertent puncture of the RA, RV, and
LV. The drain was left in place until it stopped draining and
wasa then removed. Post removal echocardiogram showed resolution
of the pericardial effusion. The pacemaker wire was removed and
placement of a pacemaker will be re-evaluated as an outpatient.
She was also placed on colchicine for two weeks to decrease
inflammation of her pericardium.
.
# Respiratory distress/Anaphylaxis: Pt was found to have hives
and in respiratory distress with stridorous breath sounds most
likely from a component of the IV Vitamin K given to patient in
ED. She was given epinephrine and intubated. She was extubated
uneventfully after the pericardiocentesis.
.
# CAD s/p NSTEMI: S/P recent NSTEMI at OSH. Pt without chest
pain throughout admission. Aspirin was changed from 81 mg to 325
mg daily. Lovastatin was changed to Atorvastatin 80mg.
Metoprolol was increased form 100mg daily to 200mg daily and
diltiazem was discontinued. Also started plavix 75mg daily.
.
# Rhythm: Had pacemaker placed at an OSH for sinus pauses after
her MI by report. While on telemetry she did not have pauses
after her pacemaker was removed. She was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
of hearts monitor to monitor for pauses. She will follow up with
EP. Her heart rhythm while admitted was atrial fibrillation with
RVR. Her heart rate was controlled with higher doses of
metoprolol while discontinuing diltiazem. Her CHADS score is 3.
Her INR was supratherapeutic on admission so she was given 10 mg
IV Vitamin K in the ED and 2U FFP. Her warfarin was restarted
after her procedures. Her INR was subtherapeutic on discharge
but in the setting of her recent bleeding and the low daily risk
of CVA she was not anticoagulated with heparin or lovenox. Her
INR should be followed to ensure adequate anticoagulation.
.
#Diastolic CHF: LVEF >55% this admission. Volume overload
worsened by IVFs and FFP. She was diuresed with IV lasix and
switched to PO lasix on discharge.
.
#Borderline hypotension: She has been asymptomatic with systolic
blood pressures in the high 80s to low 100s. Her blood pressure
is relatively low from her blood pressure medications. These
blood pressure ranges should be tolerated unless she becomes
symptomatic.
.
# Leukocytosis: Pt admitted with white count of 16, now 13.2,
afebrile. Likely stress response related to pericardial
tamponade, cardiac trauma, and anaphylaxis. Blood cultures were
negative for five days though final culture report still
pending. UA negative. Initial Ucx growing 4,000cfu/ml of
enterococcus, repeat urine culture was negative.
.
CHRONIC ISSUES:
#HLD: Lovastatin was changed to Atorvastatin 80mg PO daily for
ACS as above.
.
#Possible COPD: Has unclear history of COPD. She denies any
prior diagnosis as well as any smoking history. She was
initially treated with ipratropium though her respiratory
difficulty was more likely from fluid overload.
.
TRANSITIONAL ISSUES:
#INR monitoring: Her INR was subtherapeutic at discharge. This
should be monitored to ensure that her INR becomes therapeutic.
.
#Borderline hypotension: She has been asymptomatic with systolic
blood pressures in the high 80s to low 100s. Her blood pressure
is relatively low from her blood pressure medications. These
blood pressure ranges should be tolerated unless she becomes
symptomatic.
.
#[**Doctor Last Name **] of hearts monitor: Had pacemaker placed at OSH for sinus
pauses after her MI by report. While on telemetry she did not
have pauses after her pacemaker was removed. She was discharged
with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor to monitor for pauses. She will
follow up with electrophysiology.
Medications on Admission:
Vitamin D3 1000 unit tab
Lovastatin 40 mg qhs
Omeprazole 20 mg qday
Coumadin 2 mg qday
Metoprolol 50 mg [**Hospital1 **]
Aspirin 81 mg daily
Diltiazem CD 180 mg daily
Lactobacillus 2 caplets PO BID
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
3. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
4. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. lactobac acidoph-bifidobac [**Male First Name (un) **] 16 mg Capsule Sig: Two (2)
Capsule PO twice a day.
9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 13 days: Start on [**2163-11-10**]. Stop on [**2163-11-24**]. .
10. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Health Care Center
Discharge Diagnosis:
Pericardial Effusion
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **]:
.
You were admitted to [**Hospital1 69**] with a
pericardial effusion (fluid around your heart). The fluid was
removed and a drain was temporarily placed. The pacemaker that
was recently placed was also removed because one of the wires
from the pacemaker was most likely the cause of the effusion.
.
The changes below were made to your medications.
.
START taking the following medications:
1. START taking Colchicine 0.6 mg by mouth twice a day for two
weeks. This medication will help to prevent a scar from forming
in the space around your heart (pericardial space). This
medication was started on [**2163-11-10**] and should be taken through
[**2163-11-24**].
2. START taking Atorvastatin 80 mg by mouth at night. Your
outpatient providers may decide to switch you back to Lovastatin
40 mg by mouth at night but we recommend that you take
Atorvastatin for now.
3. START taking Lisinopril 5 mg by mouth daily. This medciation
will help protect your heart from changes to the muscle
following your heart attack.
.
Change the following medications:
1. CHANGE your Metoprolol. You were admitted on Metoprolol
tartrate 50 mg by mouth twice a day. The dose was increased and
you were changed to a longer acting formulation called
Metoprolol succinate. START taking Metoprolol succinate 200 mg
by mouth daily.
2. The dose of your Aspirin was increased from 81 mg by mouth
daily to 325 by mouth daily.
.
STOP taking the following medications:
- STOP taking Diltiazem. This medication was stopped because the
dose of your Metoprolol was increased.
Followup Instructions:
Please follow up with your cardiologist, Dr. [**Last Name (STitle) **], on [**11-21**] at 12:30.
.
Please set up an appointment with your primary care doctor
within one week after levaing the rehabilitation facility.
ICD9 Codes: 4280, 496, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1930
} | Medical Text: Admission Date: [**2151-12-10**] Discharge Date: [**2151-12-19**]
Date of Birth: [**2093-8-11**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Transfer fr OSH with sepsis and respiratory failure
Major Surgical or Invasive Procedure:
line placement
History of Present Illness:
58F w/rheumatoid arthritis on periodic prednisone, HTN who
presented to OSH on [**12-9**] w/SOB, F/C, productive cough x 1 wk.
Family members report intermittent URI Sx (cough, rhinorrhea)
since 6 wks ago when pt returned fr [**State 108**] (where she & husband
were doing some construction work on their house). Denies any
more recent travel. Over the week PTA, pt noticed worsening
cough productive of yellowish sputum, increasing DOE, and
generalized fatigue/malaise. Pt works as a nurse but does not
have any direct patient contact. Only [**Name2 (NI) **] contact is pt's
husband reports being Dx with "mild pneumonia" and is on Abx for
this.
.
At OSH [**Name (NI) **], pt was mentating well but O2Sat 85-6% on NRB so
intubated and admitted to their ICU. CXR w/bilat patchy
infiltrates; started on levoflox, clinda, imipenem, and vanco.
Labs revealed pancytopenia (reportedly new), ARF (peak creat
3.3). Pt's blood Cx fr [**2151-12-9**] grew out in [**3-28**] bottles on
[**12-10**]. Decision made to transfer care to [**Hospital1 18**] so medflighted
in. Upon arrival here [**2151-12-10**] 1 pm, MAPs 40s on levophed but
responded to IVF bolus & addition of vasopressin. Vent was AC
350 x 20, 20 PEEP, 100% FiO2 & initial ABG here was 7.12/66/79
(was 7.14/67/103 at OSH just prior to transfer).
Past Medical History:
- Rheum arthritis on periodic prednisone 5 qd (pt manages this
herself & family unsure if she has been taking prednisone
recently)
- HTN on atenolol & HCTZ
Social History:
[**2-25**] glasses of wine qd but no h/o withdrawal; no TOB; no IVDU;
lives w/husband; has 3 children
Family History:
noncontributory
Physical Exam:
VS: MAP initially mid-40s on levophed but increased to 70s after
IVF bolus & after vasopressin started; 101/55 now. HR 100-120.
Sat 90-97% on vent.
Gen: middle-age F sedated, intubated
Skin: small ecchymosis L shoulder; o/w C/D/I w/o rashes
HEENT: ETT in place, PERRLA, conjunctiva clear
Heart: S1S2 RRR, tachycardic, no murmurs appreciated
Lungs: course B.S. throughout all bilat lung fields
Abdom: hypoactive bowel sounds, soft, no masses apprec, liver
not felt below costal margin
Extrem: 2+ pulses, no edema, cold extrem to touch but good cap
refill, not mottled
Neuro/Psych: sedated, unable to assess
Pertinent Results:
.
Brief Hospital Course:
Ms. [**Known lastname **] is a 58 F w/rheumatoid arthritis, HTN transferred fr
OSH after p/w respir distress, intubated, & became septic
w/strep pneumo in blood Cx.
She was found to have ARDS/Pulm likely from initial CAP. She
had Apache score 26 so started on APC (Zygris) x 96 hrs (started
[**12-10**]). She was continued on propofol and placed on a paralytic
(chose Cisatracurium due to sepsis & multiorgan failure) due to
dyssynchronous breathing w/vent.
.
# ID/Sepsis: HPI c/w CAP; bacteremic/septic at OSH. Micro fr OSH
w/pan-sensitive Strep pneumo so changed Abx to levoflox &
ceftriaxone for double coverage.
.
# HypoTN: likely fr sepsis & dehydration. She was started on
IVF, vasopressin, and titrate levophed along with stress dose
steroids (hydrocort 50 mg IV q6h).
For H/o moderate EtOH consumption ([**2-25**] glasses wine/day): her
thiamine and folate were supplemented.
.
She was found to have ARF: creat was 3.3 @ OSH, now 1.3 after
hydration. Good UOP. Renal U/S @ OSH WNL.
.
She was started on IV protonix (NPO & on steroids) and
pneumoboots. A R fem line (double lumen) & L A-line were placed
[**12-9**] @ OSH. Also 1 PIV.
Ms. [**Known lastname **] eventually succumbed to pneumonia with sepsis and
multiorgan failure.
Medications on Admission:
Meds @ Home: atenolol 25 qd, HCTZ 25 qd, celebrex 200 [**Hospital1 **], &
prednisone 5 qd (sometimes)
.
Meds upon transfer: levoflox 250 iv qd, imipenim 250 iv q6h,
clindamycin 600 iv q8h, vanco 1 g q24h, hydrocort 100 iv q8h,
protonix 40 iv q24h, thiamine iv qd, folate iv qd, SC heparin,
bicarb drip
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
multiorgan failure sepsis pneumonia
ICD9 Codes: 5849, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1931
} | Medical Text: Admission Date: [**2188-8-5**] Discharge Date: [**2188-8-14**]
Date of Birth: [**2129-7-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
pericardiocentesis
History of Present Illness:
This is a 59 year old Chinese woman with minimal known past
medical history who initially presented yesterday ([**8-5**]) with
four days of naseau and vomiting and no bowel movements.
.
Pt was in her usual state of health until one month ago. She
reportedly worked as temp in a candy shop for 3 days, and had
extreme fatigue that was thought out of her usual condition. She
stopped working afterwards, and later developed a productive
cough, which gradually worsened in the past month. There was no
hemoptysis. Patient was evaluated by her PCP at [**Hospital3 **] on
[**7-21**], and again on [**7-30**]. A PPD was placed on [**7-30**], and
was read on [**8-1**] as nonreactive (completely negative). In the
past week, patient developed shortness of breath, malaise, and
could only ambulate to the bathroom. She c/o nausea, bilious
vomiting, intolerable to po intake. Her family also endorsed
night sweats in the past week, and an 8lbs weight loss in the
past 2 weeks. Of note, patient immigrated to US 10 months ago
from southern [**Country 651**]. She recently visited her daughter in [**Name (NI) 6607**]
two months ago.
During workup in the ED she had a CXR which showed a large
cardiac silloute and fluid overload with possible RML infection.
Her EKG showed diffusely low voltages but no ST depressions.
LFTs showed mild transaminitis (60s) with alk phos 120 with dir
bili 0.6.
.
She was initially treated for CHF, but did not respond well with
diuresis.
On the second day, an RUQ ultrasound in the ED showed a possible
pancreatic head mass (otherwise negative). Surgery recommended
an abdominal CTA with pancreatic protocol to further evaluate.
Overnight she was stable and breathing comfortably on room air.
She was hypertensive to 140s-170s. Vitals otherwise were stable.
On CT, circumferetial pericardial effusion was seen. Patient was
found to have a pulsus paradoxus of 20 mmHg. She was stat
intubated, underwent a pericardiocentesis in the cath lab, and
admitted to CCU.
Past Medical History:
beta thalessemia
atrophic gastritis
Social History:
Mandarin/[**Name (NI) **] speaking. Immigrated from [**Country 651**] 10 months
ago. Currently living with daughter, son in law, and 3
grandchildren.
Recently returned from 3 month visit in [**Country 6607**].
Works in a candy factory
Denies Smoking, Drinking or Recreational drug use.
Family History:
beta thalessemia
Physical Exam:
ADMISSION EXAM:
VS: T96.7 BP137/92 HR87 RR18 95% RA
GEN: AOx3, dry mucosal membrane.
HEENT: PERRLA. no LAD. flat jvp. neck supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, bilateral crackle / rhonchi
Abd: Soft, NT/ND, +BS, no hepatosplenomegaly.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities.
.
DISCHARGE EXAM:
VS: Tmax: 99.2 Tc: 98.0 HR: 77 (77-85) BP: 139/90
(128-143/60-90) RR: 18 SpO2: 95% RA
Pulsus of 8.
GEN: Patient was lying flat in bed in no acute distress or pain.
Moist mucosal membrane.
HEENT: PERRLA. Conjunctival pallor. Neck supple.
Cards: 7cm JVP. RRR S1/S2 normal. not distant. no
murmurs/gallops/rubs.
Pulm: Clear to auscultation bilaterally
Abd: Soft, NT/ND, +BS, no hepatosplenomegaly.
Extremities: No edema. Radial pulses, DPs, PTs 2+.
Skin: No rashes or bruising
Neuro: CNs II-XII intact. 4-/5 strength in IP. Full strength in
quads, hamstrings, tib anteriors, gastrocs. 1+ biceps, triceps,
patellar reflexes, 0 ankle reflexes bilaterally. Babinskis mute
bilaterally. Sensory exam intact to light touch and
proprioception.
Pertinent Results:
ADMISSION LABS
[**2188-8-5**] WBC-10.9 RBC-4.99 Hgb-11.2* Hct-34.0* MCV-68* MCH-22.5*
MCHC-33.0 RDW-16.1* Plt Ct-371
[**2188-8-5**] Neuts-85.2* Lymphs-8.2* Monos-5.8 Eos-0.6 Baso-0.3
[**2188-8-5**] Glucose-138* UreaN-20 Creat-0.6 Na-138 K-4.1 Cl-102
HCO3-21* AnGap-19
[**2188-8-5**] ALT-78* AST-69* AlkPhos-123* TotBili-2.4* DirBili-0.6*
IndBili-1.8
[**2188-8-5**] Calcium-9.6 Phos-3.8 Mg-2.1
[**2188-8-6**] calTIBC-244* Hapto-195 Ferritn-806* TRF-188*
[**2188-8-6**] Type-ART pO2-77* pCO2-41 pH-7.39 calTCO2-26 Base XS-0
[**2188-8-6**] calTIBC-244* Hapto-195 Ferritn-806* TRF-188*
[**2188-8-5**] Lactate-2.8*
[**2188-8-5**] Lactate-2.9*
[**2188-8-6**] Lactate-3.9*
[**2188-8-6**] Lactate-1.3 Na-139 K-3.9 Cl-107 calHCO3-24
.
DISCHARGE LABS
[**2188-8-11**] WBC-9.3 RBC-5.01 Hgb-11.4* Hct-34.7* MCV-69* MCH-22.7*
MCHC-32.8 RDW-16.5* Plt Ct-330
[**2188-8-11**] Glucose-112* UreaN-9 Creat-0.7 Na-142 K-3.9 Cl-104
HCO3-28 AnGap-14
[**2188-8-9**] ALT-241* AST-97* AlkPhos-98 TotBili-1.4
[**2188-8-11**] Calcium-9.5 Phos-3.4 Mg-2.2
[**2188-8-7**] HBsAg-NEGATIVE HBsAb-POSITIVE IgM HBc-NEGATIVE IgM
HAV-NEGATIVE
[**2188-8-7**] HCV Ab-NEGATIVE
.
.
PERTINENT STUDIES
# [**8-5**], Abd US
IMPRESSION:
1. No cholelithiasis or evidence of acute cholecystitis.
2. Possible pancreatic lesion. Correlate with nonemergent
pancreatic CT or MRI.
.
# [**8-5**], Portable CXR
FINDINGS: There are diffuse bilateral interstitial alveolar
opacities. There is a markedly tortuous aorta. The cardiac
silhouette is enlarged. Small bilateral pleural effusions are
evident. There is no pneumothorax. The osseous structures are
unremarkable.
.
IMPRESSION: Excessive volume overload likely due to cardiogenic
etiology. Repeat radiography after appropriate diuresis
recommended to assess for underlying infection. In particular,
there is slight confluent opacity in the right perihilar region
which likely reflects confluent edema; however, an underlying
pneumonia cannot be entirely excluded.
.
# [**2188-8-6**] ECHO (pre-pericardiocentesis)
FOCUSED STUDY: The right ventricular cavity is unusually small.
There is a large pericardial effusion which ranges in size from
2.4 to 3.5 cm. The effusion appears circumferential. There is
right ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
.
# [**2188-8-6**] ECHO (post-pericardiocentesis)
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2188-8-6**],
the large pericardial effusion has resolved. The heart rate has
normalized. The right ventricular cavity is larger and function
is normal.
.
# [**2188-8-7**], ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5 mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Trivial pericardial effusion without
echocardiographic evidence of tamponade. Mild pulmonary artery
systolic hypertension.
.
# TTE ([**2188-8-11**])
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is a
very small pericardial effusion. No right atrial or right
ventricular diastolic collapse is seen. Compared with the prior
study (images reviewed) of [**2188-8-7**], the pericardial effusion
is minimally larger, but remains very small.
.
.
# [**2188-8-7**] ECG
Sinus rhythm. Non-specific ST-T wave changes. Compared to the
previous tracing the rate is slower.
.
# [**2188-8-7**] CT chest w/ contrast
IMPRESSION:
1. Right lower lobe mass with centrilobular nodules and
interlobular septal thickening is concerning for primary lung
malignancy with lymphangitic carcinomatosis.
2. Extensive infiltrative mediastinal lymphadenopathy.
3. Small, malignant pericardial effusion following
percardiocentesis. No
tamponade.
4. Lytic metastasis, D11 vertebral body with invasion of the
spinal canal and impingement on thecal sac anteriorly.
5. Probable left adrenal metastasis.
.
# [**2188-8-8**] C/T/L spine MRI
Evaluation of the cervicothoracic spine demonstrates osseous
metastases at C2, C7 and T11. A posterior element lesion is also
noted at T4. Due to motion artifact, axial images are markedly
limited. At T11, there is marked motion artifact, but suggestion
of left sided anterior epidural disease . There is no
significant cord compression or myelomalacia present at this
time, however.There is bulging of the posterior vertebral body
into the canal and mild compression deformity at this level.
Evaluation of the lumbar spine demonstrates no evidence for
osseous metastatic disease. No epidural disease is seen. There
are multilevel disc bulges. Posterior element hypertrophy is
also present at multiple levels.
IMPRESSION:
Osseous metastatic disease at C2, C7, T4 and T11 as described.
At T11, there is mild compression deformity and small amount of
epidural tissue,
particularly on the left, without significant cord compression
at this time. Degenerative changes in the lumbar spine.
.
# [**2188-8-10**] ECG
Sinus rhythm. T wave inversions and poor R wave progression in
the anterior precordial leads are consistent with prior anterior
wall myocardial infarction of indeterminate age. Compared to the
previous tracing of [**2188-8-7**] the R wave progression is less
prominent.
.
Brief Hospital Course:
59F Chinese immigrant with no significant past medical history
admitted with four days of nausea and was noted to have
pericardial effusion with tamponade physiology s/p
pericardiocentesis with cytology showing adenocarcinoma. Further
workup showed metastatic lung adenocarcinoma to the spine c/b
T11 compression fracture without cord compression.
# Cardiac tamponade secondary to adenocarcinoma:
Pt developed shortness of breath, and tachycardia, with a pulsus
>20 mmHg on hospital day 2. CT abdomen showed circumferential
fluid in pericardium. Bedside ECHO showed RV collapse
consistent with tamponard physiology. Due to shortness of
breath and inability to lie flat, pt was intubated and sent to
cath lab for pericardiocentesis, which drained ~700 cc sanguous
fluid. Patient was admitted to CCU for further management.
Post-procedure ECHO showed minimal residue fluid accumulation.
Interval changes measured by ECHO and daily pulsus did not show
evidence of reaccumulation of pericardial fluid. Pt remained
asymptomatic for the remainder of her hospital course with a
baseline pulsus of <14.
# metastatic adenocarcinoma-lung primary:
Pt's presenting chest x-ray showed diffuse reticulonodular
pattern, concerning for TB, or carcinomatosis. As part of the
workup, pt underwent bronchoscopy with BAL. Of note, both
pericardiofluid and BAL showed positive adenocarcinoma on
cytology, but negative AFB. Pathology stain of the
pericardiofluid and BAL showed adenocarcinoma of lung primary.
Patient was seen by heme/onc who recommended further outpt
testing for typing and an MR head for complete staging. Pt
declined at this time. Hem/onc f/u appt to be set up in
approximately 2 weeks, where pt will discuss potential
treatment. Lung metastastes were noted at multiple vertebral
bodies, adrenals, and liver on imaging.
# Compression fracture at T11 without cord compression.
Spinal MRI was obtained due to patient's complaints of lower
back pain. There was evidence of compression fracture at T11 on
both chest CT and spinal MRI, without significant cord
compression. There was also evidence of osseous metastatic
disease at C2, C7, and T4. Pt had normal neural exam including
intact sphincter tone. Pt was evaluted by Neurosurgery, who
felt that there was no imminent risk of cord compression. Pt was
also evaluated by rad-onc who felt that radiation treatment was
not indicated at this time. Pt was fitted with a TLSO brace to
be used when upright or out of bed. Pain management included
lidocaine patch, ibuprofen and gabapentin. Tylenol was avoided
due to patient's transaminitis. Patient will have bisphosphonate
therapy arranged through her Oncologist as an outpatient.
.
# Post-obstructive pneumonia:
Pt developed fever to 101.6 on hospital day 3. Chest CT
revealed bilateral pleural effusion and density in RLL
concerning for post-obstructive pneumonia. Given patient
continued high O2 requirement, and history of cough, the
suspicion for pneumonia was high. BAL, sputum culture, blood
culture, urine culture showed no growth. Patient was treated
with Vancomycin and Zosyn for a total of 5 days. Her oxygen
requirements remained stable.
.
# Transaminitis
Patient presented with transaminitis and indirect bilirubinemia.
No evidence of biliary obstruction was found on abdominal US.
Hepatitis panel was also negative. Initial DDx include hepatic
congestion secondary to cardiac tamponarde or metastasis of
adenocarcinoma. Of note, there was a ~ 7 mm hypoenhancing foci
in right hepatic lobe on the abdominal CT, and marked
gallbladder wall edema consistent with congestive heart failure.
Patient's liver enzymes peaked on HD3 and has been down
trending since then, suggesting the transaminitis is largely
caused by hepatic congestion.
.
# Disclosure of medical information
Pt initially expressed wishes to disclose medical news to family
only, but later wanted to know herself. Given the special
culture background, social worker was involved, and family
meeting was held in the presence of patient's family, CCU team
and social worker. Agreement was reached that medical
information will be released to patient with presence of her
husband for emotional support.
.
CHRONIC ISSUES
# beta thalassemia
Patient presented with microcytic anemia, consistent with her
reported history of beta thalassemia. Her HCT remained stable
throughout this admission.
.
TRANSITIONAL ISSUES
Patient declared a full code at admission, but changed to
DNR/DNI on [**2188-8-13**]. Pt and husband initially considered
returning to [**Country 651**], given that their son-in-law did not want
them returning to the house. However, after much conversation,
pt's daughter agreed to let them return home. Patient has
follow up appointment with hem/onc in approximately 2 weeks
regarding potential treatment. As patient and husband are
[**Name (NI) 8230**] speaking only, they were given the name and number for
the [**Name (NI) 8230**] hem/onc patient nagivator to help facilitate
further care. They were also given prescriptions for 2 weeks
for pain medications to be filled at the free pharmacy, however
the patient decided to leave prior to getting authorization for
the lidocaine patches. Patient continued to refuse head MRI
during hospitalization, which made complete staging of her
disease impossible.
Language and social barriers are likely to continue to be
problem[**Name (NI) 115**] with this patient and she would benefit from close
contact with the [**Name (NI) 8230**] patient nagviator to ensure she
receives adequate care.
Medications on Admission:
Unclear Chinese Medication (two items)
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Please
wear patch for 12 hours/day, and then take off for 12 hours.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*1*
2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*42 Tablet(s)* Refills:*1*
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*14 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. lung adenocarcinoma
2. cardiac tamponade
3. thoracic compression fracture without spinal cord compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) - should wear spine brace while sitting up or
ambulating.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because of abdominal pain,
vomiting and constipation. You were found to have fluid around
your heart (tamponade) which had to be drained to help you
breath. The fluid was found to be caused by a lung cancer,
which has spread to your spine and liver. The cancer has caused
a fracture in your lower spine, which is contributing to your
pain. You should wear the back brace whenever you are sitting
up or standing. Please follow-up with your primary care doctor,
as well as the cancer doctors.
The following changes were made to your medications:
1. Please start taking Gabapentin 300mg by mouth daily
2. Ibuprofen 600mg my mouth three times a day
3. Lidocaine patch daily for up to 12 hours
Followup Instructions:
Name: [**Name6 (MD) 27839**] [**Name8 (MD) **], MD
Specialty: Internal Medicine
When: Tuesday [**8-19**] at 2:30p
Location: [**Hospital3 8233**]
Address: [**State 8234**], [**Location (un) **],[**Numeric Identifier 8235**]
Phone: [**Telephone/Fax (1) 8236**]
Please call ([**2188**] immediately to schedule an appointment
with the cancer doctors - Thoracic Oncology with Dr. [**Last Name (STitle) **],
or Dr. [**Last Name (STitle) 3274**] or Dr. [**Last Name (STitle) **].
Please call ([**Telephone/Fax (1) 89355**] if questions about spinal brace.
Please call [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Last Name (NamePattern1) 8230**]-speaking patient advocate
and cancer navigator, for social work questions.
Completed by:[**2188-8-16**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1932
} | Medical Text: Admission Date: [**2123-11-1**] Discharge Date: [**2123-11-5**]
Date of Birth: [**2060-8-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain/Dyspnea
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 3 (LIMA-LAD, SVG-PDA, SVG-OM) [**2123-11-1**]
History of Present Illness:
63 year old gentleman who developed exertional dyspnea over this
past summer. A stress test was obtained in [**Month (only) 359**] which reveal
inferior hypokinesis as well as scar in the infra-apical region
with peri-infarct ischemia. Given the findings, he was referred
on for a cardiac catheterization which revealed a 70% stenosed
left main coronary artery and three vessel disease. Given the
severity of his disease, he has been referred for surgical
revascularization.
Past Medical History:
Myocardial infarction
Hypertension
peripheral vascular disease
Hyperlipidemia
Obesity
COPD
scrotal raphe abscess
Right subclavian stenosis
Active tobacco use
Past Surgical History:
[**2110**] Right inguinal hernia repair
Nasal Septum Repair x2
[**2118**] Left inguinal hernia repair c/b epididymal hematoma
Social History:
Lives with: Wife in [**Name2 (NI) 47**]. 3 kids.
Occupation: Farmer
Tobacco: Active smoker 1 pack per day for 50 years.
ETOH: Denies
Family History:
Mother died at 88/Father alive at 91
Physical Exam:
Pulse:63 Resp: O2 sat: 98%
B/P Right: Left: 168/86
Height:5'9" Weight: 215 #
General:obese, using cane today for support as right groin is
still sore from cath
Skin: Warm[x] Dry [x] intact [x]
HEENT: NCAT[x] PERRLA [x] EOMI [x]anicteric sclera,edentulous
with the exception of one tiny partial tooth stump
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur-none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM, obese
Extremities: Warm [x], well-perfused [x] Edema -trace BLE
right groin ecchymosis s/p cath
Varicosities: bil. superficial spider veins
Neuro: Grossly intact, MAE [**4-7**] strengths, nonfocal exam
Pulses:
Femoral Right: 1+ Left:1+
DP Right: NP Left: NP
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2123-11-4**] 04:55AM BLOOD WBC-12.4* RBC-3.48* Hgb-10.8* Hct-30.5*
MCV-88 MCH-30.9 MCHC-35.4* RDW-13.9 Plt Ct-180
[**2123-11-3**] 04:55AM BLOOD WBC-14.4* RBC-3.66* Hgb-11.1* Hct-32.2*
MCV-88 MCH-30.3 MCHC-34.4 RDW-14.0 Plt Ct-168
[**2123-11-4**] 04:55AM BLOOD Glucose-105* UreaN-18 Creat-0.6 Na-134
K-3.9 Cl-95* HCO3-32 AnGap-11
Intra-op TEE [**2123-11-1**]
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%). with mild global free wall hypokinesis. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is AV-Paced, on no inotropes.
Preserved biventricular systolic fxn. Mild MR, no AI.
Aorta intact.
Brief Hospital Course:
The patient was brought to the operating room on [**2123-11-1**] where
the patient underwent CABG x 3. See operative note for details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Wellbutrin SR was initiated for smoking cessation. Chest tubes
and pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4, the patient was ambulatory, yet deconditioned, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to [**Location (un) 44563**] in [**Hospital1 10478**] in
good condition with appropriate follow up instructions.
Medications on Admission:
Aspirin 81mg daily
metoprolol SR 25 mg daily
HCTZ 25mg daily
Norvasc 5mg daily
nicotine 21 mg /24 hr patch daily
Zocor 40mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-5**]
Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea.
14. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 44563**] Nursing and Rehabilitation Center - [**Hospital1 10478**]
Discharge Diagnosis:
Coronary Artery Disease
PMH
Myocardial infarction
Hypertension
peripheral vascular disease
Hyperlipidemia
Obesity
COPD
scrotal raphe abscess
Right subclavian stenosis
Active tobacco use
Past Surgical History:
[**2110**] Right inguinal hernia repair
Nasal Septum Repair x2
[**2118**] Left inguinal hernia repair c/b epididymal hematoma
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema [**1-6**]+ bilateral LEs
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] at MWMC Thursday, [**2123-11-25**] 9am
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] Tues, [**2123-11-30**], 1pm
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) 8758**] [**Telephone/Fax (1) 67950**] in [**3-8**] weeks
Completed by:[**2123-11-5**]
ICD9 Codes: 496, 412, 4019, 4439, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1933
} | Medical Text: Admission Date: [**2161-3-1**] Discharge Date: [**2161-3-10**]
Service: VSU
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: This is an 82-year-old female
with a known abdominal aortic aneurysm who has been monitored
by Dr. [**Last Name (STitle) 1391**]. The patient is being admitted for elective
repair.
PAST MEDICAL HISTORY: Type 2 diabetes diet controlled, lung
carcinoma status post radiation therapy, history of
hyperlipidemia, history of COPD by chest x-ray.
PAST SURGICAL HISTORY: Tonsillectomy.
ALLERGIES: No known allergies.
MEDICATIONS: Include Lescol 80 mg daily and Advair 250 mg
twice a day.
SOCIAL HISTORY: The patient has a 67 pack year history of
smoking which is current. The patient does have a history of
alcohol use 1-2 drinks per day.
PHYSICAL EXAMINATION: Vital signs: The patient is afebrile,
pulse is 80, respirations 16, oxygen saturation 94% in room
air. Blood pressure is 148/78. General appearance: An alert
white female in no acute distress, oriented x3. Heart:
Regular rate and rhythm without murmurs, rubs or gallops.
Lungs: Diminished breath sounds throughout but clear.
Abdomen: Soft, nontender with palpable prominent aorta.
Extremities: Without edema. There are palpable femorals
bilaterally and dopplerable pedal pulses bilaterally.
HOSPITAL COURSE: The patient was admitted to the vascular
service. She was prepared for surgery. She underwent on
[**2161-3-2**], an aorto-bifemoral bypass graft for
resection of abdominal aortic aneurysm. She received 300 cc
of cell [**Doctor Last Name 10105**] and 1 unit of packed cells. She tolerated the
procedure well and was transferred to the PACU in stable
condition. An epidural was placed intraoperatively for
analgesic control. Her vital signs, she was hemodynamically
stable in the recovery room. Her postoperative hematocrit was
26.8. She was transfused. BUN 15, creatinine 0.7. The patient
continued to do well and was transferred to the VICU for
continued monitoring and care. Postoperative day 1, there
were no overnight events. She did develop mild confusion and
agitation which progressed during the day. Her confusion
required Haldol but the agitation continued and she developed
a temperature with tachycardia. She was placed on a CIWA
scale and transferred to the ICU for continued monitoring and
care. Her PA pressures were elevated at this time and a chest
x-ray was consistent with congestive heart failure. She was
diuresed. It was also noted that platelet count had dropped
from 120,000 to 79,000 and a HIT panel was sent. While in the
unit, her urinary output improved with diuresis. Blood
cultures were sent for the temperature. The urine did grow E.
Coli which was treated with ciprofloxacin. She remained
afebrile. The patient's epidural was discontinued on
postoperative day 2. She was given pain medications IV along
with q.1 hour neurologic signs for her low platelet count
after removal of the epidural. She did continue to require
diuresis postoperative day 3. The NG tube was removed on
postoperative day 1. Sips were begun on postoperative day 3
and her diet was advanced as tolerated. She continued to
require Lasix and she was given 25 grams albumin for her
hypoalbuminemia. The patient continued to show improvement in
her congestive failure. She remained in the ICU. Her cardiac
enzymes remained unremarkable. Her PA line was converted to a
central line on postoperative day 4. Her heparin was
restarted secondary to the HIT being negative. Her wounds
looked clean, dry and intact. She had bowel sounds. She still
remained awake but mildly agitated. Her glycemic control was
excellent. The patient was transferred to the VICU for
continued monitoring and care. Ambulation was begun and
physical therapy was requested to evaluate the patient for
discharge planning. She did require an increase in her
metoprolol to maintain her heart rate less than 80. On
postoperative day 5, she continued to progress. Physical
therapy felt that she would benefit from rehabilitation. On
postoperative day 6, her central line was discontinued and a
peripheral line was placed. She was transferred to the floor.
She continued to be diuresed. Her hematocrit remained stable
at 28.3. The remaining hospital course was unremarkable. The
patient did have a bowel movement on postoperative day 7. She
would be transferred to rehabilitation when medically stable
when bed available.
DISCHARGE DIAGNOSES:
1. Abdominal aortic aneurysm.
2. History of chronic obstructive pulmonary disease by chest
x-ray.
3. History of lung cancer, status post radiation therapy.
4. History of hyperlipidemia.
5. History of type 2 diabetes, diet controlled.
6. History of smoking 67 pack years, current smoker.
7. Postoperative confusion, resolved.
8. Postoperative withdrawal, treated.
9. Postoperative thrombocytopenia, HIT negative.
10. Postoperative blood loss anemia, transfused.
11. Postoperative acute renal failure, resolved.
12. Postoperative volume depletion, fluid resuscitated.
13. Postoperative congestive heart failure, diuresed.
14. Postoperative hypercarbia, resolved.
15. Postoperative urinary tract infection, treating for E.
Coli.
MAJOR SURGICAL PROCEDURE: Abdominal aortic aneurysm repair
with aorto-bifemoral bypass graft on [**2161-3-2**].
DISCHARGE DISPOSITION: The patient may ambulate as tolerated
and slowly progress. Diet is as tolerated. No heavy lifting
greater than 2 pounds for 6 weeks. Continue all medications
as directed. She may shower but no tub baths. No driving
until seen in follow-up. If her groin wounds become red,
swollen or drain, she should call Dr.[**Name (NI) 1392**] office. If
she develops a fever greater than 101.5, call Dr.[**Name (NI) 1392**]
office. She should continue on the stool softener while on
pain medication to prevent constipation.
DISCHARGE MEDICATIONS: Fluticasone/salmeterol 250/50 mcg
disk twice a day, ipratropium bromide 0.02% solution
inhalation q.6 hours as needed, Nicotine 14 mg 24 hour patch
daily, oxycodone/acetaminophen 5/325 elixir 5-10 cc q.4-6
hours p.r.n., quetiapine 12.5 mg twice a day, Dulcolax
tablets daily as needed, Colace 100 mg twice a day,
metoprolol 12.5 mg twice a day, aspirin 81 mg daily,
albuterol sulfate 0.083% solution q.4 hours p.r.n.,
ciprofloxacin 500 mg q.12 hours x1 day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2161-3-10**] 09:52:36
T: [**2161-3-10**] 10:40:44
Job#: [**Job Number 31418**]
ICD9 Codes: 496, 4280, 5990, 2875, 2851, 5849, 3051, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1934
} | Medical Text: Admission Date: [**2149-10-22**] Discharge Date: [**2149-10-26**]
Date of Birth: [**2106-9-6**] Sex: F
Service:
ADMISSION DIAGNOSES: Left breast cancer.
DISCHARGE DIAGNOSES: Left breast cancer.
ATTENDING PHYSICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], [**Name Initial (NameIs) **].D.
DISCHARGE MEDICATIONS:
1. Percocet 325 mg 1-2 tablets po q.4-6h p.r.n. for pain.
2. Clindamycin 150 mg capsules 2 capsules po q.6h x1 week.
3. Colace 100 mg po b.i.d. x2 weeks.
DISPOSITION: The patient was discharged to home with follow
up instructions for an appointment with Dr. [**First Name (STitle) 3228**] in 7 to 10
days.
HOSPITAL COURSE: The patient is a 43 year old African-
American female who was admitted on [**2149-10-22**] to
undergo a skin sparing left mastectomy and immediate [**Last Name (un) 5884**]
flap reconstruction. She tolerated this without complication
and postoperatively recovered in the post anesthesia care
unit. On day #1 her flap was noted to be well perfused and
the patient was allowed out of bed to a chair. Her diet was
advanced to clears. On postoperative day #2 the patient had a
migraine headache overnight that was relieved with narcotic
administration. She had a low grade temperature to 101.1, but
was afebrile by morning. Her left breast flap remained well
perfused and the patient was allowed out of bed to ambulate
with assistance. Her Foley catheter was removed and her diet
was advanced to regular as tolerated. On postoperative day #3
the patient was allowed to ambulate with increased frequency
and was allowed to shower and sponge bathe. She was
tolerating a regular diet and some mild nausea had improved
with antiemetic medication. On postoperative day #4 the
patient was without significant pain, was ambulating without
difficulty, was voiding spontaneously, and was tolerating a
regular diet. She was felt to be in stable and satisfactory
condition for discharge to home.
PROCEDURES PERFORMED: Procedures performed during this
admission was a left mastectomy on [**2149-10-22**], and
also a left [**Last Name (un) 5884**] flap reconstruction on [**2149-10-22**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], M.D. [**MD Number(2) 8076**]
Dictated By:[**Last Name (NamePattern1) 8077**]
MEDQUIST36
D: [**2150-2-24**] 09:45:39
T: [**2150-2-24**] 10:18:59
Job#: [**Job Number 8078**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1935
} | Medical Text: Admission Date: [**2122-7-14**] Discharge Date: [**2122-7-14**]
Date of Birth: [**2080-2-22**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Demerol / Valium / Percocet / Phenergan
Attending:[**First Name3 (LF) 69390**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 27363**] is a 42 yo female with a hx of atypical CP, PE x 2,
recurrent DVT (on chronic coumadin), and SVT s/p multiple
ablation with most recent RA of AVNRT in [**2115**]. She was admitted
on [**7-11**] to [**Hospital3 6592**] after she experienced the sudden onset
of pleuritic CP with palpitations while driving, similar to her
prior 'PE pain'. She presented to the the [**Hospital1 **] ED,
whereinitial ECG showed significant inferolateral ST
depressions. ? resolution with nitroglycerin. CP was relief
following morphine and ASA. ECG returned to baseline. INR was
subtherapeutic at 1.65, and given her known severe contrast
allergy, it was decided to increase her warfarin dose to treat
empirically for pulmonary embolus. There was still question as
to whether her sx were related to ACS vs PE. She received an
echo today showed normal LV function with no clear regional wall
motion abnormalities. Pharmacologic MIBI study with Lexiscan
produced severe chest pain and significant ST depressions, which
were both relieved with Aminophylline, nitroglycerin, and a 5 mg
of IV metoprolol. Her perfusion imaging was normal. However, in
view of her substantial symptoms and EKG changes with
pharmacologic stress, she is planned for transfer to [**Hospital1 18**] for
cardiac catheterization, which is currently being arranged.
Sometime overnight prior to transfer she had severalruns of NSVT
that were reportedly asymptomatic.
.
On transfer fromt he OSH she had [**8-28**] CP for which she received
nitro, ASA and dilaudid with improvement to [**4-28**] CP.
.
She is currently experiencing [**4-28**] CP that is pleuritic in
nature and occasionally associated with nausea. She denies
diaphoresis, vommiting or GERD symptoms. She does have an
allergy to CT contrast but not to cardiac catheterization dye.
.
Regarding her historty of DVT/PE, her w/u for hypercoaguable
state has been neg with the exception of her LA which was
positive on coumadin. Her 1st PE occurred as a complication of
her ablation in [**2115**].
.
Regarding her hx of atypical CP, She also has a history of
atypical chest discomfort with multiple hospital visits (q 4-6
wks). SHe is s/p cardiac catheterization x3, most recently at
[**Hospital1 112**] in [**2121**], which showed no significant coronary disease. There
has been concern expressed in the past of Munchausen's syndrome.
.
Regarding her hx of SVT, she has been refractory to
antiarrhythmics including flecainide (dizziness), amiodarone and
propafenone, and she is currently maintained on metoprolol. She
has had numerous ablations and EP studies at [**Hospital3 9947**],[**Hospital1 112**], and most recently at [**Hospital3 **]
Past Medical History:
1. CARDIAC RISK FACTORS: No Diabetes, Dyslipidemia, or
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none, most recent cath
clean in [**2121**]
-PACING/ICD: none
SVT
HYPOTHYROIDISM
THROMBOPHLEBITIS
LOW BACK PAIN
Obesity
Thyroid nodule
Radial artery occlusion, right
Palpitations
Pulmonary embolism
Social History:
Pt is divorced from an abusive relationship, has two children
age 12 and 16. She works in an ambulance as an EMT and also has
a 3rd job at a Sheriffs Department. She denies current tobacco
use. She denies any current ETOH use and denied any other drug
use.
Family History:
Father: first MI in mid 50s, h/o vtach, afib, T2DM
Son: AV nodal reentry
Aunt: Breast CA at age 52
Physical Exam:
Admission/Discharge Exam:
82 BP 1154/69 O2Sat 93%
HEENT: NC AT
CHEST: CTA BL
CV: RRR NO MRG
Abd: NT ND +BS
Ext: WWP no erythema, warmth or edema.
Pertinent Results:
ADMISSION/DISCHARGE LABS
[**2122-7-14**] 08:06AM BLOOD WBC-6.5# RBC-3.76* Hgb-12.4 Hct-36.3
MCV-97 MCH-32.9* MCHC-34.1 RDW-13.8 Plt Ct-210
[**2122-7-14**] 08:06AM BLOOD Neuts-72.6* Lymphs-18.9 Monos-6.7 Eos-1.3
Baso-0.5
[**2122-7-14**] 08:06AM BLOOD PT-41.2* PTT-47.7* INR(PT)-4.0*
[**2122-7-14**] 08:06AM BLOOD Glucose-120* UreaN-10 Creat-0.8 Na-137
K-3.9 Cl-105 HCO3-24 AnGap-12
[**2122-7-14**] 08:06AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
[**2122-7-14**] 08:06AM BLOOD D-Dimer-<150
IMAGING:
ECHO:
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). Right ventricular
chamber size is borderline dilated and free wall motion is
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure is probably normal (however the spectral Doppler
recording of the tricuspid jet is technically suboptimal). There
is no pericardial effusion.
CXR:
AP upright portable chest radiograph is obtained. The lungs are
well expanded and clear. There is no pleural effusion or
pneumothorax. The heart is normal in size with normal
cardiomediastinal contours.
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
42 yo female with a PMH notable for SVT refractory to
medications and ablations, atypical CP, and PEx2/DVT who is
transferred from OSH for cath after being admitted with
pleuritic CP.
.
Chest pain: Possible causes of her CP are ACS (however she had
clean coronaries in [**2111**] and [**2121**], EKG is normal without
reported enzyme elevations) Nothing to suggest dissection,
pericarditis, PNA or pneumothorax. Does not appear to be MSK in
nature. Pleuritic and associtated with tachycardia in this
young woman with history of unprovoked VTE's on chronic coumadin
in the setting of subtherapeutic INR raises the specter of
recurrent PE although D-dimer was 150. In addition, repeat INR
was 4.0 so she is therapuetic on her coumadin again despite
being subtherapuetic on arrival to OSH. ECHO was also
unremarkable. She slept for a few hours and on re-evaluation,
her pain had improved. She wanted to go home and we felt that
given her extensive work up was negative that she was ok for
discharge. She has close follow up with Dr. [**First Name (STitle) **] the day after
discharge on [**2122-7-15**].
.
# Tachyarrhthmia: The Telemetry tracings from [**Hospital3 6592**]
were reviewed in detail. Possible etiologies include
non-sustained Mono-morphic VT, SVT with abberency, or artifact.
It was clear the the 'narrow' QRS complex marched through the
'wide-complex' beats consistent with artifact. We continued her
home lopressor and she will follow up with Dr. [**First Name (STitle) **] on [**2122-7-15**].
.
# Elevated INR: Was 4 on admission. She was not given her
coumadin today. She will follow up with [**University/College **] vangaurd
coumadin clinic to maintain a goal INR of 2.5-3.0.
# Hypothyroidism: Continue thyroxine
.
# Anxiety: Continue lorazepam
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Warfarin 17.5 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA)
3. Metoprolol Tartrate 25 mg PO TID
4. Lorazepam 0.5 mg PO TID:PRN anxiety
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Lorazepam 0.5 mg PO TID:PRN anxiety
3. Metoprolol Tartrate 25 mg PO TID
4. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Chest Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital1 69**]
from another hospital for further evaluation of your chest pain.
Your chest pain was not cardiac in nature. There was concern
that this pain was related to a PE, but your D-dimer is low and
this make it very unlikely. In addition, your INR was elevated
at 4.0. We also do not believe this is referred pain from you
abdomen. Overall, your work up has been negative and we are
reassured that since the pain has improved since arrival that
you are ready to be discharged home.
Since you INR is elevated, please do not take your coumadin
today. It is important that you have your INR drawn in the next
48 hours and restart you coumadin to maintain a goal INR of
2.5-3.
The following medication was STOPPED:
Coumadin to be restarted when INR within goal.
There were no other changes to your medication at this time.
Followup Instructions:
Please Keep your appointment with Dr. [**First Name (STitle) **] on [**2122-7-15**].
[**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 69391**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1936
} | Medical Text: Admission Date: [**2168-1-3**] Discharge Date: [**2168-1-15**]
Date of Birth: [**2115-7-19**] Sex: F
Service: SURGERY
Allergies:
Ibuprofen / Aspirin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
[**2168-1-6**] Exploratory laparotomy and Revision of jejunojejunostomy
History of Present Illness:
Ms. [**Known lastname 47700**] is a 52 yo F s/p laparoscopic RNY gastric bypass in
[**2158**] with Dr. [**Last Name (STitle) **] who is transferred from OSH for SBO. She
began to have epigastric abdominal pain on Wednesday, described
as constant ache with breakthrough sharp pains, that was
persistent. She continued to tolerate PO and had flatus, until
yesterday, when she presented to the OSH ED after 1 episode of
emesis. Her meals have included vegetable [**Location (un) 6002**], broth,
hamburger in the past few days, which she has all tolerated
before. Of note, she has had back pain for the past 2 weeks. She
complains of persistent nausea.
At the OSH ED, NGT was placed, labs were reportedly normal and
she was hemodynamically stable. She was given morphine IV and
transferred to [**Hospital1 18**] for further care.
Past Medical History:
HTN - no longer takes medications; HLD - resolved, formerly on
crestor
Past Surgical History: cholecystectomy [**2140**], lap RNY gastric
bypass [**2158**]
Social History:
Lives at home with her husband. [**Name (NI) **] EtOH or smoking.
Family History:
Noncontributory, patient is adopted
Physical Exam:
On Admission:
Vitals 98.7 176/108 97 16 96% RA FS 210
General: mild distress, uncomfortable, A&Ox3
CV: RRR, nl s1 s2
Pulm: CTAB, no rhonchi/rales
Abd: soft, focal epigastric tenderness to light palpation, no
peritoneal signs, nondistended
Ext: WWP, no edema
On Dishcarge:
VS: T 98.9 HR 85 BP 119/78 RR 18 O2 100% RA FS 103
Constitutional: NAD
Neuro: Alert and oriented x 3
Cardiac: RRR, NL S1,S2
Lungs: CTA B/l, no respiratory distress.
Abdomen: Soft, mildly tender to palpation, no rebound
tenderness/ guarding
Wound: Abd midline incision c/d/i without steri-strips and with
some inferior border erythema that is improving
Ext: mild edema, no c/c. MAE.
Pertinent Results:
[**2168-1-3**] CT Abdomen: Findings: A large amount of stool is present
within the ascending and transverse colon. The ascending colon
is distended with bowel loops measuring up to approximately 9.5
cm in diameter. Additionally, a few mildly distended loops of
small bowel are present in the left mid abdomen near surgical
chain sutures. The small bowel measures up to about 4.3 cm in
diameter. No free intraperitoneal air is identified. Nasogastric
tube is present within the body of the stomach. Within the
chest, lungs are clear except for minimal linear atelectasis at
the bases.
IMPRESSION: Findings which may be related to partial small-bowel
obstruction as reported on review of recent outside hospital CT
by Dr. [**Last Name (STitle) **]. Recommend short-term followup radiographs or
CT.
[**2168-1-5**] CT ABD & PELVIS WITH CONTRAST:
IMPRESSION:
1. High-grade small bowel obstruction with oral contrast failing
to pass the proximal portion the efferent loop. Along with
mesenteric tortuosity
engorgement and swirl; these findings are concerning for an
internal hernia.
2. New abdominal and pelvic free fluid. No evidence of
perforation.
[**2168-1-5**] ECG:
Sinus rhythm. Consider inferior myocardial infarction. T wave
abnormalities. No previous tracing available for comparison.
[**2168-1-5**] CHEST (PORTABLE AP):
IMPRESSION:
1. Proper position of the endotracheal tube and nasogastric
tube.
2. Right internal jugular catheter ends in the right atrium
approximately 1 cm from the superior atriocaval junction.
[**2168-1-8**] CHEST (PORTABLE AP):
FINDINGS: In comparison with the study of [**1-7**], there are
continued low lung volumes. The right IJ catheter has been
removed and the nasogastric tube again extends to the upper
stomach.
There is opacification at the bases most likely reflecting small
right
effusion and bilateral atelectasis. In the appropriate clinical
setting,
superimposed pneumonia would have to be considered.
[**2168-1-8**] CHEST PORT. LINE PLACEM:
IMPRESSION:
1. PICC wire ends at the atriocaval junction. If the catheter
extends beyond the wire, would consider pulling back 2-3 cm.
2. Stable small bilateral pleural effusions and mild bibasilar
atelectasis.
[**2168-1-15**] 05:20AM BLOOD WBC-14.1* RBC-3.26* Hgb-9.6* Hct-28.6*
MCV-88 MCH-29.3 MCHC-33.5 RDW-14.8 Plt Ct-635*
[**2168-1-14**] 04:50PM BLOOD WBC-16.2* RBC-2.71* Hgb-7.8* Hct-23.8*
MCV-88 MCH-28.9 MCHC-32.9 RDW-15.4 Plt Ct-597*
[**2168-1-14**] 04:34AM BLOOD WBC-14.1* RBC-2.52* Hgb-7.4* Hct-22.5*
MCV-89 MCH-29.3 MCHC-32.9 RDW-15.2 Plt Ct-549*
[**2168-1-13**] 08:15AM BLOOD WBC-14.6*# RBC-2.79*# Hgb-8.1*#
Hct-24.3*# MCV-87 MCH-29.2 MCHC-33.5 RDW-15.6* Plt Ct-522*#
[**2168-1-9**] 09:09AM BLOOD WBC-5.2 RBC-4.54 Hgb-13.8 Hct-40.6 MCV-90
MCH-30.3 MCHC-33.9 RDW-15.0 Plt Ct-223
[**2168-1-8**] 02:26PM BLOOD WBC-7.9 RBC-4.24# Hgb-12.4# Hct-37.7#
MCV-89 MCH-29.2 MCHC-32.9 RDW-15.4 Plt Ct-194
[**2168-1-8**] 03:47AM BLOOD WBC-12.2* RBC-2.81* Hgb-8.3* Hct-25.0*
MCV-89 MCH-29.5 MCHC-33.1 RDW-15.4 Plt Ct-243
[**2168-1-7**] 02:03AM BLOOD WBC-9.9 RBC-2.82* Hgb-8.3* Hct-25.1*
MCV-89 MCH-29.2 MCHC-32.9 RDW-15.1 Plt Ct-220
[**2168-1-6**] 02:47AM BLOOD WBC-14.0* RBC-3.19* Hgb-9.5* Hct-27.4*
MCV-86 MCH-29.6 MCHC-34.5 RDW-15.2 Plt Ct-343
[**2168-1-5**] 07:50PM BLOOD WBC-13.1* RBC-4.02* Hgb-12.0 Hct-34.8*
MCV-86 MCH-29.9 MCHC-34.6 RDW-14.5 Plt Ct-424
[**2168-1-5**] 07:10AM BLOOD WBC-16.0* RBC-4.58 Hgb-13.4 Hct-39.3
MCV-86 MCH-29.3 MCHC-34.1 RDW-14.8 Plt Ct-393
[**2168-1-4**] 07:16AM BLOOD WBC-17.1* RBC-4.70 Hgb-13.7 Hct-40.9
MCV-87 MCH-29.1 MCHC-33.4 RDW-14.4 Plt Ct-353
[**2168-1-3**] 08:40PM BLOOD WBC-20.0*# RBC-4.65 Hgb-13.8 Hct-40.7
MCV-88 MCH-29.7# MCHC-33.9# RDW-14.6 Plt Ct-337
[**2168-1-7**] 02:03AM BLOOD Neuts-86.2* Lymphs-8.2* Monos-3.8 Eos-1.5
Baso-0.3
[**2168-1-6**] 02:47AM BLOOD Neuts-85* Bands-8* Lymphs-4* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2168-1-5**] 07:50PM BLOOD Neuts-56 Bands-29* Lymphs-8* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2168-1-7**] 02:03AM BLOOD PT-18.9* PTT-42.5* INR(PT)-1.8*
[**2168-1-5**] 07:50PM BLOOD PT-12.7* PTT-24.2* INR(PT)-1.2*
[**2168-1-5**] 08:40AM BLOOD PT-11.5 PTT-24.6* INR(PT)-1.1
[**2168-1-15**] 05:20AM BLOOD Glucose-96 UreaN-14 Creat-0.5 Na-131*
K-4.9 Cl-99 HCO3-24 AnGap-13
[**2168-1-13**] 08:15AM BLOOD Glucose-91 UreaN-8 Creat-0.5 Na-133 K-4.5
Cl-100 HCO3-23 AnGap-15
[**2168-1-11**] 07:18AM BLOOD Glucose-114* UreaN-7 Creat-0.4 Na-137
K-3.8 Cl-102 HCO3-25 AnGap-14
[**2168-1-9**] 09:09AM BLOOD Glucose-126* UreaN-6 Creat-0.4 Na-136
K-3.5 Cl-99 HCO3-29 AnGap-12
[**2168-1-6**] 04:22PM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-137
K-3.4 Cl-105 HCO3-24 AnGap-11
[**2168-1-5**] 07:50PM BLOOD Glucose-126* UreaN-13 Creat-0.7 Na-137
K-3.5 Cl-104 HCO3-21* AnGap-16
[**2168-1-5**] 07:10AM BLOOD Glucose-127* UreaN-8 Creat-0.6 Na-134
K-3.4 Cl-97 HCO3-26 AnGap-14
[**2168-1-4**] 07:16AM BLOOD Glucose-138* UreaN-7 Creat-0.6 Na-137
K-4.0 Cl-102 HCO3-22 AnGap-17
[**2168-1-3**] 08:40PM BLOOD Glucose-174* UreaN-6 Creat-0.6 Na-137
K-3.5 Cl-105 HCO3-21* AnGap-15
[**2168-1-7**] 02:03AM BLOOD ALT-79* AST-82* LD(LDH)-280* AlkPhos-51
TotBili-0.6
[**2168-1-6**] 02:47AM BLOOD ALT-140* AST-119* AlkPhos-55 TotBili-0.9
[**2168-1-5**] 07:10AM BLOOD ALT-62* AST-37 LD(LDH)-238 AlkPhos-55
Amylase-70 TotBili-0.6
[**2168-1-4**] 07:16AM BLOOD ALT-90* AST-75* LD(LDH)-284* AlkPhos-56
Amylase-372* TotBili-0.5
[**2168-1-3**] 08:40PM BLOOD ALT-64* AST-105* AlkPhos-56 Amylase-616*
TotBili-0.9
[**2168-1-5**] 07:10AM BLOOD Lipase-59
[**2168-1-4**] 07:16AM BLOOD Lipase-615*
[**2168-1-3**] 08:40PM BLOOD Lipase-2094*
[**2168-1-15**] 05:20AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.1
[**2168-1-13**] 08:15AM BLOOD Albumin-3.0* Calcium-8.2* Phos-4.0 Mg-1.8
[**2168-1-14**] 04:34AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.1 Iron-12*
[**2168-1-6**] 02:47AM BLOOD Albumin-3.4* Calcium-8.1* Phos-2.5*
Mg-2.1
[**2168-1-4**] 07:16AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.7 Cholest-200*
[**2168-1-3**] 08:40PM BLOOD Albumin-4.5 Calcium-9.3 Phos-3.2 Mg-1.7
Iron-170*
[**2168-1-14**] 04:34AM BLOOD calTIBC-220* VitB12-682 Ferritn-167*
TRF-169*
[**2168-1-3**] 08:40PM BLOOD VitB12-816 Folate-GREATER TH
[**2168-1-4**] 07:16AM BLOOD Triglyc-105 HDL-36 CHOL/HD-5.6
LDLcalc-143*
[**2168-1-6**] 11:39AM BLOOD Lactate-1.8
[**2168-1-6**] 03:07AM BLOOD Lactate-2.3*
[**2168-1-5**] 07:58PM BLOOD Lactate-2.9*
[**2168-1-5**] 05:09PM BLOOD Glucose-134* Lactate-2.3* Na-132* K-4.0
Cl-105
[**2168-1-5**] 04:00PM BLOOD Glucose-133* Lactate-1.9 K-3.3 Cl-104
[**2168-1-5**] 07:12AM BLOOD Lactate-2.2*
[**2168-1-4**] 07:32AM BLOOD Lactate-2.0
[**2168-1-3**] 10:43PM BLOOD Lactate-1.5
[**2168-1-6**] 03:07AM BLOOD freeCa-1.12
[**2168-1-5**] 04:00PM BLOOD freeCa-1.04*
[**2168-1-9**] 09:09AM BLOOD VITAMIN B1-Test
Brief Hospital Course:
The patient was transferred from an OSH on [**2168-1-3**] for concern
of small bowel obstruction s/p laparoscopic RNY gastric bypass
by Dr. [**Last Name (STitle) **] in [**2158**]. On admission, abdomen was noted to be
soft and without peritoneal signs. Admission labs noted
elevated pancreatic enzymes, a leukocytolysis to 20K, and a mild
tansaminitis. Radiologists at [**Hospital1 18**] reviewed the outside films
which were read as an obstruction at the jejunal anastomosis
with fluid in the abdomen, and question of internal
hernia. Discussed CT with [**Hospital1 18**] radiologist who believed the
scan was consistent with
partial obstruction, without evidence of internal hernia, and
with stool going all the way to the rectum. The patient was
made NPO, with IVF, and a foley for urine output monitoring.
The patient received IV morphine o/n and was transitioned to a
morphine PCA on HD1. On HD3, the patient experienced worsening
abdominal pain prompting a repeat Abd/ Pelvic CT scan, which
suggested high-grade small bowel with 'mesenteric tortuosity
engorgement and swirl' concern for internal hernia. Given these
findings, the patient was brought to the operating room
emergently where she underwent an exploratory laparotomy with
revision of jejunojejunostomy (reader referred to operative note
for complete detail). The patient required pressors
intraoperatively and was kept intubated overnight due to concern
for possible lactic acidosis and worsening cardiopulmonary
function which never presented itself. Patient was able to be
weaned off pressors over the next 24 hours and was extubated on
POD 1 without incident.
Neuro: Pre-operatively pain was managed with IV morphine while
NPO to good effect and a morphine PCA was started on HD 1.
Post-op, the patient experienced intermittent delirium while on
a dilauid PCA in the intensive care unit, which resolved by POD
2 after being transferred to morphine PCA with IV tylenol; When
tolerating a diet, patient was transitioned to PO pain
medications on POD 6 - initially roxicet, then transitioned to
liquid tylenol and liquid oxycodone.
CV: The patient was noted to be hypertensive upon admissions
with SBP 150-170s. Patient has a history of hypertension but no
longer takes medications for this. Blood pressure improved with
IV lopressor and better pain control, however, it remained in
the 150s. Intraoperatively the patient required pressors which
were continued until POD 1. Additionally, she was tachycardic
until POD1 which improved with aggressive fluid resuscitation,
however, she remained intermittently tachycardic throughout the
remainder of her hospitalization requiring transition to oral
metoprolol. She was hemodynamically stable by POD 3 and
transferred tot he floor. At time of discharge, her
hypertension and tachycardia were resolving and she was
instructed to follow up with her PCP about her cardiovascular
physiology and need for continuation of this medication.
Pulmonary: The patient remained intubated post-operatively. She
was gradually weaned from the ventilator and extubated on POD1.
Once extubated, she was weaned from to room air over the next 2
days and remained stable from a pulmonary standpoint. Good
pulmonary toilet, ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Patient was made NPO with IVF and an NGT upon
admission, with a foley catheter for UOP monitoring. On HD3,
the patient experienced worsening abdominal pain prompting a
repeat Abd/ Pelvic CT scan, which suggested high-grade small
bowel with 'mesenteric tortuosity engorgement and swirl' concern
for internal hernia. Given these findings, the patient was
brought to the operating room emergently where she underwent an
exploratory laparotomy with revision of jejunojejunostomy (as
described above). Post-operatively, the patient was transferred
to the intensive care unit for further management. She was kept
NPO with NGT and IVF postoperatively - requiring aggressive
fluid resuscitation until POD2. A PICC line was placed on POD3
and TPN started. As bowel function returned NGT was
discontinued and her diet was advance on POD 6 which was well
tolerated. On POD 7 she was advanced to a bariatric stage 4
diet which resulted in increased nausea and bloating and she was
told to restrict her diet and reduced to Stage 3 and
subsequently had poor PO intake. TPN was subsequently restarted
on POD 8.
Her urine output was only about 20/hr overnight on POD 0 but
after resuscitation patient started making 40/hr by the
afternoon of POD 1 and maintained good UOP thereafter. Patient
complained of burning upon urination near the end of her
hospital stay but urinalysis failed to demonstrate a UTI and
patient was not any treatment for this complaint. Patient's
intake and output were closely monitored.
ID: Patient presented with a white count of 20,000 which was
downtrending by HD1. She received intraoperative Kefzol and
Flagyl which were continued for 24 hours. The patient's fever
curves were closely watched for signs of infection, of which
there were none. However, on POD 9 the patient's midline
incision began to demonstrate erythema on the inferior border
and in light of a bump in her WBC she was started on IV ancef
until discharge at which time she was transition to keflex x 1
week. Her white count was down trending at time of discharge.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; she also received
protonix for GI prophylaxis while NGT was in place. She was
encouraged to get up and ambulate throughout her stay.
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 including: 1 week intake of oral
antibiotic, follow up with PCP regarding overall condition and
hospital course, addition of new medications including
metoprolol and discussion with PCP about discontinuation, diet
information, follow up appointments, need to return to [**Hospital1 18**] for
further care, warning signs, and activities all of which she
stated she understood and was in agreement with the discharge
plan.
Medications on Admission:
Iron, MTV 1 tab daily, glucosamine, Vitamin D, colace
Discharge Medications:
1. TPN
Volume: 1450mL. Amino Acid: 95g Dextrose 170 Fat 35
Electrolytes: NaCl 155 NaAc 0 NaPO4 20 KCl 25 KAc 0 KPO4 15
MgS04 12 CaGlu 10.
Cycle: 12 hours. Add standard multivitamin
Quantity 30 bags.
2. Outpatient Lab Work
ALT, AST, Albumin, Chem 10, Triglycerides
3. PICC Care
Weekly PICC care including prn dressing and cap change
4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**3-25**]
hours as needed for pain: Crush.
Disp:*60 Tablet(s)* Refills:*2*
5. oxycodone 5 mg/5 mL Solution Sig: [**4-28**] ml PO Q3H (every 3
hours) as needed for pain.
Disp:*500 ml* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Crush.
Disp:*60 Tablet(s)* Refills:*0*
7. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
8. calcium citrate-vitamin D3 500 mg calcium -400 unit Tablet,
Chewable Sig: Two (2) Tablet, Chewable PO once a day.
9. eszopiclone 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for insomnia.
10. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice
a day as needed for constipation.
Disp:*250 ml* Refills:*2*
11. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO twice a
day.
Disp:*600 mL* Refills:*0*
12. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
High Grade Small Bowel Obstruction with Internal Hernia
s/p Exploratory laparotomy and revision of jejunojejunostomy
Acute Pancreatitis
Constipation
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 severe abdominal pain
related to a small bowel obstruction. This became progressively
worse during your hospitalization requiring an urgent operation.
You have recovered in the hospital and are now preparing for
discharge to home on nocturnal intravenous nutrition with
follow-up scheduled on [**2168-1-27**] with Dr. [**Last Name (STitle) **] and
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RD.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
*Please present to [**Hospital1 18**] if possible for any future
complications.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-28**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications. Continue to get up and walk several times a day as
tolerated.
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.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES. Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Please contact your primary care provider to schedule [**Name Initial (PRE) **]
follow-up appointment within 1-2 weeks.
Department: BARIATRIC SURGERY
When: WEDNESDAY [**2168-1-27**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RD [**Telephone/Fax (1) 305**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BARIATRIC SURGERY
When: WEDNESDAY [**2168-1-27**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD [**Telephone/Fax (1) 305**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Pleae contact your PCP to schedule an appointment within the
next 2 weeks. Update him on your hospital course and current
medication regimen including addition of lopressor and have him
make adjustments as needed.
ICD9 Codes: 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1937
} | Medical Text: Admission Date: [**2163-6-6**] Discharge Date: [**2163-6-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
invasive sqamous scalp ca
Major Surgical or Invasive Procedure:
PICC line placement, neurosurgical intervention cancelled,
History of Present Illness:
Patient is a [**Age over 90 **] year old female with afib, cad, dm who was
transferred from [**Hospital1 **] [**Hospital1 **] for lesion on scalp (can see
brain matter). She was evaluated as an outpatient intially by
dermatology that did a biopsy of the scalp mass and she was
diagnosed with squamous cell carcinoma. The ulcerative lesion
eroding skull extending intracranially and was to have
neurosurgical intervention but the patient was supertheraputic
INR of 7.7 so she was sent to the MICU. She was reversed with
reversed with 10 IV K, 2u FFP. She was also noted to have arf
with cr of 2, anuric, dry on exam with a
sodium 158-->161. She received a NS bolus and then D5W and
avoiding lasix and acei given renal failure, renal ultrasound
with R hydro and pelvic mass (family does not want w/u). Patient
was placed on vanc and cetriaxone for meningitis proprolaxis
since there is CSF communicating with skin secondary to scc.
Patient is having PICC placed in the AM for long-term abx and
fluids. Cultures are pending.
Family is aware of poor prognosis and she is dnr/dni, family
wants conservative med management.
Past Medical History:
CHF-unknown type or EF.
bradycardia s/p pacemaker
afib-s/p cardioversion at [**Hospital1 112**]
htn
hyperthyroidism
arthritis
hernia repair
anxiety
h.o SCC of the scalp year ago per records
glaucoma
Social History:
Lives in [**Location **]. No tobacco, EtOH, or illicit drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.9, 102/666, 64, 22, 98% RA, FS140
General: Alert, trembling, cooperative
HEENT:PERRLA, 3x3cm irregular discolored raised mass, EOMI,
anicteric, MMM
neck-JVD to ear?positional, no LAD
chest-b/l ae no w/c/r
heart-s1s2 4/6 systolic murmur heard throughout precordium
abd-+bs, soft, Nt, ND
ext-NO c/c/e 1+ puluses, cold, r first toe ichemic ulcer
neuro-aaox2, moves all extremities.
Pertinent Results:
[**2163-6-6**] 05:35PM PT-63.8* PTT-41.1* INR(PT)-7.7*
[**2163-6-6**] 05:35PM WBC-13.1*# RBC-3.65* HGB-10.8* HCT-35.6*
MCV-98 MCH-29.7# MCHC-30.5* RDW-13.7
[**2163-6-6**] 05:35PM cTropnT-0.07*
[**2163-6-6**] 05:35PM WBC-13.1*# RBC-3.65* HGB-10.8* HCT-35.6*
MCV-98 MCH-29.7# MCHC-30.5* RDW-13.7
[**2163-6-6**] 05:35PM CK(CPK)-33
[**2163-6-6**] 05:55PM LACTATE-1.7
CT head:
TECHNIQUE: Axial non-contrast images performed in an outside
hospital
([**Hospital3 **]) were submitted for review. No
reconstructions were
available. No formal report was provided.
FINDINGS:
Within the brain parenchyma, there is global parenchymal
atrophy, indicated by
enlargement of the ventricles and sulci. There is also
periventricular and
subcortical white matter hypodensity, consistent with small
vessel ischemic
disease. A right cerebellar lacunar infarct is also noted. There
is no
hemorrhage, edema, or mass effect. There is no shift of normally
midline
structures. The [**Doctor Last Name 352**]-white matter differentiation appears
preserved.
There is a large destructive lesion involving the vertex of the
calvarium.
There is no underlying brain mass lesion or brain abscess,
although there is
an extra- axial, likely subdural, soft tissue/fluid component to
this lesion,
although this is difficult to evaluate due to volume averaging
at the vertex
and the lack of reconstructions. The lesion at the vertex causes
significant
osseous destruction. There is subcutaneous gas, which also
extends
intracranially, with resultant pneumocephalus.
IMPRESSION:
1. Extensive destructive lesion involving the calvarial vertex,
with
intracranial extension indicated by pneumocephalus and
extra-axial,
intracranial soft tissue/fluid component. This does not appear
to be of
primary CNS etiology. Differential includes infectious process
or a
subcutaneous or osseous malignancy. Further evaluation with
contrast-enhanced
MRI is recommended.
2. Small vessel ischemic disease, lacunar infarcts, and global
parenchymal
atrophy. There are no brain mass lesions or brain abscesses
identified.
Renal ultrasound [**2163-6-7**]:
FINDINGS: The left kidney measures 9 cm in length. There is no
left-sided
hydronephrosis. The right kidney measures 9.5 cm in length.
There is
moderate right-sided hydronephrosis. There is no renal mass or
stone. There
is a large > 15 cm cystic pelvic mass, which cannot be further
characterized.
Bladder is not visualized.
IMPRESSION:
1. Moderate right-sided hydronephrosis.
2. Non-specific, large cystic pelvic mass.
Brief Hospital Course:
Patient was a [**Age over 90 **] year old female with h.o CHF, DM, afib, who
presented with invasive scalp squamous cell carcinoma with
intracranial extension who died after code status was CMO.
.
# CMO - Had family meeting [**6-10**]. Discussed to stop vital signs,
non-essential medications other than eye drops, pain meds, and
PO antibiotics. Patient was continued on maintainance IV fluids.
.
# Pain control - This was the family's primary goal of care.
There were multiple etiologies of the pain including her chonic
right shoulder pain, sacral decubiti with possible abcess,
painful scalp leison, or the >15cm pelvic mass. Pain control was
transitioned from outpatient oxycontin pills to fenanyl patch
and oxycodone liquid. Patient was comfortably sedated and only
required additional pain medication when she was moved.
Palliative care was involved in pain management.
.
# Squamous cell ca, intracranial- The carcinoma developed over
an unknown time period. It probably developed before her care to
nursing home facility given that there was a rapid decline in
her functional status and intracraninal involvement of the
tumor. She was evaluated as an outpatient by dermatology and
was determined to have a squamous cell ca as per biopsy on [**5-25**].
Initially, the family wanted to have a neurosurgical
intervention, but the patient's INR was 7.7 so she was
transferred to the MICU for reversal. Later, the family decided
not to have surgery once it became apparent that the morbity was
high. Patient was started on vancomycin and ceftriaxone for
meningitis ppx and this was changed to PO cefepoxidime after a
family meeting determining that she would not want IV
antibiotics. Wound care was done to address her head wound.
.
# Resolved hypovolemia/ acute renal failure/ hypernatremia -
secondary to dehydration and intravascular hypovolemia in the
setting of diruetic use. Cr 2.0 on admission, most recent
baseline at [**Hospital1 18**] 1.1. This was the reason for the PICC line
placement and why the family wanted IVF.
.
# Pelvic mass - There is a large > 15 cm cystic pelvic mass seen
on renal ultrasound. This may be a source of pain.
.
# afib not on anticoagulation - Patient has a history of atrial
fibrillation but was placed on anticoagulation for a recent
phelbiltis. Given that the scalp wound oozes blood, the family
has decided that they do not want anticoagulation.
.
# DM-HISS
.
COMFORT MEASURES ONLY
DISCHARGE TO DEATH
Medications on Admission:
Medications at home:
Lasix 40 mg PO daily
Lisinopril 40 mg PO daily
OxyContin 20 mg PO q12, 10mg PO qHS
Xalatan 0.005 % Eye Drops 1 Drops(s) Once Daily, at bedtime
Azopt 1 % Eye Drops Ophthalmic 1 drop daily
Tylenol 1g PO TID
Serax 10mg PO BID
MVI PO daily
Pro-Stat 64 -- Unknown Strength, Twice Daily
Zinc Chelated 50 mg PO daily
Vitamin C 500 mg SR PO daily
Simethicone 80 mg chewable tab PO prn
.
Medications on transfer:
CeftriaXONE 1 gm IV Q24H
Vancomycin 1000 mg IV ONCE (dose by level)
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Humalog insulin sliding scale
Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Pantoprazole 40 mg PO Q24H
Docusate Sodium (Liquid) 100 mg PO BID
Multivitamins 1 TAB PO DAILY
Oxazepam 10 mg PO BID:PRN anxiety
Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
Bisacodyl 10 mg PO/PR DAILY:PRN
Senna 1 TAB PO BID:PRN
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
intracranial extension of invasive sqamous cell carcinoma
Secondary:
resolved acute renal failure secondary to dehydration
pelvic mass of unknown etiology
atrial fibrillation, chronic
hypertension
diabetes mellitus, type 2
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2163-6-15**]
ICD9 Codes: 5849, 2760, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1938
} | Medical Text: Admission Date: [**2146-7-7**] Discharge Date: [**2146-7-25**]
Date of Birth: [**2082-3-15**] Sex: M
Service: [**Hospital1 139**] Medicine
This discharge summary reflects the patient's admission from
[**2146-7-7**] through [**2146-7-17**].
CHIEF COMPLAINT: Transfer from [**Hospital6 8972**]
for right foot gangrene and MRSA sepsis with seating of left
wrist and a left ventricular thrombus.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old man
who was initially sent from the nursing home where he resides
to [**Hospital6 8972**] on [**2146-7-1**] for gangrene of his
right second and third toes. Upon admission to [**Location (un) **] his
vital signs were temperature 97, heart rate 58, respiratory
rate 16. He was alert and oriented times three and his
physical exam was unremarkable other than the gangrene.
LABORATORY DATA: Initial labs were white blood cell count of
16.7 with 94% neutrophils, hematocrit 33.3, platelet count
240,000, sodium 136, potassium 4.1, chloride 103, CO2 21, BUN
63, creatinine 1.8, glucose 237 with anion gap equal to 12,
albumin .7, normal LFTs, CK of 153, CK MB 5.7. Urinalysis
was positive for nitrites with 11-20 white blood cells, 0-2
red blood cells and many bacteria with tract protein.
Initial chest x-ray showed left lower lobe pneumonia. The
patient was then started on Cipro. The final read of the
chest x-ray showed chronic changes. However, blood cultures
4/4 bottles grew out MRSA. His antibiotics were changed from
Cipro to Vancomycin and Rifampin. Repeat blood cultures from
[**7-4**] and [**7-6**] have been negative to date. The patient's
right foot was managed with local wound care. On [**2146-3-4**] the
patient was found to become increasingly lethargic and
bradycardic to a heart rate of 37. His left wrist was noted
to be inflamed and his BUN and creatinine increased to 85 and
3.6 respectively. His left wrist was tapped and grew gram
positive cocci consistent with MRSA septic arthritis.
Atenolol was discontinued due to bradycardia. Pacemaker was
not placed due to MRSA bacteremia and because the patient was
not hemodynamically stable. From [**7-4**] to [**7-7**] his
bradycardia continued without improvement. A transthoracic
echocardiogram was obtained for evaluation endocarditis and
was notable for a large left ventricular thrombus, a
decreased EF equal to 15-20% with globally decreased systolic
function, moderate pulmonary hypertension, thickening of
aortic valve, trace mitral, aortic, and tricuspid
insufficiency. He was begun on Heparin for the left
ventricular thrombus. Furthermore, the patient was noted to
have colonic distention on KUB consistent with an ileus.
There were also reports of bright red blood per rectum.
Hospital course at [**Hospital1 **] was further complicated
by oliguric acute on chronic renal failure. His renal
function continued to deteriorate with a FENa less than 1,
consistent with a prerenal azotemia. On [**2146-7-7**] the patient
was begun on Dopamine for bradycardia, both sinus and
junctional, with relative hypotension. The patient was then
transferred to the [**Hospital1 69**] MICU
for further management.
PAST MEDICAL HISTORY: 1) Coronary artery disease with
history of a non Q wave myocardial infarction on [**2146-5-31**]. 2)
Arteriosclerotic peripheral vascular disease, status post
left BKA, status post right 4th and 5th toe amputation. 3)
Type 2 diabetes mellitus requiring insulin with retinopathy,
neuropathy and nephropathy. 4) Gout. 5) Depression. 6)
Question benign prostatic hypertrophy.
ALLERGIES: Penicillin.
MEDICATIONS: Outpatient medications: Lipitor 20 mg [**Hospital1 **],
Allopurinol 100 mg q d, NPH 22 units q a.m., 16 units q h.s.,
Humalog 2 units q a.m., 8 units at dinner, Nitro patch 0.4 mg
from 7 a.m. to 10 p.m., Nitro 0.4 mg sublingual prn, Celexa
40 mg q d, Flomax 0.4 mg q d, q h.s., Coumadin 2.5 mg q d,
Colace 100 mg q d, Tylenol prn, Milk of Magnesia prn.
Medications on admission to [**Hospital1 188**]: Dopamine drip 7 mcg/kg/minute, Wellbutrin 50 mg q d,
Lipitor 20 mg q h.s., Colace 100 mg q d, Nitro patch 0.4 mg
on in the a.m. and off at night, Flomax 0.4 mg q h.s.,
Allopurinol 100 mg q d, Celexa 40 mg q d, Rifampin 300 mg
[**Hospital1 **], Vancomycin renal dosing, Insulin NPH 11 units subcu q
a.m., 8 units subcu q p.m. and a regular insulin sliding
scale, Heparin drip as per protocol.
SOCIAL HISTORY: The patient is a [**Country **] veteran. He denies
any alcohol or tobacco use. He resides in a nursing home.
The patient's son [**Name (NI) 1158**] [**Name (NI) 43845**], is his health care proxy and is
making all medical decisions for him. The patient's son is
currently on duty for the National Guard and available only
by cell phone, [**Telephone/Fax (1) 43846**].
FAMILY HISTORY: Significant for cardiac disease.
HOSPITAL COURSE: While in the MICU, the patient's admission
labs at [**Hospital1 69**] were as follows:
White blood count was 22.4 with 96% neutrophils, hematocrit
33, platelet count 353,000, sodium 125, potassium 4, chloride
92, CO2 17, BUN 109, creatinine 4.4, glucose 93, calcium 6.9,
magnesium 3.2, phosphorus 7.5, albumin 2.8, ALT 35, AST 47,
LDH 291, alkaline phosphatase 117, total bilirubin 5.2,
triglycerides 87, Vancomycin level 13.5, lipase 85, troponin
1.9. CK 252. Consults which were obtained during the
patient's MICU stay include ID, renal, plastic, vascular and
psychiatry.
1. ID: The patient was initially begun on Vancomycin and
Rifampin IV. Later due to the patient's hyperbilirubinemia,
Rifampin was discontinued. Plastics and hand surgery were
consulted on [**2146-7-8**] suggesting an MRI of the left hand and
wrist when the patient was stable and to keep the wrist
elevated at all times. Wrist films on [**2146-7-8**] showed no
evidence of osteomyelitis, however, were positive for
osteopenia. Urine cultures were positive for greater than
100,000 yeast. Blood cultures have been negative to date.
2. Vascular: Vascular was consulted on [**2146-7-8**] and their
recommendation was that the patient requires a right above
the knee amputation since transmetatarsal amputation would
not control the infection adequately.
3. Cardiac: A PA catheter was placed on [**7-8**] for management
of acute renal failure. Initial values were CVP 15, wedge
14, cardiac output was 3.4, later improved to 4.0, cardiac
index 1.8, later improved to 2.1 and SVF was normal. The
patient was transfused two units of packed red blood cells
and given fluid to keep wedge greater than 18, however, this
did not improve renal perfusion. Furthermore, Dopamine drip
was attempted to increase cardiac output and chronotropia,
however, this caused his cardiac output to drop and SVR to
increase and therefore was discontinued. The PA catheter was
pulled on [**2146-7-10**] and his blood pressure has since improved.
Transthoracic echocardiogram on [**2146-7-8**] showed a right and
left atrium mildly dilated, mild symmetric left ventricular
hypertrophy, left ventricular function is seriously depressed
with a large left ventricular thrombus, severe global RV wall
hypokinesis, tract AR, physiologic MR, 1+ TR, mild pulmonary
hypertension, no echocardiographic evidence of endocarditis.
The patient had a slight troponin leak without EKG changes or
elevations in CK MB. Currently Aspirin was held given the
risk of bleeding with pericarditis as well as patient being
pre-op for surgery. The patient had episodes of rapid atrial
fibrillation and SVT, then returning to bradycardia in the
50's or 60's. His ectopy seemingly resolves with management
of potassium and magnesium. A uremic friction rub was
auscultated on [**2146-7-9**] indicating uremic pericarditis,
hemodialysis was initiated for treatment of this. A Heparin
drip was continued for the left ventricular clot. At this
point it was unclear if the clot was infected or not.
4. Pulmonary: Mild pulmonary edema by physical exam,
however, patient was maintaining good oxygenation.
5. GI: The patient had a KUB on [**2146-7-8**] which showed
colonic ileus. Reglan was started, however, later
discontinued due to prolonged QT intervals. KUB on [**2146-7-12**]
showed resolving dilated bowel loops. The patient was found
to have hyperbilirubinemia. His Rifampin and Lipitor were
discontinued due to this. Right upper quadrant ultrasound on
[**2146-7-9**] showed sludge in the gallbladder, however, no
pericholecystic fluid or gallbladder wall thickening or
evidence of biliary obstruction.
6. Renal: Hemodialysis was initiated on [**2146-7-9**] for uremic
pericarditis. The patient had a high phosphate level
secondary to acute renal failure which was treated with
calcium carbonate tid. Urine was sent for urine sodium and
creatinine and urine culture showing a prerenal picture.
7. Heme: The patient was transfused two units of packed red
blood cells on [**2146-7-8**] with good response of hematocrit from
28.2 to 35.1. The patient received a dose of Epogen on
[**2146-7-9**]. His iron level is 57, TIBC is decreased at 146, TRF
is decreased at 112, ferritin is 356, consistent with anemia
of chronic disease.
8. Fluids, Electrolytes & Nutrition: Ectopy is decreased
with increasing the potassium during the dialysis. The
patient's high phosphate level is treated with calcium
carbonate tid and Amphojel times two days.
9. Psychiatry: It was recommended by psychiatry consult
that Wellbutrin and Celexa be held at this point. His RPR
was non reactive, his Vitamin B12 was greater than [**2143**], his
Folate was greater than 20 and his TSH was still pending in
the MICU.
Labs on [**2146-7-12**] when the patient was transferred to the
medicine floor, white blood cells 21.3, hematocrit 33.2,
platelet count 138,000, PT 15, PTT 67.8, INR 1.6, sodium 135,
potassium 4.1, chloride 100, CO2 24, BUN 35, creatinine 2.1
and glucose 138, calcium 7.5, magnesium 2.1, phosphorus 3.2,
total bilirubin 13.7.
Physical exam on admission to the medicine floor: Vital signs
were 97.4, blood pressure 112/74, heart rate 67, respiratory
rate 15. In general, the patient was in no apparent
distress, sluggish to response, sleeping yet arousable to
voice. HEENT: Scleral icterus, moist mucus membranes,
slight thrush, right IJ is in place. Chest is clear to
auscultation bilaterally from anterior, however, bibasilar
rales. Cardiovascular, regular rate and rhythm, normal S1
and S2, unable to appreciate friction rub. Abdomen soft,
nontender, minimal distention, positive bowel sounds. GU,
scrotal edema. Extremities, 2+ pitting edema bilateral lower
extremities, 2+ pitting edema in bilateral upper extremities
and hands. The patient is status post left BKA. The
patient's right foot is dressed in a Multi Podus boot. The
patient's left wrist is dressed in a splint.
IMPRESSION: The patient is a 64-year-old man with a history
of coronary artery disease and type 2 diabetes mellitus
requiring insulin, admitted for MRSA bacteremia from primary
infected gangrenous right foot. Admission has been
complicated by a septic left wrist, bradycardia, with
tachycardic episodes, acute on chronic renal failure, uremic
pericarditis and left ventricular thrombus.
HOSPITAL COURSE: While on [**Hospital6 **].
1. Infectious Disease: The patient was continued on
Vancomycin, being dosed according to trough levels less than
15. Vancomycin levels were checked q day to determine
dosing. The patient was treated with Nystatin swish and
swallow to treat his thrush. The patient is currently
awaiting MRI for further evaluation of his septic left wrist.
Due to the 100,000 yeast noted in his urine, the patient's
Foley catheter was discontinued.
2. Vascular: The patient was taken to the operating room on
[**2146-7-15**] for a right guillotine BKA. Due to the patient's
critical condition and after consultation with anesthesia, it
was seemed safer to proceed with the guillotine right BKA
under MAC anesthesia and to proceed with AKA at a later date
after some of the [**Hospital 228**] medical issues have resolved.
The patient's right upper extremity was found to be cool on
[**2146-7-14**] and right upper extremity ultrasound was performed
which ruled out an upper extremity DVT. The patient will be
taken back to the operating room within 5-7 days under
general anesthesia to undergo a right AKA.
3. Cardiovascular: The patient continued to have episodes
of supraventricular tachycardia and paroxysmal atrial
fibrillation, alternating with relative bradycardia to the
50's and 60's. This is somewhat improved when the patient's
potassium and magnesium are above 4 and 2 respectively. The
patient is still medically too unstable to undergo pacemaker
at this time, however, when his infection clears and after
surgery is complete, EP studies will be done and the patient
will require pacemaker. The patient was continued on Heparin
sliding scale for left ventricular thrombus treatment. It is
not thought at this time that the thrombus is infected due to
the fact that blood cultures obtained here at [**Hospital1 346**] all have been negative to date. On
the evening of [**2146-7-13**] the patient was believed to have had
high blood pressure in the right arm ranging from the
200-300/dopplerable to blood pressures of 110-120/dopplerable
in the left arm. The patient also was complaining of some
vague upper back pain, therefore it was decided to rule the
patient out for an aortic dissection. Patient underwent CT
with and without contrast of the chest with pretreatment of
Mucomyst and which showed no evidence of aortic dissection
due to the absence of an intimal flap in the face of fluid
density surrounding the anterior mediastinum adjacent to the
ascending aorta. Calcified aorta of normal caliber; a small
pericardial effusion along with small left and trace right
pleural effusion; left lower lobe patchy coapts adjacent to
the effusion posteriorly; small amount of free fluid in the
abdomen surrounding the liver, spleen and tracking to the
right lower quadrant. Chest x-ray at the time showed no
enlargement of mediastinum and a left basilar opacity. It
was determined with discussions with the attending that the
patient's arteries are significantly calcified and therefore
pose difficulty in obtaining appropriate blood pressures.
When the patient was monitored that day in hemodialysis with
a Dinamap machine there were no problems getting his blood
pressures and they ranged in the 100's to one teens over 50's
to 60's. The patient has been continually monitored with the
Dinamap machine on the floor with no further issues with high
blood pressure.
4. GI: Most recently the patient's stools were guaiac
negative. An abdominal ultrasound obtained on [**2146-7-14**] for
evaluation of the biliary and urinary systems showed no signs
of biliary or urinary obstruction and was positive only for
gallbladder sludge. This study was obtained due to the
patient's continued high creatinine as well as the patient's
continued hyperbilirubinemia.
5. Renal: The patient continues on hemodialysis
approximately every other day. The patient was receiving
hemodialysis through a left femoral Quinton catheter until
[**2146-7-16**] when the catheter was pulled. The patient will
require placement of Perma-cath on Monday, [**2146-7-18**] in
preparation for hemodialysis on Tuesday, [**2146-7-19**].
6. Hematology: The patient is on Heparin sliding scale for
the left ventricular thrombus. His hematocrit was stable
subsequent to his transfusions in the MICU until [**2146-7-15**] when
his hematocrit dropped to 28.7 and after surgery the
patient's hematocrit was 27.8, therefore he was transfused
one unit of packed red blood cells with good response to
hematocrit of 30.3. The patient's PT, PTT and INR were
monitored throughout his stay. It was noted by the blood
bank that the patient had delayed transfusion reaction
forming allo antibodies. This does not preclude him from
getting further transfusions as the blood bank will merely
screen for these antibodies in the future.
7. Fluids, Electrolytes & Nutrition: When the patient was
transferred out from the MICU, he was on tube feeds running
at 35 cc per hour. These were continued throughout his stay
on the medicine floor. The patient began to take better po
on [**2146-7-15**] being begun on a renal diet. Calorie counts will
be performed and need for tube feeding in the future via NG
tube will be assessed.
8. Endocrine: The patient is currently on a regular insulin
sliding scale for his type 2 diabetes. He will be restarted
on his NPH regimen once adequate po intake is established.
9. Psychiatry: The patient has a history of depression, we
are holding his psychiatric medications as per psych
consult's request.
10. Code Status: The patient is a full code.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684
Dictated By:[**Last Name (NamePattern1) 7432**]
MEDQUIST36
D: [**2146-7-17**] 00:35
T: [**2146-7-24**] 18:35
JOB#: [**Job Number 20739**]
ICD9 Codes: 4271, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1939
} | Medical Text: Admission Date: [**2113-6-20**] Discharge Date: [**2113-11-1**]
Date of Birth: [**2113-6-20**] Sex: F
Service: NB
HISTORY: [**Known lastname **] [**Known lastname **], twin number 1, was born at 26 and 6/7
weeks gestation by cesarean section for preterm labor and
breech presentation of twin number 2. Mother is a 39-year-old
gravida 3, para 1, now 3 woman. Her prenatal screens are
blood type O positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, and group B
strep positive. This pregnancy was achieved with a Clomid
assisted intrauterine insemination resulting in a diamniotic,
dichorionic twin gestation that had been reduced from
quadruplets at 12 weeks gestation. The mother was admitted to
the hospital at 24 weeks gestation with preterm labor and
vaginal bleeding which was treated with magnesium and
betamethasone. Her course of betamethasone was complete on
[**2113-6-7**]. Due to progressive preterm labor, cesarean
section delivery was done. Membranes were intact at delivery
and there was no intrapartum antibiotic prophylaxis. This twin
emerged with good tone and spontaneous cry. Apgars were 8 at 1
minute and 8 at 5 minutes.
Birth weight was 775 grams, birth length 31 cm, and birth
head circumference 23.5 cm.
PHYSICAL EXAMINATION: An active premature infant in moderate
respiratory distress. Fontanel soft and flat. Ears, eyes and
nares normal. Palate intact. Coarse breath sounds. Poor
aeration. Grunting, flaring and retracting present. Heart
with regular rate and rhythm. No murmurs. Age appropriate
tone and reflexes.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: [**Known lastname **] was intubated soon after admission. She
received two doses of survanta for RDS. She remained
ventilated until day of life 51 when she weaned to
nasopharyngeal continuous positive airway pressure. On day of
life 92, she was successfully weaned to nasal cannula oxygen
and on day of life 112 she successfully weaned to room air
where she remains. She was treated with caffeine citrate for
apnea of prematurity from day of life 21 until day of life 71.
Her last episode of bradycardia occurred with an oral feeding
on [**2113-10-26**]. She was started on Diuril for chronic
lung disease on day of life 48 and she remains on that at the
time of discharge with a plan to outgrow her dose. Her
arterial blood gas on [**2113-10-31**], was pH 7.38, PCO2 46,
PO2 87, bicarbonate 28, and base excess of 0.
On examination her respirations are comfortable. Lung sounds
are clear and equal.
CARDIOVASCULAR: [**Known lastname **] was treated with 2 courses of
Indomethacin for patent ductus arteriosus first on day of
life 1 and then on day of life 5. A followup cardiac echo on
[**2113-6-27**], revealed no patent ductus, and a structurally
normal heart. Her echoes were repeated on [**6-27**], and [**2113-7-4**], due to a heart murmur, both were negative for patent
ductus. She did require pressor support for the first 24
hours of life and has remained normotensive since that time.
An EKG was done on day of life No. 2 for an irregular heart
rate. It showed premature atrial contractions which have
since resolved. No follow up was planned. On examination, she
has a heart with regular rate and rhythm. No murmurs. She is
pink and well perfused.
FLUIDS, ELECTROLYTES AND NUTRITION: At the time of discharge,
her weight is 4080 grams, her length 52 cm, head
circumference 37 cm.
Enteral feeds were begun on day of life 16 and advanced to
full-volume feedings by day of life 23. She was then advanced
to 30 calories per ounce feedings due to inconsistent weight
gain. We have been unable to successfully wean the calorie
concentration and so she is being discharged home on 30
calorie per ounce Enfamil, made with 6 calories per ounce of
Enfamil powder and 4 calories per ounce of corn oil. She is
also receiving potassium chloride supplements. Her last set
of electrolytes on [**2113-10-31**], were sodium 136,
potassium 5.7, chloride 103, bicarbonate 23. There was no
change made in her potassium chloride supplements and those
have now been at the same dose for several weeks. Her oral
intake is approximately 130 ml per kg per day. She has been
eating on an ad lib schedule.
She was evaluated by the [**Hospital3 1810**] feeding team on
[**10-30**]. They felt that she did show some immaturity of
feeding and would only need follow up with them as necessary.
GASTROINTESTINAL: [**Known lastname **] was treated with phototherapy for
hyperbilirubinemia of prematurity from day of life number 1
until day of life 24. Her peak bilirubin occurred on day of
life 11 and was total 4.9, direct 0.3. She has also been
treated with prune juice 1 teaspoon daily to assist with
regular bowel movements.
HEMATOLOGY: She has received multiple transfusions of packed
red blood cells during her NICU stay, the last one on [**2113-8-8**]. Her last hematocrit on [**10-31**], was 34.7 with a
reticulocyte count of 1.7%. She is receiving supplemental
iron of 2 mg per kg per day. Her blood type is O positive.
Her DAT is negative.
INFECTIOUS DISEASE: [**Known lastname **] was started on ampicillin and
gentamycin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours when the
blood cultures were negative and the infant was clinically
well. She remained off the antibiotics until day of life 10
when she was started on vancomycin and gentamycin for
clinical presentation of sepsis. She then completed 7 days of
antibiotics for presumed sepsis. Her blood cultures and
cerebrospinal fluid remained negative from that time. She
remained off antibiotics until [**2113-8-2**], when she again
had a clinical presentation of sepsis. At that time her
tracheal aspirate revealed Klebsiella. She did then complete
7 days of Unasyn and gentamycin for Klebsiella pneumonia. Her
blood cultures and cerebrospinal fluid remained negative from
that time. She has remained off antibiotics since that time.
NEUROLOGY: Her first head ultrasound on [**6-22**] was within
normal limits. Her follow up head ultrasound on [**6-27**] showed
a grade 2 intraventricular right sided hemorrhage and follow
up ultrasound showed mildly dilated lateral ventricles.
Serial head ultrasounds over the course of her NICU stay were
done showing some resolution. The last one done on [**2113-8-29**], showing resolving right subependymal hemorrhage and
stable mildly dilated lateral ventricles.
OPHTHALMOLOGY: Her eyes were last examined on [**2113-10-16**], and showed mature retinal vessels and resolved
retinopathy of prematurity. Follow up ophthalmology
examination was recommended in 6 months.
PSYCHOSOCIAL: Mom has been very involved in the infant's care
during her NICU stay. The infant is discharged home with her
mother.
She is discharged in good condition.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 63800**]. Telephone
number [**Telephone/Fax (1) 63801**].
CARE RECOMMENDATIONS AFTER DISCHARGE:
1. Feedings - 30 calorie per ounce Enfamil made with 6
calories per ounce of Enfamil powder and 4
calories per ounce of corn oil at an ad lib schedule.
2. Medications:
1. Ferrous sulfate (25 mg per ml) 0.5 ml PO daily.
2. Prune juice 5 ml PO daily
3. Diuril 69 mg PO twice a daily.
4. potassium chloride supplement 4.6 mEq 3 times a day.
3. She has passed the car seat position screening test.
4. Her last State Newborn Screens were sent on [**2113-8-30**], and was within normal limits.
5. Immunizations received:
Hepatitis B vaccine on [**2113-7-20**].
Pediarix #1 on [**2113-8-20**].
Pediarix #2 on [**2113-10-22**].
HIB #1 on [**2113-8-21**].
HIB #2 on [**2113-10-22**].
Pneumococcal vaccine #1 on [**2113-10-22**].
Synagis #1 on [**2113-10-25**].
RECOMMEND IMMUNIZATIONS:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following three criteria.
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with two of the
following: daycare during the RSV season, a smoker in
the household, neuromuscular disease, airway
abnormalities, or school age siblings.
3. with chronic lung disease.
2. Influenza immunization is recommended annually in the
Fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
Follow up appointments recommended:
1. Early Intervention at the Criterion [**Location (un) 270**] Early
Intervention Program. Telephone No. [**Telephone/Fax (1) 43148**].
2. Visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 53861**] Home Care. Telephone No. [**Telephone/Fax (1) 63802**].
3. Infant follow up program at [**Hospital3 1810**]. Telephone
No. [**Telephone/Fax (1) 37126**].
4. Ophthalmology (Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **]) telephone No.
[**Telephone/Fax (1) 54018**] at 6 months after discharge.
5. Pediatrician, Dr. [**Last Name (STitle) 63800**], on [**11-3**]
6. Pulmonary Clinic at [**Hospital3 1810**] (Dr. [**Last Name (STitle) 37305**] on
[**12-1**]. [**Telephone/Fax (1) 38834**] (page)
DISCHARGE DIAGNOSIS:
1. Prematurity at 26 and 6/7 weeks gestation, now 46 weeks.
2. Twin No. 1.
3. Respiratory distress syndrome, treated.
4. Apnea of prematurity, resolved.
5. Chronic lung disease on diuril.
6. Feeding discoordination, improved.
7. Hyperbilirubinemia of prematurity, treated.
8. Patent ductus arteriosus, treated.
9. Premature atrial contractions, resolved.
10. Hypotension, treated.
11. Presumed sepsis, treated.
12. Klebsiella pneumonia, treated.
13. Intraventricular hemorrhage, Grade II, resolved.
14. Stable mild ventriculomegaly.
15. Retinopathy of prematurity, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 58465**]
MEDQUIST36
D: [**2113-10-31**] 21:09:12
T: [**2113-11-1**] 00:39:30
Job#: [**Job Number 63803**]
ICD9 Codes: 769, 7742, V053, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1940
} | Medical Text: Admission Date: [**2136-1-20**] Discharge Date: [**2136-1-22**]
Date of Birth: [**2089-5-3**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Aphasia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
[**Known firstname **] [**Known lastname 22950**] is a 46-year-old man, with history of glioblastoma
multiforme, s/p resection in [**2135-6-6**], chemo-irradiation with
Nuvigil, 2 cycles of adjuvant temozolomide, and 3 cycles of
XL-184. He was most recently on cycle 3 XL-184 on [**2136-1-17**]. He
presents to ED on [**2136-1-20**] with complaints of
expressive/receptive aphasia. Please see admission note for
full details. He states on the morning of admission and did not
feel "quite right". His family came home found found him to be
confused and having difficulty expressing himself. They state
that it seemed like he knew what he wanted to say, but would
just say "gibberish" and would become frustrated due to this.
The patient did not recall any clonic activity and this is not
his usual symptom after having a seziure. He was seen by Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] 2 days ago and was recommended to decrease his
dexamethasone dose from 0.5 mg QOD to 0.25mg QOD. Therefore, he
did not take his dose 1 day prior to admission. Before coming
to the ED the family spoke with a nurse in the [**Hospital **]
clinic and recommended to take his dexamethasone dose as well as
increase his Keppra afternoon dose in case this may have been a
seizure.
While in the ED, he was noted to be hypertensive with SBPs 180s.
Dr. [**Last Name (STitle) 724**] was called while patient was in the ED, and
recommended BP control with hydralazine, as well as giving
increased dexamethasone for persistent headache and possible
cerebral edema. He was given hydralazine 25 mg x 1, and
dexamethasone 4 mg IV x 1 in ED. His BP improved to 150s, and
his aphasia did seem to improve in the ER per report. Patient
reported some blotchiness with hydral in ER. He had a head CT
while in the ED which showed possibly small punctate area of
hemorrhage, as well as some edema which was noted on MRI 2 days
ago. Neurosurgery was consulted in ED, and did not feel there
was any surgical issue at this time. Patient was admitted to
the MICU for blood pressure control.
Past Medical History:
PAST ONCOLOGICAL HISTORY:
(1) a stereotaxic brain biopsy by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on
[**2135-6-17**],
(2) s/p gross total surgical resection by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on
[**2135-6-22**],
(3) received involved-field cranial irradiation with
temozolomide to [**2135-7-11**] to [**2135-8-22**],
(4) started Nuvigil on [**2135-7-12**] and stopped on [**2135-9-5**],
(5) s/p 2 cycles of adjuvant temozolomide at 200 mg/m2/day x 5
days since [**2135-9-24**], and
(6) s/p 2 cycle of XL-184, which was started on [**2135-11-25**].
PAST MEDICAL HISTORY:
Arthritis
GERD
Hashimoto's thyroiditis
Glaucoma
[**Last Name (un) 8061**]
Status post shoulder surgery
Seizures
Social History:
He lives at home with wife. [**Name (NI) **] denies tobacco, drugs, or
alcohol.
Family History:
Mother with brain tumor (astrocytoma).
Physical Exam:
Neurosurgery Examination in ED:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Unable to speak states "Ah-um"
Language: Unable to process any speech
Naming not intact.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5 to 3 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-9**] throughout. No pronator drift
Sensation: Intact to light touch
On transfer to OMED:
VITAL SIGNS: Temperature 98.2 F, blood pressure 119/82, pulse
65, respiration 18, and oxygen saturation 95% in room air.
GENERAL: NAD, Comfortable, appears stated age, pleasant, some
minimal difficulty with word finding
SKIN: No lesions, rashes, bruises
HEENT: AT/NC, PERRLA, EOMI, anicteric, no conjuctival pallor,
MMM, clear oropharynx, no erythema
NECK: Supple, trachea midline, no LAD
LUNG: Clear to auscultation bilaterally, no R/R/W
CARDIOVASCULAR: S1&S2, RRR, no R/G/M
ABDOMEN: Soft, +BS, NT, ND, no rebound, no guarding
EXTREMITIES: No C/C/E. +2 pulses radial, DP, PT b/l &
symetrical
NEUROLOGICAL EXAMINATION: His Karnofsky Performance Score is
70. He is awake, alert, and oriented times 3. His language is
fluent with good comprehension, naming, and repetition. His
short-term recall is fine. Cranial Nerve Examination: His
pupils are equal and reactive to light, 4 mm to 2 mm
bilaterally. Extraocular movements are full; there is no
nystagmus. Visual
fields are full to confrontation. His face is symmetric.
Facial sensation is intact bilaterally. His hearing is intact
bilaterally. His tongue is midline. Palate goes up in the
midline. Sternocleidomastoids and upper trapezius are strong.
Motor Examination: There is no drift or pronation. His muscle
strengths are [**5-9**] at all muscle groups. His muscle tone is
normal. His reflexes are 2- and symmetric bilaterally. His
knee jerks are 2-. His ankle jerks are absent. His toes are
down going. Sensory examination is intact to touch and
proprioception. Coordination examination does not reveal
dysmetria. Gait and stance are deferred.
Pertinent Results:
On admission:
[**2136-1-20**] 03:41PM BLOOD WBC-4.5 RBC-4.66 Hgb-13.9* Hct-39.9*
MCV-86 MCH-29.7 MCHC-34.8 RDW-15.0 Plt Ct-258
[**2136-1-20**] 03:41PM BLOOD Neuts-63.9 Lymphs-18.4 Monos-3.7
Eos-12.6* Baso-1.4
[**2136-1-20**] 03:41PM BLOOD PT-11.5 PTT-21.2* INR(PT)-1.0
[**2136-1-20**] 03:41PM BLOOD Glucose-138* UreaN-10 Creat-0.9 Na-138
K-4.2 Cl-101 HCO3-28 AnGap-13
[**2136-1-20**] 03:41PM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.3 Mg-1.9
[**2136-1-20**] 03:41PM BLOOD ALT-54* AST-42* LD(LDH)-337* AlkPhos-91
TotBili-0.3
[**2136-1-20**] 03:41PM BLOOD TSH-5.0*
On discharge:
[**2136-1-22**] 07:25AM BLOOD WBC-5.9# RBC-4.77 Hgb-14.2 Hct-42.3
MCV-89 MCH-29.8 MCHC-33.6 RDW-15.0 Plt Ct-294
[**2136-1-22**] 07:25AM BLOOD Glucose-113* UreaN-17 Creat-1.0 Na-142
K-4.4 Cl-110* HCO3-19* AnGap-17
[**2136-1-22**] 07:25AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2
[**2136-1-22**] 07:25AM BLOOD ALT-47* AST-29 LD(LDH)-273* AlkPhos-82
TotBili-0.5
Imaging:
[**2136-1-20**] CT HEAD
1. Stable appearance to extensive vasogenic edema in the left
temporoparietal lobe. There is punctate hyperdensity, likely
hemorrhage, within the surgical bed. The acuity of this
hemorrhage is uncertain as there are no recent prior CTs for
comparison, although some susceptibility artifact in this region
on the prior MR suggests that it was present at that time.
There are no areas of hemorrhage outside of the lesional cavity.
2. No new mass effect. MRI is more sensitive for the detection
of acute ischemia.
[**2136-1-20**] Chest X-Ray: Mild left basilar atelectasis.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 22950**] is a 46-year-old man, with history of glioblastoma
multiforme, s/p resection in [**2135-6-6**], chemo-irradiation with
Nuvigil, 2 cycles of adjuvant temozolomide, and 3 cycles of
XL-184. He is presented with expressive/receptive aphasia and
hypertensive urgency.
(1) Aphasia: CT head with edema, possibly small punctate foci
of hemorrhage in surgical bed, but edema unchanged from prior
MRI 2 days ago. His symptoms were thought to be most consistent
with post-ictal aphasia after a seizure than due to edema or
stroke. He had no evidence of increased intracranial pressure
on serial neuro exams. He was continued on his home Keppra and
Lamictal. His dexamethasone was increased, to be taken 4 mg
every other day at time of discharge. He was also started on
acetazolamide for its anti-seizure properties.
(2) Glioblastoma Multiforme: CT head was stable. Pt was started
on cycle 3 of C3 XL-184 on [**2136-1-17**]. He will call Dr. [**First Name (STitle) **] T.
[**Doctor Last Name **] office for follow-up.
(3) Hypertensive Urgency: Possibly elevated BP due to increased
dexamethasone dose. There was no evidence of increased
intracranial pressure on serial neurological examinations. His
blood pressure was initially controlled with labetalol 100 mg
[**Hospital1 **] which was uptitrated to 200 mg [**Hospital1 **]. Hoewver, as he
subequently became hypotensive, this was discontinued. His
blood pressure control stabilized prior to floor transfer.
(4) Glaucoma: Patient continued on home eye drop medications.
(5) GERD: Patient continued on home famotidine.
(6) CODE: Full. Health care proxy is wife [**Name (NI) **]: [**Telephone/Fax (1) 82286**]).
Medications on Admission:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
3. Dexamethasone 0.5 mg daily
4. LeVETiracetam 1000 mg QAM/ 500 mg Q3PM /1250 mg QHS
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE [**Hospital1 **]
6. Docusate Sodium 100 mg PO BID
7. Famotidine 20 mg PO/NG Q12H
8. Multivitamins 1 TAB PO/NG DAILY
9. LaMOTrigine 150 mg / 75 mg / 150 mg
10. Thyroid 45 mg PO/NG DAILY
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
3. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO every other
day: Start on [**2136-1-24**]. Disp:*30 Tablet(s)* Refills:*0*
4. Levetiracetam 500 mg Tablet Sig: As directed Tablet PO three
times a day: Plesae take 1000mg qAM, 500mg q3pm, 1250mg qhs.
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Lamotrigine 25 mg Tablet Sig: As directed Tablet PO three
times a day: Please take 150 mg qAM, 75 mg q3PM, and 150 mg qHS.
10. Thyroid 30 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
11. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Aphasia, likely post-ictal
- Hypertensive urgency
Secondary
- Glioblastoma multiforme
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You presented to the hospital for confusion and difficulty
speaking. Your CT head showed no evidence of a stroke but your
blood pressures were initially elevated in the emergency room.
You were admitted to the ICU but you were transferred to the
floor after your symptoms resolved. They were thought to be an
after effect of a seizure.
The following changes were made to your medications:
- INCREASED dexamethasone
- STARTED acetazolamide
Please take all medications as prescribed.
Thank you for allowing us to take part in your medical care.
Followup Instructions:
Please call Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 1844**] to
schedule your follow up appointment with him.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1941
} | Medical Text: Admission Date: [**2145-6-9**] Discharge Date: [**2145-6-14**]
Date of Birth: [**2094-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 [**2145-6-10**] with the left
internal mammary artery to the second diagonal artery and
reverse saphenous vein grafts to the posterior descending
artery, left anterior descending artery, and the first obtuse
marginal artery.
History of Present Illness:
History of Present Illness: New onset chest and back pain
associated with indigestion and diaphoresis over the last
several
weeks. Seen by PCP and in ER where he ruled in for MI. Then
brought to cardiac catheterization lab where he was found to
have
three vessel coronary artery disease. In ER Trop 0.1, CK 303,
CK-MB 18.7
Past Medical History:
none
Social History:
Race: caucasian
Last Dental Exam:
Lives with: wife and 3 children
Occupation: commercial banker
Tobacco: denies
ETOH: [**2-3**] glasses of wine/night
Recreational drugs: denies
Family History:
father had MI at age 55
Physical Exam:
Pulse: 58 Resp: 16 O2 sat: 99% RA
B/P Right: 112/78 Left:
Height: 5'[**46**]" Weight: 84.4K
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact, nonfocal exam
Pulses:
Femoral Right: cath site Left: 2+
DP Right: - Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit no Right: Left:
Pertinent Results:
intraop ECHO
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe apical, mid and distal anterior, and distal anteroseptal
and anterolateral hypokinesis. Left ventricular ejection
fraction is in the 40 to 45% range. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
Post bypass
Patient is A paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Aorta is intact
post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting
physician
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2145-6-10**] where the patient underwent Coronary
artery bypass grafting x4 with the left
internal mammary artery to the second diagonal artery and
reverse saphenous vein grafts to the posterior descending
artery, left anterior descending artery, and the first obtuse
marginal artery [**2145-6-10**].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable 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. By the time of discharge
on POD #4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home in good condition with appropriate
follow up instructions.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] of [**Hospital3 **]
Discharge Diagnosis:
Coronary artery disease
Coronary artery bypass grafting x4 [**2145-6-10**] with the left
internal mammary artery to the second diagonal artery and
reverse saphenous vein grafts to the posterior descending
artery, left anterior descending artery, and the first obtuse
marginal artery.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
You have a follow up appointment with your surgeon Dr.[**Last Name (STitle) **]
[**2145-7-28**] at 1:00pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr. [**First Name (STitle) **] [**Last Name (NamePattern4) 85529**] [**Telephone/Fax (1) 43460**] in [**1-2**] weeks
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] [**Telephone/Fax (1) 3658**] in [**1-2**] weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2145-6-14**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1942
} | Medical Text: Admission Date: [**2107-8-20**] Discharge Date: [**2107-8-26**]
Date of Birth: [**2033-4-27**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
female, with past medical history significant for
schizophrenia, a recent T12 burst fracture complicated by
bilateral lower extremity paresis, diabetes mellitus and
COPD, who presented from her rehab with fever, change in
mental status and hypotension. In rehab, there was concern
for pneumonia, so she was given empiric Flagyl and
levofloxacin. In the emergency department, temperature was
104, heart rate 130, BP 168/63, respiratory rate 36-42, 100%
on nonrebreather, unable to answer questions. She
subsequently developed respiratory distress and was
intubated. Her orogastric tube put out small amounts of
reddish fluid. Her stool was guaiac positive. She developed
supraventricular tachycardia at a rate of approximately 150,
subsequently read out as sinus tachycardia, and she was
admitted to the ICU.
REVIEW OF SYSTEMS: Unable to be obtained at the time of
admission.
MEDS AT TRANSFER FROM OUTSIDE FACILITY: Levaquin 500 mg p.o.
x1, insulin - Lispro per sliding scale, Ativan 0.5 mg p.o.
p.r.n. anxiety, metoprolol 50 mg p.o. b.i.d., albuterol nebs,
Atrovent nebs, calcitonin 200 units inhaled q. day, Haldol 50
mg IM q. month, fluticasone 110 mcg b.i.d., Zyprexa 7.5 mg
p.o. once daily, mirtazapine 30 mg p.o. at bedtime, senna
daily, aspirin daily, Colace daily, nicotine patch q. 24 h.
11 mg, lactulose 30 mL p.o. b.i.d. p.r.n., heparin subcu
b.i.d., multivitamin, Cogentin 1 mg p.o. b.i.d.
ALLERGIES: Include Risperdal and an ACE inhibitor for which
she developed angiolaryngeal edema requiring intubation.
PAST MEDICAL HISTORY: Dementia, schizophrenia, history of GI
bleed for which she declined work-up, gastroesophageal reflux
disease, COPD, hypertension, diabetes mellitus,
osteoarthritis, neuropathy, urinary incontinence, recent T12
burst fracture complicated by bilateral lower extremity
paresis, status post T12 vertebrectomy and T11-L1 fusion by
Dr. [**Last Name (STitle) 363**]. Her OR course at that time was complicated by a
lung collapse requiring a chest tube placement, spinal,
status post PEG placement in [**2107-7-9**].
FAMILY HISTORY: Has siblings with schizophrenia, otherwise
noncontributory.
SOCIAL HISTORY: Longstanding mental illness, presently
living in nursing home.
PHYSICAL EXAM ON ADMISSION: She was intubated, sedated.
Pupils equal, round and reactive to light. Oropharynx could
not be assessed. Neck: Right IJ in place with dressing.
Chest: A few crackles at base, decreased breath sounds, no
wheezes. Cardiac: Normal S1, S2, II/VI systolic ejection
murmur heard across the chest. Abdomen soft, nontender. PEG
tube without erythema or draining. Extremities warm, no
cyanosis, clubbing or edema, 2+ DPs bilaterally. Neuro:
Unable to assess. Skin: No rash.
PERTINENT LABS TIME OF ADMISSION: White count 12.9,
hematocrit 28.8, platelets 447, 84% neutrophils, 10%
lymphocytes, INR 1.2. Chem-7 was notable for hypernatremia,
sodium 150, mild hyperglycemia--161, and a BUN and creatinine
of 51 and 0.8. There were low-grade troponin elevations of
0.17 and 0.18, but there was no significant change throughout
the hospitalization. Iron studies revealed a ferritin of 160,
an iron of 58, TIBC of 191, TSH was 1.8. Initial lactate was
2.7.
HOSPITAL COURSE: The patient was admitted to the ICU,
treated with broad-spectrum antibiotics and intubated for
respiratory failure. There was initial concern that she might
have a source of infection in her low back from recent
instrumentation. Full imaging with MRI was precluded by the
placement of hardware; however, she did have a CT and an
evaluation by orthopedics who now feel that this was the
source. Despite broad cultures, no specific organism was
identified; however, during the hospital stay she was noted
to have a left lower lobe consolidation which may be the
primary etiology of her sepsis syndrome. She was successfully
extubated and transferred to the medical floor where she
continued on vancomycin and ceftazidime. Remainder of course
by problems.
1. SCHIZOPHRENIA: Patient was restarted on olanzapine and
Cogentin and remained stable through her hospitalization.
1. SINUS TACHYCARDIA: Patient had intermittent bursts of a
sinus tachycardia at a rate of approximately 140-150;
however, despite the cardiology read this could be an
atrial tachycardia, although flutter seemed unlikely. In
order to treat this, her beta blockers were titrated up
with good effect.
1. DIABETES MELLITUS: She was continued on sliding scale
insulin with good glucose control.
1. She was noted to have several small bullous lesions on
her lower extremities which remained stable.
RELEVANT IMAGING STUDIES:
CT of the chest,INDICATION: Fever, altered mental status.
Recent spine surgery. Evaluate for abdominal source of
infection.
TECHNIQUE: MDCT-acquired axial images from the thoracic inlet to
the pubic symphysis were acquired with the use of intravenous and
oral contrast material and displayed with 5-mm slice thickness.
COMPARISONS: No prior studies are available on PACS for
comparison.
CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There is bilateral
lower lobe atelectasis, left larger than right and small left
pleural effusion. No consolidations are seen. The heart appears
normal and there is no pericardial effusion. There are coronary
artery calcifications and calcifications of the
aortic arch and left subclavian origin. There are stable
mediastinal lymph nodes, [**Location (un) **] of which meet size criteria for
pathologic enlargement. No hilar or axillary lymphadenopathy is
seen. There are pedicle screws\t the level of
L2. There are fusion rods extending up to the level of T6. A
metallic cage is seen in the space that appears to be resected
T12 vertebral body. There are transverse fixations screws in the
vertebral bodies of L1 and T11. No paravertebral fluid
collection is seen to suggest the presence of an abscess.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The gallbladder
contains several gallstones but no signs of cholecystitis are
seen. The liver, spleen, pancreas, stomach and small and large
bowel loops appear unremarkable. A G- tube is seen in
appropriate position. No free air is seen. There is no
ascites. No localized fluid collections are seen to suggest the
presence of an abscess. The kidneys contain multiple
hypoattenuating lesions, sub-centimeter in size, too small to
characterize. The right adrenal gland appears normal, the left
adrenal gland contains a 19 x 16 mm nodule which may represent an
adenoma but cannot be fully characterized on this single phase
study.
CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: There is
sigmoid diverticulosis without evidence of diverticulitis. The
rectum appears unremarkable. The bladder contains a Foley
catheter and appears unremarkable. The uterus is not well seen,
and may be atrophic or surgically absent. No
free fluid is seen in the pelvis. No abscess is seen. No pelvic
lymphadenopathy is seen.
BONE WINDOWS: Extensive post-surgical changes as described in
the chest section. There is a bony defect in the right iliac
[**Doctor First Name 362**] consistent with a bone graft harvest site. No suspicious
lytic or sclerotic lesions are seen.
IMPRESSION:
1. Status post extensive spine surgery without evidence of
paraspinal abscess.
2. Bilateral dependent atelectasis and small left pleural
effusion.
3. Cholelithiasis without evidence of cholecystitis.
4. Multiple hypoattenuating lesions in both kidneys, too small
to characterize. Statistically, these most likely represent
cysts.
5. Sigmoid diverticulosis without evidence of diverticulitis.
6. Possible left adrenal adenoma. A dedicated CT may be
performed for further evaluation if clinically inicated.
ECHOCARDIOGRAM:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened. There
is no aortic valve stenosis. Mild to moderate ([**1-10**]+) 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 mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
PORTABLE CHEST X-RAY: Compared to portable film from [**107-8-21**], there is placement of a left PICC terminating in the mid
SVC. A new patchy infiltrate is seen retrocardiac in the left
lower lobe representing either atelectasis or consolidation. The
endotracheal tube has been removed. The remainder of the
examination appears unchanged since prior film.
IMPRESSION: Placement of left PICC terminating in the distal
SVC. Interval removal of endotracheal tube. Atelectasis versus
consolidation in left lower lobe.
MAJOR INTERVENTIONS: Include endotracheal intubation, right
internal jugular subclavian vein triple-lumen catheter, and
left antecubital PICC line placement.
-Lopressor 50 mg Tablet Sig: 75 mg Tablets PO twice a day.
-Combivent 103-18 mcg/Actuation Aerosol Sig: [**1-10**] Inhalation
four times a day.
-Ceftazidime 1 g Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 3 days: Stop on [**8-28**].
-Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every
twelve (12) hours for 3 days: stop on [**8-28**].
-Nicotine 11 mg/24 hr Patch 24HR Sig: One (1) Transdermal once
a day.
-Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a
-Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
-Cogentin Sig: 1 mg PO once a day.
-Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Inhalation
twice a day.
-Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1)
Subcutaneous four times a day: As per Sliding Scale.
-Calcium 500 500 mg Tablet Sig: One (1) Tablet PO three times
a day.
-Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
-Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
-Lactulose 10 g/15 mL Solution Sig: Three (3) PO twice a day
as needed for constipation.
-Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
-Remeron 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
-Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
-Nystatin 100,000 unit/mL Suspension Sig: One (1) PO three
times a day as needed: swish&swallow.
-Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal once a day.
-Haldol Decanoate 100 mg/mL Solution Sig: 80mg Intramuscular
once a month.
-Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
-Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO 2x/week
for 3 months.
-Bactroban 2 % Ointment Sig: One (1) Topical twice a day: To
open bullae on right lower extremity
DISCHARGE DIAGNOSES -
PRIMARY:
1. Sepsis.
2. Respiratory failure.
3. Left lower lobe pneumonia.
4. Delirium.
5. 19 x 16 mm nodule left adrenal adenoma, outpatient follow-up
recommended.
DISCHARGE DIAGNOSES - SECONDARY:
1. Dementia.
2. Schizophrenia.
3. Chronic gastrointestinal bleed for which she declined
gastrointestinal work-up.
4. Gastroesophageal reflux disease.
5. Chronic obstructive pulmonary disease.
6. Vitamin D deficiency.
7. Hypertension.
8. Diabetes mellitus.
9. Osteoarthritis.
10. Neuropathy.
11. Urinary incontinence.
12. Status post T12 burst fracture complicated by paraplegia
status post T11 through L1 fusion.
13. Chest tube placement for lung collapse.
14. Laryngeal edema requiring intubation secondary to ACE
inhibitor.
15. Methicillin resistant Staphylococcus aureus.
16. Percutaneous endoscopic gastrostomy tube placement.
CONDITION ON DISCHARGE: Patient stable for transfer to
[**Hospital **] Healthcare which is the facility from which she
came.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5704**], [**MD Number(1) 5705**]
Dictated By:[**Last Name (NamePattern1) 28140**]
MEDQUIST36
D: [**2107-8-26**] 11:57:10
T: [**2107-8-26**] 13:04:31
Job#: [**Job Number 98706**]
ICD9 Codes: 0389, 486, 496, 5789, 2760, 2859, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1943
} | Medical Text: Admission Date: [**2112-9-12**] Discharge Date: [**2112-10-5**]
Date of Birth: [**2049-6-22**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
Transferred to [**Hospital1 18**] for STEMI/cardiogenic shock
Major Surgical or Invasive Procedure:
Cardiac catheterization, placement of two stents in the left
dircumflex coronary artery.
Placement of intra-aortic balloon pump.
Placement of Swan-Ganz catheter via femoral access.
Cardioversion x 3 for ventricular tachycardia.
Emergent repeat cardiac catheterization.
History of Present Illness:
The patient is a 63 year old male transfered to [**Hospital1 18**] from an
OSH for STEMI, in cardiogenic shock on pressors.
Pt initially presented to [**Hospital3 3583**] on [**2112-9-11**] with SOB
and chest pain of approximately 1 wk duration. In OSH ED, was
found to have RML PNA. He also reported fall one week prior with
facial ecchymosis, found to have nasal fx by CT. EKG showed
sinus tach in the 130s with Qs in II,III,aVF with nl. axis and
intervals and T-waves inverted in inferior leads and ST
depressions in the lateral leads. Pt received ASA, b-blockers,
morphine, nitro paste, levaquin and was pain-free with sats in
the 90%s on 100%NRB. Troponin was 0.525 with flat CK. T max
99.1. WBC 15.9, Hct 44.5%. Received lovenox sq, with last dose
at 12am [**2112-9-12**].
On [**9-12**] at noon, pt became SOB and diaphoretic with pain, and
sats fell to 77% on 100%NRB with HR120. Received 40mg of lasix,
4mg morphine, and was intubated at 12:30pm. At 1pm, EKG showed
sinus at 100, nl intervals and axis with Qs in III & aVF, ST
elevations in III>II, and ST depressions in I,aVL. Blood
pressure fell s/p intubation to 60s/20s requiring fluid
resuscitation and dopamine 10mcg/kg/min. O2 sats rose to 88% on
AC700mlx14/min + 5PEEP. CXR showed worsening of a R lung
alveolar process with extrusion to the L side, with a
differential of infection vs R>L pulmonary edema. Patient was
then transferred to [**Hospital1 18**].
Past Medical History:
1. Gout
2. EtOH abuse
3. Hypercholesterolemia
Social History:
History of EtOH abuse. No PCP.
Physical Exam:
Gen: intubated, sedated. Not responsive to calling name or
sternal rub.
Skin: Abdominal rash resolved. Feet less mottled. +posterior
scrotal excoriations. + 3 bullae filled with clear liquid on L
ventral wrists and L thumb - improving.
HEENT: PERRL, MM moist.
Heart: RRR. II/VI Holosystolic murmur at apex.
Lungs: slight crackles B vs. upper airway noise (ant
auscultation).
Abd: soft. hypoactive bowel sounds.
Extrem: tr pitting edema B LE.
Neuro/Psy: Not following commands.
Access: R IJ swan in place. L wrist with A-line.
Pertinent Results:
[**2112-9-12**] 07:58PM WBC-16.5* RBC-4.43* HGB-13.7* HCT-40.3 MCV-91
MCH-31.0 MCHC-34.1 RDW-13.2
[**2112-9-12**] 07:58PM PLT COUNT-217
[**2112-9-12**] 07:58PM PT-13.9* PTT-32.9 INR(PT)-1.2
[**2112-9-12**] 06:46PM GLUCOSE-189* LACTATE-2.2* K+-3.9
[**2112-9-12**] 03:07PM TYPE-ART PO2-57* PCO2-45 PH-7.33* TOTAL
CO2-25 BASE XS--2 INTUBATED-INTUBATED
[**2112-9-12**] 07:58PM ALT(SGPT)-14 AST(SGOT)-33 LD(LDH)-361*
CK(CPK)-214* ALK PHOS-140* AMYLASE-49 TOT BILI-0.8
[**2112-9-12**] 07:58PM GLUCOSE-179* UREA N-24* CREAT-1.5* SODIUM-136
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17
[**2112-9-12**] 11:49PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2112-9-12**] 11:49PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2112-9-12**] 11:49PM URINE RBC-[**3-25**]* WBC-0-2 BACTERIA-MANY
YEAST-NONE EPI-0-2
CATH [**2112-9-12**]: LMCA had a 40% lesion. LAD had diffuse luminal
irregularities but was free of significant stenoses and supplied
2 moderate-sized diagonal branches which were also free of
significant disease. LCX had a hazy 60% lesion in the mid
vessel and a hazy 80% lesion in the distal vessel. The RCA was a
small
vessel and was totally occluded in the mid segment. A R-PDA was
seen
filling via L-R collaterals. Resting hemodynamics revealed
evidence of cardiogenic shock with an aortic pressure of 94/53
mmHg, a cardiac index of 1.3 L/min/m2 and a
PCWP of 30 mmHg on an infusion of dopamine at 10 mcg/kg/min.
stented
with a 3.5 x 13 mm cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 55492**] and 3.0 x 13 mm cypher
[**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 22595**] at 14 atms with no residual stenosis, no dissection and
timi 3
flow.
Transthoracic Echo [**2112-9-13**]:
EF 70% The overall left ventricular ejection fraction is normal
(borderline
hyperdynamic) but the lateral wall and adjacent segments of
anterior free wall
are hypokinetic relative to the frankly hyperdynamic inferior
and posterior
walls. Right ventricular systolic function appears depressed.
There is a
trivial/physiologic pericardial effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2112-9-12**], the cardiac rhythm is atrial fibrillation with ventricular
tachycardia;
the lateral wall (which now appears relatively hypokinetic) was
not
well-visualized on the prior study; therefore no direct
comparison of
contractile function in this territory can be made.
Transesophageal Echo [**2112-9-13**]:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left
ventricular wall thickness, cavity size, and systolic function
are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter
and free of atherosclerotic plaque. The aortic valve leaflets
(3) appear
structurally normal with good leaflet excursion. Trace aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. The mitral
leaflets are
myxomatous. There is moderate/severe posterior mitral leaflet
prolapse. There
is partial mitral leaflet flail. There is moderate thickening of
the mitral
valve chordae. Severe (4+) mitral regurgitation is seen.
Brief Hospital Course:
The patient was admitted to the CCU service after his
catheterization. Overall the following weeks the pt was
determined to be extremely sick with multiple organ system
failure. He needed a mitral valve replacement surgery, however,
in order to have this surgery he would need to be extubated and
afebrile. He was treated with hemodialysis and further diuresis
was attempted with IV diuretics and BNP, however the pt's
respiratory status remained tenuous. Furthermore, he did not
wake up when sedation was weaned. He was evaluated by Neuro with
an EEG that showed only diffuse slowing and a head CT that
showed no acute changes. It was felt likely that due to his
episodes of hypotension with the VT and other hemodynamic
instability later that he had sustained anoxic brain injury.
This was all discussed with the family who felt that the pt
would not have wanted to be kept alive on a ventilator long-term
when any hope of recovery was extremely slim. As all attempts to
wean him from the ventilator were unsuccessful he was made CMO
and made comfortable with morphine. He died shortly after.
Medications on Admission:
unknown
Discharge Medications:
pt expired.
Discharge Disposition:
Home
Discharge Diagnosis:
Pt expired of respiratory failure.
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
ICD9 Codes: 4280, 5185, 4240, 5845, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1944
} | Medical Text: Admission Date: [**2115-11-20**] Discharge Date: [**2115-11-22**]
Date of Birth: [**2115-11-20**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: This late preterm infant born at
36 and 4/7 weeks was admitted to the newborn ICU for
management of respiratory distress. He was born to a 38-year-
old G1 P0 to 1 mother with prenatal screens as follows, blood
type A positive, antibody negative, group B strep negative,
hepatitis B surface antigen negative, RPR nonreactive.
Past obstetrical history remarkable for a myomectomy in
[**2114-10-23**]. Antepartum was reportedly benign. Admitted
yesterday with preterm contractions. Given uterine scar and
risk for dehiscence or abruption, decision was made to
deliver by C section under spinal anesthesia. Apgars were 8
and 9 at 1 and 5 minutes. In the delivery room the baby was
noted to be grunting, flaring and retracting, thus prompting
admission to the newborn ICU.
PHYSICAL EXAMINATION: Upon admission remarkable for preterm
infant in mild to moderate respiratory distress with vital
signs of 97.5, heart rate 120, respiratory 24, blood pressure
65/39 with a mean of 49. The baby was [**Name2 (NI) **]. Anterior
fontanelle was open and soft. Normal faces. Intact [**Last Name (un) **].
Mild retractions with fair air entry. Regular rate and
rhythm. Grade 1/6 systolic murmur at the lower left sternal
border. Present femoral pulses. Abdomen is flat, soft,
nontender without hepatosplenomegaly. Normal phallus, testes
and scrotum. Stable hips. Fair profusion, fair tone and
normal activity.
HOSPITAL COURSE: Respiratory. The infant continued to have
mild grunting with intermittent tachypnea and required blow
by oxygen intermittently for the first 12 hours. Since that
time has been in room air, breathing comfortably with
respiratory rate 30s to 40s. O2 saturation is greater than
92% in room air.
Cardiovascular. Continues to be hemodynamically stable with
blood pressures 60//40 with a mean of 47, AP 130s to 150.
Chest x-ray was done on admission revealed normal heart size,
normal bony structures, prominent pulmonary vascularity
consistent with retained fetal lung fluid, small bilateral
pleural effusions also noted. Normal sinus.
FEN. Because of the mild respiratory distress, the baby was
maintained NPO with a peripheral IV in place delivering D10W
at 60 mls per kilo per day. Baby has voided and passed
meconium stool. He has been euglycemic with D stick in the 90
range on running IV fluids. Baby started to feed on day of
life 1 and has been feeding well and IV fluids have been
discontinued. He is breast feeding.
GI. Bilirubin will be obtained with a newborn state screen
prior to discharge. No clinical evidence at this time of
jaundice.
Heme/ID. A CBC and blood culture were obtained upon
admission. The CBC showed a white count of 14.5 with 53
polys, 10 bands and 29 lymphocytes, a hematocrit of 43.2 and
platelets 230,000. Blood culture has remained negative and
infant completed a 48 hour course of antibiotics pending
cultures and clinical course.
Neurological. Baby is acting appropriate for gestational age.
Sensory. Ophthalmology exam is not indicated at this gestation
[**Doctor Last Name **]
age.
Psycho/social. Intact family. First baby.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: To the newborn nursery.
PRIMARY PEDIATRICIAN: Has not yet been identified by the
family.
CARE AND RECOMMENDATIONS AT DISCHARGE:
Feedings, continue breast feeding, supplement as needed.
Medications: s/p ampicillin and gentamicin.
Car seat position screening has not yet been performed.
State newborn screening has not yet been performed.
Immunizations, there have been none to date.
Hearing screen: to be done prior to discharge
Immunizations recommended, Synagis RSV should be
considered [**Month (only) **] through [**Month (only) 958**] for infants who meet any of
the following 3 criteria, infants born at less than 32 weeks,
infants born between 32 and 35 weeks with 2 of the following,
day care during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings and 3 infants 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 childs life, immunization
against influenza is recommended for household contacts and
out of home caregivers.
Follow up appointments recommended with the primary care
physician once identified.
DISCHARGE DIAGNOSES:
1) Prematurity at 36 and 4/7 weeks,
2)transient tachypnea of the newborn, and
3) r/o sepsis with antiobitics.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31759**], MD [**MD Number(1) 43886**]
Dictated By:[**Last Name (NamePattern1) 54678**]
MEDQUIST36
D: [**2115-11-22**] 02:08:25
T: [**2115-11-22**] 06:33:44
Job#: [**Job Number 69905**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1945
} | Medical Text: Admission Date: [**2153-4-27**] Discharge Date: [**2153-5-10**]
Date of Birth: [**2078-4-14**] Sex: M
Service: [**Hospital1 **]
CHIEF COMPLAINT: Chest pain
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
Russian speaking male with a past medical history significant
for coronary artery disease, status post myocardial
infarction in [**2143**], status post percutaneous transluminal
coronary angioplasty and stent to the LAD and left circumflex
in [**2152-10-21**] in [**Location (un) **] who presents with worsening
and more frequent episodes of chest pain.
The patient notes daily angina at rest, as well as when
exerting himself which is substernal in location without
radiation. There was no associated nausea, vomiting,
diaphoresis or shortness of breath. Prior to the day of
admission, the daily chest pain was responsive to 3 to 10
sublingual nitroglycerin per day, but over the last 24 hours
his chest pain has been refractory to nitroglycerin and so he
decided to come in. Of note, the patient was seen by his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15490**], in clinic
approximately one weeks prior to admission where the increase
in his angina had been noted. There was a plan for an
outpatient ETT and possible catheter pending those results.
REVIEW OF SYSTEMS: Negative for any orthopnea or paroxysmal
nocturnal dyspnea. There were no fevers or chills, nausea,
vomiting or diarrhea. The patient denied any abdominal pain.
In the Emergency Room, the patient was afebrile and had
stable vital signs. His electrocardiogram showed no acute
changes. His chest pain was not responsive to three
sublingual nitroglycerin, but it completely resolved with 2
mg of morphine.
PAST MEDICAL HISTORY:
1. Coronary artery disease. The patient has had multiple
cardiac catheterizations with the most recent one being done
in [**Location (un) **] in [**2152-10-21**] at which time a stent was
placed in the LAD and left circumflex. His most recent
catheter done at [**Hospital6 256**] prior
to this admission was in [**2151-4-22**]. That catheter showed
a 20% lesion in the left main, 50% in the LAD, 50% in the
left circumflex, previously placed stent which was deemed to
be hemodynamically insignificant and a 75% right coronal
artery lesion. Most recent stress MIBI done in [**2151-4-22**]
showed ischemia in the inferolateral region.
2. Benign prostatic hypertrophy
3. Hypertension
4. Hypercholesterolemia
5. History of pancreatitis during his admission in [**Location (un) **]
for his cardiac catheterization
6. Status post pacer placement in [**2148-12-22**] for sick
sinus syndrome which was upgraded in [**2152-12-22**] for
lead upgrades and generator change.
ADMISSION MEDICATIONS:
1. Aspirin 325 mg po q day
2. Lipitor 40 mg po q day
3. Prevacid 30 mg po q day
4. Prinivil 5 mg po q day
5. Toprol XL 25 mg po q day
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is originally from [**Country 532**]. He
has lived in the United States for approximately six years.
He speaks limited English. He drinks occasional alcohol. He
denies tobacco. He is married. He has one son who lives
nearby as well as a daughter who is a nurse [**First Name8 (NamePattern2) **] [**Name (NI) **].
PHYSICAL EXAM:
VITAL SIGNS: The patient was afebrile. Blood pressure
117/78, heart rate of 52, respiratory rate 18, saturating
97%.
GENERAL: The patient is alert and oriented x3 in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light. Extraocular movements intact. There was
no jugular venous distention.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm, no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended. There was no
hepatosplenomegaly. There were normoactive bowel sounds.
EXTREMITIES: Without cyanosis, clubbing or edema. The PT
pulses were 2+ bilaterally.
ADMISSION LABS: White count of 7.2, hematocrit of 47.3, MCV
of 88, platelets of 173, PT of 12.4, INR 1.1, PTT of 25.
Sodium of 144, potassium of 4.0, chloride of 110, bicarbonate
of 24, BUN of 19, creatinine of 1.0, glucose of 113, CK of
130, MB of 3, troponin less than 0.3. Electrocardiogram -
most recent cholesterol in [**2153-4-21**] showed total
cholesterol of 169, LDL of 102, HDL of 48. Electrocardiogram
showed normal sinus rhythm at 51 beats per minute with normal
axis and normal intervals, except for slight prolongation of
the QRS at 124 milliseconds. There were no acute ST or T
wave changes.
HOSPITAL COURSE: In summary, the patient is a 75-year-old
male with significant coronary artery disease who is admitted
for worsening chest pain. There was concern for possible in
stent restenosis given the patient's recent cardiac
catheterization in [**2152-10-21**]. The patient was
admitted for rule out myocardial infarction.
1. CARDIOVASCULAR: The patient was admitted as already
stated and his cardiac enzymes were cycled. Over the first
24 hours, the patient's CKs remained flat at 130 to 125 to
156, however the MB fraction went from3 to 6 to 9.
Initially, it was unclear whether the patient did have
unstable angina or not given that his enzymes were not
positive and his initial troponin was less than 0.3 despite
over one day of chest pain at home unresponsive to
nitroglycerin. In addition, there was a confounding lab
discovery of acute pancreatitis and it was felt that this may
explain the patient's pain as well. A repeat troponin on the
second hospital day came back positive at 4.4. At that time,
cardiology was consulted for cardiac catheterization given
the fact that the evidence was now showing the patient was
having unstable angina.
Cardiology saw the patient in the morning and recommended
that the patient undergo cardiac catheterization that same
day. However, the patient refused this procedure and wanted
to wait. The urgency was stressed with the patient, but he
still refused the procedure. He was started on an Integrilin
drip, as well as nitroglycerin and heparin drip. He was
continued on his beta blocker and ACE inhibitor. The hope
was that his family could convince him to undergo cardiac
catheterization and the medications would help protect
against further cardiac damage. The patient was chest pain
free with the above interventions, however his platelets
dropped after being on the Integrilin drip for 24 hours and
therefore the Integrilin had to be discontinued.
The importance of cardiac catheterization was again stressed
with the patient and his daughter was [**Name (NI) 653**] and he
finally agreed to go to cardiac catheterization. He was
scheduled to on Monday morning, the fourth hospital day and
he was stable until Monday morning. However, prior to being
transported for catheter, he then developed severe [**8-30**]
substernal chest pain and was rushed to catheterization
emergently. At catheterization, he was found to have 100%
restenosis of his LAD stent, as well as 99% occlusion of the
tube.
He also had 40% proximal in stent stenosis in the left
circumflex artery as well as 50% distal occlusion in the left
circumflex. He also had 70% calcified mid RCA lesion at 60%,
posterolateral RCA lesion. The LAD was restented with good
results. However, the patient did suffer an acute anterior
myocardial infarction prior to catheterization with his CK
peaking at 1334. His electrocardiogram evolved with eventual
development of Qs in leads V2 through V6.
After cardiac catheterization, the patient was scheduled to
return to the general medical floor, but suffered recurrent
chest pain in the recovery suite. Therefore, he was rushed
back into catheter for a re-look. There were no significant
changes during the re-look procedure and no additional
interventions were made. The patient was then transferred to
the CCU for closer monitoring given his unstable nature and
large anterior myocardial infarction.
The patient initially did well after his cardiac
catheterization, however did have intermittent chest pain
with no electrocardiogram changes. However, two days after
cardiac catheterization the patient was found to be
unresponsive to voice, tactile or noxious stimuli. An
emergent head CT was performed (an MRI could not be performed
given the patient's pacemaker as well as recent stent
placement) and it showed no evidence of a bleed, but possible
new stroke in the thalamic region.
From a cardiac standpoint, the patient has been stable
following his catheterization. His blood pressure
medications were held for a period given his acute stroke,
but has since been restarted at low doses. His blood
pressure goal at this point is around a systolic of 120. He
had an echocardiogram performed after his cardiac
catheterization and acute myocardial infarction and his
ejection fraction was found to be down to only 25%. There
was severe depression of overall left ventricular systolic
function. There was severe global hypokinesis with some
preservation of the basal wall motion. This was new compared
with prior echocardiogram. There was no evidence of left
ventricular thrombus.
Given the patient's new depressed ejection fraction, he was
started on a low dose of Lasix to prevent congestive heart
failure. He was on 20 mg po q day. However, on the day of
this discharge summary this has been held as the patient
appears to be getting too dry with this dose. He likely will
need to be on a lesser dose, possibly 20 mg po q o day.
The patient is on Plavix 75 mg for one month given his stent
placement. He is also to continue on aspirin 325 mg q day.
2. NEUROLOGIC: As already stated, the patient suffered an
acute stroke on [**2153-5-2**]. The stroke was felt to be
most likely embolic in origin possibly from plaque that had
been dislodged during the cardiac catheterization.
Neurologic exam immediately after the event showed the
patient to have no eye opening. He was spontaneously
breathing with a normal pattern. There was no blink to
threat. The right pupil was 6 mm and fixed. The left pupils
was 1 mm and could not be assessed for reactivity given how
small it was. There was sluggish response to the doll's
maneuver, but the patient was able to cross midline
bilaterally. There was no facial asymmetry to grimace. The
patient withdrew both arms to nail bed pressure and lifted
them off the bed briefly with at least antigravity power to
the deltoids. He withdrew his left leg and pulled his heel
back all the way to the buttocks. His right leg was
externally rotated and withdrew a few inches. His plantar
responses were noted to be flexor initially.
As already stated, his blood pressure was initially run
higher or attempted to be run higher at greater than 140 by
holding his blood pressure medications. Despite holding his
blood pressure medications however, his blood pressure was
never above the 120 to 130 range. He was started on
Coumadin, both given his low ejection fraction as well as to
help prevent against future cerebral events. He was
continued on heparin as a bridge. His exam was followed
closely.
At the time of this discharge summary, the patient has
improved in regards to his neurologic status. Most recent
neurologic exam performed with an interpreter shows the
patient to be somnolent, but arousable to loud stimuli. He
will open his eyes intermittently on the left. He follows
some simple commands such as sticking out his tongue or
showing two fingers or wiggling his toes. He can answer
simple questions. However, his speech was noted to be
severely dysarthric. He is noted to have a left hemiparesis,
including face, arms and legs. He also has frontal release
signs consistent with possible underlying dementia.
At the time of this discharge summary, we are repeating a
head CT to evaluate extent of the stroke and we are starting
low dose methylphenidate at 5 mg to see if this will help
with the patient's attention and arousability. The neurology
team feels that the patient has a good prognosis given his
degree of recovery in only a few days. At the time of this
discharge summary, the patient's blood pressure has been
allowed to be lower, given that it has been approximately one
week since the event.
3. PULMONARY: The patient was noted to have developed a
pneumonia during the time of his stroke. It was felt to be
likely secondary to aspiration. He was started on Levaquin
and Flagyl and on [**5-10**] he was on day 9 of 14. He is
still having thick secretions, but is improving overall. He
is requiring only 2 liters of oxygen at this point and has
been on room air during the day saturating 95% requiring
oxygen only at night.
4. GASTROINTESTINAL: An nasogastric tube was placed for
tube feeds, given that the patient was not able to feed
himself. Gastrointestinal was consulted for possible PEG
placement given that this will likely be a long term need for
the patient. They did not feel comfortable placing a PEG
given that the patient cannot be taken off Plavix for 30 days
given his high risk for restenosis. A pediatric nasogastric
tube was placed on [**5-9**] in interventional radiology.
The issue with the nasogastric tube is that the patient
continues to grab at it when his hands are unrestrained. At
the time of this discharge summary, we are going to attempt
mittens to see if this will prevent the patient from pulling
out the tube.
In addition, we will see if interventional radiology would be
willing to put in the PEG despite having Plavix on board. If
there was no way to place a PEG, then this would have to be
done when his course of Plavix is finished.
5. HEME: The patient had [**Last Name **] problem in regards to his
hematocrit. His platelets, which had dropped when he was on
the 2B3A have recovered. His most recent hematocrit was 41.9
with most platelets of 246. His Coumadin is currently being
held given the possibility of invasive procedures. He is
being heparinized.
6. FLUIDS, ELECTROLYTES AND NUTRITION: The patient is on
ProMod with fiber at 75 cc an hour with 200 cc free water
boluses 4x daily.
DISCHARGE CONDITION: Fair
DISCHARGE MEDICATIONS:
1. Captopril 6.25 mg po tid, holding for systolic blood
pressure less than 110
2. Levaquin 500 mg per nasogastric tube 24 hours, day 9 of
14
3. Flagyl 500 mg per nasogastric tube tid, day 9 of 14
4. Ritalin 5 mg po q a.m.
5. Metoprolol 12.5 mg po bid, holding for systolic pressure
less than 110 and heart rate less tan 55.
6. Tylenol prn
7. Lipitor 40 mg po q day
8. Plavix 75 mg po q day for 30 days stated on [**4-30**]
9. Senna two tablets q hs
10. Prevacid 30 mg po q day
11. Colace 100 mg [**Hospital1 **]
12. Coumadin dose to be determined with an INR goal of 2 to 3
13. Heparin sliding scale
14. Aspirin 325 glioblastoma multiforme po q day, currently
on hold for possible PEG placement. It has been on hold
since [**5-8**].
15. Lasix 20 mg po q od
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post acute myocardial
infarction
2. LAD, in stent restenosis status post new stent placement
in the LAD on [**4-30**]
3. Hypercholesterolemia
4 Aspiration pneumonia
5. Acute cerebrovascular accident to the right thalamus
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 6859**]
MEDQUIST36
D: [**2153-5-10**] 11:46
T: [**2153-5-10**] 11:41
JOB#: [**Job Number 47275**]
ICD9 Codes: 5070, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1946
} | Medical Text: Admission Date: [**2174-5-19**] Discharge Date: [**2174-5-21**]
Date of Birth: [**2124-12-2**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Left face numbness with tingling and left arm weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 year old right handed man who was diagnosed with HTN 4 years
ago, but has not been taking meds, presents with left face
tingling, and left finger tip tingling since yesterday morning.
He describes his left finger tips as feeling as if they were
frost bitten. He took the day off work because he did not feel
"right." When the symptoms persisted today, he decided to come
into the ER. Mr [**Known lastname **] has not been taking HCTZ in over 3 years
due to concerns of impotence. He has been hypertensive for 4
years. He has not been adherent to a healthy diet.
Past Medical History:
HTN
Social History:
He works as a mailman. He has 4 children, ranging in age from
19-29. He started smoking aged 13 and gave up at age 26, smoking
about 5 cigarettes per day. He drinks about 3-4 beers per week.
He does not use any recreational drugs.
Family History:
Mother had HTN, no strokes. His father died of a lymphoma.
Physical Exam:
Exam:
T-97.8 HR-71 BP-195/125-->212/125 RR-16 SpO2-100
Gen: Lying in bed, prominent eyes but not proptotic, and
slightly
injected
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] and writing
intact. Registers [**2-9**], recalls [**2-9**] in 5 minutes. No right left
confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Fundoscopy shows some silver wiring b/l consistent
with HTN changes. Visual fields are full to confrontation.
Extraocular movements intact bilaterally, no nystagmus.
Sensation
reduced to 85% on the face in V1-V3 on the left. Facial
movement
symmetric. Hearing intact to finger rub bilaterally. Palate
elevation symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
His left arm drifts down.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, vibration and proprioception
throughout. However, if he closes his eyes and attempts to touch
his nose with his left index finger, he hits his eye. Pinprick
is
diminished in the left hand in each terminal phalanx. No
extinction to DSS
Reflexes:
2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger is clumsy on the left, heel to
shin normal, RAMs are clumsy on the left.
Gait: Narrow based, steady.
Romberg: Negative
Pertinent Results:
CT head [**5-20**]
1. Stable focus of intraparenchymal hemorrhage centered in the
posterior limb of the right internal capsule.
2. Stable scattered periventricular and subcortical white matter
hypodensities likely representing the sequelae of chronic
ischemic
microvascular disease.
CXR [**5-19**] - no acute cardiopulmonary process
TTE [**5-20**]
Conclusions
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 and global systolic function
(LVEF>55%). Basal inferior hypokineis sis suggested in some
views (clips 48,49), but could not be confirmed. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with
preserved global systolic function and ?basal inferior
hypokinesis. Dilated ascending aorta.
[**2174-5-19**] 11:18PM GLUCOSE-92 UREA N-16 CREAT-1.2 SODIUM-139
POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
[**2174-5-19**] 11:18PM ALT(SGPT)-14 AST(SGOT)-25 CK(CPK)-413* ALK
PHOS-53
[**2174-5-19**] 11:18PM CK-MB-5 cTropnT-<0.01
[**2174-5-19**] 11:18PM CALCIUM-9.8 PHOSPHATE-5.5* MAGNESIUM-2.2
CHOLEST-181
[**2174-5-19**] 11:18PM %HbA1c-5.9 eAG-123
[**2174-5-19**] 11:18PM TRIGLYCER-129 HDL CHOL-38 CHOL/HDL-4.8
LDL(CALC)-117
[**2174-5-19**] 11:18PM TSH-2.8
[**2174-5-19**] 11:18PM WBC-3.3* RBC-4.90 HGB-13.3* HCT-40.8 MCV-83
MCH-27.1 MCHC-32.5 RDW-13.7
[**2174-5-19**] 11:18PM PLT COUNT-205
[**2174-5-19**] 11:18PM PT-12.4 PTT-25.2 INR(PT)-1.0
[**2174-5-19**] 03:18PM CK(CPK)-544*
[**2174-5-19**] 03:18PM CK-MB-6 cTropnT-<0.01
[**2174-5-19**] 07:25AM GLUCOSE-100 UREA N-13 CREAT-1.2 SODIUM-135
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-29 ANION GAP-13
[**2174-5-19**] 07:25AM ALT(SGPT)-21 AST(SGOT)-41* ALK PHOS-68 TOT
BILI-0.6
[**2174-5-19**] 07:25AM LIPASE-37
[**2174-5-19**] 07:25AM cTropnT-<0.01
[**2174-5-19**] 07:25AM WBC-3.8*# RBC-5.58 HGB-14.8 HCT-46.7 MCV-84
MCH-26.4* MCHC-31.6 RDW-13.6
[**2174-5-19**] 07:25AM NEUTS-48.2* LYMPHS-41.7 MONOS-5.2 EOS-3.2
BASOS-1.7
[**2174-5-19**] 07:25AM PLT COUNT-251#
[**2174-5-19**] 07:25AM PT-11.5 PTT-23.3 INR(PT)-1.0
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to neurology ICU service under care of
stroke team. He was closely observed regarding his neurological
status and was put on cardiac telemetry monitering.
Neuro
He underwent frequent neuro checks. He showed rapid subjective
as well as objective improvment in the symptoms of facial
numbness on the left side and fingertips of the left hand,
especially the index finger. He underwent repeat CT scan on [**5-20**]
which did not show any significant change in the size of bleed
on right thalamic/basal ganglia region.
Cardiac
Blood pressure was very high (212/125) on presentation. He was
in initially started on labetalol drip followed by nicardipine
drip in the ED for better control og blood pressure. He was
started on oral lisinopril 10 mg /day and did not require
nicardipine drip or prn hydrallazine shortly after coming to the
ICU. EKG , cardiac enzymes were negative for acute ischemia. He
underwent TTE which showed LVH but was otherwise not remarkable
Lipid profile showed LDL 117 and HDL 38, TG were 129. he was
advised about diet modification and increasing physical
activity. HbA1c was 5.9
FEN
he underwent bedside swallow test and was started on heart
healthy diet.
Gen care
pneumoboot for DVT prophylaxis were used. he was transfered out
of ICU to stroke floor on [**2174-5-21**].
Medications on Admission:
HCTZ (dose unknown, the patient had not taken this in over 3
years)
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Stroke - intraparenchymal hemorrhage centered in the posterior
limb
of the right internal capsule
Discharge Condition:
Normal neurological examination with no deficits.
Discharge Instructions:
You have had a stroke due to poorly controlled blood pressure.
You must take your blood pressure medication (Lisinopril) daily.
Your primary care physician, [**Name10 (NameIs) **] [**Last Name (STitle) 849**], was away, so we
communicated with her PA [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16249**] who wanted you to get
follow up with the stroke service since you are being discharged
today. In addition to your risk of stroke, your echocardiogram
showed that you heart has changes because of your high blood
pressure. Your kidney function (creatinine 1.2) has remained
stable with the addition of your lisinopril.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2174-7-4**] 2:00 pm.
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1947
} | Medical Text: Admission Date: [**2178-9-3**] Discharge Date: [**2178-9-5**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p fall
Head Trauma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo woman with CAD who presents after fall from standing
position today, causing a hip fracture as well as significant
SAH and left temporal lobe contusion. She was initially awake
and alert then declined in responsiveness. Intubated in ED.
Past Medical History:
appendectomy
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
98.5 70 173/95 16 96% intubated
Gen: verbalizing incoherently --> non-verbal; disoriented; GCS
10
Head: hematoma at occiput, PERRL
Neck: c-collar in place, no appreciable C-spine stepoffs
CV: RRR
Lungs: CTAB
Abd: soft/NT/ND
Ext: L leg externally rotated and fore-shortened
Back: no C-spine stepoffs
Rectal: guaic neg, nl tone
Pertinent Results:
[**9-3**] Head CT :Large subarachnoid hemorrhage extending along the
interhemispheric fissures and anterior aspect of the suprasellar
cistern and anterior left temporal lobe. Small left
intraparenchymal hemorrhage within the anterior left temporal
lobe. No evidence of herniation.
[**9-3**] CT C-spine: No evidence of fracture or listhesis.
Degenerative changes predominantly at the level of C5-C6 as
described above.
[**9-3**] CTA Head: no aneurysm or dissection. COW and major
tributaries opacify symmetrically. vertebrobasilar system
opacifies well. Right frontal intraparenchymal hemorrhage.
[**9-3**] Blat Hips: L intertroch femur fx
[**9-3**] Head CT:Significant interval progression of right frontal
intraparenchymal hemorrhage which now causes significant mass
effect including subfalcine herniation to the left of
approximately 11 mm. Effacement of the suprasellar cistern is
concerning for possible uncal herniation.
Brief Hospital Course:
Ms. [**Known lastname 7049**] [**Last Name (Titles) 7050**] initially awake and alert, answering questions on
arrival in the Emergency Department, but over several hours
become less and
less responsive. Her diminished mental status was felt likely
related to intracerebral hemorrhages (SAH and a small
intracranial hemorrhage). Over the course of HD #1 the
intraparenchymal hemorrhage expanded, causing mass effect
including subfalcine herniation. A family meeting was held on
[**2178-9-4**] at which time she was made CMO, extubated, and morphine
gtt was started. Ms. [**Known lastname 7049**] [**Last Name (Titles) **] on [**2178-9-4**] at 6:18 AM.
Medications on Admission:
unknown
Discharge Medications:
N/A
Discharge Disposition:
[**Date Range **]
Discharge Diagnosis:
intracerebral hemorrhage
subfalcine herniation
L intertrochanteric femur fracture
Discharge Condition:
[**Date Range **]
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2179-3-17**]
ICD9 Codes: 5990, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1948
} | Medical Text: Admission Date: [**2162-2-8**] Discharge Date: [**2162-2-23**]
Date of Birth: [**2079-12-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Nabumetone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
[**2162-2-12**] Aortic valve replacement with 21 mm [**Company **] mosiac
ultra porcine valve and coronary artery bypass graft times four.
History of Present Illness:
Ms. [**Known lastname 80837**] is an 82 year old woman who has been followed for
some time for aortic stenosis and mitral regurgitation. She
recently became symptomatic with a syncopal episode. She
therefore was referred for cardiac surgery.
Past Medical History:
aortic stenosis
mitral regurgitation
hypothryroidism
syncope
hypertension
s/p cerebral vascular incident
Social History:
Ms. [**Known lastname 80837**] is a retired legal secretary. She denies any
tobacco history.
Family History:
Her family history is unremarkable.
Physical Exam:
At the time of admission, Ms. [**Known lastname 80837**] was found in no acute
disress. Her skin exam was unremarkable, as was her head, ears,
eys, nose, and throat examination. Her neck was supple with
full range of motion. Her lungs were clear to ausculatation
bilaterally. Her heart was of regular rate and rhythm and a
grade III/VI systolic ejection mumur was appreciated. Her
abdomen was soft, non-tender, and non-distended. No edema or
varicosities were noted. Her neurological exam was grossly
intact. Her femoral, dorsal pedis, posterior tibial, and radial
pulses were noted to be 2+ bilaterally.
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 80838**]Portable TTE
(Complete) Done [**2162-2-17**] at 12:36:31 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2079-12-28**]
Age (years): 82 F Hgt (in): 60
BP (mm Hg): 107/45 Wgt (lb): 136
HR (bpm): 69 BSA (m2): 1.59 m2
Indication: Mitral Regurgitation. Pericardial effusion. S/p
AVR/CABG.
ICD-9 Codes: 423.9, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2162-2-17**] at 12:36 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W000-0:00 Machine: Vivid i-3
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.36 >= 0.29
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Arch: 2.2 cm <= 3.0 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.5 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *25 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 14 mm Hg
Aortic Valve - Pressure Half Time: 447 ms
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 2.00
Mitral Valve - E Wave deceleration time: 241 ms 140-250 ms
TR Gradient (+ RA = PASP): 25 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal aortic
arch diameter.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
leaflets move normally. Normal AVR gradient. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild (1+) MR. [Due to acoustic
shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**1-15**]+] TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Bilateral pleural effusions.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. A bioprosthetic
aortic valve prosthesis is present. The aortic valve prosthesis
leaflets appear to move normally with normal gradient for this
prosthesis. Trace 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. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Well seated aortic bioprosthesis with normal
gradient, but trace aortic regurgitation. At least mild mitral
regurgitation. Normal biventricular cavity sizes with preserved
global biventricular systolic function.
CLINICAL IMPLICATIONS:
Based on [**2160**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2162-2-17**] 16:46
PA AND LATERAL CHEST ON [**2162-2-21**]
INDICATION: Status post CABG and AVR-followup.
COMPARISON: [**2162-2-19**].
FINDINGS: Bilateral posterior effusions are evident. Frontal
views show no
significant interval change with no new consolidation and no
pneumothorax.
[**2162-2-22**] 06:40AM BLOOD WBC-12.9* RBC-3.03* Hgb-9.7* Hct-28.5*
MCV-94 MCH-32.0 MCHC-34.0 RDW-14.9 Plt Ct-257
[**2162-2-22**] 06:40AM BLOOD Plt Ct-257
[**2162-2-22**] 06:40AM BLOOD Glucose-89 UreaN-28* Creat-1.3* Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
[**2162-2-8**] 09:55PM BLOOD ALT-33 AST-58* LD(LDH)-226 AlkPhos-84
TotBili-0.2
Brief Hospital Course:
On [**2162-2-12**] Ms.[**Known lastname 80837**] was taken to the operating room and
underwent an aortic valve replacement with a 21mm [**Company 1543**]
Mosiac Ultra Porcine valve and coronary artery bypass grafting
times four (LIMA to LAD, SVG to DIAG, SVG to OM, and SVG to
PDA).Please refer to Dr[**Last Name (STitle) **] operative report for further
details. She tolerated the procedure well and was transferred in
critical but stable condition to the surgical intensive care
unit. She awoke neurologically intact, pressors were weaned and
she was extubated by post-operative day one. All lines and
drains were removed in a timely fashion. Ms.[**Known lastname 80837**] was
transferred to the surgical step down floor on post-operative
day two. There she was found to be in atrial fibrillation and
was placed on amiodarone. Due to hypotension she was
transferred back to the surgical intensive care unit for fluid
status management and tenuous pulmonary status. POD#6 Chest Ct
scan performed to evaluate tracheal malacia. Scan revealed a
sizeable left pleural effusion. left thoracentesis was done,
which drained 700cc serosanguinous fluid. Anticoagulation was
started with coumadin for atrial fibrillation. She was placed on
antibiotics for a left arm phlebitis.She continued to improve
and POD#8 she was transferred back to the step down unit. The
remainder of her post operative course was essentially
uneventful. Ms.[**Known lastname 80837**] continued to progress and she was ready
for discharge to a rehab facility by post-operative day 10 for
further increase in endurance,strength, and increase in daily
activities. All follow up appointments were advised.
Medications on Admission:
synthroid 88mcg, aspirin 325mg, ramipril 10mg, multivitamins,
calcium, vitamin D
Discharge Medications:
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
syncope
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
(AFib)
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 68568**] for Thyroid function test, TSH
6.0 so dose was increased from 88mcg 5x/wk to daily.
See Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 68568**] ([**Telephone/Fax (1) 80839**] PCP [**Last Name (NamePattern4) **] [**1-15**] weeks.
See Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] cardiology in [**1-15**] weeks.
See Dr. [**Last Name (STitle) **] cardiac surgeon ([**Telephone/Fax (2) 80840**] in [**2-16**] weeks at
[**Hospital **] Hospital.
Completed by:[**2162-2-23**]
ICD9 Codes: 4241, 2762, 5119, 4240, 4280, 4019, 2449, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1949
} | Medical Text: Admission Date: [**2145-9-6**] Discharge Date: [**2145-9-10**]
Date of Birth: [**2068-11-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain; decreased exercise tolerance
Major Surgical or Invasive Procedure:
[**2145-9-6**] - Aortic valve replacement, 25 mm [**Company 1543**] Mosaic
tissue (porcine)valve.
History of Present Illness:
76 year old gentleman with known aortic stenosis who has been
followed by serial echocardiograms. His most recent
echocardiogram has demonstrated worsening aortic stenosis as
well as aortic regurgitation in the setting of left ventricular
hypetropy. He is mildly symptomatic with chest pain with
activity and a decreased exercise tolerance. Given the
progression of his disease, he has been referred for surgical
evaluation. Cardiac cath done today for pre-op w/u revelaed nl.
cors.
Past Medical History:
Aortic stenosis/aortic insufficiency
Depression
Basal cell skin cancer
ocular migraines
mild hypothyroidism
mild memory loss
SVT
Social History:
Last Dental Exam: Every 6 months
Lives with: Alone
Occupation: Retired
Tobacco: Denies
ETOH: Denies
Family History:
Brother with AF
Physical Exam:
Pulse:61 Resp: O2 sat: 99%
B/P Right:146/60 Left:146/69
Height: 68" Weight: 140 (63.5 kg)
General: WDWN in NAD
Skin: Dry, warm and intact. Multiple actinic keratosis. some
seborrheic keratosis noted. Few well healed small scars.
HEENT: NCAT [X] PERRLA [X] EOMI [X] sclera anicteric; OP benign
Neck: Supple [X] Full ROM [X] No JVD[X]
Chest: Lungs clear bilaterally [X]anterolaterally ( on bedrest)
Heart: RRR, IV/VI holosystolic murmur radiates to carotids
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema -none
Varicosities: None (lying down on bedrest)
[X]several small healed scars BLE
Neuro: Grossly intact. Mild word finding difficulty.
Pulses:
Femoral Right:cath dressing in place Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit- Transmitted vs. Bruit bilaterally
Pertinent Results:
[**2145-9-10**] 05:10AM BLOOD WBC-5.5 RBC-3.51* Hgb-10.8* Hct-30.1*
MCV-86 MCH-30.8 MCHC-35.9* RDW-13.3 Plt Ct-169#
[**2145-9-10**] 05:10AM BLOOD Glucose-110* UreaN-21* Creat-1.0 Na-137
K-4.2 Cl-101 HCO3-29 AnGap-11
[**2145-9-10**] 05:10AM BLOOD Mg-2.2
HISTORY: Status post AVR with pleural effusion, evaluate for
interval change.
FINDINGS: The cardiomediastinal and hilar contours are
unchanged. Bilateral
small pleural effusions have slightly decreased. There has been
improved
aeration of the retrocardiac opacity with only minimal
atelectasis remaining.
No focal consolidation or pneumothorax. Sternotomy wires are
intact. Patient
is status post aortic valve replacement.
IMPRESSION: 1) Improved small bilateral pleural effusions with
associated
atelectasis. Improved aeration in the retrocardiac region.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: [**Doctor First Name **] [**2145-9-9**] 4:03 PM
Imaging Lab
Brief Hospital Course:
Mr. [**Known lastname 1617**] was admitted to the [**Hospital1 18**] on [**2145-9-6**] for surgical
management of his aortic valve disease. He was taken directly to
the operating room where he underwent an aortc valve replacement
using a tissue porcine prothesis. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Over the next several hours awoke neurologically
intact and was extubated. On postoperative day one, He was
transferred to the step down unit for further recovery. He was
gently diuresed toward his preop weight. Chest tubes and pacing
wires removed per protocol. Continued to make good progress and
was cleared for discharge to Newbridge on [**Hospital **] rehab on POD
#4. All f/u appts were advised.
Medications on Admission:
Remeron 15mg at bedtime
Ativan 0.5mg prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 1
weeks: hold for K+ > 4.5.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **]
Discharge Diagnosis:
Aortic stenosis/aortic insufficiency s/p AVR
Depression
Basal cell skin cancer
ocular migraines
mild hypothyroidism
mild memory loss
SVT
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema -
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2145-9-30**] 1:15
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD on [**9-27**] at 10am
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] in [**3-29**] weeks [**Telephone/Fax (1) 2205**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32281**],[**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2145-10-11**] 1:00
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2145-9-10**]
ICD9 Codes: 4241, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1950
} | Medical Text: Admission Date: [**2173-1-4**] Discharge Date: [**2173-1-11**]
Date of Birth: [**2110-10-7**] Sex: F
Service: MEDICINE
Allergies:
Prempro / Fiorinal / Erythromycin Base / Aleve
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 yo W w/h/o myasthenia [**Last Name (un) 2902**] on immunosuppression, htn,
hyperlipidemia, spinal compression fractures who initially
presented with tachycardia. ROS remarkable for intermittent
sinus pressure/HA, not unusual, no retroorbital pain, ear pain
or pressure, decreased hearing. On admission she was ruled out
for PE. Subsequently she developed a HA, N, V and was treated
with phenergan and lorazepam. Neurology felt symptoms could be
due to narcotic withdrawal and the pt was given Dilaudid 2x 1mg.
Subsequently she became obtunded and hypoxic.
Past Medical History:
1. Myasthenia [**Last Name (un) **]-first diagnosed in [**2163**], followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]
2. multiple spinal compression fractures s/p steroid use for MG
3. hypercholesterolemia
4. h/o migraines
5. seasonal allergies
6. HTN
7. osteoporosis
Social History:
Patient is single, lives alone. She is currently on disability.
She used to work as a histology tech a [**Hospital1 18**]. She denies
tobacco, illicit drugs, occ EToH but none since starting
narcotic medications.
Family History:
Mother: [**Name (NI) 77552**], first age 55, also CHF, deceased age 77; father
with rheumatic heart disease, deceased age 83 CVA; sister died
at age 5 of insulin dependent diabetes mellitus w/PNA.
.
Physical Exam:
VS: 102.4 120 140/85 100% on 50% FM
General: NAD, pleasant well-appering woman
HEENT: PERRL, EOMI without nystagmus, no proptosis, MMM, OP
clear, conj pink/sclera white, hirsuit
Neck: supple, no lad, JVP: 8cm, no bruits
Resp: CTA, scant left basilar crackels, no rhonchi or wheezes
CV: RRR, s1, s2 present, no murmurs, rubs, gallops
Abdomen: protuberant, soft, nontender, nondistended, +BS, no
masses, no HSM
Ext: trace edema, no c/c, 2+ radial, DP pulses bilaterally
Neuro: CN II-XII intact, A&Ox3, motor [**6-12**] UE/LE, lid lag not
tested because of photophobia, good coordination, reflexes
intact 2+ bilaterally
Pertinent Results:
[**2173-1-4**] 10:05PM CK(CPK)-27
[**2173-1-4**] 10:05PM CK-MB-NotDone cTropnT-<0.01 proBNP-<5
[**2173-1-4**] 10:05PM TSH-1.4
[**2173-1-4**] 10:05PM FREE T4-1.2
[**2173-1-4**] 10:05PM D-DIMER-783*
[**2173-1-4**] 01:40PM GLUCOSE-106* UREA N-26* CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2173-1-4**] 01:40PM estGFR-Using this
[**2173-1-4**] 01:40PM CK(CPK)-38
[**2173-1-4**] 01:40PM CK-MB-NotDone
[**2173-1-4**] 01:40PM CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-2.1
[**2173-1-4**] 01:40PM WBC-8.5# RBC-3.71* HGB-12.6 HCT-36.8 MCV-99*
MCH-34.0* MCHC-34.3 RDW-15.3
[**2173-1-4**] 01:40PM NEUTS-77.9* LYMPHS-16.6* MONOS-3.9 EOS-0.8
BASOS-0.9
[**2173-1-4**] 01:40PM POIKILOCY-1+ MACROCYT-2+
[**2173-1-4**] 01:40PM PLT COUNT-242#
[**2173-1-4**] 01:40PM PT-12.1 PTT-23.2 INR(PT)-1.0
Brief Hospital Course:
1. Hypoxia:
This developed in the setting of IV narcotics use; quick
development and rapid improvement was most suggestive of
aspiration in the context of sedation. Contributing could have
been chronic low ventilatory state in the context of OSA and MG,
although MG crisis thought to be unlikely given 5/5 strength
otherwise.
The patient never required intubation and did well after being
dosed with narcan. Overall, her respiratory status improved;
she was continued on BiPAP at night and NIFs/VCs were followed.
Her MG was treated as prior.
For the possible aspiration, initially treated with levo/flagyl,
then just levofloxacin. [**2173-1-12**] is day 7 of planned seven day
course.
2. Tachycardia:
Sinus, likley reactive. PE ruled out, TSH normal. Anemia
slightly worse then normal but not sufficient to explain
tachycardia. This was felt to be either related to beta-blocker
withdrawal or narcotic withdrawal. This resolved upon
resumption of narcotics (at home doses) and beta-blocker. Later
in the admission, the beta-blocker was again d/c'd as the
indication was unclear. Thereafter, the patient's HRs remained
<100.
3. [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]:
There was no evidence for current flare. Cellcept and
pyridostigmine were continued; neurology followed the patient.
4. Anemia:
Previous baseline hct mid 40's, over the last month decreased to
mid 30's. This was felt to be secondary to B12 deficiency with
the possible contribution of Cellcept. The B12 level was low
end of normal. MMA was checked and pending at d/c. Given that
the patient has no reason for nutritional deficiency, pernicious
anemia was entertained and IF antibody was sent (pending at
d/c).
5. Headache:
Thought to be secondary to possible migraine headache versus med
withdrawal headache.
Was treated with tylenol PRN.
6. Spinal compression fractures:
Narcotics were initially held, but restarted many of the
patient's symptoms were felt to be secondary to withdrawal.
7. Hypertension:
The patient's propranolol had recently been stopped prior to
admission. This was restarted, given the tachycardia. Later in
the admission, the patient was not hypertensive so the
beta-blocker was again held given the prior episodes of
hypotension. Her blood pressure and heart rate were normal on
discharge.
8. Hyperlipidemia:
Continued atorvastin.
Medications on Admission:
Pyridostigmine Bromide 30 mg PO Q8H
Atorvastatin 20 mg PO HS
Mycophenolate Mofetil 1000 mg PO BID
Raloxifene *NF* 60 mg Oral qd osteoporosis
Senna 1 TAB PO HS:PRN constipation
Heparin 5000 UNIT SC TID
Cyanocobalamin 1000 mcg PO DAILY
Docusate Sodium 100 mg PO HS
Calcium Carbonate [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN upset stomach
Dolasetron Mesylate 25 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/PR Q4-6H:PRN pain
Sodium Chloride Nasal [**2-10**] SPRY NU QID:PRN
Discharge Medications:
1. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO qd () as
needed for osteoporosis.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: [**2-10**] Tablet,
Chewables PO Q4H (every 4 hours) as needed for upset stomach.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-10**] Sprays Nasal
QID (4 times a day) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
13. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Sinus tachycardia
2. Narcotic withdrawal
3. Myasthenia [**Last Name (un) 2902**]
4. Anemia
5. Renal cysts
Secondary:
1. Hypertension
2. Hyperlipidemia
3. Osteoporosis
Discharge Condition:
Improved; in normal sinus rhythm.
Discharge Instructions:
You were admitted with elevated heart rates and possibly
withdrawal from narcotics. At this time, your heart rate is
normal and you do not have any symptoms of withdrawal.
If you experience worsening headaches, diarrhea, racing heart,
shortness of breath or have any other questions/concerns, please
call your PCP or go to the emergency room.
Followup Instructions:
You have the following appointments scheduled:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9899**], M.D. Phone:[**Telephone/Fax (1) 558**] Date/Time:[**2173-2-15**]
1:00
DR. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2173-2-23**]
8:00
Please be sure to schedule an appointment with your PCP to be
seen within 1-2 weeks: [**Last Name (LF) **],[**First Name3 (LF) 198**] W. [**Telephone/Fax (1) 250**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1951
} | Medical Text: Admission Date: [**2167-4-9**] Discharge Date: [**2167-4-20**]
Service: MEDICINE
Allergies:
Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization, mechanical intubation, continuous
[**Last Name (un) **]-venous hemofiltration
History of Present Illness:
85 year old woman with hx of CAD s/p prior PTCA, pVD, DM2, htn,
chol and anemia presented to NWH on [**2167-4-8**] with unstable
angina. Her EKG was described as unchanged from prior. Her labs
were notable for Trop0.06. BNP 234. creat 1.3 on arrival
(baseline 1.2).
Her evaluation there was notable for cardiac enzymes as above.
She was felt to be in mild congestive heart failure after 1 unit
of pRBCS which she received for a Hct of 26. She received 2
doses of lasix. She was started on a heparin gtt (not listed in
discharge meds. She did have small amount of blood on her toilet
tissue thought secondary to hemorrhoidal bleed. She did receive
a 2nd unit of PRBCs. A TTE (prelim only) LAE, preserved LVEF,
mild MR/TR.
.
She describes her baseline at chronic stable angina with chest
pressure at similar level of exertion such as walking [**5-17**] block
of level ground. However over the past month she noted a
decreased threshhold for her discomfort now after only 1 flight
of stairs. On the day prior to her admission she had the similar
sensation of chest pressure while at rest. It lasted for ~2
hours and improved with nitroglycerin. She had recurrent event
at 1:30pm on the 25th so she presented to the hospital. She
states her weight has been stable. She has chronic venous stasis
and has had new lower extremity swelling over the past few
weeks. She has no orthopnea or PND.
.
On floor, patient was feeling short of breath with walking to
the bathroom but otherwise feeling well. She has no current
chest pain.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools. She has been having small amount of blood on the toilet
tissue over the past few weeks. She denies recent fevers, chills
or rigors. She has exertional leg pain at 4 blocks of walking.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope.
Past Medical History:
# s/p inferior wall NQWMI in [**2157**], s/p cardiac catheterization
in [**2157**] with PTCA of RCA (RCA mid-vessel total occlusion ->
PTCA with grade C dissection -> TIMI 3 flow, no stent);
complicated by dissection and pseudoaneurysm
#. Type 2 diabetes - HgA1C 7.3% [**2166-11-12**]
- complicated by neuropathy
#. Hypertension
#. Hyperlipidemia
#. Peripheral [**Year (4 digits) 1106**] disease
#. Asthma
#. Chronic kidney disease baseline 1.1-1.2
#. GERD
#. Hyperparathyroidism
#. Osteoarthritis
#. B12 deficiency anemia
#. Appendectomy
#. Bladder suspension
#. Right meniscectomy in [**2161-1-11**]
#. Excision of benign breast mass times two
Social History:
The patient currently lives in [**Location 107641**] 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 ADl
although looking to get an aid to help clean soon.
Tobacco: None
ETOH: None
Illicits: None
Family History:
Non-Contributory
Physical Exam:
VS: 98.7 148/62 74 20 93%3L
wt. 96kg
GENERAL: obese elderly female 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. [**3-20**] MR murmur. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles at left base
greater than right.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits. external
hemorrhoids. red blood (heme+) in rectal vault.
EXTREMITIES: No c/c/e. right femoral bruit.
SKIN: +stasis dermatitis. no ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP trace PT trace
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP trace PT trace
Neuro:
-MS a,ox3. coherent response to interview.
-CN II-XII intact (pupils reactive, EOMI, face symmetric,
palate/tongue midline)
-Motor moving all 4 extremities symmetrically
-[**Last Name (un) **] light touch intact to face/hands/feet
Pertinent Results:
[**2167-4-9**] 10:40PM GLUCOSE-141* UREA N-65* CREAT-1.6* SODIUM-142
POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-17
[**2167-4-9**] 10:40PM CK(CPK)-150*
[**2167-4-9**] 10:40PM CK-MB-6 cTropnT-0.07*
[**2167-4-9**] 10:40PM WBC-9.6# RBC-2.84* HGB-9.4* HCT-26.9* MCV-95
MCH-33.2* MCHC-35.1* RDW-14.6
[**2167-4-9**] 10:40PM PLT COUNT-220
[**2167-4-9**] 10:40PM PT-13.4 PTT-36.9* INR(PT)-1.1
.
STUDIES OF RELEVANCE IN CHRONOLOGICAL ORDER:
[**2167-4-9**] CXR:
Lungs clear, mild pulmonary engorgement and top normal heart
size suggest
borderline cardiac decompensation, but there is no edema or
appreciable
pleural effusion.
[**2167-4-10**] Card Cath:
COMMENTS:
1. Coronary angiography in this right-dominant system revealed:
--the LMCA had no angiographically apparent disease.
--the LAD had a proximal <50% stenosis.
--the LCX had no angiographically apparent disease.
--the RCA had an ostial >90% stenosis.
2. Limited resting hemodynamics revealed severely elevated
left-sided
filling pressures, with LVEDP 30 mmHg. There was mild systemic
arterial
systolic hypertension with SBP 149 mmHg. There was no gradient
across
the aortic valve upon pullback of the angled pigtail catheter
from LV to
ascending aorta.
3. Successful PTCA and stenting of the ostial RCA with two
overlapping
bare metal stents - Minivision (2.5x15mm distally; 2.5x12mm
proximally)
postdilated with a 2.75mm balloon. Final angiography
demonstrated no
angiographically apparent dissection, no residual stenosis and
TIMI III
flow throughout the vesel (See PTCA comments).
4. Successful closure of the right femoral arteriotomy site
with a 6F
Angioseal closure device.
FINAL DIAGNOSIS:
1. Significant one coronary artery disease.
2. Successful PTCA and stenting of the ostial RCA with two
overlapping
bare metal stents.
3. Successful clousre of the right femoral arteriotomy site
with a 6F
Angioseal closure device.
[**2167-4-11**] ECHO:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is mild regional left ventricular
systolic dysfunction with mild basal and mid-anterior septal
hypokinesis, distal septal akinesis and probable apical
hypokinesis. The remaining segments contract normally (LVEF =
40-45%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericar
dial effusion.
IMPRESSION: Normal right ventricular systolic function. Mild
regional left ventricular systolic dysfunction, c/w CAD.
Moderate mitral regurgitation. Mild pulmonary hypertension.
[**2167-4-11**]:
IMPRESSION: CT A and P
1. Multifocal consolidations may represent pneumonia, however
pulmonary
hemorrhage in the setting of hyperdense, and likely hemorrhagic,
effusions
should be considered.
2. Retained renal contrast with vicarious excretion via the
gallbladder, all
consistent with renal failure.
3. Fibroid uterus.
[**2167-4-13**] CT Chest:
Followup of a patient with bilateral pleural
effusion, consolidations, and known pneumothorax.
COMPARISON: CT abdomen from [**2167-4-11**] and multiple chest
radiographs
obtained in the interval between [**4-9**] and [**2167-4-13**].
TECHNIQUE: Unenhanced MDCT of the chest was obtained from
thoracic inlet to upper abdomen with subsequent 1.25- and 5-mm
collimation axial images reviewed in conjunction with coronal
and sagittal reformats.
FINDINGS:
Extensive widespread consolidations involve mostly the right
upper lobe, right middle lobe, and right lower lobe but also are
seen in left lower lobe and left apex. The consolidations are
relatively high in density (the left upper lobe consolidation is
about 57 Hounsfield units in density), as are the right middle
lobe and lower lobe consolidations (ranging up to 50 Hounsfield
units). The comparison of the lung bases with a recent CT
abdomen from [**2167-4-3**] demonstrates interval progression
of the consolidations in the right middle and right lower lobe.
The bilateral pleural effusion, although did not increase
significantly in size, is still of high density (up to 46
Hounsfield units) in the lower portions of the lungs suggesting
sedimentation effect.
The mediastinal lymph nodes are enlarged ranging up to 16 mm in
right lower paratracheal area and might be reactive. Extensive
coronary calcifications are noted. The heart size is mildly
enlarged. There is no significant pericardial effusion.
Minimal left pneumothorax is demonstrated, 2A:31, seen in the
anterior
mediastinum giving the patient's supine position and might
correspond to an apical pneumothorax demonstrated on the upright
chest radiograph obtained the same day earlier at 09:09 a.m.
Although the comparison between the chest CT and chest
radiograph is difficult, the size of the pneumothorax is most
likely unchanged and is small.
The imaged portion of the upper abdomen demonstrates fat density
left adrenal lesion, -19 Hounsfield units, consistent with
lipoma. The rest is
unremarkable within the limitations of this non-enhanced study.
Again note is made of the presence of contrast enhancement of
the kidneys consistent with known failure and retained excretion
of contrast. Contrast is also
demonstrated in the renal pelvis. The vicarious excretion of the
distended
gallbladder is again noted. The bladder is at least 5 cm in
diameter,
although no wall thickening or surrounding abnormalities are
seen.
There are no [**Year (4 digits) 500**] lesions worrisome for malignancy. Degenerative
changes are seen.
IMPRESSION:
1. Extensive bilateral consolidations, right more than left, of
high density that might be consistent with multifocal
hemorrhage. The differential diagnosis in the presence of renal
failure might include vasculitis. Hemorrhagic pneumonia might be
considered in appropriate clinical setup.
2. Small left apical pneumothorax, most likely unchanged
compared to prior
chest radiograph.
3. Bilateral grossly unchanged pleural effusions, high in
density that might also contain an element of hemorrhage.
4. Extensive coronary calcifications.
5. Still present contrast enhancement of kidneys and vicarious
excretion of contrast the gallbladder consistent with known
renal failure.
Brief Hospital Course:
85-year-old woman with a history of coronary artery disease s/p
BMS x 2 in RCA on [**2167-4-10**], with post-cath course complicated by
pulmonary edema, contrast-induced nephropathy requiring CCU stay
with transition to cardiac service.
1) Unstable angina/CAD: Patient's typical anginal pain was
occurring at rest and had ST depressions in V4-6. Given concern
for ongoing bleeding cath was deferred until [**4-10**]. Cardiac
catheterization demonstrated 90% occlusion of ostial RCA which
was stented with two overlapping bare metal stents. Her chest
pain occurred intermittently since the PCI with intermittent ST
depressions in V4-V6. Nitro gtt was temporarily started for the
pain, and she remained pain free after it was discontinued.
Cardiac markers were mildly elevated, likely demand ischemia
from anemia, and CK-MB was negative. She was treated with
aspirin, statin, and plavix. Patient's metoprolol was restarted
once she stabilized.
2) Acute on chronic diastolic heart failure: Felt to be
secondary to RBC transfusions at OSH. She had an ongoing O2
requirement and desatted to 85% RA on am of [**4-11**], for which she
was transferred to the CCU and lasix gtt was started. Fluid was
initially removed via CVVH (as below), although once UOP
improved, she was successfully diuresed with IV furosemide.
3) Acute on chronic CKD: FENa 6%, likely contrast nephropathy.
Her [**Last Name (un) **] was held. Renal was consulted for poor UOP while on
lasix drip and high dose diuril. Her creatinine rose and she was
started on CVVH via L IJ line. After a few days, her UOP picked
up and responded well to 40mg IV furosemide boluses, so the CVVH
line was removed.
4) Anemia: Given concern for RP bleed related to cath, she had
CT abd, which showed bilat ?hemothoraces, but no RP bleed. Other
source could be GI bleed from external hemorrhoids. She received
1 unit of pRBCs and her hematocrit remained stable.
5) Pneumonia: Patient had frequent coughing associated with
desaturations. CT chest was concerning for atypical pneumonia
vs. alveolar hemorrhage, although pulm consult favored the
former. ANCA and anti-GBM were negative. She received a 5 day
course of azithromycin and a brief course of prednisone for
possible diffuse alveolar hemorrhage (one day each at 60mg,
40mg, 20mg, 10mg). Her cough greatly improved.
6) Diabetes mellitus: Initially on glargine, although changed to
insulin gtt in the CCU due to highly elevated (300s) sugars in
the setting of steroids. She was transitioned back to glargine
as the steroids were rapidly tapered.
Medications on Admission:
Home Meds:
Amlodopine 5mg daily
atorvastatin 20 mg daily
furosemide 40mg [**Hospital1 **]
glimepiride 4 mg daily
humalog insulin sliding scale
imdur 60 mg [**Hospital1 **]
lidoderm patch [**Hospital1 **]
nitroglycerin spray prn
pentoxifylline SR 400 mg TID with meals
diovan 320 mg daily
aspirin 325 mg dialy
calcium +D 600/200 units [**Hospital1 **]
cyanocobalamin (unknown dose)
multivitamin daily
Omega 3 fatty acids 1000 mg daily
.
Meds on transfer:
amaryl 4 mg daily
calcium +d [**Hospital1 **]
centrum daily
diovan 160 mg daily
aspirin 325 mg daily
fish oil daily
isodil 40 mg q8hours
lasix 40 mg [**Hospital1 **]
lipitor 20 mg daily
lopressor 25 mg q6
nitrostat prn
norvasc 10 mg [**Hospital1 **]
protonix 40 mg IV daily
tylenol prn
vitamin b12 daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Lidoderm Topical
10. Nitroglycerin Sublingual
11. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO three times a day: with meals.
12. Calcium 600 with Vitamin D3 600 mg(1,500mg) -200 unit Tablet
Sig: One (1) Tablet PO twice a day.
13. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
once a day.
14. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease
Angina
Pulmonary Edema
Contrast Induced Nephropathy
Discharge Condition:
Good
Discharge Instructions:
You were admitted for cardiac catheterization and stent
placement in the setting of unstable angina. You required ICU
level care for pulmonary edema and contrast-induced nephropathy.
.
Please take all your medications as prescribed.
.
Please follow-up with your providors as below.
.
Please return if you have any further chest pain or shortness of
breath.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Followup Instructions:
#You will need to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] (your PCP) ([**Telephone/Fax (1) 250**])
within one week of discharge. Please call to make this
appointment. At that time, please bring-in your daily weights
and ask your doctor to determine if he feels your Lasix needs to
be restarted. You may note that we have just restarted your [**Last Name (un) **]
(Valsartan). You are no longer on Isosorbide Dinitrate s/p your
intervention.
.
#You will need to see Dr. [**Last Name (STitle) **] (your cardiologist) within
two week of discharge. Please call to make this appointment. Ask
him to review your blood pressure and medications.
.
#Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2167-4-27**] 9:00
.
#Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2167-4-27**] 10:00
.
#Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2167-5-4**]
9:30
Completed by:[**2167-5-18**]
ICD9 Codes: 4111, 5849, 5180, 486, 4280, 4439, 2720, 5859, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1952
} | Medical Text: Admission Date: [**2153-9-18**] Discharge Date: [**2153-10-4**]
Date of Birth: [**2079-3-29**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Codeine / Demerol / Nafcillin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Cellulitis, troponin leak
Major Surgical or Invasive Procedure:
Bedside debridement of eschar on right foot
History of Present Illness:
74 yo M with MM including PVD, DM, HTN, CAD, CRI transferred
from NWH for cellulitis/LE pain because pt's podiatric surgeon
is at [**Hospital1 18**]. Initally presented to NWH because of increasing
right foot pain and redness. At NWH, found to have EKG changes
with STD in V2-V4, though patient was asymptomatic and said he
never had chest pain. Unclear if he received abx from there per
records available. Patient was transferred here for further
management.
.
Of note, patient was recently hospitalized [**Date range (1) 91344**] in the ICU
at NWH when he was found at home unresponsive - was hypoglycemic
and in ARF. Patient states he does not remember 'anything' about
that hospital stay, the medications he was on or any events that
occurred then. Per report, he was discharged on lovenox for DVT
but when NWH ED was [**Name (NI) 653**], records there indicated that he
was started on Lovenox ppx because he was immobile and was
supposed to continue taking it until he was able to consistently
walk >100 feet. Unclear if patient has been administering the
lovenox himself as he stated that he no longer gives himself
insulin because 'it's just too complicated'.
.
On past hospitalization at NWH, also had a troponin has high as
8.8 thought be due to demand ischemia in the setting of
hypoglycemia. During that admission, he never had chest pain and
a stable percent MB fraction at 0.7. He was started on aspirin,
beta blocker and statin. An ACEi was held due to intolerance in
the past.
.
In the ED here VS: AF, hr:67, bp:130/70, rr:16 98% on RA.
Received fentanyl for pain, cards and vascular were c/s. Blood
cx were drawn. Vascular recommended vanc/zosyn given their
concern for osteo which he received. He received 50mg iv
fentanyl for pain.
.
Upon transfer to the floor, patient c/o of persistent right foot
pain. Denies fever or chills, CP, SOB, N/V/D, constipation, HA
or vision changes.
.
The patient is not a competent historian. On review of systems,
he denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems per HPI.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)HTN
2. CARDIAC HISTORY:
-CABG: [**2137**] LIMA->LAD. SVG->dRCA and SVG->D1/OM.
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2150**] (no report
available), [**2147**]: 3VD, patent LIMA-->LAD, patnet SVG--> dRCA and
D1/OM, severe native vessel disease
.
-PACING/ICD: None
.
3. OTHER PAST MEDICAL HISTORY: Per OMR notes, patient states he
does not know his full medical history
PVD
CAD s/p MI in '[**49**]
HTN
Hyperlipidemia
DM2 on Insulin
Diastolic CHF
CRI (baseline 1.8-2)
h/o GI bleed
Bladder carcinoma
Cervical stenosis
Anemia
Gastroparesis
.
PAST SURGICAL HISTORY:
- Debridement of osteomyelitis with L. 5th metatarsal head
resection [**2153-4-19**]
- L CFA to BK [**Doctor Last Name **] bypass with left arm vein [**9-27**]
- L4-5 laminectomies bilat w/ resection of large disk herniation
[**4-24**]
- R 2nd second toe amp [**5-24**]
- R CFA to AK [**Doctor Last Name **] bypass using [**Doctor Last Name 4726**]-Tex [**4-23**]
- L CEA [**2-/2140**], 4 vessel CABG [**1-/2138**]
- Aorta-bifemoral bypass at NWH in [**2147**]?
Social History:
HISTORY: Unwilling to give. Per prior records, married twice,
but recently separated. He has two children. H/o EtOH abuse in
AA 35 yrs; tobacco 45 pack year history
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=97.9 BP=140/60 HR=72 RR=20 O2 sat=93 on 2L%
GENERAL: elderly male lying in bed. Oriented x3. Mood
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. dry mmm. Poor
dentition
NECK: Supple. No JVD.
CARDIAC: RRR. s1/s2. III/VI systolic murmur heard best at LLSB.
LUNGS: clear anteriorly. patient unwilling to fully sit up for
posterior thorax exam, so limited. Heard scattered wheezes and
crackles at bases posteriorly.
ABDOMEN: Soft, NTND. +bs
EXTREMITIES: chronic venous statis changes bilaterlly. warm to
touch, DP pulses dopplerable.
RLE: 2 eshcars - one on medial aspect of foot and one on plantar
aspect of foot. Area of erythema on anterior/medial aspect of
foot with increased warmth. ?collection under foot?
SKIN: as above
Pertinent Results:
Admission laboratories:
COMPLETE BLOOD COUNT ([**9-18**]) WBC: 9.2 RBC: 3.45* Hgb: 8.3*#
Hct:27.6* MCV:80* MCH:23.9* MCHC:30.0* RDW:24.4* Plt Ct: 300
DIFFERENTIAL Neuts 87.1* Bands Lymphs 6.3* Monos 4.8 Eos 1.4
Baso 0.5
[**2153-9-18**] 07:01PM
BASIC COAGULATION (PT, PTT, PLT, INR) PT 15.0*PTT 41.8*Plt Ct
INR(PT)1.3*
Chemistry
RENAL & GLUCOSE Glucose 278* UreaN 69* Creat 2.0* Na 132* K 4.6
Cl 98 HCO3 22
EKG ([**9-20**]): Sinus rhythm. Right axis deviation. Incomplete right
bundle branch block. One to two millimeter downsloping ST
segment depression in the anterior leads extending from leads
V3-V6. Consider myocardial ischemia. Compared to the previous
tracing of [**2153-9-19**] the ST-T wave changes are pretty similar
except that the lead placement is slightly different.
Rate PR QRS QT/QTc P QRS T
72 126 114 440/461 71 121 113
WOUND CULTURE (Final [**2153-9-25**]):
KLEBSIELLA OXYTOCA. SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**6-/2450**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| STAPH AUREUS COAG +
| |
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2153-9-24**]): NO ANAEROBES ISOLATED.
Imaging:
Xray of right foot ([**9-19**]):
IMPRESSION:
1. Erosive bony destructions at the first distal phalanx and at
the stump of the second proximal phalanx consistent with
osteomyelitis.
2. Severe degenerative changes in the tarsometatarsal joints and
fracture at the 3rd metatarsal, suggesting early Charcot joint
disease.
3. Significant small vessel disease.
2D-ECHOCARDIOGRAM ([**9-20**]): The left atrium is mildly dilated.
The right atrium is markedly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no left ventricular outflow
obstruction at rest or with Valsalva. The right ventricular
cavity is markedly dilated with moderate global free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The ascending
aorta is moderately dilated. The aortic valve leaflets (3) are
mildly thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-22**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2151-12-16**],
the detected pulmonary hypertension has increased. There is no
change in the left ventricular systolic function.
ETT:
[**4-/2151**]:
This 72 yo man with IDDM, mild AS s/p multiple cadiac
interventions was referred to the lab for evaluation as a part
of the Spinal Cord Stimulation study. The patient exercised for
2.5 minutes on a modified [**Doctor First Name **] protocol and stopped due a
marked drop in systolic
blood pressure. This represents a very limited exercise
tolerance for
his age. The patient denied any neck, chest, arm or back
discomfort
throughout the study. In the setting of baseline abnormalities,
an
additional 0.5mm of ST segment depression was noted in V4-V5 at
peak
exercise. These changes returned to baseline by minute 3
post-exercise. The rhythm was sinus with a single VPB in late
recovery period. Marked drop in blood pressure with exercise
(136/60mmHg at rest to 98/50mmHg at peak). Post-exercise
hypertension was noted (172/60mmHg at 10 minutes of recovery).
.
IMPRESSION: Marked drop in blood pressure with exercise.
Non-specific EKG changes without anginal type symptoms.
.
CARDIAC CATH:
[**2147**]:
COMMENTS:
1. Coronary angiography of this right dominant circulation
revealed
severe native three vessel disease. The LMCA had a 30%
narrowing. The
LAD had diffuse luminal irregularities and a 70% proximal
stenosis. The mid vessel was diffusely diseased but the distal
vessel filled via a patent LIMA->dLAD. The LAD supplied a large
S2 that had an 80% lesion at its ostium. The LAD supplied two
moderate sized diagonal branches which had diffuse luminal
irregularities. The LCX tapered quickly and was totally occluded
in the proximal vessel after a small OM branch. The RCA was
diffusely diseased and totally occluded proximally.
2. Selective vein graft angiography revealed a widely patent
SVG->dRCA and a widely patent SVG->D1/OM.
3. Selective arterial conduit arteriography demonstrated a
widely patent LIMA->LAD.
4. Resting hemodynamics revealed markedly elevated right and
left
ventricular filling pressures with an LVEDP of 29 mmHg and a
mean PCW
pressure of 22 mmHg. In addition, there were V-waves to 50 mmHg
suggesting significant mitral regurgitation. There was evidence
of
moderate to severe pulmonary hypertension with PA pressures of
62/21/39 mmHg and a pulmonary vascular resistance of 209
dynes-sec/cm5. The cardiac output was preserved at 6.9 L/min.
Note was made of a 10 mmHg gradient across the aortic valve.
5. Left ventriculography was not performed due to the patient's
underlying renal insufficiency and recent non-invasive testing
documenting a preserved LV systolic function.
.
FINAL DIAGNOSIS:
1. Severe native three vessel disease.
2. Patent LIMA->LAD.
3. Patent SVG->dRCA and SVG->D1/OM.
4. Moderate to severe left ventricular diastolic dysfunction.
5. Moderate to severe pulmonary hypertension.
CT head ([**9-24**]):
IMPRESSION:
1. No acute intracranial process.
2. Sequelae of chronic infarction involving the left
parieto-occipital
region.
Renal U/S ([**9-27**]):
IMPRESSION:
Absent diastolic flow seen in the bilateral interlobar arteries
of the
kidneys. The findings are nonspecific, but indicate renal
parenchymal
disease. There is limited evaluation of the main renal arteries,
but there is no clear evidence of renal artery stenosis. There
is no hydronephrosis.
Brief Hospital Course:
Summary: 74 yo M transferred from NWH with EKG changes, trop
here to 0.87 (baseline 0.2) and RLE cellulitis, right foot
osteomyelitis, worsening acute on chronic renal failure
# Right lower extremity cellulitis and right foot osteomyelitis:
The patient presented with right lower extremity cellulitis and
was found to have osteomyelitis in the right foot. Vascular
surgery evaluated the patient and thought that treatment for the
infection and ischemia would be a below the knee amputation,
though given the patient's poor cardiac status, he would not be
a good candidate for surgery. The patient was empirically
started on Vancomycin and Zosyn. A wound culture grew Klebsiella
oxytoca and MRSA and continued on those antibiotics. Since
vascular surgery would be high risk, podiatry was consulted for
local debridement. They debrided the area locally, yet erythema
of the right foot existed. It remained unclear whether the
erythema was due to ischemia vs. a subcutaneous abscess, so they
recommended a MRI of the foot. The MRI was never performed
because after discussion with the family and primary care
physician, [**Name10 (NameIs) **] was decided for the patient to become CMO. His
antibiotics were withdrawn and wound care applied to the area.
# Acute on chronic renal failure: The patient presented with a
creatinine close to his baseline, however, after periods of
hypotension, likely due to a peri-septic state, his creatinine
starting to rise. He was given fluid boluses of 500 cc of normal
saline as needed because his urine lytes showed a FeUrea~20-25%.
Renal was consulted and thought his creatinine rise was likely
due to acute tubular necrosis secondary to a pre-renal state.
The patient was offered aluminium hydroxide for high phosphate
levels, but the patient refused it. A renal ultrasound showed no
hydronephrosis. The patient became progressively oliguric with
UOP less than 20 cc/hour. Renal thought his kidneys would
unlikely recover (his creatinine rose to 5.3 despite
interventions). The patient and his family felt that they did
not want to pursue dialysis as an option.
#Increased troponins: The patient was noted to have high
troponins and excentuated ST wave depressions in V3-V5.
Cardiology was consulted and recommended medical management with
a beta blocker, ACE inhibitor, statin, and aspirin. The patient
was started on these medications, though became persistently
hyperkalemic, and therefore, the ACEi was discontinued. Also,
his CK and LFTs were [**Last Name (LF) 28645**], [**First Name3 (LF) **] the statin dose of 80 mg was
lowered to 20 mg and eventually discontinued due to persistently
[**First Name3 (LF) 28645**] LFTs. An echocardiogram revealed no acute wall motion
abnormality, though it did show worsening tricuspid
regurgitation and increased pulmonary artery pressure.
Throughout his stay, the patient did not have any chest pain.
#Increased LFTs: The patient has a known history of alcohol
abuse and increased LFTs in the past. During his peri-septic
period, the patient was noted to have increased LFTs, likely
multifactorial due to low perfusion to the liver and also
congestion secondary to tricuspid regurgitation. The patient did
not have any complaints of abdominal pain, though, he had
hepatomegaly on exam.
#Gastrointestinal bleed: The patient has a history of a GI bleed
and was guiaic positive in the ER. In addition, he had a
persistently elevated PT/PTT, likely due to either underlying
liver or hematologic disease. The patient's hematocrit remained
stable until [**9-26**] when his hematocrit dropped from 29.0 to 25.6
and was noted to have melenic stools. He continued to have
melenic stools, so he was transfused one unit of blood and
transferred to the MICU. His aspirin was discontinued. His
hematocrit remained stable in the MICU and transferred to the
floors where there were no signs of any GI bleeding.
Altered mental status: The patient had periods where he had
altered mental status, mostly at night. His AMS was likely
multifactorial due to infection, pain and uremia. He had
significant altered mental status on one day when he appeared
more somnolent with respirations=10/min after a dose of Morphine
2mg IV. Narcane was given with some effect. A head CT showed no
acute pathology. He continued to have periods of delirium mostly
at night.
#Pruritis: The patient has been complaining of pruritis,
especially on his back, since admission. A variety of remedies
were tried for wound care. According to his son, the pruritis
has been long-standing. It might be exacerbated by his renal
failure. A side effect of Morphine is a possibility, but he
still had the itching even before the morphine. He is being
treated with skin care, sarna lotion, hydrocortisone and
doxepin.
Goals of care: The patient entered the hospital as full code.
After the renal and GI bleeding complications from his illness,
the patient and his family decided to become DNR/DNI. After a
meeting with the PCP and the family, they thought the best route
would be to become comfort measures only instead of pursuing
dialysis and being chronically cared for in a nursing home. At
first, it was thought that his beta blocker, aspirin, and
antibiotics would be continued, however, after further
conversation, these medications were discontinued and only
palliative measures for insomnia, anxiety, pain and constipation
were ordered.
Medications on Admission:
MEDICATIONS (from NWH D/C summary on [**9-11**])
acetaminophen 1 g q8hr
ASA 325 Daily
Erythropoietin 4000 units SC weekly
Ferrous sulfate 325 mg Daily
Furosemide 40 mg daily
Lovenox 30 mg SC daily until ambulatory
NPH (8 units before breakfast and dinner
Regular insulin (5 units before breakfast and dinner
Metoprolol 12.5 mg [**Hospital1 **]
MVT daily
Miralax 17 g Daily
Nystain triamcinolone cream topically twice daily
omeprazole 29 mg daily
Sarna lotion to affected area [**Hospital1 **]
senokot qHs
Sertraline 50 mg daily
simvastatin 20 mg daily
flomax 0.4 mg daily
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Morphine 10 mg/5 mL Solution Sig: [**4-29**] mL PO Q4H (every 4
hours) as needed for pain, respiratory distress.
9. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3
times a day) as needed for itching.
10. Doxepin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
12. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
six (6) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
Cape Code Nursing & Rehabilitation Center - [**Location (un) 10072**]
Discharge Diagnosis:
Primary
-cellulitis of lower extremity
-osteomyelitis
-coronary artery disease
.
Secondary
-Hypotension
-Type II diabetes Mellitus
Discharge Condition:
Stable. Patient breathing on room air.
Discharge Instructions:
You were transferred to the hospital with right foot cellulitis
and osteomyelitis. You were started on antibiotics. Vascular
surgery evaluated the foot and were cautious to pursue surgical
intervention because you have a poor cardiac reserve. Podiatry
evaluated you and they....
.
You should come back to the hospital or call your primary care
doctor if you have chest pain, shortness of breath, weight gain,
fevers/chills or increasing pain in your right foot.
Followup Instructions:
PRN
ICD9 Codes: 5845, 2851, 2762, 2930, 5859, 4280, 2767, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1953
} | Medical Text: Admission Date: [**2144-1-23**] Discharge Date: [**2144-1-30**]
Date of Birth: [**2090-4-28**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
OSH tx for UGIB
Major Surgical or Invasive Procedure:
Endoscopy with banding of esophageal varicies
History of Present Illness:
This is a 53 y/o female with a history of chronic hepatitis C,
cirrhosis, varices and portal hypertension who presents from
[**Hospital3 2737**] when she orginally presented with hematemesis.
Unclear what the patient's presenting Hct was. However she did
receive 3U of prbcs. While it is not entirely clear, it appears
that her hct improved to 32.8.
.
An EGD was performed and showed grade III varices. Blood and
clot present in the fundus. Question of small [**Doctor First Name **]-[**Doctor Last Name **]
tear. The patient remained hemodynamically stable. She was
transferred here for further mgmt.
Past Medical History:
1. Hep C Cirrhosis, most recent MELD 13 in [**9-24**]. Complicated by
esophageal varices, seen on [**1-23**] EGD with 3 cords of grade [**11-20**]
varices.
2. DM, poorly controlled, with A1c 11.9% in [**9-24**]
3. HTN
4. Aortic stenosis: seen by Dr. [**Last Name (STitle) **] in [**8-24**], [**Location (un) 109**] 1 cm, peak
grad 63, mean grad 34. Preserved EF (75-80%). Normal persantine
[**2-23**].
Social History:
used cocaine in past. moderate EtOH until [**2137**] then quit. lives
in [**Location (un) 2498**] with children and grandchildren. Has 5 kids. not
married.
Family History:
brother had lymphoma in his 20s. no liver disease. father had
CABG.
Physical Exam:
VITALS: 96.9 68 108/62 16 93% 2L nc
GEN: healthy appearing female in NAD, lying in bed, and
comfortable
HEENT: JVP flat, MMM
CARD: nl rate, S1S2, III/VI HSM heard best along RUSB radiating
to the carotids
PULM: CTA b/l no rrw
ABD: +BS, no guarding, no rebound tenderness, no shifting
dullness, no hsm, mild distention
EXT: wwp, 2+DP bilaterally
NEURO: A&O x3, MAE
Pertinent Results:
RADIOLOGY Final Report
DUPLEX DOP ABD/PEL LIMITED [**2144-1-24**] 12:57 PM
IMPRESSION:
1. No evidence of portal vein or hepatic vein thrombosis.
2. Nodular liver, consistent with cirrhosis.
3. Small ascites.
4. Gallbladder sludge.
.
.
.
.
.
.
................................................................
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2144-1-25**] 6:53 PM
HISTORY: 53-year-old woman with esophageal surgery, now with
shortness of breath. Evaluate for free air or fluid overload.
FINDINGS: Comparison is made to the previous study from [**7-7**], [**2141**].
.
.
.
.
.
.
.
.
................................................................
RADIOLOGY Final Report
CHEST (PA & LAT) [**2144-1-28**] 1:31 PM
IMPRESSION: No new evidence of pneumonic infiltrate. Plate
atelectases on bases similarly as existed on preceding study of
[**1-25**].
.
.
.
.
.
.
.
.
.
................................................................
RADIOLOGY Final Report
PARACENTESIS DIAG. OR THERAPEUTIC [**2144-1-28**] 8:27 AM
IMPRESSION:
1. Patient status post diagnostic paracentesis with drainage 700
cc of light brown/pink ascites.
.
.
.
.
.
.
.
.
................................................................
[**2144-1-30**] 11:15AM BLOOD WBC-2.6*# RBC-3.25* Hgb-9.7* Hct-28.1*
MCV-86 MCH-29.8 MCHC-34.6 RDW-17.3* Plt Ct-41*
[**2144-1-30**] 05:55AM BLOOD WBC-1.7* RBC-2.98* Hgb-8.8* Hct-25.6*
MCV-86 MCH-29.6 MCHC-34.5 RDW-17.1* Plt Ct-38*
[**2144-1-23**] 10:25PM BLOOD WBC-3.8*# RBC-3.42* Hgb-10.2* Hct-29.2*
MCV-85 MCH-29.9 MCHC-35.1* RDW-15.7* Plt Ct-42*
[**2144-1-29**] 06:45AM BLOOD Neuts-59.9 Lymphs-30.3 Monos-6.3 Eos-3.0
Baso-0.5
[**2144-1-30**] 11:15AM BLOOD Plt Ct-41*
[**2144-1-30**] 05:55AM BLOOD Plt Ct-38*
[**2144-1-30**] 05:55AM BLOOD PT-18.4* INR(PT)-1.7*
[**2144-1-30**] 05:55AM BLOOD Gran Ct-950*
[**2144-1-30**] 05:55AM BLOOD Glucose-102 UreaN-10 Creat-0.6 Na-134
K-4.0 Cl-104 HCO3-24 AnGap-10
[**2144-1-23**] 10:25PM BLOOD Glucose-99 UreaN-31* Creat-0.8 Na-143
K-3.8 Cl-117* HCO3-17* AnGap-13
[**2144-1-30**] 05:55AM BLOOD ALT-21 AST-33 AlkPhos-53 TotBili-1.0
[**2144-1-23**] 10:25PM BLOOD ALT-45* AST-50* AlkPhos-68 Amylase-10
TotBili-1.4
[**2144-1-24**] 03:21AM BLOOD Lipase-21
[**2144-1-23**] 10:25PM BLOOD Lipase-18
[**2144-1-30**] 05:55AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.8
Brief Hospital Course:
Patient was transferred from an outside hospital for treatment
of her upper GI bleed. She was admitted to the ICU and seen by
Hepatology. The following morning the pt. underwent EGD and
banding of her esophageal varicies that showed signs of recent
bleed. The next day the patient was transferred to the general
medical floor. There she was doing well. On [**1-25**] the pt.
developed abdominal pain, shortness of breath, and a low grade
fever. A chest x-ray was done, blood and urine cultures were
sent, and she was given tylenol. Over the next several days the
patients blood cultures were followed, she underwent pulmonary
toilet, and underwent a paracentesis. She did not have SBP and
gradually her fevers resolved. On HD 8 - the patient's blood
cultures were negative, her fevers had resolved, and her
hematocrit had been stable for several days, and she was ready
for discharge. She was to follow up with the gastroenterology
team and her primary care doctor. She was tolerating regular
food and was ready for discharge.
.
# New SOB: ~7pm [**1-25**] pt. c/o abdominal pain, right scapular pain,
SOB, spiked 101.3. Ua, u cx, bld cx, and repeat hct ordered ->
hct stable, CXR no free air/consolidation +atelectisis at bases
bilaterally, no overload
- [**1-26**]: Afebrile, O2sat 95 on 2L, diminished breath sounds at
bases.
- oxygen requirement at baseline this am, pt. no longer
complaining of shortness of breath
- encouraging ISS; encouraging ambulation
- [**1-27**] no longer c/o SOB -> enocouraging ISS, consider repeat
CXR
- persistant low grade temperatures -> repeat CXR PA and lat
today -> neg for pna
--> now only with dry cough
.
# Abdominal pain/diarrhea:
- [**1-28**] no further abdominal pain; minimal gas pain yesterday
that has resolved -> encouraging ambulation
- with persistant daily temps -> [**Last Name (un) **] guided paracentesis to eval
for XBP
- 7pm [**1-25**] pt c/o abdominal pain with SOB.
- Reverted diet to clears --> advanced to regualr [**1-26**] at patient
tolerating well
- slight 'gas' pain this am but overall much improved
- continue reg diet today
- titrate lactulose to [**1-21**] BMs a day
- checking stool cultures -> pending
- c.diff -> one negative
- started flagyl [**2144-1-28**]
.
# UGIB: Patient scoped at osh, no treatment performed. Study
showed blood and clots at the fundus. Patient remained HD stable
after received 3U PRBCS. She has 18,20,22 gauge for access. Hct
has been stable. IV PPI and octreotide for now. NOW s/p EGD at
[**Hospital1 18**] w/placement of 3 bands
- continue IV PPI and octreotide gtt -> d/c [**1-25**]
- continue to cycle hct --> has been stable
- consider restarting home meds if stable through night
- [**1-26**]: Hct trend demonstrated slow decrease; repeat p.m. hct.
VSS. Guaiac stool to assess for bleed. Pt not nauseous, no
emesis. Hold home regimen of nadolol and aldactone given hct
trend. Transfuse for hct<28 (currently 28.4)
- repeat hct [**1-26**] at 34 --> result of 28.4 likely not real -> 33
[**1-27**]
.
# Hx of cirrhosis: If BP and hct remain stable overnight can
restart nadolol and aldactone
- continue lactulose and ceftriaxone for sbp ppx
.
# Hx of diabetes: ISS
- elevated blood sugars despite home regimen of lantus -> will
follow today
- tighten sliding scale
.
# Anxiety: cont alprazolam
.
# Anemia: UGIB and [**Month/Year (2) 500**] marrow suppression from hep C
- continue to cycle hct -> has been stable -> consider qOD labs
if pt. stays
.
# Thrombocytopenia: decreased synthetic liver function; stable
.
# Non anion gap acidosis: secondary to ivf resuscitation and
diarrhea.
- following lytes
.
# FEN:
- Replete lytes
- pt. tolerating regualr diet
.
# PPX:
- pneumoboots given thrombocytopenia
- IV PPI
.
# Full code
.
# Dispo: pending stable hct, tolerating PO intake, and above.
Medications on Admission:
per OMR notes and OSH notes, patient is able to recall some
medications
Omeprazole 20mg daily
Spironolactone 100mg daily
Glipizide 15mg daily
Nadolol 20mg daily
Lactulose 30mg TID
Lasix 20mg daily
Lantus discrepancy between OMR (40 units qhs) and OSH records
(55 units qhs)
Ciprofloxacin 250mg daily
Xanax 0.5mg daily
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 12 days.
Disp:*36 Tablet(s)* Refills:*0*
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Xanax 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Glipizide 5 mg Tablet Sig: Three (3) Tablet PO once a day.
9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
upper GI bleed
esophageal varicies
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital and treated for your upper
gastrointestinal bleed. You were seen by the GI team and had an
endoscopy while here. You had three bands placed in your
esophagus to control the bleeding -> this worked well. You then
began spiking temperatures - you were maintained on the
ceftriaxone and added flagyl to your regimen for concern of a
stool infection. Cultures were sent and all have been negative.
You also underwent a sampling of fluid from your abdomen. This
was negative as well. You are now doing very well and ready for
discharge.
You will need to take all of your medication as prescribed.
You will need to keep all follow-up appointments as indicated.
Call your primary care doctor or return to the ED if T>101.5,
chills, nasuea, vomiting, chest pain, shortness of breath,
worsening abdominal pain, or any other concern.
Followup Instructions:
- you need to follow-up with your primary care doctor in the
next week.
- You need to follow-up with the hepatology team in [**12-22**] weeks
for a repeat endoscopy. Please call ([**Telephone/Fax (1) 2233**] to schedule
an appointment.
**You need to make sure you keep the following appointments**
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2144-2-5**] 1:40
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2144-2-5**] 3:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2144-2-18**] 10:20
ICD9 Codes: 5715, 2762, 2875, 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1954
} | Medical Text: Admission Date: [**2163-4-20**] Discharge Date: [**2163-5-16**]
Date of Birth: [**2092-1-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Progressive dyspnea on exertion.
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 3 [**2163-4-22**].
Sternal rewiring [**2163-5-2**].
History of Present Illness:
This is a 71 yo male patient with known history coronary artery
disease who was previously turned down for a CABG in [**2143**] due to
obesity and was lost to follow-up.
He presented recently with complaints of worsening shortness of
breath with exertion and was referred for cath showing 3VD. At
that time he was transferred to the [**Hospital1 18**] for eval for CABG.
Past Medical History:
Coronary artery disease.
Hypertension.
Hyperlipidemia.
CVA in [**2148**].
Social History:
Lives in [**Hospital1 10478**] with his wife. Retired engineer. Not very
active secondary to severe shortness of breath. Reports that he
quit smoking 45 years ago afetr a 415 pack year history.
Reports very rare ETOH consumption.
Family History:
Father deceased at age 50 with MI.
Mother deceased at ago 72 with MI but [**Last Name (un) 27185**] MI in her 50s.
Pertinent Results:
[**2163-5-16**] 06:00AM BLOOD WBC-14.8* RBC-3.45* Hgb-10.1* Hct-30.7*
MCV-89 MCH-29.3 MCHC-33.0 RDW-14.1 Plt Ct-232
[**2163-5-16**] 06:00AM BLOOD Plt Ct-232
[**2163-5-7**] 09:55AM BLOOD PT-16.9* PTT-28.2 INR(PT)-1.9
[**2163-5-15**] 04:45AM BLOOD Glucose-80 UreaN-12 Creat-1.1 Na-140
K-4.1 Cl-103 HCO3-29 AnGap-12
[**2163-5-4**] 06:30AM BLOOD ALT-30 AST-19 AlkPhos-74 Amylase-18
TotBili-0.5
[**2163-5-8**] 04:10AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 32993**] was admitted from an OSH on [**2163-4-20**] pre-op for
CABG. Because of his severe 3VD he was started on heparin and
nitroglycerine drips for optimal control of his CAD. He
underwent pre-op workup including pre-op head CT (with hx of
CVA) and carotid ultrasound.
On [**2163-4-22**] he proceeded to the OR and underwent a CABG x 3 with
LIMA to the LAD, SVG to the OM, and SVG to the Ramus with patch
angioplasty and repair of ramus posterior rupture (subacute).
Please see OP note for full details.
He was successfully weened and extubated on his operative
evening.
On POD one he remained in the ICU for ongoing hemodynamic
monitoring and on POD two he was transferred to the in-patient
telemetry floor for ongoing care.
In the early morning hours on POD three, Mr. [**Name14 (STitle) 32994**] was
found to be talking non-sensically and trying to get out of bed.
A neuro consult, head CT and MRI were obtained for suspected
acute CVA. He was found to have small right parietal, left
cerebellar, and right cerebellar infarcts thought to be embolic
with new post-operative atrial fibrillation.
Over PODs four and five Mr. [**Known lastname 32993**] continued to wax and
waine; he was continued on his heparin and coumadin per neuro
recs.
On POD six his mental status was noted to be significantly
improved with neuro recs only for ongoing anticoagulation for
stroke prevention.
Also on POD six he was noted to have new sternal drainage. His
WBC bumped up to 18 (from 13) for which he was pan-cultured. He
had continued bursts of atrial fibrillation and was started on
amiodarone.
On POD seven his sternal drainage significantly increased; due
to his elevated INR, he was unable to return immediately to the
OR. On POD nine ([**5-2**]) his INR fell below 1.7 and he returned
to the OR for sternal rewiring.
On POD eleven he was found to be C. diff positive with multiple
loose stools and on POD thirteen he was noted to have guaiac
positive stools. An endoscopy showed bleeding ulcers in the
duodenal bulb accounting for the patient's GIB and hemostasis
was obtained. He was started on IV protonix with serial Hcts to
monitor progress. He was transfused as necessary and was taken
off of his anticoagulation. After two days in the ICU for close
hemodynamic monitoring in light of GIB, he was again transferred
to the inpatient floor on PODs 16 and 5.
He continued to work with the physical therapy team throughout
his stay but it was not felt that he was safe for home. He was
screened for rehabilitation.
On PODs 20 and 9, a new rash was noted on trunk and Mr.
[**Known lastname 32995**] antibiotics were discontinued. The rash resolved
and on PODs 24 and 13, it was decided that he was safe for
transfer to a rehabilitation facility for ongoing management,
treatment, and rehabilitation.
Final recommendations from the neurology service are for
coumadin as soon as cleared by GI with 325 mg aspirin daily
until then; to follow-up with primary neurologist. GI
recommends re-starting Coumadin 14 days post bleed: [**2163-5-10**].
Start coumadin at low dose and keep INR at low-end of
theraupetic.
Medications on Admission:
Aspirin 325 daily.
Multivitamin daily.
Lipitor 20 daily.
Nifidipine XL 30 daily.
Mirapex 1.5 [**Hospital1 **].
Reminyl 12 daily.
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Galantamine Hydrobromide 4 mg Tablet Sig: Three (3) Tablet PO
bid ().
9. Pramipexole Dihydrochloride 1 mg Tablet Sig: 1.5 Tablets PO
bid ().
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day.
11. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a
day for 7 days: To be followed by 200 mg daily dosing.
12. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
13. Metoprolol Tartrate 25 mg Tablet Sig: [**1-9**] Tablet PO twice a
day.
14. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
Coronary artery disease.
Cerebral vascular accident.
Sternal wound dehissence.
Gastrointestinal bleed.
Discharge Condition:
Stable.
Discharge Instructions:
Wash incisions daily with soap and water. Rinse well. Do not
apply any creams, lotions, powders, lotions, or ointments.
No lifting greater than 10 pounds.
Strict sternal precations.
[**Last Name (NamePattern4) 2138**]p Instructions:
Call to schedule appointment with Dr. [**Last Name (Prefixes) **] in 4 weeks.
Call to schedule appointment with Dr. [**Last Name (STitle) 32996**] in 2 weeks.
Call to schedule appointment with cardilogist in 2 weeks.
Call to schedule appointment with primary neurologist in [**2-11**]
weeks.
Please check Hct one week post-discharge from [**Hospital1 18**].
Low-dose Coumadin should be started [**2163-5-20**].
Completed by:[**2163-5-16**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1955
} | Medical Text: Admission Date: [**2138-3-11**] Discharge Date: [**2138-8-25**]
Date of Birth: [**2079-8-15**] Sex: M
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 27294**] was admitted to [**Hospital1 1444**] on [**2138-3-11**], for
recurrent bleeding in his left pelvis. He had a hip
replacement done almost 20 years ago in [**Country 6171**] for a hip
infection he developed as a child. Mr. [**Known lastname 27294**] did well with
his original hip replacement until [**2134**] when he was seen at
[**Hospital1 69**], at which time he was
found to have a loose prosthesis with extensive osteolysis.
He attempted a reconstruction in [**2136-8-8**]. However,
he had extensive bone loss and reconstruction was not
possible. He was left with a resection arthroplasty.
Over the ensuing months Mr. [**Known lastname 27294**] had recurrent collections
of fluid of his left thigh. These were initially drained
successfully. He was also on Coumadin therapy for deep
venous thrombosis. He was seen at [**Hospital6 1130**] by Oncology Service for recurrent collection of
seroma in his left thigh. He was also seen by an orthopaedic
oncologist. Neither of these workups revealed any cause of
the recurrent left thigh collection.
HOSPITAL COURSE: On [**2138-3-20**], at [**Hospital1 190**], the patient had a left hip exploration with
placement of Hemovac. On [**2138-4-1**], he had a left hip
exploration and a femur resection. On [**4-21**] and [**2138-4-25**],
he went to Interventional Radiology to have embolization of two
vessels off the superficial femoral artery and embolization
of two distal branches of the deep femoral artery. On
[**2138-5-6**], he had a left hip disarticulation. On [**2138-5-30**], a Plastic Surgery consultation was obtained. They said
there was no role for flap. On [**2138-5-12**], a Vascular
Surgery consultation was obtained stating that bleeding was
most likely venous, and embolization had no further role. On
[**5-15**], a PICC line was placed. On [**5-15**], a Medication
consultation for tachycardia was obtained, and a beta blocker
was started. On [**5-21**], and echocardiogram revealed normal
left ventricular function and an ejection fraction of 55%.
From the period of [**5-27**] to [**7-7**], the patient had 12
incision and drainages of left thigh/groin wound. The
patient had chest pain on [**7-13**] and was ruled out for a
myocardial infarction. The patient had a spiral CT done on
[**7-13**] as well which revealed multiple emboli in the left
and right pulmonary arteries. At that time [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**]
filter was placed. A chest tube was also placed for
hemothorax which had an initial output of 1200 mL.
The patient was transferred to the floor on [**2138-7-18**].
Total parenteral nutrition was started on approximately
[**2138-7-20**]. The patient was transferred back to the
Surgical Intensive Care Unit in respiratory distress on
[**2138-7-29**]. At that point he was intubated, and the
chest tube had an output of 1 liter. Repeat embolizations
were attempted of the superior gluteal artery on [**2138-8-6**].
Throughout the admission, the patient received approximately
110 units of packed red blood cells. Two more dressing
changes were performed in [**2138-8-9**]. Consultations
obtained during admission were as follows: Pain Service.
Plastic Surgery revealed no role for flap.
Hematology/Oncology workup including factor VIII [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] factor bleeding time was completely normal.
Vascular Surgery consultation revealed that most likely the
bleeding was venous in nature. Interventional Radiology
performed embolization on several occasions. Medicine
consultation was obtained. Infectious Disease consultation
was also obtained. The patient had vancomycin-resistant
osteomyelitis, and candidal line infection. He was initially
started on ampicillin, ceftriaxone, and Flagyl. These were
discontinued. He was then placed on cefepime and vancomycin.
These were then discontinued, and he was started on
piperacillin and gentamicin, and these were discontinued. He
was then started on imipenem and linezolid which were both
discontinued on [**8-16**]. He was also started on Bactrim,
levofloxacin, and fluconazole. Blood cultures obtained on
[**8-14**] also showed stenotrophomonas mysophilia
bacteremia.
The patient was made comfort measures only on [**2138-8-25**]. This was done with the help of the Ethics Committee.
All other services including Hematology/Oncology,
Orthopaedic/Oncology, Pulmonary, Medicine, Vascular, Plastic,
and Surgical Intensive Care Unit team all agreed there were
no other medical actions which could be taken. The patient
deceased at 11:40 a.m. on [**2138-8-25**].
CAUSE OF DEATH: Respiratory failure, sepsis, pelvic
osteomyelitis, bleeding diathesis of unknown cause.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 27295**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2138-8-25**] 12:51
T: [**2138-8-29**] 13:54
JOB#: [**Job Number 27296**]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1956
} | Medical Text: Admission Date: [**2181-2-2**] Discharge Date: [**2181-4-9**]
Service: [**Hospital Unit Name 196**]
Prior to this he was in the CCU. For [**Hospital **] hospital course
please see dictation by CCU intern.
HISTORY OF PRESENT ILLNESS: Briefly, patient is an
80-year-old male with a history of coronary artery disease,
hypertension, type 2 diabetes, gastroesophageal reflux
disease, subacute bacterial endocarditis who presented with
chest pain in the setting of taking Viagra. This was
associated with shortness of breath with no nausea, vomiting,
diaphoresis, palpitations, or lightheadedness.
Patient was found to have a new right bundle branch block
with Q-wave inversions in Lead III, aVF, and V1 through V4
with TWF in V5 through V6 and with no EKG to compare.
Patient underwent cardiac catheterization and had stent
placed to left anterior descending. The coronary angiography
revealed a right dominant system with LMCA that was normal,
left anterior descending with minor disease, left circumflex
with 80% lesion at D2 with TIMI 2 flow, right coronary artery
with 50% mid lesion.
Post catheterization patient was noted to have Mobitz II
rhythm on telemetry and hence underwent pacemaker placement
on [**2181-2-2**]. Subsequent to this patient was transferred to
the [**Hospital Unit Name 196**] service for further observation and care.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Gastroesophageal reflux disease.
3. Esophageal strictures.
4. Hypertension.
5. Type 2 diabetes.
6. Hepatitis C.
7. Subacute bacterial endocarditis 10 years ago.
8. Status post hernia repair.
9. Status post right wrist surgery with hardware placement.
MEDICATIONS ON TRANSFER:
1. Vancomycin 1 gram q. 12 hours times four doses.
2. Oxycodone p.r.n.
3. Captopril 12.5 mg one p.o. t.i.d.
4. Metoprolol 50 mg one p.o. b.i.d.
5. Celexa 20 mg one p.o. q.d.
6. Lorazepam 0.25 mg one p.o. q.d.
7. Senna p.r.n.
8. Docusate p.r.n.
9. Protonix 40 mg one p.o. q.d.
10. Regular insulin sliding scale.
11. Plavix 75 mg one p.o. q.d.
12. Aspirin 325 mg one p.o. q.d.
ALLERGIES: Patient has no known drug allergies.
SOCIAL HISTORY: He is a retired compositor. History of
intravenous drug use; none in the last six years. Prior
cocaine use; none in the last six years. Remote smoking
history; quit 60 years ago. History of heavy ETOH use but
none in the last six years. Lives alone. Separated from
second wife.
FAMILY HISTORY: Significant for father with cerebrovascular
accident at age 72. Son had myocardial infarction in 50s and
daughter had lung cancer.
PHYSICAL EXAMINATION: Vitals on admission to the [**Hospital Unit Name 196**]
service are blood pressure 170/86, pulse 68, respiratory rate
16, satting at 98% on room air. Patient is afebrile with
temperature 97.8. Generally, the patient is in no acute
distress, is alert and oriented times three. HEENT is
normocephalic, atraumatic. Extraocular muscles are intact.
Oropharynx is clear with moist mucous membranes. Neck is
supple with no jugular venous distention. Heart is regular
rate and rhythm. Pacemaker placement is clean, dry, and
intact with no evidence of oozing or hematoma. Lungs are
clear to auscultation bilaterally. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are free of any clubbing, cyanosis, or edema.
Neurologic exam: Cranial nerves II-XII are intact. Strength
is [**5-9**] and symmetric. Reflexes are intact and symmetric.
Toes are downgoing.
HOSPITAL COURSE BY SYSTEM:
1. Cardiovascular: Patient was continued on aspirin,
Plavix, beta blocker, and Captopril with good blood pressure
control. His initial hypertension was felt to be secondary
to periprocedure stress. During his hospitalization on the
[**Hospital Unit Name 196**] service, however, his angiotensin-converting enzyme was
titrated up and his beta blocker was changed to t.i.d.
dosing.
2. For Mobitz II rhythm patient was status post pacemaker.
His pacemaker was interrogated on [**2181-2-3**]. Additionally,
a chest x-ray revealed proper placement. Patient received
four doses of Vancomycin and had no other abnormalities that
were noted.
3. For diabetes patient was continued on a regular insulin
sliding scale.
4. Gastrointestinal: Patient was maintained on a proton
pump inhibitor and bowel regimen.
5. Psychiatry: Patient was maintained on Celexa as well as
Lorazepam.
FINAL DIAGNOSES:
1. Coronary artery disease status post catheterization,
status post stent to left anterior descending, and status
post pacemaker placement.
2. Coronary artery disease.
3. Gastroesophageal reflux disease.
4. Hypertension.
DISCHARGE INSTRUCTIONS:
1. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N., [**Last Name (un) 4949**], R.N. at the [**Hospital Ward Name 23**] Cardiac Center
on [**2181-2-8**] at 3 p.m.
2. Audiology at the [**Hospital Ward Name **] Otolaryngology Building on
[**2181-2-21**] at 3 p.m.
3. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], R.N. at the [**Hospital Ward Name 23**] Dermatology Center on
[**2181-3-7**] at 2:20 p.m.
4. Patient is also to follow up in the Electrophysiology
Clinic at [**Telephone/Fax (1) 59**] on [**2181-2-8**].
5. The patient was advised that he is not to take a shower
for one week.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg one p.o. q.d.
2. Plavix 75 mg one p.o. q.d.
3. Pantoprazole 40 mg one p.o. q.d.
4. Citalopram 20 mg one p.o. q.d.
5. Captopril 25 mg one p.o. t.i.d.
6. Metoprolol 50 mg one p.o. t.i.d.
DISPOSITION: Home.
DISCHARGE CONDITION: Stable, stable on room air, is able to
ambulate without difficulty, is having no further ectopy on
telemetry, is tolerating a regular diet, has had no further
episodes of chest pain, palpitations, or other cardiovascular
complaints.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 5843**]
MEDQUIST36
D: [**2181-4-9**] 11:11
T: [**2181-4-12**] 09:20
JOB#: [**Job Number 50807**]
ICD9 Codes: 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1957
} | Medical Text: Admission Date: [**2131-8-29**] Discharge Date: [**2131-9-8**]
Date of Birth: [**2058-4-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2131-8-30**] Cardiac cath
[**2131-8-31**]: Urgent coronary artery bypass graft x3: Left internal
mammary artery to left anterior descending artery; saphenous
vein grafts to diagonal and obtuse marginal arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
Mr. [**Known lastname 11845**] is a 73 M with a history of CVD s/p left carotid stent
placement on [**2131-8-8**], HTN, HL, DM2 who presents following an
episode of dizziness followed by N/V/D and associated chest
pain. He reports that he has been feeling well since his prior
hospitalization with no recurrence of neurologic symptoms
(initially had some right hand numbness/weakness which came and
went). He felt well when he went to bed last night. On awakening
this morning and turning over in bed, he felt extremely dizzy
and like the room was spinning around. He turned back and his
symptoms resolved after about 10 seconds. He then got out of bed
and walked toward his kitchen to take his medications, but felt
the sudedn onset of nausea and rushed to the bathroom where he
proceeded to vomit for ~ one hour. He also had several episodes
of "soft stool" during this period though stool was not liquidy.
No blood in emesis or stool. He was diaphoretic during this
time, and after about an hour of dry heaving began to develop
chest pain located just above the manubrium to a severity of
~6.5/10. He also had an exacerbation of chronic left biceps pain
radiating to his hand to [**10-22**] severity and throbbing in
quality. At this time, his wife called EMS. He was ultimately
able to take his morning medications and reports that though he
had some dry heaving afterward he did not vomit his pills. The
chest pain began to resolve on its own and was down to 1/10
prior to EMS arrival. En route to the ED, he received a second
325 mg of aspirin and sublingual NG spray, following which the
CP fully resolved. He did have persistence of the left arm pain,
though less severe.
.
In the ED, initial VS were T 98.0, HR 130, BP 186/102 18 100% 4L
Nasal Cannula. His arm pain improved with one dose of 4 mg IV
morphine. Labwork was significant for WBC of 17.8 with
neutrophilic predominance on differential. CXR was notable for
possible early RLL pneumonia, for which he received 1 g IV vanco
and 750 mg levofloxacin for HAP given his recent
hospitalization. EKG was unremarkable. Vitals on transfer to the
floor were HR 122, BP 179/85, RR 18, O2 sat 97% on 2L. He was
admitted to medicine for treatment of pneumonia.
.
Upon transfer to the floor, he reported feeling significantly
improved. He has had no further vertigo, nausea, vomiting, or
diarrhea/loose stool since arriving in the ED. He does not feel
SOB and denies fever, chills, night sweats, shortness of breath,
cough, pleuritic chest pain or sputum production. No current CP
or arm pain.
Past Medical History:
- Hypertension (per record of home BPs, generally runs SBP
130s-140s, HR 80s-90s)
- Hypercholesterolemia
- Diabetes mellitus type II
- Hypothyroidism
- Cerebral [**Month/Year (2) 1106**] disease s/p stent placement to left carotid
[**2131-8-8**]
- Vertigo (likely BPPV) x several months (last episode > 1 month
ago)
- Lung cancer s/p surgical excision (left sided), no
chemo/radiation
- Left inguinal hernia repair
- Partial gastrectomy for ulcer ~40 years ago
- Multiple (~4) back surgeries for bone spurs (? additional
indications), no active back problems, ? hardware in place
- Accidental amputation of right thumb
- Rotator cuff surgery
Social History:
Married (second marriage) and lives with his wife. [**Name (NI) **] has one
stepson who lives nearby and two biological grown children who
live out of state. He was previously a heavy smoker (up to 4
packs per day) but quit 40 years ago. He drinks occasional beer
but keeps this to a minimum, because he continues to work as a
bus driver (cross-country charter buses) and takes jobs as they
come.
Family History:
Raised in an orphanage - does not know his biological family.
Physical Exam:
Admission Physical Exam:
GENERAL - Well-appearing elderly gentleman in NAD, comfortable,
appropriate, speaking in full sentences
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
upper and lower dentures in place, NC in place
NECK - Supple, no thyromegaly, no JVD, soft carotid bruits
appreciable bilaterally
LUNGS - No wheeze, rales, rhonchi. However, patient has
increased vocal fremitus at right base, as well as increased
sound transmission on assessment for egophony. No significant
dullness to percussion appreciated.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - No signifcant rashes or lesions. sebhorrheic keratoses on
the back
NEURO - Awake, A&Ox3, CNs II-XII grossly intact, strength/gait
not assessed
Pertinent Results:
CHEST (PORTABLE AP): [**2131-8-29**]
1. Suboptimal study, as the left costophrenic angle is not fully
included and a small left pleural effusion cannot be excluded.
Slightly increased right lower lobe opacity, early consolidation
not excluded. Suggest dedicated PA and lateral views for better
evaluation when patient able.
TTE: [**2131-8-31**]: PRE-BYPASS: 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. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
There is mild basal and mid-inferoseptal wall hypokinesis. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic aorta. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person
of the results at time of surgery.
POST-BYPASS: The patient is AV paced, on no inotropes. There is
moderate hypokinesis of the basal and mid-inferoseptal and
inferior wall of the left ventricle. Left ventricular systolic
function is unchanged. Right ventricular function is unchanged.
Mild aortic stenosis is unchanged. Mild (1+) aortic
regurgitation is unchanged. Moderate (2+) mitral regurgitation
is seen. The ascending aorta, aortic arch, and descending aorta
are intact.
.
Cardiac catheterization [**2131-8-30**]:
1) Coronary angiography of this right-dominant system
demonstrated significant left main and functional three vessel
coronary artery disease. The LMCA had 70% stenosis with severe
damping. The LAD had 60% distal stenosis with a D1 with 70%
proximal stenosis. The LCX had 70% stenosis at the origin. The
dominant RCA had 99% proximal stenosis, 99% mid stenosis, and
99% distal stenosis with left to right collaterals. 2) Limited
resting hemodynamics revealed systemic arterial hypertension
(161/72/113). 3) Left ventriculography was deferred.
.
Non-contrast Chest CT [**2131-8-30**]:
1. Moderate calcifications of the ascending aorta, the aortic
arch, the
descending aorta and the supra-aortic branches.
Moderate-to-severe coronary
calcifications. 2. Multiple non-characteristic, partly calcified
and partly non-calcified pulmonary nodules. Several sub 5-mm
ground-glass nodules. 3. Part solid and part non-solid pulmonary
nodule in the anterior aspects of the right lower lobe, with
retractile behavior with regard to the major fissure. This
nodule needs to be followed by CT in approximately six months
from now. 4. Minimal bilateral basal scarring, left more than
right, with a minimal left pleural effusion.
CXR [**2131-9-4**]: Upright PA and lateral views of the chest show a
decrease in the left pleural effusion. The abnormal contour is
likely due to pleuralthickening seen on previous examinations.
Unchanged small right pleural effusion. Heart size is large but
unchanged. Decrease in mediastinal size with no evidence for
active bleeding. Again seen are small calcified granulomas
within the right mid lung. No pneumothorax.
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname 11845**] presented to the ED with
dizziness and chest pain. He was admitted and worked up. A
repeat troponin on the evening of the day of admission ([**8-29**])
was elevated at 0.34 and CK-MB was 39. The patient was placed on
oxygen and administered a second dose of aspirin 325 mg. A
cardiology consult was called. He was placed on telemetry and
then transferred to the cardiology floor for cardiac
catheterization. Catheterization on [**2131-8-30**] demonstrated left
main and functional three vessel disease. He was continued on a
heparin drip, aspirin, clopidogrel, beta blocker, [**Last Name (un) **] and statin
in preparation for CABG. He was brought to the operating room on
[**2131-8-31**] where he underwent an urgent coronary artery bypass
graft x 3. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. He was intubated
on propofol and Neo. He had increase bloody CT drainage
required multiple blood products, he ended up returning to the
OR for exploration. Venous bleed was found and repaired. He
returned to the ICU and was hemodynamically stable. He was
extubated that evening and was found to be alert and oriented
and breathing comfortably. The patient remained neurologically
intact and hemodynamically stable he weaned from vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed. The patient was transferred to the telemetry floor on
POD#1, his CT remained for continued drainage. His wires were
removed in timely fashion and wihtout difficulty. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. Patient has a history of vertigo
(likely BPPV), in the post-op period he was acutely dizzy and
very unsteady gait as a result, he was restarted on his
meclizine. He has a hx of carotid stenosis and was restarted on
Plavix. Due to his continued dizziness, he had carotid studies
done which showed 60-69% stenosis in right and patent left
carotid stent. He was evaluated by the neurology service who
felt that his dizziness was related his vertigo that has been
aggravated by his recent surgery and that it will improve with
time. He has remained hemodynamcically stable and remains in SR.
The wound was healing and his pain was controlled with oral
analgesics. In lgiht of his dizziness, unsteady gait and safety
concerns he was discharged to neuro rehab - [**Hospital 38**] rehab on
POD# 8.
Follow up instructions arranged [**9-6**]
Medications on Admission:
Ergocalciferol (vitamin D2) 50,000 unit Cap PO every other week
Simvastatin 80 mg PO mouth daily
Losartan 100 mg by mouth daily
Meclizine 25 mg PO up to three times per day for dizziness
Levoxyl 50 mcg PO daily
Enteric Coated Aspirin 325 mg Tab (E.C.) PO Daily
Plavix 75 mg PO daily
Metformin 850 mg PO BID
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. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. losartan 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO QID (4 times
a day).
10. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
11. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
12. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO DAILY (Daily) for 4 days.
13. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
- Hypertension
- Hypercholesterolemia
- Diabetes mellitus type II
- Hypothyroidism
- Cerebral [**Location (un) 1106**] disease s/p stent placement to left carotid
[**2131-8-8**]
- Vertigo (likely BPPV) x several months (last episode > 1 month
ago)
- Lung cancer s/p surgical excision (left sided), no
chemo/radiation
- Left inguinal hernia repair
- Partial gastrectomy for ulcer ~40 years ago
- Multiple (~4) back surgeries for bone spurs (? additional
indications), no active back problems, ? hardware in place
- Accidental amputation of right thumb
- Rotator cuff surgery
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**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] on at [**Telephone/Fax (1) 170**] Date/Time:[**2131-10-8**]
1:00
Cardiologist: Dr. [**Last Name (STitle) **] on [**10-9**] @ 11am
Please call to schedule the following:
Primary Care: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD Phone:[**Telephone/Fax (1) 2205**]
Date/Time:[**2131-9-21**] 8:30
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2131-9-11**]
ICD9 Codes: 486, 4019, 2724, 2720, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1958
} | Medical Text: Admission Date: [**2121-8-8**] Discharge Date: [**2121-8-12**]
Date of Birth: [**2036-10-16**] Sex: F
Service: MEDICINE
Allergies:
lisinopril / morphine / Oxycodone
Attending:[**Last Name (un) 2888**]
Chief Complaint:
short of breath
Major Surgical or Invasive Procedure:
aortic valvuloplasty [**8-11**]
History of Present Illness:
REASON FOR TRANSFER: need for BiPAP
HISTORY OF PRESENTING ILLNESS:
84 yo with critical aortic stenosis, diastolic heart failure (EF
65%), CAD admitted to [**Hospital1 18**] for surgical evaluation of AS
transferred to CCU due to need for BiPAP.
Patient was initially admitted to [**Hospital1 **] [**Location (un) 620**] with respiratory
distress, thought to be secondary to flash pulmonary edema. She
was initially placed on BIPAP and diuresised with IV lasix.
Course at [**Location (un) 620**] was complicated by UTI with administration of
CTX. Her creatinine was 2.2 from 2.3 with diuresis. Her heart
rate was well controlled, and was continued on her home
metoprolol. She was transferred to [**Hospital1 18**] for surgical evaluation
for her aortic stenosis and possible balloon aortic
valvuloplasty.
On arrival to BIDNC discussion involving mgmt of AS ensued and
decision was made to precede with ballon angioplasty on [**8-11**]. On
[**8-10**] patient triggered twice for tachypnea. Initially patient
responded to 20mgIV lasix (received a total of 40mg IV) however
again became tachypneic and less responsive so discussion was
made to transfer to the CCU for initiation of BiPAP. Prior to
transfer patient received additional 20mg IV lasix and ipratrium
nebulizer.
Vitals on transfer were 130/50 80-90sAF RR: 24-28 98-100
3-4LNC.
On arrival to the CCU, patient minimally interactive and patient
started on BiPAP.
REVIEW OF SYSTEMS
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:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
Critical aortic stenosis
Diastolic congestive heart failure (EF 65%)
Coronary artery disease s/p MI x 2
Atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
Myelodysplastic syndrome
Diabetes mellitus
Chronic kidney disease, baseline creatinine 1.7
Peripheral [**Month/Year (2) 1106**] disease
Peripheral neuropathy
Gout
Anemia of chronic disease
Bilateral carotid artery stenosis
Dementia
Peptic ulcer disease
Osteoarthritis
Depression
Anxiety
MEDICATIONS: (home)
Januvia 100 mg PO daily
Gabapentin 100 mg PO daily
Mirtazapine 30 mg PO daily
Carvedilol 25 mg PO BID
Torsemide 60 mg PO daily
Docusate 100 mg PO daily
Pravastatin 80 mg PO daily
Clopidogrel 75 mg PO daily
Vitamin B12 500 mg PO daily
Omeprazole 20 mg PO daily
Allopurinol 200 mg PO daily
Warfarin 2 mg daily alternating with 3 mg PO daily
Folic acid 1 mg PO daily
Trazodone 100 mg PO daily
ALLERGIES:
Lisinopril (hyperkalemia)
Social History:
Lives at home. Uses a walker. Quit smoking several years ago. No
alcohol or drug abuse.
Family History:
Non-contributory
Physical Exam:
VS: T= 97.8 BP=127/57 HR=85 Afib RR=20 O2 sat=100% on Bipap
GENERAL: Depressed affect, Bipap on
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. systolic ejection murmur in RUSB
LUNGS: Scan crackles in RLL, rhonchi over left
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting edema in bilateral lower extremities,
radial pulses 1+, DP pulses 1+. Patient mildly cool to touch,
small area of warmth and erythema over dorsal aspect of L shin
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Procedures: Coronary Angiography, RLHC, Balloon aortic
valvuloplasty
Indications: Critical aortic stenosis
Staff
Diagnostic Physician [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Fellow [**Name6 (MD) **] [**Name8 (MD) **], MD
Nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6185**], RN
Nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6692**], RN
Technologist [**Doctor First Name **] Hokinson, RTR
Technologist [**First Name8 (NamePattern2) 5335**] [**Last Name (NamePattern1) 5239**], EMT,RCIS
Technical
Anesthesia: Local
Specimens: None
Catheter placement via 5 French pulmonary artery catheter
Coronary angiography using 5 French JL3.5 JR4, Dual lumen
pigtail
Blood Oximetry Information
Baseline
Time Site Hgb(gm/dL) Sat (%) PO2 (mmHg) Content (ml per dl)
10:09 AM PA 7.80 63 6.68
10:16 AM AO 7.80 100 10.61
Cardiac Output Results
Phase Fick C.O.(l/min) Fick C.I. (l/min /m2) TD
CO (l/min) 3.30 2.11
Hemodynamic Measurements (mmHg) Baseline
Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR
PCW 30 22 30 65
AO 127 46 78 62
PA 75 34 55 62
ART 100 62
RV 77 16 25 58
RA 23 28 26 58
Baseline
Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR
LV 154 27 32 62
AO 137 47 81 59
Valve Results
Contrast Summary
Contrast Total (ml)
Omnipaque (300 mg/ml) 35
Radiation Dosage
Effective Equivalent Dose Index (mGy) 386
Radiology Summary
Total Runs
Total Fluoro Time (minutes) 15.7
Findings
ESTIMATED blood loss: < 25 cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: Moderate diffuse lumen irregularities up to 50%
LAD: Moderate diffuse lumen irregularities up to 50%
LCX: Moderate diffuse lumen irregularities up to 50%
RCA: Left dominant
Interventional details
The patient was placed under general anesthesia and the
procedure
was performed under TEE guidance. The left brachial artery was
exposed by surgical technique and coronary arteriography was
performed from the left brachial artery.
The aortic valve was then crossed with a 0.014 straight wire and
a pigtail catheter was placed in the left ventricle for
simultaneous pressure recordings.
A 0.035 Amplatz SuperStiff guidewire was placed in the left
ventricle and a single balloon inflation was performed using a
18
mm Tyshak II balloon.
Immediately after balloon deflation, the patient developed
marked
hypotension. There was no evidence of aortic regurgitation and
no evidence of pericardial fluid.
CPR was initiated but the left ventricular contractility
continued to worsen.
The patient expired at 11:11 AM.
The family was notified.
Assessment & Recommendations
1. Severe aortic stenosis
2. Non obstructive but diffuse coronary artery disease
3. Unsuccessful balloon aortic valvuloplasty resulting in death
______________________________________
Brief Hospital Course:
Ms [**Known lastname 32651**] is a 85 y/o F with PMHx of critical aortic stenosis,
CAD, DM2, transferred to the CCU for worsening respiratory
distress who underwent aortic valvuplasty with procedure
complicated by refractory hypotension and asystolic arrest.
# PUMP: Patient with known critical AS and transferred to CCU
for monitoring of heart failure symptoms prior to valvuloplasty.
She was on bipap briefly and then given lasix IV prn for
diuresis. Pt was stabilized for 48hrs prior to procedure. She
underwent elective valvuloplasty on [**8-12**]. Unfortunately
immediately after balloon deflation, the patient developed
marked hypotension. Per cath report there was no evidence of
aortic regurgitation and no evidence of pericardial fluid. CPR
was initiated but the left ventricular contractility continued
to worsen. Patient died on [**8-12**]. Family was notified.
#Anxiety: Patient had lots of anxiety leading up to procdure and
was treated with zyprexa.
#LLE Cellulitis. Treated with Vancomycin in house.
CHRONIC ISSUES
# Afib. Rate controlled in house. Coumadin was held on arrival
in plan for procedure.
# CAD, Patient with known occlusion of OM1 by CTA and
calcifications of widespread coronaries s/p MIx2. In house
contineud on home plavix 75mg, pravastatin 80 mg daily
# Diabetes mellitus type 2. Maintained on ISS + lantus in house
# Peripheral neuropathy. Continued on renally dosed Gabapentin
100 mg q 24 hrs
#PUD. Continued on Omeprazole 20 mg daily
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
2. Gabapentin 100 mg PO DAILY
3. Mirtazapine 30 mg PO HS
4. Carvedilol 25 mg PO BID
hold for sbp<95, hr<55
5. Torsemide 60 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY
7. Pravastatin 80 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Cyanocobalamin 500 mcg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Allopurinol 200 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Warfarin 2 mg PO DAILY16
14. traZODONE 100 mg PO HS:PRN insomnia
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Aortic Stenosis
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 2724, 412, 5859, 4439, 2749, 311, 4241, 5990, 2762, 5849, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1959
} | Medical Text: Admission Date: [**2110-8-17**] Discharge Date: [**2110-9-4**]
Date of Birth: [**2079-8-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Tracheostomy
PICC line placement
Bronchoscopy
History of Present Illness:
Patient is a 31 yo M with no significant PMHx who presented to
OSH with complaints of weakness developing acute respiratory
failure found to have a saddle PE started on heparin gtt
trasnferred to [**Hospital1 18**] for further management.
Patient initially presented to OSH ED with complaints of
weakness, that started 5 days prior to presentation. He was
initially seen in the ED, received 2L NS for hydration, and then
discharged. He represented with porfound weakness, requiring his
brother to help him to the [**Name (NI) **]. He had a headache and body aches.
He also noted fevers, chills, and sweats, along with n/v. Per
OSH H&P, the patient reported vomiting 10-15 times. The vomitus
was non-bloody. He denied abdominal pain or diarrhea at the time
of presentation. He denied recent travel or known sick contacts.
His friend reports that he had bowel and bladder incontinence.
He denied any sore throat.
At the OSH, the patient was initially able to provide history.
Upon presentation, his temperature was 99.3. He was thought to
have pulmoanry edema for which he received lasix. Because of his
weakness and observation that he had a sensory level at T8, he
was initially thought to have a transverse myelitis. However,
MRI of the head was negative; MRI of the cervical and thoracic
spine revealed no abnormalities. He underwent an LP at the OSH;
the LP showed WBC 550,00 with 15% polys, 19% lymphs, and 16%
monos. The patient was noted to be serologically positive for
Lyme disease as well as EBV virus. Lyme CSF was negative. He was
started on IV ceftriaxone for coverage of possible Lyme
meningitis. The patient also was given IV acyclovir prior to
presentation to [**Hospital1 18**] in case the patient's clinical picture
represented EBV encephalitis. The patient was noted to have an
acute hypoxic event on [**2110-8-11**], during this OSH
hospitalization. CTA at the OSH showed saddle PE wtih probably
lower lobe pulmoanry infarcts. LENI at OSH were negative fo DVT.
The patient was intubated and started on heparin gtt. TTE showed
dilated hypokinetic RV with flattened septum and well preserved
LV function. Cardiac surgery evaluated the patient for
thrombolectomy, who did not feel that thrombolectomy was acutely
indicated. CT abdomen/pelvis at the OSH showed normal kidney,
ureters, and bladder as well as hepatomegaly and trace ascites.
Bone windows were negative.
On arrival to the MICU, the patient is intubated and sedation.
Review of systems: Unable to obtain as patient is intubated and
sedated.
Past Medical History:
None per OSH records
Social History:
Unable to obtain as patient intuabted and sedated. [**Doctor Last Name **]. Former
Marine. Patient lives with his brother's family. He does not
drink EtOH. Smoker 1 pack cigarettes every 2 days.
Family History:
Per OSH recrods. Father died of stroke at age 69.
Physical Exam:
Admission Exam
Vitals: 98.6, 177/117, 112, 24, 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild bibasilar crackles
Abdomen: soft, exquisitely TTP, + guarding, + rebound
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact,
Discharge Exam
General: Awake and alert.
HEENT: Tracks to voice., answers to yes and no questions
Neck: Trach in place with no external blood
CV: RRR. No murmurs.
Lungs: Coarse breath sounds anteriorly. No crackles or wheezes.
Abd: BS+. Soft. NT/ND.
Ext: No clubbing, cyanosis, edema.
Neuro: Hand grip equal, [**4-14**] RUE flexion. Moving feet bilaterally
more vigorously as compared with yesterday. 1+ patellar reflexes
bilaterally. [**5-15**] plantarflexion b/l.
Pertinent Results:
[**2110-8-17**] 01:45PM BLOOD WBC-17.0* RBC-3.57* Hgb-10.5* Hct-33.4*
MCV-94 MCH-29.5 MCHC-31.6 RDW-12.8 Plt Ct-364
[**2110-8-23**] 03:44AM BLOOD WBC-11.5* RBC-3.80* Hgb-11.5* Hct-34.8*
MCV-92 MCH-30.3 MCHC-33.1 RDW-12.9 Plt Ct-571*
[**2110-8-29**] 04:38AM BLOOD WBC-11.7* RBC-3.42* Hgb-10.4* Hct-31.3*
MCV-92 MCH-30.4 MCHC-33.2 RDW-15.1 Plt Ct-435
[**2110-9-4**] 03:54AM BLOOD WBC-7.8# RBC-2.87* Hgb-9.1* Hct-24.7*
MCV-86 MCH-31.5 MCHC-36.7* RDW-15.7* Plt Ct-511*
[**2110-8-17**] 01:45PM BLOOD PT-14.0* PTT-66.0* INR(PT)-1.3*
[**2110-8-25**] 03:39AM BLOOD PT-13.1* PTT-27.3 INR(PT)-1.2*
[**2110-9-2**] 05:31AM BLOOD PT-17.6* PTT-36.6* INR(PT)-1.7*
[**2110-9-3**] 04:51AM BLOOD PT-19.2* PTT-39.0* INR(PT)-1.8*
[**2110-9-4**] 03:54AM BLOOD PT-18.6* PTT-41.0* INR(PT)-1.8*
[**2110-8-17**] 01:45PM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-142
K-4.2 Cl-101 HCO3-36* AnGap-9
[**2110-8-21**] 04:24AM BLOOD Glucose-186* UreaN-24* Creat-0.6 Na-145
K-4.7 Cl-103 HCO3-34* AnGap-13
[**2110-8-24**] 03:53AM BLOOD Glucose-126* UreaN-24* Creat-0.6 Na-139
K-4.4 Cl-100 HCO3-31 AnGap-12
[**2110-8-28**] 03:03AM BLOOD Glucose-86 UreaN-23* Creat-0.6 Na-139
K-4.6 Cl-101 HCO3-27 AnGap-16
[**2110-9-1**] 04:20AM BLOOD Glucose-124* UreaN-18 Creat-0.5 Na-134
K-4.3 Cl-96 HCO3-29 AnGap-13
[**2110-9-4**] 03:54AM BLOOD Glucose-87 UreaN-24* Creat-0.4* Na-139
K-4.4 Cl-100 HCO3-33* AnGap-10
[**2110-8-17**] 01:45PM BLOOD ALT-61* AST-40 LD(LDH)-319* AlkPhos-152*
TotBili-0.3
[**2110-8-22**] 02:58AM BLOOD ALT-150* AST-39 CK(CPK)-43* AlkPhos-110
TotBili-0.2
[**2110-8-27**] 04:01AM BLOOD ALT-93* AST-32 LD(LDH)-279* AlkPhos-92
TotBili-0.5
[**2110-9-1**] 04:20AM BLOOD ALT-92* AST-28
[**2110-9-4**] 03:54AM BLOOD ALT-82* AST-41* LD(LDH)-175 AlkPhos-88
TotBili-0.5
[**2110-8-28**] 03:03AM BLOOD Lipase-12
[**2110-9-4**] 03:54AM BLOOD Albumin-3.0* Calcium-9.5 Phos-4.5 Mg-2.0
[**2110-8-17**] 01:45PM BLOOD VitB12-1446*
[**2110-8-17**] 01:45PM BLOOD TSH-1.5
[**2110-8-20**] 04:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2110-8-17**] 07:50PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2110-8-28**] 03:03AM BLOOD IgG-1038 IgA-173 IgM-200
[**2110-8-17**] 01:45PM BLOOD PEP-NO SPECIFI
[**2110-8-20**] 04:15AM BLOOD HCV Ab-NEGATIVE
[**2110-8-18**] 02:53AM BLOOD LYME BY WESTERN BLOT-Test Name
[**2110-8-18**] 02:53AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG-Test
[**2110-8-18**] 02:53AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-Test
[**2110-8-18**] 02:53AM BLOOD BARTONELLA (ROCHALIMEA) HENSELAE
ANTIBODIES, IGG AND IGM-Test
[**2110-8-18**] 02:53AM BLOOD ARBOVIRUS ANTIBODY IGM AND IGG-Test Name
MRI Head ([**2110-8-17**])
Abnormal, multifocal, T2-signal hyperintensity throughout the
spinal cord, most severe in the cervical cord as above. Similar
abnormalities are present in the brain (that study is reported
separately). This appearance is not specific though would
favour viral infection, including that with West Nile virus.
Other infectious entities may have a similar appearance, such as
encephalomyelitis related to listeria, mycoplasma, or
campylobacter, amongst others (given the element of
rhomboencephalitis on the brain imaging).
Demyelinating processes such as MS, ADEM or neuromyelitis optica
and other
vatiants are also possibilities, as are other inflammatory
disorders such as [**Last Name (un) 39722**] encephalitis. Neoplastic or
vasculitic etiologies are less likely given the appearance,
short-interval change and extent of involvement.
MRI ([**2110-8-25**])
In comparison to [**2110-8-17**] exam, diffuse bilateral T2/FLAIR
hyperintensities have significantly progressed. Differential
considerations remain infectious or non-infectious
encephalitides, possibly a paraneoplastic process.
Demyelinating process such as ADEM is felt less likely given the
lack of
improvement despite reported treatment with steroids.
Neoplastic and
vasculitic etiologies are unlikely given appearance and
distribution.
Brief Hospital Course:
Patient is a 31 year old male with no significant PMHx who
presented to OSH with complaints of weakness developing acute
respiratory failure found to have a saddle PE started on heparin
gtt trasnferred to [**Hospital1 18**] for further management with MRI
findings suggestive of ADEM treated with IV steroids/IVIG, whose
mental status and neurological function improved.
# Respiratory failure: Multifactorial; etiologies include saddle
pulmonary embolism with infarction in combination with profound
weakness from ADEM. The patient was difficult to oxygenate at
times initially. Patient underwent trach and PEG placement in
light of prolonged intubation. Improving currently, he is
tolerating trach collar at times up to 30 minutes. Speech and
swallow are also working with him. Be sure to look for signs of
carbon dioxide retention if mental status worsens on PSV as
patient could tire out at times. He is usually arousable to
voice, alert and can nod to yes/no questions, oriented X3.
# ADEMS: Patient underwent head MRI as well as full spine MRI as
part of work-up of his clinical picture, and Neurology felt that
the findings were consistent with ADEM. He was treated with 5
days of IV steroids and five more days of IVIG. The patient's
exam improved along with repeat MRI imaging showed progression
of the lesions, but this was in the context of improved exam
clinically, and no further interventions were done. His
diaphgram has improved function with today's NIF of -43. He has
slowly regaining strength in his extremities with 3/5 UE and LE
strength (R > L). Please continue to ensure he has ongoing
physical therapy.
# Pulmonary embolism: Patient with saddle embolism at the OSH.
Patient was hemodynamically stable upon arrival to [**Hospital1 18**] with
SBP 130-140s. Patient was evaluated for thrombectomy at OSH and
it was felt that pulmonary embolectomy would be counter
productive. Patient was initially continued on heparin gtt, at
one point being transitioned Lovenox /coumadin which he
currently is on with INR of 1.8 on [**2110-9-4**], 1.8 [**9-3**], [**9-2**]
1.7. Coumadin was uptitrated to 12.5 mg from 10 mg daily on
[**9-2**]. If INR < 2.0 on [**2110-9-5**], please consider increasing
coumadin to 15 mg daily. Continue Lovenox bridge until
therapeutic INR.
# Pericarditis: He was noted to have diffuse ST elevations on
[**2110-9-3**]. He had not chest pain. They resolved with
ibuprofen 600 mg TID.
# Fevers of unknown etiology. Resolved for past few days.
Work-up at the OSH included: negative HIV; weakly positive Lyme
IgM, negative Lyme CSF, negative Monospot, Negative Babesia,
Negative anaplasma, positive EBV CSF serology. ID and neurology
were consulted upon patient's arrival. Repeat lumbar puncture
was done; culture data returned showing no growth and serologies
were negative. The patient was initially on broach spectrum
antibiotics upon ID recommendations, but with negative CSF
culture data, negative CSF data antiobiotics were then peeled
back. His fevers were attributed to ADEM and resolved week prior
to discharge
# Elevated LFTs: There was concern for viral hepatitis, though
viral serologies at [**Hospital1 18**] returned negative. RUQ ultrasound did
not show concerning findings. LFTs were trended through the
admission and remained stable.
Medications on Admission:
Medications HOME:
None
.
Medications on TRANSFER:
--Acyclovir 800mg ONCe
--Ceftriaxone 2grams IV daily
--Famotidine 20mg [**Hospital1 **]
--Heparin GTT
--Ipratropium/albuterol 6-8 puffs QID
--Propofol 1000mg GTT
--Acetaminophen 650mmh q4hours PRN PR
--Fentanyl 25mcg q1hours PRN pain
--Zofram 4mg IB q6hours PRN nausea
Discharge Medications:
1. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation.
3. Docusate Sodium (Liquid) 100 mg PO BID
hold for loose stools
4. Enoxaparin Sodium 100 mg SC Q12H
5. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID
6. Pantoprazole 40 mg IV Q24H
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 1 TAB PO BID:PRN constipation
9. Warfarin 12.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
ADEM
Saddle Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure to care for you at the hospital.
.
You were admitted for altered mental status and weakness. You
were found to have a encephalitis and lung blood clot. You
needed to be intubated during the admission and were cared for
in the ICU. You were treated for the encephalitis with IVIG and
are currently improving from a neurologic perspective. Your
respiratory status is also stable and slowly imroving.
.
Your physcial therapy and rehab. will continue at a specialized
facility.
Followup Instructions:
Please follow up with your primary care physician after
discharge
ICD9 Codes: 2762, 5180, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1960
} | Medical Text: Admission Date: [**2135-11-12**] Discharge Date: [**2135-11-17**]
Date of Birth: [**2104-8-11**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
HD line removal ([**2135-11-12**])
Temporary HD line placement ([**2135-11-15**])
Post-pyloric feeding tube placement ([**2135-11-16**])
History of Present Illness:
31 y/o M with biliary atresia s/p liver [**Month/Day/Year **] at age 4
currently listed for liver/kidney [**Month/Day/Year **], ESRD on HD who was
transferred from OSH [**2135-11-12**] with fevers, tachycardia, and
abdominal pain. Patient reported diffuse abdominal pain, worse
in RUQ x 4 days that came on suddenly then radiated to right
chest. The day prior to transfer he had coffee-ground emesis and
black diarrhea. In the ED patient was tachycardic to 140-150s
with SBP 100's and spiked a fever to 102.4. Patient was
empirically started on vancomycin and zosyn. CXR demonstrated
bilateral effusions and no infiltrate. CTA torso demonstrated no
PE, but loculated ascites with mass effect, patent portal vein,
mod-large b/l pleural effusions and jejunal wall thickening of
unknown significance. Following 3L of IVFs patient remained
tachycardia and was consequently admitted to the MICU for
concern of sepsis.
.
During his MICU stay blood cultures returned positive for
klebsiella pneumoniae and consequently his HD line was removed.
Cultures were pan-sensitive consequently vanc/zosyn was narrowed
to ceftriaxone. Additional infectious work up included: negative
influenza, negative c. diff, negative SBP, negative urine
culture. Patient had no episodes of coffee ground emesis or
melena and HCT remained stable (hemoconcentrated on admission).
Tachycardia was an ongoing problem. The MICU team attempted
small boluses of fluid with only mild improvement in his HR.
Today 6 mg adenosine was given to investigate whether rhythm was
SVT but had no effect. During his admission the patient began
complaining of back pain and a MRI spine was ordered to rule out
epidural abscess prior to transfer.
.
Upon evaluation of the patient he states his abdominal pain has
completely resolved since admission. He denies any fevers,
chills, emesis or bloody bowel movements. He states his back
pain started on saturday ("after all the fluids") but has now
improved. The pain was [**4-3**] and non-localized ("my entire
back"). Patient describes difficulty ambulating due to lower
extremity edema only. No changes in his bowel movements (loose
at baseline). The patient is oriented x 3 and states he feels
much better than on admission.
.
Of note, patient was recently admitted [**10-3**] and diagnosed with
H1N1, SVT responsive to adenosine, multifocal PNA treated with
vancomycin, zosyn, and levofloxacin, possible sick euthyroid and
acute on chronic renal failure felt to be due to ATN requiring
HD and relisting for a kidney [**Month/Year (2) **].
.
Past Medical History:
-biliary Atresia s/p liver [**Month/Year (2) **] 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. Has one child with a prior girlfriend. Does not work.
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Current: 99.4, HR 127, BP 132/89, RR 22, SaO2 98%
Last 24 hours: T 97-100.2, Tm 100.2; BP 104-145/66-90. HR
119-137 (with episodes into the 140s); RR 19-22; O2 93-97% on
RA.
GENERAL: Cachectic, comfortable, NAD
HEENT: MM dry, no LAD, neck supple
CARDIAC: Tachycardic, regular, No MRG
LUNG: Decreased breath sounds in bases bilaterally, no crackles,
wheezes.
ABDOMEN: Moderately distended, not tense, BS+, no tenderness. No
rebound or gaurding. Midline and RUQ surgical scar. Multiple
excoriations on abdomen.
EXT: 3+ pitting edema in LE's bilaterally (R > L)
NEURO: CNII-XII intact. Motor [**3-29**] upper and lower.
.
DISCHARGE
Vitals: Current: 99.0, tmax 99.7, HR 109-111, BP 114-126/74-78
(10-20 mmHg higher than yesterday), RR 20-22, SaO2 97%
IO Last 8 --> i = 240 ; o = 200
Last 24 --> i = 490 ; o = 200 + 4BM
Ultrafiltration - 2Litres negative
GENERAL: Cachectic, NAD
HEENT: MM dry, no LAD, neck supple
CARDIAC: Tachycardic, regular, No MRG
LUNG: Decreased breath sounds in bases bilaterally, no crackles,
wheezes.
ABDOMEN: distended, not tense, BS+, no tenderness. No rebound or
gaurding. Midline and RUQ surgical scar. Multiple excoriations
on abdomen.
EXT: 3+ pitting edema in LE's bilaterally, excoriations on arms
NEURO: CNII-XII intact. Motor [**3-29**] upper and lower.
SKIN: blanching erythema over left flank
Pertinent Results:
Admission
[**2135-11-12**] 06:30AM BLOOD WBC-9.5 RBC-4.13* Hgb-12.0* Hct-37.9*#
MCV-92 MCH-29.0 MCHC-31.6 RDW-17.7* Plt Ct-203
[**2135-11-12**] 06:30AM BLOOD Neuts-82* Bands-14* Lymphs-1* Monos-0
Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2135-11-12**] 12:00PM BLOOD PT-15.2* PTT-32.7 INR(PT)-1.3*
[**2135-11-12**] 06:30PM BLOOD Glucose-108* UreaN-23* Creat-2.2* Na-133
K-4.1 Cl-107 HCO3-19* AnGap-11
[**2135-11-12**] 06:30AM BLOOD ALT-21 AST-63* CK(CPK)-84 AlkPhos-486*
TotBili-0.6
[**2135-11-12**] 06:25AM BLOOD Glucose-99 Lactate-2.2* Na-137 K-4.0
Cl-106
Discharge
[**2135-11-17**] 07:45AM BLOOD WBC-9.9 RBC-2.98* Hgb-8.4* Hct-26.8*
MCV-90 MCH-28.0 MCHC-31.2 RDW-17.9* Plt Ct-295
[**2135-11-17**] 08:45AM BLOOD PT-16.0* PTT-34.0 INR(PT)-1.4*
[**2135-11-17**] 04:45PM BLOOD Glucose-115* UreaN-10 Creat-1.4* Na-137
K-3.7 Cl-101 HCO3-30 AnGap-10
[**2135-11-17**] 04:45PM BLOOD Calcium-6.9* Phos-1.3* Mg-1.4*
[**2135-11-14**] 06:14AM BLOOD TSH-1.1
[**2135-11-14**] 06:14AM BLOOD Free T4-0.79*
[**2135-11-17**] 07:45AM BLOOD Vanco-17.0
[**2135-11-17**] 07:45AM BLOOD tacroFK-4.5*
Wound Culture
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Blood Culture
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CT ABD/PELVIS
1. Severely limited study due to technique and timing of
contrast, for
evaluation for pulmonary embolism. No evidence of pulmonary
embolism in the
main or primary branches of the pulmonary artery.
2. Increased intra-abdominal ascites, with loculation and mass
effect on the intra-abdominal organs. Cirrhosis. Patent portal
vein. Perisplenic varices, compatible with portal hypertension.
3. Pulmonary edema. Moderate-to-large bilateral pleural
effusions with
associated atelectasis.
4. Two enlarged right internal mammary lymph nodes and right
greater than
left gynecomastia.
5. Mild jejunal wall thickening of unclear etiology. Eneteritis
is a
consideration. Some of these loops are mildly dilated but there
is not
obstruction.
6. Stable pneumobilia and mild common bile duct dilatation
status post
choledocojejunostomy.
7. Stable enlarged mesenteric lymph nodes.
MRI L AND T
IMPRESSION:
1. No abnormal bone marrow signal to suggest acute fracture or
osteomyelitis.
2. Bilateral L5 spondylolysis associated with proliferative bony
changes
extending into the right posterior epidural space at L4-5 which
combines with additional degenerative changes to create severe
canal narrowing.
3. Small bilateral fluid clefts at the level of spondylolysis
without a
drainable collection. Early infection within the posterior soft
tissues
cannot be fully excluded and continued followup is recommended.
Brief Hospital Course:
31 yo M w/ ESRD, ESLD s/p liver [**Month/Day/Year **] presented with
abdominal pain and tachycardia, found to have klebsiella
pneumoniae bacteremia, MSSA line site infection vs colonization
and, later cellulitis. He received ultrafiltration, HD, a
rational antibiotic regimen and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-intestinal tube for
feeding
.
# Klebsiella pneumoniae bacteremia
Presumably from his [**Last Name (NamePattern4) 2286**] line. It was pulled and replaced.
Ultimately he was discharged on Cefazolin 2 g qHD.
.
# Likely MSSA Line infection vs colonization: Pt had low grade
temperatures after transfer from MICU. His line site culture
grew MSSA and it was thought that his temperatures were related
to an untreated gram positive infection. After initiation of
cefazolin and vancomycin (below) were started, his temperature
normalized, his HR declined and his BP rose. Discharged on
Cefazolin.
.
# Rash: Discovered on Hospital day 3 and considered a cellulitis
with a hospital acquired pathogen that emerged despite
ceftriaxone. Discharged on vanc
.
# Atrial Tachycardia: Fluid unresponsive, normal TSH,
unresponsive to adenosine. Improved over time. Patient
discharged on 12.5 [**Hospital1 **] Metoprolol
.
# Lower back pain: Prior to transfer MICU team ordered MRI to
r/o epidural abscess. Unlikely based on improving back pain,
non-tender to palpation along spine, pain non-localized. No
deficits on neuro exam. L-spine wit severe DJD. Discharged on
lidocaine patches and oxycodone
.
#Pleural effusions: Albumin is less than 1 and ascites present.
Likely hepatic hydrothorax. Patient is responding to Abx,
unlikely effusions are infectious source. Patient breathing
comfortably on room air.
.
#ESLD: MELD 24 on [**11-16**]. SBP work-up negative. Persistent
concern for chronic rejection. Elevated INR may be partly
nutritional. A dobhoff was placed and the patient was discharged
with tube feeds at 45cc/hr. He was given phosphorus and
instructions for the prevention of refeeding syndome
#ESRD: [**12-27**] post-infectious glomerulonephritis, was started on HD
last admission due to ATN. Continue HD
TO BE FOLLOWED
1) Pt asked to see PCP every [**Month/Day (2) **] for MELD labs
2) Pt asked to have basic chemistries checked for surveillance
of refeeding syndrome
Medications on Admission:
asix 20mg PO daily
Lactulose 30-60cc PO QID
Reglan
Sucralfate
Tacrolimus 0.5mg PO BID
Oxycodone
Buproprion
Caltrate D
.
On transfer:
Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
Adenosine 6 mg IV ONCE
Acetaminophen 500 mg PO/NG ONCE MR1
HYDROmorphone (Dilaudid) 0.2 mg IV Q6H:PRN pain
CeftriaXONE 1 gm IV Q24H
Tacrolimus 0.5 mg PO Q12H
Lidocaine 5% Patch 1 PTCH TD DAILY
OxycoDONE (Immediate Release) 5-10 mg PO/NG Q6H:PRN pain [**11-13**] @
Pantoprazole 40 mg PO Q12H
Sarna Lotion 1 Appl TP PRN Itching
Vitamin D 400 UNIT PO/NG DAILY
Calcium Carbonate 500 mg PO/NG DAILY
Sucralfate 1 gm PO QID
Metoclopramide 10 mg PO/IV QID:PRN nausea
Lactulose 30 mL PO/NG Q8H:PRN constipation
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO four times a
day as needed for constipation.
2. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea.
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
4. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
7. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) topical
application Topical four times a day as needed for itching.
8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One
(1) Patch Topical once a day: Leave on for 12 hours, off for 12
hours.
Disp:*30 Patches* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous QHD: To be given at every Hemodialysis.
12. Cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous
QHD: To be given at every Hemodialysis.
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Outpatient Lab Work
Every [**Month/Year (2) 766**]. Check PT/INR, Sodium, Creatinine, Albumin and
bilirubin. Fax results to [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 697**].
15. Phos-NaK 280-160-250 mg Powder in Packet Sig: Two (2)
Pakcets PO twice a day.
Disp:*120 Packets* Refills:*2*
16. Outpatient Lab Work
Please check Chem 10 on Saturday [**11-19**] at HD and fax
results to [**Telephone/Fax (1) 697**]. Thanks.
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary Diagnoses:
1. Klebsiella septicemia
2. MSSA cellulitis at former HD line site
3. Hospital-acquired cellulitis of the back
4. Tachycardia
5. Severe spinal DJD and canal narrowing at L4-5
.
Secondary Diagnoses:
- Cirrhosis / ESLD
- ESRD on HD
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 MICU at [**Hospital1 18**] for abdominal pain, back
pain, bleeding, and sepsis, and you were found to have several
concurrent infections including Klebsiella bacteremia, MSSA
cellulitis from at the site of your hemodialysis catheter, and
back cellulitis that was thought to be hospital-acquired. You
were treated with IV Ceftriaxone for the Klebsiella bacteremia,
which was changed to Cefazolin with [**Hospital1 2286**], and then started
on Vancomycin with [**Hospital1 2286**] for treatment of your cellulitis.
You will continue to receive these medications for an additional
10 days, dosed each time at [**Hospital1 2286**]. Your hemodialysis line was
pulled and you were given a "line holiday" before it was
replaced. You received hemodialysis on your regular schedule, as
well as extra ultra-filtration given your fluid overload.
.
Given your bleeding your home Omeprazole was increased to twice
daily. You were also found to have severe degenerative joint
disease of the lumbar spine with severe spinal canal narrowing
on MRI that will need close follow-up of small bilateral fluid
clefts. You were started on a Lidoderm patch daily for control
of the back pain. Finally, your heart rate was found to be
elevated and you were started on a new medication called
Metoprolol to decrease the heart rate to the normal range.
.
MEDICATION CHANGES:
1. START Vancomycin 1gram IV at Hemodialysis x10 days
2. START Cefazolin 2grams IV at Hemodialysis x10 days
3. START Metoprolol 12.5mg by mouth twice daily
4. START Lidoderm patch daily for back pain
5. CHANGE Omeprazole to 40mg by mouth twice daily
.
Every [**Hospital1 766**] you must have labs drawn. You can do that here - at
the liver clinic - or at your PCP's office. Check PT/INR,
Sodium, Creatinine, Albumin and bilirubin. Fax results to
[**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 697**].
Followup Instructions:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2135-11-19**]
12:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2135-11-23**] 9:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2136-1-16**] 9:00
Completed by:[**2135-11-18**]
ICD9 Codes: 5856, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1961
} | Medical Text: Admission Date: [**2106-11-3**] Discharge Date: [**2106-11-6**]
Date of Birth: [**2030-2-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD on [**2106-11-3**]
History of Present Illness:
This is a 76 yo M with ETOH cirrhosis, HCC, grade III varicies
who presented to the ED with 5-6 episodes of BRBPR followed by
black stools. Denied n/v. Denied abdominal pain. Had mild
lightheadedness with the stools but none after that.
.
In the ED, vital signs were intially T 98, BP 120/44, HR 59; RR
18; O2sat 100% RA. 2 large bore PIVs were placed and he was
given 1L IVF, IV pantoprazole. GI consult suggested octreotide
bolus and then gtt. No NG lavage given varicies.
.
He continues to deny pain, CP, SOB, abdominal pain, headache,
nausea or vomiting, weakness, lightheadedness, headache, vision
changes.
.
Past Medical History:
-ETOH cirrhosis- quit drinking in [**2106-4-4**]
-HCC s/p radiofrequency ablation
-grade III varicies
-portal vein thrombosis - occlusive; not on anticoagulation
given high grade varicies
-DM2
Social History:
Married and lives with son. Denies smoking, alcohol or drug use.
States last alcohol was in [**Month (only) 547**] of this year.
Family History:
No family history of liver disease
Physical Exam:
Vitals: BP 122/35, HR 85, RR 19, O2sat 100% RA
General: elderly male in NAD sitting up in bed
HEENT: pale conjunctiva, anicteric sclera, MMM, no JVD
CV: RRR, 2/6 systolic murmur
Lungs: crackles at left base; otherwise clear
Abdomen: +BS, soft, NT, distended with mild ascites, well healed
laproscopic incisions, occasional healing bruises across abdomen
Extremities: venous stasis changes to BLE; DP 1+ symmetric; no
edema; no asterixis
Pertinent Results:
Admission Labs:
[**2106-11-3**] 10:30AM PLT COUNT-210
[**2106-11-3**] 10:30AM NEUTS-57.8 LYMPHS-32.5 MONOS-6.6 EOS-2.1
BASOS-1.0
[**2106-11-3**] 10:30AM WBC-7.8 RBC-2.39* HGB-7.9* HCT-24.5* MCV-102*
MCH-33.0* MCHC-32.2 RDW-17.4*
[**2106-11-3**] 10:30AM ALBUMIN-3.3*
[**2106-11-3**] 10:30AM LIPASE-105*
[**2106-11-3**] 10:30AM ALT(SGPT)-42* AST(SGOT)-44* LD(LDH)-273* ALK
PHOS-167* AMYLASE-80 TOT BILI-0.7
[**2106-11-3**] 10:30AM estGFR-Using this
[**2106-11-3**] 10:30AM GLUCOSE-118* UREA N-47* CREAT-1.5* SODIUM-140
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13
[**2106-11-3**] 10:34AM HGB-8.2* calcHCT-25
[**2106-11-3**] 10:57AM PT-14.1* PTT-29.9 INR(PT)-1.3*
[**2106-11-3**] 02:28PM HGB-8.3* calcHCT-25
[**2106-11-3**] 05:06PM PT-13.6* PTT-31.2 INR(PT)-1.2*
[**2106-11-3**] 05:06PM PLT COUNT-130*
[**2106-11-3**] 05:06PM WBC-3.8*# RBC-2.04* HGB-6.6* HCT-20.8*
MCV-102* MCH-32.5* MCHC-31.9 RDW-17.3*
[**2106-11-3**] 05:06PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-2.0
[**2106-11-3**] 05:06PM GLUCOSE-102 UREA N-39* CREAT-1.3* SODIUM-143
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-20* ANION GAP-16
[**2106-11-3**] 10:29PM HCT-29.0*#
.
EGD: Findings: Esophagus:
Protruding Lesions 4 cords of grade III varices were seen
starting at 25 cm from the incisors in the lower third of the
esophagus and middle third of the esophagus. There were stigmata
of recent bleeding.
Stomach: Normal stomach.
Duodenum:
Excavated Lesions A single acute superficial non-bleeding 7mm
ulcer was found in the first part of the duodenum. Cold forceps
surveillance biopsy samples were retrieved from the stomach
Other procedures: 6 bands were successfully placed in the lower
third of the esophagus.
.
Liver US [**2106-11-3**]: IMPRESSION: Limited evaluation of cirrhotic
liver with partially occlusive thrombus of the main portal vein
redemonstrated. Evidence of portal hypertension including
splenomegaly and ascites.
.
CT Ab/Pelvis: IMPRESSION:
1. No evidence of enhancement in the region of patient's
previously seen left-sided hepatic mass lesion to suggest
residual tumor. No definite new enhancing lesions identified.
Atrophy of the left lobe of the liver distal to site of
radiofrequency ablation again seen.
2. Progression of patient's portal venous, splenic, and SMV
thrombosis. Interval increase in amount of free abdominal and
pelvic free fluid.
.
Discharge Labs:
[**2106-11-6**] 12:35PM BLOOD WBC-5.0 RBC-3.03* Hgb-9.7* Hct-29.0*
MCV-96 MCH-32.0 MCHC-33.4 RDW-18.9* Plt Ct-143*
[**2106-11-6**] 12:35PM BLOOD Glucose-175* UreaN-20 Creat-1.3* Na-135
K-3.7 Cl-103 HCO3-21* AnGap-15
[**2106-11-5**] 06:35AM BLOOD ALT-28 AST-27 LD(LDH)-209 AlkPhos-116
TotBili-1.2
[**2106-11-6**] 12:35PM BLOOD Calcium-8.2* Phos-3.5 Mg-2.1
[**2106-11-5**] 06:35AM BLOOD ALT-28 AST-27 LD(LDH)-209 AlkPhos-116
TotBili-1.2
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2106-11-5**]): POSITIVE BY
EIA.
Brief Hospital Course:
# GI bleeding: Patient was transferred from the ED to the MICU.
At that time he was transfused 2 units PRBC in total. Patient
received an EGD [**2106-11-3**] showing 4 cords of grade III varices
with three bands placed in lower third of esophagus. There was a
duodenal ulcer noted without biopsies taken. Patient had one
melanotic stool the day of transfer and one guaiac positive
without frank blood but remained hemodynamically stable. Patient
was placed on an octreotide gtt. Patient was kept at a goal HCT
of 25-27 to avoid increasing his portal pressures. He will
receive a total of 7 days ciprofloxacin for SBP prophylaxis. He
was restarted on nadolol on the day of transfer to medicine
floor. VS on transfer T 99 HR 61 BP 118/56 RR 19 O2sat 100%RA.
On day of discharge, patient was found to be H. pylori positive.
He is discharged with 2 weeks of antibiotics for treatment of
his infection. Prior to discharge, he was restarted on his
diuretics and remained hemodynamically stable.
.
# ETOH cirrhosis/Hepatocellular carcinoma: Known 3-4cm lesion
s/p radioablation in [**9-10**]. LFTs remained at baseline. CT of
abdomen demonstrating no new lesions or evidence of residual
tumor. Continued on diuretics and nadolol as above.
.
# Acute renal failure: Creatinine initially up to 1.5 on
admission with baseline around 1. Likely prerenal given bleeding
with elevated BUN as well. Improved to 1.3 at time of discharge.
.
# DM2: On ISS as inpatient. Restarted on outpatient glipizide
at time of discharge.
.
# Code: Full
.
# Communication: Son [**Name (NI) **] [**Telephone/Fax (1) 58057**]
Medications on Admission:
GLIPIZIDE 5 mg--1 tab(s) by mouth daily
LISINOPRIL 5 mg--2 tablet(s) by mouth daily
NADOLOL 20 mg--1 tablet(s) by mouth daily
PRILOSEC 20 mg--1 capsule(s) by mouth once a day
SPIRONOLACTONE 100 mg--1 tablet(s) by mouth daily
LASIX 20 mg--1 tablet (s) by mouth daily
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. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
5. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 26 doses.
Disp:*52 Tablet(s)* Refills:*0*
6. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 26 doses.
Disp:*104 Capsule(s)* Refills:*0*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 3 bowel movements daily.
Disp:*2700 ML(s)* Refills:*0*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: GI bleed
Secondary diagnoses: Alcoholic cirrhosis, Hepatocellular
carcinoma, grade III esophageal varices, portal venous
thrombosis, type II diabetes mellitus
Discharge Condition:
Stable
Discharge Instructions:
You were admitted after several episodes of bright red blood in
your stools. While you were here, you had an EGD that showed
severe varices and these were banded. In addition, you had an
ulcer in your duodenum. You were found to be positive for the
bacteria H. Pylori, and you are being treated for 2 weeks for
this infection.
If you develop any more bright red blood in your stools, dark
tarry stools, dizziness or lightheadedness, chest pain,
shortness of breath, vomiting blood, or any other symptom that
concerns you, please go to the nearest Emergency Department or
call your doctor as soon as possible.
Please take your medications as directed.
Followup Instructions:
It is very important that you keep the following appointments:
Provider: [**Name10 (NameIs) **] WEST,ROOM TWO GI ROOMS Date/Time:[**2106-11-11**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2106-11-11**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2106-11-17**]
11:20
ICD9 Codes: 5849, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1962
} | Medical Text: Admission Date: [**2187-7-7**] Discharge Date: [**2187-7-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer to MICU for RP bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]yoW with h/o Afib on coumadin, remote right hip total
arthroplasty, severe aortic stenosis, SSS s/p pacer, presented
to OSH ED with one day right hip pain. He first noted aching
pain on rising from bed with inability to walk secondary to
pain. He denied any recent trauma or fall. He is s/p right hip
arthroplasty 10-15years ago. At the OSH HR 72 BP 140/77 RR 18.
He was found to have INR 19.3, raising concern for
intraarticular or retroperitoneal bleed. X-ray and CT abdomen
and pelvis were unremarkable. He was treated with 5mg SC and 5mg
po Vitamin K and 2units FFP prior to transfer to [**Hospital1 18**]. In [**Hospital1 18**]
ED T 97.8 HR 72 BP 169/89 RR 19 97%RA. CT right hip showed 7cm
hematoma extending from iliac [**Doctor First Name 362**] to level of right hip capsule
without evidence of hemarthrosis. CXR was consistent with CHF.
He was admitted to the floor where he remained hemodynamically
stable. His Hct, however, dropped from baseline 36 to 26 on
admission to 22 this morning with INR 3.4. He is admitted to the
MICU for further monitoring.
Past Medical History:
atrial fibrillation
s/p right total hip arthroplasty 10-15yrs ago
hypertension
dyslipidemia
h/o resected melanoma
sick sinus syndrome s/p pacer placement
mod AS; AV area 0.6cm2, AV gradient mean 30, peak 45
chronic Anemia (hct 35 in [**10/2186**])
Social History:
lives with his wife, half year in [**Name (NI) 6687**], half year in
[**State 108**]. retired from oil refineries
Denies tob use, illicits
Occasional alcohol
Family History:
non-contributory, MGF d. stroke at 42yrs
Physical Exam:
PE: T 97.0 HR 90 (78-90) BP 164/90 (138-164/70-90) RR 22 97%RA
GEN: comfortable, cooperative, except regarding foley placement,
oriented and alert, NAD
HEENT: PERRL, anicteric, MMM, OP clear
Neck: supple, no LAD, JVP 8-9cm
CV: RRR, III/VI SEM at RUSB
Resp: CTAB with one wheeze right apex, no crackles
Abd: +BS, soft, NT, ND, no masses, no HSM
Ext: pain right hip to palpation, no mass, no LE edema
Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout,
sensation intact grossly
Pertinent Results:
[**2187-7-7**] 09:51PM HCT-25.2*
[**2187-7-7**] 09:51PM PT-18.8* PTT-31.7 INR(PT)-1.8*
[**2187-7-7**] 06:51AM GLUCOSE-103 UREA N-18 CREAT-1.2 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
[**2187-7-7**] 06:51AM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.3
[**2187-7-7**] 06:51AM WBC-7.6 RBC-2.84* HGB-7.6* HCT-22.8* MCV-80*
MCH-26.6* MCHC-33.3 RDW-16.5*
[**2187-7-6**] 09:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0
LEUK-NEG
[**2187-7-6**] 09:19PM DIGOXIN-0.7*
Brief Hospital Course:
[**Age over 90 **] y/o man with h/o Afib, aortic stenosis, SSS s/p pacer, s/p
remote right total hip arthroplasty with right iliac crest
hematoma in setting of supratherapeutic INR (19).
.
1. Hematoma: He appears to have developed a retroperitoneal
bleed by CT scan read as a right iliacus muscle hematoma, which
most likely developed spontaneously in the setting of a
supratherapeutic INR. There did not appear to be any
hemarthrosis. He did not have any history of trauma to the hip
and his last surgery was 10-15 years ago. Vascular surgery was
consulted and followed Mr [**Known lastname 69679**] throughout his hospitalization.
He was transfused, in total, 4 units of FFP and 4 units of
pRBC, for a discharge Hct of 31.5. His coumadin was d/c on
admission, and he his INR subsequently decreased to 1.4 on
discharge. He was advised not to continue his coumadin until he
was seen by his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 2429**], and they would make a decision
together about whether or not the risks outweigh the benefits of
continuing his coumadin. We monitored his UOP and BUN/Cr for
any obstruction secondary to the hematoma. He had no issues in
regards to this.
.
# CHF: EF 60% with severe AS
The patient did have flash pulmonary in the ED with an initial
1L NS bolus, and was diuresed secondary to this. He was
monitored carefully during his blood transfusions for signs of
fluid overload, and he received Lasix after his units of blood
and FFP. He diuresed appropriately with good UOP, and did not
develop any shortness of breath during his transfusions.
.
# Agitation: The patient was intermittently confused and
agitated, especially at night. He required some Haldol for one
night, and subsequently only required a 1:1 sitter to keep him
safe. He was otherwise alert and oriented times three.
.
# Afib: Continue digoxin, which had a therapeutic level during
hospitalization; holding anticoagulation, V-paced.
.
# HTN: His amlodipine was held during his acute bleeding event
to prevent hypotension and to monitor the bleeding better. It
was restarted upon discharge.
.
# Hyperlipidemia: Atorvastatin was continued during the
hospitalization.
.
# Dementia: Aricept was continued throughout his
hospitalization.
.
# FEN: The patient was maintained NPO until he stabilized, when
he tolerated a regular diet well. His electrolytes were
repleted as needed.
.
# Insomnia: Benadryl prn as pt home regimen
.
# PPx: pneumoboots; bowel regimen given oxycodone pain control
.
# Communication: patient and his wife
wife: [**Name (NI) **] [**Name (NI) 69679**] [**Telephone/Fax (1) 69680**] (h), [**Telephone/Fax (1) 69681**] (c)
daughter: [**Name (NI) 17236**] [**Name (NI) 69679**] [**Telephone/Fax (1) 69682**]; [**Telephone/Fax (1) 69683**] (c)
daughter: [**Name (NI) **] [**Telephone/Fax (1) 69684**]
.
# Code: DNR/DNI -confirmed with patient with daughters present
Medications on Admission:
Coumadin 5mg, 2.5mg QOD
Lipitor 10mg daily
Norvasc 2.5mg daily
Digoxin 0.25mg daily
Lasix 40mg daily
Aricept 10mg daily
Discharge Medications:
Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Norvasc 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 65460**] [**Hospital **] Hospital Home Care
Discharge Diagnosis:
Primary: Retroperitoneal bleed
Secondary: Aortic stenosis
Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
Please do not continue to take coumadin or warfarin until
discussion with Dr. [**First Name (STitle) 2429**].
.
[**Name8 (MD) **] MD if you develop fever, chills, worsening pain in your
hip, dizziness, bleeding from nose, shortness of breath, or any
other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 22442**] Call to schedule
appointment within the next week. You should plan to have your
hematocrit and INR checked.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 4280, 4241, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1963
} | Medical Text: Admission Date: [**2208-4-27**] Discharge Date: [**2208-4-30**]
Date of Birth: [**2147-7-28**] Sex: M
Service: MEDICINE
Allergies:
Abacavir / ritonavir / Lyrica
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Chief Complaint: AMS, fever, hypoxia, renal failure
Reason for MICU transfer: AMS requiring intubation
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
This is a 60 year old gentleman with a history of HIV last cd4
in [**1-25**] was 783 and VL undetectable who arrives with respiratory
distress, fevers x1day. Also having myoclonic jerks similar to
those seen on two previous admissions, for which no etiology was
found but presumed to be [**12-17**] metabolic derangements. Initial
hypoxic to 60-70's on RA, febrile to 101.8 (R). Labs show new
renal failure. During ED stay, patient remains febrile and
becomes increasingly altered/combative.
.
Of note, patient was most recently admitted for myoclonic jerks
and altered mental status from [**Date range (1) 96656**]. He was found to be
in renal failure, positive opioid tox screen. Renal hypothesized
ritonavir-induced nephrotoxicity was initial insult (ritonavir
crystals in urine), worsened by lisinopril and prerenal azotemia
in setting of insufficient PO intake and diarrhea. On discharge
all HAART was discontinued, as was Lyrica. Morphine and Lyrica
also held during hospitalization. Per OMR, Lyrica and Morphine
were re-prescribed on [**2208-4-7**]. There are no recent notes in OMR
documenting recent healthcare, and his wife could not be reached
by phone in the MICU.
.
In the ED, initial VS were: 101.0 124 124/63 16 74% RA. Initial
physical exam was significant for tremulousness and combative
behavior. Initial labs were signficant for cr 4.9 (baseline
1.2), K+ 4.2, CK 4619, MB 58 and MBI 1.3. LFTs were mildly
elevated with a normal t.bili and lipase. A serum tox screen was
negative and urine tox screen positive for opiates. A lactate
was 1.7. A UA was negative. An EKG demonstrated sinus
tachycardia. Given his elevated CK, MB and troponin (despite
flat MBI and presence of [**Last Name (un) **]), a heparin gtt was started for
empiric management of ACS. Cards recommends continuing to trend
enzymes. His oxygen saturations on arrival were in the 70s which
improved with a non-rebreather. A PE was entertained but could
not be addressed with a CTA [**12-17**] [**Last Name (un) **], thus heparin was further
pursued. A CXR revealed evidence of a pneumonia and given
hypoxia and h/o COPD, he was started on vancomycin and cefepime
for management of a pna and IV solumedrol and albuterol and
ipratropium nebs for a copd exacerbation. He became more
combative over time and the patient was ultimately intubated for
safety after ativan and haldol did not improve his mental
status. An initial ABG demonstrated 7.24/70/93 and subsequent
was 7.24/62/99. Vent settings on transfer were: Fio2 100% PEEP
5, TV 550. An LP was performed and results were pending at the
time of transfer. A CT head demosntrated no findings. He
received 4 L NS prior to transfer. Vitals on transfer: 134/97,
64, 22
.
On arrival to the MICU, vitals are: 98.0 144/105 22 100% (vent
settings: FiO2 50% PEEP 5 TV 550). Patient was agitated and
attempting to self-extubate so was bolused with fentanyl and
midazolam.
.
Review of systems: unable to obtain, patient intubated
Past Medical History:
- COPD: workup on [**11-23**] at [**Hospital1 **] with PFTs, which demonstrated
obstructive deficit with partial reversibility during
bronchodilator testing. FEV1 67% predicted value.
- HIV: diagnosed in [**2194**], no AIDS related complications (CD4 783
and VL undetectable in [**1-24**])
- Hepatitis C (viral load 6,270,000 IU/mL on [**2207-8-12**])
- History of IV drug use.
- Herpes zoster infection with postherpetic neuralgia, on
Morphine and Pregabalin.
- HTN
- Similar episode of myoclonic jerking in fall [**2205**], admitted to
[**Hospital 1263**] Hospital (etiology & treatment unknown), completely
resolved
Social History:
- Tobacco: active smoked w/ 30 pyh - now [**11-17**] cigg/day
- Alcohol: 1 40oz beer on weekends
- Illicits: remote history of polysubstance abuse including
heroin,
cocaine, marijuana, and alcohol
- Housing: lives w/ wife in [**Location (un) 686**]
- Employment: unemployed, preiovusly in contruction - no
asbestos exposure
Family History:
father and sister with asthma
Physical Exam:
On admission:
Vitals: 98.0 144/105 77 22 100% (vent settings: FiO2 50% PEEP 5
TV 550)
General: intubated, sedated, not responsive to painful stimuli
HEENT: Sclera slightly icteric, MMM, oropharynx clear, EOMI,
PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Pupils pinpoint, reactive bilaterally. Does not respond
to pain.
Pertinent Results:
On admission:
.
[**2208-4-27**] 12:20PM BLOOD WBC-7.8 RBC-4.49* Hgb-14.0 Hct-44.5
MCV-99* MCH-31.2 MCHC-31.5 RDW-12.7 Plt Ct-128*
[**2208-4-27**] 12:20PM BLOOD PT-10.9 PTT-28.6 INR(PT)-1.0
[**2208-4-27**] 12:20PM BLOOD Glucose-123* UreaN-28* Creat-4.2*# Na-133
K-4.2 Cl-96 HCO3-27 AnGap-14
[**2208-4-27**] 12:20PM BLOOD ALT-63* AST-212* CK(CPK)-4619* AlkPhos-54
TotBili-0.6
[**2208-4-27**] 12:20PM BLOOD CK-MB-58* MB Indx-1.3
[**2208-4-28**] 03:07AM BLOOD CK-MB-31* MB Indx-1.2 cTropnT-0.01
[**2208-4-27**] 12:20PM BLOOD Albumin-4.3 Calcium-7.9* Phos-4.5 Mg-2.1
[**2208-4-27**] 05:20PM BLOOD Type-ART pO2-93 pCO2-70* pH-7.24*
calTCO2-31* Base XS-0
.
lumbar puncture: unremarkable, hsv pcr negative
.
CXR:
IMPRESSION: Patchy new right basilar opacification, which would
perhaps be
compatible with atelectasis associated with persistent elevation
of the right
hemidiaphragm, but pneumonia could also be considered in the
appropriate
setting.
.
CT Head:
IMPRESSION: No acute intracranial process. Prominent mucosal
thickening of the
ethmoidal cells
.
EKG:
EKG ([**4-28**], 0005): sinus tach, no ST changes
EKG ([**4-28**], 0138): sinus rhythm, rate 73, no ST changes
.
Brief Hospital Course:
Hospitalization Summary:
60 year old gentleman with a history of HIV last cd4 in [**1-25**] was
783 and VL undetectable who arrives with respiratory distress
and altered mental status
.
# ALTERED MENTAL STATUS - Patient presented to the ER very
agitated. His wife explained that he had been confused for the
past day. He was intubated for safety after his agitation was
not affected by ativan/haldol administration. On HD#2, he was
extubated and as his renal function improved, he became more
oriented and conversant. His confusion was thought to be
secondary to morphine, lyrica, and other medications
accumulating in his acute renal failure. His Utox was + for
morphine. He had had a similar presentation over the past year.
LP was negative, Head CT negative, and HSV PCR negative.
.
# HYPOXIC HYPERCARBIC RESPIRATORY FAILURE: Patient was hypoxic
on arrival to the ER with O2 sats in the 60s-70s on RA. Initial
ABG (likely on significant O2 nc) showed 7.24/70/93 making
hypercarbic respiratory failure from accumulation of narcotics
in renal failure most likely. He was intubated in the ER for
safety and his hypercarbia and hypoxia improved. He was
extubated on HD#2 and weaned to 2L nc prior to being called-out.
Steroids and antibiotics were intiallly started for possible
COPD exacerbation but these were later discontinued. Home
nebulizers were continued.
.
# ACUTE RENAL FAILURE: Cr was 4.2 on arrival. Acute renal
failure was thought to be pre-renal and it improved dramatically
over 2 days with IVF to his baseline of 1.1. Other causes such
as tenofovir toxicity were also entertained. HAART medications
were initially held but were restarted as Cr returned to
baseline.
.
# TRANSAMINITIS: [**Month (only) 116**] be secondary to his known HCV with high
viral load. [**Month (only) 116**] be med-related: in particular, Raltegravir can
cause elevated LFTs (especially in patients with comorbid
HBV/HCV).
.
# CARDIAC ENZYME ELEVATIONS: Trop was initially elevated to 0.09
w/ MB of 58. These trended down. No concerning EKG changes were
seen.
.
# HTN: The patient was hypertensive on the day he was called out
of the ICU. Labetalol was uptitrated.
.
# HIV: ARVs were restarted as renal function improved - truvada,
raltegravir, and etravirine.
.
DVT prophylaxis was with subcutaneous heparin. Communication
with Wife [**Name (NI) **] [**Name (NI) 96657**] (HCP). [**Telephone/Fax (1) 96658**] or [**Telephone/Fax (1) 96659**].
Code status was Full Code.
Medications on Admission:
-Albuterol 90mcg HFA inhaler 1-2 puffs q4-6 hrs PRN wheeze
-Budesonide-formoterol 160mcg-4.5mcg inh 1 puff [**Hospital1 **]
-Emtricitabine-tenofovir (Truvada) 200mg-300mg tab PO daily
-Etravirine (Intelence) 200mg PO BID
-Isoniazid 300mg PO qHS
-Morphine 100mg PO BID
-Pregabalin (Lyrica) 150mg PO BID
-Raltegravir (Isentress) 400mg PO BID
-Pyridoxine 100mg PO daily
-Lisinopril (dose unknown)
-Cyclobenzaprine (dose unknown)
Discharge Medications:
1. Raltegravir 400 mg PO BID
2. Pyridoxine 100 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
hold for sbp < 100 or map <60
RX *lisinopril 10 mg 1 Tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*3
4. Isoniazid 300 mg PO HS
5. Etravirine 200 mg PO BID
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Morphine SR (MS Contin) 100 mg PO Q12H
hold for sedation or rr < 10
8. Albuterol Inhaler [**11-16**] PUFF IH Q6H:PRN cough/wheeze
9. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
10. Labetalol 300 mg PO BID
hold for SBP < 120
RX *labetalol 300 mg 1 Tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Hypercarbic respiratory failure
Acute renal failure
SECONDARY:
HIV
Hypertension
COPD
HIV neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 96657**],
You presented because of some jerking movements that you have
had in the past. You were admitted to the ICU with respiratory
and renal failure. You were intubated, stabilized, and then
extubated from the breathing machine. After you were given IV
fluids, your kidney fuction improved back to your baseline.
The cause of your jerking movements is not entirely clear; it is
possible that due to the kidney injury there was a buildup of
medications in your blood causing these symptoms. Currently,
this has resolved.
It is very important that you refrain from using unprescribed
medications and illicit drugs, as these can lead to serious
medical issues.
Note that while you were here you had very elevated blood
pressures; your blood pressure regimen was increased.
The following changes were made to your medications:
STOP LYRICA (pregabalin)
STOP CYCLOBENZAPRINE (flexeril)
INCREASE Labetalol to 300 mg twice daily for blood pressure
RESTART Lisinopril 10 mg once daily for blood pressure
Followup Instructions:
Please call Dr.[**Name (NI) 6767**] office at ([**Telephone/Fax (1) 6732**] to schedule an
appointment for within 1 week of discharge. At that visit, you
should have labs checked to ensure that your kidney function is
still fine.
Completed by:[**2208-5-6**]
ICD9 Codes: 2762, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1964
} | Medical Text: Admission Date: [**2126-8-19**] Discharge Date: [**2126-8-23**]
Date of Birth: [**2059-9-1**] 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:
[**2126-8-19**] Four Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending
artery, with saphenous vein grafts to diagonal, obtuse marginal
and PDA
History of Present Illness:
This is a 66 year old gentleman with history of coronary disease
and myocardial infarction s/p PTCA to RCA in [**2118**]. Has been
followed by Dr. [**Last Name (STitle) 29070**] and recently had episode of chest pain
while sleeping. He ruled out for myocardial infarction but
underwent cardiac cath which revealed 50% left main disease, LAD
and LCX disease. Along with 100% occluded RCA. Also underwent
stress ETT which was positive for EKG changes and myocardial
perfusion defect. He is now referred for coronary artery bypass
surgery.
Past Medical History:
Coronary Artery Disease - Myocardial Infarction [**2108**], PTCA of
RCA
Hyperlipidemia
Hypertension
Gastroesophageal Reflux disease
Obstructive sleep apnea on CPAP
Glaucoma
Traumatic injury after falling from ladder (Bilateral arm
fractures)
s/p Eye surgery
s/p Bilateral arm surgery for above injury (implants- rod, pins)
s/p Laparoscopic Abdominal surgery for ?Meckel's diverticulum
last yr
s/p Hernia repair in 20's
s/p Tonsillectomy as child
Social History:
Occupation: Driver and maintenance work for auto dealership
Last Dental Exam: 1.5 months ago
Lives with: Wife
[**Name (NI) **]: Caucasian
Tobacco: Denies
ETOH: Occasional
Family History:
Brother with history of MI in early 60's. Died at 64.
Physical Exam:
Pulse: 68 Resp: 16
B/P Right: 140/80
Height: 5'6" Weight: 175lbs
General:
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema: Trace
Varicosities: None [X]
Neuro: Grossly intact, Alert and oriented x 3
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2126-8-19**] Intraop TEE:
PRE-BYPASS: 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%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. There are three aortic valve
leaflets. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being A paced.
1. Biventricular function is unchanged.
2. Aorta appears intact post decannulation.
3. Other findings are unchanged
[**2126-8-23**] 05:30AM BLOOD WBC-8.9 RBC-2.76* Hgb-8.4* Hct-24.5*
MCV-89 MCH-30.2 MCHC-34.1 RDW-13.8 Plt Ct-196
[**2126-8-22**] 05:12AM BLOOD WBC-10.7 RBC-2.77* Hgb-8.3* Hct-24.8*
MCV-90 MCH-30.1 MCHC-33.5 RDW-13.7 Plt Ct-149*
[**2126-8-22**] 05:12AM BLOOD Glucose-130* UreaN-25* Creat-1.1 Na-137
K-4.0 Cl-104 HCO3-28 AnGap-9
[**2126-8-23**] 05:30AM BLOOD UreaN-24* Creat-1.1 K-4.0
[**2126-8-23**] 05:30AM BLOOD Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 56758**] was admitted and underwent coronary artery
bypass grafting surgery by Dr. [**Last Name (STitle) **]. Please see operative
note for surgical details. Following the operation, he was
brought to the CVICU for invasive monitoring. Within 24 hours,
he awoke neurologically intact and was extubated without
incident. Chest tubes and pacing wires were discontinued
without complication. The patient was transferred to the
telemetry floor on POD 1 for further recovery. Postop course
was uneventful. Physical therapy evaluated the patient and
cleared him for discharge to home. Beta blocker was initiated
and the patient was gently diuresed toward his preoperative
weight. By the time of discharge on POD 4, the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. He was discharged to home with VNA and
appropriate follow-up instructions.
Medications on Admission:
Lopressor 50mg [**Hospital1 **], Zantac 150mg [**Hospital1 **], Isosorbide 10mg qd,
Simvastatin 20mg qd, Felodipine 5mg qd, Aspirin 162mg qd,
Sublingual Nitro prn, Tylenol prn, Fish oil qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Hypertension
Dyslipidemia
Prior Myocardial Infarction [**2108**]
Sleep Apnea
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**5-12**] weeks, call for appt
Dr. [**Last Name (STitle) 29070**] in [**3-12**] weeks, call for appt
Dr. [**Last Name (STitle) 32668**] in [**3-12**] weeks, call for appt
Completed by:[**2126-8-23**]
ICD9 Codes: 4111, 2724, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1965
} | Medical Text: Admission Date: [**2203-11-18**] Discharge Date: [**2203-12-3**]
Date of Birth: [**2143-10-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1242**]
Chief Complaint:
1. Hyperglycemia
2. Hypothermia
Major Surgical or Invasive Procedure:
Intubation
Dialysis
Endoscopy
History of Present Illness:
60F w seizure hx and diabetes was found down today in fetal
position and brought to ED by EMS. She was noted to be
hypothermic and hyperglycemic. Unclear how long she was down.
There was no evidence of trauma.
In the ED, she was found to have blood in her mouth, she was
intubated for airway protection and had a central line placed.
She required phenylephrine briefly during intubation, but
otherwise did not require any pressors. She was sedated with
fent/midaz. Because of the blood in her mouth and OG was placed
with return of coffee ground. She was started on a PPI gtt.
Her initial serum glucose was 900 and she was started on an
insulin drip.
For her hypothermia she was given warm saline, warm air through
the ED tube and a bear hugger. A CT scan was done which showed
pancreatic stranding around the head and gallbladder sludge. AN
ECG was note to have some QRS widening (120) comparred to prior
(100)
Upon review of previous notes in OMR, the patient intermitantly
threatens noncompliance with her insulin therapy and has a
length history of impulse control problems, for which she sees
psychiatry. Seizure disorder history is unclear and unproven,
but was prescribed Tegretol. Most recent HbA1c was 7.9. Her
last note indicates that she did agree to taking all of her
prescribed medications, including her Tegretol and insulin. She
inappropriately and frequently calls her providers and it has
been difficult in the past to get her to agree to medications
that will control her chronic issues, with threatened section
12's to get her into the hospital for appropriate treatment.
Past Medical History:
- Mild mental retardation
- DM, onset age 51
(poorly controlled, does not check FS; A1c [**10-18**] 9.7%)
- neuropathy
- dysphagia
- hx of [**Doctor Last Name **] with spontaneous remission
- PVD, angioplasty of R femoral in [**2198**]
- Seizure disorder (per pt focal, partial)
- Lower Back pain s/p fall, followed in chronic pain clinic
- posterior mediastinal mass since [**2182**], stable (likely
neurofibroma).
- Hyperlipidemia
- Urinary Incontinance
- Pneumonia ([**2198**])
- ? gastroparesis- normal gastric emptying, no reflux in [**1-/2200**]
Endoscopy with ? [**Last Name (un) **]; biopsy negative.
.
Surgical History
- Angioplasty as above ([**2198**])
- Appendectomy
.
Psychiatric History:
Patient reports growing up in state care. She has a history of
an impulse control disorder. She reports that she is not
currently not seeing any psychiatrists. She has discontinued her
use of amitriptyline.
Social History:
The patient lives alone. She is disabled and on [**Social Security Number 105858**]social security.
DMR caseworker [**Doctor First Name **] (Phone #[**Telephone/Fax (1) 105853**]) . Sister [**Name (NI) 717**]
[**Telephone/Fax (1) 105854**]. Gets Home services from [**Location (un) 1465**] Elder
Services through Case Worker [**Doctor First Name **] [**Telephone/Fax (1) 105855**]
Tobacco: Smoker since the age of 3, 2 packs per day. Quit [**2198**]
Etoh/Drugs: None
Family History:
Ovarian Cancer, Diabetes in mother and grandmother
Physical Exam:
On Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
[**2203-11-19**] 04:00PM BLOOD WBC-11.7* RBC-4.07* Hgb-12.0 Hct-33.0*
MCV-81* MCH-29.4 MCHC-36.3* RDW-14.0 Plt Ct-137*
[**2203-11-19**] 03:58AM BLOOD WBC-9.9# RBC-4.51 Hgb-13.0 Hct-37.9
MCV-84 MCH-28.8 MCHC-34.4 RDW-13.4 Plt Ct-156
[**2203-11-18**] 09:15PM BLOOD WBC-26.6* RBC-4.61 Hgb-13.3 Hct-40.6
MCV-88 MCH-28.7 MCHC-32.7 RDW-13.1 Plt Ct-249
[**2203-11-18**] 12:44PM BLOOD WBC-30.0* RBC-4.88 Hgb-14.6 Hct-46.0
MCV-94 MCH-29.9 MCHC-31.7 RDW-12.6 Plt Ct-236
[**2203-11-18**] 09:15PM BLOOD Neuts-83* Bands-2 Lymphs-11* Monos-1*
Eos-0 Baso-2 Atyps-0 Metas-1* Myelos-0
[**2203-11-19**] 04:00PM BLOOD Plt Ct-137*
[**2203-11-19**] 03:58AM BLOOD Plt Ct-156
[**2203-11-19**] 03:58AM BLOOD PT-10.5 PTT-29.6 INR(PT)-1.0
[**2203-11-18**] 12:44PM BLOOD PT-10.1 PTT-30.8 INR(PT)-0.9
[**2203-11-19**] 03:58AM BLOOD Fibrino-158*
[**2203-11-19**] 04:00PM BLOOD Glucose-124* UreaN-38* Creat-2.6* Na-142
K-4.0 Cl-111* HCO3-16* AnGap-19
[**2203-11-19**] 10:30AM BLOOD Glucose-316* UreaN-38* Creat-2.5* Na-141
K-3.5 Cl-113* HCO3-16* AnGap-16
[**2203-11-19**] 07:22AM BLOOD Glucose-274* UreaN-40* Creat-2.4* Na-141
K-4.1 Cl-116* HCO3-12* AnGap-17
[**2203-11-19**] 03:58AM BLOOD Glucose-249* UreaN-42* Creat-2.4* Na-142
K-3.6 Cl-117* HCO3-9* AnGap-20
[**2203-11-19**] 12:19AM BLOOD Glucose-357* UreaN-42* Creat-2.4* Na-143
K-4.0 Cl-115* HCO3-8* AnGap-24*
[**2203-11-18**] 12:44PM BLOOD Glucose-900* UreaN-48* Creat-2.2* Na-133
K-5.3* Cl-93* HCO3-LESS THAN
[**2203-11-19**] 10:30AM BLOOD ALT-29 AST-49* LD(LDH)-242 AlkPhos-80
TotBili-0.3
[**2203-11-19**] 03:58AM BLOOD ALT-30 AST-52* LD(LDH)-256* AlkPhos-109*
TotBili-0.3
[**2203-11-19**] 12:19AM BLOOD LD(LDH)-253* CK(CPK)-378*
[**2203-11-18**] 07:00PM BLOOD ALT-28 AST-58* LD(LDH)-299* CK(CPK)-461*
AlkPhos-153* TotBili-0.4
[**2203-11-18**] 12:44PM BLOOD CK(CPK)-381*
[**2203-11-19**] 04:00PM BLOOD Calcium-8.0* Phos-2.8# Mg-1.9
[**2203-11-19**] 10:30AM BLOOD Calcium-6.9* Phos-0.4* Mg-2.2
[**2203-11-19**] 07:22AM BLOOD Calcium-7.1* Phos-1.1* Mg-2.4
[**2203-11-19**] 12:19AM BLOOD Triglyc-272*
[**2203-11-19**] 12:19AM BLOOD Osmolal-337*
[**2203-11-19**] 12:19AM BLOOD TSH-1.6
[**2203-11-19**] 12:07PM BLOOD Cortsol-77.3*
[**2203-11-19**] 11:35AM BLOOD Cortsol-79.7*
[**2203-11-19**] 10:30AM BLOOD Cortsol-83.2*
[**2203-11-19**] 03:58AM BLOOD Cortsol-91.7*
[**2203-11-19**] 10:30AM BLOOD Carbamz-1.8*
[**2203-11-18**] 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2203-11-19**] 04:15PM BLOOD Type-ART Temp-38.8 Rates-26/6 Tidal V-500
PEEP-8 FiO2-50 pO2-74* pCO2-29* pH-7.36 calTCO2-17* Base XS--7
Intubat-INTUBATED Vent-CONTROLLED
Studies:
.
[**11-18**] CT Spine - IMPRESSION: 1. No acute fracture or subluxation
of the cervical spine. Moderate narrowing of the central canal
at C5-6 is noted, and if there are myelopathic symptoms, these
could be better evaluated with MRI. 2. Soft tissue within
pharynx and hypopharynx consistent with history of hemorrhage. A
mucosal or submucosal pharyngeal/hypopharyngeal mass is not
excluded, which could be clarified by direct visualization. 3.
Intubated patient, with the tip of endotracheal tube projecting
1 cm from the level of the carina, this should be withdrawn for
appropriate positioning vs re-evaluated with chest radiograph.
.
[**11-18**] CT Head - IMPRESSION: 1. No acute intracranial injury.
There is stable age-appropriate atrophy. 2. Air-fluid levels
within multiple paranasal sinuses.
.
[**11-18**] CT Abdomen/Pelvis - IMPRESSION: 1. Stranding of the
retroperitoneal fat in the region of the pancreatic head, second
and third portions of the duodenum, extending to the region of
the gallbladder fossa. Differential diagnosis includes
gallbladder pathology, pancreatitis, and duodenitis, which might
be clarified with laboratory analysis. 2. Bibasilar atelectasis.
A well-circumscribed stable mass is seen in the left paraspinal
location, benign.
.
[**11-19**] ECHO - IMPRESSION: Mild symmetric left ventricular
hypertrophy with normal regional and global systolic function.
Mild right ventricular cavity enlargement with low normal free
wall motion. Increased PCWP.
.
[**12-1**] Endoscopy - Impression: (dilation, biopsy) Abnormal mucosa
in the lower third of the esophagus (biopsy) Blood in the fundus
Polyp in the fundus (polypectomy)Granularity and friability with
shallow ulceration in the duodenal bulb (biopsy)Medium hiatal
hernia Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
60F with lengthy psychiatric history with impulse control and
difficult to control t2DM, now presenting with hypothermia,
extreme hyperglycemia, and severe metabolic acidosis.
.
# Severe metabolic acidosis: The patient was found down prior
to admission with markedly elevated serum glucose (900). pH on
admission was 6.84 with a minimal osmolar gap. With mild
ketones in the urine and an undetectable bicarbonate level in
the serum, this appeared to be a combination of a hyperglycemic
hyperosmolar state and a diabetic ketoacidosis. However, it was
felt that even with both of these processes at play, they likely
still could not explain the degree of acidosis. Initial thought
was given to emergent dialysis, but the acidosis corrected with
fluid boluses of D5-1/2NS + 3 amps of bicarbonate. She was also
aggressively volume resuscitated for what was presumed to be
extreme hypovolemia and kept on an insulin gtt, with refractory
glucoses requiring a gtt to up to 40 units per hour.
Toxicology screens and cultures were unrevealing in finding a
cause for her extreme acidosis.
# Respiratory failure: She was intubated in the setting of
hypothermia and visible blood in the nares. Intubation was done
mostly for airway protection. Due to persistent respiratory
alkalosis, occasional difficulty with oxygenations, and volume
overload after fluid resuscitation, she was slow to be
extubated. She was covered broadly for pulmonary processes.
Her dead space fraction was calculated at 68%. Sputum cultures
grew out MRSA. To address the anxiety component of extubation
and her home dosing of clonazepam TID, she was started on
dexmedetomidine (Precedex) to help transition to her home
benzodiazepines. Upon fluid mobilization s/p CVVH and anxiety
control, she was extubated successfully after 1 week and
continued to do quite well, with a slow improvement in her O2
dependence.
# Septic shock: Complicated by hypothermia, hyperglycemia, and
acidosis. Initially found to be hypothermic and covered broadly
for sepsis with antibiotics and administered warm NS and Bair
hugger, resulting in improving temperatures within days of
admission. When her first course of antibiotics was nearly
complete, her CXRs began to show suspicious findings for
developing infiltrates, prompting a switch in her antibiotic
course (Vanc/Zosyn --> Vanc/Cefepime). We also covered for ?C.
difficile with Flagyl and PO Vancomycin, but toxins were
negative and this course was stopped a few days later. Her
pressor requirement was slowly weaned as her fluid was mobilized
>1 week into her hospitalization. Her leukocytosis has waxed
and waned, with peak on admission of 30 and a nadir of 5.5.
# Acute kidney injury: The first few days of her admission saw
an acute rise in her creatinine from baseline and oliguria to
anuria. The Renal service was consulted and spun the urine,
noting some muddy brown casts consistent with ATN. Given her
poor urine output, minimally responsive to furosemide, and her
continued respiratory requirements, a femoral dialysis line was
placed (C-collar was still in place, preventing IJ placement)
and she was started on CVVH. Volume was aggressively
ultrafiltrated with the goal of extubation. She continued to
have oliguria and was given a brief dialysis holiday while her
femoral line was pulled. Though she continued to be responsive
to furosemide and may have some residual kidney function, it is
still too soon to predict if her renal function will return to
her prior baseline. The patient was transferred to the floor
where a temporary dialysis line was placed. She went for HD once
with removal of fluid. The patient's Cr continued to rise on the
subsequent days as did her UOP. Given rising UOP, further
dialysis was held until Cr peaked on [**2203-12-1**]. The temporary
dialysis line was removed on [**2203-12-2**] and the patient will
follow-up with nephrology for further evaluation.
# Glucose control: Inciting event leading to severe
hyperglycemia unclear. After her initial insulin resistance
with high-dose insulin drip, her blood glucose seemed to be
better controlled with close monitoring. Prior to her discharge
from the ICU, she had been started on an insulin regimen closely
resembling her home regimen with resulting hypoglycemia with
minimal symptoms. Her insulin regimen was adjusted such that
she was placed on long acting with sliding scale only. This
worked well until the patient began to eat normally on the
medicine floor. At that time her insulin dose was steadily
adjusted upwards towards her home dosing. She will be discharged
on her pre-admission dose as she is eating well and her kidney
function is improving.
# Dysphagia - The patient has a long history of dysphagia. Prior
to this admission, plan had been for EGD. While the patient was
here and EGD was done. Expected strictures were not seen
although there was abnormal mucosa in the lower third of the
esophagus, blood in the fundus, polyp in the fundus and
granularity and friability with shallow ulceration in the
duodenal bulb. The patient was dilated. PPI uptitrated.
Following this procedure the patient reported being able to eat
very well. Diet returned to baseline.
# ?unstable neck: [**Location (un) 2848**] J-collar was initially in place until
the patient was extubated and able to verbalize her lack of pain
was palpation of the C-spine. She was radiographically cleared
within a day or two of admission, but the collar was finally
removed after she was extubated >1 week later.
# Coffee grounds from OG tube: Likely epistaxis or facial trauma
given blood seen on nares. GI bleed was treated initially with
IV PPI [**Hospital1 **], but this was felt to be less likely and hematocrit
were trended and stable. She did not require any transfusion.
# CT findings - Pancreatic stranding and gallbladder sludge:
Non-specific finding with normal lipase. ?relation to
dehydration and initial hyperglycemia. Unclear if other
ingestions such as alcohol were related to the inciting event.
# ?Seizure disorder: EEG negative. She was continued on her
home AEDs (carbamazepine) with therapeutic levels on admission.
# Goals of care / HCP proxy information: She has a confusing
chain of important people in her life that help her with medical
decision making. She is a FULL code and relies on her friend
[**Name (NI) 11894**] [**Name (NI) 105858**] (cell # [**Telephone/Fax (1) 105859**] - former case worker, now
good friend) and her sister for assistance. Both have been
heavily involved in her care. Her health care is mostly
coordinated by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (NP) and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (MD), who
follows her closely.
# Transitional Issues:
1) Continue to actively encourage good glucose control
2) No need for HD. Will follow-up with renal
3) Follow-up on results of Bx from EGD
Medications on Admission:
CARBAMAZEPINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day
CLONAZEPAM 0.5mg TID
GABAPENTIN 200mg [**Hospital1 **]
INSULIN ASPART [NOVOLOG FLEXPEN] - (Prescribed by Other
Provider; Dose adjustment - no new Rx) - 100 unit/mL Insulin Pen
- 12 units with meals three times a day
INSULIN DETEMIR [LEVEMIR FLEXPEN] - 100 unit/mL (3 mL) Insulin
Pen - 24 units sq qam - No Substitution
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - one
patch qd 12 hours on and 12 hours off prn back pain
LORATADINE - 10 mg daily
MELOXICAM - 7.5 mg [**Hospital1 **]
OMEPRAZOLE [PRILOSEC] - 20 mg daily
SIMVASTATIN [ZOCOR] - 40 mg daily
TRAZODONE - 50 mg qhs PRN insomnia
Medications - OTC
CARBAMIDE PEROXIDE - 6.5 % Drops - 4 drops left ear twice a day
for ear wax blockage
GLUCERNA - Liquid - 1 can by mouth twice a day
Discharge Medications:
1. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-12**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a
day.
8. insulin aspart 100 unit/mL Solution Sig: Twelve (12) Units
Subcutaneous With Meals.
9. insulin detemir 100 unit/mL Solution Sig: Twenty Four (24)
Units Subcutaneous once a day.
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day: Apply to back
.
11. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. meloxicam 7.5 mg Tablet Sig: One (1) Tablet PO twice a day.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
16. Carbamoxide Ear Drops 6.5 % Drops Sig: Four (4) Drops Otic
twice a day as needed for ear blockage.
17. Glucerna Liquid Sig: One (1) Can PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital for Continuing Medical Care
Discharge Diagnosis:
Diabetic coma, renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]!
You initially came to this hospital severely ill in a diabetic
coma. You were in the intensive care unit for over a week. In
the hospital we have treated your diabetic coma and a number of
associated complications. You are now ready for discharge to a
rehabilitation facility
See below for changes to your home medication regimen:
1) Please INCREASE Omeprazole dosing to 40mg twice daily
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2203-12-13**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 105860**] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2203-12-20**] at 10:00 AM
With: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2203-12-27**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 105860**] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Nephrology
With: Dr. [**Last Name (STitle) 4090**]
When: [**2203-1-5**] at 1:00pm
ICD9 Codes: 0389, 5845, 5070, 2875, 4439, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1966
} | Medical Text: Admission Date: [**2136-2-12**] Discharge Date: [**2136-2-22**]
Date of Birth: [**2056-8-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 yo F w/ unknown PMH who lives with elder brothers was brought
to [**Hospital1 18**] ED by EMS after being found at home by niece to be
unfed wearing clothes soiled with urine. Per family report, she
had been increasingly lethargic over the last week. Family not
present at time of MICU admission. ED note statues pt's brother
reported 1 week h/o decreased PO intake. EMS notes state niece
reported she "believes elderly brother unable to care for her
now, may not be feeding her." EMS also notes h/o "fall" 2-3 days
ago. ED notes say that patient's brother denied h/o patient
falling, but report her sliding to floor. EMS notes also state
that patient's bed found to have large urine stains. There was a
question of elder abuse raised in the ED.
.
In the ED, her triage VS were T=95 HR=94 BP=89/61 RR=16 96=RA.
Initally, she was given 1400cc. Also started on D5 1/2NS for
hypernatremia (Na=154). CXR and UA unremarkable. CT c-spine
negative for fracture. CT head negative for bleed, but showed
prominent ventricles. Admission to medicine service was planned.
After it was noticed that she made no UOP to the inital IVF, she
was then given an additional 6L NS (total 7L NS). SBP remained
relatively low in the 90's, so she was admitted to the MICU for
further management. A dose of vanco and zosyn were ordered in
the ED prior to transfer. Vancomycin 1gm IV x1 was given. Blood
cultures not done in ED.
.
On arrival to MICU, BP initially 88/52, but improved to 128/57
without intervention. Denies all complaints, including CP, SOB,
diarrhea, abd pain; but pt clearly confused, only A&Ox1.
.
In the MICU, the patient was treated with Zosyn x 1 day and
Vanco for 2 days. Found to have RLE DVT. Started on heparin
drip. Guaic negative prior to heparin.
Past Medical History:
- PNA, [**2134**]
- Dementia, began approx 5 years ago
Social History:
Previously a school teacher - 1st grade. Never married. No
children. She is one of 9 children. Lives with younger brother
in [**Name (NI) **]. No EtOH or tobacco in 15 years, but was a social
user of alcohol/tobacco. Brother does shopping, cooking,
cleaning, laundry. During the day, she watches television and
sleeps.
Family History:
[**Name (NI) 2481**] - sister, passed at age 75
Father passed at age 76y, mother passed at age 73y of natural
causes
Physical Exam:
PHYSICAL EXAM on TRANSFER from MICU:
VS: Tm: 98.7, Tc: 97.7; HR: 78; BP: 101/51; RR 17; O2 97% RA
I/Os: [**Telephone/Fax (1) 71085**], LOS +10L
GEN: elderly woman, lying in bed, NAD, pleasant, awake
HEENT: PERRL bilat, EOMI bilat, anicteric, dry MM, OP clear
NECK: JVP not elevated, no carotid bruits
CV: RRR, distant HS, no S3, ?S4 vs systolic murmur heard best at
apex
CHEST: CTA bilat. no crackles/wheezes.
ABD: NABS, soft, ND, NT, no masses
EXT: ++ firm edema RLE, approx 2x LLE, 1+ DP pulses
SKIN: erythematous rash w/ some excoriations on buttocks and
sacrum, no skin breakdown.
NEURO: A&O x person and city only, not hospital or year; CN 2-12
grossly intact
Pertinent Results:
[**2136-2-11**] 09:45PM PT-15.7* PTT-38.8* INR(PT)-1.4*
[**2136-2-11**] 09:45PM WBC-13.6* RBC-4.58 HGB-15.1 HCT-45.4 MCV-99*
MCH-33.0* MCHC-33.2 RDW-14.9
[**2136-2-11**] 09:45PM LIPASE-31
[**2136-2-11**] 09:45PM ALT(SGPT)-23 AST(SGOT)-29 ALK PHOS-45
AMYLASE-48 TOT BILI-1.5
[**2136-2-11**] 09:45PM UREA N-45* CREAT-1.4* SODIUM-154*
POTASSIUM-3.5 CHLORIDE-122* TOTAL CO2-23 ANION GAP-13
[**2136-2-11**] 10:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-RARE
EPI-0-2
[**2136-2-11**] 10:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-TR
[**2136-2-11**] 10:43PM LACTATE-3.0*
[**2136-2-12**] 02:20AM LACTATE-2.1*
.
IMAGING:
[**2136-2-11**] PORTABLE CXR:
Mild right lower lobe atelectasis and elevation of the right
hemidiaphragm
.
[**2136-2-11**] CT HEAD:
1. Prominence of the ventricular system without obstructing
lesion
identified. No definite evidence of acute dilation. Please
correlate clinically to exclude normal pressure hydrocephalus.
2. No evidence of intracranial hemorrhage or fracture.
.
[**2136-2-11**] CT C-SPINE:
No fracture or malalignment; facet degenerative changes; minor
scarring at the lung apices; minor polypoid mucosal thickening
in the left maxillary sinus.
.
[**2136-2-13**] LE DOPPLER U/S: Positive study for DVT in the right
lower extremity. Occlusive thrombus is present in the distal
superficial femoral vein and popliteal vein. Non-occlusive
thrombus is present in the mid superficial femoral vein. Right
common femoral and proximal superficial femoral veins are
patent.
Brief Hospital Course:
Ms. [**Known lastname 71086**] is a 79 year old female with past medical history
significant for dementia who presented with failure to thrive
and sub-acute decline in mental status. She also demonstrated
signs of failure to thrive. Full neurologic work up was
performed and there was no clear explanation for her recent
decline. Per discussion with Neurology, NPH was considered as a
possible cause of worsening dementia. However, given the
chronicity of her illness, the likelihood of clinical benefit
from shunt placement was considered to be quite low, especially
in light of the known potential morbidity associated with shunt
placement. Therefore, the decision was made to not pursue this
diagnositic workup further.
.
The patient continued to have poor oral intake of both food and
liquid during her stay. Per the patient's brother, who is also
the [**Hospital 228**] Health Care Proxy, the family was not interested
in nutrition support via JPEG or TPN. Her HCP expressed his wish
that the patient receive comfort measures only.
Medications on Admission:
None.
Discharge Medications:
1. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical TID (3 times a day).
2. Bisacodyl 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. dementia
Discharge Condition:
Stable. Afebrile. Not taking PO. Patient is comfort measures
only.
Discharge Instructions:
Ms. [**Known lastname 71086**] was admitted to the hospital for altered mental
status. The change in mental status was likely related to
dementia. Primary focus is comfort measures. Further care per
nursing home medical director, ideally patient should be do not
hospitalization.
Followup Instructions:
None.
ICD9 Codes: 2760, 2762, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1967
} | Medical Text: Admission Date: [**2150-9-17**] Discharge Date: [**2150-9-17**]
Date of Birth: [**2074-1-11**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Serax
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypoxia and Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 76-yo woman w/ MMP incl DM2, Afib, ESRD on HD, CAD
s/p MI / CABG, CHF, sarcoidosis, COPD, p/w hypotension on the
way to dialysis. She was on her way from home at her long term
care facility to HD, when the ambulance noted that her SBP was
70s, so she was taken straight to the nearest ED instead. There
she also was hypoxic to the 60s. She was started on peripheral
Levophed and a facemask, given a dose of Vancomycin, and
transferred to [**Hospital1 18**] ED. On arrival here, her SBP dropped from
110 to 52, so she was started on Neosynephrine in addition to
the Levophed, and these were run in to her HD line due to the
inability to gain adequate other CVL access. She also became
more hypoxic, requiring a NRB. She was noted to have a waxing
and [**Doctor Last Name 688**] mental status. CT Head was unremarkable, but CT Torso
showed significant findings c/w pneumonia, sarcoidosis vs.
malignancy, and pulmonary congestion. She was given CTX and
Levo. Her VS - afebrile, BP 125/29, HR 80, R 22, O2-sat 97% NRB.
Her DNR/DNI status was confirmed. She was admitted to the MICU.
On arrival to the MICU, the patient appeared quite distressed,
and remained hypoxic at 85% on 100% NRB + 6L O2 NC. Her SBPs
were holding in the 120s. She was in severe respiratory
distress, so she was given 0.5mg Morphine IV, with reasonable
effect. The family was notified, and DNR/DNI was confirmed. The
possibility of BiPAP was raised, which the family declined. The
family decided to come in for further discussion regarding her
care and anticipation of moving towards Comfort Measures.
Past Medical History:
Diabetes mellitus Type 2
Hypothyroidism
Hyperlipidemia
Hypertension
CAD s/p MI x2, s/p CABG
PVD
A-fib - wide complex a-fib w/ RVR, Amio for rate control
CHF - tx w/HD in past
ESRD on HD
Nephrogenic systemic fibrosis
Sarcoidosis
COPD
Centrilobular emphysema
h/o Breast Ca s/p left mastectomy, no chemo/XRT
h/o Colon polyps
Pleural effusions
Social History:
Lives w/ husband in [**Name (NI) **]. She is dependent with her ADLs and
wheelchair-bound at home. Has [**Name (NI) 269**] and husband to care for her.
Tobacco: 25 50 pack year smoking history, quit [**2124**]. No EtOH.
Family History:
FAMILY HISTORY: One sister had lung cancer, one brother had
lung cancer and leukemia, five of the patient's six siblings
have diabetes. Father died of myocardial infarction at age 66.
There is a strong family history of hypertension.
Physical Exam:
VS - Afeb, HR 70s, SBP 120s, O2-sat 85% on NRB+6L NC
Gen - ill-appearing elderly woman
Heart - RRR, no MRG
Lungs - coarse crackles and rhonchi throughout
Abdomen - soft/NT/ND, no rebound/guarding
Extrem - cool, no c/c/e
Pertinent Results:
[**2150-9-17**] 01:20AM GLUCOSE-106* UREA N-39* CREAT-4.1*#
SODIUM-136 POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-24 ANION GAP-20
[**2150-9-17**] 01:20AM estGFR-Using this
[**2150-9-17**] 01:20AM CK(CPK)-28
[**2150-9-17**] 01:20AM cTropnT-0.12*
[**2150-9-17**] 01:20AM CK-MB-NotDone
[**2150-9-17**] 01:20AM CALCIUM-8.4 PHOSPHATE-6.8*# MAGNESIUM-2.9*
[**2150-9-17**] 01:20AM NEUTS-79.9* LYMPHS-12.5* MONOS-6.8 EOS-0.4
BASOS-0.4
[**2150-9-17**] 01:20AM NEUTS-79.9* LYMPHS-12.5* MONOS-6.8 EOS-0.4
BASOS-0.4
[**2150-9-17**] 01:20AM PLT COUNT-226
[**2150-9-17**] 01:20AM PT-57.7* PTT-99.2* INR(PT)-6.8*
Brief Hospital Course:
ASSESSMENT AND PLAN: 76-F w/ MMP incl DM2, Afib, ESRD on HD, CAD
s/p MI / CABG, NSF, CHF, sarcoidosis, COPD, p/w hypotension and
hypoxia.
.
#. Hypotension: The etiology of her hypotension is unclear, the
differential includes sepsis vs. cardiogenic vs. combined. Pt
arrived on 2 pressors with SBPs in 120s through HD line. Now
broadly covered with Vanc / CTX / Levo, although adequate
coverage would include Vanc / Zosyn. Other possibility is severe
congestive heart failure, but pt is anuric and unable to benefit
from HD at this time given her inability to sustain BPs. Family
was aware of situation and preferred to continue pt on multiple
pressors until all family was able to visit prior to
transitioning to Comfort Measures.
.
#. Hypoxia: Also of unclear etiology, DDx includes pneumonia,
aspiration, congestive heart failure, and massive burden of
sarcoidosis vs. recurrent metastatic cancer. Pt appears in
severe respiratory distress, with an oxygen saturation of 85% on
100% NRB + 6L NC. Patient's code status was DNR/DNI, which was
confirmed with family. Family also declined BiPAP, which would
have been a temporizing measure for at least the overlying fluid
congestion. Family was aware as above, preferred continuing
current treatment with O2 until all family was able to visit
prior to transitioning to Comfort Measures. see below
.
#. Goals of Care: Pt and family were aware of situation re: pt's
hypotension and hypoxia. Initially, pt was continued on
admitting treatment of antibiotics and pressors without
escalation. Family came in to see pt today, and after a family
meeting, the decision was made to transition to comfort focused
care. At this point, antibiotics and pressors were
discontinued, and morphine was used for comfort for respiratory
distress. Over several hours, the patient gradually became
increasingly hypotensive and bradycardic, and developed agonal
respirations. At 19:46 on [**2150-9-17**], the patient died. The
family requested a postmortem exam, and the paperwork for the
death and postmortem was completed.
.
Medications on Admission:
Tylenol #3 PO Q6hrs PRN pain
Amiodarone 100mg PO daily
Nexium 40mg PO daily
Lunesta 1mg PO QHS PRN
Glargine 5units SQ QAM
Lactulose 15ml PO daily PRN constipation
Levothyroxine 300mcg PO QOD, alternating with 200mcg PO QOD
Midodrine 5mg PO prior to HD
Sevelamer 400mg PO TID
Simvastatin 20mg PO QHS
Warfarin 2mg PO QAM
ASA 81mg PO daily
Beneprotein 1 tablespoon TID
Cranberry extract
RISS
Glucerna 4oz PO daily
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Arrest
Respiratory Failure
Chronic Obstructive Pulmonary Disease
Congestive Heart Failure
End Stage Renal Disease
Sarcoidosis
Nephrogenic Systemic Fibrosis
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 5856, 4275, 4280, 4589, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1968
} | Medical Text: Admission Date: [**2140-11-11**] Discharge Date: [**2140-11-16**]
Date of Birth: [**2082-7-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
vomitting
Major Surgical or Invasive Procedure:
right and left heart catheterization
blood transfusion
History of Present Illness:
Ms. [**Known lastname 13537**] is a 58 year old Female with DM, CAD, pulm. HTN
(minimally responsive to inhaled NO on cath [**9-/2136**]), presents
with a 3 day history of Nausea Vomitting and chest pain,
subjective fevers and sore throat. Unable to tolerate liquids.
ED course notable for initial BP 88/54, improved with fluids.
ECG concerning for changes, started on NTG and heparin gtt, with
resultant hypotension. Remained hypotensive, and eventually
started on pressors. Mildly elevated TnT of .12. CTA negative
for PE. Areas of mild patchy opacity in RML, which may
represent atypical inf vs inf changes.
ECG: TWI v1-v6 (old), III (new). TWF in I, II, III, F.
Past Medical History:
pulm HTN (primary vs. rheum condition vs undiagnosed cardiac
dz). Seen in [**Hospital **] clinic in [**2135**] ([**Doctor Last Name **]). PFTs 11, [**2135**]:
Reduced FVC suggests a restrictive ventilatory defect, however
the TLC was within normal limits when measured on [**2136-6-13**].
FVC 1.78 2.48 72
FEV1 1.38 1.85 75
MMF 0.90 2.61 34
FEV1/FVC 78 75 104
DMII
CAD. Cath [**9-/2136**] severe LM with 50% ostial stension. other Cs
without sig lesion. No intervention. PA syst 80, with elevated
R-sided pressures (RV 80/15), though nl L-sided, minimal
response to inhaled NO. EF 65%.
hypothyroid. MIBI in [**2136**] with no perfusion defects, but
dilated RV.
?pan-hypo pit: partially empty sella on MR [**2131**], though has not
required hormone replacement.
?small ASD. TEE in [**2135**] with no ASD or anomalous venous return.
bedside ECHO: nl LV function, TR grad 66, dilated RV, no flow
across mobile intraatrial septum.
anticardiolipin IgM
anemia
Social History:
lives with husband, has children
Family History:
noncontributory
Physical Exam:
Vitals: T 97.3, HR 66 RR BP 118/60, HR 66 PAP 82/25 PCWP 45
(40's to 50's), CO 6.3, CI 3.33 (fick and thermodilution), CVP
13, SVR 863
Gen: pleasant and cooperative
HEENT:MMM PERRLA
Pulm: CTAB no crackles
Cor: RRR no murmurs
Abd: soft NT ND
Ext: WWP DP 2+ bilaterally
Neuro/Psych: A+O x 3 moving all 4 extremities
Pertinent Results:
[**2140-11-11**] 11:56PM CK(CPK)-98
[**2140-11-11**] 11:56PM CK-MB-NotDone cTropnT-0.18*
[**2140-11-11**] 11:56PM PT-15.6* PTT->150* INR(PT)-1.5
[**2140-11-11**] 07:19PM cTropnT-0.12*
[**2140-11-11**] 07:19PM CK(CPK)-82
[**2140-11-11**] 01:00PM ALT(SGPT)-13 AST(SGOT)-26 CK(CPK)-85 ALK
PHOS-37* AMYLASE-23
[**2140-11-11**] 01:00PM GLUCOSE-160* UREA N-26* CREAT-1.3* SODIUM-136
POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-25 ANION GAP-18
[**2140-11-11**] 01:00PM LIPASE-18
[**2140-11-11**] 01:00PM ACETONE-SMALL
[**2140-11-11**] 01:00PM TSH-0.18*
[**2140-11-11**] 01:00PM WBC-10.4# RBC-4.09* HGB-11.2* HCT-33.4*
MCV-82 MCH-27.5 MCHC-33.7 RDW-13.7
ECG: Sinus rhythm, Ventricular premature complex, Right axis
deviation, Probable right ventricular hypertrophy, Inferior and
precordial ST-T wave abnormalities - may be due to right,
ventricular hypertrophy but cannot exclude in part ischemia,
Clinical correlation is suggested, Since previous tracing of
[**2140-11-12**], precordial lead ST-T wave abnormalities
decreased
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 188 100 422/450.57 80 110 -18
Cardiac Cath: COMMENTS: 1. Selective coronary angiography
of this right dominant system revealed no flow limiting coronary
disease. The LMCA contained a 40% ostial lesion but was
otherwise widely patent. The LAD contained a proximal 40%
lesion just before the takeoff of a large first diagonal branch.
The apical LAD was small in caliber. The LCX contained diffuse
plaquing with a 40% lesion after OM2. THe RCA had diffuse mild
plaquing with slow washout of contast consistent with the
patient's RV pressure elevation.
2. Resting hemodynamics revealed evidence of severe pulmonary
hypertension at baseline with mean PA pressure of 41 mm Hg, a
PVR of 605,
and a cardiac index of 2.2 l/min/m2 (Fick). With 100% oxygen
therapy, the mean PA remained approximately the same at 40mmHg,
but the PVR dropped to 385 and the cardiac index rose to 2.98
l/min/m2. Little further improvement was seen with Nitric
Oxide: the mean PA dropped slightly to 39mmHg, the PVR rose
slightly to 415, and the cardiac index fell slightly to 2.8
l/min/m2. In summary, neither oxygen nor nitric oxide
significantly dropped the mean PA pressure, but both therapies
resulted in a modest increase in CO which drove a fall in PVR
compared to baseline.
3. Left ventriculography was not performed.
FINAL DIAGNOSIS:
1. No flow limitng coronary artery disease.
2. Mild LV diastolic dysfunction.
3. Severe primary pulmonary hypertension.
4. No change in mean PA pressures with 100% oxygen or Nitric
Oxide.
Brief Hospital Course:
Ms. [**Known lastname 13537**] is a 58 year old woman with pulmonary hypertension
who presented with a likely viral gastroenteritis which quickly
resolved. She responded to NO in past on cath [**2135**]. A swan was
attempted on [**2140-11-12**] and was unsuccessful but one was placed at
cardiac cath. She had a right and left heart cath on [**2140-11-14**]
which showed no change from previous. She started sildafenil
after catheterization and was observed. It appeared to have an
effect of 30% or more improvement on her cardiac output but her
pulmonary artery pressures only seemed to decrease transiently.
It was decided that she would benefit from the sildafenil and
was discharged with a prescription and follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
In the emergency department the patient had been transiently
hypotensive in ED secondary to nitroglycerin as the patient is
preload dependent. It quickly resolved.
In terms of her CAD, Ms. [**Known lastname 13537**] had 50% LMCA stenosis,
otherwise clean Cs. Her aspirin and statin were continued and
she was restarted on bblocker. TNT elevation was thought likely
secondary to RH strain but not to ACS.
Regarding her acute renal failure, the patient's Cr is 0.8 at
baseline, and 1.3 on admit. This was thought to be prerenal and
resolved with rehydration.
Ms. [**Known lastname 13537**] was anemic with a hct drop 32 to 26 after line
placement. There was no evidence of bleed. She received a unit
of prbcs and following that her hct remained stable. She was
guaiac negative.
The patient has a history of hypothyroidism for which
levothyroxine was continued. She was discharged in her usual
state of health.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 100 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Disp:*30 Tablet(s)* Refills:*0*
8. Bosentan 62.5 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 weeks. Disp:*56 Tablet(s)* Refills:*0*
9. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2*
10. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day). Disp:*90 Tablet(s)* Refills:*2*
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 100 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
8. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Sildenafil Citrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Hypertension
CAD
Discharge Condition:
good
Discharge Instructions:
Please return to the hospital if you experience worsening chest
pain and shortness of breath, fevers, dizzyness, or any other
severe symptoms. Please call your doctor if you have any
questions about your symptoms.
Please start 2 new medications: metoprolol which is good for
your heart and sildafenil which is good for your lungs.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one week for your
pulmonary hypertension. [**Hospital1 18**] - Division of Pulmonary and
Critical Care, [**Location (un) 830**], KSB-23
[**Location (un) 86**], [**Numeric Identifier 718**], Phone: [**Telephone/Fax (1) 612**]
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Hospital1 7975**] INTERNAL MEDICINE Where: OFF
CAMPUS [**Hospital1 7975**] INTERNAL MEDICINE Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2140-12-7**] 2:00
ICD9 Codes: 4168, 5849, 2765, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1969
} | Medical Text: Admission Date: [**2170-3-25**] Discharge Date: [**2170-3-31**]
Date of Birth: [**2112-6-24**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Morphine / Iodine; Iodine Containing / Keflex /
Wellbutrin Sr / Simvastatin
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Right IJ central venous catheter placement, removed [**3-28**].
lumbar puncture
History of Present Illness:
57 year old woman with history of Crohns (chronic steroids),
peripheral neuropathy, hypertension, obesity presenting with
fever and altered mental status. She was started on cipro for a
UTI on [**2170-3-12**] however her UCx grew cipro resistant e. coli then
was switched to macrobid. She had persistent dysuria on [**2170-3-16**]
and was started on ceftin. Yesterday she was at home and
developed onset of headache and shaking chills. She stated that
bright lights hurt as well as loud noises. She denied cough,
shortness of breath, dysuria, flank pain, diarrhea, or increase
in abdominal pain. Family was concerned with her mental status
and called EMS. Upon arrival EMS found her somnolent but
arousable with small pupils. She was given 1 dose of narcan
with no change in mental status.
In the ED her initial vital signs were 102 135 151/81 20 95%RA.
She had a CT head that was unremarkable. She had an LP but was
too agitated to adequately measure an opening pressure. Her
initial lactate was 5 which triggered the sepsis protocol and
RIJ central line was placed without complication. She received
ceftriaxone 2g, vancomycin 1g, decadron 10 mg all times one
dose. She received 3 liters of saline. She was transfered to
the [**Hospital Unit Name 153**].
Past Medical History:
Crohns disease since age 16 (chronic prednisone 15 mg daily)
Obseity
Peripheral neuropathy
hypertension
depression
osteoporosis
hypercholesterolemia
Social History:
Occupation: former nurse
Drugs: none
Tobacco: none
Alcohol: none
Other: lives alone. many friends and family nearby.
Family History:
Brother and father with [**Name (NI) 4522**] disease as well as neuropathy
and
diabetes. Her father also had coronary artery disease and
diabetes, he died of CHF.
Physical Exam:
Afebrile, VSS
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : anteriorly and
posteriorly)
Abdominal: Soft, Non-tender, Bowel sounds present, lower abd
midline surgical scar
Musculoskeletal: No Muscle wasting
Skin: Warm, no rashes, no splinter
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Not Sedated, Tone: Normal,
CNII-XII intact. moving all extremites symmetrically. no neck
stiffness or photophobia
Pertinent Results:
CSF:
GRAM STAIN (Final [**2170-3-26**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
CRYPTOCOCCAL ANTIGEN (Final [**2170-3-26**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
Results should be evaluated in light of culture results
and clinical
presentation.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Herpes Simplex Virus, Type 1 & 2 DNA, Real-Time PCR
HSV 1 DNA Not Detected Not
Detected
HSV 2 DNA Not Detected Not
Detected
[**2170-3-26**] 5:59 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal aspirate.
Rapid Respiratory Viral Antigen Test (Final [**2170-3-27**]):
Respiratory viral antigens not detected.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
This kit is not FDA approved for direct detection of
parainfluenza
virus in specimens; interpret parainfluenza results with
caution.
VIRAL CULTURE (Preliminary): No Virus isolated so far
[**2170-3-25**] 10:55PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-1
Lymphs-79 Monos-20
[**2170-3-25**] 10:55PM CEREBROSPINAL FLUID (CSF) TotProt-43 Glucose-88
[**2170-3-25**] 11:49PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-negative
CT HEAD WITHOUT CONTRAST: No intracranial hemorrhage, mass
effect, shift of normally midline structures, or major vascular
territorial infarct is apparent. The density values of the brain
parenchyma are preserved. There is mild prominence of the
frontal extraaxial space bilaterally, consistent with atrophic
changes. There is mucosal thickening of multiple ethmoid air
cells. Visualized paranasal sinuses and mastoid air cells are
clear. Bony structures and surrounding soft tissue structures
are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial pathology.
2. Mild bifrontal brain atrophy.
[**2170-3-25**] 09:11PM BLOOD WBC-8.9 RBC-4.69 Hgb-10.8* Hct-34.0*
MCV-73* MCH-23.0* MCHC-31.7 RDW-15.5 Plt Ct-262#
[**2170-3-25**] 09:11PM BLOOD Neuts-94.6* Bands-0 Lymphs-2.7*
Monos-1.5* Eos-1.1 Baso-0.1
[**2170-3-25**] 09:11PM BLOOD PT-12.5 PTT-22.3 INR(PT)-1.1
[**2170-3-25**] 09:11PM BLOOD Glucose-128* UreaN-14 Creat-1.0 Na-138
K-3.4 Cl-98 HCO3-27 AnGap-16
[**2170-3-25**] 09:11PM BLOOD ALT-26 AST-25 AlkPhos-64 TotBili-0.4
[**2170-3-28**] 03:50AM BLOOD LD(LDH)-194 TotBili-0.2 DirBili-0.1
IndBili-0.1
[**2170-3-25**] 09:11PM BLOOD Lipase-136*
[**2170-3-25**] 09:11PM BLOOD Albumin-3.6
[**2170-3-26**] 10:55AM BLOOD Iron-14*
[**2170-3-26**] 10:55AM BLOOD calTIBC-324 Ferritn-115 TRF-249
[**2170-3-28**] 03:50AM BLOOD Hapto-281*
[**2170-3-25**] 09:11PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-3-25**] 09:13PM BLOOD Lactate-5.0*
[**2170-3-25**] 11:59PM BLOOD Lactate-4.2*
[**2170-3-26**] 11:19AM BLOOD Lactate-3.0*
[**2170-3-25**] 10:55PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-1
Lymphs-79 Monos-20
[**2170-3-25**] 10:55PM CEREBROSPINAL FLUID (CSF) TotProt-43 Glucose-88
Brief Hospital Course:
57 year old woman with history of Crohns disease on chronic
steroids admitted with fever, altered mental status, and lactic
acidosis with initial concern for meningitis.
.
Fever: leading sources included CNS, urine, lung, abd or skin.
of these leading concern would be for CNS infection although
mental status now markedly improved and CSF underwhelming. with
underlying immune suppressed state would be at risk for HSV or
listeria which could be more consistent with atypical
infections, however CSF with no growth and HSV PCR negative.
also chest xray normal and recent UA negative as well. Patient
received empiric abx vanc/ceftriaxone/ampicillin for 48 hours
and given negative gram stain and cell count these were
discontinued. Patient's headache and fever resolved. Possible
viral etiology causing her symptoms. Afebrile throughout the
remainder of her stay.
.
Altered Mental status: appears to be markedly improved compared
to pre-admission eval. no focal neurologic deficits nor
inability to switch sets. CT head negative. At baseline at
discharge.
.
Anemia: Baseline 25, initially 34 on admission in setting of
volume depletion. Patient has history of iron deficiency anemia.
% saturation less than 10, ferritin 125 in setting stress
response. Patient refused PO iron due to GI complaints. Received
2 units packed red cells on [**3-28**] to replete iron stores. Hct
stable prior to discharge.
.
Lactic acidosis: not likely systemic hypoperfusing given normal
to elevated blood pressure. no abdominal pain to suggest
ischemic bowel. home use of metformin may have contributed.
Lactate improved, metformin discontinued and glyburide
initiated. Patient unintentionally took 10 mg po once of
glyburide prior to discharge (was prescribed 2.5 mg po BID and
had been given four tabs to avoid having to go to pharmacy over
the weekend). Her blood glucose was monitored for six hours
prior to discharge and it remained >170 mg/dL. She was advised
to eat small snacks in addition to her meals for the next day,
hold her PM dose of glyburide the day of discharge, and check
her glucose QAC/QHS in addition to when she had hypoglycemic
symptoms. She was educated on symptoms and management of
hypoglycemia at home.
Crohns: no current evidence of flare of abdominal symptoms.
Continue steroids.
Medications on Admission:
celebrex 200-400 mg daily
celexa 80 mg daily
clonazepam 1 mg TID:prn
vitamin b12 IM qmonth
vitamin D [**Numeric Identifier 1871**] units twice weekly
folic acid 1 mg daily
gabapentin 600 mg QID
hydromorphone 4-12 mg TID:prn
lisinopril 5 mg daily
loperamide 2-4 mg q4:prn
metformin 500 mg [**Hospital1 **]
concerta 36 mg SR daily
oxycodone 30-60 mg TID:prn
pravastatin 10 mg daily
prednisone 5 mg tablets 1-4 tablets daily
prednisone 1 mg tablets 1-5 tablets daily
trazodone 200 mg daily
verapamin SR 120 mg daily
calcium carbonate 1200 mg daily
omperazole 20 mg daily
vitamin E 800 units daily
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
4. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Calcium Carbonate 1,177 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
8. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Oxycodone 5 mg Tablet Sig: Six (6) Tablet PO TID (3 times a
day) as needed for pain.
10. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
13. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. CONCERTA 36 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
16. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO twice
weekly.
17. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
18. Vitamin E 800 unit Capsule Sig: One (1) Capsule PO once a
day.
19. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
20. Glucometer
dispense one
check blood glucose QAC, QHS
21. Glucometer strips
dispense 100
refills 2
Discharge Disposition:
Home
Discharge Diagnosis:
1. lactic acidosis
2. altered mental status
3. diabetes mellitus
4. chronic steroid use/adrenal insufficiency
5. chronic pain
Discharge Condition:
stable, afebrile, ambulating.
Discharge Instructions:
You were hospitalized with altered mental status, which may have
been related to a viral illness, medications, or adrenal
insufficiency from chronic steroid use. Please call your
primary care physician with any questions or concern. Return to
the emergency department with any fever greater than 101,
chills, altered mental status, or other alarming symptoms.
Do not resume your metformin.
Followup Instructions:
Please call your primary physician, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4775**],
for follow up as soon as possible (preferably within the next
two weeks).
ICD9 Codes: 0389, 2762, 2720, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1970
} | Medical Text: Admission Date: [**2124-7-2**] Discharge Date: [**2124-7-21**]
Date of Birth: [**2073-1-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Compazine / Penicillins / Metformin / Heparin Agents
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
51 year old gentleman with COPD on home O2 and several
admissions for COPD flare requiring intubation, smoking,
diabetes type II, s/p IVC filter for DVT, and recent admission
for cellulitis presents from a nursing home with respiratory
failure. Noted at nursing home to be hypoxic to 70's, treated
with duonebs with O2 to 92% afterwards. Taken to emergency
department. In [**Name (NI) **], pt in respiratory distress on
presentation--placed on NRB and given continuous nebulizers, O2
sats began to trend to high 80's and pt became unresponsive. ABG
at that time pH 7.35 pCO2 99 pO2 69 HCO3 57, pt intubated at
that time. Of note, the respiratory therapist removed a large
mucus plug shortly after intubation. Hemodynamically the pt was
tachycardic in the 110's with SBP in the 150 systolic range.
Also given ceftriaxone. Pt was already on vancomycin and
ciprofloxacin for cellulitis for which he was admitted on [**6-30**].
Past Medical History:
DM2 on RISS
COPD on oxygen + prednisone
CHF
osteoporosis w/ related thoracic fracture
h/o MRSA (but cleared by ID at OSH)
h/o DVT s/p filter
hepatitis B
Social History:
Shx:currently lives at the [**Doctor First Name **] [**Doctor First Name **] rehab since the
vertebrate fracture; extensive smoking history, but still smokes
[**2-12**] cig/day; extensive alcohol abuse in the past, but now sober.
Has used IV drugs before, but also quit. Not married, but has
children. His HCP is mother living at [**State 2748**].
Family History:
Fhx: non-contributory
Physical Exam:
Gen: Cushingoid
Neck: old trach wound
Chest: Decreased air movement bilaterally, insp and exp wheezes
Cor: RRR, no M/R/G
Abd: Obese, soft, NT, ND, minimal bowel sounds.
Ext: Mild erythema bilaterally in ankles about [**1-12**] way up shin
extr: erythema b/l starting above the anles to upper leg area,
temp same as temp of other parts of leg although a bit colder
than temp of [**Last Name (un) **] extr, tender to palpation, distal pulses 2+, 2+
edema b/l
Neurol: No focal deficits
Back: kyphoscoliosis
Pertinent Results:
[**2124-7-2**]
TYPE-ART TEMP-36.7 PO2-289* PCO2-91* PH-7.35 TOTAL CO2-52* BASE
XS-19
LACTATE-1.3, O2 SAT-100, freeCa-1.20
TEMP-36.6 PO2-257* PCO2-87* PH-7.39 TOTAL CO2-55* BASE XS-22
LACTATE-2.1*
O2 SAT-99
TYPE-ART RATES-/24 O2 FLOW-10 PO2-69* PCO2-99* PH-7.35 TOTAL
CO2-57* BASE XS-22 INTUBATED-NOT INTUBA
GLUCOSE-150* LACTATE-2.5* NA+-139 K+-3.6 CL--80* TCO2-48*
GLUCOSE-139* UREA N-13 CREAT-0.7 SODIUM-140 POTASSIUM-3.4
CHLORIDE-87* TOTAL CO2-49* ANION GAP-7*
CK(CPK)-111
CK-MB-12* MB INDX-10.8* cTropnT-0.06* proBNP-28
WBC-17.5* RBC-4.71 HGB-13.5* HCT-39.3* MCV-83 MCH-28.7 MCHC-34.4
RDW-13.3
NEUTS-74.9* LYMPHS-16.5* MONOS-7.2 EOS-1.1 BASOS-0.3
PLT COUNT-294
.
([**2124-7-21**])
BLOOD WBC-14.1* RBC-4.19* Hgb-11.6* Hct-36.3* MCV-87 MCH-27.8
MCHC-32.0 RDW-13.6 Plt Ct-248
PT-11.1 PTT-27.1 INR(PT)-0.9
Glucose-136* UreaN-11 Creat-0.5 Na-138 K-4.7 Cl-90* HCO3-42*
AnGap-11
Albumin-3.7 Calcium-9.4 Phos-4.6*# Mg-2.2
Type-ART pO2-94 pCO2-72* pH-7.43 calTCO2-49* Base XS-18
.
LIVER ULTRASOUND
IMPRESSION:
1. Unremarkable liver.
2. No ascites.
3. No hydronephrosis. Caliceal diverticulum with crystals in
lower pole of left kidney
([**2124-7-19**]) CT Trachea
IMPRESSION:
1. Marked tracheobronchomalacia, demonstrated by near collapse
of the central airways on expiration.
2. Moderate subglottic tracheal stenosis; irregularity of the
wall suggests prior therapy by dilatation.
3. Persistent near-collapse of the right middle and lower lobes.
4. Similar focal skeletal deformity centered at T7, unchanged
over one month. However, earlier studies are not available to
confirm stability. Correlation with prior imaging if available,
any clinical factors suggesting recent or prior infection, and
consideration of MR are suggested to evaluate further. Discussed
with Dr. [**Last Name (STitle) 111595**] on [**2124-7-21**].
Brief Hospital Course:
Upon admission, the patient was on a prednisone taper for COPD
flare and finishing his course of antibiotics for bilateral
lower extremity cellulitis (the reason why he had been admitted
a few days prior)
During this admission, we addressed the following issues:
.
1) Hypoxic respiratory failure--from mucus plug/pneumonia. The
patient was intubated in the MICU. Suctioning and bronchoscopy
were successfull removing large mucus plug. Pneumonia was
treated with cefepime and vancomycin. He was initially on
solumedrol 125 TID. He was extubated on day and transferred to
the floor for continuous management of his COPD flare and
secretions. On the floor, he transitioned quickly from face mask
to nasal cannula 4 Liters. Initially on solumedrol 80 TID, then
by day 2 started on prednisone taper.
MICU Course: Breathing difficulty continued however and
bronchoscopy was performed, and a severe stenosis secondary to
fibrous tissue was found. Patient was again transfered to MICU
for airway monitoring. Patient continued to have increased work
of breathing and required ET intubation. Interventional
Pulmonary was able to re-perform tracheotomy and secure the
airway using a T-piece device. Patient had an uneventful and
rapid recovery and was only requiring supplemental O2 by time of
discharge.
.
2) Hypercarbia, at one point the pt had Co2>100, which is very
above his baseline of 60-70. This was accompanied by marked
alkalosis >60. Both parameters improved steadily. Initially
lasix was decreased to once a day, later discontinued altogether
without worsening of the patient's volume status and marked
improvement in his alkalosis.
.
After above procedure, hypercarbia improved and blood gases
returned to baseline of pCO2 near 70.
.
3) COPD. Exacerbation was managed with steroids, albuterol and
atrovent nebulizers, as well as saline nebs.
.
After airway procedure, predinsone taper was begun and patient
continued to improve.
.
6) DM : Due to steroid induced hyperglycemia, the patient was
kept on a humalog sliding scale thorughout admission, including
MICU course.
.
7) Smoking, on going: received smoking cessation counseling,
kept on nicotine patch
Medications on Admission:
Fluticasone-Salmeterol 250-50 mcg/Dose Disk Inhalation [**Hospital1 **].
2. Spironolactone 25 mg PO DAILY.
3. Lasix 60 mg PO twice a day.
4. Cholecalciferol (Vitamin D3) 400 unit PO BID (2 times a day).
5. Omeprazole 20 mg PO once a day.
6. Hexavitamin PO DAILY (Daily).
7. Insulin Regular Sliding Scale.
8. Docusate Sodium 100 mg PO BID.
9. Senna 8.6 mg PO BID as needed.
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days.
11. Terbinafine 1 % [**Hospital1 **].
12. Ipratropium Bromide 0.02 % One Inhalation Q6H.
13. Prednisone taper 60 mg PO once a day, was on taper
14. Albuterol Sulfate 0.083 % Inhalation Q2H (every 2 hours) as
needed.
15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
TID (3 times a day) as needed.
17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
18. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q3H (every 3 hours).
19. Vancomycin 1 g Intravenous Q 12H (Every 12 Hours) for 11
days.
20. Oxycodone 5 mg, 1-2 Tablets PO PRN pain
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4H
(every 4 hours) as needed for breakthrough.
10. Ipratropium Bromide Inhalation
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours)
as needed for low back pain.
13. Lorazepam 0.5-2 mg IV Q4H:PRN
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
15. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
TID (3 times a day) as needed.
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
19. Guaifenesin 100 mg/5 mL Syrup Sig: Twenty (20) ML PO Q6H
(every 6 hours).
20. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): [**7-17**] and 10.
21. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days: [**7-19**] and 12.
22. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: [**7-21**] and 14.
23. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
From [**7-23**] on.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
COPD exacerbation
CHF
Metabolic Alkalosis
Discharge Condition:
Good. At baseline oxygen (3 Liters)
Discharge Instructions:
Admitted for shortness of breath. Initially you were in the MICU
intubated, then transitioned to the floor for steroid taper and
continued management of your shortness of breath.
Please take your medications as directed. Take the prednisone as
indicated in the taper. Continue your breathing exercises as
well. Don't miss any doctor's appointments.
Followup Instructions:
With your primary care doctor within 1 week of discharge
ICD9 Codes: 5180, 4280, 486, 2762, 3051, 4168, 2768, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1971
} | Medical Text: Admission Date: [**2182-8-7**] Discharge Date: [**2182-8-14**]
Date of Birth: [**2109-9-3**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 72-year-old patient,
who has a [**2-15**] year history of chest discomfort with exertion,
which resolves with rest. He had an abnormal EKG and was
referred for stress testing. His stress test was positive
for ST depression inferiorly and laterally, which improved
with rest and he was referred for cardiac catheterization.
PAST MEDICAL HISTORY: Hypercholesterolemia.
He is a 50-pack-year smoker.
Thalassemia trait with anemia.
Claudication.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Toprol XL 50 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Imdur 30 mg p.o. q.d.
PREOPERATIVE LABORATORY DATA: Significant for a creatinine
of 1.5.
HOSPITAL COURSE: Patient was admitted to [**Hospital1 346**] on [**2182-8-7**] and underwent
cardiac catheterization. He was found to have an ejection
fraction of 60 percent, LVEDP of 14, 80 percent heavily
calcified left main coronary artery, 80 percent diffuse
proximal LAD lesion with a distal LAD lesion at 70-80
percent. An 80 percent origin of left circumflex, 90 percent
proximal left circumflex, and a totally occluded RCA with
collaterals to RDL.
Ba[**Last Name (STitle) 57772**] the results of the catheterization, it was
determined that the patient would be admitted to the hospital
and be taken for revascularization. Patient was placed on a
Heparin drip. He had ultrasound evaluation of his carotid
arteries, which showed a less than 40 percent lesion on the
right and no stenosis on the left. He had lower arterial
Doppler studies done, which showed normal flow to the left
leg with significant aortoiliac disease on the right, and
patient was taken to the operating room on [**8-9**] with
Dr. [**Last Name (Prefixes) **], where he underwent a CABG x4 LIMA to LAD,
SVG to OM-1 and OM-2, and SVG to PDA. Total cardiopulmonary
bypass time 133 minutes. Cross-clamp time 95 minutes.
Patient was transported to the Intensive Care Unit in stable
condition. Please see operative note for full details.
Patient was weaned and extubated from mechanical ventilation
on his first postoperative afternoon. On postoperative day
one, the patient was started on Lasix for diuresis and beta
blockers, and on postoperative day number one, the patient
was transferred from the Intensive Care Unit to the regular
part of the hospital. Patient began ambulating with Physical
Therapy, had continued diuresis. By postoperative day number
five, the patient had completed level 5 of Physical Therapy.
Had appropriately diuresed and was cleared for discharge to
home.
CONDITION ON DISCHARGE: T max 99.4. Pulse 64 in sinus
rhythm. Blood pressure 114/54. Respiratory rate is 18. On
room air oxygen is 94 percent. Neurologically: He is awake,
alert, and oriented times three and no obvious deficit.
Heart: Regular rate and rhythm without rub or murmur.
Respiratory: Breath sounds are clear bilaterally. GI:
Positive bowel sounds, soft, nontender, nondistended, and
tolerating a regular diet. Sternal incision is clean, dry,
and intact. Sternum is stable. Steri-Strips open to air.
Vein harvest site is clean, dry, and intact. There is no
erythema and there is no drainage.
Chest x-ray on [**8-14**] showed small bilateral pleural
effusions without any evidence of CHF, no pneumothorax.
LABORATORY DATA: Sodium 143, potassium 4.7, chloride 109,
bicarb 25, BUN 24, creatinine 1.5, glucose 79.
DISPOSITION: The patient is to be discharged to home in
stable condition.
DISCHARGE MEDICATIONS:
1. Percocet 5/325 mg 1-2 tablets p.o. q.4-6h prn.
2. Plavix 75 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Norvasc 5 mg p.o. q.d.
6. Lasix 20 mg p.o. q.d. x7 days.
7. Potassium chloride 20 mEq p.o. q.d. x7 days.
8. Toprol XL 50 mg p.o. q.d.
DISCHARGE DIAGNOSES: Coronary artery disease.
Status post coronary artery bypass graft.
Right aortoiliac disease.
FO[**Last Name (STitle) 996**]P: The patient should follow up with his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57773**] in [**1-15**] weeks. He should
follow up with Dr. [**Last Name (STitle) 1911**], his cardiologist in [**2-14**]
weeks, and he should follow up with Dr. [**Last Name (Prefixes) **] in four
weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2182-8-14**] 13:01:36
T: [**2182-8-15**] 05:12:55
Job#: [**Job Number 57774**]
ICD9 Codes: 4111, 4439, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1972
} | Medical Text: Admission Date: [**2175-5-16**] Discharge Date:
Date of Birth: [**2110-8-10**] Sex: F
Service: O-MED
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
lady with locally advanced non-small cell cancer that was
initially presented as superior vena cava syndrome more than
one year ago and recently diagnosed subsegmental PE who
initially presented to the Emergency Department on [**2175-5-16**] with nausea, vomiting, and abdominal pain.
She was subsequently found to have a large PE with a
tamponade physiology. She had a pericardial window placed on
[**2175-5-18**] without any complications. She had remained
hemodynamically stable since. Her chronic anticoagulation
for a history of superior vena cava syndrome and PE was
initially reversed to enable the pericardial placement.
Postoperatively, the decision was made to re-initiate
anticoagulation given her hypercoagulable state, but the
therapeutic INR range was decreased to 1.5 to 2. She was
also started on an intravenous heparin drip with a goal
partial thromboplastin time of 60 to 70 while her INR was
subtherapeutic.
She was called out of the Medical Intensive Care Unit to the
East Oncology/Medicine Service as she was clinically stable.
While she was in the Medical Intensive Care Unit, she also
had a barium swallowing study done to evaluate a questionable
small amount of air behind the esophagus on her admission
chest computed tomography. The barium swallowing study was
normal. Her stay int he Medical Intensive Care Unit was also
notable for episodes of psychosis which were attributable to
opioids side effects.
PAST MEDICAL HISTORY:
1. Non-small cell cancer diagnosed in [**2173-1-18**] after
the patient presented with superior vena cava syndrome.
Status post chemotherapy with carboplatin, Taxol, and
gemcitabine, and radiation therapy.
2. Hypertension.
3. Type 2 diabetes mellitus.
4. Gastroesophageal reflux disease.
5. Chronic low back pain.
6. Depression.
7. Chronic abdominal pain.
8. Esophageal strictures; status post dilatation.
9. In [**2175-1-18**], pancreatic divisum with chronic
hyperamylasemia due to macroamylasemia.
10. Status post sphincterectomy in [**2171**].
11. Subsegmental PE diagnosed in [**2175-4-18**].
12. Congestive heart failure (with an ejection fraction of
40%).
ALLERGIES: PENICILLIN and SULFA (which cause a rash) and
CODEINE.
MEDICATIONS ON TRANSFER: (To the East Oncology/Medicine
Service)
1. Warfarin 2 mg p.o. q.h.s.
2. Paxil 20 mg p.o. q.h.s.
3. Protonix 40 mg p.o. once per day.
4. Fentanyl patch 50 mcg per hour transdermally q.72h.
5. Senna one tablet p.o. twice per day.
6. Colace 100 mg p.o. twice per day.
7. Ibuprofen 600 mg p.o. three times per day (with meals).
8. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed.
9. Zofran 2 mg to 4 mg intravenously q.4-6h. as needed.
10. Seroquel 25 mg to 50 mg p.o. q.h.s. as needed.
11. Heparin drip (with a goal partial thromboplastin time of
60 to 70).
12. Regular insulin sliding-scale.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on transfer to the East Oncology/Medicine Service revealed
temperature was 96.5, blood pressure was 114/64, heart rate
was 102, respiratory rate was 14, and oxygen saturation was
99% on 2 liters. In general, a pleasant elderly woman
sitting up in bed, in no acute distress. Head and neck
examination revealed sclerae were anicteric. Mucous
membranes were moist. The oropharynx was clear. The neck
was supple. Extraocular movements were intact. Pupils were
equal, round, and reactive to light. Cardiovascular
examination revealed a regular rate and rhythm. Normal first
heart sounds and second heart sounds. Positive for rubs.
The lungs revealed bilateral basilar crackles. The abdomen
was soft. Normal active bowel sounds. Diffusely tender
especially at the epigastric region where the window was
done. The back revealed no costovertebral angle tenderness.
No spinal tenderness. Extremity examination revealed trace
edema but warm to touch. Distal pulses were 2+. Skin
revealed no rashes, and no lesions. Neurologic examination
revealed awake, alert and oriented times three. A nonfocal
examination.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
transfer to the Oncology/Medicine Service revealed white
blood cell count was 13.6, hematocrit was 25.5, and platelets
were 485. Prothrombin time was 13.6, partial thromboplastin
time was 46.6, and INR was 1.2. Sodium was 140, potassium
was 3.5, chloride was 109, bicarbonate was 18, blood urea
nitrogen was 13, creatinine was 0.8, and blood glucose was
142. Calcium was 8.7, magnesium was 2.2, and phosphate was
3.7.
HOSPITAL COURSE: During her stay on the Oncology/Medicine
Service she remained hemodynamically stable. She continued
to require ibuprofen, Tylenol, and occasional oxycodone for
her pain around the pericardial window site.
She was continued on anticoagulation without any
complications. Her Coumadin dose was increased to 3 mg p.o.
q.h.s., and her INR reached the therapeutic range. Her
hematocrit had slowly been trending down throughout her
hospital stay, which was thought most likely secondary to her
chronic disease. She received 2 units of packed red blood
cells, and her hematocrit responded nicely to the
transfusion.
Since the patient complained of recurrent dysphagia, she went
for another esophageal dilatation. The procedure itself was
not complicated. However, in the Postanesthesia Care Unit
she acute respiratory decompensation with oxygen saturations
down to 70s on room air. She was thought to have
methemoglobinemia with a methemoglobin level of up to 17, for
which she was treated with methylene blue. However, after
methemoglobinemia was resolved with methylene blue she was
also noted to have acute mental status changes with the
inability to speak. Since her mental status and neurologic
deficits resolved spontaneously, it was thought she had acute
metabolic encephalopathy due to analgesics which she received
perioperatively. However, the Neurology Service recommended
a lumbar puncture to rule out meningeal carcinomatosis. The
decision was made not to pursue lumbar puncture since the
patient was not a candidate for intrathecal chemotherapy.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to rehabilitation.
DISCHARGE DIAGNOSES:
1. Cardiac tamponade with pericardial effusion; status post
pericardial window placement.
2. Esophageal stricture; status post dilatation.
3. Delirium psychosis.
4. Metabolic encephalopathy.
5. Pulmonary emboli.
6. Type 2 diabetes mellitus.
7. Metastatic non-small cell lung cancer.
MEDICATIONS ON DISCHARGE:
1. Coumadin 3 mg p.o. q.h.s.
2. Paxil 20 mg p.o. once per day.
3. Protonix 40 mg p.o. once per day.
4. Fentanyl patch 50 mcg per hour transdermally q.72h.
5. Seroquel 25 mg p.o. q.h.s. as needed.
6. Colace 100 mg p.o. twice per day.
7. Dulcolax 10 mg p.o./p.r. once per day as needed.
8. Senna one to two tablets p.o. once per day as needed.
9. Regular insulin sliding-scale.
10. Motrin 800 mg p.o. three times per day as needed.
11. Tylenol 500 mg to 1000 mg p.o. q.4-6h. as needed (with a
maximum dose of 4000 mg p.o. once per day).
12. Lidocaine Viscous 1 cc to 2 cc p.o. q.4-6h. as needed
(for pain).
13. Oxycodone 5 mg p.o. q.4-6h. as needed (avoid this if
possible).
14. Zofran 4 mg p.o. q.4-6h. as needed.
15. Compazine 10 mg p.o. q.6-8h. as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. Please check the patient's INR twice per week until it is
stabilized in a therapeutic range of 1.5 to 2.
2. Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] office with any
questions.
[**Name (STitle) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3282**]
Dictated By:[**Last Name (NamePattern1) 225**]
MEDQUIST36
D: [**2175-5-26**] 22:57
T: [**2175-5-26**] 23:49
JOB#: [**Job Number 9354**]
ICD9 Codes: 4280, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1973
} | Medical Text: Admission Date: [**2111-1-11**] Discharge Date: [**2111-1-13**]
Date of Birth: [**2048-8-13**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Metformin
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Inferior STEMI
Major Surgical or Invasive Procedure:
[**2111-1-11**] Catheterization and stent of distal RCA
History of Present Illness:
The patient is a 62 year old female with a medical history that
includes diabetes and hypertension who presents from home with
chest pain. She was in her normal state of health (chest pain
free, able to ambulate up three flights of stairs in home w/out
symptoms) until one week ago when she started to develop
epigastric and substernal chest pain. She describes it as
[**2109-5-24**], constant, radiating to left shoulder and jaw, and
associated with nausea. It was not worse w/ activity. She
initially attributed it to acid reflux although it did not
improve with antacids. She felt that it was getting
progressively worse so she presented to [**Hospital1 **] [**Location (un) 620**].
.
In [**Location (un) 620**] ED, initial vitals were 97 BP: 171/81 (168/70 right
arm, 162/73 left arm) Resp: 18 O(2)Sat: 100. Exam was
unremarkable. EKG per report showed sinus rhythm, rate 94, 2mm
ST elevation II, III, AVF with 1mm ST depression in AVL. Initial
labs notable for WBC count 13, creatinine 2.1, troponin-T 1.62.
She was given 2SLNG with resolution of chest pain. CXR per
report with no acute process. She was given aspirin 325mg,
plavix 600mg, and heparin bolus and gtt, and sent to [**Hospital1 18**] for
urgent cardiac catheterization.
.
In the Catheterization lab at [**Hospital1 18**], she was found to have
complete occlusion of the distal RCA, 80% disease of OM1 and 70%
disease of the proximal LAD. The distal RCA lesion was believed
to be the culprit and she received one DES with good
angiographic result. She was given bivalrudin. Got 230cc of dye.
.
In the CCU, she denies chest pain, shortness of breath. Feels
some tightness in back of throat.
.
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:
1. CARDIAC RISK FACTORS:
+Diabetes
+Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
-GERD
Social History:
- works as administrative assistant
- lives in [**Location 1439**] with husband, no children
- Tobacco history: remote, quit 40 years ago
- ETOH: denies
- Illicit drugs: denies
Family History:
- Mother: alive, 87 years old, multiple PCI 10 years ago
- Father: died 40s, Hodgkins disease
- several uncles with myocardial infarction
Physical Exam:
Admission Exam:
VS: afebrile, 135/51 HR: 65 95% room air
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. I/VI systolic murmur apex
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. R radial TR band in
place
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge Exam:
VS: 100.3, 98.8, 126/65 (108-126/47-65), 64 (54-68), 20, 98%RA
Weight: 99.1kg
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis, erythema of the oral mucosa. No
xanthalesma.
NECK: Supple with JVP of 8cm, unchanged.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. II/VI early systolic murmur apex. No
rubs or gallops noted
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. R radial cath site
without tenderness, erythema or hematoma. Dressing c/d/i.
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:
OSH labs:
WBC count 13, creatinine 2.1, troponin-T 1.62
Admission Labs:
[**2111-1-12**] 12:51AM BLOOD WBC-9.6# RBC-3.34* Hgb-9.3* Hct-28.3*
MCV-85 MCH-27.9 MCHC-32.9 RDW-13.8 Plt Ct-162
[**2111-1-12**] 12:51AM BLOOD PT-12.3 PTT-125.6* INR(PT)-1.1
[**2111-1-12**] 12:51AM BLOOD Glucose-224* UreaN-38* Creat-1.8* Na-136
K-4.7 Cl-106 HCO3-22 AnGap-13
[**2111-1-12**] 12:51AM BLOOD ALT-22 AST-87* LD(LDH)-382* AlkPhos-64
TotBili-0.2
[**2111-1-12**] 12:51AM BLOOD CK-MB-32* cTropnT-3.81*
[**2111-1-12**] 09:12AM BLOOD CK-MB-15* cTropnT-2.95*
[**2111-1-12**] 12:51AM BLOOD Calcium-9.7 Phos-2.8 Mg-1.6 Iron-20*
Cholest-133
[**2111-1-12**] 12:51AM BLOOD calTIBC-278 Hapto-196 Ferritn-70 TRF-214
[**2111-1-12**] 12:51AM BLOOD Triglyc-135 HDL-41 CHOL/HD-3.2 LDLcalc-65
Discharge Labs:
[**2111-1-13**] 07:20AM BLOOD WBC-7.0 RBC-3.17* Hgb-8.9* Hct-27.3*
MCV-86 MCH-28.0 MCHC-32.5 RDW-13.7 Plt Ct-154
[**2111-1-13**] 07:20AM BLOOD PT-11.9 PTT-29.9 INR(PT)-1.1
[**2111-1-13**] 07:20AM BLOOD Glucose-179* UreaN-46* Creat-2.5* Na-137
K-4.3 Cl-107 HCO3-23 AnGap-11
[**2111-1-13**] 07:20AM BLOOD Calcium-10.4* Phos-3.3 Mg-2.5
[**2111-1-11**] Catheterization:
1. Selective angiography of this right dominant system
demonstrated 3
vessel coronary artery disease. The RCA had a 100% distal
occlusion
that was thought to be the culprit lesion for the patient's
inferior
STEMI. The RCA gave off a small PDA and a large network of
RPLs. The
LMCA was without angiographically significant coronary artery
disease.
The proximal LAD appeared aneurysmal with a long, ulcerated 70%
lesion,
but the remainder of the LAD was free of angiographically
significant
stenoses. The LCX had a focal 80% lesion in the OM1, but was
otherwise
free of angiographically significant coronary artery disease.
2. Limited resting hemodynamics revealed a normal systemic
arterial
blood pressure with a central aortic pressure of 138/68.
3. Successful PTCA and stenting of the distal RCA with a
2.5x23mm PROMUS
RX stent which was postdilated to 2.5mm. Final angiography
demonstrated
no residual stensis, no angigoraphically apparent dissection and
TIMI
III flow (see PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PTCA and stenting of the distal RCA with a DES.
3. Normal systemic arterial blood pressure.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 62 year old female with a medical history of
hypertension and diabetes who presents from home with one week
of symptoms concerning for angina, found to have inferior ST
elevation myocardial infarction, taken for urgent
catheterization and found multivessel coronary artery disease
with complete occlusion of distal RCA, which was intervened on
with one drug eluting stent with good angiographic result,
transferred to CCU post-cath.
.
# INFERIOR STEMI: Patient found to have ST elevation in inferior
leads with III > II and reciprocal depression in AVL suggesting
RCA as the culprit vessel. She also had ST depression in V1,
which may have represented contiguous infero-basal involvement.
Likely this is a late presentation of her myocardial infarction
given her symptoms have been going on for days and troponin-T
was positive to 1.6 at [**Location (un) 620**], peak troponin was 3.81 at
admission to the CCU. She was found to have complete occlusion
of distal RCA on cardiac catheterization. She was also found to
have left circumflex and anterior descending disease on
catheterization. It is not clear if these lesions are resulting
in symptomatic ischemic heart disease and less likely that
either is causative of her current presentation. She remained
chest pain free after the catheterization. Her LCx and LAD
disease will be medically managed at discharge. She was started
on aspirin, Plavix, metoprolol, and atorvastatin. On the
morning of discharge, she had some mild chest pain when lying
flat. ECG suggested some pericarditis. Pain resolved when
sitting upright. She was advised to not take NSAIDs at this time
given her acute kidney injury. She will contact her PCP should
her pain worsen. She will follow-up with cardiology regarding
future management options: CABG vs repeat PCI vs medical
management. She will also have an echocardiogram at this time
to assess her LV function.
.
# ELEVATED CREATININE: Patient without known history of renal
insufficiency with last creatinine recorded being 1.2 ([**2106**]),
found to have elevated creatinine of 2.1 at admission of unclear
[**Name2 (NI) 105600**]/duration. Given concern for contrast induced nephropathy
after her cardiac cath, her lisinopril was held. At discharge,
her creatinine was acutely worse at 2.5, likely a result of the
dye load during catheterization. Her lisinopril and metformin
were held on discharge and patient was scheduled with close
follow up ([**1-15**]) with her PCP, [**Name10 (NameIs) **] was instructed to have labs
drawn the day prior to her appointment to ensure her Creatinine
improves. SHe was also advised to avoid NSAIDs at this time.
.
#DIABETES: We held her metformin given elevated creatinine with
large dye load during PCI. She was started on an insulin
sliding scale. Her A1c during this admission was pending at
discharge. She is only on metformin at home currently, which
was not continued on discharge given her acute kidney injury.
She will have close follow up with her PCP ([**1-15**]), and provided
her Creatinine improves, can restart the metformin a few days
s/p discharge.
.
#HYPERTENSION: Blood pressure remained well controlled during
this admission. Her lisinopril was held, as discussed above, and
she was started on metoprolol.
.
#CODE STATUS: FULL
#Transitional issues
-Will require Plavix for one year and aspirin 325mg for one
month followed by 81mg daily given [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]
-Has been started on atorvastatin and metoprolol during this
admission
-Consider restarting lisinopril if creatinine improves
-Restart metformin provided creatinine improves
-Will follow up with PCP on [**1-15**].
-Will follow-up with Dr. [**Last Name (STitle) 171**] after discharge regarding
management of her CAD, she will have a repeat echo at this time
([**2-16**])
Medications on Admission:
-lisinopril 20mg daily
-metformin 1000mg [**Hospital1 **]
-aspirin 81mg daily
-folic acid 1mg daily
-calcium 600mg and vitamin D
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. Outpatient Lab Work
Please draw a basic chemisty panel on [**2111-1-14**] and fax results
to Dr. [**Last Name (STitle) **], [**First Name3 (LF) 1158**] R. (Office #[**Telephone/Fax (1) 9347**], Fax
#[**Telephone/Fax (1) 12540**]).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Inferior wall STEMI
Secondary Diagnosis:
Diabetes
Hypertension
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the Coronary Care Unit (CCU) at [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for management of your chest pain. You
were found to have a heart attack and went to the cardiac
catheterization lab urgently where we placed a drug-eluting
stent in one of your heart arteries. You were given
anti-platelet medications after your procedure. Your chest pain
resolved and you were monitored without any additional events.
.
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:
-Aspirin 325mg by mouth daily for one month. Following this,
you
should take 81mg by mouth daily.
-Plavix (Clopidogrel) 75mg by mouth daily for 1 year
-Metoprolol extended release 50mg by mouth daily
-Atorvastatin 80mg by mouth daily
-Docusate sodium 100mg by mouth as needed for constipation
.
You should STOP:
Lisinopril
Metformin
* These medications have been stopped because of your acutely
worsened kidney function. Your primary care doctor can decide
to restart them at your appointment on [**1-15**] if your blood
work comes back improved. Please have your blood work drawn on
[**1-14**].
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
You will need a follow up Cardiac echo prior to your cardiology
appointment. You should also get blood work drawn prior the day
prior to your appointment with DR. [**Last Name (STitle) 10531**].
Followup Instructions:
Name: [**Last Name (LF) 10531**],[**First Name3 (LF) **] R.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Street Address(2) 10534**], [**Location (un) **],[**Numeric Identifier 12541**]
Phone: [**Telephone/Fax (1) 9347**]
Appointment: Thursday [**2111-1-15**] 11:00am
*Please discuss with your doctor about an echocardiogram prior
to your cardiology follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**].
Department: CARDIAC SERVICES
When: MONDAY [**2111-2-16**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2111-2-16**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1974
} | Medical Text: Admission Date: [**2197-4-10**] Discharge Date: [**2197-4-19**]
Date of Birth: [**2197-4-10**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] is 31/1 weeks
gestation female weighing 1350 gm at birth, who was admitted
to the Neonatal Intensive Care Unit from OR for prematurity.
At the time of transfer to [**Hospital3 2783**] she is 9 days
old and corrected gestation of 32+3 weeks. Mother is a
33-year-old gravida 4, para 1, now 2 mom with past medical
history notable for chronic hyperreninemic hypertension since
[**11**] years of age and has been on Hydralazine, Labetalol,
Nifedipine, Catapres and potassium supplement.
OBSTETRIC HISTORY: Significant for previous 30 week infant
born by cesarean section in [**2194**] after pregnancy was
complicated by severe hypertension. Her prenatal screens
were A+, antibody negative, RPR non reactive, rubella immune
and GBS unknown. The current pregnancy, expected date of
delivery was [**2197-6-4**] based on 6 and 9 weeks ultrasound. The
current pregnancy was complicated by acute on chronic
hypertension.
She completed a course of Betamethasone on [**4-6**], following
which she developed insulin dependent gestational diabetes
mellitus. Repeat cesarean section was performed for
worsening PIH under epidural and spinal anesthetic. No
intrapartum fever or fetal tachycardia. No antibiotics
administered to mom. Rupture of membranes at the time of
delivery yielding clear amniotic fluid.
DELIVERY DETAILS: The infant emerged with good tone and weak
cry, was given some tactile stim and oral and nasal bulb
suctioning. Mild central cyanosis was noted. Apgars were
[**5-22**] and she was transferred to NICU uneventfully.
PHYSICAL EXAMINATION: On admission the weight was 1350 gm
which is between 25th and 50th percentile. Head
circumference of 27 cm, between 10th and 25th percentile and
length of 38.5 cm which is between 10th and 25th percentile.
Heart rate was 142, respiratory rate 46, temperature 96.9,
blood pressure mean of 39, saturation of 93% in room air.
Physical examination revealed anterior fontanels flat and
opened, non dysmorphic, intact palate, moderate nasal
flaring, mouth and neck normal. Chest showed mild
retractions with initial grunting respirations which were
resolved pretty soon after few scattered crackles.
Cardiovascular, well perfused, no murmur. Abdomen soft, non
distended, no organomegaly, no masses, bowel sounds active,
anus patent, normal female external genitalia, active and
responsive to stim, normal spine length, hips and clavicles.
IMPRESSION: 31+1 week gestation female with mild respiratory
distress, improving within an hour of life and low risk for
infection.
HOSPITAL COURSE:
Respiratory: She has been in room air since birth, was
loaded with caffeine for shallow breathing and has stayed on
caffeine. Is currently on 6 mg/kg/day of caffeine citrate
which is 8 mg po/PG q d. Has not had any spells and is
stable in room air.
Cardiovascular: No issues. Blood pressures have been
stable.
Fluids, Electrolytes & Nutrition: Was initially started
on D10W at 80 cc per/kilo/day. Subsequently was started on
feeds on day #2 of life, at 20 cc/kilo which were advanced
and now is on full feeds of breast milk 22. Today the
calories were advanced to 24cal/oz of breast milk at 150
cc/kilo/day. The last set of electrolytes were sodium of 142,
potassium 4.6, chloride 111 and total CO2 of 20 which was on
[**4-14**]. Blood sugar has been stable at 86 which was done on
[**4-17**].
GI: The child has been on tube feeds, tolerating breast
milk 22, given PG.
ID: Was started on Amp and Gent for rule out which were
discontinued after 48 hours once the blood cultures came back
negative.
Heme/Bili: She has been on single phototherapy,
highest bilirubin being 11.2/.3 on day #3 which is [**4-13**]. The
latest bilirubin was 5.9/.2 on [**4-18**] and is still under one
phototherapy. The last hematocrit was 58.9 on [**4-13**].
6. Neuro: Head ultrasound on [**4-19**] showed choroid plexus cysts
bilateral otherwise normal.
7. Sensory: Hearing screen is pending. Eye exam is also
pending.
CONDITION ON DISCHARGE: Stable, growing preterm infant who
needs to start feeding po and grow and that is why she is
transferred to [**Hospital3 **]. The primary pediatrician
is Dr. [**Last Name (STitle) **] [**Name (STitle) 36391**] from [**Location (un) 5028**].
Newborn screen was sent on [**4-13**], hepatitis B immunization is
pending.
CURRENT CARE RECOMMENDATIONS: The child is on 150
cc/kilo/day of breast milk 24 and plan is to continue going up
on calories, is on caffeine with the dose of 8 mg po PG q
daily. Today Ferinsol 0.1cc pg qd and vitamin E 5 IU were
added. She is also under single phototherapy. Car seat
position screening is pending. Immunizations are pending.
Immunizations recommended
i.Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**].
DISCHARGE DIAGNOSIS: 1. Prematurity. 2. Hyperbilirubinemia.
3. Rule out sepsis.
4. Shallow breathing.
5. Choroid plexus cysts on head ultrasound scan
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Doctor Last Name 42588**]
MEDQUIST36
D: [**2197-4-18**] 16:16
T: [**2197-4-18**] 16:29
JOB#: [**Job Number 42589**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1975
} | Medical Text: Admission Date: [**2151-3-29**] Discharge Date: [**2151-4-3**]
Date of Birth: [**2073-7-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
ACS, cardiogenic shock
Major Surgical or Invasive Procedure:
central line
cardiac catheterization
MVR
possible CABG
History of Present Illness:
77 year old female w/ a h/o [**First Name3 (LF) **], hypercholesterolemia, DM, PMR
on steroids who is transferred from [**Hospital 2079**] hospital w/ ACS
in cardiogenic shock. She initially presented to [**Hospital 2079**]
hospital w/ 2 days of CP and SOB. Family describes "chest
congestion" starting at ~7 pm on the night of presentation to
Southshore ([**2151-3-28**]) which was significantly worse than recently
(had been complaing of chest congestion x 2 wks) now associate
with SOB. Husband called 911 and she was brought to [**Hospital 2079**]
hospital. In the Southshore ED, patient found to have ST
depressions in V2-V6 and isolated STE in V1. She was also found
to have pulmonary edema and was managed w/ BiPAP and diuresis.
This am, patient was evaluated by Cardiology and was found to be
hypotensive in cardiogenic shock. Cr rising w/ poor UOP despite
diuresis. Cardiac enzymes were found to be elevated: CK
198->431->951-> 5403, MB 37->86->192->915, Trop
0.37->0.95->1.46->17.16. She was started on heparin gtt,
integrillin, Plavix 300mg x1. She underwent cardiac cath showing
TO LAD, 90% circ, tortuous RCA with L->L collaterals as well as
R->L collaterals to septum. IABP placed and patient was
intubated, Patient was briefly in asystole by report but
converted with CPR and was placed on Levophed via a peripheral
IV. 2 PIV's in place. Stat bedside ECHO showed moderate to
severe MR and MR w/ apical and lateral HK.
.
Upon arrival to the CCU, patient is intubated and sedated but
moving all extremities. She continues to have a high levophed
requirement to maintain her pressures. She was taken emergently
to the cardiac cath lab where her LAD TO was confirmed as well
as her 90% circ w/ L->L collaterals and RCA w/ aneurysm vs.
dissection and R->L collaterals. She received 2 BMS->Circ. The
LAD was crossed but given likely chronicity of her TO, it was
not opened.
.
Recent events discussed with patient's family. Family notes that
since THR in [**10/2150**], patient has complained of increased
fatigue. Has also had slow, slurred speech since that time.
Family notes DOE w/ [**2-4**] of a mile over the last year. She must
stop after a few steps on the stairs to rest. Patient also
complained of "chest congestion" over the last few weeks which
had recently improved. She also complained of "indigestion".
Associated w/ recent chest congestion, patient also had
orthopnea symptoms which improved w/ pillows.
Past Medical History:
# hypertension
# hypercholesterolemia
# diet controlled DM (family denies)
# Polymyalgia Rheumatica
# s/p R THR [**10/2150**]
# s/p appendectomy in her 30s
# s/p umbilical hernia repair
Social History:
Patient lives in [**Location 77420**] with husband. She has 3 daughters in
the area as well as a son. She used to smoke [**3-7**] cigs/day x 20
yrs but quit 20 yrs ago. No EtOH use.
Family History:
No significant family h/o CAD or SCD
Physical Exam:
VS: T 100.3, BP 84/60, HR 74, RR 17, O2 99% on AC400x16,PEEP5,
FiO2 100%
Gen: pale, ill appearing female, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL.
Neck: Supple with JVP of to angle of mandible.
CV: RR, normal S1, S2. No S4, no S3. II/VI sys murmur at base
Chest: Course breath sounds bilaterally w/ basilar crackles
bilaterally.
Abd: Decreased BS. Soft, NTND, No HSM or tenderness. No
abdominal bruits.
Groin: IABP in R groin. Arterial sheath and PA catheter in L
groin.
Ext: Cool extremities. Blue, cyanotic appearing L hand.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+; Femoral 2+; DP dopp
Left: Carotid 2+; Femoral 2+; DP dopp
Pertinent Results:
COMMENTS:
1. Successful stenting of the LCX with two bare metal stents 3.0
X 18 mm
and 2.5 X 12 mm Vision stents in a non-overlapping fashion with
no
residual stenosis (see PTCA comments for detail).
2. Engagement of the proximal cap of the chronic total LAD
occlusion
with Shinobi wire.
3. RCA angiography showing two proximal and mid vessel 60%
lesion an a
distal pseudoaneurysm with possible dissection.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe systolic and diastolic ventricular dysfunction.
3. Cardiogenic shock requiring IABP support.
4. Successful stenting of the LCA with two bare metal stents
-------
TTE [**3-30**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
inferolateral akinesis, as well as inferior and lateral
hypokinesis (LCx distribution). The remaining segments exhibit
compensatory hyperkinesis (LVEF = 35-40%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. There is a partial
rupture of the posterolateral papillary muscle with associated
eccentric, anteriorly-directed jet of severe (4+) mitral
regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a trivial/physiologic pericardial effusion. There is an
anterior space which most likely represents a fat pad.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Partial papillary muscle rupture with
severe mitral regurgitation. Moderate tricuspid regurgitation.
Moderate pulmonary hypertension
----------------
TTE [**3-31**] after surgery
Prebypass: moderate global LV hypokinesis (30-35%), severe
mitral regurgitation with eccentric jet, partial rupture of
posteromedial papillary muscle and chordae tendinae, moderate 2+
tricuspid regurgitation. Right ventricular free wall appears
normal. There is evidence mildly calcified aortic leaflets but
no evidence of aortic stenosis. Descending and ascending aorta
within NL limits.
Postbypass: overall LV function globally depressed (30-35%).
Minimal improvement compared to prebypass. Prosthetic mitral
valve leaflets well positioned and adequate movement of the
leaflets. . No appreciable mitral regurgitation. Moderate
tricuspid regurgitation as seen in the prebypass period.. RV
free wall unchanged and normal. Descending and ascending aorta
within normal limits and without evidence of dissection.
[**2151-4-3**] 09:24PM BLOOD WBC-7.5# RBC-1.14*# Hgb-3.5*# Hct-10.9*#
MCV-96# MCH-30.7 MCHC-32.2 RDW-15.7* Plt Ct-29*#
[**2151-4-3**] 09:24PM BLOOD Neuts-73.2* Bands-0 Lymphs-16.3*
Monos-9.5 Eos-0.2 Baso-0.8
[**2151-4-3**] 09:24PM BLOOD Plt Ct-29*#
[**2151-4-3**] 05:19AM BLOOD Glucose-142* UreaN-51* Creat-0.9 Na-146*
K-3.9 Cl-113* HCO3-24 AnGap-13
[**2151-4-2**] 08:53AM BLOOD ALT-57* AST-53* LD(LDH)-714* AlkPhos-65
Amylase-264* TotBili-0.8
[**2151-4-2**] 08:53AM BLOOD Lipase-99*
[**2151-3-31**] 03:30AM BLOOD CK-MB-76* MB Indx-13.9* cTropnT-8.97*
[**2151-4-3**] 05:19AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.2
[**2151-3-30**] 03:02AM BLOOD %HbA1c-4.9
Brief Hospital Course:
SUMMARY OSH AND CCU COURSE
77 y/o F with a history of type II diabetes, [**Month/Day/Year **], dyslipidemia,
PMR with increasing fatigue since undergoing THR in 9/[**2150**].
Patient had complaints of increasing DOE and orthopnea 2 weeks
prior to admission. She was only able to climb a few steps on
the stairs before stopping for rest. 2 days PTA patient also
complained of "chest congestion" and "indigestion", on the day
of admission patient c/o of worsening chest congestion and
dyspnea. Husband called 911 and on [**3-28**] she presented to
[**Hospital 2079**] hospital ED, in the Southshore ED patient??????s ECG
showed ST depressions in V2-V6 and isolated STE in AVR. Cardiac
enzymes revealed tropT 0.37, CK 198 and MB 37. She was started
on heparin gtt, integrillin, Plavix 300mg x1. She was also found
to have pulmonary edema and was managed w/ BiPAP and diuresis.
Next morning patient was evaluated by Cardiology and found to
be hypotensive, with rising creatinine, poor UOP despite
dieresis. Cardiac enzymes rising CK 198->431->951-> 5403, MB
37->86->192->915, Trop 0.37->0.95->1.46->17.16. She underwent
cardiac cath at [**Hospital1 34**] which showed a totally occluded LAD, 90%
occluded left circ, tortuous RCA with evidence of L->L
collaterals as well as R->L collaterals to septum. IABP placed
and patient was intubated, Patient was briefly in asystole by
report but converted with CPR . Levophed was started via a
peripheral IV. Stat ECHO showed moderate to severe MR and MR w/
apical and lateral HK., EF 40-45%. Patient was then transferred
to [**Hospital1 18**].
Upon arrival to the CCU, patient is intubated and sedated with a
high levophed requirement to maintain her pressures, ECG showed
ST depressions in V3-4, TWI V5-6. She was taken emergently to
the cardiac cath lab which showed 2 sequential 90% left circ
lesions which were stented with 2 non overlapping BMS, no
residual stenosis with TIMI 3 flow afterwards, pressor
requirements decreased with improvement in MAP. Her totally
occluded LAD was probed, were able to break the cap but the
wire was not easily advanced confirming the chronicity.RCA
angiography showed two proximal and mid vessel 60% lesions with
? of aneurysm vs. dissection and multiple septal collaterals to
LAD.
On return from cath lab pressor requirements were decreased and
patient was diuresed, PEEP increased to [**Month (only) **]. preload( [**Month (only) **] venous
return from inc. thoracic pressures) and afterload. Next morning
TTE showed EF 35-40% with inferolateral akinesis in LCx
distribution, found to have a partial rupture of the
posterolateral papillary muscle with severe (4+) mitral
regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension.
Patient taken to surgery this morning. Cardiac enzymes
trending down (tn 24 to 15, ck 4000 to 1500, mb 500 to 200)
# CAD/Ischemia: ECG w/ evidence of anterolateral ischemia. ?
whether due to collaterals from circ vs. RCA. Substantial
infarct w/ CK-MB of 960. Now s/p BMS x 2 to LCx and no
intervention on RCA. Decreased pressor requirements post PCI.
- cont asa, plavix
- cont heparin gtt
- high dose statin
- cycling cardiac enzymes
- IABP
- discuss adding beta blocker
.
# Pump: EF 40-45% w/ apical lateral HK at OSH. Now in
cardiogenic shock. Suspect worsening of EF. Elevated filling
pressures on RHC w/ PCW of 30.
- off levophed
- cont IABP 1:1. Will add ace inhibitor once weaning
- going for surgery this morning, held off further diuresis
overnight
- add beta blocker once off vasopressors
- TTE in am. If significant anteroapical AK or severely
depressed EF will consider continuation of heparin beyond 48
hours w/ transition to coumadin
.
# Rhythm:
- atrial tachycardia likely secondary to ischemia and severe MR
causing left atrial stretch, held on further diuresis
- MVR this morning
- on heparin gtt
.
# Resp: significant A-a gradient on initial ABG w/ pO2 122 on
100% FiO2. Improved with PEEP to 10mg which decreases preload
and afterload
- repeat ABG
- weaned oxygen overnight
- cont vent support on AC for now
- tx for possible aspiration pna as below
- diuresis as tolerated
.
# ARF: unknown baseline but labs at OSH w/ Cr 0.9->1.8. Likely
[**3-6**] poor forward flow in the setting of cardiogenic shock.
- creatinine trending down
- BUN elevated, component secondary to steroids
- if continues to worsen can consider urine lytes/eos
.
# ID: leukocytosis on OSH labs. Potentially secondary to stress
demargination in the setting of significant MI. Must also
consider aspiration event in the setting of cardiac arrest at
OSH. CXR w/ possible infiltrate in RUL and RLL.
- check sputum and urine cx's
- blood cultures if spikes, afebrile
- empirically cover for aspiration w/ levo/flagyl x 7 days as
WBC count and fever will be difficult to interpret in the
setting of stress dose steroids and large MI
.
# [**Month/Day (2) **]: hypotensive currently in cardiogenic shock.
- holding home dose atenolol
- stress dose steroids as below
.
# polymyalgia rheumatica: on prednisone daily at home but
unknown dose. Cannot check [**Last Name (un) 104**] stim.
- stress dose steroids with methylpred 40 mg IV Q8H, taper down
- rapid taper w/ stabilization of BP
.
# DM: documented diet controlled DM although family denies.
- HbA1C <5
- ISS
.
# FEN: NPO for now. Once stable will start TFs
- [**Hospital1 **] lytes once diuresis begun
.
# Prophylaxis: heparin gtt. PPI IV. bowel regimen
.
# Code: FULL. Confirmed w/ HCP
Underwent MVR/cabg x1 with Dr.[**Last Name (STitle) **] on [**3-31**]. Pt. already
intubated and had IABP prior to OR. Transferred to the CVICU in
fair condition on epinephrine, nitroglycerin, insulin and
propofol drips. Abx continued for presumed pre-op PNA. ENT
consulted for epistaxis. IABP removed and epinephrine drip
weaned to off on POD #2. Amiodarone started for Afib. At 9PM on
POD #3, she became acutely hypotensive and non-responsive. CPR
started, and chest opened at the bedside. Moderate amount of
blood around the heart noted.Open cardiac massage performed for
asystole.Unable to pace the heart. No obvious sites of bleeding
identified. Patient pronounced at 9:50 PM.Family notified.
Permission for autopsy granted.
Medications on Admission:
atenolol 50 mg daily
prednisone 5mg daily
advil [**Hospital1 **] prn
fosamax Qwk
Discharge Disposition:
Expired
Discharge Diagnosis:
CAD s/p MVR/cabg x1
cardiogenic shock
acute MI
ruptured papillary muscle with severe 4+ MR
[**First Name (Titles) **]
[**Last Name (Titles) **] A fib
elev. lipids
polymyalgia rheumatica
DM
Discharge Condition:
expired
Completed by:[**2151-6-24**]
ICD9 Codes: 5849, 9971, 4240, 4019, 2720, 496, 2875, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1976
} | Medical Text: Admission Date: [**2117-9-3**] Discharge Date: [**2117-9-13**]
Date of Birth: [**2049-1-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2042**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
History of Present Illness: This is a 68 yo M with h/o
metastatic melanoma and known brain mets who presents with
increasing delirium over the past week in the setting of
starting Temozolomide chemotherapy. Pt is C2D11 today. Pt was
referred in by oncologist for a infectious/metabolic workup.
.
In the ED, initial VS were 98.4 81 137/86 18 100%. Labs
revealed no leuckocytosis but a Na of 125. Head CT only showed
three known metastatic lesions without evidence of acture
process. EKG showed NSR 81, no ST changes. Blood cx were sent.
CXR showed incr growth of pulm nodule in R lower lobe, no
consolidations or effusions. Of note, pt rec'd 1L NS in ED
prior to transfer.
.
Upon arrival to the ICU, pt is comfortable, conversing
pleasantly. Deneis fevers, sore throat, nasal congestions,
diarrhea, abdominal pain or dysuria. Endorses cough. Also,
endorses constipation. Also, mentions increased urinary
frequency last few days, but denies dysuria.
.
Review of systems:
per HPI, otherwise negative. endorses dry itchy skin on back.
Past Medical History:
melanoma: diagnosed in [**2112**], s/p adjuvant IFN, later
metastasized to the chest wall confirmed by biopsy, s/p adjuvant
GM CSF treatment; that metastasized to the left neck and thigh
status HDIL2 with POD;
enrolled on protocol 08-142 (ipilimumab and Avastin in [**3-/2116**]),
but was discontinued in [**2117-7-2**] for progression of disease:
specifically, a bulky leptomeningeal mass affecting the cauda
equina with significant right lower extremity symptoms for which
was started on temozolomide with EB-XRT to LS spine (dose
reduced to 150 mg/m2 given the radiation field in the
lumbosacral spine). s/p 2 cycles now.
h/o basal cell cancer on the leg
h/o burning injuries
s/p right inguinal herniorrhaphy
Social History:
Denies tobacco (never a smoker), light-moderate EtOH before but
has not drank in last 2 months, no IVDU.
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals: T: afebrile BP: 126/76 P: 81 R: 18 O2: 97% on RA
General: AAOx2 (not time), no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx2 (not time), 3/5 strength in RLE, 5/5 strength in
LLE, decr sensation in RLE
Pertinent Results:
ADMISSION LABS:
[**2117-9-3**] 05:40PM BLOOD WBC-8.8# RBC-4.25* Hgb-13.1* Hct-35.4*
MCV-83 MCH-30.8 MCHC-37.0* RDW-14.2 Plt Ct-227
[**2117-9-4**] 03:49AM BLOOD WBC-5.5 RBC-3.82* Hgb-11.8* Hct-32.5*
MCV-85 MCH-31.0 MCHC-36.5* RDW-13.5 Plt Ct-204
[**2117-9-5**] 05:01AM BLOOD WBC-6.5 RBC-3.97* Hgb-12.2* Hct-33.7*
MCV-85 MCH-30.6 MCHC-36.1* RDW-13.5 Plt Ct-209
[**2117-9-3**] 05:40PM BLOOD Neuts-88.7* Lymphs-3.9* Monos-6.6 Eos-0.6
Baso-0.2
[**2117-9-5**] 05:01AM BLOOD Neuts-88* Bands-2 Lymphs-5* Monos-4 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2117-9-5**] 05:01AM BLOOD Plt Ct-209
[**2117-9-4**] 03:49AM BLOOD Plt Ct-204
[**2117-9-3**] 05:55PM BLOOD PT-11.8 PTT-25.7 INR(PT)-1.0
[**2117-9-3**] 05:40PM BLOOD Plt Ct-227
[**2117-9-5**] 02:30PM BLOOD Glucose-133* UreaN-10 Creat-0.7 Na-127*
K-3.9 Cl-89* HCO3-30 AnGap-12
[**2117-9-5**] 05:01AM BLOOD Glucose-87 UreaN-7 Creat-0.6 Na-127*
K-3.7 Cl-90* HCO3-29 AnGap-12
[**2117-9-4**] 08:04PM BLOOD Na-126* K-4.0 Cl-89*
[**2117-9-4**] 09:47AM BLOOD Na-125* K-3.8 Cl-88*
[**2117-9-4**] 03:49AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-126*
K-3.9 Cl-88* HCO3-30 AnGap-12
[**2117-9-3**] 11:33PM BLOOD Na-126* K-3.7 Cl-89*
[**2117-9-3**] 05:40PM BLOOD Glucose-96 UreaN-14 Creat-0.7 Na-125*
K-4.8 Cl-84* HCO3-30 AnGap-16
[**2117-9-3**] 05:40PM BLOOD estGFR-Using this
[**2117-9-3**] 05:40PM BLOOD ALT-20 AST-28 LD(LDH)-556* AlkPhos-59
TotBili-0.7
[**2117-9-5**] 02:30PM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8
[**2117-9-5**] 05:01AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8
[**2117-9-5**] 05:01AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8
[**2117-9-4**] 03:49AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.8
[**2117-9-3**] 05:40PM BLOOD Calcium-9.4 Phos-3.2 Mg-1.8
[**2117-9-3**] 05:40PM BLOOD Osmolal-259*
[**2117-9-5**] 05:01AM BLOOD TSH-0.58
[**2117-9-5**] 05:01AM BLOOD Cortsol-20.3*
[**2117-9-3**] 11:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
[**2117-9-3**] CXR: IMPRESSION: Of the two known pulmonary nodules,
presumed metastatic lesions, the one visible in the posterior
segment of the right lower lobe has demonstrated interval
growth. No superimposed acute pulmonary process seen.
.
[**2117-9-3**] CT HEAD: IMPRESSION: Known metastatic implants in the
right inferior frontal and left temporal lobe without evidence
for acute process. Comparison for interval change in size is
limited across modalities.
.
[**2117-9-4**] MRI BRAIN: IMPRESSION: Interval progression of metastatic
disease with several new lesions, many of which are in a
subependymal periventricular location.
.
DISCHARGE LABS:
Brief Hospital Course:
ASSESSMENT/PLAN: 68yo man with metastatic melanoma on
temozolamide admitted for acute delirium and hyponatremia.
Subactue cognitive deficit became acute delirium just prior to
admission. Na 125, Urine Na 29, urine osm all consistent with
SIADH. He was initially given 1L normal saline in the ED. Then,
fluid restriction started in ICU. He was transfered out of the
ICU once Na improved to 127. NaCl tabs were started and sodium
normalized. MRI brain showed progressing brain mets. RPR, B12,
folate, Utox, CXR, EKG, and U/A negative. Cultures negative.
Pallitaive whole brain XRT was started [**2117-9-8**], the last 2
fractions were held so patient could go home with hospice.
.
# Oliguria: Occurred 2 days prior to discharge. Due to
hypvolemia due to decreased po intake as he continued to
deteriorate. Responded to fluid bolus, but incontinent of urine.
I's and O's were followed with a condom catheter.
.
# Acute delirium on presentation: Due to hyponatremia and brain
mets. Mild improvement with corrected hyponatremia. Urine tox
negative. CXR negative. EKG normal. RPR negative. B12 and folate
normal. U/A and urine cx negative. Blood culture negative.
Stopped temozolamide. Hyponatremia was corrected as outlined
below. Benzodiazepines and opiates were avoided but
prescriptions were made available for hospice use as an
outpatient. The patient was continued on dexamethasone started
on [**2117-9-6**]
.
# Hyponatremia: Una 29, high Uosm, low serum osm, euvolemic, all
consistent with SIADH, likely due to worsening brain mets seen
on MRI. Normal TSH, normal AM cortisol. NaCl tabs 3g TID started
[**2117-9-5**]. Na 125 --> 139. Stopped fluid restriction. Continued
NaCl tabs.
.
# CNS mets: Progression of known CNS mets on temozolomide.
Palliative whole brain XRT started [**2117-9-8**], last two fractions
held [**9-13**] and [**9-14**] so he could go home with hospice. Decreased
dexamethasone to 4 mg [**Hospital1 **] and lansoprazole was continued for GI
prophylaxis. Anti-emetics were given prn.
.
# Dysphagia: Face turned red with swallowing food so
dexamethasone was given as an IV. When the patient was
discharged home with hospice, Dexamethasone was changed to an
elixir and Speech/Swallow consult was DC'd.
.
# Odynophagia: The patient was treated with magic mouthwash and
started on fluconazole given his high dose steroids. He was DC'd
with fluconazole elixir for a 14 day course.
.
# Metastatic melanoma: Multiple discussions occured with the
patient's family on the hospital floor on [**9-12**] regarding his
ongoing decline (requiring a two person assist, unable to sit up
in bed, incontinent of urine, oliguric due to poor po intake).
They decided to take the patient home with hospice. The
patient's primary oncologist was notified by email regarding the
family's plans. The patient's last 2 remaining fractions of XRT
were skipped to allow discharge to home hospice.
.
# Right lower extremity pain: responsive to tylenol and
ibuprofen prn (have used the latter sparingly with his brain
mets). Avoided narcotics due to his baseline confusion, but
prescriptions given for home hospice.
.
# Constipation: Resolved with bowel regimen.
.
# Nausea: Anti-emetics as needed.
.
# Anxiety/agitation: Continued home quetiapine (Seroquel).
Avoided benzodiazepines unless necessary. Used haloperidol or
olanzapine (Zyprexa) if needed.
.
# FEN: Regular diet. Stopped water restriction. Replete lytes
prn.
.
# DVT prophylaxis: Heparin SC.
.
# GI prophylaxis: PPI and bowel regimen.
.
# Lines: Peripheral IV.
.
# Precautions: None.
.
# CODE: FULL.
.
Medications on Admission:
Ativan PRN (stopped 2 days ago) anxiety/agitation
Lactulose PRN constipation
Compazine 10mg PRN nausea
Seroquel 25mg qhs
Aloe [**Doctor First Name **] cream PRN dry skin
Discharge Medications:
1. sodium chloride 1 gram Tablet [**Doctor First Name **]: Three (3) Tablet PO TID (3
times a day).
Disp:*270 Tablet(s)* Refills:*2*
2. quetiapine 25 mg Tablet [**Doctor First Name **]: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. prochlorperazine maleate 10 mg Tablet [**Doctor First Name **]: One (1) Tablet PO
Q6H (every 6 hours) as needed for Nausea.
Disp:*20 Tablet(s)* Refills:*0*
4. lactulose 10 gram/15 mL Syrup [**Doctor First Name **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for Constipation.
5. senna 8.8 mg/5 mL Syrup [**Doctor First Name **]: [**5-11**] ml PO twice a day as needed
for constipation.
Disp:*500 ml* Refills:*0*
6. docusate sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: [**5-11**] ml PO twice a day
as needed for constipation.
Disp:*500 ml* Refills:*0*
7. acetaminophen 500 mg/5 mL Liquid [**Month/Year (2) **]: Five (5) ml PO every
six (6) hours as needed for pain.
Disp:*500 ml* Refills:*0*
8. morphine 10 mg/5 mL Solution [**Month/Year (2) **]: one half ml PO every four
(4) hours as needed for pain.
Disp:*100 ml* Refills:*0*
9. Lorazepam Intensol 2 mg/mL Concentrate [**Month/Year (2) **]: one half ml PO
every four (4) hours as needed for agitation, anxiety, nausea,
insomnia.
Disp:*100 ml* Refills:*0*
10. Dexamethasone Intensol 1 mg/mL Drops [**Month/Year (2) **]: Four (4) ml PO
twice a day.
Disp:*250 ml* Refills:*2*
11. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve [**Month/Year (2) **]: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
12. lansoprazole 15 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
13. fluconazole 40 mg/mL Suspension for Reconstitution [**Last Name (STitle) **]: 2.5
ml PO once a day for 14 days.
Disp:*35 ml* Refills:*0*
14. ibuprofen 100 mg/5 mL Suspension [**Last Name (STitle) **]: [**1-3**] ml PO every six
(6) hours as needed for pain: Use tylenol first, then use
ibuprofen if needed.
Disp:*250 ml* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice of [**Hospital3 **]
Discharge Diagnosis:
1. Altered mental status (confusion).
2. Hyponatremia.
3. SIADH (syndrome of inappropriate anti-diuretic hormone).
4. Progressive Brain metastases.
5. Metastatic melanoma.
6. Fatigue/weakness.
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 admitted to the hospital for altered mental status
(confusion). This initially was thought to be due to a very low
sodium, a condition called SIADH (syndrome of inappropriate
anti-diuretic hormone), likely a manifestation of melanoma
metastases to the brain as seen on MRI. The sodium level
improved with fluid restriction and salt tablets. The salt
tablets will maintain a correct sodium, so you no longer need to
limit your drinking. Because your delirium did not improve with
correction of the sodium and steroids (dexamethasone), you were
started on radiation therapy. Because you decided to go home
with hospice, you will not receive the last two days of your
radiation.
.
MEDICATION CHANGES:
1. Salt (NaCl) 3g tablets 3x a day.
2. Dexamethasone 4 mg [**Hospital1 **]
3. You may take Docusate Sodium and Senna as needed for
constipation
4. You may take acetominophen (tylenol) liquid for pain, if pain
continues you can use ibuprofen and morphine if needed
5. Fluconazole 100 mg (2.5 ml) daily for 14 days for throat pain
6. Lansoprazole daily
7. You may take lorazepam liquid as needed for agitation,
anxiety, nausea, or insomnia
8. You may take Zofran rapid dissolve tablet as needed for
nausea
Followup Instructions:
FOR QUESTIONS/CONCERNS OR FOLLOW-UP, PLEASE CALL YOUR PRIMARY
ONCOLOGIST DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
Please call radiology at the numbers below if you need to cancel
these appointments.
.
Department: RADIOLOGY
When: TUESDAY [**2117-9-21**] at 1 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: RADIOLOGY
When: TUESDAY [**2117-9-21**] at 1:40 PM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1977
} | Medical Text: Admission Date: [**2177-7-24**] Discharge Date: [**2177-8-19**]
Date of Birth: [**2147-8-13**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril /
Morphine / Cyclosporine
Attending:[**First Name3 (LF) 8367**]
Chief Complaint:
?infected hardware
Major Surgical or Invasive Procedure:
Left Obturator artery pseudoaneurysm embolization
History of Present Illness:
Ms. [**Known lastname 14323**] is a 29 year old woman with ESRD on HD s/p failed
renal transplant (rejection [**2174**]) and s/p bilateral nephrectomy,
now s/p right tibial IMN on [**2177-6-24**] who returns from rehab with
worsening leg wound and possible infection. She also notes
worsening right knee swelling and pain.
.
Her recent admission was complicated by possible cellulitis,
which was treated with vancomycin/Zosyn to complete a 2 week
course. She was discharged from [**Hospital1 18**] on [**7-8**] and was found
hypotensive on [**7-12**] (blood cultures growing coag negative staph
sensitive to vancomycin). She received one dose of gentamicin at
that time. She responded well to IVF. The right knee was
aspirated on [**7-15**] and showed gram positive cocci in pairs and
clusters but nothing grew in cultures. She had a PICC line
catheter tip culture on [**7-12**] which grew coag negative staph
sensitive to vancomycin. She had another catheter tip sent for
culture on [**7-18**] (unclear what line) which did not grow anything.
She also underwent a debridement of the right lower extremity
wound by vascular surgery. Coumadin and heparin were
discontinued (started for DVT prophylaxis after tib/fib surgery)
and she was anticoagulated with Lovenox.
.
She was transferred back to [**Hospital1 18**] for concern for hardware
infection, and non-healing wound. The septic knee reportedly
has improved significantly with surgery and antibiotics.
.
In the ED, vital signs were T99.1, HR 100, BP 99/50, RR 16, sat
95% on room air. She received dilaudid IV for pain, in addition
to vancomycin IV x 1 (preceded by Benadryl) and clindamycin IV x
1. She was given 2 L NS for rehydration.
.
REVIEW OF SYSTEMS: She notes constipation, right lower extremity
pain (both at the site of the wound and at the knee), and low
grade temperature. She denies abdominal pain, nausea, vomiting,
shortness of [**Hospital1 1440**], dizziness, and vomiting. She has mild
numbness of the right lower extremity below the knee.
Past Medical History:
PAST MEDICAL HISTORY:
- SLE diagnosed [**2166**] complicated by lupus nephritis, anemia,
serositis and ascites
- End stage renal disease secondary to lupus, HD T/Th/Sat
- History of VSD s/p corrective surgery, age 13
- Hypertension
- ITP
- MSSA endocarditis
- Sickle cell trait
- S/p left oophorectomy related to IUD associated infection
- Restrictive lung disease noted on PFTs [**2166**]. In [**2173**], chest CT
with diffuse ground glass opacities.
- GERD
- S/p cadaveric renal transplant on [**8-/2175**] complicated by
rejection and capsule rupture 11/[**2174**].
- Right pelvic abscess s/p TAH/RSO
- B/L renal solid masses s/p resection pathology was negative
for carcinoma
- R tib/fib fx with ORIF [**2177-6-24**]
Social History:
No smoking, occasional alcohol, no drug use. Originally from
[**Country **], now lives in [**Location 2268**]. used to work at [**Hospital1 18**].
Family History:
Non-contributory
Physical Exam:
Vitals: T 97.0, BP 92/70, HR 86, RR 18, Sat 100%2L
Gen: Chronically ill appearing, no acute distress
HEENT: EOMI, OP clear
Neck: No lymphadenopathy
Cardiac: RRR, normal S1/S2, 1/6 systolic murmur at apex
Lungs: CTA bilaterally. No wheezes, rales, or rhonchi.
Abd: Soft, but distended, mildly diffusely tender, normal active
bowel sounds. No hepatosplenomegaly. Midline and bilateral
oblique scars from previous abdominal surgeries.
Ext: No clubbing, cyanosis, or edema. [**12-10**]+ DP pulses
bilaterally.
Right Knee: swollen and tender to palpation, no erythema, no
warmth
Right Leg: open wound with no purulence on anterior surface,
approximately six inches long and 4 inches wide, 2cm deep, No
swelling, no erythema.
Skin: No rashes
Neuro: A&O x 3
Pertinent Results:
.
[**7-24**] CT LLE with contrast:
1. Fluid collection due to an apparent skin defect in the
anterolateral distal calf. It may represent seroma. Abscess less
likely.
2. Distal calf intermuscular hypoattenuation which should be
followed on further series but is likely to represent muscle
edema.
3. Recent tibia and fibular fractures.
4. Subcutaneous edema in distal calf and foot.
.
8/16 L tib/fib plain film:
No definite radiographic evidence for osteomyelitis. Internally
fixated tibial fracture and impacted nondisplaced nonangulated
fibular fracture as previously described. Significant soft
tissue ulceration at the level of the fracture site.
.
[**7-24**] R knee plain film:
No definite radiographic evidence for osteomyelitis. Internally
fixated tibial fracture and impacted nondisplaced nonangulated
fibular fracture as previously described. Significant soft
tissue ulceration at the level of the fracture site.
.
Shoulder Plain film
1. Demineralization of the bones associated with a reticular
appearance, this may be seen in the setting of renal failure.
2. No erosions identified.
3. No fractures are seen.
4. Diffuse opacities within the visualized lungs, cannot exclude
underlying pneumonia.
.
R LE U/S
No evidence of DVT.
.
Bilateral arterial doppler u/s
IMPRESSION: On the right normal arterial Doppler study _____
lower extremity at rest. On the left there appears to be mild
tibial artery occlusive disease.
.
CXR
1. Stable bibasilar opacities may reflect underlying pneumonia
with possible
associated atelectasis.
2. Findings consistent with pulmonary artery hypertension.
3. Interval removal of left-sided PICC line.
.
[**7-30**] CTA Chest with and without contrast
1. Slightly limited study due to patient motion and
insufficient contrast -bolus, but no evidence of pulmonary
emboli.
2. Stable extensive airspace opacities in both lungs with
ground glass
opacities with interlobular thickening. Findings are likely
related to a
combination of left ventricular heart failure superimposed on an
underlying
chronic process such as COP or lupus pneumonitis.
3. Stable mediastinal and hilar lymphadenopathy.
4. Enlarged pulmonary artery consistent with underlying
pulmonary arterial hypertension.
.
[**8-1**] Echocardiogram with bubble study.
IMPRESSION: No ASD/PFO seen. No evidence of endocarditis.
Possible shunting
through the pulmonary vasculature. Symmetric LVH with preserved
global and
regional systolic function. Mildly dilated right ventricle with
preserved
systolic function. Moderate tricuspid regurgitation. Mild
pulmonary
hypertension.
.
Compared with the prior study (images unavailable for review) of
[**2177-2-10**], right ventricular systolic function may have slightly
improved. Severity of mitral regurgitation appears less.
Discrete mitral valve echodensity is not appreciated on the
current study. The other findings are similar.
.
[**8-7**] CT abd/ pelvis: IMPRESSION:
1. Interval decrease in size of bilateral renal fossa fluid
collections.
2. Interval development of the presumed hematoma in the left
obturator internus muscle.
3. There is significant interval change in bibasilar
ground-glass opacities, with redemonstration of a right middle
lobe pulmonary nodule now measuring 5 mm in size.
4. Stable pelvic lymphadenopathy.
.
[**8-13**] CT abd/ pelvis: IMPRESSION:
1. Slightly worsened left lower lobe peribronchial opacity and
airspace consolidation. This nonstanding.
2. Interval expansion of the obturator internus presumed
hematoma. There is also an avidly enhancing focus here. The
findings are highly concerning for pseudoaneurysm.
3. Stable nephrectomy bed postoperative collections.
.
[**8-14**] IR embolization: IMPRESSION: Angiographically successful
embolization of left obturator artery pseudoaneurysm with
microcoils and thrombin.
.
[**2177-7-24**] 04:25PM BLOOD WBC-8.6 RBC-2.82* Hgb-8.5* Hct-26.5*
MCV-94 MCH-30.2 MCHC-32.1 RDW-20.5* Plt Ct-114*#
[**2177-7-29**] 04:32AM BLOOD WBC-6.6 RBC-2.62* Hgb-8.0* Hct-25.0*
MCV-95 MCH-30.5 MCHC-31.9 RDW-19.8* Plt Ct-147*
[**2177-7-31**] 12:38PM BLOOD WBC-7.5 RBC-2.81* Hgb-8.4* Hct-26.2*
MCV-93 MCH-29.9 MCHC-32.0 RDW-19.5* Plt Ct-100*
[**2177-8-2**] 08:00AM BLOOD WBC-7.0 RBC-3.15* Hgb-9.3* Hct-28.8*
MCV-91 MCH-29.6 MCHC-32.4 RDW-19.5* Plt Ct-147*
[**2177-7-24**] 04:25PM BLOOD PT-12.8 PTT-31.3 INR(PT)-1.1
[**2177-8-1**] 05:00AM BLOOD PT-12.9 PTT-32.3 INR(PT)-1.1
[**2177-7-24**] 04:25PM BLOOD ESR-115*
[**2177-7-25**] 04:42AM BLOOD Ret Aut-4.3*
[**2177-7-24**] 04:25PM BLOOD Glucose-98 UreaN-23* Creat-7.0*# Na-136
K-4.8 Cl-101 HCO3-24 AnGap-16
[**2177-8-2**] 08:00AM BLOOD Glucose-83 UreaN-24* Creat-7.4* Na-137
K-4.5 Cl-101 HCO3-27 AnGap-14
[**2177-7-25**] 04:42AM BLOOD ALT-12 AST-19 LD(LDH)-204 AlkPhos-193*
TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2177-7-25**] 04:42AM BLOOD Albumin-2.5* Calcium-8.8 Phos-3.1 Mg-2.3
Iron-59
[**2177-7-31**] 12:38PM BLOOD Albumin-2.8* Calcium-9.1 Phos-2.6*
Mg-2.7*
[**2177-7-25**] 04:42AM BLOOD calTIBC-130* Hapto-77 Ferritn-1223*
TRF-100*
[**2177-7-26**] 05:20AM BLOOD PTH-144*
[**2177-7-29**] 08:06AM BLOOD PTH-80*
[**2177-8-2**] 08:30AM BLOOD PTH-153*
[**2177-7-25**] 04:42AM BLOOD CRP-33.6*
[**2177-7-26**] 05:20AM BLOOD PEP-POLYCLONAL IgG-3236* IgA-289 IgM-155
IFE-NO MONOCLO
[**2177-7-26**] 05:20AM BLOOD Vanco-40.4*
[**2177-7-27**] 05:59AM BLOOD Vanco-27.6*
[**2177-7-28**] 04:56AM BLOOD Vanco-26.4*
[**2177-7-29**] 04:32AM BLOOD Vanco-25.3*
.
Blood cx [**7-24**] (venipuncture):
ENTEROCOCCUS FAECIUM |
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R
All subsequent blood cultures are thus far negative.
.
Swab wound cultures: no growth (final)
Brief Hospital Course:
A/P: Ms. [**Known lastname 14323**] is a 29yo female s/p failed renal transplant
(rejection [**2174**]) and s/p bilateral nephrectomy, now s/p right
tibial IMN on [**2177-6-24**] who was transferred from [**Hospital **] rehab with
bacteremia, worsening RLE, and concern for hardware infection.
.
#) Bacteremia: The patient was transferred from rehab with
positive BCx growing coag negative staph sensitive to vancomycin
on [**7-12**], and grew VRE sensitive to Linezolid in BCx on [**7-24**].
There was no clear source for the bacteremia ?????? CXR and CT of the
chest was not suggestive of PNA. Surgery and orthopedics were
not concerned for wound infection or hardware infection as a
possible septic source. CT of the abdomen/ pelvis was without
evidence of abscess or any other infectious source. Surgery was
not concerned for the L obturator hematoma (see below) as
potential source for sepsis. The ID service was consulted, and
the patient was treated with Linezolid for VRE bacteremia and
vancomycin for coag. negative staph. Vancomycin will be dosed at
dialysis. It will be continued for an unspecified course, to be
determined during outpatient follow-up with Dr. [**Last Name (STitle) 4020**].
Surveillance cultures remained negative for the remainder of the
patient??????s hospital course and the patient was clinically well
(afebrile, without leukocytosis, negative blood cultures) upon
discharge.
.
#) Hypotension: On [**8-8**] while on the floor, the patient was
found to be lethargic with desaturation to 85% and SBPs~70's.
She had received Dilaudid >10mg IV over the course of the day
and had a rapid yet brief improvement in her mental status and
BP in response to Narcan. BP was unresponsive to IVF boluses and
she was transferred to the MICU for closer management, where she
briefly required pressors in addition to multiple fluid boluses.
She was started on Linezolid, Aztreonam, and Flagyl for presumed
sepsis, with sources likely either hardware or abdomen. She was
started on stress dose steroids, which was quickly tapered.
Hypotension stabilized while in the MICU and the patient was
transferred to the floor in stable condition. As above,
subsequent cultures have been negative to date.
.
#) RLE Ulcer: Upon presentation there was no clear purulent
drainage but the wound was exquisitely painful to touch. There
was no fever or leukocytosis, and no clear osteomyelitis on
right leg films. CT, however, demonstrated small abscess in the
anterior subcutaneous tissues near the fixation but no deep
abscess. She was started on clindamycin and vancomycin, and
plastic surgery and orthopedics were consulted for wound care.
She was continued on dry sterile dressing changes during her
hospital course. Both services monitored the wound regularly and
felt that the wound was healing well by discharge. The patient
will see orthopedics as an outpatient to follow-up re: IMR
placement and plastic surgery to follow-up progression of wound
healing.
.
#) Abdominal pain: The patient has complained of significant
diffuse abdominal pain during admission, up to [**9-17**]. CT scan of
abdomen/pelvis was unremarkable except for an incidental finding
of a L obturator hematoma (spontaneous in nature - no history of
manipulation or trauma). General surgery did not suspect any
acute process that could account for her symptoms. Pain
subsequently resolved; however, the patient began experiencing
significant LUQ pain different than prior on [**8-9**]. A repeat CT of
the abd/ pelvis showed slight interval expansion of the
hematoma, and there was a concern for a pseudoaneurysm. The
patient was taken for angiography with placement of 13 coils and
thrombin into the pseudoaneurysm with a rapid improvement in
pain. LUQ pain was thought by GI and general surgery services to
be referred pain from this pseudoaneurysm. The patient was able
to tolerate po well subsequently and had much improved pain
managed by a fentanyl patch (uptitrated to 200mcg) and oral
dilaudid by discharge.
.
#) S/p nephrectomy: The patient was continued on a Tues, Thurs,
Sat schedule for dialysis without any complication. She is to
continue as an outpatient on this schedule.
.
The patient was discharged in stable condition to home. She was
afebrile, VSS, tolerating po well, and ambulating with crutches
(secondary to RLE wound). She was discharged to home with PT
follow-up and VNA for dressing changes.
Medications on Admission:
Vitamin C 500mg [**Hospital1 **]
Aspirin 81mg daily
Amitryptyline 100mg QHS
Calcium Acetate 1334mg TID with meals
Senna [**Hospital1 **] PRN
Dulcolax 10mg daily
Lovenox 30mg QPM-->Contraindicated in HD patients?
Gabapentin 200mg PO QHS
Prednisone 5mg daily
Colace 100mg [**Hospital1 **]
Lactulose 30mg Q8H
Acetaminophen 650mg PO Q6H
Sevelamer 1600mg TID
Silver Sulfadiazine 1% cream applied [**Hospital1 **]
.
ALLERGIES: Demerol / Unasyn / Cephalosporins / Levaquin /
Moexipril
Discharge Medications:
1. Home Oxygen
Patient needs oxygen at home 2-3L NC as she has ambulatory
desaturations to 88%
2. Comode
Please give patient high comode
3. Shower Chair
Please give patient shower chair
4. Amitriptyline 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
5. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Calcium Acetate 667 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*1*
10. Sevelamer 800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Linezolid 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every
12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
13. Prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Gabapentin 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO HS (at
bedtime).
Disp:*60 Capsule(s)* Refills:*2*
15. Silver Sulfadiazine 1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 tube* Refills:*2*
16. Hydromorphone 2 mg Tablet [**Hospital1 **]: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
17. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO DAILY
(Daily) as needed for constipation.
Disp:*30 units* Refills:*1*
18. Medication during dialysis
Vancomycin IV (to be given at hemodialysis per HD protocol)
19. Outpatient Lab Work
Please draw 2 sets of blood cultures after patient finishes
linezolid on [**2177-8-14**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Right lower extremity cellulitis/wound infection
Right tibia/fibula fracture
Septic right knee
bacteremia
hypoxia
.
Secondary:
End-stage renal disease on hemodialysis
Discharge Condition:
Good, pain well-controlled, BP stable 100-130s
Discharge Instructions:
You were admitted for an infection of your right leg and
bloodstream. This was treated with antibiotics, and with
evaluation by orthopedics, plastic surgery, and vascular
surgery, who felt that the wound had good blood flow and would
heal over time. Because of the type of organism and the fact
that you have orthopedic hardware in your leg, you need to take
2 antibiotics: the first, linezolid, is an oral medication you
should take for 10 more days; the second, vancomycin is an
intravenous antibiotic which you should get during dialysis.
You will need this for several months.
We have arranged followup with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4020**] of
infectious disease, please see below for details.
You were seen by the pulmonary doctors because [**Name5 (PTitle) **] have needed
extra oxygen to avoid feeling short of [**Name5 (PTitle) 1440**]. You should
follow-up with them as an outpatient (details below - Dr. [**Name (NI) 18849**] office will call you with an appointment, but you should
have a repeat CT scan of the chest before that. You should also
have pulmonary function tests before or on the day of that
appointment, Dr.[**Name (NI) 18850**] office can arrange this).
You have been started on several new medications: linezolid,
vancomycin, and lactulose.
Please return to the emergency room if you experience
worsening knee pain, fevers, shortness of [**Name (NI) 1440**], chest pain, or
any other new or concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 4021**] [**Name11 (NameIs) **] (infectious disease specialist),
MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2177-8-28**] 11:30
.
[**2177-9-30**] 10:15am Follow-up CT Scan of the chest. Please do not
eat anything from 3 hours before study in [**Hospital Ward Name 23**] clinical
center on [**Hospital Ward Name **]. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2177-9-30**] 10:15.
.
Dr. [**First Name8 (NamePattern2) 4944**] [**Last Name (NamePattern1) **] of pulmonology and would like to see you as an
outpatient in [**1-11**] months. Her office will call you with an
appointment. If you do not hear from them in a few weeks, call
([**Telephone/Fax (1) 513**] to make an appointment.
.
Orthopedic followup: Provider: [**Name10 (NameIs) **] XRAY (SCC 2)
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2177-8-14**] 10:10 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 18851**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2177-8-14**] 10:30
.
Followup with the [**8-21**] at 1pm with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in [**Hospital Ward Name 23**]
[**Location (un) **] central suite. (she is a nurse practitioner who works
with Dr. [**Last Name (STitle) **]
Followup with Dr. [**Last Name (STitle) **] on [**10-3**] at 10:40am. If she wants to see
you sooner, someone from her office will call you.
ICD9 Codes: 5856, 2875, 7907, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1978
} | Medical Text: Admission Date: [**2136-8-14**] Discharge Date: [**2136-9-16**]
Date of Birth: [**2058-10-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Cognitive decline
Major Surgical or Invasive Procedure:
bifrontal craniotomy
peg placement
tracheostomy
History of Present Illness:
The patient is a 73-year-old female who recently
presented to my outpatient clinic. She had been followed for
decreasing cognitive decline. The patient was worked up
including imaging. A bifrontal large olfactory groove
meningioma measuring 7 x 6 cm was found. The patient was
extensively counseled. Given the family history and the large
extent of the lesion, the decision was made by the brain
tumor conference to resect the lesion for a better prognosis.
The patient was extensively counseled. The patient was
consented. The patient was taken electively to the OR.
Preoperative films had been obtained. The patient was taken
to the operating room on [**2136-8-16**].
Past Medical History:
1. macular degeneration
2. HTN
3. Hypercholesterolemia
4. meningioma
Social History:
Retired dental hygienist. She is married. She lives with her
spouse and her daughter. She does not smoke, She drinks wine
with
dinner. Denies any recreational drugs.
Family History:
Mother died at age [**Age over 90 **] of old age. Father died at age [**Age over 90 **] with
heart disease. Her sister is 71 in good health. She has two
children both in good health.
Physical Exam:
Exam [**2136-9-16**]:
Patient opens eyes to voice.
She does not speak but attempts to stick out her tongue to
command.
PERRL. 3-2 mm bilaterally. The left one is larger initially but
when rechecked is equal to the left.
Motor: Moves left arm spontaneously and squeezes to command.
Moves right arm with noxious stimuli. Withdraws both legs to
noxious stimuli.
Toes upgoing bilaterally.
Her incision has healed well.
Pertinent Results:
RADIOLOGY Final Report
[**Numeric Identifier 82379**] EXT CAROTID BILAT [**2136-8-14**] 7:55 AM
Reason: angio w/embolization for bifrontal planum sphenoidale
mening
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with bifrontal planum sphenoidale meningioma.
REASON FOR THIS EXAMINATION:
angio w/embolization for bifrontal planum sphenoidale
meningioma.
TYPE OF STUDY: Cerebral angiogram.
CLINICAL HISTORY: A 77-year-old female with bifrontal planum
sphenoidale meningioma presents for evaluation with angiogram
with possible embolization.
Comparison is made with CT angiogram of the head performed
[**2136-7-3**] and MRI of the brain performed [**2136-7-2**].
TECHNIQUE: Informed consent was obtained from the patient and
the patient's family after explaining the risks, indications,
and alternative management. Risks explained included bleeding,
hemorrhage, stroke, loss of vision and/or speech, injury to
blood vessels and/or nerves, allergic reaction to contrast
material, renal failure, and death. Additionally possible use of
embolization coils if needed was discussed.
The patient was brought to the interventional neuroradiology
suite and placed on the biplane table in the supine position.
Prior to the start of the procedure, a timeout was performed to
verify the patient's identity using two patient identifiers and
the procedure to be performed. Both groins were prepped and
draped in the usual sterile fashion. General anesthesia was
provided by the anesthesiology service. Access to the right
common femoral artery was obtained using a 19-gauge single-wall
needle, under local anesthesia using 1% lidocaine mixed with
sodium bicarbonate with aseptic precautions. Through the needle,
a 0.35 [**Last Name (un) 7648**] wire was introduced and the needle was taken out.
Over the wire, a 5-French vascular sheath was placed and
connected to a saline infusion (mixed with heparin 500 units and
500 cc of saline) with a continuous drip. Through the sheath, a
4 French Berenstein catheter was introduced and connected to the
continuous saline infusion (with heparin mixture: 1000 units of
heparin and 1000 cc saline). The following vessels were
selectively catheterized and arteriograms were performed from
these locations. After review of the study, the catheter and the
sheath were withdrawn and pressure was applied on the groin
until hemostasis was achieved. The procedure was uneventful and
the patient tolerated the procedure well without immediate
post-procedure related complications. The patient was sent to
the floor with post-procedure orders.
The following blood vessels were selectively catheterized and
arteriograms were obtained in the AP and lateral projections:
1. Right external carotid artery.
2. Right internal carotid artery.
3. Right common carotid artery.
4. Left external carotid artery.
5. Left internal carotid artery.
6. Left common carotid artery.
FINDINGS: Evaluation of the above blood vessels demonstrates no
evidence of aneurysm or vascular malformation.
Upon injection of the right internal carotid artery there is a
large hypervascular mass with a large tumoral blush identified
in the bifrontal region which is largely supplied by the right
anterior ethmoidal and right ophthalmic arteries. Additionally,
upon injection of the left internal carotid artery, there is
identification of this large hypervascular mass to be supplied
by a branch arising from the left paricallosal branch on the
anterior cerebral artery. Additionally, upon injection of the
bilateral external carotid arteries there is minimal
tumor-related blush seen to supply from branches of the
bilateral middle meningeal arteries.
Also, additionally upon injection of the left external carotid
artery there is a hypervascular mass with a prominent
tumor-related blush seen overlying the left frontal lobe. This
hypervascular mass appears to be largely supplied by branches
from the left middle meningeal artery.
IMPRESSION:
1. Large bifrontal hypervascular mass is consistent with
meningioma as reported on prior cross-sectional images which is
larger beings supplied by the right anterior ethmoidal and
ophthalmic arteries and a left branch arising from the left
callosal artery.
2. Large hypervascular mass overlying the left frontal lobe
consistent with a meningioma as correlated with prior
cross-sectional images largely being supplied by branches from
the left middle meningeal artery.
These findings were discussed with Dr. [**Last Name (STitle) **] at the time of the
examination.
Dr. [**Last Name (STitle) **], attending interventional neuroradiologist, was
present and performed the procedure.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 815**]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2136-8-21**] 3:13 PM
RADIOLOGY Final Report
[**Numeric Identifier 7649**] CAROTID/CERVICAL BILAT [**2136-8-14**] 7:55 AM
Reason: angio w/embolization for bifrontal planum sphenoidale
mening
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with bifrontal planum sphenoidale meningioma.
REASON FOR THIS EXAMINATION:
angio w/embolization for bifrontal planum sphenoidale
meningioma.
TYPE OF STUDY: Cerebral angiogram.
CLINICAL HISTORY: A 77-year-old female with bifrontal planum
sphenoidale meningioma presents for evaluation with angiogram
with possible embolization.
Comparison is made with CT angiogram of the head performed
[**2136-7-3**] and MRI of the brain performed [**2136-7-2**].
TECHNIQUE: Informed consent was obtained from the patient and
the patient's family after explaining the risks, indications,
and alternative management. Risks explained included bleeding,
hemorrhage, stroke, loss of vision and/or speech, injury to
blood vessels and/or nerves, allergic reaction to contrast
material, renal failure, and death. Additionally possible use of
embolization coils if needed was discussed.
The patient was brought to the interventional neuroradiology
suite and placed on the biplane table in the supine position.
Prior to the start of the procedure, a timeout was performed to
verify the patient's identity using two patient identifiers and
the procedure to be performed. Both groins were prepped and
draped in the usual sterile fashion. General anesthesia was
provided by the anesthesiology service. Access to the right
common femoral artery was obtained using a 19-gauge single-wall
needle, under local anesthesia using 1% lidocaine mixed with
sodium bicarbonate with aseptic precautions. Through the needle,
a 0.35 [**Last Name (un) 7648**] wire was introduced and the needle was taken out.
Over the wire, a 5-French vascular sheath was placed and
connected to a saline infusion (mixed with heparin 500 units and
500 cc of saline) with a continuous drip. Through the sheath, a
4 French Berenstein catheter was introduced and connected to the
continuous saline infusion (with heparin mixture: 1000 units of
heparin and 1000 cc saline). The following vessels were
selectively catheterized and arteriograms were performed from
these locations. After review of the study, the catheter and the
sheath were withdrawn and pressure was applied on the groin
until hemostasis was achieved. The procedure was uneventful and
the patient tolerated the procedure well without immediate
post-procedure related complications. The patient was sent to
the floor with post-procedure orders.
The following blood vessels were selectively catheterized and
arteriograms were obtained in the AP and lateral projections:
1. Right external carotid artery.
2. Right internal carotid artery.
3. Right common carotid artery.
4. Left external carotid artery.
5. Left internal carotid artery.
6. Left common carotid artery.
FINDINGS: Evaluation of the above blood vessels demonstrates no
evidence of aneurysm or vascular malformation.
Upon injection of the right internal carotid artery there is a
large hypervascular mass with a large tumoral blush identified
in the bifrontal region which is largely supplied by the right
anterior ethmoidal and right ophthalmic arteries. Additionally,
upon injection of the left internal carotid artery, there is
identification of this large hypervascular mass to be supplied
by a branch arising from the left paricallosal branch on the
anterior cerebral artery. Additionally, upon injection of the
bilateral external carotid arteries there is minimal
tumor-related blush seen to supply from branches of the
bilateral middle meningeal arteries.
Also, additionally upon injection of the left external carotid
artery there is a hypervascular mass with a prominent
tumor-related blush seen overlying the left frontal lobe. This
hypervascular mass appears to be largely supplied by branches
from the left middle meningeal artery.
IMPRESSION:
1. Large bifrontal hypervascular mass is consistent with
meningioma as reported on prior cross-sectional images which is
larger beings supplied by the right anterior ethmoidal and
ophthalmic arteries and a left branch arising from the left
callosal artery.
2. Large hypervascular mass overlying the left frontal lobe
consistent with a meningioma as correlated with prior
cross-sectional images largely being supplied by branches from
the left middle meningeal artery.
These findings were discussed with Dr. [**Last Name (STitle) **] at the time of the
examination.
Dr. [**Last Name (STitle) **], attending interventional neuroradiologist, was
present and performed the procedure.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 815**]
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2136-8-21**] 3:13 PM
RADIOLOGY Final Report
MR HEAD W/ CONTRAST [**2136-8-15**] 5:23 AM
MR HEAD W/ CONTRAST
Reason: Please do at 6 am for pre-op
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with bifrontal meningioma who will have
surgery [**8-15**]
REASON FOR THIS EXAMINATION:
Please do at 6 am for pre-op
CONTRAINDICATIONS for IV CONTRAST: None.
MRI HEAD
HISTORY: 77-year-old woman with meningiomas, here for pre-op
evaluation.
TECHNIQUE: Triplanar post-gado T1-weighted images of the head as
well as post-gado MP-RAGE of the head were obtained with
fiduciary markers in place.
FINDINGS: Comparison is made to a prior head MR from [**2136-7-2**] as
well as a CTA from [**2136-7-3**] and a cerebral angiogram from [**2136-8-14**].
Again seen is a large extra-axial enhancing mass consistent with
a planum sphenoidale meningioma which is compressing and
distorting the frontal lobes bilaterally. There is surrounding
vasogenic edema of the frontal lobes extending into the right
side of the corpus callosum with marked compression of the
frontal horns of the lateral ventricles.
There is also a approximately 3.4 x 2.8 cm extra-axial mass with
underlying hyperostosis overlying the left frontal parietal lobe
consistent with a second meningioma. This meningioma shows new
internal necrosis which is new compared to the prior study.
No new lesions are identified.
IMPRESSION: Two large meningiomas as described above with a
smaller meningioma over the left frontoparietal lobe showing
some internal necrosis which is new.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2136-8-16**] 8:53 AM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2136-8-15**] 9:01 PM
CT HEAD W/O CONTRAST
Reason: Follow up blood products
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with meningioma resection
REASON FOR THIS EXAMINATION:
Follow up blood products
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post meningioma resection.
COMPARISON: [**2136-7-3**].
TECHNIQUE: Non-contrast head CT scan.
FINDINGS: Patient is status post resection of previously seen
large bifrontal extra-axial mass. Large amount of expected
post-surgical pneumocephalus seen in the bifrontal region.
Heterogeneous appearance in the resection bed is seen, with
high-density material consistent with acute blood in the
resection bed. Scattered foci of gas also seen in the resection
bed. Hypodensity again seen in this region consistent with
edema. Configuration of the ventricles appears relatively
unchanged. No new hydrocephalus. Second calcified extra-axial
mass along the lateral aspect of the left frontal lobe appears
unchanged from prior. High-density material now also seen within
the nasopharynx. Bone windows demonstrate frontal craniotomy
defects and post-surgical hardware. Subcutaneous emphysema noted
with multiple staples in the frontal scalp. Minimal mucosal
thickening seen within the ethmoid, maxillary and sphenoid
sinuses.
IMPRESSION:
1. Status post resection of previously seen large bifrontal
extra-axial mass, with expected pneumocephalus. Heterogeneous
appearance of the resection bed, with multiple pockets of gas
and high density material consistent with blood in the resection
bed.
2. Unchanged appearance of calcified left meningioma.
3. High-density material is seen within the nasopharynx
consistent with blood. Clinical correlation recommended.
Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 10:45 p.m.,
[**2136-8-15**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: [**Doctor First Name **] [**2136-8-16**] 10:18 AM
RADIOLOGY Final Report
PORTABLE ABDOMEN [**2136-8-25**] 12:07 PM
PORTABLE ABDOMEN
Reason: eval for dilated loops
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman s/p craniotomy s/p dobhoff pneumonia, now w/
b/l rhonci, distended abdomen
REASON FOR THIS EXAMINATION:
eval for dilated loops
HISTORY: Abdominal distention.
Single supine radiograph of the abdomen demonstrates air and
stool projecting over a normal caliber rectum. Small amount of
air and stool are seen along the descending colon as well.
Multiple loops of normal caliber air-distended small bowel are
seen to collect in the middle of the abdomen. There is a
featureless collection of air within a viscus projecting over
the epigastrium. Given the presence of the patient's Dobbhoff
tube on chest radiographs both prior and subsequent to this
study the finding does not represent the stomach.
IMPRESSION:
Nonspecific bowel gas pattern. A single collection of air within
a viscus projecting over the upper mid abdomen is unlikely to
represent the stomach. Close clinical followup is requested.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: SAT [**2136-9-1**] 12:24 AM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2136-8-25**] 7:43 AM
CT HEAD W/O CONTRAST
Reason: assess for herniation, progression of lesion
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman with large meningioma, now more somnolent,
with dilated left pupil
REASON FOR THIS EXAMINATION:
assess for herniation, progression of lesion
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 77-year-old female with large meningioma with
dilated left pupil, assess for herniation.
COMPARISON: [**2136-8-20**].
TECHNIQUE: Non-contrast head CT scan.
FINDINGS: Again seen is a large calcified left frontal parietal
mass previously described as a meningioma. Hyperdensity at the
anterior medial aspects is consistent with hemorrhage and is
unchanged. Vasogenic edema has increased resulting in increased
rightward subfalcine herniation, now 6 mm and compression of the
left lateral ventricle. Suprasellar cistern is effaced and there
is mild compression on the brainstem indicating transtentorial
herniation. Fourth ventricle is largely similar in appearance.
Patient is status post bifrontal craniotomy with small amount of
expected pneumocephalus and extraaxial fluid, which represents
hemorrhage. Evolving intraparenchymal hemorrhage with associated
edema and local sulcal effacement is seen in the bifrontal lobes
anteriorly.
IMPRESSION:
1. Increased mass effect from vasogenic edema and hemorrhage
surrounding calcified left frontal parietal meningioma has
resulted in an increased rightward subfalcine herniation and
compression on the left lateral ventricle and near complete
effacement of the suprasellar cistern resulting in new
transtentorial herniation. There may be mild compression of the
brainstem.
These findings were discussed with Dr. [**Last Name (STitle) 877**] on [**2136-8-25**], at 9:35 a.m.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SAT [**2136-8-25**] 12:16 PM
Neurophysiology Report EEG Study Date of [**2136-9-1**]
OBJECT: HX OF MENINGIOMA WITH ALTERED MENTAL STATUS. EVALUATE
FOR
SEIZURES.
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
FINDINGS:
ABNORMALITY #1: Throughout the recording there is persistent
mixed
frequency theta and delta frequency slowing seen over the right
frontal
and central regions.
ABNORMALITY #2: There is some voltage asymmetry between the two
hemispheres with decreased voltage noted over the left anterior
quadrant.
ABNORMALITY #3: Throughout the recording the background rhythm
is slow
typically in the 6 Hz frequency range slightly disorganized and
poorly
reactive.
ABNORMALITY #4: Intermixed with the already slow and
disorganized
background are brief intermittent bursts of moderate amplitude
mixed
frequency slowing.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as this was a portable
study.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this
was a
portable study.
SLEEP: There were no clear transitions or change in state noted.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 78 bpm.
IMPRESSION: This is an abnormal portable EEG due to persistent
focal
slowing in the right fronto-central region suggestive of an area
of
underlying subcortical dysfunction. In addition, there was a
voltage
asymmetry of decreased amplitudes noted over the left anterior
quadrant
suggestive of a structural or destructive process in that
region. The
background rhythm was also slow, disorganized, and poorly
reactive with
admixed bursts of generalized mixed frequency slowing suggestive
of a
mild global diffuse encephalopathy. This suggests ongoing
bilateral
subcortical or deeper midline dysfunction. Medications,
metabolic
disturbances, infection, and anoxia are among the most common
causes of
encephalopathy but there are others. There were no clearly
epileptiform
discharges and no electrographic seizures were seen.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] L.
([**5-/3059**]B)
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2136-9-5**] 12:37 PM
CT HEAD W/O CONTRAST
Reason: eval interval change
[**Hospital 93**] MEDICAL CONDITION:
77F with large bifrontal meningioma, now s/p bifrontal crani,
partial resection of tumor; returned to ICU for s/s of
herniation, ameliorated w/ mannitol and decadron, persistent
hyponatremia s/p tx w/ hypertonic saline
REASON FOR THIS EXAMINATION:
eval interval change
CONTRAINDICATIONS for IV CONTRAST: None.
CT SCAN OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST
HISTORY: Large bifrontal meningioma. Status post bifrontal
craniotomy and partial resection of tumor, returned into the ICU
for signs and symptoms herniation ameliorated with mannitol and
Decadron. Persistent hyponatremia, status post treatment with
hypertonic saline. Evaluate for interval change.
TECHNIQUE: Non-contrast head CT scan.
COMPARISON STUDY: [**2136-8-30**] non-contrast head CT scan
interpreted by Dr. [**Last Name (STitle) **] as revealing "evolution of blood
products in the left frontal lobe adjacent to the meningioma.
The edema and midline shift associated with this lesion are
unchanged."
FINDINGS: The large heavily calcified lesion within the left
frontal region as well as the marked surrounding edema unaltered
in extent. There is little change in the mass effect exerted
upon the frontal [**Doctor Last Name 534**] and body of the left lateral ventricle.
There is approximately 5 mm rightward subfalcine herniation
seen. The subfrontal lesion, as before, is quite difficult to
discern, but there does appear to be residual edema, which
persists after the extensive resection. A small bifrontal
extraaxial fluid filled compartment, which appears contiguous to
and subjacent to the large frontal craniotomy flap appears
unaltered in size. No other new extracranial abnormalities are
discerned.
CONCLUSION: Relatively little change in the appearance of the
postoperative CT scan, as noted above.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**]
Approved: WED [**2136-9-5**] 3:17 PM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2136-9-5**] 5:31 AM
CHEST (PORTABLE AP)
Reason: Fever, question PNA
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman s/p craniotomy s/p dobhoff HIT+, awaiting
trach and PEG
REASON FOR THIS EXAMINATION:
Fever, question PNA
INDICATION: 77-year-old woman status post craniotomy status post
Dobbhoff; fever; evaluate for pneumonia.
COMPARISONS: Chest radiograph dated [**2136-8-30**].
FINDINGS: A single AP portable upright view of the chest was
obtained. An endotracheal tube terminates 4 cm above the carina.
The nasogastric tube terminates in the pyloric region. A left
internal jugular catheter terminates at the confluence of the
brachiocephalic veins, as before. There is increased left
basilar opacity, without pneumothorax or pulmonary vascular
congestion. The cardiac silhouette is stable.
IMPRESSION:
1. Increased left basilar opacity, compatible with a pleural
effusion and adjacent atelectasis or pneumonia.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 7805**] [**Name (STitle) **]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: [**Doctor First Name **] [**2136-9-6**] 7:40 AM
Cardiology Report ECG Study Date of [**2136-8-15**] 1:32:28 AM
Normal sinus rhythm, rate 61. Left ventricular hypertrophy.
Non-specific
lateral repolarization changes consistent with left ventricular
hypertrophy
and/or ischemia. Compared to the previous tracing of [**2136-7-24**]
probably no
significant change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
61 128 90 458/459 23 -12 115
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 106730**],[**Known firstname **] [**2058-10-11**] 77 Female [**-5/3667**]
[**Numeric Identifier 107533**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **], DR. [**Last Name (STitle) **]. ROBENS/cofc
SPECIMEN SUBMITTED: FS FRONTAL TUMOR, FRONTAL TUMOR (2).
Procedure date Tissue received Report Date Diagnosed
by
[**2136-8-15**] [**2136-8-15**] [**2136-8-20**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma??????
Previous biopsies: [**Numeric Identifier 107534**] BACK/st.
DIAGNOSIS:
Specimen #1: "Frontal tumor, ? meningioma", craniotomy (A,
B-C):
Meningioma meningothelial subtype (WHO grade I) (see note).
Note: The tumor lacks any atypical features including necrosis,
sheeting and prominent nucleoli. Mitotic rate is less than 1
per 10 hpf.
Specimen #2: "Frontal tumor, ? meningioma", craniotomy (D-H):
Meningioma, meningothelial subtype (WHO grade 1).
Clinical: ? Meningioma.
Gross: This specimen has been received in two parts.
Specimen 1, is received fresh for intraoperative consult labeled
with the patient's name "[**Known lastname **], [**Known firstname **]", and the [**Hospital 228**]
medical record number. The specimen consists of an aggregate of
soft tan tissue measuring 3.5 x 2 x 0.6 cm. 20% of the tissue
is consumed for intraoperative frozen section (FS1) smear, (SM1
and touch preps), (PP1). The frozen section diagnosis by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] is: "Meningioma with no atypical features". The
specimen is entirely submitted as follows: A=frozen section
remnant, B-C = Nonfrozen portion of specimen.
Specimen 2, is received fresh labeled with "[**Known firstname **] [**Known lastname **]", the
medical record number and "frontal tumor ?meningioma", and
consists of multiple tan pink soft tissue fragments measuring
approximately 9.0 x 4.6 x 1.8 cm in aggregate. Representative
sections are submitted in D-H.
Brief Hospital Course:
Pt was admitted through SDA for Bifrontal craniotomy for
mengioma resection / elective.
[**8-17**] pt was extubated and was noted to be abulic.
[**8-20**] Pt noted with Right facial droop and right pronator drift
with R hemiparesis. CT revealed that second known meningioma in
left parietal region with spontaneous hemorrhage. The bleed was
considered to be non surgical.
[**8-23**] CXR revealed CHF and PNA, lasix and abx started.
[**8-25**] pt with unilateral pupillary enlargement / mannitol and
decadron given emergently / re-intubated /exam followed closely.
Hyponatremia treated with 23% (twenty three) normal saline which
was then converted to 3% NS.
[**8-30**] pt with thrombocytopenia - HIT antibodies sent and were
inconclusive. All heparin products held. Trach and peg placed on
hold until plts recovered. hematology consult obtained.
[**9-1**] exam continues to fluctuate / eeg ordered / no sz activity
noted / CT scans followed. Keppra decreased [**12-30**] possible cause
of [**Month (only) **]. mental status.
[**9-5**] repeat CT stable. Decadron wean complete. Vanco started
for GNR, GPC, GPR in sputum.
[**9-8**] trach and peg complete/ off ventilator
[**9-9**] neuro exam improving / following commands / eyes open
[**9-12**] transferred to step down unit.
PT and OT have evaluated the patient and both recommended rehab.
She was accepted at [**Hospital 100**] Rehab and was supposed to go on [**9-14**]
but the bed was unavailable. On [**9-16**] the bed was available and
she was transferred to [**Hospital 100**] Rehab. Her exam prior to discharge
was stable. See physical exam section above.
Medications on Admission:
[**Last Name (un) 1724**]:
1. Toprol 25 mg
2. Lipitro 20 mg
3. Prozac 20 mg
Discharge Medications:
1. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Colace 50 mg/5 mL Liquid Sig: Two (2) PO twice a day.
5. Keppra 100 mg/mL Solution Sig: 10 ml PO twice a day.
6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
7. heparin Sig: 5,000 units Subcutaneous three times a day.
8. Ketoconazole 2 % Cream Sig: One (1) Topical Q 12 hours PRN:
Please apply under breasts.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) PO QID
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Intracranial meningioma s/p resection
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Have your incision checked for signs of infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED AN MRI OF THE BRAIN WITH AND WITHOUT GADOLINIUM
PRIOR TO YOUR VISIT.
Completed by:[**2136-9-16**]
ICD9 Codes: 5185, 2761, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1979
} | Medical Text: Admission Date: [**2168-10-17**] Discharge Date: [**2168-10-26**]
Date of Birth: [**2124-11-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
sternal incision pain, purulent drainage
Major Surgical or Invasive Procedure:
sternal debridement([**10-18**])
closure with bilat pectoral flaps and sternal plates. ([**10-20**])
History of Present Illness:
This 43 year old woman is s/p mitral valve replacement and PFO
closure on [**2168-9-19**]. She presented to an outside hospital with
eight hours of sternal incision pain and purulent drainage.
Blood cultures demonstrated 3/4 bottles positive for Methicillin
Sensitive Staph Aureus. Symptoms worsen with deep inspiration.
The patient was febrile and found to have WBC 19,000.m She was
transferred to [**Hospital1 18**] for evaluation.
Past Medical History:
Mitral regurgitation
Psoriasis
Psoriatic arthritis
Endometriosis
Obesity
Social History:
Lives with spouse
ETOH rare
Tobacco 20 year pack history - currently smoking
Not currently working
Family History:
Mother deceased at 62 from cardiomyopathy
Physical Exam:
Gen: NAD
Neuro: alert and oriented, non-focal
Pulm: lungs CTAB
Cardiac: RRR, frequent PVCs
Sternal Incision: no erythema. Wound clean. 2 JPs remain in
place.
Abd: soft, non-tender, non-distended.
Ext: warm, 1+edema
Pertinent Results:
[**2168-10-25**] 05:23AM BLOOD WBC-8.4 RBC-3.22* Hgb-9.6* Hct-29.6*
MCV-92 MCH-30.0 MCHC-32.5 RDW-16.6* Plt Ct-280
[**2168-10-25**] 05:23AM BLOOD Glucose-114* UreaN-18 Creat-0.8 Na-138
K-3.9 Cl-106 HCO3-24 AnGap-12
[**2168-10-23**] 04:47AM BLOOD ALT-10 AST-18 LD(LDH)-216 AlkPhos-83
Amylase-36 TotBili-0.2
[**2168-10-23**] 04:47AM BLOOD Lipase-79*
[**Known lastname **],[**Known firstname 8031**] M [**Medical Record Number 79500**] F 43 [**2124-11-30**]
Date: [**2168-10-26**]
Signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2168-10-26**] Affiliation: [**Hospital1 18**]
NEEDS COSIGN
Initial Intake
Infectious Disease Clinic Outpatient Antimicrobial Management
Program
Surgeon: [**Last Name (LF) **],[**Name8 (MD) 177**] MD
Infectious Disease Fellow: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111**], MD
Infectious Disease Preceptor: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], MD
Infusion Company: [**Location (un) 511**] Home Therapies
Phone: 1.[**Telephone/Fax (1) **]
Fax: [**Telephone/Fax (1) 79503**]
VNA: Home Health and Hospice of [**Location (un) **], NH
Phone: [**Telephone/Fax (1) 79504**]
Type of Intravenous Access
Where placed: RUE [**10-23**]
PICC ( X ) Length ( 52cm )
Discharge diagnosis: MSSA sternal wound infection
Brief Summary of Patient History:
Ms [**Known lastname **] is a 43-year old woman with a history of
uncomplicated
MVR (bioprosthetic) and closure of PFO in [**2168-9-19**] presenting to
[**Hospital 5279**] Hospital on [**10-14**] and transferred to [**Hospital1 18**] on [**10-17**] with
sternal wound pain and drainage.
She presented to [**Hospital 5279**] Hospital on [**10-14**] with a progressive,
2-day history chest wall pain associated with nausea, shortness
of breath, and worsened with movement. In the ER at [**Doctor First Name 5279**], she
had a temperature of 100.4, BP 80s/40s, WBC 19K (87% PMN). A
TTE
demonstrated LVEF 35%, small posterior pericardial effusion,
well-seated MV prosthesis. Blood cultures demonstrated ([**3-15**])
demonstrated MSSA, a CT of chest w/ and without contrast
demonstrated a "tiny" fluid collection at the midline incision
site. Wound cultures demonstrated WBC w/o organisms, although
at
time of transfer culture was pending. Empiric antibiotics with
vancomycin and ceftazidime ([**10-14**]) were continued. During the
admission, she remained afebrile, hemodynamically stable, and
was
transferred for further evaluation. She was taken to OR [**10-18**]
for
debridement and returned [**10-20**] for sternal plating. Blood
cultures at [**Hospital1 18**] [**Date range (1) 60609**] remain negative at time of
discharge. Although a swab culture from the wound on [**10-17**] was
negative, all 4 intra-operative swab and tissue cultures from
[**10-18**] demonstrated MSSA; no swab was taken on [**10-20**] (some necrotic
tissue was debrided). A TEE was negative for endocarditis.
For the remainder of the admission, she remained afebrile and
generally improved. Two anterior chest drains remained intact
and in place at the time of discharge (to be removed approx 1
week post-discharge). She had [**1-14**] loose stools daily for
several
days toward the end of the admission, briefly started
empirically
on metronidazole, but was C. diff toxin negative x1.
She was continued on Nafcillin starting [**10-18**], and should be
continued for 6 weeks minimum starting [**10-20**]. In clinic
follow-up, duration of antibiotics will be determined, including
possible long-term suppression with ciprofloxacin and rifampin,
as well as a further discussion with surgery re: plate removal
if
indicated.
PAST MEDICAL HISTORY:
++ Cardiomyopathy with mitral regurgitation
++ Mitral valve replacement, bioprosthetic, [**2168-9-19**]
++ patent foramen ovale closure, [**2168-9-19**]
++ Hypertension
++ Hypercholesterolemia
++ Psoriatic arthritis
++ Endometriosis
- R Salpingo-oophorectomy
++ Obesity
++ Depression
++ Panic disorder
++ Narcolepsy
[**Hospital 5279**] Hosp (micro [**Telephone/Fax (1) 79505**]):
Wound culture ([**10-16**]): light presumptive Staph
Blood culture ([**10-15**]) x2: NGTD
Blood culture ([**10-14**]): 2/2 bottles MSSA (pan-[**Last Name (un) 36**])
Urine culture ([**10-14**]): NEG
Nares culture, MRSA screen ([**10-14**]): NEG
[**Hospital1 18**]:
Sternal wound swab [**10-17**]: negative (stain w/o PMN/orgs)
Intra-op ([**10-18**])
Sternal wound swab x2: MSSA
Sternal wound tissue x2: MSSA
BCx [**10-17**] x2, [**10-20**], [**10-21**] x2: NEG/NGTD
UCx [**10-17**], [**10-21**] NGTD
Cath tip Cx [**10-17**] NGTD
Cdiff toxin [**10-18**], [**10-23**], [**10-25**]: NEG
TEE [**10-18**]
LVEF 35-40%
no veg
MV well-seated
LABORATORY REVIEW
DATE WBC ESR CRP Cr ALT/AST/tbili
*[**10-14**] 19 1.8
*[**10-15**] 121
*[**10-16**] 12 37.4 1.2
[**10-17**] 8.4 125 >300 1.0 14/17/0.5
[**10-18**] 7.8 1.1 11/15/0.3
[**10-19**] 6.2 0.8
[**10-20**] 9.5 0.8
[**10-21**] 11.4 0.9
[**10-23**] 10/18/0.2
[**10-24**] 6.9 0.9
Patient Allergies: NKDA
Prescribed Antibiotic Information:
Nafcillin 2g IV q4hr x6 weeks minimum, starting [**2168-10-20**]
laboratory monitoring required
CBC/diff, Chem 12, ESR/CRP qweek
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**]
FOLLOW-UP:
[**2168-11-18**] 10:00a ID,[**Location (un) **] [**Location (un) **]
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
ID WEST (SB)
Brief Hospital Course:
The patient was admitted for further management of her sternal
wound infection. On [**2168-10-18**] she was brought to the operating
room where she underwent sternal debridement and wound VAC
placement with the assistance of the plastic surgery team. The
patient returned to the operating room on [**10-20**] for chest closure
with pectoralis muscle flaps and plating. Please see operative
notes for details. Overall the patient tolerated the procedures
well and post-operatively was transferred to the CVICU for
observation and recovery. By POD 1 (from chest closure) she was
hemodynamically stable, extubated, alert and oriented and
breathing comfortably.
ID was consulted for assistance in antibiotic administration.
Nafcillin therapy was initiated per ID recommendations.
The patient was transferred to the step down unit on [**2168-10-22**].
She developed diarrhea and was started on Flagyl empirically.
Two c-diff toxins were negative. Imodium therapy was initiated.
A third c-diff toxin was sent. Her stool frequency decreased to
twice a day and began to firm. Only 2 doses of Imodium were
taken and Flagyl was stopped.
The patient remained in sinus rhythm,however, she continued to
have frequent PVCs with non-sustained ventricular tachycardia.
Electrolytes were repleted and beta-blocker titrated
accordingly. Her ectopy improved dramatically with these
treatments.
Two JPs remain in place and she is afebrile. ID and Plastic
Surgery continued to follow her and she was ready for discharge
on [**10-26**]. Arrangements were made for home infusion therapy for
Nafcillin and lab draws and follow-up with both infectious
disease and plastic surgery.
Medications, instructions and restrictions were discussed with
the patient before discharge.
.
Medications on Admission:
aspirin 81 mg daily
klonopin 1mg [**Hospital1 **]
folic acid 1mg daily
lasix 10mg tid
lopressor 25mg q8h
remeron 15mg daily
ativan 0.5mg q6h prn anxiety
duoneb inh q4h prn
lovenox 40mg sq
zofran 4mg q6h prn
protonix 40mg daily
vancomycin 1gIVdaily
ceftazidime 2g q12h
dilaudid 0.5-1mg IV q1h prn
morphine 2mg IV prn
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day).
Disp:*1 15gm* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO every four
(4) hours as needed for loose stool for 2 weeks: after loose
stool. No more than 6 a day.
Disp:*30 Capsule(s)* Refills:*0*
13. Ibuprofen 200 mg Tablet Sig: Four (4) Tablet PO three times
a day for 3 weeks: take with food.
Disp:*252 Tablet(s)* Refills:*0*
14. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
Disp:*60 Tablet(s)* Refills:*2*
15. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
Disp:*90 Tablet(s)* Refills:*2*
16. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2)
grams Intravenous Q4H (every 4 hours) for 6 weeks: as direscted.
Disp:*504 grams* Refills:*0*
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush for 6
weeks.
Disp:*QS ML(s)* Refills:*2*
18. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
19. saline flush Sig: 1-2 mg Intravenous every 4-6 hours for 6
weeks.
Disp:*50 * Refills:*2*
20. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**4-17**]
hours as needed for nausea for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
homehealth vna of [**Location (un) **]
Discharge Diagnosis:
sternal wound infection
s/p sternal debridement
s/p closure with bilat pectoral flaps and sternal plates
s/p MVR(tissue) & closure of PFOPsoriasis
arthritis
endometriosis
obesity
Discharge Condition:
good
Discharge Instructions:
Take all medications as prescribed.
Call for any fever greater than 100.5
report any redness or drainage from wounds
no lifting more than 10 pounds for 10 weeks
no driving until cleared by plastic surgery
Followup Instructions:
)
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2168-11-18**] 10:00
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **](plastic surgery) next week
Dr [**Last Name (STitle) 914**] in 4 weeks from original surgery ([**Telephone/Fax (1) 170**])
Completed by:[**2168-10-26**]
ICD9 Codes: 7907, 4271, 4254, 2768, 496, 4240, 4019, 3051, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1980
} | Medical Text: Admission Date: [**2168-2-2**] Discharge Date: [**2168-2-4**]
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Arterial line
History of Present Illness:
[**Age over 90 **]F with COPD, CAD, CHF sent in from [**Hospital **] rehab, russian
speaking only. History from daughter and [**Hospital 100**] rehab notes.
Per the daughter she was called by [**Hospital 100**] rehab with concerns
about her mother. [**Name (NI) **] mother's urine output had decreased she
had a new oxygen requirement, low blood pressures and poor oral
intake. The note from [**Hospital 100**] rehab is confusing as to what
exactly was going on in terms of blood pressure however it does
state that her lisinopril was stopped and she was started on
IVF. A CXR was checked which revealed a new right sided pleural
effusion. Labs at [**Hospital 100**] rehab were notable for a potassium of
6 without peaked T-waves, an increase in her creatinine from 2.2
on [**1-27**] to 4.0 on [**2-2**] with an associated drop in her bicarb
to 18. She received a kayexalate enema for her hyperkalemia.
.
She was also started on imipenem for a presumed ESBL UTI. The
patients daughter initially wanted to keep her out of the
hospital, however she asked the patient
.
In the ED, initial vs were 96.6 58 97/67 16 94% 4L. She
received vancomycin, levaquin and flagyl for initial presumption
of sepsis NOS. She received 2L of NS with no improvement in her
lactate. She was intermittently hypotensive to the 80's and
responded to a second 2L of NS. An EKG revealed AFIB without
significant changes. She had a non-contrast adbdominal CT to
look for a source of infection which was unrevealing. CXR
revealed the aformentioned new right pleural effusion. Of note
her UE BPs were unreliable in the ED, and the ED resident
attempted to check them via doppler, he was unable to find them
and bedside ultrasound revealed no radial pulses despite warm
well perfused hands. Several attempts were made at placing a
right femoral a-line which failed and finally a left femoral
a-line was placed. Two 18 gauge peripherals were placed as the
patients daughter was refusing central line. Peripheral
levophed was started prior to leaving the ED.
.
On the floor, she remained unresponsive to a 250cc NS bolus with
MAPs in the low 60's.
.
Past Medical History:
Recurrent ESBL UTIs
Dementia with hallucinations,
delerium with delusions
Hypertension
Chronic renal insufficiency
Osteoarthritis
Back Pain
Clavicle Fracture
Peripheral Artery Disease
History of an aneurysmal neck vein
A. Fib
Social History:
Lives at [**Hospital 100**] Rehab, HCP is daughter [**Name (NI) 2951**].
Family History:
Non-contributory
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2168-2-2**] 06:00PM BLOOD WBC-16.8*# RBC-4.25# Hgb-13.6# Hct-42.3#
MCV-99* MCH-32.0 MCHC-32.2 RDW-18.0* Plt Ct-97*#
[**2168-2-2**] 09:05PM BLOOD PT-17.5* PTT-38.3* INR(PT)-1.6*
[**2168-2-2**] 06:00PM BLOOD Glucose-116* UreaN-87* Creat-4.0*# Na-139
K-5.8* Cl-103 HCO3-20* AnGap-22*
[**2168-2-2**] 06:00PM BLOOD ALT-15 AST-48* CK(CPK)-98 AlkPhos-94
[**2168-2-2**] 06:00PM BLOOD CK-MB-8 cTropnT-0.12*
[**2168-2-3**] 02:42AM BLOOD Calcium-8.1* Phos-6.0*# Mg-2.2
[**2168-2-2**] 11:05PM BLOOD Type-ART Temp-37.3 FiO2-92 O2 Flow-15
pO2-204* pCO2-38 pH-7.22* calTCO2-16* Base XS--11 AADO2-431 REQ
O2-73 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2168-2-2**] 06:22PM BLOOD Lactate-3.3*
.
IMPRESSION:
1. Partially imaged moderate right and small left pleural
effusions with
overlying atelectasis. Cardiomegaly, in conjunction with diffuse
subcutaneous
edema and mesenteric haziness suggests volume overload. Small
amount of
perihepatic fluid. Presacral edema.
2. 2 to 3 small fluid density rounded structures along the
inferior medial
border of the right lobe of the liver, of unclear etiology.
Recommend
clinical correlation with history of malignancy, superinfection
cannot be
excluded.
3. Extensive colonic diverticulosis, without evidence of acute
diverticulitis.
4. Cholelithiasis.
.
[**2-2**] CXR:
IMPRESSION:
1. Interval development of moderate-to-large right pleural
effusion with
overlying atelectasis, underlying consolidation cannot be
excluded.
2. Persistent cardiomegaly. No overt pulmonary edema.
Brief Hospital Course:
In brief, this is a [**Age over 90 **] year old female who was transferred from
[**Hospital 100**] Rehab to the MICU at [**Hospital1 18**] for further evaluation of
hypotension, hypoxia, and acute on chronic kidney injury
secondary to urosepsis. She was admitted to the MICU and
despite pressor support, fluid resuscitation, and appropriate
antibiotics, it soon became clear that the patient's clinical
status would not recover as evidenced by increasing lactate and
worsening acidemia. The patient's daughter, [**Name (NI) 2951**], was
informed of the patient's worsening clinical status and given
her poor prognosis, it was decided to change her code status
from DNR/DNI to CMO. The patient passed away shortly after
institution of a morphine drip and withdrawal of pressors. The
patient's daughter, [**Name (NI) 2951**], was present at bedside and refused
autopsy. Time of death was 4:45AM. The following summarizes
her hospital course:
.
#. Urosepsis: The patient presented with a floridly positive U/A
in the setting of gross pyuria, hypotension, hypothermia,
leukocytosis, and increased respiratory rate all c/w infectious
etiology. UTI with sepsis is the most likely source. Lactate
was initially 3.3 and the patient was fluid resuscitated. Blood
and urine cultures were drawn and pending at time of death. CT
scan was unremarkable. She was started on pressors.
Meropenem/Vancomycin were started out of concern for ESBL UTI
given history of same. Levophed was changed to phenylephrine out
of concern for tachycardia. CVP was 20 in setting of 4+ TR. On
HD #2, lactate began trending up and phenylephrine was again
changed to Levophed in addition to vasopressin. She was
administered additional fluid boluses, but her lactate trended
up to 7.5 and she was acidemic with a pH of 7.05. Her daughter,
[**Name (NI) 2951**], was informed of her worsening clinical prognosis and it
was decided to change to patient's code status to CMO.
.
#. Acute on Chronic Renal Faillure: Cr was initially 4, up from
baseline of 1. Thought to be [**3-10**] ischemic ATN in the setting of
septic shock. On HD #2, Cr improved to 3.5 with IVFs.
.
#. Lactic acidosis: 3.3 on transfer to ICU. Likely [**3-10**] to septic
shock. Initially, lactate improved with IVF but on HD#2 it
began rising and peaked at 7.5. Pressors were administered as
described above.
Medications on Admission:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: Do
not take if your systolic blood pressure is less than 105.
6. Ipratropium Bromide 0.03 % Spray, Non-Aerosol Sig: Two (2)
sprays Nasal twice a day: in each nostril.
7. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation twice a day as needed for
SOB.
9. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*qs * Refills:*2*
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
ICD9 Codes: 0389, 5845, 5859, 496, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1981
} | Medical Text: Admission Date: [**2152-6-28**] Discharge Date: [**2152-7-7**]
Date of Birth: [**2152-6-28**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**Known lastname 2795**] [**Known lastname 42741**] was born at 35
and 2/7 weeks gestation to a 32 year-old gravida 3 para 1 now
2 woman. Her prenatal screens are blood type A positive,
antibody negative, Rubella immune, RPR nonreactive, hepatitis
surface antigen negative and group B strep unknown. This
twenty years and elevated blood pressures during the
pregnancy prompting a repeat cesarean section.
The infant emerged vigorous. Apgars were 8 at one minute and
9 at minutes. There was rupture of membranes at the time of
delivery. No intrapartum fever and no other sepsis risk
factors. The infant's birth weight was 1175 grams, birth
ADMISSION PHYSICAL EXAMINATION: Premature nondysmorphic
infant large for gestational age. His anterior fontanel open
and flat. Positive bilateral red reflex. Intact palette.
Positive sternal and intercostal retractions, grunting and
retracting, minimal air entry, grade [**2-2**] low pitch systolic
murmur at the left sternal border, femoral pulses +2, three
vessel umbilical cord, no hepatosplenomegaly. Testes
descended bilaterally. Patent anus. Normal sacrum. Stable
hip examination and symmetric tone and reflexes.
HOSPITAL COURSE: 1. Respiratory status: The infant was
intubated for respiratory distress soon after admission to
the Neonatal Intensive Care Unit. He received one dose of
Surfactant and extubated to room air on day of life number
one where he has remained. He had one episode of apnea,
bradycardia, and desaturation on day of life number four. He was
monitored for five days subsequent to this without further
episodes.
2. Cardiovascular status: He required a normal saline bolus
for blood pressure support on admission. The initial murmur
resolved. He has had a grade [**1-2**] soft intermittent murmur
without any hemodynamic consequences. He has remained
normotensive since day of life number one.
3. Fluid, electrolyte and nutrition status: Enteral feeds
were begun on day of life number one and advanced without
difficulty to full volume feedings. At the time of discharge
he is taking Enfamil 20 calories per ounce or breast milk on
an ad lib schedule. At the time of discharge his weight is
2105 grams. His length is 47.5 cm and his head circumference
is 32 cm. The infant initially had some hypoglycemia
requiring boluses of IV dextrose, but with adequate volume
intake of formula, that has resolved.
4. Gastrointestinal status: He was treated with
phototherapy for hyperbilirubinemia of prematurity from day
of two until day of life three. His peak bilirubin on day of
life two was total 9.4, direct 0.3.
5. Hematological status: His hematocrit at admission was
42.3. He has received no blood transfusions.
6. Infectious disease status: [**Known lastname 2795**] was started on
ampicillin and gentamicin 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.
7. Sensory status: Hearing screen was performed with
automated auditory brain stem responses, and the infant passed
in both ears.
8. Psycho/social: The parents have been very active in the
infant's care throughout his Neonatal Intensive Care Unit
stay.
CONDITION ON DISCHARGE: Good.
DISPOSITION: The infant is being discharged home with his
parents.
PEDIATRIC PROVIDER: [**Name10 (NameIs) **] pediatric care will be provided by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38807**]. Telephone number [**Telephone/Fax (1) 37949**].
SCREENING: He passed a car seat position screening test on
[**2152-7-7**]. State newborn screen was sent on [**2152-7-1**].
IMMUNIZATIONS: The infant received his first hepatitis C vaccine
on [**2152-7-2**].
FOLLOW UP: 1. Primary pediatric care provider. 2.
[**Hospital6 407**] of Greater [**Location (un) 5871**]. Telephone
number 1-[**Telephone/Fax (1) 42742**].
DISCHARGE DIAGNOSES:
1. Prematurity 35 and 2/7 weeks.
2. Status post hyaline membrane disease.
3. Sepsis ruled out.
4. Status post apnea of prematurity.
5. Infant of diabetic mother- status post hypoglycemia.
6. Status post hyperbilirubinemia.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 36864**]
MEDQUIST36
D: [**2152-7-7**] 06:41
T: [**2152-7-7**] 06:52
JOB#: [**Job Number 42743**]
ICD9 Codes: 769, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1982
} | Medical Text: Admission Date: [**2153-6-11**] Discharge Date: [**2153-6-12**]
Date of Birth: [**2094-12-22**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
elective cardiac cath
Major Surgical or Invasive Procedure:
left and right heart cath
History of Present Illness:
58 y/o male with hx borderline hyperlipidemia, remote smoking,
who presents for scheduled PCI after postitive stress test.
Taken to cath lab and found to have 90% p-LAD, 80% m-LAD
involving D1 takeoff. Normal filling pressures. LVgram 63%. Pt
had 2 overlapping stents with transient jail of D1. Pt
developed hypotension in the cath lab requiring dop gtt to 18,
now in the CCU for weaning of dopamine. Etiology of hypotension
presumably [**3-14**] medication affect.
Past Medical History:
hyperlipidemia
htn
Social History:
remote smoking
Family History:
non-contrib
Physical Exam:
AF 120's/70's 70's 15
Gen: NAD, A&O X 3
Heent: Diffuse rash over face and trunk (chronic)
Neck: No JVD
Heart: RRR no mrg
Lungs: CTAB
Abd: Soft, nt/nd. NABS
Ext: No c/c/e
Pertinent Results:
[**2153-6-12**] 04:15AM BLOOD WBC-9.1 RBC-4.34* Hgb-12.9* Hct-36.6*
MCV-84 MCH-29.6 MCHC-35.2* RDW-13.1 Plt Ct-204
[**2153-6-11**] 12:44PM BLOOD Neuts-83.2* Bands-0 Lymphs-11.5*
Monos-3.1 Eos-1.8 Baso-0.4
[**2153-6-11**] 12:44PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2153-6-12**] 04:15AM BLOOD PT-12.0 PTT-26.6 INR(PT)-0.9
[**2153-6-12**] 04:15AM BLOOD Glucose-87 UreaN-23* Creat-1.0 Na-140
K-4.0 Cl-106 HCO3-29 AnGap-9
[**2153-6-12**] 04:15AM BLOOD CK(CPK)-91
[**2153-6-12**] 04:15AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
Prox and mid LAD stented (90% and 80% resp).
Brief Hospital Course:
1. Hypotension: Liklely [**3-14**] drug effect in setting of
hypovolemia (low PCWP). Preserved CO and normal SVR, so
unlikely cardiogenic or distributive shockDop easily weaned.
Restarted BB.
2. CAD: S/P overlapping LAD stents to 90% and 80% prox and mid
LAD lesions. Cont asa/plavix/statin. Hold ACE for now. Outpt
stress in future.
3. Pump: Preserved EF and CO. Normal valves. Hypo-euvolemic.
3. Rhythm: Cont tele.
4. Rash: Pt has hx skin cancer. He has been seeing
dermatology who has prescribed him topical lotions with to help
heal the sun-damaged areas. This is a chronic problem.
5. Polyuria: Pt has a long history of polyuria. He has been
followed by urology and this problem is being worked on as an
outpt. He is c/o severe pain [**3-14**] catheter insertion, which he
has been started on pyridium for.
Medications on Admission:
lipitor
asa
atenolol
plavix
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*3*
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Elective heart cath
Discharge Condition:
good
Discharge Instructions:
If you have these symptoms, call your doctor:
- fevers/chills
- chest pain
- shortness of breath
- dizziness
- visual changes
Followup Instructions:
f/u with your PCP [**Last Name (NamePattern4) **] 2 weeks
Completed by:[**2153-6-12**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1983
} | Medical Text: Admission Date: [**2153-2-6**] Discharge Date: [**2153-3-19**]
Date of Birth: [**2094-3-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
1. Pseudoaneurysm of ascending aorta and arch
2. 2+ Aortic insufficiency
3. Respiratory failure
Major Surgical or Invasive Procedure:
[**2153-2-7**]
1. Ascending aorta hemiarch replacement with 26mm Gelweave graft
2. Aortic valve repair with 21mm pericardial tissue valve
[**2153-2-19**]
1. Tracheostomy
History of Present Illness:
58 year-old woman with hypertension, former tobacco use, and
Type B aortic dissection [**9-13**] with surgical repair. At that time
an ascending aortic hematoma was also noted. After several
missed appointments, she now presents with chest pain and
shortness of breath and a blood pressure of 200/100. She was
found to have an enlarging ascending aortic pseudoaneurysm on
CTA.
Past Medical History:
s/p type B aortic dissection repair [**9-13**]
Poorly controlled hypertension
Asthma
Obesity
COPD
s/p L frontal and R parietal lobe CVA
a fib
s/p retraoperitoneal hematoma
s/p repiratory failure with trach [**10-14**]
Social History:
Smoked 15 pk years until aortic dissection. No Etoh, No Drugs.
Family History:
Negative for aortic dissection; negative for CAD.
Physical Exam:
VS: P 60, BP 96/60 R-20 100% PS 0.4
GEN: [**Last Name (LF) 3584**], [**First Name3 (LF) 2995**]
HEENT: PERRLA EOMI
Neck: No Carotid Bruits
Heart: Distant, RRR w/o M
Chest: Bilateral Rhonchi, wheezes l>r
ABD: SNTND, no rebound
Vasc: Radial Femoral DP PT
R A-Line 2+ 2+ 2+
L 2+ 2+ 2+ 1+
Pertinent Results:
[**2153-2-23**] 04:17AM BLOOD WBC-10.4 RBC-3.22* Hgb-9.8* Hct-28.2*
MCV-88 MCH-30.4 MCHC-34.7 RDW-14.8 Plt Ct-185
[**2153-2-23**] 04:17AM BLOOD Plt Ct-185
[**2153-2-23**] 04:17AM BLOOD Glucose-94 UreaN-21* Creat-0.4 Na-142
K-4.0 Cl-106 HCO3-30* AnGap-10
[**2153-2-23**] 04:17AM BLOOD Mg-2.0
Cardiac catheter [**2154-2-6**]
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Moderate aortic regurgitation.
3. Mild systolic ventricular dysfunction.
4. Mild diastolic ventricular dysfunction.
5. Large aneurysmal dilation of the ascending aorta.
Brief Hospital Course:
After admission, Mrs. [**Known lastname 58041**] underwent a cardiac catheter.
Supravalvular aortography revealed a large aneurysmal (>7cm)
dilation arising from 2-3 cm above the aortic valve and
encroaching on the true lumen of the aorta. 2+ aortic
regurgitation was noted. On [**2-7**], she was taken to the
operating room for ascending aortic and hemiarch relacement as
well as aortic valve replacement with a tissue valve.
Postoperatively, she was admitted to the cardiac ICU. Her
postoperative course was complicated (again) by repiratory
failure. She weaned slowly off the vent but failed extubation
after successfully passing several breathing trials. She had to
be reintubated and underwent an open trachestomy by the thoracic
surgery team on [**2153-2-19**]. Her blood pressure was controlled on a
nipride drip initially. Later she could be controlled below 110
systolically on oral Antihypertensives. She was fed via a
Dobhoff tube and tube feedings. During the days she tolerated
several hours on trach mask in the chair but spend the night on
the ventilator on minimal settings. She was diuresed
appropriately until she reached preoperative weights. She was
ultimately weanod off the ventilator, and placed on trach
collar.
On [**2-23**], she was started on IV Vancomycin for MRSA on a central
line, and 1 positive blood culture. She should complete a 6
week course. Her trough levels have been approx. 17 (goal
trough per ID service is 15-20), on 1250 mg IV BID.
She has passed swallow studies, oral feedings have been
advanced, and her feeding tube was removed, as she is now eating
a regular diet without difficulty.
Her trach was downsized from a 6 to a 4, then subsequently
removed (on [**2153-3-16**]).
At discharge, she was in a good condition. Her wound was without
signs of wound infection.
Of note, during her hospitalization, she had a possible exposure
to a TB+ person. Since she had a previous +PPD, we can not use
this as a screening test to monitor sero-conversion. Ms. [**Known lastname 58041**]
therefore must be monitored for the next year for symptoms of
tuberculosis and worked up if these symptoms are found.
Medications on Admission:
Albuterol
Lopressor 50mg po bid
Amiodarone 200mg po qd
Norvasc 10mg qd
Lasix 40mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Vancomycin HCl 10 g Recon Soln Sig: 1250 mg Intravenous
twice a day for until [**4-6**] doses.
Disp:*17 doses* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
1. Pseudoaneurysm of ascending aorta and arch
2. 2+ Aortic insufficiency
3. Respiratory failure
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Of note, during her hospitalization, she had a possible exposure
to a TB+ person. Since she had a previous +PPD, we can not use
this as a screening test to monitor sero-conversion. Ms. [**Known lastname 58041**]
therefore must be monitored for the next year for symptoms of
tuberculosis and worked up if these symptoms are found.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
[**Telephone/Fax (1) **]
Follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1300**] in [**2-11**]
weeks
Completed by:[**2153-3-19**]
ICD9 Codes: 4241, 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1984
} | Medical Text: Admission Date: [**2178-10-1**] Discharge Date: [**2178-10-12**]
Date of Birth: [**2126-10-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Mechanical ventilation
PICC line placement
Left Femoral Central line, placed and removed
Right Arterial line
History of Present Illness:
Mr. [**Known lastname **] is a 51 year-old man with a history of chronic
hypercapneic respiratory failure s/p trach, COPD, and morbid
obesity who presented from [**Hospital 100**] Rehab with hypotension and is
admitted to the MICU for further management.
He was trached on [**2178-8-13**] and last discharged on [**2178-9-18**] for
hypercapneic respiratory failure which was thought to be
secondary to a cuff leak, though he was also treated for
resistant psuedomonas VAP during this admission. He went to
[**Hospital 100**] rehab and completed a course of tobramycin (last dose
?[**2178-9-19**]). He also had blood cx that grew coag negative staph
and was started on vanc on [**9-27**]. He had a leukocytosis, with a
WBC count of 16 that trended down to 6 on the day of admission.
A urine cx grew ESBL klebsiella on [**9-30**] but he was not started
on antibiotics for this for unclear reasons. During this time,
his metoprolol was also increased from 12.5 mg po tid to 25 mg
po tid on [**9-27**] for improved a. fib heart rate control.
On the day of admission, he was found to have a BP of 85/65 ->
60/palp from a baseline in the low 100s systolic after
debridement of a right flank wound. He was thought to be
bacteremic and given approximately 1L IVF bolus with no
response. He was then transferred to [**Hospital1 18**] for further
management.
On arrival, VS were 97.8 84 80/47 24 100% on unknown vent
settings. He was thought to be septic vs having beta blocker
toxicity (last metoprolol given at 2 p.m.) and was given zosyn,
1.5 L IVF, and glucagon, with improvement in SBP to 120
transiently after the glucagon. Toxicology was consulted and
felt that beta blocker toxicity was unlikely given absence of
bradycardia.
A right radial a-line and left femoral line were placed for
access. A CXR was performed and demonstrated infiltrate vs
overload. IVFs were held after the CXR, and he was started on
levophed. Per report, a bedside ECHO was also performed to eval
for tamponade but was limited secondary to body habitus.
On the floor, he was minimally responsive to verbal stimuli and
began having rhythmic, tooth clattering motions at the chin. He
was given 1 mg IV ativan x 2 with resolution.
Past Medical History:
COPD on oxygen
Obstructive Sleep Apnea and obesity hypoventilation
Anxiety on klonopin
Morbid Obesity
Chronic LLE DVT
ARF [**3-9**] AIN, recent baseline Cr low-mid 2's
Pseudomonas VAP
[**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 104697**] UTI treated with fluc
Sacral decubitus ulcer right flank
Chronic pain of unclear etiology-trach site ulceration
Constipation
AF
Anemia
Social History:
Was living at home with mother but was recently discharged to
[**Hospital 100**] rehab. He denies any history of tobacco, etoh, or drug
use. He was using a motorized chair for most of his mobility.
Family History:
Noncontributory
Physical Exam:
Vitals: 97.8 84 80/47 24 100% FIO2 50%
General: morbidly obese, trached and vented, responds to verbal
stimuli, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, gazing to the
left
Neck: supple, JVP unable to assess, no LAD
Lungs: bilateral rhonchi, no rales or wheezes
CV: distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, distended, bowel sounds present, no organomegaly
GU: purulent discharge around foley.
Ext: warm, well perfused, 2+ pulses, 1+ LE edema, erythematous
patches scattered across chest, arms, and legs.
Pertinent Results:
Admission Notes;
[**2178-10-1**] 05:59PM HGB-9.7* calcHCT-29 O2 SAT-89 CARBOXYHB-1 MET
HGB-0.1
[**2178-10-1**] 05:59PM GLUCOSE-104 LACTATE-1.0 NA+-140 K+-5.1
CL--99*
[**2178-10-1**] 05:59PM TYPE-ART RATES-/30 TIDAL VOL-500 O2-50
PO2-50* PCO2-81* PH-7.27* TOTAL CO2-39* BASE XS-6 -ASSIST/CON
INTUBATED-INTUBATED
[**2178-10-1**] 06:10PM URINE RBC-0-2 WBC-[**4-9**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2178-10-1**] 06:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2178-10-1**] 06:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2178-10-1**] 06:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2178-10-1**] 06:10PM URINE HOURS-RANDOM
[**2178-10-1**] 06:40PM FIBRINOGE-593*
[**2178-10-1**] 06:40PM PLT SMR-NORMAL PLT COUNT-229
[**2178-10-1**] 06:40PM PT-13.7* PTT-35.1* INR(PT)-1.2*
[**2178-10-1**] 06:40PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
STIPPLED-OCCASIONAL
[**2178-10-1**] 06:40PM NEUTS-69 BANDS-2 LYMPHS-10* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-5* NUC RBCS-2*
[**2178-10-1**] 06:40PM WBC-10.5 RBC-3.25* HGB-8.4* HCT-29.7* MCV-91
MCH-26.0* MCHC-28.5* RDW-19.0*
[**2178-10-1**] 06:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2178-10-1**] 06:40PM proBNP-[**Numeric Identifier 21797**]*
[**2178-10-1**] 06:40PM LIPASE-17
[**2178-10-7**] LE Dopplers:
FINDINGS: Grayscale, color and Doppler son[**Name (NI) 1417**] of bilateral
common femoral, superficial femoral, popliteal and tibial veins
were performed. Note is made that the study is limited by the
patient's body habitus. There is normal low, compression, and
augmentation seen in all of the vessels.
IMPRESSION: No evidence of deep vein thrombosis in either leg.
[**2178-10-7**] ECHO:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal systolic septal motion/position consistent
with right ventricular pressure overload. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
There is no pericardial effusion.
[**2178-10-2**] CT Head
FINDINGS: There is no intracranial hemorrhage, edema, mass
effect, or
vascular territorial infarction. The ventricles and sulci are
normal in size and in configuration. Included osseous structures
are unremarkable, and the visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION: No acute intracranial process.
[**2178-10-2**] CT CHEST:
Findings: There has seen no interval change in diffuse
paraseptal and
centrilobular emphysematous changes of the lungs which
predominantly affect the apices. Diffuse fibrotic interstitial
abnormality evidenced by
bronchiectasis, bronchiolectasis, ground-glass opacities and
honeycombing
appears unchanged. There is new focus of consolidation within
the left lower lobe. Elevated left hemidiaphragm is unchanged.
No central pathologically enlarged nodes are visualized. No
pleural or
pericardial effusion is seen. The visualized part of the upper
abdomen
including adrenal glands, superior pole of the kidneys, liver,
and spleen
appear unremarkable. Gastrostomy tube is in place.
Ultrasound LEs
CONCLUSION: No evidence of deep vein thrombosis.
KUB
FINDINGS: A gastric tube is visualized. There is a paucity of
gas is seen in the abdomen. Supine films only were obtained and
therefore I cannot assess for any air-fluid levels.
Micro-
[**2178-10-5**] 10:28 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2178-10-12**]**
GRAM STAIN (Final [**2178-10-5**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2178-10-12**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
PSEUDOMONAS AERUGINOSA. 3RD TYPE. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I 16 I
CEFTAZIDIME----------- 16 I 16 I
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 2 S 2 S
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN---------- =>128 R =>128 R
PIPERACILLIN/TAZO----- =>128 R =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
Brief Hospital Course:
Mr. [**Known lastname **] is a 51 year-old man with a history of chronic
hypercapnic respiratory failure s/p trach, COPD and Cor
Pulmonale, and morbid obesity who presented from [**Hospital 100**] Rehab
with hypotension and was admitted to the MICU for further
management
# Hypotension/Sepsis: Acute hypotension was likely related to
sepsis given coag neg staph in blood cultures and ESBL
klebsiella in urine culture, which was not yet treated at Rehab.
Pneumonia was also thought to be a source of infection. There
was some initial concern for beta blocker toxicity but this
seemed unlikely considering that patient was stable regimen for
three days and was not bradycardic on presentation. Chest CT
showed extensive interstitial lung disease with end stage
emphysema change. Pt was cultured and sputum showed growth first
of proteus and later MDR pseudomonas. Also, pt had a large flank
ulcer on the right side with drainage, with GNRs. Surgery
evaluated wound, but pt did not appear to have any pockets of
infection and was to unstable for more exploration. IVF were
given initially. Later pressors were needed to sustain SBP>110.
Echo showed worsening cor pulmonale. Pt was started on vanco and
meropenum. Later change to [**Female First Name (un) **] and vancomycin level was
supratherapeutics after the third dose throughout his
hospitalization. He required increasing amounts of vasopressors-
Levophed, vasopressin, and then on day of expiation was also on
Neo-Synephrine and tried briefly on dobutamine without
improvement in BP.
# Hypoxic/Hypercapnic respiratory failure: Multifactorial
respiratory failure secondary to obstructive COPD and
restrictive lung disease and obesity hypoventilation, s/p
tracheostomy on [**2178-8-13**]. Also had worsening cor pulmonary from
lund disease. As stated about was treated for sepsis including
pneumonia. Became difficult to ventilate and PCO2 continued to
rise despite increased ventilator settings. PCO2 rose to >100
and pt was paralyzed. Pt was continued on albuterol and
ipratropium bronchodilators. Diuresis was attempted later in his
course without significant improvement. Esophageal balloon was
placed to optimized his PEEP. As stated above he was treated
with tobramycin for his PNA. For his acidosis, as his pH fell
below 7.2, he was treated with bicarb gtt and boluses.
# Altered mental status: Was gazing to the right and had
rhythmic movements of chin/teeth clattering concerning for
seizure versus clattering from hypothermia vs electrolyte
abnormality on admission. This appeared to respond to Ativan.
Per [**Hospital 100**] rehab, usually responsive to name and does
occasionally have right [**Hospital1 **] gaze. Before paralysis pt was
responsive to simple questions with nodding/shaking of the head.
EEG was ordered to evaluate for seizure activity.
# Rash with erythematous patches: concerning for urticaria
though had received beta-lactams before without reaction.
Improved with Benadryl. Did not reoccur
# Chronic kidney injury: Cr of 1.3 was improved from creatinine
at last discharge of 2 and has had elevated Cr during recent
hospitalizations. Cr baseline was 0.6 in [**2178-8-5**]. History of
AIN. Renally dosed his medications.
# Atrial fibrillation: Was on metoprolol at rehab for rate
control, not on warfarin secondary to history of RP bleed. Held
his metoprolol due to hypotension.
On the morning of [**2178-10-12**], pt became steadily more hypoxic with
sats in the 70s despite maximizing vent settings. BP dropped
lower and pt required 3 pressors. ABG showed increasing
acidosis. Bicarb x 5 amps was given. Atropine and Epi were given
as pt became more bradycardic and then asystolic. CPR was
started and was not success in regaining a cardiac rhythm. Time
of death was 11:47. Attending called the family as these events
occurred, family arrived at bedside after pt had expired. No
autopsy was requested.
Medications on Admission:
Vancomycin - renally dosed ([**9-27**])
Lactulose 30 mL NG Q8H:PRN bm
Fentanyl Patch 100 mcg/hr TP Q72H
Clonazepam 1 mg NG [**Hospital1 **]
Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
Lidocaine 5% Patch 1 PTCH TD DAILY 12 hrs on, 12 hrs off
Magnesium Oxide 400 mg DAILY THROUGH GTUBE
Omeprazole 40 mg NG DAILY
Lorazepam 1 mg IV Q4H:PRN anxiety
Polyethylene Glycol 17 g PO DAILY:PRN
Albuterol Inhaler [**3-11**] PUFF IH Q4H:PRN dyspnea
Ipratropium Bromide MDI [**3-13**] PUFF IH QID
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Insulin SC (per Insulin Flowsheet) Sliding Scale
Heparin 5000u sc tid
Metoprolol tartrate 25 mg tid
Hydromorphone 5 mg q6h prn per gtube
Lorazepam 1 mg q2h IV prn
Morphine 4 mg q4h SL prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2178-10-12**]
ICD9 Codes: 5990, 2762, 2760, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1985
} | Medical Text: Admission Date: [**2137-11-24**] Discharge Date: [**2137-12-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Thoracentesis
Paracentesis
History of Present Illness:
81yo man with h/o CLL c/b malignant pleural effusion, primary
resected melanoma, type II diabetes mellitus, and Gout presented
to [**Hospital1 18**] ED after mechanical fall and found to have subdural
hematoma.
.
The patient reports he tripped and fell on his oxygen cord at
home. He was started on supplemental oxygen after his last d/c
from NEBH on [**2137-11-22**]. On initial presentation to ED T 98.8 HR
96 BP 99/43 RR 19 92% 2.5L. He was admitted to the MICU for
further evaluation and treatment, and neurosurgery was
consulted. Head CT showed multiple high density nodules
concerning for metastatic disease. He was loaded with dilantin
and monitored overnight without any detioration in neurologic
status. Repeat head CT showed stable appearance of the SDH.
Hematology/Oncology was consulted. He was transfused 6units
platelets in the ED, and underwent leukopheresis in the MICU.
Of note, patient was recently hospitalized [**Date range (1) 25864**]/05 on
Oncology service for leukopheresis and chemo for his CLL after
presenting with dyspnea and WBC 678K.
.
On presentation now his is oriented x3 and complains only of
pain in his right shoulder. He denies headache, dizziness,
confusion, vision changes, nausea. On ROS he denies fever,
chills, sweats, palpitations, chest pain, SOB, abdominal pain,
nausea, vomiting, diarrhea, constipation, bloody stools,
dysuria, hematuria. He notes some skin changes in his arms c/w
small bruises.
Past Medical History:
1. T cell CLL/PLL; previously treated with pentostatin,
cyclophosphamide, fludarabine, cytoxan. currently getting
regular leukopharesis and Campath. c/b left malignant pleural
effusion requiring thoracentesis
2. h/o left chest wall melanoma s/p resection, no nodal
dissection
3. type II diabetes mellitus
4. Gout
5. Hypertension
6. H/o right knee arthritis
7. H/o small bowel obstruction
Social History:
married, lives with his wife
retired construction worker, originally from [**Country 2559**]
Tob: previously smoked 2ppd, quit 21yrs ago
EtOH: avg 1/week
illicits: none
Family History:
Mother died at 86 of [**Name (NI) 2481**]
Father died at 52 of an accident
Brother died at 67 of lung cancer
Physical Exam:
T 99.3 HR 90 BP 101/55 RR 20 95%5Lnc
Gen: comfortable, alert, NAD
HEENT: anicteric, PERRL, EOMI, OP with petechia posteriorly,
MMM
Neck: supple, no LAD, R SC pheresis catheter in place, JVP
nondistended
CV: RRR, II/VI SEM, PMI nondisplaced
Resp: decreased BS B bases with mild crackles
Abd: +BS, soft, NT, ND, liver palp 2cm below costal margin,
spleen not palpable
Ext: [**1-2**]+ pitting edema BLE, nontender
Skin: petechiae arms, abdomen, legs
Neuro: A&Ox3, answers questions appropriately and follows
commands, CN II-XII intact, strength 5/5
biceps/triceps/grip/quads/dorsi&plantar flexion, sensation
intact to fine touch BUE and BLE, coordination intact FTN, no
plantar deviation. gait and romberg not assessed
Pertinent Results:
[**11-24**] Head CT:
1. High density nodules and multiple ill-defined hypodensities
scattered
throughout the brain, suggestive of a metastatic process.
2. Very small (approximately 1 mm) right extra-axial fluid
collection, with associated mild edema of the right hemisphere,
but without midline shift.
An MRI of the brain is recommended for further evaluation of
these findings.
.
[**11-24**] CXR:
New moderate-sized right pleural effusion, with underlying
collapse and/or consolidation. Atelectasis at left base.
Prominent right
hium --
.
[**11-25**] Head CT:
No interval change in the appearance of the brain. Stable tiny
right subdural hemorrhage. Unchanged appearance of multiple
high attenuation lesions scattered within the brain concerning
for metastasis.
.
[**12-1**] CXR: There is a right-sided IJ central venous catheter, with
the distal tip in the SVC, unchanged. There is again seen a
large right-sided pleural effusion likely layering and a
left-sided pleural effusion which is moderated sized. These are
unchanged from previous. There is no evidence for overt
pulmonary edema. There is a left retrocardiac opacity. This
finding is unchanged. Underlying pneumonia would be difficult to
exclude given the retrocardiac opacity and the large pleural
effusions.
.
ECHO: [**12-6**]:
Conclusions:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and systolic function (LVEF>55%). Regional left
ventricular wall motion is normal. Right ventricular chamber
size and free wall motion are normal. Trivial mitral
regurgitation is seen. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
.
CT Head [**2137-12-5**]:
FINDINGS: There is a new moderate sized mixed density subdural
fluid collection on the right. The lateral ventricle is
completely compressed indicating mass effect from the subdural
fluid collection as well as a 3 mm shift of the normally midline
structures. The mixed intensity of the collection likely
consists of blood and other fluid given the mixed densities. The
previously identified high-density lesions are subsiding
indicating that these were most likely hemorrhages rather than
amyloid angiopathy.
.
CT Head [**2137-12-6**]:
There is no change in the size or configuration of the
right-sided subdural hemorrhage. Denser blood products are
layering posteriorly. The hematoma extends under the right
temporal lobe, which is slightly elevated and medially
displaced. However, the basal cisternal spaces retain their
normal configuration. There is mild shift of midline structures
to the left, unchanged since the previous day's examination.
Brain parenchymal attenuation is also stable.
.
CT Head [**2137-12-9**]:
IMPRESSION: Stable right subdural hematoma with slight
progression of mass effect and shift of midline structures.
.
CT Head: [**2137-12-18**]:
IMPRESSION: Slightly improved right subdural hematoma and
associated mass effect, with lessened contralateral shift of
normally midline structures.
.
[**2137-11-24**] 08:17PM GLUCOSE-144* UREA N-56* CREAT-2.2* SODIUM-137
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-11
[**2137-11-24**] 08:17PM CALCIUM-7.9* PHOSPHATE-2.0* MAGNESIUM-2.1
[**2137-11-24**] 08:17PM WBC-665.6* HCT-22.5*#
[**2137-11-24**] 08:17PM PLT COUNT-51*#
[**2137-11-24**] 08:17PM PT-14.4* INR(PT)-1.4
[**2137-11-24**] 12:00PM GLUCOSE-171* UREA N-54* CREAT-2.2*#
SODIUM-136 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12
[**2137-11-24**] 12:00PM CK(CPK)-63
[**2137-11-24**] 12:00PM CK-MB-NotDone cTropnT-0.07*
[**2137-11-24**] 12:00PM CALCIUM-8.1* PHOSPHATE-1.4* MAGNESIUM-2.2
[**2137-11-24**] 12:00PM WBC-846.7*# HCT-35.0*#
[**2137-11-24**] 12:00PM NEUTS-0* BANDS-0 LYMPHS-19 MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-81*
[**2137-11-24**] 12:00PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2137-11-24**] 12:00PM PLT SMR-RARE PLT COUNT-15*#
[**2137-11-24**] 12:00PM PT-13.9* PTT-21.2* INR(PT)-1.3
Brief Hospital Course:
81yo man with h/o CLL c/b malignant pleural effusion, primary
resected melanoma, type II diabetes mellitus, and gout presented
to [**Hospital1 18**] ED after mechanical fall and found to have subdural
hematoma. During his hospitalization the following issues were
addressed:
.
#. Subdural hematoma: Hemorrhage occurred in the setting of
mechanical fall. He was seen by neurosurgery who recommended
keeping SBP <140 and loading with Dilantin. He was admitted to
the MICU for frequent neuro checks, and remained there for one
day. On day two, his Dilantin level was subtherapeutic, and he
was reloaded. On day three he developed neurologic changes of
increased lethargy and dysarthria. Findings were consistent
with Dilantin toxicity. His AM dose was held on day four, and
symptoms resolved. He was continued on Dilantin 100mg po TID.
His head CT showed multiple lesions concerning for mets disease.
It was unclear whether these lesions could be due to his
CLL/PLL or due to his remote history of nonmetastic resected
melanoma. He had a brain MR that showed a single parietal
lesion concerning for mets. The other lesions were read as
consistent with amyloid angiopathy. Neuro-oncology was
consulted, and did recommend LP for staging, and that patient
may benefit from XRT.
.
A repeat head CT on [**2137-12-5**] showed new midline shift and rebleed
(unclear of duration) without herniation. Hence, an LP was held.
Neurosurgery was consulted and patient was not a surgical
candidate because of his comorbidities and the size of the
lesion. In addition, his thrombocytopenia introduced a
substantial bleeding risk if any drains were placed in his head.
On [**2137-12-9**], another head CT showed no interval changes in the
midline shift, but worsening mass effect. Follow up CT on [**12-18**]
showed stable midline shift.
.
Throughout the hospitalization, he was transfused platelet
products for counts <50 to minimize worsening of his
intracranial hemorrhage.
.
#. CLL: The patient is followed by oncology attending Dr. [**Last Name (STitle) **]
at NEBH; but has been admitted to the BMT service at [**Hospital1 18**]
previously. He underwent leukopharesis three times prior to
transfer to BMT for hyperleukocytosis. His last dose of Campath
was at NEBH [**2137-11-22**]. He was transfused both PRBC and platelets
without much increase. In the MICU, he was followed by the BMT
fellow and BMT attending with the OMED resident/intern team
following. He underwent leukophoresis several times here with
reductions in his WBC to usually < 300K.
.
Because of his previously failed chemotherapy experiences, he
was offered to be treated with the anti-CD52 antibody, Campath.
While the family was advised about the significant risks
(inlcuding worsening of his ascites and the mass effect in his
brain) regarding the administration of this drug in the face of
his multiple medical comorbidities, they still requested that
this drug be given.
.
4 doses of Campath were given from [**Date range (1) 25865**] (with an initial test
dose of 3mg).He experienced small WBC count decrements, but soon
started to rebound. At this time, his WBC count consisted
predominantly of prolymphocytes. A short wait period was done to
assess his response to the campath. And in the face of
continuing rises in his WBC count, the family requested to have
another trial of campath. Hence, he continued to receive campath
on [**2-15**] and [**12-16**] and [**12-18**].
.
# ID issues:
- Bacteroides and Citrobacter in 2 different blood cultures
- on Vanco and ceftaz/flagyl and caspo, ganciclovir
- [**12-10**]: switched [**Last Name (un) 2830**] to ceftaz
- CMV VL [**Numeric Identifier 961**] on [**2137-12-4**]: started on Ganciclovir -> [**12-7**]: VL 7670
- CMV VL on [**12-14**]->2050
- patient was cultured significant temperature spikes.
.
# Bilateral malignant pleural effusions.
- Thoracentesis [**2137-12-3**]: 1.5L by IP service
- CXR: [**2137-12-9**]: A moderate right and small left pleural effusion
are stable.
- CXR: [**12-12**]: b/l layering pleural effusions and perihilar edema
.
# DIC: as per previous labs, pt. in chronic DIC. On [**11-16**]
pt developed persistent bleeding at site of phereis catheter.
Transfused 3 u platelets, 2 u FFP, 2 u cryoprecipitate c
improvement in clinical symptoms and improvement in DIC labs.
Plat cnt up to 60 from 20 s/p transfusions. This likely
accounts for his petechial rash. Throughout his hospitalization,
patient was transfused to keep his fibrinogen >100 for suspected
chronic DIC.
.
#. ARF: baseline creat 1.0; elevated on admission 2.1.
allopurinol and [**Last Name (un) **] held. creatinine improved daily. FeNA
calculated < 1%; appeared dry on exam. Likely prerenal in
etiology. Renal ultrasound obtained to r/o post renal etiology.
baseline creatinine of 1. Unclear cause - possibly secondary to
leukemic infiltration vs. previous TLS. Dry on physical exam;
may represent some component of pre-renal azotemia.
.
- U Na - 28, U Cr - 124, FeNA = .21%; c/w prerenal azotemia
- renal u/s showing no obstruction
- Cr 2.9 on [**2137-12-7**]: decreased ganciclovir on [**12-6**]; decreased
spironolactone on [**2137-12-7**] -> Cr 2.7 on [**12-16**]
.
#. HTN: Dyazide and Cozaar held given relative hypotension.
goal SBP <140 per neurosurgery recc's.
.
#. Skin: patient has rash [**1-2**] lymphoma per oncology; also with
diffuse petechiae.
.
#. TIIDM: maintained on sliding scale insulin with good
control.
.
# End of life issues: The hematology team had several
discussions with the [**Known lastname **] family regarding the state of health
of the patient. It was reiterated multiple times that he had
multiorgan failure and that there was only a small chance that
he could recover from his illness. It was reiterated that
campath could worsen his condition and they accepted this risk.
He continued to be a DNR/DNI during the last days of his life.
In the AM of [**12-19**], the patient passed after worsening
respiratory status for the last few days of his life. He had
become more and more unresponsive and was increasing his O2
requirements over the last few days of his life. The daughter
(proxy) was offered an autopsy, but refused.
Medications on Admission:
Meds on Admission:
Allopurinol 60mg daily
Dyazide 37.5/25 daily
Cozaar 50mg daily
Campath
supplemental O2
previously on metformin; stopped during last hospitalization
Discharge Medications:
Patient passed away in hospital
Discharge Disposition:
Expired
Discharge Diagnosis:
CLL/PLL
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2138-1-5**]
ICD9 Codes: 5119, 5849, 7907, 4280, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1986
} | Medical Text: Admission Date: [**2132-12-11**] Discharge Date: [**2132-12-17**]
Date of Birth: [**2095-6-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
abdominal pain, acute liver failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
37 YOF nurse who presents with nausea/vomiting and RUQ pain x 3
days. Presented initially to OSH where she was found to have ALT
8856 AST 7932 TB 5.9 and INR 3.4. Creat and bicarb normal. She
then revealed that she has been taking upwards of 6G APAP/day
since [**Month (only) 958**] for back pain. Isn't sure exactly how many tablets
she takes, but estimates 10 extra-strength Tylenol tabs and [**2-28**]
Tylenol PM, as well as occasional Vicodin. Denies poor PO in the
days preceeding onset of sx but since then hasn't been eating
well as oral intake has exacerbated her sx. Denies other toxic
habits/ingestions. Feels sleepy now since she has been up all
night but denies changes in mental status or excessive
sleepiness preceeding presentation. Drinks socially (about [**5-3**]
beers in one sitting, once per week or every 2 weeks) including
the night prior to the onset of her sx. Denies any suicidal
intent.
.
Reports that she lives at home w husband and 5 kids. She was
fired from her nursing job becuase of her back/neck pain, she
reports. She feels happy and safe at home and reports a close
family support system. She does admit to a suicide attempt at
age 14 but doesn't remember the details.
.
In speaking with her huband he reports that she also takes
Fioricet and Nyquil occasionally in addition to the other meds,
and agrees that this was not a deliberate attempt to hurt
herself. He corroborates that she does not use street drugs.
Past Medical History:
Body Dysmorphic Disorder
Anxiety
chronic neck/back pain [**1-29**] work-related injury
remote hx of OD suicide attempt as teen
GERD
IBS
Bilateral breast augmentation 00' and 04'
Social History:
Lives w/ husband and 5 kids (age [**4-8**]). Married 4 years. Last
worked as RN but injured back at work and was then laid off.
Parents live on [**Hospital3 **].
-Reports up to 4 drinks 3x a week (2 drinks 4 days a week) per
husband. + blackouts. [**12-31**] CAGE. No previous detoxes.
-Denies IV drugs, tobacco, cocaine
Family History:
No liver dz, AI disease, IBD or cancer
Physical Exam:
PHYSICAL EXAMINATION:
VS - Temp afebrile, BP 91/46, HR 86, R 18, O2-sat 98% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - PERRL, EOMI, sclerae mildly icteric with B/L lateral
conjunctival hemorrhages, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, TTP in RUQ & epigastrium, ND, no masses or
HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-30**] throughout, sensation grossly intact throughout, gait not
observed, no asterixis
Pertinent Results:
[**2132-12-10**] EKG: Sinus tachycardia. Modest diffuse ST-T wave
changes are non-specific. No previous tracing available for
comparison.
.
[**2132-12-11**] ECHO: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 80%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
.
[**2132-12-11**] CXR: The lungs are well expanded and clear without
focal consolidation, pleural effusion or pneumothorax. The
cardiac and mediastinal silhouette and hilar contours are
normal.
.
[**2132-12-11**] RUQ U/S: Ultrasound of the right upper quadrant
demonstrates no focal liver lesions. The gallbladder is
contracted, accentuating wall thickness. The portal vein is
patent with hepatopetal flow. No ascites is seen. No intra- or
extra-hepatic biliary dilation is seen. The CBD measures 3 mm.
No evidence of cholelithiasis is seen. IMPRESSION: 1. Patent
portal vein with hepatopetal flow. 2. Contracted gallbladder
without specific signs to suggest cholecystitis.
.
Labs:
Brief Hospital Course:
37 yo W with acute hepatitis and liver injury secondary to
chronic acetaminophen use
.
#. Acute hepatitis/liver failure: Determined to be secondary to
chronic, unintentional, overuse of tylenol for control of a
work-related back injury. On presentation the patient had grade
I encephalopathy and a transplant evaluation was initiated. She
was started on the NAC protocol. Her liver function tests
improved obviating the need for urgent transplant. She remained
on the NAC gtt for a total of 5 days, then was monitored for an
additional day, and discharged after it was ensured that her
labs were all improving. We instructed her to abstain from all
alcohol and acetaminophen until she follows up with Dr. [**Last Name (STitle) 497**] in
the Liver Clinic. At that time she will have her ceruloplasm
levels re-checked, as this was found to be low during her
transplant work-up.
.
#. Chronic back pain: secondary to a work-related injury, and
the reason she was taking large amounts of tylenol daily. The
patient has been seeing an Orthopedic Pain Specialist for
steroid injections and plans to continue this treatment. Her
pain was controlled on Tramadol, which we provided a
prescription for at discharge. She will need to follow up with
her Primary Care Physician and [**Name9 (PRE) 1194**] Specialist to develop a plan
to manage her chronic pain. She was instructed to stop all
medications with acetaminophen.
.
#. Adjustment Disorder with Anxious and Depressed Mood: The
patient was evaluated by Psychiatry and Social Work upon
admission. It was determined that her chronic acetaminophen
ingestion was not intentional. She was not currently on an
antidepressant, but has tried some in the past and discontinued
use secondary to bothersome side effects. She would likely
benefit from a SSRI or SNRI, which can be determined by the
patient and her Primary Care Physician on an outpatient basis.
.
#. RUQ abdominal pain and nausea: likely secondary to her liver
injury. The patient remained afebrile, without leukocytosis. She
was started on a daily PPI.
.
#. Urinary Tract Infection: The patient was treated with three
days of Ampicillin for an Enterococcal UTI. Her dysuria
resolved.
.
#. Herpes labialis: The patient was started on Valtrex for
recurrent HSV cold sores.
.
#. Pancytopenia: Unclear etiology, possibly secondary to
acetaminophen or NAC. Also, may have had an element of
hemodilution from the large amount of fluids received during the
admission. She had no evidence of bleeding and remained
hemodynamically stable throughout the admission.
Medications on Admission:
Tylenol
Percocet
Klonopin 5mg PRN
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 1 weeks.
Disp:*42 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for breakthrough abdominal pain for 1 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 days.
Disp:*14 Tablet(s)* Refills:*0*
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO as instructed
as needed for anxiety.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
acute hepatitis secondary to chronic acetaminophen overuse
abdominal pain
urinary tract infection
adjustment disorder
pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 19499**],
.
You were recently admitted to the [**Hospital1 1170**] for continued evaluation and management of your abdominal
pain secondary to acute liver failure from chronic overuse of
tylenol. You were initially admitted to the Intensive Care Unit,
and then transferred to the floor. We provided you with
medications and you improved. We also found evidence of a
urinary tract infection and started you on antibiotics. We also
provided you with treatment for herpes labialis (cold sores).
Please continue to see your outpatient therapist, and consider
seeing a Psychiatrist in the future for your anxiety. Also, it
is important that you keep all of your follow up appointments
after discharge.
.
We are also giving you a short course of pain medications that
are safe to take during your liver injury. You will need to
follow up with your Primary Care Physician and [**Name9 (PRE) 1194**] Specialist
to figure out the best regimen for yout to continu on to treat
your chronic neck pain.
.
We are making the following changes to your outpatient
medication regimen:
-Please STOP all products containing acetaminophen (tylenol,
eccedrin, percocet) until you follow up with Dr. [**Last Name (STitle) 497**]. Please
read all of the labels of your over the counter medications to
ensure they do not contain acetaminophen.
-Please START Famotidine twice daily
-Please START Valtrex twice daily until [**2132-12-20**]
-Please take Tramadol every 4 hours as needed for pain
-Please take Oxycodone 5 mg every 6 hours as needed for pain
(please note that this medication can be sedating as well as
cause constipation)
- You may also take colace (a stool softener to prevent
constipation)
.
It was a pleasure taking care of you during this
hospitalization.
Followup Instructions:
Name: [**Name6 (MD) 19500**] [**Name8 (MD) **],MD
Specialty: Internal Medicine
When: Thursday [**12-18**] at 10:30am
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**]
Phone: [**Telephone/Fax (1) 6699**]
** Please note that this appointment is in the [**Location (un) **] office **
.
Department: LIVER CENTER
When: FRIDAY [**2133-1-9**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1987
} | Medical Text: Admission Date: [**2136-7-25**] Discharge Date: [**2136-8-9**]
Date of Birth: [**2081-10-26**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
hemetemsis and respiratory failure
Major Surgical or Invasive Procedure:
intubation, bronchoscopy, EGD
History of Present Illness:
54 yo f with h/o Hep C cirrohsis on inferon presents after 2
days days of vomiting blood. The patient's husband reports that
she has been feeling unwell and having a lot of epigastric
abdominal pain and has had several episodes of hemetemsis over
the past few days. He noted she had a fever to [**Age over 90 **] yesterday and
some chills. He also noted that her skin became more yellow in
the past few days. The patient adamantly refused to come to the
hospital. She has been feeling SOB with a chronic cough that has
not change; her family also reports chronic diarrhea. She does
not have a history of previous varices or UGIB.
.
In the ED, initial vs were: T 99 P 110 BP 138/78 R 16 O2 sat
100% ra. On exam in the ED, she was found to have coffee ground
material in her oropharaynx, jaundice and + asterisix. Consulted
liver and surgery. She then developed 2 more episodes of coffee
ground emesis in ICU. cleared slightly with NG lavage. She
became more confused and she was intubated for airway
protection; however, the intubation was quite difficult, she was
noted to aspirate blood. In the ED, she was given Vancomycin,
octreotide drip and PPI drip. She recieved one unit of FFP but
no other blood products at the time of transfer. Her vital signs
prior to transfer were as follows: T 101.9 HR 137 BP 174/74, A/C
TV 450 RR 14 PEEP 5 FIO2 100%.
.
On the floor, urgent EGD was performed which showed diffuse
duodenal ulcers and portal hypertensive gastropathy. Also fundic
erosions were noted. One large erosion on the lesser curvature
had a clot over it suggesting it as a site of bleed. The site
was clipped. No varices were noted.
Review of systems: unable to obtain [**12-26**] sedation/intubation
Past Medical History:
# chronic hepatitis C infection dx'ed [**2128**], started
interferon/ribavirin approx 6 months ago.
# Cirrohsis
# anxiety/ depression.
# h/o viral meningitis in [**2110**].
# back pain r/t herniated disc
# likely COPD based on medications - family denies lung disease.
Social History:
Married with 2 children. Current smoker [**11-25**] PPD. EtOH rare since
starting Hep C tx, but previous heavy use. Previous h/o cocaine
use - none recently. Not currently employed.
Family History:
Mother with cardiac disease died of gastric cancer. Dad with
DM/CAD.
Physical Exam:
Upon admission to the MICU:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: rhonchorous breath sounds 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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on admission:
[**2136-7-25**] 09:15PM GLUCOSE-138* UREA N-23* CREAT-0.7 SODIUM-137
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-17* ANION GAP-13
[**2136-7-25**] 09:15PM CALCIUM-6.6* PHOSPHATE-2.0* MAGNESIUM-1.7
[**2136-7-25**] 09:15PM WBC-8.5 RBC-2.69* HGB-7.9*# HCT-25.9*#
MCV-96# MCH-29.5 MCHC-30.7* RDW-19.4*
[**2136-7-25**] 09:15PM PLT COUNT-76*#
[**2136-7-25**] 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2136-7-25**] 04:00PM URINE RBC-0 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2136-7-25**] 01:45PM ALT(SGPT)-51* AST(SGOT)-107* CK(CPK)-437* ALK
PHOS-102 TOT BILI-2.7*
[**2136-7-25**] 01:45PM LIPASE-19
[**2136-7-25**] 01:45PM cTropnT-0.02*
[**2136-7-25**] 01:45PM CK-MB-7
Micro:
[**2136-8-1**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2136-7-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-7-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-7-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST, YEAST} INPATIENT
[**2136-7-31**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2136-7-31**] MRSA SCREEN MRSA SCREEN-negative FINAL INPATIENT
[**2136-7-30**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE-negative PRELIMINARY; BLOOD/AFB CULTURE-negative
PRELIMINARY INPATIENT
[**2136-7-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST, YEAST}; LEGIONELLA CULTURE-PRELIMINARY; FUNGAL
CULTURE-PRELIMINARY {YEAST}; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY INPATIENT
[**2136-7-30**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-7-30**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram
Stain-negative FINAL INPATIENT
[**2136-7-29**] URINE Legionella Urinary Antigen -negative FINAL
INPATIENT
[**2136-7-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-7-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST, YEAST} INPATIENT
[**2136-7-29**] URINE URINE CULTURE-negative FINAL INPATIENT
[**2136-7-26**] BLOOD CULTURE Blood Culture, Routine-negative FINAL
INPATIENT
[**2136-7-26**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-negative FINAL;
RESPIRATORY CULTURE-FINAL INPATIENT
[**2136-7-26**] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY
TEST-negative FINAL INPATIENT
[**2136-7-26**] SPUTUM GRAM STAIN-negative FINAL; RESPIRATORY
CULTURE-FINAL {YEAST} INPATIENT
[**2136-7-26**] URINE URINE CULTURE-negative FINAL INPATIENT
[**2136-7-26**] BLOOD CULTURE Blood Culture, Routine-negative FINAL
INPATIENT
[**2136-7-25**] MRSA SCREEN MRSA SCREEN-negative FINAL INPATIENT
Imaging:
CXR ([**2136-7-25**]):
An endotracheal tube has been placed, the tip projects 5 cm
above
the carina. Also new is a nasogastric tube, the side port
projects over the gastroesophageal junction, the tube should be
advanced by several centimeters.
There is no evidence of complications, notably no pneumothorax.
In both lungs, on the right substantially more severe than on
the left, are aveolar densities. These create multiple air
bronchograms, in the right upper lobe, these changes create a
large area of subtotal parenchymal consolidation. Although the
changes are less severe in the left lung, ill- defined opacities
are predominant in the perihilar lung regions. There is no
evidence of lymphadenopathy and no evidence of pleural
effusions. No cardiomegaly.
Overall the image could be suggestive of parenchymal bleeding or
diffuse
alveolar damage. For ARDS, the assymetry of changes and the
distribution of the right lung pathologies would be atypical.
Another consideration would be severe aspiration with the
patient positioned in the right body position.
CT chest ([**2136-7-27**]):
IMPRESSION: Almost complete consolidation of the right upper
lobe withe
widespread multilobar ground glass opacities and more confluent
consolidations. A component is likely from pulmonary hemorrhage
given the
history, however superimosed edema is also likely and possibly
pneumoia.
Cirrhosis. Splenomegaly likely reflects portal hypertension.
U/S abdomen with dopplers ([**2136-7-30**]):
IMPRESSION:
1. Coarsened hepatic echotexture with a nodular contour,
compatible with
provided history of cirrhosis. No focal lesions identified.
2. Patent portal venous system, with directionally appropriate
flow.
3. No evidence of ascites.
Echo ([**2136-7-31**]):
The left ventricular cavity size is normal. There may be mild
left ventricular hypertrophy. Left ventricular systolic function
is hyperdynamic (EF>75%). There is a mild resting left
ventricular outflow tract obstruction. A mid-cavitary gradient
is identified. Outflow and midcavitary gradients appear to be
due to the patient's hyperdynamic state. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. There is no valvular
aortic stenosis. The increased transaortic velocity is likely
related to high cardiac output. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
CXR [**8-4**]:
The patient was extubated in the meantime interval. The right
internal
jugular line tip is at the level of low SVC. Cardiomediastinal
silhouette is stable. There is significant interval improvement
of the appearance of the chest radiograph consistent with
resolution of pulmonary edema. The right upper lobe and lower
lobe consolidations are still present but also improved most
likely due to resolution of underlying pulmonary edema. There is
no appreciable pleural effusion or pneumothorax.
Brief Hospital Course:
This is a 54 yo f with h/o Hepatitis C infection and cirrohsis
presenting with UGIB.
# UGIB - s/p EGD which showed no varices, but multiple ulcers
and s/p clipping of ulceration with clot in lesser curvature of
fundus. Findings more consistent with NSAID-induced vs H Pylori
PUD. Pt with recent history of motrin use per family though
dosage uncertain. H Pylori was negative. Patient was maintained
on IV PPI and tranfused as necessary with PRBC and FFP. IVF and
pressors were used to keep MAP>65. Patient was transitioned to
oral PPI once out of the ICU and diet was advanced as tolerated.
Patient was noted to be orthostatic on day prior to discharge,
however hematocrit was stable. This was likely [**12-26**] poor PO
intake and patient responded positively to 1L bolus of NS.
Hematocrit was stable until discharge with no sign of repeat
bleed or active bleeding.
.
# Respiratory failure - Patient intubated for airway protection
in the setting of hemetemsis and AMS. Pt with large aspiration
of blood during intubation. No CXR prior to intubation so
unclear if infiltrates r/t to observed aspiration vs previous
aspiration/evolving PNA. Bronch showed bright red blood
throughout right lung, no growth on BAL. CT chest showed 'almost
complete consolidation of the right upper lobe. Widespread
patchy opacities throughout both lungs, right worse than left,
is consistent with pulmonary hemorrhage given history.' Serial
CXR showed gradual improvement in alveolar infiltrates. Patient
was extubated on [**2136-8-3**]. She also was having fevers, and since
infection could not be excluded on imaging, she was empirically
started on cipro/vanco/cefipime/flagyl. Antibiotics stopped on
[**2136-8-3**] because afebrile, no white count, clinically stable, no
positive cultures other than [**11-27**] blood cx bottles with GPC
(likely contaminant). Patient was transferred to the floor on
2L oxygen by nasal canula and was weaned to room air overnight.
Mrs. [**Known lastname 54205**] had no oxygen requirement x48 hours, with good O2
saturation and no complaints of shortness of breath on
discharge.
.
# Fevers - Patient with fevers over much of her MICU stay, last
fever on [**7-31**]. Only positive culture was 1/4 bottles on blood
culture growing GPC, likely contaminant. Was on empiric
antibiotics for HAP/aspiration pneumonia, all d/c'ed prior to
transfer from MICU. Beta glucan and galactomannan both negative.
Also d/c'ed ribavirin for possible medication effect. Concern
for vasculitis; [**Doctor First Name **] positive at 1:640. ANCA neg. [**Last Name (un) 15412**] wnl, IgG
elevated. Anti-GBM negative. C3, C4 not significantly depressed.
Cryoglobulins negative x 2, HCV VL <43 (undetectable). Patient
was afebrile once antibiotics and ribavirin were discontinued
and remained so until discharge.
.
# Hemoptysis - Patient had bright red blood on suctioning and
BAL while intubated. See respiratory failure section for
further details. She was placed on pulse steroids x 5 days for
empiric treatment of possible vasculitis. Vasculitis work-up,
including possible cryoglobulinemia was negatvie except for [**Doctor First Name **]
1:640. She had no hemoptysis after extubation and was stable
from a respiratory standpoint on transfer to the floor and at
discharge. Patient is to follow-up in the pulmonary clinic as
an outpatient.
.
# Hepatitis C treatment - IFN discontinued prior to admission,
Ribavirin discontined during admission due to possible
medication effect causing possible fever. HCV VL negative.
Patient to follow-up with hepatologist for further management as
an outpatient.
Medications on Admission:
Advair 500-50 2 puffs [**Hospital1 **]
flonase 50 mg nasal daily
Combivent 2 pufss [**Hospital1 **]
lorazepam 1 mg PO TID
motrin 400mg PO daily PRN
omeprazole 40 mg PO daily
percocet 10-325mg 1-2 tabs q4-6 hrs PRN pain
PegIntron inject 120 mcg/0.5 ml SQ q week.
Compazine 10mg PO q 6hrs PRN nausea
Ribavirin 600mg PO QAM and 400mg PO QPM
Trazodone 50 mg PO QHS
Zoloft 100mg PO qday
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: Two (2) Tablet 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. 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*
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for anxiety.
Disp:*12 Tablet(s)* Refills:*0*
5. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
6. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal once a day.
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
1. Gastric Ulcer s/p clip
[**Clip Number (Radiology) **]. Duodenal Ulcer
3. Respiratory Failure
4. Encephalopathy
5. Hepatitis C
Discharge Condition:
Hemodynamically Stable. Tolerating PO. Ambulating
independently.
Discharge Instructions:
You were admitted to the hospital due to vomitting blood. You
were given blood products to replace the blood you lost.
Additionally, you were given medicine to artificially elevate
your blood pressure for a short period. There was concern that
you would not be able to breath on your own so you had a tube
placed in your throat so a machine could breath for you. During
this time, there was blood noticed in your right lung. This was
monitored and improved. You were given antibiotics due to
concern for infection. Your Ribavirin (treatment for your
Hepatitis C) was discontinued. Please follow-up with your PCP,
[**Name Initial (NameIs) **] lung doctor (pulmonologist) and your liver doctor
(hepatologist) as instructed below.
The following changes were made to your Medications:
1. Pegintron (discontinued), discuss with Dr. [**Last Name (STitle) **] before
restarting.
2. Ribavirin (discontinued), discuss with Dr. [**Last Name (STitle) **] before
restarting.
3. Compazine (discontinued)
4. Protonix 40mg twice daily (to replace omeprazole)
5. Omeprazole discontinued.
6. Motrin discontinued.
7. Ativan discontinued.
8. Clonazepam 0.5mg three times per day as needed for anxiety
(to replace ativan).
9. Oxycodone 5 mg by mouth every 6 hours as needed for pain
10. Stop Percocet
.
If you experience fever > 100.4, shortness of breath, chest
pain, blood in your vomit or sputum, blood in your stool,
sleepiness, light-headedness or any other symptom that concerns
you, please contact your PCP or go to the nearest emergency room
for evaluation.
Followup Instructions:
Please follow up with your PCP within one week of discharge. An
appointment has been made with you with the lung and liver
doctors as listed below.
1. Please arrange an appointment with your PCP and Counselor in
the next 2 weeks for follow-up
2. Liver Doctor (Hepatology):
[**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2136-8-30**] 11:00
3. Lung Doctor (Pulmonology): [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] [**Location (un) **]
-Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2136-9-7**] 8:40
-Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2136-9-7**] 9:00
ICD9 Codes: 5070, 2851, 2760, 5715, 2875, 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1988
} | Medical Text: Admission Date: [**2134-10-20**] Discharge Date: [**2134-10-23**]
Date of Birth: [**2078-11-11**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Penicillins / Iodine; Iodine Containing / Carbamazepine
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Bleeding R brachiocephalic AV fistula
Major Surgical or Invasive Procedure:
repair bleeding AV fistula aneurysm
History of Present Illness:
55yo male who presents wth bleeding from R brachiocephalic
fistula. Pt is s/p repair of AV fistula aneurysm on [**10-8**]. Pt
with acute blood loss and Hct drop secondary to bleeding
Past Medical History:
ESRD secondary to glomerulonephritis
HTN
Hep C
PVD
Hypoparathyroidism
CHF
Restless Leg Syndrome
Social History:
N/C
Family History:
N/C
Physical Exam:
AAO times 3
RRR S1+S2
CTA Bilat
Soft NT/ND BS+
R AV Fistula pulsating, tender
R Ulnar/Radial pulses 2+
Pertinent Results:
[**2134-10-19**] 11:55PM BLOOD WBC-4.5 RBC-2.49*# Hgb-7.1*# Hct-21.8*#
MCV-88 MCH-28.6 MCHC-32.5 RDW-18.6* Plt Ct-253
[**2134-10-20**] 04:09AM BLOOD WBC-5.9 RBC-3.18*# Hgb-9.2*# Hct-26.8*
MCV-84 MCH-28.8 MCHC-34.2 RDW-16.5* Plt Ct-189
[**2134-10-20**] 02:57PM BLOOD Hct-32.7*
[**2134-10-21**] 05:00AM BLOOD WBC-11.4*# RBC-2.54* Hgb-7.7* Hct-21.5*#
MCV-85 MCH-30.4 MCHC-36.0* RDW-18.4* Plt Ct-229
[**2134-10-21**] 08:08AM BLOOD Hct-21.1*
[**2134-10-21**] 07:30PM BLOOD Hct-24.7*
[**2134-10-22**] 05:55AM BLOOD WBC-6.4 RBC-3.13* Hgb-9.1* Hct-26.4*
MCV-85 MCH-29.2 MCHC-34.5 RDW-17.8* Plt Ct-189
[**2134-10-23**] 05:10AM BLOOD WBC-4.4 RBC-3.54* Hgb-10.7* Hct-30.4*
MCV-86 MCH-30.2 MCHC-35.2* RDW-17.0* Plt Ct-190
[**2134-10-20**] 2:10 am SWAB Site: FISTULA R A-V.
GRAM STAIN (Final [**2134-10-20**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2134-10-22**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
Pt admitted on [**2134-10-20**] with bleeding AV fistula, taken to the OR.
Aneursym of fistula ligated and resected. Pt given 3U PRBC
during the operation. Pt on GET secondary to SOB at the onset of
MAC. Pt unable to be extubated after the case, transferred to
the MICU intubated. Pt then extubated overnight, tolerated well.
Pt transferred to the floor. Pt with tunneled dialysis cath
placed on [**10-22**]. Pt continued to improve. Pt tolerated diet well,
pain controlled. Pt D/C'd with VNA for dressing changes on [**10-23**].
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO QD (once a day).
2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QD (once a day).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO QD (once a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ESRD with repaired AV fistula, tunneled dialysis catheter
Discharge Condition:
stable
Discharge Instructions:
Please keep all follow-up appointments
Take all medications as prescribed
Reuturn for dialysis as scheduled
Return to the ER if any increased pain, fevers, redness or
swelling, drainage from wound, significant weight gain or weight
loss, shortness of breath, chest pain, or nausea and vomitting
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] (TRANSPLANT) TRANSPLANT CENTER (NHB)
Where: LM [**Hospital 5628**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2134-10-25**] 1:10
Provider: [**Name Initial (NameIs) **]/ [**Doctor Last Name 1201**] Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 8302**] Date/Time:[**2135-1-5**] 4:00
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2135-3-24**] 1:00
Completed by:[**2134-10-23**]
ICD9 Codes: 4280, 2851, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1989
} | Medical Text: Admission Date: [**2145-8-2**] Discharge Date: [**2145-8-10**]
Date of Birth: [**2086-1-19**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 58-year-old female with
type 2 diabetes and extensive history of alcohol abuse, who is
admitted to an outside hospital for alcohol withdrawal after she
was found on the floor. She was discharged to a skilled-nursing
facility for rehab and she was taken to the outside hospital ED
on [**2145-8-1**] for increased fatigue, abdominal girth, and
leg swelling. The patient, however, reports that she only drinks
socially until [**Holiday 1451**] [**2143**], when she started to drink
heavily as she drinks heavily during the holiday and continues to
drink about three Manhattans per day until [**Month (only) 216**] when she did
some binge drinking before her first admission.
She denies any previous episodes of ascites or jaundice. She had
decreased appetite since the first admission, and also some
nausea and vomiting, but no fevers, chills, diarrhea, dysuria,
cough, no history of upper GI or lower GI bleed.
PAST MEDICAL HISTORY:
1. Type 2 diabetes.
2. Alcohol abuse.
MEDICATIONS ON ADMISSION:
1. Lasix.
2. Remeron.
3. Insulin.
4. Multivitamin.
5. Spironolactone.
ALLERGIES:
1. Penicillin.
2. Sulfa.
SOCIAL HISTORY: Lives in [**State 622**], but vacations in [**Hospital3 **] over the summer. She is a high school teacher, who
lives with her husband, who also is an alcohol abuser, but no
history of tobacco use and only one sexual partner, and she has
only had one blood transfusion which was in [**Month (only) 216**] of this year
at this hospital and she denies any other IV drug use.
VITALS ON ADMISSION: Temperature 97.6, pulse 90, blood
pressure 110/50, respiratory rate 22, and O2 98% on 2 liters.
PHYSICAL EXAM: In general: She is icteric. Looking older
than her stated age, but comfortable. HEENT is icteric
sclerae. Extraocular muscles are intact. Moist mucous
membranes. Oropharynx clear. Neck: There is no
lymphadenopathy. Cardiovascular: Tachycardic, though with
regular rhythm. Lungs: Left lung base without breath sounds
and left mid lung with crackles, no rhonchi or wheezes.
Abdomen is markedly distended, positive shifting dullness and
no caput medusa. Extremities: There is 2+ edema up to the
knee bilaterally. Positive Dupuytren's contractures and no
pallor or erythema. Neurologic: Is awake, alert, and
oriented times three with mild asterixis. Skin with
scattered petechiae over the abdomen, no spider angioma.
LABORATORIES ON ADMISSION: White count 14.3, hematocrit 39,
platelets 545 with 77% neutrophils, 3% lymphocytes, 14%
monocytes. Sodium is 126, potassium 4.9, chloride is 88,
bicarb 27, BUN 17, creatinine 0.4, glucose 341. INR of 1.4.
Calcium 8.5, magnesium 2.2, phosphorus 3.6. Lactate was 2.5.
Urinalysis with negative leukocyte esterase, trace blood,
nitrite negative, no white blood cells, no red blood cells,
occasional bacteria, and moderate yeast. ALT is 41, AST 162,
alkaline phosphatase 268, LDH 470, amylase 58, lipase 56, T
bilirubin 18.1, albumin 2.5, and total protein 5.5.
Diagnostic tap in the ED was 68 white blood cells and [**Pager number **]
protein, glucose 1.0.
CT of the abdomen with no intrahepatic focal cholelithiasis,
pancreas, spleen, kidney all normal. Pelvis normal. Only
large ascites.
Chest x-ray was bilateral pleural effusions left greater than
right bibasilar atelectasis. Liver ultrasound: No biliary
tract dilatation, gallbladder wall edema, no evidence of
acute cholecystitis.
EKG: Normal sinus rhythm at 100, normal axis, normal
intervals, low voltage, no ST changes.
HOSPITAL COURSE: The patient was admitted for liver failure,
which was felt to be acute alcoholic hepatitis. Her bilirubin
decreased over the course of her stay from 18.1 to 12. Her LFTs
also remained within normal range. Patient had therapeutic
paracentesis on the 5th with removal of four liters of fluid.
Patient had started to require oxygen to maintain sats in the
90s. After the tap, the patient's O2 saturations remained normal
without oxygen.
Patient was also followed by the Hepatology service, who
performed an EGD on the 2nd secondary to some coffee-ground
emesis in the morning. The EGD showed no evidence of varices,
but did show some esophagitis and some candidiasis, and
recommended proton-pump inhibitor, and antifungal.
Patient also had multiple serologies sent. Her hepatology
serologies were all negative. Her iron studies were all normal
except for slightly elevated ferritin, which was considered
consistent with her acute inflammatory state and her lipid
profile was also within normal limits. Her [**Doctor First Name **] and other
rheumatologics were also within normal. Patient was continued on
her Lasix and aldactone, and a stable level with blood pressure
remaining in the 110s. Patient had a diagnostic paracentesis in
the Emergency Room, which ruled out SBP and patient was not
started on antibiotics. Otherwise patient was also started on
pentoxifylline 400 mg t.i.d. for a total course of four weeks,
which per studies had shown to improve short-term survival in
severe alcoholic hepatitis.
Patient had mild evidence of asterixis on admission, and was
started on lactulose initially, but as she had no other
encephalopathic signs, was discontinued upon further course.
Patient was transferred to the Intensive Care Unit for the EGD
secondary to concerns of varices and risk for bleeding during her
EGD. The patient tolerated the stay well and although did become
slightly hypotensive during her stay with some oliguria, which
resolved on its own.
Patient's hematocrits remained stable after her upper GI bleed,
and scope, and did not require blood transfusion. However,
patient was also fluid restricted secondary to her hyponatremia
and her ascites to 1 liter q.d. Patient tolerated it well and he
sodium remains stable around 131.
Patient had some oliguria during her ICU stay with a FENa of
0.2%, which is consistent with prerenal in the setting of her
hypotension and decreased effective volume. Her urine output
improved and she was stable for discharge back to the floor. She
was continued on fluid restriction, but remains stable otherwise.
She was tolerating p.o. diet well, and tolerating her Lasix and
spironolactone well.
For her insulin dependent-diabetes mellitus, originally the
patient had been on oral glycemic agents, but because of her
liver disease, was started on insulin. Initially, she was
started on sliding scale with poor control and then was switched
to NPH 70/30 fixed scale with sliding scale inbetween and her
fingersticks remained in the 100 range and were fairly stable.
For patient's alcohol abuse, the patient was evaluated by
Additions and Social Work. Social Work tried to recommend and
discussed with patient about followup. Patient states that she
had been to AA meetings while at rehab and admitted that she
would like to continue working to decrease her alcohol intake.
Patient seems to be compliant and had no evidence of withdrawals
during her stay.
Patient is to be followed by PT and OT throughout her course.
Physical Therapy initially recommended patient to getting out of
bed with assistance and to ambulate with assistance as tolerated
and increasing strength. Otherwise, she would require some
endurance training prior to discharge. The patient was evaluated
and seen by Nutrition, who recommended a regular low sodium diet
with the addition of supplements secondary to decreased p.o.
intake.
For patient's depression, the patient was continued on her
Remeron 15 mg daily and seems stable through the course of her
stay.
For nutrition, the patient was on a house diet with low salt with
nutritional supplements t.i.d.
For prophylaxis and for her GI esophagitis, patient was continued
on her Protonix twice a day. Patient's electrolytes remained
normal on fluid restriction and was repleted as needed, but was
not necessary.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: Discharged to acute skilled-nursing facility.
DISCHARGE DIAGNOSES:
1. Alcoholic hepatitis.
2. Ascites.
3. Alcohol abuse.
4. Type 2 diabetes.
5. Depression.
DISCHARGE MEDICATIONS:
1. Ursodiol 1600 mg p.o. b.i.d.
2. Lasix 40 mg p.o. q.d.
3. Protonix 40 mg q.12.
4. Spironolactone 25 mg p.o. q.d.
5. Multivitamins one p.o. q.d.
6. Miconazole topical t.i.d. as needed.
7. Remeron 15 mg p.o. q.h.s.
8. Pentoxifylline 400 mg p.o. t.i.d.
9. At breakfast, patient is on 7 units of NPH and 3 units of
regular insulin. At dinnertime, patient gets 3 units of NPH
and 2 units of regular, and sliding scale as needed
inbetween.
FOLLOW-UP INSTRUCTIONS: The patient is to followup with her
primary care physician in [**Name9 (PRE) 622**] in [**12-3**] weeks, and also setup
with a hepatologist in [**State 622**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2145-8-9**] 11:28
T: [**2145-8-9**] 11:30
JOB#: [**Job Number 51713**]
ICD9 Codes: 5789, 5119, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1990
} | Medical Text: Admission Date: [**2115-11-5**] Discharge Date: [**2115-11-27**]
Date of Birth: [**2049-7-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Cardio-pulmonary Failure
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
66 yo man with PMH HTN and recent admission for pna in [**Month (only) **]
who presents to ED after syncopal episode. Pt intubated and
sedated w/o family memeber in ICU so HPI by report and records
which is missing ED resident note. Pt presented after syncopal
episode with 5-6 minute of LOC with head trauma after he got up
from dinner to get to the bathroom. No other Sx compliant but
noted to be diaphoretic; no CP or SOB. ON arrival pale and
diaphoretic. HDS during EMS travel but tachycaric with tarnsient
RBBB. ECG w/ ? STE. Given ASA/BB/NTG and started on hep gtt. Pt
became more pale, diaphoretic and less responsive. Pt intubated
for airway protection as MS changed and Pt became hypotensive.
Post intubateion SBP 50's -> levophed. CVL placed. Bedside echo
obtained which showed evidence of right sided ventricular
dilation and hypokinesis. CTA demonstrated massive b/l PE While
in ED, became hypotensive with respiratory distress. Intubated.
Bedside echo showed evidence of right sided dilation and hypok.
CTA demonstrated massive b/l PE -> heparin restarted and then
administered TPA (15 mg IVP, 42mg/hr). Unable to place foley
prior to TPA. Pt transfered to MICU.
Past Medical History:
HTN
Social History:
Lives in [**Location 86**] with his wife. Retired quality engineer. Does
not smoke or drink.
Family History:
noncontributory
Physical Exam:
General - intubated and sedated
HEENT - blood around ETT
neck - supple, oozing from left SC sight and soft tissue
swelling
CVS - tachycardic but RR, s1/s2 possible s4. no M
Lungs - CTAB b/l - ant
Abd - soft ND, + BS
Ext - cool/moist, no edema
Neuro- moves all extremities
Pertinent Results:
Admit Labs
[**2115-11-5**] 07:22PM BLOOD WBC-11.6* RBC-5.49 Hgb-17.4 Hct-49.3
MCV-90 MCH-31.6 MCHC-35.3* RDW-13.5 Plt Ct-227
[**2115-11-5**] 07:22PM BLOOD Neuts-56.5 Lymphs-35.8 Monos-4.0 Eos-1.7
Baso-2.0
[**2115-11-5**] 07:22PM BLOOD Glucose-157* UreaN-16 Creat-1.1 Na-140
K-4.4 Cl-106 HCO3-23 AnGap-15
[**2115-11-6**] 03:30AM BLOOD Calcium-7.6* Phos-3.7 Mg-2.2
[**2115-11-6**] 05:21AM BLOOD Type-ART Temp-36.8 Rates-18/ Tidal V-650
FiO2-40 pO2-84* pCO2-44 pH-7.31* calTCO2-23 Base XS--4
-ASSIST/CON Intubat-INTUBATED
[**2115-11-5**] 07:22PM BLOOD PT-12.7 PTT-23.7 INR(PT)-1.1
.
.
Significant Diagnostic Imaging Studies
.
[**2115-11-5**] ECHO:
Conclusions:
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). The right ventricular cavity
is moderately dilated. Right ventricular systolic function
appears depressed. The number of aortic valve leaflets cannot be
determined. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
.
[**2115-11-5**] CXR:
PORTABLE CHEST: Cardiac and mediastinal contours appear stable.
Pulmonary vasculature appears within normal limits. Small
nodular densities are seen over the right mid lung. No evidence
of focal consolidation or pleural effusions. Likely bibasilar
atelectasis is seen.
.
[**2115-11-5**] CTA Chest:
IMPRESSION:
1. Massive burden of pulmonary embolism bilaterally extending
from the mid to distal right and left main pulmonary arteries
outward into nearly all branches of the pulmonary arterial
vasculature.
2. Multiple pleural-based calcified plaques consistent with
prior asbestos exposure.
.
[**2115-11-5**] Head CT:
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect. No
fractures.
2. Soft tissue lesion on vertex of scalp. Please correlate
with physical examination to confirm sebaceous cyst versus
neoplasm.
.
[**11-6**] U/S Bil LE:
Nonocclusive thrombus identified within the right popliteal
vein.
.
[**11-8**] CXR:
Mild edema has developed in the lower lungs. Upper lungs are
clear, with
persistent vascular congestion on the left and diminished
vascularity
peripherally.
.
[**11-8**] f/u CXR:
Worsening patchy areas of opacity in both lower lobes. This
could be due to aspiration, hemorrhage, or pneumonia.
.
[**11-9**] CXR:
Slight interval improvement in bilateral pulmonary infiltrates.
.
[**11-10**] CXR:
Persistent bibasilar pulmonary infiltrates. No significant
internal change.
.
[**11-11**] CXR:
Lung volumes are low, and mild cardiomegaly with mediastinal
vascular
engorgement are stable. Atelectasis at the left lung base is
more pronounced. There is no pulmonary edema or pneumonia.
Lateral aspect of the left lower chest is excluded from the
examination. Pleural effusion, if any, is on the left and
small; the other pleural surfaces are unremarkable. No
pneumothorax.
.
[**11-12**] CXR:
Left lower lobe collapse has worsened, accompanied by increasing
small left pleural effusion. Major interval change has been
significant increase in caliber of mediastinal vessels
suggesting marked elevation in central venous pressure, which
could be a reflection of either volume overload, cardiac
decompensation or right heart failure due to increase in
pulmonary vascular resistance from worsening pulmonary embolism.
Left subclavian line tip projects over the left brachiocephalic
vein. No pneumothorax.
.
[**11-13**] CXR:
Lung volumes are lower, mild-to-moderate pulmonary edema has
developed.
Severe mediastinal widening suggests persistence of marked
increase in central venous pressure, exaggerated by lower lung
volumes. Tip of the left subclavian line projects over the left
brachiocephalic vein. Small left pleural effusion has
increased. No pneumothorax.
.
[**11-13**] f/u CXR:
Portable AP chest radiograph compared to [**2115-11-13**]. The
enlarged heart size is unchanged as well. There is increased
width of the mediastinum, most likely was known to be due to fat
deposition. The bilateral pleural effusions and left lung
consolidation are again noted. Noted, right more than left.
The ET tube tip is 7.8 cm above the carina. The left subclavian
line tip is in the mid portion of the left brachiocephalic vein.
.
[**11-13**] Echo:
Preserved global and regional biventricular systolic function.
Moderate pulmonary artery systolic hypertension. Mild mitral
regurgitation. Compared with the prior study (images reviewed)
of [**2115-11-5**], the right venticular cavity is smaller and free
wall motion is normal. Pulmonary artery systolic hypertension
is now identified.
.
[**11-14**] CT-PA:
1. Reduction in bulk of bilateral pulmonary embolus. The
largest amount
centrally is seen about the right upper lobe pulmonary artery
origin with
minimal opacification of right upper lobe pulmonary arteries. No
infarcts.
2. Bilateral pleural effusions and atelectasis/consolidations.
.
[**11-14**] CT Head w/o Contrast:
No acute intracranial hemorrhage. Increasing sinus
opacification, likely related to intubation.
.
[**11-14**] CXR:
The ET tube tip is too high, 6.7 cm above the carina. The
mediastinal width has been decreased with the decrease of
pulmonary edema. The left lower lobe atelectasis is unchanged.
.
[**11-15**] U/S RUQ:
1. Extremely limited study. No gallstones or biliary
dilatation.
2. Right-sided pleural effusion.
.
[**11-18**] U/S Bil LE:
Persistent nonocclusive thrombus identified within the right
popliteal vein. No evidence of DVT within the left lower
extremity.
.
[**11-20**] CT Head w/ Sinus Views
Study significantly degraded by patient motion artifact,
demonstrating
resolution of the hyperdense air/fluid level in the right
maxillary sinus, partial clearing of the left sphenoid sinus air
cell, and relatively stable, virtually complete opacification of
the right sphenoid sinus. ENT consultation suggested, and
particularly if drainage is contemplated, a repeat study is
advised.
.
[**11-22**] CXR:
Stable left lower lobe atelectasis versus airspace
consolidation.
Small left-sided pleural effusion.
.
.
Micro
.
BCX - negative from [**11-6**], [**11-8**], [**11-14**], [**11-17**].
.
UCX - negative from [**11-17**]
.
C-Diff - negative from [**11-15**] and [**11-18**].
.
Sputum - [**11-7**] & [**11-9**]
STAPH AUREUS COAG + |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
.
Sputum - [**11-14**] RARE GROWTH OROPHARYNGEAL FLORA.
.
Sputum - [**11-17**] SPARSE GROWTH OROPHARYNGEAL FLORA.
.
Central Venous Cath Tip [**11-15**] - No significant growth.
Brief Hospital Course:
Given massive bilateral PEs with associated respiratory failure
and shock, pt was stabilized in the ED, treated with TPA, and
admitted to the MICU for further management. During pt's course
in the MICU, the following issues were addressed:
.
1. Respiratory failure: Pt was intubated in the ED for airway
protection and cardiopulmonary failure [**2-14**] massive PE. Pt was
maintained on the ventilator from [**11-5**] to [**11-9**], extubated on
[**11-9**], reintubated on [**11-13**] due to further respiratory distress,
and extubated on [**11-22**]. Throughout course, pt received oral
care, HOB > 30%, serial CXRs, and daily attempts to wean O2 and
ventilator control of respiration. During intubation, pt was
sedated with propofol, midazolam, and fentanyl. Pt's
respiratory failure was complicated by resolving PEs, VAP (which
was treated with abx specific to sputum culture growth), and
some level of pulmonary edema (secondary to resuscitation
efforts which was treated with diuresis). Pt's initial trial of
extubation (beginning [**11-9**]) was successful until an acute
spontaneous decompensation of respiration on [**11-13**] during
bathing; because several nurses were with pt (bathing), he was
immediately bag-mask ventilated following desaturation; pt
progressed to hypotension with ALOC, and anesthesia was called
to bedside w/in 5 minutes of decompensation; anesthesia was able
to reintubate pt via fiberoptic ETT placement. F/u CT-PA failed
to reveal new or worsening clot burden, and CXR failed to reveal
signs of acute CHF or PTX; pt's decompensation was likely
secondary to transient mucus plugging. Pt was maintained on the
ventilator with daily efforts to wean O2 and to decrease PS;
discussion with pt's wife and family regarding trach and trial
of reextubation occurred daily, and the decision was made to
pursue trial of extubation and to defer trach unless absolutely
necessary. Following significant improvement in RSBI and
overall clinical appearance, pt was extubated on [**11-22**] w/o
issue. Pt's f/u CXR was encouraging, and pt was verbal and
AAOx3 following weaning of sedation.
.
2. Bilateral PE with hypotension - Diagnosed with [**Name (NI) **], pt's
hemodynamic shock showed significant improvement s/p TPA. Pt
was placed on heparin gtt per [**Hospital1 18**] weight-based nomogram. Pt
was supported on levophed for < 24 hours with subsequent return
of normotension. Serial HCTs and f/u CT head failed to reveal
signs of hemorrage secondary to TPA and anticoagulation. U/S
Bil LE revealed residual RLE popliteal DVT. Initial TTE
revealed that the right ventricular cavity was moderately
dilated with right ventricular systolic function appearing
depressed. F/u TTE revealed pulmonary hypertension but improved
right heart dilatation. F/u CT-PA following [**11-13**] resp distress
showed improvement w/o further clot burden. Given that this was
pt's initial episode of DVT/PE, he will need further
hypercoagulability workup following step-down from ICU setting.
.
3. Ventilator Associated PNA - Pt's difficulty weaning from the
ventilator, worsening CXRs, fever spikes, and continued copious
sputum production prompted empiric broad-spectrum abx which were
subsequently narrowed to nafcillin due to sputum samples which
grew MSSA. Pt continued to produce copious secretions and
experienced reintubation on [**11-13**] and subsequent fever spikes,
prompting switch back to broad spectrum abx. Pt's CXRs and
respiratory status continued to improve subsequenty, sputum from
[**11-18**] was negative, and the cause of his fevers became better
explained by sinusitis; pt was then switched to Unasyn to cover
sinusitis w/o further issue from VAP.
.
4. Sinusitis - pt began to spike fevers following reintubation
on [**11-13**], and he was treated with broad spectrum abx until CT of
the head identified significant maxillary and sphenoid
sinusitis. Unasyn was started to cover typical pathogens, and
ENT was consulted for advice regarding the need for drainage.
Dedicated sinus CT revealed interval improvment on Unasyn, and
surgical drainage was deferred given improving fever and
leukocytosis. Plan is to continue unasyn (or transition to
augmentin) for total of 14 day course.
.
5. Cardiovascular
(a) Rhythm - no history of rhythm abnormalities; pt developed
atrial flutter and fibrillation following his PE, which were
muted via vagal maneuvers (such as passage of stool) but
returned subsequently. Pt was managed with beta blockade and
started on amio per cardiology recommendations. Subsequently,
pt regained sinus rhythm w/o further issue.
(b) [**Name (NI) **] - pt's EF and ventricular function remained intact as
evidenced by two encouraging TTEs. Fluid overload was managed
by diuresis.
(c) Vessels = epigastric pain was worked-up for possible ACS,
and was negative on several occassions via markers and EKGs. Pt
was maintained on daily ASA.
.
5. Epigastric Pain - r/o MI with negative markers and EKGs;
occurred on several occassions when pt was intubated and NPO, so
unable to provide GI cocktail for relief; seemed to worsen with
pt was sitting up; treated with IV PPI (GERD) and IV morphine
for pain.
.
6. HTN - initially held home meds due to hypotension, metoprolol
was started as patient had tachycardia.
.
7. Right Popliteal DVT - on heparin gtt for PE, stable per f/u
U/S. Patient will need labs to eval for hypercoaguability
status.
Medications on Admission:
HCTZ 25mg PO QD
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Bilateral Pulmonary Emboli
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital if you have sudden shortness of
breath, chest pain, dizziness or fevers.
.
Please take all medications as directed. You have been started
on a new medication, Coumadin, which is a blood thinner. It is
very important that you take this medication as directed and
have your blood checked weekly.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 2 weeks
of discharge to rehab.
ICD9 Codes: 2930, 5070, 2760, 5849, 4280, 4019, 2859, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1991
} | Medical Text: Admission Date: [**2123-12-11**] Discharge Date: [**2123-12-13**]
Date of Birth: [**2078-1-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Alcohol and opioid withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45 M w/ pmh of alcoholism went to detox on [**12-9**] (from EtOH and
opiates) and was receiving ativan and methadone. Got increasing
tachycardic and hypertensive at detox so was sent to the ED w/
concern for withdrawal.
.
In the ED, initial vs were: T 97.7 P 116 BP 161/102 R 28 O2 sat
99% on RA. He was aggitated w/ visual hallucinations on arrival
to the ED. Patient was given valium 10 mg po then 10 mg IV q 10
minutes and had some witnessed apneic scales but then tachy and
hypertensive again and given another 10 mg IV valium. Also
given 1.5 L NS.
.
On the floor, he is c/o full body pain. Denies CP/SOB/N/V.
Endorses goosepimples on his skin, diarrhea, abdominal pain.
His last drink was on Monday at 8am.
.
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. No dysuria.
Past Medical History:
GERD
Hiatal hernia
Hemorroids
IVDA
Alcoholism
Social History:
1-1.5 ppd of tob since age 23. Uses [**1-11**] g of heroin per day and
a 5th of burbon daily. Lives w/ his partner. Is on SSI.
Family History:
N/C
Physical Exam:
Vitals: T: 99.6 BP: 179/96 P: 91 R: 30 18 O2: 93% on RA
General: Alert initially, able to tell an adequate medical
history, then somnolent after getting diazepam
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2123-12-11**] 01:35PM BLOOD WBC-9.2 RBC-4.61 Hgb-13.2* Hct-37.4*
MCV-81* MCH-28.6 MCHC-35.3* RDW-14.2 Plt Ct-280
[**2123-12-13**] 05:22AM BLOOD WBC-8.8 RBC-5.13 Hgb-15.6 Hct-41.4
MCV-81* MCH-30.4 MCHC-37.6* RDW-13.6 Plt Ct-263
[**2123-12-11**] 01:35PM BLOOD Neuts-77.9* Lymphs-14.5* Monos-6.7
Eos-0.4 Baso-0.5
[**2123-12-13**] 05:22AM BLOOD PT-12.5 PTT-22.6 INR(PT)-1.1
[**2123-12-11**] 01:35PM BLOOD Glucose-104 UreaN-15 Creat-0.9 Na-133
K-3.5 Cl-100 HCO3-19* AnGap-18
[**2123-12-13**] 05:22AM BLOOD Glucose-120* UreaN-16 Creat-1.0 Na-130*
K-3.6 Cl-100 HCO3-20* AnGap-14
[**2123-12-11**] 01:35PM BLOOD ALT-18 AST-33 AlkPhos-100 TotBili-0.5
[**2123-12-11**] 01:35PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.6 Mg-1.9
[**2123-12-13**] 05:22AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.2
[**2123-12-13**] 05:22AM BLOOD VitB12-459 Folate-17.1
[**2123-12-11**] 01:35PM BLOOD TSH-1.2
[**2123-12-11**] 01:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2123-12-11**] 01:44PM BLOOD Lactate-1.2
.
CXR: PORTABLE AP CHEST: Examination is limited by low lung
volumes. The heart is probably normal in size. Increased
pulmonary vascularity is likely related to vascular crowding
secondary to low lung volumes. The lungs are grossly clear.
There is no pneumothorax or definite pleural effusion.
IMPRESSION: Limited study. No definite consolidation. Recommend
repeat
examination once the patient is able to have better inspiratory
effort.
.
EKG: Sinus tach, nl axis, no LVH, sm q-wave in III, no
additional ST/TW changes
Brief Hospital Course:
This is a 45 M w/ pmh of alcohol and heroin abuse transferred
from detox w/ hypertension and tachycardia concerning for EtOH
and opioid withdrawal. He is no longer tachycardic and his
blood pressure is now stable. He is medically stable to go back
to detox.
.
# EtOH withdrawal: Had symptoms consistent with delirium tremens
w/ tachycardia (to the 120s), hypertension (up to systolic of
200) and mild fever (99.2 F -- never had an higher
temperature). Also had mild alcoholic hallucinosis per ED. He
was also aggitated, and was ripping out his IVs, urinating and
stooling in bed. By [**12-13**], he was much more coherent and asking
to go back to Bournwood to be able to continue his treatment
program. He was seen by psychiatry who also feel that he should
go back to Bournwood when medically stable.
- treated w/ diazepam per CIWA scale and received 230 mg
diazepam during the first 24 hours
- received thiamine, folate, MVI
- has required only 40 mg of diazepam since midnight and is safe
to be on a CIWA q 4-6 hours
.
# Opioid withdrawal: On arrival, was endorsing symptoms of
opioid withdrawal, with abdominal pain diarrhea, goosepimples.
He was noted to be s/p a fast methadone taper at Bournwood (20
mg on [**12-9**] mg on [**12-10**] and 10 mg on [**12-11**]).
- he was given 20 mg of methadone on [**12-12**] and [**12-13**] with a plan to
taper by 5 mg q day
- started on clonidine 0.1 mg tid in the setting of opioid
withdrawal
- given Methocarbamol 750 mg PO Q6H:PRN muscle cramps
- given HydrOXYzine 25 mg PO Q6H:PRN anxiety
- DiCYCLOmine 20 mg PO Q4H:PRN abdominal pain
- Loperamide 2 mg PO QID:PRN diarrhea
.
# Low back pain: given Ibuprofen 600 mg PO Q6H:PRN pain
.
# Gerd: PPI was continued
.
# Apnea: by report, had witnessed apneic episodes per ED. Also
intermittently desats during sleep. Given build and weight,
likely has OSA.
- outpatient work-up
.
# Tobacco abuse: nicotine patch
.
# FEN: 1L IVF, replete electrolytes, regular diet
.
# Prophylaxis: Subcutaneous heparin
.
# Access: peripherals
.
# Code: presumed full
.
# Communication: Patient, [**Name (NI) **] ([**Telephone/Fax (1) 42338**]
.
# Disposition: to Bournwood when bed available
.
Medications on Admission:
Medications:
Home:
Pantoprazole
.
At [**Hospital 42339**] Hospital:
Methadone 20 mg on [**12-9**] mg on [**12-10**] and 10 mg on [**12-11**]
Ativan taper
Thiamine
Folate
MVI
Ativan prn
Loperimide prn
Dicyclomine prn
Quinine Sulfate prn
Ibuprofen prn
Trazadone
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. 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. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for anxiety.
9. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO Q4H (every
4 hours) as needed for abdominal pain.
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO q6 hrs prn
as needed for diarrhea.
11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): taper once SBP < 130 and no longer withdrawing from
opioids; would not use for long-term treatment of hypertension.
12. Methadone 5 mg Tablet Sig: 15 mg on [**12-14**] mg on [**12-15**] mg
on [**12-16**] Tablets PO once a day for 3 days.
13. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO q6 hrs prn
as needed for muscle cramps.
14. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for CIWA > 10.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8063**] - [**Location (un) **]
Discharge Diagnosis:
Opioid withdrawal
Alcohol withdrawal
.
Secondary:
Likely obstructive sleep apnea
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted from [**Hospital 42339**] hospital in acute alcohol and
opioid withdrawal. You were treated for this and are now stable
to continue your detox treatment at [**Hospital 42339**] hospital.
Followup Instructions:
Please make an appointment to see your primary care doctor once
you are finished with your detox treatment: [**Last Name (LF) **],[**First Name3 (LF) **] S.
[**Telephone/Fax (1) 250**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1992
} | Medical Text: Admission Date: [**2197-5-10**] Discharge Date: [**2197-5-19**]
Date of Birth: [**2135-5-14**] Sex: F
Service: MED
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: The patient is a 61 year old
female with a history of small cell lung cancer diagnosed in
[**2188**], status post chemotherapy, radiation therapy including
prophylactic whole brain irradiation and stem cell rescue,
also with a history of chronic obstructive pulmonary disease
on home oxygen and recurrent right sided pleural effusion who
presented to the clinic on the day of admission with
increasing shortness of breath. The patient was sent to the
emergency department from the clinic where she was found to
be saturating in the 90s on 100 percent nonrebreathing. A
right sided thoracentesis was done with removal of 600 cc of
serous fluid which initially improved the patient's oxygen
saturation. However, the patient subsequently desaturated
again on the nonrebreather requiring intubation. The
patient's daughter reported that she has had increased
agitation and somnolence as well as green/[**Doctor Last Name 352**] sputum over
the past seven days. She had been started on levofloxacin
without significant improvement in the sputum production. On
the day prior to admission she developed increased somnolence
and lethargy prompting her visit to clinic. She received
ceftriaxone and azithromycin.
PAST MEDICAL HISTORY: Small cell lung cancer diagnosed in
[**2188**], status post radiation, chemotherapy, stem cell rescue,
prophylactic brain radiation.
Chronic obstructive pulmonary disease.
Hypothyroidism.
Atypical pneumonia.
Recurrent right pleural effusion.
Mental status changes.
SOCIAL HISTORY: The patient has been married for 38 years.
Her daughter is a nurse [**First Name (Titles) **] [**Hospital1 188**]. She is a former smoker and quit 70 pack years. She
quit in [**2188**]. She denies any alcohol or drug use.
FAMILY HISTORY: Is significant for mother diabetes and
father with hypertension.
MEDICATIONS ON ADMISSION: Synthroid 100 mcg q.d., Celebrex,
Serevent, Atrovent, albuterol, home oxygen, levofloxacin 500
mg q.d. No known drug allergies.
PHYSICAL EXAMINATION: On admission temperature 98, blood
pressure 127/63, heart rate 126, respiratory rate 22,
saturating 90 percent on 100 percent non-rebreather. In
general this is an ill appearing woman in respiratory
distress. Head, eyes, ears, nose and throat examination:
Mucous membranes slightly dry, extraocular movements intact.
Jugular venous distension was 6 cm. Cardiac examination:
Tachycardic with a regular rhythm, no murmurs, rubs or
gallops. Lung examination: Coarse breath sounds throughout
with decreased breath sounds on the right. Abdomen was soft,
nontender, nondistended with normoactive bowel sounds.
Extremities revealed 1+ lower extremity edema bilaterally.
Neurologically alert and responsive.
LABORATORY DATA: On admission: CBC revealed a white count
of 15.6 with 81 percent neutrophils, hematocrit was 39.1,
platelet count 321. Chem-7 revealed a sodium of 137 with
potassium of 5.9, chloride of 93, bicarbonate of 38, BUN of
18, creatinine of 0.4 and glucose of 106. Pleural fluid
showed 1335 white blood cells and [**Pager number 6326**] red blood cells.
Total protein was 4.1, glucose was 111 and albumin was 1.1.
Electrocardiogram showed sinus tachycardia at 132 with normal
axis and normal [**Doctor Last Name 1754**]. There were no ST or T wave
changes. There were Q waves in 3 and AVF. Chest x-ray
showed a large right pleural effusion with right lower lobe
collapse. Her endotracheal tube was in place.
HOSPITAL COURSE BY PROBLEMS:
1. Respiratory failure: Patient was intubated in the
emergency department. Her respiratory failure was felt to
be multifactorial with the pleural effusion and sizable
lobar collapse playing a large role. She was also treated
for possible pneumonia and had bronchoscopy with BAL done
on both [**5-10**] and [**5-11**]. BAL grew pansensitive pseudomonas
and she was treated for this initially with ceftriaxone
and azithromycin and then subsequently with ceftazidime to
complete a 14 day course. Given her underlying lung
disease including bronchiectasis and severe chronic
obstructive pulmonary disease, it was felt that she would
likely have a long wean off the ventilator. She therefore
underwent tracheostomy on [**5-15**]. She was initially
maintained on pressure controlled ventilation and was
eventually able to be weaned from pressure support mode.
She is currently tolerating 10 of pressure support with 5
of PEEP and an FIO2 of 0.4. On those settings she is
pulling tidal volumes in the 300s and saturating 96 to 98
percent. We did consider chest tube placement to treat
her effusion. However, the patient was oxygenating and
ventilating well and this was therefore deferred.
1. Pneumonia: As stated above patient was felt to likely
have an underlying pneumonia as the source of her acute
decompensation. She was treated with ceftazidine for
pseudomonas pneumonia and will complete a 14 day course.
She also received chest physical therapy and suctioning
p.r.n.
1. Small cell lung cancer: Cytology from both her BAL and
from her pleural fluid were negative for malignant cells.
At this time there is no evidence of disease recurrence.
1. Hypothyroidism: The patient was continued on her home
dose of Synthroid. Given her persistent tachycardia a TSH
and free T4 were checked and are pending at the time of
this dictation.
1. Tachycardia: The patient was persistently tachycardic
throughout her admission. This was initially felt to be
secondary to volume depletion. However, this did not
resolve with intravenous fluids. She underwent an
echocardiogram which showed depressed left ventricular
ejection fraction and was started on an ACE inhibitor for
afterload reduction. As mentioned above thyroid function
tests were also checked given her history of
hypothyroidism and are currently pending.
1. Fluids, electrolytes and nutrition: The patient had a
Dobhoff tube placed and has been on tube feeds since
admission. A speech and swallow evaluation is pending.
1. Metabolic alkalosis: This is felt to be compensatory for
the patient's primary respiratory acidosis from her
chronic obstructive pulmonary disease. A urine chloride
was checked and was 112 suggesting that her metabolic
alkalosis was not chloride responsive.
1. Access: Patient had a right subclavian vein and right
radial arterial line which were both discontinued prior to
discharge. A PICC line was placed by Interventional
Radiology.
1. Prophylaxis: The patient was maintained on subcutaneous
heparin, Venodynes and proton pump inhibitor.
1. Hyperglycemia: The patient was on an insulin sliding
scale with good glycemic control throughout her admission.
DISCHARGE DIAGNOSES:
1. Respiratory failure.
2. History of small cell lung cancer.
3. Recurrent pneumonia, now pseudomonas.
4. Recurrent right pleural effusion.
5. Chronic obstructive pulmonary disease.
6. Hypothyroidism.
DISCHARGE MEDICATIONS: Ceftazidime 2 grams intravenous q 8
hours times four days, Vibrazole 30 mg q.d., Flovent 110 mcg
4 puffs B.I.D, Atrovent 2 puffs q.i.d., albuterol 2 puffs q 2
hours, heparin subcutaneously 5,000 units B.I.D, Levoxyl 125
mcg P.O. q.d., Tylenol 325 mg 1 to 2 tablets P.O. q 4 to 6
ours p.r.n., Colace 100 mg P.O., B.I.D, senna 1 tablet P.O.
q.h.s., Captopril 25 mg P.O. t.i.d., Humalog insulin sliding
scale.
DISCHARGE PLAN: Patient will follow up with her primary care
doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], and was instructed to follow up with her
pulmonologist, Dr. [**Name (NI) **] in one to two weeks. She is
being discharged to rehabilitation where her ventilator will
be weaned as tolerated.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], [**MD Number(1) 6327**]
Dictated By:[**Doctor Last Name 6328**]
MEDQUIST36
D: [**2197-5-18**] 20:20:02
T: [**2197-5-18**] 21:22:44
Job#: [**Job Number 6329**]
ICD9 Codes: 5180, 5119, 2762, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1993
} | Medical Text: Admission Date: [**2150-7-24**] Discharge Date: [**2150-8-4**]
Date of Birth: [**2094-12-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right lower lobe lung nodule
Major Surgical or Invasive Procedure:
Flexible bronchoscopy, VATS right lower lobe wedge, followed by
VATS right lower lobectomy, mediastinal lymph node dissection.
History of Present Illness:
Mr. [**Known lastname 37080**] is a 55-year-old gentleman who is referred to the
Thoracic [**Hospital 32535**] Clinic by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**]. Mr.
[**Known lastname 37080**] had had a
cerebellar tumor resected in [**2140**]. The pathology on this was
adenocarcinoma, which appeared to be metastatic from an unknown
primary. During recent workup for his shoulder pain, he
underwent films which revealed a new pulmonary nodule on the
right side. This was followed with a chest CT, which confirmed
the presence of two new nodules (in comparison with CT scan done
in [**2143**]), in the right lower lobe (FDG avid) as well as a stable
nodule in the right upper lobe.
Mr. [**Known lastname 37080**] [**Last Name (Titles) **] any shortness of breath, cough, purulent
sputum production or hemoptysis. He [**Last Name (Titles) **] any recent pulmonary
infection or travel to the southwest United States. He notes
that he exercises regularly without any shortness of breath or
chest pain. He [**Last Name (Titles) **] any fevers, chills, or sweats. He [**Last Name (Titles) **]
any weight loss. He [**Last Name (Titles) **] any new body pain or neurological
symptoms.
Past Medical History:
Hypertension
Coronary artery disease s/p Myocardial infarction
CABG ([**2139**])
Heart Failure (EF 20-30%)
Hypercholexterolemia
Cerebellar tumor (adenocarcinoma) s/p resection ([**2140**])
Tremor
Anxiety
Avascular necrosis of right humerus
S/P Cholecystectomy
S/P Right shoulder surgery x 2
Hypothyroidism
Bilateral cataract surgery
Erectile dysfunction
Social History:
He is married. He has 3 children between the ages of 20-30. He
works for NSTAR and does have a history of asbestos exposure. He
smoked 2-1/2 packs per day for 20 years, but quit 10 years ago.
He does not drink alcohol.
Family History:
There is no family history of breast, ovarian, uterine, colon,
or lung cancer. His brother did have pancreatic cancer at the
age of 70. His mother died at age 83. He does not know of any
specific medical problems that she had. His father
died at age 52 of a myocardial infarction. He also had a sister
who died of an aneurysm.
Physical Exam:
VITAL SIGNS: Temperature 98.8, pulse 72, blood pressure 98/65,
respiratory rate 16, oxygen saturation 95% on room air, height
68 inches, and weight 193.8 Lbs.
GENERAL: Well-nourished, well-developed gentleman in no apparent
distress, alert and oriented x3 with an obvious tremor.
HEENT: Surgical scar on the cranium. EOMI. PERRL. Sclerae are
anicteric. Oropharynx and nasopharynx free of mucosal
abnormality. Tongue midline. Palate elevates symmetrically.
Trachea is midline.
NECK: Supple and nontender without mass. Thyroid is of normal
size.
LUNGS: Clear to auscultation and percussion. Chest excursion is
symmetric and good. There is no tactile fremitus or gapping.
There is no spine or CVA tenderness.
BACK: There is a healed median sternotomy scar.
HEART: Regular rate and rhythm without murmur, rub, or gallop.
There is no JVD, PMI is normal position.
GI: Soft, nontender, nondistended, without mass or
hepatosplenomegaly. There is a well-healed scar from his
cholecystectomy.
NEUROLOGIC: Strength is symmetric and intact. Sensation is
symmetric and intact. There is a obvious tremor. Gait is slow
but symmetric.
LYMPH NODES: No supraclavicular, cervical or axillary
lymphadenopathy.
EXTREMITIES: No clubbing, cyanosis, or edema. There is some
facial erythema.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2150-7-30**] 10:45AM 36.1*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2150-7-29**] 10:26AM 311
MISCELLANEOUS HEMATOLOGY ESR
[**2150-7-29**] 06:10AM 113*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2150-8-2**] 04:43AM 3.9
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2150-7-31**] 07:00AM 143*
OTHER ENZYMES & BILIRUBINS Lipase
[**2150-7-31**] 07:00AM 165*
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2150-7-24**] 10:50PM 15* 1.3 <0.011
ART
1 <0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
[**2150-7-24**] 02:40PM 5 <0.011
ADDED TNT,CK,CPIS [**2150-7-24**] 5:08PM
1 <0.01
[**Month/Day/Year 706**] Final Report
CHEST (PA & LAT) [**2150-7-31**] 10:36 AM
Reason: eval for interval change
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with s/p vats RLL
REASON FOR THIS EXAMINATION:
eval for interval change
INDICATION: Evaluation for interval change.
FINDINGS: There is mild improving apical right pneumothorax.
There has been interval increase in right lower lobe
atelectasis. However, the subpulmonic effusion is stable. Left
lung is clear. Heart, mediastinum and hilar contours are normal.
The patient is status post sternotomy.
IMPRESSION: Improving small right apical pneumothorax.Worsening
right basilar atelectasis
CT HEAD W/ & W/O CONTRAST [**2150-7-28**] 10:21 AM
Reason: please eval for etiology
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with aggitation altern w/ episode sedation; s/p
cerebellar tumor resection '[**40**]
REASON FOR THIS EXAMINATION:
please eval for etiology
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 55-year-old man with agitation alternating with
sedation. Status post cerebellar tumor resection in [**2140**]. Please
evaluate for etiology.
TECHNIQUE: CT scan of the head prior to and following
administration of IV contrast.
COMPARISON: MR of the head with and without contrast from
[**2150-6-20**].
FINDINGS: There is no evidence of acute intracranial hemorrhage
or major vascular territorial infarcts. [**Doctor Last Name **]-white matter
differentiation is preserved. There is hypoattenuation of the
periventricular white matter consistent with chronic
microvascular disease. The ventricles are mildly enlarged and
the sulci are prominent for the patient's age, consistent with
atrophy. The fourth ventricle is enlarged from patient's
previous cerebellar resection. The superior vermis appears to be
resected.
The visualized paranasal sinuses are clear. There are no soft
tissue or bony abnormalities.
IMPRESSION:
1. No acute intracranial abnormality.
2. Evidence of prior cerebellar resection of the superior vermis
resulting in enlargement of the fourth ventricle.
3. Periventricular white matter disease.
Cardiology Report ECG Study Date of [**2150-7-28**] 8:40:14 AM
Sinus rhythm
First degree A-V delay
Left atrial abnormality
Intraventricular conduction delay
Inferior infarct, age indeterminate
Diffuse ST-T wave abnormalities - cannot exclude ischemia -
clinical
correlation is suggested
Since previous tracing of the same date, no significant change
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 [**Telephone/Fax (2) 97846**] 23 -7
Brief Hospital Course:
Mr. [**Known lastname 37080**] was taken to the operating room where he underwent
flexible bronchoscopy, VATS right lower lobe wedge resection,
followed by a VATS right lower lobectomy and mediastinal lymph
node dissection. He was initially extubated, however in the
PACU, he developed hypotension requiring pressors, and
progressive respiratory acidosis requiring reintubation for
airway protection and repeat flexible bronchoscopy. He was
transferred in stable condition to the thoracic intensive care
unit.
He recovered quickly with improving respiratory status and was
weaned off of pressors. He was weaned from the ventilator and
extubated without complication on the morning of post-operative
day #1 ([**2150-7-25**]). Despite being awake and alert he developed
agitation and confusion requiring a 1:1 sitter, but he continued
to improve clinically, and was transferred to the floor on
[**2150-7-27**]. His chest tubes were pulled later that afternoon
without incident.
He experienced several short burst of ventricular tachycardia on
post-operative day #4 which were asymptomatic and not
hemodynamically significant. He was evaluated by the cardiology
service for possible AICD placement, however these episodes did
not recur, and it was decided to revisit the issue once his
mental status cleared. In addition, he was evaluated by the
neurology service for his confusion and agitation. CT of the
head did not demonstrate any acute abnormality.
Mr. [**Known lastname 37080**] continued to improve both clinically and mentally.
He began to get out of bed and ambulate with the assistance of
physical therapy, and his mental status gradually cleared to the
point where he no longer required a sitter or other supervision.
He is currently doing well and ready for discharge to the
rehabilitation facility. He will require cardiac follow up for
his dysrrhytmia with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] electrophysiology at
[**Hospital1 18**].
Medications on Admission:
AMIODARONE 200 MG--One by mouth qd; brand name
ASPIRIN 81MG--One by mouth every day
ATENOLOL 25MG--Half a tablet by mouth every day
FLEXERIL 10 mg--1 tablet(s) by mouth at bedtime
GEMFIBROZIL 600 MG--One tablet by mouth twice a day
IMDUR 30MG--Every day
KLONOPIN 0.5 mg--1 tablet(s) by mouth twice a day as needed for
anxiety
LEVOXYL 75MCG--One by mouth every day
PAXIL 40MG--One by mouth qd; brand name
ZESTRIL 10MG--One by mouth every day
ZOCOR 40MG--One by mouth every day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Hypertension, Coronary artery disease s/p MI & CABG '[**39**], CHF
(EF20-30%), Cerebellar tumor s/p resection '[**40**], tremor, anxiety,
^cholesterol, avascular necrosis R humerus s/p Right shoulder
surgery x2, s/p cholecystectomy.
T1/N1/Mx Lung Adenocarcinoma
Discharge Condition:
deconditioned- requires pulmonary hygeiene and physical rehab.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**]/Thoracic Surgery office [**Telephone/Fax (1) 170**] for
any post- surgical issues including: fever, shortness of breath,
chest pain, productive cough.
Followup Instructions:
Please call the Thoracic Oncology Office at [**Telephone/Fax (1) 170**] to
arrange a follow-up appointment with Dr. [**Last Name (STitle) **].
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-4-15**]
7:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6781**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2151-4-15**] 9:00
please f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (cardiology) for possible
AICD placement
[**Telephone/Fax (1) 2934**]
Completed by:[**2150-8-6**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1994
} | Medical Text: Admission Date: [**2104-2-13**] Discharge Date: [**2104-2-18**]
Date of Birth: [**2030-7-16**] Sex: F
Service: MEDICINE
Allergies:
Ketek Pak / Augmentin / Lisinopril / Cozaar / Norpace
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Palpitations/fatigue
Major Surgical or Invasive Procedure:
Atrial Flutter Ablation [**2104-2-13**]
History of Present Illness:
Mrs. [**Known lastname 95052**] is a 73 year old woman with a history of ASD repair
in [**2065**], hypertension, hyperlipidemia, atrial flutter (on
coumadin) who was admitted for an atrial flutter ablation and
developed complications of an RP bleed with hypotension, now
improved. She had been diagnosed with atrial flutter since [**2095**]
and since then has had intermittent palpitations. Lately she
developed worsening fatigue secondary to the a flutter as well
as the medications for a flutter and therefore elected to
undergo an ablation.
.
In the EP lab, she underwent a successful ablation and seemed to
tolerate the procedure well. After the procedure, the patient
developed acute hypotension. EKG revealed inferior ST elevations
and so she went to the cath lab which revealed an incidental 80%
D1 lesion as well as a total obstruction of a very small distal
LCx - no intervention was done. Her ST elevations resolved on
their own, however, a HCT showed a drop to 24 from 37
preprocedure. CT abdomen/pelvis revealed a retroperitoneal
bleed, so she was urgently admitted to the CCU. The massive
transfusion protocol was activated and she received 4 units of
PRBCs, and 4 units of FFP. Her HCT corrected to 32.8 and INR to
1.8. She was also given lasix 20mg IV for mild CHF, which
responded well. Vascular was consulted who recommended
correcting the coagulopathy, and holding pressure until INR was
1.5 or less.
.
On the floor, she noted some recurrent wheezing, dry mouth, and
groin pain where we are holding pressure.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:
- Hypertriglyceridemia
- Hypertension
2. CARDIAC HISTORY:
- Atrial flutter/fibrillation s/p DCCV ([**2-/2101**])
3. OTHER PAST MEDICAL HISTORY:
- Subclinical hypothyroidism
- Allergic rhinitis
- Osteopenia
- s/p ASD repair ([**2065**])
Social History:
Born and raised in [**Location (un) 1468**]. Married with 2 kids. No
grandchildren. Retired secretary. Smoked 2 packs per day from
age 20-40. No EtOH. Goes to the gym and does yoga, spinning,
muscle conditioning, and aerobics.
Family History:
Mother and father both with some type of CA when elderly. No
significant cardiac history.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: 97 82/50 73 21 99%RA
GENERAL: Agitated elderly woman in moderate distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with normal JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Cool extremities. No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+
Left: DP 1+
Pertinent Results:
LABS ON ADMISSION:
[**2104-2-13**] 07:35AM BLOOD WBC-6.4 RBC-4.35 Hgb-13.9 Hct-40.9 MCV-94
MCH-32.0 MCHC-34.0 RDW-12.6 Plt Ct-178
[**2104-2-13**] 07:35AM BLOOD Neuts-69.5 Lymphs-22.2 Monos-5.8 Eos-1.7
Baso-0.7
[**2104-2-13**] 07:35AM BLOOD PT-28.0* INR(PT)-2.7*
[**2104-2-13**] 07:35AM BLOOD Plt Ct-178
[**2104-2-13**] 07:35AM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-141
K-4.5 Cl-105 HCO3-28 AnGap-13
[**2104-2-13**] 06:30PM BLOOD Calcium-7.4* Phos-5.3*# Mg-1.6
CARDIAC ENZYMES:
[**2104-2-13**] 02:45PM BLOOD CK-MB-3 cTropnT-0.51*
[**2104-2-13**] 06:30PM BLOOD CK-MB-6 cTropnT-0.86*
[**2104-2-14**] 02:24AM BLOOD CK-MB-30* MB Indx-9.6* cTropnT-1.17*
[**2104-2-14**] 10:54AM BLOOD CK-MB-47* MB Indx-8.8* cTropnT-1.69*
[**2104-2-14**] 03:59PM BLOOD CK-MB-37* MB Indx-7.0* cTropnT-1.60*
Micro:
[**2104-2-15**] 4:52 pm URINE Source: CVS.
**FINAL REPORT [**2104-2-16**]**
URINE CULTURE (Final [**2104-2-16**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Imaging:
[**2-13**] TTE:
No atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen.
IMPRESSION: Low-normal LV systolic function. The inferior wall
motion is probably normal. The right ventricle appears mildly
dilated/hypokinetic. No ASD/PFO seen but cannot exclude on basis
of this study.
[**2-13**] CT Abd/Pelvis:
MPRESSION:
1. Large hematoma extending along the left pelvic sidewall into
the
preperitoneal and subperitoneal space surrounding the bladder
2. Small amount of ascites
3. Cholelithiasis without cholecystitis.
[**2-14**] TTE:
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses and cavity size are
normal. There is mild regional left ventricular systolic
dysfunction with focal hypokinesis of the apical inferior and
apical lateral segments. Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
are mildly thickened (?#). There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Mild focal LV systolic dysfunction (consistent with
known PDA occlusion). Normal size and function of right
ventricle. No significant valvular abnormality seen.
[**2-14**] CXR:
IMPRESSION:
1) Increase in vascular congestion with lower lung volumes and
new right
basilar atelectasis. No pleural effusion is seen.
2) No pulmonary edema.
[**2-14**] Renal US:
RENAL ULTRASOUND: The right kidney measures 10.4 cm and the left
kidney
measures 10.9 cm. There is no hydronephrosis, mass or stone. The
parenchymal echogenicity is symmetric bilaterally. In the upper
pole of the right kidney, there is a 9 x 8 x 7 mm anechoic
avascular cyst. This study was performed with a decompressed
urinary bladder. In the suprapubic region at the midline, there
is a 10 cm fluid collection with some solid components presumed
to be the retroperitoneal hemorrhage.
IMPRESSION: No evidence of hydronephrosis.
Brief Hospital Course:
73 year old woman with a history of ASD repair in [**2065**],
hypertension, hyperlipidemia, atrial flutter (on coumadin) who
was admitted for an atrial flutter ablation and developed
complications of an RP bleed with hypotension and STEMI
secondary to PDA ablation.
.
ACTIVE DIAGNOSES:
.
# ST elevation MI: Patient was found to have posterior STE on
EKG. At cath, she was found to have tight distal PDA lesion
likely secondary to ablation. Patient was asymptomatic despite
persistent ST elevations. TTE showed mild focal LV systolic
dysfunction (consistent with known PDA occlusion), normal size
and function of right ventricle, and no significant valvular
abnormality. Patient was eventually restarted metoprolol
succinate 50mg daily, Atorvastatin 80, ASA 81 mg PO daily,
Coumadin 2mg daily. She was not started on an ACEi or [**Last Name (un) **] as
patient is allergic.
# Atrial flutter: Now resolved s/p ablation. She was restarted
on metoprolol when her blood pressure could tolerate it, and was
started on Amiodarone 200mg PO BID x2 weeks, then 200mg PO daily
x1-2 months.
# RP bleed: The patient was found to be hypotensive after her
aflutter ablation, secondary to acute blood loss from
retroperitoneal bleed as confirmed by CT abdomen/pelvis. This
bleeding resolved with aggressive blood transfusions and FFP.
Hct stabilized 12 hours after bleed at a hct of 30, and there
was no evidence of persistent bleeding. Patient did experience
abd and back pain, likely secondary to irritation from bleeding.
Pain from irritation from bleeding was controlled with oxycodone
as needed and a lidocaine patch. Her anticoagulation was
reversed at the time of RP bleed, but Coumadin was eventually
restarted, initially at half home dose (2mg) and then titrated
to meet INR goal [**2-1**].
# Dyspnea/wheezing: After the multiple transfusions, the patient
developed wheezing on exam and dyspnea that worsened on lying
flat. Most likely etiology of dyspnea is secondary to pulmonary
edema due to aggressive volume resuscitation during RP bleed.
Patient was diuresed a total of ~2L during length of hospital
stay. Upon discharge, she was breathing comfortably and her
oxygen saturation was well-maintained on room air.
# Leukocytosis: Mild up to 12, has been up to 13 before, most
likely secondary to stress. Differential showed no bandemia.
Patient remained afebrile, with no cough, dysuria or other focal
symptoms. Urine and blood cultures showed no growth.
Leukocytosis eventually resolved.
.
CHRONIC DIAGNOSES:
.
# HLD: Patient was continued on Atorvastatin 80.
# Subclinical hypothyroidism: Last T4 was normal and pt without
sx of hypothyroidism.
Medications on Admission:
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 100 mg
Tablet Extended Release 24 hr - 2.5 (two and a half) Tablet(s)
by
mouth once a day
WARFARIN - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 73**] - 2 mg
Tablet - 2 (Two) Tablet(s) by mouth once a day/afternoon
Medications - OTC
CALCIUM CARBONATE [TUMS] - (Prescribed by Other Provider; OTC)
-
Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Capsule - 1 (One) Capsule(s) by mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Tablet -
1 Tablet(s) by mouth daily
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO once a day.
3. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
4. warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. 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*
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
12. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY:
1. atrial flutter ablation
2. retroperitoneal bleed
3. myocardial infarction secondary to RF catheter ablation
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 95052**],
You were admitted to the hospital for a procedure called atrial
flutter ablation. You developed a complication, and had bleeding
into the back (retroperitoneal bleed). During this event, you
had a small heart attack. This was managed with maximal medical
therapy. You received blood products for your bleeding, and
stabilized.
MEDICATION CHANGES:
- START amiodarone to control your heart rate
- Decrease warfarin to 3mg daily
- Decrease metoprolol succinate to 100 mg daily
- START lipitor (Atorvastatin) to help prevent heart attacks and
help the current heart attack heal
- START amiodarone to help prevent further episodes of unstable
rhythm
- START aspirin to help prevent heart attacks and help the
current heart attack heal
- START lidocaine patches for pain control
- START oxycodone as needed for pain control
- START senna as needed for constipation
- START colace for bowel control
- START tylenol as needed for pain
Please seek medical attention for worsening symptoms.
Followup Instructions:
Unfortunately we were unable to make a post-discharge
appointment for you with your primary care provider. [**Name10 (NameIs) 357**] call
Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 10813**] to follow up, we would ideally like
you seen within 1 week. If you encounter problems making a quick
appointment call [**Telephone/Fax (1) 72722**].
Department: CARDIAC SERVICES
When: THURSDAY [**2104-3-13**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], 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: CARDIAC SERVICES
When: MONDAY [**2104-4-7**] at 10:40 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2104-4-24**] at 2:20 PM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1995
} | Medical Text: Admission Date: [**2194-11-17**] Discharge Date: [**2194-11-20**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a [**Age over 90 **]-year-old gentleman who is s/p a right
colectomy for cecal adenocarcinoma on [**2194-10-28**] with Dr.
[**Last Name (STitle) **]. He was discharged to rehab on [**2194-11-5**]. Per
daughter he was having low blood pressures and constipation at
rehab. He returns now with difficulty breathing and coughing.
In the ED he is requiring 15L NRB.
Past Medical History:
# Right colecomy [**2194-11-5**]
# Hemophilia C: diagnosed in [**2194-4-24**]
# hypertension
# valvular CHF: TEE [**2194-6-24**]: Severe, possibly flail TR,
moderate AS, severe MR, EF 65-75%, PAP of 35
# question of prior rheumatic fever
# glaucoma
# BPH, s/p TURP.
# bacteremia of unknown source c/b C.diff colitis ([**2194-5-24**],
[**Hospital1 112**])
# hernia repair x 3
# Hip and Shoulder Surgery 3yrs ago
Social History:
- Tobacco: past history of 3ppd (stopped 50-60yrs ago)
- Alcohol: rare and small amounts per family (pt says not at
all)
- Ambulates with walker. Supportive and involved children.
Family History:
non-contributory
Physical Exam:
Vitals - not collected, pt 98 at 0400
Gen - A&O x 3, NAD
Pulm - crackles bilat
CV - atrial fibrillation with rate 120-150
Abd - soft, NTND, incision healing well, clean, dry, intact
extrem - bilat lower extremity edema
Pertinent Results:
none
Brief Hospital Course:
The patient was admitted to the general surgery service on
[**2194-11-17**] for treatment of a pneumonia. He was intubated on HD1
and started on broad spectrum antibiotics, which he tolerated
well.
Neuro: The patient received tylenol PO with good effect and
adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. During HD 1 he was placed
brifly on an esmolol drip and after a brief episode of
bradycardia he converted to sinus rhythm. On HD 3 he declined
further care and was made CMO, his atrial fibrillation returned
and at the time of discharge his heart rate was 120-150.
Pulmonary: The patient was intubated on HD 1 but the
ventillatoor was weaned and he remained on 4LNC throughout the
remainder of his hospital stay.
GI/GU: Fluids were kept to a minimum throughout this hospital
stay because of his history of CHF. On HD 3 he was given a 10mg
dose of lasix, which caused the patient to diurese nicely. he
took minimal PO through this hospital stay. Foley was kept in
place and the patient will be discharged to home with it for
comfort.
ID: The patient was started on IV vanc, cipro, cefapime, and
flagyl upon admission. this was continued through HD 3, when the
patient refused any further care. After HD 3 th epatient's
temperature was watched closely and treated with tylenol PRN to
provide comfort.
Prophylaxis: The patient received subcutaneous heparin until HD
3.
At the time of discharge on HD 4, the patient was afebrile abd
his pain was well controlled.
Given his decision to become CMO and to expire at his home among
his family, a palliative care consult was obtained to maximize
patient comfort while inhouse and hospice was set up for the
patient.
He will be discharged to [**Last Name (un) **] on oxygen and suction, as well as
pain medication to be administered by hospice via their
protocol.
Medications on Admission:
finasteride 5mg q/day, gabapentin 300mg q/day, tramadol 50mg
QHS, MVI, Fe, timolol gtt 0.5%, xalatan gtt 0.005%
Discharge Medications:
1. Home Oxygen
Please provide home oxygen, titrate for comfort per company
protocol.
2. Suction
Please provide suction device for patient per company protocol.
3. hyoscyamine sulfate 0.125 mg/mL Drops Sig: [**1-25**] PO every four
(4) hours as needed for shortness of breath or wheezing.
Disp:*30 ml* Refills:*0*
4. morphine concentrate 20 mg/mL Solution Sig: One (1) ml PO q1H
as needed for pain.
Disp:*30 ml* Refills:*0*
5. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) ml PO
every four (4) hours as needed: Please administer for agitation.
Disp:*30 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
Pneumonia
Sepsis
Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You have been admitted to the hospital for treatment of a
pneumonia. You have decided to decline further medical treatment
and receive hospice care. Please follow the instructions of the
Hospice Liason taht will be providing further comfort care.
Followup Instructions:
Please feel free to follow up with Dr [**Last Name (STitle) **] if you decide
you want further medical care. His office number is [**Telephone/Fax (1) 58832**].
Completed by:[**2194-11-20**]
ICD9 Codes: 0389, 5070, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1996
} | Medical Text: Admission Date: [**2139-11-28**] Discharge Date: [**2139-12-29**]
Date of Birth: [**2074-2-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceftriaxone / Strawberry / Bleach
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
groin abcess, hypotension
Major Surgical or Invasive Procedure:
ERCP with stent placement
IR procedure(percutaneous cholecystostomy tube placement)
History of Present Illness:
65F w/ IDDM, ESRD, morbid obesity, and history of multiple line
infections who recently had an I&D of a groin abscess on [**11-24**].
She presented to the ED today after undergoing HD at [**Hospital 7137**] per repacking of her abscess but was found to be
hypotensive w/ sbps in the 80s. Ms. [**Known lastname **] reports recent nausea
and vomiting related to her abx (doxy and bactrim). She reports
an undocumented fever past wednesday but none since. She has had
a productive cough since yesterday with yellowish-brown sputum.
She denies any CP, myalgias, pain. per the abscess she has been
to the ED twice for dressing and reports improvement.
She has a history of constipation and last moved her bowels a
few days ago. She has some abdominal discomfort in that she
feels bloated, and has localized TTP in the LLQ. No recent dx of
diarrhea.
In the ED, patient became hypotensive to 80/40, subjectively
feels "not right" but no reports of dizziness (no change in
symptoms from presentation). Given 250cc bolus of NS X 2.
However, she was not felt to be fluid responsive and was started
on levophed and central line was placed. Also labs came back
acidotic with bicarb of 11, repeat 15 on green top. Her EKG
demonstrated junctional rhythm at 62 bpms, LAD, NI, consistent
with prior. She had a normal lactate. Was given cipro, flagyl,.
CT Abdomen and CXR were "unremarkable". She recieved a total of
2L in ED.
.
In the MICU, she was vitally stable on a levophed drip.
.
Review of sytems:
(+) Per HPI, + LLQ pain, constipation with last BM 3 days prior
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied shortness of breath. Denied chest pain or
tightness, palpitations. Denied diarrhea. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
- atrial tachycardia: seen by Dr. [**Last Name (STitle) **] in [**10-24**] and felt to
be atrial tachy [**2-18**] illness, no indication for ablation
- hemorrhagic pericardial effusion
- Bilateral internal jugular thromboses, restarted on coumadin
[**8-24**]
- h/o bilateral lower extremity DVT's
- ESRD on HD T, Th, Sat
- IDDM
- Diastolic heart failure
- Pulmonary hypertension
- Hypercholesterolemia
- OSA, noncompliant with CPAP as outpatient (on 2L home O2)
- OA
- h/o C. Diff
- GERD
- Depression
- Morbid obesity
- Fibroid uterus; vaginal bleeding
- h/o Osteomyelitis at the T9 Vertebrae [**5-24**]; tx with Vanc
- h/o Multiple line infections
. Micro Hx:
**[**2135-12-17**]: Providencia, treated with 4 wk course of
aztreonam
**[**2135-4-17**]: Staph coag positive, sensitive to both vancomycin
and gentamicin
**[**2136-5-17**]: Staph bacteremia tx with vanc x 6 weeks
**[**2136-8-17**]: Proteius mirabilis and MSSA, treated with ceftaz
and vanc
Social History:
Patient denies tobacco, alcohol or illicit drug use. She lives
in a nursing home ([**Hospital3 2558**]) since the last 4 years. She
is separated from her husband. She has 5 children in [**Location (un) 86**]
[**Doctor Last Name **] area.
Family History:
Two children with asthma. Otherwise non-contributory.
Physical Exam:
On Admission:
Vitals: T: 99.4/37.4 BP: 86/58 P: 81 R:17 O2: 100% on 3L NC
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: 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: no foley - well healing abscess
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Discharge exam:
VS - Temp 98.5 F, 83 HR , 15 RR , 116/42 BP , 99 O2-sat % 2L
GENERAL - obese woman NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - diminished breath sounds bilat, no r/rh/wh, poor air
movement, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/obese, ttp in RUQ with deep palpation, no
masses or HSM, no rebound/guarding, +BS
EXTREMITIES - WWP, no c/c, mild 1+ edema, 2+ peripheral pulses
(radials, DPs), L sided femoral tunnelled dialysis catheter in
place CDI
SKIN - numerous SC calcifications in b/l LE
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-21**] throughout, sensation grossly intact throughout, DTRs 2+
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-7.1 RBC-3.55* Hgb-11.8* Hct-40.0 MCV-113* RDW-14.0 Plt
Ct-327
--Neuts-79.4* Lymphs-14.6* Monos-3.9 Eos-1.8 Baso-0.3
PT-34.1* PTT-34.3 INR(PT)-3.4*
Glucose-102* UreaN-17 Creat-3.4*# Na-137 K-6.0* Cl-111* HCO3-11*
ALT-23 AST-24 AlkPhos-174* TotBili-0.2
Lipase-58
Calcium-9.9 Phos-6.0*# Mg-1.9
On Discharge:
[**2139-12-29**] 06:26AM BLOOD ALT-14 AST-11 LD(LDH)-137 AlkPhos-164*
TotBili-0.2
[**2139-12-29**] 06:26AM BLOOD Glucose-111* UreaN-38* Creat-7.0*# Na-135
K-4.8 Cl-97 HCO3-29 AnGap-14
[**2139-12-29**] 06:26AM BLOOD WBC-6.4 RBC-2.28* Hgb-7.2* Hct-24.3*
MCV-107* MCH-31.7 MCHC-29.8* RDW-15.6* Plt Ct-337
=============
MICROBIOLOGY
=============
Blood Culture * 3 [**2139-11-29**]: No Growth
Urine Culture [**2139-11-29**]:
URINE CULTURE (Final [**2139-11-30**]):
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
GRAM NEGATIVE ROD(S). ~[**2128**]/ML.
Blood Cultures 1/3 [**2139-12-1**]:
Blood Culture, Routine (Final [**2139-12-4**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**] ([**Numeric Identifier 8022**]) REQUESTS SNESITIVITY TESTING TO
AZTREONAM
, TETRACYCLINE AND Tigecycline [**2139-12-3**].
Tigecycline = 2 MCG/ML = SENSITIVE, Tigecycline
Sensitivity
testing performed by Etest. AZTREONAM = RESISTANT.
AZTREONAM & TETRACYCLINE sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- 16 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- I
TETRACYCLINE---------- I
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final [**2139-12-1**]):
Reported to and read back by [**Doctor First Name **] [**Doctor Last Name 10280**] @ 1518 ON [**12-1**]
- CC6D.
GRAM NEGATIVE ROD(S).
Urine Culture [**2139-12-1**]:
URINE CULTURE (Final [**2139-12-4**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Catheter Tip Culture [**2139-12-1**]: No Growth
Blood Culture *3 [**2139-12-3**]: No Growth
Bile Culture [**2139-12-4**]:
GRAM STAIN (Final [**2139-12-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2139-12-7**]):
ESCHERICHIA COLI. SPARSE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final [**2139-12-8**]): NO ANAEROBES ISOLATED.
Blood Culture * 4 [**2139-12-6**]: No Growth
==============
OTHER STUDIES
==============
ECG [**2139-11-28**]:
Possible junctional rhythm. Left anterior fascicular block.
Compared to the
previous tracing P waves are no longer visible suggesting
junctional rhythm.
The other findings are similar.
CT Abdomen and Pelvis with Contrast [**2139-11-28**]:
IMPRESSION:
1. Choledocholithiasis and stable dilated CBD to 12 mm.
2. No colonic diverticulitis.
3. Fibroid uterus.
CT Chest W/Contrast [**2139-11-29**]:
IMPRESSION:
1. Enlarged pulmonary artery in keeping with pulmonary
hypertension.
Moderate cardiomegaly.
2. Small bilateral pleural effusions with overlying
consolidation and
atelectasis within the lower lobes bilaterally.
3. Multinodular goiter with bilateral thyroid nodules.
CT Right Lower Extremity With Contrast [**2139-11-29**]
IMPRESSION:
1. Skin thickening and irregularity along the right inguinal
fold at site ofprevious I&D. No evidence of abscess.
2. Fibroid uterus.
3. Moderate calcification of the common femoral, superficial
femoral and
profunda femoral arteries bilaterally.
Femoral Line Placement and PTC [**2139-12-4**]:
IMPRESSION:
1. Exchange of the left femoral temporary hemodialysis catheter
with a new 14 French, 24 cm temporary hemodialysis catheter. The
line is ready for use.
2. Placement of an 8 French internal-external biliary drainage
catheter via a right posterior biliary duct with its retention
pigtail loop in the duodenum.
ERCP:
Impression: A peri-ampullary diverticulum was present.
A stent was seen extruding from the ampullary orifice - This
corresponds to patient's known internal-external PTC drain.
Cannulation of the biliary duct was successful and deep with a
sphincterotome after a guidewire was placed.
Contrast medium was injected resulting in complete
opacification.
A moderate diffuse dilation was seen at the biliary tree with
the CBD measuring 15 mm.
Several filling defects were seen in the CBD consistent with
stones.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Balloon sphincteroplasty was then performed with a wire-guided
CRE balloon and the ampulla/distal CBD was successfully dilated
to 15 mm.
Several balloon sweeps were then performed with successful
extraction of two 8 mm stones.
As the bile duct was very large and complete opacificiation was
not possible, it was unclear whether there were any retained
stones.
Thus, a 5cm by 10FR dougle pigtail biliary stent was placed
successfully.
Recommendations: NPO overnight with aggressive IV hydration with
LR at 200 cc/hr.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ([**Pager number 8437**])
Further management of PTC drain as per IR.
Repeat ERCP in 1 month for stent removal and complete duct
clearance.
Pending Studies:
Wound Swab Culture from [**2139-12-29**].
Brief Hospital Course:
65 yo woman presenting from nursing facility with recent
well-healing groin abcess, admitted with cholangitis, Klebsiella
bacteremia, septic shock, and hypercarbic respiratory failure.
Hospital course was also notable for deep venous thrombosis.
#Cholangitis/Klebsiella bacteremia/Septic
Shock/Choledocholithiasis:
Patient was admitted to the Medical Intensive Care Unit in
septic shock requiring vasopressor support and found to have
Klebsiella bacteremia. LFTs were normal, but an abdominal
ultrasound showed a dilated common bile duct. Bedside ERCP was
unsuccessful but a percutaneous biliary drain was placed and the
patient improved with drainage and antibiotics and was able to
be taken off vasopressors. Once the patient was hemodynamically
stable a repeat ERCP was performed which was notable for
choledocholithiasis and a sphincterotomy with stone extraction
was performed and a biliary stent was placed. Patient completed
a 2 week course of Meropenem prior to discharge. Patient will
return for stent removal in one month from discharge.
#Hypercarbic Respiratory Failure/Obstructive Sleep Apnea:
This was felt to be related to the patient's sepsis. She was
intubated and then extubated when sepsis improved. Following
treatment of her infection she was maintained on [**1-18**] L oxygen by
nasal canula. Following second ERCP the patient did require
transfer to ICU as anesthesia did not feeel comfortable
extubating patient immediately after the procedure. She was
extubated without incident however. She has obstructive sleep
apnea and was instructed to wear her BIPAP at night once
discharged.
#Lower extremity Deep Venous Thrombosis/End stage Renal Disease
on Hemodialysis:
Patient was found to have left lower extremity DVT in the same
leg as her femoral hemodialysis line. Given the patient's
problems with access in the past, the decision after discussion
with Nephrology was to keep the line in and continue
anticoagulation. Since Coumadin was held for the patient's ERCP,
the patient required a heparin gtt bridge to Coumadin until INR
was therapeutic at goal [**2-19**]. This will be followed by providers
at patient's extended care facility.
#Groin abcess: The patient has a groin abcess, looked well
healed. Wound care was consulted and followed the patient. On
day of discharge there was pus noted from around the
hemodialysis line. Renal was made aware and cultures were taken
but the Renal team did not want to start empiric antibiotics.
The cultures will be followed by outpatient Nephrology and
antibiotics started as indicated.
# Pruritis: Upon transfer to the [**Hospital Ward Name **] prior to second
ERCP, Ms. [**Known lastname **] began to note pruritis of her back. There
existed a maculopapular rash on the regions of her back which
contact[**Name (NI) **] her sheets. She remembers an allergy to bleach. Her
pruritis improved with discontinuation of bleached sheets, sarna
lotion, and a short course of topical clobetasol. She also was
placed on miconazole power for fungal groin rash.
.
#DEPRESSION: Paxil was continued.
#GERD: PPI was continued.
#Hx of atrial tach: Amiodarone was continued.
#Diabetes mellitus type 2: continued home NPH and ISS
TRANSITIONAL ISSUES:
- Patient is having intermittent vaginal bleeding, she should be
evaluated by GYN as an outpatient for possible endometrial
biopsy
- Patient's left tunneled line was noted to have mild possibly
purulent discharge at dialysis on [**2139-12-29**]. Cultures were
obtained and will need follow up. There were however no other
symptoms or signs of infection.
Medications on Admission:
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
5. Bactrim DS 800-160 mg Tablet Sig: Two (2) Tablet PO at HD.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
7. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1)
nebulizer Inhalation q8h:prn as needed for shortness of breath
or wheezing.
8. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO once a day.
9. Insulin
Please continue your previous insulin regimen of NPH 20 units
qam and Novolog SS.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Paroxetine HCl 20 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
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. folic acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for wheezing.
5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
12. Outpatient Lab Work
Please check daily INR and CBC on [**12-31**] to ensure that patient
is therapeutic on warfarin and that hct is not downtrending
(last Hct on discharge was 24.3).
13. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
(20) Subcutaneous qam.
14. insulin lispro 100 unit/mL Solution Sig: as directed by
sliding scale Subcutaneous ASDIR (AS DIRECTED).
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain/fever.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
20. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
21. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q8H
(every 8 hours) as needed for itching.
22. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for pruritus.
23. Coumadin 1 mg Tablet Sig: Five (5) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
1. Cholangitis
2. Respiratory failure
3. Diabetes Mellitus
4. End stage renal disease requiring dialysis
5. DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted with a severe bacterial infection because of an
obstruction of your bile ducts(cholangitis). You had a biliary
drain(cholecystostomy) placed by interventional radiology to
drain infected bile, but the drain was removed after a few days
when you had the ERCP procedure. During the ERCP procedure, a
stent was placed in your bile duct.
The following changes have been made to your medications:
START Warfarin for the clot in your leg (duration to be
determined by your primary care physician)
START benadryl as needed for itching
START nephrocaps for nutrition
START sarna lotion as needed for itching
START miconazole as needed for itching or skin-based yeast
infections
Please make sure INR is checked on dialysis days for next two
weeks to ensure that it is in therapeutic range.
Followup Instructions:
1. You will be admitted to a medical acute care facility where
a physician will continue to follow your care.
2. The gastroenterology department will be scheduling a follow
up procedure(ERCP) and will contact you with the date/time.
Department: TRANSPLANT CENTER
When: MONDAY [**2140-1-25**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5856, 2762, 4280, 5990, 2767, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1997
} | Medical Text: Admission Date: [**2148-4-26**] Discharge Date: [**2148-5-3**]
Date of Birth: [**2071-3-19**] Sex: F
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Worsening ejection fraction
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 77-year-old
female with a past history of cardiac disease with an
myocardial infarction in [**2136**]. She had a cardiac
catheterization in [**2140**] and was found to have an RCA lesion
which was stented. She also had a 40% lesion in the left
main. She was followed with serial echocardiograms that
showed worsening ejection fraction, now down to 20%. She was
admitted to the hospital for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Pituitary tumor, status post XRT which caused
hypothyroidism
2. Chronic obstructive pulmonary disease
3. Osteoarthritis
4. Positive PPD, treated with INH
5. INH induced hepatitis in [**2134**]
6. AVNRT with noted ablation
7. Spinal stenosis
8. Coronary artery disease
9. Hypertension
10. Hyperlipidemia
PAST SURGICAL HISTORY:
1. Hernia repair
ALLERGIES: None known.
ADMISSION MEDICATIONS:
1. Aspirin 81 mg qd
2. Lipitor 40 mg qd
3. Unithroid 100 mcg qd
4. Neurontin 100 mg [**Hospital1 **]
5. Prilosec 20 mg qd
6. Ultram 50 mg [**Hospital1 **]
7. Toprol XL 25 mg qd
8. Azmacort inhaler
9. Atrovent inhaler
10. Norvasc 5 mg qd
11. Isosorbide mononitrate 20 mg [**Hospital1 **]
SOCIAL HISTORY: Two pack per day smoker for 40 years, quit
18 years ago.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2148-4-26**] on the medical service. She [**Date Range 1834**] a cardiac
catheterization which revealed an 80% lesion in the LMCA with
an ejection fraction of 20%. Cardiac surgery was consulted
and decision for coronary artery bypass graft was made. Ms.
[**Known lastname **] [**Last Name (Titles) 1834**] a coronary artery bypass graft x1 on [**2148-4-29**]
with a graft from the left internal mammary artery to LAD.
Postoperatively, she had high output from the chest tube for
which she was treated with replacement of blood products.
Despite this, she continued to have high output and she had a
total chest tube output of 1.4 liters. She was then taken
back to the Operating Room emergently and was re-explored.
Bleeding at the RIMA was noted which was repaired. The
patient returned to CSR in stable condition. She was
extubated on the [**1-1**]. She was then transferred on
postoperative day 1 to the CCU. She continued to make good
progress and was transferred to the regular floor on
postoperative day 2. She made good progress over the next
couple of days. Her pacing wires were discontinued on
postoperative day 3. She is ambulating with physical therapy
currently and is comfortable on po analgesics. She is now
ready for discharge to a rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg [**Hospital1 **]
2. Lasix 20 mg qd for 1 week
3. KCL 20 milliequivalents qd for 1 week
4. Colace 100 mg [**Hospital1 **]
5. Aspirin EC 325 mg qd
6. Plavix 75 mg qd
7. Flovent Metered dose inhaler 110 mcg 2 puffs [**Hospital1 **]
8. Captopril 6.25 mg q8h
9. Levothyroxine 100 mcg qd
10. Combivent metered dose inhaler 2 puffs q4h
11. Protonix 40 mg qd
12. Tylenol 650 mg q 4 to 6 hours prn
13. Neurontin 100 mg [**Hospital1 **]
14. Lipitor 40 mg qd
FOLLOW UP: Primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1391**], in two
weeks and with Dr. [**Last Name (STitle) 1537**] in four weeks.
DISCHARGE CONDITION: Stable
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2148-5-3**] 08:52
T: [**2148-5-3**] 08:57
JOB#: [**Job Number 94821**]
ICD9 Codes: 4280, 496, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1998
} | Medical Text: Admission Date: [**2107-9-2**] Discharge Date: [**2107-9-12**]
Date of Birth: [**2078-9-6**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin / Optiray 300 / Nut Flavor / Fruit Flavor /
Erythromycin Base / Magnevist / Shellfish / iv contrast dye
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
EGD x 2
History of Present Illness:
28 yo F with a history of alcoholism, several episodes of acute
alcoholic pancreatitis, transferred from OSH with 3 days of
abdominal pain, nausea and vomiting. She reported that she had
been on an alcohol binge for several days, last drink was 3 days
prior. She had severe abdominal pain, worse than with prior
episodes of pancreatitis. She was vomiting blood tinged emesis.
Labs at OSH were notable for lipase of 1000. Patient had an
episode of 300 cc of emesis with red blood streaks. Later in the
evening, she vomited 1000cc of bright red blood with clots. Her
hematocrit dropped from 33.6-28.8 over 4 hours and she received
1U PRBC and was transferred to [**Hospital1 18**] for further management.
In the ED, initial vital signs were 97.7 79 123/80 16 97%. Labs
notable for hematocrit 32. KUB was negative for free air. She
was started on pantoprazole 80mg IV and given dilaudid for pain
control. She had an episode of hematemesis. NG tube was placed
and returned bright red blood. Patient was admitted to the MICU
for further management.
Vital signs prior to transfer were 98.2 104 142/98 18 98%.
On arrival to the MICU, vital signs were BP 128/78 HR 123 O2 99%
RA. Patient vomited 350cc of bright red blood with clots.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.
Past Medical History:
- Acute alcoholic pancreatitis [**6-2**], [**8-2**], [**2-2**]- No history of
pseudocysts
- Alcohol abuse
- Hematemesis- gastritis on EGD ([**7-/2105**], [**1-/2106**])
-HTN
Social History:
Lives in [**Location 3786**] with her mother.
Used to work at [**Hospital1 18**] as a clinical auditor.
- Tobacco: quit 2 years ago
- Alcohol: last drink 3 days ago, h/o abuse for many years, as
above
- Illicits: denies
Family History:
Parents - alive, both with DM and HTN
Both mother and father were alcoholics, her older brother is an
alcoholic.
Physical Exam:
ADMISSION EXAM
Vitals: BP 128/78 HR 123 O2 99% RA
General: Well nourished female, actively vomiting
HEENT: Sclera anicteric, NGT in place.
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: diffusely tender to mild palpation with guarding.
GU: foley in place
Ext: WWP, 2+DP/PT pulses b/l, no edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred
DISCHARGE:
VS - 98 99/64 60 18 98 RA
GEN Alert, oriented, NAD
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD Nontender till sudden voluntary guarding at end of deep
palpation in all quadrants. soft, normoactive BS, ND, no
organomegaly noted, no ascites
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS
[**2107-9-2**] 09:18PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2107-9-2**] 09:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2107-9-2**] 09:18PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2107-9-2**] 09:18PM URINE MUCOUS-RARE
[**2107-9-2**] 09:00PM GLUCOSE-86 UREA N-6 CREAT-0.5 SODIUM-144
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-12* ANION GAP-25*
[**2107-9-2**] 09:00PM estGFR-Using this
[**2107-9-2**] 09:00PM ALT(SGPT)-23 AST(SGOT)-119* ALK PHOS-73 TOT
BILI-0.3
[**2107-9-2**] 09:00PM LIPASE-901*
[**2107-9-2**] 09:00PM ALBUMIN-4.2 CALCIUM-7.2* PHOSPHATE-3.3
MAGNESIUM-1.5*
[**2107-9-2**] 09:00PM WBC-6.4 RBC-3.28* HGB-10.3* HCT-32.2* MCV-98#
MCH-31.4 MCHC-31.9 RDW-14.7
[**2107-9-2**] 09:00PM NEUTS-85.9* LYMPHS-10.3* MONOS-3.2 EOS-0.4
BASOS-0.3
[**2107-9-2**] 09:00PM PLT COUNT-111*#
[**2107-9-2**] 09:00PM PT-13.5* PTT-29.3 INR(PT)-1.3*
DISCHARGE:
[**2107-9-12**] 07:50AM BLOOD WBC-7.2 RBC-3.24* Hgb-9.7* Hct-30.2*
MCV-93 MCH-30.0 MCHC-32.2 RDW-14.4 Plt Ct-613*
[**2107-9-12**] 07:50AM BLOOD Glucose-117* UreaN-11 Creat-0.5 Na-139
K-3.7 Cl-104 HCO3-24 AnGap-15
[**2107-9-12**] 07:50AM BLOOD Lipase-251*
[**2107-9-12**] 07:50AM BLOOD Calcium-9.4 Phos-4.9* Mg-1.9
IMAGING/STUDIES:
EGD [**2107-9-3**]: Impression: [**Doctor First Name **]-[**Doctor Last Name **] tear (injection,
endoclip)
Esophagitis
Granularity and erythema in the stomach body
Otherwise normal EGD to third part of the duodenum
CT ABD/PELVIS W/O CONTRAST:
1. No abdominal/retroperitoneal hemorrhage.
2. Ill-defined peripancreatic stranding is compatible with
patient's known history of pancreatitis. No peripancreatic
fluid or fluid collection to suggest peripancreatic hemorrhage
or pseudocyst formation. This unenhanced exam is limited for
the evaluation of necrotizing pancreatitis.
3. Hepatomegaly with diffuse hepatic steatosis.
4. Internal contents of the gallbladder measure 23 [**Doctor Last Name **],
intermediate density, and may represent sludge.
5. Normal caliber bowel loops and appendix. Normal terminal
ileum.
Brief Hospital Course:
28 yo F with h/o alcoholism, multiple episodes of acute
pancreatitis, presenting with acute pancreatitis and hematemesis
from two [**Doctor First Name 329**] [**Doctor Last Name **] tears.
# Hematemesis- On admission the patient was admitted to the
Medical ICU and underwent an emergent EGD which showed [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] tears likely secondary to profuse vomiting over last 3
days and no evidence of portal gastropathy. She continued to
have melenatotic stools with no evidence on CT scan of
retroperitoneal bleed and underwent a repeat EGD on [**9-5**] which
showed while one clip was intact, the other had come off and
there was a clot on that tear. She was treated with PPI drip x
24 hours and then switched to po BID. She received 5units of
pRBC between [**9-3**] and [**9-5**]. She was called out of the ICU and
remained stable on the med floor. However, she took a long time
before she started tolerating POs but was tolerating a regular
diet and her exam, while still tender, was back at baseline. The
pt refused both CT w/ contrast w/ premedication for her allergy
as well as MRI as did not believe they would be useful and did
not want to have her lip piercing taken out. She was counselled
to have the test done as an outpt.
# Alcoholic pancreatitis- BISAP score 0. Patient has a history
of 3 prior episodes of alcoholic pancreatitis requiring
hospitalization, last in 1/[**2106**]. Past imaging has been negative
for cholelithiasis and pseudocysts. She was treated with
aggressive IV hydration, vitamins and was NPO and diet was
advanced to clears and then to regular diet before dc. She
tolerated regular diet for several days prior to dc.
# Thrombocytopenia- Platelets drop >50% from last check in [**2106**].
In the ICU this was stable and was not further worked up. It is
likely due to her alcohol use.
Was 613 at time of dc.
# Alcohol abuse- she has significant alcohol abuse. She was
monitored on a CIWA scale for the first 3 days of her admission.
Social work was consulted and recommended rehab. The pt was set
up to see rehab as an outpt.
TRANSITIONAL ISSUES:
1. THE PT NEEDS [**Name (NI) 36068**] WITH OUTPT RESIDENT PCP (DR [**Last Name (STitle) **]); IS
SEEING NP THIS WEEK
2. DURATION OF PPI NEEDS TO BE READRESSED BY GI DOCTOR
3. ALCOHOL ABUSE COUNSELIING AND RESOURCES NEED TO BE PROVIDED
4. CT W/ CONTRAST OR MRI SHOULD BE CONSIDERED AS OUTPT IF STILL
HAVING PAIN
Medications on Admission:
none
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Q12 Disp #*60 Tablet
Refills:*0
2. Sucralfate 1 gm PO QID
Please start on [**2107-9-6**]
RX *Carafate 1 gram 1 tablet(s) by mouth four times a day Disp
#*80 Tablet Refills:*0
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN PAIN
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Q8
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
[**Doctor First Name **] [**Doctor Last Name **] TEAR
ACUTE PANCREATITIS
ALCOHOL ABUSE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms [**Known lastname 36069**],
You were admitted to [**Hospital1 18**] for vomitting up blood which was
found to be due to a tear in your esophagus likely due to your
alochol intake. You got an endoscopy which clipped your
esophageal tears. You were treated medically and improved slowly
after several days of bowel rest and intravenous fluids.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2107-9-15**] at 10:20 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15353**], NP [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2107-10-5**] at 8:30 AM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 2762, 2851, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1999
} | Medical Text: Admission Date: [**2113-8-7**] Discharge Date: [**2113-8-10**]
Date of Birth: [**2069-12-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2113-8-7**]
Catherization for Anterior STEMI (3VD, LAD 99%):
Cypher drug eluting stent in proximal LAD
History of Present Illness:
43 y/o Caucasian man s/p stent [**2105**] presented to [**Hospital1 5979**] ED c/o jaw pain beginning 40 minutes prior to presenting
to OSH. Pt reports having 2 alcoholic beverages and later had
burning in his chest which felt like "heart burn". Pt reports
burning in jaw bilaterally and mild diaphoresis. He denied CP,
arm pain, or shortness of breath. Pt denies anginal episodes or
CP since intervention in [**2105**].
In [**Hospital3 **] ED an EKG show ST elevation in the anterior
leads, V1-V5 and ST depression in II, III, and aVF. Pt went
into Vfib arrest, shocked (200J, 300J, 360J) and started on
amiodarone gtt, integrillin gtt and transferred to [**Hospital1 18**] cath
[**Hospital1 **].
Past Medical History:
CAD s/p PCI [**2105**]
Social History:
Tobacco: 0.5 pack X 15 years
EtOH: 1qwk
Limited exercise
Publisher of a magazine, lives in [**Location 5028**] with wife
Family History:
Mother w/ CAD
Physical Exam:
Physical Exam (on admission)
VS T97.1 P76 BP124/69 RR20 O2Sat88%4LNC->93% on face tent
GENERAL: NAD, lying flat in bed w/ face tent, speaking in
complete sentences.
HEENT: PERRL, EOMI, MMM
NECK: Supple, JVP 7cm,
CARDIOVASCULAR: S1, S2, Reg, no murmurs
LUNGS: CTAB by anterior exam only due to sheath in place
ABDOMEN: Active bowel sounds, obese, soft, NT, ND, no HSM.
EXTREMITIES: DP/PT 2+ bilat. Cool feet bilat. Otherwise, UE
warm, well-perfused.
NEURO: A/OX3, strength and sensation grossly intact
Pertinent Results:
[**2113-8-7**] 11:02PM BLOOD WBC-19.3* RBC-4.48* Hgb-14.5 Hct-41.4
MCV-92 MCH-32.4* MCHC-35.1* RDW-13.2 Plt Ct-352
[**2113-8-7**] 11:02PM BLOOD Glucose-151* UreaN-15 Creat-1.0 Na-142
K-4.0 Cl-111* HCO3-20* AnGap-15
[**2113-8-7**] 11:02PM BLOOD ALT-97* AST-194* LD(LDH)-439*
CK(CPK)-2665* AlkPhos-72 TotBili-0.7
.
[**2113-8-8**] 06:20AM BLOOD CK(CPK)-3863*
[**2113-8-8**] 01:00PM BLOOD CK(CPK)-3442*
[**2113-8-9**] 06:31AM BLOOD CK(CPK)-1792*
.
[**2113-8-7**] 11:02PM BLOOD CK-MB-319* MB Indx-12.0* cTropnT-3.44*
[**2113-8-8**] 06:20AM BLOOD CK-MB-461* MB Indx-11.9* cTropnT-7.30*
[**2113-8-8**] 01:00PM BLOOD CK-MB-308* MB Indx-8.9* cTropnT-7.23*
[**2113-8-9**] 06:31AM BLOOD CK-MB-47* MB Indx-2.6 cTropnT-4.38*
.
[**2113-8-7**] 11:02PM BLOOD Calcium-8.4 Phos-2.4* Mg-1.8
[**2113-8-8**] 06:20AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.2
[**2113-8-9**] 06:31AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.7
.
[**2113-8-7**] 09:35PM BLOOD Type-ART O2 Flow-10 pO2-57* pCO2-37
pH-7.33* calHCO3-20* Base XS--5 Intubat-NOT INTUBA
Comment-NON-REBREA
[**2113-8-9**] 06:31AM BLOOD WBC-13.6* RBC-3.98* Hgb-12.6* Hct-36.7*
MCV-92 MCH-31.8 MCHC-34.4 RDW-13.5 Plt Ct-243
.
[**2113-8-7**] ECG
Sinus rhythm. There are Q waves in leads VI-V2 with ST segment
elevations of one to two millimeters in leads I, aVL and VI-V5
consistent with acute
extensive anterolateral myocardial infarction. Generalized low
QRS voltage. ST segment depression in leads III and aVF with
inverted T waves consistent with reciprocal changes. No previous
tracing available for comparison. Clinical correlation is
suggested.
.
[**2113-8-7**] Cath Report
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated right and left sided filling pressures.
3. Successful treatment of proximal LAD with drug-eluting stent.
4. Successful treatment of ostial D1 with balloon angioplasty.
.
[**2113-8-8**] ECHO
Conclusions:
The left atrium is mildly elongated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with hypokinesis
of the disal half of the anterior septum and anterior walls and
of the distal anterior and inferior walls. The apex is near
akinetic. The remaining segments contract well. No
intraventricular thrombus is seen and the apex is not focally
aneurysmal. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets appear structurally normal
with good leaflet excursion. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There
is no pericardial effusion.
.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD (mid-LAD lesion). Mild mitral regurgitation. EF 35%-40%
Brief Hospital Course:
43M 3V CAD here w/ anterior STEMI, s/p successful LAD cypher
stent.
* Ischemia: The patient underwent cardiac catheterization which
showed 3 vessel disease. A drug eluting stent was placed in the
proximal LAD. The patient had 2 vessel unrevascularized disease,
and which may require a re-look once he stabilizes. His enzymes
were cycled until they trended downward. His trop peaked at
7.30. At discharge it was 4.38.
The [**Hospital 228**] medical management consistent of the following:
integrillin X 18 hrs, ASA 325, Plavix 75, Lipitor 80, Metop 12.5
TID advanced to Toprol 100 at discharge and lisinopril 10mg
daily..
* Pump: The patient's cardiac index in the cath [**Hospital **] was 1.8,
this was of unclear etiology. He received lasix for diuresis in
cath [**Hospital **] due to PCWP and PAD elevation and increasing O2
requirement. He received Lasix overnight with good response.
An ECHO was later done to evaluate pump function and showed an
EF on 35-40%, with an akinetic apex. The patient was
anticoagulated with Heparin and Coumadin. At the time of
discharge he was started on Lovenox.
Other medical management included lisinopril 10 mg daily and
Toprol 100 daily.
* Rhythm: The patient maintained NSR throughout his course, but
s/p VF at OSH(suspect ischemic). He was maintained on Amiodarone
gtt initially and this was later discontinued. The patient was
monitored on telemetry with no ectopy noted.
K was kept >4 and Mg was kept >2.
* Smoking cessation: The patient was counseled on the importance
of smoking cessation as it pertained to his heart disease.
* EtOH Use: The patient was kept on a CIWA scale.
* High WBC: UA and CXR were negative. Cyst drainage on back
prior to admission may have contributed to elevated wbc. The
patient remained HD stable throughout his course.
* FEN: Cardiac heart healthy diet. K was kept > 4 and Mg was
kept > 2.
* PROPHYLAXIS: SCDs while in bed. PPI.
*DISPOSITION: The patient was discharged home with VNA teaching
for his Lovenox. He was scheduled to have his INR monitored at
his PCPs office. The patient was chest pain free and
hemodynamically stable at the time of discharge.
Medications on Admission:
none
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous once a
day: 100mg daily
.
Disp:*14 syringes* Refills:*0*
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN as needed for chest pain.
Disp:*30 * Refills:*2*
9. Outpatient [**Name (NI) **] Work
Pt is on Coumadin. INR is 1.2 on discharge [**2113-8-10**]. Pt must have
blood drawn on [**2113-8-14**]. INR therapeutic range is 1.5-2.0. Pt
must have labs drawn every 2 days until therapeutic. Thereafter
pt must have weekly blood draws. [**Date Range **] results must be reported to
PCP's office Dr. [**First Name (STitle) 6164**] 1-[**Telephone/Fax (1) 64400**] or 1-[**Telephone/Fax (1) 64401**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Myocardial infarction: Anterior ST elevation myocardial
infarction
Discharge Condition:
Good
Discharge Instructions:
Pt has been instructed that he can drive and go back to work.
He has been advised not to resume any type of strenuos activity.
Pt has been instructed to call 911 immediately if he should
have any chest discomfort, is diaphoretic, nauseous or becomes
short of breath.
Pt has been instructed to adhere strictly to medications and to
a cardiac heart healthy diet.
.
VNA services has been set up to provide the patient with
instruction on Lovenox.
.
Pt has been instructed to have blood draws initially every 2
days from date of discharge on [**2113-8-14**] until INR is therapeutic
(1.5-2.0). Thereafter, pt has been instructed to have weekly
blood draws. Therapeutic goal is 1.5-2.0
Followup Instructions:
1)Pt must follow up with Dr. [**First Name (STitle) 6164**] at [**Hospital **] Medical
Associates on [**2113-8-14**] at 9:15am.(1-[**Telephone/Fax (1) 32949**]). Pt also has
an appointment at 8:30am with the [**Telephone/Fax (1) **] to have his INR checked.
The [**Telephone/Fax (1) **] is located in the same building as Dr. [**Last Name (STitle) 15321**] office.
2)Pt must follow up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] (cardiologist) in 3
months at [**Hospital1 69**]. Appt has been
made for [**11-21**] @ 2:45pm. Location: [**Hospital Ward Name 23**] Building [**Location (un) **], [**Hospital Ward Name 516**] Tel: (1-[**Telephone/Fax (1) 920**]).
Completed by:[**2114-9-1**]
ICD9 Codes: 4271 |
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