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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2000
} | Medical Text: Admission Date: [**2177-9-21**] Discharge Date: [**2177-9-25**]
Date of Birth: [**2118-11-18**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
cardiac arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization with placement of bare metal stent to
LAD.
History of Present Illness:
58 yo M with h/o MI no intervention and AFib on coumadin,
presented after cardiac arrest that occurred while at gym this
morning. Witnesses reported that he slumped over and had
labored breathing. CPR was initiated and AED placed on patient
and he received shock for "wide complex tachycardia." He was
combative with EMS on the scene and received valium.
.
Patient presented to the ED with VS: 100.6 156/97 87 20
100%. His EKG was notable for AFib with rate in 80s, PVCs, LVH
with T wave inversions in aVL and V3-V5. He was emergently
taken to the cath lab, where he was loaded with plavix and ASA.
He received a BMS for 70% stenosis of his LAD.
.
On presentation to the CCU, he denied having chest pain or
shortness of breath. His vitals were stable and he was in AFib
with normal rate. He was given statin and started on a
beta-blocker.
.
Review of systems positive for h/o upper GI bleed in [**2168**]. 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, or hemoptysis. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations. Patient had syncopal event as
described in HPI.
Past Medical History:
Outpatient Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
.
- HTN
- question of MI in past based on [**Last Name (NamePattern1) **] results, no
intervention done
- atrial fibrillation, on coumadin
- GI bleed-[**2168**], received 4 units PRBCs; EGD showed
gastritis/esophagitis; repeat EGD in [**2173**] showed Barrett's
esophagus but no gastritis
- Zenker's diverticulum s/p Cricopharyngeal myotomy and
diverticulopexy
- hiatal hernia
- L tibial fracture from MVA [**2173**]
- nephrolithiasis
- Raynaud's phenomenon
.
Cardiac Risk Factors: +Hypertension, +Dyslipidemia (LDL 125, HDL
34 in [**2166**])
.
Cardiac History: no CABG, no pacemaker/ICD, no PCI in past
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse; he reports he drinks
on social occasions. Ex-policeman; reports he is now in
construction. Works out every day and can bench press 380
pounds.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother died of "old age," father of asbestosis
and carcinoma. Siblings with HTN.
Physical Exam:
VS: T 97.1, BP 146/85, HR 71, RR 10, O2 100% on 2L NC
Gen: Healthy-appearing middle-aged man, wearing C-spine collar
in NAD, resp or otherwise. Oriented to place and time, but
repeating questions and statements multiple times, unable to
recount events of today.
HEENT: No obvious trauma to head. Sclera anicteric. PERRL,
EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa.
Neck: Supple; difficult to assess JVP with collar in place
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, normal S1, S2. No S4, no S3. No murmur.
Chest: No chest wall deformities. Resp were unlabored, no
accessory muscle use. No crackles, wheeze, rhonchi.
Abd: +BS, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. No hematoma at R groin (cath
site)
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
ETT performed [**2173**] demonstrated:
Good functional exercise capacity. No ECG or 2D
echocardiographic
evidence of inducible ischemia to achieved workload. Mild aortic
regurgitation at rest. Moderate mitral regurgitation at rest.
.
[**Year (4 digits) **] test [**2165**] not available in OMR, but per discharge
summary:
"[**Year (4 digits) **] echocardiogram thallium with equivocal EKG changes, but
moderate reversible defect in the apical inferior wall"
.
CARDIAC CATH performed on [**2177-9-21**] demonstrated:
LAD with 70% stenosis; normal LMCA, mild luminal irregularities
in LCx; RCA with mid 30% stenosis
.
HEMODYNAMICS: BP 129/75 with HR 49
.
LABORATORY DATA:
.
Significant for K of 3.1 in ED (received 40mEq KCl)
Cr 1.3 -> 1.1
Hct 45.7 and WBC 5.7
INR 2.8
CK 329
MB 7
Trop < 0.01
.
CT head [**9-21**]:
No acute intracranial hemorrhage or mass effect.
.
CT C-spine [**9-21**]:
No evidence of an acute fracture. Small osseous fragment
adjacent to the left C4-5 facet is likely degenerative.
.
ECHO [**2177-9-22**]
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity
sizes and regional/global biventricular systolic function.
Mildly dilated
thoracic aorta. Pulmonary artery systolic hypertension. Mild
aortic
regurgitation. Mild mitral regurgitation. Is there a clinical
history to suggest an acute pulmonary process (e.g., pulmonary
embolism?).
Brief Hospital Course:
58yo man with h/o MI without intervention done, AFib on coumadin
presents after cardiac arrest.
.
1. s/p Cardiac arrest: Patient presented after having cardiac
arrest while exercising on an elliptical machine for over 20
minutes. He has a history of a fib, and was on coumadin at the
time. He had not been compliant with his beta blocker. We
restarted metoprolol, and the patient remained stable, but going
into sinus bradycardia. Pt also has history of Raynauds, and was
started on trial of carvedilol instead of metoprolol, with no
change in extremities. Patient was switched back to metoprolol
25mg the day before discharge, monitored overnight and
discharged on toprol XL 50mg. Pthad 7 beat run of NSVT while in
the hospital, and the importance of staying on a bblocker was
stressed. Several attempts were made to get the AED recording
from the [**Location (un) **] sports club gym that he collapsed at, and f/u is
being attempted even on discharge.
Pt is to followup with outpatient cardiologist, Dr. [**Last Name (STitle) **].
Outpatient Cardiac MR has also been ordered to evaluate the
contribution of possible LV scar to arrhythmia and cardiac
arrest. the patient will followup with Dr. [**Last Name (STitle) **].
.
2. CAD: Patient was cathed with the finding of a calcified
stenosis of the LAD. BMS to LAD. Patient started on aspirin and
plavix. Patient is to have a [**Last Name (STitle) **] test as an outpatient,
scheduled for [**2177-10-10**].
.
3. HTN: Patient was hypokalemic, repleted through IV, and HCTZ
stopped. Patient started on trial of lisinopril, but BP was
controlled and patient discharged on Toprol XL only.
4. atrial fibrillation: patient has a long history of atrial
fibrillation. [**Country **] score of 1, so coumadin was discontinued
given plavix and aspirin, and history of GI bleed.
.
5. h/o GI bleed: Coumadin stopped, pt on aspirin and plavix. PPI
given [**Hospital1 **].
.
6. Possible head trauma: ED note concerned for head trauma
during incident and patient with impaired mental status on
admission to CCU, as he was alert and oriented, but frequently
repeating same questions, phrases. Likely due to period of
anoxia during arrhythmic arrest. No acute process on CT imaging
of head.
Medications on Admission:
Coumadin
Lopressor--pt admits he has not been taking this
HCTZ
Lipitor
Viagra
.
ALLERGIES: Demerol--nausea, vomiting
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Succinate 50 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*
Discharge Disposition:
Home
Discharge Diagnosis:
Cardiac arrest
Ventricular arrhythmias
Atrial fibrillation
Coronary artery disease;Coronary angioplasty and stent placement
Hypertension
Mitral Insufficiency
Raynaud's Phenomenon
Discharge Condition:
Stable, ambulating
Discharge Instructions:
You were admitted after a cardiac arrest. You had a cardiac
catheterization done, and a stent was placed in one of the
arteries that supplies your heart.
.
1. Please take all medications as prescribed.
.
2. You should never stop taking your Plavix without consulting
with your cardiologist. Stopping this medication with your
doctor's recommendation may be life threatening.
.
3. Please call your doctor or return to the hospital if you have
chest pain, palpitations, shortness of breath, fevers, or any
other concerning symptom.
.
4. We recommend that you refrain from exertional exercise until
after your [**Hospital1 **] test is reviewed with you. This includes
running or any weight lifting. Walking on the treadmill is
safe.
.
5. According to [**State 350**] state law you are prohibited from
driving for 6 months following cardiac arrest or until you are
instructed otherwise by your cardiologist.
Followup Instructions:
Please follow up with:
Your Cardiologist within 1 week: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
[**Telephone/Fax (1) 6937**]
.
We recommend that you get a [**Telephone/Fax (1) **] test:
Provider: [**Name10 (NameIs) 10081**] TESTING
Phone:[**Telephone/Fax (1) 1566**]
Date/Time:[**2177-10-8**] 2:00 p.m.
.
You have been referred for an MRI of your heart. You will be
contact[**Name (NI) **] by Radiology regarding the scheduling of this study.
.
You are recommended to undergo Cardiac Rehabilitation after your
[**Name (NI) **] test.
Completed by:[**2177-9-29**]
ICD9 Codes: 4275, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2001
} | Medical Text: Admission Date: [**2131-3-22**] Discharge Date: [**2131-3-26**]
Date of Birth: [**2087-8-23**] Sex: M
Service: PSYCHIATRY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1678**]
Chief Complaint:
" there was an
alteraction, but I aint' gonna talk about that"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 43 year old male with a self reported history of
bipolar disorder and schizoaffective disorder, who was brought
to the ED by ambulance after his mother called 911 expressing
that her son was being aggressive and was concered for her
safety. Initially upon presenation he denied any complaints to
ED doctor and reported that he wanted to be dishcarged. When
approaching
patient to interview, he reported he wanted to stay in the
hospital to focus on his "asthma and psych medications to calm
my nerves". He refused to elaborate on the incident that brought
him to the ED, becoming very hostile, but reported that "she is
trying to pull me down, get me to yell like a fool, but I ain't
gonna". Patient was intially hostile to this interviewers,
saying " I ain't gonna slap that black pussy.. don't look at me,
write this down" He appeared to be responding to internal
stimuli and sporactically yelled " shut up" to what may have
been halucinations. WHile he denied AH or VH, at one point
during the
interview reported " that person is trying to make me crazy,
being adversarial, stop me from answering your questions" and
pointed to the corner of the room. He denied any SI, HI,
reported that his mood was good, that he was sleeping and eating
well and had not other complaints
.
Spoke with patient's mother ([**Telephone/Fax (1) 103299**]) who reports she is
very concerned about her son. She reports that he has not been
acting like himself recently, has been talking to himself, gets
upset and angry very easily, and making accusations that she is
"going with a friend", telling her " to shut your mouth". She
also notes he has been acting this way on the streets and in
public. She expressed she is feeling threatened by him and
today, after he raised his voice, yelling for her to shut that,
that she called 911. She does not feel safe for him to return
home without psychiatric intervention and evaluation. She also
expresses concern that he may not have been taking his
medications and that while he denies substance use, is worried
that he may have been using.
Past Medical History:
-reports history of bipolar disorder/ schizophrenia diagnosed
when he was 17
- two hosptializations at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 103300**] and [**Last Name (LF) 42339**], [**First Name3 (LF) **]
mother, last [**Name2 (NI) 103301**] was 5 years ago see psychiatrist
Dr. [**First Name (STitle) 1169**] at [**Hospital1 2177**]
-Denies any suicide attempts in past
PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
- severe complex sleep disordered breathing with severe
nocturnal
and daytime hyopixa related to hypventiliation, followed by Pulm
- secondary erytrocythosis, being following by Haem
- asthma
- hypertension
Social History:
SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE): patient
denies
any substance use
.
SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL
ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL
HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):
Patient was born in [**Location (un) **]. Did not graduated highschool but
made it until senior year. Has worked odd jobs but nothing
recnetly. Gets SSDI. Lives with his mother and sister, but
sister doesn't want them in her house any longer due to his
behavior. Reports he spends his time watching TV and grocery
shopping.
Family History:
mother with asthma, otherwise noncontributory
Physical Exam:
VS: 98.8, P = 80, R = 19, 98% 02 sat, 150/76
MENTAL STATUS EXAM (USE FULL, DESCRIPTIVE SENTENCES WHERE
APPLICABLE)
APPEARANCE & FACIAL EXPRESSION: overweight male, with NC on
POSTURE: lying in bed
BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS):psychomotor agtiation
in terms of increased leg movement
ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): uncooperative,
hostile and at times almost threatening ( raised voice, used
fowl
language)
SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC, ETC.):
normal in rate and rhytm
MOOD: " good"
AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.):
irritable at times inapparopriate. Starting laughing at one
point, when asked why replied " I am thinking of something funny
that I can't remember now"
THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY,
CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): Tangential,
loosining of associations, very disorganized and difficult to
follow. Possible thought blocking.
THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS,
DELUSIONS, ETC.): denied
ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS): denied, but
appeared to be responding to internal stimuli, seemded to be
talking and pointing to something in the corner of the room
NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP,
APPETITE, ENERGY, LIBIDO): denied
SUICIDALITY/HOMICIDALITY (INCLUDE IDEATION, INTENT, PLAN):
denied
INSIGHT AND JUDGMENT: very poor
COGNITIVE ASSESSMENT:
SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert
ORIENTATION: x 3
ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): DOMBI
MEMORY (SHORT- AND LONG-TERM): [**4-2**] registation [**3-4**]
recall
CALCULATIONS: 7 quarters in $1.75
FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE): fair
PROVERB INTERPRETATION: grass is greener: What you
think is greener sometimes is a little less green
SIMILARITIES/ANALOGIES: table and chair: they both
have legs
.
Obese
HEENT: mmm
Pulm: decreased excursions and decreased breathing sounds
Cor: distant heart sounds, regular, no murmurs
Abd: obese, nl bs
Ext: no edema or ecchymoses
Pertinent Results:
[**2131-3-21**] 09:39AM URINE HOURS-RANDOM
[**2131-3-21**] 09:39AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2131-3-21**] 04:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2131-3-21**] 12:15AM estGFR-Using this
[**2131-3-21**] 12:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2131-3-26**] 04:06PM BLOOD Type-ART Temp-36.7 pO2-55* pCO2-92*
pH-7.23* calTCO2-41* Base XS-7 Intubat-NOT INTUBA Comment-O2
DELIVER
Brief Hospital Course:
Patient is a 43 year old male with a self reported history of
bipolar disorder and schizoaffective disorder, who was brought
to the ED by ambulance after his mother called 911 expressing
that her son was being aggressive and was concered for her
safety. Pt initially wanted to be discharged, but eventually
agreed to admission to have his "meds evaluated" as they are
making him "rambunctious". The patient continued to indicate
that his medications are not working. He signed CV upon
admission.
.
Abilify and perhenazine were discontinued, VPA was increased to
500BID and he was started on geodon at 60BID. He became somewhat
less agitated, but appeared to continue to respond to internal
stimuli. There were no outburst of violence. The plan was to
increase to geodon to 80BID, but due to respiratory
decompenstation (see below) his dose was kept at 60mg [**Hospital1 **]. For
the same reason, VPA was held. A DMH application was submitted,
as he is longer able to live with his sister, and his mother has
no place to live herself.
.
With respect to his medical problems, he has severe
hypoventilation syndrome, followed by Pulmonary (dr [**Last Name (STitle) 15371**]).
For polycythemia (baseline Hct of 62) he had been seen by Dr
[**Last Name (STitle) 2455**]. Both services were contact[**Name (NI) **] this admission. Asthma
medications and antihypertensives were continued, a statin was
added for hyperlipidemia.
At home, Mr [**Known lastname 732**] in on 2L NC O2 during the day, and is
supposed to wear BiPAP at night. Per his mom, there may be
non-compliance with BiPAP and he often walks around with an
empty O2 tank. On [**3-26**], Mr [**Known lastname 732**] became very somnulent and was
hard to arouse. He denied any shortness or breath or chest pain,
and did not have a fever. An ABG was obtained, showing severe
hypercarbic respiratory failure. A pulmonary consult was called,
and Mr [**Known lastname 732**] was transferred to the ICU for close monitoring
and titration of CPAP/O2. In retrospect, the underlying cause
may have been that Mr [**Known lastname 732**] received too much O2. The events
were discussed with his mother.
.
The plan is for Mr [**Known lastname 732**] to return to [**Hospital1 **] 4 when medically
cleared.
Medications on Admission:
per patient: Vanceil 84 mcq puff
depakote 500 mg po qhs
HCTZ 25 mg po dialy
Lisinopril 10 mg po daily
Abilify 30 mg po dialy
Perphenazine 8 mg po dialy
Discharge Medications:
HCTZ 25 mg po dialy
Lisinopril 10 mg po daily
simvastatin 20mg PO daily
Albuterol INH
Ipratropium INH
geodon 60mg [**Hospital1 **] PO
depakote 500mg [**Hospital1 **] PO on hold
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 22160**] transfer to ICU
Discharge Diagnosis:
schizoaffective disorder, psychosis, mania
hypoventilation syndrome
morbid obesity
asthma
hyperlipidemia
Discharge Condition:
respiratory failure, guarded
Discharge Instructions:
discharge to ICU
Followup Instructions:
discharged to ICU
Completed by:[**2131-3-29**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2002
} | Medical Text: Admission Date: [**2109-3-5**] Discharge Date: [**2109-3-12**]
Date of Birth: [**2051-9-26**] Sex: F
Service: SURGERY
Allergies:
Protamine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
B/L Debilitating intermittent claudication
Ischemic rest pain in her right foot
Major Surgical or Invasive Procedure:
Aortobifemoral bypass with 12 x 6 aortobifemoral femoral Dacron
graft.
History of Present Illness:
This 57-year-old lady has had severe debilitating intermittent
claudication of both her extremities for quite some time. She
recently developed ischemic rest pain in her right foot. A CT
angiogram was done which showed her infrarenal aorta to be open
with total occlusion of her left iliac system from the aortic
bifurcation to the groin, and a patent right common iliac
artery, but a totally occluded right external iliac artery. She
reconstituted common femoral arteries with patent superficial
femoral arteries distally. Because of her young
age and her severe symptoms, she has been recommended to have
bypass surgery.
Past Medical History:
PMH HTN,(echo - nl EF), PVD, Murmur, s/p tubal ligation
Social History:
rare alcohol approximately Q month and denies other
substances. Quit smoking 15 days ago after 40 years.
Pt lives with husband and one of her 3 adult sons in [**Name (NI) **] MA.
employed as a secratary
Family History:
n/c
Physical Exam:
VSS: 114/45, 62, 98.8, 97%RA, 18
GEN: NAD
CARD: RRR, +SEM
Lungs: CTA, diminished at bases
ABD: +BS, soft
Wound: Incisions C/D/I. Staples removed
Pulses: palp B/L DP/PT
Pertinent Results:
[**2109-3-11**] 05:30AM BLOOD WBC-10.4 RBC-3.59* Hgb-11.9* Hct-34.3*
MCV-95 MCH-33.0* MCHC-34.6 RDW-14.0 Plt Ct-427
[**2109-3-11**] 05:30AM BLOOD Plt Ct-427
[**2109-3-11**] 05:30AM BLOOD Glucose-87 UreaN-12 Creat-0.8 Na-137
K-4.2 Cl-99 HCO3-28 AnGap-14
[**2109-3-7**] 10:50AM BLOOD ALT-18 AST-22 AlkPhos-50 Amylase-37
TotBili-0.4
[**2109-3-6**] 05:09AM BLOOD CK(CPK)-370*
[**2109-3-11**] 05:30AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1
Brief Hospital Course:
Pt underwent aortobifemoral bypass on [**3-5**]. During surgery she
developed rapid SVT, hypotension and hypoxia, cardioverted with
restoration of a sinus brady and stabilized- possible protamine
rxn; she was kept intubated and sedated overnight.
Cardiology-Dr. [**Last Name (STitle) **] consulted. Echo obtained
POD 1: Patient extubated. Lopressor continued. Palpable DP
pulses. Remained in ICU- metabolic acidosis and T wave inversion
on ECG. Dr. [**Last Name (STitle) **] following patient for possible silent ischemia
in setting of SVT/ operative procedure. T wave inversion
resolved.
POD 2: VSS, pain controlled with MSO4 PCA. Diet advanced to
sips. Diuresis, OOB.
POD 3: Transient desaturation to 87% on 3L NC. Denies SOB. Chest
x-ray showing pulmonary congestion and right pleural effusion.
Lasix X 2 given . CTA to r/o PE performed. Negative for PE. CTA
showing mucous plug with total RLL collapse. Patient remained in
VICU, aggressive pulmonary toilet. Bronchoscopy performed.
POD 4: No overnight events, breathing improved. Psychiatry
consulted as patient is requesting DNR/DNI. patient deemed
competent and DNI ordered. Ambulating on oxygen with physical
therapy.
POD 5: VSS. No overnight events. Ambulating with physical
therapy not requiring oxygen. O2 sats >93% on room air and while
ambulating. Levaquin discontinued.
POD 6: VSS. No overnight events. B/L palpable DP/PT pulses.
Discharge to home with physical therapy. Staples removed. Will
follow up with Dr. [**Last Name (STitle) **] in [**1-27**] weeks.
Medications on Admission:
ASA 81, plavix 75, atenolol 25, dyazide
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
[**Date Range **]:*1 1* Refills:*3*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Obtain refill authorization from primary MD.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
5. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-29**]
hours as needed for pain.
[**Month/Day (3) **]:*40 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Month/Day (3) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
B/L Debilitating intermittent claudication
Ischemic rest pain in her right foot
Discharge Condition:
Good. VSS.
Cr 0.8, HCT 34.3
Palpable B/L DP pulses
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 81mg once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-26**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-29**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Call Dr.[**Name (NI) 5695**] office at [**Telephone/Fax (1) 3121**] to schedule post op
visit to be seen in [**1-26**] weeks.
Completed by:[**2109-3-12**]
ICD9 Codes: 486, 2762, 5180, 9971, 4280, 2859, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2003
} | Medical Text: Admission Date: [**2126-1-16**] Discharge Date: [**2126-1-20**]
Date of Birth: [**2044-9-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Patient was admitted for hypotension post-catheterization
Major Surgical or Invasive Procedure:
Cardiac catheterization with Graftmaster stenting x 5
History of Present Illness:
Ms. [**Known lastname 75926**] is a 81yoF w/h/o CAD s/p prior MIs and CABG
[**2110**](SVG->[**Last Name (LF) 8714**],[**First Name3 (LF) **], LIMA->diagonal, LAD) c/b pseudoaneurysm
formation at her SVG. In [**2118-4-4**] she underwent thrombectomy
and stenting x 4 of the SVG to the OM at [**Location (un) 20338**] Community
Hospital with three Wall stents and one Tristar stent. In [**2118**]
the patient had her proximal RCA stented. Prior catheterization
in [**2120**] had revealed [**2-5**] pseudoaneurysms (1-1.5cm) of the SVG to
the OM. Most recently a CXR revealed evidence of a hilar mass.
Follow up CT reported the pseudoaneurysms to be enlarging. She
was referred for cardiac catheterization at [**Hospital1 18**] on [**2125-12-3**]
which confirmed these aneurysms. Cardiac MR was then completed
which showed 6.3x5x5cm pseudoaneurysm w/ significant thrombus
accumulation w/ mild compression of the main and left pulmonary
artery as well as a smaller pseudoaneurysm but preserved
intraluminal flow. Plavix and aspirin were discontinued and she
was discharged to home with plans for return for compassionate
use of a Jomed covered stent. She was reloaded with 300mg Plavix
on [**2126-1-15**] and Aspirin was restarted.
.
She returned for [**Hospital1 18**] for catheterization today. In the cath
lab she had evidence of extravasation of contrast into the
mediastinum which resolved following Graftmaster stents x5.
Following cath, patient became vagal and hypotensive with groin
pressure and was noted to have a significant hematocrit drop to
21.2. Her Hct on admission was 41 and most recent value of 39
[**2125-12-4**].
.
Upon arrival to the CCU, patient complaining of significant
nausea which improved w/ IV Zofran. The patient otherwise
denies any recent complaints. She has felt well recently except
for "the flu" a few weeks ago. She denies any chest pain, SOB,
orthopnea, PND, LE swelling, presyncope or syncope, joint pains,
cough, hemoptysis, black stools or red stools.
Past Medical History:
PAST MEDICAL HISTORY:
Cardiac Risk Factors: Hypertension, Hyperlipidemia
.
Cardiac History:
CABG ([**Hospital1 2025**]) in 4/93 anatomy as follows:
SVG to OM, LIMA to diagonal and LAD (70% narrowing of proximal
second marginal artery, 60% narrowing of anterior descending
artery, 70% narrowing of first septal and first diagonal branch)
-s/p MI x3
-s/p PTCA [**4-/2118**]: 3 Wall stents and 1 TriStar stent placed in
severely diseased and degenerated SVG to OM, EF >60%
-s/p Cardiac Cath [**8-5**]: patent LIMA to LAD, patent SVG to AOMB
with 50-60% stenosis at the ostium (not hemodynamically
significant), RCA 75% stenosis proximally s/p Penta stent
placement
-s/p Cardiac Cath [**1-6**]: patent LIMA to LAD, patent SVG to OM
with 60% stenosis at the ostium, and patent RCA, EF >60%
-[**2-5**] aneurysms/pseudoaneurysms of proximal mid segment of SVG to
OM found in [**1-6**] cardiac cath
.
Other Past History:
-COPD (mild)
-h/o Factor 8 Deficiency
-h/o asthma
-h/o depression
-s/p endovascular stent graft repair of infrarenal AAA [**1-6**],
stents placed endovascularly in aorta and in left common iliac
artery
-"head aneurysm"
-s/p lumbar disc surgery
-s/p left breast biopsy for lump
-s/p total abdominal hysterectomy, bilateral
salpingo-oophorectomy
-s/p appendectomy
Social History:
Social history is significant for the absence of current tobacco
use as of 1/[**2125**]. Prior to that she smoked 6 cigarettes/day for
many years. She has a history of alcohol abuse, but is
currently sober for [**5-11**] yrs. Denies illicit drug use. Lives in
[**Hospital3 **] w/her husband. There is no family history of
premature coronary artery disease or sudden death.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 95.0, BP 127/68, HR 97, RR 23, O2 97% on RA
Gen: Elderly female in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP low.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2.2/6 holosys murmur at LLSB. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi appreciated anteriorly.
Abd: Midline lower surgical scar. +BS. Soft, NTND, No HSM or
tenderness. Mobile superficial 2-3 cm mass below the umbilicus
which is nontender. No abdominial bruits.
Groin: Sheath in place in R groin. R groin soft w/o obvious
hematoma. Scar over L groin.
Ext: LE warm. No cyanosis or edema.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
+actinic keratoses on LE
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
1+ PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
1+PT
Pertinent Results:
ADMISSION LABS:
[**2126-1-16**] 06:01PM BLOOD WBC-11.6* RBC-3.50* Hgb-10.2*# Hct-29.8*#
MCV-85 MCH-29.3 MCHC-34.4 RDW-13.7 Plt Ct-114*
[**2126-1-16**] 11:45AM BLOOD Plt Ct-101*
[**2126-1-16**] 06:01PM BLOOD K-4.0
CARDIAC ENZYMES
[**2126-1-19**] 11:30PM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2126-1-20**] 07:30AM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2126-1-19**] 11:30PM BLOOD CK(CPK)-28
[**2126-1-20**] 07:30AM BLOOD CK(CPK)-26
ECG [**2126-1-16**]: Sinus tach @ ~100. Nl axis and intervals. TWF in I,
aVL.
CARDIAC CATH performed on [**2126-1-16**] (see report for further
details):
PA sat 69%, CO 3.39, CI 2.18, RA 2, RV 17/2, PA [**11-6**], PCWP 1
SVG->OM w/ large aneurysmal disease w/ serial dilation and free
extravasation into the mediastium. Ostial 80% stenosis
s/p Graftmaster stenting x 5 w/ stoppage of all angiographic
evidence of leakage
Brief Hospital Course:
Ms. [**Known lastname 75926**] was admitted after her cardiac catheterization with
hypotension, likely multifactorial in origin. Low filling
pressures were noted on right heart catheterization, and her Hct
was significantly lower on admission than prior values
suggesting blood loss and hypovolemia. She was also in
considerable pain after the procedure, and it is possible
increased vagal tone also contributed to her hypotension.
Following the cathterization, she was transfused three units of
RBC's. Hct stabilized overnight and blood pressures normalized
to 100-110's/50-60's with the transfusions and IVF boluses.
On [**2126-1-19**], Ms. [**Known lastname 75926**] complained of substernal chest pain that
came on at rest. Two sets of cardiac enzymes were negative and
she had no new EKG changes concerning for ischemia. Her chest
pain was relieved with morphine and Imdur (she gets headaches
with SLNG), and no further intervention was performed.
Medications on Admission:
asa 325 mg daily
plavix 75 mg daily (300 mg on [**2126-1-15**])
lipitor 80 mg daily
lasix 20 mg daily
Toprol XL 50 mg daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary Diagnoses
1. Vein graft aneursym s/p stenting
2. Anemia
3. CAD
Secondary Diagnoses
1. COPD
Discharge Condition:
HD stable, Hct stable.
Discharge Instructions:
You were admitted to the hospital for a cardiac catheterization.
Your blood pressure was low after the catheterization likely
from blood loss, and you were given 2 units of red blood cells.
Your blood pressure improved.
The following changes have been made to your medications:
1. You are now taking Toprol XL 25 mg daily (half of your
previous dose)
2. You should not take your lasix. You should discuss
restarting this with Dr. [**Last Name (STitle) 911**]
3. You were started on Imdur 30 mg daily.
If you develop chest pain, shortness of breath, dizziness,
bleeding from your groin site, fevers, or any other concerning
symptoms, you should call your doctor or come to the emergency
room.
Please take all of your medications as directed.
Please keep all of your follow up appointments.
Followup Instructions:
You should follow up with your cardiologist, Dr. [**Last Name (STitle) 911**], in [**1-6**]
weeks. Please call([**Telephone/Fax (1) 24798**] to schedule an appointment if
you are not contact[**Name (NI) **] by his office directly.
Please follow up with your Primary Care Provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in
[**12-5**] weeks. You can call [**Telephone/Fax (1) 10688**] to schedule an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2004
} | Medical Text: Admission Date: [**2161-3-26**] Discharge Date: [**2161-4-4**]
Date of Birth: [**2106-6-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Wellbutrin / Lipitor
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain and shortness of breath
Major Surgical or Invasive Procedure:
[**2161-3-30**] Coronary artery bypass graft x3 (Left internal mammary
artery > left anterior descending, saphenous vein graft > obtuse
marginal, saphenous vein graft > posterior descending artery)
History of Present Illness:
54 year old woman who has been increasingly short of breath.
She was recently
cathed and found to have multi-vessel coronary artery disease.
She was transferred to [**Hospital1 18**] for surgical evaluation.
Past Medical History:
Coronary artery disease
OSA using CPAP
Diabetes mellitus type 2
hyperlipidemia
hypothyroidism
pernicious anemia
bilateral S1 radiculopathy
tubal ligation
tonsillectomy
Social History:
Lives with:husband, sons
Occupation:office worker
Tobacco:smoked 1-1/2 packs per day for 30 years, quit 8 years
ago
ETOH:does not drink EtOH
Family History:
mother died at 51 yrs old of MI
father with CABG at unknown age
sister with multi-vessel angioplasty age 58
brother diagnosed with heart disease at age 61 years
Physical Exam:
Pulse:89 Resp:18 O2 sat: 89 B/P 122/74
Height: 5'3" inches Weight:252 lbs.
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 [] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit Right: - Left: -
Discharge
VS: T: 98.5 HR: 88-97 SR BP: 103/60 Sats: 94% RA WT: 112 Kg
General: NAD
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2
Resp: decreased breath sounds with bibasilar crackles
GI: obese, bowel sounds positive, abdomen soft non-tender
Extr: warm 1+ edema, LLE VV site at knee sm hematoma
Incision: sternal c/d/i stable
Neuro: AA&O x 3
Pertinent Results:
[**2161-4-3**] 04:24AM BLOOD WBC-6.5 RBC-3.31* Hgb-9.9* Hct-29.0*
MCV-88 MCH-29.9 MCHC-34.2 RDW-14.6 Plt Ct-262#
[**2161-3-30**] 01:55PM BLOOD PT-13.6* PTT-33.7 INR(PT)-1.2*
[**2161-3-30**] 12:30PM BLOOD PT-15.7* PTT-30.7 INR(PT)-1.4*
[**2161-3-26**] 07:49PM BLOOD PT-13.6* PTT-41.7* INR(PT)-1.2*
[**2161-4-3**] 04:24AM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-143
K-4.2 Cl-106 HCO3-30 AnGap-11
Intra-op echo [**2161-3-30**]
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%).
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. No mitral
regurgitation is seen. There is no pericardial effusion.
Dr.[**Last Name (STitle) **] was notified in person of the results before surgery
incision
POST-BYPASS:
Preserved biventricular systolic function. EF 55%.
Intact thoracic aorta.
Wall motions and valvular functions are all similar to
prebypass.
CXR
[**2161-4-3**]: IMPRESSION: PA and lateral chest
Atelectasis at the lung bases and small left pleural effusions
are mild
compared to the usual postoperative appearance. Normal
postoperative
cardiomediastinal silhouette. No pulmonary edema. No
pneumothorax.
Brief Hospital Course:
Transferred in from outside hospital after undergoing cardiac
catheterization that revealed coronary artery disease. She
underwent evaluation for surgery and on [**3-30**] was brought to the
operating room for coronary artery bypass graft surgery. See
operative report for further details. She was transferred to
the intensive care unit for post operative management. In the
first twenty four hours she was weaned from sedation, awoke
neurologically intact, and was extubated without complications.
She was started on betablockers and gently diuresed toward
preoperative weight. On post operative day one she was
transferred to the floor. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility.
By the time of discharge on POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home in good
condition with appropriate follow up instructions.
Medications on Admission:
ASA 81mg daily
Fish oil 1000mg daily
Imdur 30mg daily
Lescol XL 80mg QHS
Toprol XL 50mg daily
MVI
Nitrostat 0.4mg PRN
Synthroid 137mcg daily
Vitamin B12 1000/1ml SQ once per week (Sundays)
Vitamin D [**2149**] units daily
Discharge Medications:
1. Lescol XL 80 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO daily ().
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(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:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
11. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]/[**Hospital6 89815**]
Discharge Diagnosis:
Coronary artery disease s/p cabg
OSA using CPAP
Diabetes mellitus type 2
hyperlipidemia
hypothyroidism
pernicious anemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Left EVH site with slight erythema, no drainage
Edema 1+ bilateral LEs
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] - [**Telephone/Fax (1) 170**] [**2161-4-22**] 1:00
Cardiologist: Dr [**Last Name (STitle) **] on [**4-29**] at 2:30pm
Wound check appt. [**2161-4-14**], 10:15am
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 2482**] G. [**Telephone/Fax (1) 89816**] in [**3-31**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2161-4-4**]
ICD9 Codes: 5990, 2724, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2005
} | Medical Text: Admission Date: [**2101-1-14**] Discharge Date: [**2101-1-26**]
Date of Birth: [**2031-1-31**] Sex: F
Service: SURGERY
Allergies:
Shellfish Derived / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
RUQ pain, portal vein thrombus, leukocytosis, rigors
Major Surgical or Invasive Procedure:
[**2101-1-14**]: CTA Abdomen
[**2101-1-14**]: IJ line placement
[**2101-1-17**]: Thrombolysis via TPA infusion catheter via the left
portal venous branch
[**2101-1-18**]: AngioJet assisted clot lysis
[**2101-1-21**]: Sigmoidoscopy; removal of foreign body
History of Present Illness:
69 year-old female presenting with a 1-week history of diffuse
abdominal pain, chills and subjective fevers. Initially her pain
started epigastric and after 2-3 days it radiated to her entire
abdomen. She denies any nausea or vomiting, has been mildly
constipated lately, but her last bowel movement was yesterday
and it was normal. She is being transferred from [**Hospital3 4107**]
with a RUQ U/S suspicious for PV thrombosis. She had a WBC of
20.8 and was having rigors in the [**Last Name (LF) **], [**First Name3 (LF) **] received 3g of Unasyn
for concerns for cholangitis.
Past Medical History:
None
.
Past Surgical History:
tubal ligation 40 years ago
Social History:
Lives at home with ill husband, Smokes 1PPD for >50 years.
Denies any Alcohol
Family History:
Father died of bladder cancer
Physical Exam:
VS 101.4 107 108/66 22 91% RA
General: No acute Distress
Neuro: Awake, alert, cooperative with exam, normal affect,
oriented to person, place and date.
Lungs: Clear to Auscultation bilaterally
Cardiac: Regular rate and rhythm, S1/S2
Abd: Soft, nondistended, very mildly tender on the RUQ. No
guarding or [**Doctor Last Name **] sign.
Extrem: Warm, well-perfused, no edema
Pertinent Results:
On Admission: [**2101-1-13**]
WBC-19.0* RBC-3.61* Hgb-11.4* Hct-33.2* MCV-92 MCH-31.5
MCHC-34.2 RDW-14.3 Plt Ct-285
PT-14.4* PTT-35.9* INR(PT)-1.3* Fibrino-673*
Glucose-91 UreaN-31* Creat-1.1 Na-126* K-7.9* Cl-93* HCO3-20*
AnGap-21*
ALT-36 AST-84* AlkPhos-191* TotBili-1.9* Lipase-22
Albumin-3.0* Calcium-8.6 Phos-3.7 Mg-2.4
[**2101-1-14**] HBsAg-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2101-1-16**] CEA-4.9* AFP-1.6 CA [**09**]-9 33
WBC trend:
[**2101-1-14**] WBC-11.5*
[**2101-1-17**] WBC-16.2*
[**2101-1-19**] WBC-24.5*
[**2101-1-20**] WBC-20.7*
[**2101-1-21**] WBC-25.8*
[**2101-1-24**] WBC-20.0*
[**2101-1-25**] WBC-27.4*
[**2101-1-26**] WBC-14.8*
Brief Hospital Course:
69 y/o female who presents from OSH with evidence of portal vein
thrombus on ultrasound. An ultrasound was performed on admission
to [**Hospital1 18**] showing thombosed left portal vein. Main portal and
right portal veins are patent. there is a normal gallbladder
with no gallstones. The liver is diffusely echogenic compatible
with fatty infiltrate. A CTA was then obtained to further
delineate the extent of thrombus, which showed the left portal
and anterior right portal vein thrombosis. Small thrombus
extends into the main portal vein. The posterior right portal
vein remains patent. The SMV and the splenic veins are patent.
No discrete pancreatic
mass. There is also a 6 mm left lower lobe pulmonary nodule
which would be concerning due to patients 50 pack year history
of smoking.
The patient was immediately started on a heparin drip and was
given 2 days of Unasyn due to concerns for cholangitis. Blood
and urine cultures taken on admission have been finalized with
no growth. In the meantime coverage was broadened to Vanco and
Levaquin. An echo was performed showing no evidence of
vegetations and an EF > 65%.
She was noted to have worsening abdominal pain, and on [**1-16**], a
repeat abdominal CT was obtained showing progression of the
previously noted portal vein thrombosis, which now involved the
posterior right portal vein. There was marked delayed periportal
enhancement without biliary dilatation, with findings concerning
for septic thrombophlebitis. Perforation of sigmoid colon by an
intraluminal foreign body is suggested as etiology by the
imaging findings; as there is no provided
history of any hepatobiliary stenting, there is the possibility
of an ingested foreign body.
On [**2101-1-17**] the patient underwent attempted thrombolysis. Portal
venogram demonstrating completely occluded left portal vein.
Partial filling defect noted in a branch of the right portal
vein suggestive
of partial thrombus. She had successful placement of a TPA
(Alteplase) infusion catheter via the left portal venous branch
for overnight thrombolytic infusion and was transferred to the
SICU overnight for monitoring. On [**1-18**] a pre-procedure venogram
showed no decrease in the clot. She then had a Post-AngioJet
clot lysis venogram demonstrating total clot lysis in the
branches of the right portal vein. Residual clot is still noted
in the left portal vein. The left portal vein appears small in
caliber, with little forward flow. The heparin drip was
restarted and she was able to be transferred back to the regular
surgical floor.
The thrombus remnant was sent for culture, there was no growth
obtained from this specimen.
On [**1-19**] the antibiotic coverage was changed, the levaquin was
d/c'd and Zosyn was started.
Her respiratory status was worsening, she had developed
inspiratory and expiratory wheezes, and chest xrays indicated
concern for new bilateral opacities, likely pneumonia with para
pneumonic effusions, right greater than left. Lasix was started.
Over the next few days her respiratory status improved and on
[**1-25**] a chest xray was obtained showing there is some decrease
in the still present bilateral pleural effusions with
compressive atelectasis at the bases. The pulmonary vascularity
has returned to an almost normal state.
Another CT of the abdomen was done on [**1-25**] showing increased
perihepatic and perisplenic ascites. Since [**2101-1-16**], there has
been interval removal/resolution of thrombi at the distal main
portal vein and the proximal right posterior branch, the right
posterior portal vein is now widely patent and the left portal
vein and anterior branches of the right portal vein are not
opacified with IV contrast and likely thrombosed. This is
unchanged since [**2101-1-16**].
As the patient was having persistently elevated WBC, with all
negative blood and urine cultures as well as the thrombus, the
central line was removed, and she was also switched to PO
Augmentin which should continue for an additional two weeks. The
WBC came down to 14.8 and she remained afebrile.
Medications on Admission:
None
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) VIAL Inhalation Q6H (every 6 hours).
5. ipratropium bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
8. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day:
PLEASE CHECK INR EVERY 2 DAYS UNTIL INR STABLE. THEN PER
ROUTINE.
.
Disp:*150 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Portal vein thrombosis
Pneumonia
Diverticulitis
Foreign body removal from colon
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). With oxygen requirement
Discharge Instructions:
Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills,
nausea, vomiting, diarhea, constipation, signs of bleeding to
include nosebleed, dark/tarry stool or bright red blood per
rectum or easy bruising, inability to take or keep down food,
fluids or medications, increased abdominal pain or any other
concerning symptoms. Be on lookout for worsening pulmonary
status
Monitor the INR at least twice a week until stable, patient will
need anticoagulation for the foreseeable future, and will need
follow up with a coumadin clinic or her PCP once discharged to
home
No heavy lifting
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2101-2-9**]
10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2101-1-26**]
ICD9 Codes: 486, 5119, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2006
} | Medical Text: Admission Date: [**2143-4-8**] Discharge Date: [**2143-4-11**]
Service: MEDICINE
Allergies:
Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin
/ hydrochlorothiazide
Attending:[**Last Name (NamePattern1) 13129**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 F with PMH of metastatic breast ca, HTN, and dCHF who
presented to the ED with respirtory distress and HTN to the
190's.
.
She recently presented with similar symptoms of hypertensive
urgency c/b pulmonary edema requiring a brief intubation from
[**Date range (3) 96701**], then again from [**Date range (1) 96702**] for similar
presentation. During her admission on [**2143-3-6**], her home
nifedipine was discontinued and she was started on a BP regimen
of carvedilol/ lasix/ lisinopril. She was readmitted about a
week after with similar symptoms and findings consistent with
CHF exacerbation in setting for fluid overload, hypertension,
and flash pulmonary edema. She responded to BIPAP, lasix, nitro
gtt. She was discharged on Carvedilol 25mg by mouth twice a day.
The lisinopril was stopped at the time. Her discharge wt was
58.9 kg. She recently saw her PCP, [**Name10 (NameIs) 1023**] [**Name11 (NameIs) 15618**] her lasix to
40mg on [**2143-3-29**], and planned to restart her lisinopril later.
.
On the day of this admission, pt was shopping when she felt
sudden onset of SOB. She was BIBEMS placed on BIPAP in the
field. Found to be hypertensive to 190s sbp.
.
In the ED: VS: HR115 BP170/90 RR35 100% on BIPAP. EKG with no
acute changes with an old LBB and CXR with pulm edema. Pt was
given Aspirin, Nitro gtt, vancomycin, and 40 mg iv furosemide.
She also got vanc and zosyn as CXR could not exclude PNA. She
put out 950cc. She was initially going to be admitted to the CCU
for Bipap, but she was able to be weaned off the bipap and was
conversing comfortably on 4L NC. She was felt to be appropriate
for the floor. VS prior to transfer: 150/75 75 18 97% on 4L. On
nitro gtt with bp in the 130's
.
On arrival to the floor patient reports she is feeling much
better and no longer feel short of breath. She reports that she
has had no weight gain at home (weight was 60kg at home, dry
weight here 59kg). She denies increased [**Location (un) **] but states that her
legs are always swollen and slightly red on both sides.. At
baseline she sleeps in a recliner.
.
On review of systems, she denies any prior history of stroke,
TIA, 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, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK
FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Breast Cancer with mets to lung and bone, including skull
bone, stable on anti-estrogen therapy, primary oncologist (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN
dissection.
- H/o DVT on Fragmin (has h/o allergy to Lovenox), currently
dosed via [**Company 2860**] as part of a study protocol
- Hypertension
- [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**]
- OA - severe glenohumeral osteoarthritis plus other joints
- LUMBAR SPONDYLOSIS/SPINAL STENOSIS
- GERD
- Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant
- Past Cdiff Pos ([**2139**])
.
PAST SURGICAL HISTORY - per OMR
- s/p bilateral TKA
- L hip replacement, pins in right hip, most recent surgery [**1-17**]
yr ago
- S/p TAH in [**2098**]
Social History:
She lives alone in [**Location (un) 96700**] and is very active at
baseline, independant in all ADL's, dives. Ambulates without
assisance. Spends Mon/Fri at the cultural center, Tues playing
trumpet in a band, and Weds/Thurs running erands. Has 3 cars at
home and drives. Retired teacher. Never married and without
children. Smoked 2ppd x 10-15 years until [**2094**], glass of wine
<1x/week. No other drug use. No services at home currently.
-Tobacco history: Past use, stopped [**2094**]
-ETOH: <1 glass/wk
-Illicit drugs: None
Family History:
Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **]. Father died at 49 from
coronary thrombosis. Sister with [**Name2 (NI) 499**] cancer. Another sister
with pancreatic cancer. Niece and nephew (in same family) both
with [**Name (NI) 4278**]. She is last surviving relative. HCP is his
lawyer.
Physical Exam:
On Admission:
VS: T=98 BP=159/66 on 215mcg nitro gtt HR=72 RR=24 O2 sat=97% on
4L
GENERAL: Well apeparing elderly F in NAD, breathing comfortably
and talking in complete sentences without difficulty
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Slightly dry MM
NECK: Supple with JVP of 8 cm.
CARDIAC: S1 S2 heard but difficult to discern over 4/6 systolic
murmurs heard best at LUSB
LUNGS: MOderate kyphosis, XRT mapping on skin, hard breast
tissue. Crackles at bases but otherwise good air movement.
ABDOMEN: Soft, NTND
EXTREMITIES: Warm, well perfused, 2+ pitting edema to knees
bilaterally with chronic venous stasis changes.
SKIN: no rashes, + venous stasis changes
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
On Discharge:
VS: T=98.3 BP= 149/62 (120s - 140s/50s -70s) HR= 55 (65s-70s)
RR=18 O2 sat=97% on RA
Is&Os: Yesterday - 1620/2450 First 8 hour shift - 0/600
Weight: 61.8 <- 61.5
GENERAL: Well apeparing elderly F in NAD, breathing comfortably
and talking in complete sentences without difficulty
HEENT: NCAT. Sclera anicteric.
NECK: Supple, JVP not elevated.
CARDIAC: S1 S2, 3/6 systolic murmur
LUNGS: Moderate kyphosis. No accessory muscle use. Few basilar
crackles.
ABDOMEN: Soft, NTND
EXTREMITIES: Warm, well perfused, 1+ pitting edema
SKIN: no rashes, + venous stasis changes on LE b/l
GU: Foley catheter in place, urine appears grossly bloody
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
Pertinent Results:
Admission labs:
[**2143-4-8**] 08:10PM BLOOD WBC-8.2# RBC-4.61 Hgb-12.3 Hct-39.4
MCV-85 MCH-26.8* MCHC-31.4 RDW-15.7* Plt Ct-332
[**2143-4-8**] 08:10PM BLOOD Glucose-202* UreaN-29* Creat-1.2* Na-136
K-6.0* Cl-96 HCO3-26 AnGap-20
[**2143-4-8**] 08:10PM BLOOD Calcium-9.0 Phos-6.7*# Mg-2.7*
Discharge labs:
[**2143-4-11**] 04:35AM BLOOD WBC-6.3 RBC-3.58* Hgb-9.7* Hct-29.6*
MCV-83 MCH-27.0 MCHC-32.6 RDW-16.4* Plt Ct-261
[**2143-4-11**] 04:35AM BLOOD Glucose-107* UreaN-36* Creat-0.9 Na-138
K-4.1 Cl-100 HCO3-26 AnGap-16
[**2143-4-11**] 04:35AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2
Other pertinent labs:
[**2143-4-9**] 03:30PM BLOOD CK(CPK)-92
[**2143-4-9**] 05:35AM BLOOD CK(CPK)-106
[**2143-4-9**] 03:30PM BLOOD CK-MB-4 cTropnT-0.02*
[**2143-4-9**] 05:35AM BLOOD CK-MB-6 cTropnT-0.04*
[**2143-4-8**] 08:10PM BLOOD cTropnT-0.01 proBNP-[**2104**]*
[**2143-4-9**] 05:35AM BLOOD TSH-2.9
[**2143-4-8**] EKG:
Very marked baseline artifact. Sinus tachycardia, rate 103.
Intraventricular conduction delay with left bundle-branch block
pattern and secondary ST-T wave changes. Compared to the
previous tracing of [**2143-3-18**] probably no diagnostic interval
change.
[**2143-4-8**] Portable CXR:
CHEST, AP: There has been increase in diffuse interstitial and
airspace
pulmonary opacities, with confluent opacification in the left
upper lobe and lingula, as well as the right perihilar region.
Moderate cardiomegaly is unchanged, with a tortuous and
calcified aorta. There are probable small bilateral pleural
effusions. The bones are diffusely demineralized, with
multilevel degenerative changes.
IMPRESSION: Increased pulmonary opacities, likely representing
worsening
congestive heart failure, although underlying consolidation from
infection/aspiration, mass is not excluded.
Renal ultrasound with doppler:
IMPRESSION:
1. Normal kidney size bilaterally. Incidental 8-mm right
angiomyolipoma.
Incomplete assessment of right renal vasculature but normal
brisk upstroke
arterial waveforms noted.
2. Normal left kidney with normal arterial and venous waveforms.
3. No evidence of renal arterial stenosis in either kidney.
Brief Hospital Course:
86 F with PMH of metastatic breast ca, HTN, and dCHF who
presented to the ED with respirtory distress and hypertensive
urgency initially requiring bipap. Patient now breathing
comfortably, blood pressure improved.
ACTIVE ISSUES
1. Acute Pulmonary Edema: Likely related to hypertensive
emergency as patient presented with SBPs in 190's. Patient had
crackles to mid lung field, peripheral edema, and evidence of
volume overload on CXR. Initially patient was placed on bipap
in ED, butro gtt and iv lasix. Weaned quickly off bipap in ED
and was admitted to the cardiology service. Patient initially
diuresed with IV lasix and blood pressure was controlled with
nitro gtt. Weaned off nitro gtt. Blood pressure control improved
(see below). Patient diuresed well with IV lasix boluses and
was transitioned to PO lasix. At discharge she was breathing
comfortably on room air and her peripheral edema had improved.
She was instructed to reduce sodium intake and weigh herself
every day.
2. Hypertensive emergency: Patient has had three recent
hospitalizations for CHF likely related to hypertensive
emergency/urgency. Patient was initially treated with nitro
gtt. Her home dose of carvedilol was continued. Lisinopril
dose was increased from 10 mg daily to 30 mg daily. Patient was
started on spironolactone 25 mg daily. Prior to discharge
patient's blood pressure control improved.
Work-up for secondary causes of hypertension was initiated in
hospital. Patient had normal TSH. She also had renal artery
ultrasound without evidence of renal artery stenosis.
3. Anemia: Patient had HCT drop on admission, but remained
stable in the 29 - 30 range after admission. She had some
hematuria with from foley trauma at admission, but not enough
hematuria to explain drop. Patient's HCT remained stable.
Stools were guaiac negative. Please continue outpatient anemia
work-up.
4. Acute Renal Failure: On admission, creatinine was slightly
elevated likely from poor forward flow in setting of acute
diastolic CHF. Improved to baseline on day 2 of admission.
5. CAD: No documented cath in report, low suspicion for CAD.
Troponin elevated likely in setting of demand ischemia. Peaked
at 0.04 and came down to 0.02. Patient had no chest pain.
CHRONIC/INACTIVE ISSUES
1. Breast CA: patient had been on oupatient regimen of
Fluoxymesterone but unable to obtain from manufactuer.
Patient's oncologist is aware and she will follow-up with her
oncologist.
2. CODE: Patient wished to be DNI but not DNR. This was
discussed with patient as it is difficult to resuscitate someone
without intubating. This should be further addressed with
patient.
TRANSITIONAL ISSUES:
1. Hypertensive emergency: Initiated work-up for secondary
causes of hypertension with TSH (normal) and Renal ultrasound
with dopplers that did not show renal artery stenosis. Patient
to continue endocrine work-up for secondary causes of
hypertension as outpatient.
Medications on Admission:
Aspirin 81 mg qd
Omeprazole 20 mg qd
Fluoxymesterone 10 mg [**Hospital1 **] - unable to get from manufactuer for
last several months, so not taking
Carvedilol 25 mg [**Hospital1 **]
Furosemide 40 mg qd
Scopolamine base 1.5 mg Patch q72 hr
Roxicet 5-325 mg q6 prn pain - patient states she is not taking
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
Monday [**2143-4-15**]. Please check chem 10. Fax results to:
Name: [**Last Name (LF) 2204**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Phone: [**Telephone/Fax (1) 2205**]
Fax: [**Telephone/Fax (1) 7922**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY: Acute on chronic diastolic congestive heart failure
exacebation, hypertensive emergency
SECONDARY: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Ms. [**Known lastname 96703**].
You were admitted to the hospital because your blood pressure
was very high, you had too much fluid in your lungs, making it
difficult for you to breathe. You were given medications to help
remove the fluid from your body as well as lower your blood
pressure. You felt much better and did not need any
supplemental oxygen to breath. You blood pressure is also much
better.
Please have your blood drawn on Monday [**4-15**] prior to your
doctor's appointment on Tuesday [**4-16**] so that your doctor has
the information prior to your appointment.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please make the following changes to your medications:
1. Increase your dose of lisinopirl to 30 mg daily from 10 mg
daily
2. Increase your dose of lasix to 40 mg twice a day from 40 mg
daily
3. ADD aldactone 25 mg daily
Please see below for your follow-up appointments.
Followup Instructions:
Department: [**State **]When: TUESDAY [**2143-4-16**] at 4:40 PM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: CARDIAC SERVICES
When: WEDNESDAY [**2143-4-24**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], 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: 5849, 4280, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2007
} | Medical Text: Admission Date: [**2133-11-9**] Discharge Date: [**2133-11-12**]
Date of Birth: [**2054-4-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Patient is a 79 yo female with PMH significant for HTN, COPD who
presented to OSH with acute onset of SOB on [**2133-11-5**]. She was
C/o of mild discomfort on the sides of her upper abd after which
the SOB started suddenly. Initially she thought that she was
having a panic attack but then she became diaphoretic and cold.
Daughters called 911 and she was taken to [**Hospital3 934**]
hospital. Her initial O2 sat were 88% on 4L O2 and was afebrile.
CXR showed extensive B/l alveolar infiltrates more on the rt
side. A prelim diagnosis of CHF with COPD exacerbation was made
and she was started on morphine, lasix and solumedrol levaquin,
ceftriaxone and nebulizers. She was put on BiPaP for her resp
distress and subsequently was intubated. CTA was negative for
PE. An echo performed revealed MVP with severe MR. At the
request of the family the pt is transferred to [**Hospital3 **].
ROS: Generalized fatigue for the past few months. Cough with
blood for about 2 months. Abd gas pain. No h/o CP, palpitaions,
dizziness, syncope, orthopnea, PND or pedal edema. Daughters say
that the pt has lost significant weight in the last few months.
Past Medical History:
1)COPD predominant emphysema
2)Hypertension
3)Glaucoma
4)Cataract
5)Osteoporosis
6)Seasonal Allergies
7)Anxiety
8)Arthritis
Social History:
Lives alone. Daughter lives nearby. Very active and current
smoker with 1ppd since age 16.
Family History:
Non-contributory
Physical Exam:
vitals Temp 100 HR 93 RR 24 BP 96/56 O2 sat 94%
(Vent with 50%FiO2 and 7 PEEP)
Gen-Intubated and sedated. Responds to commands
HEENT - PERRL, neck supple, JVD not appreciated
Lungs - CTA b/l
CVS - S1 soft, S2 normal, regular, palpable systolic thrill in
apex which is displaced laterally. Grade [**4-2**] holosystolic murmur
at apex
Abd - soft, nontender, BS+
Neuro - Sedated but arousable (unable to perform further neuro
exam)
Ext - B/l pedal edema, pulse++
Pertinent Results:
[**2133-11-9**] 06:50PM BLOOD WBC-8.3 RBC-3.25* Hgb-10.7* Hct-30.0*
MCV-92 MCH-33.0* MCHC-35.8* RDW-13.1 Plt Ct-183
[**2133-11-9**] 06:50PM BLOOD PT-12.8 PTT-21.8* INR(PT)-1.1
[**2133-11-9**] 06:50PM BLOOD Glucose-139* UreaN-29* Creat-0.6 Na-143
K-4.1 Cl-108 HCO3-30 AnGap-9
[**2133-11-9**] 06:50PM BLOOD CK(CPK)-295*
[**2133-11-9**] 06:50PM BLOOD Mg-2.5
[**2133-11-10**] 02:55AM BLOOD Triglyc-111 HDL-50 CHOL/HD-2.8 LDLcalc-67
[**2133-11-9**] 07:01PM BLOOD Type-ART Temp-37.8 pO2-87 pCO2-55*
pH-7.35 calTCO2-32* Base XS-2
.
ECHO [**2133-11-10**]
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%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is severe mitral
valve prolapse. There is partial mitral leaflet flail. Severe
(4+) mitral regurgitation is seen. The mitral regurgitation jet
is eccentric. The tricuspid valve leaflets are mildly thickened.
Tricuspid valve prolapse is present. Severe [4+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a small to moderate sized pericardial
effusion. The effusion appears loculated. There is brief right
atrial diastolic collapse. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling.
Impression: mitral and tricuspid valve prolapse with flail
mitral leaflets; severe mitral and tricuspid regurgitation with
hyperdynamic left ventricular contractile function
.
Brief Hospital Course:
This is 79 y/o f with wide open MR, CHF and pnumonia. She was
admitted to the CCU.
.
1) Cardiac:
Patient was admitted to the coronary care unit for management.
Her fentanyl drip was increased to provide sedation for the
insertion of an arterial line. After the procedure the patient
developed hypotension which was subsequently reversed by
naloxone. She was later started on nipride drip for persistent
hypotension.
Pt had cardiac cath which showed normal coronaries with elevated
pressures. A decision to take the patient for mitral valve
replacement surgery was made after discussion with the family
and therefore B/l chest tubes were placed to drain the pleural
effusion post cath. Hct dropped from 26.4 to 24.6 after chest
tube insertion and the pt received 1 unit of PRBC. Later the
family reconsidered their decison and the patient's daughter who
is also the health care proxy refused surgery. With the wishes
of the family the patient was then extubated and she maintained
spontaneous ventilation. We were able to communicate with her
and she expressed that she did not want any kind of intervention
to prolong her life including ET tube, chest tube or any
surgery. Subsequently after discussion with the family the pt's
status was changed to comfort measures only and she was started
on morphine drip.
.
2) Pulmonary:
She was also started on antibiotics (Ceftriaxone and
Azithromycin for pneumonia) and maintained on the ventilator.
She was oxygenating adequately. As noted previously she was
extubated and code status changed to CMO.
.
The patient expired on comfort measures only on Thursday evening
([**2133-11-12**]).
Medications on Admission:
Zyrtec 10mg daily
Lorazepam 0.5mg 1 daily
Timolol gel 1 drop each eye
Alphagan eye drops
Mavik 4mg daily
Fosamax 1 weekly
Rhinocort nasal spray
Tylenol
Vit E and C
Calcium + Vit D
Aspirin 81 mg daily
Mucinex
Discharge Medications:
(Expired)
Discharge Disposition:
Expired
Discharge Diagnosis:
Severe Mitral Regurgitation with congestive heart failure
Pneumonia
Chronic Pulmomary Obstructive disease
Discharge Condition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2133-11-16**]
ICD9 Codes: 486, 4280, 4240, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2008
} | Medical Text: Admission Date: [**2149-5-27**] Discharge Date: [**2149-6-3**]
Date of Birth: [**2085-5-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
bradycardia
Major Surgical or Invasive Procedure:
Cardioversion
History of Present Illness:
Mr [**Known lastname **] is a 63 year old gentleman with recent CABG x 2 and
MVR (OnX mechanical valve)/ MAZE/PFO closure admitted for
hypotension and bradycardia s/p DC cardioversion for
aflutter/atach. Per [**Name (NI) **], pt was recently admitted in [**2149-4-5**]
for subtherapeutic INR. During that admission, he was found to
be in aflutter. At that time he was on Toprol Xl and amiodarone.
Per the patient, amiodarone was then discontinued. Given his
multiple recent surgeries, DC cardioversion was thought to be
the best option for rhythm control. The patient himself has not
had symptoms of tachycardia, no CP, no SOB.
.
The patient underwent DC cardioversion with sedation. He then
became hypotensive and was bradycardic in a junctional rythm. He
was placed on dopamine and recovered his blood pressure. He was
subsequently admitted to the ICU for observation. Currently he
states that he felt dizzy after cardioversion, but now feels
well.
Past Medical History:
[**1-14**] complex cardiac surgery:
-- artifical MV placed
-- Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to Diag)
-- Patent Foramen Ovale closure
-- [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation
-- MAZE procedure
Atrial Fibrillation
Endocarditis - source thought to be dental abscesses
Chronic Obstructive Pulmonary Disease
Asthma
Gout
Anxiety
s/p cataract surgery
Social History:
Quit smoking in [**10/2148**] after 2ppd x 50yrs. Denies ETOH use.
Family History:
Non-contributory
Physical Exam:
Vitals: afebrile BP 114/89 HR 83 R 14 Sao2 97% RA
GEN: well appearing in NAD
HEENT: no JVD
CVS: well healed, midline chest scar RRR, mechanical S2, [**3-12**]
diastolic murmur
Resp: CTAB, no labored breathing
EXT: no edema
Neuro: Aox3
Pertinent Results:
[**2149-5-27**] 09:54PM BLOOD WBC-10.4 RBC-4.83 Hgb-13.6* Hct-40.5
MCV-84 MCH-28.1 MCHC-33.6 RDW-16.8* Plt Ct-254
[**2149-5-29**] 04:10AM BLOOD WBC-8.7 RBC-4.15* Hgb-11.9*# Hct-34.7*
MCV-84 MCH-28.8# MCHC-34.4# RDW-16.7* Plt Ct-225#
[**2149-5-27**] 09:54PM BLOOD Neuts-68.3 Lymphs-24.1 Monos-6.1 Eos-1.1
Baso-0.4
[**2149-5-27**] 12:10PM BLOOD INR(PT)-2.0*
[**2149-5-28**] 06:00AM BLOOD PT-13.7* PTT-21.6* INR(PT)-1.2*
[**2149-5-29**] 04:10AM BLOOD PT-22.6* PTT-63.7* INR(PT)-2.2*
[**2149-5-27**] 09:54PM BLOOD Glucose-133* UreaN-21* Creat-1.1 Na-141
K-3.8 Cl-104 HCO3-30 AnGap-11
[**2149-5-29**] 04:10AM BLOOD Glucose-95 UreaN-17 Creat-0.8 Na-142
K-4.2 Cl-107 HCO3-26 AnGap-13
[**2149-5-28**] 06:00AM BLOOD CK(CPK)-54
[**2149-5-28**] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2149-5-27**] 09:54PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
[**2149-5-29**] 04:10AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.1
Brief Hospital Course:
This 69 year old gentleman with a history of afib, COPD and
endocarditis underwent CABG x 2, mechanical MVR, closure of
patent foramen ovale, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation and MAZE procedure
on [**2149-1-13**] s/p DC cardioversion with subsequent hypotension and
bradycardia.
.
# Rhythm: The patient was admitted with afib/flutter for DC
cardioversion. After cardioversion the patient was hypotensive
to SBp 80's and bradycardic with a junctional rhythm of 40's. He
was placed on dopamine. Just after cardioversion, he felt dizzy
but was assymptomatic from then on. He was weaned off the
dopamine. Intially, he remained in a junctional rythm but he
sinus node then recovered to a sinus bradycardia with occaisonal
pauses. He was able to increase his HR to 60's with walking and
did not feel lightheaded or weak with excercise. Pacemaker
implantation was discussed with the pt who declined and strongly
desired to avoid device implantation. His beta blocker was
stopped.
.
# Valves: Prosthetic Mitral Valve, no acute issues. His goal INR
is 2.5-3.5. Heparin gtt was started with a low INR and coumadin
held in setting of possible pacemaker placement. Coumadin was
restarted when it was decided not to place a pacemaker. He was
kept in hospital on heparin until his INR reached 2.5; it
reached 2.6 on the day of discharge.
.
# CAD/Ischemia: no acute issues. He was maintained on ASA and
statin. BB was discontinued.
.
# Pump: Mild chronic systolic heart failure at baseline w/o
exacerbation. No signs of fluid overload on exam. Intially lasix
was held in the setting of hypotesion. It was restarted when his
blood pressure recovered.
- holding lasix and BB in setting of hypotension
.
# COPD: No excerbation. The patient was maintained on home
regimen.
.
#Contact: [**Name (NI) 553**] [**Last Name (NamePattern1) 174**] (Friend) [**Telephone/Fax (1) 9003**]
Medications on Admission:
Aspirin 81mg daily
Ranitidine 150mg [**Hospital1 **]
Toprol xl 75mg daily
Lasix 40mg daily
Multivitamin daily
Singulair 10mg daily
Coumadin as per the [**Hospital 18**] [**Hospital 197**] clinic
Lipitor 20mg daily
Colace 100mg PRN
[**Doctor First Name **] 180mg daily
Ambien 10mg PRN for sleep
Albuterol inhaler
Advair disc 250-50 1 disc twice a day
Colchicine prn for gout flares
Spiriva inhaler daily
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*180 Capsule(s)* Refills:*0*
7. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*270 Tablet(s)* Refills:*2*
8. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed. Tablet(s)
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*3 inhalers* Refills:*0*
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*3 Disk with Device(s)* Refills:*2*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*90 caps* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
13. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY16
(Once Daily at 16).
Disp:*90 Tablet(s)* Refills:*2*
14. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
16. Outpatient Lab Work
Please check INR and notify the [**Company 191**] coumadin clinic of results.
Discharge Disposition:
Home
Discharge Diagnosis:
atrial fibrillation/Atrial Flutter
Junctional Rhythm
Bradycardia
Hypotension
Hypertension
anticoagulation for mechanical valve
Discharge Condition:
Good. Ambulating, afebrile, tolerating PO.
Discharge Instructions:
You were admitted to the hospital to undergo a procedure which
would eliminate your atrial fibrillation. After the procedure,
your heart rate was extremely low and you needed to be
transferred to the CCU for closer monitoring. Over 48 hours,
your heart rate gradually increased.
.
Please take your medications as prescribed. Please do not take
your metoprolol XL (toprol XL) because this will slow your heart
rate even further. Your doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 9004**] to restart this
medication at some point later. You were started on a new blood
pressure medication called lisinopril.
.
You should have your INR checked on Thursday [**2149-6-5**] and
sent to your coumadin clinic/PCP [**Name Initial (PRE) 3726**].
.
Please follow-up as described below.
Please see your PCP or go to the emergency room if you have
fevers over 102, chills, chest pain, trouble breathing,
lightheadedness or any other symptoms which are concerning to
you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2149-6-10**] 2:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2149-6-17**] 1:40 PM
Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2149-9-23**]
9:45
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], cardiology: make an appointment in
six months by calling [**Telephone/Fax (1) 285**].
ICD9 Codes: 4589, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2009
} | Medical Text: Admission Date: [**2135-12-21**] Discharge Date: [**2135-12-28**]
Date of Birth: [**2070-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Esophageal Adenocarcinoma
Major Surgical or Invasive Procedure:
[**2135-12-21**] 1. [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy.
2. Laparoscopic jejunostomy.
3. Buttressing of intrathoracic anastomosis with thymic
fat.
4. EGD
5. Bronchoscopy
History of Present Illness:
The patient is a 65-year-old gentleman with a T2, N0 cancer of
the gastroesophageal junction. He is being admitted for
esophageal
resection.
Past Medical History:
Hypertension
CVA without residual
Social History:
He quit smoking 15 years ago. He was also a heavy alcohol user,
but quit 25 years ago. He lives at home with his wife. [**Name (NI) **]
states that he does some yard work, but is not that physically
active.
Family History:
Significant for mother with heart problems, father with a
stroke. Brother with cancer, which she believes is a melanoma.
Physical Exam:
VS: T 98.0 HR: 72 SR BP: 112/66 Sats: 97% RA
General: 65 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur/gallop or rub
Resp: crackles right 1/3 up, left crackles LLL
GI: benign. J-tube site clean
Incision: Right minimal invasive site clean well approximation
Neuro: non-focal
Pertinent Results:
[**2135-12-26**] WBC-9.4 RBC-3.85* Hgb-12.0* Hct-34.8 Plt Ct-182
[**2135-12-24**] WBC-9.4 RBC-3.69* Hgb-11.3* Hct-33.3 Plt Ct-132
[**2135-12-21**] WBC-15.1 RBC-4.23* Hgb-13.1* Hct-38.7 Plt Ct-154
[**2135-12-27**] Glucose-132* UreaN-19 Creat-0.8 Na-142 K-4.1 Cl-105
HCO3-30
[**2135-12-26**] Glucose-136* UreaN-17 Creat-0.8 Na-142 K-4.5 Cl-104
HCO3-32
[**2135-12-21**] Glucose-159* UreaN-18 Creat-1.1 Na-140 K-4.2 Cl-103
HCO3-28
[**2135-12-27**] Calcium-8.5 Phos-2.8 Mg-2.1
[**2135-12-27**] Esophagus Study:
1. No evidence of leak.
2. Free flow of barium through to the third part of duodenum.
[**2135-12-27**]: CXR: sm right basilar hydropneumothorax, small
bilateral effusions.
Brief Hospital Course:
Mr. [**Known lastname 3321**] was underwent successful, [**Known lastname 12351**] [**Doctor Last Name **]
esophagectomy, Laparoscopic jejunostomy, Buttressing of
intrathoracic anastomosis with thymic fat, EGD
Bronchoscopy. He transferred to the SICU intubated and
subsequently extubated.
Respiratory: Aggressive pulmonary toilet, nebs and IS were
continued. Over the course of his hospitalization the nasal
cannula O2 was titrated off. His room oxygen saturations were
in the high 90's.
Chest-tube: the right chest tube was removed on [**2135-12-27**]
following the esophagus study. The chest tube site required
suturing.
Cardiac: he remained in sinus rhythm 70's. Prophylactic
beta-blocker were continued. Immediately postoperative he
required a fluid challenged for hypovolemia. Once stabilized
his blood pressure remained stable in the 112-130's.
GI: The NGT continued intermittent irrigation to maintain
patency. He had a moderate amount of bilious output. It
remained in place until [**2135-12-27**]. J-tube in place. Esophagus
study was done on [**2135-12-27**] which showed passage of contrast into
the small bowel without anastomotic leak.
Nutrition: He was seen by nutrition. The J-tube feeds were
started on [**2135-12-23**] Replete titrated to Goal 110 mL x 18 hrs was
well tolerated.
Pain: well controlled by Bupivacaine/Dilaudid Epidural was
managed by the acute pain service. He was converted to PO
Roxicet once the Chest tube was removed.
Incision: Right minimal invasive incisions were clean margins
well approximated. The anastomotic JP drain was removed on
[**2135-12-27**].
Neuro: he had no neurological events during this
hospitalization.
Disposition: He was followed by physical therapy who deemed him
safe for home. He continue to make steady progress and was
discharged home with VNA and tube feeds on [**2135-12-28**]
Medications on Admission:
Lipitor 80 mg daily, ASA 325 mg daily, HCTZ 25 mg daily,
lisinopril 5 mg daily, Ascorbic Acid 500 mg daily, MVI daily,
Omega-3 1,000mg daily, Vitamin E 400 unit daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Date Range **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*400 ML(s)* Refills:*0*
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
3. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2
times a day): while taking narcotics.
4. Osmolite
Osmolite Full strength; Goal rate:110 ml/hr
Cycle: start:3pm Cycle end:9am
5. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
6. Plavix 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
7. Lipitor 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: crush
and take with apple sauce.
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
10. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once
a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Esophageal adenocarcinoma
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 your feeding tube sutures become loose or break: please tape
tube securely.
If your feeding tube falls out, save the tube, call the office
immediately.
The tube needs to be replaced in a timely manner because the
tract will close within a few hours.
Do not put any medication down the tube unless they are in
liquid form.
Daily weights: keep a log and bring it to your appointment with
Dr. [**First Name (STitle) **]
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**1-10**] 9:30am on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**]
Clinical Center [**Location (un) 24**]. Chest tube suture remvoval at time of
visit
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment
Completed by:[**2135-12-28**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2010
} | Medical Text: Admission Date: [**2155-1-27**] Discharge Date: [**2155-1-31**]
Date of Birth: [**2108-5-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Wheezing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 46 year old male with PMH of asthma and
morbid obesity, who presented to an OSH on [**2155-1-27**] with
complaint of wheezing and DOE x 2 days. Patient reports onset
of SOB, wheezing, and fevers on [**1-25**]. His PCP had prescribed
amoxicillin, but patient denied any improvement in his symptoms.
On presentation to the OSH, the patient was noted to be in
respiratory distress, with a room air O2 sat of 91%. ABG was
noted to be 7.34/53/69. He was placed on a 50% face mask, and
he was administered prednisone, Levofloxacin, and
bronchodilators. He was transferred to [**Hospital1 18**] for further
management.
Past Medical History:
1. Asthma- no history of intubation. Last flare ~7 years ago.
2. HTN
3. Morbid obesity
Social History:
The patient lives with his wife, children, and mother-in-law.
[**Name (NI) **] quit smoking on [**2154-1-25**]. He smoked 1.5 packs per day x 20-30
years. He drinks alcohol occasionally. Denies illicit drug
use.
Family History:
NC
Physical Exam:
VS: T: 100.4 BP: 154/64 HR: 101 RR: 20 O2 sat: 95% on 50%
face mask
General: Obese male lying in bed in mild respiratory distress.
Patient is able to speak in full sentences
HEENT: MMM. Oropharynx clear.
Neck: Supple. No LAD.
CVS: Distant heart sounds, tachy. No murmurs appreciated.
Lungs: Diffuse insp and exp wheezes throughout, moderate air
movement.
Abd: Obese, soft, NT, +BS.
Extr: No c/c/e. Warm.
Pertinent Results:
WBC Hgb Hct MCV Plt Ct
10.5 14.1 40.5 91 293
Neuts Bands Lymphs Monos Eos
78.4* 16.9* 4.0 0.3 0.3
Glucose UreaN Creat Na K Cl HCO3
113* 12 0.8 138 3.7 100 30*
Calcium Phos Mg
8.6 3.7 2.2
UA ([**1-28**]):
Color Appear Sp [**Last Name (un) **]
Straw Clear 1.025
Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks
NEG NEG TR NEG NEG NEG NEG 6.5 NEG
Micro:
[**1-27**]: Influenza A DFA: POS
Sputum ([**1-27**])
GRAM STAIN (Final [**2155-1-28**]):
[**10-28**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Pending):
Blood cx x 2 ([**1-28**]): pending
Urine cx ([**1-28**]): pending
Radiology:
CHEST (PORTABLE AP) [**2155-1-27**] 10:54 AM
Large size habitus of patient, but no evidence of CHF or acute
infiltrates on portable single view examination.
CHEST (PORTABLE AP) [**2155-1-28**] 6:06 AM
Hypoventilation involving the lower lobes. No evidence of active
congestion or infiltration. No evidence of pleural effusion or
pneumothoraces.
EKG:
Sinus tach 107. Nl int, nl axis. Q III. No ST/TW changes.
Brief Hospital Course:
46 year old male with PMH of asthma, HTN, and morbid obesity,
admitted to MICU on [**1-27**] with wheezing/SOB.
1) Asthma exacerbation/influenza A: The patient was admitted to
the MICU for management of his respiratory distress. He was
placed on BiPAP overnight on [**1-27**]. He was treated for an asthma
exacerbation with steroids and bronchodilators. He continued on
Levofloxacin for treatment of tracheobronchitis. On [**1-28**], the
patient spiked a temperature of 102.4 His nasopharyngeal
aspirate came back positive for influenza A. The patient was
maintained on continous nebulizers, which have been tapered to q
4 hours. Since the patient did not tolerate BiPAP, so he was
placed on nasal CPAP (12-15 cm H2O) for likely obstructive sleep
apnea. In addition, the patient was administered Wellbutrin and
a nicotine patch to assist with smoking cessation. Given
improvement in his respiratory status, the patient was
transferred to the medical floor.
2) Smoking cessation: The patient was srtarted on Wellbutrin and
Nictoine patch.
3) OSA: He was placed on nocturnal CPAP 12-15 cm H2O with a
nasal mask. Patient's PCP (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) has been contact[**Name (NI) **]
and outpatient sleep study was recommended.
4) HTN: Captopril was titrated as necessary and the dose was
converted to Lisinopril at the time of discharge.
5) Steroid-induced hyperglycemia. Glycemic control was
maintained with RISS.
6) FEN: Low Na diet.
Medications on Admission:
Medications on admission:
Azmacort
Albuterol
Avalade
Amoxicillin
Guiafenescin
Discharge Medications:
1. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours)
for 2 weeks.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
7. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QD ().
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*7 Patch 24HR(s)* Refills:*0*
13. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days: 0n [**2-1**] and [**2-2**].
Disp:*6 Tablet(s)* Refills:*0*
14. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: on [**2-3**] and [**2-4**].
Disp:*2 Tablet(s)* Refills:*0*
15. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 days: on [**2-5**] and [**2-6**].
Disp:*4 Tablet(s)* Refills:*0*
16. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 2 days: [**2-7**] and [**2-8**].
Disp:*6 Tablet(s)* Refills:*0*
17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: [**2-9**] and [**2-10**].
Disp:*2 Tablet(s)* Refills:*0*
18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: [**2-11**] and [**2-12**].
Disp:*2 Tablet(s)* Refills:*0*
19. Respitory Therapy
please supply 1 CPAP machine with all accessories necessary for
daily overnight use.
20. oxygen please supply continuous oxygen @ 2L nasal canula.
*
Pt is hypoxic at rest 89% (RA) and desaturates to <88% (RA) on
ambulation.
21. CPAP settings please set CPAP @ 12 cm and 10 L/minute 02
in-line for nightly use.
Discharge Disposition:
Home With Service
Facility:
Respiratory Solutions
Discharge Diagnosis:
1. asthma exerbation
2. tracheobroncitis
3. obstructive sleep apnea
4. hypetension
Discharge Condition:
good
Discharge Instructions:
1. call 911 or go to the nearest ER if you experience increased
shortness of breath, chest pain, fevers, chills, or feel unwell.
Followup Instructions:
1. please call your primary care physician and pulmonologist,
Dr. [**Last Name (STitle) **], to follow up on your recent admission in the next
1-2 weeks @ [**Telephone/Fax (1) 693**].
2. You are schedule to see Dr. [**First Name (STitle) **] on [**Last Name (LF) 2974**], [**4-11**] at
2:00 pm for sleep study @ 2:00 pm on [**Location (un) **] [**Hospital Ward Name 23**] Center;
call ([**Telephone/Fax (1) 9525**] for questions.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2155-6-1**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2011
} | Medical Text: Admission Date: [**2105-12-8**] Discharge Date: [**2105-12-12**]
Date of Birth: [**2039-2-10**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 37083**] is a 66-year-old man
with a history of multiple sclerosis, deep venous thromboses
status post inferior vena cava filter, and hypertension, who
was without any past cardiac history, who initially
complained of substernal chest pain at his rehabilitation
facility on the day of admission. The patient was given
three sublingual nitroglycerins and presented to the [**Hospital1 1444**] Emergency Room, where an
electrocardiogram was taken and demonstrated [**Street Address(2) 4793**]
elevations in Leads II, III, AVF and V3 through V6. His
blood pressure was in the 80s/50s, and his electrocardiogram
changes persisted.
Therefore, the patient was taken to the cardiac
catheterization laboratory emergently. Cardiac
catheterization results indicated a left main coronary artery
without disease, a left anterior descending artery with a 99%
stenosis and thrombus. The left circumflex artery had a 95%
distal stenosis. The right coronary artery had a 90%
mid-right coronary artery lesion. The left anterior
descending and left circumflex lesions were successfully
stented, however, the procedure was complicated by several
factors:
1. The patient required defibrillation x 2 for an episode of
ventricular fibrillation at the beginning of the case.
2. The patient sustained a distal aortic dissection as the
catheter was threaded through a tight, diseased iliac artery.
The patient was brought to the Coronary Care Unit for
observation and post-catheterization care, given his
instability in the catheterization laboratory, aortic
dissection, and remaining tight lesions in his coronary
anatomy. A heparin bolus of 5000 units was given in the
Emergency Department prior to catheterization.
PAST MEDICAL HISTORY:
1. Multiple sclerosis
2. Deep venous thrombosis
3. Inferior vena cava filter x 12 years
4. Hypertension
5. Right arm fasciotomy status post intravenous dye
injection
6. Left-sided Port-a-Cath for multiple sclerosis medications
7. Personality disorder
8. Chronic constipation
9. History of pancreatitis
ALLERGIES: The patient states no known drug allergies.
MEDICATIONS ON ADMISSION: Prilosec, amoxicillin, Coumadin 2
mg by mouth daily at bedtime, Phenergan, Diltiazem 180 mg by
mouth once daily, Antivert, Baclofen, and Vicodin.
SOCIAL HISTORY: The patient is a resident at [**Location (un) 2716**] Point.
He denies smoking or alcohol use.
FAMILY HISTORY: The patient was unable to give any history
of cardiac illness in the family.
PHYSICAL EXAMINATION: The patient was afebrile, with a
heart rate of 81, respiratory rate of 13, and blood pressure
of 112/68, with oxygen saturation of 100% on room air. In
general, the patient was lying in bed, alert and appropriate,
and in no acute distress. Head, eyes, ears, nose and throat
examination indicated pupils equal, round and reactive to
light, extraocular movements intact. There was no jugular
venous distention. The lungs were clear to auscultation
bilaterally, with no wheezes, rales or rhonchi. The neck was
supple, with no jugular venous distention. Coronary
examination indicated normal S1 and S2, regular rate and
rhythm, no murmurs, gallops or rubs. The abdomen was soft,
nontender, nondistended, with normal bowel sounds. On
extremity examination, the patient had 3+ edema in his lower
extremities bilaterally, and Dopplerable pulses. His groin
site was without hematoma or bruit. Neurologically, the
patient was alert and oriented x 3.
LABORATORY DATA: Initial laboratory studies
post-catheterization indicated a white count of 5.0,
hematocrit 29.1 which was down from 39.1 prior to
catheterization, and a platelet count of 200. Chem 7 was
unremarkable. Magnesium was 1.7, and free calcium was 1.15.
CK #1 was 51, with a troponin of 1.4. CK #2 was 386 with an
MB fraction of 63 and an index of 16.3.
HOSPITAL COURSE BY SYSTEM:
1. Cardiac: The patient was observed in the Cardiac
Intensive Care Unit for arrhythmia or other signs of
hemodynamic instability following his complicated cardiac
catheterization. With the exception of one episode of five
beats of nonsustained ventricular tachycardia, no further
episodes of arrhythmia were observed, and the patient was
weaned off of a lidocaine drip. The patient did not receive
Integrilin following cardiac catheterization secondary to a
recent history of gastrointestinal bleeding. On further
questioning, the patient indicated that he has had a chronic
problem with gastrointestinal bleeding, and has had a recent
colonoscopy and upper endoscopy which were reportedly
negative. The patient was started on a beta blocker, ACE
inhibitor, Lipitor, aspirin and Plavix following cardiac
catheterization. His CK peaked at 635, with an MB fraction
of 106. Troponin peaked at greater than 50. A lipid panel
was sent, which indicated total cholesterol of 157,
triglycerides of 73, HDL of 41, and LDL of 101.
With regard to the patient's aortic dissection, he remained
hemodynamically stable, with good distal pulses.
Transthoracic echocardiogram was obtained and indicated a 30%
ejection fraction, mildly dilated left atrium, mild left
ventricular hypertrophy, apical akinesis, inferoseptal
hypokinesis, 1+ mitral regurgitation, and an anterior
pericardial fat pad.
The patient was sent for a second cardiac catheterization on
hospital day number four, with a goal of intervening upon the
right coronary artery, which had not been intervened upon in
the prior catheterization due to the various complications
during that initial study. The right coronary artery was
successfully stented in the second catheterization procedure.
Given the patient's apical akinesis, poor ejection fraction,
and history of deep venous thrombosis and inferior vena cava
filter, it was decided that the patient should be started on
long-term anticoagulation. He was therefore started on a
heparin drip as well as Coumadin 5 mg by mouth daily at
bedtime. At the time of this discharge dictation, it was
planned that the patient would be discharged on Lovenox and
Coumadin until reaching a therapeutic INR of 2 to 3, at which
point the Lovenox would be discontinued.
Throughout the hospital course, the patient reported several
episodes of chest and abdominal pain. However, with each
episode, the patient reported pain in a new location, and the
patient was not able to give a consistent description of
these various pains. Furthermore, there were no
electrocardiogram changes associated with these episodes of
pain, and the pain was thought to be non-cardiac in origin.
At the time of this dictation, it was planned that the
patient would be discharged on a regimen including aspirin,
beta blocker, ACE inhibitor, lipid-lowering therapy, Plavix,
and Coumadin. He was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
2. Hematology: The patient required three transfusions of
one unit of packed red blood cells during his hospital stay
in order to keep his hematocrit above 30. At the time of
dictation, the patient had been stable from a hematologic
standpoint for 24 hours.
3. Neurology: The patient was continued on Antivert for
multiple sclerosis.
4. Infectious Disease: The patient completed a ten day
course of amoxicillin for a urinary tract infection diagnosed
prior to admission, during his hospital course.
DISPOSITION: At the time of this dictation, the patient was
to be discharged to a rehabilitation facility at [**Location (un) 2716**]
Point. He was to receive daily INR checks until he reached a
therapeutic level of 2 to 3, at which point Lovenox would be
discontinued.
DISCHARGE DIAGNOSIS:
1. Myocardial infarction
2. Coronary artery disease
3. Hypercholesterolemia
4. Hypertension
5. Multiple sclerosis
6. Deep venous thrombosis
DISCHARGE MEDICATIONS: Coumadin 5 mg by mouth daily at
bedtime on the evening of [**12-12**], then 2 mg by mouth
daily at bedtime, Lovenox 80 mg subcutaneously every 12 hours
until INR equals 2 to 3, Plavix 75 mg by mouth once daily for
30 days, enteric-coated aspirin 325 mg by mouth once daily,
Captopril 6.25 mg by mouth three times a day, Lopressor 50 mg
by mouth twice a day, Lipitor 10 mg by mouth daily at
bedtime, Antivert 25 mg by mouth three times a day,
Peri-Colace one tablet by mouth twice a day, Protonix 40 mg
by mouth once daily.
CONDITION ON DISCHARGE: Improved.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2105-12-12**] 03:16
T: [**2105-12-12**] 03:37
JOB#: [**Job Number 37084**]
ICD9 Codes: 9971, 5990, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2012
} | Medical Text: Admission Date: [**2153-3-19**] Discharge Date: [**2153-3-22**]
Date of Birth: [**2078-8-1**] Sex: M
Service: UROLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 74 year-old
male with a history of benign prostatic hypertrophy, coronary
artery disease who presented initially to the Emergency Room
in [**2152-12-29**] due to hematuria. A cystoscopy revealed
an enlarged prostate in some areas of friability possibly
causing hematuria. A CT scan was done as part of a hematuria
workup, which revealed a left adrenal mass 7.3 by 6.0 cm.
Urine catecholamines were negative for a 24 hour urine
collection.
PAST MEDICAL HISTORY: 1. Benign prostatic hypertrophy. 2.
Coronary artery disease with an EF of 45%. 3. History of
hypercholesterolemia. 4. Sleep apnea with BIPAP. 5.
Status post knee surgery. 6. Status post carpal tunnel
release. 7. Depression.
MEDICATIONS: Zoloft 50 q.d., Terazosin 10 q.d, Lipitor 20
q.d., Diovan 160 q.d., Diltiazem 240 q.d., aspirin 81 q.d.,
Flovent spray two puffs b.i.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Afebrile. Vital signs are stable.
Cor regular rate and rhythm. Abdomen soft, nontender,
nondistended, mildly obese. Lungs clear to auscultation.
Extremities on edema.
HOSPITAL COURSE: The patient was brought to the Operating
Room on [**3-19**], where he had a left adrenalectomy
performed. The procedure was tolerated well. The patient
was transferred to the Intensive Care Unit postoperatively
for close monitoring. Upon transfer to the Intensive Care
Unit the patient was extubated on the same day. The patient
received one unit of packed red blood cells for a hematocrit
of 28. He was hemodynamically stable throughout and required
no vasopressors. The patient was transferred to the floor on
postoperative day one. The patient was also started on a
Hydrocortisone taper, which was completed by postoperative
day three. The patient was ruled out postoperatively for a
myocardial infarction by enzymes. Serial electrocardiograms
postoperatively and those all showed no acute changes.
On the floor the patient was started on a clear liquid diet
on postoperative day two. This was tolerated well and he was
advanced to a regular diet. All of his medications were
changed to oral form and his pain was adequately controlled.
Physical therapy evaluation was obtained and it was decided
that Mr. [**Known lastname 11188**] would benefit from a short stay at a
rehabilitation facility. The patient was afebrile throughout
the admission. During his hospital course his Foley catheter
was removed on postoperative day three.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Zoloft 50 mg q.d., Lipitor 20 mg
q.d., Diltiazem 240 mg po q.d., Diovan 160 mg q.d., Flomax .4
mg q.d., aspirin 81 mg q.d., Isordil 60 mg t.i.d., Percocet
one to two tab po q 4 to 6 hour, Flovent two puffs b.i.d.,
Colace 100 mg b.i.d.
DISCHARGE STATUS: Rehabilitation facility. The patient will
follow up with Dr. [**Last Name (STitle) 11189**] in approximately two to three
weeks.
DISCHARGE DIAGNOSES:
1. Status post adrenalectomy.
2. Coronary artery disease.
3. Sleep apnea.
4. Benign prostatic hypertrophy.
5. Depression.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11190**], M.D. [**MD Number(1) 11191**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2153-3-22**] 08:35
T: [**2153-3-22**] 08:44
JOB#: [**Job Number 11192**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2013
} | Medical Text: Admission Date: [**2178-1-31**] Discharge Date: [**2178-2-17**]
Date of Birth: [**2178-1-31**] Sex: F
Service: NEONATOLOG
HISTORY OF PRESENT ILLNESS: 32 [**4-27**] week twin #2 female
admitted secondary to prematurity.
32 [**4-27**] week twin #2 female born to a 32 year old gravida 6,
para 0, now 2, woman.
PRENATAL SCREENS: O positive; antibody, positive (anti E);
RPR, nonreactive; hepatitis B surface antigen, negative;
GBS, negative.
Mother with chronic hypertension treated with Aldomet.
Intravenous in [**Last Name (un) 5153**] fertilization diamniotic/dichorionic
twin pregnancy. Pregnancy complicated by cervical shortening
which was treated with a cerclage at eighteen weeks
gestation. Mother presented with premature labor beginning
two days prior to delivery which was treated with Magnesium
Sulfate. Betamethasone complete on [**2178-1-17**].
Antepartum testing on the day of delivery revealed discordant
growth and concern for fetal well being of twin #1. Twin A
#1 with a biophysical profile of [**4-28**], nonreassuring,
nonstress test, absent diastolic flow. Therefore, proceeded
to Cesarean section under spinal anesthesia.
Vigorous female who required free flow oxygen and suctioning.
Apgars were 8 at one minute and 9 at five minutes. The
infant transferred to the Neonatal Intensive Care Unit for
further evaluation and treatment for prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Weight, 1,730 grams (50th
percentile); head circumference, 30 cm (40th percentile);
length, 42.5 cm (50th percentile). Anterior fontanel, soft,
flat, nondysmorphic, palate intact. Clear breath sounds
bilaterally. No murmur. Normal pulses. Soft abdomen. No
hepatosplenomegaly. Three vessel cord. Normal female
genitalia. No hip click. No sacral dimple. Patent anus.
Active with normal tone. Good perfusion.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Infant has remained
in room air throughout this hospitalization. Initially,
infant presented with tachypnea with respiratory rate to the
80s which resolved by day of life #1. Respiratory rates have
been 40 to 60 with oxygen saturations greater than 95%.
Infant was not treated with Methylxanthine this
hospitalization. The last apnea and bradycardia was on
[**2178-2-12**].
Cardiovascularly, the infant has remained hemodynamically
stable this hospitalization. No murmur. Heart rate, 140 to
150 with mean blood pressures 45 to 50.
Food, electrolytes and nutrition, the infant was initially
nothing by mouth and was receiving 80 cc per kg per day of
D10W. Enteral feedings were started on day of life #1 and
was advanced to full volume feedings by day of life #2.
Total fluids were advanced to 150 cc per kg per day by day of
life #9. Maximum caloric density of premature Enfamil 26
calories per ounce was achieved by day of life #14. Infant
tolerated feeding advancement without difficulty. Calories
were decreased on [**2-16**] and were changed to Enfamil 24
calories per ounce or breast milk 24 calories per ounce with
Enfamil powder, taking a minimum of 130 cc per kg per day
p.o. The most recent weight is 1,985 grams. Head
circumference, 30.75; length, 42.5 cm.
Gastrointestinal, the infant received phototherapy for a
total of four days. Maximum bilirubin level of 7.3 with a
direct of 0.3.
Hematology, the infant did not receive blood transfusion this
hospitalization. The most recent hematocrit on day of
delivery was 48.4 percent. Blood type, O positive; Coombs,
negative.
Infectious Disease, the infant had an initial CBC,
differential and blood culture sent on admission which showed
a white blood cell count of 13.5; hematocrit, 48.4 percent;
platelets, 357,000; 23 neutrophils; one band. Due to
improvement in respiratory status, the infant was not treated
with antibiotics. Blood cultures have remained negative to
date. The infant was treated with Miconazole from day of
life #7 to day of life #11 for a monilial diaper rash.
Neurology, a head ultrasound on [**2178-2-4**], showed no
interventricular hemorrhage.
Sensory, hearing screening was performed with automated
auditory brain stem responses. The infant passed both ears.
Ophthalmology, the infant does not meet criteria for eye
examination.
Psychosocial, [**Hospital6 256**] Social
Work involved with family. The contact Social [**Name2 (NI) 16633**] can be
reached at ([**Telephone/Fax (1) 24237**]. Parents involved.
CONDITION AT DISCHARGE: Former 32 [**4-27**] week twin #2, now 35
weeks corrected, stable on room air.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 45979**] [**Last Name (NamePattern1) 21056**], phone
number ([**Telephone/Fax (1) 45983**].
CARE RECOMMENDATIONS:
FEEDINGS AT DISCHARGE: Breast milk 24 calories per ounce
mixed with Enfamil powder or Enfamil 24 calories per ounce,
minimum 130 cc per kg per day p.o.
MEDICATIONS: Fer-In-[**Male First Name (un) **] 2 mg per kg per day p.o.
CAR SEAT: The infant passed car seat position screening.
State newborn screens were sent on [**2-3**] and [**2-14**].
Results are pending.
IMMUNIZATIONS: The infant received hepatitis B vaccine on
[**2178-2-16**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria.
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with plans for day care
during RSV season, with a smoker in the household or with
preschool sibs.
3. With chronic lung disease.
FOLLOW UP APPOINTMENTS: Primary Pediatrician.
DISCHARGE DIAGNOSIS:
1. Prematurity, twin #2.
2. Status post rule out sepsis.
3. Status post transitional tachypnea as a newborn.
4. Status post apnea of prematurity.
5. Status post hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**First Name3 (LF) 45984**]
MEDQUIST36
D: [**2178-2-16**] 22:42
T: [**2178-2-16**] 23:13
JOB#: [**Job Number **]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2014
} | Medical Text: Admission Date: [**2128-12-30**] Discharge Date: [**2129-1-8**]
Date of Birth: [**2049-12-27**] Sex: M
Service: SURGERY
Allergies:
Latex / morphine
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
reversal of [**Doctor Last Name 3379**]
Major Surgical or Invasive Procedure:
[**2128-12-31**] Ex lap
[**2128-12-30**] [**Doctor Last Name 3379**] Reversal
[**2128-12-31**] left subclavian catheter (d/c [**1-8**])
History of Present Illness:
HISTORY: Mr. [**Known lastname 91526**] is well known to the acute care surgery
service and to me status post Hartmann procedure. He is a
78-year-old gentleman with myasthenia [**Last Name (un) 2902**] on high-dose
steroids who had a perforated sigmoid diverticulitis on
[**2128-10-12**] status post Hartmann procedure. His postoperative
course was complicated by a pulmonary embolus, and he was placed
on Coumadin and subsequently developed some GI bleeding which
was
found to be superficial venous bleeding at the level of the
stoma
that was treated. He is currently on Coumadin and low-dose
steroids for suppression of his myasthenia. He presents today
for routine followup, feels well, and is anxious to have the
stoma taken down. He has some fatigue, but otherwise doing
well.
The stoma is functioning properly. He is eating well and
moving
his bowels otherwise without
Past Medical History:
PMH:
1. Myasthenia [**Last Name (un) 2902**]
2. Hypertension
3. Asthma
4. Pulmonary embolism
5. Remote history of reflux per patient
PSH:
1. radical prostatectomy for benign BPH in [**2127-11-12**]
2. R TKR 10 years ago
3. Sigmoid colectomy with creation of hartmann's pouch
Social History:
Lives with wife who is a nurse. Retired manager of electric
company. Drinks 3 glasses wine/week. Denies tobacco or illicit
drug use.
Family History:
Father deceased [**1-13**] stomach CA. Mother deceased [**1-13**] PNA, both
in 80s.
Physical Exam:
PHYSICAL EXAMINATION: upon follow-up office visit [**2128-11-9**]
VITAL SIGNS: His temperature is 97.4, pulse is 73, blood
pressure is 130/78, respiratory rate is 14, and saturating 96%.
He has no pain. He is 5 feet 10 inches and weighs 235 pounds.
HEENT: Within normal limits.
NECK: Supple.
HEART: Regular.
LUNGS: Clear.
ABDOMEN: Soft. The stoma is pink and brown stool and gas in
the
bag. The midline incision has healed well with small area that
is granulating. It was superficially debrided of some fibrinous
tissue and covered with a wet-to-dry dressing. The remainder of
the incision is intact. There is no hernia or cellulitis.
EXTREMITIES: Warm and well perfused.
Pertinent Results:
[**2129-1-6**] 04:42AM BLOOD Hct-30.1*
[**2129-1-5**] 04:45AM BLOOD WBC-8.3 RBC-3.01* Hgb-9.0* Hct-26.9*
MCV-89 MCH-30.0 MCHC-33.6 RDW-15.5 Plt Ct-168
[**2128-12-30**] 07:18PM BLOOD Neuts-82.3* Lymphs-12.7* Monos-4.3
Eos-0.5 Baso-0.2
[**2129-1-6**] 04:42AM BLOOD PT-12.9* INR(PT)-1.2*
[**2129-1-5**] 04:45AM BLOOD Plt Ct-168
[**2129-1-5**] 04:45AM BLOOD PT-13.5* INR(PT)-1.3*
[**2129-1-4**] 04:00PM BLOOD PT-12.6* PTT-26.0 INR(PT)-1.2*
[**2129-1-6**] 04:42AM BLOOD Glucose-97 UreaN-22* Creat-1.0 Na-144
K-3.1* Cl-111* HCO3-29 AnGap-7*
[**2129-1-5**] 04:45AM BLOOD Glucose-141* UreaN-27* Creat-1.1 Na-139
K-3.1* Cl-100 HCO3-34* AnGap-8
[**2129-1-4**] 05:50AM BLOOD Glucose-104* UreaN-27* Creat-1.1 Na-145
K-3.6 Cl-108 HCO3-32 AnGap-9
[**2129-1-4**] 05:06AM BLOOD Glucose-100 UreaN-30* Creat-1.1 Na-144
K-4.7 Cl-108 HCO3-29 AnGap-12
[**2129-1-2**] 02:36AM BLOOD ALT-1126* AST-608* LD(LDH)-241
AlkPhos-27* TotBili-0.6
[**2129-1-1**] 04:09AM BLOOD ALT-1361* AST-872* LD(LDH)-385*
AlkPhos-22* TotBili-1.1
[**2129-1-6**] 04:42AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
[**2129-1-5**] 04:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0
[**2128-12-31**] 05:39PM BLOOD Lactate-1.6
[**2128-12-31**] 05:39PM BLOOD freeCa-1.16
[**2128-12-31**] 09:11AM BLOOD freeCa-1.10*
[**2127-12-31**] EKG:
Sinus rhythm. Possible inferior wall myocardial infarction of
indeterminate age. Compared to the previous tracing of [**2128-10-16**]
heart rate is slower.
TRACING #1
[**2128-12-30**]: chest x-ray:
FINDINGS: In comparison with the study of [**10-19**], there are lower
lung volumes with elevation of the left hemidiaphragm and
bibasilar atelectasis. Small pleural effusions probably are
present bilaterally. In the appropriate clinical setting, the
possibility of a basilar pneumonia would have to be considered.
Upper lungs are clear and there is no vascular congestion.
[**2128-12-31**]: ECHO:
Overall left ventricular systolic function is normal
(LVEF>55%). The ascending aorta is mildly dilated. The number of
aortic valve leaflets cannot be determined. No aortic
regurgitation is seen. No mitral regurgitation is seen. There is
no pericardial effusion.
[**2128-12-31**]: EKG:
Sinus rhythm. Compared to tracing #1 there is no significant
diagnostic
change.
[**2128-12-31**]: chest x-ray:
FINDINGS: In comparison with the study of [**12-30**], there has been
placement of Foley left subclavian catheter that extends to the
mid-to-lower portion of the SVC. Continued bibasilar
opacifications most likely reflecting a combination of
atelectasis and effusion. No evidence of pulmonary congestion or
definite pneumonia.
[**2129-1-1**]: chest x-ray:
CHEST: Since the prior chest x-ray, the endotracheal has been
removed. The
tip of the subclavian line lies in the mid-to-lower SVC. Lung
fields appear clear, no evidence of pneumonia or failure is
seen.
Brief Hospital Course:
78 year old gentleman admitted to the acute care service for
reversal of [**Doctor Last Name 3379**] pouch. His operative course was stable
with a 20 cc blood loss. He required 1 liter crystalloid
intra-op. He was extubated after the procedure and monitored in
the recovery room.
His post-operative course was complicated by hypotension and a
decreased urine output despite additional intravenous fluids.
For this reason, he was transferred to the intensive care unit
for monitoring where he required 4 liters of fluid for blood
pressure support. Neosynephrine was added to maintain his tone.
Because he had an increasing lactate level, he was taken back
to the operating room on POD # 1 for an exploratory laparotomy.
He was found to have approximately 3500 mL of old and a new clot
throughout the abdomen as well as active hemorrhage from the
left side of the distal mesocolon in the area of the previous
dissection. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain was placed in the area of the
hemorrhage. During this procedure he required 3.5 liters of
crystalloid, 2 u PRBC, and 1 u FFP as well as neosynephrine.
Afte the procedure, he was transported to the intensive care
unit for further monotoring. A bedside ECHO was done which
showed good LV and RV function. On POD #1 from the exploratory
laparotomy, he was extubated and his pressors were weaned off.
His hematocrit remained stable. Because of the additional
fluids, he was started on lasix. His vital signs stabilzed and
he was transferred to the surgical floor on POD #2.
On POD #2, his [**Last Name (un) **]-gastric tube was discontinued. He continued
on his lasix because of his generalized body edema and later
changed to diamox. The diamox was discontinued on POD #7 after
he reported feeling lightheaded. At this time, he was also
having occasional atrial and ventricular ectopy. His
electrolytes have been monitored and repleted. He was started
on clears and resumed his home medications. His intravenous
prednisone was weaned down and he transitioned to his oral home
dose. He was noted to have a bloody ooze from his drain site
and from the lower aspect of his surgical wound. This resolved
with the application of pressure. His hematocrit has remained
stable at 30.0.
His vital signs are stable and he is afebrile. He is tolerating
a regular diet without complaints of nausea or vomitting. He
has resumed his daily coumadin with an INR of 1.2. He has been
encouraged to use the incentive spirometer and has maintained on
oxygen saturation of 95% on room air. His [**Doctor Last Name 406**] drain was
discontinued on POD #7 after he was found to have a decreased
amount of drainage. The foley catheter was also discontinued on
POD #7. He has had 2 isolatd bouts of diarrhea and a c.diff
culture was ordered.
Because of his deconditioning, he was evaluated by physical
therapy for assessment of his mobility status. He is preparing
for discharge home with VNA assistance. Though his INR is 1.3
at time of discharge, up from 1.1 but not yet therapeutic; he
does not wish to restart lovenox for bridging. We discussed with
his PCP coverage, and he will return home on his home dose of
coumadin, and will call his PMD first thing on Monday morning to
assess INR.
Medications on Admission:
[**Last Name (un) 1724**]: coumadin 2.5', lovenox 120', prednisone 10', atenolol 25 mg
daily, pantoprazole 40 mg daily, mestanon 30 mg QID, Bactrim
800/160 mg M/W/F, Ca + VitD 600'
Discharge Medications:
1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO EVERY MON, WED, FRI ().
2. pyridostigmine bromide 60 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours).
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: may cause increased sedation.
[**Last Name (un) **]:*25 Tablet(s)* Refills:*0*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stool.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
please monitor PT/INR .
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
reversal of [**Doctor Last Name 3379**] pouch
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for closure of your ostomy.
You had a low blood pressure afte the procedure and you required
additional fluid and monitoring in the intensive care unit. Your
system was slow to respond to the fluids, and you were taken
back to the operating room for an exploration. You were found to
have a collection blood in your abdomen which was removed. You
did require additional blood products after the procedure and
you were monitored in the intensive care unit. Your vital signs
stabilized and you were transferred to the surgical floor where
you continued to improve. You did retain some fluid after the
procedure and you were given medication to remove it. You are
eating a regular diet and your [**Doctor Last Name **] work has normalized. YOu are
now preparing for discharge home with the following
instructions:
Please call your doctor or return to the emergency room if you
have 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.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**9-26**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Completed by:[**2129-1-8**]
ICD9 Codes: 2762, 2851, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2015
} | Medical Text: Admission Date: [**2148-9-30**] [**Month/Day/Year **] Date: [**2148-10-13**]
Date of Birth: [**2090-7-16**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / ciprofloxacin / Levofloxacin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
- removal of tunneled line
History of Present Illness:
Mr. [**Known lastname 47367**] is a 58-year-old man with a history of AML s/p
allogeneic transplant [**2142**] complicated by graft-versus-host
disease, multiple vertebral fractures and ultimately development
of paraplegia in the setting of a vertebral fracture during a
code situation. Admitted multiple times, most recently [**8-/2148**]
for bacteremia and upper resp infection (cx: staph epi) and
completed a course of vancomcyin, aztreonam. Discharged from
rehab and home (wheelchair bound) with recent clinic followup
[**9-26**] noting baseline health.
Wife also states he was in his usual state of health until the
morning of admission when she went to wake him he was more
somnolent than usual and seemed to be having difficulty
breathing taking rapid shallow breaths. His wife attributed his
somnolence to recently starting Ambion and Valium 3 days prior
to admission in addition to his home narcotic regimen of
oxycontin and dilaudid. She also noted that he looked more pale
than usual. She reports that he had a cough starting over the
weekend productive of yellow sputum. No history of fevers, and
outside of baseline pain, he had no complaints. Given his
somnolence, EMS was called and administereed narcan in the field
without improvement so he was admitted to Study hospital on
[**9-30**] for acute respiratory failure. On arrival he was afebrile,
tachycardic to 160s (sinus), hypotensive to 91/58 (though fell
to 60s-70s per wife), RR of 8, and was satting 94% on BIPAP. He
was bolused 500cc with improvement of HR to 130s. He was bolused
more NS (unclear how much) and remained hypotensive so was
started on norepinephrine 2mcg/min and given stress dose
hydrocortisone. He does have a triple lumen port, but given poor
peripheral access, an intraosseous was placed. He was given an
additional dose of narcan given continued somnolence and
transferred to the [**Hospital1 18**] at the family's request given that all
of his care has been here.
In the ED, initial VS were T 98.6 HR 128 BP 89/69 RR 17 99% on
BIPAP and initial ABG was 7.27/61/83. Labs were notable for
leukocytosis to 14.2, Trop-T: 0.18, Lactate:3.4, creatinine of
1.1 (baseline 0.6-0.8), and a grossly positive urinalysis with >
182 whites and moderate bacteria. He has an indwelling foley
catheter that was changed this past Thursday. A chest x-ray was
notable for LLL consolidation. He had received emperic
vancomycin at the OSH and received a dose of Zosyn in the ED
here.
On arrival to the MICU, patient's VS were T: 99.5 HR: 115 BP
121/69 RR 20, O2 sat 93% 100% NRB and was receiving levo at
1mcg/min on arrival. He was somnolent but arousable and oriented
x 3, but slow to answer questions. Complained of pain from the
chest up, but otherwise no complaints.
Review of systems:
(+) Per HPI. His wife notes that he did a few episodes of loose
stools. Morning headaches recently.
(-) Denies fever, chills, chest pain, chest pressure,
palpitations. Denies dark or bloody stools.
Past Medical History:
Past Medical History:
- CKD (baseline Cr 0.6-0.7)
- Hyperlipidemia
- HTN
- Type 2 DM (last A1c 6.8 [**2144**])
- Depression
- Chronic pain
- Pericardial effusion s/p [**3-23**] drainage.
- Nephrolithiasis, lithotripsy and previous nephrostomy tube and
emergent surgery to repair ureteral damage.
- Left interpolar renal lesion, followed with MRs
- Basal cell carcinoma, resected.
- Squamous cell carcinoma left cheek, s/p Mohs' 6/[**2143**].
- Multiple back surgeries: Lumbar L5-S1 surgery x 3, and
cervical spine fusion (bone graft, no hardware).
- Anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**].
- Chronic numbness, neuropathic pain in left upper extremity.
- Sleep Apnea, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**].
- Lower extremity wound, s/p debridement by plastics, grew [**Last Name (un) 2830**]
resistent pseudomonas [**7-/2147**]
ONCOLOGIC HISTORY:
- diagnosed with AML in 04/[**2142**].
- [**2143-6-24**] underwent unrelated allogeneic stem cell transplant
with busulfan and cyclophosphamide as his conditioning regimen.
- continues bactrim, voriconazole, acyclovir ppx
POST TRANSPLANT COMPLICATIONS:
- GVHD of the liver and skin. Question of pulmonary cGVHD as
often requires oxygen and steroids in the setting of respiratory
infections (h/o RSV, parainfluenza)
- paraplegia [**1-18**] vertebral fractures during code [**2147**]
- Chronic lower extremity and abdominal edema, refractory to
lasix, suspected to be GVHD
- abdominal spasm - on valium (?etiology paraplegia)
- COP/BOOP: home O2 1-2liters
- Avascular necrosis (bilateral hips and left shoulder)
- Multiple compression fractures of the spine with chronic pain
- Pulmonary embolus in [**11/2144**] and [**5-/2146**], no with IVC [**Year (4 digits) 7448**]
not on anticoagulation
- s/p L5 vertebroplasty [**3-/2145**]
- Ruptured left calf hematoma ([**9-/2146**]) complicated by MRSA
wound infection
- Influenza A [**1-/2147**]
- bilateral Achilles tendon rupture [**2147-5-23**] ( attributed to
levoflox).
Social History:
Discharged from rehab in [**2148-6-16**] and has now been living at
home wiht VNA services and aid from his wife. [**Name (NI) **] is retired,
worked as a [**Company 22957**] technician. He smoked for 40 pack years, now
quit. He denies EtOH or drugs.
Family History:
Mother died suddenly in 70s. Father died of unknown cancer. One
sister with thyroid cancer. One brother has diabetes. One sister
has [**Name (NI) 5895**].
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 99.5 HR: 115 BP 121/69 RR 20, O2 sat 93% 100% NRB
General: Somnolent, but arousable, oriented x 3, no acute
distress, answers one question before falling asleep
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
copious secretions
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Transmitted upper airway sounds bilaterally, good air
movement
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Skin laceration on dorsum of left wrist
Neuro: CN 2-12 intact, strength 5/5 in UE; paralyzed from the
waist down.
[**Name (NI) 894**] PHYSICAL EXAM
Pertinent Results:
Admission labs:
[**2148-9-30**] 11:00AM BLOOD WBC-14.2* RBC-3.56* Hgb-12.5* Hct-39.2*
MCV-110* MCH-35.1* MCHC-31.9 RDW-17.7* Plt Ct-334
[**2148-9-30**] 11:00AM BLOOD Neuts-78* Bands-7* Lymphs-6* Monos-8
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2148-9-30**] 11:00AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL
Macrocy-3+ Microcy-NORMAL Polychr-1+
[**2148-9-30**] 11:00AM BLOOD PT-9.1* PTT-28.5 INR(PT)-0.8*
[**2148-9-30**] 11:00AM BLOOD Glucose-174* UreaN-17 Creat-1.1 Na-140
K-4.0 Cl-103 HCO3-27 AnGap-14
[**2148-9-30**] 05:51PM BLOOD CK(CPK)-111
[**2148-10-1**] 02:30AM BLOOD ALT-46* AST-56* AlkPhos-106 TotBili-0.3
[**2148-9-30**] 11:00AM BLOOD cTropnT-0.18*
[**2148-9-30**] 05:51PM BLOOD CK-MB-7 cTropnT-0.16*
[**2148-10-1**] 02:30AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.5*
[**2148-9-30**] 06:29PM BLOOD Type-ART O2 Flow-15 pO2-91 pCO2-70*
pH-7.23* calTCO2-31* Base XS-0 Intubat-NOT INTUBA
[**2148-9-30**] 11:31AM BLOOD Glucose-167* Lactate-3.4* K-4.0
[**Month/Day/Year **] labs:
Micro:
[**2148-10-6**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE:
PENDING
[**2148-10-5**] CATHETER TIP-IV WOUND CULTURE- NO
SIGNIFICANT GROWTH (PRELIMINARY)
[**2148-10-5**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING
[**2148-10-4**] URINE URINE CULTURE- NO GROWTH
[**2148-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2148-10-4**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING
[**2148-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2148-10-3**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-NO GROWTH; BLOOD/AFB CULTURE-NO GROWTH
[**2148-10-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2148-10-1**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PRELIMINARY {[**Female First Name (un) **] (TORULOPSIS)
GLABRATA}; BLOOD/AFB CULTURE-FINAL; Myco-F Bottle Gram
Stain-FINAL
BLOOD/FUNGAL CULTURE (Preliminary):
[**Female First Name (un) **] (TORULOPSIS) GLABRATA.
BLOOD/AFB CULTURE (Final [**2148-10-3**]):
DUE TO OVERGROWTH OF YEAST, UNABLE TO CONTINUE MONITORING
FOR AFB.
Myco-F Bottle Gram Stain (Final [**2148-10-3**]):
BUDDING YEAST.
[**2148-10-1**] URINE URINE CULTURE-FINAL {YEAST}
URINE CULTURE (Final [**2148-10-2**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2148-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2148-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2148-9-30**] URINE Legionella Urinary Antigen -FINAL -
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2148-9-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {YEAST}
Source: Expectorated.
GRAM STAIN (Final [**2148-9-30**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): BUDDING YEAST.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH Commensal Respiratory Flora.
YEAST. MODERATE GROWTH.
[**2148-9-30**] BLOOD CULTURE Blood Culture, Routine-PENDING
Studies:
[**2148-10-6**] CT CHEST W/O CONTRAST:
[**2148-10-6**] CHEST (PORTABLE): Right pleural effusion has decreased
in size with associated improvement in adjacent right basilar
atelectasis. Multifocal areas of heterogeneous consolidation
involving the left lung to a greater degree than the right, have
slightly improved. A small hyperlucency is present in the
periphery of the left upper lobe at the level of the second and
third anterior ribs, but no discrete visceral pleural line is
identified. This may represent an area of spared lung
parenchyma from the presumed multifocal pneumonia, but attention
to this area on short-term followup radiograph may be helpful to
exclude an atypical presentation of pneumothorax, given clinical
suspicion for
this entity.
[**2148-10-6**] CHEST (PORTABLE AP): Widespread combined alveolar and
interstitial opacities affecting the left lung to a greater
degree than the right have progressed in the interval,
particularly in the right lower lung where there is also an
increasing pleural effusion with adjacent consolidation and/or
atelectasis. Small left pleural effusion also appears increased
from prior radiograph.
[**2148-10-5**] CHEST (PORTABLE AP): Status post removal of right
subclavian vascular catheter. Widespread heterogeneous combined
alveolar and interstitial opacities affecting the left lung to a
greater degree than the right, have progressed in the interval,
and may represent a multifocal pneumonia with or without
coexisting pulmonary edema. Pulmonary hemorrhage is also
possible in the appropriate clinical setting.
[**2148-10-4**] CT ABD & PELVIS W & W/O
1. No evidence of IVC or iliac vein thrombosis. IVC [**Month/Day/Year 7448**] in
place.
2. Stable lung base findings include, lingular pneumonia and
bibasal peribronchovascular nodular opacities suggestive of
aspiration. Bilateral small effusions and right lower lobe
pulmonary emboli.
3. Hepatic steatosis.
[**2148-10-2**] CTA CHEST W&W/O C&RECON
1. Right lower lobe lobar to subsegmental pulmonary acute
embolism. The most proximal portion of the filling defect is
peripheral in the artery raising the question if this could be
chronic but new since [**2148-6-16**]. There is no dilatation of main
pulmonary artery or right heart [**Doctor Last Name 1754**].
2. Worsening of bilateral multifocal pneumonia.
[**2148-10-2**] CT HEAD W/O CONTRAST
1. Limited study due to motion artifact, within this
limitation, no acute intracranial pathology.
2. Multifocal paranasal sinus and bilateral mastoid air cell
opacification.
[**2148-10-2**] BILAT LOWER EXT VEINS
No deep venous thrombosis in right or left lower extremity.
Bilateral calf edema.
[**2148-10-2**] ECHO
The left atrium is mildly dilated. 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 mildly dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
(?#) appear structurally normal with good leaflet excursion.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Right ventricular cavity
dilation with free wall hypokinesis. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function.
Compared with the prior study (images reviewed) of [**2147-5-24**], the
right ventricular cavity is now dilated with free wall
hypokinesis c/w an acute pulmonary process (e.g., pulmonary
embolism, bronchospasm, etc.).
[**2148-10-2**] ECG
Sinus tachycardia with increase in rate as compared to the
previous tracing of [**2148-6-27**]. Diffuse non-specific ST-T wave
changes are more prominent in the context of wandering baseline
and much baseline artifact. There appears to be more ST segment
depression in leads V3-V6 without diagnostic interim change.
[**2148-10-2**] EEG
This is an abnormal EEG due to disorganized and slow background
mostly consisting of mixed delta and theta suggestive of
moderate encephalopathy but non-specific etiologically. There
was no focal slowing or epileptiform discharges seen. Study
limited by electrode artifact. Recommend repeat study if
clinical concern for seizures persists.
[**2148-10-1**] CHEST (PORTABLE AP)
Previous pulmonary vascular congestion has improved, but there
is still very extensive consolidation in the left lung due to
pneumonia, without improvement, possibly worsened. Smaller
region of consolidation in the right lower lung medially is
either a second focus of pneumonia or atelectasis. Mild
cardiomegaly is stable. Dual-channel right supraclavicular
central venous set ends in the region of the superior cavoatrial
junction. No pneumothorax.
[**2148-10-1**] CHEST (PORTABLE AP)
Progressive heterogeneous opacification in the left mid and
lower lung zone is most likely pneumonia worsening since [**9-30**]. There could be a second focus of right infrahilar
pneumonia, also advancing. Cardiomediastinal silhouette is
essentially unchanged over several years. Dual-channel right
supraclavicular central venous set ends close to the superior
cavoatrial junction. No pneumothorax.
[**2148-9-30**] CHEST (PORTABLE AP)
1. Worsening opacification in the left lung base with associated
bronchial wall thickening concerning for infection.
2. Slight interval improvement in previously noted airspace
disease within the right upper lobe.
3. No definite pulmonary edema.
Brief Hospital Course:
57-year-old man with AML s/p matched unrelated allogeneic stem
cell transplant in [**2142**], complicated by GVHD on chronic
prednisone with multiple admission for infections now presents
with somnolence in the setting if increased sedative medication
use, hypercarbic respiratory distress, cough and CXR with LLL
consolidation found to have segmental PE.
# Goals of care: After frequent discussions with family and
physicians involved in the pt's case and gradual reduction in
number of interventions performed, it was decided to transition
to comfort measures only on [**10-12**]. The below medical treaments,
lab draws, and imaging procedures were held. The pt was kept in
IV morphine, tylenol, and ativan to keep comfortable. He died
peacefully on the morning of [**2148-10-13**].
# PE: Patient with tachycardia, hypoxemia, hypotensive on
admission and history of PE not anticoaguated, with IVC [**Date Range 7448**]
in place. TTE on [**10-2**] revealed large and hypokinetic RV and CTA
showed segmental PE. Unclear if acute vs. subacute given
appearance of clot on CTA. This was not present in [**Month (only) **],
however. [**Month (only) **] is a potential source of clot as LENIs were
negative. CTV showed no evidence of clot in IVC [**Month (only) 7448**]. Non
contrast head CT was without hemorrhage, so started on heparin
drip with intention to bridge to lovenox. Per discussion with
inpatient heme attending and outpatient hematologist, it was
decided that the pt's risk of hemorrhage was greater than his
risk of clot given the negative LENIs and clean IVC [**Last Name (LF) 7448**], [**First Name3 (LF) **]
heparin gtt was held. He was continued on prophylactic heparin
subc.
# Pneumonia: Productive cough followed by somnolence in the
setting of starting Ambien and Valium in addition to his home
oxycontin. CXR with LLL consolidation. Sputum gram stain with
GPCs in clusters, GPCs in pairs and chains and GNRs and yeast.
Started on vanco, [**Last Name (un) 2830**] (day 1: [**9-30**]), mica (day 1: [**10-3**]) in
consultation with ID. Due to worsening CXR, vanco was changed to
linezolid (day 1: [**10-6**]) per ID recs. Also question of possible
pulmonary congestion, so pt was started on IV lasix. On [**10-8**],
the pt appeared to have worsening WBC and respiratory distress.
He was started on ambisome and given a dose of tobramycin. The
tobramycin was thereafter uptitrated with little effect.
Antibiotics were continued despite little improvement.
# Fungemia: Yeast in urine, sputum and mycolytic blood cultures
positive. Ophtho consulted and did not see evidence of fungal
retinitis. Patient does have GVHD of conjunctiva, however. He
was continued on micafungin (day 1 = [**10-3**]) and will need two
week course following clearance of fungus. Mycolitic blood
cultures were sent daily. CXR showed nodular areas, which was
conserning for a mold pneumonia. Pt was started on ambisone for
presumed fungal pneumonia. An MR head was performed which ruled
out fungal brain extension. ENT was consulted for possible
involvement of nasal sinuses, who recommended nasal irrigation
as tolerated given sedation.
# Hypotension: He was hypotensive to 60s-70s at OSH and required
pressor support prior to transfer to the [**Hospital Unit Name 153**]. Possible sepsis
as patient met SIRS criteria with tachycardia and leukocytosis
with possible sources of infection including pulmonary given LLL
opacity on CXR and productive cough. Urine source also possible
given dirty urinalysis in the setting of indwelling catheter.
Cardiogenic shock was considered given rising troponins, but
they trended down and were likely elevated in the setting of
tachycardia. ECG was without evidence of ischemia. Hypovolemic
shock also possible given that his PO intake had been down prior
to admission and his BP was fluid responsive on admission. He
was started emperically on vancomycin and meropenem (day 1 =
[**9-30**]) for pneumonia to complete an 8 day total course (through
[**10-7**]). His urine, blood, and sputum cultures all returned
positive for budding yeast (ID is [**Female First Name (un) **] (TORULOPSIS)
GLABRATA), so he was initially started on IV fluconazole and was
later transitioned to micafungin (day 1 = [**10-3**]). Ambisome was
started and uptitrated as above.
# Hypercarbic respiratory failure/somnolence: Patient difficult
to arouse at home on AM of admission, and may have worsened
since arriving to ICU. Likely multifactorial with hypercarbia
from hypoventilation in the context of new sedating medications
(ambien and valium, in addition to home narcotics), untreated
OSA with likely CO2 retention at baseline, pneumonia, underlying
GVHD of lung and PE. Pt has expressed wishes not to be
intubated. His pneumonia and PE were treated as per above. His
dyspnea was treated with either non-rebreather, venti mask, or
bipap as tolerated in order to achieve sat > 90%. Ambien and
valium were held. However, pt continued to complain of chest
wall pain thought to be secondary to PNA and was continuously
requesting more pain medication. After a goals of care
discussion was held with pt, family, and specialists, it was
decided to make the pt comfortable and give ativant and morphine
despite hypercarbia.
# Tachycardia: Continues to be in sinus tachycardia in the 130s.
Initially in the 160s, but has improved with fluids. Likely
multifactorial with PE, pain, hypovolemia, and withdrawal from
opioids all contributing. He was given several doses of narcan
at OSH and his home narcotics were initially held in the setting
of hypotension. Morphine drip was started to relieve any pain
without any improvement in tachycardia.
# [**Last Name (un) **]: Cr 1.1 from baseline of 0.6-0.7. Unclear etiology, but
likely prerenal in the setting of septic shock (above) with
hypotension and tachycardia. Creatinine improved back to
baseline with treatment of septic shock.
# UTI: Patient has indwelling foley catheter, so would be
considered complicated infection. Has grown E. coli most
recently, though did have a negative urine culture on [**9-26**].
Continue with vancomycin and meropenem as per above.
# Troponinemia: Patient with elevated troponin at OSH, which has
risen on arrival to the [**Hospital1 18**] ED. He denies chest pain and ECG
with sinus tachycardia without ischemic changes. Likely
troponin leak in the setting of tachycardia to the 160s.
# AML s/p MUD SCT in [**2142**]: Daily CBCs were checked and there was
no evidence of reoccurance. He was continued on bactrim,
acyclovir, and azithromycin. Dr. [**Last Name (STitle) **], outpatient oncologist
following.
# Chronic GVHD : In the past his chronic GVHC has primarily
involved liver and lungs. His LFT's were mildly elevated at
OSH, but has trended down while at [**Hospital1 18**]. He was continued on
prednisone 10 mg PO daily, and ppx with with acyclovir, bactrim,
and azithromycin.
- IVIG monthly (last dose Thursday)
# Type 2 DM on insulin: Most recent A1c is 6.8 from [**2144**]. His
NPh was decreased to 10 units (from 15) due to low sugars. He
was also placed on a sliding scale.
# Hypertension: metoprolol was held given hypotension
# Clot history: Prior PEs for which he was previously
anticoagulated. Anticoagulation was discontinued in the setting
of back surgery and an IVC [**Year (4 digits) 7448**] was placed. Now with segmental
PE treated with heparin as per above.
# Right axillary mass: Noticed by oncologist Dr. [**Last Name (STitle) **] and was
planning on working up as outpatient with CT scan.
# Paraplegia: Stable during this admission. A spine consult was
called regarding further management. Per Spine, lumbar and
thoracic spine x-rays were ordered -- these showed no
significant interval change.
# Transitional issues:
deceased
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
3. Atorvastatin 10 mg PO DAILY
4. Azithromycin 250 mg PO Q24H
5. Bisacodyl 10 mg PO DAILY constipation
6. Bisacodyl 10 mg PR HS
7. Duloxetine 30 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 300 mg PO BID
12. Hydrocortisone Cream 1% 1 Appl TP QID
apply to affected areas
13. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
14. NPH 15 Units Breakfast
NPH 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. Ipratropium Bromide Neb 1 NEB IH Q6H
16. MethylPHENIDATE (Ritalin) 5 mg PO NOON
17. Metoprolol Tartrate 12.5 mg PO BID
18. Montelukast Sodium 10 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. MethylPHENIDATE (Ritalin) 5 mg PO QAM
21. Oxycodone SR (OxyconTIN) 40 mg PO BID
22. Pantoprazole 40 mg PO Q24H
23. PredniSONE 10 mg PO DAILY
24. Senna 2 TAB PO HS
25. Sodium Chloride Nasal [**12-18**] SPRY NU QID:PRN nasal congestion
26. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
27. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
28. Docusate Sodium 100 mg PO BID
29. Diazepam 5 mg PO Q8H:PRN anxiety, spasm
[**Month/Day (2) **] Medications:
deceased
[**Month/Day (2) **] Disposition:
Expired
[**Month/Day (2) **] Diagnosis:
pneumonia, fungemia
[**Month/Day (2) **] Condition:
deceased
[**Month/Day (2) **] Instructions:
deceased
Followup Instructions:
deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 0389, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2016
} | Medical Text: Admission Date: [**2107-6-17**] Discharge Date: [**2107-6-26**]
Service: CME
CHIEF COMPLAINT: The patient was admitted with a chief
complaint of hypotension and bradycardia.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
gentleman with a past medical history significant for
hypertrophic obstructive cardiomyopathy (HOCM), type 2
diabetes mellitus, hypertension, polymyalgia rheumatica, and
osteoporosis who presents with fatigue and nausea after
taking an accidental extra dose of 240 mg of sustain release
verapamil and his first ever dose of atenolol (12.5 mg).
The patient was home alone and confused about whether he had
taken his medications. He took atenolol and began to feel
fatigued and nauseated with substernal chest pain. The
patient also has been complaining of increased palpations and
vision dimming lately which precipitated the addition of
atenolol in the setting of the patient's history of
hypertrophic obstructive cardiomyopathy. The patient denies
any recent fevers, chills, sweats, shortness of breath, or
dyspnea on exertion.
After the patient began to experience these symptoms, he
phoned [**Pager number **]. On arrival of Emergency Medical Service arrival,
he was found to be hypotensive with a blood pressure of
80/60. The patient was also found to be bradycardic with a
rate of 45.
In the Emergency Department, the patient was found to have
severe sinus bradycardia versus sinus arrest and junctional
escape. He was then given calcium, insulin, glucose, 7
liters of normal saline, Glucagon, and dopamine. The patient
was subsequently intubated for airway protection. He also
had a transcutaneous temporary wire placed and was then in a
normal sinus/an accelerated junctional rhythm.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Verapamil sustain release 240 mg by mouth once per day (as
noted, the patient took and extra dose on the morning of
admission).
2. Atenolol 12.5 mg by mouth once per day (which the patient
started today).
3. Glucovance 5/500 mg by mouth in the morning and 2.5/500 mg
by mouth in the evening.
4. Hydrochlorothiazide 12.5 mg by mouth once per day.
5. Prednisone 5 mg by mouth once per day.
6. Prilosec.
7. Aspirin 81 mg by mouth once per day.
8. Novolog 6 units in the morning and 4 units in the evening.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] denies
any drugs or a history of digoxin use.
FAMILY HISTORY: Family history was not able to be obtained.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
afebrile, his pulse was 80 (which was paced), his blood
pressure was 40 to 113/19 to 70, and he was on 100 percent
FiO2 and intubated with a respiratory rate of 12, tidal
volume was 600, and positive end-expiratory pressure of 5.
The patient was intubated and agitated. He had pessary
muscle contractions consistent with transcutaneous pacing.
The lungs were clear. He had a 2/6 systolic ejection murmur.
The abdomen was soft and distended. There were positive
bowel sounds. There was no hepatosplenomegaly. The rest of
his examination was not pertinent.
LABORATORY VALUES ON PRESENTATION: Initial laboratory data
revealed his white blood cell count was 17.1, his hematocrit
was 36.7, and his platelets were 243. Chemistry-7 revealed
his sodium was 138, potassium was 5.8, chloride was 102,
bicarbonate was 22, blood urea nitrogen was 31, creatinine
was 1.3, and his blood glucose was 234. A creatine kinase
was obtained which was 86. A troponin was negative.
Coagulations were unrevealing.
PERTINENT RADIOLOGY-IMAGING: An electrocardiogram revealed a
likely high junctional escape rhythm at 40 with sinus node
activity. QRS of 118, and no ST-T wave changes.
A chest x-ray showed pulmonary edema and endotracheal tube in
good position. The pacing wire was also well positioned.
Of note, the patient had a recent echocardiogram in
[**2106-10-4**] which showed an ejection fraction of 55
percent to 60 percent and symmetric left ventricular
hypertrophy, a severe resting outflow tract obstruction of
the left ventricle, as well as 3 plus mitral regurgitation, 1
plus tricuspid regurgitation, and moderate pulmonary
hypertension. The findings were consistent with hypertrophic
obstructive cardiomyopathy.
SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS:
1. HYPERTENSION AND BRADYCARDIA ISSUES: It was felt by the
Coronary Care Unit team that the most likely explanation
of his hypertension and bradycardia was from the extra
dose of verapamil he took on the day of admission. The
patient was admitted to the Coronary Care Unit intubated
with a temporary pacing wire. The patient was initially
started on dopamine and then transitioned to phenylephrine
for blood pressure support. His nodal blocking agents
were subsequently held.
Given the high white blood cell count and hypotension, there
was also some concern for sepsis. The patient had an
infections workup which included blood and urine cultures
which were all negative. The patient was initially
maintained on broad spectrum antibiotics to cover for
possible infection.
He was also initially given stress-dose steroids as there was
concern that he may have possible adrenal insufficiency given
he is on chronic steroids. Furthermore, he had a set of
cardiac enzymes which were obtained which were negative.
The patient also had a subsequent echocardiogram done while
in house which showed severe concentric left ventricular
hypertrophy, an ejection fraction of 60 percent, and left
ventricular outflow tract obstruction. Additionally, there
was mild-to-moderate mitral regurgitation seen.
Eventually, the patient's blood pressure began to recover as
the nodal agents worked off and his pacemaker was
functioning. He was initially started on a labetalol drip as
well as hydralazine for blood pressure control. It was felt
that after a few days that his nodal blocking agents had
eventually worn off. Therefore, he was started on metoprolol
and verapamil for blood pressure control and heart rate
control. The Coronary Care Unit team felt that it was
extremely important he be on nodal blocking agents in the
future, as this is the treatment for hypertrophic obstructive
cardiomyopathy. The patient was eventually continued on
verapamil 40 mg by mouth q.8h. and was then switched from
metoprolol to labetalol for further blood pressure control;
however, the patient stated that he felt extremely dizzy, and
the team attributed this to his beta blocker dose.
Therefore, he was continued on just verapamil 40 mg by mouth
q.8h., and his blood pressures subsequently returned to
[**Location 213**].
On [**2107-6-24**], the patient had a dual-chamber pacemaker
inserted. The patient tolerated the procedure well and did
not have any evidence of hematoma around the pacemaker
pocket.
1. OTHER ISSUES: As noted, the patient was initially
intubated for airway protection in the setting of
receiving 7 liters of fluid. The patient was eventually
weaned from intubation and was extubated without incident.
He was given Lasix as needed as he was clearly volume
overloaded from having received large volume
resuscitation.
As mentioned previously, none of the numerous blood cultures
that were obtained were revealing for any type of infection.
The patient was continued on an insulin sliding scale for his
type 2 diabetes mellitus.
DISCHARGE DIAGNOSES:
1. Hypertrophic obstructive cardiomyopathy.
2. Calcium channel overdose with resultant intubation and
large volume resuscitation.
3. Pacemaker insertion.
4. Type 2 diabetes mellitus.
5. Polymyalgia rheumatica.
6. Hypertension.
DISCHARGE INSTRUCTIONS-FOLLOWUP: The patient was instructed
to contact his primary care physician should he develop any
chest pain, shortness of breath, nausea, vomiting, dizziness,
or lightheadedness, as well as any other serious complaints.
MAJOR SURGICAL-INVASIVE PROCEDURES PERFORMED:
1. Intubation.
2. Pacemaker insertion.
3. Temporary pacemaker wire placement.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth once per day.
2. Several eyedrops which the patient takes at home.
3. Prednisone 5 mg by mouth once per day.
4. Protonix 40 mg by mouth once per day.
5. Metformin 1000 mg by mouth in the morning.
6. Pravastatin 40 mg by mouth once per day.
The exact verapamil dose that he will be taking will be
dictated as an Addendum as well as the remainder of his
endocrine medications.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 13600**]
Dictated By:[**Doctor Last Name 10457**]
MEDQUIST36
D: [**2107-6-25**] 17:43:03
T: [**2107-6-25**] 19:51:29
Job#: [**Job Number 103355**]
ICD9 Codes: 4240, 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2017
} | Medical Text: Admission Date: [**2147-3-7**] Discharge Date: [**2147-3-11**]
Date of Birth: [**2097-8-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Central line placement, peritoneal dialysis, lumbar puncture
History of Present Illness:
49 yo F w/met colon ca, ESRD on PD s/p transplant with diarrhea
N/V/D x 5 days who was found to be hypotensive and tachycardic
in IR the day admission after coming in for large volume LP to
evaluate for possible leptomeningeal spread of her cancer. Sent
to ER for hypotension.
In the ED, initial vitals 66/55, 20, 100%. Rectal temp 101.8.
Received 6L NS, Vancomycin and Ceftazidime, R IJ placed. Started
on levophed. Admitted to ICU for septic shock. PD fluid sent
for anaylsis but no obvious source. Lactate 2.4 -- > 1.3.
On arrival to the MICU, she stated that she feels tired and did
feel light-headed in the IR suite. She also endorses nausea and
vomiting for the past few days but no other localizing sympotms.
No fevers although some chills. No sore throat, runny nose,
cough, abdominal pain, diarrhea, SOB. Confirms anorexia. States
that she had a similar admission with similar symptoms but this
time she does not have a headache.
During her short ICU admission, she had Levophed weaned off,
recieved further boluses of IVF, continued ceftazidime and
repleted K.
The day after admission she was transferred to the OMED service
once hemodynamically stable. Upon arrival to the floor she
confirms a recent history of N/V/D that has all since resolved
the day priot to admission except one epsidoe of emesis [**2-18**] pain
while in the ICU. Denies any other localizing symptoms.
Confirms poor po intake for several weeks due to swallowing
difficulties. Intermittently gets lightheaded with prolonged
standing and has been very weak - only able to go from bed to
couch most of the day. Eager to have LP performed and get 'an
answer'.
Past Medical History:
-ESRD on PD
-SLE and associated renal failure status post two kidney
transplants with recent worsening of her kidney function
concerning for transplant failure.
-peritoneal dialysis catheter placed in preparations to begin
peritoneal dialysis.
-seizure disorder status post CVA in [**2137**]
-osteoporosisarthritis status post bilateral lower extremity
fracture in [**2144**] after a fall
-Metastatic Colon CA: C1D1 of xeloda, xelox, and oxiplatin on
[**2147-1-23**]. Her original colon cancer,diagnosed in [**2143**], presented
with a bowel obstruction.
-Multiple CN palsies
-Dysphagia
Social History:
Lives in [**Location **] alone, independent w/ ADLs, works as med records
librarian and pharmacy manager. Denies smoking. Drinks 6
drinks/month. No illicit drugs.
Family History:
Multiple relatives with cancer, including GM with stomach cancer
and grandfather with unknown type of cancer.
Physical Exam:
VS: Temp: 97.9 BP: 127/82 HR:117 RR: 18 O2sat 99% on RA
GEN: tired appearing, NAD, A & O, able to relate history without
difficulty
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: CTA b/l anteriorly with occasional rhonchi posteriorly
CV: tachy, RR, S1 and S2 wnl, III/VI systolic murmur at LUSB
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly; PD
cath w/ clean dry dressing
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: L-sided facial paralysis
Pertinent Results:
[**2147-3-7**] 08:45AM WBC-18.2*# RBC-3.48* HGB-11.4*# HCT-32.9*
MCV-95 MCH-32.6* MCHC-34.5 RDW-16.2*
[**2147-3-7**] 08:45AM NEUTS-80.7* LYMPHS-14.1* MONOS-4.9 EOS-0.3
BASOS-0.1
[**2147-3-7**] 08:45AM PLT COUNT-435
[**2147-3-7**] 08:45AM GLUCOSE-123* UREA N-10 CREAT-3.6* SODIUM-142
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16
[**2147-3-7**] 10:03AM LACTATE-2.4*
[**2147-3-7**] 02:00PM ASCITES WBC-6* RBC-2* POLYS-5* LYMPHS-39*
MONOS-43* MACROPHAG-10* OTHER-3*
[**2147-3-7**] 02:00PM ASCITES TOT PROT-<0.2 GLUCOSE-174 LD(LDH)-29
[**2147-3-7**] 04:12PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2147-3-7**] 04:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2147-3-7**] 04:12PM URINE RBC-0-2 WBC-[**3-22**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2147-3-11**] 05:35AM BLOOD Glucose-85 UreaN-12 Creat-2.3* Na-139
K-3.4 Cl-111* HCO3-25 AnGap-6*
[**2147-3-11**] 05:35AM BLOOD WBC-7.7 RBC-3.30* Hgb-10.2* Hct-30.5*
MCV-93 MCH-30.9 MCHC-33.4 RDW-15.5 Plt Ct-310
[**2147-3-11**] 05:35AM BLOOD Plt Ct-310
CSF Analysis
WBC, CSF 14 #/uL
RBC, CSF 3* #/uL 0 - 0
Polys 0 %
Lymphs 93 %
Monocytes 7 %
[**2147-3-9**] 2:57 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final [**2147-3-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2147-3-12**]): NO GROWTH.
LUMBAR PUNCTURE [**2147-3-9**] 12:39 PM
The patient was placed prone on the procedure table. Access to
the lumbar subarachnoid space at L3/4 was obtained with a
22-gauge spinal needle under fluoroscopic guidance, using
aseptic precautions and 1% lidocaine for local anesthesia.
Approximately 12 cc of clear fluid were collected. The needle
was removed, and hemostasis was achieved by manual compression.
The patient tolerated the procedure well without any immediate
complications. The patient was sent back to the floor with
post-procedure orders. The fluid was sent for laboratory
analyses as requested by the referring physician.
Brief Hospital Course:
A/P: 49 female with PMH of metastatic colon cancer, ESRD on
peritoneal dialysis presents with recurrent fever, hypotension,
nausea and vomiting.
# Fever: Unclear etiology. DDX initially included pneumonia vs
peritoneal cavity vs urine vs line infection but no evidence of
any of these. Presentation with nausea and vomiting consistent
with a viral gastroenteritis. Symptoms resolved with aggressive
rehydration and seem most consistent with a self-limiting viral
gastroenteritis. Continued initial antibiotics of Vancomycin
and Ceftazidime for 48 hrs (dosed for GFR < 10), and then
discontinued given that cultures were negative. Afebrile for 48
hours prior to discharge.
# Hypotension: DDX septic shock vs cardiogenic vs hypovolemic.
Initially considered to be most consistent with septic shock
based on CVP being low and fever. Received 5 L of NS in the ED
and received additional IVF in ICU for MAP > 65 and UOP >
50cc/hr. Given rapid improvement after volume resuscitation
with little evidence for persistent infection, likely
hypovolemia from vomiting and diarrhea and prolonged poor po
intake. Blood pressure was monitored and she was normotensive
throughout her floor stay.
# ESRD on peritoneal dialysis, s/p transplant: Renal following.
Peritoneal dialysis per Renal. Continued immunosuppression with
Rapamune and prednisone. Continued Bactrim for PCP [**Name Initial (PRE) 1102**].
# Anemia: Anemic at baseline likely due to chronic kidney
disease. Monitored Hct throughout her inpatient stay.
# HTN: Held nifedipine given hypotension, and did not require
prior to discharge. Instructed to follow-up with primary
oncologist prior to restarting medication.
# Metastatic colon cancer: Was to have a large volume LP the day
of admission by IR to evaluate for meningeal spread in setting
of bulbar palsy. Previously had extensive work-up on prior
admission including consults from ID, Rheum and Neurology. Only
work-up remaining on discharge was large volume LP for cytology,
though leptomeningeal spread from colon cancer is exceedingly
rare. Large volume LP performed by Interventional
Neuroradiology [**3-9**] without complication. Cytology pending on
discharge and will follow-up with primary oncologist to discuss
results.
# Dysphagia: Patient states that this is at her baseline. Given
inability to eat larger quantities of food, and with complaint
of weight loss, she was given supplemental shakes while
inpatient. Per ENT consult obtained on last admission, vocal
[**Last Name **] problem may resolve with time. They additionally
recommended outpatient follow-up (patient was unable to keep
appointment). ENT re-evaluated patient while in the hospital
and reported no interval improvement. Rescheduled for
outpatient appointment upon discharge.
Medications on Admission:
Rapamune 2 mg qam
Prednisone 5 mg daily
ASA 81 mg daily
Bactrim three times per week
Nifedipine 60 mg daily
Iron daily
Supposed to be taking nephrocaps
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Daily dose to be administered at 6am .
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Metastatic colon cancer, sepsis
Secondary: End Stage Renal Disease, prior renal transplant
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted following a viral illness that left you very
dehydrated, and subsequently you had very low blood pressure
during your outpatient procedure. You were treated with
antibiotics and IV fluids until your blood pressure improved.
Given no bacterial culture growth, you were not continued on
antibiotics. You also had a lumbar puncture for further
evaluation of your neurological problems and the results of this
study were pending at the time of your discharge.
Please take all medications as prescribed. Your nifedipine has
been held while you were in the hospital. You should not
restart this medication until discussing it with Dr. [**Last Name (STitle) 4253**].
Please keep all outpatient appointments.
Return to a hospital or seek medical advice if you notice fever,
chills, shortness of breath, progressive weakness, cough or any
other symptom which is concerning to you.
Followup Instructions:
Provider: [**Name10 (NameIs) 5005**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2147-3-17**] 9:30
You should also have follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1837**]
for your vocal cord issues. Please call his office at ([**Telephone/Fax (1) 72400**] on Monday [**3-13**] to confirm you appointment date/time for
the following week.
ICD9 Codes: 0389, 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2018
} | Medical Text: Admission Date: [**2155-10-13**] Discharge Date: [**2155-10-21**]
Date of Birth: [**2155-10-13**] Sex: F
Service: NB
DICTATOR: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
HISTORY: Baby Girl [**Known lastname 8976**] is the 1.815 kg product of a 31
week gestation, both to a 26 year old primigravida, with a
history of GBS bacteruria, depression, smoking. Prenatal
screens: O-positive, antibody negative, RPR non-reactive,
rubella-immune, hepatitis surface antigen negative, GBS
unknown. Pregnancy complicated by first SVT at 8 weeks
gestation, treated with adenosine and digoxin, then placenta
previa and preterm labor. Admitted to [**Hospital3 **] on [**9-2**] at
25 weeks with bleeding and preterm labor, treated with
magnesium sulfate and a complete course of betamethasone.
Remained in house on bedrest since. On day of delivery,
further bleeding noted, therefore delivered by cesarean
section. Abdominal rupture of membranes at delivery for
clear fluid. No maternal fever. Positive nuchal cord times
one. Baby emerged with spontaneous cry, required blow-by O2,
and some CPAP to maintain pink color. Apgars were assigned
at 7 and 8.
PHYSICAL EXAMINATION ON ADMISSION: Non-dysmorphic with
overall appearance consistent with estimated gestational age,
weight 1815, head circumference 29 cm, length 44.5 cm.
Anterior fontanel soft, open and flat. Facial bruising. Red
reflex present bilaterally. Palate intact. Intermittent
grunting. Subcostal, intercostal retractions. Breath sounds
symmetric, diminished bilaterally. Regular rate and rhythm
without murmur. 2+ peripheral pulses including femorals.
Abdomen benign, nontender, without hepatosplenomegaly or
masses. Three-vessel cord. Normal female genitalia for
gestational age. Normal back and extremities with hips
deferred. Skin pink and well perfused.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Infant
was admitted to the newborn intensive care unit and placed on
CPAP for management of respiratory distress. She remained on
CPAP for 72 hours, at which time she transitioned to room air
and has been stable on room air since that time.
CARDIOVASCULAR: Has had no issues. EKG was performed in
light of maternal digoxin use and EKG was within normal
limits.
FLUID/ELECTROLYTES: Infant's birth weight was 1815 grams.
The infant was initially started at 80 cc/kg per day of
D10/W. Enteral feedings were initiated on day of life number
3. Infant is currently receiving 150 cc/kg per day of
Premature Enfamil 22 calorie, breast milk 22 calorie,
tolerating feeds fine.
GI/GU: Peak bilirubin was on day of life number 3 of
12.0/0.3. She was treated with phototherapy and her most
recent bilirubin is ___ on [**10-22**]. Infant noted to have a 2-
vessel cord on admission.
HEMATOLOGY: Hematocrit on admission was 48.7. Infant has
not required any blood products.
INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC was benign and blood cultures remained
negative at 48 hours. Ampicillin and gentamicin were
discontinued at that time.
NEURO: Has been appropriate for gestational age. Head
ultrasound at day of life 9 showed question of small right
germinal matrix hemorrhage..
Sensory:
Hearing screen was not performed but is suggetsed prior to
ultimate discharge home.
PSYCHOSOCIAL: Parents are involved with this infant. Mother
is a nurse in the adult medical field.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 **].
PRIMARY PEDIATRICIAN: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 50617**] ([**Telephone/Fax (1) 38385**]).
FEEDS AT DISCHARGE: Continue 150 cc/kg per day. Breast milk
24 or Premature Enfamil 24 calorie. Advance in calories as
appropriate to maintain weight gain.
MEDICATIONS: Not applicable.
Physician screening has not been performed. State newborn
screens have been sent per protocol. Repeat was sent in
light of the initial having an elevated 17-OHP of 138. The
repeat was sent on [**10-20**].
IMMUNIZATIONS RECEIVED: The infant has not received any
immunizations.
IMMUNIZATIONS RECOMMENDED: 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
week; 2) Born between 32 and 35 weeks with two of the
following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, or 3) Chronic lung disease. Influenza
immunization is recommended annually in the fall for all
infants once they reach 6 months of age. Before this age and
for the first 24 months of the child's life, immunization
against influenza is recommended for household contact and
out of home care-givers.
DISCHARGE DIAGNOSES: Premature infant, both at 31 weeks,
corrected to 32-2/7. Respiratory distress. Rule out sepsis
with antibiotics. 2-vessel cord.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 56160**]
MEDQUIST36
D: [**2155-10-21**] 21:34:50
T: [**2155-10-21**] 22:17:49
Job#: [**Job Number 62611**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2019
} | Medical Text: Admission Date: [**2126-6-19**] Discharge Date: [**2126-6-26**]
Date of Birth: [**2047-9-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
tramadol
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest heaviness and dyspnea
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4
1. Left internal mammary artery to left anterior descending
artery.
2. Reverse saphenous vein graft from the aorta to the
obtuse marginal 1 branch of the circumflex artery.
3. Bypass from the ascending aorta to the diagonal artery
branch off the anterior descending artery using reversed
autogenous saphenous vein graft.
4. Bypass from the ascending aorta to the distal right
coronary artery using reversed autologous saphenous vein
graft.
History of Present Illness:
78 year old female who reports progressive, exertional chest
discomfort over the past 4 months and relieved with rest.
Walking up 2 flights of stairs, water
aerobics and walking at a brisk pace will bring on the chest
pain and is associated with shortness of breath. A stress echo
was performed and she developed chest pain at 5 minutes,
borderline ischemic EKG changes and no regional wall motion
abnormality. She was referred for a cardiac catheterization and
was found to have coronary artery disease and is now being
referred to cardiac surgery for revascularization.
Past Medical History:
Coronary artery disease
Secondary:
Diabetes mellitus type 1
Hypertension
Hyperlipidemia
Spinal stenosis
Osteoarthritis
Osteoporosis
Abnormal Mammogram/Calcium Deposits
Social History:
Race:Caucaisan
Last Dental Exam:[**12/2125**]
Lives with:Husband
Contact:[**Name (NI) **] (husband) Phone #[**Telephone/Fax (1) 61124**]
Occupation:retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**3-5**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
non-contributory
Physical Exam:
Admission Physical Exam
Pulse:72 Resp:20 O2 sat:99/RA
B/P Left: 157/52
Height:5'1.75" Weight:145 lbs
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 [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+, stretch marks
[]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right:+2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: cath site Left:+2
Carotid Bruit Right: None Left:none
Pertinent Results:
Intra-op TEE [**2126-6-19**]
Conclusions
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. 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 and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
There are focal calcifications in the aortic root. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen.
The posterior mitral valve leaflet is moderately to severely
thickened and calcified. The anterior mitral valve leaflet is
moderately thickened with a morphology suggestive of rheumatic
mitral disease. No mitral stenosis is seen. Physiologic mitral
regurgitation is seen (within normal limits). The anterolateral
papillary muscle & cords are thickened. Tips appear calcified.
There is a trivial/physiologic pericardial effusion.
POSTBYPASS:
The patient is A paced on low dose norepinephrine infusion.
Biventricular function is maintained. Valves appear unchanged.
The aorta remains intact after decannulation
[**2126-6-26**] 03:56AM BLOOD WBC-9.5 RBC-3.46* Hgb-10.3* Hct-31.0*
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.7 Plt Ct-341#
[**2126-6-19**] 01:52PM BLOOD WBC-12.1*# RBC-2.42*# Hgb-7.0*#
Hct-21.4*# MCV-88 MCH-28.8 MCHC-32.7 RDW-12.5 Plt Ct-152
[**2126-6-26**] 03:56AM BLOOD PT-18.2* INR(PT)-1.7*
[**2126-6-19**] 01:52PM BLOOD PT-14.1* PTT-26.5 INR(PT)-1.3*
[**2126-6-26**] 03:56AM BLOOD UreaN-20 Creat-0.8 Na-137 K-4.6 Cl-98
[**2126-6-19**] 03:30PM BLOOD UreaN-11 Creat-0.5 Na-142 K-4.0 Cl-116*
HCO3-21* AnGap-9
Brief Hospital Course:
On [**2126-6-19**] Ms.[**Known lastname 61125**] was taken to the operating room and
underwent Coronary artery bypass grafting x4 (Left internal
mammary artery to left anterior descending
artery/ Reverse saphenous vein graft from the aorta to the
obtuse marginal 1 branch of the circumflex artery, Bypass from
the ascending aorta to the diagonal artery
branch off the anterior descending artery using reversed
autogenous saphenous vein graft, Bypass from the ascending aorta
to the distal right coronary artery using reversed autologous
saphenous vein graft) with Dr.[**First Name (STitle) **]. Please see operative
report for further surgical details. She tolerated the procedure
well and was transferred to the CVICU intubated and sedated. She
awoke neurologically intact and extubated postop night without
difficulty. She received packed red blood cells for a hematocrit
of 21 likely due to volume resucitation. She was weaned off
pressor support and beta-blocker, statin, aspirin were
initiated. Chest tubes and pacing wires were discontinued per
protocol. On POD#1 she was transferred to the step down unit for
further monitoring and recovey. Physical Therapy was consulted
for evaluation of strength and mobility. She developed post-op
AFib and was started on amiodarone and coumadin. She continued
to progress and on POD#7 she was discharged to Newbridge on the
[**Hospital **] rehabilitation. All follow up appointments were advised.
Medications on Admission:
ENALAPRIL MALEATE 20 mg [**Hospital1 **]
GLUCAGON 1 mg Kit - use as directed for severe hypoglycemia as
educated
HYDROCHLOROTHIAZIDE 25 mg Daily
LANTUS 9 units q am and 12 units q hs
INSULIN LISPRO [HUMALOG] [**Name8 (MD) **] md sliding scale
SIMVASTATIN 20 mg Daily
ASPIRIN 162.5 mg Daily
EXCEDRIN EXTRA STRENGTH 250 mg/250 mg/65 mg [**Name8 (MD) 8426**] - 2 Tablets
[**Hospital1 **] PRN
TUMS 1000 mg Daily
VITAMIN D3 1,000 unit daily
VITAMIN B-12 1,000 mcg daily
FOLIC ACID 400 mcg daily
MAGNESIUM 250 mg daily
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] 1 [**Hospital1 8426**] daily
NIACIN 250 mg daily
FISH OIL 1,000 mg [**Hospital1 **]
Discharge Medications:
1. potassium chloride 10 mEq [**Hospital1 8426**] Extended Release Sig: Two
(2) [**Hospital1 8426**] Extended Release PO Q12H (every 12 hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
4. acetaminophen 325 mg [**Hospital1 8426**] Sig: Two (2) [**Hospital1 8426**] PO Q4H (every
4 hours) as needed for pain/fever.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. simvastatin 10 mg [**Hospital1 8426**] Sig: Two (2) [**Hospital1 8426**] PO DAILY
(Daily).
7. niacin 250 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO DAILY (Daily).
8. oxycodone-acetaminophen 5-325 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**]
PO Q4H (every 4 hours) as needed for pain.
Disp:*45 [**Hospital1 8426**](s)* Refills:*0*
9. ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
11. metoprolol tartrate 25 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO TID
(3 times a day).
12. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4
PM.
13. amiodarone 200 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO BID (2 times
a day): x 7 days then decrease to 200 mg [**Hospital1 **] x 7 days then
decrease to 200 mg daily.
14. insulin lispro 100 unit/mL Cartridge Sig: One (1)
Subcutaneous ACHS: *Per HISS.
15. warfarin 1 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO ONCE (Once) for
1 doses.
16. enalapril maleate 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
17. Lasix 80 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO twice a day: wean
dose as weight/edema resolves.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Coronary artery disease
Secondary:
Diabetes mellitus type 1
Hypertension
Hyperlipidemia
Spinal stenosis
Osteoarthritis
Osteoporosis
Abnormal Mammogram/Calcium Deposits
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Shower Daily including washing incisions gently with mild soap,
No baths or swimming until cleared by surgeon.
Look at your incisions daily for redness or drainage
NO lotions, cream, powder, or ointments to incisions
Daily weights: keep a log
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
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2126-7-17**] 10:40 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical
Center [**Location (un) **]
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2126-7-23**] 1:45 in the [**Hospital 2577**] Medical Building [**Last Name (NamePattern1) 10357**] [**Hospital Unit Name **]
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2126-8-20**]
11:00
in the [**Hospital 2577**] Medical Building [**Location (un) **] GERONTOLOGY
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2126-6-26**]
ICD9 Codes: 9971, 4019, 2724, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2020
} | Medical Text: Admission Date: [**2129-10-6**] Discharge Date: [**2129-10-15**]
Date of Birth: [**2050-12-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
new onset angina
Major Surgical or Invasive Procedure:
[**2129-10-7**] cardiac catheterization
[**2129-10-11**] AVR ( 21mm CE pericardial)/ cabg x1 (LIMA to LAD)
History of Present Illness:
78 yo male awakened from sleep with sharp chest spasm that
radiated down right arm. It lasted approx. 30 seconds and then
he had multiple episodes over 10 minutes. Has had several
episodes per day. Also noted to have left sided twitching over
precordial area. Had associated nausea.
Past Medical History:
severe PVD with multiple aneurysms in LE
COPD- in pulm. rehab
OSA on CPAP
CHF [**5-10**]
multiple PNAs
AS
carotid stenosis
elev. chol.
PSH: bil. LE bypass procedures x 6; last bypass with goretex due
to unusable vein
eye surgery as a child
Social History:
lives with wife
100 pack-year history-quit 22 years ago
12 beers a month/ one shot of sambuca per week
drives school bus
Family History:
son with MI at 46
Physical Exam:
5'3" 74.8 kg
SR 83 RR 15 123/78
NAD
diminshed BS bilat.;increased AP diameter
RRR 2/6 harsh SEM heard best at left axilla
soft NT, ND + BS
warm, well-perfused, trace edema, several well-healed scars BLE
no varicosities noted
1+ bil. fems
trace to 1+ right DP/PTs
dopplerable left DP/PTs
2+ bil. radials
no carotid bruits
Pertinent Results:
COMMENTS:
1. Selective coronary angiography of this right-dominant system
demonstrated one-vessel coronary artery disease. The LMCA, LCX,
and RCA
were all free of angiographically-appareny flow-limiting
stenoses. The
LAD had a proximal eccentric and likely ulcerated 70% stenosis.
2. Resting hemodynamics demonstrated moderate aortic stenosis
with a
gradient of 19 mmHg. Right- and left-sided filling pressures
were
high-normal with an RVEDP of 8 mmHg and a PCWP a-wave of 10.
There was
mild pulmonary hypertension with an RVSP of 36 mmHg.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderate aortic stenosis.
3. Mild pulmonary arterial hypertension.
ATTENDING PHYSICIAN: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] B.
[**Last Name (LF) **],[**First Name3 (LF) **]
ATTENDING STAFF: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J.
([**Numeric Identifier 79780**])
Conclusions
PREBYPASS
A patent foramen ovale is present with left-to-right shunt at
rest. Left ventricular wall thicknesses and cavity size are
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). The
right ventricular cavity is mildly dilated with borderline
normal free wall function. The ascending aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets are severely
thickened/deformed. There is moderate to severe aortic valve
stenosis (area ~1.2 cm2 Mild to moderate ([**2-2**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits).
POSTBYPASS
Patent has poor windows post bypass, LV function appears to
remain good with EF 55% but segmental motion hard to identify.
The aortic contour is smooth post decannulation. An prostetic
aortic valve is well seated in the aortic annulus. Trace
perivalvular leak is seen. Mitral regurgitation is seen post
bypass but remains unchanged from prior study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**Known firstname **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician
Radiology Report CHEST (PORTABLE AP) Study Date of [**2129-10-13**] 3:06
PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2129-10-13**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79781**]
Reason: ? ptx s/p mt removal
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? ptx s/p mt removal
Provisional Findings Impression: IPf [**Doctor First Name **] [**2129-10-13**] 4:53 PM
No pneumothorax.
Final Report
PROCEDURE: Portable AP chest radiograph.
Comparison done with chest radiograph from [**10-13**] at 1:27
p.m.
78-year-old man with status post CABG, questionable pneumothorax
status post
mid thoracic chest tube removal.
_____: Mid thoracic chest tube removed. No pneumothorax. The
rest of the
lungs appear unchanged.
IMPRESSION: No pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2129-10-13**] 5:26 PM
Imaging Lab
?????? [**2124**] CareGroup IS. All rights reserved.
[**2129-10-15**] 08:20AM BLOOD WBC-14.9* RBC-3.47* Hgb-9.9* Hct-29.1*
MCV-84 MCH-28.6 MCHC-34.1 RDW-14.7 Plt Ct-180#
[**2129-10-6**] 11:50PM BLOOD WBC-9.0 RBC-4.87 Hgb-13.6* Hct-39.4*
MCV-81* MCH-28.0 MCHC-34.6 RDW-14.0 Plt Ct-275
[**2129-10-13**] 02:02AM BLOOD PT-12.8 PTT-25.0 INR(PT)-1.1
[**2129-10-6**] 11:50PM BLOOD PT-13.2 PTT-25.1 INR(PT)-1.1
[**2129-10-15**] 08:20AM BLOOD Glucose-140* UreaN-20 Creat-0.9 Na-135
K-4.1
[**2129-10-6**] 11:50PM BLOOD Glucose-134* UreaN-23* Creat-1.3* Na-139
K-4.0 Cl-98 HCO3-30 AnGap-15
[**2129-10-12**] 02:05AM BLOOD Type-ART pO2-100 pCO2-42 pH-7.37
calTCO2-25 Base XS-0
Brief Hospital Course:
Admitted [**10-6**] and had a cardiology consult done. Cath the next
day showed AS and LAD dz. Carotid US showed [**Country **] 60-69%. Vein
mapping,echo, and pulm consult also done pre-op. Underwent CABG
x1/AVR (#21mm [**Doctor Last Name **]) with Dr. [**First Name (STitle) **] on [**10-11**]. Please refer to
Dr[**Doctor First Name **] operative report for further details. Transferred to
the CVICU in stable condition on titrated phenylephrine and
propofol drips. Extubated late that night and steroid taper
started. Aggressive pulmonary toilet done. POD#1 he was
transferred to the SDU for further telemetry monitoring ans
recovery. The remainder of his postoperative course was
essentially unremarkable.POD#3 small serous drainage seen on
his sternotomy incision. Prior to discharge his sternum was
stable, C/D/I. He continued to progress and on POD#4 was
discharged to home with VNA. He was advised on all followup
appointments.
Medications on Admission:
prednisone 5 mg every other day
singulair 10 mg daily
dyazide 25/37.5 mg dialy
xopenex nebulizer TID
lovastatin 40 mg daily
ECASA 81 mg daily
plavix 75 mg daily
spiriva one daily
advair 250/50 2 puffs [**Hospital1 **]
albuterol prn ( uses 2-3x /day)
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for PVD.
Disp:*30 Tablet(s)* Refills:*0*
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
continuous doses.
Disp:*30 Tablet(s)* Refills:*0*
8. 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*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
12. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
Two (2) Disk with Device Inhalation [**Hospital1 **] ().
Disp:*120 Disk with Device(s)* Refills:*0*
13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
AS/CAD s/p AVR/CABG x1
COPD (in pulm. rehab)
OSA on BiPAP
CHF [**5-10**]
multiple PNAs
carotid stenosis
severe PVD with multiple aneurysms in bil. LE s/p 6 bypass
procedures
elev. chol.
Discharge Condition:
good
Discharge Instructions:
shower daily and pat incisions dry
no lotions, creams or powders on any incision
no driving for one month AND until off all narcotics
call for fever greater than 100.5, redness, or drainage
no lifting greater than 10 pounds for 10 weeks
Followup Instructions:
see Dr. [**Last Name (STitle) 79782**] in [**2-2**] weeks
see Dr. [**Last Name (STitle) 7659**] in [**3-6**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2129-10-15**]
ICD9 Codes: 4241, 5180, 4168, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2021
} | Medical Text: Unit No: [**Numeric Identifier 74822**]
Admission Date: [**2162-10-22**]
Discharge Date: [**2162-11-3**]
Date of Birth: [**2162-10-22**]
Sex: M
Service: NB
DATE OF BIRTH: [**2162-10-22**].
SEX: Male.
DATE OF ADMISSION: [**2162-10-22**].
DATE OF DISCHARGE: [**2162-11-3**].
HISTORY OF PRESENT ILLNESS: Baby by [**Name2 (NI) 74823**] [**Known lastname **] is a former
1.895 kg product of a 33 and [**5-8**] week gestation pregnancy,
born to a 41-year-old, G4, P2, now 3 woman. Prenatal screens:
[**Month/Day (4) **] type O-, antibody negative, Rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group beta
strep status unknown.
This pregnancy was complicated by advanced maternal age and
premature, prolonged rupture of membranes. Mother initially
presented to [**Hospital3 **] with leakage of fluid on [**2162-10-19**]. At that time she was started on erythromycin and
clindamycin and was given a course of betamethasone. Her
prior OB history was notable for a delivery at 33 weeks
gestation with a history of a placenta abruption. That child
is now 7 years old and alive and well. This mother proceeded
to have a spontaneous vaginal delivery after unstoppable
preterm labor. Apgars were 8 at one minute and 8 at five
minutes. She had a total of 4 days ruptured membranes prior
to delivery. The infant was admitted to the neonatal
intensive care unit for treatment of prematurity.
ANTHROPOMETRIC MEASUREMENTS: Upon admission to the neonatal
intensive care unit- weight 1.895 kg, 50th percentile. Length
44 cm, 50th percentile. Head circumference 31 cm, 50th
percentile.
PHYSICAL EXAMINATION: At discharge, weight 2.025 kg, length
45 cm, head circumference 31.25 cm. General: Alert and non-
dysmorphic infant, comfortable in room air. Skin warm and
dry. Color pink. Head, ears, eyes, nose and throat: Anterior
fontanelle open and flat. Sutures opposed. Symmetric facial
features. Palate intact. Neck supple. Clavicle is intact.
Chest: Breath sounds equal and clear bilaterally. Easy
respirations. Cardiovascular: Regular rate and rhythm, no
murmur, normal S1, S2, 2+ femoral pulses. Abdomen soft,
nontender, nondistended, no masses, active bowel sounds. GU:
Circumcision healing, normal male genitalia, testes descended
bilaterally, patent anus. Spine straight, no sacral
anomalies. Hips stable. Extremities pink and well perfused.
Neuro: Appropriate tone and reflexes, positive suck, positive
grasp, positive Moro.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. RESPIRATORY: This baby has been on room air for his
entire neonatal intensive care unit admission. He did
not have any episodes of spontaneous apnea or
bradycardia. At the time of discharge, he is breathing
comfortably with a respiratory rate of 30-40 breaths per
minute.
2. CARDIOVASCULAR: This baby has maintained normal heart
rates and [**Year (4 digits) **] pressures. No murmurs have been noted.
Baseline heart rate is 150-170 beats per minute with a
recent [**Year (4 digits) **] pressure of 69/40 mmHg and a mean, arterial
pressure of 50 mmHg.
3. FLUIDS/ELECTROLYTES/NUTRITION: This infant was initially
started on intravenous fluids and feedings were begun by
gavage. He was gradually advanced to full volume and
feedings have been well tolerated. He has been breast
feeding or taking breast milk with Enfamil powder 24
kcal/ounce all p.o. for the 48 hours prior to discharge.
Weight on the day of discharge is 2.025 kg. Serum
electrolytes were checked on the second day of life and
were within normal limits.
4. INFECTIOUS DISEASE: Due to the preterm labor and unknown
group beta strep status of the mother, this baby was
evaluated for sepsis upon admission to the neonatal
intensive care unit. The initial white [**Year (4 digits) **] cell count
was 7,700 with 2% polymorphonuclear cells and 0% band
neutrophils. A repeat CBC at 24 hours of life had a
white [**Year (4 digits) **] cell count of 8,700 with 47%
polymorphonuclear cells, 4% band neutrophils. A [**Year (4 digits) **]
culture was obtained prior to starting intravenous
ampicillin and gentamycin. The [**Year (4 digits) **] culture was no
growth at 48 hours and the antibiotics were
discontinued.
5. HEMATOLOGICAL: This baby is [**Name2 (NI) **] type A+ and was Coombs
positive. His hematocrit at birth was 52.9%, repeat
hematocrit at 24 hours was 52.6%. He did not require any
transfusions of [**Name2 (NI) **] products.
6. GASTROINTESTINAL: This baby was treated for unconjugated
hyperbilirubinemia with phototherapy. Peak serum
bilirubin occurred on day of 1, total of 9.1 mEq/dl. He
was treated with phototherapy for 6 days. His most
recent rebound bilirubin was on [**2162-10-31**], a
total of 7.6 mg/dl.
7. NEUROLOGY: This baby has maintained a normal
neurological exam during admission. There are no
neurological concerns at the time of discharge.
8. SENSORY/AUDIOLOGY: Hearing screening was performed with
automated auditory brain stem responses. This baby
passed in both ears on [**2162-11-2**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD, [**Hospital **]
Pediatrics, [**Location (un) 8170**], [**Location (un) **], [**Numeric Identifier **]. Phone
[**Telephone/Fax (1) 43701**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: Ad lib breast feeding or breast milk fortified
to 24 kcal/ounce with Enfamil powder.
2. Medications: Goldline baby vitamins 1 ml p.o. once
daily, ferrous sulfate 25 mg/ml dilution 0.2 ml p.o.
once daily.
3. Iron and vitamin D supplementation: Iron supplementation
is recommended for preterm and low birthweight infants
until 12 months corrected age. All infants fed
predominantly breast milk should receive vitamin D
supplementation at 200 international units (may be
provided as a multivitamin preparation) daily until 12
months corrected age.
4. Car seat position screening was performed. This baby was
observed in his car seat for 90 minutes without any
episodes of bradycardia or oxygen desaturation.
5. State newborn screen was done on [**2162-10-25**].
There has been no notification of abnormal results to
date. A repeat screen was sent on the day of discharge,
[**2162-11-3**].
6. Immunizations: Hepatitis B vaccine was administered on
[**2162-11-2**].
7. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following 4
criteria: First- born at less than 32 weeks; Second- born
between 32 and 35 weeks with 2 of the following: Daycare
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities, or school-age siblings;
Thirdly- chronic lung disease; or Fourth, hemodynamically
significant congenital heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
This infant has not received 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.
FOLLOWUP: Follow-up appointments scheduled or recommended:
Appointment with Dr. [**Last Name (STitle) 8651**] within 3 days of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 33 and 4/7 weeks gestation.
2. Suspicion for sepsis ruled out.
3. ABO [**Last Name (STitle) **] incompatibility.
4. Status post ritual circumcision.
Dictated by:[**Last Name (Titles) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern4) 56030**]
MEDQUIST36
D: [**2162-11-3**] 01:35:42
T: [**2162-11-3**] 11:09:34
Job#: [**Job Number 74824**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2022
} | Medical Text: Admission Date: [**2191-1-25**] Discharge Date: [**2191-1-30**]
Date of Birth: [**2143-7-12**] Sex: F
Service: MEDICINE
Allergies:
Zidovudine
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
hypotension in addition to cough and green sputum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 47F with AIDS, HCV, cardiomyopathy, and
antiphospholipid antibody syndrome who presents with cough and
green sputum, subjective fevers at home. She is circumferential
as a historian, but it seems that she never recovered to her
baseline functional status after admission in [**Month (only) **]-early [**Month (only) **], in
terms of feeling tired all the time and complaining of mild
dyspnea.
In the ED, arrival vital signs 95.3, 89, 75/50, 36, 95% RA;
received 4L IVF, refused central line for hypotension. Received
levofloxacin and vancomycin for pna.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath,
orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
1. HIV/AIDS, diagnosed [**2176**], off HAART.
- acquired via heterosexual intercourse.
- CD4 184, VL 254k [**2190-12-5**]
- nadir CD4 69 [**6-11**]
2. HCV antibody+
3. [**Doctor First Name **] [**1-/2182**] - was not complaint with Rx.
4. Oral thrush
5. Recurrent episodes of pneumococcal pneumonia.
6. Lymphocytic pneumonitis - diagnosed by trans-bronchial bx.
7. Dilated cardiomyopathy-EF20-25%, last echo [**4-13**].
8. LV thrombus
9. Antiphospholipid antibody syndrome
10. Lower extremity arterial thrombus
11. Asthma/bronchiectasis
12. Myocardial infarction [**2184**], clean coronaries at that time
13. L MCA stroke, residual right hemiparesis
14. Cocaine abuse
15. Pulmonary Nodules on chest CT
16. Zoster
17. Cholelithiasis
Social History:
smokes "occassionally" X many years, no recent alcohol, h/o
cocaine abuse, but none recently, and has been homeless in the
past
Family History:
mother with DM
Physical Exam:
Vitals: T:97.0 BP:92/69 HR:98 RR:30 O2Sat:98% RA
GEN: chronically ill appearing woman
[**Year (4 digits) 4459**]: anicteric, edentulous except for lower incisors, + oral
thrush
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs scattered crackles, but esp at the L lower [**1-8**],
where there are also rhonchi
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2191-1-25**] 07:06PM GLUCOSE-82 UREA N-56* CREAT-1.6* SODIUM-139
POTASSIUM-3.1* CHLORIDE-114* TOTAL CO2-15* ANION GAP-13
[**2191-1-25**] 07:06PM MAGNESIUM-1.8
[**2191-1-25**] 07:06PM PT-99.5* PTT-54.3* INR(PT)-13.2*
[**2191-1-25**] 02:25PM [**Month/Day/Year 14246**] HOURS-RANDOM UREA N-828 CREAT-107
SODIUM-37 POTASSIUM-23 CHLORIDE-14
[**2191-1-25**] 02:25PM [**Month/Day/Year 14246**] [**Month/Day/Year 3143**]-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2191-1-25**] 02:25PM [**Month/Day/Year 14246**] RBC-[**3-10**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2191-1-25**] 01:04PM GLUCOSE-79 LACTATE-1.4 NA+-135 K+-3.5 CL--102
TCO2-20*
[**2191-1-25**] 01:04PM HGB-11.3* calcHCT-34
[**2191-1-25**] 01:03PM ALT(SGPT)-27 AST(SGOT)-55* LD(LDH)-430* ALK
PHOS-52 TOT BILI-0.7
[**2191-1-25**] 01:03PM ALBUMIN-2.6*
[**2191-1-25**] 01:03PM DIGOXIN-0.4*
[**2191-1-25**] 01:03PM WBC-3.4* RBC-3.46* HGB-10.6* HCT-29.5* MCV-85
MCH-30.7 MCHC-36.0* RDW-15.7*
[**2191-1-25**] 01:03PM NEUTS-74* BANDS-0 LYMPHS-23 MONOS-3 EOS-0
BASOS-0
[**2191-1-25**] 01:03PM PLT COUNT-143*
ECG: SR LVH by voltage, TWI II, III, flat in aVF, V4-V6; no
significant change from [**2190-11-28**].
Imaging:
CXR: AP supine, compared to [**2190-11-28**]. LLL opacity, concerning
for infection. Reticulonodular pattern relatively unchanged from
[**Name (NI) **]. Slightly enlarged cardiomediastinal silhouette,
unchanged from [**Month (only) **].
Brief Hospital Course:
Assesment: Ms. [**Known lastname **] is a 47F with AIDS, HCV, cardiomyopathy,
and antiphospholipid antibody syndrome who presents with ~6
weeks of fatigue and dyspnea, now worse in the last 3-4 days,
with productive cough
.
Plan:
# Pneumonia: SIRS criteria of hypotension (note that
outpt/ambulatory [**Known lastname **] pressures have been 100-110s), T95.3 on
arrival, RR 36; plus symptoms of resp infection and infiltrate
on CXR. She was covered initially for CAP with CTX and azithro.
She was ruled out for TB by 3 negative AFBs. DFA was negative
for [**Known lastname **]. Bronch was considered but as she improved on this
treatment, it was not done. She was followed by ID who
recommended changing CTX to cefpodoxime on discharge to complete
a 10-day course and to complete a 5-day course of azithro.
# HIV: not on HAART [**2-7**] poor compliance. Has been taking
atovaquone sporadically (reports taking for 2 of last 6 weeks);
this was restarted in-house. Social work was consulted to help
identify barriers to outpatient followup and compliance, and she
was set up with a food program.
# antiphospholipid syndrome: Her INR was supratherapeutic on
admission, so coumadin was held. The importance of compliacne
with INR monitoring was emphasized to her, and she was
discharged on coumadin 5 mg to be restarted on [**2-1**] with close
ouptaient monitoring. Of note, closer monitoring of the INR in
a patient with APA syndrome is required.
# cardiomyopathy: held ACE-I, BB, digoxin [**2-7**] hypotension,
infection.
# ARF: likely prerenal in setting of febrile illness. This
improved with volume resuscitation.
# oral thrush: continued fluconazole 100mg po daily
# Depression/anxiety: continued ativan
.
# Social: asked SW to see re: poor social supports, difficulty
with outpt med compliance. As she reported she had difficulty
getting food at home, she was set up with a food program.
Medications on Admission:
Medications--she reports that she filled a 2 week supply of
these in early [**Month (only) 1096**], then ran out until 2 days ago:
Lorazepam 0.5 mg PO BID
Fluconazole 100 mg PO Q24H
Senna 8.6 mg [**Hospital1 **]
Digoxin .0625 mg one half Tablet PO DAILY
Warfarin 5 mg Daily
Metoprolol Succinate 12.5mg Sustained Release PO DAILY
Lisinopril 2.5 mg PO DAILY
Atovaquone 1500 mg PO once a day
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO DAILY
(Daily).
5. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
6. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Restart this medication on [**2-1**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: pneumonia
Secondary: HIV, anxiety, cardiomyopathy, hypertension
Discharge Condition:
good, stable, ambulating independently, not requiring oxygen
Discharge Instructions:
You were evaluated for shortness of breath and cough and found
to have a pneumonia. This is improving with antibiotics.
It is VERY important for you to follow up with your outpatient
providers to be sure you are improving. Several of your
medications were stopped during the admission, and you must
follow up with your doctors to know when to restart them. Do not
take your digoxin, metoprolol, or lisinopril for now as your
[**Location (un) **] pressure is low-normal. Finish your antibiotics as
prescribed.
It is VERY important to have your INR checked so that your
coumadin can be dosed appropriately.
If you have fevers, chills, shortness of breath, chest pain,
lightheadedness, worsening cough, episodes of loss of
consciousness, or any other concerning symptoms, call your
doctor or seek medical attention immediately.
Followup Instructions:
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Infectious
Disease on [**2191-2-11**] at 11:00am. Call his office at [**Telephone/Fax (1) 457**]
with any questions.
ICD9 Codes: 486, 5849, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2023
} | Medical Text: Admission Date: [**2120-10-10**] Discharge Date: [**2120-10-20**]
Date of Birth: [**2040-9-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ferrous Sulfate
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x4 (Left internal mammary artery >
left anterior descending, saphenous vein graft > diagonal,
saphenous vein graft > obtuse marginal, saphenous vein graft >
right coronary artery) [**2120-10-10**]
History of Present Illness:
80F, Russian speaking. Reports chest discomfort over the
previous two months, worse with humidity, and responsive to
nitroglycerin. Describes discomfort in the left shoulder
radiating to the left chest and down left arm. Stress test was
abnormal. Cath reveals severe 3 vessel Coronary Artery Disease.
She is referred for surgical revascularization.
Past Medical History:
Coronary Artery Disease
Bilateral Patellofemoral Osteoarthritis
Hypertension
Hemolytic Anemia
Hyperlipidemia
Anxiety
Social History:
She is married and lives with her husband,
She emigrated to US 3.5 years ago.
Cigarettes: Smoked no [x]
ETOH: denies
Family History:
non contributory
Physical Exam:
Pulse: 61SR Resp: 12 O2 sat: 100%RA
B/P Right: Left: 140/68
Height: Weight: 133lb
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] none_
Varicosities: minor
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: cath Left:2+
Carotid Bruit no bruits
Pertinent Results:
CXR [**10-14**]
PA AND LATERAL CHEST:
Chest tubes and mediastinal drains have been removed. A right IJ
line again extends to the cavoatrial junction. There is
decreased pulmonary vascular congestion and edema. There is a
persistent small right subpulmonic effusion and likely trace
left pleural effusion. There is no pneumothorax. Right
hemidiaphragm remains elevated, with atelectasis at the right
lung base. Additional atelectasis is seen in the left base,
though the aeration here is improved from prior study.
Cardiomediastinal contour is unchanged. Sternotomy wires remain
aligned.
IMPRESSION:
1. Interval removal of mediastinal drains and chest tubes.
Persistent right and likely trace left pleural effusions. No
pneumothorax.
2. Decreased atelectasis, with improved aeration of the left
base compared to prior study.
3. Resolution of pulmonary edema.
Echocardiogram [**10-10**]
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Normal LV
cavity size. Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Normal aortic arch
diameter. Simple atheroma in aortic arch. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]S.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results at time of surgery.
POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Biventricular function is unchanged. Mitral
regurgitation is unchanged. Tricuspid regurgitation is
unchanged. The aorta is intact post-decannulation.
[**2120-10-15**] 04:32AM BLOOD WBC-5.0 RBC-3.72* Hgb-11.0* Hct-33.1*
MCV-89 MCH-29.5 MCHC-33.2 RDW-14.8 Plt Ct-179
[**2120-10-11**] 02:09AM BLOOD PT-13.3 PTT-30.3 INR(PT)-1.1
[**2120-10-18**] 06:13AM BLOOD Glucose-106* UreaN-22* Creat-0.8 Na-143
K-4.8 Cl-107 HCO3-26 AnGap-15
Brief Hospital Course:
Ms [**Known lastname 79959**] was admitted for same day surgery and underwent
coronary artery bypass graft surgery. Of note she had issues
with bleeding in her endovein harvest site from her left leg in
the operating room and postoperatively. See operative report
for further details. She received cefazolin for perioperative
antibiotics and was transferred to the intensive care unit for
post operative management. She remained intubated overnight and
on neosynephrine for blood pressure management. The leg
continued to ooze and it was monitored overnight with a hemovac
for drainage. Blood transfusions were required for a decreased
hematocrit. On post operative day one she had no further
bleeding from the leg, she was weaned from sedation, awoke, and
was extubated without complications. She was started on
betablockers and then on post operative day two started on
lisinopril for blood pressure management. Additionally she was
started on lasix for diuresis. She was transferred to the floor
on post operative day two for the remainder of her care.
Physical therapy was consulted for strength and mobility. She
continued to progress slowly and was ambulating with a walker.
Wound care was consulted for skin impairment of left leg with no
evidence of infection.Twice daily softsorb dressing changes were
recommended. Keflex was re-started prophylactically. She will
be seen early next week for a wound check. The wound service
stated that they would be happy to be paged for consultation
during that out-patient wound check if there continue to be
concerns. By post-operative day eight she was ready to be
discharged to home. All appropriate follow-up appointments were
advised.
Medications on Admission:
Norvasc 5 mg po daily
Atenolol 25 mg po daily
Folic acid 1 mg daily
Propranolol 80 mg daily
Simvastatin 20 mg daily
Aspirin 81 mg daily
Santura XR 60 mg daily
Nitrostat 0.4 prn
Discharge Medications:
1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. 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. Sanctura XR 60 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
6. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 weeks.
Disp:*56 Capsule(s)* Refills:*2*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 14 days.
Disp:*28 Tablet(s)* Refills:*2*
11. wound care
Softsorb dressing to left leg wounds two times each day for two
weeks. Wash wounds gently with soap and pat dry daily with a
towel.
Discharge Disposition:
Home
Facility:
tbd
Discharge Diagnosis:
Coronary artery disease s/p CABG
Hypertension
Hyperlipidemia
Anxiety
Hemolytic anemia
Osteoarthritis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with walker
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - with multiple abrasions along medial calf
Edema - 1 to 2+ bilat
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check cardiac surgery office - [**Telephone/Fax (1) 170**]
Date/Time:[**2120-10-22**] 11:00
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2120-11-13**] 1:30
PCP/Cardiologist: Dr [**Last Name (STitle) 3357**] [**Telephone/Fax (1) 4606**] on [**2120-11-14**] 2:45pm
**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:[**2120-10-18**]
ICD9 Codes: 2859, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2024
} | Medical Text: Admission Date: [**2157-6-20**] Discharge Date: [**2157-7-5**]
Date of Birth: [**2097-2-13**] Sex: F
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: The patient is a 50-year old
female with a history of hypertension, diabetes mellitus,
hypercholesterolemia, and glottic/subglottic stenosis with an
esophageal by computer tomography who was admitted for a
workup of this mass.
The patient first developed neck pain and persistent phlegm
and a hoarse voice approximately six months ago. The patient
was initially treated conservatively with antibiotics and
saline mist with some improvement in the hoarseness of her
voice, but no complete resolution of symptoms. Evaluation by
bronchoscopy showed a laryngeal mass. The mass was biopsied
but reportedly was benign.
A follow-up neck computer tomography showed a high-grade
narrowing of the glottic and subglottic airway with extensive
edema and soft tissue thickening as well as an esophageal
mass impinging on the trachea. She has recently noticed
worsening neck pain with the left greater than right and
odynophagia. However, the patient denies any fevers, chills,
chest pain, or shortness of breath.
PAST MEDICAL HISTORY: Hypertension.
Type 2 diabetes mellitus.
Chronic sinusitis.
Asthma.
Hypothyroidism.
Hypercholesterolemia.
Gastroesophageal reflux disease.
Glaucoma.
History of kidney stones.
PAST SURGICAL HISTORY: Status post total abdominal
hysterectomy.
Status post toe surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. TriCor 54 mg once per day.
2. Prednisone 5 mg by mouth every other day (for asthma).
3. Levoxyl 75 mcg by mouth once per day.
4. Albuterol as needed.
5. Protonix 40 mg by mouth once per day.
6. Lipitor 40 mg by mouth once per day.
7. Avapro 300 mg by mouth once per day.
8. Metolazone 5 mg by mouth once per day.
9. Potassium chloride 10 mEq by mouth twice per day.
10. Lasix 80 mg by mouth once per day.
11. Actonel 35 mg by mouth every week.
12. Vitamin D.
13. Calcium.
14. Humalog sliding scale.
15. Lantus 27 units in the evening.
16. Flovent 2 puffs twice per day.
17. Alphagan 0.15 percent twice per day.
18. Actos 30 mg by mouth once per day.
19. Albuterol nebulizers as needed.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
temperature was 98, heart rate was 86, blood pressure was
136/64, respiratory rate was 20, and 96 percent on room air.
In general, in no acute distress. Awake and alert. Head,
eyes, ears, nose, and throat examination revealed
normocephalic and atraumatic, anicteric. Pupils equal, round
and reactive to light. OC/OP clear. The chest was clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. The abdomen was soft,
nontender, and nondistended. Extremities revealed 1 plus
pitting edema of the bilateral lower extremities.
RADIOLOGY: A computer tomography from [**2157-6-1**] showed
high-grade narrowing of the glottic and subglottic airway
with extensive edema and soft tissue thickening. There was a
soft tissue density at the level of the glottis which
appeared to cause obstruction of laryngeal cartilage and
extended laterally to the cartilage. There was a proximal
esophageal mass displacing the trachea anteriorly.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to
undergo an ENT evaluation and possible biopsy. This took
place on [**2157-6-21**]. The patient was taken to the
operating room and underwent a laryngoscopy, esophagoscopy,
and three biopsies.
The patient was noted to have a normal esophageal mucosa. No
lesions or masses were seen. There was a sluggish right
vocal cord, a normal right vocal cord, and a normal left
vocal cord. There was no glottic or subglottic mass seen.
The [**Doctor Last Name 19634**] formed sinuses were clear. This was an
essentially a normal examination. Please see the dictated
Operative Note for further details.
Postoperatively, the patient was found to have right-sided
back pain - pleuritic in nature - and difficulty breathing.
The patient denied any chest pain, abdominal pain, nausea, or
vomiting. The patient received albuterol and Atrovent
nebulizers without improvement. A bedside laryngoscopy
showed laryngeal edema; unchanged from appearance in the
Operating Room. A chest x-ray showed dulled costophrenic
angles consistent with effusions, but no pneumomediastinum.
Because the patient had undergone a rigid esophagoscopy,
there was some concern that the patient may have received an
esophageal perforation; however, the chest x-ray did not show
this. The other concern was that the patient was having
possible bronchospasm. The patient was therefore given
Decadron 10 mg intravenously and kept nothing by mouth. The
patient was also continued on her nebulizer treatments.
A chest computer tomography was obtained later that day which
showed an interval development of a right-sided pneumothorax
and pneumomediastinum with ill-definition of the inferior
esophagus and new bilateral pleural effusions. Therefore,
the patient was returned to the Operating Room with the
Thoracic Surgery Service and underwent a right thoracotomy
with repair of an esophageal perforation along with an open
gastrostomy and open jejunostomy. The perforation was
approximately 1 cm long in the right anterolateral mid
esophagus. A right neck mass was also removed and sent for
pathology. The pathology on that mass later came back
showing a benign cyst outlined by respiratory epithelium with
acute and chronic inflammation with fibrosis; most consistent
with a bronchogenic cyst. Please see the dictated Operative
Note for further details of the operations.
The patient was started on imipenem postoperatively, and the
endotracheal tube was switched from a double to a single
lumen tube. On postoperative day one, the patient spiked a
temperature to 101.9 degrees and was pan-cultured. All
cultures taken in the Operating Room came back negative;
however, the Operating Room cultures taken during the repair
of the esophagus later showed methicillin-resistant
Staphylococcus aureus along with sparse growth of
Enterococcus and Streptococcus viridans. As a consequence,
the patient was switched from imipenem to vancomycin; to
which imipenem was then added back. The patient was
ultimately discharged on vancomycin and meropenem for a total
6-week course.
On postoperative day three, the patient continued to be
stable and was extubated without incident. On postoperative
day five, the patient's tube feeds were started via the
jejunostomy tube. Over the course of the next several days
tube feeds were advanced without incident. The patient's
chest tubes were changed from bulb suction to water seal on
postoperative day seven. Also on postoperative day seven,
the patient was noted to have some right arm swelling. The
patient underwent a right upper extremity ultrasound which
showed no deep venous thrombosis. The swelling in the leg
resolved by the time of the patient's discharge.
On postoperative day eight, the patient underwent an upper
gastrointestinal swallowing evaluation which showed no
evidence for a leak. On postoperative day nine, as the
patient continued to do well, the patient's chest tube was
removed. An Infectious Disease consultation was obtained; in
which the total 6-week course of vancomycin and
imipenem/meropenem was recommended. The patient was also
started on a clears diet, which she tolerated well.
Over the next several days, the patient was kept in house due
to continual spiking of fevers. As noted above, all blood
cultures were negative. However, the patient did have chest
x-rays showing right middle lobe and right lower lobe
parenchymal opacities consistent with either atelectasis or
pneumonia. Therefore, the patient received aggressive chest
physical therapy; especially on the right. On postoperative
day eleven, the patient was noted to have a hematocrit of
22.5, for which she received 1 unit of packed red blood cells
- bringing her hematocrit up to 30.5.
On postoperative day thirteen, the patient underwent a chest
computer tomography with and without contrast in which
loculated pleural effusions were seen at the right lung base.
One of these effusions was drained using computed tomography-
guidance and later showed no growth on culture.
DISCHARGE DISPOSITION: As the patient's temperature spikes
had subsided, a peripherally inserted central catheter line
was placed on postoperative day fourteen, and the patient was
discharged to home with services in good condition.
DISCHARGE DIAGNOSES: In addition to the admission diagnoses
listed above, the patient had an esophageal perforation;
status post esophageal repair and a benign right mediastinal
cyst outlined by respiratory epithelium (most consistent with
a bronchogenic cyst).
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with services.
MEDICATIONS ON DISCHARGE:
1. Prednisone 5 mg by mouth every other day.
2. Levoxyl 75 mcg by mouth once per day
3. Albuterol 1 to 2 puffs q.4h. as needed.
4. Fluticasone 2 puffs twice per day.
5. Protonix 40 mg by mouth once per day.
6. Lipitor 40 mg by mouth once per day.
7. Irbesartan 300 mg by mouth once per day.
8. Metolazone 5 mg by mouth once per day.
9. Lasix 80 mg by mouth once per day.
10. Potassium chloride 10 mEq by mouth twice per day.
11. Actonel 35 mg by mouth every week.
12. Lantus 37 units subcutaneously in the evening.
13. Humalog insulin sliding scale.
14. Pioglitazone 30 mg by mouth once per day.
15. TriCor 54 mg by mouth once per day.
16. Brimonidine tartrate 0.2 percent 1 drop ophthalmic
twice per day.
17. Metoprolol tartrate 25 mg by mouth twice per day.
18. Meropenem 1000 mg intravenously q.8h. (times 28
days).
19. Vancomycin 1000 mg intravenously q.12h. (times 28
days).
DISCHARGE FOLLOWUP: The patient was instructed to call and
schedule a follow-up appointment in one to two weeks with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**].
The patient was instructed to call and schedule a follow-up
appointment in one to two weeks with Dr. [**First Name (STitle) **] [**Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 7082**]
Dictated By:[**Last Name (NamePattern1) 15517**]
MEDQUIST36
D: [**2157-7-14**] 16:41:36
T: [**2157-7-14**] 17:53:12
Job#: [**Job Number 55988**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2025
} | Medical Text: Admission Date: [**2111-6-12**] Discharge Date: [**2111-6-29**]
Date of Birth: [**2029-11-22**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Unstable neck fracture
Major Surgical or Invasive Procedure:
Occipito cervical fusion O to C4 fusion
History of Present Illness:
81M with PMHx of primary speech apraxia, DM2, COPD, asbestosis,
and recent fall for which he was admitted and placed in a
[**Location (un) 2848**]-J collar (noted to have an old C1-C2 fracture) who
presents from rehab with concern for ill-fitting collar and
possible mental status changes. Patient was discharged to rehab
yesterday to rehab, and was reportedly complaining of nausea,
anorexia, dizziness, and headache. There was a question of
worsening of his apraxia. He required a 1:1 sitter last night
for agitation and was sent to the ED from his rehab for further
evaluation.
In the ED, initial VS were 98 90 157/70 15 95%. Labs were
significant for stable hyponatremia & anemia. Preliminary read
of non-contrast head CT showed no acute process. U/A was
negative. Patient did not receive any medications or fluids in
the ED; they did note that the patient fell asleep twice during
interview. Patient was seen by neurosurgery who felt that his
mental status was at baseline. They determined that there was no
acute neurosurgical issues and that his C-collar was
appropriately fit. Patient reportedly denied weakness or gait
abnormalities. Patient was admitted to medicine for placement,
as his rehab facility refused to take him back. Vital signs on
transfer were 98.5 ??????F (36.9 ??????C), Pulse: 99, RR: 16, BP: 139/70,
O2Sat: 94%RA.
On arrival to the floor, patient appears calm and comfortable.
Communication is difficult [**1-29**] apraxia, but pt able to answer
yes/no. He correctly circled (on a piece of paper) that he is at
the hospital and said "no" when asked if he was in pain.
Past Medical History:
Copd, Asbestosis, Diabetes, primary speech apraxia
Social History:
Widowed, Remote ETOH and Smoking history, lives in
[**Hospital3 **] in [**Location 7182**] : [**Street Address(2) 101207**].
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O:
T: 98 BP: 157/70 HR:90 R 15 O2Sats 95%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: at baseline dysarthria. Primarily communicates by
writing
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-2**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right: + + + + +
Left + + + + +
PHYSICAL EXAMINATION ON DISCHARGE:
same
Pertinent Results:
[**2111-6-12**] Head CT:
IMPRESSION: No evidence of acute intracranial process.
[**2111-6-12**] CXR:
IMPRESSION: Extensive bilateral calcified pleural plaque, likely
reflecting prior asbestos exposure. No signs of superimposed
pneumonia.
[**2111-6-12**] 07:56PM URINE HOURS-RANDOM
[**2111-6-12**] 07:56PM URINE GR HOLD-HOLD
[**2111-6-12**] 07:56PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2111-6-11**] 07:02AM GLUCOSE-101* UREA N-10 CREAT-0.5 SODIUM-126*
POTASSIUM-4.3 CHLORIDE-88* TOTAL CO2-29 ANION GAP-13
[**2111-6-11**] 07:02AM WBC-8.0 RBC-4.18* HGB-12.8* HCT-38.7* MCV-93
MCH-30.7 MCHC-33.1 RDW-13.6
[**2111-6-11**] 07:02AM PLT COUNT-266
Brief Hospital Course:
Initially, the patient was admitted to the medical service. An
extensive conversation with the HCP was had, who felt the
patient was at his baseline. He was noted to be hypovolemic, no
worse than previous admission, and this was felt to be secondary
to hypovolemia, so he was managed with gentle IV hydration. He
was transferred to the neurosurgery service for work-up of his
cervical spine fracture.
On [**6-14**], after discussion with the HCP, it was determined that
the patient would be electively intubated on [**6-15**] and placed in
traction prior to undergoing occipital-cranial fusion. He
remained hyponatremic with a sodium of 125. On [**6-16**], patient
remained intubated. He was taken out of traction in CT scanner
for a CT c-spine which showed stable c1/c2 fracture with good
reduction. On exam, MAE and squeezes hand. He was pre-oped for
OR on [**6-17**]. On [**6-17**] he was stable in the ICU, intubated, and on
cervical traction while awaiting OR for occipital to C2 fusion.
C0-C4 fusion was performed on [**6-17**] without any intraoperative
complications.On [**6-18**] patient remained stable, intubated in the
ICU. He was leethargic, but opened his eyes, squeezes hands and
moves toes bilaterally on command. Bronchoscopy showed airway
edema necesitating General Surgery consult for tracheostomy.
Traheostomy was performed on [**6-20**], he remained in the ICU until
[**6-23**] when he was transferred to floor. He was evaluated by
Speech Therapy prior to his transfer, on [**6-22**] and was seen again
once he was on the floor. On [**6-24**] he failed the speech and
swallow study and poorly tolerated his PMV. At that time PEG was
suggested but both patient and his HCP/nephew declined the PEG
citing limited evidence that it would improve his survival.
After further discussion on [**6-25**] the patient changed his mind
and agreed to have the PEG placed. PEG was placed on [**6-26**], tube
feeds were started on [**6-27**] and stopped. Tube feeds restarted on
[**6-28**] and found to be at goal per GI. Staples removed from
incisional wound on [**6-29**].
Medications on Admission:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH TID copd
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID Patient may refuse. Hold if
patient has loose stools.
5. FoLIC Acid 1 mg PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH TID copd
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Omeprazole 20 mg PO DAILY
11. Quinapril 10 mg PO DAILY
12. Simvastatin 20 mg PO DAILY
13. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
14. Tamsulosin 0.4 mg PO HS
15. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Vitamin D 800 UNIT PO DAILY
2. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *Ultram 50 mg 1 Tablet(s) by mouth Q6H:PRN Disp #*100 Tablet
Refills:*0
3. Tamsulosin 0.4 mg PO HS
4. Simvastatin 20 mg PO DAILY
5. Senna 1 TAB PO BID
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Quinapril 10 mg PO DAILY
Hold for SBP < 100
8. Multivitamins 1 TAB PO DAILY
9. Heparin 5000 UNIT SC TID
10. FoLIC Acid 1 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
Patient may refuse. Hold if patient has loose stools.
12. Bisacodyl 10 mg PO/PR DAILY
13. Ipratropium Bromide Neb 1 NEB IH Q6H
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Odontoid type 2 fracture unstable.
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? Dressing may be removed on Day 2 after surgery.
?????? If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? If you are required to wear one, wear your cervical collar or
back brace as instructed.
?????? You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any medications such as Aspirin unless directed by
your doctor.
?????? Unless you had a fusion, you should take Advil/Ibuprofen
400mg three times daily
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Physical Therapy:
activity as tolerated.
Brace to be worn out of bed while ambulating. No need of brace
in bed or in chair.
Treatments Frequency:
see discharge instructions.
Keep incisions dry
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in [**7-7**] days (from date of surgery)
for removal of your staples/sutures and/or a wound check. This
appointment can be made with the Physician Assistant or [**Name9 (PRE) **]
Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 2 weeks.
??????You will need x-rays/CT-scan prior to your appointment.
Completed by:[**2111-6-29**]
ICD9 Codes: 2761, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2026
} | Medical Text: Admission Date: [**2143-7-12**] Discharge Date: [**2143-7-24**]
Date of Birth: [**2093-7-6**] Sex: F
Service: MEDICINE
Allergies:
Protonix / Cephalosporins / Penicillins / Tetracycline /
Gentamicin / Heparin Agents / Benzodiazepines / Trusopt /
Clindamycin / Dipivefrin / Lovenox / Erythromycin Base /
Etanercept / Remicade / Versed / Pantoprazole / Sulfa
(Sulfonamides) / Trimethoprim / Doxycycline
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
OSH tranfter for antibiotics and access.
Major Surgical or Invasive Procedure:
Portacath Placement
Femoral Line Placement
s/p Cardiopulmonary Resuscitation
Intubation
History of Present Illness:
50 y.o. female with a past medical history of idiopathic
clotting disorder with known subclavian DVT and IJ thrombus and
multiple antibiotic allergies was transferred from an OSH for
further treatment of bacteremia and needing IV access on [**7-12**].
.
Patient was recently admitted to [**Hospital1 18**] from [**Date range (1) 92890**] with
complaints of hip pain secondary to bilateral avascular necrosis
of hip. According to the discharge summary, there was much
discussion regarding whether she would have surgery at [**Hospital1 15204**] (who would not admit her for urgent surgery and
recommended outpatient surgery), at [**Hospital1 18**] (evaluated by ortho
who recommended outpatient surgery), [**Hospital1 2025**] (who declined accepting
her), or [**Hospital1 112**]. She ultimately was discharged to the [**Hospital1 112**] ED for
immediate surgical evaluation. During that admission, she had
chronic pain requiring IV dilaudid. She had a PICC line placed
for administration of IVIg for her common variable
immunodeficiency.
.
Patient then presented to OSH on [**2143-7-10**] with fever and
bilateral lower extremity cellulitis. An additional source was
thought to be PICC line infection, so the line was pulled;
however, no additional access was obtained despite attempts by
surgery and IR at OSH. Possible sources for patient's fever
included RUE septic thrombophlebitis (at site of old PICC line)
and bacteremia (blood culture growing GPC on [**2143-7-11**]). ID at OSH
was recommending IV vancomycin, although no access could be
obtained. Patient was reportedly receiving IM daptomycin,
although it is unclear if she actually received a dose.
.
Since admission to [**Hospital1 18**] on [**7-12**], she was treated for
possible cellulitis at PICC line site. She was treated with
Vancomycin/Daptomycin for possible sepsis from this same line.
OSH culture grew Gram + rods found to be Staph Epi, likely
contamination. The site was deemed unlikely cellulitis as she
had no warmth, and it was blancheable. Blood cultures were
negative x 5 days and on [**7-18**], vancomycin was discontinued. As
she has CVID, she had a port-a-cath placed in place of her PICC
for IVIg on [**7-17**]. There was a question of whether this line
could be used or not. She developed LLE pain thought to be
cellulitis vs. RSD.
.
On the evening of [**2143-7-18**], the patient refused her PO pain
medications at approximately 8:05 PM. Per Ms. [**Known lastname **] RN, the
patient was shaking and shivering, although she was alert and
oriented. She had a temp of 102. At approximately 10 PM, the
patient was given IV dilaudid 0.5 mg for chronic pain and then
was "babbling," hyperventilating, and praying with the hospital
Chaplain in broken speech. Workup for AMS included CXR, blood
cultures, and urine cultures. Haldol 25 mg was given at
midnight and again 20 minutes later (NOTE: on review of [**Month (only) 16**], no
record of Haldol was seen in chart for that date). 2 mg Ativan
was given for possible seizure activity as witnessed by leg
tremulousness and eye rolling. The patient then became blue and
unresponsive, pulseless, and arrested for approximately 20
seconds. CPR was begun; a CODE BLUE was called. She was found
in PEA arrest and quickly restored pulse and spontaneous
breathing. A femoral line was placed and the patient was
intubated for airway protection. She was then transferred to
the MICU for further care.
.
MICU Course: She was initially hypercarbic on initial ABG after
intubation. She was oxygenating fine and tolerated a PSV trial
and was extubated on [**2143-7-19**]. She is currently comfortable on 2
L NC. She was febrile and placed on empiric antibiotics. These
were stopped her second day in the MICU. All of her culture
data remained negative. Her sedation and opiods were stopped
and then gradually reintroduced. She was eventually stable on
oxycontin 60 [**Hospital1 **] and Dialudid 4 mg po prn. Interventional
radiology reassessed her port, which they deemed patent,
uninfected, and useable. She completed her treatment for
cellulitis.
.
She was transferred to the Medicine team on [**7-21**] for pain
control.
Past Medical History:
Morbid Obesity
Common variable immune deficiency
Vasculitis (on Prednisone for 15 years)
Bilateral upper ext dvt (on fondaparinux for 4 years)
Pickwickian syndrome
Depression
Sleep apnea (home O2 1.5L)
Hashimoto's thyroid disease
hx of VRE, MRSA
hx of ERCP
Social History:
27 years x 1 ppd tobbacco, denies alcohol, IVDU
Family History:
Father with DM and CAD in 70s
Physical Exam:
ADMISSION:
===========
101.4 93/44 88 22 96% O2 Sat on AC 100% 500 x 16
Gen: morbid obesity intubated and sedated
HEENT: MMM
NECK: Supple, No LAD, Cannot assess JVD
CV: very distant heart sounds RR, NL rate. NL S1, S2. could not
appreciate murmurs/rubs/gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: + BS, obese, Soft, NT, ND. NL BS. No HSM
EXT: left lower extremity with slight erythema with no warmth or
induration; SKIN:
NEURO: Sedate and intubated, [**12-18**]+ reflexes, equal BL.
TRANSFER TO MEDICINE:
=====================
98 102/54 66 12 96% O2 Sat on 2 L NC
Gen: morbidly obese, comfortable appearing, sleepy, NAD
HEENT: MMM, anicteric, pupils 3 mm, equal, reactive
NECK: supple, no LAD, cannot assess JVD
CV: very distant heart sounds, RR, NL rate. NL s1, s2. Could
not appreciate any murmurs/rubs/gallops.
LUNGS: CTA, BS BL, no w/r/c, port in [**Doctor Last Name **] chest.
ABD: + BS, obese, soft, NTND, no HSM.
EXT: left lower extremity with slight erythema and no warmth or
induration.
NEURO: AAO x 3, no focal findings.
Pertinent Results:
ADMISSION LABS:
=================
10.5
7.7 >-----< 346 MCV 88
32.0
Neuts 51.8 Lymphs 31.8 Monos 10.2 Eos 5.2 Baso 1.0
138 93 15
-----|-----|------< 88
3.5 40 1.1
Ca 9.4 Phos 5.1 Mg 1.7
Fe 28 TIBC 339 Hapto 271 Ferritin 26
.
PERTINENT LABS DURING ADMISSION:
==================================
WBC trend: 7.7 - 10.6 - 6.1 - 8.5 - 7.6 - 9.0 - 12.3 - 11.9 -
9.3 - 6.9
Bicarbonate (range) 33 - 42
.
Potassium ([**7-19**]): 2.7 - 2.9
.
ABG (from earliest ABG to most recent):
7.76/27/104
7.48/55/74
7.47/60/41
7.47/57/339
7.40/66/118
.
Lactate ([**7-19**]): 3.9 - 1.7 - 0.9 - 0.9
.
Blood Cultures: 4 sets negative; 1 pending
Urine Culture: negative x 2
.
STUDIES:
========
CHEST (PORTABLE AP) [**2143-7-13**]
IMPRESSION: Line placement as described.
.
US GUID FOR VAS. ACCESS [**2143-7-17**]
FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE [**2143-7-17**]
IMPRESSION: Successful placement of a single lumen port catheter
through the left IJ . The tip of the catheter is located in the
distal SVC. The line is ready for use.
.
CHEST PORT. LINE PLACEMENT [**2143-7-18**]
Left Port-A-Catheter tip is in the mid SVC. Aside from discoid
atelectasis in the left lower lung, the lungs are clear.
Cardiomediastinal contour is unchanged compared to prior study
dated [**2143-7-13**] and is unremarkable. There is no pneumothorax
or pleural effusion.
.
CHEST (PORTABLE AP) [**2143-7-18**]
IMPRESSION: Low lung volumes with left lower lung zone
atelectasis.
.
CHEST (PORTABLE AP) [**2143-7-19**]
IMPRESSION: Low lung volumes, status post nasogastric tube and
endotracheal tube placement.
.
CT HEAD W/O CONTRAST [**2143-7-19**]
FINDINGS: There is no hemorrhage, mass effect, shift of the
normally midline structures, or major vascular territorial
infarct. The [**Doctor Last Name 352**]-white matter differentiation is preserved.
There is no hydrocephalus. The overlying soft tissues are
unremarkable. There is focal hyperostosis extending off the
outer table of the left occipital bone. Polypoid mucosal
thickening is seen within the left maxillary sinus and there is
mild mucosal thickening of the ethmoid air cells. The frontal
sinuses are hypoplastic. An endotracheal and nasogastric tube
are partially visualized.
.
IMPRESSION:
1. No hemorrhage or mass effect.
.
EKG [**2143-7-19**]
Sinus bradycardia. Modest prolonged QTc interval.
Intraventricular conduction defect. Non-specific inferolateral
ST-T wave changes. No previous tracing available for comparison.
.
EEG [**2143-7-20**]
IMPRESSION: This is a normal portable EEG in the primarily
sleeping
states. There were no regions of focal, lateralized, or
epileptiform
features noted.
.
RIB BILAT, W/AP CHEST [**2143-7-21**]
FINDINGS: Comparison to [**2141-7-19**]. There is a Port-A-Cath in
place with tip in the SVC. Linear subsegmental atelectasis is
seen at the lung bases, particularly on the left. No pleural
effusion or pneumothorax is noted. Cardiomediastinal silhouette
is within normal limits. No acute displaced rib fracture is
identified. Osseous structures are otherwise intact.
.
IMPRESSION:
No evidence of displaced rib fracture.
Brief Hospital Course:
Ms. [**Known lastname 4702**] is a 50 y.o. F with CVID, idiopathic clotting d/o
with known subclavian DVT and IJ thrombus, morbid obesity, and
several allergies admitted for BLE cellulitis and inability to
obtain access from OSH on [**7-12**], transferred to MICU s/p PEA
arrest (presumed [**1-18**] medication), and then transferred to
medicine floor for pain management.
.
# S/P Respiratory failure and PEA arrest: On [**7-18**], patient
s/p episode of incoherent speech with ?seizure activity. She
also received antipsychotics and benzodiazapene which would
depress her respiratory drive. Also, considered infectious
process because of CVID. A pre-code ABG was 7.76/27/104, and her
hyperventillation induced respiratory alkalosis contributed to
tiring out with associated electrolyte imbalances. She was
intubated for airway protection and was weaned off the
ventilator quickly. After extubation, she maintained O2
saturations in the upper 90's on 2L NC (her home oxygen
therapy).
.
# Acute mental status changes ([**7-18**]) of unknown etiology:
Possible mechanisms include sundowning, delirium in setting of
fevers/possible infection, medications (she received dilauded
before her delerium), stroke, seizures, electrolyte
disturbances. Head CT was negative. EEG negative. Her
electrolytes were repleted as needed, specifically her potassium
(unknown cause with accompanying anion gap lactic acidosis).
Her lactic acidosis was unlikely due to be sepsis with normal
BP, but she was febrile. Her mental status returned to baseline
quickly.
.
# Fevers, resolved: Possible etiologies include drug fevers,
infection, inflammatory process. Her blood cultures and her
urine cultures remained negative throughout her hospitalization.
Vancomycin and levoquin were empirically started while in the
MICU, but quickly stopped after patient remained afebrile
without an elevated WBC. Her WBC trend spiked at 12.3, but
returned to WNL without any signs or symptoms of infection while
on the medicine floor.
.
#. Cellulitis in LE: She completed a full course of antibiotics.
.
#. Bilateral AVN: Patient with persistent and longterm pain.
AVN most likely from long-term use of steroids. Continued her
home regimen of oxycontin 60 [**Hospital1 **] and dilaudid 4 mg po q4 hours
prn. Continued Vitamin D. Upon discharge, pt's pain at its
baseline.
.
# Chest pain secondary to chest compressions: Pt with MSK pain.
Rib series negative for displaced fractures. Continued her home
regimen of oxycontin and dilaudid prn. Counseled on slow healing
of bruising to chest.
.
# Common variable immune deficiency: Stable during
hospitalization. IVIG given on [**7-14**]. Next IVIG due this [**Month/Year (2) 1017**]
[**2143-7-28**]. She will receive this at her rehab center.
.
# BLE edema, improving: With 1-2+ pitting edema to ankles. Pt's
toresemide was re-started at a low dose upon return to the floor
due to somewhat low BPs. She tolerated this well, and her edema
improved. She may need to be placed back on her potassium pills
now that her diuretic has been restarted.
.
# HTN: Pt's SBPs in 100-120's, so all BP meds except toresamide
(restarted for edema) were held. She can follow up with her PCP
to consider need for BP meds.
.
# Clotting Disorder: Patient with multiple DVTs in the past.
Unknown etiology. As pt is nonambulatory, she was given
Fondaparinux 10 mg SC daily for weight-based dosing.
.
# Vasculitis: Unknown etiology. No active issues during
hospitalization. Continued methylprednisolone 8 mg PO every
other day
.
# Depression: Stable during hospitalization. Continued seroquel
and duloxetine.
.
# Hypothyroidism: History of Hashimoto's. Stable. Continued on
outpatient levothyroxine.
.
# Anemia: Has been stable at 28-30 while in hospital. Continued
folate and iron supplementaion.
.
# Sleep apnea (home O2 2L): Pt states that she had a sleep study
completed recently and was told that she did not need CPAP.
.
# Nosebleed x 2 during hospitalization: Was relieved with
pressure and Afrin. Pt stated that she occasionally has
nosebleeds. HCT always stable.
.
# Dry Cough: Started after extubation; most likely secondary to
intubation. Also consider bronchitis, but lung exam CTAB. No
WBC and afebrile, so did not treat with antibiotics. Cephacol
lozenges prn.
.
# Hypercholesterolemia: stable. Continued zocor and zetia.
.
# Aphthous Ulcers: viscous lidocaine prn
.
# Seasonal allergies: continued singulair
.
#. CODE: FULL CODE
.
#. COMM: [**Name (NI) **], [**Name (NI) **] [**Name (NI) 4702**] (Mother) - [**Telephone/Fax (1) 92891**]
.
#. Access: Portacath.
TO DO:
Check electrolytes now that diuretic has been restarted on
Thursday [**2143-7-25**].
[**Month (only) 116**] need to be on oral potassium replacement now that diuretic
has been restarted.
[**Month (only) 1017**] [**2143-7-28**] she needs IVIG.
Medications on Admission:
Folate 2mg PO daily
Spironolactone 25mg PO daily
Trazodone 200mg PO qhs prn sleep
Esomperazole 20mg PO bid
Calcium Carbonate 500mg PO qid
Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Duloxetine 40mg PO bid
Vytorin [**10-5**] 10-20mg PO daily
Fondaparinux 7.5mg SC daily
Methylprednisolon 8mg PO qod
Levothyrxoine 188mcg PO daily
Docusate 100mg PO bid
Simethicone 80mg PO qid
Vitamin D3 800U PO daily
Oxycontin SR 60mg PO bid
Seroquel 100mg PO qhs
Tylenol 650mg PO q6h
Benadryl 50mg PO q6h prn
Ondansetron 4mg PO q8h prn nausea
Discharge Medications:
1. Methylprednisolone 2 mg Tablet Sig: Four (4) Tablet PO QODHS
(every other day (at bedtime)).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO every twelve (12) hours.
13. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for chronic pain- home med.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
16. Fondaparinux 5 mg/0.4 mL Syringe Sig: Two (2) Subcutaneous
DAILY (Daily).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
19. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
21. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [**12-18**]
puffs Inhalation Q6H (every 6 hours) as needed.
22. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
23. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: [**12-18**] Lozenges
Mucous membrane Q4H (every 4 hours) as needed.
24. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed.
25. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
26. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical once a day as needed
for pain for 1 doses.
27. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
28. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for 3 days.
29. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
30. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal
QID (4 times a day) as needed.
31. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
s/p Cardiopulmonary arrest
Common Variable Immunodeficiency
Avascular necrosis of Bilateral Hips
Bilateral Lower Extremity Cellulitis
.
Secondary:
Morbid Obesity
Vasculitis
Bilateral Upper Extremity Deep Venous Thrombosis
Depression
Discharge Condition:
Stable.
Discharge Instructions:
You came into the hospital after being transferred from another
hospital for a possible infection. We tested your blood, urine
and lungs, and we found no source of infection. You also got a
Portacath which provides permanent access for your IVIG
treatments.
.
Please keep all medical appointments and take all your
medications as prescribed. We decreased your Demadex dose to 20
mg daily as your blood pressure was a little on the low side.
Please follow up with your primary care physician for further
management.
.
If you get a fever>102, significant chills, constant nausea or
vomiting, severe abdominal pain, constant diarrhea, or any other
concerning symptoms, please call your primary care physician and
report to the nearest Emergency Room.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-18**] weeks.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 21748**].
.
Please get your next IVIG treatment this [**Last Name (LF) 1017**], [**7-28**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2143-7-26**]
ICD9 Codes: 0389, 2762, 4275, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2027
} | Medical Text: Admission Date: [**2155-5-23**] Discharge Date: [**2155-5-28**]
Date of Birth: [**2101-12-1**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Keflex / Lisinopril / Insulin Glargine
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
palpitations and flushing
Major Surgical or Invasive Procedure:
pacemaker insertion
History of Present Illness:
The patient is a 53 yoF w/ a h/o CAD s/p CABG in [**2141**], DM II c/b
renal failure s/p renal tx in [**2132**] and again in [**2148**] presented
to [**Hospital6 4287**] initially on [**5-22**] with symptomatic
bradycardia. She had some flushing, warmth, palpitations and
abdominal discomfort (initially she attributed this to Thai food
which is unusual for her to eat).
.
At [**Hospital3 **] she was noted to have complete heart block with a
rate of 38. Her rhythm improved slowly to 1:1 conduction and she
was transferred to the [**Hospital1 **] for continued medication washout. (she
was on lopressor 100mg po qam and 150mg po qpm).
.
She states prior to her admission she felt palpitations while
changing and getting ready for bed, she said her pulse was fast
and would skip a beat every 4 or so beats. She did not feel
presyncope, no sycope then or recently. She felt warm and asked
her husband to call 911. She denies CP. She has had DOE upon
ambulation > 1 block x 1 week, stable [**2-26**] pillow orthopnea, no
PND, no leg edema. Her normal weight is 136-139 lbs, current
weight is 141.5 lbs. No abdominal pain, one episode of diarrhea
in the hospital the day prior to transfer to the [**Hospital1 **].
.
Initial VS: 98.3 38 150/50 12 100% RA
Transfer VS: 39 151/55 17 99% RA
.
In the ER she was given calcium gluconate 2g for CCB reversal
(also on nifedipine). She was admitted from the ER to the floor
with a diagnosis of 2:1 block and bradycardia, but a normal
blood pressure. Upon transfer from the ER stretcher to her floor
bed she was noted to become more bradycardia, from a rate of 40
to 28. Her block had worsened from 2:1 to 3:1. Her SBP was 150.
She had been experiencing nausea for 1 hour prior to her
transfer (after taking aspirin).
Past Medical History:
Diabetes Mellitus, Coronary Artery Disease s/p CABG, HTN, s/p
CRT failed '[**32**], [**Name8 (MD) **] CRT [**2148**], anemia, HCV
Social History:
lives with husband, works full time for [**Name (NI) 25120**] department at
[**Location (un) 25121**] AFB doing administrative desk work. Recent loss of
mother. [**Name (NI) 25122**] care of father at home. Normally does not use any
assistive devices.
Family History:
non contributory
Physical Exam:
PHYSICAL EXAMINATION:
VS: T= 98.5 BP= 150/100 HR= 30 RR= 13 O2 sat= 98% RA
GENERAL: NAD, AOx3
HEENT: unable to evaluate JVP, MMM, OP clear, EOMI, sclera
anicteric, conjunctiva pink
CARDIAC: bradycardic, 2/6 SEM best heard at USB
LUNGS: rales [**1-25**] way up bilaterally, no wheezes
ABDOMEN: Soft, mildly distended, non tender, no masses or
organomegaly
EXTREMITIES: WWP, no c/c/e
SKIN: stasis dermatitis of LE
Pertinent Results:
[**2155-5-28**] 05:10AM BLOOD WBC-5.2 RBC-3.38* Hgb-10.4* Hct-31.4*
MCV-93 MCH-30.7 MCHC-33.0 RDW-14.3 Plt Ct-165
[**2155-5-28**] 05:10AM BLOOD Glucose-158* UreaN-60* Creat-2.0* Na-140
K-5.1 Cl-107 HCO3-23 AnGap-15
[**2155-5-24**] 07:05PM BLOOD T4-11.3
[**2155-5-24**] 07:05PM BLOOD TSH-0.036*
[**2155-5-28**] 05:10AM BLOOD tacroFK-9.0
[**2155-5-27**] 05:44PM BLOOD tacroFK-8.1
.
Renal ultrasound [**2155-5-26**]:
HISTORY: 53-year-old woman with renal transplant.
COMPARISON: Renal ultrasound, [**2152-5-24**].
FINDINGS: Renal ultrasound was performed of the renal transplant
in the left hemipelvis. The renal transplant measures 12.3 cm.
There is no evidence of hydronephrosis or perinephric fluid.
Doppler evaluation of the transplant shows symmetric flow
through the kidney, and resistive indices range from 0.85 at the
upper pole, 0.82 to 0.88 at the mid pole, and 0.81 to 0.83 at
lower pole, and in the main renal artery of 0.89. Normal flow is
seen in the renal vein.
IMPRESSION:
1. Slight increase in resistive indices in all poles of the
transplant kidney compared to prior study, now ranging from 0.81
to 0.89.
2. No hydronephrosis or perinephric fluid.
.
CXR [**2155-5-24**]:
FINDINGS: Left-sided permanent pacemaker is present, with leads
terminating
in the right atrium and right ventricle, with no visible
pneumothorax. Heart remains enlarged, and there is mild
pulmonary vascular congestion. Small pleural effusion is
demonstrated on the right. Bones are demineralized and
demonstrate mild decreased height in the mid thoracic spine
without change since [**2154-3-13**].
IMPRESSION:
1. Pacing leads in standard position with no pneumothorax.
2. Mild CHF.
.
EP: placement of [**Company 1543**] ADAPTA [**Company **]
Brief Hospital Course:
#Complete Heart Block s/p [**Name (NI) 19721**]
Pt was admitted from [**Hospital6 2561**] with bradycardia,
found to be complete heart block at rate of 38. Received Calcium
IV. to reverse calcium channel blocker and beta blocker was
discontinued. Pt rec'd a BiV [**Hospital6 **] on [**2155-5-23**] with no
complications. Her Nifedipine and Metoprolol was resumed after
the [**Date Range **] was placed for BP control. She will follow up at the
device clinic at [**Hospital1 18**] 1 week after placement and with her
cardiologist, Dr. [**Last Name (STitle) **] for continued treatment of her CAD and
hypertension. Activity restrictions were reviewed with pt before
discharge.
#Acute on chronic Renal Failure s/p Transplant: Creatinine
increased to max of 2.4 during hospital stay and was 2.0 at
discharge. It was thought that she was pre-renal and her lasix
was initially held. She was followed by the renal transplant
team and her Prograf was decreased for high levels. She will be
followed by Dr. [**Last Name (STitle) **] after discharge and her creatinine and
prograf level will be checked at her device appt. Bactrim and
Prednisone was continued at previous dose.
#Acute on Chronic Diastolic congestive Heart Failure:
Fluid overload on lung exam over course of hospitalization in
setting of acute renal failure. Responded well to low dose IV
lasix. PO Lasix was restarted before discharge. Weight at
discharge was 64.7 kg.
#Hyperglycemia
[**3-4**] A1C 7.4, likely due to dietary indiscretion. Insulin
regimen from home was continued during hospital stay.
#Hypertension: Pt was restarted on previous doses of Nifedipine
and Metoprolol after pacemaker was placed. Clonidine was
decreased to 0.1 mg daily.
Medications on Admission:
Lasix 20mg po daily
Nifedipine 60mg po bid
Prednisone 5mg po daily
Prograf 2mg po bid
Metoprolol 150mg po qpm, 100mg po qam
HISS and NPH
Clonidine 0.1mg po daily
Pravachol 10mg po daily
Levothyroxine 250 mcg po daily
Bactrim DS one tab 3x/week
Aspirin 81 mg daily
Discharge Medications:
1. Outpatient Lab Work
Please check Chem 7 and Tacrolimus level on Friday [**5-30**] with
results to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 3618**]
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (3 times a week).
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day: Resume sliding scale and
NPH dose from before admission. .
11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
12. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO twice a
day.
Disp:*180 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Complete Heart block s/p Pacemaker
Acute on Chronic Renal Failure
Acute on chronic Diastolic Congestive Heart Failure
diabetes mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a very slow heart rate and a pacemaker was placed. No
lifting your left arm over your head or lifting more than 5
pounds for 6 weeks. You will have the device checked on [**5-30**] and
will then go every 6 months. We were also concerned about your
kidneys as your creatinine rose to 2.4 but is decreasing now.
The Nephrology team followed you and decreased your Prograf to
1.5 mg twice daily. Please get your creatinine and Prograf level
checked on Friday when you come in for your pacemaker check.
Medication changes:
1. Decrease Metoprolol to 100mg twice daily
2. Decrease Tacrolimus dose to 1.5 mg twice daily. You should
get your level drawn on Friday when you are at the device clinic
appt. Make sure that is has been 12 hours after your last dose
of Tacrolimus when you get the blood drawn. As your appt is at
9am, please take your Tacrolimus at 8pm the night before, get
the blood drawn at [**Hospital Ward Name 23**] before the device clinic and then
take the Tacrolimus after.
3. Decrease Clonidine to 0.1 mg once daily
.
Please check your blood pressure at home and call Dr. [**Last Name (STitle) **] if
your blood pressure is more than 160 or less than 100. You may
have to adjust your medicine.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Electrophysiology:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2155-5-30**] 9:00am.
[**Hospital Ward Name 23**] [**Location (un) 436**].
.
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: Wed [**6-25**] at
2:40pm.
Pulmonary:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2155-8-13**] 2:10
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2155-8-13**] 2:30
.
Nephrology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: ([**Telephone/Fax (1) 3618**] Date/time: [**6-16**] at
4:20pm.
.
Completed by:[**2155-6-3**]
ICD9 Codes: 5845, 5859, 2449, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2028
} | Medical Text: Admission Date: [**2200-10-19**] Discharge Date: [**2200-10-30**]
Date of Birth: [**2127-2-9**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old
female who presented to the medical center six weeks status
post ascending aortic aneurysm repair with aortic valve
replacement and coronary artery bypass graft times one with a
one day history of brownish drainage from a pin point opening
at the inferior pole of her sternal incision. The patient
reported that there had been no drainage from the incision
during her hospitalization here at [**Hospital1 190**] and during her subsequent discharge to a rehab
facility. There had been some moistness to the wound. The
patient denied any history of fevers, chills, increasing
pain, increasing erythema to the incision, respiratory
symptoms or warmth. She did report that the wound had
sometimes been moist at the area.
PAST MEDICAL HISTORY: Hypertension, depression, peptic ulcer
disease, valvular heart disease.
PAST SURGICAL HISTORY: Aortic aneurysm repair.
MEDICATIONS: Prevacid 30 mg po q day, Percocet, Lactulose,
Remeron 15 mg po q.h.s., Trazodone 100 mg po q.h.s., Ativan
.5 mg po, Metoprolol 150 mg po b.i.d., aspirin 325 mg po q
day and Imipramine 25 mg po q.h.s.
PHYSICAL EXAMINATION: Vital signs 98.6, 88 and sinus,
135/64, 98% on room air. In general, the patient was well
appearing elderly female in no acute distress. Neck no
lymphadenopathy, supple. Cardiovascular regular rate and
rhythm, normal S1 and S2. Chest/lungs clear to auscultation
bilaterally. Healing sternal incision with minimal erythema,
approximately 5 mm open spot near the distal end of the
incision. Watery brownish fluid draining spontaneously with
thick brown pus expressible. Area soft, but not fluctuant.
Abdomen soft, nontender, nondistended. Extremities, the
right shoulder minimally tender to palpation, but with an
area of tenderness noted near the medial edge of the scapula
posteriorly with normal range of movement. The right calf
vein harvest site was healing well with a 5 cm gap at the
distal end with a healing rim of erythema.
LABORATORIES ON ADMISSION: CBC was 18.5, 27.9, 473.
IMAGING: Chest x-ray on admission showed no acute
cardiopulmonary process, left middle lobe atelectasis
unchanged from prior examination.
HOSPITAL COURSE: On arrival in the Emergency Department the
patient was seen by the Cardiothoracic Surgery team.
Antibiotic treatment was initiated in the Emergency
Department with the patient receiving a dose of Ancef.
Following transfer to the floor the patient's antibiotic
regimen was changed to Vancomycin and Levaquin. The decision
was made to incise and drain the patient's sternal wound in
the Emergency Department. This was done with expression of
moderate amount of brownish purulent material. The wound was
thereafter packed with gauze. The patient was transferred to
the Cardiothoracic Surgery floor for continued management.
On hospital day number two the wound was further explored
with pocket of purulent material drained. Antibiotic therapy
remained unchanged. On hospital day number three, which was
[**2200-10-21**] the decision was made to place a PICC line given the
fact that the patient would need long term antibiotic therapy
following discharge. Plastic Surgery consultation was also
requested. A decision was ultimately made to take the
patient to the Operating Room for sternal debridement and
rewiring of her sternum, which was noted to be separated.
This was documented on CAT scan with air being noted deep to
the sternum. The plastic surgery team would be involved and
would perform a pectoral flap. The patient was taken to the
Operating Room on [**2200-10-24**] and the patient's sternum
debrided, rewired and pectoral flap constructed. The patient
was extubated without complications and transferred to the
Cardiac Surgery Recovery Unit for continued monitoring.
Please note that although the patient preoperative urinalysis
was negative, the patient's urine culture ultimately grew
Vancomycin resistant enterococcus. Cultures from her sternal
wound ultimately grew MRSA. The patient was transferred back
to the Cardiothoracic Surgery Floor on postoperative day
number one. She had an uncomplicated recovery. Her sternal
wound was inspected daily and was noted to be improving by
the time of discharge. She was continued on Vancomycin and
Levaquin. Her white blood cell count was monitored and noted
to be decreasing by the time of discharge. The drainage from
her two [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains was also monitored. The JP
drains are expected to remain in place until the patient's
follow up appointment with the Plastic Surgery team on the
week following discharge. The patient's appetite remained
good during her entire admission. By postop day number five
the patient was deemed stable and ready for discharge to a
skilled nursing facility. The patient is expected to require
several weeks of intravenous antibiotic therapy following
discharge. No treatment was initiated specifically for the
VRE noted to be growing in the patient's urine given the fact
that the patient was entirely asymptomatic. It was suspected
that the organisms might have been a contaminant. The
patient's serum creatinine remained stable during the entire
admission.
The patient's hypertension was noted to be poorly controlled
early during her admission. She was at that time only on
Metoprolol. The decision was made to add Labetalol to the
patient's hypertensive medication regimen. The Metoprolol
was later discontinued and the Labetalol dose was increased
with apparent good control of her blood pressure.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Labetalol 600 mg po b.i.d., Colace
100 mg po b.i.d., Vancomycin 750 mg intravenous q 24 hours.
Heparin 5000 units subQ b.i.d. Prevacid 30 mg po q day.
Enteric coated aspirin 325 mg po q day. Folic acid 1 mg po q
day. Levofloxacin 500 mg po q day. Imipramine 25 mg po
q.h.s. 11. Senna two tablets po b.i.d. prn. Percocet one
to two tablets po q to 6 hours prn. Ativan .25 to .5 mg po q
4 to 6 hours prn. Simethicone 40 to 80 mg po q.i.d. prn.
Trazodone 100 mg po q.h.s. Milk of Magnesia 7 milliliters po
q 6 hours prn.
FO[**Last Name (STitle) 996**]P: 1. The patient is to call Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**]
office for follow up appointment following discharge. 2.
The patient is to follow up with Plastic Surgery team in
clinic on [**2200-11-4**]. She needs to call [**Telephone/Fax (1) 274**] for an
appointment. 3. The patient is to follow up with her
primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] following discharge.
DISCHARGE DIAGNOSIS:
Sternal wound infection following coronary artery bypass
graft.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2200-10-30**] 11:31
T: [**2200-10-30**] 11:35
JOB#: [**Job Number 10100**]
ICD9 Codes: 5180, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2029
} | Medical Text: Admission Date: [**2131-5-23**] Discharge Date: [**2131-6-28**]
Date of Birth: [**2064-7-16**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / Cefazolin / Coreg / Dopamine
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
foot infection, sepsis
Major Surgical or Invasive Procedure:
L toe ulcer debridement
thoracentesis
History of Present Illness:
Mr. [**Known firstname **] is a 66 y/o male patient of Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] with
diabetes c/b peripheral neuropathy, ulcers, and amputation, a
history of a pro-coaguable disorder requiring chronic
prophylaxis with enoxaparin and a neuropathic heel ulcer
presents with a week of fever, malaise, nausea/vomiting, and
change in mental status.
According to the family the patient was in his usual state of
health until one week PTA, when he had an episode of emesis. The
following day he went to [**Hospital3 **] but again had nausea
and emesis.
Two nights PTA the patient began to have worsening of his great
toe ulcer with redness and drainage. In addition he developed a
low grade temperature and increase malaise. In the emergency
room he was given ceftazidime and vancomycin. A code sepsis was
called and a central line was placed. Dopamine was started for
pressure support. The patient was sent to the ICU for further
management.
Upon arrival to the floor the patient was slightly lethargic but
alert & oriented x 3. An arterial line was placed, and the
patient was noted to have monomorphic ventricular tachycardia on
an EKG, during which the patient dropped his blood pressures. He
was changed from dopamine to neosynephrine and an EP consult was
obtained. The patient received a total of 1250cc of NS. Once on
neosynephrine his ventricular tachycardia resolved.
Vascular surgery came to evaluate the patient and incised his
toe wound. They isolated three pockets of pus and cultures were
sent.
Past Medical History:
DMII
CAD, ischemic cardiomyopathy EF 20%
Afib s/p ablation, pacemaker
SMA thrombosis with small bowel and large bowel infarcts status
post small bowel and large bowel resection and resulting short
gut syndrome
Bacterial peritonitis
PVD s/p R BKA
Hypercoagulable state, DVTs
Peripheral neuropathy
Plantar fasciitis
CVA
PV
Nonhealing anal fissure
Social History:
Mr. [**Known lastname 21212**] is a retired systems programmer for a management
consulting
firm. He is married with no children.
He denies alcohol, tobacco or drug use. Prior 3 yrs of tobb
abuse.
Family History:
Family history is negative for hypercoagulable state, PVD
Physical Exam:
PE: HR 75, ABP 102/61, O2 97%
Gen: Lying in bed in mild distress.
HEENT: NCAT, MMM. RIJ in place.
CV: RRR
Chest: CTA bilaterally on anterior exam other than slight
crackles at right lower base.
Abd: Scaphoid, benign.
Ext: Patient with BKA on left foot. Right toe is ulcerated and
erythematous with streaking cellulitis 2/3 up shin to knee.
Neuro: Complaining, arousable, A&O x 3.
Pertinent Results:
[**2131-5-23**] 08:33AM BLOOD WBC-18.6* RBC-5.43# Hgb-14.6# Hct-44.5#
MCV-82# MCH-26.9*# MCHC-32.8 RDW-20.2* Plt Ct-287
[**2131-5-23**] 08:33AM BLOOD Neuts-91.7* Bands-0 Lymphs-5.7*
Monos-1.8* Eos-0.6 Baso-0.2
[**2131-5-23**] 02:34PM BLOOD WBC-24.1* RBC-5.68 Hgb-15.5 Hct-47.1
MCV-83 MCH-27.4 MCHC-33.0 RDW-20.3* Plt Ct-350
[**2131-5-24**] 04:13AM BLOOD WBC-20.1* RBC-5.05 Hgb-14.0 Hct-41.2
MCV-82 MCH-27.7 MCHC-33.9 RDW-20.6* Plt Ct-384
[**2131-5-25**] 04:36AM BLOOD WBC-14.6* RBC-4.76 Hgb-12.6* Hct-39.0*
MCV-82 MCH-26.6* MCHC-32.4 RDW-20.5* Plt Ct-335
[**2131-5-24**] 04:13AM BLOOD PT-21.8* PTT-39.1* INR(PT)-2.1*
[**2131-5-25**] 04:36AM BLOOD PT-18.2* PTT-78.8* INR(PT)-1.7*
[**2131-5-25**] 11:15AM BLOOD PT-17.6* PTT-44.1* INR(PT)-1.6*
[**2131-5-23**] 08:40AM BLOOD Glucose-222* UreaN-60* Creat-1.8* Na-133
K-4.5 Cl-103 HCO3-15* AnGap-20
[**2131-5-23**] 02:34PM BLOOD Glucose-149* UreaN-60* Creat-1.9* Na-133
K-4.3 Cl-101 HCO3-17* AnGap-19
[**2131-5-25**] 04:36AM BLOOD Glucose-118* UreaN-47* Creat-1.7* Na-136
K-4.4 Cl-111* HCO3-15* AnGap-14
[**2131-5-23**] 08:40AM BLOOD ALT-25 AST-18 LD(LDH)-423* CK(CPK)-116
AlkPhos-84 TotBili-0.9
[**2131-5-24**] 04:13AM BLOOD ALT-22 AST-13 LD(LDH)-335* AlkPhos-76
TotBili-0.6
[**2131-5-23**] 08:40AM BLOOD CK-MB-6 cTropnT-0.07* proBNP-[**Numeric Identifier 23738**]*
[**2131-5-23**] 08:40AM BLOOD Lipase-27
[**2131-5-23**] 08:40AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.6
[**2131-5-23**] 02:34PM BLOOD Calcium-8.1* Phos-3.8 Mg-1.8
[**2131-5-24**] 04:13AM BLOOD Albumin-3.4 Calcium-7.9* Phos-5.3*
Mg-2.9*
[**2131-5-23**] 08:40AM BLOOD Cortsol-29.9*
[**2131-5-23**] 08:40AM BLOOD CRP-85.4*
[**2131-5-24**] 03:58PM BLOOD Vanco-19.2
[**2131-5-23**] 02:34PM BLOOD Digoxin-0.8*
[**2131-5-23**] 03:02PM BLOOD Type-ART Temp-35.7 Rates-/14 O2 Flow-6
pO2-84* pCO2-35 pH-7.26* calTCO2-16* Base XS--10 Intubat-NOT
INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2131-5-24**] 04:29PM BLOOD Lactate-1.4
[**2131-5-23**] 03:02PM BLOOD Lactate-0.9
[**2131-5-23**] 08:49AM BLOOD Lactate-1.6
FOOT 2 VIEWS LEFT [**2131-5-23**] 8:51 AM
FINDINGS: Bedside AP and lateral views (the former, degraded by
motion- blurring) are compared with the study dated [**2130-11-28**].
There is now a small soft tissue defect at the tibial (medial)
aspect of the plantar soft tissues, overlying the base of the
1st distal phalanx. However, this does not appear to reach bone
on either view, with no subjacent subcutaneous emphysema or
retained radiopaque foreign body. There is no evidence of
periosteal reaction, cortical erosion or medullary lucency in
subjacent bone to specifically suggest osteomyelitis, and the
appearance of the remainder of the foot is unchanged, including
vascular calcification and prominent dorsal calcaneal
enthesophyte.
IMPRESSION: Known ulcer in the plantar soft tissues of the 1st
digit does not reach bone, with no radiographic sign of
osteomyelitis.
.
CHEST (PORTABLE AP) [**2131-5-23**] 8:51 AM
SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: A dual-lead
pacing device remains in unchanged position. Moderate
cardiomegaly, reaccumulation of an asymmetric large right
pleural effusion, and associated right perihilar hazy opacity
are suggestive of asymmetric pulmonary edema, and represent
decompensated mitral valve regurgitation. The left lung is
relatively clear. No discrete focal airspace consolidation is
identified. The bony thorax again demonstrates an S-shaped
scoliosis of the thoracic spine.
IMPRESSION: Asymmetric right-sided largely parahilar airspace
disease and re- accumulated large pleural effusion, as on
previous episodes. This may represent "atypcial" edema related
to decompensation of known mitral regurgitation; alternatively,
a pneumonic process cannot be completely excluded.
CHEST (PORTABLE AP) [**2131-5-24**] 3:36 AM
Allowing the difference in position of the patient, large right
pleural effusion. There has been interval increase in moderate
left pleural effusion. Mild asymmetric pulmonary edema, greater
on the right side, is stable. Right IJ catheter tip is in the
upper to mid SVC. Cardiomegaly is unchanged. Left transvenous
pacemaker leads remain in standard positions.
CHEST (PORTABLE AP) [**2131-5-25**] 3:36 AM
In the interim, there is severe worsening of a right extensive
pleural effusion with adjacent atelectasis and airspace disease
in the collapsed right lung. There is also worsening of
perihilar airspace disease in the left lung. Small left pleural
effusion is also new. The heart size is mild-to-moderately
enlarged, but stable. The left-sided subclavian pacemaker leads
are stable.
IMPRESSION:
1. Severe worsening of right pleural effusion with almost
collapse of the right lung.
2. Bilateral airspace disease in both lungs, worsening on the
left lung, likely edema.
3. Mild-to-moderate cardiomegaly.
Brief Hospital Course:
66 y/o male with diabetes, cardiomyopathy, foot ulcer presenting
with toe infection, septic physiology, and ventricular
tachycardia.
Hospital course by problem:
# Sepsis/Toe Wound: Patient's exam was consistent with infected
L 1st toe ulcer and leg cellulitis and he was hypotensive. He
was admitted to the medical intensive care unit, and was started
on a neosynephrine drip which was weaned [**5-24**] and he was started
on vancomycin and zosyn. Vascular surgery and podiatry evaluated
him and debrided the ulcers. Surgery initially thought he might
need an amputation, but he clinically improved and this was
deferred in favor of [**Hospital1 **] WTD dressing changes. He was soon
transferred to the floor.
His blood grew proteus mirabilis (pan-sensitive) and
streptococcus (penicillin-sensitive but clindamycin and
erythromycin-resistant). Zosyn was changed to unasyn, but the
patient clinically worsened and with concern for an undetected
element of the likely polymicrobial sepsis which started his
course, unasyn was discontinued and zosyn restarted. Of note, no
pseudomonas grew out at any time in his wound or blood cultures.
Gram-positive cocci and more Proteus grew out of a wound culture
as vascular surgery continued to follow, drain abscesses and
debride tissue. The GPCs ultimately proved to be pan-sensitive
MSSA, and once this sensitivity was available, vancomycin was
discontinued. Eventually, zosyn was discontinued and unasyn was
restarted, with no ill effects. Flagyl was added for C. diff
protection although he did not grow out C. diff--see below.
In terms of ongoing management, on the initial evaluation the
wound had probed to bone in the earliest portion of this
hospital course. There was some concern, particularly from the
infectious disease service (which had been consulted, and which
had followed the patient in the past for recurrent C. diff) that
he would not be able to endure a six-week course of antibiotics
because of his short gut, past history of recurrent C. diff, and
that an operation might be superior. In consultation with the
surgeons and the primary care physician (who also served as the
hospital attending), and after the primary care physician had
[**Name9 (PRE) 103662**] discussion with the patient of risks and benefits of
non-operative management, amputation was deferred in favor of
medical management. Given his high risk of recurrent C. diff and
his short gut, and the potentially dire consequences for this
patient of not being able to tolerate a long course of
antibiotics, and in consultation with the infectious disease
service, we took the unusual step of treating C. diff
empirically despite negative toxins.
The total course of antibiotics will be six weeks, with day 1 of
effective antibiosis = [**5-29**]. Therefore last doses should be on
[**7-10**]. Weekly labs should be sent to the infectious disease
clinic; follow-up lab instructions are in the outpatient orders
(med list) of this discharge summary. Flagyl should be continued
through this time, and then for seven days after (until [**7-17**]).
In detail, starting dates were:
Zosyn and vanco: [**5-23**] (on admission)
Zosyn replaced with unasyn: [**5-26**]
Flagyl: [**5-26**] (pt has had recurrent C diff as above)
Unasyn stopped and replaced again with Zosyn: [**5-27**]
Vancomycin stopped [**6-3**]
Zosyn stopped and replaced with Unasyn: [**6-3**]
Ending dates for Unasyn and Flagyl: [**7-10**] and [**7-17**]
respectively, as above.
Podiary has said that he is full weight-bearing.
# Chronic systolic heart failure and cardiomyopathy: In the
MICU, the patient had an increased O2 requirement, 93% on 6L NC
O2, with large R sided pleural effusion. He had an US-guided
thoracentesis on [**5-25**] (therapeutic and diagnostic) which
revealed a transudative sterile fluid which carried signs of
neither infection nor malignancy. He has a lasix requirement at
home and ultimately as sepsis and hypotension resolved, he was
started back on lasix, first prn, and then 40 [**Hospital1 **] (his home
dose); on [**6-9**] this was changed to 60 [**Hospital1 **]. He had several
incidents in which he more acutely desaturated, each of which
was solved by extra doses of lasix.
He did continue to have an oxygen requirement, associated with
what appeared to be his fluid status, but was stable. We would
expect with increasing activity he might be able to mobilize
more of this fluid; however, reconsideration of his diuretic
dose might be necessary if he is not able to decrease and then
wean his oxygen requirement. At home prior to this admission he
has been on digoxin and lisinopril. In light of his continuing
renal insufficiency these were not restarted though the
lisinopril in particular should be given consideration for
restarting at the earliest opportunity.
Earlier in admission transudative effusion c/w heart failure
when tapped, with large drainage.
Pain control was adquate with Oxycontin, Oxycodone, and
Dilauidid for breakthrough pain.
# Ventricular Tachycardia: Early in the admission, the patient
had one episode of asymptomatic VT that developed in the setting
of dopamine and low Mg, and in the setting of the immediate
post-sepsis period. This resolved with no further episodes while
on the floor, until [**6-11**], when he had a series of runs of
NSVT in the morning. He was asymptomatic with these events. The
electrophysiology service was consulted. He does not have an ICD
in place but given that he is being treated for infection, EP
felt it would be better to keep him on telemetry but defer ICD
placement if indicated. In the meantime, the EP service
recommended putting him on amiodarone, on the schedule listed
below in the medication orders. A follow-up appointment with a
nurse practitioner in [**Name (NI) 103663**] office was made (shown
below); additionally the patient should have direct follow-up
with Dr. [**Last Name (STitle) **] arranged within the next 2-6 weeks. The
amiodrone has been tapered down to 200mg PO daily, and after one
week without active issue the patient was removed off telemetry.
# Renal Failure: Acute on Chronic. Acute from CHF hypoperfusion
and contrast interaction and chronic from diabetes. Early in the
admission, Mr [**Known lastname 21212**] had elevated creatinine as far up as 1.9 on
[**5-24**] in the context of his early sepsis and MICU stay, which had
trended down. It declined to 1.3 and 1.4 in early [**Month (only) **], but
after an angiographic study gave him a large contrast load, it
went back up to the 1.7-2.0 range peaking at 2.1 on [**6-7**]. This
was wavering in the period of [**5-26**] with an uncertain
direction. This should be followed in the rehabilitation
setting. Although it likely had the effect of raising the Cr, we
continued to give lasix, feeling that it was likely best to
support renal perfusion, and because it was necessary for
respiratory function. He has been tolerating a high dose of
lasix, 120mg [**Hospital1 **], and sometimes still requires an additional
60mg IV to maintain negative fluid balance. The patient has not
had any signs of ototoxicity. On [**6-25**] mg of po HCTZ was
added to his diuretic regimen, and was given [**Hospital1 **], 30 minutes
prior to furosemide administration. Following this change, LUE
edema decreased significantly. On [**6-27**], HCTZ was decreased to
once daily. HCTZ was discontinued upon hospital discharge.
# Diabetes: Maintained patient on insulin sliding scale; his NPH
was restarted and was titrated up as the patient's PO intake
increased and his scale requirements increased.
# Hypercoagulability: The patient has had disastrous sequelae of
clotting in the past including ischemic bowel and resulting
short gut, and stroke; thus anticoagulation was scrupulously
maintained. The patient was kept on a heparin sliding scale for
much of the admission in order to preserve operative options
while also continuing anticoagulation which is provided by
lovenox as an outpatient. On [**6-11**], with anticipation of
discharge and no further operations planned, [**Hospital1 **] Lovenox was
started. Factor Xa level was drawn in the pm of [**6-12**] after the
third dose of lovenox was given, and found to be 0.43 U/mL. It
was rechecked [**6-16**] and [**6-23**], and found to be 0.71 and 0.80 U/mL
respectively.
# Depression: citalopram was continued. Mr [**Known lastname 21212**] had various
periods of frustration with his care. He likely also has some
element of depression and perhaps small cognitive losses from
past stroke. Given the very real stressors of his
hospitalization here, including the ongoing possibility that he
might lose his foot and his mobility, it was assumed that some
portion of his mood was reactive, management was not changed.
As his medical situation stabilizes and improves, if his mood
does not improve simultaneously, he may benefit from revisiting
his treatment for depression.
# Leukocytosis- most likely secondary to a myeloproliferative
disorder, previously characterized as polycythemia [**Doctor First Name **].
# Neuropathy: The patient was maintained on oxycontin,
neurontin, and vicodin.
# PPX: The patient was given heparin for thrombosis prophylaxis
which was converted to LMWH as above, as well as a PPI per home
regimen.
Medications on Admission:
Hydrocodone/Acetaminophen 5/235
Captopril 25
Furosemide 20
Fosamax 70
Digoxin 250mcg
Oxycontin 10 [**Hospital1 **]
Neurontin 800
Folic Acid 1mg
Ranitidine 150 tab
Toprol Xl 25 Daily
Loperamide 2mg Q6PRN
Lovenox 60mg Daily
Citalopram 40 daily
Discharge Medications:
1. Outpatient Lab Work
Laboratory monitoring required; frequency: weekly.
Draw: Creat, BUN, Alt, Ast, WBC, Hct/Hgb
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**]. All questions regarding outpatient or
rehabilitation antibiotics should be directed to the infectious
disease R.Ns. at ([**Telephone/Fax (1) 14199**]
2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 7 days: To be given [**6-11**] through [**6-18**]; then followed by 200
mg [**Hospital1 **] for one week thereafter; and then 200 mg daily after
that. Follow up closely with Dr[**Name (NI) 7914**] office.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
8. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-27**]
Drops Ophthalmic PRN (as needed).
13. Psyllium 1.7 g Wafer Sig: [**12-27**] Wafers PO BID (2 times a day).
14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
15. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous [**Hospital1 **] (2 times a day).
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10mL Normal Saline followed by Heparin as above daily and PRN
per lumen. .
18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
19. Hydromorphone 2 mg/mL Solution Sig: 0.5-2 mg Injection Q3H
(every 3 hours) as needed: for breakthrough pain. hold for
sedation or RR <12.
20. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
21. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours): until [**7-17**].
22. Ampicillin-Sulbactam 3 gram Recon Soln Sig: Three (3) grams
Injection Q8H (every 8 hours) for 14 days: Give through [**7-10**].
Disp:*42 doses* Refills:*0*
23. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
injection Subcutaneous qAM: gradually increasing dose; likely to
need further increases as PO intake increases; currently at 20
mg in AM.
24. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous qACHS: before breakfast, lunch and dinner, and at
bedtime (4 x /day). Use scale:
If <60, crackers and juice or [**12-27**] amp D50.
60-160 mg/dL 0 Units
161-200: 2 Units.
201-240: 4Units. 241-280: 6 Units. 281-320 8 Units. 321-360 10
Units.
361-400 12 Units.
25. oxygen
2L continuous via nasal cannula pulse dose for portability.
26. semi-electric bed with rails, equipped for patient's height
and weight
27. PICC line care per NEHT protocol, saline and heparin flushes
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY:
OSTEOMYELITIS
CONGESTIVE HEART FAILURE
Discharge Condition:
Stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 mL fluid per day
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2131-7-5**]
11:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-7-11**]
2:30
Provider: [**Name10 (NameIs) 251**] [**Name Initial (NameIs) **] [**Last Name (NamePattern4) **], CARDIOLOGY Phone:[**Telephone/Fax (1) 62**]
Date/Time: [**2131-7-11**] 3:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1111**] Phone:[**Telephone/Fax (1) 3121**] Date/Time:[**2131-9-2**]
2:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule
appointment
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
Completed by:[**2131-7-27**]
ICD9 Codes: 0389, 5849, 4254, 5119, 4271, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2030
} | Medical Text: Admission Date: [**2110-4-2**] Discharge Date: [**2110-4-4**]
Date of Birth: [**2030-7-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
elective carotid stent
Major Surgical or Invasive Procedure:
carotid stents
History of Present Illness:
Mr. [**Known lastname 95068**] is a 79 year-old man with a history of a TIA about
3-4 years ago. On [**2110-3-8**], he was sitting at the breakfast table
when he an acute onset of decreased vision and blurriness in the
right eye. He was found to have approximately 75% stenosis of
his right carotid artery. He denies any slurred speech or right
sided weakness. There was no change in vision in the left eye.
A Carotid U/S on [**2109-7-23**] showed diffuse right ICA isoechoic wall
thickening
associated with a 60-69% ICA stenosis. Similar plaque on the
left, but to a lesser extent and unassociated with any
significant stenosis.
[**2109-7-26**] Echo: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. LV wall thickness, cavity size,
and systolic function normal (LVEF >55%).
[**2110-3-14**] Head/Brain/Carotid MRI/MRA: High grade stenosis
involving the right internal carotid artery just superior to the
common carotid bifurcation.
(+) HTN (+) hyperlipidemia (-) DM (-) cigarette smoking
Mf. denies claudication, PND, orthopnea, edema. He reports
occasional lightheadedness when he gets up too quickly.
ROS: (+) TIA (-) CVA (-) melana/GIB
Past Medical History:
prostate ca
right upper lobectomy for Stage I adencarcinoma of the lung
[**2109-8-5**]
right central retinal artery occlusion
carotid artery disease
left fem-[**Doctor Last Name **] bypass [**2096**] - per pt, no info found CCC
gallstones
TIA 3-4 years ago that lasted 20 seconds (slurred speech)
Social History:
He has been married 52 years.
Family History:
(-) FHx CAD
Physical Exam:
T 97.6, HR 49 BP 111/51 98% on RA, I/O 3800/1800
Gen: sleeping but pleasant and cooperative when awake
HEENT: MMM CN II-XII individually tested and intact except CN II
on the right which is chronic
Cor: RRR no M/R/G
Pulm: CTAB anteriorly
Abd: obese, soft NT ND
Ext: WWP, right groin with dressings C/D/I no hematoma or bruit,
DP 1+ bilaterally
Pertinent Results:
[**2110-4-4**] 05:35AM BLOOD WBC-5.2 RBC-3.93* Hgb-11.6* Hct-33.7*
MCV-86 MCH-29.5 MCHC-34.4 RDW-13.8 Plt Ct-192
[**2110-4-4**] 05:35AM BLOOD PT-13.4 PTT-25.6 INR(PT)-1.1
[**2110-4-4**] 05:35AM BLOOD Glucose-96 UreaN-19 Creat-1.2 Na-139
K-4.0 Cl-107 HCO3-27 AnGap-9
[**2110-4-3**] 02:03AM BLOOD CK(CPK)-61
[**2110-4-4**] 05:35AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7
COMMENTS:
1. Retrograde access was obtained via the right common femoral
artery
for selective angiography of the subclavian, vertebral, and
carotid
arteries.
2. Limited resting hemodynamics revealed central hypertension
with
opening blood pressures of 180/74 mmHg.
3. Angiography demonstrated a type 1 aortic arch. Subclavian
arteries
were without angiographically significant, flow-limiting disease
or
gradient. The right common carotid artery was without flow
limiting
disease. The right internal carotid artery had an eccentric 90%
lesion
and filled the ACA and MCA. The right vertebral artery was small
and
totally occluded at the level of the basilar artery. The left
common
carotid arteyr and internal carotid artery were without
flow-limiting
disease. The left vertebral was without significant disease and
filled
the cerebellar circulation.
4. Successful placement of [**6-25**] x 40 mm AccuLink stent
postdilated with
a 4.5 mm balloon in the right internal carotid artery (ICA)
using
AccuNet filter distal embolic protection. Final angiography
demonstrated
a 20% residual stenosis, no angiographically apparent
dissection, and
normal flow (See PTCA Comments).
5. Successful placement of 6 French Angioseal device in right
femoral
arteriotomy without complications.
FINAL DIAGNOSIS:
1. Severe right internal carotid artery stenosis.
2. Successful placement of stent in right internal carotid
artery.
3. Successful use of filter embolic protection device.
4. Central hypertension.
5. Successful placement of Angioseal in right femoral
arteriotomy.
Brief Hospital Course:
Mr. [**Known lastname 95068**] is a 79 year-old man with a h/o TIA, recent right
eye vision
loss, high grade stenosis of the right ICA, referred for carotid
revascularization.
The carotid stents were placed without complication. The
patient's blood pressures were extremely labile overnight,
requiring both pressor support and intermittently labetolol
drip. As much as possible, his SBP was kept from 100-140. He was
also continued on plavix and aspirin. His neosynephrine was
weaned after one day and his blood pressure remained
normotensive with fewer swings. He was restarted on home
medications except for antihypertensives. Mr. [**Known lastname 95068**] was
discharged on day 2 with strict instructions to return to the
cath holding area for a blood pressure check and lab draw.
Medications on Admission:
Isordil 5mg TID
Lipitor 20mg daily
ASA 325mg daily
Plavix 75mg daily
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 Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
carotid stenosis
Discharge Condition:
stable
Discharge Instructions:
Please take aspirin and plavix.
Call your doctor for head ache, changes in vision, drooping
face, loss of sensation, weakness, or if there are any concerns
at all.
Come back to the cath lab holding area on Monday for a blood
pressure check and to have labs drawn.
Followup Instructions:
Provider: [**Name10 (NameIs) **] THORACIC MULTI SPEC-CC9 MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI
Date/Time:[**2110-4-17**] 2:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2695**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-9-18**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2111-2-16**] 2:15
Please call [**Last Name (LF) **],[**First Name3 (LF) **] L [**Telephone/Fax (1) 82541**] for an appointment in
the next 2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2031
} | Medical Text: Admission Date: [**2167-11-16**] Discharge Date: [**2167-11-17**]
Date of Birth: [**2097-9-6**] Sex: M
Service: VASCULAR
DATE OF EXPIRATION: [**2167-11-17**].
HISTORY OF PRESENT ILLNESS: The patient is an unfortunate 70
year old gentleman with a past medical history that is
significant for a coronary artery bypass graft times three
that was done in [**2167-2-28**] here at [**Hospital1 190**]. He had a history of a right carotid
endarterectomy done in [**2156**] and a history of mitral valve
regurgitation and atrial fibrillation that was cardioverted
in [**2165**], and the patient was taking Amiodarone.
He also had a history of gout and hypertension. He was found
to have an abdominal aortic aneurysm and most recently he
underwent an abdominal CT scan for surveillance and it
revealed that his abdominal aortic aneurysm had increased ins
size to 5 cm. He was evaluated in the office on the Vascular
Service and he was found to be not an adequate candidate for
a usual stent graft repair of this aneurysm. He was offered
an open elective repair for which the patient agreed. He was
scheduled to have this operation electively on [**2167-11-16**].
He had a cardiac and medical clearance by his primary care
physician as well as his Cardiologist and he was deemed to be
in good condition to undergo this operation. On [**2167-11-16**], the patient was taken to the Operating Room and
underwent an open abdominal aortic aneurysm repair with an
aorta [**Hospital1 **]-iliac Dacron graft. The operation was complicated
with a lower pole splenic tear that was tried to be repaired
primarily and which ultimately required a splenectomy for
persistent bleeding.
In the Operating Room he received 11 liters of crystalloid
and made only 150 cc of urine and there was an estimated
blood loss of 4.5 liters. He received a total of four units
of packed red blood cells and [**Pager number **] cc of Cellsaver. He was
transferred to the Recovery Room where he persistent aneuric
and acidotic requiring pressors and fluid in order to
maintain his hemodynamics. Ultimately, he was transferred to
the Surgery Intensive Care Unit on the sixth floor to
continue his monitoring by the surgical house staff as well
as the attending.
Once in the Intensive Care Unit, his acidosis worsened and
despite aggressive intravenous fluid resuscitation and
pressor medications, the patient remained hypotensive. An
emergent Cardiology consultation and a transthoracic
echocardiogram was obtained but unfortunately at that time,
this study revealed poor windows and there was no obvious or
acute evidence of hypokinesis nor pericardial effusion.
Despite these results, because once again due to poor windows
and due to the body habitus of this patient, a
transesophageal echocardiogram was recommended and obtained.
This study revealed marked left ventricular hypokinesis as
well as an akinetic septum with severe left ventricular
function depression. There was a very poor ejection fraction
despite the pressor medications.
Renal was consulted as well because the patient was anuric
for many hours and he had a worsening acidosis. The
recommendation for the nephrologist was to start him on a
Dopamine drip, trying to improve perfusion to his kidneys.
In spite of all the above mentioned measures, the patient
remained hypotensive and his hematocrit drifted down,
becoming progressively more distended in the abdominal
region. At that time, upon discussion with Dr. [**Last Name (STitle) **], the
attending of record, the decision was made to take him back
to the Operating Room for a re-exploration.
Upon taking him back to the Operating Room, approximately
[**2163**] cc of blood and clot were found in the left upper
quadrant but upon evacuating this hematoma, there was no
obvious source of bleeding identified. The patient was
closed loosely with a rubber [**Doctor Last Name **] and a big Ioban and it was
elected to leave the abdomen open with two medium sized
[**Location (un) 1661**]-[**Location (un) 1662**] drains on the lateral aspect. Once again, the
patient was transferred to the Intensive Care Unit on
multiple pressors including Levophed, Neo-synephrine,
vasopressin, dopamine and intravenous fluids running at 200
cc an hour.
Within the next couple of hours, the acidosis persisted and
the patient continued to bleed extensively from his
[**Location (un) 1661**]-[**Location (un) 1662**] drains. A new set of coagulation studies was
sent and the INR at this point was found to be 11.0 with a
PTT in the mid 100s and an elevated PT. The fibrinogen was
low and further repletion with fresh frozen plasma, Cryo, and
more units of packed red blood cells were also started and
initiated.
The case was discussed again with the attending of record and
upon consultation with the Surgical attendings on the
vascular service. It was decided to continue to fully
support him and try to correct his coagulopathy before trying
to explore him again in the Operating Room as he was very
unstable to be transferred anywhere. The patient's abdomen
progressively became more distended and a Foley catheter
pressure was transduced and came back high on 33 mm of water.
Because he was markedly unstable to be moved to the Operating
Room, the decision was made to open his abdomen in the
Intensive Care Unit for which purpose an abdominal kit and a
bulb electrocardia as well as pulse suction and multiple
canisters were brought to the Intensive Care Unit to do the
abdominal wound exploration.
At this point, the patient had received 26 units of packed
red blood cells, 14 units of fresh frozen plasma, 6 units of
platelets, one unit of cryo, 5 gram load of Amicar as well as
a continuous rip and a Factor VII that included 4800
micrograms infused.
Upon opening the abdomen, we found about 3000 cc of half
clotted blood that was evacuated with a bulb sucker. Once
again, no obvious source of bleeding was found nor
identified. The aorta repair appeared to be intact with no
clot extravasation. The bowel was noted to be diffusely
edematous with multiple patches of ischemia all along its
length. There was a feculent smell in the abdomen with no
obvious bowel perforation identified. Upon packing all four
quadrants, the abdomen was closed again with a rubber [**Doctor Last Name **] and
an Ioban and two medium sized [**Location (un) 1661**]-[**Location (un) 1662**] drains were left
on the lateral aspect of the wound.
At his point, the patient was still on Levophed, epinephrine,
dopamine and pitressin to keep his systolic blood pressure
barely above 90s. He remained anuric and his acidosis
progressively worsened despite bicarbonate infusions.
The patient's family was aware of the patient's condition and
upon their request, they were allowed to enter the Intensive
Care Unit room to see the patient. Despite full support, the
patient expired and was pronounced at 12:14 p.m. [**2167-11-17**].
The family was present as well as a catholic priest and the
Surgery Intensive Care Unit staff. Medical examiner was
notified and he declined the case. The family was offered a
post mortem examination which was accepted. We will arrange
for this to happen in our Pathology Department.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
MEDQUIST36
D: [**2167-11-17**] 14:23
T: [**2167-11-17**] 14:56
JOB#: [**Job Number 106555**]
ICD9 Codes: 4275, 5185, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2032
} | Medical Text: Admission Date: [**2140-5-20**] Discharge Date: [**2140-5-25**]
Date of Birth: [**2100-4-8**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
cyclist struck
Major Surgical or Invasive Procedure:
[**2140-5-20**]: ORIF Left tibia, ORIF left hip, I&D right elbow
laceration, I&D left shoulder laceration.
History of Present Illness:
Mr. [**Known lastname 78400**] is a 40 year old man who was a cyclist struck. He
was taken to the [**Hospital1 18**] for further evaluation and care.
Past Medical History:
denies
Social History:
Lives with wife
[**Name (NI) 1403**] as a computer programmer
Very active
Family History:
n/a
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear, intubated for airway protection
Abdomen: Soft non-tender non-distended
Extremities: LLE Angulated L ankle with obvious fx, shortned
externall rotated, + sensation/moevement. R elbow large
laceration, + pulses/sensation.
Pertinent Results:
[**2140-5-25**] 04:55AM BLOOD WBC-5.6 RBC-3.60* Hgb-10.3* Hct-30.2*
MCV-84 MCH-28.5 MCHC-34.0 RDW-14.4 Plt Ct-208
[**2140-5-24**] 04:35AM BLOOD Hct-24.4*
[**2140-5-23**] 06:25AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.0* Hct-25.4*
MCV-83 MCH-29.3 MCHC-35.3* RDW-13.0 Plt Ct-140*
[**2140-5-22**] 02:20AM BLOOD WBC-8.8 RBC-3.40* Hgb-10.1* Hct-28.4*
MCV-83 MCH-29.6 MCHC-35.4* RDW-13.2 Plt Ct-138*
[**2140-5-21**] 03:19PM BLOOD Hct-29.3*
[**2140-5-21**] 03:39AM BLOOD WBC-8.0# RBC-3.67*# Hgb-10.7*# Hct-30.3*#
MCV-83 MCH-29.2 MCHC-35.3* RDW-13.5 Plt Ct-129*
[**2140-5-20**] 10:38PM BLOOD WBC-17.5* RBC-5.00 Hgb-14.5 Hct-42.0
MCV-84 MCH-28.9 MCHC-34.5 RDW-13.5 Plt Ct-216
[**2140-5-23**] 06:25AM BLOOD PT-13.3 PTT-33.1 INR(PT)-1.1
[**2140-5-20**] 07:41PM BLOOD PT-13.2 PTT-23.1 INR(PT)-1.1
[**2140-5-25**] 04:55AM BLOOD Glucose-95 UreaN-12 Creat-0.9 Na-139
K-3.8 Cl-106 HCO3-26 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 78400**] is a 40 year old man who was a cyclist struck. He
was taken to the [**Hospital1 18**] emergency department and evaluated by the
orthopaedic and trauma surgery departments. He was found to
have a left tibia and hip fracture. He was also found to have a
left shoulder laceration and right elbow laceration. He
intubated, admitted to the ICU for further monitoring. He was
later taken to the operating room and underwent and I&D of both
lacerations and ORIF of his hip and tibia. He tolerated the
procedures well and was transferred back to the ICU. On [**2140-5-21**]
he was extubated without difficulty. On [**2140-5-22**] he was
transferred to the floor under the care of the orthopaedics. He
was seen by physical therapy to improve his strength and
mobility. On [**2140-5-24**] he was transfused with 2 units of packed
red blood cells due to acute blood loss anemia. The rest of his
hospital stay was uneventful with his lab data and vital signs
within normal limits and his pain controlled. He is being
discharged today in stable condition.
Medications on Admission:
denies
Discharge Medications:
1. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 1 weeks.
Disp:*21 Capsule(s)* Refills:*0*
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg syringe
Subcutaneous Q 24H (Every 24 Hours) for 4 weeks.
Disp:*28 40mg syringe* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p cyclist struck
Left tibia fracture
Left intertrochanteric fracture
Right elbow laceration
Left shoulder laceration
Acute blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Continue to be weight bearing as tolerated on your left leg
Continue to take your medications as prescribed by your doctor
If you notice any increased redness, drainage, or swelling, or
if you have a temperature greater than 101.5 please call the
office or come to the emergency department.
Physical Therapy:
Activity: Ambulate
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
Right upper extremity: Full weight bearing
Left upper extremity: Full weight bearing
Treatment Frequency:
Staples/sutures out 14 days after surgery or at follow up
appointment
Dry sterile dressing daily or as needed for drainge or comfort
Followup Instructions:
Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 78401**], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2140-5-26**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2033
} | Medical Text: Admission Date: [**2178-1-14**] Discharge Date: [**2178-1-25**]
Date of Birth: [**2149-11-25**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2344**]
Chief Complaint:
Fever, Rigors
Major Surgical or Invasive Procedure:
endotracheal intubation ([**Date range (1) 85753**])
transesophageal echocardiogram (TEE, [**1-21**])
History of Present Illness:
28yo F with no significant past medical history said that 4 days
prior to admission she started to have fevers to 103 and
drenching diaphoresis. At that time she also had a diffuse
headache that was different from her migraines. She noted at
that time she had some pain with eye and neck movement
associated with the high fevers. Symptoms were relieved with
advil 3-4 per day. When the fevers were not present, she did not
have any pain as described above. She also noted general
muscular pain with chills and shivering. She was going to work
on the day of admission and felt so cold and shivering that she
went home and felt she needed to come to the hospital. She
travelled to [**Country 4574**] in [**Month (only) **] and received all the proper
vaccinations. She has not been sexually active in over a year
and a half and last kissed someone over one month ago. She does
not smoke or use drugs. She has never had any blood
transfusions. She is unaware of any recent sick contacts. She
denies any rhinorrhea, sore throat, odynophargia, SOB, DOE,
pleuritic pain, chest pain, n/v/d or joint pain. Did not get flu
shot this year.
.
In ED VS were: 102.9 159 111/52 18 100% RA 1.5gm of tylenol was
given as well as 5L of NS, CXR and cultures were done. Current
VS: T 100.5HR 119, SBP 91 with IVF running, RR: 20, 100%RA.
.
Lactate 4.5 -> 2.4 with 4L IVF.
K+ 3.0
WBC 1.1, Plt 44. Menstrual period 5 days ago. No petichae.
.
Influenza DFA pending - not enough cells
Monospot pending
Urine culture, blood culture pending
.
Equivocal UA - trace leuk, mod blood, 25 protein, tr ketones,
0-2 RBC, [**2-21**] wbc, mod bacteria, [**11-8**] epi
.
Review of systems:
(+/-) Per HPI
Past Medical History:
- Panic disorder, Anxiety
- Cyclothymia
- Recurrent UTIs
- Genital HSV
- Migraines
- Alcohol abuse
Social History:
Denies tobacco use. Former alcoholic, last drink was new years.
Marijuana use few times a year. No IVDU or other recreational
drugs. Works as software designer.
Family History:
Grandmother had heart disease and was a chronic smoker. No
history of cancer, hyperlipidemia, diabetes. No sick contacts in
her family.
Physical Exam:
ADMISSION EXAM:
DISCHARGE EXAM:
VS: Tm 100.4, Tc 98.6, BP 88/46 (88-112/46-59), HR 94, RR 18
Gen: alert, oriented x3, NAD
HEENT: EOMI, moist MM
CV: Tachycardic, no m/r/g
Pulm: CTAB
Abd: soft, nt/nd; active bs; no organomegaly
Extremities: no edema; 2+ PTs, DPs
Neurologic: alert and oriented x3; motor and sensation grossly
intact, no visual field deficits.
Pertinent Results:
DISCHARGE LABS
[**2178-1-25**] 05:41AM BLOOD WBC-5.3 RBC-3.14* Hgb-9.1* Hct-27.0*
MCV-86 MCH-29.0 MCHC-33.7 RDW-13.3 Plt Ct-590*
[**2178-1-21**] 06:15AM BLOOD Neuts-72.9* Lymphs-19.9 Monos-4.2 Eos-2.6
Baso-0.4
[**2178-1-25**] 05:41AM BLOOD Glucose-102* UreaN-13 Creat-0.7 Na-141
K-4.5 Cl-102 HCO3-30 AnGap-14
[**2178-1-24**] 11:37AM BLOOD CK(CPK)-56
[**2178-1-25**] 05:41AM BLOOD Calcium-9.3 Phos-4.6* Mg-2.2
[**1-21**] TEE
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is functionally bicuspid (fusion of the right and
left coronary leaflets). There is a echodensity seen at the tips
of the aortic valve leaflets that measures 0.7 x 0.8 cm and
could reporesent a vegetation or partial flail leaflet. This is
best seen in clips 77, 78 and 81 (also 10,13, 28, 31, 37-47).
Severe (4+) aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
No mass or vegetation is seen on the mitral valve. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Probable moderate sized vegetation on bicuspid
aortic valve. Severe (4+) aortic regurgitation. No intracardiac
shunt identified. Normal global left ventricular systolic
function.
Brief Hospital Course:
28 yo F with no significant PMHx who presented with 4 days of
influenza-like illness and developed ARDS requiring intubation
[**1-16**]. Extubated successfully on [**1-19**]. Found to have endocarditis
& severe (4+) aortic regurgitation.
.
# Culture-negative endocarditis: Patient found to have moderate
sized vegatation on bicuspid aortic valve. Likely embolic source
of occipital lobe infarct. Cardiac surgery recommends
re-evaluation after antibiotic course is complete in 6 weeks.
Patient was discharged on ceftriaxone, gentamicin & daptomycin.
Microbiology was pending at discharge, but patient will follow
up with Infectious Disease clinic as an outpatient.
.
# Jaw dislocation: Completely resolved. Patient's jaw was
dislocated during TEE. Dental consult reset it and placed brace.
Patient currently denies any jaw pain or discomfort. Dental team
recommended a soft diet & jaw brace x 1 week
.
# Occipital lobe embolic infarct: Head MRI showed left occipital
lobe infarct which occurred within the past week per radiology.
Etiology of septic embolus likely vegetation on aortic valve.
Patient had no focal neurologic symptoms or visual field
defects.
.
# Anemia: DIC & hemolysis labs were negative in ICU. Possibly
secondary marrow suppression from acute illness. Other cell
lines were initially low, but recovered.
.
# Depression/Anxiety: Patient has anxiety which occasionally
manifested as sinus tachycardia. Continued her buspirone,
lamotrigine and clonazepam.
Medications on Admission:
BUSPIRONE - 30 mg Tablet - 1 Tablet(s) by mouth three times a
day
CLONAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day
DULOXETINE [CYMBALTA] - 60 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth in am and [**12-21**] tab in pm
LAMOTRIGINE - 100 mg Tablet - 2 Tablet(s) by mouth once a day
ZOLMITRIPTAN [ZOMIG] - (Dose adjustment - no new Rx) - 5 mg
Tablet - 1 Tablet(s) by mouth w/ ha onset, MR in 2 hr prn --max
2
tabs in 24hs---
MULTIVITAMIN - (OTC) - Capsule - 1 Capsule(s) by mouth once a
day
Discharge Medications:
1. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours) for 6 weeks:
Last dose 3/17.
Disp:*qs * Refills:*0*
2. gentamicin in NaCl (iso-osm) 80 mg/100 mL Piggyback Sig:
Eighty (80) mg Intravenous every eight (8) hours for 6 weeks:
Last dose 3/17.
Disp:*qs * Refills:*0*
3. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Outpatient Lab Work
-Weekly: CBC, BUN, Crea, LFTs, CK.
-Twice weekly: Gentamicin trough.
-All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 4591**].
-All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 21403**]
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
7. daptomycin 500 mg Recon Soln Sig: Four [**Age over 90 1230**]y (450) mg
Intravenous once a day for 6 weeks: D1= [**1-24**], last dose = [**3-7**].
Disp:*qs * Refills:*0*
8. buspirone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Zomig 5 mg Tablet Sig: One (1) Tablet PO prn as needed for
headache: may repeat in 2 hrs as needed; max 2 tabs in 24hs.
11. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO qAM.
12. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO qPM.
Discharge Disposition:
Home With Service
Facility:
[**Company 4916**]
Discharge Diagnosis:
Primary diagnosis:
1. infectious endocarditis
2. hypoxic respiratory failure
3. occipital lobe infarct
Secondary diagnosis:
1. anemia
2. anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
# You were admitted to the hospital for flu-like illness and
developed acute respiratory failure requiring intubation in the
intensive care unit.
.
# You were found to have an embolic infarct in your brain on
MRI, so an echocardiogram was performed to evaluate your heart
valves & see if there was a source for the embolism to your
brain. The TEE showed a growth on your aortic valve, also known
as endocarditis. As a result of this growth, your aortic valve
is leaky, a condition called aortic regurgitation. This likely
contributed to your respiratory failure. Incidentally, you were
found to have a biscupid aortic valve.
.
# You were started on three antibiotics (ceftriaxone, gentamicin
& daptomycin) which you will need to take for 6 weeks (last dose
[**3-5**] for ceftriaxone & gentamicin; last dose 3/19 for
daptomycin). It is very important that you take all of your
medications as prescribed, keep your appointments with the
infectious disease doctors & get the appropriate lab work
checked weekly and twice weekly.
- Weekly: CBC, BUN, Crea, LFTs, CK
- Twice weekly: Gentamicin trough
- All lab results should be faxed to Infectious disease R.Ns.
at ([**Telephone/Fax (1) 1353**].
- Any questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 21403**] or to
the [**Name8 (MD) 11582**] MD in when clinic is closed.
.
# On admission your platelet count, as well as red & white blood
cell counts, was low. It is possible that your acute illness
caused suppression of your bone marrow, which produces these
cells. Your cell counts improved during your admission, although
you are still anemic. You should follow this up with your
primary care doctor.
.
# It is very important that you follow up with cardiothoracic
surgery after your antibiotic course is complete to have them
re-evaluate your aortic valve. It is possible that you will need
a valve replacement.
.
# During your echocardiogram on [**1-21**], your jaw was dislocated.
You were seen by oral/maxillofacial surgery who reset your jaw
and gave you a jaw brace. They recommended that you wear the
brace and eat a soft diet until Wed, [**1-28**].
Followup Instructions:
Department: [**State **]When: WEDNESDAY [**2178-1-28**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 9862**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: [**Last Name (un) 12214**] [**Doctor Last Name **] MED GRP
When: THURSDAY [**2178-1-29**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD [**Telephone/Fax (1) 5068**]
Building: [**Location (un) **] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: INFECTIOUS DISEASE
When: THURSDAY [**2178-2-5**] at 2:10 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2178-1-31**]
ICD9 Codes: 0389, 5185, 486, 2762, 5990, 2768, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2034
} | Medical Text: Admission Date: [**2199-12-30**] Discharge Date: [**2200-1-20**]
Date of Birth: [**2141-3-16**] Sex: M
Service: SURGERY
Allergies:
Anspor / Wellbutrin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal aortic aneurysm.
Major Surgical or Invasive Procedure:
[**2199-12-30**]: 1. Repair of juxtarenal abdominal aortic aneurysm with
14 mm tube graft. 2. Splenectomy for bleeding.
.
[**2200-1-8**]: Over the scope clip to gastric perforation by endoscopy
History of Present Illness:
The patient is a male with history of aortic aneurysms had
progressive increase in size; now has an aortic aneurysm greater
than 5.5 cm. Due to his young age and his family history, the
decision was made to repair. Due to his anatomy, it was felt
that he would not be a good stent graft candidate.
Past Medical History:
PMH: 5.7cm infra-renal/juxta-renal AAA, COPD, obesity, asthma,
hypercholesterolemia, BPH, lumbosacral radiculopathy, colonic
adenoma
.
PSH: multiple skin grafts on left ankle after burn ([**2159**]),
multiple knee surgeries on L. and arthroscopic on R. ([**2159**]), R.
rotator cuff repair ([**2168**])
Social History:
Current smoker.
Family History:
Familial history of AAA.
Physical Exam:
Physical Exam on Discharge:
AVSS
Abdomen, soft, non-distended, non-tender
Vertical midline incision with small eschar patches, without
induration or signs of infection
Pulses:
R: p/p/p/p
L: p/p/weakly palp/p
Pertinent Results:
[**2199-12-30**] 02:35PM BLOOD WBC-12.7* RBC-3.36*# Hgb-10.7*#
Hct-30.2*# MCV-90 MCH-31.9 MCHC-35.5* RDW-13.8 Plt Ct-188
[**2200-1-8**] 04:29AM BLOOD WBC-22.4* RBC-3.93* Hgb-11.7* Hct-34.4*
MCV-88 MCH-29.9 MCHC-34.1 RDW-14.0 Plt Ct-855*
[**2199-12-30**] 02:35PM BLOOD PT-15.7* PTT-46.9* INR(PT)-1.5*
[**2200-1-8**] 04:29AM BLOOD PT-19.2* PTT-28.1 INR(PT)-1.8*
[**2199-12-30**] 06:21PM BLOOD Glucose-134* UreaN-13 Creat-1.0 Na-139
K-4.6 Cl-109* HCO3-26 AnGap-9
[**2199-12-30**] 06:21PM BLOOD ALT-48* AST-59* LD(LDH)-301*
CK(CPK)-1703* AlkPhos-43 TotBili-2.2*
[**2199-12-30**] 06:21PM BLOOD CK-MB-21* MB Indx-1.2 cTropnT-<0.01
[**2199-12-31**] 02:40AM BLOOD CK-MB-102* cTropnT-<0.01
[**2199-12-31**] 12:04PM BLOOD CK-MB-145* MB Indx-1.3 cTropnT-<0.01
[**2199-12-31**] 08:30PM BLOOD CK-MB-188* MB Indx-1.1 cTropnT-<0.01
[**2200-1-1**] 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEGATIVE
[**2200-1-19**] 07:02AM BLOOD WBC-15.0* RBC-3.65* Hgb-11.2* Hct-32.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-14.0 Plt Ct-792*
[**2200-1-20**] 06:45AM BLOOD WBC-14.7* RBC-3.74* Hgb-11.1* Hct-33.0*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.2 Plt Ct-697*
[**2200-1-9**] 08:59AM BLOOD PT-15.2* PTT-25.3 INR(PT)-1.4*
[**2199-12-30**] 02:35PM BLOOD Fibrino-120*
[**2200-1-20**] 06:45AM BLOOD Glucose-113* UreaN-14 Creat-1.0 Na-135
K-4.8 Cl-99 HCO3-27 AnGap-14
[**2200-1-14**] 06:06AM BLOOD ALT-30 AST-19 AlkPhos-71 TotBili-0.2
[**2200-1-20**] 06:45AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.3
[**2200-1-9**] 06:34AM BLOOD Triglyc-146
[**2200-1-15**] 06:07AM BLOOD Vanco-22.8*
[**2200-1-6**] 07:56AM BLOOD K-3.3
.
[**2200-1-7**] CT Torso with NGT and IV contrast:
IMPRESSION:
1. Leakage of contrast from the posterosuperior aspect of the
gastric fundus with oral contrast present within the left upper
quadrant and splenectomy bed.
2. Satisfactory postoperative appearance of open abdominal
aortic aneurysm repair.
3. Scattered colonic diverticulosis.
4. Moderate prostatic enlargement.
5. Left sided varicocele.
.
[**2200-1-8**] Endoscopy/Over the Scope Clipping by GI service:
Findings: Esophagus: Normal esophagus. Stomach: Mucosa: A few
areas of erythema and erosions were noted in the antrum
consistent with NG tube induced injury. Other A small 8 mm
opening was noted at the fundus surrounded by an area of
erythema and mucosal edema s/o site of the perforation. Turbid
fluid could be aspirated through the opening. An over the scope
clip (12mm, T-type, OTSC) was loaded over the scope and the
scope advanced to the region of the perforation. The opposing
ends of the defect were suctioned into the clip cap. The OTSC
was then successfully deployed at the perforation. The clip
appeared in good position. No fluid could be suctioned through
this region. Duodenum: Normal duodenum. Other findings: After
the OTSC placement, an NG tube was placed under endoscopic
vision successfully into gastric antrum. Impression: A few
areas of erythema and erosions were noted in the antrum
consistent with NG tube trauma. A small opening was noted at the
fundus surrounded by an area of erythema and mucosal edema c/w
the site of the perforation. An over the scope clip (OTSC) was
successfully deployed to close the perforation. Another NG tube
was then placed in the antrum. Otherwise normal EGD to third
part of the duodenum
.
[**2200-1-9**] CT a/p:
IMPRESSION:
1. No oral contrast extravasation on today's exam. No evidence
of leak.
2. Residual about 9 x 2.7 x 3.4 cm low to intermediate density
fluid in the subphrenics space with drain in place.
3. Moderate left pleural effusion and left basilar atelectasis.
.
[**2200-1-14**] UGI:
IMPRESSION: No extraluminal oral contrast. No fluoroscopic
evidence of
gastric perforation.
.
[**2200-1-15**] CT a/p:
IMPRESSION:
1. No evidence of extraluminal oral contrast.
2. Small, 3.6 cm peripherally enhancing collection abutting the
posterior
aspect of the fundus as described above.
3. Two perigastric surgical drains as described above.
4. Post-surgical appearance following abdominal aortic aneurysm
repair.
5. Right lower lobe lung nodule. This likely represents
inflected or inflamed lung, though recommend followup to
resolution to exclude an underlying nodule.
6. Diverticulosis.
Brief Hospital Course:
SUMMARY: 58M with 5.7cm infra-renal/juxta-renal AAA who
presented for open AAA resection-suprarenal cross clamp, with
intraoperative course complicated splenic laceration requiring
splenectomy, and post-operative course complicated by small
gastric fundal perforation requiring endoclipping.
.
BRIEF HOSPITAL COURSE:
The patient was brought to the OR on [**2199-12-30**] for open repair of
juxtarenal abdominal aortic aneurysm with 14 mm tube graft. A
perioperative epidural was placed. Reader referred to operative
note for full details. Intraoperative bleeding with splenic
laceration was noted, for which the ACS service was consulted,
and ultimately performed a splenectomy during the same procedure
(attending surgeon, Dr. [**Last Name (STitle) **]. 2 [**Doctor Last Name **] drains were placed post
operatively in the left flank, and the patient was transferred
to the PACU and the ICU intubated, with an NGT, in stable
condition.
.
ICU Course: The patient had an uneventful ICU course. He was
appropriately diuresed with a lasix drip, and transfused as
necessary. Tube feeds were begun on POD 4, and HIT panel
returned negative. His epidural was removed, and he was weaned
off the ventilator, extubated on POD5. On POD5 erythema
surrounding his midline vertical abdominal incision was noted
and he was begun on cefazolin given concern for a superficial
skin infection. He was transferred to the floor (VICU) on
[**2200-1-6**] in stable condition, tolerating clears which were begun
on [**2200-1-6**] (POD 7).
.
VICU and floor course: Prior to initiating clears on HD8, the
patient had serosanguineous output from his 2 flank JP drains in
the splenic bed. Following initiation of clears on POD7,
however, JP output markedly increased to over a liter per day
from each drain. The color of the drains also became bilious.
Given the change in JP output and a persistently uptrending WBC
count, the patient underwent a CTA torso on POD 8, [**2200-1-7**],
which showed a small gastric perforation along the greater
curvature of the stomach. In discussion between the ACS service
and the gastroenterology service, the patient underwent an
endocscopy-guided clipping (over the scope clipping, OTSC) of
the gastric fundus perforation on [**2200-1-8**] by the GI service,
without complication. JP output markedly decreased post
procedure. Day 1 of TPN was initiated thereafter on [**2200-1-9**] (POD
10), and the patient underwent 7 days total of TPN. CT a/p on
[**2200-1-9**] (POD 10) with contrast via NGT showed no active
extravasation, UGI series on [**2200-1-14**] confirmed no extravasation,
and the NGT was removed on [**2200-1-14**] (POD 15). He received
post-splenectomy vaccinations on [**2200-1-10**] (POD 11). Fluconazole
was added to his emperic vancomycin/ciprofloxacin/flagyl on
[**2200-1-14**] when budding yeast returned from one of his JP drains.
He completed a total 2 week course of v/c/f, and 5 days of
fluconazole. Repeat CT a/p on [**2200-1-15**] again showed no active
extravasation, and demonstrated a small residual peri-splenic
bed collection (residual 9 x 2.7 x 3.4 cm subphrenic
collection). The collection was thought not ammenable to
additional drainage at that time given potential injury to
pancreas/lung. It will be monitored in the future with repeat CT
as necessary as an outpatient to evaluate
progression/resolution. The patient was again started on clears
[**2200-1-15**], which he tolerated, and his diet was advanced slowly.
JP output remained stable during this time. One flank JP was
removed on [**2200-1-17**], and the second and final JP on [**2200-1-19**]. His
central line was removed, and tip culture returned negative. On
discharge he was tolerating a regular diet, ambulating
independently, with pain well controlled on oral medications.
Regarding his pulse-exam post operatively, he had palpable
distal pulses throughout his post-operative period. Vertical
midline staples were removed prior to discharge. He was
discharged home on HD22 with instructions to follow up with Dr.
[**Last Name (STitle) **] of vascular surgery and the ACS service.
Medications on Admission:
Fluticasone (FLOVENT HFA) 220 mcg 1 puff [**Hospital1 **], albuterol sulfate
(Proair) 90 mcg 2 puffs q4-6 hrs, lipitor 80 mg po qd,
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
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:*2*
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. metformin 500 mg Tablet Sig: 1-2 Tablets PO twice a day: 1
tab twice daily for 7 days then increase to 2 tabs twice daily.
.
Disp:*98 Tablet(s)* Refills:*2*
5. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every 4-6 hours as needed for wheeze:
shortness of breath, wheezes.
7. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Nicoderm CQ 21 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day: wean to 14mg/hr patches when tolerable.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal aortic aneurysm, status post open repair
Splenectomy
Gastric Perforation, status post endoscopic repair
Dyslipidemia
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a repair of your
abdominal aortic aneurysm on [**2199-12-30**]. Your spleen was also
removed, and a small perforation in your stomach was repaired
with an endoclip.
.
We have started you on several new medications, metoprolol
(lopressor) for high blood pressure, pantoprazole (protonix) for
stomach acid, aspirin for your blood vessels and metformin for
high blood sugars. Additionally, please continue all your
regular home medications.
.
It is imperative than you remain smoke free! While you were in
the hospital we gave you nicotine patches at 21mg/day. Please
continue to use the patches if needed and wean the dosage as
tolerable.
.
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
.
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**5-2**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
.
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**12-27**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
.
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
.
What activities you can and cannot do:
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered.
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks at [**First Name9 (NamePattern2) 2287**] [**Location (un) **], his office will
call you to arrange.
.
Please call and make an appointment to be seen by your PCP for
monitoring of the new medications we started you on in the
hospital.
.
Please follow up with the acute care surgeons (who removed your
spleen) in [**12-28**] weeks. Please call [**Telephone/Fax (1) 1864**] to make an
appointment.
Completed by:[**2200-1-20**]
ICD9 Codes: 2851, 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2035
} | Medical Text: Admission Date: [**2122-5-4**] Discharge Date: [**2122-5-9**]
Date of Birth: [**2050-3-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath and fatigue
Major Surgical or Invasive Procedure:
[**2122-5-4**] - Ascending aorta replacement with a 29mm Gelweave graft
and aortic valve replacement with a #23 [**Company 1543**] Mosaic tissue
valve.
History of Present Illness:
This is a 72-year-old female with a 13-year known history of a
bicuspid aortic valve. She was followed during this time with
progression of the aortic stenosis and some dilation of the
ascending aorta. During the most recent
echocardiogram, it showed an aortic valve area of 0.5 with a
peak gradient in the mid 30s and an ascending aneurysm that was
approximately 4 cm in size. Based on these findings, the
progression of the disease and the extreme small aortic valve
area, it was decided to proceed with repair. The risks and
benefits were explained to the patient and she agreed to
proceed. The patient agreed to undergo aortic valve replacement
with a tissue valve.
Past Medical History:
Aortic stenosis
Bicuspid Aorti Valve
Dilated Ascending Aorta
Hyperlipidemia
Osteoporosis
Neuropathy
Colon polyps
Social History:
Retired. Never smoked and drinks 4 alcoholic beverages per week.
Lives with her husband.
Family History:
None
Physical Exam:
82 SR 18 130/80
GEN: Well appearing 72 y/o female in NAD
HEENT: Unremarkable
LUNGS: CTA
HEART: RRR, 4/5 SEM
ABD: Soft, NT, ND, NABS
EXT: warm, well perfused, 1+ LE Edema. Pulses [**11-18**]+.
NEURO: Nonfocal
Pertinent Results:
[**2122-5-4**] - PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is moderately dilated. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic aorta.
5. The aortic valve is bicuspid. The aortic valve leaflets are
severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine.
1. A well-seated bioprosthetic valve is seen in the aortic
position with
normal leaflet motion and gradients (mean gradient = 5 mmHg). No
aortic
regurgitation is seen.
2. An ascending aorta tube graft is also seen.
3. Biventricular function is preserved
4. Other findings are unchanged
Brief Hospital Course:
Mrs. [**Known lastname 97516**] was admitted to the [**Hospital1 18**] on [**2122-5-4**] for surgical
management of her aorta and aortic valve disease. She was taken
directly to the operating room where she underwent an aortic
valve replacement with a 23mm tissue valve and replacement of
her ascending aorta. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. By postoperative day one she had awoke
neurologically intact and was extubated. She was then
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility. She had progressed well
with her mobility, and is ready to be discharged home today.
Medications on Admission:
Aspirin 81mg QD
Fosamax
lipitor 20mg QD
Vitamins/Minerals
Discharge Medications:
1. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Packet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Bicuspid Aortic Valve, Aortic Stenosis, Dilated Ascending Aorta
- s/p AVR and Replacement of Ascending Aorta
PMH: Hyperlipidemia, Neuropathy, Osteoporosis, Colon polyps
Discharge Condition:
Stable
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:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Follow-up with Dr. [**First Name (STitle) 1313**] in 2 weeks. ([**Telephone/Fax (1) 97517**]
Please call all providers for appointments.
Scheduled Appointments:
Provider: [**Name Initial (NameIs) 326**] (B) BONE DENSITOMETRY [**Name Initial (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**]
Date/Time:[**2122-8-10**] 11:00
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-9-15**] 2:00
Completed by:[**2122-5-9**]
ICD9 Codes: 4241, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2036
} | Medical Text: Admission Date: [**2184-12-27**] Discharge Date: [**2184-12-31**]
Date of Birth: [**2101-12-18**] Sex: F
Service: SURGERY
Allergies:
IV Dye, Iodine Containing Contrast Media / Labetalol /
furosemide / amlodipine
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2184-12-28**]: Incisional hernia repair, primary closure
History of Present Illness:
83F with distant history of appendectomy and known asymptomatic
ventral hernia for more than 20 years presents with a one day
history of the hernia "being stuck, hard, and painful". Reports
she woke up with the pain this morning and has not been able to
reduce since. Has never had it incarcerate in the past. Has
felt nauseated and vomited once this morning. Last bowel
movement was yesterday and she does not recall passing flatus
today. Denies fevers or chills.
Past Medical History:
HTN, HLD, osteoporosis, osteoarthritis, trigeminal
neuralgia, infectious colitis (admitted to [**Hospital1 18**] [**Date range (1) 69839**]/[**2184**])
PSH: appendectomy @ age 17 for perforated appendicitis; cerebral
aneurysm s/p clipping in mid [**2162**] @ [**Hospital1 2025**]
Social History:
High functioning, lives alone in [**Name (NI) 3146**], MA, son lives 30
minutes away and assists her when needed. Denies smoking, rare
EtOH, no drug use.
Family History:
Brother with heart disesae. No known h/o inflammatory bowel
disease, colon cancer, or other GI malignancies.
Physical Exam:
ON admission:
Vitals 97.3 65 [**Telephone/Fax (2) 91913**]0%RA
NAD, AAOx3
RRR, unlabored respirations
abdomen soft, non-distended, 4 inch x 3 inch bulge in
hypogastric
region, tender, firm and with mild erythematous skin changes,
irreducible
DRE minimal stool in vault, normal tone, guaiac negative
ext no edema
=
On discharge
Vitals 97.1 83 138/70 16 94%RA
Gen-NAD, AAOx3
Card- RRR
Pulm- unlabored respirations, CTAB
Abd- soft, non-distended, incision healing, no erythema
Ext- no ededea
Pertinent Results:
[**2184-12-27**] 04:42PM BLOOD Glucose-108* UreaN-17 Creat-1.0 Na-131*
K-5.7* Cl-97 HCO3-20* AnGap-20
[**2184-12-27**] 04:51PM BLOOD Lactate-1.2 K-4.6
[**2184-12-27**] 04:42PM BLOOD WBC-18.1*# RBC-4.13* Hgb-12.8 Hct-36.8
MCV-89 MCH-30.9 MCHC-34.7 RDW-11.6 Plt Ct-308
CT abdomen/pelvis:
1. Large midline ventral hernia, now with new involvement of
distended small bowel since [**2184-11-23**], with moderate
neighboring [**Name2 (NI) **] stranding, concerning for incarceration. Lack of
IV contrast makes evaluation of bowel wall enhancement to
evaluate for ischemia impossible. No free air or pneumatosis
seen.
2. Right middle lobe opacities, minimally changed since [**11-24**], [**2183**], but not fully imaged/not fully evaluated, may represent
chronic aspiration or inflammation vs chronic infection.
Brief Hospital Course:
Ms. [**Known lastname 59975**] was taken to the OR emergently on [**2183-12-28**] for
incisional hernia repair for her incarcerated hernia. She was
extubated in the OR and brought to the ICU in stable condition.
She was noted to be hypertensive to 200/100 immediately postop
and responded well to morphine and hydralazine. With improved
pain control, her hypertension resolved. She was transferred to
the floor on POD#1.
Once transferred to the floor she continued to progress. Her NG
output had diminished and was removed on POD# 2. Her diet was
advanced slowly. Once able to tolerate a diet her Morphine PCA
was stopped and she was started on oral pain medications; Ultram
and Tylenol were added as well.
During the remainder of her stay her blood pressures remained
stable ranging in the 130's/70's. Physical therapy worked with
her and deemed her safe for home. At time of discharge the
patient was tolerating a regular diet, ambulating with a cane
and minimal assistance, voiding without difficulty, and had
minimal pain. The patient was discharged to rehab with follow up
in [**Hospital 2536**] clinic.
Medications on Admission:
losartan 100', carbamazepine 200''', simvastatin 40',
spironolactone 50''
Discharge Medications:
1. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for diarrhea.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Incarcerated incisional hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with an incarcerated ventral
hernia requiring an operation to repair this. You have done well
from your surgery are now being discharged to rehab.
Bulb Suction Drain Care:
*Please look at the drain site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warmth, and fever).
*Maintain the bulb on suction.
*Record the color, consistency, and amount of fluid in the
drain. Call the [**Location (un) 5059**], nurse practitioner, or VNA nurse if
the amount increases significantly or changes in character.
*Empty the drain frequently.
*You may shower and wash the drain site gently with warm, soapy
water. You may also wash with half strength hydrogen peroxide
followed by saline rinse.
*Keep the insertion site clean and dry otherwise. Place a drain
sponge for cleanliness.
*Avoid swimming, baths, and hot tubs. Do not submerge yourself
in water.
*Attach the drain securely to your body to prevent pulling or
dislocation.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Location (un) 5059**] at your next visit.
Don't lift more than 15-20 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your [**Month (only) 5059**].
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2185-1-18**] at 2:15 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**] ACUTE CARE CLINIC
Phone: [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2037
} | Medical Text: Admission Date: [**2161-11-29**] Discharge Date: [**2161-12-10**]
Date of Birth: [**2096-5-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2474**]
Chief Complaint:
CC: shortness of breath
Major Surgical or Invasive Procedure:
Intubation, Arterial Blood Gases
History of Present Illness:
This is a 65 year old with mental retardation, severe COPD and
recent admission with COPD exacerbation treated with intubation
presents with SOB. The patient normal has oxygen sats in the
high 80s on RA, however today he was noted to be 72% on RA. He
uses 2L of oxygen at home at night. He complains of SOB. He has
had cough with clear sputum production for the last 3 weeks. He
denies chills or fevers. He restarted smoke 3 weeks ago. He was
brought to the ED by EMS.
.
In the ED, initial vs were: T 99 P 80 BP 117/78 R 22 O2 sat 98%
NRB. A CXR showed a questionable LLL PNA. Patient was given
Albuterol and ipratropium nebs, Levofloxacin 750mg IV,
Prednisone 60mg, and 1L NS. ABG showed respiratory acidosis with
pCO2 of 88 (baseline 70s) and preserved oxygenation. The patient
was clearly against intubation in the ED. CPAP was started in
the ED prior to transfer. VS prior to transfer were 97, HR 75,
98/60, 50, 95%3L. PIV x 2 were placed in the ED. The patient
received 15 min of BiPAP in the ED with improvement in
mentation.
.
On the floor, patient [**Last Name (un) **] tachypneic, with cynanotic lips but
felt that his breathing is improved from the ED.
.
Past Medical History:
1) COPD: FEV1 23% predicted, home 1.5-2L O2 at night only
2) Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO
[**2159-9-18**])
3) Schizophrenia
4) Hx GI bleeding
5) Mental Retardation
6) Pulmonary Hypertension
7) s/p tonsillectomy
Social History:
Lives in [**Location **] with brother and brother-in-law. On
disability since [**2149**] for mental health issues. Has home nurse
visit every morning and evening. Reports ~50 pack-year smoking
and has now cut down to 3 cigs/day. Denies any ETOH/drug use.
Family History:
Patient unable to provide.
Physical Exam:
Physical examination:
- Gen: Well-appearing in NAD.
- [**Year (4 digits) 4459**]: Conj/sclera/lids normal, PERRL, EOM full, and no
nystagmus. Hearing grossly normal bilaterally. Sinuses
non-tender. Nasal mucosa and turbinates normal. Oropharynx clear
w/out lesions.
- Neck: Supple with no thyromegaly or lymphadenopathy.
- Chest: Normal respirations and breathing comfortably on room
air. Lungs clear to auscultation bilaterally.
- CV: PMI normal size and not displaced. Regular rhythm. Normal
S1, S2. No murmurs or gallops. JVP <5 cm. 2+ carotids. No
carotid bruits.
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
Liver/spleen not enlarged.
- Rectal: No external lesions. Normal tone, stool guaiac
negative.
- Extremities: No ankle edema.
- MSK: Joints with no redness, swelling, warmth, tenderness.
Normal ROM in all major joints.
- Skin: No lesions, bruises, rashes.
- Neuro: Alert, oriented x3. Good fund of knowledge. Able to
discuss current events and memory is intact. CN 2-12 intact.
Speech and language are normal. No involuntary movements or
muscle atrophy. Normal tone in all extremities. Motor [**6-10**] in
upper and lower extremities bilaterally. Gait normal. DTRs 2+ at
brachioradialis and patella bilaterally. Plantar reflex down
(neg Babinski). Finger-to-nose and heel-to-shin normal. Romberg
and pronator drift negative. Sensation to light touch intact in
upper and lower extremities bilaterally.
- Psych: Appearance, behavior, and affect all normal. No
suicidal or homicidal ideations.
Pertinent Results:
[**2161-12-8**] 06:03AM BLOOD WBC-9.3 RBC-4.13* Hgb-12.6* Hct-37.7*
MCV-91 MCH-30.5 MCHC-33.3 RDW-13.5 Plt Ct-267
[**2161-11-29**] 09:40PM BLOOD WBC-11.4* RBC-4.16* Hgb-12.7* Hct-39.9*
MCV-96 MCH-30.4 MCHC-31.7 RDW-14.0 Plt Ct-412#
[**2161-12-9**] 06:05AM BLOOD Glucose-182* UreaN-17 Creat-0.7 Na-145
K-3.6 Cl-101 HCO3-40* AnGap-8
[**2161-11-29**] 09:40PM BLOOD Glucose-173* UreaN-19 Creat-1.0 Na-146*
K-4.1 Cl-101 HCO3-40* AnGap-9
[**2161-12-8**] 06:03AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9
[**2161-11-30**] 05:05AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8
.
Blood Gases
[**2161-12-8**] 04:36PM BLOOD Type-ART pO2-60* pCO2-62* pH-7.43
calTCO2-43* Base
[**2161-12-8**] 04:36PM BLOOD Type-ART pO2-60* pCO2-62* pH-7.43
calTCO2-43* Base XS-13
[**2161-12-5**] 04:42AM BLOOD Type-ART pO2-129* pCO2-60* pH-7.45
calTCO2-43* Base XS-15
[**2161-12-2**] 12:42PM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-8
FiO2-21 pO2-58* pCO2-45 pH-7.49* calTCO2-35* Base XS-9
-ASSIST/CON Intubat-INTUBATED
[**2161-12-2**] 10:37AM BLOOD Type-ART Temp-36.3 Rates-16/ Tidal V-500
PEEP-8 FiO2-35 pO2-115* pCO2-66* pH-7.41 calTCO2-43* Base XS-14
-ASSIST/CON Intubat-INTUBATED Vent-IMV
[**2161-12-2**] 09:27AM BLOOD Type-ART FiO2-35 pO2-94 pCO2-97* pH-7.28*
calTCO2-48* Base XS-14 Intubat-NOT INTUBA
.
[**2161-12-1**] 12:41PM BLOOD Type-ART pO2-101 pCO2-89* pH-7.28*
calTCO2-44* Base XS-11 Intubat-NOT INTUBA
[**2161-11-30**] 12:31AM BLOOD Type-ART pO2-84* pCO2-88* pH-7.32*
calTCO2-47* Base XS-14
[**2161-12-6**] 06:21PM BLOOD Lactate-0.9 K-4.2
[**2161-12-6**] 02:17PM BLOOD Lactate-1.0 K-3.5
[**2161-12-1**] 12:41PM BLOOD Glucose-202* Lactate-1.2 K-5.0
[**2161-12-5**] 01:34PM BLOOD freeCa-1.15
.
[**2161-11-29**] CXR
IMPRESSION: Findings suggestive of early left lower lobe
pneumonia.
.
CXR [**2161-12-8**]
IMPRESSION: AP chest compared to chest radiographs since [**2159**],
most recently
[**12-6**]:
Aeration at the base of the right lung has improved, with
remission of
peribronchial opacification. The discrete flame-shaped lesion in
the left mid lung whch appeared on [**11-30**] is smaller,
probably atelectasis in a region of an acute infection or
infarction. No indication of current pneumonia or cardiac
decompensation. Heart size normal. Of note prior chest CT scans
have findings suggesting a propensity to tracheobronchomalacia,
as well as moderately severe emphysema.
Left PIC catheter ends in the upper SVC. No pneumothorax or
pleural effusion.
Brief Hospital Course:
65 y/o with severe COPD, mild mental retardation presented with
hypercarbic resp failure.
.
# Acute on Chronic Respiratory Failure: This patient has Co2
chronically in the high 80s and presented with worsening dyspnea
consistent with a COPD exacerbation in the setting of
Bronchitis, and resuming smoking was likely. This patient has
been hospitalized with multiple prior intubations during the
past year. After some respiratory distress on HD 3 he was put
on BIPAP and did not tolerate it well with a high amount of
respiratory secretions which could not be suctioned. He was
transferred to intensive care unit where he remained tachypneic
and in respiratory distress and therefore was intubated. He
completed a complete 7 day course of levofloxacin for COPD
exacerbation. He was diuresed 2.5 liters while in the intensive
care unit. He was successfully extubated HD 8, and tolerated
nasal cannula well. He was continued on prednisone 60mg and
started a slow taper after transfer to the floor when he was
clinically stable from a respiratory standpoint. He was
continued on aggressive Albuterol and Atrovent nebulizer
treatment. On the floor he had an episode of transient
unresponsiveness and was found to be in hypoxic respiratory
distress on arterial blood gas. He recovered quickly with a
nebulizer treatment and was stable for the duration of his
hospitalization. He was discharged on the remainder of his
prednisone taper and on home 24 hour oxygen with nursing
services and close primary care follow-up.
.
#Hypotension - While in the intensive care unit, the patient
required Dopamine for few hours because of systolic pressures in
the 70??????s. After administration of 2 liters of normal saline
the patient was normotensive and blood pressures were stable
throughout the remainder of his hospitalization.
.
# Schizophrenia: The patient was continued on Zyprexa.
.
# Glucose intolerance. The patient was placed on an insulin
sliding scale due to elevated blood sugars in the setting of
prednisone. The patient declined insulin on discharge stating
he would not take it if prescribed, as he had not taken it in
the past. He will have close follow-up with his primary care
physician and will tolerated mildly elevated blood sugars given
the temporary duration of prednisone therapy.
.
# Anemia: HCT at baseline, normocytic. Trended HCT Q daily
Medications on Admission:
Zyprexa 7.5 mg daily
Advair Diskus 500 mcg-50 mcg inhaled twice daily
Spiriva 1 capsule inhaled daily
Aspirin 81 mg daily
Nicotine 14 mg/24 hr daily Patch
ProAir HFA 90 mcg/Actuation Aerosol Inhaler 2 puffs(s) inhaled
twice a day and q 4 hours prn wheeze
Multivitamin with Minerals daily
Famotidine 20 mg twice daily
Discharge Medications:
1. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every 4-6 hours as needed
for wheeze/sob.
Disp:*30 units* Refills:*0*
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day: Apply patch once a day for one month then switch to
7mg patch for one month then stop. (Continue as started on
[**11-17**]).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid
Dissolves PO DAILY (Daily).
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation twice a day: Additional 2 puffs as
needed every 4 hours for SOB.
8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
11. multivitamin Capsule Sig: One (1) Capsule PO once a day.
12. Home Oxygen
1- 2 liters nasal canula to keep O2 sat above 90%. Ambulatory
Saturation on Room Air is 86%. Ambulatory Saturation on 1L NC
is 88%. Please use nasal cannula during night and day to keep
saturations above 90%.
13. prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Start friday [**2161-12-11**]. Take for three days.
Disp:*3 Tablet(s)* Refills:*0*
14. prednisone 10 mg Tablet Sig: as taper directs Tablet PO once
a day: start after 50mg prednisone, take 4 tablets daily for
three days, then take 3 tablets daily for 3 days, then take 2
tablets daily for 3 days then take 1 tablet daily for 3 days.
Disp:*40 Tablet(s)* Refills:*0*
15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every
four (4) hours as needed for pain.
16. Home Nebulyzer Machine
Diagnosis: COPD
Discharge Disposition:
Home With Service
Facility:
[**Hospital 7272**] Health Systems
Discharge Diagnosis:
1. COPD exacerbation
2. Secondary pulmonary hypertension, DM2, schizophrenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for management of a chronic obstructive
pulmonary disease (COPD) exacerbation. Your ability to breathe
on your own was compromised such that you were intubated for
several days. You were treated with a complete antibiotic
course during your admission and were given steroids treat the
inflammation in your lungs. You required oxygen supplementation
throughout the day in addition to your nightly requirement.
In addition to your regular medications,
Please continue the prednisone taper as directed.
Please continue daytime home oxygen as directed until otherwise
insructed by your primary care physician.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2161-12-15**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**]
ICD9 Codes: 486, 2760, 2762, 4168, 2859, 4589, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2038
} | Medical Text: Admission Date: [**2123-6-26**] Discharge Date: [**2123-7-19**]
Date of Birth: [**2080-2-1**] Sex: M
Service: MEDICINE
Allergies:
Zemplar / Ampicillin
Attending:[**First Name3 (LF) 826**]
Chief Complaint:
Bacteremia
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
History of Present Illness:
Patient is a 43 yo Thai speaking male with ESRD on HD, HTN
presented to [**Hospital1 18**] on [**6-26**] after being notified that blood
cultures drawn on [**6-24**] returned positive for GPC in [**1-28**] bottles.
He arrived to HD on [**6-24**] with rigors and chills, but was
afebrile to 99.1, and had blood cx's drawn. On arrival to the
ED, he was afebrile to 96.8, with BP 92/38, and was admitted to
medicine for further work-up. He was given 1g vanco x1, 1 g
ceftaz x1, which were continued on the floor. ROS were negative
for any fever, cough, SOB, dysuria, odynophagia or any other
localizing symptoms. It was felt that his tunneled HD line was
likely the source, and it was planned to have that line removed.
Pt was dialyzed on [**6-26**] through his still maturing AVF in his L
arm.
On [**6-27**], pt became increasingly hypotensive, with BPs at 80/40.
He was otherwise afebrile to 97.8, but Tmax 100.3, with HR 70s,
RR 20s, and satting 100% on RA. He was given 1L NS bolus without
improvement in his blood pressure. Pt was transferred to the ICU
for closer monitoring. He was transferred to the floor after he
was hemodynamically stable.
Past Medical History:
HTN
ESRD ([**1-28**] HTN) AVF placed [**2123-4-9**] (awaiting maturation)
Anemia (baseline hct 30)
CHF EF 40%
Uric acid elevation
Social History:
No smoking, no alcohol, no drug use.
Family History:
Father and mother died at age 40-50. Brothers with HTN. No
family history of stroke or MI.
Physical Exam:
VS: T 98 BP80/34 HR72 RR o2sat:
GEN: lying on bed, does not appear toxic. able to speak in full
sentences without difficulty.
HEENT: PERRL, EOMI, anicteric, MM dry.
NECK: Supple, no elev JVP.
CHEST: CTAB, no c/w/r.
HEART: RRR, nl S1 and S2, no m/r/g
ABD: Soft, NTND, NABS, no bruits, no HSM
EXT: Warm, 2+ pulses bilaterally, 1+ pitting edema bilaterally
Neuro: A&O x 3, no focal neurologic signs.
Brief Hospital Course:
Patient is a 43 yo male with history of ESRD [**1-28**] HTN presents
with high-grade bacteremia with 2/2 bottles of pansensitive
Enterococcus and Enterobacter and 4/4 bottles of GNR.
1. Enterococcal/Enterobacter bacteremia: Patient with
polymicrobial bacteremia secondary to infected tunneled HD line;
no other localizing symptoms on admission. Initially hypotensive
with BPs in 80/40's consistent with sepsis. He was transferred
to the MICU for closer management, no pressors were required.
His tunneled HD Line was pulled and he was started on Vancomycin
and Levaquin, as per ID. He also had been on Ceftaz,
Meperidine, and Linezolid, all of which were stopped in the
MICU. TTE was done and did not suggest any vegetations or
abcesses. TEE was then done and showed a moderate sized aortic
vegetation that was consistent with aortic regurgitation, which
was auscultated on exam. Patient was seen by CT surgery and felt
that he would require AVR after he had completed his 6 week
course of antibiotics and suggested he undergo cardiac
catheterization as part of the pre-op evaluation. Patient was
also seen by cardiology was consulted Vancomycin was changed to
Ampicillin, as per ID, who felt that Enterococcus was more
sensitive to this drug. Two weeks later he became neutropenic,
developed a diffuse erythematous rash, and started spiking
temperatures.
2. ESRD: Patient on hemodialysis TTHSat d/t ESRD from HTN. s/p
HD yest on [**6-26**], not due for HD until Tues. tunneled line pulled
on [**6-26**], renal consulting, following, dialyzed through mature av
fistula on [**6-29**].
3. HTN
- Hold antihypertensives given sepsis, restart on floor once
stable
4. Anemia:
At baseline Hct ~30. Continue Epo 6000units qhd.
Medications on Admission:
Meds at home:
Metoprolol 75mg PO bid
norvasc 10mg PO qday
tums 500mg PO tid
epo 6000 units qhd
calajex 2mcg qhd
Discharge Medications:
1. Vancomycin HCl 1250 mg IV QHD
Please dose at hemodialysis
2. Gentamicin 60 mg IV QHD
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours).
Disp:*15 Tablet(s)* Refills:*0*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Endocarditis
2. End stage renal disease on HD
3. Hypertension
Discharge Condition:
Stable
Discharge Instructions:
1. You are being treated for a bacterial infection with 3
antibiotics for 6 weeks ([**Date range (1) 67279**]). Two of the antibiotics
will be given at hemodialysis. The third antibiotic is Levaquin.
You will take 1 tablet every 2 days until [**2123-8-12**].
2. Recommended follow-up as listed below
3. If you experience any fevers, chills, chest pain, SOB or any
other concerning symptoms please return to the ER>
Followup Instructions:
1. You will getting hemodialysis on Tuesdays, Thursdays, and
Saturdays at [**Hospital1 18**]. You will be informed about the time and
place.
2. Please have labs done at hemodialysis. Weekly CBC, LFTs,
vancomycin trough, and gentamycin peak/trough levels should be
faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**].
3. You are scheduled for an appointment with Cardiothoracic
Surgery on [**8-11**] at 2:30pm.
4. You are scheduled to have an echocardiogram on Thursday,
[**8-5**] at 8am in the [**Hospital Ward Name 23**] Building, [**Location (un) 436**]. Phone
number [**Telephone/Fax (1) 128**].
5. Dr. [**Last Name (STitle) **] will be contacting you regarding your appointment
for tooth extraction.
6. You are scheduled for an appointment with Infectious Disease
clinic, DR. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2123-8-17**]
11:00
ICD9 Codes: 5856, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2039
} | Medical Text: Admission Date: [**2171-10-25**] Discharge Date: [**2171-10-31**]
Service: CSU
HISTORY OF PRESENT ILLNESS: This is an 81 year old gentleman
who reports having chest discomfort for the past four years
with recent increase in frequency. He had a stress test,
which was positive and he was referred to [**Hospital1 346**] for cardiac catheterization and
subsequently a coronary artery bypass grafting.
PAST MEDICAL HISTORY: Hypertension. Demyelinating
polyneuropathy. Sciatica. Decreased vision in his left eye
due to retinal problems. Status post hernia repair.
ALLERGIES: Inderal which causes claustrophobia and asthma.
PREOPERATIVE MEDICATIONS:
1. Verapamil 240 mg p.o. q a.m. and 120 mg p.o. q p.m.
2. Hydrochlorothiazide 25 mg p.o. q. Day.
3. Trileptal 300 mg p.o. twice a day.
4. Ditropan XL 10 mg p.o. q. Day.
5. Lisinopril 10 mg p.o. twice a day.
6. Aspirin 162 mg p.o. twice a day.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**11-3**] for a cardiac
catheterization. Cardiac catheterization showed an ejection
fraction of 65 percent. A 70 to 90 percent left anterior
descending lesion; 90 percent first diagonal lesion; 50
percent obtuse marginal one lesion and 80 percent right
coronary artery lesion. The patient was referred to Dr.
[**Last Name (STitle) **] for coronary artery bypass grafting. The patient's
cardiac catheterization was on [**2171-10-14**]. The patient was
discharged to home after his cardiac catheterization and was
readmitted on [**10-25**] for his surgery. He was taken to the
operating room for coronary artery bypass grafting times
four; left internal mammary artery to left anterior
descending; saphenous vein graft to first diagonal; saphenous
vein graft to second diagonal and saphenous vein graft to
right coronary artery. Total cardiopulmonary bypass time was
87 minutes. Cross clamp time was 69 minutes. The patient
was transferred to the Intensive Care Unit in stable
condition on Neo-Synephrine and Propofol. The patient
initially had moderate amount of tube drainage and was
treated with packed red blood cells. He was weaned and
extubated from mechanical ventilation on his first
postoperative evening. On postoperative day number one, the
patient intermittently required some Neo-Synephrine. He
remained in the Intensive Care Unit for some pulmonary
toilette as well as some hypotension. By the evening of
postoperative day number one, the patient had been started on
Lopressor and became hypertensive. The patient was started
on Neo-Synephrine. The patient had some intermittent
wheezing and congestive cough and required some pulmonary
toilette and some Nebulizer treatment. On postoperative day
number two, the patient's chest tubes and pacing wires and
Foley catheter were removed without incident. On
postoperative day number three, the patient was transferred
from the Intensive Care Unit to the regular part of the
hospital, where he began working with physical therapy. It
was determined that the patient would benefit from a stay at
short term rehabilitation. Over the next couple of days, the
patient continued on diuretics and beta blockers. By
postoperative day number five, the patient was cleared for
discharge to rehabilitation.
CONDITION ON DISCHARGE: Temperature 98.2; blood pressure
100/60; pulse 80 and regular. Oxygen saturation 95 percent
on room air. The patient's weight was 100.3 kg;
preoperatively, the patient weighed 94.8 kg. Neurologically,
the patient was awake, alert, grossly intact, oriented times
three. Respiratory: Breath sounds were decreased at
bilateral bases. Heart is regular rate and rhythm. Abdomen is
soft, nontender, nondistended. Extremities: Warm and well
perfused. The patient has 1 plus pedal edema bilaterally.
Sternal and leg incisions are clean, dry and intact without
any erythema or drainage.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. twice a day times seven days.
2. Potassium chloride 20 mEq p.o. twice a day times seven
days.
3. Colace 100 mg p.o. twice a day.
4. Zantac 150 mg p.o. twice a day.
5. Trileptal 300 mg p.o. twice a day.
6. Detrol XL 5 mg p.o. twice a day.
7. Lopressor 100 mg p.o. twice a day.
DISCHARGE DIAGNOSES: Coronary artery disease.
Hypertension.
Demyelinating polyneuropathy.
DISPOSITION: The patient is to be discharged to
rehabilitation in stable condition. He is to follow up with
Dr. [**Last Name (STitle) **] in one to two weeks. He is to follow-up with
Dr. [**Last Name (STitle) **] in one to two weeks. He is to follow-up with Dr.
[**Last Name (STitle) **] in three to four weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2171-10-30**] 20:08:45
T: [**2171-10-30**] 20:45:32
Job#: [**Job Number 45350**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2040
} | Medical Text: Admission Date: [**2180-3-7**] Discharge Date: [**2180-3-15**]
Date of Birth: [**2153-12-22**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5378**]
Chief Complaint:
OSH transfer for AMS, seizures
Major Surgical or Invasive Procedure:
extubation, Lumbar puncture
History of Present Illness:
Per admitting resident:
26 year old RH man with an unremakable PMH who was last seen in
his USOH in the early am (prior to going to work) and then at
noon (normal conversation with his wife over the phone) p/w
confusion and question of seizure.
Today at around 13:00 he was found confused by his peers. The
report says he could not maintain a conversation and was
thrashing and moving his arms and legs bl and symmetrically. He
did not have a facial droop. He was not bumping into objects per
wife. [**Name (NI) **] was not seen seizing. There was no documented LOC.
While
taken by EMS to OSH, there is the question of a seizure episode.
Unfortunately, I see no documentation in this regard. EMS took
the pt to [**Hospital **] hospital. The pt was noted to have a fever
101.9F with 139/ 68 and 155 bpm and 24 RR with So2 100% in RA.
Pt
received a CT CNS w/o contrast that showed LEF Ttemporo-parietal
hypodense wedge shaped lesion. No fractures or bleed. No
hydrocephalus or herniation data. His Chem showed a normal Na
and
Ca. His Glu was 177. He did have an AG of 22. He was tapped: LP
showed:
Pr 58, glu 92
BRCs 50, 2 WBC (100% L)
RBCs 48, 2 WBCs. (100% L)
His EKG showed a sinus tachycardia w/o repol abnormalities.
His C-spine scan was negative.
He received ceftriaxone 2 g iv and vancomycin 1 g iv. He
received
1 g PHT iv and was ETT'd at 14:45 after sedation with
sucinylcholine and vecuronium and placed on a versed drip.
Once at [**Hospital1 18**], he was started on propofol drip and bolussed with
versed (agitated). He also received acyclovir 800 mg iv.
ROS is negative otherwise. NO sick contacts. [**Name (NI) **] ID symptoms. No
headaches. NO seizure hx. NO aneurisms hx.
Baseline: IADLS.
Additional hx obtained from witness:
Per discussion with witness, patient was working on a boat
engine. Last seen normal at noon time. Owner heard back from
him when calling his name at 1pm on another part of the boat. ~
30 minutes later, owner heard loud banging, ran to see pt. and
oted that him laying on floor, arms and legs stiffened, head
shaking and banging on the back of the metal wall. This lasted
nearly 1-2 minutes. Once banging stopped, patient appeared to
be unconscious with heavy breathing. EMS arrived and by this
time (10 mins) he "came to" crawled out of area on his own,
could not say his name to EMS, did not know where he was,
"glassy eyed" and dazed.
Few minutes later had another episode: eyes opened wide,
clenched his teath, foam coming out of his mouth, body
straightened/rigid. This lasted 2 minutes and then became loose
again and confused. Patient was at that time transported to OSH.
Past Medical History:
none
Social History:
Lives with wife and daughter
Exercises (-)
Tobacco occasional cigarrettes.
ETOH two beers per night
Drugs (-)
He works as an electrician.
Family History:
Hx of early strokes (-)
Seizures (-)
CNS tumors (+) - granmother.
Demyelinating conditions (-)
Autoimmune conditions (-)
Procoagulant conditions (-)
CAD (-)
Aneurysm (+) grandfather.
Physical Exam:
Exam on admission:
176/ 76, 136 bpm: agitated.
When sedated: 130/ 80s.
On vent, CMV mode breathing at 22 RR (overbreathing the vent).
Sedated on Propofol at 50 mcg/ kg/ min which was stopped 15
minutes prior to my examination.
Gen: Lying in bed, fighting the tube.
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
Back: No point tenderness or erythema
CV: Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, nontender, non-distended. No masses or megalies.
Percussion within normal limits. +BS.
Ext: no edema, no DVT data. Pulses ++ and symmetric.
Neurologic examination:
MS:
He is responsive to noxious stimuli in all limbs. He does
withdraw to pain symmetrically and localizes well.
CN: Brain stem reflexes : preserved:
Corneals + bl. Pupils 3.5 to 2.5 bl and symmetrically. resisting
my pupillary exam. Closes his eyes symmetrically. No gaze
deviation. No bobbing or Robbing. No nystagmus. No facial
asymmetries.
Gag +.
Tone: normal.
DTR: 2+. Toes : would not allow exam (withdraws and quicks)
Labs: reviewed.
U Tox and serum tox: negative, except for tylenol level (7.5:
given at [**Hospital1 18**] and at OSH).
Pertinent Results:
Labs on admission:
[**2180-3-7**] 07:25PM BLOOD WBC-16.1* RBC-4.77 Hgb-14.4 Hct-41.8
MCV-88 MCH-30.1 MCHC-34.3 RDW-12.4 Plt Ct-232
[**2180-3-9**] 03:17AM BLOOD WBC-8.8 RBC-4.45* Hgb-13.5* Hct-38.9*
MCV-87 MCH-30.3 MCHC-34.6 RDW-12.7 Plt Ct-190
[**2180-3-7**] 07:25PM BLOOD Neuts-92.3* Lymphs-4.0* Monos-3.4 Eos-0.1
Baso-0.2
[**2180-3-7**] 07:25PM BLOOD PT-12.5 PTT-22.5 INR(PT)-1.1
[**2180-3-7**] 07:25PM BLOOD Glucose-148* UreaN-13 Creat-1.7* Na-139
K-3.8 Cl-106 HCO3-24 AnGap-13
[**2180-3-8**] 01:55PM BLOOD UreaN-11 Creat-1.6* Na-142 K-3.7 Cl-111*
HCO3-25 AnGap-10
[**2180-3-9**] 12:36PM BLOOD Glucose-121* UreaN-7 Creat-1.3* Na-141
K-3.3 Cl-105 HCO3-28 AnGap-11
[**2180-3-8**] 12:02AM BLOOD ALT-61* AST-193* CK(CPK)-[**Numeric Identifier 85885**]*
AlkPhos-43 TotBili-0.7
[**2180-3-8**] 01:55PM BLOOD CK(CPK)-[**Numeric Identifier **]*
[**2180-3-8**] 10:32PM BLOOD CK(CPK)-[**Numeric Identifier 85886**]*
[**2180-3-9**] 03:17AM BLOOD ALT-141* AST-622* LD(LDH)-1687*
CK(CPK)-[**Numeric Identifier 85887**]*
AlkPhos-32* TotBili-0.4 DirBili-0.2 IndBili-0.2
[**2180-3-9**] 12:36PM BLOOD CK(CPK)-[**Numeric Identifier 85888**]*
[**2180-3-7**] 07:25PM BLOOD Albumin-4.4 Calcium-8.3* Phos-2.9 Mg-2.8*
[**2180-3-8**] 12:02AM BLOOD Triglyc-101 HDL-48 CHOL/HD-3.7
LDLcalc-108
[**2180-3-8**] 01:55PM BLOOD ANCA-NEGATIVE B
[**2180-3-7**] 07:25PM BLOOD CRP-8.7*
[**2180-3-7**] 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7.6*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Labs during hospital stay
CBC
[**2180-3-14**] 04:20AM BLOOD WBC-5.9 RBC-4.67 Hgb-13.8* Hct-39.5*
MCV-85 MCH-29.6 MCHC-35.0 RDW-12.4 Plt Ct-227
[**2180-3-13**] 05:15AM BLOOD WBC-5.3 RBC-4.31* Hgb-13.2* Hct-36.5*
MCV-85 MCH-30.7 MCHC-36.2* RDW-12.3 Plt Ct-174
[**2180-3-12**] 05:50AM BLOOD WBC-4.1 RBC-4.09* Hgb-12.5* Hct-35.0*
MCV-85 MCH-30.5 MCHC-35.7* RDW-12.2 Plt Ct-171
[**2180-3-11**] 04:17AM BLOOD WBC-5.6 RBC-4.06* Hgb-12.8* Hct-35.5*
MCV-88 MCH-31.6 MCHC-36.1* RDW-12.1 Plt Ct-182
[**2180-3-10**] 03:17AM BLOOD WBC-6.8 RBC-4.39* Hgb-13.3* Hct-38.8*
MCV-89 MCH-30.4 MCHC-34.4 RDW-12.2 Plt Ct-191
[**2180-3-9**] 03:17AM BLOOD WBC-8.8 RBC-4.45* Hgb-13.5* Hct-38.9*
MCV-87 MCH-30.3 MCHC-34.6 RDW-12.7 Plt Ct-190
[**2180-3-8**] 01:55PM BLOOD Hct-36.8*#
[**2180-3-8**] 12:02AM BLOOD WBC-14.0* RBC-5.27 Hgb-16.0 Hct-47.0
MCV-89 MCH-30.4 MCHC-34.0 RDW-12.3 Plt Ct-262
[**2180-3-13**] 05:15AM BLOOD Neuts-66.0 Lymphs-29.4 Monos-3.1 Eos-1.1
Baso-0.3
[**2180-3-9**] 03:17AM BLOOD Neuts-80.4* Lymphs-14.2* Monos-4.8
Eos-0.2 Baso-0.4
[**2180-3-14**] 04:20AM BLOOD Plt Ct-227
[**2180-3-13**] 05:15AM BLOOD Plt Ct-174
[**2180-3-12**] 05:50AM BLOOD Plt Ct-171
[**2180-3-11**] 04:17AM BLOOD Plt Ct-182
[**2180-3-10**] 03:17AM BLOOD Plt Ct-191
[**2180-3-9**] 03:17AM BLOOD Plt Ct-190
[**2180-3-8**] 01:55PM BLOOD ESR-1
Chem 7
[**2180-3-14**] 04:20AM BLOOD Glucose-94 UreaN-15 Creat-1.0 Na-140
K-3.8 Cl-100 HCO3-30 AnGap-14
[**2180-3-13**] 05:35PM BLOOD Glucose-110* UreaN-13 Creat-1.0 Na-140
K-4.2 Cl-103 HCO3-30 AnGap-11
[**2180-3-13**] 05:15AM BLOOD Glucose-110* UreaN-11 Creat-1.2 Na-139
K-3.7 Cl-102 HCO3-30 AnGap-11
[**2180-3-12**] 03:22PM BLOOD Glucose-120* UreaN-10 Creat-1.0 Na-140
K-3.6 Cl-102 HCO3-30 AnGap-12
[**2180-3-12**] 05:50AM BLOOD Glucose-112* UreaN-9 Creat-1.1 Na-138
K-3.5 Cl-102 HCO3-30 AnGap-10
[**2180-3-11**] 03:24PM BLOOD Glucose-105* UreaN-8 Creat-1.2 Na-139
K-3.1* Cl-98 HCO3-35* AnGap-9
[**2180-3-11**] 04:17AM BLOOD Glucose-170* UreaN-7 Creat-1.1 Na-140
K-3.3 Cl-100 HCO3-34* AnGap-9
[**2180-3-10**] 02:37PM BLOOD Glucose-118* UreaN-6 Creat-1.1 Na-140
K-3.6 Cl-103 HCO3-34* AnGap-7*
[**2180-3-10**] 03:17AM BLOOD Glucose-167* UreaN-5* Creat-1.1 Na-140
K-3.4 Cl-103 HCO3-33* AnGap-7*
[**2180-3-9**] 07:50PM BLOOD Glucose-131* UreaN-6 Creat-1.3* Na-140
K-3.8 Cl-103 HCO3-32 AnGap-9
[**2180-3-9**] 12:36PM BLOOD Glucose-121* UreaN-7 Creat-1.3* Na-141
K-3.3 Cl-105 HCO3-28 AnGap-11
[**2180-3-8**] 01:55PM BLOOD UreaN-11 Creat-1.6* Na-142 K-3.7 Cl-111*
HCO3-25 AnGap-10
Muscle enzymes
[**2180-3-14**] 04:20AM BLOOD ALT-436* AST-448* LD(LDH)-484*
CK(CPK)-[**Numeric Identifier 85889**]*
[**2180-3-13**] 05:35PM BLOOD CK(CPK)-[**Numeric Identifier 85890**]*
[**2180-3-13**] 05:15AM BLOOD ALT-487* AST-803* CK(CPK)-[**Numeric Identifier 85891**]*
AlkPhos-57 TotBili-0.4
[**2180-3-12**] 05:50AM BLOOD ALT-377* AST-994* LD(LDH)-2039*
CK(CPK)-[**Numeric Identifier **]* AlkPhos-46 TotBili-0.4
[**2180-3-11**] 04:17AM BLOOD ALT-299* AST-1062* CK(CPK)-[**Numeric Identifier 85892**]*
AlkPhos-34* TotBili-0.3
[**2180-3-10**] 02:37PM BLOOD CK(CPK)-[**Numeric Identifier 85893**]*
[**2180-3-10**] 03:17AM BLOOD ALT-224* AST-890* LD(LDH)-3034*
CK(CPK)-[**Numeric Identifier 85894**]* AlkPhos-29* TotBili-0.2
[**2180-3-9**] 07:50PM BLOOD CK(CPK)-[**Numeric Identifier 85895**]*
[**2180-3-9**] 12:36PM BLOOD CK(CPK)-[**Numeric Identifier 85888**]*
LFTs
[**2180-3-9**] 03:17AM BLOOD ALT-141* AST-622* LD(LDH)-1687*
CK(CPK)-[**Numeric Identifier 85887**]* AlkPhos-32* TotBili-0.4 DirBili-0.2 IndBili-0.2
[**2180-3-8**] 10:32PM BLOOD CK(CPK)-[**Numeric Identifier 85886**]*
Ca/Mg/P
[**2180-3-14**] 04:20AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.9
[**2180-3-13**] 05:35PM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0 Iron-67
[**2180-3-13**] 05:15AM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.7 Mg-1.8
[**2180-3-12**] 03:22PM BLOOD Calcium-7.9* Phos-2.4* Mg-1.8
[**2180-3-12**] 05:50AM BLOOD Albumin-3.2* Calcium-7.7* Phos-2.1*
Mg-1.8
[**2180-3-11**] 03:24PM BLOOD Calcium-7.8* Phos-2.5* Mg-1.8
[**2180-3-10**] 02:37PM BLOOD Calcium-7.7* Phos-2.0* Mg-1.9
[**2180-3-10**] 03:17AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.8
Other tests
[**2180-3-10**] 03:17AM BLOOD TSH-1.8
[**2180-3-8**] 12:02AM BLOOD TSH-1.5
[**2180-3-8**] 01:55PM BLOOD ANCA-NEGATIVE B
[**2180-3-8**] 01:55PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2180-3-10**] 02:37PM BLOOD HIV Ab-NEGATIVE
[**2180-3-7**] 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7.6*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Urine
[**2180-3-11**] 12:58PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2180-3-11**] 12:58PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-9.0* Leuks-NEG
CSF
[**2180-3-9**] 10:33AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-22*
Polys-33 Lymphs-49 Monos-18
[**2180-3-9**] 10:33AM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-125*
Polys-13 Lymphs-80 Monos-7
[**2180-3-9**] 10:33AM CEREBROSPINAL FLUID (CSF) TotProt-24 Glucose-81
CSF other tests
HSV, EBV, HHV 6, CMV - negative
Lyme, MS profile- pending
Microbiology
HIV-1 Viral Load/Ultrasensitive (Final [**2180-3-13**]):
HIV-1 RNA is not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test.
Detection range: 48 - 10,000,000 copies/ml.
This test is approved for monitoring HIV-1 viral load in
known
HIV-positive patients. It is not approved for diagnosis of
acute HIV
infection.
In symptomatic acute HIV infection (acute retroviral
syndrome), the
viral load is usually very high (>>1000 copies/mL). If
acute HIV
infection is clinically suspected and there is a
detectable but low
viral load, please contact the laboratory for
interpretation.
It is recommended that any NEW positive HIV-1 viral load
result, in
the absence of positive serology, be confirmed by
submitting a new
sample FOR HIV-1 PCR, in addition to serological testing.
RAPID PLASMA REAGIN TEST (Final [**2180-3-13**]):
NONREACTIVE.
Reference Range: Non-Reactive.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2180-3-13**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2180-3-13**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2180-3-13**]):
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop 6-8 weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
CMV IgG ANTIBODY (Final [**2180-3-10**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
23 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2180-3-10**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
A positive IgG result generally indicates past exposure.
Infection with CMV once contracted remains latent and may
reactivate
when immunity is compromised.
If current infection is suspected, submit follow-up serum
in [**2-16**]
weeks.
Greatly elevated serum protein with IgG levels >[**2170**] mg/dl
may cause
interference with CMV IgM results.
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2180-3-9**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2180-3-9**]):
Negative for Influenza B.
TOXOPLASMA IgG ANTIBODY (Final [**2180-3-10**]):
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
0.0 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
LYME SEROLOGY (Final [**2180-3-9**]):
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
[**2-16**] weeks.
ASO Screen (Final [**2180-3-9**]):
POSITIVE by Latex Agglutination.
Reference Range: < 200 IU/ml (Adults and children > 6
years old).
ASO TITER (Final [**2180-3-9**]):
POSITIVE 200-400 IU/ml.
Performed by latex agglutination.
Reference Range: < 200 IU/ml (Adults and children > 6
years old).
TOXOPLASMA IgM ANTIBODY (Final [**2180-3-10**]):
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2180-3-12**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85896**],RN 12:15PM [**2180-3-12**].
Blood Culture, Routine [**3-8**] (Final [**2180-3-14**]): NO GROWTH.
[**2180-3-7**] 11:38 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2180-3-14**]**
Blood Culture, Routine (Final [**2180-3-14**]): NO GROWTH.
Imaging:
MRI/A of head and neck:
IMPRESSION:
1. FLAIR abnormality in the subcortical left occipital lobe with
some focal
overlying cortical involvement and no evidence of associated
hemorrhage,
restricted diffusion, or definitive enhancement. The
differential diagnosis
includes low-grade primary glial neoplasm and tumefactive
demyelination.
2. Unremarkable MRA of the head and neck without evidence of
tumor
vascularity, shunting, or flow-limiting stenosis.
3. Sinus disease as described above, the activity of which is to
be
determined clinically.
TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No echo evidence of endocarditis.
Brief Hospital Course:
26 year old RH man with an unremakable PMH who was last seen in
his USOH in the early am (prior to going to work) and then at
noon (normal conversation with his wife over the phone) p/w two
subsequent seizures with associated leukocytosis, fever,
non-blanching erythematous rash, conj. hemorrhage,
rhabdomyolisis, ARF, transaminitis with a L parietal lesion on
MRI representative on edema w/o [**Year/Month/Day **] enhancement.
NEURO. Unclear what the unifying diagnosis is at time of
presentation. DDx included an underlying primary CNS malignancy
with edema, leading to seizure and subsequent rhabdomyolisis,
ARF, though given fever and rash an infectious process (viral
HSV, EBV, HHV-6) could not be definitively ruled out. In
addition, a metastasis from a lymphoma in this patient was also
considered. OSH LP negative and viral studies w/ cultures
pending. Patient treated empirically with
Acyclovir/CFTX/Vancomycin as per ID recommendation for possible
coverage of HSV encephalitis (atypical presentation), possible
meningitis and/or endocarditis with vancomycin. No stigmata of
endocarditis were noted and TTE was negative. BCx were negative.
Additionally, vasculitis etiology was considered, however ESR
was 1 and ANCA was negative.
He underwent a repeat LP for cytology which showed 5 cells,
normal protein and gluocose.
Opening pressure was 32.
Viral studies inclusind HSV, VZV, EBV, HHV-6 were negative.
Lyme serology and CSF were negative
Olygoclonal bands were obtained with concern for atypical ADEM
and were negative.
Neuro-oncology was consulted who recommended outpatient follow
up for biopsy of brain tumor after normalisation of high CK and
improvement in general medical condition.
EEG was obtained and showed spikes nearly Q1-2mins w/o NCSE,
thus patient was continued on Dilantin with goal of > 10
corrected for albumin, which was later changed to keppra which
was continued as outpatient.
PULM. Pt. was extubated on HD1. No further respiratory issues
were noted, after trasnfer to floor.
HEME/RENAL. CK on arrival ~ 18K treated with moderate IVF rate,
and rose to peak of 100 K. Pt. was treated with D5HCO3 and NS
titrated to goal UOP of > 200cc/hr with aid of lasix. Cr peaked
at 1.9 and microscopic analysis was notable for granular casts
concerning for tubular renal injury. Cr at time of discharge
was 4000s, with rapid downward trend.
ID. Pt. w/ fever on presentation and recurrence on HD2. He was
empirically treated with IV ABx for etiologies concerning above,
however no clear source was identified. BCx, UCx were pending
and CXR was negative for infection. There was opacification of
sinuses, however patient did report URI sx prior to
presentation.
He was continued on oral antibiotics for total of 7 days for
presumptiveaspiration pneumonia.
Medications on Admission:
none
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left parietal area wedge shaped brain lesion ? neoplastic
Rhabdomyolyis- recovering
aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted for evaluation of seizure. You were initially
admitted to ICU for monitering. You were found to have a wedge
shaped lesion on left side of brain. You were seen by Neuro
oncology team who suggested biopsy as an outpatient in next few
weeks after the general condition permits.
You had a condition called rhabdomyolysis which results from
injury to muscles. You were evaluated by renal team, and treated
with IV fluids with very good response.
You were found to have aspiration pneumonia for which you
recieved/will be recieving antibiotics for total duration of 1
week.
You were started on a medicine called keppra for control of
seizures which you will be taking even after discharge.
Please take your medicines as directed. Please call 911 or your
doctor if any questions or concerns.
Followup Instructions:
Please follow up with
1. Neuro oncology
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2180-3-27**]
4:00
2. Renal
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2180-4-25**] 2:30
3. Primary care
Provider: [**First Name8 (NamePattern2) 1112**] [**Last Name (NamePattern1) 18569**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2180-3-28**] 1:45
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]
ICD9 Codes: 5070, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2041
} | Medical Text: Name: [**Known lastname 11946**],[**Known firstname 732**] Unit No: [**Numeric Identifier 11947**]
Admission Date: [**2108-6-20**] Discharge Date: [**2108-7-3**]
Date of Birth: [**2039-7-6**] Sex: F
Service: SURGERY
Allergies:
Bactrim / Cogentin
Attending:[**First Name3 (LF) 9036**]
Addendum:
Patient discharged on [**2108-6-29**] to [**Hospital 1238**] rehab facility.
Chief Complaint:
s/p post colonic perforation w/ ileostomy
Major Surgical or Invasive Procedure:
[**2108-6-21**] Exploratory lap, Ileostomy take down w/ ileo-transverse
colostomy
History of Present Illness:
68 yo female with schizoaffective disorder and
diabetes insipidus, probably from lithium use. She suffered a
perforated colon approximately 6 months ago due to C-
difficile colitis incidentally found at her operation for
gross peritonitis was an ileal carcinoid which was resected
and had positive nodal metastases. She has been
intolerant of her ileostomy due to food and electrolyte
issues and has been in the hospital for renal failure on two
occasions on the medicine service despite trying her best to
manage her fluid intake herself. She also has extensive skin
excoriation and dermatitis problems due to her ileostomy. She
is, therefore, electively brought in for ileostomy reversal.
Past Medical History:
carcinoid syndrome, ARF/CRF, hypoNa, hypoMag, hypothyroid, UTI
([**5-31**]), PNA ([**3-31**]), psoriasis, elevated transaminases
(resolved), mental retardation, schizoaffective d/o, r elbow
hemarthrosis
PSHx: ileosotomy [**11-29**]
Social History:
Previously resided in group home
Family History:
Noncontributory
Physical Exam:
VS: Temp 99, HR 114, BP 130/86, Resp 18, SaO2, 98% on RA.
Neuro: Pleasant, MR
CVS: normal S1, S2, RRR
Pulm: CTA b/l
Abd: Soft, NT, ostomy intact, psoriasis
Ext: good peripheral pulses, no edema
Pertinent Results:
[**2108-6-20**] 08:00PM GLUCOSE-128* UREA N-15 CREAT-1.7* SODIUM-140
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
[**2108-6-20**] 08:00PM CALCIUM-9.1 PHOSPHATE-5.1* MAGNESIUM-1.4*
[**2108-6-20**] 08:00PM WBC-7.2 RBC-3.55*# HGB-11.6*# HCT-31.7*
MCV-89 MCH-32.7* MCHC-36.6*# RDW-15.8*
[**2108-6-20**] 08:00PM PLT COUNT-377
[**2108-6-20**] 08:00PM PT-15.9* PTT-27.6 INR(PT)-1.4*
CHEST (PRE-OP PA & LAT)
Reason: S/P ILEOSTOMY; DIABETES INSIPIDIS; SCHIZO-AFFECTIVE
DISORDER
[**Hospital 5**] MEDICAL CONDITION:
68 year old woman here for reversal of ileostomy and ileocolic
anastamosis
REASON FOR THIS EXAMINATION:
pre-op
INDICATION: 68-year-old woman here for reversal of ileostomy and
ileocolic anastomosis. Preop.
COMPARISON: [**2108-2-29**].
FINDINGS: Since prior exam, the right PICC line has been
removed. The cardiac silhouette, mediastinal and hilar contours
are stable. The lungs are clear. No evidence of pneumothorax.
The aorta is mildly tortuous.
IMPRESSION: No evidence of acute cardiopulmonary process.
Brief Hospital Course:
She was admitted to the Surgical Service and taken to the
operating room for exploratory lap, ileostomy takedown with
ileo-transverse colostomy on [**6-21**]. There were no intraoperative
complications. Postoperatively she has done fairly well, her
diet was advanced slowly; she is having bowel movements. She was
started on Imodium and Metamucil to help minimize frequent
stools. Her ileostomy site is being packed with moist to dry
dressing changes [**Hospital1 **]; her staples will remain in place until
next week when she follows up with Dr. [**Last Name (STitle) **]. Her medications
were changed from intravenous to oral, she is tolerating these
without difficulty; appetite is good. Her fluids and
electrolytes have been monitored closely and repleted
accordingly. Her most recent sodium on [**6-28**] was 145.
The wound ostomy nurse specialists were consulted because of
dermatitis issues; Nystatin cream was recommended to these
areas. Miconazole powder is being used to her perineal region.
Medications on Admission:
tincture of opium, mag oxide, oscal, medroline, vitD,
levothyroxine, zyprexa, heparin, folate, tylenol,
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed for breakthrough agitation.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): hold for HR <60; SBP <110.
7. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
11. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-27**]
Tablet, Delayed Release (E.C.)s PO twice a day as needed for
constipation.
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day).
15. Metamucil Powder Sig: One (1) TBSP PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 4356**] - [**Location (un) 164**]
Discharge Diagnosis:
Ileostomy takedown
Secondary diagnosis:
Diabetes Insipidus
Discharge Condition:
Stable
Discharge Instructions:
Please call your primary care physician or go to the nearest ER
if you experience any pain uncontrollable on your medications,
blood in your stool, temperature greater than 101.5, increased
diarrhea, nausea/vomiting, or any other symptoms that are
concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in Surgery Clinic in [**12-27**] weeks, call
[**Telephone/Fax (1) 11871**] for an appointment.
[**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**]
Completed by:[**2108-6-29**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2042
} | Medical Text: Admission Date: [**2145-4-27**] Discharge Date:
Date of Birth: [**2067-11-11**] Sex: F
Service: [**Hospital Unit Name 153**]
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
female with multiple medical problems including dysphagia,
emphysema, congestive heart failure, coronary artery disease,
who was recently discharged from the [**Hospital6 649**] on [**2145-4-23**], following treatment of
Methicillin-resistant Staphylococcus aureus pneumonia and
hypotension. The patient had previously been admitted to the
Medicine Intensive Care Unit on the sepsis protocol, was
hypotensive to the 60s without improvement following fluids
and was also febrile to 102.8. In the Medicine Intensive
Care Unit, hypotension was believed to be multifactorial
(including hypovolemia in a preload dependent patient,
bacterial versus viral infection and acute renal failure).
Fluid resuscitated with improvement, briefly on pressors.
Sputum growing Methicillin-sensitive resistant Staphylococcus
aureus with chest x-ray showing left lower lobe infiltrate
and the patient was started on a two week course of
Vancomycin intravenously. Blood cultures showed no growth.
She was ruled out for myocardial infarction with three sets
of negative cardiac enzymes. She developed diarrhea which
was improving at the time of discharge. Three sets of
Clostridium difficile were negative. The patient had refused
rehabilitation placement on previous admissions and was
discharged with home services.
Since discharge, the patient states that she had been eating
and drinking well. On the day prior to admission she went to
the grocery store and cooked a meal. Over the past day she
noticed decreased urine output although continued to drink
well (two to three glasses of water per day). The patient
told the Emergency Room staff that she had been taking her
Lasix since discharge. She told me upon admission she was
not taking her Lasix.
The patient was seen by her [**Hospital6 407**] on the
day of admission and was concerned about the patient's
condition. She went to see her primary care physician and
was found to be hypotensive with systolic blood pressure in
the 80s and unsteady on her feet. In the Emergency
Department, she was still hypotensive with systolic blood
pressure in the 80s although she appeared to be improving to
the 100s with intravenous fluids. Her creatinine was
elevated to 4.9 from a baseline of approximately 0.7. It is
to note that the patient did suffer from acute renal failure
in her Medicine Intensive Care Unit course earlier in [**Month (only) 958**],
to a maximum creatinine of 2.3.
PAST MEDICAL HISTORY:
1. Dysphagia, motility study in [**2144-1-29**] showed no
esophageal contraction.
2. Prerenal, acute renal failure in [**2144-3-28**] secondary to
poor p.o. intake and again in [**2145-3-29**] secondary to poor
p.o. intake.
3. Obstructive sleep apnea on CPAP at 8 to 10 cm of water.
4. Emphysema on home oxygen 2 to 4 liters, nasal cannula.
5. Bronchiectasis.
6. Pulmonary hypertension.
7. Symptomatic bradycardia, status post VDD pacemaker in
[**2143-11-29**].
8. Gastroesophageal reflux disease.
9. History of Methicillin-resistant Staphylococcus aureus in
her sputum following hernia repair and again in [**2145-3-29**]
with documented pneumonia.
10. Status post hernia repair.
11. Right ventricular systolic function with echocardiogram
from [**2145-3-29**] showing right ventricular dilation,
borderline left ventricular dilation, ejection fraction
greater than 55% and borderline normal right ventricular
function, 1+ mitral regurgitation.
12. Coronary artery disease.
13. Hypertension.
14. Status post appendectomy.
15. Status post total abdominal hysterectomy.
16. Status post back surgery.
17. Status post right total hip.
18. Chronic lower back pain with questionable narcotic use
recently.
ALLERGIES: Penicillin, codeine and Bactrim.
MEDICATIONS ON ADMISSION:
1. Colace 100 mg p.o. b.i.d.
2. Fluticasone 4 puffs inhaler b.i.d.
3. Salmeterol inhaler q. 12 hours.
4. Reglan 5 mg p.o. t.i.d., a.c. h.s.
5. Senna 8.6 b.i.d.
6. Levofloxacin 250 mg p.o. q. day to complete a two week
course.
7. Valsartan 150 mg p.o. q. day
8. Atorvastatin 40 mg p.o. q.h.s.
9. Calcium carbonate 500 p.o. t.i.d.
10. Vitamin D 400 units p.o. q. day
11. Gabapentin 800 mg in the morning and 400 mg in the
afternoon and 800 mg at night.
12. Vancomycin 1.5 gm intravenously q. 24 hours to complete a
two week course.
13. Combivent 2 puffs inhaler b.i.d.
SOCIAL HISTORY: History of tobacco use, rare alcohol use.
Lives with her cousin. [**Name (NI) **] refused rehabilitation in the
past and has visiting nurses.
FAMILY HISTORY: The patient has a father and brother with
chronic obstructive pulmonary disease. A sister with breast
cancer.
PHYSICAL EXAMINATION: On admission vital signs with
temperature 98.3, blood pressure 108/52, pulse 70,
respirations 14, 95% on 2 liters oxygen by nasal cannula.
General: Lethargic, overweight woman answering questions
appropriately but answering slowly. Left upper extremity and
left lower extremity appeared to be twitching intermittently
in no acute distress, breathing comfortably. Head, eyes,
ears, nose and throat: Sclera anicteric, eyelids dropping
bilaterally. Mucous membranes moist. Chest, decreased
breath sounds at the left lower base, greater than right
lower base, no egophony, scattered expiratory and inspiratory
wheezing. Cardiovascular, regular rate and rhythm, II/VI
diastolic murmur best heard at the left upper sternal border.
Abdomen: Soft, obese, nontender. Good bowel sounds, no
rebound, no guarding. Extremities: 2+ lower extremity
pitting edema, left greater than right. Positive asterixes.
Neurologic: Lethargic but easily arousable. Oriented times
three. Speech fluent. Pupils asymmetric from previous
cardiac surgery but reactive to light, able to close eyes
against resistance bilaterally. Sensation over face intact.
Says saliva comes out of the right corner of her mouth but
face and smile appears symmetric. Able to puff cheeks
against resistance. Tongue midline. Grip [**6-2**] bilaterally.
Sensation intact bilaterally. Reflexes, toes equivocal
bilaterally, no clonus, positive asterixes.
LABORATORY DATA: Laboratory data on admission revealed white
blood count 13.3 with 76 polys, 15 lymphocytes, no bands,
hematocrit 32.3, platelets 408. Chemistry was significant
for a potassium of 5.8, bicarbonate 23. His creatinine was
4.9, BUN 38. Electrocardiogram showed sinus rhythm at 70
with questionable right bundle branch block, no peak T waves,
left axis deviation. Chest x-ray showed unchanged
cardiomegaly and position of left-sided pacemaker. NO
evidence of congestive heart failure or focal pulmonary
parenchymal consolidation. Unchanged bibasilar and
interstitial markings.
HOSPITAL COURSE: (By problem) 1. Acute renal failure - The
patient's urine electrolytes were checked and her FENA was
found to be 0.3 indicating likely a prerenal etiology. Urine
was negative for eosinophils. The patient had a renal
ultrasound which was negative for hydronephrosis or
obstruction. The patient's creatinine continued to climb in
the initial 24 hours of admission. Her maximum creatinine
was 6.0. At this time, the patient was still making a small
amount of urine. A renal consult was obtained and followed
the patient closely during her hospitalization. It was
thought the patient may have a mixture of prerenal etiology
as well as acute tubular necrosis. It is unclear if the
patient had any ingestions prior to her admission as she was
a poor historian. She does suffer from chronic lower back
pain and may have ingested some non-steroidal
anti-inflammatory drugs. The patient was also on Vancomycin
since her last admission with extremely high levels of 73.1
on the day after admission. The patient's levels trended
downward and on the day of this dictation are 37.4. It was
thought that this may also have been renal toxic. At the
time of this dictation, the patient's etiology of her renal
failure remains somewhat unclear. [**Name2 (NI) **] [**Last Name (un) **] medication was
held as well as any diuresis. The patient was given a small
fluid challenge in the Intensive Care Unit with 1 unit of
packed cells and approximately 2 liters of intravenous
fluids. The patient's creatinine did respond to this and
began to trend downward. Her urine output greatly improved
and on the day prior to transfer to the floor, the patient
was making urine at greater than 50 cc/hr. Please see
addendum to this dictation for further workup and treatment
of the patient's acute renal failure.
2. Delta MS - On the day after admission, the patient was
found with a depressed mental status. she was alert to voice
but not very arousable. A blood gas at that time showed a pH
of 7.18, pCO2 of 67 and pO2 of 81. Lactate was 0.7. The
patient's hypercarbia was felt to be due to some respiratory
depression of unclear etiology. There was a possibility that
the patient had ingested some narcotics for lower back pain
at home prior to admission. The patient was transferred to
the Intensive Care Unit after initiation of BiPAP on the
floor on [**Hospital Ward Name 517**]. Upon arrival to the Intensive Care
Unit, the patient continued to have hypercarbia. It was
thought that the patient might be progressing towards
intubation. However, a trial of intravenous Narcan times two
at 0.4 mg was given to the patient for the thought of recent
narcotic use. The patient had instant and dramatic
improvement in her mental status upon injection of Narcan.
It was thought that with the patient's acute renal failure,
recent narcotic use may not have cleared. The patient's
mental status continued to improve and her blood gases began
to look less hypercarbic. She was transitioned to a nasal
cannula at 4 liters and did well over the next two days. The
patient was continued on her BiPAP at 10/5 in the evening for
her known obstructive sleep apnea. The patient maintained
good saturations during her admission and oxygenation was not
an issue. The patient's hypercarbia was likely contributing
to poor mental status and once resolved, the patient's mental
status was at her baseline.
3. Fevers - The patient has a questionable left lower lobe
infiltrate on her x-ray with a recent confirmed
Methicillin-resistant Staphylococcus aureus pneumonia. Her
Vancomycin level remained very elevated during her admission
and she would not redose Vancomycin during her [**Hospital Unit Name 153**] course.
Upon transfer to the floor, she was on day #10 of Vancomycin.
She was also treated empirically with Levaquin beginning on
her last admission for presumed community acquired pneumonia.
She is currently on day #10 of this, at renal dosing. The
patient was pancultured with no growth to date on her
cultures during this admission.
4. Hypotension - The patient's hypotension resolved after
initial overnight stay on the regular medicine floor. The
patient's blood pressure medications were held. She was
given gentle fluid challenges during her stay in the
Intensive Care Unit with good response. On day of transfer
to the floor, the patient actually became hypertensive, it
was thought that we should continue to hold her [**Last Name (un) **] and now a
trial of Nifedipine was started as this was thought to
increase renal blood flow.
5. Obstructive sleep apnea - The patient was continued on
her BiPAP at 10/5 during this admission.
6. Coronary artery disease - The patient had no acute chest
pain during this admission, however, she did have a troponin
leak with normal MB index. The patient's electrocardiogram
was without any changes. It was thought that the patient may
have had a troponin leak in the setting for initial
hypotension and in the setting of acute renal failure, this
was difficult to interpret. There was no workup for acute
ischemia, and the patient's troponin began to trend down.
She was continued on her Atorvastatin. She was not started
on Aspirin in the setting of her acute renal failure. She is
not on a beta blocker currently and we did not start one in
her [**Hospital Unit Name 153**] course due to her chronic obstructive pulmonary
disease, intermittent wheezing and oxygen requirement.
7. Fluids, electrolytes and nutrition - The patient was kept
NPO for her stay in Intensive Care Unit until her mental
status improved. Once her mental status improved she had a
great appetite. She was started on PhosLo for a phosphorus
of 7.7.
8. Prophylaxis - The patient was given subcutaneous heparin
and intravenous Famotidine and was switched to p.o.
Famotidine.
9. Contacts - The patient's brother [**Name (NI) **] as well as her cousin
were the patient's contacts. The patient's cousin and proxy
was currently hospitalized at [**Hospital6 1708**].
The most contact with the patient's cousin was made through
the patient's primary care physician, [**Last Name (NamePattern4) **] .[**Doctor Last Name **].
DISPOSITION: The patient was discharged to the floor on
[**2145-5-1**] in stable condition.
Please see addendum to this discharge summary for further
discharge planning and medications as well as hospital
course upon transfer to general medical service.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **], 17-AFO
Dictated By:[**Last Name (NamePattern1) 9244**]
MEDQUIST36
D: [**2145-5-1**] 18:08
T: [**2145-5-1**] 18:39
JOB#: [**Job Number 30897**]
ICD9 Codes: 5845, 2765, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2043
} | Medical Text: Admission Date: [**2134-5-5**] Discharge Date: [**2134-5-11**]
Date of Birth: [**2053-11-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
T3 mid esophageal lesion and dysphagia
Major Surgical or Invasive Procedure:
[**2134-5-7**] Left Port-A-Cath via cephalic vein access and a
PEG tube.
[**2134-5-7**] Evacuation of left port-a-cath hematoma
History of Present Illness:
The patient is an 80-year-old
gentleman with esophageal cancer who presents for feeding
tube access and port for chemotherapy.
Past Medical History:
HTN
Social History:
The patient lives alone in [**Hospital3 4634**] near
the Symphony. He has a son who is an anesthesiologist and
practices locally. His son is married and has three children.
The patient smoked 10 cigarettes per day, but quit in [**2120**]. He
smoked for approximately 25 years. He came to the United States
in [**2120**]. In [**Country 651**], he worked previously in importing business.
The patient drinks alcohol rarely.
Family History:
NC
Physical Exam:
Discharge Vital Signs:
T: 97.0 BP: 112/62 HR 65 SR RR 18 O2 sats:96%
Discharge Physical Exam:
Gen: pleasant in NAD, A & O x 3
Lungs: clear b/l
CV: RRR S1, S2 no MRG
Abd: soft, NT, ND, PEG intact without redness, purulence or drg
Ext: warm without edema. L portacath with eccyhmosis near axilla
without swelling,drg or redness near site, incision covered with
dermabond.
Pertinent Results:
[**2134-5-8**] 07:20AM BLOOD WBC-6.2 RBC-4.10* Hgb-13.8* Hct-39.1*
MCV-95 MCH-33.7* MCHC-35.4* RDW-13.7 Plt Ct-126*
[**2134-5-5**] 04:05PM BLOOD WBC-4.8 RBC-4.47* Hgb-14.9 Hct-42.1
MCV-94 MCH-33.3* MCHC-35.4* RDW-13.9 Plt Ct-146*
[**2134-5-8**] 07:20AM BLOOD Glucose-141* UreaN-10 Creat-1.0 Na-139
K-3.8 Cl-105 HCO3-26 AnGap-12
[**2134-5-5**] 04:05PM BLOOD Glucose-101* UreaN-18 Creat-0.9 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
[**2134-5-8**] 07:20AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8
CXR [**2134-5-7**]
REASON FOR EXAMINATION: Evaluation of the patient after
Port-A-Cath
placement.
Portable AP chest radiograph was reviewed in comparison to CT
torso from [**2134-4-24**].
The Port-A-Cath catheter was inserted through the left central
venous
approach. The tip is at the level of cavoatrial junction. There
is no
evidence of pneumothorax.
The heart size and mediastinal silhouettes are stable. No
interval
development of focal consolidation or interstitial abnormalities
were noted.
Pulmonary nodules seen on the CT torso are below the resolution
of chest
radiograph.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to Thoracic surgery service, ICU on [**2134-5-4**]
after EUS for esophageal cancer, for complaints of dysphagia.
Urgent endoscopy was done and food bolus was seen, on [**2134-5-5**].
The patient was stable after resolution of food bolus, and then
transferred to the floor, NPO with IV fluids. Radiation and
medical oncology teams were consulted and after discussion with
the patient and his son, it was decided to go forth with
chemotherapy and radiation therapy. A port-a-cath and feeding
tube were requested, therefore Dr. [**Last Name (STitle) **] took the patient
down to the operating room late on [**2134-5-7**] for a left Port-A-Cath
via cephalic vein access and a
PEG tube. He went back that evening for evacuation of left
hematoma of port-a-cath site. Below is a systems review of his
hospital course:
Pulm: Incentive spirometry and early mobilization were utilized.
CV: The patient remained hemodynamically stable in NSR.
GI: The patient was kept NPO and hydrated with IVF.
Nutrition: Nutrition consulted and recommended Fibersource HN at
70ml/hour x 24 hours. POD 1 this was started and tolerated. On
[**5-10**] this was switched to bolus feedings, of 7 cans a day. The
patient returned repeat demonstration on bolus feedings through
his PEG.
Renal: The patient voided well throughout his stay.
Proph: SQ heparin and SCD's were instituted to prevent VTE.
ID: No active ID issues throughout this stay.
Pain/Neuro: The patient remained neurologically intact
throughout his stay, Mandarin interpretor was used. His pain was
initially controlled with IV dilaudid then controlled with prn
roxicet, with 1/10 pain on discharge without pain medication.
DISPO: Physical Therapy saw the patient and felt he would be
find for home with stabilization device, and gave him a cane.
The patient lives alone, therefore VNA services established.
Social worker, case management, and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Cancer
navigator all met with the patient and discussed home discharge
with him and his son, given that the patient lives alone in
[**Hospital3 4634**]. Community supports were initiated to assist the
patient.
Please see social work notes for full details. The patient was
discharged home on [**2134-5-11**] with his son and tube feeds and
supplies.
Medications on Admission:
HCTZ 25mg po daily
Discharge Medications:
1. Tube feedings
Formula: Fibersource
Bolus feedings: 2 cans of fibersource through G-tube at
breakfast, lunch and dinner. One can at 8pm.
Water flush: Before and after each feeding flush G-tube with
50ml of water.
Supply with 60ml syringe for bolus feeding.
2. shower chair
as needed for safety while showering
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Esophageal cancer
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2348**] if you have:
fevers greater than 101.5, chills, shakes, nausea, vomiting,
diarrhea, abdominal pain, shortness of breath, cough of chest
pains.
Call if left port-a-cath site becomes swollen or incision
becomes red, or drains. Call if your feeding tube becomes
clogged or falls out.
PEG tube site: [**Month (only) 116**] leave open to air.
Activity: You may shower.
Walk several times a day and use the incentive spirometer at
home.
Pain: You may get over the counter liquid acetaminophen if you
have pain.
Followup Instructions:
Followup with Dr. [**Last Name (STitle) **] of radiation oncology on [**2134-5-13**] at
10am Location: [**Location (un) 442**] treatment planning.
The following appointments are located on [**Hospital Ward Name **] [**Location (un) **]
[**Hospital Ward Name 23**] center:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2134-5-20**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2134-5-20**] 9:00
Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2134-5-20**] 10:00
Dr. [**Last Name (STitle) **] [**2134-5-20**] at 2:30pm [**Hospital Ward Name 23**] [**Location (un) **]
Completed by:[**2134-5-12**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2044
} | Medical Text: Admission Date: [**2174-8-18**] Discharge Date: [**2174-8-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
89 yo woman who is a nursing home resident with dementia here
with increasing hypoxia, hypotension and rapid afib, this
morning at rehab while being escorted to bathroom, just passed
out, caught by support staff, she did not fall, but the could
not get a BP or O2sat so called 911.
[**Name8 (MD) **] NP at [**Hospital3 2558**], she had had a pna 6 weeks ago that was
not clearing with associated wheezing and so was started on
steroids which have slowly been tapered. On [**8-9**] was noted to
be more lethargic and had a positive UA and so was started on
levofloxacin for 10 day course. Today as above episode of
syncope and per EMS vitals Sat 95% on RA, P 149-160 and HR
100/60. In ED, HR 160 with BP initially 160/24, but then 105/65
and given diltiazem 10mg x 2 and then started on ditiazem gtt at
5mg/hr, also given 4L NS, ceftriaxone 1gm x1 and azithro 500mg
x1, tylenol and then transferred to [**Hospital Unit Name 153**] for monitoring, given
borderline BP's.
On arrival here, pt appears comfortable off O2, b/c she pulled
it off with sats 90-93%, HR 115 in fib and BP 74/56, after pt
stablized, spontaneously converted to sinus rhythym with HR 69
and BP 74/56. Diltiazem stopped and given fluid bolus.
Per sister here, pt has advanced dementia and does not recognize
any of her family memebers and has not been any different
recently, mostly non-communicative.
Past Medical History:
MR
[**Name13 (STitle) **] dementia
atypical psychosis
depressive d/o with hx of suicidal ideations
elevated alk phos
osteopenia
weight loss
Social History:
Russian speaking lives at nsg home, had previously lived by
self, but too much to care for by self and for 2yrs in Nsg home,
only son died [**2170**] of pancreatic ca. Sister is visiting from
chigcago, pt's granddaughter is HCP, [**Name (NI) 62943**] [**Name (NI) 62944**]
[**Telephone/Fax (1) 62945**].
Family History:
son died of pancreatic ca
Physical Exam:
VS: T 96.8ax P 118 (118--151) BP 150/126(91--160/58-126) R 24
Sat 88-93%on RA
GEN awake, elderly woman, not responding to questions, moving
all extremities
HEENT PERRL, +tardive dyskinesia with lip smacking, flat JVP
CHEST CTAb, poor resp air mvmt, possibly slightly decreased
sounds at RLL
CV irregularly, irregular, +3/6 SEM best heard at apex
Abd soft NT/NS, +BS
EXT no edema, slight area of erythema on left hip
Pertinent Results:
Labs on admission:
[**2174-8-18**] 09:10AM BLOOD WBC-8.1 RBC-5.07 Hgb-14.2 Hct-42.8 MCV-84
MCH-28.0 MCHC-33.2 RDW-13.3 Plt Ct-335
[**2174-8-18**] 09:10AM BLOOD Neuts-62.7 Lymphs-27.2 Monos-4.6 Eos-5.3*
Baso-0.1
[**2174-8-18**] 09:10AM BLOOD PT-13.0 PTT-26.8 INR(PT)-1.1
[**2174-8-18**] 09:10AM BLOOD Glucose-124* UreaN-13 Creat-0.9 Na-141
K-4.2 Cl-103 HCO3-23 AnGap-19
[**2174-8-18**] 09:10AM BLOOD CK(CPK)-43
[**2174-8-18**] 09:10AM BLOOD cTropnT-<0.01
[**2174-8-19**] 01:30AM BLOOD CK(CPK)-66
[**2174-8-19**] 01:30AM BLOOD CK-MB-5 cTropnT-0.02*
[**2174-8-19**] 01:30AM BLOOD Calcium-8.0* Phos-1.9* Mg-1.7
[**2174-8-18**] 09:10AM BLOOD TSH-4.2
[**2174-8-18**] 10:54AM BLOOD Lactate-1.5
EKG: Afib with RVR rate 160bpm, ST depressions in II, aVF, v2,
v3, v4 after converting, NSR at 69bpm, nl axis, no [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 62946**] or LVH, borderline QT, Twave flattening inferiorly
.
CXR: prelim with RLL infiltrate, no effusions or cardiomegaly
Brief Hospital Course:
A/P: 89 yo nursing home pt here with RLL pna, new afib and
hypotension in setting of Afib with RVR and likely hypovolemia.
.
Pna: with RML/RLL infiltrate, but no white count, fevers, likley
aspiration pneumonitis especially given nursing home's hx of
poor po's at baseline with dementia and is on a pureed diet at
baseline. Initially started on ceftriazxone/azithro, for CAP
and then flagyl added for possible aspiration, but as not signs
of pna clinically. All abx were d/c'd and can possibly restart
flagyl if needed. She had been started on prednisone at NSH [**Name6 (MD) **]
her NP for bronchospasm from persistent pna about 6 weeks ago
and was on a slow taper, currently at 5mg, but as she did not
need this and was at a physiologic dose, this was discontinued.
Her CXr did have concern for obtuse angle of her carina for
possible left atrial enlargement vs mass effect and elevated
left hemi-diaphragm, as [**Last Name (LF) 62947**], [**First Name3 (LF) **] just reccommend
follow up CXR in a few weeks time to make sure stable.
.
UTI: positive UA at NSH and had completed 7days of levofloxacin
and no further need as UA here without signs of infection.
.
Hypotension: likley hypovolemia and rate related. Improved with
fluid boluses and rate control. Diltiazem was stopped after she
spontaeously converted after arrival in [**Hospital Unit Name 153**]. She received a
few fluid boluses, with good BP response and at time of d/c was
off IVF and toelrating some po's. Hypotension not thhought to
be related to sepsis, without leukocytosis, fevers, lactate or
other signs of overwhelming septic infection.
.
syncope: witnessed event am of admission while walking, most
likely related to decreased perfusion with hypotension from Afib
with RVR and dehydration. She improved with rate control and
volume rescusitation and no further events.
.
Afib: new, isolated afib, spontaneously converted after rate
control. Ruled out, but most likley trigger was hypoxia or
volume depletion. Her baseline BP is good and HR in sinus was
in the 60's so no nodal agents were added and she has no need
for anticoagulation given this was an isolated event.
.
dementia: stable at baseline, cont nsg home meds as needed.
.
FEN: IVf as needed, pureed diet
.
CODE: FULL, will need to discuss with her guardian, who has been
newly appointed per PCP, [**Name10 (NameIs) **] need discussion of goals, but were
unable to reach during this hospital stay.
Medications on Admission:
lexapro 20mg qd
prednisone 5mg qd
mirtazapine 7.5qhs
aricept 10mg qd
risperidol 1mg qhs
trazadone 25mg qhs
MVI
maalox 30 ml prn
bisacodyl prn
guiafenacin prn
tylenol prn
colace 50mg [**Hospital1 **]
levoquin 500mg qd started on [**2174-8-10**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
aspiration pneumonitis
hypotension
volume depletion
atrial fibrillation with rapid ventricular rate
alzheimer's dementia
atypical psychosis
Discharge Condition:
good, breathing comfortably on room air sats around 95-97%, HR
in 60's and SBP>100
Discharge Instructions:
Please call or return if you become more short of breath, start
coughing or have fevers. Please take all medications as
prescribed.
Followup Instructions:
Please follow up with your PCP at your nursing home.
Completed by:[**2174-8-19**]
ICD9 Codes: 5070, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2045
} | Medical Text: Admission Date: [**2160-7-3**] Discharge Date: [**2160-7-23**]
Service: Medicine, [**Hospital1 139**] Firm
HISTORY OF PRESENT ILLNESS: This is a 77-year-old male who
was admitted on [**2160-7-3**], to the Medical Intensive Care
Unit for hypotension.
Mr. [**Known lastname **] was sent to the Emergency Department after he
was found by his primary medical doctor to be hypotensive to
70/30. For several days prior to this admission the patient
reports increased weakness and lightheadedness, particularly
upon standing. He also complains of weight loss of
approximately 10 pounds.
This patient was recently admitted to the [**Hospital1 346**] from [**2160-6-15**] to [**2160-6-22**].
During this admission he was found to be in atrial
fibrillation, and in the setting of anticoagulation for this
condition developed a gastrointestinal bleed. Endoscopy
revealed peptic ulcer disease (duodenal ulcers), and the
patient was also found to be H. pylori positive. After being
hemodynamically stabilized the patient was discharged on
amoxicillin, clarithromycin, and a proton pump inhibitor for
treatment of his H. pylori infection.
In the Medical Intensive Care Unit the patient was found to
have a central venous pressure of 1.5. He was placed on
dopamine which was quickly weaned off. The patient responded
well to aggressive hydration. An echocardiogram was done
which showed an [**Year (4 digits) **] fraction of greater than 55%, mild
aortic insufficiency, moderate-to-severe tricuspid
regurgitation, and mild pulmonary hypertension. Cardiac
enzymes were cycled, and the patient was ruled out for a
myocardial infarction. His heart rate in the setting of
atrial fibrillation was controlled with Lopressor. The
patient also developed low-grade fevers during his Medical
Intensive Care Unit stay of 100 to 100.7. Blood and urine
cultures were all negative. Chest x-ray was normal. No
source of infection was found during the [**Hospital 228**] Medical
Intensive Care Unit stay.
At the time of transfer to the Medical floor on [**2160-7-5**], the patient felt well. His only complaint was the
development of a cough.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction in [**2139**], 2-vessel coronary artery bypass graft in
[**2139**], anterior myocardial infarction in [**2156**], and
percutaneous transluminal coronary angioplasty and stenting
of saphenous vein graft in [**2156**].
2. History of congestive heart failure.
3. Atrial fibrillation since [**2160-5-25**].
4. Hypertension.
5. High cholesterol.
6. Peptic ulcer disease, status post upper gastrointestinal
bleed in [**2160-5-25**].
7. Gastroesophageal reflux disease.
8. Diverticulosis.
9. Ventral hernia.
10. Questionable history of prostate cancer.
11. Type 2 diabetes mellitus times 20 years.
12. Peripheral vascular disease.
13. Status post appendectomy.
MEDICATIONS ON ADMISSION: Medications on admission were
glyburide 10 mg p.o. b.i.d., Diovan, insulin, Lipitor,
allopurinol, Zantac, Cardura, Lopressor, multivitamin.
ALLERGIES: MORPHINE causes gastrointestinal upset.
SOCIAL HISTORY: The patient denies tobacco or alcohol use.
PHYSICAL EXAMINATION ON ADMISSION: Temperature was 97.9,
heart rate was 110 and irregular, blood pressure was 105/65,
oxygen saturation was 97% on room air. In general, the
patient was comfortable, alert and oriented. HEENT revealed
anicteric sclerae. Extraocular muscles were intact. Pupils
were equal, round, and reactive to light. Mucous membranes
appeared dry. Neck examination revealed the patient had a
large V-wave in the jugular venous pulse. Neck was supple.
Cardiovascular examination was irregular, a 2/6 systolic
murmur at the left lower sternal border. No gallops.
Pulmonary examination showed increased expiratory phase and
crackles at the right base. Abdominal examination revealed
soft, nontender, and nondistended, positive bowel sounds. No
masses. No hepatosplenomegaly. Rectal examination was
heme-positive in the Emergency Department. Extremities
revealed no edema. Right leg had diffuse purple bruising
which the patient reported to be one week old. The patient
stated that he had seen an orthopaedic surgeon for this and
was told that he had a torn hamstring.
LABORATORY DATA ON ADMISSION: White blood cell count of 6.3,
hematocrit of 34.3, platelets of 121. Differential was
63 neutrophils, 2 bands, 2 nucleated red blood cells,
1 atypical cell, 1 meta cell, and 25 lymphocytes. Chem-7
revealed sodium of 135, potassium 4.5, chloride 101,
bicarbonate 24, BUN 45, creatinine 1.9, and glucose of 60.
RADIOLOGY/IMAGING: Chest x-ray was unremarkable.
Electrocardiogram showed no changes from previous study on
[**2160-6-20**].
HOSPITAL COURSE: (Since transfer to the medical floor). On
transfer to the medical floor a workup for a source of the
patient's fevers was continued. Because of the patient's
complaint of cough, a chest x-ray was performed which showed
right middle lobe infiltrated.
On [**2160-7-6**], the patient was started on Levaquin to
treat empirically for pneumonia. On [**7-7**], 1/2 bottles
of the patient's blood cultures grew gram-positive cocci.
However, since central line had been removed it was
determined not to treat this, but to re-culture. All further
blood cultures were negative.
On [**7-8**], a CT of the abdomen was performed to evaluate
for abdominal sources of infection which was unremarkable. A
repeat chest x-ray showed right middle lobe and retrocardiac
opacities. The patient continued to spike fevers and had
intermittent episodes of hypotension to approximately 80/50.
These episodes responded well to small fluid boluses.
At this time the Infectious Disease Service was consulted.
Many cultures and serologies suggested by Infectious Disease
were performed. None yielded a source of infection for this
patient. Levofloxacin was discontinued on [**7-12**] due to
concern that the patient was still spiking fevers after seven
days of treatment. Blood cultures and urine cultures were
done while the patient was off antibiotics which also did not
yield an organism.
On approximately [**2160-7-14**], the patient's fever spikes
subsided into a consistent low-grade temperature. Although
there had been a mild improvement in clinical status, the
patient did not appear to be continuing to improve.
Therefore, on [**7-16**] a bronchoscopy was performed with
bronchoalveolar lavage. The lavage showed gram-positive
cocci on the Gram stain but no growth occurred on culture.
Multiple studies for viral and other pathogens were also
negative. The patient was subsequently placed back on
levofloxacin for an expected 3-week course. The patient
showed slow but consistent improvement over the next few
days.
On [**2160-7-18**], the patient was noted to have left lower
extremity swelling, and Doppler studies were positive for
deep venous thrombosis of the popliteal to common femoral
veins. The patient was started on Lovenox. By the time of
discharge, the patient's cough had markedly subsided. He had
been afebrile for several days, and he had good oxygen
saturations off of oxygen both at rest and with ambulation.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. b.i.d.
2. NPH 14 units subcutaneous q.a.m. and 10 units
subcutaneous q.p.m.
3. Ferrous gluconate 300 mg p.o. t.i.d.
4. Lipitor 10 mg p.o. q.d.
5. Lopressor 50 mg p.o. b.i.d.
6. Cozaar 25 mg p.o. q.d.
7. Levaquin 500 mg p.o. q.d. (to be continued until
[**2160-8-6**]).
8. Lovenox 60 mg subcutaneous b.i.d.
9. Tylenol 650 mg p.o. q.4-6h. p.r.n.
10. Serax 15 mg p.o. q.h.s. p.r.n. for insomnia.
11. Cepacol lozenges p.r.n.
12. Tessalon Perles 100 mg p.o. t.i.d. p.r.n. for cough.
13. Regular insulin sliding-scale.
DISCHARGE STATUS: The patient was discharged to a
rehabilitation facility.
DISCHARGE FOLLOWUP: Followup by Dr. [**First Name (STitle) 1313**].
CONDITION AT DISCHARGE: The patient was stable for discharge
to a rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Bilateral pneumonia.
2. Left lower extremity deep venous thrombosis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 31943**], M.D. [**MD Number(1) 31944**]
Dictated By:[**Last Name (NamePattern1) 15468**]
MEDQUIST36
D: [**2160-7-22**] 18:18
T: [**2160-7-22**] 17:46
JOB#: [**Job Number **]
ICD9 Codes: 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2046
} | Medical Text: Admission Date: [**2194-12-7**] Discharge Date: [**2194-12-23**]
Date of Birth: [**2118-3-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Amiodarone Analogues
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
severe aortic stenosis, coronary artery disease
Major Surgical or Invasive Procedure:
liver biopsy
CABG x1 (LIMA->LAD), AVR (19mm CE magna) [**12-18**]
History of Present Illness:
Mr. [**Known lastname 30842**] is a 76-year-old male, with known severe critical
aortic stenosis that has been followed and now reached a level
of 0.5 cm2 by echocardiography, who [**Known lastname 1834**] cardiac
catheterization that confirmed the presence of critical aortic
stenosis and showed an 80-90% proximal left anterior descending
stenosis, with a 70% stenosis of a small ramus branch. He is
presenting for valve and coronary surgery. The ejection fraction
is preserved.
Past Medical History:
idiopathic thrombocytopenic purpura
hepatitis C x8-10years
coronary artery disease
aortic stenosis
hypertension
hyperlipidemia
atrial fibrillation
pulmonary fibrosis secondary to amiodarone
squamous cell CA of the RLE
PSH:
TURP [**2171**]
hernia repair [**2171**]
Social History:
quit smoking 13 years ago
rare use of alcohol
Family History:
Father: diabetes, died at age 55yo from unknown causes
Mother: died in 70s
Physical Exam:
T 98.6 HR 73 BP 129/72 RR 18 97%RA
NAD
RRR, incis: c/d/i
CTAB
s/nt/nd, +BS
no c/c/e
Pertinent Results:
[**12-8**] Carotids
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Minimal plaque was identified. On the right, peak
systolic velocities are 62, 66, 66 in the ICA, CCA, ECA
respectively. The ICA to CCA ratio is 0.9. This is consistent
with no stenosis. On the left, peak systolic velocities are 59,
54, 73 in the ICA, CCA, ECA respectively. The ICA to CCA ratio
is 1.1. This is consistent with no stenosis. There is antegrade
flow in both vertebral arteries.
[**12-10**] abdominal u/s:
FINDINGS: The liver is normal in echotexture without focal
lesions. Gallbladder contains several layering stones without
signs of cholecystitis. Common bile duct is normal in diameter
measuring 0.4 cm. The pancreas is unremarkable. The aorta is
normal in diameter. The right kidney measures 10.1 cm in length.
There is a caliceal diverticulum in the upper pole containing
calcium with an additional 0.6 x 4.2 x 1.0 cm simple cyst. The
spleen is normal in size measuring 10.2 cm.
[**2194-12-12**] Liver needle biopsy:
1) Mild portal chronic, predominantly mononuclear cell,
inflammation.
2) Focal, mild steatosis.
3) Trichrome stain: Focal mild portal fibrosis.
4) Iron stain: No stainable iron.
[**2194-12-7**] 03:40PM BLOOD WBC-6.9 RBC-4.50* Hgb-14.6 Hct-43.3
MCV-96 MCH-32.4* MCHC-33.8 RDW-12.5 Plt Ct-74*
[**2194-12-18**] 11:05AM BLOOD WBC-12.5* RBC-2.43*# Hgb-8.3*# Hct-24.3*#
MCV-100* MCH-34.2* MCHC-34.2 RDW-12.8 Plt Ct-63*
[**2194-12-18**] 05:06PM BLOOD WBC-15.0* RBC-3.51*# Hgb-11.4*#
Hct-32.5*# MCV-92# MCH-32.4* MCHC-35.1* RDW-15.1 Plt Ct-148*#
[**2194-12-23**] 07:05AM BLOOD WBC-14.1* RBC-4.28* Hgb-13.8* Hct-39.9*
MCV-93 MCH-32.1* MCHC-34.5 RDW-15.1 Plt Ct-54*
[**2194-12-21**] 05:30AM BLOOD PT-14.4* INR(PT)-1.4
[**2194-12-22**] 07:30AM BLOOD PT-14.1* INR(PT)-1.4
[**2194-12-10**] 07:25AM BLOOD HCV Ab-POSITIVE
Brief Hospital Course:
Mr. [**Known lastname 30842**] was admitted to the Cardiac Surgery service under the
care of Dr. [**Last Name (STitle) **]. Given his low platelet counts (74) at
[**Hospital1 **] and at [**Hospital1 18**], a hematology consult was obtained for
further evaluation. His thrombocytopenia had been previously
documented and worked up by Dr. [**Last Name (STitle) 30843**]. An abdominal ultrasound
showed no signs of splenomegaly and his heparin-dependent
antibody assay was negative. In addition, the Hepatology team
was asked to evaluate Mr. [**Known lastname 30842**] for his thrombocytopenia in the
presence of HCV. On [**12-12**], Mr. [**Known lastname 30842**] [**Last Name (Titles) 1834**] an
ultrasound-guided liver biopsy. The results were mild portal
chronic, predominantly mononuclear cell, inflammation; and
focal, mild steatosis.
Mr. [**Known lastname 30842**] was cleared for surgery by the Hematology and
Hepatology teams. His chronic thrombocytopenia was attributed
to either ITP or HCV. He received platelet transfusions
pre-operatively. On [**12-18**], he [**Month/Year (2) 1834**] his CABG x1 and AVR
without complications. Please see Dr.[**Name (NI) 5572**] Operative Note
for further detail.
Post-operatively, he did well. He was extubated, his chest
tubes removed, and transferred to the floor by POD #2. His
platelet and hematocrit levels were closely followed. By the
time of discharge on POD #5, his epicardial wires were removed,
he was evaluated by physical therapy, had good pain control, and
was tolerating a regular diet, although complained of poor
appetite. His Coumadin was restarted on [**12-20**] for his atrial
fibrillation.
Medications on Admission:
Coumadin 2.5mg PO daily
Atacand 32mg PO daily
Lopressor 100mg PO BID
Insulin NPH 22 [**Hospital1 **]
Glucotrol 5'
Digoxin 0.125'
Lipitor 20'
Celexa 20'
Protonix 40'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
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
Q4H (every 4 hours) as needed for pain.
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
titrate for INR between 1.5-2.5.
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: for [**Date range (1) 24295**].
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days: to start [**Date range (1) 30844**].
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Humulin N 100 unit/mL Suspension Sig: Eleven (11) units
Subcutaneous twice a day.
15. Humalog 100 unit/mL Cartridge Sig: One (1) Units
Subcutaneous four times a day as needed for hyperglycemia:
insulin sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location (un) 47**]
Discharge Diagnosis:
idiopathic thrombocytopenic purpura
coronary artery disease
aortic stenosis
diabetes
hyperlipidemia
atrial fibrillation
hepatitis C
Discharge Condition:
Good
Discharge Instructions:
If you have any chest pain, difficulty breathing, persistent
nausea/vomiting, redness/oozing from your incision site, seek
medical attention immediately.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 6256**] Follow-up appointment
should be in 2 weeks
Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Completed by:[**2194-12-23**]
ICD9 Codes: 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2047
} | Medical Text: Admission Date: [**2166-10-9**] Discharge Date: [**2166-10-14**]
Date of Birth: [**2080-5-14**] Sex: F
Service: MEDICINE
Allergies:
Macrobid
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING [**Hospital **] TRANSFER TO FLOOR ACCEPT
NOTE
The patient is an 86 yo F with h/o orthostatic hypotension and
recent SAH in [**6-/2166**] sustained following a mechanical fall who
presented to the ED this evening with acutely altered mental
status with incoherent speech.
For the past week, she has been having b/l "body" tremors
including UE and head. The episodes last about 10 mins and are
low amplitude. Her daughter describes an episode where she
begins to fall following the episode, but that she is speaking
during the event and is not confused either during or after the
episode. She also has been experiencing a [**Hospital1 **]-temporal headache
that began on Wednesday evening and was associated with
decreased appetite, nausea and vomiting. The daughter's report
that their mother described it as pressure like on both sides of
her head.
On the night prior to admission, she got up to use the bathroom
and reported sustained a mechanical fall on to her left hip (not
uncommon for her according to her daughter), following which she
was "normal" and went back to sleep. She woke up in the morning,
her home health associate noted that she "was not her self" and
took her to see her PCP. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 91538**] head CT (NCHCT) was done
and reportedly negative. She also had left hip films which
revealed fractures of the L superior and inferior pubic rami
(subacute vs old) with minor degenerative changes. Her BP was
recorded at 124/70. Of note, the patient sustained a hip
fracture over the summer.
Upon returning home, she slept from 2pm-5pm and upon wakening,
she was acutely altered and confused with incoherent speech and
was brought to the ED.
In the ED, inital vitals were, 191/127, 94, 22, 98% on RA. A
Code Stroke was called. She was electively intubated due to
agitation so that she could undergo her imaging studies. A NCHCT
preliminary showed no acute intracranial process. As per the
neuro consult note, a CTA of the head and neck showed normal
vasculature with no thrombi or dissections and a CT perfusion
study did not reveal any perfusion deficits. She was not given
tPA as she thought to be outside of the therapeutic window.
Neurology reported her neuro exam was non localizing and that
the etiology of her AMS was not entirely clear. They are
concerned for PRES or a hypertensive encephalopathy given her
dramatic swings in BP. Of note, during her ED course, she spiked
a fever to 102 F and was also found to have a UA c/w UTI and was
given ceftriaxone. She was then transfered to the ICU for
further management.
Vitals on transfer were, 103/79 98 RR 16 on vent, Vt 400, PEEP
5, FiO2 50%. She was hypertensive on arrival with a recorded SBP
of 190. She was not given antihypertensives, however following
sedation with propofol her SBP was in the 140s. She was switched
from propofol to fent/versed just prior to transfer. Of note,
she dropped her BP to 82/55 while being moved to the stretcher
and required a 500cc bolus. Her BP then improved to 106/66. In
the ICU, her UTI was treated with bactrim. She was subsequently
extubated and her mental status was found to be at baseline. In
the ICU, her UTI was treated with bactrim. She was transferred
to the medicine floor for further management.
On the medicine floor, she reports no problems. She endorses
left hip pain only when she is moving around. She denies
headache, chest pain, shortness of breath, diarrhea, fevers,
chills, nausea, vomitting.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies visual changes, headache, dizziness, sinus
tenderness, neck stiffness, rhinorrhea, congestion, sore throat
or dysphagia. Denies chest pain, palpitations, orthopnea,
dyspnea on exertion. Denies shortness of breath, cough or
wheezes. Denies nausea, vomiting, heartburn, diarrhea,
constipation, BRBPR, melena, or abdominal pain. No dysuria,
urinary frequency. Denies arthralgias or myalgias. Denies
rashes. No increasing lower extremity swelling. No
numbness/tingling or muscle weakness in extremities. No feelings
of depression or anxiety. All other review of systems negative.
Past Medical History:
- Orthostatic hypotension, BP range on average 90-150 systolic.
- SAH ([**6-/2166**]) following ?mechanical fall during which she also
sustained a orbital fracture
- Hyperlipidema
- Urinary incontinence
- Hip fracture, noted in [**Month (only) 205**]. Imaging studies not entirely
clear, but daughter reported it is on the L and was incorrectly
reported as R on CT.
- Chronic LE edema
- Chronic hearing Loss
- Osteoporosis
Social History:
Lives by her self, has HHA but not 24 hrs, family attempts to
fill gaps in supervision. Has frequent falls primarily [**1-29**]
orthostatic hypotension sustaining injuries including SAH, hip
fx, facial fx. Was in rehab following fall from a stair for 6
weeks in Summer [**2165**].
Family History:
Not relevent to presentation of altered mental status and UTI in
an 86 y/o F.
Physical Exam:
VS: 98.2 134/60 89 20 96%RA; 0/10 pain at rest; [**7-6**] left hip
pain with movement
GEN: No apparent distress, pleasant
HEENT: No trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CV: Regular rate and rhythm, no murmurs/gallops/rubs
PULM: Clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: Soft, non-tender, non-distended; no guarding/rebound
EXT: No clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV
present; pneumoboots in place
NEURO: Alert and oriented to person, place and situation; CN
II-XII intact, [**5-1**] motor function globally
DERM: Ecchymoses on left upper posterior thigh/butt
Pertinent Results:
[**2166-10-9**] 08:15PM BLOOD WBC-9.8 RBC-3.46* Hgb-11.3* Hct-32.9*
MCV-95 MCH-32.6* MCHC-34.3 RDW-13.3 Plt Ct-290
[**2166-10-9**] 08:15PM BLOOD PT-12.7 PTT-19.8* INR(PT)-1.1
[**2166-10-10**] 04:30AM BLOOD Glucose-148* UreaN-16 Creat-1.0 Na-136
K-4.2 Cl-102 HCO3-27 AnGap-11
[**2166-10-10**] 04:30AM BLOOD ALT-6 AST-24 LD(LDH)-153 CK(CPK)-136
AlkPhos-21* TotBili-0.5
[**2166-10-9**] 08:15PM BLOOD cTropnT-<0.01
[**2166-10-10**] 04:30AM BLOOD Albumin-3.4* Calcium-8.4 Phos-4.0 Mg-1.6
[**2166-10-10**] 04:30AM BLOOD TSH-2.4
[**2166-10-10**] 04:30AM BLOOD VitB12-565 Folate-GREATER TH
[**2166-10-11**] 04:27AM BLOOD Hapto-71
[**2166-10-14**] 07:05AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-139
K-3.5 Cl-103 HCO3-26 AnGap-14
[**2166-10-14**] 07:05AM BLOOD WBC-8.2 RBC-2.88* Hgb-9.2* Hct-27.2*
MCV-95 MCH-32.0 MCHC-33.8 RDW-15.3 Plt Ct-277
URINALYSIS:
[**2166-10-9**] 10:30PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.046*
[**2166-10-9**] 10:30PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
[**2166-10-9**] 10:30PM URINE RBC-66* WBC-83* Bacteri-MANY Yeast-NONE
Epi-0
[**2166-10-9**] 10:30PM URINE CastHy-2*
[**2166-10-9**] 10:30 pm URINE Site: CATHETER
**FINAL REPORT [**2166-10-12**]**
URINE CULTURE (Final [**2166-10-12**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
CTA Head ([**2166-10-9**])
IMPRESSION:
1. No evidence of infarction, or hemorrhage.
2. No evidence of stenosis, occlusion, or aneurysm .
3. Calcified plaque at the left distal common carotid artery
causing approximately 25% stenosis.
CXR ([**2166-10-9**])
IMPRESSION: Endotracheal tube in appropriate position. Trace
right pleural effusion.
MRI HEAD ([**2166-10-10**])
IMPRESSION: Limited study. With this limitation in mind, there
is no large territorial infarct seen on diffusion-weighted
imaging.
CT Chest/Abd/Pelvis ([**2166-10-11**])
IMPRESSION:
1. Massive left gluteal/posterior thigh hematoma measuring 12.9
x 7.7 x 19.8 cm. Active extravasation cannot be assessed given
the lack of intravenous contrast material.
2. Multiple old fractures involving the left scapula, left
posterior ribs,
and left pelvic bones, as described above.
3. Lingular pulmonary nodule measuring 2 mm requires no
additional followup if this patient is a non-smoker and has no
prior history of malignancy. Otherwise, followup with a chest CT
in one year is recommended.
Brief Hospital Course:
86 year-old woman with orthostatic hypotension and recent SAH in
[**6-/2166**] following a mechanical fall presented to the ED this
evening with acutely altered mental status with incoherent
speech.
#. Delirium from Metabolic Encephalopathy: The patient presented
with an acute alteration in her mental status which was
originally concerning for a neurologic origin. A Code Stroke was
called and her initial imaging (NCHCT, CTA head, and CT
perfusion imaging) did not reveal an acute neurologic cause.
Neurology was consulted and recommened an MRI of the head to
evaluate for other causes including PRES or hypertensive
encephalopathy, and while the study was limited by motion
artifact, it did not reveal any neurology abnormalities. Upon
arrival, the patient was found to have a UA consistent with a
UTI. She was originally treated with antibiotics as below, and
her mental status greatly improved and it seems most likely that
her AMS was a result of her infection. Upon transfer from the
ICU, the patient was reportedly almost back at her baseline
mental status which some residual confusion as per her daughter.
She was alert and oriented to name and place, and was not
oriented to year, but did know that it was [**Month (only) 359**]. On the floor
she is alert and oriented to name, place, and date, but does
still get confused sometimes.
#. Orthostatic hypotension:
Upon arrival to the ICU, the patients blood pressure was highly
elevated. Following her intubation, her BP began to drop and
fluctuated widely early in her admission. Her home medications
for orthostatic hypotension were held and her sedation while
intubated was limited to minimize swings in BP. Following
extubation, her BP remained more stable and her home medications
were restarted. The day of transfer from the MICU, her BP ranged
from 123/55 to 166/77.
- Continue home midodrine and fludrocortisone
#. Urinary Tract Infection, E Coli: Patient's urinalysis was
found to be consistent with UTI. She was started on ceftriaxone
and her mental status improved as above. When cultures returned,
she was transitioned to Bactrim in the ICU. Due to a concern for
potential allergy to Bactrim per ICU and per Ucx sensitivities,
her Bactrim was changed to ciprofloxacin. 5 total days of
antibiotics were administered.
#. Anemia: Stable. It was noted that the patients hematocrit
had decreased from admission (34.9 to 24.0). Hemolysis labs were
done and were unrevealing. A CT scan of the Chest/Abdomen/Pelvis
was done which revealed a large hematoma surronding her left hip
(consistent with the events surronding her fall prior to
admission). She was closely monitored for compartment syndrome.
She received a total of 4 units of PRBCs while in the ICU and
her hematocrit stablized.
#. Respiratory Status: Stable. The patient was electively
intubated for airway protection in the setting of her acute
agitation and need for emergent head imaging. She was extubated
without event the following afternoon and was satting well on
room air prior to and after her transfer to the general medical
floor.
#. Hip Fractures: At the time of her fall prior to admission,
the patient also fell onto her L hip. Plain films done at her
PCPs office revealed left sided fractures, which were known from
a prior fall. As above, the patient also underwent a CT scan
which revealed a large hematoma around her left hip.
- Pain control with acetaminophen and lidocaine patch. Avoid
narcotic pain medications if possible as they may worsen her
confusion.
#. Hyperlipidemia: The patient statin was initially held when
she was intubated and restarted prior to her transfer to the
general medical floor. Continue home simvastatin.
#. Communication: Daughter: [**First Name8 (NamePattern2) **] [**Known lastname 16807**]: [**Telephone/Fax (1) 91539**]
#. CODE: Full code
Medications on Admission:
-Potassium Chloride 10 mEq Oral Tablet Extended Release Take 1
tablet twice daily or as otherwise directed
-Midodrine 10 mg Oral Tablet take one tablet three times daily
or as otherwise prescribed
-Fludrocortisone (FLORINEF) 0.1 mg Oral Tablet take 1 tablet
daily until otherwise instructed
-Simvastatin 40 mg Oral Tablet 1 tablet every evening for
cholesterol
-CALCIUM ORAL
-MULTIVITAMIN ORAL
Discharge Medications:
1. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO twice a day.
5. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for left lower back.
8. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**4-2**]
hours as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
- Metabolic encephalopathy
- Urinary tract infection
- Anemia from acute blood loss
- Left upper thigh hematoma
- Orthostatic hypotension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - should not ambulate without
assistance from another person to supervise.
Discharge Instructions:
You presented with delirium likely caused by Urinary Tract
Infection. CT scan of the head did not reveal a stroke. You
were also found to have a low blood count and were found to have
bleeding into your upper left thigh. You received blood
transfusions. Your confusion is improving, but you are not
quite at your baseline yet. You will complete a course of
antibiotics for your urinary tract infection. Your blood count
was stable after the blood transfusions.
Followup Instructions:
After you are discharged from rehab, you should make an
appointment for follow-up with your primary care physician:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J
Location: [**Location (un) 2274**]-[**Location **]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 28551**]
ICD9 Codes: 5990, 2930, 2851, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2048
} | Medical Text: Admission Date: [**2142-1-1**] Discharge Date: [**2142-1-3**]
Date of Birth: [**2099-12-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9871**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
42 y/o F PMH Breast Cancer metastatic to lungs, cranium, spine
(epidural T1/T4, cervical/upper thoracic spine) and bone (spine
and sternum) and leptomeniges. According to recent Oncology
notes current treatment is Doxorubicin (last treatment
[**2141-12-26**]), steroids and s/p XRT for leptomenigeal disease.
Patient currently intubated consequently history from OMR and
family.
.
Patient presented to ED T 95.3, BP 129/95, HR 98, O2 Sat 100% (?
oxygen) and triggered for respiratory distress. She was placed
on NRB with O2 Sat 93%. Respiratory status worsened despite
inhalers and patient became increasing somnelent and
consequently was intubated. Patient was given levaquin for
concern of PNA.
.
Per family patient had 1 week history of SOB with exertion.
Breathing increasingly laboured over the past week at rest.
Family reports several months of SOB but with exertion only.
Denies associated fever, chills, cough, hemopytsis. Daughter has
cold, but not severe and requires no antibiotics. No chest pain.
Does report bloody nose last night and usually every other week.
Mother reports patient more disoriented this afternoon and
easily tired. Family not aware of lung metastasis.
.
Of note patient's most recent admission [**2141-10-17**] for headaches
started on steroids/radiation therapy, dyspnea ruled out for PE
felt to be secondary to metastasis. Recent Heme Onc notes
notable for agitation/hallucinations felt to be related to
steroids.
Past Medical History:
Past Oncologic History:
- diagnosed in late [**2135**] with infiltrating ductal carcinomas of
the right breast with positive sentinel node, ER positive, PR
positive, and HER-2/neu negative
- underwent dose-dense AC followed by dose-dense Taxol, then
mastectomy and level 1 axillary node dissection with only one
focus residual DCIS, then postoperative radiation therapy and
hormonal therapy
- developed bone metastases in [**2139-5-31**] and subsequently
received multiple hormonal and chemotherapy regimens and
radiation therapy to symptomatic sites
- began Abraxane and Avastin on [**2141-5-31**], had 3 cycles (last
one on [**2141-7-28**]
- began complaining soon after of increased pain in bilateral
ribs at the mid chest level.
-MRI on [**2141-6-9**], showed further compression of the T4 and
T6 vertebral bodies and new fusiform abnormalities in the
posterior epidural space at T6-8 and T9-10 without evidence of
spinal cord signal abnormality or significant compression.
- C1D1 Gemzar [**2141-8-18**], has recieved 2 cycles (cycle 2 on
[**2141-9-8**])
- Most recent regimen Doxil (Doxorubicin 10mg/m2 d1,d8,d15);
following chemo zometa every 3 months
- Whole brain irradiation from [**Date range (3) 98116**] Dr. [**Last Name (STitle) 3929**]
.
- Depression
Social History:
Lives with her daughter and her mother lives in the [**Last Name (un) **]
downstairs.
- Tobacco: previously smoked 1ppd. Quit 2 months ago.
- etOH: social drinker, last had a drink 2 months ago.
- Illicits: smokes marijuana about every other week.
Family History:
Mother with cervical cancer. No family history of breast or
ovarian cancer.
Physical Exam:
Admission Physical Exam:
VS: BP: 111/58 HR: 74 RR: 27 O2sat: 99% vent
GEN: intubated and sedated, not responsive to verbal stimuli
HEENT: PERRL, anicteric, MMM, op without lesions
RESP: CTA b/l with good air movement anterior
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
Pertinent Results:
Admission Labs [**2142-1-1**]:
-WBC-7.2 RBC-3.58* Hgb-10.7* Hct-32.0* MCV-89 MCH-29.9 MCHC-33.5
RDW-20.4* Plt Ct-17*
-Neuts-59 Bands-4 Lymphs-13* Monos-12* Eos-3 Baso-0 Atyps-0
Metas-3* Myelos-4* Promyel-2* NRBC-19*
-Hypochr-1+ Anisocy-3+ Poiklo-1+ Macrocy-1+ Microcy-1+
Polychr-1+ Schisto-1+ Tear Dr[**Last Name (STitle) **]1+ Bite-1+
-PT-13.2 PTT-21.9* INR(PT)-1.1
-Fibrino-551*
-Glucose-121* UreaN-24* Creat-0.8 Na-131* K-5.1 Cl-99 HCO3-23
AnGap-14
-ALT-62* AST-73* LD(LDH)-947* AlkPhos-148* TotBili-0.8
-proBNP-411*
-Hapto-<5*
-Type-ART Rates-/16 Tidal V-450 PEEP-5 FiO2-70 pO2-234* pCO2-40
pH-7.42 calTCO2-27 Base XS-1 Intubat-INTUBATED
-Lactate-0.9
.
[**2142-1-3**]:
-Platlets 14*
.
Select Reports:
-CTA: 1. No pulmonary embolus. 2. Progression of metastatic
disease involving mediastinal and right hilar nodes. True extent
of malignancy likely underestimated by low lung volumes and
bibasilar consolidations, due to combination of aspiration and
pneumonia. 3. Given septal thickening at least in part due to
pulmonary edema, lymphangitic spread of carcinomatosis would be
difficult to exclude. 4. Left breast nodule, though
subcentimeter, is larger than in [**2141-8-30**].
.
-TTE: The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). 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
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2140-9-29**], probably no major change.
.
-CT Head: There is no evidence of hemorrhage, edema, mass
effect, or infarction. The ventricles and sulci are normal in
size and configuration. [**Doctor Last Name **]-white matter differentiation is
well preserved. Paranasal sinuses and mastoid air cells are
clear and well aerated. Re-demonstrated is diffuse metastastic
involvement of the calvarium and skull base.
.
-CXR on day of discharge [**2142-1-3**]: In comparison with the study of
[**1-2**], there is increasing diffuse bilateral pulmonary
opacifications. In view of the enlargement of the cardiac
silhouette and blunting costophrenic angles, this could well
represent pulmonary edema. However, the possibility of
supervening pneumonia or even ARDS would have to be considered.
Brief Hospital Course:
A/P: 42 year old female PMH metastatic breast cancer (lung,
spine and leptomeningeal) who presents with respiratory distress
of 1 week duration requiring intubation on arrival to ED. No
specific cause was found for her deterioration whcich was put
down to disease progression following an unchanged TTE, negative
CT-PA for PE, no evidence radiologically for DVTs and no culture
data to suggest an infectious precipitant.
.
.
# Respiratory Distress: Thsi was considered likely due to
progression of knoen metastatic breast cancer. Her primary
oncologist felt that she should not be intubated again. Mrs
[**Known lastname 98114**] was celebrating birthday with family, unable to blow
candles out. She then noted increasing sob, family called EMS.
On NRB at presentation to the EW, sO2 91%. A&O at that time and
stated she would like to be intubated, if needed. She then ecame
tachypneic and lethargic and was intubated and commenced on
propofol. She was transferred to the MICU for further care CXR
showed no evidence of pneumonia. Sputum revealed respiratory
commensal flora. Given progressive shortness of breath without
symptoms of cough/fever concerning for PE especially in setting
of known metastatic disease. She therefore had a CT-[**MD Number(3) 24709**]
showed no evidence of PE but did show progression of metastatic
disease involving mediastinal and right hilar nodes. In
addition, teh report noted that given septal thickening at least
in part due to pulmonary edema, lymphangitic spread of
carcinomatosis was considered difficult to exclude. The Left
breast nodule, was larger than in [**2141-8-30**]. LENIs were done and
were negative for DVTs. Given possible pulmonary edema, she had
a TTE which showed no significant change from prior. She had
furosemide IV prior to extubation given above BNP 411 and she
had a good diuresis to this. She was treated Levofloxacin and
Vancomycin and thsi was stopped post extubation. She was
successfully extubated on the evening of [**1-2**] and passed a SBT.
She was saturating well on room air and transferred to teh
oncology service and was discharged on [**1-3**].
.
# Altered Mental Status: This was initially presnet at time of
hospital admission and peri-intubation and resolved [**1-2**] post
intubation. She had a CT-head which showed no acute process. She
was at her baseline after this.
.
# Thrombocytopenia: Slowly trending down from [**2141-11-10**]. Last
platelet count [**2141-12-28**] 23. Most likely chemotherapy side effect
- received Doxorubicin [**2141-12-26**] - espeically in setting of diff
with metas/myelos/nRBC. This was felt unlikely DIC as PT/PTT
within normal limits, no schistocytes, fibrinogen elevated. This
was trended and trended remaining around 15. There was no sign
of active bleeding.
# Hyponatremia: This was initially felt most likely hypovolemic
or SIADH. Urine Na 49 and urine osmo 441 suggested SIADH. She
has several possible causes for SIADH including metastatic
disease, possible pneumonia or CNS involvement. This was trended
and improved to 140 on discharge.
.
# Anemia: Above baseline 26-29. This was trended.
.
# Transaminitis: Slightly elevated from prior however labs
hemolyzed. Prior CT A/P showed no metastatic disease within the
abdomen and pelvis. This was trended and decreased by teh time
of discharge. No further work-up was performed.
.
# Metastatic breast cancer: Overall poor prognosis due to
metastasis to lung and bone. MR head [**2141-12-20**] near total
resolution of the previously noted pachymeningeal and
leptomeningeal disease compared to [**2141-9-29**] s/p XRT. Per ED,
patient wished to be intubated and also discuss with mother. O/P
oncologist felt that patient should not be intubated in future.
We started dexamethasone 4mg [**Hospital1 **]. - Confirm whether patient
currently taking Dexamethasone 4 mg [**Hospital1 **]. She was extubated on
[**1-2**] and was saturating well on room air. Post extubation, we
restarted her outpatient pain regimen of Fentanyl and Oxycodone.
.
# Depression/Anxiety: WE held Alprazolam while on midazolamd
infusion adn post extubation on [**1-2**] we restarted he home regime
of alprazolam, Setraline and Perphenazine.
Medications on Admission:
ALPRAZOLAM - 0.5 mg Tablet - one Tablet(s) by mouth tab po TID
and one PRN for agitation
DEXAMETHASONE - (Prescribed by Other Provider) - 4 mg Tablet - 1
Tablet(s) by mouth twice a day
FENTANYL - 50 mcg/hour Patch 72 hr - TD q72H
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - Apply topically to
port one hour prior to chemotherapy - No Substitution
OXYCODONE - 20 mg Tablet - 2 Tablet(s) by mouth every 4-6 hours
as needed for pain. - No Substitution
PERPHENAZINE - 2 mg Tablet - one Tablet(s) by mouth [**2-1**]
times/day
SCALP PROSTHESIS - - 174.9
SERTRALINE - 50 mg Tablet - one Tablet(s) by mouth daily
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 6 days: to be finished on [**2142-1-9**].
Disp:*6 Tablet(s)* Refills:*0*
2. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for agitation.
4. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
5. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Transdermal q 72
hours: please resume prior schedule.
6. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) application
Topical prior to chemotherapy: Apply topically to
port one hour prior to chemotherapy - No Substitution .
7. oxycodone 20 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
8. perphenazine 2 mg Tablet Sig: One (1) Tablet PO 2 to 3 times
per day.
9. scalp prosthesis Sig: as directed as needed.
10. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
thrombocytopenia
metastatic breast cancer
respiratory distress
pulmonary edema
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms [**Known lastname 98114**],
You were recently admitted for management of shortness of
breath. You were initially admitted to the Intensive Care Unit
(ICU) where you had a machine helping you breathe. They provided
you with antibiotics and medications to remove excess fluid and
you improved. You were transferred to the floor. We are
providing you with a prescription for an antibiotic to continue
after discharge.
.
Your platelets were discovered to be very low during this
admission. You will need to return for a follow up appointment
tomorrow morning at 9 AM (detail below). You will need to have
your platelets re-checked. Please be very careful that you do
not fall, as injurying yourself could be very dangerous because
with low platelets your blood does not clot appropriately.
.
We are making the following changes to your outpatient regimen:
-Please START Levofloxacin 750 mg by mouth daily until [**2142-1-9**]
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2142-1-9**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 73088**], NP [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: THURSDAY [**2142-1-18**] at 1:30 PM
With: [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 486, 2761, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2049
} | Medical Text: Admission Date: [**2110-7-7**] Discharge Date: [**2110-7-10**]
Date of Birth: [**2062-4-13**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Mitral regurgitation
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 12750**] is a 48 year old
male with a history of mitral valve disease. Cardiac
catheterization confirmed 4+ mitral regurgitation and normal
coronary arteries. He presents for evaluation and treatment
of his mitral regurgitation.
PAST MEDICAL HISTORY: Tonsillectomy.
MEDICATIONS ON ADMISSION: Zestril 20 mg q.d., Klonopin 0.5
mg b.i.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Heartrate 68, blood pressure 120/80.
His heart is regular rate and rhythm, systolic murmur at the
apex. His lungs are clear to auscultation bilaterally. His
abdomen is soft, nontender, nondistended with normoactive
bowel sounds. His extremities are without cyanosis, clubbing
or edema.
HOSPITAL COURSE: Mr. [**Known lastname 12750**] was taken to the Operating Room
on [**2110-7-7**] for minimally invasive mitral valve repair.
The procedure as performed without complication and Mr.
[**Known lastname 12750**] was subsequently transferred to the Cardiac Surgical
Intensive Care Unit. He was weaned off of drips, extubated
and hemodynamically stabilized. Postoperative chest x-ray
revealed an air leak and consequently Mr. [**Known lastname 12750**] was left
with his chest tube on suction. Otherwise he had an
uneventful stay in the Intensive Care Unit and was
transferred to the floor on postoperative day #1. By
postoperative day #2 his air leak had resolved. Chest x-ray
revealed resolution of pneumothorax and subsequently the
chest tube was discontinued. Mr. [**Known lastname 12750**] [**Last Name (Titles) 8337**] this
well. He continued to improve on the floor. He was
tolerating an oral diet and his pain was controlled with oral
medications. He was switched from Percocet to Tylenol #3 and
Motrin due to a feeling of over-sedation from the Percocet.
Mr. [**Known lastname 12750**] was ambulating well with physical therapy
completing a Level 5 performance test. On postoperative day
#3 Mr. [**Known lastname 12750**] was felt stable for discharge home.
Physical examination at discharge revealed temperature 99.6,
pulse 67, blood pressure 130/60, respirations 18 and oxygen
saturation 98% on room air. His heart was regular rate and
rhythm. His lungs were clear to auscultation bilaterally.
Incisions were clean, dry and intact. Abdomen was soft,
nontender, nondistended with normoactive bowel sounds.
Extremities were without cyanosis, clubbing or edema.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Lisinopril 15 mg q.d.
3. Clonazepam 0.5 mg b.i.d.
4. Docusate 100 mg b.i.d. prn
5. Amiodarone 400 mg q.d.
6. Ibuprofen 600 mg q. 6 hours prn
7. Tylenol #3 one to two tablets q. 4 hours prn
FO[**Last Name (STitle) 996**]P: Mr. [**Known lastname 12750**] should follow up with Dr. [**Last Name (STitle) 4127**]
in three to four weeks and Dr. [**Last Name (Prefixes) **] in four weeks.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Mr. [**Known lastname 12750**] is to be discharged home.
DISCHARGE DIAGNOSIS: Status post mitral valve repair.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 11235**]
MEDQUIST36
D: [**2110-7-10**] 09:50
T: [**2110-7-10**] 10:06
JOB#: [**Job Number 12751**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2050
} | Medical Text: Admission Date: [**2116-12-13**] Discharge Date: [**2116-12-18**]
Date of Birth: [**2042-4-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Lower extremity weakness
Major Surgical or Invasive Procedure:
Dobhoff placement and removal
History of Present Illness:
Mrs. [**Known lastname **] is a 74 year old woman with history of metastatic
pancreatic cancer and distant history of [**First Name9 (NamePattern2) 7816**] [**Location (un) **] Syndrome
who is now transferred from an outside hospital with lower
extremity weakness. Patient is unable to provide any history at
present. Chart review from the OSH and discussion with patient's
husband provided history contained here. Per husband, the
patient had her last chemotherapy about 10 days ago and was
feeling well one day following. Was able to go shopping with a
few friends for an hour or two. The following day the patient
complained of generalized malaise, fatigue, then rigoring at
home. EMS took her to [**Hospital **] Hospital [**2116-12-8**] where she was
noted to be febrile and she was treated with Ceftriaxone and
Azithromicin for ? RLL pneumonia and UTI. The patient improved
the following day and was ambulatory in the hospital, however
the following day (Sat. [**12-12**]) the patient was very lethargic
and slept most of the day. This continued to Sunday [**12-13**] and pt
was noted to be unable to get out of bed on her own. She could
sit at the edge of the bed but her "legs were like a rag
doll's," and she was unable to stand. Her arms also seemed weak.
The patient and her husband had a negative experience with a
neurologist at [**Hospital1 **], and they love their GI surgeon here at
[**Hospital1 18**] and requested transfer for further evaluation. The patient
underwent MRI of her T and L spine without note of cord
compression at the OSH prior to transfer.
Vitals at OSH T 98--Tm 99, BP 98-120/56-82, she was on 2L NC sat
91-93%, Prior to transfer NIF -30, Vital capacity 1 Liter. MRI T
and L spine with no reported compression, ? bone metastsis in T
5, T6, T10. Pt was more drowsy than earlier due to ____ she got
(for MRI sedation?). Also given 1g solumedrol earlier in the
day.
She was treated with ceftriaxone and azithromycine for RLL
pneumonia and also treated for E. Coli UTI.
In arrival to the Trauma ICU the patient was hypoxic at 89% and
started on 40% facemask.
Patient is unable to offer a full ROS. She denies any pain or
discomfort at present.
Past Medical History:
1) Metastatic Pancreatic Cancer- diagnosed with obstructive
jaundice d/t pancreatic head mass, mets to liver and ? lung,
tumor is inoperable. She is s/p biliary stent placement. Pt was
undergoing chemotherapy, last dose ~10 days ago, her oncologist
is Dr. [**First Name4 (NamePattern1) 19948**] [**Last Name (NamePattern1) **] in [**Hospital1 **], MA.
2) [**First Name9 (NamePattern2) 79755**] [**Location (un) **] Syndrome- "GBS approximately 5 years ago a few
weeks after receiving a flu shot. She describes being at work
(at [**Hospital1 3597**] Witchcraft Elementary School) when a young boy asked
her to help tie his shoe, when she reached to tie the shoe her
hands completely passed their mark and she was concerned. She
rapidly worsened with total body weakness prompting
hospitalization at [**Hospital **] Hospital where she was plasmapheresed
x 5 days. She did have a few days of dyspnea but did not
require ventilatory support. Residual pins and needles
sensation in the hands and feet and residual BLE weakness. She
thought she might have had a recurrence a few years ago (felt
weak for 2 days), but these symptoms resolved on their own."
3) Hypertension
4) Hypothyroidism
5) Hyperlipidemia
6) Esopageal spasm
7) S/p CCK.
Social History:
Married with 2 children. Worked at [**Hospital1 3597**] Elemetary in kitchen;
retired after GBS. Quit smoking 5 years ago, no recent ETOH. No
illicits.
Family History:
Father died of MI
Mother died of stroke
No history of other neurologic disease or malignancy
Physical Exam:
Vitals: T 96.7, HR 105, BP 106/70, R 24, 94% on 40% FM
Gen- ill appearing, drowsy but arouses briefly to voice, appears
comfortable.
HEENT- NCAT, pale, anicteric sclera, MMM, OP clear
Neck- no carotid bruits.
CV- tachycardic, no MRG
Pulm- scattered crackles throughout.
Abd- soft, nt, nd, BS+
Extrem- no CCE.
Neurologic Exam:
MS- place=[**Hospital **] hospital, month=[**Month (only) **], year=?. She is
inattentive. able to name days of week forwards, but when asked
to say them backwards she is unable to switch tasks. Her naming
of "watch" is intact, but with other objects the patient is too
inattentive to comply with further testing. She follows simple
commands, but is perseverative "open your eyes" but difficulty
with "show me two fingers on your left hand"
CN- smell not tested, pupils 4mm-->3mm and sluggish to light
bilaterally, EOM's are full, no nystagmus. blinks to threat
bilaterally. Funduscopic exam could not be performed due pt
uncooperativeness with exam (pulled eyes shut forcibly). face is
symmetric with symmetric sensation to LT. no ptosis. hearing
intact to FR bilat, unable to view palate with face mask for O2,
tongue protrudes at midline.
Motor- no adventitious movements, tone appears low throughout.
She displays motor impersistence. Holds both arms antigravity
for 2-3 seconds and they fall to her chest. She spontaneously
holds her legs antigravity briefly. When asked to move her legs
to command she is unable to do so. She briskly withdraws her
legs to noxious stim.
Sensory- intact to light touch in all extrem, intact to noxious
in all extrem. unable to perform detailed sensory testing due to
mental status.
Reflexes: unable to elicit any DTR's in [**Hospital1 **], tri, [**Last Name (un) **], patell,
ankles.
Plantar response down on right, up on left.
Gait- unable to test.
Pertinent Results:
CHEST RADIOGRAPH AP ([**2116-12-13**]): Mild cardiomegaly. No vascular
engorgement. No lung consolidation or mass. No pleural effusion.
Metallic stent projects over the right upper quadrant.
CT HEAD WITHOUT CONTRAST ([**2116-12-14**]): 1. No evidence of
infarction, hemorrhage, of mass effect. 2. MR [**First Name (Titles) 151**] [**Last Name (Titles) **] is
most sensitive for evaluation of intracranial metastatic
disease.
BILATERAL LOWER EXTREMITY DOPPLERS ([**2116-12-15**]): No DVT in the
bilateral lower extremities.
CHEST PA/LAT ([**2116-12-16**]): In comparison with the study of [**12-14**],
the patient has taken a somewhat better inspiration and the
atelectatic changes at the bases have decreased. Some
costophrenic angle filling posteriorly suggests small pleural
effusions. Dobbhoff tube remains in place. Specifically, no
evidence of acute pneumonia.
[**2116-12-18**] 06:30AM BLOOD WBC-7.9 RBC-2.87* Hgb-9.6* Hct-28.3*
MCV-99* MCH-33.4* MCHC-33.9 RDW-17.4* Plt Ct-342
[**2116-12-16**] 07:55AM BLOOD Neuts-71.7* Lymphs-18.2 Monos-6.8 Eos-2.6
Baso-0.7
[**2116-12-16**] 07:55AM BLOOD PT-14.0* PTT-27.2 INR(PT)-1.2*
[**2116-12-18**] 06:30AM BLOOD Glucose-108* UreaN-6 Creat-0.6 Na-143
K-4.3 Cl-105 HCO3-33* AnGap-9
[**2116-12-16**] 07:55AM BLOOD ALT-52* AST-88* LD(LDH)-358* AlkPhos-120*
TotBili-0.2
[**2116-12-16**] 07:55AM BLOOD calTIBC-157* VitB12-767 Folate-17.4
Ferritn-334* TRF-121*
[**2116-12-13**] 10:05PM BLOOD TSH-0.069*
[**2116-12-15**] 01:17AM BLOOD Free T4-0.89*
[**2116-12-14**] 12:13AM BLOOD Type-ART pO2-84* pCO2-37 pH-7.46*
calTCO2-27
[**2116-12-14**] 12:13AM BLOOD Lactate-1.5
Brief Hospital Course:
74 year-old female with pancreatic cancer metastatic to her
liver and possibly lung, GBS 5 years ago after a flu shot,
hypertension, and hyperlipidemia who intially presented to an
OSH with a fever after chemotherapy and was found to have
pneumonia and E. coli UTI, and then was transferred to [**Hospital1 18**] for
neurological evaluation for lower extremity weakness. Hospital
course was as follows.
NeuroICU course:
Her neurologic examination on admission was notable for marked
inattention, which further limited detailed motor and sensory
testing; however, she was able to hold her legs antigravity.
Neurologic exam the morning after her admission showed [**3-2**]
strength in the IPs, [**4-3**] in the deltoids and quads, and 5-/5- in
all other muscle groups. She was areflexic, but this was
documented in previous neurology notes from [**2116-8-31**]. Her
inattention was thought to be due to toxic metabolic
encephalopathy, likely due to her underlying pneumonia and UTI.
It was determined that GBS was not the cause of her symptoms,
and her encephalopathy improved by the second day (oriented to
person, place, and date). Head CT showed no evidence of
infarction, hemorrhage, of mass effect. Ammonia 10, ALT 13/AST
31, LDH 489, AP 166, T bili 0.3, alb 2.5, INR 1.6, amylase
14/lipase 8, TSH 0.069, T4 6.0; free T4 0.89. She was continued
on ASA 325 mg daily, Amlodipine 5 mg daily, and Levothyroxine 75
mcg daily. Her PNA and UTI were treated with CTX and
azithromycin. The medicine team was consulted for her PNA and
UTI, and the patient was called out to the medicine floor with
neurology following.
Medicine course:
On arrival to medicine floor, patient appeared well. Her
breathing felt improved over her baseline and she felt stronger
than when she arrived initially. Her active issues included
resolving mental status changes, ?RUL PNA (sat's 98% on 60%FM,
apparently baseline O2 sat in low 90's), UTI, and climbing WBC
(12) on antibiotics. As above, the patient's weakness was
thought to be secondary toxic metabolic encephalopathy; she
continued to improve on antibiotics for treatment of UTI and
community acquired pneumonia. Patient completed a 5 day course
of azithromycin and 7 day course of ceftriaxone. Blood cultures
remained no growth to date of discharge, and patient was unable
to provide sputum specimen. Leukcytosis resolved. Concurrently
the patient's hypoxia also improved. Of note, patient has
history of COPD with baseline sats in the low 90's. She was
initially kept on standing albuterol and ipratropium nebulizer
treatments. Patient worked with physical therapy as well. On day
of discharge, patient was satting at baseline at rest but
requiring oxygen (1 to 2 liters) with ambulation. Remained of
care was as follows.
- Hypertension: Continued antihypertensives per home regimen.
- Hypothyroidism: TSH, FT4 low. Given acute illness, no changes
to medication regimen were made. Patient will require recheck of
TFTs as outpatient.
- Anemia: Hematocrit slightly lower than baseline on admission.
B12 and folate normal. Labs consistent with anemia of chronic
disease. Continued folate, iron per home regimen.
- GERD: Continued omeprazole per home regimen.
- Hyperglycemia: Patient was started on metformin for
persistently elevated blood glucose. Blood glucose should be
checked at rehab facility and hypoglycemics titrated as needed.
- Nutrition: Patient required Dobhoff for short duration in
neuroICU. On medicine floor, she was evaluated by speech therapy
and was found to be able to take regular food and thin liquids
without problem.
**Code status: DNR/DNI
**Communication: [**Name (NI) **] [**Name (NI) **] (husband), ([**Telephone/Fax (1) 79756**]
Medications on Admission:
Medications on Transfer:
Amlodipine 5mg daily
ASA 325mg daily
Azithromycin 500mg daily (day 1 is ??)
Ceftriaxone 1gram IV daily (day 1 is ??)
Carbamazepine 200mg [**Hospital1 **]
Folate 1mg daily
Gabapentin 600mg TID
Heparin 5000units SC TID
Synthroid 0.075mg daily
MVI
Nortriptyline 50mg QHS
Prilosec 20mg daily
Potassium Chloride 20mg PO daily
Albuterol 1puff INH Q6h
Zofran 4mg IV q6h
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Calcium 500 With D 500 (1,250)-400 mg-unit Tablet Sig: One
(1) Tablet PO once a day.
4. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO
once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 month supply* Refills:*2*
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
16. Home oxygen
1-2L oxygen by nasal cannula, continuous.
Goal is to maintain O2 sat greater than 90%.
17. Tegretol 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary:
- Toxic metabolic encephalopathy secondary to urinary tract
infection, community acquired pneumonia]
- Hyperglycemia
Secondary:
- History of [**Last Name (un) 4584**] [**Location (un) **]
- Pancreatic cancer
- Hypothyroidism
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were transferred to [**Hospital1 **] Hospital on
[**2116-12-13**] for further care of your weakness. You were
initially admitted by the neurology team, who felt that your
weakness was due to an infection in your bladder or lungs. You
were treated with antibiotics for both of these infections and
your weakness improved. You also required a feeding tube placed
temporarily. You worked with physical therapy and your strength
and coordination improved, and you will be going to a
rehabilitation facility for more physical therapy. On discharge,
you are eating and drinking well.
Your medication regimen has changed. We added a new medication,
Metformin, for better control of your blood glucose. Other than
this change, you may resume your home medications just as you
were doing prior to this hospitalization.
Please be sure to follow-up with your appointments as listed
below.
Please call your physician or return to the emergency department
for any worsening weakness, shortness of breath, fevers, or for
any other concerns.
Followup Instructions:
Someone from Dr.[**Name (NI) 60764**] office (neurology) will call you
with an appointment time. If you do not hear from them by
Monday, please give them a call at ([**Telephone/Fax (1) 79757**] on Tuesday.
Someone from your primary care physician's office will call you
early next week with an appointment date with Dr. [**First Name (STitle) **]. If you
do not hear from them on Monday, please call the office at
([**Telephone/Fax (1) 79758**].
Completed by:[**2116-12-18**]
ICD9 Codes: 486, 5990, 4019, 2449, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2051
} | Medical Text: Admission Date: [**2152-1-15**] Discharge Date: [**2152-1-21**]
Date of Birth: [**2090-1-26**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
respiratory distress, transferred from OSH
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
This is a 61 y/o male with a PMH significant for HTN and
?history of pleurisy 20+ year ago, with symptoms of dyspnea,
tachypnea, and pleuritic chest pain intermittently since [**Month (only) 359**]
of this year, who presented with acute respiratory distress 1
day ago. History is obtained primarily from the patient's
family due to patient's respiratory status and lack of records:
.
The patient is generally a healthy male with only HTN who began
having pulmonary symptoms back in [**Month (only) 359**] of this year. Per his
wife, the patient was having intermittent dyspnea with exertion
and at rest with pleuritic chest pain. No orthopnea, PND. In
addition, he has intermittent fevers with temps up to 101.4 with
his symptoms - no night sweats. No cough, hemoptysis, URI
symptoms. No recent known sick contacts. [**Name (NI) **] saw his PCP for
these symptoms and was tried on at least 2 course of antibiotics
with minimal improvement. In addition, he saw a pulmonologist
as well, and was told that his symptoms may be secondary to an
"allergy" exposure. He has had several CXRs and CT scans which
reportedly "did not show anything bad." He had a negative PPD 1
month ago and has had no exposures to TB or other agents that
the family is aware of. Between his episodes of symptoms, he
would feel well back to his baseline and was back to his
baseline state of health for 3-4 weeks prior to this
presentation. He recently traveled to [**State 4260**] for a business trip
and returned late Wednesday night (3 days PTA) and was feeling
well until yesterday (Friday) morning when he began having
symptoms of dyspnea and pleuritic chest pain again. This
occured while he was at work and he was noted to appear very ill
by his secretary, who called EMS. The patient also reported
symptoms of nausea and dizzness at the time of his respiratory
distress. He was taken to [**Hospital6 17032**] by EMS.
.
At the OSH, initial VS were T 97.3, BP 97/50, HR 60, RR 28-30,
SaO2 100%/2L. The patient was dyspneic but able to speak
complete sentences per the family. He became progressively
tachypneic into the 50's and diaphoretic, unable to complete
full sentences. A CXR by report demonstrated "multiple opacities
in the right lung field and RLL infiltrate." An initial ABG was
7.46/28/36 on 2 L NC. Per report, a CT (?CTA) of the chest
showed bilateral infiltrates. He spiked to 101.6 around 9pm at
the OSH. He received 750 mg IV levaquin, 2 gm IV Rocephin, and
60 mg IV solumedrol q6 hours. He also received IV morphine and
ativan. During his ED course, he became progressively dyspneic
and tachypneic, and was feeling more fatigued. A repeat CXR per
report showed worsening bilateral infiltrates. The patient was
intubated subsequently for hypoxic respiratory distress around 3
am [**2152-1-15**] on settings AC 500x14, FiO2 100%, PEEP 10 with PIP's
28-30. He was then transferred to [**Hospital1 18**] for further management.
.
Upon arrival to the MICU, the patient was intubated and sedated.
A left IJ CVL was placed and a right A-line was placed. He was
briefly on peripheral dopamine for hypotension (SBP 80's) in the
setting of increased sedation while intubated.
.
ROS - No URI sx, cough, hemoptysis, chest pain (except for the
pleuritic chest pain at the time of symptoms), n/v/abdominal
pain, diarrhea, blood in stools, dysuria, hematuria, edema.
+40-lb weight loss since Septemeber intentionally. No changes in
appetite. No early satiety. No skin changes. +frequent travels
to the East Coast and Midwest for business.
Past Medical History:
HTN
?pleurisy 20 years ago
Social History:
Lives at home with his wife in [**Name (NI) 8117**], [**Name (NI) **] for 22 years,
previously lived in [**State 2690**] 22 years ago for 12 years. Works as a
salesman in a plastics plant, and travels frequently for
business (3-4x/month) mainly in the midwest ([**Location (un) **], [**State **]) and
east coast. No international travel. Was never incarcerated.
Has no history of tobacco use. Occasional to rare EtOH only.
No illicit drug use.
Family History:
Father (deceased) - HTN, colon CA, MI at age 80, renal CA
Mother (deceased) - [**Name (NI) 2481**]
Children healthy
One sibling with asthma
Physical Exam:
VS: Tc 97.6, BP 89-104/50-54, HR 70, RR 20-21, AC 500x14, FiO2
60%, PEEP 10, SaO2 97%
General: Intubated, sedated
HEENT: NC/AT, PERRL. ETT in place.
Neck: supple, + L IJ CVL; difficult to appreciate JVD
Chest: minimal BS at the bases, no wheezes or crackles
CV: distant heart sounds, RRR no m/g/r
Abd: soft, obese, NT, NABS
Ext: no c/c/e, wwp - ?deformity of left ankle
Neuro: sedated, intubated. Not following commands
Skin: no rashes noted
Pertinent Results:
[**1-14**] OSH:
WBC 3.2, Hct 46.2, Plts 180, diff N44, B42, L11
BNP 69.6
Na 140, K 3.1, Cl 109, HCO3 25, BUN 21, Cr 1.0, Ca 8.6
TP 6.4, Albumin 3.6, Tbili 1.3, ASA 21, ALT 26, Alk P 53
CK 78, Trop <0.04
PT 13, PTT 25.5, INR 1.1
.
IMAGING - OSH CT reviewed in detail with radiology: Diffuse
airspace disease, with less involvement of the anterior
segments; no PE appreciated; 1 calcified granuloma in the RUL;
no emphysematous changes
.
[**1-14**] EKG at OSH - Sinus bradycardia at 58 bpm. Slightly
prolonged PR interval. LAD. No ischemic ST or T wave changes
noted. No prior for comparison.
.
[**1-17**] CT chest:
Endotracheal tube terminates just above the thoracic inlet
level, approximately 7 cm above the carina. Nasogastric tube
terminates in the stomach, and a left internal jugular catheter
terminates in the left brachiocephalic vein.
Within the lungs, dependent areas of consolidation are present
within both lower lobes, and a gradient of ground-glass
attenuation is present in the remainder of the lungs, more
prominent posteriorly with relative sparing of the most
nondependent anterior portions of the lungs. Specifically, there
are no areas of consolidation within the least dependent
portions of the lungs. Central airways are remarkable for
retained secretions within the right main, right upper lobe, and
bronchus intermedius. Incidental note is made of a calcified
granuloma in the right upper lobe with associated calcified
lymph nodes in the right paratracheal and right hilar regions.
Slightly prominent noncalcified lymph nodes are present within
the subcarinal region. Heart size is normal. Coronary artery
calcifications are present. No pericardial or substantial
pleural effusions are identified.
Examination was not specifically tailored to evaluate the
subdiaphragmatic region, but adrenal glands are well visualized
and normal in appearance. High attenuation is present within the
gallbladder, possibly due to vicarious excretion if the patient
has had recent intravenous contrast-enhanced study (no contrast
given for this examination).
Skeletal structures demonstrate no suspicious lytic or blastic
skeletal lesions.
IMPRESSION:
1. Lung parenchymal findings consistent with provided history of
ARDS, but coexisting infection cannot be excluded by imaging
alone.
2. Proximal position of endotracheal tube which has been
advanced since the time of the CT scan (as documented on
separate CXR).
3. High attenuation material within the gallbladder, possibly
due to vicarious excretion of contrast if the patient has
received recent contrast administration. In the absence of
contrast administration, this may represent high attenuation
sludge. Gallbladder ultrasound could be considered if warranted
clinically.
.
Echo [**1-17**]:
The left atrium is elongated. 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 systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
61 y/o male with HTN, recent symptoms of intermittent DOE and
pleuritic chest pain x 2 months, now with acute respiratory
failure.
.
# Respiratory distress - hypoxic in nature, acute on chronic
distress with findings suggestive of ARDS. Intubated at OSH,
changed to ARDSnet protocol. PaO2/FiO2 113 with bilateral ground
glass opacities on CT chest from OSH. Patient does not appear
volume overloaded and has a normal-sized heart on CT, BNP at
OSH<100, so less likely to be from CHF. He received an ECHO
during admission which confirmed normal cardiac function.
Potential etiologies of ARDS include infection (bacterial,
atypical, fungal, PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] no known immunocompromised
state), alveolar hemorrhage, BOOP, idiopathic ARDS,
hypersensitivity pneumonitis. He initially had ARF but resolved
rapidly with IVFs so pulmonary renal syndrome was thought to be
less likely. [**Doctor First Name **], ANCA, and anti-GBM were negative. He received
bronchoscopy and BAL which revealed PMNS and bands but only
minimal eos and no organisms. He was continued on empiric
levofloxacin and vancomycin with improvement in his
leukocytosis. His CT chest also improved, suggesting potential
infectious component. Cultures remained negative throughout
admission. Atypical pneumonia antigens were sent. He was
successfully extubated [**2152-1-19**] and has been on nasal cannula
since. He is being continued on Vancomycin and Levofloxacin for
a 7-day empiric source for nosocomial PNA, although no pathogens
have been isolated. Other cultures, including blood and urine
were negative to date. His atypical antigens were pending at
the time of discharge.
.
It is unclear what the ARDS was a result from. Review of prior
CT in [**Month (only) 359**] (at OSH), CT at OSH prior to admission here, and
CT here all demonstrate ground-glass opacities, suggestive of
ARDS. His outpatient pulmonologist, Dr. [**Last Name (STitle) **], is aware of the
admission, and the patient should follow-up with him as an
outpatient.
.
# HTN - on home regimen
.
# PPx - PPI, heparin SC
.
# Code - full
.
# Communication - wife, [**Name (NI) **] (h) [**Telephone/Fax (1) 75528**], (c)
[**Telephone/Fax (1) 75529**]; son, [**Name (NI) **] (c) [**Telephone/Fax (1) 75530**]; daughter, [**Name (NI) **]
(c) [**Telephone/Fax (1) 75531**]
Medications on Admission:
Norvasc 5 mg daily
Atenolol 50 mg daily
HCTZ 25 mg daily
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
showhegan vna
Discharge Diagnosis:
Primary -
Hypoxic respiratory distress
ARDS
Secondary -
HTN
Discharge Condition:
Stable, O2 sats mid 90s on room air and with ambulation
Discharge Instructions:
You were admitted with respiratory failure of unclear etiology.
You were treated with antibiotics for 7 days and improved
significantly. Please follow-up with your pulmonologist and PCP
[**Last Name (NamePattern4) **] [**2-9**] weeks for follow-up, as it is still not clear what caused
your symptoms. You should have a repeat CT of the chest in [**3-14**]
weeks to assess for changes.
Please continue your home medications as prescribed.
Followup Instructions:
Please follow-up with your PCP and pulmonologist in [**2-9**] weeks.
ICD9 Codes: 486, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2052
} | Medical Text: Admission Date: [**2198-3-29**] Discharge Date: [**2198-4-4**]
Date of Birth: [**2143-8-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Found unresponsive
Major Surgical or Invasive Procedure:
Mechanical ventilation
Intubation
History of Present Illness:
Mr. [**Known firstname 85836**] [**Known lastname 1005**] is a 54 yo man with a history of DM,
polysubstance abuse, HCV, liver cirrhosis, and gastric ulcer who
was BIBA to [**Hospital3 **] ED after being found unresponsive on his
bed by his roommate with needles scattered around him. He had
not been seen for 2 days. EMS was called and administered
Narcan on arrival with with minimal improvement.
At [**Hospital3 **], the pt was febrile to 105.4, for which he
received tylenol. He was again given narcan without improvement
so was intubated. On AC with 400/20/5/100%, ABG was
7.29/27/463. WBC 18.4 (83%N), Hct 39.5. Na 150, K 5.6, Cl 117,
HCO3 14, BUN 76, Cr 3.1, anion gap 27. AST 101, ALT 38, AP 112,
TB 1.8. CK 2431, CK-MB 9.5, Trop 1.98 (nl <0.3). U/A with
[**10-27**] WBC and RBC, 3+ bact, + epis, ketones, [**1-12**] hyaline casts.
Tox screen was neg. EKG without peaked T waves, ST dep in
lateral leads, old q waves in inferior leads. CT head neg but
could not exclude mild cerebral edema due to motion artifact.
CXR with question of RML infiltrate, and as there was concern
for meningitis given his AMS, he was given vancomycin 1gm,
ceftriaxone 2gm. He received a total of 4L NS IVF.
In our ED, initial VS were: T 101, P 131, BP 119/65, R 48, O2
sat 100% on AC 760/?/5/100%. ABG 7.25/33/81/15. FSG 128. Pt
was not sedated but was minimally responsive to painful stimuli.
Pupils reactive. BS rhonchorous b/l. No e/o trauma. Noted to
have melena; OG tube here without any hematemesis. Lactate 4.6.
WBC 22.6. Bcx drawn. CXR without obvious infiltrate but
question of R paratracheal stripe. An LP was not done because
of INR 3. Patient was given tylenol 650mg pr and abx coverage
broadened to metronidazole 500mg IV and cefepime for pseudomonal
coverage. He received 1 L NS. On transfer to MICU, VS: T 101
(rectal), P 134, BP 112/70, RR 47, O2sat 100% on vent, CPAP
15/5, FiO2 100%.
Review of OSH records shows that pt was admitted from [**Date range (1) 85837**]
for LLE cellulitis and hematoma d/t trauma from fall; no acute
fractures. During that hospital course, he did have a work-up
for abdominal pain. CT abd ruled out pancreatitis with an
abnormal duodenal finding; EGD showed severe duodenitis and
small esophageal varices. He was started on pantoprazole 40mg
[**Hospital1 **]. There were concerns about drug-seeking behavior although
pt was discharged with 30 tabs of oxycodone due to recent
trauma.
Review of systems: Unable to elicit
Past Medical History:
(Per OSH records; daughter confirms diabetes and "liver disease"
as well as addictions to alcohol, heroin and possible meth)
DM
GERD
Left leg cellulitits
Left leg ecchymosis/hematoma
Thrombocytopenia
Hepatitis C
Hepatic cirrhosis c/b encephalopathy, small gastric varices
Polysubstance abuse
H/o anasarca
Stasis dermatitis
Gastric ulcer (biopsy from EGD on [**2198-3-23**] negative for stain for
H. pylori)
Social History:
Unable to elicit from patient. Has two adult daughters who live
in [**Name (NI) 74122**], PA as well as a son in [**Name2 (NI) **] who is in jail. Daughter
[**Name (NI) 50269**] can be contact[**Name (NI) **] at [**Telephone/Fax (1) 85838**] (home), [**Telephone/Fax (1) 85839**]
(cell), or [**Telephone/Fax (1) 85840**] (cell) Lives with a roommate (contact
info unknown). Not currently employed. Polysubstance abuse
history including alcohol and heroin, possibly other drugs as
well per daughter.
Family History:
Unknown
Physical Exam:
Vitals: T 99.7, P 133, BP 124/71, RR 48, O2sat 99 on PS 10/5
General: Obtunded, tachypneic, using accessory muscles of
respiration
HEENT: Sclera anicteric, intubated, +OG tube
Neck: Supple, JVP not elevated, no LAD
Lungs: Coarse rhonchi b/l
CV: Tachycardic, regular rhythm, normal S1 + S2, unable to
appreciate m/r/g
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: Warm, well perfused, 2+ pulses, venous
Neuro: Pupils reactive b/l, unable to elicit corneal/gag
reflexes or cough w/ suctioning, nl tone, no asterixis, small
withdrawal to pain in all extremities except LUE, pronating
response to DTR, toes equivocal (?upgoing on left) to Babinski.
Pertinent Results:
LABS ON ADMISSION:
[**2198-3-29**] 01:25AM URINE EOS-NEGATIVE
[**2198-3-29**] 01:25AM URINE RBC-[**2-9**]* WBC-[**5-17**]* BACTERIA-FEW
YEAST-NONE EPI-0-2 TRANS EPI-0-2
[**2198-3-29**] 01:25AM URINE BLOOD-LG NITRITE-NEG PROTEIN-150
GLUCOSE-100 KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2198-3-29**] 01:25AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2198-3-29**] 01:25AM FIBRINOGE-215
[**2198-3-29**] 01:25AM PT-30.3* PTT-50.1* INR(PT)-3.0*
[**2198-3-29**] 01:25AM PLT COUNT-69*
[**2198-3-29**] 01:25AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL BURR-1+ TEARDROP-OCCASIONAL BITE-OCCASIONAL
[**2198-3-29**] 01:25AM NEUTS-92* BANDS-1 LYMPHS-3* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2198-3-29**] 01:25AM WBC-22.6* RBC-3.53* HGB-10.7* HCT-32.8*
MCV-93 MCH-30.5 MCHC-32.8 RDW-17.8*
[**2198-3-29**] 01:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2198-3-29**] 01:25AM URINE GR HOLD-HOLD
[**2198-3-29**] 01:25AM URINE OSMOLAL-460
[**2198-3-29**] 01:25AM URINE HOURS-RANDOM
[**2198-3-29**] 01:25AM URINE HOURS-RANDOM UREA N-471 CREAT-108
SODIUM-19 PROT/CREA-2.0*
[**2198-3-29**] 01:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2198-3-29**] 01:25AM PEP-AWAITING F IgG-1430 IgA-728* IgM-151
[**2198-3-29**] 01:25AM TSH-0.57
[**2198-3-29**] 01:25AM OSMOLAL-346*
[**2198-3-29**] 01:25AM calTIBC-224* VIT B12-GREATER TH
FOLATE-GREATER TH HAPTOGLOB-<5* FERRITIN-585* TRF-172*
[**2198-3-29**] 01:25AM TOT PROT-5.6* ALBUMIN-2.4* GLOBULIN-3.2
CALCIUM-7.5* PHOSPHATE-5.3* MAGNESIUM-1.8 IRON-53
[**2198-3-29**] 01:25AM CK-MB-17* MB INDX-0.6 cTropnT-0.26
[**2198-3-29**] 01:25AM LIPASE-47
[**2198-3-29**] 01:25AM ALT(SGPT)-55* AST(SGOT)-231* LD(LDH)-684*
CK(CPK)-2749* ALK PHOS-95 TOT BILI-1.3
[**2198-3-29**] 01:25AM estGFR-Using this
[**2198-3-29**] 01:25AM GLUCOSE-109* UREA N-77* CREAT-3.1*
SODIUM-154* POTASSIUM-3.9 CHLORIDE-126* TOTAL CO2-11* ANION
GAP-21*
[**2198-3-29**] 01:34AM LACTATE-4.6*
[**2198-3-29**] 01:34AM TYPE-ART TEMP-40.0 RATES-/50 TIDAL VOL-760
PEEP-5 O2-100 PO2-81* PCO2-33* PH-7.25* TOTAL CO2-15* BASE
XS--11 AADO2-613 REQ O2-98 INTUBATED-INTUBATED VENT-SPONTANEOU
[**2198-3-29**] 02:55AM RET MAN-4.2*
[**2198-3-29**] 02:55AM FDP-40-80*
[**2198-3-29**] 02:55AM HCT-32.0*
[**2198-3-29**] 02:55AM AMMONIA-20
[**2198-3-29**] 03:47AM TYPE-ART TEMP-37.3 RATES-/47 TIDAL VOL-640
PEEP-5 O2-90 PO2-497* PCO2-22* PH-7.34* TOTAL CO2-12* BASE
XS--11 AADO2-135 REQ O2-32 INTUBATED-INTUBATED VENT-SPONTANEOU
[**2198-3-29**] 07:44AM PT-31.7* PTT-45.7* INR(PT)-3.2*
[**2198-3-29**] 07:44AM PLT COUNT-45*
[**2198-3-29**] 07:44AM WBC-15.7* RBC-3.16* HGB-9.9* HCT-29.7* MCV-94
MCH-31.2 MCHC-33.2 RDW-18.0*
[**2198-3-29**] 07:44AM CALCIUM-7.8* PHOSPHATE-6.8* MAGNESIUM-1.7
[**2198-3-29**] 07:44AM CK-MB-26* MB INDX-1.0 cTropnT-0.20*
[**2198-3-29**] 07:44AM CK(CPK)-2698*
[**2198-3-29**] 07:44AM GLUCOSE-201* UREA N-85* CREAT-3.9*
SODIUM-150* POTASSIUM-4.4 CHLORIDE-122* TOTAL CO2-9* ANION
GAP-23*
[**2198-3-29**] 08:00AM LACTATE-6.2*
[**2198-3-29**] 08:00AM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2198-3-29**] 11:45AM PLT COUNT-50*
[**2198-3-29**] 12:05PM LACTATE-6.0*
[**2198-3-29**] 12:05PM TYPE-[**Last Name (un) **] TEMP-38.1 PO2-263* PCO2-20* PH-7.34*
TOTAL CO2-11* BASE XS--12 INTUBATED-INTUBATED VENT-CONTROLLED
[**2198-3-29**] 02:34PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-476*
POLYS-18 LYMPHS-35 MONOS-47
[**2198-3-29**] 04:41PM FIBRINOGE-184
[**2198-3-29**] 04:41PM PT-24.6* PTT-42.0* INR(PT)-2.4*
[**2198-3-29**] 04:42PM PLT COUNT-42*
[**2198-3-29**] 04:42PM HCT-24.4*
[**2198-3-29**] 04:42PM CALCIUM-7.5* PHOSPHATE-4.8*# MAGNESIUM-1.8
[**2198-3-29**] 04:42PM CK(CPK)-1838*
[**2198-3-29**] 04:42PM GLUCOSE-368* UREA N-89* CREAT-4.1* SODIUM-144
POTASSIUM-3.1* CHLORIDE-116* TOTAL CO2-14* ANION GAP-17
[**2198-3-29**] 04:54PM O2 SAT-99
[**2198-3-29**] 04:54PM LACTATE-4.7*
[**2198-3-29**] 04:54PM TYPE-ART PO2-141* PCO2-22* PH-7.51* TOTAL
CO2-18* BASE XS--2
[**2198-3-29**] 08:15PM PT-26.2* PTT-40.8* INR(PT)-2.5*
[**2198-3-29**] 08:15PM PLT COUNT-36*
[**2198-3-29**] 08:15PM HCT-24.3*
[**2198-3-29**] 08:15PM CALCIUM-7.4* PHOSPHATE-4.4 MAGNESIUM-1.8
[**2198-3-29**] 08:15PM CK(CPK)-1608*
[**2198-3-29**] 08:15PM GLUCOSE-264* UREA N-89* CREAT-4.2* SODIUM-144
POTASSIUM-3.2* CHLORIDE-116* TOTAL CO2-17* ANION GAP-14
========
MICROBIOLOGY:
- [**2198-3-29**] Blood culture - PENDING **
- [**2198-3-29**] Blood culture - PENDING **
- [**2198-3-29**] Blood culture - PENDING **
- [**2198-3-29**] MRSA screen - no MRSA isolates
- [**2198-3-29**] Urine culture - no growth
- [**2198-3-29**] Urine legionella antigen - negative
- [**2198-3-29**] RPR - non-reactive
- [**2198-3-29**] CSF: gram stain - negative; culture - no growth; viral
culture - PENDING **
- [**2198-3-30**] Sputum: > 25 PMNs, < 10 epithelial cells, 1+ GPC in
pairs/chains; culture: ESCHERICHIA COLI - sensitivities:
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
- [**2198-3-30**] Bacterial stool studies (incl. Yersinia, E. coli) -
negative
- [**2198-3-30**] C. difficile toxin - negative
- [**2198-3-31**] Urine culture - negative, final
- [**2198-3-31**] Sputum: > 25 PMNs, < 10 epithelial cells, no
microorganisms; culture - Gram negative rods, sparse
- [**2198-3-31**] Blood culture - PENDING, no growth to date
- [**2198-3-31**] Blood culture - PENDING, no growth to date
========
IMAGES/STUDIES:
- [**2198-3-29**] ECG: Sinus tachycardia and respiratory variation in
QRS complex suggesting dyspnea. No previous tracing available
for comparison.
- [**2198-3-29**] ECG: Sinus tachycardia. Compared to the previous
tracing of [**2198-3-29**] no diagnostic interim change.
- [**2198-3-29**] CXR portable: SINGLE FRONTAL PORTABLE CHEST
RADIOGRAPH: The endotracheal tube terminates approximately 5.8
cm above the carina. The NG tube terminates in the first portion
of the duodenum. There is appearance of widening of upper
mediastinum, likely secondary to mediastinal lipomatosis. The
lungs are clear. There is no pneumothorax or pleural effusions.
The cardiac silhouette is normal. The hilar contour and
pulmonary vasculature are within normal limits. The underlying
osseous structures are normal. A rounded lucency in the right
lateral lung is likely atelectasis. There is no radiographic
evidence of acute displaced rib fracture. IMPRESSION: No
pneumothorax or pleural effusion. No acute displaced rib
fracture. Recommend follow-up with upright view to better assess
the mediastinum when the patient can tolerate it.
- [**2198-3-29**] Liver/GB ultrasound: FINDINGS: The liver is coarsened
and echogenic, consistent with cirrhosis. There are no focal
lesions and there is no biliary dilatation. The common duct
measures 5.5 mm at the porta hepatis. The gallbladder is
unremarkable, without shadowing stones or sludge. The main
portal vein is patent, with normal direction of flow. The
pancreas is not visualized due to overlying bowel gas. The
spleen is enlarged, measuring 17.1 cm. The right kidney measures
12.0 cm, and the left kidney measures 13.1 cm. The kidneys are
unremarkable bilaterally, without focal lesion or
hydronephrosis. There is no ascites. The visualized abdominal
aorta and IVC are unremarkable. There is loculated fluid in the
anterior right pleural space. IMPRESSION: 1. Cirrhosis, without
focal lesion. 2. Splenomegaly. 3. Loculated fluid in the
anterior right pleural cavity.
- [**2198-3-30**] TTE: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). There is a
trivial/physiologic pericardial effusion. No vegetation seen
(cannot definitively exclude).
- [**2198-3-30**] ECG: Normal sinus rhythm. Diffuse T wave flattening
throughout the tracing. Compared to the previous tracing of
[**2198-3-29**] patient's rhythm has changed from sinus tachycardia at a
rate of 132 to normal sinus rhythm at a rate of 72. Diffuse T
wave flattening is more prominent on this tracing. Consider
electrolyte abnormality.
- [**2198-3-30**] CXR portable: SINGLE PORTABLE CHEST RADIOGRAPH:
Retrocardiac opacity, new since one day prior, most likely
represents atelectasis and less likely pneumonia. Also new is a
small left pleural effusion. The right lung is clear. Mild
cardiomegaly is unchanged. Fullness of central vascular markings
is suggestive of mild volume overload or cardiac decompensation.
There is no pneumothorax. Tubes and lines are in stable
positions since one day prior. IMPRESSION: 1. New left lower
lobe atelectasis, less likely pneumonia. 2. New small left
pleural effusion. 3. Mild volume overload versus cardiac
decompensation.
- [**2198-3-31**] EEG: Report PENDING **
- [**2198-3-31**] CXR portable:FINDINGS: As compared to the previous
radiograph, there is minimal improvement with partial resolution
of the pre-existing left retrocardiac atelectasis. Overall, the
ventilation of the lung parenchyma has slightly improved.
Unchanged size of the cardiac silhouette. No focal parenchymal
opacity suggesting pneumonia. No larger pleural effusions. No
pneumothorax. The size of the cardiac silhouette is at the upper
range of normal.
- [**2198-4-1**] EEG: Report PENDING **
- [**2198-4-1**] CXR portable: FINDINGS: As compared to the previous
radiograph, the three monitoring and support devices are in
unchanged position. Unchanged borderline size of the cardiac
silhouette without evidence of pulmonary edema. The pre-existing
retrocardiac atelectasis has mostly resolved. No evidence of
newly appeared focal parenchymal opacities suggesting pneumonia.
No pleural effusions.
- [**2198-4-2**] EEG: Report PENDING **
- [**2198-4-2**] CXR portable: As compared to the previous radiograph,
there is no relevant change. The monitoring and support devices
are in unchanged position. Unchanged size of the cardiac
silhouette, unchanged absence of focal parenchymal opacities
suggesting pneumonia. No visualization of pleural effusions.
- [**2198-4-3**]: FINDINGS: In comparison with the study of [**4-2**], the
monitoring and support devices remain in place. Some
indistinctness of pulmonary vessels raises the possibility of
elevated pulmonary venous pressure. No evidence of acute focal
pneumonia or pleural effusion.
-MRI ([**4-2**]): IMPRESSION:
1. Diffuse bilateral subacute ischemic changes consistent with a
global
anoxic brain injury.
2. Sinus and mastoid disease as described above, the activity of
which is to be determined clinically.
3. Old left frontal lobe infarction.
------
Brief Hospital Course:
51 yo man with a h/o diabetes mellitus II, polysubstance abuse
(alcohol and heroin), HCV, cirrhosis, small esophageal varices,
duodenitis/gastritis presenting with unresponsiveness.
# Unresponsiveness, most likely from anoxic brain injury: The
patient was found unresponsive, intubated at OSH ED for airway
protection. There was concern for intoxication given finding of
needles but tox screens negative. Pt also recently discharged
with short course oxycodone despite concerns of drug seeking
behavior; pupils noted to be pinpoint by EMS but minimal
response to Narcan. Given IV drug use, concern that pt may have
endocarditis with embolic showering, though TTE negative and no
acute intracranial event seen on OSH CT head. The patient was
started on Vancomycin and cefepime for treatment of possible
meningitis, though lumbar puncture was not indicative of a CNS
infection. Metabolic reasons for unresponsiveness included
hepatic encephalopathy, hypernatremia, hyperglycemia, and
low-grade uremia which were all treated. B12, TSH and RPR were
normal. Neurology consulted on the patient and diagnosed him
with anoxic brain injury likely due to hypotension and later
confirmed through a MRI. Prior to extubation, the patient seemed
more responsive. He was extubated and able to understand
commands with limited verbalization. His speech sounded
dysarthric.
# Respiratory failure: The patient required intubation and
mechanical ventilation for inability to protect his airway
secondary to his unresponsiveness. He was continued on pressure
support ventilation and was extubated without difficulty.
# Seizure disorder: The patient was found to have a subclinical
seizure disorder on EEG, most likely secondary to his anoxic
brain injury. The patient was started on Keppra and uptitrated
to 1000 mg [**Hospital1 **]. He was also loaded with fosphenytoin per
neurology recommendations. He will continue on Keppra and has
neurology followup. Final EEG [**Location (un) 1131**] was pending on discharge.
# E. coli pneumonia: The patient presented with fever and was
initially broadly covered with vancomycin, cefepime, acyclovir
and flagyl. Sputum culture revealed E.coli and antibiotics were
narrowed with a course of 7 days for IV cefepime.
# E. coli urinary tract infection: The patient was found to have
a E. coli UTI which was treated with 7 days of IV cefepime.
# Acute renal failure: The patient presented with a Cr to 4.9
(baseline unknown). Nephrology felt that it was most likely due
to acute tubular necrosis (secondary to pre-renal from
hypoperfusion). Rhado (CKs elevated on admission) might have
also played a role. With time, the patient's creatinine contined
to improve and he continued to produce adequate urine output.
# Upper GI bleed: The patient was noted to have black tarry,
guaiac positive stools. His EGD report from OSH was obtained
which showed small esophageal varices and gastritis/duodenitis.
Per his OG tube, he did not have active hematemesis. He was
initially started on PPI and octreotide drips. He required 4
units of pRBCs. Since he did not have any evidence of blood per
OG tube, it was concluded that he did not have a brisk bleed and
his initial bleed was likely due to his gastritis/duodenitis.
His hematocrit remained stable over the last couple days of his
hospitalization and did not need any transfusions. He will
continue on PPI. Baseline Hct unknown.
# Hypernatremia: The patient presented with hypernatremia,
likely due to decreased PO intake. The patient was started on
free water to treat his deficit. He was continued on
maintainence fluids of D5 [**12-9**] normal saline for poor PO intake.
# Type II Diabetes mellitus: The patient has a history of
diabetes mellitus. His home glipizide was held and he was
started on an insulin drip with tubefeeds due to hyperglycemia.
His insulin regimen was later switched to 18 units of humalog
[**Hospital1 **] with a sliding scale. He will likely need further titration
based on nutritional requirements.
# Anion gap metabolic acidosis: The patient presented with an
anion gap metabolic acidosis with elevated lactate. Toxic
ingestion on differential but serum tox negative and renal
consult felt that the AG metabolic acidosis was unlikely. With
IV hydration, improved renal function and treatment of
underlying issues, his anion gap metabolic acidosis improved.
# Polysubstance abuse: The patient has a history of narcotics
and alcohol abuse. It remains unclear on how his addictions
played into his clinical presentation and course. He did not
receive any benzodiazepine doses for alcohol withdrawal and he
is out of the window for any withdrawal symptoms.
# Coronary artery disease with demand ischemia: At OSH, CK,
CK-MB, and trop all elevated; EKG with ST depressions. Here, CK
remains elevated but trop improving with resolution of ST
depressions. [**Month (only) 116**] represent demand in setting of tachycardia,
exacerbated by renal failure. Possible that CK elevation may
also reflect muscle breakdown as may have been nonresponsive for
up to 2 days before being found. Echo without any wall motion
abnormalities and normal left ventricular EF>55%.
# Cirrhosis: The patient has hepatic cirrhosis complicated by
encephalopathy and small gastric varices. The etiology of his
cirrhosis is presumably hepatitis C and alcohol. Initially his
transaminases were elevated, likely due to liver hypoperfusion,
but continued to trend downward. His total bilirubin was 2.7 on
discharge. He has evidence of synthetic dynsfunction, though not
compensated. Further details pertaining to his liver disease
were not available during this hospitalization.
# Coagulopathy: The patient was noted to have an INR elevated to
3.0. He received Vitamin K with improvement. His continued
elevated INR is likely due to his underlying cirrhosis.
# Thrombocytopenia: Pt w/ history thrombocytopenia per OSH
records. Pt also with anemia but DIC unlikely with nl
fibrinogen. Probably splenic sequestration in setting of
cirrhosis.
# Hepatitis C: No current issues.
# Nutrition/fluids: Pureed diet. Fluids of D51/2 normal saline
at 75 cc/hr for maintainence while low PO intake
# Prophylaxis: DVT: pneumoboots, GI: PPI
.
# Access: Right internal jugular. Will need a PICC line for
access since IV nurse unable to find peripheral IV.
Medications on Admission:
Doxazosin 2mg qhs
Tiotropium 1 cap daily
Omeprazole 20mg daily
Lasix 40mg [**Hospital1 **]
Ipratropium/albuterol 1 puff qid
Glipizide ER 10mg [**Hospital1 **]
MVI daily
Oxycodone 15mg q6h
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-9**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
2. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. Levetiracetam 500 mg/5 mL Solution Sig: 1000 (1000) mg
Intravenous [**Hospital1 **] (2 times a day).
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for goal 3 BM daily.
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
9. Humalog 100 unit/mL Cartridge Sig: Eighteen (18) units
Subcutaneous twice a day: Hold dose when NPO.
10. Humalog 100 unit/mL Cartridge Sig: see comment Subcutaneous
at meals and bedtime: per attached sliding scale.
11. D5 %-0.45 % Sodium Chloride Parenteral Solution Sig:
Seventy Five (75) cc/hr Intravenous continuous.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
-respiratory failure
-anoxic brain injury
-acute renal failure
.
Secondary:
-upper gastrointestinal bleed
-seizure disorder not otherwise specified
-liver cirrhosis
-hepatic encephalopathy
-esophageal varices
-gastritis, duodenitis
-diabetes mellitus
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted because you were found unresponsive. You
required mechanical ventilation to help you breath. You were
found to have injuries to your brain from low oxygen and
subsequent sub-clinical seizures. You also had a problem with
your kidneys called renal failure, which started to recover at
the end of your hospitalization. You also had a pneumonia and
urinary tract infection which were treated with antibiotics.
.
Your medications have changed:
-start pantoprazole
-stop omeprazole
-stop oxycodone
-stop lasix
-stop doxazosin
-stop glipizide
-start humalog insulin
Followup Instructions:
You have the following appointments scheduled:
.
Physician: [**Name10 (NameIs) **],[**Name11 (NameIs) 4739**] MD, neurology
Date/Time: [**2198-5-9**] at 1:30 pm
Location: [**Hospital Ward Name 23**] Building, [**Location (un) **] neurology, [**Hospital1 771**], [**Location (un) 830**], [**Location (un) 86**], [**Numeric Identifier 718**]
Phone: ([**Telephone/Fax (1) 2528**]
ICD9 Codes: 5715, 2875, 2859, 5845, 2762, 2760, 5990, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2053
} | Medical Text: Admission Date: [**2131-6-7**] Discharge Date: [**2131-6-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Bright red blood in bowel movement
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 83yo female with a past medical history of CAD/CVA,
DM2, hypertension, hypercholesterolemia, chronic pain on hospice
for pain control, with abd pain x 2 days, BRBPR x 1. Initially
constipated for 1 day, then took dulcolax and now with brbpr in
stool on the day of admission. She apparently fainted while
having bm, no fall, and then vomited x 1. Denied f/c/sob.
.
In ED, + BRBPR in vault, + TTP LLQ/RLQ. CT abd performed with
results suggestive of proctocolitis, differential including
ischemic bowel vs. less likely, infectious etiology. Surgery was
consulted for possible bowel ischemia, who recommended IVF, Hct
trending and possible OR if abdominal exams worsen.
.
Past Medical History:
- CAD: s/p CABG '[**15**] (reportedly had 2 vein grafts, but unclear
anatomy) and cath at [**Name (NI) 336**] in [**3-22**] revealed severe triple vessel
disease, patent SVG to RCA, SVG to OM, SVG to D1, SVG to D2, SVG
to OM1.
- h/o multiple CVA's: residual L sided weakness. Severely
limited activity at home, with daughter providing help with all
[**Name (NI) 5669**].
- h/o seizures (last sz reportedly 1 yr ago, on keppra at home)
- DM2 x 20 yrs
- HTN
- hyperlipidemia
- hypothyroidism (on synthroid)
- arthritis
- spinal stenosis w/ chronic leg and hand pain
Social History:
Lives at home with elderly partner. Daughter helps with most
ADL. No tobacco, EtOH or illicit drugs. Retired professional
singer
Family History:
Mother died of stomach CA. Brother and sister with "heart
problems."
Physical Exam:
PHYSICAL EXAM:
Vitals: Tm 99.0 P 64 BP 154/72 R [**12-7**] 100%ra I/O- 1.6/1.5
General: Anxious appearing, but NAD
HEENT: AT/NC, PERRL, EOMI, anicteric. OP clear, MM dry.
Neck: no LAD. JVP at 5cm. Neck supple. EJ in place, c/d/i
Lungs: CTAB no w/r/r
Heart: RRR no m/r/g +S3
Abd: soft, ND, mild ttp LLQ, no rebound/guarding
Ext: no e/c/c. warm and well perfused. 2+ DP pulses.
Neuro: CN II-XII in tact bilaterally. Mild [**3-22**] LUE weakness, hip
flexors LLE [**3-22**], plantarflexion on L [**4-21**]. Right [**4-21**].
Pertinent Results:
Pt. had a spike in WBC to 17.9 with a left shift on [**6-7**] which
subsequently decreased to 12.0 on discharge with resolution of L
shift.
.
Upon admission ([**6-6**]), BUN/Creat were elevated to 31/1.5 which
subsequently decreased with treatment to normal limits (9/0.7).
Potassium on [**6-6**] was 8.5 and decreased to normal limits by
discharge.
.
Troponin-T ranged from 0.17 to 0.10.
.
Stool studies showed WBCs, but was negative for all of the
following: C.dif, O+P, Salmonella and Shigella.
.
Urine cx showed no growth, blood cx: ******
.
EKG ([**6-13**])Atrial fibrillation, average ventricular response 116.
Since [**2131-6-11**] atrial fibrillation is now seen. The inferior T
wave inversions are
less prominent. The Q-T interval is shortened. Increased ST-T
wave abnormalities are noted
.
CXR: ([**6-6**])IMPRESSION: No acute cardiopulmonary process.
.
CTA Head ([**6-12**]):
IMPRESSION:
1) Occlusion of the entire visualized superior left internal
carotid artery and left middle cerebral artery. The left
anterior cerebral artery is supplied from the right via the
ACOM. Obscuration of the left putamen
consistent with evolving left MCA infarction. No evidence of
acute
intracranial hemorrhage or hemorrhagic transformation. Findings
discussed
immediately with the neurology team, and an MRA with Gadolinium
of the neck was suggested to evaluate the more proximal carotid
system.
2) Short segment stenosis of the left posterior cerebral artery.
3) Scattered chronic small vessel ischemic disease in the white
matter and
chronic right thalamic lacune.
.
MRA/MRI Head/Neck ([**6-12**]):
IMPRESSION:
1) Evolving infarction involving the left putamen, caudate body,
corona
radiata, and medial aspect of the left temporal lobe.
2) Occlusion of the distal left cervical ICA, with two probable
areas of high-grade stenosis in the proximal left cervical ICA,
though the latter would be far better assessed with a gadolinium
enhanced study, and if the patient is able to tolerate such, a
repeat study with gadolinium is recommended.
.
Echocardiogram ([**6-14**]):Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with basal inferior and
inferolateral hypokinesis. There is normal systolic function of
the remaining segments. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild regional left ventricular systolic dysfunction.
Moderate-to-severe mitral regurgitation. Moderate pulmonary
hypertension.
.
Compared with the prior study (images reviewed) of [**2130-12-12**],
mitral
regurgitation severity has increased and pulmonary pressures are
higher. The other findings are similar.
.
CT Abdomen/Pelvis:
IMPRESSION:
1. Uniform, circumferential bowel wall thickening involving the
descending colon, sigmoid and rectum, concerning for an
inflammatory or infectious etiology. Rectal involvement make
ischemic etiology less likely.
2. Multiple hypodensities within the kidneys, too small to
characterize.
Brief Hospital Course:
The patient was initially admitted to the MICU for monitoring of
BRBPR. Her HCT fell from 42.8-- 34-- 29 over 20 hours (baseline
28-32). The patient was evaluated by GI and felt to have an
ischemic vs. infectious proctocolitis. She was given
levo/flagyl, IV ppi, 2L LR. Kayexelate was held as the patient
was having diarrhea and no peaked t's. She remained stable
throughout her MICU course, she was given 1 unit of blood, she
remained afebrile with stable vitals and was transferred out to
the floor the following day.
.
On the floor her GI sx shortly resolved with levo/flagyl, and
her pain was adequately controlled. She had a run of atrial
fibrillation with RVR that responded to IV Diltizem and returned
to sinus. This recurred once again during her stay and again
converted to sinus after IV Dilt. and was maintained on po
metoprolol.
.
On the morning of [**6-12**] she was found to have a new right sided
facial droop and R sided hemiparesis as well as aphasia. A
stroke alert was called, the patient was given aspirin and
underwent urgent CT/CTA of the head which showed a L sided
carotid occlusion and evolving area of infarction in the L
internal capsule. There was no bleed. MRI/MRA confirmed these
findings. Due to the unclear time of onset of symptoms,
thrombolysis was not performed. In addition, due to the
patient's history of bleeding and risk of hemorrhagic
transformation of the infarction, heparin was not given.
Coumadin was started on [**6-14**] due to discovery of paroxysmal Afib
to prevent future embolic events.
.
The patient remained stable throughout the remainder of the
hospital course. Speech/swallow eval determined that she was in
fact globally aphasic, and recommended pureed foods and nectars.
On the days of discharge she was afebrile, displaying normal
vital signs (sinus rhythm) and tolerating po with assistance.
Medications on Admission:
Colace sodium 100 mg 1 cap(s) [**Hospital1 **]
Synthroid 75 mcg (0.075 mg) 1 tab(s) once a day
atenolol 25 mg 1 tab(s) once a day
aspirin 325 mg 1 tab(s) qd
roxanol 20 mg/mL .25 ml Q4H
benadryl 25 mg 1 tab(s) TID
Sarna 0.5%-0.5% as directed TID
Claritin 10 mg 1 tab(s) once a day
lactulose 10 g/15 mL 15 mL [**Hospital1 **]
Protonix 40 mg 1 tab(s) once a day
metformin 500 mg 1 tab(s) [**Hospital1 **]
Zetia 10 mg 1 tab(s) once a day
Aspirin Low Strength 81 mg 1 tab(s) once a day
Keppra 250 mg 2 tab(s) [**Hospital1 **]
simvastatin 40 mg 1 tab(s) once a day (at bedtime)
lisinopril 10 mg 1 tab(s) once a day
Morphine IR 15 mg 1 tab(s) q 12 hrs
morphine 5 mg sl q2hrs
.
Medications on transfer:
1. DiphenhydrAMINE 25 mg PO Q6H:PRN
2. Insulin SC (per Insulin Flowsheet)
3. Levofloxacin 750 mg IV Q48H
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Levetiracetam 500 mg PO BID
6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
7. Morphine Sulfate 2-4 mg IV Q6H:PRN pain in abd, legs
8. Pantoprazole 40 mg IV Q24H
9. Simvastatin 40 mg PO DAILY
10. Vancomycin 1000 mg IV Q24H
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for prn pain.
4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
5. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale
Injection ASDIR (AS DIRECTED).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) infusion Intravenous Q8H (every 8 hours) for 7 days.
13. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: One (1)
infusion Intravenous once a day for 7 days.
15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
16. Morphine 2 mg/mL Syringe Sig: Two (2) mg Injection Q4H
(every 4 hours) as needed for pain legs/abd/chest.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Infectious colitis
2. L-sided CVA (Stroke)
2. DMII
3. Chronic pain
Discharge Condition:
fair
Discharge Instructions:
You were admitted with an infection of your intestines and
placed on antibiotics. While you were in the hospital you
suffered a stroke that resulted in weakness of the right side of
your face and body.
Continue full course of antibiotics and take all other
medications as prescribed.
If your condition worsens, such as severe abdominal pain,
vomiting, bloody diarrhea contact your physician.
[**Name10 (NameIs) **] if you have any new weakness, chest pain, difficulty
breathing or palpitations seek medical care.
Continue to keep all health care appointments.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**] in
one week of discharge from your rehab facility.
Follow-up with your physician for blood work to check INR and
adjust Coumadin dose as necessary
ICD9 Codes: 5849, 2767, 4240, 2449, 4168, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2054
} | Medical Text: Admission Date: [**2130-9-11**] Discharge Date: [**2130-9-25**]
Service:HEPATOBILIARY SURGERY SERVICE
DISCHARGE DIAGNOSIS
1. Adenocarcinoma of the gallbladder.
2. Hypertension.
3. Aortic stenosis.
4. Cataracts.
CHIEF COMPLAINT: Painless jaundice.
HISTORY OF PRESENT ILLNESS: This 79-year-old female presents
on [**2130-9-11**] with painless jaundice for ten days. The patient
had felt weak with a decrease in appetite for the past three
to four weeks and had a five pound weight loss. The patient
denied any abdominal pain, no nausea, vomiting, history of
ulcer disease. The patient had an endoscopic retrograde
cholangiopancreatography on [**2130-9-6**]. Study showed
obstruction in portions above the cystic duct. The patient
also had entry of the cystic duct that was irregular
consistent with tumor brush biopsies and a 17 French stent
was placed. The patient had no diarrhea since barium for CT
scan. Denied feeling febrile or having chills. No nausea or
vomiting, some constipation, no chest pain, short of breath,
dysuria, normal bowel habits.
PAST MEDICAL HISTORY: Significant for hypertension, heart
murmur, bilateral cataracts, early menopause, right wrist
fracture in [**2096**] and aortic stenosis.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Potassium chloride 20 mEq q day.
2. Hydrochlorothiazide 25 mg q day.
3. Lipitor 10 mg q day.
4. Toprol 50 mg q day.
5. Aspirin 81 mg q day.
SOCIAL HISTORY: The patient had a history of smoking 20 pack
years, quit 29 years ago, one drink per day.
FAMILY HISTORY: No history of cancer. Mother had a stroke.
Father had a heart attack.
LABORATORY: At [**Hospital3 **] Hospital showed a total bilirubin of
40, sodium 129, potassium 2.4, chloride 95, bicarbonate 20,
the albumin was 3.6, white count 9.8, CA-199 was 26,000. The
patient had an ultrasound done also at [**Hospital3 **] Hospital
which showed positive gallstone obstruction, intrahepatic
ducts without dilated or distended common bile duct or
dilated pancreatic duct. The patient had CT which showed
calcified gallstones in the gallbladder, dilated
intra-hepatic bile ducts, no gross masses.
Chest x-ray showed chronic interstitial and chronic
obstructive pulmonary disease, bibasilar linear densities
consistent with fibrosis. An echocardiogram showed ejection
fraction of 65% Mild aortic regurg, Doppler evidence of left
ventricular diastolic dysfunction. Moderate severe calcified
aortic stenosis.
PHYSICAL EXAMINATION: The patient was afebrile with normal
vital signs. The patient was alert and oriented. Had
icteric sclera and was very jaundice. Regular rate and
rhythm with a 3/6 systolic ejection murmur. Lungs were clear
to auscultation bilaterally. Her abdomen was soft,
nontender, nondistended. There was no edema. Her
neurological exam showed cranial nerves 2 through 12 were
grossly intact and normal. She had grossly intact sensory
and motor function.
The patient was admitted as a 79-year-old female with a
questionable mass, was scheduled for percutaneous
transhepatic tubes to be placed in the morning, was made NPO,
put on intravenous fluid maintenance at 100, started on
Ampicillin and Gentamicin for on-call for the percutaneous
transluminal coronary angioplasty. The patient was scheduled
to be seen by Cardiology for cardiac workup. Cardiology
consult on the patient and recommended close hemodynamic
monitoring if surgery was needed with a Swann, no further
workup needed and to continue beta-blockade during admission.
On hospital day two, the patient was afebrile, vital signs
were stable, the patient was brought for PTC performed with
bilateral PTC drains placed. However PTC wad cancelled on
hospital day two because prior to patient being called she
spiked a temperature to 101.7. On hospital day three the
patient was brought and PTC stents were placed. The patient
tolerated the procedure well and was transferred back to the
floor, however, the patient had a T-max of 101.2, was
afebrile immediately following the procedure. The patient
was subsequently transferred to the Intensive Care Unit for a
low blood pressure and elevated temperature, the patient's
white count was 21.0 and required a Neo drip to maintain
adequate blood pressures. The patient had a significant
fluid requirement in addition however, the patient did well.
Arterial line and left subclavian line were placed to better
monitor the patient's hemodynamic status and better
facilitate resuscitation. The patient continued to be weaned
from a Neo drip in the Intensive Care Unit, blood pressures
responding well, continued to receive intravenous fluids.
White count trended down on hospital day five, post procedure
day two, the patient is on intravenous Vancomycin and Zosyn.
Her white count at this time was 7.6.
On hospital day seven the patient was transferred from
Intensive Care Unit to the floor. The patient had been
weaned from her drips and was continued to do well. The
patient continued to have a low white count, was afebrile,
continued to be jaundiced and have hypokalemia and an
elevated bilirubin but was overall hemodynamically stable.
The patient was transfused with one unit of packed red blood
cells on hospital day eight for anemia. The Vancomycin was
removed. The patient was continued on Zosyn.
On hospital day eight, Anesthesia was consulted for the
possibility of an operative candidacy for removal of possible
mass. The patient was seen by Anesthesia and was deemed to
be moderate to severe risk. The patient was continued on
intravenous antibiotics. On hospital day nine, in addition
to having hyperkalemia was found to have low albumin and TPN
was started for nutritional supplement. The patient was
started on a soft diet. The patient's bilirubin continued to
be elevated at 14.4.
On hospital day ten the patient went for cholangiogram.
Cholangiogram showed stenosis in both biliary trees. The
patient had a transient jump in temperature to 100.4 after
cholangiogram and a slight jump in her white count from 7 to
11.2. The patient however continued to remain stable.
Bilirubin also jumped from 14 to 16.7. The patient was
continued on TPN, regular diet and transitioned to oral pain
medicines.
The patient was begun on calorie counts, it was found that
the patient was receiving approximately 773 calories, it was
felt that she can continue with her TPN and calorie counting.
At this time pathology brushings were returned and it was
found that the patient had adenocarcinoma. This was
discussed with the patient and the patient's family and a
family meeting was arranged. Palliative care was also
available. The patient was met with husband and children and
discussed goals of care. The patient had understood at this
time that she had a surgically unresectable tumor and her
prognosis was three the four months. She was agreeable to
continuing with Hospice care and VNA outside the hospital.
On hospital day two, the patient was continued on TPN and
pain management as needed. The patient was begun planning
for hospice care on hospital day 15. The patient continued
to be afebrile, vital signs were stable. The patient's
laboratory showed an elevated bilirubin to 13, however, white
count was stable. The patient was comfortable in no acute
distress. The patient had explored hospice options and plan
was to discharge patient with home hospice care. The patient
will be discharged on her medicines, Atorvastatin 10 mg p.o.
q day, Percocet 1 to 2 tablets p.o. every 4 to 6 hours as
needed for pain, Actigall 300 mg tablets, one tablet by mouth
three times a day, Metoprolol 50 mg tablets half tablet by
mouth twice a day, Hydrochlorothiazide 25 mg one tablet by
mouth per day, Protonix 40 mg one tablet by mouth per day and
Ciprofloxacin 500 mg tablets, one tablet by mouth twice a day
for 14 days.
The patient will follow-up with her primary care physician
and will [**Name9 (PRE) 702**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one to two
weeks. The patient will have VNA to keep drain tubes kept
and to keep dressings around drains dry and intact. The
patient will keep a regular diet, will not have any TPN but
may supplement her diet with nutritional shakes. The
patient's post discharge services will be with Hospice care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D.
02-366
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2130-9-25**] 13:43
T: [**2130-9-25**] 15:33
JOB#: [**Job Number 50276**]
ICD9 Codes: 4241, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2055
} | Medical Text: Admission Date: [**2103-8-15**] Discharge Date: [**2103-9-1**]
Date of Birth: [**2028-4-2**] Sex: M
Service: NEUROLOGIC
CONTINUATION:
MEDICATIONS: Allopurinol 200 mg po q.d., Synthroid 75
micrograms q.d., HCTZ 25 mg q.d., Theophylline 200 mg po
b.i.d., multivitamin one po q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Mr. [**Known lastname 724**] lives with his wife and son. [**Name (NI) **]
smoked one pack per day for forty years, but quit forty years
ago. He drinks alcohol socially.
FAMILY HISTORY: Stroke in brother in his 50s. No seizures.
PHYSICAL EXAMINATION: Temperature 98.7. Blood pressure
100/60. Respiratory rate 15. Heart rate 100. SPO2 98% on
room air. General, elderly man who is arousable. Head and
neck normocephalic, atraumatic. Neck is supple. No bruits.
Cardiovascular regular rate and rhythm. Pulmonary clear to
auscultation bilaterally. Abdomen positive bowel sounds,
soft, nontender. Neurological arousable minimally. Opens
eyes to voice. Pupils are equal, round and reactive to
light. Extraocular movements are full to excursion. Fundi
appear normal bilaterally. The face is symmetric except for
a hint of right facial droop on primary position. Motor bulk
is normal. Tone in the right arm is decreased, but increased
in the right and left legs. Reflexes 1+ on the right arm and
right leg. Brisk on the left patellar. No ankle jerk
appreciated. Toes are downgoing on the left and equivocal on
the right. Reflexes, withdraws to noxious stimuli on all
four extremities.
Note that this examination is as noted by the author and is
worse then the examination noted by Dr. [**Last Name (STitle) 102587**] and [**Doctor Last Name 1004**]
previously where they show that the patient was more alert
and responsive and able to follow commands more readily with
right sided hemiparesis, but mild.
LABORATORY: White blood cell count 13, hematocrit 38.8,
platelets 307, INR 1.3, sodium 137, potassium 2.7, chloride
95, bicarb 27, BUN 9, creatinine 0.8, glucose 123, CK 104,
103, MB 1 and 3, troponin less then 0.3 times two.
MR IMAGING: Increased diffusion weighted signal on the left
parietal occipital region with a left ICA and an MCA with
severely diminished flow. Perfusion study revealed a defect t
hat
extende that seen on diffusion.
HOSPITAL COURSE: Mr. [**Known lastname 724**] was admitted to the Neurological
Intensive Care Unit for an acute stroke management. Given the
mismatch in the perfusion and diffusion imaging sequences we f
elt
that Mr. [**Known lastname 724**] likely has ischemic and stunned neuronal tissue
that may be salvaged if a perfusion can be maintained with hig
h
pressures. Therefore he underwent central line placement
along with arterial line placement for continuous blood
pressure monitoring. He was initially started on
neo-synephrine to maintain his systolic blood pressure
between 160 and 190. However, escalating doses of
neo-synephrine was ineffective in maintaining his blood
pressure and therefore he was switched to Levophed with good
results. He appeared to be clinically better and more
responsive on the hypertensive therapy. He was able to open
his eyes and repeat one, two, three in Chinese only one day
after high perfusion pressure treatment.
Cardiac echocardiogram revealed a normal left ventricular
systolic function with an ejection fraction greater then 55%
without significant wall motion abnormalities. Carotid
duplex revealed significant plaque in the cervical left ICA
and minimal disease in the right carotids. The right peak
systolic velocities suggest less then 40% stenosis. The left
velocity in the ICA was diminished with a systolic/diastolic
of 32/0. This is concerning for high grade distal stenosis
or occlusion of the ICA on the left. Therefore further
studies with an angiogram was done and Dr. [**Last Name (STitle) 1132**] performed
this procedure, which revealed a proximal left MCA occlusion.
The left A1 was also occluded. The left bifurcation was 85%
stenotic. The left petrous ICA was 50% stenotic. The right
ICA supplies the right and left ACA. There are no posterior
communicating arteries. In summary, there was a 85% stenotic
lesion at the proximal left ICA and a 50% stenotic lesion in t
he
petrous ICA on the left with a complete occlusion of the MCA
on the left. No intervention was done at this time. Mr.
[**Known lastname 724**] was subsequently weaned off pressor support with blood
pressures maintained at adequate levels. Clinically he
remained stable.
Given the significant extracranial vascular disease the
stroke attending recommended that Mr. [**Known lastname 724**] be started on
aspirin and Plavix for prevention of further ischemic events.
While in the Intensive Care Unit Mr. [**Known lastname 724**] was found to have a
urinary tract infection with cultures growing enterococcus
species and staph coag negative species. He was started on
Levofloxacin for this urinary tract infection. We note,
however, that the staph species was resistant to
Levofloxacin. Sputum cultures also revealed staph aureus,
which was felt to be colonization and therefore Mr. [**Known lastname 724**] was
not started on antibiotics. However, on the day of this
dictation Mr. [**Known lastname 724**] had a temperature of 101.8. Blood, urine
and sputum cultures were resent and I recommended starting
Vancomycin to cover for staph aureus.
From a gastrointestinal perspective Mr. [**Known lastname **] hematocrit has
been trending down from about 35 to 32 today. We will
continue to monitor the hematocrit given his recent history
of coffee ground emesis in the Emergency Room on admission.
We intend to continue Pantoprazole prophylaxis. He is
currently not alert enough to take po, however, we anticipate
that with treatment of his acute infectious process that he
will likely be able to take po fluids and medications. In
the meantime, it is not unreasonable to consider tube
feeding.
Finally, regarding long term management of his
cerebrovascular disease we would favor initiating a statin
drug. We realize that his cholesterol may not be high in the
usual sense, however, a low dose statin at for example of 10
mg of Lipitor q day is favored by the Stroke Intensive Care
Unit Service.
At this time Mr. [**Known lastname 724**] is clinically stable and appropriate
for transfer to the floor under the care of the Neurological
Service.
MEDICATIONS ON TRANSFER: 1. Aspirin 300 mg pr q.d. 2.
Vancomycin 1000 mg intravenous q 12. 3. Levofloxacin 500 mg
intravenous q 24 hours. 4. Levothyroxine 50 micrograms
intravenous q day. 5. Pantoprazole 40 mg po intravenous q
24 hours. 6. Heparin 5000 units subQ q 12. 7. Albuterol
and Atrovent nebulizers q 4 hours prn. 8. Insulin sliding
scale per flow sheet. 9. Beclomethasone depro two puffs
t.i.d. 10. Plavix 75 mg po q day when taking po.
DISCHARGE DIAGNOSES:
1. Left hemispheric infarction, evidence of left MCA
occlusion and severely stenotic left ICA.
2. Hypertension.
3. Chronic obstructive pulmonary disease.
4. Gout.
5. Urinary tract infection.
6. Question of pneumonia.
The on service neurology house staff will complete this
dictation upon Mr. [**Known lastname **] discharge from this hospital.
Thank you very much for the opportunity to participate in the
care of this very pleasant man.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**]
Dictated By:[**Last Name (NamePattern4) 25132**]
MEDQUIST36
D: [**2103-8-20**] 23:27
T: [**2103-8-21**] 07:29
JOB#: [**Job Number 102588**]
ICD9 Codes: 5990, 486, 2449, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2056
} | Medical Text: Admission Date: [**2194-2-6**] Discharge Date: [**2194-3-12**]
Date of Birth: [**2123-4-12**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
Liver transplant
Intracranial bolt
Tunneled dialysis line
Post pyloric feeding tube placement
ERCP
Liver Biopsy x 2
History of Present Illness:
Mr [**Known lastname **] is a pleasant 70 yo previously healthy gentleman with
no significant PMH who presented to liver clinic for the first
time today on referral from his PCP for jaundice, dark urine and
[**Male First Name (un) 1658**] colored stool x 2wks. PT states that since [**10/2193**] he has
generally been feeling unwell, with decreased energy, night
sweats, decreased exercise tolerance and SOB with walking short
distances. He states that he initially attributed this to old
age however became more concerned on [**2194-1-20**] when he developed
dark urine, pale stools. This progressed to decreased appetite
on [**1-25**] and jaundice on [**1-26**]. He postponed calling his PCP
because of the holidays, however was then advised to go to the
hospital on [**2194-1-28**] when he was able to reach his PCP. [**Name10 (NameIs) **]
presented to [**Hospital3 **] where he was found to have bili >10
and ast/alt >900. He was admitted and CT of the abdomen was
performed and per, report, showed gallbladder thickening. CXR
was WNL. Pt was offered further inpatient w/u however elected
to f/u with his PCP who [**Name Initial (PRE) **]/u with hepatitis serologies (negative)
and advised ERCP which was performed on [**1-31**], and was normal
other than a large peri-ampullar diverticulum. At that time,
labs were notable for a bili of 20, ALT/AST> 900 and elevated ap
to 196. INR was 1.4. He was scheduled to f/u with Dr. [**First Name (STitle) **] in
clinic today.
.
In clinic today, labs BP was low at 90/60 and the pt appeared
dry. Labs were sent and were pending on admission to the floor.
Pt was admitted for further w/u of his liver failure.
.
On arrival to the floor pt confirms the above history and denies
any new complaints. He denies fevers (took temp at home and no
greater than 100), N/V/D, abd pain. He states that he has no hx
of drug/EtOH abuse or tatoos. He has not traveled outside the
the country in 15 yrs, denies new food exposures (including wild
mushrooms) and has not been around children or in daycare
centers recently. He has no fam hx of liver disease. He has
not ever used tylenol and has not recently started any
medications.
Past Medical History:
Tubulovillous adenoma
Rotator cuff syndrome, s/p repair x2
Inguinal hernia repair [**2158**], [**2188**]
Osteoarthritis
Hypertension
Social History:
Small amount of chemical exposure as a worker in an
instrumention lab
Smoking: Former Smoker (quit [**2185-4-15**]) 1 ppd, 55 pack-years
Alcohol: social
Family History:
Father Deceased CAD/PVD
Mother Deceased CAD/PVD
Sisters: Diabetes - Type II; MS, Stroke
Denies family history of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 114/76 76 18 wt 101.4 kgs
GENERAL: Well appearing 70 yo M who appears stated age.
Comfortable, appropriate and in good humor. Diffusely Jaundiced
HEENT: Sclera icteric. PERRL, EOMI.
NECK: Supple with nl JVP, no LAD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Mildly distended but soft, non-tender to palpation
except over the liver edge where there is mild TTP. No fluid
wave or shifting dulness. Liver edge palpable 2 cm below the
costal margin, no splenomegaly.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
mild [**Location (un) **] bilaterally to knees. 2+ DP/PT pulses
NEURO: aao x3, CNs [**3-9**] intact, strength and sensation grossly
intact.
Pertinent Results:
On Admission: [**2194-2-6**]
WBC-11.4*# RBC-3.06*# Hgb-10.6*# Hct-25.0*# MCV-76*# MCH-34.6*#
MCHC-45.8*# RDW-19.9* Plt Ct-343#
PT-15.6* INR(PT)-1.5*
Glucose-141* UreaN-38* Creat-1.7* Na-135 K-4.3 Cl-101 HCO3-20*
AnGap-18
ALT-1293* AST-858* AlkPhos-165* TotBili-60.5*
Albumin-3.2* Iron-224*
Calcium-9.0 Phos-4.8* Mg-2.1
HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE
IgM HAV-NEGATIVE AMA-NEGATIVE Smooth-POSITIVE A
HIV Ab-NEGATIVE
.
[**2194-2-10**] 08:31AM BLOOD ALT-208* AST-178* LD(LDH)-2680*
AlkPhos-67 TotBili-82.2*
Transplant [**2194-2-11**]
At Discharge [**2194-3-12**]
WBC-6.6 RBC-3.08* Hgb-10.0* Hct-30.2* MCV-98 MCH-32.4* MCHC-33.0
RDW-17.8* Plt Ct-248
PT-9.4 PTT-27.4 INR(PT)-0.9
Glucose-126* UreaN-86* Creat-6.0*# Na-137 K-5.5* Cl-96 HCO3-29
AnGap-18
ALT-32 AST-23 AlkPhos-183* TotBili-1.4 Albumin-2.6*
Calcium-8.5 Phos-5.2* Mg-2.5
tacroFK-5.8
Brief Hospital Course:
70 yo Male admitted with jaundice with abnormal LFTs. Etiology
unknown and extensive workup undertaken. Liver biopsy was done
to evaluate for autoimmune vs malignant etiology. Steroid
treatment with prednisone was initiated [**2-7**] pending diagnosis.
On [**2-8**], the patient rapidly decompensated and was in fulminant
liver failure. Tbili rose to 70, Hct dropped to 18, and INR
rose to 9. He was emergently treated with FFP, pRBCs, and
steroids. He was transferred to the SICU for management
Transvenous biopsy was done. WBC was 31.4 on [**2-8**], elevated
from 16.6. He was afebrile with no clear etiology. Empiric
treatment with Ceftriaxone was started. Mental status worsened.
On [**2194-2-9**], Dr. [**Last Name (STitle) **] placed a Right-sided high frontal
intracranial pressure bolt placement. Renal function declined
and CVVHD was started for worsening renal function.
Liver biopsy was notable for histologic features in keeping with
an acute, fulminant hepatitis with a clinical differential of
acute viral or immune-mediated injury (either primary autoimmune
hepatitis or immune-mediated drug reaction). No infiltrative
neoplasm was identified. A transplant work up was completed and
he was listed for liver transplant.
On [**2194-2-11**], a liver donor offer became available and was
accepted. He was taken to the OR with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He
received an Orthotopic deceased donor liver
transplant (piggyback), portal vein-portal vein anastomosis,
common bile duct to common bile duct anastomosis without a
T-tube, and celiac patch of the donor to the common hepatic
artery of the recipient. Of note, his native liver was reported
as firm but without evidence of cirrhosis. He tolerated the
procedure without complication and was transferred to the SICU
in stable condition.
In the post operative period, his recovery was very slow, and he
remained intubated through POD 10. His mental status had
initially been very slow to improve.
Additionally, the patient had elevated WBC into the mid 20's.
Although he was not febrile, Infectious disease was consulted
and Culture data was closely followed. On POD 3 a BAL was
performed which yielded yeast and Haemophilus influenzae. Prior
to transplant had been on Vanco and Zosyn due to his rapid
decompensation, however once the culture data was retuned he was
started on meropenem. All antibiotics have been off since POD10,
WBC has returned to [**Location 213**] and he has remained afebrile.
Prior to transplant, the patient was in acute kidney failure,
and was started on CVVHD while in the ICU prior to the
transplant. There has yet to be return of kidney function. CVVH
was done until POD 11, and then he was started on intermittent
HD, with the first HD treatment done in the ICU with good
tolerance of fluid removal. However, he was transferred to [**Hospital Ward Name 121**]
10, and his first attempt at intermittent HD outside of the ICU
caused hypotension, and he was returned to the SICU, and CVVH
was once again resumed. Once he was more stable, intermittent HD
was tried again, and since that time he has continued on
intermittent HD every Monday, Wednesday, Friday with typical
fluid removal from 1-2 Liters as tolerated. Urine output has
been zero until about POD 27 when he has started to make about
100 to 200 cc's daily. His weight has decreased from a maximum
112 kg around POD 3 to about 95 kg at discharge.
The patient had transferred out of the ICU on POD 15, returned
to the ICU with hypotension on dialysis, spent another 8 days in
the ICU and has been on [**Hospital Ward Name 121**] 10, with routine surgical care
since POD 24.
The patient has been receiving tube feeds via a post pyloric
feeding tube with good tolerance. His appetite is poor at this
time.
The patient underwent routine induction immunosuppression at
time of transplant to include solumedrol with taper, cellcept,
prednisone taper per protocol once solumedrol was completed, and
prograf which was started on the evening of POD 1. Levels have
been monitored daily with adjustments per level.
Total bilirubin was 75.6 on day of transplant, and has decreased
over the course of the hospitalization to 1.4 on day of
discharge. AST and ALT are WNL. Alk phos was 65 on day of
transplant, and although initially was trending down, by POD 11
was noted to be trending back up and was 397 on POD 14. On [**2-25**]
he underwent liver biopsy which showed cholestasis and bile duct
proliferation, so on [**2194-2-27**] he underwent an ERCP which showed a
mis-match in the diameter of the donor and native duct. [Donor
duct was 8 mm in diameter and native duct was 4 mm in diameter].
No strictures were noted. The anastomosis was patent. No
resistance to flow of contrast or passage of 5 mm balloon was
noted. No extravasation was contrast was noted. Both right and
left hepatic ducts filled normally. The alk phos has started to
trend back towards normal and was 183 on day of discharge.
The patient has been evaluated by physical therapy and will
require extensive rehab. He receives hemodialysis via right
tunneled HD line every Monday, Weds, Friday, is taking tube
feeds via PPFT, and has poor appetite, appears to be tolerating
the tube feeds, and has had normalization of bowel function.
Medications on Admission:
-Metoprolol Succinate 25 mg Oral Tablet Extended Release 24 hr
Take 1 tablet daily
Pt dc'd the following medications 2 days PTA out of concern for
AEs in the setting of new jaundice:
-Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) Take 1
capsule 30 minutes before first meal of day
-Naproxen Sodium 220 mg Oral Tablet 2 tabs po bid prn
-Aspirin 81 mg Oral Tablet
-Vitamin
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
4. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-27**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
5. midodrine 5 mg Tablet Sig: 2.5 Tablets PO TID (3 times a
day).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
10. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
11. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,FR).
12. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
13. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for [**3-12**] and [**3-13**] then decrease to every other day for
1 week then stop on [**3-20**].
15. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TU) for 4 weeks.
16. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): follow taper.
17. insulin lispro 100 unit/mL Solution Sig: follow sliding
scale units Subcutaneous four times a day.
18. NPH insulin human recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous once a day: AM dose.
19. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous once a day: Suppertime dose.
20. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day:
Check trough level friday [**3-14**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]-[**Location (un) **]
Discharge Diagnosis:
fuliminant hepatic failure of unknown etiology
malnutrition
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:
For this week only, please draw labs on Friday [**3-14**]. CBC, Chem
10, AST, ALT, T bili, Alk Phos, Trough Prograf, fax results to
[**Telephone/Fax (1) 697**], then resume Monday/Thursday labs
You will be transferring to [**Hospital **] Rehab in [**Location (un) 53637**]
You will continue to receive Hemodialysis 3 times per week
Labs will be drawn every Monday and Thursday starting week of
[**3-17**]
Tube feeds will continue until you are able to take in
sufficient calories to meet your body's needs
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2194-3-19**] 1:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2194-3-26**] 9:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2194-3-26**] 10:30
Completed by:[**2194-3-12**]
ICD9 Codes: 5845, 5070, 0389, 2762, 2930, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2057
} | Medical Text: Admission Date: [**2197-11-14**] Discharge Date: [**2197-11-19**]
Service: MEDICINE
Allergies:
Morphine / Shellfish
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
hypoglycemia and hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 year old female with ESRD on HD Tu/Th/Sat, CAD s/p PCI LAD,
OM1 '[**91**], NSTEMI [**7-18**], DM2, RAS who presented to OSH from nursing
home with confusion and diaphoresis. Glucose noted to be in the
30's and given D50 with improvement in mental status. At OSH she
had abdominal pain and a CT Abd/Pelvis without contrast was
performed which showed no evidence of obstruction, free air, or
AAA but had significant bandemia. She was given Ceftriaxone and
flagyl and transferred to [**Hospital1 18**].
.
On transfer to [**Hospital1 18**] ED, SBP in 60's, hypoglycemic to 40's with
abdominal pain. She was guaiac (+) with dark flecks of material
on rectal. An NG lavage was done with bilious material which
cleared with 700cc NS (no blood). Surgery was consulted,
reviewed her CT scans from OSH and felt there was no acute
surgical issue. She was given Vanco x1. U/A was positive, and
patient was given 2 L NS with SBP into 120s and HR 60's. Blood
sugars improved to 140's with 1 amp D50. Blood and urine
cultures drawn. Patient was due for dialysis on the day of
admission. Renal was contact[**Name (NI) **] about missing her HD but felt no
acute need for HD. On admission, patient was unable to recall
preceding events. Does not remember why she was sent in from NH.
Denied fevers, chills, nausea, vomiting, diarrhea. Did complain
of some left-sided abdominal pain.
Past Medical History:
CAD
PCI LAD, OM1 '[**91**]
NSTEMI [**8-11**]
ESRD
Chronic HD
DM2
HTN
Dyslipidemia
Hypothyroidism
RAS
Dementia
Depression
RBBB/LAFB/Bradycardia
Staph Epidermis infection dialysis catheter [**7-18**]
OA
Social History:
Widowed. Lives at Pine Manor Nursing Center. STM loss.
Has 2 grown sons. [**Name (NI) **], [**Name (NI) 122**] is power of attorney and health
care proxy for patient.
Nonsmoker. Denies alcohol use.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
VS: T: 98.0; HR: 70; BP: 130/87; RR 18; O2 95% RA
GEN: awake, alert, oriented to self and year. Thought she was @
[**Hospital1 112**].
HEENT: EOMI. MMM. OP clear. 3 cm diameter soft, mobile,
nontender mass over R occiput (?lipoma). Pt states has been
present for x4mos.
NECK: supple, no JVD.
CV: RRR. Nl S1, S2. [**3-20**] sys murmur at LUSB.
PULM: bibasilar crackles.
ABD: (+) BS. soft, ND. Minimal epigastic tenderness. No rebound
or guarding.
BACK: No CVA tenderness
EXT: Lower extremities warm, well-perfused. 1+ DP pules bilat.
No edema.
Pertinent Results:
[**2197-11-14**] 02:50PM PT-15.4* PTT-68.3* INR(PT)-1.4*
[**2197-11-14**] 02:50PM PLT SMR-NORMAL PLT COUNT-163
[**2197-11-14**] 02:50PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL BURR-1+
[**2197-11-14**] 02:50PM NEUTS-78.0* BANDS-0 LYMPHS-16.9* MONOS-3.9
EOS-1.1 BASOS-0.1
[**2197-11-14**] 02:50PM WBC-4.9# RBC-3.20* HGB-11.0* HCT-33.6*
MCV-105* MCH-34.4* MCHC-32.8 RDW-18.0*
[**2197-11-14**] 02:50PM CALCIUM-6.7* PHOSPHATE-7.1*# MAGNESIUM-1.4*
[**2197-11-14**] 02:50PM CK-MB-NotDone cTropnT-0.03*
[**2197-11-14**] 02:50PM LIPASE-12
[**2197-11-14**] 02:50PM ALT(SGPT)-18 AST(SGOT)-22 CK(CPK)-23* ALK
PHOS-91 TOT BILI-0.2
[**2197-11-14**] 02:50PM GLUCOSE-42* UREA N-60* CREAT-5.3*# SODIUM-139
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-19* ANION GAP-24*
[**2197-11-14**] 09:30PM CK-MB-NotDone cTropnT-0.05*
[**2197-11-17**] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2197-11-17**] 07:19PM BLOOD CK-MB-NotDone cTropnT-0.31*
[**2197-11-19**] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2197-11-19**] 06:55AM BLOOD WBC-5.1 RBC-3.76* Hgb-12.7 Hct-39.4
MCV-105* MCH-33.9* MCHC-32.3 RDW-17.5* Plt Ct-219
[**2197-11-19**] 06:55AM BLOOD Plt Ct-219
[**2197-11-19**] 06:55AM BLOOD Glucose-73 UreaN-26* Creat-5.1*# Na-140
K-3.9 Cl-100 HCO3-28 AnGap-16
[**2197-11-19**] 06:55AM BLOOD CK(CPK)-38
[**2197-11-19**] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2197-11-19**] 06:55AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3
KUB: IMPRESSION: Nonspecific bowel gas pattern without evidence
of obstruction.
Brief Hospital Course:
87 year old female with ESRD on HD, CAD s/p MI and PCI, DM2, RAS
presented from OSH with hypoglycemia, hypotension, abdominal
pain, UTI, now normotensive with new epigastic pain and
persistent intermittent hypoglycemia.
--In the MICU, patient treated for UTI and question of urosepsis
with Cipro. Pyelonephritis was considered possible source of
abdominal pain. Urine cultures came back positive for
pansensitive E. coli and patient was continued on Cipro. There
was no growth in blood cultures. She was ruled out for MI with
mild troponin elevation in the setting of renal failure but flat
CKs. Patient was restarted on HD the day following admission.
Her labetolol, norvasc, clonidine, and isosorbide were held. She
had no further hypotension following initial volume
recessitation. However, she continued to be hypoglycemic at
times, thought most likely secondary to persistent blood levels
of glipizide in the setting of renal insufficiency as well as
poor po intake. Patient's po intake began to improve and prior
to transfer to the floor, BGs had improved to 70-140 [**11-16**]. MICU
stay also complicated by epigastric abdominal pain and emesis,
bilious and non-bloody. Pancreatic enzymes and LFTs were normal.
PTT and INR elevated in MICU. Heparin sc stopped. Both trended
down on repeat checks.
.
The morning after transfer, the patient was found to have
increasing nausea and vomiting that was poorly responsive to
anti-nausea meds. As there was concern for cardiac ischemia, an
EKG was done that showed new T-wave inversions in the lateral
leads. Pt had significan troponin elevation and cardiology was
consulted. Though the patient was likely having mild episode
of cardiac ischemia, given the patient's significant
comorbidities and resolvation of symptoms as well as no
hemodynamic compromise, the patient was treated medically with
aspirin, plavix, beta blocker and oxygen. The patient was
asymptomatic and had downtrending troponins. For the remainder
of the hospital, the patient has stable vital signs and no other
complaints of chest pressure.
.
# UTI: Urine culture positive for pansensitive E coli. Was
initially treated with cipro, but with the patient's nausea and
vomiting, it was changed to levofloxacin QHD. Pt now on day 6
of appropriate abx. Currently afebrile. CVA tenderness noted on
admission now resolved. Pyelonephritis possible cause of initial
abdominal pain but no clear evidence of that on CT abdomen from
OSH.
.
# ESRD on HD (Tues/Thurs/Sat) Pt now on MWF schedule,
nephrology following.
- next session due [**11-20**]
- monitor electrolytes
- continue nephrocaps
.
# EPIGASTRIC TENDERNESS/VOMITING: minimal epigastric tenderness
on exam, +N/V. Unclear etiology. LFTs, pancreatic enzymes
normal. [**Month (only) 116**] be [**3-16**] to gastroparesis given h/o DM and patient
reports chronic N/V prior to admission. Now asymptomatic, if
persists, nay need gastric emptying study.
.
# DMII: patient p/w hypoglycemia, now resolved. Was likely [**3-16**]
oral hypoglycemics in setting of worsened renal function due to
infection. Stable finger sticks on day of discharge, pt on
insulin sliding scale
- monitor QID finger sticks
- cont to hold glyburide as was hypoglycemic
- RISS if needed
.
# HTN: Labetalol, clonidine, and norvasc held on admission to
MICU given hypotension. Restarted prior to discharge.
.
# CAD: stable, denies CP. slight troponin elevation likely [**3-16**]
renal failure, but slight elevation likely due to mild ischemic
event, managed medically as pt has multiple comorbities. CK/MB
negative.
- continue ASA, Plavix, statin
.
# Right hip pain- pt given history of falling prior to
admission. X ray on admission showed no signs of occult fracture
though small linear lucency on x ray. Pt with large hematoma on
hip that precludes anticoagulation.
.
# HYPOTHYROIDISM: continue levothyroxine
.
# DEPRESSION: continue sertraline
.
# CODE: DNR/DNI confirmed with patient at the time of transfer
Medications on Admission:
ASA 325
Plavix
Labetalol 200 [**Hospital1 **]
clonidine 0.3mg po bid
sucralfate 1g qid
nephrocaps
FeSO4 325 qday
glyburide 5mg qday
isosorbide Mononitrate 60 qday
levothyroxine 100 qday
lipitor 80
norvasc 10 qday
sertraline 50 qday
colace/senna/dulcolax
protonix 40 qday
razadyne 4mg qhs
ativan 0.5mg qday prn
prochlorperazine 25 mg pr prn nausea
tylenol/benadryl prn
sl NTG prn
percocetq4 prn pain
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
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. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
14. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred
Fifty (250) mg Intravenous Q48H (every 48 hours): please give
at dialysis.
15. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
16. Razadyne 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, fever.
18. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
19. Labetalol 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
20. Insulin Regular Human 100 unit/mL Solution Sig: see sliding
scale Injection ASDIR (AS DIRECTED): Check glucose QID, if < 70
give [**2-13**] amp D 50 and [**Name8 (MD) 138**] MD, if 70-150 no insulin, if 151-200
give 2 U, if 201-250 give 4 U, if 300-350 give 6 U, if 351-400
give 8 U, if >400, give 10 U and [**Name8 (MD) 138**] MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 25499**] Manor - [**Location (un) 47**]
Discharge Diagnosis:
Urinary tract infection, hypoglycemia
Discharge Condition:
Stable; tolerating PO intake and afebrile
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Please take your medications as directed
Please keep your follow-up appointments
Followup Instructions:
Please make an appointment with [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 69239**] for
the next 7-10 days.
Please return to your normal hemodialysis schedule
ICD9 Codes: 5990, 5856, 4589, 311, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2058
} | Medical Text: Admission Date: [**2104-12-14**] Discharge Date: [**2104-12-22**]
Service: CARDIOTHORACIC
Allergies:
Methotrexate / Sulfa (Sulfonamides) / Quinine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
presyncope & DOE
Major Surgical or Invasive Procedure:
cardiac catheterization
AVR(#21CE Magna pericardial)PFO closure [**12-19**]
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS:
Ms. [**Known lastname 33681**] is an 87 yo female with severe AS, HTN, PVD, s/p
CVAx2 who presents for pre-operative catheterization and aortic
valve replacement. Ms. [**Known lastname 33681**] reports that she has had
shortness of breath for more than six months and has had
increasing pre-syncope over the past few months. She reports
intermittent leg swelling, but none at present. She reports
orthopnea, but no PND. She is unable to walk more than one
block due to both claudication and shortness of breath.
.
At present she denies shortess of breath, chest pain, fevers,
chills, nausea, vomiting, diarrhea.
.
Past Medical History:
PAST MEDICAL HISTORY:
severe Aortic Stenosis with AI
Hypertenion
Peripheral [**Known lastname 1106**] disease with severe claudication
Transient ischemic attack
B/l Carotid stenosis
CRI (Cr 1.5-1.9)
Rheumatoid arthritis
COPD
Osteoporosis
s/p CVA x 2 (occipital, cerebellar)
Social History:
Social history is significant for the absence of current tobacco
use, though patient has a 25 PY smoking history and quit 10
years ago. There is no history of alcohol abuse but has one
drink per day. There is no family history of premature coronary
artery disease or sudden death.
Family History:
Family history is significant for son with diabetes and sister
with stroke.
Physical Exam:
PHYSICAL EXAMINATION:
VS - T 98.4, BP 150/50, HR 68, RR 18, 02 Sat 98% on RA
Gen: WDWN middle aged 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: no JVP.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. 2/6 Systolic ejection murmur. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, wheezes or
rhonchi. Crackles at bases bilaterally.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Brief Hospital Course:
Ms. [**Known lastname 33681**] was admitted for preoperative cardiac cath which
she underwent on [**12-15**]. She was maintained on IV heparin after
cath due to her history of CVA and coumadin use. She was seen by
renal. She was cleared for surgery by dental. She had a UTI for
which she was treated with cipro and her surgery was postponed.
She was taken to the operating room on [**12-19**] where she underwent
an AVR (tissue) and PFO closure. She was transferred to the ICU
in critical but stable condition. She was treated with
prophylactic vancomycin perioperatively because she was in house
preoperatively. She was given stress dose steroids. She remained
intubated overnight. Initially, She had complete heart block and
was paced, however her rhythm recovered to NSR. She was
extubated on POD #1. She was transferred to the floor on POD #2.
She did well postoperatively and was ready for discharge to
rehab on POD #3. She was restarted on coumadin. She is being
treated for a UTI, her foley could be discontinued on [**12-23**].
Medications on Admission:
CURRENT MEDICATIONS:
Actonel 35 mg PO once a week
Prednisone 5 mg Tablet dialy
Toprol XL 50 mg daily
Pantoprazole 40 mg PO Q12H
Atorvastatin 10 mg PO DAILY
Warfarin 2 mg Tablet QHS (Last dose Friday)
Aspirin 325 mg Tablet PO once a day
Citracal 2 tabs [**Hospital1 **]
Centrum silver daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Tablet, Delayed Release (E.C.)(s)
6. PredniSONE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Risedronate 35 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Check INR [**12-24**].
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
sev AS w/AI, PFO now s/p AVR/PFO closure
HTN,PVD w/claudication,TIA,B/L Carotid Stenosis, COPD,
Osteoporosis,CVAx2(occipital/cerebellar),CRI(1.5-1.9)
Discharge Condition:
GOod.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Already scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2105-2-25**] 3:40
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern1) 13280**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2105-4-13**] 2:45
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2105-4-21**]
3:00
Completed by:[**2104-12-22**]
ICD9 Codes: 4241, 5990, 4439, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2059
} | Medical Text: Admission Date: [**2170-3-23**] Discharge Date: [**2170-4-21**]
Service: MEDICINE
Allergies:
Sulfonamides
Attending:[**First Name3 (LF) 9598**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 85 yo woman with h/o lymphoma who presents s/p
fall at home. The patient has reportedly experienced a low grade
fever and increased fatigue over the past three days and
unsteadiness on her feet. Last night, she attempted to sit on
the toilet and only recalls coming to lying on back with her
head resting on a pipe.
She pressed the emergency button and EMS arrived on scene. The
event was unwitnessed, she does not recall feeling light headed,
having any chest pain or palpitations or blurry vision,hitting
her head, any seizure activity, aura or post ictal state or loss
of bowel or bladder control. She does have prior history of
falls, most recent five years ago.On one occaision she had
suffered a SAH following a mechanical fall. She is unable to
give clear hx regarding her other falls but does state that she
had fallen on a hot day.
She has a hx of EBV driven B and T cell proliferation-probably
angio-immunoblastic lymphoma and is s/p 6 cycles CHOP completed
[**10-16**] currently in remission. She had presented with LAD in neck
in [**2165**] with CT showing multiple lymph nodes and biopsy cervical
lymph node showing an atypical lymphoproliferative disorder,
highly suggestive of evolving T-cell lymphoma. Subsequent
inguinal biopsy in [**5-16**] was interpreted as either EBV expressing
large B cell NHL or angio-immunoblastic lymphoma with an EBV
expressing malignant B cell clone. She underwent 6 cycles of
R-chop completed in [**10-16**]. PET/CT on [**2169-11-14**] showed no evidence
of disease.
In the ED, the patient's VS were T 99.3, BP 105/35, P 91, O2 96%
on RA. She had a CT Head and Neck, which did not show any
evidence of ICH or fracture. She had a CXR, which was negative
for PNA, CHF, with trace fluid in R fissure, no pleural
effusion. She was initially placed in ED Obs, where she was seen
by PT and found to be orthostatic (SBP 140 to 80s). She received
1L IVF. She was admitted to medicine for further workup and
evaluation.
On floor, patient had a low grade temp to 99.4 and rigoring.
Past Medical History:
PAST MEDICAL HISTORY:
Notable for status post cholecystectomy,
status post subarachnoid hemorrhage [**4-/2167**] with no residua,
status post appendectomy,
hypertension
Gerd
Hypothyroidism
Lymphoma
Social History:
The patient lives in a retirement community and continues to be
active in all facets of her life.
Family History:
Non-contributory
Physical Exam:
On admission:
VS - Temp 99.4 HR: 91 BP: 127/70 RR: 18 02 SAT: 100% RA
GENERAL -comfortable, pleasant, shivering.
HEENT - mucous membranes dry, OPC, unable to visualize tympanic
membranes [**1-9**] wax, no ear pain with exam, no erythema, swelling
externally.
NECK - neck veins flat, no carotid bruit, no LAD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, II/VI holosystolic murmur heard
best at apex.
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 rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-11**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait exam deferred.
SKIN: 1cm erythematous plaque left lower lip.
Pertinent Results:
Admission Labs
[**2170-3-23**] 09:10AM BLOOD WBC-8.3 RBC-3.19* Hgb-9.8* Hct-29.0*
MCV-91 MCH-30.8 MCHC-33.8 RDW-16.0* Plt Ct-138*
[**2170-3-23**] 09:10AM BLOOD Neuts-80.2* Lymphs-6.9* Monos-4.3
Eos-8.4* Baso-0.3
[**2170-3-23**] 09:10AM BLOOD Glucose-143* UreaN-22* Creat-0.9 Na-133
K-4.5 Cl-103 HCO3-23 AnGap-12
[**2170-3-23**] 09:20PM BLOOD CK(CPK)-24*
[**2170-3-23**] 09:10AM BLOOD cTropnT-<0.01
Other Labs
[**2170-3-24**] 06:30AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1
[**2170-3-27**] 09:00AM BLOOD FDP-0-10
[**2170-3-27**] 09:00AM BLOOD Fibrino-283#
[**2170-3-30**] 01:00PM BLOOD Ret Aut-1.8
[**2170-4-3**] 06:00AM BLOOD VitB12-462 Folate-18.6
[**2170-3-30**] 01:00PM BLOOD Hapto-109
[**2170-3-27**] 09:00AM BLOOD D-Dimer-1013*
[**2170-3-27**] 09:00AM BLOOD Hapto-159
[**2170-3-24**] 06:30AM BLOOD TSH-2.6
[**2170-3-24**] 06:30AM BLOOD Cortsol-37.7*
[**2170-3-30**] 08:00AM BLOOD HIV Ab-NEGATIVE
[**2170-4-6**] 07:19PM BLOOD Vanco-13.7
CXR ([**3-23**]) - IMPRESSION: Apparent enlargement of the left
atrium for which clinical correlation is advised. Mild
interstitial coarsening which could be related to interstitial
disease or may be exaggerated due to technique.
CT Head ([**3-23**]) - IMPRESSION:
1. No acute intracranial process. No displaced fracture.
2. Stable age-related involutional change, small vessel ischemic
disease.
3. Mild paranasal sinus disease.
CT C-Spine ([**3-23**]) - IMPRESSION:
1. No acute fracture within the cervical spine.
2. Mild multilevel degenerative disease. Stable minimal C7 on T1
anterolisthesis.
MRI Head ([**3-25**]) - CONCLUSION: No evidence of intracranial
lymphoma. Two small foci of old hemorrhage in the right frontal
and temporal lobes.
CT C/A/P ([**3-25**]) - IMPRESSION:
1. Numerous new mediastinal, hilar, axillary, retroperitoneal,
intraabdominal, mesenteric, pelvic, and inguinal enlarged
abnormal lymph nodes are consistent with recurrent lymphoma.
Mildly increased size of the spleen.
2. Wall thickening with surrounding fat stranding of the
ascending colon,
hepatic flexure, and proximal transverse colon, consistent with
colitis.
Etiologies include infectious, inflammatory, and ischemic.
Clinical
correlation is recommended.
3. Small bilateral pleural effusions with adjacent atelectasis.
Small
intra-abdominal and pelvic ascites, new since prior exam.
[**Month/Year (2) **] ([**3-27**]) - The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 70%). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). There is
no ventricular septal defect. 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. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2169-7-7**], the mitral
regurgitation may be somewhat reduced.
Bone Marrow Bx ([**3-28**]) - SPECIMEN: BONE MARROW ASPIRATE AND CORE
BIOPSY:
DIAGNOSIS: - HYPERCELLULAR MARROW WITH ATYPICAL T-CELL DOMINANT
LYMPHOID AGGREGATES, SUSPICIOUS FOR BONE MARROW INVOLVEMENT BY
T-CELL LYMPHOPROLIFERATIVE PROCESS (SEE NOTE)
Bone Marrow Bx Cytogenetics ([**3-28**]) - INTERPRETATION: No clonal
cytogenetic aberrations were identified in 20 metaphases
analyzed from this unstimulated specimen. This normal result
does not exclude a
neoplastic proliferation. Mosaicism and small chromosome
anomalies may not be detectable using the standard methods
employed.
[**4-1**] CT Head: No acute intracranial process as clinically
questioned. If there is concern for lymphoma, an MRI of the
brain may be obtained for further characterization.
[**2170-4-4**] CXR: 1. Worsening moderate pulmonary edema. 2.
Increased pleural effusions, large on the right and small on the
left.
[**2170-4-5**] ECG: Atrial fibrillation with a controlled ventricular
response. Left axis deviation. Non-specific ST-T wave changes.
Compared to the previous tracing the rate is slower.
[**2170-4-9**] CXR: In comparison with the study of [**4-7**], the
cardiomediastinal contours are unchanged. Bilateral pleural
effusions persist. Indistinctness of pulmonary vessels. This
suggests some underlying elevation of pulmonary venous pressure.
Retrocardiac opacification is consistent with left basilar
atelectasis. Monitoring and support devices remain in place.
[**2170-4-11**] RUE Ultrasound: No evidence of DVT
Brief Hospital Course:
This is an 85 year old female with hx HTN, lymphoma s/p R-CHOP,
SAH in setting of mechanical fall, admitted following
unwittnessed non-mechanical fall and found to have recurrent
lymphoma.
#. Syncope: Pt presented s/p fall with loss of consciousness. 0f
note she was orthostatic in ER and has had prior episodes which
sound vasovagal in nature and it is likely that her vasovagal
syncope and orthostasis was secondary to hypovolemia. Patient
noted to have moderate MR [**First Name (Titles) **] [**Last Name (Titles) **] '[**67**]. Pt had mild peripheral
edema, with MR [**First Name (Titles) 21782**] [**Last Name (Titles) 34106**] to poor forward flow and
syncope, however repeat [**Last Name (Titles) 113**] showed no concerning features to
suggest this. Pt has also had low grade fevers, rigors and
fatigue for several days, suggesting possible infection although
exam non focal without elevated white count Her urine cultures
showed staph UTI. She received IVF, tylenol and demerol as
needed.
#. Lymphoma: She has a history of EBV driven B and T cell
proliferation-probably angio-immunoblastic lymphoma and is s/p 6
cycles R-CHOP concluding [**10-16**] with PET in [**11-15**] showing no
evidence active disease. Her presentation was discussed with her
hematologist/oncologist who concluded that her rigors, fevers
and fatigue was also strongly suggestive of B sypmtoms due to
lymphoma recurrence. Patient also had cervical, inguinal, and
axillary lymphadenopathy. She was transferred to the OMED
service for further evaluation. A bone marrow biopsy was
performed which showed lymphoma recurrence. Originally there
were plans to start her on Rituxan, Doxil, and Velcade.
However, she developed altered mental status and severe
hyponatremia and chemotherapy was ultimately deferred due to her
poor functional status.
#. Thrombocytopenia: Patient noted to have platelets trending
down. Initial concern was HIT as patient had a pre-test
probability that was intermediate based on her 4T score. She was
empirically started on argatroban. A HIT antibody was sent with
a mildly positive result (Optic Density of 0.44) This was
repeated and was negative. Given the high negative predictive
value of this test, it was concluded that the patient did not
have HIT. Her argatroban was discontinued. A bone marrow biopsy
showed involvement of lymphoma in her bone marrow and it was
ultimately felt that she had bone marrow suppression and
thrombocytopenia from lymphoma.
#. Atrial Fibrillation: New onset during this hospitalization
with rates in the 140s. Patient was started on metoprolol
tartrate and uptitrated as patient could tolerate. During her
ICU stay hypotension was limiting use of metoprolol, therefore
she was loaded with amiodarone. She was monitored on telemetry
and was noted to be in and out of atrial fibrillation. Patient
remained asymptomatic. CHADS2 score at least 2. She was
continued on ASA 81 mg but was not further anticoagulated due to
thrombocytopenia. Her dose of amiodarone should be tapered to
200mg po daily after discharge (should switch to this dose on
[**4-23**])
#. Hyponatremia: While on the oncology service, the patient
developed mental status changes with associated hyponatremia.
Her sodium trended down, and renal was consulted. She was
started on fluid restriction and given lasix because she was
felt to be volume overloaded; however, her sodium continued to
trend down and she became more somnolent and confused. She was
transferred to the ICU for hypertonic saline administration. Her
sodium improved with hypertonic saline. Ultimately, her
hypertonic saline was stopped and she was started on lasix, NaCL
tabs, tubefeeds, and 1L fluid restriction per renal
recommendations. She had hypotension, however, and was therefore
unable to tolerate the lasix. She was given some saline boluses
with improvement in her sodium. Urine sodium decreased,
suggesting improvement of her underlying SIADH. SIADH may be [**1-9**]
oncologic process or respiratory infection. She was then weaned
off salt tabs and her sodium remained stable on only a 1L fluid
restriction.
#. Delirium: Onset of delirium occurred with hyponatremia. Her
delirium improved with hypertonic saline administration in the
ICU but she remained mild delirious, felt to be due to resolving
ICU delirium, UTI effect, bronchitis effect, or hyponatremia
effect.
#. Bronchitis: While in the ICU she developed a cough. Sputum
cultures failed to reveal a bacteria and she remained afebrile.
She was empirically started and completed on a 7 day course of
levofloxacin. Her cough improved.
#. HTN: She remained normotensive however given concern for
infection and potential to decompensate to septic physiology,
her diovan was initially held. While in the ICU, after being
started on [**Hospital1 **] lasix, the patient had some problems with
hypotension. For this, she was given NS boluses with improvment
in BP. She remained normotensive after discontinuation of all
BP medications.
#. Anemia: She had a normocytic anemia likely secondary to
disease progression in her marrow and anemia of chronic disease.
Hct was trended daily and remained stable and stools were guaiac
negative. She did get intermittent blood transfusions during
her stay.
#. Hypothyroid: Continued home levothyroxine dosage. TSH 2.6 on
[**3-24**].
#. UTIs: Initially found to have a Klebsiella UTI, for which she
completed a 5 day course of ciprofloxacin. She was later found
to have an MRSA UTI, for which she completed a 7 day course of
vancomycin.
Medications on Admission:
Acetaminophen 650 mg PO/NG Q6H:PRN fever
Aspirin 81 mg PO/NG DAILY
Calcium Carbonate 500 mg PO/NG TID
Ciprofloxacin HCl 500 mg PO/NG Q12H
Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **]
Levothyroxine Sodium 100 mcg PO/NG DAILY
Multivitamins 1 TAB PO/NG DAILY
Oxybutynin 5 mg PO BID
Pantoprazole 40 mg PO Q24H
Vitamin D 400 UNIT PO/NG DAILY
Diovan 160 daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Continue 200mg po bid until [**4-22**], then change to 200mg
po daily.
7. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet
Sig: One (1) Powder in Packet PO TID (3 times a day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
9. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
10. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 100913**] House
Discharge Diagnosis:
Primary Diagnosis:
Non-Hodgkin's Lymphoma
Secondary Diagnoses:
Hyponatremia
Altered Mental Status due to Urinary Tract Infection
Urinary Tract Infection
Bronchitis
Hypothyroidism
Hypertension
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
You were admitted to the hospital because you had fallen and we
needed to evaluate why you fell. You were also spiking fevers
and were found to have recurrence of your lymphoma.
You were transferred to the oncology service where you were
going to receive chemotherapy. However, you developed altered
mental status and low sodium. You were transferred to the ICU
temporarily due to your low sodium level. You were given IV
fluids with extra sodium and your sodium improved. Your mental
status has also slowly improved.
You were seen by Dr. [**Last Name (STitle) **] while you were in the hospital
and it was decided not to give you any chemotherapy. You are
being discharged back to the facility where you came from with
hospice.
The following changes were made to your medications:
ADDED amiodarone 200mg by mouth twice daily through [**4-22**]. On
[**4-23**], you should start taking amiodarone 200mg by mouth daily.
Followup Instructions:
You have the following appointments scheduled:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2170-6-25**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], 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
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] will also be involved in your care
while you are at your facility with hospice.
[**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**]
ICD9 Codes: 2930, 5990, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2060
} | Medical Text: Admission Date: [**2166-7-31**] Discharge Date: [**2166-8-8**]
Date of Birth: [**2122-11-1**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 43-year-old female had a
known history significant for coronary artery disease. She
had a non-ST elevation myocardial infarction in [**2166-5-13**]
with stenting of her LAD and circumflex. She returned two
weeks after that with angina and a positive exercise
tolerance test. Had a stent placed to the RCA at that time.
A stress test on [**8-4**] depressions with
partially reversible defect to the lateral wall, which was
new since the study in [**2166-5-13**]. She reported ongoing
angina mostly at rest relieved with sublingual nitroglycerin
and shortness of breath with exertion. She had a cardiac
catheterization done on [**2166-5-31**], which showed patent
prior stents and a 70 percent left main stenosis.
PAST MEDICAL HISTORY: Coronary artery disease with stents to
the LAD, circumflex, and RCA as above.
Hypertension.
Hypercholesterolemia.
Status post tonsillectomy.
Status post tubal ligation.
History of D and C status post stillborn birth.
ALLERGIES: Codeine which caused vomiting.
MEDS PRIOR TO CATH:
1. Aspirin 325 mg daily.
2. Lisinopril 5 mg p.o. daily.
3. Toprol XL 100 mg p.o. daily.
4. Lipitor 80 mg p.o. daily.
5. Plavix 150 mg p.o. daily.
6. Paxil 10 mg p.o. daily.
7. Ambien 5 mg p.o. q.h.s.
SOCIAL HISTORY: The patient lives in [**Location **] with
family, her husband and two children ages 17 and 20. She
quit smoking in [**2166-5-13**] with a 30 plus pack year
history. She admits to one alcoholic drink per week.
FAMILY HISTORY: Her family history was positive. Her mother
had coronary artery disease at 47 years of age. Is still
living. Her father had a myocardial infarction in his 60's.
REVIEW OF SYSTEMS: Weight is stable. She was sleeping well
with the Ambien with no difficulty with her appetite at this
time. She was negative for psoriasis, pruritus, or sores.
She had positive history of rare migraines, but negative for
cataracts, glaucoma, sinusitis, rhinorrhea, or epistaxis.
She had no history of asthma, pneumonia, bronchitis, TB;
other than a remote episode of pneumonia more than 20 years
ago. Her cardiovascular systems review is positive for
palpitations and angina and myocardial infarction, but
negative for CHF, PND, orthopnea, or edema. She also had a
history of claudication. She had no history of nausea,
vomiting, diarrhea, or constipation, problems with [**Name2 (NI) **] or
hemorrhoids as well as negative for dysuria, frequency, or
burning. Her musculoskeletal system was negative for
arthritis, fractures, or dislocations. Neurologically: She
was intact with no neurologic history. Negative for CVA,
seizures, syncope, and TIAs. She had no history of bleeding
problems or bruising, and was on Paxil for her smoking
cessation with no history of depression or anxiety.
PHYSICAL EXAMINATION: On exam, she is 5'3" tall, 153 pounds
with a heart rate of 47. Blood pressure 102/98. Saturating
98 percent on room air. She was lying in bed in no apparent
distress. She was alert and oriented times three,
appropriate, and neurologically grossly intact. Her lungs
were clear bilaterally. Heart had good tones at S1, S2,
regular rate and rhythm, bradycardic with no murmurs, rubs,
or gallops. Her abdomen was soft, obese, nontender, and
nondistended and had positive bowel sounds. Her extremities
were warm and well perfused with no varicosities or edema.
She had 2 plus bilateral radial, DP and PT pulses.
PREOPERATIVE LABS: White count 9.3, hematocrit 33.7,
platelet count 320,000. Sodium 138, K 4.1, chloride 104, CO2
21, BUN 13, creatinine 0.9 with a blood sugar of 162. PT
14.3, PTT 131.8 on Heparin, INR 1.3. ALT 23, AST 20,
alkaline phosphatase 122, amylase 32, total bilirubin is 0.3,
and albumin 4.2.
HOSPITAL COURSE: The patient was referred to Dr. [**First Name (STitle) **]
[**Name (STitle) **] of Cardiothoracic Surgery for coronary artery bypass
grafting. Of note on prior cardiac catheterization in [**2166-5-13**], the patient had complication of left superficial
femoral artery occlusion in the Cath Lab. In addition,
echocardiogram performed preoperatively showed ejection
fraction of approximately 50-55 percent and on [**2166-8-1**], the patient underwent coronary artery bypass grafting
x2 with a LIMA to the LAD and a vein graft to the OM by Dr.
[**Last Name (STitle) **]. The patient was taken to the Cardiothoracic ICU in
stable condition on an Epinephrine drip at 0.02
mcg/kg/minute, nitroglycerin drip at 0.3 mcg/kg/day, and a
Neo-Synephrine drip at 1.5 mcg/kg/minute.
Approximately 1-2 hours after arrival on the Cardiothoracic
ICU, the patient displayed a depressed cardiac index with
very high normal filling pressures. Echocardiogram was
performed, which showed the distal [**1-14**] of the LV to be
severely hypokinetic at the apex, which appeared to be
akinetic and ejection fraction of approximately 25 percent.
The RV size was normal. RV systolic function was mild-to-
moderately depressed. There was trace MR, no AI, mild
tricuspid regurgitation, no PR, no ASD, PFO by 2-D color
Doppler. Decision was made to take the patient emergently
back to the Cardiac Catheterization Laboratory fearing the
patient had suffered an acute MI approximately two hours
after bypass surgery.
The hemodynamics in the Cath Lab were consistent with
cardiogenic shock and a depressed cardiac index. Aortogram
did show diffuse aortoiliac disease with a minimum diameter
of 2 mm in bilateral common femoral arteries which was too
small for any intra-aortic balloon pump to be safely placed.
Cardiac catheterization showed that the vein graft to the OM
had 100 percent proximal occlusion with thrombus and the LIMA
to LAD was widely patent with 40 percent anastomotic lesion
and diffuse spasm in the LAD beyond the touchdown.
In the Cath Lab, the distal RCA was stented with a Cypher
stent and dilatation in the area of spasm. Left main was
also stented with a Cypher stent and the distal OM occlusion
was crossed, dilated, and intracoronary nitroglycerin was
given via balloon to relieve spasm. Please refer to the
final cardiac catheterization report from [**8-1**]. The
patient was then transported back to the Cardiothoracic ICU.
On postoperative day one, the patient remained on a Neo-
Synephrine drip at 1.5 mcg/kg/minute and milrinone drip at
0.375 mcg/kg/minute, insulin drip at 10, lidocaine drip at
2.0, propofol drip at 20, nitroglycerin drip at 0.05. She
was A-paced with a blood pressure of 131/72 and heart rate of
90, most A-paced. Her cardiac index was 2.4. She remained
intubated and sedated.
Postoperative laboratory work revealed a white count of 11.6,
hematocrit of 27.4, platelet count of 207,000. BUN 10,
creatinine 0.8. She had decreased breath sounds bilaterally
and decreased bowel sounds and 2 plus edema in her
extremities. She began IV Lasix for diuresis. Her INR was
2.9.
On postoperative day two, she remained on propofol drip, Neo-
Synephrine drip, milrinone at 2.5, and nitroglycerin at 0.5,
as well as a lidocaine drip at 1 mg/minute. She remained on
pressure support and SIMV. Her white count rose slightly to
15 and her laboratories remained relatively stable. Her
lungs had coarse breath sounds bilaterally. Heart was
regular rate and rhythm. She continued on her perioperative
Vancomycin with monitoring to try and wean some drips.
On postoperative day three, she remained on insulin drip,
milrinone at 0.25. Neo-Synephrine was turned off. A
nitroglycerin drip at 0.8. Precedex at 0.4. She continued
with her Plavix at 75 mg p.o. daily and was receiving Lasix
also intravenously. Her white count came down to 9.8 with a
hematocrit of 29.6. K of 3.6, BUN 12, creatinine 0.6. Blood
pressure 115/60 in sinus rhythm in the 90s. She had no
crackles, but decreased breath sounds bilaterally. Heart was
regular rate and rhythm and the plan was to wean and extubate
her. She continued on her Lasix diuresis.
On postoperative day four, she was in sinus rhythm in the
morning with some previous ectopy on amiodarone overnight,
which continued. She was saturating 90 percent on 2 liters
nasal cannula, continued on an insulin drip, and milrinone
drip at 0.125, and nitroglycerin drip at 0.2. Amiodarone
drip at 1. Her laboratory work was stable. She had crackles
bilaterally. Her sternum was stable. Her incisions were
clean, dry, and intact. She had 2 plus peripheral edema,
significant amount of fluid on board, and continued her Lasix
diuresis. She was screened by the Clinical Nutrition team
and evaluated by Physical Therapy.
Also on postoperative day five, she remained on amiodarone
orally now. Captopril was started at 6.25 mg p.o. t.i.d. as
well as diltiazem 30 mg p.o. q.d. to help prevent spasm. She
also continued on her Plavix for her stents. She had a blood
pressure of 111/88. Her creatinine rose slightly to 1.0.
She was hemodynamically stable and was transferred out to the
floor. She was evaluated again by Physical Therapy while she
was out there. Pulmonary toilet was begun as well as
ambulation.
On postoperative day six, she had some pain only when she was
coughing. Was hemodynamically stable with good blood
pressure. She had decreased breath sounds bilaterally and 2
plus peripheral edema, but otherwise her examination was
unremarkable. She was encouraged to have aggressive physical
therapy as well as chest physical therapy and work with her
incentive spirometer. She was also seen by the Case
Management team to evaluate her ability to go home with VNA
or to go to the facility in [**Hospital1 41677**].
On postoperative day seven, she was awake and alert with a T
max of 97.9, blood pressure of 120/76, a heart rate of 74 in
sinus rhythm with a respiratory rate of 20. Her lungs were
clear. Her heart sounds were normal. Incisions were clean,
dry, and intact. Sternum was stable. Patient was doing very
well. Repeat echocardiogram revealed an ejection fraction of
50 percent with a plan for the patient to go home that day.
She was ambulating well. Was taking p.o. Dilaudid for pain
relief an to be followed by [**Hospital2 **] [**Hospital3 **] VNA. She was
discharged on [**8-8**] in stable condition.
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting times two.
Status post emergent cardiac catheterization with placement
of coronary stents.
Hypertension.
Hypercholesterolemia.
Status post tonsillectomy.
Status post tubal ligation.
History of dilatation and curettage for status post stillborn
birth.
Status post stent placements in [**2166-5-13**].
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. twice a day x7 days.
2. Potassium chloride 20 mEq p.o. twice a day for seven days.
3. Docusate sodium 100 mg p.o. twice a day.
4. Enteric coated aspirin 325 mg p.o. once a day.
5. Isosorbide mononitrate 30 mg sustained release p.o. once a
day.
6. Amiodarone 400 mg p.o. twice a day x7 days, then
amiodarone 400 mg p.o. once a day x7 days, then amiodarone
200 mg p.o. once a day x2 weeks.
7. Lipitor 80 mg p.o. once a day.
8. Paxil 10 mg p.o. once a day.
9. Captopril 12.5 mg p.o. 3x a day.
10. Hydromorphone/hydrochloride 2 mg 1-2 tablets p.o.
prn q.4-6h for pain.
11. Plavix 150 mg p.o. once a day.
12. Diltiazem 120 mg p.o. once a day.
FOLLOW-UP INSTRUCTIONS: The patient was instructed to make a
follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3357**], her primary
care physician and cardiologist in approximately 1-2 weeks
after discharge and to followup with Dr. [**Last Name (STitle) **] for her
postoperative surgical visit in the office in approximately
four weeks post discharge.
CONDITION ON DISCHARGE AND DISPOSITION: Patient was
discharged in stable condition to a home with VNA services on
[**2166-8-8**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2166-8-26**] 11:02:44
T: [**2166-8-26**] 11:40:50
Job#: [**Job Number 55808**]
ICD9 Codes: 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2061
} | Medical Text: Admission Date: [**2114-6-26**] Discharge Date: [**2114-7-3**]
Date of Birth: [**2067-10-16**] Sex: M
Service: MED
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
nausea, vomiting, SOB
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
This is a 46 year old diabetic male who was hospitalized for
hypertensive emergency, NSTEMI, and DKA. Briefly, patient was
admitted to hospital [**2114-6-25**] with 3 days of nausea, vomiting, and
headache. He vomited every morning for three days prior to
admission. He had throat discomfort and a pressure in his
chest. He did not have arm/shoulder/jaw pain. He did not have
SOB/Diaphoresis, palp, edema, lightheadedness.
In the ED he was found to be in DKA with glucose of 430.
Insulin drip was started. BP was 218/110 with HR 62. TN 0.69
and MBI 10%. ECG with ST/T changes consistent with baseline
ECG. He was started on ASA, BB, IIb/IIIa, heparin. Admitted
to he MICU
Past Medical History:
Addison??????s Disease- [**2099**] on Hydrocort 25, 12.5
DM- dx in [**2099**], insulin-requiring. + triopathy
CRI (baseline 3.5)
Anemia
Peripheral Neuropathy
Peripheral Edema
?CAD: ETT MIBI (-) at RPP of 18,000 in [**4-20**]
s/p right retinal hemorrhage repair
Social History:
Lives alone. On disability for one year. Not married, no kids.
No smoking or drug use. Drinks EtOH rarely.
Family History:
Father died at 50 of an unknown cancer and mother at 60 of
breast cancer. Of four brothers, one died in [**2108**] with diabetes.
One living brother with diabetes.
Physical Exam:
97.4 62, 218/110, 17, 98%RA
Gen: Pleasant , NAD, A/O x3
HEENT: PEARLA, Anicteric, OP clear. MM dry
CV:RR, No M/R/C/G
Pulm: CTA b/l
ABD:S/NT/ND
Ext:3+ LE edema
Neuro: CNII-XII GI. Motor [**3-21**]. Sensation GI
Pertinent Results:
[**2114-6-25**] 02:00PM WBC-7.8 RBC-4.33* HGB-13.0* HCT-36.7* MCV-85
MCH-30.0 MCHC-35.4* RDW-13.9
[**2114-6-25**] 02:00PM PLT COUNT-246
[**2114-6-25**] 02:00PM CK-MB-10 MB INDX-9.3* cTropnT-0.69*
[**2114-6-25**] 02:00PM CK(CPK)-107
[**2114-6-25**] 02:00PM GLUCOSE-422* UREA N-84* CREAT-5.0*#
SODIUM-131* POTASSIUM-3.9 CHLORIDE-91* TOTAL CO2-21* ANION
GAP-23*
[**2114-6-25**] 08:15PM CK-MB-11* MB INDX-9.8*
[**2114-6-25**] 08:15PM cTropnT-0.59*
[**2114-6-25**] 08:15PM CK(CPK)-112
[**2114-6-26**] 06:00AM CK-MB-12* MB INDX-10.2*
[**2114-6-26**] 06:00AM cTropnT-0.56*
[**2114-6-26**] 06:00AM CK(CPK)-118
[**2114-6-26**] 03:50PM CORTISOL-33.4*
[**2114-6-26**] 08:10PM GLUCOSE-326* UREA N-77* CREAT-5.1*
SODIUM-132* POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-18* ANION
GAP-18
Brief Hospital Course:
1. Non ST-segment myocardial infarction- The patient was
admitted CCU after ruling in for a NSTEMI. The etiology is
unclear, but it occurred in the setting of SBP > 200. Patient's
nausea, vomiting, and throat pain were likely anginal
equivalents. He was treated with aspirin, beta-blocker,
IIb/IIIa, heparin and lipitor. Tight glucose control was
obtained with an insulin drip. Given patient's high risk TIMI
score, cardiology suggested that patient proceed with
catherization. Given his creatinine of 5.0, nephrology was
consulted. Nephrology concluded that there was a significant
risk that the patient may require life-long dialysis if he
proceeded with catheterization. The patient decided to defer the
catherization procedure to an outpatient procedure. Patient
wanted time to discuss treatment options with his nephrologist,
Dr. [**Known firstname **]. The patient continued to be treated medically
with goal of normalizing blood pressures and glucose levels.
After the patient was stablized on the medical floor, a
pharmacologic stress test was performed which showed no angina
or EKG changes at peak exertion. The perfusion scan was w/o
focal abnormalities but with the non-specific finding of
dilation with stress (? 3 vessel disease). Given that the
patient was free of sx, he chose to defer catheterization.
2. DM- On admission, patient was found to be in DKA. He was
placed on on an insulin drip, with resolution of anion gap
metabolic acidosis. The patient was followed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Diabetes Center endocrinologist. He was transitioned to insulin
sliding scale. He was eventually restarted on his outpatient
dose of NPH with the ISS. Blood sugars were high intermittently,
but urine remained neg for ketones and gap was normal. Glucose
control was well-controlled on discharged on NPH (16, 18). He
was advised to follow-up at the [**Hospital **] clinic as an outpatient.
3. Hypertension- On admission, blood pressures were over 200.
During the course of his hospitalization, Labetolol was
increased to 800 mg tid. Losartan 30 mg was added to blood
pressure regimen. Patient's PMD was consulted, and acknowledged
that pressures have also been difficult to treat as an
outpatient. At time of discharge BP was 120/70 on Labetolol 800
tid, hydralazine 50 qid and nifedipine 90. He was instructed to
follow up with his PMD.
4. Renal Failure- Patient's renal failure was thought to be
pre-renal and a result of both, vomiting and dehydration. During
hospitalization Cr decreased from 5.1 to 4.5. He was also
discharged on epo injections.
5. Peripheral Edema- patient was gently diuresed on last two
days of hospitalization.
He was discharged on Lasix 20 mg [**Hospital1 **].
6. Addison's: He was maintained on fludrocortisone 0.1 and
hydrocort 20 qAM, 5 qPM
Medications on Admission:
Labetalol 200 mg 3 tabs [**Hospital1 **].
Nifedipine XL 90 mg qd.
Hydralazine 50 mg qid.
Procrit 5000 units injection weekly.
Hydrocortisone 20 mg tablets 1 tablet am, tablet pm.
Levothyroxine 50 mcg qd.
Metolazone 2.5 mg qd.
Lorazepam 0.5 mg prn
Protonix 40 mg qd.
Fludrocortisone Acetate 0.1 mg 3 tabs qd.
Lasix 80 mg qd.
Aspirin 325 mg qd.
Insulin- 16 q AM, 17 qPM
Lipitor 10 mg qd.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. 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*
3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO QD (once a day).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
4. Fludrocortisone Acetate 0.1 mg Tablet Sig: Three (3) Tablet
PO QD (once a day).
Disp:*75 Tablet(s)* Refills:*2*
5. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Disp:*30 Tablet(s)* Refills:*2*
10. Labetalol HCl 200 mg Tablet Sig: Four (4) Tablet PO TID (3
times a day).
Disp:*360 Tablet(s)* Refills:*2*
11. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
Disp:*14 Tablet(s)* Refills:*0*
13. Hydrocortisone 5 mg Tablet Sig: 2.5 Tablets PO at bedtime.
Disp:*90 Tablet(s)* Refills:*2*
14. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO qAM.
Disp:*30 Tablet(s)* Refills:*2*
15. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO qAM: total
of 25 qAM.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Non ST-segment Elevation Myocardial Infarction
Insulin Dependent Diabetes
Chronic Renal Insufficiency
Addison's Disease
Anemia
Peripheral Neuropathy
Peripheral Edema
Discharge Condition:
Stable
Discharge Instructions:
Your persantine MIBI (cardiac stress test) demonstrated no
regional reversible defects but did demonstrate enlargement of
the heart with stress. As we discussed there is a risk that you
have coronary artery disease and should go to the ER or call 911
with any symptoms of chest discomfort, shortness of breath,
lightheadedness, fatigue or any other symptoms with exertion.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to renal diet (see handout)
Fluid Restriction: 1500 ml
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1144**] with any quesitions
or concerns.
Followup Instructions:
You have an appointment w/ Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2114-7-5**] at
10:00 AM.
Please call your kidney doctor, Dr. [**First Name8 (NamePattern2) **] [**Known firstname 805**] ([**Telephone/Fax (1) 817**]
to be seen within 1 week.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 542**] Where: PA [**Location (un) 5259**] BUILDING ([**Hospital Ward Name **] COMPLEX)
Date/Time:[**2114-7-11**] 1:20
Provider: [**Name10 (NameIs) 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Where: [**Hospital6 29**] CARDIAC
SERVICES. Please schedule an appointment with Dr. [**Last Name (STitle) **] over
the next month.
[**Last Name (un) **] Appts:
Thursday, [**7-5**] at 3:30 pm with [**First Name4 (NamePattern1) 16883**] [**Last Name (NamePattern1) 52672**], RN
Tuesday, [**7-10**] at 11am with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**]-Ossure
Completed by:[**2114-9-23**]
ICD9 Codes: 5849, 2765, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2062
} | Medical Text: Admission Date: [**2145-1-13**] Discharge Date: [**2145-2-10**]
Date of Birth: [**2068-9-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
endotracheal intubation
tracheostomy
PEG placement
History of Present Illness:
76 yo male with a history of end-stage pulmonary sarcoidosis who
presents with increased shortness of breath over last 24hrs,
tachycardia, general fatigue x 1 week. Similar prior
presentations, felt to be related to sarcoidosis. Denies any
increase in cough or sputum production, fevers, chills or
sweats. No abdominal pain, nausea, vomting or diarrhea.
Past Medical History:
1. Pulmonary sarcoidosis with pumonary fibrosis, dx [**2128**], s/p
lung bx
2. BPH
3. Hypercholesterolemia
4. Orthostatic hypotension
5. L eye ptosis since birth
6. Glucose intolerance
7. Chronic Encephalomalacia secondary to head trauma while
playing ice hockey in [**2106**]
8. h/o "tummy tuck" remotely
Social History:
Retired from import/export business in plumbing. Ran his own
business. Only out of country travel was to Bermuda years ago.
Smoking hx 1-1/2 ppd x 15 yrs, quit [**2117**]. No etoh or drugs.
Lives alone. Brother and his familiy live in [**Name (NI) 3146**].
Family History:
mother died at [**Age over 90 **] y.o. hx [**Name (NI) 11964**], Father died at 75 yo,
stroke/cerebral hemorrhage. Patient has 2 brothers, healthy.
[**Name2 (NI) 4084**] married, no children
Physical Exam:
PE on admission:
GEN: tachypnic appearing male
HEENT: [**Name (NI) 2994**], ptosis on left, anicteric, dry mucous membranes,
op without lesions, no supraclavicular or cervical
lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or
thyroid nodules
RESP: rhonchorous diffusely, poor air movement, using accessory
muscles of neck and abdomen to assist with ventilation
CV: tachycardic, no murmurs
ABD: nd, +b/s, soft though muscles contracted
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
.
Exam on Discharge
Gen: awake and alert w/trach in place, sitting up in bed, thin
frail-appearing man
HEENT: PERRLA. EOMI.
CV: rrr, no m/g/r
Lungs: diffuse coarse inspiratory and expiratory sounds.
Expiratory wheezing more prominent on right lung fields.
[**Last Name (un) **]: soft nondistended and nontender
Ext: no edema, + peripheral pulses bilaterally
Neuro: grossly intact, writing notes to communicate
Pertinent Results:
Admission Labs
[**2145-1-13**] 11:30AM BLOOD WBC-13.6*# RBC-4.83# Hgb-15.2# Hct-45.7#
MCV-95 MCH-31.5 MCHC-33.3 RDW-13.0 Plt Ct-247
[**2145-1-13**] 11:30AM BLOOD Neuts-91.1* Lymphs-5.6* Monos-2.7 Eos-0.3
Baso-0.4
[**2145-1-13**] 11:30AM BLOOD Glucose-107* UreaN-15 Creat-0.8 Na-143
K-3.8 Cl-101 HCO3-31 AnGap-15
[**2145-1-13**] 11:30AM BLOOD cTropnT-<0.01
[**2145-1-13**] 07:56PM BLOOD CK-MB-3 cTropnT-<0.01
[**2145-1-14**] 06:19AM BLOOD CK-MB-3
[**2145-1-13**] 07:56PM BLOOD Calcium-7.1* Phos-2.6* Mg-1.4*
[**2145-1-13**] 07:56PM BLOOD Cortsol-29.8*
[**2145-1-13**] 11:33AM BLOOD Lactate-2.1* K-3.7
.
Pertinent Labs
[**2145-1-17**] 04:42AM BLOOD WBC-7.0 RBC-3.36* Hgb-10.5* Hct-31.6*
MCV-94 MCH-31.2 MCHC-33.2 RDW-13.1 Plt Ct-196
[**2145-1-22**] 03:02AM BLOOD WBC-9.1 RBC-3.56* Hgb-10.8* Hct-32.5*
MCV-91 MCH-30.4 MCHC-33.3 RDW-12.7 Plt Ct-341
[**2145-1-26**] 02:44AM BLOOD WBC-9.3 RBC-3.08* Hgb-9.5* Hct-28.4*
MCV-92 MCH-30.9 MCHC-33.5 RDW-13.3 Plt Ct-399
[**2145-2-7**] 04:20AM BLOOD WBC-9.5 RBC-3.81* Hgb-11.9* Hct-35.9*
MCV-94 MCH-31.3 MCHC-33.2 RDW-13.8 Plt Ct-449*
[**2145-1-21**] 04:06AM BLOOD Plt Ct-323
[**2145-1-26**] 02:44AM BLOOD Plt Ct-399
[**2145-2-6**] 06:07AM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1
[**2145-2-7**] 04:20AM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1
[**2145-1-22**] 04:23PM BLOOD Glucose-86 UreaN-18 Creat-0.4* Na-139
K-3.5 Cl-94* HCO3-39* AnGap-10
[**2145-1-25**] 03:01AM BLOOD Glucose-87 UreaN-21* Creat-0.4* Na-146*
K-3.7 Cl-106 HCO3-38* AnGap-6*
[**2145-2-4**] 04:07AM BLOOD Glucose-78 UreaN-19 Creat-0.4* Na-145
K-3.8 Cl-98 HCO3-40* AnGap-11
[**2145-2-7**] 04:20AM BLOOD Glucose-101* UreaN-16 Creat-0.5 Na-148*
K-3.9 Cl-100 HCO3-43* AnGap-9
[**2145-1-25**] 03:01AM BLOOD ALT-33 AST-24 LD(LDH)-162 AlkPhos-98
TotBili-0.2
[**2145-1-15**] 03:44AM BLOOD Type-ART Temp-36.8 Rates-/25 PEEP-5
FiO2-40 pO2-163* pCO2-59* pH-7.33* calTCO2-33* Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2145-1-22**] 04:34PM BLOOD Type-[**Last Name (un) **] Temp-37.5 Rates-/12 Tidal V-320
PEEP-5 FiO2-30 pO2-48* pCO2-66* pH-7.43 calTCO2-45* Base XS-15
Intubat-INTUBATED Vent-SPONTANEOU
[**2145-1-27**] 03:36AM BLOOD Type-[**Last Name (un) **] Temp-38.2 Rates-/28 Tidal V-400
PEEP-5 FiO2-30 pO2-32* pCO2-59* pH-7.41 calTCO2-39* Base XS-8
Intubat-INTUBATED Vent-SPONTANEOU
[**2145-2-4**] 12:07AM BLOOD Type-ART pO2-127* pCO2-73* pH-7.39
calTCO2-46* Base XS-15 Intubat-INTUBATED
.
Microbiology
[**2145-1-13**] 12:00PM URINE Blood-MOD Nitrite-NEG Protein-150
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2145-1-18**] 03:34PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2145-2-6**] 02:12PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
.
Blood cultures ([**2145-1-13**]): No growth
Urine culture ([**2145-1-13**]): No growth
Sputum ([**2145-1-13**]): GRAM STAIN (Final [**2145-1-13**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT
WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2145-1-15**]): SPARSE GROWTH Commensal
Respiratory Flora.
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2145-1-14**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2145-1-14**]):
Negative for Influenza B.
Blood cultures ([**2145-1-15**]): No growth
Blood cultures ([**2145-1-18**]): No growth
Blood cultures ([**2145-1-27**]): No growth
CXR ([**2145-1-13**]): Aside from slightly lower lung volumes, there is
no significant interval change in the appearance of the
end-stage sarcoidosis as previously documented.
.
CXR ([**2145-1-24**]): Comparison with the previous study done
[**2145-1-20**]. There are extensive parenchymal and pleural changes
consistent with end-stage
sarcoidosis as before. An endotracheal tube and nasogastric tube
remain in
place. Allowing for differences in technique, there is no
significant change. No significant interval change.
.
CXR ([**2145-2-3**]): Previously questioned retrocardiac nodular
infection has cleared, presumably representing secretions
resolved from a region of cystic lung. In all other respects the
radiographic appearance of these severely scarred and
bronchiectatic lungs, as well as bilateral pleural abnormalities
are unchanged over the long-term. There are no findings to
suggest acute pneumonia or pulmonary edema.
Brief Hospital Course:
76 yo male with end stage sarcoidosis presenting with dyspnea.
.
# HYPERCARBIC RESPIRATORY FAILURE: Pt presented to the ER with
increased shortness of breath over 24hrs, tachycardia, and
generalized fatigue. Similar prior presentations were felt to be
related to sarcoid flares. CXR showed end stage pulmonary
fibrosis but no other abnormalities. It was felt his sx likely
represented pneumonia in setting of severe underlying fibrotic
lung disease. Pt was unable to sustain high minute ventilatory
rate, evidenced by a rising pCO2 and thus required emergent
intubation shortly after arrival to ICU. The patient was treated
for presumed pneumonia with levofloxacin and meropenem given
leukocytosis and dyspnea. Infectious work-up including multiple
blood cultures and viral cultures were negative. The patient
was not given steroids since it was felt that his sx were
related to an infectious process rather than a flair of his
sarcoid lung disease. The patient was made DNR after talking
with the son. IP consult was sought for trach placement given
the patient's inability to wean off the ventilator with
subsequent placement of tracheostomy and PEG on [**1-26**] and [**1-27**]
respectively. Pt tolerated trach mask well. He was transferred
to the floor on [**2-3**]. Later that afternoon he was noted to
desat into the 50's with increased work of breathing and was
requiring high levels of nursing care. He was transferred back
to the MICU where he again experienced agitation and increased
work of breathing. He was placed back on the vent on PS
overnight and tolerated this well and eventually was able to
transition to trach mask throughtout the day and night. Clinical
decompensation attributed to mucus plugging.
# CHRONIC ORTHOSTATIC HYPOTENSION: Pt normotensive on admission
to ICU. His home medications of midodrine and fludricortisone
were continued while admitted.
# Agitation: The patient had issues with agitation especially at
night. Geriatrics was consulted and a regimen of Seroquel was
initiated as well as efforts to limit lines and to orient him
frequently. His mental status waxed and waned and he fell out of
bed twice but sustained no injuries. By [**2-1**] his delirium had
improved on a regimen of seroquel to 12.5 mg [**Hospital1 **], seroquel 25 mg
QHS and Seroquel 25mg prn. Upon readmission to the MICU,
however, he again became significantly agitated and required IV
haldol in addition to his scheduled seroquel. EKG the following
morning did not show any eveidence of prolonged QT. Per
geriatric recommendations the pt's seroquel was increased to
50mg qhs and his sundowning improved. QTc was noted to 419 on
discharge dose of seroquel.
.
The patient was on SubQ heparin for DVT prophylaxis and PPI for
stress ulcer prophylaxis. Communication was with the patient and
his [**Last Name (LF) 802**], [**Name (NI) **] [**Name (NI) 2013**] ([**Name (NI) 802**]) [**Telephone/Fax (1) 97950**]. Code status was
DNR/DNI, confirmed with HCP.
.
# Malnutrition: He failed swallowing test twice with concern for
aspiration. PEG tube was placed and his tube feeds were
advanced to goal rate of 35 cc/hr. Medium chain trigylcerides
were added for coloric help.
.
Follow up at Rehab
1. Sundowning: [**Month (only) 116**] increase his schedule dose of seroquel [**Hospital1 **]
and qhs. His QTc on current dose is only 419. Please check EKG
after increasing his dose to ensure there is no significant QTc
prolongation.
Medications on Admission:
1. Fludrocortisone 0.1 mg DAILY
2. Tamsulosin 0.4 mg HS
3. Docusate Sodium 100 mg [**Hospital1 **] as needed for constipation
4. Midodrine 1.25 mg PO BID
5. Acetaminophen 1000 mg PO Q6H as needed for pain
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
2. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
3. senna 8.8 mg/5 mL Syrup [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. midodrine 2.5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a
day).
6. beclomethasone dipropionate 80 mcg/Actuation Aerosol [**Hospital1 **]: One
(1) Inhalation [**Hospital1 **] (2 times a day).
7. fludrocortisone 0.1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a
day).
11. nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
12. acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: One (1) ML
Miscellaneous Q4H (every 4 hours).
13. oxycodone-acetaminophen 5-325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
14. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing.
15. quetiapine 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QHS (once a
day (at bedtime)).
16. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q8H
(every 8 hours).
17. medium chain triglycerides 7.7 kcal/mL Oil [**Last Name (STitle) **]: One (1) ML
PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary Diagnosis
1. Hypercarbic respiratory failure
2. Pneumonia
3. Sarcoidosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted because you had shortness of breath which was
thought to be due to a pneumonia in setting of your underlying
sarcoidosis. You were treated with antibiotics called MEROPENEM
and VANCOMCYIN. You needed help with mechanical ventilation to
breathe. A tracheostomy was performed as you required prolong
ventilatory support. You were removed off of mechanical
ventilation and were breathing on trach collar mask prior to
transfer to [**Hospital **] rehab.
.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2145-3-10**] at 3:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2145-3-10**] at 4:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2145-3-10**] at 4:00 PM
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 486, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2063
} | Medical Text: Admission Date: [**2123-12-16**] Discharge Date: [**2123-12-18**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
fever, hematuria
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
79 y/o M w/CAD, CHF, CVA, C diff, B urolithiasis causing ARF
requiring R ureteral stent and L perc nephrostomy tube, who
presented to the ED tonight with one day of fever,
nausea/vomiting. Per NH notes, he became increasingly lethargic
and had an O2 sat of 85% on 2L so was sent to the ED for further
eval. His only complaint is that he was having hematuria. He was
seen in the ED on [**12-13**] for hematuria, had a negative renal u/s
and was seen by urology who recommended d/c home with f/u.
.
In the ED, his vitals were T 102.8, BP: 106/56, P: 122, RR: 28,
98% on 4L (90%RA). His bp dropped as low as 80s/50s but was
mostly 90s-110s/60s-70s. He received 6L NS. He was noted to have
a UTI on his UA and was given levofloxacin, and also was given
flagyl as he has a hx of c.diff. Central line was attempted but
the wire was unable to be threaded.
Past Medical History:
CVA - [**2117**] with residual right-sided weakness
OSA - on 2L NC during day and night; refused home CPAP
CAD - s/p MI 3 yrs ago
CHF - diastolic dysfunction
Anemia - [**8-24**] EGD with gastritis, colonoscopy with
diverticulosis, with GI bleeding
C diff colitis [**8-25**], [**11-24**]
Depression
s/p right shoulder surgery
s/p knee replacement
h/o right ureteral stent placement and left nephrostomy tube
placement for obstructive nephrolithiasis - removed [**7-25**]
right subcapsular perinephric hematoma
Social History:
Married, currently at [**Hospital **] rehab. H/o tobacco, 30 pack-years,
quit about 20 years ago. Drinks 2 drinks/week. No IVDU
Family History:
Noncontributory
Physical Exam:
T: 95.8 BP: 111/67 P: 113 R: 29 O2 sat: 98% on 4L
Gen: sleeping, arouses to voice, answers ?'s appropriately but
quickly falls back to sleep
HEENT: NC, AT, MM dry
Neck: supple, neck veins flat
Lungs: CTA anteriorly, pt unable to sit forward for posterior
exam
CV: regular, tachycardic, no murmur
Abd: soft, nt/nd, +bs
Ext: warm/dry, no edema, 2+ dp bilaterally
Neuro: arouses to voice, R pupil reactive, L pupil surgical,
intermittently following commands
Pertinent Results:
[**2123-12-16**] 08:22PM GLUCOSE-125* POTASSIUM-4.1
[**2123-12-16**] 08:22PM CALCIUM-8.0* MAGNESIUM-2.3
[**2123-12-16**] 08:22PM HCT-24.5*
[**2123-12-16**] 05:39PM FIBRINOGE-391 D-DIMER-9675*
[**2123-12-16**] 04:41PM HCT-26.1*
[**2123-12-16**] 04:41PM FDP-80-160*
[**2123-12-16**] 03:53AM GLUCOSE-117* UREA N-27* CREAT-1.4* SODIUM-140
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-12
[**2123-12-16**] 03:53AM ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-49 TOT
BILI-0.6
[**2123-12-16**] 03:53AM CALCIUM-7.5* PHOSPHATE-3.4 MAGNESIUM-1.5*
[**2123-12-16**] 03:53AM WBC-13.7*# RBC-3.06* HGB-9.2* HCT-27.0*
MCV-88 MCH-30.1 MCHC-34.0 RDW-16.9*
[**2123-12-16**] 03:53AM NEUTS-79* BANDS-9* LYMPHS-3* MONOS-7 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2123-12-16**] 03:53AM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL
[**2123-12-16**] 03:53AM PLT COUNT-71*
[**2123-12-16**] 03:53AM PT-15.6* PTT-30.5 INR(PT)-1.4*
[**2123-12-16**] 12:15AM GLUCOSE-101 UREA N-27* CREAT-1.5* SODIUM-140
POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-19* ANION GAP-16
[**2123-12-16**] 12:15AM CALCIUM-7.7* PHOSPHATE-2.2* MAGNESIUM-1.3*
[**2123-12-15**] 09:43PM URINE COLOR-DkAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2123-12-15**] 09:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2123-12-15**] 09:43PM URINE RBC->50 WBC-[**5-29**]* BACTERIA-OCC
YEAST-NONE EPI-0
[**2123-12-15**] 09:24PM LACTATE-2.0
[**2123-12-15**] 09:15PM GLUCOSE-131* UREA N-33* CREAT-1.7* SODIUM-136
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
[**2123-12-15**] 09:15PM CK(CPK)-29*
[**2123-12-15**] 09:15PM CK-MB-NotDone cTropnT-0.05*
[**2123-12-15**] 09:15PM CALCIUM-9.1 PHOSPHATE-1.8*# MAGNESIUM-1.5*
[**2123-12-15**] 09:15PM WBC-7.3 RBC-3.69* HGB-10.9* HCT-31.8* MCV-86
MCH-29.5 MCHC-34.2 RDW-17.0*
[**2123-12-15**] 09:15PM NEUTS-84* BANDS-12* LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2123-12-15**] 09:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2123-12-15**] 09:15PM PLT SMR-VERY LOW PLT COUNT-79*
[**2123-12-15**] 09:15PM PT-13.3* PTT-25.0 INR(PT)-1.2*
.
Microbiology:
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2123-12-16**]):
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
Blood culture: [**12-15**]
KLEBSIELLA PNEUMONIAE
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- R
GENTAMICIN------------ S
LEVOFLOXACIN---------- R
MEROPENEM------------- S
TOBRAMYCIN------------ S
.
Urine culture: [**12-15**] >100,000
KLEBSIELLA PNEUMONIAE
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 32 R
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Imaging:
[**12-16**]: CTU Abdomen/Pelvis
IMPRESSION:
1. Inappropriately placed Foley catheter, with the balloon
inflated in the bulbous portion of the urethra, causing
obstructive uropathy with a distended urinary bladder, prominent
ureters, and full collecting systems bilaterally.
2. Improvement in the right kidney subcapsular fluid collection
since the prior study. Nonspecific bilateral perinephric
stranding.
3. Punctate nonobstructing right kidney stones.
4. Multiple bilateral hypodensities in both kidneys are
incompletely
evaluated. Some of these are high density, and further workup
with ultrasound
or MR, if not already completed, should be considered.
5. Multiple small hypodensities in the liver are likely cysts
but are too small to characterize.
6. Diverticulosis without diverticulitis.
7. Pleural calcifications bilaterally consistent with prior
asbestos
exposure. Bibasilar atelectasis and small bilateral pleural
effusions.
.
[**12-17**]: Bladder US
IMPRESSION: Limited study that demonstrates Foley catheter
balloon in decompressed urinary bladder
Brief Hospital Course:
This is a 79 y/o M w/ CAD, CHF, CVA, hx C.diff, B urolithiasis
with ARF and R ureteral stent and left percutaneous nephrostomy
tube, who came to ED on [**12-16**] with fever, nausea, vomiting and
hematuria, likely with urosepsis, initially hypotensive on
arrival to the MICU, stabilized, developed volume overload and
oxygen requirment, then transferred to medical floor.
.
1. Urosepsis: Originally came in with fever to 103, hypotension
(80s/50s), resolved with the administration of 6L of NS in the
ED as well as IV antibiotics (Levo/Flagyl). Originally, he was
admitted to the MICU and treated for gram negative rod sepsis
with meropenem (start date: [**12-16**]) given history of EBSL in
urine. He did not require any pressors during his period of
hypotension. Lactate was not elevated and he did not have any
evidence of end-organ hypoperfusion. On the floor, he was
continued on meropenem, gram negative rods speciated to
Klebsiella pneumoniae. Sensitivities showed sensitivity to
ceftriaxone, so spectrum was narrowed, and he was discharged on
ceftriaxone 1g q24. This should be continued until [**2123-12-30**]. PICC line was placed for antibiotic administration.
.
2. Hematuria: Urology following patient while in house. ? If
hematuria was secondary to traumatic foley placement as
evidenced on CTU, but thrombocytopenia may have played a role.
Foley was placed on [**12-16**] (confirmed by ultrasound), and should
remain in place for a total of two weeks until he follows up
with Dr. [**Last Name (STitle) 4229**]. He should have his foley flushed every 8 hours.
Thrombocytopenia was resolving at discharge with
discontinuation of PPI (which was thought to be the cause).
.
3. Congestive Heart Failure: TTE [**5-25**] with preserved EF,
however, volume overloaded on exam after receiving 6L with
initial hypotension. He was given IV Lasix prn for diuresis and
responded well. He was weaned down to 1L of oxygen prior to
discharge.
.
4. Clostridium difficile: C.diff was checked given that he had
it in [**8-25**] as a possible cause of his sepsis, although he did
not have any symptoms of diarrhea. It came back positive and he
was started on flagyl on [**12-16**]. This should be continued for a
total of two weeks until [**2122-12-30**]. Patient not symptomatic with
diarrhea, leukocytosis is resolving.
.
5. Thrombocytopenia: ? cause as platelets were normal previously
as an outpatient. PPI was discontinued in MICU for question of
cause of thrombocytopenia. No heparin products administered
during stay. Platelets continued to trend up with
discontinuation of PPI. He should likely be kept off this
medication unless he is being monitored closels.
.
6. Chronic Renal Insufficiency: Creatinine at baseline. CKD
likely due to hydronephrosis from renal stones. Trended
creatinine, which remained stable.
.
7. CAD: No signs or symptoms of ischemia; troponin checked in ED
was mildly elevated at 0.05 but unclear significance of this.
Aspirin has been on hold at NH, ? if due to thrombocytopenia.
Initially held metoprolol given sepsis, but restarted due to
hypertension [**12-17**]. LDL < 100, not on statin.
.
8. Anemia: Hct above baseline, no indications for transfusion or
clinical signs of bleeding. He was continued on his outpt iron
regimen.
.
9. FEN: He was on a cardiac/heart healthy diet, lytes were
repleted prn
.
10. Code: Full
.
11. Communication: With patient
.
12. Dispo: Back to rehab center
Medications on Admission:
multivitamin
prilosec
spiriva
lopressor 25 [**Hospital1 **]
aspirin 81 (on hold)
tylenol
lidoderm patch
oxycodone
iron 325 mg tid
ultram 25 mg [**Hospital1 **]
colace
senna
dulcolax
compazine prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 11 days.
5. CeftriaXONE 1 gm IV Q24H
Day 1: [**12-16**]
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
13. Compazine 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
14. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
C. diff colitis
Urosepsis with klebsiella pneumonia
CHF
.
Secondary diagnosis:
CAD
OSA
CVA with residual right-sided weakness
Depression
Pseudogout
Discharge Condition:
Good
Discharge Instructions:
You were admitted with urosepsis and C. diff colitis. You are
being treated with ceftriaxone and metronidazole, which should
be continued for a total of 2 weeks ([**2123-12-30**]).
.
Please call your doctor if you have fevers, chills, chest pain,
shortness of breath, abdominal pain, hematuria, diarrhea.
Followup Instructions:
You have the following appointment already scheduled with Dr.
[**Last Name (STitle) 4229**]. You should reschedule it for [**2123-12-30**] or close to it to
have your foley catheter removed. You can reach his office at:
Phone:[**Telephone/Fax (1) 10941**]
Your appointment is for: Date/Time:[**2123-12-21**] 11:30
.
Please make an appointment to see your primary care doctor, Dr.
[**Last Name (STitle) **] after discharged from rehab. You can reach his
office at: [**Telephone/Fax (1) 1579**]
ICD9 Codes: 2875, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2064
} | Medical Text: Admission Date: [**2157-1-27**] Discharge Date: [**2157-2-4**]
Date of Birth: [**2108-11-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Unstable angina
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times two (LIMA->LAD, SVG->OM)
[**2157-1-31**]
History of Present Illness:
Mr. [**Known lastname 84091**] is ESRD on HD since '[**46**] who developed angina about 3
years ago. Cardiac cath at that time showed CAD and PCI was not
successful. Patient was not interested in surgery at that time.
Since [**2154**], patient has become wheelchair bound, had
significant decrease in appetite, and significant weight loss.
Patient has had increasing frequency of angina, sometimes taking
up to 12 SL NTG/day. He was given prescriptions for plavix, but
was unable to afford it. He is now willing to consider surgery.
He underwent cardiac cath today
which showed EF 25% and severe 3vd.
Past Medical History:
ESRD on HD since [**2146**] d/t polycyctic kidney disease
HTN
hyperlipidemia
RBBB
CAD
depression
restless leg syndrome
s/p bilateral hip fractures-s/p surgical repair
s/p ankle fracture-s/p repair
osteoporosis
hyperparathyroidism secondary to renal disease-unable to afford
medication
hyperkalemia
remote h/o AF
s/p repair of bilat hipfracture
s/p repair of ankle fracture
s/p multiple L AV fistulas and revisions
Social History:
Lives with:wife
Occupation:disabled driver
Tobacco:remote-quit [**2130**]
ETOH:denies
Family History:
unremarkable
Physical Exam:
Pulse:76 Resp:15 O2 sat: 96 on RA
B/P Right:170/90 Left: unable d/t fistula
Height: Weight:54kg
General:cachetic
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 [] Murmur3/6 diastolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x], distal LE w/loss of hair and ruborous color
Neuro: Grossly intact
Pulses:
Femoral Right: 2+-cath site without hemaotma Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2157-2-3**] 12:00PM BLOOD WBC-7.5 RBC-3.15* Hgb-9.6* Hct-29.7*
MCV-95 MCH-30.5 MCHC-32.3 RDW-15.6* Plt Ct-239
[**2157-1-31**] 06:50PM BLOOD PT-14.1* PTT-36.8* INR(PT)-1.2*
[**2157-2-3**] 12:00PM BLOOD Glucose-109* UreaN-64* Creat-5.7*#
Na-132* K-4.9 Cl-93* HCO3-27 AnGap-17
[**Known lastname **],[**Known firstname **] A [**Age over 90 84092**] M 48 [**2108-11-30**]
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2157-1-31**] 9:45 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2157-1-31**] 9:45 PM
CHEST PORT. LINE PLACEMENT Clip # [**Clip Number (Radiology) 84093**]
Reason: ptx
[**Hospital 93**] MEDICAL CONDITION:
48 year old man with s/p CABG - please [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 84094**] with
results if there
is concern with findings
REASON FOR THIS EXAMINATION:
ptx
Final Report
CXR PORTABLE FILM
HISTORY: Status post CABG.
FINDINGS: Bilateral lower lobe opacities/atelectases noted.
Sternotomy.
Small left apical pneumothorax. ET tube tip lies 5 cm above the
carina and is
satisfactory. Swan-Ganz catheter tip lies in the main pulmonary
artery
outflow.
CONCLUSION: Postop changes. Small left apical pneumothorax. Left
chest tube
is in place.
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: [**First Name8 (NamePattern2) **] [**2157-2-1**] 11:47 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84095**] (Complete)
Done [**2157-1-31**] at 3:09:41 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2108-11-30**]
Age (years): 48 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG
ICD-9 Codes: 786.05, 786.51, 424.0
Test Information
Date/Time: [**2157-1-31**] at 15:09 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW1-: Machine: aw5
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 - 50 %), 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. No mitral regurgitation is
seen.
There is no pericardial effusion.
Post-CPB:
There is preserved biventricular systolic fxn. No AI, no MR.
Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2157-2-2**] 17:45
Brief Hospital Course:
The patient was transferred from [**Hospital6 1109**] on
[**2157-1-27**]. He continued to have daily chest pain and was on IV
NTG. He had HD and on [**2157-1-31**] he underwent coronary artery
bypass grafting times two with LIMA->LAD and SVG->OM. He
tolerated the procedure well and was transferred to the CVICU on
neo and propofol in stable condition. The cross clamp time was
38 minutes and the total bypass time was 49 minutes. He was
extubated on the post op night and was transferred to the floor
on POD#2. He was dialyzed on POD#1. His chest tubes were
discontinued on POD#1. His epicardial pacing wires were
discontinued on POD#3. He continued to progress and was
discharged to rehab in stable condition on POD#4.
Medications on Admission:
toprol xl 100mg by mouth twice daily
univasc 15mg by mouth twice daily
asprin 162 mg by mouth twice daily
renvalia 2-3 tabs w/meals
SL NTG
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q6H (every 6 hours) as needed
for pain.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed for anxiety.
12. Univasc 7.5 mg Tablet Sig: One (1) Tablet PO twice a day:
home dose 15mg [**Hospital1 **]- titrate as [**Last Name (un) 1815**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5176**] Pines Extended Care - Facility (Spec)
Discharge Diagnosis:
ESRD on HD
polycystic kidney disease
hypertension
coronary artery disease
hyperlipidemia
depression
restless leg syndrome
s/p bilateral hip fractures
osteoporosis
hyperparathyroidism
atrial fibrillation in past
s/p multiple AV fistula revisions
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Recommended Follow-up:Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 84096**]) in [**1-22**] weeks
Cardiologist Dr. [**Last Name (STitle) 20222**] ([**Telephone/Fax (1) **]) in [**1-22**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2157-2-4**]
ICD9 Codes: 5856, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2065
} | Medical Text: Admission Date: [**2179-2-1**] Discharge Date: [**2179-2-8**]
Date of Birth: [**2114-2-8**] Sex: M
Service: MEDICINE
Allergies:
Doxepin / Levofloxacin / Oxycontin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
stenting of SVC
History of Present Illness:
64 yo man with h/o lung CA s/p R pneumonectomy, severe COPD,
with prolonged respiratory failure requiring prolonged trach (2
months ago) wean presents from rehab with increased bilateral
upper extremety edema (present since [**10-31**] admission) and left
sided chest pain for 2 days(continuous for about 20hrs). Patient
denies any fevers, chills, cough, radiation, diaphoeris, no
similar pain in past, no pleuritic nature, n/v/diaphoresis. No
associated triggers or change with positions, no pain currently.
He had been doing well at rehab this past week after ativan and
valium were stopped and started on haldol with good relief.
Past Medical History:
1. Squamous cell lung carcinoma, status post right
pneumonectomy in [**2174**].
2. Prostate cancer, status post radical prostatectomy.
3. Perioperative pulmonary embolus [**2174**].
4. Type 2 diabetes mellitus.
5. Chronic obstructive pulmonary disease.
6. Atrial fibrillation.
7. Transient ischemic attack in [**2165**].
8. Gout.
9. Atypical chest pain since [**2164**].
10. Gastroesophageal reflux disease.
11. Obstructive sleep apnea. unable to tolerate BiPAP.
12. Hypertension.
13. Colonic polyps.
14. Hypercholesterolemia.
15. Basal cell carcinoma on his back.
16. Anxiety.
17. Sciatica.
18. History of herpes zoster.
19. multiple admissions for pneumonia (including pseudomonas)
and bronchitis, last in [**10-31**] resulting in ventilator
dependence, trach and [**Date Range 282**] placement
20. vitamin B12 deficiency.
21. Diastolic heart failure. Echo [**7-31**]: LVEF>55%
21. Cataracts
22. bradycardia on amiodarone
Social History:
Recently discharged to [**Hospital **] rehab s/p trach and [**Hospital 282**]. He has
a 3-pack-per-day tobacco history but quit in [**2174**] and an overall
160-pack-per-year history. No recent history of alcohol use.
Family History:
Mother with coronary artery disease.
Physical Exam:
VS: T 99.2 P 72-91 BP 129/75 R19 Sat 100% on AC 500/20/5/40%
GEN aao, nad, able to mouth responses to questions
HEENT PERRL, MMM, +trach in place
CHEST CTAB with diffuse expiratory wheezes bilaterally
posteriorly
CV RRR- no murmurs
ABD soft, +[**Year (4 digits) 282**] in place, +BS, nontender
EXT no edema BLE, +edema BUE with scabs and excoriations
Pertinent Results:
[**2179-2-1**] 05:00PM CK(CPK)-54 CK-MB-NotDone cTropnT-0.09*
[**2179-2-2**] 12:00AM CK(CPK)-55 CK-MB-NotDone cTropnT-0.12*
[**2179-2-2**] 05:25AM BLOOD CK(CPK)-56 CK-MB-NotDone cTropnT-0.14*
[**2179-2-2**] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2179-2-2**] 08:12PM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2179-2-3**] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.12*
.
[**2179-2-1**] 05:00PM GLUCOSE-77 UREA N-18 CREAT-0.6 SODIUM-137
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-43* ANION GAP-3*
[**2179-2-1**] 05:00PM WBC-9.1 RBC-3.36* HGB-9.3* HCT-30.4* MCV-91
MCH-27.8 MCHC-30.7* RDW-13.9
[**2179-2-1**] 05:00PM NEUTS-87.3* LYMPHS-7.4* MONOS-3.7 EOS-1.2
BASOS-0.3
[**2179-2-1**] 05:00PM PLT COUNT-358
[**2179-2-1**] 05:00PM PT-18.0* PTT-31.0 INR(PT)-2.0
.
CTA
1. No CT evidence of pulmonary embolism.
2. Stable right pneumonectomy changes.
3. Stable left upper lobe pulmonary nodule.
4. Small mediastinal lymph nodes, none of which meet criteria
for pathologic enlargement.
5. Stable appearance of the superior vena cava which is patent
throughout, but compressed proximally to a slit-like lumen.
5. Chronic occlusion of the left subclavian artery and vein with
numerous vascular collaterals demonstrated within the anterior
chest wall.
.
Brief Hospital Course:
A/P: 64 yo man s/p lung ca s/p pneumonectomy and severe COPD
here after prolonged admission for respiratory failure requiring
tracheostomy placement here with new left sided chest pain.
.
1. Chest pain: Multiple sets of cardiac enzymes were cycled and
CK/MB remained flat while troponin increased slightly and then
remained stable at 0.12. Repeat EKGs showed no changes.
Cardiology was consulted and agreed that there was no evidence
of an acute ischemic event. Pt was continued on ASA. The pt's
chest pain may be related to his chronic SVC syndrome.
.
2. Respiratory Failure: Pt on a prolonged ventilator wean
secondary to COPD, pneumonectomy, lung cancer and hx of
recurrent pneumonias. Pt was continued on AC at night and
pressure support during the day. He will continued to wean at
rehab.
.
3. Bilateral upper extremety swelling: This has been chronic
since last admission w/o evidence of DVT. Pt had another CTA in
the ER that showed no PE but did show a narrowing of the SVC.
Interventional radiology placed a stent in the SVC and over the
next several days, the pt's upper ext swelling improved.
.
4. Atrial fibrillation: Pt remained in normal sinus rhythm for
most of the hospital stay except for a brief episode of a fib
with rapid ventricular rate which resolved on its own. Pt was
continued on his coumadin.
.
5. Anxiety: Pt has a long history of anxiety controlled on
fentanyl, morphine prn, haldol. AVOID benzos as pt has
paradoxical response.
*
6. Anemia: Likely secondary to chronic disease- baseline around
28. Iron studies were sent and revealed a low iron with normal
TIBC, ferritin. He was transfused once to [**Last Name (un) 291**] hct>30.
.
7. DM type 2: Pt's glucose was controlled with glargine and an
insulin sliding scale.
.
8. Access: A PICC line was placed by IR when pt was having his
SVC stented. If this line is not needed, it should be pulled to
decrease infection risk. It was placed on [**2179-2-4**].
Medications on Admission:
haldol 2mg at q800/1400 and 5mg qhs and 1mg prn tid
bacitracin, clotrimazole/betamethasone, albuterol neb q4hrs,
budesonide 0.5mg neb q12hrs, ipratropium neb q4hrs, casec powder
wafarin 7mg qd, colace 100mg [**Hospital1 **], glargine 14units qam, glycerin
suppository daily, MVI qd, magnes hydroxide 30ml qd
lactulose 20gm tid, acetaminaphen 650mg q4hr prn, SSI, ambien
10mg qhs prn, ascorbic acid 500mg [**Hospital1 **], zinc sulfate 220mg qd,
sodium bicarbonate 10cc qd, lansoprazole 30mg qd, fentanyl 75mcg
patch q72hrs, morphine 2-4mg IV prn
Discharge Medications:
1. Haloperidol 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
2. Haloperidol 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8AM/2PM ().
3. Haloperidol 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day) as needed for agitation.
4. Docusate Sodium 150 mg/15 mL Liquid [**Hospital1 **]: Fifteen (15) mL PO
BID (2 times a day).
5. Zolpidem Tartrate 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime) as needed for insomnia.
6. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Fentanyl 75 mcg/hr Patch 72HR [**Hospital1 **]: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
11. Multivitamin Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
12. Ascorbic Acid 100 mg/mL Drops [**Hospital1 **]: One (1) mL PO BID (2
times a day).
13. Zinc Sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
14. Clotrimazole 1 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
15. Betamethasone Dipropionate 0.05 % Cream [**Hospital1 **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
16. Bacitracin Zinc 500 unit/g Ointment [**Hospital1 **]: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
17. Warfarin Sodium 5 mg Tablet [**Hospital1 **]: 1.5 Tablets PO HS (at
bedtime): goal INR [**12-31**].
18. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (3) **]: Four (4) Puff
Inhalation Q4H (every 4 hours).
19. Ipratropium Bromide 18 mcg/Actuation Aerosol [**Month/Day (3) **]: Two (2)
Puff Inhalation QID (4 times a day).
20. Fluticasone Propionate 110 mcg/Actuation Aerosol [**Month/Day (3) **]: Two
(2) Puff Inhalation [**Hospital1 **] (2 times a day).
21. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Fourteen (14)
units Subcutaneous at bedtime.
22. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
23. Senna 8.8 mg/5 mL Syrup [**Hospital1 **]: Five (5) mL) PO BID (2 times a
day) as needed.
24. Morphine Sulfate 2 mg/mL Syringe [**Hospital1 **]: [**11-29**] mL [**Month/Day (2) **] Q4H
(every 4 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnosis:
1. SVC syndrome
2. Angina
Secondary Diagnosis:
1. Respiratory Failure s/p trach
2. Anxiety
Discharge Condition:
good
Discharge Instructions:
take all medications as prescribed and go to all follow-up
appointments
Followup Instructions:
Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], as needed
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 496, 4280, 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2066
} | Medical Text: Admission Date: [**2119-7-1**] Discharge Date: [**2119-7-6**]
Date of Birth: [**2050-12-3**] Sex: F
Service: MEDICINE
Allergies:
fentanyl
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Obtunded
Major Surgical or Invasive Procedure:
Central Venous Catheter Placement
History of Present Illness:
68-year-old female with chronic neck/back pain on high dose
narcotics who presents with altered mental status. Her mental
status has been poor for the past two days and her family
suspects she took too many narcotics. No known nausea/vomiting
or fever/chills. Family called EMS today where she was found
sitting on the couch slumped over to her right. She was "out of
it like this since Thursday (2 days prior to admission)." EMS
found patient to be moaning with minimal movement and pupils
were 3mm and sluggishly reactive. 1L NS was given and 1mg narcan
was given. EMS reported after narcan "patient opens her eyes and
responds verbally to EMS questioning, some words are
understandable and correct in their response, while others are
incomprehensible." She was given another 1mg narcan en route to
OSH, however there was no documented response after this dose.
At the OSH, AST/ALT were elevated in the thousands, APAP level
negative. CT head showed no acute intracranial process. CXR
showed minimal right basilar atelectasis. She was intubated for
airway protection.
.
Upon arrival to the [**Hospital1 18**] ED, vitals: were afebrile SBP 70-80s,
minimally responsive. Subclavian CVL placed and norepinephrine
started. BP improved to 120/60. Received 2 doses of NAC.
Vancomycin and zosyn given. She recieved 5L NS with minimal
urine output. ECG showed sinus rhythm at 74bpm, RAD with ST
depressions v3-v6. Labs notable for AST 617 ALT 750 CK 3800, Cr
4.1, BUN 50, HCO3 20, K 3.1, lactate 1.5, WBC 11.7, HCT 33, INR
4.4. Urine tox positive for benzodiazepines and opiates. Serum
tox negative for ASA, ETOH, APAP, TCA, benzo, barbs. UA with 56
WBC moderate leukesterase and few bacteria and hyaline casts.
Seen by toxicology who recommended evaluation of gap, continuing
NAC. Vitals prior to transfer: 36.7C, HR 65 RR 22 100% 126/53.
.
On arrival to the MICU, she awoke and nearly pulled out her ET
tube. She opens her eyes to voice and follows simple commands.
She was breathing comfortably.
Past Medical History:
Fibromylagia
anxiety
depression
COPD
HTN
hyperchol
breast cancer s/p left breast lumpectomy
s/p b/l CEA
s/p bladder suspension
bilateral hip fractures
Social History:
unable to obtain
Family History:
unable to obtain
Physical Exam:
ADMISSION EXAM:
Vitals: 98.5, 70, 110/44, 100% on vent
General: Intubated, not sedated, awakes to voice and follows
simple commands
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no edema, unstagable coccyx
ulcers
Neuro: PERRL, moving all 4 extremities, responding to simple
commands
.
DISCHARGE EXAM:
Vitals: 97.9, 176/73, 77, 20, 99% on 2L NC
General: No acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, non-tender, mildly distended, bowel sounds
present, no organomegaly
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no edema, unstageable
coccyx ulcers
Neuro: Knows name and where she is. Able to state month and
year. Moves all 4 extremities on command.
Pertinent Results:
ADMISSION LABS:
[**2119-7-1**] 09:20PM BLOOD WBC-11.7* RBC-3.59* Hgb-10.2* Hct-33.2*
MCV-93 MCH-28.5 MCHC-30.8* RDW-15.4 Plt Ct-340
[**2119-7-1**] 09:20PM BLOOD Neuts-90.1* Lymphs-7.3* Monos-2.1 Eos-0.4
Baso-0.1
[**2119-7-1**] 09:20PM BLOOD PT-44.7* PTT-58.8* INR(PT)-4.4*
[**2119-7-1**] 09:20PM BLOOD Glucose-156* UreaN-50* Creat-4.1* Na-136
K-3.1* Cl-99 HCO3-20* AnGap-20
[**2119-7-1**] 09:20PM BLOOD ALT-617* AST-750* CK(CPK)-3800*
AlkPhos-102 TotBili-0.3
[**2119-7-1**] 09:20PM BLOOD Lipase-37
[**2119-7-1**] 09:20PM BLOOD Albumin-2.7* Calcium-6.9* Phos-5.8*
Mg-1.7
[**2119-7-1**] 09:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2119-7-1**] 09:30PM BLOOD Lactate-1.5
.
PERTINENT LABS:
[**2119-7-1**] 09:20PM BLOOD cTropnT-0.18*
[**2119-7-2**] 04:01AM BLOOD CK-MB-13* MB Indx-0.5 cTropnT-0.17*
[**2119-7-2**] 04:30PM BLOOD CK-MB-10 MB Indx-0.6 cTropnT-0.14*
[**2119-7-3**] 01:56AM BLOOD CK-MB-8 cTropnT-0.11*
[**2119-7-3**] 04:25AM BLOOD CK-MB-12* MB Indx-0.4 cTropnT-0.16*
.
[**2119-7-1**] 08:35PM URINE Color-YELLOW Appear-Cloudy Sp [**Last Name (un) **]-1.014
[**2119-7-1**] 08:35PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2119-7-1**] 08:35PM URINE RBC-3* WBC-56* Bacteri-FEW Yeast-NONE
Epi-3
[**2119-7-2**] 09:30AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2119-7-2**] 09:30AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2119-7-2**] 09:30AM URINE RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
.
DISCHARGE LABS:
[**2119-7-5**] 03:23AM BLOOD WBC-6.0 RBC-3.07* Hgb-8.8* Hct-28.4*
MCV-92 MCH-28.6 MCHC-31.0 RDW-16.5* Plt Ct-316
[**2119-7-4**] 04:17AM BLOOD PT-13.7* PTT-27.9 INR(PT)-1.3*
[**2119-7-5**] 03:23AM BLOOD Glucose-88 UreaN-17 Creat-0.8 Na-144
K-3.8 Cl-109* HCO3-27 AnGap-12
[**2119-7-5**] 03:23AM BLOOD ALT-170* AST-50* LD(LDH)-216 AlkPhos-76
TotBili-0.5
[**2119-7-5**] 03:23AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0
.
MICROBIOLOGY:
[**2119-7-1**] Blood cultrue: no growth to date
[**2119-7-2**] Urine culture: no growth
.
IMAGING:
[**2119-7-1**] CXR: Single portable view of the chest. No prior.
Endotracheal tube is seen with tip approximately 4.5 cm from the
carina. Endotracheal tube is seen coiled in the stomach with tip
at the gastric fundus. The lungs are clear of large confluent
consolidation or effusion. Cardiac silhouette is within normal
limits. There is no evidence of pulmonary vascular engorgement.
Osseous and soft tissue structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process. ET and enteric
tubes as above.
.
[**2119-7-3**] CT Head w/o con: There is no hemorrhage, edema, mass
effect, or territorial infarction. The ventricles and sulci are
prominent, consistent with generalized atrophy. Periventricular
white matter hypodensities are consistent with chronic small
vessel ischemic disease. The basal cisterns are patent and
[**Doctor Last Name 352**]-white matter differentiation is preserved. There is no
fracture. The visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear.
IMPRESSION: No acute intracranial process.
.
[**2119-7-4**] CXR: As compared to the previous radiograph, patient
has received a new endotracheal tube with the tip projects 5 cm
above the carina. The other monitoring and support devices are
constant. Unchanged lung volumes. Unchanged size of the cardiac
silhouette. The right hilus appears a little more prominent,
likely because of patient rotation. No new parenchymal
opacities, pleural effusion or other lung parenchymal
abnormalities.
Brief Hospital Course:
68-year-old female with chronic neck/back pain on high dose
narcotics who presented with altered mental status and shock.
.
# Altered mental status: Likely secondary to narcotic overdose
given high home doses of oxycodone/oxycontin and reported
improvement with narcan by EMS. Narcotics were initially held
with continued improvement in mental status. CT head negative
for bleed, stroke, or other acute process. Tox screen negative
and no metabolic abnormalities. EEG negative for seizure
activity. Patient was treated empirically with vanc/zosyn which
were discontinued when there were no signs of infection (UA
negative, CXR negative, blood cultures no growth to date). We
restarted Oxycodone liquid 5mg Q8h prn pain, but are holding the
oxycontin and gabapentin. Could consider restarting as needed if
her mental status continues to improve. Social work evaluated
the patient and this does not appear to have been an intentional
overdose. The patient is currently alert and oriented to self
and place and can state the month and year, however she is not
back at her baseline mental status. Suspect that there is a
component of hypoxic brain injury.
.
# Shock: Likely hypovolemic shock in the setting of narcotic
overdose and poor PO intake for several days. Patient was
initially on pressors and was empirically on vanc/zosyn which
were later discontinued after all cultures and CXR were negative
for infectious process. Patient was given IVF, narcotics were
held, and her BP improved and she was weaned off the pressors.
.
# Acute kidney injury: Admission creatinine was 4.1 which was
felt to be secondary to poor renal perfusion in the setting of
hypovolemic shock. She was fluid resuscitated and her cratinine
improved to 0.8 upon discharge.
.
# Acute liver failure: Admission ALT and AST were elevated,
likely secondary to shock liver. They downtrended throughout
this admission and are currently ALT 170, AST 50. Would continue
to trend.
.
# Hypertension: Medications were initially held given shock,
however her home dose of lasix 40mg daily was later restarted.
.
# Hypercholesterolemia: Continued simvastatin 40mg daily.
.
# COPD: Continued Combivent prn.
.
# Depression/anxiety: Continued Abilify.
Medications on Admission:
1. Lasix 40 mg once a day
2. Simvastatin 40 mg once a day
3. K dur 10 once a day
4. Combivent 90-18 2 inh QID PRN
5. Famotidine 20 mg once a day
6. Gabapentin 600 mg (? 4x/day)
7. Oxycontin 40 mg(? TID)
8. Oxycodone 5 mg (? TID)
9. Abilify 10 mg once a day
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day.
4. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2)
inhalations Inhalation four times a day as needed for shortness
of breath or wheezing.
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q8H (every 8
hours) as needed for pain.
7. Abilify 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Oaks Long Term Care Facility - [**Location (un) 5503**]
Discharge Diagnosis:
Altered mental status secondary to narcotic overdose
Hypovolemic shock
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were brought to the hospital because you were very sleepy.
This is likely because you took too many of the pain
medications. Please be careful in the future and only take the
medications as prescribed. You initially had low blood pressures
and required medications for this. Your blood pressures improved
after we held your pain medications and gave you fluids.
Followup Instructions:
To be managed by rehab physicians
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5849, 496, 2720, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2067
} | Medical Text: Admission Date: [**2192-3-3**] Discharge Date: [**2192-3-25**]
Date of Birth: [**2137-1-5**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 55 year old man
who was transferred in from an outside hospital on [**2192-3-3**]. The patient two days prior to seeking medical
attention at the outside hospital complained of a headache.
This headache seemed to get worse over a few days. He
actually did have a head computerized tomography scan
approximately on either [**2-29**] or [**3-1**] which did
not show any abnormal findings. He represented to [**Hospital3 38285**] on [**3-2**] complaining of headache. Over night
the patient became more lethargic and unresponsive. A head
computerized tomography scan was obtained that showed
hydrocephalus as well as a small amount of dependent
intraventricular hemorrhage that had settled at the bottom of
the occipital [**Doctor Last Name 534**]. The patient was then transferred to [**Hospital6 1760**] for further evaluation. In
transit the patient received 2 units of FFP.
PAST MEDICAL HISTORY: Coronary artery disease, status post
ventricular fibrillation and cardiac arrest in [**2191-6-25**]
requiring defibrillation, hypercholesterolemia.
MEDICATIONS ON ADMISSION: The patient is on Aspirin 325 q.
day, Coumadin for his coronary artery disease as well as
severe peripheral vascular disease and Lopressor.
PHYSICAL EXAMINATION: On transfer the patient's initial
physical examination revealed temperature 99 degrees,
heartrate 80, blood pressure 147/81. The patient was
intubated. The patient withdraws to upper extremity pain,
more on the right than on the left. Initial INR on transfer
was 2.9.
HOSPITAL COURSE: The patient was transfused with FFP as fast
as possible. Once the patient's INR had come down to an
acceptable range a ventricular catheter was placed in the
right frontal area, in the right frontal [**Doctor Last Name 534**] of the lateral
ventricle. The patient began to wake up after placement of
his drain. The patient remained in the Intensive Care Unit
for monitoring with q. one hour neurological checks,
monitored for neurological decline. His blood pressure was
below 140 to prevent rebleed and for ventricular catheter
drainage management. The patient was then taken to the
Angiography Suite by Dr. [**Last Name (STitle) 1132**] on [**3-7**] to rule out any
underlying lesion that may have caused ventricular
hemorrhage. There was no evidence of any type of aneurysm.
There was a right M1 fenestration but this was felt to be an
incidental finding. It was assumed that the patient had a
small bleed secondary to being on Coumadin. The patient
stayed in the Intensive Care Unit for several days. He was
moving all extremities well. The patient was oriented to
name, however, he has always had a difficult time and was
never truly oriented to time and would occasionally be
oriented to hospital. We attempted to wean the patient's
ventricular drain over several days. On [**3-18**], the
patient's ventricular drain was taken out. The patient,
however, continued to have leakage of cerebrospinal fluid
from the site where the ventricular catheter had been taken
out of. The patient was kept on antibiotics. Because the
patient continued to have a cerebrospinal leak it was felt
that the patient most likely needed a ventriculoperitoneal
shunt, however, the patient had become febrile, so we wanted
to make sure that the patient had cerebrospinal fluid
cultures negative before placing the ventriculoperitoneal
shunt. Thus, at this time we replaced the ventricular drain
on the right in a new twist drill hole to avoid infection.
This was placed on [**3-20**] and the patient was then taken
to the Operating Room on [**3-22**] after all the patient's
cerebrospinal fluid cultures had been negative for greater
than 48 hours. His ventriculoperitoneal shunt was placed on
[**3-22**] into the left vertical [**Doctor Last Name 534**] without difficulty
and the right frontoventricular catheter was removed. The
patient did well, was neurologically stable and ready for
discharge to rehabilitation as of [**3-26**].
DISCHARGE DIAGNOSIS: Hydrocephalus status post
intraventricular hemorrhage and status post placement of
ventriculoperitoneal shunt on [**2192-3-22**].
DISCHARGE MEDICATIONS:
1. Lisinopril 20 mg p.o. q. day, hold for systolic blood
pressure less than 110.
2. Colace 100 mg p.o. b.i.d.
3. Metoprolol 12.5 mg p.o. t.i.d., hold for systolic blood
pressure less than 110, heartrate less than 50
4. Zantac 150 mg p.o. b.i.d.
5. Simvastatin 20 mg p.o. q. day
6. Tylenol 325 to 650 mg p.o. q. 4-6 hours prn
7. Sliding scale regular insulin subcutaneously
FOLLOW UP: The patient is to follow up with Dr. [**First Name (STitle) **] of
Neurosurgery in one month with noncontrast head computerized
tomography scan at that time. The patient should also follow
up with his primary care physician in two to three weeks to
discuss management of his lower extremity vascular disease.
We continue to recommend that the patient not be put back on
Coumadin if at all possible.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2192-3-25**] 14:56
T: [**2192-3-25**] 15:04
JOB#: [**Job Number 46042**]
ICD9 Codes: 431, 2761, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2068
} | Medical Text: Admission Date: [**2108-7-1**] Discharge Date: [**2108-7-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4071**]
Chief Complaint:
pulseless left hand
Major Surgical or Invasive Procedure:
[**2108-7-1**] Left axillary to brachial artery bypass with reversed
right greater saphenous vein.
[**2108-7-1**] Open reduction left proximal humerus fracture with
manipulation.
[**2108-7-16**] Pacemaker placement
History of Present Illness:
87F s/p unwitnessed fall in driveway this morning. Her
neighbors found her and called EMS who arrived at 9:40am. On
the scene she was complaining of left arm pain and per EMS
report she had a palpable pulse with good capillary refill. She
was taken to [**Hospital1 18**] [**Location (un) 620**] where she was found to have a left
humeral neck fracture. She was transferred to [**Hospital1 18**] for further
management.
Upon arrival she was noted to have a cool left hand with no
radial pulse, no motor function, and decreased sensation in the
radial distribution. In the ED at [**Hospital1 18**], orthopedics attempted
to reduce left arm and left hand became a bit warmer yet pulses
were still intermittent.
Past Medical History:
PMH: Alzheimers dementia, falls, anxiety, hyperlipidemia, ?htn,
depression, DJD, thrombocytopenia, Anemia, ?afib
Past Surgical History: s/p TAH/BSO
Social History:
Son is HCP [**Name (NI) 21976**] [**Telephone/Fax (1) 82944**], who lives in [**State 531**].
Lives with husband in [**Name (NI) 620**], has one son.
-Tobacco history: smoked as teen x 4 years [**12-16**] PPD
-ETOH: wine on holidays
-Illicit drugs: none
Family History:
Noncontributory
Physical Exam:
On admission [**2108-7-1**]
PE: 72, 184/71, 22, 99% on NRB
HEENT: PERLA, EOMI, bilateral ecchymoses, forhead laceration
Chest: RRR, lungs clear
Abdomen: soft, nontender, nondistended, well healed
infraumbilical midline incision
Ext: bilateral LE edema
Right arm: 2+ radial pulse, motor and sensation intact
Left arm: dopplerable pulse, hand cool, insensate in radial
distribution, no motor function
Pulses: palpable femoral and DP bilaterally, palpable right
radial, dopplerable left radial
Pertinent Results:
LABORATORIES:
[**2108-7-15**] 06:45AM BLOOD WBC-9.2 RBC-3.24* Hgb-9.9* Hct-31.9*
MCV-99* MCH-30.6 MCHC-31.0 RDW-21.8* Plt Ct-245
[**2108-7-5**] 04:25AM BLOOD WBC-11.3* RBC-3.13* Hgb-9.5* Hct-28.3*
MCV-90 MCH-30.5 MCHC-33.7 RDW-20.6* Plt Ct-244
[**2108-7-1**] 04:00PM BLOOD WBC-24.5* RBC-3.67* Hgb-12.5 Hct-36.0
MCV-98 MCH-34.1* MCHC-34.8 RDW-21.1* Plt Ct-263
[**2108-7-5**] 04:25AM BLOOD Plt Ct-244
[**2108-7-1**] 04:00PM BLOOD Plt Ct-263
[**2108-7-15**] 06:45AM BLOOD Glucose-84 UreaN-18 Creat-0.7 Na-138
K-4.3 Cl-102 HCO3-27 AnGap-13
[**2108-7-5**] 04:25AM BLOOD Glucose-114* UreaN-17 Creat-0.6 Na-139
K-3.8 Cl-106 HCO3-25 AnGap-12
[**2108-7-1**] 02:38PM BLOOD Glucose-160* UreaN-18 Creat-0.6 Na-140
K-3.5 Cl-107 HCO3-21* AnGap-16
[**2108-7-11**] 06:55AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1
[**2108-7-5**] 04:25AM BLOOD Calcium-8.1* Phos-1.4* Mg-2.3
[**2108-7-1**] 09:45PM BLOOD Calcium-7.9* Phos-3.5 Mg-1.9
[**2108-7-12**] 07:00AM BLOOD CK(CPK)-23*
[**2108-7-12**] 07:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2108-7-2**] 12:49AM BLOOD CK(CPK)-231*
[**2108-7-1**] 02:38PM BLOOD CK(CPK)-116
=========================
[**2108-7-3**] Shoulder X-Ray:
FINDINGS: Again seen are comminuted fractures of the left
humeral head and neck with medial displacement of the humeral
diaphysis. Alignment is not significantly changed since the
previous radiograph. The acromioclavicular joint is intact.
There has been placement of staples overlying the anterolateral
left chest.
IMPRESSION:
Comminuted fractures of the proximal left humerus, not
significantly changed.
.
[**2108-7-1**] Shoulder X-ray:
LEFT HUMERUS, PORTABLE FRONTAL VIEW: The severely comminuted
fracture of the humeral head and neck, with marked medial
displacement of the humeral shaft is unchanged.
IMPRESSION: Comminuted fracture of the left humeral head and
neck. Please
refer to subsequent CT for additional details.
.
[**2108-7-1**] CTA OF THE LEFT SHOULDER AND PROXIMAL HUMERUS:
Comparison is made with a left humeral radiograph from earlier
the same day.
FINDINGS: There is a comminuted fracture of the left humeral
head and neck with dislocation of the left humeral head
fragments from the glenoid fossa. The distal shaft of the
humerus is medially and posteriorly displaced. There is
extensive surrounding hematoma. The left AC joint appears well
aligned. No additional fractures are seen.
In the included portion of the left lung, hypoventilatory
changes are noted without frank consolidation or effusion. The
heart is enlarged, though incompletely imaged. There is no
pneumothorax or rib fracture. The scapula appears intact.
CTA: The subclavian artery and proximal segment of the left
axillary artery appear widely patent and normal in course and
caliber. There is a truncated appearance of the distal aspect of
the left axillary artery at the level just distal to the origin
of the posterior circumflex humeral artery. Distal to this
point, the left brachial artery is thrombosed. There is a small
collateral vessel along the medial left humerus, which is
contrast-filled and this likely represents the ulnar collateral
artery. There is no extravascular pooling of contrast to
indicate active extravasation.
IMPRESSION:
1. Thrombosis of the left brachial artery at the level just
distal to the origin of the posterior circumflex humeral artery.
2. Comminuted fracture of the left humeral head with associated
dislocation.
.
[**2108-7-5**] CHEST (PORTABLE AP)
The right subclavian line tip is at the right atrium and should
be pulled back for about 2 cm to secure its position at the
cavoatrial junction or low SVC. Cardiomediastinal silhouette is
unchanged. There are no areas of consolidation worrisome for
interval development of pneumonia. Minimal opacity at the left
lung base is unchanged and most likely representing area of
atelectasis. There is no appreciable pleural effusion or
peumothorax.
The patient is after recent surgery of the left arm, most likely
related to left humerus fracture. Enchondroma of the right
humeral head is noted.
IMPRESSION: The right subclavian line tip is in the proximal
right atrium and should be pulled back for about 2 cm. Known
left humerus fracture.
Enchondroma of the right humerus.
.
[**2108-7-17**] CXR:
As compared to the previous radiograph, the image quality is
improved. There is no evidence of right-sided pneumothorax after
pacemaker implantation. No evidence of overhydration, no pleural
effusions. Unremarkable course of the pacemaker leads. Normal
size of the cardiac silhouette. Known bilateral shoulder
pathologies.
========================
TTE [**2108-7-6**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal(LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Normal global and regional biventricular systolic function. Mild
pulmonary hypertension.
Brief Hospital Course:
87yo woman was admitted after fall with humerus fracture.
.
# L Humeral Fracture: Patient was Transfered from [**Hospital1 18**] [**Location (un) 620**]
after unwitnessed fall. She underwent Left axillary to brachial
artery bypass with reversed right greater saphenous vein by
vascular surgery and open reduction left proximal humerus
fracture with manipulation by orthopedics. The patient has
almost no motor function of the left hand and arm below the
biceps and very limited sensation post-fall and
post-operatively, though the hand is now well perfused with a
good pulse. Patient's pain was very well controlled with
standing tylenol 1000mg TID. Mrs. [**Known lastname 82945**] needs to keep her
followup appointments with the Orthopedic and Vascular surgeons.
She will also be followed by occupational therapy at acute
rehab.
.
# Tachy-Brady Syndrome: Patient was found to be in afib on
arrival to ED and preop. Because of persistent afib, patient was
transferred to cardiology service on [**7-5**] for better management
of her arrythmia. Metoprolol and ASA were started. Electrolytes
repleted and pain controlled prior to transfer. Upon transfer,
she was given separate trials of PO diltiazem and metoprolol for
rate control, which were both unsuccessful. Her rate initially
had to be controlled on a diltiazem drip; when the diltiazem
drip was used in combination with oral nodal agents, there were
apparent attempts to self-cardiovert with conversion pauses of 2
to 3 seconds and brief episodes of sinus bradycardia in the 30s.
After consultation with the Electrophysiology service,
amiodarone was started; once loaded, the amiodarone appeared to
significantly help control rhythm. During the first couple of
days, she had conversion pauses lasting up to 4.7 seconds;
however, the patient was soon mostly controlled in sinus
bradycardia with rate in the 50s with frequent PACs and PVCs.
She did have multiple brief episodes of atrial fibrillation into
the 120s-140s, but these were easily controlled with 5mg IV
metoprolol; the IV metoprolol would slow her rate down enough to
allow it to convert itself back to sinus bradycardia. Due to
the lability of the patient's rate and rhythm, a pacemaker was
placed on [**7-16**]. The pacemaker was not placed until the urinary
tract infection had completely cleared. Since the pacemaker was
placed, patient continued to go into afib episodically, so PO
metoprolol dose was gradually increased. On discharge to acute
rehab, patient's PO metoprolol was at 50mg TID with good blood
pressure. In the discharge instruction, the rehab was informed
that the dose can be increased to 75mg TID if blood pressure
tolerates the higher dose.
.
# Urinary Tract Infection: Mrs. [**Known lastname 82945**] was found to have a
positive urine analysis and treated accordingly with
cephalosporins. Sulfa drugs were avoided due to a reported
allergy; fluoroquinolones were avoided because the patient had a
prolonged QT initially. She was treated for 14 days for a
complicated UTI; the pacemaker was placed after finishing a full
10 days of antibiotics. The urinary tract infection was likely
largely contributing to the altered mental status of the patient
on admission and post-operatively.
.
# Bright Red Blood Per Rectum: The patient had 1 episode of [**12-16**]
teaspoons of bright red blood per rectum, likely from
hemorrhoids. Her hematocrit remained stable throughout the rest
of her hospitalization, though she was typed and screened as a
precaution. The patient appears to have a problem with
constipation, so she was given an escalated bowel regimen. Her
colonoscopy history was unclear, and she may need a colonoscopy
as an outpatient to rule out other sources of GI bleed.
.
# Hyperlipidemia: Home statin was continued.
.
# Dementia: Patient had significant sundowning and
delirium/agitation. She was confused about where she was most of
the time, and required frequent reorientation. She was out in
[**Female First Name (un) **] chair at the Nursing Station frequently when she was more
agitated which seemed to help.
.
# Anemia: Hct was stable at 28-30, baseline not known.
.
# Anxiety/Depression: Patient was put on sertraline which
appeared to help.
.
# FEN: Patient was put on cardiac diet, she tolerated POs well.
.
Patient was on subcutaneous heparin for DVT ppx. She received
bowel regimen. She was continued on ranitidine given that it is
home med, though no clear h/o GERD. Her code was full (confirmed
with son). Her contact is son [**Name (NI) 21976**] (HCP):
[**Telephone/Fax (5) 82946**] (aware of transfer to medicine);
husband [**Name (NI) **]: [**Telephone/Fax (1) 82947**].
Medications on Admission:
Ranitidine 150mg daily
Lorazepam 0.5mg daily
Lipitor 5mg daily
B12 1000mcg daily
MVI daily
Calcium and Vitamin D
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 0.5 ml
Injection TID (3 times a day).
4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for SBP<90 or HR<50.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold if loose stools.
12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constipation.
13. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q6H
(every 6 hours) as needed for constipation.
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
15. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
16. B-12 DOTS 500 mcg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary Diagnoses:
- s/p fall
- left humeral neck fracture c/b traumatic injury to left
axillary artery
- s/p Left axillary to brachial artery bypass with reversed
right greater saphenous vein and open reduction left proximal
humerus fracture with manipulation
- Atrial Fibrillation s/p Pacemaker placement
- Urinary Tract Infection
- Delirium
Secondary diagnoses:
- Hyperlidipemia
- Dementia--has poor short term memory but is verbal and
interactive
- Anemia (baseline not known)
- Possible Myelodysplastic syndrome
- Anxiety/Depression
- Osteoarthritis
Discharge Condition:
Stable, afebrile, A-V paced. Patient occasionally goes into afib
with HR in the 150s. Patient is asymptomatic when this happens.
If this does occur, please consider giving patient 25mg PO
metoprolol.
Discharge Instructions:
It was a pleasure to be involved in your care, Mrs.
[**Known lastname 82945**]. You were admitted to [**Hospital1 1170**] after having fallen. You had orthopedic and vascular
surgery to fix your Left arm. You have been having some trouble
moving your left arm since the fall, but an occupational
therapist will help you rehabilitate your arm in the extended
care facility.
While you were in the hospital recovering from surgery, you were
found to have an irregular heart rhythm called Atrial
Fibrillation. This rhythm was going very fast, and we had some
difficulty controlling it; with medicines, it would go too slow,
so you underwent a procedure to get a pacemaker.
You were also found to have a Urinary Tract Infecton, for which
you were treated with antibiotics.
The following changes were made to your medications:
Lorazepam was discontinued
We added the following medications:
Aspirin 325 mg PO DAILY
Metoprolol Tartrate 50 mg PO TID
Amiodarone 200mg PO DAILY
Tylenol 1000mg TID
Sertraline 25 mg PO DAILY
Heparin 5000 units SubQ TID
TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Ibuprofen 400 mg PO Q8H:PRN pain
Please follow the following instructions from the Vascular
Surgeons:
Division of Vascular and Endovascular Surgery
Upper Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the arm you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-17**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative arm:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches) no direct spray on
incision, let the soapy water run over incision, rinse and pat
dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks (from
[**7-6**]) for staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your arm or the
ability to feel your arm
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Please be sure to keep all of your followup appointments.
Please seek medical attention if you begin to have dizziness,
chest pain, shortness of breath, palpitations, fevers, or if
experience anything other symptoms that concern you.
Followup Instructions:
Please keep the following appointments that have been scheduled
for you:
Orthopedic Surgery: You have a visit scheduled with Dr.
[**Last Name (STitle) **] on Thursday, [**2108-7-26**] at 9:00pm on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building at [**Hospital1 18**] in [**Location (un) 86**]. Office number:
[**Telephone/Fax (1) 1228**]. Please arrive at 8:40am to get x-ray done. If Dr.
[**Last Name (STitle) **] needs to change the date of your appointment, he will
call you directly.
You have a visit scheduled with Dr.[**Name (NI) 7446**] office on
Date/Time: [**2108-7-26**] 11:45. [**Telephone/Fax (1) 2625**]. [**Hospital Ward Name **] Office Building,
[**Doctor First Name **] 5B [**Location (un) 86**], [**Numeric Identifier 718**]
You have a visit scheduled in the Device clinic for your
pacemaker check on [**2108-8-6**] at 3pm. [**Location (un) 8661**] building, [**Location (un) 436**],
at [**Hospital1 18**].
Cardiologist:
You have a visit scheduled with Dr. [**Last Name (STitle) 29111**] [**Name (STitle) 11302**]. ([**Telephone/Fax (1) 69986**]
Wed, [**2108-8-1**]. 11:00am
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**]
ICD9 Codes: 5990, 2930, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2069
} | Medical Text: Admission Date: [**2164-4-29**] Discharge Date: [**2164-5-10**]
Date of Birth: [**2083-6-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath; chest pain with radiation to left arm
Major Surgical or Invasive Procedure:
Redo Sternotomy, Aortic Valve Replacement (21mm Biocore Epic)
[**2164-5-1**]
History of Present Illness:
This patient is an 80 year old
female with severe aortic stenosis and history significant of
CAD
s/p CABG, atrial fibrillation on Coumadin, pulmonary
hypertension, hyperlipidemia, sleep apnea, and worsening renal
insufficiency stage III. The patient was seen by Dr [**Last Name (STitle) 51681**]
for
follow up of her worsening dyspnea, now having to sit after
walking as little as 3 steps. This is a marked decrease to what
she could do 3-6 months ago. She fatigues more easily and has
cut back on her activities wanting to sleep all the time. She
also notes LUE pain that starts in the left arm and radiates
upward to the heart happens when she is short of breath. She
also does have some chest pain that is exertional. She sits
down
and it gets better rather quickly. The patient is unable to
perform pulmonary function tests because of her difficulty with
performing the test. An echocardiogram on [**2164-1-25**] revealed
severe aortic stenosis with peak transalvular velocity of 4.44
m/sec, peak/mean pressure gradiesnt of 79/45 mmHg, and
calculated
[**Location (un) 109**] by continuity equation of 0.5-0.6 cm2. LVEF was 50-55%.
Cardiac catheterization revealed mild-moderate coronary artery
disease which will be managed medically. She presents
pre-operatively for heparin prior to redo sternotomy.
Past Medical History:
Aortic Stenosis, s/p Aortic Valve Replacement
PMH:
CAD: s/p CABG [**2155**] at [**Hospital3 8834**]
Atrial fibrillation, on Coumadin
Pulmonary HTN
Hypertension
Hyperlipidemia
Sleep apnea, unable to tolerate CPAP
Stage III renal insufficiency
Hypothyroid
Cancer-skin of face
Difficulty swallowing
Anxiety
Depression
Mild dementia
Rhinitis
Tinnitus
Spinal stenosis
S/P gallstone
GERD
Past Surgical History:
S/P C-section x4
Right Knee replacement
Social History:
Lives with son and daughter-in-law. Retired
clerical worker at unemployment office in [**Location (un) **].
Discharge contact: [**Name (NI) 16883**] [**Name (NI) 18199**], daughter. C: [**Telephone/Fax (1) 101696**]
[**Name2 (NI) **] Care Services: Housekeeper once per week. Companion [**2-10**]
Tobacco: Never
ETOH: None
Recreational drug use: Denies
Family History:
Mother had CAD in her 70's
Physical Exam:
Pulse: 62 Resp: 20 O2 sat: 99%RA
B/P Right: Left: 115/55
Height: 5'3" Weight: 170lb
General: NAD, pleasant, forgetful, poor historian
Skin: Dry [x] intact [x] well healed sternotomy
HEENT: PERRLA [x] EOMI [x]
tympanic membranes in tact bilaterally without evidence of
erythema or fluid
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [x] grade __3/6__
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] trace
(wearing
compression stockings), well healed incisions of endoscopic vein
harvest of LLE, with incision of open harvest in thigh.
well-healed incision of right TKA
Varicosities: None []
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit Right: Left:
bruits vs. radiation of cardiac murmur
Pertinent Results:
[**2164-5-1**] ECHO
PREBYPASS
A patent foramen ovale is present. There is a bidirectional
shunt across the interatrial septum at rest. Left ventricular
wall thicknesses are normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is mildly
depressed (LVEF= 45 %). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There are complex (>4mm) atheroma in the descending thoracic
aorta. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Moderate (2+) aortic regurgitation is
seen. There is a minimally increased gradient consistent with
trivial mitral stenosis. Mild (1+) mitral regurgitation is seen.
The main pulmonary artery is dilated. Dr. [**Last Name (STitle) **] was notified
in person of the results on [**2164-5-1**] at 930 am.
POSTBYPASS
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Bioprosthetic
valve seen in the aortic position. It appears to be well seated.
There is mild aortic insufficiency noted at the junction of the
native non and right coronary cusps. 1- 2+ mitral regurgitation
present. Aorta is intact post decannulation. Rest of the
examination is unchanged.
Very poor transgastric views.
Brief Hospital Course:
The patient was brought to the operating Room on [**2164-5-1**] where
she underwent redo sternotomy, and aortic valve replacement by
Dr. [**Last Name (STitle) **]. Please see operative note for details. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition. She was left
intubated and sedated overnight. She required packed red blood
cells for a postoperative anemia. On postoperative day one, she
awoke neurologically intact and was extubated without incident.
She initially experienced intermittent hypertension which
responded well to Nicardipine drip. Warfarin was resumed for
atrial fibrillation but held after one dose due to
supratherapeutic INR. Over several days, beta blockade and
Diltiazem were titrated accordingly with much improved blood
pressure and rate control. However required titration down due
to bradycardia. She responded well to Lasix, and dose adjusted
for diuresis. INR gradually improved, and low dose Warfarin was
resumed. She continued to progress and physical therapy worked
with her on strength and mobility. On post-op day number 7, her
INR was 2.5, the coumadin dose was help on [**2164-5-8**]. On post-op
day 9, the patient's INR is stable at 2.6. She will be advised
to take Coumadin 0.5mg on [**2164-5-10**], and INR will be followed
every other day until a steady therapeutic INR is achieved. It
is now felt that the patient is safe to be discharged to
rehabilitation center on post-op day #9.
Medications on Admission:
Allopurinol 100mg daily, aricept 2.5mg am, 5mg pm, aspirin 81mg
daily, calcium 500mg tid, centrum mvi daily, cranberry caps [**Hospital1 **],
crestor 5mg daily, digoxin 0.125 QOD (LD [**4-27**]), diltiazem cd 180
daily, enablex 7.5mg daily, fluoxeetine 40mg daily, fluticasone
nasal spray daily, folic acid 1mg daily, furosemide 40mg daily,
levothyroxine 100mcg daily, losartan 25mg daily, metoprolol 25mg
[**Hospital1 **], nicobid 250mg daily, ntg prn, omeprazole 20mg daily,k
vitamin d 400 u daily, warfarin 3mg daily (LD [**2164-4-25**]), claritin
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. warfarin 1 mg Tablet Sig: 0.5 mg PO DAILY (Daily): please
draw INR on [**2164-5-11**].
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-9**] Inhalation Q6H (every 6 hours) as needed
for dypsnea.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
13. 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*
14. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
15. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. donepezil 5 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in
the morning)).
17. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
19. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
22. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days: Then after 7 days, decrease Lasix to 40mg by
mouth daily.
23. potassium chloride 20 mEq Packet Sig: One (1) PO twice a
day for 7 days: after 7 days, decrease KCL to 20mEq by mouth
daily.
24. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]
Discharge Diagnosis:
Aortic Stenosis, s/p Aortic Valve Replacement
PMH:
CAD: s/p CABG [**2155**] at [**Hospital3 8834**]
Atrial fibrillation, on Coumadin
Pulmonary HTN
Hypertension
Hyperlipidemia
Sleep apnea, unable to tolerate CPAP
Stage III renal insufficiency
Hypothyroid
Cancer-skin of face
Difficulty swallowing
Anxiety
Depression
Mild dementia
Rhinitis
Tinnitus
Spinal stenosis
S/P gallstone
GERD
Past Surgical History:
S/P C-section x4
Right Knee replacement
Discharge Condition:
Alert and oriented x ***** nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] [**2164-6-6**] at 1:30pm [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**Last Name (STitle) **] [**2164-5-23**] at 11:00am
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 101697**] in [**4-12**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for atrial fibrillation
Goal INR 2.0 - 2.5
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
[**Last Name (STitle) 24307**] to phone fax
Completed by:[**2164-5-10**]
ICD9 Codes: 4241, 4168, 5119, 4280, 2449, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2070
} | Medical Text: Admission Date: [**2141-10-16**] Discharge Date: [**2141-10-23**]
Date of Birth: Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: The patient is a 78 year-old
male with a past medical history of coronary artery disease
status post coronary artery bypass graft, congestive heart
failure, diabetes, and chronic renal insufficiency who is
admitted for asymptomatic right carotid stenosis now here for
stenting. As an outpatient the patient underwent ultrasound
on [**2141-9-22**], which showed a 40 to 60% stenosis and
his right carotid artery and a 20 to 40% stenosis in his left
carotid artery. The patient reports no associated symptoms
with this and denies any weakness or neurological defects.
He did have a left CEA in [**2131**]. He also reports a previous
MRI that showed "old tiny strokes," but otherwise has no
neurological history. The patient was admitted for an
elective stenting of his right carotid artery. The patient
underwent stenting of his right coronary artery without any
complications. He was then admitted to the Coronary Care
Unit for close monitoring following this procedure. At the
time of his admission to the Coronary Care Unit the patient
denies any concurrent complaints and confirms the above
history.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft in [**2131**] four vessel disease. Cardiac
catheterization in [**2141-7-11**].
2. Congestive heart failure.
3. Diabetes mellitus type 2.
4. Peripheral neuropathy.
5. Chronic renal insufficiency.
6. Hypertension.
7. Hypercholesterolemia.
8. History of basal cell carcinoma status post resection.
9. History of diverticulosis.
HOME MEDICATIONS:
1. NPH insulin b.i.d.
2. Lasix.
3. Atenolol.
4. Altace.
5. Lipitor.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives at home with wife. [**Name (NI) **] tobacco or
alcohol use. Retired accountant.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature
96.5. Blood pressure 158/58. Pulse 67. Respirations 18.
Satting 100% on room air. Physical examination older
gentleman in no acute distress, conversant. Alert and
oriented times three. HEENT bilateral surgical pupils.
Extraocular movements intact. Oropharynx is clear. Neck no
JVD. Cardiovascular regular rate. 2 out of 6 systolic
murmur at the apex. Lungs clear to auscultation bilaterally.
Abdomen positive bowel sounds, soft and nontender.
Extremities no edema or cyanosis. Pulses intact in
extremities times four. Cranial nerves II through XII
intact. Strength and sensation grossly intact.
LABORATORIES ON ADMISSION: White blood cell count 8.4,
hematocrit 31, platelets 160, BUN 39, creatinine 2.8. Chest
x-ray cardiomegaly, large pericardial fat pad, no acute
infiltrates. Electrocardiogram sinus rhythm at a rate of 68,
PR interval .256, right bundle, no acute ST changes.
HOSPITAL COURSE: 1. Right ICA stent: The patient was
admitted for elective stenting of his right ICA. This was
following a carotid duplex in [**Month (only) **], which showed
significant occlusion in his right ICA with moderate to
severe disease with 40 to 60% stenosis on the right. The
patient did undergo a right ICA stent without any
intraoperative complications. He was subsequently started on
aspirin. Initially Plavix was held given plans for mitral
valve replacement in the near future, however, later in the
hospitalization following discussion with CT surgery staff he
was started on Plavix. The patient was closely monitored
after the surgery and remained neurologically intact.
Initially his systolic blood pressures were kept elevated to
ensure cerebral perfusion several days postop. These were
slowly lowered as he was restarted on his outpatient
antihypertensive medications.
2. Cardiovascular: Coronary artery disease, the patient
with a history of coronary artery disease status post
coronary artery bypass graft. He had a recent cardiac
catheterization prior to admission at an outside hospital,
however, this was a technically complicated procedure and his
grafts were thought to not be well visualized during this
catheterization. Additionally the patient had no symptoms of
ischemia at admission. Several days into his hospitalization
he did develop acute angina and had minor electrocardiogram
changes, which did resolve with nitroglycerin. Given the
patient's new unstable angina and his recent catheterization,
which showed poor visualization of his grafts the patient did
undergo coronary catheterization. The catheterization
revealed three vessel coronary artery disease. His LMCA was
without any significant stenosis. His proximal left anterior
descending coronary artery was 50% stenosed and was totally
occluded in the mid left anterior descending coronary artery.
His left circumflex had a 50% stenosis at the origin, 70%
stenosis proximally and 80% stenosis in the portion supplying
collaterals to his right coronary artery. He was already
known to have total occlusion of his right coronary artery
graft and this was not further explored. His left internal
mammary coronary artery left anterior descending coronary
artery graft was widely patent. His saphenous vein grafts
were already known to be occluded and were not further
explored. The patient underwent percutaneous transluminal
coronary angioplasty in the AV groove branch of the LCX and
also in the proximal LCX. Subsequent repeat angiography
showed these vessels to now be patent. The patient was
maintained on a regimen of aspirin, Plavix, statin and beta
blocker. He did have occasional pauses on telemetry, thus
his beta blocker was unable to be titrated up. The patient
was briefly on heparin prior to catheterization given his
unstable angina. Following the catheterization with
successful angioplasty he was taken off his heparin.
Pump, the patient admitted with diagnosis of congestive heart
failure. He had no echocardiogram reports on file, but
reportedly had an EF of approximately 30%. The patient had
no active symptoms of heart failure throughout the
hospitalization. He was maintained on ace inhibitor for
after load reduction as per his outpatient regimen.
Valve, the patient with known mitral valve disease who was
thought to need a mitral valve repair in the future. This
surgery had been delayed until his right ICA could be
stented. The patient was maintained on an ace inhibitor for
after load reduction. He had no acute symptoms related to
his mitral disease. The patient was to follow up with CT
surgery following discharge to formulate plans for mitral
valve repair.
Rhythm, the patient maintained on telemetry throughout the
hospitalization. He did have brief sinus pauses on
telemetry, but related to nodal blockade. His beta blocker
was titrated down and these symptoms resolved. The patient
had no acute symptoms related to this and remained
hemodynamically stable throughout the hospitalization.
2. Renal: Patient with chronic renal insufficiency with a
baseline creatinine of approximately 2.1. He did have a mild
bump in his creatinine at this admission thought to be due to
dye nephropathy. He received intravenous fluids and Mucomyst
with his catheterization and his creatinine stabilized and
returned to his baseline prior to discharge.
3. FEN: The patient maintained on cardiac diet. His
electrolytes were followed and his potassium and magnesium
were maintained.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home with services.
DISCHARGE DIAGNOSES:
1. Right ICA stenosis status post stent placement.
2. Coronary artery disease status post catheterization with
percutaneous transluminal coronary angioplasty to his left
circumflex.
3. Urinary tract infection.
DISCHARGE MEDICATIONS:
1. Multivitamin q day.
2. Atorvastatin 20 q day.
3. Loperamide 2 mg q.i.d. prn.
4. Aspirin 325 mg q.d.
5. Ramipril 10 mg q.d.
6. Plavix 75 mg q day.
7. Metoprolol 37.5 mg b.i.d.
8. Epo injections two times per week.
9. NPH insulin 10 units b.i.d.
10. Sliding scale regular insulin as directed per sliding
scale.
11. Ciprofloxacin 250 mg q day times seven days.
DI[**Last Name (STitle) 408**]E FOLLOW UP:
1. Follow up with CT surgery Dr. [**Last Name (Prefixes) **] on [**11-2**]
at 1:30 p.m. with plans for MVR in approximately one month as
per Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] evaluations.
2. Follow up with Dr. [**First Name (STitle) **] on [**11-10**] at 9:00 a.m.
3. Follow up with Dr. [**First Name (STitle) **] in approximately three months
with a carotid ultrasound at this point.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36
D: [**2142-1-18**] 08:41
T: [**2142-1-19**] 10:07
JOB#: [**Job Number 50578**]
ICD9 Codes: 4111, 4280, 4240, 3572, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2071
} | Medical Text: Admission Date: [**2103-3-27**] Discharge Date: [**2103-4-3**]
Date of Birth: [**2053-3-20**] Sex: M
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Sent from home by VNA for blood pressure control
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Type B dissection aorta.
History Present Illness: 50 year old male known type B aortic
dissection, diagnosed in [**2103-1-15**] at [**Hospital6 **];
transferred here per patient request. Was in house for a few
days
for control of blood pressure.
He was seen by VNA today found to have a BP of of 160s so was
sent to the ED. He had no complaints of abdominal or chest pain,
No SOB.
Past Medical History:
Hypertension
Chronic Renal Insufficiency
Sickle Cell Trait
Social History:
Currently not working. He currently lives his mother. [**Name (NI) **]
alcohol. No tobacco. He is single with no children.
Family History:
No premature coronary disease. Hypertension; Brother Diabetic.
Physical Exam:
Vitals:
98.3 61 143/79 18 100%RA
Gen: A&Ox3, NAD
CV: RRR
Lungs: CTA-B
Abd: Soft, NTND, no palpable anurysm
ext: good distal pulses, no edema
Pertinent Results:
[**2103-3-29**] 06:05PM BLOOD Glucose-145* UreaN-25* Creat-1.6* Na-136
K-4.0 Cl-100 HCO3-25 AnGap-15
Brief Hospital Course:
Mr [**Known lastname **] was admitted on [**2103-3-27**] for management of his blood
pressure. Initially he was started on a nitro drip to control
his blood pressure and was observed in the ICU. On HD3 the
patient was weaned completely off drips and transferred to the
floor. While in house his blood pressure was controlled with
several anti-hypertensives which were quickly titrated up due to
the inability to lower his blood pressure.
While in house the patient remained hemodynamically stable. He
tolerated a regular diet and ambulated daily. He was kept on
subcutaneous heparin for DVT prophylaxis. He should follow-up
with his primary care doctor 1-2 weeks for continued blood
pressure management. At the time of discharge his blood
pressure was ranging in the mid 130s. He is being discharged in
stable condition
Medications on Admission:
Amlodpine 10mg, Clonidine 0.2mg TID, Labetolol 900mg TID,
Lisinopril 40mg, Hydralazine 100mg TID
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Disp:*30 tabs* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Hydralazine 25 mg Tablet Sig: Four (4) Tablet PO Q6H (every 6
hours).
Discharge Disposition:
Home
Discharge Diagnosis:
descending aortic dissection
Discharge Condition:
stable, ambulating and mentating normal
Discharge Instructions:
You were seen and evaluated for your elevated blood pressure.
The most important thing for you to do when you get home is
check your blood pressure and record it twice a day. You should
bring these recordings to your primary care doctor at your next
appointment. Your primary care doctor will be responsible for
managing your blood pressure
Please follow the general discharge instructions below:
Activity: no strenuous activity or heavy lifting
Diet: please limit the salt in your diet, this will help your
blood pressure.
Medications: Some of your medications have changed while in the
hospital. Please only take the medications that have been
prescribed to you while in the hospital.
Followup Instructions:
You should follow-up with Dr. [**Last Name (STitle) **] in [**2-15**] weeks. Please call
his office for that appointment. ([**Telephone/Fax (1) 2867**]
You should schedule an appointment with your primary care doctor
for management of your blood pressure medications. Please make
arrangements to see them in the next 1-2 weeks (Dr. [**First Name (STitle) **]
[**Telephone/Fax (1) 250**])
ICD9 Codes: 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2072
} | Medical Text: Admission Date: [**2117-6-11**] Discharge Date: [**2117-6-15**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
female with a history of hypertension who presented to an
outside hospital on [**2117-6-10**] with a complaint of central
chest pain lasting 30 minutes.
The pain was [**10-15**] in intensity, did not have any radiation,
and was not associated with any shortness of breath,
diaphoresis, or palpitations. The patient was treated in the
Emergency Department with aspirin and nitroglycerin which did
not relieve the pain.
Electrocardiogram demonstrated ST elevations of 2 mm to 4 mm
in leads V1 through V5, a right bundle-branch block, and Q
waves in leads V1 through V3. She was started on heparin, an
nitroglycerin drip, and then treated with TNK 30 mg
intravenously for thrombolysis.
A repeat electrocardiogram one hour later demonstrated
persistent ST elevations, and the patient continued to have
pain rating [**3-15**] in intensity. The nitroglycerin drip was
increased to 90 mcg per minute prior to transfer to [**Hospital1 1444**] for intervention, and she was
then pain free.
PAST MEDICAL HISTORY:
1. Hypertension (on multiple medications).
2. Bilateral cataracts.
3. Status post cholecystectomy.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin.
2. Atenolol 75 mg p.o. once per day.
3. Diovan 80 mg p.o. once per day.
4. Clonidine 0.1 mg p.o. once per day.
5. Norvasc 5 mg p.o. once per day.
6. Isosorbide dinitrate 20 mg p.o. two to three times per
day.
7. Amitriptyline 10 mg p.o. q.h.s.
SOCIAL HISTORY: The patient denies any tobacco history. She
lives at home alone.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient was afebrile with a temperature of
98.2, heart rate was 77, blood pressure was 150/70,
respiratory rate was 16, and oxygen saturation was 94% on 2
liters by nasal cannula. In general, the patient was
pleasant and in no apparent distress. Head and neck
examination revealed mucous membranes were dry. The
oropharynx was clear. No carotid bruits. The lungs were
clear to auscultation bilaterally. Cardiovascular
examination revealed a regular rate and rhythm with a
systolic murmur and positive third heart sound. The abdomen
was benign. Extremities had trace edema bilaterally.
Neurologic examination revealed cranial nerves II through XII
were grossly intact and the patient had 5/5 strength.
PERTINENT LABORATORY VALUES ON PRESENTATION: Outside
hospital laboratories demonstrated white blood cell count was
13.1, hematocrit was 39.7, and platelets were 353. A
Chemistry-7 panel was significant for a blood urea nitrogen
of 40 and a creatinine of 1.7. Initial creatine kinase
levels at the outside hospital were negative.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray demonstrated no
acute process.
Upon left heart catheterization, the patient's left main
coronary artery was found to be normal. The left anterior
descending artery had diffuse disease with a focal proximal
80% lesion. The left circumflex had minimal irregularities.
The right coronary artery had a 60% to 70% mid lesion. The
left anterior descending artery lesion was stented
successfully. Right heart catheterization demonstrated right
atrial pressures of 10, right ventricular of 40/70, pulmonary
artery pressures of 38/19, and a pulmonary capillary wedge
pressure of 22. Cardiac output and index were 3.06 and 1.99;
respectively.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CORONARY ARTERY DISEASE: The patient's repeat
electrocardiogram demonstrated resolution of the ST
elevations and large Q waves in leads V1 through V5.
She was treated with aspirin, Plavix, and a statin was
started. Her creatine kinase peaked at 7400, and the MB peak
was 1075.
A repeat echocardiogram demonstrated an ejection fraction of
30% to 35%, and the patient experienced some mild heart
failure. She was diuresed with Lasix and maintained good
oxygen saturations. She was also started on her beta blocker
and ACE inhibitor as well as long-acting nitrates.
Due to her depressed ejection fraction and large anterior
wall myocardial infarction, the patient was at risk for
sudden cardiac death from arrhythmias. The option of an
internal defibrillator was discussed with the patient, and
she wished to defer at this time. Her right coronary artery
lesion may be addressed within six months.
Further monitoring on telemetry demonstrated no progressive
dysrhythmias.
2. RENAL ISSUES: Repeat laboratories demonstrated a normal
creatinine of 1. She did not require any fluids for
rehydration, nor did she have any renal failure during her
hospitalization.
3. HYPERTENSION ISSUES: The patient's blood pressure was
maintained well with beta blocker, ACE inhibitor, and
continued calcium channel blocker. Her clonidine was
discontinued.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE STATUS: The patient was to be discharged to
rehabilitation.
DISCHARGE DIAGNOSES:
1. Anterior myocardial infarction.
2. Hypertension.
3. Congestive heart failure (with an ejection fraction of
35%).
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. once per day.
2. Plavix 75 mg p.o. once per day (times nine months).
3. Atenolol 75 mg p.o. once per day.
4. Lisinopril 10 mg p.o. once per day.
5. Norvasc 5 mg p.o. once per day.
6. Imdur 30 mg p.o. once per day.
7. Lipitor 10 mg p.o. once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with her primary care
provider in one to two weeks.
2. The patient was to follow up with her cardiologist in
several months and consider addressing her right coronary
artery lesion as well as placement of an automatic internal
cardioverter-defibrillator if she wishes.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 6916**]
MEDQUIST36
D: [**2117-6-15**] 12:46
T: [**2117-6-15**] 13:01
JOB#: [**Job Number 48060**]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2073
} | Medical Text: Admission Date: [**2171-9-15**] Discharge Date: [**2171-9-19**]
Date of Birth: [**2111-2-14**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
60 year old male complaining of lightheadedness and weakness.
Major Surgical or Invasive Procedure:
Packed red blood cell transfusion
Endoscopy
History of Present Illness:
Mr. [**Known lastname 12056**] is a 60 yo M with history of HTN, DM II, aortic valve
endocarditis s/p replacement with a mechanical valve and atrial
fibrillation who presented to the ED because of lightheadedness
and low BP (at home) for 4 days. Patient reports that he was in
his usual state of health until last Thursday when he noticed he
was becoming lightheaded upon standing and he was getting short
of breath with minimal acitvity and sometimes at rest, and his
physical therapist took his blood pressure and it was ~90/50. He
called his cardiologist who told him to stop his lasix which he
did. He had persistent symptoms throughout the weekend. He
reports having ~3 black, loose stools/day for one week but he
attributes this to eating more fruit.
.
In the ED, initial vs were: T 99.4, HR 70, BP 118/53, RR 17,
100% O2 sat. Patient was found to have a Hct of 19.4, be guaiac
(+) brown stools and an NG lavage showed coffee grounds that
cleared after 500 mL. He was given 1L NS, IV pantoprazole 80 mg
x2 and transfused 1 unit PRBC's. He was seen by GI in the ED.
.
On the floor, the patient states he is feeling better but
persistently weak.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache,
rhinorrhea or congestion. Denies cough, or wheezing. Denies
chest pain, chest pressure. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency.
.
Past Medical History:
Hypertension
Diabetes Mellitus Type II
Anxiety
Peripheral Neuropathy
Aortic Valve Replacement ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]) secondary to endocarditis
Atrial fibrillation
Diastolic CHF EF - 55%
Anxiety
Social History:
Mechanical engineer, [**Location (un) 67351**], MA, Married, EtOH "3 beers a day"
but has trouble cutting back. Remote history of tobacco,
currently smokes cigars, denies illicits.
Family History:
Mother pancreatic CA, deceased
Father alcoholism, deceased
Brother with CABG, CVA.
Physical Exam:
Physical Exam:
Vitals: T: 96.4 BP: 123/69 P: 70 R: 18 O2: 96% on RA
FS: 171 6 am, 274 noon, 261 6 pm, 214 midnight
General: Obese, man laying propped up in bed, alert, oriented,
no acute distress
HEENT: Sclera anicteric, DMM, oropharynx clear
Neck: supple, JVP not appreciable, no LAD, no carotid bruit
Lungs: Bilateral inspiratory crackles [**2-3**] way up, no wheezes or
ronchi
CV: Regular rate and rhythm, normal S1, pronounced mechanical
S2, flow systolic murmur loudest at USB, no rubs, gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, palpable liver edge
2 in below liver, palpable spleen
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace edema to ankles, no
clubbing, cyanosis
Psych: Mood "tired," affect sad
Pertinent Results:
[**2171-9-15**] 06:15PM WBC-4.6 RBC-2.71*# HGB-6.4*# HCT-19.7*#
MCV-73*# MCH-23.8* MCHC-32.8 RDW-20.2*
[**2171-9-15**] 06:30PM PT-23.7* PTT-25.9 INR(PT)-2.3*
[**2171-9-15**] 06:15PM cTropnT-< 0.01
[**2171-9-15**] 06:15PM proBNP-1270*
.
Labs on Callout:
.
[**2171-9-16**] 06:07AM BLOOD Hct-24.5*
[**2171-9-16**] 06:07AM BLOOD PT-21.1* PTT-24.7 INR(PT)-2.0*
.
Labs on Discharge:
[**2171-9-19**] 06:50AM BLOOD Hct-30.7* MCV-80* MCH-25.6* MCHC-31.9
RDW-19.0* Plt Ct-110*
[**2171-9-19**] 06:50AM BLOOD PT-22.4* PTT-25.6 INR(PT)-2.1*
.
Imaging:
RUQ US [**2171-9-16**]:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
2. Splenomegaly.
.
Studies:
EGD:
Findings:
Esophagus: Mucosa: Area of linear erythema without bleeding
noted at GE junction potentially related to NG tube trauma. of
the mucosa was noted throughout the esophagus.
Protruding Lesions 1 cords of grade I varices were seen in the
lower third of the esophagus and gastroesophageal junction. The
varices were not bleeding.
Stomach: Protruding Lesions What appeared to be large gastric
varices were seen in the cardia without stigmata of recent
bleeding.
Duodenum: Normal duodenum.
Impression: Gastric varices
Area of linear erythema without bleeding noted at GE junction
potentially related to NG tube trauma. in the esophagus
Varices at the lower third of the esophagus and gastroesophageal
junction
Otherwise normal EGD to second part of the duodenum
Recommendations: Given computer difficulty images not retained.
Area of erythema at GE junction likely from NG trauma though
unclear. [**Name2 (NI) **] active bleeding.What appeared to be a grade 1 varix
distal esophagus without cherry red spot. What appeared to be
gastric varices at the fundus without active bleeding. No hx of
cirrhosis or portal hypertension in the past. Recommend imaging
of abdomen, assessment of portal and splenic vasculature. LFTS,
albumin. Heparin gtt. If active bleeding, liver team for
potential injection of varices.
Brief Hospital Course:
# Acute blood loss: Presented with symptomatic acute blood loss
and signs/history consistent with upper GI etiology. EGD
demonstrated gastric varices (not actively bleeding) and grade 1
esophageal varices. Hct on admission was 19.7 from 30 @ baseline
and lactate was 3.3. Lactate normalized to 1.1 after 3 units of
pRBCs, but Hct showed an incomplete response to 24.5, prompting
an additional unit, after which Hct remained stable for the
duration, at ~27 on call-out from ICU, which then increased to
30 upon discharge.
- Though not actively bleeding at time of EGD source felt to be
gastric varices but to rule out lower etiology patient was
recommended to follow-up with pcp for colonoscopy [**Name9 (PRE) 13511**].
# Gastric Varices / Portal HTN work-up / lower GI bleed work-up:
Varices found on EGD prompted an RUQ US, which showed fatty
liver and splenomegaly. Cirrhosis work-up included negative Hep
serologies, GGT, AFP, and Fe studies. Further outpatient work-up
with hepatology will include alpha-1 antitrypsin and US with
doppler. Pt was prescribed low dose nadolol 20 mg to help reduce
splanchnic blood flow and reduce risk of variceal bleed.
- Patient should receive Hepatitis B and A vaccine
- Patient scheduled with liver for follow-up and further work-up
# Mechanical valve: Coumadin was held in the setting of an acute
bleed while pRBCs were transfused until Hct stabilized HD2. It
was re-initated at dose of 10 mg daily and pt's INR was
monitored up to discharge at 2.1. Pt was counseled that
therapeutic range of INR for him is 2.5 to 3.
# A-Fib / [**Last Name (LF) 9215**], [**First Name3 (LF) **] 55%: Coumadin was held as described above
until Hct stabilized on HD2 and restarted HD3. Showed signs of
left heart failure with wet adventitial sounds on exam; diuresed
with IV Lasix, titrated to -1L daily and clinically improved.
Remained hemodynamically stable without RVR and without signs of
R heart failure; discharged in hemodynamically stable condition
and normalized volume status. Restarted on home [**Hospital1 **] 80 Lasix PO.
Discharged on dronedarone and metoprolol per home meds. Will to
continue to follow with cardiology as an outpatient.
# Alcohol abuse: Patient declined intervention offered by social
work. Consoled on risk of alcohol use especially with new
diagnosis of liver disease.
Medications on Admission:
Januvia 100mg daily
Metformin 500mg [**Hospital1 **]
Metoprolol Succinate 100mg daily
Furosemide 80mg [**Hospital1 **]
Warfarin 10mg daily
Lisinopril 40mg daily
Cymbalta 30mg daily
Lantus 100u HS
Humalog ISS
Aspirin 81mg daily
Dronedarone 400mg [**Hospital1 **]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lantus 100 unit/mL Cartridge Sig: One (1) 100 Subcutaneous at
bedtime.
6. Humalog KwikPen Subcutaneous
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
9. Warfarin 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Cymbalta 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Gastric varices
Acute blood loss
Steatohepatitis/cirrhosis
Alcohol dependence
Secondary diagnoses:
Diastolic congestive heart failure
Mechanical aortic valve
Atrial fibrillation
Type II Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for lighteadeness and weakness which we think
was due to a significant drop in your hematocrit and loss of
blood in your stool. The endoscopy found varices (swollen
veins) in your stomach which probably were bleeding into your
stomach. We transfused you by giving you back red blood cells
which stabilized your hematocrit. We are discharging you on a
new medication called Nadolol to control the varices. You will
need to discuss with your primary care doctor having a
colonoscopy.
Please monitor your stool, and if you see black-colored stool,
call your primary care doctor.
Please continue the metoprolol and the dronedarone, as well as
the lasix, as prescribed by Dr [**Last Name (STitle) 911**], and weigh yourself every
morning. Please [**Name8 (MD) 138**] MD if your weight goes up more than 3 lbs
or if you get very dizzy or lightheaded.
We encourage you to avoid drinking alcohol in order to stop the
damage of your liver and reduce your chances of having a major
bleed in your stomach. We offered help to quit alcohol from our
social worker.
In terms of medications we STOPPED your Metformin.
We have HELD your Januvia please discuss re-starting with your
doctor that controls your diabetes due to your liver disease.
We are continuing your warfarin. It is very important to follow
your INR with your primary care doctor to ensure goal INR
2.5-3.5.
We ADDED nadolol to help prevent the chance of a bleed in your
stomach.
Otherwise we made no changes to your medication.
Followup Instructions:
You have the following appointments for follow-up with your
primary care doctor, the liver specialists, and the
gastrointestinal doctors.
Department: [**State **] SQ
When: TUESDAY [**2171-10-8**] at 1:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
You need to discuss having a colonoscopy with your primary care
doctor.
Department: LIVER CENTER
When: TUESDAY [**2171-10-15**] at 10:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
We have adjusted your diabetes medications. We STOPPED Metformin
and HELD your Januvia. Please schedule an appointment with your
diabetic doctor to discuss your management.
Completed by:[**2171-9-21**]
ICD9 Codes: 5789, 2851, 2762, 4019, 4280, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2074
} | Medical Text: Admission Date: [**2101-4-29**] Discharge Date: [**2101-5-21**]
Date of Birth: [**2101-4-29**] Sex: M
Service: NEONATOLOGY
HISTORY: [**Known lastname **] [**Known lastname 12967**] was born to a 35-year-old gravida I,
para 0 mother. Prenatal screens: Blood type O positive,
antibody negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, group beta strep status unknown.
This pregnancy was complicated by pre-term labor. Mother was
originally admitted on [**2101-4-18**], with cervical changes
(3 to 4 cm dilated), and contractions every few minutes. She
was managed with magnesium sulfate. In addition, she was
started on betamethasone, which was completed on [**2101-4-19**]. She was also started on ampicillin. Due to fetal
monitoring showing some fetal heart decelerations, the mother
was induced for delivery on the afternoon of [**2101-4-28**].
Fetal survey at 18 weeks was within normal limits. Maternal
history also notable for two small anterior fibroids and was
treated for a yeast infection in mid-[**2101-1-18**].
Maternal medications included Zantac, Colace, iron
supplements, multivitamins, and magnesium sulfate,
betamethasone, and ampicillin. The parents were seen several
times in neonatal consultation prior to delivery. This was
an induced vaginal delivery. The Newborn Intensive Care Unit
team was present at the delivery. The infant emerged with
spontaneous cry and respiratory effort. He was bulb
suctioned, dried and stimulated. Blow-by oxygen was given
for approximately one minute. He was wrapped, shown to his
parents, and transported to the Newborn Intensive Care Unit
for further care. Apgar scores were 8 at one minute and 8 at
five minutes of age.
PHYSICAL EXAMINATION: On admission, vital signs: Heart rate
165, respiratory rate 35, oxygen saturation on room air 98%,
blood pressure 54/21, with a mean arterial pressure of 31,
blood glucose 62. Weight 2530 grams (greater than 75th
percentile), head circumference 33 cm (greater than 75th
percentile), length 46 cm (50th to 75th percentile). Infant
on radiant warmer, pink, active, crying, anterior fontanel
soft and flat, positive molding, lips, gums and palate
intact, fair suck. Lungs clear to auscultation, equal, with
fair aeration, no grunting, flaring or retracting.
Cardiovascular: Heart regular rate and rhythm, II/VI murmur
was auscultated at the left upper sternal border. +2 pulses
in upper and lower extremities. Genitourinary: Normal
phallus, testes descended bilaterally, although riding
slightly high. Patent anus. No sacral anomalies. Stable
hips. Extremities pink, with capillary refill of 3 seconds,
positive acrocyanosis, improving tone.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: [**Known lastname **] was admitted to the Newborn Intensive
Care Unit and has been in room air throughout his
hospitalization. He has not demonstrated any desaturations
or apnea of prematurity throughout his hospitalization, and
methylxanthines were not required.
2. Cardiovascular: [**Known lastname **] required two normal saline boluses
for blood pressure support shortly after admission to the
Newborn Intensive Care Unit. Thereafter, his blood pressure
has remained stable throughout his hospitalization.
Intermittent murmur has been noted during his
hospitalization, thought to be a PPS murmur.
3. Fluids, electrolytes and nutrition: Upon admission to
the Newborn Intensive Care Unit, intravenous fluids of D-10-W
were initiated at 80 cc/kg/day. On day of life one, enteral
feedings were started at 40 cc/kg/day. He advanced to full
volume feeds at 140 cc/kg/day without difficulty. Caloric
density was increased to a maximum of 26 calorie breast milk
with ProMod, which was tolerated well. Currently he is
taking ad lib amounts of breast milk or Enfamil without
difficulty. His electrolytes have remained within normal
limits throughout his hospitalization. His last set of
electrolytes on [**5-12**] were a sodium of 138, potassium of
5.0, chloride of 101, and a total CO2 of 27, a calcium of
9.9, and albumin of 4, a phosphorous of 7.3, and an alkaline
phosphatase of 295. [**Known lastname **] has had a history of intermittent
spitting throughout his hospitalization. His weight at the
time of discharge is 2865 grams, head circumference 34 cm,
and length 51 cm.
4. Gastrointestinal: Peak bilirubin on day of life four was
9.8, with a direct of 0.3. Phototherapy was not indicated
for this infant.
5. Hematology: [**Known lastname 40781**] hematocrit upon admission to the
Newborn Intensive Care Unit was 49. He has not received any
blood products throughout his hospitalization.
6. Infectious Disease: Complete blood count with
differential and a blood culture were sent upon admission to
the Newborn Intensive Care Unit. His white blood cell count
was 15,000, with a hematocrit of 49,000 and a platelet count
of 299,000, with 24% neutrophils and 0% bands. Blood
cultures were negative. He received a 48 hour course of
ampicillin and gentamicin. There have been no other issues
of infection for the remainder of his hospitalization.
7. Neurology: Head ultrasound was not indicated for this 33
[**6-24**] week infant.
8. Sensory: Hearing screening was performed with automated
auditory brain stem responses. He passed in both ears.
Ophthalmology: An ophthalmologic examination was not
indicated for this 33 [**6-24**] week infant.
9. Psychosocial: A [**Hospital1 69**]
social worker has been involved with the family. The contact
social worker can be reached at [**Telephone/Fax (1) **].
CONDITION AT DISCHARGE: Infant stable, tolerating full
volume feeds and ad lib amounts, temperature stable in open
crib, and infant without apnea or respiratory distress.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 3094**] [**Last Name (NamePattern1) **], [**Hospital **]
Pediatrics, phone number [**Telephone/Fax (1) 40204**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: Ad lib demand feedings of Enfamil or
breast feeding.
2. Medications: Iron supplements.
3. Car seat position screening: A car seat test was
performed on [**5-21**], and he passed his car seat screening.
4. State newborn screens have been sent and no abnormal
results have been reported.
5. Immunizations received: [**Known lastname **] received his first
hepatitis B immunization on [**5-13**].
6. Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation; (2) Born
between 32 and 35 weeks, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
Influenza immunization should be considered annually in the
fall for pre-term infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
7. Follow up appointments has been scheduled at [**Hospital **]
Pediatrics for [**Last Name (LF) 1017**], [**5-22**].
DISCHARGE DIAGNOSIS:
1. Prematurity at 33 6/7 weeks
2. Rule out sepsis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Month (only) 37441**]
MEDQUIST36
D: [**2101-5-21**] 02:14
T: [**2101-5-21**] 02:56
JOB#: [**Job Number 40782**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2075
} | Medical Text: Admission Date: [**2198-6-1**] Discharge Date: [**2198-6-5**]
Date of Birth: [**2145-3-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
myasthenia w/ worsening upper extremity weakness
Major Surgical or Invasive Procedure:
Thymectomy [**2198-6-1**]
History of Present Illness:
The patient is a delightful 53-
year-old woman who had been having symptoms consistent with
myasthenia, dating back 5-7 years. She was diagnosed with
myasthenia and placed on prednisone in 10/[**2195**]. Her
symptoms, at the time, included mostly weakness of the upper
and lower extremities and initially episodes of double vision
and some dysphagia. Since starting the medical therapy, she
has had no double vision or dysphagia but has been having
worsening weakness of her upper and lower extremities with a
tendency to drop items that she picks up. She also had other
little changes that she noticed when her medication was
weaned aggressively. She has been treated with Imuran and
Azathioprine and had been treated with high dose steroids for
a significant period of time. She was seen by another surgeon
at the [**Hospital3 **] who felt that a surgical resection was
not indicated, particularly given her obesity and high dose
steroids and the potentially limited beneficial effects for
myasthenia [**Last Name (un) 2902**]. She presented to me for a second opinion
and our evaluation found a thymoma within the thymus.
Therefore, she had to have a resection for oncological
purposes.
Past Medical History:
: myasthenia [**Last Name (un) 2902**],,obese, DJD,HTN, Afib,depression, DM,
trigeminal neuralgia,
Social History:
married, has daughter
smoked 1ppd x 10 years, quit [**2188**]; no etoh
Family History:
mother died age 76- kidney failure
father- [**Name (NI) 3672**] alive
Physical Exam:
General- obese female
HEENT-PERRLA, anicteric sclera, no lymphadenopathy
resp-CTA
cor-RRR
abd-obese, soft, NT, +BS
ext- obese, 1+ edema
neuro- mae; strength- UE [**3-6**]; LE [**3-6**] ; proficient stair walking
w/ PT [**2198-6-5**]. Uses rolling walker for support when outside.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2198-6-5**] 06:40AM 30.9*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2198-6-4**] 05:11AM 251
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2198-6-4**] 04:05PM 4.0
[**2198-6-4**] 05:11AM 104 10 0.6 135 3.2* 99 291 10
1 NOTE UPDATED REFERENCE RANGE AS OF [**2198-6-1**]
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2198-6-4**] 05:11AM 8.5 3.3 1.8
Pathology- thymus -pending
Brief Hospital Course:
Patient admitted SDA [**2198-6-1**] for thymectomy operative procedure
for thymoma. Patient tolerated procedure well, transferred to
PACU intubated on SIMV mode quickly weaned to nasal cannula, 2
mediastinal chest tubes in place to suction, foley in place,
pain control w/ MSO4 IV then transitioning to Dilaudid PCA, ivf
@100/hr.
Pt admitted to SICU pm of post-op day 0,
POD#1- Pain control w/ Dil PCA, po meds started, ivf d/c,
[**Doctor First Name **]/Cardiac healthy diet started. CT to sx w/ moderate output,
good u/o by foley. PT consult done. Lasix x1.
POD#2- Remains in SICU- Diladid PCA transitioned to percocet,
foley d/cin PM.Pt OOB to chair and ambulation, IS done.
POD#3-Pt transferred out of SICU to regular floor, good pain
control w/ percocet; OOB ambulating, good po intake, CT to sx
w/o leak.
POD#4- CT to water seal w/o leak, CXRAY indicates no
pneumothorax, CT x2 medistinal d/c w/o complication and no
pneumothorax by CXRY. Good pain control cont w/ percocet,
cleared for d/c by PT.
Patient discharged home in stable condition in company of
husband without additional services. Discharge instructions
given and reviewed by nursing. Pt to f/u per d/c instructions
Medications on Admission:
omeprazole 20, azathioprine 200,pyridostigmine 60,digoxin
0.125',lasix 40',diovan 160',asa 80,bupropion 150",celexa
20',glyburide/glucophage [**Telephone/Fax (1) 12846**],trazodone50',calcium
1200,neurontin600,caarbamazepine 600,tramadol/tylenol 50/325,
diclofenac 75,humalog/RISS, prednisone 30 QOD,alendronate 70 qwk
Discharge Medications:
1. Azathioprine 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
2. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Carbamazepine 200 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD ().
8. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Piroxicam 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Myasthenia [**Last Name (un) 2902**], thymomaobese, Degenerative joint
disease,Hypertension, Afib,depression, DM, trigeminal neuralgia,
tonsilectomy
Discharge Condition:
Good
Discharge Instructions:
Call the Dr.[**Name (NI) 1816**] [**Telephone/Fax (1) 170**]-office if you experience
fever, chills, Shortness of breath, chest pain, redness or
discharge at the incision, productive cough, or any other
concern.
-Resume regular medicines.
-Take new medications as directed
-No driving if taking narcotics
-You may shower in 2 days, then remove chest tube dressing and
replace w/ dry gauze. Leave small tapes in place on incision
site until they fall off.
-Avoid tub baths, swimming for 3-4 weeks.
Followup Instructions:
Call Dr.[**Name (NI) 1816**] office for appointment in [**9-14**] days. Please
call [**Telephone/Fax (1) 170**].
Completed by:[**2198-6-8**]
ICD9 Codes: 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2076
} | Medical Text: Admission Date: [**2184-5-27**] Discharge Date: [**2184-6-9**]
Date of Birth: [**2139-8-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Nausea and Vomiting
Major Surgical or Invasive Procedure:
[**5-30**]: Stereotactic brain biopsy
History of Present Illness:
44yo F with recent dx of lung lesion (3wks ago...currently
undergoing outpt w/u) admitted for nausea & vomiting. Per
patient she has not been feeling quite herself recently
(mentally) and it got to a point on [**5-27**] where she soughtmedical
treatment. Does not report any difficulty with motor skills,
gait, sensation, or vision at the time of presentation. She
reports her current state in very vague terms as "not feeling
right".
Past Medical History:
-Asthma
-Recent tooth infection/extractions ( [**2184-2-15**].)
-metaphalangeal subluxation following an injury on [**2178-6-17**]
-Obesity
Social History:
Lives with three children and Fiancee in [**Location (un) 1411**].
Originally from Sicily, [**Country 2559**]. Moved to US in 60s.
Travels include [**Country 2559**], Caribbean and US.
US travels ( [**State 108**], NC, [**State 350**].)
TB risk factors: prior incarceration for one day during teens.
Hx
of homelesness during teens.
Hx + BCG, has had negative PPDs in past (used to work in health
care facility.)
Recurrently on disability after injury at work. Used to work in
health care field.
Tob:One pack daily x 30 years.
EtOH: N
IVDU: past cocaine (snorting) and IVDU in teens. None recent.
Sexual history: 3 lifetime sexual partners. Genital warts.
HIV neg in [**2177**].
Exposures: + sick contact. Fiance with cold symptoms.
Pets: + dog
Family History:
-No hx htn, cad/mi, cancer
-Diabetes--mother, grandfather, grandmother
-Father passed away at 76 due to "natural causes'
-Mother is 76
Physical Exam:
On Admission:
Vitals: T 99.5 BP 187/79 (180-217/70-85) HR 68 RR 18 SaO2 96%ra
General: no acute distress, sitting in bed talking on phone,
comfortable and appropriate
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: supple, no nuchal rigidity, no bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated
Skin: no rashes
Neurologic Examination:
Mental Status:
Awake and alert, following all commands, slightly odd affect
Oriented to person, place, time
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors, or asterixis. Strength full power [**6-15**] throughout. No
pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 1 1 1 3 1
Left 2 2 2 3 2
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Exam on Discharge:
XXXXXXXXXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2184-5-27**] 11:00PM BLOOD WBC-10.3 RBC-3.95* Hgb-11.5* Hct-34.2*
MCV-87 MCH-29.0 MCHC-33.6 RDW-14.0 Plt Ct-425
[**2184-5-27**] 11:00PM BLOOD Neuts-71.6* Lymphs-19.4 Monos-3.2
Eos-5.1* Baso-0.8
[**2184-5-28**] 05:20AM BLOOD PT-14.9* PTT-33.1 INR(PT)-1.3*
[**2184-5-27**] 11:00PM BLOOD Glucose-89 UreaN-7 Creat-0.7 Na-143 K-3.4
Cl-103 HCO3-28 AnGap-15
[**2184-5-27**] 11:00PM BLOOD ALT-17 AST-14 LD(LDH)-281* AlkPhos-80
Amylase-29 TotBili-0.5
.
Imaging:
EKG [**5-27**]:
Sinus bradycardia. Poor R wave progression. Cannot rule out
prior
anteroseptal myocardial infarction. Compared to the previous
tracing of [**2184-5-14**] there is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 142 82 468/461 56 75 59
.
CXR 4.17:
FINDINGS: Heart size unchanged. Right upper lobe opacification
and right
mediatinal fullness corresponds to thick walled upper lobe
cavity and
mediastinal lymphadenopathy with differential including
Wegener's, SCC/cancer, and fungal infection. No new focus of
consolidation is seen. There is no effusion or pneumothorax.
IMPRESSION: Unchanged highly abnormal chest radiograph.
.
MRI Head [**5-29**]:
IMPRESSION: Multiple enhancing lesions are identified in the
brain as
described above. Although metastatic disease is a consideration,
given the
restricted diffusion on the diffusion-weighted images, infection
needs to be considered in the differential diagnosis. The
appearances could also be
secondary to multiple tuberculomas given a cavitary lesion in
the lung.
.
CT Torso [**5-30**]:
IMPRESSION:
1. Findings consistent with extensive metastatic disease,
including pulmonary nodules, bilateral adrenal masses, and
bilateral renal masses. Lymphadenopathy in mediastinal, right
greater than left hilar, retroperitoneal, and mesenteric
locations, consistent with nodal spread of neoplastic disease.
Bronchoscopic biopsy is recommended.
2. Cavitary pulmonary nodule in the posterior segment of the
right upper
lobe, suspicious for primary lung carcinoma. Please see the
differential
discussion in the prior chest CTA report for less likely
considerations.
3. Right upper lobe pulmonary interstitial thickening,
suspicious for
lymphangetic spread.
4. Subtle sclerosis in the T4 vertebral body. While
indeterminate, osseous
metastasis is not excluded. If there will be a change in
clinical management, then a bone scan may be helpful.
5. Wedge-shaped peripheral opacity in the right middle lobe,
evolving since
the prior chest CTA. Second evolving process in the right upper.
While these may be secondary to infection, the morphology of the
right middle lobe opacity raises the possibility of a pulmonary
infarct.
6. Aberrant right subclavian artery.
.
Head CT [**5-30**](post-bx):
IMPRESSION: Post-surgical changes from recent resection of the
left frontal
lesion with minimal high attenuation in the resection bed and
moderate
perilesional vasogenic edema causing effacement of the left
frontal [**Doctor Last Name 534**] of
the left lateral ventricle without shift of midline structures.
.
ECHO [**2184-6-1**]
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: No valveular pathology or pathologic flow
identified. Normal biventricular cavity sizes and regiona/global
systolic function.
.
[**2184-6-4**] CT head
IMPRESSION: Extensive bilateral areas of vasogenic edema, from
known brain
metastasis. Compared to [**2184-5-30**], the overall appearance
is not
significantly changed.
.
Labs on discharge:
***************
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] after complaints of nausea,
vomiting, and not "feeling herself". Of significance, she is
status post diagnosis of lung mass for which she was being
worked up on an outpatient basis.
.
1. NSCLC, metastatic to brain/nausea/vomiting/headache -- Upon
admission a head CT was performed which identified multiple
infra and supra tentorial brain lesions, including the brain
stem. High dose steroid therapy was initiated to treat
associated vasogenic edema. A left stereotactic brain biopsy
was performed on [**5-30**]. Post-operatively a head CT was done, and
determined to be stable. She was then returned to the ICU
pending diagnosis and further management. She was initiated on
whole brain radiation on [**2184-6-2**] and was monitored in the ICU
for signs and symptoms of increased ICP. She was subsequently
transferred to the hospitalist service for the remainder of her
course.
During initiation of her brain radiation treatments, patient had
intractable nausea, vomiting, headache, and hypertension, but
repeat CT head did not show increased edema. She continued on
IV dexamethasone 6 mg q6 hours, IV keppra 1000mg q12 hours, and
IV hydralazine for blood pressure control (see below).
For nausea control, she was kept on compazine, zofran, ativan,
phenergen PRN.
Oncology, neuro-oncology, and neurosurgery was involved
throughout her hospital course. Her symptoms gradually subsided
and she was transitioned to po meds. She will complete the
remainder of her radiation treatments as an outpatient. She has
follow up scheduled with thorcaic oncology and neuro-oncology.
.
2. Hypertension -- While unable to tolerate po, she was treated
with IV hydralazine for goal SBP of less than 130 mmHg. When
able to tolerate po, she was transitioned to Lisinopril. The
patient was instructed to followup with her PCP regarding her
blood pressure.
.
3. Asthma -- remained stable throughout her course, continued
prn albuterol.
.
4. Hyperglycemia -- associated with high dose steroids and
managed with a sliding scale without difficulty.
.
5. Dispo: The patient ambulated without difficulty and was
discharged home in stable conition.
Medications on Admission:
albuterol, percocet
Discharge Medications:
1. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
2. Dexamethasone 6 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 20 days.
Disp:*80 Tablet(s)* Refills:*0*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
5. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for fever or pain.
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath.
7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO q6h prn pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Non-small cell lung cancer with multiple brain metastases
2. Hypertension
Discharge Condition:
Neurologically Stable
Discharge Instructions:
You were admitted with altered mental status secondary to your
newly [**First Name9 (NamePattern2) 106995**] [**Last Name (un) **] metastasis. You underwent brain biopsy and
whole brain radiation. You should attend follow up appointments
with the thoracic oncologist and neuro-oncolgist.
.
- Take lisinopril for high blood pressure. Your PCP should
follow up on your blood pressure.
- Take lorazepam at night as needed for anxiety.
.
General Instructions/Information
?????? Have a friend/family member check your incision daily
for signs of infection.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Use a shower cap to cover your head if you are going to
shower.
?????? You have been prescribed Keppra for anti-seizure medicine,
take it as prescribed
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? [**Male First Name (un) **] NOT DRIVE. Clearance to drive and return to work will be
addressed at your post-operative office visit.
.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions:
- Follow up with your PCP on [**Name9 (PRE) 766**] [**6-14**] at 6pm regarding
this hospitalization. Please call and reschedule if you cannot
make this appointment.
- Please call the neurosurgery clinic to arrange an appointment
for removal of your sutures and a wound check. This appointment
can be made with the Nurse Practitioner. Please make this
appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a
distance from that office, please make arrangements for the
same, with your PCP.
[**Name10 (NameIs) 106996**] your radiation treatments as scheduled at 12pm on [**3-17**], [**6-14**] and [**6-15**].
- Thoracic oncology clinic: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD
Phone:[**0-0-**] Date/Time:[**2184-6-22**] -10:30
- [**Hospital **] clinic. Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD
Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2184-6-28**] 3:00. The Brain [**Hospital 341**]
Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**]
Building. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you
need to change your appointment, or require additional
directions.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2184-6-9**]
ICD9 Codes: 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2077
} | Medical Text: Admission Date: [**2191-2-13**] Discharge Date: [**2191-2-17**]
Date of Birth: [**2113-2-15**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins / Comtan / Shellfish Derived
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2191-2-14**]: Left hip hemiarthroplasty
History of Present Illness:
Mr. [**Known lastname **] is an 78 year old man who had a mechanical fall at
home. He was taken to the [**Hospital1 18**] for further evaluation and
care.
Past Medical History:
Afib anticoagulated, INR 2.5
CAD s/p CABG [**2175**], EF 25%
ICD for low EF and his NSVT
Parkinson's disease
Right hip replacement x 2
DJD spine
HTN
Social History:
Walks with cane
Lives alone has 24hr care
Family History:
n/a
Physical Exam:
Upon admission:
VS T 98.2, P 93, BP 135/69, R 16, O2 sat 98% RA
Gen- well-appearing, NAD
HEENT- NCAT, anicteric, no injections, PERRLA, EOMI, MMM
Neck- no JVD or bruit
Cor- irreg irreg, [**1-28**] HSM heard best at apex
Pulm- clear, no crackles or wheezes
Abd- + bs, soft, nt, nd, no masses or hsm
Extrem- LLE shortened, externally rotated, no skin tenting, TTP
over hip, pedal pulses 2+ b/l
Skin- no rash
At discharge
Tm 99.3 Tc 97.1 HR 83 BP 120/84 RR 24 O2sat 100RA
NAD
RRR, no m/g/r
CTA B/L
+BS, nt/nd
LLE: [**Last Name (un) 938**]/FHL/GS [**3-29**], sensate DP/PT palp; inc c/d/i, no erythema,
minimal serous drainage on dressing, +ecchymosis
Pertinent Results:
[**2191-2-13**] 12:35PM BLOOD WBC-5.0 RBC-3.84* Hgb-11.1* Hct-32.8*
MCV-85 MCH-29.0 MCHC-33.9 RDW-16.1* Plt Ct-164
[**2191-2-14**] 01:15PM BLOOD WBC-8.5# RBC-3.59* Hgb-10.4* Hct-30.8*
MCV-86 MCH-28.9 MCHC-33.7 RDW-16.1* Plt Ct-167
[**2191-2-14**] 03:08PM BLOOD WBC-6.7 RBC-3.53* Hgb-10.6* Hct-29.8*
MCV-84 MCH-30.0 MCHC-35.7* RDW-16.1* Plt Ct-164
[**2191-2-14**] 07:14PM BLOOD Hct-27.1*
[**2191-2-15**] 05:35AM BLOOD WBC-5.1 RBC-3.63* Hgb-11.0* Hct-30.8*
MCV-85 MCH-30.4 MCHC-35.7* RDW-16.2* Plt Ct-163
[**2191-2-16**] 05:35AM BLOOD WBC-5.2 RBC-3.44* Hgb-9.9* Hct-29.3*
MCV-85 MCH-28.7 MCHC-33.6 RDW-16.3* Plt Ct-152
[**2191-2-17**] 06:50AM BLOOD Hct-27.8*
[**2191-2-13**] 12:35PM BLOOD PT-25.1* PTT-32.9 INR(PT)-2.5*
[**2191-2-14**] 05:00AM BLOOD PT-23.3* INR(PT)-2.3*
[**2191-2-14**] 01:15PM BLOOD PT-19.4* PTT-31.6 INR(PT)-1.8*
[**2191-2-14**] 05:17PM BLOOD PT-18.7* INR(PT)-1.7*
[**2191-2-15**] 05:35AM BLOOD PT-22.5* PTT-34.5 INR(PT)-2.2*
[**2191-2-16**] 05:35AM BLOOD PT-25.8* INR(PT)-2.5*
[**2191-2-17**] 06:50AM BLOOD PT-31.1* INR(PT)-3.2*
[**2191-2-13**] 12:35PM BLOOD Glucose-113* UreaN-26* Creat-1.1 Na-140
K-3.8 Cl-104 HCO3-27 AnGap-13
[**2191-2-14**] 03:08PM BLOOD Glucose-126* UreaN-19 Creat-0.9 Na-139
K-4.0 Cl-106 HCO3-25 AnGap-12
[**2191-2-15**] 06:54AM BLOOD Glucose-118* UreaN-21* Creat-0.9 Na-138
K-4.3 Cl-103 HCO3-27 AnGap-12
[**2191-2-16**] 05:35AM BLOOD Glucose-130* UreaN-22* Creat-0.9 Na-135
K-4.1 Cl-102 HCO3-27 AnGap-10
[**2191-2-15**] 06:54AM BLOOD CK-MB-5 cTropnT-0.02*
[**2191-2-15**] 06:54AM BLOOD CK(CPK)-368*
[**2191-2-15**] 03:50PM BLOOD CK-MB-6 cTropnT-0.02*
[**2191-2-15**] 03:50PM BLOOD CK(CPK)-661*
[**2191-2-15**] 09:40PM BLOOD CK-MB-7 cTropnT-0.02*
[**2191-2-15**] 09:40PM BLOOD CK(CPK)-839*
[**2191-2-15**] 06:54AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9
[**2191-2-16**] 05:35AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname **] presented to the [**Hospital1 18**] on [**2191-2-13**] after a fall at home.
He was evaluated by the orthopaedic surgery service and found
to have a left hip fracture. He was admitted, consented,
cleared for surgery by medicine, and prepped for surgery. On
[**2191-2-14**] he was given 2units of FFP due to elevated INR and then
he was taken to the operating room and underwent a Left hip
hemiarthroplasty. He tolerated the procedure well, was
extubated, and transferred to the recovery. In the recovery he
was transfused with 2 units of packed red blood cells due to
actue blood loss anemia. He was also noted to be hypertensive
which was treated with IV lopressor and labetalol with effect.
He became normotensive and was transferred to the floor. On the
floor he was seen by physical therapy to improve his strength
and mobility. He was restarted on his coumadin. His INR was 3.2
on [**2-17**], prior to discharge.
He was followed throughout his hospital course by EP and
medicine. The rest of his hospital stay was uneventful with his
lab data and vital signs within normal limits and his pain
controlled. He is being discharged today in stable condition.
Medications on Admission:
atorvastatin 10 mg qd
sinemet 25-100 mg - 8 tablets qd
parcopa tid prn
requip xd 16 mg qd
digoxin 0.125 mcg qd
lasix 20 mg qd
lisinopril 20 mg qd
toprol xl 25 mg qd
xalatan eye gtts .005 OU qhs
coumadin 5 mg 6 days per wk, 3 mg mondays
cipro 250 mg [**Hospital1 **]
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
2. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Ropinirole 1 mg Tablet Sig: Sixteen (16) Tablet PO QAM (once
a day (in the morning)).
5. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO
ASDIR (AS DIRECTED).
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
ASDIR (AS DIRECTED).
7. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Vesicare 10 mg Tablet Sig: One (1) Tablet PO qHS ().
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: INR 2.0-2.5
please give 3mg on [**2-17**].
takes 5mg 6 days a week, and 3mg on Monday.
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
20. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
s/p fall
Left hip fracture
Acute blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Continue to be weight bearing as tolerated on your left leg
Check INR, adjust coumadin dosing as needed to keep INR 2.0-2.5.
INR was 3.2 on [**2-17**], day of discharge - give 3 coumadin [**2-17**] PM
Please take medications as prescribed
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5 please call the office
or come to the emergency department.
Physical Therapy:
Activity: Activity as tolerated
Left lower extremity: Full weight bearing
Treatments Frequency:
Staples/sutures out 14 days after surgery (surgical date
[**2191-2-14**])
Keep incision clean and dry
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 2
weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.
Appointments at the [**Hospital1 18**] already made prior to admission:
ovider: DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2191-4-27**]
3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2191-4-27**] 4:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2191-2-17**]
ICD9 Codes: 4271, 2851, 4019, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2078
} | Medical Text: Admission Date: [**2164-7-13**] Discharge Date: [**2164-7-21**]
Date of Birth: [**2088-8-19**] Sex: F
Service: UROLOGY
Allergies:
Aspirin / Bactrim / Tenormin / A.C.E Inhibitors / Serevent
Attending:[**First Name3 (LF) 4533**]
Chief Complaint:
Renal Tumor
Major Surgical or Invasive Procedure:
Left Open Nephrectomy
Exploration of retroperitoneum for surgical bleeding
History of Present Illness:
75yF with left kidney mass. Her Ultrasound indicated a moderate
sized left kidney mass amenable to possible nephrectomy.
Past Medical History:
PMH:
1. Congenital nystagmus
2. Asthma (albuterol inhaler PRN)
3. Nasal polyps with chronic rhonitis
4. Hypertension
5. Chronic Anxiety
6. Osteoporosis
7. GERD
PSH:
1. S/p 4 C sections
2. Sinus surgery
Social History:
Born and raised in [**State 350**]. She was a house wife and is
now a retired child care worker. She has 3 daughters, one of
whom is mentally retarded, and lost a daughter to an illness.
She is a widow who lives alone but has family in [**State 2690**].
Family History:
CAD father, mother with depression died at age 37 with CVA.
Maternal cousin with leukemia, brother with bladder CA
Physical Exam:
No acute distress. Alert and oriented x 3. Regular rate and
rhythm no murmurs rubs or gallops. Clear to auscultation no
wheezes rales or rhonchi. Soft Nontender, nondistended, bs+
normoactive. No clubbing, cyanosis, edema. Pulses 2+ equal
bilaterally.
Pertinent Results:
Path report DIAGNOSIS:
1. Kidney, left total nephrectomy (A-J):
A. Renal cell carcinoma, clear cell type with focal rhabdoid
morphology. See synoptic report.
B. Non-neoplastic renal parenchyma with no diagnostic
abnormalities recognized.
C. Adrenal gland with nodular hyperplasia.
2. Rib, left 11th, excision (T):
Benign bone. See note.
[**7-13**] cxr
1. Left pneumothorax.
2. Right subclavian central venous line with tip in the expected
region of the right atrium. For optimal positioning the tip may
be withdrawn approximately 3 cm.
3. Endotracheal tube is well positioned.
4. Nasogastric tube should be advanced approximately 5 cm for
optimal positioning.
[**7-19**] cxr
The left chest tube was removed. The left subcutaneous emphysema
is slightly decreased in size but still present. No evidence of
pneumothorax is demonstrated. Bibasal atelectases are again
noted as well as a right pleural effusion. The left central
venous line tip terminates at the junction of brachiocephalic
vein and SVC. No evidence of congestive heart failure is
present.
Brief Hospital Course:
The patient tolerated the initial surgery (EBL 150cc) and was
taken to the PACU. In the PACU, she became unresponsive and
hypotensive. She was subsequently intubated without sedation and
a code blue was called; a femoral a line and right subclavian
triple lumen were placed (after failed attempt at left
subclavian and right IJ complicated by arterial puncture). Per
nursing there was a brief episode of ? PEA/Asystole, but once
the MICU code team responded they noted a DP/femoral pulses. She
was responsive and following commands (squeezed hand to
command). There was attempted resuscitation in the PACU for one
hour after which the patient was taken to the OR for exploration
as her blood pressure remained labile despite tansfusion of 4
units. Of note, the patient was able to move all limbs during
this time and the patient seemed to respond to her family prior
to returning to the OR.
In the OR, the patient was found to be bleeding from the the
renal left renal artery into her RP. Her retroperitoneum was
evacuated and the bleeding site was oversewn. Assistance was
provided by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] of Transplant Surgery. The patient had
strong pulses and stable vitals throughout the procedure. She
was given 2gm cefazolin periop.
In sum, the estimated blood loss was -2.5 L. She received 2.7L
of PBRC (~ 18 U), many of which were not cross-matched ([**9-26**])-pt
has autoantibodies: anti-[**Doctor Last Name **], anti-JKa. She also received 8 [**Location 97341**] and 3L of LR.
Postoperatively she was transferred to the MICU for further
management including central monitoring, delayed extubation, and
transient requirement for neosynephrine. In the [**Hospital Unit Name 153**] the patient
was noted to have a left pneumothorax and required Gen [**Doctor First Name **] to
place a chest tube on POD #0. During the several days in the
ICU, pt required fluid management with hydration and lasix,
respiratory support with intubation until POD2 and O2
supplementation until leaving the ICU.
Once transfered to Urology, the patient required a PT consult
[**2-17**] difficulty ambulating and a nutrition consult [**2-17**] decreased
po intake.
Upon discharge, pt afebrile with vital signs stable. Pt going
to rehab center for PT. Pt tolerating po feeds and requires
supplements that she normally takes as an outpatient. Pt pain
controlled with po pain meds.
Medications on Admission:
Meds on admit:
10mg po oxazepam qd prn
flovent 110 2 puffs [**Hospital1 **]
FLUTICASONE PROPIONATE 50MCG 2 SPRAYS EACH NOSTRIL DAILY
hctz 12.5mg po qd
pantoprazole 40mg po qd
ventolin 90mcg q4 prn
verapamil SR 240mg qd
Discharge Medications:
1. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every
4-6 hours as needed for pain for 2 weeks.
Disp:*40 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
2 weeks: Take with Tylenol #3 hold for loose stool.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Renal CA
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or come to the ER if you notice blood
from the wound, fever greater than 101.5, severe pain not
controlled by medication, inability to void, or any other
concerns. Okay to shower. Please resume taking your home meds.
Followup Instructions:
Please call Dr. [**First Name (STitle) **]??????s office to schedule a follow up
appointment. The phone number is [**Telephone/Fax (1) **].
ICD9 Codes: 5185, 2851, 4019, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2079
} | Medical Text: Admission Date: [**2170-5-27**] Discharge Date: [**2144-1-27**]
Date of Birth: [**2107-6-10**] Sex: M
Service: VASCULAR SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
male who has a history of diabetes, hypertension, coronary
artery disease and peripheral vascular disease, as well as
alcohol. He presented to [**Hospital 1474**] Hospital with bilateral
claudication and underwent a right SFA angioplasty and a left
femoral popliteal. He returned to the hospital on [**5-19**]
with a left groin wound dehiscence and bleed after days of an
unsteady gait. The wound was explored at [**Hospital1 1474**] and a
Prolene stitch was placed and the wound was closed over the
graft. The patient had a myocardial infarction at the
outside hospital and was ruling in for a myocardial
infarction and at this point was transferred to the [**Hospital6 1760**] Cardiology Service for
further care of his coronary artery disease.
TRANSFER MEDICATIONS:
1. Vancomycin
2. Tequin
3. Lopressor
4. Aspirin
5. Thiamine
6. Folate
7. Diazepam
ALLERGIES: PENICILLIN
PAST MEDICAL HISTORY:
1. Diabetes
2. Hypertension
3. Hyperlipidemia
4. Recent left femoral popliteal
5. Peripheral vascular disease
6. Coronary artery disease
7. History of Methicillin resistant Staphylococcus aureus
PAST SURGICAL HISTORY:
1. Right SFA angioplasty [**1-/2170**]
2. Left femoral popliteal, probably an above the knee
popliteal, on [**2170-3-28**]
EXAM:
VITAL SIGNS: He was afebrile with stable vital signs when
vascular surgery was consulted.
GENERAL: He is an elderly man, short of breath in supine
position.
HEART: Regular.
LUNGS: Clear.
ABDOMEN: Soft and nontender.
EXTREMITIES: Left groin - there was a 4 inch x 1.5 inch open
wound with serous drainage without the graft obviously
exposed.
PULSE EXAM: He had palpable femorals bilaterally, palpable
popliteals bilaterally, palpable DPs bilaterally and his CTs
were dopplerable. The graft appeared to be open at this
time.
ADMISSION LABS: His white count was 14. His hematocrit was
30. Platelets 519. His chem-7 was sodium 127, potassium of
4.9, creatinine of 1.9, INR of 1.3.
HOSPITAL COURSE: At this time, the vascular surgery in
vascular surgery consultation. He was seen by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Dry dressings tid or qid were advised, as the wound
was still wet. Myocardial infarction management per
cardiology and antibiotics to continue from the outside
hospital which included Tequin and vancomycin given his
history of Methicillin resistant Staphylococcus aureus. The
patient did relatively well overnight and was given diuresis
by the cardiology service as well as afterload reduction with
an ACE inhibitor.
On the night of [**5-28**], approximately 11:30 a.m., vascular
surgery was called emergently for diffuse arterial bleeding
from the patient's open left groin wound. Pressure was held
at this site. His blood pressure was 120, heart rate 86. He
had slightly decreased T-waves in the lateral leads and his
left foot was warm. At this point, he was transfused
urgently 2 units of blood. Labs were sent off and he was
taken to the Operating Room by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. In the
Operating Room, the patient was emergently explored. The
graft was noted to be grossly infected and required arterial
debridement.
At this time, in the Operating Room, the patient underwent a
removal of the femoral portion of the femoral popliteal
graft, debridement of the femoral artery and vein patch
angioplasty, rotational sartorius myoplasty and
retroperitoneal exposure of the iliac artery for proximal
control. The patient tolerated this relatively well and the
following day, the patient's foot appeared relatively
ischemic and the patient was taken back to the Operating
Room.
At this time, he underwent a left profunda femoris artery to
anterior tibial artery bypass using non reverse right
saphenous vein as well as the profunda femoris endarterectomy
and profundoplasty, a left lower leg fasciotomy, ligation of
the popliteal artery, intraoperative angiogram performance,
[**Doctor Last Name **] catheter, thromboembolectomy and vein patch
angioplasty repair of the proximal graft. This was performed
by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1476**].
At this time, the patient was transferred to the Intensive
Care Unit after his bypass. He was hemodynamically stable on
no pressors with a blood pressure of 109/47. He had a Swan
which showed a wedge of 10 and a cardiac index of 4. He
received 4 units of blood during the operation, 5 liters of
intravenous fluids with an estimated blood loss of 1500. His
hematocrit was 29.6. At this time, he had a palpable graft
pulse, but no dopplerable distal pedal pulses and his foot
was mottled.
On postoperative day 1, he was continued on vancomycin and
propofol for sedation. He was oxygenating well on 60% and 5
of PEEP with a PO2 of 156. He was hemodynamically stable
with a cardiac output of 7.8. His CT was 1.4 at this time.
He ruled out for a myocardial infarction. His foot was still
cool and mottled without distal Doppler signals, although he
had a strong palpable graft pulse. At this time, cardiology
continued to follow him. He continued to rule out for
myocardial infarction and was started on intravenous beta
blockade, as well as aspirin. The patient continued in the
Intensive Care Unit.
On postoperative day 2, he was started on some dopamine for
low blood pressures. His hematocrit was stable at 31. He
continued to rule out for a myocardial infarction whose chest
x-ray showed left lower lobe collapse, for which he underwent
a bronchoscopy which greatly improved his saturations and his
respiratory rate. At this point, the patient slowly
improved.
Postoperative day 3, his cardiac index was 3.1. His
oxygenation was PO2 of 131 on 50% and 5 of PEEP, made
adequate urine at 2 liters per day. His wound graft grew
Staphylococcus aureus coagulase positive Staphylococcus. He
was continued on vancomycin for this and his pressors were
weaned. His left foot continued to be cool and mild to above
the ankle with a palpable graft pulse. The patient continued
to slowly improve.
Postoperative day 4, he was only on a small amount of pressor
support, received 1 unit of blood as well as some diuresis,
but remained intermittently agitated. His foot continued to
be ischemic and we followed this very closely. The patient
continued to wean off pressors and continued to slowly
improve. He was seen by cardiology who was happy with his
progress.
By postoperative day 5, he was continued on vancomycin,
Ativan and Dilaudid for sedation and a small amount of
dopamine. He had received 2 units of blood and his
hemodynamics were stable. At this point, his foot started to
become necrotic to above the ankle with skin sloughing
medially. The graft pulse is still palpable. He was totally
weaned off of any pressors and his Swan was changed over to a
triple lumen due to his improving hemodynamics.
At this time, sputum and wound grew out yeast and he was
started on fluconazole in addition to his vancomycin.
Additionally, the vent was weaned as tolerated. His leg
continued to deteriorate slightly, so at this time, on [**5-6**] he was taken to the Operating Room for a wound
debridement of his groin and mid wound and partial closure
and packing, as well as a left guillotine amputation by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient tolerated the procedure without
any complications and returned to the Intensive Care Unit.
His wounds continued to slowly improve. He was continued on
vancomycin and fluconazole. He continued to make adequate
urine with a creatinine of 1.3.
By postoperative day 9 and 2, he had some increasing
temperatures, spiked a fever to 102.9??????. His white count went
up to 14. He was pan cultured. Again, all of his wounds
grew out Methicillin resistant Staphylococcus aureus and
yeast. Additional coverage was added by the infectious
disease service, as well as line changes were done. His
guillotine amputation site looked really well. The patient
continued to slowly improve. The patient was started on
ceftriaxone for further coverage. Because of his increasing
white count and fevers and complaints of some abdominal pain,
general surgery was consulted to rule out cholecystitis.
Ultrasound was performed which showed sludge. The patient
improved and it was felt that the patient did not have a
calculous cholecystitis.
By postoperative day 12, he had some right arm swelling and
an ultrasound was done which showed no deep venous
thrombosis. His abdominal pain resolved. He was started on
Zosyn for coverage of his abdomen and was continued on total
parenteral nutrition. At this point, his antibiotic regimen
was vancomycin, Zosyn, Flagyl and fluconazole.
By postoperative day 13 and 6, the patient began to
defervesce. His white count was 15. He had an abdominal CT
that just showed sludge in the gallbladder, bilateral
effusions and atelectasis with a small rectus sheath
hematoma. Cultures from his prior bronchoscopy grew
Staphylococcus aureus, as well as his line tips, sputum grew
yeast and urine grew yeast. He was continued on his
antibiotics. He started on tube feeds which he began to
tolerate and again his line was changed for fevers.
By postoperative day 15 and 8, he was afebrile. White count
was still 15, creatinine 1.4. He is making 3600 of urine
with gentle diuresis, exercising on CPAP during the day and
resting on IMV at night. On the [**5-14**], the patient
went to the Operating Room for a completion amputation. He
underwent a left below knee amputation and incision and
drainage of his open thigh wound by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He
tolerated this well and postoperatively was stable. He
returned to the Intensive Care Unit at this time.
At this time, he spiked a fever postoperatively which was
felt to be due to atelectasis and removal of necrotic tissue
during the operation. He required 1 unit of blood. Again,
he ruled out for a myocardial infarction and by postoperative
day 17, a set if mechanics were checked. The patient
continued to wean. He was on 5 of PEEP, 5 of pressure
support on CPAP. He underwent multiple ............. trials
which he performed well. He had excellent mechanics and he
continued to diurese.
Then, on postoperative day 18 the patient was extubated, as
he met all criteria and did well for 9 to 10 hours and became
hypertensive and tachycardic with poor saturation and
increased respiratory rate requiring reintubation. He
required 40% FIO2 and 10 of PEEP at this time. Again, he
ruled out for myocardial infarction. His tube feeds were
restarted and the patient underwent a percutaneous
tracheostomy on postoperative day 22, 14 and 6, uneventfully
at the bedside under bronchoscopy guidance. His bronch
showed a small amount of clear secretions. He tolerated this
procedure well and was quickly weaned back to CPAP with
minimal pressure support which he tolerated well. His
antibiotics were slowly decreased. The fluconazole was
discontinued after one week.
He underwent, on postoperative ay 23, 16 and, a PICC line
placement for a long six week course of vancomycin for his
infected graft, as well as a percutaneous endoscopic
jejunostomy tube placed in Interventional Radiology for tube
feeds. This went uneventfully. The patient tolerated this
well and has continued to improve and have no further
problems. His creatinine went down to 0.8 and he has been on
trach mask for the last 24 hours, this being on postoperative
day 27, 20 and 12 at which time he is ready for discharge.
His requirements are trach care. He needs a vent facility
with the capability of ventilator. He is on trach mask 40%
with oxygenation and PO2 in the range of 190, getting gentle
diuresis each day, tolerating 70 of Impact with fiber tube
feeds through his PEG.
DISCHARGE MEDICATIONS:
1. Captopril 12.5 mg per J-tube tid
2. Lopressor 100 mg per J-tube tid
3. Ativan 2 mg per J-tube tid
4. Clonidine patch 1 patch transdermally each Saturday
5. Fentanyl patch 25 mcg per hour transdermally every 72
hours
6. Vancomycin 750 mg intravenous through the PICC line every
24 hours for a period of 6 weeks.
7. Zantac 150 mg per J-tube [**Hospital1 **]
8. Sliding scale insulin of regular subcutaneous. 0 to 200
no units, 201 to 250 2 units, 251 to 300 4 units, 301 to 350
6 units, 351 to 400 8 units, greater than 400 10 units.
9. Heparin 5000 units subcutaneously q 12 hours
10. Aspirin 325 mg per J-tube q day
11. Albuterol nebulizers or metered dose inhalers q6h
12. Flovent 110 4 puffs [**Hospital1 **]
13. Salmeterol 1 to 2 puffs inhaled [**Hospital1 **]
14. Miconazole powder 2% prn
15. Ativan 1 to 2 mg intravenous q4h prn
16. Tylenol 650 mg per J-tube q 4 to 6 hours prn
17. Percocet elixir 5 to 10 cc per J-tube q 4 to 6 hours prn
DISCHARGE INSTRUCTIONS: The patient requires physical
therapy, trach care. He needs normal saline wet to dry
dressings on his left groin and mid thigh wound [**Hospital1 **] with dry
dressing on his left stump without any stump shrinking
apparatus, just a dry dressing with an Ace wrap to the stump.
No pressure on the stump. An air bed would be preferable.
He also needs physical therapy, PICC line care, PEG care and
the patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
([**Telephone/Fax (1) 10880**] in two to three weeks for checking of all left
groin, thigh and stump wounds.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Name8 (MD) 25739**]
MEDQUIST36
D: [**2170-6-25**] 09:18
T: [**2170-6-25**] 09:22
JOB#: [**Job Number 25740**]
ICD9 Codes: 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2080
} | Medical Text: Admission Date: [**2118-4-25**] Discharge Date: [**2118-5-30**]
Date of Birth: [**2058-4-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Acute type A dissection
Major Surgical or Invasive Procedure:
[**2118-5-16**]- sternal debridement,
[**2118-5-2**] - Flexible bronchoscopy with aspiration, open
tracheostomy tube with 8-0 Portex tracheostomy and 20-French PEG
tube placement.
[**2118-4-25**] - Repair of acute type A aortic dissection with 30mm
Dacron interposition tube graft from the sinotubular junction to
the hemiarch using deep hypothermic circulatory arrest with
aortic valve resuspension.
History of Present Illness:
Mr. [**Known lastname 1391**] is a 60 year old man who was admitted on [**2118-4-25**]
with a Type A aortic dissection. He had been at work earlier in
the day, and reportedly acutely complained of chest pain and
clutched his chest ~ 12:30 pm while
doing physical labor. He was brought to an outside hospital
where he was initially conversant, but then became less
responsive and unstable. A CT scan revealed a dissection from
the aortic root to the bifurcation, and occlusion of the R
carotid artery. His intubation was reportedly traumatic, with a
fair amount of bleeding. Upon arrival at [**Hospital1 18**] he was sedated
and had an unclear
neurological status. Neuro consult was obtained and he was taken
emergently to the operating room for repair.
Past Medical History:
None known.
Social History:
Works on a farm in Msssachusetts doing manual labor. Smokes
1/2-1 ppd of tobacco. Drinks alcohol- up to 4 drinks per day.
Family History:
Grandchild and daughter in law with pneumonia a few weeks ago
Physical Exam:
[**2118-4-25**] -
Gen- critically ill, intubated and recently sedated.
MS- no response to noxious stimuli
CN- pupils 4mm and unreactive to light, absent oculocephalic
response, absent corneal reflex, face appears symmetric.
apparently has gag to suction, strong cough reflex.
Motor- no movement, no withdrawal to noxious
Reflexes- trace 1+ reflexes on the left [**Hospital1 **], brachiorad, patella.
I am unable to elicite reflexes on the right side.
Toes are mute bilaterally.
[**2118-4-29**] -
Vitals: T max 39.1, T c 99.8 HR 67-99 BP 108/56-155/68 RR
18-24 O2 sat 97-100%
General: Intubated, mild-mod respiratory distress with abdominal
retractions
HEENT: Pupils ~ 1mm, equal and reactive, no conjunctival
injection, intubated
Neck: supple. No LAD.
Respiratory: Lungs coarse bilaterally.
Cardiovascular: RRR, no murmurs appreciated
Chest: Sternal-abdominal midline surgical site clean, dry, no
erythema
Back: Deferred
Gastrointestinal: Soft, nondistended, dressing clean and dry
Genitourinary: Foley in place
Ext: Right index finger with black macule under nail.
Extremities
edematous, L arm> R. No stigmata of endocarditis.
Neurological: Does not respond to commands, minimal response to
pain
Access: L IJ, L radial A line
Pertinent Results:
[**2118-4-26**] Carotid Ultrasound
1. 80-99% stenosis in the right internal carotid artery.
2. 60-69% stenosis in the left internal carotid artery.
[**2118-4-28**] Brain MRI
IMPRESSION:
Multiple foci of acute ischemia, as detailed above.
Cortical signal abnormality in the occipital lobe/right frontal
lobe may be related to hypoxia.
Moderate right and mild left carotid narrowing in the neck. This
appears to be discordant with the ultrasound report. Recommend
correlation with a CTA for further evaluation.
Right A1 stenosis, otherwise unremarkable MRA of the brain.
[**2118-4-25**] ECHO
Pre Bypass: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
The ascending aorta is markedly dilated A mobile density is seen
in the ascending aorta consistent with an intimal flap/aortic
dissection. The dissection is seen as far down as the probe
passes in the descending aorta. There are three aortic valve
leaflets. There is no aortic valve stenosis. Severe (4+) aortic
regurgitation is seen, owing to the dissection flap prolapsing
through the aortic valve. The aortic root is dilated, but not
completely effaced. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen.
Post Bypass: The aortic valve has be resuspended and has mild
aortic insufficiency. There is a tube graft in the ascending
aorta with laminar flow. Biventricular fuction is preserved.
Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
[**2118-5-2**] Lower Extremity Ultrasound
No evidence of deep vein thrombosis in either leg.
[**2118-5-30**] 03:56AM BLOOD WBC-20.1* RBC-2.88* Hgb-8.8* Hct-26.9*
MCV-93 MCH-30.5 MCHC-32.7 RDW-14.6 Plt Ct-527*
[**2118-4-25**] 04:44PM BLOOD WBC-22.3* RBC-4.17* Hgb-13.7* Hct-41.8
MCV-100* MCH-32.9* MCHC-32.8 RDW-13.5 Plt Ct-147*
[**2118-5-30**] 03:56AM BLOOD PT-15.9* PTT-89.3* INR(PT)-1.4*
[**2118-4-25**] 04:44PM BLOOD PT-17.1* PTT-36.3* INR(PT)-1.5*
[**2118-5-30**] 03:56AM BLOOD Glucose-104 UreaN-49* Creat-0.9 Na-144
K-4.5 Cl-103 HCO3-32 AnGap-14
[**2118-4-26**] 02:04AM BLOOD Glucose-174* UreaN-21* Creat-1.8* Na-149*
K-3.1* Cl-114* HCO3-23 AnGap-15
[**2118-5-26**] 06:19AM BLOOD ALT-156* AST-77* LD(LDH)-612*
AlkPhos-163* Amylase-57 TotBili-0.3
[**2118-5-14**] 02:18PM BLOOD ALT-230* AST-159* LD(LDH)-569* AlkPhos-85
Amylase-74 TotBili-0.3
[**2118-5-30**] 03:56AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.8*
[**Known lastname **],[**Known firstname **] [**Medical Record Number 82249**] M 60 [**2058-4-23**]
Neurophysiology Report EEG Study Date of [**2118-5-6**]
OBJECT: S/P AORTIC DISSECTION NOW UNRESPONSIVE, EVALUATE FOR
SEIZURE.
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
FINDINGS:
ABNORMALITY #1: The background rhythm was slow a poorly
modulated
reaching a 6 Hz maximum in the most awake state.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as the patient was
unresponsive and could not cooperate.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this
was a
portable study.
SLEEP: No normal waking morphologies were seen. The patient did
appear
to briefly enter stage II sleep towards the end of the tracing.
IMPRESSION: This is an abnormal routine EEG due to the slow and
disorganized background indicative of a mild encephalopathy.
Medications, metabolic disturbances, and infections are among
the most
common causes. Anoxia is another possibility. There were no
areas of
focal slowing although encephalopathies can obscure focal
findings.
There were no epileptiform features noted.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 7495**] B.
(09-1060C)
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82250**] (Complete)
Done [**2118-5-16**] at 3:15:03 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2058-4-23**]
Age (years): 60 M Hgt (in): 70
BP (mm Hg): / Wgt (lb): 175
HR (bpm): BSA (m2): 1.97 m2
Indication: Aortic dissection. H/O cardiac surgery. Left
ventricular function. Right ventricular function.
ICD-9 Codes: 441.00, 423.9, 424.1
Test Information
Date/Time: [**2118-5-16**] at 15:15 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW0-0: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 40% >= 55%
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Descending Thoracic: *3.8 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Pericardium - Effusion Size: 1.9 cm
Findings
LEFT ATRIUM: All four pulmonary veins identified and enter the
left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.
AORTA: Moderately dilated descending aorta Aortic arch intimal
flap/dissection. Descending aorta intimal flap/aortic
dissection.
AORTIC VALVE: Three aortic valve leaflets. No AS. Mild (1+) AR.
MITRAL VALVE: Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Moderate to large pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Overall left ventricular systolic function is mildly depressed
(LVEF= 40 %).
Right ventricular chamber size and free wall motion are mildly
depressed.
A mobile density is seen in the aortic arch consistent with a
chronic intimal flap/aortic dissection which descends down
throughout the visualized portions of the descending thoracic
aorta.
An ascending aortic tube graft is in place. There is clot and
spontaneous echo contrast within the false lumen. The are small
loculated bilateral pleural effusions.
The is a moderate to large pericardial effusion (greatest
dimesion along RV) with no echocardiographic signs of tamponade
.
There are three aortic valve leaflets.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. Trivial mitral regurgitation is seen.
A portion of the PICC line is seen in the SVC.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2118-5-20**] 11:25
?????? [**2112**] CareGroup IS. All rights reserved.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 82249**] M 60 [**2058-4-23**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2118-5-15**]
2:12 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2118-5-15**] 2:12 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 82251**]
Reason: evaluate for ischemia no contrast for head CT
[**Hospital 93**] MEDICAL CONDITION:
60 year old man with s/p asc aorta replacement
REASON FOR THIS EXAMINATION:
evaluate for ischemia no contrast for head CT
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: PXDb SUN [**2118-5-15**] 4:12 PM
No acute intracranial process. Please note limited sensitivity
of CT for acute
infarct for which MR is a better modality
Final Report
INDICATION: 60-year-old man status post ascending aortic repair.
Evaluate
for ischemia.
COMPARISON: [**2118-4-26**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no intra- or extra-axial hemorrhage, mass
effect, masses,
or shift of normally midline structures. There are no acute
vascular
territorial infarcts. The ventricles and sulci are normal in
size and
configuration. The [**Doctor Last Name 352**] and white matter differentiation is well
preserved.
Osseous structures are unremarkable. There is mild mucosal
thickening in the
sphenoid and right maxillary sinus; otherwise, the paranasal air
sinuses are
well aerated.
IMPRESSION: No acute intracranial process. Please note limited
sensitivity
of CT for evaluation of ischemia, for which MR is a better
modality.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: SUN [**2118-5-15**] 8:11 PM
Imaging Lab
Brief Hospital Course:
Mr. [**Known lastname 1391**] was admitted to the [**Hospital1 1170**] for emergent surgical reepair of his type A aortic
dissection. An emergent neurology consult was obatined for input
regarding the appropriateness of taking Mr. [**Known lastname 1391**] to the
operating room. No clear contraindication was seen as he was
intubated and sedated. He was then taken urgently to the
operating room where he underwent repair of his type A aortic
dissection. Please see operative note for details.Transferred to
the CVICU in serious condition on aniodarone, milrinone,
epinephrine, phenylephrine, and propofol drips.Neurology
continued to follow him postop as he did not make a neurological
recovery. Amiodarone was loaded for ventricular ectopy and
ventricular tachycardia. He developed facial twitching and
neurology was again consulted. A carotid ultrasound was obtained
as the dissection involved the carotids. This revealed an 80-99%
stenosis in the right internal carotid artery and a 60-69%
stenosis in the left internal carotid artery. Sedation was
weaned and Mr. [**Known lastname 1391**] remained unresponsive without
spontaneous movement. A continuous EEG recording was started.
Dilantin was started for seizure activity. Given the complexity
of his postoperative course, the remainder of the summary will
be broken down into systems.
Neurologic:
Mr. [**Known lastname 1391**] suffered a cerebral infarct and developed seizure
activity. Dilantin was loaded and the neurology service was
consulted and followed him daily. An MRA/MRI revealed watershed
infarcts with multiple areas of acute infarcts. He was noted to
withdraw his bilateral lower extremities and his right upper
extremity to pain. A weak gag reflex was noted. He remained
severely compromised neurologically throughout his postoperative
course without significant recovery.
Infectious disease:
Mr. [**Known lastname 1391**] developed fevers intermittently throughout his
postoperative course. He was found to have H. Influenzae in his
sputum and was treated with ampicillin. He destabilized his
sternum with his coughing for which strict sternal precautions
were followed. As his white blood cell count increased and he
developed fevers, mediastinitis was a concern. Ciprofloxacin and
vancomycin were started for prophylactic coverage of his
sternotomy. A PICC Line was placed for intravenous access. His
sternum became unstable as a fluid collection was noted.
returned to the OR on [**5-16**] for sternal debridement and plating.
Plastics followed thereafter. Ciprofloxacin was continued to
complete treatment of his H. influenzae.Fevers of unknown origin
persisted. ID continued to follow. Antibiotics were discontinued
as a possible source of temperature. [**5-24**] A CT scan of
chest/Abdomen/pelvis was done and DVT of his leg was found as
mutiple pulm. emboli. Heparin was started.
Respiratory:
As he never was able to successfully wean from mechanical
ventilations, the thoracic surgery service was consulted for a
tracheostomy. He underwent a tracheostomy and placement of a
feeding tube without complication. He was slowly weaned off the
vent and by [**2118-5-9**] he was off the ventilator entirely.
Cardiac:
He slowly weaned from blood pressure support. He remained
relatively stable from a cardiovascular standpoint.
Betablockade, aspirin and a statin were started. Blood pressure
was tightly controlled.
Physical therapy and occupational therapy worked with him daily
for range of motion.
It is likely the fevers are due to CNS disorder or the pulmonary
emboli. He still is spiking temps to approx. 102 with no other
infectious source found.
He continued to make steady progress and remained stable
hemodynamically. On POD #35/27/14 he was discharged to
rehabilitation for further recovery. He will follow-up with Dr.
[**Last Name (STitle) 914**], the neurology service and his primary care physician as
an outpatient if need is determined by the rehab specialist.
Medications on Admission:
None
Discharge Medications:
1. Warfarin 1 mg [**Last Name (STitle) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4
PM: INR goal >2.0.
2. Carvedilol 3.125 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO BID (2
times a day).
3. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a
day).
4. Levetiracetam 100 mg/mL Solution Sig: Five (5) PO BID (2
times a day): *total of 500 mg [**Hospital1 **].
5. Amiodarone 200 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times
a day).
6. Atorvastatin 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
7. Aspirin 81 mg [**Hospital1 8426**], Chewable Sig: One (1) [**Hospital1 8426**], Chewable
PO DAILY (Daily).
8. Lisinopril 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily):
Hold for SBP<90.
9. Furosemide 40 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a
day).
10. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection every six (6) hours: per sliding scale.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for bronchospasm.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezes.
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough .
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
15. Acetaminophen 650 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO Q4H
(every 4 hours) as needed for temperature >38.0.
16. Dextrose 50% in Water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for glucose < 60.
17. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML
Injection PRN (as needed) as needed for line flush.
18. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for nausea/vomiting.
19. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed: for SBP>140.
20. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): 1700
units/hour for PTT goal 60-80, please check PTT q6h after any
changes have been made.
21. Warfarin 5 mg [**Hospital1 8426**] Sig: 1.5 Tablets PO ONCE (Once) for 1
days: today.
22. Magnesium Sulfate 4 % Solution Sig: One (1) Injection PRN
(as needed) as needed for mg <2.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Ascending Aortic Dissection
s/p repair ascending aortic dissection
perioperative stroke
postop fevers
Hypertension
Pneumonia
Respiratory failure
choleloithiasis/cholecystitis
s/p tracheostomy
s/p perctutaneous gastrostomy tube
sternal dehiscense
sternal debridement [**5-16**]
pulmonary emboli
deep vein thrombosis
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that there is
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) Call with any questions or concerns.
Followup Instructions:
any followup required can be scheduled by rehab prn
Completed by:[**2118-5-30**]
ICD9 Codes: 5070, 4271, 2760, 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2081
} | Medical Text: Admission Date: [**2163-12-13**] Discharge Date: [**2163-12-18**]
Date of Birth: [**2114-11-9**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This is a 49 year-old male with
a past medical history significant for coronary artery
disease status post an obtuse marginal stent in the past,
hyperlipidemia, gastroesophageal reflux disease, asthma,
obesity with no history of tobacco or alcohol use or abuse.
ALLERGIES: The patient has allergies to codeine.
MEDICATIONS PRIOR TO ADMISSION: Lipitor 10 mg po q.h.s.,
aspirin one tab q.d., Prevacid 30 mg po q day, Atenolol 100
mg po q.a.m., Isordil 10 mg po t.i.d., Univasc 15 mg po
q.a.m.
This is a 49 year-old male who was transferred to [**Hospital1 346**] for cardiac catheterization after
being admitted to [**Hospital 1474**] Hospital the day prior to
admission, which was [**2164-1-11**] for chest pain and shortness
of breath with electrocardiogram changes suggestive of
ischemia. The patient has a history of cardiac
catheterization in [**2163-10-12**] with stents placed to
the left circumflex and obtuse marginal revealing left main
to 20% and right coronary artery occlusion of 100% as well as
left anterior descending coronary artery disease of 60%. The
patient's chest pain was substernal nonradiating with no
complaints of nausea, vomiting or diaphoresis. It occurred
at rest as well as worsening with exertion. Nitroglycerin
with good relief. He was ruled out for anterior myocardial
infarction by enzymes.
The patient underwent cardiac catheterization on the day of
his admission, which was [**12-13**], which revealed 50% left
main coronary artery disease, 50% mid left anterior
descending coronary artery disease, 90% disease of the left
circumflex at the origin and 60% in stent restenosis of the
left circumflex, 90% origin of obtuse marginal one and obtuse
marginal two and the right coronary artery was not injected.
It had a known total occlusion filling via the left coronary
collaterals.
The patient underwent coronary artery bypass grafting times
three [**2163-12-14**] with a left internal mammary artery
to the left anterior descending, saphenous vein graft to the
diagonal and right radial artery to the obtuse marginal. The
patient's total cardiopulmonary bypass time was 89 minutes
and total cross clamp time 56 minutes. The patient was
transferred to the Cardiac Surgery Recovery Unit in stable
condition on nitroglycerin and propofol. The patient was
extubated later on the day of surgery. Postoperative day one
the patient remained afebrile in sinus rhythm at 82 on nitro
drip at one and insulin drip of three with a stable
hematocrit and good urine output. Physical examination
unremarkable with the plan to discontinued the nitroglycerin
and to begin Imdur po and to fast track to the floor.
Postoperative day two at 2:00 in the morning the patient
went into atrial fibrillation with a heart rate in the 150s,
blood pressure 185/90, 5 mg of Lopresor was administered
times two as well as an Amiodarone bolus of 150 mg. An
additional 25 mg of Lopressor po was needed to increase his
daily dose to 50 mg po b.i.d. He was started on Amiodarone
400 mg po t.i.d. with his heart rate coming down to the 90s
and blood pressure 136/60 without further intervention.
On postoperative day two later on that day the patient is
without complaints aside from the episode of atrial
fibrillation earlier. Afebrile, vital signs are stable in
sinus rhythm. Plan to continue Lopressor now at 50 mg po
b.i.d. as well as Amiodarone and to discontinue the chest
tubes and Foley catheter. Postoperative day three the
patient with no further episodes of atrial fibrillation over
the last 24 hours without complaints with good pain control
in sinus rhythm at 73 with low grade temperature of
temperature max 99.6. Physical examination remained
unchanged with the plan to possibly discharge the patient to
home the following day. Postoperative day four the patient
was without complaints overnight. Aside from constipation
for which the patient was administered Colace without effect.
The patient was discharged home with services.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q day, atenolol 100
mg po q.d., Lansoprazole 30 mg po q day, Simvastatin 20 mg po
q day, Acetaminophen 650 mg po q 4 hours prn pain. Percocet
one to two tabs po q 4 to 6 hours prn pain, potassium
chloride 20 milliequivalents po q day, Isosorbide dinitrate
20 mg po t.i.d.
DISCHARGE CONDITION: The patient was discharged home in
stable condition.
DISCHARGE DIAGNOSIS:
Coronary artery disease status post coronary artery bypass
grafting times three.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 5577**]
MEDQUIST36
D: [**2164-1-12**] 11:19
T: [**2164-1-16**] 07:55
JOB#: [**Job Number 28294**]
ICD9 Codes: 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2082
} | Medical Text: Admission Date: [**2198-9-18**] Discharge Date: [**2198-9-20**]
Date of Birth: [**2133-10-11**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Penicillins / Oxycodone/Apap / Niaspan
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname 7677**] is a very pleasant 64 yo woman with CAD s/p recent
CABG ([**7-14**]), PVD (multiple LE stents and CEA), HTN,
hyperlipidemia and hypothyroidism who presented to an OSH with
syncope. She was transferred to [**Hospital1 18**] because of possible
complete heart block noted on EKG.
.
She reports that she awoke with LBP, which is not unusual for
her. After lunch, she became nauseated and diaphoretic and then
vomited. She went to the doctor with her husband, and her
husband's doctor prescribed her a stronger pain medication,
shich she took later in the day. She went to bed early, and then
felt nauseated again, she sat up from bed and then lost
consciousness. When she awoke, she had vomited and been
incontinent of stool. She states 15 minutes passed between when
she had gone to bed and when she woke up, so she could not have
been unconscious for more than a couple of minutes. She called
her sister who lives down the street, and her husband, who was
out bowling. When she awoke, she was not confused, and she had
not bitten her tongue. Her husband then took her to an OSH [**Name (NI) **].
.
In the ED at the OSH, her EKG revealed CHB with a rate in the
30s. She was otherwise hemodynamically stable, with BPs in the
140s-160s/60s-70s. She received a dose of ondansetron in the ED
with good effect. She had a head CT that reportedly did not show
any acute change. She was transferred to [**Hospital1 18**] for further
evaluation and treatment.
.
She denies any chest pain or shortness of breath, but she did
have diaphoresis with her first episode of vomiting after lunch
on the day PTA.
.
On ROS, she has denies any claudicative symptoms. She has a h/o
GI bleed (unknown source requiring 3 units pRBCs) while on
aspirin and clopidogrel ~2 years ago. She denies headache,
cough, hemoptysis, exertional dyspnea, PND, orthopnea, ankle
swelling, palpitations or any prior episodes of syncope.
Carotid U/S [**7-14**]: 40-59% right ICA stenosis. 70-99% left ICA
stenosis
with calcified plaque.
Past Medical History:
OUTPATIENT CARDIOLOGIST: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] [**Telephone/Fax (1) 55203**]
OUTPATIENT PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17369**] [**Telephone/Fax (1) 55204**]
.
CAD 3VD:
CABG, in [**7-14**] anatomy as follows: LIMA to LAD, SVG to DIAG, SVG
to PDA
Coronary angio pre-CABG [**7-14**]: 90% RCA, Diag 70%, and 50% mid LAD
.
PVD s/p lower extremity stents (total of 7)including bilateral
common iliac stenting, right "fem-[**Doctor Last Name **]" bovine patch angioplasty
and stenting
GI Bleed 1.5 year ago with 3 unit transfusion while on Plavix
and ASA- At that time had a normal colonscopy as well as
enteroscopy at [**Hospital1 18**] [**4-12**].
Right carotid endarterectomy [**2193**] at [**Hospital3 **] (note
records from [**Hospital1 **] indicate bilateral CEA's, however patient
denies this)
Carotid angio [**9-/2197**]: 50% subclavian stenosis, 90% carotid
siphon lesion, 60-70% right internal carotid stenosis, less than
50% left internal carotid stenosis, type I aortic arch.
Hyperlipidemia
Hypertension
Recurrent vasovagal syncope
"Lypodystrophy" (decreased fat cell distribution) as a child s/p
plastic surgery with fat flaps transferred from stomach to face
[**Hospital1 756**] and Women??????s)
Peripheral neuropathy
hypothyroidism
bone spurs removed from right arm
total abdominal hysterectomy
hyponatremia
Raynaud's syndrome
Social History:
no history of tobacco use or alcohol abuse
lives with husband
retired [**Name (NI) 22957**] accountant
Family History:
Mother had CHF, brother had MI at age 56 and died of brain
cancer at 58.
Physical Exam:
VS: T 97.6, BP 137/53, HR 41, RR 17, O2 99% on RA
Gen: WDWN woman in NAD, resp or otherwise. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. I-II/VI systolic murmur heard
best at the LUSB
Chest: Well-healed strenal scar. Resp were unlabored, no
accessory muscle use. mild crackles at R base, no wheeze,
rhonchi.
Abd: well-healed infraumbilical scar, soft, NTND, No HSM or
tenderness. + abdominal bruit
Ext: no cyanosis, clubbing or edema, + bilateral femoral bruits.
Pulses:
Right: Carotid 1+ with bruit; Femoral 1+ with bruit; 1+ DP
Left: Carotid 1+ with bruit; Femoral 1+ with bruit; 1+ DP
Pertinent Results:
[**2198-9-19**] 05:24AM [**Month/Day/Year 3143**] WBC-4.8 RBC-3.92* Hgb-11.5* Hct-33.6*
MCV-86 MCH-29.5 MCHC-34.3 RDW-16.2* Plt Ct-184
[**2198-9-19**] 05:24AM [**Month/Day/Year 3143**] PT-14.3* PTT-37.3* INR(PT)-1.3*
[**2198-9-19**] 05:24AM [**Month/Day/Year 3143**] Lupus-NEG
[**2198-9-19**] 05:24AM [**Month/Day/Year 3143**] Glucose-90 UreaN-17 Creat-0.9 Na-134
K-4.5 Cl-97 HCO3-27 AnGap-15
[**2198-9-18**] 08:55PM [**Month/Day/Year 3143**] CK(CPK)-70
[**2198-9-18**] 08:55PM [**Month/Day/Year 3143**] CK-MB-NotDone cTropnT-<0.01
[**2198-9-18**] 11:19AM [**Month/Day/Year 3143**] CK(CPK)-73
[**2198-9-18**] 11:19AM [**Month/Day/Year 3143**] CK-MB-NotDone cTropnT-<0.01
[**2198-9-18**] 11:19AM [**Month/Day/Year 3143**] TSH-0.24*
.
Lipoprotein a and Anticardiolipin antibody was pending at time
of discharge.
.
EKG from OSH demonstrated junctional bradycardia (? retrograde P
waves on rhythm strip) with a rate in the mid-30s, RBBB, no LVH
or RVH, no ST changes in the lateral, inferior or anterior
leads, normal RWP, early transition.
.
EKG on transfer demonstrated sinus bradycardia at ~42 bpm,
normal axis, normal PR and QTc, wide QRS c/w RBBB, no chamber
abnormalities, no ST segment deviation, isolated TWI in lead II
inferiorly, normal RWP, early transition.
.
Carotid U/S [**7-14**]: 40-59% right ICA stenosis. 70-99% left ICA
stenosis
with calcified plaque.
.
Intra-op TEE [**7-14**]: No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are complex (>4mm) atheroma in the aortic
arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
.
CARDIAC CATH performed on [**2198-7-13**] demonstrated:
1. Selective coronary angiography of this right dominant system
revealed diffuse calcification thorughout the coronary arteries.
There was a flow-limiting 90% ostial RCA stenosis as well as
moderate diffuse disease in the dominant rca vessel. There was
diffuse mild disease in a heavily-calcificed left coronary
system. There was a dual LAD with the larger diagonal system
having a 70% lesion at a bifurcation. The LCX had < 50%
proximal disease. There were faint left-->right collaterals
evident.
2. Hemodynamic evaluation revealed normal systolic pressure and
normal LVEDP.
3. Abdominal aortogram with runoff was performed given the
patient's extensive history of PVD and revealed moderate
diffuse, heavily calcified vessels but no evidence of critical
flow-limiting stenosis was apparent. There was evidence of
moderate in-stent restenosis in the right leg.
Brief Hospital Course:
ASSESSMENT: 64 yo woman with CAD s/p recent CABG, PAD s/p
multiple LE stent implantations and R CEA, HTN, hyperlipidemia
presented to OSH ED with syncope with possible complete heart
block. Transferred to [**Hospital1 18**] for pacemaker evaluation.
.
## Cardiac:
- Rhythm: Initial EKG had retrograde P waves in the rhythm
strip and there was a question as to whether she had CHB vs
atrial asystole. Etiology unclear, but most likely is idiopathic
progressive conduction disease. Other possible etiology include
acute ischemia, especially given nausea, diaphoresis, but
without evidence of ischemia on EKG and negative enzymes. The
team also considered hypothyroidism, but her dose of
levothyroxine appears to be appropriate given that her TSH was
at the low end of the normal range. Alternatively, she could
have had increased vagal tone in the setting of nausea and
vomiting. She described taking indomethacin and tramadol for
back pain prior to her episode, and she was advised to avoid
these medications. Metoprolol likely contributed as well.
.
Initially, nodal blocking agents were held and the patient was
monitored on telemetry with transcutaneous pacer pads. Although
she did have some 2 second pauses on telemetry the morning she
was admitted, she continued to be in Normal Sinus Rhythm for >
24 hours prior to discharge. Electrophysiology was consulted
and felt that she had sinus dysfunction. Her beta blocker was
restarted at her home dose, which she tolerated well without any
bradycardic episodes for >24 hours. She was sent home and will
have a Lifewatch cardiac monitor delivered to her house within
24 hours of discharge. She will have follow-up with
electrophysiology (Dr. [**Last Name (STitle) **] at [**Hospital1 18**] on [**10-23**].
.
- Ischemia: Patient had a recent CABG and her EKG did not show
new ischemic changes. Her cardiac enzymes were followed and
remained normal, so it was not felt that her symptoms had
resulted from a new ischemic event.
.
- Pump: normal LV function on intra-op TEE [**7-14**].
.
## Syncope: It was unclear whether the patient had a vasovagal
episode from her nausea or whether this represented symptomatic
bradycardia. She did not have any further episodes of syncope
or presyncope during her hospitalization.
.
## HTN: The team initially held [**Month/Year (2) **] pressure medications given
her recent syncopal episode. After she was restarted on
metoprolol 25 po bid, her [**Month/Year (2) **] pressure was at goal (110s to
120s systolic) without her amlodipine or spironolactone. In
addition, her potassium remained normal. Thus, at the time of
discharge, she was instructed not to continue the amlodipine or
spironolactone unless these were restarted by her outpatient
cardiologist or PCP.
.
## PVD: This was notable for the absence of typical risk
factors, including smoking or diabetes. Lupus anticoagulant was
negative. Lipoprotein a and anticardiolipin antibodies were
sent and were pending at the time of discharge.
Medications on Admission:
ALLERGIES: Iodine / Penicillins / Oxycodone/Apap / Niaspan, IV
dye
.
Metoprolol 25 [**Hospital1 **]
Amlodipine 2.5 daily
Spironolactone 12.5 qTuesday, Thursday
Irbesartan 300 daily
Pravastatin 80 daily
Aspirin 81 daily
Levothyroxine 100 daily
Pantoprazole 40 daily
Ferrous sulfate 325 daily
Vitamin C 500 daily
Risedronate 35 weekly
Cetirizine (Zyrtec) 10 daily
Fluticasone nasal 1 spray daily
Calcium/Vit D
Fish oil
Discharge Medications:
1. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily ().
2. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
11. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
spray Nasal once a day.
12. Fish Oil Capsule Sig: [**1-9**] Capsules PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Syncope
Secondary Diagnoses: Sinus dysfunction with bradycardia,
Coronary Artery Disease, Hypertension
Discharge Condition:
Patient was stable, she had been monitored on telemetry without
any bradycardia for > 24 hours. She had no further syncopal
episodes. She was provided with a cardiac 'lifewatch' monitor
that will be delivered to her home within 24 hours.
Discharge Instructions:
You were admitted with a syncopal episode (meaning you fell and
lost consciousness briefly). You were evaluated for a slow
heart rate sometimes referred to as "sick sinus syndrome,"
meaning that the heart's natural pacemaker was firing slowly.
You were monitored closely and had no further events after you
were admitted. Electrophysiology did not advise placing a
pacemaker at this time.
1. Please take all medications as prescribed. Please avoid
taking indomethacin or tramadol as advised by electrophysiology.
Your norvasc (amlodipine) was stopped because your [**Month/Day (2) **]
pressures were at goal without it, and your spironolactone was
stopped because your potassium and [**Month/Day (2) **] pressure were good
without it. Your cardiologist can restart these medications if
appropriate at your follow-up visit.
2. Please attend all follow-up appointments as listed below.
3. Please call your doctor or return to the hospital if you have
chest pain, shortness of breath, palpitations, another episode
when you pass out, or any other concerning symptom.
Followup Instructions:
1. Dr. [**Last Name (STitle) 10543**], your cardiologist, next week.
2. Electrophysiology, Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D.
Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2198-10-23**] 3:00. [**Location (un) 436**] of [**Hospital Ward Name 23**]
Center.
3. Your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17369**], in early [**Month (only) **].
Completed by:[**2198-9-20**]
ICD9 Codes: 2761, 4019, 4439, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2083
} | Medical Text: Admission Date: [**2167-12-8**] Discharge Date: [**2167-12-30**]
Date of Birth: [**2096-4-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Central line placement
Arterial line placement
History of Present Illness:
Ms. [**Known lastname **] is a 71 morbidly obese, ARF, ho of multiple UTIs
(ESBL Klebsiella in past), hypoglycemia (similar in the past).
Came in at 80's systolic and got vanco 1 gm and levofloxacin 750
mg x 1. K and Mag repleted in ED along with 3 L NS. Despite
increasing initially, her CVP remained low [**7-29**]. She is guiaic
positive and had a HCT drop. Admitted to ICU for low urine
output and BP refractory to 3 L NS. On arrival to [**Hospital Unit Name 153**], BP
difficult to obtain secondary to body habitus, ranging from
80's-120/50-70. Intubated. Judged to be urosepsis and
pneuomonia. Eventually recovered from sepsis. Sent to floor. Had
ATN/ARF from her sepsis. Pt was made DNR/DNI.
Past Medical History:
MRSA
Right Femur Fx S/P ORIF ([**10/2165**]: Tripped Over Commode)
HTN
Hyperlipidemia
DMII
Peripheral Neuropathy
CKD with baseline creat 1.5
Obesity
Anemia if chronic disease, bl 30
IBS (Chronic Constipation, Abdominal Pain and Intermittent
Diarrhea) Chronic LBP/Sciatica (Osteoporisis, DJD/OA, Spinal
Stenosis) Depression/Anxiety
Panic Disorder
Parotid Gland Tumor S/P Resection
S/P Multiple Falls
H/O Herpes Zoster
S/P CCY
B/L Cataract Removal.
Social History:
She lives with her daughter, who is very involved with her care.
She had 11 children, and one passed away. She was a homemaker.
She quit smoking 20 years ago and had between [**4-28**] py. She uses
ETOH rarely (<1x/month).
Family History:
Her mother had DM. She knows nothing of her father. [**Name (NI) **] sister
died of [**Name (NI) **] at 60.
Physical Exam:
Vitals: 97.5, 115/70, 80's, 14, 97%2L
Gen: slightly confused, easily arousable, oriented to place
HEENT: dry MMM, unable to assess JVP,
Card: RRR no MRG
Chest: CTA
Abd: NT, soft, no rebound
Ext: no edema
Skin: no rash, RUE skin breakdown, sacral decubitus stage 1
Pertinent Results:
[**2167-12-30**] 03:58AM BLOOD WBC-7.7 RBC-3.02* Hgb-8.8* Hct-27.1*
MCV-90 MCH-29.3 MCHC-32.6 RDW-15.8* Plt Ct-232
[**2167-12-26**] 03:15PM BLOOD Neuts-62.8 Lymphs-27.1 Monos-6.8 Eos-2.9
Baso-0.4
[**2167-12-30**] 03:58AM BLOOD UreaN-10 Creat-1.0 Na-145 K-3.5 HCO3-33*
[**2167-12-23**] 05:00AM BLOOD ALT-8 AST-11 AlkPhos-84 TotBili-0.4
[**2167-12-14**] 05:54AM BLOOD Lipase-57
[**2167-12-19**] 05:35AM BLOOD CK-MB-2 cTropnT-0.05*
[**2167-12-30**] 03:58AM BLOOD Phos-3.2 Mg-1.2*
[**2167-12-22**] 04:10PM BLOOD Cortsol-34.5*
[**2167-12-22**] 05:57AM BLOOD Vanco-16.3
ECHO: Conclusions:
1. The left atrium is mildly dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Regional left ventricular wall motion is
normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is
seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is
seen.
6.There is an anterior space which most likely represents a fat
pad.
Brief Hospital Course:
Pt completed course of antibiotics. ARF resolved. Anasarca was
treated with diuresis. Pt improved clinically, however was
markedly delerious. This was felt to be multifactorial due to
narcotics and sedating meds. These were decreased with
improvement to mental status back to baseline. Pt developed
sacral decubitus during admission. She also had a PICC line in
the RUE which developed skin breakdown. Both of these were
addressed with the wound care team.
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*180 Tablet Sustained Release 12HR(s)* Refills:*0*
2. Oxycodone 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
Disp:*224 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed.
Disp:*1 tube* Refills:*4*
11. Oxycodone 5 mg Tablet Sig: Six (6) Tablet PO Q6H (every 6
hours) as needed for pain.
12. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day) as needed.
Disp:*1 tube* Refills:*3*
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for antifungal.
Disp:*1 bottle* Refills:*3*
14. Double Guard Cream Sig: One (1) appl Topical twice a
day.
Disp:*1 tube* Refills:*2*
15. Aloe Vesta 2-n-1 Antifungal 2 % Ointment Sig: One (1) appl
Topical twice a day.
Disp:*1 tube* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 86**]
Discharge Diagnosis:
Sepsis
Urinary Tract Infection
Respiratory Failure Due to Nosocomial Pneumonia
Diastolic Congestive Heart Failure
Perirectal Ulcer
Anxiety
Morbid Obesity
Discharge Condition:
stable
Discharge Instructions:
Please make sure you take your medications as listed below.
Please make sure you follow up with Dr. [**Last Name (STitle) **] in the next
week. Please call your doctor if you experience
fever/chills/shortness of breath/or confusion/or any other
concerning symptoms.
Followup Instructions:
1. Please call for an appointement to follow up with Dr.
[**Last Name (STitle) **] in the next week.
ICD9 Codes: 0389, 5990, 5849, 486, 2768, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2084
} | Medical Text: Admission Date: [**2197-10-24**] Discharge Date: [**2197-10-26**]
Date of Birth: [**2144-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
dark stools, nausea
Major Surgical or Invasive Procedure:
EGD [**2197-10-25**]
Paracentesis [**2197-10-26**]
History of Present Illness:
53F PMHx sig HepC cirrhosis c/b esophageal varices s/p banding
and multiple episodes of UGI bleeds presents with 2d hx of
melena and nausea. First noticed loose, dark stools yesterday.
Felt a little more fatigued and like her heart was racing this
AM. Mild nausea, one episode of retching with small amount of
"dark" mucous, but no vomiting. Does say she had a few glasses
of wine over the weekend, but no NSAID use. Denies dizziness,
shortness of breath, BRBPR, or abdominal distention (though she
says this fluctuates). No confusions, fevers, or chills. She
went to see her PCP today for evaluation of the melena, where
she was noted to be tachycardic and was sent to the ED for
further evaluation.
.
In the ED, inital vitals were 97.8 116 124/72 18 99% RA. Exam
was remarkable for tachycardia and black stool, grossly
guaiac-positive. Initial labs were remarkable for a H/H of
6.4/21.3 (down from 31.3 on [**9-8**]) and INR 1.7. NG lavage came
back with pink fluid, no coffee grounds. GI/Liver was consulted
in the ED and advised transfer to the MICU for planned EGD in
the early AM. She was given 2 L NS, transfused 1 unit PRBCs
(typed and crossed for 4 units), ceftriaxone 1 g, and started on
octreotide and pantoprazole gtt.
.
On arrival to the MICU, pt is in no distress, hemodynamically
stable.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, or wheezing. Denies
chest pain, chest pressure, or weakness. Denies constipation or
abdominal pain. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- Hepatitis C c/b by varices s/p banding in [**5-14**]
- h/o PUD and antral erosions in past s/p H. pylori treatment in
[**9-/2194**]
- Iron deficiency anemia
- GERD
- Hypertension
Social History:
She lives alone, works in marketing
- Tobacco: denies
- Alcohol: occasionally has a few glasses of wine on weekends
- Illicits: denies
Family History:
No family history of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 100.5 BP: 144/60 P: 111 R: 26 O2: 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera mildly icteric, MMM, oropharynx clear
Neck: supple, JVP ~7, no LAD
CV: tachycardic w regular rhythm, normal S1 + S2, systolic
ejection murmur heard at base
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: BS+, soft, distended but minimal fluid wave,
non-tender, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Physical Exam on Discharge:
Vitals: 100.4, Normotensive, normal heart rate and sating
100%RA
General: AAOx3 in NAD
HEENT: Clear rhinorrhea, +sinus tenderness bilteral maxillary
sinuses. No visible exudate in the posterior pharynx
CV: RRR, no MRG
Lungs: CTAB
Abdomen: Soft, protuberant, small shifting dullness of ~1inch,
no palpable organomegaly
Ext: Warm, well perfused, no edema cyanosis
Pertinent Results:
LABS:
On admission:
[**2197-10-24**] 07:40PM BLOOD WBC-4.1 RBC-2.36*# Hgb-6.4*# Hct-21.3*#
MCV-90# MCH-27.2# MCHC-30.1* RDW-17.5* Plt Ct-108*#
[**2197-10-24**] 07:40PM BLOOD Neuts-67.7 Bands-0 Lymphs-24.2 Monos-7.8
Eos-0.2 Baso-0.1
[**2197-10-24**] 07:40PM BLOOD PT-19.0* PTT-26.7 INR(PT)-1.7*
[**2197-10-24**] 07:40PM BLOOD Glucose-94 UreaN-14 Creat-0.6 Na-142
K-3.5 Cl-107 HCO3-24 AnGap-15
[**2197-10-25**] 06:39AM BLOOD ALT-30 AST-85* AlkPhos-51 TotBili-2.2*
[**2197-10-25**] 06:39AM BLOOD Calcium-7.2* Phos-3.4 Mg-1.4* Iron-222*
[**2197-10-25**] 06:39AM BLOOD calTIBC-309 VitB12-746 Folate-8.8
Ferritn-31 TRF-238
.
Labs on discharge:
[**2197-10-26**] 07:00AM BLOOD WBC-2.7* RBC-2.95* Hgb-8.0* Hct-25.8*
MCV-87 MCH-27.2 MCHC-31.2 RDW-17.6* Plt Ct-77*
[**2197-10-25**] 09:10PM BLOOD Neuts-71.6* Lymphs-21.7 Monos-4.9 Eos-1.5
Baso-0.2
[**2197-10-25**] 09:10PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Spheroc-OCCASIONAL
Ovalocy-1+
[**2197-10-26**] 07:00AM BLOOD Plt Ct-77*
[**2197-10-26**] 07:00AM BLOOD Glucose-107* UreaN-5* Creat-0.7 Na-136
K-3.3 Cl-103 HCO3-24 AnGap-12
[**2197-10-26**] 07:00AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.6
.
EGD:
Varices at the lower third of the esophagus
Erythema and mosaic appearance in the stomach body compatible
with moderate portal gastropathy, which was likely the cause of
bleeding
Small ulcer in the stomach body
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
Ascites Fluid: [**2197-10-26**] 09:23AM ASCITES WBC-175* RBC-[**Numeric Identifier 3871**]*
Polys-7* Lymphs-42* Monos-46* Macroph-5* Other-0
Micro:
[**2197-10-25**]
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2197-10-27**]):
NEGATIVE BY EIA.
[**2197-10-26**]
HCV VIRAL LOAD (Final [**2197-10-27**]):
173,000 IU/mL.
[**2197-10-26**] Blood cultures x 2- PENDING
Imaging:
[**2197-10-25**]
FINDINGS: As compared to the previous radiograph there is no
relevant change. Borderline size of the cardiac silhouette with
mild tortuosity of the thoracic aorta, mild reducing lung
volumes. No pneumonia, no pleural effusions. No pneumothorax.
The hilar and mediastinal structures are unremarkable.
[**2197-10-26**]
Trace fluid and tiny pocket of free fluid. Ultrasound-guided
aspration of 0.5 ml of slightly blood-tinged clear ascitic
fluid. Given the
small volume, sample could only be sent for one laboratory
evaluation.1
Brief Hospital Course:
53F PMHx sig HepC cirrhosis c/b esophageal varices s/p banding
and multiple episodes of UGI bleeds presents with 2d hx of
melena and nausea, likely upper GI bleed, who developed a fever
in the setting of URI symptoms unlikely to be due to SBP or
bacteremia.
.
# GI bleed: Positive NG lavage and hx of bleeding varices and
ulcers made suspicion very high for upper GI source. She was
transfused 2 units PRBCs for her severe anemia, and her
hematocrits then stayed stable on frequent monitoring. She was
started on a PPI and octreotide gtt and given ceftriaxone for
antibiotic prophylaxis. EGD was performed and showed portal
gastropathy (presumed cause of bleeding) and non-bleeding
varices not requiring any banding. Her melena decreased, and
she was stable for transfer out of the MICU. On the floor she
remained stable with no furhter episodes of melena. She was
switched to oral PPI [**Hospital1 **] and switched to PO antibiotics to
complete a 10 day course.
.
#Fever: Patient developed a fever at the time she arrived on
themedical floor. Her CXR was clear, ans she had URI symptoms
with sinus pressure. She was on ceftriaxone at the time, and
given she had a small amount of ascites, she had a tap of the
ascites performed by IR who saw minimal amount of fluid and only
got 1/2 cc, which was sent for cell count which was negative for
SBP. THe patient did not want to wait another day to be
monitored in hospital, so she was discharged with instructions
to call her PCP or come back to the ED if she spiked a fever.
The cause of the fever is likely sinusisit, she was discharged
on a 10 day course of cipro, whch would cover her for her UGIB
abx prophylaxis as well as sinusitis.
.
# Anemia: hx of iron-deficiency anemia, per report. Hct
baseline appears to be in high 20s, acute drop due to GI bleed
as above. As the iron studies performed during this admission
were during the time she received a blood transfusion, these
should be repeated on a outpatient basis.
.
# Hepatitis C cirrhosis: Other than GI bleeding, no signs of
acute decompensation. She was continued on her home dose of
nadalol 40 mg [**Hospital1 **] initially, however the hepatology team
recommended up-titrating the dose to a HR of 55-65, and she was
discharged on nadolol 60mg po BID.
ransitional Issues:
Pending labs: Blood cultures [**2197-10-25**], HCV viral load [**10-25**],
Hpylori serology pending.
Medications started:
1.Ciprofloxacin 500 mg pill by mouth twice a day x 10 days
(antibiotic)
2.Flonase as prescribed for sinus/nasal symptoms
Medications stopped: None
Medications changed:
1. Nadolol- please increase the dose to 60mg by mouth twice a
day (new prescription given)
If you develop a high fever, please call your doctor, or feel
free to come back to the ED.
Medications on Admission:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. nadolol 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
6. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
8. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**2-5**] sprays
Nasal twice a day as needed for cold symptoms.
Disp:*1 bottle* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Upper gastrointestinal bleed from portal gastropathy
Secondary: Hepatitis C cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted to the hospital for an upper gastrointestinal
bleed where you were having dark tary stools. In the ED they
found that you had lost a lot of blood and required a blood
transfusion and you were monitored in the intensive care unit.
You underwent a camera study called endoscopy, which showed
stomach inflammation, likely from your liver disease, as the
cause for your bleeding. We would recommend that you limit any
your alcohol intake and continue the medications below.
After you were transferred to the regular medical floor you had
a fever and we were concerned that you could have an infection
in the fluid in your abdomen, so we performed a paracentesis
(take the fluid amount out). The source of your fever is likely
your sinuses, and we will send you out on an antibiotic pill to
cover you for both the sinus infection as well as preventing
infections after having the GI bleed.
Transitional Issues:
Pending labs: Blood cultures [**2197-10-25**], HCV viral load [**10-25**],
Hpylori serology pending.
Medications started:
1.Ciprofloxacin 500 mg pill by mouth twice a day x 10 days
(antibiotic)
2.Flonase as prescribed for sinus/nasal symptoms
Medications stopped: None
Medications changed:
1. Nadolol- please increase the dose to 60mg by mouth twice a
day (new prescription given)
If you develop a high fever, please call your doctor, or feel
free to come back to the ED.
Followup Instructions:
Name: [**Last Name (LF) 26390**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Thursday [**2197-11-2**] 2:20pm
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appointment: Thursday [**2197-11-2**] 3:20pm
ICD9 Codes: 2851, 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2085
} | Medical Text: Admission Date: [**2172-7-5**] Discharge Date: [**2172-7-7**]
Date of Birth: [**2098-9-11**] Sex: M
Service: MICU
This is an interim discharge summary that includes the
patient's initial admission data as well as his course in the
Medical Intensive Care Unit.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 6359**] is a 73 year-old
gentleman with a past medical history significant for chronic
obstructive pulmonary disease and asthma. He has never been
intubated for the asthma and he has had most recently within
the past year had two steroid tapers, one in [**2172-4-17**]
for one week and one in [**2171-11-18**]. The patient's past
medical history is also significant for hypertension. He was
in his usual state of health until approximately one week
prior to admission when he noted a cough and nasal
congestion. His symptoms were initially limited so he
decided to proceed with a flight from [**State 4565**] where he
resides to [**Location (un) 86**] to attend his granddaughter's fifth
birthday party. Unfortunately beginning one day prior to
admission the patient noted worsening shortness of breath and
cough, which at the time of presentation to the Emergency
Department was accompanied by chills with occasional shakes
as well as a right sided severe pleuritic chest pain worse
with deep inspiration. When the symptoms persisted he
proceeded to the Emergency Department.
In the Emergency Department given the patient's recent flight
from the West Coast to [**Location (un) 86**] as well as his new right sided
chest pain CTA was obtained to look for any evidence of a
pulmonary embolus. The CTA was negative for pulmonary
embolus, but the scan did show bibasilar consolidation. the
patient at the time of presentation in the Emergency
Department was also noted to be in new atrial fibrillation
with a rapid ventricular response. He was given 20 mg of
intravenous Diltiazem in the Emergency Department just prior
to being seen by the admitting medicine team.
PAST MEDICAL HISTORY: As mentioned is significant for
chronic sinusitis, chronic obstructive pulmonary disease,
postop aspiration pneumonia in [**2171-11-18**], asthma,
hypertension, status post cerebrovascular accident six years
ago, status post removal of a penile tumor in [**2163**].
OUTPATIENT MEDICATIONS: Advair b.i.d., Norvasc 5 mg po q.d.,
aspirin 81 mg po q day.
ALLERGIES: Keflex, which causes a rash, Penicillin, which
causes a rash and Percocet, which causes delirium.
FAMILY HISTORY: Notable for a mother who died in [**2110**] at the
age of 39 of tuberculosis. Father died at the age of 73 of
an myocardial infarction. Sister who is alive and well at
age 61 with mild Parkinson's disease.
SOCIAL HISTORY: Significant for a thirty six pack year
history. He quit tobacco in [**2151**]. He lives with his wife in
[**Name (NI) 4565**]. His daughter lives here in the [**Name (NI) 86**] area.
PHYSICAL EXAMINATION ON PRESENTATION: His temperature is
97.9, heart rate 130, blood pressure 106/65, O2 sat 92% on
room air. The patient is in mild respiratory distress with
audible upper airway congestion. He appears to be quite
fatigued. HEENT examination sclera anicteric. He has small
pupils, which are reactive to light. Dry mucous membranes
and no oral lesions. Neck is supple with no lymphadenopathy.
Lungs have coarse upper airway breath sounds throughout.
There is good air movement. Cardiovascular examination he is
tachycardic with a irregular irregular rhythm. Normal S1 and
S2. No murmurs, rubs or gallops is heard. Abdomen is soft,
nontender, nondistended. He has central obesity. There are
normoactive bowel sounds. Extremities are without clubbing,
cyanosis or edema. There is no calf tenderness or swelling
noted on physical examination.
INITIAL LABORATORY DATA: White blood cell count 6.4 with 67%
polys, 11% bands, 18% lymphocytes and 2% monocytes.
Hematocrit 33.2, hemoglobin 11.4, platelet count 248, MCV 92,
RDW 12.6, sodium 142, potassium 3.1, chloride 111, bicarb 21,
BUN 16, creatinine 0.6, glucose 122. PT 13.7, PTT 28.2, INR
1.3. AST is 10, alkaline phosphatase 53, total bili 0.9,
amylase 12, CK 101 with an MB of 1 and a troponin of less
then 0.3. Imaging studies showed a chest CT, which shows
bilateral lower lobe consolidations posteriorly. There is a
small right pleural effusion and a trace left pleural
effusion. There is no evidence of pulmonary embolus. There
is a small subcentimeter bilateral hilar lymph nodes,
prevascular, pretracheal and subcranial. Electrocardiogram
is notable for atrial fibrillation on initial presentation to
the Emergency Department with a rate of 126, axis 15 degrees,
T wave inversion in lead 3, T wave flattening in AVF. There
is a Q wave in AVF. Compared with a prior study form [**2165**]
atrial fibrillation and a T wave inversion in lead three are
both new findings.
In summary, this 73 year-old gentleman with a history of
chronic obstructive pulmonary disease and asthma presents
with shortness of breath, right sided chest pain that is
pleuritic in nature as well as onset of shaking and chills on
the day of presentation to the Emergency Department. He is
found to have bibasilar pneumonia by CT of the chest.
However, the CT of the chest is not consistent with evidence
of a pulmonary embolus. The patient was initially admitted
to the Medical Flor and treated for pneumonia. He received
intravenous Levofloxacin and Flagyl in the Emergency
Department for empiric treatment of his pneumonia given his
history of past aspiration pneumonia in the postoperative
setting. Blood cultures were obtained in the Emergency
Department. The sputum culture was not obtained initially,
but was obtained later when the patient arrived on the
medical floor. The patient was continued on non-steroidal
anti-inflammatory drugs for his pleuritic chest pain as well
as Toradol for pain control.
In terms of the patient's atrial fibrillation this was new in
onset likely secondary to this pneumonia. The patient's rate
was controlled with Diltiazem. When the patient was
transferred to the medical floor he was noted to be in sinus
rhythm and remained in sinus rhythm for his time on the
medical floor as well as for the duration of his stay in the
Intensive Care Unit.
In terms of his chronic obstructive pulmonary disease the
patient was continued on MDI and nebulizers.
In terms of GI the patient was put on Zantac. He was also
put initially on intravenous heparin when he was admitted to
the medical floor.
In terms of fluid, electrolytes and nutrition, he was put on
a house diet as tolerated with intravenous fluids until the
patient was taking better po and his electrolytes were
followed.
The patient on the [**12-5**] in the early evening at
approximately 8:00 p.m. was noted to be hypotensive on the
medical floor with blood pressures 60s/40s and oxygen
saturation dropping from 86% on 2 liters increasing to 89 to
90% on 5 liters. He was then put on a 50% ventimask, which
increased his oxygenation to 93%. Subsequently it dropped to
91%. The patient was then put on 50% face mask and his
oxygen saturation remained approximately 91%. In the setting
of his hypoxia as well as his hypotension the patient was
transferred to the Medical Intensive Care Unit for further
evaluation. On arrival to the Medical Intensive Care Unit
the patient's blood pressure continued to be approximately
50s to 60s systolic over 40s diastolic. The patient was,
however, mentating quite well throughout this period of
hypotension. He had a right femoral line placed on arrival
to the Intensive Care Unit as well as a left arterial line
placed. The patient was then started on Levophed at initial
dose of 10 micrograms per minute as well as on Vasopressin as
dose of 0.04 units per minute. The patient was continued on
these pressors overnight for additional blood pressure
support. The patient also was treated with 2 liters of
normal saline run wide open for additional pressure support.
The patient was not responsive to the fluid resuscitation and
therefore did require the initiation of the pressors as
mentioned. The patient was continued on Levo, Flagyl and
Vancomycin was also started.
The patient's cardiac enzymes were cycled and were found to
be not elevated. His CK and troponin were both within the
normal range. In terms of rhythm, the patient was not in
atrial fibrillation on transfer to the Medical Intensive Care
Unit and remained in sinus rhythm during his stay in the
Medical Intensive Care Unit.
As mentioned on the evening of admission he was hypotensive
with blood pressure 60s/40s. Given his pneumonia and
significant bandemia as well as a history of shakes and
chills prior to admission it was felt that the patient was
septic. He was put on pressors for blood pressure support,
given fluid 2 liters as mentioned and he was continued on
broad spectrum antibiotics. From a pulmonary standpoint he
was treated for the pneumonia as mentioned. The heparin drip
was discontinued, because the patient had no evidence of a PE
on CTA. He was continued on Albuterol and Atrovent MDIs as
well as Flovent and Serevent given his history of chronic
obstructive pulmonary disease. His blood gas on admission to
the MCI was 737, 29, 77. From a GI standpoint the patient
was continued on Zantac. From a renal FEN standpoint, the
patient was NPO. His potassium was repleted and intravenous
fluids for initial level of 3.1. It was noted that his
creatinine increased to 1.4 from 0.6 on admission likely
secondary to poor perfusion in the setting of hypotension.
His creatinine was followed closely every day. From an
infectious disease standpoint the patient's sputum was sent
for culture. Preliminary data showed 4+ gram positive coxae
in pairs and clusters as well as 1+ gram positive rods. At
the time of this dictation there is no additional data on
respiratory culture. The patient's temperature max on the
medical floor was 100. He did not spike a temperature during
his stay in the Intensive Care Unit.
On the second day in the Intensive Care Unit on the morning
following his transfer the patient had remained on a
nonrebreather with O2 sats in the high 90s overnight. His
Levophed was starting to be titrated down from 10 to 6 and
ultimately down to 3. His Vasopressin was at 0.04 overnight
on the first evening in the Intensive Care Unit. He also
received q 2 hour nebulizers overnight. Laboratory data on
the morning following his admission to the MICU included a
white count increased to 11.2, hematocrit stable at 33.8,
repeat electrolytes showed a sodium of 134, potassium 6.1,
chloride 106, bicarb 15, BUN 27, creatinine 1.5, glucose 103.
CKs were 101, 84, and 82. Troponin less then 0.3. Calcium
7.7, phos 3.4, magnesium 2.3. Cortisol was sent off and came
back at 14. Coagulation studies revealed a PT of 14.5, PTT
32.8, INR of 1.5. Microbiology data still with a sputum gram
stain 4+ gram positive coxae in pairs and clusters, 1+ gram
positive rods. No respiratory culture data as of yet.
In terms of the patient's pneumonia he was continued on Levo,
Flagyl and Vancomycin. White blood cell count was noted to
be up, however, the patient remained afebrile and his oxygen
saturation remained good on the nonrebreather.
In terms of his hypotension and sepsis, the decision was made
to give the patient 1 liter of D5W with 3 amps of bicarb to
be repeated times two or three as needed for blood pressure
support. It was also decided to start the patient on high
dose steroids Hydrocortisone 100 mg q 8 hours times three
doses. There was discussion with the team whether the
patient would be a candidate for activated protein C. The
conclusion was that the patient would possibly be a candidate
and the team decided to wait to see how he did throughout the
afternoon on the [**12-6**] before actually starting the
patient on the activated protein C.
In terms of the patient's renal failure his creatinine was
1.4 again the morning following his admission to the MICU. A
notable increase from his baseline of .6. It was felt that
this bump in his creatinine was due to hyperperfusion in the
setting of hypotension and the patient was given hydration as
mentioned with 1 liter fluid boluses. He was continued on
Levofloxacin and Vancomycin at full dose as opposed to
renally dosing them given how sick he was.
In terms of his acid base status, the patient's bicarb was 16
on the morning following his admission to the MICU. His
lactate was up to 3.5. His morning blood gas was 7.33, 34,
87 indicating the patient was adequately compensating for his
metabolic acidosis.
From a GI standpoint the patient was continued on Zantac. In
terms of prophylaxis the patient was put on subcutaneous
heparin. In terms of pain the patient was continued on
Toradol for his pleuritic chest pain.
At the time of this dictation, which is the [**12-7**] the
patient has been off of his Levophed since 3:00 p.m. on [**2172-7-6**]. He has been approximately 24 hours off of Levophed
and has been off Vasopressin for approximately a day and a
half. His laboratory data is much improved at the time of
this dictation. His bicarb is up to 26. His creatinine is
down to 0.9. His blood pressure has been completely stable
following volume boluses, which have included a total of 2
liters of D5W each with 3 amps of sodium bicarb. He has had
no temperature spikes and his O2 sats have been in high 90s
on a nonrebreather and ultimately on 4 liters nasal cannula.
His laboratory data is notable for a white blood cell count
increase to 17.9 in the setting of high dose steroids.
Hematocrit 30.9 in the setting of aggresive hydration.
Sodium 134, potassium 4.9, chloride 100, bicarb 26, BUN 18,
creatinine 0.9, glucose 109, calcium 7.8, magnesium 2.1, phos
3.7, Cortisol 14, albumin 2.6. The patient's microdata, only
the sputum gram stain is back with 4 positive gram positive
coxae in pairs and cultures. Culture data is pending. Blood
cultures are no growth so far.
From a pneumonia standpoint the patient is continued on broad
spectrum antibiotics including Levofloxacin, Flagyl and
Vancomycin. His respiratory status is significantly improved
and he is on nasal cannula 4 liters. He has not had any
temperature spikes during his stay in the Intensive Care
Unit.
From a hypotension/sepsis standpoint the patient's blood
pressures have been completely stable overnight as well as
the entire day on the [**7-6**]. He has been on pressors
for more then 24 hours. His blood pressure is 99 to 122
systolic/65 to 80 diastolic. The patient never received
activated protein C. Instead he received broad spectrum
antibiotics, fluid resuscitation and high dose steroids.
From a renal standpoint his creatinine is trending down
nicely to 0.9. He is starting to mobilize his fluids and his
renal function appears to be improved.
From an acid base standpoint it has lactated down today to
1.9. Arterial blood gas was 7.44, 51, 114, bicarb of 226
yesterday afternoon and again this morning. His acidosis has
resoled.
In terms of hematologic, the patient's hematocrit is noted to
be 30.9 down from 33 in the setting of being approximately 3
liters positive over the past 24 hours. His admission
hematocrit is noted to be 34, therefore we are checking iron
studies, LDH, haptoglobin, B-12 and folate levels. The
patient is without any known history of anemia. His stools
will be guaiaced during the remainder of his hospital stay.
In terms of GI the patient was continued on Zantac. His diet
will be advanced today as tolerated.
In terms of fluid, electrolytes and nutrition, the patient's
electrolytes were essentially within normal limits. It was
noted that his albumin was decreased to 2.6, which seems
somewhat dramatic given that he has been without nutritional
support for only two days. It is now clear what his baseline
albumin is, but he looks like he is a well developed, well
nourished gentleman and this may be something for his primary
care physician to follow up in the outpatient setting.
In terms of disposition the patient is full code.
In terms of access his right femoral and left arterial line
were both pulled without any adverse event on the [**2172-7-6**]. Communications have been with the patient's wife and
daughter who have been in the hospital for much of his
hospital stay in the Intensive Care Unit. The remainder of
the [**Hospital 228**] hospital stay including his discharge
medications will be dictated at the time of discharge. He is
being transferred to the medical floor on Vancomycin 1 gram q
12 hours, Levofloxacin 500 mg po q day, Flagyl 500 mg po
t.i.d., Zantac 50 mg po t.i.d., Albuterol and Atrovent
nebulizers, Tylenol, Flovent, Serevent, Droperidol, aspirin
and Prednisone 60 mg po q day.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1379**]
Dictated By:[**Last Name (NamePattern1) 29450**]
MEDQUIST36
D: [**2172-7-7**] 15:03
T: [**2172-7-7**] 15:26
JOB#: [**Job Number 42253**]
ICD9 Codes: 5070, 0389, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2086
} | Medical Text: Admission Date: [**2128-9-16**] Discharge Date: [**2128-10-1**]
Date of Birth: [**2051-9-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
increasing weakness and shortness of breath
Major Surgical or Invasive Procedure:
placement and removal of right internal jugular central venous
catheter
History of Present Illness:
76 y/o male with ischemic cardiomyopathy EF 15%, severe MR [**First Name (Titles) **] [**Last Name (Titles) **], restrictive lung disease, and smoldering multiple myeloma
who presented to the ED on [**2128-9-16**] with weakness. He was
initially admitted to the meidicine floor but was transferred to
the MICU for closer monitoring. He does have baseline shortness
of breath but this has worsened over the past couple of days,
especially with exertion. The farthest he can walk is his
bathroom without getting dyspneic and he cannot go up stairs at
home. He denies orthopnea and PND and does not report ankle
swelling. He feels albuterol helps his breathing but he has not
noted wheezing. In the past 4-5 days, he has not been taking
most of his medications because he ran out.
.
In terms of his weight loss, he reports going from 235lbs ->
175lbs in the last four months. He feels bloated when he eats
("like when you drink a lot of water.") There have been no new
changes in his medications, just that he ran out of several of
them recently. He does not admit to dietary indiscretion.
.
[**Date Range **]: Denies recent F/C. Denies CP. Admits to baseline DOE
(cannot walk up his 14 steps at home without having SOB). Denies
melena or hematochezia. Positive for weight loss. Denies cough.
Denies orthopnea or PND. Denies significant increase in LE
edema. No abdominal pain or diarrhea.
Past Medical History:
CAD--not a candidate for revascularization
dilated cardiomyopathy (EF 15% in [**2128-6-25**], with 3+ MR, 3+ TR,
and pulmonary artery HTN)
plasma cell dyscrasia - elevated IgG; also history of follicular
lymphoma s/p XRT, followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
pulmonary fibrosis [**2-27**] XRT
gout
hypercholesterolemia
high blood pressure
Social History:
Lives with wife in [**Location (un) 686**] with 2 cats. Retired, but still
works part time on air force base. 30 pack year smoking history,
quit 20 years ago. No alcohol, no illicits.
Family History:
No family history of early CAD or sudden death.
Physical Exam:
VS 97.1 98/77 90 14 98% on 3L NC
Gen: cachectic elderly male. Oriented x3. Mood, affect
appropriate. Breathing comfortably at rest, but only able to
speak a few words before becomes short of breath.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 14 cm. RIJ in place.
CV: PMI diffuse. RR, normal S1, S2. I-II/VI systolic murmur at
apex. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, using accessory muscles. Rales 1/2 up the lung
fields bilaterally. No wheezes or rhonchi.
Abd: Scaphoid. Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: Cool to the touch.
Pertinent Results:
[**2128-9-16**] 10:20AM BLOOD WBC-7.1# RBC-4.66 Hgb-14.8# Hct-48.7#
MCV-104*# MCH-31.8 MCHC-30.5* RDW-18.5* Plt Ct-141*
[**2128-9-16**] 10:20AM BLOOD Neuts-60.9 Lymphs-33.3 Monos-3.7 Eos-0.9
Baso-1.1
[**2128-9-16**] 10:20AM BLOOD PT-19.9* PTT-41.0* INR(PT)-1.9*
[**2128-9-16**] 10:20AM BLOOD Glucose-73 UreaN-51* Creat-1.6* Na-139
K-6.1* Cl-102 HCO3-18* AnGap-25*
[**2128-9-16**] 10:20AM BLOOD CK-MB-NotDone cTropnT-0.05* proBNP-9747*
[**2128-9-16**] 10:10AM BLOOD Type-ART pO2-103 pCO2-21* pH-7.34*
calTCO2-12* Base XS--12 Intubat-NOT INTUBA
[**2128-9-16**] 09:55AM BLOOD Glucose-60* Lactate-9.1* Na-142 K-7.3*
Cl-110
[**2128-9-16**] 10:10AM BLOOD Glucose-76 Lactate-8.9* Na-139 K-5.3
Cl-111
[**2128-9-16**] 11:08AM BLOOD Lactate-6.4*
.
Lower extremity U/S:
IMPRESSION: No evidence of lower extremity deep vein thrombosis,
bilaterally.
.
CXR:
1. Right basal opacity likely representing atelectasis; however,
pneumonia cannot be excluded.
2. Cardiomegaly, unchanged.
3. Chronic pulmonary changes, grossly unchanged.
ECHO:, [**9-17**]:
The left atrium is moderately dilated. The right atrium is
markedly dilated. Left ventricular wall thicknesses are normal.
The left ventricular cavity is moderately dilated. There is
severe global left ventricular hypokinesis (LVEF=15-20%). No
masses or thrombi are seen in the left ventricle. The right
ventricular cavity is markedly dilated. There is moderate global
right ventricular free wall hypokinesis. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate to severe (3+) mitral regurgitation
is seen with a regurgitant volume of 45 cc/beat. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Biventricular dilatation with severe global
biventricular systolic dysfunction. Moderate to severe mitral
regurgitation. Moderate to severe tricuspid regurgitation.
Moderate pulmonary hypertension.
.
[**9-16**] CT abd/pelvis:
IMPRESSION:
1. In this limited study, there are no signs of advanced bowel
ischemia, although ischemia cannot be ruled out on this study.
2. No evidence for pneumonia or large abdominal abscess.
3. Moderate cardiomegaly, anasarca, ascites and right pleural
effusion consistent with known congestive heart failure.
4. Progressive interstitial lung disease; the upper lobe
predominance is not typical for idiopathic pulmonary fibrosis
and suggests etiologies such as sarcoidosis, hypersensitivity
pneumonitis, or silicosis.
.
[**2128-9-27**] 06:25AM BLOOD WBC-6.3 RBC-4.90 Hgb-16.2 Hct-48.9
MCV-100* MCH-33.0* MCHC-33.1 RDW-18.7* Plt Ct-92*
[**2128-9-27**] 06:25AM BLOOD Glucose-88 UreaN-59* Creat-0.6 Na-134
K-3.5 Cl-89* HCO3-35* AnGap-14
[**2128-9-22**] 07:00AM BLOOD ALT-203* AST-178* LD(LDH)-260*
AlkPhos-169* TotBili-4.8*
[**2128-9-27**] 06:25AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.0
[**2128-9-21**] 07:05AM BLOOD PEP-BROAD BASE b2micro-4.9* IgG-3146*
IgA-44* IgM-22*
Brief Hospital Course:
76 y/o male with dilated cardiomyopathy EF 15%, HTN, COPD, and
smoldering MM who presented with weakness and mild increase in
shortness of breath, likely representing cardiac cachexia and
decompensating failure. The decision was made with him and his
family to make him comfort measures due to his grim prognosis.
He was very comfortable on discharge. Still arrousable to voice
and able to state his needs.
.
# Cardiac
Ischemia: No evidence of active coronary ischemia. Dilated
cardiomyopathy, cardiac catheterization demonstrated three
vessel disease, but patient is not a candidate for surgical
revascularization based on poor myocardial viability.
.
Pump - end-stage CHF, with dilated ischemic cardiomyopathy and
severe valvular disease. Diuresed initially with lasix infusion
and then with lasix 40mg IV bid, with slight improvement in
valvular regurgitation on echo after diuresis. Discussed
invasive hemodynamic monitoring with tailored therapy as a
potential option with patient and family, but patient did not
wish invasive measures.
.
Rhythm - Sinus rhythm with PVCs
.
COPD, also restrictive lung disease post XRT:
- no real benefit at this time for nebs, but pt may use for
subjective relief
- supplemental O2 as needed
.
ARF: anuric on discharge
.
UTI: UCx negative, completed 7 days of Abx
.
smoldering myeloma: at last visit, disease as stable, no active
issues at this time
.
# Elevated LFT's: most likely [**2-27**] to right sided heart failure
and congestion
- received PO Vitamin K for elevated INR
.
# FEN: diet as tolerated, was not taking much by po on
discharge
.
# Code: comfort measures/DNR/DNI
Medications on Admission:
ASA 81mg
colchicine 0.6mg (last filled [**5-26**] for 1 month)
Toprol XL 25mg daily (last filled [**5-26**] for 1 month)
Lisinopril 5mg (last filled [**8-8**] for 1 month)
Lipitor 40mg (last filled [**7-26**] for 1 month)
Allopurinol 300mg (last filled [**8-9**] for 1 month)
albuterol inh (last filled [**6-2**] for 1 month)
not clear how compliant patient has been with any meds
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
2. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1H
(every hour) as needed for Pain or shortness of breath.
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
4. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual Q3-4H (Every 3 to 4 Hours) as
needed for for respiratory secretions.
5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for agitation/anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
# ischemic cardiomyopathy, ejection fraction 15%
# three vessel coronary artery disease not amenable to
revascularization due to minimal myocardial viability
# IgG plasma cell dyscrasia (smoldering myeloma)
# pulmonary fibrosis
Discharge Condition:
poor
Discharge Instructions:
You have end-stage congestive heart failure. Because of the
extent and prognosis of your heart failure, you have indicated
that you wish your goals of care to be comfort.
Followup Instructions:
With your PCP, [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] [**Telephone/Fax (1) 250**], and with your
cardiologist, Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2386**], as needed
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 4280, 496, 4240, 5849, 5990, 4019, 4168, 2749, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2087
} | Medical Text: Admission Date: [**2137-5-8**] Discharge Date: [**2137-5-9**]
Date of Birth: [**2085-4-12**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Patient presents with known ACOMM aneurysm for coiling
Major Surgical or Invasive Procedure:
Coiling of ACOMM aneurysm
History of Present Illness:
Known ACOMM aneurysm
Past Medical History:
-HTN
Social History:
-smokes tobacco daily, no etoh or drugs.
35Pack year history
Family History:
-mother with cerebral aneurysm rupture
Physical Exam:
NECK: no carotid bruits; ROM full;
CV; RRR, no murmurs
Pulm; CTA
Abd; soft, nt, nd
Extr; no edema, clubbing, cyanosis; distal pulses can be
palpated;
Neuro;
MS; A&Ox3, attentive; able to relate history without
difficulty. Speech fluent. Naming, repetition, and
comprehension intact. No apraxia; Memory: 3/3/3 minutes;
moderate
fund of knowledge;
CN; PERRL 4mm-->2mm, Fundus: no edema; EOM's intact, no
nystagmus. Face sensation intact V1-V3, very mild flattening of
left NLF, but left face moves similar to right; hearing
symmetric; [**Doctor Last Name 11586**] midline; palate symmetric, trapezius
symmetric, tongue midline.
Motor; normal bulk and tone; mild left pronator drift; 5/5
strength on the right arm and both legs; 5-/5 at left wrist and
finger extensor and IO;
Reflexes: slightly more pronounced on the left; ankle reflexes
diminished bilaterally; upgoing toe on left;
Sensory; intact to light touch and pinprick throughout
Coordination; mild dysmetria on FNF on the left; slowed FFM on
the left; HTS symmetric; nl stance and gait;
Exam on Discharge: Neurologically intact, with the exception of
some left arm weakness which may be due to pain in the shoulder.
Brief Hospital Course:
Patient was admitted to undergo an elective coiling for ACOMM
aneurysm. The preformed procedure was uncomplicated. Post
procedure the patient was transferred to the surgical ICU for
close monitoring. She remained on a Heparin drip until the
morning at which time we discontinued the heparin and started
her on Plavix.
Patient is being discharged home with appropriate follow up.
Medications on Admission:
Asprin 325mg daily
Metoprolol 100 mg ER daily
Simvastatin 40mg daily
lisinopril 20 mg daily
amlodipine 5mg daily
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*40 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Anterior communicatin artery anerusym
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please call our office for a follow up appointment with Dr.
[**First Name (STitle) **]. You will need a MRI/MRA before your visit. We will
schedule this study for you when you call. You should maake an
appointment 4 weeks from the date of your coiling.
Completed by:[**2137-5-9**]
ICD9 Codes: 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2088
} | Medical Text: Admission Date: [**2125-3-19**] Discharge Date: [**2125-4-6**]
Date of Birth: [**2125-3-19**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 805**] is the 1800
gram product of a 33-1/2 week twin gestation born to a 25
year-old mother who is Gravida VIII, Para II, now IV with
blood type A positive, antibody screen negative, hepatitis B
surface antigen negative, Rubella immune, RPR nonreactive,
GBS screen unknown. Mother presented in labor and labor
progressed to a vaginal delivery of diamniotic/dichorionic
twins. The baby emerged after delivery. He was given blow-
by oxygen and stimulation. His Apgars were 8 at 1 minute and
9 at 5 minutes. He was brought to the NICU after visiting
with his parents.
On admission exam, he was 1800 grams which was 25th
percentile. His length was 42.5 cm which was 25th percentile
and his head circumference was 30 cm which is 25th
percentile. He was pink, active and non dysmorphic. He was
well saturated and perfused in room air. His skin was without
lesions. His head and neck exam were within normal limits.
His lungs were clear. Cardiac exam revealed normal heart
sounds and no murmurs. His abdomen was benign. His genitals
were normal. His left testis was palpable in the canal but
the right was not palpable. Neuro exam was non focal and age
appropriate. His anus was patent and his spine was intact.
HOSPITAL COURSE: His hospital course by systems is as
follows:
1. Respiratory: He was on room air. He had a very brief
oxygen requirement by nasal cannula but this was
discontinued by second day of life and he has been on
room air throughout his stay with excellent saturation
and no problems with apnea.
1. Cardiovascular: He has been cardiovascularly stable with
normal blood pressure and perfusion throughout his stay.
1. Fluids, electrolytes and nutrition: He had normal
glucoses. He was initially on IV fluid but enteral
feedings were initiated on day of life 1 and slowly
advanced to full feedings by day of life 3. He has been
taking full volume feedings and has been doing all of his
feeding by mouth for the last 2 days. His most recent
weight is 2225 grams. He is taking ad lib Enfamil 24
calories.
1. Gastrointestinal: He has had no significant problems
with feeding. He does have heme positive stools which are
thought to be secondary to perianal fissures. He had a
bilirubin that peaked on day of life 3 at 8.2 but it did
not require phototherapy. He had a rebound or decrease
in his bilirubin to 4.3 by day of life 5. The direct
component at that time was 0.3.
1. Hematology: He had an initial hematocrit of 59% with a
normal white blood cell count and platelets.
1. Infectious disease: He had a blood culture shortly after
birth and was placed on Ampicillin and Gentamycin. He
completed a 48 hour course and they were discontinued at
the time his blood culture was negative, greater than 48
hours.
1. Sensory: Hearing screening was pending at the time of
dictation.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 56128**] [**Last Name (NamePattern1) **], MD, [**Hospital3 18242**] Primary Health Care Center. [**Telephone/Fax (1) 29830**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: Enfamil 20 kilocalories per ounce ad
lib.
2. Medications: Iron 0.2 ml by mouth daily.
3. Car seat position screening was pending at the time of
dictation.
4. State newborn screening was performed.
5. Immunizations received: He received a hepatitis B
vaccination on the [**3-30**]. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
FOLLOW UP: He should see his pediatrician Monday after
discharge, that is 3 days after discharge.
DISCHARGE DIAGNOSES:
1. Prematurity, 33-1/2 weeks.
2. Twin gestation.
3. Presumed sepsis.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2125-4-5**] 15:53:36
T: [**2125-4-5**] 17:20:55
Job#: [**Job Number 65866**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2089
} | Medical Text: Admission Date: [**2196-7-28**] Discharge Date: [**2196-8-6**]
Date of Birth: [**2135-11-11**] Sex: F
Service: MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is a 60-year-old
African-American female with a history of end-stage renal
disease on hemodialysis, hypertension, peripheral vascular
disease, status post bilateral AKAs, diabetes type 2, CVA,
coronary artery disease, status post CABG and mitral valve
repair, history of DVT and PE, COPD, who presents from
outpatient hemodialysis with increasing lethargy. At
baseline, the patient is responsive and interactive verbally.
On admission, the patient was only responsive to sternal rub.
At hemodialysis, the temperature was 99.8, pulse 130-140, 02
saturation 85% on room air which went up to 100% on a
nonrebreather; 2 kilograms of fluid were removed at
hemodialysis over two hours and then the patient was sent to
the Emergency Room.
The initial vital signs were a temperature of 99.8, blood
pressure 100/53, heart rate 120, respirations 30, saturating
99% on a nonrebreather. The initial physical examination was
positive for abdominal tenderness. The patient was sent for
an abdominal CT which showed extensive atherosclerotic
changes involving all of the abdominal vasculature and
possible thickening of the small bowel walls. Mesenteric
ischemic could be excluded. No evidence of obstruction. No
perforation or abscess.
General Surgery were consulted but no operative intervention
was deemed necessary at that time. The patient continued to
have a blood pressure systolic 80s to 100s, responsive to 2
liters of normal saline. The patient's chest x-ray also
showed evolving bilateral opacities and the patient was
treated with vancomycin, ceftriaxone, and Flagyl.
The patient was weaned off the nonrebreather to 4 liters
nasal cannula. CTA was done to rule out PE given the
patient's hypoxia, hypertension, and tachycardia. The study
was negative for PE but did show new ground glass opacities
at the right lung base suspicious for aspiration pneumonitis.
There was also chronic consolidation of the left lung base
and radiation changes of the right hemithorax which were
stable.
The patient was transferred initially to the Medical
Intensive Care Unit for further management.
REVIEW OF SYSTEMS: The patient had diarrhea for the past
week. No nausea, vomiting, no change in her chronic
abdominal pain. No change in her chronic cough. No fevers,
chills, dysphagia. The patient is anuric at baseline.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis every Tuesday,
Thursday, and Saturday.
2. Coronary artery disease, status post CABG.
3. CVA.
4. COPD.
5. Diabetes type 2.
6. History of PE and DVT.
7. History of hypertrophic obstructive cardiomyopathy with a
LV outflow tract gradient of 50 mmHg, EF 65-75%.
8. Peripheral vascular disease, status post bilateral AKA in
[**5-1**].
9. Breast cancer, status post right mastectomy and XRT in
[**2185**].
10. Status post mitral valve repair.
11. Hypertension, baseline systolic blood pressure in the
160s to 200s.
12. History of pseudoseizures.
13. History of MRSA line infection.
14. Status post appendectomy.
15. Status post TAH/BSO.
16. Status post cataract surgery.
ALLERGIES: The patient is allergic to penicillin, aspirin,
Oxycodone, cephalosporins, and benzodiazepines.
HOME MEDICATIONS:
1. Toprol XL 25.
2. Lactulose 3 mg p.o. q.d.
3. Lisinopril 80 mg p.o. q.d.
4. Nephrocaps 1 mg one tablet p.o. q.d.
5. Colace 100 mg p.o. b.i.d.
6. Renagel 1,600 mg p.o. t.i.d.
7. Combivent inhaler.
8. Celexa 20 mg p.o. q.d.
9. Prevacid 30 mg p.o. q.d.
10. Senna one tablet p.o. q.d.
11. Diltiazem 180 mg p.o. q.d.
12. Nifedipine 10 mg p.o. on hemodialysis days.
SOCIAL HISTORY: The patient is a Jehovah's witness and does
not accept blood products. She has a 60 pack year smoking
history. No history of alcohol. She lives with her son in a
handicapped apartment.
FAMILY HISTORY: Positive for hypertension and diabetes.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
99.8, heart rate 88, blood pressure 86/42, respirations 19,
saturating 100% on 4 liters nasal cannula. General: The
patient is somnolent and arousable to sternal rub, unable to
follow commands. More verbal when family is around. No
clear communication. HEENT: The patient is anicteric. The
oropharynx is dry. Cardiovascular: Regular rate and rhythm.
No murmurs. Lungs: Diffuse rhonchi bilaterally. Decreased
breath sounds, left greater than right base. Abdomen: Soft,
nontender, nondistended, normoactive bowel sounds, Guaiac
negative. Extremities: Status post bilateral AKA right
upper extremity, slightly more edematous than her left upper
extremity, 1+ pitting edema.
LABORATORY/RADIOLOGIC DATA: Head CT showed multiple old
infarct including occipital infarct bilaterally as well as
lacunar infarct in the right thalamus and left putamen which
appear unchanged compared to [**2196-3-1**]. There is a new
infarct in the left side of the pons, unable to comment on
exact timing. No mass affect. No hemorrhage.
CT of the abdomen showed question of possible small bowel
thickening, mesenteric ischemia could not be excluded. No
obstruction, no perforation, no abscess.
CT angiogram showed no PE, new ground glass patchy opacities
at the right lung base suspicious for aspiration pneumonitis,
chronic left lung base consolidation and radiation treatments
to the right hemithorax.
Right upper quadrant ultrasound showed no intra or
extrahepatic biliary ductal dilatation, small amount of
pericholecystic fluid but no gallbladder wall edema, several
small gallstones. No biliary obstruction.
Cardiac echocardiogram showed mild left atrial dilation,
symmetric LVH, moderate global LV hypokinesis, moderate
global right ventricular free wall hypokinesis, 1+ MR, 2+ TR,
mild pulmonary artery systolic hypertension, significant
pulmonary regurgitation, trivial pericardial effusions.
Ejection fraction of 30%, TR gradient 34.
HOSPITAL COURSE: 1. The patient was found to have
gram-negative rod bacteremia with Stenotrophomonas and
Enterobacter, likely from gut translocation from her acute on
chronic mesenteric ischemia. The patient also had evidence
of an aspiration pneumonia. The patient was treated with
Levaquin and Flagyl, a total course of 14 days as well as an
initial five day course of gentamicin. During this time, the
patient's right-sided Hickman was kept in place per renal.
The patient subsequently had 48 hours worth of negative blood
cultures.
2. HYPOTENSION: Secondary to sepsis from gram-negative rod
bacteremia, plus/minus pneumonia. The patient was treated
with normal saline boluses as well as transient use of
dopamine. The patient's blood pressure eventually stabilized
to the 120s systolic; however, her antihypertensives were
never reintroduced secondary to hypotension after
hemodialysis. As of discharge, the patient is still not on
home antihypertensive medications.
3. HYPOXIA: Secondary to sepsis and aspiration pneumonia.
The patient was treated with antibiotics for the above and
quickly weaned off her 02 requirement.
4. MIXED ACID BASE DISORDER: Initially, the patient came in
with nongap metabolic alkalosis as well as respiratory
alkalosis. These all resolved as the patient's sepsis
improved.
5. NEUROLOGIC STATUS: The patient's mental status improved
with treatment of sepsis.
6. END-STAGE RENAL DISEASE: The patient continued to
receive dialysis through her right subclavian Hickman. This
was never removed despite the patient's bacteremia. The
patient's most recent dialysis before discharge was on
[**2196-8-5**]. She was able to tolerate ultrafiltration; however,
no fluid was able to be removed secondary to hypotension down
to the 80s-90s systolic.
7. GASTROINTESTINAL: The patient is known to have bad
diffuse atherosclerosis, likely has chronic mesenteric
ischemia. MRA of the abdomen was unable to be performed
since the patient did not have any access to receive the MRI
contrast dye. Given the low likelihood that any surgical or
angioplastic interventions would be likely in this patient
given all of her comorbidities, MRA was deferred at this
time. The patient's abdominal pain had improved by the time
of discharge and she was tolerating a full cardiac and renal
diet.
8. HEMATOLOGY: The patient is a Jehovah's witness and does
not accept any blood transfusion products. She initially had
a low crit likely from hemodilution which eventually
stabilized. She also came in with thrombocytopenia. Workup
was negative for HIT antibody as well as DIC. The patient
gets Epogen at hemodialysis.
9. CODE STATUS: After a family meeting, it was decided that
the patient would be do not intubate (DNI); however, CPR and
resuscitation were still desired.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Discharge the patient to rehabilitation.
DISCHARGE DIAGNOSIS:
1. Stenotrophomonas and Enterobacter bacteremia and sepsis.
2. Acute on chronic mesenteric ischemia.
3. End-stage renal disease, on hemodialysis.
4. Peripheral vascular disease, status post bilateral AKAs
and impossible venous access.
5. Delirium from sepsis.
6. Aspiration pneumonia.
7. Anemia of chronic disease.
DISCHARGE MEDICATIONS:
1. Flagyl 500 mg p.o. b.i.d. until [**2196-8-10**] to complete a 14
day course.
2. Regular insulin sliding scale.
3. Levofloxacin 200 mg p.o. q. 48 hours until [**2196-8-10**] to
complete a 14 day course.
4. Protonix 40 mg p.o. q. 24 hours.
5. Atrovent two puffs q. six hours.
6. Albuterol two puffs q. six hours p.r.n.
7. Tylenol 325 mg p.o. q. four to six hours p.r.n.
FOLLOW-UP: The patient is to follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], in [**9-13**] days.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 7112**]
MEDQUIST36
D: [**2196-8-6**] 01:12
T: [**2196-8-6**] 13:52
JOB#: [**Job Number 14374**]
ICD9 Codes: 5070, 496, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2090
} | Medical Text: Admission Date: [**2173-1-25**] Discharge Date: [**2173-1-25**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
left lower extremity ishemia
Major Surgical or Invasive Procedure:
left lower extremity above knee amputation
History of Present Illness:
This patient is an 85 year old male who was transferred from an
outside hospital for acute left lower extremity ischemia.
Past Medical History:
PMH: TIAs, cardiomyopathy, CAD, CHF, PVD, BPH, CRI (2.0),
hypothyroid, paraoxysmal A-fib,MI '[**70**], demntia
PSH: CABG '[**39**] and '[**51**], ? LLE BPG
Social History:
n/c
Family History:
n/c
Physical Exam:
This patient arrived on the floor in ventricular tachycardia,
unresponsive. Lungs were clear. Abdomen was soft. Left lower
extremity was mottled and blue.
Pertinent Results:
[**2173-1-25**] 07:01AM BLOOD WBC-3.1* RBC-3.08* Hgb-9.8* Hct-29.3*
MCV-95 MCH-31.7 MCHC-33.3 RDW-13.7 Plt Ct-107*
[**2173-1-25**] 07:01AM BLOOD PT-20.5* PTT-59.4* INR(PT)-1.9*
[**2173-1-25**] 04:03PM BLOOD PT-25.1* PTT->150 INR(PT)-2.5*
[**2173-1-25**] 07:01AM BLOOD ALT-136* AST-294* LD(LDH)-412*
CK(CPK)-6636* AlkPhos-23* Amylase-28 TotBili-0.5
[**2173-1-25**] 02:11PM BLOOD ALT-330* AST-909* LD(LDH)-857*
CK(CPK)-[**Numeric Identifier 18897**]* AlkPhos-20* Amylase-51 TotBili-1.0
[**2173-1-25**] 04:03PM BLOOD Glucose-158* UreaN-52* Creat-2.0* Na-152*
K-3.6 Cl-112* HCO3-19* AnGap-25*
[**2173-1-25**] 04:03PM BLOOD Calcium-7.2* Phos-6.3* Mg-1.8
[**2173-1-25**] 07:01AM BLOOD CK-MB-33* MB Indx-0.5 cTropnT-0.68*
[**2173-1-25**] 08:01AM BLOOD Type-ART pO2-423* pCO2-36 pH-7.11*
calTCO2-12* Base XS--17
[**2173-1-25**] 08:48AM BLOOD Type-ART pO2-177* pCO2-44 pH-7.37
calTCO2-26 Base XS-0
[**2173-1-25**] 01:17PM BLOOD Type-ART pO2-82* pCO2-35 pH-7.30*
calTCO2-18* Base XS--7
[**2173-1-25**] 05:06PM BLOOD Type-ART pO2-61* pCO2-38 pH-7.25*
calTCO2-17* Base XS--9
Brief Hospital Course:
This patient arrived at [**Hospital1 18**] in ventricular tachycardia and was
unresponsive. He was quickly asessed by the surgical team and
intubated and transferred to the ICU. He spontaneously
converted to sinus rhythum after a liter or so of IV fluids. A
central venous line and an A-line was placed. The patient
became progressively acidotic and hypotensive. He was started
on Levophed and Vasopressin and eventually Neosynepherine. He
was maxed out on these drugs. The decision was made to go
through with a bedside above the knee amputation with a gigli
saw. This was thought to be his only hope of survival beacause
this was thought to be the cause of his sepsis. His condition
continued to get worse however. He was made CMO by his family
later that day and he died shortly therafter.
Medications on Admission:
amlodipine 5', amio 200', asa 81', celexa 20', flomax 0.4',
isosorbide 20', synthroid 0.075', zocor 80', ativan 0.5',
lopressor 25', plavix 75', quinapril 20', salasate 750',
metamucil, tylenol, colace, MOM, dulcolax, melatonin
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
left lower extremity ischemia, sepsis, septic shock
Discharge Condition:
death
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2173-1-28**]
ICD9 Codes: 4271, 4254, 2851, 0389, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2091
} | Medical Text: Admission Date: [**2137-2-16**] Discharge Date: [**2137-2-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Right AVF thrombosis
Major Surgical or Invasive Procedure:
AVF revision/thrombectomy
History of Present Illness:
86M with ESRD on HD admitted for fistula thrombectomy, which
occurred yesterday, now with systolic BP in 70s at dialysis,
chest pain, EKG changes with ST depressions in V3-V5. SBP rose
to 100s after IVF. At HD, 1L taken off, BP dropped to 70s,
fistula was used. CP started at noon, didn't resolve after 2
hours. Cards did a bedside echo which showed normal wall motion,
rec no need for CCU. Pt still having L arm numbness. Per renal,
ok to use HD catheter as fistula is now working for HD.
.
Pt states that chest pain is substernal, worse with deep
inspiration, feels like a hammer pounding into his chest. Does
have some numbness in his L arm which he says is intermittent.
Chest pain has stayed constant since its onset around noon. Pt's
BP dropped at HD last Saturday to 60s-70s [**Name8 (MD) **] RN (per records,
in 80s) but he did not have any chest pain. Feels that his chest
pain is similar to chest pain in past that resulted in CABG x4.
The most exertion pt performs at home is climbing a flight of
stairs, which results in no chest pressure but he has been
getting more short of breath.
.
Per cards, no evidence of CHF and no regional wall motion
abnormalities on echo - appears dry. Rec rate control and
heparin for a fib. Pt also has h/o NHL, s/p chemo and rituxan,
and per oncologist is not active.
.
Access includes 1 peripheral, R AV fistula, groin HD catheter.
Pt also has not had BM x3 days, concern for gastric dilatation.
.
Past Medical History:
CAD s/p CABG x4 [**2128**]
ESRD with R AVF
HTN
Hyperlipidemia
Non-Hodgkin's lymphoma
Prostate Ca
Seizure d/o
PVD
Lumbar stenosis and disk herniation
Social History:
Patient currently lives with his wife.
[**Name (NI) 1139**]: Previous, quit 20 years ago.
ETOH: None
Illicits: None
Family History:
Patient currently lives with his wife.
[**Name (NI) 1139**]: Previous, quit 20 years ago.
ETOH: None
Illicits: None
Physical Exam:
Vitals: T- 98.9, Tmx: 99.1
BP: 118/35 113-132/59-86
HR: 71
RR: 13-18 O2: 97-100% on 2L NC
I/O: 690/140 LOS: +5229
.
General: Patient is an elderly male, + chronic sun
exposure/hyperpigmented skin, pleasant, tired, in NAD
HEENT: NCAT, EOMI. OP: + upper dentures. MMM, no lesions
Neck: JVP visible, approximately 6cm
Chest: Mild course expiratory breath sounds, no focal rhonchi,
wheezes, crackles anterior or laterally. Posterior exam limited
secondary to lying flat on back s/p removal of groin line
Cor: RRR, normal S1/S2. II/VI systolic murmur, loudest at RUSB
Abdomen: Mildly distended, mildly tender diffusely but without
rebound or guarding. Notable abdominal "fullness", particularly
periumbilical
Extremity:
RUE: Dressing over fistula, C/D/I. Sutures intact, no erythema.
+Thrill
LE: Venodynes in place, [**1-29**]+ pedal edema
Pertinent Results:
Admission Labs:
[**2137-2-16**] 01:33PM BLOOD WBC-5.1 RBC-3.45* Hgb-11.3* Hct-33.7*
MCV-98 MCH-32.8* MCHC-33.6 RDW-15.6* Plt Ct-158
[**2137-2-17**] 02:05AM BLOOD PT-12.3 PTT-150* INR(PT)-1.1
[**2137-2-16**] 01:24PM BLOOD Glucose-75 UreaN-120* Creat-10.2*# Na-135
K-7.8* Cl-97 HCO3-20* AnGap-26*
[**2137-2-16**] 05:30PM BLOOD Calcium-8.4 Phos-8.2*# Mg-2.4
[**2137-2-16**] 05:30PM BLOOD CK(CPK)-55
Pertinent Labs/Studies:
[**2137-2-19**] CT Chest/Abdomen/Pelvis
1. Hyperenhancing left renal mass, which may represent lymphoma
or RCC.
2. Multiple new pulmonary nodules in the left lung as described.
A three- month followup CT is recommended for assessment of
stability.
3. Left adrenal mass.
4. Small bilateral pleural effusions
.
[**2137-2-19**] Echo: Conclusions:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is dilated. Right
ventricular systolic function appears to be normal but views
were technically limited. The aortic root is mildly dilated at
the sinus level. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION:
Technically limited study due to poor acoustic windows.
Preserved
global/regional left ventricular systolic function. Right
ventricle may be dilated but function appears normal. No
structural valve disease. No
pericardial effusion.
.
[**2137-2-20**]: Chest Pa/Lat - FINDINGS: Compared to [**2137-2-19**], allowing
for differences in technique and rotation, no acute process or
significant interval change identified.
.
Troponin: 0.56 ([**2137-2-21**]) -> 0.38 ([**2137-2-23**])
Dilantin: ([**2137-2-25**]) 2.9 - dilantin increased to 200mg [**Hospital1 **] after
this level
Discharge Labs
.
[**2137-2-27**] 06:05AM BLOOD WBC-6.2 RBC-3.23* Hgb-10.3* Hct-30.8*
MCV-95 MCH-31.9 MCHC-33.6 RDW-16.5* Plt Ct-202
[**2137-2-27**] 06:05AM BLOOD Glucose-87 UreaN-29* Creat-6.5*# Na-141
K-3.8 Cl-102 HCO3-30 AnGap-13
Brief Hospital Course:
Prior to floor transfer: Patient is a 86M with ESRD on HD
admitted for fistula thrombectomy, which occurred [**2136-2-21**],
admitted to the MICU after devloping systolic BP in 70s at
dialysis, chest pain, EKG changes with ST depressions in V3-V5.
This was thought possibly to occur in the setting of blood loss
related to AV fistula thrombectoy. SBP rose to 100s after IVF.
At HD, 1L taken off, BP dropped to 70s, fistula was used. CP
started at noon, didn't resolve after 2 hours. Cards did a
bedside echo which showed normal wall motion, rec no need for
CCU and to medically manage. The patient was initially covered
with broad spectrum antibiotics including amp, cipro, flagyl
which were eventually D/C given no evidence for infectious
etiology of hypotension.
.
[**Hospital 38133**] hospital course also notable for abdominal pain. Given
Hct drop, CT C/A/P performed. No leaking AAA or similar seen,
but a left renal mass was observed, possible concerning for
recurrent lymphoma vs. RCC. Per MICU team, discussion with Onc
attending revealed that patient was likely not a candidate for
further treatment at this time.
.
On the floor:
1. Hypotension - As above, the likely etiology of the patient's
hypotension was bleed from surgery. He was covered with
antibiotics in the Micu, but did not exhibit infection. On the
floor the patient remained normotensive and eventally a low dose
beta-blocker was added given his recent NSTEMI which he
tolerated well. This was then changed to long acting Toprol.
Patient would likely ultimately benefit from addition of an ACE
inhibitor as pressures allow. This can be added as an outpatient
at the discretion of the patient's PCP.
.
2. NSTEMI - As above, the patient experienced an NSTEMI in the
setting of hypotension and Hct drop. Per cardiology, the patient
was medically managed with ASA, Plavix, and statin without plan
for acute intervention given the [**Hospital 228**] medical
comorbidities. Given his hypotension and bleed a beta-blocker
and heparin drip were held. His blood pressure improved on the
floor and he was started on a BB. He had no further events on
the floor. Consideration for follow-up with cardiology and
potential stress test can be made as on outpatient. However,
multiple co-morbidities may defer further evaluation or invasive
procedures regardless. As above, the patient may additionally
benefit from addition of an ACE if his BP remains WNL. This may
be started as an outpatient at the discretion of the patient's
PCP and other treaters.
.
2A. PAfib - patient with history of pafib. Patient is currently
on Toprol XL with normal heart rates. Patient was not initiated
on anti-coagulation given Hct drop, and hypotension earlier this
admission. Consideration towards initiation of anti-coagulation
should be performed as an outpatient after acute illness
resolved with consideration towards embolic risk as well as
malignancy and recent bleeding event, although this likely
occurred in the setting of surgical procedure.
.
3. Anemia - The patient received 3U PRBCs during the MICU
course, after his thrombectomy. On the floor his hematocrit
remained stable and was closely followed and his iron studies
revealed a component of anemia of chronic disease. His
stabilized by the time of discharge.
.
4. Renal Mass - The patient's renal mass is concerning for
recurrent lymphoma vs. RCC. Per conversation with MICU team, the
patient's treating Oncologist is aware of the renal mass and is
being followed. Pulmonary and Liver nodules, on CT are new
however since last imaging. Unfortunately, given multiple
medical comorbidities, patient not thought to be a likely
candidate for therapy regardless of etiology. He will have
ongoing follow-up with his oncologist as an outpatient.
.
5. ESRD on HD - The patient received dialysis with his new
fistula with no complications. He remained stable at dialysis
and had close care by the renal team. He will continue to
receive dialysis as scheduled on MWF.
.
6. Seizure disorder - The patient was continued on Phenytoin per
outpatient regimen. His levels were sub-therapuetic with
adjustment this admission. The patient should have levels
repeated during his rehab stay with goal [**11-11**]. If patient
remains sub-therapeutic, his Dilantin should be titrated as
appropriate. He remained seizure free during his course.
Continuation of this medication can be re-addressed as an
outpatient given notes which indicate thoughts towards
discontinuing this medication.
.
7. Dispo: the patient was discharged to nursing facility for
ongoing rehabilitation
.
8. Code status: patient is DNR/DNI, this was confirmed with the
patient and his wife [**Name (NI) 382**] this admission
Medications on Admission:
doxepin 25mg qHS
lisinopril 10mg [**Hospital1 **]
omeprazole 20mg [**Hospital1 **]
phenytoin 100mg [**Hospital1 **]
simvastatin 20mg daily
pentoxifylline 400mg daily
quinine 260mg daily
temazepam 15mg
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for prn pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Disp:*45 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for nausea.
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**]
Drops Ophthalmic PRN (as needed).
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may repeat upto 3 times every 5 minutes.
15. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab Hospital
Discharge Diagnosis:
Primary:
1. RUE AV fistula thrombosis.
2. NSTEMI
3. Hypotension NOS.
4. New 4.6 x 4.8 cm left renal mass.
5. New 3.5 x 3 cm left adrenal mass.
6. Multiple new left pulmonary nodules.
7. CKD Stage V on HD
8. Blood loss anemia.
Secondary:
1. Low grade NHL.
2. Seizure D/O NOS.
3. CAD s/p CABG.
4. HTN.
5. Prostate CA
Discharge Condition:
Stable. tolerating oral medications and nutrition
Discharge Instructions:
1. Call Transplant office [**Telephone/Fax (1) 673**] if fever, chills, nausea,
vomiting, decreased urine output, diarrhea, weight gain of 3
pounds in a day, edema or redness/bleeding/pain at incision.
Malfunction of AV fistula, bleeding/redness/increased drainage
at fistula or numbness/discoloration or increased swelling in
right arm
Continue HD M-W-F.
.
Please take all medications as directed.
.
Please make and attend the recommended follow-up appointments
Followup Instructions:
Scheduled Appointments :
.
Please call the office of your primary care physician to make an
[**Telephone/Fax (1) 648**] to be seen within one to two weeks.
.
You have an [**Telephone/Fax (1) 648**] with your Oncologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], MD. [**First Name (Titles) 2172**] [**Last Name (Titles) 648**] is on [**2137-3-12**] at 09:30, located
on [**Hospital Ward Name 23**] 9. Please call his office at [**0-0-**] at your
convenience if you have any scheduling needs or questions.
.
You have an [**Year (4 digits) 648**] with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] from the
division of Transplant Surgery. Your [**Last Name (NamePattern4) 648**] is on [**2137-3-7**]
at 3:00. Please call his office at [**Telephone/Fax (1) 673**] with any
questions or scheduling needs.
.
Please call the office of your Nephrologist, Dr. [**Last Name (STitle) 12596**] E. Reyad
to make an [**Last Name (STitle) 648**] for follow up.
ICD9 Codes: 2767, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2092
} | Medical Text: Admission Date: [**2159-9-24**] Discharge Date: [**2159-11-1**]
Date of Birth: [**2159-9-24**] Sex: F
Service: Neonatology
HISTORY: Baby girl [**Known lastname 47618**] was born on [**2159-9-24**] to
a 20-year-old G3/P0 to 1. Prenatal screens were blood type O
positive, antibody negative, RPR nonreactive, rubella immune,
HBS antigen negative, GBS unknown. Pregnancy was complicated
by elevated AFP, suspicious for trisomy 21. Amniocentesis was
done and demonstrated normal karyotype 46XX. Mother presented at
28 and [**3-19**] gestational age to [**Hospital 1474**] Hospital with the concern
of preterm labor and cervical changes. She was treated with
terbutaline and magnesium sulfate for tocolysis. Despite the
treatment she progressed with labor and was transferred to
[**Hospital1 69**]. She received 2 doses of
betamethasone prior to delivery. She was taken for C-section
on [**2159-9-24**]. Spinal anesthesia was given without
adequate pain control. Therefore, delivery was done under
general anesthesia. Infant emerged floppy with a heart rate
above 100 and poor respiratory effort. She required brief
positive pressure ventilation and vigorous stimulation.
Apgar's were 4 and 8. Infant was transported to the neonatal
intensive care unit on blow-by oxygen without complications.
PHYSICAL EXAMINATION: On admission to neonatal intensive
care unit; premature infant in mild respiratory distress,
pink with blow-by oxygen, weight 1205 grams (50th
percentile), length 38 cm (50th percentile), head
circumference 26 cm (25th percentile), temperature 97.1,
heart rate 168, blood pressure 49/18, with a mean of 29,
respiratory rate 34, saturation 87 on room air.
HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY: Infant was initially placed on nasal cannula
oxygen, but due to increased oxygen requirement and work
of breathing she was transitioned to CPAP 6. She remained
on CPAP with low oxygen requirement until day of life 2.
She was weaned to room air on [**2159-10-2**] and
remained on room air through the rest of her hospital
stay. She was followed for apnea of prematurity, and due
to increase in the amount of spells she was started on
caffeine on day of life 5. Caffeine was discontinued on
[**2159-10-30**] at day of life 30. She remained stable
without any spells since then.
1. CARDIOVASCULAR: Baby girl [**Known lastname 62541**] exam through the
hospital stay remained unremarkable. Her blood pressure
remained stable. Soft intermittent murmur was noted
through her hospital stay and was interpreted as a flow
murmur.
1. FEN/GI: On admission, baby girl [**Name (NI) 47618**] was made n.p.o..
PN was initiated on day of life 1. Enteral feeds were
introduced on day of life 2. She was weaned off PN and
transitioned to full feeds on day of life 8. Through her
hospital stay her calories were increased to 30 calories
per ounce with ProMod. She demonstrated a good weight
with this calorie intake. We started to wean her calories
on day of life 39. At discharge, baby girl [**Name (NI) 47618**] is at
150 cc/kg p.o. feeds with 24-calories per ounce breast
milk or Enfamil supplemented with Enfamil powder. She
remained with good weight gain on 24 calories. Her
discharge weight is 2850 grams.
She developed jaundice on day of life 2 with peak bilirubin
level of 7.1. She was started on phototherapy. She continued
with phototherapy until day of life 12. Her follow-up
bilirubin level was 5.4 on day of life 14.
1. HEMATOLOGY: Her initial CBC was 37.9 white blood cells,
50 poly's, 12 bands, 36 lymphocytes, her hematocrit was
37.8 and platelets 535. Her hematocrit was followed
through her hospital course, with the last hematocrit
level done on [**2159-11-8**] with hematocrit level 25.2
and reticulocyte's 4.5. She is currently on
supplementation of iron with 2 mg/kg per day.
1. INFECTIOUS DISEASE: Due to maternal history of preterm
labor baby girl [**Name (NI) 47618**] was started on antibiotics on
arrival to the NICU. Ampicillin and gentamicin were
discontinued after 48 hours when initial blood cultures
were negative. She remained without signs of infection
through the rest of her hospital course.
1. NEUROLOGY: Baby girl [**Known lastname 47618**] had several head ultrasounds
done through her hospital course. Last head ultrasound
was done on [**2159-11-16**] and was within normal limits
without any signs of intraventricular hemorrhages. Her
neurological exam remained stable through her hospital
course.
1. AUDIOLOGY: Hearing screen was performed, and infant passed in
both ears.
1. OPHTHALMOLOGY: Eyes were examined most recently on
[**2159-11-19**] revealing mature retinal vessels. A
follow-up exam is recommended in 9 months.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) 55701**] in
[**Hospital1 1474**]; phone number is ([**Telephone/Fax (1) 62542**] or [**Telephone/Fax (1) **].
CARE RECOMMENDATIONS:
1. Feeds at discharge are p.o. ad lib 150 cc/kg minimum of
Enfamil/breast milk 24 calories per ounce.
2. Medications are ferrous sulfate 0.25 cc p.o. once a day,
multivitamins 1 cc p.o. once a day.
3. Car seat test position study was done and passed.
4. State newborn screen was last sent on [**2159-11-20**]
and was within normal limits.
IMMUNIZATIONS RECOMMENDED: Baby girl [**Known lastname 47618**] received
hepatitis B vaccine on [**2159-10-31**]. Pediarix was given
on [**2159-11-29**]. HIB was given on [**2159-11-29**].
Pneumococcal vaccine was given on [**2159-11-29**]. Synagis
was given on [**2159-12-2**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: (1) born at less than 32
weeks gestation; (2) born between 32 and 35 weeks with 2 of
the following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings; (3) with chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of child's life)
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE FOLLOWUP: Follow-up appointment recommended with
primary care doctor within two days of discharge. Hip
ultrasound is recommended at 2 months of age due to breech
presentation in female infant.
DISCHARGE DIAGNOSES:
1. Prematurity; resolved.
2. Apnea of prematurity; resolved.
3. Feeding immaturity; resolved.
4. Sepsis rule out; resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name8 (MD) 62543**]
MEDQUIST36
D: [**2159-11-30**] 17:05:40
T: [**2159-12-1**] 10:53:30
Job#: [**Job Number 62544**]
ICD9 Codes: 769, 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2093
} | Medical Text: Admission Date: [**2173-6-22**] Discharge Date: [**2173-7-12**]
Date of Birth: [**2173-6-22**] Sex: M
Service: NB
Baby [**Name (NI) **] [**Known lastname 64246**]-[**Known lastname **] is the 1520 gram product of a 31 and [**12-11**]
week gestation born to a 28 year old G1 P0 now 1 mother.
Prenatal screens were: Blood type - O positive, antibody screen
negative, Hepatitis B surface antigen negative. RPR nonreactive,
rubella immune, GBS positive.
This pregnancy was complicated by premature rupture of membranes
on the morning of delivery, maternal transfer from [**Hospital **]
Hospital, history of normal fetal survey. Received first dose of
betamethasone on [**6-22**] and also started ampicillin and
erythromycin. During monitoring on Labor and Delivery, fetal
decelerations were noted, prompting the decision for delivery.
Rupture of membranes x 18 hours. No maternal fever. Amniotic
fluid clear. Maternal anesthesia by spinal. Delivery by cesarean
section. The infant emerged pink with spontaneous cry.
Routine drying, suctioning and stimulation. Apgars assigned
as 8 and 8.
PHYSICAL EXAMINATION ON ADMISSION: Weight was 1520 grams,
50th percentile. Length was 41 cm, 50th percentile. Head
circumference was 28 cm, 25-50th percentile. The infant was
pink with blow-by O2, with mild flaring. No grunting or
retractions at this time. Non dysmorphic. Anterior fontanel
soft and flat. Red reflex present bilaterally. Normal set
ears, intact palate and clavicles. Supple neck. Regular rate
and rhythm. No murmur. There were 2+ femoral pulses. Lungs
clear. Fair to good aeration. Equal breath sounds, minimal
flaring, no grunting or retracting. Abdomen soft. Positive
bowel sounds. GU - Normal male, testes down bilaterally. No
sacral anomalies. Hips stable. Tone normal, strength and
symmetric movements.
HISTORY OF HOSPITAL COURSE BY SYSTEM:
1. RESPIRATORY. [**Known lastname 915**] has remained stable in room air
throughout hospital course. Caffeine citrate started on
day of life #2 for apnea and bradycardia of prematurity.
This was discontinued on [**2173-7-3**] and he has had no apnea and
bradycardia in the past 5 days.
2. CARDIOVASCULAR. Baby has been noted to have a very soft
intermittent systolic murmur at the left sternal border. Cardiac
exam has otherwise been unremarkable. Murmur should be followed
clinically.
3. FLUID AND ELECTROLYTES. Birth weight was 1520 grams.
Discharge weight is 1855 grams. The infant was initially
started on 80 cc/kg/day of D10W. Enteral feedings were initiated
on day of life #1. He is currently on 140 ml/kg/day of P.E.
28 calorie/oz (PE24 with MCT oil 4kcal/oz and Promod, tolerating
well by gavage. First bottle attempted on [**7-11**] - took
10 ml.
4. GI. Initial peak bilirubin was on day of life #2 of 9.5 over
0.4. Bilirubin was checked again on [**7-7**] because of clinical
jaundice and was found to be 14.3. Phototherapy was initiated
and he was treated for 4 days. Last bilirubin off phototherapy
on [**7-11**] at 21:00 was 10.0/0.4/9.6.
This late onset jaundice/hyperbilirubinemia was felt to be
secondary to his urinary tract infection.
5. HEMATOLOGY. Hematocrit on admission was 54.4%. Blood type
is A positive, direct Coombs negative. He has not required
any blood transfusions. Most recent Hct on [**2173-7-8**] was 36.7%
reticulocyte count 2.5%.
6. INFECTIOUS DISEASE. CBC and blood culture were obtained on
admission. CBC was benign. Blood culture remained negative
at 48 hours, at which time ampicillin and gentamicin were
discontinued.
On [**7-7**], baby had a sepsis evaluation performed because of some
temp instability, decreased activity level and recurrence of
jaundice. Work-up initially included urine and blood cultures.
Blood cultures X 2 were negative. Urine culture positive for
Enterobacter cloacae. Initial urinalysis revealed 110 wbc per
high powered field and only 2 rbc/HPF.
Baby was started initially on cefotaxime and is now on day 4 of
treatment. Because of delay in ID of the gram negative organism,
ampicillin was started on Saturday [**7-10**]. Sensitivity results
today revealed that the organism is sensitive to cefotaxime,
resistant to gentamicin, ampicillin testing was not performed.
Noted with the sensitivity report was the fact that this organism
can develop resistance to cephalosporins after 4-5 days.
Therefore repeat culture is recommended. Plan was for 10 days of
treatment. Baby also had an LP performed on [**2173-7-9**] - results - 9
wbc 1045 rbcs wbc diff - 12P 1B 29L 56 macrophages. Cultures
have been no growth.
7. RENAL. Ultrasound on [**2173-7-12**] was within normal limits except
for mild left dilation that was noted to be within normal limits.
VCUG is recommended after antibiotic course is completed.
8. NEURO. Head ultrasound on [**2173-6-29**] was unremarkable.
9. SENSORY. Hearing screen has not yet been performed. Should
be done prior to discharge to home.
Eye exam was performed by Dr.[**Name (NI) **] [**Name (STitle) 56687**] on [**2173-7-12**] and
revealed vessels that were still immature in Zone 3 but with no
ROP. FU is recommended in 3 weeks.
10. PSYCHOSOCIAL. A social worker has been involved with the
family and can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Transfer to [**Hospital **] Hospital on [**2173-7-12**].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15532**].
CARE RECOMMENDATIONS: Continue 140 cc/kg/day of Premature
Enfamil 28 calories.
MEDICATIONS:
Cefotaxime, ampicillin, FeSo4.
State newborn screen has been sent per protocol and has been
within normal limits. Results of [**2173-7-6**] screen pending at time of
transfer. The infant has not received any
immunizations at this time.
DISCHARGE DIAGNOSES:
1. Premature infant, born at 31-1/7 weeks.
2. Initial - rule out sepsis with antibiotics.
3. Hyperbilirubinemia initial physiologic and late onset
associate with urinary tract infection.
4. Urinary tract infection - Enterobacter cloacae.
5. Apnea and bradycardia of prematurity.
6. Cardiac murmur - intermittent - presumed benign flow murmur.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
Dictation Summary: [**2173-7-12**]
Job#: [**Job Number 50740**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2094
} | Medical Text: Admission Date: [**2181-1-30**] Discharge Date: [**2181-2-5**]
Service: MEDICINE
Allergies:
Penicillins / Epinephrine / Novocain / Codeine / Celebrex /
Naprosyn
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Patient is an 89F with hx of CAD s/p Cypher to 80% OM in [**Month (only) 547**]
[**2178**] who reports that she has't been feeling well all week. Had
some SOB during exertion that was not alleviated with rest. She
denies any chest pain, but describes tightness with breathing.
Also complained of nausea and headache in the back of her head.
She had a constant feeling of weakness all over that lasted for
a couple of hours. She felt fatigued for the remainder of the
weak. and was unable to complete a flight of stairs.
.
She denies CP, palpitations. Reports chronic orthopnea with 2
pillows, some lightheadeness with shortness of breath. Chronic
lower extremity edema. + Hemmorhoids with occasional blood on
TP.
.
On review of symptoms, 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. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
*** Cardiac review of systems is notable for absence of chest
pain, paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
HTN
hyperlipidemia
coronary artery disease s/p stent in [**2178**]
gout
osteoarthritis
hyperparathyroidism.
Social History:
Social history is significant for the absence of current tobacco
use. 42 pack/yr history, quit 35 yrs ago. There is no history of
alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 35.8, BP 132/77 , HR 73 , RR 21, O2 99% on 2L
Gen: WDWN elderly female in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. R lid ptosis
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi anteriorly
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: 2+ pitting edema to mid-calf bilaterally. No femoral
bruits.
Skin: +chronic venous stasis dermatitis
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Neuro: R lid ptosis; otherwise CX II-Xii intact; tongue midline;
decreased light touch over toes bilaterally; moves all 4- unable
to assess strength 2/2 femoral sheath
Pertinent Results:
[**2181-1-30**] 03:30PM PT-12.6 PTT-28.1 INR(PT)-1.1
[**2181-1-30**] 03:30PM PLT COUNT-207
[**2181-1-30**] 03:30PM NEUTS-62.5 LYMPHS-27.0 MONOS-9.3 EOS-1.1
BASOS-0.1
[**2181-1-30**] 03:30PM WBC-4.8 RBC-3.75* HGB-12.1 HCT-35.7* MCV-95
MCH-32.3* MCHC-33.9 RDW-14.3
[**2181-1-30**] 03:30PM cTropnT-0.82*
[**2181-1-30**] 03:30PM CK(CPK)-45
[**2181-1-30**] 03:30PM GLUCOSE-146* UREA N-40* CREAT-1.6* SODIUM-139
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2181-1-30**] 03:53PM HGB-12.2 calcHCT-37 O2 SAT-99
[**2181-1-30**] 03:53PM TYPE-ART PO2-123* PCO2-31* PH-7.44 TOTAL
CO2-22 BASE XS--1 INTUBATED-NOT INTUBA
[**2181-1-30**] 05:00PM URINE RBC-0-2 WBC->1000 BACTERIA-MANY
YEAST-NONE EPI-0
[**2181-1-30**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2181-1-30**] 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.024
[**2181-1-30**] 11:15PM CK-MB-NotDone cTropnT-0.69*
[**2181-1-30**] 11:15PM CK(CPK)-33
.
ECHO:Mild symmetric left ventricular hypertrophy with regional
systolic dysfunction. Mild aortic regurgitation. Pulmonary
artery systolic hypertension. Dilated ascending aorta.
Compared with the report of the prior study (images unavailable
for review) of [**2178-3-24**], the regional left ventricular systolic
dysfunction is new and c/w multivessel CAD or Takotsumo
cardiomyopathy. The estimated pulmonary artery systolic pressure
is higher. The ascending aorta dilation is similar.
.
MRI/MRA head:
1. Infundibulum at the origin of the left posterior cerebral
artery P1 segment versus sub-3-mm aneurysm in this area. A CTA
of the head would be valuable in clarifying this issue.
2. Extensive bilateral white matter T2/FLAIR hyperintensity
consistent with small vessel ischemic disease.
3. Incompletely evaluated degenerative change of the upper
cervical spine.
.
Cardiac catheterization:
1. Non-obstructive CAD with 40% proximal LAD thrombus likely
representing resolved thrombus.
2. Elevated left sided filling pressures.
3. Mild pulmonary arterial hypertension.
Brief Hospital Course:
ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS:
.
89F with PMH of CAD s/p DES to OM [**2178**], HTN, hyperlipidemia
presents with 1 week of shortness of breath.
.
# CAD/Ischemia: Patient presented with one week of shortness of
breath but denied chest pain. Noted to have diffuse, nonspecific
ST elevations on ECG. Underwent cardiac catheterization
significant for patent stent and 40% proximal LAD thrombus. Pt
had persistent ST elevations post cath. Unclear etiology. No
evidence of pericarditis clinically. ESR was slightly elevated
making myocarditis unlikely. No apical ballooning noted on ECHO
but patient did have diffuse hypokinesis making stress
cardiomyopathy a possible etiology of her ECG changes. No
evidence of aneurysm. Patient was continued on aspirin, statin,
started on ace inhibitor and bblocker was titrated. Her plavix
was discontinued as her stent was placed in [**2178**].
.
# Pump: Echo with EF of 25%. Patient required nasal cannula and
was decompensated heart failure with pulmonary edema. She was
treated with diuresis and discharged on double her home dose
lasix. An ace inhibitor was added for afterload reduction.
.
# Rhythm: Patient had one episode of afib with RVR complicated
by hypotension converted to sinus rhythm s/p amiodarone load.
Remained in sinus on telemetry for duration of stay. Discharged
on amiodaron 200mg daily. Toprol was titrated up as tolerated by
her blood pressure.
.
# HTN: Titrated her toprol and lisinopril as tolerated by blood
pressure.
.
# Pansensitive E.coli UTI: Treated with 5 days of bactrim. Foley
was removed. Symptoms improved.
.
# Chronic kidney disease: Presumed chronic kidney disease. Hx of
partial nephrectomy. Creatinine remained stable in setting of
diuresis.
.
# FEN: cardiac/heart healthy diet; replete lytes PRN
.
# Code: Full, discussed with patient and husband
.
# Communication: patient and husband ([**Telephone/Fax (1) 97554**] (home);
Office ([**Telephone/Fax (1) 97555**]
.
Medications on Admission:
Toprol XL 12.5 daily
Diovan 80mg daily
Lasix 40mg daily
Lipitor 10mg daily
Protonix 40mg daily
Plavix 75mg daily
Aspirin 325mg daily
SL nitro PRN
Allopurinol 100mg daily
Colchicine?
Triamcinolone creme
Silver sulfadiazine
Discharge Medications:
1. Aspirin 325 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Congestive heart failure, atrial fibrillation
Secondary: Coronary artery disease
Discharge Condition:
Good, chest pain free, vital signs stable
Discharge Instructions:
You were admitted to the hospital with shortness of breath.
Adjustments were made to your medications. You were also noted
to develop an abnormal heart rhythm. This resolved with the
addition of a new medication.
Changes to your medication include:
Toprol XL 25mg daily
Amiodarone 200mg daily
Lasix 40mg twice daily
Lisinopril 5mg daily
Lipitor 40mg daily
Discontinue diovan
.
Please follow up with your cardiologist in 2 weeks.
Please follow up with your primary care doctor in 4 weeks.
.
Please contact your doctor or return to the emergency room i f
you develop any worrisome symptoms such as chest pain, worsening
shortness of breath, lightheadedness, fluttering in your chest,
passing out, etc.
Followup Instructions:
Please follow up with your cardiologist in 2 weeks.
Please follow up with your primary care doctor in 4 weeks.
ICD9 Codes: 5990, 4280, 5859, 2724, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2095
} | Medical Text: Admission Date: [**2166-7-17**] Discharge Date: [**2166-7-27**]
Date of Birth: [**2108-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
increased SOB
Major Surgical or Invasive Procedure:
CABG x3
History of Present Illness:
57 yo male with increasewd SOB and + ETT on [**7-15**] . This revealed
ischemic cardiomyopathy with EF 23%. R/O for MI at [**Hospital1 **] Med.
Ctr and underwent cath which showed occluded LAD, 90% cx, 90%
OM2, 60% RCA, 90% PDA. Referred to Dr. [**Last Name (STitle) **] , and transferred
to [**Hospital1 18**] on dopamine and dobutamine for CABG.
Past Medical History:
COPD
HTN
elev. chol.
CHF
basal cell Ca
hx of lower field cut left eye
Social History:
smokes 2 ppd X 45 years
[**2-28**] highballs per night with ? beer
occasionally lives with girlfriend
Family History:
positive for CAD
Physical Exam:
NAD
NC/AT, PERRLA, EOMI,benign oropharynx
neck supple with full ROM, no lymphadenopathy or thyromegaly,
carotid 2+ without bruits
lungs CTA bilat.
RRR without M/R/G S1S2 present
abd soft, NT without masses or hepatosplenomegaly
extrems no c/c/e, with bil. varicosities, pulses 1+ bilat.
throughout
neuro nonfocal
Pertinent Results:
[**2166-7-27**] 10:00AM BLOOD WBC-8.9 RBC-3.95* Hgb-11.7* Hct-34.6*
MCV-88 MCH-29.6 MCHC-33.8 RDW-13.0 Plt Ct-299
[**2166-7-27**] 10:00AM BLOOD Plt Ct-299
[**2166-7-27**] 10:00AM BLOOD Glucose-189* UreaN-14 Creat-0.9 Na-140
K-4.8 Cl-104 HCO3-25 AnGap-16
[**2166-7-18**] 06:00AM BLOOD CK(CPK)-38
[**2166-7-18**] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2166-7-27**] 10:00AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.3
Brief Hospital Course:
Underwent CABG x3 on [**7-21**] with Dr. [**Last Name (STitle) **] (LIMA to LAD, SVG to
OM1, SVG to OM2). Transferred to CSRU in stable condition on
milrinone , epinephrine, and propofol drips. Extubated later
that evening, with epinephrine, milrinone, and neosynephrine
drips on POD #1. Weaning began for all drips. Off milrinone and
epinephrine on POD #2, and CTs removed. Remained on neo at 0.4
on POD #3 and was OOB in the CSRU. CVL removed and weaned off
neo,with lasix diuresis, then transferred to floor on [**7-25**]. Seen
and evaluated by PT and case management.Pacer wires DCed [**7-25**] and
lopressor beta blockade begun. Pt. alert and oriented, MAE, but
had a 7 beat run of NSVT on [**7-27**]. Seen by Dr. [**Last Name (STitle) 73**] of EP
service, with recs for follow-up echo and Holter monitor in
approx. one month. Pt. remained in SR and was discharged to home
with VNA on [**2166-7-27**].
Medications on Admission:
lipitor 10 mg qd
lasix 40 mg [**Hospital1 **]
vasotec 25 mg [**Hospital1 **]
ASA 325 mg qd
Ambien 5 mg qd
bisoprolol 25 mg [**Hospital1 **]
rocephin 1 gram qd
zithromax 250 mg TID
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. 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:*40 Tablet(s)* Refills:*0*
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Discharge Disposition:
Home With Service
Facility:
VNAs of [**Location (un) 511**]
Discharge Diagnosis:
Coronary artery bypass grafting X3
coronary artery disease
chronic obstructive pulm disease
hypertension
elev. chol.
congestive heart failure
basal cell Ca
lower field cut left eye
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
In [**3-28**] weeks with Dr. [**Last Name (STitle) **]
[**Name (STitle) **] your cardiologist in [**1-26**] weeks, you can also see Dr.
[**Last Name (STitle) 7965**] here at [**Hospital3 **] his number is: [**Telephone/Fax (1) 902**]
Completed by:[**2166-10-20**]
ICD9 Codes: 486, 4280, 496, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2096
} | Medical Text: Admission Date: [**2147-6-18**] Discharge Date: [**2147-6-30**]
Date of Birth: [**2077-11-4**] Sex: F
Service: MEDICINE
Allergies:
Plavix / Heparin Agents
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Fever, tachypnea, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
69 y/o F w/ a h/o respiratory failure s/p trach placement and
revision [**5-/2147**], pansensitive TB on 3 drug regimen, MDS with
pancytopenia, recently discharged [**2147-6-16**] for hemoptysis, trach
stenosis, VAP and sepsis who was referred to ED intensivist at
[**Hospital **] rehab, Dr. [**Last Name (STitle) 83106**], for tachypnea, tachycardia to the
140s, minute ventilation of 16, pancytopenia(unchanged from
recent hospitalization), and non-gap acidosis. Patient has
remained febrile, presumed secondary to medication reaction (see
below). Also noted that she had a modest amt of hemoptysis
(thin, frothy).
.
Recent admission [**Date range (3) 102692**] for hemoptysis, inability to
ventilate, VAP, and septic shock. Septic shock presumably
secondary to VAP and was treated with levophed, IVF, cefepime,
and tobramycin (colonized with MDR pseudomonas and initially
treated with cefepime but isolated again from sputum now
resistent to cefepime). Blood cultures remained negative but MDR
pseudomonas isolated from sputum. Patient then became volume
overloaded following fluid resuscitation but responded well to
diuresis. Plan was to discharge to [**Hospital **] rehab for a scheduled
14 day course of cefepime/tobramycin to be completed [**6-17**].
However, patient had creatinine elevation prior to discharge
thought to be due to Tobramycin, which was discontinued.
Patient found to have 80% stenosis of trach tube with
granulation tissue. Patient intubated from above. IP revised her
trach with placement of [**Last Name (un) **] device and excision of
granulation tissue. [**Last Name (un) 295**] was then replaced [**6-9**] with a
permanent customined #7 Shiley trach. Patient required
mechanical ventilation throughout hospitalization with periods
of apnea and presumed to have muscle weakness potentially from
central process due to h/o CVAs.
Hospitalization complicated by persistent low grade fevers
despite appropriate antibiotics thought to be most likely
medication related rather than infectious(INH, ethambutol most
likely). Also complicated by chronic pancytopenia secondary to
MDS and chronic hemolysis from frequent blood transfusions.
.
In ED, T104, BP 80s/60s, HR 170s, RR 30-40s, O2 100%. She
received Tylenol with temp decrease to 101.6. A right femoral
CVL was placed. She was volume resuscitated with 7L NS but
remained persistently hypotensive so Levophed started with SBPs
to 90s. Patient remained tachypneic breathing over vent. Labs
notable for ABG 7.35/20/180. ARF with Cr 3.3 from last 1.4.
Pancytopenic but stable from prior discharge without left shift.
CXR intially showed improved R middle and lower lung opacities.
However, a repeat CXR following volume resuscitation showed
blossoming consolidation in R lung. She received cefepime x 1.
Past Medical History:
-Pulm TB (pan sensitive) with liver/spleen granulomas
s/p R sided vats, r supraclavic LN, liver bx +
-h/o +PPD w/o tx
-AFB on BAL [**2147-1-2**]
-tx continious since 2/1 per prior dc summ
-1)Diabetes mellitus - diet controlled
2)OSA - on BiPAP 12/8
3)Cataract in the left eye
4)CVA/TIA (positive MRI) - right frontal with L arm/hand
hemiparesis; etiology likely moderate degree stenosis of the ICA
in the cavernous region, stable on recent CTA
5)Asthma
6)Hypercholesterolemia
7)Seizure- uncertain diagnosis - L arm involuntary movements
[**2144**]
8)Recent colonoscopy in [**2144**] with single sessile 4-5 mm
non-bleeding polyp of benign appearance, s/p removal.
mammography yearly unremarkable.
9)Sickle trait
Social History:
Has been living in [**Hospital **] rehab MACU since [**2147-1-19**] getting
tx for disseminated TB. Previosly lived alone in [**Location (un) 86**].
Supportive family nearby. Remote history of tobacco use. One-two
glasses of alcohol per week. Retired, used to work in a post
office.
Family History:
Diabetes in son, sister, and brother. [**Name (NI) 102689**] with
epilepsy. [**Name (NI) **] brother with possible lung cancer. Uncle with
TB.
Physical Exam:
T: 99.6 BP: 100/52 HR: 115 RR: 30 O2 100% on 0.5 FiO2, AC
400x26, PEEP 5
Gen: intubated, sedated, responsive to pain
HEENT: Pupils equal and reactive. Trach in place.
NECK: Supple. Cannot assess JVP. No JVD
CV: regular. tachycardic. No MRG
LUNGS: course breath sounds throughout. No rales
ABD: Absent bowel sounds. Obese. Soft, NT, ND. PEG in place
EXT: WWP, NO CCE. Right femoral CVL oozing blood
NEURO: Reactive to painful stimuli, opens eyes and withdraws.
Cannot follow commands. GCS 10.
Pertinent Results:
[**2147-6-18**] 10:39PM GLUCOSE-108* UREA N-64* CREAT-2.9*
SODIUM-149* POTASSIUM-4.1 CHLORIDE-128* TOTAL CO2-12* ANION
GAP-13
[**2147-6-18**] 10:39PM ALT(SGPT)-29 AST(SGOT)-149* LD(LDH)-620* ALK
PHOS-103 TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2
[**2147-6-18**] 10:39PM WBC-7.2# RBC-1.87*# HGB-5.7*# HCT-17.0*#
MCV-91 MCH-30.5 MCHC-33.5 RDW-16.6*
[**2147-6-18**] 10:39PM PLT SMR-VERY LOW PLT COUNT-52*
[**2147-6-18**] 10:39PM PT-16.5* PTT-39.7* INR(PT)-1.5*
[**2147-6-18**] 10:39PM FIBRINOGE-285
[**2147-6-18**] 07:57PM RATES-26/20 TIDAL VOL-400 PEEP-5 O2-50
PO2-180* PCO2-20* PH-7.35 TOTAL CO2-12* BASE XS--11 -ASSIST/CON
[**2147-6-18**] 07:00PM URINE GR HOLD-HOLD
[**2147-6-18**] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-NEG
[**2147-6-18**] 07:00PM URINE RBC-21-50* WBC-[**1-23**] BACTERIA-FEW
YEAST-RARE EPI-0-2 TRANS EPI-0-2
[**2147-6-18**] 07:00PM URINE AMORPH-MOD
[**2147-6-18**] 06:04PM K+-4.0
[**2147-6-18**] 04:20PM GLUCOSE-188* UREA N-71* CREAT-3.3*#
SODIUM-141 POTASSIUM-7.4* CHLORIDE-119* TOTAL CO2-13* ANION
GAP-16
[**2147-6-18**] 04:20PM ALT(SGPT)-23 AST(SGOT)-109* CK(CPK)-222* ALK
PHOS-128* AMYLASE-95 TOT BILI-0.3
[**2147-6-18**] 04:20PM CK-MB-1 cTropnT-0.13*
[**2147-6-18**] 04:20PM WBC-3.3* RBC-2.73* HGB-8.4* HCT-24.9* MCV-91
MCH-30.8 MCHC-33.7 RDW-16.6*
[**2147-6-18**] 04:20PM NEUTS-53.7 LYMPHS-39.7 MONOS-2.7 EOS-2.5
BASOS-1.3
[**2147-6-18**] 04:20PM PT-14.9* PTT-27.0 INR(PT)-1.3*
.
[**6-21**] CT HEAD: COMPARISON: Head CT, [**2147-2-10**]. FINDINGS:
Compared to prior examination, there is again evidence of prior
right frontal lobe infarct with cortical gyriform
calcifications. This is unchanged in appearance. There is also
a focal hypodense lesion seen in the
region of the right internal capsule, which may represent prior
lacunar
infarct. This is also unchanged. There are prominent sulci and
ventricles with parenchymal volume loss. There is no evidence
of hemorrhage, mass effect, shift of normally midline
structures, or new areas of infarction. The [**Doctor Last Name 352**] and white
matter differentiation is preserved. There is moderate mucosal
thickening of the sphenoid sinus on the left side. There is
minimal mucosal thickening of the left mastoid air cells.
IMPRESSION: There is no evidence of hemorrhage or new areas of
infarction.
.
[**2147-6-23**] MRI HEAD: FINDINGS: There is an area of encephalomalacia
seen in the right frontal lobe with areas of low signal on
susceptibility images indicative of chronic blood products. In
this irregular area of encephalomalacia there is a irregular
area of high signal on diffusion images with low signal on ADC
map indicating slow diffusion. Given the presence of chronic
blood product slow diffusion is most likely related to the blood
products. This is unlikely to represent acute ischemia in this
location given the appearance. Also in absence of vasogenic
edema and presence of encephalomalacia an abscess within this
location also appears less likely. However, when the patient's
condition permit, gadolinium-enhanced MRI would help for further
assessment. There is mild-to-moderate brain atrophy and changes
of small vessel disease are seen. Coronal images through the
temporal lobe demonstrate medial temporal atrophy without
evidence of intrinsic signal abnormalities within the
hippocampal regions. IMPRESSION: Large area of encephalomalacia
in the right frontal lobe extending to inferior frontal lobe
region which could be related to prior trauma or ischemia.
Irregular area of chronic blood product is seen in this region
which demonstrate slow diffusion and which most likely is
secondary to chronic blood products. However if patient's
condition permit, gadolinium. Enhanced imaging would help for
further assessment. Soft tissue changes, left mastoid air
cells. No acute infarct is identified. No mass effect or
hydrocephalus is seen.
.
[**6-27**] EEG FINDINGS: Demonstrated a disorganized and poorly
modulated
rhythm in the [**3-26**] Hz frequency range. There were no prominent
focal,
lateralized, or epileptiform features. There were no repetitive
discharges or electrographic seizures. SLEEP: There were no
normal waking or sleeping morphologies seen. CARDIAC MONITOR:
Showed a generally regular rhythm. SPIKE DETECTION PROGRAMS:
Consisted mainly of electrode artifacts about the C3 and O2
electrodes. SEIZURE DETECTION PROGRAMS: There were 31 entries in
these files. All were artifactual. PUSHBUTTON ACTIVATIONS: There
were none. IMPRESSION: This telemetry captured no pushbutton
activations. However, this continues to be an abnormal bedside
EEG due to the presence of a slow, disorganized, and poorly
modulated background rhythm consistent with a severe
encephalopathy. Medications, infection,
metabolic disturbances, and anoxia are among the most common
causes but
there are others. There were no prominent focal, lateralized, or
epileptiform features. However, severe encephalopathies can
obscure
focal findings. No electrographic seizures were noted on this
recording.
.
.
Brief Hospital Course:
MEDICAL ICU COURSE: Ms. [**Known lastname **] was admitted to the MICU from the
ED with acute renal failure and evidence of worsening pneumonia
and sepsis, recently discharged [**2147-6-16**] after a hospital stay
treating hemoptysis, trach stenosis, VAP and sepsis.
.
#. Sepsis: Her sepsis was presumed secondary to pneumonia seen
on CXR. Initally her hypotension was unresponsive to aggressive
volume resuscitation in ED requiring pressors; however,
pressures stablized in ICU. Prior cultures significant for MDR
pseudomonas sensitive to Cipro from sputum [**6-10**] and MDR E coli
sensitive (ESBL) to Meropenem from sputum [**6-9**]. Also, VRE from
cath tip on [**6-21**], started on Daptomycin. For the new PNA and
sepsis, the patient was initially administered vancomycin,
ciprofloxacin, meropenem for broad coverage with day 1 of
therapy [**6-18**]. Vancomycin was discontinued on [**6-21**]. Tobramycin
was added on [**6-19**]. Tobramycin, ciprofloxacin, and meropenem
were planned for 14 day course per infectious disease
consultants recommendations. The full course of vancomycin and
meropenem will be completed on [**7-2**] and for tobramycin
[**7-3**]. Of note, during stay flagyl was begun for empiric C.
dificle coverage but was discontinued after assays X3 were
completed. Also daptomycin was begun as a removed catheter tip
grew VRE; however, daptomycin was discontinued due to negative
blood cx on [**6-23**] for VRE. The patient receive 4 days of
daptomycin.
.
# ARF: Her baseline creatinine 0.8-1.0. During her last
admission creatinine elevation believed to be secondary to
Tobramycin and antibiotic discontinued at that time. Cr 1.4
prior to discharge. This admission her renal failure was
thought to be due to ATN given her history of hypotension,
noting a possible contribution of Tobramycin to renal failure;
the benefits of tobramycin in treating infection were felt to be
greater than their contribution to her renal failure. Her renal
function improved during her ICU stay and her creatinine at
discharge was 2.4 (3.3 on admission.
.
# Respiratory failure: She was tachypneic on admission and has
chronic respiratory failure s/p trach placement. She could not
be weaned from ventilator during recent admission or this
current admission. ABG showed respiratory alkalosis with
concomitant metabolic acidosis, which could be primary non-gap
acidosis due renal failure or respiratory compensation for
metabolic acidosis due to sepsis with baseline chronic
respiratory alkalosis due to increased central drive
(bicarbonate less than expected for acute, but bicarbonate
values perhaps consistent with chronic pC02 drop). Upon
discharge her respiratory status was ventilatory dependent and
stable.
.
# Anemia: The patient required multiple blood transfusions this
admission to keep her hematocrit above a tranfusion goal that
ranged from 21-25. Thigh bleeding was noted on exam in the
region of a femoral line, which was removed secondary to
question of possible art stick initially. Retroperitoneal bleed
was ruled on imaging. CVL was re-sited. Her hematocrit was 22.0
upon discharge and stable.
.
# Altered Mental Status: Her GCS was 9 upon discharge
(nonverbal, withdraws to pain, eyes open). Per her family, the
patient had decreased alertness and orientation during this
admission. The neurology service was consulted and followed the
patient throughout admission. Anoxic brain injury was suspected
given recent history of hypotension/hypoventilation. A CT head
showed no interval change, old R frontal stroke. EEG results as
above. MRI results as above.
.
# Fever: No leukocytosis or left shift was noted during stay but
has h/o pancytopenia. She was intermittently febrile during
recent admission which could have been in part secondary to
medication (INH, ethambutol most likely as was thought during
her last admission). However, medications cannot be stopped.
Her current pneumonia/sepsis likely also contributed to her
intermittent fevers. Urine cultures were negative. Sputum
cultures grew culture PSEUDOMONAS, SENSITIVE to ciprofloxacin,
tobramycin, resistant to meropenum. A catheter tip grew VRE
although blood cultures were negative. More recent blood
cultures are currently pending but show no growth to date.
.
# Tachycardia: HR was systolically in 170s on admission and had
appearance of sinus tach on EKG though it was doubtfully sinus
given patient's age and level of tachycardia. Tachycardia was
likely secondary to hypotension and a PE was unlikely as
oxygenating well.
.
# Disseminated TB: Pan sensitive TB with liver and spleen
granulomas on INH, Ethambutol, Pyrazinamide since 2/[**2146**]. Pt is
s/p R sided VATS, R supraclavicular LN, and liver bx positive.
Recently ruled out for active TB w/ 3 negative sputums last
admission [**5-27**]. Continue INH, Ethambutol, Pyrazinamide with
complete course not finished until [**8-/2147**] at the earliest; ID
to be reconsulted again before discontinuing TB antibiotics in
the future. No respiratory precautions were observed given
negative sputum x 3 for TB.
.
# Pancytopenia: She has a h/o MDS seen on bone marrow biopsy
with borderline transformation to AML. However, no blasts on
peripheral smear during recent admission to raise concern for
progression. Counts improved since recent discharge.
Counts were as low as 1.0 but have increased again, WBC up to
4.0 today, on neupogen. She was given final dose of neupogen X1
today with plans to not continue neupogen in rehabilitation.
.
# Diabetes Mellitus: Reasonable BG control currently. Lantus at
half dose while NPO
and insulin sliding scale controlled sugars reasonably well
during admission.
.
# h/o CVA: h/o R ICA with residual L arm/hand hemiparesis and
aphasia. Neuro exam cannot be assessed secondary to patient's
clincial status. GCS currently 9(eyes open, withdraws/localizes
to pain, nonverbal). CT head and MRI during this admission
showed no new CVA. Please see CT/MRI study results as above.
.
# Asthma: No evidence of obstruction on ABG in ED.
Albuterol/atrovent MDI prnwere administered.
.
# Hypercholesterolemia: Statin was held given mild LFT
elevation.
.
# FEN: Tube feeds were administered at goal. Lytes repleted
lytes as necessary. g-tube in place.
.
# PPx:
- No heparin give h/o +HIT. Pneumoboots.
- PPI, sucralfate
- colace, senna, lactulose, bisacodyl for bowel regimen, but
holding bowel regimen now given diarrhea.
.
# ACCESS: PICC. PIV x2.
.
# CODE: FULL
.
# COMM: [**Name (NI) **] [**Name (NI) **] ([**Hospital **] Health care proxy ) [**Telephone/Fax (1) 102690**],
[**Telephone/Fax (1) 102691**].
Medications on Admission:
Acetaminophen 325 mg PO Q6H as needed for pain/fever.
Albuterol 90 mcg/Actuation Aerosol 6-8 Puffs Inhalation Q4H
(every 4 hours) as needed for wheezing/SOB.
Bisacodyl 10 mg PO DAILY (Daily) as needed.
Docusate Sodium 100 mg PO BID
Ethambutol 1200 mg PO DAILY
Insulin Glargine(15) units Subcutaneous at bedtime.
Insulin Regular Human Subcutaneous four times a day: 4 units for
FSBS 150-200, and 2 units for every additional 50 FSBS points
over 200.
Ipratropium Bromide(2) Puff Inhalation QID
Isoniazid 300 mg PO DAILY
Lactulose 20 gm PO Q6H
Lansoprazole 30 mg PO DAILY
Pyrazinamide 1250 mg PO DAILY
Pyridoxine 50 mg PO DAILY
Senna 8.6 mg PO BID as needed.
Simvastatin 40 mgPO DAILY
Sucralfate 1 g PO QID
Tobramycin Sulfate 180 mg IV Q36H x 5 days: doses due 7/24pm,
7/26am, 7/27pm; course will then be complete
Vancomycin 1000 mg IV Q 24H x 10 days: discontinue
if blood cultures from [**6-10**] remain negative.
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID (4 times a day).
4. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
injection Injection QID per sliding scale: 2 units for BG
150-200, 4 units for BG 201-250, 6 units for BG 251-300, 8 units
for BG 301-350, 10 units for BG 351-400. 12 units for BG>400.
5. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Seven (7) units
Subcutaneous at bedtime.
6. Isoniazid 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
7. Pyrazinamide 500 mg Tablet [**Last Name (STitle) **]: 2.5 Tablets PO DAILY (Daily).
8. Pyridoxine 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. Sucralfate 1 g Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a
day).
10. Ethambutol 400 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Q36H
(every 36 hours).
11. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed.
12. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed.
13. Lactulose 10 g/15 mL Syrup [**Age over 90 **]: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
14. Senna 8.6 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Docusate Sodium 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) mg
PO BID (2 times a day).
16. Sodium Bicarbonate 650 mg Tablet [**Age over 90 **]: One (1) Tablet PO Q6H
(every 6 hours).
17. Cipro 10 mg/mL Solution [**Age over 90 **]: Four Hundred (400) mg
Intravenous once a day for 4 days.
18. Meropenem 500 mg Recon Soln [**Age over 90 **]: Five Hundred (500) mg
Intravenous Q12H (every 12 hours) for 4 days.
19. Fentanyl Citrate 25-100 mcg IV Q6H:PRN
20. Midazolam 2-4 mg IV Q4H:PRN
21. Tobramycin Sulfate 40 mg/mL Solution [**Age over 90 **]: One Hundred (100)
mg Injection Q48H (every 48 hours) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Pneumonia
2. Renal Failure
3. Tuberculosis
Discharge Condition:
Stable vitals. Responds to noxious stimuli. Cannot follow
commands. Persistently tachypneic.
Discharge Instructions:
You were evaluated and treated in the hospital for complicated
bacterial pneumonia, renal failure, and your long-standing
disseminated tuberculosis. You will need to continue taking
antibiotics for 4 days as prescribed to complete a 14 day
course.
Please call your doctor or return immediately to the emergency
department for any difficulty breathing, fevers greater than
102, or any other concern.
Followup Instructions:
Please call your primary care doctor to arrange follow-up in the
next week.
ICD9 Codes: 0389, 5845, 2762, 2851, 2760, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2097
} | Medical Text: Admission Date: [**2191-3-9**] Discharge Date: [**2191-3-18**]
Date of Birth: [**2139-4-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51 F presenting with somnolence and SBP=60s. She states that she
has had diarrhea (watery stools w/ mucus, 5 times a day, large
volume, mostly 30 minutes after eating, but also nocturnal)
starting [**2191-12-29**] when following cholecystectomy (performed at
[**Hospital1 2025**]). No abd pain, no rectal pain, no nausea, no vomiting, no
blood, no travel. Flagyl was given empirically without benefit.
States that she has lost nearly 100 lbs in the past three
months. She also states that her levothyroxine dose was
incrementally increased from 100 to 250 over the course of the
last six months.
.
Stool studies performed on [**2191-2-25**] were unrevealing: NO
MICROSPORIDIUM, NO CYCLOSPORA, NO SALMONELLA OR SHIGELLA, NO
CAMPYLOBACTER, NO OVA AND PARASITES, NO VIBRIO, NO YERSINIA, NO
E.COLI 0157:H7 FOUND, NO CRYPTOSPORIDIUM OR GIARDIA, FECES
NEGATIVE FOR C. DIFFICILE TOXIN. EGD and colonoscopy performed
on [**2191-2-28**] were unrevealing, except a few non-bleeding erosions
were noted in the antrum. Bxs from these procedures were also
unrevealing.
.
She saw Dr. [**Last Name (STitle) **] on [**2191-2-25**] who thought her presentation
could be consistent w/ Bile salt induced diarrhea from
malabsorption of bile salts following cholecystectomy, with
other possibilities being drug induced, such as increased
thyroxine or ropinirole or carbidopa
.
The patient is a 51 year old female with a history of
Parkinson's disease, DMII, and recent cholecystectomy at [**Hospital1 2025**] on
[**2191-1-17**] who initially presented to the ED with somnolence,
fever to 101.2, and hypotension with SBP=60s.
.
The patient states that her diarrhea started 6 days post-op from
her cholecystectomy at [**Hospital1 2025**]. She complains of nonbloody diarrhea
that is brownish-green in appearance with 5-6 episodes per day.
At home, she tried to increase her PO intake. She denies any
abdominal pain but states that she feels "numb" in her RUQ since
the surgery. She denies any nausea/vomiting and is able to take
PO. No sick contacts, recent travel.
.
She called her surgeon's office at [**Hospital1 2025**] and spoke to a NP and was
given Flagyl empirically which she took for 3 days with some
relief but then her diarrhea resumed. She states that she
unintentionally has lost nearly 100 lbs in the past three months
(from 200 to 127 lbs).
.
She had recently been admitted for similar symptoms from [**2-24**] to
[**2191-3-2**] (no DC summary available) at which time she was evaluated
by GI and told that her diarrhea was secondary to bile acid
malabsorption. She had an EGD and colonoscopy during that
admission on [**2191-2-28**] which showed:
Past Medical History:
--Total thyroidectomy [**2190-7-12**] for multinodular thyroid goiter
--hypothyroidism [**2-25**] thyroidectomy
--Cholecystectomy on [**2191-1-17**] at [**Hospital1 2025**]
--OSA not on BIPAP at home
--Parkinson's Dz - sees Dr. [**Last Name (STitle) 21191**] as outpatient (private),
no history of seizures
--DM2
--anxiety/depression
--dysphonia/dysphagia thought [**2-25**]/ GERD (dx [**2191-3-2**])
--MVA as the patient fell asleep at the wheel - no head trauma,
chest wall trauma on [**2191-1-5**].
--GERD
-- h/o LBP
-- Microcytic anemia, baseline Hct 28-34
Social History:
lives alone in elderly/disabled housing complex in [**Location (un) **] ([**Doctor Last Name **]
towers). She has one daughter, 28, who lives in [**Location **] area and
is pursuing a PhD.
Family History:
Non-contributory
Physical Exam:
Tm=101.2, Tc=98
BP=138/69
HR=69
RR=14
O2sat=99%
GEN: lyign in bed, conversant, nad
HEENT: no elevated jvp, no lad
CV: rrr, nl s1/s2
PULMO: ctab
ABD: bs+, soft, nt, nd
EXT: warm, 2+DP, no c/c/e
Pertinent Results:
[**2191-3-8**] 07:15PM BLOOD WBC-21.2*# RBC-4.22 Hgb-10.7* Hct-30.9*
MCV-73* MCH-25.5* MCHC-34.7 RDW-15.0 Plt Ct-448*
[**2191-3-12**] 12:46PM BLOOD WBC-14.4* RBC-4.16* Hgb-10.6* Hct-31.2*
MCV-75* MCH-25.5* MCHC-34.0 RDW-15.2 Plt Ct-441*
[**2191-3-12**] 12:46PM BLOOD Plt Ct-441*
[**2191-3-8**] 07:15PM BLOOD Glucose-112* UreaN-36* Creat-2.2*#
Na-128* K-3.7 Cl-95* HCO3-20* AnGap-17
[**2191-3-12**] 12:46PM BLOOD Glucose-129* UreaN-3* Creat-0.8 Na-136
K-3.6 Cl-100 HCO3-25 AnGap-15
[**2191-3-10**] 06:07AM BLOOD CK(CPK)-66
[**2191-3-8**] 07:15PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2191-3-10**] 06:07AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2191-3-9**] 05:35AM BLOOD CRP-115.2*
[**2191-3-8**] 07:21PM BLOOD Lactate-1.1
[**2191-3-10**] 06:20AM BLOOD Lactate-0.8
CT ABD/PEL [**2191-3-9**]: New severe wall thickening with
thumbprinting in the transverse colon. The finding is
nonspecific, but given rapid evolution and clinical evidence of
sepsis, the most likely etiology is infectious, with the
distribution favoring C. difficile colitis. The finding is
nonspecific, however, and ischemia or inflammatory processes are
also on the differential.
.
CXR [**2191-3-10**]: Left mid lung atelectasis.
.
CT Head [**2191-3-9**]: Negative.
.
Micro:
Blood cultures [**2191-3-8**]:
.
2/2 bottles with Group B strep sensitive to :
.
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN------------<=0.06 S
VANCOMYCIN------------ <=1 S
.
Blood Cx [**3-10**] and [**3-11**] still pending.
.
Stool Cx [**2191-3-9**]: NO SALMONELLA OR SHIGELLA FOUND. NO
CAMPYLOBACTER FOUND. NO OVA AND PARASITES SEEN. MODERATE
POLYMORPHONUCLEAR LEUKOCYTES. FECES NEGATIVE FOR C. DIFFICILE
TOXIN BY EIA.
.
H. Pylori [**2191-2-28**]: POSITIVE.
Brief Hospital Course:
A/P: 51 yo female w/ Parkinsons Dz s/p recent CCY with green,
watery diarrhea since surgery who presented with fevers,
hypotension, and group B strep in BCX now on ampicillin,
gentamicin with H. Pylori and persistent diarrhea.
DIARRHEA:
-The patient most likely does have a component of bile acid
malabsorption status post CCY in addition to an infectious
source at present with colitis on CT A/P.
- Checked C diff toxin B as toxin A negative which was positive.
Patient Started on Flagyl for a full2 weeks course. Last dose
should be on [**2191-3-25**]. Patient's diarrhea resolved 3 days prior to
discharge and she did not have any abdominal pain by the time of
discharge. She had a repeat CT of the abdomen that showed
interval improvement of colitis. She was discharged on
colesevelam 625 mg PO TID. In addition, however, the patient
has H. pylori. She was given the Flagyl for the H. Pylori as
well as initially ampicillin and gentamicin to cover any
additional GI infectious bugs. However, gentamicin was
discontined and ciprofloxacin was started for adequate coverage.
The patient's white count continued to fall although was still
somewhat elevated at the time of discharge. She remained
afebrile the last 5 days of her stay . Also, Celexa may cause
diarrhea as well, Patient was initially on 40mg on admission,
[**2191-3-12**] dose was decreased to 10mg.
FEVERS: Likely secondary to C. diff and/or Group B Strep
bacteremia. She was initially started on ampicillin and
gentamicin while in the intensive care unit but her regimen was
changed as above and she continued to do well. in the unit
She will be continued on Flagyl for a full 2 week course, and
ampicillin and ciprofloxacin for a complete 10 day course.
.
HYPO/HYPERTENSION:
-- Dyazide and atenolol held with hypotension on admit. Although
restarted as patient's vital signs tolerated. Her Metoprolol was
eventually increased to 75 mg which she did well on.
.
PARKINSONS:
--continued Amantidine and Carbidopa-Levodopa. Discussed PD meds
with neurology: think the patient is well controlled and do not
feel there is an indication to change doses. Feel her movement
disorder is as below.
.
?SEIZURES:
-- This was noted by staff in ICU. Unclear whether the patient
sleeps with her eyes open or was actually seizing.
- Seen by neurology for ? of seizures: feel her activity is REM
activity which is common in Parkinson's patients secondary to a
disinhibtion of movement pathways during sleep. Did not feel it
necessary to perfomr EEG or further brain imaging.
.
HYPOTHYROIDISM/HYPERTHYROIDISM:
--The patient's TSH had been checked during her last admission
and found to be extremely low at : 0.066 and 0.058. Her free T4
was elevated 2.4 (NL 1.7 max).
- Therefore, her Synthroid was decreased from 237 to 137 on
discharge. However, the patient states she was taking 237 prior
to this admission.
- Repeat TSH was normal at 2.3. Continued Synthroid 137 mcg with
outpatient endocrinology follow up.
.
# ACUTE RENAL FAILURE
- Her initial Cr was 2.2, but Cr resolved with resolution of
sepsis
- Her metformin was held at that time but was restarted with
resolution of renal function.
.
# DM2:
-- Resumed metformin once taking good POs and renal function at
baseline.
-- SSI to cover in house
.
OSA: The patient did not use BIPAP at home for insurance reasons
and refused to wear it here. Gave O2 for comfort. She had no
desats while sleeping.
.
GERD, H. PYLORI:
--PPI [**Hospital1 **], added flagyl 500 TID x 14 days with last dose [**2191-3-25**]
and continued ampicillin/ciprofloxacin with group B strep as
well for total of 10 days.
.
ANEMIA, MICROCYTIC:
-- Hct at baseline of 29. Continued to monitor. Had erosions in
antrum with H. Pylori - likely source. Stable throughout
hospital stay.
.
ANXIETY/DEPRESSION:
--continued lexapro. No indication for acute inpatient
psychiatric evaluation as patient denied SI/HI.
.
RESTLESS LEG:
--continued Ropinirole
.
Patient discharged to rehab for continued physical therapy.
Medications on Admission:
1. Synthroid 237 mcg
2. Amantidine 100mg [**Hospital1 **]
3. Atenolol 50mg daily
4. Triamterene-Hydrochlorothiazide 37.5-25 mg Two caps daily
5. Metformin 500mg [**Hospital1 **]
6. Lorazepam 1 mg q8h prn
7. Escitalopram 10 mg daily
8. Carbidopa-Levodopa 10-100 mg four times daily
9. Olmesartan 40 mg daily
10. Ropinirole 4 mg tid
11. Naproxen 500 mg q 12 hr prn
12. Pantoprazole 40 mg Q12H
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H
Discharge Medications:
1. Carbidopa-Levodopa 10-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
2. Amantadine 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Ropinirole 1 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days: Last dose [**2191-3-25**].
Disp:*24 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Colesevelam 625 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days: Last dose [**2191-3-25**].
Disp:*16 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough/congestion.
13. Ampicillin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 7 days: Last dose [**2191-3-24**].
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare - [**Hospital **] Rehabilitation Center
Discharge Diagnosis:
- Diarrhea
- Bacteremia/Sepsis
- diabetes mellitus
- hypertension
- anxiety
Discharge Condition:
Fair
Discharge Instructions:
You were evaluated in the hospital for your diarrhea and sepsis.
You were treated with IV antibiotics. You should continue
taking your medications as prescribed.
Your Metoprolol dose was changed to 75 mg twice a day. Please
continue this new dosage as prescribed. No other medication
changes were made to your normal daily regimen of medicines.
.
See your own doctor right away or go to the ER if any problems
develop, including the following:
* Fever > 101
* Severe Abdominal Pain
* Severe Diarrhea
* Severe Nausea and Vomiting
* Your chest pain or chest discomfort lasts longer than 5
minutes.
* Your chest pain or chest discomfort gets worse in any
way.
* You have angina and your chest pain or chest discomfort
is worse, lasts longer than usual or comes on with less
activity than usual.
* You have angina and your chest pain or chest discomfort
is not relieved by your usual medicines.
* You develop any shortness of breath, sweats, dizziness,
throwing up or nausea with your chest pain or chest
discomfort.
* Your chest pain or chest discomfort moves into your
arm, neck, back, jaw or stomach.
* Anything else that worries you.
Even if you feel better and have no further chest pain or chest
discomfort, follow-up with your own doctor in one week.
The Emergency Department is open 24 hours a day for any
problems.
Followup Instructions:
You should follow-up with your primary care doctor in 24-48
hours. You should call [**Telephone/Fax (1) 20792**] and schedule an
appointment.
.
You should keep the following appointments as previously
scheduled:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21189**], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2191-4-5**] 9:00
.
You should have the following tests as previously recommended:
Test for consideration post-discharge: anti-Gliadin Antibody,
IgA
Test for consideration post-discharge: anti-Tissue
Transglutaminase Antibody, IgA
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5849, 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2098
} | Medical Text: Admission Date: [**2153-7-12**] Discharge Date: [**2153-7-21**]
Date of Birth: [**2083-4-9**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Vicodin
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Partial Gastrectomy + Cholecystectomy + Abdominoplastia (7/21/5)
History of Present Illness:
Patient has abdominal pain, study at [**Hospital1 2025**] with Ultrasound and CT
scan, that showed an exophitic gastric mass
Past Medical History:
Morbid Obese, HTN, Hyperchol, COPD, Cholelithiasis, DM II,
Ventral Hernia
Family History:
Not pertinent to this admission
Physical Exam:
Obese patient, alert, oriented. RRR, CTA B, Abdomen soft, right
upper quadrant pain, non distended, ventral hernia. Motor full,
no edema
Pertinent Results:
[**2153-7-12**] 09:05PM HCT-24.3*
[**2153-7-12**] 02:40PM GLUCOSE-182* POTASSIUM-4.2
[**2153-7-12**] 02:40PM PLT COUNT-272
[**2153-7-12**] 01:29PM TYPE-ART PO2-162* PCO2-42 PH-7.37 TOTAL
CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2153-7-12**] 09:02AM GLUCOSE-160* NA+-136 K+-3.8
PROCEDURE PERFORMED:
1. Exploratory laparotomy with lysis of adhesions.
2. Partial gastrectomy.
3. Cholecystectomy.
PROCEDURES: Panniculectomy, repair ventral hernia.
Brief Hospital Course:
Patient was admited to the regular hospital floor s/p open
cholycystectomy, panniculectomy and gastrectomy. On post day one
the patient was following a regular post operative coarse with a
PCA for pain, foley catheter to monitor urine output and an NGT
to decompress the resection from above. On the night of
postoperative day one to day two the patient experienced low
urine output and was bolused nearly four liters of fluid. She
was monitored with serial hematocrit checks which remained
stable. The patient encountered respiratory compromise from
acute renal failure was transferred to the ICU where her urine
output, CVP and general health were closely monitored. The
patient stayed in the ICU for four days until her creatinine
trended down from 2.2 to 1.4 and she was reliably making urine.
The patient's oxygen requirement was also decreased to 2L nasal
cannula prior to transfer to the floor on post op day six. While
on the regular hospital floor the patient tolerated a regular
diet, was able to urinate on her own, and maintained excellent
pain control. Her abdominal incision appears clean, without
evidence of infection or cellulitis. She will be discharged with
a JP drain, the drain is to remain inplace and its output should
be monitored and recorded. The patient is also taking lasix,
this is not one of her prior home medications, therefore this
med ought to be discontinued in three to fours days from
discharge.
Medications on Admission:
Atenolol, Avandia, Diovan, Lipitor
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
4. Dolasetron 100 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for nausea.
5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2
hours) as needed for 5 days.
10. Rosiglitazone Maleate 8 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection ONCE (once) for 1 doses.
12. Furosemide 20 mg IV DAILY
13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
CVL - flush each lumen and inspect site every shift
14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
LIFECARE CENTER OF [**Location (un) **]
Discharge Diagnosis:
Gastric Gastrointestinal Stromal Tumor (GIST) + cholelithiasis +
ventral hernia
Discharge Condition:
Good
Discharge Instructions:
-Call to ([**Telephone/Fax (1) 5323**] for an appointment with Dr [**Last Name (STitle) 519**]. Keep a
record of drains output
-Resume home meds
-Follow up C. Dif stool study
Followup Instructions:
Upon dishcharge please call to ([**Telephone/Fax (1) 5323**] for an appointment
with Dr [**Last Name (STitle) 519**]. Pleasd monitor and record JP drainage output.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 496, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2099
} | Medical Text: Admission Date: [**2117-9-2**] Discharge Date: [**2117-9-4**]
Date of Birth: Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old
gentleman with a past medical history significant for
hypertension who was admitted to [**Hospital1 190**] for cardiac catheterization.
The patient was in his usual state of health until admission
when he noted a coldness and numbness and urinary symptoms.
No fevers or chills. His symptoms persisted. The patient
then presented to his primary care physician's office three
days prior to admission complaining of a cough and mild
shortness of breath. He was found to be in atrial
fibrillation with a heart rate of 150. He was given a
prescription for a beta blocker. He was started on Lopressor
50 mg by mouth twice per day. The patient took three doses
of this, but he continued to have symptoms. He then began to
experience a significant cough. The patient then presented
to [**Hospital3 15174**].
Upon admission to the Emergency Department, the patient was
noted to be in a near complex tachycardia with a rate in the
140s to 150s; thought to be atrial flutter versus atrial
tachycardia. The patient received adenosine without any
response. He had also received a pulmonary embolism protocol
computed tomography which was negative. He had an
echocardiogram which revealed an ejection fraction of 20% and
severe mitral regurgitation. He continued to be symptomatic.
He also received Lopressor, nitroglycerin paste, and Flovent,
Lasix, digoxin, amiodarone, and Cardizem. He also received
four shocks. He was then transferred to [**Hospital1 346**] for a cardiac catheterization.
He cardiac catheterization revealed single-vessel coronary
artery disease with 80% stenosis of his proximal left
anterior descending artery. The patient received a cypher
stent to his proximal left anterior descending artery.
Cardiac catheterization revealed systolic and diastolic
ventricular dysfunction. The patient was then admitted to
the Coronary Care Unit for further management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. No known coronary artery disease.
MEDICATIONS ON ADMISSION: Lopressor 50 mg by mouth twice per
day (times two days).
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is retired. No alcohol use. He
quit tobacco seven years prior.
FAMILY HISTORY: No family history of coronary artery
disease.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient's temperature was 97.7
degrees Fahrenheit, his blood pressure was 149/63, his heart
rate was 127, his respiratory rate was 19, and his oxygen
saturation was 96% on 2 liters oxygen via nasal cannula. In
general, the patient was pleasant and conversant. The
patient was in no acute distress. Head, eyes, ears, nose,
and throat examination revealed the pupils were equal, round,
and reactive to light and accommodation. The extraocular
movements were intact. The oropharynx was clear. The
patient had poor dentition. Neck examination revealed the
neck was supple and soft. Jugular venous pulsation to the
ear. Cardiovascular examination revealed an irregular rate
and rhythm. A 1/6 systolic ejection murmur heard at the
apex. The abdominal examination revealed positive bowel
sounds. The abdomen was soft and obese. The liver edge was
palpated two inches below the costal margin. The lungs were
clear to auscultation bilaterally. Extremity examination
revealed the extremities were warm and dry. The dorsalis
pedis and posterior tibialis pulses were 2+. There was 1+
lower extremity edema. Neurologic examination revealed no
focal deficits.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CARDIOVASCULAR ISSUES: (a) Coronary artery disease:
The patient was transferred to the [**Hospital1 190**] for cardiac catheterization.
There was concern that his recent atrial fibrillation and
severe congestive heart failure could be ischemic in origin.
However, his cardiac catheterization showed only 1-vessel
disease with an 80% stenosis of his left anterior descending
artery. This lesion was stented; however, this was thought
not to be contributing to his current symptoms. The patient
had no active ischemic symptoms or chest pain during his
hospitalization. Following the cypher stent to his left
anterior descending artery, the patient was stable and had no
complications with stenting.
(b) Pump: The patient was admitted with no prior history of
coronary artery disease. However, an echocardiogram done at
an outside hospital revealed severe systolic and diastolic
dysfunction with an ejection fraction of 20%. The patient
was thought to have a new onset dilated cardiomyopathy likely
following a viral myocarditis subsequent to his recent viral
upper respiratory tract infection.
The patient was started on Coumadin for anticoagulation given
his severe ventricular dysfunction. The patient was also
started on a beta blocker and an ACE inhibitor. The patient
was admitted in significant heart failure. He was placed on
a Natrecor drip and successfully diuresed. He was then
converted to a daily dose of Lasix. He was weaned off
oxygen, and his respiratory status remained stable on room
air.
(c) Rhythm: The patient was admitted with the new onset of
atrial fibrillation/atrial flutter following his new onset
dilated cardiomyopathy and myocarditis.
The patient underwent an atrial flutter ablation. He was
then started on amiodarone which was then slowly titrated up.
The patient's amiodarone dose was to continue to be titrated
up following his discharge. The patient was also to follow
up with the Device Clinic in the morning to obtain [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
Hearts monitor. The patient was also started on Coumadin and
maintained on aspirin and Plavix.
2. TRANSAMINITIS ISSUES: The patient was admitted with
mildly elevated liver function tests. These were trending
down and normalized during his hospitalization. These were
thought to be related to his acute viral syndrome and to
concomitant congestive heart failure.
3. RENAL ISSUES: The patient was admitted with a slightly
elevated creatinine which was thought to be acute renal
failure due to his dye load following the cardiac
catheterization. The patient had also received a computed
tomography contrast at the outside hospital. The patient was
well hydrated and concomitantly diuresed, and his creatinine
quickly normalized.
4. PULMONARY ISSUES: A computed tomography at the outside
hospital showed a right upper lobe nodule. The patient will
need outpatient followup of this nodule. The patient did not
have any acute pulmonary issues during this hospitalization.
The patient was briefly on oxygen in the setting of
congestive heart failure, but he was quickly weaned to room
air which he tolerated well.
5. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was
initially nothing by mouth for procedures. He was then
placed on a cardiac diet which he tolerated well. His
electrolytes were followed, and he had no significant
abnormalities.
DISCHARGE DIAGNOSES:
1. Dilated cardiomyopathy.
2. Viral myocarditis.
3. Atrial fibrillation/atrial flutter.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Captopril 6.25 mg by mouth three times per day.
2. Coumadin 5 mg by mouth at hour of sleep.
3. Metoprolol 50 mg by mouth three times per day.
4. Plavix 75 mg by mouth once per day.
5. Aspirin 325 mg by mouth once per day.
6. Amiodarone 400 mg by mouth three times per day times one
day; then 600 mg by mouth once per day times one week; then
400 mg by mouth once per day times two weeks; and then 200 mg
by mouth once per day indefinitely.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up in the Device
Clinic on the day following discharge for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
monitor and INR checks.
2. The patient was also instructed to follow up with his
primary care physician (Dr. [**Last Name (STitle) **] two days following his
discharge for further assessment of his INR and Coumadin
dosing.
3. The patient was to be followed by his primary care
physician in the [**Hospital 197**] Clinic as needed for Coumadin
dosing.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**]
Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36
D: [**2117-10-18**] 15:46
T: [**2117-10-19**] 07:52
JOB#: [**Job Number 50054**]
ICD9 Codes: 4254, 4280, 4240 |
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