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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2100
} | Medical Text: Admission Date: [**2123-6-6**] Discharge Date: [**2123-6-18**]
Date of Birth: [**2039-8-14**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Heparin Agents / argatroban / Lepirudin
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
R arm numbness/weakness
Major Surgical or Invasive Procedure:
upper endoscopy
Colonoscopy with polyp removal
History of Present Illness:
The pt is a 83 y/o RHF with history of multiple TIA's and
bilateral CEA's mos most recent 2 weeks ago for a left CEA after
"TIA's". She comes in today as an OSH transfer for two episodes
concerning for TIA. She states that yesterday she had a sudden
onset inability to get her words out. She states that this
lasted
hours, was not all words, and had no slurred speech, no
inability
to understand speech and she knew which words she wanted to say.
This resolved and then today had another event where she was
suddenly unable to use her right hand. She states she was trying
to use a fork for dinner and was unable to do so. This lasted
about 3 hours and then resolved. During this time those around
her stated that she had a left sided droop and possibly slurred
speech. At this point she feels back to baseline. She is unable
to give me any useful information regarding her previous
"TIA's".
On ROS she denies current HA, language difficulty, vertigo, CP,
SOB, fever or chills, weakness or chances to sensation. She does
however support pain in her low back and hips with walking and
uses support for ambulation.
Past Medical History:
1. HTN
2. asthma
3. emphysema
4. Hx of GI bleed
5. GERD
6. right subclavian stenosis
7. hypothyroid
8. anemia
Social History:
Former smoker. Drinks wine daily
Family History:
N/C
Physical Exam:
Physical Exam on Admission:
Vitals: T: 98 P:56 R: 16 BP:178/78 SaO2:99%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: left side post surgical scar clean and intact. No nuchal
rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G appreciated
Abdomen: soft.
Extremities: 1+ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Unable to provide details
to history. Able to name DOW backward without difficulty.
Language is fluent with intact repetition and comprehension.
There were no paraphasic errors. Pt. was able to name both high
and low frequency objects. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**12-14**] at 5 minutes [**1-14**] with prompts.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: right side slight facial droop.
VIII: Hearing not intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Right side pronator drift
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: decreased vibratory sensation at the feet. No
extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was extensor on the left mute on the right.
-Coordination: No rebounding. No dysmetria on FNF bilaterally.
-Gait: deferred.
Pertinent Results:
Labs on admission:
[**2123-6-6**] 08:21PM PT-12.9 PTT-23.9 INR(PT)-1.1
[**2123-6-6**] 08:21PM PLT COUNT-174#
[**2123-6-6**] 08:21PM NEUTS-67.1 LYMPHS-21.2 MONOS-7.6 EOS-3.6
BASOS-0.5
[**2123-6-6**] 08:21PM WBC-5.2 RBC-2.86* HGB-10.0* HCT-29.3*
MCV-103* MCH-35.1* MCHC-34.2 RDW-13.0
[**2123-6-6**] 08:21PM estGFR-Using this
[**2123-6-6**] 08:21PM GLUCOSE-103* UREA N-30* CREAT-1.6* SODIUM-139
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
[**2123-6-6**] 08:30PM URINE MUCOUS-RARE
[**2123-6-6**] 08:30PM URINE HYALINE-3*
[**2123-6-6**] 08:30PM URINE RBC-1 WBC-46* BACTERIA-NONE YEAST-NONE
EPI-3 TRANS EPI-1
[**2123-6-6**] 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
[**2123-6-6**] 08:30PM URINE GR HOLD-HOLD
[**2123-6-6**] 08:30PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2123-6-6**] 08:30PM URINE HOURS-RANDOM
Imaging:
CT-A [**6-6**]
IMPRESSION:
1. Small low attenuation in the left caudate head consistent
with an infarct
of indeterminate age, likely chronic.
2. Small area of low density in the left subinsular white
matter, infarct of
indeterminate age.
3. No evidence of intracranial hemorrhage.
4. Status post left carotid endarterectomy with soft tissue
changes and
without evidence of a flow-limiting stenosis in the major neck
vessels.
5. Thrombus in the right proximal subclavian artery.
6. Calcifications of the vertebral artery origin, limit
evaluation for
stenosis.
MRI-HEAD [**6-7**]
IMPRESSION:
Two small foci of bright diffusion signal abnormalities in the
left frontal cortex and left centrum semiovale associated with
FLAIR signal changes likely to suggest recent infarcts without
convincing ADC abnormality. Old lacunar infarct in the left head
of caudate nucleus.
.
.
EEG [**6-9**]
IMPRESSION: This is an abnormal video EEG despite the normal
posterior
dominant rhythm during the waking state due to the presence of
bursts
of generalized delta frequency slowing which represents deep
midline
and subcortical dysfunction. There were no epileptiform
discharges or
electrographic seizures seen
.
.
ECHO [**6-9**]
IMPRESSION: Suboptimal image quality. No obvious cardiac source
of embolism in a technically limited study. Normal global left
ventricular systolic function. Technically suboptimal to exclude
focal wall motion abnormality. Right ventricle not
well-visualized. Borderline pulmonary hypertension.
.
.
MR HEAD W/O CONTRAST [**6-9**]
IMPRESSION: Acute watershed infarction involving the left
cerebral
hemisphere, new since the prior MRI of the brain dated [**2123-6-7**], also
seen on the prior CT perfusion from [**2123-6-9**]. No
hemorrhagic
transformation is seen.
.
CT- HEAD [**6-11**]
IMPRESSION: Evolving left hemispheric watershed infarcts, with
no evidence of hemorrhagic conversion. No new acute process is
seen.
.
KUB
IMPRESSION:
1. No obstruction or free air.
2. Bibasilar atelectasis and pleural effusions.
3. Gallstones.
.
.
Labs at discharge:
Brief Hospital Course:
NEURO: STROKE
83 yo RHW with h/o L CEA [**2123-5-25**] presented with transient
episodes of R hand and arm numbness and speech difficulties.
She was initially transferred to the [**Month/Day/Year 1106**] service from
[**Hospital3 17921**] Center in NH. She had a transient episode of
right hand numbness that spread over the right arm and face over
seconds to minutes, followed by difficulty using the right hand,
disorientation and difficulties speaking. This occured on [**6-5**]
and again on [**6-6**].
Neurology was consulted on [**6-7**]. Neuro exam was significant for
right pronator drift and slowness with finger tapping. CTA
showed bilateral carotids had no significant stenosis. The
patient had been started on heparin drip empirically by [**Month/Year (2) 1106**]
service. At that concern, neuro team was concerned for hyper- or
reperfusion syndrome s/p L CEA. It was therefore recommended to
keep her blood pressure well controlled (SBP<160) and stop the
heparin drip given risk of edema and hemorrhage. EEG was
performed to rule out seizure.
On [**6-8**] overnight, the patient's neuro exam worsened. On evening
rounds, she had some slowness in right hand fast finger
movements. At 2am, her right arm was flaccid and could not lift
it antigravity. Neurology nightfloat saw the patient, however at
that point it was still unclear whether this episode was due to
developing stroke or seizure secondary to hyperperfusion
syndrome. The patient's blood pressure was being kept
controlled between sBP 100-120 for concern of hyperperfusion
syndrome. At 4am, patient was R hemiplegic and aphasic. CT with
perfusion done at that time showed ischemia in the L anterior
and posterior watershed borderzones. CTA showed small plaque in
the proximal L common carotid artery. There was no hemorrhage.
The patient was transferred to the Neuro ICU. She was started on
heparin drip again for concern of L CCA plaque. She was
immediately bolused with 2L IVF and then started on
neosynephrine to keep MAP >90-100. She improved with these
interventions. Her language improved significantly, her right
leg was antigravity, though her right arm remained densely
plegic. MRI showed watershed infarct in the L MCA-PCA borderzone
and internal borderzone superiorly. Her neuro exam continued to
improve over the next 24 hours. Both expressive and receptive
language was intact, RLE strength was nearly full, and she was
able to shrug her RUE proximally.
She was transferred to the neuro step down unit on [**6-10**]. She was
continued on heparin drip, with plan to transition to coumadin,
but this plan was aborted due to falling hematocrit on [**6-11**].
The pathophysiology of the stroke remains unclear. The most
likely cause is a mechanical event at the L carotid
post-operatively, that transiently blocked the vessel and made
the brain suspectible to watershed stroke. Repeat CT of the Head
did not show hemorrhagic conversion and the patient was started
on heparin, however transient thrombocytopenia and dropping HCT
(likely from GI bleed), led to discontinuation of
anticoagulation.
The patient also had a RUE ultrasound that did not show any DVT.
Over the next days, her clinical motor exam improved daily and
her strength in her R upper extremity increased significantly.
She was seen by PT who recommended inpatient rehabilitation.
HEME:
The patient's HCT at admission was 29. It declined gradually to
25 and then to 23.5 on [**6-10**]. She received 1 U PRBCs on [**6-10**]. HCT
repeated after transfusion was unchanged, and HCT continued to
drop over the next 12 hours. CT abdomen and pelvisd was
negative. Medicine and GI were consulted. Hemolysis labs were
negative. Given the thrombocytopenia, there was a concern for
HIT. Heparin was transitioned to Argotroban. However, she
developed a rash and this medication was stopped. She was also
briefly started on lepirudin, but another rash led to
discontinuing these medications as well. Repeat falling HCT and
concern for GI bleed led to discontinuation of all
anticoagulation other than aspirin. HIT antibodies were
positive, however the optical density of this test was low and
suggestive of a false positive result. Currently, we do not
feel this patinet has HIT. At the time of discharge, the
SEROTONIN RELEASE ASSAY RESULTS ARE PENDING.
GI:
Rectal guiaic was positive without [**Month/Year (2) **] blood, however NG
lavage was negative. Patient was started on Protonix drip
empirically which was transitioned to IV push [**Hospital1 **].
She then underwent upper and lower endoscopy which revealed "A
few small angioectasias with stigmata of recent bleeding seen in
the second part of the duodenum. A gold probe was applied for
hemostasis successfully." "A single sessile 1.8 cm polyp of
benign appearance was found in the transverse colon and this was
resected. There was melena found in the ascending colon during
this colonoscopy.
After colonoscopy, she remained on aspirin (despite
recommendations from GI post-procedure), although she was not
started on other anticoagulants. On the night after the
procedure, she developed abdominal pain (worse in the RLQ) that
was concerning for possible post-procedure complications. KUB
did not show free air and the pain decreased over the next 2
days without interventions. Her diet was advanced without
complication prior to her discharge.
Her HCT remained stable in the low-mid 20s over last 2 days of
this admission. GI was reconsulted but did not recommend other
acute interventions at this time. She will be followed by GI
services as an outpatient in [**2-12**] weeks at which time further
investigation (repeat colonoscopy or capsule endoscopy) might be
undertaken.
CKD: Patient had baseline Cr 1.4-1.6 which was stable.
Medications on Admission:
ASA 325
Plavix
Levothyroixine 25mcg daily
Rosuvastatin 20mg Daily
Doxazosin 8mg daily
Synthroid 25mcg
clonidine 0.1 PO TID
Colace
Percocet 5/125 1PO q6
Lasix 40mg Daily
Potassium
B12
Senna
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-13**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes/
blurriness.
7. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
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. furosemide 40 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 twice a day.
12. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 17921**] Center - [**Location (un) 5450**], NH
Discharge Diagnosis:
Primary
L hemispheric stroke
GI bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
NEUROLOGIC EXAM: Residual right arm weakness, with distal
weakness predominant ([**12-16**] FE, [**2-13**] WE)
Discharge Instructions:
You were admitted to the [**Hospital3 **] Medical center for numbness
and weakness in your arm. Upon further investigation and imaging
studies it became clear that you had suffered a stroke. This was
likely a complication from a previous surgery -endarterectomy-
on your left carotid. Your weakness improved during your stay
and we believe you will benefit from rehabilitation.
Your hospitalization was complicated by an intestinal bleed.
Because of this, you underwent an endoscopy and a colonoscopy to
investigate the source of bleeding. You had a polyp removed from
you colon and small bleeding vessel was intervened on in your
stomach. After this you had some abdominal pain that appeared to
resolve without intervention. However, given your ongoing
bleeding, you were given blood products. We also held blood
thinning agents other than aspirin given your ongoing bleeding.
We believe your bleeding then slowed down and you were restarted
on blood thining agents.
During your hospitalization, some of your medications changed,
you should note the following:
START:
- Pantoprazole PO BID
- Artificial tears
STOP:
-Plavix
-Clonidine
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2123-7-14**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD (Neurologist)
Phone:[**Telephone/Fax (1) 2574**]
Date/Time: [**2123-8-6**] at 2:00 pm
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2123-7-14**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
.
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD (Neurologist)
Phone:[**Telephone/Fax (1) 2574**]
Date/Time: [**2123-8-6**] at 2:00 pm
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 2875, 4280, 5859, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2101
} | Medical Text: Admission Date: [**2199-10-26**] Discharge Date: [**11-21**] /[**2198**]
Date of Birth: [**2199-10-26**] Sex: M
DISCHARGE DIAGNOSIS: Premature twin 2, 34 2/7 weeks gestation.
HISTORY OF PRESENT ILLNESS: [**Location (un) 2412**] is the former [**2121**] gram
twin number two born at 34 and 2/7 weeks gestation to a 25
year-old gravida 3 para 1 now 3 living 3, O positive female.
Pregnancy was a diamniotic dichorionic spontaneous twins,
premature rupture of membranes 24 hours prior to delivery
transverse and converted to breech. Infants were delivered
vaginally.
Twin number two emerged with Apgars of 1 and 8 and was given
bag and mask ventilation in the Delivery Room. He was
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **].
31.5 cm, length 47 cm, all appropriate for gestational age.
PROBLEMS DURING HOSPITAL STAY: 1. Respiratory: Infant
remained in room air throughout his hospital course. He did
have apnea and bradycardia of prematurity. However,
insufficient to start medication. He remained in hospital
until he was at least five days free of any episodes.
2. Cardiac: Initially the infant required a saline bolus
for hypotension. Following that he remained normotensive
throughout the remainder of his hospital stay. The patient
did have a soft murmur heard along the left sternal
border, and under both clavicles,loudest towards the apex
and can be heard over both scapula. It is grade 1, no bounding
pulses and thought to be consistent with peripheral pulmonic
stenosis.
If the murmur is still heard two months post delivery he will
be followed up at [**Hospital1 **] Cardiology.
3. Infectious disease: Because of the prolonged ruptured
membranes and prematurity he had a CBC, which was benign and
a blood culture at 48 hours Ampicillin and Gentamycin were
discontinued with negative culture results.
Monilial rash in diaper area, treated with Nystatin.
4. Feeding and nutrition: The infant initially was slow to
start po feeding. At the time of discharge he is being
bottle and breast fed with no more then two breast feedings
suggested a day. He is currently on breast milk or Enfamil
20 calories per ounce.His discharge weight is 2545 grams
5. Immunizations: Mother has requested that hepatitis B nor
Synagis be given. This was discussed with her and
pediatrician is aware. Mom has not immunized her other two
children.
6. Hematologic: The infant had a peak bilirubin level of 13.3
and was under phototherapy for several days.
His admission hematocrit was 50.1. He is not on FerInSol as his
mother has not been bringing in much breastmilk and he
is on for formula with iron.
7. Hearing screen passed on [**11-21**].
DISCHARGE MEDICATIONS: Poly-Vi-[**Male First Name (un) **] 1 cc daily, Fer-In-[**Male First Name (un) **]
0.2 cc daily were D'C'd as baby mostly on formula with iron.
.
FOLLOW UP: At [**Hospital1 **] Coppley Center Dr. [**Last Name (STitle) **] and
mother will see physician within five days of discharge.
Will be seen on [**11-26**] with sibling.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 38370**]
Dictated By:[**Last Name (NamePattern1) 38304**]
MEDQUIST36
D: [**2199-11-14**] 09:05
T: [**2199-11-14**] 09:10
JOB#: [**Job Number 42748**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2102
} | Medical Text: Admission Date: [**2101-3-4**] Discharge Date: [**2101-3-10**]
Date of Birth: [**2023-10-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
CABG X 4 (LIMA >LAD, SVG>Diag, SVG>OM, SVG>PDA)([**2101-3-4**])
History of Present Illness:
77 yo M with DOE x 4-5 months, also occasional CP with exertion.
+ Stress test, cath with 3VD. Referred for surgery.
Past Medical History:
Hypertension
"Borderline" Hypercholesterolemia
Renal cell carcinoma s/p left nephrectomy in [**2098**]
Right knee replacement
Bilateral rotator cuff injury
Partial colectomy for mass that was found to be benign
Depression
Social History:
The patient lives with his girlfriend of 30 years in an
apartment. He also has family in the area. He reports that he
has 80 pack year smoking history, but quit 24 years ago. He does
not drink alcohol.
Family History:
Father fatal MI age 55; mother died age 87; brother died age 82;
another brother still alive age 85.
Physical Exam:
HR 46 RR 14 BP 121/59
NAD
Lungs CTAB
Heart RRR, No murmur
Abdomen soft, NT. Well healed [**Doctor First Name **].
Extrem warm, no edema, spider veins at ankle.
Pertinent Results:
[**2101-3-10**] 05:55AM BLOOD WBC-8.2 RBC-3.31* Hgb-10.0* Hct-29.4*
MCV-89 MCH-30.2 MCHC-34.0 RDW-15.1 Plt Ct-346#
[**2101-3-10**] 05:55AM BLOOD Plt Ct-346#
[**2101-3-10**] 05:55AM BLOOD Glucose-103 UreaN-35* Creat-1.3* Na-142
K-5.3* Cl-104 HCO3-31 AnGap-12
[**2101-3-8**] 11:06AM BLOOD Glucose-134* UreaN-33* Creat-1.2 Na-139
K-4.3 Cl-98 HCO3-33* AnGap-12
[**2101-3-8**] 03:46AM BLOOD Glucose-102 UreaN-29* Creat-1.3* Na-137
K-4.3 Cl-98 HCO3-30 AnGap-13
[**2101-3-8**] 01:00AM BLOOD Glucose-117* UreaN-30* Creat-1.4* Na-136
K-5.3* Cl-99 HCO3-30 AnGap-12
CHEST (PORTABLE AP) [**2101-3-8**] 7:30 AM
CHEST (PORTABLE AP)
Reason: evaluate ? effusion
[**Hospital 93**] MEDICAL CONDITION:
77 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate ? effusion
HISTORY: Status post CABG.
FINDINGS: In comparison with the study of [**3-7**], there is little
overall change. Again, there is evidence of some bilateral
pleural effusions with basilar atelectatic changes in a patient
with intact sternal sutures.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 38863**] (Complete)
Done [**2101-3-4**] at 8:58:44 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2023-10-26**]
Age (years): 77 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Coronary artery disease. Left ventricular function.
Preoperative assessment.
ICD-9 Codes: 440.0
Test Information
Date/Time: [**2101-3-4**] at 08:58 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: *4.0 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV
systolic function.
AORTA: Normal aortic diameter at the sinus level. Complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
thickening of mitral valve chordae. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
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.
Conclusions
PREBYPASS
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%). The
right ventricular cavity is moderately dilated with normal free
wall contractility. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
POSTBYPASS
Preserved biventricular systolic function. The study is
unchanged from the prebypass period.
Brief Hospital Course:
On [**2-/2022**] he underwent a CABG x 4. He was transferred to the ICU
in stable condition on neo and propofol. He was extubated later
that day. On [**3-7**] he was found on the floor after getting himself
out of the chair, atrial wires were dc'd in the process,
otherwise no signs of injury. He had some atrial fibrillation
for which he was started on amiodarone and converted to NSR. He
was transferred to the floor with a bedside sitter. He was
transfused one unit. He otherwise did well postoperatively and
was ready for discharge home on POD #6.
Medications on Admission:
Plavix 75', ASA 325', Toprol XL 50'(at home), Paxil 20',
Lopressor 50(in hospital), Trazodone.
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 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Paxil 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 1 weeks: then reassess need for diuresis.
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Klonopin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
CAD now s/p CABG
HTN, depression, chronic shoulder pain, s/p L.nephrectomy (RCC)
in [**2098**], s/p colon resection, s/p R TKR
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.
No lifting more than 10 pounds for 10 weeks from surgery.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 7047**] 2 weeks
Already scheduled appointments:
Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2101-8-12**]
11:15
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2101-7-6**] 11:30
Completed by:[**2101-3-10**]
ICD9 Codes: 9971, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2103
} | Medical Text: Admission Date: [**2106-6-22**] Discharge Date: [**2106-6-25**]
Date of Birth: [**2054-3-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Chief Complaint: shortness of breath
Reason for MICU transfer: tachypnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 year old man with morbid obesity, homelessness who presents
with shortness of breath that began 1-2 months prior to
admission that progressively worsened over the past couple of
days. He reports a productive cough of thick phleghm with blood
tinged sputum that started yesterday (only minimal amount of
blood). He has a fever to 102 and anorexia. Denies TB exposure.
He has chronic knee pain secondary to arthritis per his report.
He has a distant history of smoking. He was originally seen at
OSH ([**Hospital1 **]) due to a positive d-dimer. He could not
fit into the CT scanner to evaluate for PE. CXR at OSH was
notable for pneumonia and thus he was started on azithromycin
and ceftriaxone.
In the ED, initial VS were: 98.7 98 136/78 24 96%. He weighs
536lb. Labs notable for WBC 28 with 5% bands, lactate 2.9, chem
7 within normal limits. No imaging was completed. Received
oxycodone-acetaminopehn 10mg/650mg. RR ranged 20-40s on 100% on
10L face mask. Received 1L NS. 1 PIV 18G. Blood cultures sent.
Most recent vitals 99F 99 28 145/76 100% 10L facemask. CXR
showed RLL airspace opacity, atelectasis, aspiration. He was
admitted with respiratory and TB precautions.
On arrival to the MICU, patient complains of some cough and
dyspnea. Otherwise no complaints.
Past Medical History:
Morbid obesity
Type 2 DM
Hypertension
High cholesterol
Sleep apnea on CPAP (does not clean his CPAP mask)
Chronic lower leg pain
Social History:
Homelessness - lives in truck, spends most of the day sitting in
his truck. no tobacco use. Works at a group home as night sift
supervisor.
Family History:
Obesity, CAD
Physical Exam:
Admission exam:
General: Obese, alert, oriented, no acute distress, on NRB
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, obese
CV: RRR, S1, S2, distant [**3-4**] body habitus
Lungs: Breathing comfortably, distant breath sounds
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: trace edema
Neuro: Alert, oriented, moving all extremities
Discharge Exam:
VS - Tm 98.1 BP 168/98
GENERAL - Obese man sitting up in chair in NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Thick, difficult to appreciate JVD due to habitus
LUNGS - Speaks in full sentences and is minimally labored on
room air. Decreased breath sounds throughout, likely due to
habitus.
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - Obese, soft/ND, nontender without rebound/guarding,
difficult to appreciate masses or organomegaly
EXTREMITIES - no apparent edema
SKIN - Chronic venous stasis changes BLE
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
full and symmetric throughout
Pertinent Results:
Admission labs:
[**2106-6-22**] 03:00AM BLOOD WBC-28.0* RBC-4.47* Hgb-12.4* Hct-40.6
MCV-91 MCH-27.6 MCHC-30.5* RDW-12.4 Plt Ct-276
[**2106-6-22**] 03:00AM BLOOD PT-13.5* INR(PT)-1.3*
[**2106-6-22**] 03:00AM BLOOD Glucose-200* UreaN-12 Creat-1.1 Na-138
K-4.3 Cl-98 HCO3-26 AnGap-18
[**2106-6-22**] 03:00AM BLOOD ALT-20 AST-25 CK(CPK)-333* AlkPhos-65
TotBili-1.5
[**2106-6-22**] 03:00AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-[**2001**]*
[**2106-6-22**] 10:30PM BLOOD Calcium-8.7 Phos-2.3* Mg-1.9
[**2106-6-23**] 09:40AM BLOOD D-Dim
DISCHARGE LABS:
[**2106-6-25**] 06:30AM BLOOD WBC-8.6 RBC-4.29* Hgb-12.0* Hct-38.7*
MCV-90 MCH-28.0 MCHC-31.1 RDW-12.4 Plt Ct-302
[**2106-6-25**] 06:30AM BLOOD PT-11.5 PTT-30.1 INR(PT)-1.1
[**2106-6-25**] 06:30AM BLOOD Glucose-197* UreaN-13 Creat-0.8 Na-140
K-4.4 Cl-97 HCO3-33* AnGap-14
[**2106-6-25**] 06:30AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.0
OTHER LABS:
[**2106-6-23**] 09:40AM BLOOD D-Dimer-533*
[**2106-6-23**] 09:30AM BLOOD HIV Ab-NEGATIVE
[**2106-6-22**] 03:00AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-[**2001**]*
[**2106-6-23**] 09:30AM BLOOD CK-MB-1 cTropnT-<0.01
URINE:
[**2106-6-22**] 10:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2106-6-22**] 10:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG
[**2106-6-22**] 11:02PM URINE Hours-RANDOM Na-69 K-20 Cl-66
[**2106-6-22**] 11:02PM URINE Osmolal-412
STUDIES:
[**2106-6-22**] Radiology CHEST (PORTABLE AP)
There are low lung volumes, and there is airspace opacity in the
right lower lobe which does not silhouette the heart border.
The cardiac silhouette is mildly enlarged. The mediastinal
contours are normal.
IMPRESSION: Right lower lobe airspace opacity, could represent
infection, atelectasis, or aspiration.
[**2106-6-23**] Cardiovascular ECHO
Suboptimal image quality - even with addition of myocardial
contrast. Moderately dilated left ventricle with normal global
ventricular function. Normal size and function of right
ventricle. Borderline
[**2106-6-22**] Radiology BILAT LOWER EXT VEINS
The exam is limited due to patient's large body habitus. There
is
normal compressibility, flow, and augmentation of the common
femoral,
superficial femoral, and popliteal veins bilaterally. Normal
color flow is
demonstrated in the bilateral peroneal and posterior tibial
veins.
[**2106-6-24**] Radiology CTA CHEST W&W/O C&RECON
1. No pulmonary embolism to the proximal lobar levels.
2. Multifocal pneumonia.
MICROBIOLOGY:
Blood Cx: 5/22x5 NGTD
Respiratory Viral Cx: [**6-22**] No growth
Urine [**6-22**]: Mixed bacterial flora, no legionella
Sputumx3: No AFB on concentrated smear, AFB cultures pending
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
52 year old man with morbid obesity and recent homelessness who
presents with shortness of breath found to have pneumonia with
bandemia and positive d-dimer. Patient was admitted to ICU given
oxygen requirement, patient was initially on NRB. Patient was
treated for community acquiremed pneumonia and was started on
heparin gtt for possible PE. Subsequent CTA ruled out PE and
heparin was discontinued. He was discharged to complete 5days of
azithromycin and 10 days of cefpodoxime.
# Pneumonia: Patient initially required NRB given hypoxia.
Pneumonia was felt to be most likely given productive cough and
bandemia as well as RLL infiltrate seen on CXR. Community
acquired pathogens most likely, with possible TB given bloody
sputum, persistent cough and homelessness. Patient was started
on ceftriaxone and azithromycin for CAP. Patient had elevated
d-dimer (530) and initially could not fit into CT scanner for
eval for PE. VQ scan was also felt to be difficult for patient.
Patient was borderline tachycardiac in the 90s - 100s when at
rest, but had bursts up to 150s when standing. He was
empirically started on heparin gtt to treat PE. Patient was also
kept in respiratory isolation until AFB x3 ruled out Tb.
Patient had ECHO done which was difficult to interpret secondary
to body habitus. Upon call out to the medicine floor, he was
saturating well on room air. CTA was obtained which did not show
PE and confirmed multifocal pneumonia. Heparin gtt was stopped
and patient's symptoms were significantly improved. He was
discharged to complete 5 days of azithromycin and 10 days of
cefpodoxime.
#HTN: Patient on lisinopril 20mg and HCTZ 12.5 at home. Meds
were initially held on admission to ICU. As he improved, he
became hypertensive and lisinopril and HCTZ were added back on
and uptitrated to 25mg HCTZ and 40mg lisinopril. He received
captopril as needed for SBP's>180.
CHRONIC PROBLEMS
# Type 2 DM: On metformin home. Patient kept on HISS while
in-house.
# Hyperlipidemia: Continued simvastatin 20 mg daily
# OSA: On CPAP, uses on regular basis. Continued CPAP while in
house.
TRANSITIONAL ISSUES:
- Recheck Chem7 1 week following discharge given increased
lisinopril and hydrochlorothiazide dose
Medications on Admission:
Lisinopril 20
HCTZ 12.5
Metformin 1000 mg [**Hospital1 **]
Ibuprofen 800 mg [**Hospital1 **]
Simvastatin 10 mg daily
Discharge Medications:
1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
3. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
4. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
8. CPAP nightly
Discharge Disposition:
Home
Discharge Diagnosis:
1. Community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital because you were having fevers
and a cough. We found you had a bad pneumonia and started you on
antibiotics. Because there was concern you may have had a blood
clot in your lungs, we also started you on heparin until a CT
scan showed that you did NOT have a blood clot in your lungs.
You began to feel better and you are now safe to go home. Please
note the following changes to your medications:
Start Azithromycin 250mg once daily through [**6-26**]
Start Cefpodoxime 200mg by mouth twice daily through [**7-1**]
Increase lisinopril to 40mg daily
Increase hydrochlorothiazide to 25mg daily
No other changes were made to your medications. Please note the
following appointments that have been scheduled for you. It has
been a pleasure taking care of you.
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED
When: THURSDAY [**2106-7-1**] at 8:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 103167**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
ICD9 Codes: 486, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2104
} | Medical Text: Admission Date: [**2178-9-15**] Discharge Date: [**2178-9-21**]
Date of Birth: [**2121-1-31**] Sex: F
Service: MEDICINE
Allergies:
Sulfisoxazole
Attending:[**First Name3 (LF) 1580**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57 F with Hep C cirrhosis, s/p liver transplant, recurrent
hepatic encephalopathy, admit with altered mental status. Her
husband found her to be confused early this morning and brought
her to the ED. Recently admitted from [**Date range (1) 90625**] at [**Hospital1 1774**] and
then again from about [**Date range (1) 84215**] at [**Hospital **] Hospital for hepatic
encephalopathy (also admitted on at least 2 other occasions in
[**Month (only) **]). Urine, blood, stool studies at [**Hospital1 1774**] admission
without evidence of infectious cause. No [**Doctor First Name 4397**] done. Per
summary, improved with just lactulose and rifaximin (thought
secondary to inadequate lactulose). Since most recent discharge,
husband reports she has been doing well, mental status much more
clear - conversant and appropriate, watched movie with him last
night. Husband gives all meds and reports that she has been med
compliant (including lactulose 60 ml Q4 hours except with break
at nighttime). Was at baseline when went to bed at 10pm; then
husband heard her wake up to go to BR at 1 am and was confused
with worsening gait (baseline some unsteadiness that husband
reports is multifactorial). No trauma, fever, abdominal pain,
cough, shortness of breath, urinary difficulties, headache.
.
Patient was in the process of setting up an appointment to see
Dr. [**Last Name (STitle) **] for purposes of transplant candidancy. Her
hepatologist is Dr. [**First Name8 (NamePattern2) 2174**] [**Last Name (NamePattern1) 1726**] at [**Hospital1 1774**] and she was
previously transplanted at [**Hospital1 1774**]; however, [**Hospital1 1774**] does not
perform second OLTs.
.
In the ED, initial VS were: 97.8, P78, 146/69, R19, 100% RA. She
was moaning and mumbling and minimally responsive but was
protecting her airway. Guaiac postive brown stool. Given
lactulose PR.
Past Medical History:
- Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and
autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in
past. Complicated by recurrent hepatic encephalopathy, SBP prior
to transplant per husband, GI bleeding (both BRBPR and melena,
last 3-4 months ago per husband, but per husband does not seem
that she has ever required blood transfusions etc).
- recurrent facial cellulitis of cheeks
- asthma
- DM
- HTN
- osteoporosis
- nephrolithiasis
- h/o C.diff
- zoster
Social History:
Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use.
Family History:
Mother with some type of liver disease and CHF.
Physical Exam:
Vitals: T95.6 (ax), 122/55, P72, R19, 100% RA
General: jaundiced, obtunded moaning, withdraws/moans to sternal
rub, minimally responsive to voice (moans).
HEENT: Pupils reactive, L sl larger than R (6->4 vs 5->3),
slight icterus. MM slightly dry. atraumatic.
NECK: supple, no adenopathy.
Chest: CTA anterolaterally, decreased at bases.
Heart: RRR, S1 S2, [**1-7**] SM at RUSB
Abdomen: +BS, soft, appears NT, not particularly distended, no
definite evidence of ascites. No masses. + OLT midline scar.
Extrem: trace to 1+ LE edema, warm.
Neuro: Obtunded, not following commands, responsive to pain as
above, moving all extremities spontaneously in bed.
.
Pertinent Results:
[**2178-9-15**] abd u/s
1. Heterogeneous liver without focal liver lesions.
2. No evidence of ascites, thus no site marked for paracentesis.
3. Patent portal vein, with low velocity and bidirectionality of
flow during respiratory cycle.
4. Increased flow in the hepatic arteries.
5. Reversal of flow in splenic vein suggestive of portal
hypertension and
shunt.
.
Head CT [**9-15**]
Normal
.
CT abd [**9-19**]
1. Focal nodule abutting the left lateral lobe of the liver
which may
represent a splenule, however, an exophytic hepatocellular
carcinoma cannot be
entirely excluded. A nuclear medicine liver-spleen scan with
SPECT CT is
recommended for differentiation of these two possibilities.
Otherwise, no
arterially enhancing lesions to suggest hepatocellular carcinoma
identified.
2. Probable 2 mm aneurysm of the proper hepatic artery just
proximal to its bifurction. Calcified stenosis of the origin of
the left hepatic artery.
3. Splenorenal shunt and splenic artery aneurysm.
4. Gastric and paraesophageal varices.
5. Splenomegaly.
6. Anterior wedging fracture deformities of the T11 and T12
vertebral bodies.
[**2178-9-15**] 04:59AM BLOOD WBC-5.0 RBC-3.64* Hgb-10.8* Hct-33.6*
MCV-92 MCH-29.5 MCHC-32.0 RDW-17.0* Plt Ct-82*
[**2178-9-21**] 05:40AM BLOOD WBC-4.4 RBC-2.86* Hgb-9.0* Hct-26.4*
MCV-93 MCH-31.5 MCHC-34.0 RDW-17.4* Plt Ct-66*
[**2178-9-15**] 04:59AM BLOOD Neuts-56.6 Lymphs-30.2 Monos-6.2 Eos-6.8*
Baso-0.3
[**2178-9-17**] 07:10PM BLOOD Neuts-68.1 Lymphs-22.4 Monos-6.4 Eos-3.0
Baso-0.1
[**2178-9-15**] 04:59AM BLOOD PT-25.9* PTT-46.7* INR(PT)-2.6*
[**2178-9-20**] 05:25AM BLOOD PT-24.9* PTT-49.6* INR(PT)-2.4*
[**2178-9-17**] 07:10PM BLOOD Fibrino-90*
[**2178-9-15**] 04:59AM BLOOD Glucose-154* UreaN-22* Creat-0.9 Na-140
K-4.3 Cl-108 HCO3-28 AnGap-8
[**2178-9-21**] 05:40AM BLOOD Glucose-155* UreaN-20 Creat-0.9 Na-135
K-4.0 Cl-107 HCO3-24 AnGap-8
[**2178-9-17**] 07:10PM BLOOD Lipase-70* GGT-56*
[**2178-9-15**] 04:59AM BLOOD Albumin-2.5* Calcium-9.0 Phos-3.2 Mg-1.6
Iron-201*
[**2178-9-21**] 05:40AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.2*
[**2178-9-15**] 04:59AM BLOOD calTIBC-242* VitB12-GREATER TH
Ferritn-220* TRF-186*
[**2178-9-17**] 07:10PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE
[**2178-9-17**] 01:42PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2178-9-17**] 01:42PM BLOOD Smooth-POSITIVE A
[**2178-9-17**] 07:10PM BLOOD CEA-5.3* AFP-4.9
[**2178-9-17**] 01:42PM BLOOD IgG-3727*
[**2178-9-17**] 07:10PM BLOOD HIV Ab-NEGATIVE
[**2178-9-15**] 04:59AM BLOOD tacroFK-7.4
[**2178-9-20**] 05:25AM BLOOD tacroFK-9.8
[**2178-9-17**] 07:10PM BLOOD HCV Ab-POSITIVE
Brief Hospital Course:
A/P: 57 F with history of Hep C cirrhosis s/p OLT in [**2172**] c/b
recurrence of cirrhosis and recurrent hepatic encephalopathy;
now admited with altered mental status improved on Rifaximin and
Lactulose.
# Altered mental status: In patient with known cirrhosis and
recurrent hepatic encephalopathy, AMS most likely again
represents severe hepatic encephalopathy. AMS improved
dramatically on Lactulose via NGT and Rifaximin with stool
output 1 liter per day. No ascites on US so no paracetesis
performed. Lytes, glucose, tox screen (other than APAP)
negative. Initially treated with NAC but given low suspicion for
tylenol overdose and other more likely etiologies of AMS was
discontinued. No evidence of obvious intracranial pathology on
NCHCT. Trigger for this episode of encephalopathy unclear;
differential includes infection (including recurrent HCV, SBP),
autoimmune hepatic failure, GI bleed (known guaiac pos stools in
ED), medication noncompliance (though per husband's report seems
to have been very compliant), less likely portal venous
thrombosis. Admitted with stage 3-4 encephalopathy now much
improved. Liver, transplant teams following. Blood and urine cx
pending at time of transfer. Lactulose 60 mL PO/NG TID, hold for
> 6BMs daily at time of transfer. Mental status had
significantly improved after lactulose and rifaximin; patient
A&Ox3 and followed all commands. She was transferred to the
floor and was A/OX3 for several days, ambulating around the unit
before being d/c'd.
# Cirrhosis. History of Hep C with OLT in [**2172**] with subsequent
cirrhosis. Etiologies of recurrent cirrhosis include AIH vs.
recurrent Hep C. Seeking potential second OLT, hepatology and
transplant following, will consider OLT depending on etiology of
recurrent cirrhosis. Followed coags, LFTs, transaminases.
Transaminases stable. If remians elevated or any signs of
bleeding will give vitamin K. Discussed patient with her Liver
Transplant Team Nurse ([**Doctor First Name **] at [**Telephone/Fax (1) 62885**]) at [**Hospital3 **],
all old lab and pathology/biopsy reports were faxed to the [**Hospital1 **],
including all old HCV VL which did not include VLs past the
Spring of [**2175**]. At time of transfer, HCV viral loads, [**Doctor First Name **] and
[**Last Name (un) 15412**] for autoimmune hepatitis; and additional labs for
transplant acceptance were pending. Continued on
immunosuppresive agents (cellcept 1000mg qam and 500gm qpm,
prograf 0.5mg PO qHS, prednisone). Husband brought the actual
liver biopsy slides from [**Hospital1 1774**] and they were discussed at liver
pathology confernce.
# Transaminitis: At or below most recent baseline, stable since
admission. Thought to have some component of autoimmune
hepatitis ?rejection affecting transplant. Trasnaminitis
trending down. Tylenol level negative . DC'ed NAC since had such
significant improvement on lactulose and has other etiologies of
known liver disease. Transaminases, AP, Tbili trended slowly
downward through hospitalization.
# Guaiac positive stools: Husband reports past history of GI
bleeds ?source - notes both melena and BRBPR. Status of varices
unknown. Guaiac positive but brown stools and no evidence of
very active bleed. Hct trended, decrease of 31-->26 on [**9-16**]
with increase to 28 without intervention. Corrected coagulopathy
with phytonadione.
# Anemia: baseline from [**Hospital1 1774**] hospitalization is high 20's-low
30's. Normocytic with normal iron, B12 on admission. Hct
dropped for a time in the MICU but returned to baseline and
remained stable to time of d/c.
.
# DM. On lantus and sliding scale. No hypoglycemia. Continued
outpatient regimen with FSG QID.
# HTN. Continued home metoprolol.BP well controlled.
# ? Pulmonary nodule: On first CXR. Will need Outpatient
followup.
# FEN: Regular-Protein diet at time of transfer.
# PPX: PPI, pneumoboots
Code: Full
Medications on Admission:
- cellcept [**Pager number **] mg daily
- prograf 0.5 mg QHS
- xifaxan 400 mg TID
- lactulose 60 ml Q 4 hours
- mag oxide 400 mg TID
- metoprolol 25 mg [**Hospital1 **]
- Tums 2 tab TID
- Prednisone 10 mg daily
- folate 1 mg daily
- MVI
- vitamin D daily
- protonix 40 mg daily
- lantus 8 units QHS
- Humalog sliding scale
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q4H
(every 4 hours).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
QAM (once a day (in the morning)).
7. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QPM (once a day (in the evening)).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
11. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QHS (once
a day (at bedtime)).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Insulin Glargine 100 unit/mL Solution Sig: Nine (9) Units
Subcutaneous at bedtime.
14. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 1 doses.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Hepatic encephalopathy
Recurrent cirrhosis
Secondary
Diabetes Mellitus type II
Hypertension
Discharge Condition:
Stable.
Discharge Instructions:
You have been diagnosed with hepatic encephalopathy. The exact
cause of your repeated episodes is unknown, but you will need to
continue taking your lactulose to have more than 3 bowel
movements per day. You also need to make sure to take your
rifaximin as prescribed. We increased your daily lantus
(insulin) dose to 9 units because your blood sugars were high,
otherwise we did not change your medications. You will hear from
Dr.[**Name (NI) 948**] office eventually regarding your transplant
eligibility status.
Please take all of your medications exactly as prescribed.
If you have any confusion, bleeding, dark stools, vomiting
blood, fevers, chills, night sweats, chest pain, abdominal pain
or any other concerning symptoms please call your doctor
immediately or go to the emergency department.
Followup Instructions:
Please call Dr.[**Name (NI) 948**] office for an appointment next week
([**Telephone/Fax (1) 3618**].
Please call Dr. [**Last Name (STitle) **] for an appointment in [**12-3**] weeks.
[**Doctor Last Name **],ZINAIDA [**Telephone/Fax (1) 7751**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]
Completed by:[**2178-9-24**]
ICD9 Codes: 5715, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2105
} | Medical Text: Admission Date: [**2155-7-13**] Discharge Date: [**2155-7-21**]
Date of Birth: [**2088-5-22**] Sex: F
Service: MEDICINE
Allergies:
Lidocaine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
intubated
History of Present Illness:
67 yo woman with h/o NHL s/p CHOP [**2153**], myelodysplasia, hep C,
PUD, eosinophilia with recent admits on [**4-2**] with RLL PNA
and [**Date range (1) 32291**] for a fib with RVR now comes in with chest pain
and shortness of breath. Patient's english is only fair, but she
declines the use of an interpreter.
States she was discharged recently. Since her discharge, she has
been very tired and weak. She has shortness of breath that
started with exertion, but then progressed to sob at rest. The
exact timing of this is not clear. She sleeps on one pillow and
has no PND. No [**Date range (1) 5162**], or chills, weight changes. She may have
slight ankle swelling that is new.
She has also had some intermittent chest pains. The exact timing
of these is difficult to elicit. It appears to occur at rest and
with exertion. It is not associated with the sob, n/v, abd pain,
lh, or diaphoresis. The pain lasts from seconds to 25 minutes.
Last episode was yesterday. It does not appear pleuritic in
nature.
Past Medical History:
NHL s/p CHOP in [**2153**]-[**2154**].
Myelodysplasia dx in [**2154**]. ? resulted from her chemotherapy
Chronic hepaitis C
h/o duodenal ulcer
GERD
depression
?angioedema/eosinophilia
atrial fibrillatio: dx [**6-12**]. no coumadin due to myelodysplasia
Social History:
Married
2 children
No tobacco or ETOH
On disability
Originally from [**Location (un) 3156**]. Taught lab medicine while there?
Family History:
NC
Physical Exam:
on admission:
Vitals : T 99.4, 58, 123/55, 17, 98% 2L, 94 % RA
Gen: alert and oriented x 3, NAD
HEENT: PERRL, OP clear, no LAD, conjunctival pallor
CV: RRR, no m/r/g
Lungs: RLL decreased breath sounds with dullness to percussion,
left CTA
Abd: soft, NTND +BS
Ext: 1+ bilateral LE edema, 2+DPs
Skin: no rashes
Pertinent Results:
[**2155-7-13**] 11:00AM WBC-2.5* RBC-2.41*# HGB-7.1*# HCT-20.8*#
MCV-86 MCH-29.5 MCHC-34.2 RDW-15.6*
[**2155-7-13**] 11:00AM PLT SMR-VERY LOW PLT COUNT-26*
[**2155-7-13**] 11:00AM NEUTS-54 BANDS-5 LYMPHS-28 MONOS-6 EOS-1
BASOS-0 ATYPS-6* METAS-0 MYELOS-0 NUC RBCS-3*
[**2155-7-13**] 11:00AM PT-13.6* PTT-25.0 INR(PT)-1.2
[**2155-7-13**] 11:00AM GLUCOSE-144* UREA N-26* CREAT-0.9 SODIUM-129*
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-22 ANION GAP-15
[**2155-7-13**] 11:00AM CK(CPK)-17*
chest x ray: diffuse haziness in right lung base with probable
effusion and possible posterior layering. No pna or chf
CTA: airways patent. mild-large right pleural effusion with mild
atelectasis. Slight left pleural effusion. Mild septal
thickening and ground glass c/w volume overload. Right PNA
improving. left base nodule not well seen. no axillary lad.
persistent, but unchanged, mediastinal adenopathy. No PE. Upper
abdomen without abnormalities. bone windows are unremarkable.
Brief Hospital Course:
This patient is a 67 year old female with NHL s/p CHOP, MDS, Hep
C, recently diagnosed afib [**6-12**] transfered to MICU for hypoxia
on floor accompanied by [**Month/Year (2) 5162**], frequent episodes of afib with
RVR, also hypotension originally thought to be consistent with
sepsis.
1)SIRS/ Sepsis: Patient had episodes of fever and hypotension
(during tachycardia and not during tachycardia), lactate 1.5,
temp most likely related to pna
-patient placed on vanco, levo, flagyl originally- changed to
vanc and zosyn since patient continued to spike [**Month/Year (2) 5162**]. Patient
also had her line changed in the unit as she continued to spike
[**Month/Year (2) 5162**]. Plan was to consider tap of pleural effusion if patient
remained febrile. The though was that patients underlying MDS
and ?functional neutropenia was impairing her ability to clear
her pna. Her clinical status continued to decline.
2) Hypoxia: Unclear how hypoxic patient was while on the floor,
but likelyw as due to pna and tachycardia. was on a 6.0 liter nc
in the unit
3) Hypotension: related to her underlying infection and afib
with rvr
4) CV: patient had intermittent episodes of afib with rvr,
responded well to lopressor but difficult situation given her
low bp. Cardiology was consulted and she was started on amio and
digoxin. We attemped to use PO metoprolo for rate control.
Patient was not being anticoagulated as she is a fall risk and
platelets very low with high inr. Echo with mild sysytolic
dysfuction, likely with some doastolic dysfuction.
5) Anemia/ thrombocytopenia: heme onc thinks this was a
manifestation of MDS in setting of being infected, no evidence
of hemolysis on peripheral smear
6) Elevated bili: workup with RUQ and HIDA scan was been
negative
------
Patient resp and clinical status continued to decline. She
became septic and hypotensive on three pressors. She was
intubated. A family meeting was held and she was made cmo. Her
tube was pulled and she passed away shortly after.
Medications on Admission:
Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
prn
Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
amiodarone 400 mg po qd x 2 weeks, then 200 mg po daily
indefinitely
Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
Completed by:[**2155-7-22**]
ICD9 Codes: 486, 2761, 2765, 0389, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2106
} | Medical Text: Admission Date: [**2192-3-19**] Discharge Date: [**2192-3-27**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old man
with known valvular disease and rheumatic fever as a child,
who presented with exertional dyspnea. The patient underwent
cardiac catheterization on the day of presentation. The
cardiac catheterization demonstrated four plus mitral
regurgitation with an ejection fraction of 45% and
three-vessel disease.
PAST MEDICAL HISTORY:
1. Non-insulin dependent diabetes mellitus.
2. Hypertension.
3. Benign prostatic hypertrophy.
4. Mitral regurgitation.
SOCIAL HISTORY: No tobacco.
PHYSICAL EXAMINATION: On examination, Neurologic intact.
HEENT: No jugular venous distention, no jaundice. Pupils
equally round and reactive to light. No bruits. Lungs are
clear. Cardiac: Regular rate and rhythm. No S4. Abdomen
soft, nontender, nondistended. Extremities with good veins.
LABORATORY: Hematocrit of 39, creatinine of 1.4.
HOSPITAL COURSE: On [**2192-3-19**], the patient underwent a
three-vessel coronary artery bypass graft with left internal
mammary artery to the left anterior descending, saphenous
vein graft to obtuse marginal 1 and saphenous vein graft to
PDA. The patient did well postoperatively and was
transferred to the CSRU. The patient was extubated on
postoperative day number one and his Nitroglycerin drip was
weaned off.
The patient was started on an Amiodarone drip for
postoperative atrial fibrillation. The patient's mediastinal
chest tubes were removed on postoperative day number one as
well as his Swan-Ganz catheter. On postoperative day number
one, the patient was transferred to the Floor. On
postoperative day number two, it was noted that the patient
was in complete heart block. The patient was 100%
ventricular paced with his external wires.
On postoperative day number three, the patient was seen by
the EP fellow who felt that the patient might require a
permanent pacemaker if he did not come out of this rhythm.
The patient was noted to have bilateral stable pneumothoraces
before and after chest tube removal. These pneumothoraces
appeared to be getting smaller on repeat chest x-rays daily.
On postoperative day number seven, the patient was taken for
a permanent pacemaker placement. This went well.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2192-3-27**] 11:13
T: [**2192-3-27**] 11:16
JOB#: [**Job Number 25974**]
ICD9 Codes: 9971, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2107
} | Medical Text: Admission Date: [**2143-9-30**] Discharge Date: [**2143-10-4**]
Date of Birth: [**2085-6-27**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12657**]
Chief Complaint:
progressive neck swelling
and decreased PO intake
Major Surgical or Invasive Procedure:
open incision and drainage of abscess
History of Present Illness:
Mr. [**Known lastname 84988**] is a 58 M with 2 days of progressive neck swelling
and decreased PO intake. Yesterday he had pain/difficulty
swallowing food. Today he states he forced self to drink
minimal water w/AM meds. He reports being afraid to sleep for
fear his throat will close. He endorses nightsweats x 2-3 days.
No
fever/chills. No other pain or swelling. No SOB. No stridor.
The patient reports his voice has been getting progressively
more muffled since this morning. He denies any previous issues
with neck swelling in the past.
Shortly after presentation he was found to have a 2.7x2.4cm rim
enhancing collection suggestive of an infected thyroglossal duct
cyst on CT scan. On exam, there was significant supraglottic
edema.
Past Medical History:
1. CAD, s/p MI
2. Hypercholesterolemia
3. Hypertension
4. s/p lacunar infarct
5. Pulmonary nodules
6. Obesity
7. Cervical disc disease
8. Impaired fasting glucose
9. h/o colon polyp
10. Harmartoma, left hand
Social History:
Works as the chief engineer for a hotel. Married, lives with
wife and son. Quit smoking almost a year ago, about 1 ppd
previously. Rarely drinks alcohol.
Family History:
Father had an MI at age 44
Physical Exam:
VITALS: 98.7 61 165/92 16 96-RA
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
Neck incision without evidence of infection, nontender.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2.
RESP: Clear to auscultation bilaterally. Breathing comfortably.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses.
Pertinent Results:
[**2143-9-30**] 03:45PM BLOOD WBC-12.6* RBC-4.23* Hgb-13.3* Hct-36.9*
MCV-87 MCH-31.4 MCHC-36.0* RDW-13.8 Plt Ct-205
[**2143-10-4**] 04:40AM BLOOD WBC-9.7 RBC-3.85* Hgb-11.8* Hct-34.3*
MCV-89 MCH-30.6 MCHC-34.3 RDW-13.1 Plt Ct-253
[**2143-9-30**] 03:45PM BLOOD Glucose-97 UreaN-20 Creat-1.2 Na-145
K-3.3 Cl-106 HCO3-29 AnGap-13
[**2143-10-4**] 04:40AM BLOOD Glucose-109* UreaN-17 Creat-1.0 Na-142
K-3.4 Cl-105 HCO3-24 AnGap-16
CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of [**2143-9-30**]
1. 2.7 cm rim-enhancing midline collection just superior to the
hyoid bone, most compatible with thyroglossal duct cyst with
probable superinfection. Surrounding edema notably involving the
epiglottis, likely reactive.
2. 1cm left thyroid nodule. Ultrasound can be obtained if
indicated.
[**2143-9-30**] 11:21 pm SWAB Site: NECK
GRAM STAIN (Final [**2143-10-1**]):
THIS IS A CORRECTED REPORT [**2143-10-2**].
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
PREVIOUSLY REPORTED AS ([**2143-10-1**]).
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by DR. [**Last Name (STitle) **]. [**Doctor Last Name **] ON [**2143-10-1**] AT
0315.
WOUND CULTURE (Preliminary):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. MODERATE
GROWTH.
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
SECOND MORPHOLOGY.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
Brief Hospital Course:
It was decided to take the patient to the OR for surgical
management of his presumed infected thyroglossal duct cyst.
After proper consent was received from the patient, he was
admitted the ORL service for open incision and drainage. The
patient tolerated the procedure without intra-operative
complications. Please refer to Dr. [**Last Name (STitle) 3878**]??????s dictated operative
note for complete details. Post-operatively, the patient was
transferred to the surgical ICU, intubated and in stable
condition. He was later extubated per SICU protocol and
remained in the SICU for one additional night for monitoring
before being transferred to the floor. On the floor the
remainder of his postoperative course was without complication.
His foley was removed, a penrose drain from the operation was
removed from his incision, and his diet was advanced.
* HEENT: Pt's OC/OP/NC clean with no active bleeding or oozing,
moist mucosa, face symmetric without palsy or deficits & normal
voice. The patient's neck incision remained clean, dry, & intact
with sutures without hematoma or infection. His neck penrose
drain was removed at bedside; he tolerated this well without
complication.
* N: The patient's pain was initially well controlled with IV
pain medication, he was then transitioned to PO liquid pain
medication once extubated and his pain stayed well-controlled.
When he was awake enough to follow commands, CN 2-12 remained
grossly intact throughout admission without deficit.
* CV: The patient's blood pressure was noted to be elevated at
several points throughout the admission, with SBP as high as
approximately 180. This was managed with his home medications
and iv hydralazine. He is instructed to follow up with his PCP
for this.
* P: Once extubated, the patient was gradually weaned to room
air. At time of discharge he was ambulating independently
without supplemental oxygen.
* GI: The patient was initially NPO. He was slowly advanced,
but this was limited initially due to pain with swallowing; this
resolved with the roxicet. At time of discharge he was
tolerating his diet without nausea, vomiting, or diarrhea.
* GU: The patient initially had a foley catheter. This was
removed on [**2143-10-3**] and he subsequently voided without
complications.
* HEME: The patient was offered SCH and pneumoboots throughout
admission for DVT prophylaxis.
* ID: The patient received perioperative antibiotics, and
remained on iv unasyn while in the hospital. Upon discharge, he
was given PO augmentin, which he will take until his follow up
visit, at which point he can receive further instructions
regarding length of treatment.
The remainder of the hospital course was relatively
unremarkable, and patient was discharged in stable condition,
ambulating well independently, voiding regularly, and with
adequate pain control. It was incidentally noted on his CT scan
that he had a 1-cm thyroid nodule; he was instructed to follow
up with his PCP for this.
Today, on POD#4, both the patient and staff feel that he is
ready & stable for discharge home. The patient was given
explicit instructions to call Dr. [**Last Name (STitle) 3878**] for a follow-up
appointment, and to follow-up with his PCP [**Last Name (NamePattern4) **] [**2-3**] weeks. He was
also given detailed discharge instructions outlining wound care,
activity, diet, follow up care, and the appropriate medication
prescriptions.
Medications on Admission:
[**Last Name (LF) **], [**First Name3 (LF) **], Lisinopril, metop, rosuvastatin
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain: no alcohol or
driving. do not take additional tylenol when taking this drug.
take an over the counter stool softener when taking this drug.
Disp:*300 ML(s)* Refills:*0*
7. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
infected suspected thyroglossal duct cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
- Seek immediate medical attention if you experience difficulty
breathing, increased trouble swallowing, fever (> 101.5) or
chills, signs of wound infection (increasing redness, increasing
swelling, draining pus, increased pain), throat swelling, chest
pain, shortness of breath, abdominal pain, or anything else that
is troubling you.
- Wound: Tape called Steri-strip is on your wound. These will
fall off by themselves. You may get them wet. Your sutures are
dissolvable and do NOT need removal.
- Activity: Walk as tolerated; do not vigorously exercise
until after your follow-up appointment, at least. Do not get
wound wet for 48 hours after surgery or your last drain was
removed. After 48 hours you may get wound wet during showers,
however avoid soaking the incision site (no baths, swimming, hot
tubs) for 2-4 weeks after surgery.
- Diet: You may consume a regular diet as previously
tolerated.
- Medications: Take medications as prescribed. You may resume
home medications. Do not drive or drink alcohol while taking
narcotic pain medications. Narcotic pain medications may cause
constipation. If this occurs, take an over the counter stool
softener. If you prefer you may take over the counter Tylenol in
place of your prescribed pain medication. DO NOT take Ibuprofen
or Aspirin for at least 3 days.
- Please call Dr.[**Name (NI) 37129**] office to schedule a follow-up
visit, at [**Telephone/Fax (1) 29891**]. Call your primary care provider to make
[**Name Initial (PRE) **] follow up appointment in [**2-3**] weeks.
Followup Instructions:
Please call Dr.[**Name (NI) 37129**] office to schedule a follow-up visit,
at [**Telephone/Fax (1) 29891**].
Call your primary care provider to make [**Name Initial (PRE) **] follow up appointment
in [**2-3**] weeks. Please discuss your blood pressure and your 1-cm
left thyroid nodule seen on CT scan.
Completed by:[**2143-10-4**]
ICD9 Codes: 412, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2108
} | Medical Text: Admission Date: [**2201-7-8**] Discharge Date: [**2201-7-13**]
Date of Birth: [**2142-3-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2201-7-9**]:
Coronary artery bypass grafting x4 with left internal mammary
artery to left anterior descending coronary; reverse saphenous
vein single graft from aorta to first diagonal coronary artery;
reverse saphenous vein single graft from aorta to first obtuse
marginal coronary
artery; reverse saphenous vein single graft from aorta to
posterior descending coronary artery.
History of Present Illness:
59 yr old male with history of chronic joint pain, htn,
hyperlipidemia, hemochromatosis who developed worsening upper
back pain with burning that became more prominent and
progressive over the last few months with radiation to right
hand. Last evening his pain became more severe and his wife
brought him to the ER early AM. He was noted to have EKG
changs, ruled in for MI initial troponin 5. Recieved Nitro, asa
and morphine after which his pain resolved. His cardiac
catherization revealed significant CAD with 70% LM. Prior to
transfer to [**Hospital1 18**] he v-fib arrested, was defibrillated, recieved
a few minutes of CPR, started on Amiodarone gtt. He returned to
stable rhythm and was
neurologically intact. He eventually was trasnsferred to [**Hospital1 18**]
for evaluation and consideration for CABG. Pt has no history for
cardiac disease.
Past Medical History:
Htn, hyperlipidemia, chronic joint pain, hemochromatosis
(ferritin levels checked q 6-9 weeks), Arthroscopy to Right
knee, liver biopsy
Social History:
Last Dental Exam:6months ago no issues
Lives with:Married lives with wife [**Name (NI) **], ****Jehovah's
Witness*****
Occupation:Does not work, takes care of grandchildren
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:Never
ETOH: < 1 drink/week [x] [**2-23**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
+ cardiomyopathy in sister died at age 57
Physical Exam:
Pulse: Resp: 14 O2 sat: 98%
B/P Right: 125/70 Left: 120/75
Height:5ft 9inches Weight:213lbs
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
+ []
Extremities: Warm [x], well-perfused [x] Edema [] _None____
Varicosities: None [none]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:+1 Left:+1
DP Right: trace Left:Trace
PT [**Name (NI) 167**]:Trace Left:trace
Radial Right: +1 Left:+1
Carotid Bruit None Right: Left:
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 89094**] (Complete)
Done [**2201-7-9**] at 10:36:16 AM 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: [**2142-3-29**]
Age (years): 59 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: [**2201-7-9**] at 10:36 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 #: 2011AW1-: Machine: us2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Low normal 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. Mild (1+)
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 low normal (LVEF
50-55%), with apical HK.
There is 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 stenosis or aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is A-Paced, on no inotropes.
Preserved LV systolic fxn.
RV remains globally mildly hypokinetic.
1+ MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Brief Hospital Course:
The patient was brought to the operating room on [**2201-7-9**] where
the patient underwent CABG x 4 (Lima-d2; SVG-OM 1, SVG-D1,
SVG-RPDA). Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable, weaned from inotropic and vasopressor
support. Amiodarone IV for episode of VF arrest at OSH was
converted to PO and Beta blocker was initiated. Statin were
restarted. The patient is a Jehovah Witness no blood
transfusions were given. The patient was gently diuresed toward
the preoperative weight. He transferred to the telemetry floor
for further recovery. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD #4 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged home in good
condition with appropriate follow up instructions.
Medications on Admission:
Celebrex 200mg daily, Voltaren cream prn, Tricor 145mg daily,
Pravachol 40mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. acetaminophen 650 mg/20.3 mL Solution Sig: [**1-18**] PO Q4H (every
4 hours) as needed for pain/fever.
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. fenofibrate micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*2*
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
10. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
daily for 7 days then decrease to 200mg daily ongoing.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1514**] Regional [**Hospital6 407**]
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
Hyperlipidemia
Chronic joint pain
Hemochromatosis(ferritin levels checked q 6-9 weeks)
Arthroscopy to Right knee
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) 914**] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2201-8-4**] 1:45pm
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2201-7-21**] 10:45
Please call to schedule appointments with your
Cardiologist: Dr [**Last Name (STitle) 39975**] in 3 weeks
Primary Care Dr. [**Last Name (STitle) 36375**] in [**4-21**] weeks [**Telephone/Fax (1) 78735**]
**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:[**2201-7-13**]
ICD9 Codes: 2761, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2109
} | Medical Text: Admission Date: [**2187-6-9**] Discharge Date: [**2187-6-12**]
Date of Birth: [**2145-2-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
Ms. [**Known lastname 69966**] is a 42 y/o F with a h/o PKD, EtOH abuse and recently
identified pancreatic mass in the setting of weight loss, who
presented to the ED with 4-5 days of grossly bloody BMs. She
describes her BM's as non-explosive and denied ever having
episodes like this before. ROS is positive for multiple
episodes of lightheadedness leading to syncope multiple times
over the last several days, as well as SOB. She had 2 episodes
of syncope both r/t postural changes. She fell with both
episodes. She denied CP, cough, fever and abdominal pain. She
called [**Company 191**] to talk to her PCP about the symptoms this afternoon
and was told to go to the ED immediately for evaulation and
treatement.
In the ED, VS were T 99.4, HR 98, BP 107/67, RR nml, 97% RA.
She was found to have Hct 11.8, down from a baseline in the
upper 20's to low 30's. The GI team was consulted and
recommended a tagged RBC scan, which was not performed b/c her
blood loss from below had subsided. She was given three units
of RBCs, and approx 1.5 L NS.
Head CT was performed b/c of the h/o syncope (though she had no
neuro findings on exam); it was negative for acute processes.
Chest x-ray was normal. Lactate was 2.1, prompting abdominal
CT; per the ED read, there has been interval increase in the
pancreatic tail mass (compared to [**11-4**] MRI), but otherwise no
evidence of ischemic bowel or other processes.
On arrival to the ICU, she reported that stools have become less
bloody since getting to the hospital. She says that the amount
of blood in her stool has waxed and waned over the past few
days. She feels well now while lying down.
ROS:
Gen: +fatigue, no f/c, +weight loss in fall, but she put most of
weight back on. She thought weight loss due to lack of appetite
due to nausea and vomiting in AM.
CV: +palpitations, denies CP, +syncope/lightheaded (see HPI)
Lungs: +SOB earlier, no cough
Abd: denies abd pain, +nausea, +vomiting (food stuff), denies
coffee ground emesis or hematemesis, +diarrhea with
tenesmus(uncommon for her to have diarrhea), denies
constipation, denies hx of liver dz/cirrhosis.
GU: denies hx of heavy bleeding with menses
Heme: denies h/o bleeding d/o.
Neuro: patient denies confusion, tongue biting, incontinence
stool or urine. falls were unwitnessed.
Past Medical History:
PMHx:
1. Alcohol abuse, complicated by pancreatitis in [**12/2184**],
associated LFT abnormalities. Possibly chronic pancreatitis
also.
2. Probable traveler's diarrhea status post inpatient hospital
admission in 12/[**2185**].
3. Polycystic kidney disease -dx [**2185**].
4. Electrolyte deficiencies (magnesium, potassium, calcium).
5. Poorly defined soft tissue density within the pancreatic
body
noted on MR in 12/[**2185**]. Pancreatic mass felt to be c/w chronic
pancreatitis on EGD [**3-6**].
6. Status post tonsillectomy.
7. Status post loss of two toes on the left foot following
trauma.
8. Anemia - thought to be r/t EtOH abuse.
Social History:
The patient works as a real estate [**Doctor Last Name 360**] for commercial
properties.
EtOH: She reports that she is currently consuming [**11-29**] standard
size glass of wine nightly. Her last drink was 2 days ago.
Tob: approximately [**1-31**] cigarettes daily and has been smoking at
this
level for many years.
Ilicit drugs: She occasionally uses marijuana but no
other recreational drugs.
She is not currently in a relationship. She lives alone
Family History:
The patient's father and brother both have autosomal dominant
polycystic kidney disease. The patient's father was first
diagnosed in his 60s; he is currently 64, and he is told he is
3-4 years away from needing dialysis. There is no other
recognized history of medical conditions that run in the family.
GF - died of lung cancer at early age. No family hx of IBD or
bleeding diathesis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
V/S: T 99.3 HR 91 BP 137/86 RR 23 O2sat 98% on RA
GEN: lying comfortably in bed, pale. pleasant, conversant, NAD
HEENT: NCAT, sclera pale, PERRLA, oropharynx with moist mucosa,
poor denition, tongue with flim on it.
NECK: no cervical or supraclavicular LAD; JVD not appreciated
PULM: CTA in all lung fields
CV: RRR, S1 & S2 nl, no m/r/g
ABD: soft, ND, hyperactive BS, mild epigastric tenderness to
deep palp, no rebound, guarding
Ext: warm hands and feet, 2+ radial pulses, no LE edema
Neuro: A&Ox3
Pertinent Results:
ADMISSION LABS:
[**2187-6-9**] 03:56PM BLOOD WBC-5.4 RBC-1.24*# Hgb-3.4*# Hct-11.8*#
MCV-95# MCH-27.5# MCHC-29.0*# RDW-17.8* Plt Ct-395#
[**2187-6-9**] 03:56PM BLOOD Neuts-65.1 Lymphs-27.5 Monos-6.3 Eos-1.0
Baso-0.2
[**2187-6-9**] 03:56PM BLOOD PT-13.3 PTT-24.5 INR(PT)-1.1
[**2187-6-9**] 03:56PM BLOOD Glucose-96 UreaN-8 Creat-0.5 Na-136 K-3.5
Cl-104 HCO3-19* AnGap-17
[**2187-6-9**] 03:56PM BLOOD ALT-22 AST-41* AlkPhos-78 TotBili-0.2
[**2187-6-9**] 03:56PM BLOOD Lipase-33
[**2187-6-9**] 03:56PM BLOOD Calcium-7.8* Phos-2.7 Mg-1.6
.
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2187-6-12**] 04:31AM 5.1 3.36* 9.7* 28.5* 85 29.0 34.2 17.7*
309
[**2187-6-11**] 04:08PM 30.8*
Source: Line-PIV
[**2187-6-11**] 05:28AM 5.0 3.44* 9.9* 28.1* 82 28.9 35.3* 18.2*
258
[**2187-6-10**] 10:15PM 30.1*
[**2187-6-10**] 01:56PM 29.4*
[**2187-6-10**] 09:40AM 5.5 3.39*# 9.6*# 27.6*# 81*#1 28.5 35.0#
18.1* 246
[**2187-6-9**] 11:54PM 21.9*#
CXR [**2187-6-9**] - No acute intrathoracic process.
.
CT Head [**2187-6-9**] - Preliminary Report
No acute hemorrhage or other acute intracranial pathology.
.
CT abd/pelvis [**2187-6-9**] -Interval development of large panc head
mass with severe narrowing of SMV and distal ductal dilation -
findings concerning for pancreatic adenocarcinoma. No
explanation for patient's anemia. No colitis, no retroperitoneal
hemorrhage.
.
EKG [**2187-6-9**] - HR 90, NSR, no signs of ischemia or infarct.
.
[**6-10**] EGD Esophagitis in the gastroesophageal junction
Schatzki's ring
Erosions in the antrum
Erythema and edema in the duodenal bulb, normal second part of
the duodenum and papilla major compatible with duodenitis
Diverticulum in the second part of the duodenum
.
[**6-11**] Colonoscopy Impression: Diverticulosis of the sigmoid colon
Grade 1 internal & external hemorrhoids.
Otherwise normal colonoscopy to terminal ileum
[**6-12**] CEA 2.8; CA [**97**]-9 pending; H. pylori pending
Brief Hospital Course:
#GI Bleed - The patient remained hemodynamically stable despite
being initially subjectively orthostatic. 2 large bore IV's were
placed and the patient was transfused with 6 U PRBC with
improvement in Hct from 11.8 to 29.4. Bleeding quickly subsided
after admission and Hct, initially checked q4 hours followed by
[**Hospital1 **], remained stable. EGD did not reveal a source of bleeding.
Colonoscopy showed sigmoid diverticuli and internal and external
hemorrhoids, the former felt to be the likely source of this
acute episode. The patient was given a PPI to be taken
post-discharge and H. Pylori serology was sent, pending at this
time. She tolerated a regular diet prior to discharge.
.
#Pancreatic mass - Abd CT scan on admission revealed interval
enlargement of the mass, concerning for malignany. The patient
was seen in consultation by GI and general surgery, who
recommended a repeat [**Hospital1 2963**] with biopsy of the mass for definitive
diagnosis, which is scheduled for [**2187-6-13**]. CA [**97**]-9 level is
pending at this time.
.
#EtOH abuse - The patient was placed on a CIWA protocol but did
not exhibit signs or symptoms of withdrawal. She was given
thiamine, folate, and MVI.
.
#HTN - Once it was clear that bleeding had resolved and there
was no hemodynamic compromise, the patient was restarted on her
home dose of lisinopril.
.
#Anxiety d/o - Ativan PRN anxiety was continued.
.
#Prophylaxis - Pneumoboots given recent bleeding, and PPI.
Medications on Admission:
Lisinopril 10mg PO Qday
Citalopram 20mg PO Qday (in record) - patient states that home
dose is 80mg daily.
Lorazepam 1mg PO BID PRN anxiety
MVI
Discharge Medications:
1. Omeprazole 40 mg by mouth once daily
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
1) Acute blood loss anemia
2) Diverticulosis
3) Internal and external hemorrhoids
4) Pancreatic mass
Secondary diagnosis:
Polycystic kidney disease
Discharge Condition:
Fair, with stable hemodynamics and hematocrit.
Discharge Instructions:
You were admitted to the hospital because you were having bloody
stools and your blood count was very low, also called anemia.
You were transfused 6 units of blood. You were seen by the
gastroenterologists who did an upper endoscopy which showed
inflammation of parts of your esophagus, stomach and upper small
intestine, but no source for your blood loss. You also had a
colonoscopy which showed hemerrhoids and diverticulosis. The
most likely cause of the bleeding is diverticulosis. Your
bleeding stopped prior to discharge but could occur again. If
you notice return of blood in your stool, please call your
primary care doctor immediately to have your blood count
checked.
You were also evaluated by the general surgeons for the mass or
cyst that has been seen in your pancreas. You are scheduled to
have an endoscopic ultrasound and biopsy of this mass on the day
after your discharge, [**2187-6-13**].
You were prescribed omeprazole 20 mg by mouth twice daily for
the inflammation in the upper GI tract. None of your other
medications were changed. Please continue taking your
medications at the usual dosages.
Please call your doctor or return to the hospital if you
experience any concerning symptoms including blood in your
stool, light headeness, weakness/fatigue, fainting, falls,
yellowing of your skin or any other worrisome symptoms.
Followup Instructions:
You have an appointment scheduled tomorrow morning [**2187-6-13**] at
8AM for ultrasound and biopsy of the mass in your pancreas.
Please do not eat or drink anything after midnight tonight,
[**2187-6-12**]. Please arrive at [**Hospital Ward Name 1950**] [**Location (un) **] Endoscopy Suite by
7:30 to have pre-procedure screening and preparation for your
8:00 appointment.
Provider: [**Name Initial (NameIs) 2963**] (ST-4) GI ROOMS Date/Time:[**2187-6-13**] 8:00
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2187-6-13**] 8:00
You have an appointment scheduled to follow up with Dr. [**Last Name (STitle) **] on
[**2187-6-26**] at 2:00 in the [**Hospital Ward Name 23**] building [**Location (un) **], south suite.
Dr. [**Last Name (STitle) **] works with Dr. [**Last Name (STitle) 11009**], whose first available
appointment is not until [**Month (only) 462**].
Please contact the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital1 18**]
Department of General Surgery at [**Telephone/Fax (1) 1231**] to arrange an
appointment in 6 weeks after discharge.
Completed by:[**2187-6-12**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2110
} | Medical Text: Admission Date: [**2180-1-8**] Discharge Date: [**2180-1-10**]
Service: MEDICINE
Allergies:
Meclofenamate Sodium
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
84yo F admitted on [**2180-1-8**] for progressively worsening dyspnea x
1 week felt to be a CHF exacerbation +/- NSTEMI developed
dizziness tonight and, per tele, became bradycardic w/ complete
heart block. She then became unresponsive w/ PEA arrest. She was
intubated w/o event (ABG 7.44/44/431/31) and received
epinephrine x2, atropine x2, and bicarb x1 with establishment of
a palpable pulse. By rhythm strip, then appeared to be in sinus
tach. BP stable w/ SBP in 150s. R femoral line was placed for
central access. 12 lead EKG was obtained and revealed ST
elevations in aVR and V1-V3 with reciprocal ST depressions in V5
and V6. Repeat EKGs revealed persistence of ST elevations and
plans were made to take her to cath. Stat CXR revealed
improvement in her pleural effusions from earlier today, but
still w/ persistent hilar fullness. Labs were drawn and were
pending at time of cath.
.
For PMH, she has known CAD s/p PCI to Lcx in [**2163**] (at the time,
was found to have 2VD), CHF, HTN, DM type II, and COPD. Per her
[**Hospital Unit Name 196**] admission note by Dr. [**Last Name (STitle) 11315**], she began developing SOB 1
week ago. She would have SOB ("gasping for air") mostly with
walking [**9-17**] feet. These episodes lasted 15 min and resolved
with deep breathing. These episodes became more frequent over
the last few days. She normally sleeps with the head of her bed
elevated, but the night prior to admission she awoke gasping for
air at 1:30 am. The episode resolved on its own and she went
back to sleep. In the morning, she was again SOB when speaking
and her family called 911.
.
ROS + for angina recently (had not had it for several yrs) ->
described as bilateral shoulder discomfort ("squeezing") w/o
radiation. Associated w/ SOB, relieved w/ NTG. + LLE, unchanged.
No medication noncompliance or dietary indiscretion.
.
Per ED trip sheet/OSH records, pt was 90% on RA on arrival, 98%
on NRB. At OSH given ASA, NTP 1", lasix 80 mg IV, heparin bolus
and morphine (for anxiety). Was transferred to our ED where her
VS were
T 98, HR 63, BP 144/53, RR 18, sats of 100% NRB. On exam, she
had rales bilaterally and 2+ pitting edema. Labs were notable
for elevated BNP and trop 0.77. EKG with NSR, rate 63, ST dep 1
mm in I, avL, V5-V6, no ST segment elevation. TWI in I, avL, V4,
flat TW in V5-V6. She was admitted to the [**Hospital Unit Name 196**] service for CHF
exacerbationWas transferred up to the floor where she appeared
to do well overnight. She received 2 additional doses of IV
lasix, with net I/O of -500cc. On exam this AM, was SOB at rest
sitting 90 degrees upright in a chair.
.
Past Medical History:
1. CAD
Cath [**12/2163**]: done for postitive ETT
a. Limited angiography of the left coronary artery
demonstrated moderate disease of the LAD with stenoses of the
proximal and mid artery. The circumflex artery had a total
occlusion
after the takeoff of a large first OM. The distal circumflex and
OM2
filled by retrograde left to left collaterals.
b. Resting hemodynamics were normal.
c. Successful PTCA of the totally occluded mid-LCX
2. CHF
3. COPD - on home O2 of 3L
4. HTN
5. DM2 on insulin
6. Hypothyroidism
7. Sleep apnea on CPAP
8. bilateral TKR
9. Hearing loss with hearing aid
10. Basal and squamous cell skin cancer s/p resection
11. Mastectomy for ?benign breast tumor
Social History:
(per admit note) Lives with grandson in [**Name (NI) 15289**],
performs all ADLs, quit smoking 35 years ago (unable to quantify
how much), occ ETOH
Family History:
NC
Physical Exam:
On admission to CCU:
.
VS - T 99.8, BP 107/61, HR 90-100, RR 18, sats 100% by vent
Vent: AC FiO2 100%, Tv 500 (set), Tv 530 (actual), PEEP 5, RR 14
Gen: Sedated, intubated
HEENT: Sclera anicteric
Neck: Supple, JVP
CV: RR, NL S1, S2, no m/r/g appreciated.
Lungs: Vented BS anteriorly. No crackles/wheezes.
Abd: Soft, obese, NT/ND, + BS, no masses.
Ext: Bilateral LE 2+ edema up 1/3 of shins, +chronic venous
stasis changes
.
Pertinent Results:
Labs on admission:
[**2180-1-8**] 06:00PM BLOOD WBC-9.4 RBC-3.64* Hgb-9.6* Hct-29.2*
MCV-80* MCH-26.5* MCHC-32.9 RDW-15.7* Plt Ct-300
[**2180-1-8**] 06:00PM BLOOD Neuts-80.7* Lymphs-15.4* Monos-3.5
Eos-0.2 Baso-0.2
[**2180-1-8**] 06:00PM BLOOD PT-14.9* PTT-88.6* INR(PT)-1.3*
[**2180-1-8**] 06:00PM BLOOD Glucose-84 UreaN-44* Creat-1.4* Na-141
K-4.6 Cl-100 HCO3-31 AnGap-15
[**2180-1-8**] 06:00PM BLOOD CK(CPK)-101
[**2180-1-8**] 06:00PM BLOOD CK-MB-6 proBNP-7327*
[**2180-1-8**] 06:00PM BLOOD cTropnT-0.77*
[**2180-1-8**] 11:36PM BLOOD CK(CPK)-98
[**2180-1-8**] 11:36PM BLOOD CK-MB-NotDone
[**2180-1-8**] 11:36PM BLOOD cTropnT-0.66*
.
Labs on discharge:
[**2180-1-9**] 05:30AM BLOOD CK(CPK)-113
[**2180-1-9**] 05:30AM BLOOD CK-MB-8 cTropnT-0.57*
[**2180-1-9**] 05:30AM BLOOD calTIBC-241* Ferritn-145 TRF-185*
[**2180-1-9**] 05:30AM BLOOD TSH-1.1
[**2180-1-9**] 10:43PM BLOOD Type-ART pO2-431* pCO2-44 pH-7.44
calHCO3-31* Base XS-5
[**2180-1-8**] 06:16PM BLOOD Glucose-80 K-4.7 calHCO3-36*
[**2180-1-9**] 10:43PM BLOOD Lactate-7.3* K-4.3
[**2180-1-9**] 11:55PM BLOOD WBC-13.3* RBC-3.43* Hgb-9.2* Hct-27.3*
MCV-80* MCH-26.8* MCHC-33.7 RDW-15.9* Plt Ct-332
[**2180-1-9**] 11:55PM BLOOD Neuts-90.0* Bands-0 Lymphs-7.1* Monos-2.7
Eos-0.2 Baso-0.1
[**2180-1-9**] 11:55PM BLOOD PT-14.3* PTT-52.9* INR(PT)-1.3*
[**2180-1-9**] 11:55PM BLOOD Glucose-142* UreaN-51* Creat-1.4* Na-141
K-4.4 Cl-99 HCO3-31 AnGap-15
[**2180-1-9**] 11:55PM BLOOD ALT-22 AST-50* LD(LDH)-319* CK(CPK)-313*
AlkPhos-140* TotBili-0.3
[**2180-1-9**] 11:55PM BLOOD CK-MB-30* MB Indx-9.6* cTropnT-0.78*
.
Imaging:
CXR [**2180-1-10**]: PA and lateral views of the chest. Pulmonary edema
and bilateral pleural effusions are present, obscuring the
cardiac contours. Mediastinal contours are within normal limits.
There is no pneumothorax. Degenerative changes are noted in the
thoracic spine. IMPRESSION: Congestive heart failure with
bilateral pleural effusions.
Brief Hospital Course:
Mrs. [**Known lastname 30119**] is an 84yo F admitted on [**2180-1-8**] for progressively
worsening dyspnea x 1 week felt to be a CHF exacerbation +/-
NSTEMI developed dizziness tonight and, per tele, became
bradycardic w/ complete heart block. She then became
unresponsive w/ PEA arrest. She was intubated w/o event (ABG
7.44/44/431/31) and received epinephrine x2, atropine x2, and
bicarb x1 with establishment of a palpable pulse. By rhythm
strip, then appeared to be in sinus tach. BP stable w/ SBP in
150s. R femoral line was placed for central access. 12 lead EKG
was obtained and revealed ST elevations in aVR and V1-V3 with
reciprocal ST depressions in V5 and V6. Repeat EKGs revealed
persistence of ST elevations and plans were made to take her to
cath. Stat CXR revealed improvement in her pleural effusions
from earlier today, but still showed persistent hilar fullness.
Labs were drawn and showed elevated cardiac enzymes. Her family
was contact[**Name (NI) **] and made aware of need for urgent cardiac cath,
and with her EKG changes, the likely possibility of left main
disease with probable need for CABG. Pt is a poor surgical
candidate currently and with this in mind, and with the
knowledge of the patient's wishes, the family did not want to
proceed with cardiac catheterization. Ms. [**Known lastname 92959**] family said
that the patient did not want to intubated, so they decided to
extubate her and to continue with medical management, knowing
that she may not survive once extubated. She was given morphine
to help with her tachypnea and apparent dyspnea. Thirty minutes
after being extubated, Mrs. [**Known lastname 30119**] passed away from
respiratory failure.
Medications on Admission:
isosorbine mononitrate
naproxen 375 mg [**Hospital1 **]
levoxyl 150 mcg qd
metroprolol 125 mg [**Hospital1 **]
lasix 80 mg qd
insulin 54 u NPH/44 u NPH pm
ecotrin
quinine sulfate 260 mg qhs
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
STEMI
Cardiopulmonary arrest
Respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
ICD9 Codes: 4280, 496, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2111
} | Medical Text: Admission Date: [**2132-4-10**] Discharge Date: [**2132-4-12**]
Date of Birth: [**2080-12-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
DOE and tachycardia
Major Surgical or Invasive Procedure:
- Upper esophagogastroduodenoscopy (EGD) [**2132-4-11**]
History of Present Illness:
Mr. [**Name13 (STitle) **] is a 51 year-old man no significant medical history
presents from PCP appointment with dyspnea, tachycardia, back
pain, to ED found to have new significant Hct drop. Pt is s/p ED
visit [**4-8**] for sudden onset SOB. At that time he also c/o back
pain for 10 days. In the ED, he was found to have mild
leukocytosis, no left shift, neg trop x2, neg ddimer, CXR clear,
nuclear stress test normal. EKG showed sinus tachycardia. Pt was
discharged for f/u. Since discharge pt continued to experience
SOB. At this point could barely climb 2 flights of stairs or
cross the street which is much more limited than his usual
baseline. He denies orthopnea/PND, but endorses mild chest
discomfort in the subcostal areas bilaterally, exacerbated by
movement but not by cough or positional changes.
.
On [**4-8**] he noted dyspnea coinciding now with dark stools. No
diarrhea or BRBPR. No nausea/vomiting. Pt denies any history -
personal or familial - of GI problems ([**Name2 (NI) 110517**] discussed
colon CA). Pt is 51 years of age and has not had a colonoscopy.
No history of liver disease or known varices. He denies alcohol
or other drug use, no tattoos, and has not spent any time in
prison. He does not use medications except that last week he did
use NSAIDs for back pain; he only used 10 pills over the course
of 3 days and stopped as he felt they may be causing some
abdominal pain. Of note, pt has had 15lb weight loss in the past
3 months
.
ROS: denies headache fever, chill, cough, N/V/D, recent travel
or
sick contacts.
.
ED Course:
-Initial vitals in the ED were 98.8 108 125/70 20 100%RA.
On exam, marroon stool was noted in the rectal vault.
-Labs showed
CBC: 12.3 > 23.6/7.8 < 212
on [**4-8**] had H/H of 13.6/40.7
Trop-T: <0.01
chemistry:
137/3.6 104/24 23/0.9 glu93
ALT: 17 AP: 56 Tbili: 0.3 Alb: 3.7
AST: 19 Lip: 31
proBNP: 21
N:64.4 L:29.3 M:5.2 E:0.7 Bas:0.5
PT: 11.6 PTT: 26.6 INR: 1.1
-Imaging
CTPA: 5/3/12prelim dictation no acute intrathoracic process
CXR [**2132-4-10**] prelim dictation no acute cardiopulmonary process
EKG: SR @ 110. TWI in II,aVF, V4-V6.
-Interventions:
Pt was given ASA, pantoprazole 40mg IV and admitted to the MICU.
On arrival to the MICU, patient's VS were 105 112/69 99% RA
Past Medical History:
none (pilonidal abscess drained years ago without issues)
Social History:
From [**State 33977**] originally, works at [**Hospital1 18**] garage, is a priest.
has not seen a doctor in 10 years. Single, lives with roommates
in a house. Has one son, one daughter, both in 20s. Not
sexually active.
denies smoking, EtOH, illicit drug.
Family History:
Mother: leukemia, died at age 60s, hypertension
Father: prostate cancer, diet at age 70s
Physical Exam:
Admission:
Vitals: HR 103 BP 125/75 98% RA
General: Overweight male. Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge:
VS - 98.5=Tmax 150/83 (122-150)/(68-83) 97P 18R 100%RA
GENERAL - Mr. [**Known lastname **] is a pleasant and cooperative man in NAD
HEENT- MMM. No sclera icterus, jaundice, or pallor. Oropharynx
clear.
HEART - RRR, no m/r/g, no JVD
LUNGS - CTAB, no wheeze or rhonchi, unlabored, no accessory
muscle use
ABDOMEN - protuberant, soft, non-tender, no organomegaly,
hyperactive bowel sounds in 4 quadrants of the abdomen
EXTREMITIES - WWP, no clubbing, cyanosis, or edema. DP 2+
bilaterally. PT was not palpated bilaterally.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, sensation
grossly intact in upper and lower extremity.
Pertinent Results:
[**2132-4-10**] 08:39PM BLOOD WBC-12.3* RBC-2.72*# Hgb-7.8*# Hct-23.6*#
MCV-90 MCH-29.3 MCHC-32.5 RDW-14.0 Plt Ct-212
[**2132-4-10**] 08:39PM BLOOD Neuts-64.4 Lymphs-29.3 Monos-5.2 Eos-0.7
Baso-0.5
[**2132-4-10**] 08:39PM BLOOD PT-11.6 PTT-26.6 INR(PT)-1.1
[**2132-4-10**] 08:39PM BLOOD Glucose-93 UreaN-23* Creat-0.9 Na-137
K-3.6 Cl-104 HCO3-24 AnGap-13
[**2132-4-10**] 08:39PM BLOOD ALT-17 AST-19 AlkPhos-56 TotBili-0.3
[**2132-4-10**] 08:39PM BLOOD proBNP-21
[**2132-4-10**] 08:39PM BLOOD cTropnT-<0.01
[**2132-4-10**] 08:39PM BLOOD Albumin-3.7
[**2132-4-10**] 08:39PM BLOOD TSH-4.0
[**2132-4-10**] 08:39PM BLOOD Lipase-31
[**2132-4-11**] 05:49AM BLOOD CK-MB-3 cTropnT-<0.01
[**2132-4-10**] 11:43PM BLOOD WBC-11.5* RBC-2.59* Hgb-7.5* Hct-23.2*
MCV-90 MCH-29.0 MCHC-32.4 RDW-14.3 Plt Ct-189
[**2132-4-11**] 05:49AM BLOOD WBC-11.7* RBC-3.11* Hgb-9.3* Hct-28.1*
MCV-90 MCH-29.8 MCHC-33.0 RDW-14.6 Plt Ct-195
[**2132-4-11**] 09:24AM BLOOD Hct-27.2*
[**2132-4-11**] 01:46PM BLOOD Hct-26.6*
[**2132-4-12**] 06:15AM BLOOD WBC-8.5 RBC-2.99* Hgb-8.9* Hct-26.8*
MCV-90 MCH-29.8 MCHC-33.2 RDW-15.0 Plt Ct-205
**FINAL REPORT [**2132-4-11**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2132-4-11**]):
POSITIVE BY EIA.
(Reference Range-Negative).
[**2132-4-9**]
- Nuclear Exercise Stress Test
RESTING DATA
EKG: SIN.TACH., LVH, REPOL. ABN., LAE
HEART RATE: 100 BLOOD PRESSURE: 136/88
PROTOCOL MODIFIED [**Doctor First Name 569**] - TREADMILL /
STAGE TIME SPEED ELEVATION HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
0 0-3 1.0 8 146 144/78 [**Numeric Identifier 110518**]
1 [**2-12**] 1.7 10 169 168/72 [**Numeric Identifier 110519**]
2 6-6.5 2.5 12 171 168/70 [**Numeric Identifier **]
TOTAL EXERCISE TIME: 6.5 % MAX HRT RATE ACHIEVED: 101
SYMPTOMS: NONE
INTERPRETATION: This 51 year old man was referred to the lab
from
the ER following negative serial cardiac markers for evaluation
of back
pain as a possible anginal equivalent. The patient exercised for
6.5
minutes of a modified [**Doctor First Name **] protocol and stopped for fatigue.
The
estimated peak MET capacity was 4.8 which represents a poor
functional
capacity for his age. No arm, neck, back or chest discomfort was
reported by the patient throughout the study. The baseline EKG
showed
LVH with repolarization abnormalities, LAE and sinus
tachycardia. The
biphasic T waves normalized with exercise and returned to
baseline in
recovery. Appropriate BP response to exercise with sinus
tachycardia at
rest.
IMPRESSION: Uninterpretable ST segments secondary to left
ventricular
hypertrophy in the absence of anginal type symptoms at a high
cardiac demand and poor functional capacity. Nuclear medicine
report
sent separately.
RADIOPHARMACEUTICAL DATA:
11.0 mCi Tc-[**Age over 90 **]m Sestamibi Rest ([**2132-4-9**]);
32.6 mCi Tc-99m Sestamibi Stress ([**2132-4-9**]);
HISTORY:
51 yo man referred for evaluation of back pain that was
concerning as a possible
anginal equivalent.
SUMMARY OF DATA FROM THE EXERCISE LAB:
Exercise protocol: Modified [**Doctor First Name **]
Resting heart rate: 100
Resting blood pressure: 136/88
Exercise Duration: 6.5 min
Peak heart rate: 171
Percent maximum predicted heart rate obtained: 101%
Peak blood pressure: 168/72
Symptoms during exercise: None
Reason exercise terminated: Fatigue
ECG findings: Uninterpretable ECG for ischemia
METHOD:
Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi.
Tracer was
injected approximately 45 minutes prior to obtaining the resting
images.
At peak exercise, approximately three times the resting dose of
Tc-[**Age over 90 **]m sestamibi was administered IV. Stress images were
obtained approximately 45 minutes following tracer injection.
Imaging Protocol: Gated SPECT
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
The image quality is adequate but limited due to soft tissue
attenuation.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal septal hypokinesis with normal thickening,
consistent with intraventricular conduction delay. Overall left
ventricular systolic function is normal with no concerning wall
motion abnormalities.
The calculated left ventricular ejection fraction is 61% with an
EDV of 61 ml.
IMPRESSION:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic dysfunction.
[**2132-4-10**]
- CTA chest
FINDINGS: There is no filling defect in the pulmonary arteries
to the
subsegmental level to suggest pulmonary embolus.
Tracheobronchial tree is
patent to subsegmental levels. No significant mediastinal, hilar
or axillary lymphadenopathy. Great vessels appear unremarkable.
Aorta is normal in caliber throughout with no evidence of
dissection or aneurysm. The left lung is clear. The right lung
shows some very minimal areas of dependent atelectasis (3:37).
Below the diaphragm there are no gross abnormalities noted. No
suspicious
lytic or sclerotic lesions are seen.
IMPRESSION: No pulmonary embolus or other acute intrathoracic
process.
[**2132-4-11**]
- EGD
Erythema in the duodenal bulb compatible with duodenitis
Esophagitis in the GE junction compatible with mild esophagitis
Multiple ulcers were noted in the antrum. None had high risk
features or stigmata of recent bleeding
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
51 y/o M unclear PMH presents with persistent back/chest pain,
dyspnea and tachycardia in setting of black tarry stools, found
to have significant HCT drop over the last 2 days concerning for
GI bleed.
# Upper GI bleed likely due to antral gastric ulcers: Patient
was noted to have significant hematocrit drop down to 23 from 40
over 2 days. Initial chest discomfort was likely due to the
gastric ulcers. Stress test was negative. The initial
tachycardia could also be [**1-10**] acute blood loss. CTA was
negative for PE or dissection. He does not have liver disease
or coagulopathy. He received 2 units of pRBC during the
hospital course. He received pantoprazole bolus then
transitioned to an infusion. Admitted to the MICU and did not
have further melena there. He underwent EGD which revealed
clean-based gastric antrum ulcers that were not bleeding, as
well as esophagitis and duodenitis. His H. pylori Ab was
positive. Patient was transitioned to 40 mg pantoprazole [**Hospital1 **]
and started on clarithromycin and amoxicillin for a total of 14
days course to treat for H. pylori. He will continue with high
dose PPI [**Hospital1 **] afterward. Patient was transferred to the floor
and maintained stable Hct. His orthostatics were negative on the
day of discharge.
# Weight loss. Patient reports unintentional weight loss over
15 months. No clear etiology. LDH was within normal limits.
No known history of smoking. He has not yet had screening
colonoscopy. No other constitutional symptoms. He will need to
have age appropriate cancer screening in the outpatient setting.
Transitional issues:
[] f/u CBC with PCP
[] routine screening colonoscopy
[] please arrange for repeat EGD in [**9-19**] weeks per GI
recommendation
Medications on Admission:
None
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: take 30 minutes
prior to breakfast and dinner.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
3. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Upper gastrointestinal bleed from gastric ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was our pleasure to care for you in the hospital. You were
admitted to [**Hospital1 69**] because of
gastrointestinal bleeding (GI bleeding).
While in the hospital, you received 2 units of red blood cells
transfusion for your low blood count. In addition, you also had
an upper endoscopy of your esophagus, stomach, and part of the
small intestines. You did not get a colonoscopy. The upper
endoscopy showed that you have ulcers in your stomach, which
explains some of the pain that you had before and the maroon
colored stool. It was not bleeding anymore. We started a
medication called omeprazole to control the acid in your
stomach. You were found to have a bacterial infection in your
stomach called H. pylori, which we are treating with
antibiotics.
You should not take any more pain medications such as ibuprofen,
aspirin, Aleve, Advil, or similar medications known as NSAIDs.
If you buy any over the counter medications, you should ask a
pharmacist if they contain NSAIDs. You should avoid drinking
alcohol. In addition, avoid coffee, citric food, chocolate,
sweets, or oily food.
You have an appointment with your primary care doctor [**First Name (Titles) **] [**4-17**] to make sure that you are feeling good and that your blood
counts are stable.
Please note the following changes in your medications:
- START omeprazole (Prilosec) 40 mg, 1 tab, twice a day. You
should take this medication 30 minutes before eating breakfast
and dinner.
- START amoxicillin 500 mg tab, 2 tabs (total of 1 gram), by
mouth, twice a day.
- START clarithromycin 500 mg tab, 1 tab, by mouth, twice a day.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2132-4-17**] at 3:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 110520**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2112
} | Medical Text: Admission Date: [**2165-6-4**] Discharge Date: [**2165-6-14**]
Date of Birth: [**2094-1-2**] Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
1. Open treatment thoracic fracture dislocation.
2. Posterior instrumentation T10 through L2.
3. Posterolateral fusion T10 through L2.
4. Local autograft for fusion augmentation.
History of Present Illness:
Reason for Consult: C1 fx
HPI: 71M w hx CHF, AF on coumadin, tfr from [**Hospital3 **] for
C1 fracture. Pt sustained mechanical fall backwards from 6ft
ladder around 4pm today. +LOC for ~30sec. Ambulated at Neck
pain.
Neuro intact in ED and complained only have neck and back pain.
No reports of numbness/tingling. HD stable. CT head showed no
ICH. CT c-spine showed C1 fx. He then vomited x2 and was
intubated for airway protection. CT chest, abd, pelv deferred
to [**Hospital1 **]. INR 1.4.
PMH: DM2, HTN, HLD, schizophrenia, AFIB, CAD s/p 2 cardiac
stents, Ischemic CMP, multi-infarct dementia, mood disorders
MED: Aldactone, Crestor, Coumadin 5 mg daily, Janumet,
Lasix, Niaspan, Risperdal, Toprol, Trilipix, aspirin, glipizide,
lisinopril, Augmentin
ALL: nkda
SH: denies smoking & drugs admits to social etoh, married lives
with wife, has 4 children, retired
PE:
AVSS
Intubated, sedated
Opens eyes to command
Superficial occiptal abrasion
c-collar in place
Moving all extremities x 4 spontaneously
BUE skin clean and intact
No deformity, erythema, edema, induration or ecchymosis
Arms and forearms are soft
2+ radial pulses
BLE skin clean and intact
No deformity, erythema, edema, induration or ecchymosis
Thighs and legs are soft
1+ pitting edema BLE
1+ PT and DP pulses
No step-offs or deformities to T,L spine
Superficial abrasion over L-spine and perianal
LABS: Hct 38, INR 1.4
IMAGING: CT c-spine: C1 fx through right lateral mass and
posterior arch, minimally-displaced
CT
IMPRESSION & RECOMMENDATIONS:
71M s/p mech fall off ladder with C1 anterior and posterior arch
fractures. Ambulatory at scene and NVI in OSH ED prior to
intubation.
-Recommend CT scan T,L,S spine to assess for additional spine
injury
-Log roll precautions
-[**Location (un) 2848**] J c-collar at all times
-Stable c-spine injury pattern - will treat conservatively with
non-operative management
CT scan TL Spine
1. Acute transverse fracture across a T12 vertebral body
hemangioma and
coursing into the left lamina, with minimal retropulsion. MR
should be
considered for further evaluation to assess for cord injury.
2. Hepatic steatosis.
3. Trace bilateral pleural effusions. Area of left lower lobe
consolidation
may reflect mild aspiration.
4. 21 mm cystic lesion arising from the lower pole of the right
kidney is
indeterminate on this single phase study. Further outpatient
evaluation with
ultrasound could be considered in six months to assess for
stability.
5. Minimally displaced left 12th rib and left L2 and right L3
(2:81)
transverse process fractures.
MRI
1. No evidence of spinal cord edema/contusion. There is no
significant
spinal canal narrowing seen.
2. T12 vertebral body fracture with minimal anterior epidural
swelling as
described above. Also seen is an acute compression fracture of
C7 and T1.
Fractures of C1 and posterior element fractures are better seen
on the recent
CT study.
3. Multilevel degenerative changes without significant canal
stenosis. There
is narrowing of the subarticular recesses bilaterally at L4-L5
contacting the
traversing [**Name (NI) 13032**] nerve roots.
See prior CT Torso.
Past Medical History:
- afib
- HTN
- Hypercholestremia
- DM Type II
- CAD s/p 2 cardiac stents
- [**10-15**] Cath: LAD 80% prox stenosis followed by 90% apical
lesion. LCx mild-mod diffuse disease. Cypher stent placed to LAD
- ischemic CMP w/ h/o flash pulmonary edema; CHF (EF 35%), mod
MR
- PSYCHIATRIC HISTORY:
- Multi-infarct dementia
- Mood Disorder NOS; r/o BPAD vs. MDD with psychotic
features with h/o of multiple hospitalizations
- - Carried dx of schizophrenia x 25yrs; previous trial of
Stelazine
Social History:
Pt was born in [**Country 2559**], has lived in US since his 20s. Married
with 4 living children. Has degrees in both visual arts and
architecture. And, though currently retired continues to work
with iron and other sculpture mediums. Lives [**Location 6409**] with
wife. Denies h/o illicit drug use, admits to social EtOH use.
Denies tobacco use currently.
Family History:
Denies
Physical Exam:
see HPI
Pertinent Results:
[**2165-6-4**] 08:42PM TYPE-ART RATES-/14 TIDAL VOL-500 O2-100
PO2-170* PCO2-62* PH-7.27* TOTAL CO2-30 BASE XS-0 AADO2-474 REQ
O2-81 -ASSIST/CON INTUBATED-INTUBATED
[**2165-6-4**] 10:12PM FIBRINOGE-214
[**2165-6-4**] 10:12PM PLT COUNT-230
[**2165-6-4**] 10:12PM PT-15.1* PTT-27.4 INR(PT)-1.4*
[**2165-6-4**] 10:12PM WBC-11.8* RBC-3.90* HGB-12.1* HCT-35.9*
MCV-92 MCH-30.9 MCHC-33.6 RDW-13.8
[**2165-6-4**] 10:12PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-6-4**] 10:12PM cTropnT-<0.01
[**2165-6-4**] 10:12PM LIPASE-50
[**2165-6-4**] 10:12PM estGFR-Using this
[**2165-6-4**] 10:12PM UREA N-15 CREAT-1.1
[**2165-6-4**] 10:24PM freeCa-0.85*
[**2165-6-4**] 10:24PM HGB-12.1* calcHCT-36 O2 SAT-92 CARBOXYHB-7*
MET HGB-0
[**2165-6-4**] 10:24PM GLUCOSE-130* LACTATE-1.4 NA+-141 K+-4.7
CL--107 TCO2-21
[**2165-6-4**] 10:24PM PH-7.51* COMMENTS-GREEN
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service. He was
brought intubated from OSH and admitted to ICU. CT scan and MRi
spinI scans of the spine revealed T12 unstable fracture in
addition to C1 fracture (stable). Neurological status was
difficult to assess. He was and taken to the Operating Room for
the above procedure for T12 fracture. Refer to the dictated
operative note for further details. The surgery was without
complication and the patient was transferred to the ICU in a
stable condition. TEDs/pnemoboots were used for postoperative
DVT prophylaxis. Intravenous antibiotics were continued for
24hrs postop per standard protocol. Initial postop pain was
controlled.
No HVAC drains were used.
Events in the hospital
[**6-6**]: Extubated
[**6-7**]: Difficult to arouse, does not move UE and LE adequately.
Only some movement in fingers and toes. Requested limited scan
of the spine.
[**6-8**]: No evidence of ongoing cord compresison on MRI.
[**6-10**]: Moving better, dressing changed, Incision CDI, okay to
anticoagulate.
Foley was removed on POD#2.
Physical therapy was consulted for mobilization OOB to ambulate.
On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet.
Medications on Admission:
Coumadin 2.5, Spironolactone 25, Rosuvastatin 40 HS,
Sitagliptin-Metformin (Janumet) 1 tab'', Lasix 80, Niaspan ER
500, Risperdal 50 IM twice weekly, Toprol XL 50, Fenofibric acid
135, ASA 81, Glipizide 10, Lisinopril 20
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
13. diltiazem HCl 120 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
14. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
15. Janumet 50-1,000 mg Tablet Sig: One (1) Tablet PO bid ().
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
17. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Target INR [**3-15**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
C1 anterior and posterior arch fractures ([**Location (un) 26524**]) - Stable
T12 extension distraction fracture (Unstable)
Ankylosing Spondylitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
- Activity: As tolerated in brace.
- Rehabilitation/ Physical Therapy:
o You can walk as much as you can tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You have been given a brace (TLSO and [**Location (un) 2848**] J).
This brace is to be worn when you are walking. You may take TLSO
off when sitting in a chair or while lying in bed. Keep [**Location (un) 2848**] J
at all times.
- Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to
control your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
PLease follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] 2 weeks from the date of
discharge
Completed by:[**2165-6-14**]
ICD9 Codes: 2762, 4280, 412, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2113
} | Medical Text: Admission Date: [**2176-11-9**] Discharge Date: [**2176-11-18**]
Date of Birth: [**2107-6-22**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male with end-stage renal disease, who was three hours into a
hemodialysis session when it was stopped secondary to nausea
and tightness at his throat. He does have a history of
peripheral vascular disease with bilateral renal artery
stenosis and had stenting. He also has a history of
hypertension and hyperlipidemia.
In the Emergency Department, he was chest pain free and found
to be hypertensive with a blood pressure of 194/74. He went
to CT scan to rule out pulmonary embolus and on routine, was
noted to have [**Street Address(2) 4793**] depressions on telemetry, but no EKG
changes. He did complain of [**5-28**] chest pressure, which was
treated with sublingual nitroglycerin and a nitroglycerin
drip was started. He also received 5 of IV Lopressor and 325
mg of aspirin. Upon admission, he was chest pain free and
without shortness of breath.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Peripheral vascular disease status post right iliac stent
and left iliac stent with claudication.
3. Renal artery stenosis severe bilaterally, and he is status
post stents bilaterally.
4. End-stage renal disease on hemodialysis.
5. Diabetes mellitus.
6. Depression.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] does not smoke
and he does not drink.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Glipizide 5 mg p.o. q.d.
3. Isosorbide mononitrate 30 mg p.o. q.d.
4. Labetalol 400 mg p.o. b.i.d.
5. Lipitor 20 mg p.o. q.d.
6. Norvasc 10 mg p.o. b.i.d.
7. Plavix 75 mg p.o. q.d.
8. Ramipril one tablet p.o. q.d.
9. Fluoxetine 20 mg p.o. q.d.
PHYSICAL EXAMINATION: On physical exam, his temperature is
97.6, heart rate 74, blood pressure is 148/100. He is alert
and oriented times three, pleasant male in no apparent
distress. His HEENT includes PERRL. EOMI. His pharynx is
clear. His neck is supple with no JVD. Hemodialysis
catheter on the left, this is clean, dry, and intact. His
heart is regular, rate, and rhythm without murmurs, rubs, or
gallops. His lungs were clear to auscultation bilaterally.
His abdomen was soft, nontender, nondistended with positive
bowel sounds. He has no hepatosplenomegaly. His extremities
are without clubbing, cyanosis, or edema. He has no ulcers
and no palpable cords. His neurologic examination shows his
cranial nerves to be intact and remainder of his examination
to be grossly intact.
His chest x-ray showed normal pulmonary vasculature and no
evidence of CHF.
A CT scan showed no sign of pulmonary embolus.
His laboratories include a white count of 9.8, hematocrit is
47.4%, platelet count of 302,000. Sodium 138, potassium 4.7,
chloride ......., CO2 29, BUN 52, creatinine 5.7, and a blood
glucose of 156. His PT 12.5, PTT of 30, and an INR of 1.
Troponin was 0.07 with a CK of 57.
His echocardiogram which was done a month prior showed an EF
of greater than 55% with normal valves; and a stress test
previous [**Month (only) 956**] showed no ischemic or anginal symptoms.
While in the hospital, he remained asymptomatic while
awaiting eventual cardiac catheterization. He did undergo
hemodialysis on [**11-11**] and also that day had a cardiac
catheterization, which showed right dominant coronary system
with left main having tubular 50% stenosis, LAD with an 80%
ostial angulated disease, and a mid segment 60% tubular
lesion left circumflex, and a 60% ostial lesion with a 70%
tubular lesion of the distal segment at the trifurcation of
the OM-2 and the right coronary artery to be a dominant
vessel with a distal 90% lesion.
Dr. [**Last Name (STitle) **] was then consulted for probable coronary artery
bypass grafting. Patient underwent one more round of
hemodialysis prior to cardiac surgery. On [**2176-11-13**],
he underwent coronary artery bypass grafting x4 with a left
internal mammary artery to the proximal LAD, saphenous vein
graft to the distal LAD, saphenous vein graft to the OM, and
saphenous vein graft to the PDA. This surgery was performed
under general endotracheal anesthesia with a cardiopulmonary
bypass time of 70 minutes and cross-clamp time of 60 minutes.
The surgery was performed by Dr. [**Last Name (STitle) **] with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96760**],
NP, and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. as assistant. The patient
tolerated the procedure well and was transferred to the
Cardiac Surgery Recovery Unit in A paced at 88 on
Neo-Synephrine and propofol drips.
He was able to awaken from the anesthesia easily and was
extubated on the operative night. He did require insulin
drip on the operative night, but this was weaned off during
the night. He was then transferred to the Surgical Floor on
postoperative day #2.
On postoperative day #2, he underwent hemodialysis again and
began to resume his usual schedule. He continued to progress
well on postoperative day #3. He had his wires and chest
tube D/C'd without incident. He worked with Physical
Therapy, and increased his ambulation and began to enter more
aggressive cardiac rehab.
On the morning of [**11-18**], he did receive final run of
hemodialysis prior to discharge home. He will be discharged
home today as he is doing very well, and visiting nurse
services will follow him there.
His discharge exam shows him to be afebrile with a heart rate
of 69, blood pressure of 123/65, respirations 18, and O2
saturation of 96% on room air. He is alert and oriented
times three and in no apparent distress. His heart is
regular, rate, and rhythm. His lungs are clear to
auscultation bilaterally. His abdomen is soft, nontender,
nondistended, and his wounds are clean, dry, and intact, and
the sternum is stable.
His laboratories include a white count of 8.6, hematocrit of
24.3%, platelet count of 335,000. Sodium is 134, potassium
3.9, chloride 99, CO2 23, BUN 60, creatinine 6.8, and a blood
glucose of 148.
His discharge chest x-ray is clear with no signs of effusion
and very minimal atelectasis. With this exam and considering
how he has been doing with Physical Therapy, it is felt that
he will be ready to be discharged to home with visiting nurse
services on postoperative day #5.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery bypass grafting x4.
2. Renal artery stenosis.
3. End-stage renal disease on hemodialysis.
4. Diabetes mellitus.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Lipitor 20 mg p.o. q.d.
3. Fluoxetine 20 mg p.o. q.d.
4. Multivitamin one cap p.o. q.d.
5. Plavix 75 mg p.o. q.d.
6. Lopressor 12.5 mg p.o. b.i.d.
7. Glipizide 5 mg p.o. q.d.
8. Calcium acetate 667 mg tablet p.o. t.i.d.
9. Percocet 5/325 mg 1-2 tablets p.o. q.4h. prn pain.
FOLLOW-UP INSTRUCTIONS: He should follow up with his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] in [**12-21**] weeks or as
scheduled on [**12-18**]. He should follow up with his
cardiologist in [**1-22**] weeks and with Dr. [**Last Name (STitle) **] in four weeks.
He should also have contact with his hemodialysis center and
resume the schedule there and follow up with his nephrologist
in [**12-21**] weeks. He should have his cardiopulmonary status and
wound healing monitored by visiting nurse and be encouraged
to cough and deep breathe and ambulate, and he should check
his fingerstick blood sugars 3-4x a day.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 96761**]
MEDQUIST36
D: [**2176-11-18**] 13:40
T: [**2176-11-18**] 13:52
JOB#: [**Job Number 96762**]
ICD9 Codes: 4439, 311, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2114
} | Medical Text: Unit No: [**Numeric Identifier 77935**]
Admission Date: [**2167-3-21**]
Discharge Date: [**2167-4-1**]
Date of Birth: [**2167-3-21**]
Sex: F
Service: NB
IDENTIFYING INFORMATION:
This patient's post discharge name is [**Name (NI) **] [**Name (NI) **].
Her [**Hospital3 1810**] medical record number is [**Numeric Identifier 77936**].
HISTORY:
This is a former 3.405 kg product of a 41 and [**2-9**] week
gestation pregnancy, born to a 27 year-old, G2, P1 now 2
woman. Prenatal screens: Blood type 0 positive, antibody
negative, Rubella immune, RPR nonreactive, hepatitis B
surface antigen negative, group beta strep status positive.
The labor was induced due to post dates. Maternal Tmax in
labor was 100.4 degrees. Rupture of membranes occurred 20
hours prior to delivery. The mother received several doses of
antepartum antibiotics. There were variable fetal heart rate
decelerations noted in labor.
Infant was born by spontaneous vaginal delivery. There was a
nuchal and body cord noted at the time of delivery. The
infant emerged apneic with good heart rate. She received
positive pressure ventilation. The NICU team was called and
arrived at one minute of life. Positive pressure ventilation
was continued with good response. Spontaneous respirations
had onset by 4 minutes of age. Apgars were 2 at 1 minute and
7 at 5 minutes. The infant was admitted to the NICU where she
received a normal saline bolus and transitioned well. She was
transferred to the newborn nursery at approximately 8 hours
of age. Between 8 and 9 hours of age, she was noted to have
seizures and was transferred back to the Neonatal Intensive
Care Unit.
Anthropometric measurements upon admission to the NICU:
Weight 3.405 kg, 50 to 75th percentile. Length 52 cm, 75 to
90th percentile. Head circumference 34.5 cm, 50 to 75th
percentile.
PHYSICAL EXAM AT DISCHARGE: Weight 3.610 kg, 7 pounds, 15
ounces. Length 52 cm. Head circumference 36 cm. General:
Active, non dysmorphic, term female in room air. Skin warm
and dry. Color pink, well perfused. Oral mucosa clear. Head,
ears, eyes, nose and throat: Anterior fontanel open and
flat. Sutures apposed. Positive red reflex bilaterally.
Pupils equally reactive to light. Palate intact. Ears and
nose normal. Neck supple without masses. Chest: Breath
sounds clear and equal. Cardiovascular: Regular rate and
rhythm. No murmur. Normal S1 and S2. Femoral pulses +2.
Abdomen soft, nontender, nondistended. No
hepatosplenomegaly. Cord off. Umbilicus healing.
Genitourinary: Normal term female. Musculoskeletal: Spine
straight with normal sacrum. Extremities: Moving all well.
Hips stable. Neuro: Slightly increased tone in both upper and
lower extremities; 1-3 beats ankle clonus bilaterally.
Positive suc k, positive grasp, positive Moro.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
Respiratory: This infant required nasal cannula 02
intermittently during her Neonatal Intensive Care Unit course
largely due to hypoventilation secondary to treatment with
anticonvulsants. Her oxygen requirement was never more than
100 cc per minute. At the time of discharge, she has been in
room air for 96 hours. Baseline respiratory rate at the time
of discharge is 30 to 60 breaths per minute with oxygen
saturations greater than 95%.
Cardiovascular: As noted, this infant required one normal
saline bolus during her initial stabilization. She maintained
normal heart rates and blood pressures during admission. No
murmurs have been noted. Baseline heart rate at the time of
discharge is 120 to 150 beats per minute with a recent blood
pressure of 79/41 mmHg. Mean arterial pressure 55 mmHg.
Fluids, electrolytes and nutrition: Infant was initially
maintained n.p.o. and was treated with IV fluids and total
parenteral nutrition. Enteral feedings were initiated on day
of life 4 which were well tolerated. At the time of
discharge, she is ad lib breast feeding or taking Enfamil 20
calorie per ounce formula. She takes upwards of 200 ml per kg
per day. Her serum electrolytes remained in the normal range.
Her BUN and creatinine were initially elevated at 14 and 1.2.
They normalized by day of life 5 to BUN of 4 and creatinine of
0.5. Weight on the day of discharge is 3.61 kg.
Infectious disease: Due to the maternal temperature and
presentation at the time of delivery, this infant was
evaluated for sepsis upon her initial admission to the NICU.
A blood culture and complete blood count were obtained. The
white blood cell count and differential were within normal
limits. The blood culture was no growth at 48 hours. Due to
the unknown etiology of the seizure disorder, this infant was
treated with antibiotics for 5 days. The initial antibiotics
were ampicillin and gentamicin. The gentamicin was later
changed to Cefotaxime due to concerns for renal function. A
lumbar puncture was obtained, showing 33 white blood cells
with 39 polys per high power field. The culture was no
growth. The gram stain was negative. Cerebral spinal fluid
for herpes simplex virus PCR was negative.
Hematology: Hematocrit at birth was 56.4% and was repeated on
day of life 3 and was 53.6%. This infant did not receive any
transfusions of blood products. Platelet count was normal.
Gastrointestinal: Liver function tests were found to be
elevated on day of life 1 with an AST of 193 and an ALT of
99. These normalized by day of life 5 with an AST of 46 and
an ALT of 69. Peak serum bilirubin occurred on day of life 3
at 8.7 mg/dl. Repeat bilirubin on day of life 5 was 6.7
mg/dl. This infant was not treated with phototherapy.
Neurologic: As previously noted, this infant had onset of
seizures at 8 to 9 hours of life. The seizures were initially
difficult to control and required two anticonvulsants:
Phenobarbital and Dilantin. Seizure activity was noted on
EEG; however, the overall background was considered within
normal limits. The Dilantin was discontinued on [**2166-3-25**].
The infant remains on Phenobarbital dosing at the time of
discharge, 15 mg p.o. daily. Her last seizure was Sunday,
[**3-22**].
A head computed tomography scan was obtained on [**2167-3-21**]
showing a posterior interhemispheric/subdural hemorrhage. A
magnetic resonance imaging was obtained on [**2166-3-25**] with
results as follows: Multi-focal areas of restricted effusion
noted within the frontal regions, periparietal occipital
regions, corpus callosum and posterior left thalamus,
consistent with hypoxic ischemic encephalopathy. Subdural
hemorrhage was evident among the tentorial margins. More
focal areas of susceptibility artifact were noted in the left
cerebellum and left parietal lobe and was thought to be
related to hemorrhage within the subarachnoid space or brain
parenchyma. Incidental note was made of a right nasal
lacrimal duct cyst.
The infant was evaluated by the neurology consultation
service from [**Hospital3 1810**]. They met with the parents
to discuss the EEG, CT and MRI findings. The overall
prognosis is difficult to predict but possible ranges along
the spectrum of minimal to mild/moderate sequelae were
discussed including an increased likelihood for epilepsy. The
infant will be followed by the neonatal neurology program at
[**Hospital3 1810**] at 6 to 9 weeks of life. A repeat EEG is
recommended within 3 to 6 months. A follow-up MRI is
recommended at 9 months.
Sensory:
Audiology: Hearing screen was performed with automated
auditory brain stem responses. This infant passed in both
ears on [**2167-3-30**].
Psychosocial: [**Hospital1 69**] social
work was involved with this family. The contact social worker
is [**Name (NI) 36130**] [**Name (NI) 36527**] and she can be reached at [**Telephone/Fax (1) 55529**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, [**Hospital 7740**]
Pediatrics, [**Location 53083**], [**Location 942**], [**Numeric Identifier 53084**].
Telephone number [**Telephone/Fax (1) 53085**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feedings: PO ad lib Breast feeding or Enfamil 20 calorie
per ounce formula.
2. Medications: Phenobarbital 15 mg p.o. daily.
3. Iron and vitamin D supplementation: Iron
supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age. All
infants fed predominantly breast milk should receive
Vitamin D supplementation at 200 i.u. (may be provided as
a multi-vitamin preparation) daily until 12 months
corrected age.
4. Car seat position screening was performed due to the
oxygen requirement and seizure disorder. This infant was
observed in her car seat for 90 minutes without any
episodes of oxygen desaturation or bradycardia.
5. State newborn screen was sent on [**3-24**] and [**2167-4-1**]. No
notification of abnormal results to date.
6. Immunizations: Hepatitis B vaccine was administered on
[**2167-3-29**].
Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following
four 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 or (4) 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 the rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following discharge
from the hospital if they are clinically stable or at
least 6 weeks but fewer than 12 weeks of age.
Follow-up appointments scheduled or recommended:
1. Appointment with Dr. [**Last Name (STitle) **], primary pediatrician, on
[**2167-4-3**].
2. Neonatal neurology program at [**Hospital3 1810**] at 6 to
9 weeks of age. Telephone number [**Telephone/Fax (1) 36468**].
3. Follow-up EEG at 3 to 6 months of age.
4. Follow-up MRI at 9 months of age.
5. Referral for Early Intervention Program.
DISCHARGE DIAGNOSES:
1. Term female newborn
2. Perinatal depression
3. Neonatal seizures
4 Hypoxic ischemic encephalopathy
5. Posterior interhemispheric/subdural intracranial hemorrhage
6. Suspicion for sepsis ruled out
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 75740**]
MEDQUIST36
D: [**2167-4-1**] 01:06:07
T: [**2167-4-1**] 04:56:31
Job#: [**Job Number 77937**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2115
} | Medical Text: Admission Date: [**2130-5-15**] Discharge Date: [**2130-9-12**]
Date of Birth: [**2130-5-15**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 67074**] is the 1.33 kg product of a 29-
3/7 weeks twin gestation, born to a 25-year-old G1, P0, now 2
woman. Prenatal screens were O positive, direct Coombs
negative, hepatitis surface antigen negative, RPR
nonreactive, rubella immune, GBS unknown. Medical history is
notable for insulin-dependent diabetes. This pregnancy was
complicated by a 2-vessel cord in twin #2 with otherwise
normal fetal survey and by IUGR, oligohydramnios and absent
end-diastolic flow in twin #2. Mother received a full course
of betamethasone 2 weeks prior to delivery. She proceeded to
cesarean section without labor under spinal anesthesia due to
absent end-diastolic Doppler flow in twin #2, as described
above. There was no fever or other clinical evidence of
chorioamnionitis. Rupture of membranes occurred at delivery,
yielding clear amniotic fluid.
NEONATAL COURSE: The infant was active and crying at
delivery, orally and nasally bulb suctioned. Free flow oxygen
and brief facial CPAP administered. Apgars were 7 at 1 minute
and 8 at 5 minutes.
PHYSICAL EXAMINATION ON ADMISSION: Weight was 1.33 kg, head
circumference 28.5 cm, length 38 cm. Anterior fontanelle was
soft and flat, non dysmorphic, palate intact. Neck and mouth
were normal, mild nasal flaring. Chest had mild intercostal
retractions, slightly decreased breath sounds bilaterally, a
few scattered crackles. Cardiovascular was well perfused,
regular rate and rhythm. Femoral pulses were normal. S1 and
S2 were normal, no murmur. Abdomen was soft, nondistended, no
organomegaly, no masses, bowel sounds active. Anus was patent
with 3-vessel umbilical cord, normal male genitalia. CNS -
active, responsive to stimuli. Tone appropriate for
gestational age and symmetric. Moves all extremities. Gag is
intact. Grasp is symmetric. Musculoskeletal - normal spine,
limbs, hips and clavicles.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname 67075**] was
admitted to the newborn intensive care unit and intubated for
management of respiratory distress syndrome. He received a
total of 2 doses of surfactant and remained intubated for a
total of 22 days at which time he transitioned to nasal prong
CPAP. He remained on CPAP for a total of 41 days at which
time he transitioned to nasal cannula O2. He weaned to room
air on [**2130-8-12**] and he remained stable on room air.
During his respiratory course, [**Known lastname 67075**] was started on Lasix and
Aldactone on [**2130-7-6**] and they were discontinued on
[**2130-8-29**]. He was also treated with caffeine citrate
for management of apnea and bradycardia of prematurity which
was discontinued on [**2130-7-10**].
CARDIOVASCULAR: [**Known lastname 67075**] was treated with indomethacin for a
total of 2 courses for an echocardiogram demonstrating patent
ductus arteriosus. The most recent echocardiogram done on
[**2130-6-19**] demonstrated a small patent ductus arteriosus
with continuous left-to-right flow. The infant currently is
cardiovascularly stable without audible murmur and blood
pressures average about 78/51 with a mean of 58.
FLUIDS AND ELECTROLYTES: Birth weight was 1.330 kg, length 38
cm, head circumference 28.5 cm. Discharge weight is
4560 gm. Length is 67 cm. Head circumference is
37 cm. The infant was admitted to the newborn intensive
care unit on 80 cc/kg/day of D10W of parenteral nutrition.
Enteral feedings were initiated on day of life #10. Infant
achieved full enteral feedings by day of life #15. His
maximum enteral intake was 130 cc/kg/day of Special Care 32
calorie with protein. He is currently receiving 130 cc/kg/day
of Similac 28 calorie. His issue continues to be poor p.o.
intake.
GI/GU: Peak bilirubin was 7/0.3 on day of life #3, was
treated with phototherapy and the issue has resolved. We have
consulted gastroenterology team after a feeding team
evaluation with a recommendation to place a G tube due to
poor p.o. feeding skills. The infant has a scheduled OR date
of [**Hospital3 1810**] on [**2130-9-12**] for the
placement of a G tube. [**Known lastname 67075**] is currently being treated with
Prilosec and Reglan for management of reflux. His Prilosec
dose is 4.1 mg b.i.d. and Reglan is 0.4 mg 4 times a day.
HEMATOLOGY: Blood type is O positive, Coombs negative. He was
transfused on [**2130-6-9**] for a hematocrit of 28.9 and has
not required any further transfusions. His most recent
hematocrit was 35.6 on [**2130-8-14**]. He is currently
received Fer-In-[**Male First Name (un) **] supplementation of 0.4 ml p.o. daily of
25 mg/ml concentration.
INFECTIOUS DISEASE: Initial CBC and blood culture obtained on
admission revealed CBC was benign and blood culture remained
negative at 48 hours at which time ampicillin and gentamicin
were discontinued. On day of life #15, the infant was noted
to be having increased frequency of spells and lethargic. A
CBC and blood culture were obtained at that time. Blood
culture later grew out staph aureus. Repeat cultures remained
positive for staph aureus for 3 cultures. The negative
culture was finally obtained on [**2130-6-4**]. The infant was
treated with vancomycin for a total of 42 days which
completed on [**2130-7-16**]. He was treated for an extended
length of time due to presumed meningitis and the infant had
nodules present on right shoulder and right forearm with
concern of an abscess. Skeletal surveys and bone scans were
negative and Infectious Disease was consulted at length.
During this prolonged course of vancomycin, the infant
presented with a monilial rash in his groin and was treated
with miconazole powder. This has resolved.
NEUROLOGIC: Head ultrasounds on day of life #7 and 1 month of
age were within normal limits.
SENSORY: Hearing has not yet been done which should be done
prior to discharge. Ophthalmology - the infant was being
followed closely by Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **]. His most recent eye
exam was on [**2130-8-7**] and was normal mature. Dr.[**Doctor Last Name 67076**] telephone number is [**Telephone/Fax (1) 50314**]. The infant's
recommended follow-up is at 6 months of age.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 1810**].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 64592**], telephone
number [**Telephone/Fax (1) 67077**].
FEEDS AT DISCHARGE: Continue 130 cc/kg/day of Similac 28
calorie.
MEDICATIONS: Reglan 0.4 mg 4 times a day, omeprazole 4.1 mg
b.i.d., ferrous sulfate (25 mg/ml) 0.4 ml daily.
CAR SEAT POSITION SCREENING: Has not yet been performed.
STATE NEWBORN SCREEN: Have been sent per protocol and have
all been within normal limits.
IMMUNIZATIONS RECEIVED: [**Known lastname 67075**] received Pediarix, HIB and
Pneumococcal 7-valent on [**2130-7-18**].
DISCHARGE DIAGNOSES: Premature infant born at 29-3/7 weeks
gestation, corrected to 46 weeks gestation, respiratory
distress syndrome, rule out sepsis with antibiotics, patent
ductus arteriosus, hyperbilirubinemia, presumed
osteomyelitis, staph aureus bacteremia, presumed meningitis,
apnea and bradycardia of prematurity, anemia of prematurity.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Last Name (NamePattern1) 67078**]
MEDQUIST36
D: [**2130-9-9**] 00:52:58
T: [**2130-9-9**] 07:06:05
Job#: [**Job Number 67079**]
ICD9 Codes: 769, 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2116
} | Medical Text: Admission Date: [**2164-6-11**] Discharge Date: [**2164-6-15**]
Date of Birth: [**2127-3-10**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Morbid obesity, gallstones
Major Surgical or Invasive Procedure:
Laproscopic Roux-en-Y gastric bypass, laproscopic
Cholecystectomy
History of Present Illness:
The patient is a37-year-old woman who has been on multiple
supervised diets with a maximum weight loss of 80 pounds with
regain. She reports being heavy her entire life. She has been
evaluated by [**Hospital1 **] [**First Name (Titles) 1560**] [**Last Name (Titles) 28350**] Program
and deemed a good candidate for surgical weight loss.
Past Medical History:
hypertension
dysplipidemia
gallstones
laparoscopy for ovarian cysts
Social History:
Denies alcohol, tobacco, or drug use. She is married with one
daughter who is age 18.
Physical Exam:
BP 110/62, weight of 305 pounds
Gen: alert, awake, NAD
Neck: supple, no LAD
Pulm: CTAB
CV: RRR, no murmurs
ABd: soft, NT, no rebound/gaurding
Extr: warm, well-perfused
Pertinent Results:
[**2164-6-11**] 12:26PM BLOOD Hct-35.5*
[**2164-6-12**] 02:13AM BLOOD WBC-9.3 RBC-3.75* Hgb-11.2* Hct-32.9*
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.4 Plt Ct-146*
[**2164-6-13**] 02:28AM BLOOD WBC-9.4 RBC-3.81* Hgb-11.2* Hct-33.6*
MCV-88 MCH-29.4 MCHC-33.3 RDW-13.7 Plt Ct-136*
[**2164-6-14**] 05:32AM BLOOD WBC-7.3 RBC-3.54* Hgb-10.7* Hct-30.9*
MCV-88 MCH-30.3 MCHC-34.6 RDW-13.5 Plt Ct-149*
[**2164-6-12**] 02:13AM BLOOD PT-12.8 PTT-23.3 INR(PT)-1.1
[**2164-6-12**] 02:13AM BLOOD Glucose-122* UreaN-5* Creat-0.5 Na-140
K-3.5 Cl-105 HCO3-26 AnGap-13
[**2164-6-13**] 02:28AM BLOOD Glucose-110* UreaN-8 Creat-0.5 Na-142
K-3.4 Cl-108 HCO3-27 AnGap-10
[**2164-6-14**] 05:32AM BLOOD Glucose-83 UreaN-10 Creat-0.6 Na-144
K-3.9 Cl-107 HCO3-28 AnGap-13
[**2164-6-12**] 02:13AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.5*
[**2164-6-13**] 02:28AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.9
[**2164-6-14**] 05:32AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7
[**2164-6-12**] Upper GI Evaluation: patent anastamosis, no leak
Brief Hospital Course:
This is a 37year old female with morbid obesity and gallstones
who presented
for operative management. SHe underwent a laparoscopic roux-en-y
gastric bypass procedure with cholecystectomy on [**2164-6-11**]
(please see the operative note of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for full
details). Postoperatively she had some issues with pain control
and respiratory issues requiring an overnight stay in the
intensive care unit. She had an upper GI swallow evaluation on
post-op day 1 which revealed a patent anastamosis with no leak.
She was then started on a stage 1 diet. Her foley catheter was
removed and she was transitioned to roxicet off her PCA. She
ambulated on her own. On post-op day 2 she was started on a
stage 2 diet which was advanced to stage 3 which she tolerated
well. She was discharged to home on post-op day 4 in good
condition. All questions were answered to her satisfaction upon
discharge.
Discharge Medications:
1. Methadone 10 mg/5 mL Solution Sig: Eighty (80) ml PO once a
day for 2 days.
Disp:*160 ml* Refills:*0*
2. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO twice a
day.
Disp:*600 ml* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ml PO every 4-6 hours as needed for pain.
Disp:*200 ml* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Morbid obesity with comorbidities.
Discharge Condition:
stable
Discharge Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in two weeks. You may shower.
Please return to the hospital or call the office if you develop
fevers, red streaking around the wound, nausea, or vommitting.
Please follow the diet that you were taught by the
nutritionists. Please take an adult multi-vitamin a day.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in two weeks. His office number
is [**Telephone/Fax (1) 61050**].
Completed by:[**2164-7-18**]
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2117
} | Medical Text: Admission Date: [**2119-7-13**] Discharge Date: [**2119-7-18**]
Date of Birth: [**2053-11-10**] Sex: F
Service: MEDICINE
Allergies:
Zosyn / ceftriaxone / tuberculin ppd skin test
Attending:[**First Name3 (LF) 16115**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 65 year old female with history of multiple
sclerosis, dementia, neurogenic bladder with indwelling foley,
right staghorn calculus, left obstructing UVJ stone with
nephrostomy tube presented from [**Hospital1 1501**] with worsening lethargy and
no output from nephrostomy tube for the two days prior to
admission. The patient was also reported to have been satting at
77% on NBR when EMS arrived. The patient has been admitted three
times in the past year with urosepsis.
In the ER, the patient was febrile to 102.8 and tachycardic. She
had a leukocytosis to 16.4. Her foley catheter was exchanged and
foul-smelling urine emerged. She had numerous excoriations
within and around her vagina and decubitus ulcers on her sacrum.
The nephrostomy tube was encrusted, and when cleaned, purulent
discharge emerged. She also had erythema and fluctuance with
expressible pus around the nephrostomy site. The patient was
given vancomycin, aztreonam, and flagyl. She was transferred to
the MICU with a systolic pressure of 85 on peripheral low-dose
levophed.
Past Medical History:
Multiple Sclerosis - about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
- wheelchair at baseline, lives in nursing home
- has no use of her lower extremities, sometimes spastic
movements
- bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent in past
[**Last Name (un) 8304**] Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-27**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral Decub
LE spasticity
Hx of jaw pain -- ?TMJ, improved on [**First Name3 (LF) **]
Social History:
Lives in nursing home for last 4 [**First Name3 (LF) 1686**]. Husband is HCP, lives
with one of their daughters. [**Name (NI) **] daughter married and lives
in the area. Nonambulatory and in wheelchair at baseline,
dependent for transfers and some of ADLs. Has no use of lower
extremities at baseline. On pureed thickened liquids at rehab.
-Tobacco: started at age 20, quit about 15yrs ago
-ETOH: social, occasional, per husband
-[**Name (NI) 3264**]: none
Family History:
No family members with Multiple Sclerosis.
Physical Exam:
Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Physical Exam on Discharge
VS: RR16-18
Gen: Debilitated female in no acute distress
HEENT: EOMI with horizontal nystagmus, MMM
CV: RRR, no m/g/r
Resp: anterolateral exam limited, CTAB, no w/r/r
GU: Foley, nephrostomy in place, clear yellow urine
Neuro: unable to assess due to pt dementia/decompensation
MSK: unable to assess due to pt dementia/decompensation
Pertinent Results:
Abdominal XR ([**7-13**]): The left percutaneous nephrostomy tube is
in similar position
compared with prior imaging. If the patient continues to have
symptoms and clinical concern exists for malposition of tube, a
dedicated antegrade nephrostomy tube study would be recommended.
.
LABS ON ADMISSION
[**2119-7-13**] 09:35AM BLOOD WBC-16.4*# RBC-4.08* Hgb-11.5* Hct-37.5
MCV-92 MCH-28.2 MCHC-30.6* RDW-16.1* Plt Ct-533*#
[**2119-7-13**] 09:35AM BLOOD Neuts-87.6* Lymphs-7.8* Monos-4.2 Eos-0.2
Baso-0.2
[**2119-7-13**] 09:35AM BLOOD PT-31.0* PTT-43.6* INR(PT)-3.0*
[**2119-7-13**] 09:35AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-144
K-3.9 Cl-108 HCO3-25 AnGap-15
[**2119-7-13**] 09:35AM BLOOD cTropnT-<0.01
[**2119-7-13**] 09:35AM BLOOD CK-MB-2
[**2119-7-13**] 09:35AM BLOOD Albumin-2.3* Calcium-8.0* Phos-3.4 Mg-2.1
[**2119-7-13**] 10:14AM BLOOD Lactate-2.3*
.
LABS ON DISCHARGE
lab draws were discontinued due to patient and husband's wishes
for comfort measures only.
Brief Hospital Course:
The patient is a 65 year old female with history of MS,
dementia, neurogenic bladder with indwelling foley, b/l calculi
s/p left nephrostomy presenting with fatige and found to have
urosepsis.
.
ACUTE ISSUES
#Urosepsis:
The patient has long history of urinary tract infections with
MDR organisms including ESBL e. coli and pseudomonas due to her
abnormal anatomy. She has been considered for lithotripsy of
left UVJ stone in past but thought to be high risk due to
cardiac co-morbidities. The patient also has a staghorn calculus
in the right kidney. She presented febrile to 102.8 and with
systolic pressure in the 80s. Patient was found to have
foul-smelling urine from foley and purulent material emanating
from nephrostomy tube in the ER. She was started on low-dose
peripheral levophed and transferred to the MICU. She was started
on meropenem for likely ESBL E. coli and vancomycin. A Dobhoff
tube was inserted and the patient was started on tube feeds. A
goals of care discussion was had with the patient's husband, and
it was decided that the patient would seek comfort measures only
(see below). The patient was transferred to the floor for
continued management despite low pressures. On the floor she
remained clinically stable without the need for pressure
support. Her antibiotics were discontinued upon discharge.
.
#Goals of care:
The goals of care were discussed with the patient and husband in
both the ICU and the general medicine floor. After a long
discussion, it was decided that the patient would be continued
on IV antibiotics and tube feeds while inpatient. On the floor,
the patient removed her Dobhoff tube, and it was decided with
the husband not to reinitiate it. The patient's husband wished
to keep patient comfort at the forefront, but wanted to continue
interventions until the patient either declined or discontinued
them herself. Palliative care was consulted and it was planned
that the patient would return to her longterm care facility for
hospice services. IV antibiotics were discontinued, as they
would require PICC placement, which would not have been
consistent with pt and husband's goals of care. She was
discharged without antibiotics.
.
[**Month/Day/Year **] ISSUES
#Multiple sclerosis:
Long history of MS (14 years), quite debilitated, now
experiencing dementia. The patient's home baclofen and
cyclobenzaprine were continued while inpatient.
.
#COPD:
The patient had a history of COPD with nknown baseline status.
It was reported that the patient uses home O2 at unknown rate.
She was continued on her ipratropium and fluticasone at home
doses and she was given O2 by nasal canula as needed.
.
#Depression:
Patient has [**Month/Day/Year **] depression and has been on SSRI at home.
This was continued while inpatient.
.
TRANSITIONAL ISSUES
- Hospice care to be initiated once patient at [**Location (un) 583**] [**Hospital1 1501**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Hospital1 1501**] documentation.
1. Sertraline 100 mg PO DAILY
2. Baclofen 10 mg PO BID
3. carBAMazepine *NF* 300 mg Oral [**Hospital1 **]
4. Cyclobenzaprine 10 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Ipratropium Bromide Neb 1 NEB IH Q6H
7. methenamine hippurate *NF* 1 gram Oral [**Hospital1 **]
8. Simvastatin 20 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H:PRN pain
10. Bisacodyl 10 mg PR DAILY:PRN constipation
11. cranberry ext-C-L. sporogenes *NF* [**Medical Record Number 18595**] mg-mg-million
Oral daily
12. Docusate Sodium 100 mg PO BID
13. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Morphine Sulfate (Concentrated Oral Soln) 5-15 mg PO Q2H:PRN
pain
2. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO DAILY:PRN
agitation
3. Acetaminophen 1000 mg PO Q8H:PRN pain
4. carBAMazepine *NF* 300 mg Oral [**Hospital1 **]
5. cranberry ext-C-L. sporogenes *NF* [**Medical Record Number 18595**] mg-mg-million
Oral daily
6. methenamine hippurate *NF* 1 gram Oral [**Hospital1 **]
7. Sertraline 100 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Bisacodyl 10 mg PR DAILY:PRN constipation
10. Baclofen 10 mg PO BID
11. Cyclobenzaprine 10 mg PO BID
12. Docusate Sodium 100 mg PO BID
13. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
14. Ipratropium Bromide Neb 1 NEB IH Q6H
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House Rehab & Nursing Center
Discharge Diagnosis:
Primary diagnoses:
Urosepsis
L UVJ calculus causing obstruction s/p nephrostomy
Neurogenic bladder s/p indwelling foley catheter
Secondary diagnoses:
Multiple sclerosis
Advancing dementia
Discharge Condition:
Mental status: responds to questions, limited speech
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted with infections in your urinary tract that
causes your blood pressure to be low. You were given antibiotics
and feedings by tube while you were here. You, your husband, and
the medical team discussed your goals of care. It was decided
that we would make you as comfortable as possible before
discharging you back to [**Location (un) 583**] House.
You are being discharged to a nursing facility. Please follow-up
with the physician there or your PCP.
Completed by:[**2119-7-19**]
ICD9 Codes: 0389, 5990, 496, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2118
} | Medical Text: Admission Date: [**2102-4-8**] Discharge Date: [**2102-4-17**]
Date of Birth: [**2041-2-3**] Sex: F
Service: MEDICINE/ACOVE
HISTORY OF THE PRESENT ILLNESS: This is a 61-year-old woman
with left breast cancer status post chemotherapy and
radiation treatment in [**2099**] who was recently diagnosed with
liver metastases, who was admitted on [**2102-4-8**] with
complaints of fatigue, decreased oral intake, hypotension,
and acute renal failure secondary to acute tubular necrosis
and contrast-induced nephropathy. The patient's creatinine
was noted to be 5.7 on admission, and her normal baseline
creatinine is 1.2.
The patient initially was admitted to the Medical Intensive
Care Unit and was aggressively fluid resuscitated with a
return of her systolic blood pressure to a baseline of
100-110 and her creatinine improved to 1.6. The patient
became fluid overloaded in the Intensive Care Unit with net
25 liters positive fluid intake. She demonstrated
significant third spacing of her fluids with total body
anasarca.
The [**Hospital 228**] hospital course has been complicated by
leukocytosis without fever, and with an elevated total
bilirubin. In the Intensive Care Unit, the patient
empirically was started on ampicillin, levofloxacin, and
Flagyl for a question of biliary sepsis. An abdominal
ultrasound on [**2102-4-9**], however, showed no common bile
duct dilatation, and no evidence of cholecystitis. In
addition, an MRCP was performed on [**2102-4-11**] which showed
no intra or extrahepatic duct dilatation but did show diffuse
metastatic disease to the liver and splenomegaly with diffuse
anasarca. The ERCP Service was consulted and felt that there
was no need for ERCP at this time given these imaging
findings.
The patient also has been complaining of severe back pain.
An MRI of the L spine was obtained which showed no evidence
of metastatic disease to the L spine and the pain was thought
to be secondary to capsular distention from her extensive
hepatic metastatic disease. The Pain Service was consulted
and the patient was placed on a Ketamine drip briefly but
then was transitioned to Dilaudid and morphine orally p.r.n.
with good pain relief. An epidural catheter was considered;
however, after further discussion with the patient, the
patient's family, and Dr. [**First Name (STitle) **], the patient's oncologist, it
was thought that the epidural catheter would not be the best
decision given the management issues surrounding taking care
of an epidural catheter. The patient was also started on
Xeloda for her metastatic breast cancer while in the
Intensive Care Unit.
She was transitioned out of the Intensive Care Unit on [**2102-4-15**].
PAST MEDICAL HISTORY:
1. Left breast cancer in [**2099**], status post chemotherapy and
radiation treatment in [**2100-10-23**], status post
lumpectomy and axillary lymph node dissection. Liver
metastases diagnosed in [**2102-3-23**].
2. Hypothyroidism.
3. Hypertension.
4. Depression.
5. Sciatica.
ADMISSION MEDICATIONS:
1. Atenolol 50 mg p.o. q.d.
2. Roxicet one tablet p.o. q. six hours.
3. Levoxyl.
4. Fioricet one tablet q.a.m.
5. Paxil 20 mg p.o. q.d.
6. Tamoxifen 20 mg p.o. q.d.
SOCIAL HISTORY: The patient smoked one pack per day times 20
years, now quit. She had minimal alcohol use. She is
self-employed and has a 21-year-old step-son.
FAMILY HISTORY: Positive for liver cancer in her father at
age 86, mother with coronary artery disease in her 80s.
PHYSICAL EXAMINATION ON ADMISSION: General: On admission,
the patient was a pleasant elderly woman in no acute
distress. She had difficulty speaking secondary to a dry
mouth. Vital signs: Temperature 98, blood pressure 111/37,
heart rate 72, respiratory rate 18, oxygen saturation 99% on
room air. HEENT: Pupils equal, round, and reactive to
light. Extraocular movements intact. Sclerae anicteric.
The oropharynx was dry and perched. No lymphadenopathy. No
jugular venous distention. Cardiovascular: Normal S1 and S2
with a regular rate and rhythm without murmurs, rubs, or
gallops. Pulses paradoxus was less than 10. Lungs: Minimal
crackles at the right base, otherwise clear to auscultation.
Abdomen: Soft, diffuse tenderness, especially in the right
upper quadrant without masses. Decreased bowel sounds
throughout with liver edge palpable below the rib cage.
Extremities: There was 1+ edema bilaterally in the lower
extremities below the knees. Neurologic: Alert and oriented
times three. Cranial nerves II through XII were intact.
Strength was [**2-25**] bilaterally.
LABORATORY/RADIOLOGIC DATA: White count 12.1, hematocrit 32,
platelets 243,000. The Chem-7 was within normal limits. The
LFTs were remarkable for an ALT of 198, AST 526, alkaline
phosphatase 451, total bilirubin 2.0, albumin 3.0. CEA on
[**2102-4-5**] was 203, CA19-9 32 and CA27.29 459.
Chest x-ray: Enlarged heart with atelectasis at the left
costophrenic angle and low lung volumes. No pneumothorax.
No pleural effusions. No pulmonary opacities.
HOSPITAL COURSE: As noted above, the patient was transferred
out of the Intensive Care Unit on [**2102-4-15**]. However, on
[**2102-4-16**], the patient became hypotensive with blood
pressures running 70/40 without response to fluid boluses.
In addition, the patient's urine output significantly
declined to less than 100 cc in an eight hour shift. The
patient's Foley catheter was replaced times two without any
success in urine output. A bladder scan was obtained which
showed 330 cc present; however, it was felt that this result
was likely erroneous given the patient's anasarca. The Foley
was removed and a voiding trial was attempted; however, the
patient did not urinate successfully and, therefore, the
Foley catheter was replaced.
The patient's creatinine rose from 1.6 to 1.9 on [**2102-4-16**]. It was thought that her hypotension may have been
secondary to increasing dose of narcotics, as well as the
patient was likely intravascularly volume depleted. The
patient's volume issues were extremely difficult to handle as
the patient clearly demonstrated anasarca with third spacing
issues; however, the patient likely was intravascularly
volume depleted. The patient's nutritional status was
extremely poor as she was unable to eat much orally and it
was decided during her Intensive Care Unit stay that TPN
should not be initiated given her fluid spacing issues. The
patient's albumin was noted to be 1.8 which was likely
contributing to her third spacing.
Given the patient's poor prognosis and profound hypotension,
a brief family meeting was initially held with the patient's
brother and sister in-laws without the husband being present.
At that time, it was decided that aggressive measures to
increase her blood pressure via pressors was not indicated.
It was also reiterated that the goal of care at this time was
comfort. Further discussion occurred with the cross-covering
medicine team and the patient's husband and at that time it
was again re-emphasized that the role of pressor treatment in
the Intensive Care Unit would likely be only a transient
measure as the patient does have progressive metastatic
breast cancer and was likely not to recover.
On [**2102-4-17**], the patient became progressively
unresponsive and more hypotensive with near aneuric urine
output. The patient was made CMO on the morning of [**2102-4-17**] after further discussion with the husband and the
patient's proxy. The patient was made comfortable with a
morphine drip and all other medications were terminated.
The patient expired shortly thereafter at 9:30 p.m. on [**2102-4-17**].
CONDITION ON DISCHARGE: Expired.
DISCHARGE DIAGNOSIS: Metastatic breast cancer with extensive
liver metastases.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], M.D. [**MD Number(1) 1208**]
Dictated By:[**Last Name (NamePattern1) 1336**]
MEDQUIST36
D: [**2102-4-26**] 04:05
T: [**2102-4-29**] 14:17
JOB#: [**Job Number 16056**]
ICD9 Codes: 5845, 0389, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2119
} | Medical Text: Admission Date: [**2119-2-5**] Discharge Date: [**2119-2-10**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1865**]
Chief Complaint:
unwitnessed fall
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Ms. [**Known lastname 104277**] is a [**Age over 90 **] yo blind female with a dementia and h/o
colon cancer in [**2083**], rectal prolapse, gait disturbance and
osteoporosis who was found down in nursing home. It is unknown
how long she was down, or if there was LOC (though patient
denies), unknown if she hit her head/neck. Patient has had
rectal prolapse for many years per her assistant and uses stool
softeners and has refused treatment in past. Patient says she
has had BRBPR for many years. She also has longstanding RLE
weakness and uses a walker to get around. She says she has
frequent falls.
.
In the ED, her C-spine films were negative as was a head CT. A
surgery consult was called and they reduced the rectal prolapse
at bedside. She did have n/v x1 which resolved with anzemet. Her
VS were stable. She was given 2L IVF and a tetnus shot. Her EKG
showed slight ST depression in V4 and V5 (likely from poor
baseline). U/A and BCx were sent in addition to labs.
.
Patient is demented but ROS on the floor is as follows: she
denies pain except for a burning in her eyes which is long
standing. She denies SOB, CP, dysuria (she has a foley in),
abdominal pain or rectal pain. She denies n/v, f/c.
Past Medical History:
1. Osteoporosis.
2. Colon Cancer in [**2083**].
3. Memory loss.
4. Hypothyroidism
5. History of frequent falls
6. rectal prolapse
7. Infiltrating lobular carcinoma of the breast
8. Mild renal insufficiency baseline creatinine 1.3-1.5
.
PAST SURGICAL HISTORY:
1. Left Hemicolectomy in [**2083**].
2. Open reduction/internal fixation of the left hip in [**2107**].
3. Cataract surgery.
4. Left modified radical mastectomy Dr [**Last Name (STitle) 11635**] [**2113**]
Social History:
The patient lives in the [**Hospital3 537**]. She
has been a widow for eight years.
Family History:
Family history is significant only for a
maternal niece with breast cancer at the age of 78.
Physical Exam:
Vitals - 97, 112/60, 16, 96% RA, FS 173. Weight 56.2 kg
General: ill appearing elderly female smelling of melena
HEENT: Pt would not open mouth for exam. left eye opaque.
LUNGS: diminished breath sounds bilaterally without w/r/r
CV: RRR with 3/6 systolic murmur heard best at USB
ABDOMEN: +BS, midline scar, soft, NTND
EXTREMITIES: R elbow skin tear. No e/c/c. R lateral malleolous
is edematous but non-tender. Echymoses surrounding IV sites.
RECTAL: rectal prolapse with small amount of BRBPR
Pertinent Results:
STudies:
CT C spine [**2119-2-5**]
IMPRESSION: Marked degenerative changes. No acute fracture.
Dilated upper esophagus with fluid level. Please correlate
clinically.
.
Xray pelvis: [**2119-2-5**]
IMPRESSION:
1. Limited study due to overlying bowel gas.
2. No evidence of displaced fracture involving the right hip.
3. Faint lucency along the right iliac [**Doctor First Name 362**] could represent an
artifact, however, cannot rule out a fracture
.
CT pelvis: [**2119-2-5**]
IMPRESSION: No evidence of acute femoral or acetabular fracture.
.
[**2119-2-5**] CXR:
IMPRESSION: No evidence of acute cardiopulmonary process. Large
hiatal hernia.
.
[**2119-2-7**]
EGD:
Impression: Large hiatal hernia
Ulcers in the gastroesophageal junction above the hiatal hernia
Normal mucosa in the stomach
Normal mucosa in the duodenum
.
Pertinent labs:
CE x3 negative
U/A on admission was negative
U/A on discharge is pending and culture pending. Will need to
be followed up.
.
Hct on admission was 44.6 and dropped to 29.7 the next morning
and then repeat was 24.1. After transfusions and EGD, Hct on
discharge was stable at 30.2.
.
Chemistries on discharge: Glucose-106* UreaN-23* Creat-1.2*
Na-144 K-3.9 Cl-111* HCO3-21*
.
CBC on discharge: WBC-9.7 RBC-3.40* Hgb-10.5* Hct-30.2* MCV-89
MCH-31.0 MCHC-34.9 RDW-16.9* Plt Ct-213
Brief Hospital Course:
Ms. [**Known lastname 104277**] is a [**Age over 90 **] year old female with a history of
dementia, chronic falls with gait disturbance, chronic rectal
prolapse, colon cancer in [**2083**] who presented s/p unwitnessed
fall and rectal prolapse. While on the medical floor, pt was
noted to have melanotic stools x2, as well as BRBPR (chronic),
and 1 episode of coffee ground emesis. Her hct decreased from
44.6 on admission to 29.7 the next morning with repeat at 24.1
(recent baseline in [**8-10**] was 30). Her BP was 80/50 transiently,
but this improved after IVF. She received 2 U PRBC's. MICU
admission was requested for frequent vital monitoring and hct
checks prior to endoscopy. She went to MICU on [**2119-2-7**]. Her hct
was stable in the ICU and she remained hemodynamically stable.
She went for EGD the afternoon of [**2119-2-8**] and was transferred
back to the floor. Her hospital course is described by problem
below.
.
# GI Bleed - Extensive discussion with the patient and her
daughter revealed that they did not want a colonoscopy done nor
did they want extensive procedures or surgeries. The patient's
DNR/DNI status was confirmed and treatments would be
symptomatic. A EGD was acceptable in case there was an on going
bleed which could be easily intervened on. EGD showed large
sliding hiatal hernia and a few non-bleeding ulcers in teh GE
junction above the hernia. These ulcers were believed to be the
source of bleeding. She was monitored with serial Hct which were
stable (30.2 on discharge). She was being treated with twice
daily pantoprazole for the ulcers and stool softeners for her
chronic rectal prolapse. She continues to have guiac positive
stools. Hct should be checked on [**2119-2-13**] to ensure no active
blood loss needing transfusion. She will be discharged on
omeprazole [**Hospital1 **].
.
# Hypernatremia: After the episode of GI bleeding, she became
hypernatremic to 152. Her free water deficit was calculated to
be 2.3L and she was repleted with D5W and her hypernatremia
resolved.
.
# Rectal prolapse/BRBPR: chronic issue. Surgery was consulted in
the ED and reduced the rectal prolapse. Again per family and
patient, patient has not wanted further aggressive treatment for
this condition. She does have h/o colon cancer. Last CEA in [**8-10**]
was 4.1 from 2.6 in [**2113**]. Of course a colonoscopy would be
recommended, but the patient and family have declined. She
should be continued on stool softeners to help prevent rectal
straining.
.
# Fall: The patient originally presented with an unwitnessed
fall. Imaging studies revealed no fractures. She was ruled out
for an MI with CE x3 being negative and no events on telemety.
Her fall was likely related to her GI bleed and dehydration. In
addition, this could likely be mechanical given history of
recurrent falls, blindness, and dysequillibrium. Physical
therapy worked with the patient while in house and found her to
be quite weak and needing extensive assisstence. They
recommended rehab for physical therapy as the patient currently
lives in [**Hospital3 **] with help only during the week days.
The patient's daughter agreed.
.
# low grade fevers: She had a low grade fever of 100.1 one time,
and a U/A and culture was pending at discharge. This will need
to be followed up in case she had a UTI.
.
# Hypothyroidism: continued levothyroxine.
.
# CRI: Cr is around baseline 1.2 (1.3-1.5). Her Cr was stable
through admission.
.
# Dementia: continued home medications.
.
# Eye burning: chronic issue. Patient legally blind. Her eye
drops were continued.
.
#FEN: regular diet with ensure supplements TID; replace lytes
prn. Hypernatremia as above. Hypophosphatemia and hyokalemia
were issues while in house. Please check electrolytes as in
discharge instructions on [**2119-2-13**] and replete as needed.
.
#PPX: pneumoboots for DVT ppx given bleeding, PPI for GI ppx,
bowel regimen
.
#Codes status: DNR/DNI. Confirmed with daughter [**Name (NI) **] [**Last Name (NamePattern1) 14**]
who is the HCP, as [**Name2 (NI) **] of patient is main concern. No
invasive procedures or surgery.
.
# Contacts:
Daughter: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14**] [**Telephone/Fax (1) 104278**](c) [**Telephone/Fax (1) 104279**] (h)
[**Telephone/Fax (1) 104280**] X 404 work
[**Doctor First Name **] (caretaker): [**Telephone/Fax (1) 104281**] (c) [**Telephone/Fax (1) 104282**] (h)
.
# Dispo: [**Location (un) **] rehab in [**Location (un) 620**]. Patient has follow up with
Dr. [**Last Name (STitle) **] (PCP) on [**2-20**] at 11:10AM. [**Hospital1 18**] [**Telephone/Fax (1) 250**].
Medications on Admission:
Prilosec.
Multivitamin.
Synthroid 25 MCG P.O. q. d.
Namenda *NF* 10 mg Oral [**Hospital1 **]
Arimidex *NF* 1 mg Oral QAM Ascorbic Acid 500 mg PO QAM
Donepezil 10 mg PO QAM
Levobunolol *NF* 1 DROP OU [**Hospital1 **]
PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE [**Hospital1 **]
Vitamin E 400 UNIT PO BID
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
2. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
6. Hexavitamin Tablet Sig: One (1) Cap PO QAM (once a day
(in the morning)).
7. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
11. Levobunolol 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
12. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO every twelve (12) hours.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Outpatient Lab Work
Please check CBC and electrolytes including sodium, potassium,
BUN, Cr, Cl, Bicarb, magnesium, phosphate, calcium glucose on
[**Hospital1 766**] [**2119-2-13**].
15. DVT ppx
Please place pneumoboots to lower extremities.
16. Neutra-Phos [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) PO three
times a day for 1 days: please start in AM on [**2119-2-11**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Primary diagnosis:
UGI bleed- ulcers
s/p fall
rectal prolapse with chronic BRBPR
hypernatremia
.
Secondary diagnosis:
hypothyroidism
CRI with basline Cr 1.3-1.5
h/o colon cancer
Discharge Condition:
Stable Hct and vital signs. Tolerating oral intake.
Discharge Instructions:
You were admitted after a fall. You likely fell because you
were dehydrated from bleeding in your stomach. You were found to
have ulcers in your stomach and should now take prilosec twice a
day instead of once a day.
.
You have a urinalysis and culture pending at the time of
discharge. You will need to have this followed up as an
outpatient. You will receive a call if your culture is positive
for infection and you will then need antibiotics.
.
Please check CBC and electrolytes including sodium, potassium,
BUN, Cr, Cl, Bicarb, magnesium, phosphate, calcium glucose on
[**Location (un) 766**] [**2119-2-13**]. Please replete as needed. Please fax the results
to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 3382**].
.
Given your hospitalization, you will need physical therapy to
help rebuild your strength. This is why you are going to a
rehab facility.
.
Please continue your medications as prescribed.
.
Please return to your physician or to the emergency room if you
have fevers >101, chills, black or tarry stools, large amounts
of blood from the rectum or bloody emesis, lightheadedness or
any other symptoms which are concerning to you.
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **], your PCP, [**Name10 (NameIs) 766**]
[**2119-2-20**] 11:10AM. Please call [**Telephone/Fax (1) 250**] if you need
to change this appointment.
Completed by:[**2119-2-10**]
ICD9 Codes: 2851, 5859, 2760, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2120
} | Medical Text: Admission Date: [**2162-12-20**] Discharge Date: [**2162-12-23**]
Date of Birth: [**2094-2-6**] Sex: M
Service: NEUROLOGY
Allergies:
fresh frozen plasma
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
word finding difficulties
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 68 y/o RHM with a history of a stroke (R
paramedian pontine w/ left sided deficits in [**4-2**]) who
presented to [**Hospital3 **] today after a day of not talking
right. Symptoms were noted yesterday around 2 pm by family
members, they noted that he seemed confused at times and was not
using the right words. He refused to go to the ED yesterday and
showed up today after symptoms did not resolve and perhaps a
little worse. He is on Coumadin and his last dose was yesterday
at 5pm. His only complaint at this time is a slight headache but
otherwise does not note the language difficulty and describes
yesterday as only feeling "rotten".
At OSH he was given 10mg vit K and was being given FFP but had
an
allergic reaction to the FFP, he was transferred here afterward.
on ROS: he denies CP, SOB, fever or chills, visual changes, his
only complaint is being hungry. family also denies him having
atrial fibrillation but did note that at the time of the stroke
he was on a heart monitor and that there might have been
something abnormal.
Past Medical History:
HTN
HLD
CVA (right paramedian pontine stroke)
OSA?
Social History:
Social Hx: no bad habits expressed by family
Family History:
Family Hx: Mom with DM
Physical Exam:
Physical Exam on Admission:
Vitals: T:100.3 P:70 R: 20 BP:140/92 SaO2:100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, dry MM,
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No C/C/E bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self. Unable to fully
comprehend questions, could sometimes follow simple commands,
frequent paraphasic errors (phenomic / semantic). Unable to
repeat. Speech was not dysarthric.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Right lower quadrantanopia?.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop appreciated.
VIII: Hearing intact to tunning fork bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone increased on the left. + pronation of
the left arm. No tremor, asterixis noted.
Strength appreciated as full bilaterally in the proximal and
distal muscles.
-Sensory: not tested.
-DTRs: [**Name2 (NI) **] 2 on the right 2+ on the left.
Plantar response was extensor on the left.
-Coordination: No intention tremor, No dysmetria on FNF
bilaterally.
-Gait: not tested
Physical Exam On Discharge:
Vitals: T:97.6 P:60-70's R: 20 BP: 120-140's SaO2:100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, dry MM,
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No C/C/E bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self. Unable to fully
comprehend questions, could follow simple commands about 75% of
the time,
frequent paraphasic errors (phenomic / semantic). Difficulty
with repetition. Difficulty with [**Location (un) 1131**] and with writing
(would make multiple paraphasic or semantic errors). Speech was
not dysarthric.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop appreciated.
VIII: Hearing intact to tunning fork bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone increased on the left. + pronation of
the left arm. No tremor, asterixis noted. Strength appreciated
as full bilaterally in the proximal and distal muscles.
-Sensory: intact to light touch bilaterally
-DTRs: [**Name2 (NI) **] 2 on the right 2+ on the left.
Plantar response was extensor on the left.
-Coordination: No intention tremor, No dysmetria on FNF
bilaterally.
-Gait: not tested
Pertinent Results:
Labs on admission:
[**2162-12-20**] 03:10PM PT-32.9* PTT-38.1* INR(PT)-3.3*
[**2162-12-20**] 03:10PM PLT COUNT-252
[**2162-12-20**] 03:10PM NEUTS-70.4* LYMPHS-22.8 MONOS-5.4 EOS-1.1
BASOS-0.4
[**2162-12-20**] 03:10PM WBC-10.1 RBC-4.96 HGB-14.8 HCT-42.8 MCV-86
MCH-29.8 MCHC-34.5 RDW-12.7
[**2162-12-20**] 03:10PM estGFR-Using this
[**2162-12-20**] 03:10PM GLUCOSE-87 UREA N-21* CREAT-1.2 SODIUM-139
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-29 ANION GAP-14
Labs on discharge:
[**2162-12-23**] 04:35AM BLOOD WBC-10.0 RBC-4.68 Hgb-13.9* Hct-40.5
MCV-87 MCH-29.8 MCHC-34.4 RDW-13.0 Plt Ct-230
[**2162-12-23**] 04:35AM BLOOD PT-12.0 INR(PT)-1.1
[**2162-12-23**] 04:35AM BLOOD Glucose-85 UreaN-31* Creat-1.2 Na-138
K-3.8 Cl-99 HCO3-31 AnGap-12
[**2162-12-23**] 04:35AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.9
[**2162-12-21**] 02:04AM BLOOD Triglyc-147 HDL-30 CHOL/HD-4.2 LDLcalc-66
Imaging studies:
CT-HEAD [**2162-12-20**]:
Stable large left temporal hemorrhage since prior study at 11am.
Minimal mass effect on the left lateral ventricle. Stable
paramedian pontine infarction.
CT-HEAD [**2162-12-21**]:1. In comparison to [**2162-12-20**] exam, there is
minimal increase in focus of intraparenchymal hemorrhage
centered within the left temporal region with associated
vasogenic edema and mass effect on the left lateral ventricle.
No new area of intracranial hemorrhage is noted. A hypodense
area within may relate to ongoing hemorrhage with small fluid
level or cystic focus. Correlate clinically to decide on further
workup for excluding underlying vascular or neoplastic etiology.
2. Remote pontine infarction, unchanged.
MR HEAD [**2162-12-21**]: 1. Redemonstration of the left parietal
intraparenchymal hematoma, with small amount of fluid level in
the center. Mild peripheral slightly irregular enhancement noted
which may relate to the subacute stage of the hematoma. There
is NO obvious nodular thick rind of enhancing tissue to suggest
obvious tumor. A few vascular structures noted adjacent and
in/close proximity to the
hematoma. MRA may be helpful for better assessment for vascular
lesions. A
followup can be considered to assess for stability/progression.
Persistent
moderate vasogenic edema and mass effect on the atrium of the
left lateral
ventricle.
2. A small focus of negative susceptibility in the right
temporal lobe which may relate to
microhemorrhage/mineralization/amyloid angiopathy. Other details
as above.
ECHO [**2162-12-22**]: Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
regurgitation seen. The left ventricular inflow pattern suggests
impaired relaxation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No apparent cardiac source
of embolism although limited acoustic windows. Mild symmetric
left symmetric left ventricular hypertrophy with preserved
global biventricular systolic function. Mild aortic
regurgitation. Mildly dilated thoracic aorta.
Brief Hospital Course:
68 yo M with recent paramedian pontine stroke on
aspirin/coumadin, who presented with expressive aphasia >24hrs
and was found to have a L parietal bleed that remained stable
over 4 hrs, with INR that was reveresed with profiline in the
ED. Deficits on exam continued to be expressive and some
receptive aphasia, both of which improved throughout the
hospitalization.
.
# NEURO: patient's aspirin and coumadin were held. Plan to
restarte the ASA 7 days after the onset of the hemorrhage
([**12-26**]). Plan to hold coumadin until patient can be seen in f/u
in 6 weeks with repeat MRI imaging. This plan was discussed
with pt's wife, including that it carries the inherent risk of
clot formation if he goes back into afib. She agreed that the
risk of bleeding was too high with coumadin, and she agreed with
the plan to hold coumadin. Patient's language deficits improved
daily while here, but at discharge he was stil having some
paraphasic and semantic errors in spontaneous speech, as well as
similar errors with [**Location (un) 1131**] out loud and writing. He was unable
to repeat more than [**1-24**] words at time and he would frequently
make mistakes. He could point to objects that he frequently
could not noame, He followed about 75-80% of commands correctly
and frequently required repetition of commands to complete them.
# CARDS: per pt's wife, he was put on coumadin initially because
during his first stroke in the ICU he was noted to have an
irregular heart rythm. While here, we held his coumadin as
above. We used PRN hydralazine to keep his SBP <160. We
continued his home amlodipine, lisinopril, metoprolol and HCTZ.
However, we held his statin because of increased bleeding risk.
This will be held until his f/u appt, and at that point it can
be determined if it needs to be restarted or not. His LDL was
66 on this admission.
# HEME: patient was reversed in the ED with activated factor IX
because of an allergic rxn to FFP at the OSH. He did not
require any more activated Factor IX while here, and at dispo
his INR was 1.1.
# ENDO: while an inpatient we kept Mr. [**Known lastname 90915**] on an insulin
sliding scale.
# CODE: Full
PENDING LABS:
NONE
TRANSITIONAL CARE ISSUES:
Patient will likely have his coumadin restarted at a later date
after his repeat MRI is completed in 6 weeks. His outpatient
neurologist will make this decision. In addition, his
outpatient neurologist will make the decision of when to restart
his statin given the possible increased risk of bleeding it can
cause.
Medications on Admission:
- Norvasc 5
- HCTZ 25
- ASA 81
- Metoprolol tartrate 50 [**Hospital1 **]
- lisinopril 20 [**Hospital1 **]
- Simvastatin 40
- Coumadin
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: DO NOT START
TAKING UNTIL [**2162-12-26**].
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Intracerebral hemorrhage
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
NEURO EXAM: expressive and receptive aphasia, mild LUE weakness
Discharge Instructions:
Dear Mr. [**Known lastname 90915**],
You were seen in the hospital for difficulty speaking. You were
determined to have had a bleed in your brain. We did an MRI,
and were not able to determine the source of the bleed. We held
your coumadin and aspirin while you were here. You will start
your aspirin again on [**12-26**]. You will not restart your
coumadin until you are told to do so by your neurologist in
[**Month (only) 404**]. You will have an MRI on [**1-31**] and then be seen
in clinic that same day when it will be decided if you should
restart coumadin.
We made the following changes to your medications:
1) We STOPPED your ASPIRIN. We want you to restart this on
[**12-26**] (7 days after your symptoms started).
2) We STOPPED your COUMADIN. We do not want you to restart this
until told to do so by your neurologist.
3) We STOPPED your SIMVASTATIN. We do not want you to restart
this until told to do so by your neurologist.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Department: [**Hospital1 **] MRI (MOBILE)
When: MONDAY [**2163-1-31**] at 10:35 AM
With: MRI [**Telephone/Fax (1) 327**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Please call [**Telephone/Fax (1) 10676**] to speak with registration to update
your information prior to your follow-up appointment.
Department: NEUROLOGY
When: MONDAY [**2163-1-31**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You will be called for an appointment for a swallowing study to
see if you have made any progress in your swallowing.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 431, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2121
} | Medical Text: Admission Date: [**2170-11-7**] Discharge Date: [**2170-11-15**]
Date of Birth: [**2111-4-23**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 59 year old
male with a history of hypertension, hypercholesterolemia and
DVT in [**6-/2170**], now on Coumadin, who presented to his primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], this a.m. with a chief complaint of
squeezing substernal chest pressure that he began to
experience three days prior to admission. Three days ago, the
patient developed new-onset chest pressure with exertion
walking from the car to house with radiating pain into his
bilateral shoulders. He admits to some nausea but no
diaphoresis, shortness of breath. He at first believed that
it was secondary to indigestion and tried drinking milk
without relief. The night before admission, he again
experienced a substernal chest pressure and decided to see
his primary care physician [**Last Name (NamePattern4) **] [**2170-11-7**] who sent him to the
Emergency Room. He has never had chest pressure or pain in
the past. He states that each time the pain lasted for
approximately 5 minutes and resolved spontaneously.
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia and
DVT in [**6-/2170**], presently on Coumadin.
SOCIAL HISTORY: The patient is from [**Country 2045**] and works as a cab
driver. He denies any tobacco or alcohol use.
FAMILY HISTORY: Noncontributory. There is no history of CAD,
diabetes mellitus or hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient's medications at time of Cardiac
Surgery consult were aspirin, atorvastatin, Integrilin,
heparin drip, Lopressor, morphine prn and sublingual
nitroglycerin.
PHYSICAL EXAMINATION: Vital signs reveal a temperature of
97.9, pulse 66, blood pressure 104/63, oxygen saturation of
100 percent. Generally, the patient was in no apparent
distress, alert and oriented times three. HEENT - his head
was normocephalic, atraumatic. The pupils are equal, round
and reactive to light. Extraocular movements are intact.
There are no carotid bruits bilaterally. His heart rate was
regular rate and rhythm with no murmurs, rubs or gallops,
positive S1 and S2. His lungs were clear bilaterally. His
abdomen was soft, nontender, nondistended with active bowel
sounds, no organomegaly. His extremities were non cyanotic
without clubbing. The patient had trace pedal edema and 1
plus DP pulses bilaterally.
LABORATORY: The patient's preop laboratory work was as
follows. His white count was 13.8, hematocrit 39.2, platelets
229. His UA was negative. His sodium was 139, potassium 5.1
which was elevated and was hemolyzed. His chloride was 105,
bicarb 22, BUN 10, creatinine 1, glucose 148, CK 288, CK-MB
18, troponin I of 0.1. Chest x-ray showed a tortuous thoracic
aorta. His EKG showed a rate of 77 sinus rhythm, old inferior
infarct and also showed anterior/septal and lateral ST-T
changes possibly due to myocardial ischemia. The patient
underwent a cardiac catheterization on [**2170-11-8**]. Cardiac
catheterization showed the patient had three vessel coronary
artery disease. His LMCA was normal. His LAD was subtotal mid
occluded with TIMI 2 flow. His left circumflex was long mid
90 percent stenosis. RCA had a proximal occlusion with
collateral filling of the distal vessel. The patient's
ejection fraction was 65 percent. An intraaortic balloon pump
was inserted via the right femoral artery and was prepared
for an urgent coronary artery bypass graft surgery.
HOSPITAL COURSE: As stated earlier, the patient came to the
hospital on [**11-7**] for chest pain and had EKG changes that
were conclusive for myocardial ischemia. He underwent cardiac
catheterization on [**11-8**] which showed severe three vessel
disease. An intraaortic balloon pump was inserted and the
patient needed to be urgently brought to the Operating Room
for bypass surgery. Once he was in the Operating Room, he
underwent a coronary artery bypass graft surgery times three
with LIMA to LAD, saphenous vein graft to RCA and saphenous
vein graft to OM. The indications for the urgent CABG was
impending LAD occlusion. The patient tolerated the procedure
well. His total cardiopulmonary bypass time was 86 minutes.
Cross-clamp time was 52 minutes. Following the procedure, the
patient was brought to CSRU. He was receiving a nitroglycerin
drip at 0.5 mcg/kg/min and being titrated on propofol. His
heart rate was 88, normal sinus rhythm. Mean arterial
pressure was 87. CVP was 11. PA diastolic was 9. PA mean was
20.
On postop day 2, the patient was weaned off of nitroglycerin.
The patient was still was on an IABP at 1:1. The patient had
to receive 2.5 liters of crystalloid for decreased pressures
and CVP and he had a good response. He was hemodynamically
stable. His heart rate was 75, sinus rhythm with blood
pressure of 112/55. CVP was 8. PA pressures were 27/13. The
plan was to wean the balloon pump and then discontinue it. We
continued to recheck his hematocrit. Today, his hematocrit
was 24.3 and if it isn't stable or increase, then the patient
may have to received packed red blood cells and continue to
stay in the ICU until further improvement. Also, on postop
day 1, the patient was weaned from the ventilator and
successfully extubated and breathing on his own.
On postop day 2, the patient was hemodynamically stable.
Blood pressure was 135/74. He was receiving 6 liters nasal
cannula with oxygen saturation at 95 percent. His heart rate
was slightly increased at 97. Neurologically, on physical
examination, he was alert and oriented times three, moving
all extremities. His heart rate was regular rate and rhythm.
His lungs were clear bilaterally. The patient appeared to be
doing well. He was going to be started on Lasix and
Lopressor.
On postop day 3, the patient continued to appear stable and
his vital signs were good. His chest tubes were discontinued
today along with his epicardial pacing wires and he was
transferred to [**Hospital Ward Name **] telemetry floor.
On postop day 5, the patient was hemodynamically stable and
labs included a white count of 14.4, hematocrit of 31.1,
platelets 335, INR 1.3, PTT of 27. His physical examination
was unremarkable besides 1 plus edema in his lower
extremities. His incisions were clean and dry, not draining
any fluid nor were they erythematous. The plan was to start
heparin since the patient had a history of DVT, continue
Coumadin and have the patient increase his mobility and get
him out of bed and have PT continue to see the patient. The
plan was to discharge the patient in the next 24-48 hours
depending on the level.
On postop day 6, the patient continued to be stable and was
improving with his level status and ambulating well. The plan
was to discharge the patient when his INR increased over 2.
The patient's physical examination was unremarkable again
besides 1 plus edema.
On postop day 7, the patient was Level 5. He was
hemodynamically stable. Blood pressure was 116/69,
respiratory rate 20, pulse of 88, sinus rhythm. His
hematocrit today was 28.1. His physical examination on the
day of discharge was as follows: Neurologically, he was
alert and oriented with no focal deficits. His lungs were
clear bilaterally. His heart rate was regular rate and
rhythm. His sternal incision was clean, dry and intact with
no drainage and no erythema. His abdomen was soft, nontender,
nondistended with positive bowel sounds. His extremities were
warm, nonedematous. His leg incision was clean and dry. The
patient was discharged to home with VNA services in good
condition. He was told to follow up with Dr. [**Last Name (STitle) **] in two to
three weeks and Dr. [**Last Name (STitle) 70**] in six weeks and have his INR
checked on [**11-16**] and [**11-19**].
FINAL DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
graft times three. The grafts were LIMA to LAD, saphenous
vein graft to RCA, saphenous vein graft to OM.
2. Hypertension.
3. Hypercholesterolemia.
4. Status post right DVT in [**6-/2170**], currently on Coumadin.
DISCHARGE MEDICATIONS:
1. Percocet 5/325 and the patient is told to take one to two
tablets po q4-6h as needed.
2. Colace 100 mg po bid.
3. Lipitor 20 mg daily.
4. Aspirin 81 mg daily.
5. Coumadin 1 mg daily with a goal INR of [**2-12**].5. The patient
was scheduled to have it rechecked on [**11-16**] and [**11-19**].
6.
Lasix 20 mg po bid.
7. Lopressor 50 mg, take two tablets po bid.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 25060**]
MEDQUIST36
D: [**2170-12-12**] 11:32:35
T: [**2170-12-12**] 13:29:10
Job#: [**Job Number 50376**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2122
} | Medical Text: Admission Date: [**2149-7-7**] Discharge Date: [**2149-7-14**]
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
worsening shortness of breath, severe aortic stenosis, here to
get corevalve
Major Surgical or Invasive Procedure:
corevalve [**2149-7-8**]
History of Present Illness:
Cardiac Surgeon: Dr. [**First Name (STitle) **] [**Name (STitle) **], MD
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Referring Physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
PCP:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Reason for Consult: severe aortic stenosis
Chief Complaint: worsening shortness of breath
HPI: 89 year old gentleman with history of severe aortic
stenosis
followed by serial echocardiograms. In [**Month (only) 205**] he had a lower
gastrointestinal bleed on coumadin and work-up revealed an
adenocarcinoma. Given his critical aortic stenosis, he underwent
an aortic valvuloplasty so that he could undergo a
hemicolectomy.
His valve area improved from 0.68cm2 to 0.82cm2. Postoperative
course was complicated by heparin induced thrombocytopenia. In
regards to his aortic stenosis, he continues to be symptomatic
with increasing fatigue over the last few months, shortness of
breath after going up 5 stairs, shortness of breath with walking
on an incline. He denies chest pain or lightheadedness. Family
reports a decline in his functional status. He was evaluated by
cardiac surgery and deemed to be of prohibitive extreme surgical
risk for conventional surgical AVR. After informed consent, he
was screened for Corevalve TAVR. He met all inclusion criteria
and did not meet exclusion criteria. He is admitted for
transfemoral TAVR procedure.
NYHA Class: III
Past Medical History:
Aortic stensosis
Atrial fibrillation (low dose warfarin due to hematuria)
Arthritis
RLE DVT
Peptic ulcer disease
Congestive Heart Failure
Rheumatoid arthritis (hands)
GERD
Adenocarcinoma of colon s/p resection
***Heparin Induced Thrombocytopenia***
Past Surgical History:
[**2148-6-22**] Left hemicolectomy with primary anastomosis
[**2148-6-21**] Aortic valvuloplasty
Active Medication list as of [**2149-7-7**]:
Medications - Prescription
FINASTERIDE - (Prescribed by Other Provider) - 5 mg tablet - 1
tablet(s) by mouth daily
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg tablet - 3
tablet(s) by mouth daily 120mg daily
HERBAL LAXATIVE - (Prescribed by Other Provider) - - 2 tabs
daily
LISINOPRIL - (Prescribed by Other Provider) - 40 mg tablet - 1
tablet(s) by mouth daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
tablet extended release 24 hr - 1 tablet(s) by mouth DAILY
(Daily)
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg
capsule,delayed release(DR/EC) - 1 Capsule(s) by mouth DAILY
(Daily)
POTASSIUM CHLORIDE [KLOR-CON 10] - (Prescribed by Other
Provider) - 10 mEq tablet extended release - 1 tablet(s) by
mouth daily
TAMSULOSIN - (Prescribed by Other Provider) - 0.4 mg
capsule,extended release 24hr - 1 Capsule(s) by mouth DAILY
(Daily)
WARFARIN [COUMADIN] - (Prescribed by Other Provider) - 4 mg
tablet - 1 tablet(s) by mouth Once Daily at 4 PM dose daily
based on INR goal of [**1-17**]
Medications - OTC
CALCIUM CARBONATE [ANTACID] - (Prescribed by Other Provider) -
200 mg calcium (500 mg) tablet, chewable - 1 Tablet(s) by mouth
three times a day
COENZYME Q10 [CO Q-10] - (Prescribed by Other Provider) - 300
mg capsule - 1 capsule(s) by mouth daily
--------------- --------------- --------------- ---------------
Allergies: HEPARIN AGENTS
Social History:
SOCIAL HISTORY: Lives with wife in one level home. Works at his
bowling alley 7 days/week x 53 years. Independent ADL's, drives.
Family History:
FAMILY HISTORY: Father deceased age 80's, CAD. Mother deceased
age [**Age over 90 **], sepsis. Brother deceased age 87, cirrhosis, CAD, DM.
Sons
x 4, alive and well.
Physical Exam:
Pulse: 68 (irreg)
B/P: 145/64
Resp: 22
O2 Sat: 100% (RA)
Temp: 97.5
Height: Weight: 62.9 kg
General: Alert pleasant elderly male in NAD at rest, vague at
times.
Skin: Color tan, skin warm and dry. Turgor fair.
HEENT: Normocephalic, thinning hair. Anicteric. EOMI's. Good
dentition, oropharynx moist.
Neck: supple, trachea midline, carotid bruit vs. referred murmer
Chest: Decreased bases, no whz, otherwise clear.
Heart: murmer RSB radiating throughout
Abdomen: soft, nontender, nondistended. (+)BS. New left soft
mass left groin c/w inguinal hernia. Prior well healed surgical
scar. No discoloration, nontender. 2+palp femoral pulses bilat.
No bruits. 1x2cm palpable ridge rt groin prior cath site area.
Extremities: 1+ lower extremity edemaleft, trace edema RLE. 2+
edema, tight fingers with decreased ROM c/w rheum arth.
Neuro: alert, pleasant, vague at times, denies pain, gait fairly
steady. Limited STM.
Pulses: palpable peripheral pulses.
Pertinent Results:
[**2149-7-7**] 12:00PM GLUCOSE-90 UREA N-22* CREAT-1.0 SODIUM-141
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-33* ANION GAP-13
[**2149-7-7**] 12:00PM estGFR-Using this
[**2149-7-7**] 12:00PM ALT(SGPT)-13 AST(SGOT)-23 CK(CPK)-102 ALK
PHOS-67 TOT BILI-0.8
[**2149-7-7**] 12:00PM proBNP-2620*
[**2149-7-7**] 12:00PM ALBUMIN-4.3
[**2149-7-7**] 12:00PM WBC-5.4 RBC-4.03* HGB-12.3* HCT-36.7* MCV-91
MCH-30.4 MCHC-33.4 RDW-15.4
[**2149-7-7**] 12:00PM PLT COUNT-132*
[**2149-7-7**] 12:00PM PT-15.7* PTT-35.5 INR(PT)-1.5*
Cardiac Catheterization: Study Date [**2148-6-21**]
Interventional details
Crossed the aortic valve with a straight wire through a 5 French
[**Doctor Last Name **]-1 catheter. Advanced a 20 mm x 6 cm Tyshak balloon and
inflated while rapid ventricular pacing at 200 bpm to arrest the
heart. A single manual inflation was performed without
incident.
Peak to peak gradient decreased from 60 mm hg to 25 mm Hg
approximately with an increase in systemic blood pressure.
Assessment & Recommendations
1. No significant coronary disease
2. Sheath out when ACT <180 seconds
3. 8 Hours bed rest.
Echocardiogram: [**2149-6-12**] Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.4 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *7.6 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Left Ventricle - Stroke Volume: 57 ml/beat
Left Ventricle - Cardiac Output: 3.17 L/min
Left Ventricle - Cardiac Index: *1.80 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 11 < 15
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aorta - Arch: 2.9 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *5.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *100 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 60 mm Hg
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.4 cm2 >= 3.0 cm2
Aortic Valve - Pressure Half Time: 588 ms
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A ratio: 3.33
Mitral Valve - E Wave deceleration time: 165 ms 140-250 ms
TR Gradient (+ RA = PASP): *38 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH. Normal LV cavity
size. Low normal LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: RV hypertrophy. Dilated RV cavity. RV function
depressed. [Intrinsic RV systolic function likely more depressed
given the severity of TR].
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Focal calcifications in aortic arch.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Moderate (2+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
Moderate (2+) MR. [Due to acoustic shadowing, the severity of MR
may be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve supporting structures. No TS. Moderate to severe
[3+] TR. Eccentric TR jet. Moderate PA systolic hypertension.
Given severity of TR, PASP may be underestimated due to elevated
RA pressure.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is markedly dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated with depressed free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There are focal calcifications in the aortic
arch. The aortic valve leaflets are severely thickened/deformed.
There is critical aortic valve stenosis (valve area 0.4 cm2). At
least moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate to severe [3+] tricuspid
regurgitation is seen. The tricuspid regurgitation jet is
eccentric and may be underestimated. There is at least moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
EKG:
CT Scan : ([**2149-6-12**])
FINDINGS:
CT CHEST: Airways are patent to the subsegmental level
bilaterally. Bilateral subpleural interstitial opacities are
noted, most likely representing nonspecific interstitial lung
disease. No masses or consolidations to suggest infectious
process or neoplasm is demonstrated. Small amount of left
pleural effusion is present.
Degenerative changes are present in the thoracic spine but no
lytic or sclerotic lesions worrisome for infection or neoplasm
is demonstrated.
No mediastinal, hilar or axillary pathologically enlarged
lymph nodes are present.
Pulmonary artery is substantially enlarged up to 4.2 cm with
also enlargement of the right, 3 cm, and left, 2.7 cm arteries,
highly suspicious for pulmonary hypertension.
No pericardial effusion is present.
CT ABDOMEN: Liver, gallbladder, spleen, adrenals and kidneys are
unremarkable. There is no evidence of bowel wall dilatation or
bowel wall thickening. The patient is after transverse colon
surgery.
CT PELVIS: Inguinal hernia containing a most likely small bowel
loop is noted without strangulation. Substantially enlarged
prostate is demonstrated, approaching 7 x 8 cm in diameter.
Minimal amount of free pelvic fluid is noted, origin unclear.
Irregularity in the wall of the bladder are demonstrated,
potentially might be related to hypertrophy, but dedicated
imaging with ultrasound is required.
No lytic or sclerotic lesions are noted in the imaged portion
of the skeleton in abdomen and pelvis. Extensive degenerative
changes are seen.
Small pericardial effusion is present.
Coronary arteries have conventional origin.
Assessment of aortic valve demonstrate the following parameters:
diameter 22.7 x 29.8mm, perimeter 110mm.
Aorta is calcified with focal aneurysmatic dilatation at the
level of the aortic arch. No aneurysmatic dilatation of the
aorta throughout is demonstrated.
Substantial dilatation of celiac trunk is demonstrated up to
12 cm,
aneurysmatic.
Abdominal aorta is tortuous. There is also tortuosity of both
iliac arteries noted. Iliac vessels are patent.
Diameter of the peripheral axis are as following: right common
iliac artery 12.1*14.6mm, right external iliac artery
9.1*11.1mm, right superficial femoral artery 6.3*8.9mm; left
common iliac artery 10.8*13.7mm, left external iliac artery
10.6*8.8mm, left superficial femoral artery 9.3*7.9mm.
IMPRESSION:
1. CT criteria worrisome for pulmonary hypertension.
2. Extensive coronary and aortic valve calcifications
consistent with known aortic stenosis. Mild cardiomegaly.
3. Dilated celiac artery up to 12 cm.
4. Inguinal hernia containing small bowel loop with no current
evidence of obstruction.
5. Substantial enlargement of the prostate. Questionable
irregularity of the bladder wall, correlation with ultrasound is
required.
PFT's: ([**2149-6-12**])
FEV1 2.10L/102%, DLCO 78%
Carotid dopplers: ([**2149-6-12**])
Impression: Right ICA <40% stenosis.
Left ICA <40% stenosis.
LV diastolic dysfunction
Grade: [ ] None [ ] I [ ] II [ ] III [ ] IV
Chest wall deformity Yes [ ] No [x]
History of IE Yes [ ] No [x]
Peripheral vascular disease Yes [ ] No [x]
Cirrhosis of Liver Yes [ ] No [x]
If yes, Child [**Doctor Last Name 14477**] Score A [ ] B [ ] C [ ]
History of anemia req transfusion Yes [x] No [ ]
Ulcer disease Yes [ ] No [x]
Connective tissue disease Yes [ ] No [x]
Hostile mediastinum Yes [ ] No [x]
Immunosuppressive therapy Yes [ ] No [x]
Previous Cardiac Surgery?: NO
Previous Balloon Valvuloplasty?: BAV ([**2148-6-21**])
Permanent Pacemaker/ICD in-situ?: none
Brief Hospital Course:
89 year old gentleman with history of severe aortic stenosis,
atrial fibrillation on low dose coumadin, systolic CHF (EF
45-50%), h/o DVT, HIT, GI bleed on coumadin and colon CA s/p
resection came to [**Hospital1 18**] for a corevalvae for severe aortic
stenosis.
# Severe aortic stenosis: [**Location (un) 109**] 0.4cm2, peak gradient 60mmHg prior
to corevalve. Currently doing well following surgery, no
evidence of perivalvular leak or other complications. The
corevalve procedure was uncomplicated (please see the results
section for detail on the procedure) He was extubated the
evening after the procedure. He was monitored very closely and
was placed on the corevalve protocol. He was on neosynephrine
the day after the procedure but that was discontinued the next
day. Patient had a relatively benign post-op course and was
transferred down to the cardiology floor for further monitoring
until discharge. He was discharged on an increased dose of
Metoprolol succinate 100 mg daily and a decreased dose of
Lisinopril 10 mg daily (from 40 mg). His lasix 120 mg daily was
also held as patient was euvolemic during hospital course after
the procedure. [**7-10**] echo showed trace paravalvular aortic
valve leak is present. This will be followed up in the
outpatient setting with Dr [**Last Name (STitle) **].
# Bradycardia: Noted to have bradycardia in the 30s prior to
corevalve placement, so opted to have permanent pacemaker placed
during corevalve procedure.We gave him cefazolin 2g IV q8H for 3
days as per protocol for placing a pacemaker. Post op xray
confirmed correct placement of the pacemaker leads. No further
issues of bradycardia during post-op course
# Chronic diastolic and systolic heart failure: most recent EF
40% on TEE . Pt's CHF was well controlled and he did not
require lasix. Lisinopril management as above. As above, lasix
is being held.
# Atrial fibrillation: At home he is rate controlled with
metoprolol and anticoagulated with coumadin at home. His
metoprolol was held at first and then we started him back on it.
We gave him PO 50 metoprolol TID. We also gave him
IV metoprolol 2.5mg boluses PRN for HR >100 though when his PO
metoprolol dose was increased heh no longer needed those doses.
He was successfully bridged back to coumadin and is being
discharged on 5 mg daily. INR upon discharge was 1.7.
# Hematuria: Patient had hematuria after Foley placement.
Urology consulted and felt this was from the foley. Hematuria
resolved in on [**2149-7-10**].
#Anemia: Ht dropped from 31 to 26 on the second day of hospital
stay after the procedure. We felt this was most likely from some
blood loss from the procesure as well as from his hematuria.
Differential included: blood loss from hematuria vs hemolytic
anemia from corevalve causing shearing of RBCs vs GIB (though he
has adenocarcinoma s/p colectomy GIB unlikely bc he did not have
bowelmovements) vs TTP (he did have low platlets as well however
his kidney function, mental status were fine he has no fever
either). There may also be a hemodiltuion effect bc he is net
positive 3L since he has been and his platelets are also lowWe
did not transfuse as he was not symptomatic and his Ht was
stable. No recurrent signs of acute anemia.
#Thrombocytopenia: Platelets were 83 dropped from 101. Most
likely from blood loss from the procedure. Also considered was
shearing pletlets and RBCs from new corevalve. He has h/o HIT
however he was not been given any heparin, not even heparin
flushes while in house. He was not been given thiazides or sulfa
medications which are also known to cause HIT. Pt has no known
liver disease, normal LFTs. We continued to monitor his platlets
and there was no further acute drop
# H/o HIT: Bivalrudin used in the peri-op period rather than
heparin, however it was stopped. Patient was given no heparin
products while here. He was given plavix and ASA as dual
antiplatelets
CHRONIC ISSUES:
#BPH: patients tamsulosin was restarted soon after the procedure
#GERD: continued omeprazole
TRANSITIONAL ISSUES:
# patient will follow up with Dr [**Last Name (STitle) **] regarding how he is doing
post-corevalve.
# Discharged on lower dose of lisinopril than admitted with.
(40-->10mg). Needs cardiology f/u for uptitration
# Also needs f/u for his lasix 120 mg daily that was being held
in the hospital. He was discharged without a current dose
#[**7-10**] echo (post corevalave) showed trace paravalvular aortic
valve leak is present. This will be followed up in the
outpatient settingwith Dr [**Last Name (STitle) **]
Medications on Admission:
FINASTERIDE - (Prescribed by Other Provider) - 5 mg tablet - 1
tablet(s) by mouth daily
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg tablet - 3
tablet(s) by mouth daily 120mg daily
HERBAL LAXATIVE - (Prescribed by Other Provider) - - 2 tabs
daily
LISINOPRIL - (Prescribed by Other Provider) - 40 mg tablet - 1
tablet(s) by mouth daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
tablet extended release 24 hr - 1 tablet(s) by mouth DAILY
(Daily)
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg
capsule,delayed release(DR/EC) - 1 Capsule(s) by mouth DAILY
(Daily)
POTASSIUM CHLORIDE [KLOR-CON 10] - (Prescribed by Other
Provider) - 10 mEq tablet extended release - 1 tablet(s) by
mouth daily
TAMSULOSIN - (Prescribed by Other Provider) - 0.4 mg
capsule,extended release 24hr - 1 Capsule(s) by mouth DAILY
(Daily)
WARFARIN [COUMADIN] - (Prescribed by Other Provider) - 4 mg
tablet - 1 tablet(s) by mouth Once Daily at 4 PM dose daily
based on INR goal of [**1-17**]
Medications - OTC
CALCIUM CARBONATE [ANTACID] - (Prescribed by Other Provider) -
200 mg calcium (500 mg) tablet, chewable - 1 Tablet(s) by mouth
three times a day
COENZYME Q10 [CO Q-10] - (Prescribed by Other Provider) - 300
mg capsule - 1 capsule(s) by mouth daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
do not give if he has diarrhea
3. Finasteride 5 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
please hold for SBP<100 and HR<60
6. Omeprazole 20 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Warfarin 5 mg PO DAILY16
INR goal 2-2.5
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
Severe aortic stenosis s/p corevalve and permanent pacemaker
placement
Chronic systolic and diastolic heart failure
Atrial Fibrillation
Hyperlipidemia
Hematuria on high dose anticoagulation therapy
HIT- heparin induced thrombocytopenia [**2147**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 88841**],
You were admitted to the hospital for a "core valve" procedure.
This procedure allowed your cardiologist to place a new aortic
valve in your heart by a transcatheter percutaneous approach.
You also received a permanent pacemaker which ensures your heart
rate does not go too slow. You had a smooth post-operative
course and we moved you down to the main cardiology floor from
the CCU. The following changes to your medications have been
made
1. Metoprolol Succinate has been INCREASED to 100 mg daily, from
50 mg daily
2. Lisinopril has been DECREASED from 40 mg daily to 10 mg daily
3. Furosemide has been STOPPED for now. You will follow up with
your cardiologist regarding resuming this medication
It has been a pleasure taking care of you while at [**Hospital1 18**] Mr.
[**Known lastname 70820**]
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2149-7-18**] at 2:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ECHO LAB
When: WEDNESDAY [**2149-8-13**] at 10:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2149-8-13**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Your Primary Care Physicians office will be calling you at home
with an appointment, if you have not heard in two days please
call their office.
Name: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 10541**], MD
Specialty: Primary Care
Location: [**Hospital **] MEDICAL GROUP-[**Location (un) 8720**] CARDIOLOGY
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY, [**Location 8723**],[**Numeric Identifier 8724**]
Phone: [**Telephone/Fax (1) 8725**]
Your Primary Care Physicians office will be calling you at home
with an appointment, if you have not heard in two days please
call their office.
ICD9 Codes: 4241, 2851, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2123
} | Medical Text: Admission Date: [**2153-4-23**] Discharge Date: [**2153-4-29**]
Date of Birth: [**2083-5-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
fever, altered mental status
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
History obtained from MICU team; patient appears to be
unreliable historian.
Pt is a 69M with dementia, s/p cardiac arrest [**2149**] with anoxic
brain injury, paroxysmal atrial fibrillation, DM2, and HTN
admitted from [**Hospital3 537**] with fever and altered mental
status. Per [**Hospital3 537**] staff, "hasn't been himself" since
day prior to admission; testing there demonstrated leukocytosis
(WBC 15.5K) with borderline pyuria (5 WBCs) and received empiric
ciprofloxacin for possible UTI. On day of admission, noted to
have unstable gait, "leaning to right", unable to get to
bathroom by himself (apparently normally able to ambulate
independently with walker). Sent to [**Hospital1 18**] ED for further
evaluation.
Further history obtained from daughter [**Name (NI) 7346**], who reports
patient was lethargic, "not talking", "wincing" when touched
approximately 48hrs prior to his admission. Patient was not
reporting any specific symptoms, however has noted to be
recently "choking on his food". Has a chronic cough (since his
VF arrest in [**2149**]), but recently more productive. Poor PO
intake prior to admission. Daughter reports that patient is
currently (evening of [**4-25**]) very close to his baseline mental
status.
In ED, febrile ro 103.8, in afib with RVR 150s-170s, with serum
Na=153. Treated with IV fluids (2L), vancomycin/ciprofloxacin,
diltiazem, and right IJ CVL placed. Subsequent transient
hypotension to 80s, resolved spontaneously without pressor
support. Admitted to [**Hospital Unit Name 153**] for possible sepsis.
In [**Hospital Unit Name 153**], converted to sinus rhythm with HR 70s. Antibiotics
continued empirically. D5W infusion administered in setting of
hypernatremia. Blood, urine cultures unrevealing. Chest x-ray
without overt infiltrate. Head CT without mass or acute bleed.
Abd/pelvis CT unremarkable per preliminary report. Per MICU
notes, overall mental status much improved according to
patient's daughter, though not yet at baseline.
Past Medical History:
1. DM2
2. Hypertension
3. Hyperlipidemia
4. h/o VFIB arrest in [**12-17**] secondary to cocaine/EtOH use,
complicated by coma, anoxic brain injury, and evidence if IMI,
inferior ischemia with resultant improvement in heart function
5. Paroxysmal AFib: not on anticoagulation due to fall risk
6. Anoxic Brain Injury/Dementia
7. Pulmonary Hypertension
8. BPH with urinary retention
9. GERD
Social History:
[**Hospital3 537**] resident. Daughter [**First Name8 (NamePattern2) 7346**] [**Last Name (NamePattern1) 3924**] is his legal
guardian; she is a registered nurse. Prior history of
EtOH/cocaine abuse.
Ambulates with cane at baseline.
Family History:
Non-contributory.
Physical Exam:
T 99.2 / BP 154/92 / HR 90s / O2 sat 96% RA / RR 21
GEN: Awake and alert in NAD. Disoriented.
HEENT: Pupils 2mm round and reactive, anicteric sclerae, moist
mucous membranes, atraumatic.
NECK: Right IJ CVL in place, no palpable lymphadenopathy.
Supple.
CHEST: Clear to auscultation and resonant to percussion
bilaterally.
COR: S1 S2 tachycardic regular without audible murmur.
ABD: Soft, non-tender, non-distended, without organomegaly.
NABS.
EXTREM: Trace ankle edema. Dupuytren's contracture right hand.
No clubbing or cyanosis.
NEURO: Oriented only to self. Counts 10 to 1 fluently, names
days of week forward but not backwards. CN II-XII intact. No
asterixis. No pronator drift. Motor strength 5/5 bilateral
delt/tri/[**Hospital1 **]/wrist ext/wrist flex, iliopsoas/quad/hams/ankle
ext/ankle flex. Toes downgoing bilaterally. DTRs 2+ biceps,
brachioradialis, patella bilaterally. Sensation to LT grossly
intact throughout.
Pertinent Results:
Admission labs:
Na 157 K 4.0 Cl 122 CO2 25 BUN 37 Cr 1.3 Gluc 80; AG 10
CPK 1050, Trop 0.08, CK-MB 4
Ca 8.3, Phos 3.2, Mag 1.9
WBC 12.5, HCT 40.7, PLT 174
Lact 2.7 -> 4.5
UA negative
Repeat labs:
Na 153, Cr 1.7, AG 19
CPK 1348, Trop 0.06, CK-MB 5
LFTs wnl
WBC 12.4 (91N)
EKG: Afib/flutter 155, QRS axis WNL, Q waves in III/F, 1mm ST
depression in I, avL
IMAGING:
HEAD CT: No mass or bleed.
CT ABD/PELVIS: No source of infection identified; stable
peri-renal stranding since [**2151**] study.
CXR: No acute infiltrate.
Brief Hospital Course:
Mr. [**Known lastname 10321**] is a 69 yo M with a history of dementia/anoxic brain
injury, DM2, HTN admitted with fever and altered mental status,
noted to be in atrial flutter with RVR. Transferred to [**Hospital1 1516**]
cardiology floor for diltiazem drip as rate not responding to IV
metoprolol and diltiazem. Converted to NSR on dilt gtt so was
switched to po dilt 240 mg SR, and went back into aflutter with
RVR. EP consulted and recommended starting quinidine on [**2153-4-26**].
Patient was successfully converted to NSR on quinidine. His
hospital course is outlined by problem below:
.
#. Atrial Flutter with intermittant RVR: Hemodynamically stable.
Patient had been in AFib with RVR when initially admitted to the
ICU, but spontaneously converted to NSR during his stay. After
being called out, the patient has had sustained ventricular
rates in 130-150s and had not responded to IV metoprolol and
diltiazem. The patient was transferred for IV diltiazem gtt. Per
medical record, no anticoagulation in setting of baseline fall
risk. He was started on a heparin gtt and dilt gtt on [**2153-4-25**].
Converted to NSR on dilt gtt so was switched to po dilt 240 mg
SR, and went back into aflutter with RVR. EP consulted and
recommended starting quinidine on [**2153-4-26**]. Patient was
successfully converted to NSR on quinidine. Continue quinidine
at 324 mg q8H as outpatient with close monitoring of QTc with
daily EKGs. Baseline QTc [**2153-4-23**] was 466. Monitor for QT
prolongation of increase in QTc 25% above baseline. His QTc at
time of discharge was ~480. Continue to replete K<4.0 and
Mg<2.0; he will be discharged on 400mg magnesium oxide [**Hospital1 **].
Continue daily aspirin per baseline regimen. PT consult to
evaluate fall risk; pt is significant fall risk. Because of
this, he will not be anticoagulated with coumadin as outpatient
at time of discharge.
.
#. Fever/leukocytosis: Resolved. Afebrile, pt has clinically
improved since admission. Potential sources urinary, pulm have
been ruled out. Only symptom appears to be mildly productive
cough. Patient had been on antibiotics (Vanc/Levo) while in the
ICU, but these were discontinued in the absence of identified
bacterial process and clinical improvement. NGTD on urine or
blood cultures suggestive of infection.
Since transfer to [**Hospital1 1516**] cardiology on [**2153-4-25**] patient was
afebrile and had resolution of leukocytosis with normal WBC at
time of discharge.
.
#. Anemia: Stable HCT of 38.4. Asymptomatic.
.
#. AMS: Improved. Suspect that patient had waxing and [**Doctor Last Name 688**]
delirium in setting of fever, hypernatremia, and hypovolemia
when he was admitted. Patient has had CT head that did not show
new infarct or bleed. Continued baseline fluoxetine, donepezil,
risperidone, and prn Haldol. Haldol was discontinued without
issues regarding agitation on morning of [**2153-4-28**], given increase
in QTc.
.
#. Hypernatremia: Na 148 on admission, resolved with normal
serum sodium of 141 with po free water repletion.
.
#. HTN: Held beta blocker and ACEI while on dilt gtt. Restarted
lisinopril [**4-26**].
.
#. ARF, pre-renal: Improved s/p fluid resusitation. Cr 1.1, at
baseline.
.
#. Mild Rhabdo, elevated CPK: CK 815. Unclear etiology. Suspect
related to acute illness. Held statin initially with
improvement. Restarted at time of discharge.
.
# FEN: Patient had speech and swallow evaluation on [**2153-4-25**]. No
evidence of aspiration. Okay to continue on regular diet with
distant supervision per their recommedations.
.
# Continue DVT prophylaxis with Heparin SC.
.
# Emergency Contact: daughter [**Name (NI) 7346**] [**Name (NI) 3924**] who is guardian and
HCP: [**Telephone/Fax (1) 19907**].
.
# Code: Full (confirmed) this admission. The patient will have
follow-up with Dr. [**Last Name (STitle) 19911**] and his PCP as an outpatient within
2 weeks of discharge.
Medications on Admission:
22LiPer [**Hospital3 537**] [**Month (only) 16**]:
1. Omeprazole 20 daily
2. Glipizide 5 daily
3. Aspirin 325 daily
4. Doxazosin 4 daily
5. Fluoxetine 40 daily
6. Furosemide 20 daily
7. Lisinopril 2.5 daily
8. Trazodone 25 at noon, 50 at night
9. Aricept 10 daily
10. Colace 200 daily
11. Simvastatin 40 daily
12. Metformin 1000 twice daily
13. Senna 1 twice daily
14. Risperidone 0.5 twice daily
15. Metoprolol 25 three times daily
16. Lantus 20 units each morning
17. Novolin insulin sliding scale
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous QAM.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q8H (every 8 hours). Tablet
Sustained Release(s)
12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection every eight (8) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Atrial flutter.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 10321**], you were admitted to the hospital because of a fever
and change in your mental status. We think that the fever and
mental status changes were caused by an infection and you were
treated with antibiotics for this and improved. During your
hospitalization, your heart rate became very fast and you had an
irregular heart beat called atrial flutter. You were treated
with medications called diltiazem and quinidine for this, and
your heart beat returned to [**Location 213**]. You are now deemed medically
stable and fit for discharge back to [**Hospital3 537**].
.
The following changes have been made to your medications:
1. STOP Metoprolol Tartrate 25 mg TID.
2. START Diltiazem 240 mg SR by mouth once daily.
3. START Magnesium Oxide 400 mg by mouth twice daily.
4. START QUINIDINE Gluconate ER 324 mg by mouth every eight
hours.
.
It was a pleasure caring for you during this hospitalization.
Followup Instructions:
Please make a follow-up appointment with your primary care
doctor within 2 weeks of discharge from the hospital.
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
Completed by:[**2153-4-29**]
ICD9 Codes: 0389, 5849, 2760, 4168, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2124
} | Medical Text: Admission Date: [**2171-5-1**] Discharge Date: [**2171-5-15**]
Date of Birth: [**2120-5-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2171-5-6**] - CABGx3 (Free RIMA->PDA, LIMA-LAD, (L) Radial->Obtuse
Marginal 2)
[**2171-5-2**] - Cardiac Catheterization
History of Present Illness:
50 yo man with PMH of HTN, hyperlipidemia, 35 pack yr smoking
history, transferred from [**Hospital 6930**] Hospital in [**Location (un) 3844**] for
further management. The pt states that he was in his usual
state of health until 1 month PTA when he noted CP while sitting
at his computer. He has now had CP intermittently every day for
the past month. His CP lasts hrs at a time and is described as
a substernal, sharp, pressure-like, burning pain. He
occasionally has associated SOB and radiation to his L shoulder,
but he has no associated nausea. His pain can be alleviate with
3 NTG tabs at a time. Per pt report, he presented to [**Hospital 6930**]
hospital 1 month ago and was observed overnight. He was sent
home and he returned the following day for persistent chest
pain. Again, the pt was sent home and he followed up with his
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 78049**]. The pt says he was sent for stress test
with imaging, and he was told it was inconclusive. The pt was
seen by a cardiologist on [**4-29**], and while in the doctors office
the pt had CP. He was then sent to Catholic [**Hospital1 107**]. Had
?NSTEMI. He underwent cardiac cath on [**4-29**] and was noted to have
3 vessel disease. He developed anaphylaxis in which his face
swelled, so cardiac cath was aborted at this point. Today pt
was seen in [**Hospital 6930**] Hospital as he [**Hospital 5058**] at 10 am with severe
CP today. He was given ASA, NTG x2, IV morphine, nitro gtt, and
heparin gtt. EKG was reportedly without ST changes. Cardiac
enzymes were negative. In the ambulance here the pt was having
intermittent chest pressure and low blood pressure.
Past Medical History:
HTN
DJD
s/p R Total Knee Replacement
lumbar surgery in [**2158**] with L3-L4 diskectomy
L maxillary reconsturction in 1970a
hyperlipidemia
Cardiac Cath 4/17 per Dr. [**Last Name (STitle) **]: occl rca, 90% circ, 50% LAD
?NSTEMI [**4-29**] at OSH per Dr. [**Last Name (STitle) **]
Social History:
Lives in [**Location **] with his wife, on disability due to back injury,
quit tobacco 3 days ago but prior smoked 1.5 ppd for 35 years,
no ETOH or illicits
Family History:
Father died of MI at 57
Brother is s/p CABG age 35
Father with DM, brother with DM
Physical Exam:
VS: T97.9 BP 125/49 in L arm, 115/41 in R arm P 71 R 22 Sat
93%RA
GEN: obese man, lying in bed, NAD
HEENT: PERRL, conjunctivae anicteric/noninjected, MMM
Neck: obese, no JVD appreciated
CV: distant heart sounds, barely audible S1/S2, +chest wall
tenderness to palpation partially mimicking pts pain
PUL: CTAB with decreased breath sounds throughout
ABD: protuberant, soft, NTND, NABS
EXT: no c/c/e, wwp, 2+dp/pt pulses
Pertinent Results:
Labs at OSH:
WBC 14, Plt 231, Troponin I 0.01
.
EKG: NSR, normal axis, isolated Q wave in III
.
[**2171-5-1**] 09:05PM GLUCOSE-120* UREA N-24* CREAT-1.0 SODIUM-144
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-28 ANION GAP-14
[**2171-5-1**] 09:05PM ALT(SGPT)-40 AST(SGOT)-19 CK(CPK)-106 ALK
PHOS-68
[**2171-5-1**] 09:05PM CK-MB-2 cTropnT-<0.01
[**2171-5-1**] 09:05PM CALCIUM-8.6 PHOSPHATE-3.4 MAGNESIUM-2.0
[**2171-5-1**] 09:05PM WBC-12.7* RBC-4.84 HGB-14.2 HCT-41.1 MCV-85
MCH-29.3 MCHC-34.4 RDW-14.3
[**2171-5-1**] 09:05PM NEUTS-50.1 LYMPHS-44.7* MONOS-4.2 EOS-0.8
BASOS-0.3
[**2171-5-1**] 09:05PM PLT COUNT-230
[**2171-5-1**] 09:05PM PT-11.4 PTT-25.5 INR(PT)-1.0
.
Cardiac Catheterization [**2171-5-2**]:
COMMENTS:
1. Selective coronary angiography showed a right dominant system
with
60-70% proximal LAD ulcerated plaque extending back into the
left main
coronary artery. The left circumflex artery and the OM1 were
totally
occluded and filled via L->L collaterals. The RCA was totally
proximally
occluded over a very long segment. Distal PDA and PLV were
diffusely
diseased and filled via L->R collaterals.
2. Left ventriculography was deferred given allergic reaction to
iodine
contrast.
3. Limited hemodynamic assessment showed normal aortic systemic
pressure.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal ventricular function.
[**2171-5-13**] CXR
Right lower lobe atelectasis is improving. Pulmonary vascular
congestion has worsened. Postoperative cardiomediastinal
silhouette unremarkable and unchanged. Small left pleural
effusion is stable. No pneumothorax. Sternal wires are intact
and unchanged.
[**2171-5-6**] ECHO
Prebypass:
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. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Resting regional wall motion abnormalities
include mildly hypokinetic basal and midportions of the inferior
wall. Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. The transgastric views were very poor.
Post Bypass:
Patient is receiving an infusion of phenylephrine.
Biventricular systolic fuction is preserved. Aorta intact post
decannulation. Mild mitral regurgitation persists.
[**2171-5-3**] Carotid Ultrasound
Patent bilateral brachial arteries and ulnar arteries with
diameters as noted above
Brief Hospital Course:
Mr. [**Known lastname 63915**] was admitted to the [**Hospital1 18**] on [**2171-5-1**] for further
management and evaluation of his chest pain. Heparin and
nitroglycerin were given with relief of his symptoms. A cardiac
catheterization was performed which revealed severe three vessel
coronary artery disease. A plavix load was given. Given the
severity of his disease, the cardiac surgery service was
consulted for surgical revascularization. Mr. [**Known lastname 63915**] was
worked-up in the usual preoperative manner including a carotid
duplex ultrasound which did not reveal any flow limiting disease
of the bilateral internal carotid arteries. Given his young age
arterial conduit was elected. A radial artery ultrasound was
performed which showed patent bilateral radial arteries with an
acceptable diameter. On [**2171-5-6**], Mr. [**Known lastname 63915**] was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels using a left internal mammary artery,
a free right internal mammary artery and a left radial artery.
Grafts went to the left anterior descending artery, the obtuse
marginal artery and the posterior descending artery.
Postoperatively he was taken to the cardiac intensive care unit
for monitoring. On postoperative day one, Mr. [**Known lastname 63915**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. He remained in the
intensive care unit for several extra days with a small Levophed
requirement. He was transfused with packed red blood cells for
postoperative anemia. Vancomycin and levofloxacin were started
for serous drainage from his sternum. He was gently diuresed
towards his postoperative weight. The physical therapy service
was consulted for assistance with his postoperative strength and
mobility. On postoperative day six, Mr. [**Known lastname 63915**] was transferred
to the cardiac service nursing floor for further recovery.
Strict sternal precautions were maintained for a mild sternal
click noted on exam. Mr. [**Known lastname 63915**] continued to make steady
progress and was discharged home on postoperative day nine. He
will return to the nursing floor in 1 week for a wound check and
continue levofloxacin for week. He will follow-up with Dr.
[**Last Name (STitle) **], his cardiologist and his primary care physician as an
outpatient. of note, an attempt was made to medicate with
isosorbide for his arterial conduit however, his blood pressure
would not tolerate this. It is recommended to attempt to start
isosorbide and a beta blocker as an outpatient on follow-up with
his cardiologist in 1 to 2 weeks.
Medications on Admission:
Norvasc 5 mg po qd
Zocor 40 mg po qd
Metoprolol 100 mg po bid
Ranitidine 150 mg po bid
Oxycontin 60 mg qam, 80 mg q midday, 60 mg po qpm
Oxycodone prn
ASA 325
Discharge Medications:
1. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while taking narcotics to prevent
constipation.
Disp:*60 Capsule(s)* Refills:*2*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days:
Take with lasix and stop when lasix stopped.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community health and hospice
Discharge Diagnosis:
Coronary Artery Disease
Hypercholesterolemia
HTN
NSTEMI
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wound for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain greater then 2 pounds in 24 hours or 5
pounds in 1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month and while taking narcotics.
6) Take levofloxacin for 1 week (until no pills left).
7) Eventually you will need to be started on Isosorbide and a
beta blocaker. This will be done by your cardiologist as an
outpatient as your blood pressure tolerates.
8) Take lasix twice daily and potassium once daily for five days
and then stop.
9) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks. ([**Telephone/Fax (1) 1504**]
Follow-up with Cardiologist Dr. [**Last Name (STitle) 11250**] in [**1-14**] weeks. ([**Telephone/Fax (1) 78961**]
Follow-up with primary care physician [**Last Name (NamePattern4) **] [**2-16**] weeks. Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Follow-up on [**Hospital Ward Name 121**] 2 with nurses for wound check in 1 week.
Please call all providers for appointments.
Completed by:[**2171-5-15**]
ICD9 Codes: 4111, 4019, 2859, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2125
} | Medical Text: Admission Date: [**2131-8-6**] Discharge Date: [**2131-8-10**]
Date of Birth: [**2092-11-18**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Location (un) 1279**]
Chief Complaint:
Ventricular Tachycardia
Major Surgical or Invasive Procedure:
Electrophysiology Studies (VT ID/Ablation)
History of Present Illness:
38M h/o Hodgkins lymphoma, s/p failed chemotherapy and allo BMT
initially transferred [**2131-8-6**] from OSH ([**Hospital1 **]) for EP study
following an episode of VT. He initially presented to OSH ED
[**2131-8-4**] with 3 days of increased fatigue and 1 day of orthopnea
with right sided chest pain. There, he was found to be in stable
VT with rate 200. Given verapamil and amiodarone without effect.
Subsequently he became nauseous and lightheaded with a presumed
aspiration event, at which time he was sedated, intubated, then
successfully DC cardioverted. Pt's OSH hospital course c/b fever
to 103 for which he was empirically treated with Zosyn and
vancomyin. He received stress dose steroids at the outside
hospital. He was also transiently hypotensive with sbp 90s, felt
to be secondary to oversedation with Propofol. Troponin peaked
at 2.53 at OSH following cardioversion. Patient was extubated
and transferred to [**Hospital1 18**] for EP evaluation.
Past Medical History:
(1) Hodgkin's disease: dx4/01. s/p XRT, ABVD X 5, AVD X1 c/b
bleomycin toxicity. Auto BMT in [**1-22**] followed by a
non-myeloablative allo BMT in [**9-23**] wth disease recurrence. Most
recently s/p donor lymphocyte infusion [**4-24**]. (2) GVHD of liver
(3) Bleomycin pneumonitis (4) Esophageal stricture s/p dilation
(5) Gout (6) S/P Tonsillectomy (6) S/P R Inguinal Hernia Repair
Social History:
Lives with his father in [**Name (NI) 6691**] MA. No tobacco, ethanol or
IVDU, unemployed
Family History:
Grandfather had head and neck cancer, father has hypertension,
mother had brain aneurysm.
Physical Exam:
PE Tc 98.8, pc 83, bpc 108/80, resp 19 94% RA
Gen: Young male, A&OX3, NAD, NRD
HEENT: PERRL, EOMI, normal conj, anicteric, OMMM, OP clear, ,
neck supple without lymphadenopathy or JVD
Cardiac: RRR. No murmurs appreciated
Pulmonary: Decreased breath sounds at bases bilaterally with
minimal crackles at right base.
Abd: NABS, soft, NT/ND
Extremities: No edema, cyanosis. 2+ DP bilaterally
Neuro: No focal deficits noted
Pertinent Results:
[**2131-8-6**] 08:14PM GLUCOSE-109* UREA N-13 CREAT-0.9 SODIUM-145
POTASSIUM-3.2* CHLORIDE-108 TOTAL CO2-26 ANION GAP-14
[**2131-8-6**] 08:14PM ALT(SGPT)-111* AST(SGOT)-45* LD(LDH)-217 ALK
PHOS-63 TOT BILI-0.6
[**2131-8-6**] 08:14PM CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-1.8
[**2131-8-6**] 08:14PM TSH-6.5*
[**2131-8-6**] 08:14PM WBC-13.2*# RBC-3.93* HGB-13.6* HCT-37.0*
MCV-94 MCH-34.5* MCHC-36.7* RDW-14.5
[**2131-8-6**] 08:14PM PLT COUNT-206
Brief Hospital Course:
38M h/o Hodgkin's disease transferred from OSH after VT
cardioconversion and
aspiration PNA s/p extubation admitted for evaluation of VT.
EP study [**8-7**] w/ inducible VT (probably intraseptal), however
ablation was unsuccessful. Started on beta-blocker.
1) VT. Unclear etiology of VT. There was a concern for malignant
infiltration of myocardium. Ablation of the VT was unsuccessful
due to a site of origin very close to the bundle of His. Post-VT
ablation there was a new RBBB. ECHO showed: Very small
pericardial effusion, but otherwise normal study with preserved
global and regional biventricular systolic function. Cardiac MR
showed: nml arteries, no WMA, but small anterior scar. An ETT w/
cardiac imaging was performed to evaluate for ETT-inducible
dysrhytmias: none were found and he tolerated the ETT well. ETT
imaging showed: Small anterior fixed defect. The etiology of the
defect was not clear, but unlikely to be related to malignant
infiltration. The patient was monitored on telemetry, which
showed frequent PVCs, but no more than 4 beat runs. He was
initially started on Metoprolol 25mg PO BID, but was changed to
Sotalol 80 mg [**Hospital1 **]. Follow up ECGs (x2) did not reveal QT
lengthening. Pt was sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to
evaluate for further dysrhytmias.
2) Aspiration pneumonia. The pt was febrile with dyspnea at the
OSH after extubation. He was continued broad-spectrum abx for a
14 day course of Flagyl and Augmentin(Levo was not chosen
because of QT prolongation in conjunction with Sotalol). It was
also believed that pre-existing bleomycin toxicity contributed
to his initial hypoxia. The pt's O2 requirement, temperature and
WBC all decreased over his hospital course. At the time of
discharge, his oxygen saturation was stable at 94% on RA with
ambulation.
3) Hodgkins disease. The patient had mildly elevated LFTs likely
[**1-22**] GVHD. He was continued on Prednisone and continued on
Bactrim and Acyclovir for PPx.
4) Elevated TSH. (TSH = 6.4, T4 nml) Given setting of acute
illness, with dysrhythmias, thyroxine was not administered. He
was instructed to have follow up studies in 1 month with his
PCP/Cardiologist.
5) PT. Seen and cleared by PT.
6) PPx. Continued on PPI.
7) Code. Full.
8) Dispo. To home.
Medications on Admission:
1) Acyclovir 400 mg orally three times a day
2) Acetaminophen prn
3) Atenolol 50 mg orally daily
4) Folic acid 1 mg orally daily
5) Heparin 500 units SC three times a day
6) Pantoprazole 40 mg orally daily
7) Piperacillin-tazobactam 4.5 gm IV every 8 hours (day 5)
8) Prednisone 10 mg orally daily
9) Sulfameth/Trimethoprim DS 1 tab orally daily
10) Zolpidem 5 mg orally at bedtime prn
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QD (once a day).
4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
7. Sotalol HCl 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ventricular tacycardia
Secondary: aspiration pneumonia, hodgkin's disease,
graft-versus-host disease
Discharge Condition:
Good
Discharge Instructions:
1) Please take all your medications as prescribed. Your new
medications include sotolol, a medication to control your
cardiac rhythm.
2) You have been given [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor in order to
monitor your heart rate. Please have the results sent to Dr.
[**Last Name (STitle) 284**].
3) Please call your primary care physician or come to the
emergency room if you develop palpitations, shortness of breath,
chest pain, lightheadedness, or any other symptoms that you find
concerning
Followup Instructions:
1) Cardiology: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**]
([**Telephone/Fax (1) 285**]) to be seen within 4-6 weeks following discharge.
2) Primary care: Please follow-up with your primary care
physician [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 37713**]) to be seen within [**12-22**]
weeks following discharge
-- you should have thyroid function tests (TSH, free T4) checked
in 1 month
3) Hematology/Oncology
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2131-8-24**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2131-8-24**] 9:00
Completed by:[**2131-8-10**]
ICD9 Codes: 4271, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2126
} | Medical Text: Admission Date: [**2198-9-16**] Discharge Date: [**2198-9-28**]
Date of Birth: [**2143-9-8**] Sex: M
Service: MEDICINE
Allergies:
Ilosone / Dicloxacillin / Ace Inhibitors
Attending:[**Last Name (un) 11220**]
Chief Complaint:
acute kidney injury
rhabdomyolysis
pulmonary hypertension
congestive heart failure
Major Surgical or Invasive Procedure:
left internal jugular CVC placement
History of Present Illness:
In the ED, initial VS were:T-97.8 P-103 BP-112/70 R-18 O2%-90%
RA
54-year-old man with a history of HIV on HAART, hepatitis C, CAD
status post CABG in [**2182**], CHF with an EF of 50%, hypertension,
hyperlipidemia, and a severe stroke in [**2184**] with residual
dysarthria and left greater than right-sided weakness who
presents after falling from his wheelchair and hitting his
head. On ground for around an hr. Pt recently d/c'd [**9-14**] with
desats to 80s [**1-25**] PNA. Pt denies any CP, SOB, dizziness before
the fall or after.
IN the ED:
PT triggered for hypoxia to 70s. Sat up and did well and came
back up to 100% w/ a NRB. hypoT, never tachy . Got labs from art
stick. Had no access for peripheral and given L-IJ central line.
Pt received 1.5 l NS. Elevated trop with normal CK index. Had
negative CT head and neck.
On arrival to the MICU:
Pt had foley placed with 300CC of tea colored urine produced and
received 1.5 L of NS bolus. ABG was drawn.
Past Medical History:
-HIV: dx [**2176**], likely through IVDU (last CD4 count 438/30% vl
128 on [**2198-4-30**])
-HCV: no therapy, stage I to II fibrosis on liver biopsy in
[**2193**], genotype 1A
-CAD: CABB x 1 Lima to LAD [**8-/2184**] s/p MI [**2176**]
-Diastolic CHF, EF 50-55%
-CVA: [**2-/2185**] intercerebral hemorrhage in medial/superior
cerebellar peduncle, wheelchair bound w/ residual L paresis
-HTN
-hypercholesterolemia
Social History:
He lives alone in an apartment, has assistance from PCAs that
come in to help him, not currently working, but formerly worked
many jobs including construction and campus police. He is a
former smoker, quit many years ago, but smoked actively for 30
years, half to one pack a day. He denies any pets or other
environmental exposures.
Family History:
There is a significant family history of premature coronary
artery disease of the father who had an MI at age 56 and uncles
who have had heart attacks in the past. Otherwise, there is no
other history of unexplained heart failure or sudden death.
Physical Exam:
Admission physical exam:
Vitals: T:afeb BP:113/72 P:82 R:18 O2:96
General: Alert, oriented,
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Wheezing and crackles in all lung fields
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Hypospadias foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Baseline left facial droop with markedlydysarthric
speech,LUE and LLE with 4/5 strength, RUE and RLE [**4-28**]. Sensation
grossly intact
Discharge Physical Exam:
VS - 98.7 118/54 70 20 93% on shovel face mask 10L
GEN: Awake, alert and oriented. No acute cardiopulmonary
distress
HEENT: Sclera anicteric, MMM, OP clear
NECK: Supple, elevated JVP
PULM: Good aeration, CTAB, without w/r/r.
CV: RRR normal S1/S2, no mrg/
ABD: Soft, non-tender, obese, nondistended, no rebound or
guarding.
EXT: WWP. 2+ right radial pulse. left radial pulse not palpable,
but left hand is well perfused. DP/PT pulses difficult to
palpate [**1-25**] edema. 2+ pitting edema b/l LEs to knee, improved
from yesterday.
NEURO: awake, A&Ox3, dysarthric. left facial droop. left upper
and lower extremities 4/5 strength. Right extremities [**4-28**]
strength.
SKIN: no ulcers or lesions. venous stasis/chronic edema changes
in b/l lower extremities
Pertinent Results:
Admission labs:
[**2198-9-16**] 06:30PM BLOOD WBC-11.8* RBC-4.81 Hgb-15.5 Hct-47.7
MCV-99* MCH-32.2* MCHC-32.4 RDW-16.7* Plt Ct-296
[**2198-9-16**] 06:30PM BLOOD PT-17.7* PTT-33.7 INR(PT)-1.7*
[**2198-9-16**] 06:30PM BLOOD Glucose-115* UreaN-42* Creat-3.6*# Na-141
K-3.5 Cl-95* HCO3-32 AnGap-18
[**2198-9-16**] 06:30PM BLOOD CK(CPK)-[**Numeric Identifier 104043**]*
[**2198-9-16**] 06:30PM BLOOD CK-MB-34* MB Indx-0.2 cTropnT-1.67*
[**2198-9-16**] 06:37PM BLOOD Type-[**Last Name (un) **] pO2-49* pCO2-53* pH-7.41
calTCO2-35* Base XS-6
[**2198-9-16**] 06:37PM BLOOD Lactate-2.6*
Pertinent labs:
[**2198-9-17**] 04:13AM BLOOD CK-MB-26* MB Indx-0.2 cTropnT-1.69*
[**2198-9-17**] 04:13AM BLOOD ALT-42* AST-316* CK(CPK)-[**Numeric Identifier 104044**]*
AlkPhos-52
[**2198-9-17**] 04:13AM BLOOD Glucose-154* UreaN-41* Creat-2.9* Na-140
K-3.5 Cl-100 HCO3-33* AnGap-11
[**2198-9-21**] 01:14AM BLOOD WBC-11.3* RBC-3.79* Hgb-12.2* Hct-38.7*
MCV-102* MCH-32.1* MCHC-31.4 RDW-17.8* Plt Ct-265
[**2198-9-22**] 01:35AM BLOOD WBC-9.0 RBC-4.14* Hgb-13.1* Hct-41.0
MCV-99* MCH-31.8 MCHC-32.0 RDW-17.5* Plt Ct-[**Numeric Identifier **]/02/12 03:43AM
BLOOD WBC-7.4 RBC-4.16* Hgb-13.0* Hct-41.7 MCV-100* MCH-31.3
MCHC-31.2 RDW-16.5* Plt Ct-283
[**2198-9-27**] 05:11AM BLOOD WBC-7.1 RBC-3.90* Hgb-12.4* Hct-38.5*
MCV-99* MCH-31.8 MCHC-32.2 RDW-16.4* Plt Ct-239
[**2198-9-20**] 04:54AM BLOOD Glucose-90 UreaN-64* Creat-3.0* Na-143
K-3.9 Cl-108 HCO3-23 AnGap-16
[**2198-9-21**] 01:14AM BLOOD Glucose-84 UreaN-67* Creat-2.7* Na-149*
K-3.3 Cl-110* HCO3-27 AnGap-15
[**2198-9-22**] 01:30AM BLOOD Glucose-93 UreaN-59* Creat-2.2* Na-150*
K-3.3 Cl-109* HCO3-32 AnGap-12
[**2198-9-23**] 04:32AM BLOOD Glucose-110* UreaN-50* Creat-1.7* Na-150*
K-3.3 Cl-107 HCO3-39* AnGap-7*
[**2198-9-25**] 03:43AM BLOOD Glucose-116* UreaN-37* Creat-1.6* Na-143
K-3.7 Cl-97 HCO3-39* AnGap-11
[**2198-9-27**] 05:11AM BLOOD Glucose-108* UreaN-36* Creat-1.7* Na-140
K-4.0 Cl-94* HCO3-40* AnGap-10
[**2198-9-16**] 06:30PM BLOOD CK(CPK)-[**Numeric Identifier 104043**]*
[**2198-9-17**] 04:13AM BLOOD ALT-42* AST-316* CK(CPK)-[**Numeric Identifier 104044**]*
AlkPhos-52
[**2198-9-18**] 04:45PM BLOOD CK(CPK)-724*
[**2198-9-18**] 05:05AM BLOOD Type-ART Temp-38.6 pO2-89 pCO2-74*
pH-7.17* calTCO2-28 Base XS--3 Intubat-NOT INTUBA
[**2198-9-22**] 01:34PM BLOOD Type-ART pO2-67* pCO2-59* pH-7.40
calTCO2-38* Base XS-8
[**2198-9-26**] 11:21AM BLOOD Type-[**Last Name (un) **] pO2-40* pCO2-71* pH-7.40
calTCO2-46* Base XS-14
[**2198-9-27**] 05:31AM BLOOD Type-[**Last Name (un) **] pO2-57* pCO2-72* pH-7.39
calTCO2-45* Base XS-14
[**2198-9-17**] 01:28AM BLOOD Lactate-2.2*
[**2198-9-22**] 01:34PM BLOOD Lactate-1.0
Imaging
[**9-16**] CXR
PORTABLE CHEST: [**2198-9-16**].
HISTORY: 55-year-old man with shortness of breath and acute
hypoxia.
FINDINGS: Single portable view of the chest is compared to
previous exam from
[**2198-9-11**]. Compared to prior, there has been interval
improvement of
aeration at the lung bases. There are some persistent bibasilar
opacities,
right greater than left. Cardiomediastinal silhouette is stable
as are the
osseous and soft tissue structures.
IMPRESSION: Mild interval improvement in the previously seen
bibasilar
opacities which persist. These could be due to resolving
infiltrates or
atelectasis or potentially aspiration.
[**9-16**] CT head
FINDINGS: There is no acute intra-axial or extra-axial
hemorrhage, mass,
midline shift, or territorial infarct. Right occipital lobe
encephalomalacia
as well as regions of encephalomalacia centered in the right
middle cerebellar
peduncle are again seen. Global volume loss of the cerebellum
is again noted.
Elsewhere, [**Doctor Last Name 352**]-white matter differentiation is preserved.
There is partial opacification of the inferior right mastoid air
cells.
Mucous retention cyst seen in the right maxillary sinus. Other
paranasal
sinuses and left mastoids are clear. The skull and extracranial
soft tissues
are unremarkable.
IMPRESSION:
No acute intracranial process. Encephalomalacia within the
right occipital
lobe and right middle cerebellar peduncle, unchanged from prior
[**2198-9-17**]
TTE: Poor image quality.The left atrium is normal in size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. No late
contrast is seen in the left heart (suggesting absence of
intrapulmonary shunting). There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
dilated with mild global free wall hypokinesis. There is
abnormal septal motion/position. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The tricuspid regurgitation
jet is eccentric and may be underestimated. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2197-12-22**],
due to poor image quality on prior study, a direct comparison of
RV size nad function is not possible. The current study suggests
a more dilated/dysfunctional RV though.
[**2198-9-17**] lower-extremity venous u/s
IMPRESSION: No deep vein thrombosis.
[**2198-9-22**] CXR
1. Nasogastric tube is seen coursing below the diaphragm with
the tip not identified. Left internal jugular central line has
its tip in the proximal SVC. There continues to be diffuse
bilateral airspace process with probable associated layering
effusions. This may reflect worsening pulmonary edema, although
superimposed bilateral pneumonia cannot be entirely excluded.
Clinical correlation is advised. No pneumothorax is seen.
Overall, cardiac and mediastinal contours are likely stable, but
somewhat difficult to assess due to diffuse airspace process.
[**2198-9-23**] Head CT
IMPRESSION: No acute intracranial process identified to explain
patient's neurologic decline.
[**2198-9-23**] EEG (from neurology note)
EEG was done and showed spikes of 3Hz with right hemispheric
predominance.
[**2198-9-26**] Video Swallow
FINDINGS: Barium passes freely through the oropharynx and
esophagus without evidence of obstruction. There was evidence of
intermittent penetration of thin, as well as intermittent
aspiration of nectar consistency. For further details, please
refer to speech and swallow division note in OMR.
Preliminary Report IMPRESSION:
Penetration of thin consistency and aspiration of nectar
consistency, both intermittently.
Brief Hospital Course:
Active Problems
#rhabdomyolysis- Pt found on the ground for an extended period
of time which could be the cause for his rhabdo. PT received
aggressive IV fluid to try to maintaine a 200CC urine output
while not compromissing his respiratory status. His CK
eventually came down but CR was still elevated. Renal was
consulted and recommended no HD. PT still producing urine and CR
was stable. Creatinine stabilized at 1.6-1.7. This likely
represents his new baseline. He continued to have good urine
output throughtout rest of admission.
#elevated trop- Pt has signigicant elevation of trop. EKG
similar to previous. Pt received 325 [**Month/Day/Year **]. His CK-MB index was
never elevated and trop was not raising so a cards consult was
not obtained.
#ATN: Muddy brown cast found in urine [**9-19**]. Most likely [**1-25**] to
rhabdo. Improving toward baseline. Most likely CKD at this
point. Cr remains stable at 1.7. Good urine output maintained
throughout admission. Pt. to follow-up with renal as outpatient
#Hypoxemia- Chronic O2 requirment likely multifactorial related
to pulmonary HTN, COPD, OSA, OHS. Current increase in O2
requirement likely [**1-25**] PE vs heart failure. Unable to obtain CTA
at this time due to pt [**Name (NI) **]. Has been improving with diuresis and
thus it is most likely [**1-25**] CHF/pulmonary edema, less likely PE,
heparin was switched to subcut. As patient continues to improve
with diuresis, did not pursue further PE work-up. Treated with
vanco and cefipime after 8 day HCAP coverage. Currently no
clinical evidence of pneumonia. Pt. responded well to IV Lasix
40mg [**Hospital1 **]. Upon discharge, pt. likely at his baseline hypoxemia.
No evidence of significant pulmonary edema on most recent CXR
and only mild bibasilar crackles on exam. Still 5 liters net
positive for length of stay [**1-25**] aggressive fulid resuscitation
for severe rhabdo upon initial presentation. Would recommend
continued diuresis to achieve euvolemia and optimize respiratory
status. Renal function slowly improving, so patient likely able
to autodiurese soon. Though not confirmed, pt. likely has
significant pulmonary HTN based on old TTE, recent chest CT with
enlarged PA, and multiple pulmonary HTN risk factors as outlined
above. Pt. scheduled to follow in pulmonary clinic with Dr.
[**Last Name (STitle) **] for further w/u and treatment of this presumed pulmonary
HTN. At time of discharge, pt. saturating in low 90s on nasal
canula, which is likely around his baseline oxygenation. No
pulmonary symptoms.
#new onset seizure activity- PT experienced change in mental
status while in the ICU with echolalia, confusion, and leftward
gaze deviation with random leftward saccadic eye movements.. A
CT head was ordered which showed NAP and EEG which showed
epileptiform discharges. Neurology was called and pt was placed
on Keppra. His mental status improved significantly back to
baseline without any further evidence of seizure activity or
changes in mental status. Pt. to be discharged on Keppra 500mg
[**Hospital1 **]. Pt. will f/u in epilepsy clinic in [**3-30**] weeks time after
discharge for furthur management.
#Nutrition - video swallow. Speech therapy recommend ground
solids with nectar thickened liquids. Likely chronic aspirator
[**1-25**] to prior CVA. Pt. to be discharged on this diet.
Chronic Problems
#HTN - antihypertensives were held throughout admission,
particularly in setting of agressive diuresis following
resolution of rhabdo. Metoprolol and triamterene-HCTZ can be
restarted once pt. back to euvolemia.
#HIV - pt. was maintained on his regimen of Saquinavir and
Ritonavir
Transitional Issues
#Volume overload - upon discharge, pt. net positive 5 liters for
length of stay. has been getting IV lasix 40mg [**Hospital1 **]. Would
recommend continuing diuresis with goal of euvolemia. Diuresis
was associated with significant improvement of pt.'s respiratory
status. Discharged on 5L nc, with saturations in low 90s.
Probably will only require a couple more days of diuresis, as
renal function continues to improve toward his baseline. Would
recommend checking daily electrolytes while actively diuresing
and while Cr continuing to normalize.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 50 mg PO TID
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO DAILY
5. Saquinavir (Invirase) Cap 400 mg PO BID
6. RiTONAvir 400 mg PO BID
7. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
8. Levofloxacin 750 mg PO DAILY
Day 1= [**9-11**], finishes on [**2198-9-15**]
9. Tiotropium Bromide 1 CAP IH DAILY
10. Albuterol Inhaler [**12-25**] PUFF IH Q4H:PRN wheezing, shortness of
breath
11. oxygen
416.8 Other chronic pulmonary heart diseases
Home oxygen @ 5 LPM continuous via shovel mask, conserving
device for portablity
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. RiTONAvir 400 mg PO BID
3. Saquinavir (Invirase) Cap 400 mg PO BID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze/SOB
5. Furosemide 40 mg IV BID
6. LeVETiracetam 500 mg PO BID
7. Albuterol Inhaler [**12-25**] PUFF IH Q6H:PRN shortness of
breath/wheezing
8. Docusate Sodium 50 mg PO BID
9. Metoprolol Succinate XL 12.5 mg PO DAILY (being held for
continued diuresis)
10. Tiotropium Bromide 1 CAP IH DAILY
11. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Rhabdomyolysis
Acute Kidney Injury
Acute on chronic diastolic congestive heart failure
Non-convulsive seizure activity
Discharge Condition:
Mental status: clear, oriented
Ambulatory status: requires wheelchair. Full assist for
transfers
Discharge Instructions:
Dear Mr. [**Known lastname 15352**],
It was a pleasure taking part in your care here at [**Hospital1 771**]. You were admitted for muscle breakdown
known as rhabdomyolysis caused by your fall. This muscle
breakdown caused damage to your kidneys, which was treated with
IV fluids. Your kidneys and the muscle breakdown improved with
IV fluids. You also developed a pneumonia, which was treated
with IV antibiotics and your breathing improved. You continued
to require more oxygen than normal. This was likely due to some
of the fluid that you received backing up into your lungs. We
treated this with a medicine called Lasix, which helped to
remove fluid, and your breathing improved. You also had a period
during which you were very confused. We performed a brain
activity test called an EEG which showed some seizure activity.
We treated this with an anti-seizure medication called Keppra.
Your mental status improved significantly and is now back to
normal. You are being transferred to a rehabilitation facility
where they will continue to remove fluid to help improve your
breathing. They will also work on regaining your strength
through physical therapy.
It is likely that you have a lung disease known as pulmonary
hypertension. This is likely why your oxygen levels are always
low. It will be very important that you follow-up with your
pulmonologist (lung doctor) Dr. [**Last Name (STitle) **].
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2198-10-4**] at 2:00 PM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3172**] [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2198-10-18**] at 2:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]
ICD9 Codes: 5845, 486, 2760, 2720, 496, 4168, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2127
} | Medical Text: Admission Date: [**2193-12-15**] Discharge Date: [**2193-12-28**]
Date of Birth: [**2116-11-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Haldol
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
Acute renal failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 24071**] is a 77y.o. man who presents from [**Hospital 24072**] with acute renal failure. He was admitted there on
[**11-14**] after acute hospitalization for encephalopathy of unknown
origin, concern for NMS (though ruled out by neurology), and
failure to wean of mechanical ventilation. He had originally
presented at that time with agitation, disorientation and
admitted to psych. He received Haldol and developed "movements"
throughout his body. Subsequent course is unknown at this time.
His course over the last month at NE Specialty is also not
known.
However, over the last week he has developed renal failure.
According to lab results from rehab, his Cr was 2.7 on [**12-7**].3 on [**12-8**] on [**12-11**], and 3.3 today. BUN has been
consistently over 100. There is no notation of events,
treatments that occurred during this time. At rehab today, he
was started on dopamine at 2, but this was stopped on his
arrival to ED here. His BP at rehab today was also 80/48.
In the ED here, pt received treatment for his hyperkalemia with
CaGluc, Insulin, Bicarb, and kayexalate.
Past Medical History:
1. CAD: s/p IMI, s/p 3v CABG ('[**79**]), s/p cath in '[**92**] with LMCA
stent and POBA of LAD.
2. Cardiomyopathy, Ischemic: TTE in [**2-9**] showed EF 40%, 2+ MR.
3. HTN
4. Hypercholesterolemia
5. PVD: extensive with occl right SFA, LCI, LCF.
6. COPD with bullous emphysema
7. Chronic respiratory failure: recent vent settings were AC
500 x 14 O2 0.5 PEEP 5 with last ABG today of 7.26/43/57/85%.
8. Recent MRSA, stenotrophomonas, pseudomonas in sputum, ?
treated.
Social History:
Married. Now resides at rehab.
Former cigarette smoker (? amount).
No h/o EtOH abuse or IVDA.
Family History:
Unable to obtain.
Physical Exam:
VS>>
.
GEN>> turns head to voice but does not follow commands, tongue
writhing movements, in NAD
HEENT>> NCAT. Pupils 1mm equal and min reactive to light. OP
with thrush with MMM.
NECK>> Right subclavian site C/D/I. JVP not appreciated due to
pt's mouth movements.
Lungs>> coarse BS b/l but clear o/w
CV>> RRR, nml S1S2, m/r/g not appreciated due to loud BS
ABD>> PEG in place and site C/D/I. Soft, NT, ND, na BS.
EXT>> 3+ pitting edema of b/l UE. 1+ pitting edema of b/l LE.
+ sacral edema.
NEURO>> does not follow commands but orients to face (baseline
per NH).
..
Pertinent Results:
[**2193-12-15**] 07:51PM WBC-12.0* RBC-2.98*# HGB-9.2*# HCT-27.7*#
MCV-93
NEUTS-89* BANDS-2 LYMPHS-2* MONOS-4 EOS-0 BASOS-0 ATYPS-0
PLT COUNT-210
..
[**2193-12-15**] 07:51PM PT-13.5* PTT-26.4 INR(PT)-1.2
..
[**2193-12-15**] 07:51PM GLUCOSE-87 UREA N-158* CREAT-3.7*# SODIUM-135
POTASSIUM-6.8* CHLORIDE-99 TOTAL CO2-18* ANION GAP-18
..
[**2193-12-15**] 07:51PM CK(CPK)-134
[**2193-12-15**] 07:51PM cTropnT-0.14*
[**2193-12-15**] 07:51PM CK-MB-6
..
[**2193-12-15**] 07:51PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD
RBC-[**10-27**]* WBC-[**5-17**]* BACTERIA-MOD YEAST-OCC EPI-0-2 TRANS
EPI-[**2-9**]
.
[**2193-12-15**] 07:51PM URINE UREA N-380 CREAT-114 SODIUM-18
POTASSIUM-24 CHLORIDE-30 TOT PROT-182 PROT/CREA-1.6*
..
[**2193-12-15**] 07:51PM CALCIUM-6.9* PHOSPHATE-12.8*# MAGNESIUM-2.5
..
..
CXR: mild instertial edema with confluent opacities in both
lung bases
..
ECG: Sinus brady at 45 bpm. IVCD (old). nml axis. diffuse
pseudonormalization of T waves. No acute ST changes.
.
MR C/T/L spine - IMPRESSION:
No abnormal enhancing lesions noted to suggest epidural abscess.
If symptoms persist, a followup MRI may be performed in one to
two weeks with a small field of view in the area of interest.
.
EMG -
IMPRESSION:
Abnormal study. There is electrophysiologic evidence for a
severe,
generalized, polyneuropathy which is predominantly axonal in
nature. In this clinical context, this finding is consistent
with a diagnosis of critical illness polyneuropathy. A
superimposed myopathic process, although difficult to exclude
with certainty, does not appear to be present.
.
EEG - Abnormal portable EEG due to the disorganized and slowed
background with occasional bursts of generalized slowing. These
findings indicate a moderate encephalopathy affecting both
cortical and
subcortical structures. Medications, metabolic disturbances, and
infection are among the most common causes. There was no
prominent
focal abnormality although encephalopathies may obscure focal
findings.
There were no epileptiform features
Brief Hospital Course:
77 y.o. man with h/o extensive CAD, ischemic cardiomyopathy,
PVD, ill-defined nervous system insult, now ventilator-dependent
presenting with acute renal failure that has been waxing and
[**Doctor Last Name 688**] 1 week prior to admission. Renal service was consulted
who belived that the pt likely was intravascularly dry but total
body overloaded. They recommended diuresing pt with lasix and
diuril, there was no improvement in renal function. Pt
underwent hemodialysis X 3 days with no improvement in mental
status. Neurology was also following who recommended several
studies including mri, emg, eeg. All tests were inconclusive
and pt likely had critical care neuropathy. His respiratory
status was not clear as to why pt was vent dependent. After
several days in the hospital and not much improvement in
clinical status family meeting was done, where the family
decided to change the code status to comfort measures only. He
was taken of the ventilator and expired few hours later.
Medications on Admission:
Depakote 500mg qhs
Heparin SC 5000U tid
Epogen 20000U SC weekly
Duoneb q6h
Prednisone 10mg daily
Colace 100mg [**Hospital1 **]
Norvasc 10mg daily
Labetalol 600mg [**Hospital1 **]
Valium 2.5mg qhs
Nitropaste 1 inch q6h
Nystatin
Zoloft 25mg daily
MVI
Iron sulfate 325mg [**Hospital1 **]
Ranitidine 150mg daily
Lasix 80mg IV x 1 on [**12-14**]
Dopamine gtt 2mcg/kg/min started [**12-14**]
SSRI
Discharge Medications:
none
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2194-1-6**]
ICD9 Codes: 5849, 4280, 2767, 5990, 2762, 4019, 2720, 2859, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2128
} | Medical Text: Admission Date: [**2143-1-7**] Discharge Date: [**2143-1-22**]
Date of Birth: [**2074-4-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
V/Q scan
CT scans
TTE
TEE
PICC placement
Bedside thoracentesis
CT-guided thoracentesis
Persantine cardiac stress test
History of Present Illness:
Pt. is a 68 yo active retired man with hemochromatosis,
cirrhosis and DM, who had a mechanical fall 2 weeks prior to
admission while at his winter home in [**State 108**]. After falling,
he developed left sided rib pain (later found to be due to rib
fracture), and sought care at the local ED, where he was told to
take tylenol. After continuing to have pain for several more
days he returned to the ED and was prescribed motrin for the rib
pain. He reports taking 600mg every 4-5 hrs for 3-4 days. He
also reports having very diminished appetite and eating and
drinking very little during this time. Three days PTA, he
developed SOB. At the urging of his children, he flew back from
FL to be seen here in [**Location (un) 86**]. In addition to decreased PO
intake, he reported insomnia and nausea/dry heaves. He denied
abdominal pain, fevers, chills, sick contacts, or travel out of
the country.
.
On admission, EKG showed right heart strain and possible lateral
ischemic changes. Pulmonary embolism was considered; V/Q scan
was read as low probability. Acute coronary syndrome was also
considered, and cardiac enzymes were elevated with troponin 0.12
and MB index 14.8. Heparin gtt was started, along with ASA and
beta blocker. Also on admission, he was found to have lactic
acidosis in setting of ARF (creatinine 3.4 with baseline 1.1)
with serum lactate 3.9 --> 6.7 and Anion Gap of 25. Serum
potassium was 6.0 and bicarb 12. He was given bicarb gtt for
acidosis and kayexelate, insulin and glucose for elevated K.
.
Initial temp was 94.4 and CXR showed vague opacity in RML.
Blood cultures were drawn and levo/vanc started. In the ED,
patient has 2 transient episodes of hypotension which resolved
spontaneously. He was admitted to the MICU.
Past Medical History:
PMH:
* Hemochromatosis with monthly phlebotomy; dx 15 yrs ago
* Cardiac involvement from hemochromatosis
* DM
* hx of colon polyps
* gallstones (asx)
* Hypothyroidism
* ARF in setting of NSAID use 13 years ago, requiring 5 months
of HD.
Social History:
Widowed, occ alcohol, no cigarettes
Family History:
Parents died in their 50s, unknown cause
Physical Exam:
VS: T 95.2 BP 132/43 HR 74 RR 15 O2sat 100% NRB
GEN: NAD, pleasant
HEENT: PERRL, EOMI, no scleral icterus, MM dry
NECK: JVP flat, no LAD
CHEST: gynecomastia, decreased breath sounds at the bases, no
wheezes, no crackles
CV: Distant heart sounds, RRR, No m/r/g
ABD: Normal bowel sounds, soft, nontender, no hepatomegaly
EXT: bilateral 2+ pitting edema, flat maculopapular rash on left
foot, 2+DP bilaterally
NRO: CN 2-12 intact, 5/5 strength throughout
Pertinent Results:
LABS ON ADMISSION [**2143-1-7**]:
.
WBC-16.3*# RBC-4.63 HGB-13.8* HCT-39.5* PLT COUNT-131* MCV-85
MCH-29.7 MCHC-34.8 RDW-16.6*
NEUTS-92.6* LYMPHS-4.4* MONOS-2.9 EOS-0 BASOS-0.1
.
SODIUM-130* CHLORIDE-92* TOTAL CO2-13*
GLUCOSE-291* UREA N-52* CREAT-3.2*# SODIUM-129* POTASSIUM-5.4*
CHLORIDE-93* TOTAL CO2-14* ANION GAP-27* LACTATE-6.7*
.
ALT(SGPT)-21 AST(SGOT)-37 CK(CPK)-122 ALK PHOS-156* AMYLASE-265*
TOT BILI-1.1 LIPASE-12 ALBUMIN-2.6*
.
CK-MB-18* MB INDX-14.8* cTropnT-0.12*
.
URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD
URINE RBC-0-2 WBC-[**5-25**]* BACTERIA-NONE YEAST-NONE EPI-0
URINE HOURS-RANDOM UREA N-247 CREAT-178 SODIUM-49 POTASSIUM-38
URINE OSMOLAL-358
.
TYPE-ART PO2-74* PCO2-29* PH-7.35 TOTAL CO2-17* BASE XS--7
.
.
STUDIES:
.
#. V/Q scan [**2143-1-7**]
INTERPRETATION:
Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views
demonstrate very heterogenous ventilation with numerous
subsegmental defects bilaterally. Perfusion images in the same 8
views show numerous small bilateral non-segmental defects. These
defects are in the same areas as the ventilation defects, but
are less prominent. The AP dimension is enlarged, and the
diaphgrams are flattened. The chest x-ray is clear.
The above findings are consistent with a low probability for
pulmonary embolism, but are consistent with COPD.
.
#. TTE [**2143-1-8**]
Conclusions:
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size and systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The right ventricular cavity is
moderately dilated with severe global free wall hypokinesis.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is moderate to severe pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global systolic function. Right ventricular cavity
enlargement with free wall hypokinesis and moderate-severe
pulmonary artery systolic hypertension c/w a primary pulmonary
process.
.
#. ECG [**2143-1-9**]
Sinus rhythm, right ventricular hypertrophy, Diffuse ST-T wave
changes with borderline prolonged/upper limits of normal Q-Tc
interval - could be due in part to right ventricular hypertrophy
but clinical correlation is suggested Since previous tracing of
[**2143-1-8**], further ST-T wave changes present and Q-Tc interval
appears short.
.
#. CT chest with Contrast [**2143-1-9**]
IMPRESSION:
1. Right loculated collection which has high CT attenuation
value and may represent either empyema or hemorrhage within
pleural effusion.
2. Right lower lobe opacity with bronchial wall thickening which
may represent pneumonia/aspiration.
3. Right basilar atelectasis.
4. Small left pleural effusion.
5. Ground-glass opacity in the right apex. This should be
followed up with a CT in three months.
6. Focal ground-glass opacity in the right middle lobe and right
lower lobe may represent infectious/inflammatory etiology. This
could also be followed up on the CT which will be obtained in
three months.
7. Atherosclerotic coronary calcifications.
8. Gallstones without evidence of cholecystitis.
9. Liver granulomas.
.
#. Renal US [**2143-1-10**]:
FINDINGS: The right kidney measures 9 cm in length, previously
measuring 9.5 cm. The left kidney measures 10.2 cm in length,
previously measuring 10.7 cm in length. In the interpolar region
of the right kidney, there is an area with lobulated appearance
consistent with cortical scarring, unchanged from the prior
study. In the interpolar region of the left kidney, there is a
tiny cortical crystal. There is no hydronephrosis, stones, or
renal masses. There is no perirenal fluid. The bladder is
unremarkable.
IMPRESSION:
1. Slight interval decrease in size in both kidneys.
2. There is no hydronephrosis.
3. Stable area of cortical scarring in the right kidney.
.
#. TEE [**2143-1-15**]
Conclusions:
1. The left atrium is dilated.
2. The left ventricular cavity size is normal. Due to suboptimal
technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is
difficult to assess but is probably
normal.
3. There are complex (>4mm) sessile atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta.
4. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
6. There is a small pericardial effusion.
7. No evidence of endocarditis seen.
.
#. CTA Chest [**2143-1-16**]:
1. No evidence of pulmonary embolism.
2. Unchanged right loculated collection within the pleural space
of hyperattenuation. Given the appearance with increased
subpleural fat, this has the appearance of chronic right
effusion. It is difficult to comment on possible thickening of
the pleura.
3. Small left simple effusion, slightly increased from the prior
study.
4. 3-mm nodule in the right middle lobe. In the absence of known
malignancy, one-year CT followup could be considered.
5. Atherosclerotic coronary artery calcifications.
6. Cirrhosis of the liver, with low-attenuation oval lesion near
the dome. It is incompletely characterized on the study.
7. Gallstones without evidence of cholecystitis.
8. Left lateral fifth and seventh rib fractures.
9. Cystic structure above the manubrial notch without
enhancement, incompletely characterized on this study.
.
#. Core biopsy of R solid pleural effusion [**2143-1-17**]
.
#. Stress test [**2143-1-21**]
Exercising stress test: No anginal symptoms or ECG changes from
baseline. N
Persantine MIBI: Left ventricular cavity size is normal. Resting
and stress perfusion images reveal uniform tracer uptake
throughout the
myocardium. Gated images reveal normal wall motion. The
calculated left ventricular ejection fraction is 71%. No prior
studies are available for comparison. IMPRESSION: Normal
myocardial perfusion. EF 71%.
Brief Hospital Course:
#. Anion Gap Acidosis:
Was likely due to lactic acidosis given his high lactate on
admission. High lactate production likely occurred [**1-17**] sepsis
and poor perfusion, and ARF prevented clearance of lactate. Was
treated with bicarb in the ED and Gap resolved.
.
#. Hyperkalemia: resolved after receiving kayexelate, insulin
and glucose in ED.
.
#. RV strain/Pulmonary Hypertension:
On [**1-8**] TTE was obtained and showed a dilated RV with severe
global free wall hypokinesis and abnormal septal movement. He
was also noted to have moderate-severe pulmonary artery systolic
hypertension consistent with a primary pulmonary process. LVEF
was >55%. Elevated tropinins measured in the ED were thought to
be due to RV strain combined with decreased renal clearance. By
[**1-9**], troponin had trended down and heparin gtt was
discontinued. For his pulmonary hypertension observed on echo, a
pulmonary consult was obtained. Acute PE was thought to be an
unlikely cause of his echo findings given the negative V/Q scan
on admission, but chronic PE was thought to be a possibility.
CTA was obtained on [**1-16**], which was negative. Other etiologies
were considered, including porto-pulmonary hypertension from
cirrhosis. HIV, [**Doctor First Name **] and RF were sent and found to be negative.
Scleroderma antibody test is pending. He will undergo an
outpatient work-up for pulmonary hypertension with PFTs, sleep
study, and outpatient appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
.
#. Hypoxia:
The patient was dyspneic on admission, and was maintained on
supplemental oxygen for oxygen saturations that dropped into the
high 80's at rest on room air. This was thought to be related to
a presumed RML pneumonia (seen as opacity on admission CXR) and
underlying pulmonary hypertension seen on Echo. However, the
opacity observed on CXR was not seen on CT from [**1-16**], so it is
unlikely that the original opacity represented a pneumonia as
originally thought. His dyspnea slowly improved, and he was
weaned from supplemental oxygen by [**1-14**]. However, on [**1-15**] he
again developed an oxygen requirement after IV fluids were
initiated in preparation for receiving IV contrast, and on [**1-16**],
resting oxygen saturation was measured at 89% on room air at
rest, 85% while ambulating. CTA [**1-16**] showed an enlarged
left-sided pleural effusion (fluid density) and a R-sided
pleural effusion that was determined to be solid on
thorocentesis (Path result is pending). These findings, in
combination with his pulmonary hypertension and deconditioning
were thought to account for the patient's continued hypoxia.
Diuresis was initiated the following day, and satrurations
improved, but he continued to have an oxygen requirement. He had
also been noted to have worsened dyspnea while ambulating, and a
stress test was performed to rule-out an anginal component.
Stress test was normal, showing no ECG changes or anginal
component and normal myocardial perfusion with Ejection Fraction
of 71%. By discharge, oxygen saturations were 98% on 3L, and he
was discharged home on 2L oxygen via nasal cannula.
.
#. Acute Renal Failure:
On admission, the patient had a creatinine level of 3.4. This
appeared to be related to a prerenal state, as supported by his
history of very poor PO intake x 10 days and FENa<1%. The
possibility of ATN from NSAIDs was also considered given his
recent history of taking Motrin for pain, and renal followed the
patient until Cr had improved. Renal ultrasound showed no
hydronephrosis. Creatinine slowly improved with IVF and time,
and had decreased to 1.2 by [**1-16**] (most recent baseline
measurement was 1.1 in [**2140**]). When the patient's home diuretics
were subsequently restarted for hyponatremia and fluid overload,
Cr rose again to 1.6. By discharge, the patient's creatinine was
1.4.
.
#. Staph Bacteremia:
Blood cultures on admission grew MSSA (4/4 bottles from [**1-7**]).
Renally-dosed vancomycin was started on [**1-8**], then switched to
oxacillin on [**1-10**] when sensitivities returned. 2/2 blood
cultures from [**1-10**] also grew staph aureus. Surveillance cultures
since then have been negative. TEE done [**1-15**] not show any
valvular abnormalities. A PICC line was placed on [**1-12**] and the
patient completed a 14-day course of IV antibiotics on [**2143-1-22**]
and the PICC was removed prior to discharge.
.
#. Hyponatremia:
While in the ICU, the patient had one set of serum chemistries
with serum sodium of 122. Remainder of values were in 130s until
fluids were started on [**1-14**] in preparation for CTA with dye
load. Next measured Na was 127 on [**1-16**]. He was fluid restricted
to 1500cc/day and encouraged to improve his food intake, which
had been poor throughout his admission. Given that he also had
evidence of total body fluid overload (peripheral and abdominal
edema), he was restarted on his home diuretic regimen of Lasix
20mg and spironolactone 25mg. By [**1-22**], Na had risen to 131.
.
#. UTI:
Urine labs from [**1-9**] showed UTI, for which the patient was
treated with a 7 day course of Levofloxacin that finished on
[**1-16**]. Urine Cx was negative, but was sent after the patient had
started Levofloxacin and Vancomycin. Fever curve remained flat.
.
#. Anxiety: The patient consistently reported having a "nervous
stomach" that felt like it had "knots in it." He has had these
sensations for many years, and reported that it made eating
difficult because it caused him to feel nauseus. This was
thought to be a manifestation of anxiety, and the patient was
tried on 0.5mg of Ativan. This was subsequently discontinued
when he was found to be excessively somnolent. The patient
agreed to start Remeron for help with anxiety and appetite
stimulation. He tolerated it well and was discharged on 15mg
Remeron QHS.
.
#. DM: The patient recived QID finger sticks and was treated
with bedtime glargine and ISS. Blood glucose measurments
fluxuated with his PO intake and adjustments were made as
appropriate.
.
#. Hypertension/ CAD: The patient was treated with ASA 325mg and
Metoprolol 12.5mg TID. As the patient had no apparent indication
for digoxin, this was held during his hospitalization. He was
discharged on atenolol 12.5mg daily and ASA 325mg daily. Stress
test revealed no hypoperfusion at rest or with persantine
stimulation.
.
#. Nutrition:
Albumin was 2.6 on admission, 2.4 on [**1-16**]. The patient reported a
10 day history of anorexia on admission and continued to have
poor PO intake throughout most of his hospitalization. He cited
lack of appetite and nausea caused by his "nervous stomach" as
reasons for his poor intake. The patient was maintained on a
renal diet with liquid supplements (Boost) TID. He had poor
compliance until 2 days prior to discharge, when he reported an
increase in appetite and improved PO intake was recorded.
.
#. Hemochromatosis/cirrhosis: Remained stable during this
hospitalization.
.
#. Hypothyroidism: Remained stable. He was treated with his home
dose of Levothyroxine 100 mcg daily during this admission.
.
# Physical Therapy: The patient was evaluated and followed by
PT, who felt he was safe to return to his daugter's home.
.
# Prophylaxis:
The patient was treated with incentive spirometry, H2 blocker,
and SC heparin (which was discontinued when he began ambulating)
.
#. Abnormal tests requiring outpatient follow-up:
Seen on CTA [**2143-1-16**]:
1. 3mm pulmonary nodule in the right middle lobe.
2. hypodense oval lesion approx 8mm at the liver dome.
Recommend follow-up CT in 1 year.
Medications on Admission:
Meds on admission:
* Spironolactone 25mg daily
* Lasix 20mg daily
* Digoxin 0.125mg daily
* Synthroid 0.1mg daily
* Folic Acid 1mg daily
* Diltiazem 30mg daily
* insulin
Discharge Medications:
* Spironolactone 25mg daily
* Furosemide 20mg daily
* Synthroid 0.1mg daily
* Folic Acid 1mg daily
* Diltiazem 30mg daily
* Mirtazapine 15mg at bedtime
* Aspirin 81mg daily
* Combivent 103-18 mcg/Actuation Aerosol 1 puff QID
* Oxygen 2-3L via nasal cannula to keep O2 sat>94%
* insulin
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
1. Staph aureus bacteremia
2. Pulmonary hypertension
3. Acute renal failure
4. Lactic acidosis
5. Dibetes mellitus
6. hemochromatosis/cirrhosis
Discharge Condition:
Stable. Requiring supplemental oxygen at 2L via nasal cannula.
Discharge Instructions:
1. Call your doctor or go to the ER for:
- fever > 101
- chest pain, shortness of breath, weakness
- other concerns
2. Please use wear your oxygen at all times. Avoid smoking or
open flames as oxygen is flammable.
3. Please take all of your medications as prescribed
5. Take the Ensure supplement drinks three times a day; these
can be purchased at most pharmacies.
Followup Instructions:
1. DR. [**Last Name (STitle) **] [**2143-1-24**] at 9:15 AM [**Telephone/Fax (1) 1983**]
(Please call before appointment to update your registration
information)
2. SLEEP STUDY-Office will call you to schedule appointment. You
can contact them at [**Telephone/Fax (1) 16716**]
3. PULMONARY FUNCTION TESTS: [**2143-2-14**] 11:30AM
(Please go to the [**Hospital Ward Name 23**] building [**Location (un) **] & check-in at Rehab
Services)
4. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (PULMONARY) [**2143-2-14**] 1:10PM [**Telephone/Fax (1) 612**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
ICD9 Codes: 5849, 2762, 2767, 5715, 2761, 5119, 496, 5990, 4280, 4168, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2129
} | Medical Text: Admission Date: [**2194-12-28**] Discharge Date: [**2195-1-8**]
Date of Birth: [**2172-11-19**] Sex: F
Service: Medicine, [**Hospital1 139**] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 22-year-old
female with no significant past medical history who was
transferred here from an outside hospital after a Tylenol PM
overdose.
The patient was in her usual state of health until the day
prior to admission when she had a "fight" with her boss at
work. She was seen wondering about the house at
approximately 11 p.m. speaking nonsensically by her father
who encouraged her to go to sleep. She was then discovered
on the day of admission at 1 p.m. in her bedroom and
unresponsive by her father.
Emergency Medical Service transported her to [**Hospital **]
Hospital. It was subsequently discovered that she had
ingested approximately one and a half bottles of Tylenol PM.
At the outside hospital, the patient received 2 gram of
ceftriaxone. She had a negative head computed tomography.
She was intubated for altered mental status. A serum
toxicology screen revealed a Tylenol level of over 200. The
patient was given 140 mg/kg of N-acetylcysteine and charcoal
followed by nasogastric lavage and bicarbonate. Nasogastric
lavage was occult-blood positive and rectal examination was
guaiac-positive. She was then transferred to [**Hospital1 346**] for further management in out
Medical Intensive Care Unit.
PAST MEDICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Diet pills that the patient
purchased over the internet. She is not clear exactly what
they were.
FAMILY HISTORY: Family history was noncontributory.
SOCIAL HISTORY: The patient reportedly drinks alcohol
socially. She uses tobacco socially. She does have a
history of cocaine use; per her cousin she quit last year.
No history of intravenous drug use. She works in a health
club. Her parents are divorced. She lives with her father.
She has some recreational Percocet use in the last year.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 96.2
degrees Fahrenheit, her heart rate was in the 120s, her blood
pressure was 93 to 116/57 to 63, she was on pressure support
ventilation of 20/5/40% with a rate of 21 and a tidal volume
of 880. Her oxygen saturation was 97% to 99% on room air.
In general, the patient was an obese, sedated, and intubated
woman. Skin showed pressure shores on her left forearm and
left hip. Head, eyes, ears, nose, and throat examination
revealed pupils were 5 mm and minimally reactive to light.
She had charcoal around her mouth. Neck examination revealed
a large smooth bulge on the right side with no
lymphadenopathy. Cardiovascular examination revealed
tachycardia; otherwise regular. Pulmonary examination was
clear. The abdomen was obese but soft and nontender. There
were positive bowel sounds. Extremity examination revealed
no edema. There were strong bilateral radial pulses. There
was normal capillary refill in her left arm and fingers. On
neurologic examination, the patient was sedated and
intubated. She had absent deep tendon reflexes in her
patellar and Achilles. Her toes were upgoing bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 26.9 (differential with 84% neutrophils, 10%
bands, 3% lymphocytes, and 3% monocytes), her hematocrit was
52.8, and her platelets were in the 300s. Her INR was 3.2,
her prothrombin time was 22, and her partial thromboplastin
time was 35.8. Chemistry-7 revealed her sodium was 141,
potassium was 4.7, chloride was 113, bicarbonate was 6, blood
urea nitrogen was 10, creatinine was 0.9, and her blood
glucose was 186. Her anion gap was 22. Her calcium was 8,
her phosphate was 3.2, and her magnesium was 2.2.
Alanine-aminotransferase was 291, her aspartate
aminotransferase was 312, her lactate dehydrogenase was 276,
creatine kinase was 39,700. Her alkaline phosphatase was 92.
Her total bilirubin was 2. Her albumin was 4.3. Her Tylenol
level was 706. Serum osmolalities were 314. Her lactate was
13.5. Acetone was negative. Ethanol was negative.
Urinalysis revealed a specific gravity of 1.025, large blood,
30 protein, 250 glucose, 27 red blood cells, 27 white blood
cells, and a few bacteria.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a
narrow complex tachycardia and R prime in V1.
IMPRESSION: The patient is a 22-year-old female status post
a suicide attempt with a large number of Tylenol PM who
presented with an altered mental status requiring intubation
with severe anion gap metabolic acidosis, coagulopathy, liver
enzyme abnormalities, leukocytosis, rhabdomyolysis, and left
arm compression.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. TOXICOLOGIC ISSUES: The patient presented with both a
Tylenol and Benadryl overdose.
The Tylenol overdose was treated with an infusion of
N-acetylcysteine at 17.5 mg/kg per hour to decrease any
further toxicity to the liver and kidneys. Additionally, the
patient underwent urgent hemodialysis in an effort to
decrease the Tylenol level given that it was over 700 on
presentation to [**Hospital1 69**] which
was at least 20 hours after ingestion. N-acetylcysteine was
continued until the patient's liver enzymes had normalized to
be below 1000.
For the Benadryl overdose, the patient was treated
supportively with benzodiazepines as needed for agitation
from the anticholinergic effects of the Benadryl.
The remaining toxicology screens for possible other
substances ingested were negative.
2. LIVER ISSUES: The patient's liver enzymes and
coagulation times were carefully monitored to determine liver
function. Her alanine-aminotransferase peaked at
approximately 12,000. Her aspartate aminotransferase peaked
at about 8500. Additionally, the patient's INR peaked at
approximately 10. Her bilirubin peaked at approximately 12.
All were consistent with her being in hepatic failure.
The patient was evaluated by the Liver Transplant team on the
day of arrival. During her hospital course, she was in fact
placed on the transplant list. However, her liver function
began to recover and is in fact nearing normal currently.
Thus, she did not need a liver transplant. Currently, her
INR is 1.3. Her bilirubin is 3. Her liver enzymes are
nearly normal.
3. RENAL ISSUES: Initially, the patient's kidney function
was normal. She underwent emergent hemodialysis for
decreasing the Tylenol level. However, several days into her
hospital course, the patient developed decreased urine output
and with an increasing urine sodium; concerning for acute
tubular necrosis secondary to Tylenol toxicity. The patient
was therefore restarted on hemodialysis for her acute renal
failure through a right femoral Quinton catheter. The
patient tolerated this very well. Over her hospital course,
the patient's kidney function began to recover. By the time
of discharge she had excellent urine output of over 2 liters
of urine per day, and her creatinine was starting to
normalize without hemodialysis. Her creatinine went from 6.6
on [**1-7**] to 6 on [**2195-1-8**]. Her kidney
function will need to continue to be followed daily for the
next several days after discharge to insure that it continues
to recover.
4. RHABDOMYOLYSIS ISSUES: Rhabdomyolysis likely secondary
to her prolonged time down on her left side. The patient was
treated with vigorous hydration to prevent renal failure
secondary to elevated myoglobin levels. Her creatine kinases
normalized while she was in the hospital.
5. COAGULOPATHY ISSUES: The patient's initial coagulopathy
on presentation to the outside hospital was likely secondary
to direct effects of Tylenol on Factor VII. However, she
subsequently developed a significant coagulopathy secondary
to her renal failure. The patient received multiple units of
fresh frozen plasma while she was in the hospital to correct
her coagulopathy for procedures and other line placements.
Additionally, she received multiple doses of vitamin K. By
the time of discharge, her INR was 1.3.
6. LEFT RADIAL NERVE PALSY ISSUES: Initially, when the
patient presented she had left arm swelling. There was
concern for a possible compartment syndrome.
The Orthopaedic Service was consulted and felt that she did
not show signs of compartment syndrome after she was
extubated, and her mental status had improved, neurologic and
motor testing on her left arm revealed decreased thumb
extension and abduction which was consistent with a left
radial nerve palsy which was likely from compression. The
Orthopaedic Service recommended a wrist splint to prevent
thumb flexion contractors, and she was to follow up with Dr.
[**Last Name (STitle) **] in the Hand Clinic one to two weeks after discharge.
7. SUICIDE ATTEMPT ISSUES: The patient had no known prior
history of depression or suicide attempts. She was
maintained with a one-to-one sitter for her entire in the
hospital.
Once the patient was extubated and was able to speak, the
Psychiatry Service was involved in her care. They are
arranging for her to receive inpatient psychiatric treatment
now that her medical issues have nearly resolved.
8. ANION GAP METABOLIC ACIDOSIS ISSUES: The patient
initially presented with a severe anion gap metabolic
acidosis which was most likely secondary to a lactic acidosis
which was most likely from a combination of the
rhabdomyolysis and the fact that her liver was failing and
was not effectively clearing lactate.
The patient was treated with fluids containing bicarbonate,
and the metabolic acidosis resolved over the first several
days she was in the hospital.
9. ALTERED MENTAL STATUS ISSUES: On presentation, the
patient's altered mental status was likely secondary to her
large ingestion of Benadryl. Her mental status improved as
she cleared over the first several days.
10. ASPIRATION PNEUMONIA ISSUES: The patient came in with
an elevated white blood cell count and began spiking fevers.
Chest x-rays and computed tomography scans were consistent
with aspiration pneumonia. The patient was treated with a
10-day course of levofloxacin and Flagyl with resolution of
her sputum production and fevers as well as improvement in
her white blood cell counts.
11. ANEMIA ISSUES: The patient was noted to develop a
decrease in her hematocrit while she was here in the
hospital. Her hematocrit on admission was most likely
hemoconcentrated. Nevertheless, while she was in here toward
the end of her hospital course, her hematocrit levels were
consistently in the 27 to 31 range. The etiology of this are
currently unclear as iron studies, B12, and folate studies
were pending at the time of this dictation. Although, given
her age and the fact that she was menstruating, this was most
likely reflective of an iron deficiency anemia. If the
laboratories are consistent with this, the patient will be
started on iron daily.
At the time of this dictation, the [**Hospital 228**] medical issues
have largely resolved or are near resolution. Her only
current outstanding issues is her kidney failure; which, at
this time, appears to be progressing toward resolution with a
decrease in her creatinine today. The patient will need her
kidney function to be followed daily for at least the next
several days, but at this time we do not expect that she will
need any further hemodialysis. Therefore, she is medically
stable to go to an inpatient psychiatric facility.
CONDITION AT DISCHARGE: Condition on discharge was improved.
The patient currently denies any suicidal ideation.
DISCHARGE STATUS: To inpatient psychiatric facility.
DISCHARGE DIAGNOSES:
1. Suicide attempt by Tylenol overdose.
2. Fulminant hepatic failure secondary to Tylenol toxicity;
nearly resolved.
3. Acute renal failure secondary to Tylenol toxicity
requiring hemodialysis; resolving.
4. Left radial nerve compression injury.
5. Rhabdomyolysis; resolved.
6. Anemia.
7. Aspiration pneumonia; resolved.
8. Anion gap metabolic acidosis; resolved.
9. Mental status changes; resolved.
10. Coagulopathy; resolved.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg by mouth once per day.
2. Calcium carbonate 1000 mg by mouth three times per day
(with meals); to be continued as long as phosphate is
elevated.
3. Robitussin DM 5 mL to 10 mL by mouth q.4h. as needed.
4. Cepacol lozenges as needed.
5. Ferrous sulfate 325 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with Inpatient
Psychiatry, and upon discharge from the psychiatric facility
was to follow up with outpatient Psychiatry as they direct.
2. The patient was also instructed to follow up with Dr. [**Last Name (STitle) **]
for her left hand and thumb weakness. The patient was to
call telemetry [**Telephone/Fax (1) 4845**] to schedule an appointment in
approximately one to two weeks; she was to continue wearing
the wrist splint until then to prevent flexion contractures.
3. Finally, the patient was instructed to follow up with her
primary care physician upon discharge to further assess her
renal function and make sure that it has returned to [**Location 213**].
4. Additionally, while the patient is at the psychiatric
facility she should have a Chemistry-10 checked daily for the
next several days until her renal function normalizes or is
nearly normal; at which point she should have it checked
every three days for approximately one more week.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 8978**]
MEDQUIST36
D: [**2195-1-8**] 14:33
T: [**2195-1-8**] 15:30
JOB#: [**Job Number 52902**]
ICD9 Codes: 2762, 5070, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2130
} | Medical Text: Admission Date: [**2155-5-28**] Discharge Date: [**2155-6-5**]
Date of Birth: [**2155-5-28**] Sex: M
Service: NEONATAOLO
HISTORY OF THE PRESENT ILLNESS: Baby boy [**Known lastname 30207**] is a former
36 week infant born by cesarean section under epidural
anesthesia to a mother with a history of mitral stenosis in
apparent arrest with previous delivery.
unremarkable except for unknown GBS. No other sepsis risk
factors. Mother receives systemic narcotics just prior to
delivery. The patient emerged vigorous with large amounts of
oral secretions. Apgars 6 at 1 minute and 8 at 5 minutes;
given blow-by oxygen and CPAP for grunting, flaring, and
retracting in the delivery room; transferred to the Newborn
Intensive Care Unit after visiting with parents briefly.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: Pink, active, nondysmorphic male who was well
saturated and perfused in 25% to 50% oxygen. Lungs with
moderate retracting and grunting on CPAP, slight coarse
breath sounds bilaterally equal. Abdomen was benign. Normal
rate and rhythm, S1 and S2 no murmur. Neurological:
Decreased spontaneous activity, but symmetrical, nonfocal,
both hips normal, normal male phallus, bilateral descended
testes, straight spine, no dimples.
REVIEW OF HOSPITAL COURSE BY SYSTEM:
The baby remained on CPAP for approximately 48 hours. He had
an initial arterial blood gas of 737, 39, 60. Transitioned
off CPAP to nasal cannula O2, which he remained in until day
of life #5. He transitioned to room air. He had a day of
some brief desaturations and at the time of discharge he has
been in room air for three days with no desaturations for
greater than 24 hours. The baby's baseline respiratory rate
is 30 to 60s. Bilaterally clear and equal breath sounds.
There was no further respiratory issues.
GASTROINTESTINAL: Baby did exhibit indirect physiological
jaundice; did not require phototherapy. Peak bilirubin on
day of life #4 was 12.2/0.3. Bilirubin on [**6-3**] was 10.3/0.3.
HEMATOLOGY: The baby did not require any blood products
during this admission. The baby had a hematocrit on
admission of 46.
INFECTIOUS DISEASE: The baby had an initial sepsis
evaluation because of his respiratory distress. He had a
white count of 11.1, with 28 polys, 1 band, 78 lymphs,
platelet count 299,000, hematocrit of 46. The baby was
started on Ampicillin and Gentamicin for 48 hours. Blood
cultures remained negative. Baby's clinical condition was
improved so antibiotics were discontinued. He did not have
any further issues with infection.
NEUROLOGICAL: The baby was neurologically appropriate. The
baby did not have a head ultrasound based on the gestational
age of greater than 32 weeks.
SENSORY/AUDIOLOGY TEST/HEARING SCREEN/OPHTHALMOLOGY: Not
examined based on gestational age.
PSYCHOSOCIAL: Parents have been visiting and look forward to
transition home.
CONDITION ON DISCHARGE: Stable.
The patient was discharged home with family.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17108**] at Hamscomb
Air Force Base. [**Telephone/Fax (1) 42163**]. Fax: [**Telephone/Fax (1) 42164**].
FEEDINGS AT DISCHARGE: As lib. Enfamil 20 with iron; taking
in greater than 100 cc per kilo per day.
MEDICATIONS: None.
CAR SEAT SCREENING: Passed. Newborn screening sample sent to
NERNSP on [**6-2**]. No reports received.
At discharge immunizations received were the following:
Hepatitis B vaccine on [**6-3**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] to [**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 siblings or 3. 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, family and other
care givers should be considered for immunization against
influenza to protect the infant.
FOLLOW-UP APPOINTMENT: The patient is to followup with the
primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17108**] within three to five days.
Cardiology followup with Dr. [**Last Name (STitle) 42165**] [**Name (STitle) **] on [**2155-7-2**]
at 10:15 am. Parents are aware of this appointment.
DISCHARGE DIAGNOSES:
1. Premature 36 and 3/4th week male.
2. Status post respiratory distress syndrome.
3. Status post rule out sepsis with antibiotics.
4. Small VSD.
CARDIOVASCULAR: Baby was noted to have a persistent murmur;
had cardiac evaluation including echocardiogram, which showed
a small VSD. Cardiology team at the [**Hospital3 1810**] will
followup with him after discharge as indicated below. He has
not been symptomatic of this VSD. Parents have been informed
that most likely will not require surgery. He may require
prophylaxis with procedures if it does not close.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 36251**]
MEDQUIST36
D: [**2155-6-5**] 16:16
T: [**2155-6-5**] 16:25
JOB#: [**Job Number 42166**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2131
} | Medical Text: Admission Date: [**2186-12-1**] Discharge Date: [**2186-12-8**]
Date of Birth: [**2139-6-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] is a 47 year old gentleman from [**State 531**] that
traveled via bus to [**Location (un) 86**] for evaluation at the [**Hospital **] clinic.
He was seen today, and given his elevated blood pressures (200
systolic) and blood sugar of 375, he was transferred to the ED
for further evaluation.
In the ED, initial vs were: 98.4 [**Telephone/Fax (2) 84313**] 100% on RA. Head
and Ab/Pelvis CT obtained. Patient was given Labetalol 80mg
total IV and gtt started; 8 units Reg Insulin, 20 units Levemir;
30 units glargine; Reglan, Comapzine, Benadryl and Zofran as
well as 2 units of NS. Neuro & [**Last Name (un) **] were consulted with
recommendations implemented (sliding scale and MRI when stable).
Vitals on transfer: 222/118 97 20 99%
On arrival to the MICU, the patient is somewhat somnolent from
anti-nausea medications, but is arousable and appropriate. He
confirms the story above, and complains only of mild nausea at
this time. He denies any chest pain, headache or vision
changes.
We discussed the issue of pork products and he is amenable to
porcine heparin.
Past Medical History:
Type II DM - for over 10 years
Chronic Kidney disease (baseline Cr 3)
Peripheral Neuropathy
HTN
Episodes of vomiting precipitated by hyperglycemia
Social History:
Lives in [**Location 7349**] with his wife, works with developmentally delayed
adults. Denies ETOH/tobacco/drugs. No children. Keeps strictly
Kosher.
Family History:
Sister with Type 2 DM
Physical Exam:
Vitals: T: 98.8 BP: 198/110 P: 102 R: 21 O2: 95%
General: Somnolent but arousable, Alert, oriented, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, Dilated
fundoscopic exam without active retinal hemorrhaging
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Fast S1 & S2 without murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, Ankle/pedal edema
Neuro: AAOx3, CN IV-XII intact, dilated pupils make II/III
evaluation difficult.
Pertinent Results:
ADMISSION LABS [**2186-12-1**]:
BLOOD
[**2186-12-1**] 10:00AM WBC-7.6 Hgb-11.5* Hct-33.9*
[**2186-12-1**] 10:00AM Neuts-75.5* Lymphs-16.5* Monos-4.4 Eos-2.8
Baso-0.6
[**2186-12-1**] 10:00AM Glucose-363* UreaN-46* Creat-3.3* Na-138 K-5.6*
Cl-105 HCO3-24 AnGap-15
[**2186-12-1**] 10:00AM ALT-14 AST-11 CK(CPK)-175* AlkPhos-96
TotBili-0.4
[**2186-12-1**] 10:00AM CK-MB-6 cTropnT-0.10*
[**2186-12-1**] 10:00AM ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
URINE
[**2186-12-1**] 10:10AM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2186-12-1**] 10:10AM Blood-MOD Nitrite-NEG Protein->300 Glucose-500
Ketone-15 Bilirub-NEG Urobiln-0.2 pH-6.0 Leuks-NEG
[**2186-12-1**] 10:10AM RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0
PERTINENT LABS:
CE TREND:
[**2186-12-1**] 10:00AM CK(CPK)-175*
[**2186-12-2**] 04:07AM CK(CPK)-116
[**2186-12-1**] 10:00AM CK-MB-6 cTropnT-0.10*
[**2186-12-1**] 06:30PM CK-MB-6 cTropnT-0.07*
[**2186-12-2**] 04:07AM CK-MB-4 cTropnT-0.06*
HCT TREND:
[**2186-12-1**] 10:00AM Hct-33.9*
[**2186-12-2**] 04:07AM Hct-30.2*
[**2186-12-3**] 09:40AM Hct-31.9*
[**2186-12-4**] 06:50AM Hct-32.9*
[**2186-12-5**] 06:54AM Hct-30.3*
[**2186-12-6**] 06:20AM Hct-29.0*
[**2186-12-7**] 06:50AM Hct-33.2*
[**2186-12-8**] 07:12AM Hct-29.0*
ANEMIA WORKUP:
[**2186-12-2**] 04:07AM Ret Aut-1.3
[**2186-12-1**] 10:43PM Iron-38*
[**2186-12-1**] 10:43PM calTIBC-256* VitB12-475 Folate-10.0 Ferritn-138
TRF-197*
BUN/Cr TREND:
[**2186-12-1**] 10:00AM UreaN-46* Creat-3.3*
[**2186-12-1**] 10:43PM UreaN-47* Creat-3.3*
[**2186-12-2**] 04:07AM UreaN-47* Creat-3.3*
[**2186-12-2**] 03:18PM Creat-3.6*
[**2186-12-3**] 09:40AM UreaN-47* Creat-3.4*
[**2186-12-4**] 06:50AM UreaN-40* Creat-3.3*
[**2186-12-5**] 06:54AM UreaN-38* Creat-3.0*
[**2186-12-6**] 06:20AM UreaN-37* Creat-2.9*
[**2186-12-7**] 06:50AM UreaN-40* Creat-2.9*
[**2186-12-8**] 07:12AM UreaN-47* Creat-3.0*
MICROBIOLOGY:
[**2186-12-1**] MRSA screen: negative
[**2186-12-1**] UCx: negative
[**2186-12-3**] BCx: negative
STUDIES:
[**2186-12-1**] EKG: NSR @ 101
[**2186-12-1**] CXR: No acute cardiopulmonary abnormality
[**2186-12-1**] CT head: No acute intracranial process
[**2186-12-1**] CT abd/pelvis: No acute intra-abdominal process
[**2186-12-4**] Gastric emptying study: Normal gastric emptying study
DISCHARGE LABS [**2186-12-8**]:
[**2186-12-8**] 07:12AM WBC-7.0 Hgb-10.0* Hct-29.0* Plt Ct-133*
[**2186-12-8**] 07:12AM Glucose-285* UreaN-47* Creat-3.0* Na-136 K-4.7
Cl-102 HCO3-25 AnGap-14
Brief Hospital Course:
A 47 year old gentleman that travelled here from [**Location (un) 7349**] for [**Last Name (un) **]
evaluation transferred to the MICU for hypertensive
urgency/emergency.
#. Hypertensive Urgency: The patient was admitted with
hypertensive urgency to the 200s without clear signs of end
organ damage other than proteinuria, but his meds and old labs
suggest chronic renal disease. Given his home regimen and
history of poor compliance this does not likely represent a
great departure from baseline. Neuro evaluation was normal.
Troponins were elevated but this likely represents demand
ischemia and poor renal clearance. In the ICU he was continued
on a labetalol drip until his blood pressures dropped to the
120s systolic. The labetalol drip was stopped at that time and
he was started on carvedilol 25 mg [**Hospital1 **]. On the floor, BP
remained difficult to control, with elevations >200/100. The
patient was continued on Carvedilol 25mg PO BID, restarted on
Clonidine, increased dose of Aliskiren 300mg, Lasix 40mg qAM and
20mg qPM, and additional Nifedipine 60mg PO daily. BP was well
controlled on discharge.
#. Uncontrolled Type 2 DM: Poor history, reason for his trip to
[**Location (un) 86**]. [**Last Name (un) **] is already consulted and is following. He was
started on a regimen of lantus [**Hospital1 **] with a humalog sliding scale.
He had episodes of hypo and hyperglycemia while in house. He was
discharged on Lantus 40 units qhs with Humalog sliding scale
with FS under better control. The patient will continue to
follow with [**Last Name (un) **] as an outpatient.
#. Nausea/Vomiting: Per patient history, related to
hyperglycemia. The patient had an episode of dysconjugate gaze
in the [**Last Name (LF) **], [**First Name3 (LF) **] Compazine and Reglan were held. N/V was controlled
with Zofran and Ativan. Gastric emptying study was normal. The
patient was tolerating POs with no further nausea after the 3rd
hospital day.
#. Chronic renal insufficiency: The patient has baseline
elevated creatinine. Lasix was held initially, but restarted
with no increase in creatinine. The patient follows with a
nephrologist as an outpatient.
#. Elevated Troponin: The patient was admitted with elevated
trop, likely tachycardia induced strain with poor renal
clearance. CEs trended down overnight. No evidence of ischemic
event.
#. Anemia: No past records, no signs of active bleeding. Likely
related to chronic renal disease. HCT was stable during
hospitalization.
#. GERD: Pt was continued on home H2 blocker.
#. Hyperlipidemia: Continued on home statin.
Medications on Admission:
Lipitor 10mg daily
Donnatol 1 tab TID prn nausea/vomiting
Furosemide 20mg [**Hospital1 **]
Vitamin D 50,000 units once weekly
Famotidine 20 mg [**Hospital1 **]
Clonidine 0.3mg [**Hospital1 **]
Aliskiren 150mg Daily
Carvedilol 12.5 mg [**Hospital1 **]
Calcitriol 0.25mcg MWF
70/30 30 units with breakfast and dinner
Levamir 30 units QHS
Humalog sliding scale - 250 -> 4 units, 350 -> 6 units
Not taking aspirin as prescribed
Discharge Medications:
1. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
6. Aliskiren 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. Insulin Glargine 100 unit/mL Cartridge Sig: Forty (40) units
Subcutaneous at bedtime.
9. Humalog 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous four times a day: please see attached sliding
scale.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
12. Donnatal 16.2 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
13. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Hypertension
- Diabetes Mellitus
Discharge Condition:
Stable, improved, tolerating oral diet, ambulating at baseline.
Discharge Instructions:
You were admitted to the hospital with elevated blood pressures
and high blood sugars. You also had severe nausea and vomiting
on admission. You were given several medications for your nausea
in the emergency department, including Reglan and Compazine. You
then developed disconjugate gaze, which the Neurologists believe
were due to those nausea medications. You had a CT scan of your
head and your abdomen that were unremarkable.
Your blood pressure was brought under control in the intensive
care unit with a Labetalol drip. You were then restarted on your
home medications, which were adjusted to control your blood
pressure. You were also started on Nifedipine CR to help control
your blood pressure.
You continued to have nausea while you were hospitalized. This
was brought under control with Zofran and Ativan. You had a
gastric emptying study to rule out gastroparesis. The study was
normal.
You were evaluated by [**Last Name (un) **] Diabetes doctors to [**Name5 (PTitle) **] [**Name5 (PTitle) **]
control of your blood sugars.
The following changes have been made to your medications:
1. Increase Carvedilol 12.5mg by mouth twice daily to 25mg by
mouth twice daily
2. Increase Aliskiren from 150mg daily to 300mg daily
3. Follow the attached sliding scale, recommended by the [**Last Name (un) **]
doctors. Stop your previous insulin regimen.
4. Take Nifedipine CR 60mg by mouth daily
5. Increase Lasix to 40mg in the morning and continue taking
20mg in the evening
If you experience worsening nausea, vomiting, headache, changes
in vision, sweating, trembling, shortness of breath, chest pain,
or any other concerning symptoms, please call your primary care
doctor or return to the emergency department.
Followup Instructions:
Please follow up with your primary care doctor early next week
to have your blood pressure and your sugars checked. You should
have your blood drawn at this time to monitor your electrolytes
and creatinine. You have an appointment with Dr. [**Last Name (STitle) **] next
Tuesday morning, [**2186-12-12**], at 11:30 AM.
ICD9 Codes: 2724, 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2132
} | Medical Text: Admission Date: [**2153-2-19**] Discharge Date: [**2153-2-22**]
Date of Birth: [**2071-9-28**] Sex: F
Service: MEDICINE
Allergies:
Toradol
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy [**2153-2-20**]
Mesenteric Angiogram [**2153-2-19**]
Blood transfusion
History of Present Illness:
Pt is a pleasant 81 year old female with h/o diverticulitis,
previous SBO, multiple surgeries for LOA, partial bowel
resection who presented to [**Hospital 1110**] Hospital after episode of
rectal bleeding. Pt stated that she noted two bowel movements at
home that were grossly bloody. She then presented to [**Hospital 1110**]
Hospital, where she was noted to pass 50 milliliters of bright
red blood in the ED. She was also noted to be orthostatic and
reported palpitations. Later in the ED stay, she was noted to be
hypotensive while sitting to 80/40. She was given 2 L IVF and
her pressure came up to 129/62. She was transferred to [**Hospital1 18**] for
concern of lower GI bleed and further evaluation. In the [**Hospital1 18**]
ED, she had another bloody bowel movement.
Initially admitted to the MICU, the patient was without any
complaints. She stated that she felt comfortable and that she
had felt comfortable since her symptoms began the prior evening.
She denied chest pain, shortness of breath, fevers, chills,
abdominal pain, nausea, vomiting, or discomfort.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
(1) Diverticular disease/diverticulitis
(2) SBO
(3) anxiety
(4) hemorrhoids
Past Surgical History:
(1) s/p TAH/BSO
(2) s/p sigmoid colectomy ~88
(3) s/p exlap/LOA [**6-29**]
(4) s/p exlap/LOA/SBR [**12-31**]
Social History:
Retired bookkeeper; Not married; Lives alone in senior living
community; Has three children, three grandchildren; does ADLs on
her own (+) Tobacco x 60 years at 1/2-1 PPD; 2 glasses wine per
night.
Family History:
Noncontributory
Physical Exam:
On transfer to the floor:
Vitals: T: 97.6 BP: 149/66 P: 59 R: 16 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, flat JVP, no LAD
Lungs: CTAB, no W/R/R
CV: RRR, nl S1/S2, no MRG
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: 2+ pulses, no edema
Pertinent Results:
[**2153-2-19**] 10:32PM GLUCOSE-114* UREA N-6 CREAT-0.5 SODIUM-142
POTASSIUM-3.2* CHLORIDE-112* TOTAL CO2-19* ANION GAP-14
[**2153-2-19**] 10:32PM CALCIUM-7.4* PHOSPHATE-2.8 MAGNESIUM-1.4*
[**2153-2-19**] 10:32PM HCT-27.5*
[**2153-2-19**] 10:32PM PT-13.0 PTT-27.1 INR(PT)-1.1
[**2153-2-19**] 08:07PM HCT-32.6*
[**2153-2-19**] 02:25PM HCT-35.0*
[**2153-2-19**] 08:26AM GLUCOSE-91 UREA N-9 CREAT-0.5 SODIUM-141
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-24 ANION GAP-13
[**2153-2-19**] 08:26AM CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-1.7
[**2153-2-19**] 08:26AM WBC-5.9 RBC-3.77* HGB-11.6* HCT-34.0* MCV-90
MCH-30.9 MCHC-34.2 RDW-13.6
[**2153-2-19**] 08:26AM NEUTS-67.1 LYMPHS-25.6 MONOS-4.0 EOS-2.6
BASOS-0.8
[**2153-2-19**] 08:26AM PLT COUNT-376
[**2153-2-19**] 08:26AM PT-12.1 PTT-26.4 INR(PT)-1.0
[**2153-2-19**] 02:00AM GLUCOSE-112* UREA N-11 CREAT-0.5 SODIUM-137
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15
[**2153-2-19**] 02:00AM estGFR-Using this
[**2153-2-19**] 02:00AM WBC-8.5 RBC-3.81* HGB-11.6* HCT-33.7* MCV-88
MCH-30.3 MCHC-34.3 RDW-13.1
[**2153-2-19**] 02:00AM NEUTS-74.4* LYMPHS-20.1 MONOS-3.5 EOS-1.7
BASOS-0.3
[**2153-2-19**] 02:00AM PLT COUNT-353
[**2153-2-19**] 02:00AM PT-12.6 PTT-26.5 INR(PT)-1.1
Brief Hospital Course:
Ms. [**Known lastname 8549**] is an 81 yo F with history of diverticulosis and
diverticulitis s/p signmoid colectomy and SBR who presented with
BRBPR. Hospital course will be reviewed by problem:
# GI bleed: Patient initially presented with multiple episodes
of bright red blood per rectum over past two days. Suspicion was
higher that she had a LGIB given history of diverticulosis in
addition to a non-bloody NG lavage in the ED.
On the patient's first hospital day, she had two episodes of
BRBPR estimated at a couple hundred cc's volume. She then got up
to use toilet again and had a syncopal episode. At that time,
she was noted to be hypotensive into SBP 60s. HCT at that time
dropped from 32.6 to 27.5. She was transfused 4 units in
addition to the 1 unit she received at the OSH.
IR was called to take the patient straight to angiography. GI
and general surgery services were aware of the patient's
admission and change in status. The patient underwent a
mesenteric angiogram that did not reveal a source of bleeding in
[**Female First Name (un) 899**] or SMA. On hopital day 2, she had a repeat HCT 38.2. Her
HCT was then stable at 37.
The patient received multiple enemas, and she then underwent a
colonoscopy with GI that also did not detect evidence of an
active bleeding source. Patient transfused a total of 5 units
of blood with good response.
Prior to discharge she was seen by nutrition for education on a
high fiber diet as appropriate for her diverticulosis. Her
hematocrit was stable for 48 hours. She had one melanic bowel
movement but no BRBPR for 48 hours.
# Anxiety: The patient was continued on her home regimen of
xanax.
She was discharged home in stable condition on [**2153-2-22**].
Medications on Admission:
(1) Xanax 0.25mg prn
(2) Protonix 40mg DAILY
(3) Reglan
Discharge Medications:
1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for anxiety.
2. Calcium Carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: [**11-25**]
Tablet, Chewables PO three times a day as needed for heartburn.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Lower GI bleed
Divericulosis
.
Secondary:
h/o diverticulitis
h/o SBO
Anxiety
Hemorrhoids
s/p TAH/BSO
s/p sigmoid colectomy ~88
s/p exlap/LOA [**6-29**]
s/p exlap/LOA/SBR [**12-31**]
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Dear Ms. [**Known lastname 8549**],
You were admitted to [**Hospital1 69**] for
evaluation of your rectal bleeding. You had an engiogram and a
colonoscopy which could not definitively identify the source of
bleeding although it appeared that the bleeding was coming from
your diverticulosis. You received 1 unit of blood at [**Hospital 1110**]
Hospital and 4 units of blood at [**Hospital1 18**].
The following medications were changed:
Please STOP reglan until you are seen by a gastroenterologist.
Followup Instructions:
The following appointments were made for you:
Dr. [**Last Name (STitle) **] [**Name (STitle) 8051**] (Primary Care) on [**2-26**] at 2:30pm
at [**Street Address(2) 8550**], [**Location (un) 1110**]. Please call ([**Telephone/Fax (1) 8052**]
with further questions.
Dr. [**First Name (STitle) **] [**Name (STitle) 8551**] (GI) on [**2-28**] at 9am on [**Apartment Address(1) 8552**], [**Location (un) 47**], [**Numeric Identifier 7398**] Please call
[**Telephone/Fax (1) 8553**] with further questions.
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2133
} | Medical Text: Admission Date: [**2196-4-5**] Discharge Date: [**2196-4-10**]
Date of Birth: [**2131-5-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2196-4-5**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to
OM, SVG to PDA), Mitral Valve Replacement w/ 31mm St. [**Male First Name (un) 923**] Epic
Tissue Valve
History of Present Illness:
64 y/o male with symptoms of fatigue who had episode of
congestive heart failure last year which prompted echocardiogram
and cardiac cath. Studies revealed three vessel coronary artery
disease along with severe mitral regurgitation. Referred for
surgery.
Past Medical History:
Coronary Artery Disease w/ Myocardial Infarction [**2185**] s/p
PCI/Stent to LCX, Hypertension, Hypercholesterolemia,
Diverticular Disease
Social History:
Quit smoking in [**2177**], occas. cigar since. [**5-21**] ETOH beverages/wk.
Family History:
Non-contributory
Physical Exam:
Gen: 64 y/o male in NAD
Skin: W/D intact
HEENT: NCAT, EOMI, PERRL
Neck: Supple, FROM -JVD, -Carotid bruit
Chest: CTAB -w/r/r
Heart: RRR 2/6 systolic murmur
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**4-7**] Echo: PRE-BYPASS: 1. The left atrium and right atrium are
normal in cavity size. No atrial septal defect is seen by 2D or
color Doppler. 2. Left ventricular wall thickness, cavity size,
and global systolic function are normal (LVEF>55%). Overall left
ventricular systolic function is normal (LVEF>55%). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] 3. Right
ventricular chamber size and free wall motion are normal. 4.
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. 5. The mitral
valve leaflets are mildly thickened. An eccentric, posterior
directed jet of Severe (4+) mitral regurgitation is seen. A1, A2
severe prolapse is seen. No obvious chordal rupture or flail
noted. Mitral Annulus is not dilated. POST-BYPASS: For the
post-bypass study, the patient was receiving vasoactive
infusions including phenylephrine and is being A paced. 1. A
bioprosthesis is well seated in the Mitral position. Leaflets
open well. No MR is seen. Mean gradient across the valve is 5 mm
of Hg with a CO of 4.5 l/min. Although one of the mitral struts
appears to encroach the LVOT, peak gradient across the LVOT and
AV is less than 15 mm of Hg. 2. LV Anterior wall appears
slightly hypokinetic. RV function is preserved. 3. Aorta is
intact post decannulation. 4. IVC-RA junction appears intact, no
turbulence noted on CFD. (intrapericardial IVC repair done)
[**2196-4-5**] 11:48AM BLOOD WBC-11.4*# RBC-2.62*# Hgb-8.2*#
Hct-24.4*# MCV-93 MCH-31.3 MCHC-33.6 RDW-14.7 Plt Ct-158
[**2196-4-7**] 05:20AM BLOOD WBC-9.5 RBC-2.37* Hgb-7.3* Hct-22.2*
MCV-94 MCH-30.8 MCHC-32.8 RDW-15.4 Plt Ct-119*
[**2196-4-5**] 11:48AM BLOOD PT-15.4* PTT-33.5 INR(PT)-1.4*
[**2196-4-6**] 04:02AM BLOOD PT-13.5* PTT-29.7 INR(PT)-1.2*
[**2196-4-7**] 05:20AM BLOOD Glucose-115* UreaN-19 Creat-1.1 Na-134
K-4.8 Cl-99 HCO3-27 AnGap-13
[**2196-4-9**] 06:50AM BLOOD WBC-10.6 RBC-2.98* Hgb-9.1* Hct-27.1*
MCV-91 MCH-30.6 MCHC-33.8 RDW-15.6* Plt Ct-136*
[**2196-4-6**] 04:02AM BLOOD PT-13.5* PTT-29.7 INR(PT)-1.2*
[**2196-4-10**] 07:15AM BLOOD UreaN-24* Creat-0.9 K-4.3
Brief Hospital Course:
Mr. [**Known lastname 23219**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On [**4-5**] he was brought
to the operating room where he underwent a coronary artery
bypass graft x 3 and mitral valve replacement. Please see
operative report for surgical details. Following surgery he was
transferred to the CVICU for invasive monitoring in stable
condition. Within 24 hours he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one he was
started on beta blockers and diuretics and gently diuresed
towards his pre-op weight. Later on this day he was transferred
to the telemetry floor for further care. On post-op day two his
chest tubes were removed. He continued to improve
post-operatively and worked with physical therapy for strength
and mobility. He was continued to be diuresised and was weaned
from oxygen. On post-op day 5 he was discharged home with VNA
services and the appropriate medications and follow-up
appointments.
Medications on Admission:
Aspirin 81mg qd, Lisinopril 20mg qd, Toprol XL 50mg qd, Crestor
5mg qd, Lasix 20mg qd, Aldactone 25mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
4. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day) for 1 weeks.
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
Disp:*10 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks: please take 40mg twice a day for 7 days then
decrease to 40mg once a day for 7 days please follow up with
cardiologist prior to completing dose.
Disp:*21 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 2
weeks: take 20 meq twice a day for 7 days then decrease to 20
meq for days .
Disp:*21 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Mitral Regurgitation s/p Mitral Valve Replacement
PMH: Myocardial Infarction [**2185**] s/p PCI/Stent to LCX,
Hypertension, Hypercholesterolemia, Diverticular Disease
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions and pat dry; no
baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) **] - (call to schedule
appointment at [**Hospital1 **] for follow up appointment with Dr
[**Last Name (STitle) **]
Dr. [**First Name (STitle) 1075**] in 2 weeks [**Telephone/Fax (1) **]
Dr. [**Last Name (STitle) 20764**] in 1 weeks [**Telephone/Fax (1) 17568**]
Wound check appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] heart
center in 2 weeks - please call to schedule appointment
[**Telephone/Fax (1) **]
Completed by:[**2196-4-11**]
ICD9 Codes: 5990, 4240, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2134
} | Medical Text: Admission Date: [**2154-3-5**] Discharge Date: [**2154-3-26**]
Date of Birth: [**2079-12-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
s/p Cardiac Arrest
Major Surgical or Invasive Procedure:
diagnostic thoracentesis
History of Present Illness:
The pt is a 74y/o F with a PMH of CAD, DM, CVA with recent
diagnosis of cholangiocarcinoma with metastasis to the
transverse colon, presenting s/p cardiac arrest. Pt sent from NH
to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for evaluation of altered mental status. Per report
the pt was recently started on bactim on [**2-22**] for PNA. Today she
became letharic with no verbal response. T 96.5. Sat 94-96% on
4L NC. FS 325.
.
At OSH, the patient presented in cardiac arrest. Per report
inital BP at 850 unable to obtain, given 1amp atropine and
transcutaneous pacing started. She was intubated and dopamine
started. Given additional 1amp atropine and 1 amp epi, 1am
calcium gluconate and 2mg glucagon with return to perfusing
rhythm at approx 915. Per ER physician report CT head with w/o
bleed, abd with free fluid, no free air, + gallbladder stent,
and right sided effusion. No formal read available at time of
transfer. Per report she also received "broad spectrum
antibiotics"
.
In the ED, initial vs were: T 98.2 P 82 BP 122/77 R 17 O2 sat
100%. On levophed 0.03mcg/kg/min. CT Torso demonstrated large
right pleural effusion with right lower lobe collapse, RML
atelectasis, and possible superimposed pneumonia. Patient was
given albuterol neb. Sedation with fentanyl and versed.
.
On arrival to the ICU, the patient was intubated and sedated
with stable hemodynamics.
.
Review of sytems: Unable to obtain
.
Past Medical History:
Cholangiocarcinoma with metastasis to the transverse colon,
unresectable - diagnosed [**1-25**] complicated by post ERCP
pancreatitis
MRSA bacteremia - received course of Vancomycin
Bowel obstruction s/p R colectomy c/b wound dehiscence -
received course of linezolid, ceftazidime and flagyl
R pleural effusion
G tube placement
CAD s/p CABG [**2147**]
Diabetes Mellitus
HTN
PVD
R femoral tibial grast
CVA [**2137**] with residual R sided weakness
Hyperlipidemia
Osteoarthritis
.
Social History:
The patient is originally from [**Country 5976**], moved to US 30 years ago.
Spanish speaking. She previously lived with her husband,
daughter and [**Name2 (NI) 81260**] in JP, most recently in NH. No
tobacco/etoh history.
Family History:
Father - CAD
Physical Exam:
Vitals: T: 99.8, HR 93, BP 115/72, RR 25, Sat 100%
General: Intubated, sedated, chronically ill-appearing
HEENT: Sclera anicteric, MMM, oropharynx clear, NGtube and ET
tube in place
Neck: supple, JVP 10, no LAD, L SC
Lungs: Clear to auscultation anteriorly, decreased R base to [**1-18**]
up lung field, dull to percussion, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, midline inscision well healed, PEG
tube site C/D/I, ostomy with liquid stool, guaiac +,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: cool, 1+ pulses, no edema, multiple scars lower ext b/l
.
Pertinent Results:
[**Hospital3 **]:
WBC 19.0
HCT 37.9
Plt 238
BNP 4330
Trop 0.61
INR 2.05
Na 136
K 6.0
Cl 107
HCO3 16
BUN 35
Cr 1.2
ABG 7.18/39/181/15
.
CT Torso [**3-5**] - Large right pleural effusion with right lower
lobe collapse, RML atelectasis, and possible superimposed
pneumonia. Endotracheal tube terminates just < 1 cm above
carina, requires retraction. Ascites. No evidence of bowel
obstruction. Atherosclerotic disease
.
EKG: OSH: [**3-4**] - R 96bpm, nl intervals, nl axis, ST dep II, AVF,
V3-V6
[**3-5**] - NSR 81bpm, nl axis/nl interval, TWI I, II, AVF, V3-V6
.
[**3-8**] Neck U/S
HISTORY: Soft tissue calcifications noted on video swallow.
FINDINGS: Calcifications are seen in the soft tissues of the
left neck
measuring up to 11 mm in greatest diameter. These are separate
from the spine and are of unclear etiology. Degenerative changes
are noted of the cervical spine, most marked at C5-6 with
sclerosis, disc space narrowing, and anterior osteophytes.
.
[**2154-3-26**] 06:55AM BLOOD WBC-8.9 RBC-3.29* Hgb-10.3* Hct-31.5*
MCV-96 MCH-31.3 MCHC-32.6 RDW-15.8* Plt Ct-276
[**2154-3-25**] 06:00AM BLOOD WBC-9.1 RBC-3.20* Hgb-9.9* Hct-30.6*
MCV-95 MCH-30.9 MCHC-32.4 RDW-15.6* Plt Ct-233
[**2154-3-24**] 07:30AM BLOOD WBC-11.2* RBC-3.39* Hgb-10.6* Hct-32.8*
MCV-97 MCH-31.1 MCHC-32.2 RDW-15.9* Plt Ct-264
[**2154-3-23**] 06:45AM BLOOD WBC-9.6 RBC-3.11* Hgb-9.7* Hct-30.0*
MCV-96 MCH-31.2 MCHC-32.4 RDW-15.9* Plt Ct-193
[**2154-3-22**] 10:25AM BLOOD WBC-9.3 RBC-3.27* Hgb-10.2* Hct-31.9*
MCV-98 MCH-31.3 MCHC-32.1 RDW-15.7* Plt Ct-169
[**2154-3-21**] 07:40AM BLOOD Neuts-82.0* Lymphs-13.1* Monos-3.7
Eos-1.1 Baso-0.2
[**2154-3-20**] 06:15AM BLOOD Neuts-87.5* Lymphs-6.4* Monos-5.2 Eos-0.3
Baso-0.5
[**2154-3-19**] 05:22AM BLOOD Neuts-84* Bands-5 Lymphs-4* Monos-5 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2154-3-26**] 06:55AM BLOOD Plt Ct-276
[**2154-3-25**] 06:00AM BLOOD Plt Ct-233
[**2154-3-24**] 07:30AM BLOOD Plt Ct-264
[**2154-3-26**] 06:55AM BLOOD Glucose-222* UreaN-14 Creat-0.6 Na-132*
K-4.9 Cl-100 HCO3-26 AnGap-11
[**2154-3-25**] 06:00AM BLOOD Glucose-246* UreaN-15 Creat-0.6 Na-133
K-5.2* Cl-101 HCO3-23 AnGap-14
[**2154-3-24**] 07:30AM BLOOD Glucose-158* UreaN-17 Creat-0.6 Na-133
K-5.0 Cl-99 HCO3-21* AnGap-18
[**2154-3-23**] 06:45AM BLOOD Glucose-115* UreaN-18 Na-132* K-5.1
Cl-101 HCO3-23 AnGap-13
[**2154-3-21**] 07:40AM BLOOD ALT-17 AST-23 AlkPhos-272* TotBili-0.5
[**2154-3-19**] 05:22AM BLOOD ALT-18 AST-29 AlkPhos-324* TotBili-0.7
[**2154-3-11**] 06:21AM BLOOD ALT-45* AST-28 LD(LDH)-237 AlkPhos-279*
TotBili-0.7
[**2154-3-10**] 05:15AM BLOOD ALT-57* AST-33 LD(LDH)-236 AlkPhos-278*
TotBili-0.6
[**2154-3-26**] 06:55AM BLOOD Mg-2.2
Brief Hospital Course:
The pt is a 74y/o F with a PMH of CAD, DM, recent diagnosis of
cholangiocarcinoma with metaseses to the transverse colon s/p
resection and PEG placement admitted s/p PEA arrest.
.
# PEA Arrest: Unclear precipitating event. Possible causes of
PEA included pneumonia +/- mucuous plug causing transient
hypoxemia or possible primary cardiomyopathy. Patient has
decreased EF to 15-20% unlcear primary or secondary to recent
code. Patient also had hyperkalemia (K 6) on presentation,
another possible factor. Ruled out PE with negative PE-CTA.
She was promptly extubated without complication.
.
# healthcare-associated pneumonia: On admission, patient had
leukocytosis and RLL effusion. She was afebrile, and blood
cultures were negative. She was initially treated with
vanc/zosyn. Diagnostic thoracentesis demonstrated a
transudative process, thought to be parapneumonic vs
CHF-related. Mini-BAL grew ESBL-producing klebsiella.
Antibiotics were changed to meropenem, and she received 7 days
or meropenem. On [**3-19**], nearly one week after completing
Meropenem therapy, patient was found to have an elevated WBC
count. Patient's PICC line was discontinued and cultures
periperally and from PICC were obtained. Cultures on [**3-21**] grew
out GNR, eventually speciated to Klebiella pneumoniae. Patient
was started again on Meropenem on [**3-22**]. Paitent's WBC count has
been trending down since. Paitent remained afebrile throughout
the second course and vitals were stable.
- Continue Meropenem 500mg IB q6hrs for total 14 day course
.
# Acute renal failure: Creatinine on admission was 1.1 and rose
to 2.0 in the days after the arrest. Most likely prerenal due
to poor forward flow in the pericode period. FeNa was 0.6%
initially. There was likely also a component of ATN secondary
to contrast. Urine output also decreased to ~10 cc/h with poor
response to IV lasix. The renal consult service was involved
and recommended conservative management. Urine output
increased, and creatinine fell back to baseline .8-1.0.
.
# acute on chronic systolic congestive heart failure: EF
15-20%, newly decreased this admission. After resuscitation
patient appeared total body overloaded. Diuresis was limited by
ARF, as above. Despite CXR findings of significant pulmonary
edema and bilateral pleural effusions, her O2 Sat was 98% on RA.
Her outpatient dose of furosemide 20 mg daily was restarted and
she was kept net negative daily. Effusions and peripheral edema
decreased.
.
# Pleural Effusion: Diagnostic thoracentesis showed a
transudative process. Differential included parapneumonic
process, metastatic disease, and/or effusion secondary to
cardiomyopathy. Now resolving.
.
# Metastatic Cholangiocarcinoma: Patient with recent diagnosis
and complicated course including mets to transverse colon s/p
resection. Tumor unresectable, felt to have poor likelihood of
tolerating chemotherapy per OSH oncology notes. LFTs were
stable.
.
# Guaiac + stools: The pt was found to have grossly bloody
stool from ostomy site. Hct was stable. PPI was continued.
.
# Bowel obstruction s/p R colectomy ?????? Tube feeds were continued.
S&S evaluation was done and diet advanced to ground solids and
subsequently to regular. Tube feeds were held for 3 days to do
a calorie count. Because she was only taking ~500 calories
daily, tube feeds were re-instituted.
.
# CAD s/p CABG [**2147**] - Beta blocker was continued, ACEI held
given ARF, lasix given as above, statin held. ACEI was
restarted prior to discharge. Patient started on ASA 81mg
.
# Diabetes Mellitus - Lantus and RISS were continued. Lantus
was decreased for hypoglycemia in the setting of holding tube
feeds. This will need to be titrated.
.
# Nutrition - Patient was getting tube feeds. These were
stopped temporarily and a calorie count demonstrated inadequate
intake. Tubefeeds were re-instituted. Speech and swallow saw
her and cleared her initially for pureed solids and later for
regular solids as mental status improved. She was also cleared
for thin liquids but preferred to continue nectar-thickened.
.
# Access: Patient is being discharged with a PICC line in
place, placed by IR on [**2154-3-26**].
Medications on Admission:
Tylenol 650mg Q 4 PRN
Milk of Magnesia 30ml po daily PRN
Bisacodyl
Arixtra 2 gram daily
Lantus 24U QHS
RISS
Colace
Atarax 10mg 1 tab Q 8 PRN
Senna
Duragesic 25mcg Q 72
Bactrim DS 2 tab daily X 10 days stop [**3-9**]
Promod [**1-18**]
oxycontin 10mg po BID
Reglan
Lopressor 50mg [**Hospital1 **]
MVI
Prilosec 20mg daily
Zocor 40mg daily
Zestril 40mg daily
Lasix 20mg daily
Discharge Medications:
1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. insulin
Please given lantus 10 units and humalog insulin sliding scale,
attached.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for fever or pain.
9. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q8H (every 8 hours) as needed.
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
15. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four
times a day: per sliding scale
.
16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: Please do not exceed
4g/24hrs.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
primary: cardiac arrest, hospital acquired pneumonia, acute
renal failure, congestive heart failure
secondary: metastatic cholangiocarcinoma, coronary artery
disease, diabetes
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital after a cardiac arrest. CPR
was given, and you were revived. It is thought that you cardiac
arrest was secondary to hypoxia from pneumonia. You were also
treated for a pneumonia. You were found to have bateremia a
week prior to discharge and are going to a rehab facility with
plan for continued meropenem for a full 14 day course.
.
Many of your medications were changed, please take as directed.
.
.
Please return to the hospital or call your doctor if you
experience chest pain, shortness of breath, high fevers and
chills, or other symptoms that are concerning to you.
Followup Instructions:
Please follow up with the physician at your rehabilitation
faciity.
Completed by:[**2154-3-27**]
ICD9 Codes: 5845, 4254, 7907, 5990, 2761, 4280, 2767, 4019, 4439, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2135
} | Medical Text: Admission Date: [**2166-5-31**] Discharge Date: [**2166-6-1**]
Date of Birth: [**2105-10-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Kiwi (Actinidia Chinensis)
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
"I fell"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 year old white male s/p fall for SAH. Pt, wife and family
friend give report. His wife states that they were leaving a
friends house and that he went to start the car. Her and the
friend came out approx 10 minutes later to
find him lying on the ground. He had LOC for ? approx 10
minutes. He thinks that he most likely tripped and fell [**3-12**] to
working the last three nights. As well he admits to two glasses
of wine. He was not immediately aware of the events at the time.
He does not recall how he fell. He [**Month/Day (2) **] that he had a
syncopal event. He recalls the ambulance ride and OSH eval.
Currently he
admits to pain above his left eye and fracturing some of his
teeth. He also admits to nausea without emesis from narcotic
administration at OSH. He does not think that he swallowed any
of them. He [**Month/Day (2) **] CP, SOB, visual changes, neck pain or pain
in other parts of his body. They deny any seizure activity or
incontinence.
Past Medical History:
meniscectomy / right knee
high cholesterol
Social History:
lives at home with wife, employed/ physician, [**Name10 (NameIs) **] tobacco,
occasional alcohol use, no drug use.
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
O: T: AF BP: 138/ 90 HR:90 R 18 O2Sats99
Gen: WD/WN, comfortable, NAD.
HEENT: Left peri-orbital ecchymosis / inferior linear chin
laceration (no sutures at OSH), abrasion to left frontal region,
scalp without laceration or bony step off / Pupils: [**4-9**]
bilaterally/ No battles or raccoon sign / no CSF
rhinorrhea/otorrhea / no hemotympanum. EOMI / no obvious
entrapment
Neck: Supple. / no tenderness to palpation
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.
Recall: [**4-10**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields grossly intact.
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 [**6-12**] throughout. No pronator drift
Sensation: Intact to light touch
No clonus
Upon discharge:
neurologically intact, L orbital ecchymosis, facial lacerations
Pertinent Results:
head CT [**2166-5-31**]: 1. Left frontal punctate hemorrhage and
resolving subarachnoid hemorrhage are post-traumatic in
etiology.
2. Partial re-demonstration of multiple facial fractures better
described on the dedicated facial bone CT
facial CT [**2166-5-30**]: There are comminuted and depressed fractures
of the left cribriform plate/planum sphenoidale, orbital roof,
and lamina papyracea, resulting in trace pneumocephalus.
Nondisplaced fractures are seen involving the left frontal
calvarium and extending into the orbital rim, as well as in the
left zygomatic arch. Mild irregularity is noted in the left
nasal bone. Soft tissue swelling is present over the frontal and
nasal soft tissues, as well as the left zygoma.
The orbits and intraconal structures are preserved, without
evidence of
hemorrhage or rupture. A few locules of gas are seen tracking in
the left
extraconal space, anterior to the left globe. There is a
moderate amount of layering hemorrhage throughout the paranasal
sinuses. Additional polypoid mucosal thickening is noted in the
maxillary and ethmoid sinuses, left greater than right.
There is a minimally displaced oblique fracture through the head
of the right mandibular condyle. There is mild fragmentation of
the adjacent tympanic portion of the right temporal bone,
without evidence of middle or inner ear involvement. A mildly
displaced oblique left mandibular parasymphyseal fracture is
present, extending through the roots of the left lower cuspid,
first and second bicuspids, and first molar. There is mild
diffuse soft tissue swelling, with punctate hyperdense focus
along the right lower jaw that may represent a retained foreign
body.
Intracranial structures are unremarkable. Cervical lymph nodes
are not
pathologically enlarged. Upper cervical spine alignment is
preserved.
cervical spine CT(from [**Location (un) 620**]) degenerative changes, no
malalignment or fractures
[**2166-5-31**] 12:10AM GLUCOSE-118* UREA N-18 CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
[**2166-5-31**] 12:10AM WBC-13.8*# RBC-4.58* HGB-13.9* HCT-40.4
MCV-88 MCH-30.5 MCHC-34.5 RDW-12.5
[**2166-5-31**] 12:10AM NEUTS-86.9* LYMPHS-9.2* MONOS-3.2 EOS-0.4
BASOS-0.4
[**2166-5-31**] 12:10AM PLT COUNT-292
[**2166-5-31**] 12:10AM PT-12.9 PTT-22.5 INR(PT)-1.1
[**2166-5-31**] Echo:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). There is a mild
resting left ventricular outflow tract obstruction and there is
chordal systolic anterior motion. The gradient increased mildly
with the Valsalva manuever. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
Brief Hospital Course:
Pt was admitted to the neurosurgery service in TICU. He was
monitored closely and remained neurologically intact during his
stay with no signs of CSF leakage. He was evaluated by plastics
for his facial fractures which were felt to be non-opersative
but he required antibiotics for prophylaxis for 10 days. He had
chin sutures placed which will be removed [**2166-6-4**]. He was also
evaluated by ophthomology and had normal exam with no signs of
entrapment. He had some loose teeth and has dentist appt
scheduled for [**2166-6-2**]. He had syncopal work up with
echocardiogram which was within normal limits. He was also
evalutated by cardiology and will follow up 4/25 for holter
monitor.
Medications on Admission:
SA 325 mg daily / last dose this am
simvastatin 40 mg po daily
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain fever.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on narcotic.
Disp:*60 Capsule(s)* Refills:*0*
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic brain injury
Facial/orbital/mandibular fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] [**6-2**] for Holter monitor.
Please follow up with your dentisit.
Please follow up with your PCP.
[**Name10 (NameIs) 357**] follow up with Dr [**Last Name (STitle) 548**] and Head CT in 4 weeks - call
[**Telephone/Fax (1) 2992**] to schedule this.
Please follow up with plastic surgery for chin suture removal
[**2166-6-4**]
Completed by:[**2166-6-1**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2136
} | Medical Text: Admission Date: [**2121-1-31**] Discharge Date: [**2121-1-31**]
Date of Birth: [**2074-11-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Tegretol / Dilantin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Brain Hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 year old male presents from OSH with large brain
hemorrhage found on CT. At baseline he is wheelchair bound due
to
MS and has h/o DM. He was sitting in the chair when staff a
member noticed that he slumped over. He was brought to the OSH
and the CT showed a 2.2 cm x 2.7 cm parenchymal bleed arising
from the right thalamus. There is intraventricular extension
into
lateral ventricles and 3rd or 4th ventricle. The patient was
transferred to [**Hospital1 18**]. The patient received labetalol to decrease
the blood pressure which was in the 200s/100s upon arrival and
an
a-line was placed.
Past Medical History:
DM, MS, COPD
Social History:
lives in group home, wheelchair bound - long history
of multiple sclerosis
Family History:
Unknown
Physical Exam:
T:afebrile BP:224/103 HR:124 RR:25 O2Sats: 100%
Gen: Obese, intubated patient, who is not responding to
commands.
HEENT: Significant Exophthalmus bilaterally with erythematous
sclera.
Pupils: 2mm, unreactive EOMs - unable to test
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Distended, firm, BS+.
Extrem: Warm, very dry skin.
Neuro:
Mental status: Not responding to commands.
(+)gag reflex. (-) corneal reflexes.
Does not respond to commands and does not move extremities.
When arms are supinated, patient has tremors in both arms.
(+) clonus in both lower extremities
Toes mute
Pertinent Results:
None
Brief Hospital Course:
46 year old male with a large hemorrhage likely originating from
thalamus on right with intraventricular extension and SAH. In
the emergency room, it was determined that there was no
neurosurgical intervention as this was a devastating injury. The
patient was transferred to the ICU. His sister/health care proxy
expressed that she did not want the patient to suffer anymore
and decided to make the
patient DNR and CMO. The patient was extubated in the ICU and
died shortly thereafter.
Medications on Admission:
Unknown
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Large hemorrhage likely originating from thalamus on right with
intraventricular extension and SAH.
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2121-3-21**]
ICD9 Codes: 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2137
} | Medical Text: Admission Date: Discharge Date: [**2127-5-6**]
Date of Birth: [**2080-1-31**] Sex: M
Service: TRANSPLANT SERVICE
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
white male with a history of hepatitis B and hepatitis C,
Child C class on the liver transplant list who presented to
the Emergency Room on [**2127-4-10**], with lethargy, weakness,
and a hematocrit of 19, abdominal pain, status post
hemodialysis.
In the Emergency Room, the patient received 3 U packed red
blood cells and 4 U FFP. Hematocrit raised from 19 to 22,
and the patient was given approximately 8 L intravenous
fluids, and Dopamine drip for a brief period of hypotension.
hepatitis C, Child C class cirrhosis, and the patient was a
liver transplant candidate.
HOSPITAL COURSE: The patient was admitted to the Surgical
Intensive Care Unit. The patient was started on tube feeds
on hospital day #2, and tube feeds were increased to goal
nutritional status. The patient was initially intubated
because of his worsening respiratory conditions and was
placed on Lasix for diuresis and hemodialysis. The patient
was hepatitis C cirrhosis and was found to have
intraperitoneal bleeding and positive paracentesis sample for
coagulase negative Staphylococcus aureus. Infectious Disease
was consulted on [**4-16**], and with their recommendation,
resampling of the ascitic fluids were carried out, and the
patient was started on Vancomycin; however, the patient's
condition still remained critical.
In the Intensive Care Unit, he was still intubated with
multiple blood transfusions for platelet coagulation factors.
FFP and packed red blood cells were given in order to stop
the hemorrhage and correct his coagulopathy. The patient
developed ARDS on hospital day #3. Several attempts to tap
the ascites were carried out, and each time several liters of
fluid was removed. Per Nephrology recommendation, the
patient was started on CVVH on [**2127-4-22**], for rising BUN
and creatinine because the patient was not able to tolerate
the hemodialysis due to hypotension.
On [**4-24**], the patient was started on TPN due to his
worsening nutritional status. On [**4-27**], a large volume
paracentesis was again carried out. Approximately 6.5 L of
fluid was drained from his ascites. The patient's condition
continued to deteriorate in the Intensive Care Unit. On
hospital day #22, it was decided that the patient was no
longer eligible for liver transplant due to his worsening
medical condition, and the patient was taken off the
transplant list, and the options were discussed with the
family members.
With the patient requiring blood products almost daily due to
his coagulopathy and liver failure, on [**2127-5-6**], it was
discussed with the patient's family, and the patient was made
DNR and CMO. After withdraw of the care per family, the
patient expired at 1852 on [**2127-5-6**]. Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) 13853**] was notified, and the options were discussed with the
patient's family regarding postmortem examination. The
patient's sister refused.
The patient expired due to end-stage liver disease,
cirrhosis, and cardiopulmonary arrest, and multiple organ
failures.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**First Name3 (LF) 13854**]
MEDQUIST36
D: [**2127-5-6**] 19:45
T: [**2127-5-6**] 19:51
JOB#: [**Job Number 13855**]
ICD9 Codes: 5715, 5845, 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2138
} | Medical Text: Admission Date: [**2138-8-23**] Discharge Date: [**2138-9-11**]
Date of Birth: [**2138-8-23**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname **] was a newborn infant admitted to
the NICU with dusky episodes. She was born at 11:44 a.m. on
[**2138-8-23**], the product of a 38-6/7 weeks gestation
pregnancy. She was born to a 38-year-old G5, P2, now 3 mother
with an [**Name (NI) 37516**] of [**2138-8-31**]. Prenatal labs were blood type O
positive, antibody negative, RPR nonreactive, rubella immune,
HBsAg negative and GBS negative. This pregnancy was
reportedly unremarkable. Intrapartum course was notable for
rupture of membranes 3 hours prior to delivery with a
maternal fever to 100.3 and no maternal antibiotic treatment
was given. The infant was born by a SVD, emerging vigorous
with Apgars of 9 and 9. She was admitted initially to the
newborn nursery where several dusky episodes were witnessed.
These appeared to be associated with shallow respirations or
periodic breathing, and at times, required stimulation. She
was then transferred to the NICU.
PHYSICAL EXAMINATION: Physical examination on admission was
a birth weight of 2905 grams which is 25th-50th percentile,
head circumference 34 cm which is 50th-75th percentile,
length 48 cm which is 25th-50th percentile. Her vital signs
were stable. Her O2 saturation was 98% in room air. She was
an active and vigorous female infant in no distress, warm and
dry skin with no lesions and a pigmented area on her back.
HEENT - fontanelle soft and flat, intact palate. Nares were
normal. Ears were normal. Neck was supple with no lesions.
Chest was clear to auscultation. No grunting, flaring or
retracting. Cardiac - normal rate and rhythm, no murmurs.
Abdomen - soft, no hepatosplenomegaly, no mass, active bowel
sounds. GU - normal female with a patent anus and normal
femoral pulses. Extremities, back and hips were normal.
Neurologic - the tone and activity were appropriate with
normal reflexes.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
infant remained stable on room air since admission to the
NICU. A chest x-ray was obtained on the newborn day which
showed some mild TTN. She has remained on room air since that
time. She has had episodes of apnea and bradycardia, mostly
bradycardia and desaturations with feedings or with pacifiers
were noted. She continued to do this, meaning having
desaturations with feedings which were slowly improving, but
did continue. Her most recent dusky episode with feedings was
on [**2138-9-3**]. On the day of discharge, she will be 3 days
without a dusky episode. She has required no medications for
dusky episodes. No methylxanthine was given.
Cardiovascular: She had a transitional murmur lasting less
than 1 day on day of life 3, [**2138-8-26**]. No workup was
done. She has had no murmurs since, a normal heart rate and
rhythm, normal blood pressures.
Fluid, Electrolytes and Nutrition: On the newborn day, she
was started on ad lib p.o. feedings. She continued to have ad
lib p.o. feedings and, as mentioned previously, did have
dusky episodes and spells [**2-10**] a day with her feedings. She is
presently feeding [**Doctor Last Name **]-20 with iron or breast milk and does
also breastfeed. She has an excellent intake, taking
approximately 180 ml/kg/day by bottle plus breastfeeding on
top of that. She is showing steady weight gain and she has
surpassed her birth weight. At the time of discharge her weight
3335 grams, HC 34 cm, and length 52 cm.
GI: She has had mild hyperbilirubinemia, not requiring any
phototherapy with a peak bilirubin level of 10.4/0.3. Due to
the bradycardic episodes during feedings, a feeding team
consult was done on [**2138-9-2**] and a swallow study was
recommended for [**2138-9-4**]. At that time, a swallow study
was found to be normal. She continue to be monitored in the
hospital until her feeding immaturity improved. At the time of
discharge, she had gone 72 hours without and feeding immaturity.
Hematology: The hematocrit at birth was 56.7 with a platelet
count of 280. No further hematocrits have been measured. No
blood typing has been done.
Infectious Disease: Due to the dusky episodes, a CBC and
blood culture was screened on admission to the NICU. The CBC
was benign with a white count of 20.5, 56 polys, 10 bands and
I:T of 0.15. She received 48 hours of ampicillin and
gentamicin which were subsequently discontinued when the
blood culture remained negative at 48 hours.
Neurology: She has maintained a normal neurologic exam for
gestational age.
Sensory: Audiology - a hearing screen was performed with
automated auditory brainstem responses and she passed in both
ears.
Psychosocial: A [**Hospital1 18**] social worker has been involved with
the family. The contact social worker can be reached at [**Telephone/Fax (1) 56048**]. There are no active psychosocial issues at this
time.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: She will be followed by [**Hospital3 51914**] Pediatrics in [**Hospital1 392**], telephone number [**Telephone/Fax (1) 65968**].
CARE/RECOMMENDATIONS: Ad lib p.o. feedings of breastfeeding
and supplementing ad lib with [**Doctor Last Name **]-20 with iron.
MEDICATIONS: None.
No car seat screening was performed. State newborn screening
was sent on day of life 3 and the results are pending.
IMMUNIZATIONS RECEIVED: She received the hepatitis B vaccine
on [**2138-8-26**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 3 criteria:
2. Born at less than 32 weeks gestation.
3. Born between 32 and 35 weeks gestation with 2 of the
following - either day care during RSV season, a smoker
in the household, neuromuscular disease, airway
abnormalities or school age siblings.
4. With chronic lung disease.
5. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
FOLLOW UP: Follow-up appointment is recommended with [**Hospital3 51914**] Pediatrics within 48 hours of discharge.
DISCHARGE DIAGNOSES:
1. Sepsis ruled out.
2. Dusky episodes, resolved.
3. Feeding discoordination (feeding immaturity), resolved.
4. Mild hyperbilirubinemia, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) **]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2138-9-5**] 19:55:40
T: [**2138-9-5**] 21:29:07
Job#: [**Job Number 69810**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2139
} | Medical Text: Admission Date: [**2193-1-1**] Discharge Date: [**2193-3-27**]
Date of Birth: [**2113-8-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 16983**]
Chief Complaint:
79 yo m with aplastic anemia, Fournier's gangrene and history of
possible old TB exposure admitted [**1-1**] for a 5 day course of ATG
and initition of CSA
Major Surgical or Invasive Procedure:
Transverse colectomy with creation of Hartmann's pouch and
proximal revision of colostomy to an end colostomy.
History of Present Illness:
79 year old male with untreated aplastic anemia is being
admitted for ATG + cyclosporine treatment. Pt was found to have
a hematopoietic disorder in [**4-19**] when he went to his PCP for [**Name Initial (PRE) **]
follow up after experiencing lethargy. Patient's marrow was
initially aplastic on [**2192-6-28**]. Since then, he has been tried on
IVIG and prednisone without significant effect. His medical
course has been complicated by line infection, perianal abscess,
retinal bleed and the findings of pulmonary nodules and
granulomatous disease. Hence, at this time he is finishing a 9
month course of INH. His CT Chest shows improved nodules
allowing him to undergo ATG + Cyclosporine at this time. At
home, he denies any fevers, chest pain, SOB or bodily pain.
Denies any rashes, bleeding.
Past Medical History:
1) Aplastic anemia dx [**4-19**] by bone marrow biopsy. Given some
questions about a history of TB, he was treated with INH for one
month and then started on prednisone 60mg daily on [**2192-7-5**]. He
requires platelet transfusions weekly, and blood transfusions
every several weeks or so. Complicated by retinal hemorrhage.
2) Pt remembers living in a sanitorium from age [**2-24**]. This
prompted an investigation for TB, with subsequent sputum and
bone marrow negative for acid fast bacilli. However, given a
concern for this in face of starting steroids, pt is being
treated with Isoniazid and Pyridoxine since [**2192-5-29**]. Chest CT
showed evidence of granulomatous disease in the past, but no
active disease.
3) kyphoscoliosis
4) L inguinal hernia, reducible present for long time, not
painful
Social History:
Lives with wife in [**Name (NI) **]. Has two grown daughters nearby.
[**Name2 (NI) **] tobacco, quit 40 years ago
Rare alcohol when he goes out
Family History:
There is no history of blood disorders.
Physical Exam:
Gen: Thin elderly male in NAD
HEENT: Oropharynx clear
CV: +s1+s2 RRR No murmurs
Resp: CTA B/L No crackles or wheezing
Abd: R ostomy bag.
GU: No perianal signs of abscess or skin degradation. Inguinal
hernia present.
Neuro: AAO x 3. CN 2-12 grossly intact.
Pertinent Results:
[**2193-1-1**] 06:35PM BLOOD WBC-2.4* RBC-2.97* Hgb-8.5* Hct-24.7*
MCV-83 MCH-28.7 MCHC-34.4 RDW-13.9 Plt Ct-15*#
[**2193-1-3**] 12:10AM BLOOD WBC-0.3*# RBC-2.60* Hgb-7.5* Hct-21.5*
MCV-83 MCH-28.9 MCHC-34.8 RDW-14.2 Plt Ct-20*#
[**2193-1-6**] 01:15AM BLOOD WBC-0.3* RBC-3.77* Hgb-10.7* Hct-30.4*
MCV-81* MCH-28.4 MCHC-35.2* RDW-14.2 Plt Ct-46*
[**2193-1-9**] 06:13PM BLOOD WBC-1.2* RBC-3.72* Hgb-10.8* Hct-29.3*
MCV-79* MCH-29.0 MCHC-36.8* RDW-14.3 Plt Ct-80*#
[**2193-1-19**] 12:42AM BLOOD WBC-0.3* RBC-2.99* Hgb-8.5* Hct-24.0*
MCV-80* MCH-28.4 MCHC-35.3* RDW-13.4 Plt Ct-28*
[**2193-2-1**] 07:08AM BLOOD WBC-1.1* RBC-2.95* Hgb-8.5* Hct-23.5*
MCV-80* MCH-28.9 MCHC-36.3* RDW-13.5 Plt Ct-13*
[**2193-2-4**] 06:50AM BLOOD WBC-0.9* RBC-2.67* Hgb-7.7* Hct-20.9*
MCV-78* MCH-28.8 MCHC-36.8* RDW-13.3 Plt Ct-85*
[**2193-2-7**] 06:30AM BLOOD WBC-1.1* RBC-3.28* Hgb-9.5* Hct-25.6*
MCV-78* MCH-28.8 MCHC-36.9* RDW-13.9 Plt Ct-20*
[**2193-1-1**] 06:35PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2193-1-1**] 06:35PM BLOOD Plt Smr-RARE Plt Ct-15*#
[**2193-1-3**] 11:55AM BLOOD Plt Ct-49*#
[**2193-1-8**] 08:09AM BLOOD Plt Ct-11*
[**2193-1-24**] 07:20AM BLOOD Plt Ct-7*
[**2193-2-1**] 02:54PM BLOOD Plt Ct-51*#
[**2193-2-2**] 06:55AM BLOOD Plt Ct-208
[**2193-2-7**] 06:30AM BLOOD Plt Ct-20*
[**2193-1-1**] 06:35PM BLOOD Gran Ct-560*
[**2193-1-31**] 06:45AM BLOOD Gran Ct-280*
[**2193-1-1**] 06:35PM BLOOD Glucose-101 UreaN-27* Creat-1.2 Na-142
K-3.9 Cl-102 HCO3-25 AnGap-19
[**2193-1-8**] 01:08AM BLOOD Glucose-196* UreaN-25* Creat-0.8 Na-136
K-3.2* Cl-105 HCO3-24 AnGap-10
[**2193-1-16**] 01:31AM BLOOD Glucose-135* UreaN-37* Creat-0.9 Na-135
K-5.9* Cl-101 HCO3-31 AnGap-9
[**2193-2-1**] 07:08AM BLOOD Glucose-89 UreaN-16 Creat-0.9 Na-141
K-3.4 Cl-101 HCO3-33* AnGap-10
[**2193-2-7**] 06:30AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
[**2193-1-1**] 06:35PM BLOOD ALT-20 AST-28 AlkPhos-142* TotBili-0.5
[**2193-1-9**] 06:08AM BLOOD ALT-87* AST-66* AlkPhos-147* TotBili-3.0*
[**2193-1-30**] 12:10AM BLOOD ALT-35 AST-20 LD(LDH)-101 AlkPhos-130*
TotBili-0.6
[**2193-2-4**] 06:50AM BLOOD Albumin-2.7* Iron-127
[**2193-2-4**] 06:50AM BLOOD calTIBC-139* TRF-107*
[**2193-1-3**] 07:30PM BLOOD Hapto-221*
[**2193-1-18**] 12:00AM BLOOD Cortsol-9.5
[**2193-1-7**] 08:50AM BLOOD Cyclspr-357
[**2193-2-1**] 07:08AM BLOOD Cyclspr-107
[**2193-2-6**] 06:10AM BLOOD Cyclspr-155
[**2193-1-4**] 09:40AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2193-1-4**] 09:40AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
.
URINE CULTURE (Final [**2193-1-8**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
IMIPENEM RESISTANT sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- R
MEROPENEM------------- =>16 R
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ =>16 R
[**2193-1-21**] 1:07 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2193-1-23**]**
URINE CULTURE (Final [**2193-1-23**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
WORK-UP PER DR [**First Name (STitle) **] ([**Numeric Identifier 21495**]).
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
SUGGESTING PSEUDOMONAS.
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
ORGANISM. 10,000-100,000 ORGANISMS/ML..
URINE CULTURE (Final [**2193-1-20**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- <=4 S
LEVOFLOXACIN---------- =>8 R
LINEZOLID------------- 1 S
NITROFURANTOIN-------- 256 R
VANCOMYCIN------------ =>32 R
AEROBIC BOTTLE (Final [**2193-1-23**]):
REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **] -7F- @ 14:45 [**2193-1-21**].
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
LEVOFLOXACIN---------- 0.5 S
PENICILLIN------------ 2 S
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2193-1-23**]):
ENTEROCOCCUS FAECALIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
AEROBIC BOTTLE (Final [**2193-1-25**]):
ENTEROCOCCUS FAECALIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
202-6864S
[**2193-1-21**].
ANAEROBIC BOTTLE (Final [**2193-1-25**]):
ENTEROCOCCUS FAECALIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
202-6864S
[**2193-1-21**].
WOUND CULTURE (Final [**2193-1-25**]):
ENTEROCOCCUS SP.. <15 colonies.
Isolate(s) identified and susceptibility testing
performed because
of concomitant positive blood culture(s) Comparison of
the
susceptibility patterns may be helpful to assess
clinical
significance.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LEVOFLOXACIN---------- 0.5 S
PENICILLIN------------ 2 S
VANCOMYCIN------------ <=1 S
URINE CULTURE (Final [**2193-1-27**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 22095**] [**2193-1-24**].
.
ABDOMEN (SUPINE & ERECT) [**2193-1-8**] 7:16 PM
Large soft tissue density overlying right lower quadrant
secondary to the prolapsed bowel. A few gas-filled minimally
dilated loops of small bowel are present with small air-fluid
levels, no definite evidence for intestinal obstruction.
Calcific densities in the known calcified atrophic left kidney
and left mid abdomen. No free intraperitoneal gas.
.
[**1-9**] Abd U/S: Normal appearing liver less scattered granulomas,
no findings to explain the patient's rising LFTs. Incidental
note of an adherent cholesterol stone versus gallbladder polyps.
.
[**1-24**] 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 systolic function are normal (LVEF
60%). 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 ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2192-11-19**], no major change is evident. The absence of a
vegetation by 2D echocardiography does not exclude endocarditis
if clinically suggested.
.
[**2-1**] Pathology:
TRANSVERSE COLON AND PROXIMAL LIMB OF COLON (2).
DIAGNOSIS:
I. Transverse colon (A-G):
1. Focal area of submucosal fibrosis.
2. Peritoneal fibrous adhesions.
3. Intact mucosa.
II. Proximal limb of colon (H-K):
1. Stoma with focal ulcer and granulation tissue.
2. Peritoneal fibrous adhesions.
.
[**2-4**] TTE: The left atrium is normal in size. No spontaneous echo
contrast is seen in the left atrial appendage. No thrombus is
seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. There is a small pericardial
effusion.
IMPRESSION: No evidence of endocarditis.
.
[**2-9**] CT abdomen/pelvis:
1. Dilatation of cecum and terminal ileum between two fixed
points, i.e., new stoma and patulous left inguinal orifice. The
possibility of a closed-loop obstruction is considered given the
extent of the cecal distension.No proximal small bowel
distension is seen however
2. Prior granulomatous disease affecting multiple visceral
organs.
.
[**2-12**] CXR: 1. Cardiomegaly.
2. Improvement of congestive heart failure.
3. Slightly dilated loops of small bowel with air-fluid level
within it and may represent SBO- a clinical correlation is
suggested.
.
[**2-13**] Chest CT:
1. Interval development of bilateral pleural effusions.
2. Calcified right upper lobe granuloma, calcified mediastinal
and hilar lymph nodes, calcified intra-abdominal lymph nodes, as
well as punctate calcifications in the spleen and liver and
atrophic calcified left kidney are all consistent with previous
granulomatous infection including tuberculosis infection.
3. Vague opacity in the right upper lobe is unchanged.
.
[**2-13**] Head CT: No evidence of hemorrhage or acute infarction.
.
[**2-15**] CT abdomen/pelvis: 1. Distal right colon at ostomy
concerning in appearance for ischemia vs inflammation, with
markedly abnormal heterogeneous, thickened bowel wall; infection
is less likely. Small amount of air concerning for bowel
perforation at the distal ostomy site.
2. Similar appearance to prior dilated loops of bowel in left
lower quadrant concerning in appearance for closed-loop
obstruction. After discussion with Dr. [**Last Name (STitle) **], this is
apparently a reducible hernia.
3. Unchanged appearance of evidence of prior granulomatous
infection including multiple calcified granulomata in liver,
spleen, and left "putty" kidney.
4. Otherwise stable examination since [**2193-2-9**].
.
[**2-16**] CT abdomen/pelvis:
1. Markedly abnormal appearance of the large bowel leading into
the patient's diverting colostomy with edematous-appearing wall
again demonstrated. Differential diagnosis includes ischemia,
infectious or inflammatory process.
2. Free fluid and sigmoid colon containing right inguinal
hernia.
3. Small bowel and free fluid in a left inguinal hernia.
4. Bilateral pleural effusions with associated atelectasis.
5. Bilateral hydroceles.
.
[**2-21**] CT abdomen/pelvis: Continued but slightly improved distal
colitis. Otherwise stable appearance of the abdomen and pelvis
compared to [**2193-2-16**].
.
[**2-28**] CT abdomen/pelvis:
1. Peripherally enhancing cystic structures in the seminal
vesicles are new since the study of [**11-15**], and raise the
possibility of seminal vesiculitis and/or prostatitis with
abscesses. Consider Urology consult. Transrectal aspiration can
be performed under ultrasound guidance if clinically indicated.
2. Slight improvement in the bilateral pleural effusions since
the study of [**2193-2-21**].
3. Calcified granulomas in the lung, calcified mediastinal and
mesenteric lymph nodes, punctate calcifications in the liver and
spleen, as well as the atrophic and calcified appearance of the
right kidney are all consistent with prior granulomatous
infection.
4. Bilateral bowel-containing inguinal hernias without evidence
of incarceration.
5. Improving appearance of the colitis adjacent to the right
upper quadrant ostomy with persistent fat stranding in this
region.
.
[**3-8**] Prostate U/S: No evidence of prostatic or seminal vesicle
abscesses. The presumed small infected collection demonstrated
on prior CT (and diminishing in size on followup CT) has
completely resolved. Consequently, the planned TRUS guided
aspiration was canceled.
Brief Hospital Course:
Initial BMT Course:
Patient with known history of aplastic anemia was admitted for
ATG + cyclosporine therapy. The patient was educated that it
would take a few months to see any effects of the therapy. He
was also advised of the potential risks and mortality of this
regimen.
.
COURSE PRIOR TO SURGERY:
.
*Aplastic anemia: The patient has aplastic anemia of unknown
etiology. He was admitted for ATG and cyclosporine therapy. He
finished a 5 day course of ATG ([**Date range (1) 22096**]) @ 3.5mg/kg/day. His
cyclosporine was started at 300 mg PO BID. His dose was changed
initially to 200 mg PO q12 because of hypertension, tachycardia
and developement of spasms, that were thought to be secondary to
cylosporin. Patient also developed rigors. The rigors resolved
with demerol and for the fevers, he was given tylenol. For the
hypertension, he was started on nifedipine with good control. He
was also started on prednisone during his course and this was
slowly tapered down. His hct was maintained above 25 and plts
above 10 with transfusions, though he remained neutropenic,
requiring products approximately every 3-4 days. He was started
on GCSF 480 mcg qd b/c of this. He was started on Atovaquone for
PCP [**Name Initial (PRE) 1102**].
.
* H/o of granulomatous disease The patient had a h/o of old
granulomatous disease. At the time of admission, patient did not
appear to have active infection by CT scan, but known old
granulomatous lesions were seen in the lungs, LN, spleen and
liver. He was continued on isoniazide and pyridoxine for
empiric treatment of TB and was to follow-up with ID after
discharge regarding when to stop these medications. His O2 sats
remained stable throughout BMT course.
.
* Enterococcus bacteremia: Patient spiked a temperature and was
found to have growth of enterococcus sensitive to ampicillan
from PICC line on [**1-21**]. The PICC line was removed and the
patient was treated with ampicillan and gentamicin.
Surveillance cultures showed no growth and patient remained
afebrile throughout the rest of his BMT stay.
.
*Hyperkalemia: Patient became hyperkalemic for several days
during his admission. Was thought to be secondary to
cyclosporine. She was treated with fluids, lasix and lactulose
to help decrease her potassium levels. Her potassium levels
normalized after addition of florinef and remained stable
throughout the rest of her admission.
.
* Pseudomonas UTI: Patient developed pseudomonas UTI for which
he was treated with Ceftazidime for 7 days. Repeat cultures were
negative.
.
*Oral lesions: Patient had lesions on his upper lip that
appeared to be HSV and his HSV 1 serology was positive. He was
treated for this with acyclovir and the lip lesions resolved.
The patient then developed some white spotes in the back of his
throat. It was thought this was possibly [**Female First Name (un) **] growing over
oral HSV lesions. These regions were swabbed and showed no
growth. Nystatin was started and the lesions disappeared over
the course of the admission.
.
* HTN: His hypertension was well controlled with Nifedepine TID.
.
*Bowel edema: Patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pouch secondary to necrotic
bowel resection from several months prior. On [**12-8**] pt had
increased edema (the thought was that somehow the bowel edema
was exacerbated by his treatment) in his prolapsed bowel. We
were unable to support the bowel with a truss because of fear of
strangulating the blood supply to the bowel and making the small
areas of necrosis even worse. He received sugar on bowel to try
to osmotically shrink the edema; this was tried 3 times with
small improvement. Surgery was consulted regarding the
management of this bowel issue. We felt that it would be
advantageous for him to have surgical intervention while in
house, in a situation where his medical issues were better
controlled rather than to send him to rehab, where potential
worsening of his bowel edema would constitute a surgical
emergency.
.
.
Surgery Course:
Patient was taken to the OR on HD31 after all blood and urine
infections were resolved as well as abnormal electrolytes issues
were under control. Patient received stress dose steroids,
platelets on call to the OR as well as dapsone, gent, and flagyl
for 72 hours. Surgery was uneventful and successful in revision
of his colostomy. Patient was extubated in the OR, taken to the
PACU, and then transferred to the floor when met criteria.
Platelets were initially transfused to maintain a level above
100 in the immediate post-op period. Steroid taper was also
initiated. Cyclosporine levels were monitored and increased
accordingly. Stoma looked healthy throughout the post-operative
course. Flatus was first noted on POD4 at which time clears were
started, then advanced to fulls and regular as tolerated.
Patient had a TEE per ID recs to rule out endocarditis which was
negative.
PT worked with the patient throughout and recommended rehab for
the patient.
BP control was done with lopressor and hydralazine. On [**2-5**] he
was advanced to clears and PO meds, then fulls on POD4. PT saw
him and helped him ambulate. [**Last Name (un) **] was consulted for Glucose
control. POD7 CT scan showed dilated R colon and he was febrile
to 102.5. C.Diff x 3 was sent - all of which were negative and
pt was started on Zosyn along with flagyl and linezolid, and
made NPO. Tx to TSICU on POD9 after started on ambisome and had
BP drop. BP responded to 2U of PRBCs. Urine Cx from [**2-9**] came
back pos for pseudomonas. ID and Heme closely followed pt and
pt was stable on floor. occassionally had high BP to 180s
controlled by PRN hydralazine. On [**2-13**] he had a CT of his head
for suspected change in MS that was negative. CT on [**2-15**] showed
increased inflammatory changes in R colon, and pt. was started
on TPN. Decision was made to cont to watch him. [**2-16**] CT also
showed similar results. On [**2-19**] he was tx to Heme/Onc and
Surgery will cont to closely follow.
.
.
Subseqent BMT Course:
# Aplastic anemia: Danazol and epogen ([**2-27**]) were started in
addition to prior neupogen to try and aid hematopoiesis.
Neupogen was stopped on [**3-18**] as his ANC did not seem to improve
on this therapy. He was tapered off of cyclosporin, stopping on
[**2-26**]. He was transfused to maintain his hct>25 and plt>10. He
was also continued on atovaquone for PCP prophylaxis and
fluconazole was added for ppx. He will follow up with hem/onc
([**Doctor Last Name 410**]) as an outpatient for repeated transfusions and decision
regarding need for further epogen and danazol.
.
# Bradycardia: pt was put on telemetry after having a brief
episode of disorientation, red face, ?dyspnea (witnessed by
nurse) - recovered quickly. On tele, pt noted to become
bradycardic with coughing episodes (likely vagal). Otherwise
asymptomatic. He ruled out for MI by cardiac enzymes.
metoprolol was lowered to 12.5 tid as of [**3-22**].
.
# H/o of granulomatous disease: As above. The patient had
completed a 9-month course of INH/pyridoxine, so this was
discontinued on [**2193-2-26**].
.
# HTN: As above, hypertension was exacerbated by cyclosporine.
The patient was treated with nifedipine, metoprolol, and
hydralazine at the time of transfer from SICU. Lisinopril was
added and hydralazine discontinued to simplify the regimen.
Later, HCTZ was added with the hope of discontinuing metoprolol,
as the patient was noted to have episodes of asymptomatic
bradycardia. HCTZ was d/c as it caused his creatine to rise, and
he was discharged on nifedipine, lisinopril, and metoprolol.
.
# Colostomy revision: Surgery continued to follow the patient
when he was transferred back to the BMT service. Serial CT
scans showed gradual improvement of distal colitis. The
patient's diet was advanced and he was weaned off TPN. He was
tolerating a regular diet at the time of discharge and learned
self ostomy care.
.
# Fever: At the time of transfer the patient was afebrile, and
he was soon switched to PO antibiotics. He then had an isolated
fever spike. At that time a CT of the abdomen and pelvis
revealed a possible seminal vesiculitis vs. prostatitis.
Urology evaluated the patient and recommended ultrasound guided
aspiration of this area. Ultrasound revealed no abnormality, so
the aspiration procedure was cancelled. The patient remained
afebrile thereafter except for one elevated [**Location (un) 1131**] which
revealed nothing on culture or exam.
.
# Mild Renal Insufficiency: Patient had poor PO intake and was
maintained on gentle IVF's for much of his hospital admission.
However, he was encouraged to increase intake and florinef was
added to aid in retention of intravascular volume, and Cr was
stable at ~1.1.
# Confusion: The patient developed mental status changes while
on the surgery service. CT head was negative. Sedating
medications were held. The patient's mental status improved
prior to transfer to the BMT service, and he remained at his
baseline throughout the remainder of the hospital course.
Medications on Admission:
Medications:
1. G-CSF 300 mcg/mL Q24H
2. Colace 100mg [**Hospital1 **]
3. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg PRN
5. Folic Acid 1 mg PO DAILY
6. Pyridoxine 50 mg PO DAILY
7. Pantoprazole 40 mg delayed release Q24.
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY
(Daily).
Disp:*300 ml* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(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. Peppermint Oil Oil Sig: One (1) Miscell. ONGOING () as
needed for colostomy.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Danazol 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
Disp:*60 Capsule(s)* Refills:*2*
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day) as needed for thrush.
Disp:*30 Troche(s)* Refills:*0*
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
13. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**])
units Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*QS units* Refills:*2*
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
15. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Physician [**Name9 (PRE) **] [**Name9 (PRE) **]
Discharge Diagnosis:
Primary Diagnosis:
transfusion dependent aplastic anemia
prolapsed stoma
pseudomonas urinary tract infection
enterococcus bacteremia
Discharge Condition:
good
Discharge Instructions:
If you experience fever, chills, severe nausea, vomiting, or
abdominal pain, shortness of breath, or any other new or
concerning symptoms, please call your doctor or return to the
emergency room for evaluation.
.
Please take all medications as prescribed.
.
Please attend all follow up appointments.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 410**].
10:30Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2193-3-28**] 9:30
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2193-3-28**] 9:30
.
2. Please follow up with Dr. [**Last Name (STitle) **] on [**4-19**] at 8:00 a.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16984**] MD, [**MD Number(3) 16985**]
ICD9 Codes: 7907, 2767, 5990, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2140
} | Medical Text: Admission Date: [**2158-3-4**] Discharge Date: [**2158-3-8**]
Date of Birth: [**2105-9-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
STEMI.
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent placed in left
circumflex.
Intraaortic balloon pump
Swan-Ganz catheter
History of Present Illness:
Mr [**Known lastname 45820**] is a 52-year-old man with hypertension and
dyslipidemia, transferred from [**Hospital3 3583**] with STEMI,
[**Location (un) 7622**] to [**Hospital1 18**], cath. lab.
Patient was at a neighbour's place, help to fell trees when he
experienced sub-sternal chest pressure. He paused, considering
that this might be an AMI, decided not to work on another tree,
collected his things, walked over the road to his house and
called 911. He sat down, the pain improved, then worsened again.
En route he developed diaphoresis, palor and began vomiting. He
developed ventricular fibrillation and was shocked out of this
rhythm with re-establishment of sinus rhythm, also notable for
5-[**Street Address(2) **] depression and t-wave inversion in V2-4, ST depression
of 1 mm in I and large t-waves in III. En route he was given 162
mg ASA. He was briefly at [**Hospital3 **] where ST-segment
depression seen on EMS was again noted. He described sub-sternal
chest pain, weakness and nausea. He was given aspirin 162 for a
total of 324 mg, plavix 600 mg, SLN x 2, lidocaine 100 mg IV, 50
mcg fentanyl, heparin bolus 3600 units IV. Chest pain improved.
He continued to vomit and likely lost some medication, so
another 600 mg of Plavix was given. He was given Zofran (8 mg)
prior to [**Location (un) **] arrival for evacuation to [**Hospital1 18**]. Given a
question of torsades (unclear but seen on beginning four inches
of EMS strip EKG) he was sent on [**Location (un) **] with magnesium, but
this was not given in the ED. On [**Location (un) 7622**], Mr. [**Known lastname 45820**] [**Last Name (Titles) 43254**]
again, was given 100 mcg more of fentanyl with chest pain
dropping from [**4-3**] to [**12-4**]. He arrived at [**Hospital1 18**] and was taken
directly to the cath lab where one bare metal stent was placed
in the almost completely occluded proximal left circumflex. RCA
was approximately 50 % stenosed at its narrowest point and
branches of the left anterior descending, septal perforators and
diagonals, were tightly stenosed. Throughout this period from
home until arrival in the cath lab, he was hemodynamically
stable with pressures slightly elevated from 130s to 150s.
Opening blood pressure was 124 mmHg systolic, but decreased by
the end of the procedure to 80s systolic. Dopamine drip was
started and a baloon pump placed. Given that atrial fibrillation
was thought to be new and was likely contributing to
hypotension, the patient was further sedated with successful
electrical cardioversion. He received 4.5 L of IV fluids in
total.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for (+) chest pain,
without dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension (had 'cold' with RR about 2-3 per Dr. [**Last Name (STitle) **]
2. CARDIAC HISTORY:
-CABG: No.
-PERCUTANEOUS CORONARY INTERVENTIONS: No prior.
-PACING/ICD: No.
3. OTHER PAST MEDICAL HISTORY:
(a) HYPERTENSION - controlled with HCTZ
(b) SEASONAL ALLERGIES
(c) SINUS HEADACHES
(d) GASTROESOPHAGEAL REFLUX on prevacid with good control of sx.
(e) CARPAL TUNNEL SYNDROME
(f) LIVING WILL (see Code Status below)
(g) HYPERLIPIDEMIA - not on statin
(h) COLONIC POLYP, ascending colon, benign
Social History:
- Tobacco history: Never
- ETOH: No drinking since [**2127**].
- Illicit drugs: No
Works in cutomer service for Clean Habors.
Family History:
Father had MI at 60. No family history of arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: T= [**Age over 90 **] F BP= 115/60 mmHg HR= 94 RR= 31 O2 sat= 94% on NRB
GENERAL: Alert. Oriented x3. Mood, affect appropriate. Baloon
pump by bed, NRB in place.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP unable to be assessed - lying flat.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles throughout, no
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Some hair loss at
ankles and shiny skin on feet.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Labs at Admission
[**2158-3-4**] 08:41PM BLOOD WBC-31.0* RBC-4.60 Hgb-13.4* Hct-39.4*
MCV-86 MCH-29.2 MCHC-34.2 RDW-13.0 Plt Ct-222
[**2158-3-4**] 08:41PM BLOOD Neuts-89* Bands-2 Lymphs-8* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2158-3-4**] 08:41PM BLOOD PT-14.5* PTT-150* INR(PT)-1.3*
[**2158-3-4**] 08:41PM BLOOD Glucose-221* UreaN-12 Creat-1.1 Na-141
K-3.4 Cl-101 HCO3-25 AnGap-18
[**2158-3-4**] 08:41PM BLOOD CK(CPK)-217
[**2158-3-5**] 08:00AM BLOOD ALT-45* LD(LDH)-478* CK(CPK)-2724*
AlkPhos-48 TotBili-0.7
[**2158-3-4**] 08:41PM BLOOD Calcium-8.7 Phos-4.4 Mg-2.3
[**2158-3-4**] 08:41PM BLOOD CK-MB-5 cTropnT-0.05*
[**2158-3-4**] 08:41PM BLOOD %HbA1c-5.4 eAG-108
[**2158-3-5**] 03:42AM BLOOD Triglyc-87 HDL-40 CHOL/HD-4.5 LDLcalc-121
[**2158-3-4**] 11:17PM BLOOD Type-[**Last Name (un) **] pO2-38* pCO2-46* pH-7.34*
calTCO2-26 Base XS--1
[**2158-3-4**] 11:17PM BLOOD Lactate-2.6*
[**2158-3-4**] 11:17PM BLOOD O2 Sat-69
[**2158-3-4**] 11:17PM BLOOD freeCa-1.08*
Cardiac Enzymes
[**2158-3-4**] 08:41PM BLOOD CK-MB-5 cTropnT-0.05*
[**2158-3-5**] 03:42AM BLOOD CK-MB-324* MB Indx-12.4* cTropnT-2.56*
[**2158-3-5**] 08:00AM BLOOD CK-MB-294* MB Indx-10.8* cTropnT-2.92*
[**2158-3-5**] 02:19PM BLOOD CK-MB-252* MB Indx-7.6* cTropnT-5.42*
[**2158-3-5**] 10:07PM BLOOD CK-MB-153* MB Indx-5.0 cTropnT-8.25*
[**2158-3-6**] 06:12AM BLOOD CK-MB-87* cTropnT-7.82*
[**2158-3-6**] 03:03PM BLOOD CK-MB-44* MB Indx-3.1 cTropnT-5.82*
[**2158-3-7**] 06:25AM BLOOD CK-MB-16* MB Indx-2.4 cTropnT-5.20*
Labs at Discharge
[**2158-3-8**] 06:30AM BLOOD WBC-8.9 RBC-4.11* Hgb-11.5* Hct-34.9*
MCV-85 MCH-27.9 MCHC-32.8 RDW-13.8 Plt Ct-189
[**2158-3-8**] 06:30AM BLOOD PT-12.9 PTT-25.0 INR(PT)-1.1
[**2158-3-8**] 06:30AM BLOOD Glucose-90 UreaN-13 Creat-1.0 Na-141
K-4.2 Cl-105 HCO3-29 AnGap-11
[**2158-3-7**] 06:25AM BLOOD CK(CPK)-657*
[**2158-3-8**] 06:30AM BLOOD Calcium-8.8 Phos-4.8* Mg-2.0
Cardiac Cath.
BRIEF HISTORY:
52 year old man with hypertension presented with chest pain,
nausea/vomiting and ventricular fibrillation to an outside
hospital.
The V fib was successfully cardioverted, and an ECG was
consistent with
inferoposterior STEMI. He was transferred emergently to the
[**Hospital1 18**]
cardiac catheterization lab for right and left heart cath.
INDICATIONS FOR CATHETERIZATION:
inferoposterior STEMI
cad
chest pain
ventricular fibrillation
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 6 XB 3.5 guide, advanced to the
ascending
aorta through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL3.5 and a 5 French JR4 catheter, with manual contrast
injections.
Intra-aortic balloon counterpulsation: was initiated with an
introducer
sheath using a Cardiac Assist 9 French 40cc wire guided
catheter,
inserted via the right femoral artery.
Percutaneous coronary revascularization was performed using
placement of
bare-metal stent(s).
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.8 m2
HEMOGLOBIN: 13.2 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} */19/16
RIGHT VENTRICLE {s/ed} 38/16
PULMONARY ARTERY {s/d/m} 38/25/33
PULMONARY WEDGE {a/v/m} */34/25
AORTA {s/d/m} 124-90-106
**CARDIAC OUTPUT
HEART RATE {beats/min} 107
RHYTHM ATRIAL FIBRILLATION
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 39
CARD. OP/IND FICK {l/mn/m2} 5.8/3.2
**RESISTANCES
PULMONARY VASC. RESISTANCE 110
**% SATURATION DATA (NL)
PA MAIN 77
AO 99
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA DIFFUSELY DISEASED 50
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD DISCRETE 90
8) DISTAL LAD NORMAL
9) DIAGONAL-1 DISCRETE
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX DISCRETE 100
**PTCA RESULTS
CX
PTCA COMMENTS: Initial angiography revealed a proximally
occluded
LCx. We planned to treat this with PTCA and stenting. Heparin
and
Integrillin were given prophylactically. A 6F XB3.5 guide
provided good
support. A Prowater wire crossed the wire without difficulty.
Thrombectomy was performed with an Export catheter followed by
predilation with a 2.0x15mm Voyager balloon. A 3.0x18mm Vision
bare
metal stent was then deployed at 16atm. Post-dilation was
performed with
3.25x15mm and 3.5x15mm Quantum Maverick balloons at 21 and
20atm,
respectively. Final angiography revealed no residual stenosis,
TIMI 3
flow, and no apparent dissection.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 14 minutes.
Arterial time = 1 hour 12 minutes.
Fluoro time = 13.0 minutes.
IRP dose = 879 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 140 ml
Premedications:
ASA 325 mg P.O.
Clopidogrel 600 mg PO x2
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin [**2147**] units IV
Other medication:
Heparin gtt 1100 units/hour
Dopamine 7.4 mg IV
Metoprolol 5 mg IV
Lidocaine gtt 4608 mg IV
Integrillin 36.2 mg IV
Cardiac Cath Supplies Used:
.014IN [**Doctor Last Name **], PROWATER 300CM
2.0MM [**Doctor Last Name **], VOYAGER 15MM
3.25MM [**Company **], QUANTUM MAVERICK 15MM
3.5MM [**Company **], QUANTUM MAVERICK 15MM
6FR CORDIS, XB 3.5
8FR ARROW, IABP ULTRA FIBEROPTIX CATHETER 40CC
3.0MM [**Doctor Last Name **], VISION 18MM
6FR [**Company **], EXPORT ASPIRATION CATHETER
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
- [**Company **], RIGHT HEART KIT
- [**Doctor Last Name **], PRIORITY PACK 20/30
5FR ARROW, BALLOON WEDGE PRESSURE CATHETER 110CM
7FR [**Doctor Last Name **], SWAN-GANZ VIP
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated two vessel coronary artery disease. The LMCA was
free of
angiographically apparent flow limiting stenosis. The LAD had a
complex
trifurcating lesion in the mid vessel that was 80-90%. There
was an 80%
stenosis in the mid LAD that involved the origin of a major
diagonal
branch. That diagonal branch also had a 90% stenosis. The LCx
had a
100% proximal stenosis. The RCA had a long 50% stenosis in the
mid
vessel.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP 16mmHg, and mean PCWP 25mmHg. There was
mild
pulmonary arterial hypertension with PASP 38mmHg on dopamine
gtt. The
cardiac index on dopamine was preserved at 3.17 l/min/m2, it
declined to
1.58 l/min/m2 when dopamine was weaned off because of continued
ventricular ectopy. Following the placement of the IABP the
cardiac
index improved to 2.3 l/min/m2.
3. Left ventriculography was deferred.
4. An intra-aortic balloon pump was placed sheathed via the
right
femoral artery, with MAP 77 mmHg on [**11-25**] counterpulsation.
5. Successful PCI of the proximal LCx occlusion with a 3.0x18mm
Vision
BMS, post-dilated to 3.5mm.
6. Because of low blood pressure in the presence of rapid atrial
fibrillation, cardioversion to NSR was performed with a single
shock of
360 joules after the patient was sedated with the help of a
member of
the anesthesia department.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Mildly elevated right and left sided filling pressures.
3. Mild pulmonary arterial hypertension.
4. Successful placement of intra-aortic balloon pump.
5. Successful PCI of the LCx with BMS.
6. Successful cardioversion of atrial fibrillation.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) 21753**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] A.
[**Last Name (LF) **],[**First Name3 (LF) **] M.
EKG [**3-4**]
Sinus rhythm. Occasional ventricular premature beats. Compared
to the
previous tracing of [**2157-2-2**] ectopy is new.
Rate PR QRS QT/QTc P QRS T
95 156 84 354/415 61 19 70
EKG [**3-5**]
Normal sinus rhythm. Non-specific ST-T wave abnormalities.
Compared to the
previous tracing of [**2158-3-5**] ventricular premature beats are no
longer seen.
Echo [**3-6**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild to moderate regional left ventricular systolic dysfunction
with lateral akinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
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. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension.
CXR [**3-7**]
Resolved pulmonary vascular congestion. No newly developed
consolidation.
Rate PR QRS QT/QTc P QRS T
76 138 78 392/420 38 -19 54
Brief Hospital Course:
Mr [**Known lastname 45820**] presented with STEMI in the context of a 'cold' and
dyslipidemia. A bare mental stent was placed in the proximal
left circumflex culprit lesion. The patient will take Plavix and
other CAD regimen for one month, allowing for endothelium to
appear within stent, before elective CABG, given extensive CAD.
Coronary Artery Disease
The patient underwent cardiac catheterization which revealed
significant RCA, LAD (including diagonal)and LCx disease and had
a stent placed to the LCx. Symptomatic ischemia and EKG changes
were likely derived from the occluded LCx. CAD is a new
diagnosis for this patient. LDL 121 and HbA1c 5.4 suggesting he
does not have diabetes. He was given integrillin for 18 hrs.
Given extensive coronary disease, the patient is a candidate for
CABG. Cardiac surgery was consulted and it was decided to defer
this surgery by one month, allowing endothelium to appear within
the LCx stent. The patient was given a dose of prasugrel for
rapid onset of purine receptor block, followed by Plavix. He is
being discharged on plavix [**Hospital1 **] for one week then Q day,
atorvastatin, metoprolol, lisinopril, and full dose aspirin. He
will follow up with Dr. [**Last Name (STitle) **] for cardiac surgery and with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] for cardiology.
Atrial Fibrillation, Ventricular Tachycardia, Torsades de
Pointes
Although atypical, AF appears to be an ischemic rhythm in this
case (concern for new onset MR, possibly consistent with echo,
and atrial stretch). It appeared responsible for hypotension,
but hypotension continued despite resolution of AF ?????? however,
each of the above rhythms is also associated with lowered
pressure. Cardioversion was desirable and successful in the
cath. lab (sedated, electrical) and a baloon pump was placed.
Over the night following catheterization, the patient had
frequent bouts of ventricular ectopy with PVCs, VT, AIVR, and
one 14 second episode of self-limited torsades de [**Last Name (un) **]. Due
to low blood pressures, beta-blocker was initially avoided and
patient was loaded with amiodarone and started on an amiodarone
gtt. Swan-Ganz catheter was removed to prevent triggering
arrhythmias. The ventricular ectopy decreased, and after
discussion with EP, low dose metoprolol was initiated and
amidarone was stopped. K and Mg were aggressively repleted.
Ectopy was very substantially decreased about 24 hours after the
event, suggestive of extended reperfusion ectopy. He had very
few to no ectopy at discharge.
Hypertension/Hypotension
Balloon pump was used for the first 24 hours to support
cardiac function and blood pressure. He was also briefly on
dopamine in the cath. lab., which was discontinued upon arrival
on the floor. Systolic blood pressures were initially in the
80s, lower during VT, even after having 4.5L of fluid. His
pressures spontaneously increased on the day following
admission. HCTZ was held.
Leukocytosis
Likely stress demargination in ACS and resolved with time.
Supported by diff with minimal bands and evening cortisol of 26
at presentation.
Medications on Admission:
- Esomeprazole Magnesium, 40 mg Capsule, Delayed Release, QD
- Fluticasone, 50 mcg Spray, Suspension, 2 sprays each nostril,
QD
- Hydrochlorothiazide, 12.5 mg Capsule, 1 Capsule, QD
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO Q day ().
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day:
start on [**2158-3-14**] after twice daily dosing is done.
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. 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*
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 mintues for total of 3 [**Date Range 4319**]: if you still
have chest pain after 3 [**Date Range 4319**], call 911.
Disp:*25 tablets* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial infarction
Acute Systolic Dysfunction: EF 45%
Hypertension
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a large heart attack and a bare metal stent was placed
in your left circumflex artery. You had some heart arrhythmias
including atrial fibrillation and ventricular fibrillation that
required cardioversion (shock) to fix, and short runs of
ventricular tachycardia. All of this irregular rhythms were
thought to be due to your heart attack and have now resolved.
Your echocardiogram showed some wall motion abnormalities and
your heart function is not as strong as it was before but we
think this will improve over time. For now, you will need to
exercise accoring to your exercise prescription, take all of
your medicines and follow up with your new cardiologists. A
bypass operation will be scheduled in the future.
.
Medication changes:
1. Stop taking hydrochlorothizide
2. Start taking aspirin every day to keep the stent open
3. Start taking Plavix every day to keep the stent open, do not
miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr. [**Last Name (STitle) **] tells you
to.
4. Start taking Atorvastain to keep your cholesterol down
5. Start taking Metoprolol to keep your heart rate low
6. Start taking Lisinopril to keep your blood pressure low.
7. Start using nitroglycerin if you have similar chest pain.
Take this tablet under your tongue and wait 5 minutes between
[**Last Name (STitle) 4319**]. If you still have chest pain after 3 [**Last Name (STitle) 4319**], call 911.
Tell Dr. [**Last Name (STitle) 45821**] or Dr. [**Last Name (STitle) **] if you use any nitroglycerin at
all.
.
Followup Instructions:
Cardiology:
ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2158-4-11**] 11:00
Please call for location.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2158-3-24**]
9:40
Primary Care:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Phone:[**Telephone/Fax (1) 250**] Date/Time:
Thursday [**3-16**] at 3:40pm.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2158-4-4**] 11:00
Cardiac Surgery:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 45821**] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**2158-4-6**]
at 2:00pm.
ICD9 Codes: 4271, 4280, 2768, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2141
} | Medical Text: Admission Date: [**2123-8-2**] Discharge Date: [**2123-8-5**]
Date of Birth: [**2066-3-12**] Sex: M
Service: CCU
CHIEF COMPLAINT: Chest pain today.
HISTORY OF THE PRESENT ILLNESS: This is a 57-year-old male
with a history of positive stress test in [**2116**], cardiac
catheterization revealing four vessel disease, status post
CABG with LIMA to the LAD and saphenous vein grafts times
three to the D1, OM2, and PDA, who was chest pain-free until
this afternoon of admission when, while driving, he
experienced similar chest pain as prior to CABG described as
crushing substernal, diffuse in the midsternum radiating to
the left arm with tingling and numbness. The patient was
diaphoretic and short of breath. The patient described the
pain as [**7-4**] continued and constant. Denied any syncope,
nausea, lightheadedness. The patient then drove home. His
wife called the ambulance and they brought him to an outside
hospital where he was still complaining of pain. The patient
was given aspirin, nitroglycerin with relief of the pain from
[**4-3**] to [**2-1**] continuously. The EKG showed ST elevations in
leads III, aVF, T wave inversions in aVL, V1, V2, and ST
depressions in aVL, V3-V4.
The patient was transferred to [**Hospital1 18**] for further management
after initial Plavix loading 300 mg times one, Integrelin,
and heparin drip started.
The patient was taken emergently to the Cardiac
Catheterization Laboratory which showed 100% proximal lesion
with thrombus, saphenous vein graft to the PDA which was
stented after thrombectomy. There was a high-grade lesion in
the left main and intermediate stenosis not treated at the
time for further intervention in the future. Hemodynamics
showed mildly elevated filling pressures but no evidence of
RV infarct and left dominant circulation.
The patient was transferred to the CCU for further
management.
PAST MEDICAL HISTORY:
1. Status post CABG in [**2116-12-26**] with LIMA to the
LAD, saphenous vein graft to D1, saphenous vein graft to OM2,
and saphenous vein graft to PDA.
2. Cardiac catheterization, left dominant system, 100%
diffuse disease in the proximal RCA, 90% disease discreet in
the proximal LAD, 100% discreet lesion in the mid LAD, and an
80-90% diffuse moderate midcircumflex.
3. Left knee arthritis, status post arthroscopic knee
surgery.
ADMISSION MEDICATIONS: Occasional Alleve, no other
medications.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: Positive tobacco history times one pack per
day times 35 years, rare alcohol use, no IV drug use or
cocaine. He is married and lives with his wife in [**Name (NI) 15089**].
FAMILY HISTORY: No history of coronary artery disease.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.9, blood pressure 111/59, heart rate 76, respiratory rate
18, saturating 98% on 1 liter nasal cannula, weight 72.6
kilograms. General: Sitting comfortably in bed, in no
apparent distress. HEENT: Normocephalic, atraumatic.
Extraocular muscles intact. Pupils equally round and
reactive to light. The oropharynx was benign. The mucous
membranes were dry. Neck: Supple, no jugular venous
distention. No lymphadenopathy. No masses. Chest: Clear
to auscultation bilaterally, anterior and lateral
examination. Coronary: Soft heart sounds, regular rate and
rhythm, no murmurs, rubs, or gallops. Abdomen: Soft,
nontender, nondistended, positive bowel sounds, no masses.
Groin: Right groin dressing clean, dry, and intact, no
bruits, no cords, no hematoma, 2+ pulses distally.
Extremities: Warm and well perfused. No edema. Neurologic:
Alert and oriented. Cranial nerves II through XII intact,
[**3-29**] bilateral upper and lower extremity strength.
LABORATORY/RADIOLOGIC DATA: White count 12.2 with a
differential of 74% polys, 21 lymphs, 5 monos, 0 eos,
hematocrit 41.2, potassium 4.3, creatinine 0.8, magnesium
1.9. Initial CK 1,145. Outside hospital laboratories: CK
85, troponin I 0.16.
EKG: Normal sinus rhythm at 93 degrees, normal axis, AV
delay, Q waves in III, aVF, ST segments inferiorly,
normalized ST depressions 0.5 mm in V3 through V5.
Cardiac catheterization: Hemodynamics: Cardiac
output/cardiac index 6.10/3.18, wedge pressure 12.
HOSPITAL COURSE: 1. CORONARY: The patient is status post
inferior wall MI with stent placement in the saphenous vein
graft to the PDA. The patient was maintained on aspirin,
Plavix, and Integrelin times 18 hours after catheterization.
The patient was maintained on a beta blocker and slowly
titrated to maintain a goal heart rate of 55-65. ACE
inhibitor was started for afterload reduction and ventricular
wall mottling. The patient's initial cardiac catheterization
showed a nonintervened left main and LAD lesion of ramus.
The patient was taken back to cardiac catheterization on
[**2123-8-4**] for a successful stenting of the ramus
lesion and the left main and rescue PTCA of a jailed left
circumflex. The patient had an uneventful course after that.
The patient was maintained again on Plavix and Integrelin 18
hours post cardiac catheterization.
The patient had a peak CK of 1,888.
MYOCARDIUM: The patient had an ejection fraction of 40-45%
on an echocardiogram during this hospitalization. The
echocardiogram showed mild regional left ventricular systolic
dysfunction. It showed basal inferior akinesis as well as
midinferior akinesis. Trivial MR. The patient had no
evidence of dyskinesis at which point there was no need for
anticoagulation. Akinesis was likely due to stunned
myocardium. The patient was gently diuresed approximately
-500 cc during the hospital stay and was subsequently
maintained euvolemic.
RHYTHM: On hospital day number two, the patient experienced
a 25 beat run of wide complex tachycardia. The patient was
sleeping at the time. When awakened, he complained of [**3-4**]
chest pain. The tachycardia resolved spontaneously. The
patient was not treated with sublingual nitroglycerin
secondary to SBP of 104 at the time. The chest pain resolved
spontaneously without any further episodes. The patient was
monitored on telemetry. An EP consult was considered;
however, the patient had no further runs of V tach after
that. Given his second recatheterization during this
hospital stay, this was initially thought to be due to
consistent ischemia and with the revascularization with stent
the patient was not reperfused. The patient's beta blocker
was titrated up further. He had no further runs of V tach
during this hospitalization stay. The patient was maintained
on telemetry until discharge.
2. PULMONARY: The patient had stable sats during this
hospital stay without any evidence of failure or pneumonia.
Chest x-ray initially showed no acute cardiopulmonary
process.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
maintained on a cardiac healthy diet during the
hospitalization stay initially, n.p.o. after cardiac
catheterization with slow advancement to the cardiac diet.
4. KNEE: On the day of discharge, the patient developed
significant effusion in his right knee without any redness,
fever spike, or change in his white blood cell count. A
diagnostic therapeutic tap was obtained prior to discharge.
Gram's stain was negative for any organisms besides
polymorphonuclear leukocytes. This was likely due to trauma
after catheterization. There was no gross evidence of
infection. The patient was followed-up with his primary care
physician.
5. PROPHYLAXIS: The patient was maintained on Tylenol for
fever, pneumoboots for DVT prophylaxis, as well as
subcutaneous heparin.
6. CODE: The patient was maintained on full code during
this hospitalization stay.
7. COMMUNICATIONS: With his wife.
FINAL DIAGNOSIS:
1. Acute myocardial infarction, inferior, initial episode.
2. Coronary artery disease, native.
3. Coronary artery disease, saphenous vein graft.
RECOMMENDED FOLLOW-UP: Please follow-up with your primary
care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], call [**Telephone/Fax (1) 15090**] to make
an appointment within the next week. Please inform of your
recent hospitalization including any new medications that
have been set up. Primary cardiology to follow your course.
Please follow-up joint culture by calling [**Telephone/Fax (1) 4645**] and
have your information available.
CONDITION ON DISCHARGE: Stable blood pressure and heart
rate. No further arrhythmias. Afebrile. No chest pain.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Atorvostatin 10 mg p.o. q.d.
3. Lisinopril 5 mg p.o. q.d.
4. Metoprolol tartrate 50 mg p.o. q.d.
5. Plavix 75 mg p.o. q.d.
6. Percocet 5/325 one to two tablets p.o. q. four to six
hours as needed for pain relief.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**]
Dictated By:[**Last Name (NamePattern1) 5227**]
MEDQUIST36
D: [**2123-10-4**] 02:10
T: [**2123-10-5**] 08:51
JOB#: [**Job Number 15091**]
ICD9 Codes: 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2142
} | Medical Text: Admission Date: [**2112-3-21**] Discharge Date: [**2112-4-1**]
Date of Birth: [**2039-11-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
PICC line placed
History of Present Illness:
This is a 72 yo M with DMI, HTN, h/o MI, Chronic Kidney Disease
s/p LURT [**9-/2105**] from wife, recent diagnosis of adenocarcinoma
of lung Stage 1A T1NO (with left upper lobectomy) who presents
with SOB over the past week and decreased UO. The pt states that
he stopped taking his Lasix 1 week ago due to excessive
urination at that time. He has had progressive SOB now over the
past 3 days, to now feeling SOB even at rest. He admits to
orthopnea, PND, and cough (non-productive). He states that the
swelling in his legs has actually improved over the past 2
weeks.
.
In the ED, the patient's vitals were: BP 130/52 (102-122/31-66)
HR 118 (102-115) RR 26 O2 Sat 100% on NRB. He was noted to be
anemic with a hct of 18 (Baseline 26-30), but was guaiac
negative. BNP was elevated at 7882. He received Lasix 60 mg IV
after 1 unit of PRBC. Cr is elevated at 2.9 (baseline 2-2.5).
Iron studies and hemolysis labs were ordered per renal recs. CXR
was consistent with pulmonary edema.
.
On ROS, pt denies weight changes, chest pain, palpitations,
abdominal pain. He admits to no bowel movement in several days.
Past Medical History:
1. Diabetes x25 years
2. hypertension
3. cholesterolemia
4. myocardial infarction in [**2104**]
5. severe osteoarthritis effecting the hips, shoulders, knees
6. spinal stenosis bothering his back
7. chronic kidney disease s/p living related renal transplant in
[**9-/2105**] with a graft from his wife
8. peripheral vascular disease s/p bilateral lower extremity
revascularizations and bilateral toe amputations.
9. left upper lobectomy for an asymptomatic newly defined left
upper lobe pulmonary nodule seen at the time of revision of
lower extremity bypass graft back in [**2111-9-27**]. Path revealed
poorly differentiated adenocarcinoma, 0/5 lymph nodes positive.
His postoperative course was complicated by urinary retention
and a subsequent readmission with urosepsis. He was staged as T1
N0, stage 1A, without need for further treatment.
10. Diastolic Heart Dysfunction: Echo [**1-3**]: There is mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated athe sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2).
11. Klebsiella bacteremia, UTI and sepsis [**2-3**]
Social History:
Smoked cigarettes until [**2083**]. No ETOH. He lives at home.
Retired, but was previously a truck driver.
Family History:
Significant for lung cancer in the patient's father who
developed this at age 75, but subsequently died of a stroke.
Physical Exam:
Vitals: BP 136/37 HR 95 RR 26 Sat 100% NRB-->ABG: 7.41/37/112
GEN: obese caucasian male sitting at 60 degrees in bed with
respiratory accessory muscle use and paradoxical abdominal wall
movements with breathing
HEENT: pupils constricted, conjunctivae anicteric/noninjected
but pale, MMM
NECK: JVP at mandible with +HJR
CV: distant heart sounds, regular rhythm, no m/r/g
LUNGS: rales at bilateral lung bases R>L, poor air movement
AB: soft, nontender, mildly distended and protuberant,
paradoxical abdominal wall movements with breathing
EXTREM: 2+ pitting edema in BL LE up to the knees, BL toe
amputations (all 10 toes amputated), 1+ radial pulses
bilaterally
SKIN: chronic venous insufficiency changes in the BL LE
NEURO: alert and oriented, moving all 4 extremities
Pertinent Results:
Studies:
[**2112-3-21**] EKG: EKG: sinus tachnycardia, nl axis, TWI and 1mm ST
depressions in V5-6, [**Street Address(2) 4793**] elevation in V2, TWI in lateral and
inferior leads-->all old from [**1-3**]
.
[**2112-3-21**] CXR: IMPRESSION:
Moderate bilateral pulmonary edema, with more focal
consolidative process involving the right lower lobe, likely
representing areas of alveolar pulmonary edema. Cardiogenic
versus renal etiology is not completely clear; recommend
correlation with clinical history and labs to clarify the
etiology.
.
[**2112-3-22**] Renal transplant ultrasound: IMPRESSION: Normal renal
transplant ultrasound.
.
[**2112-3-22**] CXR: FINDINGS: A portable upright chest radiograph shows
diffuse alveolar edema, right greater than left, with some
sparing of the left upper lobe. Top normal heart size and mild
central pulmonary vascular congestion. Compared to yesterday's
study, there may be slightly more focal consolidation at the
right base. PICC line placed via the right upper extremity is
seen with the tip at the level of the mid superior vena cava.
.
[**2112-3-23**] CXR: PORTABLE CHEST: Comparison to a day prior reveals
persistent alveolar edema again with some sparing of the left
upper lobe. Heart size and pulmonary vascular congestion appears
unchanged. Although more focal consolidation at the right base
is less evident on today's film, this may simply be due to
patient rotation. Evaluation of the apices are limited by head
positioning. Worsening of small pleural effusions is noted
bilaterally. A right sided PIC catheter is unchanged in
position.
.
[**2112-3-24**] CXR: Compared to prior studies from [**3-22**] and 28th,
there has been interval improvement in now mild interstitial
pulmonary edema. Right lower lobe consolidation has also
improved. Cardiomediastinal contour is unchanged. There is
blunting of the posterior CP angles likely small pleural
effusions. Right PICC line tip is in the SVC.
.
[**2112-3-22**] ECHO: LVEF 60% Conclusions:
The left atrium is moderately dilated. There is moderate
symmetric left
ventricular hypertrophy. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity
imaging are consistent with Grade II (moderate) LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] The tricuspid valve leaflets
are mildly thickened. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2112-1-27**],
tissue Doppler analysis was included in the current study with
evidence of elevated LV filling pressure.
.
EGD: Grade 1 esophagitis in the lower third of the esophagus
.
Colonoscopy:
1. Diverticulosis of the sigmoid colon
2. Polyps in the cecum (polypectomy)
3. Polyp in the descending colon (polypectomy)
Brief Hospital Course:
Mr. [**Known lastname 27548**] is a 72 year old male with DMI, HTN, h/o MI, ESRD
s/p LURT [**9-/2105**] from wife, recent diagnosis of adenocarcinoma
of lungs Stage 1A T1NO (with left upper lobectomy) who presented
with SOB most consistent with pulmonary edema.
.
#Shortness of Breath/Hypoxia: The patient had pulmonary edema
likely in the setting of diastolic dysfunction exacerbated by
self-discontinuation of lasix (pt. self d/c'd because he was
"tired of urinating all the time"). Additionally, he was
tachycardic on admission and has known diastolic dysfunction
which likely also played a role. BNP was 7000 on admission.
Another likely contributor to his dyspnea was his anemia, as
below. There were no signs of PNA clinically, and serial CXR
showed improvement of pulmonary edema. He was initially
admitted to the ICU and required a NRB to keep his oxygen
saturation greater than 90%. He was placed on a nitro gtt to
decrease his preload. He had an ECHO which showed grade II
diastolic dysfunction and a LVEF of >60%. He was given
metoprolol with a goal HR in the 60s and SBP in the 120s. His
respiratory status improved markedly with diuresis and cardiac
rate control and he will be discharged to rehab maintaining
oxygen saturations on room air. He is back on his home dose of
80mg PO lasix daily to which he has been putting out well.
.
#Acute on Chronic Renal Insufficiency: His baseline creatinine
is 1.9 to 2.9, with a recent trend upward from 1.9 (max 3.6
during this hospitalization). He is s/p living related donor
renal transplant in [**2105**] and is on sirolimus, cellcept, and
prednisone. This was likely multifactorial in the setting of
decompensated CHF and worsening anemia. FeUrea was consistent w/
pre-renal cause. Renal transplant US was normal without
evidence of obstruction. Per renal recommendations his
immunosuppression meds were originally decreased as his
sirolimus level was 9 on admission (goal [**5-2**] as he is 7 years
out from transplant). His sirolimus was changed from 3mg daily
to 2mg. He will, however, be discharged on 3mg sirolimus daily
as his level trended down during his stay. This should be
followed qweekly at rehab until follow up with renal. His
cellcept was changed from 500mg TID to 250mg [**Hospital1 **] and he was
continued on prednisone 5mg daily. Given his acute on chronic
renal failure and anemia (discussed further below), an SPEP and
UPEP were sent, both of which were negative. His renal function
continued to improve during his stay with continued diuresis and
PRBC transfusions and creatinine on discharge was 1.7. His
prophylactic bactrim was held during his stay secondary to his
worsened renal function, but should be reinitiated upon follow
up as long as his renal function remains stable.
.
#Anemia: His HCT was 18 on admission from a previous baseline of
26-30. His chronic anemia likely from CKD and chronic
inflammation, but acute exacerbation was not initially clear.
During his hospital stay, he required a total of 6units of
prbcs. He was consistently guaiac negative although reports
several weeks prior to admission he had a large grossly bloody
BM, but none since. EGD and colonoscopy were performed which did
not reveal a source of bleed. GI recommended small bowel follow
through prior to pill endoscopy, but patient could not tolerate
original study due to hip pain and then refused repeat prior to
discharge. His reticulocyte count was appropriately elevated,
making marrow suppression unlikely. Iron studies revealed
significantly low iron and he was repleted with IV iron. A
serum TTG was sent to rule out celiac disease. He will be
discharged on PO iron supplementation. Hemolysis labs were not
suggestive of active hemolysis. He will be discharged on
erythropoeitin in addition to iron supplementation. His
hematocrit should be followed at rehab. He should follow up as
scheduled with hematology and iron studies should be rechecked
in [**2-28**] weeks. Hematocrit on discharge was 29.3.
.
#DM: He was admitted on 100 Units NPH [**Hospital1 **]. His insulin
requirement, however, was significantly lower while inpatient,
however, appears now to be consistently increasing. He will be
discharged on 34Units qam and 36Units qhs, but this will need to
be adjusted.
.
# UTI: Urine cultures on admission grew Klebsiella sensitive to
ciprofloxacin. He has a history of BPH and high PVRs as well as
a history of recurrent UTIs and bacteremia. He is followed by
urology as an outpatient. His foley was removed here and he has
been voiding without difficulty without elevated PVRs. A recent
urine culture grwe enterococcus sensitive to vanco, ampicillin
(pt. allergic to PCN), nitrofurantoin (contraindicated in pt's
w/ crcl <60). He will need to be continued on vancomycin for a
10 day course. Vancomycin levels should be followed at rehab to
ensure therapeutic levels. He is to complete his course of
ciprofloxacin for klebsiella on [**2112-4-4**].
.
#CAD: On admission, he was found to be tachycardic. Cardiac
enzymes were felt to be secondary to tachycardia in the setting
of severe anemia. He had no EKG changes consistent with acute
ischemia nor symptoms of chest pain. He was continued on
metoprolol for improved rate control, aspirin, and lipitor.
.
#Grade 1 Esophagitis: Asymptomatic, but found on endoscopy
performed in the setting of his anemia. H. pylori antibody was
sent which will need to be followed up. He was started on a PPI
to be taken twice daily for 1 week and then once daily
thereafter.
.
#Hyperlipidemia: He was continued on his home dose statin.
.
#PPX: SC Heparin until increasingly ambulatory with physical
therapy.
.
#Access: PICC line placed during this hospitalization.
.
#CODE: FULL
Medications on Admission:
Trimethoprim-Sulfamethoxazole 160-800 mg Tablet daiy
Prednisone 5 mg daily
Doxazosin 4 mg qhs
Lasix 80 mg daily
Norvasc 5 mg daily
Metoprolol 100 mg [**Hospital1 **]
Gabapentin 100 mg twice daily
Sirolimus 3 mg qhs
Mycophenolate Mofetil 500 mg three times daily
NPH insulin 100 units [**Hospital1 **]
Tamsulosin 0.4 mg Capsule, Sust. Release 24HR daily
Lipitor 60 mg daily
Niaspan 500 mg Tablet Sustained Release qhs
Colace
ASA 81 mg daily
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
8. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24
hours).
9. Atorvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous once a day for 10 days.
16. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**])
units Injection QMOWEFR (Monday -Wednesday-Friday).
17. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
5 days.
19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: Following the
completion of twice daily dosing (in 5 days).
20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 34
units qam, 36 units qhs Subcutaneous daily.
21. Humalog 100 unit/mL Solution Sig: sliding scale as directed
Subcutaneous daily.
22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
23. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary:
Diastolic congestive hear failure
Urinary tract infection
Acute on chronic renal failure
Anemia
Diabetes mellitus
.
Secondary:
Coronary artery disease
Hypertension
Hypercholesterolemia
Lung adenocarcinoma
Discharge Condition:
Stable maintaining oxygen saturation on room air. Hematocrit
stable.
Discharge Instructions:
Please call your doctor or return to the emergency room if you
develop worsening shortness of breath, lower extremity swelling,
chest pain, fevers, chills, pain/discomfort with urination,
blood in your stool or any other symptoms that concern you.
.
Please follow up with your appointments as outlined below.
.
Please complete your course of antibiotics as prescribed.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] on Monday [**4-18**] at 2pm.
.
Please follow up with Dr. [**First Name (STitle) 805**] on [**4-26**] at 1:30pm.
.
Please follow up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2112-4-20**] 1:00pm (Hematology/Oncology)
.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14116**] on [**7-1**] at
3:30pm at [**Last Name (un) **] Diabetes Center.
.
Please call Dr.[**Name (NI) 825**] office in order to arrange for
urologic follow up ([**Telephone/Fax (1) 7707**].
.
Appointments scheduled prior to this admission:
1. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2112-4-7**]
10:00
2. Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**]
Date/Time:[**2112-4-7**] 3:30
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
ICD9 Codes: 5990, 5849, 5859, 4280, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2143
} | Medical Text: Admission Date: [**2129-10-14**] Discharge Date: [**2129-10-19**]
Date of Birth: [**2098-3-31**] Sex: M
Service: BMT
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 51946**] is a 31-year-old
male s/p a a sibling matched allogeneic bone marrow
transplant for severe aplastic anemia. His brother was his
donor. The transplant was performed on 04/[**2129**]. The patient
also has a history of gouty arthritis. His brother and father
both have gout. He was recently started on prednisone for
treatment of his gout.
Prednisone was chosen as the patient has had severe
side-effects to Allopurinol therapy. Following the administration
of allopurinol he developed aplastic anemia. While on prednisone
therapy, the patient noted marked improvement in his gouty
arthritis.
Two days prior to admission, he developed a right
eye pain. He noticed multiple vesicles on his right
forehead. This prompted him to go to the [**Hospital1 346**] Emergency Room, where he was noted
to have multiple vesicular lesions in groups on an
erythematous base. The lesions were also found on his neck,
upper back,and chest.
REVIEW OF SYSTEMS: His review of systems were significant
for fever and decreased p.o. intake. He denied any recent
history of cough, pleuritic chest pain, dyspnea, urinary
symptoms, constipation, diarrhea, lower extremity swelling.
PHYSICAL EXAM: Vitals: Temperature 100.0. Heart rate 111.
Blood pressure 164/93. Respiratory rate 16. O2 saturation
96% on room air. HEENT: Right eye erythema with
photophobia. No evidence of diplopia. Visual acuity was
intact bilaterally. Multiple vesicles noted around right
forehead and neck. Vesicles were on an
erythematous base, and were grouped in small clusters. There
was no crossing of the midline. However, these vesicles were
found on several dermatomes. Neck: Supple without jugular
venous distention, no bruits detected, no lymphadenopathy
appreciated. Heart: Normal S1, S2 without murmurs, rubs, or
gallops. Respiration: Lungs were clear to auscultation
bilaterally without wheezes or rhonchi. Abdomen: Soft,
nontender, nondistended, no organomegaly appreciated.
LABORATORIES ON ADMISSION: WBC 9.4, hematocrit 35.9,
platelets 254. Chemistries were a sodium of 132, potassium
4.4, chloride 94, bicarb 27, BUN 15, creatinine 1.1, glucose
103.
HOSPITAL COURSE: On admission to the hospital, the patient's
main complaint was right eye pain and photophobia. An ID
consult was ordered, and Ophthalmology was also consulted.
He was treated with IV acyclovir 10 mg/kg, for disseminated
zoster. In addition, Ophthalmology
also requested that the patient be started on Pred Forte,
erythromycin eye ointment, and homoatropine eyedrops. The
patient was started on these medications as well as
IV fluids.
The following day his sodium was noted to be low at 127. IV
hydration was briefly stopped. However, given the fact that
he was on high-dose acyclovir therapy, we restarted IV
hydration with normal saline at 200 cc/hour. His sodium did
correct by the following day. The patient also noted marked
improvement by day two of hospitalization. His eye was no
longer painful and no new lesions were noted by the patient.
The patient, by day three of hospitalization, no longer
required pain medications for his zoster. The patient,
however, had an exacerbation of his gout during his
hospitalization. Thus, he was started on prednisone again
during his hospitalization. He was initially started on at
10 b.i.d. On this dose, he noted marked improvement in his
gout. No new lesions were observed while on prednisone
therapy.
On discharge, the patient's Pred Forte was discontinued and
he was ordered to take two additional days of erythromycin
eye ointment and home atropine. IV acyclovir was D/C'd, and
the patient was switched to Famvir 500 mg t.i.d. He was
scheduled for a follow-up appointment with Dr. [**First Name (STitle) 1557**] within
one week.
DR.[**First Name (STitle) **],[**First Name3 (LF) 1730**] 12-AHK
Dictated By:[**Name8 (MD) 51947**]
MEDQUIST36
D: [**2129-10-20**] 16:38
T: [**2129-10-21**] 07:48
JOB#: [**Job Number 51948**]
ICD9 Codes: 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2144
} | Medical Text: Admission Date: [**2152-4-28**] Discharge Date: [**2152-5-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
Hypoxia and decreased mental status.
Major Surgical or Invasive Procedure:
Right central line placed. Removed on [**2152-4-30**].
History of Present Illness:
Patinet is an 86 year old woman with COPD on 2L at baseline,
congestive heart failure, and a resident at [**Hospital1 10151**] facility who was transferred due to concern for
decreased mental status and hypoxia. On day of admission, she
developed hypoxia, requiring a 100% NRB to maintain good
saturation. Vitals on transfer were BP 100/60, T 102, and she
was given morphine 8 mg SL. EMS was called and per verbal
report, during transfer SBP dropped to 60s but this responded to
2L NS. According to personnel at rehab center, patient has had
increased difficulty breathing over past week. Treatment was
started with Lasix, albuterol, levofloxacin, and prednisone
taper.
.
In the ED, patient was obtunded and febrile to 101.3 F axillary.
RR was in the 30s, HR was 161, and blood pressure was in the
70-90s. On presentation, a central line was placed under
standard sterile conditions. ED staff noted patient has had
significant diarrhea while there, also witnessed an aspiration
event. She was treated with solumedrol for possible COPD flare,
blood gas obtained which showed ph 7.32, co2 72. Labs in ED
otherwise notable for leukocytosis, bicarbonate 41, creatinine
1.5, and sodium 152.
ED staff discussed with pt's son, her HCP. Confirmed that she is
DNR but would want intubation. She was treated with vancomycin,
ceftriaxone, and metronidazole. 1.4 mg Narcan was given with
some response.
Past Medical History:
-[**Hospital1 5595**] has a [**Location (un) 27292**] epidemic-symptom free for 10 days
-Influenza vaccine [**2151-12-7**]
-COPD/emphysema with CO2 retention: admitted in [**2152-2-14**] to
NEBH with fever, hypoxia and respiratory distress with
improvement with bipap, nebulizers, levoquin and steroids. ABG
on admission in [**2-20**] was 7.38/64/70-per d/c summary report. In
[**2152-2-14**], found to have bilateral lower lobe PNA and
presented with hypotension with BP 83/50 requiring ICU
admission.
-Schizophrenia
-Cataracts, status post iridectomy ROS
-Congestive heart failure: EF 55% and mild pulmonary
hypertension ([**2152-4-13**])
-Vitamin B12 deficiency, with macrocytic anemia
-Dementia
-Bladder spasm
-Urinary incontinece
-Partial lung collapse in [**2149**]
-Diabetes Type II, with creatinine in [**2152-2-14**] of 0.8
Social History:
At baseline, she is able to hold a superficial conversation. Her
memory is quite poor. Dependent for all ADL. She could feed
herself after the tray was set up. Spoke to [**First Name8 (NamePattern2) 47532**] [**Last Name (NamePattern1) 4894**] at
[**Hospital 100**] Rehab who notes that patient is dependent in all ADLS
except feeding. Total care. Been at [**Hospital1 5595**] for 2 weeks.
Family History:
Noncontributory.
Physical Exam:
(on admission to MICU):
Vitals: Tm = 97.0 on the floor and 103.8 in the ED, Tc = 95.5,
83/31, CVP= 10, HR 71-82,
AC 30%, PEEP = 10, VT = 400s, 7.28/64/48
GEN: Elderly female who appears younger than her stated age
NECK: No LAD
HEENT: PEERLA
CARD: nml S1, S2, distant heart sounds.
CHEST: Coarse breaths sounds with upper airway sounds
ABD:nabs, soft nt.
EXT: no edema.
NEURO: obeys simple commands
SKIN: No obvious wounds or rashes.
Pertinent Results:
Images:
-Chest Xray ([**2152-4-28**]): Evidence of congestive heart failure.
There may be superimposed pneumonia versus atelectasis of the
right middle lobe.
.
-Cardiac ECHO ([**2152-4-29**]): EF >55%. Right atrial pressure
11-15mmHg. Dilated RV cavity with RVH suggestive of chronic
pulmonary
hypertension. Normal RV systolic function suggests no acute (on
chronic) RV strain.
.
-Head CT ([**2152-4-28**]): 1. No hemorrhage or mass effect. 2.
Chronic microvascular infarction.
.
EKG ([**2152-4-28**]): SVT at 161 bpm.
.
.
MICRO:
Blood culture ([**4-28**], [**4-30**]): Negative to date.
.
Urine ([**2152-4-28**] and [**2152-4-30**]): Negative.
.
Stool ([**2152-4-28**]): NO CAMPYLOBACTER FOUND. NO E.COLI 0157:H7
FOUND. FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
.
LABS:
[**2152-5-2**] 07:00AM BLOOD WBC-11.5* RBC-3.01* Hgb-10.0* Hct-29.8*
MCV-99* MCH-33.1* MCHC-33.4 RDW-16.0* Plt Ct-289
[**2152-5-1**] 10:01AM BLOOD WBC-11.1* RBC-2.83* Hgb-9.4* Hct-28.0*
MCV-99* MCH-33.3* MCHC-33.6 RDW-16.1* Plt Ct-268
[**2152-4-28**] 10:30AM BLOOD WBC-14.1* RBC-3.20* Hgb-10.4* Hct-33.5*
MCV-105* MCH-32.6* MCHC-31.1 RDW-15.9* Plt Ct-317
[**2152-4-29**] 02:51AM BLOOD Neuts-88.6* Lymphs-9.8* Monos-1.5*
Eos-0.1 Baso-0
[**2152-4-28**] 10:30AM BLOOD Neuts-76.7* Lymphs-17.2* Monos-5.5
Eos-0.5 Baso-0.2
[**2152-5-2**] 07:00AM BLOOD Plt Ct-289
[**2152-5-2**] 07:00AM BLOOD PT-12.2 PTT-38.0* INR(PT)-1.0
[**2152-4-28**] 10:30AM BLOOD PT-12.4 PTT-25.8 INR(PT)-1.1
[**2152-5-2**] 07:00AM BLOOD Glucose-154* UreaN-18 Creat-0.7 Na-147*
K-4.4 Cl-108 HCO3-31 AnGap-12
[**2152-4-28**] 10:30AM BLOOD Glucose-87 UreaN-60* Creat-1.4* Na-154*
K-4.4 Cl-108 HCO3-37* AnGap-13
[**2152-4-28**] 05:20PM BLOOD ALT-22 AST-36 LD(LDH)-250 CK(CPK)-158*
AlkPhos-44 TotBili-0.2
[**2152-4-28**] 05:20PM BLOOD CK-MB-8 cTropnT-<0.01 proBNP-5066*
[**2152-4-28**] 10:30AM BLOOD CK-MB-4 cTropnT-0.05*
[**2152-5-2**] 07:00AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.3
[**2152-4-28**] 10:30AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.7*
[**2152-5-1**] 04:24PM BLOOD Type-ART pO2-71* pCO2-53* pH-7.47*
calTCO2-40* Base XS-12
[**2152-4-28**] 10:41AM BLOOD Type-ART pO2-167* pCO2-73* pH-7.34*
calTCO2-41* Base XS-10
[**2152-5-1**] 10:15AM BLOOD Type-ART pO2-67* pCO2-58* pH-7.46*
calTCO2-42* Base XS-14 Intubat-NOT INTUBA
[**2152-4-30**] 08:23AM BLOOD Type-ART Temp-37.6 pO2-80* pCO2-58*
pH-7.42 calTCO2-39* Base XS-10 Intubat-NOT INTUBA
[**2152-4-30**] 04:15AM BLOOD Type-MIX pO2-33* pCO2-56* pH-7.39
calTCO2-35* Base XS-6
[**2152-4-28**] 02:16PM BLOOD Type-ART pO2-96 pCO2-71* pH-7.31*
calTCO2-37* Base XS-5
[**2152-5-1**] 04:24PM BLOOD Glucose-152* Lactate-1.72 Na-141 K-4.1
Cl-99* calHCO3-38*
[**2152-5-1**] 04:24PM BLOOD freeCa-1.19
[**2152-5-1**] 10:15AM BLOOD freeCa-1.21
Brief Hospital Course:
Hospital Course/Assessment/Plan:
Patient is an 86 year old woman with COPD, CHF, who was
transferred for an acute respiratory hypercarbic hypoxemic
failure thought to be due to COPD exacerbation. Patient with
pronounced diarrhea, with cultures negative. Hypernatremic and
resolving renal failure. Cultures to date negative.
.
.
1)Infectious Process:
On admission to the MICU, patient thought to have sepsis and
severe hypovolemia in the setting of diarrhea. Concern for
aspiration pneumonia or infectious diarrhea. Reccurent episodes
of pneumonia and COPD exacerbation concerning for potential
aspiration.
-In MICU, required IV fluids and neosynephrine. CVP 10-14.
Received solumedrol in ED. Initially, started broad spectrum
vancomycin, ceftriaxone, and flagyl. Urine, blood, and stool
cultures negative. Patient came from nursing home where large
outbreak of [**Location (un) **] virus.
-Speech and swallow performed video swallowing study, as concern
for aspiration pneumonia. Patient will need to continue on
pureed solids and thick liquids to prevent aspiration.
-Will be discharged on levofloxacin for four more days for COPD
exacerbation.
.
2)Respiratory Distress:
Hypercarbic and hypoxemic repsiratory failure most likely
secondary to COPD flare. Previous ABGs revealed carbon dioxide
retention. Cardiac ECHO on [**4-29**] revealed elevated right atrial
pressure and dilated right ventricle, consistent with pulmonary
hypertension. Placed on bi-pap initially, but on discharge
tolerating 2L nasal canula. At baseline, patient requires
supplemental oxygen.
-Patient to continue on levofloxacin and prednisone, as
respiratory distress most consistent with COPD exacerbation.
Will continue prednisone for four more days. 40mg for the next
two days and then 20mg for the following two days. Patient will
also complete four more days of levofloxacin.
-Patient will be discharged on lasix 40mg daily, PRN for
pulmonary congestion.
.
3)Hypernatremia:
On admission, appeared hypovolemic, in setting of diarrhea.
Patient with dementia, so difficult to maintain adequate
hydration. Initially, calculated free water deficit of 3.9
liters. Continued to gently hydrate with IV fluids and follow
serum sodium levels. By discharge, sodium corrected at 147.
Continue to encourage PO liquid supplementation.
.
4)Diarrhea:
Patient from nursing home where previous norovirus outbreak.
Sent stool cultures for C. dificile and cultures. Initially
started metronidazole for empiric coverage.
-Patient's diarrhea resolved on discharge. Stool cultures
negative to date.
.
5) Altered Mental Status:
Underlying schizophrenia and dementia. Improved mental status
with improved ventilation. Head CT negative for intracranial
hemorrhage. Vitamin B12 864. Depakote level 16. Initially
held all psychotropic medications for schizophrenia, but
restarted on [**4-29**].
.
6) Acute renal insufficiency:
On presentation, creatinine 1.4, with baseline creatinin
0.8-1.0. With IV fluids, creatinine improved to 0.7.
.
7) Anemia:
Patient with history of macrocytic anemia on B12
supplementation. Iron studies on [**2152-4-4**] demonstrated ferritin
127, TIBC 246, iron 53.
.
8) Diabetes:
Placed on insulin sliding scale. Switched to glargine 10 and
humalong sliding scale.
-On discharge, will need to continue to monitor blood sugars, as
patient receiving prednisone.
.
9) Prophylaxis:
Placed on PPI and heparin subcutaneously. Previously colonized
with MRSA, so placed on precautions.
.
10) Code:
HCP: [**Name (NI) 25812**] [**Name (NI) **] [**Telephone/Fax (1) 61335**].
DNR, but can intubate for short periods of time.
Medications on Admission:
-albuterol
-Vitamin C
-Aricept
-Lasix 40 mg po qd
-Levofloxacin ([**2152-4-26**]->[**2152-5-3**])
-Morphine oral q4
-Magnexium oxide
-Ditropan
-Prednisone 40 mg as part of taper started at prednisone 60 mg
po qd on [**2152-4-26**]
-Risperdal 1 mg [**Hospital1 **]
-Depakote 500 qam
-Depakote 250 q pm
-Trazadone 50 mg po qhs
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
3. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QPM (once a day (in the
evening)).
4. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
q6hr PRN as needed for shortness of breath or wheezing.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
q6hr PRN as needed for shortness of breath or wheezing.
9. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
10. Ditropan 5 mg Tablet Sig: One (1) Tablet PO once a day.
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as
needed for shortness of breath or wheezing.
13. MEDICATION
Continue on insulin sliding scale (see attached)
14. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 2 days: Give 40 mg on [**5-3**] and [**5-4**].
15. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Give 20mg on [**5-5**] and [**2152-5-6**]. No
further prednisone after [**5-6**] required.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
-COPD exacerbation
.
Secondary:
-Schizophrenia
-Cataracts, status post iridectomy
-Congestive heart failure: EF 55% and mild pulmonary
hypertension ([**2152-4-13**])
-Vitamin B12 deficiency, with macrocytic anemia
-Dementia
-Bladder spasm
-Urinary incontinece
-Partial lung collapse in [**2149**]
-Diabetes Type II
-Influenza vaccine [**2151-12-7**]
Discharge Condition:
Stable.
Discharge Instructions:
-You were admitted for hypoxia and decreased mental status. You
were started on a bi-pap machine. Most likely, you had an
exacerbation of your underlying COPD. Antibiotics were started
and you will continue on levofloxacin for four more days.
Prednisone will be continued for four more days (40mg per day on
[**5-3**] and [**5-4**], followed by 20mg per day on [**5-5**] and [**5-6**]).
-Continue on all medications prescribed on discharge. Lasix can
be used for increased edema or pulmonary congestion.
-You should continue to be followed by an attending physician at
your facility.
-If you experience any chest pain, shortness of breath, or any
other concerning symptoms, call your PCP or come to the ED
immediately.
Followup Instructions:
-You should continue to be followed by an attending physician at
your facility.
ICD9 Codes: 0389, 4280, 2760, 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2145
} | Medical Text: Admission Date: [**2163-6-23**] Discharge Date: [**2163-7-7**]
Date of Birth: [**2116-5-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
nausea, vomiting, diarrhea, and anemia
Major Surgical or Invasive Procedure:
Exploratory laparotomy, cholecystectomy, gastrojejunostomy tube
placement.
History of Present Illness:
The patient is a 47 y/o female who presented to the ED early on
the morning of [**2163-6-23**] with complaints of nausea, vomiting,
diarrhea, and anemia. Before any history could be obtained, she
became hypotensive, tachycardic, and hemodynamically unstable.
She had a large brown heme positive bowel movement. She was
intubated, started on neosynephrine and levophed, and given 6L
of saline and 2u pRBC.
Past Medical History:
severe alcoholism
cocaine use
Social History:
unknown
Family History:
non-contributory
Physical Exam:
T 97.9 R 119 BP [**10/2147**] R 31
AC 500/18/5/100%
Gen: Intubated, awake, in distress, not following commands
Lungs: rhonchi throughout
Heart: Regular rate and rhythm, tachycardic
abd: distended, diffusely tender, rebound tenderness, guarding
difficult to assess, no incisional scars
extrem: cool, dry, 1+ pulses, no edema
Pertinent Results:
[**2163-6-23**] 02:30AM BLOOD WBC-8.8 RBC-3.21*# Hgb-8.7*# Hct-26.6*#
MCV-83 MCH-27.1 MCHC-32.6 RDW-17.3* Plt Ct-79*
[**2163-6-23**] 02:30AM BLOOD Neuts-65 Bands-12* Lymphs-17* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* NRBC-1*
[**2163-6-23**] 02:30AM BLOOD PT-16.8* PTT-45.9* INR(PT)-1.5*
[**2163-6-23**] 02:30AM BLOOD Plt Smr-VERY LOW Plt Ct-79*
[**2163-6-23**] 01:59PM BLOOD Fibrino-400
[**2163-6-23**] 02:30AM BLOOD Glucose-61* UreaN-47* Creat-2.9*# Na-137
K-3.1* Cl-96 HCO3-5* AnGap-39*
[**2163-6-23**] 02:30AM BLOOD ALT-296* AST-2805* AlkPhos-520*
Amylase-211* TotBili-1.3
[**2163-6-23**] 02:30AM BLOOD Lipase-9
[**2163-6-23**] 11:28AM BLOOD CK-MB-9 cTropnT-0.09*
[**2163-6-23**] 01:59PM BLOOD CK-MB-9 cTropnT-0.08*
[**2163-6-23**] 08:21PM BLOOD CK-MB-10 MB Indx-2.9 cTropnT-0.08*
[**2163-6-23**] 02:30AM BLOOD Albumin-2.4* Calcium-3.5* Phos-11.5*
Mg-1.0*
[**2163-6-23**] 02:30AM BLOOD Osmolal-299
[**2163-6-23**] 04:30AM BLOOD Cortsol-48.7*
[**2163-6-23**] 02:30AM BLOOD HCG-<5
[**2163-6-23**] 04:30AM BLOOD CRP-84.9*
[**2163-6-23**] 04:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2163-6-23**] 04:30AM BLOOD Comment-GREEN TOP
[**2163-6-23**] 04:30AM BLOOD Lactate-5.3*
[**2163-6-23**] 07:50AM BLOOD freeCa-0.45*
[**2163-6-23**] 01:37PM BLOOD ALCOHOL PROFILE-TEST: METHANOL - RESULT:
NONE DETCTED
[**2163-6-23**] 01:37PM BLOOD ETHYLENE GLYCOL-TEST: ETHYLENE GLYCOL
RESULT: <10 REFERENCE RANGE/UNITS <10 MG/DL
[**2163-6-25**] 12:33PM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2163-7-5**] 06:07AM BLOOD WBC-18.0* RBC-2.91* Hgb-8.7* Hct-25.5*
MCV-88 MCH-30.1 MCHC-34.2 RDW-17.5* Plt Ct-137*
[**2163-7-5**] 06:07AM BLOOD Glucose-94 UreaN-34* Creat-2.6* Na-144
K-3.3 Cl-110* HCO3-16* AnGap-21*
[**2163-7-5**] 06:07AM BLOOD Calcium-6.1* Phos-4.0 Mg-1.6
[**2163-6-30**] 11:47AM BLOOD Glucose-84 Lactate-1.0
[**2163-6-29**] 02:30AM BLOOD ALT-30 AST-20 AlkPhos-155* TotBili-1.2
[**2163-6-23**] 07:54PM URINE RBC-0-2 WBC-[**6-4**]* Bacteri-MOD Yeast-NONE
Epi-[**2-27**] TransE-0-2 RenalEp-0-2
[**2163-6-23**] 07:54PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2163-6-23**] 07:54PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2163-6-23**] 2:40 am URINE Site: CATHETER
**FINAL REPORT [**2163-6-24**]**
URINE CULTURE (Final [**2163-6-24**]):
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
2ND ISOLATE. <10,000 organisms/ml.
Time Taken Not Noted Log-In Date/Time: [**2163-6-23**] 4:15 am
BLOOD CULTURE
**FINAL REPORT [**2163-6-29**]**
AEROBIC BOTTLE (Final [**2163-6-25**]):
[**2163-6-24**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) 3239**] [**Last Name (NamePattern1) 39466**] AT 4:00 AM.
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
IMIPENEM-------------- 2 S
MEROPENEM------------- 0.5 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2163-6-29**]): NO GROWTH.
Brief Hospital Course:
Patient was admitted in acute respiratory distress,
resuscitated, and transferred to the ICU for supportive care.
The patient was treated empirically with vancomycin, levoquin,
and metronidazole and transfused 2 units frozen plasma for
active GI bleed with severe shock. Blood culture [**6-23**] grew
pan-sensitive pseudomonas and urine culture grem alpha hemolytic
or lactobacillus.
CT scan showed
1. Diffuse wall abnormality with irregular wall thickening seen
throughout the small and large bowel. This finding is more
consistent with diffuse intramural hemorrhage. Question bleeding
diathesis. Less likely, this could represent an infectious
etiology or ischemic etiology. Contrast is seen extending into
the hepatic flexure with no evidence of obstruction.
2. Bilateral consolidations consistent either with infection or
aspiration.
3. Gallstones with mildly distended gallbladder. No definite
evidence of wall thickening.
4. Bulky calcifications within the pancreas with no acute
inflammatory changes. Question history of chronic pancreatitis.
5. Tiny nonobstructive right kidney stone.
6. A small amount of ascites.
7. Diffuse osteopenia and sclerosis, which could be secondary
signs of chronic renal failure.
The patient's lactate and WBC continued to rise. There was a
likelihood that the patient had an ischemic or infected bowel
and an ex-lap, cholecystectomy, and open G/J tube placement was
performed to examine the patient's abdomen. Global
hypoperfusion of the bowel was found during the operation. The
etiology of the patient's acidosis remained unclear and ICU
supportive care was continued. Tube feeds and Zosyn were
started post-operatively.
Echo was obtained to investigate possible cardiac etiology which
showed: The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular
systolic function is low normal (LVEF 50%). No masses or thrombi
are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial
effusion.
The patient continued to be in oliguric renal failure consistent
with ATN and renal was consulted for advice. The patient was
weaned off vasopressors [**2163-6-24**] and transfused 1 unit of
platelets [**2163-6-25**] and [**2163-6-26**] for her thrombocytopenia which was
likely related to sepsis with a small element of DIC. Pt did
not require dialysis as she began to have good urine output and
her renal failure began to resolve. Renal ultrasound showed
tiny simple cyst within the right kidney, otherwise normal renal
ultrasound without evidence for hydronephrosis or stones.
Antibiotics were discontinued [**2163-6-28**] with the exception of
Zosyn. Pt was able to be weaned off the vent and started on
flagyl for empiric treatment of C. diff colitis [**6-30**]. CXR showed
basilar atelectasis and effusion and incentive spirometry was
encouraged. Pt was started on a regular diet and tolerated that
well and was transferred to the floor [**7-3**]. She refused her tube
feeds because it made her "too full" and is discharged to rehab
tolerating a regular diet.
Medications on Admission:
vitamin B12
tums
neurontin
vit D
oxycodone
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
2. Zosyn 2.25 g Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 3 days.
Disp:*9 Recon Soln* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. HydrALAZINE HCl 10 mg IV Q4-6H:PRN keep SBP<140
hoold for SBO<100
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
Disp:*30 actuations* Refills:*0*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY
(Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*2*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
12. Oxycodone 5 mg/5 mL Solution Sig: [**12-27**] PO Q4-6H (every 4 to
6 hours) as needed.
Disp:*100 mL* Refills:*0*
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
14. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 16662**] - [**Street Address(1) **]
Discharge Diagnosis:
alcoholic ketoacidosis, bowel ischemia vs. infected bowel,
sepsis
Discharge Condition:
stable
Discharge Instructions:
Call your doctor if you experience fever, chills,
lightheadedness, dizziness, shortness of breath, chest pain,
palpitations, severe abdominal pain, nausea/vomiting, or
bleeding from abdominal incision.
Do not swim or take baths.
Activity as tolerated.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in 1 week. Call [**Telephone/Fax (1) 2359**] for
appointment.
Please follow up with your primary care physician at [**Name9 (PRE) **]
Community Center in 1 week. Cal [**Telephone/Fax (1) 15982**] for appointment.
ICD9 Codes: 0389, 5845, 2762, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2146
} | Medical Text: Admission Date: [**2105-3-7**] Discharge Date: [**2105-3-20**]
Date of Birth: [**2035-12-6**] Sex: M
Service: MEDICINE
Allergies:
pseudoephedrine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 3265**] is a 69y M with a history of C5/C7 injury 25 yrs ago
from a fall, who had a trach placed 3 years ago following a PNA
but is non-ventilator dependent living at home with 24 hr VNA,
who was found to be difficult to arouse by his VNA at 6 am this
morning. Per report by his wife, he had become increasingly
lethargic yesterday and was noted to have decreased urine output
(200cc for the day) despite pushing increased PO fluids. He has
a chronic indwelling foley catheter. He also had some nausea
and temp 99.7, but otherwise denies cough, shortness of breath,
URI symtpoms, emesis, diarrhea, abdominal pain. He was
vaccinated for flu this fall and had pneumovax 2 yrs ago. He is
followed by pulmonologist Dr. [**Last Name (STitle) **] at [**Hospital1 112**]. Of note he does
have a history of MRSA/klebsiella pna treated at [**Hospital1 112**]? as well as
UTI with citrobacter/ecoli/kleb/staph per record from [**Hospital1 882**].
.
This morning, when EMS arrived he was ambu-bagged and suctioned
at home then brought to [**Hospital 882**] hosp were he was noted to have
thick secretions and placed on vent via his trach, settings A/C
12, volume 450cc, FiO2 50%, 5 PEEP. He was noted to be hypoxic
and hypotensive to 81/50 and was resuscitated with 3L NS, which
improved his BP to 106/70. Chest X ray at [**Hospital1 882**] showed LLL
and RML pna. WBC was 18.9 and sodium was 118, urine na was 22.
Bld and urine cx were obtained. He was given levaquin and it
patient received flagyl. He was going to be transferred to [**Hospital1 112**],
but there were no ICU beds available so he was transferred to
[**Hospital1 18**] for ICU level care.
.
In the ED at [**Hospital1 18**] VS were 96.9 95/56 80 12 97% He was
alert and answering questions. He received 1 L IVF and 2 gm
cefepime. CXR showed right middle and lower lobe whiteout. Na
126 (improved from 118 at OSH).
.
On arrival to the ICU the patient's vent settings were: Pressure
support, 16/5, FI02 50%. Pt was alert and denied complaint.
.
ROS: As per HPI: Also denies history of cardiac problems, rash,
change in bowel habbits, muscle or joint pain, headache, vision
changes.
.
Past Medical History:
PUD
HL
SIADH
Hypothyroid
C5/C7 injury with resulting lower extremity paralysis
Aspiration pneumonia s.p trach placement in [**2102**]
MRSA/Klebsiella PNA
ESBL UTI
Social History:
Mr. [**Known lastname 3265**] is married with children. He lives at home in W
[**Location (un) 669**] with his wife and has 24 hr a day VNA care. He is
bedbound from his C5-C7 spinal cord injury but has movement of
his left hand and minimal movement of his right hand, which is
fused. He used to work as a carpenter prior to the injury. He
denies smoking or etoh use.
Family History:
non contributory
Physical Exam:
On Admission:
VS: Temp: 98.3 BP: 119/51 HR: 69 RR: 17 95%b O2sat
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd
RESP: rhonchorous breath sounds throughout lungs
CV: RR, difficult to appreciate heart sounds
ABD: distended ad tympanic abdomen, +b/s, no tenderness
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. o/5 strength in lower
extremities blaterally although able to move left toe minimally.
[**4-11**] RUE strength with fused hand, [**5-12**] left UE strength.
Pertinent Results:
OSH labs
WBC 18.9 - 95% neut
Na 118, K 3.7, Cl 83, Co2 28, BUN 15, Cr 0.36
Glucose 159
trop T 0.012, TSH 4.25, albumin 2.9, LFTs WNL, INR 1.1
.
UA hazy, small leuks, nitrite neg, Ket 15, [**12-27**] WBC, 3+
bacteria, 2+ mucus, 2 gran casts
.
urine Na 22, K 43, Cl 36
.
[**Hospital1 18**] Labs
[**2105-3-7**] 11:05AM WBC-18.9*# RBC-3.27* HGB-9.4*# HCT-27.8*#
MCV-85# MCH-28.8 MCHC-33.8 RDW-14.8
[**2105-3-7**] 11:05AM NEUTS-93.6* LYMPHS-2.0* MONOS-3.8 EOS-0.4
BASOS-0.1
[**2105-3-7**] 11:05AM PLT COUNT-290
[**2105-3-7**] 11:05AM PT-14.2* PTT-31.0 INR(PT)-1.2*
[**2105-3-7**] 11:05AM GLUCOSE-113* UREA N-11 CREAT-0.2* SODIUM-126*
POTASSIUM-3.6 CHLORIDE-97 TOTAL CO2-20* ANION GAP-13
[**2105-3-7**] 11:25AM GLUCOSE-116* LACTATE-1.0 K+-3.5
[**2105-3-7**] 11:25AM TYPE-ART RATES-/12 TIDAL VOL-450 PEEP-5
PO2-110* PCO2-35 PH-7.44 TOTAL CO2-25 BASE XS-0 -ASSIST/CON
INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
[**2105-3-7**] 11:20PM URINE HOURS-RANDOM CREAT-48 SODIUM-10
POTASSIUM-65 CHLORIDE-82
[**2105-3-7**] 11:20PM URINE OSMOLAL-561
[**2105-3-7**] 11:05AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2105-3-7**] 11:05AM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2105-3-7**] 11:05AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
.
Micro:
Urine cx: GNR>100,000
Pleural fluid:
[**2105-3-9**] 07:01PM PLEURAL WBC-475* RBC-2140* Polys-98* Lymphs-0
Monos-2*
[**2105-3-9**] 07:01PM PLEURAL TotProt-4.4 Glucose-46 LD(LDH)-1286
No PMNs or organisms on Gram stain
.
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
[**Hospital1 18**] LABS
MICRO:
urine cx - >100,000 GNR
[**Hospital1 **] cx - NGTD
.
STUDIES/IMAGING:
EKG: NSR 96 bpm, nml axis, 1st degree AV block, no ST changes
.
CXR: [**3-7**]
IMPRESSION: Right mid and lower lung opacification, concerning
for
consolidation, pneumonia and or atelectasis, and effusion.
Followup to
resolution.
.
[**2105-3-14**] sputum: PSEUDOMONAS AERUGINOSA
STENOTROPHOMONAS (XANTHOMONAS) MALTOPH
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
[**2105-3-7**] sputum: PSEUDOMONAS AERUGINOSA
| STENOTROPHOMONAS (XANTHOMONAS)
MALTOPH
| | PSEUDOMONAS
AERUGINOSA
| | |
CEFEPIME-------------- 8 S <=1 S
CEFTAZIDIME----------- 8 S 4 S 2 S
CIPROFLOXACIN--------- =>4 R 1 S
GENTAMICIN------------ 8 I <=1 S
LEVOFLOXACIN---------- <=1 S
MEROPENEM------------- 0.5 S 0.5 S
PIPERACILLIN/TAZO----- 32 S 16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=2 S
LEGIONELLA CULTURE (Final [**2105-3-14**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
[**2105-3-7**] urine:
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
69M with history significant for C5-C7 spinal injury bed bound
with trach and chronic foley who presented to OSH with altered
mental status, low urine output, hypotension, and was found to
have right and lower lobe infiltrates on CXR and development of
loculated pleural effusion, on pressure-support ventilation.
.
# Right and Middle lobe PNA: Patient with chronic trach, placed
on pressure support ventilation on admission. CXR showed absence
of right heart border and diaphragmatic border with interstitial
opacity concerning for pneumonia versus collapsed lung. Given
pt lives at home with no recent hospitalizations he was covered
for CAP however due to history of MRSA PNA, as well ESBL UTI
empirically covered with vancomycin and meropenem. Sputum
culture with GNRs and returned with pseudomonas and
stenotrophomonas. The pseudomonas was resistant to meropenem but
susceptible to ciprofloxacin. He should receive a 15 day course
of ciprofloxacin (day [**5-22**]). In regards to stenotrophomonas the
patient was started on bactrim (day [**7-22**]) and should receive a
15 day course of that medication as well.
.
#. Pleural effusion: Evidence of loculation on chest-x-ray and
CT scan. He had an U/S guided pigtail catheter insertion which
did not drain well. Labs were consistent with exudative effusion
with pH of 6.85 and elevated LDH of 1228. He underwent VATs with
2 chest tubes placed. The chest tubes were eventually
discontinued and pleural fluid was without growth.
.
# UTI: Pt has remote history of ESBL in urine and currently has
chronic indwelling foley catheter. Foley was changed at OSH. UA
from OSH with 100,000 gram negative rods, speciated to E. coli,
resistance to quinolones and Bactrim, sensitive to the penems.
Urine culture on admission to [**Hospital1 **] with >100,000 of speciated
E.coli, with sensitivity profile similar to [**Hospital1 882**] cultures.
He will be treated with a 14 day course of meropenem (day
[**1-21**]).
.
# Hypoxic respiratory failure: The patient had a chronic trach
at home although did not require ventilation. Upon presentation
he required mechanical ventilation for respiratory support. With
treatment of infection, aggressive chest PT with
insuflator/exsuflator we were able to wean to trach collar
during day with mechanical ventilation overnight at pressure
support [**6-11**], FiO2 40%. His SaO2 are 86-88 at baseline per
report. He did develop acute hypoxemia which was secondary to
mucous plug. This improved with chest physical therapy and
suctioning.
.
# Hypotension: Initially related to hypovolemia. The patient had
intermittent hypotension which was thought to be secondary to
decreased salt intake and autonomic dysregulation. HCT remained
relatively stable. The patient was started on salt tabs with
improved [**Month/Day (1) **] pressure. The patient remained asymptomatic even
during periods of relative hypotension. [**Name2 (NI) **] cultures remained
negative.
.
# L DVT: Unclear [**Name2 (NI) 99474**]. The patient was started on heparin
gtt for 48 hours without dropping hct. Switched to lovenox 60mg
[**Hospital1 **] while bridged to warfarin. INR currently subtherapeutic.
Will need monitoring and titration or warfarin dosing.
.
# L hip pain and displaced femoral neck fracture: Ortho
following. Hip fx old from 4-5 years ago but pt having increased
pain concerning for acute process such as displacement or
infection. Ortho evaluated and recommended pain management
without further imaging at this time.
.
# Anemia: Patient has normocytic anemia. Transfused s/p VATS and
slowly trending down. Guaiac negative. Likely anemia of chronic
disease.
.
# S/P C5-C7 spinal cord injury: continued neurontin, bisacodyl
suppositories, colace, senakot, lactulose, will add enemas prn
constipation, ditropan. He has a baclofen pump which will need
to be refilled prior to [**2105-4-3**]. This will need to be done
through [**Hospital1 112**] pain clinic.
Medications on Admission:
Medications at home:
ASA 81mg
Levothyroxine 75mcg
Prilosecmg
artifical tears to both eye TID
neurontin 400mg TID
bisacodyl 10mg PR every other day and prn (with bowel
stimulation)
Flonase spray to each nostril Qday
Colace 6 tabs every other PM with dinner
senakot 6 tabs every other PM with dinner
valium 5mg HS
ditropan 10mg XL qday
Nystatin poweder TID prn yeast infection
Ambien 5mg HS
Xenoderm ointment QID to pressure sore
baclofen pump
miralax 17g in 8 oz water every other day
Hydrocortisone 1% to penis prn rash
MV qday
Mortrin 200mg prn pain
Tyelnol 500mg 1-2 tabs prn pain
Preparation H prn
Metamucil Fiber Wafer 9-12g PO every other day
.
Medications at transfer:
Vancomycin 1000 mg IV Q 8H
Magnesium Sulfate IV Sliding Scale
Potassium Phosphate Replacement (Oncology) IV Sliding Scale
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Insulin SC (per Insulin Flowsheet) Sliding Scale
Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY
Docusate Sodium (Liquid) 600 mg PO/NG EVERY OTHER DAY
in PM, hold for loose stool
Multivitamins 1 TAB PO/NG DAILY liquid
Hydrocortisone Cream 1% 1 Appl TP [**Hospital1 **]:PRN
Polyethylene Glycol 17 g PO/NG EVERY OTHER DAY:PRN constipation
Miconazole Powder 2% 1 Appl TP TID:PRN yeast infection
Oxybutynin 5 mg PO BID
Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Diazepam 5 mg PO/NG HS hold for sedation, rr<12
Senna 6 TAB PO/NG EVERY OTHER DAY constipation
give in PM, hold for loose stool
Fluticasone Propionate NASAL 2 SPRY NU DAILY
one spray in each nostril= 2 sprays total/day
Bisacodyl 10 mg PR EVERY OTHER DAY
hold for loose stool [**3-8**] @ 1430 View
Gabapentin 400 mg PO/NG TID
Artificial Tears 1-2 DROP BOTH EYES TID [**3-8**] @ 1430 View
Azithromycin 250 mg IV Q24H
Acetaminophen 650 mg PO/NG Q6H:PRN fever
Meropenem 500 mg IV Q6H
Heparin 5000 UNIT SC TID
Bisacodyl 10 mg PR HS:PRN constipation
Levothyroxine Sodium 75 mcg PO/NG DAILY
Aspirin 81 mg PO/NG DAILY
Discharge Medications:
1. levothyroxine 75 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
2. bisacodyl 10 mg Suppository [**Month/Year (2) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. acetaminophen 650 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Month/Year (2) **]: [**2-8**]
Drops Ophthalmic TID (3 times a day).
5. gabapentin 400 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO TID (3
times a day).
6. fluticasone 50 mcg/Actuation Spray, Suspension [**Month/Day (2) **]: Two (2)
Spray Nasal DAILY (Daily).
7. senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day) as needed for constipation.
8. diazepam 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime).
9. zolpidem 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. oxybutynin chloride 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
11. polyethylene glycol 3350 17 gram/dose Powder [**Month/Day (2) **]: One (1)
PO EVERY OTHER DAY (Every Other Day) as needed for constipation.
12. therapeutic multivitamin Liquid [**Month/Day (2) **]: One (1) Tablet PO
DAILY (Daily).
13. docusate sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: 600mg PO EVERY OTHER
DAY (Every Other Day).
14. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. glucagon (human recombinant) 1 mg Recon Soln [**Last Name (STitle) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
16. chlorhexidine gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: One (1) ML
Mucous membrane TID (3 times a day).
17. baclofen Intrathecal
18. oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
19. nystatin 100,000 unit/g Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12hrs
on 12 hrs off.
21. lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
22. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension [**Hospital1 **]:
Fifty (50) ML PO TID (3 times a day).
23. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed for rash.
24. sodium chloride 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day).
25. ciprofloxacin 250 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Q12H
(every 12 hours).
26. warfarin 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at
4 PM.
27. enoxaparin 60 mg/0.6 mL Syringe [**Hospital1 **]: 60mg Subcutaneous Q12H
(every 12 hours).
28. acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: Three (3) ML
Miscellaneous Q2H (every 2 hours) as needed for mucous plug.
29. meropenem 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous Q6H (every 6 hours).
30. dextrose 50% in water (D50W) Syringe [**Hospital1 **]: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
31. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
32. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
33. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Pneumonia, empyema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with a pneumonia. You were also found to have
a urinary tract infection. You were started on meropenem,
ciprofloxacin and bactrim. These antibiotics will need to be
continued (as described below). During your hospitalization you
had a video assisted thorascopy and bronchoscopy to evaluate
your respiratory status. The VATs helped drain a pulmonary
effusion. The bronchoscopy was for a mucous plug. Your
respiratory status improved and you were on trach collar during
the day and requiring pressure support [**6-11**], FiO2 40% overnight.
You were discharged to a long term acute care unit for further
weaning of your ventilation and continued antiobiotics.
.
You are on day [**1-21**] of meropenem. Day [**7-22**] of bactrim. Cipro
day [**5-22**]. These should be continued for the rest of the course.
.
You will need to have a follow up appointment with [**Hospital1 112**] pain
clinic for a baclofen pump refill. This will need to be done
prior to [**2105-4-3**] when your baclofen pump will run out. It is
very improtant that you make this appointment.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2105-4-28**] 9:30 [**Hospital1 **] 116
Get a chest xray 30 minutes prior to your followup on [**Location (un) 470**]
clinical center.
.
[**Hospital1 112**] pain clinic for refill of baclofen pump. This needs to be
done prior to [**2105-4-3**].
ICD9 Codes: 5119, 5990, 2761, 4019, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2147
} | Medical Text: Admission Date: [**2165-7-30**] Discharge Date: [**2165-8-16**]
Date of Birth: [**2098-12-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
66yo male found to have Asc Ao aneurysm by CT done for workup of
several month complaint of cough.
Direct admit to operating room after preop evaluation in CT [**Doctor First Name **]
clinic
Major Surgical or Invasive Procedure:
s/p Ascending aortic hemiarch replacement(32mm
Gelweave)/AVR(27mm CE Magna pericardial) [**2165-7-30**]
History of Present Illness:
found to have ascendin aortic aneurysm by chest CT done to w/u
complaint of cough x several months. History of previous
Aorto-bifem bypass graft
Past Medical History:
2+AI,6.4 cm Aortic aneurysm
hypertention
^cholesterol
Mitral valve prolapse
Basal cell skin CA
L hernia repair
Aorto-bifem graft-[**2162**]
Elbow ORIF
Social History:
Maintenance worker part time
Married lives with wife
[**Name (NI) 1139**]: 40 pack years, currently 6 cigarettes/day
Alcohol: 1 drink/month
Family History:
Father deceased at 62 "blood clot"
Brother deceased at 62 myocardial infarction
Physical Exam:
Pre operative:
Vitals: Blood pressure 176/80, Heart Rate 64, Weight 184 pounds
General: well developed male in no acute distress
HEENT: oropharynx benign
Neck: supple
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds, well healed
scar
Ext: well perfused, no edema, no varicosities
Pulses: +2 dorsal pedal, +1 posterior tibial, +2 radial
Neuro: nonfocal
Skin: well healed basal cell scars left anterior chest wall
Discharge:
VS: T98.4 HR79SR BP110/60 RR18 Sat95%RA
Gen: NAD
Neuro: A+O, nonfocal exam
Pulm: CTA
CV: RRR, Sternum stable, incision CDI
Abdm: soft, NT/ND/NABS
Ext warm and well perfused, no edema
Pertinent Results:
[**2165-7-30**] 01:15PM WBC-19.9* RBC-3.75* HGB-12.0* HCT-33.8*
MCV-90 MCH-32.0 MCHC-35.6* RDW-13.5
[**2165-7-30**] 01:15PM PLT COUNT-226
[**2165-7-30**] 12:09PM GLUCOSE-134* NA+-140 K+-5.2
[**2165-8-12**] 05:30AM BLOOD WBC-15.2* RBC-3.68* Hgb-11.5* Hct-33.7*
MCV-92 MCH-31.1 MCHC-34.0 RDW-13.8 Plt Ct-627*
[**2165-8-11**] 09:54PM BLOOD PT-17.3* PTT-61.2* INR(PT)-1.6*
[**2165-8-12**] 05:30AM BLOOD Glucose-71 UreaN-14 Creat-0.9 Na-141
K-4.8 Cl-104 HCO3-27 AnGap-15
Brief Hospital Course:
Mr [**Known lastname 1637**] was a direct admission to the operating room for
Aortic aneurysm repair on [**7-30**]. At that time he had an Ascending
Aorta and Hemiarch replacement with #32 Gelweave graft and
Aorticvalve replacement with #27 CE magna pericardial tissue
valve. His bypass time was 140 minutes and crossclamp was 87
minutes with circulatory arrest of 8 minutes. PLease see
operating room report for full details.
He tolerated the operation and was transferred from the OR to
cardiac surgery intensive care on Epinephrine, Neosynephrine and
Propofol infusions. The patient was hemodynamically stable once
in the ICU and the Epinephrine was weaned off. He was slow to
wake and therefore was not extubated until the morning after
surgery. Additional he was noted to have right sided hemiparesis
for which Neurology was consulted. The patient also suffered
episodes of intermittent confusion most exagerated during the
nightime hours.
HE also ahd intermittent episode of post-op Atrial fibrillation
that was not well controlled with beta blockers and he was
started on Amiodarone as well as Heparin and Coumadin. He stayed
in the ICU to monitor his hemodynamic/pulmonary and neurologic
status until POD 8 at which time he was transferred to the step
down floor for continuing post-op care. Once on the floor the
patients post-op course was largely uneventful. He continued to
make slow progress in his physical therapy, he was slowly
anticoagulated and continued to have intermittent episodes of
atrial fibrillation but was generally in sinus rhythm, and he
only had rare episodes of disorientation that were easily
corrected with reminders.
On POD 12 it was decided that the patient was stable and ready
to be discharged to rehabilitation at [**Hospital 69348**] Rehabilitation
Center.
Medications on Admission:
Diltiazem 420 QD
Pravachol 20 QD
Amoxicillin PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD x 7days then 200mg QD.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
9. Warfarin 1 mg Tablet Sig: 1-10 mg PO DAILY (Daily): Adjust
dose QD to
Target INR 2.0-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Asc Ao and Hemiarch replacement(#32Gelweave)AVR(#27 CE Magna
pericardial)
cva, post-op Afib
PMH: HTN,^chol,MVP,Aorto-Fem BPG, L hernia repair, ORIF elbow,
removal Basal cell CA
Discharge Condition:
Good.
Discharge Instructions:
Keep wounds clean and dry. ok to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
Make an appointment with Dr. [**Name (NI) 23019**] 1-2 weeks after d/c
from rehab.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Completed by:[**2165-8-12**]
ICD9 Codes: 4241, 5990, 4019, 3051, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2148
} | Medical Text: Admission Date: [**2169-4-16**] Discharge Date: [**2169-4-25**]
Date of Birth: [**2090-12-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
78 yo F w/ abd pain
Major Surgical or Invasive Procedure:
right femoral line
right upper extremity PICC
transient levophed
History of Present Illness:
78 yo F w/ h/o hyperchol, IDDM, asthma, and s/p CCY several
years ago who presents from rehab w/ c/o RUQ abd pain x 3 days.
Patient d/c from [**Hospital1 18**] [**2169-4-14**] following a right transmetatarsal
amputation for gangrenous right foot. Patient's admission was
uncomplicated other than a fever spike on POD #1 o/n but CXR
negative and patient defervesced. She required 1 U PRBC
intraoperatively for hct 26.8. Per daughter, patient is somewhat
confused and currently an unreliable historian, thus I relied on
her daughter for hx. Her daughter states that her mom first
started c/o diffuse abdominal pain but particularly subxiphoidal
abdominal pain on Friday. Her mother states that the pain was
occasionally worse w/ eating but her daughter states that her
mom was eating a full liquid diet. She has been vomiting,
however. Occasionally it is the food she just ate and other
times she will vomit up her pills. However, she had soup and
jello this am w/o vomiting. Her mom has also been c/o back pain
but as far as her daughter can tell this is just her chronic
LBP. She doesn't seem to relate the pain to her abdominal pain.
Patient's daughter thinks her mom's last BM was on Friday but
she is really not sure. Per notes, patient spiked temp of 101 at
rehab. Patient's daughter is not aware of any h/o PUD or CAD in
her mother. [**Name (NI) **] mom did have a gall bladder attack severeal
years ago leading to CCY, but o/w no abdominal surgeries/issues.
+ h/o BRBPR. Daughter not sure if she's had a c-scope in the
past. Daughter is not aware of any urinary complaints
On further ROS:
Patient has been having hallucinations which started in the
hospital, attributed to pain medications.
+ SOB which is worse if she lies flat since her last admission
to [**Hospital1 18**]
Per notes, her mother also reported some chest tightness.
Past Medical History:
# hx hypercaoguable state - but no clear h/o DVT/PE
# hypercholestremia
# ? hx Dm2 - recent dx in setting of recent MTA
# asthma
# s/p cholecystectomy
# PVD: on coumadin, s/p left metatarsal amputation '[**62**], right
metatarsal amputation [**2169-4-11**]
- cath [**4-18**]: clean coronary arteries
- ECHO [**5-21**]: EF > 60%
Social History:
Lived alone prior to d/c [**3-25**] when she was d/c to rehabiltation
(Scherrill House)
Denies tobacco and ETOH use
Worked as greenhouse worker and babys[**Name (NI) 1786**] in the past
6 kids (2 deceased), divorced, her daughter [**Name (NI) 1787**] has been very
involved w/ this hospitalization
Family History:
no h/o PUD, pancreatic cancer or pancreatitis
+ h/o DM
Physical Exam:
T 99.5 bp 147/53 hr 78 rr 21 O2 97% RA
genrl: lethargic but when aroused seems very awake but then
quickly falls back to sleep, in nad at any time during my exam
heent: pinpoint pupils but reactive (3mm->2mm), no photophobia,
eomi, sclera anicteric, op clear but limited exam due to poor
patient cooperation
neck: supple
cv: rrr, no m/r/g
pulm: minimal expiratory wheeze, o/w CTA bilaterally, moves air
well
back: no cva tenderness, localizes back pain to L4/5 w/o spinous
process tenderness
abd: nabs, RUQ oblique scar (6" long, c/d/i), soft, mildly
tender to palpation of RUQ w/o rebound/guarding, no masses/hsm
extr: no c/c/e, s/p right metatarsal amputation - c/d/i w/o skin
changes, left metatarsal amputation site appears somewhat
cyanotic but warm bilaterally, slight underlying erythema but
does not appear infected, no fluctuance and no d/c from surgical
incision
Pertinent Results:
CK: 106 MB: 3 Trop-*T*: <0.01 x 2
Lactate:1.1
133 95 10 91
3.9 30 0.7
Ca: Pnd Mg: Pnd P: Pnd
ALT: 86 AP: 165 Tbili: 0.6 Alb: 3.3
AST: 77 [**Doctor First Name **]: 60 Lip: 16
PT: 19.9 PTT: 31.6 INR: 2.5
[**2169-4-16**] 12:30PM WBC-12.2* RBC-3.68* HGB-10.0* HCT-30.4*
MCV-83 MCH-27.1 MCHC-32.8 RDW-14.0
N:77.8 L:15.6 M:5.2 E:1.2 Bas:0.2
Hypochr: 1+ Poiklo: 1+
[**2169-4-16**] 07:42PM calTIBC-256* VIT B12-678 FOLATE-12.7
FERRITIN-568* TRF-197* RETIC 2.3%
[**2169-4-16**] 07:42PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
Hep A IgG pos, IgM neg
[**2169-4-16**] 07:42PM HCV Ab-NEGATIVE
random cortisol 1.1
HGB A1C: pending
TSH: 1.8
RPR: NR
c diff neg x 3
Unit admission:
FDP 10-40, fibrinogen 672
CT abd/pelvis [**4-16**]:
1. Mild dilatation of the distal common duct with no
choledocholithiasis, unchanged from the prior ultrasound.
2. Status post cholecystectomy.
3. Likely left renal cyst, although too small to characterize.
4. Sigmoid diverticulosis.
5. Calcified fibroids.
6. Bilateral 2 cm adrenal masses, which cannot be characterized
further on this study.
7. Fluid collection in the left groin, presumably related to
recent
catheterization. 6.0 x 3.0 cm
RUQ U/S [**2169-4-18**]:
IMPRESSION: Diffusely prominent common duct, as described above,
unchanged in appearance from the patient's previous ultrasound
exam of [**2167-6-9**]. This
finding is likely related to the remote history of
cholecystectomy. Otherwise, an unremarkable right upper quadrant
ultrasound.
CXR [**4-16**]:
Right hilar fullness on the AP view without a definite
abnormality
on the lateral view. A repeat good technique AP and lateral may
be performed to see whether this should be further evaluated
with CT.
EKG: sinus at 82 bpm, old QIII, no STTW changes
urine cx [**4-13**]: > 100K GP bacteria - lactobacillus or alphastrep,
neg nit/LE on UA at the time
[**Last Name (un) **] cx [**2169-4-17**]: > 100K enterococcus sensitive to vanc,
ampicillin, levo
bld cx [**4-16**], [**4-17**]: no growth
Brief Hospital Course:
78 yo F w/ h/o hyperchol, ? T2DM, asthma, and h/o PVD s/p
bilateral MTA, most recently on the right ([**2169-4-11**]) who presents
from rehab w/ c/o RUQ abd pain x 3 days.
# Abdominal pain/vomiting
CT abd/pelvis did not show anything that might explain this
patient's presenting complaint. Her LFTs were slightly elevated
on presentation concerning for possible cholestasis postop but
they essentially normalized. Her statin was held
prophylactically. Hepatitis panel was unremarkable, positive for
hep A IgG but negative for hep A IgM. Her h/o vomiting was
concerning for pancreatitis but her lipase/amylase WNL. Given ?
h/o BM, we considered constipation as a cause of her abdominal
pain and tx w/ aggressive bowel regimen. Consideration was made
for a RP bleed or leaking AAA given h/o left groin hematoma
following cath [**3-30**] but her presenting pain was in the RUQ, in
addition to c/o her chronic L4/5 back pain. In addition her hct
remained stable and her CT was unremarkable. Ms. [**Known lastname 1794**] had no
h/o PUD but did report h/o BRBPR years ago so we considered a
possible stress ulcer and tx her accordingly w/ PPI, guiacing
all her stools. There was no lactic acisosis to suggest ischemic
gut and her lytes were WNL. She ultimately ended up being dx w/
urosepsis. Her urine cx showed > 100K colonies/ml of
enterococcus sensitive to amp/levo/vanc. Plan to tx w/ vanc x 10
days (long duration of antibx for concurrent MTA cellulitis).
Patient currently has no further c/o abdominal pain.
# Decreased MS
[**First Name (Titles) **] [**Last Name (Titles) 1795**] on initial presentation given pinpoint pupils,
h/o hallucinations, and being tx w/ dilaudid, MS contin, and
neurontin at rehab. However, her MS [**First Name (Titles) 1796**] [**Last Name (Titles) 1797**] despite
holding pain medications, at which time patient was found to be
hypotensive (70/palp w/ doppler assist). She was transiently
started on pressors, aggressively hydrated, and MS returned to
[**Location 213**] w/in 24 hours. She was thus also dx w/ urosepsis. Of
note, blood cultures were negative for any growth.
Folate/B12/TSH/RPR were all unremarkable. CXR was w/o
infiltrate.
# Fever/leukocytosis
Patient ultimately dx w/ enterococcal UTI and right stump
cellulitis. Plan to tx w/ a total of 10 days of vancomycin +
zosyn. Of note, CXR w/o overt infiltrate. She did have loose
stools this admission but was c diff neg x 3. Blood cx were no
growth.
# Hypocortisolism
Patient w/ cortisol 1.1 on transfer to ICU. She was noted to
have bilateral adrenal masses which will need to be w/u as
outpatient as potential cause of adrenal insufficiency. Due to
patient's hypotn, she was tx w/ stress dosed steroids which will
be tapered to off as an outpatient.
# right MTA cellulitis
Patient p/w mild cellulitis of her right MTA stump. This
improved on antibx. Vascular was consulted and recommended,
ultimately BKA. However, given patient is s/p urosepsis and on
stress dose steroids, plan for d/c to rehab w/ plan to return
for BKA in the future. She will undergo persantine MIBI prior to
d/c for cardiac risk stratification preop. She will need to be
on ASA and BB perioperatively. Her home BB was restarted on the
day of d/c. Dr. [**Last Name (STitle) **] is her vascular surgeon and is adamant
that patient remain anticoagulated for dx hypercoagulable state.
Her coumadin was held prior to d/c given supratherapeutic INR
while on antibx. Today her INR is 1.9 so we will start lovenox
and restart her coumadin w/ goal INR 2-2.5, at which time
lovenox can be d/c.
# CV
- CAD: cath [**4-18**] w/ clean coronaries, EF > 60%, no CP this
admission
- Pump: bp well controlled, no failure on CXR
- sinus rhythm
# h/o asthma: Patient was tx w/ scheduled atrovent w/ albuterol
prn given somewhat wheezy on exam.
# Chronic anemia: Hct stable. Checking iron studies/folate/b12.
# IDDM: RSSI. DM diet. Checking hgb A1c to further characterize.
# PPX: PPI, on coumadin, bowel regimen, aspiration/fall precxs
# FEN:
Patient initially p/w mild hyponatremia (Na 133, down from
135-138 on last admission). Patient did not appear severely dry
on exam but given h/o decreased MS, I suspected hypovolemic
hyponatremia. However, after 1 L NS, patient's Na was down to
127. Patient's daughter had given h/o ? orthopnea at rehab and
given patient's response to NS, patient was postulated to be
hypervolemic. Thus, attempt was made for diuresis w/ lasix. This
also did not improve patient's sodium and bp decreased to
85/palp. Patient subsequently responded to 1L NS bolus and was
kept on maintenance NS o/n but in the AM was hypotn to 70/palp
w/ sodium back up to 136. After aggressive rehydration in the
ICU, her sodium improved further to 142. Her sodium has been
stable since.
Patient maintained on DM/cardiac diet. She underwent swallow
evaluation which showed no evidence of aspiration.
# Access: Patient has difficult access. Thus, a right UE PICC
placed.
# Full code
# Dispo: to rehab, return for BKA in future
Medications on Admission:
hydromorphone 2 mg po q4h prn
albuterol prn
colace 100 mg po bid
ms contin 15 mg po bid
neurontin 100 mg po tid
lipitor 20 mg po qd
metoprolol 25 mg po bid
tylenol prn
coumadin 2 mg po qhs
lactulose prn
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every 4-6 hours as needed.
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. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection four times a day: Please follow attached
RSSI.
6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 days: [**4-25**].
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: [**4-26**], [**4-27**].
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: [**4-28**], [**4-29**].
11. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 grams
Intravenous Q6H (every 6 hours) for 4 days: through [**2169-4-27**].
12. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous
Q24H (every 24 hours) for 4 days: through [**2169-4-27**].
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: 10ml NS followed by
1ml of 100 units/ml heparin (100 units heparin) each lumen QD
and PRN. Inspect site every shift until PICC d/c.
14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day: hold for sbp < 110 or hr < 60.
16. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous twice a day: until INR > 2 on 2 consecutive days.
17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: goal
INR 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
urosepsis
right stump cellulitis
Discharge Condition:
good: bp stable, awake, alert, afebrile
Discharge Instructions:
Please call Dr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**] at [**Telephone/Fax (1) 1792**] for temperature
> 101, decreased mental status, redness/swelling of right stump,
or any other concerning symptoms.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **] on [**2169-5-3**] at 11:15 to
discuss your need for further surgery on your right leg. Phone:
([**Telephone/Fax (1) 1798**]
2. Please follow-up with Dr. [**Last Name (STitle) 1789**] in 1 week to
ICD9 Codes: 0389, 5990, 2761, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2149
} | Medical Text: Admission Date: [**2165-5-22**] Discharge Date: [**2165-6-5**]
Date of Birth: [**2087-6-7**] Sex: F
Service: MEDICINE
Allergies:
Rapamune / Ativan
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
PICC line [**2165-6-3**]
History of Present Illness:
77 y.o. female with PMHx of PCKD and PCLD (s/p bil native
nephrectomy and liver dissection) and s/p cadaveric renal
transplant in [**2155**] with past history of multiple abd surgeries
including rectopexy for irreducible rectal prolapse on [**2165-3-27**]
presented to the ED with increasing shortness of breath. Patient
reports becoming acutely short of breath on the night prior to
admission. On the following day, she was hypertensive to 199/90
with a mild headache and noted a temperature of 99. She also
noted profound weakness and thus came into the ER for further
evaluation. She denies any chest pain, palpitations, fevers,
recent sick contacts or travel.
In the ED, vitals were T 99.5, P 76, BP 183/75, RR 25, O2: 77%
on RA, 96% [**Date Range 597**]. O2 sats began to trend down on [**Last Name (LF) 597**], [**First Name3 (LF) **] she was
eventually switched to CPAP. Given the hypoxia, a CXR was
ordered which showed bibasilar PNA and CHF. BNP was elevated to
53,163. Patient was also noted to have a distended abdomen,
concerning for SBO. KUB showed no ileus or obstruction. Surgery
was consulted and felt that there were no acute surgical issues
and that a CT scan of the abdomen could be performed if there
were increasing concern for obstruction. Given the CXR findings,
patient was started on Levofloxacin. She was additionally given
a dose of Flagyl for concern of an intrabdominal process. She
was then admitted to the ICU for PNA/CHF.
Past Medical History:
1. s/p cadaveric renal transplant in [**2155**] for polycystic
kidney disease, status post bilateral nephrectomy ([**2148**], [**2152**])
2. Polycystic liver disease- s/p liver resection- left Hepatic
Trisegmentectomy and Right Lobe Cyst Reduction ('[**57**]).
3. Recurrent partial small bowel obstruction
4. s/p cholecystectomy
5. s/p appendectomy
6. s/p excision of parathyroid adenoma '[**58**] [**Doctor Last Name **]
7. Hypertension
8. Breast cancer, s/p L radical mastectomy ([**2151**])
9. History of right elbow and humeral fracture
10. History of incarcerated hernias although per history
"reduced" nonsurgically in the past
11. spinal stenosis
12. Irreducible Rectal Prolapse, s/p abdominal rectopexy
([**2165-3-27**])- [**Doctor Last Name **]
Social History:
Lives with husband who recently fractured his hip, has two
children who live locally. Denies tobacco, EtOH, drugs.
Family History:
Polycystic kidney disease.
Physical Exam:
PE: BP 173/64, 16, HR 75, 97 on 4L
Gen: Awake, alert, breathing comfortably on nasal cannula, NAD
Heart: S1, S2 nl, II/VI SEM, II/VI SEM noted.
Lungs: Bilateral lower lobe crackles diminished breath sounds,
RUL crackles
Abd: Multiple surgical incisions, abdomen is firm, distended,
NT,
decreased BS
Rectal: Guaiac negative per ICU
Ext: Warm, well perfused, no C/C/E.
Neuro: CN II-XII grossly intact.
Skin: Multiple ecchymotic lesions
Pertinent Results:
[**5-22**]: Portable Abdomen:
FINDINGS: A single portable AP view of the abdomen is obtained
which excludes the upper abdomen. Multiple surgical clips are
again noted in the mid abdomen which are unchanged from prior
study. There has been interval removal of the skin staples. The
bowel gas pattern is nonspecific, though demonstrates no
definite evidence of ileus or obstruction. The abdominal aorta
is calcified and appears tortuous. Visualized osseous structures
are unremarkable.
[**5-22**]: Abdominal US:
FINDINGS: Limited four quadrant views of the abdomen demonstrate
large amount of simple-appearing ascites in all four quadrants,
including the right perihepatic space.
[**5-22**]: Chest x-ray
FINDINGS: Two bedside frontal views labeled "upright at 12:50,
1:00 p.m." with lordotic positioning, are compared with most
recent study dated [**2165-4-15**]. There is dense retrocardiac opacity
with air bronchograms and obscuration of that hemidiaphragm,
likely representing combination of consolidation and effusion,
new. There is also further patchy opacity at the right lung
base; this process is likely pneumonic. There is cardiomegaly
with pulmonary vascular congestion and blurring and small
bilateral pleural effusions. Noted are numerous surgical clips
in the upper abdomen, particularly on the right and a right
shoulder arthroplasty.
[**5-23**]: Chest x-ray
IMPRESSION:
1. Increasing right lung consolidation suggesting worsening
infection.
2. Increasing left basilar opacity possibly representing a
combination of atelectasis and effusion, although infection
cannot be excluded.
[**5-23**]: Abdominal US
IMPRESSION:
1. Patent hepatic vessels with normal directional flow.
2. Numerous cysts throughout the liver.
3. Dilated extrahepatic common bile duct measuring 16 mm in
greatest dimension.
[**5-23**]: ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral
Doppler and tissue velocity imaging are consistent with Grade II
(moderate) LV diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is severe pulmonary artery systolic hypertension. There is
a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2165-3-26**],
left ventricular diastolic function has worsened. The amounts of
mitral regurgitation, tricuspid regurgitation, and estimated
pumonary artery systolic pressure have increased.
[**5-27**]: CT Torso
FINDINGS: There is severe scoliosis of the thoracic spine.
Consecutive asymmetry of the rib cage. Multicystic liver
disease. In the thorax, the right-sided pleural effusion has a
diameter of 5.2 mm at its largest size. Considerably smaller
left-sided pleural effusion. The most remarkable finding in the
lung parenchyma is a right-sided extensive perihilar opacity
with air bronchograms and central consolidations. This opacity
has a subtle ground- glass halo and several satellite lesions.
At the apex and the base of the right lung, linear areas of
atelectasis are seen. _Areas of hypoventilation at the lung
bases. Calcification of the mediastinal vessels, no
pneumothorax.
Brief Hospital Course:
77 year old female with extensive PMH who was admitted with PNA
and pulmonary edema, requiring non-invasive ventilation. She
was initially in the intensive care unit until her breathing
status improved.
In the ICU, the patient was diuresed with IV Lasix and received
antibiotics for her PNA. Initially, she was on BiPAP but
improved throughout her course of stay until she was saturating
comfortably on room air. On admission the patient had a surgical
eval for abdominal distention which resolved w/o intervention,
her imaging was negative for SBO. She was transferred to the
floor for further management.
On exam, the patient had dyspnea and fever felt most likely
secondary to a factor of both CHF and PNA noted on CXR. The
patient was treated with levofloxacin for a likely community
acquired pneumonia. She was also treated initially with IV
Lasix as her xray seemed consistent with a degree of heart
failure.
The patient has a history of multiple SBOs in the setting of
numerous abdominal surgeries. She denied any vomiting, though
she did have some mild nausea at the beginning of her
hospitalization. Her last BM was the day before admission and
she denies passing flatus since. She says that her current
abdominal distention is not comparable to previous SBOs. Of
note, she was started on iron supplements approximately one week
ago and has noted constipation with this. The patient was
treated with an aggressive bowel regimen.
For her chronic polycystic kidney disease s/p transplant, the
patient was treated with her usual dose of prednisone and a
slightly decreased dose of CellCept given her neutropenia. Her
polycystic liver disease was stable. She did have a RUQ US
which showed dilation of her common bile duct. LFTs and exam
remained stable throughout her hospital course and she was
discharged to follow this finding up with her PCP.
The patient has a history of hypertension for which she was
taking atenolol and diltiazem as an outpatient. Her blood
pressure was markedly elevated upon arrival. Per her history,
the patient has had problems with hypertensive urgency in the
past. She was initially treated with metoprolol and diltiazem
with PRN hydralazine. Doxazosin was introduced once the patient
was called out to the floor, however, the patient experienced
relative hypotension likely causing a bump in her creatinine.
The doxazosin was discontinued with a slow improvement in her
creatinine. Her outpatient Lasix was held and she was advised
to discuss restarting this medication with her primary care
doctor.
The patient was continued on her outpatient Epogen regimen for
her anemia. She received one unit of packed red blood cells as
well as six infusions of IV Ferrlecit.
The patient was continued on her outpatient regimens for her
spinal stenosis, depression, anxiety and insomnia with the
following medications Neurontin, Tramadol, Zoloft, Klonopin and
Ambien.
# Communication: [**Doctor First Name 717**] (daughter) [**Telephone/Fax (1) 106650**]; [**Name (NI) **] (son)
[**Telephone/Fax (1) 106651**]
.
# Code: FULL (confirmed with patient and daughter)
Medications on Admission:
Ambien 5 mg QHS
Atenolol 75 mg QD (occasionally 150 mg for severe HTN)
Cartia XT 240 mg PO QD
Lasix 20 mg PO QD
Zoloft 50 mg PO QD
Prednisone 6 mg PO QD
Cellcept [**Pager number **] mg PO BID
Tramadol (dose unknown)
Neurontin (dose unknown, but taken TID)
Klonopin 1 mg PO QD
Senna
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
6. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) Powder in Packet PO daily () as needed for prn
constipation.
11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please take a total of 6 mg daily.
12. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day:
please take 6 mg daily.
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Outpatient Lab Work
Please have your CBC, Chemistries, and renal function tests
(Creatinine, BUN), drawn this Friday, [**2165-6-7**]. These results
need to be called into Dr.[**Name (NI) 9377**] office at ([**Telephone/Fax (1) 6117**]
15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary -
Pneumonia, complicated by a parapneumonic effusion
Acute on chronic renal failure
Secondary -
Polycystic Kidney Disease s/p transplant
Polycystic Liver Disease
Hypertension
Anemia
Spinal stenosis
Discharge Condition:
Stable, O2 sats above 95% on room air
Discharge Instructions:
You were admitted for a pneumonia which required treatment with
antibiotics and oxygen. You were also started on new medication
for your blood pressure, doxazosin, which was stopped while you
were in the hospital due to elevated kidney function tests.
Your lasix has been stopped and should not be started until you
see Dr. [**Last Name (STitle) **].
You need to have your labs checked again this Friday, including
your renal function tests (lab slip included). These should be
called into Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 6117**].
Please continue all medications as instructed. You have an
appointment with Dr. [**Last Name (STitle) **] on [**6-11**] for follow-up. While you
were in the hospital, an ultrasound demonstrated dilitation of
your common bile duct. You did not have any lab abnormalities
or symptoms associated with this finding. Please follow up this
result with your primary care physician at your appointment.
If you experience any symptoms of fevers, difficulty breathing,
shortness of breath, chest pain, or any other concerning
symptoms, please seek medical attention immediately.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2165-6-11**] 4:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2165-7-2**] 1:00
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
ICD9 Codes: 486, 5849, 4280, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2150
} | Medical Text: Admission Date: [**2204-6-4**] Discharge Date: [**2204-6-11**]
Date of Birth: [**2142-12-26**] Sex: F
Service: MEDICINE
Allergies:
Norvasc / Infed
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Pulmonary Edema
Major Surgical or Invasive Procedure:
RIGHT tunneled IJ HD catheter
History of Present Illness:
61 yo F with CAD, CHF EF 30%, ESRD s/p transplant, now failed
who presents with pulmonary edema, AoCRF and need for dialysis.
Patient was seen by PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**5-29**] who thought she was
euvolemic at the time. After that went to [**Hospital3 **] for vacation
with her family and for the past several days she has been
feeling progressively more SOB. Today was the worst day so she
decided to go to [**Hospital3 **] Hospital. At CCH she was found to be
in respiratory distress and was intubated. She was given
furosemide 60 mg IV and kayexalate 30 mg but her urine output
was only 30 mL. Her labs were remarkable for WB 8.3, trop
0.274, BNP 4428, K 5.5 and BUN/Cr 88/5.4. She was then
transferred to [**Hospital1 18**] for futher care.
.
In the ED, initial labs remarkable for WBC 11.3, Hct 27.8, BNP
[**Numeric Identifier 104608**], BUN 88/5.7. Patient was initially on dopamine for low BP
but after propofol was switched to fentanyl/midazolam her BP
came up and dopamine was weaned off. CXR was consistent with
pulmonary edema. Renal was contact[**Name (NI) **] for need of emergent
dialysis. VS prior to transfer BP 97/59 HR 57 Sat 100% on CMV
100% FiO2, Tv 480 mL and PEEP 10.
.
On the floor, she is intubated and sedated.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- systolic CHF with EF 30 %
- recent NSTEMI
3. OTHER PAST MEDICAL HISTORY:
-end-stage renal disease, status post allograft transplant in
[**2197**] complicated by rejection, now again with chronic renal
insufficiency
-CAD, status post LAD and RCA stents
-congestive heart failure (EF 30%, [**2201**])
-HTN, poorly controlled
-peripheral [**Year (4 digits) 1106**] disease s/p R to L fem-fem bypass, R
external iliac stenting
-scleroderma
-history of GI bleed
Social History:
Lives at home with husband and son.
- Tobacco history: Heavy [**Year (4 digits) 1818**], quit in [**Month (only) 958**]
- Alcohol/Drugs: Denies EtOH and drug use.
Family History:
No FmHx of MI, HTN, CA, HL. Father - brain cancer, died in his
30's
Physical Exam:
ADDMISSION EXAM:
General: Intubated, sedated, not responding to stimuli
HEENT: Sclera anicteric, DMM, 1-2mm pupils but equal and
reactive
Neck: supple, no LAD
Lungs: Bilateral crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, multiple
surgical scars
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
General: NAD, comfortable
HEENT-PERRLA, EOMI
LUNGS: CTABL, symmetrical chest wall movement
GU: foley removed, urinating without difficulty
Rest of exam unchanged from admission
Pertinent Results:
[**2204-6-4**] 11:49AM GLUCOSE-145* UREA N-89* CREAT-5.8* SODIUM-143
POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-23 ANION GAP-21*
[**2204-6-4**] 04:23AM UREA N-88* CREAT-5.7*
[**2204-6-4**] 04:23AM CK-MB-6 proBNP-[**Numeric Identifier 104608**]*
[**2204-6-4**] 04:23AM WBC-11.3* RBC-3.06* HGB-9.0* HCT-27.8* MCV-91
MCH-29.2 MCHC-32.2 RDW-15.5
[**2204-6-4**] 04:23AM FIBRINOGE-545*
[**2204-6-4**]:Rate PR QRS QT/QTc P QRS T
67 172 106 394/406 47 -1 106
DISCHARGE LABS:
[**2204-6-10**] 07:00AM BLOOD WBC-6.2 RBC-3.08* Hgb-9.2* Hct-27.6*
MCV-90 MCH-29.9 MCHC-33.3 RDW-15.1 Plt Ct-154
[**2204-6-11**] 06:40 Glucose 140 UreaN 58* Creat3.9* Na141 K 4.0
Cl100 HCO327 AnGap18
[**2204-6-11**] 06:40 Ca 9.0 P 5.6* Mg 1.9
[**2204-6-9**] 08:00 TacroFK <2.01
[**2204-6-4**] ECHO: The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is
severely depressed (LVEF= 20-25 %) with global hypokinesis and
regional akinesis/dyskinesis of the distal LV/apex.The inferior
wall is akinetic. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal with borderline free wall contractility
(RV apex not well seen). The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a
prominent fat pad.
CXR [**2204-6-4**]: Cardiomegaly, [**Month/Day/Year 1106**] congestion, and bilateral
parenchymal
opacities most compatible with pulmonary edema. Radiographic
followup after diuresis is recommended.
Renal Transplant US [**2204-6-4**]: Progression of high resistance
pattern of flow within the transplanted kidney with lack of
antegrade diastolic flow in the intrarenal and main renal
arteries. Patent renal vein.
BILAT LOWER EXT VEINS PORT [**2204-6-4**]
No evidence of DVT.
CHEST (PORTABLE AP) [**2204-6-5**]:
Pulmonary edema present on [**6-4**] has substantially improved.
Residual
opacification at the lung bases is probably a combination of
residual edema, pleural effusions and atelectasis.
Heart size is normal. Mediastinal and hilar contours are
unremarkable. Tip
of the endotracheal tube, with the chin in neutral or elevation
is less than 2 cm from the carina and should be withdrawn 2-3 cm
to avoid unilateral intubation. Clinical service notified.
CHEST (PA & LAT) [**2204-6-7**]
Comparison is made with prior study [**6-5**].
Cardiomegaly is unchanged. Moderate-to-large bilateral pleural
effusions are larger on the left side associated with
atelectasis in the bases of the lungs, left greater than right.
Multiple calcified lung nodules in the right upper lobe are
again noted. Pulmonary edema continues to improve, now mild.
There are no new lung abnormalities.
Brief Hospital Course:
Assessment and Plan:
61 yo F with CAD, CHF EF 30%, ESRD s/p transplant now failing,
not yet on HD who presented to OSH with dyspnea and was
intubated due to pulmonary edema causing respiratory distress.
Now transferred to [**Hospital1 18**] for emergent HD.
#. Respiratory distress: Patient presented to OSH with dyspnea
and was intubated due to respiratory distress. A CXR showed
pulmonary edema and her BNP was measured at [**Numeric Identifier 104608**]. Felt to be
secondary to worsening renal function causing oliguria, fluid
overload and pulmonary edema due to fluid poor cardiac reserve.
Patient was started on lasix drip with good urine output and was
extubated on [**6-6**]. She has been slowly weaned off of O2
requirements and is now saturating 98% on room air.
#. AoCRF: Patient's last Cr was 4.4 at PCP's office on [**5-29**] and
5.7 on [**6-6**] during this admission. Unclear as to cause of acute
change but failing transplant is most likely. Renal ultrasound
showed progression of high resistance pattern of flow within the
transplanted kidney with lack of antegrade diastolic flow in the
intrarenal and main renal arteries. Patent renal vein. A right
IJ tunneled line was placed and hemodialysis was started during
this admission. She received 3 HD treatments prior to discharge.
She will be continuing HD on a regular out patient basis. Per
nephrology recommendations we will be continuing Tacrolimus,
Mycophenolate Mofetil and Prednisone for her renal transplant.
She was setup for M,W,F HD as outpt.
#. Congestive Heart Failure: A cardiolgy evaluation was
performed while she was in the MICU given her history of
worsening SOB and fluid overload on admission. An echocardiogram
was performed on this admission which showed overall left
ventricular systolic function that is severely depressed (LVEF=
20-25 %) with global hypokinesis and regional
akinesis/dyskinesis of the distal LV/apex and an akinectic
inferior wall. This EF is decreased from 30% documented on a
prior echo on [**9-2**]. She has been diuresed with furosemide 80mg
[**Hospital1 **]. She is not longer hypervolemic on exam and her SOB has
resolved. We are holding her Carvediolol and Lasix at the
present time due to sbp's lower than her baseline.
#. Hypotension: Presented with low BP in setting of propofol.
Her blood pressures have remained low during this admission
sbp's 90s-100s. We have held her out pt HTN meds: carvedilol,
clonidine, enalapril, hydralazine, isosorbide mononitrate, Lasix
and amlodipine. She has a close follow up appointment with her
Cardiologist where her blood pressures can be reassessed at that
time.
#. Anemia: felt to be secondary to decreased eyrhtropoesis. At
her baseline H/H at the time of discharge.
#. Sceleroderma: not an active issue while inpatient.
#. Transitional: She will have a follow up appointment with her
primary care physician, [**Name10 (NameIs) **] cardiologist following this
hospitalization. She will be receiving weekly regular
hemodialysis treatment and her nephrologist will be following
her in this setting. Her blood pressures should be re-checked
following this admission for re-evaluation of her home HTN
medication needs.
Medications on Admission:
-Torsemide 20 mg daily
-ProAir 1-2 puffs inhalation 4-6 hours p.r.n
-Aspirin 81 mg daily
-atorvastatin 80 mg daily
-Calcitrol 0.25 mcg oral daily
-Carvedilol 25 mg p.o. b.i.d.
-Clonidine 0.1 mg 24-hour patch weekly
-Darbepoetin 100 mcg inj every other week
-Enalapril 5 mg daily
-Hydralazine 25 mg p.o. b.i.d.
-Isosorbide mononitrate ER 120 mg daily
-Nitroglycerin 0.4 sublingual p.r.n. for chest pain
-Prednisone 2 mg daily
-Sodium bicarbonte 1300 mg b.i.d.
-Tacrolimus 1 mg b.i.d.
-mycophenolate mofetil 500 mg [**Hospital1 **]
-amlodipine 5 mg daily
-famotidine 20 mg daily
-pantoprazole 40 mg daily
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
9. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO twice
a day.
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed for heartburn.
11. darbepoetin alfa in polysorbat 100 mcg/0.5 mL Syringe Sig:
One (1) Injection every other week.
12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes up to 3 times as needed for chest
pain.
14. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day as needed for
heartburn.
15. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**11-27**]
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
16. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic Renal Failure
Acute on Chronic Systolic Congestive Heart Failure Exacerbation
Secondary Diagnosis:
Hypertension
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:
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with acute
renal failure and fluid in your lungs. The fluid in your lung
was reduced with diurectic medications. It was determined that
you will need hemodialysis in the future and you will be
following up with nephrology for this treatment.
Changes to your Medications:
STOPPED: CARVEDILOL, CLONIDINE, ENALAPRIL, HYDRALAZINE,
ISOSORBIDE MONONITRATE, AMLODIPINE,TORSEMIDE
STARTED:
FUROSEMIDE 80MG TWICE A DAY
VITAMIN B COMPLEX-VITAMIN C COMPLEX-FOLIC ACID 1MG CAPSULE ONCE
A DAY
Please weigh yourself every morning, and call Dr. [**Last Name (STitle) 171**] if
weight goes up more than 3 lbs.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2204-6-21**] at 10:00 AM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
***This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Department: CARDIAC SERVICES
When: TUESDAY [**2204-6-19**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Location (un) **] [**Location (un) **] Dialysis Center
[**Location 8262**], [**Numeric Identifier 99847**]
Fax:[**Telephone/Fax (1) 10374**]
Tel: [**Telephone/Fax (1) 5972**]
Nephrologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Your outpatient dialysis schedule will be every Mon, Wed and Fri
at 3:30pm
Department: GASTROENTEROLOGY
When: WEDNESDAY [**2204-6-13**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2204-6-20**] at 9:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 5849, 2760, 4280, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2151
} | Medical Text: Admission Date: [**2123-6-9**] Discharge Date: [**2123-6-15**]
Date of Birth: [**2099-2-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zithromax
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
SOB, fatigue, headaches
Major Surgical or Invasive Procedure:
[**6-9**] AVR (OnX Mechanical) & Ascending Aorta
History of Present Illness:
24 yo with known bicuspid valve & AI since childhood, with
recent increase in symptoms.
Past Medical History:
Charcot-[**Doctor Last Name **]-Tooth
s/p Umbilical hernia repair
s/p RIH repair
s/p foot injury/surgery
Social History:
[**1-11**] ppd x 10 years, quit [**1-15**]
No etoh
lives with Mother
unemployed
Family History:
maternal grandfather deceased from MI age 55
father deceased from MI age 30
Physical Exam:
On admission:
NAD RR20 HR 84 BP 146/82
RRR SEM
Lungs CTAB
Extremeties warm, no edema
Pertinent Results:
[**2123-6-15**] 06:20AM BLOOD Hct-24.4* Plt Ct-405
[**2123-6-14**] 01:30PM BLOOD Hct-24.2* Plt Ct-322#
[**2123-6-13**] 04:40AM BLOOD Hct-23.5*
[**2123-6-12**] 04:45AM BLOOD WBC-8.4 RBC-2.79* Hgb-8.2* Hct-22.7*
MCV-82 MCH-29.2 MCHC-35.9* RDW-13.2 Plt Ct-181
[**2123-6-15**] 06:20AM BLOOD Plt Ct-405
[**2123-6-15**] 06:20AM BLOOD PT-29.3* INR(PT)-3.1*
[**2123-6-14**] 01:30PM BLOOD PT-30.9* INR(PT)-3.3*
[**2123-6-14**] 06:00AM BLOOD PT-24.5* PTT-53.5* INR(PT)-2.5*
[**2123-6-13**] 04:40AM BLOOD PT-13.3* PTT-23.1 INR(PT)-1.2*
[**2123-6-12**] 04:45AM BLOOD PT-11.8 PTT-24.2 INR(PT)-1.0
[**2123-6-12**] 04:45AM BLOOD Glucose-97 UreaN-16 Creat-0.8 Na-133
K-4.4 Cl-98 HCO3-25 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname **] was taken to the operating room on [**2123-6-9**] where he
underwent an AVR with a #23 Onyx mechanical valve, and an
ascending aortic replacement with a #22 gelweave sidearm graft
(8mm). He was transferred to the CSRU in critical but stable
condition. He was extubated by POD #1 and transferred to the
floor on POD #2. He was started on coumadin and a heparin bridge
for his mechanical valve. He awaited therapeutic anticoagulation
and was ready for discharge on [**2123-6-15**]. His goal INR is [**2-12**].
Medications on Admission:
None.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily) for 5 days.
Disp:*5 Capsule, Sustained Release(s)* Refills:*0*
10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime): Check INR [**2123-6-17**] can call results to
Dr. [**First Name (STitle) **] .
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 11485**] VNA
Discharge Diagnosis:
Charcot [**Doctor Last Name **] tooth
s/p Umbilical hernia
s/p RIH
s/p surgery for foot injury
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 heavy lifting or driving until follow up with surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] 2 weeks
Cardiac Surgeon Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2123-6-15**]
ICD9 Codes: 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2152
} | Medical Text: Admission Date: [**2131-5-13**] [**Month/Day/Year **] Date: [**2131-5-17**]
Date of Birth: [**2072-5-31**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2131-5-13**] Facial laceration sutured
History of Present Illness:
58M s/p fall down stairs who presents to the ED with left
scapular and left rib tenderness. +EtOH.
Past Medical History:
Arthritis, scoliosis
Family History:
Noncontributory
Pertinent Results:
[**2131-5-13**] 09:20AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2131-5-13**] 07:15AM UREA N-13 CREAT-0.7
[**2131-5-13**] 07:15AM WBC-10.0 RBC-3.56* HGB-12.3* HCT-35.4*
MCV-99* MCH-34.5* MCHC-34.7 RDW-13.9
[**2131-5-13**] 07:15AM PLT COUNT-244
[**2131-5-13**] 07:15AM PT-11.8 PTT-23.0 INR(PT)-1.0
Imaging upon admission: CT head - no acute intracranial process.
subcutaneous air in the posterior deep fat starting at the skull
base,
extending inferiorly, incompletely assessed on this study. also
retropharyngeal air, incompletely assessed.
metallic density foreign body in the left orbit, please
correlate with history of eye surgery, possible new foreign
body?
CT C-spine: no fracture. alignment maintained. extensive
subcutaneous air in the left neck, prevertebral soft tissues
extending from mediastinum.
CT torso - 1. small left basilar and apical pneumothorax.
extensive subcutaneous air in the left chest wall extending to
neck; pneumomediastinum extending to prevertebral soft tissues.
2. small left hemothorax.
3. Left rib fractures: acute 1st through 6th ribs.
4. Right rib fractures: 5, 7, 8, 9 subacute.
5. Bibasilar atelectasis/possible aspiration.
6. acute left inferior pubic ramus fracture with adjacent small
hematoma.
7. left scapular fracture.
Brief Hospital Course:
He was admitted to the Trauma service and transferred to the
Trauma ICU for close monitoring given his small hemothorax and
multiple rib fractures. Orthopedics consulted for his injuries
which were managed non operatively. He may weight bear as
tolerated on his lower extremities. A sling for comfort is being
used for his scapula fracture. He will follow up as an
outpatient in [**Hospital 5498**] clinic in 2 weeks.
Acute Pain Service was consulted for his multiple rib fractures.
An epidural was placed for managing his pain. The epidural
remained in place for several days and was removed. His pain was
not adequately controlled with short acting narcotics alone so
long acting meds were added. His pain is fairly well controlled,
he will require ongoing adjustment of his pain meds.
He has a reported history of regular alcohol use and was placed
on CIWA protocol. He did not experience any delirium tremors
during his hospital stay.
He was evaluated by Physical and Occupational therapy and is
being recommended for rehab after his acute hospital stay.
Medications on Admission:
Cymbalta 60
[**Hospital **] Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
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. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
7. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for breathrough pain.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
[**Hospital **] Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab Hospital Unit at [**Hospital1 **]
[**Hospital1 **] Diagnosis:
s/p Fall
Facial laceration
Left scapula fracture
Left inferior pubic ramus fracture
Left rib fractures [**1-24**]
[**Month/Day (3) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Month/Day (3) **] Instructions:
You were hospitalized after a fall where you sustained fractures
to your left shoulder blade and ribs [**1-24**] on the left side. Your
injuries did not require any operations. Rib fractures can take
several weeks, sometimes months to heal and can be very painful.
Pain control and breathing exercises are key to minimizing
complications such as pneumonia.
You also sustained a laceration on the left side of your face
which was cleaned and sutured; these sutures will be taken out
in [**4-23**] days.
Followup Instructions:
Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP for Orthopedic
Trauma; call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma for evaluation of
your rib fractures; call [**Telephone/Fax (1) 1864**] for an appointment.
Follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2131-6-13**]
ICD9 Codes: 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2153
} | Medical Text: Admission Date: [**2119-10-1**] Discharge Date: [**2119-10-19**]
Date of Birth: [**2068-4-6**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
pedestrian struck by car
Major Surgical or Invasive Procedure:
[**2119-10-2**] Right tibia nail, with irrigation and debridement of
right tibia
[**2119-10-4**] ORIF right distal radius fracture
[**2119-10-10**] right tibialis muscle flap and skin
History of Present Illness:
Mr. [**Known lastname 21006**] is a 51 year old man who was struck by a car. He
was then presented to the [**Hospital1 18**] with injuries
Past Medical History:
unknown
IVC filter in place
Social History:
Homeless
Daily ETOH and drug use per patient report
Family History:
unknown
Physical Exam:
Upon admission:
Spanish speaking, following commands
Cardiac: Regular rate/rhythm
Chest: Clear bilaterally
Abdomen: Soft non-tender/non-distended
Extremities: RLE open tib/fib + pulses, + movement and
sensation
RUE: closed deformity +pain to palpatation, + pulses,
+sensation/movement.
Pertinent Results:
[**2119-10-14**] 06:15AM BLOOD WBC-8.4 RBC-3.26* Hgb-10.0* Hct-30.7*
MCV-94 MCH-30.8 MCHC-32.7 RDW-14.9 Plt Ct-733*
[**2119-10-12**] 06:00AM BLOOD WBC-9.4 RBC-3.11* Hgb-10.0* Hct-28.6*
MCV-92 MCH-32.1* MCHC-34.9 RDW-15.2 Plt Ct-610*#
[**2119-10-1**] 09:05PM BLOOD WBC-9.0 RBC-3.47* Hgb-12.0* Hct-33.7*
MCV-97 MCH-34.7* MCHC-35.7* RDW-14.0 Plt Ct-195
[**2119-10-2**] 04:30AM BLOOD WBC-11.1* RBC-2.97* Hgb-9.6* Hct-28.2*
MCV-95 MCH-32.4* MCHC-34.1 RDW-13.7 Plt Ct-185
[**2119-10-14**] 06:15AM BLOOD Plt Ct-733*
[**2119-10-1**] 09:05PM BLOOD PT-12.6 PTT-43.1* INR(PT)-1.1
[**2119-10-13**] 06:35AM BLOOD Glucose-91 UreaN-10 Creat-0.7 Na-135
K-4.3 Cl-103 HCO3-23 AnGap-13
[**2119-10-2**] 04:30AM BLOOD Glucose-118* UreaN-9 Creat-1.0 Na-144
K-3.9 Cl-109* HCO3-24 AnGap-15
[**2119-10-14**] 06:15AM BLOOD ALT-39 AST-70* LD(LDH)-214 AlkPhos-200*
TotBili-0.7
[**2119-10-5**] 08:00PM BLOOD ALT-31 AST-74* LD(LDH)-220 AlkPhos-89
TotBili-1.9*
[**2119-10-14**] 06:15AM BLOOD Albumin-3.5
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] K.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on FRI [**2119-10-6**] 4:48
PM
Name: [**Known lastname **],[**Known firstname 58427**]
Unit No: [**Numeric Identifier 69834**]
Service: ORT
Date: [**2119-10-1**]
Date of Birth: [**2065-1-27**]
Sex: M
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4158**]
PREOPERATIVE DIAGNOSES:
1. Right grade 3B open segmental tibia fracture.
2. Right closed both-bone forearm fracture.
POSTOPERATIVE DIAGNOSES:
1. Right grade 3B open segmental tibia fracture.
2. Right closed both-bone forearm fracture.
PROCEDURE:
1. Irrigation and debridement, right open tibia fracture.
2. Intramedullary nailing, right open tibia fracture with
Synthes 345 x 10 mm Expert system.
3. Closed treatment and splinting of right forearm both-bone
fracture.
INDICATIONS: Mr. [**Known lastname **] [**Known lastname **] [**Known firstname **] is a 54-year-old gentleman
who was a pedestrian hit by a motor vehicle. The patient was
heavily intoxicated and tested positive for alcohol and
cocaine use. He was in no condition for written consent;
however, given the extensive nature of his lower extremity
injury, I deemed the need for debridement and stabilization
an emergency, and I am taking him to the operating room in
the patient's best interest. The procedure will be limited
today to the management of the open right lower extremity
wound. We will defer the right closed forearm fracture
dilator until later when the patient is able to provide
informed consent.
PROCEDURE IN DETAIL: The patient was brought to the
operating room and, after successful induction of general
anesthesia, the right lower extremity was prepped and draped
in the usual sterile manner. Aggressive debridement of the
open fracture, including any piece of devitalized bone and
dirty edges, was performed, and lavage was performed with 6
liters of pulsed irrigation solution. After appropriate
debridement had been achieved, an intramedullary nail was
placed.
An 8 cm incision on the knee was performed and via a medial
parapatellar exposure, the entry point was identified and
reamed to prepare entry of the nail. A long beaded guidewire
was inserted into the canal, and the fracture was reduced
over the beaded guidewire under fluoroscopic imaging. The
canal was subsequently reamed to a size 11.5 mm, and 10 mm x
345 nail was inserted with great care not to displac ethe
proximal tibia fracture reduction. The Expert system
allowed the placement of 5 proximal screws that managed the
proximal tibia fracture which was closed, and also allowed
for management of the distal shaft fracture. The fracture was
a segmental fracture of the shaft with a proximal tibia plane
approximately 5 cm from the joint in a distal open fracture
with extensive comminution. There was significant loss of
anterior bone cortex in the order of 2 cm, but the posterior
cortex fragments appeared to span the defect. The nail was
locked distally using freehand technique with 2 screws, and a
vacuum dressing was applied in anterior open wound. The
patient tolerated the procedure well and was taken back to
the trauma ICU for further workup and assessment.
SPECIAL ISSUES:
This was a difficult case given the segmatnal nature of the
proximal tibia fracture. It requried careful nailplacment and
care to keep a high proximal tibia fracture reducd while a
distal open fracture with bone loss while also addressed with
the same implant
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16347**]
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] K.
**NOT REVIEWED BY ATTENDING**
Name: [**Known lastname **], [**Known firstname 58427**] Unit No: [**Numeric Identifier 69834**]
Service: Date: [**2119-10-4**]
Date of Birth: [**2065-1-27**] Sex: M
Surgeon:
PREOPERATIVE DIAGNOSIS: Right both bones forearm fracture,
right distal radius styloid fracture, right distal ulna
fracture, right grade 3 open tibia fracture.
POSTOPERATIVE DIAGNOSIS: Right both bones forearm fracture,
right distal radius styloid fracture, right distal ulna
fracture, right grade 3 open tibia fracture.
PROCEDURE:
1. Open reduction internal fixation both bones forearm
fracture with plating.
2. Open reduction internal fixation distal radius pilon
fracture with percutaneous pins.
3. Irrigation and debridement down to muscle and vacuum
change dressing of right tibia wound fracture.
ASSISTANT: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], PA.
INDICATIONS: This is a staged procedure for Mr. [**Known firstname **]
[**Known lastname 21006**] who was hit by a motor vehicle. He underwent
emergent fixation of his tibia at the time of presentation.
He now presents for a staged management of his forearm
fracture and staged debridement of his wound.
PROCEDURE IN DETAIL: The patient was brought to the
operating room. After the successful induction of general
anesthesia, he was put in the supine position and the right
upper extremity was prepped and draped in the usual sterile
fashion. Approach to the fracture was exposed, preserving the
radial artery. The fracture was reduced with tenaculums and
plated with a 3.5 mm DCP plate using cortical screws. The
ulna was then exposed through a dorsal incision and also
plated with a DCP plate. This was a 7 hole plate. The final
reduction was found to be satisfactory in stability and
imaging in AP and lateral views. The acetabular fracture was
pinned percutaneously with two 1.5 mm K wires. The wounds
were copiously irrigated and closed in layers with Vicryl
sutures and staples. Attention was then turned to the right
lower extremity which was managed by removing the existing
vacuum dressing, irrigating and debriding the wound down to
the level of the muscle which appeared to be healthy and
clean. Subsequently a new vacuum dressing was applied. The
patient tolerated the procedure well and was taken to the
recovery room without incident. Dr. [**Last Name (STitle) 1005**] was present for
the entire procedure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16347**]
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] K.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] on FRI [**2119-10-6**] 4:48
PM
Name: [**Known lastname **],[**Known firstname 58427**]
Unit No: [**Numeric Identifier 69834**]
Service: ORT
Date: [**2119-10-1**]
Date of Birth: [**2065-1-27**]
Sex: M
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4158**]
PREOPERATIVE DIAGNOSES:
1. Right grade 3B open segmental tibia fracture.
2. Right closed both-bone forearm fracture.
POSTOPERATIVE DIAGNOSES:
1. Right grade 3B open segmental tibia fracture.
2. Right closed both-bone forearm fracture.
PROCEDURE:
1. Irrigation and debridement, right open tibia fracture.
2. Intramedullary nailing, right open tibia fracture with
Synthes 345 x 10 mm Expert system.
3. Closed treatment and splinting of right forearm both-bone
fracture.
INDICATIONS: Mr. [**Known lastname **] [**Known lastname **] [**Known firstname **] is a 54-year-old gentleman
who was a pedestrian hit by a motor vehicle. The patient was
heavily intoxicated and tested positive for alcohol and
cocaine use. He was in no condition for written consent;
however, given the extensive nature of his lower extremity
injury, I deemed the need for debridement and stabilization
an emergency, and I am taking him to the operating room in
the patient's best interest. The procedure will be limited
today to the management of the open right lower extremity
wound. We will defer the right closed forearm fracture
dilator until later when the patient is able to provide
informed consent.
PROCEDURE IN DETAIL: The patient was brought to the
operating room and, after successful induction of general
anesthesia, the right lower extremity was prepped and draped
in the usual sterile manner. Aggressive debridement of the
open fracture, including any piece of devitalized bone and
dirty edges, was performed, and lavage was performed with 6
liters of pulsed irrigation solution. After appropriate
debridement had been achieved, an intramedullary nail was
placed.
An 8 cm incision on the knee was performed and via a medial
parapatellar exposure, the entry point was identified and
reamed to prepare entry of the nail. A long beaded guidewire
was inserted into the canal, and the fracture was reduced
over the beaded guidewire under fluoroscopic imaging. The
canal was subsequently reamed to a size 11.5 mm, and 10 mm x
345 nail was inserted with great care not to displac ethe
proximal tibia fracture reduction. The Expert system
allowed the placement of 5 proximal screws that managed the
proximal tibia fracture which was closed, and also allowed
for management of the distal shaft fracture. The fracture was
a segmental fracture of the shaft with a proximal tibia plane
approximately 5 cm from the joint in a distal open fracture
with extensive comminution. There was significant loss of
anterior bone cortex in the order of 2 cm, but the posterior
cortex fragments appeared to span the defect. The nail was
locked distally using freehand technique with 2 screws, and a
vacuum dressing was applied in anterior open wound. The
patient tolerated the procedure well and was taken back to
the trauma ICU for further workup and assessment.
SPECIAL ISSUES:
This was a difficult case given the segmatnal nature of the
proximal tibia fracture. It requried careful nailplacment and
care to keep a high proximal tibia fracture reducd while a
distal open fracture with bone loss while also addressed with
the same implant
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16347**]
Brief Hospital Course:
Mr. [**Known lastname 21006**] was admitted to the [**Hospital1 1170**] on [**10-1**]/006 after being hit by a car while walking on the
street. He was evaluated by the trauma surgery service which
consulted neurosurgery and orthopaedics. His injuries were open
Right tib-fib fracture, Right forearm both bone fracture, and
small Left subdural hematoma. He intubated and taken to the OR
on [**2119-10-1**] for a right tibial nailing with debridement and splint
placement on Right forearm. He remained intubated
postoperatively and was taken to the Trauma Intensive Care Unit.
He was extubated without difficulty on [**2119-10-2**] and a repeat head
CT was done which showed no changes, at that time Neurosurgery
signed off with instructions to follow up with a repeat head CT
in 6 weeks. Mr. [**Known lastname 21006**] was placed on a CIWA scale with ativan
to monitor for any signs of ETOH withdrawal. On [**2119-10-3**] he was
transfered to the floor from the ICU for further care. On [**2119-10-4**]
he was again taken to the operating room for an ORIF for a right
distal radius fracture. On [**2119-10-5**] medicine was consulted to
help with managment of delerium tremens which recommende
treatment be changed from ativan to valium. Also at this time
he was placed on bedside sitters to provide safety. On [**2119-10-6**]
Mr. [**Known lastname 21006**] has a right leg angiography done to evaluate for
graft placement. On [**2119-10-10**] he was taken to the operating room
by plastic surgery for a muscle flap/split thickness skin graft
to his right leg. A VAC dressing was placed over the graft per
plastic surgery. On [**2119-10-11**] Mr. [**Known lastname 21006**] was appropriate
following commands with no signs of withdrawal noted and his
sitter was discontinued. Per plastic surgery he remained on
bedrest for 7 days after the flap placement. On [**2119-10-17**] he was
able to get off bedrest and keep his right leg dependent for 10
minutes 4 times a day while keeping his right leg non-weight
bearing. He can progress each day to an additional 5 minutes of
dependent positioning each day. He will follow up with Plastic
surgery this Friday. Please call to make that appointment.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for temp > 101.5.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 weeks.
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
s/p pedestrian struck
Discharge Condition:
stable
Discharge Instructions:
Keep the incision/dressing clean and dry.
You may apply a dry sterile dressing as needed for drainage or
comfort.
If you are experiencing any redness, swelling, pain, or have a
temperature >101.5, please call your doctor or go to the
emergency room for evaluation.
Resume all of your home medication and take all medication as
prescribed by your doctor.
*Continue your Lovenox injections as prescribed for
anticoagulation.
Please continue to be non-weight bearing on your right leg.
Physical Therapy:
Activity: Right lower extremity: Non weight bearing
Left lower extremity: Full weight bearing
dangle 15 minutes qid increase by 5 minutes each day starting
[**2119-10-18**]
Treatments Frequency:
Keep dry dressing over flap.
Keep clean and dry
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1005**] in 2 weeks, please call
[**Telephone/Fax (1) 1228**] to schedule that appointment.
Please follow up in plastic surgery clinic this Friday, please
call [**Telephone/Fax (1) 4652**] to scheudle that appointment.
Please follow up with Dr. [**Last Name (STitle) 69835**] in [**Hospital 4695**] Clinic in
6 weeks, please call [**Telephone/Fax (1) 1669**] to schedule that appointment,
please inform them that you need a follow up Head CT when you
make that appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2119-10-19**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2154
} | Medical Text: Admission Date: [**2175-2-16**] Discharge Date: [**2175-2-22**]
Date of Birth: [**2106-10-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
Ms. [**Known lastname 1356**] is a 68 yo F with recent history of L humerus fracture
[**2-6**] (nonoperative) who developed SOB & LH the day of admission.
C/o near syncopal event while walking to the bathroom. Father
and son called ambulance. Presented to OSH with these
complaints, hypotensive (60/p --> 76/51 --> 102/63) s/p fluid
resuscitation. Guaiac negative, CT with saddle emboli. Given
4000u heparin bolus and transferred to [**Hospital1 18**] for further
management. In our ED intial VS 132, 113/60, 22, 97/3L. Did
bedside cariac ultrasound, which was poor quality but did not
reveal RV strain. Lowest SBP 104/69 in ED. Able to answer all
questions. On heparin gtt from OSH to here. She is currently
getting IVF and has recieved approximately 200cc while in the
ED.
.
On arrival to the ICU, patient is conversant and mild tremulous
[**12-26**] 'nerves'. Relays history as above & denies any sense of
palpitations, chest pain or difficulty breathing. States her
left arm, which is significantly swollen, has actually improved
since the fracture. She also has some swelling / bruising of her
left breast s/p fall. She is right-handed. C/o of being
dehydrated and very thirsty. Denies any current pain.
.
Review of sytems:
(+) Per HPI; lost 9lbs approximately 3 months prior with
increased walking
(-) Denies fever, chills, night sweats, recent or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
myalgias.
Past Medical History:
Left humerus fracture - [**2-6**] nonoperative care using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8688**]
brace
HTN
Bipolar disorder
Anxiety
Social History:
Patient lives with her husband, 2 sons, and a daughter-in-law.
[**Name (NI) **] reports remote use of tobacco (but denies inhaling). She
denies alcohol or other recreational drug use.
Family History:
Patient denies FH of coagulopathy. Mother had [**Name2 (NI) 499**] cancer and
died at age 76. Father died at 79 during terrible accident when
her mother [**Name (NI) 53185**] ran over him with their car while backing
out of the garage.
Physical Exam:
Vitals: T: 97.1 BP: 116/66 P: 142 R: 22 O2: 100/2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi; L breast ecchymoses
CV: Regular rhythm, tachycardia, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: LUE with swelling, mild yellow appearance of skin, fingers
are warm and well perfused, brace on upper arm only, 2+ pitting
edema; RUE, LLE and RLE without erythema, edema or clubbing
.
Pertinent Results:
Admission Labs:
[**2175-2-16**] 04:00AM WBC-14.6* RBC-3.47* HGB-9.8* HCT-31.0* MCV-90
MCH-28.3 MCHC-31.6 RDW-13.3
[**2175-2-16**] 04:00AM NEUTS-90.7* LYMPHS-6.4* MONOS-1.4* EOS-1.4
BASOS-0.1
[**2175-2-16**] 04:00AM PLT COUNT-335
[**2175-2-16**] 04:00AM PT-14.8* PTT-150* INR(PT)-1.3*
[**2175-2-16**] 04:00AM CK-MB-NotDone cTropnT-0.06*
[**2175-2-16**] 04:00AM CK(CPK)-48
[**2175-2-16**] 04:00AM GLUCOSE-191* UREA N-18 CREAT-1.0 SODIUM-141
POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-20* ANION GAP-13
[**2175-2-16**] 04:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2175-2-16**] 08:36AM CK-MB-NotDone cTropnT-0.04*
.
ECHO - [**2-16**] - The left atrium is normal in size. The estimated
right atrial pressure is 10-20mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal(LVEF 70%). The right ventricular cavity is moderately
dilated with focal basal free wall hypokinesis. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Dilated right ventricle with severe hypokinesis and
relative preservation of apical function c/w large pulmonary
embolism ([**Last Name (un) 13367**] sign). Mild to moderate tricuspid
regurgitation. There is mild to moderate pulmonary hypertension
(UNDERestimated based on TR jet velocity as RA pressures are
likely greater than 15-20 mm Hg). Normal regional and global
left ventricular systolic function.
.
LENI Bilateral LEs [**2-16**] -
1. Deep vein thrombosis: Occlusive thrombus demonstrated in the
left
popliteal vein extending to the left calf veins.
2. Occlusive thrombus in the left greater saphenous vein
extending to its'
junction with the common femoral vein.
3. Left [**Hospital Ward Name 4675**] cyst.
No DVT of the left upper extremity.
.
LENI LUE [**2-16**] -
No DVT of the left upper extremity.
Brief Hospital Course:
68 yo woman wtih bipolar disorder, hypertension, and recent
humeral fracture who presented with shortness of breath to
outside hospital, found to have saddle pulmonary embolus on CTA,
now s/p IVC filter placement and discharged on coumadin.
.
Hospital course by problem:
.
# Pulmonary embolism: The etiology of the patient's PE is
unclear though it is expected to be partially due to recent
fracture and possible decreased mobility. Source was a large
left lower extremity DVT. Hemodynamic instability at the
outside hospital that resolved with fluids was presumably due to
preload dependency due to right heart strain. This was further
reenforced by formal echocardiogam here that showed severe right
ventricle hypokinesis. Nevertheless, the patient remained
hemodynamically stable after transfer to [**Hospital1 18**]. She had an IVC
filter placed given concern for further embolic events. She was
maintained on heparin and transitioned to coumadin on the night
of [**2175-2-17**]. She became therapeutic on coumadin and was
discharged with VNA follow up of INR.
.
# Left humerus fracture: This was sustained on [**2-6**]. She was
maintained in her previously placed brace and followed by
orthopedics. She was discharged with follow up appointments with
orthopedic surgery.
.
# Leukocytosis: This was noted upon admission to ED and the
patient had a left shift. Nevertheless, she was afebrile with
a negative UA and this was considered possibly just due to
stress in context of large PE. She ws monitored and her
leukocytosis resolved. She then developed a new leukocytosis and
was noted to have a UTI on UA and was discharged on antibiotics
for the UTI.
.
# Anemia: Patient had normocytic anemia, newly developed since
last admission. HCT 32 at OSH ED. Could possibly be marrow
suppression due to inflammatory state s/p fracture, but also on
heparin gtt. No h/o GIB. Guaiac negative at OSH prior to Heparin
gtt start. The pt was discharged with plans for outpatient
follow up of her anemia.
.
# Nongap metabolic acidosis: Present on presentation probably
due to compensatory tachypnea and respiratory acidosis. No
history of diarrhea or other increased bicarbonate losses. This
resolved over the course of her hospitalization.
.
# Bipolar disorder / Anxiety: The patient was stable on her home
psychiatric meds (lithium and trifluoperazine. )
.
# Hypertension: The patient was initially hypotensive on her
presentation to the outside hospital. Nevertheless she became
hypertensive here and was eventually started back on her home
anti-hypertensive regimen.
.
Medications on Admission:
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Trifluoperazine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day - states
stopped 2-3 days prior for low blood pressure
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever > 101.
2. Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
3. Trifluoperazine 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*3 Tablet(s)* Refills:*0*
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
Please draw INR on [**2175-2-23**] and fax to [**Telephone/Fax (1) 41861**] [**First Name9 (NamePattern2) 5035**]
[**Last Name (LF) **],[**First Name3 (LF) **] L.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis;
Pulmonary Embolism
Deep Vein thrombosis
Secondary Diagnoses:
Hypertension
Bipolar affective disorder
Discharge Condition:
Good, breathing comfortably on room air, able to ambulate with
some assistance.
Discharge Instructions:
Ms [**Known lastname 1356**]: You were admitted due to a large blood clot in your
lung. We monitored you and gave you blood thinners to keep this
clot from getting bigger. We eventually transitioned you to an
oral blood thinner. You are being discharged to complete your
therapy.
.
Your home medications remain the same. You have been STARTED on
short course of Cipro for a urinary tract infection. You have
also been STARTED on Warfarin for your pulmonary embolus. You
will need close follow up of your INR (a blood test) to follow
the levels of your warfarin.
.
Please return to the hospital or call your doctor if you have
fevers or chills, worsening chest pain or shortness of breath,
or any other concerning changes to your health.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2175-2-28**] 2:15
.
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Specialty: Primary Care
Date and time: [**3-2**] at 10:30am
Location: [**Street Address(2) 53186**], [**Location (un) 620**]
Phone number: [**Telephone/Fax (1) 5294**]
Special instructions if applicable: Patient is followed by above
NP
ICD9 Codes: 2762, 5990, 4019, 4168, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2155
} | Medical Text: Admission Date: [**2112-9-2**] Discharge Date: [**2112-9-6**]
Date of Birth: [**2059-2-6**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 53 year old male
patient with known coronary artery disease and chest pain ten
years ago with catheterization and percutaneous transluminal
coronary angioplasty. He has had five catheterizations since
that time. More recently he has had episodes with chest
pain, now severely affecting his quality of life. He has a
strong family history of aortic dissection and early cardiac
death. He has a long history of heart murmur with bicuspid
aortic valve. He complains also of increased shortness of
breath, fatigue even at rest, diaphoresis, nausea and
presyncopal episodes. Cardiac catheterization on [**2112-7-15**],
showed left main 20 percent lesion, left anterior descending
coronary artery 20 percent lesion, left circumflex and right
coronary artery normal, ejection fraction 55 percent, no
mitral regurgitation, no aortic insufficiency, moderately
dilated aortic root. Echocardiogram showed trace aortic
insufficiency, trace mitral regurgitation, 4.1 centimeter
ascending aorta with an ejection fraction of 65 percent and
mild left ventricular hypertrophy.
PAST MEDICAL HISTORY: Coronary artery disease with
percutaneous transluminal coronary angioplasty of left
anterior descending coronary artery in [**2103**].
Hypertension.
Hyperlipidemia.
Liver cyst.
Gastroesophageal reflux disease.
Thoracolumbar degenerative disc disease.
PAST SURGICAL HISTORY: Right leg cyst removal.
MEDICATIONS ON ADMISSION:
1. Lipitor 20 mg once daily.
2. Lisinopril 2.5 mg once daily.
3. Protonix 40 mg once daily.
4. Atenolol 12.5 mg once daily.
5. Diltiazem 120 mg once daily.
6. Aspirin 81 mg once daily.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs revealed heart rate 76
beats per minute and regular, blood pressure right 142/88,
left 128/84, height five feet eight inches tall, weight 185
pounds. In general, a stalky young man with slight shortness
of breath on examination. Skin - no obvious lesions. Head,
eyes, ears, nose and throat examination - The pupils are
equal, round and reactive to light and accommodation.
Extraocular movements are intact. Anicteric, not injected.
Neck - no jugular venous distention, no bruits. Chest is
clear to auscultation bilaterally. The heart is regular rate
and rhythm, S1 and S2, faint I/VI systolic ejection murmur
without radiation. The abdomen is soft, nontender,
nondistended, positive bowel sounds, no costovertebral angle
tenderness. Extremities are warm, well perfused.
Varicosities in the right posterior calf. Neurologically,
cranial nerves II through XII are grossly intact. Nonfocal
examination. Excellent strength in all four extremities.
HOSPITAL COURSE: The patient was admitted on [**2112-9-2**], with
diagnosis of dilated ascending aorta and bicuspid aortic
valve. He underwent a supracoronary ascending aortic graft
with a 24 millimeter gel weave graft and a resuspension of
the aortic valve under general anesthesia. Cross clamp time
was 53 minutes. Cardiopulmonary bypass time was 70 minutes.
He was transferred out of the operating room to the Cardiac
Surgery Recovery Unit in normal sinus rhythm with a rate of
84 and Propofol drip with a mean arterial pressure of 70, CVP
10, PAT 13. Postoperative day number one was uneventful with
a small amount of Neo-Synephrine continued for blood pressure
support. He was extubated also on postoperative day number
one. On postoperative day number two, his hematocrit was
down to 21. He was transfused two units of packed red blood
cells with increase in hematocrit to 27.3. He was
transferred to the inpatient unit on postoperative day number
two. He continued without any events on postoperative day
number three. His atrial and ventricular pacing wires were
discontinued. He had a brief episode of supraventricular
tachycardia that resolved spontaneously and did not recur.
His mediastinal chest tubes were also discontinued on
postoperative day number three. He was followed by physical
therapy throughout his hospital course and was found to be
safe for home on [**2112-9-6**]. He was discharged home with
visiting nurse at that time.
CONDITION ON DISCHARGE: On physical examination, his lungs
were clear to auscultation. Cardiovascular examination -
regular rate and rhythm, S1 and S2, no murmurs, rubs or
gallops. Incisions are clean, dry and intact. Sternum is
stable. Abdomen reveals positive bowel sounds, positive
bowel movement. Laboratories on discharge revealed white
blood cell count 8.6, hematocrit 27.5, platelet count
168,000. Sodium 139, potassium 4.1, chloride 103,
bicarbonate 29, blood urea nitrogen 13, creatinine 0.9,
glucose 110. Chest x-ray on the date of discharge showed
small bilateral pleural effusions, left greater than right,
patchy atelectasis within the left base, no pneumothorax.
DISCHARGE STATUS: To home with [**Hospital6 407**].
DISCHARGE DIAGNOSES: Coronary artery disease, status post
percutaneous transluminal coronary angioplasty of the left
anterior descending coronary artery in [**2103**].
Hypertension.
Elevated cholesterol.
Status post ascending aortic graft and resuspension of the
aortic valve.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Aspirin 325 mg p.o. once daily.
3. Percocet one to two tablets p.o. q4-6hours p.r.n.
4. Lipitor 20 mg p.o. once daily.
5. Protonix 40 mg p.o. once daily.
6. Ferrous Sulfate 325 mg p.o. once daily.
7. Vitamin C 500 mg p.o. twice a day.
8. Ibuprofen 600 mg p.o. q6hours p.r.n.
9. Lopressor 50 mg p.o. twice a day.
10. Lasix 20 mg p.o. once daily for seven days.
11. Potassium Chloride 20 mEq p.o. once daily for seven
days.
FO[**Last Name (STitle) 996**]P: Appointment with Dr. [**Last Name (STitle) 36206**] in one to two
weeks. Appointment with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 28068**]
MEDQUIST36
D: [**2112-9-6**] 17:18:38
T: [**2112-9-6**] 19:45:16
Job#: [**Job Number 55509**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2156
} | Medical Text: Admission Date: [**2145-5-20**] Discharge Date: [**2145-6-28**]
Date of Birth: [**2075-7-5**] Sex: F
Service: EMERGENCY
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Admission for transplant
Major Surgical or Invasive Procedure:
Tunnelled Central Line Placement
History of Present Illness:
69 y/o F with hx of AML with FLT3 mutation diagnosed in [**Month (only) 404**]
of [**2145**] after she presented to [**Hospital1 18**] [**Location (un) 620**] with fatigue. She
is s/p chemotherapy (7 + 3 induction) Day +141. She is being
admitted for nonmyeloablative allogeneic double cord transplant
with Fludarabine, Melphalan and ATG conditioning regimen.
.
Currently, patient reports that she feels well, has no
complaints and is anxious to start the treatment protocol.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
ONCOLOGICAL HISTORY:
From OMR admission note:
Ms. [**Known lastname 20281**] is a 69-year-old woman with a past medical history
significant for aortic valvular replacement for aortic stenosis
in [**2143**] and venous occlusion of the retinal vein in [**10/2144**], who
presented on [**2145-1-27**] to the [**Hospital 18**] [**Hospital 620**] campus with
increasing fatigue and shortness of breath. She had no fevers,
chills, or night sweats, but noted some easy bruising. She also
had some visual changes with diplopia and blurry vision due to
recent retinal vein occlusion. At [**Hospital1 18**] [**Location (un) 620**], Ms. [**Known lastname 20281**] was
found of a white blood count of 300,000 with 94% blasts. She was
started on IV fluids with
bicarbonate and was transferred to [**Hospital1 18**] for further management.
Flow cytometry on [**2145-1-27**] from her peripheral blood showed a
majority of the cells in the CD45 intermediate low side scatter
blast region. The cells expressed CD33 along with dim CD4 and
dim CD19. Cells were negative for CD34 and HLA-DR. [**Last Name (STitle) 20282**] were
negative for other myeloid markers including CD13, CD14, CD15,
CD41, CD64, glycolphorin, CD17. Immunophenotyping findings were
consistent with involvement by acute myeloid leukemia with a
peripheral smear revealing cup-like nuclei. Cytogenetics were
notable for FLT3 and NPM positivity. Echocardiogram showed a
left ejection fraction of greater than 65%. Because of her high
white count, Ms. [**Known lastname 20281**] [**Last Name (Titles) 1834**] leukophoresis and initially
received hydroxyurea. On [**2145-1-28**], she was initiated on 7 and
3 induction regimen with idarubicin and ara-C. Her course was
complicated by fever and neutropenia. She also was noted for a
drop in her ejection fraction to 20-25% on [**2145-2-14**], which was
felt due to anthracycline use. She has been managed medically
initially with spironolactone, furosemide, lisinopril, and
metoprolol and is followed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], NP as an outpatient. She is currently on spironolactone,
furosemide, diovan, and metoprolol. Her lisinopril was
discontinued due to cough which has since resolved. Ms. [**Known lastname 20283**]
course was complicated by her deconditioning and depression
regarding her diagnosis and conditioning. She was followed by
psychiatry while an inpatient and was discharged on [**2145-3-3**]
to [**Hospital1 **] House Rehabilitation in order to improve her strength
before moving forward with further therapy. Her cardiomyopathy
also limited her ability to receive further chemotherapy.
As an outpatient, Ms. [**Known lastname 20281**] was noted for a drop in her platelet
count. She had noted a superficial saphenous vein clot and was
started on Lovenox approximately two weeks prior to this. Her
Lovenox had been stopped due to her decreasing platelet count.
However, she was found to have a positive HIT antibody and was
admitted for initiation of Argatroban therapy on [**2145-3-22**].
Followup testing with serotonin releasing assay was negative,
thereby making HIT diagnosis unlikely. It was decided to stop
Argatroban. She had a repeat bone marrow aspirate and biopsy
done on [**2145-3-18**] and [**2145-3-26**], both showing no evidence for
patient's known leukemia, although the specimen on [**2145-3-26**]
showed megakaryocytic hypoplasia. Repeat testing for FLT3
mutation and NPM mutation were sent on [**2145-3-27**] and were
negative. Ms. [**Known lastname 20281**] was further evaluated with a repeat
ultrasound which continued to shows a superficial clot in the
saphenous vein, but there was no evidence for deep vein
thrombosis, so she did not require any further anticoagultion,
which would have been difficult as her platelet count has
remained low. She also was reevaluated with echocardiogram which
showed improvement in her left ventricular ejection fraction to
50-55%. Ms. [**Known lastname 20281**] was initially discharged to home on
[**2145-3-31**], but fell. She was readmitted overnight. CT of the
head was negative, and she was discharged to [**Location (un) 1036**] for
further rehabilitation. She has been followed in the outpatient
setting for transfusion support.
Over the past 4 - 6 weeks, Ms. [**Known lastname 20281**] has received periodic
transfusion support but her counts have slowly recovered. She
had a repeat bone marrow aspirate and biopsy on [**2145-4-23**] which
showed a hypocellular erythroid dominant bone marrow with
trilineage hematopoiesis whit no evidence for acute leukemia.
Her FLT3 mutation and NPM mutation have remained negative. Ms.
[**Known lastname 20281**] has also been transitioned to home with physical therapy.
She has increased her strength and conditioning and remains
independent in her care and is walking without issues. She has
increased her activity. This is also in the setting of improved
cardiomyopathy. Because of her known mutations, she is at high
risk for recurrent leukemia and is in need of n allogeneic
transplant. She is being admitted today for her nonmyeloablative
allogeneic double cord transplant with Fludarabine, Melphalan
and ATG conditioning regimen.
Past Medical History:
1. AML, cup-like.
2: Aortic valve replacement in [**4-/2143**] secondary to aortic
stenosis.
3. Hypertension.
4. Hypercholesterolemia.
5. History of hepatic cyst (noted on a preoperative workup for
AVR and stable on imaging) - was concerning for an echinococcal
cyst, and treated empirically with albendazole in [**10/2143**];
repeat CT from [**2145-2-16**] notes the cyst to be markedly smaller at
10.6 x 10.1 mm from 8.5 x 6.2 cm.
6. Cholelithiasis.
7. History of dysfunctional uterine bleeding.
8. Appendectomy.
9. Left retinal vein occlusion [**10/2144**] thought to be in setting
of leukocytosis [**2-22**] AML
10. Typhilitis during induction chemotherapy
Social History:
Married, lives with her husband in [**Name (NI) 620**], originally from
[**Name (NI) **], has 4 children, some live locally. Lifelong
non-smoker, very rare EtOH.
Family History:
Sister recently passed away of "unknown causes" while she was in
a NH. Sister had diabetes. No FH of cardiac disease. No history
of leukemia or lymphoma.
Physical Exam:
Vitals - T:97.9 BP:128/82 HR:79 RR:18 02 sat:100% on RA
GENERAL: NAD, elderly female, well appearing, thinned hair
HEENT: OP clear, no lesions or evidence of thrush, EOMI, PERRL
on R side, L pupil very sluggish-non-reactive has known L
retinal occlusion
CARDIAC: regular rate, 3/6 SEM throughout precordium, loudest at
LLSB, no heave
LUNG: CTAB, no wheezes, rhonchi or rales
ABDOMEN: +bs, well healed surgical scars from appendectomy and
aortic valve replacement surgery
EXT: 1+ non pitting edema, mild chronic venous stasis changes,
2+ DP pulses
NEURO: alert and oriented to person, place, time and purpose,
strength 5/5 UE/LE bilaterally, sensation intact throughtout, CN
[**3-4**] intact
DERM: no lesions appreciated
Pertinent Results:
LABS ON ADMISSION:
[**2145-5-19**] 09:35AM BLOOD Neuts-60.2 Lymphs-29.9 Monos-7.2 Eos-2.0
Baso-0.8
[**2145-5-19**] 09:35AM BLOOD WBC-2.9* RBC-2.91* Hgb-10.0* Hct-28.3*
MCV-97 MCH-34.2* MCHC-35.2* RDW-21.3* Plt Ct-126*
[**2145-5-19**] 09:35AM BLOOD PT-12.1 PTT-21.9* INR(PT)-1.0
[**2145-5-20**] 09:45AM BLOOD Fibrino-482*
[**2145-5-22**] 12:00AM BLOOD Gran Ct-9120*
[**2145-5-19**] 09:35AM BLOOD ALT-20 AST-24 LD(LDH)-216 AlkPhos-76
TotBili-0.5 DirBili-0.1 IndBili-0.4
[**2145-5-19**] 09:35AM BLOOD Albumin-4.2 Calcium-9.3 Phos-4.0 Mg-2.2
.
URINE:
[**2145-5-20**] 04:46PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2145-5-20**] 04:46PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2145-5-31**] 11:40AM URINE RBC-3* WBC-5 Bacteri-FEW Yeast-NONE
Epi-29 TransE-10
.
MICROBIO:
Bl Cx - [**6-3**] - E. coli
Bl Cx - [**2061-6-11**] Enterococcus faecium
IV Cath tip - [**6-13**] E. faecium
C. diff negative
Urine cx - negative
.
CARDIOLOGY:
TTE ([**6-13**]):
Conclusions
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %). A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis leaflets appear to move normally. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Emergent on-call
echocardiogram. Mild left ventricular systolic dysfunction.
Aortic valve bioprosthesis without obvious vegetations. Mild
mitral regurgitation.
If clinically indicated, a TEE will better assess for valvular
vegetations, especially in the presence of a prosthetic valve.
Compared with the prior study (images reviewed) of [**2145-5-7**],
left ventricular systolic function is less vigorous.
.
NEURO:
EEG ([**5-/2145**]):
This is an abnormal routine EEG due to a slow and poorly
modulated background indicative of a moderate to severe
encephalopathy.
Medications, metabolic disturbances, and infection are among the
most
common causes. There are no areas of prominent focal slowing
although
encephalopathies can obscure focal findings. There are no
epileptiform
features.
.
RADIOLOGY:
MRI Brain [**6-24**]:
IMPRESSION:
1. No acute infarction.
2. Diffuse bilateral mastoid air cells disease, mucosal
thickening and/or
fluid and also in the pneumatized petrous apices. While the
presence of
mucosal thickening and fluid does not by itself mean
mastoiditis, to
correlate clinically and with ENT examination to exclude
infective mastoiditis and if necessary LP, based on clinical
examination.
MRV without contrast can also be considered to assess Venous
sinuses.
3. The left internal carotid artery flow void in the carotid
canal is not
clearly identifiable on the present study unclear if this is
abnormal or
related to the oblique orientation of the head. MR angiogram of
the head
without IV contrast can be considered.
Brief Hospital Course:
Pt was admitted for allo-double cord transplant. On expiration
she was on day 31 of transplant. Her course was complicated by
prolonged MICU course as follows.
MICU course:
.
This is a 69 year old woman with AML, s/p 7+3, day 15 of
non-myeloablative allogeneic double cord transplant, with PMH of
bioprosthetic aortic valve, now in the ICU with worsening mental
status, increasing oxygen needs, and evident fluid overload in
the setting of acute renal failure and likely chronic heart
failure as well as recent VRE bacteremia.
.
HYPOXIA: Gradual increase in O2 requirement before transfer to
MICU, with increasing evidence of fluid overload. Repeat
echocardiogram showed EF newly depressed to 30%. She was given
high-dose Lasix followed by Lasix drip with minimal urine
output. O2 requirement continued to increase, and she was
intubated. CVVH was begun to remove volume. CVVH was continued
throughout her course. She was unable to be extubated.
.
CHF: EF newly depressed to 25-30% as seen on TTE the day of
transfer to MICU. Possibly secondary to prior chemotherapy.
Milrinone gtt was started with standing metoprolol to decrease
heart rate. SvO2s improved and milrinone was weaned. On later
echo EF improved to 35-40%. However, on day of expiration EF was
reduced to less 10% and she appeared to have cardiogenic shock.
.
ATRIAL FIBRILLATION: The patient developed atrial fibrillation
with a rate of 140s, compromising her forward flow and resulting
blood pressure. She received unsuccessful cardioversion but
then converted to NSR after two amiodarone loads. Amiodarone
was started and then discontinued after milrinone was stopped.
She had intermittent afib throughout her stay and was restarted
on metoprolol. In the last 24 hours her afib with RVR returned
when her BP dropped. She was given IVF boluses that temporarily
improved her HR before her final decompensation.
.
HYPOTENSION: This was likely secondary to atrial fibrillation as
well as a diffuse inflammatory response from engraftment causing
mixed cardiogenic and distributive shock. She required
phenylephrine in addition to milrinone initially. With the
administration of steroids and rate correction, the patient??????s
hemodynamics markedly improved. However, on day of death
hypotension returned and was not responsive to multiple pressors
and IVF. At that time it appeared to be cardiogenic and septic
in nature.
.
VRE BACTEREMIA: Linezolid was continued. No evidence of
vegetation on TTE or TEE.
.
ACUTE RENAL FAILURE: She had granular casts in urine and
presumably ATN. She was increasingly volume overloaded and
oliguric. During the first day in the ICU, she failed to
respond to 160 mg of Lasix followed by a Lasix gtt at 20mg/h as
well as metolazone. A temporary line was placed and CVVH
initiated. She remained on CVVH. On her last 2 days she has 6
liters of fluid removed per day. She was anuric at the time.
.
ALTERED MENTAL STATUS: Prior to intubation the patient was
altered in excess of her baseline anxiety. Differential
diagnosis includes bacteremia, sepsis, renal failure/uremia,
underlying malignancy, med effect, delirium of the critically
ill. MS did not improve during her course. She only would open
her eyes and blink in a non-responsive manner. She had a gag
reflex. MR of the head did not show a source. LP was attempted
at bedside but not able to be completed.
.
FEVER (WITH NEUTROPENIA): Cefepime, Flagyl, and micafungin for
empiric coverage of earlier fevers. Vancomycin had been started
before VRE was identified. Given this, continuing linezolid for
VRE. Filgrastim was continued. Three days prior to death
linezolid was changed to daptomycin due to suppressed cell
counts. Pt appeared to have a septic component on her final day.
.
AML: Tacrolimus was held and levels checked. CellCept was
continued. Methylprednisolone was started for likely engraftment
syndrome. Filgrastim was continued per BMT recs. She was on day
31 at time of death. Her WBC was still 0.1 without change.
.
Coagulopathy: INR trended up slowly. She was given vitamin K.
Seems out of proportion to liver impairment. Likely contribution
from poor nutritional status
.
Transaminitis: LFTs increased slightly from yesterday, unclear
significance but not likely hypoxic/shock, no new infections or
toxic medication effect.
Events of 24 hours proceeding expiration:
Pt had CVVH with 6 liters removed. Became hypotensive and had
afib with RVR. Given fluid, 3 liters of NS, but BP only
temporarily responded. SBP in 60s, started Neo-Synephrine and
required addition of Levophed. BP continued to be labile. IVF
boluses were continued. Stat echo showed EF of less than 10%. Pt
had code blue with hypoxia and PEA arrest. Briefly on Epi gtt.
Had <1 minute of compressions. Hypoxia and hypotension continued
once pulse returned. Primary oncologist also present during
events. Discussion with family and pt was made CMO. Pt expired.
Family declined autopsy.
Medications on Admission:
Furosemide 20 mg qd
Metoprolol Tartrate 50 mg tid
Mirtazapine 15 mg qhs
Sertraline 25mg qd
Spironolactone 12.5mg qd
Valsartan 80 mg [**Hospital1 **]
Acetaminophen 325 mg q6h prn pain
Multivitamin 1 tab qd
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2145-7-1**]
ICD9 Codes: 5845, 2762, 7907, 4254, 4280, 2767, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2157
} | Medical Text: Admission Date: [**2133-5-31**] Discharge Date: [**2133-6-4**]
Date of Birth: [**2083-9-24**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Morphine / Shellfish / Ferrous
Sulfate / [**Location (un) **] Syrup
Attending:[**First Name3 (LF) 10682**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Upper endoscopy
Sigmoidoscopy
History of Present Illness:
Ms. [**Name13 (STitle) **] is a 49 yo F w/multiple medical problems including
?autoimmune enteropathy, ? Crohn's disease, PE on coumadin, SVC
syndrome due to prior catheters s/p SVC stent, prior colectomy,
past GIB, chronic abdominal pain on narcotics who presents with
bright red blood per rectum. She reports 2 days of BRBPR with
every bowel movement and a single episode of hematemesis 1 day
ago which was a small amount and mostly water. She reports
about [**7-1**] bowel movements in the last 24 hours with increasing
amount of blood. She started measuring them with a hat and
reports [**11-4**] oz of blood. She states that there's no stool
with with bowel movements. She began to have symptoms of
lightheadedness and feeling unwell so she came into the ED. She
has not been eating anything but did have some raviolis at 7pm
the night prior to admission.
She was previously admitted [**Date range (3) 106850**] for GI bleed and
facial swelling. EGD showed candidal esophagitis and she was
treated with fluconazole and nystatin. Sigmoidoscopy was
normal. HCT trended down to 25.6 during that admission but she
received no PRBCs and recovered. She received a total of 4
units of FFP that admission. HCT recovered and level prior to
current admission was 35.5.
She reports that she takes 10mg of coumadin daily and uses a
home monitoring device to adjust her dose. She has been on a
stable dose of coumadin for several months. Goal INR is 2.5-3.5
per patient.
In the ED, initial vs were: T95.7 123 181/101 16 100% RA. She
brought in a jar with bloody stool and reportedly had a total of
8 jars at home. NG lavage was positive for black specks
although it was difficult to determine if these were coffee
grounds as she had recently eaten and it cleared immediately.
Guaiac was positive with bright red and brown stool. She was
given Pantoprazole 80mg IV x 1 and was started on a Pantoprazole
gtt. Her INR of 3.4 was not treated. She was given 2L of NS.
GI was consulted. She has 1 18 and 1 20 PIV. HR was 100 and BP
150/80 on transfer. She received 100mcg of Fentanyl prior to NG
lavage and another 100mcg of Fentanyl at 10pm due to abdominal
pain but the Fentanyl did not help with the pain.
On the floor, she reports [**9-2**] abdominal discomfort and a
feeling that her belly is "not quite right." She has abdominal
distention and bloating. She reports [**9-2**] low back pain. She
reports morning stiffness for which she takes PO dilaudid.
Review of sytems:
(+) Per HPI, + subjective fevers and chills
(-) otherwise negative
Past Medical History:
1. Question collagenous colitis dx'd by bx 98 status post
laparoscopic ileostomy in [**9-/2123**] followed by colectomy with
ileorectal anastomosis in [**1-/2124**]
2. Question Crohn's disease treated with Remicade in past c/b
?serum sickness and Pentasa.
3. Question seronegative spondyloarthropathy treated
with methotrexate--off since ~[**9-29**].
4. Chronic abdominal pain for which she is maintained on chronic
narcotic medications (methadone/morphine) and followed by the
pain clinic, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 106839**]- generally placed on PCA by pain
service during her admissions
5. Multiple prior central venous lines Hickman catheter in the
right subclavian in [**8-/2123**] and a Port-A-Cath in the left
subclavian in [**5-/2124**], most recently Hickman in the right,
removed [**9-29**] in setting of VRE bacteremia.
6. History of bilateral pneumothoraces
7. Raynaud's phenomenon
8. Migraine headaches
9. Irregular menses
10. Anxiety/depression, pt has not wanted to see psychiatry.
11. Acid reflux
12. Macrocytic anemia
13. Right-sided lumpectomy for benign mass
14. Question SVC syndrome; per Dr. [**Last Name (STitle) 6944**] is s/p SVC stent
placement (NO filter) in the setting of chronic indwelling
catheter status post failed attempt at PTCA in [**3-/2127**],
resolution of swelling upon line removal [**9-29**]
15. H/o multiple PE - on coumadin
16. H/o Klebsiella bacteremia
17. H/o Thrush
18. Polyclonal gammopathy.
19. Pancreatic insufficiency
20. Mult rib fractures
21. Osteonecrosis
Social History:
Lives at home with her husband and children; does not work d/t
medical problems, smokes 1ppd, drinks ~2 beers per day, no
illicit drug use.
Family History:
Father has polycythemia, mother has melanoma.
Physical Exam:
Physical Exam on Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no rales, rhonchi, +
end-expiratory wheezes diffusely
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly distended. Midline well-healed incision
as well as RLQ prior ostomy site which is well healed and
unremarkable. Discomfort on palpation without rebound or
guarding.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2133-5-31**] 09:00PM BLOOD WBC-7.7# RBC-4.39 Hgb-12.5 Hct-36.1
MCV-82 MCH-28.5# MCHC-34.7 RDW-18.6* Plt Ct-219
[**2133-5-31**] 09:00PM BLOOD Neuts-71.5* Lymphs-22.2 Monos-2.6 Eos-3.5
Baso-0.3
[**2133-5-31**] 09:00PM BLOOD PT-34.1* PTT-47.9* INR(PT)-3.4*
[**2133-5-31**] 09:00PM BLOOD Glucose-95 UreaN-9 Creat-0.8 Na-134 K-3.9
Cl-102 HCO3-21* AnGap-15
[**2133-6-1**] 02:27AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8
Discharge labs:
[**2133-6-4**] 09:44AM BLOOD WBC-4.9 RBC-4.28 Hgb-11.8* Hct-37.0
MCV-87 MCH-27.6 MCHC-31.9 RDW-18.9* Plt Ct-200
[**2133-6-4**] 09:44AM BLOOD PT-15.4* PTT-126.3* INR(PT)-1.3*
[**2133-6-3**] 02:39AM BLOOD Glucose-81 UreaN-6 Creat-1.0 Na-134 K-4.0
Cl-101 HCO3-26 AnGap-11
EGD, Wednesday, [**2133-6-3**]
Findings:
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Other procedures:
Cold forceps biopsies were performed for histology at the third
part of the duodenum.
Cold forceps biopsies were performed for histology at the
stomach antrum.
Cold forceps biopsies were performed for histology at the
stomach fundus.
Impression: (biopsy, biopsy, biopsy)
Otherwise normal EGD to third part of the duodenum
Sigmoidoscopy, Wednesday, [**2133-6-3**]
Findings:
Lumen: Evidence of a previous ileo-colonic anastomosis was seen.
The colonic mucosa ended at 30 cm. All mucosa had a normal
appearance and there was no inflammation.
Other procedures:
Cold forceps biopsies were performed for histology at the ileum.
Cold forceps biopsies were performed for histology at the
rectum.
Impression: Previous ileo-colonic anastomosis of the colon
(biopsy, biopsy)
Otherwise normal sigmoidoscopy to 70 cm
Brief Hospital Course:
Ms. [**Known lastname **] is a 49 yo F w/hx of multiple medical problems
including possible [**Name (NI) 4522**] disease and prior colectomy for
collagenous colitis, who presents with bright red blood per
rectum, admitted to the [**Hospital Unit Name 153**] for observation overnight.
1. Gastrointestinal bleed: She had no episodes of BRBPR while
in the hospital. Her HCT remained stable throughout, requiring
no transfusions. In the ICU, the patient was continued on a
pantoprazole gtt, transitioned to [**Hospital1 **] on the floor. GI was
consulted performed EGD and sigmoidoscopy, which did not reveal
a source of bleeding.
2. Hx of PE and SVC Syndrome: According to records, she had a
PE in [**2128**] which was treated, then SVC syndrome related to a
Hickman catheter s/p SVC stenting and removal of the catheter in
[**2128**]. She has had recurrent SVC syndrome with narrowing of the
L subclavian s/p venoplasty in [**2130**]. She had a nonocclusive
thrombus of the SVC stent [**2-1**]. Most recently MRV [**11-2**] showed
patent vasculature. She had been on coumadin and fondaparanox
in the past, now on coumadin with a goal INR of 2.5-3.5 (per Dr.
[**Last Name (STitle) 106851**] notes 3.0-3.5). Coumadin was held on admission, then
she was bridged with heparin gtt/lovenox for home. She did not
require reversal.
3. Hx of Crohn's Disease: She has persistent diarrhea and per
records last saw Dr. [**Last Name (STitle) 79**] on [**2133-4-8**], at which time she
recommended EGD and sigmoidoscopy for diagnostic purposes.
Biopsies were taken, which will need to be followed up.
4. Chronic Pain: She was continued on Fentanyl and Dilaudid per
home doses. She is also on Gabapentin. Flexiril was started.
5. Anxiety: She was continued on Clonazepam and Citalopram.
Medications on Admission:
albuterol sulfate 90 mcg HFA q6H PRN
citalopram 40 mg PO daily
clonazepam 1mg PO QID
dronabinol 10mg PO QID PRN nausea/cramping
Vitamin D 50,000 units qweek
fentanyl 50mcg patch TP q72H + 12mcg q72 hours
fluticasone inh 2 puffs [**Hospital1 **] PRN
gabapentin 800 mg Tablet PO TID
hydromorphone 2-4 mg PO q6H PRN shoulder pain - takes ~6 tabs
(2mg each) per day
omeprazole 40 mg cap PO BID
warfarin 10mg PO qdaily
zoledronic acid-mannitol&water [Reclast]
calcium carbonate-vitamin D3 600 mg-400 units 2 tabs [**Hospital1 **]
IV Iron infusions
Discharge Medications:
1. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day for 2 weeks.
Disp:*28 syringes* Refills:*0*
2. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back pain.
Disp:*20 Tablet(s)* Refills:*0*
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing, SOB.
4. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. clonazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
6. dronabinol 10 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for nausea.
7. cholecalciferol (vitamin D3) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
8. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. gabapentin 800 mg Tablet Sig: One (1) Tablet PO three times
a day.
12. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
14. warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Please adjust as necessary.
15. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: Two
(2) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleed
Chronic pulmonary embolus
Superior vena cava syndrome
Crohn's disease
Chronic Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were admitted for bleeding from the gastrointestinal tract.
Your blood counts have remained stable. You had an endoscopy
and sigmoidoscopy that did not reveal any source of bleeding.
Biopsies were taken to evaluated your diarrhea.
You were discharged on lovenox until your coumadin reaches
2.5-3.5 for 2 days in a row. Then you may stop the lovenox
injections.
You were also given a limited prescription of Flexiril for your
back pain. Please follow up with your Pain specialist.
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2133-6-17**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2133-7-15**] at 10:55 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: RHEUMATOLOGY
When: TUESDAY [**2133-8-25**] at 12:00 PM
With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please also follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as needed. Her
clinic number is [**Telephone/Fax (1) 250**].
ICD9 Codes: 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2158
} | Medical Text: Admission Date: [**2166-11-9**] Discharge Date: [**2166-11-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation
Left subclavian central line
History of Present Illness:
81 yo man with hx sig for CVA with residual seizure d/o and
hemiparesis presents with apparent sepsis, hypernatremia and
altered mental status from rehab. Per discussion with the ED
and [**Hospital 100**] rehab staff, the patient had [**Doctor Last Name 688**] mental status and
poor po intake over the past few days. He was empirically
startd on levofloxacin yesterday for ? PNA and ?UTI with labs
pending. He complained of feeling ill today but went out with
his wife, drinking only coffee. He was found later, obtunded,
with chicken in his mouth and hypoxic and hypotensive. Per
report, his heart rate was in the 80s in the field and BP was
60/40. O2 sat was 88% on RA. He received 250 cc NS in the
ambulance en route with improvement in BP to 80/39; this quickly
came up to 140s systolic with IVF.
In the ED, the pt was intubated for airway protection. Code
sepsis was called. He had a central line placed, and received
just less than 7 L of NS. Temperature was 100.1. Initial labs
showed high lactate and low Hct; repeat labs after hydration
showed CBC likely erroneous and lactate much improved. CXR
showed b/l PNA, head CT negative for bleed. The patient received
ceftriaxone, vanc and azithromycin for CAP and ? nosocomial PNA.
"Brown chunky secretions" in moderate amount were suctioned
from the ETT in the ED.
Past Medical History:
1. Hypertension.
2. Status post right frontal cerebrovascular accident with
residual left hemiparesis.
3. Status post left basal ganglionic hemorrhage with
residual right hemiparesis.
4. Status post generalized tonic/clonic seizures , most recent
here in ED [**5-6**].
5. Status post bilateral hip replacement.
6. Osteoarthritis
7. BPH s/p TURP
8. Hx RBBB
9. Depression
10. Mild Cognitive Impairment
11. Remote appendectomy
12. Lipoma excision
13. Achilles tendon repair
14. CRI (1.2)
15. Behavior d/o (aggressive)
Social History:
He is a retired mechanical engineer. No alcohol or tobacco use.
He is living at [**Hospital 100**] Rehab due to mobility issues at home.
He is married, he wife still lives at home.
Family History:
NC
Physical Exam:
Vitals: 97.4F, 72, 153/73, CVP 8, O2 100% on ventilator
Gen: Elderely man, sedated and intubated
HEENT: no icterus, dry mm, slowly reactive pupils
Neck: JVP approx 4
Heart: rr, no m/g/r
Lungs: coarse breath sounds with scattered rhonchi
Abd: s/nt/mildly distended, +BS, no hsm
Ext: thin, hairless, no c/c/e, 1+ dps
Psych: sedated and intubated
Skin: no decubs per rns
Pertinent Results:
Studies:
EKG: SR with RBBB, rate 88, no actue ST changes, similar to [**5-6**]
CXR [**2166-11-9**]: 1) ETT 5.5 cm above the carina, more optimally
positioned if advanced 1-2 cm. 2) Unchanged right upper and
lower lobe pneumonia.
Head CT [**2166-11-9**]: There is no hemorrhage, mass effect, shift of
normally midline structures, or hydrocephalus. There is
unchanged prominence of the ventricles and sulci, consistent
with involutional change. There are multiple lacunar infarcts,
specifically within the basal ganglia bilaterally, unchanged
from the prior study. There is stable periventricular
subcortical white matter low attenuation, which is consistent
with chronic microvascular ischemic changes. The surrounding
osseous and soft tissue structures are unremarkable.
CXR [**2166-11-14**]: Right upper lobe consolidation has substantially
cleared. Heart size top normal. Mediastinal widening suggests
vascular engorgement. No large pleural effusion and no
pneumothorax.
Admission Labs:
URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.025
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG RBC-0-2 WBC-0
BACTERIA-FEW YEAST-NONE EPI-0-2
WBC-8.6 RBC-2.27*# HGB-7.3*# HCT-22.8*# MCV-100*# MCH-32.3*
MCHC-32.2 RDW-13.6 NEUTS-79.3* BANDS-0 LYMPHS-16.7* MONOS-3.2
EOS-0.7 BASOS-0.1
PLT COUNT-114*#
PT-17.1* PTT-47.3* INR(PT)-2.0
GLUCOSE-170* UREA N-70* CREAT-2.8*# SODIUM-163* POTASSIUM-3.5
CHLORIDE-129* TOTAL CO2-22 CALCIUM-7.4* PHOSPHATE-2.0*
MAGNESIUM-2.3
1) CK(CPK)-297* cTropnT-0.05* CK-MB-10 MB INDX-3.4
2) CK(CPK)-400* CK-MB-14* MB INDX-3.5 cTropnT-0.10*
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-POS mthdone-NEG
LACTATE-4.4*
TYPE-ART PO2-176* PCO2-38 PH-7.40 TOTAL CO2-24 BASE XS-0
Brief Hospital Course:
81 y/o man with h/o cva and residual left hemiparesis presents
with PNA and sepsis.
1) PNA likely secondary to aspiriation requiring intubation.
Initial CXR showed RUL and RLL infiltrates. Started initially
on ctx, azithro, vanc and flagyl. On [**11-11**] his ABX was narrowed
to ctx and azithro. He tolerated cpap trial on [**11-11**] and was
successfully extubated on [**11-12**]. His respiratory status has been
stable since extubation. He finished a 5 day course of azithro
on [**11-14**]. He will be discharged to the acute care unit at
[**Hospital 100**] Rehab with an IJ central line to complete a 7 day course
of CTX (to end [**2166-11-16**]).
2) Sepsis. Pt volume resuscitated with 7 L of fluid in the ED.
He was monitored with frequent checks of lactate and
chemistries; lactate quickly normalized. Although he was
hypotensive in the field, he was hemodynamically stable and
never required pressors. He also rec'd 1u prbcs for likely
spurious hematocrit result. A random cortisol was normal.
3) AMS: Pt ws unresonsive per EMS and withdrew only to pain in
ED. Head CT was negative. The differential diagnosis for his
altered mental status includes post-ictal state (known sz
disorder), infection, hypernatremia, or new CVA not yet seen on
CT. His baseline mental status is unclear however he was alert
and answering questions appropriately prior to discharge. He
was continued on lamictal for sz and his infection and
hypernatremia were treated.
4) Hypernatremia (initial Na of 167): etiology thought to be
volume depletion, as suggested by elevated BUN/Cr and poor PO
intake as per NH staff. He was agressively rehydrated with NS
for intravascular depletion and his free water deficit of 5.1
liters was corrected with 200 cc /hr of D51/2 NS and free water
boluses through his NG tube. His Na normalized by [**11-13**].
5) Acute renal failure: Pt with longstanding mild CRI (1.2),
exacerbation likely [**2-5**] prerenal etiology and ATN. He was
rehydrated as above and his creatinine improved. His ACE
inhibitor was initially held given sepsis and ARF.
6) Hypertension: Initially held ACEI for renal failure. He was
started on a nitro drip on [**11-12**] prior to extubation. It was
discontinued on [**11-14**] and he was restarted on Lisinopril 40 mg
daily. His BP continued to be elevated in the 160's however no
additional changes were made to his medical regimen. Consider
starting a B-B as an outpatient.
7) Anemia: Pt's initial hct was 22 down from 40 in [**9-8**]. This
was likley a spurious result as repeat Hct after aggressive
hydration was 32. He received 1u prbcs. He hct remained stable
in the high 20's/low 30's during his hospital stay. He was
guaiac negative in the ED. The etiology of his anemia is
unclear.
8) Troponin leak: Likely in setting of ARF and demand ischemia;
enzymes negative by MB index.
9) FEN: He received Tube Feeds while intubated. Once extubated
he refused a formal speech and swallow evalution, however, his
nurse feels he is able to eat small amount of soft foods. He
should be continued on aspiration precautions.
11) Access: left IJ
Medications on Admission:
Zoloft 150 mg po qam
Lamictal 225 mg po qhs
Lisinopril 40 mg po qam
MVI liquid
Levaquin 250 mg po qd
Seroquel 25 mg po qhs
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
5. Lamotrigine 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): total dose of 225 qpm. Tablet(s)
6. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO at bedtime:
total of 225 at night.
7. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Ceftriaxone 1 g Recon Soln Sig: One (1) Intravenous once a
day for 2 days.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Aspiration Pneumonia requiring Intubation
Discharge Condition:
Fair
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience worsening shortness of breath,
confusion, chest pain, fever, or have any other concerns.
Please continue IV Ceftriaxone through central line to end
[**2166-11-16**].
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 14943**]) in one to two
weeks.
ICD9 Codes: 0389, 5070, 2760, 5849, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2159
} | Medical Text: Admission Date: [**2188-1-24**] Discharge Date: [**2188-1-29**]
Date of Birth: [**2105-3-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Pt. presented [**2188-1-24**] to [**Hospital1 **] with c/o headache, n/v times 1
and bifrontal headaches.
Major Surgical or Invasive Procedure:
Posterior Fossa Craniotomy for evacuation of a hemorrhage.
History of Present Illness:
This is a 82 year old gentelman with a history of
HTN,Hyperlipidemia,PVD s/p femoral bypass, ruptured AAA and Afib
on Coumadin who presented with c/p dizziness, ataxia and nausea
and vomitting with bifrontal headaches. CT scan of the head
revealed a posterior fossa lesion suspicious for a mass. Pt. was
taken off his Coumadin and taken to the OR for exploration of
this lesion which ended up being a hemorrhage.
Past Medical History:
PMH: Afib, HTN, LBP, syncope, PVD
PSH: s/p AICD, LLE bypass
Social History:
non smoker
non driner
Married
Family History:
n/c
Physical Exam:
Gen: Awake, alert, comfortable, NAD.
HEENT: Sclerae anicteric, no conjunctival injection, oropharynx
clear.
Neck: Supple.
Abd: Soft, NTND, BS+
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, speech
is
fluent with normal comprehension and repetition; naming intact.
No dysarthria. Registers [**3-11**], recalls 0/3 in 5 minutes even with
prompting. No right-left confusion. No evidence of apraxia or
neglect.
Cranial Nerves:
II: Pupils equally round and reactive to light, 4 to 2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally with
nystagmus at right end gaze.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline, movements intact without fasciculations.
Motor: No observed myoclonus, asterixis, or tremor. Slightl left
drift.
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Wound: Midline, neck incision closed with staples, C/D/I
Pertinent Results:
CT head:
IMPRESSION: Post-surgical changes after right posterior fossa
craniectomy
identified. Interval improvement in the amount of pneumocephalus
with
persistent foci of hemorrhage observed.
Brief Hospital Course:
This is a 82 year old gentelman with a history of
HTN,Hyperlipidemia,PVD s/p femoral bypass, ruptured AAA and Afib
on Coumadin who presented with c/p dizziness, ataxia and nausea
and vomitting with bifrontal headaches. CT scan of the head
revealed a posterior fossa lesion suspicious for a mass. Pt. was
taken off his Coumadin and reversed and eventually taken to the
OR for exploration of this lesion which ended up being a
hemorrhage, with no evidence of tumor.
Medications on Admission:
ISS, Zoloft, Imdur, Lasix, Doxazosin, Lipitor, Atenolol,
Allopurinol, Senna/Colace.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for sbp>170.
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Location **] Hospital
Discharge Diagnosis:
Cerebellar Hemorrhage
HTN
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair gently, do not scrub the area where the
staples are.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
. Do not resume your coumadin until clearence is given to you
by Dr. [**Last Name (STitle) 26803**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-18**] days(from your date of
surgery) for removal of your staples/sutures and/or 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 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) 26803**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2188-1-29**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2160
} | Medical Text: Admission Date: [**2114-12-23**] Discharge Date:
Date of Birth: [**2076-5-17**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Miss [**Known lastname 17811**] is a 38-year-old
female who originally had a lesion in the mid-sigmoid region,
which had been diagnosed as a diverticulitis. For this she
underwent a cecostomy. Postoperatively she underwent a
colonoscopy. However, the scope could not pass through and
biopsy revealed a carcinoma. A CT scan performed at this
hospital prior to surgery revealed no evidence of any
liver metastasis and a barium enema still showed an
obstructing lesion in the sigmoid. The gastrografin through
the cecostomy showed multiple large amounts of stool
collection without obvious lesions. Of note, is that in the
past the patient was difficult to intubate/extubate and she
is status post repair of the cleft palate a long time ago.
It was felt that a subtotal colectomy of this obstructing
lesion would be appropriate, since it was difficult to prep
the bowel. We discussed with the mother and the patient at
the time the benefit of getting rid of the cecostomy, which
was poorly functioning with skin complications.
PAST MEDICAL/SURGICAL HISTORY:
1. Colon cancer.
2. Cecostomy performed for obstructing diverticulitis.
3. Palate reconstruction.
4. Tracheal stenosis.
5. Hearing impairment.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: History of tobacco use. No history of
alcohol or drug use.
PHYSICAL EXAMINATION: Temperature 97.4, heart rate 68, blood
pressure 134/56, respiratory rate 20. 95% on room air.
General: Alert and oriented in no acute distress. Young
female. Head, eyes, ears, nose and throat exam within normal
limits. Lungs clear to auscultation bilaterally. Cardiac:
Regular rate and rhythm. No murmurs. Abdomen soft,
nontender. Cecostomy present. Bowel sounds present. Rectal
exam is within normal limits.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
General Surgery service. On [**2114-12-23**] she underwent subtotal
colectomy and take down of the cecostomy. She tolerated the
procedure well. There were no complications. Please see the
full operative note for detail. She remained intubated and
was kept in the Post Anesthesia Care Unit, then transferred
to the Intensive Care Unit. She was maintained on
intravenous fluids. Her white count decreased. An attempt
was made to extubate the patient, however, there was no cuff
leak and she did not tolerate it, requiring re-intubation.
Her hematocrit was noted to decrease and she was transfused
with packed red blood cells.
Otolaryngology was consulted and a CT scan of the neck was
done showing single enlarged left paratracheal lymph node,
numerous small lymph nodes throughout mediastinum and neck,
left lower lobe collapse and left pleural effusion as well as
incidental node of right aortic arch with possible apparent
left subclavian artery. The ENT service also did a
fiberscopic study, showing abnormal abduction of the vocal
cords and also a narrowing.
The patient was started on tube feeds and also
transparenteral nutrition. She spiked a fever to 103.7 with
blood cultures positive for staph aureus as well as the
central line tip. She was started on Vancomycin, Levaquin
and Flagyl. The patient continued to improve however.
Unfortunately she failed a second extubation attempt and
there still was no cuff leak. As a result on [**2115-1-3**] the
patient underwent tracheostomy. She tolerated the procedure
well. She was eventually transferred to the regular floor.
She continued to receive tracheostomy care as instructed.
She received an antibiotic course for a pneumonia diagnosed
on scan.
She had a clot in the left internal jugular vein. A PICC
line was placed on the other side and the central line was
removed. A repeat ultrasound of the internal jugular vein
showed partial resolution of the clot in the left internal
jugular. She was started on Lovenox 60 mg twice a day
injections. She was having diarrhea but C. difficile stool
test remained negative. A swallow examination was performed
and the patient was thought to be able to tolerate regular
consistency diet. A Passy/Muir valve was placed. She was
started on clear liquids and advanced to a regular diet which
she tolerated well. The tube feeds were discontinued and
feeding tube was removed. The TPN was stopped. She was
ambulating without difficulty. She remained afebrile.
Physical therapy consult recommended [**Hospital 3058**]
rehabilitation. The patient was discharged on [**2115-1-14**].
CONDITION ON DISCHARGE: Good.
DISPOSITION: Rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Colon cancer.
2. Subtotal colectomy.
3. Respiratory failure and vocal cord abnormality,
Status post tracheostomy.
4. Left internal jugular thrombosis.
5. Pneumonia.
DISCHARGE MEDICATIONS:
1. Percocet one to two tabs p.o. q 4 to 6 hours p.r.n.
pain.
2. Lovenox 60 mg subcutaneously q 12 hour injection
times one month.
3. Miconazole powder p.r.n.
4. Reglan 10 mg intravenous q 6.
5. Insulin sliding scale.
6. Tylenol 650 mg q 6 p.r.n.
7. Zofran p.r.n.
DISCHARGE INSTRUCTIONS: The patient is to follow-up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] (ENT) in 7 to 10 days for tracheostomy
check.
The patient is to follow-up with Dr. [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 3314**], her
surgeon, in approximately two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5014**], M.D. [**MD Number(1) 35804**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2115-1-14**] 21:44
T: [**2115-1-14**] 19:20
JOB#: [**Job Number 45780**]
ICD9 Codes: 5185, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2161
} | Medical Text: Admission Date: [**2181-11-4**] Discharge Date: [**2181-11-24**]
Date of Birth: [**2123-12-13**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 15373**]
Chief Complaint:
57 year old man with history of malignant melanoma, left
parietal infarct, multiple intracranial lesions most likely
consistent with metastasis, and ischemic right foot.
Major Surgical or Invasive Procedure:
1. Status post lumbar puncture
2. Right femoral popliteal bypass
History of Present Illness:
Mr. [**Name14 (STitle) 66264**] is a 57 year old man with a history of melanoma
status post excision in [**2181-7-14**], lung nodule on CXR 2-3 months
ago, as well as history of deep vein thrombosis, peripheral
vascular disease and hypothyroidism who transferred to [**Hospital1 18**] on
[**11-4**] for workup of a cold, blue right foot.
.
Over the past 2 weeks, his family has noted intermittent
episodes of confusion and agitation. The first episode occured
about two weeks ago when he was driving his car erratically. The
passenger reported that he was speaking nonsensically and
mumbling so that she could not understand him. When his wife
arrived to the scene, she says that he "looked funny" but was
unable to further characterize his appearance. She also noted
that the patient had difficulty walking "as if he were drunk."
She took him home and he slept for a few hours. On awakening, he
"was fine". He has no recollection of this event. Later in the
week, he had several more, similar episodes characterized by
nonsensical speech, confusion, and amnesia. On Saturday [**11-4**],
he went for an MRI of his right foot and leg. His wife reports
that his foot had been bothering him for the past year. After
the MRI, he again seemed confused and tired. He went to bed when
he came home and slept for much of the day. When he woke up, his
speech again "did not make sense". His wife said that he kept
repeating that he "needed help". He also complained of a mild
headache and vomited several times. His wife called an ambulance
and he was brought to a local ED where he was found to have a
cold, blue foot.
Past Medical History:
1. Malignant Melanoma-on back s/p excision [**7-19**] - 2 x 1.4cm
lesion, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 68586**] [**Last Name (NamePattern1) 1105**], w/greatest thickness of .5mm. Four
axillary LNs were sampled and found to be negative.
2. Lung nodule on Chest CT 3 months ago at [**Hospital 487**] Hospital
3. Deep vein thrombosis [**2179**]
4. Peripheral vascular disease
5. Hypothyroidism
6. No history of stroke or seizure
7. ?GERD-admitted on Protonix
Social History:
No history of tobacco or alcohol. Works as facilities manager
and lives with wife and children.
Family History:
Father died of "rare blood disease" at 39. History of diabetes
in his mother. [**Name (NI) **] other known history of cancer.
Physical Exam:
Exam:
T-99.5 BP-142/77 HR-81-89 RR-[**11-28**] O2Sat-96%
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
CV: RRR, Nl S1 and S2
Lung: Clear to auscultation bilaterally
Abd: +BS soft, nontender
Ext: right foot cold and mottled, no palpable pulse.
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, teary
throughout exam. Unable to relay a coherent history. Oriented to
person, place (Knows that this is [**Hospital3 **], but thinks he is
in [**Location (un) **], MA), month and year. Inttentive, says DOW
forwards, but unable to say them backwards. Speech is fluent
with mildly impaired comrehension (unable to "point to source of
illumination" though can follow simpler appendicular commands),
repetition is intact; naming impaired for low frequency objects,
but was able to name all items on the stroke card. No
dysarthria. [**Location (un) **] and writing profoundly impaired: He is able
to write illegibly in capital letters, but no discernable words
formed. Registers [**3-16**], recalls 0/3 in 5 minutes. He has right
left
confusion. No finger anomia. Unable to do simple calculations.
Evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Extinguishes DSS in right visual field. Extraocular
movements intact bilaterally, no nystagmus. Sensation intact
V1-V3. Facial movement symmetric. Hearing intact to finger rub
bilaterally. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. Right drift.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 * * * *
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
*limited by pain but at least [**3-18**]
Sensation: Intact to light touch, pinprick, + extinction to DSS
on right. JPS and vibration difficult to assess given
inattention.
Reflexes: +2 and symmetric throughout. Toes downgoing on left,
unable to asses on right due to pain.
Coordination: Finger-nose-finger normal, RAMs normal.
Gait/Romberg: Unable to assess due to ischemic foot.
Pertinent Results:
[**2181-11-3**] 09:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2181-11-4**] 05:50AM BLOOD %HbA1c-6.4* [Hgb]-DONE [A1c]-DONE
[**2181-11-4**] 05:50AM BLOOD Triglyc-78 HDL-35 CHOL/HD-4.3 LDLcalc-99
[**2181-11-4**] 05:50AM BLOOD TSH-1.2
[**2181-11-4**] 05:50AM BLOOD Free T4-1.2
.
EEG:[**2181-11-4**] This is an abnormal EEG of stage II sleep due to
the
infrequent bursts of generalized delta frequency slowing. This
abnormality suggests a deep midline subcortical dysfunction.
.
CT brain: 10/22/061. Enhancing 7 mm lesion in the left parietal
lobe, concerning for metastatic focus given history of melanoma.
2. Surrounding edema within the left parietal lobe may be
secondary to this metastatic focus. Given its large distribution
relative to metastatic lesion and loss of [**Doctor Last Name 352**]-white matter
differentiation and sulcal effacement, infarction should also be
considered. An MRI would be of further utility in evaluating for
additional nonvisualized metastatic lesions as well as
infarction.
3. Mild shift of midline rightward approximately 2 mm. No
evidence of gross herniation.
.
MRI [**2181-11-4**]:
1. Subacute infarction in the left posterior MCA/PCA - MCA
watershed zone distribution. 2. Three more rounded areas of
enhancement in the left hemisphere, likely representing
metastatic disease.
.
MRI [**2181-11-23**]: Left MCA stroke with underlying history of
melanoma. T1-weighted axial and sagittal images are performed
through the brain following intravenous gadolinium
administration. Comparison is made to the prior exam from
[**2181-11-4**]. The examination is significantly degraded due
to patient motion and patient shaking during the exam.
There is a wedge-shaped area of increased T1 signal which
partially enhances following intravenous gadolinium
administration involving the left posterior parietal lobe along
the watershed distribution. This corresponds to the previously
seen area of infarction from the previous exam of [**2181-10-14**].
No other abnormal enhancements are seen within the brain
parenchyma. The ventricular system is symmetrical without
hydrocephalus. The examination does not exclude the presence of
metastatic disease. A repeat examination would be recommended
preferably with sedation for further evaluation of the brain
parenchyma. There is a small enhancing lesion involving the left
caudate nucleus which was present on the previous exam. The left
posterior parietal lesion is not visualized on the current exam.
Overall, the exam remains degraded by motion artifact and repeat
study with gadolinium administration using MP-RAGE protocol
would be recommended for further evaluation.
.
ECG: [**2181-11-15**] Sinus rhythm. Possible prior inferior infarct.
Since previous tracing, no significant change.
.
Carotid Ultrasound: No evidence of internal carotid artery
stenosis on either side.
Brief Hospital Course:
Hospital course by system:
1. Neurology: When transferred here on [**11-4**], Mr. [**Known lastname 68587**]
remained confused. Imaging studies demonstrated a subacute
infarction in the left posterior MCA/PCA territory along with
multiple lesions suggestive of metastatic disease, question
melanoma. Outside pathology confirmed incidence of malignant
melanoma ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1105**]) on his back from that was removed with
negative lymph nodes in [**7-19**]. A Neuro-oncology consult was
obtained and workup for potential source of metastatic appearing
brain lesions was performed. On [**11-6**], a CT torso was negative;
notably, it did not show evidence of the pulmonary nodules seen
previously at [**Hospital3 **]. On [**11-7**], a bone scan was
negative for osseious disease. Cytology from cerebrospinal fluid
failed to demonstrate malignant cells in the CSF. Social work
was involved to support the family through the admission. The
family were able to meet with Neuro-Oncologist [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 4253**] to
discuss options for diagnosis of the brain lesions and
therapeutic options. A brain biopsy was recommended. A WAND
study of the brain was conducted on [**2181-11-22**], and due to changes
in the parietal lesion, which was more wedge-shaped and
consistent with infarct, the decision was made to reimage the
brain via MRI with and without contrast and MR spectroscopy with
plan to discharge Mr. [**Known lastname 68587**] to rehab and have him follow-up
with the [**Known lastname **] and Neurosurgical teams. His case will be
discussed in the multidisciplinary Brain [**Hospital 341**] Clinic and follow
up brains will be figured out at that time.
.
In regards to his initial presentation, seizures were considered
a possible explanation for his behavioral changes. EEG was
abnormal but without epileptiform activity. Patient was started
on Keppra but developed depressed mood. Keppra was ceased and
dilantin commenced. Dilantin was ceased on [**2181-11-19**] due to
supratherapeutic levels and suspected drug rash owing to
associated blanching erythematous maculopapular rash and fever.
Trileptal was commenced for seizure prophylaxis and foot pain.
He will titrate up to a dose of 900 mg po bid.
.
In regards to his left parietal lobe stroke, a stroke work up
was undertaken. ECG showed changes suggestive of old infarct.
Cardiac enzymes were negative. Patient was started on Aspirin.
Cardiac echo was unremarkable. Stroke work up showed normal
lipids on statin treatment. The statin was continued. Duplex
ultrasound of carotids found no significant disease. HbA1c was
6.4.
.
2. Vascular: Patient presented with ischemic right foot. Right
lower extremity angiogram was performed. This showed occlusion
of the distal SFA with reconstitution of an anterior tibial
artery at its origin with run off to the foot via this vessel.
There was some stenosis or occlusion of the mid anterior tibial
with reconstitution distally and flow into the foot via patent
dorsalis pedis artery (Please see results). The decision was
made to take the patient to the operating room for a lower
extremity revascularization. Prior to surgery Mr. [**Known lastname 68587**] was
placed on heparin GTT.
.
As Mr. [**Known lastname 68587**] continued to experience significant pain, a pain
consult was obtained and his pain regiment was improved,
although it remained difficult to control due to ischemia. He
was cleared by cardiology, and a right femoral-popliteal bypass
was performed on [**11-13**]. The operation went well. He was
transferred to the vascular service on the day of surgery and
returned to the neurology service on [**2181-11-17**]. The wound is
healing well. Mr [**Known lastname 68587**] has some post operative pain likely
neuropathic in origin due to vascular damage to nerves. This was
treated with Trileptal. PT was involved to mobilize. His
staples will be removed as an outpatient in the vascular surgery
clinic; please call to schedule an appointment in one week.
.
3. GI: Patient was continued on protonix.
.
4. Respiratory: Mr [**Known lastname 68587**] required oxygen via nasal cannulae
to 2L intermittently throughout the admission. There was no
deterioration throughout.
.
5. Infectitious disease: Post operative fevers occurred on
[**2181-11-17**] and [**2181-11-19**]. Urine, blood cultures and CXR were
unremarkable. CXR, urine cx, and blood cx from [**2181-11-20**] were also
unremarkable.
.
6. Endocrine: Thyroid function was normal. Thyroxine continued.
.
7. Derm: The patient developed an erythematous morbilliform rash
during the last week of his admission. It was felt that this was
most likely due to Dilantin hypersensitivity. Dilantin was
discontinued.
Medications on Admission:
1. Oxycontin 20 mg [**Hospital1 **] prn
2. Protonix 40mg QD
3. Lipitor 20mg QD
4. Levoxyl 25mg QD
5. [**Doctor Last Name 18928**] 30mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Insulin Regular Human 100 unit/mL Solution Sig: variable
units Injection ASDIR (AS DIRECTED): per adult sliding scale.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One Hundred
(100) mg Injection TID (3 times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-15**] Sprays Nasal
TID (3 times a day) as needed.
9. Oxcarbazepine 300 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Increase to 3 tablets (900 mg po bid) on Wednesday
[**11-28**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
1. Left MCA parietal lobe stroke, question underlying mass
lesions
2. Peripheral vascular disease status post ischemic right leg
status post femoral popliteal bypass
3. Melanoma removal from back [**7-19**]
4. Question seizures
5. Hypothyroidism
Discharge Condition:
Fair. Still with residual parietal lobe infarction signs with
difficulty attending to the right side of the world,
dyscalculia, difficulty [**Location (un) 1131**] and writing, right left
confusion, and finger agnosia.
Discharge Instructions:
Please take all medications as prescribed.
Please keep all follow up appointments.
Please return to the closest Emergency Room if you have any
headaches, visual changes, speech or language disturbances,
focal numbness, weakness, incoordination.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 68588**] at [**Telephone/Fax (1) 68589**] to schedule
follow up.
The Brain [**Hospital 341**] Clinic will contact you regarding follow up with
[**Name (NI) **] and NeuroSurgery. Their number is [**Telephone/Fax (1) 1844**].
Patient needs follow up in the [**Hospital **] Clinic with Dr. [**Last Name (STitle) **].
Please call for an appointment; needs to be seen in 1 week to
have staples removed. Call [**Telephone/Fax (1) 2395**] for appointment
ICD9 Codes: 5180, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2162
} | Medical Text: Admission Date: [**2200-9-3**] Discharge Date: [**2200-9-19**]
Date of Birth: [**2134-4-5**] Sex: M
Service: CARDIAC S.
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 42326**] is a 66-year-old
male with at least a four year history of stable angina. He
has been very active and often feels more discomfort at the
beginning of the walk. If he continues, the discomfort
usually disappears. He also noticed discomfort occurring
when he would carry heavy objects. Most of the discomfort
occurred in the area of his neck, as well as chest. It would
disappear with rest. The patient did not complain of any
shortness of breath, increased fatigue, or discomfort at
rest. The patient had several imaging studies performed in
the past. One in [**2200-8-3**] showed reversible
inferoseptal and inferior defects, as well as dilated right
ventricular cavity. The patient denied any symptoms of
claudication, orthopnea, edema, paroxysmal nocturnal dyspnea,
or lightheadedness. The patient does have a history of
hypertension, high cholesterol, and he is a former cigar
smoker. Prior to admission, the patient had cardiac
catheterization on [**2200-9-3**], given exertional angina and
positive stress test. Cardiac catheterization showed
three-vessel coronary artery disease. Specifically, the left
main coronary artery had a 50% osteal lesion. The left
anterior descending artery was totally occluded at the level
of the proximal segment. The circumflex system had a 95%
occlusion at the bifurcation point of the obtuse marginal I.
The right coronary artery had a proximal 20% stenosis and it
was calcified. Given these findings, the patient was
referred to cardiac surgery for a possible surgical
intervention.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
PAST SURGICAL HISTORY: Appendectomy.
SOCIAL HISTORY: History of smoking cigars.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg PO q.d.
2. Norvasc 5 mg PO q.h.s.
3. Lescol 20 mg PO q.h.s.
4. Atenolol 75 mg PO q.d.
5. Multivitamins.
LABORATORY DATA: Laboratory data revealed the following:
Hematocrit 44, WBC count 8.2, platelet count 138,000,
potassium 4.2, glucose 143, BUN 16, creatinine 0.9, sodium
138, creatinine kinase 90, AST 20, ALT 19, amylase 51,
alkaline phosphatase 63.
PHYSICAL EXAMINATION: Examination revealed that the patient
was alert and oriented and in no apparent distress. Heart
rate: 72. Blood pressure 142/79. Respiratory rate 18. 98%
on room air. Afebrile. HEENT: Within normal limits. No
JVD. No bruits. CARDIAC: Examination revealed regular rate
and rhythm, no murmurs, gallops or rubs. LUNGS: Lungs were
clear to auscultation bilaterally. ABDOMEN: Soft,
nontender, nondistended. Bowel sounds present. EXTREMITIES:
Warm and well perfused. Pulses present bilaterally in the
upper and lower extremities.
HOSPITAL COURSE: Cardiac catheterization performed on
[**2200-9-3**] showed three-vessel coronary artery disease with
normal systolic function and mild-to-moderate diastolic
dysfunction. The patient was admitted to the Cardiac Surgery
Service for a coronary artery bypass graft.
On [**2200-9-4**], the patient underwent coronary artery bypass
grafting times two with left internal mammary artery to left
anterior descending coronary artery and reverse saphenous
vein graft from the aorta to the obtuse marginal coronary
artery. The patient tolerated the procedure well. There
were no complications. Please see the full operative report
for details.
The patient was transferred to the Intensive Care Unit in
fair condition. The patient remained intubated.
In the Intensive Care Unit the patient remained in sinus
rhythm with occasional paroxysmal atrial contractions noted.
The patient was extubated the same day. He continued to make
adequate urine. The chest tubes were removed on
postoperative day #1. Intensive pulmonary toilette was
applied. The patient remained on insulin drip. The patient
was continued beta blocker and aspirin.
On postoperative day #2, the patient went into rapid atrial
fibrillation. The patient was put on an amiodarone drip.
Electrolytes were repleted as necessary. He had a mild
hypoxic episode. Given the hypoxic episode. The
pulmonologist was consulted.
The patient was continued on Levaquin and also on heparin
drip, as well as Lopressor, amiodarone, and Plavix. The
sputum culture obtained at the time showed yeast, otherwise,
unremarkable. The patient was re-intubated on postoperative
day #4 for hypoxia and respiratory failure. It was thought
that the patient aspirated during intubation. The patient
continued to have occasional bursts of atrial fibrillation,
but otherwise, remained in sinus rhythm. The patient
continued to be febrile. The possibility of aspiration
versus ARDS was raised. Tube feeds were initiated. A chest
x-ray obtained on [**2200-9-8**] showed improving pulmonary edema.
Echocardiogram was obtained on [**2200-9-7**], which was limited,
but did show a small pericardial effusion. The patient was
started on Vancomycin and Clindamycin, in addition to
Levofloxacin. Blood cultures were obtained, which showed no
growth. Pumonology consultation thought that ARDS was less
likely.
Nutritional Services were consulted and monitored the
patient's tube feeds and provided recommendations. The
patient proved to be difficult to wean off pressure supports.
The patient continued to have low-grade fevers, without
clearly identified source.
On postoperative day #11, the patient was noted to have
increased secretions. He consequently underwent a bedside
bronchoscopy, which showed minimal secretions present. The
patient was finally extubated again on postoperative day #12.
Pulmonary status improved gradually. Physical Therapy
Department was consulted. The followed the patient
throughout his hospitalization. The patient was eventually
transferred to the regular floor in stable condition. The
patient was continued on oral Amiodarone and Lopressor. He
remained in sinus rhythm. The hematocrit was stable. The
blood pressure and heart rate remained stable, as well. He
was clear to auscultation with decreased breath sounds at the
bases, but, otherwise, within normal limits. The patient was
ambulating.
The Department of Physical Therapy worked with the patient
and cleared him to go home.
On [**2200-9-19**], the patient was discharged to home in stable
condition.
CONDITION ON DISCHARGE: Good.
DISCHARGE DESTINATION: Home.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times two.
2. Hypertension.
3. Hypercholesterolemia.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg PO q.d. times one month.
2. Percocet 1 to 2 tablets PO q.4h. to 6h.p.r.n. pain.
3. Albuterol inhalers 1 to 2 puffs every six hours p.r.n.
4. Lescol 20 mg PO q.d.
5. Protonix 40 mg PO q.d.
6. Enteric coated aspirin 325 mg PO q.d.
7. Colace 100 mg PO b.i.d. p.r.n. constipation.
8. Potassium chloride 20 mEq PO b.i.d. times 10 days.
9. Lasix 20 mg PO b.i.d. times ten days.
10. Lopressor 12.5 mg PO b.i.d.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with his surgeon,
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in approximately six weeks.
2. The patient is to follow up with his cardiologist,
Dr. [**Last Name (STitle) 11493**] in approximately 3-4 weeks.
3. The patient is to followup with his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in approximately one to two
weeks.
4. The patient is to have his liver function enzymes checked
next week while he remains on Amiodarone with the results
sent to his primary care physician.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2200-9-22**] 15:11
T: [**2200-9-22**] 15:16
JOB#: [**Job Number **]
ICD9 Codes: 5185, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2163
} | Medical Text: Admission Date: [**2181-4-24**] Discharge Date: [**2181-4-27**]
Date of Birth: [**2113-2-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Capsular hematoma and pneumothorax post liver biopsy.
Major Surgical or Invasive Procedure:
percutaneous liver biopsy
History of Present Illness:
68 year-old male with recently diagnosed HTN and liver mass
admitted for hemodynamic monitoring from intraperitoneal bleed
after liver biopsy. Mass was incidentally discovered on a CT for
nephrolithiasis [**2113**], and initially believed to be in
pancreas. CT and MR of the abdomen showed 4x3cm mass to be in
caudate liver. He presented for IR liver biopsy on [**4-24**], which
was complicated by small RUL ptx. He was under observation when
HCT dropped from 53 (admit) to 41 this morning. Of note, HCT was
45 post bx-->41 14 hrs later. CT abd/pelvis showed subcapsular
hematoma, retroperitoneal bleed, blood in pelvis. On transfer to
MICU for close observation hemodynamically stable and normal.
Denies SOB, dizziness, abd pain. Had stopped baby ASA one week
prior to liver bx.
Past Medical History:
1. Liver mass as above
2. AAA 3x3 with minimal prior dissection
3. Nephrolithiasis (fall [**2179**])
4. Hypertension (diagnosed two weeks prior, no medications)
5. Right inguinal hernia status post repair [**5-/2180**]
6. Arthritis
7. Alcohol abuse
Social History:
Retired school teacher, lives in [**Hospital1 1562**] currently with dying
brother. [**Name (NI) **] reports smoking [**5-31**] cigs/day for 40 years and 2
drinks/week. However, cousin told nurse that patient drinks and
smokes much more than he admits. No prior blood transfusions.
Family History:
Brother has prostate Ca, colon cancer, CAD s/p bypass, now dying
from cancer metastases. No family hx of pancreatic/liver
disease.
Physical Exam:
98.8 HR 82-88NSR BP 159/65(not accurate) RR24-28 O2sat 91-96% on
room air
Gen: AOX3. NAD
HEENT: anicteric, PERRL, OP clear, no JVD
Chest: RRR, nml S1 S2
Pulm: CTAB
Abd: +Bs, NT, soft, tympanitic, no guarding, mildly distended
Extr: No edema
Pertinent Results:
Labwork on admission:
[**2181-4-24**] WBC-6.8 HGB-17.9 HCT-53.0* MCV-102* MCH-34.5* MCHC-33.8
PLT 178
[**2181-4-27**] WBC 5.2 Hgb 11.2 Hct 32.5 Plt Ct 120
[**2181-4-24**] 09:15AM PLT COUNT-192
[**2181-4-24**] 09:15AM PT-11.2 INR(PT)-0.9
[**2181-4-24**] 04:30PM WBC-8.8 RBC-4.46* HGB-15.5 HCT-45.1 MCV-101*
MCH-34.7* MCHC-34.3 RDW-14.0
[**2181-4-24**] 04:30PM PLT COUNT-178
[**2181-4-24**] 04:30PM cTropnT-<0.01
.
CT LIVER BX [**2181-4-24**]
IMPRESSION:
1. Technically successful CT fluoroscopic-guided biopsy of
periportal/caudate lobe lesion.
2. Small right (10-15%) pneumothorax.
.
CHEST (PA & LAT) [**2181-4-24**] 3:19 PM
CHEST, TWO VIEWS, PA AND LATERAL
History of liver biopsy with pneumothorax on post-scan
radiograph.
The previous chest radiographs are not on PACS for review. There
is a small right pneumothorax.
.
CHEST (PA & LAT) [**2181-4-24**] 5:02 PM
CONCLUSION: Stable right apical pneumothorax as compared to
earlier today at 3:30 p.m.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2181-4-24**]
FINDINGS: This study was performed in conjunction with the CT
fluoroscopic-guided biopsy done on same day ([**2181-4-24**]). Study
was performed to assess feasibility to see if the lesion could
be biopsied by ultrasound or CT fluoroscopy.
Again seen is a periportal echogenic vascular lesion measuring
approximately 2.2 cm in size. However, based on its location, it
was decided that the best approach for sampling this lesion
would be performed by CT fluoroscopy.
.
ECG Study Date of [**2181-4-24**] 4:16:14 PM
Sinus rhythm. Biatrial enlargement. Non-specific inferolateral
ST-T wave
flattening. Delayed precordial R wave progression. No previous
tracing
available for comparison.
.
CT ABD W&W/O C [**2181-4-25**]
IMPRESSION:
1. Unchanged right hepatic hematoma. No active extravasation.
Increased prominence of the segment VII and VIII hepatic artery
branch could reflect that this was the prior source of bleeding,
though this is uncertain.
2. Heterogeneous perfusion of the liver likely related to _____
hematoma and the fact that the patient had heterogeneous
perfusion prior to the procedure. No narrowing or thrombosis of
hepatic or portal veins.
3. Large lesser sac hematoma and hemoperitoneum, as before.
4. Unchanged appearance of mass adjacent to the caudate lobe.
5. Decreased size of right pneumothorax with small remaining
pneumothorax.
6. High-grade right renal artery stenosis.
.
CHEST (PA & LAT) [**2181-4-25**]
REASON FOR EXAMINATION: Followup of pneumothorax after liver
biopsy.
PA and lateral upright chest radiograph compared to [**2181-4-24**].
The small right apical pneumothorax is stable or slightly
decreased compared to the previous study giving the expiratory
technique of the current exam. The marked emphysema and
subpleural bullae are unchanged in appearance. The
cardiomediastinal silhouette is stable.
.
CHEST (PA & LAT) [**2181-4-26**]
CHEST TWO VIEWS PA AND LATERAL
History of liver biopsy and pneumothorax.
There is a persistent small right apical pneumothorax
essentially unchanged since the previous film of [**2181-4-25**],
there are new lung lesions.
Brief Hospital Course:
68 year old male with incidentally discovered liver mass who
presented to CT guided liver biopsy, compicated by right apical
pneumothorax and peri-hepatic/intrapelvic hematoma, transferred
to the ICU for closer monitoring.
1) Liver mass: As above, the patient underwent CT guided biopsy
on arrival. The pathology is still pending at the time of
discharge. Complicated by pneumothorax and bleeding (see
below). The patient will follow up with his home GI doctor, Dr.
[**Last Name (STitle) **], who should call Dr. [**Last Name (STitle) **] for results of the liver
biopsy.
2) Peri-hepatic hematoma/intra-pelvic bleed: Secondary to liver
biopsy. His hematocrit on arrival was 53, declining to 45
post-procedure, and then slowly trending down by a couple of
points an hour to a nadir of 31.5. He did not require any red
blood cell transfusions, and his hematocrit stabilized at around
32; 32.5 on the day of discharge. His aspirin had been
discontinued 7 days prior to admission, and should not be
restarted for at least a week, possibly longer, pending repeat
hematocrit check by his PCP.
3) Pneumothorax: He developed a small right apical pneumothorax
secondary to the procedure. His oxygenation was never impaired
(>95% on room air throughout). He was given high flow O2 to
speed the resolution. Followup chest x-rays demonstrated
improvement/resolution of the pneumothorax.
4) Alcohol abuse: Though he denied significant alcohol use, his
platelet count was on the low side, with elevated MCV, and his
family reported significant use. He was therefore placed on a
CIWA scale and required only one 10 mg dose of valium. He was
not tachycardic, and appeared comfortable on discharge. He had
a social work consult who spoke to him about both his alcohol
use and smoking. He would like to try the patch and he was
given a prescription for this. He is somewhat in denial about
having a problem with drinking.
5) Hypertension: He was normotensive during the admission.
This will be followed by his PCP.
Medications on Admission:
ASA 81 mg daily
MVI
Discharge Medications:
1. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day.
Disp:*30 patches* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Intrabdominal bleed (subcapsular hematoma of liver, pelvis)
Right upper lobe pneumothorax secondary to liver biopsy
complications.
Hepatic mass
Alcohol withdrawal
Discharge Condition:
stable, no signs/symptoms of further bleeding
Discharge Instructions:
You had a liver biopsy which resulted in minor collapse of your
R lung which is resolving, and some internal bleeding. You were
monitored with serial checks of blood levels which were fine.
Please seek medical attention immediately if you experience any
symptoms of further bleeding such as shortness of breath,
dizziness or chest pain.
Because of your bleeding, you should not take your baby Aspirin
for at least the next week, and probably not until you see your
primary care doctor, who should recheck your blood level.
Followup Instructions:
Follow up with PCP (Dr. [**Last Name (STitle) 71330**] in [**12-26**] weeks.
Please see Dr. [**Last Name (STitle) **] in the next 1-2 weeks. He should call Dr. [**Name (NI) 71331**] office at [**Telephone/Fax (1) 1983**] to get the report from your
liver biopsy.
ICD9 Codes: 2851, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2164
} | Medical Text: Admission Date: [**2186-6-24**] Discharge Date: [**2186-7-4**]
Date of Birth: [**2131-12-23**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Chief Complaint: L 4th toe gangrene
.
Reason for ICU Transfer: Hypoxemic Respiratory Failure
Major Surgical or Invasive Procedure:
[**2186-6-27**]:
1. Ultrasound-guided puncture of right common femoral
artery.
2. Contralateral second-order catheterization of left
external iliac artery.
3. Abdominal aortogram.
4. Serial arteriogram of left lower extremity.
5. Balloon angioplasty of left superficial femoral artery
x3, one in the proximal superficial femoral artery, one
in the mid superficial femoral artery, one in the very
distal superficial femoral artery.
6. Stent placement along the superficial femoral artery x4.
[**2186-6-29**]:
1. Radical debridement of left foot down to [**Month/Day/Year 500**].
2. Application of negative pressure wound therapy.
History of Present Illness:
Ms. [**Known lastname **] is a 53yo female with IDDM, HTN, CAD s/p prior stents
to OM, CKD with baseline creatinine of 1.9, and COPD who
presented to OSH with foot pain, now s/p amputation of the L 4th
toe for gangrene and transferred to the MICU post-op for
hypoxemic respiratory failure.
.
The pt cut herself on the bottom of her foot 2 weeks ago. She
had pain on the dorsum of her foot for three days prior to
admission with redness and bluish discoloration of that region.
She received unasyn and vancomycin at an OSH and transferred to
[**Hospital1 18**] ED for further evaluation. Her SpO2 was noted to be 92% on
RA upon transfer. Podiatry was consulted who performed beside
debridement of left fourth toe gangrene and planned for
amputation in OR on [**2186-6-24**]. Her labs were notable for a WBC of
16.4, glucose of 435 with UA showing no ketones, and creatinine
of 1.4 with sodium of 132. She was given cipro (vanc and unasyn
given at OSH). She was admitted to medicine overnight and kept
NPO and continued on vanc/cipro/flagyl.
.
She was tachypnic prior to intubation this morning with
desaturations to the 80s on RA. She was intubated and throughout
the case had desaturations to the 80s which took 10-15min to
come back up to the 90s. During weaning of sedation, she began
to cough and desaturate, and further weaning was not attempted.
Her ABG was 7.23/62/74 and temp was 38 intraoperatively. She
received a total of 600mL crystalloid during the case and was on
phenylephrine at 0.6 at time of transfer to the PACU. Her SBPs
ranged 80s-200s during the case. Estimated blood loss was
<30cc. There was less bleeding than expected and the plan was to
consult vascular for possible further interventions. Her
Propofol was kept at 100. She received Vanc and Flagyl intra-op
and is still receiving Cipro as well. FS was in the 300s in the
PACU, and she was given 3 units of Humalog. Her last vent
settings in the PACU were AC 500/100/10/7, with overbreathing of
the vent. Last PACU vitals were 99.1, 118/48, 98, 19, 100%.
.
Of note, per her husband, in [**2185-12-17**], she was treated for
PNA, CHF, and an MI. She was in a medically-induced coma for 2
weeks at [**Hospital6 15083**] in [**Hospital1 1559**], and required HD [**1-18**]
volume overload. She is on nocturnal O2 but per report had a
negative sleep study at some point.
.
In the ICU, she is intubated and sedated.
Past Medical History:
1. CAD s/p PCI in [**2179**]/[**2176**] (Please see cath report for anatomy)
2. IDDM complicated by neuropathy
3. Hypertension
4. COPD
5. HTN
6. HL
7. CKD
8. Anxiety
9. Depression
10. OA
11. Thoracic radiculopathy
12. Chronic pain
13. Chronic sinusitis
14. h/o of R toe cellulitis
15. h/o PNA
16. s/p R breast cyst exicision [**2179**]
Social History:
- Tobacco: 1ppd x 33 yrs, current
- Alcohol: denies
- Illicits: denies
Lives with husband and teenage son. Homemaker.
Family History:
Father with MI in 50s, CABGx2, paternal grandmother with CVA,
DM. Otherwise non-contributory.
Physical Exam:
ON ADMISSION:
Vitals: T: 98.2 BP: 151/70 P: 83 R: 18 O2: 89%
General: Intubated, sedated, not following commands
HEENT: Sclera anicteric, ETT in place, pupils constricted and
minimally reactive but equal
Neck: supple, JVP not seen [**1-18**] habitus, Mallampati [**2-17**].
Lungs: Diffuse rhonchi, no rales or wheeze.
CV: Regular rhythm, slightly fast, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: slightly cool distal LE, somewhat sluggish cap refill,
non-palpable distal pulses, palpable femoral b/l, L foot with
drsg [**Name5 (PTitle) **] [**Name5 (PTitle) **]
[**Name5 (PTitle) **]: Streaky erythema over medial LLE, border marked
On Discharge:
Gen: Obese female in nad, alert and oriented x 3, normal affect
Heent: PERRLA, oropharynx pink and moist
Neck: Supple, no jvd
Lungs: CTA bilat
CV: RRR
Abd: Obese, soft, +bs, no m/t/o
Ext: Warm, well perfused. Left 4th digit is amputated with open
wound from met head resection. Wound is pink without drainage or
surrounding erythema.
Pulses: DP/PT - dopplerable bilat
Pertinent Results:
ADMISSION LABS:
[**2186-6-24**] 12:50AM BLOOD WBC-16.4*# RBC-4.59 Hgb-14.5# Hct-41.2
MCV-90 MCH-31.5 MCHC-35.2* RDW-13.8 Plt Ct-409
[**2186-6-24**] 12:50AM BLOOD Neuts-85.6* Lymphs-8.9* Monos-3.5 Eos-1.0
Baso-1.0
[**2186-6-24**] 12:50AM BLOOD PT-12.1 PTT-24.4 INR(PT)-1.0
[**2186-6-24**] 12:50AM BLOOD Glucose-435* UreaN-34* Creat-1.4*#
Na-132* K-4.4 Cl-96 HCO3-21* AnGap-19
[**2186-6-24**] 03:45PM BLOOD ALT-20 AST-29 CK(CPK)-68 AlkPhos-107*
TotBili-0.3
[**2186-6-24**] 03:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2186-6-24**] 03:45PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9
[**2186-6-24**] 12:50AM BLOOD CRP-264.4*
[**2186-6-24**] 11:43AM BLOOD Type-ART Rates-/12 Tidal V-600 FiO2-100
O2 Flow-6 pO2-74* pCO2-62* pH-7.23* calTCO2-27 Base XS--2
AADO2-587 REQ O2-95 Intubat-INTUBATED Vent-CONTROLLED
[**2186-6-24**] 11:43AM BLOOD Glucose-311* Lactate-1.6 Na-133* K-4.7
Cl-99* calHCO3-27
MICROBIOLOGY:
[**6-24**] Foot wound Cx: Staph aureus coag positive, moderate growth.
IMAGING:
- [**6-24**] foot XR: Soft tissue defect about the base of the fourth
toe, but no
radiographic evidence for osteomyelitis. If clinical concern for
osteomyelitis persists, MR [**First Name (Titles) **] [**Last Name (Titles) 500**] scan may be considered.
- [**6-24**] BL LE US: No evidence DVT in either lower extremity. Only
one posterior tibial vein seen bilaterally and one peroneal vein
seen on the right, calf vein thrombosis can therefore not be
entirely excluded
-[**6-25**] CXR: CHF with interstitial edema, probably slightly better
compared with [**2186-6-24**]. Bibasilar collapse and/or consolidation,
slightly worse compared with [**2186-6-24**].
[**2186-6-24**] 12:50AM BLOOD WBC-16.4*# RBC-4.59 Hgb-14.5# Hct-41.2
MCV-90 MCH-31.5 MCHC-35.2* RDW-13.8 Plt Ct-409
[**2186-6-24**] 03:45PM BLOOD WBC-18.0* RBC-4.28 Hgb-13.2 Hct-38.0
MCV-89 MCH-30.8 MCHC-34.7 RDW-13.7 Plt Ct-427
[**2186-6-24**] 11:03PM BLOOD Hct-35.6*
[**2186-6-25**] 04:03AM BLOOD WBC-13.1* RBC-3.95* Hgb-12.5 Hct-35.2*
MCV-89 MCH-31.6 MCHC-35.5* RDW-13.9 Plt Ct-354
[**2186-6-26**] 08:00AM BLOOD WBC-14.0* RBC-4.24 Hgb-13.1 Hct-39.1
MCV-92 MCH-31.0 MCHC-33.6 RDW-13.6 Plt Ct-404
[**2186-6-27**] 07:40AM BLOOD WBC-10.3 RBC-4.04* Hgb-12.6 Hct-36.9
MCV-91 MCH-31.1 MCHC-34.1 RDW-13.5 Plt Ct-416
[**2186-6-28**] 07:05AM BLOOD WBC-11.9* RBC-4.24 Hgb-13.1 Hct-37.2
MCV-88 MCH-30.8 MCHC-35.1* RDW-13.8 Plt Ct-428
[**2186-6-29**] 06:25AM BLOOD WBC-12.7* RBC-4.03* Hgb-12.1 Hct-36.6
MCV-91 MCH-30.1 MCHC-33.2 RDW-13.8 Plt Ct-454*
[**2186-6-30**] 06:55AM BLOOD WBC-13.3* RBC-4.08* Hgb-12.5 Hct-37.1
MCV-91 MCH-30.8 MCHC-33.8 RDW-13.5 Plt Ct-451*
[**2186-7-1**] 07:45AM BLOOD WBC-14.1* RBC-4.07* Hgb-12.4 Hct-35.9*
MCV-88 MCH-30.4 MCHC-34.6 RDW-13.9 Plt Ct-533*
[**2186-7-2**] 05:45AM BLOOD WBC-12.5* RBC-3.84* Hgb-11.9* Hct-34.7*
MCV-90 MCH-31.0 MCHC-34.4 RDW-13.8 Plt Ct-509*
[**2186-7-2**] 05:45AM BLOOD WBC-12.5* RBC-3.84* Hgb-11.9* Hct-34.7*
MCV-90 MCH-31.0 MCHC-34.4 RDW-13.8 Plt Ct-509*
[**2186-7-4**] 05:55AM BLOOD WBC-11.5* RBC-3.87* Hgb-12.1 Hct-35.1*
MCV-91 MCH-31.4 MCHC-34.6 RDW-13.9 Plt Ct-658*
[**2186-6-24**] 12:50AM BLOOD Glucose-435* UreaN-34* Creat-1.4*#
Na-132* K-4.4 Cl-96 HCO3-21* AnGap-19
[**2186-6-24**] 03:45PM BLOOD Glucose-311* UreaN-30* Creat-1.3* Na-134
K-4.9 Cl-101 HCO3-21* AnGap-17
[**2186-6-25**] 04:03AM BLOOD Glucose-112* UreaN-29* Creat-1.3* Na-137
K-3.8 Cl-103 HCO3-22 AnGap-16
[**2186-6-26**] 08:00AM BLOOD Glucose-180* UreaN-30* Creat-1.3* Na-143
K-3.9 Cl-103 HCO3-24 AnGap-20
[**2186-6-27**] 07:40AM BLOOD Glucose-373* UreaN-27* Creat-1.3* Na-141
K-4.0 Cl-106 HCO3-22 AnGap-17
[**2186-6-28**] 07:05AM BLOOD Glucose-186* UreaN-23* Creat-1.1 Na-140
K-4.6 Cl-104 HCO3-24 AnGap-17
[**2186-6-29**] 06:25AM BLOOD Glucose-223* UreaN-22* Creat-1.1 Na-140
K-4.1 Cl-106 HCO3-21* AnGap-17
[**2186-6-30**] 06:55AM BLOOD Glucose-396* UreaN-21* Creat-1.1 Na-134
K-4.2 Cl-101 HCO3-23 AnGap-14
[**2186-7-1**] 07:45AM BLOOD Glucose-262* UreaN-24* Creat-1.1 Na-134
K-4.4 Cl-103 HCO3-22 AnGap-13
[**2186-7-2**] 05:45AM BLOOD Glucose-297* UreaN-25* Creat-1.1 Na-135
K-4.7 Cl-105 HCO3-22 AnGap-13
[**2186-7-3**] 06:30AM BLOOD Glucose-205* UreaN-21* Creat-1.1 Na-140
K-4.5 Cl-108 HCO3-21* AnGap-16
[**2186-6-24**] 03:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2186-6-24**] 11:03PM BLOOD CK-MB-2 cTropnT-0.01
[**2186-6-25**] 04:03AM BLOOD CK-MB-2 cTropnT-0.01
[**2186-6-24**] 03:45PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9
[**2186-6-25**] 04:03AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.0
[**2186-6-26**] 08:00AM BLOOD Calcium-9.5 Phos-2.9 Mg-2.1
[**2186-6-27**] 07:40AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9
[**2186-6-28**] 07:05AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8
[**2186-6-29**] 06:25AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.7
[**2186-6-30**] 06:55AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.8
[**2186-7-1**] 07:45AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8
[**2186-7-2**] 05:45AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.7
[**2186-7-3**] 06:30AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
[**2186-6-24**] 12:50AM BLOOD CRP-264.4*
[**2186-6-27**] 07:40AM BLOOD Vanco-23.4*
[**2186-6-29**] 11:15AM BLOOD Vanco-22.2*
[**2186-6-30**] 06:55AM BLOOD Vanco-8.4*
[**2186-7-1**] 07:45AM BLOOD Vanco-7.8*
[**2186-7-2**] 07:20PM BLOOD Vanco-15.5
[**2186-6-24**] 12:20 am BLOOD CULTURE
**FINAL REPORT [**2186-6-30**]**
Blood Culture, Routine (Final [**2186-6-30**]): NO GROWTH.
[**2186-6-24**] 12:50 am BLOOD CULTURE
**FINAL REPORT [**2186-6-30**]**
Blood Culture, Routine (Final [**2186-6-30**]): NO GROWTH.
[**2186-6-24**] 11:00 am FOOT CULTURE LEFT FOOT - 4TH TOE CULTURE.
**FINAL REPORT [**2186-6-26**]**
GRAM STAIN (Final [**2186-6-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
WOUND CULTURE (Final [**2186-6-26**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2186-6-24**] 3:45 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2186-6-26**]**
MRSA SCREEN (Final [**2186-6-26**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2186-6-24**] 5:28 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2186-6-26**]**
GRAM STAIN (Final [**2186-6-24**]):
[**10-10**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2186-6-26**]): NO GROWTH.
[**2186-6-29**] 9:00 am TISSUE Site: FOOT 4TH LEFT METATARSAL
HEAD.
GRAM STAIN (Final [**2186-6-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2186-7-2**]):
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 326-0163L [**2186-6-24**].
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2186-7-3**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2186-6-24**] 02:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2186-6-24**] 02:30AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2186-6-24**] 02:30AM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
[**2186-6-24**] 02:30AM URINE Mucous-RARE
[**2186-6-24**] 02:30AM URINE Hours-RANDOM
[**2186-6-24**] 02:30AM URINE Uhold-HOLD
Radiology Report FOOT AP,LAT & OBL LEFT Study Date of [**2186-6-24**]
12:25 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] FA2 [**2186-6-24**] 12:25 PM
FOOT AP,LAT & OBL LEFT; -76 BY SAME PHYSICIAN [**Name Initial (PRE) 7417**] # [**Clip Number (Radiology) 15084**]
Reason: s/p debridement
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman s/p partial amp 4th left toe
REASON FOR THIS EXAMINATION:
s/p debridement
Final Report
LEFT FOOT, THREE VIEWS
REASON FOR EXAM: Status post partial amputation of fourth left
toe and
debridement.
Comparison is made with prior study performed 11 hours earlier.
In the interim, there has been partial amputation distal to the
metatarsophalangeal joint of the fourth toe. There are no other
interval
changes.
Radiology Report ART EXT (REST ONLY) Study Date of [**2186-6-27**]
10:11 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] FA2 [**2186-6-27**] 10:11 AM
ART EXT (REST ONLY) Clip # [**Clip Number (Radiology) 15085**]
Reason: evaluate peripheral arterial disease
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with ? PVD
REASON FOR THIS EXAMINATION:
evaluate peripheral arterial disease
Final Report
BILATERAL ARTERIAL DOPPLER
CLINICAL INFORMATION: 54-year-old female with 20 years of
diabetes mellitus.
The patient has neuropathy in both feet and the hands. Recent
amputation of
the left fourth toe performed.
ABIs, Doppler waveforms and PVRs were obtained bilaterally at
rest.
ABIs, right PT 0.50, DP 0.51, left PT 0.66, left DP 0.51.
Segmental
pressures, Doppler waveforms, and PVRs are significantly
decreased bilaterally
from the thighs down, left greater than right. In addition, on
the left side,
there is additional infrapopliteal disease.
IMPRESSION: Findings suggest bilateral inflow disease with
moderate
depression of the ABIs at rest on both sides. It was confirmed
by the
waveforms, pressures and Doppler. In addition, there appears to
be a
superimposed disease in the infrapopliteal region on the left.
Radiology Report FOOT AP,LAT & OBL LEFT PORT Study Date of
[**2186-6-29**] 9:50 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] FA5 [**2186-6-29**] 9:50 AM
FOOT AP,LAT & OBL LEFT PORT Clip # [**Clip Number (Radiology) 15086**]
Reason: L 4th met head resection cut
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman s/p removal of L 4th residual proximal
phalanx & met head.
REASON FOR THIS EXAMINATION:
L 4th met head resection cut
Final Report
INDICATION: Status post removal of the fourth proximal phalanx.
COMPARISON: [**2186-6-24**].
THREE VIEWS LEFT FOOT: Patient is status post amputation at the
level of the
fourth metatarsal neck with an overlying VAC and soft tissue
changes.
Remainder of the digits are grossly unremarkable. There is no
acute fracture
appreciated. Small plantar calcaneal spur is noted.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2186-7-3**] 2:14 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] FA5 [**2186-7-3**] 2:14 PM
CHEST PORT. LINE PLACEMENT Clip # [**Clip Number (Radiology) 15087**]
Reason: 46cm right picc. tip?
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with new picc
REASON FOR THIS EXAMINATION:
46cm right picc. tip?
Final Report
INDICATION: A 54-year-old woman with new PICC line.
COMPARISON: Chest radiograph from [**2186-6-25**].
ONE VIEW OF THE CHEST:
The lungs are well expanded and clear. The cardiac silhouette is
top normal.
The mediastinal silhouette and hilar contours are normal. No
pleural effusion
or pneumothorax is present. A right-sided PICC line terminates
with its tip
in the distal SVC.
Brief Hospital Course:
Ms. [**Known lastname **] is a 53-year-old female with IDDM, HTN, CAD s/p prior
stents to OM, CKD with baseline creatinine of 1.9 and COPD who
is admitted with left fourth toe gangrene and ascending
lymphangitis, now intubated s/p amputation for hypoxemic
respiratory failure and with hypotension.
.
# Hypoxemic Respiratory Failure: The etiology of her respiratory
failure is unclear; the DDx includes COPD exacerbation vs CHF vs
pneumonia. Her CXR post-op appears suggests volume overload. The
patient is an active smoker as well, and likely has some
component of OSA which may also be contributing. Leukocytosis
and fever suggest infectious component contributing, nothing to
suggest aspiration. ACS also possible given cardiac hx, and P.E.
was also on the differential. She was given standing ipratropium
and albuterol MDIs and broad spectrum antibiotics with
Vanc/Cefepime/Flagyl for HCAP. Sputum and blood cultures were
sent. Tidal volumes of 6mg/kg were given because of the risk of
ARDS. No diuresis was induced given her tenuous BP, and IVF were
minimized. An ACS workup was done as below. Respiratory status
improved on the floor and she was satting well without oxygen at
the time of discharge
.
# Hypotension: Her BPs very labile during her toe amputation
procedure, and in the MICU she was requiring phenylephrine to
maintain MAP >65. This could be a medication effect from
propofol in the setting of positive intrathoracic pressure. It
could also possibly be related to ARDS and sepsis given toe
infection and leukocytosis, fever. ACS is also possible given
CAD history causing cardiogenic shock. Her sedation was changed
from propofol to fentanyl/midazolam, and she was weaned from
phenylephrine to keep MAP>60. Over her hospital stay she
remained off pressors and was placed back on her home
antihypertensive regimen which she tolerated well.
.
# Left fourth toe gangrene/ascending lymphangitis: She is now
s/p amputation of 4th toe by podiatry, s/p LLE angio showng SFA
occlusion s/p balloon PTA SFA and stent x 4, and L 4th met head
resection. A wound VAC was attempted after met head resection
but given the location of the wound was not working effectively.
Wet to dry dressings were initiated and her wound showed
appropriate progress. She is discharged with daily wet to dry
dressings. Given her mrsa wound culture data, a PICC line was
placed and she was discharged on vancomycin. Her insurance was
only active through the end of [**Month (only) 205**], and thus she will get IV
vanco through [**7-15**]. At that time she will transition to PO
bactrim [**Hospital1 **] x 4 weeks.
# CAD: She is at risk for MI, which could be contributing to
hypoxemia and hypotension. She had 3 sets of negative cardiac
enzymes. We continued her ASA 325mg PO daily, atorvastatin 80mg
PO daily, and held metoprolol and nitro patch in the setting of
hypotension. Once BPs were stable, her antihypertensives were
restarted. Nitro patch was not restarted in house, but it is
recommended she follow up with her PCP and cardiologist within
10 days of discharge.
.
# Hypertension: She was initially hypotensive, so we held
zestril and metoprolol and lasix. As she improved metoprolol
was resumed. AT the time of discharge her BP's were consistently
>130 and her lasix and lisinopril were resumed.
# IDDM: She was hyperglycemic in house and [**Last Name (un) **] diabetes team
was consulted. Her Lantus was increased to 90 units QHS and an
agressive humalog sliding scale was titrated. At the time of
discharge her glucose was stable.
.
# Hyponatremia: This was mild at 132 on admission, and it is
improving now. Her Na returned to [**Location 213**].
.
# COPD: Her COPD likely contributed to her resp. failure. We
held her home Advair and tiotripium and gave her MDIs as above.
Once respiratory status improved back to baseline home meds
were resumed.
.
#. CKD: Her creatinine was at 1.4 and trended down to 1.1 , and
remained there for most of her hospitalization
.
#. Chronic pain: Pain was well controlled with oral and iv
narcotics while in house. She is stable on an oral regimen at
the time of discahrge
.
#. Chronic sinusitis: stable; she was given Flonase nasal spray.
She is discharged in stable condition, home with VNA services.
She is touch down heel weight bearing on her LLE and maintains
this without difficulty. She will follow up with vascular and
podiatry in 1 week. She is instructed to follow up with her PCP
and cardiologist in the next 1-2 weeks.
Medications on Admission:
Gabapentin 600 mg po TID
Metoprolol XL 100 mg po qdaily
Lantus 80 units qhs
Zestril 10 mg po qdaily
Lipitor 80 mg po qdaily
Lasix 40 mg po qdaily
Advair 50/500 inh [**Hospital1 **]
Spiriva 18 mcg inh qdaily
Nitro 0.2 mg/hr patch daily 12 hrs on/12 hrs off
Nitro 0.4 mg SL q4 prn chest pain
Fluticasone 50 mcg inh [**Hospital1 **]
Oxycodone 5 mg po q4 prn pain
Albuterol 90 mcg inh [**Hospital1 **]
Senna 8.6 mg po BID
Colace 100 mg po BID
Thiamine 100 mg po qdaily
MVA po qdaily
Aspirin 325 mg po qdaily
Tylenol 500 mg po BID
Fish oil
Discharge Medications:
1. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
Recon Soln Intravenous Q 12H (Every 12 Hours) for 2 weeks: until
[**7-15**].
Disp:*qs Recon Soln(s)* Refills:*0*
2. Outpatient Lab Work
Please draw Chem 7, Vanc trough q week
3. 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.
4. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
5. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
6. Lantus 100 unit/mL Solution Sig: Ninety (90) units
Subcutaneous at bedtime: this is a higher dose than you were
previously on.
7. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous
four times a day.
8. sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
Glucose Insulin Dose
0-70mg/dL -----Proceed with hypoglycemia protocol----
71-150mg/dL 0Units 0Units 0Units 0Units
151-200mg/dL 8Units 8Units 10Units 0Units
201-250mg/dL 10Units 10Units 12Units 2Units
251-300mg/dL 12Units 12Units 14Units 3Units
301-350mg/dL 14Units 14Units 16Units 4Units
351-400mg/dL 16Units 16Units 18Units 5Units
> 400mg/dL [**Name8 (MD) 15088**] M.D.-------------------
9. Zestril 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
15. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO DAILY (Daily).
17. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): call pcp for refills.
Disp:*30 Tablet(s)* Refills:*2*
18. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
21. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
22. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: while on narcotics
.
23. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): while on narcotics.
24. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
25. Nitro
if your cardiologist recocmmended that you be on a nitro patch
or take sub lingual nitro prn for chest pain, please resume
those meds as prescribed
26. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 4 weeks: you should start this medication when your
vancomycin has completed .
Disp:*56 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Ovrelook VNA
Discharge Diagnosis:
Left lower extremity ischemia with gangrene, and osteomyelitis
left foot.
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:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? You will be on IV vancomycin for 2 weeks. After you complete
that course you will start oral bactrim ds twice daily for 4
weeks. Please continue all other medications you were taking
before surgery. We have increased your lantus dose and adjusted
your sliding scale regimen.
?????? 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 [**1-19**]
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 only touch down weight bear on your left heel. DO NOT
bear weight through your left foot!
?????? Your groin 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. Your left
foot wound should be packed with wet to dry dressing daily by
the VNA.
?????? 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 cleared by surgeon, and no longer on pain
meds.
?????? Call and schedule an appointment to be seen in [**2-17**] weeks for
post procedure check and ultrasound
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)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2186-7-10**] 8:05
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2186-7-12**] 11:45
Completed by:[**2186-7-4**]
ICD9 Codes: 5185, 2761, 496, 3572, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2165
} | Medical Text: Admission Date: [**2189-10-19**] Discharge Date: [**2189-10-23**]
Date of Birth: [**2126-9-25**] Sex: F
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6157**]
Chief Complaint:
63 yo female with 2cm R upper pole renal mass found on CT.
Major Surgical or Invasive Procedure:
Partial right nephrectomy
History of Present Illness:
63F w/ Hx B breast CA s/p surgery/chemo/XRT and chronic anemia,
with 2cm R upper pole renal mass found on CT A/P obtained for
persistent anemia and elevated AFP. Percutaneous Bx not
possible due to proximity to lung.
Past Medical History:
1) L breast CA treated with lumpectomy, chemotherapy, and XRT.
2) subsequent R breast CA [**2188**] treated with RT. 3) anemia 4)
pleurisy 5) HTN
Social History:
Nonsmoker. 1 cup caffeinated products per day. 2 cups of wine
per day.
Family History:
No family history of kidney cancer.
Physical Exam:
HEENT: No supraclavicular lymphadenopathy. No carotid bruits.
Heart: RRR.
Chest: CTAB
ABD: Soft, nontender. No palpable mass or suprapubic discomfort
Extrem: No C/C/E.
Pertinent Results:
[**2189-10-22**] 07:20AM BLOOD WBC-8.6 RBC-2.76* Hgb-9.5* Hct-28.2*
MCV-102* MCH-34.3* MCHC-33.5 RDW-21.1* Plt Ct-175
[**2189-10-21**] 05:05AM BLOOD WBC-8.3 RBC-2.84*# Hgb-9.7*# Hct-28.1*
MCV-99*# MCH-34.2* MCHC-34.6 RDW-21.8* Plt Ct-157
[**2189-10-20**] 08:10PM BLOOD Hct-30.2*#
[**2189-10-20**] 12:20PM BLOOD WBC-7.5 RBC-1.88* Hgb-6.7* Hct-21.3*
MCV-113* MCH-35.8* MCHC-31.7 RDW-16.5* Plt Ct-178
[**2189-10-20**] 06:40AM BLOOD WBC-7.6 RBC-2.03* Hgb-7.4* Hct-22.5*
MCV-111* MCH-36.5* MCHC-33.0 RDW-16.2* Plt Ct-215
[**2189-10-19**] 05:47PM BLOOD Hct-25.1*
[**2189-10-19**] 12:54PM BLOOD WBC-9.2 RBC-2.12* Hgb-8.0* Hct-23.5*
MCV-111* MCH-37.9* MCHC-34.3 RDW-16.4* Plt Ct-223
[**2189-10-22**] 07:20AM BLOOD Plt Ct-175
[**2189-10-21**] 05:05AM BLOOD Plt Ct-157
[**2189-10-20**] 12:20PM BLOOD Plt Ct-178
[**2189-10-20**] 12:20PM BLOOD PT-11.0 PTT-28.9 INR(PT)-0.9
[**2189-10-20**] 06:40AM BLOOD Plt Ct-215
[**2189-10-19**] 12:54PM BLOOD Plt Ct-223
[**2189-10-19**] 12:54PM BLOOD PT-13.6* PTT-32.2 INR(PT)-1.2*
[**2189-10-22**] 07:20AM BLOOD Glucose-129* UreaN-18 Creat-1.4* Na-130*
K-3.6 Cl-102 HCO3-22 AnGap-10
[**2189-10-21**] 05:05AM BLOOD Glucose-119* UreaN-19 Creat-1.5* Na-130*
K-4.5 Cl-101 HCO3-19* AnGap-15
[**2189-10-20**] 08:10PM BLOOD Glucose-124* UreaN-19 Creat-1.6* Na-131*
K-4.8 Cl-100 HCO3-20* AnGap-16
[**2189-10-20**] 12:20PM BLOOD Glucose-147* UreaN-20 Creat-1.7* Na-131*
K-5.9* Cl-103 HCO3-20* AnGap-14
[**2189-10-20**] 06:40AM BLOOD Glucose-156* UreaN-20 Creat-1.6* Na-129*
K-5.4* Cl-101 HCO3-21* AnGap-12
[**2189-10-19**] 12:54PM BLOOD Glucose-137* UreaN-17 Creat-1.2* Na-131*
K-3.8 Cl-99 HCO3-16* AnGap-20
[**2189-10-22**] 07:20AM BLOOD Calcium-8.2* Mg-1.6
[**2189-10-21**] 05:05AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.5*
[**2189-10-20**] 08:10PM BLOOD Calcium-7.8* Phos-3.7 Mg-1.7
[**2189-10-20**] 12:20PM BLOOD Calcium-7.1* Mg-1.7
[**2189-10-20**] 06:40AM BLOOD Calcium-7.4* Mg-1.8
[**2189-10-19**] 05:47PM BLOOD Mg-2.1
[**2189-10-19**] 12:54PM BLOOD Calcium-7.8* Mg-0.9*
[**2189-10-19**] 11:03AM BLOOD Type-ART pO2-215* pCO2-36 pH-7.30*
calTCO2-18* Base XS--7 Intubat-INTUBATED Vent-CONTROLLED
[**2189-10-19**] 09:53AM BLOOD Type-ART Rates-7/ Tidal V-550 pO2-213*
pCO2-43 pH-7.29* calTCO2-22 Base XS--5 Intubat-INTUBATED
Vent-CONTROLLED
[**2189-10-19**] 11:03AM BLOOD Glucose-117* Lactate-5.3* Na-130* K-3.6
Cl-100
[**2189-10-19**] 09:53AM BLOOD Glucose-135* Lactate-4.1* Na-134* K-3.8
Cl-100
[**2189-10-19**] 11:03AM BLOOD Hgb-7.9* calcHCT-24
[**2189-10-19**] 09:53AM BLOOD Hgb-9.4* calcHCT-28
[**2189-10-19**] 11:03AM BLOOD freeCa-1.05*
[**2189-10-19**] 09:53AM BLOOD freeCa-1.10*
[**2189-10-22**] 09:25AM OTHER BODY FLUID Creat-1.3
Cardiology Report ECG Study Date of [**2189-10-20**] 11:57:28 AM
Baseline artifact
Sinus rhythm
Probably normal ECG
Since previous tracing of [**2189-10-7**], T waves less prominent
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 192 92 [**Telephone/Fax (2) 98576**] 21 36
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2189-10-19**] 2:02 PM
CHEST (PORTABLE AP)
Reason: R/o PTX. Thank you.
[**Hospital 93**] MEDICAL CONDITION:
63F s/p R partial nephrectomy for incidental R upper pole renal
mass.
REASON FOR THIS EXAMINATION:
R/o PTX. Thank you.
CHEST RADIOGRAPH
INDICATION: 63-year-old female, status post partial nephrectomy.
COMPARISON: Radiograph of the chest dated [**2189-10-7**].
FINDINGS: Single AP view of the chest demonstrates interval
placement of the endotracheal tube with its tip projecting 6 cm
above the carina. An oval- shaped opacity in the left upper
chest is seen, most likely represents an external overlying
device. Clinical correlation is suggested. There is minimal
amount of pleural effusion, bilaterally. No evidence of focal
areas of parenchymal consolidation. No evidence of pneumothorax.
The images of the upper abdomen demonstrate small
pneumoperitoneum, consistent with recent surgery.
IMPRESSION:
1. Interval placement of an endotracheal tube.
2. Small pneumoperitoneum consistent with recent abdominal
surgery.
3. No evidence of pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17726**]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: TUE [**2189-10-20**] 7:58 AM
Brief Hospital Course:
POD0 ([**2189-10-19**]): Patient underwent R upper pole partial
nephrectomy with clear surgical margins. 3.5 L of crystalloid
were given with 170 cc of urine produced. EBL was 250 cc. She
was extubated in the ICU and transferred to the floor. Orders
were placed for 24 hours of cefazolin. On postoperative exam,
some tremulousness was noted. She was AOx3. Hematocrit was noted
to be 23.5 with INR of 1.2 and PT of 13.6. Her JP drain was
draining appropriately.
POD1: Patient experienced hypotension and anxiety, which
prompted transfer to the [**Hospital Unit Name 153**]. Etiology appeared to be related
to a combination of chronic anemia; epidural; and inadequate
fluid recussitation. She was transfused with 2 units of packed
RBCs and began to feel better in the evening. She began sips in
the evening.
POD2: Epidural was D/C'ed early in the morning. Her condition
was noted to be stable, and so she was transferred back to the
floor. She was noted to be hyperkalemic and was treated with
kayexalate. She scored 0-1 on the CIWA scale. Patient tolerated
clear fluids in the evening
[**10-22**]: Patient complained of some pain and was begun on oral
dilaudid. She noted less weakness. On examination, heart was RRR
with no M/R/G. Lungs were CTAB. Her Foley catheter was draining
slightly turbid fluid. Wound was clean, dry, an d intact. Her JP
drained serosanguinous fluid on the order of 160 cc. IV access
was heparin locked. She resumed her oral medication regimen.
Medications on Admission:
diovan, lopressor, femara, folate, B12, procrit 40K qFri
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain: do not take alcohol with this medication.
Do not take more than 4 grams of tylenol with this medication.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right upper pole kidney mass
Discharge Condition:
Good
Discharge Instructions:
You are safe to go home at this time.
1) [**Name6 (MD) **] your MD or report to the emergency room if you have a
fever >101.5, chest pain, shortness of breath, bleeding,
collapse, or anything that concerns you.
2) It is important that you follow up with Dr. [**Last Name (STitle) 4229**]
3) Do not drink alcohol or drive while taking the pain
medication. It is important that you take the stool softener
while taking the pain medication.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2189-11-5**] 10:00
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 6733**]
Date/Time:[**2189-12-3**] 9:45
Follow up with Dr. [**Last Name (STitle) 4229**] in [**3-13**] weeks.
Completed by:[**2189-10-23**]
ICD9 Codes: 2767, 5859, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2166
} | Medical Text: Admission Date: [**2119-2-7**] Discharge Date: [**2119-2-18**]
Date of Birth: [**2042-10-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Pulsation in Abdomen for some time, without any associated
symptoms. Loosing weight over last year.
Major Surgical or Invasive Procedure:
Resection repair of abdominal week aneurysm with
24 x 12 bifurcated aortobi-iliac graft.
History of Present Illness:
76 y.o old male with hx of being aware of a pulsation in his
abdomen for some time, with out any associated symptoms. He has
been loosing weight. Pt reiceved a CT scan. Showed an aortic
anuerysm. Referd to Dr.[**Last Name (STitle) **] Dr. [**Last Name (STitle) **] for repair.
Past Medical History:
IMI
CABG ( NEDH): LIMA to LAD, SVG to dLAD, SVG to D1, SVG to
OM1,SVG to OM2
ETT with myoview
Exercised 7 minutes 15 seconds [**Doctor First Name **]. 96% PHR. Stopped d/t chest
pain and EKG changes. 2mm inferior and anterolateral ST
depression. Pain continued 6 minutes into recovery. + LV cavity
dilatation with stress, moderate territory of inferior and
lateral ischemia. Small amount of anterior ischemia. EF 66%.
left sided facial twitch
CAD
Appy
TIA
CVA
Melenoma
GIB
Social History:
denies smoking
denies alcohol
Family History:
non contributary
Physical Exam:
A/O x 3, NAD
NCAT, PERRL, EOMI / neg lesions oral pharnyx, auditory canals,
nare
SUPPLE, FAROM / neg lyphandopathy, supra clavicular nodes
CTA B/L with slight crackles at the bases
Irregular, irregular
Soft, NTTP, ND, pos bowel signs, neg CVA
LE DP/PT 2 plus
Pertinent Results:
[**2119-2-16**]
BLOOD WBC-6.5 RBC-3.50* Hgb-11.3* Hct-33.8* MCV-97 MCH-32.1*
MCHC-33.3 RDW-14.0 Plt Ct-149*
[**2119-2-17**]
Glucose-98 UreaN-41* Creat-1.8* Na-146* K-4.1 Cl-111* HCO3-30*
AnGap-9
[**2119-2-17**]
Calcium-7.6* Phos-2.7 Mg-2.0
[**2119-2-16**]
Swallowing Study
SUMMARY / IMPRESSION:
Pt is demonstrating overt s&s aspiration at bedside with thin
liquids, consistently, however he appears to be tolerating
nectar
thick liquids and softer solids. Unclear etiology of dysphagia
though pt is presenting with some generalized oral and
pharyngeal
weakness. As such, would suggest initiate modified po diet
texture at this time with repeat bedside swallow evaluation in
[**1-20**] days.
[**2119-2-14**]
Cardiology Report ECG
Atrial flutter with ventricular premature beat. Incomplete right
bundle-branch block. Since the previous tracing of [**2119-2-14**]
atrial wave morphology is slightly more suggestive of flutter,
but probably no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 0 114 400/428.57 0 48 17
[**2119-2-7**]
CHEST (PORTABLE AP)
SUPINE PORTABLE CHEST X-RAY: Swan-Ganz catheter is present with
its tip in the right ventricular outflow tract. There is an NG
tube in good position and endotracheal tube also in good
position. Prominence of the aortic knob is noted. There is no
pneumothorax. Sternotomy wires and mediastinal clips are noted
again. Lung volumes are lower than on the prior film, but there
are no focal areas of opacity with the exception of some
subsegmental atelectasis in the left lower lobe. There is some
blunting of the left CP angle, may relate to atelectasis or
small effusion.
IMPRESSION: Satisfactory lines and tubes without pneumothorax.
Possible small left pleural effusion.
Brief Hospital Course:
Pt admitted to the vascular service [**2119-2-7**]
Pt underwent a resection repair of abdominal week aneurysm with
24 x 12 bifurcated aortobi-iliac graft. on [**2119-2-7**]. Pt tolerated
the procedure well with no complications. Pt transferred to the
[**Date Range 13042**] in stable condition, In the [**Name (NI) 13042**] pt did recieve fluids. He
was weaned off the vent on [**2119-2-8**].
On [**2119-2-8**] pt [**Date Range **] to the VICU in stable condition.
[**2117-2-9**] pt had difficulty maintaining o2 sats, a CXR, was
obtained - showed mild CHF. Pt was was given lasix with good
response. Pt also experienced ICU pshychosis - give haldol.
During this state of confusion the pt again became hypoxic. Pt
transferd to the SICU.
[**2119-2-10**] - [**2119-2-16**] In the SICU multiple of entites occured. 1) PT
experienced A - Fib, started on heperin. given beta blocker for
rate control. Pt R/O for MI. 2) Pt also experienced increase of
temperature to 101, pt was pan cx. his sputum grew gram neg
rods, CXR showed RUL pneumonia - tx with AB, CPT, NEBS. 3) CHF,
pt treated with restriction of fluids, lasix, weight monitered.
This resolved. 4) Pt experienced ARF secondary to hypovolemai
from lasix. Pt cret.pre op was 1.2 got to 2.3, on DC improved to
1.8.
[**2119-2-15**] Pt started to improve, PT/Casemanagement/ got involved.
Also pt had a hard time swallowing a swallowing study was
obtained. Pt swallowing gradually improved uon discharge.
Coumadin was started for a-fib.
[**2119-2-16**] Pt [**Name (NI) 22925**] to floor. Foley was [**Name (NI) 1788**], pt was able to
ambulate without difficulty.
[**2119-2-17**] PT discharged in stable condition.
Medications on Admission:
ASA 81 mg PO QD
Baclofen 20 mg po tid
Lipitor 20 mg po qd
Clonazepam .5 mg po tid
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 1 doses.
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34165**] of [**Location (un) 2498**]
Discharge Diagnosis:
Hospital Stay
Abdominal aortic aneurysm.
Pneumonia
PAF (INR goal 2 - 2.5)
P/O ICU pshycosis
ARF baseline creat - 1.2, high 2.3, On discharge 1.8
Pre admission
IMI
CABG ( NEDH): LIMA to LAD, SVG to dLAD, SVG to D1, SVG to
OM1,SVG to OM2
ETT with myoview
Exercised 7 minutes 15 seconds [**Doctor First Name **]. 96% PHR. Stopped d/t chest
pain and EKG changes. 2mm inferior and anterolateral ST
depression. Pain continued 6 minutes into recovery. + LV cavity
dilatation with stress, moderate territory of inferior and
lateral ischemia. Small amount of anterior ischemia. EF 66%.
left sided facial twitch
CAD
Appy
TIA
CVA
Melenoma
GIB
Discharge Condition:
Stable
Discharge Instructions:
Pt. must have his Coumadin adjusted by checking levels of his
PTT. Take 1 mg today and tomorrow.
Pt has difficulty swallowing, please watch for aspiration. Try
to keep HOB elevated.
Watch for signs of systemic infection - fever, chills and night
sweats. If this happens take approriate measures
Check wound for infection - erythema, swelling, discharge Call
Dr [**Last Name (STitle) **] [**Name (STitle) 2678**] if this happens.
Physycal Therapy
Adjust dosing of coumadin for INR 2 - 2.5 for a fib.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in two weeks. Please call for
appt. at [**Telephone/Fax (1) 34166**].
Follow up with your cadiologist for post op atrial fibrillation.
Please call Dr [**Last Name (STitle) **] and make appt. Call [**Telephone/Fax (1) 34167**].
Completed by:[**2119-2-18**]
ICD9 Codes: 4280, 5070, 5849, 2765, 2875, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2167
} | Medical Text: Admission Date: [**2155-4-13**] Discharge Date: [**2155-4-19**]
Date of Birth: [**2104-7-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2155-4-15**] - CABGx3 (lima->Left anterior descending, vein sequence
to posterior descending artery and posterior lft ventricular
artery)
History of Present Illness:
This is a 50-year-old male who in [**2147**] was suffering from a mild
IMI which led to a RCA stent placement. Over the last 6 weeks he
complained of some increase in chest pain and underwent a recent
catheterization which showed at his point 3-vessel disease
including LAD, posterior left ventricular coronary artery as
well as posterior descending artery. The patient had a preserved
left ventricular function and with these findings the patient
was recommended to undergo coronary artery bypass graft.
Past Medical History:
CAD
IMI
PCI to RCA [**2152**]
HTN
Hypercholesterolemia
Sleep apnea
obesity
Social History:
Lives with wife. 8 children. Works in administration. No
smoking.
Family History:
Dad with fatal MI in his 20's.
Physical Exam:
64 114/61 19 93% RA Sat
WDWN in NAD A+Ox3
RRR, Sot S1-S2
CTA
Obesem NT, ND NABS
No JVP, no bruits
No edema, no cyanosis or clubbing
Pertinent Results:
[**2155-4-13**] 01:41PM PT-12.4 PTT-58.9* INR(PT)-1.1
[**2155-4-13**] 01:41PM PLT COUNT-293#
[**2155-4-13**] 01:41PM WBC-5.2 RBC-4.64 HGB-14.2# HCT-40.6 MCV-88
MCH-30.6 MCHC-34.9 RDW-13.1
[**2155-4-13**] 01:41PM ALT(SGPT)-355* AST(SGOT)-196* LD(LDH)-257*
ALK PHOS-90 TOT BILI-0.6
[**2155-4-13**] 01:41PM GLUCOSE-90 UREA N-9 CREAT-0.9 SODIUM-140
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2155-4-13**] 01:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2155-4-13**] 08:19PM ALT(SGPT)-363* AST(SGOT)-177* LD(LDH)-255*
ALK PHOS-94 TOT BILI-0.6
[**2155-4-13**] Abdominal Ultrasound
Diffuse fatty liver with focal fatty sparing. Gallbladder is
unremarkable, and CBD was not visualized.
[**2155-4-15**] ECHO
PRE-BYPASS:
1) No mass/thrombus is seen in the left atrium or left atrial
appendage. No spontaneous echo contrast is seen in the left
atrial appendage.
2) No atrial septal defect is seen by 2D or color Doppler.
3) There is mild regional left ventricular systolic dysfunction
with basal inf septal hypokinesis. Overall left ventricular
systolic function is mildly depressed. The remaining left
ventricular segments contract normally.
4) Right ventricular chamber size and free wall motion are
normal.
5) There are simple atheroma in the descending thoracic aorta.
6) The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 7) The
mitral valve appears
structurally normal with trivial mitral regurgitation.
8) There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
Apaced. Biventricular function is preserved. No new valvular or
aortic abnormalities are observed.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2155-4-13**] via transfer
from [**Hospital6 3872**] for surgical management of his
coronary artery disease. He was worked-up in the usual fashion
and found to have elevated liver function studies. A liver
consult was obtained. An abdominal ultrasound was obtained which
showed a diffuse fatty liver with focal fatty sparing and a
normal gallbladder. Hepatitis work-up was negative as well and
it was assumed his medications were the caause of his elevated
liver enzymes. A repeat liver function test showed improving
numbers and his plavix was thought to be the cause of his
elevated liver enzymes. On [**2155-4-15**], Mr. [**Known lastname **] was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels. Please see operative report for
details. Postoperatively he was taken to the intensive care unit
for monitoring. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. He was then transferred
to the step down unit for further recovery. Mr. [**Known lastname **] was
gently diuresed towards his preoperative weight. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. He spiked a temp to 101.8
early am on [**4-19**]. His CXR & U/A were negative, his repeat WBC
was 5.2. Mr. [**Known lastname **] has remained hemodynamically stable, and
is ready to be discharged home.
Medications on Admission:
Toprol
Benzopril
Folic acid
Zocor
Aspirin
Tricor
Niaspan
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] homecare and hospice
Discharge Diagnosis:
CAD s/p CABG
IMI
PCI to RCA [**2152**]
HTN
Obesity
Sleep Apnea
Discharge Condition:
Good.
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 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. 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.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr. [**Last Name (STitle) 1295**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 17567**] (PCP) in [**3-16**] weeks. [**Telephone/Fax (1) 17568**]
Completed by:[**2155-4-19**]
ICD9 Codes: 4111, 2720, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2168
} | Medical Text: Admission Date: [**2191-12-11**] Discharge Date: [**2191-12-17**]
Date of Birth: [**2113-2-15**] Sex: M
Service: MEDICINE
Allergies:
Pollen Extracts / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
fever and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Dr. [**Known lastname 84496**] is a 78 year-old man with history of unresectable
intrahepatic cholangiocarcinoma s/p nine cycles of
cisplatin/gemcitabine last in [**2191-7-7**] who presents with
persistent fevers and weakness of unclear etiology. His course
was complicated by E. faecium and Klebsiella bacteremia in
8/[**2191**]. This was presumably due to a biliary source and because
his biliary stent was not removable he was treated with IV
antibiotics then started on chronic augmentin therapy. Patient
represented to [**Hospital3 **] hospital in [**9-/2191**] with recurrent fevers
and was treated with IV antibiotics for two days without
positive cultures or clear source of infection and discharged
home on augmentin. He returned again to [**Hospital3 **] hospital where
he had a similar admission on [**2191-12-3**]. He was discharged home
on [**2191-12-7**] but returned again to their ED with fevers and
weakness on [**2191-12-10**]. He was found to have a temperatoure of
102.9 F. He was given 1.5 L NS, vancomycin 500 mg IV, zosyn 4.5
g IV, and Acetaminophen 650 mg po. As patient receives his
oncology and infectious disease care at [**Hospital1 18**] he was transferred
to our ED for further evaluation.
In the ED his initial vitals were, T 100.4 HR 86 BP 146/70 RR 18
96% RA. Patient denied any localizing symptoms but was visibly
rigoring. Labs were notable for WBC 11.8, Hct 31, negative UA.
He was given additional 500 mg vancomycin as he had already
received 500 mg at [**Hospital3 **] hospital, acetaminophen 1 g po,
zofran 4 mg IV, ranitidine 150 mg po, and 1 L NS IV. On
presentation he was in sinus rhythm but during ED evaluation
went into atrial fibrillation with heart rates as high as 150s.
He was given diltiazem mg 10 mg IV x 2 and metoprolol 25 mg po
with little response. Due to persistent HR > 120 he was started
on a diltiazem gtt and admitted to the ICU.
On arrival to the ICU, patient denies any focal complaints. He
denies recent travel, sick contacts, new pets. He denies
headache, abdominal pain, nausea, diarrhea, dark or bloody
stools, chest pain, shortness of breath, productive cough, back
pain. He admits to poor appetite, intermittent inability to get
out of bed. He has a chronic dry cough that is unchanged x
years. He had one episode of emesis associated with coughing
yesterday.
Past Medical History:
- Cholangiocarcinoma dx [**10/2190**] with metal biliary stents s/p 9
cycles of cisplatin/gemcitabine
- s/p CCY [**10/2190**]
- Enterococcal (vanc sensitive) and Klebsiella bacteremia [**8-/2191**]
- Hypertension
- Glaucoma
- Borderline diabetes mellitus
- Status post knee surgery
Social History:
Dr. [**Known lastname 84496**] is a retired Ph.D. in immunology. He currently
lives with his wife in [**Hospital3 **] where he has resided for the
past 17 years. He denies any history of tobacco or illicit drug
use. He no longer drinks alcohol. He has a cat and a dog (35lbs
Bichon Frise).
Family History:
The patient's mother died at 85 of complications of diabetes
mellitus. The patient's father died in his 80s of complications
of diabetes mellitus. The patient's brother died in his 70s of
Alzheimer's disease. He has a brother who is 88 years old alive
with diabetes mellitus who was also treated for cancer of the
sinus two years ago. His maternal grandfather and mother's
three siblings all died of complications of diabetes mellitus.
Physical Exam:
Physical Exam on Admission to [**Hospital Unit Name 153**]
.
VS: Temp: 96 BP: 123/72 HR: 82 RR: 13 O2sat 91% RA
GEN: pleasant, flat affect, weak voice, comfortable,
diaphoretic, NAD, poor hearing acuity
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits
RESP: nonlabored breathing, dry cough, CTA b/l with good air
movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses
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.
.
Physical exam on discharge from the floor
.
Tc: 97 Tm:99 BP 146/77 (140-150/65-77) HR: 68 (68-88) RR: 20
O2: 95% RA
GEN: NAD, hiccuping, conversant. He is A/Ox3
HEENT: sclera anicteric, MMM, no LAD
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: non-labored breathing, clear to auscultation bilaterally,
no crackles or wheezes, but occasional cough
Abd: soft, NT, +BS. no rebound/guarding. no HSM.
Extremities: wwp, no edema.
Neuro/Psych: AOx3, CNs II-XII grossly intact.
Pertinent Results:
ADMISSION LABS
.
[**2191-12-10**] 11:40PM BLOOD WBC-11.9* RBC-3.51* Hgb-11.1* Hct-31.4*
MCV-90 MCH-31.5 MCHC-35.2* RDW-16.2* Plt Ct-175
[**2191-12-10**] 11:40PM BLOOD Neuts-93.3* Lymphs-3.7* Monos-2.4 Eos-0.4
Baso-0.2
[**2191-12-10**] 11:40PM BLOOD PT-14.6* PTT-24.8 INR(PT)-1.3*
[**2191-12-10**] 11:40PM BLOOD Glucose-173* UreaN-13 Creat-0.9 Na-132*
K-3.7 Cl-101 HCO3-25 AnGap-10
[**2191-12-10**] 11:40PM BLOOD ALT-193* AST-168* AlkPhos-344*
TotBili-1.7*
[**2191-12-11**] 10:45AM BLOOD CK-MB-5 cTropnT-<0.01
[**2191-12-10**] 11:40PM BLOOD Lipase-24
[**2191-12-11**] 10:45AM BLOOD Albumin-2.5* Calcium-8.3* Phos-2.3*
Mg-1.9
[**2191-12-11**] 12:00AM BLOOD Lactate-1.7 K-3.7
.
DISCHARGE LABS
.
[**2191-12-16**] 06:00AM BLOOD WBC-4.8 RBC-3.05* Hgb-9.5* Hct-28.2*
MCV-93 MCH-31.2 MCHC-33.7 RDW-16.7* Plt Ct-135*
[**2191-12-16**] 06:00AM BLOOD Glucose-120* UreaN-11 Creat-0.6 Na-138
K-3.7 Cl-103 HCO3-29 AnGap-10
[**2191-12-16**] 06:00AM BLOOD ALT-158* AST-116* AlkPhos-511*
TotBili-1.2
[**2191-12-15**] 06:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8
Micro:
.
Blood Cx [**12-10**], [**12-11**], [**11-22**]: Positive for Klebsiella oxytoca.
_________________________________________________________
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Blood Cx [**12-13**]: PND on discharge
.
Urine Cx [**12-10**], [**12-12**]: Negative
.
IMAGING:
.
[**2191-12-12**]
- Transthoracic Echocardiogram: The left atrium and right atrium
are normal in cavity size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with mild hypokinesis of the apical segments and
apex. 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. A mass is present on the aortic valve. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Mild symmetric LVH with mild focal hypokinesis.
There is small calcified mass on the aortic valve that could be
focal calcification or a small, healed vegetation. No
significant valvular abnormality seen.
.
Abd U/S [**2191-12-13**]:
ABDOMINAL ULTRASOUND: The liver is echogenic, consistent with
fatty
infiltration or fibrosis/cirrhosis. There are multiple simple
cysts within
the liver as seen on prior CT. The largest within segment VIII
measures 3.9 cm. The left lobe is atrophied with an ill-defined
mass, consistent with known cholangiocarcinoma. There is no
intrahepatic biliary ductal dilation. Two stents are seen within
the common bile duct and extending towards the pancreatic head.
The portal vein is patent with antegrade flow. There is no
ascites.
IMPRESSION:
1. Common bile duct stents in situ, with no intrahepatic biliary
ductal
dilation or evidence of abscess.
2. Redemonstration of left lobe cholangiocarcinoma and hepatic
cysts.
.
CXR [**2191-12-15**]:
FINDINGS: In comparison with the study of [**12-10**], there is little
overall
change. The heart remains within normal limits and the lungs are
free of
acute infiltrate. There is blunting of the costophrenic angles
posteriorly. Hyperexpansion of the lungs is consistent with
chronic pulmonary disease. Central catheter remains in place
with the tip at the level of the mid portion of the SVC.
Brief Hospital Course:
78 year-old man with history of unresectable intrahepatic
cholangiocarcinoma s/p nine cycles of cisplatin/gemcitabine last
in [**2191-7-7**] who presents with persistent fevers and weakness.
# GNR Bacteremia. Likely [**2-22**] to a biliary source with a
possible nidus in the CBD metal stent. He also recently stopped
his augmentin as an outpatient which could likely have
contributed. GNR bacteremia was confirmed by OSH (4 cultures)
as well as here at [**Hospital1 18**] with further speciation significant for
Klebsiella Oxytoca. He was initially started on vanc/zosyn in
the ICU which was changed to vanc/meropenem on [**12-12**]. Pt did
quite well on the regimen without any recurrence of
fevers/rigors after transfer to the floor on [**12-12**]. Vanc was
d/c'd given no evidence of gram positive bacteremia, and ID was
consulted who recommended chaning meropenem to outpatient course
of ertapenem. He received one dose of this prior to discharge
which he tolerated well, and was sent home with IV VNA services
to continue the IV ertapenem for a total of 2 weeks retroactive
to initiation of antibiotics. He will then be put on
suppressive levofloxacin therapy 500mg daily thereafter. He
will be set up with ID follow up. Of note, MRCP was considered
to assess for abcess vs progression of cholangiocarcinoma, but
given patient's clinical stability, this was not further
pursued. He is scheduled for an outpt CT scan to further assess
his disease in early [**Month (only) 1096**].
.
# Transaminitis. Likely from underlying cholangiocarcinoma and
bacteremia. He does not have any abdominal discomfort or GI
symptoms. Of note, his transaminitis is worse than baseline.
It trended down throughout admission, with the exception of his
alk-phos which trended from 291 to 511 indicating an obstructive
process likely related to malignancy. He is scheduled for an
outpatient CT to assess for disease progression.
.
# Cholangiocarcinoma, s/p metal stent & 9 cycles of
cisplatin/gemcitabine. No chemotherapy given in-house.
.
# Weakness, generalized. Likely [**2-22**] bacteremia and underlying
malignancy. No focal weakness or neurological defict was noted
on physical exam. His strength improved throughout admission,
and he was discharged home with PT services.
.
# Normocytic Anemia, baseline. Iron studies were consistent
with anemia of chronic disease. Hct remained stable between
26.6-30.9 throughout admission.
.
# Sinus tachycardia: Patient initially thought to have atrial
fibrillation in the Emergency Department and was started on dilt
ggt. However, upon reviewing, it was found to be in sinus
tachycardia. Diltiazem gtt was stopped. Sinus tachycardia
resolved with 4.5 L of fluid resuscitation, and was not
tachycardic for rest of admission.
.
# Hyponatremia: Na 132 on presentation which was down from
recent baseline. Given persistent fevers, chills, and poor
appetite this was likely due to hypovolemia. Urine lytes FeNa
0.5%, suggesting pre-renal as well. It resolved with fluid
resuscitation, and sodium was 138 on discharge.
.
# Hiccups: Pt with persistent hiccups throughout admission
likely due to malignancy and phrenic nerve irritation. They
were unresponsive to thorazine, reglan, reglan/baclofen, and
baclofen/gabapentin. He was sent home with Rx's for baclofen
and reglan to take PRN if he feels that it begins to help.
Medications on Admission:
****PATIENT's PRIMARY CARE PROVIDER INSTRUCTED HIM TO
DISCONTINUE ALL MEDICATIONS ONE WEEK PRIOR TO ARRIVAL****
- AMOXICILLIN-POT CLAVULANATE- 875 mg-125 mg Tablet- 1 Tablet(s)
by mouth two times a day
- LATANOPROST [XALATAN]- (Prescribed by Other Provider) - 0.005
% Drops - 1 in each eye once a day
- PANTOPRAZOLE- (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth every
twenty-four(24) hours
- CETIRIZINE- (OTC)- 5 mg Tablet- Tablet(s) by mouth as needed
for allergies
- MULTIVIT WITH MIN-FA-LYCOPENE [ONE-A-DAY MEN'S]- (Prescribed
by Other Provider; OTC)- 0.4 mg-600 mcg Tablet- 1 Tablet(s) by
mouth daily
Discharge Medications:
1. ertapenem 1 gram Recon Soln Sig: One (1) g Intravenous once a
day for 8 days: take your next dose on [**12-18**] and last dose [**12-25**].
Disp:*qs * Refills:*0*
2. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*90 Capsule(s)* Refills:*1*
3. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for hiccups.
Disp:*90 Tablet(s)* Refills:*2*
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for hiccups.
Disp:*90 Capsule(s)* Refills:*2*
6. guaifenesin 50 mg/5 mL Liquid Sig: [**5-30**] ml PO every six (6)
hours as needed for cough.
Disp:*qs * Refills:*0*
7. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day:
start this on [**12-26**] after you finish ertapenem on [**12-25**].
Disp:*30 Tablet(s)* Refills:*2*
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
chatam-[**Location (un) **] VNA
Discharge Diagnosis:
Primary:
Klebsiella Oxytoca bacteremia
Intractable Hiccups
Secondary:
Intrahepatic cholangiocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 84496**],
You were admitted to the hospital for fevers and chills. We
found that you had an infection in your blood, likely from your
billiary tract. We have treated you with antibiotics and you
have done well without new fevers or pain.
We determined that it was not necessary to do the MRCP since you
seemed to be improving. You should continue to keep your
appointment for follow up CT scan next week
Please note thes following medication changes:
STARTED: Ertapenem 1g IV daily. Last dose [**2191-12-25**]
STARTED: Levofloxacin 500mg by mouth daily. You will start this
medication on [**12-26**] after you finish your ertapenem course on
[**12-25**]. You will need to take this ongoing to prevent further
infections
STARTED: Benzonatate 100mg by mouth 3 times daily as needed (for
cough)
STARTED: Baclofen 10mg by mouth 3 times daily as needed (for
hiccups)
STARTED: Gabapentin 100mg by mouth 3 times daily as needed (for
hiccups)
STARTED: Ranitidine 150mg by mouth twice daily
STOPPED: Protonix (pantoprazole)
Followup Instructions:
Department: RADIOLOGY
When: WEDNESDAY [**2191-12-28**] at 11:00 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2192-1-6**] at 12:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN [**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: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2192-1-6**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 84497**],MD
Department: Internal Medicine
Address: [**Location (un) 10215**], [**Location (un) **],[**Numeric Identifier 58635**]
Phone: [**Telephone/Fax (1) 77632**]
Please call your primary care physician to make an appointment
to see him within the next 2 weeks. The office will be open
Monday morning at 9am for you to call.
You need to be seen by one of the physicians in the Infectious
Disease Department here at [**Hospital1 18**] within the next 2 weeks. Please
call [**Telephone/Fax (1) 457**] on Monday morning to make the appointment.
ICD9 Codes: 7907, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2169
} | Medical Text: Admission Date: [**2109-9-6**] Discharge Date: [**2109-9-11**]
Date of Birth: [**2024-12-26**] Sex: F
Service: SURGERY
Allergies:
Morphine / Keflex / Latex
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
hepatocellular carcinoma
Major Surgical or Invasive Procedure:
[**2109-9-6**] liver wedge resection
History of Present Illness:
Ms. [**Known lastname **] is a 84 y.o. female who presented to her PCP in [**Name9 (PRE) 116**]
[**2109**] w/ 25 lb weight loss, fatigue, and anorexia. CT scan showed
a new 2.6 cm isodense lesion with a hypodense rim of right liver
lobe anteriorly. A repeat CT scan on [**2109-7-23**], demonstrated
a 2.5-cm enhancing mass in the inferior aspect of the right lobe
suspicious for neoplasm. A CT guided liver biopsy was performed
on [**8-2**] and showed a well-differentiated hepatocellular
carcinoma. She was referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Oncology who
then referred the patient to Dr. [**First Name (STitle) **] [**Name (STitle) **] who had performed
an ERCP in [**2107**] for choledocholithiasis. A chest CT did not
show evidence of pulmonary metastases. An abdominal CT
demonstrated a 3.0 x 3.0 cm heterogeneous lesion within segment
5 of the liver where there is an arterial enhancement and subtle
delayed phase washout consistent with biopsy-proven HCC. In
segment 7, there was an 11 x 8 mm arterial enhancing lesion that
had a slight washout on delayed imaging. Additional
subcentimeter arterial enhancing lesions throughout the liver
did not show portal venous or delayed phase washout.
Additionally in segment 7, there was a 1.8 x 1.3 cm flash
filling hemangioma and a 4mm round hypodensity in segment 6,
likely a cyst. Her LFTs were: AST 20, ALT 12, alk phos 50,
total bili 0.3, AFP 1.7 and CA19-9 6. Hepatitis serologies were
all nonreactive. The patient underwent further workup in
preparation for
surgical resection. PFTs were obtained because of her extensive
smoking history, and showed: FEV1 of 0.86 (76% predicted), FVC
1.39 (77% predicted) and FEV1:FVC 62 (99% predicted). She was
seen by Dr. [**Last Name (NamePattern1) 4512**]from Pulmonary who felt that she was
at moderately increased risk for pneumonitis and/or respiratory
failure and prolonged ventilation postoperatively. A
dipyridamole stress thallium demonstrated normal myocardial
perfusion with no areas of
ischemia. There was normal wall motion with normally calculated
ejection fraction of 74%. An echocardiogram was obtained and
showed mild pulmonary hypertension with pressures of 44 mmHg and
with a normal EF of 65%. There was
no abnormality in the right or left ventricular function. She is
to undergo a hepatic resection after providing informed consent.
Past Medical History:
-Liver cancer.
-Hypertension.
PSH:
- cholecystectomy.
- colon resection for diverticulitis
- knee replacement
Social History:
She lives in [**Location 26671**] with her family. She is retired but used
to work in several factories. She is a current smoker, 62
pack-year history. Her mother who died at age [**Age over 90 **] of diabetes and
her father who died at age 79 of an MI.
Family History:
DM in the family.
Her sister had metastatic cancer of unknown primary origin.
Physical Exam:
97.2 97 52 142/59 17 100% 5L NC
Gen: A&Ox3, NAD
CV: RRR, no murmurs
Lung: CTAB
Abd: incision c/d/i, no bleeding, soft, nontender, nondistended,
+BS
Ext: Warm, 2+ pulses
Pertinent Results:
[**2109-9-6**] 06:53PM BLOOD Albumin-3.2* Calcium-8.3* Phos-4.8*
Mg-1.7
[**2109-9-6**] 06:53PM BLOOD ALT-75* AST-155* AlkPhos-41 TotBili-1.1
[**2109-9-6**] 06:53PM BLOOD Glucose-151* UreaN-20 Creat-0.7 Na-140
K-3.9 Cl-109* HCO3-24 AnGap-11
[**2109-9-6**] 03:40PM BLOOD PT-14.6* PTT-40.2* INR(PT)-1.3*
[**2109-9-6**] 03:40PM BLOOD WBC-6.9 RBC-3.04* Hgb-10.2* Hct-29.4*
MCV-97 MCH-33.7* MCHC-34.8 RDW-13.8 Plt Ct-273
[**2109-9-9**] 08:14AM BLOOD WBC-11.1* RBC-3.18* Hgb-10.6* Hct-30.8*
MCV-97 MCH-33.4* MCHC-34.5 RDW-14.1 Plt Ct-215
[**2109-9-9**] 08:14AM BLOOD Glucose-115* UreaN-9 Creat-0.7 Na-139
K-4.0 Cl-103 HCO3-27 AnGap-13
[**2109-9-9**] 08:14AM BLOOD ALT-64* AST-45* AlkPhos-48 TotBili-0.8
[**9-6**] intra-operative ultrasound: Solid right lobe mass
consistent with the known biopsy proven hepatoma.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the hepatobiliary service on
[**2109-9-6**] after undergoing a segment 5 mass resection with
intraoperative ultrasound. In the operating room, she received
3000 mL crystalloid, 1 unit of packed red cells and made 270 mL
of urine. She tolerated the procedure well. She was NPO,
received IV dilaudid for pain control and was on maintenance IV
fluids. On POD 1, she was advanced to sips and restarted on her
home medications. She complained of some intermittent nausea
that resolved. On POD 2, her IV fluids were discontinued and she
was advanced to a clear liquid diet. On POD 3, her foley was
discontinued, she ambulated out of bed, and was put on a regular
diet, which she tolerated well. On POD 4, she passed flatus and
had a loose bowel movement. Her wound remained clean, dry, and
intact, without discharge. She was ready for discharge to home
on POD 5.
Medications on Admission:
-dorzolamide-timolol [Cosopt] 2 %-0.5 % Drops
1 in the right eye daily
-Econopred Plus Dosage uncertain
-hydrochlorothiazide 25 mg Tablet 1 Tablet(s) by mouth once a
day
* OTCs *
-acetaminophen 500 mg Tablet [**7-25**] Tablet(s) by mouth per day as
needed for pain
-B complex vitamins Capsule 1 Capsule(s) by mouth Daily (OTC)
[**2109-8-21**]
-multivitamin with minerals [Multi-Vitamin W/Minerals] Capsule 1
Capsule(s) by mouth Daily (OTC)
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Temp above 101F.
3. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic DAILY (Daily).
4. Multiple Vitamin-Minerals Tablet Sig: One (1) Tablet PO
once a day.
5. Colace 50 mg Capsule Sig: [**2-17**] Capsules PO twice a day as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
hepatocellular carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Hepatobiliary surgery service for
partial liver segment resection for hepatocellular carcinoma.
MEDICATIONS:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
DIET:
- Drink plenty of fluids.
- you may resume your regular diet.
ACTIVITY
- Do NOT drink alcohol, drive or operate heavy machinery for at
least two weeks after your surgery or while taking pain
medication.
- Do NOT do heavy lifting (nothing more than a gallon of milk)
for 6 weeks after your surgery.
- Light activity (i.e. walking, office work, climbing stairs,
etc.) as soon as you feel comfortable is fine.
INCISION CARE
- Gently cleanse the area around the incision daily with mild
soap and water.
- You [**Month (only) **] take a shower, but avoid baths, swimming and saunas
for 4-6 weeks after surgery.
Followup Instructions:
Please following up with the following appointments:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2109-9-18**]
3:00
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2109-12-31**]
2:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2109-9-11**]
ICD9 Codes: 4168, 496, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2170
} | Medical Text: Admission Date: [**2119-10-22**] Discharge Date: [**2119-11-22**]
Date of Birth: [**2063-2-4**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Perforated duodenal ulcer
Major Surgical or Invasive Procedure:
[**2119-10-22**]
1. Exploratory laparotomy.
2. Drainage of retroperitoneal abscess.
3. Oversew of giant duodenal ulcer, pyloric exclusion.
4. Roux-Y gastrojejunostomy, jejunostomy tube and gastric
tube.
History of Present Illness:
Mr. [**Known lastname **] is a 56-year-old male who presented to an outside
institution after being found unresponsive. Found to be
hypoglycemic at the scene. He underwent endoscopy which
demonstrated what appeared to be a colonic duodenal fistula or
perforation. CT scan was performed that demonstrated a large
retroperitoneal abscess from a perforation, and he was sent to
[**Hospital1 18**] for definitive treatment.
Past Medical History:
Hypertension
Hypercholesterolemia
DM
ETOH abuse (quit 4 yrs ago)
History of CDiff
CAD
PUD/UGIB (h/o Ex-lap for GIB)
S/P open cholecystectomy
Social History:
Previous ETOH abuse
Lives in a sober house
Previous cocaine use
No history of tobacco
Family History:
Father died of prostate Ca
Physical Exam:
Arousable
Pupils dilated, reactive, equal
Neck supple
Lungs clear to auscultation
Tachycardic, regular
Abdomen soft, tender diffusely to tap and shake, umbilical
hernia
Rectal exam deferred
Pertinent Results:
[**2119-10-22**] 03:37PM WBC-7.4 RBC-3.43* HGB-10.6* HCT-31.2* MCV-91
MCH-30.8 MCHC-33.9 RDW-15.4
[**2119-10-22**] 03:37PM PLT COUNT-214
[**2119-10-22**] 03:37PM PT-17.6* PTT-39.6* INR(PT)-2.2
[**2119-10-22**] 03:37PM GLUCOSE-150* UREA N-44* CREAT-2.0* SODIUM-133
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-14* ANION GAP-20
[**2119-10-22**] 03:37PM ALT(SGPT)-22 AST(SGOT)-40 ALK PHOS-71
AMYLASE-62 TOT BILI-0.7
[**2119-10-22**] 03:37PM LIPASE-26
[**2119-10-22**] 03:37PM ALBUMIN-2.5* CALCIUM-6.9* PHOSPHATE-3.9
MAGNESIUM-1.1* IRON-6*
[**2119-10-26**] Echocardiogram
Conclusions: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 70-80%). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
[**2119-10-27**] CT Chest/Abdomen/Pelvis
IMPRESSION:
1. Large amount of fluid seen throughout the abdomen extending
into the pelvis. The fluid in the right posterior perianal space
appears to have pockets of gas within, concerning for an
infected collection. Some bowel wall thickening is seen as well,
likely secondary to the free fluid.
2. Bilateral pleural effusions with associated atelectasis,
right greater than left.
CT GUIDED DRAINAGE: Under CT fluoro guidance an 8-French pigtail
catheter was localized and advanced into the right
retroperitoneal collection. Aspiration yielded 25 cc of bloody
material, a sample was sent to analysis
[**2119-10-29**] CT Abdomen/Pelvis
1. Interval increase in the large amount of free fluid
throughout the abdomen and pelvis.
2. Interval decrease in size in the right retroperitoneal
collection with pigtail catheter in place.
3. Mild generalized bowel wall thickening of the colon,
unchanged from the prior study, there is no pneumatosis.
4. Unchanged bilateral pleural effusions with adjacent bilateral
subsegmental consolidations.
5. There is no extravasation of the contrast media.
[**2119-10-29**] Foot X-ray
FINDINGS: As visualized through casting material, it is
difficult to find the fracture site. I suspect it may be at the
proximal aspect of the first metatarsal. No old films were
available. These could be scanned in to PACS for comparison.
Regardless there is no misalignment and the fragments should be
in good apposition due to the inapparent nature on these films.
Incidental note is made of degenerative changes at the MTP joint
of the first digit.
[**2119-11-4**] CT Abdomen/Pelvis
1. No contrast leakage from bowel or findings concerning for
perforation. Small amount of gas adjacent to the right upper
quadrant drain is likely related to the drain.
2. No change in size of right posterior pararenal space fluid
collection with pigtail catheter, or anterior pararenal fluid
collection. Both of these appear heterogeneous, as does the
fluid extending into the pelvis.
3. Decrease in overall ascites with small partially organized
fluid collection along the anterior peritoneum within the
pelvis.
4. Decreased wall thickening of the colon with resolution of
wall thickening in some areas consistent with resolving colonic
process. No pneumatosis.
5. Unchanged pleural effusions and bilateral lower lobe
atelectasis.
[**2119-11-8**] Ankle X-ray
FINDINGS: Cast overlies the right ankle which obscures fine bony
detail. Persistent fracture lucency is seen through the distal
fibula; however, it appears somewhat less distinct on the
current exam as compared with [**2119-10-29**]. There is osseous
demineralization, and dorsal spurs projecting from the talus. No
new fracture identified.
[**2119-11-15**] CT Abdomen/Pelvis
1. No significant interval change in the appearance of the
complex retroperitoneal fluid collection, involving the anterior
and posterior pararenal spaces, as well as a connection to fluid
collection in the presacral space in the pelvis.
2. Fluid collection anterior to the bladder, as well, with a
similar appearance.
3. Continued improvement in the appearance of the colon.
4. Reduced pleural effusions. Also improvement in ascites.
[**2119-11-16**] CT guided drainage of fluid collection
Brief Hospital Course:
The patient was admitted to the SICU and put on broad spectrum
antibiotics and volume resuscitated. He was taken emergently to
the OR for exploratory laparotomy for surgical repair of a
duodenal perforation. Please see operative note for details of
procedure. He remained extubated post-operatively with a NG
tube in place. He required pressor support secondary to sepsis
and amphotericin was added to the antibiotic regimen of
Vanco/Levo/Flagyl. He self-extubated on POD1 and subsequently
was re-intubated for inability to maintain oxygen saturation.
J-tube feeds were begun on POD2 but he continued to require
sedation, pressor support, and he had evidence of developing
acute lung injury that progressed to ARDS. An echocardiogram
was obtained on [**10-26**] which showed LVEF 70-80% with trivial MR.
A CT of the chest, abdomen, and pelvis on [**10-27**] showed fluid
throughout the abdomen and bilateral pleural effusions in
addition to a large right-sided retroperitoneal collection which
was subsequently drained under CT guidance. Levofloxacin was
changed to Meropenem. TPN was started on [**10-29**] and the tube
feeds were maintained at 10cc/hour. The JP drain had evidence
of a bile leak at this point but it was well-drained. A
follow-up CT on [**10-29**] showed an interval decrease in the free
fluid and in the size of the right retroperitoneal collection
with the pigtail in place. The patient was found to be C.Diff
positive on [**10-30**] and H.Pylori antibody was negative. Culture
data revealed VRE and the vanco was changed to Linezolid.
Cultures also grew klebsiella, MRSA, and yeast. A vac dressing
was placed on [**11-2**] for a small wound dehiscence. He remained
intermittently febrile. He was able to wean off of pressor
support by [**11-3**] and then was slowly weaned of the vent and was
successfully extubated [**11-5**]. Tube feeds were advanced and he
was diuresed.
The patient was transferred out of the SICU on [**11-7**]. A
follow-up C.diff was negative on [**11-10**]. Physical therapy began
working with the patient. Tube feeds were increased to goal and
his diet was slowly advanced beginning on [**11-10**]. He remained on
antibiotics and remained afebrile. Radiology performed a
CT-guided drainage of the right retroperitoneum on [**11-16**] after a
follow-up CT from [**11-15**] showed a persistent collection. ID was
consulted and will follow the patient also at the rehab
facility. The patient will stay on antibiotics for 6weeks. A
Picc line was placed on [**11-21**]. Follow-up C.Diff toxins have
been negative and a follow-up JP drain culture is pending. His
tube feeds are currently cycled. The patient requires
encouragement for PO intake.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day). Tablet(s)
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Amphotericin B Liposome 50 mg Suspension for Reconstitution
Sig: Five (5) Suspension for Reconstitution Intravenous Q24H
(every 24 hours): 250mg IV q24h.
14. Meropenem 1000 mg IV Q8H
Discharge Disposition:
Extended Care
Facility:
VA [**Hospital1 1474**]-TCU
Discharge Diagnosis:
Perforated duodenal ulcer
Retroperitoneal abscess
Discharge Condition:
Good
Discharge Instructions:
Please call if you experience any new and continued fevers or
chills, if you have increasing abdominal pain, if you are unable
to tolerated food and fluids by mouth, or if you have any
redness or swelling at your incision site.
Followup Instructions:
Please call the clinic for a follow-up appointment [**Telephone/Fax (1) 48857**]
ICD9 Codes: 5185, 5849, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2171
} | Medical Text: Admission Date: [**2110-9-22**] Discharge Date: [**2110-9-24**]
Date of Birth: [**2081-4-17**] Sex: F
Service: ICU
HISTORY OF THE PRESENT ILLNESS: This is a 29-year-old female
with a past medical history significant for recent
right-sided aortic arch repair due to posterior aortic arch
with tracheal and esophageal compression, as well as severe
tracheomalacia status post posterior tracheal mesh placement
by Interventional Pulmonology. Both of these procedures were
done within the past two to three months at [**Hospital6 1760**]; this hospital course was
complicated by Pseudomonal sepsis and MRSA pneumonia. The
patient was admitted to the Intensive Care Unit on [**2110-9-22**] after arriving in the Interventional Pulmonary Suite
for question of scheduled appointment. There seemed to have
been some confusion as the patient was unexpected at the
Bronch Suite and was subsequently transferred to the
Emergency Department for ventilator support while awaiting
transfer back to pulmonary rehabilitation.
Upon arrival to the Emergency Room, the patient complained of
diffuse abdominal pain as well as nausea and vomiting, which
appeared to have been chronic times two months. However, the
patient was subsequently admitted to the ICU for ventilator
support and question of diffuse abdominal pain despite a
negative KUB in the Emergency Department.
PAST MEDICAL HISTORY:
1. Aortic arch repair as stated in HPI.
2. Severe tracheobronchial malacia, status post posterior
mesh placement, followed by Dr. [**First Name (STitle) **] [**Name (STitle) **].
3. Asthma.
4. Schizophrenia.
5. Bipolar disorder.
6. Behavioral disorder.
7. Status post percutaneous enterogastrostomy tube.
8. Status post tracheostomy.
9. History of pseudomonal sepsis and MRSA.
ALLERGIES: The patient is allergic to sulfa and penicillin.
SOCIAL HISTORY: The patient is a prior group home resident
in [**Location (un) 5503**]; however, has been at pulmonary rehabilitation
since tracheostomy placement. No tobacco or alcohol use.
Father lives in [**Location (un) 5503**].
ADMISSION MEDICATIONS:
1. Metoprolol 37.5 mg p.o. t.i.d.
2. Lisinopril 10 mg p.o. q.d.
3. Heparin 5,000 units subcutaneously q. 12.
4. Colace 100 mg p.o. b.i.d.
5. Synthroid 75 micrograms p.o. q.d.
6. MiraLax p.r.n.
7. Protonix 40 mg p.o. q.d.
8. Reglan 10 mg IV q. six hours.
9. Ativan 0.5 mg IV q. six hours p.r.n.
10. Remeron 30 mg p.o. q.h.s.
11. Haldol 2.5 mg p.o. q.h.s.
Of note, all medications are through the G tube.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Heart rate
97, blood pressure 153/85, respiratory rate 18-26, saturating
98-100% on ventilator settings, pressure support 20, with
PEEP 10, FI02 40%. HEENT: Mucous membranes moist. The
oropharynx was with mild thrush. The pupils were equal,
round, and reactive to light. The extraocular movements were
intact. Neck: Tracheostomy site with mild purulence but no
erythema, edema, or evidence of infection. No stridor.
Pulmonary: Clear to auscultation bilaterally with vented
breath sounds and poor inspiratory effort. Cardiovascular:
Regular rate and rhythm. No murmurs, rubs, or gallops.
Normal S1, S2. Abdomen: Diffusely tender with no rebound or
guarding. Normoactive bowel sounds. No right upper quadrant
tenderness. No splinting. No fluctuants at the G tube site.
The G tube site was clean, dry, and intact without evidence
of erythema or crepitus. Extremities: No clubbing, cyanosis
or edema, 2+ distal pulses. Neurologic: Cranial nerves II
through XII were intact. Pupils were equal, round, and
reactive to light. Moving all extremities and responsive to
questions appropriately.
LABORATORY/RADIOLOGIC DATA: Notable for a potassium of 3.1,
magnesium 1.2, TSH 14. Hematocrit 27.2, which is baseline
for the patient.
Plain film of the abdomen revealed no air-fluid levels or
free air.
HOSPITAL COURSE: The patient was admitted to the ICU for
ventilator support. She was hemodynamically stable
throughout. Her potassium and magnesium were repleted as
appropriate. The patient was given IV fluids for a
creatinine of 1.2 as well as inability to tolerate tube
feeds. The patient's inability to tolerate tube feeds as
well as diffuse mild abdominal pain and watery diarrhea is
chronic since her discharge from the hospital. She has been
tested for C. difficile multiple times, all of which have
returned negative at the outside facility. C. difficile was
sent again from our facility and is currently pending at the
time of discharge.
The patient has been maintained on Reglan which does not seem
to have much of an effect in terms of advancing tube feeds.
The patient did have one episode of nonbloody emesis when
tube feeds were at 10 cc per hour. Thus, they were turned
off. The patient was not given any Colace, MiraLax while
here and had mild watery diarrhea.
Would recommend close monitoring of electrolytes, especially
potassium and magnesium for need for repletion given
persistent watery diarrhea. There was no evidence of acute
infection; however, C. difficile is pending and will
follow-up on this. The patient may need supplemental IV
fluid through left antecubital PICC line which is patent at
the time of transfer.
In terms of respiratory support, the patient had CT trachea
with reconstruction imaging as well as CT vasculature to
assess aortic arch repair. It is important to note that
there is no acute concern for vascular issues at this time.
This was just done to reevaluate status post major surgery.
Final radiology read of CT trachea and vasculature in the
chest is pending at the time of transfer. However, the film
was reviewed with the attending pulmonologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and there were no acute mechanical or obstruction issues
identified.
Would recommend that rehabilitation obtain a copy of final
report of CT trachea and chest when final report becomes
available. This can be obtained by calling [**Telephone/Fax (1) 2756**] and
asking for the Radiology Department.
DISCHARGE STATUS: The patient is being discharged to the
[**Hospital 12286**] Hospital in [**Location (un) 5503**], [**State 350**] not [**Location (un) 48297**] [**Hospital 4094**] Hospital in [**Location (un) 38**] as this facility is
closer to her former group home and her father. She has been
accepted and will be transferred there upon discharge from
the [**Hospital6 256**]
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Metoprolol 37.5 mg p.o. t.i.d.
2. Lisinopril 10 mg p.o. q.d.
3. Heparin 5,000 units subcutaneously q. eight hours.
4. Synthroid 100 micrograms p.o. q.d. (of note, this is
increased from 75 micrograms p.o. q.d. secondary to TSH of
14).
5. Protonix 40 mg p.o. q.d.
6. Reglan 10 mg IV q. six hours.
7. Ativan 0.5 mg IV q. four to six hours standing.
8. Remeron 30 mg via G tube q.h.s.
9. Haldol 2.5 mg via G tube q.h.s.
10. Magnesium oxide 400 mg via G tube b.i.d.
DISCHARGE DIAGNOSIS:
1. Ventilatory support secondary to chronic tracheostomy and
respiratory failure.
2. Chronic diffuse abdominal pain.
3. Chronic watery diarrhea. k
4. Hypothyroidism.
5. Status post right aortic arch repair.
6. Status post posterior tracheal mesh placement for severe
tracheobronchomalacia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**]
Dictated By:[**Name8 (MD) 10996**]
MEDQUIST36
D: 10/22/2200 12:54
T: [**2110-9-24**] 13:00
JOB#: [**Job Number 48298**]
ICD9 Codes: 2449, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2172
} | Medical Text: Admission Date: [**2112-9-8**] Discharge Date: [**2112-9-10**]
Date of Birth: [**2035-8-21**] Sex: M
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
found in driveway slumped in car
Major Surgical or Invasive Procedure:
Placement of extraventricular drains
History of Present Illness:
77yo M was reported by wife to be heading to coffee shop and
was found a while later slumped in car. GCS 14 at scene,
brought
to OSH, CT showed large IVH 4th, 3rd, lateral ventricles. Pt
deteriorated, was extubated and transferred to [**Hospital1 18**] ED for
further evaluation/management.
Past Medical History:
htn,tia,gerd,inc chol, depression, psoriasis, s/p appy
Social History:
lives w/ wife, retired air traffic controller
Family History:
father stroke
\mother [**Name (NI) 74528**] ca
Physical Exam:
O: T:98.2 BP:102 /56 HR: 74 R 16 O2Sats
97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4mm NR
Extrem: Warm and well-perfused.
Neuro:
Mental status:intubated, sedated. no corneals, + cough
extensor posturing UEs
triple flex LEs
Pertinent Results:
CT:Large amount of intraventricular hemorrhage with associated
hydrocephalus predominately within the fourth ventricle but also
involving the third and lateral ventricles. The underlying cause
is not clearly identified, and a ruptured aneurysm of the
posterior circulation should be considered. MRA or CTA
recommended as clinically indicated.
CTA:
1. New ventricular catheter via a right frontal approach.
2. The distal vertebral arteries and proximal basilar artery do
not opacify with contrast, possibly due to thrombosis or
occlusion, of indeterminate acuity. There is minimal thready
contrast opacification of the upper or distal basilar artery.
3. Findings concerning for an AVM of the posterior fossa,
possibly involving the inferior vermis. As both PICAs are
prominent, arterial supply could be from both vessels, and a
possible draining vein is seen adjoining the straight sinus. The
nidus is not visualized and could be compressed by extensive
intraventricular hemorrhage.
Brief Hospital Course:
Mr. [**Known lastname **] was a 77-year-old man who was found to have an
intraventricular hemorrhage. He underwent placement of 2 EVDs
urgently in the ED. He subsequently underwent a CT Angiogram
that showed no aneurysm or AVM. He was monitored closely in the
Neuro ICU, but had little improvement after the drains were
placed. He was covered with Dilantin and Ancef. Given his poor
prognosis, his family decided to make him Comfort Measures Only
(CMO). He was extubated, placed on a morphine drip, and
transferred to the floor. He passed peacefully shortly
thereafter. His wife was notified and was offered but declined
an autopsy.
Medications on Admission:
Medications prior to admission: unknown
Discharge Disposition:
Expired
Discharge Diagnosis:
Intraventricular hemorrhage
Discharge Condition:
Expired.
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2112-9-10**]
ICD9 Codes: 431, 2762, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2173
} | Medical Text: Admission Date: [**2116-11-11**] Discharge Date: [**2116-11-16**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
rectal prolapse
Major Surgical or Invasive Procedure:
OR reduction rectal prolapse, end colostomy, Hartmanns creation
[**2116-11-11**]
History of Present Illness:
Ms [**Known lastname 67432**] is an 86yo woman with a history of dementia who
presents as a transfer from an OSH with several hours of rectal
prolapse. Per reports, as patient poor historian secondary to
dementia, the prolapse was noted at 2pm with bleeding and she
was
brought to the OSH where attempts at reduction using lidoacaine,
morhpine, and sugar failed to reduce. She was advised by a
surgeon that surgey was needed, and the patient was transferred
to [**Hospital1 18**] ED after receiving 2 units FFP as patient on coumadin.
Patient is complaining of pain in her rectum, with no other
complaints. No chest pain, SOB, fevers, chills, nause or
vomiting.
The patient was noted to have a tender prolapsed rectum,and
attempts to reduce with Fentanyl, sugar, and ice in the ED by
the
Attending Surgeon were unsuccessful.
Past Medical History:
alzheimer's dementia, AFIB, HTN, arthritis, diverticulitis,
DNR
Social History:
SH: no smoking, no ETOH; lives in Nursing home
Family History:
NC
Physical Exam:
PE:
97.2 90 129/82 16 98% RA
Gen: pleasantly demented elderly woman in NAD
HEENT: MMdry, scerla anicteric
CV: irregular
Lungs: decreased bases
Abd: soft, NT/ND
ext: no c/c/e
Pertinent Results:
CXR [**11-11**]: Abnormal buldge along the posterior heart border of
unclear
etiology. Dedicated PA/Lateral view is recommended for further
evaluation.
[**2116-11-15**] 07:10AM BLOOD WBC-14.2* RBC-3.82* Hgb-12.0 Hct-35.5*
MCV-93 MCH-31.4 MCHC-33.7 RDW-13.7 Plt Ct-317
[**2116-11-14**] 07:50AM BLOOD WBC-16.4* RBC-3.57* Hgb-11.2* Hct-33.6*
MCV-94 MCH-31.5 MCHC-33.5 RDW-13.8 Plt Ct-271
[**2116-11-13**] 03:47AM BLOOD WBC-17.7* RBC-3.77* Hgb-12.0 Hct-36.3
MCV-96 MCH-31.7 MCHC-32.9 RDW-14.8 Plt Ct-257
[**2116-11-12**] 03:29AM BLOOD WBC-12.8* RBC-3.99* Hgb-12.5 Hct-37.8
MCV-95 MCH-31.4 MCHC-33.2 RDW-14.7 Plt Ct-296
[**2116-11-11**] 09:00PM BLOOD WBC-13.5* RBC-4.26 Hgb-13.2 Hct-40.8
MCV-96 MCH-30.9 MCHC-32.3 RDW-14.9 Plt Ct-309
[**2116-11-11**] 09:00PM BLOOD Neuts-84.0* Lymphs-9.4* Monos-5.4 Eos-0.8
Baso-0.4
[**2116-11-16**] 06:15AM BLOOD PT-15.5* INR(PT)-1.4*
[**2116-11-15**] 07:10AM BLOOD PT-13.5* PTT-31.1 INR(PT)-1.2*
[**2116-11-15**] 07:10AM BLOOD Glucose-109* UreaN-24* Creat-1.2* Na-135
K-4.0 Cl-99 HCO3-25 AnGap-15
[**2116-11-14**] 07:50AM BLOOD Glucose-102 UreaN-28* Creat-1.2* Na-135
K-4.5 Cl-101 HCO3-26 AnGap-13
[**2116-11-13**] 03:47AM BLOOD Glucose-102 UreaN-35* Creat-1.3* Na-138
K-4.6 Cl-103 HCO3-26 AnGap-14
[**2116-11-15**] 07:10AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9
[**2116-11-14**] 07:50AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.8
[**2116-11-14**] 08:45AM BLOOD Digoxin-1.9
[**2116-11-14**] 07:50AM BLOOD Digoxin-2.4*
[**2116-11-13**] 08:48PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2116-11-13**] 08:48PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2116-11-13**] 08:48PM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
.
MRSA SCREEN (Final [**2116-11-14**]): No MRSA isolated.
.
cxr [**2116-11-11**]
Abnormal buldge along the posterior heart border of unclear
etiology. Dedicated PA/Lateral view is recommended for further
evaluation.
Brief Hospital Course:
[**11-11**] pt admitted to the surgical service ICU s/p OR reduction
rectal prolapse, end colostomy, Hartmann's creation. She was
kept intubated overnight, NPO/ IVF, NGT/ Foley in place.
Fentanyl for pain control
[**11-12**]: Pt extubated without incident. She was started on her
home dose coumadin and morphine PCA. Pt has known a fib but had
rate 100-120s despite treatment with metoprolol and diltiazem.
[**11-13**]: Pt'd diet advanced. Diltiazem increased.
She was transferred to the general surgery floor on [**11-13**]. She
tolerated a regular diet, iv medications were changed to oral
and IVF was d/c'd. She was seen by phyisical therapy and it was
they rec rehab. Her home coumadin was restarted and her INR on
[**2116-11-16**] was 1.4. The rehab will continue to check INR and
adjust coumadin as needed.
She will Follow up with Dr. [**Last Name (STitle) 1120**] in [**12-20**] weeks.
Medications on Admission:
Dilt CD 240, Lipitor 20, Lisinopril 20, Namenda 10, MOM [**Name (NI) **],
Triamterene HCTZ 37.5/25 Coumadin 3.5, Tyenol prn
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
4. Warfarin 3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO once a day.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain for 2 weeks.
7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
8. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Codeine Sulfate 30 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for pain for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 8641**] Healthcare, NH
Discharge Diagnosis:
rectal prolapse
Post-op low urine output
Discharge Condition:
stable.
Tolerating regular diet.
Pain well controlled.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours
.
Followup Instructions:
1. Please call Dr.[**Name (NI) 3377**] office, [**Telephone/Fax (1) 160**], to make a
follow up appointment in [**12-20**] weeks.
Completed by:[**2116-11-19**]
ICD9 Codes: 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2174
} | Medical Text: Admission Date: [**2173-5-4**] Discharge Date: [**2173-5-11**]
Service: CARD [**Doctor First Name 147**]
CHIEF COMPLAINT: Positive stress test.
HISTORY OF PRESENT ILLNESS: The patient is an 81 year old
male referred for an outpatient cardiac catheterization due
to positive stress test. He had been followed by
Cardiologist for known coronary artery disease. He had a
routine stress test done on [**2173-4-15**], which was positive
and he was referred to the hospital for cardiac
catheterization.
PAST MEDICAL HISTORY:
1. Elevated PSA.
2. Coronary artery disease.
3. Hypertension.
4. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. Transurethral resection of the prostate.
2. Colon repair.
3. Appendectomy.
ALLERGIES: Lidocaine, causing vomiting.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg q. day.
2. Norvasc 2.5 mg q. day.
3. Toprol XL 50 mg q. day.
4. Zocor 20 mg q. day.
HOSPITAL COURSE: The patient underwent a cardiac
catheterization and was found to have coronary artery disease
amenable to coronary artery bypass graft. Cardiac Surgery
was consulted and the decision to take him to the Operating
Room was made.
The patient underwent a coronary artery bypass graft times
two with left internal mammary artery to the left anterior
descending and saphenous vein graft to right PL on
[**2173-5-5**]. He was taken to the Cardiothoracic Intensive
Care Unit postoperatively. He was extubated on the same day.
He had a stable day in the CSICU and was transferred to the
Regular Floor on postoperative day one. His subsequent
postoperative course was fairly smooth.
He did have to have his Foley catheter reinserted twice for
failure to void. He also received two units of blood
transfusion for a low hematocrit. He is currently ready for
discharge home and has been cleared by Physical Therapy. He
will be discharged home with a leg bag and will follow-up
with his urologist, Dr. [**Last Name (STitle) 27536**] on [**5-18**]; the appointment has
already been made.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg q. day times one week.
2. KCL 20 mEq q. day times one week.
3. Colace 100 mg twice a day.
4. Zocor 20 mg q. day.
5. Enteric coated aspirin 325 mg q. day.
6. Iron sulfate 325 mg twice a day.
7. Lopressor 25 mg twice a day.
8. Percocet one to two tablets p.o. q. four to six hours
p.r.n.
DISCHARGE INSTRUCTIONS:
1. Follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12816**] in two
weeks.
2. Follow-up with Dr. [**Last Name (STitle) 27536**], Urologist, on [**5-18**], at 02:10
p.m.
3. Follow-up with Dr. [**Last Name (STitle) **] in four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2173-5-11**] 11:54
T: [**2173-5-12**] 15:44
JOB#: [**Job Number 27537**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2175
} | Medical Text: Admission Date: [**2187-11-17**] Discharge Date: [**2187-11-23**]
Date of Birth: [**2148-4-3**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2187-11-17**]: angiogram with coiling of right posterior
communicating artery
History of Present Illness:
This is a 39 year old woman who reports the worse headache
of her life on [**2187-11-17**]. She has recurring menstrual headaches
and
constant frontal headaches for the past 2-3 months. She was
taking Fioricet prescribed by her PCP. [**Name10 (NameIs) **] day of admission when
she sat up
after waking up she had a very intense pain and pressure in the
frontal areas and behind her eyes. After a minute or two the
pressure subsided but the pain persisted and traveled to her
neck. She had photophobia, nausea and phonophobia. She reported
associated symptoms with her recurring headaches but has
never been diagnosed with migraines. A CT head was performed at
[**Hospital3 **]
was without hemorrhage and MRI was without abnormality. LP was
done showing which was positive for Red Blood Cell's. She was
transferred to [**Hospital1 18**] for further evaluation and treatment.
Past Medical History:
migraines, depression, hypercholesterolemia
Social History:
She is right handed. She smoked [**10-20**] cigarettes per day. She
drinks almost a bottle of wine daily. She is a dental assistant.
She denies use of illegal substances.
Family History:
noncontributory
Physical Exam:
On admission:
PHYSICAL EXAM:
O: 99.0 61 120/76 15 97%
Gen: WD/WN, comfortable, NAD. eyes closed.
HEENT: Pupils: 2-1.5 EOMs intact
Neck: +nuchal rigidity
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake but sleepy following Dilaudid, cooperative
with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2-1.5mm
bilaterally.
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 [**5-10**] throughout. No pronator drift
Sensation: Intact to light touch.
Toes downgoing bilaterally
Handedness Right
ON DISHCARGE [**2187-11-23**]
The patient was alert and oriented to person, place, and time
She was ambulating with a steady gait independetly. Strength
was full [**5-10**] in all 4 extremities. Sensation was intact. Toes
were downgoing. There was no pronator drift. pupils were
reactive. face was symetrical. toungue midline. EOMs were
intact. right groin site was c/eam/dry/intact- there was no
hematoma or eccymosis. pedal pulses were palpable and strong
Pertinent Results:
[**2187-11-16**] CTA Head
CT angiography of the head demonstrates an approximately 7-mm
aneurysm in the right posterior communicating artery with 3-mm
neck and somewhat bilobed appearance of the aneurysm.
cerebral angiogram : Study Date of [**2187-11-17**] 10:31 AM
IMPRESSION: [**Known firstname **] [**Known lastname 91495**] underwent cerebral angiography and
coil embolization of a right posterior communicating artery
aneurysm mesuring 6.34 x 4.62 mm. Though there was no CT scan
evidence of rupture, the spinal fluid was suggestive of a
ruptured aneurysm.
Cardiology Report ECG Study Date of [**2187-11-17**] 8:31:12 AM
Sinus rhythm with sinus arrhythmia. Otherwise, tracing is within
normal limits. No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
53 152 88 454/441 75 46 45
Complete Transcranial Doppler Ultrasound Study [**2187-11-19**]
No evidence of vasospasm seen.
Complete Transcranial Doppler Ultrasound Study [**2187-11-20**]
No evidence of vasospasm seen.
Complete Transcranial Doppler Ultrasound Study [**2187-11-21**]
Impression: Normal TCD evaluation. There was no evidence of
vasospasm.
[**2187-11-16**] 07:50PM PLT COUNT-233
[**2187-11-16**] 07:50PM NEUTS-71.2* LYMPHS-23.2 MONOS-4.9 EOS-0.4
BASOS-0.2
[**2187-11-16**] 07:50PM WBC-10.5 RBC-4.07* HGB-12.8 HCT-37.0 MCV-91
MCH-31.5 MCHC-34.7 RDW-13.2
[**2187-11-16**] 07:50PM estGFR-Using this
[**2187-11-16**] 07:50PM GLUCOSE-95 UREA N-10 CREAT-0.7 SODIUM-143
POTASSIUM-3.8 CHLORIDE-114* TOTAL CO2-17* ANION GAP-16
[**2187-11-16**] 09:45PM PT-12.6 PTT-20.7* INR(PT)-1.1
[**2187-11-16**] 09:45PM PLT COUNT-237
[**2187-11-16**] 09:45PM NEUTS-73.8* LYMPHS-21.4 MONOS-4.2 EOS-0.4
BASOS-0.2
[**2187-11-16**] 09:45PM WBC-10.6 RBC-3.91* HGB-12.4 HCT-36.1 MCV-93
MCH-31.7 MCHC-34.3 RDW-12.7
[**2187-11-16**] 09:45PM HCG-<5
[**2187-11-16**] 09:45PM GLUCOSE-91 UREA N-11 CREAT-0.7 SODIUM-143
POTASSIUM-3.7 CHLORIDE-113* TOTAL CO2-17* ANION GAP-17
[**2187-11-17**] 02:40AM PT-13.2 PTT-21.6* INR(PT)-1.1
[**2187-11-17**] 02:40AM PLT COUNT-238
[**2187-11-17**] 02:40AM WBC-9.8 RBC-3.75* HGB-11.9* HCT-34.7* MCV-93
MCH-31.6 MCHC-34.2 RDW-12.9
[**2187-11-17**] 02:40AM ALBUMIN-3.8 CALCIUM-8.7 PHOSPHATE-3.4
MAGNESIUM-2.2
[**2187-11-17**] 02:40AM CK-MB-1 cTropnT-<0.01
[**2187-11-17**] 02:40AM ALT(SGPT)-9 AST(SGOT)-16 CK(CPK)-52 ALK
PHOS-45 TOT BILI-0.2
[**2187-11-17**] 02:40AM GLUCOSE-89 UREA N-11 CREAT-0.7 SODIUM-142
POTASSIUM-3.8 CHLORIDE-113* TOTAL CO2-17* ANION GAP-16
[**2187-11-17**] 02:04PM PTT-129.3*
[**2187-11-17**] 03:15PM PTT-73.2*
[**2187-11-17**] 03:30PM PTT-71.1*
[**2187-11-22**] 05:15AM BLOOD WBC-8.4 RBC-3.35* Hgb-10.6* Hct-30.6*
MCV-91 MCH-31.7 MCHC-34.8 RDW-13.1 Plt Ct-235
[**2187-11-22**] 05:15AM BLOOD Plt Ct-235
[**2187-11-22**] 05:15AM BLOOD PT-12.2 PTT-23.0 INR(PT)-1.0
[**2187-11-22**] 05:15AM BLOOD Glucose-89 UreaN-6 Creat-0.6 Na-141 K-3.6
Cl-104 HCO3-27 AnGap-14
[**2187-11-22**] 05:15AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8
Brief Hospital Course:
This 39 year old woman who reports the worse headache of her
life upon presentation. On the day of admission when she sat up
after waking up she had a very intense pain and pressure in the
frontal areas and behind her eyes. After a minute or two the
pressure subsided but the pain persisted and traveled to her
neck. She had photophobia, nausea and phonophobia. She presented
to [**Hospital3 **] where a CT of the head was performed with no
evidence of Subarachnoid Hemorhage, a subsequent Lumbar Puncture
was performed which was positive for Red Blood Cells. The
patient was transferred to [**Hospital1 18**] for further evaluation. A CTA
was performed which was consistent with approximately 7-mm
aneurysm in the right posterior communicating artery with 3-mm
neck and somewhat bilobed appearance of the aneurysm.
On [**2187-11-17**], The patient underwent a cerebral angiogram under
anesthesia and right sided Posterior Communicating artery
aneurysm was coiled.The patient was placed on a Heparin
intravenous drip post cerebral angiogram.
The patient was transferred to the ICU post procedure for
monitoring. We do not believe that the patient had a primary Sub
Arachnoid Hemmorhage on the day of admission therefore
Nimodipine was discontinued.
On [**2187-11-18**], The heparin intravenous drip was discontinued per
protocol. Aspirin 325 mg po was initiated status post angiogram
and coiling. The patient continued to experience servere
headaches and a prednisone taper was initiated for this.The
patients diet was advanced and the foley catheter was
discontinued.
On [**2187-11-19**], The patient had a transcranial doppler that did
not reveal vasospasm.The patient was mobilized and tolerating a
PO diet. The patient was voiding independently.
On [**2187-11-20**],The patient had a transcranial doppler that did
not reveal vasospasm. started Toradol for headaches, TCDs
requested by ICU team
On [**2187-11-21**], The patient had a transcranial doppler that did
not reveal vasospasm. The patient was transferred to the Step
Down Unit and a pain management consult was initiated for
persistent headache.
On [**2187-11-22**], The patient was evaluated by neurology for
headache management. The patient was transferred from the Step
Down Unit to floor. A Pain consult was obtained and it was
recommended that Dilaudid be tapered and no long acting pain
medications.
On [**2187-11-23**], The day of discharge, the patient's headache had
decreased. The patient was tolerating a regular diet and
voiding without difficulty independently and had a bowel
movement. The patient was able to ambulate independently with a
steady gait. Upon exam, the patient was neurologically intact.
The patient's strength was full in all extremities. There was
no pronator drift. The face of the patient was symetric. The
right groin angio site was clean, dry, and intact. Pedal pulses
were palpated bilaterally. Neurology was called and a follow up
apointment was made in the [**Hospital 878**] clinic to follow up with Dr
[**Last Name (STitle) 2442**] and Dr [**Last Name (STitle) 1968**] for the patient's ongoing headaches. Per
Neurology's recommendations the patient was discharged on
Tramadol with po Dilaudid for breakthrough pain. Neurology
recommended that Fioricet be discontinued. The patient was also
discharged on Topramate which is a home medication that she
takes for her migraines. The patient was given instructions to
follow up in the [**Hospital 4695**] clinic in 6 weeks with a MRI/MRA.
Medications on Admission:
Zoloft 100 QD
Simvastatin 20mg po QD
Topiramate
Nifedipine
Advair
Discharge Medications:
1. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
home medication.
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): home medication.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 6 months.
Disp:*200 Tablet(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily): home medication.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
8. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): home medication.
Disp:*30 Tablet(s)* Refills:*0*
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for Pain: hold for lethargy, do not drive while
taking this medication.
Disp:*20 Tablet(s)* Refills:*0*
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): home medication.
Disp:*30 Tablet(s)* Refills:*0*
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for headache: try this first,then dilaudid.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right posterior communicating artery aneurysm
Headache
Discharge Condition:
alert and oriented to person, place and time. The patient is
ambulating independently with a steady gait and tolerating a
regular diet. The patient had a bowel movement today and is
voiding without difficulty. strength is full. sensation is full.
right groin site is clean/dry/intact/ pedal pulses are present.
Discharge Instructions:
You were admitted to the hospital after severe headache. You
had a right Posterior Communicating Artery Aneurysm Coiled. You
were started on Aspirin for this. You did well with this and
there were no complications. Given your history of headaches
and the severity of this one, you were seen the Neurology and
Pain service. Their recommendations were followed and you will
follow up with Neurology from here on for your headaches.
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 6 weeks.
??????You will need a MRI/MRA Brain prior to your appointment. This
can be scheduled when you call to make your office visit
appointment.
For your Headaches you will follow up with Dr [**Last Name (STitle) 2442**]/ Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1968**] in the [**Hospital 878**] Clinic, [**Hospital Ward Name 23**] 8 on [**12-19**] at
4:30 pm. The office number to the neurology clinic if you need
to make changes to this appointment is [**Telephone/Fax (1) 3506**].
Completed by:[**2187-11-23**]
ICD9 Codes: 2724, 3051, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2176
} | Medical Text: Admission Date: [**2136-9-10**] Discharge Date: [**2136-9-11**]
Date of Birth: [**2059-5-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname **] is a 77 year old male with PMH significant for CAD
with 2 prior bypass surgeries and 2 PCIs, PAD s/p carotid
stenting and per patient b/l LE bypass, hypertension,
hyperlipidemia, chronic stable angina who presented with a VF
arrest.
His wife describes that the patient was awoken by tooth pain
overnight yesterday that did not resolve with Percocet or
Ambien; she adds that he has had difficulty sleeping for the
past 2 weeks due to increasing chest discomfort at rest. The
patient also has had palpitations and SOB with exertion that
seemed to be worsening over the past 4-6 weeks. The patient also
describes occasional L arm pain in shoulder. One month ago he
had a exercise stress test at [**Hospital1 3278**] to evaluate these worsening
symptoms- this showed poor exercise toleranace and so the
patient underwent diagnostic cath showing patent CABG grafts,
patent stents, no new occlusions. Of note, the patient stopped
taking Ranexa two weeks ago because of diarrhea side effects; he
associates his worsening symptoms with this. He has extensive
CAD and vascular history as outlined below but has no history of
arrythmis or syncope.
Today, the patient experienced his chronic anginal chest pain
while walking to the board of directors meeting for the
hospital. During the meeting, the patient became unresponsive
and was found to be pulseless; CPR was initiated and the patient
was intubated. Cardiac monitoring demonstrated VF and a 360J
shock was delivered, and chest compressions were continued. The
patient immediately returned to a normal perfusing rhythm, and
was extubated.
He was transferred to the [**Hospital Unit Name 153**]. While in the [**Hospital Unit Name 153**], the patient
was complaining of [**7-24**] sub-sternal chest pain, EKG showed
depressions in I, II, III, aVF, V4-V6. Patient was given ASA and
a bolus of lidocaine. Underwent catheterization which
demonstrated patent stents and LIMA and prominent severe AR.
ROS negative except as for described above.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes +, Dyslipidemia +,
Hypertension +
2. CARDIAC HISTORY: CAD: CABG x2 [**45**] years; Cath x3 with 2
stents placed, last 2 years ago; Carotid endarterectomy 3 years
ago
3. OTHER PAST MEDICAL HISTORY:
OSA on CPAP
HTN
HL
DM
Osteoporosis
Social History:
Smokes [**12-17**] ppd
EtOH- daily wine. Occasional vodka/irish whiskey.
Family History:
CAD with MI on both mother and fathers side of the family
Physical Exam:
GENERAL: Oriented x3 and in NAD. Mood, affect appropriate.
HEENT: NCAT. Moist mucous membranes.
CARDIAC: RR, normal S1, S2. Harsh systolic murmur loudest at
RUSB with no radiation to carotids or axilla.
LUNGS: No chest wall deformities. Resp unlabored, no accessory
muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND.
EXTREMITIES: No lower extremity edema. Bandages in bilateral
groins, without oozing or erythema.
PULSES: Pedal pulses detectable on doppler.
Pertinent Results:
[**2136-9-10**] 05:38PM BLOOD WBC-6.7 RBC-3.46* Hgb-12.4* Hct-37.5*
MCV-108* MCH-35.9* MCHC-33.1 RDW-14.2 Plt Ct-157
[**2136-9-10**] 09:35PM BLOOD WBC-7.7 RBC-3.34* Hgb-12.0* Hct-36.8*
MCV-110* MCH-35.9* MCHC-32.6 RDW-15.1 Plt Ct-155
[**2136-9-11**] 05:51AM BLOOD WBC-4.9 RBC-3.04* Hgb-11.2* Hct-32.5*
MCV-107* MCH-36.9* MCHC-34.5 RDW-15.2 Plt Ct-131*
[**2136-9-10**] 05:38PM BLOOD Neuts-55.8 Lymphs-38.4 Monos-4.5 Eos-0.8
Baso-0.5
[**2136-9-10**] 05:38PM BLOOD PT-13.0 PTT-24.1 INR(PT)-1.1
[**2136-9-11**] 05:51AM BLOOD PT-12.5 PTT-24.6 INR(PT)-1.1
[**2136-9-11**] 05:51AM BLOOD Plt Ct-131*
[**2136-9-10**] 05:38PM BLOOD Glucose-145* UreaN-51* Creat-1.8* Na-140
K-4.2 Cl-104 HCO3-19* AnGap-21*
[**2136-9-10**] 09:35PM BLOOD Glucose-112* UreaN-45* Creat-1.4* Na-138
K-4.3 Cl-106 HCO3-21* AnGap-15
[**2136-9-11**] 05:51AM BLOOD Glucose-134* UreaN-33* Creat-1.2 Na-137
K-4.0 Cl-106 HCO3-23 AnGap-12
[**2136-9-10**] 05:38PM BLOOD ALT-123* AST-187* LD(LDH)-354*
CK(CPK)-168 AlkPhos-59 TotBili-0.3
[**2136-9-10**] 09:35PM BLOOD CK(CPK)-1058*
[**2136-9-11**] 05:51AM BLOOD CK(CPK)-1647*
[**2136-9-10**] 05:38PM BLOOD CK-MB-8 cTropnT-<0.01
[**2136-9-10**] 09:35PM BLOOD CK-MB-27* MB Indx-2.6 cTropnT-0.21*
[**2136-9-11**] 05:51AM BLOOD CK-MB-27* MB Indx-1.6 cTropnT-0.12*
[**2136-9-10**] 05:38PM BLOOD Albumin-4.4 Calcium-9.1 Phos-4.9* Mg-1.7
Cholest-129
[**2136-9-11**] 05:51AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.0
[**2136-9-10**] 05:38PM BLOOD Triglyc-158* HDL-49 CHOL/HD-2.6
LDLcalc-48
CT Head ([**2136-9-11**])- IMPRESSION: No acute intracranial hemorrhage.
No evidence of hypoxic
ischemic injury.
Brief Hospital Course:
Patient was admitted to the CCU after going into cardiac arrest.
Prior to arrival to CCU, a code STEMI was called and patient
underwent cardiac catheterization. Prior grafts and stents were
patent and now new coronary lesions were found. Patient
remained hemodynamically stable and was alert and oriented after
the procedure. While in the CCU, he was monitored closely. He
denied any further episodes of angina, shortness of breath, or
palpitations. He was started on metoprolol 12.5mg TID and
continued on his other home medications including aggrenox,
rousvastatin, valsartan and plavix. His chest pain was
attributed to compression and was controlled with percocet and a
lidocaine patch. Follow-up EKG's did not show any new ST
changes. Post-cath check was normal and he did well overnight.
He underwent a head CT which did not show any acute intracranial
pathology or evidence of hypoxic ischemic injury.
He is being transferred to [**Hospital 3278**] Medical Center as his primary
cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14714**], is based there. He will need an
EP consult for ICD placement.
Medications on Admission:
Aggrenox (ASA+Dipyrimadole) (25/200) AM, PM
Allopurinol 300 mg AM
Crestor (Rosuvastatin) 40 mg AM
Diovan (Valsartan) 80 mg AM
Folic acid, 5 pills PM
Lasix 20 mg AM
Isosorbide (Imdur) 60 mg AM
Namenda (Memantine) 10 mg [**Hospital1 **] (AM, PM)
Niaspan (Niacin) 750 mg PM
Plavix 75 mg PM
Tricor (Fenofibrate) 145 mg AM
Zetia (Ezetimibe) 10 mg PM
Boniva 150 mg AM (once monthly)
Ipratropium Spray (.06%) as needed
Nitrolingual Spray as needed
Zolpidem Tartrate (Ambien) - as needed
Calcium Citrate +D (600/300)
Mucinex 600 mg [**Hospital1 **] (AM, PM)
ToprolXL 25mg daily
Zyrtec 10 mg PM
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
3. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
4. Niacin 250 mg Capsule, Sustained Release Sig: Three (3)
Capsule, Sustained Release PO DAILY (Daily).
5. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath.
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for pain.
13. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses.
15. Namenda 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
17. Boniva 150 mg Tablet Sig: One (1) Tablet PO once a month.
18. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
19. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day as needed for cough.
20. Medication
Calcium Citrate +D (600/300) daily
21. Nitromist 0.4 mg/Dose Aerosol Sig: One (1) spray
Translingual once a day as needed for chest pain.
Discharge Disposition:
Extended Care
Facility:
other
Discharge Diagnosis:
Primary: Cardiac Arrest
Secondary: Coronary artery disease, aortic stenosis, aortic
regurgitation, hypertension, hyperlipidemia, diabetes mellitus
Discharge Condition:
Alert and oriented
Vital signs stable.
Discharge Instructions:
You were admitted to the Cardiac Care Unit after going into
cardiac arrest yesterday afternoon. You underwent resuscitation
with return of your heart function. A cardiac catheterization
was performed which did demonstrated that your cardiac anatomy
was stable. There were no new coronary lesions. You remained
hemodynamically stable while here. You are being transferred to
[**Hospital 3278**] Medical Center for further management.
No changes were made to your medications.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 69015**] on discharge from [**Hospital 3278**]
Medical Center
Completed by:[**2136-9-12**]
ICD9 Codes: 4275, 4019, 2724, 4241, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2177
} | Medical Text: Admission Date: [**2190-8-28**] Discharge Date: [**2190-9-6**]
Date of Birth: [**2171-8-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p self inflicted neck laceration
Major Surgical or Invasive Procedure:
s/p Ligation of transected right internal jugular
s/p Closure of right pharyngeal laceration
History of Present Illness:
19 yo male with history depression and psychosis; s/p right
internal jugular ligation and hypopharyngeal injury secondary to
suicide attempt.
Past Medical History:
Depression
Psychosis
Suicidal ideation
Social History:
Born and raised in [**Location (un) 86**], MA
Lives with both parents.
Family History:
Noncontributory
Pertinent Results:
[**2190-8-28**] 05:49PM GLUCOSE-124* UREA N-7 CREAT-0.7 SODIUM-143
POTASSIUM-4.0 CHLORIDE-116* TOTAL CO2-19* ANION GAP-12
[**2190-8-28**] 05:49PM CALCIUM-7.0* PHOSPHATE-3.2 MAGNESIUM-1.2*
[**2190-8-28**] 05:49PM WBC-14.8* RBC-3.57* HGB-11.3*# HCT-32.7*
MCV-92 MCH-31.8 MCHC-34.7 RDW-13.0
[**2190-8-28**] 05:49PM PLT COUNT-106*#
[**2190-8-28**] 04:26PM GLUCOSE-119* LACTATE-1.1 NA+-140 K+-3.3*
CL--117*
[**2190-8-28**] 01:21PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
ESOPHAGUS [**2190-9-2**] 2:41 PM
ESOPHAGUS
Reason: Please evaluate pharynx s/p stab with injury which was
repai
[**Hospital 93**] MEDICAL CONDITION:
19 year old man with
REASON FOR THIS EXAMINATION:
Please evaluate pharynx s/p stab with injury which was repaired
operatively on [**8-28**]. Please have patient drink contrast. LEAVE
NGT. Please perform in am on [**2190-9-2**].
HISTORY: 19-year-old man with recent stabbing injury to right
neck. Please assess pharynx and swallowing function.
TECHNIQUE: Barium esophagogram.
FINDINGS: Water soluble Conray liquid contrast was administered.
Water soluable contrast passed freely through the esophagus.
There was no aspiration into the airway and no significant
retention in the folliculi or piriform sinuses. There was no
extravasation of contrast. There were normal primary peristaltic
contractions. After evaluation with Conray water soluable
contrast without detectable extravasation, thin liquid barium
was administered and the exam was repeated again, confirming the
above findings. There was no hiatus hernia. No free GE reflux
and the stomach filled and emptied promptly.
IMPRESSION: No extravasation of contrast. Contrast passes freely
through the esophagus and stomach. No aspiration.
CHEST (PORTABLE AP) [**2190-8-29**] 8:19 AM
CHEST (PORTABLE AP)
Reason: ? aspiration pneumonia
[**Hospital 93**] MEDICAL CONDITION:
19 year old man with neck & pharyngeal lac
REASON FOR THIS EXAMINATION:
? aspiration pneumonia
CHEST, SINGLE VIEW ON [**8-29**]
HISTORY: Status post pharyngeal laceration, question aspiration
pneumonia.
FINDINGS: The endotracheal tube tip is 4 cm above the carina.
The NG tube is in the stomach. There is pulmonary vascular
redistribution with some vascular ill definition suggesting
fluid overload. There is no focal infiltrate. Skin staples and a
drain are visualized in the neck.
Brief Hospital Course:
Patient admitted to the Trauma Service. He was emergently taken
to the operating room for bilateral neck exploration; ligation
of right internal jugular and facial vein; he was started on IV
Clindamycin. Psychaitry was also consulted given patient's
history of depression; it was recommended that 1:1 sitter be
continued; continue with Risperdal. On hospital day #3 a code
Purple was called as patient attempted to leave unit; he was
escorted back to his room and agreed to accept medications. He
has been much more cooperative following this episode. He
underwent a Swallow evaluation and passed; his diet was advanced
to House; he has been tolerating that without difficulty. His IV
antibiotics were changed to oral on day of discharge. Physical
therapy has worked with patient as well, he has been ambulating
independently. Patient will be discharged to inpatient
Psychiatry unit.
Medications on Admission:
Prozac
Risperdol
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for fever or pain.
2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times
a day: give 30 min prior to meals.
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Risperidone 2 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
10. Clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO three
times a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
s/p Self inflicted neck laceration
Discharge Condition:
Stable
Discharge Instructions:
Follow up in Trauma Clinic in 3 weeks.
Follow up with Otolaryngology in 1 week.
Follow up with Psychiatry as indicated.
Followup Instructions:
Trauma Clinic appointment, Tuesday, [**9-28**] at 10 [**Initials (NamePattern5) **] [**Last Name (NamePattern5) **]
Medical Bldg, [**Last Name (NamePattern1) **]. [**Location (un) 86**], [**Location (un) 470**]. Tel number
[**Telephone/Fax (1) 6439**].
Appointment with Dr. [**First Name (STitle) **] on Wed, [**9-15**] at 1 p.m. [**Location (un) **]., [**Last Name (un) **] [**Doctor Last Name **], MA. Tel number [**Telephone/Fax (1) 2349**].
Completed by:[**2190-9-6**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2178
} | Medical Text: Unit No: [**Numeric Identifier 75537**]
Admission Date: [**2158-9-22**]
Discharge Date: [**2158-9-24**]
Date of Birth: [**2158-9-19**]
Sex: F
Service: NBB
HISTORY OF PRESENT ILLNESS: [**First Name9 (NamePattern2) 75538**] [**Known lastname 75539**] is the former 3.46
kg product of a 39 5/7 weeks' gestation pregnancy born to a
23-year-old G2, P1 woman. (Prenatal screens: blood type A+,
antibody negative, rubella immune, RPR nonreactive, hepatitis
B surface antigen negative, and group beta Strep status
negative.) The pregnancy was uncomplicated. The mother
experienced ruptured membranes 5 hours prior to delivery and
had an intrapartum fever to 100.7 degrees Fahrenheit. The
infant was born by spontaneous vaginal delivery and with
Apgars of 8 and 9. She had a sepsis evaluation performed in
the neonatal intensive care unit and was then transferred to
the newborn nursery. On [**2158-9-20**], she had an elevated
temperature to 100.3 degrees Fahrenheit. Upon request of her
pediatrician, a second complete blood count and blood culture
were obtained. The infant was discharged home on [**2158-9-22**]. The blood culture results were reported as gram-
positive cocci in pairs and clusters, which were later
identified as Staphylococcus epidermidis. The baby was
readmitted on [**2158-9-22**] for further evaluation and
treatment. Weight upon admission to the neonatal intensive
care unit was 3.22 kg.
DISCHARGE PHYSICAL EXAMINATION: Weight 3.33 kg; length 49
cm; head circumference 33 cm. General: Alert, nondistressed
female in room air. Head/Eyes/Ears/Nose/Throat: Anterior
fontanelle soft and flat; nares patent; mucous membranes
moist; palate intact. Neck: Supple; without masses.
Cardiovascular: Regular rate and rhythm; without murmur; 2+
radial and femoral pulses; brisk capillary refill. Chest:
Clear breath sounds bilaterally; no increased work of
breathing. Abdomen: Soft; nontender; nondistended; no masses
or hepatosplenomegaly. GU: Normal female external genitalia.
Anus: Patent. Spine: No cleft, [**Hospital1 **], or dimple. Extremities:
Stable; moving all. Skin: Mildly jaundiced; nevus flammeus
over the left eyelid; small pigmented nevus over the left
buttock; nevi on the sole of the left foot; mongolian spot on
the anterior surface of the left ankle; 2 small abrasions on
the dorsum of both feet. Neurologic: Alert; active; moving
all extremities; normal tone and reflexes.
HOSPITAL COURSE BY SYSTEM AND INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory. The infant remained in room air and had no
episodes of apnea.
2. Cardiovascular. The infant maintained normal heart rates
and blood pressures. No murmurs were noted.
3. Fluids, Electrolytes, and Nutrition. The infant
continued to ad. lib. breastfeed or take expressed
mother's milk by bottle. Serum glucoses were stable.
Weight on the day of discharge was 3.33 kg.
4. Infectious Disease. A complete blood count was within
normal limits. Another blood culture was obtained on, and
the infant was started on vancomycin and gentamicin. The
blood culture obtained on [**2158-9-22**] prior to
starting the antibiotics was no growth, and the
antibiotics were discontinued after 48 hours.
5. Gastrointestinal. A serum bilirubin was obtained upon
admission to the neonatal intensive care unit and was
12.4 mg/dL total.
6. Neurology. This infant has maintained a normal
neurological exam, and there were no neurological
concerns at the time of discharge.
7. Sensory/Audiology. Hearing screening was performed on
the first/birth admission and the infant passed in both
ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents.
PRIMARY PEDIATRICIAN: [**First Name11 (Name Pattern1) 41215**] [**Last Name (NamePattern4) 75540**], MD
[**Location (un) 75541**], MA
Phone number: [**Telephone/Fax (1) 41217**]
DISCHARGE CARE AND RECOMMENDATIONS:
1. Ad. lib. breastfeeding.
2. No medications.
3. Iron and vitamin D supplementation:
a. Iron supplementation is recommended for preterm
and low birth weight infants until 12 months' corrected
age.
b. 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 not indicated.
5. Newborn screens were sent with the newborn admission.
6. No further immunizations administered.
7. Immunizations Recommended:
a. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criteria: 1) born at less than 32 weeks; 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) chronic lung disease; 4)
hemodynamically significant congenital heart disease.
b. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of
age. Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
c. This infant has not received a 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.
DISCHARGE DIAGNOSIS: Suspicion for sepsis - ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2158-9-24**] 01:22:16
T: [**2158-9-25**] 08:53:21
Job#: [**Job Number 75542**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2179
} | Medical Text: Admission Date: [**2118-1-20**] Discharge Date: [**2118-1-21**]
Date of Birth: [**2060-7-12**] Sex: M
Service: MEDICINE
Allergies:
Tetanus
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Asystolic cardiac arrest after DCCV
Major Surgical or Invasive Procedure:
DCCV on [**2118-1-20**] complicated by asystolic cardiac arrest
History of Present Illness:
Mr. [**Known lastname 28812**] is a 57 yo M with history of paroxysmal atrial
fibrillation s/p PVI x2 ([**2113**] and [**2117**]), atypical atrial flutter
s/p ablation x2 ([**2109**] and [**2117**]), HTN, TIA ([**9-18**]) and depression
who presents to the CCU due to PEA after DCCV. Patient came in
to the [**Hospital1 18**] today for scheduled routine DCCV for atrial
fibrillation/flutter. After the procedure the patient had
asystolic cardiac arrest for which he received atropine 1 mg,
epinephrine 1 mg, peripheral dopamine and CPR (for ~2 minutes)
then spontaneously woke up. After awaking he was kept on
dopamine, and both epinephrine and phenylephrine drips started
due to SBP in the 80-90's. He was breathing spontaneously and AO
x3. Subsequently his hemodynamics improved with HR NSR at 85
bpm, BP 121/31, O2 sat 100% on 6 L FM. He was then transfered to
the CVICU.
.
In the CVICU the patient's epinephrine drip was stopped due to
hypertension and both dopamine and phenylphrine drips minimized.
He states he is feeling well and has no complaints.
.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations or presyncope.
Past Medical History:
Afib dx'd [**2106**] but has been symptomatic for several years prior
Aflutter ablation Fall [**2109**]
S/p approximately 7 cardioversions, the first dating back to
Fall [**2109**]
HTN
Depression
H/o TIA in [**9-18**] (brain MRI was negative) with word finding
difficulties
Social History:
He has a girlfriend. [**Name (NI) **] works as a freelance journalist. He
smoked for 9 months many years ago. He drinks occasional glass
of wine, or [**1-16**] shots of hard. He is eating healthy diet with 5
servings of fruits and vegetables every day. He exercises
regularly.
Family History:
Mother had Afib.
Physical Exam:
ON ADMISSION:
VS: T= 96.7 BP= 11/77 HR= 53 RR= 12 O2 sat= 100% 3L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. NABS.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
No change in physical exam at discharge
Pertinent Results:
ADMISSION LABS:
[**2118-1-20**] 12:22PM BLOOD WBC-13.6*# RBC-4.57* Hgb-14.6 Hct-43.7
MCV-96 MCH-31.9 MCHC-33.4 RDW-13.2 Plt Ct-320
[**2118-1-20**] 07:15AM BLOOD PT-28.0* PTT-31.7 INR(PT)-2.7*
[**2118-1-20**] 12:22PM BLOOD Glucose-133* UreaN-15 Creat-1.1 Na-140
K-4.4 Cl-106 HCO3-23 AnGap-15
[**2118-1-20**] 12:22PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.1
DISCHARGE LABS:
[**2118-1-21**] 04:50AM BLOOD WBC-7.9 RBC-3.63* Hgb-11.8* Hct-33.3*#
MCV-92 MCH-32.6* MCHC-35.5* RDW-13.2 Plt Ct-240
[**2118-1-21**] 09:46AM BLOOD Hct-33.9*
[**2118-1-21**] 04:50AM BLOOD PT-27.6* PTT-32.3 INR(PT)-2.7*
[**2118-1-21**] 04:50AM BLOOD Glucose-87 UreaN-15 Creat-1.0 Na-139
K-4.3 Cl-108 HCO3-26 AnGap-9
[**2118-1-21**] 04:50AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1
STUDIES:
.
Admisson EKG [**1-20**]: Atrial flutter with a rapid ventricular
response. The axis is indeterminate. Right bundle-branch block.
Compared to the previous tracing of [**2117-9-22**] atrial flutter is
new.
.
Discharge EKG [**1-21**]: Sinus bradycardia. Right axis deviation.
Right bundle-branch block. Compared to the previous tracing of
[**2118-1-20**] atrial ectopy is no longer present.
.
Pre DCCV echo [**1-20**]:
This study was compared to the report of the prior study (images
not available) of [**2113-11-1**].
LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA
ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast
in the body of the RA. Mild spontaneous echo contrast in the
RAA. Good RAA ejection velocity (>20cm/s). No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Low normal LVEF.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Filamentous strands on the aortic leaflets c/with Lambl's
excresences (normal variant). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No 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 monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The patient was sedated
for the TEE. Medications and dosages are listed above (see Test
Information section). The posterior pharynx was anesthetized
with 2% viscous lidocaine. 0.1 mg of IV glycopyrrolate was given
as an antisialogogue prior to TEE probe insertion. No TEE
related complications.
Conclusions
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No mass/thrombus is seen in the
left atrium or left atrial appendage. Mild spontaneous echo
contrast is seen in the body of the right atrium. Mild
spontaneous echo contrast is seen in the right atrial appendage.
Right atrial appendage ejection velocity is good (>20 cm/s). No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 45 cm
from the incisors. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. There are
filamentous strands on the aortic leaflets consistent with
Lambl's excresences (normal variant). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No atrial thrombus seen. Mild spontaneous echo
contrast in the right atrium and right atrial appendage. Low
normal left ventricular systolic function.
Compared with the report of the prior study (images unavailable
for review) of [**2113-11-1**], left ventricular function is now low
normal.
Brief Hospital Course:
Patient is a 57 yo M with history of AF/flutter s/p multiple
ablations and cardioversions who presented today for routine
DCCV and had a brief asystolic cardiac arrest after.
.
# Asystolic cardiac arrest: Pt initially presenting for routine
DCCV for afib/a flutter, and was found to have a brief episode
of asystolic cardiac arrest post DCCV requiring epinephrine,
atropine and CPR for ~2 minutes. He spontaneously awoke without
deficits but was hypotensive requiring pressors. Likely cause of
arrest was increased vagal tone and cardiac stunning also
causing his persistent hypotension. Dopamine and phenylepherine
drips were able to be quickly weaned and he remained
normotensive upon admission to the CCU and remained so overnight
into the day of discharge.
.
# RHYTHM: Pt came to the CCU in NSR after DCCV. His rate
remained 50s-60s overnight without major events on tele. His
flecanide was continued in house. However, upon discharge the
decision was made to discontinue his flecanide along with his
home atenolol and quinapril given his borderline bradycardia and
NSR. He has follow up with PCP and cardiology at which point
restarting antiarrhytnmics can be discussed. He was discharged
on his home coumadin regimen and should have INR checked per his
normal regimen. He remained therapeutic on his coumadin
in-house.
.
# Hct drop: Pt was noticed to have a Hct drop from 43.7 on
admission to 33.3. This was likely to be dilutional given his
significant fluid resuscitation and comparable decrease in both
his WBC and platelet counts. He was guaiac negative and denied
any BRBRP or dark stools. Repeat hct on the day of discharge
was stable at 33.9 so we did not feel there was any active
bleed. His hct should be followed up as an outpatient to ensure
normalization.
.
# Depression: Continued venlafaxine and lorazepam
Medications on Admission:
Atenolol 25 mg daily
Breaker 45C 200 mg EOD
Flecainide 100 mg [**Hospital1 **]
Folic Acid 1 mg daily
Lorazepam 0.5 mg daily PRN anxiety
Quinapril 10 mg daily
Ranitidine 300 mg daily PRN dyspepsia
Sildenafil 50 mg PRN
Venlafaxine XR 37.5 mg daily
Warfarin 2.5 mg x4 week, 5 mg x3 week
Aspirin 325 mg daily
Vitamin D 3,000 units daily during winter months
Coenzyme Q10 100 mg daily
Niacin SR 300 mg daily
Omega 3 PUFA's
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) as needed for GERD.
3. sildenafil 50 mg Tablet Sig: One (1) Tablet PO as needed.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA).
7. niacin 250 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 7.5 Tablets
PO DAILY (Daily).
9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety.
11. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a
day.
12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 4x per week:
[**Doctor First Name **], mo, we, fr.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Asystolic cardiac arrest
atrial fibrillation
atrial flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 28812**],
You came to the hospital for ablation of your atrial
fibrillation/atrial flutter. After the procedure, you had a
brief episode of cardiac arrest with dropping of your blood
pressure, so you were admitted to the CCU. You did very well
overnight with your blood pressures and heart rate remaining
stable. You were also noted to have a drop in your blood count
but on recheck it appeared to be stable.
Please note your appointments below. It is very important that
you follow up with your PCP and cardiologist which have been
scheduled for you.
We have made the following changes to your medications:
STOPPED quinapril
STOPPED atenolol
STOPPED flecainide
You should continue all other medications as your were taking
You should also have your INR (coumadin level) checked when you
see your PCP [**Last Name (NamePattern4) **] [**1-24**]
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2118-1-24**] at 10:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2118-1-27**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28813**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRAVEL CLINIC
When: FRIDAY [**2118-1-28**] at 1:30 PM
ICD9 Codes: 9971, 4275, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2180
} | Medical Text: Admission Date: [**2110-9-29**] Discharge Date: [**2110-10-10**]
Date of Birth: [**2052-12-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
Shaking, fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
: 57yo M w/ PMH of progressive metastatic rectal cancer, DM and
HTN presented to the ER with worsening fatigue ("I don't have my
get-up-and-go"), diarrhea and LE edema. He was recently admitted
to [**Hospital1 18**] for pneumonia and given a course of levaquin for
treatment. He was discharged on [**9-20**], but continued taking
levaquin per his PCP up until today. His symptoms began
approximately 4 days ago, with increasing fatigue, decreased
energy and diarrhea (2 loose BM daily). He denies any
f/c/CP/SOB/dizziness/LH/weight changes/n/v/loss of appetite. On
arrival to the ER tonight, his T was 100, HR 180/104, HR 88, RR
24, and sats were 96% on RA. Exam was notable for guaiac
positive stool and yellow icteric sclera. Given his recent abx
use, the diarrhea was concerning for [**Last Name (LF) **], [**First Name3 (LF) **] cultures were
taken and labs drawn. His labs revealed a serum glu of 26 and
repeat FS was 20. He was given 1 amp D50 and ate his dinner,
with an improvement in his FS to 137. Repeat FS after that was
42 and then 26. He was given another amp of D50, then D51/2NS at
100/hr x1L, with improvement in his FS to 130s. He was started
on flagyl 500mg PO x1 for presumed C diff and blood cultures
were sent. His repeat FS were 55 and then 45. He was then
switched to a D10 gtt at 100/hr and he was transferred to the
[**Hospital Unit Name 153**] for further management of his hypoglycemia.
.
His prognosis was discussed with his primary oncologist and it
was felt that the course was indicative of limited reserve.
Palliative care was consulted and [**Hospital Unit Name 153**] team felt that the
discussion was moving toward CMO.
Past Medical History:
1. Onc history from OMR: Between [**Month (only) **]-[**2108-11-26**], Mr. [**Known lastname 16745**]
noticed blood in his stool and ongoing abdominal discomfort. In
[**2108-11-26**], he presented with acute worsening abdominal pain and
peritonitis. Radiological findings suggested large mass at the
rectosigmoid junction adhering to the bladder wall causing
cancerous colovesical fistula. During the surgical exploration,
colonoscopy was done which showed exophytic tumor w/ biopsy
positive for invasive adenocarcinoma. He then underwent
diverting colostomy. Repeat CEA showed increase in number
suggesting progression of the cancer. Further staging CT on
[**2109-1-31**] revealed 2 lesions in the liver suggestive of metastatis.
RUQ ultrasound showed portal vein thrombosis and he was started
and has completed coumadin. He received neoadjuvant chemotherapy
with FOLFOX and Avastin. Underwent resection of rectum with
colostomy, Cystoscopy and bilateral ureteral stent placement,
Cystoprostatectomy and urinary diversion into a colonic loop,
and Bilateral nephrostomy placement in [**8-30**]. He was on break
from chemotherapy from [**5-1**] to [**7-31**] but followup CT scans showed
significant progression of disease. He was started on single
[**Doctor Last Name 360**] weekly Irinotecan on [**2110-8-20**]. Patient missed his first
Erbitux dose on [**9-17**] because of nausea/abdominal discomfort.
.
Other PMHx:
2. IDDM
3. HTN
4. Portal vein thrombosis
Social History:
He is a widower and lost his wife in '[**94**], has 7 adult children.
Currently on disability, previously worked as a computer
engineer. Lives with girlfriend, with whom he has been
monogamous >2years. Last HIV test was 5 years ago-negative.
Tobacco: None
Alcohol: used to drink, stopped drinking 5 years ago.
Drugs: None
Family History:
No family hx of colon or prostate cancer
Physical Exam:
VS - T 100.1, BP 175/95, HR 78-85, RR 24-32, O2 sats 99% on RA
Gen: WDWN AfAm male in NAD, lying in bed.
HEENT: Sclera slightly icteric. PERRL, 3->2mm bilaterally. EOMI.
OP clear, no exudates or erythema. Neck supple, no evidence of
JVD.
CV: RR, normal S1, S2. No m/r/g.
Lungs: Decreased BS at R base, but otherwise clear, no crackles.
Abd: Soft, NTND. Has large midline scar, well healed. Has
colostomy bag in R middle quadrant w/ large amt of formed brown
stool + gas. Has urostomy bag in L middle quadrant. Ostomy pink,
nontender. Urine thick, yellow.
Ext: 2+ pitting edema in his feet bilaterally, but 2+ DP pulses
bilaterally. No c/c. No rashes. Skin dry.
Neuro: AAO x3. Has flat affect.
Pertinent Results:
[**2110-9-29**] 04:04PM LACTATE-2.0
[**2110-9-29**] 04:03PM GLUCOSE-26* UREA N-13 CREAT-0.6 SODIUM-135
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14
[**2110-9-29**] 04:03PM ALT(SGPT)-87* AST(SGOT)-184* LD(LDH)-3096*
ALK PHOS-801* AMYLASE-53 TOT BILI-6.4*
[**2110-9-29**] 04:03PM ALT(SGPT)-87* AST(SGOT)-184* LD(LDH)-3096*
ALK PHOS-801* AMYLASE-53 TOT BILI-6.4*
[**2110-9-29**] 04:03PM ALBUMIN-2.5*
[**2110-9-29**] 04:03PM WBC-14.0* RBC-3.96* HGB-10.6*# HCT-31.9*
MCV-81* MCH-26.8* MCHC-33.3 RDW-21.5*
[**2110-9-29**] 04:03PM NEUTS-82* BANDS-0 LYMPHS-12* MONOS-5 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2110-9-29**] 04:03PM PT-16.8* PTT-28.0 INR(PT)-1.5*
[**2110-10-6**] 06:05AM BLOOD WBC-15.3* RBC-3.71* Hgb-9.3* Hct-28.9*
MCV-78* MCH-25.2* MCHC-32.3 RDW-22.4* Plt Ct-860*
[**2110-10-6**] 06:05AM BLOOD Plt Ct-860*
[**2110-10-6**] 06:05AM BLOOD Glucose-130* UreaN-77* Creat-2.3* Na-129*
K-5.3* Cl-93* HCO3-19* AnGap-22*
[**2110-10-6**] 06:05AM BLOOD ALT-143* AST-288* AlkPhos-549*
TotBili-13.1*
[**2110-10-6**] 06:05AM BLOOD Albumin-2.2* Calcium-8.9 Phos-6.0*
Mg-3.3*
[**2110-10-5**] 06:40AM BLOOD Hapto-558*
[**2110-10-7**] 07:00PM BLOOD TSH-1.8
.
Right LE doppler:
RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **]-scale and Doppler
son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and
popliteal veins were performed. These demonstrate normal
augmentation, compressibility, flow and waveforms. No
intraluminal echogenic thrombus is identified.
IMPRESSION: No evidence of right lower extremity deep venous
thrombosis.
Brief Hospital Course:
57yo M w/ metastatic rectal cancer presents with fatigue,
diarrhea, and persistent hypoglycemia.
.
1. RECTAL CANCER: The majority of problems that the patient
experienced while inpatient were thought to be due to advanced
metastatic disease. Initially the patient was evaluated for
hospice care, but the patient expired prior to this being
arranged.
.
2. HYPOGLYCEMIA/Hyperglycemia - The patient was initially
admitted with severe hypoglycemia that has now resolved. The
initial cause is likely a combination of decreased metabolism of
insulin with possible infection (now resolved). Pt was treated
with antibiotics at first, but discontinued as pt was afebrile
without localizing symptoms. For the management of his
hypoglycemia, pt was managed in the ICU and required dextrose
IV. Eventually, the glucose level was improved and he was
transfered to the medicine floors. He was kept off insulin
intially. Then small doses of glargine were started, but pt
began to have hypoglycemia and the lantus was discontinued.
.
3. Liver Failure: Pt with significant elevation of LFTs over
last weeks which was likely due to invasive process with cancer.
Continues to be elevated. Pt likely with progression of liver
disease as a result of liver metastases.
- RUQ u/s showed echogenic liver consistent with history of
multiple hepatic metastasis. No ductal dilation.
- LFT elevation limits opportunities for chemotherapy.
.
4. Renal failure- pt has increasing BUN, creatinine. Likely
hepatorenal syndrome and due to metastatic disease.
.
5. Thrush: pt continues to have oral symptoms. Will add
peridex, keep on nystatin.
.
6. DIARRHEA: Per pt, somewhat at baseline. Unclear if changed.
Stool cultures negative.
.
7. HTN: Metoprolol.
.
8. LE EDEMA: New issue for the patient. He has had increasing
swelling while inpatient. He had some relief with
spironolactone.
.
In last days of hospitalization the patient's mental status
declined such that it was impossible to take PO meds or eat. He
was made comfort measures only and given medications to limit
pain. The patient expired in the hospital.
Medications on Admission:
Atenolol 100mg PO QD
Hydrochlorothiazide 25mg PO QD
Glargine 35u SC QHS
Levofloxacin 500mg PO QD - last dose on day of admission
Percocet 5-325 mg PO every 4-6 hours prn x 10 pills
Discharge Medications:
Pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
End-stage Metastatic rectal cancer
Secondary
Hypoglycemia
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2181
} | Medical Text: Admission Date: [**2145-11-16**] Discharge Date: [**2145-11-21**]
Date of Birth: [**2088-6-4**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
female with a history of hypothyroidism, hypertension and has
a long history of intermittent headaches. Recently her
headaches have intensified in the setting of bouts of
hypertension with systolic blood pressure of up to 190. As
part of her work up she underwent an MRI and MRA, which
revealed small left middle cerebral artery wide based
aneurysm. These findings on CT angio confirmed that the left
MCA 3 to 4 mm bilobed aneurysm and also suggesting a
possibility of anterior cerebral artery aneurysm as well.
Following the dye injection of her CTA she developed a severe
reaction to contrast agents, resulting in a whole body rash,
for which she was being treated on prednisone.
SOCIAL HISTORY: She works as a teacher. Distant history of
smoking, quit 13 years ago. She denies any alcohol use.
ALLERGIES: Contrast dye.
PHYSICAL EXAMINATION: She is awake, alert and oriented x3.
Neurologic exam including cranial nerves, motor and
cerebellar testing were within normal limits.
The patient underwent an angiogram which confirmed the
bilobed left MCA aneurysm, the size of the two lobes were 2.5
and 3.5 mm respectively. Post-angiogram she did complain of
left calf pain contralateral to the puncture and compression
site, which a lower extremity ultrasound confirmed a
superficial vein thrombosis. She received IVC filter and she
was started on labetalol 100 mg p.o. b.i.d. for control of
her hypertension. On [**2145-11-16**], the patient had a left sided
craniotomy for clipping of an MCA aneurysm. Postoperatively
her blood pressure was 132/62, pulse 58, respirations 16, 97%
on room air. She was easily arousable and awake and alert
and oriented x3. Heart was regular rate and rhythm, S1 and
S2. Lungs were clear.
She was kept in the ICU overnight. On her first
postoperative day her temperature was 99.4, pulse 67, blood
pressure 130/63. Postoperative labs - her white count was
16.9, hematocrit 26.6, 244 platelets, sodium 138, 3.9
potassium, 108 chloride, 21 bicarb, 16 BUN and 0.5
creatinine. Her left eye had some swelling her face was
symmetric. She had no drift. Her grips were full
bilaterally. She was able to repeat "no ifs, ands or buts".
Her naming was intact two out of two. She had a repeat
hematocrit, was also started on heparin. Repeat hematocrit
was 25.6. She also had bilateral ultrasounds on [**11-17**], which
showed stable muscular DVT.
On [**2145-11-18**], she was transferred to the floor and she was
noted to have left sided IA edema. On [**11-19**], she was
ambulating with physical therapy, she had no drift, her EOMs
were full, grips were full, IPs were full. She was
tolerating regular diet and ambulating. Later on [**11-19**], she
did go to angiogram where she had a cerebral angiogram, which
showed stable appearance of her aneurysm clipping. She had
no complications post procedure. Physical therapy also saw
her that day and recommended that she walk three times a day.
She should be discharged on [**11-20**], with the following
instructions: She should have her staples removed on [**11-26**],
she should keep her wound clean and dry until that time and
watch for any redness at the site. She should return if she
has any severe headaches, neck pain, shortness of breath,
fever or chest pain. She should see Dr. [**Last Name (STitle) 1132**] in 2 weeks and
she was given a number to call for an appointment.
DISCHARGE MEDICATIONS: Colace 100 mg p.o. b.i.d., should use
that while continuing on the Percocet, Levothyroxine, sodium
88 mcg one tablet p.o. q.day, hydrochlorothiazide 25 mg one
tablet p.o. q.day, Dilantin 100 mg one p.o. t.i.d., Percocet
one to two tablets every 4 to 6 hours p.r.n., ferrous sulfate
325 mg p.o. q.day, hydralazine 10 mg two tablets p.o. q6
hours, labetalol 200 mg p.o. b.i.d.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2145-11-20**] 01:48
T: [**2145-11-24**] 08:22
JOB#: [**Job Number 53440**]
ICD9 Codes: 5990, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2182
} | Medical Text: Admission Date: [**2154-5-30**] Discharge Date: [**2154-6-3**]
Date of Birth: [**2089-4-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Levofloxacin / ceftriaxone / Keflex / Flagyl /
vancomycin
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yo female with no significant PMHx recently s/p excisional
biopsy of salivary gland tumor on [**2154-5-16**] (did not have a
parotid dissection). Two days later she presented to the ED with
dysphagia and found to have cellulitis of surgical wound. She
was hospitalized for 5 days, treated with antibiotics and
discharged on Keflex. She had been doing well until Tuesday/Wed
when she began experiencing fevers with associated generalized
malaise, fatigue and weakness. These symptoms persisted, did
improve with Tylenol or Advil, until she saw her OTL surgeon
this morning for follow up. She was found to be febrile to 103
and with hypotension to mid-80s systolic. She was sent to the ED
with evaluation.
On review of systems the patient is completely asymptomatic
aside from weakness and malaise. No sore throat, no runny nose,
eye pain or discharge, sinus pain, no neck pain or stiffness, no
redness, swelling or pain at site of incision. No cough, SOB,
chest pain, no abdominal pain, nausea, vomiting or diarrhea.
Patient does endorse increased urinary frequency but no dysuria.
No rashes or joint pain, no leg swelling.
In the ED, initial vitals were 99 101 93/49 16 96%. CBC showed
white blood cell count of 5.1K. Sodium was 128 on Chem7.
Lactate was 1.0. Urinalysis was negative and blood cultures
were sent. Patient was administered 1 liter NS. Chest X-ray
showed no focal consolidation or effusion, no acute process.
ENT was consulted and initially did not think there was anything
going on with the surgical site. CT neck was performed which
showed fat stranding at site of right posterior submandibular
node resection, with no drainable fluid collection. Overall
there was an improved post-op appearance compared to recent
imaging in [**4-/2154**], with less mass effect upon the parapharyngeal
space and stable edema of the right sternocleidomastoid. CTA
chest was also performed with no pulmonary emboli noted, but
scattered mediastinal lymph nodes measuring up to 9 mm.
Initially, cephalexin and trimethoprim/sulfamethoxazole were
administered PO. Patient was admitted to observation with plan
for likely discharge in the morning. Around 0230, patient
dropped systolic blood pressures to 70s, was tachycardic to the
130s, with a temperature of 104.8F, RR 40s, with O2 sat 77% on
RA, but improved to mid-90s with nasal cannula O2
administration. She was reported to have skin mottling of the
extremities. A left external jugular peripheral line was
inserted and administration of 2 liters NS IVF was bolused.
Patient was administed vancomycin, ceftriaxone and metronidazole
IV. ENT was contact[**Name (NI) **] and recommended MICU admission, and
thought there was no surgical intervention needed.
Past Medical History:
s/p excisional biopsy of salivary gland tumor on [**2154-5-16**]
hx of pneumonia
Social History:
She has smoked for eight to ten years, a half
pack per day. She smokes generally in intervals of years and is
not currently smoking. From the standpoint of alcohol, she
rarely drinks it.
Family History:
Her mother had [**Name2 (NI) 499**] cancer, and her daughter
had a brain tumor. There is also a history of hearing loss, and
migraines.
Physical Exam:
Admission Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Discharge Exam:
VITALS: 98.4 79 125/84 20 97RA
GENERAL: awake, alert, NAD
NECK: Surgical scar on right submandibular region is C/D/I
without erythema.
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT/ND, NABS
EXTREMITIES: WWP no c/c/e.
SKIN: scattered pink papules worst on back and upper arms,
thighs, non-pruritic. no vesicles, no ulceration
Pertinent Results:
[**2154-5-30**] 06:12PM URINE HOURS-RANDOM
[**2154-5-30**] 06:12PM URINE GR HOLD-HOLD
[**2154-5-30**] 06:12PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2154-5-30**] 06:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2154-5-30**] 06:12PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-1 RENAL EPI-<1
[**2154-5-30**] 06:12PM URINE HYALINE-5*
[**2154-5-30**] 06:12PM URINE MUCOUS-FEW
[**2154-5-30**] 05:14PM PT-11.9 PTT-29.3 INR(PT)-1.1
[**2154-5-30**] 04:57PM LACTATE-1.0
[**2154-5-30**] 04:50PM GLUCOSE-109* UREA N-12 CREAT-0.8 SODIUM-128*
POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-23 ANION GAP-12
[**2154-5-30**] 04:50PM estGFR-Using this
[**2154-5-30**] 04:50PM WBC-5.1 RBC-4.82 HGB-13.3 HCT-39.3 MCV-81*
MCH-27.5 MCHC-33.8 RDW-13.6
[**2154-5-30**] 04:50PM NEUTS-87.4* LYMPHS-8.0* MONOS-1.6* EOS-2.8
BASOS-0.1
[**2154-5-30**] 04:50PM PLT COUNT-217
Brief Hospital Course:
65 yo female with no significant PMHx recently s/p excisional
biopsy of salivary gland tumor on [**2154-5-16**] with a postop
course complicated by cellulitis, now presenting with fevers and
hypotension. Treatment with fluids and Abx in ICU resolved
hypotension and fever, but she developed a rash which is most
likely drug-induced. Abx discontinued and she was transfered to
the floor where she has remained stable. Discharged on hospital
stay day 4.
Active issues:
# Cellulitis: Pt admitted with hypotension occurring during
treatment for cellulitis on Keflex. Pt received approximately
13days of Keflex prior to admission to ICU. While in the ICU pt
received Vanc/CTX/Flagyl IV and ICU stay was complicated by drug
eruption (see below). IV abx were discontinued and pt remained
afebrile and stable for >36 hrs prior to discharge. Pt was
transferred to the floor where she continued to do well with no
evidence of recurrence of cellulitis. We discussed with ENT and
they agreed that she does not need to be sent home on
antibiotics.
# Drug Eruption: Pt. was febrile, tachycardic and hypotensive
with pruritic pink papules over her back and arms that developed
after taking a cephalosporin for post-op cellulitis. There was
no infectious etiology determined as CXR, UA, Ucx were negative
and CT of neck did not reveal a fluid collection around surgical
site. Pt was fluid resuscitated and received benadryl and
famotidine for drug rxn and topical steroid for pruritis.
Eruption slowly faded and became non-pruritic.
#Hyponatremia: Most likely hypovolemic hyponatremia that
resolved with fluid resuscitation.
# Anemia: unknown etiology with HH 11.4&35. H&H remained stable
over admission and eventually recovered to 12.4 on day of
discharge.
Chronic issues:
None
Transitional issues:
f/u excisional salivary tumor bx
Infectious workup: f/u viral Cx [**2154-5-1**]
Medications on Admission:
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by
mouth Every 4 hours as needed for pain
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Drug Eruption
Discharge Condition:
Stable. Incision c/d/i. No erythema. Drug eruption fading and
non-pruritic.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
Thank you for choosing us for your care. You were admitted with
cellulitis (a skin infection) and hypotension (low blood
pressure). In the ICU you received IV fluids and antibiotics.
You developed a rash that was likely a response to the
antibiotics you recieved. In this context, we stopped the
antibiotics. You have been off antibiotics for 3 days and your
skin infection has resolved.
We are not sure which of the antibiotics contributed to your
rash, but in the future, please just be on alert when using any
of the following: Vancomycin, Ceftriaxone, Flagyl, Keflex,
Bactrim.
There are no changes to your medications. Please continue to
take the medicines you had been on at home.
Followup Instructions:
Department: OTOLARYNGOLOGY-AUDIOLOGY
When: TUESDAY [**2154-6-11**] at 8:45 AM
With: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital **] MEDICAL GROUP
When: THURSDAY [**2154-6-13**] at 10:45 AM
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2400**] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2154-6-3**]
ICD9 Codes: 4589, 2761, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2183
} | Medical Text: Admission Date: [**2113-7-17**] Discharge Date: [**2113-7-20**]
Date of Birth: [**2062-5-23**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Witnessed seizure
Major Surgical or Invasive Procedure:
[**2113-7-17**]: Intubation and mechanical ventilation.
History of Present Illness:
Mr. [**Known lastname 8360**] is a 51 year old gentleman with a history of
alcoholism, traumatic brain injury, frequent EtOH withdrawal
seizures, ? epilepsy who is presenting after he was witnessed to
be having a seizure outside the [**Hospital Ward Name 23**] Clinical Center earlier
today.
EMS was called and he was brought to the ED. Not felt to be
seizing when arrived in ED and no clear seizure events since. He
was intubated for airway protection and started on fentanyl and
midazolam. Slight eye deviation to right appreciated on initial
exam. A head CT was relatively unchanged from prior. He was
started him on CTX for a possible UTI. BPs fine, afebrile. Vent
Settings at time of transfer AC 550 x 14 PEEP 5. 2x PIVs for
access. On arrival to the MICU he was intubated and sedated.
Per report, the patient has a long history of alcoholism,
drinking up to 1 pint of vodka every day. He was seen in the ED
the day prior to admission ([**7-16**]) after being found intoxicated
on the ground. At that time he was found to have an blood
alcohol level of 383. Approximately three weeks prior to this
(on [**6-24**]) he was admitted to [**Hospital1 18**] for a seizure in the setting
of alcohol withdrawal. During that admission he was intubated
and extubated without complication. He expressed some interest
in going to detox however then eloped on [**6-28**] prior to any
arrangements being made. He did not have any prescriptions when
he eloped. An attempt was made to contact his sister to locate
him however she was not aware of his whereabouts.
Past Medical History:
1) EtOh abuse, hx of DTs with seizures, previously intubated
2) Essential tremor
3) Epilepsy
4) Incarceration in [**2108**] for 2 years
5) TBI after being hit in head with 2x4 and subsequent seizure
d/o
6) HL not on meds
7) HTN not on meds
Social History:
Patient is homeless, lives with friends and frequently at [**Name (NI) 89924**] Inn, begs on the street for money, has been drinking
"a quart" of vodka since he was 13. Smoked 1pp week for the last
3-4 years. Denies illicits. Has 2 daughters, is estranged from
family.
Family History:
Father died at age 44 from alcoholic complications; mother died
at age 65 from alcoholic complications.
Physical Exam:
ADMISSION PHYSICAL EXAM ([**2113-7-17**]):
Vitals: hr 82 bp 142/94 sat 100% on FiO2 40 550 x 14 PEEP 5
General: Somnolent/heavily sedated/unresponsive
HEENT: pupils constricted but equal and sluggishly reactive to
light, MMM, intubated
Lungs: intubated but clear anteriorly
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, palpable distal pulses, thick
unclipped toenails, no clubbing, cyanosis or edema.
DISCHARGE PHYSICAL EXAM ([**2113-7-20**]):
PHYSICAL EXAM:
VS - Tm 99.1F, Tc 98.5, BP 100-120/57-75, HR 60-96, R 18, 95-98%
O2-sat % RA.
GENERAL - disheveled, NAD, uncomfortable, in C-collar
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength 5/5
throughout, sensation intact in all extremities. Gait deferred.
Pertinent Results:
ADMISSION LABS:
[**2113-7-17**] 07:48PM BLOOD WBC-3.6*# RBC-4.32* Hgb-13.2* Hct-41.7
MCV-97 MCH-30.5 MCHC-31.6 RDW-14.9 Plt Ct-225
[**2113-7-17**] 07:48PM BLOOD Neuts-76.1* Lymphs-15.4* Monos-6.3
Eos-1.1 Baso-1.2
[**2113-7-17**] 07:48PM BLOOD Glucose-90 UreaN-4* Creat-0.9 Na-143
K-3.8 Cl-104 HCO3-19* AnGap-24*
[**2113-7-18**] 04:44AM BLOOD Calcium-8.3* Phos-1.9* Mg-1.7
[**2113-7-17**] 07:59PM BLOOD Type-ART Rates-14/ Tidal V-550 PEEP-5
FiO2-100 pO2-457* pCO2-35 pH-7.37 calTCO2-21 Base XS--3
AADO2-220 REQ O2-45 -ASSIST/CON Intubat-INTUBATED
[**2113-7-17**] 07:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2113-7-17**] 07:45PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM
[**2113-7-17**] 07:45PM URINE RBC-6* WBC-51* Bacteri-MOD Yeast-NONE
Epi-0 TransE-<1 RenalEp-<1
DISCHARGE LABS:
[**2113-7-20**] 07:00AM BLOOD WBC-4.6 RBC-4.62 Hgb-14.7 Hct-44.4 MCV-96
MCH-31.8 MCHC-33.1 RDW-14.4 Plt Ct-201
[**2113-7-18**] 04:44AM BLOOD Neuts-80.5* Lymphs-12.1* Monos-5.9
Eos-1.1 Baso-0.3
[**2113-7-20**] 07:00AM BLOOD Glucose-98 UreaN-6 Creat-0.7 Na-138 K-4.4
Cl-103 HCO3-24 AnGap-15
[**2113-7-20**] 07:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9
MICRO:
[**2113-7-17**] UCxr:
URINE CULTURE (Final [**2113-7-19**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
IMAGING:
[**2113-7-19**] C-spine MRI
IMPRESSION:
1. There is no evidence of cervical malalignment, the signal
intensity
throughout the cervical spinal cord is normal with no evidence
of focal or diffuse lesions.
2. Multilevel disc degenerative changes, more significant at
C4/C5, C5/C6 and C6/C7 levels.
[**2113-7-18**] CXR
IMPRESSION: Right lower lobe opacity consistent with pneumonia.
[**2113-7-17**] CT C-Spine w/o Contrast
No evidence of fracture or dislocation.
[**2113-7-17**] CT Head w/o Contrast
No evidence of acute process. Stable encephalomalacia in the
left frontal lobe.
[**2113-7-17**] CXR
Endotracheal tube tip projects approximately 5.5 cm above the
carina. Esophageal catheter tip projects over left upper
quadrant, likely within the stomach. Right costophrenic angle
incompletely imaged.
Brief Hospital Course:
51yo homeless gentleman with an extensive history of alcoholism
and TBI with seizure d/o who has had multiple ED visits and
admissions for ETOH toxicity/seizures who was admitted after a
generalized seizure likely [**12-29**] to alcohol withdrawal
# Alcohol Withdrawal/Abuse: Patient has an extensive history of
alcoholism with multiple admission for alcohol intoxication and
presumed withrawal seizures. Per patient, he drinks 1 quart of
vodka per day since he was a teenager. Patient was maintained on
a CIWA scale while inpatient and did not have significant
symptoms except diaphoresis, he did not receive any diazepam for
over 48 hours prior to discharge. He was treated with thiamine,
folate and multivitamins. He was seen by social work and
provided with detox information and housing resources. He was
evaluated by psych due to concern of capacity/insight/underlying
undiagnosed pychiatric disorder. He was assessed to have
capacity/insight but just makes poor decisions. He was offered a
stay at the [**Doctor Last Name **] House which he declined. Patient expresses
a wish to return to [**State 1727**] as soon as possible and was discharged
to a shelter with information on how to access outpatient
alcohol abstinence programs.
# Seizures: Patient's seizure prior to admission was most likely
due to ETOH withdrawal based on history. He also has a history
of TBI with resulting seizure disorder which likely contributes
as well. He has not taken his prescribed Keppra in 2 years.
Patient did not demonstrate seizure activity throughout
admission. He was restarted on Keppra and discharged with a
prescription.
# C-spine tenderness: Patient has baseline C-spine tenderness
after he was struck by a car in [**2-6**]. He displayed worsening
posterior midline neck pain after his witnessed seizure. He was
maintained in a C-collar throughout admission. C-spine CT and
MRI were negative for acute processes, only degenerative
changes. He was evaluated by neurosurgery who recommended a
C-collar for 4 weeks and follow-up with the spine clinic. We
provided him with the number for the Spine Clinic and he was
discharged with a [**Location (un) 2848**] J collar.
# UTI: Patient's UA was suggestive of a UTI with 51 WBCs,
moderate bacteria, nitrite positive, small leuk. Patient also
had a Foley catheter placed at admission. It was unclear if he
was symptomatic. Urcine culture grew out >100,000 Coag negative
Staph which was pan sensitive. He was treated for a complicated
UTI with IV ceftriaxone for 4 days and discharged on DS Bactrim
until Sunday [**7-23**] for a total of a 7day course.
# Code status: Patient was FULL CODE throughout admission.
# Transitional issues:
-Discharged in [**Location (un) 2848**] J collar with phone number for spine clinic
to follow-up in 4 weeks
-Discharged with prescription for Keppra and asked to make an
appointment with a PCP, [**Name10 (NameIs) **] was given the phone number for [**Company 191**] as
well as the [**Doctor Last Name **] House Primary Care Clinic.
-He was given information on local outpatient alcohol abuse
programs which he expressed some interest in attending
Medications on Admission:
1) Keppra 1000mg PO BID (not taking)
2) Thiamine 100mg PO daily (not taking)
3) Folate 1mg PO daily (not taking)
4) Multivitamin 1 tab PO daily (not taking)
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
2. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth Twice daily Disp
#*60 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*2
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
Please take last dose on Sunday [**7-23**].
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth Twice daily Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Seizure, likely secondary to alcohol withdrawal
Alcohol detoxification
Secondary diagnosis:
Acute on chronic cervical spine pain
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:
Hi Mr. [**Known lastname 8360**],
You were admitted to the hospital on [**2113-7-17**], because you
suffered a seizure from alcohol withdrawal. You were initially
in the intensive care unit and intubated for protection of your
airway. You were extubated the next day and transferred to the
medicine floor to manage your alcohol withdrawal symptoms. You
did not demonstrate any seizure activity and you did not display
any significant symptoms of withdrawal. You were placed in a
neck collar due to concern for neck injury. While you have
chronic neck pain and your CT and MRI scans were negative for
any damage to your spinal cord, you will need to keep the collar
on for the next 4 weeks. You will need to see a specialist in
the spine clinic at that time.
You were also seen by social work who provided with information
of alcohol abstinence programs and housing resources. You were
also restarted on Keppra to control your seizures. You should
continue this medication and it will be important to avoid
alcohol.
You also had a urinary tract infection which we treated with
antibiotics. Please take Bactrim twice daily until Sunday [**7-23**].
You have expressed wishes to return to [**State 1727**] as soon as
possible. We offered you a short stay at the [**Doctor Last Name **] House, but
you declined.
Followup Instructions:
You should see a PCP [**Name Initial (PRE) 176**] 3-5 days of discharge. The [**Hospital1 18**]
primary care practice phone number is [**Telephone/Fax (1) 2010**]. The [**Doctor Last Name **]
house phone number is [**Telephone/Fax (1) 89925**]. You may also see a PCP in
[**Name9 (PRE) 1727**] if you return there.
If you will stay in [**Location (un) 86**], please follow up with the [**Hospital1 18**]
Spine Clinic in 4 weeks in regards to your neck collar and
cervical spine pain, their phone number is [**Telephone/Fax (1) 8603**]. If you
return to [**State 1727**], please try to see a primary care physician for
management of your health.
ICD9 Codes: 2724, 4019, 2762, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2184
} | Medical Text: Admission Date: [**2128-1-23**] Discharge Date: [**2128-2-4**]
Date of Birth: [**2058-1-11**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4533**]
Chief Complaint:
Ureteroileal anastomotic strictures, Hypotension, A. fib with
RVR.
Major Surgical or Invasive Procedure:
Removal of neobladder (cystectomy), excision of
lymphocele wall, creation of ileal conduit urinary diversion
(conversion of [**Last Name (un) 59286**] chimney to an ileal conduit with a new
[**Location (un) 9241**] double barrel ureteral ileal anastomosis), Dr. [**First Name (STitle) **],
[**2127-1-23**]
History of Present Illness:
69 y.o. Male w/ h.o. high grade invasive transitional call
carcinoma of the bladder s/p lap cystectomy, neobladder
formation [**2-24**], A. fib w/ RVR in the OR today for removal of
neobladder, creation of ileal conduit urinary diversion.
Transfer to ICU for A. fib with RVR, hypotension.
.
Pt [**Month/Year (2) 1834**] removal of his neobladder with excision of ileal
conduit urinary diversion. Prior to the surgery he was noted to
be hypotensive in the 90s after receiving Diltiazem PO. During
the surgery he was estimated to have a 500cc bld loss. He was
noted intra-operatively to go into A. fib with RVR with a rate
100-110s and SBP in the 80s. He received a total of 9L of fluid
with minimal response to hypotension. He was also given PO
Diltiazem with no resulting effect. He was thus started on a
dilt gtt and transferred to Dilt gtt. In addition to fluid he
also received 2u PRBCs given his pre-op Hct was 28.
.
Upon arrival to the floor his vitals were noted to be T 97.4, HR
110, BP 103/50. Pt denied any chest pain, chest palpitations,
SOB, lightheadedness, recent fevers, chills.
.
On review of his prior hospitalizations it appears his microdata
is significant for VRE as well as pan sensitive E.coli. During
his neobladder construction he was noted to be hypotensive that
was thought to be due to sepsis from VRE. At that time he was on
a regimen of Linezolid and Zosyn.
.
REVIEW OF SYSTEMS:
(+)ve:
(-)ve: fever, chills, chest pain, palpitations, dyspnea, nausea,
vomiting, diarrhea.
Past Medical History:
1. h/o MI - 17 yrs ago, treated at [**Hospital **] Hospital, per patient
treated with a "clot busting medication" (possibly tPA),
hospitalized x 6 days and discharged. As noted previously, he
did not take medications after discharge and did not follow up
with any physicians
2.Paroxysmal atrial fibrillation, discovered at time of cancer
diagnosis [**10/2126**], difficult to control post-operatively [**2-24**].
Has recurrences of AF/RVR during last hospitalization.
3.High-grade invasive transitional cell carcinoma
4.Osteoarthritis of ankles
5.C. difficle colitis
6. Klebsiella bacteremia (last [**5-23**]) with Klebsiella UTI
7. Gastritis/duodenitis
8.Left Percutaneous nephrostomy tube for presumed obstructive
uropathy.
9.Right percutaneous nephrostomy tube, emergent, for obstructed
pyelonephritis.
10. VRE septic shock s/p neobladder construction ([**2127**])
Social History:
-Married and lives with wife in [**Name (NI) **]. Retired, worked as a
construction worker.
-Smoking: 30+ py, quit before [**2118**]
-EtOH: denies
-Drugs: denies
Family History:
-Mother died at [**Age over 90 **]yrs.
-Father died in early 70's from asbestosis
Physical Exam:
T=97.4. BP=103/50 HR=110 RR=16 O2= 98%
.
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing Caucasian Male in NAD
HEENT: No scleral icterus. EOMI. MMM.
CARDIAC: Irregularly, irregular, S1, S2, borderline tachy
(110s)LUNGS: CTAB, good air movement biaterally.
ABDOMEN: RLQ Ostomy noted with drain in place. B/l quadrants
have JP drains. Abd dressing c/d/i.
EXTREMITIES: No edema
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2128-2-1**] 06:00AM BLOOD WBC-6.8 RBC-3.19* Hgb-9.0* Hct-27.2*
MCV-85 MCH-28.1 MCHC-33.1 RDW-15.8* Plt Ct-245
[**2128-1-23**] 05:34PM BLOOD Neuts-86.6* Lymphs-8.4* Monos-3.3 Eos-1.4
Baso-0.4
[**2128-2-4**] 06:15AM BLOOD PT-19.4* INR(PT)-1.8*
[**2128-2-2**] 07:40AM BLOOD PT-17.8* INR(PT)-1.6*
[**2128-2-1**] 06:00AM BLOOD PT-17.0* INR(PT)-1.5*
[**2128-2-3**] 07:50AM BLOOD Glucose-84 UreaN-7 Creat-1.3* Na-138
K-4.3 Cl-103 HCO3-28 AnGap-11
[**2128-2-3**] 07:50AM BLOOD Calcium-8.0* Mg-1.9
Brief Hospital Course:
ICU Course (By Problem):
##. Hypotension: Patient was admitted to ICU rather than floor
post-op due to hypotension. Hypotension was thought to be
related to A. fib with RVR with rates ranging from 110-120s. Pt
received a total of 7L NS in the PACU over 7 hours but was still
noted to have a BP in the mid 70s, asymptomatic. Differential
included A. fib with RVR given his prior history, however would
expect a more impressive rate to give such hypotension. Other
differentials to consider included possible sepsis that could
have occured peri-op, he was also noted to have leukocytosis
prior to his operation. On review of his record he has had
septic shock after GU procedures as well as a history of VRE,
pan sensitive E.Coli. Pt's BP also noted to decrease after
Diltiazem 120mg was given. For possible sepsis patient was
bolused with 500cc LR to check BP response, pt mentating well
currently. Changed antiobiotics of Vanc and Ceftriaxone to Zosyn
(for broad Gram positive, negative coverage) and Linezolid (VRE
coverage). Pt received Diltiazem and is on Morphine PCA which
could also explain the hypotension. Blood cultures were sent.
Antibiotics were then discontinued on post-op day 2 per Urology,
given no evidence of infection, and resolution of hypotension.
.
##. A. fib with RVR: Pt has history of A. fib with RVR post-op
following a prior GU surgery performed in [**2127**]. On review of
anaesthesia records it appears his A. fib was in the 100-120
range, he received a total of 9L NS as mentioned above as well
as 2u packed red blood cells. He received Diltiazem 120mg SR
with his rate responding 85-103. On review it appeared he
required Amiodarone 150mg bolus and drip during prior episodes.
Amiodarone was started on post-op day 1. This was discontinued
per Cardiology consult, and the patient's rate was subsequently
controlled with diltiazem IV boluses, follow by a diltiazem
drip. He was on warfarin at home given his atrial fibrillation,
despite having a CHADS2 score of zero, and warfarin was
continued during his hospital course. The diltiazem drip was
discontinued and transitioned to oral. Initial dose was
diltiazem 90 mg PO QID, increased to 120 mg QID for rate
control. Bradycardia to 40s followed first 120 mg dose, and
patient was converted back to diltiazem 90 mg PO QID. Adequate
rate control was achieved with this dose, and the patient was
subsequently transferred out of the ICU.
.
##. s/p Ileal Conduit urinary diversion: Pt [**Year (4 digits) 1834**] ileal
conduit urinary diversion in addition to neobladder. Urology
currently following pt, who is NPO per their recommendations.
Patient remained NPO on post-op day 2, with slow transition to
clears on POD 4. Ileus remained.
.
##. Leukocytosis: Pt noted to have leukocytosis of 16.4 on
admission. Unclear as to the etiology, pt does have h.o. of VRE
colonization within his GU system, multiple infections. No
fevers reported. Leukocyte count trended down.
.
##. Renal Insufficiency: Pt currently sees a Nephrologist in
[**Location (un) **] for his insufficiency. Prior to admission baseline
Creatinine has ranged from 1.9-2.0. Prior Creatinine level of
[**4-19**] was thought to be due to ATN from hypovolemia. Renal
insufficiency is thought to be [**2-17**] obstruction from transitional
bladder cell cancer with obstruction. Creatinine was improved
from baseline on POD #2.
.
##. Hyperchloremic Acidosis: Likely related to large volume
resuscitation from NS. Trended during course
.
##. FEN: Keep NPO for now per Urology. Replete lytes PRN
.
##. PPX: DVT ppx with Pneumoboots, pain management with Morphine
PCA.
.
##. ACCESS: 2 PIV's
.
##. CODE STATUS: FULL CODE confirmed
.
##. EMERGENCY CONTACT: [**Name (NI) **] [**Name (NI) 53270**] (wife and HCP) [**Telephone/Fax (1) 80394**]
.
##. DISPOSITION: Pending resolution of symptoms.
Floor Hospital Course:
Mr. [**Known lastname 53270**] [**Last Name (Titles) 1834**] conversion of ileal neobladder to an ileal
conduit on [**2128-1-23**] and was transferred to the [**Hospital Unit Name 153**] (as detailed
above) for close monitoring due to Afib and hypotension. No
concerning intraoperative events occurred; please see dictated
operative note for details. Once his acute cardiac issues
stabilized, he was deemed stable for transfer out of the [**Hospital Unit Name 153**] to
Dr.[**Name (NI) 24219**] Urology service. Patient received perioperative
antibiotic prophylaxis and deep vein thrombosis prophylaxis with
[**Name (NI) **]. His INR was noted to be supratherapeutic after two
doses of [**Name (NI) 197**] and subsequent doses were held until his INR
dropped in the therapeutic range. With the passage of flatus,
patient's diet was advanced. The patient was ambulating and pain
was controlled on oral medications by this time. Physical
therapy worked with the patient and cleared him for discharge
home once stable from a medical standpoint. The ostomy nurse saw
the patient for ostomy teaching. At the time of discharge the
wound was healing well with no evidence of erythema, swelling,
or purulent drainage. The ostomy was perfused and patent.
Patient is scheduled to follow up in one week's time in clinic
for wound check. Additionally his PCP's office was [**Name (NI) 653**]
regarding Mr. [**Known lastname 80395**] discharge dosages of [**Known lastname **] and
diltiazem. Dr. [**Last Name (STitle) 80396**] nurse [**Doctor Last Name 2048**] has arranged follow up in 2
days.
Medications on Admission:
Metoprolol 25mg XL daily
Diltiazem SR 120mg daily
MVI 1tab daily
Colace 100mg daily
Warfarin 3mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every
six (6) hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
4. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Bladder cancer
Discharge Condition:
Stable
Discharge Instructions:
-Please resume all home meds
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily
Tylenol dose is 4gm, note that narcotic pain medication also
contains Tylenol (acetaminophen).
-Do not drive while taking narcotic pain medication
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops
-You may shower, but do not immerse incision, no tub
baths/swimming
-Small white steri-strips bandages will fall off in [**5-21**] days,
you may remove at that time if irritating, if staples are
present they will be removed by Dr. [**First Name (STitle) **] at a follow up
appointment in [**7-24**] days
--If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest ER
-Please refer to visiting nurses (VNA) for management of the
ileal conduit.
-Please make an appointment to see your cardiologist, PCP, [**Name10 (NameIs) **]
whoever manages your [**Name10 (NameIs) 197**] and blood pressure/heart
medications within the next 2 days.
Followup Instructions:
Please contact Dr.[**Name (NI) 24219**] office upon discharge to arrange
follow up appointment.
Please contact your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 70012**] upon discharge to arrange for
management of your INR, [**Last Name (STitle) **] dosage and hypertension
medications.
Completed by:[**2128-2-4**]
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2185
} | Medical Text: Admission Date: [**2125-12-4**] Discharge Date: [**2126-1-25**]
Date of Birth: [**2125-12-4**] Sex: M
HISTORY OF PRESENT ILLNESS: The patient is a 27 [**11-27**] week
gestation male admitted for prematurity.
Maternal history - A 29 year old gravida 1, para 0, now one
virus infection (no lesions currently). Obstetrical history
notable for bicornuate versus septate uterus. No medication
used during pregnancy.
Prenatal screen - A positive, antibody negative. RPR
nonreactive, Rubella immune. Hepatitis B surface antigen
negative, Group B Streptococcus unknown.
Pregnancy history - Pregnancy reportedly uncomplicated with
onset of hypertension one week prior to delivery, followed
by decreased fetal movement two days prior to delivery.
Biophysical profile, [**12-29**] on admission (nonreactive),
nonstress test leading to cesarean section under spinal
anesthesia. No labor, rupture of membranes at delivery,
yielding clear amniotic fluid. No interpartum fever.
Neonatal course - Infant apneic and hypotonic at delivery,
with initial heartrate approximately 60. Infant was dried,
orally and nasally bulb suctioned, and then received bag mask
ventilation with fairly high inspiratory pressures for two
minutes. The infant was intubated uneventfully
with a 2.5 French endotracheal tube, with improvement in
bradycardia to 120, and gradual resolution of cyanosis over
several minutes. Apgars were 1 at one minute, 5 at five
minutes and 7 at ten minutes. The patient was transferred to
Neonatal Intensive Care Unit uneventfully.
PHYSICAL EXAMINATION ON ADMISSION: Birthweight was 685 gm
(10th to 25th percentile), head circumference 23.5 cm (10th
to 25th percentile), length 31 cm (10th percentile).
Anterior fontanelle soft and flat, palate intact, 2.5 French
oral endotracheal tube in place. Neck/mouth normal. Chest
with moderate retractions with spontaneous respiratory effort
prior to high frequency ventilator, poor excursion with
positive pressure ventilation with Ambu bag. Good
breathsounds bilaterally, scattered coarse crackles. Fair
perfusion, femoral pulses normal, normal S1, S1, no murmur.
Abdomen soft, nondistended, three vessel cord, no
organomegaly, no masses, anus patent, normal male preterm
genitalia, testes undescended bilaterally. The infant was
responsive to stimulus, tone decreased and symmetric to
distribution but consistent with gestational age, moving
limbs, skin normal for gestational age, normal spine,
clavicles intact.
HOSPITAL COURSE: Respiratory - The infant was placed on high
frequency oscillatory ventilator on day of delivery with
maximum settings of amplitude 21, mean airway pressure of 11,
receiving 30% oxygen. The infant received four doses of
Survanta and weaned to conventional ventilator by day of life
#3 and was weaned to a CPAP of 6 by day of life #7. The
infant remained on CPAP from day of life #7 to day of life 44
and at that time he weaned to nasal cannula 200 cc room air.
Caffeine was started on day of life #5 and the infant remains
on caffeine 8 mg/kg/day.
On day of life #51, the infant had a large emesis with a
significant desaturation requiring positive pressure
ventilation and increased work of breathing with increased
oxygen requirement, leading to intubation. The infant is
currently on ventilator setting of 24/5 and a rate of 18 in
21 to 25% FIO2 with respiratory rates in the 40s to 60s. The
most recent capillary blood gas was 7.33/46.
Cardiovascular - Infant received one normal saline bolus on
day of delivery for blood pressure means which were 24 to 25.
Infant did not require vasopressors this hospitalization and
is currently hemodynamically stable with a heartrate of 120
to 140s with most recent blood pressure 64/44 (51). The
infant has had an intermittent soft murmur, Grade 2 to 6
throughout this hospitalization.
Fluids, electrolytes and nutrition - Infant was initially NPO
receiving 100 cc/kg/day of D10/W and was advanced to 160
cc/kg/day by day of life #4. Enteral feedings were started
on day of life #4 of premature Enfamil 20 cal/oz and advanced
to full volume feeding by day of life #13. The infant
received total parenteral nutrition during feeding
advancement. The infant tolerated feedings without
difficulty and was advanced to 30 cal/oz by day of life #20.
On day of life #42 the infant was noted to have loose watery
stools which were guaiac negative. At that time, calories
were decreased to 20 cal/oz premature Enfamil with
improvement noted by formed stools after two days on day of
life #46. Calories were increased to 28 cal/oz and diarrhea
started again on day of life #48. Calories were decreased to
20 ca/oz again and on day of life #51, due to increased
abdominal distention on KUB, the infant was made NPO and is
currently NPO on total parenteral nutrition of D10/W with
interlipids at 130 cc/kg/day. The most recent electrolytes
on [**1-25**] were sodium 132, potassium 4.0, chloride 100, pCO2
25. The current weight is 1235 gm.
Gastrointestinal - With diarrhea that was noted on day of
life #42, yielding guaiac negative stools, no abdominal
distention, stool was sent for reducing substances which was
negative and was also sent for Clostridium difficile at that
time which was also negative. On day of life #51 with
increasing abdominal distention, Gastroenterology and Surgical
services from [**Hospital3 1810**] were consulted and the infant
was sent over to [**Hospital3 1810**] for upper
gastrointestinal contrast and contrast enema. Studies
revealed possible stricture in the terminal ileus. The
infant is currently being transferred to the [**Hospital3 18242**] for exploratory laparotomy. KUBs were obtained
every 6 to 8 hours, showing increase of small bowel
distention, no perforations noted on x-rays. Infant is
currently NPO with [**Last Name (un) 37079**] to continuous flow suction with
small amount of bilious drainage noted on day of life #51.
Also of note, after the upper gastrointestinal contrast study,
infant passed a very large bloody stool. The infant has had only
scant stools upon returning to [**Hospital6 2018**].
Hematology - The infant's blood type is A positive/Coomb's
negative. The infant has received four packed red blood cell
transfusions this hospitalization. The most recent blood
transfusion was on [**1-23**], day of life #50 for a hematocrit
of 25%, the most recent hematocrit on day of life 51 was
39.6%.
Infectious disease - The infant received seven days of
ampicillin and cefotaxime from day of life 0 to day of life
#7. The infant has not received antibiotics until day of
life #50, when a blood culture was drawn due to persistent
diarrhea which showed gram positive cocci which was
identified as coagulase negative Staphylococcus. The patient
is currently on Vancomycin and Gentamicin and Clindamycin. A
repeat blood culture on [**1-23**] is negative to date.
Neurology - The infant has had four head ultrasounds on
[**12-5**], [**12-3**], [**12-14**] and [**1-13**], all with
no intraventricular hemorrhage, no PVL.
Sensory - Hearing screening should be performed.
Ophthalmology - Eye examination on [**1-16**] showed Stage 1
retinopathy of prematurity. Follow up in one week.
Psychosocial - [**Hospital6 256**] social
worker involved with family. Contact social worker can be
reached at [**Telephone/Fax (1) 8717**]. Parents are involved with infant's
care.
CONDITION ON DISCHARGE: Former 26 [**11-27**] weeker, now 33 4/7
weeks corrected, guarded.
DISCHARGE DISPOSITION: Transferred to [**Hospital3 1810**]
for exploratory laparotomy. Primary pediatrician - Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 8071**].
DISCHARGE INSTRUCTIONS:
1. Discharge medications - i. Caffeine 8.5 mg intravenously
q. day; ii. Vancomycin; iii. Gentamicin; iv. Clindamycin
2. Newborn screens - Normal
3. Immunizations - Infant has not received any immunizations
this hospitalization.
DISCHARGE DIAGNOSIS:
1. Prematurity, 26 1/7 weeks, gestation male
2. Status post surfactant deficiency
3. Status post sepsis
4. Status post hyperbilirubinemia
5. Apnea of prematurity
6. Rule out necrotizing enterocolitis, possible stricture in
terminal ileum from upper gastrointestinal series
7. Anemia of prematurity
8. Retinopathy of prematurity
9. Chronic lung disease
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (NamePattern1) 46312**]
MEDQUIST36
D: [**2126-1-25**] 14:24
T: [**2126-1-25**] 20:53
JOB#: [**Job Number 46313**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2186
} | Medical Text: Admission Date: [**2198-1-19**] Discharge Date: [**2198-1-29**]
Date of Birth: [**2127-3-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iron
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
femoral line
intubation/extubation
lumbar puncture
tracheal stent
History of Present Illness:
70 y/o female with COPD, HTN, alcoholism who presents with
worsening stridor now intubated for enlarging mediastinal mass
eroding into the trachea. Pt was recently evaluated [**12-20**] by her
PCP for worsening dysphagia and weight loss. Given her history
of tracheostomy and high risk of head and neck malignancy with
smoking and EtOH she was referred to ENT. She was seen by ENT on
[**12-25**] who noted true vocal cord paralysis on larygoscopy and
planned to have her evaluated with neck and upper chest CT for
mass which was perfrormed [**1-4**]. CT scan revealed pulmonary
nodules with an esophageal mass(report not available)concerning
for metastatic esophageal CA. She continued to have mild
dysphagia but began developing worseing SOB and decreased voice.
On [**1-18**] she presented to [**Hospital3 **] ED and was found to be
anxious, tachycardic, and short of breath with stridor with no
hypoxia. CXR revealed upper mediastinal mass and pulmonary
nodules, so CTA was performed to better characterize them. CT
revealed a new RLL mass, LLL atelactasis, enlarging left
infrahilar mass, and enlarging esophageal mass which is now
eroding into the trachea. She was treated with Levofloxacin,
Solumedrol, Ativan, Seroquel and nebulizers. She was transferred
to [**Hospital1 18**] for further evaluation. In the ED she continued to be
stridulous and was seen by thoracic surgery who reported that
she was not an operative candidate as the mass dissected through
multiple planes. Due to risk of worsening erosion of this mass
she was intubated by anesthesia. She was also given a dose of
flagyl to cover aspiration PNA given OSH CT findings.
Past Medical History:
Hypothyroidism
Pneumonitis requiring tracheostomy
Pna
Copd
Peptic ulcer disease
Irritable bowel
Colon polyps
Alcoholic pancreatitis
Alcoholism
HTN
Polio
Vertebroplasty
Right elbow fx
Deafness
Decreased vision
Osteoporosis
? liver disease with hepatic encephalopathy
Social History:
Cont to smoke 1ppd which she has done for 54 years, hx of EtOH
withdrawal and heavy abuse in past. She is separated with 1
grown child. Previously taught at [**University/College 5130**] [**Location (un) **].
.
Family History:
Ovarian CA and CVA but unclear which fam members
.
Physical Exam:
T 99.0 HR 110 BP 120/75 AC 450/20 peep 5 FIO2 50%
Gen-sedated and intubated
HEENT-PERRL, no elev JVP, MMM, no ant or post cerv LAD
Hrt-tachy RR, nS1S2 no MRG
Lungs-CTA bilat
Abd-soft, NT, ND, no HSM
Extrem-2+rad and dp pulses, no cyanosis or clubbing
Neuro-withdrawing to pain, absent reflexes but not compliant
with exam
Skin-no rashes or lesions
Pertinent Results:
Labs and studies-
pH
7.34 pCO2 43 pO2 104 HCO3 24
Na:142 K:3.5 Cl:109 TCO2:24 Glu:170
Lactate:2.3
.
Trop-T: <0.01
Chem 7
139 108 11 191 AGap=14
3.5 21 0.9
.
CK: 59 MB: Notdone
.
WBC 13.4 Hgb 10.1 Plt 487 Hct 29.9
N:95.5 Band:0 L:3.4 M:0.3 E:0.7 Bas:0
.
PT: 14.4 PTT: 30 INR: 1.3
.
ECG-sinus tachy at 110, TW flat in II,III,AVF with st dep 1mm
v3-6
.
CXR-LLL infiltrate, left hilar fullness, multiple pulmonary
nodules.
.
[**2198-1-19**] Chest CT: Diffusely infiltrating soft tissue density mass
centered in the esophagus and extending from the cricopharyngeus
muscle approximately 10 cm inferiorly. Evidence of invasion into
the posterior trachea, and aorta. Severe tracheal narrowing to
about half the normal luminal caliber. The endotracheal tube is
positioned above the most severe segment of narrowing. Multiples
metastases within the imaged lungs, mediastinal, and portacaval
lymphadenopathy.
.
[**1-20**] UE U/S: Limited study without demonstration of basilic and
cephalic veins, however, no evidence of DVT.
.
[**1-22**] CT head: Probable minor degree of chronic small vessel
infarction without other findings to account for the patient's
stated unresponsiveness.
.
[**1-22**] MR [**Name13 (STitle) 2853**]: Minor cervical spondylosis with demonstration of
presumed esophageal mass causing esophageal obstruction.
.
[**1-22**] MRA Brain: 1. No definite evidence for acute brain ischemia.
2. Probable anterior communicating artery aneurysm.
Limited study.
Within these severe limitations, there is demonstration and
confirmation of the suspected small (3-mm) anterior
communicating artery aneurysm. No other definite vascular
abnormalities are seen, again allowing for the very limited
resolution provided by this study. The right vertebral artery
appears to be the dominant vessel.
.
[**1-23**] EEG: This was an abnormal routine EEG due to the slow and
disorganized background with generalized bursts of slowing as
well as
generalized suppression. These findings are consistent with a
moderately
severe encephalopathy. There were also bursts of generalized
sharps or
sharp and slow wave complexes predominantly in the frontocentral
regions, which may be seen with in patients with severe
encephalopathy,
but may also suggest cortical irritability in the frontal
regions. No
clear electrographic seizures were seen. If the mental status
does not
improve, a repeat study may be beneficial.
.
[**1-25**] CXR: 1. Status post tracheal stent placement, centered at
approximately the level of the clavicular heads and 2.2 cm from
the distal tip of the endotracheal tube. It is 1.5 cm from the
carina.
2. Improvement of bilateral basilar atelectasis with stable
appearance to retrocardiac opacity and small bilateral pleural
effusions.
Brief Hospital Course:
70 y/o female with COPD, HTN, alcoholism who presented with
worsening stridor, tubated for enlarging mediastinal mass
eroding into the trachea.
.
* Mediastinal mass: CT showed esophageal mass eroding into
trachea as well as into aorta. OSH biopsy demonstrated a
squamous cell CA. Cancer likely esophageal with pulmonary mets
given location and smoking and EtOH history. Patient was
intubated on [**1-18**] for worsening stridor. S/p tracheal stent for
airway protection [**2198-1-24**] by IP. CXR [**2198-1-25**] confirmed position of
stent. Stent of esophagus by GI was considered, but GI deferred
stent given proximity to aorta and pt's mental status ->
patient's daughter supported decision for no procedures. DNR
status was decided upon, but with re-intubation if necessary.
Extubation was attempted [**2198-1-27**], but patient did not do well
and was re-intubated within hours. On [**2198-1-29**] goals of care
were re-addressed and decision was made for terminal
extubation/CMO.
.
* MS changes: Patient had remained very sedated after having
been off sedation for several days. Then later improved
somewhat. Head CT, LP and MRI of the head did not demonstrate a
source for the sedation. Ammonia and b12 levels normal. RPR
negative. Had UTI which may have contributed. Patient later
appeared to be slightly more arousable, suggesting this was due
to a problem with medication clearance or metabolic
derangements. EEG [**2198-1-24**] showed moderately severe
encephalopathy. Neurology consult followed. Sedating
medications were held as muhc as possible. Lactulose was also
given daily (which had apparently been helpful in the past for
confusion).
.
* Leukocytosis: Likely secondary to klebsiella UTI, treated with
ceftriaxone. No evidence of underlying pneumonia. Blood
cultures were negative and 2 c. diff toxins negative. Resolved.
.
* Anemia: Hct trending down over several days to 23-24. No sign
of active bleeding. Bleeding at site of mets invading aorta was
considered as etiology. Hct stabilized around this level.
.
* Metabolic acidosis: Non-gap acidosis initially. Improved.
Thought to be due to saline and possibly a small component of
hypoperfusion.
.
* HTN: BP was controlled with IV metoprolol.
.
* EtOH abuse: Pt was initially considered at risk for
withdrawal. CIWA scale was ultimately dc'd [**1-19**] to
sedation/intubation. Folate and thiamine were given.
.
* Hypothyroidism: TSH normal, free T4 slightly low, felt to be
euthyroid sick syndrome in setting of acute illness. Continued
on outpt synthroid but as IV at 1/2 of PO dose.
.
* Depression: zoloft held due to NPO
.
On [**2198-1-29**], another family meeting was held with the patient's
daughter who decided on terminal extubation and CMO. The
patient expired on [**2198-1-29**] at 1704h while CMO and on a morphine
gtt.
Medications on Admission:
.
Meds-
Toprol Xl 50mg qd
Fosamax 70mg weekly
Synthroid 75mg qd
Naltrexone 25mg qd
Protonix 40
Zoloft 50mg qd
questran 4mg qd
MVI
Calcium
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
esophageal cancer, with mass eroding into trachea and aorta
respiratory failre due to airway obstruction by mass
klebsiella urinary tract infection
hypertension
hypothyroidism
depression
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 5180, 496, 5990, 2449, 3051, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2187
} | Medical Text: Admission Date: [**2198-8-31**] Discharge Date: [**2198-10-15**]
Date of Birth: [**2137-9-5**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pneumonia, pancreatic pseudocyst
Major Surgical or Invasive Procedure:
[**2198-9-4**]- Aborted PEG placement
[**2198-9-5**]- GJ tube placement
8/10,14,28,25/09- Laparoscopic pancreatic necrosectomy and
drainage tube placement
History of Present Illness:
Pt is a 60 yo F transferred from [**Hospital3 **] for
management of complicated pancreatitis as well as possible
pnuemonia. Transferred for worsening respiratory status as well
as failure to progress w/ pancreatitis/pseudocyst tx. Pt was
originally admitted on [**2198-6-8**] for gallstone pancreatitis,
complicated by infected pseudocyst, pneumonia, ARDS and
persistent fevers. She has failed multiple ERCP stent
palacements. Per OSH records, she developed fever to 101.8 and
white count of 16.8 today prior to transfer to [**Hospital1 **]. Her
amylase/lipase have normalized. The patient underwent
tracheostomy on [**2198-7-12**] and was weaned from the vent on [**2198-7-24**],
and has been stable on trach mask w/ 10L O2. Of note, pt has
been treated for VRE and CDiff during her extended
hospitalization.
Past Medical History:
-Prior left foot surgery for a heel spur
-no other PMH prior to gallstone pancreatitis
-as above: ARDS, PNA, gallstones, pancreatitis, pseudocyst,
tachy-brady syndrome
Social History:
Patient is engaged and her fiancee is her health care proxy.
She denies tobacco, EtOH, or IVDU.
Family History:
Noncontributory.
Physical Exam:
VS 96.4 92 104/60 20 100%TM
Gen: A&O, NAD, Trached
Neuro: CN II-XII grossly intact
HEENT: NCAT, Anicteric
Card: RRR -mgr
Pulm: + Ronchi bilat, Diffuse crackles
Abd: Soft, NTND, 3 drains in place draining brown fluid, GJ
clamped
Ext: No cyanosis, clubbing, or edema
Skin: No ulcers
Pertinent Results:
[**2198-8-31**] 10:51PM ALT(SGPT)-18 AST(SGOT)-19 LD(LDH)-270* ALK
PHOS-170* AMYLASE-31
[**2198-8-31**] 10:51PM LIPASE-27
[**2198-8-31**] 10:51PM ALBUMIN-2.0* CALCIUM-8.8 PHOSPHATE-3.5
MAGNESIUM-2.2 IRON-37
[**2198-8-31**] 10:51PM calTIBC-117* FERRITIN-GREATER TH TRF-90*
[**2198-8-31**] 10:51PM TRIGLYCER-78
[**2198-8-31**] 10:51PM WBC-13.5* RBC-2.82* HGB-8.3* HCT-27.7* MCV-98
MCH-29.4 MCHC-29.9* RDW-15.7*
[**2198-8-31**] 10:51PM PLT COUNT-530*
[**2198-8-31**] 10:51PM PT-13.4 PTT-24.3 INR(PT)-1.1
[**2198-8-31**] 11:24PM URINE HYALINE-[**4-5**]*
[**2198-8-31**] 11:24PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
Brief Hospital Course:
Briefly, this is a 60F with gallstone pancreatitis [**6-9**] with
unsuccessful ERCP
complicated by ARDS (now s/p trach) and severe pancreatitis
resulting in multiple pseudocysts with prolonged, intermittent
fevers. Was at [**Hospital 8**] Hospital/[**Hospital1 **] for extended period
with VRE from pseudocysts, pseudomonas PNA and UTI (treated with
amikacin, details unclear), and c diff treated with oral vanco.
Was transferred to [**Hospital1 **] for futher management and possible cyst
gastrectomy.
The patient was admitted from OSH at the beginning of [**Month (only) 216**],
expressing suicidal ideation, refusing ventilator, refusing
surgery. Per psychiatry evaluation, patient having delirium,
currently denying suicidal ideation and expressing desire to go
ahead with further medical/surgical interventions.
Over the ensuing days, her affect improved, the suicidal
ideation ceased, and she agreed to treatment of her
pancreatitis. Upon transfer, was thought to be poor candidate
for cyst gastrostomy, and has been managed with multiple
pseudocyst
debridements - OR on [**9-10**] (placement of two drainage and
irrigation systems), [**9-14**] (necrosectomy), [**9-18**] (necrosectomy),
[**9-25**] (laparoscopic necrosectomy, 2 L flank drains placed, others
not changed, of note there was a concern for a possible enteric
fistula based on the nature of the drainge). She was found to
have stool leakage and then then underwent a CT scan which
revealed a pancreaticocolonic fistula. No small bowel fistula
was ever identified on Small Bowel Follow Through study. Based
on this finding, she was made NPO and put on TPN, which she
needs to continue on until surgical follow up.
She also underwent GJ tube placement on [**2198-9-5**]. The GJ is not
currently being used and should be clamped until after her
follow up visit.
As far as her infectious disease course during this
hospitalization, pseudocyst cultures have grown heavy
pseudomonas and sparse enterococcus. She had a BAL with 10-100K
oral flora and >100k pseudomonas ([**Last Name (un) 36**] to pip-tazo, tobra, but
intermed to meropenem and R to cipro). C diff was negative x 3
but was sent here on oral vancomycin and finished a 14 day
course.
She was on linezolid/meropenem/oral vanco then changed to
linezolid/pip-tazo/tobra (conventional dosing)/oral vanco. Based
on sensitivities of the pseudomonas and the enterococcus, was
then on a course of dapto, zosyn, tobramycin. At that time,
adequate drainage was in place after drains placed in OR, and
remaining positive cultures of drain fluid most likely
represented colonization rather than infection, and so once
completed over 14 days of antibiotics, they were discontinued on
[**9-20**].
Had a possible VAP with RLL infiltrate/collapse, BAL [**9-1**] done
and with 2+polys, grew pseudomonas, treated with zosyn and
inhaled tobra initially, and then iv tobra, and completed a
treatment course on [**9-13**] in case of a VAP or aspiration pna.
Antibiotics were then resumed when there was evidence of colonic
fistula formation. At the time of discharge, she was on IV
Ciprofloxacin and IV Tobramycin, which she should continue for 2
weeks until surgical follow up.
Medications on Admission:
-Albuterol/Ipratropium -4 puffs TID
-Ferrous Sulfate 325mg daily
-Lovenox 40mg SC daily
same medications on transfer:
-Guaifenesin 200mg q4hrs PRN
-Tylenol 650mg q6hrs PRN
-Albuterol INH, 4 puffs qhour PRN
-Lactobacillus Acidophilis/lactinex -1 tablet daily
-Miconazole 2% ointment PRN
-Octreotide acetate 100 mcg SC TID
-olanzapine 10mg PO qhs
-Protonix 40mg IV BID
-Vitamin A&D external cream PRN
-Zinc oxide ointment PRN
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for For
wheezes.
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
3. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1)
Intravenous Q12H (every 12 hours) for 2 weeks.
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed for secretions.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
9. Hydromorphone (PF) 1 mg/mL Syringe Sig: [**2-2**] Injection Q4H
(every 4 hours) as needed for pain.
10. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for pain.
11. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain .
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
13. Ondansetron 8 mg IV Q8H:PRN nausea
14. Tobramycin Sulfate 80 mg/8mL Solution Sig: 90 mg
Intravenous every eight (8) hours for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Gallstone pancreatitis, pseudocysts percutaneously, and
pneumonia s/p tracheostomy as well as waxing mental status,
perc/lap necrosectomy x 4
Discharge Condition:
Good, meeting discharge criteria, stable respiratory status with
trach mask, NPO and chronically on TPN at baseline.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-15**] lbs) for 6 weeks.
* You may shower and wash. No tub baths or swimming.
* Monitor your incision for signs of infections
JP Drain Care:
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Maintain the bulb deflated to provide adequate suction.
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Be sure to empty the drain frequently.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling
Followup Instructions:
Call Dr.[**Name (NI) 5067**] office at ([**Telephone/Fax (1) 6347**] to schedule a follow up
appointment in 2 weeks.
ICD9 Codes: 5990, 5180, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2188
} | Medical Text: Admission Date: [**2138-9-20**] Discharge Date: [**2138-9-22**]
Date of Birth: [**2138-9-20**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 44083**] is a 36 and
[**5-20**] week gestation female infant admitted to the NICU for
evaluation of initial hypotonia. Obstetrician, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 23**], delivering obstetrician, Dr. [**First Name4 (NamePattern1) 22362**] [**Last Name (NamePattern1) **]
pediatrician, Dr. [**First Name8 (NamePattern2) 1060**] [**Last Name (NamePattern1) **] [**Hospital 5176**] Pediatrics.
PREGNANCY: Mother is a 31 year old gravida I, para 0, now I.
Prenatal screens revealed hepatitis B surface antigen
negative, RPR nonreactive, A positive antibody negative,
rubella immune, GBS unknown.
Pregnancy was uncomplicated until just prior to delivery when
she was noted to have a mildly elevated blood pressure. She
prior to delivery. No maternal fever was noted. During
labor, fetal heart rate decelerations were noted. She was
treated with an amnio infusion, however, deep variable
decelerations were noted again, and the decision was made to
delivery by cesarean section.
Amniotic fluid was clear. Delivery was uncomplicated except
for noted cord around body. The baby emerged with no
respiratory effort and very poor tone. She was treated with
bulb suctioning and bag and mask ventilation with good
response of heart rate, respiratory effort and color. The
baby, however, initially had a diffusely poor tone and
hyperalert appearance. Her tone and activity level gradually
improved over twenty to thirty minutes. Apgar scores were
four, two heart rate, one color, one reflex, seven at five
minutes, two heart rate, one tone, one color, one reflex, two
respiratory and 8 at ten minutes, two heart rate, two
respiratory rate, one tone, one reflex, two color. The baby
was transferred to the NICU for further assessment.
PHYSICAL EXAMINATION: On admission, birth weight 2230 grams,
20th percentile, transfer weight 2160 grams, length 47.5
centimeters, 50th percentile, head circumference 30
centimeters, 25th percentile. Vital signs on admission were
temperature 95.5, heart rate 150, respiratory rate 50, blood
pressure 65/51 with a mean of 56 and oxygen saturation
greater than 95% in room air. Head, eyes, ears, nose and
throat examination - Anterior fontanelle soft and flat. Eyes
- The pupils are equal, round, and reactive to light and
accommodation. Normal red reflexes. Palate intact. Normal
facies. Small amount of molding. Sutures mobile.
Respiratory - Lungs clear and equal, no retractions.
Cardiovascular - S1 and S2 normal intensity, no murmur,
perfusion good. Abdomen is soft with normal bowel sounds,
three vessel cord, no organomegaly. Genitourinary - normal
female, anus patent. Neurologic - tone initially reduced,
improved to normal limits in both upper and lower
extremities, symmetrical examination, good suck reflex, hips
stable, clavicles intact.
HOSPITAL COURSE:
1. Respiratory - The baby remained in room air and did not
require any respiratory support. The baby had no apnea or
bradycardia and had oxygen saturation greater than 95%. No
issues.
2. Cardiovascular - Baseline heart rate 120s to 140s, blood
pressure stable with mean greater than 40, no murmur, no
issues.
3. Fluid, electrolytes and nutrition - Initially, the baby
had an intravenous started of [**Name (NI) 44084**] at 60 cc/kilogram via
peripheral intravenous. Initial dextrose stick was 75 and it
did drop down to 34. The baby required one [**Name (NI) 44084**] bolus and
subsequent dextrose sticks were greater than 60. The baby
was started on enteral feeds and did require two calories of
Polycose per ounce to maintain adequate glucose levels.
Polycose was discontinued on day of life one. Dextrose stick
remained stable on three hourly feedings. They were advanced
to q4hours with stable dextrose stick. Mother is breast
feeding supplementing with Enfamil 20 ad lib and dextrose
sticks have been greater than 50. The baby is being
transferred to the [**Name (NI) **] Nursery with supplemental feedings
after breast feeding with continuation of ACD sticks until
greater than 50 times two. The baby has been voiding and
stooling. No issues.
4. Gastrointestinal - No bilirubin has been done. The baby
is not jaundiced at the time of transfer.
5. Hematology - No blood type was done. No transfusions
required during this admission. Hematocrit on admission was
48.0.
6. Infectious disease - The baby did have a complete blood
count drawn on admission with a white blood cell count of
21.0, 62 polys, 1 band, platelet count 457,000. Blood
culture was not sent as the baby had no risk factors for
infection, and the baby looks clinically well. There were no
antibiotics given.
7. Neurology - Initial hypotonia and hyperalert state
quickly resolved. There was no seizure activity noted, and
the baby has a normal examination for gestational age. No
further evaluation indicated at this time.
8. Sensory - Audiology screening not done at the time of
transfer.
9. Ophthalmology - Examination not done. Based on advanced
gestational age, not required.
10. Psychosocial - The parents have been visiting,
appropriately concerned about [**Known lastname 44085**] issues and look
forward to transfer to [**Known lastname **] Nursery.
CONDITION ON TRANSFER: Stable.
DISCHARGE DISPOSITION: To the [**Known lastname **] Nursery at the [**Hospital1 1444**]. Primary pediatrician, Dr.
[**First Name8 (NamePattern2) 1060**] [**Last Name (NamePattern1) **], telephone [**Telephone/Fax (1) 44086**], fax [**Telephone/Fax (1) 44087**].
CARE RECOMMENDATIONS:
1. Feedings at discharge - Continue breast feeding with PC
of Enfamil 20 with iron.
2. Medications - None at this time.
3. Car seat screening - Not done at the time of transfer,
recommended prior to discharge.
4. State [**Telephone/Fax (1) **] Screen Status - First screen will be due
tomorrow, [**2138-9-23**].
5. Immunizations Received - The parents have signed consent
for hepatitis B vaccine and it has not been given at the time
of transfer.
FOLLOW-UP APPOINTMENTS: Primary care pediatrician per
routine.
DISCHARGE DIAGNOSIS: 36 and [**5-20**] week premature female,
status post hypoglycemia, status post hypotonia.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36095**]
Dictated By:[**Last Name (NamePattern1) 36144**]
MEDQUIST36
D: [**2138-9-22**] 19:01
T: [**2138-9-22**] 20:09
JOB#: [**Job Number **]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2189
} | Medical Text: Admission Date: [**2162-6-30**] Discharge Date: [**2162-7-8**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85 year old
male who was admitted on [**6-30**] for a syncopal episode while
climbing up to the stairs at his home. At that time the
patient lost consciousness. He was found by his daughter who
then called the paramedics. Upon admission the patient had a
syncopal workup which included a head computerized tomography
scan which was negative, as well as a carotid duplex which
was negative. The patient had an electrocardiogram done
which showed no ST elevation and nonspecific changes. He was
then sent for a stress test which had uninterpretable changes
because of his current regimen which included Digoxin. It
was thought that at that time the patient may have increased
vagal tone which may have lead to the syncopal episode so a
biventricular pacer was then placed. The patient at that
time was still in atrial fibrillation which he has been in
for some time. Following his pacer placement, the patient
was doing well but the following morning he was found
unresponsive and pulseless by the house staff. The patient
was immediately given oxygen and recovered quickly without
cardiopulmonary resuscitation or any other means. The
patient was then transferred to the Cardiac Care Unit. Upon
admission the patient was found to be afebrile with a
temperature of 98 degrees. His heartrate ranged between 72
and 83 with atrial fibrillation. His respirations ranged
from 17 to 26, blood pressure systolic ranged from 103 to
112/51 to 59. He was sating at 99% on 2 liters of oxygen,
nasal cannula. His ins and outs at that time for a 20 hour
period were 501 cc in, 1105 cc out for a negative total of
604 cc.
PHYSICAL EXAMINATION: On examination the patient was calm,
in no apparent distress but was found to have [**Last Name (un) 6055**]-[**Doctor Last Name **]
respirations with notable hyperventilation followed by apneic
periods. Head and neck examination, the patient was
nonicteric, mucosa were moist. No jugulovenous distension
was noted. His chest was clear to auscultation, anteriorly
and laterally. Cardiac examination, he had an irregularly
irregular rhythm with a II/VI murmur, no rubs were noted.
His abdomen had positive bowel sounds, nontender,
nondistended. His extremities showed no cyanosis, clubbing
or edema with intact 2+ pulses bilaterally. Neurological
examination, he was alert and oriented times three. Pupils
were equally round and reactive to light, extraocular
movements intact. The patient had no nystagmus. Mild
increase in tone in all four limbs symmetrically with
downgoing toes bilaterally. His strength and sensation were
grossly intact and symmetrical bilaterally.
LABORATORY DATA: Laboratory studies on admission revealed
the patient had a white count of 6.4, hemoglobin 9.5,
hematocrit of 27.1. Chem-7 with sodium 143, potassium 4.5,
chloride 108, bicarbonate 23, BUN 31, creatinine 1.7. His
AST was 24, ALT 20, lactate of 3.7. The patient had serial
cardiac enzymes with a peak CPK of 487, calcium 9.0,
phosphorus 3.2, magnesium 2.1. He had a urine culture from
[**6-30**] which was positive for enterococcus over 100,000
units. The previous head computerized tomography scan was
negative. Chest x-ray showed a possible small infiltrate.
Stress test, electrocardiogram was uninterpretable because of
Digoxin therapy. His echocardiogram done on [**7-2**] showed a
dilated left ventricle, decreased left ventricular systolic
function with an ejection fraction of 25% with 1 to 2+ aortic
regurgitation and 1 to 2+ mitral regurgitation, 2+ tricuspid
regurgitation with some mild pulmonary hypertension, all
findings which were similar to a previous echocardiogram,
[**2161-11-15**]. Carotid duplex showed no abnormalities.
HOSPITAL COURSE: During the patient's admission to Cardiac
Care Unit, serial cardiac enzymes were drawn at which time he
ruled in for a myocardial infarction with no ST segment
elevation. The patient was started on a beta blocker,
Aspirin, heparin with an Ace inhibitor which was held
temporarily because of his increase in creatinine which was
thought to be due to his hypotensive episode. The patient
was then sent the following day for a cardiac catheterization
which revealed no change in his coronary artery disease and
no intervention was done at that time. The following day,
[**7-6**], the patient was transferred to the floor and was
found to have a creatinine that improved to 1.2. At that
time an ACE inhibitor was started. The following day, [**7-7**], the patient did well but had some confusion over night
and was found to have a slight decrease in urine output with
a slight rise in creatinine to 1.4. The patient had gentle
intravenous hydration. The case manager was consulted at
that time as well as physical therapy. The patient's Foley
catheter was discontinued. The following day [**7-8**], the
patient did well over night with no confusion noted. The
patient did urinate some dark red urine which was thought to
be related to trauma from his Foley catheter. It was also
decided at that time that the patient should be cardioverted
for his atrial fibrillation so that his biventricular pacer
could function more efficiently. It was also decided at that
time that the patient should continue on anticoagulation with
Coumadin after his discharge from the hospital because of the
future risk of atrial fibrillation and history of stroke.
The following day, the patient did well. He had somewhat
decreased urine output which was red, thought to be secondary
to his Foley catheter which had since been removed. The
patient had a chest x-ray which showed no signs of congestive
heart failure so he continued with gentle intravenous
hydration. His creatinine at that time was found to be 1.5.
His blood pressure was stable with systolics to the 160s so
the patient's Lopressor was increased to 50 mg b.i.d. and his
ACE inhibitor was changed to Lisinopril 5 mg q.d. Because
the patient's INR was 1.5 on his Coumadin dose of 60 mg per
day, the patient was placed on Lovenox temporarily until his
INR became therapeutic between 2 and 3. The patient was then
discharged to a rehabilitation facility. At discharge, the
patient's status was good. The patient was found to have
good mental status, bibasilar crackles with some lower
extremity edema 1+, but the rest of the examination was
unremarkable.
DISCHARGE DIAGNOSIS:
1. Syncope with permanent pacer placement
2. Acute myocardial infarction
3. Atrial fibrillation status post cardioversion
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg once a day
2. Lipitor 10 mg once a day
3. Amiodarone 400 mg twice a day
4. Coumadin 6 mg once a day
5. Metoprolol XL 50 mg twice a day
6. Lisinopril 5 mg once a day
7. Docusate 100 mg twice a day
8. Lovenox 80 mg subcutaneously q. 12 until his INR is
therapeutic
FOLLOW UP: The patient's follow up plans are to go to a
rehabilitation facility where he will have his INR checked
and continue Coumadin. The patient will have frequent
creatinine checks with close monitoring of his ins and outs
with gentle intravenous hydration. The patient will also
continue on his Amiodarone where he will follow up with
pulmonary function tests, liver function tests and thyroid
function tests to monitor toxicities. The patient after
rehabilitation will have follow up appointments with Device
Clinic for his pacemaker, have a cardiology follow up
appointment with Dr. [**Last Name (STitle) **]. He will follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30867**] for an appointment in
approximately two to three weeks. The patient will also
follow up with INR checks either at home or at [**Hospital 263**] Clinic.
DISPOSITION: The patient will be transferred to [**Hospital3 7511**] for rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern4) 30868**]
MEDQUIST36
D: [**2162-7-8**] 15:05
T: [**2162-7-8**] 16:45
JOB#: [**Job Number 30869**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2190
} | Medical Text: Admission Date: [**2158-8-6**] Discharge Date: [**2158-8-18**]
Date of Birth: [**2090-11-5**] Sex: F
Service:
CHIEF COMPLAINT: This 67-year-old white female presents with
a 5-day headache and nausea and vomiting for two days.
HISTORY OF PRESENT ILLNESS: This is a 67-year-old woman with
a headache for five days which increased to an intensity of
[**8-14**] three days prior to admission after chemotherapy. She
noted a throbbing in the midline and frontal parietal area
with no exacerbating factors, and she noted partial relief
with analgesics, and the pain is now [**2-11**]. The patient also
noted the onset of nausea and vomiting two days prior to
admission with a report that she had vomited approximately 10
to 15 times on the day of admission but denied any projectile
vomiting. She also complained of a brief blurring of vision
in the right eye lasting for a few minutes four days prior to
admission but denies any diplopia or photophobia. She denied
any motor, sensory, bowel or bladder dysfunction.
She presented to the [**Hospital6 6640**] in [**Location (un) 8545**]
where a CT scan of the head was done and showed a small right
occipital hypodensity 1 cm X 1 cm near the surface of the
brain and right-sided 2-cm X 1.5-cm area of hypodensity in
the right parietal paramedian region. There was also a left
hypodensity of 1 cm X 0.5 cm in the left parietal convexity.
The patient was then transferred to the [**Hospital1 190**] for further neurosurgical and neurologic
evaluation. The patient received 10 mg of Decadron and 1 g
of Dilantin at the [**Hospital6 6640**].
PAST MEDICAL HISTORY: (Previous medical history includes a
history of)
1. Hypertension.
2. Migraine with no reported migraine headaches in the
preceding two years prior to admission.
3. Gastroesophageal reflux disease
4. Laryngeal carcinoma and status post radiotherapy for
this.
5. Prior history of colon cancer.
6. Left subclavian clot with a Port-A-Cath in the past.
PAST SURGICAL HISTORY: (Previous surgical history includes)
1. Transverse colectomy for colon cancer.
2. History of appendectomy.
3. Prior dilatation and curettage.
4. Port-A-Cath placement.
ALLERGIES: Allergy history includes PENICILLIN and a
reported allergy to YELLOW DYE.
MEDICATIONS ON ADMISSION: Medications at the time of
admission included Toprol 50 mg p.o. q.d., Lasix 1 tablet
every two days (the patient was uncertain of the dose),
potassium supplement 20 mEq p.o. q.d., Zantac 150 mg p.o.
q.a.m., Coumadin 2 mg p.o. q.d., and Compazine p.r.n.
PHYSICAL EXAMINATION ON ADMISSION: The patient was seen
while sitting comfortably in bed, in no obvious distress.
Temperature was 98.2, blood pressure 143/56, heart rate 91,
respiratory rate 21, oxygen saturation 93% on room air. She
was alert and oriented times three. Conjunctivae were moist.
Pupils were 4 mm, briskly reactive to 2 mm bilaterally. The
tympanic membranes and oropharynx were not inflamed. There
was no jugular venous distention, and no lymphadenopathy.
The chest was clear to auscultation. Cardiovascular
examination showed a left Port-A-Cath site with S1 and S2
normal, and no added sounds. The abdomen was soft and
nontender with no organomegaly. There was no tenderness over
the spine, and no flank or costovertebral angle tenderness.
The patient was noted to move all four limbs. Rectal
examination was deferred. Neurologic examination revealed
she was alert and oriented times three with fluent speech.
Cranial nerve I was deferred; II was normal visual acuity and
fields; III, IV, and VI revealed extraocular movements were
intact, no nystagmus; nerves V and VII revealed motor and
sensory modalities in the face were normal; cranial nerves
VIII, IX, X and XII were normal uvula and palatal movement,
tongue was central, no fasciculations, and lateral movement
was normal; cranial nerve [**Doctor First Name 81**] revealed the trapezius was with
good motor strength. The motor strength of all major muscle
groups of the bilateral upper and lower extremities was [**4-8**],
and there was no pronator drift. Sensory examination was
within normal limits to light touch and pinprick, and the
biceps, triceps, ankles, and knees were 2+ bilaterally.
Finger-to-nose movement was normal.
LABORATORY DATA ON ADMISSION: White blood cell count 11.6,
hematocrit 45.1, platelet count 200. PT 17, PTT 44, INR 2.
Sodium 137, potassium 3.3, chloride 103, bicarbonate 25,
BUN 11, creatinine 0.8, glucose 190. Calcium 9.
HOSPITAL COURSE: Due to the clinical findings the patient
was admitted with a history of hypertension, gastroesophageal
reflux disease, and a history of colon cancer and laryngeal
cancer, and being on Coumadin for subclavian thrombosis.
The patient was begun on Decadron 4 mg q.8.h., sliding-scale
regular insulin, Dilantin 100 mg t.i.d., 2 units of fresh
frozen plasma were given with 10 mg of Lasix, and
vitamin K 10 mg subcutaneous times three days.
MRI with contrast and MR venogram were done to rule out sinus
thrombosis, and coagulations were repleted after the fresh
frozen plasma, and the patient was admitted to the Surgical
Intensive Care Unit. The patient remained in the Surgical
Intensive Care Unit for approximately four days and was
discharged to the floor after the MRI was felt to be stable
and consistent with the CT scan findings, and the patient
went to the hospital floor on [**2158-8-8**].
The patient was noted to be stable on [**8-9**] as well as
early on [**8-10**], but in the late afternoon of
[**8-10**] and early evening of [**8-10**] she complained
of recurrent increased headache. She was sent down for a
repeat CT scan which showed a slight increased bleed, and the
patient was readmitted to the Surgical Intensive Care Unit.
The patient's neurologic examination was stable. She was
maintained again in the Surgical Intensive Care Unit for 48
hours with neurologic status stable. She went for an
angiogram on [**8-12**] in the early morning hours, and this
showed an occluded left internal jugular vein with drainage
through collateral circulation, and the superior sagittal
sinus with good drainage. There was a patent severe sagittal
sinus, transverse sinus, and internal jugulars on the right.
There was focal stenosis at the junction of the left
subclavian vein with Port-A-Cath tip present at that level.
The patient was subsequently returned to the Surgical
Intensive Care Unit with no sequelae from the angiogram, and
a head CT was scheduled for the following day. The head CT
showed no significant change from the prior head CT of
[**8-11**], and the patient subsequently was returned to the
floor on the morning of [**2158-8-14**]. The remainder of
her postoperative hospitalization was essentially
unremarkable and stable.
DISCHARGE DISPOSITION: The patient was seen during this
hospitalization with Neurology/Oncology as well as
Physiotherapy and Occupational Therapy. It was felt that the
patient would benefit from a short stay in an acute
rehabilitation center, and arrangements were made for this to
occur at the time of discharge with arrangements for the
patient to be directly transferred to an acute rehabilitation
center with plan for discharge on [**2158-8-18**].
MEDICATIONS ON DISCHARGE:
1. Toprol 50 mg p.o. q.d.
2. Lasix 20 mg p.o. q.d.
3. Potassium supplements.
4. Decadron.
5. Zantac.
6. Tylenol.
7. Zofran.
8. Percocet.
9. Depakote.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 33505**], M.D. [**MD Number(1) 33506**]
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2158-8-17**] 12:32
T: [**2158-8-18**] 09:39
JOB#: [**Job Number 34138**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2191
} | Medical Text: Admission Date: [**2156-3-7**] Discharge Date: [**2156-3-10**]
Date of Birth: Sex:
Service: CARDIOLOGY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 11075**] is a pleasant 74
year-old man with no clear history of coronary artery
disease, but positive electrocardiograms changes on recent
stress echocardiogram as well as history of hypertension and
hypercholesterolemia, who presented with complaint of chest
pain. The patient is a very active man who spends
approximately forty minutes on a treadmill every other day.
Approximately three weeks prior to presentation he noted
chest pain during his treadmill exercises. The patient
characterized the pain as substernal pressure that originated
in the center of his chest. It did not radiate elsewhere and
was not pleuritic. Mr. [**Known lastname 11075**] [**Last Name (Titles) **] these episodes as
approximately 3 out of 10 in severity, and said they
initially occurred after about fifteen minuets of exercise.
When these episodes occurred during exercise the patient
would stop exercising and take some nitro spray (prescribed
"years ago" by Dr. [**Last Name (STitle) **], though the patient cannot recall
why). The nitroglycerin did not seem to help the patient's
symptoms appreciably, but the pain would abate somewhat and
he would then resume exercising. The pain would disappear
completely after about an hour and a half.
Because of these exercise related episodes of chest pressure,
the patient saw his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. The stress echocardiogram was done on [**2156-3-3**]. The echocardiogram portion of the examination was
normal, however, during exercise 1 to 1.5 mm horizontal down
sloping ST segment depressions were noted and isolated to
leads V2 through V3. Additionally, T wave inversions were
noted at lead V2. These changes resolved slowly post
exercise and were not absent until ten minutes post exercise.
The rhythm was sinus with frequent atrial irritability noted
throughout exercise. No palpitations were reported and the
patient remained hemodynamically stable.
On the day prior to admission at about 5:00 p.m., shortly
after finishing dinner, the patient noted the above chest
pressure symptoms, though this time he was sitting and at
rest. He took some Pepcid, which alleviated the discomfort
somewhat and then took nitroglycerin and Atenolol. The pain
lasted approximately an hour and a half. The pain occurred
again on the morning of presentation while the patient was
sitting, [**Location (un) 1131**] on line. He then decided to present to the
Emergency Department.
REVIEW OF SYSTEMS: The patient denied recent illness and
injury (aside from his chronic fatigue syndromes). The
patient denied prior history of angina, orthopnea, paroxysmal
nocturnal dyspnea, lower extremity edema and claudication.
He also denies fevers or chills, nausea, vomiting, melena,
hematochezia, dysuria or hematuria.
In the Emergency Department the patient was without
significant electrocardiogram changes, however, his troponin
was noted to be elevated to 8.9. He was given aspirin, beta
blocker and started on a heparin drip as well as Integrilin
and the nitro drip. The patient was subsequently taken to
cardiac catheterization.
PAST MEDICAL HISTORY: Stress echocardiogram ([**2156-3-3**])
ejection fraction 60% with no wall motion abnormalities or
inducible echocardiogram ischemia, however, there were
notable electrocardiogram changes as described above.
Hypertension. Hypercholesterolemia. Symptom cluster deemed
chronic fatigue syndrome. Status post appendectomy. Status
post tonsillectomy. Status post ring finger trigger finger
release complicated by infection.
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS: Atenolol 25 mg q.d., Zoloft 100 mg
q.d., Proscar 5 mg q.d., Modafinil, Hytrin, Naproxen prn,
aspirin 325 mg q.d.
SOCIAL HISTORY: The patient lives in [**Location 5344**],
[**State 350**] with his wife. They have no children. The
patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] professor [**First Name (Titles) **] [**Last Name (Titles) **] art. He quit
smoking approximately thirty five years ago after a ten pack
year history. He drinks one glass of wine per day. He
denies history of elicit drug use.
PHYSICAL EXAMINATION: Vital signs, heart rate 61, blood
pressure 112/61. Respirations 18. Sating 96% on 1 liter and
98% on room air. General, awake, and in no acute distress.
HEENT normocephalic, atraumatic. Sclera anicteric. Pupils
are equal, round, and reactive to light and accommodation.
Extraocular movements intact bilaterally. Mucous membranes
are moist without lesions. Neck supple. No JVD or left
anterior descending coronary artery. No carotid bruits.
Cardiovascular regular rate and rhythm. Normal S1 and S2
without murmurs, rubs or gallops. Chest clear to
auscultation bilaterally. Abdomen soft, nontender,
nondistended, positive normoactive bowel sounds. No
hepatosplenomegaly or pulsatile masses. Rectal examination
revealed normal sphincter tone with brown stool that was
guaiac negative. Extremities 2+ dorsalis pedis pulses
bilaterally. No clubbing, cyanosis or edema. Neurological
examination revealed the patient to be alert and oriented
times three. His speech was normal and appropriate. Cranial
nerves II through XII were intact bilaterally. The patient's
right upper extremity had some weakness, approximately 4 out
of 5 strength both proximally and distally, which the patient
attributes to his chronic fatigue, otherwise, strength
testing was both 5 out of 5 both proximally and distally.
LABORATORY DATA: CBC revealed a white count of 8.8,
hematocrit 39.7, platelets 212. Cardiac studies revealed an
INR of 1.1, PT 12.8, PTT 24.8. Chem 7 revealed sodium 138,
potassium 4.1, chloride 105, bicarb 24, BUN 24, creatinine
1.0, glucose 118. Initial CK was 253 with an MB fraction of
28 and an MB index of 11.1. Troponin was 8.9. Urinalysis
was negative. Electrocardiogram revealed normal sinus rhythm
at a rate of 60 beats per minute, old Q wave in lead 3.
There were no acute ST or T changes. There were no changes
versus prior study of [**2155-6-3**]. Chest x-ray no evidence
of pleural effusions, infiltrates or congestive heart
failure.
HOSPITAL COURSE: The patient was initially admitted to the
[**Hospital Unit Name 196**] Service for further evaluation and treatment for his
above noted conditions. On the evening of admission the
patient went to cardiac catheterization. At the time of this
dictation no official report is available on the computer
regarding the catheterization. However, preliminary report
reveals that the system was right dominant. There was no
significant obstructive disease in the LMCA. There was no
moderate disease in the left anterior descending coronary
artery with 40% mid stenosis in the right coronary artery.
There was total occlusion of the distal left circumflex. The
obtuse marginal one and obtuse marginal two were stented.
The left circumflex was jailed and subsequently rescued.
This event was complicated by bradycardia and hypotension as
well as chest pain. Thus, the patient required a brief
course of Dopamine and was transferred briefly to the Cardiac
Care Unit. He was quickly weaned off Dopamine following
admission to the Cardiac CAre Unit and was transferred back
to the Medicine Floor the following day.
Aside from the above noted catheterization and interventions
the patient was treated medically with aspirin, Plavix, beta
blocker and an Ace inhibitor. As his LDL was found to be
elevated to 129 he was started on Lipitor. The patient did
well during the remainder of his hospitalization
CONDITION ON DISCHARGE: Vital signs stable, afebrile. Free
of chest pain and shortness of breath. Fully ambulatory.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post stent placement to
obtuse marginal one and obtuse marginal two. Complicated by
jailing of left circumflex artery, which was subsequently
rescued.
2. Hypertension.
3. Hypercholesterolemia.
DISCHARGE MEDICATIONS: The patient was discharged on his
above noted outpatient medication regimen. He was given
prescriptions for Captopril 6.25 mg t.i.d., as well as
Lipitor 10 mg po q.d. and Plavix 75 mg po q.d.
FOLLOW UP: The patient is to follow up with his primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one week.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2156-3-12**] 16:47
T: [**2156-3-15**] 07:55
JOB#: [**Job Number 107208**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2192
} | Medical Text: Admission Date: [**2157-8-16**] Discharge Date: [**2157-8-23**]
Date of Birth: [**2090-1-6**] Sex: F
Service: [**Doctor Last Name 1181**]
HISTORY OF THE PRESENT ILLNESS: The patient is a 67-year-old
woman who is one month status post radioactive iodine for
hyperthyroidism. She noted palpitations, increased heart
rate at 1 AM, rapid shallow breathing, jaw tightness, and
shooting pain down her side. She came to the emergency
department. She denies chest tight, paroxysmal nocturnal
dyspnea, orthopnea. The patient says that she has been
having shorter episodes of palpitations, most lasting ten
minutes for the past six weeks. The patient has an extensive
thyroid history. In the 80s she was found to be hypothyroid
and she was started on Synthroid for many years. However,
after further testing, the thyroid function came back normal
and Synthroid was discontinued. In [**2149**], she was noted to
have thyroid function test. Thyroid uptake scan was done,
which showed 54% uptake, however, at that time therapeutic
options for the hyperthyroidism were discussed with the
patient and the patient chose not to take any steps. She
says that they continued to follow the thyroid for many
years, but stopped after it seemed not to be an issue. The
patient says that six weeks ago she started having
palpitations on a routine visit to her hospital and she noted
that the TSH level was less than 0.05 and she had elevated
free T4. The patient was scheduled for another uptake scan,
which showed 24% uptake. They decided to proceed with
radioactive iodide treatment. Prior to that point, the
patient said that she was having problems with fatigue, which
was longstanding. The patient apparently had been diagnosed
with chronic fatigue syndrome. She also noted that she had
increasing bowel movements in the morning. She said that she
had cold intolerance. At the time of the first visit to the
thyroid clinic, they noted her thyroid to be 60 grams, and
nontender. The patient had radioactive iodide therapy done
on [**7-20**]. She returned to the clinic complaining of pain in
her thyroid, neck region. Also, the patient had extreme
episodes of fatigue, where she would have to lie down and she
would immediately fall asleep. She also had heat intolerance.
In the emergency room, EKG was done and revealed that the
patient was in atrial fibrillation. She was given 20 mg
Diltiazem and then switched to beta blockers and given three
successive Lopressor pushes at 5 mg and then 25 mg PO. Heart
rate decreased to the 130s from the 180s to 190s. The jaw
pain disappeared and she complained of no chest pain after
that. The systolic blood pressure fell to the 70s. She
became diaphoretic. She had a headache and she had some
chest tightness, but no confusion. After given a bolus of
250 cc normal saline the blood pressure went up to the 90s.
She felt better, but she could not say that the chest
pressure was done. The cardiologist was consulted,
Dr. [**First Name (STitle) **], who agreed with proceeding with cardioversion
in the ED. The patient was sedated and cardioverter to sinus
rhythm in the emergency department.
PAST MEDICAL HISTORY:
1. History includes chronic fatigue syndrome.
2. Headaches.
3. Leg pain.
4. Osteoporosis.
5. Osteoarthritis.
6. Thyroid history as per history of present illness.
7. Right pneumonectomy status post injury in the warm of
independence in [**Country **] 40 years ago.
8. Hypercholesterolemia status post total abdominal
hysterectomy, no bilateral salpingo-oophorectomy.
9. Vertigo status post appendectomy.
ALLERGIES: The patient is allergic to SULFA, CODEINE,
PENICILLIN, TETRACYCLINE. She also had breast cancer in [**2135**]
and chemotherapy and mastectomy. There was no radiation.
She has gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION:
1. Neurontin.
2. Zocor.
3. Fosamax 335 mg per week.
4. Prilosec, which the patient takes with the Fosamax.
5. Excedrin.
PHYSICAL EXAMINATION: Examination revealed the following:
Temperature 98.9, pulse 189, but then fell to 130 after rate
control. Blood pressure 104/60. Respiratory rate 22. Pulse
oximetry 95% on room air. She is a well-developed,
well-nourished woman in no acute distress. No JVD. Eyes
were anicteric. Oropharynx clear. Pupils equal, round, and
reactive to light. Extraocular muscles are intact. NECK:
Supple. CHEST: The patient's right chest had a scar on it
from mastectomy. She had decreased breath sounds on the
right. On the left she had basilar crackles. ABDOMEN:
Positive bowel sounds, soft nontender, healed scar. No
clubbing, cyanosis or edema. NEUROLOGICAL: Nonfocal, alert
and oriented.
FAMILY HISTORY: Strokes noted in both parents, brother with
a brain tumor.
SOCIAL HISTORY: The patient denies alcohol, drugs, or
smoking. She lives with the husband. She is a retired law
professor.
LABORATORY DATA: On admission the labs revealed the
following: Sodium 143, potassium 3.6, chloride 104,
bicarbonate 30, BUN 24, creatinine 0.6, glucose 138, White
blood cell 10.5, hematocrit 35.3, platelet count 330, PTT
25.2, INR 1.1, 40% polyps, 40% lymphs, 6% monocytes, 3%
eosinophils. The HDL was 51, LDL 140, triglycerides 141,
The first set of cardiac enzymes showed CPK of 39. EKG:
Rapid atrial fibrillation, normal axis, diffusely depressed
ST depression, good R-wave progressive.
The Department of Cardiology was consulted and agreed with
the plan to keeping the patient on beta blocker for rate
control. Chest x-ray at the time showed effusion of the left
base, questionable atelectasis versus infiltrate in the left
lower lobe.
HOSPITAL COURSE: The patient was transferred to CC7 for
observation, status post cardioversion. She was kept on beta
blocker. The patient started complaining of increasing
shortness of breath. Lungs were, at that time , were clear
to auscultation with the exception of decreased breath sounds
at the left lower lung. The patient's beta blocker dose was
decreased to 12.5 for possible bronchial spasm. However,
during the course of the night, she went into progressively
worse respiratory distress and finally had decreased mental
status and extreme bronchospasm/congestive heart failure.
The patient's ABG showed pCO2 of 130 and a pO2 in the 100s.
The pH at that time was 7.0. The Department of
Anesthesiology was called and the patient was intubated and
transferred to the MICU. The patient was diuresed. Chest
x-ray showed fluids in the lungs and she diuresed 1.5 liters.
The respiratory status improved. The patient was extubated
the next day.
PULMONARY: The patient still had shortness of breath and at
times low oxygen saturation. However, she improved with
Atrovent nebulizer and diuresis. It is felt that the
symptoms were secondary to both bronchospasm from the beta
blocker and volume overload from the fluid she received in
the emergency department. Repeat chest ray showed the
pleural effusion had improved, however, it showed signs of
atelectasis/pneumonia. The patient also had an episode of
emesis during the time of respiratory distress and it was
feared that she had aspiration pneumonia. However, the
patient remained afebrile and repeat chest x-ray showed no
infiltrate. The patient's respiratory status improved after
she was given incentive spirometer and she started
ambulating. On discharge she will still receive Atrovent
nebulizer treatments.
CARDIAC: Coronary artery disease. The patient has no known
coronary artery disease, however, she had transient troponin
of 4.4, after cardioversion. It is believed that this is
most likely from the cardioversion and not ischemia.
However, the patient will benefit from stress test after her
hypothyroidism issues resolve. The patient was kept on
Lipitor 20 mg q.d. during her admission for
cardiac-productive measures.
PUMP: The patient had an echocardiogram done on [**2157-8-17**],
showing mild LV hypertrophy, left ventricular cavity size
normal, overall ventricular systolic function with normal
with left ventricular ejection fraction of greater than 55%.
Aortic valve leaflets are mildly thickened. No aortic
regurgitation seen. Mitral leaflets are moderately
thickened. There is mild pulmonary artery systolic
hypertension and no pericardial effusion noted. It is felt
that some of her respiratory distress might have been due to
fluid overload. She improved with diuresis. However, she
does not need further diuretic therapy in the future since
she showed no signs of diastolic or systolic failure.
RATE AND RHYTHM: The patient was cardioverted in the ED and
remained in sinus rhythm, however, while in the MICU, during
instrumentation, in particular when endoscopy was about to be
performed, the patient went back into atrial fibrillation.
The patient initially was treated with beta blocker, but due
to questionable bronchospasm, she was switched to Diltiazem.
The patient's atrial fibrillation resolved on its own
spontaneously. The patient was eventually on short-acting
Diltiazem, but changed to extended released 260 mg q.d. She
was also started on Digoxin 0.125 mg q.d.
The Electrophysiology Service was consulted and believed that
starting antiarrhythmic is unnecessary, since the cause was
believed to be hyperthyroidism. The Department of
Electrophysiology Service decided not to start Dofetilide by
discharge. She will be sent on Digoxin and Diltiazem
extended release 250 mg q.d.
GASTROINTESTINAL: During the course of her admission, the
hospital course was complicated by upper GI bleed. She had
melena and the hematocrit dropped. She had been on heparin
for anticoagulation for atrial fibrillation. However, this
had to be discontinued.
The patient was seen by the GI Department. She was put on
Protonix 40 mg b.i.d. and scheduled for endoscopy. However,
when endoscopy was attempted, she went into atrial
fibrillation and the procedure was aborted. The patient's
hematocrit was followed. She was transferred two units of
blood. The hematocrit went from 23 to 34 and then the next
day fell to 31. The patient, however, during the rest of the
course of her hospital stay, received blood draws since
phlebotomy had been sticking her several times and had been
unable to get blood. The patient was informed of the
importance of following the hematocrit in order to determine
if she needed further transfusion, but still refused further
blood draws. It is unknown what the hematocrit is at the
time of discharge. However, the patient has had no further
melena in the days prior to discharge. Stool was guaiac
positive, however, it was well formed and brownish. The day
prior to discharge the patient reportedly had a stool that
was guaiac negative, but the stool was not reported in the
chart. The patient refused repeat endoscopy and on the day
of discharge she wants to follow up with Dr. [**Last Name (STitle) 1940**], who at
the time is on vacation. The patient will make an
appointment with Dr. [**Last Name (STitle) 1940**] on her own at which time he will
evaluate her for the need of endoscopy.
The patient has been advised of the need to get a follow up
hematocrit to make sure she is not severely anemic. She has
also been advised to return to the emergency department if
she notes melena in her stool or becomes short of breath.
Endocrine was consulted. The initial thyroid function
studies came back surprisingly normal. TSH was less than
0.05. However, the free T4 was in the normal range at 1.6.
It was repeated and subsequently came back slightly elevated
at 2.1. The patient was started on Tapazole 30 mg PO q.d. to
decreased hormone synthesis. It is believed that that the
atrial fibrillation is related to her hyperthyroid state, may
be secondary to thyroiditis from the radioactive iodide
therapy. The patient was cleared by the Endocrine Department
to start Amiodarone, however, the Department of Cardiology
feels that the patient does not need Amiodarone at the time
and rate control with calcium channel blockers and Digoxin
were enough.
The patient will follow up with her endocrinologist,
Dr. [**Last Name (STitle) 104947**] in the outpatient setting, where it will be
decided whether she needs to continue with the Tapazole.
INFECTIOUS DISEASE: The patient remained afebrile for the
majority of her hospital course, however, she had a low-grade
temperature of 100 following moving from the MICU to the
floor. This was believed to be secondary to atelectasis,
however, the patient also had thrombophlebitis in her right
decubitus fossa, which was treated with heat pads. Although
the inflammation seems to be resolving. The patient was
noted to have a elevated white blood count of 17 several days
ago. For this reason, the patient will be discharged on
Clindamycin for a seven-day course.
The patient has a cough, however, it is believed that this
cough is secondary to her intubation/bronchitis. It is being
treated with Robitussin. The patient is advised to return to
the hospital if she starts becoming febrile or if her cough
worsens.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged home with VNA
service.
DISCHARGE DIAGNOSES:
1. Paroxysmal atrial fibrillation.
2. Hyperthyroidism.
3. Upper GI bleed.
4. Respiratory distress secondary to bronchospasm.
5. Congestive heart failure exacerbation.
DISCHARGE MEDICATIONS:
1. Atrovent nebulizer q.6h.p.r.n.
2. Diltiazem extended release 240 mg PO q.d.
3. Tapazole 30 mg PO q.d.
4. Protonix 40 mg PO b.i.d.
5. Neurontin 900 mg PO q.a.m.; 600 mg PO q.h.s.
6. Zocor 209 mg PO q.d.
7. Digoxin 0.125 mg PO q.d.'
8. Clindamycin 300 mg PO q.i.d. times seven days.
The patient will follow up with the primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 13783**]. She will also follow up with the Cardiologist,
Dr. [**First Name (STitle) **] and the Endocrinologist,
Dr. [**Last Name (STitle) 104948**]. She will make an appointment with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**] in one to two weeks, where he will
assess the need for endoscopy.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 23326**]
MEDQUIST36
D: [**2157-8-23**] 14:57
T: [**2157-8-23**] 15:24
JOB#: [**Job Number **]
ICD9 Codes: 4280, 5180, 5789, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2193
} | Medical Text: Admission Date: [**2137-4-17**] Discharge Date: [**2137-4-20**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left lower lobe lung cancer.
Major Surgical or Invasive Procedure:
bronch, left lower lobectomy VATs
History of Present Illness:
Mr. [**Known lastname **] is an 86-year-old
gentleman who had a chest x-ray which noted a left-sided
opacity and underwent bronchoscopy which diagnosis a nonsmall-
cell lung cancer. His staging was remarkable for suspicious
hilar nodes but no other sign of mediastinal or distant
disease. A mediastinoscopy was negative for any N2 or N3
adenopathy. today he is admitted for left lower lobectomy
Past Medical History:
hypertension
hyperlipidemia
hypothyroidism
GERD
severe mitral regurgitation
mild renal insufficiency
Social History:
quit smoking 35 yrs ago. smoked 1 ppd for 10 yrs. quit etoh 40
yrs ago. no IVDU. lives in [**Location **] with wife
Family History:
non-contributory
Physical Exam:
general: well appearing 86 yo male in NAD
HEENT: unremarkable
Chest: CTA bilat
COR RRR S1, S2
abd: soft, NT, ND, +BS
extrem: no C/C/E
neuro: intact.
Inc: CDI
Pertinent Results:
[**2137-4-17**] Pathology Tissue: LEVEL 9, LEVEL 11, LEVEL [**2137-4-17**]
[**Last Name (LF) 1533**],[**First Name3 (LF) 1532**] P. Not Finalized
[**2137-4-17**] 03:55PM GLUCOSE-140* UREA N-28* CREAT-1.1 SODIUM-140
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16
Brief Hospital Course:
pt was admitted and taken to the OR for left VATS loer
lobectomy. OR course was uncomplicated. Extubated but due to
patient's age and co-morbidities he was admitted to the ICU for
post op monitoring. He remained stable overnoc and was
transferred to the floor on POD#1. The 2 pleural blakes placed
in the OR were draining small amounts of serosang fluid and were
placed to bulb sxn on POD#1. On POD#2 [**Doctor Last Name **] drains were d/c'd.
Pt was tolerating reg diet, pain was well controlled on po pain
med, ambulating w/ RA sats mid 90's. D/c'd to home w/ VNA
services [**2137-4-20**]
Medications on Admission:
HCTZ 25',synthroid 100mcg',Omeprazole 20',felodipine 5'
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*70 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Felodipine 5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
left lower lobe VATs
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop fever,
chills, chest pain, shortness of breath, redness or drainage
from your incision site.
You may shower on sunday. After showering, remove your chest
tube site dressing and cover the site with a clean bandaid daily
until healed.
Followup Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] for a folow up
appointment
Completed by:[**2137-4-20**]
ICD9 Codes: 4240, 2449, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2194
} | Medical Text: Admission Date: [**2179-5-21**] Discharge Date: [**2179-5-26**]
Date of Birth: [**2111-10-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2179-5-21**] Cardiac catheterization with intra aortic balloon pump
placement
[**2179-5-21**] Urgent Coronary artery bypass graft x3 (left internal
mammary artery > left anterior descending, saphenous vein graft
> obtuse marginal, saphenous vein graft > right coronary artery)
History of Present Illness:
67 year old male with known coronary artery disease s/p stents
to the RCA and OM in [**2172**], an active smoker, and GERD. He
presented to his cardiologist's office for an episodic visit due
to exertional chest burning that started few days prior to
office visit. His pain occurred with mowing his lawn or working
in his yard. He presented to [**Hospital1 18**] for outpatient
catheterization that revealed significant left main disease with
active chest pain requiring IABP insertion. Cardiac surgery was
consulted and he was taken to the operating room emergently from
the catheterization lab due to chest pain.
Past Medical History:
Coronary artery disease
Non ST elevation myocardial infarction [**2172**]
Chronic obstructive pulmonary disease
Gastroesophageal reflux disease
RCA and OM stents [**2172**]
Abdominal surgery [**07**] years ago
Social History:
He lives with his spouse
[**Name (NI) **] is a retired truck driver
He smokes [**6-13**] cigarettes a day and drinks a couple beers a day.
Family History:
non contributory
Physical Exam:
Pulse: 83 Resp: 12 O2 sat: 100%
B/P Right: 136/82 Left: 130/72
Height: 5'7" Weight: 71.7 kg
General: On cath lab table with chest pain no respiratory
distress
Skin: Dry [x] intact [x] unable to exam posterior skin
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] anteriorly
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: IABP Left: unable to access
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit no bruit bilateral
Pertinent Results:
Date/Time: [**2179-5-21**]
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 4 mm Hg < 20 mm Hg
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Left-to-right shunt
across the interatrial septum at rest. Small secundum ASD.
LEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly
depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in aortic arch. Simple
atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mild [1+] TR.
Conclusions
Prebypass
A left-to-right shunt across the interatrial septum is seen at
rest. A small secundum atrial septal defect is present. There is
mild regional left ventricular systolic dysfunction with
hypokinesia of the apical and mid portions of the inferior and
anteroseptal walls. Overall left ventricular systolic function
is mildly depressed (LVEF= 40- 45% %). Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen.
Post bypass
Patient is AV paced and receiving an infusion of phenylpephrine.
Biventricular systolic function is unchanged. Aorta is intact
post decannulation.
[**2179-5-26**] 06:15AM BLOOD WBC-10.4 RBC-4.04* Hgb-12.4* Hct-36.9*
MCV-91 MCH-30.7 MCHC-33.6 RDW-12.8 Plt Ct-169
[**2179-5-21**] 09:15AM BLOOD WBC-7.2 RBC-4.55* Hgb-14.2 Hct-41.4
MCV-91 MCH-31.3 MCHC-34.3 RDW-13.1 Plt Ct-163
[**2179-5-26**] 06:15AM BLOOD Plt Ct-169
[**2179-5-22**] 04:13AM BLOOD PT-12.8 PTT-26.3 INR(PT)-1.1
[**2179-5-21**] 09:15AM BLOOD Plt Ct-163
[**2179-5-21**] 09:15AM BLOOD PT-12.7 PTT-28.6 INR(PT)-1.1
[**2179-5-26**] 06:15AM BLOOD Glucose-107* UreaN-16 Creat-0.9 Na-137
K-4.3 Cl-97 HCO3-32 AnGap-12
[**2179-5-21**] 09:15AM BLOOD Glucose-119* UreaN-13 Creat-0.8 Na-137
K-4.3 Cl-106 HCO3-24 AnGap-11
[**2179-5-21**] 09:15AM BLOOD ALT-15 AST-16 CK(CPK)-79 AlkPhos-54
TotBili-0.5
[**2179-5-21**] 09:15AM BLOOD CK-MB-4 cTropnT-<0.01
[**2179-5-26**] 06:15AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.0
[**2179-5-21**] 09:15AM BLOOD Albumin-3.8
[**2179-5-23**] 06:35AM BLOOD Mg-2.2
[**2179-5-21**] 09:15AM BLOOD %HbA1c-5.4 eAG-108
COMPARISON: Chest radiographs dating back to [**2179-5-21**], most
recent from
[**2179-5-23**].
PA AND LATERAL CHEST RADIOGRAPHS: New ill-defined opacities are
identified in
the lung bases, left greater than right, findings suggestive of
subsegmental
atelectasis. There are small bilateral pleural effusions. The
upper lung
zones appear clear. There is no pneumothorax, vascular
congestion, or overt
pulmonary edema. Cardiomediastinal and hilar contours are within
normal
limits. Median sternotomy wires are intact. On the lateral
projection, there
are small rounded lucencies in the inferior retrosternal region,
likely
residual post-operative air. The clicking sound on physical
examine may
actually be from mild crepitus due to residual air.
IMPRESSION:
1. Bibasilar opacities, left greater than right, probable
atelectasis.
2. Small bilateral pleural effusions.
3. Intact median sternotomy wires.
4. Retrosternal foci of air secondary to recent surgery.
Brief Hospital Course:
On [**5-21**] Mr. [**Known lastname 64660**] [**Last Name (Titles) 1834**] a cardiac catheterization which
revealed muti-vessel disease including significant left main
stenosis. He was having active chest pain during the procedure
so an intra-aortic balloon pump was placed and he was brought
urgently to the operating room for a coronary artery bypass
grafting. Please see the operative note for details. He
received cefazolin for perioperative antibiotics and was
transferred to the intensive care unit for post operative
manamgent. That evening he was weaned from sedation, awoke
neurologically intact and was extubated without complications.
Post operative day one his intra aortic balloon pump was removed
and he was started on betablockers and diuretics. Later that
day he was transferred to the floor. Physical therapy worked
with him on strength and mobility. His chest tubes and
epicardial wires were removed per protocol. He was started on
wellbutrin for smoking cessation and provide education, and
currently denied any urges to smoke. He continued on inhalers
for pulmonary and mucinex was added to help with mucous
clearance. On post operative day three he developed a sternal
click with no drainage, chest xray revealed wires intact. He
was monitored and repeat Chest Xray [**5-26**] wires remained intact.
He was ready for discharge home on post operative day five with
services.
Medications on Admission:
TIOTROPIUM BROMIDE 18 mcg Capsule, w/Inhalation Device - 1 (One)
puff inhaled daily
ASPIRIN 81 mg daily,
OMEGA-3 FATTY ACIDS-FISH OIL 360 mg-1,200 mg Capsule - 3
Capsule(s) daily OMEPRAZOLE 20 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
Disp:*15 Tablet(s)* Refills:*0*
4. guaifenesin 600 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO BID () for 5 days.
Disp:*20 Tablet Extended Release(s)* Refills:*0*
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*qs Cap(s)* Refills:*0*
6. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
Disp:*qs qs* Refills:*0*
8. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day: start twice a day [**5-27**].
Disp:*60 Tablet Extended Release(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
10. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 7 days.
Disp:*7 Tablet Extended Release(s)* Refills:*0*
11. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily).
Disp:*30 gram* Refills:*0*
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*0*
13. acetaminophen-codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Chronic obstructive pulmonary disease
Gastric esophageal reflux disease
Tobacco abuse
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Codiene as needed
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage
Edema none
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**]
Smoking cessation: it has been discussed with you that you
should quit smoking and you have been started on Wellbutrin,
please call PCP if you find this not effective for further
options to assist with quiting smoking
**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 in Dr [**First Name (STitle) **] Clinic - to evaluate sternum [**5-31**] at
2:45 pm
[**Telephone/Fax (1) 170**]
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**6-21**] at 1pm
Cardiologist:Dr. [**Last Name (STitle) 1911**] [**Telephone/Fax (1) 11767**] on [**6-14**] 10am
Liver function test in 1 month with Dr [**Last Name (STitle) 1911**] due to
statin
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 17029**] [**Telephone/Fax (1) 17030**] in [**3-9**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2179-5-26**]
ICD9 Codes: 4111, 412, 4019, 496, 3051, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2195
} | Medical Text: Admission Date: [**2167-6-22**] Discharge Date: [**2167-7-2**]
Date of Birth: [**2121-1-4**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Levofloxacin / Flagyl
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Chief Complaint: unresponsive
Reason for MICU transfer: need for Narcan gtt
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 805**] is a 46 year old woman with h/o hemorrhagic stroke
with residual spasticity and weakness, seizure disorder,
depression, Hepatitis C, who was brought it by EMS after being
found unresponsive at home.
The patient got in an argument with her mother this morning,
after which she locked herself in her room and took a handful of
pills -- Morphine and a muscle relaxant (patient unsure of
medication name, but is prescribed Flexeril). She states that
she did not expect to wake up and is quite tearful at the time
of interview. She just returned home 4 days prior after being
discharged from [**Hospital 38**] rehab. She states that her mother
[**Name (NI) **] is "the devil" and was trying to find another home for
her because she couldn't take care of her anymore.
Her family found her unresponsive in her room and called EMS.
Narcan 0.4mg x1 was given in the field. Patient woke up
immediately, but then became more responsive again.
In the ED, initial VS were: 98.2 110 130/82 5 100%. Patient was
given Naloxone 0.4mg IV x1, then started on a Naloxone gtt @
0.3mg/hr given that she was still somnolent. Serum tox was
negative, but urine tox was not obtained.
On arrival to the MICU, patient's VS: P 105 BP 136/90 RR 11
O2sat 100%2LNC. The patient is alert and answering questions
appropriately. She is tearful and is wondering why she is still
alive. She notes some mild headache x3 days, but no vision
changes or changes in weakness. Abdominal distension is old per
patient, and she notes having a BM this morning.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
shortness of breath, cough, dyspnea or wheezing. Denies chest
pain, chest pressure, palpitations. Denies diarrhea, dark or
bloody stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. s/p stroke - left parieto-occipital hemorrhagic stroke in
[**9-11**], unclear etiology, s/p craniotomy to evacuate hemorrhage,
secondary herniation syndrome w subfalcine and transtentorial
herniation, bilat Wallerian degeneration syndrome, quadraparesis
with increasing spastic paraparesis worse on R, prox upper &
both lower extremities, s/p Baclofen pump placement
-Evaluated at [**Hospital1 2025**] by Dr [**Last Name (STitle) **] in [**2163**]
-ongoing issues with increasing spasticity
-[**5-15**] was off Baclofen pump and PO
-[**2-15**] on Baclofen PO (no pump), MS Contin, tizanidine
-[**7-18**] only on MS Contin for pain management
-[**12-19**] on Baclofen PO (no pump), MS Contin & IR PRN
2. hyperhomocysteinemia, mildly elevated, no further w/u planned
3. carries psychiatric diagnoses of OCD & depression with
suicidal ideation; patient notes suicidal attempt at age 13, cut
her wrists
4. sickle cell trait
5. Hepatitis C, genotype 3, viral load 799,000 in [**February 2163**], no
plans to treat as transaminases normal, f/u planned in [**2165**]
6. microcytic anemia with normal iron studies
7. restrictive lung disease due to weakened resp muscles
following stroke
8. GI h/o duodenitis, colitis in [**July 2165**], treated with abx
9. Epilepsy, during [**July 2165**] admission (no clear provoking
factor). She has now had about six or so, her mother thinks.
[**Name2 (NI) **] have been in the hospital. She has had two at home: She
will become agitated and non-sensical, with right gaze
deviation, repetitive verbalizations: "help me", "open it", etc.
Her mother says that she has had no generalized seizures at
home.
10. Question of motor neuron disease (primary lateral
sclerosis)raised in prior MRI findings, EMG and nerve conduction
studies [**12-15**] provided no evidence for the diagnosis.
Social History:
Discharged from [**Hospital 38**] rehab [**2167-6-18**], now staying with her
mother. [**Name (NI) **] smoking (smoked prior to stroke in [**2158**]). No alcohol.
Family History:
Arthritis, walks with cane. Father - unknown. [**Name2 (NI) **]-one with
seizures.
Physical Exam:
Admission Physical Exam:
Vitals: P 105 BP 136/90 RR 11 O2sat 100%2LNC
General: Alert, orientedx2 (aware of place, but thought it was
[**2168-6-8**]), no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: firm, distended, bowel sounds present, baclofen pump in
RLQ, some tenderness to palpation in bilateral lower quadrants,
no rebound or guarding
GU: no foley
Ext: 1+ pulses, no clubbing, cyanosis or edema, LE in braces
Neuro: CNII-XII intact, decreased strength in all extremities,
UE contractions
Pertinent Results:
ADMISSION LABS:
[**2167-6-22**] 05:10PM BLOOD WBC-8.3 RBC-4.40 Hgb-11.8* Hct-37.7
MCV-86 MCH-26.9* MCHC-31.4 RDW-15.3 Plt Ct-288
[**2167-6-22**] 05:10PM BLOOD Neuts-71.2* Lymphs-23.1 Monos-2.5 Eos-2.5
Baso-0.7
[**2167-6-22**] 05:10PM BLOOD Glucose-107* UreaN-10 Creat-0.5 Na-136
K-4.5 Cl-100 HCO3-28 AnGap-13
[**2167-6-22**] 05:10PM BLOOD Calcium-8.5 Phos-4.5# Mg-1.9
[**2167-6-22**] 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
IMAGING:
-[**2167-6-22**] CXR:
CONCLUSION: Likely early developing pneumonia left base.
.
-[**2167-6-22**] KUB:
IMPRESSION: Significant distention of the stomach. NG tube
should be
considered. No free air.
.
EEG pending
Brief Hospital Course:
discharge exam:
98.1 121/73 86-90
making eye contact, answering basic questions
her pain level is unchanged, [**2165-5-14**]
stable neurological exam
data:
dilantin trough: 10.3
Ms. [**Known lastname 805**] is a 46 year old woman with h/o hemorrhagic stroke
with residual spasticity and weakness, seizure disorder,
depression, Hepatitis C, who was brought it by EMS after being
found unresponsive at home, after a suicide attempt
.
ACTIVE ISSUES:
.
# Acute overdose: Likely due to ingestion of Morphine, +/-
Flexeril. Serum tox was negative. No evidence of active
infection. Her mental status quickly improved on Narcan gtt,
which was d/c'd after the pt woke up. We initially held sedating
medications: morphine, seroquel, flexeril, hydroxyzine; but
later restarted seroquel when pt was highly agitated. She also
received tramadol as substitute for morphine for her chronic leg
pain, but then refused this medication. Currently she is on
morphine 5mg PO q6h.
# Depression/Suicide attempt: Patient ingested morphine and
other pills in a suicidal attempt after an argument with her
mother. She continued to be tearful and extremely upset that she
was still alive, and was refusing medications, radiology, and
blood draws. She was maintained on a 1:1 sitter and suicide
precautions. Psych evaluated her on [**6-23**], and recommended haldol
IV prn as well as inpatient psychiatric hospitalization. She
became agitated and yelled out at RN staffing on [**6-28**] and then
received a dose of oral and then a dose of IV haldol. She will
receive further psychiatric care in the inpatient psych setting.
#Chronic Spasticity/Pain: Managed with baclofen pump as an
outpatient and she is followed by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 24792**], at his
office address on [**Street Address(2) 94477**], [**Location (un) 38**], [**Numeric Identifier 34404**]. His phone number is [**Telephone/Fax (1) 94478**].
The chronic pain service here spoke with Dr. [**Last Name (STitle) 24792**] and agreed
to refill her baclofen pump while she is an inpatient at [**Hospital1 18**]
to avoid having her travel to brain tree as she remains on
suidice precautions. However, intrathecal baclofen not
available until [**7-2**] at the earliest. The chronic pain service
is available to refill her pump at [**Hospital1 18**] if she is hospitalized
at DEAC4. They will perform the refill at her bedside when the
baclofen intrathecal dose is available from the pharmacy in the
next few days. They can be paged by typing OUCH into the paging
directory (Contact has been Dr. [**Last Name (STitle) 94479**] [**Name (STitle) **]). Baclofen 5mg PO
TID started to help diminish spasticity, as plan will be to
increase intraethcal dose when it is refilled.
however, If she does not have baclofen pump refill prior to [**7-10**], then the receiving staff should arrange for her baclofen pump
to be refilled on [**7-10**] or [**7-11**] at Dr.[**Name (NI) 94480**] office.
# Seizure disorder: Neurology followed the patient. At her
last discharge she was sent to rehab on 3 AEDs including
dilantin, keppra, and lacosamide. At discharge she was only
continued only on dilantin for unclear reasons. Given lack of
clinical seizure activity during this admission and no seizure
activity on an EEG here, neurology recommended continuing her
only on the dilantin alone and arranging for outpatient
neurology f/u with her epilepsy specialist upon discharge from
her psych admission.
# Abdominal distension/vomiting: Patient initially p/w firm,
tender abdomen on exam, but no rebound or guarding. Per patient,
this is not new, and she had a BM after admission. She had a KUB
with large gastric bubble, ?pill bezoar, urinary retention may
have contributed to her abd discomfort. This improved and she
had no active complaints of this symptom.
# Urinary retention: Has baseline retention from her h/o CVAs
and is being treated with Flomax as an outpatient. Large dose of
narcotics she took may be contributing as well. Patient refused
Foley placement or straight cath after admission. We continued
Flomax. She underwent straight cath on [**6-25**] with 1400 cc of NS.
She began voiding spontaneously on [**6-26**].
.
#Possible Aspiration: CXR with increased LLL opacity, which
could have represented pneumonia vs pneumonitis due to possible
aspiration event while the patient was unresponsive. Given that
the patient had no fever, elevated WBC count, cough, we held on
treating possible PNA.
CHRONIC ISSUES:
# Seizure disorder: continued dilantin, level 10.3 (trough on
[**6-28**])
TRANSITIONS OF CARE:
[]monitor seizure activity and adjust AEDs as indicated
[]further psychiatric treatment
[]continue treatment of chronic leg pain
[]REFILL BACLOFEN PUMP BEFORE [**7-12**] (pain fellow pager OUCH,
Dr. [**Last Name (STitle) **] will arrange for baclofen pump refill on the DEAC4
floor.
Medications on Admission:
Medications: per [**Hospital 38**] rehab d/c med list on [**2167-6-18**]
Morphine 7.5mg PO q4h
Seroquel 25mg PO q6h prn agitation
Celexa 40mg PO daily
Fosamax 70mg PO qweek
Vitamin C 500mg PO q8h
Oscal D
Flexeril 10mg PO q12h
Heparin 5000units SC BID
Hiprex 1mg PO q12h
Nitrofurantoin 50mg PO q6h
Zyprexa 1.25mg PO q12h
Dilantin 100mg PO q8h
Flomax 0.4mg PO BID
Hydroxyzine 50mg PO q6h prn
Zofran 4mg q6h prn
Vitamin D3 1000units PO daily
Acetaminophen 650mg PO q6h prn
Bisacodyl 10mg PR daily prn
Senna 2tab PO qhs
Colace 100mg PO BID
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO BID (2 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
11. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
12. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
13. haloperidol 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
14. haloperidol lactate 5 mg/mL Solution Sig: One (1) Injection
[**Hospital1 **] (2 times a day) as needed for severe agitation.
15. morphine 10 mg/5 mL Solution Sig: One (1) PO Q6H (every 6
hours) as needed for pain.
16. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Suicide attempt
Acute encephalopathy
Seizure disorder
Urinary retention
Discharge Condition:
requires assistance with ADLs.
Discharge Instructions:
You were admitted after a suicide attempt. You improved with
reversal of the morphine medication. You were ultimately
discharged to a psychiatric hospital
TRANSITIONS OF CARE:
[]monitor seizure activity and adjust AEDs as indicated
[]further psychiatric treatment
[]continue treatment of chronic leg pain
[]REFILL BACLOFEN PUMP BEFORE [**7-12**] (pain fellow pager OUCH,
Dr. [**Last Name (STitle) **] will arrange for baclofen pump refill on the DEAC4
floor.
Medication Changes
[]baclofen 5mg TID
[]morphine PRN pain
Followup Instructions:
You can be referred back to dr. [**Last Name (STitle) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 24792**], to
determine any adjustments or management of your pain medication.
His address on [**Street Address(2) 65289**], [**Location (un) 38**], [**Numeric Identifier 34404**] His phone
number is [**Telephone/Fax (1) 94478**]
YOU ARE ADVISED TO HAVE OUTPATIENT PSYCHIATRY/PSYCHOLOGY
FOLLOWUP ARRANGED.
PLEASE SCHEDULE VISIT WITH THE PATIENT'S [**Hospital1 18**] NEUROLOGIST UPON
DISCHARGE, to manage your epilepsy
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Office Phone:([**Telephone/Fax (1) 35413**]
Office Fax:([**Telephone/Fax (1) 94481**]
Patient Location:[**Hospital Ward Name 860**] 4 Comprehensive Epilepsy Center
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2196
} | Medical Text: Admission Date: [**2143-12-11**] Discharge Date: [**2143-12-27**]
Date of Birth: [**2080-6-6**] Sex: F
Service:
CHIEF COMPLAINT: Shortness of breath and weakness.
HISTORY OF PRESENT ILLNESS: The patient is a 62 year old
female with a past medical history of progressive multiple
sclerosis, hypertension, diabetes Type 1, obesity, saddle
pulmonary emboli secondary to deep vein thrombosis,
obstructive sleep apnea. Over the past month she has been
noticing increasing lower extremity weakness with recurrent
falls as well as increasing shortness of breath. Due to
recurrent falls she has been using a wheelchair. Her
multiple sclerosis type is relaxing and remitting and she has
had in the past bilateral optic neuritis requiring multiple
hospitalizations as well as treatment for multiple sclerosis
with Cytoxan, adrenocorticotropic hormone and high dose
steroids. She has never returned to baseline after her
initial flare at age 31. Her multiple sclerosis has also
resulted in the loss of gag reflex with increasing difficulty
swallowing and a baseline very hoarse voice although she has
had no documentation of aspiration pneumonia. Her shortness
of breath is described as progressive and she has significant
dyspnea on even mild exertion. There is no reported
shortness of breath at rest or paroxysmal nocturnal dyspnea
or orthopnea or chest pain. She presented to [**Hospital6 1760**] on [**2143-12-11**] for a
suspected multiple sclerosis flare due to weakness and falls.
A PICC line was placed and she was treated with a nine day
course of high dose steroids. [**Hospital1 **] was called for control
of her diabetes on steroids. Later that day she was felt to
be volume overloaded and in light of her symptomatology she
was started on Aldactone 25 mg b.i.d. p.o. Pulmonary was
consulted to assess her shortness of breath on [**12-14**] and
electrocardiogram was ordered and read as normal. The
patient was ruled out for acute myocardial infarction by
cardiac enzymes. Pulmonary requested pulmonary function
tests which were done and were found to be within normal
limits. FVC was 90%, FEV 1 of 97%, FEV 1/FVC 108%, total
lung capacity of 91% and DLCO corrected for lung volumes of
80% which were read as low normal. The MIP of 67% which was
indicative of mild respiratory muscle weakness. A
computerized tomography scan was ordered to assess for
pulmonary emboli and was read as low probability. Lower
extremity noninvasive studies were read as negative for deep
vein thrombosis. Cardiac echocardiogram showed no
significant abnormality and arterial blood gases taken with
readings of 7.37 pH, pCO2 of 36 and pO2 of 73 on room air.
The patient then underwent a chest computerized tomography
scan and was found to have evidence of severe tracheomalacia
with narrowing of the trachea and main stem bronchi to a near
crescent with partial collapse on inspiration. There was no
evidence of interstitial lung disease. In addition the
patient was found to have acute renal failure with a rise in
creatinine from a baseline of .8 to 1.0 to a peak recorded
value of 1.6 in the hospitalization on [**2143-12-23**].
PAST MEDICAL HISTORY: The patient's past medical history is
significant for multiple sclerosis, diabetes Type 1, obesity,
hypercholesterolemia, hypertension, obstructive sleep apnea
for which she does not use CPAP, saddle pulmonary emboli in
[**2136**] in the setting of hospitalization and deep vein
thrombosis. The hospitalization was secondary to multiple
sclerosis. She has had thoracic herpetic eruptions status
post excision of two benign breast masses and numerous basal
cell carcinomas of the face.
MEDICATIONS ON ADMISSION: Insulin NPH 40 q. AM, 20 q. PM;
Betaseron 1 cc q.o.d.; Pravastatin 20 mg q. PM; Macrodantin
500 mg q. PM; Diazepam 2 mg q.h.s.; Halcion 0.25 mg q.h.s.;
Effexor 112 mg/75 mg; Coumadin 7.5 mg q.h.s.; Baclofen 40 mg
p.o. q.h.s.; Cardizem CD 300 mg p.o. q.d.; Mirapex 0.27 mg
p.o. q.h.s.; Multivitamins; Fibercon; calcium supplements.
ALLERGIES: Penicillin, Sulfa and Tetracyclines, nature of
reactions is unknown.
SOCIAL HISTORY: The patient was a past smoker, she quit many
years ago. She lives with her husband. She is on
disability.
FAMILY HISTORY: She has two other siblings with multiple
sclerosis and there is also significant coronary artery
disease.
REVIEW OF SYSTEMS: She has had no fevers, no nightsweats, no
chest pain, no weight changes, no heat or cold intolerance,
no headache, no urinary symptoms, no change in bowel habits,
no bright red blood per rectum, no melena, no abdominal pain,
no visual changes and no rashes. Positive chronic lower
extremity edema. No paroxysmal nocturnal dyspnea or
orthopnea.
PHYSICAL EXAMINATION: On admission 99.8 temperature, blood
pressure 140/80, heartrate in the 90s, respiratory rate 16,
99% on room air, fasting. Blood sugars were recorded at 120
to 200. General, she is not in apparent distress, morbidly
obese with hoarse voice. Cardiovascular, regular rate and
rhythm, S1 and S2, no murmurs, rubs or gallops. Respiratory,
clear to auscultation bilaterally with mild upper airway
noises. Abdomen, obese, soft, nontender, nondistended,
positive bowel sounds. Extremities, 2+ lower extremity edema
bilaterally. Neurological, alert and oriented times three.
LABORATORY DATA: Laboratory values on transfer to Medicine
revealed white blood cell count of 19.1, hematocrit 30.7,
platelets 224, INR 1.5, sodium 133, potassium 5.4, chloride
106, carbon dioxide 23, BUN 58, creatinine 1.5, glucose 141,
calcium 8.3, magnesium 2.6, phosphate 3.5. Urinalysis had
100 mg/dl of protein, otherwise clear.
HOSPITAL COURSE: (By systems) 1. Multiple sclerosis -
Neurological, the patient was treated with high dose steroids
per routine for multiple sclerosis. Neurology felt that she
responded well. She was taken off Prednisone without a taper
and then due to her electrolyte abnormalities there was worry
of adrenal insufficiency and she was put back on Prednisone
on a short taper. There were no further neurological issues.
2. Shortness of breath - Initial differential for this
patient's shortness of breath included cardiac, coronary
artery disease, pulmonary emboli, pneumonia or interstitial
lung disease, respiratory muscle weakness. Tracheomalacia
was found incidentally on computerized tomography scan as
well as a mild respiratory muscle weakness. As other causes
of shortness of breath and dyspnea were ruled out it is felt
that the patient's shortness of breath is multifactorial
caused by a combination of morbid obesity, tracheomalacia and
respiratory muscle weakness secondary to multiple sclerosis.
The patient's trachea and bronchi were stented open by
Interventional Pulmonology with good effect and no
complications which resulted in a subjective improvement in
this patient's breathing. She was also counseled and given a
nutrition consult for weight loss which should improve her
breathing as well. Hopefully also conditioning at
rehabilitation will improve her exercise tolerance.
3. Fluids, electrolytes and nutrition - Over the course of
the hospitalization the patient had a recent drop in sodium
and increase in potassium. This was most probably secondary
to the patient's starting Aldactone at a relatively high dose
of 25 b.i.d. The patient's Aldactone was discontinued on
[**12-24**]. There was not significant improvement by the
time of dictation on [**12-26**], however, values remain
stable and the patient was asymptomatic. It is probable that
she is having residual electrolyte balancing abnormalities
secondary to the acute renal insufficiency complicated by the
residual effects of Aldactone expected to resolve over time.
3. Acute renal insufficiency - This patient had her Pheno
recorded at 0.6 which is less than 1% which is consistent
with prerenal failure. The patient was not taking p.o. as
well and was diuresed as well during hospitalization for
thoughts of volume overload as the cause of shortness of
breath. The patient was given fluids and her creatinine
promptly responded dropping to less than 1.2 by the time of
discharge.
4. Diabetes - With the help of [**Hospital1 **] attending this
patient's glucose was well controlled throughout the
admission observing no change from her insulin regimen and
this will be followed up as an outpatient.
5. Cardiac - There was no evidence of substantial cardiac or
coronary artery disease in this patient at this time.
6. Pulmonary - Emboli, this patient is maintained on
Coumadin with goal INR of 2. to 2.5. She will be restarted
on Coumadin prior to leaving and bridged with Lovenox at
rehabilitation.
7. Psyche - Her Effexor was continued.
8. Endocrine - This patient's thyroid function was assessed
as a possible cause of the patient's dyspnea and contributing
factor and obesity. TSH was found to be 1.2, within normal
limits.
DISPOSITION: The patient was discharged to rehabilitation
and from there to home with services.
DISCHARGE MEDICATIONS:
1. Maalox 15 to 30 mg p.o. q.i.d. prn
2. Prednisone taper to end in [**2144-1-5**]
3. Mirapex 0.25 mg p.o. q.h.s.
4. Solium one packet p.o. q.h.s.
5. Baclofen 40 mg p.o. q.h.s.
6. Halcion 0.5 mg p.o. q.h.s.
7. Diazepam 2 to 4 mg p.o. q.h.s.
8. Pravastatin 20 mg p.o. q.d.
9. Nitrofurantoin 100 mg p.o. q.d. with dinner
10. Diltiazem extended release 300 mg p.o. q.d.
11. Multivitamins one caplet p.o. q.d.
12. Calcium carbonate 500 mg p.o. b.i.d.
13. Betaseron 0.3 mg subcutaneously q.o.d.
14. Lisinopril 40 mg p.o. q.d.
15. Venlafaxine Effexor 112 mg p.o. b.i.d.
16. Ranitidine 150 mg p.o. b.i.d.
17. Insulin, sliding scale and fixed NPH 40 q. AM and 20 q.
PM
18. Tylenol 325 to 650 mg p.o. q. 4 to 6 hours prn
DISCHARGE DIAGNOSIS:
1. Multiple sclerosis flare
2. Acute renal insufficiency
3. Tracheomalacia
4. Obesity
5. Obstructive sleep apnea
6. Diabetes mellitus Type 1
7. Hypercholesterolemia
8. Hypertension
9. Pulmonary emboli
CONDITION ON DISCHARGE: Good.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 1737**]
MEDQUIST36
D: [**2143-12-26**] 14:15
T: [**2143-12-26**] 14:39
JOB#: [**Job Number 32149**]
ICD9 Codes: 5849, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2197
} | Medical Text: Admission Date: [**2138-10-22**] Discharge Date: [**2138-10-24**]
Date of Birth: [**2068-5-13**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
elective carotid stenting
Major Surgical or Invasive Procedure:
[**Doctor First Name 3098**] stenting
History of Present Illness:
70 yo male with PMH DM, HTN, hyperlipid, smoking, mult strokes
admitted for elective carotid angiography/intervention.
*
Carotid ultrasound in [**Month (only) **] found occlusion of right internal
carotid artery and a high grade stenosis of the origin of the
left internal cartoid artery.
*
Pt denies any neurologic symptoms (visual, slurred speech,
numbness, weakness, other stroke-like sx.
*
In cath lab found occluded [**Country **], focal 90% stenosis of [**Doctor First Name 3098**].
Successful stenting of the [**Doctor First Name 3098**] was performed.
Past Medical History:
NIDDM (diet control)
Non small cell lung cancer 16 yrs ago s/p chemo and XRT
2-3 years ago had EMPYEMA rx??????d with decortication & chest tube
Hematuria 2 weeks ago, now resolved
S/P IVP/cystourethrogram on [**2138-9-24**]
COPD
s/p cardiac stent
h/o pseudomona sepsis [**4-29**]
hypercholesterolemia
HTN
Social History:
+ Cigs (now smokes 1/2ppd (previously [**1-28**])for 50years) still
smoking, occasional alcohol, no illicit drugs. lives with wife
on farm, owns bed and bkfst.
Family History:
dad ?; mom died of pneumonia, (+) HTN; daughter- HTN
Physical Exam:
VS: t98, p80, 120/80
Gen: NAD, pleasant
HEENT: PERRL, EOMI, clear OP
Neck: supple, no LAD
CVS: RRR, nl s1 s2, no m/g/r, distant heart sounds
Lungs: CTAB, no c/w/r
Abd: soft, NT, ND, +BS
Ext: no c/e/e
Neuro: CN2-12 intact, [**4-30**] upper and lower extremity strength,
sensation intact to light touch
Pertinent Results:
[**2138-10-23**] 05:57AM BLOOD WBC-8.4 RBC-4.15* Hgb-12.3* Hct-35.4*
MCV-85 MCH-29.6 MCHC-34.7 RDW-14.4 Plt Ct-196
[**2138-10-23**] 05:57AM BLOOD PT-12.6 PTT-25.9 INR(PT)-1.0
.
[**2138-10-22**] 08:56PM GLUCOSE-84 UREA N-26* CREAT-0.9 SODIUM-135
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12
[**2138-10-22**] 08:56PM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-1.8
.
[**2138-10-22**] Cardiac cath:
1. Access was retrograde via the right CFA to the selective
subclavian,
carotid, and vertebral arteries.
2. The thoracic arch was Type I without significant disease.
3. Subclavian arteries: The RSC was normal. The LSC had mild
disease
without lesions.
4. Carotid/vertebrals: The RCCA was normal. The [**Country **] was
occluded.
The right vertebral was normal. The right vertebral filled the
cerebellar and basilar sytems and the right MCA via the PCOM.
The left
vertebral was without lesions. The [**Doctor First Name 3098**] had a focal 90% lesion.
The
ICA filled the ACA/MCA with contralateral filling of the ACA.
5. Successful stenting of the [**Doctor First Name 3098**] was performed with a tapered
[**10-2**] x
30 mm Acculink stent.
6. Angioseal of the right groin was performed.
FINAL DIAGNOSIS:
1. Occluded [**Country **].
2. Severe stenosis of [**Doctor First Name 3098**].
3. Stenting of the [**Doctor First Name 3098**].
4. Angioseal of groin.
Brief Hospital Course:
1. [**Doctor First Name 3098**] stenosis. Pt had a left carotid stent placed without any
complications. He was initially started on neosynephrine given
risk of hypotension with disruption of baroreceptors. He was
gradually weaned off of neo for SBP between 95-140. Serial neuro
checks were normal. Pt was continued on Plavix.
*
2. CAD: No active issues. Pt was continued on asa, bb, ace,
statin.
*
3. DM: No active issues. Pt was continued on amaryl
*
4. COPD: Pt was continued on home inhalers.
Medications on Admission:
NIDDM, HTN, CAD ([**4-29**]:s/p PCI x 2,cypher to LAD and taxus to
RCA), hyperlipid,COPD, hematuria 2 weeks ago (s/p
IVP/cystourethrogram), non-small cell lung cancer
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. 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*
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-27**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*3*
5. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Disp:*1 1* Refills:*3*
7. Amaryl 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
L internal carotid artery stenosis
Discharge Condition:
Stable
Discharge Instructions:
Restart your home medications.
call Dr. [**First Name (STitle) **] to schedule a follow-up appointment
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **]
ICD9 Codes: 496, 4019, 2724, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2198
} | Medical Text: Admission Date: [**2173-4-12**] Discharge Date: [**2173-4-14**]
Date of Birth: [**2173-4-9**] Sex: F
Service:
HISTORY: Thirty-seven and 6/7 weeks female infant
transferred to the Neonatal Intensive Care Unit on day of
life three for duskiness during feeding.
Infant born at 37-6/7 weeks gestation to a 21-year-old
gravida 2, para 1 mother with negative prenatal screens, which
were blood type A positive, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, GBS negative, and positive chlamydia. Admitted in
spontaneous labor. Cesarean section for nonreassuring fetal
heart tracing. Apgars were 8 at 1 minute and 8 at 5 minutes.
Birth weight of 2315 grams (borderline small for gestational
age). Admitted to nursery with temperature of 95.7, but
readily warmed under double-warming lights. Variable feeding
quality at breast. Normal blood glucoses. Weight on
admission: 21/85 grams (up 1 ounce). Evaluated for nasal
stuffiness and earlier on date of admission with duskiness
with feeding. Nasal congestion noted on admission to the
Neonatal Intensive Care Unit.
PHYSICAL EXAM ON ADMISSION: Exam remarkable for well
appearing term infant in no distress with pink color, soft
anterior fontanel, intact palate, normal facies, and no
grunting, flaring, or retracting, clear breath sounds, no
murmur, present femoral pulses, flat, soft, and nontender
abdomen without hepatosplenomegaly, normal external
genitalia, stable hips, normal tone/activity, and normal
perfusion. Birth weight 2315 grams (10th percentile).
Length 46 cm (25th percentile). Head circumference 32 cm
(25th percentile).
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Infant has remained in room air throughout
this hospitalization. Duskiness during feeding and signs
consistent with nasal congestion. No evidence of significant
nasal airway obstruction as evidenced by feeding tube passage
via [**Last Name (LF) 50847**], [**First Name3 (LF) **] intermittent nature of finding. Infant has not
had any apnea or bradycardia this hospitalization.
Respiratory rates have been 30s-60s with oxygen saturations
greater than 95%. Infant has not had any further
desaturations this hospitalization.
2. Cardiovascular: Infant has remained hemodynamically
stable, no murmur, heart rate 110-150s.
3. Fluids, electrolytes, and nutrition: Infant has been
breast-feeding adlib and taking Enfamil 20 calories p.o.
adlib. Normal urine output, stooling q.s. Electrolytes on
admission were a sodium of 143, chloride 108, potassium 3.5,
CO2 of 20. The current weight is 2275 grams.
4. GI: Infant did not receive phototherapy this
hospitalization. The most recent bilirubin level on [**4-12**] was a total of 8.1 with a direct of 0.4.
5. Hematology: A CBC, differential, and blood culture were
drawn on admission. The CBC showed a hematocrit of 58%. The
infant did not receive any blood transfusions this
hospitalization.
6. Infectious disease: Blood culture was drawn on admission.
No antibiotics were started. The CBC on admission showed a
white blood cell count of 10, hematocrit 58%, platelets
209,000, 69 neutrophils, 0 bands, 27 lymphocytes. Blood
cultures remained negative to date.
7. Neurology: Normal neurologic exam.
8. Audiology: Hearing screening was performed with automated
auditory brain stem responses. Results are
9. Ophthalmology: Infant does not meet criteria for eye
exam.
10. Psychosocial: [**Hospital1 69**]
Social Work involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable on room air.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: [**Street Address(1) **].
Phone number [**Telephone/Fax (1) 53078**].
CARE RECOMMENDATIONS: Feedings at discharge: Enfamil 20
calories/ounce or breast-feeding p.o. adlib.
MEDICATIONS: None.
STATE NEWBORN SCREEN: Was sent on [**2173-4-12**]. Results
are pending.
IMMUNIZATIONS: Infant received hepatitis B vaccine on [**2173-4-13**].
FOLLOW-UP APPOINTMENTS: Primary pediatrician and Visiting
Nurses Association.
DISCHARGE DIAGNOSES:
1. Full-term female, borderline small for gestational age.
2. Status post mild respiratory distress.
3. Status post rule out sepsis, ruled out.
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Last Name (NamePattern1) 43219**]
MEDQUIST36
D: [**2173-4-13**] 23:31
T: [**2173-4-14**] 05:58
JOB#: [**Job Number 53079**]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2199
} | Medical Text: Admission Date: [**2117-7-12**] Discharge Date: [**2117-7-21**]
Service: THORACIC SURGERY
CHIEF COMPLAINT: Presyncope.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 46**] is a 78 year-old
woman with severe aortic stenosis who presents with syncopal
episodes. Upon admission echocardiogram was performed, which
revealed critical aortic stenosis of 0.6 cm with increased
peak gradient of 58 mmHg and increased mean gradient of 35
mmHg. Ms. [**Known lastname 46**] was subsequently taken for cardiac
catheterization, which revealed severe aortic stenosis with
calcification of the annulus. The catheterization also
showed severe coronary artery disease with 75% left anterior
descending coronary artery and 100% right coronary artery
occlusion. The left subclavian artery was occluded. Given
these results Ms. [**Known lastname 46**] was evaluated for cardiac surgery.
PAST MEDICAL HISTORY: 1. Hypertension. 2. Paroxysmal
atrial fibrillation. 3. Anemia. 4. Macular degeneration.
5. Right knee replacement.
SOCIAL HISTORY: No smoking or ethanol use.
FAMILY HISTORY: Positive for diabetes mellitus. Her father
had a stroke.
MEDICATIONS: 1. Digoxin 0.125. 2. Aspirin 325 mg q.d. 3.
Minipress 2 mg b.i.d.
ALLERGIES: 1. Codeine. 2. Tenormin. 3. Vasotec. 4.
Cardizem. 5. Procardia.
REVIEW OF SYSTEMS: Negative unless otherwise stated above.
PHYSICAL EXAMINATION: Vital signs blood pressure 120/80 in
the left arm, 160/80 in the right arm. Pulse 68.
Respirations 20. The patient is afebrile. On examination
head is normocephalic, atraumatic. Neck is supple with no
bruits. Chest heart is regular rate and rhythm with a
systolic murmur. Lungs were clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended with
normoactive bowel sounds. Extremities are without clubbing,
cyanosis or edema.
HOSPITAL COURSE: Ms. [**Known lastname 46**] was taken to the Operating Room
on [**2117-7-16**] for a coronary artery bypass graft times
three and aortic valve replacement. Coronary artery bypass
graft included saphenous vein graft to AOA, saphenous vein
graft to obtuse marginal one, saphenous vein graft to
posterior descending coronary artery. Aortic valve was
replaced with a CE 21 mm Bovine tissue valve. Ms. [**Known lastname 46**]
[**Last Name (Titles) 8337**] the operation well and was subsequently transferred
to the cardiac Intensive Care Unit. In the Intensive Care
Unit she was weaned off drips and hemodynamically monitored.
She was extubated on postoperative day one. Chest tubes were
discontinued on postoperative day two. Ms. [**Known lastname 46**] did have
some episodes of confusion, but these resolved without
intervention. Also during her Intensive Care Unit stay Ms.
[**Known lastname 46**] developed episodes of atrial fibrillation, which were
controlled with Amiodarone. On postoperative day three Ms.
[**Known lastname 46**] had been adequately fluid resuscitated. She was
hemodynamically stable. She was felt in good condition to be
transferred to the floor.
While on the floor Ms. [**Known lastname 46**] continued to improve. She was
ambulating with assistance. Her pain was under control and
she was tolerating an oral diet. She did have a urinalysis,
which was consistent with a urinary tract infection and she
was subsequently placed on Bactrim and will complete her
course following discharge. After three uneventful days on
the floor Ms. [**Known lastname 46**] was felt ready to be transferred to a
rehabilitation facility.
PHYSICAL EXAMINATION ON DISCHARGE: Vital signs temperature
99.1. Pulse 72. Blood pressure 111/57. Respiratory rate
20. O2 sat 97% on room air. Heart was regular rate and
rhythm. Lungs were clear to auscultation bilaterally.
Abdomen was soft, nontender, nondistended with normoactive
bowel sounds. Extremities were remarkable for 1+ bilateral
lower extremity edema. Her incisions were clean, dry and
intact.
DISCHARGE MEDICATIONS: Amiodarone 200 mg q.d., Lasix 20 mg
po q day for four days, K-Ciel 20 milliequivalents po q day
times four days, aspirin enteric coated 325 mg po q day.
Docusate 100 mg po b.i.d. as needed. Metoprolol 12.5 mg po
b.i.d. Acetaminophen 325 to 650 mg q 4 to 6 hours as needed
for pain. Bactrim double strength one tab po b.i.d. for two
days.
FOLLOW UP: Ms. [**Known lastname 46**] should follow up with Dr. [**Last Name (STitle) 1537**] in four
weeks. He should follow up with Dr. [**Last Name (STitle) **] in three to four
weeks.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: The patient is to be discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSIS:
Status post coronary artery bypass graft times three and
aortic valve replacement.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Doctor First Name 24423**]
MEDQUIST36
D: [**2117-7-21**] 11:05
T: [**2117-7-21**] 12:43
JOB#: [**Job Number **]
ICD9 Codes: 4241, 5990, 4019 |
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