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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2400
} | Medical Text: Admission Date: [**2117-4-30**] Discharge Date: [**2117-5-2**]
Date of Birth: [**2046-12-1**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Back and bilateral lower leg pain
Major Surgical or Invasive Procedure:
Axillary bifemoral bypass graft with PTFE
History of Present Illness:
The patient is a 70 y/o F with known h/o AAA who has had
increasing lumbar and bilateal lower extremity [**Last Name (un) **] for 1.5
months. She has had recent accelerating with progression of her
symptoms. Pt reports pain, numbness, back pain, and cool
mottled extremities below the waist.
Past Medical History:
HTN, AAA x 5 cm, Chronic lower back pain
Social History:
Pt is married with children
Family History:
Non contributory
Physical Exam:
HR 94 BP 126/78
Elderly woman in pain. Speaks appropriately.
RRR
CTAB
Abd soft, nontender, no hernias
Palpable radial pulses bilaterally
R femoral pulse -- None
L femoral pulse -- Weak
R > L leg mottled
Legs cold
Brief Hospital Course:
Pt was taken from the ER straight to the operating room where an
emergent R axillary-bifemoral bypass graft was performed with
PTFE to restore blood flow to the lower extremities after an
acute aortic occlusion. Postopreatively, the patient initially
did well. She was quickly extubated. Within a short amount of
time the patient began to have problems maintaining adequate
blood pressure requiring the use of pressors. She was found to
have an acute metabolic acidosis for which the patient was
placed on a bicarbonate drip. Over the course of the next 12 to
18 hours the patients condition worsened. A swan ganz catheter
was placed to better monitor the patient's needs. She was found
to have low SVO2's, High SVR's, low PAD's/CVP's/Wedges. The
patient was bolused many liters of fluid. Because the patient's
cardiac output/index were low she was tried on milrinone. This
did not in effect help. It only made her tachycardic.
Meanwhile the patient began to have respiratory distress.
Emergent tracheostomy was performed as endotracheal intubation
was not an option due to pharyngeal edema. Persistent lactic
acidosis and developing renal failure then prompted consultation
with the general surgery service. The patient was then taken to
the OR for abdominal exploration. The patient had ischemic
right colon but it did not appear dead. No resection was
performed. Furthermore, the pt's hemodynamics improved with
abdominal decompression indicating abdominal compartment
syndrome. Over the next day the patient required large amounts
of fluid and began to develop further problems with hemodynamic
stability. In the early morning of [**2114-5-2**] the patient was being
turned and became suddenly unable to be ventilated. The patient
was amboo'd. Airway resistence was strikingly high.
Auscultation revealed decreased breath sounds on the L lung
field. An emergent chest tube was placed with immediate
drainage of about 1400 cc of serosanguinous fluid. CO2
detectors were used to insure CO2 exchange which was confirmed
present. A stat blood gas showed a PCO2 in the 20's and a PO2
in the 200's. Meanwhile, the pt began to brady down and become
asystolic. CPR was performed for approximately 20 minutes while
numerous chemical modalities were tried to revive the patient.
Ultimately we were unsuccessful, and the patient was declared
dead at 443 am on [**2117-5-2**].
Medications on Admission:
Lipitor, Tamoxifen, Motrin, Atenolol, HCTZ, ASA
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Aortic occlusion
Axillary bifemoral bypass graft with PTFE
Ischemic colon
Respiratory failure
Cardiac arrest
Metabolic acidosis
Abdominal compartment syndrome
Pleural effusion
Shock
AAA
Mesenteric ischemia
Exploratory laparotomy
Coagulopathy
Acute renal failure
Discharge Condition:
Deceased
Discharge Instructions:
Post mortem exam requested by family
Followup Instructions:
None
ICD9 Codes: 5849, 2762, 5119, 4019, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2401
} | Medical Text: Admission Date: [**2170-4-8**] Discharge Date:
Date of Birth: [**2170-4-8**] Sex: M
Service:
The child is being transferred to [**Hospital3 28900**] on
[**2170-4-23**].
HISTORY: This infant was a 39-3/7 week 3505 gram male infant
born to a 28 year old Gravida 3, para 0-1 woman with serology
treated with several doses of antibiotics prior to delivery.
She had a prenatal ultrasound which showed echogenicity on
the liver. On delivery there was meconium and nuchal cord
times one. The membranes were ruptured only for 9 hours. The
infant was delivered by vacuum assistance with Apgars of 8
and 9. The child had a bath in Labor and Delivery and a
temperature of 97.1. At 2 hours of life the infant went to
hypothermia resolved with heat lamps but the child had poor
feeding and a dextrose stick of 10. The infant was admitted
from normal newborn and had a repeat dextrose stick of 14 and
received an infusion of D10-W after a bolus of 3 cc's of
D10-W per kilo for hypoglycemia.
ADMISSION EXAMINATION: Weight was 3505 in the 75% percentile,
length was 21-3/4 cm, head circumference 35 cm. The infant
was vigorous, non-dysmorphic, anterior fontanel open and flat
with a positive caput. Palate was intact. Respirations were
unlabored. Breath sounds clear and equal. The infant had
regular rate and rhythm. No murmur, was pink and well perfused.
Femoral pulses were 2+ equal. The abdomen soft without
distension. There were positive bowel sounds. Both testes were
descended, normal male genitalia. There was a mongolian spot
over the buttocks. The infant had a negative hip exam. Anus was
patent. There was some mild jitteriness.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS
1. Respiratory. The infant was in room air since birth with
a respiratory rate in the 30 to 50's, no issues. A blood gas
on [**4-12**] was 7.37/38/94/27 and negative 2 for the base
access.
2. Cardiovascular. There were no murmurs. Heart rate runs
from the 120's to 140's. Blood pressure 60 to 70/30 to 40
with mean 45 to 57. No issues.
3. Fluid, Electrolytes and Nutrition: The infant breast fed
with supplementation of breast milk or Enfamil 20 when the
mother was not present. On admission an intravenous of D10-W
was begun at 80 cc's per kg per day. The infant had
persistent hypoglycemia. On day of life two we attempted to
wean the intravenous rate down to 20 cc's per kg and the
infant had a dextrose stick of 33. We went up on the glucose
infusion to 40 cc's per kilo and also added an additional two
calories per ounce to the formulary breast milk and the
infant was placed on q 3 hour feedings. On day four of life
we again attempted to wean the intravenous rate down to 20
cc's per day and the dextrose sticks went down to 27. We
increased to 40 cc's per kilogram at that point. We were
successful in discontinuing the intravenous on day of life
five and on day of life seven the infant was switched to 20
calorie formula.
Metabolic and endocrine consults were requested for persistent
hypoglycemia. The electrolytes on day of life four which was
on [**4-12**] were sodium 134, potassium 3.7, chloride 101, CO2 20.
Metabolic workup was initiated on day of life four. There
was no metabolic acidosis by the blood gas and CO2 was in
normal range on the electrolytes. The infant had an ammonia
initially of 165 and that was decreased to 118 on [**4-17**], day
of life 9. A state screen was sent on [**4-11**] and that was
within normal limits. The Cortisol level was less than one
on [**2170-4-19**]. T4 was 7.5, TSH results pending. 17
HydroxyProgesterone was 13.5 by the State Screen. The calculated
TBG was 1.07. The uptake was 0.84, the calculated FTI was 6.3.
The insulin level was less than 2. Growth hormone was 3 on [**4-18**]
and two on the [**4-19**]. Results were consistent with a
panhypopituitarism of undetermined etiology. Final results for
cranial MRI completed on [**4-20**] are pending at the time of
dictation.
Gastrointestinal: The infant had a liver scan on [**4-13**]
which was normal. There was no echogenicity seen at that
time. The infant was started on triple bank phototherapy on
day of life four for a bilirubin of 22/0.5. Phototherapy was
discontinued on day of life six and a rebound bili later that
day was 11.5/0.3. The latest bilirubin on [**2170-4-19**] was
11.9/0.4.
Hematology: The infant required no transfusion and had no
type or cross match done. The initial hematocrit was 46.8
with a platelet count of 197.
ID: The blood culture done on admission on [**4-8**] was negative
for 48 hours and the child was never started on antibiotics.
Initial white blood count was 7.8 with 40 polys and 4 bands.
Neurology: On [**4-20**] he had a head magnetic resonance scan
done which showed an ectopic posterior pituitary secondary to
question of discontinuous pituitary infadibulum. The septum
tosidum was present. The optic nerves were slightly
atrophic. There was no intraorbital lesion seen. The right
orbital globe had significant abnormalities which could be
due to retinal detachment.
At the recommendation of endocrinology we did a workup for
septo-optic dysplasia. The ophthalmology exam on [**4-20**] showed
left hypoplastic optic nerve on the right, there was a
retrolental mass and there was question of a detached retina.
A repeat ophthalmology exam done on [**4-23**] was suspicious for a
right retinoblastoma. The infant was screened for hearing
and passed with the Automated Auditory Brainstem Response
also performed.
[**Hospital1 69**] social work is involved
with the family. The contact social worker is [**Name (NI) **] and she
can be reached at [**Telephone/Fax (1) **].
CONDITION AT DISCHARGE: This child is stable from a
cardiovascular perspective and is on full feeding
with borderline Dextrose sticks, the last one being 56 and is
being treated for pan hypopituitarism. The child is being
transferred to [**Location (un) 86**] [**Hospital1 **] for further evaluation of a
possible right retinoblastoma and continued management of pan
hypopituitarism.
CARE/RECOMMENDATIONS: This infant requires feedings at
discharge of breast milk or Enfamil 20 if the mother is
[**Name2 (NI) 16535**] for breast feeding. The child is on the
following medications:
1.Hydrocortisone, 2 mg every morning and 1 mg at evening, that
was switched over today.
2.Synthroid 37.5 mcg every day.
3.The infant is being treated for a monilial rash with Miconazole
powder to the diaper area three times a day.
The infant will be following up with the primary pediatrician who
is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28003**],[**Telephone/Fax (1) 37875**], the Fax #[**Telephone/Fax (1) 49847**]. The
infant will also require follow-up with Endocrine with Dr. [**Last Name (STitle) 49848**],
Extension [**2073**] and Ophthalmology Dr. [**First Name (STitle) **], extension 1486.
We recommend TFTs be repeated in six weeks at the
recommendation of Endocrine and the infant will need ammonia
levels drawn prior to discharge to follow-up on the elevated
levels.
Parents will need extensive training and glucose monitoring,
medication administration and stress dose administration.
DISCHARGE DIAGNOSIS:
1. Term AGA male.
2. Hypoglycemia.
3. Pan hypopituitarism.
4. Resolved hyperbilirubinemia.
5. Detached retina on the right eye.
6. Possible retinoblastoma on the right eye.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Name8 (MD) 49849**]
MEDQUIST36
D: [**2170-4-23**] 16:23
T: [**2170-4-23**] 17:01
JOB#: [**Job Number 49850**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2402
} | Medical Text: Admission Date: [**2107-1-10**] Discharge Date: [**2107-2-1**]
Date of Birth: [**2036-6-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Pericardial drain placement and removal
PEG placement
PICC placement
Intubation/extubation, mechanical ventilation
Thoracentesis X2 (bilaterally)
History of Present Illness:
The patient is a 70 yo man with ho DM2, HTN, and recent
diagnoses of AFib who was transferred from OSH on [**2107-1-10**] for
evaluation of pericardial effusion. Around [**2106-12-17**], pt had
CHF-like symptoms, and he was started on diuretics. Four days
prior to admission patient had new onset Atrial flutter and was
started on Coumadin. On [**12-27**], the patient was admitted to [**Hospital1 3325**] for a worsening dyspnea over 4 weeks. He was intubated
in the ED and transferred to the CCU, where he was started on a
Dilt gtt and was eventually extubated on [**1-6**]. Then pt had AMS,
thought to be metabolic and had a CT-chest showing a large
pericardial effusion and bilateral upper lobe and RML air space
disease. He started Imipenem and continued Levofloxacin. TTE at
that time showed LVEF of 25%. He underwent a TEE with attempt to
cardiovert, but he was found to have an atrial thrombus, so this
was not attempted. He was transferred to [**Hospital1 18**] for further care
and possible pericardiocentesis since effusion appears to
progress. At OSH he also had ARF, hematuria, and anemia (hct
24).
.
On transfer his echo showed tamponade changes and he was
transfered to the CCU for pericardial drainage. Repeat echo [**1-13**]
showed no reaccumulation of fluid. Due to his garbled speech and
dysphagia, neurology was consulted and felt he had a left
parietal cardioembolic stroke (h/o A. fib). After failing S&S
eval, decision has been made to pursue PEG after transfer to the
floor. He was also found to have a pneumonia, so is being
treated with Zosyn. On the floor he has had more agitation and
has been given haldol 1mg and zyprexa 5mg. Then pt became more
somulent and a ABG showed 7.19/92/56 on a shovel mask with 2
liters. HR was in the 80s and BP in 120s. He was transfered to
MICU for airway concern and hypercabic resp failure.
.
On arrival to the MICU he was unresponsive. He did not tolerate
placement of a BIPAP, so was intubated. On intubation he was
noted to have a large amount of material in the thorat, possible
food. He had some transient runs of bradycarida that quickly
recovered to 90s without intervention.
.
Review of Systems: Unable to obtain due to solmulence and
intubation.
Past Medical History:
DM2
HTN
BPH
Congestive Heart Failure
Anxiety Disorder
Atrial Fibrillation
Alcohol dependance and abuse
Social History:
Per OSH medical records, the patient smokes 2 cigars and one
cigarette daily. He drinks a six pack of beer daily. He lives
with his wife.
.
Family History:
Non-contributory
Physical Exam:
GEN: Middle aged man, AAOx1, in NAD
VS: 126/70, P 66, R 16, O2 99% on 4L
HEENT: PERRL, EOMI, Mucous membranes dry
CV: Distant heart sounds. JVD elevated to angle of jaw.
PULM: Coarse breath sounds throughout lung fields bilaterally
ABD: +BS, NT, ND
LIMBS: No edema. 5/5 strength bilaterally
SKIN: No rashes or ecchymoses
NEURO: AAOx1, Moving all extremities. Unable to follow commands.
.
On transfer to the MICU:
Vitals: T: 96.9 BP: 97/38 P: 53-90 R: 19 O2: 97% on bag mask,
then 100% on vent
General: responsive to pain, solument
HEENT: Sclera anicteric, dry MM, OP with debris
Neck: supple, JVP not elevated, no LAD
Lungs: rhonchi B, decreased left breath sounds, no crackles
CV: Regular rate and rhythm, no murmurs, 2+ pulses
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley with clear urine
Ext: warm, well perfused, no clubbing, cyanosis or edema
Pertinent Results:
ADMISSION LABS:
[**2107-1-11**] 03:49AM BLOOD WBC-12.6* RBC-2.82* Hgb-8.8* Hct-26.6*
MCV-95 MCH-31.1 MCHC-32.9 RDW-16.0* Plt Ct-751*
[**2107-1-11**] 03:49AM BLOOD Neuts-76* Bands-1 Lymphs-15* Monos-7
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2107-1-11**] 03:49AM BLOOD PT-27.8* PTT-36.9* INR(PT)-2.7*
[**2107-1-11**] 03:49AM BLOOD Glucose-171* UreaN-114* Creat-2.0* Na-143
K-4.1 Cl-100 HCO3-32 AnGap-15
[**2107-1-11**] 03:49AM BLOOD ALT-32 AST-41* LD(LDH)-288* CK(CPK)-88
AlkPhos-105 TotBili-0.8
[**2107-1-11**] 03:49AM BLOOD Albumin-3.4* Calcium-8.7 Phos-4.8*
Mg-3.3* Iron-43*
[**2107-1-11**] 03:49AM BLOOD calTIBC-229* VitB12-862 Folate-16.0
Ferritn-1190* TRF-176*
-----------------
DISCHARGE LABS:
-----------------
STUDIES:
.
PERICARDIAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes, monocytes, and mesothelial cells.
.
RHCath and Pericardiocentesis:
1. Right heart catheterization prior to pericardiocensis showed
elevation and equalization of diastolic filling pressures
(20-22mmHg) that were similar to the opening pericardial
pressure (19mmHg). Pulsus paradoxus recorded via the a-line
tracing was approximately 20mmHg.
2. Pericardiocentesis was performed with needle entry from the
subxiphoid position. The opening pericardial pressure was 19
mmHg.
3. Subsequent to removal of 920 cc of blood fluid (all sent for
studies) and confirmation by echocardiography of complete fluid
removal, the pericardial pressure decreased to -2 to 1 mmHg and
RA pressure decreased to 15 mmHg.
4. Anesthesia was present during the case to manage the
patient's airway given his tenuous respiratory status. He was
maintained on 100% oxygen therapy.
FINAL DIAGNOSIS:
1. Pericardial tamponade with improvement in hemodynamics after
removal of 920 cc of bloody fluid.
2. Pericardial drain in place.
.
CT HEAD [**1-11**]:
There is no evidence of hemorrhage, edema, masses, mass effect,
or infarction. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. The ventricles and sulci are prominent, most
compatible with atrophic change. Note is made of bilateral
atherosclerotic calcification within the carotid siphons. The
visualized portions of the paranasal sinuses and mastoid air
cells are well aerated.
.
ECHO [**1-11**] #1:
No atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 10-15mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Overall left ventricular systolic function is low normal (LVEF
50-55%). with borderline normal free wall function. The aortic
valve leaflets are moderately thickened. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. The pulmonary artery systolic pressure
could not be determined. There is a large pericardial effusion.
The effusion appears circumferential. The effusion is echo
dense, consistent with blood, inflammation or other cellular
elements. There is right ventricular diastolic compression,
consistent with impaired fillling/tamponade physiology.
IMPRESSION: Large pericardial effusion with echo evidence of
impaired filling/tamponade physiology.
.
ECHO [**1-11**] #2:
Overall left ventricular systolic function is normal (LVEF>55%).
RV with borderline normal free wall function. There is no
residual pericardial effusion. There are no echocardiographic
signs of tamponade.
Compared with the prior study (images reviewed) of [**2107-1-11**],
pericardial effusion (post tap) has resolved. There is no longer
evidence of RV compression.
.
ECHO [**1-13**]:
The left atrium is moderately 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.
The left ventricular cavity is mildly dilated. Overall left
ventricular systolic function is normal (LVEF 60-70%). Right
ventricular chamber size is normal. with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets are moderately thickened. There
is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
MR head without contrast: There is no acute infarct, hemorrhage,
edema, or mass effect. The ventricles and sulci are prominent,
consistent with age-related atrophy. Scattered T2 hyperintense
periventricular and supratentorial white matter abnormalities
represent mild chronic small vessel ischemic disease.
The patient is intubated. Mild mucosal sinus thickening is seen
in the
bilateral maxillary, ethmoid, and frontal sinuses. The
osteomeatal units
appear patent bilaterally. There is partial opacification of the
bilateral
mastoid air cells.
IMPRESSION: No acute intracranial process.
.
CT chest [**1-19**]: 1. Massive bilateral pleural effusions,
responsible for severe atelectasis of the adjacent lung.
2. Severe aortic valvular calcifications, which represent severe
aortic
stenosis until proven otherwise.
3. Enlarged pulmonary arterial trunk, suggestive of pulmonary
arterial
hypertension.
4. No evidence of aspiration.
.
CT chest [**1-27**]: 1. Substantial improvement in previously large
bilateral pleural effusions,
stable pericardial effusion. No indication of malignant implants
in the
pleural space or development of tamponade.
2. New predominantly right lower lobe pneumonia or hemorrhage.
3. Marked improvement in previous lower lobe collapse.
4. Global cardiomegaly, probable pulmonary hypertension,
probable calcific
aortic stenosis, severe coronary and innominate artery
atherosclerosis.
5. Mild emphysema.
.
ECHO [**1-24**]: The left atrium and right atrium are normal in cavity
size. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. Significant pulmonic regurgitation is
seen. There is an anterior space which most likely represents a
fat pad. There are prominent bilateral pleural effusion.
.
ECHO [**1-28**]: The left and right atrium are moderately dilated. The
estimated right atrial pressure is 0-10mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50%). The
estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size is normal
with borderline normal free wall function. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.2cm2). The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2107-1-24**],
global biventricular systolic function is less vigorous (now low
normal), c/w diffuse process. The heart rate is also slightly
lower.
In the absence of a history of hypertension, an infiltrative
process (e.g., amyloid) should be considered.
Brief Hospital Course:
70 yo man with h/o HTN and recently diagnosed AFlutter who
presented from OSH with pericardial effusion, AMS, and ARF. He
was intubated for 10 days after presentation to OSH. A CT showed
a pericardial effusion and RML PNA. He was transfered to [**Hospital1 18**]
on Imipenem and Levofloxacin for management of the effusion. The
effusion was bloody and large (1L), though he was on
anticoagulation. After extubation, he had AMS with a notable
Wernicke's aphasia with preserved repetition and limited but
largely intact comprehension and direction following. After
failing multiple speech and swallow evaluations, the plan was
for the patient to receive a PEG (once his INR was within
acceptable limits). In the interim, patient was found to have a
pneumonia and was started on Zosyn. He became more agitated on
the Medicine floor, and received Haldol 1mg and Zyprexa 5mg. He
then became somnolent, hypercarbic and acidotic and was
transferred to the MICU where he did not tolerate BiPap, so he
was intubated. Upon intubation, large amounts of tube feeds were
found in his throat, so that his acute respiratory failure was
felt due to his chronic large bilateral pleural effusions in
conjunction with an aspiration event.
.
# Altered Mental Status/CVA/Thrombocytosis: The patient has had
AMS, waxing and [**Doctor Last Name 688**] delirium, since extubation at OSH. EEG
was c/w metabolic encephalopathy, but common metabolic causes
ruled out (normal folate/B12). An urgent head CT was ordered
that did not demonstrate e/o of an acute intracranial process.
Neurology was consulted and was concerned for CVA. Carotid U/S
demonstrated <40% stenosis on L and 40-60% on R. Recommended
MRI, but patient could not tolerate MRI without sedation. Neuro
recommended anticoagulation, speech therapy, outpatient
follow-up. Of note, patient was found to have a right atrial
thrombus on OSH imaging and MRI/MRA once patient was intubated
confirmed periventricular and supratentorial white matter
abnormalities suggestive of cerebroembolic event; this was
consistent with Neurology's findings on physical exam. Patient
also had markedly elevated platelets, which in the setting of
pneumonia can result in a hypercoagulable state (Arch Neurol.
[**2106**];67(1):33-38) resulting in a thrombotic, small vessel CVA.
At the same time, he has thrombocytosis (Platelets between
760-960), possibly myelodysplastic in origin, which could also
cause a thrombo/embolic CVA. The workup of essential
thrombocytosis was not pursued inpatient since it is very low
yield (JAK2 mutations being positive in no more than 50% of ET
cases) and the damage (stroke) had already been wrought. The
patient was continued on a heparin drip in the MICU and started
on bridge to Coumadin on [**1-28**], upon transfer back to the
regular floors. At the time of discharge, the patient was taking
6mg of Coumadin with a subtherapeutic INR, compensated by
Heparin gtt.
.
# Respiratory Distress/Pleural effusions: Patient's initial
hypercarbic, respiratory acidotic episode was felt likely due to
the exacerbation of his pulmonary status with the large pleural
effusions by aspiration of food contents. Haldol and Zyprexa may
have also slightly contributed. Patient was trialed on Bipap on
admission to the MICU without significant improvement and was
shortly intubated. Diagnostic thoracentesis showed exudative
processes. Patient was extubated on [**1-22**] after Lasix
diuresis but developed hypercarbic, respiratory acidosis 10
hours later. Etiology unclear - ?flash pulmonary edema as
patient was hypertensive to SBP190s during this vs. tiring off
the ventilator vs. continued significant pleural effusions.
Ultimately, thoracenteses were done bilaterally, removing 3.5-4
liters total. All the fluid studies came back suggestive of
exudative processes. Rheumatology was consulted in the setting
of significantly elevated ESR and CRP but did not feel the
patient had an underlying rheumatologic processes. Repeat CT
chest & a CXR performed on the day of discharge did not show
signs of infection, malignancy or reaccumulation of fluid.
Etiology for patient's large pleural effusions remains unclear
but the patient may benefit from anti-histone serology or
cardiac MRI for further work-up if his effusions recur.
.
Patient also noted to have multiple apneic episodes as long as
20 seconds at a time. Pulmonology was consulted and felt that
the patient's apnea was likely secondary to both a central and
obstructive process. They felt that he was safe for discharge,
but felt he would benefit from a sleep study to further evaluate
the etiology of his apnea and determine whether he could benefit
from CPAP once his delirium improved.
.
#. Pericardial effusion: Patient was transferred to [**Hospital1 18**] for
pericardial effusion and tamponade physiology. Pericardial
drain was placed, and bloody effusion was noted. Pericardial
fluid is negative for malignant cells. No microorganism was
isolated. Repeat TTE demonstrated no reaccumulation of the
effusion, so drain was pulled on [**1-13**]. Repeat ECHOs showed no
reaccumulation of pericardial effusion and patient's physical
exam remained benign. The etiology of his pericardial effusion
remained unclear, possibly due to a viral syndrome given his
concurrent pleural effusions. Repeat ECHO on [**1-28**], after
removal of large pleural effusions (and pericardial effusion),
showed global biventricular systolic function was less vigorous
(now low normal), consistent with a diffuse process. If
patient's hypertension has not been long-standing, amyloidosis
is on the differential and may explain both the pericardial and
pleural effusions (per cardiology). Given the patient's
functional baseline, however, myocardial biopsy was not pursued
as an inpatient. A CXR on [**2-1**] did not demonstrate evidence of
pericardial or pleural effusions.
.
#. Multifocal Pneumonia: The patient was found to have a
suggestion of multifocal PNA on a CT dated [**1-9**]. He was
transferred on Imipenem and Levofloxacin. Given the fact that
the patient was intubated for 10 days, he may have had a HAP,
but sputum cultures from OSH taken on [**1-4**] were negative. CXR
demonstrated bilateral pleural effusions consistent with
overload, but no obvious consolidation. Patient did not spike
during this admission, but temperatures and WBC remained mildly
elevated before normalizing. Upon admission to [**Hospital1 18**], he was
treated with Zosyn for 8 day course from [**1-10**], last day [**1-20**]
(given aspiration found when intubated). A PEG was ultimately
placed with good effect while patient was intubated. Of note,
multiple blood, urine and sputum cultures were drawn which were
all no growth to date for an infectious etiology to his
symptoms. Patient's EBV/CMV were also negative for acute
infection.
.
#. Atrial Flutter/Atrial Fibrillation: Patient was initially in
atrial flutter, but later during this hospital stay, he was in
and out of atrial fibrillation. His RA thrombus noted at OSH is
a contraindication to cardioversion. Digoxin & Cardizem were
held and Metoprolol was continued. He was anticoagulated with
Coumadin after pericardial drain was pulled. Patient had a
number of bradycardic episodes initially while in the MICU that
Cardiology felt was due to a vasovagal response to ETT
placement. These episodes resolved, but he also had intermittent
episodes of AF with RVR that responded to IV Metoprolol. Patient
may benefit from discussions with EP as an outpatient regarding
need for ablation for his AFib or pacer placement if he has
recurrent episodes of bradycardia.
.
# Hypernatremia: Patient's Na was 143 on admission, which went
up to 153 the next day. Urine Osm??????s and electrolytes supported a
hypovolemic hyponatremia. Patient was given free water flushes
with TF. His Na improved on this regimen. Once the PEG tube was
placed, the patient was continued on small volumes of free water
flushes with good effect. His sodium normalized and he was
discharged with serum Na of 140.
.
#. Acute renal failure: The patient's creatinine increased at
the OSH from his baseline of 0.5 to 2.6, in the setting of
extensive diuresis. Cr quickly normalized to baseline after
admission to [**Hospital1 18**]. Upon transfer out of the MICU back to the
floor, patient's creatinine was back to baseline at 0.4 where it
continued to be until discharge.
.
#. Hematuria: The patient was found to have hematuria at OSH
while on anticoagulation, and there was concern for bladder
cancer, given his history of smoking. Urology was consulted and
recommended an outpatient cystoscopy. His hematuria improved
after anticoagulation was held, but resumed with restarting
Coumadin. The patient will need follow up with Urology as an
outpatient and his home Flomax should be restarted prior to
discontinuation of his Foley which was in place at the time of
discharge.
.
#. Anemia: Patient with an anemia on admission. Guaiac was
negative at OSH. B12 and folate were normal. Fe studies showed
19% saturation, Fe 43, and Ferritin 1190, consistent with
ongoing inflammation and possible mild Fe deficiency. Ferrous
Sulfate 325mg PO daily was continued. His hematocrit did
intermittently decrease to lows of 23, felt likely due to the
procedures he underwent. He did not require any pRBC
transfusions while in the MICU or on the medicine floor and was
discharged with a Hct of 24.8.
.
# Hypertension: Patient's home regimen is Lopressor 25mg twice
daily and Nifedipine 30mg daily. While in the hospital, patient
was kept on Amlodipine 10mg daily and his Lopressor was titrated
to 50mg TID. His blood pressures were well-controlled on this
regimen.
.
# Dysphagia: Patient developed dysphagia, likely secondary to
stroke. PEG placed on [**1-18**] without any complications,
but he continued to fail speech and swallow evaluations until
the day of discharge and was recommended to remain NPO.
.
# CODE: Full
Medications on Admission:
Home Medications:
Lasix 40 mg PO daily
Lopressor 25 mg PO BID
Flomax 0.4 mg PO daily
Glucophage 500 mg PO BID
Nifedipine 30 mg PO daily
Coumadin 5 mg PO daily
Ativan 1 mg TID prn
.
Medications on Transfer:
Fluconazole 100 mg PO daily
Imipenem 500 mg PO IV q12h
Levofloxacin 500 mg IV qod
Protonix 40 mg IV daily
Combivent nebulizer qid
Digoxin 0.25 mg via NG daily
Cardizem 90 mg via NG q6h
Lactobacillus 1 pack via NG TID with meals
Metoprolol 25 mg NG TID
Modafinil 200 mg NG daily
Lovenox 100 mg SQ daily
SSI
Zyprexa 7.5 mg IM q4h prn
Reglan 5-10 mg IV q6h prn
Combivent nebulizers q2h prn
Tylenol prn
Colace prn
Milk of Magnesia prn
Zantac 150 mg NG daily prn
Senna prn
Artificial tears 1 gtt each eye prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnoses:
- pericardical effusion/tamponade
- respiratory failure requiring intubation
- stroke
- atrial flutter/atrial fibrillation
.
Secondary diagnoses:
- diabetes
- hypertension
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive, with expressive
aphasia
Activity Status:Bedbound
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname **]. You
were admitted to [**Hospital1 18**] for fluid around your heart. A drain was
placed, which provided sufficient drainage of the fluid. The
drain was pulled out 3 days later after an echocardiogram
confirmed no more accumulation of fluid. Furthermore, you were
treated with antibiotics for your pneumonia. Your heart rhythm
showed atrial flutter / atrial fibrillation, which are
arrythmias coming from the top of your heart. You had some
trouble with your speech and you had some mental status changes,
so you were evaluated by our Neurology service. The Neurology
consult concluded that you had a stroke. You will need to be on
blood thinners for further stroke prevention. You were also
seen by the Speech and Swallow service, who noted that you have
a high risk of aspirations, so a gastric tube was placed by the
Gastroenterology service. You will get tube feeds through this
gastric tube.
Your medications have been changed and are as follows:
Acetaminophen 325-650 mg PO/NG Q6H:PRN pain/ fever
Lansoprazole Oral Disintegrating Tab 30 mg PO/NG DAILY
Metolazone 5 mg PO DAILY
Amlodipine 10 mg PO/NG DAILY
Metoprolol Tartrate 50 mg PO/NG TID
Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes
Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **]
Ferrous Sulfate 300 mg PO/NG DAILY
Senna 1 TAB NG [**Hospital1 **]:PRN constipation
Warfarin 4 mg PO/NG QHS
Followup Instructions:
Please follow-up with a neurologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 162**], MD on
[**2107-2-14**] at 2:00PM. To reschedule, please call:[**Telephone/Fax (1) 44**].
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1617**],
on [**2-16**] at 3:00PM. His offices are located at [**Last Name (un) 85842**]. [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 85843**]. To reschedule, please call:
[**Telephone/Fax (1) 85844**].
Please schedule a pulmonology appointment at your convenience by
calling: ([**Telephone/Fax (1) 513**].
Please scheduled a follow-up appointment with your regular
cardiologist, but if you would like to see a [**Hospital1 18**] cardiologist,
please call [**Telephone/Fax (1) 62**] to schedule an appointment.
ICD9 Codes: 486, 5849, 2760, 2762, 5119, 2859, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2403
} | Medical Text: Admission Date: [**2175-12-11**] Discharge Date: [**2175-12-23**]
Date of Birth: [**2092-8-31**] Sex: F
Service: MEDICINE
Allergies:
Atorvastatin / Celebrex
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 83-year-old woman with chronic diastolic CHF
(LVH, EF 75%), chronic atrial fibrillation on anticoagulation,
severe pulmonary hypertension, diabetes, hypertension,
dyslipidemia, and metastatic thyroid cancer undergoing
cyberknife therapy, who presents to the ED today with complaints
of 20-pound weight gain over the last two weeks and increasing
shortness of breath, dyspnea on exertion, orthopnea, and PND.
She denies any palpitations, presyncope, or syncope. She was
evaluated by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**2175-11-6**], at which
point her digoxin was stopped due to her normal EF and her
Lopressor was changed to Toprol XL and the dose was doubled. She
subsequently has been undergoing CyberKnife therapy for her
metastatic thyroid cancer, completing treatment [**4-16**] today. She
complained of progressive symptoms and was referred in to the ED
for further evaluation.
.
In the ED: VS - HR 130s, BP 80/54, Weight 148lbs (up from
124lbs). Her baseline SBPs are known to be in the 100s. ECG
showed AFib w/ RVR. CXR showed no significant effusion,
pneumothorax, or focal consolidation. She had a shock ultrasound
that was negative and was started on Neosynephrine for her
hypotension. She received Ceftriaxone as empiric coverage given
concern for sepsis contributing to her hypotension and possible
underlying pneumonia. She was seen by the CCU team in the ED and
started on an Esmolol drip and IV Digoxin. Esmolol and
Neosynephrine were titrated up and she received 1 more dose of
IV Digoxin. She was also hypoxic, with room air ABG 7.35/51/61.
She did not tolerate BiPAP so she was transitioned to NRB. She
is being admitted to the CCU for further care.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
PAST CARDIAC HISTORY:
1. Chronic Diastolic Heart Failure: EF 75%
2. Atrial Fibrillation on Coumadin
3. Severe pulmonary hypertension
.
OTHER PAST MEDICAL HISTORY:
4. Type 2 DM: complicated by diabetic retinopathy and peripheral
neuropathy
5. Hyperlipidemia
6. Chronic Lymphedema with multiple lower extremity ulcers
7. Goiter: prior Radioiodine therapy, followed Dr. [**Last Name (STitle) 80040**]
8. GERD
9. Crohn's Disease
10. Cholelithiasis - seen on U/S in past, no previous sx.
11. Achalasia
12. Sleep Apnea: h/o abnormal overnight pulse oximetry, but
large thryoid goiter obstructs depending upon patient position
.
PAST SURGICAL HISTORY:
1. TAH-BSO
2. Tonsillectomy
3. Cataract surgery
Social History:
Widowed. Lives in [**Location 3915**], MA in an apartment by herself. Her
son, [**Name (NI) **] leaves nearby, as do multiple grandchildren. Remote
smoking history, occasional alcohol consumption, no illicit
drugs.
Family History:
Father with coronary artery disease,
Two children and five grandchildren alive and healthy
Daughter with hyperthyroidism
Physical Exam:
VS: afeb, BP= 90s/40s, HR= 110s-130s, RR= 14-18, O2 sat= 96-99%
NRB
GENERAL: WD/WN elderly woman in moderate respiratory distress.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink,
no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with significant JVD to just below the angle of the
jaw. Large firm multinodular mass in the thyroid area. Carotid
upstrokes normal in volume and contour, without bruits. Trachea
is midline but not highly mobile. Tachycardia sensitive to
Carotid Sinus Massage.
CARDIAC: PMI located in 5th intercostal space, anterior axillary
line. Irregularly irregular. Normal S1, widely split S2 w/
prominent P2, no S3 or S4. +[**2-16**] HSM at apex.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
tachypneic but unlabored, mild accessory muscle use. +Crackles
and decreased breath sounds at the bases bilaterally. No rhonchi
or wheezes.
ABDOMEN: +BS, soft/NT/ND. Mildly obese. No HSM or tenderness.
Abd aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: WWP, 2+ pedal edema bilaterally, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] in
compressive wrappings.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: Awake, A&Ox3, mood and affect appropriate. Fluently
conversant w/ no focal neurologic abnormalities.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+ Radial 2+
Left: Carotid 2+ DP 2+ PT 2+ Radial 2+
Pertinent Results:
ADMISSION LABS:
[**2175-12-11**] 11:30AM WBC-4.6 RBC-4.15* HGB-10.5* HCT-33.0* MCV-79*
MCH-25.3*# MCHC-31.8 RDW-17.5*
[**2175-12-11**] 11:30AM GLUCOSE-82 UREA N-72* CREAT-1.4* SODIUM-139
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-27 ANION GAP-16
[**2175-12-11**] 11:45AM PT-26.2* PTT-32.8 INR(PT)-2.6*
.
Cardiac enzymes:
[**2175-12-11**] 11:45AM CK(CPK)-62
[**2175-12-11**] 11:45AM cTropnT-<0.01
[**2175-12-11**] 08:00PM cTropnT-<0.01
[**2175-12-11**] 08:00PM CK(CPK)-49
.
Thyroid labs:
[**2175-12-11**] 08:00PM T4-9.2 FREE T4-1.7
[**2175-12-11**] 08:00PM TSH-0.067*
.
.
Labs on Transfer:
[**2175-12-21**] 05:31AM BLOOD PT-55.3* PTT-37.2* INR(PT)-6.5*
[**2175-12-21**] 05:31AM BLOOD Glucose-177* UreaN-86* Creat-1.5* Na-143
K-4.4 Cl-95* HCO3-38* AnGap-14
.
.
CARDIOLOGY:
.
EKG [**2175-12-11**]
Atrial fibrillation with rapid ventricular response. Right axis
deviation.
Low limb lead QRS voltage. RSR' pattern in lead VI. Persistent
prominent
S waves in the left precordial leads. Modest right precordial
lead T wave
changes. Findings are consistent with right ventricular
hypertrophy/right
ventricular overload. Clinical correlation is suggested. No
previous tracing
available for comparison.
.
TTE [**2175-12-12**]
IMPRESSION: Markedly dilated right ventricle with moderate
global hypokinesis and relative sparing of the basal right
ventricular segments. Preserved left ventricular regional and
global systolic function. Severe diastolic dysfunction. Moderate
to severe pulmonary hypertension. Mild aortic and moderate
mitral regurgitation.
.
.
RADIOLOGY:
CXR ([**2175-12-12**]):
FINDINGS: Large right thyroid masses again appreciated with
calcification and leftward deviation of the trachea. Numerous
rounded masses within the chest bilaterally are again depicted
consistent with known metastatic disease. No significant
effusion or pneumothorax is detected. Double density with regard
to the cardiac shadow is consistent with a large hiatal hernia.
No focal consolidation to suggest pneumonia is detected.
.
CTA Chest ([**2175-12-13**]):
IMPRESSION:
1. No pulmonary embolism. Large pulmonary artery measuring 3.4
cm, greater
than the aorta. The heart is enlarged with large atria
bilaterally, right
ventricle greater than the left, although this has not changed
in appearance since [**8-14**]. Septal thickening consistent with fluid overload.
3. Large pleural effusions, right greater than left, much worse
than in
[**Month (only) **]. Significant right and left lower lobe atelectasis.
4. Numerous metastatic pulmonary nodules as before.
5. Hiatal hernia.
.
CT Chest ([**12-21**]): pending
Brief Hospital Course:
ASSESSMENT AND PLAN: 83-yo woman w/ chronic dCHF (LVH, EF 75%),
chronic A-fib on anticoagulation, severe pulm HTN, DM, HTN, HL,
and metastatic thyroid Ca s/p CyberKnife therapy, p/w 20-pound
weight gain x2 weeks and progressively worsening SOB and DOE,
found to be in A-fib w/ RVR in the ED, hypotensive, and hypoxic,
admitted to the CCU, improved w diuresis and transferred
temporarily to regular floor. Readmitted to CCU for hypercarbic
respiratory failure improved on BiPaP. Diltiazem had been used
for rate control - beta blockers were discontinued given concern
for ?contribution to respiratory decompensation on the floor.
She was empirically started on vancomycin and zosyn for possible
HAP on [**12-20**]. She was transfered to the MICU at the request of
the patient's family.
.
# Hypercarbic/hypoxemic respiratory failure: Multiple potential
etiologies, in part secondary to her hypervolemia as well as
known pulmonary hypertension, cardiogenic pulmonary edema.
Pulmonary consult was following the patient, then the patient
was transfered to the MICU. Considered tapping pleural
effusions, but determined to be technically difficult as the
patient had elevated INR. The patient was aggressively diuresed
with lasix drip. The patient was continued on BiPAP and was
able to be weaned to NC only. Neurology was consulted,
paradoxical breathing could be result of myopathy. However, the
patient decided after much discussion that she desired to have
comfort measures only. The patient was made comfortable,
underwent respiratory arrest and cardiac arrest in minutes
following.
.
#. PUMP: Pt w/ known chronic dCHF (LVH and EF 75%), p/w acute
exacerbation in the setting of afib with RVR. She was
overloaded on exam and was responsive to a lasix drip with
improvement in volume status. TTE showed EF 70-75%, markedly
dilated RV w/ moderate global HK, preserved LV regional and
global systolic function, severe diastolic dysfunction, moderate
to severe pulmonary hypertenion. Given hypotension and mild
acute renal failure, lasix drip was continued with 1-1.5 L net
diuresis daily. Spironolactone was also continued at home dose.
With improvement in her volume status, she was transferred to
the regular floor, however, readmitted to CCU for
hypercarbic/hypoxemic respiratory failure. Pt i/o slightly net
negative, but unable to adequately diurese secondary to
hypotension. Nonetheless, the patient appears volume
overloaded, restarted on lasix gtt yesterday. Continued lasix
gtt, then switched to bolus lasix.
.
# RHYTHM: Pt was noted to have chronic atrial fibrillation, no
previous attempts at cardioversion. She was in a-Fib w/ RVR on
presentation to ED, w/ hypotension as below, in setting of
worsening symptoms since stopping Digoxin and uptitrating Toprol
XL. Low TSH also suggested a contribution of thyrotoxicity
secondary to CyberKnife therapy for thyroid cancer. She was
started on Esmolol gtt which was titrated to max in ED. Also
given IV Digoxin 250mg x 2 in ED. Upon arrival to CCU,
Diltiazem bolus + gtt were started with good effect, and esmolol
was titrated off. No more digoxin was given. Rate was
subsequently well controlled on PO and diltiazem, which were
increased for goal HR <80. Coumadin was continued but INR
became supratherapeutic. Now s/p diltiazem and esmolol drips on
PO diltiazem and metoprolol with HR 90-100. Low TSH suggests
probable contribution from thyrotoxicity likely from CyberKnife
therapy to thyroid cancer. Due to supratherapeutic INR,
coumadin was d/c'd.
.
# CORONARIES: No known CAD, but w/ many risk factors.
.
# HYPOTENSION: Pt w/ SBP 80s-90s in ED in the setting of RVR,
and neosynephrine was started for BP support while on
rate-controlling agents. She continued to mentate well even
though hypotensive. She was briefly febrile, but no infection
was identified and sepsis was considered unlikely. Random
cortisol was high, ruling out adrenal insufficiency as a cause.
Hypotension was attributed to poor forward flow from acute on
chronic diastolic CHF and A-Fib/RVR. Blood pressure improved
with rate control and diuresis. Now low normal BP with
fluctuating mentation. Low UOP on lasix drip, ultrafiltration
was considered.
.
# ACUTE RENAL FAILURE: Likely [**1-15**] poor forward flow from
A-Fib/RVR. Will likely improve with HR control and diuresis.
Urine lytes c/w prerenal physiology. Renal following.
.
# DIABETES: On oral meds at home for glycemic control. ISS while
inpatient.
.
# CROHN'S DISEASE: continued home Pentasa, PPI.
.
# SUPRATHERAPEUTIC INR: Pt on coumadin for a-fib, but INR now >
6, unclear etiology.
.
# ETHICS: Pt was DNR/DNI, but family says pt confused. Patient
says "I want to die" but son wants full code. Had family meeting
with PCP and endocrinology. Ethics following. She has a
tortuous trachea - ENT has eval'd think intubation would not be
problem[**Name (NI) 115**]. Family meetings- pt to remain full code for now and
aggrees to trial intubation if needed. Pt eventually CMO.
Medications on Admission:
- Lasix 60mg PO daily
- Glyburide 2.5mg PO daily
- Lisinopril 2.5mg PO daily
- Lorazepam 0.5mg PO daily
- Pentasa 1000mg PO BID
- Toprol XL 200mg PO daily
- Omeprazole 40mg PO daily
- Spironolactone 25mg PO daily
- Warfarin 5mg PO daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2175-12-26**]
ICD9 Codes: 5849, 486, 4589, 4168, 4280, 2724, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2404
} | Medical Text: Admission Date: [**2101-9-9**] Discharge Date: [**2101-10-7**]
Date of Birth: [**2075-10-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Cervical esophageal perforation
Major Surgical or Invasive Procedure:
1) Repair of cervical esophageal perforation with wide drainage
of the neck
2) Right thoracotomy and exploration and wide drainage of the
mediastinum
3) Placement of percutaneous endoscopic gastrostomy tube
4) Placement of left chest tube
5) Esophagogastroduodenoscopy
6) Flexible bronchoscopy
7) Left thoracoscopy with intrapleural pneumolysis and
evacuation of loculated pleural effusion and empyema
8) Placement of intercostal rib locks-multiple
History of Present Illness:
Mr. [**Known lastname **] is a 25-year-old incarcerated gentleman who was beaten
in a prison fight 4 days prior to presentation in the emergency
room. He complained of diffuse pain but then this worsened to
odynophagia and finally developed neck swelling and crepitus. On
his preoperative studies, a chest CT noted the
presence of pneumomediastinum and air around the cervical
esophagus. There was pleural fluid which looked more complex
than a simple effusion in both pleural spaces. A Gastrograffin
swallow confirmed the location of the tear to be in the cervical
esophagus. There did not appear to be any other esophageal
pathology.
Past Medical History:
Depression
Social History:
Positive for Tobacco, alcohol and marijuana use. He denies
IVDU.
Physical Exam:
On discharge, patient's physical exam is as follows:
Vitals: AVSS
Gen: NAD
HEENT: PERRLA, EOMI, occipital decubitus
CVS: RRR, no MRG
PULM: CTA bilaterally
ABD: soft, NT/ND, +BS
EXT: no CCE
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2101-10-5**] 12:50PM 9.9 3.00* 7.9* 25.4* 85 26.4* 31.2 16.7*
489*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2101-9-19**] 07:33AM 81* 0 7* 9 1 0 0 2* 0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2101-9-19**] 07:33AM 1+ NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**2101-10-5**] 12:50PM 489*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2101-10-5**] 1:54 PM
Reason: eval for interval change, s/p pleural drain d/c [**10-4**]
[**Hospital 93**] MEDICAL CONDITION:
25 year old man with rupt esophagus, 1 pleural drain to bulb
suction s/p loculated bilateral pleural effusions; now w/ some
pain s/p drian pull [**10-4**].
REASON FOR THIS EXAMINATION:
eval for interval change, s/p pleural drain d/c [**10-4**]
CHEST, TWO VIEWS
INDICATION: 25-year-old man with ruptured esophagus.
COMMENTS: PA and lateral radiographs of the chest are reviewed,
and compared with previous study of [**2101-10-2**].
The left chest tube remains in place. There is continued small
left pleural effusion with atelectasis in the left lung base.
Minimal patchy atelectasis is seen at the right lung base. The
lungs are clear otherwise. The heart and mediastinum are within
normal limits.
The tip of the right-sided PICC line is identified in the distal
portion of the right subclavian vein. No pneumothorax is noted.
RADIOLOGY Final Report
ESOPHAGUS [**2101-9-28**] 2:22 PM
Reason: swallow study w/ WATER SOLUBLE CONTRAST ONLY.eval for
esopha
[**Hospital 93**] MEDICAL CONDITION:
25 year old man with esophgeal rupture and repair.
REASON FOR THIS EXAMINATION:
swallow study w/ WATER SOLUBLE CONTRAST ONLY.eval for esophageal
leak.
BARIUM ESOPHAGRAM
INDICATION: 25-year-old man with esophageal rupture and repair.
BARIUM ESOPHAGRAM: Orally administered Optiray contrast was
observed under fluoroscopic guidance passing freely into the
stomach with no evidence for extra luminal extravasation. Thin
barium was then orally administered for better resolution of the
esophagus. There is no aspiration into the airway and no
significant retention in the vallecular or piriformis sinuses.
No structural abnormalities are detected in the region of the
pharynx, cervical esophagus, or mid and distal esophagus. Normal
primary peristaltic contractions. There is no evidence for extra
luminal extravasation of contrast.
IMPRESSION: No evidence for extraluminal extravasation.
RADIOLOGY Final Report
TEETH (PANOREX FOR DENTAL) [**2101-9-28**] 1:59 PM
Reason: abscess
[**Hospital 93**] MEDICAL CONDITION:
25 year old man with poor dentition
REASON FOR THIS EXAMINATION:
abscess
HISTORY: Abscess, ____.
Panorex single view. The mandibular condyles and TM joints are
excluded from this view. There is increased density over the
mental portion of the mandible, obscuring fine bony detail.
There is a broken tooth posteriorly on the right.
RADIOLOGY Final Report
ESOPHAGUS [**2101-9-8**] 8:23 PM
Reason: need swallow study under fluoro to assess for esophageal
[**Doctor First Name **]
Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
25 year old man with
REASON FOR THIS EXAMINATION:
need swallow study under fluoro to assess for esophageal leak
ESOPHAGEAL STUDY
INDICATION FOR STUDY: Evaluate for esophageal leak following
trauma to neck.
A scout film of the upper thorax and neck reveals free air
within the mediastinum. Thereafter, a water-soluble esophageal
study was performed which demonstrates a leak in the upper
esophagus on the right side at the level of the manubrium. Free
extravasation of air and contrast is noted to the right side of
the esophagus at this level with passage of leaked contents both
superiorly and inferiorly tracking along the right side of the
esophagus. The remaining mid and distal esophagus is entirely
normal with no leakage present or mucosal irregularities.
IMPRESSION: Rupture of esophagus on right side at level of
manubrium with leaked contents traveling both superiorly and
inferiorly along the right side of the esophagus. These findings
were communicated immediately to the ordering surgeon Dr.
[**Last Name (STitle) **].
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to Dr.[**Name (NI) 2347**] service at [**Hospital1 18**] via
the ED on [**2101-9-8**]. On that day, he underwent a repair of his
cervical esophageal perforation with wide drainage of the neck,
right thoracotomy, exploration and wide drainage of the
mediastinum, placement of percutaneous endoscopic gastrostomy
tube, placement of left chest tube, esophagogastroduodenoscopy
and flexible bronchoscopy. For details of the procedure, see
operative dictation. He was taken to the SICU post-operatively
intubated and sedated. He was placed on Vancomycin, Zosyn and
Fluconazole as prophylaxis.
Upon presentation, his diagnosis was made via an esophagram
which showed his esophageal rupture was at the level of
manubrium with leaked contents traveling both superiorly and
inferiorly along the right side of the esophagus. A follow-up
esophagram was done on POD 9 but showed a continued leak. He
was therefore kept NPO. This exam was then repeated on POD 20
with resolution of the leak. He was transitioned to sips of
clears on that day and then slowly advanced thereafter; all of
which was well tolerated and without issue. Lastly, he had been
on tube feeds throughout his hospital course and which were
begun on POD 4. He was then cycled starting on POD 23. These
were discontinued on POD 25 given his very good PO intake.
From an infectious disease standpoint, a sputum culture on [**9-11**]
returned positive for Klebsiella and he was additionally placed
on Unasyn. Furthermore, a JP fluid culture from [**9-22**] was also
positive for Klebsiella and he was then switched from Unasyn to
Levofloxacin on [**2101-9-24**] for more narrowed, specific antibiotic
coverage. He, however, continued to spike intermittent fevers
during his initial hospital course despite broad and specific
spectrum antibiotic coverage. He was then taken back to the OR
on [**2101-9-26**] for a Left VATS after two large loculated pleural
effusions were noted on imaging. For details of the procedure,
see operative dictation. His vancomycin was stopped at that
time and he was continued on zosyn, fluconazole and levofloxacin
which will continue for about one month after discharge from the
hospital.
On POD 25, he was deemed fit to return to his Corrections
Facility. He had been afebrile for approximately a
week--beginning a day or two after his left VATS. He was
ambulating without difficulty and was tolerating a regular diet.
He was then discharged in good condition in the care of the
State Corrections System. He is asked to return each week for
follow-up so that his last remaining neck drain may be evaluated
and slowly removed.
Medications on Admission:
Seroquel
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
5. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs ML(s)* Refills:*0*
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*1 qs* Refills:*2*
8. Zosyn 4.5 g Recon Soln Sig: One (1) Intravenous every eight
(8) hours for 4 weeks.
Disp:*1 qs* Refills:*0*
9. Lansoprazole 30 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:*2*
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day) for 2 weeks.
Disp:*1 qs* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Esophageal rupture
Empyema
Discharge Condition:
Good
Discharge Instructions:
Please call Thoracic Surgery/Dr.[**Name (NI) 2347**] office (Thoracic
Surgery) at [**Telephone/Fax (1) 170**] for any post surgical issues.
Left pleural drain remains in place. Zosyn IV, fluconazole po,
levofloxacin po UNTIL left pleural drain discontinued.
Pleural drain to be evaluated by Dr.[**Last Name (STitle) **] on a weekly
basis, until drain discontinued.
Appointment with Dr. [**Last Name (STitle) **], [**2101-10-13**] at 11:00am for
follow-up visit.See details below.
No heavy lifting or exertion for 4- 6 weeks.
Zosyn IV, fluconazole po, levofloxacin po UNTIL left pleural
drain discontinued.
You may take a brief shower(no baths) every 2-3 days. Dry area
near drain well, change dressing daily and after each shower
Followup Instructions:
Patient to be seen by Dr. [**Last Name (STitle) **], [**2101-10-13**] at 11:00am
for follow-up visit at [**Hospital1 69**],
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Location (un) 86**], MA, [**Location (un) 8939**], Thoracic Surgery Clinic.
If this appointment cannot be kept call [**Telephone/Fax (1) 170**].
Completed by:[**2101-10-7**]
ICD9 Codes: 5185, 311, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2405
} | Medical Text: Admission Date: [**2195-8-18**] Discharge Date: [**2195-8-24**]
Date of Birth: [**2176-5-4**] Sex: F
Service: SURGERY
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Trauma: MVC:
L hemo/pneumothorax s/p CT
nondisplaced R iliac fracture
L [**5-20**] rib fxs [**3-20**] flail
grade III splenic laceration
Major Surgical or Invasive Procedure:
chest tube placement [**8-18**]
removal of chest tube [**8-20**]
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
Hope Eu Critical is a 19-year-old woman who was the
unrestrained driver of a car without airbags who hit a tree.
The patient was seen and stabilized at [**Hospital 8641**] Hospital where
she was diagnosed with a left hemopneumothorax, spleen
laceration, pulmonary contusions, right iliac fracture. She
had a left chest tube placed without difficulty, received a
blood transfusion and has been hemodynamically stable during
transport.
Timing: Sudden Onset
Quality: Sharp
Severity: Moderate
Duration: Hours
Location: Left upper quadrant
Context/Circumstances: Status post motor vehicle
collision
Mod.Factors: Worse with Movement
Associated Signs/Symptoms: Hypotension
Past Medical History:
Hypothyroidism
Social History:
Denies Drugs and Smoking
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission: [**2195-8-18**]
Temp: 98.8 HR: 95 BP: 135/85 Resp: 20 O(2)Sat: 100 Normal
Constitutional: Patient is awake, alert and responding to
my questions. She is nontoxic in appearance
HEENT: No evidence of head trauma, pupils are equal and
reactive, Extraocular muscles intact
No cervical bony tenderness
Chest: Lungs are clear bilaterally
Cardiovascular: Normal S1-S2
Abdominal: Her belly is soft, but tender in the left upper
quadrant, no peritoneal signs
Pelvic: Pelvis is stable
Rectal: Normal rectal exam
GU/Flank: No CVA tenderness
Extr/Back: No extremity deformities
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2195-8-22**] 06:20AM BLOOD Hct-23.4*
[**2195-8-21**] 07:15AM BLOOD WBC-7.1 RBC-3.03* Hgb-9.3* Hct-25.3*
MCV-84 MCH-30.7 MCHC-36.8* RDW-13.9 Plt Ct-118*
[**2195-8-20**] 05:59PM BLOOD Hct-24.6*
[**2195-8-19**] 03:57AM BLOOD WBC-11.4* RBC-3.63* Hgb-11.0* Hct-29.8*
MCV-82 MCH-30.3 MCHC-36.9* RDW-14.1 Plt Ct-144*
[**2195-8-18**] 03:45PM BLOOD WBC-17.7* RBC-4.04* Hgb-12.3 Hct-33.7*
MCV-83 MCH-30.5 MCHC-36.5* RDW-14.1 Plt Ct-188
[**2195-8-18**] 01:25PM BLOOD WBC-17.8* RBC-3.79* Hgb-11.8* Hct-32.2*
MCV-85 MCH-31.0 MCHC-36.6* RDW-13.6 Plt Ct-205
[**2195-8-21**] 07:15AM BLOOD Plt Ct-118*
[**2195-8-20**] 09:00AM BLOOD Plt Ct-117*
[**2195-8-18**] 01:25PM BLOOD PT-13.1 PTT-21.7* INR(PT)-1.1
[**2195-8-21**] 07:15AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-140
K-4.1 Cl-105 HCO3-28 AnGap-11
[**2195-8-20**] 09:00AM BLOOD Glucose-99 UreaN-12 Creat-0.7 Na-138
K-4.0 Cl-105 HCO3-27 AnGap-10
[**2195-8-21**] 07:15AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1
[**2195-8-20**] 09:00AM BLOOD Calcium-8.3* Phos-2.0*# Mg-2.0
[**2195-8-18**]: chest x-ray:
IMPRESSION: Left-sided chest tube with likely left hemothorax.
There may be an air component as well when correlated to the
outside imaging. Diffuse opacity in particular in the left lower
lobe likely indicates some element of pulmonary contusion as
well. Mediastinal shift and splaying of the ipsilateral ribs is
worrisome for at least in part tension physiology. Left-sided
rib fractures noted.
[**2195-8-18**]: cat scan of the abdomen and pelvis:
IMPRESSION:
1. Extensive left lower lobe pulmonary contusion and laceration
with a small
residual hemopneumothorax on the left and an indwelling chest
tube as above.
Chest tube repositioning is likely indicated. The trauma surgery
team is
aware.
2. Grade III splenic lacerations as detailed above. There is no
active
extravasation appreciated or significant increase in the
perisplenic
hemorrhage; however, there has been interval increase in the
amount of pelvic
hemoperitoneum identified.
3. Question low grade right renal laceration. Correlate with
hematuria.
Collecting system intact.
4. Deep pelvic linear high attenuation adjacent to the left
aspect of the
uterus. The overall course suggests an accessory uterine vein or
arterial
however, the morphology is slightly irregular and the
possibility of
extravasation from a small injured vessel is raised. The lack of
extravasated contrast from prior imaging is reassuring; however,
in light of the increasing pelvic hemoperitoneum and continued
hemodynamic instability, attention on for further scanning is
advised. This was discussed at length with Dr. [**Last Name (STitle) **] at
approximately 3:00 p.m. on the day of study.
[**2195-8-18**]: angiogram:
IMPRESSION: Left common iliac and splenic arteriograms without
evidence of active extravasation.
[**2195-8-18**]: angiogram:
FINDINGS:
1. Left common iliac arteriogram demonstrated normal anatomy
with no contrast extravasation.
2. Splenic artery digital subtraction angiogram demonstrated
parenchymal
contrast blush in the spleen, corresponding to areas of
post-traumatic
hyperemia. Avascular areas were also noted within the spleen
corresponding to known lacerations. No extra splenic contrast
extravasation was visualized.
[**2195-8-18**]: chest x-ray:
FINDINGS: AP single view of the chest obtained with patient in
supine
position is analyzed in direct comparison with the next
preceding supine chest examination obtained four and a half
hours earlier during the same day. The patient is now intubated
and ETT seen to terminate in the trachea some 4 cm above the
level of the carina. An NG tube has been advanced and reaches
below the diaphragm including its side port. A left-sided chest
tube is in place and has changed its position in comparison with
the next previous study.
Whereas it earlier terminated in the upper hemithorax at the
level of the
fourth and fifth vertebral body, it has now been pulled back and
the tip
points towards the area of the seventh and eighth thoracic
vertebral body. A diffuse haze that was overlying the left
hemithorax on the previous study has regressed but basal density
exists and coincides with the area of previously by chest CT
identified pulmonary parenchymal contusion area. As on the
previous examination, there may be a small left-sided apical
pneumothorax but it has not increased during the latest
examination interval. No new major displacements of the
previously identified left-sided multiple rib fractures.
The right-sided hemithorax appears intact.
[**2195-8-19**]: chest x-ray:
FINDINGS: In comparison to the earlier film, a small
pneumothorax is seen
apically in the left lung. The left chest tube remains in place.
Patchy
opacification of the left base persists; however, it is less
dense than
earlier today.
[**2195-8-20**]: chest x-ray:
FINDINGS: AP single view of the chest has been obtained with
patient in
upright position. Comparison is made with the next preceding
supine chest
examination of [**2195-8-19**]. During the interval, the
left-sided chest tube has been removed. The previously described
hazy density over the left lung base persists and is compatible
with some pleural effusion. The tube has been removed, but no
pneumothorax is identified anywhere in the left hemithorax, and
the apical area is free.
No new pulmonary abnormalities are seen, and no mediastinal
shift can be
identified
[**2195-8-21**]: chest x-ray:
FINDINGS: In comparison to the previous examination this
radiograph is
grossly unchanged. There remains a haziness in the left lower
lung field
which is likely a combination of atelectasis, pulmonary
contusion, and pleural hemorrhage or effusion. The right lung is
grossly clear. Mediastinal silhouette is unremarkable.
Brief Hospital Course:
19 year old female, unrestrained driver, involved in a motor
vehicle accident admitted to the acute care service from an
outside hospital. She sustained a left hemo-pneumothorax for
which a left sided chest tube was placed prior to admission. She
also sustained left sided rib fractures. Radiographic imaging
showed a grade 4 splenic laceration and a right iliac [**Doctor First Name 362**]
fracture. She was hypotensive upon arrival to the emergency
room and her chest tube was replaced. She underwent a cat scan
with iv contrast and experienced shortness of breath and
anxiety. She was subsequently treated with benadryl. Upon
arrival to the intensive care unit, she was intubated for airway
protection and because there was a concern for a contrast
allergy. To further investigate any further bleeding into her
abdomen, she underwent angiography to investigate the possibilty
of a left pelvic bleed and bleeding from the spleen. No
contrast extravasation was noted. She was extubated on [**8-19**]. She
was evaluated by orthopedics for her iliac [**Doctor First Name 362**] fracture and
recommendations made for follow-up in 4 weeks.
Transferred to the surgical floor on [**8-20**]. Her left sided chest
tube was discontinued. She was started on clear liquids with
gradual advancement to to a regular diet. Her pain was
controlled with oral analgesia. She was evaluated by physical
therapy who recommended a walker for ambulation and home
physical therapy. Because she had poor recollection of the
accident, cognitive evaluation is recommended 1-2 weeks after
discharge.
Her vital signs are stable and she is afebrile. Her current
hematocrit is 29 which is elevated from her baseline of 23-25.
She is voiding without difficulty. She is preparing for
discharge home with VNA physical therapy and follow-up visit
with the acute care service, orthopedics, and cognitive
neurology.
Medications on Admission:
[**Last Name (un) 1724**]: levothyroxine
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
2. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain: may cause drowsiness, avoid driving while on
this medication.
Disp:*25 Tablet(s)* Refills:*0*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Trauma: MVC:
L hemo/pneumothorax s/p CT
nondisplaced R iliac fracture
L [**5-20**] rib fxs [**3-20**] flail
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)( walker for support)
Discharge Instructions:
You were admitted to the hospital with after you were involved
in a motor vehicle accident. You sustained a injury to your
spleen and a fracture to the part of your hip. You also
received a bruise to your lungs with a fluid collection for
which you needed a chest tube placed. You were seen by
orthopedics and they determined that you did not need surgery to
repair your hip. As a result of the accident you did sustain
left sided rib fractures. You are slowly recovering and you are
ready to be discharged home with the following instructions:
Because you had a splenic laceration please follow these
instructions:
AVOID contact sports and/or any activity that may cause injury
to your abdominal area for the next 6-8 weeks.
*If you suddenly become dizzy, lightheaded, feeling as if you
are going to pass out go to the nearest Emergency Room as this
could be a sign that you are having inernal bleeding from your
liver or spleen injury.
*AVOID any blood thinners such as Motrin, Naprosyn, Indocin,
Aspirin, Coumadin or Plavix for at least 3-5 days unless
otherwise instructed by the MD/NP/PA.
You also sustained rib fractures from the accident, please
follow these instructions:
Your injury caused left sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
Followup Instructions:
Please follow up with the acute care service in 2 weeks. You
can schedule your appointment 24 hours after you are discharged
by calling #[**Telephone/Fax (1) 600**]. Please let them know that you will
need a chest x-ray prior to your visit.
Please follow up with the Dr. [**First Name (STitle) **] in 1 week. You can
schedule your appointment by calling # [**Telephone/Fax (1) 6335**]
You will also need to follow up with Orthopedics, Dr. [**Last Name (STitle) 2637**]
in [**3-18**] weeks. You can schedule this appointment by calling #
[**Telephone/Fax (1) 1228**]
Completed by:[**2195-8-24**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2406
} | Medical Text: Admission Date: [**2132-5-29**] Discharge Date: [**2132-6-7**]
Date of Birth: [**2055-10-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Atrial flutter ablation & D/C cardioversion ([**2132-5-30**])
Intubation for respiratory distress ([**2132-5-30**])
Left & right heart cardiac catheterization ([**2132-6-2**] & [**2132-6-6**])
Placement of ICD ([**2132-6-4**])
History of Present Illness:
76 y/o man with h/o CAD, s/p MI ([**2107**], [**2131**]), CHF EF 20%, DM, a.
fib/flutter admitted to [**Hospital3 417**] hospital on [**2132-5-21**] for
SOB. Of note, the pt had been admitted to [**Hospital3 417**]
hospital on [**2132-4-26**] with the same complaints. At that time, he
pt was found to be in respiratory distress and was intubated and
diuresed (and extubated 1 day following intubation). His
respiratory decompsensation on [**4-26**] was thought to be due CHF
after missing 2 days of lasix. On [**5-21**], the pt's wife called
911 after the pt became acutely SOB at home. EMS intubated the
pt en route to [**Hospital3 417**] hospital. Again, the pt was
diuresed with rapid improvement, leading to extubation within
days. There was question of PNA, for which he was tx'd with
abx. Myoview stress testing during the admission was reportedly
negative for ischemia. Echo on [**5-22**] showed EF = 10%. Pt found
to be in AFR Creatinine w/ Crt peaking at 2 upon admission but
came back to baseline (thought to be ~1.7). Additionally,
during this admission to [**Hospital3 **], the pt was in afib. (The pt
does not know when his afib started, and has never undergone
electrocardioversion. He was started on coumadin in early [**Month (only) **].)
On [**2132-5-29**], the pt was transferred to [**Hospital1 18**] to undergo EP
evaluation and possible intervention.
.
Upon review of systems, the pt reported that he can walk the
length of the hallway before getting short of breath. He denies
lightheadedness, orthnopnea, PND, leg edema, or ascites. He had
self-limited palpitations yesterday. No current SOB, and is
comfortable and ambulatory on room air.
Past Medical History:
1. a-fib - [**2132-5-13**] INR 3.0
2. CHF EF 20%
- [**2132-4-27**] Echo: EF 20-25% with global hypokinesis, Trace TR, mild
pulmonary hypertension.
- [**2132-5-22**] Echo: severe global hypokinesis and EF of 10% c/w
ischemic cardiomyopathy, mild LA enlargement, RV systolic
function mildly reduced, moderate MR, IVC dilated.
3. MI in [**2107**]
4. LBBB
5. COPD
6. diabetes
7. hyperlipidemia
8. CRI with baseline Cr of 1.7 on [**2132-5-5**]
9. Anemia
Social History:
SH: retired, formerly worked as a carpenter. Has been married
for 33 years with his second wife, has 7 children with his first
wife. [**Name (NI) **] [**Name2 (NI) 1818**], 63 pack years. Rare alcohol use, no
illicit drug abuse history.
Family History:
FH: No h/o CAD, no HTN. grandmother and brother with diabetes.
Brother with laryngeal cancer, mom died of stomach cancer at 73,
father died of aneurysm at 73.
Physical Exam:
Vitals T: 97.0oF HR: 88 BP: 110/50 RR: 16 O2sat: 96% RA
Ht: 5??????9?????? Wt: 154lbs Glucose 465
Gen pleasant, NAD
Derm skin normal coloration and texture for age, nails without
clubbing or cyanosis. No rash. Hair of normal texture for age
HEENT Anicteric. conjunctiva pink. PERRLA, EOMs normal, VFs
full. Oropharynx clear. Mucous membranes moist. Trachea midline.
Neck supple. No cervical LAD, no enlarged or tender thyroid.
Pulm CTAB. No crackles or wheezes
CV JVP 8 cm above the sternal angle at 45&#[**Numeric Identifier 18014**]; elevation.
irregularly irregular pulse, pulsus alternans. normal S1, S2. No
c/m/r/g.
Pedal and radial pulses symmetrical and strong,.
Abd Non-distended. No scars/herniae. +BS. No aortic/renal artery
bruits. Hollow to percussion. S/NT/ND. Liver, spleen not
palpable.
Ext no c/c/e.
Neuro MSE: alert, Ox3. Rest of MMSE not performed
CN: II-XII intact to direct testing.
Sensory: Light touch intact in UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **].
Motor: Good bulk and tone, ROM full and smooth. Strength 5/5
throughout.
Coordination: Gait normal.
Pertinent Results:
[**2132-5-29**] 09:57PM GLUCOSE-358* UREA N-46* CREAT-2.6* SODIUM-135
POTASSIUM-4.8 CHLORIDE-92* TOTAL CO2-31 ANION GAP-17
[**2132-5-29**] 09:57PM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-2.2
IRON-68
[**2132-5-29**] 09:57PM calTIBC-397 FERRITIN-135 TRF-305
[**2132-5-29**] 09:57PM WBC-10.2 RBC-3.27* HGB-10.2* HCT-28.8* MCV-88
MCH-31.1 MCHC-35.3* RDW-14.0
[**2132-5-29**] 09:57PM PLT COUNT-358
[**2132-5-29**] 09:57PM PT-15.5* PTT-27.8 INR(PT)-1.4*
[**2132-5-29**] 09:57PM RET AUT-4.0*
[**2132-6-6**] 11:37PM BLOOD Type-ART pO2-74* pCO2-39 pH-7.48*
calTCO2-30 Base XS-5
[**2132-6-7**] 11:57AM BLOOD Glucose-151*
[**2132-6-7**] 11:57AM BLOOD Hgb-8.7* calcHCT-26 O2 Sat-62
[**2132-6-6**] 05:08AM BLOOD freeCa-1.04*
[**2132-6-6**] 10:02PM BLOOD CK(CPK)-1035*
[**2132-6-7**] 06:02AM BLOOD CK-MB-38*
[**2132-6-7**] 06:02AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7
[**2132-6-7**] 06:02AM BLOOD Glucose-182* UreaN-15 Creat-1.9* Na-137
K-3.6 Cl-97 HCO3-30 AnGap-14
[**2132-6-7**] 06:02AM BLOOD WBC-11.1* RBC-2.88* Hgb-8.9* Hct-25.1*
MCV-87 MCH-30.8 MCHC-35.3* RDW-14.7 Plt Ct-398
.
TTE [**2132-5-30**]:
1. The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The left atrial appendage emptying velocity is
depressed (~0.2m/s). No atrial septal defect is seen by 2D or
color Doppler.
2.The left ventricular cavity is dilated. Overall left
ventricular systolic function is severely depressed 15-20%.
3.There are complex (>4mm) 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 structurally normal. Moderate
(2+) mitral
regurgitation is seen.
6.There is no pericardial effusion.
.
Cardiac Cath [**2132-6-2**]:
COMMENTS:
1. Selective coronary angiography of this left dominant system
revealed
a one vessel coronary disease. The LMCA was without flow
limiting
stenosis. The LAD was a large vessel that gave rise to three
diaginal
branches. Proximal LAD had a diffuse 40% stenosis with a
superimposed
90% focal stenosis before a take off of a major diagonal branch
(D3).
The LCx was a dominant vessel with a 30% proximal stenosis and a
30%
stenosis of OM3. The RCA was a small non-dominant vessel with a
mild
diffuse disease throughout.
2. Left ventriculograhy was deferred given renal insufficiency.
3. Resting hemodynamics revealed a moderately high left sided
filling
pressures with a PCWP of 18. The CI was 2.47.
3. The proximal LAD lesion was predilated with a 2.5 x 15
maverick
balloon and stented with a 3.0 x 28 balloon. The final angiogram
showed
TIMI III flow with no residual stenosis, no dissection, no
embolisation
and no perforation (see PTCA comments)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Moderately elevated left sided filling pressures.
3. Successful PTCA/stent of the proximal LAD with excellent
result.
Brief Hospital Course:
I would like to mention at the onset that the patient has
refused further care during this hospitalization and wants to go
home. Fllowing is his brief hospital course:
Upon arrival to [**Hospital1 18**], the pt underwent TEE followed by electric
cardioversion and Aflutter albation. Post procedure, the pt was
transferred to the floor and was noted to be agitated by wife.
[**Name (NI) **] became hypertensive with SBP in 180s, tachypnic & hypoxemic.
He was intubated, given IV lasix and nitro gtt and transfered to
the CCU. After receiving lasix, the pt diuresed well and showed
rapid improvement. No other cause of resp distress was found,
other than acute pulmonary edema. Thus, he was extubated the
following day.
24hrs s/p extubation the pt became anxious & SOB again,
progressing to respiratory distress. He was found, as before,
to be in acute pulmonary edema. Intubation was averted after
giving morphine, nitro gtt, lasix, ativan and starting BiPAP.
On [**2132-6-2**], pt underwent right & left heart cath with PTCI of
LAD with drug eluting stent placement. On [**2132-6-4**], the pt
underwent ICD placement. Despite medical therapy & the above
interventions, the patient continued to have repeated episodes
of acute pulmonary edema, each episode treated with morphine,
lasix, ativan, +/- nebulizers and BiPAP, avoiding intubation in
each instance. These episodes of acute (or "flash") pulmonary
edema were triggered in some cases by a small to moderate volume
load (for cardiac catheterization, for instance); however, other
episodes were triggered by seemingly inocuous causes such as
transfering onto a bed pan. The pt expressed the desire to not
be intubated again, though he wants to have BiPAP therapy should
he develop respiratory distress again. After discussing his
prognosis and options for therapy with both him & his wife, he
decided to be DNR/DNI on [**2132-6-5**]. He also expressed the desire
to minimize interventions and the amount of time hospitalized.
His goal is to go home, knowing that he could die there in his
condition. His wish is to spend as much time with his wife as
possible at home, though he does not want to undergo extensive
hospital care and therapy to accomplish this.
After making these decisions, the pt again went into acute
respiratory distress on the AM of [**2132-6-6**]. He was treated with
the same regimen as described above. His cardiac enzymes were
elevated (w/ a troponin of 1.29). The pt agreed to undergo
diagnostic catheterization to determine if his LAD stent had
occluded and also to determine his hemodynamic numbers. If the
stent was found to be occluded or a new lesion was found, he
agreed to treatment through PTCI--with the aim of optimizing his
condition before going home. At catheterization, the in-stent
thrombosis was re-stented
Additional Hospital Course Issues:
## CV:
# CAD - From the outset, it was thought that the pt very likely
had extensive baseline ischemia--given his h/o CAD, diabetes,
smoking, and thick ventricle (diastolic failure). Based on
this, he was taken for a diagnostic cath on [**6-2**], where he was
found to only have LAD disease, which was stented with drug
eluting stent. Based on these results, it was concluded that he
most likely has idiopathic ischemic cardiomyopathy. He was
treated medically with ASA, plavix, BB, & statin.
On [**2140-6-5**], pt's SBP dropped & his anti-hypertensives were held.
It is thought that a new ischemic event may have contributed to
this.
# [**Name (NI) **] - Pt's initial TEE revealed global hypokinesis (EF ~20%).
Right heart cath on [**6-4**] showed PCWP 18 and cardiac index of
2.47. Post-LAD stenting echo revealed no improvement in LV
function (estimated EF ~15%).
# Rhythm - Pt was in flutter upon arrival at [**Hospital1 18**]. He
underwent a.flutter ablation and cardioversion into NSR. His
rhythm degenerated into afib after the procedure. Pt treated
with heparin and later coumadin for afib. Pt underwent ICD
placement and cardioversion on [**6-5**] (prior to deciding to be
DNR/DNI). Given his disorganized atrial arrhythmias at times
and his left atrial flutter and the apparent benefit of him
being in sinus rhythm, he was started on amiodarone therapy
(recommended by EP for month at 200mg [**Hospital1 **] and thereafter 200mg
QD).
.
## Respiratory Failure - Intubated on [**2132-5-30**] after developing
respiratory distress, which was thought to be due to acute pulm
edema as above. Pt extubated following day ([**5-31**]).
.
#Agitation/anxiety: likely contributed to episodes of shortness
of breath. Pt started on ativan 0.5mg [**Hospital1 **], which was changed to
longer acting clonazepam (started on [**6-3**]).
.
## COPD - Though not previously documented, pt's appears to have
COPD--CXR reveals significant hyperinflation of lungs. He
refuses to stop smoking. Pt given spiriva inhalers & albuterol.
.
## Anemia- reportedly has h/o anemia, though cause unknown.
Pt's hct dropped during admission & he was transfused 1uPRBCs
during admission. Hct stabilized thereafter. No obvious source
of bleeding.
.
## DM - Pt's outpt glipizide & NPH held. He was treated with
RISS and NPH [**7-1**] (when not NPO).
.
## CRI - baseline creatinine estimated to be approximately 1.7.
Had ARF thought to be pre-renal in nature with Crt peaking at
2.3. ARF now resolved with Crt at 1.6.
.
## Hyperlipidemia - atorvastatin continued.
.
## code - DNR/DNI
## Communication - wife [**Name (NI) 382**], who is legally blind
Medications on Admission:
1. digoxin 0.125mg qday
2. esomeprazole magnesium 40mg
3. salmeterol/fluticasone 250 1 puff [**Hospital1 **]
4. tiotropium bromide 18mcg qday
5. atorvastatin 20mg qday with supper
6. Mylanta 30mL q6h prn
7. aspirin 325 mg qday
8. furosemide 80mg qAM and 40mg qHS
9. glipizide 10mg [**Hospital1 **]
10. metoprolol 100mg [**Hospital1 **]
11. enoxaparin qday
12. acetaminophen 325-650mg q4-6h prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Digoxin 125 mcg Tablet Sig: 0.125mg Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1hr
prn as needed for shortness of breath or wheezing.
Disp:*60 cc* Refills:*0*
5. Ativan 1 mg Tablet Sig: 1-2 Tablets PO q2hr as needed.
Disp:*10 Tablet(s)* Refills:*0*
6. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) patch
Transdermal every seventy-two (72) hours.
Disp:*10 patches* Refills:*0*
7. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1) tab
Sublingual four times a day as needed for secretions.
Disp:*30 * Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 mdi* Refills:*0*
9. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 mdi* Refills:*0*
10. Morphine 10 mg/5 mL Solution Sig: 5-20 mg PO q1hr as needed
for shortness of breath or wheezing.
Disp:*120 ml* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Severe diastolic & systolic CHF with acute pulmonary edema, CAD,
ischemic cardiomyopathy, afib & COPD
Discharge Condition:
Stable but patient has refused any further care
Discharge Instructions:
Continue taking aspirin and clopidogrel daily as instructed. DO
NOT STOP these medications unless given permission by your
cardiologist.
Please take all medications as prescribed
If you have chest pain, shortness of breath, dizziness,
palpitations, pain in abdomen, vomitting, diarrhea please call
your primary care provider
Followup Instructions:
Please call your PCP Dr [**Last Name (STitle) 17025**] ([**Telephone/Fax (1) 3183**]) to make a
follow up appointment
Completed by:[**2132-6-7**]
ICD9 Codes: 5859, 496, 5185, 5849, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2407
} | Medical Text: Admission Date: [**2173-2-16**] Discharge Date: [**2173-2-21**]
Date of Birth: [**2095-10-23**] Sex: F
Service: Neurology
CHIEF COMPLAINT: Left-sided weakness and left hand
twitching.
HISTORY OF PRESENT ILLNESS: This is a 77 year old female who
was noted at around 2:40 PM on the afternoon of admission by
the nursing staff to be slumped over while at group activity
and then to become slightly confused and have slurred speech.
her face was noted to be twitching around to the left side.
Emergency medical services was called and they attempted to
assess her grip strength but she was too confused to follow
directions. Her fingerstick was normal. She was given 4 mg
of Ativan and she initially arrived to the [**Hospital6 1760**] Emergency Department because
she was felt to have convulsive status and was gargling.
Because of the gargling she was intubated and brought to the
Intensive Care Unit. She was initially suspected of having a
stroke with onset of seizure by the admitting Intensive Care
Unit and Neurology Team. The magnetic resonance imaging scan
was negative and she was treated for a seizure with
fosphenytoin load of 1 gm of Phenytoin equivalent. It was
also noted that when she was brought to the Emergency
Department she was minimally responsive and had twitching of
her left arm.
PAST MEDICAL HISTORY: 1. Seizures - Two years ago found
alone in home after a seizure and suffered an myocardial
infarction concomitantly. She did have a seizure 14 months
prior to this admission with confusion, twitching and
clutching of the hand although her daughter is not sure which
side this is. There was also staring associated with that
episode. She is maintained on Dilantin and her most recent
level was 17 in [**2172-12-14**]. 2. Status post myocardial
infarction. 3. Total abdominal hysterectomy ten years
prior.
MEDICATIONS ON ADMISSION: 1. Neurontin 300 mg p.o. t.i.d.;
2. Ativan 0.5 mg p.o. q.d.; 3. Dilantin 300 mg p.o. q.d.;
4. Metoprolol; 5. Aspirin 325 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives in [**Hospital3 **]. Husband had
Alzheimer's disease.
PHYSICAL EXAMINATION: Blood pressure 150/90, heart rate 70,
respirations 20, afebrile. General: Well developed, elderly
female lying in bed. Head, eyes, ears, nose and throat:
Neck supple with no lymphadenopathy and no thyromegaly.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs or
gallops. Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended, no
hepatosplenomegaly. Extremities: No cyanosis, clubbing or
edema. Neurological: Mental status on admission: Opens
eyes slightly to painful stimulus. Does not follow any
commands. No vocalizations. Cranial nerves, optic discs are
sharp, the extraocular movements were notable for deviation
to the left but with an intact oculocephalic reflex. Pupils
were equally reactive. Corneas were intact. There was a 5+
facial nerve palsy. The tongue seemed deviated towards the
left. Motor examination: Normal bulk. Diffusely hypotonic.
Some spontaneous movements on the right arm, withdrew
purposely from painful stimulus in all extremities except for
the left arm. Deep tendon reflexes 2+ biceps, triceps and
brachioradialis. Nothing at patella or ankle. Toes were
down. No clonus.
LABORATORY DATA: Laboratory data upon admission were
unremarkable with normal coagulation screen and normal
complete blood count. Chem-7 was normal as well.
HOSPITAL COURSE: 1. Apparent seizure - The patient as
mentioned was loaded on fosphenytoin 1 gm and started no
Keppra 500 mg p.o. b.i.d. She was monitored closely in the
Intensive Care Unit and extubated on [**2173-2-18**]. She
did also receive 1 dose of Ceftriaxone prophylactically as
she was having fevers. This was thought to be aspiration
pneumonia by chest x-ray done on [**2-18**]. She was started
on Levofloxacin and Flagyl. She did well over night and was
transferred to the floor on [**2173-2-19**]. At the time of
the transfer, she denied any major complaints and was talking
fluently. She had amnesia for the event and was somewhat
confused about to where she was but she was oriented to time.
Review of systems was negative for shortness of breath,
cough, abdominal pain, nausea, vomiting or diarrhea. As
mentioned she was started on Keppra 500 mg p.o. b.i.d. and
increased to 1 gm p.o. b.i.d. She was discontinued off of
Neurontin. She will be continued on Dilantin and Keppra
together.
2. Pneumonia - She completed the seven day course of
Levofloxacin and Flagyl.
3. With the history of myocardial infarction she was ruled
out with enzymes. She was kept on her Aspirin and statin.
4. Diabetes monitoring - The patient should have a
hemoglobin A1c done by her primary care physician.
DISPOSITION: The physical therapy and occupational therapy
saw the patient and felt that she should be screened for
rehabilitation. She was lives at [**Location **] Crossing which has a
skilled nursing facility. I have faxed to the facility and
she will be discharged there.
RADIOLOGICAL STUDIES: Computerized tomography scan of the
head done late [**2-16**] with no evidence of hemorrhage.
Magnetic resonance of the head with angio and post
gadolinium, there was no evidence of infarction and the
magnetic resonance angiography was relatively normal. There
was mild periventricular subcortical white matter
intensities.
Several portable chest x-rays which showed not only
satisfactory positioning of the endotracheal tube, but also
mild cardiomegaly with interstitial edema.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg p.o. q.d.
2. Levofloxacin 500 mg p.o. q.d. until [**2173-2-24**].
3. Metronidazole 500 mg p.o. t.i.d. until [**2173-2-24**].
4. Keppra 1 gm p.o. b.i.d.
5. Atorvastatin 10 p.o. q.d.
6. Phenytoin 300 mg p.o. q.d.
7. Heparin 5000 units subcutaneously q. 12 hours
8. Aspirin 325 mg p.o. q.d.
CONDITION ON DISCHARGE: Good.
DISPOSITION: To rehabilitation skilled nursing facility at
[**Doctor First Name **] Crossing.
FOLLOW UP: The patient is to follow up with her own primary
care physician and her neurologist, Dr. [**Last Name (STitle) 52627**].
[**Name6 (MD) 52628**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**]
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2173-2-22**] 06:46
T: [**2173-2-22**] 07:02
JOB#: [**Job Number 52629**]
ICD9 Codes: 5070, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2408
} | Medical Text: Admission Date: [**2147-11-8**] Discharge Date: [**2147-11-15**]
Date of Birth: [**2092-4-12**] Sex: F
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old
woman with mastocytosis activation syndrome with one urine
histamine of
9000. She was admitted with chest pain on this admission.
Previously, on [**2145-10-9**], she was admitted after a
reaction to gadolinium in which she developed severe nausea,
and airway tightness, and shortness of breath. She was given
epinephrine and developed severe chest pain. Serial
electrocardiograms at that time showed ST-T wave changes and
a troponin of 20 which then decreased to 1.5. An
echocardiogram at that time showed akinesis at the base of
fraction of 35%.
Since that admission, she has had chest pain every day,
usually muscle pain episodes each day. The pain is worse
with food, and occasionally worse with exercise, and
occasionally awakens the patient from sound sleep. She uses
nitroglycerin (two at a time) every two to three days. She
also gets chest pain which radiates to her back accompanied
by occasional shortness of breath. The chest pain has been
worse over the past several days and finally has required her
to seek treatment in the Emergency Department.
The patient has chronic abdominal pain which improved on
Gastrocrom 200 mg p.o. q.i.d. which was increased this Fall
from 100 mg p.o. q.d. However, because the patient's
abdominal pain was improved she decreased her dose to 100 mg
of Gastrocrom q.i.d. She notes that the Gastrocrom did not
help her chest pain. The patient has also been on Vistaril,
[**Doctor First Name **], and Zantac for histamine suppression. On previous
hospitalizations, she has required steroids.
Additionally, the patient notes the presence of chills and
joint pain. Her hands have become worse with swelling and
erythema since discontinuing her Vioxx at last admission when
she was started on Coumadin for cardiomyopathy.
She denies any fevers or night sweats and has no headaches or
change in her bowels. She does describe some malaise. She
says she has not played tennis since her [**Month (only) 359**] admission.
She has a minimal appetite and is forcing herself to eat.
She does say she noted some bright red blood per rectum mixed
with stool that had streaks of dark color on the day of
admission. The patient does have a history of internal
hemorrhoids.
PAST MEDICAL HISTORY:
1. Cholecystectomy in [**2143**]; followed by a bile leak that was
treated with a stent. She subsequently had pancreatitis in
[**2143-7-3**] and in [**2144**]. She had increased liver function
tests, and a sphincterotomy times two.
2. In [**2145-4-3**] she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16164**] procedure (uterine
suspension) followed by increased lipase and liver function
tests accompanied by abdominal pain.
3. In [**2145-10-3**], sural nerve biopsy, and endoscopic
retrograde cholangiopancreatography muscle biopsy, and liver
biopsy. Subsequently, multiple admissions for abdominal pain
accompanied by increased liver function tests and increased
amylase and lipase.
4. In [**2147-6-3**], tarsal tunnel release and subsequent
neuropathy.
5. In [**2147-7-3**], abdominal pain with scleral icterus.
6. Esophagogastroduodenoscopy on [**2146-12-13**] showed
prominent mass cells with granulation in the duodenum and
mild esophagitis.
7. Additionally, the patient is status post multiple episode
of anaphylaxis treated by epinephrine.
8. The patient also has seronegative arthritis.
ALLERGIES: COMPAZINE, DROPERIDOL, GADOLINIUM, SULFA.
MEDICATIONS ON ADMISSION:
1. Coumadin 7.5 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d.
3. Lisinopril 10 mg p.o. q.d.
4. Zantac 300 mg p.o. q.h.s.
5. [**Doctor First Name **] 180 mg p.o. q.d.
6. Ativan p.o. as needed.
7. Cromolyn 100 mg p.o. q.i.d.
8. Vistaril 25 mg p.o. q.h.s.
9. Glucosamine and chondroitin sulfate.
FAMILY HISTORY: Mother with a myocardial infarction at the
age 76.
SOCIAL HISTORY: The patient is married and active in sports.
Two children who are well. The patient is an Emergency Room
technician.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98,
blood pressure was 120/66, heart rate was 60, respiratory
rate was 20, oxygen saturation was 100% on room air. In
general, the patient was in pain, holding her chest. Head,
eyes, ears, nose, and throat examination revealed anicteric.
Erythematous lids. The mouth was moist without ulcers. The
neck revealed no adenopathy. The thyroid was normal.
Cardiovascular examination revealed a regular rate and
rhythm. Normal first heart sound and second heart sound. No
murmurs. The lungs revealed inspiratory wheezes posteriorly
on the left. Expiratory wheezes scattered bilaterally.
Normal to percussion. The abdomen was nondistended with
tenderness and guarding in the epigastric region. Positive
bowel sounds. Rectal examination revealed no stool or blood,
normal tone. Extremities revealed swelling and tenderness on
the right and left proximal interphalangeal joint and distal
interphalangeal joint, left third distal interphalangeal was
warm to touch. The patient without lower extremity edema.
There was mild palmar erythema.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
revealed white blood cell count was 5.1, hematocrit was 34.3,
platelets were 231. Electrolytes were within normal limits.
PT was 17.4, PTT was 32.1, INR was 2. Creatine kinases and
troponin were normal times three. ALT was 22, AST was 32,
amylase was 83, lipase was 93.
RADIOLOGY/IMAGING: CT revealed left lung base with a small
nodule. Splenic calcifications. Normal aorta, celiac,
superior mesenteric artery, and internal mammary artery
takeoff. No aneurysm.
Electrocardiogram was notable for nonsloping ST-T wave
changes, poor progression in V1 and V2, generally low
voltage.
HOSPITAL COURSE:
1. CARDIOVASCULAR SYSTEM: The patient's primary issue
during her hospitalization was her chest pain. She typically
had three episodes of severe debilitating chest pain per day
during her admission. She described these as 7/10 chest pain
in general, radiating to her back, and were accompanied with
nausea and dry heaves. On each occasion during her
admission, an electrocardiogram was obtained, and there was
never any change in her electrocardiograms.
Her pain generally resolved with several sublingual
nitroglycerin coupled with 2 mg to 4 mg of intravenous
Dilaudid, and Zofran and Ativan were also frequently
required. Her chest pain in general did not seem to improve
during her admission, in that it did not decrease in
frequency or severity. Her histamine blockade was increased
with her Gastrocrom, and she was started on steroids,
however, it became evident during her admission that she was
throwing away her prednisone.
Cardiology was involved and did not feel that her chest pain
was consistent with a cardiac etiology. An echocardiogram
was obtained and showed that her ejection fraction had
rebounded to 75% from 35% on her last admission.
An Allergy consultation was obtained, and there was some
suggestion that histamine release could cause coronary with
muscle spasm; however, this was felt to be somewhat less
likely. Additionally as her repeat electrocardiogram showed
no evidence of ischemia with chest pain, and her cardiac
function was normal, we felt the patient's cardiovascular
status was good.
2. GASTROINTESTINAL SYSTEM: Possible gastrointestinal
etiology for the patient's symptoms were closely considered.
This was felt to be somewhat likely given the patient's
history of gastrointestinal manifestations of mast cell
activation. There was suspicion for esophageal spasm given
the resolution of symptoms with nitroglycerin in the presence
of no electrocardiogram changes.
GI was involved and an esophagogastroduodenoscopy was
performed which was grossly normal. However, biopsy
specimens were taken. The patient may still require
[**Doctor Last Name **] test in the future for possible esophageal spasm.
In terms of the patient's lower gastrointestinal bleed, a
flexible sigmoidoscopy was performed and revealed only
hemorrhoids. The patient's abdominal pain was well
controlled throughout her admission with histamine blockade
and Gastrocrom.
3. PULMONARY SYSTEM: As the patient's chest pain episodes
continued throughout her admission, she began to experience
increasing respiratory distress with these episodes. Her
respiratory issues consisted of wheezing during her chest
pain episodes and were worrisome for anaphylaxis.
On two occasions, the patient received epinephrine which
seemed to help symptoms to some degree. However, on the
second occasion, after receiving racemic epinephrine and
still having some stridorous sounds worrisome for
anaphylaxis, the patient was transferred to the Medical
Intensive Care Unit for observation. She was closely
observed there but did not have any further events and was
stable from a pulmonary perspective. It was unclear to what
extent her wheezing was related to histamine release and
anaphylaxis, as there also seemed to be some anxiety
component that was worsening these episodes.
Her arterial blood gas after the episode causing the
Medical Intensive Care Unit transfer was consistent with some
degree of a panic attack. The patient was started on a
chromone inhaler in house.
4. HEMATOLOGY: The patient's mastocytosis syndrome was
aggressively treated with antihistamines and cromolyn.
Prednisone was started on admission; however, the patient
refused this medication. A tryptase alpha and beta were
sent. A 24-hour urine was performed; however, it was unclear
to what extent to the 24-hour urine was collected properly.
5. PSYCHIATRY: On the day prior to discharge, the patient
began to act in a hypomanic state. Her speech became
tangential and pressured. The patient was adamant that she
wanted to be discharged to home. It was revealed that the
patient had been taking her own Effexor 75 mg p.o. q.d.
throughout the hospital stay.
Psychiatry was consulted, and it was felt that it was very
likely that the patient's mood and anxiety contributed in
some way to the patient's physical symptoms. Additionally,
Psychiatry felt that she had no active psychiatric problem
that should delay her discharge. She was to follow up with
outpatient psychiatric treaters.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE DIAGNOSES:
1. Mastocytosis syndrome.
2. Internal hemorrhoids.
3. Anxiety.
MEDICATIONS ON DISCHARGE:
1. [**Doctor First Name **] 180 mg p.o. b.i.d.
2. Vistaril 25 mg p.o. q.a.m. and 50 mg p.o. q.h.s.
3. Ranitidine 300 mg p.o. b.i.d.
4. Vioxx 25 mg p.o. q.d.
5. Gastrocrom 200 mg p.o. q.i.d.
6. Inhaled cromolyn 100 mg q.i.d.
7. Sublingual nitroglycerin as needed.
8. Isosorbide mononitrate 60 mg p.o. q.d.
9. Multivitamin.
10. Lisinopril 10 mg p.o. q.d.
11. Percocet one to two tablets p.o. q.4-6h. as needed for
pain (the patient has home supply).
DISCHARGE FOLLOWUP: The patient was to follow up with Dr.
[**Last Name (STitle) 79**] in two weeks and to follow up with primary care
physician in two weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 21723**]
Dictated By:[**Last Name (NamePattern1) 23006**]
MEDQUIST36
D: [**2147-11-21**] 13:22
T: [**2147-11-22**] 10:16
JOB#: [**Job Number 23007**]
ICD9 Codes: 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2409
} | Medical Text: Admission Date: [**2176-1-31**] Discharge Date: [**2176-2-7**]
Date of Birth: [**2126-7-16**] Sex: M
Service: CSU
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 49-year-old
male patient who had had no problems with his health. At a
routine physical exam he was noted to have a cardiac murmur
and was referred for echocardiogram in [**2175-7-16**], revealing
an ejection fraction of 55 percent with severe mitral
regurgitation and mitral valve prolapse with a thickened and
redundant anterior mitral valve leaflet and a thickened
posterior mitral valve leaflet. Also noted to have mild
tricuspid regurgitation with a pulmonary artery pressure of
26 mm/Hg. He proceeded to have a stress echocardiogram on
[**2175-8-10**], that showed no cardiac ischemia and at this
time he was referred to Dr. [**Last Name (Prefixes) **] for evaluation for
mitral valve replacement.
PAST MEDICAL HISTORY: Significant only for an appendectomy
in his childhood.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a Jehovah's Witness. He
lives in [**Location **] with his wife and works full-time for a
cleaning business.
PHYSICAL EXAMINATION: On presentation height 5 feet 11
inches tall, weight 187 pounds. Blood pressure 160/90.
Heart rate 51. General: The patient was in nonacute
distress. Skin without rashes. HEENT: Atraumatic,
normocephalic. Pupils equal, round and reactive to light.
Extraocular movements intact. No jugular venous distension.
Neck without masses. Chest clear to auscultation
bilaterally. Heart regular rate and rhythm with a 2/6
systolic ejection murmur at the apex. Abdomen soft and
nontender, nondistended with positive appendectomy scar that
is well healed. Extremities are warm and well perfused
without edema or varicosities. Neurologically, the patient
is intact, alert and oriented times three. Nonfocal exam.
PREOPERATIVE LABS: White blood cell count 3.8, hematocrit
of 38.0, platelets of 228. PT 13.1, PTT 23.1, INR 1.1,
sodium 138, potassium 3.7, chloride 106, bicarbonate 24, BUN
13, creatinine 0.7 and glucose 127. ALT 14, AST 19.
Alkaline phosphatase 58. T-bili 0.5, albumin 4.1.
Preoperative EKG: Sinus bradycardia.
Preoperative cardiac catheterization on [**2176-1-9**]:
Severe three plus mitral regurgitation with an ejection
fraction of 59 percent and no significant coronary artery
disease. Slightly elevated right and left heart filling
pressures.
SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname **] was admitted on his
operative day, [**2176-1-31**], and proceeded to the
Operating Room with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. He underwent
mitral valve replacement with a [**Street Address(2) 12523**]. [**Male First Name (un) 923**] mechanical
valve. Total cardiopulmonary bypass time was 101 minutes
with a crossclamp time of 84 minutes. His operative course
was uneventful. He was transferred to the Cardiac Surgery
Recovery Unit with a mean arterial pressure of 76, CVP of 8,
A-paced at a rate of 88 on a nitroglycerine drip. Please see
operative report for complete details.
On the evening of his operation he was successfully weaned
and extubated. On postoperative day one his Neo-Synephrine
was weaned and it was felt that he was stable for transfer to
the in-patient floor for ongoing recovery and rehabilitation.
On postoperative day two Mr. [**Known lastname **] continued to do very
well. His chest tubes were discontinued and he was started
on Coumadin for anticoagulation with his mechanical valve.
His cardiac pacing wires were grounded.
The evening of postoperative day two, Mr. [**Known lastname **] experienced
short bursts of a junctional rhythm, for which cardiology
consultation was obtained and noted that there was no
evidence of AV block or prolonged AV conduction and
recommended only observation with plan for followup with
cardiology in three to four weeks with Holter monitor, two
days prior to appointment.
On postoperative day three, Mr. [**Known lastname 10437**] temporary cardiac
pacing wires were discontinued and physical therapy was
increased. On that evening, Mr. [**Known lastname **] was noted on
telemetry to have a six second bout of asystole, proceeded by
a run of A-flutter and spontaneous conversion to normal sinus
rhythm. This was discussed with the primary team, as well
electrophysiologist, who decided there was no need for
intervention at this time and that it would be evaluated in
the EP lab at a later date and beta blockers would be
avoided. The patient did report some diaphoresis and
presyncope with the episode. Mr. [**Known lastname **] was also started on
heparin drip for anticoagulation while awaiting jump in his
INR.
Postoperative day five continued with bursts of atrial
fibrillation and atrial flutter.
Postoperative day six was significant for further asystolic
pauses lasting up to seven seconds. First the
electrophysiology team was again consulted and they agreed
that they felt the patient needed a pacer, however, the
patient was extremely reluctant to get a pacer. This was
discussed at length between primary cardiac surgery team,
electrophysiology team and Mr. [**Known lastname **].
On postoperative day seven it was decided that Mr. [**Known lastname **]
would be safe for discharge home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
monitor and followup with the electrophysiology service
within four weeks time to make a decision regarding his heart
rhythm and possible ablation versus cardiac pacemaker
placement. On postoperative day seven his INR had also risen
to 2.2 and it was decided that his heparin could be
discontinued and he could be discharged home. Mr. [**Known lastname 10437**]
INR will be drawn on [**2-8**] by the visiting nurses and
called in to us if his INR has dropped below 2. He will need
intravenous heparin if it is at 2.2 or above. He will
continue on his p.o. Coumadin dosing at home.
CONDITION ON DISCHARGE: Stable
DISCHARGE STATUS: Home with visiting nurses to follow.
DISCHARGE DIAGNOSES: Mitral valve prolapse and mitral
regurgitation status post mitral valve replacement with a 33
mm St. Jude valve. Postoperative atrial fibrillation, atrial
flutter and asystolic pauses.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. daily
2. Ferrous sulphate 325 mg p.o. daily
3. Vitamin C 500 mg p.o. b.i.d.
4. Coumadin as daily directed by primary care physician with
dose of 6 mg on [**2-7**].
5. Acetaminophen codeine 300 - 30 mg tablets, 1-2 tablets
p.o. q.4h prn for pain.
FO[**Last Name (STitle) 996**]P: Followup with Dr. [**Last Name (Prefixes) **] within one month.
Followup with Dr. [**Last Name (STitle) **] in two to three weeks, or as needed
for INR checks. Followup with Dr. [**Last Name (STitle) **] within one
month.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) 28068**]
MEDQUIST36
D: [**2176-2-7**] 17:31:16
T: [**2176-2-7**] 18:28:14
Job#: [**Job Number 59290**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2410
} | Medical Text: Admission Date: [**2178-8-3**] Discharge Date: [**2178-8-26**]
Date of Birth: [**2100-9-20**] Sex: M
Service: MEDICINE
Allergies:
Dilantin Kapseal / Sulfa (Sulfonamide Antibiotics) / Tegretol /
Fentanyl / Thiopental / Succinylcholine / Vecuronium Bromide
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Weight gain
Major Surgical or Invasive Procedure:
PICC line placement
Milrinone infusion
admission to the cardiac intensive care unit
right heart catheterization
History of Present Illness:
Mr. [**Known lastname 109642**] is 77M with h/o systolic and diastolic CHF, a-fib,
cardiac amyloidosis, and multiple myeloma transferred from
[**Hospital1 **] initially for volume overload and need for lasix
drip and chemotherapy.
The patient was recently discharged from [**Hospital1 18**] on [**2178-6-5**], at
which time RV biopsy demonstrated cardiac amyloidosis, as well
as a bone marrow biopsy with e/o multiple myeloma. ECHO showed
e/o new systolic heart failure on top of preexisting diastolic
heart failure and is s/p cardiac catheterization with e/o 50%
left main disease, 50% LAD stenosis.
Since discharge, the patient reports weight gain, as well as
DOE. He denies orthopnea, PND, palpitations, syncope or
presyncope. He waited until he was seen by Dr. [**Last Name (STitle) **] on [**2178-7-22**]
where he was noted to have elevated JVD and 3+ LE edema. Lasix
was switched to torsemide 40mg [**Hospital1 **] with continued spironolactone
50mg daily.
When he initially presented to [**Hospital1 **], the patient was
noted to have change in mental status that was attributed to
uremia, [**Last Name (un) **], and medication side effect from torsemide. He also
had a bandemia of 9% and was initially treated for a potential
UTI. His CXR showed recurrent right pleural effusion. He was
treated for acute on chronic systolic and diastolic heart
failure with IV lasix but of note this was limited by his BP's.
Weight prior to discharge from [**Location (un) 620**] 105kg.
While on the [**Hospital1 1516**] service, the patient was being diuresed on
Lasix drip 30 mg/hour, with diuresis limited by increasing
creatinine. After discussion with Dr. [**First Name (STitle) 437**], it was thought that
the patient could benefit from milronone drip in the setting of
having a Swan placed to measure his wedge and his CO. The
patient also has an element of systolic failure, which could
also be improved with milronone.
On transfer to the floor, the patient reports feeling well.
Past Medical History:
Afib on coumadin
Diastolic heart failure (EF 60-65%)
OSA
Gout
GERD with Barrett's esophagus
Hiatal hernia
Elevated PSA
Erectile dysfunction
s/p cholecystectomy ([**2172**])
s/p right hip replacement ([**2170**])
s/p tailers bunion, fascia release, prosthesis (left foot)
([**2169**])
s/p deviated septum repair ([**2168**])
s/p tailers bunion removal ([**2166**])
s/p multiple laminectomies ([**2164**], [**2151**], [**2148**])
s/p tendon repair right arm ([**2145**])
s/p hemorrhoidectomy ([**2126**])
s/p pilonidal cyst removal ([**2120**])
s/p appendectomy ([**2116**])
s/p bone removal left foot ([**2114**])
s/p tonsillectomy ([**2106**])
Social History:
The patient is married and worked in the import business and
worked for the navy in the shipyards. He never smoked.
Family History:
Positive for hay fever.
Physical Exam:
ADMISSION EXAM:
VS - 97.9 117/63 72 18 98% on RA 105.7kg
GENERAL - chronically ill appearing male in NAD, comfortable,
slightly short of breath while speaking
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, JVP at 12, no carotid bruits
LUNGS - bibasilar crackles
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft, NT, distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 3+ pitting LE edema to upper thighs, 2+
peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-13**] throughout
DISCHARGE EXAM:
24hr I/O: 1236/1620
87.6 ->88 ->89.1
General: Well NAD,pleasant, well appearing, elderly gentleman in
NAD, laying comfortably in bed
HEENT: EOMI, PERRLA, no cerivcal lymphadenopathy, 12cm JVP
LUNGS: Fine Crackles at right base, no wheezing, rhonchi
HEART - PMI non-displaced, RRR, II/VI systolic murmur at apex,
nl S1-S2,
ABDOMEN - +BS, soft, NT, distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - 1+ pitting edema to calves, 2+ peripheral pulses
(radials, DPs), PICC Line in right arm w/o errythema or
tenderness.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-13**] throughout
Pertinent Results:
ADMISSION LABS:
[**2178-8-3**] 11:39PM BLOOD WBC-10.8 RBC-3.43* Hgb-11.1* Hct-35.0*
MCV-102* MCH-32.3* MCHC-31.6 RDW-15.7* Plt Ct-194
[**2178-8-3**] 11:39PM BLOOD Neuts-80.9* Lymphs-8.5* Monos-9.1 Eos-1.0
Baso-0.5
[**2178-8-3**] 11:39PM BLOOD PT-25.4* PTT-37.9* INR(PT)-2.4*
[**2178-8-3**] 11:39PM BLOOD Glucose-119* UreaN-50* Creat-1.6* Na-138
K-4.3 Cl-98 HCO3-30 AnGap-14
[**2178-8-5**] 04:20PM BLOOD CK(CPK)-31*
[**2178-8-5**] 04:20PM BLOOD CK-MB-4 cTropnT-0.14*
[**2178-8-3**] 11:39PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.4
TRANSFER LABS:
[**2178-8-7**] 03:45PM BLOOD PT-27.2* INR(PT)-2.6*
[**2178-8-7**] 03:10PM BLOOD Glucose-100 UreaN-81* Creat-2.3* Na-135
K-4.0 Cl-91* HCO3-31 AnGap-17
[**2178-8-7**] 03:10PM BLOOD Calcium-8.9 Phos-4.8* Mg-2.6
[**2178-8-6**] 11:19AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2178-8-6**] 11:19AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
[**2178-8-6**] 11:19AM URINE Hours-RANDOM Creat-37 Na-74 K-38 Cl-88
DISCHARGE LABS:
[**2178-8-26**] 04:26AM BLOOD WBC-15.9* RBC-3.02* Hgb-9.2* Hct-28.3*
MCV-94 MCH-30.4 MCHC-32.4 RDW-16.1* Plt Ct-233
[**2178-8-25**] 05:32AM BLOOD PT-22.4* PTT-36.2 INR(PT)-2.1*
[**2178-8-26**] 04:26AM BLOOD Glucose-118* UreaN-66* Creat-1.7* Na-131*
K-4.6 Cl-93* HCO3-29 AnGap-14
[**2178-8-15**] 06:40AM BLOOD ALT-22 AST-22 AlkPhos-93 TotBili-0.9
[**2178-8-26**] 04:26AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
Blood Culture, Routine (Final [**2178-8-26**]): NO GROWTH.
URINE CULTURE (Final [**2178-8-21**]): NO GROWTH.
KAPPA/LAMDA:
Test Result Reference
Range/Units
FREE KAPPA, SERUM 20.0 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 2.7 L 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 7.41 H 0.26-1.65
Cardiac Cath Report [**8-19**]: Elevated right- and left-sided filling
pressures, moderate pulmonary arterial hypertension in the
setting of left-sided heart failure, large V waves suggestive of
moderate to severe mitral regurgitation. Normal cardiac output
and index.
EKG [**2178-8-25**]
Atrial fibrillation. Right bundle-branch block. Left axis
deviation. Left
anterior fascicular block. Old inferior myocardial infarction.
Compared to
the previous tracing of [**2178-8-22**] no significant changes are
noted.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 0 148 440/457 0 -70 107
CXR [**2178-8-20**]: As compared to the previous radiograph, the patient
has received a Swan-Ganz catheter. The catheter needs to be
pulled back given that the tip is projecting over distal parts
of the right pulmonary artery. An opacity that pre-existed at
the bases of the right upper lobe is no longer visible. However,
the lung volumes have decreased and a small pleural effusion is
unchanged at the right lung base. Unchanged moderate
cardiomegaly. The right PICC line is constant in position.
RENAL ULTRASOUND:
1. No hydronephrosis. Simple bilateral renal cysts.
2. Right pleural effusion and trace of ascites seen in the
right upper
quadrant.
3. Arterial and venous flow is documented within each of the
kidneys,
however, further Doppler analysis cannot be performed as the
patient is unable to hold his breath.
Social Work:
Family has met w/ palliative team and wife expresses that the
conversation is "premature". Pt and wife have not signed DNR and
still solidifying long-term plans. Pt, wife and [**Name2 (NI) **] are aware of
life expectancy ([**7-21**] mos) and reiterated to SW and physician
that Pt is going to optimize highest level of care and the
priority is to be at home.
Pt and family met w/ infusion home care co. as an option for
next
steps. Physician communicated to pt/family that PT will be
consulted on recommendations for home vs rehab.
Family and Pt are continuing to explore all options and continue
to look into rehab's that can manage current medications however
family has reiterated that going home is their first preference.
Assessment: Family and Pt is experiencing difficult adjustment
to
illness and next steps on the best approach for Pt. SW provided
empathic listening, guidance on resources that are available,
and
encouraged Pt and family to continue to utilize clinicians to
help make an informed decision on where Pt should transition to
next.
Brief Hospital Course:
Mr. [**Known lastname 109642**] is 77M with history of atrial fibrillation on
coumadin, systolic and diastolic heart failure, cardiac
amylodosis, and multiple myeloma who initially presented from
OSH with weight gain and need aggressive IV diuresis, requiring
CCU admission for initiation of milrinone drip.
.
# Acute on chronic systolic and diastolic heart failure: Patient
with baseline restrictive disease secondary to his cardiac
amyloid. Also with systolic CHF first seen [**5-21**] with RV free
wall hypokinesis. He presented with diffuse peripheral edema,
worsening abdominal distention and JVP elevated to 12 cm,
consistent with right sided failure. He also presented with
right pleural effusion that represented transudate [**3-12**] CHF. He
was initially diuresed with lasix drip and metolazone with good
effect, but was stopped after increasing creatinine. He was
then transferred to the ICU for diuresis with milrinone for
inotropic effect and pulomary vasodilation allowing right sided
unloading. His right heart pressures were monitored by swan-ganz
cath with PA pressure 50 to 40s and wedge pressures of 28 to 19
after administartion of milrinone. He diuresed well in the CCU,
was transfered to the floor, but after weaning milrinone, he
required reinitiation of milrinone in the CCU due to drop off in
energy level, urine output an reaccumulation of fluid. He
tolerated reinstitution of milrinone infusion well and was
transferred to the floor. He was also continued spironolactone
and torsemide after period of autodiuresis from [**Last Name (un) **] ended. Over
the course of the hospitalization he lost about 40lbs. His
discharge weight was roughly equivalent to his dry weight at
89.1 kg (196 lbs). He was counseled on the importance of daily
weights and CHF management. He will follow up with Dr. [**Last Name (STitle) **]
in cardiology clinic.
.
[**Last Name (un) **]: Pt developed [**Last Name (un) **] in the setting of aggressive diuresis.
Nephrology was consulted and felt this was likely ATN vs
pre-renal due to hypoperfusion. It was unlikely a sequelae of
MM or amyloid as no protein was found in the urine. After
discontinuing Lasix gtt, he autodiuresed. Upon discharge, his
Creatinine returned to his baseline of 1.7.
.
Community Acquired Pneumonia: Pt developed cough and
leukocytosis with CXR findings of right upper lobe infiltrate.
He was treated with Ciprofloxacin and then Levofloxacin caused
him to have a supratherapeutic INR above 5. For the remainder
of 10 day abx course, his coumadin was held.
.
# Cardiac amyloidosis with restrictive myopathy: The patient has
history of cardiac amyloidosis confirmed on RV biopsy, and has
resulting restrictive heart disease, with subsequent R sided
dilation and R sided heart failure as above.
.
# Multiple Myeloma: During his last admission, patient was found
to have a monoclonal kappa band and severe hypogammaglobulinemia
on SPEP/UPEP. He underwent bone marrow biopsy which showed 40%
plasma cells. Abdominal fat pad biopsy both performed [**5-28**],
revealed no amyloid but RV cardiac biopsy was positive for
amyloid. He also continued dexamentasone/velcade treatment
while inpatient. Cycle4 Day8 Velcade administration on [**8-25**].
Will continue treatment with Dr. [**Last Name (STitle) 109643**].
.
# Coronaries: The patient has history of 3VD s/p NSTEMI during
his last admission. Cath from that admission with e/o 50% left
main disease, 50% LAD stenosis. It was decided that the patient
was too high risk for CABG, as well as PCI given his amyloidosis
and was discharge on medical management of his CAD. He was
continued on atorvastatin 80 mg daily, ASA 162 mg daily,
metoprolol 12.5 mg [**Hospital1 **].
.
# Afib: Stable. CHADS score of 2 (age and CHF). He was
continued on coumadin for goal INR of 2.0-2.5 given for
increased risk of bleeding with amyloid. During the hospital
course, he reached a supratherapeutic INR ~5 after
fluoroquinolones were addded. His coumadin was held for a few
days and restarted to maintain appropriate anticoagulation. He
will continue INR checks and Coumadin management through Dr. [**Name (NI) 109644**] office.
.
# BPH: stable, continued doxazosin
.
# GERD/Barrett's/hiatal hernia: stable, continued omeprazole,
home tums
.
# DEPRESSION/sleep: stable, continued amitriptyline, zolpidem.
.
# GOUT: stable, continued allopurinol, colchine, tramadol prn
.
TRANSITIONAL ISSUES:
-Cycle4 Day8 Velcade administration on [**8-25**]. will f/u with Dr.
[**Last Name (STitle) 3759**]
[**Name (STitle) **] monitored by Dr. [**Last Name (STitle) 3759**]
[**Name (STitle) 30412**] not amenable to palliative care now
-patient is a full code
-?depression versus adjustment reaction with depression
-Discharge and dry weight 89.1 kg (196 lbs).
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR OSH records.
1. Atenolol 12.5 mg PO DAILY
2. Aspirin 162 mg PO DAILY
3. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral qAM
4. Multivitamins 1 TAB PO DAILY
5. Torsemide 40 mg PO BID
6. Omeprazole 20 mg PO BID
7. Spironolactone 50 mg PO DAILY
8. Amitriptyline 30 mg PO HS
9. Doxazosin 4 mg PO HS
10. Zolpidem Tartrate 5-10 mg PO HS
11. Allopurinol 100 mg PO QHS
12. Colchicine 0.6 mg PO HS
13. Guaifenesin Dose is Unknown PO Frequency is Unknown
14. Warfarin 5 mg PO DAILY16
15. TraMADOL (Ultram) 50 mg PO QID pain
16. Nitroglycerin SL 0.3 mg SL PRN CP
17. Gaviscon *NF* ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg Oral prn indigestion
Discharge Medications:
1. Hospital Bed
2. Milrinone 0.26 mcg/kg/min IV INFUSION
RX *milrinone in D5W 20 mg/100 mL (200 mcg/mL) 0.26 mcg/kg/min
continuous infusion Disp #*1 Mutually Defined Refills:*12
3. Amitriptyline 30 mg PO HS
4. Aspirin 162 mg PO DAILY
5. Gaviscon *NF* ([**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) 80-14.2 mg Oral prn indigestion
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*3
9. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
10. Warfarin 4 mg PO DAILY16
RX *warfarin 2 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
11. Zolpidem Tartrate 10 mg PO HS:PRN sleep
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
RX *Milk of Magnesia 400 mg/5 mL 30 mL(s) by mouth every 6 hours
Disp #*1 Bottle Refills:*3
13. Sarna Lotion 1 Appl TP DAILY:PRN itchy
RX *Sarna Anti-Itch 0.5 %-0.5 % apply to itchy skin daily Disp
#*1 Bottle Refills:*3
14. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 tablet by mouth twice daily Disp #*60 Tablet
Refills:*3
15. Simethicone 40-80 mg PO QID:PRN bloating
RX *simethicone 80 mg 1-2 tablets by mouth four times a day Disp
#*120 Tablet Refills:*3
16. calcium carbonate-vitamin D3 *NF* 500mg (1,250mg) -600 unit
Oral qAM
17. Nitroglycerin SL 0.3 mg SL PRN CP
18. Allopurinol 100 mg PO QHS
19. Outpatient Lab Work
INR check on [**8-28**] with results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 109645**] at
[**Telephone/Fax (1) 21962**]. ICD-9 427.31
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
PRIMARY
-acute on chronic systolic heart failure
-amyloidosis with restrictive myopathy
-multiple myeloma
-community acquired pneumonia
-Hyponatremia
-acute kidney injury
-atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure caring for you while you were at [**Hospital1 18**]. You
were admitted for treatment of your congestive heart failure.
Our testing suggested this was a result of the effects on your
heart from your multiple myeloma. You were started on a
medication called milrinone that helped your heart pump better
and given medications to help you urinate off all the excess
fluid. Your weight was decreased by about 40 pounds. We tried
to stop the milrinone infusion, but your clinical picture
worsened without this medication and it was determined that you
will need it chronically infusing from now on. Home services to
assist with this have been set up for you. You also continued
to recieve therapy for your multiple myeloma while and inpatient
and will continue to see Dr. [**Last Name (STitle) 109645**] as an outpatient.
You were discharged on diuretics (torsemide) in order to keep
your weight down. Your discharge weight was 89.1 kg (196 lbs),
you should call Dr.[**Name (NI) 10159**] office at [**Telephone/Fax (1) 9832**] if you
notice your daily weight goes up by more than 3 lbs in a day or
if you notice worsening swelling in your legs, shortness of
breath while walking or any other symptoms that concern you.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2178-9-1**] at 2:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2178-9-1**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2178-9-1**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2178-8-30**]
ICD9 Codes: 486, 5845, 2761, 4280, 2749, 412, 311, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2411
} | Medical Text: Admission Date: [**2107-3-21**] Discharge Date: [**2107-4-4**]
Date of Birth: [**2041-7-11**] Sex: F
Service: VASCULAR
CHIEF COMPLAINT: Left leg ischemia and cellulitis.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old female
with severe bilateral lower extremity inflow and outflow
disease who was scheduled for an aorto-bifemoral bypass on
[**3-25**] with Dr. [**Last Name (STitle) **] with prior three-week history of
left foot pain with ambulation. She requires wheelchair for
ambulation. Prior to that, she ambulated independently
without claudication symptoms. There was a painful cut on
the left lateral foot which progressed to weeping and pain
over the last three days. She was started on Augmentin two
days prior to admission. She denied constitutional symptoms.
The patient also has a history of carotid disease and stated
that she was to have carotid endarterectomy prior to her
aorto-bifemoral. She denied any symptoms. The patient was
admitted for further vascular evaluation and treatment.
PAST MEDICAL HISTORY: History of Hodgkin's lymphoma 13 years
ago. Status post splenectomy and thoracic lymph node
dissection. Status post radiation to the chest and
mediastinum. History of hypercholesterolemia. History of
hypertension. History of dementia, Alzheimer's type.
History of hypothyroidism. History of asthma; she has not
been intubated, no history of hospitalizations, or steroid
use for her asthma. Status post cerebrovascular accident
without residual. Peripheral vascular disease.
SOCIAL HISTORY: She has greater than 103 pack-year smoking
history. Nondrinker.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: Lipitor 20 mg q.d., Aricept 5 mg q.d.,
Euthyroid 75 mg q.d., Pulmicort 1 q.d., Augmentin 500 mg
b.i.d., Albuterol p.r.n.
PHYSICAL EXAMINATION: Vital signs: 97.4, 101, 205/76, 18,
98% on room air. Blood pressure rechecked was 166/58.
General: This was a pleasant but difficult to understand
white female in no acute distress. She was oriented to
person and place but not time. HEENT: Unremarkable. She
had a left carotid bruit. Lungs: Clear to auscultation but
diminished throughout. Heart: Irregular rate and rhythm.
There was a 2/6 systolic ejection murmur at the right upper
sternal border. Abdomen: Nontender and nondistended. There
was a well-healed median abdominal incision. She has a
palpable liver edge. Atympanic. Rectum: Unremarkable.
Guaiac negative. No abdominal aortic aneurysm. Extremities:
Pulse exam showed palpable femorals bilaterally. The
dorsalis pedis and posterior tibial with Dopplerable signals
only bilaterally. The left foot with diffuse streaky
erythema and edema. There was a 1 cm diameter draining
wound. There were small fissures along the lateral aspect of
the left foot near the heel. There was no drainage or active
bleeding. Neurological: Cranial nerves II-XII grossly
intact. Left foot motor was intact with diminished sensation
to light touch. Extremity strength was symmetrical without
deficits.
LABORATORY DATA: CBC with a white count of 19.2, hematocrit
40.9, differential with polys of 74, lymphs 17, no bands;
electrolytes with a BUN of 21, creatinine 1.0, potassium 4.9,
glucose 129.
Electrocardiogram was normal sinus rhythm with inverted Ts in
II, III, and AVF. There were no changes from previous
electrocardiogram of [**2107-3-10**].
Chest x-ray showed no active cardiopulmonary disease. There
was a small mediastinal irregular opacity without change from
prior chest x-ray.
Other studies included an arteriogram which showed extensive
infrarenal aortic disease, left common iliac occluded, left
internal iliac reconstructed by right collaterals from the
external iliac, left common femoral profunda with multifocal
SFA disease proximally, distal SFA and popliteal were patent,
there was disease of the tibial, proximal posterior tibial,
and peroneal arteries, the left AT is in major runoff vessel
but diseased proximally and mid portions. Foot fed by
collaterals. The right common iliac and external iliac
diseased. The right common femoral profunda, SFA, popliteal
were patent. There was two-vessel runoff via the posterior
tibial and the dorsalis pedis on the right.
A MIBI stress test on [**3-17**] showed no wall motion
abnormalities, ejection fraction was calculated at 54%. The
ultrasound of the carotid showed left internal carotid artery
stenosis of 85-90%, right internal carotid stenosis of 60-70%
at the origins, right internal carotid artery subvalvular
stenosis of 85% 2 cm above the bifurcation. The left
vertebral was totally occluded. The right vertebral was
patent.
The ultrasound of the carotids showed a 70-79% bilateral
internal carotid artery stenosis with nonvisualized left
vertebral artery.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service. She was placed on Metoprolol 25 mg b.i.d.,
Levofloxacin 500 q.24, and Flagyl 500 mg q.8. Subcue Heparin
was begun for DVT prophylaxis. She was continued on her
preadmission medications.
Dressings were normal saline wet-to-dry dressings b.i.d. with
multi-podis boot of the affected foot. She was placed on a
house diet. She was placed on bedrest with the leg elevated.
She was allowed to receive Percocet tablets 5/325 one-half to
one q.4-6 hours p.r.n. for pain. Vancomycin 1 g IV q.12
hours was begun with peak and trough levels with third dose.
Lopressor was increased to 50 mg b.i.d. hospital day #2.
Vancomycin was discontinued on [**3-24**], and Oxacillin 1 g q.6
hours IV was begun for MSSA.
The patient underwent on [**3-25**] a left carotid endarterectomy.
She tolerated the procedure well, and she was transferred to
the PACU in stable condition. The patient was intubated,
alert, and responded to commands. She was without chest
pain. Her vitals signs were stable. She was hemodynamically
stable. Her neck dressing was clean, dry, and intact. There
was no hematoma. She was extubated in the PACU and
transferred to the VICU for continued monitoring and care.
Nitroglycerin was weaned off on postoperative day #1. She
required reintubation in the PACU secondary to sedation. She
was afebrile. Her hematocrit was 29.6. Her electrolytes
remained stable. Her exam showed bilateral lung wheezing
with generalized edema. She was diuresed. She received
nebulizations around the clock. Stool for C-diff was sent.
Her diet was advanced as tolerated. Her Foley was continued
to monitor urinary output, and she remained in the VICU. Her
Lopressor was dosed at 37.5 b.i.d. and required decreased
dosing strength secondary to bronchospasm. Her chest x-ray
showed mildly improved interstitial edema. Her hematocrit
remained stable. Her wheezing was still present on
auscultation of her lungs but diminished from prior exam. We
continued aggressive pulmonary toiletry and physical therapy.
Ambulation in the chair was begun. Diuresis was continued.
The patient remained in the VICU.
On postoperative day #3, the patient received a total of 40
Lasix IV during the previous 24 hours. She remained afebrile
and hemodynamically stable. She was negative 2600. Her
hematocrit remained stable at 33.2, although her white count
remained elevated at 24. Chest x-ray was unremarkable. CPKs
were obtained; total CPK peaked at 236, with an MB of 5, and
a troponin less than 0.3.
Her respiratory status seemed much improved. She continued
on the current management. Narcotics were discontinued. She
remained in the VICU. Because of the persistent white count
elevation, Infectious Disease was consulted. Sputum culture
from [**3-28**] showed greater than 25 polys, with 40 epithelials,
but 1+ ................. consistent with oropharyngeal flora.
A chest x-ray was pending. Urinalysis C&S was no growth.
The foot swab gram was with no polys, 2+ gram positive cocci,
pairs, chains, and clusters. It grew out MSSA. The blood
cultures were no growth. The abdominal ultrasound showed
normal liver with moderate distended gallbladder with no
stones, no wall thickening, no dilated ducts. Chest x-ray
showed resolved congestive failure with a left lower lobe
atelectasis. The foot film showed no evidence of
osteomyelitis.
She was begun on Ceftriaxone for her left lower lobe
infiltrate, and she was continued on Oxacillin. The
Levofloxacin and Flagyl were discontinued. She remained in
the VICU.
On postoperative day #5, she was transferred out of the VICU.
She remained afebrile. She did have some end expiratory
wheezing, but otherwise the lungs were unremarkable. The
left foot erythema was nearly gone. The white count was at
22.3. Her neutrophils were 68, lymphs 22, and monos 7. The
patient continued to progress. Repeat x-ray was
unremarkable, and the Ceftriaxone was discontinued.
Recommendations of Infectious Disease were to continue her
Oxacillin through her anticipated bifemoral surgery and then
to continue antibiotics two weeks postsurgery.
On [**2107-4-11**], the patient underwent a right
axillo-bilateral femoral artery bypass with 8 mm [**Doctor Last Name 4726**]-Tex
graft. She tolerated the procedure well. She required 1 U
packed red blood cells intraoperatively and was transferred
to the PACU in stable condition. Her immediate postoperative
check revealed her to be stable. She was on Nitroglycerin at
3 mg/kg/min. Her hematocrit was 32. Chest x-ray was
unremarkable. The patient was neurologically intact. Groin
was without hematomas bilaterally, and she had palpable
dorsalis pedis and posterior tibial on the right and
Dopplerable dorsalis pedis and posterior tibial on the left.
The patient continued to remain stable. She was continued on
around-the-clock nebulizations and was transferred to the
VICU for continued monitoring and care. She still required
her Nitroglycerin to maintain her systolic below 110. Her
exam was unremarkable. Her Nitroglycerin was weaned, and
oral medications were begun. Fluids were Hep-Locked. Diet
was advanced as tolerated. She was continued on subcue
heparinization for DVT prophylaxis.
On postoperative day #2, she continued to do well. Her
hematocrit remained stable at 31.1. Her white count peaked
at 28.3. Her electrolytes were unremarkable. Her CVL was
discontinued, and a peripheral line was placed. The Foley
was maintained. She otherwise did well.
On postoperative day #3, there were no overnight events, and
the hematocrit remained stable at 31.9, and the white count
was decreased to 25.7. The right groin was mildly
erythematous. There was no hematoma. The right dorsalis
pedis and posterior tibial were palpable. The left dorsalis
pedis and posterior tibial remained Dopplerable. Chest exam
was unremarkable. A PICC line was placed for continued for
continued antibiotic therapy. Physical Therapy was requested
to see the patient and begin assessment for rehabilitation
placement. The Foley was discontinued.
The patient was discharged in stable condition.
DISCHARGE MEDICATIONS: Aspirin 325 mg q.d., Tylenol 650 mg
q.4 hours p.r.n., Flovent 2 puffs b.i.d., Lopressor 25 mg
b.i.d., hold for systolic blood pressure less than 100, heart
rate less than 60, subcue Heparin 5000 U t.i.d., Synthroid 75
mcg q.d., Oxacillin 1 g IV q.6 hours, this is to be continued
for a total of two weeks from [**4-1**], to [**4-15**], Albuterol
nebulizer q.4 hours p.r.n., Aricept 5 mg q.d., Lipitor 20 mg
q.d.
DISCHARGE DIAGNOSIS:
1. Bilateral carotid disease status post left carotid
endarterectomy.
2. Left foot ischemic ulcerations with cellulitis, status
post axillo-bifemoral bypass.
3. Asthma with exacerbation, treated.
4. Congestive heart failure, resolved.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2107-4-4**] 10:29
T: [**2107-4-4**] 10:41
JOB#: [**Job Number 33875**]
ICD9 Codes: 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2412
} | Medical Text: Admission Date: [**2179-2-8**] Discharge Date: [**2179-2-12**]
Date of Birth: [**2125-1-21**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old
white female with a history of hypertension,
hypercholesterolemia, and smoking history, who was
transferred to [**Hospital1 69**] with
acute anterior myocardial infarction, status post failed
thrombolysis at outside hospital.
The patient reports onset of symptoms on the morning of
admission of acute midback pain with eventual radiation to
the chest, seven out of ten, with radiation to her left upper
extremity with associated shortness of breath, nausea and
diaphoresis.
She called EMS within five minutes and was brought to [**Hospital3 6454**] Emergency Department where she was found to have
anterior ST elevations in V1 through V4. She was given
Morphine 2 mg intravenously times two, sublingual
Nitroglycerin and Nitroglycerin drip, Heparin and Reteplase
times two.
Per records, she arrived at the [**Hospital3 1280**] Emergency
Department at 10:40 a.m. Symptom onset was approximated to
be at 10:00 a.m. She received her first dose of Reteplase at
10:53 a.m. and her second dose at 11:23 a.m. Her symptoms
did not improved and her ST elevation persisted and she was
transferred to [**Hospital1 69**] for
emergent catheterization.
She arrived at the catheterization laboratory at 1:30 p.m.
At cardiac catheterization, she was found to have a tortuous
coronary circulation with a totally occluded distal left
anterior descending which was stented with timi two flow post
and complicated by grade B dissection distally. She was
given intracoronary vasodilators and no further intervention
was pursued. Her left circumflex, right coronary artery and
left main coronary artery were without significant disease.
A left ventriculogram was performed and notable for
anteroapical and inferoapical akinesis with an ejection
fraction of 40%.
Right heart cardiac catheterization revealed pulmonary
capillary wedge pressure of 18 and right atrial pressure of
13. Postprocedure, she was given full dose Integrilin for 18
hours.
Upon arrival to the CCU, she had the chief complaint of
nausea but denied shortness of breath or chest pain.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Osteoporosis.
4. History of atypical colitis, steroid dependent since
[**9-4**]. History of diagnosis of collagenous colitis in the past.
6. Status post tubal ligation.
MEDICATIONS ON ADMISSION:
1. Zestril 2.5 mg p.o. once daily.
2. Prednisone 20 mg p.o. once daily.
3. Asacol 1600 mg p.o. three times a day.
4. Rowasa enemas PR once daily.
5. Fosamax 10 mg p.o. once daily.
6. Prempro p.o. once daily.
7. Serax p.r.n.
8. Zomig p.r.n.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: No history of early coronary artery disease
or myocardial infarction.
SOCIAL HISTORY: The patient lives in [**Location 38080**] with
husband. She has two children. She has smoked one pack per
day since college. She has one to two cocktails per night.
Recently laid off.
PHYSICAL EXAMINATION: On examination, temperature is
afebrile, blood pressure 135/74, heart rate 90, respiratory
rate 16, oxygen saturation 98% on two liters. In general,
the patient is somnolent in no apparent distress. Head,
eyes, ears, nose and throat - The pupils are equal, round,
and reactive to light and accommodation. Extraocular
movements are intact. Mucous membranes are mildly dry. The
neck is soft, supple, no lymphadenopathy, jugular venous
distention, thyromegaly or masses. Cardiac examination -
regular rate and rhythm, no murmurs, S4 gallop. The lungs
are clear to auscultation bilaterally. The abdomen is soft,
nondistended, nontender, no organomegaly or masses,
normoactive bowel sounds. Extremities - right groin with
small hematoma. Extremities without edema, warm and with
good distal pulses. Neurologically, the patient is alert and
oriented times three, grossly nonfocal.
LABORATORY DATA: White count 15.8, hematocrit 36.5,
platelets 238,000. INR 1.1. Sodium 137, potassium 4.7,
blood urea nitrogen 7, creatinine 0.6, glucose 150. CK peak
1148, CK MB peak 150.
Initial electrocardiogram normal sinus rhythm, normal axis,
intervals, 2.[**Street Address(2) 2811**] elevations in V2 through V4 with
peaked T waves, 1.[**Street Address(2) 2811**] elevations in I and II, 0.[**Street Address(2) 38081**] elevations in V5 and V6.
HOSPITAL COURSE:
1. Coronary artery disease - Status post acute anterior
myocardial infarction, total occlusion of the distal left
anterior descending, status post left anterior descending
stent, complicated by distal dissection and with timi two
flow post intervention. The patient was hemodynamically
stable throughout her hospitalization. Her CK peaked at 1148
and then trended down. She was treated with Integrilin for
18 hours postcatheterization and then received Aspirin,
Plavix, beta blocker and ace inhibitor. She was also started
on Lipitor for a lipid panel with total cholesterol of 249,
and LDL of 143. She will be discharged on Aspirin, Plavix to
finish one month course, Atenolol, Zestril and Lipitor.
2. Pump - Left ventriculogram during cardiac catheterization
was notable for apical akinesis and ejection fraction of 40%.
She had no signs or symptoms of congestive heart failure
during her hospitalization. She was started on beta blocker
and ace inhibitor as above. Given her apical akinesis, she
was started on anticoagulation initially with Heparin drip
and then with low molecular weight Heparin as well as
Coumadin. She will be discharged on Lovenox and Coumadin, to
have INR followed up as an outpatient.
3. Electrophysiology - The patient with no adverse events on
telemetry during her hospitalization except for rare
premature ventricular contractions.
4. Hematology - The patient with right groin hematoma,
status post cardiac catheterization. She was also noted on
the following evening to have a bruit over that area. An
ultrasound revealed 1.7 by 2.0 centimeter pseudoaneurysm
which was treated with thrombin injection with good result.
Her anticoagulation was held temporarily during these events
and then restarted without complications. At the time of
discharge, the patient still has residual ecchymosis over her
right lower extremity as well as a small but stable hematoma.
5. Gastrointestinal - The patient had no gastrointestinal
symptoms during her hospitalization and was continued on her
outpatient regimen of Asacol and Rowasa enemas. She received
stress dose steroids pericatheterization and then was
switched to a p.o. Prednisone taper starting at 60 mg to be
tapered down to her baseline of 20 mg.
6. Endocrine - The patient has been on Prempro as an
outpatient. This was held in the setting of her acute
myocardial infarction but she will be able to restart this as
an outpatient.
MEDICATIONS ON DISCHARGE:
1. Enteric Coated Aspirin 325 mg p.o. once daily.
2. Plavix 75 mg p.o. once daily, to continue one month
course.
3. Coumadin 5 mg p.o. once daily.
4. Lovenox 60 mg subcutaneous times three more doses.
5. Zestril 2.5 mg p.o. once daily.
6. Atenolol 25 mg p.o. once daily.
7. Prednisone taper down to 20 mg once daily.
8. Asacol 1600 mg p.o. three times a day.
9. Rowasa enema once a day.
10. Fosamax 10 mg p.o. once daily.
11. Prempro p.o. once daily.
12. Serax p.r.n.
The patient has been ask to discontinue Zomig in the setting
of coronary artery disease.
DISCHARGE FOLLOW-UP: With primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 9959**]
[**Name (STitle) 9960**], telephone [**2179**].
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 4925**]
MEDQUIST36
D: [**2179-2-12**] 13:01
T: [**2179-2-15**] 17:11
JOB#: [**Job Number **]
ICD9 Codes: 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2413
} | Medical Text: Admission Date: [**2181-11-17**] Discharge Date: [**2181-11-24**]
Date of Birth: [**2126-10-22**] Sex: M
Service: SURGERY
Allergies:
Penicillin G
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55 M hospitalized in [**2180**] for severe necrotizing pancreatitis.
He was eventually
discharged to rehab after multiple laparoscopic necrosectomies
as well as takedown of an EC fistula and SBR. He was in his
usual state of health until 3 days ago when he started having
gradual onset of epigastric pain. Pain consistently worsened
over the past 48 hours so he presented to [**Hospital3 **] where
he got a CT abdomen and then transferred to [**Hospital1 18**]. En route he
vomited 3
times. He denies fevers, chills, shortness of breath, or chest
pain. Today he has had zero bowel movements, when normally he
has 6 loose ones daily. He also reports that he resumed drinking
[**Hospital1 **] 3 months ago (approximately [**1-20**] pints per day). Despite
2mg IV morphine every 15 minutes, he complains of severe
abdominal pain.
Past Medical History:
PMH:
Hypertension, Ulcerative colitis s/p colectomy, J pouch, Removal
of nonmalignant brain tumor, [**Month/Day (2) **] abuse, Chronic Methadone
Maintenance
PSH:
Takedown EC fistula with small-bowel resection and primary
anastomosis, extended adhesiolysis, repair of enterotomy, G-tube
placement, and J-tube placement [**2180-5-25**]; resection non-malignant
brain tumor [**2161**]; colectomy [**2157**]
Social History:
Lives w/sister. History long-term smoking. Chronic [**Year (4 digits) **] use.
Denies IVDU.
Family History:
Not-contributory
Physical Exam:
On discharge:
The patient was afebrile with vital signs stable.
Gen: AAOx3. NAD.
Card: RRR. No r/g/m
Pulm: CTA b/l. No r/r/w/c
Abd: Soft. ND. NT. NO rebound tenderness or guarding noted on
exam.
Pertinent Results:
[**2181-11-17**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2181-11-17**] 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2181-11-17**] 06:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2181-11-17**] 06:30PM URINE AMORPH-MOD
[**2181-11-17**] 04:09PM LACTATE-3.0*
[**2181-11-17**] 03:55PM GLUCOSE-152* UREA N-26* CREAT-1.6* SODIUM-139
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-29 ANION GAP-16
[**2181-11-17**] 03:55PM ALT(SGPT)-150* AST(SGOT)-160* ALK PHOS-655*
TOT BILI-2.2*
[**2181-11-17**] 03:55PM LIPASE-1334*
[**2181-11-17**] 03:55PM WBC-9.8 RBC-3.73* HGB-12.0* HCT-35.6* MCV-96
MCH-32.2* MCHC-33.7# RDW-13.2
[**2181-11-17**] 03:55PM NEUTS-91.6* LYMPHS-3.7* MONOS-4.4 EOS-0.1
BASOS-0.3
[**2181-11-17**] 03:55PM PLT COUNT-326
[**2181-11-17**] 03:55PM PT-12.3 PTT-21.0* INR(PT)-1.0
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. The patient arrived on the floor NPO,
on IV fluids, with a foley catheter, Dilaudid PCA for pain
control. The patient was hemodynamically stable.
Neuro: The patient received morphine IV in the mergency
department with minimal dimunition of pain as per patient. On
admission the patient was placed on a Dilaudid PCA.
CV: The patient was written for Hydralazine with holding
parameters for proper blood pressure control. Vital signs were
routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was made NPO with IV fluids. The patient
was placed on Protonix IV for GI prophylaxis, as well as Zofran
for nausea. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
On HD#2, the patient developed signs of delirium tremens and
acute [**Month/Day/Year **] withdrawal. The patient was transferred to the ICU
and was placed on Diazepam, Lorazepam, and Midazolam as needed
to control his delirium tremens. The patient was resuscitated
wih IVF which was increased from 150 to 200. The patient was
placed on Mechanical Ventilation with Assist control (Volume
Targeted). Tidal volume was 500 cc. Respiratory rate was 18.
PEEP was 5cm/h2o. FIO2 was maintained at 80%. The FiO2 was
weaned to 40 by the evening of the same day. The patient was
started on Ampicillin-Sulbactam.
HD#3: The patient was given a PICC line for total parenteral
nutrition. His Dilaudid PCA was switched to a PRN Dilaudid. The
patient was also started on methadone. The ampicillin sulbactam
was discontinued on the evening of that day.
HD#4: The patient's mechanical ventilation was changed to CPAP
(5 cm/h2o PEEP: 5 cm/h2o FIO2: 40 %) early in the morning. After
several hours tolerating this, the patient was extubated. The
patient was given a PICC line.
HD#5: The patient was started on sips, wich he tolerated. The
patient was transferred to the floor, with a Dilaudid IV PRN for
pain control, On IV fluids, on sips, and on telemetry. The
patient had a clonidine patch as well as Hydralazine with hold
parameters for blood pressure control.
HD#6: The patient was found to have a swollen upper extremity.
An UE U/S was obtained which revealed no DVT in the upper
extremity. The patient was started on clear liquids and HCTZ
which the patient tolerated. The Protonix was switched to PO
from IV. The patient was written for PO medications including
Mirtazapine and Citalopram.
HD#7: The patient's Diazepam was weaned from Diazepam 5 mg PO/NG
Q6H
to Q8H. The patient's telemtry was stopped. Diet was advanced to
full liquids. The patient was written fro tylenol and ibuprofen
for pain control.
HD#8: The patient's diet was advanced to regular which he
tolerated. At the time of discharge, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. The PICC line was d/c'ed
prior to discharge.
Medications on Admission:
klonopin 1', remeron 15 QHS, HCTZ 12.5', ? other
anti-hypertensives but patient unsure
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. methadone 10 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily).
3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
acute on chronic pancreatitis; [**Month/Day/Year **] withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
[**Last Name (un) **] were seen in the hospital with acute on chronic
pancreatitis. Your hospital stay was complicated by withdrawal
and delirium tremens. You were given an appropriate course of
valium to treat this very dangerous condition. This medication
is being stopped before your discharge. Please return to the
hospital if you experience palpitations, vomiting, nausea,
excessive sweating, or fevers.
You have been diagnosed with chronic pancreatitis. Your pancreas
is inflamed and may be permanently scarred. The pancreas is an
organ that produces chemicals and hormones that help you digest
food and use sugar for energy. Gallstones are one of the most
common causes of pancreatitis. These hard stones form in the
gallbladder, which shares a passage with the pancreas into the
small intestine. If gallstones block this passage, fluid can't
escape the pancreas. The fluid backs up and causes inflammation
and pain. Chronic use of [**Last Name (un) **] is another cause of chronic
pancreatitis. Here's what you can do at home to help with your
condition.
Home Care
Ask someone to drive you to appointments until you know how the
illness has affected you.
Tell your doctor about any medications you are taking. Some
medications can cause pancreatitis.
Ask your doctor about over-the-counter medications for pain.
Work with your doctor to control blood sugar levels.
Learn to take your own pulse. Keep a record of your results.
Ask your doctor [**First Name (Titles) 6643**] [**Last Name (Titles) 21636**] mean that you need medical
attention.
Watch for symptoms that your pancreatitis is getting worse.
These symptoms include abdominal pain, nausea and vomiting, and
fever.
Diet Changes
Eat a low-fat diet. Ask your doctor [**First Name (Titles) **] [**Last Name (Titles) 81326**] and other diet
information.
Take vitamins A, D, and E, and add calcium to your diet.
Stop drinking, especially if your illness was caused by [**Last Name (Titles) **].
Ask your doctor [**First Name (Titles) **] [**Last Name (Titles) **] abuse programs and support groups
such as Alcoholics Anonymous.
Ask your doctor [**First Name (Titles) **] [**Last Name (Titles) 16615**] medications that can help you
stop drinking.
When to Call Your Doctor
Call your doctor right away if you have any of the following:
Fever above 100??????F
Severe pain in your upper abdomen to your back
Nausea and vomiting
Abdominal swelling and tenderness
Dizziness or lightheadedness
Yellowing of your skin or eyes (jaundice)
Bruises on your abdomen or back
Rapid pulse
Shallow, fast breathing
Loss of weight without dieting
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2182-1-4**] 11:00 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]. You will have a
MRI prior your appointment with Dr. [**Last Name (STitle) **], please call Dr. [**Name (NI) 60612**] office to clarify the date and time of the MRI.
.
Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-20**] weeks after discharge
Completed by:[**2181-12-4**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2414
} | Medical Text: Admission Date: [**2125-3-28**] Discharge Date: [**2125-4-6**]
Date of Birth: [**2086-7-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 25342**]
Chief Complaint:
found unconcious in front of drug deal outside [**Doctor First Name 60501**] place
Major Surgical or Invasive Procedure:
intubation in micu
History of Present Illness:
Patient is a 38 year old female with h/o etoh abuse, asthma,
seizure d/o was found unresponsive outside [**Doctor First Name **] place.
She was found with empty bottle of tegretol (2 wk supply, bottle
date 4/5/5)
Full bottle of Trazodone 400mg HS (date [**2125-3-17**])
Full bottle of Fluoxitine 80mg daily (date [**2125-3-17**])
Multiple samples of [**Doctor First Name **] in Backpack
Was brought to [**Hospital1 18**], and did not respond to narcan so was
intubated for airway protection. Tox screen + for benzo's and
etoh. Was initially treated with levo/flagyl for emperic
coverage for aspiration pneumonia but then was d/c'd on [**3-31**].
She was extubated on [**4-1**].
Was treated with propafol and then valium for withdrawal in MICU
Now more awake, no n/v/d/cp/sob,patient is not complaining
Past Medical History:
According to [**Hospital3 2568**] notes, Asthma, Seizure DO, diet
controlled DM?
Social History:
lives at pine street inn, long hx of etoh use. Has a husband
(who only wants to be involved if consent is needed etc) and two
teenage children.
Family History:
Family hx: NC
Physical Exam:
O: T 98.9 BP 136/90 P76 RR 20
Gen: NAD, tearful, slightly tremulous
HEENT: anicteric, PERRLA, EOMI
Lungs: mild scattered wheezes otherwise CTA x 2
Heart: S1, S2 no m/r/g
Abd: soft, nd, mild tenderness in suprapubic area
Ext: no c/c/e
bilateral numbness up to knees, +pulses
Pertinent Results:
CXRAY [**4-3**]- neg
[**2125-3-28**] 12:02PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2125-3-28**] 12:02PM ASA-NEG ETHANOL-263* CARBAMZPN-4.7
ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2125-3-28**] 12:02PM ALT(SGPT)-39 AST(SGOT)-67* LD(LDH)-262*
CK(CPK)-177* ALK PHOS-50 AMYLASE-28 TOT BILI-0.3
iron (low nl), b12, folate, ferritin all wnl
Brief Hospital Course:
A/P: Patient is a 38 year old female who was transferred out of
MICU s/p intubation for possible post ictal vs. toxic ingestion.
On admission to the medical service patient was off ativan gtt.
ETOH withdrawal-level 263 on arrival to ED, out of window for
DT's on admission to medicine. She was started on a ciwa scale
and did not require valium after the second day of admission.
She was given folate, MVI, thiamine. At the day of discharge
she was less tremulous and able to walk around with no
withdrawal symptoms.
seizure d/o- had a witnessed grand mal seizure night before
admission, had adequate levels of tegretol at admission.
Unclear etiology of seizure disorder. Is not followed by a
neurologist (she was in the past but does not remember his name)
She was continued on tegretol when admitted to medicine and her
levels were within nl limits.
asthma- nebs prn, will try to send patient with an inhaler when
she leaves
Psych- after their first meeting with the patient, psych did not
think that the patient has capacity to leave, thought patient
may have korsakoff's. However, pt/ot cleared the patient and
the next day psych thought that she was much clearer stating
that their initial concerns may have stemmed from mild
withdrawal symptoms. They thought she was safe to leave the
hospital. She wanted to leave b/c she wanted to see her son off
to the prom. This was corrobarated with the son over the phone.
-I have set her up with an outpatient psych appointment
-I have only given her enough trazadone, and fluoxetine to last
her to her pcp's appointment due to the worry that she may have
overdosed. Initially the patient should be given short
prescriptions for these meds until it is obvious that the
patient is reliable and not overdosing.
-I will continue the trazodone since this is vital for her
seizure d/o
numbness- unclear etiology, did improve over hospitalization, nl
b12, may be diabetes related although fs wnl in micu, should
have continued evaluation and monitor for progression.
HTN- she was well controlled on outpatient clonidine .1 mg
Anemia- normocytic, low nl iron, nl b12/folate
full code this admission
Medications on Admission:
carbamazepine
trazadone
fluoxetine
clonidine
Discharge Medications:
1. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*50 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-10**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*qs qs* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Trazodone HCl 100 mg Tablet Sig: Four (4) Tablet PO at
bedtime for 6 days.
Disp:*24 Tablet(s)* Refills:*0*
8. Fluoxetine HCl 40 mg Capsule Sig: Two (2) Capsule PO once a
day for 6 days.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
asthma
seizure d/o
Discharge Condition:
stable
Discharge Instructions:
Please come directly to the ED if you have chest pain, or
shortness of breath.
Please stop drinking alcohol- it may kill you.
Followup Instructions:
Please see a pcp next week as listed below
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2125-4-11**] 2:30
Completed by:[**2125-4-11**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2415
} | Medical Text: Admission Date: [**2188-7-2**] Discharge Date: [**2188-7-17**]
Date of Birth: [**2188-7-2**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: This interim covers from dates
of [**2188-7-2**] through [**2188-7-17**].
The patient is a 15-day-old former 34 and 3/7 weeks infant
who is now corrected to 36 and 4/7 weeks gestational age. He
was born at 1,800 gm by spontaneous vaginal delivery of a 30-
year-old G 1, P 0 mother with the following prenatal labs: O
positive, antibody negative, rubella immune, RPR nonreactive,
hepatitis B surface antigen negative. The pregnancy was
complicated by supraventricular tachycardia with a normal
cardiac workup. In addition, this was a spontaneous
diamniotic-dichorionic twin pregnancy of which this infant
was twin B.
The mother's membranes were ruptured for approximately eight
hours prior to delivery on twin A. However, this twin's
membranes were not ruptured until the time of delivery.
Nonetheless, the mother had received two doses of ampicillin
prior to delivery. This infant emerged active but pale and
limp. He had Apgar scores of seven and eight with
unremarkable resuscitation. He developed some mild symptoms
of respiratory distress and was admitted to the Neonatal
Intensive Care Unit for further management of prematurity.
PHYSICAL EXAMINATION: On admission, weight was 1,800 gm
(fiftieth percentile), length 44.5 cm (fiftieth percentile),
head circumference 31 cm (twenty-five to fiftieth
percentile). General: Infant of stated gestation age. Vital
signs: Temperature 98.1, heart rate 160, respiratory rate
56, 100 percent saturation on room air, blood pressure 56/43,
D6 of 62. HEENT: Normocephalic, anterior fontanel open and
flat, palate intact, neck supple. Cardiovascular: Regular
rate and rhythm, no murmur. Femoral pulses two plus
bilaterally. Lungs: Clear to auscultation bilaterally,
decreased breath sounds, intermittent grunting with constant
intercostal retractions and nasal flaring. Abdomen: Soft
with active bowel sounds, no masses or distention.
Genitourinary: Normal male, testes palpable bilaterally,
anus patent. Spine: Midline without any dimpling. Hips:
Stable. Clavicles: Intact. Neurological: Motor, tone and
reflexes appropriate for gestational age.
HOSPITAL COURSE: Respiratory: This infant had mild
respiratory symptoms for which he was started on CPAP. The
patient did quite well with need for CPAP support for only
about 24 hour's duration. After that time, he has been on
room air without any concerns. He is not on caffeine nor has
he had any apnea of prematurity.
Cardiovascular: The patient has been quite stable from a
cardiovascular standpoint with intermittent soft murmur
present.
Fluids, electrolytes and nutrition: The patient was able to
start feeds on day of life one with gradual advance. At
present, he is on breast milk 24 k-cal at 150 cc/kg/day. He
takes approximately one-half of this feed orally. The
additional feeds are still by gavage. The patient is making
gradual progress on his oral feeding, but still demonstrates
dysmaturity.
Gastrointestinal: The patient had a benign course from the
standpoint of hyperbilirubinemia. He never required
phototherapy and had reassuring levels.
Hematology: Admitting CBC had a platelet count of 225 with a
hematocrit of 43.7.
Infectious Disease: This infant had a rule out sepsis at the
time of delivery with reassuring CBC (white blood cell count
of 9.0 with 22 polycytes and zero bands) and a negative
culture. He has had no additional issues from an infectious
standpoint.
Health Maintenance: Hepatitis B was administered on
[**2188-7-15**] with a normal DARE on [**2188-7-16**].
INTERIM DIAGNOSES:
1. Premature infant at 34 and 3/7 weeks gestation, twin B.
2. Mild HMD, resolved.
3. Rule out sepsis, negative.
4. Feeding dysmaturity.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 55724**]
MEDQUIST36
D: [**2188-7-17**] 16:19:33
T: [**2188-7-17**] 16:47:01
Job#: [**Job Number 58447**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2416
} | Medical Text: Admission Date: [**2103-11-6**] Discharge Date: [**2103-12-9**]
Date of Birth: [**2041-12-27**] Sex: M
Service: SURGERY
Allergies:
Gluten
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
free air
Major Surgical or Invasive Procedure:
EGD x2
exlap, small bowel resection x2 with primary reanastamosis
exlap, small bowel resection, jejunal stoma formation, mucous
fistula formation for anastomotic breakdown
percutaneous cholecystostomy tube placement
percutaneous drainage of perihepatic fluid collection
bilateral chest tube placement
History of Present Illness:
Mr. [**Known lastname 496**] is a 61 M with a medical history notable for
celiac disease. Of note, he was recently admitted to [**Hospital1 18**] from
[**2103-9-10**] to [**2103-9-19**] for worsening GI symptoms thought to be
related to his difficult-to-control celiac disease. He was
started on budesonide, loperamide, and TPN. An endoscopy
performed during that admission revealed duodenitis.
He reports feeling well at dischcarge on the TPN and was even
able to travel on [**Hospital3 **]. However, approximately 3 weeks ago
he noted marked fatigue and dyspnea on exertion. He is currently
very weak and unable to perform basic activities around his
house. His abominal cramping has also increased and his diarrhea
has returned. His bowel movements are "muddy" with rare bright
red blood (usually with straining), but no melena. No NSIADs or
recent alcohol use.
Since discharge he was started on prednisone and started on
mercaptopurine on [**11-5**]. He was seen in [**Hospital **] clinic on [**11-5**].
After his routine laboratory studies returned with worsening
anemia he was referred to the ED.
Vital signs on arrival to [**Hospital1 18**] ED: T 98.2, P 100, BP 129/76,
100% RA. His evaluation in the ED was notable for a HCT of 22.5,
guaiac positive stool, and a negative gastric lavage. In the ED
he received pantoprazole 40mg IV, morphine, 1 unit of packed red
blood cells, and IV fluids.
On [**2103-11-7**] he underwent EGD showing friable duodenal mucosa
with contact bleeding. Since the procedure he has had worsening
abdominal pain, and was found to have copious free air on CXR
and KUB. We were contact[**Name (NI) **] to evaluate him for possible
perforation.
Past Medical History:
Hypertension
Celiac disease diagnosed in [**2097**] after work-up for osteoporosis
Social History:
Patient lives with his wife. [**Name (NI) **] is a retired history teacher. He
has two children. Patient reports smoking a pipe occassionally
and previously drank wine on occasions but none recently.
Family History:
He is adopted and has no family history of sprue of which he is
aware. Has two healthy children.
Physical Exam:
Vital Signs: T 99.3, P 83, BP 132/83, 96% on RA. Current pain
[**4-23**].
Physical examination prior to EGD by GI on [**2103-11-7**]:
- Gen: Thin male, appears chronically ill.
- HEENT: Pale conjunctiva. Oropharynx clear w/out lesions.
- Chest: Normal respirations and breathing comfortably on room
air. Lungs clear to auscultation bilaterally.
- CV: Regular rhythm. Normal S1, S2. No murmurs or gallops. JVP
<5 cm.
- Abdomen: Normal bowel sounds. He is diffusely tender
throughout his abdomen with no rebound or guarding.
- Extremities: 1+ ankle edema to the knees bilaterally.
- Skin: No lesions, bruises, rashes.
- Neuro: Alert, oriented x3. Good fund of knowledge. Able to
discuss current events and memory is intact. CN 2-12 intact.
Speech and language are normal.
- Psych: Appearance, behavior, and affect all normal.
Upon surgical evaluation after the EGD:
96.8 127 128/74 22 99% 2L
uncomfortable, anxious
no respiratory distress
abdomen distended, tympanytic +rebound +guarding
no scars, no hernias
Pertinent Results:
[**2103-11-5**] 09:44AM WBC-20.6* RBC-3.01*# HGB-8.0*# HCT-25.8*#
MCV-86 MCH-26.7* MCHC-31.2 RDW-15.6*
[**2103-11-5**] 09:44AM NEUTS-95* BANDS-0 LYMPHS-2* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2103-11-5**] 09:44AM CRP-126.1*
[**2103-11-5**] 09:44AM TOT PROT-4.8* ALBUMIN-2.1* GLOBULIN-2.7
CALCIUM-7.3* PHOSPHATE-2.1*# MAGNESIUM-2.2
[**2103-11-5**] 09:44AM ALT(SGPT)-37 AST(SGOT)-18 LD(LDH)-183 ALK
PHOS-209* TOT BILI-0.6
CXR [**2103-11-7**]: In comparison with the study of [**11-6**], there is a
substantial amount of free intraperitoneal gas beneath the
hemidiaphragms. Atelectatic change with possible effusion again
seen at the right base.
CTAP [**2103-11-8**]: 1. Extraluminal oral contrast seen adjacent to a
loop of mid jejunum in the lower mid abdomen, presumably
representing a site of small bowel perforation with resultant
pneumoperitoneum and fluid in the abdomen. 2. Small bowel mural
thickening, presumably related to known diagnosis of celiac
sprue. 3. Large area of mesenteric adenopathy and 'mistiness'.
This finding is unchanged since [**2103-9-11**] and though it
may be related to reactive changes from the known celiac
disease, lymphoma is another consideration and ongoing followup
is recommended as per the previous study. 4. Distended
gallbladder
PATHOLOGY SMALL BOWEL RESECTION [**2103-11-8**]: 1) Small bowel, at 110
cm, resection (A-B, Q-AB): Small bowel segment with multiple
perforations and associated full thickness ulceration, exudative
inflammation and extensive granulation tissue. Adjacent intact
mucosa with extensive villous blunting with increased
intraepithelial lymphocytes consistent with prior history of
refractory celiac disease. Atypical lymphoid infiltrate, refer
to part 2 for further characterization. 2) Small bowel,
resection (C-P, AC-AJ): Small bowel segment with multiple
perforations and associated full thickness ulceration, exudative
inflammation and extensive granulation tissue. Adjacent intact
mucosa with extensive villous blunting with increased
intraepithelial lymphocytes consistent with prior history of
refractory celiac disease. Atypical lymphoid infiltrate, see
note.
PATHOLOGY SMALL BOWEL RESECTION [**2103-11-17**]: Small bowel, resection:
1. Small intestinal segment with acute and chronic
inflammation, patchy ulceration, focal anastomotic site mucosal
necrosis, prominent submucosal edema, and extensive serositis;
no definitive perforation identified. 2. Viable margins with
marked edema, focal mucosal ulceration and mild active
inflammation. 3. Increased intraepithelial lymphocytes, villous
shortening, and crypt hyperplasia, consistent with involvement
by patient's known celiac disease; Paneth cells do not appear
overall decreased in viable mucosal areas. See hemepath note.
4. One unremarkable lymph node.
CT Torso [**2103-11-27**]: 1. Bilateral pleural effusions, increased
compared with previous study. 2. Diffuse anasarca and diffusely
abnormal small and large bowel wall thickening consistent with
mucosal edema. Given the diffuse involvement this likely
represents third spacing. 3. Diffuse mesenteric fat stranding
and mesenteric lymphadenopathy. 4. Moderate amount of free fluid
in the pelvis and both paracolic gutters. No discrete localized
fluid collection seen however infection cannot be excluded. 5.
Interval formation of bilateral stomas. 6. Lower abdominal wound
dehiscence. 7. Distended gallbladder. 8. Left inguinal hernia
containing fluid.
CT guided percutaneous cholecystostomy tube placement [**2103-11-29**]:
Technically successful percutaneous cholecystostomy tube
placement. Sample sent for microbiology analysis. A total of 200
cc of dark green turbid bile were aspirated.
CT guided percutaneous abdominal fluid collection drainage
[**2103-11-29**]: Technically successful aspiration and drainage
catheter placement right upper quadrant ascitic fluid pocket as
above. 200 cc clear straw-colored fluid were aspirated to bag.
CT Torso [**2103-12-5**]: 1. Stable bilateral pleural effusions. 2. New
diffuse bilateral ground glass opacities, infectious vs.
aspiration. 3. Thickened small and large bowel with surrounding
mesenteric stranding and fluid, relatively unchanged from prior.
4. Stable midline wound with interval resolution of associated
free air and contrast extravasation. Interval resolution of
anterior abdominal fluid collection in the right upper quadrant,
with interval placement of a peripherally placed percutaneous
drain. GJ-tube in place. 5. Cholecystomy drain in place with
surrounding decompressed gallbladder. 6. Stable pelvic fluid
collection with stable adjacent enhancement of peritoneum.
RUQ U/S [**2103-12-6**]: 1. No intrahepatic biliary ductal dilatation.
2. 3-mm CBD containing echogenic material, most likely
representing sludge or pus. 3. Catheter within the gallbladder,
which appears collapsed. 4. No ascites. 5. Right pleural
effusion
Cholangiogram through percutaneous cholecystostomy tube
[**2103-12-6**]: free flow of contrast into the duodenum
Brief Hospital Course:
Mr. [**Known lastname 496**] is a 61 yo gentleman with severe, medically
refractory celiac disease who underwent push endoscopy on
[**2103-11-7**] with multiple biopsies. After this procedure, he
developed significant abdominal pain and a chest xray and KUB
showed massive free air. Follow up CT scan of the Abdomen
revealed contrast extravasation from the bowel lumen indicative
of perforation. For this reason, he was taken emergently to the
OR on [**2103-11-8**] and underwent bowel resections x2 (over 160 cm of
small bowel in total) with two primary reanastamoses.
Unfortunately, these anastamoses broke down over the ensuing
days likely secondary to his baseline poor nutrition as well as
the inherent friability of his intestines secondary to his
severe, medically refractory sprue. He ultimately required
reoperation on [**2103-11-17**]. During this operation, a further 20 cm
of bowel were resected and a jejunal stoma as well as a mucous
fistula were created. The patient continued to do poorly overall
and ultimately was transferred to the ICU on [**2103-11-28**] for
respiratory distress and was intubated and later found to have
developed a hospital acquired pseudomonal pneumonia. During the
next 11 days, the patient developed a new fascial dehiscence
with enterocutaneous fistula which was controlled with bag
drainage. He also underwent percutaneous cholecystostomy tube
placement for a distended gallbladder and a drain placed
percutaneously into a perihepatic collection but this did little
to alleviate his problems. [**Name (NI) **] further developed an acutely
dropping hematocrit and underwent EGD which showed a fresh clot
but no active bleeding in his stomach. This was treated with a
pantoprazole drip. Concurrently, he developed worsening hepatic
failure with cholestasis and a bilirubin rising to 18.0 and
worsening coagulopathy indicative of liver failure. In a last
ditch effort to identify a source of his sepsis and worsening
organ failure, bilateral chest tubes were placed which drained
serous fluid. In discussions with his family, it was decided to
make him Comfort Measures Only on [**2103-12-9**]. He was terminally
extubated and passed soon thereafter.
His hospital course is summarized below by system:
Neuro: His pain was controlled throughout his hospital stay on a
combination of IV or PO medications. At the time of his terminal
extubation, he was placed on a fentanyl and versed drip to
ensure sufficient treatment of his pain, dyspnea, and anxiety.
CV: For most of his hospital stay, he remained, in general,
hemodynamically stable. In the last days of his hospitalization,
he had an ever-worsening pressor requirement and was ultimately
on levophed, neosynephrine, and vasopressin at the time of his
extubation. After extubation, his demise was so quick that the
pressors had not yet even been turned off.
Pulm: For the most part, the patient did well from a pulmonary
perspective. However, on transfer to the unit on [**11-28**], he had
begun to develop respiratory failure and was intubated for
hypoxemic respiratory failure thought to be secondary to
pseudomonal pneumonia. He grew out numerous colonies of P.
aeruginosa, most of which were resistant to numerous
antibiotics. During his last few days, chest tubes were placed
bilaterally to see if this would improve his pulmonary mechanics
and function. After his terminal extubation, he quickly
developed worsening hypoxemia and hypercarbia whereupon he
passed away quickly.
GI/FEN: After his endoscopy, he required emergent operation for
bowel perforation. At his first operation, at 7 enterotomies
were discovered in two different segments of bowel starting
approximately 110 cm from the ligament of Treitz. These two
areas of bowel (approximately 150 cm and 10 cm respectively)
were resected with primary reanastamoses. Initially, he seemed
to have tolerated the procedure as well as could be expected.
However, he soon developed serous drainage from the superior
portion of his wound and it was noted that he had a developing
fascial dehiscence. He went back to the OR and had the
intervening 20 cm of small bowel resected and the proximal end
of his bowel was brought out in the LLQ as a jejunal stoma. The
distal portion was brought out in the RLQ as a mucous fistula. A
gtube was also placed to help with feeds. His abdomen was again
reapproximated and retention sutures were left in place. His
initial high output from his jejunal stoma was treated with
tincture of opium as well as immodium and psyllium wafers
without much improvement in the total output. Ultimately, his
wound dehisced again along with the development of an
enterocutaneous fistula which was controlled with a large ostomy
appliance to the wound. He began growing pseudomonas from this
wound as well. In addition, in order to rule out and treat other
possible sources of his sepsis, he underwent percutaneous
cholecystostomy tube placement as well as drainage of a
perihepatic fluid collection. This proved to be futile. Although
earlier in his course he was able to take some POs, his gut did
not appear to tolerate any enteral nutrition either through the
Gtube or PO. The patient had been on TPN prior to his
hospitalization and this was continued in house due to concern
over the ability of his gut to absorb nutrition as well as over
his poor nutritional status in general. His albumin levels
remained low accordingly and he required lots of colloid and
crystalloid resuscitation as well as blood product transfusion,
when indicated, in order to maintain intravascular volume
although he developed progressively worsening anasarca
indicative of his overall poor nutritional status and inability
to tolerate enteral feeds. In the last week of his
hospitalization, as part of his overall septic picture, he
started to develop worsening liver failure with elevated
bilirubin, progressive coagulopathy which was complicated by an
UGIB as noted on repeat EGD. This was treated with transfusions,
vitamin K, as well as a pantoprazole drip.
GU: He had a foley in place for most of his hospital stay for
urine output monitoring. At some point he also grew out
pseudomonas from his urine as well. This infection was treated
concurrently with his pneumonia with broad-spectrum antibiotics.
Endo: After his initial surgery, he was given stress-dose
steroids and then was tapered off the steroids completely due to
concerns that they were adversely impacting his ability to heal
his wounds. Due to concerns for adrenal insufficiency, he
underwent a cortisol stimulation test which showed a normal
response in his adrenal glands. Blood sugars were monitored and
treated appropriately.
Heme: Due to his many surgeries and critically ill state, the
patient's white count and hematocrit were closely monitored.
Ultimately he had a rising white count (into the 30s) as well as
a falling hematocrit. He was treated with RBCs and other blood
products as necessary in order to treat his coagulopathy and
bleeding-induced anemia.
ID: ID consultation was obtained due to the patient's resistant
pseudomonus found in his sputum. He was treated with various
antibiotics and was ultimately placed on vancomycin, doripenem,
and amikacin for his hospital acquired PNA with double-coverage
of the pseudomonas.
Medications on Admission:
Prilosec 20mg daily
prednisone 40mg daily
Percocet PRN pain
mercaptopurine 50 mg daily
labetalol 50mg once daily
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
CELIAC DISEASE, SEVERE TYPE 2
Multiorgan system failure secondary to sepsis
Pseudomonas pneumonia
enterocutaneous fistula
anastomotic breakdown
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
ICD9 Codes: 0389, 5789, 2851, 4271, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2417
} | Medical Text: Admission Date: [**2150-3-29**] Discharge Date: [**2150-4-1**]
Service: MEDICINE
Allergies:
Anesthesia IV / Flagyl
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
ICU monitoring
History of Present Illness:
[**Age over 90 **] year old female with a history of paroxysmal atrial fib
presented to the ED with a chief complaint of chest pain. The
patient was recently discharged from the [**Hospital1 1516**] service on [**2150-3-25**]
after an attempt at chemical cardioversion with amiodarone
infusion and question DC cardioversion. During that
hospitalization, her rate was controlled and she was sent home
with PO amiodarone 200mg daily. Her VNA called in the day
following discharge that her rate was still elevated to 120s.
She was instructed to take amiodarone 200mg [**Hospital1 **] for one week in
an attempt to rate control. She was scheduled to follow up as an
outpatient, however she was experiencing chest pain at home and
presented to the ED. This morning she had chest pain while in
bed, it was band like on her left chest.
.
In the ED, the patient's HR was in the 150s with a SBP at 156 on
arrival. An ECG showed afib with LBBB. She had CEs sent which
were negative. The patient received ASA, Dilt 10mg IV x 2 and
attempted dilt drip temporarily, Amiodarone 400mg PO X1.
Lopressor 5mg IV x 3 given with no response. SBP down to 80s
following, although she was asymptomatic, she received 900ccs of
IVF. On transfer to the CCU, she continued to have mild chest
tightness and shortness of breath. She had a CXR which showed
evidence of volume overload.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Past Medical History:
HTN
Paroxysmal afib
Osteoarthritis
Hearing loss
s/p Appy
3 C sections
Diverticulitis
Mitral regurgitation- ECHO '[**42**] w/ EF 65%, 3+ MR, 2+TR, LVH
Depression
Osteoporosis
s/p right knee replacement
Social History:
Social history is significant for the absence of current or past
tobacco use. There is no history of alcohol abuse. Pt lives in
duplex with her dtr living upstairs and her son next door.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T=98.6 BP=106/70 HR=145 RR=36 O2 sat=92%
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no elevation of JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregularly irregular tachycardic, 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. Mild crackles BL, 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.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
.
Pertinent Results:
ECHO: The left atrium is dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-12**]+) mitral regurgitation
is seen. There is no pericardial effusion.
IMPRESSION: No intracardiac thrombus seen. Diffuse, but
non-mobile aortic atheromata.
.
CXR [**2150-3-29**]: In comparison to the prior study, there has been
progression of the interstitial and alveolar edema with slight
enlargement of the left
pleural effusion. Repeat radiography following appropriate
diuresis
recommended to assess for underlying infection
.
CXR [**2150-3-29**]: In comparison with the earlier study of this date,
the pulmonary vessels appear somewhat less engorged. Continued
left pleural effusion. Prominence of the right hilum persists,
much of which may merely be vascular. Mild atelectatic changes
are again seen at the left base.
.
CXR [**2150-3-31**]: As compared to the previous radiograph, moderate
bilateral pleural effusions have newly occurred. There is
associated retrocardiac atelectasis. The size of the cardiac
silhouette is mildly increased; there is an increase in vascular
diameters. In addition, mild peribronchial cuffing is seen.
Overall, these findings are suggestive of moderate pulmonary
edema.
Otherwise, no relevant changes, there is no evidence of newly
appeared
parenchymal opacities suggesting pneumonia.
.
Lab Results:
[**2150-3-29**] 10:30AM BLOOD WBC-14.1* RBC-5.36 Hgb-16.3* Hct-49.8*
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.2 Plt Ct-383
[**2150-3-29**] 05:12PM BLOOD WBC-17.8* RBC-4.97 Hgb-14.7 Hct-45.6
MCV-92 MCH-29.7 MCHC-32.3 RDW-14.1 Plt Ct-368
[**2150-3-30**] 05:06AM BLOOD WBC-17.6* RBC-4.64 Hgb-13.8 Hct-41.9
MCV-90 MCH-29.7 MCHC-32.9 RDW-14.0 Plt Ct-322
[**2150-3-31**] 02:33AM BLOOD WBC-16.9* RBC-4.52 Hgb-13.5 Hct-40.6
MCV-90 MCH-29.8 MCHC-33.1 RDW-14.0 Plt Ct-317
[**2150-4-1**] 06:20AM BLOOD WBC-14.1* RBC-4.38 Hgb-12.9 Hct-39.1
MCV-89 MCH-29.5 MCHC-33.0 RDW-13.8 Plt Ct-332
[**2150-3-29**] 10:30AM BLOOD PT-13.9* PTT-37.8* INR(PT)-1.2*
[**2150-3-29**] 05:12PM BLOOD PT-13.6* PTT-35.0 INR(PT)-1.2*
[**2150-3-30**] 05:06AM BLOOD PT-14.3* PTT-142.8* INR(PT)-1.2*
[**2150-3-31**] 02:33AM BLOOD PT-13.7* PTT-70.8* INR(PT)-1.2*
[**2150-4-1**] 06:20AM BLOOD PT-14.8* PTT-58.8* INR(PT)-1.3*
[**2150-3-29**] 10:30AM BLOOD Glucose-112* UreaN-26* Creat-1.2* Na-141
K-4.8 Cl-103 HCO3-25 AnGap-18
[**2150-3-29**] 05:12PM BLOOD Glucose-117* UreaN-27* Creat-1.1 Na-140
K-5.1 Cl-106 HCO3-21* AnGap-18
[**2150-3-30**] 05:06AM BLOOD Glucose-127* UreaN-29* Creat-1.3* Na-136
K-4.4 Cl-100 HCO3-24 AnGap-16
[**2150-3-31**] 02:33AM BLOOD Glucose-96 UreaN-40* Creat-1.7* Na-138
K-3.7 Cl-102 HCO3-23 AnGap-17
[**2150-3-31**] 01:50PM BLOOD UreaN-42* Creat-1.7* Na-139 K-3.9 Cl-101
HCO3-25 AnGap-17
[**2150-4-1**] 06:20AM BLOOD Glucose-96 UreaN-43* Creat-1.6* Na-137
K-4.0 Cl-99 HCO3-26 AnGap-16
[**2150-3-29**] 10:30AM BLOOD CK(CPK)-22*
[**2150-3-29**] 05:12PM BLOOD CK(CPK)-33
[**2150-3-30**] 12:11AM BLOOD CK(CPK)-28
[**2150-3-30**] 05:06AM BLOOD CK(CPK)-34
[**2150-3-29**] 10:30AM BLOOD cTropnT-<0.01
[**2150-3-29**] 05:12PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2150-3-30**] 12:11AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2150-3-30**] 05:06AM BLOOD CK-MB-NotDone cTropnT-<0.01
Brief Hospital Course:
[**Age over 90 **] yo female with history of paroxysmal atrial fib admitted to
the CCU for recurrent a fib with RVR.
.
# A fib: The patient is followed by Dr. [**Last Name (STitle) **] as an
outpatient for this condition. She had taken amiodarone for
years in the past, however discontinued and restarted recently
following DC cardioversion. No clear cause of increased
occurences of a fib with RVR, TSH on last admission wnl, UA and
CXR today showed no signs of infection however pt has
leukocytosis. Patient was placed on amiodarone drip after bolus
for rate control. Esmolol drip was attempted, however patient's
blood pressure did not tolerate. She was started on a heparin
drip and then underwent TEE (which showed no clot) and DCCV
after which she converted to NSR with a rate in the 60s on the
amiodarone gtt. Per her outpatient cardiologist she was not on
anti-coagulation with coumadin for her afib. Her cardiologist
decided that she should be on coumadin 1mg as an outpatient for
anticoagulation. She was transitioned off the amiodarone drip
and started on an oral load. She will take 400mg QD for a
month. At that time she will follow up with her primary
cardiologist for further direction. She will need frequent INR
checks at the acute rehab as amiodarone can effect the
metabolism of coumadin.
.
# PUMP: Pt has history of diastolic dysfunction with LVH but
preserved EF. Pt had evidence of volume overload after
aggressive volume resuscitation in the ED on admission, likely
worsened by her rapid ventricular rate. She was given 40mg of
IV lasix on admission and thereafter was treated with PRN lasix
for increased oxygen requirement. After converting to NSR, she
only required one additional dose of 40mg IV lasix on the day of
discharge. Her weight should be monitored daily as well as her
respiratory status at the rehab facility. If she her weight
increases by 3lbs or she has other signs of heart failure, she
should be given 40mg of IV lasix. The patient had an increase
in her Crn to 1.7 after diuresis, 1.6 at discharge. Chem 7
should be checked this week at rehab to trend renal function.
.
# CORONARIES: No previous cath, no previous history of MI. She
was ruled out for MI with serial cardiac enzymes and continued
on ASA.
.
# Hypertension: On recent admission lisinopril, amlodipine,
metoprolol and HCTZ were discontinued. These medications were
not restarted. Did not require anti-hypertensives during her
hospitalization.
.
# Leukocytosis: Initially no clear sign of infection on CXR or
UA and was thought likely stress reaction, as noted on previous
admission as well. Spiked fever and had positive UA a few days
into admission. Was started on ceftriaxone on [**2150-3-30**] and then
discharged on cefpodoxime po. Plan to trend leukocytosis with
CBCs and symptoms of UTI at rehab.
.
PROPHYLAXIS:
-DVT ppx with heparin drip transitioned to coumadin, home
ranitidine
-Pain managment with tylenol
-Bowel regimen with colace and senna
CODE: Full Code
Medications on Admission:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Medications:
1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 6 days.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
give on sundays.
8. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
9. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months: start [**2150-4-2**].
12. Outpatient Lab Work
Please send Chem-7, CBC and INR on thursday [**2150-4-2**]. Goal INR is
[**1-13**]
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Urinary Tract infection
Acute on chronic Diastolic congestive heart failure
Discharge Condition:
stable
Discharge Instructions:
You were admitted with chest pain and a rapid heart rate from
your atrial fibrillation. We cardioverted you and restarted you
on amiodarone. You are now in a regular rhythm. You were
continued on an aspirin to prevent blood clots. A urine test
showed you may have an infection so you were started on an
antibiotic. You had some fluid overload because of your rapid
heart rate and a diuretic was given to help your body eliminate
the extra fluid.
Weigh yourself daily, call Dr. [**Last Name (STitle) 713**] if you note that your
weight is increasing more than 3 pounds in 1 day or 6 pounds in
3 days.
Follow at 2000mg sodium diet.
Call Dr. [**Last Name (STitle) 713**] if you notice that your feet are swelling, if
you have trouble lying flat to sleep or develop a new cough.
Also call for worsening shortness of breath.
Medication changes:
1. STOP taking Norvasc, Metoprolol, Lisinopril and
Hydrochlorothiazide
2. START taking cefpodoxime for your urinary infection, you will
have 7 days total.
3. Start taking warfarin, a blood thinner to prevent a stroke.
.
Continue with Amiodarone, Aspirin, and Fosamax
Followup Instructions:
Primary Care:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2150-4-7**]
3:15
Cardiology:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2150-5-22**] 2:20
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2150-11-27**] 4:00
Completed by:[**2150-4-1**]
ICD9 Codes: 5849, 5990, 4280, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2418
} | Medical Text: Admission Date: [**2140-6-9**] Discharge Date: [**2140-6-17**]
Date of Birth: [**2083-1-21**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / Levaquin / Ciprofloxacin / Sulfa (Sulfonamides) /
Percocet / Codeine
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy, repair of enterotomy
History of Present Illness:
Ms [**Known lastname 9063**] is a 57F with h/o ovarian ca, POD #1 from laparoscopic
IP port placement. She went home and had abdominal pain [**2-10**]
hours after getting home. Pain bilateral lower abdomen near the
groin and over the incision sites. Felt similar to prior
episodes of pain with renal stones. Took 2 vicodin without
significant improvement. She went to OSH where a CT without
contrast showed some fat stranding and free air thought
secondary to recent surgery. She was given meropenam and flagyl
and transferred to [**Hospital1 18**].
.
On presentation to [**Hospital1 18**], T 100.5, BP 86/58 HR 136 Was given
600cc IVF with SBP 120 and HR 110s. WBC of 37.4 and on exam
noted to have significant abdominal pain, guarding so taken to
OR for ex-lap. Prior to OR given Vanc/Cefepime and flagyl.
.
In the OR, patient noted to have a small bowel enterotomy, which
was repaired. Recently placed port was removed and adhesions
were lysed. There was no collection of pus or any abscess
visualized. A JP drain was placed. Was given propofol for
sedation. EBL 150, Received 3L LR and 1L NS. UOP 400 CC
.
ROS: received neulasta [**2140-5-24**]. Recent sinus infection 4 days
ago.
Past Medical History:
Ovarian cancer
Nephrolithiasis
Ureteral stents
.
Past surgical history:
- [**2140-6-8**] - peritoneal shunt placed.
- [**2140-4-25**] Ex-lap, lysis of adhesions, resection of sigmoid
mesocolon nodule, bilateral pelvic and periaortic lymph node
sampling, infracolic omentectomy
- [**2140-4-1**] Vaginal hysterectomy, laparoscopic BSO
Social History:
The patient has smoked one-half pack per day for 30 years. She
does not drink. She is a nurse instructor.
Family History:
Significant for a mother who had breast and possibly ovarian
cancer and died of one of these cancers at age 43. She also has
a maternal aunt who died of a question of stomach cancer in her
40s. A maternal grandmother had bladder cancer.
Physical Exam:
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL, constricted
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) Rub,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Dressing Clean, Dry Intact
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
Pertinent Results:
Hematology:
[**2140-6-9**] 07:52PM BLOOD WBC-37.4*# RBC-4.05* Hgb-11.7* Hct-34.5*
MCV-85 MCH-29.0 MCHC-34.0 RDW-14.2 Plt Ct-455*
[**2140-6-10**] 02:47AM BLOOD WBC-41.4* RBC-3.69* Hgb-11.0* Hct-31.5*
MCV-86 MCH-29.9 MCHC-35.0 RDW-14.7 Plt Ct-411
[**2140-6-11**] 04:00AM BLOOD WBC-24.9* RBC-2.72*# Hgb-8.2*# Hct-23.2*#
MCV-85 MCH-30.0 MCHC-35.1* RDW-14.8 Plt Ct-309
[**2140-6-11**] 12:51PM BLOOD WBC-17.9* RBC-2.73* Hgb-7.9* Hct-23.6*
MCV-87 MCH-28.8 MCHC-33.3 RDW-14.4 Plt Ct-334
[**2140-6-12**] 04:32AM BLOOD WBC-14.3* RBC-3.08* Hgb-9.0* Hct-26.1*
MCV-85 MCH-29.1 MCHC-34.4 RDW-14.8 Plt Ct-347
[**2140-6-13**] 04:04AM BLOOD WBC-9.7 RBC-3.03* Hgb-9.0* Hct-25.2*
MCV-83 MCH-29.8 MCHC-35.8* RDW-15.0 Plt Ct-301
[**2140-6-14**] 05:18AM BLOOD WBC-10.2 RBC-3.29* Hgb-9.7* Hct-28.2*
MCV-86 MCH-29.6 MCHC-34.6 RDW-15.0 Plt Ct-377
[**2140-6-15**] 05:38AM BLOOD WBC-6.5 RBC-3.04* Hgb-9.0* Hct-25.2*
MCV-83 MCH-29.8 MCHC-35.8* RDW-15.2 Plt Ct-352
[**2140-6-9**] 07:52PM BLOOD Neuts-86* Bands-3 Lymphs-2* Monos-9 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2140-6-10**] 02:47AM BLOOD Neuts-88* Bands-5 Lymphs-2* Monos-3 Eos-0
Baso-0 Atyps-1* Metas-1* Myelos-0
[**2140-6-13**] 04:04AM BLOOD Neuts-77.0* Lymphs-13.3* Monos-8.6
Eos-0.9 Baso-0.2
[**2140-6-14**] 05:18AM BLOOD Neuts-76.8* Lymphs-13.2* Monos-8.2
Eos-1.7 Baso-0.1
[**2140-6-9**] 07:52PM BLOOD PT-15.0* PTT-24.3 INR(PT)-1.3*
[**2140-6-10**] 02:47AM BLOOD PT-15.0* PTT-26.6 INR(PT)-1.3*
[**2140-6-11**] 04:00AM BLOOD PT-13.4 PTT-28.7 INR(PT)-1.2*
[**2140-6-9**] 07:52PM BLOOD Glucose-141* UreaN-13 Creat-0.6 Na-136
K-3.9 Cl-108 HCO3-17* AnGap-15
[**2140-6-10**] 02:47AM BLOOD Glucose-155* UreaN-11 Creat-0.5 Na-136
K-4.1 Cl-110* HCO3-19* AnGap-11
[**2140-6-11**] 04:00AM BLOOD Glucose-101 UreaN-11 Creat-0.5 Na-136
K-4.0 Cl-108 HCO3-23 AnGap-9
[**2140-6-12**] 04:32AM BLOOD Glucose-85 UreaN-6 Creat-0.4 Na-134 K-3.6
Cl-103 HCO3-23 AnGap-12
[**2140-6-13**] 04:04AM BLOOD Glucose-93 UreaN-5* Creat-0.4 Na-140
K-3.9 Cl-104 HCO3-26 AnGap-14
[**2140-6-14**] 05:18AM BLOOD Glucose-70 UreaN-6 Creat-0.4 Na-136 K-3.8
Cl-102 HCO3-25 AnGap-13
[**2140-6-15**] 05:38AM BLOOD Glucose-105 UreaN-3* Creat-0.4 Na-139
K-3.6 Cl-105 HCO3-27 AnGap-11
[**2140-6-16**] 07:02AM BLOOD Glucose-108* UreaN-2* Creat-0.5 Na-140
K-3.9 Cl-106 HCO3-27 AnGap-11
Brief Hospital Course:
On presentation to [**Hospital1 18**], vital signs were as follows: T 100.5,
BP 86/58 HR 136. Laboratory data was notable for a WBC count of
37.4. She was given Vancomycin, cefepime, and flagyl, and taken
to the OR where she was noted to have a small bowel enterotomy,
which was repaired. Her recently placed port was removed and
adhesions were lysed. There was no collection of pus or any
abscess visualized. A JP drain was placed. She was kept on
assist control ventilation given the concern for septic shock.
Details of the procedure are available elsewhere in a separate
operative note.
Upon transfer to the ICU, the patient was febrile and
hypotensive. A right internal jugular central venous catheter
and arterial line were placed, and the patient was volume
resuscitated. Her mean arterial pressures and urine output were
finally optimized, consistently >65 and 30cc/kg/hr respectively
after about 11L of NS over 36 hour, she did not require any
pressors to achieve this. She was continued on a regimen of
vancomycin, cefepime, and flagyl for presumed gram negative
sepsis. On her second ICU day she was successfully extubated.
Vancomycin was discontinued on her third ICU day and she was
transferred to GYN for further management.
Upon arrival to the GYN surgical floor on POD#4 until her
discharge on POD#8, she received routine postoperative care.
She was transitioned from the fentanyl PCA to dilaudid SC, then
subsequently to oral medications with her pain well controlled.
Once ambulant without assistance, her foley was removed, and
patient was voiding spontaneously. Given that she remained
afebrile for greater than 48hours, the remaining antibiotics
were discontinued. She did not develop any fevers subsequently.
She remained somewhat nauseated, but never had an episode of
emesis. Her diet was slowly advanced and she was tolerating a
regular, although in small amounts, on POD#7. Given that she
was able to take in adequate amount of fluid, her IV fluids were
discontinued. Her right internal jugular line was removed on
POD#8.
She was discharged home on POD#8 in stable condition: afebrile,
stable vital signs, ambulant, tolerating regular diet, voidnig
spontaneously, and with pain controlled.
Medications on Admission:
[**Doctor First Name **]
Prilosec
calcium citrate
vitamin D
Prochlorperazine Edisylate
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Lorazepam 2 mg/mL Syringe Sig: [**2-10**] Injection every 4-6 hours
as needed for anxiety.
4. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as
needed: do not exceed 4g per 24h period.
Disp:*60 Tablet(s)* Refills:*2*
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed: please take with food/fluid.
Disp:*60 Tablet(s)* Refills:*0*
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, enterotomy.
Discharge Condition:
Stable
Discharge Instructions:
- Please call your doctor if you experience fever > 101,
chills, nausea and vomiting, worsening or severe abdominal pain,
heavy vaginal bleeding, chest pain, trouble breathing, or if you
have any other questions or concerns. Please call if you have
redness and warmth around the incision, if your incision is
draining pus-like material, or if your incision reopens.
- No driving for two weeks and while taking narcotic pain
medication as it can make you drowsy.
- No heavy lifting or strenuous exercise for 6 weeks to allow
your incision to heal adequately.
- Nothing per vagina (no tampons, intercourse, douching for 6
weeks.
- Please keep your follow-up appointments as outlined below.
Followup Instructions:
*** PLEASE CALL DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] OFFICE TO SCHEDULE A FOLLOW
UP APPOINTMENT: [**Telephone/Fax (1) 5777**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2140-7-7**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7706**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2140-7-7**] 8:30
Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2140-7-7**] 10:00
Completed by:[**2140-6-17**]
ICD9 Codes: 0389, 5185, 2851, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2419
} | Medical Text: Admission Date: [**2108-3-10**] Discharge Date: [**2108-3-16**]
Date of Birth: [**2055-5-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
A fib with RVR, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]
Major Surgical or Invasive Procedure:
TEE
ICU monitoring
History of Present Illness:
52 yo male with history of a fib, HTN, hyperlipidemia, morbid
obesity, transferred from [**Hospital 1474**] Hospital for management of A
fib with RVR in the setting of a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]. The patient
presented to his primary care physician [**Last Name (NamePattern4) **] [**2108-3-9**] with a chief
complaint of malaise. The patient was recently treated for an
episode of possible bronchitis at the end of [**Month (only) 404**] with a
course of moxifloxacin. He reported he felt persistent
productive cough since that time. The cough has been productive
of clear to white sputum. Over the past two days prior to
admission he reported worsening fatigue and malaise as well as
dyspnea on exertion. The patient reports he was able to walk
approximately 100feet before becoming short of breath. He does
report at times he has felt lightheaded, however has never lost
consciousness. He reports this episode was very similar to when
he presented with a wide complex tachycardia in [**2107-1-7**]. He
denies any orthopnea or PND. He denies any chest pain or
palpitations.
EMS gave the patient diltiazem en route to the [**Hospital1 1474**] ER as
his rate was in the 180's. In the ER at [**Hospital1 1474**], he received
another 110mg of diltiazem and 15mg of IV lopressor. Cardiology
was consulted in the ER and recommended heparin drip, diltiazem
drip, digoxin 0.25mg and lasix 40mg. After this treatment, the
patient became transiently hypotensive to the 80's systolic.
The diltiazem drip was discontinued while the patient was still
in the ER. He was then given a bolus of amiodarone and
continued on a drip following. On admission to the floor, the
patient was continued on this regimen. DC cardioversion was
discussed, however a TEE showed evidence of a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]. Upon
further investigation, it was discovered that the patient has a
history of WPW with wide complex tachycardia in [**2107-1-7**]. At
this time, all nodal agents were held and digoxin was
discontinued. The patient was also found to be febrile, have
leukocytosis and productive cough. He was treated with
ceftriaxone and azithromycin temporarily for presumed CAP,
however this was discontinued prior to transfer. On transfer,
the patient's HR was in the 170's, but normotensive.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, myalgias, joint pains,
hemoptysis, black stools or red stools. He denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
[**Doctor Last Name 79**] Parkinson White syndrome, with wide complex tachycardia in
[**2107-1-7**], converted with amiodarone and lopressor
Cardiac catheterization: Normal Coronaries [**2107-3-8**]
OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Hashimoto's Thyroiditis
S/P Gastric banding [**9-11**]
OSA, on CPAP at night, pressure of 10
Cholelithiasis
CARDIAC RISK FACTORS: HTN, hyperlipidemia
Social History:
Clergy
No hx of tobbacco, EtOH, recreational drug use
Family History:
Father has hypertension, no history of arrhythmias or sudden
death
Physical Exam:
VS: Temp: 102.7 HR 175 BP 140/98 RR 25 O2 95% on 4L
GENERAL: obese male in mild respiratory distress, able to speak
in complete, however short, sentences, diaphoretic, flushed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink.
NECK: Supple unable to appreciate JVP given habitus
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregularly irregular rhythm, tachycardic, normal S1, S2.
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, however difficult to appreciate secondary to
habitus.
ABDOMEN: Soft, obese NTND. No HSM or tenderness. No abdominial
bruits.
EXTREMITIES: 2+ pitting edema to the thigh BL LE. No femoral
bruits.
SKIN: Stasis dermatitis BL, worse on left than right with
redness worse on left than right, no ulcers, scars.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1 PT 1
Left: Carotid 2+ Femoral 2+ DP 1 PT 1
Pertinent Results:
ECG: Atrial fibrillation with delta waves in II, III, and AVF
at a rate of 188
TELEMETRY: Narrow complex tachycardia at a rate of 175-200
2D-ECHOCARDIOGRAM: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**], to be reviewed by TEE attending
CARDIAC CATH: Per report, clean coronaries [**2106**]
Admission Labs:
[**2108-3-10**] 09:40PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.025
[**2108-3-10**] 09:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-MOD
[**2108-3-10**] 09:40PM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2108-3-10**] 05:35PM GLUCOSE-95 UREA N-25* CREAT-1.6* SODIUM-138
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
[**2108-3-10**] 05:35PM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.8
CHOLEST-108
[**2108-3-10**] 05:35PM TRIGLYCER-119 HDL CHOL-41 CHOL/HDL-2.6
LDL(CALC)-43
[**2108-3-10**] 05:35PM FREE T4-1.7
[**2108-3-10**] 05:35PM WBC-15.4* RBC-4.07* HGB-11.8* HCT-34.8*
MCV-86 MCH-29.1 MCHC-34.0 RDW-14.1
[**2108-3-10**] 05:35PM PLT COUNT-222
[**2108-3-10**] 05:35PM PT-15.1* PTT-29.9 INR(PT)-1.3*
Brief Hospital Course:
# A fib with RVR: As the patient had a history of WPW with wide
complex tachycardia, consistent with antidromic preexcitation in
[**2107-1-7**], we refrained from using verapamil and digoxin as could
have promoted conduction down the accessory pathway. Also, as
the patient had evidence of a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**] on TEE, we refrained
from DC or chemical cardioversion with procainamide especially
since patient was stable on admission. Instead the patient was
started on an amiodarone drip with beta blockers in an attempt
to control his rate. Likely febrile illness and over treatment
with levothyroxine for Hashimoto's thyroiditis contributed to
patient's a fib with rapid ventricular rate. As the patient
remained in a narrow complex tachycardia, the team felt
comfortable using diltiazem for rate control in addition to beta
blockers as his rate was not well controlled and the likelihood
of him converting into a wide complex tachycardia was low. His
rate was eventually controlled on a diltiazem drip and the
amiodarone was discontinued. The patient then spontaneously
converted into sinus rhythm with a wide QRS indicative of a
right posterior/inferior bypass tract consistent with WPW. The
diltiazem was discontinued and the patient was controlled on
beta blockers alone. The patient was continued on a heparin drip
for anticoagulation from the time of admission and coumadin was
started during hospitalization. The patient was discharged on
propranolol, as there is a possibility thyrotoxicosis could have
initially contributed to the A fib with RVR, and coumadin for
management of his A fib. He will be seen as an outpatient to
discuss the possibility of ablation of the WPW bypass tract to
prevent further episodes of wide complex tachycardia.
# [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]: The patient presented with a TEE done at
[**Hospital 1474**] hospital which showed evidence of a left atrial
appendage thrombus. Our TEE attending reviewed the echo and
could not rule out the presence of a thrombus. The patient was
continued on a heparin drip during his hospitalization and
started on coumadin. A TTE was done which could not visualize
the left atrial appendage, therefore could not rule out the
presence of a thrombus. A TEE was done here which showed no
thrombus. The patient was discharged on coumadin with
instructions to follow up with his primary care physician for an
INR check on Monday following discharge.
# Febrile Illness: Fever, leukocytosis and productive cough
likely secondary to respiratory illness. As the patient has had
cough, malaise and general body weakness flu was on
differential, however ruled out during hospitalization. The CXR
on admission showed possible LLL and RLL infiltrate, thus the
patient was started on doxycycline and ceftriaxone for CAP. The
patient also had a UA which showed possible evidence of a UTI
however the urine culture was negative. The patient was
continued on ceftriaxone and doxycycline during hospitalization
and discharged on cefpodoxime and doxycycline to complete a 10
day course.
# Hypertension: Initially held antihypertensives in the setting
of A fib with RVR with episode of hypotension at OSH in order to
up-titrate beta blocker for control of AF as much as possible.
Once the patient was stable on propranolol 80mg TID, lisinopril
and triamterene-hydrochlorothiazide were restarted. The patient
was discharged on this regimen.
# Hyperlipidemia: Lipids checked and were not elevated despite
lack of statin therapy. As had clean coronaries in [**2106**] no
indication for statin.
# Hashimoto's Thyroiditis: Pt's TSH at OSH was 0.07, however
free T4 and T3 within normal limits. TFTs here were similar.
Consulted endocrine who said the patient was on too high of a
replacement dose of levothyroxine. They recommended adding
levothyroxine 150mcg back once stable. Discharged on this dose.
# Depression: Continued sertraline.
# S/P Gastric Banding: Continued vitamin supplementation and
diet restrictions.
# OSA: Continued on home CPAP settings, pressure of 10, while
inpatient.
# ACCESS: R IJ placed at [**Hospital1 1474**], confirmed placement with CXR.
Was documented from OSH as sterile placement so was kept in
place. The line was pulled prior to discharge.
# CODE: Full Code
# Contact: [**Name (NI) **] [**Last Name (NamePattern1) 1007**], sister, HCP, [**Telephone/Fax (1) 65282**], [**Name2 (NI) 1743**]
[**Last Name (NamePattern1) 56192**], fiance [**Telephone/Fax (1) 65283**]
Medications on Admission:
Lopressor 100mg [**Hospital1 **]
Levothyroxine 400mcg daily
Lisinopril 40mg daily ? unclear if taking
Sertraline 25mg daily
Triamterene 37.5 mg daily
Calcium with Vit D2 1000 units daily
MVI daily
Potassium 10mEq daily
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 4 days.
Disp:*10 Capsule(s)* Refills:*0*
4. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
Disp:*10 Tablet(s)* Refills:*0*
9. Propranolol 60 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
10. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please have INR drawn 3 days after discharge at Dr.[**Name (NI) 65284**]
office. They will have a lab slip waiting downstairs.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
- Atrial Fibrillation
- [**Doctor Last Name 13534**] Parkinson White syndrome
- Bronchitis/Community Acquired Pneumonia
.
Secondary Diagnoses:
- Hypertension
- Hashimoto's Thyroiditis
- Morbid Obesity
Discharge Condition:
The patient was afebrile and hemodynamically stable prior to
discharge.
Discharge Instructions:
You were admitted to the hospital with a fast heart rate and
respiratory illness. You were found to have atrial fibrillation
and an accessory pathway in your heart called [**Doctor Last Name 13534**] Parkinson
White. You were also thought to have a clot in your heart. A
repeat echocardiogram was done here which showed no clot in your
heart. You were treated with medications to slow your heart rate
and to thin your blood. You will be continued on these
medications as an outpatient. You were also treated with
antibiotics for your respiratory illness.
.
These medications where added/changed:
- Coumadin 7.5mg to be taken daily, you will have to have your
INR checked in two days following discharge.
- Propranolol 60mg three times a day, to be taken instead of
your home metoprolol - please do not take both of these
medications
- Levothyroxine 150mcg daily, to be taken instead of the 400mcg
you were taking previously
- Doxycycline 100mg twice a day until [**2108-3-20**]
- Cefpodoxime 200mg twice a day until [**2108-3-20**]
.
Your other medications should continue as prescribed, including
Lisinopril 40mg daily
Triamterene-Hydrochlorthiazide 1 cap daily
Sertraline 25mg daily
Multivitamin and Calcium with Vit D
.
If you experience worsening shortness of breath, chest pain,
palpitations, fevers, chills or any other worrisome symptoms
please seek medical attention.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 4 weeks for discussion of
treatment options. The phone number to make an appointment is
([**Telephone/Fax (1) 2037**]
.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 17025**], on Monday for an INR check. The phone number to
make an appointment is [**Telephone/Fax (1) 6699**].
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], RD,LDN Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2108-6-27**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2108-6-27**] 2:00
Completed by:[**2108-3-16**]
ICD9 Codes: 486, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2420
} | Medical Text: Admission Date: [**2120-2-20**] Discharge Date: [**2120-2-27**]
Date of Birth: [**2058-6-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Indomethacin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
atypical chest pain
Major Surgical or Invasive Procedure:
s/p CABGx1(SVG-> prox RCA) [**2-20**]
History of Present Illness:
61 year old woman with 2-3 year history of DOE. Work up revealed
an anomolous RCA. She waws referred to cardiac surgery and was
admitted for surgery on [**2-20**].
Past Medical History:
HTN
Hypercholesterolemia
Obesity
CCY
Tubal Ligation
Appy
Cataracts
Umbilical Hernia Repair
Rt Varicose Vein stripping
Social History:
Lives with husband in [**Name (NI) 108**]
Brother and mother-CABG
[**Name2 (NI) 1403**] as home health aide
Denies tobacco and ETOH
Family History:
Mother & brother CABG
Physical Exam:
Admission
VS HR 67 BP 140/59 RR 16 02sat 99%RA Ht 4'8" Wt 165lbs
Gen: NAD
HEENT nl oropharynx, PERRL/EOMI, anicteric-noninjected. Supple
no JVD or bruit\
Chest CTA bilat
CV RRR no M/R/G
Abdm soft, NT/ND/+BS
Ext warm, well perfused, 1+LE edema. Rt leg superficial
varicosities/left ok
Discharge
VS T98.1 HR65 SR BP 98/48 RR 18 02sat 99%RA
Gen NAD
Neuro nonfocal
Pulm CTA- bilat
CV RRR no murmur
Abdm soft, NT/+BS
Ext warm, trace edema. Lft SVG site CDI
Pertinent Results:
[**2120-2-20**] 02:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2120-2-20**] 02:40PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2120-2-20**] 02:40PM URINE RBC-[**3-13**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-<1 RENAL EPI-<1
[**2120-2-20**] 12:12PM GLUCOSE-91 NA+-139 K+-3.6
[**2120-2-20**] 12:04PM UREA N-15 CREAT-0.7 CHLORIDE-114* TOTAL
CO2-24
[**2120-2-20**] 12:04PM WBC-10.9 RBC-3.75* HGB-11.2* HCT-32.1* MCV-86
MCH-29.8 MCHC-34.7 RDW-13.3
[**2120-2-20**] 12:04PM PLT COUNT-218
[**2120-2-20**] 12:04PM PT-13.4 PTT-31.8 INR(PT)-1.2*
[**2120-2-26**] 07:25AM BLOOD WBC-7.1 RBC-3.16* Hgb-9.0* Hct-27.8*
MCV-88 MCH-28.3 MCHC-32.2 RDW-13.3 Plt Ct-325
[**2120-2-26**] 07:25AM BLOOD Plt Ct-325
[**2120-2-26**] 07:25AM BLOOD Glucose-123* UreaN-11 Creat-0.7 Na-138
K-4.3 Cl-100 HCO3-31 AnGap-11
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2120-2-22**] 2:40 PM
CHEST (PORTABLE AP)
Reason: eval ptx s/p CT d/c
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
eval ptx s/p CT d/c
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: Status post bypass surgery. Evaluate after chest
tube removal.
FINDINGS: AP single view of the chest obtained with patient in
semi-upright position is analyzed in direct comparison with a
preceding similar study of [**2120-2-20**]. During the
interval the patient has been extubated and both chest tubes and
the remaining right internal jugular sheath have been removed.
No pneumothorax has developed, no new infiltrates are detected.
IMPRESSION: Satisfactory findings after instrument removal.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2120-2-22**] 6:51 PM
[**Known lastname 7405**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76155**] (Complete)
Done [**2120-2-20**] at 9:09:51 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2058-6-9**]
Age (years): 61 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Chest pain. Left ventricular function. Preoperative
assessment.
ICD-9 Codes: 440.0
Test Information
Date/Time: [**2120-2-20**] at 09:09 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 #: 2008AW209-9:1 Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
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: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
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.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
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%). 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. No aortic regurgitation
is seen. The mitral valve leaflets are structurally normal. Mild
(1+) mitral regurgitation is seen.
POSTBYPASS
Preserved biventicular systolic function. The study is otherwise
unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2120-2-23**] 13:03
Brief Hospital Course:
Patient was a direct admission to the operating room for
scheduled CABG. In summary she had SVG-prox RCA, please see OR
report for details. She tolerated the operation well and was
transferred from the OR to Cardiac surgery ICU in stable
condition. She did well in the immediate post-op period was
weaned from the ventilator and extubated. She remained
hemodynamically stable on the day of surgery and on POD1 was
transferred to the floors for continued post-op recovery. Once
on the floor the patient had an uneventful recovery, her chest
tubes and epicardial wires were removed on POD 2&3. She worked
with nursing and PT to increase her activity level daily. On POD
4 she was noted to have intermittent Afib and was started on
Amiodarone. On POD 7 it was decided she was ready for discharge
to her hotel. She is to have f/u with Dr [**Last Name (STitle) **] in 2 weeks
following which she will return home.
Medications on Admission:
Lopressor 50 tid
Diovan 80/12.5 1tab QD
Niaspan 500QHS
ASA 81 QD
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
Disp:*50 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO Qhs ().
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours: [**Hospital1 **] x 7days then 200mg QD.
Disp:*35 Tablet(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p CABG
HTN, ^chol, s/p CCY, s/p R vein stripping, s/p bilat cataract
surgery, s/p appy
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Call our office for sternal drainage, temp>101.5
Do not use creams, lotions, or powders on wounds.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 76156**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 76157**] for 4 weeks.
Completed by:[**2120-2-27**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2421
} | Medical Text: Admission Date: [**2108-5-8**] Discharge Date: [**2108-5-22**]
Date of Birth: [**2026-11-18**] Sex: F
Service: SURGERY
Allergies:
Amlodipine / Pro-Banthine / Zyprexa / Bactrim Ds / Iodine;
Iodine Containing
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Diffuse, severe, non-radiating crampy abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy
Extensive lysis of adhesions
Reduction and repair of incisional hernia
History of Present Illness:
Ms [**Known lastname **] is an 81 year old italian speaking female with
multiple medical problems who presented to the emergency
department with complaints of severe non-radiating, crampy
abdominal pain with associated nausea and vomiting for 24 hours.
She complained of constipation, and reported no bowel movement
for the past 3 days.
Past Medical History:
PMH: hypothyroid, h/o SBO, thrombocytopenia secondary to
heparin: no diagnosed HIT. renal insufficiency, depression,
Breast CA, DM2, HTN, hypercholestremia, GERD, Neuropathy,Hernia,
stent x 4 years.
Past surgical history: exploratory lap for small bowel
obstruction [**2101**]. Arthroplasty, left knee.
Social History:
Lives at home with supportive son [**Name (NI) **] and daughter in law
[**Name (NI) 2152**], who is health care proxy.
Family History:
n/c
Physical Exam:
T: 99.0 HR 76 BP 160/70 RR 18, Spo2 94% on RA
HEENT: aniceteric, no acute distress, PERRLA, membranes dry, no
JVD.
Cardivascular: Regular S1S2.
Pulmonary: Clear to auscultation bilaterally
Abdomen: obese, distended, diffusely tender, hernia in upper
midline
Rectal: guaic negative, normal tone
Pertinent Results:
CT abd/pelvis [**2108-5-8**]
IMPRESSION: Dilated proximal loops of small bowel and collapsed
distal ileum and colon are consistent with small-bowel
obstruction. Focal transition points are located within two
adjacent but separate right anterior abdominal wall hernias.
Findings suggest that there is some passage of fluid containing
oral contrast beyond the transition points. There are no
findings to suggest strangulation/incarceration.
.
ADDENDUM: Delayed images 3 hours after the initial study were
obtained to assess passage of contrast. There is some
progression of contrast in proximal small bowel loops, though
there is no significant progression of contrast into distal
loops, which remain collapsed, suggesting a high-grade
obstruction. These findings were discussed with the surgery
resident, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 5:30 am on [**2108-5-8**].
.
Cardiac cath
PTCA COMMENTS: The angiogram showed a mid circumflex lesion
of
90 percent. We planned to treat this lesion with POBA and stent
only if
needed. We used Bivalirudin, Aspirin and Clopidogrel
prophylactically. A
6F XB 3.5 guide provided adequate support. A Prowater wire
crossed in to
the distal vessel easily. We then performed PTCA of the lesion
with a
2.5 X 15mm Voyager balloon at10 atm X 3. The final angiogram
showed TIMI
III flow with no residual stenosis, small non flow limiting
dissection,
no perforation and no embolisation. The patient left the lab in
a stable
condition.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease. The totally occluded
diagonal
branch is not suitable for angioplasty.
2. New-onset atrial fibrillation with rapid ventricular response
and
hypotension.
3. Patient intubated.
4. Successful POBA of the mid LCX lesion
.
Echo
Conclusions:
The left ventricular cavity is small. Left ventricular systolic
function is hyperdynamic (EF>75%). The right ventricular cavity
is small. Right
ventricular systolic function is normal. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen.
. Right upper extremity ultrasound
IMPRESSION: No evidence of deep venous thrombosis of the left
upper extremity
.
[**2108-5-8**] 04:09PM GLUCOSE-138* LACTATE-3.6* NA+-137 K+-3.8
CL--110
[**2108-5-8**] 04:09PM TYPE-ART PO2-163* PCO2-34* PH-7.42 TOTAL
CO2-23 BASE XS--1 INTUBATED-INTUBATED
[**2108-5-9**] 01:53AM BLOOD CK-MB-15* MB Indx-1.3 cTropnT-0.05*
[**2108-5-9**] 10:08AM BLOOD CK-MB-37* MB Indx-1.9 cTropnT-0.08*
[**2108-5-9**] 06:16PM BLOOD CK-MB-52* MB Indx-2.6 cTropnT-0.18*
[**2108-5-10**] 02:35AM BLOOD CK-MB-52* MB Indx-3.3 cTropnT-0.32*
[**2108-5-18**] 05:45AM BLOOD proBNP-223
[**2108-5-14**] 03:06AM BLOOD ALT-9 AST-17 AlkPhos-113 Amylase-44
TotBili-1.4 DirBili-1.0* IndBili-0.4
[**2108-5-7**] 08:50PM BLOOD Glucose-114* UreaN-32* Creat-1.1 Na-136
K-5.9* Cl-100 HCO3-20* AnGap-22*
[**2108-5-12**] 03:06AM BLOOD Glucose-159* UreaN-34* Creat-0.8 Na-137
K-3.8 Cl-105 HCO3-24 AnGap-12
[**2108-5-21**] 06:00PM BLOOD Glucose-122* UreaN-37* Creat-1.1 Na-135
K-5.0 Cl-97 HCO3-29 AnGap-14
[**2108-5-7**] 10:56AM BLOOD WBC-14.3* RBC-4.55 Hgb-14.3 Hct-44.9
MCV-99*# MCH-31.5 MCHC-32.0 RDW-13.8 Plt Ct-293
[**2108-5-21**] 06:00PM BLOOD WBC-11.9* RBC-3.77* Hgb-12.1 Hct-36.5
MCV-97 MCH-32.1* MCHC-33.1 RDW-14.6 Plt Ct-393
[**2108-5-9**] 01:53AM BLOOD WBC-22.2*# RBC-3.66* Hgb-11.6* Hct-35.5*
MCV-97 MCH-31.8 MCHC-32.7 RDW-14.1 Plt Ct-270#
Brief Hospital Course:
Ms [**Known lastname **] was evaluated in the ED and found to have a high grade
small bowel obstruction. She was taken to the OR directly. She
tolerated the procedure well, she was extubated and transferred
to ICU.
.
Cardiovascular: POD#1 developed low blood pressure and was
started on low dose Neo. POD#2, had positive troponins, ruled in
for MI. She was sent for emergent cardiac cath. She recieved
angioplasty of the left circumflex artery. Developed afib, and
was cardioverted. She was initiated on amiodarone drip.
Converted to sinus rhythm. Femoral sheaths pulled POD#5. Had
persistent hypertension throughout ICU course, managed by her
PCP. [**Name10 (NameIs) **] with nitro and metoprolol. Diuresed throughout
admission with lasix.
.
Pulmonary: Was reintubated POD#2 secondary to NSTEMI. POD#3
developed right upper lobe nosocomial pneumonia. Initiated on
Vanco/Zosyn. Extubated POD#5. Respiratory status improved with
antibiotics, weaned to room air at time of discharge.
.
Abdomen: remained soft, nontender with midline incision intact.
2 JP drains in place. JP#1 removed POD#11. JP#2 removed POD#12.
Staples removed POD#14. Incision remains dry and intact.
.
GI: Pt remained with NGT in place due to an ileus. NGT removed
and ileus resolved POD#7. Developed frequent diarrhea POD#8,
CDiff positive. Initiated Vanco liquid, due to intolerance to
Flagyl. On Vanco taper per Dr. [**First Name (STitle) 10113**], gastroenterology.
.
GU: Recieved aggressive fluid resuscitation for low urine
output. Foley catheter until POD#10. Incontinent of urine.
.
Nutrition: On TPN until POD#8. Tolerated regular diet on POD#9.
Monitored with calorie counts to ensure adequate oral intake.
TPN tapered off on POD#11.
.
Extremities: Edema of upper and lower extremities at times
during admission, due to aggressive fluid resuscitation and
history of CHF. Left upper extremity was swollen POD#9.
Ultrasound revealed no thrombus.
.
Musculoskeletal: PT worked with her consistently for
strengthening and conditioning.
.
Pt was transferred to med-[**Doctor First Name **] floor on POD#8. She continued to
follow an uneventful post-op course.
.
Medications on Admission:
Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily () as
needed for breast ca
Lipitor 10 mg po qd
Cipro 250 mg po qd
Lasix 20 mg po qd
Gabapentin 300 mg po qd
Humulin 70/30
Topamax 25/50
Lopressor 25 mg po bid
Elavil 10 mg po qhs
Omeprazole 20 mg po qd
Paxil 40 mg po qd
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily () as
needed for breast ca.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
12. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 14 days.
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. insulin
Breakfast Dinner
70 / 30 25 Units 70 / 30 22 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL [**1-10**] amp D50 [**1-10**] amp D50 [**1-10**] amp D50 [**1-10**] amp D50
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-140 mg/dL 3 Units 3 Units 3 Units 2 Units
141-160 mg/dL 6 Units 6 Units 6 Units 4 Units
161-180 mg/dL 9 Units 9 Units 9 Units 6 Units
181-200 mg/dL 12 Units 12 Units 12 Units 8 Units
201-220 mg/dL 15 Units 15 Units 15 Units 10 Units
221-240 mg/dL 18 Units 18 Units 18 Units 12 Units
241-260 mg/dL 21 Units 21 Units 21 Units 14 Units
261-280 mg/dL 24 Units 24 Units 24 Units 16 Units
281-300 mg/dL 27 Units 27 Units 27 Units 18 Units
301-320 mg/dL 30 Units 30 Units 30 Units 20 Units
18. Amiodarone
After completion of 14 days of amiodarone 200 mg [**Hospital1 **], taper
dosing to Amiodarone 200 mg po qd. [**2108-5-22**] is day 2 of her dose
of amiodarone 200mg [**Hospital1 **].
19. Vancomycin
Vancomycin 250 mg po liquid q6 hours x 7 days.
then Vancomycin 250 mg po TID x 7 days.
then Vancomycin 250 mg po BID x 7 days.
then Vancomycin 250 mg po qd x 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Incarcerated incisional hernia
NSTEMI
post-op ileus
nosocomial pneumonia
Atrial fibrillation
Discharge Condition:
stable
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Activity: No heavy lifting of items [**10-22**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications. You should take a
stool softener, Colace 100 mg twice daily as needed for
constipation. You will be given pain medication which may make
you drowsy. No driving while taking pain medicine.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2108-6-5**] 10:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2108-6-8**] 10:20
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2041**]
Date/Time:[**2108-6-15**] 11:20
You have an apointment to see Dr. [**Last Name (STitle) **] on [**5-28**] at 12:45.
[**Telephone/Fax (1) 8792**]. [**Street Address(2) **], [**Location (un) **] [**Apartment Address(1) **] west.
Please make an appointment to see your cardiologist in 1 month
for follow up of your amiodarone.
Please call [**Telephone/Fax (1) 96976**] and schedule an appointment to see Dr.
[**First Name (STitle) 10113**] in 1 month.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2108-5-22**]
ICD9 Codes: 9971, 486, 4280, 5849, 2875, 5185, 2449, 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2422
} | Medical Text: Admission Date: [**2195-12-3**] Discharge Date: [**2195-12-10**]
Date of Birth: [**2132-11-18**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nifedipine / Premarin / Morphine / Crestor /
Atorvastatin / Codeine
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
63 year olf female with history of DMII, CAD, CVA s/p recent
hospitalization for GIB, UTI presents within one day of
returning home from rehab with nausea, vomiting. In ED, her
emesis and stool were black, her hct was 32 (baseline 30) and
she was hemodynamically stable (hypertensive). Of note she was
scoped 1 week ago, colonoscopy showed 2 polyps that were removed
and EGD showed gastritis with no active bleeding. She complains
of vomiting x 1 day and nausea for past several days. She does
not know the color of her stool/emesis as she is blind. SHe
denies abdominal pain, chest pain, SOB, palps, dysuria.
In the ED, hypertensive to 180s/100s. Hct 32. She had an AG of
16. ABG was 7.46/42/185. Groin line place b/c unable to get
peripherals. Got 2L IVF, Cipro and Flagyl. On arrival to [**Hospital Unit Name 153**]
she was given insulin 10 units IV and started on insulin drip
for her diabetic ketosis. Her ECG showed TWI in lateral leads,
CKs were flat, trop 0.04. She was given metoprolol 5 IV and her
BP improved.
Past Medical History:
HTN
DMII
Hyperlipidemia
h/o CVA w/ residual L sided hemiparesis
CAD- w/ stent '[**86**] and '[**89**]
Asthma
Rheumatic fever
Femoral Bypass - [**1-15**] complication of most recent cath
Asthma - last hospitalization mult years ago, uses rescue
albuterol inhaler 1-2 times per week
migraine headaches - tx with vicodin or tylenol
Breast Cancer - node negative (surgery only, no chemo, no rad)
Degenerative Disk Disease
Osteoarthritis
Osteoporosis
GERD
Social History:
lives alone at home [**Location (un) 6409**]; wheelchair bound s/p CVA; no
h/o ETOH or tobacco use
Family History:
non-contributory
Physical Exam:
Physical Exam on Admission:
VS: 98 182/108 80 [**11-28**] 100% 5LNC
HEENT: dry MM, no elevated JVP
Cor: RRR no MRG
LUNGS: clear
ABD: soft/NT/ND/+BS
NEURO: Appropriate, oriented, speaking in full sentences, pupils
not reactive (hard to tell)
EXT: 1+ pedeal pulses on R, 2+ on L
Pertinent Results:
Laboratory studies on admission:
[**2195-12-3**]
WBC-12.7 HGB-11.7 HCT-32.1 MCV-81 RDW-14.0 PLT COUNT-149
NEUTS-87.8 LYMPHS-10.0 MONOS-2.1 EOS-0.1 BASOS-0
CK-MB-NotDone cTropnT-0.04
GLUCOSE-446 UREA N-33 CREAT-1.3 SODIUM-145 POTASSIUM-3.6
CHLORIDE-99 TOTAL CO2-30
PT-11.9 PTT-24.6 INR(PT)-1.0
Laboratory studies on discharge:
[**2195-12-10**]
WBC-6.8 Hgb-10.4 Hct-29.2 MCV-82 RDW-13.9 Plt Ct-131
Neuts-62.3 Lymphs-27.4 Monos-7.6 Eos-2.6 Baso-0.2
PT-11.8 PTT-25.0 INR(PT)-1.0
Glucose-172 UreaN-12 Creat-1.0 Na-144 K-3.7 Cl-105 HCO3-33
[**12-3**] EKG: Sinus rhythm. No significant change from the tracing
of [**2195-9-26**]. The tracing continues to show left ventricular
hypertrophy by voltage in lead aVL and non-specific ST-T wave
abnormalities which may be due in part to the left ventricular
hypertrophy.
Radiology
[**12-3**] CXR: No evidence of cardiopulmonary process.
[**12-6**] bleeding scan: No GI bleeding focus identified.
Endoscopy:
[**12-8**] colonoscopy: Grade 2 internal hemorrhoids. Polyps in the
sigmoid colon and ascending colon
[**11-24**] colonoscopy: Polyp in the proximal ascending colon
(polypectomy, path c/w adenoma). Polyp in the descending
colon/40cm (polypectomy, path c/w hyperplastic). Diverticulosis
of the sigmoid colon and distal descending colon. Grade 1
internal hemorrhoids.
[**11-24**] upper endoscopy: Patchy discontinuous erythema of the
mucosa with no bleeding was noted in the stomach body and
antrum. These findings are compatible with Gastritis. Cold
forceps biopsies were performed for histology at the stomach
antrum (normal pathology)
Brief Hospital Course:
63 year old female with type II diabetes presents with
nausea/vomiting/melena. She was initially admitted to the
intensive care unit, where she became hypotensive and her HCT
dropped to 23. She was transfused 2 units of PRBC and
transferred to the general medical floor on the evening of
[**2195-12-5**].
1) GI bleeding/acute blood loss anemia: The melena/coffee-ground
emesis on admission was most likely secondary to gastritis
versus possible [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear in the setting of vomiting
(possibly from gastroparesis versus gastroenteritis). As
indicated above, she received 2 units of PRBC in the intensive
care unit. GI was consulted, who did not recommend repeat EGD,
given recent EGD [**2195-11-24**] (see results section). She remained
stable until [**2195-12-6**], when she had bright red blood per rectum
and a hematocrit drop to 25. She was transfused 2 units of PRBC
along with 1 unit of platelets given thrombocytopenia (see
below) with stabilization of her hematocrit. She underwent a
bleeding scan, which was negative. On the evening of [**12-7**], she
had another episode of BRBPR; she was prepped for a colonoscopy,
which she underwent [**12-8**]. Although the preparation was poor, no
bleeding source was identified. The GI service felt that her
rectal bleeding was most likely from her [**11-24**] polypectomy
sites. At the time of discharge, her hematocrit was stable at
29, despite re-initiation of Plavix. She will follow-up with
gastroenterology as an outpatient and have a repeat hematocrit
checked within 1 week. She was continued on a PPI twice a day
for gastritis.
3) Type II diabetes poorly controlled with complications: The
patient had previously been on 22 units of lantus with a sliding
scale in [**9-/2195**], recently switched to metformin alone. As
mentioned above, she was briefly on an insulin drip while in the
ICU given concern for DKA. At time of discharge, her blood
sugars were well-controlled on metformin alone.
4) UTI: The patient's urine culture grew >100k E. coli resistant
to quinolones, sensitive to ceftriaxone. She will complete a 7
day course of cefpodoxime.
5) Thrombocytopenia: The patient's platelet count nadired at 84,
rising to 133 at time of discharge. The etiology is unclear, but
it may have been related to acute illness. Her fibrinogen/PT/PTT
were not consistent with DIC and HIT antibody was negative. Her
platelet count should be monitored as an outpatient; if
thrombocytopenia persists, an outpatient hematology consult may
be considered at the discretion of her PCP.
6) h/o CVA: No embolic source had been identified during her
prior admission, but she had been started on coumadin and
Plavix, although her INR was only 1 on admission. Her
neurological exam remained stable, and she was restarted on
Plavix as indicated above. She will have a repeat hematocrit
checked within 1 week; if she remains stable, her coumadin can
be restarted by her PCP for [**Name Initial (PRE) **] goal INR 2-2.5.
7) CAD: The patient's EKG showed lateral ST depressions on
admissions, however cardiac enzymes were not consistent with
active ischemia. She was continued on beta-blocker and, as
mentioned above, Plavix was restarted by the time of discharge.
8) HTN: The patient's blood pressure remained labile. At time of
discharge, she had been restarted on her home doses of Coreg,
Lasix, and lisinopril.
9) Full Code
Medications on Admission:
coumadin 5mg qHS
- Coreg 6.25mg [**Hospital1 **]
- plavix 75mg qD
- zyrtec 10mg qHS
- senna 2 tab [**Hospital1 **] PRN
- ocean nasal spray 2 spray TID
- glucophage 850mg qAM, 500 qPM
- lisinopril 40mg qD
- prilosec 20mg [**Hospital1 **]
- lasix 40mg qD
- neurontin 300mg qD
- welchol 625mg [**Hospital1 **]
- compazine 25mg PR q12h PRN
Discharge Medications:
1. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Metformin 850 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*0*
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*0*
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
8. Colesevelam 625 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Neurontin 300 mg Capsule Sig: One (1) Capsule PO once a day.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO qHS ().
Disp:*30 Tablet(s)* Refills:*0*
12. Compazine 25 mg Suppository Sig: One (1) suppository Rectal
twice a day as needed for nausea.
Disp:*30 suppositories* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: gastrointestinal bleeding
Secondary: acute blood loss anemia, hypertension, Type II
diabetes well-controlled with complications, thrombocytopenia,
hypercholesterolemia, urinary tract infection, history of stroke
Discharge Condition:
Good
Discharge Instructions:
1) Please follow-up as indicated below
2) Please take all medications as prescribed. You should not
restart coumadin until instructed to do so by your PCP. [**Name10 (NameIs) **] will
take 5 more days of cepodoxime to treat the urinary tract
infection.
3) Please come to the emergency room or see your PCP if you
develop rectal bleeding, nausea/vomiting, black stool, fevers,
chills, or other symptoms that concern you.
Followup Instructions:
1) Primary Care
Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **], RNC Date/Time:[**2195-12-18**] 10:00
- you should have a repeat hematocrit and platelet count checked
at that time to ensure stability
2) Gastroenterology
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] WEST OFFICE (SB)
Date/Time:[**2195-12-30**] 1:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2195-12-10**]
ICD9 Codes: 2851, 5849, 2875, 5990, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2423
} | Medical Text: Admission Date: [**2101-7-11**] Discharge Date: [**2101-8-18**]
Date of Birth: [**2050-8-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
nausea, vomiting, dysuria
Major Surgical or Invasive Procedure:
[**2101-7-22**] Incision and Drainage of perinephric Mass
[**2101-7-27**]: Resection of medial [**1-24**] of right clavicle. Resection
of sternoclavicular joint. Partial resection of sternum and
costochondral junction of the 1st rib.
[**2101-8-3**] 1. Surgical preparation of chest wound 12 x 12 cm.
2. Pectoralis myofascial flap.
3. Local tissue advancement and rearrangement of skin for
closure of chest defect 12 x 12 cm.
Right thoracentesis with chest tube placement and subsequent
removal
History of Present Illness:
This is a 50 year old female with PMH of asthma, questionable
TIA vs. complex migraine 2 months ago, poorly controlled DM1
with last A1C of 13 and HTN c/b ESRD s/p living related donor
renal transplant in [**2092**] presenting with 4 days of dysuria and 2
days of nausea and non-bloody, non-bilious emesis. She was seen
today at her PCP's office and referred to the ED after being
found to be orthostatic with a BP of 118/62 lying, 82/36
sitting, and 70/40 standing. She has had no urinary frequency or
hematuria and was noted to be extremely anxious about potential
renal failure. Of note, she was also seen last week for fever to
102, cough, and diarrhea and prescribed azithromycin with
resolution of her symptoms. She currently denies any F, abd
pain, diarrhea, constipation, or cough. She has been having some
chest burning likely related to esophageal irritation from
frequent vomiting. She has also been having some right shoulder
pain which she attributes to an injury she had from grabbing the
toilet in an episode of violent vomiting. She has also noted
dyspnea on exertion and chills as of late.
.
In ED, vitals were 98.2 82 129/58 16 97% RA. Per her PCP's exam,
she was noted to have some difficulty standing for orthostatics
and mild epigastric tenderness. She was also noted to have right
shoulder pain worse with movement, coughing, and lifting. On ED
exam her graft was not TTP. Per the [**Last Name (LF) **], [**First Name3 (LF) **] EKG did not show any
changes from prior. A CXR was also performed and did not show
any acute cardiopulmonary abnormality per the ED. A renal
transplant ultrasound was performed but not reviewed in the ED.
Labs were significant for a WBC count of 25.4, thrombocytosis to
980, floridly positive UA, hyponatremia to 127, creatinine of
2.5, and an anion gap of 15. She was given
Maalox/simethicone/lidocaine which did not help her chest
burning and she reported vomiting it up, morphine 4mg IV for
right shoulder pain, cipro 400mg IV, and 2L of NS. Blood
cultures were performed, but urine culture was not sent. She was
admitted for UTI and acute renal failure. Most recent vitals:
97.8 108 124/56 18 100RA.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest tightness,
palpitations. Denied diarrhea, constipation.
Past Medical History:
-Hypertension
-Type 1 diabetes since [**2063**], poorly controlled with last A1C of
13
-Asthma
-ESRD s/p living-related renal transplant in [**2092**]
-TIA vs. complex migraine in [**5-2**], started on Plavix thereafter
Social History:
She lives with her mother at home and is her mother's primary
caretaker. [**Name (NI) **] brother has flown in from [**Name (NI) 4565**] to care for
her while she is hospitalized. She does not have any children
but reports good social support from friends and [**Name2 (NI) **]-workers. She
works for the Massport website full-time. She does not smoke or
drink EtOH.
Family History:
Father had ALS but otherwise not significant.
Physical Exam:
ADMISSION:
VS - Temp=99.2, BP=102/60, HR=110, R=20, O2-sat 99% RA
GENERAL - well-appearing female in NAD, comfortable,
appropriate, with intermittent chills noted
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no JVD.
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - tachycardic, 2/6 SEM noted
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c/e.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-26**] throughout, sensation grossly intact throughout.
DISCHARGE:
General: no longer with intermittant rigors
Heart: RRR, 2/6 SEM at RUSB
Lungs: rales at the bases of the posterior lung fields
bilaterally
Extremities: 2+ pitting edema in the lower extremities
bilaterally
Otherwise unchanged from admission
Pertinent Results:
ADMISSION LABS:
[**2101-7-11**] 02:16PM BLOOD WBC-25.4*# RBC-4.34 Hgb-11.1* Hct-35.1*
MCV-81*# MCH-25.4* MCHC-31.4 RDW-13.0 Plt Ct-980*
[**2101-7-11**] 02:16PM BLOOD Neuts-92.1* Lymphs-5.5* Monos-1.6*
Eos-0.7 Baso-0.2
[**2101-7-11**] 02:16PM BLOOD Plt Ct-980*
[**2101-7-13**] 04:35AM BLOOD PT-14.2* PTT-33.9 INR(PT)-1.2*
[**2101-7-11**] 02:16PM BLOOD Glucose-187* UreaN-70* Creat-2.5*#
Na-127* K-4.6 Cl-91* HCO3-21* AnGap-20
[**2101-7-11**] 02:16PM BLOOD ALT-13 AST-15 AlkPhos-108* TotBili-0.3
[**2101-7-11**] 04:22PM BLOOD Type-[**Last Name (un) **] pO2-66* pCO2-29* pH-7.30*
calTCO2-15* Base XS--10 Comment-GREEN TOP
PERTINENT LABS:
[**2101-7-16**] 04:20AM BLOOD ESR-24*
[**2101-8-11**] 06:40AM BLOOD ALT-14 AST-28 LD(LDH)-366* AlkPhos-120*
TotBili-0.3
[**2101-8-8**] 04:55AM BLOOD Lipase-8
[**2101-8-8**] 04:55AM BLOOD cTropnT-<0.01
[**2101-7-13**] 04:35AM BLOOD calTIBC-139* Hapto-362* TRF-107*
[**2101-7-16**] 12:50PM BLOOD CRP-194.9*
[**2101-7-22**] 04:25AM BLOOD PEP-NO SPECIFI
[**2101-7-26**] 11:05AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-
[**2101-7-26**] 11:05AM BLOOD FREE KAPPA AND LAMBDA, WITH K/L
RATIO-Test
[**2101-7-22**] 04:25AM BLOOD JAK2 MUTATION (V617F) ANALYSIS, PLASMA
BASED-Test
[**2101-7-18**] 12:46PM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-
[**2101-7-16**] 12:50PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
[**2101-7-16**] 12:50PM BLOOD B-GLUCAN-Test
[**2101-7-15**] 05:45PM BLOOD ADENOVIRUS PCR-Test Name
MICROBIOLOGY:
BLOOD CX [**2101-7-11**]: neg
URINE CX [**2101-7-11**]: lactobacillus species
VRE Swab negative
Urine Cx [**7-14**]:neg
Blood culture [**7-14**], [**7-15**]: neg
Mycobacteria and Fungal cultures 6/25: neg
[**7-17**] Stool culture-neg,
[**7-17**] C. Diff Toxin A and B-neg,
[**7-17**] Campybacterium culture-neg
[**7-17**] stool viral culture -prelim neg
[**7-22**] CMV viral load neg
[**7-22**] perinephric mass biopsy culture: PMNs seen on gram stain.
culture beta streptococcus group B
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CLINDAMYCIN----------- S
ERYTHROMYCIN---------- S
ANAEROBIC CULTURE (Final [**2101-7-26**]): NO ANAEROBES ISOLATED
[**7-22**] chest swab PMNs on gram stain; beta strep group B on
culture.
[**7-22**] fluid from chest PMNs, no growth on culture
[**7-22**] peri-nephric mass fluid beta strep group B.
[**7-27**] right sternoclavicular joint first rib ***
[**7-27**] pectoralis muscle ***
[**7-27**] sternoclavicular fluid ***
[**7-19**] Urine cytology: Urothelial cells, histiocytes, and
neutrophils.Many squamous cells, anucleate squames, and bacteria
consistent with vaginal contamination.Note: Atypical squamous
cells consistent with low grade squamous intraepithelial lesion
(LSIL) are present.
no other blood/urine cultures positive
PATHOLOGY:
PeriNephric Mass Biopsy [**7-20**] Fragments of fibrovascular tissue
and chronic inflammation. See note.
Note: The biopsy is mostly comprised of fibrous tissue and
lymphocytes with some crush artifact. A separate discrete
aggregate of plasma cells are identified. These plasma cells
are small with eosinophilic cytoplasm and eccentrically located
nuclei. No atypical forms are seen. By immunohistochemistry
the plasma cells are positive for CD138 and Bcl-2 and are
polytypic by Kappa and Lambda staining. CD20 and CD10 are
negative in the plasma cells with CD20 staining scattered
B-cells. CD3 and CD5 highlight admixed T-cells. Overall, the
findings are non-specific. The differential diagnosis includes
a reactive process (favored). Since an early evolving
(hyperplasia) post-transplant lymphoproliferative disorder
cannot be excluded (due to sampling) a repeat excision may be
warranted if clinically indicated.
Addendum: Kappa and lambda ISH reveals a mixed polytypic plasma
cell population. [**Last Name (un) **] is negative. Overall features do not
suggest a clonal process; No evidence of PTLD seen. The above
diagnosis remains unchanged.
Immunophenotyping [**7-22**] Three color gating is performed (light
scatter vs. CD45) to optimize blast/lymphocyte yield. Due to
paucicellular nature of the specimen, a limited panel is
performed to determine B-cell clonality.
B cells are scant in nature precluding evaluation of clonality.
[**7-22**] Biopsies of Chest wall and Perinephric Mass
1. Mass, right chest wall (A-B):
a. Skeletal muscle with chronic, patchy mildly active
inflammation.
b. Fibroadipose tissue.
c. No malignancy identified.
2. Mass, peri-nephric (C):
Fibroadipose tissue with acute and chronic inflammation and
fat necrosis consistent with abscess wall.
[**8-10**] Pleural Fluid Cytology: NEGATIVE FOR MALIGNANT CELLS.
ULTRASOUNDS:
RENAL U/S [**2101-7-11**]:
IMPRESSION:
1. Abnormal intrarenal waveforms with blunted waveforms and lack
of diastolic flow in the interpolar region. Findings concerning
for graft dysfunction.
2. A 3.7 x 3.2 x 2.8 cm hypoechoic lesion with internal
vascularity in the
interpolar region of the transplant kidney is concerning for a
neoplasm.
Further assessment with MR is recommended.
U/S Chest Wall [**7-21**] Soft tissue mass which is hypoechoic,
predominantly solid, but with areas of partial liquefaction.
This is avascular and most likely represents a focus of PTLD as
the appearance is not dissimilar from the peri-transplant
masses, which were biopsied yesterday.
[**2101-7-21**] Chest U/S:
CONCLUSION: Soft tissue mass which is hypoechoic, predominantly
solid, but
with areas of partial liquefaction. This is avascular and most
likely
represents a focus of PTLD as the appearance is not dissimilar
from the
peri-transplant masses, which were biopsied yesterday.
[**2101-7-21**] Right Upper Extremity U/S 1. No right upper extremity
DVT.
2. Extensive right supraclavicular lymphadenopathy.
[**7-26**] LENIs: No evidence of deep vein thrombosis in either leg.
CT SCANS
[**2101-7-21**] CT Chest without contrast 1. Chest wall abnormality
could represent PTLD, but extention into the thoracic cavity and
associated bone destruction raises concern for infection. In an
immunocompromised host, this could be due to invasive fungal
organisms, actinomycosis, and TB, among others. 2. Lung
consolidation, pleural effusions and interlobular septal
thickening are nonspecific. Such findings have been associated
with PTLD but can also be associated with infection and
hydrostatic edema.
[**2101-7-26**] CT Abdomen and Pelvis
IMPRESSION:
1. Multiloculated rim-enhancing fluid collection in the right
anterior chest with internal foci of gas and minimal osseous
destruction of the encased first rib, thought to represent
abscess has had a minimal decrease in size.
2. Bilateral pleural effusions with worsening right lower lung
opacification, may represent ateletasis but underlying pneumonia
cannot excluded.
3. Four fluid collections identified around the transplanted
kidney in the
left lower quadrant. Two had recent instrumentation and
drainage, superior
and lateral, and are decreased in size compared to recent MRI.
Two larger
collections noted medial and inferior demonstrate rim
enhancement and
intermediate density fluid concerning for infectious process.
4. Foci of gas in the collecting system of the transplanted
kidney, likely
due to air reflux from bladder foley placement, less likely
pyelitis.
5. Hyperdensities in native kidneys, particularly in the right
upper pole
likely represent hemorrhagic cysts, particularly given
appearance on recent
MRI.
6. Volume overload is demonstrated by bilateral pleural
effusions,
pericardial effusion, anasarca, periportal edema and mild
ascites.
7. Linear lucency in right second rib likey due to recent
surgery. Please
correlate with operative note when available.
[**8-8**] CT Chest Abdomen and Pelvis:
IMPRESSION:
1. Increased size of mild pericardial effusion with
hyperenhancing
pericardium.
2. Right labia is enlarged with indurated subcutaneous fat
without focal
fluid collection.
3. Decrease in size of anterior right chest wall abscess with
two drains in
place and minimal residual fluid.
4. Increased bilateral pleural effusions and atelectasis.
5. Increase in periportal and pericholecystic fluid with
hyperenhancing
gallbladder wall suggestive of edema versus gallbladder
contraction.
6. Decrease in size of collections surrounding the transplanted
kidney and
collection along the lateral abdominal wall measuring 3.3 and
2.0 cm
respectively from 4.8 and 2.1 cm on prior examination.
7. Air again seen in transplanted kidney, likely refluxing air.
MRI:
[**2101-7-15**] MRI Abdomen and Pelvis: IMPRESSION:
1. Transplanted kidney in left lower quadrant. At least three
perirenal
masses suspicious for PTLD or lymphoma. The lesions are
accessible by
percutaneous biopsy.
2. Multiple native renal cysts, some of them with
hemorrhagic/proteinaceous
content.
3. Bilateral pleural effusions, right moderate amount, on the
left small
amount.
[**7-19**] shoulder MRI:IMPRESSION:
1. Motion-degraded study. No evidence of septic arthritis.
2. Nonspecific mild edema involving the infraspinatus, teres
minor, and teres major.
3. Abnormality adjacent to the coracoid process which is
suboptimally
evaluated on this motion-degraded study - recommend further
evaluation with
contrast-enhanced CT, as this could represent a mass or
lymphadenopathy;
collection of fluid is less likely given imaging
characteristics.
4. Large signal intensity abnormality in the peripheral aspect
of the right
upper lung, corresponding to known consolidation.
[**8-4**] MRI/MRA: IMPRESSION:
1. Acute infarct involving rostrum of corpus callosum.
2. Multiple focal dilatations involving ACA and MCA branches
bilaterally.
3. Both the infarction and the vascular abnormalities suggest
multiple septic emboli.
ECHOCARDIOGRAMS
ECHO [**2101-7-18**]:
MPRESSION:No endocarditis or abscess seen. Moderate symmetric
left ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild mitral regurgitation.
Moderate pulmonary artery systolic hypertension.
ECHO [**2101-7-27**]:
This is a limited examination to r/o endocarditis.
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is an echo
dense mass a probable vegetation on the P2 portion of the mitral
valve. It measures 2- 3mm in size. Dr [**First Name (STitle) 6507**] present to confirm
findings as well. Mild (1+) mitral regurgitation is seen. There
is a trivial/physiologic pericardial effusion. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
was notified in person of the results on [**2101-7-27**] at 1245pm.
ECHO [**2101-8-8**]:
The left atrium is normal in size. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). A mid-cavitary gradient (30mmHg peak) is
identified. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. The estimated pulmonary artery
systolic pressure is normal. There is a small to moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2101-7-18**],
the pericardial effusion and mid-cavitary gradient are now
identified.
Serial evaluation is suggested.
ECHO [**2101-8-10**]:
IMPRESSION: Very small echodensity attached to the posterior
mitral annular calcification at the level of the P2 scallop.
Compared to the prior study dated [**2101-7-27**] (images reviewed),
the echodensity is smaller and less mobile and probably c/w with
healing vegetation. Small circumferential pericardial effusion
without evidence of tamponade.
ECHO [**2101-8-15**]: NO effusion: The left atrium is elongated. There
is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
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. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. IMPRESSION: Mild symmetric
left ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild mitral regurgitation with
mild leaflet thickening, but no discrete vegetation. Compared
with the prior study (images reviewed) of [**2101-7-18**], the
findings are similar.CLINICAL IMPLICATIONS:
Based on [**2097**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
CHEST X-RAYS
[**2101-7-11**]: IMPRESSION: No acute cardiopulmonary abnormality.
[**2101-7-16**]:FINDINGS: There are bilateral pleural effusions with
volume loss at both bases. There is new right mid lung
infiltrate. Overall, the pulmonary appearance has worsened
compared to the film from five days ago.
[**2101-7-18**]:FINDINGS: Largely loculated moderate dependent bilateral
pleural effusions with associated atelectasis are new or
substantially larger from [**2101-7-11**]. Difference in effusion size
from [**2101-7-16**] is likely due to depth of inspiration. Improved
aeration in the non-dependent lungs on the lateral
decubitus views is secondary to positioning. The right upper
lobe pneumonia is unchanged. No new consolidation is seen in the
left lung. No pneumothorax.
[**2101-7-21**]: IMPRESSION: Stable chest findings in comparison with
preceding study of [**2101-7-18**]. Recommend CT examination to
evaluate alleged new anterior chest wall mass.
[**2101-7-25**]: There are low inspiratory volumes and slightly less
penetration of the film compared with [**2101-7-21**]. Allowing for
this, no significant interval change is detected. Again seen are
small effusions at the right and left bases, with underlying
collapse and/or consolidation. There is a hazy opacity in the
right mid zone, corresponding to the right lung abnormality seen
abutting the anterior chest wall on the [**2101-7-21**] CT scan. There
is upper zone redistribution, without other evidence of CHF.
[**2101-7-27**]: AP UPRIGHT VIEW OF THE CHEST: There is new moderate
right-sided pneumothorax with partial collapse of the entire
right lung following resection of the medial one-third of the
right clavicle and first anterior rib. Minimal leftward shift of
the mediastinum may be related to large left lower lung
atelectasis. Small right effusion is present. Heart size is
enlarged.
[**2101-7-27**]: There is still present right large pneumothorax with
significant collapse of the right lung, left mediastinal chest
and left lower lobe consolidation. Pneumomediastinum cannot be
excluded. The patient is after recent resection of the part of
the clavicle and adjacent chest wall debridement.
[**2101-7-27**]: On the current study, there is evidence of significant
decrease in the right pneumothorax with only small amount of
pneumothorax is seen. There is still present pneumomediastinum.
Reexpanding right lung is noted associated with small pleural
effusion. Left lower lobe consolidation is unchanged.
[**2101-7-28**]: Current study demonstrates bibasal consolidations,
bilateral pleural effusions and small amount of pneumothorax is
still present as well as potentially small amount of
pneumomediastinum.
[**2101-7-29**]: Previous mild pulmonary edema has largely cleared,
moderate right pleural effusion is smaller, but bibasilar
atelectasis is still severe. No
pneumothorax. Heart size normal. Stomach is moderately distended
with air
and fluid. Medial right clavicle has been resected.
[**2101-7-31**]: There are low inspiratory volumes. There are small
bilateral effusions with underlying collapse and/or
consolidation. There is borderline cardiomegaly. There is upper
zone redistribution, but no overt CHF. The medial aspect of the
right clavicle is not visualized, consistent with history of
resection, and the medial right clavicle is inferiorly displaced
with respect to its normal position. Of note, there is some
faint opacity in the right suprahilar region, more pronounced
than on [**2101-7-29**], which may represent a re-developing pneumonic
infiltrate.
[**2101-8-1**]: Persisting bilateral pleural effusion and bibasilar
atelectases.
Stable right suprahilar opacity which likely represents
atelectasis/consolidation
[**2101-8-1**]: Stable bilateral pleural effusion and bibasal
atelectasis No evidence of pneumothorax
[**2101-8-2**]: IMPRESSION:
1. Tip of the PICC line is 5.4 cm below the cavoatrial junction.
2. Stomach has been consistently distended since at least [**7-21**], [**2101**]. Such distension might increase the likelihood of
aspiration.
3. No acute cardiopulmonary changes compared with last chest
x-ray.
[**2101-8-3**]: Mild interstitial edema. Left lower lobe atelectasis.
No pneumothorax.
[**2101-8-4**]: IMPRESSION: Little overall change.
[**2101-8-4**]: FINDINGS: In comparison with the earlier study of this
date, there again is evidence of increased pulmonary venous
pressure, mild enlargement of the cardiac silhouette, bilateral
pleural effusions, and evidence of resection of the medial
aspect of the right clavicle. Central catheter remains in place.
Dilatation of the gas-filled stomach persists, for which a
nasogastric tube might be helpful.
[**2101-8-8**]: FINDINGS: In comparison with the study of [**8-4**], there
is little overall change. Continued enlargement of the cardiac
silhouette with evidence of elevated pulmonary venous pressure
and bilateral pleural effusions with compressive atelectasis.
Evidence of resection of the medial half of the right clavicle
is again seen. Dilatation of the gas-filled stomach appears to
have resolved.
[**2101-8-10**]: There has been interval decrease in right pleural
effusion after positioning of right chest tube. Left pleural
effusion is unchanged. Bibasilar atelectasis are larger on the
left side. Cardiomegaly is stable. medial chest drains are again
noted. Surgical clips project in the right medial hemithorax.
There are low lung volumes.
Discharge Labs:
Brief Hospital Course:
Patient is a 50 year old female with PMH of asthma, poorly
controlled DM1 with last A1C of 13, HTN, ESRD s/p living related
donor renal transplant in [**2092**], who was admitted for fevers and
UTI, and found to have pneumonia, vegetative endocarditis and
abscesses of chest wall and perinephric growing group B strep.
Also with acute infarct of rostrum of corpus callosum and
possible mycotic aneurisms (neurologically intact), and episodic
hypotension.
.
Acute Care:
.
1. Endocarditis: A small vegetation seen on mitral valve with
mild mitral regurgitation on [**2101-7-27**]. This is the probable origin
of septic emboli seeding patient's perinephric abscess and chest
wall abscess. Microbiology from patient's abscesses grew
PCN-sensitive GBS. Given patient's history of PCN allergy, she
was started on IV vancomycin for coverage of the abscesses. When
patient was showing only slow improvement, and there were new
findings of infarct of the rostrum of patient's corpus callosum
and formation of mycotic aneurisms, it was decided that patient
should undergo PCN de-sensitization in the ICU and initiate PCN
therapy. After treatment with IV PCN, repeat echocardiogram on
[**2101-8-15**] was unable to revisualize the vegetation, consistent
with healing.
.
2. Right Chest Wall Abscess: Patient was found to have a large
abscess of the right chest wall involving the soft tissue,
clavicle, and first rib and extending to the pleural space.
Cardiothoracic surgery debrided the abscess and removed infected
portions of patient's clavicle and first rib. Plastic surgery
closed the wound with a flap, and patient was discharged with
instructions to follow up in office for suture removal and JP
drain removal. IV PCN therapy was administered as definitive
treatment for patient's GBS infection.
.
3. Perinephric Abscess: A mass discovered adjacent to patient's
grafted kidney was found by biopsy to be an abscess. In the OR,
the abscess was drained, but there were portions that were not
ammenable to drainage. Culture of the drainage grew GBS
sensitive to PCN, and served as the target organism for
antibiotic therapy with regards to patient's multiple areas of
infection. Repeat imaging showed decrease in size of abscess on
discharge. Patient was d/c'd with a PICC line and instructions
to follow up with infectious disease as she is completing PCN
therapy at rehab.
.
4. Infarct of Rostrum of Corpus Callosum and Mycotic Aneurisms:
Patient experienced several vasovagal syncopal episodes in
house, and during the workup of one of these episodes, the
findings of acute infarct of the rostum of the corpus callosum
and two areas of probable mycotic aneurism were seen on MRA.
Patient had no neurologic deficits on multiple neurologic exams.
Felt to be caused by septic emboli from patient's vegetative
endocarditis, these lesions were treated with IV PCN as were
patient's other infectious foci.
.
5. Vasovagal episodes: Patient had a total of 4 vasovagal
syncopal episodes in this hospital stay. Patient's heart rate
dipped below 40, she lost consciousness and quickly recovered
without lasting deficit within minutes each time. Two occured
after using the bathroom, one ocurred post-surgically, and one
occured after eating a large meal and was followed by vomiting.
These episodes can be explained by patient's rapidly changing
fluid status related to multiple surgeries, and by a degree of
relative adrenal insufficiency in the setting of prolonged
stress from surgery and infection. Telemetry revealed episodic
atrial tachycardia, so patient was placed on low dose
metoprolol. Patient was without further episodes for several
days with persistently stable vital signs for several days
before discharge.
.
6. Acute renal failure: On presentation, patient's creatinine
was as elevated to 2.2 from baseline 1.1. There was likely an
initial component of AIN due to NSAID use, but also a pre-renal
component related to fluid loss from vomiting and insensible
losses on presentation. Patient was given IV fluids during her
hospitalization and by discharge patient's creatinine recovered
to baseline.
.
7. Anasarca: With multiple surgeries and procedures, and with
possible relative AI and low vascular tone in the setting of
infection, patient intermittantly required administration of
crystalloid solution to support intravascular volume. This led
to the accumulation of large lower extremity edema, bilateral
pleural effusions, and pericardial effusion. Patient also
experienced asymetric labial swelling. The right pleural
effusion was tapped, a chest tube was temporarily placed, and
labs showed transudative fluid so chest tubes were discontinued.
With some days of accelerated diuresis with loop diuretics, the
pleural effusions, the pericardial effusion, the lower extremity
edema, and the labial swelling improved.
.
8. Oozing of blood from sites of intervention: Patient had a
drop of Hct on [**8-12**] and she had oozing of blood from previous
sites of intervention including site of chest tube. Her plavix,
which she was on for throbocytosis and previous episdode of TIA,
was held for concern of bleeding. Given vasocagal episodes
in-house concern for fall led to this being held as well, though
she was stable and without incident in-hospital for days before
discharge. She was discharged with instructions to follow up
with hematology for potential re-start of plavix.
.
Chronic Care:
.
1. S/p living related donor renal transplant. Patient was
transplanted in [**2092**]. On this stay her tacrolimus was continued.
Cellcept was held for concern of PTLD, but once ruled out and
patient was stable, cellcept was restarted. Prednisone was
continued but at stress dosing and was decreased on discharge.
.
2. DM1: A1c 13.6 most recently. The [**Hospital **] Clinic was consulted
on this admission and good glucose control was achieved on
insulin schedule.
.
3. hyperlipidemia: Patient was continued on home lipid-lowering
[**Doctor Last Name 360**].
.
4. Depression: Social work followed patient during this
admission.
.
5. TIA history: Patient had an episode of a migraine with
neurologic symptoms 2 months ago. She has a history of migraines
in the past with blurry vision. MRI from [**2-/2101**], showed Punctate
focus of slow diffusion in the left posterior frontal lobe
consistent with a tiny acute infarct. Background mild
microangiopathic small vessel disease as well. Patient was
taking plavix but because of concern for bleed and fall it was
held.
.
Transitional Care:
Patient has multiple follow-up appointments to keep with her
PCP, [**Name10 (NameIs) **], neurology, nephrology, transplant nephrology,
Hematology, Plastic Surgery, and [**Hospital **] Clinic.
Patient should have a repeat head MRA around [**2101-9-5**] to evaluate
status of mycotic aneurisms and infarct of corpus callosum.
Patient will have follow-up CT scan [**2101-9-5**] for imaging of
perinephric abscess.
Patient is to complete PCN G therapy in rehab until [**9-16**].
#. Contact - patient, her mother is [**Name (NI) **] [**Name (NI) 9780**] [**Telephone/Fax (1) 31412**]
brother, [**Name (NI) 401**] [**Name (NI) 9780**] cell [**Numeric Identifier 31413**] or home [**Telephone/Fax (3) 31414**]
# Full Code
Medications on Admission:
-ATORVASTATIN 10 mg by mouth once a day
-CLOPIDOGREL 75 mg by mouth daily
-FUROSEMIDE 20 mg by mouth once a day
-METOPROLOL TARTRATE 50 mg by mouth four times a day - taking
3x/day
-MYCOPHENOLATE MOFETIL 1000 mg by mouth twice a day
-PREDNISONE 1 mg by mouth once a day
-TACROLIMUS 2 mg by mouth twice a day
-INSULIN REGULAR sliding scale 5 units qam and prn
-NPH 40units sq qam, 10 units q pm
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous QAM.
3. Humalog 100 unit/mL Solution Sig: One (1) dose Subcutaneous
QACHS: please follow sliding scale.
4. Outpatient Lab Work
Please check labs - Chem-7, CBC, and LFTs weekly while patient
is on penicillin and have the results faxed to ([**Telephone/Fax (1) 21403**]
5. penicillin G potassium 20 million unit Recon Soln Sig: 4
million Recon Solns Injection Q4H (every 4 hours): Until [**9-16**]
for a course of 6 weeks. .
6. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
7. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
8. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. prednisone 5 mg Tablet Sig: 1.5 Tablets PO once a day.
13. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
14. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO four times a day as needed for heartburn.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
16. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO every
six (6) hours: hold for SBP<100 or HR<60.
17. nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO four
times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary:
1) Vegetative endocarditis
2) Perinephric and chest wall abscess
3) Mycotic Aneurism and Infarct of Rostrum of Corpus Callosum
4) Urinary Tract Infection
5) Pneumonia
6) Acute Kidney Injury
Secondary:
1) s/p renal transplant
2) Type 1 Diabetes Mellitus
3) Hypertension
4) Thrombocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 9780**],
It was a pleasure taking part in your care. You were admitted to
the hospital with 4 days of painful urination and two days of
nausea and vomiting. In the hospital we found that you had a
urinary tract infection, a growth of bacteria on one of the
valves of your heart, and multiple areas of infection related to
this. One was around your kidney, another was in your chest
wall, and there were a few small areas of the brain that were
concerning for infection as well. You were treated with surgery
for the chest wall and kidney, and you were treated with
penicillin for ramaining infection. Repeat imaging was unable to
detect growth on your heart valves after receiving treatment.
Please make the following changes to your medications:
STOP clopidogrel
STOP Lasix
CHANGE Prednisone to 7.5mg by mouth daily
CHANGE Mycophenolate Mofetil to 500mg by mouth twice daily
CHANGE Metoprolol to 12.5mg by mouth every 12 hours
CHANGE Insulin to Lantus 40 units in the morning and sliding
scale with meals and before bed
CHANGE Tacrolimus to 5mg by mouth every 12 hours
START Penicillin G at 4million units by IV every 4 hours until
[**9-16**]
START Nystatin 5mL by mouth four times daily until [**9-16**]
Please continue all other medications you were taking prior to
this admission.
Please keep all of your follow-up appointments.
Followup Instructions:
Please follow-up with the following appointments:
- Please call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] for an appointment
2 weeks following discharge from rehab or hospital This is the
apopintment with transplant nephrology
- Please call [**Telephone/Fax (1) 4652**] for an appointment in Plastic Surgery
clinic for drain removal and suture removal. Your appointment
should take place on the first Friday after your discharge.
-Please call for a confirm your follow-up appointment with Dr.
[**First Name (STitle) 805**], your nephrologist. The appointment has been made, so
please confirm date and time. ([**Telephone/Fax (1) 3637**]
Department: RADIOLOGY
When: MONDAY [**2101-9-5**] at 3:00 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: MONDAY [**2101-9-5**] at 4:20 PM
With: XMR [**Telephone/Fax (1) 327**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2101-9-9**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 14591**], [**First Name3 (LF) 14590**] N. MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: Monday [**2101-8-29**] 2:30pm
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: HEMATOLOGY/BMT
When: WEDNESDAY [**2101-9-21**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appointment in Neurology with Dr.
[**First Name4 (NamePattern1) 803**] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1726**]. The office will contact
you at home with an appointment. If you have not heard within 2
business days or have any questions please call [**Telephone/Fax (1) 31415**].
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
ICD9 Codes: 486, 2761, 2762, 5849, 5119, 2767, 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2424
} | Medical Text: Admission Date: [**2123-2-22**] Discharge Date: [**2123-3-16**]
Date of Birth: [**2047-7-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
SOB, R sided chest pain
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
75 yo Male with COPD, CHF (EF 55%), Coomb's positive
hemolytic anemia (transfusion dependent), 5Q Syndrome(loss of
long arm of chromosome 5 causing transfusion dependent anemia -
subtype of MDS), remote history of DVT, DM II, presents with
sudden onset SOB, new orthopnea, R-sided pleurtic chest pain,
and new lower extremity edema. Pt was transfused one unit [**Unit Number **]
days prior to admission and he had recently stopped prednisone
for coomb's positive hemolytic anemia. Pt denies fever and
chills at home. Pt was admitted with similar complaints in
[**2122-11-6**] at NEBH. At the time, the BAL cultures were
negative and the patient was treated with abx and steroids. CT
at time of discharge demonstrated worsening cystic formation.
.
In the ED, ECG showed ST depressions in leads V4-V6. The
patient was subsequently started on heparin gtt. Given CXR
findings of increased perihilar haziness, and R infrahilar
haziness, in conjunction with fever to 100.4 and a lactate of
3.5, he also received azithro 500mg x1, ceftriaxone 1g IV x1,
and Lasix 20mg IV x 1. After diuresis, the patient subsequently
became hypotensive with decrease in SBP from 130s to 90s. He
was then given NS 250 cc with some return of SBP to 110s. The
patient did not receive a CTA to rule out a PE due to the
developing acute renal failure. (No urine output to lasix.)
.
The patient was evaluated by the MICU resident on night of
admission for respiratory distress. He was subsequently
intubated due to hypoxia and respiratory distress. The patient
was subseqeuntly found to have bilateral PEs on CTA consistent
with findings of DVT on LE dopplers. The patient was not
started on anticoagulation however given the concern for
bleeding with several episodes of hemoptysis. In addition the
patient also had a presumed aspiration PNA with an as yet
unisolated organism. He had multiple cystic lesions which were
concerning for infection, super infection or intrinsic lung
disease and multiple bronchoscopy and BAL were unable to
identify neither the infection or the underlying lung disease.
However the patient did improve clinically on vancomycin,
levofloxacin and flagyl. Although extubation was initially
complicated by persistent secretions and poor spontaneous
breathing trials, the patient was successfully extubated on
[**2123-3-9**]. During his MICU course, the patient also received
several blood transfusions for his Anemia and 5Q syndrome as
well as multiple boluses of fluid to maintain blood pressure.
The patient did well for 24 hours post extubation and was
transferred to the floor hemodynamically stable.
Past Medical History:
1. Chronic obstructive pulmonary
disease/ emphysema.
2. Hypertension.
3. Sideroblastic anemia.
4. Cholecystectomy four years ago.
5. Status post appendectomy.
6. History of right-sided deep venous thrombosis. [**2101**]
7. h.o ETOH abuse
8. Recent ICU stay [**Month (only) 359**] at [**Hospital1 **] for Pneumonia requiring
intubation.
9. IDDM
10. 5Q Minus Syndrome (loss of long arm of chromosome 5 causing
anemia and MDS)
11. CHF, EF 55%, last echo [**2-8**]--> 1+ MR, mild PA HTN
12. Coomb's positive hemolytic anemia, recent at NEBH
Social History:
Pt is a retired architect who was raised in RI. He admits to
having smoked 3ppd for over 20+ years but quit smoking tobacco
in [**2087**]. He also admits to drinking 1 [**Doctor Last Name 6654**] and 0.5 bottle of
wine every night with dinner. He has been drinking for 50+
years. The patient denies any illicit drug use ever.
Family History:
Mother - deceased at age [**Age over 90 **] due to "natural causes"
Father - first MI at age 70s
3 sisters all of whom are healthy
Physical Exam:
Physical Examination on Admission to [**Hospital1 18**]
VS: T: 100.4 BP: 107-63 HR: 101 RR: 20 SaO2: 93% on 4.5L
NC
Gen: elderly male, labored breathing, sitting bolt upright in
bed
HEENT: EOMI, PERRL, mmm
Neck: fleshy
CV: RRR, difficult to auscultate above breath sounds
Lungs: bibasilar rales, rhonchi [**2-7**] way up right side, no
wheezes
Abd: obese, soft, NT, ND, no hepatosplenomegaly
Ext: bilateral 2+ LE edema l>R (normal for patient)
.
.
Physical Examination on Transfer to Floor [**2123-3-10**]:
VS: BP: 179/76 HR: 62 RR: 20 SaO2: 97% on 4L and 93% on RA
Gen: caucasian male lying in bed wearing NC in NAD. Pt is
conversing in full sentences, no accessory muscle use.
HEENT: PERRL, HEENT, anicteric, pale conjunctiva, mmm, posterior
pharynx with mild erythema.
Neck: no LAD, supple, full ROM
CV: RRR S1, S2, no murmurs, rubs, gallops
Chest: crackles on right side, however pt with large bandage
over former chest tube site
Abd: obese, soft, NT, ND, BS+, 8cm patch of petechiae over right
upper abd below bandage
Ext: 3+ pitting edema [**4-9**] way up shins, slightly cold, intact to
sensation
Neuro: A+Ox3 (although pt initially thought it was [**2068**], he
corrected himself soon after), CN II-XII intact, sensation
intact to light touch.
.
Pertinent Results:
[**2123-2-21**] 11:30PM WBC-4.5 RBC-3.69*# HGB-11.1* HCT-30.9*
MCV-84# MCH-30.0# MCHC-35.8* RDW-15.0
[**2123-2-21**] 11:30PM NEUTS-75.8* LYMPHS-15.3* MONOS-6.9 EOS-1.2
BASOS-0.9
[**2123-2-21**] 11:30PM MICROCYT-1+
[**2123-2-21**] 11:30PM PLT COUNT-331#
[**2123-2-21**] 11:30PM PT-13.8* PTT-23.2 INR(PT)-1.2
[**2123-2-21**] 11:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2123-2-21**] 11:30PM ACETONE-NEG
[**2123-2-21**] 11:30PM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-2.3*
MAGNESIUM-1.5*
[**2123-2-21**] 11:30PM GLUCOSE-244* UREA N-38* CREAT-1.6* SODIUM-134
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-23 ANION GAP-17
[**2123-2-21**] 11:30PM ALT(SGPT)-88* AST(SGOT)-37 CK(CPK)-71 ALK
PHOS-116 AMYLASE-28 TOT BILI-1.0
[**2123-2-21**] 11:30PM cTropnT-0.04*
[**2123-2-21**] 11:30PM CK-MB-NotDone
[**2123-2-22**] 06:00AM CK-MB-NotDone cTropnT-0.04*
[**2123-2-22**] 06:00AM CK(CPK)-89
[**2123-2-22**] 08:49AM CK-MB-4 cTropnT-0.03*
[**2123-2-22**] 08:49AM CK(CPK)-183*
[**2123-2-22**] 05:41PM CK-MB-4
[**2123-2-22**] 05:41PM cTropnT-0.02*
[**2123-2-22**] 06:04PM TYPE-ART TEMP-36.9 PO2-86 PCO2-30* PH-7.48*
TOTAL CO2-23 BASE XS-0 INTUBATED-NOT INTUBA
[**2123-2-22**] 06:51PM O2 SAT-84
.
.
CXR [**2123-2-21**]: "FINDINGS:
Cardiac and mediastinal contours are unchanged with mild
cardiomegaly and a tortuous and unfolded aorta. There is
increased perihilar haziness. There is also patchy increased
opacity in the right infrahilar region. No definite effusions
are identified. Lung volumes overall are slightly reduced. There
is no pneumothorax. The osseous structures are unremarkable.
IMPRESSION: 1. Increased perihilar haziness compared to the
prior study may represent early CHF.
2. Increased right infrahilar opacity, concerning for pnemonia
given the history of fever."
.
.
Bilateral LE US [**2123-2-22**]:
"The veins of the right lower extremity from the groin to below
the popliteal trifurcation show normal color flow, normal
Doppler with augmentation and normal compressibility. On the
left side, however, the popliteal vein and anterior tibial vein
are distended, noncompressible and partially occluded. The
superficial femoral vein, greater saphenous and common femoral
vein all show normal flow, compressibility, and Doppler wave
forms.
CONCLUSION:
Acute DVT involving the left popliteal and anterior tibial
veins. The remainder of the venous system is fully patent."
.
.
TTE [**2123-2-23**]: "Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
The right ventricular cavity is mildly dilated. Right
ventricular systolic function is normal. The aortic root is
mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a fat pad.
IMPRESSION: Right ventricular cavity enlargement with preserved
biventricular systolic function.
Compared with the prior study (tape reviewed) of [**2121-9-9**], the
rhythm is now atrial fibrillation, and the right ventricular
cavity appears larger. Based on [**2115**] AHA endocarditis
prophylaxis recommendations, the echo findings indicate a low
risk (prophylaxis not recommended). Clinical decisions
regarding the need for prophylaxis should be based on clinical
and echocardiographic data. "
.
.
[**2123-3-1**] IVC filter placement: "Successful placement of
retrievable Recovery nitinol IVC filter just inferior to the
level of the renal veins. The filter can be removed up to three
months from the time of placement, or left in place
permanently."
.
.
[**2123-3-1**] CTA: "1) Filling defects in the right main pulmonary
artery and a left lower lobe segmental branch. There is also
necrotizing pneumonia involving the right lower lobe. These
findings may represent two separate processes. Infarction
involving the right lower lobe complicated by superinfection may
also be considered in the differential diagnosis. The filling
defect in the right main pulmonary artery directly abuts the
dense consolidation in the right lower lobe raising the
possibility of an invasive infectious process such as
aspergillosis involving the right pulmonary artery.
2) Fullness of the left adrenal gland with a Houndsfield unit
value of 4.5, likely representing an adrenal adenoma."
.
.
[**2123-3-3**] TTE:
"MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *7.0 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.1 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.1 cm
Left Ventricle - Fractional Shortening: 0.57 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Right Ventricle - Diastolic Dimension: *3.6 cm (nl <= 2.1 cm)
Aorta - Valve Level: *3.7 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - E Wave Deceleration Time: 235 msec
TR Gradient (+ RA = PASP): *29 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2123-2-23**].
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Mildly dilated aortic root. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is markedly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). The
right ventricular cavity is mildly dilated. Right ventricular
systolic function is normal. The aortic root is mildly dilated.
The ascending aorta is mildly dilated. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (tape reviewed) of [**2123-2-23**],
there is no
significant change. "
.
.
[**2123-3-4**]:
"UNILAT UP EXT VEINS US RIGHT P
Reason: RUE SWELLING
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with PNA, interstitial lung disease now with RUE
swelling.
REASON FOR THIS EXAMINATION:
rule out DVT
STUDY: Doppler ultrasound of upper limb veins.
INDICATION: The patient with pneumonia. Right upper arm
swelling. Rule out thrombosis.
TECHNIQUE: Standard grayscale, color flow and pulse wave Doppler
interrogation of the deep veins of the right upper limb was
performed. Dynamic compression maneuvers were used where
appropriate to evaluate the venous patency.
COMPARISON: No study available for comparison.
REPORT: The internal jugular vein, subclavian vein, brachial
vein, basilic vein and cephalic vein are all clearly visualized
and are patent. These demonstrate normal compressibility,
augmentation, and respiratory variation where appropriate. There
is no evidence of DVT.
CONCLUSION:
No evidence of right-sided upper extremity DVT."
.
.
EMG [**2123-3-12**]:
"Pt. is a 75 yo male with a complicated PMHx including MDS on
steroids, CHF, COPD amd recent prolonged hospitalization for
respiratory distress during which he was intubated and sedated.
Upon awakening he was profoundly weak.
Directed examination revealed severe weakness of all
extremities,
approxiamately 1-2/5 except for triceps and wrist extensors
which were 2+/5. Sensory exam was essentially normal except for
vibratory loss in the toes and [**Last Name (un) 64146**]. He was areflexic, atonic,
and edematous throughout all four extremities.
This study was requested to rule out a generalized myopathy.
FINDINGS:
Motor nerve conduction studies(NCSs) of the left median nerve
revealed
severely reduced response amplitude(RA) with distal stimulation,
no response with proximal stimulation and normal distal latency;
F waves were
unobtainable.
Motor NCSs of the left ulnar nerve revealed severely reduced RA
with normal conduction velocity below the elbow, mildly slowed
velocity across the elbow and a mildly prolonged distal latency;
F waves were unobtainable.
Motor responses of the left tibial nerve recording abductor
hallicis and of the deep peroneal nerve recording extensor
digitorum brevis and tibialis anterior were unobtainable.
Sensory NCS of the left median nerve revealed moderately reduced
RA with
normal conduction velocity.
Sensory NCS of the left ulnar nerve revealed moderately reduced
RA with normal conduction velocity.
Sensory NCS of the left radial nerve revealed mildly reduced RA
with normal conduction velocity.
Sensory NCS of the right sural nerve revealed moderately
decreased RA with
moderate slowing of conduction velocity. Sensory response of the
left sural nerve was unobtainable.
3HZ repetitive nerve stimuation of the left ulnar nerve
recording abductor
digiti minimi did not reveal any signficant decrement. There was
no
facilitation of the left abductor digiti minimi compound muscle
action
potential with 10 seconds of maximal voluntary contraction.
Concentric needle electromyography(EMG) of the left deltoid and
biceps
revealed early recruitment of motor units with an excess of
small amplitude, short duration, polyphasic motor units; a few
fibrillation potentials were noted in biceps.
EMG of the left tibialis anterior revealed early recruitment of
motor units with an excess of small amplitude, short duration,
polyphasic motor units without evidence of denervation. Exam of
the left vastus lateralis revealed early recruitment of markedly
small amplitude, short duration, polyphasic motor units without
denervation.
IMPRESSION:
Abnormal study. There is electrophysiologic evidence for a
severe,
generalized myopathic process with evidence for scant ongoing
denervation (as can be seen in critical illness myopathy). The
generalized reduction in sensory amplitudes may be due to the
patient's generalized edema; however, a generalized
polyneuropathy cannot be excluded. The findings do not suggest a
pre- or post-synaptic disorder of neuromuscular transmission."
.
.
.
MRI C-spine [**2123-3-13**]:
"MR [**Name13 (STitle) **] W& W/O CONTRAST [**2123-3-13**] 6:49 PM
MR [**Name13 (STitle) **] W& W/O CONTRAST; MR CONTRAST GADOLIN
Reason: please do w/ and w/o gad, fat sats, looking for epidural
abs
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with chf, copd, mds, recent icu stay now with
weakness in all extrm
REASON FOR THIS EXAMINATION:
please do w/ and w/o gad, fat sats, looking for epidural abscess
CLINICAL INFORMATION: Patient with weakness in all extremities
for further evaluation. The examination is performed to rule out
epidural abscess.
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2
gradient echo and T1 axial images of the cervical spine were
acquired. The patient was unable to continue and was unable to
hold still leading to motion artifacts on the images.
FINDINGS: The examination is limited due to motion artifact. No
evidence of high-grade spinal stenosis is seen. On gradient echo
and T1 axial images, no evidence of extrinsic spinal cord
compression is appreciated. On sagittal T2 and inversion
recovery images, artifacts have limited evaluation of the spinal
canal and spinal cord. There is no evidence of vertebral
malalignment seen. No evidence of ligamentous destruction is
noted.
IMPRESSION: Markedly limited study secondary to motion. On axial
images, no evidence of high-grade spinal stenosis is seen. A
repeat study with sedation would be helpful for further
evaluation of the spinal canal if clinically indicated."
.
.
[**2123-3-1**] BAL: "NEGATIVE FOR MALIGNANT CELLS.
Pulmonary macrophages, neutrophils and lymphocytes.
No viral inclusions or fungus seen. "
"GRAM STAIN (Final [**2123-3-1**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2123-3-3**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2123-3-2**]):
PNEUMOCYSTIS CARINII NOT SEEN.
FUNGAL CULTURE (Preliminary):
YEAST, PRESUMPTIVELY NOT C. ALBICANS.
WORK-UP REQUESTED BY DR [**Last Name (STitle) **],[**Doctor Last Name 9406**] .
FURTHER IDENTIFICATION TO FOLLOW.
ACID FAST SMEAR (Final [**2123-3-2**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
VIRAL CULTURE (Final [**2123-3-2**]):
TEST CANCELLED, PATIENT CREDITED.
DUPLICATE SPECIMEN.
PLEASE REFET TO SPECIMEN # 182-7308S [**2123-3-1**] FOR RESULTS.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2123-3-2**]):
TEST CANCELLED, PATIENT CREDITED.
DUPLICATE SPECIMEN.
PLEASE REFER TO VIRAL CULTURE ON SPECIMEN # 182-7308S
[**2123-3-1**] FOR
RESULTS.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2123-3-2**]): BUDDING
YEAST. "
.
.
Brief Hospital Course:
A/P: 75yo Male with COPD, 5Q minus syndrome, Coombs positive
hemolytic anemia, HTN, and CHF who presents w/ acute onset SOB,
low grade fever(despite several Tylenol doses), and hypotension
responsive to 250cc Bolus concerning for PNA and ? dehydration.
.
1. Respiratory failure: Initially on admission to [**Hospital1 18**], the
etiology of the respiratory failure was unclear. However at
time of presentation, he was found to be in profound respiratory
distress and was transferred immediately to the Medical ICU. On
initial CXR, the patient was found to have a spontaneous right
apical pneumothorax and infiltrate concerning for possible PNA
vs. CHF. A chest tube was placed by thoracic surgery to
decompress the pneumothorax. A subsequent LE US demonstrated
left popliteal DVT and the patient was started anticoagulation
with a heparin gtt for presumed pulmonary embolus. A CTA was
eventually performed which confirmed the diagnosis of pulmonary
embolus.. Later during the course of his hospital stay, the
patient developed hemoptysis and the heparin gtt was stopped. In
addition, the patient was started on antibiotics for his PNA
(vancomycin/ceftriaxons/flagyl). A chest CT was not initially
performed due to his hemodynamic instability. He was intubated
on [**2123-2-23**] for worsening respiratory distress. A
Bronchoscopy performed at the time was not revealing for any
obvious pathology and BAL returned negative for all cultures.
During his ICU stay, he had work up for fungal process x 2. BAL
x 2 here without any isolation of organimss. The patient
clinically responded well to abx treatment and althoug had some
difficulty with extubation secondary to persistent secretions,
he was extubated on [**2123-3-9**]. Since extubation, he has remained
stable and was transferred to the floor. Since arrival to
floor, he remained stable from a hemodynamic and respiratory
standpoint. (see subsections below for more details).
.
A) Infection: Pt initially admitted with low grade fever and SOB
(as well as hypotension which was responsive to fluids). The
CXR was consistent with a blossoming PNA RLL (necrotizing
component as per report). And a following CT demonstrated
diffuse ground glass opacity, LLL abscess, and honeycombing. New
cystic areas were noticeable compared to [**9-9**]. His workup
however was not revealing for any particular organism. Stool
was found to be negative for c.diff x3, urine cultures did not
result in any growth from [**2-22**] and [**2-26**], sputum grew out only
sparse bacillus and was negative for yeast. BAL demonstrated no
fungus, legionella, PCP, [**Name10 (NameIs) 11381**], [**Name11 (NameIs) 103824**] on two separate
occations ([**2-23**] and [**2-25**]). Blood cultures were also negative
throughout his hospital course and the patient tested negative
for galactomannan. Although no organism grew from any source,
his rapid response to antibiotics made it likely that he was
infected with possible a pneumococcus (given his residence
within the community, and sudden onset. A VATS was considered
and CT surgery was consulted, they did not feel it was indicated
considering his rapid improvement on antibiotics.
.
B) PE: Pt with documented bilateral PEs on CTA. An IVC filter
was placed by IR (the filter is a 3 month filter which can be
removed at the time). The patient was initially started on
anticoagulation with heparin, howeve due to episodes of
hemoptysis, the anticoagulation was stopped. TTE on [**2-23**]
demonstrated mild pulmonary HTN with EF >55%. We recommend,
re-starting anticoagulation with coumadin with target INR of [**3-11**]
several weeks from discharge and removal of IVC filter in 3
months as it may become thrombogenic at that point.
.
C) Pneumothorax: The patient was found to have right apical
pneumothorax on admission CXR on [**2-21**]. As the pneumothorax was
enlarging by CXR on [**2-23**], thoracic surgery was consulted and a
chest tube was placed. The CXR was removed a week later without
complication and surveillance CXR since then showed complete
resolution of CXR.
.
D) COPD: Pt did not appear to have an acute exacerbation of his
COPD. He was continued on nebulizers without an issue.
.
2. Anemia: Pt with a history of 5Qminus syndrome (a subset of
MDS with mutation leading to loss of function of epo receptor on
RBC) and a history of Coomb's positive hemolytic anemia which
was previously treated with decadron. The patient has been
followed by Dr. [**Last Name (STitle) **] (heme/onc - can be reached at
[**Telephone/Fax (1) 103825**]). He was admitted on thalidomide for his MDS and
decadron for his hemolytic anemia. However the thalidomide was
held while in house. A daily Hct was followed with intention to
transfuse for goal Hct >25. After the patient recovered from
respiratory distress and was extubated successfully, he was
transferred to the floor. There he was started on rituximab
(865 IV once a week for 4 weeks) as per Dr. [**Last Name (STitle) **]. The decadron
was tapered down to 6mg once daily with intentions to decrease
decadron even further. Dr. [**Last Name (STitle) **] will follow the patint while
at [**Hospital3 **] for his rituximab dosing as well as his
decadron taper (anticipate decreasing decadron to 4mg PO once
daily on Thurs [**2123-3-18**]). IVIG was considered for immune
re-constitutions as well as for his MDS, however this will be
started as an outpatient at Dr. [**Last Name (STitle) 103826**] discretion. Recommend
following CBC every two-three days to monitor for signs of blood
loss.
.
3. CHF: On admission to [**Hospital1 18**], the patient was initially
hypotensive responsive to fluids. While in the MICU, the
patient was given numerous fluid boluses to maintain blood
pressure and overall resulted in gross anasarca. On transfer to
the floor, he was found to have 3+ pitting edemea bilaterally in
both the upper and lower extremities. He was aggressively
diuresed with lasix 40mg IV BID with goal to diurese 2L/day. On
day of discharge, the patient had significantly improved from a
clinical standpoint - upper extremity edema was resolved and the
patient had 1+ lower extremity edema. The patient was placed
back on his outpatient regimen of lasix 80mg PO once daily in
addition to aldactone 25mg PO TID. The creatinie was stable
during the active diuresis at 0.5 and BUN of 20s. The patient
did have an isolated episode of hyponatremia. This was thought
to be due to hypervolemic hyponatremia given his gross anasarca.
The hyponatremia resolved with continued diuresis. Recommend
continued diuresis until euvolemic.
.
4. Myopathy: On transfer to the floor, the patient was found to
have significant weakness - myopathy. At the time, this was
though to be due most likely to ICU myopathy vs. steroid
myopathy as pt was intubated and sedated for 16 days while on
chronic steroids. Neurology was consulted and an C-spine MRI as
well as EMG was performed. The clinical findings as well as the
results of the EMG was consistent with ICU myopathy and no
pathology was found on C-spine MRI. The patient continued to
receive PT while on the floor and improved steadily. However he
still required significant help with all ADLs. Anticipate
several months of intensive rehab necessary to regain his
funcational status.
.
5. AFib: Pt developed afib with rapid vent response on [**2-23**]. At
the time, the patient failed DCCV X 2 but reverted back to sinus
rhythm spontaneously later on. Patient was loaded on IV amio
and placed on amio gtt. Patient is now on amiodarone 200mg once
daily with good control. Lopressor was added for additional
control in MICU. Since transfer to floor, the patient has been
in NSR without evidence of afib.
.
6. ARF: Pt was initially found to be in ARF. This was thought
to be due to pre-renal failure secondary. After fluid boluses
the ARF resolved with Creatinine back to baseline. Creatinine
was stable even after aggressive diuresis on the floor.
7. DM: Pt required insulin gtt while in unit due to decadron.
The patient was placed back on outpatient dose of 20/30 20units
[**Hospital1 **] with tight RISS. The FS remained within the normal range on
his outpatient regimen for diabetes after titration of decadron.
.
8. Hypotension: The patient was admitted with hypotension which
was responsive to fluids. [**Last Name (un) **] stim test was negative. Lactates
trended down and BP was no longer an issue after his acute
management.
.
9. Code: DNR but intubatable. Confirmed with patient on
multiple occasions.
.
10. If you have any question, please page Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of
[**Hospital1 69**] at #[**Numeric Identifier 9522**].
.
Medications on Admission:
On Admission to [**Hospital1 18**]:
1. Thalidomide
2. Coumadin
3. 70/30 20units [**Hospital1 **]
4. Lisinopril
5. Diovon
6. Toprol
7. Lasix 80mg once daily
8. Spironolactone 25mg TID
9. Advair
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) puffs
Inhalation Q2H (every 2 hours) as needed.
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-7**]
Puffs Inhalation Q4H (every 4 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
8. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) tx Inhalation
Q4H (every 4 hours).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) tx
Inhalation Q4H (every 4 hours).
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
13. Vancomycin HCl 500 mg Recon Soln Sig: 1500 (1500) mg
Intravenous Q12H (every 12 hours) for 6 days.
14. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
16. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
17. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
19. Insulin 70/30 70-30 unit/mL Suspension Sig: Twenty (20)
units Subcutaneous twice a day.
20. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
21. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO once a
day.
22. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Pulmonary Embolus, Pneumonia, Spontaneous Pneumothorax
Secondary: 5Q minus Syndrome, Coombs Hemolytic anemia, HTN,
COPD, CHF
Discharge Condition:
Stable.
Discharge Instructions:
Please take all of your medications.
Please follow up with your doctors, especially Dr. [**Last Name (STitle) **]
If you notice any shortness of breath, difficulty breathing or
fever please call your Dr. [**Last Name (STitle) **].
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] within one week of discharge.
You must call him for your rituxin dosing prior to Mon [**2123-3-22**].
Please call for an appointment: [**Telephone/Fax (1) 103825**].
Completed by:[**2123-3-17**]
ICD9 Codes: 5849, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2425
} | Medical Text: Admission Date: [**2174-2-19**] Discharge Date: [**2174-3-16**]
Date of Birth: [**2122-12-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
R internal jugular central line
History of Present Illness:
51 yo male with AIDs (dx [**2158**], on HAART, VL undetectable, CD4 90
[**1-3**], h/o thrush and esophagitis) admitted with back pain/flank
pain and fevers. He was in hus USOH until [**2174-1-27**] when he went
to his PCP's with R sided pleurtic chest pain. He also had a
resurangence of fevers to 102 - 105 and night sweats which he
had had for 13 years, then stopped 2 years prior when he started
HAART. CXR on [**2174-1-27**] showed infiltrate within the left upper
lobe and an opacityl at the right heart border. He was started
on Levaquin at that time. Then on [**2174-2-3**], he went to [**Hospital1 **]
[**Location (un) 620**] with L calf pain. He was admitted with a DVT and
multiple PEs. Chest CT at that time also showed multiple
bilateral segments and subsegmental pulmonary emboli,
consolidation vs. infarct in the posterior left upper lobe and
anterior right lower lobe, multiple bilateral pulmonary nodules,
and mediastinal lymphadenopathy. MDs there were also concerned
that he could have TB as he had weight loss, fevers, and pulm
nodules. He underwent bronch on [**2174-2-7**] which was "normal".
Cytology showedd atypical flora. Cultures/labs from there showed
negative crypto ag, oral flora from the bronch, AFB smear
negative, culture pending. He was started on coumadin and
heparin and a second of levofloxacin. During this stay, he had
no pulmonary symptoms.
.
On discharge from [**Location (un) 620**], he noticed his Right leg now was
tender, where it had not been before. He then was switched to a
course of Doxy on [**2-11**] my his PCP. [**Name10 (NameIs) **] was not doing well at home
since he was having extreem pain in both his legs. The swelling
in the LLE diminished, but the right increased. He had no
pulmonary symptoms until the afternoon on [**2-18**] when he began to
become SOB. He came to the ED.
.
In ED, initial vitals were 103.6, HR 145, BP 78/62, RR 18, 98%
-> 100% on 2L .He was complaiing of worsening SOB and pleurtic
right chest pain. Code sepsis called, RIJ placed. Initial CVP
was 7. he was boluesd 8 L NS in the ED. Of note, his O2 sat on
arrival was 98% RA, then 100% 2l in the ED,94% on 4L NC on
arrival to MICU. he was started on Dopamine and levophed. He was
given 1 gram of vancomycin, 1 gram of CTX, and a DS bactrim.
Blood cultures and urine cultures were sent. A ct chest revealed
a left upper lobe opacity, subsegmental PE's, multiple B pulm
nodules.
.
Currently, he is SOB and c/o pleurtic right sided and posterior
chest pain and bilateral calf pain. He has been having fevers to
102 - 105 daily with night sweats. Denies large weight gain (he
has had touble with weight loss since his MAC). No HA. No neck
pain. No nausea. No vomiting. Has one loose BM daily [**3-3**] HAART.
Denies missing any of his medicine. Quit smoking 2 eeks agi. No
recent PPD. No TB contacts. [**Name (NI) **] Rashes. No recent travel.
Past Medical History:
AIDS on HAART c/b thrush
H/O MAC infection of unknown site
DVT left leg- [**2174-2-3**]
COPD- bullous changes
intermittent diplopia
asymptomatic UTI
Moderate cervical spondylosis with moderate spinal canal
stenosis
and multilevel bilateral neural foraminal narrowing seen on MR
cervical spine- [**2170**]
Epidermal inclusion cyst- right thigh
Social History:
+tobacco ([**1-31**] pack a day) x35 years and quit 2 weeks ago, no
ETOH. no illict drugs, lives alone. Works part-time with
caterers.
Family History:
Mother- breast cancer, stomach cancer Father: CVA, heart disease
Physical Exam:
wt: 62kg, 97.9 po, p123, 108/75 (dopamine 9, levophed .2), r28,
96% on 4l nc (ED 8liter in and 1500cc out)
General: mild resp distress, talkitave. Able to relate history
well.
HEENT: NC/AT, PERRLA. dentures in, no thrush seen. no scleral
icterus noted, MMM.
Neck: Supple, JVP normal
Pulmonary: Anterior reveals a three componet pulmonary rub.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: diffusly tender with voluntary guarding. normoactive
bowel sounds, no masses or organomegaly noted. extreme right
CVAT
Extremities: 1+ pitting edema bilaterally on calf. VERY tender
gastroc. 2+ radial, DP and PT pulses b/l.
Neurologic: A and O x3; srength grossly normal.
Brief Hospital Course:
Assessment: 51 yo m with AIDS, recent diagnosis of PE, pulmonary
nodules, fevers, and shock. His shock is most likely due to
sepsis given his increasing WBC and low CVP making right heart
strain from PE unlikley.
.
Plan:
# Septic shock: He seems to be in distributive shock. Most
likely this is sepsis, given that he is immunocompromised with
fevers and respiratory distress. However, Adrenal insufficiency
unlikely given normal [**Last Name (un) 104**] stim test. Given his
immunocomprimised state, he has many potential sources for
sepsis including bactreial, fungal, and viral. Infectious
disease was consulted who recommended continue treatment with
caspofungin, azithromycin, imipenem-cilastin. Continue
antiretrovirals and bactrim ppx. Unclear source at this point.
So far all cultures NGTD, cryptococcus, CMV, and histo
serologies negative, AFB x3, PCP stain, [**Name9 (PRE) 20613**] ag, negative. Pt
was placed on Sepsis protocol. With frequent NS fluid bolus for
CVP >12 and pressors. He had episode of NSVT on arrival while
on dopamine and was changed over to levophed, which he required
for several days of his addmision to keep MAP>65. Given
persistent hypotension concern for neurogenic shock secondary to
autonomic dysfunction, Neuro consult was obtained who did not
think that patient has autonomic dysfunction on initial
assessement.
.
# Respiratory distress - as above, most likely secondary to
pulmonary infection complicated by pulmonary emboli. Required
significant oxygen supplementation initially but this was
reduced by 6 days of hospitalization from NRB to 40% by
facemask.
.
# PE/DVT: Hx of DVT and PE on recent hospitalization. RL LENI
shows DVT this admission. Given likely coumadin failure IVC
filter was placed. Pt was started on heparin initially and then
changed over to lovenox 1mcg/kg [**Hospital1 **]. [**2-27**] AM with RUE swelling
as well, with DVT. Heme onc consulted, started on heparin as
developing DVTs through lovenox.
- Given recurrent dvt and ?pulmonary nodules and enlarged
lymphnode concern for malignancy in setting of hypercoguble
state high.
- Currently morphine prn.
.
#. hemoptysis - likely secondary to underlying pulmonary
processes. Consider bronchoscopy only if this worsens (currently
stable).
.
#Polyuria - Unclear etiology. Continues to urinate to the point
of hypotension despite IVF being stopped. [**Month (only) 116**] have neprogenic DI
[**3-3**] ambisome. [**Month (only) 116**] also not be able to concentrate urine to
excrete all the salt he has gotten on the sepsis portocol
causing an solute diuresis. Gave dose of ddAVP to see if can
concentrate urine. Ambisome switched to caspofungin.
- Renal was consulted given concern for DI. They did not think
that the pt has diabetes insipidus given that the patient has
had normal Uosm and Una. More likely, this is consistent with a
solute diuresis from the large amounts of fluid the patient has
received during this hospitalization. It is unclear whether he
is intravascularly depleted or overloaded, and his weight is up
approx 6kg. If he is making appropriate urine to previous IVF
administration, would expect his urine now to more accurately
match his input. With restriction on NS IVF, pt's urine output
has improved.
.
# Infection - unclear etiology most likely source of infectionis
pulmonary, but differential in this immunocompromised patient is
very broad. ID following. So far all cultures NGTD,
cryptococcus, CMV, and histo serologies negative
- on retrovirals, azithro/bactrim
- imipenem dc'd- continuing with vanco
.
## Neuro - pt with c/o diplopia this morning which is new. Also
with nystagmus on exam concerning for brainstem process.
- per discussion with neuro attg, given pt's likely
hypercoaguble state need to rule out stroke.
- MRI/MRA -small L cerebellar stroke, w/ sluggish basilar artery
flow, CTA also showed no thrombus but decreased basilar artery
flow. Per Neuro ordered TTE w/ bubble, no ASD or PFO
- Daily CT showed no change (needs daily CTx7 day to assess no
hemorrhagic development
.
#Hemoptysis - likel secodary to PE and PNA. Stable in amount and
frequency. Is small amounts at this time. If decompensates of
hemoptysis progresses beyond tsp amounts will need bronchoscopy
and possible surgical consult.
.
## Neuro - pt with c/o diplopia this morning which is new. Also
with nystagmus on exam concerning for brainstem process.
- per discussion with neuro attg, given pt's likely
hypercoaguble state need to rule out stroke.
- MRI/MRA to eval for stroke.
.
# AIDS: Initially held HAART therapy. Restarted on [**2173-2-24**].
#. pulm nodules - concern for malignancy given fevers, LAD. o/w
infection as above. with LUL mass, discuss timing of biopsy as
differential includes lymphoma vs lung neoplasm, will need to
discuss holding anticoagulation.
.
PPx: PPI, no pneumoboots, lovenox, increase bowel regimen given
constipation, no bowel movement since admission per pt
FEN: po diet as resp status stable
Access: RIJ, R art line, PIV
Communication: sister [**Name (NI) **]
Dispo: ICU until HD stable
# Code Status: Full, discussed extensively with paitent and HCP,
[**Name (NI) **], his sister. [**Name (NI) **] is very nervous about intubation, but
agrees that he may benefit from it in the short term.
# Dispo: ICU for now given hypotension.
# Contact: [**Name (NI) **], sister ...
The patient had a prolonged intensive care unit stay. He
developed further progressive thromboses. An IVC filter was
placed to prevent further pulmonary emboli. He developed
ischemic bowel with thrombosis of celiac and mesenteric
arteries. After extensive discussion with patient and his
sister [**Name (NI) **], the patient was made care and comfort measures
only. He was treated with IV morphine and expired peacefully on
[**2174-3-16**].
Medications on Admission:
Truvada
Reyataz 150'
Norvir 100'
Bactrim DS'
Azithromycin twice weekly
Ambien prn
Doxycycline 100 mg [**Hospital1 **] since [**2-11**]
Vicodin 5/725 prn for leg pain
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Acquired immune deficiency syndrome
adenocarcinoma of lung
pulmonary emboli
mesenteric ischemia
Discharge Condition:
Deceased
Discharge Instructions:
Remains released to funeral home
Followup Instructions:
None
ICD9 Codes: 0389, 496, 486, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2426
} | Medical Text: Admission Date: [**2136-1-16**] Discharge Date: [**2136-1-30**]
Date of Birth: [**2136-1-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 42484**] is the number one
first born triplet of a 34 and [**1-11**] week gestation pregnancy
born to a 36 year-old G4 P2 woman. Estimated date of
confinement was [**2136-2-26**]. Prenatal screens blood type B
negative, antibody positive, anti-D treated with RhoGAM,
hepatitis C surface antigen negative, RPR nonreactive,
Rubella immune, group beta strep status unknown. Pregnancy
was complicated by pregnancy induced hypertension. This was
a spontaneous triplet conception. This infant was born by
cesarean section. Apgars were 9 at one minute and 9 at five
minutes. He was admitted to the Neonatal Intensive Care Unit
for treatment of prematurity and respiratory distress.
PHYSICAL EXAMINATION: Weight 2.090 kilograms, length 43.5
cm, head circumference 32 cm. General, age appropriate with
obvious respiratory distress. Head, eyes, ears, nose and
throat normocephalic, atraumatic. Scalp palate intact. Red
reflex present bilaterally. Neck supple with no masses.
Chest lungs with poor air entry, active grunting, intercostal
retractions and nasal flaring. Cardiovascular regular rate
and rhythm. No murmur. Abdomen soft with active bowel
sounds. Femoral pulses 2+. Hips stable by midline. Anus
patent. Genitourinary male with testes present bilaterally
in canal. Neurological tone and reflexes consistent with
gestational age.
HOSPITAL COURSE/PERTINENT LABORATORY DATA: 1. Respiratory:
[**Known lastname **] required intubation and received one dose of
surfactant. He was extubated on room air on day of life
number one and remained in room air through the rest of his
Neonatal Intensive Care Unit admission. He has had no
episodes of spontaneous apnea or bradycardia.
2. Cardiovascular: [**Known lastname **] has maintained normal heart rates
and blood pressures, a soft murmur was heard on day of life
12. Has been intermittent since then. It is felt to be
benign in nature.
3. Fluids, electrolytes and nutrition: [**Known lastname **] was initially
NPO and maintained on intravenous fluids. Enteral feeds were
started on day of life number one and gradually advanced to
full volume. He has been all po since day of life number 10
[**2136-1-26**]. At the time of discharge he is taking Enfamil 24
calories per ounce minimum of 130 cc per kilogram per day.
Discharge weight is 2.37 kilograms with a length of 47 cm and
a head circumference of 33 cm.
4. Infectious disease: Due to the unknown etiology of his
respiratory distress [**Known lastname **] was evaluated for sepsis and
treated presumptively. A white blood cell count was 14,300
with a differential of 30% polys, 0% bands. The blood
culture was obtained prior to starting antibiotics. The
blood culture was no growth at 48 hours and the antibiotics
were discontinued.
5. Gastrointestinal: Peak serum bilirubin occurred on day
of life number three a total of 5.6/0.3 mg per deciliter
direct. He did not require treatment.
6. Neurological: [**Known lastname **] has maintained a normal
neurological examination during admission and there are no
neurological concerns at the time of discharge.
7. Sensory: Audiology, hearing screen was performed with
automated auditory brain stem responses. [**Known lastname **] passed in
both ears.
8. Hematological: [**Known lastname **] is blood type A positive, Coombs
negative. Birth hematocrit was 43.5%.
CONDITION ON DISCHARGE: Good.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 1894**] [**Last Name (NamePattern1) 53133**] General Medical
associates [**Apartment Address(1) 53134**], [**Location (un) 86**],
[**Numeric Identifier 53135**]. Phone number [**Telephone/Fax (1) 53136**]. Fax number
is [**Telephone/Fax (1) 53137**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: Enfamil 24 calories per ounce ad lib.
2. No medications.
3. Car seat position screening was performed. [**Known lastname **] was
observed in his car seat for 90 minutes without any episodes
of desaturation or bradycardia.
4. State new born screen: Initial was sent on [**2136-1-19**]
with a repeat on the day of discharge [**2136-1-30**]. No
notification of abnormal results to date.
5. Immunizations received: Hepatitis B vaccine was
administered on [**2136-1-25**].
6. Immunizations recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants
who meet any of the following three criterias, first born at
less then 32 weeks; second born between 32 and 35 weeks with
two of three of the following; day care during RSV season,
smoker on the household, neuromuscular disease, airway
abnormalities, or school age siblings; or thirdly with
chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months age. Before this age the family and other
care givers should be considered for immunization against
influenza to protect the infant.
7. Follow up appointments: Recommended with Dr. [**Last Name (STitle) 53133**]
within three days of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and [**1-11**] week gestation.
2. Triplet number one of triplet gestation.
3. Respiratory distress syndrome.
4. Suspicion for sepsis ruled out.
5. Intermittent heart murmur likely benign
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 50655**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2136-1-30**] 06:37
T: [**2136-1-30**] 06:27
JOB#: [**Job Number 53138**]
ICD9 Codes: 769, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2427
} | Medical Text: Admission Date: [**2144-5-19**] Discharge Date: [**2144-5-27**]
Date of Birth: [**2059-7-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 20741**] is an 84 yo M with COPD (not on home oxygen),
asbestos exposure, OSA, and CAD s/p CABG (LIMA->LAD) in [**2144-4-21**]
who presents from [**Hospital 100**] Rehab with acute onset shortness of
breath and R sided chest pain. The patient has been hospitalized
multiple times over the past month. Briefly, the patient
underwent elective minimally invasive, endoscopic CABG on
[**2144-4-21**] after experiencing worsening exertional chest pain. His
hospital course was complicated by the need to return to the OR
for re-exploration of his chest for bleeding after increased
chest tube output was noted, and a L sided pleural effusion,
have an increased oxygen requirement at that time that was
unable to be weaned. He was discharged to [**Hospital1 **] for
cardiac rehab on [**4-29**]. The patient re-presented on [**5-6**] with
fever and abdominal pain and diagnosed with acute cholecysitis.
He was deemed a poor surgical candidate, so a perc chole was
placed on [**5-8**], capped on [**5-15**] due to poor drainage through
cystic duct noted on T-tube cholangiogram, and he completed a 10
day course of cipro/flagyl (completed on [**5-17**]). This hospital
course was c/b an acute stroke on [**5-12**] where the pt experienced
decreased sensation on the right upper extremity which was
improving, as well as a right field cut, a right upper motor
neuron hemiparesis, and a right hemisensory deficit. His Head
CT and MRI showed acute infarctions in the left occipital lobe,
left thalamus, left cerebellar hemisphere and right superior
cerebellum. TEE on [**5-15**] negative for left atrial thrombus. The
etiology was thought to be cardioembolic, and lifelong
anticoagulation was recommended with coumadin. He was discharged
to [**Hospital 100**] Rehab on [**5-15**] to complete his heparin bridge to
coumadin.
Per discussion with the family, the patient was progressing well
at rehab over the past few days, although he has had an new
oxygen requirement (minimal 2-3 L NC) since his CABG. Last
Saturday, the patient was noted to walk 250 feet and
experiencing only mild SOB. Over the weekend, he developed a low
grade fever, and [**Name8 (MD) **] MD notes was noted to be hypoxic to 86% on
RA (improved to 95% on 2L). CXR at rehab showed multiple scars,
patchy bilateral radio-opacities, and evidence for pleural
thickening with fluid on the left. Yesterday, around 4 pm, one
of his family members also noted that he was back on oxygen at
the rehab and was a bit more lethargic than usual, and
perseverating. He also developed a new leukocytosis. (10.4 on
[**5-16**] ->21.0 on [**5-19**]). On the morning of admission, the patient
endorsed R sided pleuritic chest 'tightness' and 'inability to
catch his breath.' Hewas given lasix 20 mg IV x1, started on a
heparin gtt, and transferred to [**Hospital1 18**] ED for further evaluation.
In ED VS were 99.7 85 112/49 21 95% on 3 L. His labs were
significant for a WBC of 23.1 with a left shift, plt of 691, CK
15 Trop-I < 0.01, INR of 2.3. EKG without new ischemic changes.
CTA Chest showed no evidence of PE, but worsening BL pleural
effusions with evidence of loculation, pneumonia could not be
excluded. T-tube test of perc chole showed patent flow. Bedside
U/S per report showed no pericardial effusion. CT surgery was
consulted and did not think his pleural effusions were
significantly larger than before, and recommended no emergent
surgical intervention. He was given Vancomcyin 1 gram IV x1 and
Zosyn 4.5 grams IV x1, combivent nebs x1, and 2 L NS. Lactate
trend was 2.4-> 1.2 ->0.9. Patient was admitted to the medicine
floor.
Per report from ED resident to floor medicine resident Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**], patient appeared comfortable on nasal cannula
alone. When the patient arrived to the floor, he was noted to be
tachypneic to the 30s and on 12 L ventimask. His oxygen
saturations on 2 L NC was 84%. ABG was 7.45/34/65. MICU resident
was consulted for transfer to MICU for further monitering given
hypoxia, increasing oxygen requirement. His VS were 34, 88
119/50 94% 6 L NC + 50% venti face mask prior to transfer to the
ICU.
On the floor prior to transfer, the patient was AOx2 (name,
'[**Hospital1 18**]'). He stated his breathing was more 'shallow' than
normal. Denied any chest pain or abdominal pain. He is unable to
bring up any sputum with his coughing.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied chest pain or tightness, palpitations. Denied nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
- CAD s/p right coronary artery stent x2 ([**10-3**], [**3-4**]) and s/p
elective CABG on [**2144-4-21**] (LIMA-> LAD), c/b re-exploration
required for bleeding
- acute cholecystitis s/p perc chole placement on [**2144-5-12**]
- Hypertension
- Hyperlipidemia
- Chronic obstructive pulmonary disease
- Asbestos exposure
- Chronic back pain,
- Insomnia and obstructive sleep apnea (untreated)
Social History:
Lives with wife.
Exposure to asbestos.
Defers all medical decisions to son who is a chiropractor.
Occupation: retired postal worker.
Tobacco: 3 PPD x 30 years, quit 45 years ago
ETOH: None
Family History:
Non-contributory.
Physical Exam:
VS: 99 91 123/60 74 26 91-94% on 50% venti face mask
GA: elderly male, AOx2, mild respiratory distress but not using
accessory muscles to breathe.
HEENT: PERRLA. MM dry. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: poor air movement, increased expiratory phase. decreased
BS at the bases.
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. perc
chole not erythematous, tube capped.
Extremities: DPs, PTs 2+. decreased temperature noted in both
feet BL.
Neuro/Psych: CNs II-XII intact. 4/5 strength in U/L extremities.
DTRs 1+ BL (biceps, achilles, patellar). sensation intact
grossly. cerebellar fxn intact (FTN, HTS). gait deferred.
decreased sensation over RUE to light touch.
Pertinent Results:
ADMISSION LABS:
[**2144-5-19**] 11:10AM WBC-23.1* RBC-3.67* Hgb-11.6* Hct-36.0* MCV-98
Plt Ct-691*
[**2144-5-19**] 11:10AM Neuts-92.9* Lymphs-3.7* Monos-2.7 Eos-0.3
Baso-0.3
[**2144-5-19**] 11:10AM PT-27.0* PTT-88.6* INR(PT)-2.6*
[**2144-5-19**] 11:10AM UreaN-14 Creat-1.1 Na-133 K-4.5 Cl-97 HCO3-27
AnGap-14
[**2144-5-19**] 11:10AM ALT-14 AST-15 CK(CPK)-15* AlkPhos-99
TotBili-0.4
[**2144-5-19**] 11:10AM Lipase-27
[**2144-5-19**] 11:10AM CK-MB-1
[**2144-5-19**] 11:10AM cTropnT-<0.01
[**2144-5-19**] 11:10AM Calcium-9.0 Phos-3.7 Mg-1.8
[**2144-5-19**] 11:10AM D-Dimer-4272*
[**2144-5-19**] 11:14AM Lactate-2.4*
URINE:
[**2144-5-19**] 04:30PM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2144-5-19**] 04:30PM Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
OTHER PERTINENT LABS:
[**2144-5-19**] 11:10AM CK(CPK)-15* CK-MB-1 cTropnT-<0.01
[**2144-5-20**] 02:10AM CK(CPK)-14* CK-MB-NotDone cTropnT-<0.01
[**2144-5-20**] 06:44PM CK(CPK)-12* CK-MB-NotDone cTropnT-<0.01
[**2144-5-19**] 09:30PM Type-ART pO2-65* pCO2-34* pH-7.45 calTCO2-24
Base XS-0
MICRO:
[**5-19**] BCx: NGTD
[**5-20**] UCx: NEGATIVE
[**5-20**] BCx: NGTD
STUDIES:
[**5-19**] EKG:
Sinus rhythm. Poor R wave progression that is non-diagnostic.
Diffuse T wave changes that are non-specific
[**5-19**] CXR:
Bilateral pleural effusions, left greater than right, but
unchanged from prior study; no new opacity.
[**5-19**] CT chest:
1. No pulmonary embolism or acute aortic syndrome.
2. Indwelling cholecystostomy drain as detailed above. Overall,
the
gallbladder again demonstrates marked circumferential uniform
wall thickening but remains incompletely distended with numerous
small gallstones. The appearances as best can be compared
grossly stable relative to the prior chest CT dated [**2144-5-13**]
in which the gallbladder was not fully evaluated.
3. Bilateral pleural effusions have increased in size and
demonstrate
morphology suggestive of loculation with associated atelectasis,
but no
definite pneumonia.
4. Incidental note is made of extensive pleural plaques
consistent with prior asbestos exposure.
5. Renal lesions as detailed above.
6. Extensive atherosclerotic disease as detailed above.
Post-CABG.
[**5-19**] Cholangiogram:
Appropriate placement of percutaneous cholecystostomy drain with
contrast
strange into the duodenum as expected.
DISCHARGE LABS:
***
Brief Hospital Course:
84 yo M with COPD, asbestos exposure, CAD s/p CABG who presents
with acute worsening of SOB and increasing oxygen requirement.
# Shortness of Breath: SOB likely multifactorial: fluid
overload, PNA, COPD exacerbation. He was initially admitted on
12LNC, then required BiPAP for ~12hours. He was quickly weaned
off and back down to his new baseline of 4LNC. Given the fast
improvement, the pt likely flashed and improved with Lasix IV.
However, given his tenuous respiratory status, recent
hospitalizations and rehab admissions over the the past month,
leukocytosis, increased sputum production, and worsened
loculated pleural effusions, the patient was also started on
treatment for HAP with Vanc/Zosyn/Levo. He was also started on
treatment for COPD exacerbation with IV steroids and weaned to
PO prednisone prior to transfer from the ICU to the floor. Chest
CT showed new R sided pleural effusions in addition to old L
sided pleural effusions - the patient was evaluated by CT [**Doctor First Name **],
but no procedure was necessary at this time as the effusions
were not large enough. He also has multiple underlying pulmonary
diseases including emphysema, OSA, and pleural thickening likely
from asbestos exposure. On [**5-25**], his IV abx (zosyn and vanc)
were discontinued, partly because there was no evidence of
infiltrate and partly because his increasing vancomycin trough
was likely compounding his renal failure (below). He was
discharged on levaquin for a 10 day course. He occassionally
desaturated with ambulation. However, on the day of discharge,
he did not and was therefore not sent home on O2.
FOLLOW UPS:
1. Hypoxia - patient tolerating ambulation without supplemental
O2 on discharge. The need for further supplementation is to be
assessed dynamically by [**Name6 (MD) 269**] and MD's.
2. Presumed HAP - the patient received 6 days of IDSA
reccommended antibiosis before discontinuation in the face of
renal failure, persistent afebrile condition and lack of
pulmonary infiltrates. He is to be continued on levaquin for a
10 day course. This will have implications for his coumadin
dosign
# s/p stroke: Patient with acute stroke on [**5-12**] with multiple R
sided deficits and mild lethargy. His Head CT and MRI showed
acute infarctions in the left occipital lobe, left thalamus,
left cerebellar hemisphere and right superior cerebellum. TEE on
[**5-15**] negative for left atrial thrombus. Deemed to be
thromboembolic and now on lifelong coumadin.
FOLLOW UP:
1. Coumadin dosing - patient was supratherapeutic on 4mg with
antibiotics. He was discharged on 2mg. The appropriate dosing
must be re-evaluated dynamically in the coming weeks.
# CAD: Patient with know 2 VD (RCA s/p 2 stents and LAD s/p
elective CABG with LIMA->LAD on [**4-21**]). Patient's R sided CP is
pleuritic and unlike his anginal equivalent, which is exertional
in nature. EKG without new ischemic changes and CE were negative
x3. He was continued on his BB and Plavix, and restarted on [**Month/Year (2) **].
FOLLOW UP:
1. The need for dual anti-platelet therapy with coumadin should
be addressed by outpatient providers
# Acute CCY: Denies abd pain. s/p perc chole placement. Recent
T-tube placement demonstrates patent internal flow. Will need
cholecystectomy once infectious issues have resolved.
FOLLOW UP:
1. The patient has an appointment with General Surgery to have
the tube addressed and the possibility of a definitive
cholecystectomy determine.
# HTN: continued BB.
# HLD: continue statin
#FEN: regular diet, replete electrolytes prn, IVFs/encourage PO
fluid intake
#PPX: H2 blocker, bowel regimen, therapeutic on coumadin
#Code: FULL (confirmed with patient)
#Communication:
[**Name (NI) 2013**] (wife and HCP) [**Telephone/Fax (1) 44999**]
Son [**Name (NI) **] [**Telephone/Fax (1) 45000**] ("spokesperson")
#Dispo: Medical ICU
REVIEW OF FOLLOW UPS:
1. Hypoxia - patient tolerating ambulation without supplemental
O2 on discharge. The need for further supplementation is to be
assessed dynamically by [**Name6 (MD) 269**] and MD's.
2. Presumed HAP - the patient received 6 days of IDSA
reccommended antibiosis before discontinuation in the face of
renal failure, persistent afebrile condition and lack of
pulmonary infiltrates. He is to be continued on levaquin for a
10 day course. This will have implications for his coumadin
dosign
3. Coumadin dosing - patient was supratherapeutic on 4mg with
antibiotics. He was discharged on 2mg. The appropriate dosing
must be re-evaluated dynamically in the coming weeks.
4. The need for dual anti-platelet therapy with coumadin should
be addressed by outpatient providers
5. The patient has an appointment with General Surgery to have
the tube addressed and the possibility of a definitive
cholecystectomy determine.
Medications on Admission:
Metoprolol Tartrate 25 mg PO TID
Docusate Sodium 100 mg PO BID 3. Plavix 75 mg PO once a day.
Ranitidine HCl 150 mg Tablet [**Name6 (MD) **]: One (1) Tablet PO once a
day.
Tramadol 50 mg PO every 4-6 hours as needed for pain.
Acetaminophen 325 mg Tablet [**Name6 (MD) **]: 1-2 Tablets PO q4H:PRN pain.
Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Name6 (MD) **]:
One (1) Disk Dose Inhalation [**Hospital1 **] (2 times a day).
Simvastatin 20 mg PO DAILY
Tiotropium Bromide 18 mcg INH daily.
Zolpidem 5 mg Tablet PO [**Hospital1 **]:PRN insomnia.
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
1-2 Puffs Inhalation Q6H (every 6 hours).
Warfarin 4 mg Tablet PO once a day: goal
Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO HS (at bedtime).
Multivitamin
Plavix 75 mg PO daily
Ranitidine 150 mg PO BID
Bisacodyl Suppository 10 mg PR daily
Nitroglycerin SL PRN: chest pain
Discharge Medications:
1. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
3. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
5. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
8. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) puff Inhalation twice a day.
10. Levofloxacin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: last day is [**2144-5-29**].
[**Year (4 digits) **]:*3 Tablet(s)* Refills:*0*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Year (4 digits) **]:
One (1) puff Inhalation once a day.
12. Bisacodyl 10 mg Suppository [**Year (4 digits) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Warfarin 2 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO Once Daily at 4
PM.
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*2*
14. Zolpidem 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
15. Aspirin 81 mg Tablet, Chewable [**Year (4 digits) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Outpatient Lab Work
1. [**Year (4 digits) 2974**] [**5-30**]: INR, Na, K, Cl, HC03, Creatinine and BUN
check. Communicate results to PCP.
17. Lasix 20 mg Tablet [**Month (only) **]: One (1) Tablet PO once a day: do not
start taking this medication until you are instructed to by your
PCP.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2*
18. Cholecystostomy Tube
Please provide dressing changes and teaching regarding
tube/drainage bag care
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area [**Location (un) 269**]
Discharge Diagnosis:
primary: pulmonary edema
secondary: pneumonia, acute renal failure, chest pain syndrome
Discharge Condition:
Mental Status: confused sometimes
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for trouble breathing. We gave you antibiotics
and a fluid pill called lasix to try to take some fluid out of
your lungs and you got better. You experienced some kidney
troubles that were likely related to the lasix, cat-scan dye and
antibiotics. This was improving by the time you were discharged.
Additionally, you had some chest pain that was not related to
any further heart muscle damage
.
NEW MEDICATION
1. Antibiotics - Levaquin - you will need to take this for 3
more days
NEW DOSES
1. Coumadin - there were issues with the thin-ness of your blood
this admission. this is because your coumadin interacts with
antibiotics. We ask you to take 2 mg daily - that is ONE HALF of
your previous dose. Your blood MUST be monitored while taking
this medication with antibiotics and this dose IS subject to
change. The need for this medication long term will be
determined by your PCP.
2. Lasix - this will prevent fluid from building up in your
lungs. Only start taking this medication when you are instructed
to do so by your PCP.
.
RETURN TO THE HOSPITAL IF:
you have fevers, chills, chest pain that does not resolve with 2
nitroglycerin tablets (5 minutes apart), or any other symptoms
that concern you.
.
WEIGH YOURSELF DAILY! And if your weight changes by 3 pounds or
more, call your PCP.
.
Keep your gall bladder drainage tube clean. Daily dressing
changes.
Followup Instructions:
Please go to the following appointments that we have arranged
for you:
Name: [**Last Name (un) **],PERMINDER
When: [**Last Name (LF) 2974**], [**2145-5-29**]:30am
Address: [**Apartment Address(1) 45001**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 29110**]
.
Department: CARDIAC SURGERY
When: MONDAY [**2144-6-1**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: SURGICAL SPECIALTIES
When: [**Doctor First Name **] [**2144-6-19**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD [**Telephone/Fax (1) 1231**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: WEDNESDAY [**2144-7-1**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2144-5-27**]
ICD9 Codes: 2724, 4019, 486, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2428
} | Medical Text: Admission Date: [**2135-6-22**] Discharge Date: [**2135-7-2**]
Date of Birth: [**2076-4-4**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
male with a history of metastatic melanoma to bowel and known
pulmonary and CNS metastases status post craniotomy with
resection of the brain metastases. The patient presented
with a three day history of intermittent worsening and crampy
abdominal pain in the lower quadrants, worse on the right
than on the left. The pain was described as severe. The
patient had a bowel movement until the day prior to
admission. KUB on arrival in the Emergency Department showed
dilated loops of small bowel with air fluid levels. A CT
scan obtained shortly thereafter showed two large mesenteric
masses with erosion into small bowel and free perforation of
the more proximal segment of small bowel, as well as
mechanical mid small bowel obstruction.
PAST MEDICAL HISTORY:
1. Metastatic melanoma with metastases to the lung, brain,
bowel, left flank
MEDICATIONS:
1. Nexium 40 mg po qd
2. Flomax
3. Flonase
4. Compazine
5. Ambien 10 mg
6. Quinine 260 mg
7. Prednisone 10 mg po
8. 50 mcg fentanyl patch
The patient had recently been on his first week to Taxol
dexamethasone therapy and had also been through four cycles
of IL-2/temozolomide for his metastatic melanoma.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient had smoked one pack per day for
about 20 years, but quit 20 years ago.
PHYSICAL EXAM:
VITAL SIGNS: Temperature 98.8??????, blood pressure 120/70, pulse
117, respiratory rate 20, O2 saturation 96% on room air.
GENERAL: The patient was awake and comfortable and appeared
well nourished.
HEAD, EARS, EYES, NOSE AND THROAT: No jugular venous
distention, no palpable nodes. Oropharynx was clear.
NECK: Supple.
HEART: S1, S2, tachycardic with no murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Distended, nontender, no hepatosplenomegaly. There
were decreased bowel sounds. Abdomen was tense and was a 7
cm subcutaneous mass on the left flank.
EXTREMITIES: There was no lower extremity edema, cyanosis or
clubbing.
LABS: White cell count 9.8, hematocrit 13.8, platelets 947.
PT 12.8, PTT 21.5, INR 1.1. Chem-7 - sodium 136, potassium
4.8, chloride 98, bicarbonate 23, BUN 23, creatinine 0.6,
glucose 146, calcium 8.7, magnesium 1.8, phosphorus 4.2.
HOSPITAL COURSE: The patient arrived in the hospital on the
evening of [**6-22**] and evaluation was initiated. The patient
was taken to the Operating Room late in the night of [**6-22**]
where, per the Operating Room note, tumors were discovered in
the ileum and jejunum with free perforation of both lesions.
The patient was then transferred to the Intensive Care Unit.
The patient was started on ampicillin, levofloxacin and
Flagyl.
On postoperative day #2, which was [**2135-6-25**], the patient was
started on TPN. His antibiotics were continued. On
postoperative day #3, the patient was noted to have a
slightly increased temperature to 100.2??????. He was pan
cultured given the fact he had recently been on steroids.
His central line was also changed. During the course of the
day, the patient was agitated at one point and pulled his
A-line. Haldol was prescribed.
On postoperative day #4, the patient appeared to be less
confused. He was transferred to the floor with a sitter. By
postoperative day #5, while the patient was on the floor, he
was appearing much more lucid, communicating appropriately
and the sitter was discontinued. The patient was continued
on total parenteral nutrition. Because of continued increase
in white cell count from 14.3 on postoperative day #4 to 16.0
on postoperative day #5, the patient was sent for an
abdominal CT. Although no abscess was identified that could
explain the patient's increase in white cell count, the
patient was noted to have developed mural thrombus in his
abdominal aorta and in the left iliac artery. The patient
was also noted to develop some new bilateral pleural
effusions with some barium in the left lung base. On being
notified of these findings, the surgical team immediately
consulted the patient's neuro-oncologist and oncologist team
for advice on the propriety of placing the patient on
anticoagulation.
The patient was seen by his neuro-oncologist on postoperative
day #6, which was the [**4-29**]. The patient's
neuro-oncologist requested head CT be obtained to rule out
any new brain metastases with bleeding because this would
determine the patient's suitably for anticoagulation. The
head CTs were negative and per neuro-oncology, there was no
contraindication to anticoagulating the patient. The patient
was seen by his oncologist team also on postoperative day #6.
Oncology was of the opinion of the patient, was unsuitable
for anticoagulation with Coumadin or heparin but that aspirin
could be initiated. The patient was therefore started on
aspirin.
The patient's steroids were also tapered beginning on
postoperative day #7. His fluconazole was discontinued. At
the suggestion of the patient's oncology team, the surgery
team also transfused the patient with 1 unit packed red blood
cells on postoperative day #8 for borderline low hematocrit
of 26.1. On postoperative day #7, the patient's diet was
changed from NPO to sips. The patient tolerated this well
and so on postoperative day #8, the patient was advanced to a
clear liquid diet and his TPN was discontinued. By the
evening of postoperative day #8, the patient was able to
tolerate a regular diet and on the day of discharge, which
was [**2135-7-2**], the patient had a regular breakfast without any
problems. [**Name (NI) **] is to be discharged home with visiting nurse
assistant for wound care. Mr. [**Known lastname **] continues to have an
open vertical incision in the midline of his abdomen that
would require wet to dry dressings twice a day.
DISCHARGE MEDICATIONS:
1. Flomax
2. Flonase
3. Compazine
4. Ambien
5. Quinine
6. Prednisone 10 mg po qd
7. Protonix 40 mg po bid
8. Percocet 5 1 to 2 tablets by mouth every 4 to 6 hours
9. Levofloxacin 500 mg po qd x5 more days
FOLLOW UP: The patient is to follow up with oncology on [**7-18**]. The patient is to call Dr.[**Name (NI) 1863**] office for
follow up appointment this coming week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**First Name (STitle) 30359**]
MEDQUIST36
D: [**2135-7-2**] 10:51
T: [**2135-7-2**] 11:14
JOB#: [**Job Number 18599**]
ICD9 Codes: 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2429
} | Medical Text: Admission Date: [**2148-9-19**] Discharge Date: [**2148-9-25**]
Date of Birth: [**2089-3-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
[**2148-9-19**] Coronary Artery Bypass graft x1 off pump (left internal
mammary artery > left anterior descending)
History of Present Illness:
59 year old male with exertional angina for 1 year. Angina
continued to increase and occurring at rest occassionally.
Underwent cardiac work up that revealed coronary artery disease.
Past Medical History:
Coronary artery disease
Hypertension
Left ventricular hypertrophy
Elevated cholesterol
Social History:
Works as housekeeper
Lives with wife
[**Name (NI) 1139**] quit 17 years ago
ETOH social
Family History:
no premature cardiovascular disease
Physical Exam:
General WDWM in NAD
Skin, HEENT unremarkable
Neck full rom, supple
Chest CTA bilat
Heart RRR
Abd soft, NT, ND +BS
Ext warm well perfused no edema, pulses palpable
Neuro grossly intact
Pertinent Results:
[**2148-9-23**] 07:20AM BLOOD WBC-7.9 RBC-3.46* Hgb-11.2* Hct-33.2*
MCV-96 MCH-32.4* MCHC-33.8 RDW-12.2 Plt Ct-302
[**2148-9-19**] 09:48AM BLOOD WBC-8.4 RBC-3.50* Hgb-11.5*# Hct-33.1*
MCV-94 MCH-32.8* MCHC-34.8 RDW-12.1 Plt Ct-193
[**2148-9-24**] 06:40AM BLOOD PT-12.4 INR(PT)-1.1
[**2148-9-23**] 07:20AM BLOOD Plt Ct-302
[**2148-9-19**] 09:48AM BLOOD Plt Ct-193
[**2148-9-19**] 09:48AM BLOOD PT-15.7* PTT-33.8 INR(PT)-1.4*
[**2148-9-19**] 09:48AM BLOOD Fibrino-251
[**2148-9-23**] 07:20AM BLOOD Glucose-118* UreaN-14 Creat-0.9 Na-141
K-3.6 Cl-103 HCO3-27 AnGap-15
[**2148-9-19**] 10:39AM BLOOD UreaN-16 Creat-0.7 Cl-109* HCO3-24
[**2148-9-23**] 07:20AM BLOOD Amylase-93
[**2148-9-23**] 07:20AM BLOOD Lipase-44
[**2148-9-23**] 07:20AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.3
RADIOLOGY Final Report
CHEST (PA & LAT) [**2148-9-22**] 7:58 AM
CHEST (PA & LAT)
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with s/p POD 3 OP CABG
REASON FOR THIS EXAMINATION:
interval change
EXAMINATION: PA and lateral chest.
INDICATION: Status post CABG.
Single AP view of the chest is obtained on [**2148-9-22**] at 0830 hours
and compared with the prior radiograph of [**2148-9-20**].
The patient is status post CABG. Again is seen increased
retrocardiac density on the left side consistent with airspace
disease/atelectasis at the left base. Linear atelectasis is seen
in the right base. There appears to be a small left pleural
effusion. Allowing for technical differences, there has not
being any marked change since the prior examination.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Approved: SUN [**2148-9-22**] 10:53 AM
Cardiology Report ECG Study Date of [**2148-9-19**] 12:25:42 PM
Sinus bradycardia. Possible inferoposterior myocardial
infarction. Compared
to previous tracing of [**2148-9-17**] no definite change.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
52 192 98 468/454 21 -8 43
Cardiology Report ECHO Study Date of [**2148-9-19**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG procedure
Height: (in) 69
Weight (lb): 194
BSA (m2): 2.04 m2
BP (mm Hg): 123/67
HR (bpm): 72
Status: Inpatient
Date/Time: [**2148-9-19**] at 09:47
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Ascending: *3.9 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 7 mm Hg
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A Ratio: 1.75
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Normal descending 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: Normal tricuspid valve leaflets with trivial
TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was under
general anesthesia throughout the procedure. No TEE related
complications. The
patient appears to be in sinus rhythm. Results were personally
reviewed with
the MD caring for the patient.
Conclusions:
1. No atrial septal defect is seen by 2D or color Doppler.
2.Regional left ventricular wall motion is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.The ascending aorta is mildly dilated. There are simple
atheroma in the
descending thoracic aorta.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7. Post revascularization biventricular systolic function is
unchanged.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2148-9-19**] 14:38.
[**Location (un) **] PHYSICIAN
Brief Hospital Course:
Admitted [**9-19**] and underwent OPCABG x1 with Dr. [**Last Name (STitle) **].
Transferred to the CSRU in stable condition on a propofol drip.
Extubated that afternoon and transferred to the floor on POD #1
to begin increasing his activity level. Chest tubes and pacing
wires removed without incident. Went into Afib and was treated
with amiodarone and coumadin. Made excellent progress and was
cleared for discharge to home with VNA services on POD #6. First
blood draw is scheduled for Friday [**9-27**]. Pt. to make all appts.
as per discharge instructions.
Medications on Admission:
plavix
zocor
diovan/hctz
toprol xl
ASA
NTG
Discharge Medications:
1. Outpatient Lab Work
Lab: PT/INR mon/wed/fri for coumadin dosing - goal INR 2-2.5 for
atrial fibrillation
results to Dr [**Last Name (STitle) 14522**] office # [**Telephone/Fax (1) 14525**] fax # [**Telephone/Fax (1) 66753**]
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 BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: 400 mg [**Hospital1 **] until [**9-30**], then 400 mg daily for
7 days, then 200 mg daily ongoing until stopped by cardiologist.
Disp:*50 Tablet(s)* Refills:*1*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once) for
1 doses: 3 mg today and tomorrow, then daily dosing per Dr.
[**Last Name (STitle) 14522**].
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 86**]
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Post op atrial fibrillation
Hypertension
Left ventricular hypertrophy
elevated cholesterol
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 14522**] in [**1-9**] week ([**Telephone/Fax (1) 14525**]) please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])-
Lab: PT/INR mon/wed/fri for coumadin dosing - goal INR 2-2.5 for
atrial fibrillation
results to Dr [**Last Name (STitle) 14522**] office # [**Telephone/Fax (1) 14525**] fax # [**Telephone/Fax (1) 66753**]
Completed by:[**2148-9-25**]
ICD9 Codes: 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2430
} | Medical Text: Admission Date: [**2142-8-22**] Discharge Date: [**2142-8-23**]
Date of Birth: [**2074-11-21**] 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 Right Internal Carotid Artery angioplasty and stenting.
Major Surgical or Invasive Procedure:
Right Internal Carotid Artery angioplasty and stenting.
History of Present Illness:
Pt is a 67 yo M with HTN, Hypercholesterolemia, PVD, and recent
Right Carotid U/S on [**2142-7-3**] revealing a 95% ulcerated lesion.
He was admitted for elective angioplasty and stenting of his
right internal carotid by Dr. [**First Name (STitle) **] (enrolled in CREST study).
Baseline SBP prior to intervention was 200. Pt is very active at
baseline without dyspnea on exerction. Pt denies symptoms of
CP/SOB/visual changes/HA/numbness/weakness.
Past Medical History:
1. HTN
2. hypercholesterolemia
3. PVD
4. BPH
5. Colonoscopy w/ polypectomy on [**4-22**]
6. h/o melanoma s/p resection
7. s/p hand surgery
Social History:
Married with 3 children. Employeed as engineer. Quit tob many
years ago with a 12 pack year history. EtOH; [**2-20**] drinks per
night.
Family History:
No family h/o premature CAD <55 years of age.
Physical Exam:
T 96.2 142/60 57 20 Wt 105 kg Sat 99% RA
Gen: well appearing, NAD
HEENT: MMM, anicteric, PERRL
Neck: No JVD
CV: brady, regular, normal S1S2. No M/R/G. No S3S4.
Lungs: CTAB
Abd: obese, soft, NT/ND, pos BS
Ext: no C/C/E
Neuro: A&Ox4, CN II-XII intact, [**5-23**] UE strength, [**5-23**]
dorsi/plantar flexion
Pertinent Results:
[**2142-8-22**] 05:01PM POTASSIUM-4.1
[**2142-8-22**] 05:01PM CK(CPK)-60
[**2142-8-22**] 05:01PM CK-MB-NotDone
[**2142-8-22**] 05:01PM PLT COUNT-143*
Brief Hospital Course:
Pt is a 67 yo M with HTN, Hypercholesterolemia, PVD, and Right
Carotid Stenosis admitted for elective angioplasty and stenting
of his right internal carotid by Dr. [**First Name (STitle) **] (enrolled in CREST
study).
1. Right Internal Carotid Stenosis. Pt underwent angioplasty
and stenting without complications. His BP was maintained at
goal between 120 and 150 post procedure without requiring
Neosynephrine, Nipride, or Norvasc. Pt had no change in his
neurological status post-op or evidence of vagal episodes. He
remained on Plavix and ASA. He was seen by Dr. [**Last Name (STitle) **] prior to
discharge.
2. HTN. The pt was restarted on Accuretic at dicharge. He is to
call Dr. [**First Name (STitle) **] in 4 days with his BP, and will add Norvasc if
needed at that time.
3. Hyperchol. LDL of 105. Goal LDL <100. Consider increasing
Lipitor 20 as outpatient.
Medications on Admission:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Accuretic 20-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Accuretic 20-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Norvasc 5 mg Tablet Sig: One (1) Tablet PO as per Dr. [**First Name (STitle) **]
on Monday.
Discharge Disposition:
Home
Discharge Diagnosis:
Right Internal Carotid Artery Stenosis with angioplasty and
stenting.
Discharge Condition:
Stable.
Discharge Instructions:
Please call your physician if you experience confusion, change
in vision, bleeding, or any other problems.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2142-9-11**] 1:00
2. Please call Dr. [**First Name (STitle) **] on Monday to report your Blood
Pressure. Do not take Norvasc unless advised by Dr. [**First Name (STitle) **].
3. Please follow-up with Dr. [**Last Name (STitle) **] in one month.
ICD9 Codes: 4019, 2720, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2431
} | Medical Text: Admission Date: [**2169-9-30**] Discharge Date: [**2169-10-6**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
NG tube
History of Present Illness:
Patient is an 87 year old female s/p ? mechanical fall with
head contusion. Taken to [**Hospital6 1597**] where she had a
head CT which showed bilateral SDH. Pet [**Hospital3 2568**] reports, she
was confused and slow to follow commands. As a result, she was
intubated for airway protection and transferred to [**Hospital1 18**].
On arrival, patient had a blood pressure 200/95 and intubated
but
moving purposeful. She was motioning for the tube to come out.
Past Medical History:
HTN, hypercholesterolemia, glaucoma, vertigo, syncope
Social History:
unknown
Family History:
nc
Physical Exam:
O: T:AF BP: 200/82 HR: 84 R 16 O2Sats 100%40%
FIO2
Gen: intubated/seated
HEENT: traumatic with left occiput swelling, eyes: surgical,
clera, ears - no otorrhea, nose patent, tube at 27cm at teeth
Pupils:PERRL EOMs - full
Neck: Supple, ETT in place
Lungs: CTA bilaterally, good chest rise b/l
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
GCS E:4,V1M5-6 11T
Pupils are surgical, no papilledema of fundoscopic exam
Patient is purposeful bilateraly, moves for tube, nods to
question, wants the tube out. MAEs fully. Grimaces to pain
No clonus
Toes downgoing bilaterally
Pertinent Results:
CT HEAD W/O CONTRAST [**2169-10-1**]
IMPRESSION:
1. Diffuse extra-axial hemorrhage including bilateral
frontoparietal subdural
hematomas and subarachnoid hemorrhage.
2. Mild posterior layering intraventricular hemorrhage. No
signs of
developing obstructive hydrocephalus.
3. Large inferior frontal intraparenchymal hemorrhagic
contusions.
4. No midline shift or evidence of impending herniation.
CT HEAD W/O CONTRAST [**2169-10-5**]
CONCLUSION:
1. Slight increase in the size of the right subdural hematoma
with increased
mass effect on the sulci and right lateral ventricle.
2. Slight increase in leftward shift of normally midline
structures.
3. Stable appearance of left subdural hematoma, bifrontal
parenchymal
hematomas, bilateral subarachnoid hematomas and slight decrease
in the
intraventricular hematoma.
[**2169-9-30**] 03:30PM BLOOD WBC-14.8* RBC-4.03* Hgb-12.2 Hct-37.1
MCV-92 MCH-30.2 MCHC-32.8 RDW-12.6 Plt Ct-262
[**2169-10-5**] 06:10AM BLOOD WBC-8.3 RBC-3.70* Hgb-11.0* Hct-33.6*
MCV-91 MCH-29.7 MCHC-32.7 RDW-13.3 Plt Ct-261
[**2169-9-30**] 03:30PM BLOOD Neuts-88.9* Lymphs-6.6* Monos-3.0 Eos-0.9
Baso-0.6
[**2169-9-30**] 03:30PM BLOOD Plt Ct-262
[**2169-9-30**] 04:30PM BLOOD PT-9.8 PTT-25.7 INR(PT)-0.9
[**2169-10-5**] 06:10AM BLOOD PT-10.4 PTT-26.9 INR(PT)-1.0
[**2169-10-5**] 06:10AM BLOOD Plt Ct-261
[**2169-10-1**] 04:00AM BLOOD Fibrino-237
[**2169-9-30**] 03:30PM BLOOD Glucose-98 UreaN-16 Creat-0.7 Na-136
K-3.6 Cl-101 HCO3-22 AnGap-17
[**2169-10-5**] 01:00PM BLOOD Glucose-197* UreaN-27* Creat-1.1 Na-148*
K-4.2 Cl-115* HCO3-19* AnGap-18
[**2169-10-1**] 04:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
[**2169-10-5**] 01:00PM BLOOD Calcium-8.0* Phos-4.2 Mg-2.3
[**2169-9-30**] 03:46PM BLOOD pO2-77* pCO2-43 pH-7.39 calTCO2-27 Base
XS-0 Comment-GREEN TOP
[**2169-9-30**] 04:00PM BLOOD Type-ART Rates-14/ Tidal V-400 PEEP-5
FiO2-50 pO2-206* pCO2-36 pH-7.45 calTCO2-26 Base XS-2
-ASSIST/CON Intubat-INTUBATED
[**2169-10-5**] 01:08PM BLOOD Lactate-3.3* Na-143 K-3.8 Cl-116*
[**2169-10-5**] 01:15PM BLOOD Lactate-3.8*
[**2169-9-30**] 04:10PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2169-9-30**] 04:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2169-10-4**] 08:00PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
[**2169-10-4**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2169-10-5**] 10:09AM URINE Hours-RANDOM UreaN-864 Creat-67 Na-11
K-70 Cl-36
[**2169-10-5**] 10:09AM URINE Osmolal-529
Brief Hospital Course:
87 y/o F s/p fall presents with bilateral SDHs, bifrontal
contusions, subarachnoid hemorrhage, and intraventricular
hemorrhage.
ACTIVE ISSUES:
# MECHANICAL FALL C/B INTRACRANIAL HEMATOMAS: She was admitted
to the neurosurgery with bilateral SDHs, bifrontal contusions,
subarachnoid hemorrhage, and intraventricular bleed S/P
mechanical fall and placed in the ICU for close monitoring. She
was started on dilantin. On examination, patient was slightly
confused, but alert to place and name. She was moving all
extremities with good strength. On [**10-1**], repeat head CT was
performed which showed blossoming of bifrontal contusions and
stable SDHs with SAH and IVH. She remained in the ICU for close
monitoring with a stable exam. Dilantin level was 12.9. On [**10-2**]
the patient had a waxing and [**Doctor Last Name 688**] level of alertness, only
responsive to noxious stimuli at times. She was sent for a
repeat CT of the head which showed a minimally increased
hematoma and no evidence of herniation. When the patient was
transferred to medicine on [**2169-10-4**], she was sleepy but roused to
verbal commands and oriented only to self. Though she could
repeat "[**Hospital3 **]", she did not know that this was a hospital.
Her neurologic exam on [**10-5**] changed to show a flattening of the
left nasolabial fold. A repeat study on the 23rd showed evidence
of right subdural hematoma expansion with midline shift. The
brainstem was not compromised.
# Hyponatremia, hyperkalemia: The patient was held NPO with
minimal IVF. Her serum sodium slowly trended up and her
potassium slowly trended down. On [**10-4**], the patient was
transferred to the medicine service for management of a Na of
157 and a K of 2.5. The patient's free water deficit was
calculated at approximately 2.5 liters and with the aid of a
nephrology consult, her sodium was corrected slowly so as to
avoid any intracranial edema in the setting of six already known
bleeds. She was corrected at less than 0.5 mEq/L/hr. Her
potassium was also repleted.
# Atrial fibrillation: the patient was found to be in new atrial
fibrillation on [**2169-10-4**] when she was transferred to the medicine
service. This was thought likely due to her low intravascular
volume status with possible contribution from her severe
electrolyte disturbances. Her medication regimen was changed and
she responded very well to PO metoprolol, mostly remaining in
sinus afterwards. Further episodes of atrial fibrillation
responded very well to IV metoprolol.
# Tachypnea: On approximately 1230 on [**10-5**], the patient's
respiratory rate abruptly increased to the mid 30s and her
oxygen saturation dropped to the 50s. This increased to the 80s
with a non-rebreather, but her tachypnea did not respond. She
was seen immediately by the medical team. Her lungs were clear
at the time and NG tube yielded only scant dark liquid. A stat
chest X ray showed clear lungs, which corroborated the exam.
Therefore acute cardiac decompensation was ruled out. It was
thought most likely that she had had a massive pulmonary
embolism despite her heparin prophylaxis. The possibility of an
expansion of one of her six head bleeds was also entertained,
but considered less likely given her tachypnea. Her sodium had
been corrected very slowly to avoid any cerebral edema and CT
head confirmed this. Although the patient may have aspirated,
the sudden and dramatic desaturation with the most recent PO
intake having been a small amount of tea and broth several hours
earlier that morning made this unlikely. The primary team had
extensive discussion with the family and the decision was made
to transition the patient to comfort measures only. Her oxygen
hunger was treated with morphine and benzodiazepines. She died
on the morning of [**2169-10-6**].
Medications on Admission:
Losartan 50mg [**Hospital1 **]
HCTZ 25mg daily,
Mirtazapine 50mg qhs
timolol opthalmic solution daily
Discharge Medications:
Deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Bifrontal contusions
Bilateral SDH
IVH
SAH
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
ICD9 Codes: 2760, 2851, 2762, 4019, 2724, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2432
} | Medical Text: Admission Date: [**2170-11-2**] Discharge Date: [**2170-11-11**]
Date of Birth: [**2108-6-17**] Sex: M
Service: UROLOGY
Allergies:
Synvisc
Attending:[**First Name3 (LF) 824**]
Chief Complaint:
hematuria, obstructed foley
Major Surgical or Invasive Procedure:
s/p cystectomy, urostomy
History of Present Illness:
62M s/p TURBT for recurrent hematuria, foley obstruction with
blood clots, now s/p cystectomy and urostomy.
Past Medical History:
diabetes, type 2
hypertension
stroke [**2165**], no residual sx
bladder cancer [**2166**]
former smoker 20py
Physical Exam:
afebrile, vital signs normal
NAD, NCAT, EOM full
Chest clear
Heart regular, no murmurs/rubs/gallops
Abdomen obese, soft, NT, ND, NABS; urostomy pink, slightly
retracted, yellow urine
Penis with foley in place
LE with trace pitting edema
Pertinent Results:
[**2170-11-2**] 09:11PM BLOOD WBC-28.8*# RBC-4.25* Hgb-12.4* Hct-36.9*
MCV-87 MCH-29.2 MCHC-33.6 RDW-14.2 Plt Ct-397
[**2170-11-3**] 03:17PM BLOOD Hct-31.6*
[**2170-11-4**] 12:23AM BLOOD Hct-28.5*
[**2170-11-4**] 03:52AM BLOOD WBC-12.4* RBC-3.37* Hgb-10.3* Hct-29.8*
MCV-88 MCH-30.5 MCHC-34.5 RDW-14.5 Plt Ct-240
[**2170-11-4**] 01:07PM BLOOD WBC-16.7* RBC-3.96* Hgb-11.9* Hct-35.5*
MCV-90 MCH-30.0 MCHC-33.5 RDW-14.4 Plt Ct-249
----------------
CHEST (PORTABLE AP) [**2170-11-3**] 5:17 AM
CHEST (PORTABLE AP)
Reason: evaluate ET tube placement and evaluate for volume
overload
[**Hospital 93**] MEDICAL CONDITION:
62 year old man intubated s/p cystoprostatectomy
REASON FOR THIS EXAMINATION:
evaluate ET tube placement and evaluate for volume overload
PORTABLE CHEST, [**2170-11-3**] AT 05:59 HOURS.
COMPARISON STUDY: [**2170-11-2**]
CLINICAL INFORMATION: ET tube placement, question volume
overload
FINDINGS:
There are low lung volumes. There is mild bibasilar atelectasis
and mild prominence of central pulmonary vasculature which may
indicate a small degree of volume overload. The endotracheal
tube terminates at the thoracic inlet. The nasogastric tube
courses below the diaphragm but the tip is not seen.
IMPRESSION:
Low lung volumes, and mild volume overload.
----------------
[**2170-11-9**] 09:00AM BLOOD WBC-10.6 RBC-3.87* Hgb-11.4* Hct-33.8*
MCV-87 MCH-29.5 MCHC-33.8 RDW-13.8 Plt Ct-453*
-----------------
PORTABLE ABDOMEN [**2170-11-9**] 1:38 AM
PORTABLE ABDOMEN
Reason: portable KUB requesting for possible post-op ileus
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with upper epigastric pains
REASON FOR THIS EXAMINATION:
portable KUB requesting for possible post-op ileus
INDICATION: _____ ? postop ileus.
COMPARISON: No abdominal films for comparison.
There are dilated loops of small bowel which are consistent with
ileus. No evidence of free air on this supine view. There are
surgical clips in the pelvis. There are staples in the overlying
skin. The limited views of the bones show osteophytes in the
lumber spine.
IMPRESSION: _____ consistent with postoperative ileus. Followup
radiographs recommended.
DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
PORTABLE ABDOMEN [**2170-11-10**] 7:53 AM
PORTABLE ABDOMEN
Reason: ileus vs obstruction
[**Hospital 93**] MEDICAL CONDITION:
62M s/p cystectomy, ileal conduit, now emesis
REASON FOR THIS EXAMINATION:
ileus vs obstruction
EXAMINATION: Portable supine abdomen, one view.
INDICATION: Status post cystectomy with ileal conduit presenting
with emesis.
COMPARISON: Comparison is made with the previous portable
abdomen from [**2170-11-9**].
FINDINGS: There are diffuse and dilated loops of both small and
large bowel which are relatively unchanged when compared to the
previous radiograph and are consistent with ileus. This is a
supine radiograph and an assessment of free air cannot be made.
Surgical clips are seen in the pelvis with some staples
overlying the skin.
IMPRESSION: Dilated loops of both small and large bowel which
are unchanged and appearances are consistent with ileus.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: SUN [**2170-11-11**] 11:03 AM
--------------
[**2170-11-11**] 06:10AM BLOOD WBC-7.3 RBC-3.61* Hgb-10.4* Hct-31.3*
MCV-87 MCH-28.7 MCHC-33.1 RDW-13.9 Plt Ct-532*
[**2170-11-11**] 06:10AM BLOOD Glucose-87 UreaN-17 Creat-1.0 Na-140
K-3.4 Cl-104 HCO3-26 AnGap-13
Brief Hospital Course:
GU: Admitted postoperatively after cystectomy and urostomy
creation. Ureteral stents into ileal conduit and visible
through stoma. Immediately postop, good urine output with some
mucous. IVF were discontinued on POD5 and he was allowed to
auto-diurese, producing good urine output even while off IVF and
taking only sips on POD7-8.
CV: Immediately postop, the pt went to the ICU and was
hypotensive, requiring pressors through POD1. By POD2, pressors
were weaned and the pt was hemodynamically stable, returning to
baseline hypertension; he was transferred to the floor and
started on IV lopressor. On POD4, he was started on his home
diuretics and metoprolol 12.5 [**Hospital1 **], remaining normotensive. On
POD6, after an episode of LUQ pain and emesis an EKG was done,
which demonstrated stable findings when compared to his
pre-operative EKG from [**10-10**]. The pt was continued on
perioperative beta-blockade through POD8 after which the
metoprolol was discontinued.
Pulm: Pt was weaned off O2 by POD1 and did not require
supplemental O2 after this time. Saturations remained >94% on
RA. He did require occasional nebulizer treatments for
intermittent wheezing during this hospitalization.
GI: The patient passed flatus on POD3 and on POD4 he was started
on sips and advanced to clears. By POD 5, after a small bowel
movement, he was advanced to a regular diet without any
problems. [**Name (NI) **] continued to pass flatus. On POD6, the pt
developed LUQ abdominal pain that did not resolve with
simethicone or morphine. He had two episodes of non-bloody
emesis, after which the pain resolved. KUB demostrated no
obstructions, but dilated loops throughout, consistent with
ileus. On POD7, his diet was limited to sips of clears. On
POD9, after being emesis free for 40 hours, his diet was
advanced to clears then regular diabetic diet, which he
tolerated well. Prior to admission, the pt had one loose and
one formed bowel movement.
Heme: Intraoperatively, difficult procedure with EBL of 3L; pt
was transfused 8 units of red cells in the OR, and required an
additional 2 units of red cells on POD1 for a hematocrit that
was trending down to 28.5 at its lowest point. It remained
stable at 32-33 for the remainder of the hospitalization.
ID: Pt was on ancef perioperatively and did not require
additonal antibiotics. His wound became minimally erythematous
by POD5, but this slowly resolved without antibiotics.
TLD: Pt was discharged with urostomy and bag in place; teaching
was done in-house and follow up with a visiting nurse was
arranged upon discharge.
Discharge Medications:
1. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
2. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: Two
(2) Cap PO DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 976**] VNA Inc
Discharge Diagnosis:
bladder tumor s/p cystectomy, urostomy, postop ileus
Discharge Condition:
good
Discharge Instructions:
You may shower but do not bathe, swim or otherwise immerse your
incision. Do not lift anything heavier than a phone book. Do
not drive or drink alcohol while taking narcotic pain
medications. Resume all of your home medications, but please
avoid aspirin and motrin/advil for 1 week. Call your
Urologist's office ([**Telephone/Fax (1) 164**]) to schedule a follow-up
appointment in [**12-5**] weeks, or if you have any questions. 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 emergency room.
Followup Instructions:
Call your Urologist's office ([**Telephone/Fax (1) 164**]) to schedule a
follow-up appointment in [**12-5**] weeks, or if you have any
questions.
Follow up with your primary care provider [**Last Name (NamePattern4) **] 1 week.
ICD9 Codes: 5185, 2851, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2433
} | Medical Text: Admission Date: [**2156-7-16**] Discharge Date: [**2156-7-20**]
Date of Birth: [**2102-5-13**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Face and right sided chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
this is a 54 year old patient with PMHx significant for CAD
with 4 drug eluting stents on Plavix who was riding his
motorcycle on [**7-16**] when he swerved to avoid traffic going
approximately 40 miles per hour and ended up crashing his
motorcycle into the pavement without striking another vehicle.
He
remembers striking his head on the pavement and was helmeted. He
denies LOC at the time of the crash. He came to [**Hospital1 18**] via EMS
following the crash and was found to have multiple injuires
including a left temporal SAH and contusions, high right frontal
IPH, and left tentoial SDH. Other injuries included ? right
orbital fx, rigth periorbital ecchymosis, right clavicle fx,
right 4th and 5th rib fx's, and right gluteal hematoma.
Past Medical History:
PMH: HTN (multiyear history, untreated), ankle & shoulder
fractures in childhood
PSH: none
Social History:
Married, lives with wife, no tobacco, no ETOH
Family History:
non contributory
Physical Exam:
Temp 99 BP 140/70 HR 90 RR 20 O2 sat 95% RA
Gen: multiple abrasions, obese, in no distress
HEENT: large right periorbital hematoma Pupils: PERRL EOMs
intact
Neck: cervical collar in place Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-19**] 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, 3mm to
2mm bilaterally. Visual fields are grossly full to
confrontation,
difficult to fully assess given eye injury.
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: RUE extremity strength is limited by right clavicle
injury
but is full in bicep, tricep, grasps, and wrist extensors and
flexors. LUE, LLE< and RLE are full. Normal bulk and tone
bilaterally. No abnormal movements, tremors. Not able to assess
pronator drift given R clavicle fracture limiting movement of
proximal RUE
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2156-7-16**] 05:40PM WBC-8.0 RBC-4.17* HGB-12.7* HCT-37.1* MCV-89
MCH-30.4 MCHC-34.2 RDW-14.3
[**2156-7-16**] 05:40PM PLT COUNT-211
[**2156-7-16**] 05:40PM PT-12.3 PTT-23.5 INR(PT)-1.0
[**2156-7-16**] 05:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-5* bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2156-7-16**] 05:40PM UREA N-17 CREAT-0.8
[**2156-7-16**] 05:55PM GLUCOSE-146* LACTATE-3.6* NA+-143 K+-3.1*
CL--103 TCO2-25
[**2156-7-16**] 10:18PM HCT-26.4*#
[**2156-7-16**] Chest Xray :
Distal right clavicular fracture. Otherwise, no acute
cardiopulmonary abnormality
[**2156-7-16**] Head CT :
1. Multifocal intracranial hemorrhage including left frontal and
temporal
lobe subarachnoid hemorrhage, left subdural hematoma and two
foci of right
intraparenchymal hemorrhage at the vertex in the right frontal
lobe.
2. Right periorbital hematoma with extension along the lateral
rectus muscle, which appears to be extraconal and causes some
proptosis.
3. Small foci of pneumocephalus in the left temporal fossa
without definite temporal bone fracture identified. A temporal
bone CT can be obtained for further evaluation.
[**2156-7-16**] CT C spine :
1. No acute fracture or malalignment.
2. Mild multilevel degenerative changes, most prominent at C5-C6
where there is mild canal narrowing and neural foraminal
stenosis.
[**2156-7-16**] CT Chest/Abd/pelvis :
1. No acute intrathoracic, abdominal or pelvic abnormality.
2. Right gluteal muscle hematoma with active extravasation.
3. Comminuted right clavicular fracture.
4. Nondisplaced right fourth and fifth lateral rib fractures.
5. Radiopaque density in the anterior abdominal wall of
uncertain
significance. Clinical correlation recommended.
6. 7-mm enhancing focus in the left lobe of the liver, possibly
a vascular
shunt, flash-filling hemangioma, or arterially enhancing lesion
such as an
adenoma or area of FNH. If the patient has a history of
hepatitis, chronic
liver disease, or malignancy then further evaluation with MRI is
recommended.
[**2156-7-17**] Head CT :
1. Continued evolution of left-sided subarachnoid hemorrhage and
subdural
hematoma.
2. Stable appearance of the right frontal lobe intraparenchymal
hemorrhagic contusions.
3. Resolving right-sided subgaleal and periorbital hematoma with
new resolved right-sided proptosis, with right lateral orbital
wall fracture.
NOTE ADDED IN ATTENDING REVIEW: There are also extensive
hemorrhagic
contusions in the left temporal lobe, with evolving adjacent
vasogenic edema.
[**2156-7-18**] Head CT :
1. Similar appearance of right frontal intraparenchymal
hemorrhage, left
frontotemporal subarachnoid hemorrhage, left temporal
hemorrhagic contusions, and left tentorial subdural blood;
slightly increased prominence of the intraventricular hemorrhage
layering in the occipital horns of the lateral ventricles.
2. Improved appearance of right frontal subgaleal and
periorbital soft tissue swelling.
Brief Hospital Course:
Mr. [**Known lastname 4109**] was evaluated by the Trauma team in the Emergency
Room and scans were reviewed. He had a subarachnoid and subdural
hemorrhage with a right intraparenchymal hemorrhage in the
setting of taking aspirin and Plavix. He was seen by the
Neurosurgery service and admitted to the Trauma ICU for close
neurologic monitoring. He began Dilantin therapy
prophylactically. He was also evaluated by the Plastic Surgery
service for his right orbital wall fracture which was deemed non
operable. The Opt homology service also evaluated him on a
number of occasions to rule out a retrobulbar hematoma which was
not present.
During his ICU stay he remained hemodynamically stable despite
active extravasation. His hematocrit on admission was 37 and
after resuscitation was in the 23 range consistently. He did
receive a platelet transfusion on admission but never required
packed cells. Head CTs were followed daily as his second scan
showed continued evolution of his SAH and SDH. His neurologic
exam did not change ad he had no seizure activity.
Following transfer to the Trauma floor he continued to progress.
His aspirin and Plavix were resumed on [**2156-7-18**] without any
deleterious effects. He was evaluated by the Physical and
Occupational Therapy services for a cognitive screen and full
evaluation for ambulating. His cognitive screen revealed some
deficits with memory and he was referred to the Cognitive
Neurology service for an out patient evaluation. The Physical
Therapist worked with him on numerous occasions and recommended
home physical therapy to maximize his functional capacity.
His right clavicle fracture is not displaced and non operative.
He is in a sling for comfort and should do pendulum exercises
three times a day plus range of motion to his elbow and wrist.
The home physical therapist can review that with him and he
should follow up in 2 weeks here or in [**Doctor Last Name 792**]if he
chooses.
He was tolerating a regular diabetic diet, walking independently
and his hematocrit remained stable. After an uncomplicated
recovery he was discharged to home on [**2156-7-20**].
Medications on Admission:
lisinopril 20', bystolic 10', simvastatin 40', metformin 500'',
plavix 75', asa325'
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Dilantin Kapseal 100 mg Capsule Sig: One (1) Capsule PO three
times a day: thru [**2156-7-22**].
Disp:*10 Capsule(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Bystolic 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
VNS of Greater rRode Island
Discharge Diagnosis:
S/P MCC
1. Left SAH
2. Left SDH
3. Right IPH
4. Right lateral orbital wall fracture
5. Right clavicle fracture
6. Right rib fractures [**3-23**]
7. Right gluteal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital after your motorcycle
accident with multiple injuries including bruising in your
brain, a broken collar bone, rib fractures, facial fracture and
a large hematoma on your right buttock/upper thigh
.
* Your right ribs [**3-23**] are fractured which can cause severe pain
and subsequently cause you to take shallow breaths because of
the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Keep your right arm in a sling for comfort and don't put any
weight in it.
* The large hematoma on your thigh will resolve over time and
color changes will continue to take place.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ), visual changes, headaches or any
other symptoms that concern you.
Followup Instructions:
Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment in 4 weeks. You will need a non contrast head CT
prior to your appointment and the secretary can arrange that for
you.
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Cognitive Neurology at
[**Telephone/Fax (1) 1690**] for a follow up appointment in 1 week.
Call the Plastic Surgery Clinic at [**Telephone/Fax (1) 6742**] for a follow up
appointment on Friday [**2156-7-23**].
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up
appointment in 2 weeks. If you prefer you can follow up with an
orthopedist in [**Doctor Last Name 792**]in 2 weeks.
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-22**] weeks.
Call your Eye doctor [**First Name (Titles) **] [**Last Name (Titles) **] for a follow up appointment in [**1-22**]
weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2156-7-20**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2434
} | Medical Text: Admission Date: [**2137-11-13**] Discharge Date: [**2137-11-20**]
Date of Birth: [**2070-3-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14820**]
Chief Complaint:
acute dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 yo M with DM2, HTN, and recent dx of a-fib 1 month ago
presents with acute dyspnea and found to be in afib with RVR.
The patient recently started taking diltiazem and coumadin 3
weeks ago. He was feeling well until he acutely felt short of
breath yesterday morning. He presented to his PCP's office where
an EKG was significant for afib with RVR in the 140s. He was
then sent to [**Hospital3 **] for further evaluation. CXR
revealed pulmonary edema and fluid overload. He was started on a
hep gtt for a sub-therapeutic INR, diltiazem gtt, nitro gtt, and
transferred to [**Hospital1 18**] for further care.
.
In the ED, initial vitals BP 96/68 HR 107. He was given 80 then
160 mg IV lasix with approximately 1L urine output. In spite of
a diltiazem gtt, his HR remained in the 110s. A repeat CXR
showed small bilateral pleural effusions and mild pulmonary
edema. Labs were significant for a troponin leak up to 0.66
with flat CKs, BNP [**Numeric Identifier 39390**], INR 1.5, and Cr 1.7. While in the ED
overnight, he desatted down to low 80s and was placed on BIPAP
and then a NRB with sats improving to >94%. He was unable to be
weaned off the NRB in spite of putting out approximately 1 L
urine to IV lasix. Due to continued tachycardia, respiratory
distress, and ? hemodynamic instability, the pt was taken for
TEE/cardioversion. TEE revealed a left atrium thrombus. He was
then admitted to the CCU for further care.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He reports having calf pain on exertion and is on cilastazol for
peripheral arterial disease. He also reports have 2 incidents
of hypoglycemia in the past month; his beta-blocker was stopped
and he was started on a CCB. All of the other review of systems
were negative.
.
Cardiac review of systems is notable for dyspnea, but the
absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
Past Medical History:
DM II
HTN
Erectile Dysfunction
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension,
Former smoker
Social History:
Social history is significant for the absence of current tobacco
use. He quit over 20 years ago. There is no history of alcohol
abuse.
Family History:
non-contributory
Physical Exam:
VS: T 98.3 , BP 132/72 , HR (112-126), RR 36 , O2 96% on NRB
Gen: elderly male, in moderate resp distress on NRB appears more
comfortable, Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of [**12-20**] cm.
CV: irregular, tachycardic; normal S1, S2. No S4, no S3.
Chest: Resp were labored, with accessory muscle use. decreased
BS bilateral bases with crackles halfway up posterior lung
fields. few scattered expiratory wheezes
Abd: Obese, soft, NTND, No HSM or tenderness.
Ext: No c/c/e.
Skin: venous stasis changes bilateral lower extremities.
Pulses:
Right: Carotid 2+; radial 2+; 1+ DP/PT
[**Name (NI) 2325**]: Carotid 2+; radial; 2+; 1+ DP/PT
Pertinent Results:
[**2137-11-20**] 05:45AM BLOOD WBC-7.8 RBC-4.34* Hgb-13.7* Hct-39.8*
MCV-92 MCH-31.5 MCHC-34.3 RDW-14.2 Plt Ct-335
[**2137-11-20**] 05:45AM BLOOD PT-17.3* PTT-90.2* INR(PT)-1.6*
[**2137-11-20**] 05:45AM BLOOD Glucose-101 UreaN-29* Creat-1.3* Na-138
K-4.1 Cl-100 HCO3-30 AnGap-12
[**2137-11-13**] 11:29PM BLOOD CK(CPK)-51
[**2137-11-12**] 05:30PM BLOOD CK(CPK)-135
[**2137-11-13**] 03:51PM BLOOD CK-MB-NotDone cTropnT-0.66*
[**2137-11-12**] 05:30PM BLOOD CK-MB-12* MB Indx-8.9* proBNP-[**Numeric Identifier 39390**]*
[**2137-11-17**] 06:15AM BLOOD Albumin-3.6 Calcium-11.3* Phos-4.2
Mg-3.0*
[**2137-11-18**] 05:35AM BLOOD Digoxin-1.1
[**2137-11-16**] 09:00AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2137-11-16**] 09:00AM URINE Blood-LGE Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2137-11-16**] 09:00AM URINE RBC-11* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
.
IMAGING:
.
[**2137-11-12**] CXR
IMPRESSION: Cardiomegaly with bilateral small pleural effusions
and mild
pulmonary edema
.
[**2137-11-14**] CXR
FINDINGS: In comparison with the study of [**11-12**], there is
continued
cardiomegaly with apparent worsening of the pulmonary edema.
Generalized
haziness bilaterally is consistent with large pleural effusions
.
[**2137-11-15**] CXR
There is marked
improvement in the bilateral perihilar parenchymal opacities
representing
marked improvement of pulmonary edema. There is no change in
bilateral
moderate pleural effusions and bibasal atelectasis. The
moderately enlarged heart is stable and there is no change in
the mediastinal contours.
.
[**2137-11-17**] CXR:
Previous pulmonary edema and bilateral pleural effusions have
resolved. Mild cardiomegaly and upper lobe vascular congestion
remain following substantial improvement in congestive heart
failure. No pneumothorax.
.
[**2137-11-13**] TEE:
The left atrium is dilated. No spontaneous echo contrast or
thrombus/ mass is seen in the body of the left atrium. Mild
spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). A probable thrombus is seen in the left
atrial appendage. No spontaneous echo contrast is seen in the
body of the right atrium. Mild spontaneous echo contrast is seen
in the right atrial appendage. The right atrial appendage
ejection velocity is depressed (<0.2m/s). No thrombus is seen in
the right atrial appendage No atrial septal defect is seen by 2D
or color Doppler. LV systolic function and right ventricular
systolic function appears depressed. There are simple atheroma
in the aortic arch and descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen (severity
of mitral regurgitation may be UNDERestimated due to limited
views). There is no pericardial effusion.
.
IMPRESSION: Probable left atrial appendage thrombus. Moderate
mitral regurgitation (may be underestimated). Biventricular
systolic dysfunction.
.
[**2137-11-18**] TTE:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
estimated right atrial pressure is 0-10mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Overall left ventricular systolic function is low normal (LVEF
50%). Right ventricular chamber size and free wall motion are
normal. There is abnormal septal motion/position. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are moderately thickened with characteristic rheumatic
deformity/restricted anterior and posterior leaflet motion..
There is a minimally increased gradient consistent with trivial
mitral stenosis. Mild to moderate ([**1-8**]+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
IMPRESSION: Minimal rheumatic mitral stenosis. Mild-moderate
mitral regurgitation. Low normal left ventricular systolic
function Mild pulmonary artery systolic hypertension.
.
[**2137-11-12**] ECG:
Atrial fibrillation, average ventricular rate 100-110.
Non-specific
repolarization changes. Compared to the previous tracing of
[**2135-3-21**] normal
sinus rhythm has given way to atrial fibrillation and the
ventricular rate has increased.
.
[**2137-11-16**] ECG:
Atrial fibrillation with rapid ventricular response
Left ventricular hypertrophy
Diffuse nonspecific ST-T wave abnormalities
Since previous tracing of [**2137-11-15**], further ST-T wave changes
present
Brief Hospital Course:
67 yo male with Afib diagnosed 1 month ago presents with Afib
with RVR and hypervolemia admitted for cardioversion but found
to have left atrial appendage thrombus on TEE, admitted to CCU
for monitoring and diuresis.
.
# Rhythym: AFib with RVR. unable to cardiovert due to [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 1916**] thrombus on TEE. The patient was initially started on
digoxin and a diltiazem gtt for rate control. The diltiazem was
converted to a PO dosing regimen which the patient tolerated
well. His HR continued to be slightly fast, therefore low dose
metoprolol was started. As an outpatient, the patient had been
on high doses of Toprol likely causing his adverse reactions and
no response to hypoglycemia, but the patient's glucose was well
controlled during his hospitalization and he tolerated the
metoprolol dosing well. The patient was started on a heparin
gtt, and was bridge to coumadin with lovenox as an outpatient.
His goal INR is [**2-9**] and will need to be followed by his PCP. [**Name10 (NameIs) **]
will followup in cardiology clinic for his A.fib. He will need
a repeat TEE in [**4-12**] weeks to determine resolution of the left
atrial appendage thrombus if he will have cardioversion.
.
# Pump: CHF with EF of 43% at OSH. TEE not able to accurately
determine EF. A TTE prior to discharge showed an EF of 50%.
The patient was diuresed with IV lasix initially, but was then
converted to a PO dosing schedule to further keep him even to
slightly negative as an outpatient.
.
# Ischemia: elevated troponin likely from demand ischemia in
setting of AFib with RVR. The patient did not have cardiac
catheterization during this hospitalization. He will likely
need an outpatient stress test or catheterization based on the
decision of his cardiologist. The patient did not complain of
chestpain throughout this hospitalization. He will continue on
aspirin, statin, and metoprolol as an outpatient.
.
# HTN-The patient's blood pressure was well controlled on his
regimen of diltiazem, metoprolol, and lisinopril. He will
continue these medications as an outpatient.
.
# DM: The patient initially had blood glucose levels in the
400s. His NPH and HISS were up-titrated for improved control.
Prior to discharge, the patient was on NPH 30/14 with a tight
HISS with good glucose control 120-150s. He has a long history
with Dr. [**Last Name (STitle) 19862**] at the [**Last Name (un) **] who follows him as an outpatient.
Dr. [**Last Name (STitle) 19862**] was informed of the patient's admission, and the
patient will followup at the [**Last Name (un) **] with his scheduled
appointments.
Medications on Admission:
Lasix 40 mg daily
Lipitor 20 mg daily
Cardia 180 mg QAM
cilastazole 100 mg [**Hospital1 **]
warfarin 2.5 mg QHS
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*60 Capsule, Sustained Release(s)* Refills:*2*
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: AS
DIRECTED units Subcutaneous twice a day: 30 units at breakfast,
14 units at dinner.
Disp:*QS units* Refills:*2*
10. Insulin Regular Human 100 unit/mL Solution Sig: AS DIRECTED
units Injection four times a day: per home sliding scale.
11. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) units
Subcutaneous twice a day for 2 weeks: please continue until INR
[**2-9**]. .
Disp:*QS syringe* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis: Atrial Fibrillation with Rapid Ventricular
Rate
Secondary Diagnosis: Pulmonary Edema
Hypertension
Discharge Condition:
stable, off O2
Discharge Instructions:
You were admitted for atrial fibrillation with a rapid heart
rate and fluid overload, predominantly in your lungs. You were
started on medications to slow down your heart rate, and you
were also given medication to decrease the fluid in your body.
Initially, you required oxygen via a mask at admission, but by
the time of discharge, you were off of oxygen and were able to
walk around without difficulty.
Please take all medications as prescribed.
Please make all appointments as scheduled.
VNA services will teach you how to administer lovenox until your
INR is therapeutic. They will also check your INR and adjust
accordingly with the help of Dr. [**Last Name (STitle) 18323**]. When VNA no longer
come visit please go back to coming to the hospital as
previously for your INR checks.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 4023**]
Date/Time:[**2137-12-4**] 1:40
PLEASE SCHEDULE AN APPOINTMENT WITH YOUR PCP TO BE SEEN WITHIN
1-2 WEEKS
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2435
} | Medical Text: Admission Date: [**2150-10-12**] Discharge Date: [**2150-10-28**]
Date of Birth: [**2125-2-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
s/p unrestrained driver in MVA vs telephone pole
Major Surgical or Invasive Procedure:
[**10-13**]: ICP Monitor Placement
[**10-6**]: Tracheostomy and PEG placement
History of Present Illness:
This is a 25 year old male who is status post motor vehicle
accident and was found at the scene with a GCS 3. He was
brought to an outside hospital and intubated and transferred
here for further care.His parents arrive to the emergency
department after the initial patient evaluation.At the outside
hospital the patient recieved dilantin 1 gram, rocuronium,
propofol.
Past Medical History:
none
Social History:
parents mom- cell [**Telephone/Fax (1) 87035**] [**First Name8 (NamePattern2) **] [**Known lastname **]/ dad
cell [**Telephone/Fax (1) 87036**] [**First Name8 (NamePattern2) **] [**Known lastname **]. Patient does not live at home
with his parents.
Family History:
unknown
Physical Exam:
Gen: intubated- GCS=6T
HEENT: right head laceration Pupils:L NR 4mm, right 4-3.5
sluggish reaction EOMs no eye opening
Neck: hard cervical collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated no eye opening, non verbal
Orientation: Not oriented person, place, and date.
Recall/Language:intubated non verbal
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3.5
mm bilaterally.visual fields unable to test
III, IV, VI, V, VII, VIII,IX, X,[**Doctor First Name 81**],XII:unable to test
Motor: Strength withdraws X4. Pronator drift-unable to test
Toes downgoing bilaterally
Physical Exam upon discharge:
Movesd all extremities, Pupils 8mm/5mm, EO to noxious, follows
simple commands
Pertinent Results:
CT HEAD W/O CONTRAST [**2150-10-12**]
1. Multiple punctate foci of hemorrhage. While some of these may
be in the
subarachnoid space, some appear at the [**Doctor Last Name 352**]-white junction,
raising the
question of [**Doctor First Name **].
2. Right frontal subgaleal and subcutaneous hematoma with
several foreign
bodies. No underlying fracture.
CT C-SPINE W/O CONTRAST [**2150-10-12**]
No acute fracture or malalignment
CT head [**2150-10-12**]
1. Right frontal lobe bolt placement with small foci of
hemorrhage along it.
2. Multiple foci of punctate hemorrhages at the [**Doctor Last Name 352**]-white
matter junction, consistent with diffuse axonal injury.
3. Newly visualized subarachnoid hemorrhage in the
interhemispheric fissure and in bilateral frontal lobes,
consistent with shifting of blood.
4. Unchanged right frontal subgaleal hematoma
CT head [**2150-10-14**]
This study is significantly limited by motion. However, in the
visualized
portions, the intraventricular hemorrhage appears unchanged.
Fluid in the
ethmoidal air cells and sphenoid sinuses which could be related
to intubation
CTA Chest [**10-15**]:
Bilateral upper, lower and lingular consolidations have now
progressed. These likely represent areas of pneumonia. ETT is
very high and should be advanced by 3-4 cm
MRI Head [**10-17**]:
IMPRESSION:
1. Multiple foci of hemorrhagic diffuse axonal injury in the
bifrontal and
left posterior temporal subcortical white matter, as well as
abutting the
temporal [**Doctor Last Name 534**] of the right lateral ventricle. Non-hemorrhagic
diffuse axonal injury in the posterior limb of the left internal
capsule and in the splenium of the corpus callosum.
2. Bilateral subarachnoid hemorrhage again noted along the
convexities.
Small amount of intraventricular hemorrhage also again noted
MRI C-spine [**10-18**]: IMPRESSION: No findings suggestive of
ligamentous injury or cord injury in the cervical spine. Mild
cervical spondylosis as above.
MRI/A Brain & C-spine [**10-19**]: IMPRESSION:
1. No evidence of dissection in the vertebral, or carotid
artery.
2. Diffuse axonal injury, and small amount of blood in the
occipital [**Doctor Last Name 534**] of the lateral ventricles, better evaluated on
dedicated MR head from [**2150-10-17**].
MRI Shoulder [**10-19**]:IMPRESSION:
1. Limited exam due to suboptimal technique. Infraspinatus edema
and
probable bursal surface fraying of the infraspinatus tendon.
This is
nonspecific and most likely represents posttraumatic
musculotendinous tear. Lower in the differential diagnosis are
etiologies such as early denervation and inflammatory
etiologies.
2. Possible small tear of the anteroinferior labrum. Lack of
joint fluid
limits evaluation of the labrum.
Brief Hospital Course:
25 y/o M s/p MVA vs telephone pole presents to [**Hospital1 18**] with a GCS
of 3. CT head concerning for [**Doctor First Name **] and punctate hemorrhages.
Mannitol bolus was given in the ED and will continue at 50Q6H.
On examination, patient is more brisk with his L side
spontaneous and purposeful, on the R he flexes and w/d to
noxious stimuli, no eye opening or commands. He was admitted to
the ICU and a bolt was placed with an ICP of 23. His ICP was
subsequently medically managed with hyperosmlar therapy. Repeat
head CT was stable.
[**2070-10-13**] Repeat CT head on [**10-14**] remained stable and his ICP
remained stable on hyperosmolar therapy. On [**10-15**] he was started
on vancomycin, cefepime,flagyl and cipro for significant
hospital aquired pneumonia and respiratory failure. He reamined
intubated. He had a CTA Chest that was negative for a PE.
On [**10-16**] - his ICPs remained <20 and his exam remained stable.
His ICP monitor was discontinued on [**10-17**]. An MRI in the
afternoon revealed multiple foci of hemorrhagic diffuse axonal
injury in the bifrontal and left posterior temporal subcortical
white matter. His mannitol was weaned to 12.5mg QD, and SQH was
started that evening.
On [**10-19**], his mannitol was discontinued. Due to persistent
ventilation requirement, a consult for a PEG/Treach by General
Surgery was obtained, and he went to the OR on [**10-21**] to have
these placed. Pt's antibiotics changed to vancomycin only per
ID recommendation on [**10-22**]. Pt was febrile on [**2150-10-23**] and blood
cultures were obtained. He was transferred to the SDU on
[**2150-10-24**].
On [**10-25**] & [**10-26**] pt remained neurologically stable and afebrile.
Infectious Disease team recommended discontinuing antibiotics as
the pt had completed sufficient course. PT and OT were consulted
for assistance with discharge planning and acute rehab was
recommended.
On [**10-27**] the patient was again stable and cleared for discharge
to rehab facility pending bed availability. He remained stable
following this and on the morning of [**10-28**] he was discharged to
[**Hospital1 **] for rehab
Medications on Admission:
None
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. clonidine 0.3 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
5. oxycodone 5 mg/5 mL Solution Sig: [**5-25**] ml PO Q3H (every 3
hours) as needed for pain.
6. quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
9. lorazepam 2 mg/mL Syringe Sig: 0.25 ml Injection Q4H (every 4
hours) as needed for agitation.
10. hydralazine 20 mg/mL Solution Sig: 0.5 ml Injection Q6H
(every 6 hours) as needed for SBP greater than 160.
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
15. Lorazepam 1 mg IV Q4H:PRN agitation
agitation
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
[**Doctor First Name **], punctate hemorrhages, RIVH
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
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.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy 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.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2150-10-28**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2436
} | Medical Text: Admission Date: [**2197-7-12**] Discharge Date: [**2197-7-20**]
Service:
Dictating for: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Nurse practitioner
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
gentleman who was transferred on [**7-12**] from [**Hospital 882**]
Hospital with a right thalamus/post ventricular/subarachnoid
hemorrhage and hydrocephalus, status post a ventricular drain
placement.
The patient was admitted to an outside hospital on [**2197-7-7**] with shortness of breath and fever. He was diagnosed
with pneumonia and a chronic obstructive pulmonary disease
exacerbation. Initially, he did well. His mental status
improved. He then suddenly experienced mental status changes
and was transferred to the Intensive Care Unit. At that
time, he was obtunded and was noted to have an acute
intracerebral hemorrhage.
He computed tomography revealed a small amount of blood in
the right basal ganglia as well as bilateral ventricles as
well as blood in the superior cerebellar cistern, as well as
hydrocephalus, and obstruction of the cerebral duct. He was
transferred to [**Hospital1 69**] for
management.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Chronic obstructive pulmonary disease.
2. Dementia.
3. History of cerebrovascular accident.
4. Hypertension.
5. Diabetes mellitus.
6. History of traumatic brain injury.
7. History of methicillin-resistant Staphylococcus aureus;
positive sputum.
8. Peripheral vascular disease.
9. Status post recent coiling of an aneurysm at [**Hospital3 2358**]
in [**2196-10-4**].
BRIEF SUMMARY OF HOSPITAL COURSE: He arrived at [**Hospital1 346**] sedated and intubated. He was
opening his eyes spontaneously. He was not following
commands. The lungs were noted to have bilateral coarse
breath sounds. Heart revealed a regular rate and rhythm.
Normal first heart sounds and second heart sounds. The
abdomen was soft, nontender, and obese. Extremities revealed
no edema. On neurologic examination, he opened his eyes
spontaneously. He did not follow commands. The right pupil
was fixed and dilated. The left pupil was 2 mm to 1.8 mm
reactive. He had minimal movement noted on the left side
with no movement of the left upper extremity. He did have
positive movement of the left lower extremity to noxious
stimuli. He did have good movement on the right side with
good strength.
He was admitted to the Neurology Intensive Care Unit. The
patient's condition remained unchanged. A right ventricular
drain was placed. A left radial arterial line was also
placed on [**2197-7-11**]. The patient developed respiratory
problems despite aggressive pulmonary toilet.
A family conference was called. He was made comfort measures
only. The patient died on [**7-20**] at 0018.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Doctor First Name 51026**]
MEDQUIST36
D: [**2197-12-14**] 12:24
T: [**2197-12-16**] 08:28
JOB#: [**Job Number 51027**]
ICD9 Codes: 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2437
} | Medical Text: Admission Date: [**2176-6-13**] Discharge Date: [**2176-6-15**]
Date of Birth: [**2108-8-25**] Sex: M
Service: MEDICINE
Allergies:
Chocolate Flavor
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Claudication-->re-look LE angiography.
Claudication-->Elective PERIPHERAL VASCULAR angiography
Major Surgical or Invasive Procedure:
S/P PTA of L SFA & CFA, athrectomy of R CFA, PTA/Stent (3) of R
SFA
& PTA of R TPT
History of Present Illness:
This 67 year old man has a history of hypertension,
hyperlipidemia, tobacco abuse, CAD s/p CABG and known PVD, s/p
many prior LE interventions. Mr [**Known lastname 30301**] presents for a relook
LE angiography. The patient's daughter reports that about three
weeks ago her father began to have recurrent leg claudication,
occurring with walking about half a block. She is unclear on
which leg may be bothersome. After his last revascularization,
for a brief period, he had some improvement of his claudiation,
which has returned since.
.
In terms of cardiac symptoms, he has no chest discomfort. He
does
have dyspnea with activity such climbing up one flight of
stairs. It is worse with the recent increase in humidity. He is
on oxygen 2l via nasal cannula at
night while sleeping.
Past Medical History:
-HTN
-CAD s/p CABG ([**2169**]: ([**Hospital1 18**]) LIMA to LAD, SVG to RAMUS)
-PVD s/p multiple interventions (see below)
-cigarette smoking 1ppd/50+yrs
-Polio as a child
-BPH
-emphysema/COPD, uses 2 liters nasal cannula at hs
-hyperlipidemia
-s/p lung resection 40+ years ago after a stab wound
-Right inguinal hernia repair
-Back pain
-Cataracts (surgery scheduled for [**2176-7-9**])
-[**3-30**]: Paroxysmal atrial flutter
Peripheral vasc. history includes:
[**2175-4-3**] ABI: 0.51 right, 0.59 left
[**2175-7-10**] Lower extremity angiogram: Right- Internal iliac artery
occluded. External iliac artery occluded at the exit to the CFA.
The CFA had a short occlusion to the SFA/PFA bifurcation with
the PDA filling the distal SFA. Left- Common iliac artery was
normal. External iliac artery was occluded at the bifurcation
with the internal iliac artery. Common femoral artery occluded.
SFA patent below the occlusion. S/P successful Right CFA and
[**Month/Day/Year 30302**] intervention with cryoplasty to the SFA.
[**2175-8-2**]: successful recanalization of the [**Female First Name (un) 7195**] followed by
atherectomy and stenting
[**2176-2-14**] LE angio: (right brachial artery access):
RLE: diffuse disease in the CIA. IIA with an 80% stenosis. CFA
totally occluded.
LLE: moderate diffuse disease of the CIA. Prior EIA stent with
an 80% lesion and no flow down the external iliac artery. SFA
totally occluded proximally. Attempt at revascularization of the
left EIA unsuccessful.
[**2176-2-15**]: (access via left brachial artery):PTA of the origin of
the left internal iliac artery with a 5.0 mm balloon. Successful
PTA of the totally occluded RCFA and SFA with a 4.0 balloon.
[**2176-2-16**] LLE angiography: prior stent and CFA patent with a
distal dissection noted in the CFA with ulceration. SFA flush
occluded at the origin, PFA patent with collateralization of the
distal SFA. Successful recanalization of the Left SFA with PTA
using a 5.0 mm balloon. Successful cryoplasty of the [**Doctor First Name **], LCFA
into the [**Doctor First Name 30303**].
[**2176-4-23**]:MRI of LE: Mild atherosclerotic disease in the iliac
arteries and LE's. No hemodynamically significant stenosis
present.
[**2176-6-7**] MRI/MRA of abdomen (limited examination): Moderate focal
stenosis of the origin of the celiac artery. Diffuse narrowing
of the left common iliac artery with approximately a 7 mm long
segment of moderate to severe stenosis in the proximal left
common iliac artery, about 5mm from its origin. Possible severe
stenosis at the origins of the internal iliac arteries. Several
areas of mild stenosis in the right external iliac artery. No
definite flow seen in the right SFA consistent with occlusion.
LLE: (limited due to opacification)-Appearance of flow in the
left SFA although evaluation is limited. Flow in the popliteal
appears less than compared to the right. Flow in the left AT to
the level of the ankle noted with poor appearing flow in the
distal left anterior tibial and dorsalis pedis arteries.
Social History:
Pt lives alone in [**Hospital1 1474**]. Close with daughter. Drinks 3+
[**Name2 (NI) 17963**] a day & smokes (as above).
Family History:
(-) FHx CAD
Physical Exam:
VS: 107/53, HR 70's, O2 92% RA
Gen- a&ox3, nad
Chest-CTAB
Heart-
(Post-procedure)
R Fem Site: (-) hematoma or ooze, (+) bruit--consitent with
baseline
L Fem Site: (-) hematoma or ooze, (+) bruits--consitent with
baseline
R Brachial Site: mild bruit (-) hematoma or ooze
Pertinent Results:
Angiography & PTA -- [**2176-6-13**]
*** Not Signed Out ***
FINAL DIAGNOSIS:
1. Diffuse and critical bilateral CFA, SFA disease.
2. successful PTA of the LCFA
3. succesful PTA of the [**Month/Day/Year 30303**]
4. Successful PTA and stenting of the [**Month/Day/Year 30302**]
5. Successful PTA of the popliteal perforation
6. Successful PTA of the RCFA.
.
ART DUP EXT UP UNI LMTD RIGHT [**2176-6-14**]
FINDINGS: No pseudoaneurysm or AV fistula involving the right
brachial access site. A focal area of velocity elevation in the
brachial artery just above the antecubital fossa is identified,
reaching 486 cm/sec. This indicates a high-grade stenosis in
this area.
.
Angiography & PTA -- [**2176-6-14**]
*** Not Signed Out ***
FINAL DIAGNOSIS:
1. Occluded RBA treated with PTA
2. Occluded RCFA treated with stenting and thrombectomy
Brief Hospital Course:
Mr [**Known lastname 30301**] presents for a relook LE angiography. He
has a ho multiple LLE interventions in the past. He also has a
background of CABG, current smoking and COPD.
.
He underwent angiography & PTA of LCFA & [**Name (NI) 30303**], PTA and stenting
of the [**Name (NI) 30302**], PTA of the popliteal perforation, PTA of the RCFA.
Following the procedure, the pt underwent duplex scan of his
right arm, which suggested a significant
obstruction in his R brachial artery. The pt was taken back to
the cath lab for further evaluation with angiography. During
catheterization, the pt was found to have occluded RBA treated
with PTA. He was also found to have occluded RCFA treated with
stenting and thrombectomy.
.
The pt recovered well from the procedures. However, his HCT
dropped and he was transfused 2uPRBCs. The drop was thought to
be due to blood loss & fluids given peri-procedure. His Hct
repsonded appropriately to the transfusion. He was discharged
following transfusion.
Medications on Admission:
Aspirin 325mg daily
Zestril 20mg daily
HCTZ 12.5mg daily
Metoprolol 75mg tablets twice a day
Colace 100mg twice a day
Folic acid 1mg daily
Theophylline 200mg one tablet daily
Lipitor 40mg daily
Prednisone 5mg daily
Pletal 100mg twice a day
Digitek .25mg daily every morning
Plavix 75mg daily
Methocarbamol 750mg three times a day
Thiamine 100 daily
Percocet 1-2 tablets every 8 hours prn
MVI
Advair 500/50 twice a day
Spiriva 18mcg one puff once a day
Albuterol inhaler, prn
Albuterol nebulizer 2-4 times per day
Cromolyn sodium 20mg (nebulizer)2-4 times per day
Omeprazole 40mg daily
Ambien 10mg prn at bedtime
Ensure plus one can daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for refills please call Dr. [**First Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*11*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Zestril 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Theophylline 200 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO DAILY (Daily).
9. Lipitor 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Digitek 250 mcg Tablet Sig: One (1) Tablet PO once a day.
11. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
15. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every six (6) hours as needed.
16. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
18. Ensure Liquid Sig: One (1) PO once a day.
19. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
PVD
Anemia
Seconday:
CAD
BPH
COPD
HTN
Hyperlipidemia
Discharge Condition:
Stable
VS: 107/53, 70's, 92% RA
Labs: hct 34.5 (after tranfusion of 2uPRBC's), plt 339, k 4.4,
buncr 10/0.7, alt 17, ast 24, ck 86
R Fem Site: (-) hematoma or ooze, (+) bruit--consitent with
baseline
L Fem Site: (-) hematoma or ooze, (+) bruits--consitent with
baseline
R Brachial Site: mild bruit (-) hematoma or ooze
Discharge Instructions:
-Continue taking all of your medications as directed.
-Take Aspirin 325mg & Plavix 75mg daily. Do not stop these
medications unless directed by Dr. [**First Name (STitle) **]
[**Name (STitle) **] are not longer taking pletal
-You need to return in 2 weeks for an intervention on your left
leg & right brachial artery in your arm, you will be called
regarding scheduling this.
-Seek immediate medical attention for any recurrent symptoms,
temperature change, pain or discoloration of your extremities,
any issues with your groin site including fever or any other
concerning symptom.
Followup Instructions:
-Dr. [**First Name (STitle) **] will call you tomorrow to check on you. If you have
any questions, you may try to reach him at his office, phone:
([**Telephone/Fax (1) 7236**].
-You have an appointment at in the Vascular Lab at [**Hospital1 18**] on
Monday, [**2176-6-17**], Time: 10:00. This is for a VASCULAR STUDY.
Please call if you need directions or have any questions
Phone:[**Telephone/Fax (1) 327**]
- Please make an appointment to see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 1
week.
-Return to lab in 2 weeks for LLE & R Brachial intervention.
ICD9 Codes: 496, 4019, 2724, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2438
} | Medical Text: Admission Date: [**2188-3-1**] Discharge Date: [**2188-3-15**]
Date of Birth: [**2131-8-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
transfer from NEBH for SOB, possible need for cath given rising
troponin
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Coronary Artery Bypass Grafting
LIMA-->LAD, SVG-->OM, SVG-->PDA
History of Present Illness:
56 y/o male patient of Dr. [**Last Name (STitle) **] with HTN, hypercholesterolemia,
DM2, current smoking, PVD s/p Left CEA and totally occluded
[**Country **], with chest discomfort begining three weeks ago which he
describes as "stressed out feeing" right before the holidays.
Denies pain or associated symptomes of SOB, diasphoresis, light
headedness, nausea, or leg swelling. He has been chest dicomfort
free for the last several weeks since then, with the exception
of increased SOB, mostly at night, and increased leg swelling,
cough, and PND.
He presented to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39934**] office with SOB, cough, and
sputum production, was treated with antibiotics with no
resolution of symptomes, and had a CXR suggestive of pulm edema,
and so was referred to NEBH ambulatory services for evaluation.
He was admitted to NEBH for r/o MI, troponins 1.82 to 4.16 to
5.35 with CK 173 to 161 to 181. Started on asa, plavix, lovenox
and transferred for possible cath/CABG given rising troponins.
Denies chest pain currently. Denies SOB.
Past Medical History:
HTN
hypercholesterolemia
DM2
current smoking
PVD s/p Left CEA and totally occluded [**Country **]
Hypothyroidism
S/P Cholecystectomy
S/P Cervical Surgery
S/P B/L Knee Surgery
Social History:
Smoker of 35 years at 2 ppd. No recent alcohol use, but remote
history of frequent use.
Family History:
Father had MI at 65 years old.
Physical Exam:
General: Well appearing man in no distress. Approproately
responsive.
Vitals: T 96.2 BP 131/54 HR 61 RR 18 Sat 100% 1L O2 NC FS 58 Wt
110kg
HEENT: normal, anicteric sclera
Neck: Carotid bruits B/L R>L
Chest: Lungs with decreased breath sounds at bases, otherwise
clear
ABD: Scar over RUQ and above umbilicus, +bowel sounds, soft, NT,
ND, no organomegaly
EXT: No edema. Good femoral pulses B/L without bruits.
Pertinent Results:
INDICATIONS FOR CATHETERIZATION:
NSTEMI, low EF, 30 beats of monomorphic VT
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 6 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 French angled pigtail catheter,
advanced
to the left ventricle through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French JL4 and a 6 French JR4 catheter, with manual contrast
injections.
Left Ventriculography: was performed in the 30 degrees [**Doctor Last Name **]
projection,
using 33 ml of contrast injected at 11 ml/sec, through the
angled
pigtail catheter.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.21 m2
HEMOGLOBIN: 14 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 15/16/9
RIGHT VENTRICLE {s/ed} 45/15
PULMONARY ARTERY {s/d/m} 45/18/28
PULMONARY WEDGE {a/v/m} 24/25/22
LEFT VENTRICLE {s/ed} 141/24
AORTA {s/d/m} 141/64/71
**CARDIAC OUTPUT
HEART RATE {beats/min} 55
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 38
CARD. OP/IND FICK {l/mn/m2} 7.3/3.3
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 680
PULMONARY VASC. RESISTANCE 66
**% SATURATION DATA (NL)
SVC LOW 70
PA MAIN 68
AO 88
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
LEFT VENTRICULOGRAPHY:
Volumetric data:
LV ejection fraction (nl 50%-80%). 25
Qualitative wall motion:
[**Doctor Last Name **]:
1. Antero basal - hypokinetic
2. Antero lateral - hypokinetic
3. Apical - hypokinetic
4. Inferior - hypokinetic
5. Postero basal - hypokinetic
Other findings:
Mitral valve was normal.
Aortic valve was normal.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA DISCRETE 50
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA DISCRETE 95
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 DIFFUSELY DISEASED 70
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
12) PROXIMAL CX DISCRETE 70
13) MID CX DIFFUSELY DISEASED
13A) DISTAL CX DIFFUSELY DISEASED
14) OBTUSE MARGINAL-1 DISCRETE 95
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour41 minutes.
Arterial time = 0 hour25 minutes.
Fluoro time = 5.6 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 83 ml,
Indications - Hemodynamic
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Fentanyl 25 mcg IV
Versed 0.5 mg IV
Lasix 20 mg IV
Cardiac Cath Supplies Used:
200CC MALLINCRODT, OPTIRAY 200CC
100CC MALLINCRODT, OPTIRAY 100CC
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system.
There was no angiographically apparent CAD in the LMCA. The LAD
had a
long diffusely diseased segment with a 70% stenosis. The LCX had
a 70%
proximal stenosis. The OM had a 95% origin stenosis. There was
moderate
diffuse distal disease in the LCx. The RCA had a 50% mid vessel
stenosis
and 95% bifurcation disease at the PDA and PL.
2. Hemodynamics on entry showed elevated filling pressures, mild
to
moderate pulmonary hypertension, and a normal cardiac output.
There was
no gradient across the aortic valve on pullback.
3. Left ventriculography showed a dilated ventricle which was
globally
hypokinetic.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate systolic and mild diastolic ventricular dysfunction.
3. Mild to moderate pulmonary hypertension.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) 10897**] B.
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Cardiology Report ECG Study Date of [**2188-3-5**] 3:51:14 PM
Ectopic atrial rhythm. Ventricular premature beat with possible
pacemaker
fusion. Lone pacemaker spike in the third beat of the rhythm
strip. Consider
sensing malfunction.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
51 [**Telephone/Fax (3) 32880**]/446.86 -53 95 -157
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2188-3-7**] 12:47 PM
CHEST (PORTABLE AP)
Reason: PTX
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with increasing dyspnea s/p CABG now s/p R-IJ
change over wire and d/c CTs
REASON FOR THIS EXAMINATION:
PTX
CHEST, SINGLE AP FILM
History of CABG and increasing dyspnea with CV line change.
Status post CABG. Right jugular CV line is in the SVC. No
pneumothorax. The right costophrenic region is not included on
the film. There is opacity at the left base obscuring the left
hemidiaphragm consistent with atelectasis in the left lower lobe
and associated small left pleural effusion. Status post cervical
spine fusion.
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
Approved: [**First Name9 (NamePattern2) **] [**2188-3-7**] 2:55 PM
RADIOLOGY Final Report
CAROTID SERIES COMPLETE [**2188-3-4**] 3:40 PM
CAROTID SERIES COMPLETE
Reason: please eval for extent of carotid stenosis b/l
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with h/o PVD s/p left CEA and known [**Country **]
occlussion. ON exam with b/l carotid bruits R>L and diminsihed R
carotid pulse.
REASON FOR THIS EXAMINATION:
please eval for extent of carotid stenosis b/l
HISTORY: Status post left carotid endarterectomy with right
carotid occlusion.
TECHNIQUE: [**Doctor Last Name **] scale ultrasound, color Doppler, and spectral
Doppler interrogation of the extracranial carotid arteries were
performed.
RIGHT: No flow was demonstrated within the right internal
carotid artery. Peak systolic velocity in the right external
carotid artery was 193 cm/sec, common carotid artery 43 cm/sec.
Blood flow within the right vertebral artery was antegrade.
LEFT SIDE: Mild calcified plaques were noted at the origin of
the left internal carotid artery. Peak systolic velocities were
as follows: 112 cm/sec ICA, 71 cm/sec CCA, 132 cm/sec ECA. Blood
flow direction within the left vertebral artery was antegrade.
The ICA-CCA ratio on the left was 1.57.
IMPRESSION:
1. Right internal carotid artery is occluded.
2. Nonhemodynamically significant stenosis of less than 40% was
demonstrated in the left internal carotid artery.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 39935**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 39936**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Approved: WED [**2188-3-5**] 9:51 AM
Brief Hospital Course:
56 y/o male with HTN, hypercholesterolemia, current smoking,
DM2, PVD S/P L CEA and occluded [**Country **] presents from outside
hospital after completed MI with shortness of breath, was chest
pain free and ruled out for active ischemic event. He was
started on metoprolol and captopril. His shortness of breath
improved with diuresis (40 mg IV lasix QD). He had a 30 second
episode of monomorphic VT symptomatic with lightheadedness on
[**2188-3-3**]. He went for elective cath on [**2188-3-4**], which showed 3VD,
and so he was scheduled for CABG. He was started on amiodarone
for VT.
He was continued on his home regimen of 60 units 75/25 QD before
breakfast for DM2, but his evening dose of 60 units NPH was
halved for morning hypoglycemia.
He had a carotid US for his h/o PVD with CEA of left carotid and
known totally occluded [**Country **]. It showed 40% Left Stenosis and
totally occluded [**Country **]. He had an abnormally elevated TSH to 25,
but his free T4 was normal. We continued his home dose of
levothyroxine 300 mcg QD. He may need an EP study for possible
ablation of ventricular focus given his episode of monomorphic
VT as an Outpatient per Dr. [**Last Name (STitle) **]. He may also need an ICD given
his low EF an documented episode of symptomatic monomorphic VT.
Mr. [**Known lastname 3075**] [**Last Name (Titles) 1834**] cardiac catheterization where he was found
to have no angiographically apparent CAD in the LMCA. The LAD
had a long diffusely diseased segment with a 70% stenosis. The
LCX had a 70% proximal stenosis. The OM had a 95% origin
stenosis. There was moderate diffuse distal disease in the LCx.
The RCA had a 50% mid vessel stenosis and 95% bifurcation
disease at the PDA and PL. Given the severity of his disease,
the cardiac surgical service was consulted for surgical
revascularization. He was worked-up in the usual preoperative
manner. On [**2188-3-5**] he successfully [**Date Range 1834**] CABGx (LIMA->LAD,
SVG->PDA, SVG->OM). Afterward he was transferred to the Cardiac
surgery recovery unit in stable condition and awakened
neurologically intake. He was weaned from ventilator support,
extubated, and pressors were weaned. On POD 2 he was then
transferred to the cardiac stepdown unit for further recovery.
His chest tubes were removed without complication. He was
gently diuresed toward his preoperative weight with lasix. Beta
blockade, aspirin, and plavix were resumed. The physical therapy
service was consulted to assist with his postoperative strength
and mobility. Electrolytes were repleted as needed. On POD 3
his epicardial pacing wires were removed without complication.
The Electrophysiology service was consulted regarding history of
ventricular tachycardia that occurred preoperatively.
Consideration was given to performing an EP study with ablation
however due to his continued tenuous pulmonary status Dr. [**Last Name (STitle) **],
Mr. [**Known lastname 39937**] cardiologist elected to continue observation and
perform any further work up as an outpatient. Also on POD 3 he
began to complain of decreased sensation and flexion to his left
calf and shin. This was attributed to peroneal nerve injury
from fluid accumulation or positioning, for which the physical
therapy service gave an ankle foot orthotic. We will continue
watchful waiting for the return of his left lower extremity
function. If indicated further workup will be conducted as an
outpatient. He continued to improve his ability to ambulate
including climbing stairs without severe respiratory distress or
chest pain. His room air saturations improved to 98% despite
continuing to require combivent, albuterol, and advair. On POD
9 Mr. [**Known lastname 3075**] was at his preop weight with good exercise
tolerance, no SOB, or Chest pain. His blood pressure was
stable. His sternotomy and leg incision were clean, dry, and
intact, however he was placed on levaquin 500mg for seven days
due to sersanquinous drainage at the inferior portion of his
sternotomy. He was discharged to home on POD 9, with cardiac
diet, sternal precautions, and instructed to follow up with his
PCP and cardiologist in [**2-18**] weeks. He will follow up for a
wound check on Mon or Tues. at [**Hospital Ward Name 121**] 2. He will follow up with
Dr. [**Last Name (STitle) **] in four weeks.
Medications on Admission:
Home Meds:
Valium 5 mg TID
Humulin N 60 units QD at dinnertime
Humalog 75/25 60 units QD before breakfast
Levothyroxine 300mcg QD
Percocet 5mg/325mg [**2-18**] Q4H PRN
Additional Meds on transfer:
ASA 325 QD
Plavix 300 once
Nitro Paste 2inches
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. 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*
7. 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*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*2*
13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*qs qs* Refills:*2*
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
every 4-6 hours.
Disp:*qs qs* Refills:*2*
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day.
Disp:*qs 30* Refills:*2*
17. Humalog Mix 75-25 75-25 unit/mL Suspension Sig: One (1) 60
Subcutaneous qBreakfast.
Disp:*qs 30* Refills:*2*
18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
60 Subcutaneous at bedtime.
Disp:*qs 30* Refills:*2*
19. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
Disp:*qs ML(s)* Refills:*0*
20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
21. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
care group
Discharge Diagnosis:
CAD, PVD s/p Left CEA, totally occluded [**Country **], Hypothyroidism,
s/p CCY, cervical injury, s/p Bilateral knee replacement with
intra-op brady arrest, IDDM, HTN, Hypercholesteremia
Discharge Condition:
Good
Discharge Instructions:
Shower, wash incisions with mild soap and water and pat dry. No
lotions, creams or powders to incisions.
Call with fever >101, redness or drainage from incision, or
weight gain more than 2 pounds in one day or five pounds in one
week.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] in four weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 5456**] in [**2-18**] weeks [**Telephone/Fax (1) 25798**]
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2394**] in [**2-18**] weeks
Completed by:[**2188-3-15**]
ICD9 Codes: 4280, 4271, 4019, 2720, 3051, 4439, 2449, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2439
} | Medical Text: Admission Date: [**2107-10-21**] Discharge Date: [**2107-10-25**]
Date of Birth: [**2020-2-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Coronary Artery Disease
Major Surgical or Invasive Procedure:
CABG X4 (LIMA-LAD, SVG-OM, PDA,PLD) on [**2107-10-21**]
History of Present Illness:
87 year old male, known to our service (see H&P from [**2107-8-12**]),
who sustained an STEMI in [**2107-7-24**]. A bare metal stent was
placed to the RCA at that time. A TTE on [**2107-8-13**] showed inferior
hypokinesis and an EF of 35-40%. He was seen by cardiac surgery
and was considering CABG at the time of discharge however wanted
to wait for the time being. Since that time he has felt quite
well and has been symptom free. He walks 20 minutes daily
without issue. He was seen by Dr. [**Last Name (STitle) 911**] in consultation and it
was recommended that he would be best served with going forward
with surgical revascularization. Recent echo showed left
ventricular
wall motion abnormalities and overall left ventricular systolic
function that are significantly improved compared to prior echo.
He presented for surgical discussion.
Past Medical History:
Glaucoma
Mechanical fall c/b left proximal ulnar fracture [**4-/2105**]
Mild cognitive impairment
Left peroneal impairment
Prostate Cancer s/p TURP and Lupron therapy 12 years ago
GERD
Past Surgical History:
s/p TURP
Past Cardiac Procedures:
[**2107-8-12**] s/p BMS to RCA
Social History:
Race: Caucasian
Last Dental Exam: 3 months ago
Lives with: alone
Contact: [**Name (NI) 84169**] (son) Phone #[**Telephone/Fax (1) 84170**]
Occupation:retired
Cigarettes: Smoked no [x] yes []
Other Tobacco use: Never
ETOH: < 1 drink/week [x] [**3-1**] drinks/week [] >8 drinks/week []
Illicit drug use: Denies
Family History:
The patient has a twin brother who has a history of heart
disease and heart failure
Physical Exam:
Pulse: 59 Resp: 16 O2 sat: 100/RA
B/P 140/75
Height: 5'8" Weight: 75.7 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur []
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] No Edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:1+ Left:1+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2107-10-24**] 05:40AM BLOOD Hct-28.5*
[**2107-10-23**] 06:15AM BLOOD WBC-9.7 RBC-3.15* Hgb-9.2* Hct-27.9*
MCV-89 MCH-29.3 MCHC-33.1 RDW-15.1 Plt Ct-128*
[**2107-10-22**] 02:37AM BLOOD WBC-10.0 RBC-3.26* Hgb-9.6* Hct-28.8*
MCV-88 MCH-29.4 MCHC-33.3 RDW-14.8 Plt Ct-126*
[**2107-10-21**] 07:27PM BLOOD Hct-29.0*
[**2107-10-24**] 05:40AM BLOOD UreaN-25* Creat-1.2 Na-132* K-4.3 Cl-100
[**2107-10-23**] 06:15AM BLOOD Glucose-108* UreaN-22* Creat-1.2 Na-135
K-4.1 Cl-103 HCO3-26 AnGap-10
[**2107-10-22**] 02:37AM BLOOD Glucose-149* UreaN-19 Creat-1.3* Na-136
K-4.8 Cl-108 HCO3-22 AnGap-11
[**2107-10-21**] 12:17PM BLOOD UreaN-19 Creat-1.2 Na-141 K-4.3 Cl-114*
HCO3-22 AnGap-9
[**2107-10-21**] TTE
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 borderline normal free wall function. There are
simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is paced, on no inotropes.
Preserved biventricular systolic fxn.
Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on **** where the patient underwent *********.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. ***** was used
for surgical antibiotic prophylaxis. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. The
patient was neurologically intact and hemodynamically stable on
no inotropic or vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued without complication. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD **** the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged ***** in good
condition with appropriate follow up instructions.
Medications on Admission:
ATORVASTATIN 80 mg tablet 1 tablet(s) by mouth daily
CLOPIDOGREL [PLAVIX] 75 mg tablet once a day
LISINOPRIL 5 mg by mouth once a day
METOPROLOL SUCCINATE [TOPROL XL] 25 mg tablet,extended release 1
Tablet(s) by mouth once a day
NITROGLYCERIN [NITROSTAT] - Nitrostat 0.4 mg sublingual tablet
1 tablet(s) sublingually as directed PRN
TIMOLOL MALEATE - Dosage uncertain
ASPIRIN 325 mg tablet,delayed release 1 Tablet(s) by mouth once
a day
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*100 Tablet Refills:*0
2. Atorvastatin 80 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Tartrate 50 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
5. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
Hold for K+ > 4.5
RX *potassium chloride 20 mEq 1 by mouth daily Disp #*1 Tablet
Refills:*0
6. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **]
8. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
9. Lisinorpil 5 mg po daily
10. Plavix 75 mg po daily
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. 1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] on [**2107-11-22**] at 2:30pm
Cardiologist: Dr. [**Last Name (STitle) 911**] [**2107-11-16**] at 3:20pm ([**Hospital Ward Name 23**] 7)
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**4-28**] weeks [**Telephone/Fax (1) 2010**]
**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:[**2107-10-25**]
ICD9 Codes: 412, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2440
} | Medical Text: Admission Date: [**2123-8-10**] Discharge Date: [**2123-8-20**]
Service: [**Hospital Unit Name 14178**]
CHIEF COMPLAINT: Admission from clinic for tachycardia.
HISTORY OF THE PRESENT ILLNESS: This is an 85-year-old
African-American female with a past medical history of
hypothyroidism and hypertension who presented to her primary
care physician with new onset shortness of breath, dyspnea,
lightheadedness, and PND. Symptoms have progressed over the
past two weeks prior to admission. Upon presentation to her
primary care physician, [**Name10 (NameIs) **] showed narrow complex tachycardia
and an old known left bundle branch block. The patient's
pulse in the office was at 128, at which point, the patient
was referred to the Emergency Department. Of note, the
patient does not have any cardiac history. She was 100%
functional without experiencing shortness of breath prior to
this episode.
In the Emergency Department, a CTA ruled out a pulmonary
embolism. The patient was given IV Lasix and 12.5 mg
Lopressor empirically for CHF. A chest x-ray revealed
basilar congestion and atelectasis but no evidence of CHF.
The patient developed bradycardia with a pulse of 35 and
hypotension with a blood pressure of 60-40 after having
received the Lopressor. The patient was fluid resuscitated
and the blood pressure was raised to 120. The patient again
became tachycardiac with a pulse of 120 and was admitted to
[**Hospital Unit Name 196**] and scheduled for EP.
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. Hypertension.
3. Remote GI bleed.
4. Breast biopsy in [**2112**].
5. Knee surgery in [**2115**].
6. Hip surgery in [**2121**].
HOME MEDICATIONS:
1. Hydrochlorothiazide 25 mg p.o. q.o.d.
2. Levothyroxine 100 micrograms q.d.
3. Hydrocortisone 2.5% twice as needed to scalp.
4. Triamcinolone.
5. Acetamide 0.1% twice as needed.
6. Tylenol p.r.n. pain.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: History of diabetes mellitus in mother and
hypertension.
SOCIAL HISTORY: The patient lives with a roommate. She has
a remote history of smoking one to two cigarettes a day for
approximately 20 years. The patient admits to quitting 15
years ago. The patient denied alcohol use, denied any other
drug use.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
was afebrile, blood pressure 124/81, heart rate 140s,
respiratory rate 12. The 02 saturation was 97% on room air.
HEENT: No JVD noted, no scleral icterus. Mucosa moist.
Cardiovascular: Distant heart sounds, tachycardiac, S1 and
S2 present, I/VI holosystolic murmur. Respiratory: Positive
bibasilar crackles, worse on the right, diffuse wheezing.
Abdomen: Tender in the epigastric region, otherwise
nondistended, soft, bowel sounds present. Extremities:
There were +2 pedal pulses, no edema noted.
LABORATORY/RADIOLOGIC DATA: Hemoglobin 13.1, hematocrit
37.8, white blood cells 8.2, and platelets 176,000.
Electrolytes: Sodium 140, potassium 3.2, chloride 102,
bicarbonate 24, BUN 10, and creatinine 1.1, sugar 104. CKs
were 136, MB 3, and troponin 0.01. Enzymes were continued to
be cycled and the patient was ruled out for acute MI.
HOSPITAL COURSE: Upon admission to [**Hospital Unit Name 196**] on the floor, the
patient developed torsades which was attributed to treatment
with beta blockade in the ED and resultant prolongation of
QRS on the background of bradycardia. The patient was
transferred to the CCU where she was given 2 mg of magnesium
sulfate and converted to sinus. The next morning, [**2123-8-11**], the patient underwent EP study with RFA radiofrequency
ablation and dual-chamber pacemaker placement. This RFA
addressed her supraventricular tachycardia. The pacemaker
addressed her bradycardia.
Post EP study and pacemaker insertion on the floor, the
patient developed tachypnea and diaphoresis with a rising
blood pressure to 208/119, pulse 120, and SA02 of 90% on 2
liters. Chest x-ray done at that time showed evidence of
congestion and the patient was given 40 mg of IV Lasix.
Echocardiogram also performed at this time showed severe MR
[**First Name (Titles) 151**] [**Last Name (Titles) 14179**] left ventricular [**Last Name (Titles) 14179**] LV and EF of
30%. The next morning, [**2123-8-12**], the patient underwent
a catheterization which showed 100% RCA ostium occlusion and
otherwise patent LAD and circumflex.
A stent was placed in the RCA. Mitral regurgitation was
assessed as moderate by left ventriculogram. Post
catheterization, the patient continued to be in congestion
with significant pleural effusion. The CHF Service, under
Dr. [**Last Name (STitle) **], were also on consult following the patient. The
patient was started on Nisiritide on [**2123-8-15**] and was
continued on Nisiritide with successful diuresis until
[**2123-8-20**]. Throughout the course, the patient received
Captopril for afterload reduction and beta blockade.
The patient improved significantly and is able to ambulate
with PT. The patient is on room air and saturating at 97%
oxygen. The patient was discharged to [**Hospital6 14180**].
FINAL DIAGNOSIS:
1. Ischemic cardiomyopathy.
2. Mitral regurgitation
3. Acute congestive heart failure due to number two.
4. Supraventricular tachycardia.
5. Hypertension.
6. Hypothyroidism.
RECOMMENDED FOLLOW-UP:
1. Follow-up with cardiologist, Dr. [**Last Name (STitle) 73**], in one week,
phone number [**Telephone/Fax (1) 902**].
2. Follow-up with outpatient echocardiogram on [**2123-9-3**] at 11:00 [**Initials (NamePattern4) **] [**Hospital Ward Name 516**].
3. Follow-up with Dr. [**Last Name (STitle) 8499**], primary care physician,
[**Name10 (NameIs) **] three weeks.
POSTDISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Lisinopril 10 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d.
4. Spironolactone 25 mg p.o. q.d.
5. Lipitor 10 mg p.o. q.d.
6. Aspirin 325 mg p.o. q.d.
7. Digoxin 0.125 mg p.o. q.d.
8. Levothyroxine 125 micrograms p.o. q.d.
9. Protonix 40 mg p.o. q.d.
10. Acetaminophen 325 mg tablets, p.r.n.
11. Albuterol sulfate solution p.r.n. for wheezing.
DISCHARGE STATUS: Good.
CONDITION ON DISCHARGE: Good.
DR.[**Last Name (STitle) 14181**],[**First Name3 (LF) 2064**] 12-ABZ
Dictated By:[**Name8 (MD) 9784**]
MEDQUIST36
D: [**2123-8-20**] 01:15
T: [**2123-8-20**] 13:18
JOB#: [**Job Number 14182**]
cc:[**Hospital6 14183**]
ICD9 Codes: 4240, 4280, 4271, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2441
} | Medical Text: Admission Date: [**2122-8-10**] Discharge Date: [**2122-8-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 663**]
Chief Complaint:
Hematochezia and weakness
Major Surgical or Invasive Procedure:
3 PRBC Blood transfusion.
Flexible Sigmoidoscopy.
History of Present Illness:
[**Age over 90 **] year old man with history of alcohol abuse, paroxysmal atrial
tachycardia and frequent lower gastrointestinal bleeding,
presenting with 1 week history of bright red blood per rectum
with bowel movements. Patient reports he was in his otherwise
good state of health until last Monday, when he began having
diarrhea with bright red blood, which stained his toilet water
red. Patient also complains of weakness, fatigue when going up a
single set of stairs (different than his baseline)
The patient also Complaints of "nose/throat issues" and reports
a scratchy feeling in his throat. Denies any recent travel,
fevers, chills, nausea, vomiting, chest pain, but does report
feeling dizzy.
In ED, Temp: 99.4 HR: 86 BP: 89/51 RR: 19 O2 Sat:99% RA.
Patient given 1 unit of PRBC with improvement in SBP to 100's.
Hct found to be 18 (baseline 34). Patient admitted to MICU for
further management.
Past Medical History:
- alcohol abuse; drank an average of 2 large bottles of [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 5261**] per week (per prior OMR notes) patient reports he has
since quit (x 1 month)
- paroxysmal atrial tachycardia
- anemia, mild leukopenia
- dementia (baseline oriented to person, place)
- BPH s/p TURP
- chronic LGIB (question of AVM vs Diverticuli)
- gout
Social History:
Patient had history of [**1-22**] drinks of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] per day as
documented in OMR. Prior tobacco, quit in 60s. Lives with his
wife. [**Name (NI) **] has two kids and 2 grandkids.
Family History:
Non-contributory, no colon CA
Physical Exam:
Vital signs:
Temp: 99.4 HR: 92 BP: 133/50 RR: 25 O2 Sat: 100%
GEN: Elderly man in no acute distress, well appearing. Alert,
oriented to self, place, year, month and day of the week.
HEENT: PERRL with anicteric sclera, pale conjuctivae.
CV: Irregular rate with frequent beats out of sequence. No
murmurs, rubs or gallops.
Lungs: Clear to auscultation bilaterally, no rales, rhonchi or
wheezes.
Abdomen: Soft, non tender, non distended.
Ext: Warm, well perfused.
Pertinent Results:
==================
ADMISSION LABS
==================
WBC-7.6 RBC-1.84* Hgb-5.3* Hct-18.3* MCV-100* MCH-28.8
MCHC-28.9* RDW-14.3 Plt Ct-323
Neuts-73.2* Lymphs-19.9 Monos-6.2 Eos-0.6 Baso-0
PT-13.3 PTT-26.4 INR(PT)-1.1
Glucose-117* UreaN-12 Creat-1.2 Na-143 K-3.8 Cl-106 HCO3-26
AnGap-15
ALT-10 AST-15 AlkPhos-47 TotBili-0.3
Lipase-20
===============
SIGMOIDOSCOPY
===============
[**2120-1-21**]
Findings: Protruding Lesions Medium internal hemorrhoids with
stigmata of recent bleeding were noted. There was erythema and
red spots on the internal hemorrhoids.
Excavated Lesions Multiple severe diverticula with wide-mouth
openings were seen in the sigmoid colon and descending colon.
[**2118-1-20**]
Impression: Diverticulosis of the sigmoid colon and descending
colon internal and external hemorrhoids
Flat Lesions A few angioectasias that were not bleeding were
seen in the rectum. An Argon-Beam Coagulator was applied for
hemostasis successfully. Excavated Lesions Multiple diverticula
were seen in the left colon.
Brief Hospital Course:
[**Age over 90 **] year old man with h.o. alzheimers dementia, Etoh abuse, HTN,
paroxysmal atrial tachycardia s/p 3u PRBC transfusion for GI
bleed admitted to the ICU with dizziness and hematochezia.
##. Hematochezia: Mr. [**Known lastname **] presented to the ED with a 1 week
history of hematochezia, weakness, fatigue. In the ER he was
noted to have a Hct 18 and was thus transfused 3units of PRBCs
and transferred to the ICU. In the ICU he was noted to have a
post transfusion Hct of 27 that remained stable. Pt was
transferred back to the floor and received a sigmoidoscopy that
showed sigmoidal polyp and grade II internal hemorrhoid. Pt has
been seen in the past by Dr. [**Last Name (STitle) **] for hemorrhoidal banding,
on discharge pt was given instructions to contract Dr. [**Last Name (STitle) **]
to band his hemorrhoid.
##. Alcohol abuse: Pt had an extensive history of Alcohol abuse
however he has not had an alcoholic drink for 4 weeks. Whilst in
the hospital Mr. [**Known lastname **] showed no signs of withdrawal and was
given thiamine, folate, and multivitamin supplementation.
##. Paroxysmal atrial tachycardia: Patient was controlled on his
home regimen of Diltiazem.
##. Glaucoma: Patient was continued on his outpatient eye drops.
Medications on Admission:
ALLOPURINOL - 300 mg Tablet - [**1-21**] Tablet(s) by mouth once a day
BRIMONIDINE TARTRATE - 0.15% Drops - ONE DROP EACH EYE EVERY 8
HOURS
DILTIAZEM HCL [DILT-XR] - 180 mg Capsule
POTASSIUM CHLORIDE - 8 mEq Tablet Sustained Release - 1
Tablet(s)
by mouth once a day
TIMOLOL MALEATE - 0.25% Drops - ONE DROP EACH EYE TWO TIMES A
DAY
FERROUS SULFATE - 250 mg Capsule, Sustained Release
Discharge Medications:
1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
2. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI Bleed, likely internal hemorrhoids
Discharge Condition:
Stable, afebrile.
Discharge Instructions:
You were admitted to the hospital for a lower gastrointestinal
bleed, you needed a blood transfusion as your blood level was
low. Please go to the surgery clinics as scheduled on [**2122-8-19**] to have further treatment of your hemorrhoids.
Before you left the hospital you were able to eat a full meal
without bleeding again.
We stopped your diltiazem medication. Please do not take this
medication at home.
You will be given a presciption for Pantoprazole (Protonix)
which is an indigestion pill, please take it as instructed. You
will also be given a medication called Docusate Sodium (Colace)
which will help soften your bowel movements, please take as
instructed.
If you start bleeding again please return to the ER.
Followup Instructions:
1. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2122-9-1**] 2:30
2. Please call Dr. [**Last Name (STitle) **] for an appointment next week to have
your stage II internal hemorrhoid banded.
ICD9 Codes: 2851, 4589, 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2442
} | Medical Text: Admission Date: [**2171-12-29**] Discharge Date: [**2172-1-1**]
Date of Birth: [**2093-10-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Throat and arm pain
Major Surgical or Invasive Procedure:
cardiac catheterization with thrombectomy of stent and promus
drug eluting stent to the mid right coronary artery
History of Present Illness:
78 year old female with history of NIDDM, MI x 3, and COPD who
presents who presents with chest pain found to have EKG changes
concerning for STEMI.
.
The patient was in her usual state of health until about two
weeks ago when she developed intermittent throat and arm pain.
This happened a few times but has increased in frequency over
the last three days, which is when she noted the developed of
chest pain as well. At around 1300 today, the pain became
constant, rated at an [**2170-9-11**], which was very concerning to the
patient so she called EMS at 1800 and was brought to [**Hospital1 18**] ED
for further evaluation. Of note, the patient reports poor
compliance with her home medications of late, which include PO
antihyperglycemics, aspirin, and plavix.
.
She received ASA 325mg in the ambulance and rated her pain at
[**2170-3-7**] on arrival to the ED. She denied any SOB and reports the
pain was different than the pain she experienced with her prior
MI. In the ED, EKG was concerning for STEMI and cardiology was
notified. She received heparin gtt, plavix 600mg, and
integrillin and was sent for urgent cardiac catheterization.
During the cath, she was found to have a in-stent thrombosis in
the RCA, which was suctioned and angioplastied. Per report,
"successful primary angioplasty for inferior STEMI with 80%
thrombotic stenosis in the mid portion of previously placed
stent; this was treated with PCI and stenting utilizing 3.5x23mm
Promus DES, post-dilated to 3.75mm with excellent result." The
patient tolerated the procedure well and is being admitted to
the CCU for further monitoring.
.
On arrival to the CCU, vital signs were T- 97.6, HR- 90, BP-
103/77, RR- 19, SaO2- 88% on RA. The patient denies chest pain,
shortness of breath or headache. She remains hemodynamically
stable.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems, at this time, is notable for absence
of chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(-)Hypertension
2. CARDIAC HISTORY:
- CABG: n/a
- PERCUTANEOUS CORONARY INTERVENTIONS: AMI in [**2159**]- tPA followed
by PTCA/PCI of RCA and LCx. She has had two other interventions
with a total of four stents placed
- PACING/ICD: n/a
3. OTHER PAST MEDICAL HISTORY:
1. Coronary artery disease status post multiple PCIs.
2. Diabetes mellitus- non-insulin dependant, with peripheral
neuropathy
3. Hyperlipidemia.
4. COPD from smoking
5. Status post hysterectomy.
6. Status post right common femoral arterial thrombectomy in
[**2164-11-2**].
Social History:
#SOCIAL HISTORY: Patients husband died at age 41, she has worked
as a waitress all of her life. Until recently worked as a
cashier at CVS. Lives at home with her Daughter [**Name (NI) **]
[**Telephone/Fax (1) 25793**], son-in-law and grand children. Able to complete
all ADLs/IADLS. No etoh or IV drugs
Family History:
#FAMILY HISTORY:
Mom MI [**35**]
Son died mi [**97**]
Brother died MI
Aunt MI [**01**]
DAD bone cancer died 92
Physical Exam:
ON admission:
VS: T- 97.6, HR- 90, BP- 103/77, RR- 19, SaO2- 88% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with normal JVP.
CARDIAC: Regular rate and rhythm, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Bibasilar crackles with no wheezes or rhonchi. no
accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness.
No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
.
On discharge:
Vitals - Tm/Tc: 97.8/97.1 HR: 73-76 BP:102-123/48-51 RR:20 02
sat: 96% RA
In/Out:
Last 24H: [**Telephone/Fax (1) 25794**]
Last 8H:
Weight: 66.2 (68.5)
.
Tele: SR, few PVC's
.
FS: 273/211/191
.
GENERAL: 78 yo F in no acute distress, lying flat in bed
HEENT: no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated
CHEST: crackles right base, [**Month (only) **] BS on left
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, obese, BS normoactive. no
rebound/guarding.
EXT: wwp, no edema. DPs, PTs 2+.
NEURO: A/O, pleasant and conversant, MAE, good memory of recent
events
SKIN: no rash
Pertinent Results:
ON admission:
[**2171-12-29**] 07:10PM BLOOD WBC-6.1 RBC-4.21 Hgb-12.4 Hct-40.0 MCV-95
MCH-29.5 MCHC-31.1 RDW-12.4 Plt Ct-242
[**2171-12-30**] 04:03AM BLOOD Glucose-284* UreaN-13 Creat-0.7 Na-138
K-4.1 Cl-102 HCO3-31 AnGap-9
[**2171-12-30**] 04:03AM BLOOD CK(CPK)-213*
[**2171-12-30**] 06:20PM BLOOD CK-MB-10 MB Indx-7.8* cTropnT-0.17*
[**2171-12-30**] 12:02PM BLOOD CK(CPK)-187
[**2171-12-30**] 06:20PM BLOOD CK(CPK)-129
[**2171-12-30**] 04:03AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.0
.
On discharge:
[**2172-1-1**] 06:55AM BLOOD WBC-6.1 RBC-3.92* Hgb-11.8* Hct-36.6
MCV-93 MCH-30.0 MCHC-32.1 RDW-12.7 Plt Ct-225
[**2172-1-1**] 06:55AM BLOOD Glucose-222* UreaN-20 Creat-0.7 Na-138
K-4.2 Cl-101 HCO3-32 AnGap-9
[**2171-12-30**] 04:03AM BLOOD CK-MB-22* MB Indx-10.3* cTropnT-0.39*
[**2171-12-30**] 12:02PM BLOOD CK-MB-16* MB Indx-8.6* cTropnT-0.25*
[**2171-12-30**] 06:20PM BLOOD CK-MB-10 MB Indx-7.8* cTropnT-0.17*
.
Cardiac catheterization: [**12-29**]
1. Selected coronary angiography in this right dominant system
demonstrated 2 vessel coronary artery disease. The LMCA had no
angiographically apparent disease. The LAD had a 30-40% mid
vessel
stenosis slightly worsened from [**2164**]. The LCX in known to have
a
total flush occlusion. The mid RCA is diffulsely disease with an
80% in
stent restenosis and possible thrombus suggestive of very late
ISRS.
There is a focal 50% lesion at the distal RCA bifurcation
worsened from
[**2164**]. THE RPLV (very substantive vessel) stent placed in [**2164**]
is widely
patient.
2. Limited resting hemodynamics revealed a normotensive central
systemic
arterial pressure of 124/71 mm Hg.
3. Successful thrombectomy and PCI to the mRCA using 3.5x23mm
Promus
DES.
4. No complications.
FINAL DIAGNOSIS:
1. 2 vessel coronary artery disease with in stent restenosis of
RCA.
2. Successful PCI to the mRCA with Promus DES.
3. No complications.
.
ECHO [**12-30**]: preliminary only
Brief Hospital Course:
# Right coronary artery ST elevation myocardial infarction: S/P
RCA STEMI with succesful DES to site of in-stent thrombosis and
early resolution of EKG abnormalities. NO further chest pain,
CK's have downtrended. On BB, ACEi, statin, plavix and ASA. ECHO
with poor windows and no WMA, preserved EF on first read,
reviewed by Dr. [**Last Name (STitle) **] who felt there was an inferior wall motion
abnormality with EF 45%. Appears euvolemic. Plan to continue
clopidogrel for 1 year/month for DES and likely forever. NP and
SW saw pt for her history of medicaton non-complience. She is
able to afford her medicines, just stated she was "stubborn" and
didn't feel that she needed the medicine anymore. Her diabetes
regimen is also onerous to her and she wishes it could be
simplified. She states she now realizes that she needs to take
her medications daily.
.
# RHYTHM: SR, no VEA
.
# Hyperlipidemia- high dose atorvastatin for now, change back to
rosuvastatin at discharge because of her history of myalgias on
high dose statin. She has [**Last Name (un) **] tolerating 20 mg of rosuvastatin
so far.
.
# Diabetes mellitus- on glypizide and onglyza at home,
struggling to do fingersticks 4 times per day and take her meds.
Last A1c in [**11/2171**] was 10.5. Followed by Dr. [**Last Name (STitle) **] from [**Last Name (un) **]
in [**Location (un) 620**]. Her home PO meds were restarted at discharge and she
has a f/u appt with Dr. [**Last Name (STitle) **] at the end of the week.
.
Transitional issues:
1. VNA at home to monitor for medication compliance and to do
diabetic teaching
2. ASA and plavix for one year at least
3. F/U with Dr. [**Last Name (STitle) **] in 2 weeks.
4. VNA to check BP and HR on new lisinopril and metoprolol
Medications on Admission:
HOME MEDICATIONS: confirmed with [**Company 25795**]
1. Glipizide XL 10 mg daily
2. Onglyza 5 mg daily
3. Crestor 20 mg daily
4. Aspirin 81mg daily
5. Plavix 75mg daily (did not fill for one month)
6. Amytripiline- 25mg qHS
7. Omeprazole 20 mg daily
8. Hydrocodone/acetaminophen 7.5/750mg TID as needed
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
5. Onglyza 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*2*
9. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ST elevation myocardial infarction
Diabetes Mellitus type 2
Coronary artery disease
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at [**Hospital1 18**].
You had a heart attack that was caused by a clot in an earlier
stent from being off your plavix. The clot was removed and
another drug eluting stent was placed over the previous stent.
You will need to take a full aspirin (325mg) and Plavix 75 mg
every day for the next year and likely longer. Do not stop
taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] tells you to.
This is very important to prevent another heart attack or
possibly death. An echocardiogram showed that your heart
function is good.
.
We made the following changes to your medicines:
1. Increase aspirin to 325 mg for the next year
2. Continue Crestor at 20 mg daily
3. STOP taking omeprazole (prilosec), take ranitidine instead
for your heartburn
4. START lisinopril to lower your blood pressure
5. START metoprolol to lower your heart rate and help your heart
recover from the heart attack.
Followup Instructions:
Dr. [**Last Name (STitle) **] on Monday [**1-13**], the office will call you at home
with an appt.
Dr. [**Last Name (STitle) **] on Friday [**1-3**] as previously scheduled.
ICD9 Codes: 2724, 496, 3572, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2443
} | Medical Text: Admission Date: [**2126-1-24**] Discharge Date: [**2126-2-4**]
Service:
HISTORY OF THE PRESENT ILLNESS: This is a 79-year-old woman
admitted from [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **], where she has been living since
[**2125-9-20**] with acute respiratory distress, hypoxia with
oxygen saturation registered at 50% to 70%. In the Emergency
department, the patient was evaluated for hypoxia and perfuse
secretions per her trach. There were thick, yellow sections
suctioned. The oxygen saturation, following suctioning,
improved to 98% on room air and 100% on full trach mask. The
patient's trach was changed from cuff trach and she was
placed on the ventilator. Chest x-ray revealed right greater
than left infiltrate consistent with pneumonia. The patient
was so Levofloxacin and Vancomycin. Arterial line was placed
and the patient was transferred to the medical ICU.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft.
2. Aortic stenosis status post aortic valve replacement.
3. Hypertension.
4. Elevated cholesterol.
5. Diabetes mellitus.
6. Chronic renal insufficiency.
7. Depression.
8. History of cerebrovascular accident in [**2118**].
9. History of atrial fibrillation.
MEDICATIONS ON ADMISSION:
1. Lorazepam 0.25 mg p.o.q.d. and p.r.n.
2. Enteric coated aspirin 325 mg p.o.q.d.
3. Colace 100 mg p.o.q.d.
4. Effexor 50 mg q.a.m.; 25 mg q.p.m.
5. Levoxyl 150 mcg p.o.q.d.
6. Metoprolol 25 mg p.o.b.i.d.
7. Trazodone 50 mg p.o.q.h.s.
8. Nitroglycerin 0.4 mg sublingual p.r.n.
9. Pureed tube feeds per G tube.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: No alcohol, no smoking.
PHYSICAL EXAMINATION: Admission physical examination
revealed the following: VITAL SIGNS: 98.6, blood pressure
184/70, heart rate 83, oxygen saturation 99% on 100% trach
mask. The patient is alert and responsive to commands.
HEENT: Pupils equal, round, and reactive to light.
Extraocular muscles are intact. Sclerae anicteric.
Oropharynx clear. CARDIOVASCULAR: Regular rate and rhythm,
normal S1 and S2; 2/6 systolic ejection murmur appreciable at
the left upper sternal border. LUNGS: Lungs revealed
bilateral coarse rhonchi. ABDOMEN: Soft, nontender,
nondistended with active bowel sounds. EXTREMITIES: No
appreciable edema.
LABORATORY DATA: Admission laboratory studies revealed the
following: white blood count 19.4, hematocrit 42.5, platelet
count 223,000, sodium 126, chloride 95, bicarbonate 20, BUN
26, creatinine 1.2, and glucose 232. Initial blood gas
revealed the pH of 7.31, pCO2 55, pAO2 of 63 on 100%
nonrebreather. Chest x-ray revealed bilateral infiltrates
right greater than left, urinalysis negative.
HOSPITAL COURSE: (by system)
PULMONARY: The patient was admitted for respiratory distress
with copious-purulent secretions from the trach and evidence
of pneumonia by chest x-ray. The patient was afebrile, but
with elevated white blood count. The patient was treated for
a right-sided pneumonia, possibly aspiration in origin with a
ten-day course of Levaquin and Vancomycin. The patient was
treated with Vancomycin and given a history of Methicillin
resistant Staphylococcus aureus. Sputum cultures were
negative, except for evidence of oropharyngeal flora.
Bronchoalveolar lavage was performed on the second day of
admission, which revealed relatively normal-looking bronchi.
Lavage was positive for polys and gram-negative rods, which
turned out to be oropharyngeal flora. Legionella cultures,
fungal cultures, and RSV cultures were negative. Blood
cultures remained negative throughout this hospitalization
with the exception of one bottle, which grew out
Vancomycin-resistant Enterococcus thought to be contaminate
versus colonized as it was repeated and not reproducible.
The patient was evaluated by the Interventional Pulmonary
Service, namely Dr. [**Last Name (STitle) **], for trach, which had been placed
within the last year for the diagnosis of tracheomalacia
status post prolonged intubation for status post coronary
artery bypass graft. The patient had had a prior tracheal
stent placed, which had been discontinued and has since been
on a trach mask since that time with plans for a larger trach
versus repeat stenting. Bronchoscopy on this admission
revealed mild tracheitis, but otherwise, normal trachea. it
was thought that her problems with secretions and
intermittent tracheal obstruction were largely related to
supraglottic edema secondary to persistent regurgitation
versus chronic aspiration. Bronchoscopy revealed
supraglottic edema as noted. This had been confirmed to a
lesser extent by the patient's ENT physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
The patient was again evaluated by ENT during this
hospitalization and it was felt that her supraglottic edema
would ultimately resolve on a strict antireflux regimen with
strict anti-aspiration precautions and management of
secretions. Ultimately, one the supraglottic edema resolved,
it is thought that the patient may be able to have her trach
removed without need for a stent or more long-term trach
placement. The Interventional Pulmonary Service agreed. ENT
team, with Dr. [**Last Name (STitle) **], planned to see the patient again
prior to discharge to confirm long-range management plans.
The patient was started on b.i.d. Protonix IV and then
ultimately transitioned to Prevacid suspension b.i.d. through
the PEG tube.
CARDIOVASCULAR: The patient has a history of coronary artery
disease. She was continued on her aspirin and Lopressor.
Captopril was added and titrated up for blood pressure
control. This was thought to be especially important given
significant proteinuria noticed on urinalysis. The patient
also has an elevated protein:creatinine ratio. The patient
was intermittently hypertension throughout her
hospitalization at times to the 220s systolic, asymptomatic,
often in the setting of agitation and difficulty with the
trach. For the acute exacerbation she was treated with IV
Hydralazine. Following the placement of a new trach and
weaning from the vent, the patient's blood pressure did
improve, but remained consistently in the 150s to 160s
systolic. She was continued on her Lopressor and her ACE
inhibitor was gradually titrated up to control. Heart rate
in the 50s did not allow much room for titration of the beta
blocker.
INFECTIOUS DISEASE: In addition to the pneumonia noted
above, the patient was found to have Urinary tract infection
positive for yeast. She was treated with a seven-day course
of Fluconazole. As noted above, the patient had [**11-23**]
blood-culture bottles positive for Vancomycin-resistant
enterococcus. This was thought to be colonized, as it was
not replicable on repeat blood cultures. She was not treated
for this per se.
ENDOCRINOLOGY: The patient has a history of diabetes
mellitus with poorly controlled blood sugars. She was
initially maintained on just a regular insulin sliding scale.
She was later started on low-dose Glyburide with dramatic
improvement in her fingersticks.
NEUROLOGICAL: The patient had significantly depressed mental
status, poorly responsive for much of her MICU course,
ultimately deemed secondary to weaning from her sedatives.
She took a long time to awakened after being weaned off the
vent. Additional administration of Haldol and p.r.n.
narcotics perpetuated her depressed mental status. By the
time the patient was transferred to the floor, she was at her
baseline.
RENAL: The patient was noted to have proteinuria by
urinalysis and elevated protein:creatinine ratio. She was
started on an ACE inhibitor and should ideally have renal
followup at the time of discharge. This is attributable to
either hypertensive versus diabetic nephropathy versus other
etiology.
GASTROINTESTINAL: The patient was noted to have C. difficile
colitis. The patient was treated with a ten-day course of
Flagyl. She had persistently guaiac-positive loose stools.
This was thought to be secondary to GI bleed versus C.
difficile infection. Hematocrit gradually trended down, and
she was transfused two units of packed red blood cells to
which she responded appropriately. Hematocrit remained
stable for the remainder of her hospitalization. She should
be evaluated as an outpatient with a colonoscopy. The
primary care physician is aware of this.
PSYCHIATRY: The patient has history of depression treated
with Effexor at prior dose. The patient was noted to have
improved mood as per her family.
ACCESS: The patient had a right PIC placed for blood draws
and IV access.
PROPHYLAXIS: The patient was on Protonix and Pneumoboots
during this hospitalization.
COMMUNICATION: There were several family meetings held
during this hospitalization to keep the family up-to-date on
the progress of the interventions and long-term planning.
CODE STATUS: The patient was a full code.
Please see addendum to discharge summary for the remainder of
the hospital course following transfer to the medical floor,
as well as for long-term discharge planning and discharge
medications.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 1569**] 12-684
Dictated By:[**Last Name (NamePattern4) 97564**]
D: [**2126-2-4**] 16:40
T: [**2126-2-4**] 16:46
JOB#: [**Job Number 97565**]
ICD9 Codes: 5070, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2444
} | Medical Text: Admission Date: [**2189-3-24**] Discharge Date: [**2189-3-29**]
Date of Birth: [**2121-3-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
CP with exertion
Major Surgical or Invasive Procedure:
CABGx4
History of Present Illness:
67 M with increasing angina and pos nuclear stress. Referred to
cath - positive multivessel disease.
Past Medical History:
HTN
hyperlipidemia
T&A
Social History:
10 PY hx quit in [**2152**], social ETOH, lives with wife
Family History:
brother with CABG in 60's
Physical Exam:
AAOx3 NAD
RRR
CTAB
Sternum stable c/d/i
soft NT/ND
Pertinent Results:
[**2189-3-29**] 05:30AM BLOOD Hct-26.2*
[**2189-3-28**] 04:25AM BLOOD WBC-11.5* RBC-2.78* Hgb-8.9* Hct-25.8*
MCV-93 MCH-32.1* MCHC-34.5 RDW-13.3 Plt Ct-175
[**2189-3-25**] 02:12PM BLOOD PT-15.3* PTT-31.0 INR(PT)-1.4*
[**2189-3-28**] 04:25AM BLOOD Glucose-123* UreaN-21* Creat-1.0 Na-137
K-4.2 Cl-99 HCO3-29 AnGap-13
[**2189-3-24**] 06:08PM BLOOD ALT-32 AST-27 LD(LDH)-200 AlkPhos-72
TotBili-0.3
[**2189-3-24**] 06:08PM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE
[**2189-3-26**] 01:18PM BLOOD Glucose-116* K-3.6
Brief Hospital Course:
Pt underwent CABG x4 without complications. Chest tubes were
d/c'd POD1Wires were taken out [**3-28**]. POD1 he was sent to the
floor. He worked with PT and tolerated his diet being advanced.
He is in good condition for discharge.
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
Disp:*40 Packet(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*40 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Good
Discharge Instructions:
Please call or return if you have fevers >101, chest pain,
shortness of breath, or anything that causes you concern.
[**Last Name (NamePattern4) 2138**]p Instructions:
Call Dr. [**Last Name (Prefixes) **] for an appointment - [**Telephone/Fax (1) 170**]
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 170**] Follow-up
appointment should be in 1 month
Provider: [**Name10 (NameIs) 17010**] cardiologist Appointment should be in [**7-28**] days
Provider: [**Name10 (NameIs) 17010**] PCP [**Name9 (PRE) **] to schedule appointment
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2445
} | Medical Text: Admission Date: [**2113-3-29**] Discharge Date: [**2113-4-4**]
Service: MEDICINE
Allergies:
Iodine / Xylocaine / Nitroglycerin
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterizations: [**2113-3-30**] & [**2113-3-31**]
History of Present Illness:
85F with hypertrophic cardiomyopathy, paroxysmal atrial
fibrillation on amiodarone, reported EF of 32% who reports with
increasing substernal [**7-14**] chest pressure lasting 15 minutes to
hours with radiation to her neck, associated with palpitations,
exacerbated with movement, alleviated with rest. Patient reports
that she's had increasing chest pain over the past few months
who presents with increasing chest pain pver 5 days refusing to
go to the ED but came to Dr. [**Last Name (STitle) 1911**]??????s office on [**2113-3-29**].
He did blood tests and told her to go to the ED. She did not and
instead went home. The labs came back with a troponin of 2.28 so
he called her and had her come to [**Location (un) **] ED for transport to
our cath lab. Of note she had a nuclear stress test in [**12-10**] that
was reported as completely normal. Her EF was 32%.
.
Labs at [**Location (un) **]:
WBC 8.3 Hgb 14.9 Hct 42.5 Plt 180 INR 1.0 Calcium 8.9
Na 131 K 3.9 Cl 86 CO2 29 [**Name8 (MD) **] Crt CPK 173 MB 19.8 Index 11.2
Troponin 2.28
Past Medical History:
CAD
Hypertrophic cardiomyopathy
Paroxysmal atrial fibrillation
dermatomyositis
Social History:
Etoh neg Tob neg Illicits neg
Family History:
NC
Physical Exam:
VS: T:95.3 BP:68/41 HR:65 RR:18 O2:99% 2LNC
Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 2 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. II/VI SEM along precordium. No rubs or
gallops. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar crackles. No
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: bilateral lower extremity ecchymosis. No stasis
dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
Imaging:
C.CATH Study Date of [**2113-3-29**]
COMMENTS:
1. Coronary angiography of this left dominant system revealed
severe
single vessel coronary artery disease. The left main coronary
artery
had no angiographically apparent flow limiting stenoses. The
LAD had a
90% stenosis in the mid segment involving the bifurcation of the
first
major diagonal branch. The LCX was a large caliber dominant
artery and
had no angiographically apparent flow limiting stenoses. The
RCA was a
small caliber nondominant vessel with no angiographically
apparent flow
limiting stenoses.
2. Resting hemodynamics revealed low right sided filling
pressures
(mean RA pressure was 3 mm Hg and RVEDP was 4 mm Hg). Pulmonary
artery
pressures were normal (PA pressure was 30/11 mm Hg). Left sided
filling
pressures were normal (mean PCW pressure was 13 mm Hg).
Systemic
arterial pressure ranged from low to normal (aortic pressure
averaged
90/47 mm Hg). Cardiac output was low (CI was 2.1 L/min/m2).
Post
intervention and bolus administration normal saline, left sided
filling
pressures were slightly higher (mean PCW pressure was 14 mm Hg).
3. Successful PCI/stent to mid LAD/Diagonal bifurcation with a
3.0x23mm
Cypher stent deployed at 14atms. Excellent result with normal
flow and
no residual stenosis in both vessels. Patient left cathlab
painfree.
FINAL DIAGNOSIS:
1. Severe single vessel coronary artery disease.
2. Low right sided filling pressures and relatively low left
sided
filling pressures.
3. Successful rotation atherectomy, angioplasty, and stenting
with DES
of the mid LAD with rescue of the first diagonal branch.
.
CT PELVIS W/O CONTRAST [**2113-3-30**] 9:32 AM
IMPRESSION:
1. No evidence of retroperitoneal bleed but hematoma in right
groin in soft tissues at site of recent cath.
2. Heavy coronary artery and aortic calcifications.
3. Low-attenuation lesion in segment 3 of the liver which is too
small to characterize but may represent a cyst.
4. Minimal free fluid in the pelvis.
5. Catheter in situ in right common femoral artery and vein
.
CHEST (PORTABLE AP) [**2113-3-30**] 7:05 AM
IMPRESSION: Interval resolution of pulmonary edema and
effusions.
.
ECHO Study Date of [**2113-3-30**]
Conclusions:
The left atrium is mildly dilated. The estimated right atrial
pressure is
11-15mmHg. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Overall left ventricular systolic function is mildly depressed
(ejection fraction 40-50 percent) secondary to hypokinesis of
the interventricular septum and apex. There is a mild resting
left ventricular outflow tract obstruction. The gradient
increased with the Valsalva manuever. Right ventricular chamber
size and free wall motion are normal. There are focal
calcifications in the aortic arch. The aortic valve leaflets
(3) are mildly thickened. There is a minimally increased
gradient consistent with minimal aortic valve stenosis
(preacceleration of flow in the left ventricular outflow tract
may also be contributing to the elevated flow velocity across
the aortic valve). No aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. There is severe mitral
annular calcification. There is a minimally increased gradient
consistent with trivial mitral stenosis. Moderate to severe
(3+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly
UNDERestimated.] There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There is an anterior space which most likely
represents a fat pad.
Impression:
1. septal and apical hypokinesis
2. left ventricular hypertrophy
3. Mild-to-moderate left ventricular outflow tract obstruction
4. Minimal mitral stenosis (from severe annular calcification)
5. At least moderate-to-severe mitral regurgitation
6. Possible minimal aortic stenosis
.
C.CATH Study Date of [**2113-3-31**]
COMMENTS:
1. Patent mid LAD stent.
2. Diagonal branch has no significant stenosis
3. Normal dominant LCX and RCA
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Patent mid LAD stent with no major stenosis in diagonal side
branch.
.
ECHO Study Date of [**2113-3-31**]
Conclusions:
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with hypokinesis of basal and
mid-anterior septum. Right ventricular chamber size and free
wall motion are normal. Mild (1+) aortic regurgitation is seen.
There is severe mitral annular calcification. Moderate to
severe (3+) mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Focused study, showing mild regional left
ventricular systolic dysfunction. Mild aortic regurgitation.
Moderate-to-severe mitral regurgitation.
.
CHEST (PA & LAT) [**2113-4-1**] 6:13 PM
IMPRESSION: New small bilateral pleural effusions with adjacent
basilar atelectasis.
.
FEMORAL VASCULAR US RIGHT [**2113-4-1**] 2:01 PM
IMPRESSION: No evidence of AV fistula, pseudoaneurysm, or large
hematoma.
.
Micro:
[**2113-4-1**]
Sputum Cx: no growth
[**4-3**]
Urine Cx: pending
.
Admission Labs:
[**2113-3-29**] 06:29PM O2 SAT-98
[**2113-3-29**] 06:29PM NA+-121* K+-2.8*
[**2113-3-29**] 06:29PM TYPE-ART PO2-152* PCO2-39 PH-7.43 TOTAL
CO2-27 BASE XS-2 INTUBATED-NOT INTUBA
[**2113-3-29**] 07:25PM CALCIUM-7.0* PHOSPHATE-4.2 MAGNESIUM-1.7
[**2113-3-29**] 07:25PM estGFR-Using this
[**2113-3-29**] 07:25PM GLUCOSE-154* UREA N-17 CREAT-0.9 SODIUM-123*
POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-24 ANION GAP-13
[**2113-3-29**] 08:31PM PT-12.8 PTT-150* INR(PT)-1.1
[**2113-3-29**] 08:31PM PLT COUNT-159
[**2113-3-29**] 08:31PM WBC-6.6 RBC-3.83* HGB-13.1 HCT-38.1 MCV-99*
MCH-34.3* MCHC-34.5 RDW-16.6*
[**2113-3-29**] 08:31PM URINE OSMOLAL-233
[**2113-3-29**] 08:31PM URINE HOURS-RANDOM CREAT-6 SODIUM-47
[**2113-3-29**] 08:31PM FREE T4-1.5
[**2113-3-29**] 08:31PM TSH-0.34
[**2113-3-29**] 08:31PM OSMOLAL-281
[**2113-3-29**] 08:31PM ALBUMIN-2.9* CALCIUM-6.8* PHOSPHATE-4.1
MAGNESIUM-1.6
[**2113-3-29**] 08:31PM CK-MB-22* MB INDX-10.0*
[**2113-3-29**] 08:31PM CK(CPK)-219*
[**2113-3-29**] 08:31PM GLUCOSE-175* UREA N-15 CREAT-0.9 SODIUM-126*
POTASSIUM-3.1* CHLORIDE-94* TOTAL CO2-19* ANION GAP-16
[**2113-3-29**] 10:07PM URINE RBC-[**2-6**]* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2113-3-29**] 10:07PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2113-3-29**] 10:07PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.030
[**2113-3-29**] 11:30PM UREA N-15 CREAT-0.8 SODIUM-133 POTASSIUM-4.8
Brief Hospital Course:
Pt is a 85F with NSTEMI s/p catheterization and DES to LAD,
with subsequent hypotension, transiently on pressors, currently
normotensive without support.
.
#) CAD: Patient with diagnosed CAD, s/p Cypher stent to mid-LAD.
Pateint underwent repeat cardiac catheterization on [**3-31**] in the
setting of chest pain,. Probability of instent thrombosis was
low and cath revealed patent mid-LAD cypher stent. Patient
never had EKG changes. Patient also had US or R groin given a
new bruit, although, as reported above, there was no evidence of
fistula or aneurysm. The patient was continued on ASA & Plavix,
and had daily EKG without changes. She had episodic bouts of
chest pain without EKG changes and it was thought that these
this pain was no ischemic. She was not given nitrates in the
setting of mild HCM, and this pain responded well to low dose
opiates.
.
#). Chest Pain: Patient with transient chest pain,
nonpositional, nonpleuritic, not associated with SOB, and
temporally associated with food intake. Probability of ischemia
is low, recent re-cath negative, EKGs without significant
changes. Patient may have an esophageal component of chest pain.
Ddx includes DES, Zenker's diverticulum, GERD. Other less likely
etiologies include Boerhaave's/MWT, Schatzki's ring. Patient
has been CP free for over 24 hours and may benefit from an
outpatient workup for possible GI relates issues.
.
#) Pump: Given Right heart catheterization, patient presented
hypovolemic and is also hypotensive. Patient with known HCM and
the best BP support for her was fluids. She was also transiently
on neosynephrine to which she responded well. She received
aggressive volume support and had mild pulmonary edema, that of
which she autodiuresed well. Her diuretics were held and these
were not restarted upon discharge. She was hoever, started on
Toprol XL.
.
.#) Rhythm: hx of pAF, although not on Coumadin given prior hx
of bleeding risk. Patient has hx of cardioversion in 2/[**2111**].
Patient was continue on Amiodarone 200 qd and monitored on
telemetry without event.
.
#)UTI- Patient with urinary symptoms, and was started
empirically on Bactrim for a 3 day course.
.
#) Dermatomysositis:
- Continue Prednisone 2.5 mg po qd
Medications on Admission:
Prednisone 2.5 mg daily LD this am
Methotrexate weekly LD [**2113-3-21**]
Amiodarone 200 mg daily LD this am
Fosamax weekly LD was Sunday [**3-26**]
Aldactazide 2.5/25 mg daily LD this am
ASA 325 mg @ 12:40pm today
Benadryl 50 mg po @ 12:40 pm today
Zantac 150 mg po @ 12:40 pm today
Solumedrol 60 mg IV @ 12:40 am today
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*3*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 10 days.
Disp:*10 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
12. Omeprazole 20 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:*2*
13. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 0.5
Tablet Sustained Release 24 hr PO once a day for 10 days.
Disp:*5 Tablet Sustained Release 24 hr(s)* Refills:*0*
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Primary Diagnosis: Myocardial Infarction
.
Secondary Diagnoses:
Hypertrophic cardiomyopathy
Paroxysmal atrial fibrillation S/P DCCV in [**1-/2112**]
CHF
Dermatomyosistis diagnosed [**2107**] - on MTX/Prednisone
Osteoporosis
Cataracts
Discharge Condition:
Afebrile, stable vital signs, tolerating POs, ambulating without
assistance.
Discharge Instructions:
You were admitted for treatment of a heart attack. You had a
stent placed into one of the main arteries of your heart. You
also had low blood pressure that was treated with fluid
hydration.
.
1. Please take all medication as prescribed.
2. Please attempt to make all medical appointments.
3. Please return to the Emergency Room if you have any
concerning symptoms.
Followup Instructions:
Please call your PCP: [**Last Name (LF) 32375**],[**First Name3 (LF) 2801**] M. [**Telephone/Fax (1) 32376**]
.
Please call [**Doctor First Name **] [**Doctor Last Name 1911**] for a follow-up appointment
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2113-5-19**] 3:40
Completed by:[**2113-4-4**]
ICD9 Codes: 4254, 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2446
} | Medical Text: Admission Date: [**2171-10-18**] Discharge Date: [**2171-10-26**]
Date of Birth: [**2109-4-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
right shoulder - pain- RUL lung tumor for excision s/p
chemotherapy and radiation
Major Surgical or Invasive Procedure:
Right posterior and lateral thoracotomy, right upper
lobectomy with en bloc chest wall resection of ribs 2 and
3.
2. Right cervical incision with scalene fat pad and lymph
node resection as well as mobilization of superior sulcus
tumor off of 1st rib and division of the 2nd rib
anteriorly.
3. Thoracic lymphadenectomy.
4. Flexible bronchoscopy.
History of Present Illness:
62-year-old woman who developed right shoulder pain and was
found to have a large right upper lobe tumor invading into the
2nd and 3rd ribs and abutting up against the 1st rib. She
underwent cervical mediastinoscopy as well as peripheral
metastatic workup. There were no positive lymph nodes and no
metastasis. She underwent induction of chemoradiotherapy to
shrink the tumor away from the subclavian artery and subclavian
vein as well as the brachial plexus. She has been restaged and
was found to have excellent response. We, therefore, took her
forward for a resection of the superior sulcus tumor. Our plan
was to biopsy the scalene fat pad and lymph nodes and if there
is no evidence of tumor to move on to mobilize the superior
sulcus tumor from the cervical incision, including division of
ribs as necessary. We would then move on to a posterolateral
thoracotomy for completion of the procedure.
Past Medical History:
Gastric esophogeal reflux disease, Coronary artery disease,
diabetes type 2, chronic obstructive pulmonary disease, Non
small cell lung cancer s/p chemotherapy and radiation.
Social History:
lives at home, has many family members nearby.
[**Name2 (NI) **] in past
Physical Exam:
General-Elderly female NAD
Resp- Course diminished BS throughout- baseline
Cor-RRR
Abd- Sl distended, NT, + BS,
Ext- no edema
Neuro- fully intact, no R sided deficits
Skin- anterior and posterior thorax incisions. Staples removed,
incision clean and dry.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2171-10-25**] 06:10AM 8.9 3.15* 9.9* 29.0* 92 31.4 34.1 15.4
289
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2171-10-26**] 09:20AM 13.4* 27.9 1.2
INHIBITORS & ANTICOAGULANTS LMWH
[**2171-10-26**] 11:10AM 0.781
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2171-10-25**] 06:10AM 145* 12 0.5 137 4.4 97 311 13
1 NOTE UPDATED REFERENCE RANGE AS OF [**2171-6-21**]
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2171-10-23**] 04:50PM 128
[**2171-10-23**] 03:48PM 115
[**2171-10-23**] 09:30AM 148*
CPK ISOENZYMES CK-MB cTropnT
[**2171-10-23**] 04:50PM 2
[**2171-10-23**] 03:48PM 1
[**2171-10-23**] 09:30AM 2 <0.011
1 <0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2171-10-25**] 06:10AM 8.4 4.2 2.0
RADIOLOGY Final Report
CHEST (PA & LAT) [**2171-10-24**] 11:29 AM
Reason: eval for PTX
[**Hospital 93**] MEDICAL CONDITION:
62 year old woman with lung CA post CT pull
REASON FOR THIS EXAMINATION:
eval for PTX
HISTORY: 62-year-old woman with lung cancer status post surgical
resection. Please evaluate for pneumothorax.
TECHNIQUE: PA and lateral views of the chest were obtained and
compared to [**2171-10-22**].
FINDINGS: There has been interval removal of two right apical
chest tubes. No definite pneumothorax identified. There are
post-surgical changes at the right apex including signs of
volume loss of the right hemithorax with persistent elevation of
the right hemidiaphragm and mediastinal shift to the right.
Again noted are multiple surgical rib defects at the right apex.
The right lung base and the left lung are grossly clear. Heart
size and cardiomediastinal contours are stable given differences
and patient rotation.
IMPRESSION: Interval removal of right apical pleural drains. No
definite pneumothorax. Surgical changes at the right apex with
associated volume loss of the right hemithorax.
Brief Hospital Course:
Pt was admitted on [**2171-10-18**] for ecxision of Pancoast tumor in
RUL. Pain control w/ epidrual is at T6/T7 14/5. She is split
receiving both bupivicaine .1% thru epidural and dilaudid PCA
because she has a wide incision on multiple dermatomes and a
neck incision. She was supported w/ low dose neo while on
epidural. Briefly intubated in ICU and, successfully extubated.
POD#2 AFIB despite IV lopressor. Treated w/ IV amiodarone bolus,
gtt, 2nd bolus and 2 doses of diltiazem. Pain control w/
Epidural- bupivicaine + Dil PCA. 2 chest tubes to suction.
Activity OOB > chair, PT, IS.
POD#3 Transition to po amiodarone w/ recurrent Afib alt w/ NSR.
Re-bolused amiodarone iv and placed back on gtt. Lopressor cont
po. CT 1&2 to water seal w/o ptx. Drainage #1<200cc and d/c w/o
complication, #2 remained to w/s w/ moderate drainage. Incision
anterior and posterior clean and dry, staples intact.
POD#4-Amiod po started, lopressor ^50mgBID. Overnight pt had
episodes of HR 40 SB-150 Afib, treated with IV lopresssor and
Dilt IV with fair rate control. Cardiology consulted.Lopressor
[**Month (only) **]'d 25 [**Hospital1 **].NSR resumed during day. CT #2 d/c w/o complication.
PT, IS, ambulation cont w/ high compliance. BS course, very good
airation. Inhalers cont. Remains on [**12-23**] L O2. Pt R/O'd for MI by
enzymes and EKG.
POD#5- Per Cardiology rec- Amiod 400 BIDpo; Epid d/c, PCA cont.
Lovenox started for anticoagulation in setting of intermittent
Afib post epidural d/c. Evidence of left antecubital
phlebitis(red, swollen, min discomfort) at old IV site present,
Keflex po x10 days started, warm soaks locally w/ small
improvement. Chest tube drainge moderate from CT site. Dressing
changed prn.
POD#6-Remains NSR on Amiod [**Hospital1 **]; PCA weaned, PO Dilaudid started
w/ fair effect. Coumadin 5mg dose #1 @1800. Activity/IS
compliance excellent. Staples removed and steri-strips applied.
Incision- no erythema, small amount serous drainage superior
posterior incision. BS course- good airation, inhalers cont. O2
weaned to off w/ good sat at rest and w/ ambulation- 95%RA.
POD#7- Cont in NSR,Amiod 400BIDpo, lopresor increased to 50 [**Hospital1 **],
restart Imdur 30 mg (1/2 dose), lisinopril 2.5 mg ([**12-25**] daily
dose); Coumadin 5mg dose #2 @1800, lovenox ocnt. Pain med
changed to percocet w/ very good effect. BM- occurred. Plan for
discharge in am POD#8.
Discharge plans arranged for anticoagulation follow-up with: VNA
for blood draw and post op nursing care, Cardiology clinic short
term, then [**Company 191**] coumadin clinic as of [**2171-12-3**]. Follow-up
appointments w/ [**Company 191**] [**10-31**], Cardiology [**11-5**] made. PCP, [**Name10 (NameIs) **]
NP, Cardiology NP and Cardiologist informed of plans.Discharge
instructions, new medication regimen and instructions reviewed
with patient
POD#8-Patient discharged to home in stable condition in company
of family. Discharge instructions given and reviewed w/ patient
and family.
Medications on Admission:
ALBUTEROL 90, ATIVAN 1"PRN, ATROVENT, AZMACORT, ecASA 325',
HUMULIN 70/30 36qam, HUMULIN N 100 20-22qhs, HUMULIN R 100
10-12QDINNER, IMDUR 60', LIPITOR 10', LISINOPRIL 5", METFORMIN
850 TT/T, METOPROLOL 100", SLNG 300 MCG (1/200 GR), PROTONIX
40MG'
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
[**Hospital1 **] (2 times a day).
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)): and 1 pill at bedtime .
Disp:*90 Tablet(s)* Refills:*1*
14. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
16. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
18. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: as
directed.
Disp:*30 Tablet(s)* Refills:*1*
19. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: as
directed.
Disp:*60 Tablet(s)* Refills:*0*
20. hospital bed semi electric
lung cancer s/p chemotherapy, radiation, RUL pancoast tumor
excision.
coronary artery disease, COPD, DM2, GERD
Positioning-pt unable to lie flat while sleeping.
21. overnight pulse oximetry on room air
for oxygenation evaluation at night
22. Enoxaparin 60 mg/0.6mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 4 days.
Disp:*8 syringe* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Gastric esophogeal reflux disease, Coronary artery disease,
diabetes type 2, chronic obstructive pulmonary disease, Non
small cell lung cancer s/p chemotherapy and radiation.
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 1816**] office for: fever, shortness of breath, chest
pain, redness drainage from incision site.
Take medication as directed on discharge. Your medications and
dosages have changed.
Coumadin dosage Sat [**10-26**] =5mg; Sunday [**10-26**] 2.5mg. No dose on
Monday [**10-28**] until called by Cardiology NP. If she has not called
by 3pm, call her at[**Telephone/Fax (1) 14926**].
Take pain medication as directed. No driving until off narcotic
pain medication.
You will be followed by [**Company **]--[**Telephone/Fax (1) 24704**]-- who
will draw your blood for coumadin level and call/fax result to
Cardiology clinic at [**Hospital1 18**] -[**Telephone/Fax (1) 127**] phone; [**Telephone/Fax (1) 14926**]
fax. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 496**]/ [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Nurse Practitioners will be
following you there until you will be followed by [**Hospital 197**]
Clinic in [**Hospital6 733**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24705**] office.
You may shower Sunday [**10-27**], remove dressing and replace with
bandaid as needed after showering.
Followup Instructions:
Call Dr.[**Name (NI) 1816**]/Thoracic office for an appointment in [**12-23**]
weeks- [**Telephone/Fax (1) 170**].[**Hospital Ward Name 23**] Clinical Center [**Location (un) **].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**] [**Hospital Ward Name 23**]
clinical Center 7 th floor Date/Time:[**2171-11-5**] 3:45
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] appointment [**10-31**] at 5pm. You can
call [**Doctor First Name **] to reschedule as needed.
[**Hospital Ward Name 23**] clinical Center [**Location (un) **]
An you have a previously scheduled appointment on [**2171-12-10**]
@10:20am
Completed by:[**2171-10-29**]
ICD9 Codes: 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2447
} | Medical Text: Admission Date: [**2113-9-25**] Discharge Date: [**2113-10-1**]
Service: [**Hospital Unit Name 196**]/CCU
HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with a history of coronary artery disease with two-vessel
disease on [**7-3**] who had a catheterization that showed total
occlusion of the right coronary artery and 50% left anterior
descending without percutaneous intervention, history of
hypertension, insulin-dependent diabetes, who presented with
the acute onset of progressively worsening substernal chest
pain radiating to her right arm, throat, teeth and back.
She also complained of abdominal pain that followed the chest
pain. She denied nausea, vomiting and diaphoresis. She
reported that the pain was 8 out of 10 and was associated
with shortness of breath and radiation as above similar to
the episode in [**2112-7-2**] prior to her catheterization.
She has had no recent changes in her exercise tolerance. She
denied paroxysmal nocturnal dyspnea. She did report
orthopnea, and she did report increasing lower extremity
edema.
In the Emergency Room was started on a Nitroglycerin drip,
Lopressor, 2 mg Morphine x 2 with resulting decrease in her blood
pressure and resolution of her chest pain.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post myocardial infarction in [**2112-7-2**], status post
catheterization in [**2112-8-1**] with total occlusion of the
right coronary artery with collaterals and 50% left anterior
descending; no percutaneous intervention was done; ejection
fraction of 30-40%; equivocal stress test in [**2112-12-2**].
2. Hypertension. 3. Diabetes mellitus, Insulin dependent.
4. Elevated lipids. 5. Status post left carotid
endarterectomy.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Lipitor 10 mg q.d., Toprol XL 25
mg q.d., Levaquin discontinued, Lisinopril 5 mg q.d.,
Isordil/Imdur, Lasix, Doxycin, Folate, NPH 100 q.a.m., 100
q.p.m. with Humalog sliding scale, p.r.n. Darvocet, Aspirin.
FAMILY HISTORY: Father with myocardial infarction at age 60.
SOCIAL HISTORY: No tobacco; he quit 30 years ago. No
alcohol.
PHYSICAL EXAMINATION: Vital signs: The patient was
afebrile, blood pressure [**Telephone/Fax (3) 109323**]/80-150/70 in the
Emergency Department, heart rate 100, respirations 16, oxygen
saturation 98% on 2 L. General: The patient was in no
apparent distress. He was alert and oriented times three.
Obese. HEENT: Oropharynx clear. Moist mucous membranes.
Chest: Clear to auscultation bilaterally. Cardiovascular:
regular rhythm. No rubs or gallops. There was a 2 out of 6
systolic murmur at the left upper sternal border. JVP at 10
cm. Abdomen: He had positive right upper quadrant
tenderness. No guarding. No rebound tenderness. He had
decreased bowel sounds diffusely. No hepatosplenomegaly. No
chest wall tenderness. Extremities: He had 1+ edema. No
rash. Rectal: Guaiac negative stool.
LABORATORY DATA: White count 9.2, hematocrit 30.7, platelet
count 284; potassium 5.3, bicarb 21, acetone negative,
troponin 0.05, CK 106, MB 5, second set troponin 0.31, MB 16,
CK 181.
Electrocardiogram normal sinus rhythm at 70 beats per minute,
3-[**Street Address(2) 109324**] depressions in V3-V5, leads I, II and
AVL, normal axis.
CT of the chest showed diffuse aortic atheromatous disease,
no PE, no abdominal aortic aneurysm, no dissection.
Dense left anterior descending, right coronary artery
calcifications, mural thrombus in the aortic arch, question
of small intimal flap, no PE.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Medicine Service initially.
1. Coronary artery disease: The patient had improved, diffuse
downsloping ST depressions after heart rate and blood pressure
went down with elimination of chest pain. This was concerning
for coronary ischemia, especially in a patient with known two-
vessel disease on catheterization in [**2112-7-2**], who was
hypertensive and diabetic with positive cardiac biomarkers.
She was treated with Aspirin, Lipitor, Heparin drip,
Nitroglycerin and Integrilin with a plan for early cardiac
catheterization and possible percutaneous intervention. She was
placed on telemetry for.
However, given the concern for a possible intimal flap on the
aorta, MRI was planned to clarify the issue of early
dissection flap in the aorta; however, the study could not be
completed, and the patient was sent back to the floor where she
had some episodes of nausea, tiredness and frustration after
awaiting all day for this test. She described some back pain,
and Morphine was prescribed.
The Cardiology fellow spoke with the patient, and the patient
clearly said that she did not want to go back for completion of
her MRI and that she was consistent and understood the
consequences including myocardial infarction or death. She
was very adamant about this, and it was decided to respect her
wishes, since she seemed to be mentating normally at the time and
understood the consequences of her decision.
The plan was to do an early morning MRI to definitively rule
out dissection flap which would then allowing cardiac
catheterization and full adjunctive anticoagulation if
necessary.
The medical intern at the time had again spoken with the patient
regarding the risks of refusing MRI, and the patient was
aware of the possibility of aortic dissection and the risk of
hemorrhage and death. She had capacity for decision
making at the time. Plan was for MRI in the morning.
At around midnight that night, the patient suffered an
asystolic, PEA, ventricular fibrillatory arrest which required
intubation and chest compressions. The patient was
noted to be posturing at the time. She was resuscitated using
ACLS protocol and sent to the CCU Cardiology fellow spoke with
the sister regarding this situation, and the patient was
transferred to the CCU Service. Her care was transferred at this
point to Dr. [**Last Name (STitle) 911**] and the CCU team.
In the CCU, the patient was ventilated and hemodynamically
monitored. During the day, the patient was transfused with packed
red blood cells for a hematocrit of 28.5, both for better
oxygenation carrying capacity, as well as precatheterization.
2. Cardiovascular: We continued Aspirin and increased her
beta-blocker, titrated to a goal heart rate of 60s. We
continued Aspirin and statin and oxygen. Her blood pressure
medication was changed to Hydralazine from ACE inhibitor
since she was not tolerating any p.o., and we continued to
follow her peak CKs.
The patient remained hemodynamically stable during her hospital
course in the CCU with no evidence of recurrent hemodynamically
significant arrhythmia. No difference in blood pressures was
noted in both arms. Because of continued hemodynamic stability
without clinical evidence of propagating aortic dissection,
investigation of possible aortic dissection was not undertaken
until her neurologic prognosis was determined.
3. Myocardial: Her ejection fraction was 20-30%, and she
was given appropriate afterload reduction.
4. Conduction: She had a history of asystole, question of
ventricular fibrillation. There appeared to be a stable
rhythm. She continued to be monitored on telemetry.
5. Respiratory: The patient was placed on AC ventilation. The
plan was to decrease her FIO2 and hope for improvement of her
ventilation; however, it was noted that in reducing support, she
had no spontaneous respirations on the ventilator.
6. Renal: The patient's creatinine increased moderately
after her arrest. Urinalysis exam showed muddy brown casts and
consistent with acute tubular necrosis due to transient ischemia
after the arrest. We followed her urine output and minimized
nephrotoxic agents and repleted her potassium. The creatinine
stabilized at 2.4 which was consistent with previous baseline
values.
7. Infectious disease: The patient had a urinary tract
infection, and she was treated with Levofloxacin. Urine
cultures were pending at the time.
8. Gastrointestinal: The patient had elevations in her liver
function transaminases and had initial bilious emesis, although
not consistent with cholestatic picture. The patient had no
obvious abdominal tenderness during her stay in the CCU. Her
statin was discontinued. We considered right upper quadrant
ultrasound. The suspected diagonosis was shock liver due to
asystolic event and she was managed conservatively and enzymes
began to decrease.
9. Prophylaxis: The patient was maintained on pneumoboots for
DVT prophylaxis. Protime pump inhibitor was given for GI
prophylaxis and Tylenol for fever.
10. Access: The patient had a left subclavian.
11. Neurological: Given the fact that the patient was
posturing and may have suffered a significant amount of time
without circulation, Neurology was consulted regarding the
management of this patient. The impression was that the patient
had suffered anoxic encephalopathy with a guarded prognosis.
An EEG to assess higher cortical functions was performed to
rule out any suspect on nonconvulsive status after the
anoxia. EEG was performed that showed diffuse encephalopathy
with minimal brainstem responses. A head CT was also
performed which showed loss of [**Doctor Last Name 352**] white matter, border
differentiation and severe edema with no focal area of
new infarction.
Repeat EEG was done with the sedation in hopes that he had an
improved examination, but this was still consistent with
diffuse encephalopathy and minimal brainstem responses.
Neurology reported that according to accepted criteria, the
patient's hope of significant neurologic recovery at one year was
minimal. Given the grim prognosis, a discussion was made with the
attending, Dr. [**Last Name (STitle) 911**], in the CCU regarding the EEG and Neurology
consultants regarding the prognosis for recovery.
A family meeting was called, and the decision was made that
the patient should have no further resuscitation measures.
On [**9-29**], the decision was made to make the patient
comfort measures only with a Morphine drip intravenously
started and ventilatory support weaned off. Intravenous
antibiotics and blood pressure medications were discontinued
at that time.
On [**10-1**] at approximately 4:45 a.m., the intern was
called to pronounce the patient's death. Given the fact that
she was on the Morphine drip, on arrival the patient was
warm. She had nonreactive pupils and no spontaneous
movement, no heart sounds for two minutes, no breath sounds
for two minutes, and no response to noxious stimuli, at which
point the patient's family was informed of her death. The
time of death was recorded as 0445.
The attending was [**Name (NI) 653**], and the patient's family refused
the postmortem examination.
Communication: With the patient's family, including sister,
brother-in-law and son.
DISPOSITION: The patient expired on [**2113-10-1**], at 4:45
a.m.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Last Name (NamePattern1) 5227**]
MEDQUIST36
D: [**2113-11-7**] 13:41
T: [**2113-11-7**] 13:57
JOB#: [**Job Number 109325**]
ICD9 Codes: 5845, 4275, 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2448
} | Medical Text: Admission Date: [**2166-12-29**] Discharge Date: [**2167-1-2**]
Service: CCU
HISTORY OF THE PRESENT ILLNESS: The patient is an
83-year-old female with COPD, atrial fibrillation, CHF, and
aortic stenosis who has had progressive worsening of her
shortness of breath. Previous evaluation by echocardiogram
at an outside hospital revealed worsening of her aortic valve
stenosis and mitral regurgitation. The patient was referred to
[**Hospital1 18**] for possible aortic valve replacement.
On[**Last Name (STitle) 53680**]ate of admission, a TEE was performed which showed an
aortic valve area of 0.8 as well as no evidence of mitral valve
regurgitation. Given these findings, Dr. [**Last Name (Prefixes) **], the
cardiothoracic surgeon, felt that further investigation of her
dypnea was preferable since the aortic stenosis may not have
been the primary culprit in her symptoms. A valvuloplasty was
considered as a diagnostic tool and the surgery was postponed.
The patient was transferred to the CCU Service for medical
management and work-up.
PAST MEDICAL HISTORY:
1. COPD.
2. CHF with an ejection fraction of 35%.
3. Atrial fibrillation.
4. Aortic stenosis.
5. Osteoporosis.
6. Osteoarthritis.
7. GERD.
8. Esophageal spasm, status post esophageal dilation.
PAST SURGICAL HISTORY:
1. Pacemaker in [**2165-12-6**].
2. Hip arthroplasty.
3. Hernia repair.
4. Hysterectomy.
ADMISSION MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Prilosec 20 mg p.o. q.d.
3. Actonel 35 mg p.o. q. weekly.
4. Lasix 40 mg p.o. q.d.
5. Clonazepam 0.25 mg p.o. b.i.d.
6. Amiodarone 200 mg p.o. q.d.
7. Prednisone 2.5 mg p.o. q.d.
8. Mirapex 0.125 mg p.o. b.i.d.
9. Calcium carbonate.
10. Vitamin D.
11. Senna.
ALLERGIES: The patient is allergic to morphine, methadone,
Percocet, Darvocet, Albuterol, penicillin, and ampicillin.
SOCIAL HISTORY: The patient lives in [**Hospital3 **]. Her
two daughters are very involved in her care. She denied a
history of smoking. She denied a history of a history of
alcohol use.
FAMILY HISTORY: Her mother died from heart disease.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Afebrile
with a blood pressure of 118/67, heart rate 77, respiratory
rate of 20, oxygen saturation 99% on face mask following
extubation. The physical examination is notable for labored
breathing but no accessory muscle use. There are no crackles
or wheezes on examination. The patient has a III/VI systolic
ejection murmur heard throughout the precordium. There is no
lower extremity edema.
HOSPITAL COURSE: 1. AORTIC STENOSIS: The patient was
recently discharged from [**Hospital1 18**] approximately a month prior to
admission following cardiac catheterization. At that time,
she was found to have an aortic valve area of 0.9 with a
cardiac index of 3.1 and a peak gradient of 31. In the
interim since her discharge, the patient had an outpatient
echocardiogram at an outside hospital. At that time, it was
felt that her aortic valve area had worsened to 0.6 and that
there was also evidence of mitral valve regurgitation. The
patient was referred by her primary cardiologist for aortic
valve and mitral valve replacement.
On the date of admission, the patient was taken to the
Operating Room. A transesophageal echocardiogram was
performed prior to the procedure. It showed an aortic valve
area of 0.8 and no evidence of mitral valve regurgitation.
On the following day, the patient was taken to cardiac
catheterization for repeat evaulation and standby valvuloplasty.
She was found to have a cardiac output of 5.14 and a cardiac
index of 3.61. Her aortic valve area was measured at 0.8 with an
area index of 0.53. The aortic valve gradient was 43.14. The
patient had normal filling pressures. Due to these findings,
namely her relatively preserved cardiac output and normal
filling pressures, it was decided not to perform valvuloplasty on
the patient. It was felt that her aortic stenosis was not severe
enough to explain her dyspnea in isolation.
Of note, an echocardiogram done on the day of cardiac
catheterization showed [**First Name8 (NamePattern2) **] [**Location (un) 109**] initially of 0.4 cm. Upon review,
it was noted that the MR jet was eccentric and was
overestimating the stenosis and gradient.
2. ATRIAL FIBRILLATION: The patient has a history of atrial
fibrillation. She had a pacemaker placed in [**2165-12-6**]. Multiple EKGs showed a V-paced rhythm. She was
continued on her home dose of Amiodarone as well as aspirin.
The patient experienced no episodes of atrial fibrillation
during the hospitalization.
3. CONGESTIVE HEART FAILURE: The patient has a history of
congestive heart failure with an ejection fraction of 38%.
The patient was started on a low-dose of an ACE inhibitor
which she tolerated well. Her systolic blood pressures
remained stable in the low 100s. She was also restarted on
her home dose of Lasix 40 mg p.o. q.d. prior to discharge.
4. PULMONARY: Since it was not felt that her pulmonary
symptoms could be entirely explained by her aortic stenosis,
a pulmonary consult was obtained. According to the patient's
primary pulmonologist, Dr. [**Last Name (STitle) 36953**], the patient has a history
of a mild obstructive picture. Dr. [**Last Name (STitle) 36953**] had performed a
thorough pulmonary workup in the past including PFTs and
chest CT. Although unusual considering the patient has no
smoking history, the patient's picture most likely fits COPD.
During the hospitalization, pulmonary function tests were
obtained which revealed a FEV1 of 540 cc (41% predicted), an
FVC of 0.98 liters (47% predicted), and an FEV1/FVC ratio of
86% predicted. Her lung volumes were also decreased. Her
total lung capacity was 2.47 (65% predicted). Her DLCO was
also decreased at 4.16 (28% predicted). The patient was found
to have no desaturations on ambulation with a good pulse ox
[**Location (un) 1131**].
A chest CT was obtained which showed mild emphysematous
changes but no evidence of interstitial disease or
bronchiectasis. She also had a focal ground glass opacity in
the right lung apex as well as small branching opacity of the
right lower lobe consistent with a focal mucoid impactation
or focal atelectasis. The ground glass opacity is of unknown
significance.
Pulmonary consult was asked to comment on the findings. They
felt that the results were consistent with a moderate to
severe restrictive pattern secondary to her severe
kyphoscoliosis and possibly in part from her cardiomegaly
although the percent predicted was not that impression given
the patient's age and size. They felt that the decrement was
likely very significant. However, they were not able to
offer any therapy for her chest wall deformity. The DLCO
decrement was felt to correct for lung volume and they were
reassured that the patient did not desaturate during
ambulation. Pulmonary consult felt that possible etiologies
for the trend down as compared to previous PFTs included the
small ground glass opacity, mucous, possible history of
aspiration due to esophageal dilation, pulmonary edema, or
Amiodarone.
Pulmonary consult recommended repeating a CT to follow the
ground glass opacity seen in the right upper lobe. They also
recommended an outpatient speech and swallow evaluation to
rule out aspiration given the patient's history of esophageal
dilation. They recommended stopping Amiodarone, although the
patient is on Amiodarone for her atrial fibrillation. Seeing
how her pulmonary status is likely to continue worsening, it
was felt that the patient's primary care physician,
[**Name10 (NameIs) 2085**], or pulmonologist should discuss code status
considering the need for oxygen or ventilation. An attempt
will be made to contact Dr. [**Last Name (STitle) 36953**] to discuss these new
findings.
5. RIGHT FEMORAL AV FISTULA: The day following cardiac
catheterization, the patient was found to have a right
femoral bruit on examination. There was no evidence of
hematoma at that site. A femoral vascular ultrasound was
performed which showed an AV fistula but no evidence of
pseudoaneurysm. Following discussion with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
in Vascular Surgery, it was decided to make a follow-up
appointment with him as well as a follow-up femoral
ultrasound study in three to four weeks following discharge.
6. OSTEOPOROSIS: The patient has severe osteoporosis as
evidenced by kyphoscoliosis and a history of compression
fractures. The patient was continued on calcium, vitamin C,
and Actonel during the hospitalization.
CONDITION ON DISCHARGE: Stable. Saturating 98% on room air
and ambulating with a walker.
DISCHARGE STATUS: The patient is discharged back to her
[**Hospital3 **] facility.
DISCHARGE DIAGNOSIS:
1. Dyspnea.
2. Aortic stenosis.
3. Restrictive lung disease secondary to kyphoscoliosis.
4. Congestive heart failure.
5. Paroxysmal atrial fibrillation.
6. Osteoporosis.
7. AV fistula.
8. Gastroesophageal reflux disease.
9. Osteoporosis.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Amiodarone 200 mg p.o. q.d.
3. Mirapex 0.125 mg p.o. b.i.d.
4. Calcium carbonate 500 mg p.o. b.i.d.
5. Vitamin D 400 units p.o. q.d.
6. Actonel 35 mg p.o. q. weekly.
7. Lisinopril 5 mg p.o. q.d.
8. Prilosec 20 mg p.o. q.d.
9. Lasix 40 mg p.o. q.d.
10. Senna p.o. b.i.d. p.r.n. constipation.
FOLLOW-UP PLANS: The patient is asked to follow-up with the
following:
1. Primary cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**].
2. Primary pulmonologist, Dr. [**Last Name (STitle) 36953**].
3. Primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 27598**].
4. Vascular surgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in three weeks.
5. An outpatient femoral ultrasound study to evaluate the AV
fistula on Friday, [**2167-1-23**], at 10:30 a.m.
Attempts were made to make appointments for the patient;
however, since it was a holiday, offices were not open. The
patient and her family were given phone numbers to call to
make these appointments.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2167-1-2**] 01:39
T: [**2167-1-3**] 17:52
JOB#: [**Job Number 53681**]
ICD9 Codes: 4241, 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2449
} | Medical Text: Admission Date: [**2144-3-13**] Discharge Date: [**2144-4-3**]
Date of Birth: [**2076-8-1**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypoxia, shortness of breath, chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
67 M with poorly controlled IDDM, afib on coumadin, s/p partial
right foot amputation p/w erythema, swelling, & wounds on RLE.
Pt states that symptoms began 4 day ago with purulent drainage
from foot lesions. Endorses fevers at home yesterday. Pt
recently treated for cellulitis in RLE 1 months ago with good
resolution. No antecedent trauma but pt scratching legs
vigorously.
.
Also endorses decreased appetite with 20 lb weight loss in the
past month.
.
Vital signs in the ED: 98.0, 149/70, 80, 18, 98% 2L
.
In the [**Name (NI) **], pt given IV vancomycin in ED.
.
REVIEW OF SYSTEMS:
(+): As above
(-): Chest pain, SOB, abdominal pain, nausea, vomiting, diarrea,
headache.
Past Medical History:
-CHF EF 45% ([**12/2143**]) - on home oxygen 1-2L
-CAD s/p 4 MI's ([**2125**], [**2134**], [**2142**]), s/p 3 vessel CABG and recent
BMS of D1 ([**3-27**])
-Chronic Atrial Flutter
-Diabetes mellitus type II c/b Neuropathy, Retinopathy, diabetic
foot ulcer s/p amputations
-PVD
-Hypertension
-Hyperlipidemia
-GERD
-Depression
-h/o alcoholism- stopped drinking 25 years ago
-Ischemic colitis
-Left Subclavian Stenosis (45 mmHg pressure drop across the
stenotic lesion, Cath [**5-/2142**])
.
Past Surgical History:
L 2nd toe amp
R TMA
R partial colectomy for ischemic colitis
3 vessel CABG
R fem-DP
l fem-[**Doctor Last Name **] with stent bilaterally
s/p aortoiliac stenting
Social History:
Patient lives in [**Location **] with 3 of his brothers. [**Name (NI) **] retired in
his late 50s but he previously owned a radiator repiar business.
No ETOH X 25 years, but hx of heavy drinking X 15 years ("all
day long"), Hx of tobacco use (4ppd X 15 years), no IVDU.
Family History:
-no CAD, lung disease, or DM in the family
-HTN in father
-Breast cancer in mother
Physical Exam:
ON ADMISSION:
Tcurrent: 37 ??????C (98.6 ??????F)
HR: 94 (94 - 94) bpm
BP: 121/32(53) {121/32(53) - 121/32(53)} mmHg
RR: 21 (21 - 22) insp/min
SpO2: 98%
Heart rhythm: AF (Atrial Fibrillation)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. muddy sclera. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of in line with jaw line
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Crackles at bilateral bases, good air movement throughout
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. missing front foot on R, missing toes and
ulcerations on remaining on left, RLE dressing c/d/i
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
.
AT DISCHARGE:
Pertinent Results:
- ECG: LBBB at rate 90-112. Greater than 5mm ST elevations
than previous, although hard to delineate ST baseline.
.
- ECHO:
[**12-27**]:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with severe
hypokinesis of the inferior, inferolateral and basal
inferoseptal segments. The remaining segments contract normally
(LVEF = 40%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation. Moderate pulmonary
hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2143-1-15**], the findings appear similar.
.
- CARDIAC CATH:
RHC [**1-26**]:
COMMENTS:
1. Resting hemodynamics revealed normal right ventricular
filling
pressures with RVEDP 7 mmHg and mildly elevated left sided
filling
pressures with PCWP 19 mmHg. There was pulmonary arterial
hypertension with a mean PA pressures of 33 mmHg (PA prrresure
55/19 mmHg). The pulmonary vascular resistance was 157
dynes-sec/cm5. The cardiac index was normal at 3.26 L/min/m2.
2. Treatment with 100% FiO2 demonstrated lowering of the
pulmonary
artery resistance (97 dynes-sec/cm5) due to a rise in calculated
cardiac index (5.27 L/min/m2) with a stable PCW of 19 mmHg. The
mean PA pressure was measured at 33 mmHg.
3. Treatment with inhaled NO at 40 ppm in addition to 100% FiO2
did not change the pulmonary pressures significantly with a mean
PA pressure of 30mmHg. There was just a mild change in the mean
PCWP measured at 17 mmHg. The pulmonary artery resistance was
(107 dynes-sec/cm5) due to a rise in the calculated cardiac
index (4.43 l/min/m2).
FINAL DIAGNOSIS:
1. Pulmonary arterial hypertension at baseline with no
improvement in
mean PA pressures with 100% o2 and iNO at 40ppm.
2. Mildly elevated left ventricular filling pressures.
.
LHC [**5-26**]:
COMMENTS:
1. Coronary angiography in this left-dominant system revealed
diffuse
coronary artery disease. The LMCA was a small caliber vessel
without
disease. The LAD had 60-70% calcified stenoses of the proximal
section, as well as the diagonal branch, and was occluded after
the mid-section. The LCX had sequential stenoses of the proximal
and distal LCX, with occluded OM1 and OM2 branches, and total
occlusion after the distal LCX. The RCA was a non-dominant
vessel with sequential 80% stenoses. 2. Selective graft
venography revealed a widely patent SVG-PDA and LPL graft. The
SVG-OM1 graft had a 30-40% stenosis in the mid-SVG, and was
patent to the OM1 branch.
3. Selective graft arteriography revealed a widely patent
LIMA-LAD
graft. 4. Resting hemodynamics revealed elevated right- and
left-sided filling pressures, with mean RA pressure of 15 mmHg,
and mean PCW pressure of 30 mmHg. The wedge tracing was notable
for a prominant v-wave with pressure of 51 mmHg, consistent with
possible mitral regurgitation. There was mild pulmonary
hypertension with mean PA pressure of 38 mmHg, and mild systemic
hypertension, with SBP of 140mmHg. The cardiac output was
normal at 5.1 L/min. There was no aortic stenosis detected by
pullback technique.
5. Nonselective left subclavian injection revealed a 70%
stenosis of the proximal left subclavian artery, with a 45 mmHg
pressure drop across the stenotic lesion.
FINAL DIAGNOSIS:
1. Diffuse coronary artery disease.
2. Elevated left- and right-sided filling pressures.
3. Mild pulmonary and systemic hypertension.
4. Subclavian stenosis.
Brief Hospital Course:
Patient expired as explained in OMR Death Note summarized here:
At approximately 12:30AM, telemetry in the ICU demonstrated
ventricular tachycardia. Dr. [**Last Name (STitle) 39070**] [**Name (STitle) 39071**] was present at bedside
and the patient was found to be pulseless. Code status was noted
to be DNR and he became asystolic shortly thereafter. Dr. [**Last Name (STitle) 39071**]
called the time of death to be 12:36AM on [**2144-4-3**] after
listening
for breath sounds bilaterally and not appreciating any. He also
listened for heart sounds and did not appreciate any. He felt
for
peripheral pulses for 1 minute at both radial arteries, and did
not appreciate any. He had absent corneal reflexes bilaterally.
Dr. [**Last Name (STitle) 39071**] has made several phone calls to patients brothers
in attempt to inform them of grave situation. Organ bank was
also
notified by Dr. [**Last Name (STitle) 39071**] and they have declined.
Below is a brief summary of his hospital course:
Mr. [**Known lastname 17029**] is a 67 year old man with a past medical history
significant for CABG, CAD, sCHF, DM, PVD, originally admitted
for RLE cellulitis who was transferred to the CCU after
developing acute pulmonary edema. His course was complicated by
pulseless VT arrest on [**3-21**] and respiratory failure and is now in
the MICU for further management
.
# Hypoxemic Respiratory Failure: Initially upon admission, Mr.
[**Known lastname 17029**] had an SpO2 of 100% on 2L. Given appearance of
hypovolemia on exam, and concern for infection his home
torsemide was held and he was given 1L NS. On the first night of
admission, he became hypoxemic to SpO2 in the 70s. CXR at the
time demonstrated pulmonary edema. SBP was 150. Hypoxemia
initially improved with BiPap and diuresis. He was transferred
to the CCU for further management given concern for ACS. On [**3-15**]
he was able to be weaned from bipap with lasix gtt and nitro gtt
after 2L of diuresis, however on [**3-15**] he removed his NRB mask
and desaturated to the 60s, was obtunded and bradycardic in
aflutter with variable block and he was intubated. ABG
initially demonstrated a moderate P/F ratio of ~250 suggestive
of [**Doctor Last Name **] which has roughly remained constant. CT chest
demonstrated bilateral ground glass opacities worsened in
non-dependent areas since [**1-26**] of unknown etiology. Overall,
non-resolving infiltrates were seen as likely secondary to flash
pulmonary edema with component of alveolar hemorrhage given
profound coagulopathy on admission. Given spike to 102 on [**2143-3-20**]
and CXR with worsening bilateral infiltrates, VAP was seen as
likely and broad spectrum Abx (Vanc, Zosyn, and Levofloxacin)
were started. Furthermore, Swan on [**2143-3-21**] demonstrated wedge of
15-18 indicating a smaller component of L heart dysfunction than
previously thought. Furthermore PVR in 800s indicated that
pulmonary hypertension occurred out of proportion to left heart
dysfunction. After 1 week of intubation, his mental status had
improved to the point where he could be safely extubated on
[**2144-3-24**]. P/F ratio prior to extubation demonstrated a ratio of
250 which was similar to his baseline. For one day following
extubation, he was able to maintain an SpO2 of 97-99% on the
high flow mask, but progressively became more tachypneic and
demonstrated paradoxical respirations. Bipap was initiated on
[**2144-3-25**].
.
He was transferred to the MICU for further care [**3-26**]. Upon
arrival his mental status was poor and appeared having
significant difficulty on bipap. It was decided to re-intubate
the patient. He was continued on vancomycin and meropenem. A
bronchocsopy was performed which showed hemosiderin laden
macrophages. His hypoxia was felt to be a combination of
cardiogenic pulmonary edema given elevated V waves on swan plus
intrinsic pulmonary process of undiagnosed etiology. A lung
biopsy was considered.
.
# PULSELESS VT ARREST: While Mr. [**Known lastname 17029**] was being weaned from
sedation on [**2144-3-21**], he experienced an episode of pulseless VT.
There was no evidence of cardiac ischemia, electrolytes were
within normal limits, and QTc was 420. He had ROSC after 1 shock
and an amiodarone load. The etiology of this event was unclear,
but was thought to occur secondary to catecholamine surge in the
setting of sedation wean and profound agitation. In the MICU,
the patient had increased ectopy and NSVT. Due to the increasing
frequency, he was restarted on amiodarone with improved ectopy.
.
# [**Last Name (un) **] ?????? With diuresis, Mr. [**Known lastname 54896**] renal function
progressively deteriorated to a peak BUN/Cr of 178/4.5 from a
baseline of 34/1.7. After a peak Cr of 4.5, Mr. [**Known lastname 54896**] cr
began to improve to a Cr of 2.8 upon transfer to the MICU. HE
continued to maintain good UOP and followed closely by
nephrology. He did not need renal replacement therapy while in
the MICU.
.
# Hypernatremia: Mr. [**Known lastname 17029**] became quite hypernatremic when
his tube feeds were held following extubation. Initial attempts
to replete with 1/2 NS were unsuccessful, and his Na was 157 on
[**2144-3-26**] consistent with a 6.5 L free water deficit. D5W and free
water flushes were started with good effect.
.
#AMS ?????? A large component of Mr. [**Known lastname 54896**] prolonged intubation
was altered mental status. Following initial sedation with
fentanyl and midazolam he became quite sedated and would not
follow commands. Sedation was changed to propofol after
inadequate sedation with precedex. Given supratherapeutic INR,
CT head was obtained which demonstrated atrophy but no acute
changes. Neuro consult was obtained, and their assessment was
that his delerium was secondary to toxic metabolic causes
(sedation, uremia, hypernatremia, and ICU delerium). EEG shows
metabolic encephalopathy, no epileptiform activity. As his renal
function and hypernatremia improved, the patient's mental status
slowly improved while on the vent.
.
# Nutrition: Upon transfer to the MICU, mental status precluded
PO intake, and Bipap precluded nasogastric tube feeds. Tube
feeds were initiated in the MICU.
.
# DM ?????? Blood sugars were difficult to control in the CCU, and an
insulin drip was started. [**Last Name (un) **] was consulted and saw the
patient often for close monitoring of his blood sugars.
.
# Fevers/Infection: Fever to 102 on [**2144-3-22**] with leukocytosis
peak to 24 on [**2144-3-26**]. There existed concern for VAP with
prolonged intubation (no definite infiltrates for VAP), as well
as UTI given prolonged foley catheterization (prior UA with WBCs
but urine cx with only yeast). Less likely was meningitis given
AMS, because time course/physical exam was inconsistent (he
became altered before fevers started and no nuchal rigidity).
Initially vanc/zosyn/levofloxacin were started for VAP on
[**2144-3-18**]. Levofloxacin was stopped on [**2144-3-21**] following VT arrest
and concern for QT prolongation. He was broadened to vancomycin
and [**Last Name (un) 2830**] upon transfer to the MICU and his wbc improved.
.
# CAD ?????? Mr. [**Known lastname 17029**] experienced chest pain in setting of
respiratory decompensation on admission without EKG changes from
baseline, cardiac enzymes peaked on [**3-15**] with MB of 21 and trop
of 1.21. Troponin was baseline and worsened with worsening CKD.
Overall his MB bump was seen as demand related to his hypoxemia
and there was little concern for ACS. He remained CP free since
initial decompensation.
# LIVER: LFTs were elevated on admission to ALT/AST in the 300s.
Etiology is likely secondary to congestive hepatopathy as RUQ US
ruled out abscess or reversal of flow, but was suggestive of CHF
and congestive hepatopathy. HCV ab was negative. HBV serologies
negative. Given downtrending LFTs with diuresis, further workup
was deferred. Furthermore, INR improved dramatically with Vit K
administration c/w malnutrition.
.
#Anemia. Hematocrit slowly worsened from baseline of 29 on
admission to a nadir of 22.1. He was transfused on [**2143-3-21**] due to
low SvO2 of 35%. Cause of anemia has been thought to be
secondary to CKD and/or anemia of chronic disease. Hemolysis was
ruled out with negative smear for schistocytes, elevated
haptoglobin, and normal fibrinogen. In light of brown guiac
positive stools, protonix [**Hospital1 **] was initiated. In the MICU, he had
a low Hct of 20.6 and received two units of pbrcs with good
effect.
Medications on Admission:
- Aspirin 81 mg QD
- Trazodone 100 mg QHS PRN
- Atorvastatin 80 mg QHS
- Sertraline 100 mg QD
- Clonazepam 0.5 mg TID PRN anxiety
- [**Hospital1 23928**] 10 mg QD
- Torsemide 20 mg QD
- Warfarin 1 mg QD
- Spironolactone 12.5 mg QD
- Isosorbide mononitrate 60 mg ER QD
- Fluticasone-salmeterol 250-50 mcg/dose Disk [**Hospital1 **]
- Metoprolol succinate 12.5 mg ER QD
- Albuterol sulfate 90 mcg MDI [**2-17**] INH Q6H PRN SOB, wheeze
- Humulin-N 100 unit/mL Suspension 20 units QAM, 24 units QPM
- Humalog 100 unit/mL Solution 10 units QAM, 12 units QPM
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 486, 5849, 2760, 2762, 4271, 4280, 4439, 311, 4275, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2450
} | Medical Text: Admission Date: [**2133-5-28**] Discharge Date: [**2133-6-11**]
Date of Birth: [**2049-2-4**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / adhesive tape / lisinopril / Enalapril / amiodarone
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84yoF with breast cancer, dilated cardiomyopathy (LVEF 25%) NYHA
Stage II , coronary artery disease s/p BMS to proximal-LAD,
moderate mitral and tricuspid regurgitation, atrial fibrillation
on coumadin s/p PPM placement who presents s/p fall at home. The
patient said that she had just recently been discharged from
Rehab. She said that she was doing well there, walking freely
and at times with a walker or a cane. She went home, where she
lives alone, but has frequent visitors. She was sitting on her
bed trying to put her sock on and she slipped off the bed and
fell. She hit her coccyx. She was on the ground for 3 hours,
until she was found by a friend who brought her to [**Hospital1 18**]. She
said that at the time of the fall, she had no lightheadedness or
dizziness, no palpitations, diaphoresis, chest pain, SOB, LOC.
She repeatedly said she just slipped off the bed.
She said that this year she has fallen 3 times, but prior to
that she had not had a history of falls. She said the other 2
times were also mechanical. One time she slipped in the rain
outside and the other time she was walking with tea in her hand
at home and she tripped over a stool. She says that usually she
is able to walk well. She manages her own finances. She says she
does her own cooking and cleaning. She has friends shop for her.
She has had visiting nurses in the past, but no permanent home
care attendent because she felt there was no need for that. She
has lots of friends and family who visit.
In the ED, initial vitals are as follows: 97.6 80 96/56 16. Labs
notable for trop 0.02 with 2nd trop 0.01, INR - 1.8, H/H:
11.3/38.6 The pt underwent CT head - No acute intracranial
process, CT C-spine - No fracture. Large bilateral pleural
effusions, CXR - Mild pulmonary edema, with b/l pl effusions
(stable). L basilar opacification, atelectasis vs infxn, Lumbar
spine, pelvis plain films - No acute fracture or subluxation The
pt received ceftriaxone and azithromycin in the ED for lactate
of 3.0. Vitals prior to transfer: T 98.3 p 75 rr 18 bp 137/88
sa02 unable (blood gas drawn and pending) 92 % on abg, patient
was not suitable for PT/CM in the ED so being admitted to the
floor.
Currently, lying in bed, upset that she is being asked all the
same questions.
ROS: Per HPI
Past Medical History:
- Hypertension
- s/p BMS to proximal LAD on [**2131-12-17**]
- CAD s/p NSTEMI in [**11/2131**]
- Dilated cardiomyopathy, EF 25% on [**2133-2-9**] TTE
- Valvular Disease: 2+ MR, 2+ TR on [**2133-2-9**] TTE
- s/p BMS to proximal LAD on [**2131-12-17**]
- Atrial fibrillation, diagnosed [**10/2132**] s/p failed
cardioversion and s/p PPM placement, on Coumadin
- Hypertension
- Arthritis
- Left breast cancer s/p mastectomy, node dissection, radiation
in [**2113**]
- h/o gastritis/GI bleed
- Macular degeneration
- presumed SIADH (see d/c summary from [**11/2131**]) s/p tolvaptan at
that time
Social History:
Lives alone, never married, no children. Nephew [**Name (NI) **] [**Name (NI) 7049**] is
her HCP. Denies alcohol, tobacco, or illicit drug use. Former
dancer-singer on the [**First Name8 (NamePattern2) **] [**Location (un) **] Show.
Family History:
Mother died of ? stomach cancer in her 70s. Father died of
natural causes in his 70s. 9 siblings, all deceased, no medical
problems. Denies family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T: 97.4 BP: 97/50 HR: 73 RR: 20 02 sat: 92% on ABG as
difficult to get pulse ox
GENERAL: Pleasant, tired appearing woman, lying flat in bed and
speaking comfortably
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Very dry MM.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2.
Holosystolic murmur heard throughout
LUNGS: CTAB anteriorly (patient did not want to sit up for full
lung exam)
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Left arm larger than right. Patient with 3-4+
pitting edema of feet and slowly tapers up to knees. Also with
sacral edema. PT pulses dopplerable, unable to doppler DP pulses
(nurse able to doppler [**12-29**] DP pulses, patient hands cool to
touch and slightly cyanotic. Patients feet were cold to touch
and cyanotic, she was able to move her feet with full range of
motion and 5/5 strength although her sensation to light touch
was depressed. She had skin tears on her feet bilaterally that
weren't healing, toenails were long, her feet were tender to
touch
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact.
PSYCH: Listens and responds to questions appropriately, pleasant
.
DISCHARGE PHYSICAL EXAM:
Vitals (CMO): RR 14-20
I&Os: [**Telephone/Fax (1) 105938**]
General: Awake patient lying in bed in NAD, comfortable.
HEENT: EOMI. Dry MM. Tongue midlline
CV: Regular rate and rhythm. 2/6 systolic murmur appreciated at
the LLSB and at the cardiac apex.
Lungs: Absent breath sounds at the bases bilaterally. Crackles
in the mid-lung fields bilaterally, posteriorly. No wheezes. No
increased work of breathing.
Abdomen: Soft. ND. BS+. Tenderness in RUQ.
Ext: Cyanosis present of the R hand. No clubbing. 2+ pitting
edema of the ankles bilaterally, with pitting edema extended to
the mid-shins bilaterally, worse on the left (2+) than on the
right.
Pertinent Results:
ADMISSION LABS
[**2133-5-28**] 12:00PM BLOOD WBC-6.0 RBC-4.20 Hgb-11.3* Hct-38.6
MCV-92 MCH-27.0 MCHC-29.3* RDW-16.8* Plt Ct-359
[**2133-5-28**] 12:00PM BLOOD Neuts-73.9* Lymphs-19.9 Monos-5.5 Eos-0.3
Baso-0.5
[**2133-5-28**] 12:00PM BLOOD PT-19.0* PTT-33.2 INR(PT)-1.8*
[**2133-5-28**] 12:00PM BLOOD Glucose-78 UreaN-28* Creat-1.0 Na-135
K-4.4 Cl-97 HCO3-24 AnGap-18
[**2133-5-28**] 12:00PM BLOOD CK(CPK)-189
[**2133-5-28**] 12:00PM BLOOD cTropnT-0.02*
[**2133-5-28**] 05:52PM BLOOD cTropnT-0.01
[**2133-5-29**] 07:50AM BLOOD Albumin-3.2* Calcium-8.4 Phos-4.2 Mg-1.8
[**2133-5-28**] 12:00PM BLOOD Digoxin-2.0
[**2133-5-28**] 11:11PM BLOOD Type-ART pO2-76* pCO2-32* pH-7.46*
calTCO2-23 Base XS-0
[**2133-5-28**] 09:31PM BLOOD Lactate-3.0*
[**2133-5-28**] 11:11PM BLOOD Lactate-1.4
[**2133-5-28**] 03:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2133-5-28**] 03:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2133-5-28**] 03:20PM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-0.
MICRO
[**2133-5-29**] 1:00 am BLOOD CULTURE
**FINAL REPORT [**2133-6-4**]**
Blood Culture, Routine (Final [**2133-6-4**]): NO GROWTH.
[**2133-5-28**] 9:20 pm BLOOD CULTURE
**FINAL REPORT [**2133-6-3**]**
Blood Culture, Routine (Final [**2133-6-3**]): NO GROWTH.
.
IMAGING
-[**5-28**] PELVIS XR:
FINDINGS:
No acute fracture or dislocation is present. Diffuse
demineralization of the osseous structures is noted. There is
no diastasis of the pubic symphysis or sacroiliac joints. No
suspicious lytic or sclerotic osseous abnormalities are seen.
Scattered phleboliths are seen within the left hemipelvis.
There are surgical clips noted pelvis. There are mild
degenerative changes with joint space narrowing of the hips.
IMPRESSION:
No acute fracture or dislocation.
.
5/31 L-spine XR
IMPRESSION:
No acute fracture or subluxation.
.
[**5-28**] CXR:
IMPRESSION:
Mild pulmonary edema, with continued bilateral pleural
effusions, moderate on the left and small on the right. Fluid is
noted to track over the apices bilaterally. Left basilar
opacification may reflect compressive atelectasis though
infection is difficult to exclude.
.
[**5-28**] C-spine w/ contrast:
IMPRESSION:
1. No fracture or change in alignment.
2. Bilateral pleural effusions.
.
[**5-28**] Head CT:
FINDINGS: There is no acute hemorrhage, edema, or shift of
normally midline structures. Prominence of the ventricles and
sulci is compatible with age-related atrophy. There is no large
territorial vascular infarction. Diffuse periventricular white
matter hypodensities, though nonspecific, likely relate to
chronic small vessel ischemic disease. Again noted are small
air-fluid levels within the mastoid air cells associated with
mild sclerosis suggesting a chronic inflammatory process. The
remaining visualized paranasal sinuses are well aerated.
Calcifications are seen within the carotid siphons and within
the subcutaneous portion of the skin overlying the anterior
skull. There is no fracture identified.
IMPRESSION: No acute intracranial process.
.
[**6-4**] TTE
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20 %) secondary to global hypokinesis as well as marked
ventricular interaction. The right ventricular free wall
thickness is normal. The right ventricular cavity is markedly
dilated with severe global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload with consequent ventricular
interaction. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. Severe [4+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2133-2-19**], mitral and tricuspid regurgitation are
significantly increased. Right ventricular pressure and volume
overload are much more prominent, with consequent increased
ventricular interaction further reducing left ventricular
systolic and diastolic performance.
[**6-5**] Head CT:
FINDINGS: There is no hemorrhage, edema, shift of midline
structures, or territorial infarction. The ventricles and sulci
are prominent, consistent with global atrophy. Subcortical and
periventricular white matter hypodensities, most marked in the
frontal lobes are unchanged and consistent with chronic small
vessel ischemic disease. The calvaria are unremarkable. The
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
84yoF with breast cancer, dilated cardiomyopathy (LVEF 25%) NYHA
Stage II , coronary artery disease s/p BMS to proximal-LAD,
moderate mitral and tricuspid regurgitation, atrial fibrillation
on coumadin s/p PPM placement who presents s/p fall at home.
She was r/o for traumatic fractures in the ED, and was admitted
for monitoring and eval prior to dispo to rehab. On [**6-2**], she
triggered for SBP's to the 70's amidst a presyncopal episode,
likely vasovagal in the setting of orthostasis/intravascular
depletion and having a large bowel movement (her BP's improved
shortly after being returned to bed). On 6/6am, she became
abruptly unresponsive while being assisted to go to the
bathroom, and was transferred to the MICU for unresponsiveness
and then subsequently transferred to the cardiology service for
diuresis and continued management for end-stage heart failure,
who was later made CMO.
============================================================
General Medicine Floor Course:
.
# Unresponsiveness: On 6/6am, she became abruptly unresponsive
while being assisted to go to the bathroom, and did not respond
to painful stimuli. She was afeb with SBP's in the 100s; EKG's
and CXR were unremarkable other than mild pulmonary edema; she
was given 1mg IV ativan for empiric seizure treatment. After
about an hour, she began slowly regaining responsiveness and was
moving all 4 limbs with nonfocal neuro exam, but did not regain
full baseline cognition. She was transferred to the MICU.
# Delirium: The patient was delirious o/n on [**5-29**] when she
required a small dose of IM haldol for extreme agitation
(calling 911 from room). The delirium was likely [**1-29**] hospital
delirium, possibly exacerbated by the diazepam which the patient
consistently takes. Toxic metabolic etiology was unlikley as her
labs were largely unremarkable; infection or injury were also
unlikely given no localizing evidence (clean UA, CXR, no fever).
Per the patient's PCP, [**Name10 (NameIs) **] patient insists on taking and needs
her diazepam so this likely cannot be down-titrated, although it
may contribute to her underlying delirium. The patient was
monitored on fall precautions, aspiration precautions.
.
# s/p Mechanical Fall: Upon presentation, the patient had no
active sign/symptoms of bleeding, fracture, or other acute
process; all trauma scans were unremarkable. Patient's fall may
have been mechanical, although she has had increased number of
falls at home this year. Her feet have decreased sensation and
poor blood flow likely worsening her ambulatory abilities. In
addition, while her strength was intact, at rest, her legs
appeared limp as if very weak. She lives at home with no help
for most of the day, but particularly at night. She is a high
risk for repeated fall, but she may not be amenable to
placement. PT eval recommended dispo to rehab.
.
=============================================================
ICU Course ([**6-3**] -> [**6-5**])
The patient was transferred to the ICU on the morning of [**6-3**]
after an episode of unresponsiveness and for worsening cyanosis.
Neurology was consulted and thought the picture was most
consistent with either a metabolic encephalopathy - possibly
related to hypoxia and cardiogenic shock. A diagnosis of
hypoactive delirium was also entertained. EEG showed R temporal
epileptic discharges. Neurology recommended repeat Head CT -
both were unremarkable for acute causes. Her mental status
improved over the course of her ICU stay, and she was conversant
and oriented x 2 prior to being called-out. For her worsening
cyanosis, cardiology recommended optimizing her systolic
function. CXR showed volume overload and TTE showed worsening
MR, TR and volume overload. She was bolused with lasix and then
started on a lasix drip as well as metolazone to try and improve
diuresis. The patient's urine output remained poor at the time
of call-out. Vascular surgery was also consulted for the
patient's peripheral cyanosis - they thought it to be most
consistent with global hypoperfusion with superimposed PVD.
Coumadin was held for an INR of 5.3. Digoxin level was sent with
plans to restart reduced dose. Her chronic valium was held due
to altered mental status and had not been restarted prior to
call-out.
.
===============================================================
Cardiology Floor Course:
.
# CARDIOGENIC SHOCK: Upon transfer from the unit, the patient
was on a lasix drip but appeared to be in cardiogenic shock with
cold extremities and cyanosis. Urine output was monitored, and
the patient made a great deal of urine to the lasix drip. Her
color and temperature of extremities improved. Electrolytes were
monitored and repleted as needed to maintain potassium of 4 and
magnesium of 2. Lasix drip was discontinued after the patient
pulled her PICC line. She was subsequently transitioned to an
oral dose of torsemide. Medical team met w/ patient's HCP, her
nephew [**Name (NI) **]. Discussed with [**Doctor Last Name **] the end-stage nature of
her heart failure. Palliative care became involved during this
[**Hospital 228**] hospital course, and the decision was made to
transition to comfort measures only. Initially, she was given
oral torsemide at a daily dose, but the patient consistently
made approximately 3 liters of fluid daily with poor oral
intake. Thus standing doses of torsemide were discontinued with
the plan to give the patient 40mg of oral torsemide as needed
for shortness breath.
******
The following issues were also addressed initially during the
patient's Cardiology floor stay prior to the decision to make
the patient comfort measures only:
# ELEVATED INR: Etiology was unclear; differential included DIC
(in light of elevated PTT and falling HCT) versus congestive
hepatopathy in light of worsening heart failure. DIC was ruled
out. With rising LFTs, the cause of the elevated INR was
attributed to congestive heaptopathy in light of systolic heart
failure. LFTs were initially trended and noted to be decreasing
with downtrending INR. With the decision to transition care
towards comfort, no further INRs were drawn.
# ATRIAL FIBRILLATION: INR supratherapeutic upon admission to
the cardiology service. Coumadin was held as was the digoxin.
Patient's INR downtrended. With decision to focus care on
comfort, no other lab draws were done.
# CAD: Initially continue ASA 81mg daily, losartan, metoprolol
(with holding parameters) until the decision was made to focus
care of comfort.
# ARTHRITIS: Acetaminophen PRN for management of pain control.
# LEFT BREAST CANCER S/P MASTECTOMY: Chronic lymphedema in left
arm, no BP checks in left arm or lab draws were attempted.
# HYPOTHYROIDISM: Normal TSH on [**6-2**]. Continued home
levothyroxine, until the decision was made to transition care to
comfort measures only.
TRANSITION OF CARE:
--Focus of patient's care is towards comfort measures only. All
medications with the exception of her diuretic and rate
regulating medication were discontinued.
--Administer torsemide 40mg orally as needed for symptoms of
shorntess of breath.
Medications on Admission:
- Adult Low Dose Aspirin 81 mg Tab, Delayed Release 1 Tablet(s)
by mouth once a day
- acetaminophen 500 mg Tab 1 Tablet(s) by mouth four times a day
as needed
- diazepam 2 mg Tab 1 (One) Tablet(s) by mouth four times a day
- furosemide 20 mg Tab 4 Tablet(s) by mouth daily
- losartan 25 mg Tab 0.5 (One half) Tablet(s) by mouth daily
- digoxin 125 mcg Tab 1 Tablet(s) by mouth daily
- Lo-Peramide 2 mg Tab 1 Tablet(s) by mouth twice daily as
needed for diarrhea
- levothyroxine 25 mcg Tab 1 Tablet(s) by mouth daily
- warfarin 2 mg Tab [**12-29**] Tablet(s) by mouth daily or as directed
- multivitamin Tab 1 Tablet(s) by mouth daily
- metoprolol succinate ER 50 mg 24 hr Tab one and [**12-29**] Tablet(s)
by mouth once a day
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Anxiety.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
5. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for shortness of breath or wheezing.
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: HOLD
for HR < 60 .
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Primary diagnosis:
--status post fall
--Cardiogenic shock
Secondary diagnoses:
- Hypertension
- Coronary artery disase
- Atrial fibrillation
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 7049**],
It was a privilege to provide care for you here at the [**Hospital1 1535**].
You were admitted because you had a fall at home. You received
various X-rays and CT-scans, which did not show fractures.
During this admission, you had a very serious heart failure
exacerbation. You were diuresed initially and responded well.
Family meetings were conducted during this admission, and the
decision was made to transition your care to comfort meausres
only.
Medications that focus on your comfort have been continued,
including medications for anxiety, pain, and shortness of
breath.
Followup Instructions:
Patient will be managed symptomatically at [**Hospital1 1501**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
ICD9 Codes: 2930, 4240, 4280, 4019, 4439, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2451
} | Medical Text: Admission Date: [**2111-12-20**] Discharge Date: [**2111-12-24**]
Date of Birth: [**2046-8-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
History of TIA
Major Surgical or Invasive Procedure:
[**2111-12-21**] Minimally Invasive Closure of Patent Foramen Ovale
History of Present Illness:
This is a 65 year old male with history of hypertension and
multiple TIA's. His first neurological event took place in [**2088**].
His most recent was in [**2111-9-17**]. Evaluation at [**Location (un) 47**]
was notable for a patent foramen ovale which was detected by
transesophageal echocardiogram. He now presents for cardiac
surgical intervention.
Past Medical History:
Patent Foramen Ovale, History of TIA's, Hypertension, Hip
Arthritis, Prior Hernia Repair
Social History:
He is a bartender. Admits to 16 pack year history of tobacco. He
denies excessive ETOH.
Family History:
Father died of throat cancer at age 52. Mother died in her 80's.
Physical Exam:
Vitals: BP 140's/90-100, HR 65, RR 20, SAT 95% on room air
Weight: 71.6 kg
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2111-12-20**] 11:19PM BLOOD WBC-9.5 RBC-4.07* Hgb-14.3 Hct-39.1*
MCV-96 MCH-35.2* MCHC-36.7* RDW-12.7 Plt Ct-223
[**2111-12-20**] 11:19PM BLOOD PT-11.3 INR(PT)-0.8
[**2111-12-20**] 11:19PM BLOOD Glucose-157* UreaN-15 Creat-1.0 Na-143
K-4.2 Cl-102 HCO3-28 AnGap-17
[**2111-12-23**] 06:25AM BLOOD WBC-12.1* RBC-3.15* Hgb-10.9* Hct-29.3*
MCV-93 MCH-34.7* MCHC-37.3* RDW-14.3 Plt Ct-152
[**2111-12-24**] 06:40AM BLOOD UreaN-22* Creat-1.0 K-3.9
[**2111-12-24**] 06:40AM BLOOD Mg-2.4
Brief Hospital Course:
Upon admission, patient underwent surgical closure of his patent
foramen ovale which was performed through a minimally invasive
incision. The operation was uneventful and he was brought to the
CSRU in stable condition. Within 24 hours, he awoke
neurologically intact and was extubated without incident. He was
started on low dose beta blockade. He maintained stable
hemodynamics and transferred to the SDU on postoperative day
one. He required gentle diuresis. Beta blockade was slowly
advanced as tolerated. He remained in a normal sinus rhythm. He
required multiple medications for adequate pain control. He
continued to make clinical improvements and was cleared for
discharge to home on postoperative day three. Discharge chest
x-ray revealed a tiny residual right apical pneumothorax with
some subcutaneous emphysema in the right chest wall. There were
small bilateral effusions and atelectasis at both lung bases.
Vitals at discharge were BP 120/70 with heart rate 78 in sinus
and 96% on room air. All surgical incisions were clean, dry and
intact.
Medications on Admission:
Aggrenox [**Hospital1 **], Lipitor 20 qd, HCTZ 25 qd, Mobic 7.5 mg qd,
Selenium
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. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
6. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Health and Hospice at St. Josephs
Discharge Diagnosis:
Patent Foramen Ovale; History of TIA's; Hypertension; Hip
Arthritis; Prior Hernia Repair
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**4-21**] weeks, call [**Telephone/Fax (1) 170**].
Local PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45802**] in [**2-19**] weeks - office will call
patient.
Local cardiologist in [**State 1727**] in [**2-19**] weeks - will be arranged by
PCP.
Completed by:[**2111-12-24**]
ICD9 Codes: 5119, 5180, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2452
} | Medical Text: Admission Date: [**2129-2-11**] Discharge Date: [**2129-2-14**]
Date of Birth: [**2086-5-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
42 y/o male with HIV, Hep C, cardiomyopathy, hypertension,
polysubstance abuse including cocaine in addition to membranous
GN now ESRD on HD presenting with acute SOB, epigastric pain,
respiratory distress. The patient is a heavy smoker and per
verbal report from mother, patient and girlfriend broke up more
recently, and consumption of cocaine may have surrounded this
event.
.
In the ED, he triggered on arrival for sat of 84% on RA. He
usually is not hypoxic. On exam he was hypertensive and
clinically had fluid overload. CXR demonstrated diffuse
pulmonary infiltrates consistent with volume overload. Started
on nitro drip and BIPAP in addition to 2.5mg IV enaparil.
.
An EKG in sinus tachycardia with depressions V4-V6 slightly
worse than his baseline. His overall status improved with BiPAP
-> agitation decreased, although still confused mildly. Trop
and BNP sent. Dilaudid, Ativan, refused straight cath, on
nitro
drip with improved BP from 200/110 to 186/110.
.
WBC 24k, no report of fevers but covered with levo/vanco/flagyl.
On transfer BP 186/104 97.7 96 RR high 20's 90% on NRB.
.
Past Medical History:
1. HIV - He was diagnosed with HIV in [**2112**]. Risk factors
included unprotected heterosexual sex as well as intravenous
drug use. His nadir CD4 count is 91 and he has no known
opportunistic infections. Last viral load undetectable, CD4 556
([**10-31**]).
2. Hepatitis C. Genotype 1B. Viral load 187,000 in [**12-28**].
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%.
5. Chronic renal insufficiency - MPGN by biopsy in [**2123**] and
hypertensive nephrosclerosis
5. GERD.
6. Hypertension.
7. Gynecomastia; s/p bilateral gynecomastia excision with
liposuction [**2126-7-23**].
8. Polysubstance abuse, including cocaine and alcohol.
9. Anemia, hematocrit 20-24.
10. Hypertriglyceridemia - TG 282 in [**3-/2126**]
11. Right hydrocele.
12. A subacute infarct in the right caudate head seen on MRI in
[**1-29**]
13. Influenza B, [**2126-2-22**].
14. Erectile dysfunction.
15. Depression
16. Inguinal hernia repair in [**2123**].
17. Left ankle ORIF in [**2122**].
18. Appendectomy in [**2101**].
Social History:
History of incarceration for 4 yrs. Is self-employed, unmarried.
He
has three children. Denies alcohol. Reports marijuana use daily,
denies tobacco or cocaine.
Family History:
Mother and father have hypertension; has 3 bros, 3 sis: all
healthy, none with HTN. There is also a family history of type 2
diabetes mellitus. No family history of sudden death and
premature atherosclerotic cardiovascular disease.
Physical Exam:
On admission:
97.9, 88-105, 137/90 (137-197/90-114), 97% 3L NC
GEN: Sleeping initially, no acute distress. Mild diaphoresis.
HEENT: MMM
Heart: S1+, S2+, RRR
Lungs: CTA b/l
Ab: scar from appendectomy, soft, non-distended, minimal
abdominal tenderness in the epigastric region. No rebound or
gaurding.
Ex: No edema. Fistula site on left without skin breakdown or
erythema or warmth.
Skin: No rashes, mild diaphoresis.
.
On Discharge:
Physical exam:
Tm/c: 98.6/96.7, BP 106/74 (82-106/55-74), HR: 76 (60-76), RR:
16, O2 97%
GEN: Awake in bed, no acute distress.
HEENT: MMM, no LAD, neck supple
Heart: S1+, S2+, RRR, harsh murmur in right upper sternal
border,
Lungs: CTA b/l
Ab: scar from appendectomy, soft, non-distended, minimal
abdominal tenderness in the epigastric region. No rebound or
gaurding.
Ex: No edema. Fistula site on left without skin breakdown or
erythema or warmth. +thrill over fistula site
Skin: No rashes, mild diaphoresis, multiple tattoos, one on left
chest and left hand homemade, while right shoulder seems
professional, multiple scars on right chest from HD lines.
Pertinent Results:
CBC:
[**2129-2-11**] 08:20PM BLOOD WBC-24.6*# RBC-3.83* Hgb-12.9* Hct-38.1*
MCV-99* MCH-33.6* MCHC-33.8 RDW-14.0 Plt Ct-301
[**2129-2-12**] 03:00AM BLOOD WBC-31.2* RBC-3.38* Hgb-11.4* Hct-32.7*
MCV-97 MCH-33.6* MCHC-34.7 RDW-14.1 Plt Ct-271
[**2129-2-14**] 06:30AM BLOOD WBC-12.9* RBC-3.56* Hgb-11.9* Hct-35.4*
MCV-99* MCH-33.4* MCHC-33.6 RDW-13.8 Plt Ct-258
.
Diff:
[**2129-2-11**] 08:20PM BLOOD Neuts-95.1* Lymphs-2.5* Monos-2.1 Eos-0.2
Baso-0.1
[**2129-2-13**] 06:25AM BLOOD Neuts-87.5* Lymphs-6.7* Monos-4.6 Eos-0.6
Baso-0.7
.
Coags:
[**2129-2-11**] 08:20PM BLOOD PT-14.8* PTT-29.5 INR(PT)-1.3*
[**2129-2-13**] 06:25AM BLOOD PT-19.6* PTT-33.3 INR(PT)-1.8*
[**2129-2-14**] 09:55AM BLOOD PT-18.5* PTT-32.5 INR(PT)-1.7*
.
BMP:
[**2129-2-11**] 08:20PM BLOOD Glucose-153* UreaN-40* Creat-4.1* Na-143
K-4.3 Cl-99 HCO3-28 AnGap-20
[**2129-2-13**] 06:25AM BLOOD Glucose-104* UreaN-46* Creat-4.8* Na-139
K-4.8 Cl-93* HCO3-30 AnGap-21*
[**2129-2-14**] 06:30AM BLOOD Glucose-97 UreaN-79* Creat-7.4*# Na-137
K-4.4 Cl-92* HCO3-26 AnGap-23*
.
LFT:
[**2129-2-11**] 08:20PM BLOOD ALT-19 AST-29 LD(LDH)-236 AlkPhos-183*
TotBili-0.5
[**2129-2-14**] 06:30AM BLOOD ALT-24 AST-25 LD(LDH)-149 CK(CPK)-23*
AlkPhos-137* TotBili-0.6
.
Cardiac Enzymes:
[**2129-2-11**] 08:20PM BLOOD cTropnT-<0.01 proBNP-[**Numeric Identifier 95484**]*
[**2129-2-12**] 03:00AM BLOOD cTropnT-0.03*
[**2129-2-13**] 06:25AM BLOOD CK-MB-2 cTropnT-0.07*
[**2129-2-14**] 06:30AM BLOOD CK-MB-1 cTropnT-0.18*
.
Mineral:
[**2129-2-11**] 08:20PM BLOOD Albumin-4.4 Calcium-10.2 Phos-4.6*#
Mg-2.2
[**2129-2-14**] 06:30AM BLOOD Albumin-3.9 Calcium-9.3 Phos-5.8* Mg-2.5
[**2129-2-11**] 08:26PM BLOOD Glucose-155* Lactate-2.7* K-4.5
[**2129-2-13**] 07:27AM BLOOD Lactate-2.5*
##########################################################
[**2129-2-11**] CXR
FINDINGS: There is diffuse interstitial and alveolar opacity
throughout both lungs, favoring the lung bases. Slightly more
confluent opacity is noted at the medial right lung. The
mediastinum is unremarkable. The cardiac silhouette has actually
decreased significantly in size from the prior exam suggesting a
resolved pericardial effusion. There are bilateral pleural
effusions, left slightly greater than right. No pneumothorax is
seen. The osseous structures are unremarkable.
IMPRESSION: Overall, the radiographic features favor diffuse
interstitial and alveolar edema. The opacity at the medial right
lung base may indicate
confluent edema or possibly underlying concurrent infection or
significant
aspiration. Correlate clinically. Repeat radiography after
appropriate
diuresis is recommended to assess for underlying infection.
.
[**2129-2-12**] CXR
FINDINGS: As compared to the previous radiograph from [**3-14**], the signs of bilateral diffuse pulmonary edema
have completely resolved. No remnant focal parenchymal
opacities. Borderline size of the cardiac silhouette. No pleural
effusions. No pneumothorax.
.
[**2129-2-14**] ECHO
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild global left ventricular hypokinesis (LVEF =
quantitative 44%). Systolic function of apical segments is
relatively preserved. The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
.
IMPRESSION: Symmetric left ventricular hypertrophy with mild
global hypokinesis c/w diffuse process (toxin, metabolic, etc.).
Dilated ascending aorta.
.
Compared with the prior study (images reviewed) of [**2128-11-18**],
global left ventricular systolic function is slightly less
vigorous.
Brief Hospital Course:
42 y/o male with MMP, ESRD on dialysis presents with
hypertensive emergency and shortness of breath in the setting of
likely cocaine use.
.
#) Hypertensive emergency: The patient's baseline hypertension
is very difficult to control--per our records he is on
isosorbide, hydralazine, carvedilol, and clonidine at baseline.
On his first night in the MICU, his blood pressure decrased
approximately 20% on nitro drip and enalapril IV; diastolic
stable at 100. Potential for concurrent cocaine use makes
treatment additionally challenging. Beta blockers were avoided
given cocaine use. Pt started on amlodipine 10mg daily, as well
as valsartan 160mg daily x 1. He received dialysis on the
morning after admission. After dialysis his hypertension
resolved. There was some concern that his hypertensive episode
was related to cocaine use (though pt adamently denied). He has
had previous admissions for similar symptoms and each time he
has tested positive for cocaine. He refused tox screen at this
time. He is more aware of this now as he knows it may interfere
with his transplant prospects. The patient stabilized and he
was transferred to the floor for further management. His BP
meds were continued and this was no longer an active issue. In
fact, his blood pressure was borderline low on less medications
than he reportedly takes at home raising the question of
noncompliance as an outpatient.
.
#) Inferior lead ST depressions: Likely demand ischemia, but
given initially flat troponins there was unclear [**Name2 (NI) 68402**].
The patient was asymptomatic. He received an ECHO, which was
unrevealing and had no wall motion abnormalities. There was
evidence of known non-ischemic cardiomyopathy. Repeat EKG had
persistent depressions and unclear as to the underlying cause,
but ECHO was negative. He was continued on aspirin 81 daily,
beta blocker and nitrate and will follow up with his PCP.
.
#) Leukocytosis: likely stress response in context of pulmonary
edema/hypertension. No clear evidence of infection. Pt was
empirically started on vanc/zosyn that was later removed and his
white count trended down without Abx. He remained afebrile and
no further workup was done.
.
Abd Pain: pt having persistent chronic abdominal pain. There
was initial concern that this pain, was different and new, but
after speaking with the patient, he said it was the same pain
and did not want further imaging since all CT scanning has come
back negative. He is scheduled for repair of his ventral hernia
in [**Month (only) 956**] and believes that this is the source of the pain.
He said if this surgery does not resolve his pain he will seek
medical help for further evaluation.
.
#) HIV: HAART regimen restarted on the morning after admission.
This was not an active issue during this hospitalization.
.
#) Substance abuse: Unclear if patient is on methadone
currently, and if so for pain or for chronic abuse. Attmepted
to clarify dose while in the MICU, but unable to reach his
methadone clinic. Started on reported home dose of 40mg daily,
pending verification. I was able to reach the patient's
methadone clinic while he was on the floor, but he was being
discharged that day and so the paperwork that needed to get
faxed over to verify his dose was never sent. If he returns, he
will need his dose verified. He goes to the community clinic in
[**Location (un) **] MA for his methadone.
.
#)GERD: Ranitidine. This was not an active issue during his
hospital stay.
Medications on Admission:
Abacavir 300 x 2
Carvediolol 50mg [**Hospital1 **]
Clonidine 0.4 TID
Sustiva 600 daily
Hydral 50 Q8
Isosorbide 30 daily
Lamivudine 2.5 after HD
Methadone 50mg daily
Ranitidine 150 [**Hospital1 **]
Terazosin 3mg QHS
Discharge Medications:
1. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. lamivudine 10 mg/mL Solution Sig: 2.5 PO three times/week
after HD ().
6. methadone 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
10. docusate sodium 100 mg Capsule Sig: [**1-23**] Capsules PO twice a
day.
11. [**Doctor First Name **]-Vite 0.8 mg Tablet Sig: One (1) Tablet PO once a day.
12. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
13. hydralazine 50 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hypertensive Emergency
.
Secondary Diagnosis:
1. HIV - He was diagnosed with HIV in [**2112**]. Risk factors
included unprotected heterosexual sex as well as intravenous
drug use. His nadir CD4 count is 91 and he has no known
opportunistic infections. Last viral load undetectable, CD4 556
([**10-31**]).
2. Hepatitis C. Genotype 1B. Viral load 187,000 in [**12-28**].
3. Cryoglobulinemia
4. Cardiomyopathy with an EF of 45-50%.
5. Chronic renal insufficiency - MPGN by biopsy in [**2123**] and
hypertensive nephrosclerosis
5. GERD.
6. Hypertension.
7. Gynecomastia; s/p bilateral gynecomastia excision with
liposuction [**2126-7-23**].
8. Polysubstance abuse, including cocaine and alcohol.
9. Anemia, hematocrit 20-24.
10. Hypertriglyceridemia - TG 282 in [**3-/2126**]
11. Right hydrocele.
12. A subacute infarct in the right caudate head seen on MRI in
[**1-29**]
13. Influenza B, [**2126-2-22**].
14. Erectile dysfunction.
15. Depression
16. Inguinal hernia repair in [**2123**].
17. Left ankle ORIF in [**2122**].
18. Appendectomy in [**2101**].
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were
intially admitted to the hospital for extremely elevated blood
pressure and difficulty breathing. You were admitted to the
intensive care unit and you receive emergency hemodialysis to
have the fluid removed from your body. After that, your
breathing greatly improved and you were ready to be transferred
to the general medicine floor. There were some concerning lab
values that were likely all secondary to the stress your body
went through during the elevated blood pressure and fluid
overload. You also had some abdominal pain, but this pain was
the same as chronic pain you have had in the past. We wanted to
do a further work up of this pain and do some abdominal
immaging, but you denied this as you have said this was done
multiple times in the past and always negative. You said you
have a hernia that is being repaired in [**Month (only) 956**]. You will be
discharged from the hospital with close follow up with your PCP.
.
please take all your medications as prescribed.
Followup Instructions:
Department: PAT-PREADMISSION TESTING
When: FRIDAY [**2129-2-18**] at 11:00 AM
With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2129-2-25**] at 11:40 AM
With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2129-3-4**] at 11:10 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15398**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: LIVER CENTER
When: FRIDAY [**2129-3-4**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5856, 4254, 2724, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2453
} | Medical Text: Admission Date: [**2141-9-12**] Discharge Date: [**2141-9-20**]
Date of Birth: [**2078-2-12**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
collapse, transfer from OSH in coma
Major Surgical or Invasive Procedure:
tPA, cerebral angiography, c/b groin/femoral hematoma, resolved
with pressure, pressure-dressing
History of Present Illness:
[**Known firstname 87998**] [**Known lastname **] is a 62 yo man working today on [**Hospital3 635**] as a
landscaper when he suddenly collapsed around 1pm. He was
initially brought to [**Hospital3 **] Hospital and found to be in Afib.
SBP on arrival was in the 160s-180s. GCS was 3; he was
subsequently intubated and sedated. CT head showed possible
edema of the posterior fossa. CTA was then obtained and
demonstrated basilar artery thrombus as well as thrombus in the
left vertebral artery. IV tPA was given and the patient was
life
flighted to [**Hospital1 18**] for further care. On arrival here. A repeat
CT
of the head was showed evolution of a left cerebellar infarct
and
a hyper density in the left vertebral artery. The patient was
taken immediately to the Angio suite for clot retrieval. There,
off of propofol, his pupils where pinpoint and non-reactive;
there was no spontaneous movement. Angiography demonstrated a
clear basilar with clots in the bilateral PCAs and these where
successfully removed.
Past Medical History:
Have documents from pts pharmacy in [**Location (un) 15158**] NY
(Kraupner Pharmacy- [**Telephone/Fax (1) 87999**]). This documents listed [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 88000**], MD as his PCP (Phone: ([**Telephone/Fax (1) 88001**]) and was able to
receive the following information. Pt was last seen in her
office in [**2141-3-2**]. Her past medical history for the
patient was noted as:
- Gunshot wound [**2115**] with bowel injury
- Hypertension
- Hyperlipidemia (last cholesterol 167) simvastatin LDL
- Atrial Fibrillation on Coumadin (last INR by PCP in [**Name9 (PRE) 547**] was
therapeutic at 2.2)
- No known surgeries, implants.
No known allergies
Social History:
Pt was working as a landscaper. In speaking with
is niece, he has been living on [**Location (un) 945**] since [**Month (only) 958**] or [**Month (only) 547**].
It is unclear if he has been seen by a PCP or as continued to
take his medications. He is married, wife is [**Name (NI) 88002**] [**Name (NI) **] and
has 2 daughters, [**Name (NI) **] [**Name (NI) **] (who consented to the procedure
today)
and [**Female First Name (un) 88003**], all of whom live in NY.
Family History:
nc
Physical Exam:
(on admission, just prior to angiography procedure)
Extremely limited. This exam was with the patient off propofol
for 20minutes during prep for angio.
Pupils pinpoint, non-reactive. No spontaneous movements, no
withdrawal. Unable to test brainstem reflexes further.
<<See scanned inpatient notes in OMR for progression of
physical/neurologic examination during his 1wk stay in the ICU
[**9-12**] - [**9-20**]>
Pertinent Results:
>>
[**2141-9-12**] 10:05PM WBC-13.5* RBC-4.86 HGB-15.2 HCT-46.1 MCV-95
MCH-31.3 MCHC-33.0 RDW-14.2
[**2141-9-12**] 10:05PM PLT COUNT-233
[**2141-9-12**] 08:46PM %HbA1c-6.0* eAG-126*
[**2141-9-12**] 06:57PM TYPE-ART PO2-333* PCO2-43 PH-7.40 TOTAL
CO2-28 BASE XS-1
[**2141-9-12**] 06:57PM GLUCOSE-139* LACTATE-1.7 NA+-141 K+-4.0
CL--101
[**2141-9-12**] 06:57PM HGB-15.1 calcHCT-45
[**2141-9-12**] 06:57PM freeCa-1.10*
[**2141-9-12**] 05:45PM GLUCOSE-116* UREA N-19 CREAT-1.0 SODIUM-140
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2141-9-12**] 05:45PM estGFR-Using this
[**2141-9-12**] 05:45PM cTropnT-<0.01
[**2141-9-12**] 05:45PM WBC-14.4* RBC-4.75 HGB-15.1 HCT-45.2 MCV-95
MCH-31.7 MCHC-33.3 RDW-14.1
[**2141-9-12**] 05:45PM NEUTS-86.5* LYMPHS-9.5* MONOS-2.7 EOS-0.9
BASOS-0.4
[**2141-9-12**] 05:45PM PLT COUNT-223
[**2141-9-12**] 05:45PM PT-15.8* PTT-46.5* INR(PT)-1.4*
CT brain without contrast on [**2141-9-12**]:
IMPRESSION:
1. Hypodensity within left cerebellar hemisphere may reflect
acute infarct,
although MRI would be more sensitive for this evaluation.
2. Mucosal thickening and air-fluid levels in the sinuses
secondary to
patient's intubated status.
[**2141-9-12**]
Conventional angiogram:
IMPRESSION:
Mr. [**Known firstname 87998**] [**Known lastname **] underwent diagnostic cerebral angiogram, which
demonstrated embolic occlusion of the proximal bilateral P2
segments of the posterior cerebral arteries. The basilar artery
and left vertebral artery were widely patent at the time of the
exam. After discussion with the stroke team, the decision was
made to perform intervention with direct intra-arterial
injection of TPA and mechanical thrombectomy. Post intervention
left vertebral artery angiogram demonstrated widely patent right
PCA and partial recanalization of left PCA.
Due to failure of angioseal device, direct pressure was
necessary for 3-1/2 hours, during which time a large right groin
hematoma formed. Vascular surgery was consulted at the beginning
of the direct pressure procedure and was made aware of the groin
hematoma. The right groin hematoma was stable in size for the
last hour and half of the procedure. The patient was taken to
the ICU and closely monitored by the ICU staff prior to and
after hemostasis.
CT brain on [**2142-9-18**]:
IMPRESSION:
1. Worsening of obstructive hydrocephalus with complete
effacement of the
fourth ventricle and interval dilation of the third and lateral
ventricles
with transependymal flow.
2. Tonsillar herniation.
3. No new hemorrhage identified.
Brief Hospital Course:
Mr. [**Known lastname **] was thought on admission to our Neurology service (in
SICU-B) to have a presentation suggestive of top-of-the-basilar
syndrome, most likely due to cardioembolism from AFib and
subtherapeutic INR. He was given IV/IA tPA and close
neurological monitoring. MRI/DWI confirmed extensive infarction.
He was never extubated, and his exam did not improve and
although he was producing spontaneous respirations while
intubated on a ventilator, his Neurological status, especially
his extensive brainstem infarction and poor airway/secretions
clearance, did not permit extubation. He was maintained on 3%
NaCl IV to minimize intracranial pressure with anticipated
brainstem swelling from his extensive posterior circulation
infarct and reperfusion after tPA. His family was reluctant to
withdraw artificial life support, and a decision re.
tracheostomy was delayed. He developed sepsis and hypotension
overnight 11/2-3, and became pulseless (PEA arrest) [**9-20**]
mid-morning requiring CPR/ACLS as his family had requested that
he remain full-code. He was coded (CPR-ACLS) for roughly 30min
without return of pulse, and I declared death that morning at
8:58am. The family did not request autopsy.
Medications on Admission:
Last documented medications:
- Warfarin 5mg/7.5
- Flomax 0.4
- Amlodipine 2.5mg
- Enalapril 10mg daily
- Simcor 500/20
Discharge Medications:
died [**2141-9-20**]
Discharge Disposition:
Expired
Discharge Diagnosis:
died [**2141-9-20**] in SICU-B with brainstem swelling ([**12-20**] brainstem
stroke) and septic shock
Discharge Condition:
died [**2141-9-20**]
Discharge Instructions:
n/a (died)
Followup Instructions:
n/a (died)
Completed by:[**2142-3-16**]
ICD9 Codes: 2760, 5180, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2454
} | Medical Text: Admission Date: [**2168-7-15**] Discharge Date: [**2168-7-28**]
Date of Birth: Sex: M
Service:
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF PRESENT ILLNESS: This is a 67 year-old gentleman
with a history of heavy smoking, noninsulin dependent
diabetes, recently diagnosed large cell lung cancer
transferred from OMED Service to the [**Hospital Unit Name 153**] for worsening of
respiratory distress. He was initially admitted to the
hospital on [**7-15**] to the OMED Service status post right
neck wedge biopsy, which revealed large cell lung cancer. He
did spike a fever to 101 on [**7-17**], but the chest x-ray was
unremarkable and culture was also negative. He was thought
to have aspiration events in the setting of over sedation.
He received a dose of chemo with Carboplatin and Paxil on
[**7-21**]. He tolerated the chemo well, but started to have
desaturation episodes with increased O2 requirements. His
chest x-ray showed increased bilateral basilar infiltrates
with left greater then right. His white count also trended
upwards with increased bandemia up to 29%. He was then
started on Levofloxacin and Flagyl for possible aspiration
pneumonia on [**7-22**]. He remained in NPO in the past two to
three days given concern for aspiration. He was transferred
to the [**Hospital Unit Name 153**] on [**7-23**] for worsening of hypoxia and impending
respiratory failure.
PAST MEDICAL HISTORY:
1. Noninsulin dependent diabetes mellitus.
2. Status post cataract surgery.
3. Status post left retinal detachment.
4. Status post colonoscopy in [**2167-9-20**], showed
positive sigmoid diverticuli.
ALLERGIES: No known drug allergies.
MEDICATIONS PRIOR TO ADMISSION:
1. Percocet.
2. Glicazidium.
SOCIAL HISTORY: Heavy smoking since age 35.
FAMILY HISTORY: Mother died of colon cancer at age 85,
father died of accident, sister who is in good health at age
55.
PHYSICAL EXAMINATION ON TRANSFER TO [**Hospital Unit Name 153**]: Temperature 100.2.
Heart rate 120. Blood pressure 100/44 went down to 80/40s.
Respirations 28. O2 sat 94% on nonrebreather. General,
cachectic elderly man, tachycardic with nonrebreather. Head
and neck examination anicteric sclera. Palpable
lymphadenopathy bilaterally. Cardiovascular distant heart
sounds. Regular rate by pulses. Lungs coarse breath sounds
bilaterally. No wheezing. Abdomen soft, nontender,
nondistended. Extremities no edema, 1 to 2+ distal pulses.
Neurological alert, awake and oriented times three.
LABORATORIES ON TRANSFER TO [**Hospital Unit Name 36166**] [**7-23**]: White blood cell
count of 15.7, hematocrit 27.2, 23% bands, platelets 430, PT
14.8, PTT 26.3, INR 1.5. Sodium 125, potassium 5.2, chloride
86, bicarb 22, BUN 64, creatinine 1.6 up from baseline of .6
to .8. Glucose 170, albumin 2.6, total bili .5, ALT 27, AST
79, alkaline phosphatase 184, LDH 375. Calcium 7.9,
magnesium 1.9, phos 6.0. Amylase 32, lipase 16. Arterial
blood gas 7.41, 38, 115 then went down to 7.45, 34 and 77.
Sputum four gram stain culture showed 2+ oral flora and on
[**7-23**] showed 4+ yeast, 2+ oral flora. Cultures still
pending, uric acid 13.5. Blood cultures on [**7-22**] pending.
Urinalysis showed negative nitrites, negative leukocyte
esterase, 5 red blood cells, no white blood cell, rare
bacteria, less then 1 epi. Positive for uric acid crystals.
TSH 3.0, cortisol 17.
HOSPITAL COURSE: The patient was intubated on the day of
transfer to the MICU. He was started on broad antibiotic
coverage for sepsis. He remained hypotensive and tachycardic
for which he was started on multiple pressors. However,
despite aggressive measures the patient continued to
deteriorate clinically. After a long discussion with the
family and Dr. [**Last Name (STitle) **] the patient's oncologist the
decision was made to withdraw care given his extremely poor
prognosis. The patient passed away in peace on [**2168-7-28**].
DISCHARGE DIAGNOSES:
1. Respiratory failure.
2. Sepsis.
3. Acute renal failure.
4. Large cell lung cancer.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], M.D. [**MD Number(1) 8654**]
Dictated By:[**Last Name (NamePattern1) 4432**]
MEDQUIST36
D: [**2168-8-31**] 11:49
T: [**2168-9-2**] 10:31
JOB#: [**Job Number 36167**]
ICD9 Codes: 5070, 5849, 0389, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2455
} | Medical Text: Admission Date: [**2140-11-3**] Discharge Date: [**2140-11-7**]
Date of Birth: [**2081-3-15**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 59 year-old gentleman with
severe triple coronary artery disease, had a positive stress
test prior to admission. He was referred for cardiac
catheterization. Cardiac catheterization showed a 100%
circumflex lesion, 80% RCA blockage, and 80% LAD lesion.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease.
3. Status post back surgery [**63**] years ago.
4. Status post bowel surgery as a child.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 milligrams q day.
2. Zestril 20 milligrams q day.
3. Atenolol 50 milligrams q day.
4. Ativan 0.5 milligrams [**Hospital1 **].
5. Imdur 30 milligrams q day.
LABORATORY DATA: He did have preoperative work up done prior
to his admission for his cardiac catheterization.
PHYSICAL EXAMINATION: He had a negative HEENT exam. No
pulmonary symptoms. No cardiac symptoms. He was obese. His
blood pressure was 126/86 with a heart rate of 65. He had no
carotid bruits. His heart was regular rate and rhythm. His
lungs were clear. He had good bowel sounds. His extremities
had normal peripheral pulses and no varicosities.
HOSPITAL COURSE: This gentleman was to go home and return
for his cardiac surgery which was scheduled for [**2140-11-3**].
On [**2140-11-3**] he underwent coronary artery bypass grafting
times three with a LIMA to the LAD, a vein graft to the PDA
and a radial artery to the OM. He was transferred to the
Cardiothoracic ICU in stable condition on a Neo-synephrine
drip, nitroglycerin and Propofol.
On postoperative day one he had been extubated. His blood
pressure was good. He was hemodynamically stable with a
pressure of 104/58. He was in sinus rhythm in the 80s. His
post extubation gas was good. His hematocrit was 30.9 with a
white count of 10.5, platelet count 198,000, sodium 138,
potassium 4.8, chloride 107, CO2 25, BUN 12, creatinine 1.2.
He was awake and alert. His heart was regular rate and
rhythm. His lungs were clear. His sternum was stable with
chest tubes in place. His left hand was warm with good
sensation and motor function intact and good capillary
refill. He remained on Neo-Synephrine and a nitroglycerin
for his radial artery. His nitroglycerin was discontinued
and he was switched back over the po Imdur and started his
Lopressor, Lasix diuresis and aspirin again. He was
transferred out to the floor.
He was seen by Physical Therapy for evaluation on the floor.
On postoperative day two he had some pain issues which were
controlled with narcotics. He had positive air leak in his
chest tubes. His breath sounds were decreased bilaterally
with crackles on the right. His dressings were clean, dry
and intact. His sternum had minimal exudate. His heart was
regular rate and rhythm. His abdominal exam was negative.
Chest films were ordered to evaluate his air leak. He
continued his Physical Therapy and rehabilitation on the
floor.
On postoperative day three he was comfortable, no pain
issues. Blood pressure 115/73, heart rate 102, saturation
95% on two liters. He had no air leak but did put out 255
from his chest tube on the day prior. His lungs were clear
bilaterally. His abdominal exam was negative. He was doing
well and ambulating very well. He had only put out 45 since
midnight so his chest tube was discontinued. He continued to
work on his ambulation and rehabilitation on the floor.
On[**Last Name (STitle) 14810**]perative day five he was doing well. His vital signs
were stable. His wires were pulled. His sternum was stable.
His Lopressor was increased. He was instructed about Lasix
diuresis for approximately one week. He was seen again by
Physical Therapy for final evaluation and was discharged to
home on [**2140-11-7**] with instructions to follow up with Dr. [**Last Name (Prefixes) 411**] at three to four weeks.
DISCHARGE MEDICATIONS:
1. Lopressor 100 milligrams po bid.
2. Lasix 20 milligrams po q day times seven days.
3. K-Dur 20 milliequivalents po q day.
4. Colace 100 milligrams po bid.
5. Zantac 150 milligrams po bid.
6. Aspirin 325 milligrams po q day.
7. Isosorbide 30 milligrams po q day.
8. Nicotine Patch q day.
9. Thiamine 100 milligrams po bid.
10. Multi vitamin 1 tab q day.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting times three.
2. Coronary artery disease.
3. Hypertension.
4. Obesity.
5. Status post back surgery [**63**] years ago.
6. Status post bowel surgery as a child.
DISCHARGE CONDITION: The patient was discharged to home in
stable condition on [**2140-11-7**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2141-2-1**] 09:42
T: [**2141-2-1**] 10:10
JOB#: [**Job Number 37714**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2456
} | Medical Text: Admission Date: [**2169-2-15**] Discharge Date: [**2169-3-3**]
Date of Birth: [**2102-1-19**] Sex: M
Service: MEDICINE
Allergies:
Tagamet / Ditropan / Penicillins / Lisinopril / Heparin Agents
Attending:[**Known firstname 1881**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
This is a 67 yom s/p tracheostomy, h/o
Pseudomonas/Acineterbacter MDR PNA who is admitted from [**Hospital 100**]
Rehab with T 104.6 rectally. Mr. [**Known lastname **] was recently admitted
twice to [**Hospital1 18**] MICU green from [**Date range (1) 95399**]/09 and then
[**Date range (2) 95402**] for similar system of complaints. During that
admission he was initially treated with Vancomycin/Amikaicin and
Colistin for treatment of his history of MDR Pneumonia. He was
seen by ID during that admission and decision was made to stop
amikacin/colistin as his sputum cultures grew only MRSA. He was
treated for an MRSA pneumonia and completed his course of
Vancomycin on [**2168-2-12**].
Per his wife, Mr. [**Known lastname **] was doing well at the rehab center until
yesterday when he [**Known lastname 28316**] to 101 at the rehab center. He was
alert yesterday morning and then became more somnolent. She
also reports that he stated he was feeling nauseous on monday,
no emesis.
Per records from [**Hospital 100**] Rehab, Mr. [**Known lastname **] [**Last Name (Titles) 28316**] a temperature to
101.4 on [**2169-2-14**]. He was pancultured. CXR was done which
showed no change from CXR from [**2169-2-9**]. PICC line was
discontinued and the tip sent for culture. Blood cultures were
drawn from the PICC line and from the periphery. Foley was
changed and UA, UCx were sent. Sputum culture was sent as well.
WBC 18.3, HCT 28.3, PLT 220.
Today, Mr. [**Known lastname **] became febrile to 104.6 rectally, with HR 120,
BP 118/70 at the rehab center. UA showed > 50 WBC, [**11-24**] RBC,
neg nitrite, 3+ Leuk esterase. Midline was placed. He was
given Vancomycin 1gm IV x 1, Amikacin 750mg IV x 1. Chem 7 done
and showed Cr rise from 1.5 ([**2169-2-12**]) to 3.0 on [**2169-2-15**]. He was
sent to [**Hospital1 18**] for further evaluation.
In the ED on arrival, VS were Temp 103, HR 108, BP 118/70, RR
16. He was given 3L IVF. UA showed > 50 WBC, Mod Bacteria,
+leuks, neg nitrites and Many yeast. Blood Cx sent. CXR showed
Mild CHF and bilateral pleural effusions. bibasilar air space
opacities likely related to atelectasis.
Past Medical History:
- [**8-/2168**] fall + subdural hematoma c/by S. bovis endocarditis. Tx
6 weeks ceftriaxone. Course c/by MRSA, Enterococcal thought to
be line-related bacteremia.
- [**11/2168**] PCN/Vanc sensitive Enterococcal aortic valve
endocarditis. Tx 6 weeks vancomycin (pcn allergic) - completed 6
weeks tx [**2168-12-21**].
- [**11/2168**] admit c/by Acinetobacter in sputum (? colonization
versus VAP), treated with tobramycin and unasyn (plan was to d/c
on [**12-1**]).
- [**Date range (3) 95358**], one day after discharge, resp failure,
re-intubated. ESBL Klebsiella pna: treated with Meropenem x 12
days. Tracheostomy. Sputum later grew Acinetobacter on [**2168-12-10**]
-> unasyn and tobramycin as above. [**Date range (3) 95400**]. DC [**12-16**] on
trach mask.
- Morbid obesity
- DM type 2 poorly controlled with complications
- Chronic renal insufficiency (new baseline as of [**12-12**] - Cr
1.6-2)
- HTN
- reactive airways disease
- h/o asbestos exposure with pleural plaques
- GERD
- Parkinson's disease
- detrusor instability
- gout
- hypothyroidism
- aortic stenosis, valve area 0.9cm2, peak gradient 24, median
gradient 48
- Anemia
- h/o nephrolithiasis
Social History:
-- has wife, [**Name (NI) **], who is HCP; also with two daughters
-- no alcohol or tobacco use
-- currently resides at [**Hospital 100**] Rehab
-- formerly owned pizzaria restuarants
Family History:
non-contributory
Physical Exam:
VS on arival to MICU: T 99.5, HR 106, BP 105/67, RR 23, AC
550/12/5/0.50
General: Mild distress,diaphoretic; obese
HEENT: +tracheostomy
LUNGS: +mild crackles anterior lung fields
CARDIO: +S1/S2, no M/R/G, tachycardic
ABD: + BS, NT/ND, obese
EXTREMITIES: no c/c. +1 peripheral edema
NEURO: responds to verbal stimuli
Pertinent Results:
[**2169-2-28**] 05:01AM BLOOD WBC-8.9 RBC-2.65* Hgb-7.5* Hct-24.6*
MCV-93 MCH-28.4 MCHC-30.6* RDW-15.7* Plt Ct-196
[**2169-2-24**] 03:56AM BLOOD PT-15.6* PTT-39.5* INR(PT)-1.4*
[**2169-2-28**] 05:01AM BLOOD Glucose-108* UreaN-96* Creat-3.6* Na-147*
K-4.6 Cl-116* HCO3-22 AnGap-14
[**2169-2-24**] 03:56AM BLOOD ALT-19 AST-32 LD(LDH)-263* AlkPhos-81
TotBili-0.2
[**2169-2-28**] 05:01AM BLOOD Calcium-9.1 Phos-5.3* Mg-2.3
[**2169-2-22**] 04:07AM BLOOD Vanco-20.4*
Micro:
GRAM STAIN (Final [**2169-2-24**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2169-2-27**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER BAUMANNII. HEAVY GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
267-4170W([**2169-2-17**]).
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 8 I
MEROPENEM------------- 8 I
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
GRAM STAIN (Final [**2169-2-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2169-2-21**]):
OROPHARYNGEAL FLORA ABSENT.
ACINETOBACTER BAUMANNII COMPLEX. 10,000-100,000
ORGANISMS/ML..
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
STAPH AUREUS COAG +. ~5000/ML.
Isolates are considered potential pathogens in amounts
>1000
cfu/ml. SENSITIVITIES PERFORMED ON REQUEST..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN/SULBACTAM-- 16 I
CEFEPIME-------------- =>64 R 32 R
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- =>4 R 2 I
GENTAMICIN------------ =>16 R 8 I
IMIPENEM-------------- 8 I
MEROPENEM------------- 4 S
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 32 S
TOBRAMYCIN------------ 4 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood Culture, Routine (Final [**2169-2-23**]):
[**Female First Name (un) **] ALBICANS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
267-2475N
[**2169-2-15**].
Aerobic Bottle Gram Stain (Final [**2169-2-19**]): YEAST(S).
Brief Hospital Course:
67 yom s/p tracheostomy, h/o Pseudomonas/Acineterbacter MDR PNA
who is admitted from [**Hospital 100**] Rehab with sepsis, found to have
fungemia, Coag neg staph bacteremia as well as Klebsiella UTI.
Patient expired peacefully after family decision to make comfort
care only.
#. Sepsis/Fungemia: The pt had a history of recurrent MDR PNA as
well as history of endocarditis. Recent admission with MRSA PNA,
completed 14 day course of vancomycin on [**2-12**] now readmitted with
fever. Blood cultures with yeast (prelim- C. albicans) and
Coagulase negative Staph. Urine cultures with Klebsiella. He
was treated with Vanc/Meropenem/caspofungin which was changed to
fluconazole and then no therapy once made comfort care only.
# Acute on Chronic Renal Failure: Pt with history of AIN from
colistin, Cr had improved to 1.5 but then rose. The patient had
peristent tube feeds until made comfort measures by the family.
Tube feeds were stopped during his comfort course when it became
clear that he had limited GI motility.
# R UE Pain ?????? Pt developed right wrist pain which was evaluated
with x-ray. During the terminal aspect of his care his pain was
controlled with Dilaudid.
# Right Brachial DVT: RUE with swelling on admission, +brachial
DVT on U/S. As this is not proximal, decision was not to treat
at this time.
# Respiratory Failure: has had a tracheostomy for 2 months.
Started on AC but changed back to tracheal mask
#. PARKINSON's DISEASE: Continued Sinemet and Ropinirole.
#. HYPOTHYROIDISM: Levothyroxine 88 mcg continued until made
comfort care when stopped.
.
#. ANEMIA: Hx of chronic anemia. Received 2uPRBC on admission
Medications on Admission:
Albuterol Neb q4h
ASA 81mg
Calcium Carb 650mg [**Hospital1 **]
Carbidopa/levodopa QID
Chlorhexadine 12mg [**Hospital1 **]
Vit D 1000u daily
Docusate 100mg [**Hospital1 **]
Ferrous Sulfate 325mg [**Hospital1 **]
Lantus 30u SQ qHS
HISS
Levothyroxine 88mcg daily
Omeprazole 20mg daily
Ropinirole 1mg QID
Senna [**Hospital1 **]
Simvastatin 10mg qHS
Vancomycin 1gm IV [**2169-2-14**] at 2200
Amikacin 750mg IV x 1 [**2169-2-15**] 0100
Discharge Disposition:
Expired
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Parkinson's Disease
Fungemia
Discharge Condition:
Patient expired
[**Known firstname **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
ICD9 Codes: 5990, 5849, 2930, 2760, 5859, 4241, 2749, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2457
} | Medical Text: Admission Date: [**2133-5-28**] Discharge Date: [**2133-6-15**]
Date of Birth: [**2057-7-5**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old
woman with a past medical history significant for coronary
artery disease, status post coronary artery bypass graft in
[**2115**], hypertension and elevated cholesterol who presented on
[**2133-5-28**] with burning epigastric pain. This was originally
thought to be cardiac ischemia and the patient was taken to
cardiac catheterization and found to have patent vein grafts.
Laboratory studies then revealed that the patient had
pancreatitis with an amylase of approximately 3300. The
patient was intubated somewhat prophylactically in the
catheter lab and then admitted to the Medical Intensive Care
Unit. The Medical Intensive Care Unit course was complicated
by hypotension. The patient was on dopamine transiently,
which was thought to secondary to a gastrointestinal
infection. She was anemic to 24 and received multiple units
of packed red blood cells. She also began to spike some
temperatures on [**2133-6-1**], despite being on antibiotics and
continued to have fevers up until her transfer to the floor.
The patient was covered with ceftriaxone and clindamycin
initially for a multilobar vent associated pneumonia. Sputum
grew out Serratia which was sensitive to ceftriaxone. The
patient was ultimately transitioned from clindamycin to
Flagyl in part because there was concern that the patient
might have Clostridium difficile colitis. Flagyl was
ultimately discontinued after the patient had three negative
Clostridium difficile cultures. The patient also had some
transient oliguria, presumably from fluid sequestration while
in the Intensive Care Unit. Over the course of her Medical
Intensive Care Unit stay, she became approximately 10 liters
positive. Her liver function tests, amylase and lipase
decreased to normal and the patient improved clinically an
was extubated on [**2133-6-9**] and transferred that day to the
general wards. The patient currently denies any shortness of
breath, chest pain or abdominal pain.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft performed at [**Hospital1 2025**] 15 years ago with a diagonal to
LAD graft and saphenous vein graft to PDA graft.
2. Hypertension
3. Elevated cholesterol
4. Question history of chronic obstructive pulmonary disease
HOME MEDICATIONS (to be confirmed by her primary care
physician):
1. Aspirin
2. Atenolol
3. Lipitor
4. Hydrochlorothiazide
5. Vasotec
TRANSFER TO FLOOR MEDICATIONS FROM MEDICAL INTENSIVE CARE
UNIT:
[**Unit Number **]. Regular insulin sliding scale
2. Protonix 40 mg intravenous q 24 hours
3. Ceftriaxone 1 gm intravenous q 24 hours
4. Miconazole cream
5. Flagyl 500 mg intravenous q 8 hours
6. Lopressor 10 mg intravenous q6h
7. Nitroglycerin drip for which the patient was currently
being weaned off.
ALLERGIES: No known drug allergies.
PHYSICAL EXAM AT TRANSFER TO THE GENERAL FLOOR:
VITAL SIGNS: Temperature 98.8??????, pulse 90, blood pressure
169/84, respiratory rate 20s, pulse oximetry 98% to 99% on a
shelf mask.
GENERAL APPEARANCE: The patient was awake, alert and mildly
uncomfortable, appearing in no acute distress.
HEAD, EARS, EYES, NOSE AND THROAT: Dry oral mucosa, no oral
lesions.
NECK: Jugular venous pressure was prominent.
CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2, no
murmurs.
LUNGS: Bilateral rales and crackles. There were no wheezes.
Breath sounds were decreased at the bases bilaterally.
ABDOMEN: Soft, nontender, nondistended with active bowel
sounds.
EXTREMITIES: The patient complained of left wrist pain which
later resolved after re-siting of the patient's peripheral
intravenous.
NEUROLOGIC: The patient moved all four extremities and
followed commands.
IMAGING AND LABORATORY STUDIES ON [**2133-6-10**]: White blood count
20.1, hematocrit 32.6, platelets 636. INR 1.2, sodium 145,
potassium 3.3, chloride 106, bicarbonate 26, BUN 32,
creatinine 0.6, glucose 136. The patient had a prior
echocardiogram which showed a normal ejection fraction of 61%
with posterobasal wall motion abnormalities, normal filling
pressures on cardiac catheterization of [**2133-5-28**]. In addition
to sputum culture on [**2133-6-6**] revealing Serratia sensitive to
ceftriaxone, urine cultures on [**2133-6-8**] revealed greater than
100,000 organisms per ml of yeast. In response to this
culture result, the patient's Foley catheter was discontinued
and replaced.
HOSPITAL COURSE BY SYSTEM:
1. INFECTIOUS DISEASE: The patient ultimately presented to
the Intensive Care Unit intubated with evidence of a vent
associated pneumonia. Sputum cultures were positive for
Serratia, sensitive to ceftriaxone for which the patient
received a 14 day course of antibiotics. The patient was
temporarily on anaerobic coverage for question of aspiration
pneumonia, as well as for question of Clostridium difficile
colitis. The patient gradually defervesced on antibiotics
and her respiratory status improved substantially to the
point where she was saturating 95% on room air by the time of
discharge. The patient continued to have bilateral crackles
which were thought to be consistent with some underlying
interstitial lung disease which will be confirmed with her
primary care physician prior to discharge. Regarding the
question of Clostridium difficile, the patient had three
negative cultures and was taken off Flagyl following her
transfer to the floor. The patient's only other infectious
issue was a question of a sinusitis, given recurrent fevers
on antibiotics and the patient's history of having a
nasogastric tube in place while she was in the Intensive Care
Unit. CT of the sinuses did reveal some paranasal sinus
thickening and partial opacification of the mastoid air
cells. Given that the patient was essentially afebrile
following her transfer to the floor, she was taken off of
Flagyl and this etiology was not further pursued. We did
hesitate to place an additional nasogastric tube for feeding
purposes given this result.
2. GASTROINTESTINAL: Patient with presumed gallstone
pancreatitis resolved by the time of her transfer to the
floor. Her amylase and liver function tests had essentially
returned to baseline. The patient received TPN for nutrition
while in the Intensive Care Unit. Please see the nutrition
section for further details. The patient denied any
abdominal pain through the remainder of her hospital stay and
tolerated her advanced diet.
3. CARDIOVASCULAR: The patient with a history of
hypertension by report. As she was unable to take po's, she
relied on intravenous Lopressor and hydralazine for blood
pressure control. After she was started back on po's, she
was put on po Lopressor, po hydralazine and po Vasotec. The
doses of these will be confirmed with her primary care
physician and noted in page 1.
The patient also with a history of coronary artery disease.
She underwent a cardiac catheterization when she was admitted
thinking that her symptoms were related to cardiac ischemia.
This study revealed patent grafts. She has an intact
ejection fraction with some posterobasal wall motion
abnormality as noted on recent cardiac echocardiogram.
During her course on the floor, the patient was gently
diuresed to keep her 500 cc to 1 liter negative per day,
given the fact that she was 10 liters positive and seemed to
mobilizing a lot of fluid following her extubation in the
Medical Intensive Care Unit. The patient was noted to have
some short runs of supraventricular tachycardia for which she
was asymptomatic while in the Intensive Care Unit. She was
kept in telemetry during her floor course for further
monitoring.
4. ENDOCRINE: Patient with slightly elevated blood sugars
while on TPN. Her sugars were followed as we returned her to
her regular diet. She had no known history of diabetes.
5. NUTRITION: The patient relied on TPN while in the
Medical Intensive Care Unit. She failed a swallowing study
upon her return to the floor and was continued on TPN for
several days. A repeat swallowing study on [**2133-6-15**] revealed
good tolerance of po's. She was subsequently taken off of
TPN and her diet gradually advanced.
6. HEMATOLOGICAL: The patient was anemic requiring
transfusion in the setting of her Intensive Care Unit
presentation.
7. ORTHOPEDICS: The patient initially complained of some
left wrist pain while in the Intensive Care Unit. She had
negative wrist x-rays. After resetting of her intravenous,
she exhibited full range of motion without pain of that
extremity.
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSIS:
1. Coronary artery disease with a history of coronary artery
bypass grafts x2
2. Hypertension
3. Pancreatitis
4. Serratia pneumonia
5. Interstitial lung disease
DISCHARGE MEDICATIONS: Please see page 1 for full details.
1. Enteric coated aspirin 325 mg po qd
2. Protonix 40 mg po qd
3. Hydralazine 25 mg po tid
4. Lopressor 25 mg po bid
5. Lipitor 10 mg po qd
6. Vasotec dose to be confirmed by her primary care
physician
7. Albuterol metered dose inhaler 2 puffs q 4 to 6 hours
prn.
DISCHARGE INSTRUCTIONS: At rehabilitation, the patient
should receive physical therapy and occupational therapy.
She should have pulmonary toilet as necessary. She should
have outpatient follow up schedule with her primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42281**], whose phone number is
([**Telephone/Fax (1) 42282**].
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern4) 4689**]
MEDQUIST36
D: [**2133-6-16**] 07:25
T: [**2133-6-16**] 07:34
JOB#: [**Job Number 42283**]
ICD9 Codes: 5070, 2859, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2458
} | Medical Text: Admission Date: [**2123-4-7**] Discharge Date: [**2123-5-11**]
Date of Birth: [**2044-2-14**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Loose stools and fevers
Major Surgical or Invasive Procedure:
[**2123-4-8**] right chest tube (pleurex tube)
[**2123-4-13**] ERCP
[**2123-4-15**] removal of pleurex tube and insertion of pigtail catheter
[**2123-4-30**] Right-sided pigtail catheter drainage
[**2123-5-4**] Talc pleurodesis right lung
[**2123-5-7**] ERCP
History of Present Illness:
79F s/p segment VII resection of metastatic colon CA to liver
([**3-1**]). Was here to have pleurex catheter placed but was having
abdominal pain, fevers, and nausea and was sent to the ED. She
reports passing flatus and stool.
Past Medical History:
Past Medical History:
Bipolar
HTN
Past Surgical History;
TAH
Appendectomy
Social History:
Married, lives with husband and son, drinks one glass of wine
per day, former smoker
Family History:
Non-contributory
Physical Exam:
In ED
97.4, 94, 86/54 to 149/71 96% 3L NC
NAD
RRR
decreased Breath sounds in bases R>L
Abdomen soft, obese, nondistended, no tympany, Midline incision
inferior to umbilicus well healed with 2 small incisional
hernias. Bowel easily reducible.
EXT: warm and dry
Pertinent Results:
JP drain fluid
GRAM STAIN (Final [**2123-4-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
[**2123-4-7**] 12:05PM BLOOD WBC-19.7*# RBC-4.20 Hgb-11.5* Hct-35.2*
MCV-84 MCH-27.4 MCHC-32.7 RDW-14.1 Plt Ct-316#
[**2123-4-7**] 12:05PM BLOOD Neuts-95.4* Bands-0 Lymphs-2.4* Monos-2.0
Eos-0.1 Baso-0.1
[**2123-4-8**] 08:40AM BLOOD PT-16.1* PTT-28.2 INR(PT)-1.4*
[**2123-4-8**] 05:30AM BLOOD Glucose-106* UreaN-14 Creat-1.1 Na-135
K-3.9 Cl-101 HCO3-27 AnGap-11
[**2123-4-7**] 12:05PM BLOOD ALT-15 AST-24 AlkPhos-156* TotBili-0.4
[**2123-4-8**] 05:30AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
[**2123-4-7**] 12:17PM BLOOD Lactate-2.9*
[**4-7**] CT chest/abd/pelvis
IMPRESSION:
1. Dilated loops of small bowel up to 3.5 cm, with air-fluid
levels, and transition point in small ventral hernia in the
midline lower abdomen, after which bowel loops are decompressed,
and contain no oral contrast. This appearance is concerning for
small-bowel obstruction, although the presence of gas within the
colon and rectum suggests that it may be an early obstruction,
or a partial obstruction.
2. Heterogeneous 6.3 x 2.5 cm fluid collection posterior to the
right hepatectomy resection margin could represent post-surgical
change and material such as Surgicel, although it is difficult
to exclude abscess formation.
3. Increased size of multiple hypodense lesions within the liver
concerning for progression of metastatic disease.
4. Unchanged appearance of ill-defined hypodense lesion within
the spleen. This lesion was characterized by MRI from [**2123-1-10**] as
having features suggestive of a lymphangioma.
5. Large right pleural effusion and right lower lobe atelectasis
Small left pleural effusion.
6. Small-volume ascites.
.
Labs at discharge: [**2123-5-8**]
WBC-8.4 RBC-4.27 Hgb-11.6* Hct-36.5 MCV-85 MCH-27.1 MCHC-31.8
RDW-14.4 Plt Ct-298
Glucose-99 UreaN-10 Creat-0.7 Na-144 K-3.7 Cl-104 HCO3-33*
AnGap-11
ALT-14 AST-20 AlkPhos-111 Amylase-35 TotBili-0.4
Albumin-2.5*
Brief Hospital Course:
Patient was seen in ED and admitted to General Surgery service.
IV cipro and flagyl was started, an NGT and Foley were placed,
and she was kept NPO with IVF. An abdominal CT was done showing
dilated loops of small bowel up to 3.5 cm, with air-fluid
levels. Point of obstruction appeared to be a ventral hernia in
the lower abdominal wall. A heterogeneous 6.3 x 2.5 cm fluid
collection posterior to the right hepatectomy resection was
noted. There was increased size of multiple hypodense lesions
within the liver concerning for progression of metastatic
disease and small-volume ascites. A large right pleural effusion
and right lower lobe atelectasis with a small left pleural
effusion was noted.
.
Interventional pulmonology was contact[**Name (NI) **] and on [**Name (NI) 58274**] a right
pleurex catheter was placed and attached to a pleuravac and
suction. This initially drained ~ one liter of straw colored
fluid. She remained on O2 nasal cannula with diminished breath
sounds in the lower lobes. On [**4-13**], 700cc of serous fluid was
removed from the pleurx tube. The pleurx catheter was removed on
[**4-14**] due to persistent leaking at the connection site to the
pleuravac. A right pleural 14 french pigtail catheter was placed
at the 5th ICS. The pigtail was connected to a pleuravac. On
[**2123-5-4**] a talc pleuradesis was performed on her right lung with
follow-up CXRs with no PTX and stable pleural effusion. She
remains on O2 via nasal cannula. O2 sats drop into high 80's
when ambulating, she remains asymptomatic. Most recent Chest
xray on [**5-7**] shows: the bilateral moderate pleural effusions are
unchanged with associated right lower lobe atelectasis.
.
On [**4-9**], the NG tube was removed. Diet was advanced slowly and
tolerated. LFTs remained stable as well as chemistries.
.
The JP continued to drain bilious fluid. This fluid was cultured
and grew two species of E.coli resistent to ampicillin and
cipro, but sensitive to Bactrim. Therefore, Bactrim DS [**Hospital1 **] was
started on [**4-11**]. The JP drainage averaged approximately 70cc/day.
On [**4-13**], ERCP was performed noting bile leak. Sphincterotomy was
done with stent placement. Post ERCP, the JP drainage decreased
to ~ 30cc/day. WBC was 17 on admission with downward trend to
11. She had a second ERCP on [**5-7**] and she had a stent
exchanged. She will remain on Bactrim on discharge. The JP drain
remians in place.
.
She had a UTI with a resistant strain of E coli. She received 10
days of Meropenem IV. There was also concern for urinary
retention. She should be encouraged for frequent toileting and
bladder training. Urine culture from [**5-4**] was no growth. A
surveillance culture was sent on [**5-11**] prior to discharge and
should be followed up as an outpatient.
.
Dr.[**Name (NI) 3377**] team was consulted regarding possibility of
repairing ventral hernia. Given bile leak, infection and
effusion repair was deferred at this time.
.
PT/OT evaluated her. She was safe to transfer and ambulate with
nursing, but continued to require PT. The plan was for her to go
to rehab facility for further rehab, as she is requiring
assistive devices and has increased O2 requirements with
activity.
Medications on Admission:
atenolol 50', lasix 20', keppra 500", risperidol 1.5', mvi',
folic acid'
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Risperidone 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
9. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
abdominal pain
right pleural effusion
UTI
Bile leak
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever >101,
chills, nausea, vomiting, abdominal distension or increased
abdominal pain, jaundice, shortness of breath,
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 673**] [**2123-5-19**] 2:00 PM
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-5-31**]
11:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-5-31**]
11:30
ERCP 2 (ST-4) GI ROOMS Date/Time:[**2123-7-20**] 4:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2123-5-11**]
ICD9 Codes: 5119, 5180, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2459
} | Medical Text: Admission Date: [**2177-3-29**] Discharge Date: [**2177-4-5**]
Date of Birth: [**2104-1-22**] Sex: M
Service: C-MEDICINE
CHIEF COMPLAINT: Dyspnea.
HISTORY OF PRESENT ILLNESS: This is a 73 year old African
American male diagnosed with congestive heart failure in
[**11-9**], who presents with sudden fatigue, weakness and dyspnea
while bringing out his trash. The patient felt well until
the morning of admission and was brought to the [**Hospital1 346**] Emergency Department by ambulance.
In the Emergency Department, the patient was asymptomatic and
denied previous oxygen requirement or lower extremity edema.
He has been compliant with his congestive heart failure
medication including low sodium diet and daily weights. He
states that he is without symptoms at this time. In the
Emergency Department, he was noted to have atrial flutter
with heart rate 120 to 130 with mild hypotension. Due to his
abrupt symptoms, the patient underwent VQ scan which
indicated low probability for pulmonary embolus.
Review of systems was negative for fever, chills, upper
respiratory infection symptoms, chest pain, positive for
shortness of breath, negative for nausea, vomiting,
diaphoresis or abdominal pain.
PAST MEDICAL HISTORY:
1. Congestive heart failure diagnosed in [**11-9**].
Catheterization at that time was negative except for apical
and septal akinesis, ejection fraction noted to be 12%.
2. Hypertension.
3. Noninsulin dependent diabetes mellitus which is diet
controlled.
4. Prostate cancer, status post prostatectomy.
5. ? multiple myeloma.
6. Hernia, status post herniorrhaphy.
7. Keloid scars.
8. Status post bilateral total knee replacement.
9. Carpal tunnel syndrome.
10. Prolapsed rectum.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Univasc 15 mg p.o. q.d.
2. Norvasc 10 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Lasix 20 mg p.o. q.d.
5. Carvedilol 3.125 mg p.o. b.i.d.
SOCIAL HISTORY: The patient has a history of alcohol use.
He also has a history of tobacco use approximately one pack
per day for thirty-five to forty years, but quit twenty years
ago.
FAMILY HISTORY: Mother died of myocardial infarction at age
80. Brother died of diabetes mellitus in his 30s and sister
died of diabetes mellitus/systemic lupus erythematosus in her
50s.
PHYSICAL EXAMINATION: Vital signs revealed temperature of
96.5, blood pressure 122/70, pulse 113, respiratory rate 20,
oxygen saturation 97% on three liters, weight 74.5 kilograms.
In general, this is a moderately obese African American male
lying in bed in no acute distress. Extraocular movements are
intact. Anicteric sclera. Mucous membranes are moist. No
lymphadenopathy. No jugular venous distention.
Cardiovascular - the heart rate was fast but regular, no
murmurs, rubs or gallops. The lungs are clear to
auscultation bilaterally. The abdomen revealed normoactive
bowel sounds, nontender, nondistended, no masses.
Extremities - no cyanosis, clubbing or edema, no swelling,
good dorsalis pedis and posterior tibial pulses.
LABORATORY DATA: On admission, white count was 10.1,
hematocrit 38, platelets 276,000. Prothrombin time 14.2,
partial thromboplastin time 28.0, INR 1.4. Chem7 showed a
sodium of 140, potassium 4.7, chloride 105, bicarbonate 25,
blood urea nitrogen 46, creatinine 1.9, blood sugar 175,
calcium 9.5.
Electrocardiogram showed normal axis, wide QRS with possible
Q waves in V1 through V3 with poor R wave progression. There
is right bundle branch block.
HOSPITAL COURSE:
1. Cardiovascular - atrial flutter - The patient was started
on Heparin in the Emergency Department and underwent
transesophageal echocardiogram on [**2177-3-31**], which showed the
following: dilated left atrium with no spontaneous
echocardiographic contrast seen in the body of the left
atrium or left atrial appendage with markedly reduced left
atrial appendage emptying. There were two mobile echogenic
masses seen in the left atrial appendage on multiple views
consistent with probable thrombus. There was also severe
global left ventricular hypokinesis with right ventricular
systolic function appearing depressed. There are small
echogenic masses on the ventricular surface of the aortic
valve. Mitral regurgitation 1+ was seen.
At that time, direct cardioversion was held secondary to the
possibility of emboli/clot. That night, the patient was
noted to have hypotension to the 70s to 80s which was
moderately responsive to intravenous fluids. It was thought
secondary to poor atrial kick and decompensation of the
heart.
The following morning the patient underwent atrial flutter
ablation with mild improvement of systolic blood pressure to
90s. The patient continued to have poor response to
intravenous fluids with poor urine output. Creatinine was
noted to be increased from 2.1 on [**2177-4-1**], to 2.5 on
[**2177-4-2**].
At that time, he was transferred to the CCU for intravenous
Dopamine for improvement of pressure and diuresed with Lasix
drip.
Right IJ and right arterial line were introduced at that
time. Pulmonary artery catheter was introduced as well
noting introductory pressures of the following: right atrial
pressure 16 with pulmonary artery pressure of 47/32 with a
wedge of 32, cardiac index 2.21 and SVR 1200. He was started
on Dopamine with approximate 6.3 liters diuresis after Lasix
drip. Wedge decreased to 22 to 23 with cardiac output
increased to 6.0 and cardiac index improved to 2.5.
The patient was gradually weaned off Lasix drip and placed on
p.o. Lasix b.i.d. Dopamine was weaned off on [**2177-4-3**]. On
[**2177-4-4**], the patient was transferred back to the floor for
further management.
That night, Carvedilol was restarted with good effect.
2. Renal - The patient was noted to have times of prerenal,
acute renal failure on [**2177-3-31**], at admission with blood urea
nitrogen and creatinine both increased. He was given mild
intravenous fluids with worsening of creatinine the following
day. On [**2177-4-2**], creatinine was noted to be 2.5 with
potassium 5.4. He was given Kayexalate to improve his
hyperkalemia. Urine electrolytes noted prerenal defect with
FENA of 0.21%. At that time, he was transferred to the CCU
for Lasix drip and severe diuresis. Blood urea nitrogen and
creatinine were noted to be improved. Creatinine on
[**2177-4-4**], was noted to be 1.4 which is almost back to
baseline.
3. Hematology - The patient was noted to have hematocrit of
38.0 on admission which has decreased after every procedure.
Hematocrit on [**2177-4-4**], was noted to be 28.5. Analysis and
iron study laboratories were sent off. Heparin and Coumadin
were continued for left atrial thrombus and to prevent
embolization.
DISPOSITION: The patient will likely be discharged home on
[**2177-4-5**]. He will follow-up with Dr. [**Last Name (STitle) **] in approximately
two to three weeks in Advanced [**Hospital **] Clinic.
MEDICATIONS ON DISCHARGE:
1. Lovenox 60 mg subcutaneous b.i.d.
2. Amiodarone 400 mg p.o. q.d. times three months and then
switch to 200 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Coreg 3.125 mg b.i.d.
5. Enalapril 2.5 mg p.o. b.i.d.
6. Lasix 40 mg p.o. b.i.d.
7. Coumadin 5 mg p.o. q.d.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. New atrial flutter, status post ablation.
2. Congestive heart failure.
3. Hypertension.
4. Noninsulin dependent diabetes mellitus.
5. Prostate cancer.
6. Herniorrhaphy.
7. Keloid scar.
8. Bilateral total knee replacement.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Name8 (MD) 8073**]
MEDQUIST36
D: [**2177-4-4**] 13:26
T: [**2177-4-5**] 09:27
JOB#: [**Job Number 96473**]
ICD9 Codes: 4280, 5849, 4254, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2460
} | Medical Text: Admission Date: [**2192-8-9**] Discharge Date: [**2192-9-4**]
Date of Birth: [**2125-2-14**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
I am here for chemotherapy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67M with no significant past medical history who noted enlarged
groin lymph nodes several weeks ago. One of these was excised
and while the pathology was pending he became quite ill. He
vomited 5 days ago and was noted to be jaundiced by his wife.
[**Name (NI) **]
was then admitted to [**Hospital6 33**] for liver and renal
failure.
The pathology on his inguinal node is diffuse large B-cell
lymphoma. He was transferred here for further evaluation and
treatment. His most recent bilirubin is 21, Cr 2.6, LDH 2500.
Past Medical History:
Hypertension
Social History:
Married and lives with his wife, worked at [**Location (un) **] air base, now
retired. Stopped smoking in [**2147**], occasional EtOH.
Family History:
Mother with hx unknown cancer, father with heart disease.
Physical Exam:
Vitals: T:99.5 BP:126/60 P:101 R:38 O2: 95% 2L
General: Alert, oriented, no acute distress, jaundiced
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs
[**2192-8-9**] 07:24PM GLUCOSE-129* UREA N-55* CREAT-2.4*
SODIUM-127* POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-16* ANION GAP-19
[**2192-8-9**] 07:24PM estGFR-Using this
[**2192-8-9**] 07:24PM ALT(SGPT)-85* AST(SGOT)-264* LD(LDH)-2448*
ALK PHOS-820* TOT BILI-23.7* DIR BILI-18.9* INDIR BIL-4.8
[**2192-8-9**] 07:24PM ALBUMIN-2.2* CALCIUM-7.9* PHOSPHATE-3.5
MAGNESIUM-2.9* URIC ACID-4.3
[**2192-8-9**] 07:24PM PT-19.4* PTT-33.2 INR(PT)-1.8*
[**2192-8-9**] 07:24PM FIBRINOGE-532*
[**2192-8-9**] 07:14PM WBC-11.5* RBC-3.43* HGB-10.5* HCT-31.4*
MCV-92 MCH-30.5 MCHC-33.4 RDW-18.2*
[**2192-8-9**] 07:14PM NEUTS-80* BANDS-0 LYMPHS-13* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-3*
[**2192-8-9**] 07:14PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL
[**2192-8-9**] 07:14PM PLT SMR-LOW PLT COUNT-144*
[**2192-8-9**] 07:12PM TYPE-ART PO2-96 PCO2-26* PH-7.42 TOTAL
CO2-17* BASE XS--5
[**2192-8-9**] 07:12PM LACTATE-4.8* K+-4.0
[**2192-8-9**] 07:12PM freeCa-1.01*
.
Discharge labs
.
[**2192-9-4**] 12:00AM BLOOD WBC-8.5 RBC-2.51* Hgb-8.3* Hct-24.2*
MCV-97 MCH-33.0* MCHC-34.1 RDW-24.1* Plt Ct-138*
[**2192-9-4**] 12:00AM BLOOD Neuts-96.3* Lymphs-1.4* Monos-1.7*
Eos-0.6 Baso-0.1
[**2192-9-4**] 12:00AM BLOOD PT-12.2 PTT-19.8* INR(PT)-1.0
[**2192-9-2**] 12:22AM BLOOD Fibrino-423*
[**2192-8-27**] 12:00AM BLOOD Gran Ct-3698
[**2192-9-4**] 12:00AM BLOOD Glucose-309* UreaN-33* Creat-0.8 Na-135
K-4.0 Cl-100 HCO3-24 AnGap-15
[**2192-9-4**] 12:00AM BLOOD ALT-64* AST-30 AlkPhos-213* TotBili-2.7*
[**2192-9-4**] 12:00AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.9
[**2192-8-18**] 12:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE
[**2192-8-18**] 03:27PM BLOOD Smooth-NEGATIVE
[**2192-8-18**] 03:27PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2192-8-19**] 12:05AM BLOOD HIV Ab-NEGATIVE
[**2192-8-18**] 12:30AM BLOOD HCV Ab-NEGATIVE
[**2192-8-21**] 12:00AM BLOOD ANTI-PLATELET ANTIBODY-TEST
.
CXR [**2192-8-25**] Right internal jugular line tip is at the level of
cavoatrial junction. The heart size is normal. Mediastinum is
normal. There is slight interval decrease in the right pleural
effusion as compared to [**2192-8-10**]. There are no new focal
consolidations worrisome for infectious process. There is no
evidence of failure. If clinically warranted, further
evaluation with cross-sectional imaging toexclude the
possibility of occult infection.
.
ECG [**2192-8-25**] Sinus tachycardia, rate 131. Moderate baseline
artifact. Consider left atrial
abnormality. Late transition. No previous tracing available for
comparison.
.
ECHO [**2192-8-20**] The left atrium and right atrium are normal in
cavity size. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Left ventricular systolic function is hyperdynamic (EF>75%).
There is a mild resting left ventricular outflow tract
obstruction. 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) 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 estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Small LV cavity size with moderate symmetric LVH and
hyperdynamic LV systolic function. Consequently, there is an
intra-cavitary gradient which likely occurs at the
mid-ventricular level.. Mildly thickened mitral and aortic
valves without significant stenosis or regurgitation.
.
CT TORSO [**2192-8-12**] contrast IMPRESSION:
1. Moderate right pleural effusion, and small left pleural
effusion, and
bibasilar atelectasis, worse on the right.
2. Bilateral prominent axillary lymph nodes, and prominent hilar
and
mediastinal lymph nodes.
3. Multiple liver hypodensity, suboptimally characterized due to
size and
single-phase contrast.
4. Splenic hypodensities concerning for splenic lymphoma
involvement, or
splenic infarct.
5. Large lymph nodes in periportal area.
6. Multiple prominent lymph nodes in mesentery and
retroperitoneum and along
pancreas and splenic hilum.
7. Bilateral prominent lymph nodes in inguinal and groin area.
8. Small amount of ascites.
9. Right groin fluid collection, could be evolving hematoma,
seroma, or
lypmhocele. Correlate if history of recent biopsy/intervention
in area.
.
Abdomen U/S [**2192-8-10**]
1. Diffusely increased hepatic echogenicity with multiple
hypoechoic masses
scattered throughout the liver. This appearance is highly
suspicious for
malignancy. Further characterization of these findings with MR
imaging is
recommended.
2. Multiple enlarged periportal lymph nodes as described.
3. Mild splenomegaly. Please note that a large left abdominal
mass mentioned
in the history was not identified with ultrasound and further
evaluation could
be obtained with CT if clinically indicated.
4. Gallstones along with gallbladder sludge. No intra- or
extra-hepatic
biliary duct dilation.
5. Small right pleural effusion.
.
CXR [**2192-8-10**]
The right central venous line tip was repositioned and is
currently at the low SVC. There is slight interval increase in
bilateral pleural effusions in the interim. Mild vascular
engorgement cannot be excluded. Mediastinal widening in
particular along the right paratracheal area at the level of the
azygos vein as well as at the aortopulmonic window is unchanged
and most likely
consistent with diagnosis of B-cell lymphoma.
Brief Hospital Course:
# Diffuse B-cell lymphoma: Mr [**Name13 (STitle) 11752**] was admitted with newly
diagnosed diffuse large B-cell non-Hodgkin's lymphoma. He
received dexamethasone and mechlorethamine while in the ICU on
[**2192-8-10**]. His dexamethasone was changed to daily solumedrol
upon return to the floor [**2192-8-11**]. A CT of his torso to
evaluate the burden of his disease revelaed extensive
para-aortic and hilar lymphadenopathy and intrahepatic
involvement. Rituxan was initiated on [**8-14**] to decrease his
tumor burden and was repeated on [**8-17**]. Tumor lysis labs were
followed and Mr. [**Name13 (STitle) 11752**] was continued on allopurinol therapy. The
initiation of standard therapy could not be initiated until his
liver function improved. His AST and ALT eventually normalized,
however his total bilirubin took longer to normalize. The goal
to initiate therapy was a total bilirubin of 2, so as to not
compromise standard therapy of R-CHOP through significant
re-dosing. On [**2192-8-31**], it appeared that Mr. [**Name13 (STitle) 87096**] total
bilirubin had plateaued at 3. Mechlorethamine was administered,
10mg twice over two days. Mr. [**Name13 (STitle) 87096**] tolerated the therapy
well, he was treated with 5 days of high dose steroids after
chemotherapy and experienced a slight increase in LFTs likely as
a result of the therapy. As Mr. [**Name13 (STitle) 87096**] was clinically stable,
it was decided to discharge him to home with regular follow-up
for evaluation for future care.
.
# Acute Kidney Injury: Mr. [**Initials (NamePattern4) 87096**] [**Last Name (NamePattern4) **] was likely prerenal. He
was transferred to the ICU briefly after admission secondary to
tachypnea likely from metabolic acidosis. His [**Last Name (un) **] resolved with
IV fluids and he was transferred back to the floor.
.
# Hepatic failure: He was noted to have elevated liver enzymes
with LDH of 2400 and T. Bili of 24.0 on admission. His liver
function tests continued to rise throughout his admission,
maximally elevated at ALT 128 and AST 264 with peak LDH 2448,
maximal Alkphos of 833 and total bilirubin of 26.3. His
cholestatic liver disease began to improve on HD 6. Rituxan was
initiated on [**8-14**] and [**8-17**]. Mr. [**Name13 (STitle) 87096**] encephalopathy improved
throughout his hospital stay. He was clinically at baseline at
the time of discharge.
.
# Urinary Tract Infection: Mr. [**Known lastname 16968**] began to develop symptoms
of dysuria on HD 5. A urine culture grew coagulase negative
staph aureas and Mr. [**Known lastname 16968**] was started on PO ciprofloxacin.
Mr. [**Name13 (STitle) 87096**] foley catheter was not removed or replaced at this
time, because of significant edema, ongoing chemotherapy and the
need to follow urine out-put during chemotherapy. On Day 2,
ciprofloxacin was changed to IV given Mr. [**Name13 (STitle) 87096**] bowel edema to
ensure adequate therapy.
.
# Edema: Mr. [**Name13 (STitle) 87096**] was admitted to the hospital with
significant edema that initially worsened throughout his stay.
Evidence of bowel edema and mild ascities on CT. He responded
well to IV Lasix. His edema was significantly improved at the
time of discharge.
.
# Right Inguinal Node Biopsy Site: Mr. [**Name13 (STitle) 87096**] developed poor
wound healing at the site of his lymph node biopsy at an OSH.
The bx site was deep between skin folds. Evidence of a hematoma
or seroma was visualized on CT. General Surgery was consulted
to examine the wound, antibiotic therapy was deferred and wet to
dry dressing was applied three times a day. Wound culture grew
MRSA, he was treated for several days with IV Daptomycin, as Mr.
[**Known lastname 16968**] reportedly has a vancomycin allergy, which was
discontinued as the culture appeared more consistent with a
contaminant. A wound vacuum was applied for almost a week to
help with wound healing. The vacuum was discontinued prior to
discharge. Mr. [**Known lastname 16968**] was discharged to home with nursing
assistance to continue dressing changes.
Medications on Admission:
Zofran 4 mg IV q 4 PRN
Dilaudid 1 mg IV q 4 prn
Reglan 5 mg TID
Lovenox 30 mg q day
Protonix 40 mg q 12 IV
Levaquin 500
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for groin skin changes.
Disp:*1 Bottle* Refills:*0*
4. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*120 Tablet(s)* Refills:*2*
5. Prednisone 5 mg Tablets, Dose Pack Sig: 4-1 Tablets, Dose
Packs PO once a day for 3 days: Take 4 pills on day 1
([**2192-9-5**]), take 2 pills on day 2 ([**2192-9-6**]) and take 1 pill
on day 3 ([**2192-9-7**]).
Disp:*7 Tablets, Dose Pack(s)* Refills:*0*
6. Outpatient Physical Therapy
67 year old gentleman with new diagnosis large B cell lymphoma
with de-conditioning after a long hospital stay.
7. Neupogen 480 mcg/1.6 mL Solution Sig: One (1) Injection once
a day for 10 days.
Disp:*10 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Centrus Home Care
Discharge Diagnosis:
1. Large B Cell Lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for initiation of treatment of Large B Cell
Lymphoma. Your liver function was affected by the lymphoma
preventing standard treatment, which requires normal liver
function. You were given special chemotherapy treatments
(Mechlorethamine and Rituxan) to help restore your liver
function in hopes of initiating standard treatment. Your
treatment course was complicated by kidney failure, that
required several days in the intensive care unit. Your kidney
is now functioning normally.
Your oncologist is Dr. [**First Name (STitle) **], who is the physician who admitted
you. You will follow up in clinic on Friday [**2192-9-7**] to check
your blood counts and receive a third dose of Rituxan. You have
been started on a new medication, Neupogen, on the day of your
discharge to help with your counts.
You also developed a wound at the site of your lymph node
biopsy. Our general surgeons were consulted. They treated the
wound with a vacuum and eventually wet-to-dry dressing. A home
nursing aid will change your dressing daily.
You were started on several medications during your hospital
stay, that people with lymphoma often take during treatment.
Please continue taking the allopurinol, ursodiol and acyclovir
as directed.
Your blood sugars have been high for the last several days
because of the high dose steroids you received over the weekend
with the chemotherapy. We expect your blood sugars to return to
normal on their own. Your home nursing aid will check your
blood sugars for you. We are also sending you home on a steroid
taper to ease yourself off prednisone.
Followup Instructions:
1. Date/Time:[**2192-9-7**] 9:00Provider: BED 5-HEM ONC 7F
HEMATOLOGY/ONCOLOGY-7F
2. Date/Time:[**2192-9-10**] 3:00Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC
Phone:[**Telephone/Fax (1) 3241**]
3. (Primary Oncology) Date/Time:[**2192-9-10**] 3:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 19272**], MD Phone:[**Telephone/Fax (1) 3237**]
ICD9 Codes: 5849, 5990, 2762, 4019, 2749, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2461
} | Medical Text: Admission Date: [**2178-8-29**] Discharge Date: [**2178-9-7**]
Date of Birth: [**2124-1-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
Aortic balloon pump insertion
arterial line placement
intubation
swan-ganz catheter placement
History of Present Illness:
Pt is a 54 y/o man w/ a PMH significant for HTN who developed
substernal chest pressure while working outside in his yard. He
went inside and lay down on the floor in front of the fan where
he was found by his wife. She called EMS and he denied fall or
LOC when they arrived. He received aspirin, nitro, and NS and
was transfered to the [**Hospital3 3583**]. In [**Hospital1 46**], he was
hypertensive to 164/118 and bradycardic to 42. His EKG was
significant for complete heart block with ST elevations in II,
III, aVF, and V3-6 as well as ST depressions in I, aVL, V1-2.
He was started on heparin, aggrastat, asa and morphine prior to
being transfered to [**Hospital1 18**]. Of note, his wife said that he has
developed mild pedal edema over the past few days and states
that his exercise tolerance has dropped recently.
.
In the cath lab, he was seen to be actuely vagal with
hypotension and emesis. He was also acutely acidotic and
hypoxic. He was intubated for airway protection. An
intra-aortic balloon pump was placed secondary to his
hypotension. He had several episodes of VT that aborted with
amiodarone 150mg bolus and lidocaine 75mg bolus. He was started
on an amiodarone drip. His cath demonstrated a totally occluded
mid-RCA that was stented. His RPL was ballooned. His right
sided filling pressures were elevated with a PCW 37, RA 27, RV
62/18, and PA 62/38. He had no step up. He received 80mg of
lasix in the lab.
Past Medical History:
HTN
asthma
lumbar disc herniation
Social History:
no smoking, social alcohol, no ivdu. lives w/ wife and
daughter.
Family History:
father died at 49 from MI and mother w/ cardiac issues "at
birth" and died at 49 from "cardiac issues". siblings w/out
medical issues
Physical Exam:
Gen: Pt intubated and sedated with an OG tube
HEENT: PERRL
Neck: -LAD
CV: RRR, s1/s2 intact, -M/G/R
Lungs: Coarse breath sounds b/l
Abd: S/NT/ND, + BS
Groin: R groin oozing w/out hematoma/bruit, L groin w/out O/H/B
Ext: -C/C/E, palpable LE pulses b/l
Pertinent Results:
[**2178-8-29**] 03:57PM BLOOD WBC-18.3* RBC-4.67 Hgb-14.6 Hct-41.6
MCV-89 MCH-31.4 MCHC-35.2* RDW-13.6 Plt Ct-223
[**2178-8-29**] 03:57PM BLOOD Neuts-85.3* Lymphs-10.9* Monos-3.4
Eos-0.2 Baso-0.1
[**2178-8-29**] 03:57PM BLOOD PT-16.4* PTT-150* INR(PT)-1.8
[**2178-8-29**] 03:57PM BLOOD Glucose-159* UreaN-18 Creat-1.4* Na-139
K-3.4 Cl-108 HCO3-15* AnGap-19
[**2178-8-29**] 11:30PM BLOOD CK(CPK)-3357*
[**2178-8-30**] 04:51AM BLOOD CK(CPK)-4161*
[**2178-8-30**] 11:49AM BLOOD CK(CPK)-4962*
[**2178-8-31**] 12:37AM BLOOD CK(CPK)-4473*
[**2178-8-31**] 04:43AM BLOOD CK(CPK)-3865*
[**2178-9-1**] 03:57AM BLOOD ALT-104* AST-169* LD(LDH)-975* AlkPhos-40
TotBili-1.8*
[**2178-8-29**] 11:30PM BLOOD CK-MB-GREATER TH
[**2178-8-30**] 04:51AM BLOOD CK-MB-GREATER TH
[**2178-8-30**] 11:49AM BLOOD CK-MB-420* MB Indx-8.5*
[**2178-8-31**] 12:37AM BLOOD CK-MB-235* MB Indx-5.3 cTropnT-10.06*
[**2178-8-31**] 04:43AM BLOOD CK-MB-149* MB Indx-3.9
[**2178-9-2**] 03:27AM BLOOD calTIBC-186* VitB12-210* Folate-11.4
Ferritn-451* TRF-143*
[**2178-8-30**] 04:51AM BLOOD Triglyc-80 HDL-43 CHOL/HD-3.2 LDLcalc-80
.
ECHO [**8-21**]:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with inferior and
inferio-lateral hypokinesis. The RV size and systolic function
are probably within normal limits (suboptimal views). The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Trivial mitral regurgitation
is seen. There is an anterior space which most likely represents
a fat pad.
.
Cath [**8-21**]:
1. Selective coronary angiography revealed a right dominant
system with
acute occlusion of a large right coronary artery before it gave
off any
marginal branches. The LMCA had no significant disease. The
LAD had
mild diffuse luminal plaquing up to 40% along its length. The
LCx was
non-dominant and had no significant coronary artery disease.
After the
RCA thrombotic stenosis was treated, there was evidence of
distal
emoblization with an abrupt cut off of the terminal R PDA.
2. Hemodynamics revealed severely elevated left and right heart
filling
pressures. The RV and PA pressures were elevated above 50mm Hg
systolic, suggesting some element of chronic pulmonary
hypertension.
The cardiac output and index were preserved however this was in
the face
of dopamine infusion which was probably causing some degree of
splanchnic vasodilation and L > R shunting.
3. Left ventriculography was not performed.
4. Successful placement of temporary 5 French pacing wire during
procedure for heart block via the right femoral vein without
complications. The pacing wire was removed at the conclusion of
the
procedure.
5. Successful placement of 8 French, 40 cc IABP via the left
femoral
artery under fluoroscopic guidance without complications.
Appropriate
systolic unloading and diastolic augmentation were noted with
invasive
hemodynamic measurements.
6. Intubation for hypoxemia, acidemia, and airway control during
the
procedure without complications and with fluoroscopic
confirmation of
appropriate ETT placement.
7. Successful treatment of culprit mid-RCA with a 3.5 x 18 mm
Cypher
drug-eluting stent postdilated with a 3.75 mm balloon. Final
angigraphy
demonstrated no residual stenosis, no angiographically apparent
dissection, and normal flow (See PTCA Comments).
8. Successful treatment of thrombus migration to the r-PL using
balloon
inflations with a 2.5 x 15 mm Voyager balloon. Final angiography
demonstrated no significant residual stenosis, no
angiographically
apparent dissection, and normal flow
Brief Hospital Course:
A/P: Pt is a 54 y/o man w/ a PMH significant for HTN who
presented to [**Hospital1 18**] for urgent cath in the setting of an acute
infero-posterior STEMI.
.
1. CAD - pt presented after an acute infero-posterior STEMI and
received an RCA stent. he was intubated during this process for
respiratory compromise in the setting of cardiogenic shock
during his catheterization. he was started on aspirin, statin,
bb, plavix, and ace in the post-catheterization setting. he
received an echo showing an EF of 45% and
inferior/infero-lateral hypokinesis. he developed a large
hematoma at the groin site that resolved throughout his stay.
he did not have cp after the intervention and tolerated PT
evaluation w/out complaint. he was d/c home on his inpatient
medications w/ close follow-up.
.
2. Hypotension: the patient developed cardiogenic shock during
his catheterization requiring IABP and dopamine. he received 9
L total between OSH and [**Hospital1 18**]. he was weaned off both the
pressors and iabp in the ccu in the days after his
catheterization w/out problem. his bp was monitored w/ an
a-line until transfer to the floor. he was started on bb and
ace after his pressors were weaned and his pressure had
normalized. he tolerated both of these well and was d/c home to
continue bp titration as an outpatient.
.
3. Arrhythmia - pt w/ VT in the cath lab that spontaneously
aborted and was most likely secondary to ischemia and subsequent
reperfusion. he was transiently placed on an amiodarone drip
overnight but was taken off this the next morning and did not
have recurrence of arrhythmia throughout his stay.
.
4. Respiratory - pt w/ a hx of asthma and was intubated for
airway protection during cath. he bit through his ngt while in
the ccu and was noted to have aspirated. empiric abx were
started and the pt subsequently developed a fever/wbc bump that
responded well to abx. he was slowly weaned off his sedation
and extubated successfully following a spontaneous breathing
trial. he was on supplemental oxygen after extubation but this
was slowly weaned both in the ccu and on the floor.
.
5. ARF - pt developed mild arf w/ Cr of 1.4 here (1.2 at outside
hospital). his cr normalized throughout his stay and his ace-i
was started after his cr normalized.
.
Medications on Admission:
Univasc
primatene mist
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-18**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Dicloxacillin Sodium 250 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Infero-lateral ST elevation MI
Discharge Condition:
Stable
Discharge Instructions:
Please keep all your appointments as scheduled
Please take all of your medications as directed
Do NOT stop your plavix or aspirin without taking to your
cardiologist first.
Return to the ER/Call your PCP [**Name Initial (PRE) **]:
1. chest pain
2. shortness of breath
3. fever to 101
4. fainting spells
5. other alarming symptoms
Followup Instructions:
Please see Dr. [**Last Name (STitle) 63700**] in [**Hospital Ward Name 23**] 7 on [**2178-10-5**] at 1:15pm
([**Telephone/Fax (1) 4022**])
Please see Dr [**Last Name (STitle) 32467**]
Completed by:[**2178-10-20**]
ICD9 Codes: 4280, 5849, 5070, 4019, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2462
} | Medical Text: Admission Date: [**2120-4-24**] Discharge Date: [**2120-4-27**]
Date of Birth: [**2092-9-12**] Sex: M
Service: MEDICINE
Allergies:
Effexor
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
acute mental status changes and agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
27 yo M with PMHx of polysubstance of abuse, bipolar disorder,
transfer from [**Hospital1 **] for AMS. He was there on a section 12
for lamictal 100mg OD on [**4-19**] after presenting with lethargy and
nausea to [**Hospital3 **]. His tox was found to be positive
for Cannibis. Per report he has taken [**9-14**] pills in an
intentional overdose but denied SI but was reportedly
disorganized and not a reliable historian. He was treated with
haldol, ativan, risperidone, benadryl, and cogentin. On the
first few days after admission, he became more clear and was
able to participate in thepary, however is mental status began
to decompensate yesterday. He was referred here for confusion
and worsening mental status. There was a question of what or not
he might have ingested drugs over the weekend (from visitors).
Vitals signs at bornewood notable for [**2120-4-23**] HR 136 am and
100pm and [**2120-4-24**] 136am 100 pm. Prior to transfer BP 97.2 115/81
117 20 97%.
In the ED, 98.5 84 120/76 18 98% RA. Reported initial
improvement in mental status and plan for discharge. However,
when EMS arrived to take the patient back to [**Hospital1 **], he
became very agitated. He was given ativan 2mg and haldol 5mg but
continued to be aggitated. He appeared confused and was having
auditory and visual hallucinations. Pulse transiently 151 prior
to physostigmine. Tox c/s thought he had anticholinergic
toxicity symptoms including dry skin and garbled speech. Thought
he improved to physostigmine 2mg over 5 minutes. Speech cleared.
Then agitated in angry way which was different. Thought this was
diagnostic. VS prior to transfer 76 117/82 18 97%RA. Normal head
CT. Labs normal. Tox wants to old all antipsychotics, use
benzos. In 4 points and ativan prior to sedation.
In the ICU, patient was agitated and whimpering. He wanted to
get out of his restraints. Still not oriented to person, place
or time.
Past Medical History:
-polysubstance abuse->dependent on cannabis
-depression
-?bipolar disorder
Social History:
Smoke [**12-3**] ppd, marijuana 1 joint per day. Periodic alcohol use.
Family History:
Unknown
Physical Exam:
Exam on Admission:
VS: Temp: 96.7 BP: 126/73 HR:85 RR:13 O2sat 96% on RA
GEN: agitated and trying to get out of restraints
HEENT: PERRL, EOMI, anicteric, dryMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: tachycardia, RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters, multiple piercings and
tattoos
NEURO: Purposeful movement, AAOx0, could not participate in
formal exam
Exam on discharge:
GEN: calm, A/Ox3 man sitting in chair, in NAD
HEENT: EOMI, anicteric, MMM
RESP: CTA b/l with good air movement throughout
CV: RRR, normal S1 and S2, no m/r/g
ABD: soft, nontender, nondistended, +b/s
EXT: no c/c/e.
SKIN: no rashes/no jaundice, multiple piercings and tattoos
Mental Status: A/Ox3, talkative, answers questions with poor
insight
Pertinent Results:
[**2120-4-24**] 03:22PM URINE HOURS-RANDOM
[**2120-4-24**] 03:22PM URINE HOURS-RANDOM
[**2120-4-24**] 03:22PM URINE GR HOLD-HOLD
[**2120-4-24**] 03:22PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2120-4-24**] 03:22PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2120-4-24**] 03:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2120-4-24**] 10:10AM GLUCOSE-103* UREA N-8 CREAT-0.8 SODIUM-140
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
[**2120-4-24**] 10:10AM estGFR-Using this
[**2120-4-24**] 10:10AM ALT(SGPT)-16 AST(SGOT)-21 ALK PHOS-56 TOT
BILI-1.0
[**2120-4-24**] 10:10AM LIPASE-21
[**2120-4-24**] 10:10AM ALBUMIN-4.8 CALCIUM-10.5* PHOSPHATE-3.9
MAGNESIUM-2.0
[**2120-4-24**] 10:10AM AMMONIA-21
[**2120-4-24**] 10:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2120-4-24**] 10:10AM WBC-6.9 RBC-4.77 HGB-14.6 HCT-41.8 MCV-88
MCH-30.7 MCHC-35.1* RDW-12.4
[**2120-4-24**] 10:10AM NEUTS-66.1 LYMPHS-26.5 MONOS-5.6 EOS-1.4
BASOS-0.4
[**2120-4-24**] 10:10AM PLT COUNT-289
EKG: sinus arrhythmia at 79bpm, borderline right axis, NI, TWF
in V1, TWI in V3 and III, otherwise no Q waves or ST deviations.
Imaging:
CT head: Normal non-contrast head CT.
CXR [**4-26**]: Current study demonstrates no evidence of radiopaque
foreign bodies seen on the previous examination. Heart size is
normal. Mediastinum is normal. Azygos lobe, anatomical variant
is noted. Lungs are essentially clear. There is no appreciable
pleural effusion or pneumothorax seen.
Brief Hospital Course:
27 yo M with history of polysubstance of abuse, bipolar
disorder, and a mood disorder who was transfered from [**Hospital1 **]
for acute mental status changes.
# Toxic metabolic encephalopathy: Likely secondary to alcohol
withdrawal. The patient's acute mental status changes were
initially thought to be due to delirium in the setting of
possible anticholinergic syndrome from benadryl and congentin in
addition to other psych meds. In support of this, he was
reported to improve with physostigmine. The patient was also
treated with a total of 60mg Valium over 24 hours, with
resolution of his agitation. It subsequently became clear that
the patient drinks a very large amount of alcohol, and in
retrospect, it seemed likely that his symptoms may have also
been due to EtOH withdrawal. Toxicology followed the patient
in-house as did Psychiatry. He continued to receive 5mg Haldol
[**Hospital1 **] PRN for agitation. His mental status improved to baseline.
He had a 1:1 sitter throughout his hospital stay. Section 12
was filed by psychiatry and he is being discharged to inpt
psychiatry at [**Hospital1 18**].
#Polysubstance abuse: Per report, the patient has a history of
benzo abuse and likely alcohol abuse. He has poor insight. He
was placed on a CIWA scale with 5mg of Valium given for CIWAs >
10. His valium was self-tapered in this way. He was continued
on MVI, thiamine, folate, and a nicotine patch throughout his
hospitalization.
# Anxiety/mood disorder: The patient's mood is likely unstable
at home given a recent possible overdose to "sleep off his
emotions." Psychiatry followed throughout his hospitalization,
and recommended an inpatient psychiatric hospitalization for
further management. He was not started on any standing
psychiatric medications during this hospitalization. He was
only given haldol for agitation as above.
# Radiodense foreign body: On radiograph, the patient was
observed to have a curvilinear radiodensity overlying his
abdomen, which was gone on repeat x-ray. The patient denied
having swallowed anything. A search of his skin did not reveal
any evidence of a foreign body, making it possible that this
finding was something external to him. He did not complain of
abdominal pain and was otherwise asymptomatic.
Medications on Admission:
No prescription medications prior to admission to [**Hospital1 **]. He
had not seen a PCP in years.
Medications at [**Hospital1 **]:
-risperidone 2mg [**Hospital1 **]
-Ativan 1mg q4h prn
-nicotine patch
-ibuprofen 400mg q4 prn
-haldol 5mg PO q4hr prn
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 18**] [**Hospital1 **] 4
Discharge Diagnosis:
Primary Diagnosis:
Anticholinergic toxicity
Secondary diagnoses:
Polysubstance Abuse
Mood Disorder, NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with confusion and agitation.
It was likely from either withdrawal from alcohol or
benzodiazepines or an anticholinergic toxicity. We may never
know exactly what it was. You improved with proper treatment.
Because of your overdose, we had the psychiatrists see you.
They wanted to make some changes to your medications and watch
you for the next few days while receiving these medications.
- Please take take only the medications recommended by the
psychiatrists.
We made the following changes to your medications:
We STARTED thiamine, folate, multivitamin and nicotine patch.
Followup Instructions:
Please follow up with your new primary care physician [**Name Initial (PRE) 176**] [**12-3**]
weeks after discharge. Please follow up with your mental health
providers as directed by your inpatient mental health team.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2120-4-27**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2463
} | Medical Text: Admission Date: [**2105-4-13**] Discharge Date: [**2105-4-17**]
Date of Birth: [**2047-10-19**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
female with a past medical history of hypothyroidism and
hypercholesterolemia. She presented with chest pain. For
the past one year the patient has been having exertional
angina on fast walking. She felt this was related to her
breathing. On [**2105-4-10**] the patient felt a short episode of
chest pain at rest, sharp substernal pain, no radiation,
associated with diaphoresis. The pain would wax and wane
over the weekend but got worse on the night prior to
admission. She presented to an outside hospital and was
transferred here for catheterization which showed severe
three-vessel disease with total occlusion of the distal right
coronary artery. She described no orthopnea and no
paroxysmal nocturnal dyspnea, no edema, no claudication, no
recurrent illnesses or recent illnesses, no urinary symptoms,
no diarrhea, no melena, no bright red blood per rectum.
PHYSICAL EXAMINATION: Temperature 98.7, heart rate 77, blood
pressure 104-109/46-47, respiratory rate 18, 98% on room air.
General: No apparent distress, alert and oriented x 3.
HEENT: Normocephalic, atraumatic, malformation of right
eyelid with right eye blindness since birth. Cardiovascular:
S1 and S2, no murmurs, gallops, or rubs. Respiratory: Clear
to auscultation bilaterally anterior. Abdomen: Soft,
nontender, no distention, bowel sounds positive with an
ecchymosis at the catheterization site, no bruit.
Extremities: No cyanosis, clubbing or edema. Strong distal
pedal pulses.
MEDICATIONS ON ADMISSION: 1. Aspirin, which she was not
taking. 2. Lipitor, not taking although both prescribed. 3.
Levoxyl 100 mcg per day.
PAST MEDICAL HISTORY: 1. Hypothyroidism. 2.
Hypercholesterolemia. 3. Recurrent bronchitis. 4. The
patient is blind in her right eye from birth secondary to
trachoma.
SOCIAL HISTORY: No tobacco, occasional glass of wine with
dinner; self-employed. Of note the patient is a Jehovah's
Witness, no blood products.
LABORATORY DATA: White blood cell count 8.2, hematocrit
40.8, platelet count 226, INR 1.6, PTT 150, sodium 138,
potassium 4.6, chloride 106, CO2 17, BUN 12, creatinine 0.6,
glucose 118, ALT 32, AST 91, CK 549, troponin greater than
50.
EKG showed normal sinus rhythm, rate of 100, normal axis,
normal intervals; 2-[**Street Address(2) 2051**] elevations in 2, 3, and aVF with
reciprocal changes in the precordial leads, and 3-4 mm
depressions in 1, aVL, and V2.
HOSPITAL COURSE: Coronary artery disease: Patient was
started on Lopressor, heparin drip, Aggrastat and Plavix at
the outside hospital. These were continued. At
catheterization she was found to have no left main disease,
left anterior descending coronary artery 40-50% proximal
occlusion and 80% mid occlusion; left circumflex coronary
artery was 70% proximal and distal and diffuse occlusions;
right coronary artery 70% mid occlusion with a distal total
occlusion, also diffusely diseased. She received stents in
the RCA and LAD.
The patient has diffuse coronary artery disease. She was
found to have the culprit occlusion in the distal right
coronary artery as well as a severe lesion in the left
anterior descending coronary artery. These were both
stented. The catheterization was complicated by a large
hematoma at the catheterization site in the groin as well as
slight oozing. This was associated with an hematocrit drop
from approximately 40 to 33 to 35. Hematocrit was then
afterward stable. The patient had no pain. Distant pulses
were unchanged. The patient was started on aspirin, Plavix,
Lipitor, Lopressor and lisinopril which she tolerated well.
She was also given ranitidine and kept on her thyroxine while
in the hospital. She was educated about her coronary artery
disease and scheduled with Dr. [**Last Name (STitle) 10543**], who is associated with
her primary care physician, [**Name10 (NameIs) **] close follow up. The patient
has been educated about the nature and severity of her
illness and the necessity for adequate follow up and
compliance with medications. She had no arrhythmias during
the hospitalization and there was no evidence of clinical
heart failure. An ejection fraction done at this
hospitalization was 40-45% with the expected inferior wall
abnormalities. This echocardiogram should be repeated in the
future to assess residual damage.
No other systems were active during this hospitalization.
The patient recovered uneventfully and was discharged to home
on [**2105-4-17**].
DISCHARGE MEDICATIONS:
1. Lopressor 25 b.i.d.
2. Lisinopril 2.5 mg q.d.
3. Aspirin 325 mg q.d.
4. Plavix 75 mg p.o. q.d.
5. Levothyroxine 100 mcg p.o. q.d.
6. Lipitor 10 mg p.o. q.d.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Acute inferior myocardial infarction.
3. Hyperlipidemia.
4. Hypothyroidism.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Last Name (NamePattern1) 1737**]
MEDQUIST36
D: [**2105-4-16**] 13:32
T: [**2105-4-22**] 07:21
JOB#: [**Job Number 49477**]
ICD9 Codes: 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2464
} | Medical Text: Admission Date: [**2186-2-13**] Discharge Date: [**2186-2-21**]
Service: NEUROLOGY
Allergies:
Naprosyn / Vicodin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
stroke vs. seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 84 year-old right-handed woman with a PMH of HTN,
HLD, afib and recent bilateral parieto-occipital infarcts and
smaller bilateral frontal infarcts. She is known to me from her
last presentation as a code stroke in [**2185-7-19**]. At that time
she presented with the infarcts described above.
.
This morning she was reportedly in her USOH and was then found
at breakfast "not answering questions". Details of this are not
known but she was taken to [**Hospital3 **] hospital where she was
reportedly witnessed to have a R sided seizure, and a question
of L eye deviation. Her BS was reportedly 140 and her BP 160.
She was given 1mg of Ativan and then was reportedly awake but
details of her exam are not known. It appears that she was given
serial NIHSS from 9-11am with scores in the 30's, however it is
not listed if she was awake during this time (or encephalopathic
vs post -ictal). She was then given dilantin 1gm and flumazenil
0.25mg IV. She had a screening CT at the OSH which reportedly
showed new infarct however on review and comparison with her
CT's here, there is no clear change. Screening labs with a
CBC,UA, and chemistry were unremarkable, however her INR was
3.1. She was then intubated "for airway protection prior to med
flight" and transferred here.
Past Medical History:
- paroxysmal afib
- OA
- HTN
- HLD
- depression
- C7 compression fracture
- Schmorl's node
- transient global amnesia
- memory impairments
- macular degeneration
- BSO
- bilateral parieto-occipital infarcts and smaller bilateral
frontal infarcts
- recent syncope in [**12-26**] with w/u of unknown results
Social History:
-lives in [**Hospital3 **]
-former tobacco (remote)
-no EtOH or tobacco
Family History:
mother: died of stroke
Physical Exam:
Vitals: T: 96.6 P: 116/47 R: 15 BP: 116/47 SaO2: 100% vent
General: NAD
HEENT: NC/AT, no scleral icterus noted, ET in place
Neck: Supple, no carotid bruits appreciated
Pulmonary: decreased breath sounds at the bases
Cardiac: regular, nl S1,S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no edema
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: unresponsive to nox stim
.
CN
I: not tested
II,III: pupils 1.5mm sluggishly reactive, unable to visualize
fundi
III,IV,V: no dolls
V: + corneals & nasal tickle
VII: face appears symmetrical
VIII: UA to formally test
IX,X: + gag
[**Doctor First Name 81**]: UA to formally test
XII: UA
.
Motor: increased tone in all extremites with ankles flexed, no
withdrawal to nox stim in any extremity
.
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 0 Extensor
R 2 2 2 2 0 Extensor
-Sensory: no withdrawal to nox stim in any extremity
-Coordination: NA
-Gait: NA
Pertinent Results:
Admission Labs:
[**2186-2-13**] 01:58PM NEUTS-77.5* LYMPHS-17.8* MONOS-3.5 EOS-0.9
BASOS-0.4
[**2186-2-13**] 01:58PM WBC-7.6 RBC-3.80* HGB-11.9* HCT-34.4* MCV-91
MCH-31.2 MCHC-34.5 RDW-12.9 PLT COUNT-277
[**2186-2-13**] 01:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2186-2-13**] 01:58PM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-3.4
MAGNESIUM-2.2
[**2186-2-13**] 01:58PM CK-MB-NotDone cTropnT-<0.01
[**2186-2-13**] 01:58PM ALT(SGPT)-27 AST(SGOT)-33 CK(CPK)-81 ALK
PHOS-73 TOT BILI-1.0
[**2186-2-13**] 01:58PM GLUCOSE-111* UREA N-23* CREAT-1.0 SODIUM-140
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-26 ANION GAP-16
[**2186-2-13**] 02:05PM FIBRINOGE-300
[**2186-2-13**] 02:05PM PT-35.5* PTT-55.0* INR(PT)-3.8*
[**2186-2-13**] 03:44PM URINE RBC-0-2 WBC-[**6-28**]* BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2186-2-13**] 03:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2186-2-13**] 03:44PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
.
MRI/A Head:
FINDINGS: In comparison with the prior examinations, there are
persistent T2 and FLAIR hyperintensity areas consistent with
encephalomalacia from prior ischemic event involving both
parietal lobes. Cortical areas of hyperintensity signal are
demonstrated on T1, possibly consistent with pseudo-laminar
necrosis, multiple T2 and FLAIR hyperintense foci are also
visualized in the subcortical and periventricular white matter
consistent with chronic microvascular ischemic changes. No
diffusion abnormalities are detected, or acute ischemic changes.
After the administration of gadolinium contrast material, mild
gyriform enhancement is identified in the prior ischemic events.
Bilateral patchy mastoid mucosal thickening is identified. The
orbits are unremarkable.
.
IMPRESSION: Sequelae of prior infarctions involving the parietal
lobes, producing encephalomalacia as described above. Multiple
areas of hyperintensity signal are noted in the subcortical and
periventricular white matter consistent with chronic ischemic
changes. No diffusion abnormalities are detected, or acute
ischemic changes. There is no evidence of abnormal enhancement.
.
MRA OF THE HEAD.
FINDINGS: Again there is a small basilar artery, possibly
related with bilateral fetal PCAs . No significant change is
identified since the prior study. The carotid arteries and
vertebral arteries are patent with no evidence of occlusion or
stenosis.
.
IMPRESSION: No significant change since the prior study. The
carotid and vertebral arteries are patent without evidence of
stenosis or occlusion.
.
EEG: Borderline abnormal EEG due to persistant slowing for the
majority of the recording. This could be due to excessive
drowsiness although it may also be due to a mild encephalopathic
state. Nevertheless there were no epileptiform features noted.
Brief Hospital Course:
Patient is a 84 year old RHW here with acute onset of speech
difficulties followed by a witnessed right-side seizure during
her evaluation at OSH. She was treated with Ativan, loaded with
dilantin, sedated, intubated and transferred to [**Hospital1 18**]
for further management. She is well-known to the stroke service
and she wasn't able to provide any history at the time of
admission.
Her initial labs were noted for elevated INR of 3.8. Head CT
showed no ICH
or early signs of ischemia. It only showed old bilateral
parietal infarcts and MRI also showed no new ischemia. The most
likely explanation for her current presentation is a focal
seizure secondary to her known old left parietal infarct.
EEG was obtained which ruled out non-convulsive seizure and also
showed no epileptiform focus. She was successfully extubated
and transferred to neurology floor service where she continued
to make clinical improvements including mental status. Her
Dilantin was switched to Keppra and her Coumadin was titrated
with goal INR 2~3.
She was evaluated per PT/OT who recommeds acute rehab given
deconditioning from the admission including the ICU stay. She
will also require close INR monitoring with Coumadin titration.
She will be following up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as
outpatient.
Medications on Admission:
-lisinopril 10 mg daily
-Protonix 40 mg daily
-metoprolol 100 mg b.i.d.
-Lipitor 10 mg q.h.s.
-Lexapro 5 mg daily
-alendronate 70 mg once per month
-calcium carbonate and vitamin D
-Lasix 20 mg daily
-warfarin 4 mg on Tuesdays, Thursdays and 3 mg all other days
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Outpatient Lab Work
Daily INR with goal INR between 2~3 until Coumadin dosing stable
- may be spaced out further (1~2x/week) once INR therapeutic and
Coumadin dosing stable. Please forward the results to PCP (Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **]) for instructions.
Discharge Disposition:
Extended Care
Facility:
Cape [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]
Discharge Diagnosis:
Seizure disorder
Atrial fibrillation
hx of biparieto-occipital stroke
Discharge Condition:
Stable - oriented to self but fluent speech although frequent
word finding difficulty; ambulatory with assistance.
Discharge Instructions:
You were admitted after a witnessed episode of generalized
tonic-clonic seizure activity and you were initially intubated
for airway protection. You were successfully extubated within
48 hrs and you were transferred out of the ICU to the neurology
floor where you remained stable without further seizure
activity.
You were evaluated further including MRI/A of head which showed
no new infarcts hence your seizure was likely precipitated by
the old stroke. Also, your INR was supratherapeutic (INR 3.5)
on admission hence your Coumadin was held until for 2 days
before restarting and the dose was continually titrated during
this admission. Your INR is 2 on the day of discharge and
current dose is 2mg daily but will need to be continually
monitored and titrated as needed based on INR with goal INR 2~3.
You also had EEG which showed generalized slow background but no
epileptiform activity. However, given that you are at increased
risk factor for recurrent seizure activity from the stroke and
since you already had witnessed event, you need to be continued
on Keppra indefinitely.
Given the deconditioning with this admission which included an
ICU stay, physical and occupational therapy recommends
rehabilitation in an inpatient facility.
Please take your medication as scheduled - your Coumadin dosing
may further change based on your INR (goal INR 2~3). Also,
please follow up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (neurology) as
scheduled and please see your PCP [**Name Initial (PRE) 176**] 2~3 weeks of discharge
from rehab for follow-up.
If you have new weakness, numbness, visual problems, speech
problems such as slurring, and/or other concerns, please call
your PCP.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2186-3-17**]
1:00
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2186-4-24**] 1:30 - [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
Completed by:[**2186-2-21**]
ICD9 Codes: 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2465
} | Medical Text: Admission Date: [**2174-6-6**] Discharge Date: [**2174-6-16**]
Date of Birth: [**2121-12-16**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Reglan / Opioids-Morphine & Related
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Thoracentesis (multiple)
Chest Tube
History of Present Illness:
52 year old female with a history of lone atrial fibrillation
and Lyme meningitis presenting with progressive shortness of
breath over past 2 weeks. On [**5-23**], patient awoke with 10/10
pleuritic pain radiating down to left shoulder to left arm
associated with SOB and diaphoresis. She went to PCP who
ordered [**Name Initial (PRE) **] CTA which was negative for PE and diagnosed her with
pleurisy. She was prescribed motrin 800mg TID.
.
Her pain was mildy improved with the motrin but she developed
DOE which progressed to dyspnea at rest over the past 2 weeks.
Also endorsing chest heaviness, pleuritis left sided/LUQ pain,
orthopnea and PND. Her pain would be releived sitting forward.
Denies LE edema. 1 week ago she experienced 1 day of vomiting x5
episodes NBNB. In the past few days had fevers/chills and abd
distention associated with constipation and low grade headache.
TMax of 101.3. Also had dry cough. Saw PCP who took CXR which
showed pna with b/l pleural effusions.
.
In the ED, initial vitals were T 101 HR 120 BP 120/77 RR 18 Pox
89% RA. Resp distress. CXR L>R effusion and pericardial
effusion. Triggered in the ED for hypoxia to 89% RA, placed on
O2 by N/C + abx(CTX and lev), 2L bolus, followed by 150/hr.
Cards c/s: resolving pericardial effusion, decided not to tap.
Labs notable for ALT: 146 AP: 483 Tbili: 2.4 Alb: 3.3 WBC to 17
(no bands). Believe that pleural effusion may be bigger issue.
Had thoracentesis in ED 1200cc straw colored fluid. Prior to
transfer, 99.4, 110, 122/85, 20, 100% by N/C 5L.
.
Upon arriving to the ICU, patient was in [**10-31**] left sided
pleuritic chest pain. She felt SOB slightly improved. Pain worse
and different after thoracentesis. Also endorsed "contact"
dermatitis with couple blisters on lower extremities worse 2
weeks ago thought to be a nickel allergy. She has been drinking
POs well recently but appetite poor. Endorsed 1 year of
nightsweats which she believes are postmenopausal. Of note, she
missed her [**2173**] mammogram.
.
ROS:
Review of Systems:
(+) Per HPI
(-) Review of Systems: GEN: No recent weight loss or gain.
HEENT: No sinus tenderness, rhinorrhea or congestion. CV: No
palpitations. PULM: No wheezing. GI: No nausea, diarrhea, or
abdominal pain. No recent change in bowel habits, no
hematochezia or melena. GUI: No dysuria or change in bladder
habits. MSK: No arthritis, arthralgias, or myalgias. NEURO: No
numbness/tingling in extremities. PSYCH: No feelings of
depression or anxiety. All other review of systems negative.
Past Medical History:
SHOULDER PAIN, LEFT-S/P LABRAL TEAR REPAIR AND AC REPAIR
FRACTURE, FINGER
OSTEOPENIA
MENOPAUSAL STATE
LYME DISEASE meningitis [**2170**] s/p 3 years of abx(seasonal
plaquinel plus doxycycline alternating with clarithromycin,
finished in [**12-31**]
ATRIAL FIBRILLATION-PAROXSYMAL since age 24
MIGRAINE
HERPES SIMPLEX
COSTOCHONDRITIS
Social History:
She has one dtr age 8. She is a landscape designer who runs her
own business. She does not smoke. Denies recent travel. Does
live in [**Location (un) 1514**] and has hiked recently but no noted ticks.
Denies ever having PPD placed
ETOH: [**1-23**] martinis a week.
Tobacco: none
Illicits: none
Family History:
Mother-MI [**95**] but survived
4 younger siblings healthy
father died of [**First Name9 (NamePattern2) 18275**] [**Last Name (un) 3711**] at 54, grandfather died of lung ca
in 50s, a smoker, paternal aunt had [**Name2 (NI) 18276**] cancer died in 50s
Physical Exam:
VS: 97.3 113 122/76 93%3L, pulsus 12mmHg
GEN: pleasant, visibly in discomfort from L sided chest pain
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, JVP to jaw, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: decreased bS at b/l bases with poor airmovement [**2-23**] effort
and pain
CV: RR, S1 and S2 wnl, no m/r/g
ABD: mild distension, +b/s, soft, TTP in b/l upper quadrants, no
masses or hepatosplenomegaly, no rebound or guarding
EXT: no c/c/e
SKIN: no jaundice/no splinters, left skin with 1inch diameter
round erythematous plaque, ? EN, right posterior LE with small 1
cm erythmatous bliser
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL:deffered
Pertinent Results:
EKG: sinus tachycardia at a rate of 117, normal axis,
non-specific ST,T changes, diffusly low voltage, RBBB pattern.
right bundeloid. ST, T changes are new since [**2-1**].
.
2D-ECHOCARDIOGRAM: ([**2174-6-6**])
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). 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 stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is a moderate sized pericardial effusion (1.3 cm
anteriorly and 1.8 cm around the right atrium). The effusion is
echo dense, consistent with blood, inflammation or other
cellular elements. Stranding is visualized within the
pericardial space c/w organization. No right ventricular
diastolic collapse is seen. There is brief right atrial
diastolic invagination. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling.
.
Compared with the prior study (images reviewed) of [**2174-3-9**],
the pericardial effusion is new. No overt tamponade is seen
however elevated intrapericardial pressure is suggested.
.
Echo: [**6-14**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The small pericardial effusion is echo dense, consistent with
blood, inflammation or other cellular elements and appears
largely organized with minimal free fluid. The pericardium may
be thickened.
.
Compared with the prior study (images reviewed) of [**6-8**]/201, the
pericardial effusion now appears slightly smaller
.
LABORATORY DATA:
140 104 14
---|----|---|------< 17.4 >------< 424
3.9 26 0.8 33
Troponin < 0.01
ALT: 146 AP: 483 Tbili: 2.4 Alb: 3.3
AST: 33 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 17
PT: 15.9 PTT: 30.5 INR: 1.4
.
Micro:
Pleural, Blood, Urine cultures, Urine Legionella negative.
RUBEOLA ANTIBODY IgG positive.
.
CXR [**6-6**]: Extensive left pleural effusion, that
occupies approximately one-half of the left hemithorax. A small
right basal pleural effusion. Additional mild fluid markings of
the fissures and slight distention of the vasculature suggests
mild pulmonary edema. Subsequent areas of bilateral atelectasis.
The contour of the cardiac silhouette cannot be reliably
determined.
.
CXR post [**Female First Name (un) 576**]: Infiltrate worse on right, improved on left, no
PTX
.
[**5-23**] CTA Grossly normal study, specifically no evidence of
pulmonary
embolism.
.
CXR: [**2174-6-15**]
INDICATION: Bilateral pleural effusions, status post right
thoracocentesis.
.
COMPARISON: [**2174-6-15**] at 01:33 p.m. (approximately three
hours earlier).
.
CHEST RADIOGRAPH, PORTABLE VIEW: Interval removal of left
pigtail catheter. When compared to the most recent study, there
has been decrease in bilateral pleural effusion, now small.
.
No pneumothorax is noted. Bibasilar atelectasis is again noted,
left more
than right.
.
The cardiomediastinal and hilar silhouettes appear unchanged.
.
Pleural fluid: [**2174-6-15**]
ATYPICAL.
Rare atypical epithelioid cell in a background of reactive
mesothelial cells, histiocytes, and lymphocytes; see note.
Note: One hematology slide labeled 1556E-[**2174-6-15**] was
reviewed and demonstrates mesothelial cells; no atypical
cells seen.
.
Brief Hospital Course:
52 year old female with a history of lone atrial fibrillation
and Lyme meningitis presenting with progressive shortness of
breath and DOE over past 2 weeks admitted to the MICU with
pleural effusions and a pericardial effusion in the setting of
presumed viral pleurisy and pericarditis that developed into an
effusion after chronic NSAID use possible aspiration/CAP PNA who
developed AFIB with RVR secondary to pain and pericardial
effusion, transaminitis with cholestasis and acute renal failure
in the setting of anemia and NSAID use who has a persistent O2
requirement with pleuritic pain and resolving pericardial
effusion. She improved clinically prior to discharge after CT
placement for her L effusion and a thoracentesis to remove her R
sided pleural effusion.
.
# SOB/CP/hypoxia: Likely multifactorial with most obvious
etiologies being pleural, pericardial effusions, and . PE was
less likely given [**5-23**] CTA negative. Due to her effusions, it was
thought she may have an underlying PNA and she was started on
levaquin for CAP. She was given a prolonged course due to
concern that she may have had infection in her pericardial
fluid. The day after admission ([**6-7**]) she was intubated for
hemodynamic control(Afib RVR 150s), pain control, and for
potential procedure for a possible pericardial window. From a
respiratory prospective she was comfortable prior to intubation
which was done under rapid sequence given signs of early
tamponade. She was extubated without event when it was
determined that cardiology did not think her pericardal effusion
needed to be drained. Instead, cardiology recommended serial
Echo's to follow the effusions size. An echo on [**6-14**] showed
that the effusion was reduced in size compared to prior imaging.
.
#Afib with RVR: The Patient has a history of lone atrial
fibrillation. On day of admission patient went to Afib to 200s
briefly sustaining in the 160s. This was thought [**2-23**] to pain
and infection vs tamponade physiology. She received metroprolol
IV and dilt drip. When patient was intubated, she converted back
to sinus rhythm and maintained in sinus rhythm. After
extubation and while on the floor the patient did not have any
palpitations or further episodes of Afib wtih RVR.
- She will need to discuss with her outpatient physician
[**Name9 (PRE) **] with aspirin when her pericardial effusion
resolves.
.
# Pleural Effusions: She presented with pleuritic chest pain
which was initially attributed to her pleural effusions.
Initially, the DDx was broad including infectious(Lyme/parvo
negative, [**Location (un) **] pending), malignant(cytology ultimately
negative), and rheumatologic([**Doctor First Name **] negative and C3/C4 normal). CHF
and cirrhosis unlikely based on H+P. Lipase normal makes
pancreatits unlikely. Thoracentesis reveals exudate, likely
parapneumonic given fevers, and a viral pleuritis was also
considered. ID was consulted who recommended empiric coverage
for CAP with a prolonged course of Levofloxacin (14 days -
finish on [**6-20**]) due to a concern that the pericardial fluid
could [**Hospital1 **] infection. Cytology negative, cultures negative.
Morphine and fentanyl pleuritic CP. The most likely diagnosis
was a viral infection with a superimposed bacterial process
possibly in the setting of aspiration 1 week prior. Of note her
effusions persisted despite antibiotic therapy and NSAID
therapy. She was given diuretics with lasix which did not
reduced the size of her effusion. Therefore, a L sided chest
tube placement by IP in addition to a right sided thoracentesis.
After subsequent removal of her bilateral pleural effusions,
her symptoms of SOB and O2 requirement resolved.
.
# Pericardial Effusion: Initially echo concerning for early but
not overt tamponade physiology and exam was concerning. Patient
was given IVF to maintain preload. Serologies were sent as
above. Her pulsus was monitored closely and was never above
12mmHG. Cardiology consult followed closely and serial echos
showed improvement in effusions. The decision was made not to
drain effusions for diagnostic purposes given the risks
involved. She was restarted on NSAID therapy for viral
pericarditis. Of note, her effusion improved by echo prior to
discharge.
.
# CAP: Given her exudative effusion and viral pleuritis there
was concern for CAP and possible aspiration. She was given a
two week course of levofloxacin to finish on the date listed
above.
.
# Diarrhea: She had transient episode of diarrhea while on
antibiotics, and her diarrhea resolved.
.
# [**Last Name (un) **]/Low UO: Dark urine and poor output early in ICU course.
Thought potentially from NSAIDs. Renal spun urine and it was not
active. She had low UOP, which improved with IVF.
.
Cholestasis and Hepatitis: She was noted to have to have
abnormal LFT's with cholestatsis in addition to pleuritic R
sided abdominal pain. There was concern that she could have
either a viral induced hepatitis with cholestasis versus a
congestive hepatopathy in the setting of mild volume overload.
Cholecystitis was less likely given the absence of a white
count. Her LFT's trended down independent of diuresis thereby
suggesting/confirming a possible viral etiology for her
hepatitis and cholestasis. Of note her hepatitis serologies
were negative.
.
# Anemia: Baseline hct 40s most recently in [**2171**]. No signs or
symptoms of bleeding. Likely from systemic process going on.
Normal colonoscopy in [**2171**]. Of note, she is currently
menopausal, and has iron studies that suggest she has anemia of
chronic disease, or at least anemia with acute inflammation.
- She will need a CBC as an outpatient.
Medications on Admission:
-ASPIRIN TAB 81MG EC (ASPIRIN) 1 QD
Discharge Medications:
1. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
pack PO DAILY (Daily) as needed for constipation.
Disp:*30 packets* Refills:*0*
2. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*5 Adhesive Patch, Medicated(s)* Refills:*0*
4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for Prior to Morphine: Please take before
Morphine as needed for itching. Please do not drive after
taking this medication.
Disp:*20 Capsule(s)* Refills:*0*
7. morphine 10 mg Capsule, Ext Release Pellets Sig: One (1)
Capsule, Ext Release Pellets PO every six (6) hours as needed
for pain: Please do not drive after taking this medication.
Disp:*20 Capsule, Ext Release Pellets(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pleuritis with Bilateral Pleural Effusion and Pericardial
Effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Dear Mrs. [**Known lastname 3271**],
You were admitted for worsening shortness of breath due to fluid
in your lungs and around your heart. The exact cause of this is
unknown. Your breathing has markedly improved and you are
presently able to breathe without use of supplemental oxygen.
You will need to be followed by your primary care physician.
[**Name10 (NameIs) **] were started on an antibiotics and ibuprofen.
The following medicaiton changes were made:
ADDED: levaquin, ibuprofen, miralax, morphine, lidocaine patch,
benadryl, morphine, colace
STOPPED: aspirin
Followup Instructions:
Please visit your primary care physician for [**Name9 (PRE) 702**] bloodwork
and to determine whether you will need to take more Lasix (the
'water-pill' that you during your stay in the hopsital).
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: PERSONAL [**Hospital **] HEALTH CARE, P.C.
Address: [**Location (un) 3881**], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1408**]
Appt: [**6-21**] at 4pm
Completed by:[**2174-7-12**]
ICD9 Codes: 486, 5849, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2466
} | Medical Text: Admission Date: [**2127-1-13**] Discharge Date: [**2127-1-25**]
Date of Birth: [**2083-8-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
hypothermia, altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: This is a 41 homeless man with no known medical history
who was found down in the park today. The patient had been in
the park drinking Listerine with a friend. When the patient was
found by EMS he had a temp of 74. They were unable to obtain a
blood pressure or a pulse.
.
On arrival to [**Hospital1 18**] his temp was 74.6, BP 57/49, R16. Upon
arrival the patient was able to open his eyes, but he was not
responsive. Given his clinical picture, he was intubated. The
patient received a bear hugger. He was resuscitated with warm
fluids. Head CT was obtained and showed a comminuted nasal bone
fracture. No acute hemorrhage. CTA was negative for a PE. EKG
showed NSR at 55, no ST elevations or depressions
Past Medical History:
MHX: unknown
Physical Exam:
PE: T97.2 HR100 BP 104/56 AC O2sat 99%
GEN: thin, poorly groomed Caucasian male who is intubated and
sedated
HEENT: poorly dental hygeine, dried dirt in nares
HEART: nl rate, S1S2, no gmr
LUNGS: CTA-anteriorly
ABD: benign
EXT: cool, +DP bilaterally
Neuro: unable to assess
Pertinent Results:
[**2127-1-13**] 02:50PM PLT SMR-VERY LOW PLT COUNT-79*
[**2127-1-13**] 02:50PM WBC-11.1* RBC-4.79 HGB-17.0 HCT-47.9 MCV-100*
MCH-35.4* MCHC-35.4* RDW-14.1
[**2127-1-13**] 02:50PM ASA-NEG ETHANOL-261* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-1-13**] 02:50PM AMYLASE-132*
[**2127-1-13**] 02:50PM GLUCOSE-23* UREA N-20 CREAT-0.8 SODIUM-145
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-13* ANION GAP-34*
[**2127-1-13**] 03:10PM CK-MB-36* MB INDX-1.2 cTropnT-0.01
[**2127-1-13**] 03:10PM CK(CPK)-2987*
[**2127-1-13**] 06:35PM WBC-4.5# RBC-3.35*# HGB-11.9*# HCT-34.4*#
MCV-103* MCH-35.4* MCHC-34.5 RDW-13.3
[**2127-1-13**] 06:35PM OSMOLAL-345*
[**2127-1-13**] 06:35PM ALBUMIN-2.7* CALCIUM-6.2* PHOSPHATE-3.8
MAGNESIUM-1.7
[**2127-1-13**] 06:35PM GLUCOSE-95 UREA N-17 CREAT-0.5 SODIUM-146*
POTASSIUM-3.2* CHLORIDE-115* TOTAL CO2-11* ANION GAP-23*
[**2127-1-25**] 07:02AM BLOOD WBC-5.0 RBC-3.26* Hgb-11.4* Hct-31.7*
MCV-97 MCH-34.9* MCHC-35.9* RDW-13.5 Plt Ct-187
[**2127-1-25**] 07:02AM BLOOD Glucose-138* UreaN-12 Creat-0.8 Na-140
K-4.0 Cl-105 HCO3-22 AnGap-17
[**2127-1-22**] 04:35AM BLOOD ALT-40 AST-31 AlkPhos-70 TotBili-0.5
.
CT spine:
1. Comminuted nasal bone fractures.
2. Severe mucosal thickening in the ethmoid sinuses and nasal
cavity.
3. No evidence of acute intracranial hemorrhage.
.
CXR: 24 year-old male with hypothermia, intubation. A single
portable view of the chest reveals slight rotation to the right.
No evidence of a pneumothorax. An endotracheal tube is in
satisfactory position. The lungs are well inflated. The ribcage
is intact with no evidence of a fracture. A nasogastric tube tip
lies in the stomach.
.
EKG: Baseline artifact. Sinus bradycardia. Modest non-specific
intraventricular conduction delay. Prominent"J" point in leads
V4-V6 - possible [**Doctor Last Name **] wave. Findings suggest hypothermia.
Clinical correlation is suggested. No previous tracing available
for comparison.
.
CTA:
1. No evidence of pulmonary embolism.
2. Moderate-to-large bilateral pleural effusions with associated
atelectasis.
3. Airspace opacity and infiltrate noted in the lungs, most
predominantly in the left lower lobe. Diffuse patchy nodular
opacities also seen scattered throughout the upper and right
middle lobes. Nodular findings could represent infection versus
metastasis, and followup imaging following treatment is
recommended to document resolution.
.
ECHO: The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
systolic anterior motion of the mitral valve leaflets. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Brief Hospital Course:
43 year old white male with hypothermia and unknown source of
fevers.
1. Pulmonary - Patient was initally intubated for airway
production but rapidly extubated after improvement of
hemodynamics, metabolic acidosis, and mental status. Upon
extubation, patient had a nonproductive cough and fevers
concerning for PNA. Although he had a clear CXR, given LOC and
possible aspiration event, he was started on Unasyn. His fever
and cough persisted with a continued O2 requirement despite
antibiotics. Antibiotics were thus changed to Zosyn. The
patient was started on vancomycin for persistent fevers and
tachypnea. He received nebulizer treatments and chest PT given
possible underlying obstructive lung disease. Seven days prior
to discharge, patient was changed to oral cefpdoxime (with plan
to end course on [**1-27**]); patient's respiratory status was at
baseline, on room air, satting well with ambulation. No evidence
of hospital acquired organisms.
.
2. Hypothermia - Unclear etiology of hypothermia, although
likely secondary to exposure in setting of LOC vs early SIRS.
Patient was warmed with bear hugger and warmed IV fluids.
Workup for hypothyroidism was negative. At the time of
transfer, the patient had been warmed to normal body
temperature.
.
3. Cardiovascular - Patient was admitted with hypothermia, low
WBC, and hypotension concerning for sepsis. Resuscitated with
large volumes of IV fluids to which his blood pressure
responded. He remained bradycardic throughout his time in the
ED however maintained a normal blood pressure after fluid
resuscitation without further intervention. Patient had two,
asymptomatic episodes of bradycardia while on the floor. His
heart rate was maintained between 60-70s prior to discharge.
.
4. Neuro/Psyche - Patient had altered mental status on
admission, likely secondary to hypothermia, hypoglycemia, or
intoxication. At the time of transfer, his mental status
improved and he was alert and oriented to person, place, and
time. He remained oriented to time and place throughout his
stay. Psychiatry was consulted to address a possible underlying
depression, for which remeron treatment was initiated. He was
ruled out for a dual diagnosis and not deemed appropriate for an
inpatient hospitalization.
- Alcoholism: Patient received thiamine iv x3 days, folate, and
an MVI. He was treated for withdrawal with lorazepam by CIWA
scale and was seen by the addiction nurse.
- Extremity tingling - was initiated on neurontin 200 qhs two
days prior to discharge. Patient should follow up with his PCP
regarding possible EtOH induced neuropathy.
.
5. Rhabdomyolysis: Patient was admitted with elevated CK likely
secondary to prolonged LOC. He was treated with aggressive
fluid hydration to prevent renal failure. Serial CKs
demonstrated a steadily decreasing CK. Creatinine was 0.5 at the
time of transfer. Renal function remained stable throughout
stay.
.
6. Pancreatitis: Admitted with elevated pancreatic enzymes,
likely secondary to EtOH. His enzymes trended down throughout
his admission. He was asymptomatic through the admission and
tolerated a PO diet at the time of transfer.
- hepatitis serologies were checked, which showed prior exposure
to hepatitis B.
.
7. Left hand swelling: Likely [**1-24**] trauma. He was followed
clinically without any evidence of compartment syndrome or clot.
Edema had resolved at time of transfer.
.
8. Heme:
- Thrombocytopenia: Unknown etiology/baseline. HIT negative.
Question secondary to alcoholism/hypersplenism. [**Month (only) 116**] be secondary
to marrow suppression in setting of acute illness. HIV was
negative
- Anemia: Normocytic, although MCV 96. Unknown
etiology/baseline. Likely marrow suppression in setting of
alcoholism. [**Month (only) 116**] be secondary to marrow suppression in setting of
acute illness. HIV was also on differential but was negative.
.
9. Comminuted nasal fracture: The patient was seen by plastic
surgery, who believed the fracture to be chronic. No further
management was deemed necessary.
Medications on Admission:
unknown
Discharge Medications:
1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 7 doses: To complete course on [**2127-1-27**].
Disp:*14 Tablet(s)* Refills:*0*
2. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypothermia
Pneumonia
Lung nodules
.
Secondary:
Elevated liver function tests
Alcholism
Anemia
Thrombocytopenia
Comminuted nasal fracture
Pancreatitis
Rhabdomyolosis
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were admitted for hypothermia (low body temperature) and
decreased ability to breath. You subsequently acquired fevers,
with no obvious source found, but you clinically improved.
Your breathing also improved a few days after admission.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, abdominal pain, nausea,
diarrhea, or any other concernging symptoms.
.
Please take your medications as prescribed.
.
Please see Dr.[**Name (NI) 5118**], your physician, [**Name10 (NameIs) **] receive your
medical care.
Followup Instructions:
1. Dr.[**Doctor Last Name 5118**] - he will set this appt up for you or you
should go to his clinic within 2 weeks to set it up. He visited
you here in the hospital and knows of your discharge from here.
.
Patient needs a follow-up CT scan to assess lung nodules. CT
scan showed airspace opacity and infiltrate noted in the lungs,
most predominantly in the left lower lobe. Diffuse patchy
nodular opacities also seen scattered throughout the upper and
right middle lobes. Nodular findings could represent infection
versus metastasis, and followup imaging following treatment is
recommended to document resolution.
.
Patient was evaluated by psychiatry while an inpatient. It was
recommended that Mr. [**Known lastname 38758**] follow-up with a psychiatrist as an
outpatient.
.
Patient will need a colonoscopy for routine screening (with
anemia signs by laboratories).
ICD9 Codes: 5070, 2875, 0389, 2762, 5180, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2467
} | Medical Text: Admission Date: [**2156-3-20**] Discharge Date: [**2156-3-22**]
Date of Birth: [**2096-5-10**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Necrotizing Pancreatitis, Abdominal Compartment Syndrome
Major Surgical or Invasive Procedure:
[**3-21**] - Exploratory Laparotomy
[**3-22**] - Exploratory Laparotomy, Total Abdominal Colectomy, Small
Bowel Resection, Partial Necrosectomy
History of Present Illness:
59 F with no significant medical history being transferred
from [**Hospital6 **] hemodinamically unstable, on 3
pressors with severe abdominal pain. Patient has a history of
heavy alcohol use, and had developed a severe abdominal pain
since 1 day prior to presentation, after drinking some alcohol
(unknown how much). Per OSH recors, pt had pain mostly in the
upper abdomen, associated with nausea and vomiting, reason why
pt
went to [**Hospital **] hospital and was found to have a necrotizing
pancreatitis. At the OSH, she was doing progressively worse
requiring intubation and 3 pressors to keep her stable. Bladder
pressures extremely high up to 200 and peak pressures in the 40s
by the time she was transferred to us.
Past Medical History:
None
Past Surgical History: None
Social History:
H/o tob. ~2 glassed red wine/day
Family History:
Mother w/ lung Ca
Physical Exam:
On Admission:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Firm, tense and dilated, diffusely tender to palpation,
with
severe guarding.
Ext: No LE edema, LE warm and well perfused
On Discharge: Deceased
Pertinent Results:
CT A/P (OSH): Large right and small left pleural effusion with
extensive adjacent atelectasis. Small amount of pericardial
fluid
or pericardial thickening. Small to moderate ascites with large
amount of fluid surrounding the pancreas. No free air. Segmental
mural thickening involving jejunum from treitz, secondary to
ascites vs. enteritis vs. ischemic causes
Brief Hospital Course:
The patient was seen in the emergency department and admitted
directly to the surgical icu. At the time of admission, she was
requiring three pressors to maintain a perfusing pressure. She
was taken to the operating room for a decompressive laparotomy,
and tolerate the procedure without an acute change in her
status. Her abdomen was left open with a [**Location (un) **] bag in place,
and the patient returned to the ICU overnight. Over the course
of the night, she continued to require three pressors and had
lactates ranging from [**5-20**]. Her LFTs were rising, consistent with
shock liver. Additionally, her abdominal pressures continued to
be in the upper twenties despite her open abdome. On [**3-22**] she
returned to the operating room were she was found to have
ischemia of her entire colon, ileum and large segments of the
jejunum. This was resected and the patient was left in
discontinuity. A small area of necrotic pancreas was also
resected. The patient was left with an open abdomen and returned
to the ICU. A family meeting was held regarding the patients
condition and it was determined that CMO status was most in line
with her wishes. On [**3-22**] she was made CMO and was pronounced at
16:19.
Medications on Admission:
None
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Necrotizing Pancreatitis
Mesenteric/Colonic ischemia
Abdominal Compartment Syndrome
Discharge Condition:
Deceased
Discharge Instructions:
N/a
Followup Instructions:
N/a
ICD9 Codes: 0389, 5119, 5849, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2468
} | Medical Text: Admission Date: [**2185-8-10**] Discharge Date: [**2185-9-1**]
Date of Birth: [**2122-7-2**] Sex: M
Service: MEDICINE
Allergies:
Adhesive Tape
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
-R IJ dialysis line placement
-CVVHD
-Lumbar puncture
History of Present Illness:
62 y/o M with hx of renal transplant and diagnosis of diffuse
Large B Cell Lymphoma s/p [**Hospital1 **] chmotherapy and recent
intrathecal chemotherapy presents with headache. pt has been
apparently getting worsening headache since 15th with some
photophobia and some confusion at times. no focal neurological
complaints. no fever/chill/rigor. no neck stiffness or
photophobia. no visual disturbances or nausea. pt subsequently
saw Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**8-8**] and underwent MRI of brain for
evaluation. This apparently demonstrated extensive lesion in
both hemispheres but restricted to white matter only, he was
therefore referred to the ED for evaluation. In [**Name (NI) **] pt was seen
by neurology consult, onc consult and renal consult. his only
current complaint is mild headache which responded to po
tylenol. he underwent LP per neuro recommendation and is
admitted for further evaluations.
.
In the hospital pt was LP'd and had brain bx which confirmed B
lymphoma. He subsequently underwent high dose MTX therapy via
CVVH which completed. His course was complicated by enterococcus
UTI treated with amoxicillin and C. Diff treated with Flagyl. Of
note pt is on atovaqon for PCP prophylaxis and is getting
lekovorin for rescue. He was just switched from [**Last Name (un) **] to FK due
to falling counts. today he under went LUE uss for possible dvt
which was negative.
.
Past Medical History:
# Chronic renal failure secondary to diabetic nephropathy s/p
Kidney transplant [**4-/2180**]
# Brittle DM on insulin w/ multiple episodes of hypoglycemia
# Right lenticulostriate/basal ganglia stroke found on [**2185-2-28**]
# CAD s/p CABG [**2173**]
# HTN
# Hyperlipidemia
# s/p aortoilliac bybass
# s/p AKA amputation during [**Country 3992**] after gunshot with phantom
limb pain
# Osteomylitis of L hip
# h/o kidney stone
# MVA s/p splenectomy [**6-/2181**]
# Diabetic retinopathy
# Bilateral carotid stenosis
# s/p cervical fusion
# Anxiety with PTSD
# h/o colitis in [**2183**] s/p colonoscopy w/ ileitis/colitis, ?
crohns
vs microscopic colitis
Social History:
Lives with his wife and son. Worked as a counselor at the VA.
Remote 15-20 pack/yr smoking history. No alcohol use. No illicit
drug use.
Family History:
Mother: Died with ovarian cancer
Father: Diabetes, "brain tumor"
Oldest of 9 children, several with DM, CHF. No history of blood
disorders, leukemia or lymphoma. No history of strokes.
Physical Exam:
temp 98.6, hr 70/min, rr 16/min, sats 96% on 3L
neck supple, no jvd
rrr, nl s1+s2, no m/r/g
bilateral wheeze worse on right
[**Last Name (un) 103**] soft, non tender, nl bs
ext warm, leg amputation, good pulse in other leg
cns [**3-24**] intact
Pertinent Results:
[**2185-8-10**] 06:14AM BLOOD WBC-3.8*# RBC-3.23* Hgb-10.7* Hct-33.0*
MCV-102* MCH-33.1* MCHC-32.3 RDW-19.1* Plt Ct-97*
[**2185-8-29**] 12:00AM BLOOD WBC-3.5*# RBC-2.72* Hgb-8.8* Hct-26.8*
MCV-99* MCH-32.3* MCHC-32.8 RDW-18.9* Plt Ct-79*
[**2185-8-27**] 12:00AM BLOOD Gran Ct-1305*
[**2185-8-29**] 12:00AM BLOOD Plt Smr-VERY LOW Plt Ct-79*
[**2185-8-29**] 12:00AM BLOOD Glucose-190* UreaN-67* Creat-1.8* Na-144
K-5.0 Cl-114* HCO3-20* AnGap-15
[**2185-8-29**] 12:00AM BLOOD ALT-11 AST-15 LD(LDH)-368* AlkPhos-82
TotBili-0.6
[**2185-8-29**] 12:00AM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.2 Mg-2.0
[**2185-8-28**] 05:29AM BLOOD tacroFK-5.8
TEST RESULT
---- ------
HEPARIN DEPENDENT ANTIBODIES NEGATIVE
COMMENT: NEGATIVE PF4 HEPARIN ANTIBODY BY [**Doctor First Name **]
MRI OF THE HEAD WITH AND WITHOUT CONTRAST
CLINICAL INDICATION: 63-year-old man with history of CNS
lymphoma, status
post high dose of chemotherapy, now with worsening mental status
change, MRI to evaluate progression of CNS lymphoma.
COMPARISON: Multiple prior examinations of the head, the most
recent
consistent with CT of the head without contrast dated [**2185-8-25**] at 1034
hours, prior MRI of the head dated [**2185-8-12**] and [**2185-8-9**].
TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images
were obtained,axial FLAIR, axial T2, axial magnetic
susceptibility and axial diffusion-weighted sequences. After the
administration of gadolinium contrast, the T1-weighted images
were repeated in axial T1, sagittal MP-RAGE and multiplanar
reconstructions.
FINDINGS: In comparison with the most recent MRI dated [**2185-8-10**], there is evidence of larger pattern of vasogenic edema,
involving the right temporal lobe, apparently extending at the
right parahippocampal formation (4:10), the pattern of abnormal
enhancement on the right temporal lobe lesion remains similar,
extending at the head of the caudate nucleus on the right. The
pattern of abnormal enhancement involving the left
occipitoparietal region remains stable with a new area of
enhancement tracking the biopsy site, post-surgical changes are
identified on the left parietal convexity consistent with a burr
hole. On the diffusion-weighted sequence, there is evidence of a
heterogeneous area of high signal at the head of the caudate
nucleus, which is not clearly identified on the corresponding
ADC map, however, the possibility of small areas with subacute
ischemia cannot be completely excluded (702:16). Normal flow
void signal is identified in the major vascular structures.
There are no new areas with abnormal enhancement. The area of
abnormal enhancement on the right temporal lobe measures
approximately 18.6 x 22.7 mm in size. The area of abnormal
enhancement on the head of the caudate nucleus measures
approximately 9.9 x 15.3 mm and the area of abnormal enhancement
on the left parietooccipital region measures approximately 32.8
x 32.5 mm in maximum dimensions. Persistent mucosal thickening
is identified on the left maxillary sinus, presumably a small
mucous retention cyst.
IMPRESSION: Larger area of vasogenic edema and effacement of the
sulci
involving the right temporal lobe as described above, apparently
extending at the right hippocampal formation, no definite uncal
herniation is identified, the perimesencephalic cisterns are
patent. The pattern of enhancement in the different lesions
located at the right temporal lobe, right head of the caudate
nucleus and left parietooccipital regions remain stable with
similar pattern of enhancement and vasogenic edema, new track of
abnormal enhancement is identified in the surgical site with
associated surgical changes consistent with a left parietal burr
hole. Questionable area of restricted diffusion identified on
the diffusion-weighted sequence of the head of the caudate
nucleus (702:16), which is not clearly identified on the
corresponding ADC map, however, ischemic changes cannot be
completely excluded, please correlate clinically.
Brief Hospital Course:
63-year-old male with DM-II, HTN, CAD, CKD, non-Hodgkin B-cell
lymphoma s/p chemotherapy (no radiation therapy), s/p kidney
transplant (on Rapamune & Prednisone) who presented with
worsening HTN urgency and 2 weeks of throbbing headaches and
found to have extensive bihemispheric white matter lesions on
MRI (R temporal and L parieto-occipital).
.
#HEME/Oncology: The patient was diagnosed with B-cell lymphoma
diagnosed [**1-/2185**] and is s/p 6 cycles of chemotherapy (R-[**Hospital1 **]
x5, R-CHOP x1) and 2 cycles of IT ara-C with last dose given on
[**2185-7-13**] per OMR. The had an LP and imaging which showed
significant mets to the brain. He was treated with methotrexate.
The patient also recieved leucovorin, bicarb and CVVHD to aid in
renal protection. The patient developed an acutely worsening
mental status. He was given steroids and had repeat imaging
which showed worsening of mets in increased brain edema. The
decision was made to start whole brain radiation as treatment.
After two treatments with whole brain radiation, and worsening
of clinical condition, the family decided to make the patient
comfort measures only. The whole family was present for the
decision and the patient's death. Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] were
informed of the decision. He was started on a morphine drip and
standing ativan.
.
#Headaches: While presentation was initially concerning for
hypertensive urgency, multiple lesions were found on brain MRI
and thought to be the cause of his pain. Pt was sent for brain
biopsy which was highly suggestive of lymphoma. Patient was
treated initially with tylenol for pain, however required IV
pain medications for severe headaches.
.
#Hypertension: Prior to admission, pts SBPs have been
intermittently in the 170s over last month per OMR notes and his
usual lisinopril and lasix have been discontinued for unclear
reasons (likely related to his chemotherapies). On admission he
was hypertensive to the 180s-200s. He was treated with PO
labetalol and clonidine while in the ICU; pt also required
labetalol gtt to achieve post-surgical BP goals of 130-160. Pt
was transitioned to home regimen of carvedilol 12.5 mg [**Hospital1 **] and
clonidine 0.1 mg [**Hospital1 **].
.
#Renal transplant: His was improved from his usual baseline of
1.6-1.7 for most of his ICU stay. He is on sirolimus and
prednisone for immunosuppression which were continued in the
ICU. He underwent CVVHD following methotrexate therapy to
preserve remaining renal function. CVVHD therapy was
complicated by filter clotting but was continued to achieve a
methotrexate level of <0.05. Due to concern of worsening
thrombocytopenia, sirolimus (switched to tacrolimus), bactrim
and acyclovir were discontinued.
.
# Thrombocytopenia: HIT ab negative, concern for
chemotherapy-induced thrombocytopenia. [**Month (only) 116**] also be a result of
sirolimus treatment so switched to prograft on [**8-18**] for
immunosuppression. Also d/ced bactrim (switched to atovoquone)
and acyclovir.
.
# UTI: Pt was cultured on [**8-15**] for fevers. Urine grew
enterococci susceptible to ampcillin. Empiric therapy with
vancomycin was switched to ampcillin.
.
# Diabetes mellitus II: Etiology of his renal failure per OMR.
Usually on home Lantus with humalog sliding scale. Followed by
[**Hospital **] Clinic. Lantus dose was decreased while inpatient for
hypoglycemia and was supplemented by ISS.
.
# Coronary artery disease: status-post 3V CABG in [**2173**]. No chest
pain, EKG with no ischemic changes on admission. He remained
asymptomatic currently in [**Hospital Unit Name 153**]. Aspirin on hold due to IT
chemotherapy per OMR. Anti-hypertensives continued.
.
#Phantom limb pain: continue tylenol as needed, recently stopped
taking Vicodin.
.
Medications on Admission:
Acyclovir 400 mg PO TID
Carvedilol 12.5 mg PO BID
Clonazepam 1 mg PO QHS
Clonidine 0.1 mg PO BID
Clotrimazole 1 TROC PO QID
Fluconazole 100 mg PO Daily
Hydrocodone-Acetaminophen 5 mg-500 mg 1-2 Tabs PO Q12 hours PRN
Pain
Novolog Sliding Scale SC QID
Insulin Glargine 24 Units SC QHS
Lidocaine Viscous 20 mg/mL Solution 1 mL PO TID PRN Pain
Lorazepam 0.5 mg 1-2 Tabs PO Q4Hours PRN Nausea
Ondansetron 8mg PO Q8hours PRN Nausea
Pantoprazole 40 mg PO BID
Prednisone 2.5 mg PO Daily
Prochlorperazine 10 mg PO Q6h PRN Nausea
Caphosol QID
Sirolimus 2mg and 3mg alt days
Docusate Sodium 100 mg PO BID
Senna 1 Tab PO BID:PRN Constipation
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
ICD9 Codes: 486, 5990, 2875, 2767, 4439, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2469
} | Medical Text: Admission Date: [**2130-5-23**] Discharge Date: [**2130-6-15**]
Date of Birth: [**2070-8-30**] Sex: F
Service: PLASTIC
Allergies:
Amoxicillin / aspirin / Tylenol / lisinopril / Augmentin
Attending:[**First Name3 (LF) 36263**]
Chief Complaint:
Suicide attempt with tylenol/benzo overdose and self inflicted
bilateral wrist lacerations
Major Surgical or Invasive Procedure:
[**2130-5-23**]
1. Exploration complex laceration left wrist.
2. Repair ulnar artery with reverse interposition vein graft
from dorsum left foot.
3. Repair complex laceration left wrist.
.
[**2130-6-6**]
1. Irrigation and debridement of skin, subcutaneous tissue,
flexor tendon.
2. Left open carpal tunnel release.
.
[**2130-6-12**]
1) Left below elbow amputation, left upper extremity.
2) Removed neuromas, removed nerve x6, left forearm.
History of Present Illness:
59F s/p suicide attempt with presumed Tylenol and Klonopin
overdose as well as wrist lacerations. Patient has history of
depression and anxiety but she stopped her medications about 3
weeks ago because she didn't think it was working and so she
weaned herself off. She was found by EMS at mid-day on [**5-22**] and
taken to [**Hospital **] Hospital. She was taken for surgical repair of her
wrist lacerations early in the morning of [**5-23**]. She was deemed
unfit to consent for the procedure by the psychiatry service.
She remained intubated following surgery for her mental status.
Per report, she was initially A&O x 3. Following surgery she was
obtunded. Her LFTs spiked significantly between her admission
and the following morning. Her acetaminophen level on admission
was 33, and 15 on redraw. She was transferred to the SICU at
[**Hospital1 18**] for evaluation of acute liver failure.
Past Medical History:
lupus
scleroderma
depression/anxiety (prior suicide attempt [**9-14**])
HTN
PUD prior GIB
endometriosis
Raynauds disease
.
PSH: unknown
Social History:
SH: Prior suicide attempts. [**Known firstname 4457**] owns her home and works FT for
a limo company making reservations. She is a former (25 years
ago) RN. [**Known firstname 4457**] has a
company vehicle. Her roommate [**Doctor First Name 4051**] doesn't drive and doesn't
have a vehicle. [**Known firstname 4457**] is single, has one son [**Doctor Last Name **] but there is
a restraining order against him because he is physically
abusive, her parents are deceased, and she has no siblings. [**Known firstname 4457**]
smokes "a lot" of cigarettes a day but doesn't use any other
drugs that her friends know of and she is not a drinker.
Physical Exam:
Vitals: 103.8 125 108/72 28 100% on AC 100/450 x 20/5 wt 72kg
General: intubated, sedated, opens eyes minimally to voice
.
RUE
Laceration over volar wrist closed with intact sutures.
Dopperable radial and ulnar pulses as well as superficial arch.
Arm, forearm and hand compartments soft. Digits warm and
well-perfused with cap refill < 2sec.
.
LUE
Laceration over volar wrist closed with intact sutures. No
dopperable ulnar pulse. Weak dopplerable superficial arch. Arm,
forearm and hand compartments soft. Index, long, ring, and small
fingers mottled to palmar crease. Poor cap refill >2sec.
Pertinent Results:
ADMISSION LABS:
[**2130-5-23**] 06:20PM GLUCOSE-150* UREA N-30* CREAT-2.3* SODIUM-141
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-18* ANION GAP-17
[**2130-5-23**] 06:20PM ALT(SGPT)-[**2041**]* AST(SGOT)-1337* ALK PHOS-56
TOT BILI-0.6
[**2130-5-23**] 06:20PM CALCIUM-8.0* PHOSPHATE-3.1# MAGNESIUM-1.6
[**2130-5-23**] 06:20PM ACETMNPHN-9*
[**2130-5-23**] 06:20PM WBC-17.0* RBC-2.88* HGB-8.6* HCT-26.7* MCV-93
MCH-29.9 MCHC-32.2 RDW-14.4
[**2130-5-23**] 06:20PM PLT COUNT-105*
[**2130-5-23**] 06:20PM PT-16.2* PTT-37.5* INR(PT)-1.5*
[**2130-5-23**] 06:20PM FIBRINOGE-338
[**2130-5-23**] 03:58PM TYPE-ART PO2-154* PCO2-33* PH-7.32* TOTAL
CO2-18* BASE XS--8
[**2130-5-23**] 03:58PM LACTATE-1.1
[**2130-5-23**] 03:58PM freeCa-1.07*
[**2130-5-23**] 03:36PM URINE HOURS-RANDOM UREA N-263 CREAT-140
SODIUM-28 POTASSIUM-96 CHLORIDE-<10 AMYLASE-427 TOT PROT-35
CALCIUM-6.4 PHOSPHATE-42.3 MAGNESIUM-5.8 URIC ACID-10.4 TOTAL
CO2-LESS [**First Name8 (NamePattern2) **] [**Doctor First Name 674**]/CREAT-3.1 PROT/CREA-0.3*
[**2130-5-23**] 03:36PM URINE OSMOLAL-374
[**2130-5-23**] 03:36PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2130-5-23**] 03:36PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2130-5-23**] 03:36PM URINE RBC-5* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
[**2130-5-23**] 03:36PM URINE GRANULAR-4* HYALINE-4*
[**2130-5-23**] 03:36PM URINE MUCOUS-RARE
[**2130-5-23**] 01:10PM TYPE-ART PO2-356* PCO2-30* PH-7.33* TOTAL
CO2-17* BASE XS--8
[**2130-5-23**] 01:10PM LACTATE-1.0
[**2130-5-23**] 12:56PM TYPE-[**Last Name (un) **] PO2-54* PCO2-40 PH-7.31* TOTAL
CO2-21 BASE XS--5
[**2130-5-23**] 12:56PM TYPE-[**Last Name (un) **] PO2-54* PCO2-40 PH-7.31* TOTAL
CO2-21 BASE XS--5
[**2130-5-23**] 12:56PM freeCa-1.10*
[**2130-5-23**] 12:40PM GLUCOSE-125* UREA N-32* CREAT-2.9* SODIUM-138
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-19* ANION GAP-15
[**2130-5-23**] 12:40PM estGFR-Using this
[**2130-5-23**] 12:40PM ALT(SGPT)-2376* AST(SGOT)-[**2124**]* LD(LDH)-2404*
ALK PHOS-54 AMYLASE-496* TOT BILI-0.4
[**2130-5-23**] 12:40PM LIPASE-66*
[**2130-5-23**] 12:40PM CK-MB-14* cTropnT-0.03*
[**2130-5-23**] 12:40PM ALBUMIN-2.5* CALCIUM-7.7* PHOSPHATE-1.2*
MAGNESIUM-1.7
[**2130-5-23**] 12:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-11 bnzodzpn-POS
barbitrt-NEG tricyclic-NEG
[**2130-5-23**] 12:40PM WBC-14.3* RBC-3.22* HGB-9.9* HCT-30.1* MCV-93
MCH-30.7 MCHC-33.0 RDW-14.0
[**2130-5-23**] 12:40PM NEUTS-87.5* LYMPHS-8.5* MONOS-3.7 EOS-0
BASOS-0.2
[**2130-5-23**] 12:40PM PLT COUNT-127*
[**2130-5-23**] 12:40PM PT-20.0* PTT-40.8* INR(PT)-1.9*
[**2130-5-23**] 12:40PM FIBRINOGE-281
[**2130-5-23**] 12:38PM URINE HOURS-RANDOM CREAT-137 SODIUM-29
POTASSIUM-96 CHLORIDE-<10 CALCIUM-6.7
[**2130-5-23**] 12:38PM URINE HOURS-RANDOM CREAT-137 SODIUM-29
POTASSIUM-96 CHLORIDE-<10 CALCIUM-6.7
[**2130-5-23**] 12:38PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
.
DISCHARGE LABS:
[**2130-6-11**] 05:40AM BLOOD WBC-15.2* RBC-3.21* Hgb-9.7* Hct-30.4*
MCV-95 MCH-30.1 MCHC-31.8 RDW-15.4 Plt Ct-594*
[**2130-6-11**] 05:40AM BLOOD Glucose-83 UreaN-4* Creat-0.6 Na-136
K-3.9 Cl-101 HCO3-24 AnGap-15
[**2130-6-8**] 02:04AM BLOOD ALT-63* AST-31 AlkPhos-68 TotBili-0.7
[**2130-6-11**] 05:40AM BLOOD Albumin-3.0* Calcium-9.2 Phos-3.5 Mg-1.5*
.
CARDIOLOGY;
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
75%). 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 mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
.
RADIOLOGY
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2130-5-23**]
4:19 PM :
IMPRESSION:
1. No acute intracranial process.
2. Prominence of the ventricles and sulci, inappropriate for
the patient's age.
.
[**2130-5-27**] 12:51 am URINE Source: Catheter.
**FINAL REPORT [**2130-5-31**]**
URINE CULTURE (Final [**2130-5-31**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 8 S <=2 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S 32 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 2 S
Brief Hospital Course:
She was admitted to the SICU at [**Hospital1 18**] on [**2130-5-23**]. The NAC drip
was continued and she was evaluated by transplant surgery and
hepatology. She was deemed not a transplant candidate given her
suicide attempts but aggressive supportive care was maintained.
Her course, by systems:
.
Neuro: Per reports, she was AAOx3 on presentation to the OSH
but became increasingly obtunded and especially after her radial
artery repair at the OSH. At [**Hospital1 18**], she became progressively
more responsive though demonstrated limited movement of her
extremities. She received flumazenil initially and was believed
to be improving; the flumazenil was therefore held. The tylenol
level was 11 on admission (33 at the OSH) and trended downward;
the NAC drip was dc'd on [**5-25**].
On [**5-27**] she was noted to be less responsive in the AM than prior
and a STAT Head CT demonstrated no changes. She gradually
improved over the course of the day into the next morning,
following commands and ultimately moving her extremities. She
was extubated on [**2130-5-29**] and was alert and interactive though
demonstrating slight confusion. Her confusion resolved and she
was alert and oriented x 3 for the rest of the hospitalization.
.
Psych: Consulted for evaluation after extubation. They
determined the pt to be unsafe for home discharge considering
her suicide attempt. She was placed under section 12, had 1:1
sitter at all times while an inpatient. She was discharged to
inpatient psych facility following this hospitalization.
.
CV: Baseline hypertension on home atenolol but allowed to be
hypertensive to the 160s (treated with metoprolol around the
clock/labetalol only for SBP>160) to allow for improved
perfusion to the extremities. She was ultimately transitioned
to nifedipine q8 during this hospitalization and her BP was
allowed to be mildly elevated w/ sbps in 140s-150s to allow for
better perfusion of her extremities during surgery. She was
discharged with orders to restart her atenolol dose.
.
Resp: She was weaned on the vent and tolerating CPAP 5/5 as of
[**5-28**]. She was noted to have a small left apical pneumothorax on
CXR [**5-25**]. It was followed by serial CXR and had decreased in
size on [**5-26**] and remained stable. She was extubated on [**5-29**].
She was weaned successfully to room air and remained that way
during the rest of this hospitalization.
.
GI: Her LFTs trended downwards during her admission. Initially
she presented with ALT 2376 AST [**2124**] AP 54 Tb 0.4 and a lipase
of 66. By [**5-28**] ALT/AST were 432/112.
Her Tb and AP remained within normal limits. Following
administration of NAC her LFTs normalized. She was tolerating a
regular diet and having normal Bowel movements at time of
discharge.
.
GU: She was in acute renal failure on admission with a Cr of
2.9. She was hydrated with progressive improvement. Cr was 0.6
as of [**5-28**]. She received lasix 10 IV BID to good effect on
[**5-31**]. Her kidney function remained normal throughout the
rest of the admission.
.
Endo: She was maintained on RISS and methylprednisolone 12 mg
daily (to account for her home prednisone) initially then
switched to Prednisone 15mg daily, her home dose.
.
Heme: LENIS on [**5-26**] due to perceived asymmetry of RLE vs. LLE
on exam (RLE>LLE), it was negative for DVT. She was started on
a heparin drip after her ulnar artery revision on [**5-23**] and this
was continued until [**5-31**]. Patient was then maintained on
subcutaneous heparin injections and encouraged to ambulate as
much as possible during the remainder of her inpatient stay.
.
ID: Febrile on admission to 103.8. She was pan cultured
(cultures did not grow anything) and continued to spike
low-grade fevers until [**5-27**] when she spiked a temperature of
102.0. She was re-cultured again, including sputum culture, and
was started empirically on vanc/cefepime. Her urine culture
returned positive for e.coli and enterococcus which were both
pan sensitive. She completed a five day course of Ceftriaxone.
The rest of her cultures were negative during this admission.
.
Upper Extremities: As noted, she had bilateral lacerations with
repair of the radial artery injuries at the OSH. At [**Hospital1 18**], she
was urgently taken back to the OR on [**2130-5-23**] for exploration and
repair of her left ulnar and radial arteries (thrombosed).
Post-operatively, she demonstrated ischemic gangrene of the left
hand along the ulnar artery distribution. She returned to the OR
on [**2130-6-6**] for surgical debridement for necrotic tissue of the
left hand. Patient had a wound vac in place to her left hand
wound but exhibited poorly healing granulation tissue, exposed
bone, tendon and nerve. She ultimately requested a left hand
amputation after lengthy discussion of poor healing and utility
prognosis for her left hand. Patient underwent a left below
elbow amputation on [**2130-6-13**] and tolerated this well. Her left
forearm stump sutures were clean and intact upon discharge. The
patient's right hand did not require any surgical intervention
on our part and continued to heal well and gain full function
after her reparative surgery at [**State 792**]Hospital.
Medications on Admission:
1. Atenolol 50 mg PO DAILY
2. PredniSONE 15 mg PO DAILY
3. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN pain
4. Klonopin
(clonazepam, alprazolam, ambien, and fluvoxamine in the past)
Discharge Medications:
1. PredniSONE 15 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO TID
4. Nicotine Patch 14 mg TD DAILY
5. OLANZapine 2.5 mg PO HS
6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
7. Pantoprazole 40 mg PO Q24H
8. Senna 1 TAB PO BID:PRN constipation
9. Atenolol 50 mg PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1) acute liver failure s/p suicide attempt (acetaminophen
overdose)
2) acute renal failure
3) left hand ischemia
4) right wrist laceration
Discharge Condition:
Alert and oriented x 3
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were recently admitted to the hospital for acute liver
failure and treatment for bilateral wrist lacerations. Your
liver function recovered well and is now normalized.
Unfortunately, the damage to your left hand was irreversible and
you required an amputation to the [**Last Name (un) **] of your mid-forearm. You
have sutures in place to that wound and these will need to be
removed in 2 weeks at your follow up visit to our Hand Clinic.
Your right wrist laceration, repaired at another hospital, has
healed well and your sutures have now been removed.
.
* Your left forearm sutures may be left open to air, without a
dressing.
* If you note swelling of your left arm, then you should elevate
it above the level of your heart to help alleviate this.
* You may shower.
* You should continue to increase your walking to increase your
stamina after your inpatient hospital stay.
* Monitor your left forearm suture site for any signs of
infection; redness, increased pain at site, swelling, and
drainage. Any evidence of infection should be reported to
Plastic/Hand surgery team: [**Telephone/Fax (1) 9986**] Pager [**Numeric Identifier 88994**]
Followup Instructions:
You should follow up with Primary Care Provider after discharge
to review the details of your recent hospitalization.
.
You will need to follow up in our hand clinic in two weeks to
remove the sutures from left arm.
DATE: Tuesday, [**2130-6-27**]
TIME: 9AM
LOCATION: Dept of Orthopaedics, [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building,
[**Location (un) **]
NUMBER: ([**Telephone/Fax (1) 2007**]
The clinic is open from 8-12pm most Tuesdays. The clinic is
located on the [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **]. Please
make sure that you obtain a referral from your insurance company
prior to your clinic appointment.
Completed by:[**2130-6-14**]
ICD9 Codes: 5849, 2762, 5990, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2470
} | Medical Text: Admission Date: [**2189-12-24**] Discharge Date: [**2189-12-30**]
Date of Birth: [**2124-7-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Scapular pain
Major Surgical or Invasive Procedure:
[**2189-12-24**] Redo-Sternotomy, Coronary Artery Bypass Graft x 3 (SVG to
Diag to OM, SVG to PDA), Aortic Valve Replacement w/ 25mm CE
Magna pericardial tissue valve
History of Present Illness:
65 y/o male s/p CABG in [**2179**] now experiencing mild scapular back
pain. Cardiac cath revealed severe native coronary artery
disease with patent grafts. Echo performed showed severe aortic
stenosis with a valve are of 0.7cm2. He was then referred for
surgical intervention.
Past Medical History:
Coronary Artery Disease s/p Coronary Artery Bypass Graft [**2179**],
s/p PTCA of RCA [**2178**], Hypertension, Hypercholesterolemia,
Diabetes Mellitus, Chronic Obstructive Pulmonary Disease,
Anemia, s/p Anal fistulotomy
Social History:
Patient smoked one ppd x 53 years, quit in [**2189-5-23**]
Divorced and lives alone. He has four children. Retired, used to
work as a cop.
Family History:
Father died at age 77 from an MI. Mother was
diabetic and had an MI in her 70's.
Physical Exam:
VS: 70 14 140/80 5'9" 220#
Skin: Unremarkable with well-healed MSI
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, -carotid bruit
Chest: CTAB -w/r/r
Heart: RRR, 4/6 SEM
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, 2+ pulses throughout, -edema or
varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2189-12-24**] Echo: PRE-CPB: The left atrium is mildly dilated. There
is severe symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Transmitral Doppler and tissue velocity
imaging are consistent with normal LV diastolic function. Right
ventricular chamber size and free wall motion are normal. Right
ventricular chamber size is normal. Right ventricular systolic
function is normal. There are simple atheroma in the aortic
root. 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. The aortic valve leaflets are severely
thickened/deformed. No masses or vegetations are seen on the
aortic valve. There is moderate aortic valve stenosis (area
0.8-1.19cm2) Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. No mass or
vegetation is seen on the mitral valve. There is a minimally
increased gradient consistent with trivial mitral stenosis. Mild
(1+) mitral regurgitation is seen. POST-CPB: On phenylephrine
infusion. There is a well-seated bioprosthetic valve in the
aortic position with no AI seen. Flow is seen in the LMCA. The
measured gradient across the aortic valve is now 6 mmHg. There
is preserved biventricular systolic function. LVEF 65%. There is
no [**Male First Name (un) **]. MR is trace. The aortic contour is normal post
decannulation.
[**2189-12-29**] CXR: Bilateral pleural effusions have significantly
decreased in size since prior exam. Small bilateral pleural
effusions remain. The cardiac silhouette, mediastinal and hilar
contours are stable in size status post CABG and AVR. The
pulmonary vasculature is normal and there is no pneumothorax. No
consolidations are seen bilaterally.
[**2189-12-24**] 01:33PM BLOOD WBC-13.8*# RBC-3.33*# Hgb-7.3*#
Hct-22.3*# MCV-67* MCH-21.9* MCHC-32.8 RDW-15.0 Plt Ct-65*#
[**2189-12-26**] 05:10PM BLOOD WBC-8.2 RBC-2.90* Hgb-6.5* Hct-19.3*
MCV-67* MCH-22.3* MCHC-33.6 RDW-15.5 Plt Ct-110*
[**2189-12-30**] 05:50AM BLOOD WBC-7.4 RBC-3.51* Hgb-8.5* Hct-24.9*
MCV-71* MCH-24.3* MCHC-34.3 RDW-18.7* Plt Ct-273#
[**2189-12-24**] 01:33PM BLOOD PT-19.5* PTT-50.7* INR(PT)-1.9*
[**2189-12-28**] 06:25AM BLOOD PT-16.0* INR(PT)-1.5*
[**2189-12-29**] 06:10AM BLOOD PT-35.0* INR(PT)-3.8*
[**2189-12-29**] 10:55AM BLOOD PT-43.4* INR(PT)-5.0*
[**2189-12-30**] 05:50AM BLOOD PT-32.3* INR(PT)-3.5*
[**2189-12-24**] 03:18PM BLOOD Glucose-93 UreaN-11 Creat-0.6 Cl-115*
HCO3-28
[**2189-12-30**] 05:50AM BLOOD Glucose-113* UreaN-18 Creat-0.9 Na-139
K-4.1 Cl-100 HCO3-33* AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 80687**] was a same day admit (underwent pre-op work-up as on
outpatient) and was brought directly to the operating room where
he underwent a redo coronary artery bypass graft x 3 and aortic
valve replacement. Please see operative report for surgical
details. Following surgery he was transferred to the CSRU for
invasive monitoring in stable condition. Later on op day he was
weaned from sedation, awoke neurologically intact and extubated.
Beta blockers and diuretics were initiated and he was gently
diuresed towards his pre-op weight. He was then transferred to
the telemetry floor. On post-op day three his chest tubes and
epicardial pacing wires were removed. Post-op his HCT was low
and on day three it was 19. He was therefore transfused with
several units of blood. By discharge it was 24.9. Also on
post-op day three he had an episode of atrial fibrillation. He
was bolused with Amiodarone and given Lopressor. Lopressor was
titrated, Amiodarone was eventually given PO and he was started
on Heparin. Coumadin was started on post-op day four and
titrated for goal INR between [**12-26**]. INR abruptly rose up to 5 by
post-op day five and Coumadin was held and INR trended down
towards therapeutic level by discharge. On post-op day five
antibiotics were started d/t left arm phlebitis. Physical
therapy followed patient during entire post-op course for
strength and mobility. He appeared to be doing well on post-op
day six and was discharged home with VNA services and the
appropriate follow-up appointments. Dr. [**Last Name (STitle) **] was contact and
will manage his Coumadin as an outpatient.
Medications on Admission:
Aspirin 325mg qd, Benicar 40mg qd, Avandamet 500mg qd,
Ninpeolomine 3mg qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
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. 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*
4. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*1*
6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Take 400mg [**Hospital1 **] for 1 week. Then 200mg [**Hospital1 **] for 1 week.
Then 200mg QD until stopped by your cardiologist.
Disp:*60 Tablet(s)* Refills:*1*
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
10 days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
14. Nifedipine (Bulk) Powder Sig: One (1) Miscellaneous TID
(3 times a day) as needed for anal fissures: 0.2% gel rectally
for anal fissures.
Disp:*30 1* Refills:*0*
15. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day).
Disp:*90 Packet(s)* Refills:*0*
16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Adust dosage according to Dr. [**Last Name (STitle) **]. Goal INR 2-3.0.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Coronary Artery Disease/Aortic Stenosis s/p Redo-Sternotomy,
Coronary Artery Bypass Graft x 3, Aortic Valve Replacement
PMH: s/p Coronary Artery Bypass Graft [**2179**], s/p PTCA of RCA
[**2178**], Hypertension, Hypercholesterolemia, Diabetes Mellitus,
Chronic Obstructive Pulmonary Disease, Anemia, s/p Anal
fistulotomy
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Dr. [**Last Name (STitle) **] will manage your Coumadin.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in 2 weeksProvider: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2190-1-29**] 12:00
Completed by:[**2189-12-30**]
ICD9 Codes: 4241, 9971, 496, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2471
} | Medical Text: Admission Date: [**2167-11-8**] Discharge Date: [**2167-11-17**]
Date of Birth: [**2092-9-7**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 74-year-old man with
known coronary artery disease status post RCA stent in
[**2164-8-11**]. He presented to an outside hospital in the
afternoon of [**2167-11-8**], with chest pain that began in
the morning with minimal exertion. He states the chest pain
was accompanied by shortness of breath, diaphoresis and
pallor with radiation to both of his arms. In the Emergency
Department he was noted to have ST elevation in 2, 3 and AVF
and he was transferred to the [**Hospital1 188**] for cardiac catheterization.
Catheterization demonstrated a left main stenosis of 40
percent, LAD 70 percent, proximal with mid stenosis, 80
percent, left circumflex 60 percent, intermedius 70 percent,
RCA 95 percent, mid PDA at 60 percent. At that time he was
referred to the cardiac surgery service for evaluation for
coronary artery bypass grafting. He remained an in-patient,
undergoing evaluation for cardiac surgery until [**2167-11-12**], when he underwent a CABG x 3.
PAST MEDICAL HISTORY: Significant for coronary artery
disease status post stent in [**2164-8-11**], hypertension,
hyperlipidemia, gastroesophageal reflux disease, benign
prostatic hypertrophy and cataracts.
ALLERGIES: INTEGRILIN CAUSES LOW PLATELETS AND PENICILLIN
CAUSES RASH
MEDICATIONS PRIOR TO ADMISSION: Aspirin 81 mg daily
Lipitor 10 mg daily
Lopressor, unknown dose
Multivitamin daily
PHYSICAL EXAMINATION: On admission his examination showed a
heart rate in the 70s, sinus rhythm. BP 110-130/70-80.
General appearance was within normal limits. Neck with no
JVD. Respiratory good effort and clear to auscultation.
Neurologic alert and oriented with good mood and affect.
Cardiovascular examination revealed a regular rate and rhythm
with S1 and S2, no MR or G. GI, abdomen soft and nontender,
nondistended with positive bowel sounds. Post
catheterization he was noted to have a 1 cm x 1 cm right
groin hematoma with good pulses and distal extremities.
SUMMARY OF HOSPITAL COURSE: As above in HPI. The patient
proceeded to the Operating Room on [**2167-11-12**] and underwent a
CABG x 3 with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] with a LIMA to the LAD
saphenous vein graft, diagonal and saphenous vein graft to
the PDA. Total cardiopulmonary bypass time of seventy-four
minutes and a cross-clamp time of forty-six minutes. He was
transferred to the cardiac surgery recovery room in a normal
sinus rhythm, rate of 86, MAP of 70 and CVP of 3 on Neo-
Synephrine and propofol drips for support. The evening of
his surgical day was uneventful with successful extubation,
weaning of his IV drips, medications, discontinuation of his
Foley catheter and he was transferred to the in-patient floor
on postoperative day one.
Postoperative day two continued with physical therapy,
increasing activity level, increase of his Lopressor dose and
discontinuation of his chest tubes and temporary cardiac
pacing wires.
Postoperative day three and four were significant only for
patient complaints of increasing acid reflux, not found to be
related to cardiac etiology and treated with p.o. Zantac with
good relief.
The physical therapy team followed Mr. [**Known lastname **] throughout his
hospital stay and on [**2167-11-16**] found that he was familiar
with the activity guidelines and was safe for discharge home
having met all goals of evaluation.
On postoperative day five, [**2167-11-17**], Mr. [**Known lastname **] was found to
be medically ready for home and was discharged with a
visiting nurse.
CONDITION ON DISCHARGE: Vital signs: Temperature 98.8,
pulse 80 and sinus rhythm, BP 109/75, respiratory rate 18,
oxygen saturation 95 percent on room air. Weight 73 kg, up
from preoperative weight of 69 kg.
Physical exam: Neurologic - alert and oriented, nonfocal.
Pulmonary - lungs clear bilaterally. Cardiac - regular rate
and rhythm, S1 and S2. Sternal incision without drainage or
erythema. Sternum stable and incision with Steri-Strips.
Abdomen - soft, nontender and nondistended with positive
bowel sounds. Extremities - warm without edema. Left leg
incision clean and dry with Steri-Strips intact.
DISCHARGE DIAGNOSES: Coronary artery disease status post
coronary artery bypass graft times three.
Hypertension.
Hyperlipidemia.
Gastroesophageal reflux disease.
Benign prostatic hypertrophy.
Cataracts.
Bladder neck contractures.
DISCHARGE MEDICATIONS: Lasix 20 mg p.o. daily for fourteen
days
Calcium chloride 20 mEq p.o. daily for fourteen days
Colace 100 mg p.o. b.i.d.
Aspirin 81 mg p.o. daily
Plavix 75 mg p.o. daily
Lipitor 10 mg p.o. daily
Polysaccharide-iron complex 150 mg p.o. daily
Vitamin C 500 mg p.o. b.i.d. for one month
Folic acid 1 mg p.o. daily for one month
Flomax 0.4 mg capsule p.o. daily
Hydromorphone 2 mg tablets, 1-2 tablets p.o. q.4-6h prn
Lopressor 25 mg p.o. b.i.d.
FOLLOW UP: The patient was discharged with visiting nurses
association. He will return to the postoperative wound
clinic in two weeks and plans to followup with Dr.
[**Last Name (STitle) 5310**], in three to four weeks and Dr. [**Last Name (STitle) 70**], in six
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 28068**]
MEDQUIST36
D: [**2167-11-17**] 12:33:23
T: [**2167-11-17**] 14:23:39
Job#: [**Job Number 35868**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2472
} | Medical Text: Admission Date: [**2129-1-21**] Discharge Date: [**2129-1-24**]
Date of Birth: [**2061-12-10**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 67 year old man
with a history of coronary artery disease, peripheral
vascular disease, status post bilateral above the knee
amputation, chronic renal insufficiency, diabetes mellitus,
abdominal aortic aneurysm, who presented with a two day
history of cough, and one day of nausea and vomiting without
producing any sputum. The patient also noted feeling hot and
experiencing diaphoresis. He awoke on the day of admission
and ate a normal breakfast and felt nauseated and vomited
once. He was [**Doctor Last Name 352**], he denied hematemesis, hemoptysis,
diarrhea, bright red blood per rectum, melena or abdominal
pain or dysuria.
The patient called his primary care physician and was
referred to an outside hospital where he was evaluated and
found to have increased creatinine to 2.1, baseline in the
high 1.0 range, and a potassium of 6.2. He also had
increased amylase and lipase of 188 and 368. His CPK was 88
and troponin I was 0.9. At the outside hospital, he
subsequently became hypotensive into the 70s systolic and
tachycardic into the 120s. He was placed on Dopamine and
transported to [**Hospital1 69**] for
further management. Symptoms were felt to be secondary to
pancreatitis with acute on chronic renal failure and
hyperkalemia. Chest x-ray was clear and electrocardiogram
was without changes.
PAST MEDICAL HISTORY:
1. Coronary artery disease with a myocardial infarction in
[**2104**], coronary artery bypass graft in [**2112**], most recent
ejection fraction was 15 to 20%.
2. History of Guillain-[**Location (un) **] disease.
3. History of peripheral vascular disease, status post
bilateral above the knee amputation.
4. Ischemic bowel in [**2121**].
5. Ischemic colitis [**10/2128**].
6. Chronic renal insufficiency with creatinine 1.9 to 2.4.
7. Diabetes mellitus, type II.
8. Abdominal aortic aneurysm with a right iliac aneurysm.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Lopressor 50 milligrams once a day.
2. Zestril 10 milligrams once a day.
3. Lasix 20 milligrams once a day.
4. Aldactone 25 milligrams once a day.
5. Protonics 40 milligrams once a day.
6. Enteric Coated Aspirin 325 milligrams once a day.
7. Lipitor 40 milligrams once a day.
8. Iron 325 milligrams once a day.
9. Digoxin 250 once a day.
10. Allopurinol 300 milligrams once a day.
TRANSFER MEDICATIONS:
1. Subcutaneous Heparin.
2. Enteric Coated Aspirin 325 milligrams once a day.
3. Allopurinol 300 milligrams once a day.
4. Lipitor 40 milligrams once a day.
5. Digoxin 0.25 milligrams once a day.
6. Colace 100 milligrams twice a day.
7. Prilosec 20 milligrams once a day.
LABORATORY DATA: On admission to [**Hospital1 190**] were troponin 0.9, CK 88. Chem7 revealed
sodium 133, potassium 6.2, chloride 96, bicarbonate 25, blood
urea nitrogen 56, creatinine 2.9. White count 7.4,
hematocrit 43.0, amylase 188, lipase 368, total bilirubin
0.6, ALT 15, AST 19, alkaline phosphatase 132. INR was 1.1,.
Chest x-ray was without infiltrate or congestive heart
failure. KUB showed no ileus and no free air.
HOSPITAL COURSE: In the Medical Intensive Care Unit, the
patient's hypotension responded well to boluses of
intravenous fluid. The following day he was ready for
transfer to the floor. The patient did well on the floor
tolerating a regular diet by his second day on the floor.
He had an abdominal CT scan to rule out pancreatic phlegmon
and had no abdominal tenderness. His lipase and amylase
trended steadily downward. In addition, his blood urea
nitrogen and creatinine returned toward their baseline values
with a creatinine on the day of discharge being 2.1.
The patient was discharged in stable condition. He will
follow-up with Doctor [**Doctor Last Name 11679**] one week after discharge.
DISCHARGE MEDICATIONS:
1. Lopressor 50 milligrams once a day.
2. Zestril 10 milligrams once a day.
3. Lasix 20 milligrams once a day.
4. Aldactone 25 milligrams once a day.
5. Protonics 40 milligrams once a day.
6. Enteric Coated Aspirin 325 milligrams once a day.
7. Lipitor 40 milligrams once a day.
8. Iron 325 milligrams once a day.
9. Digoxin 250 once a day.
10. Allopurinol 300 milligrams once a day.
DISCHARGE DIAGNOSES:
1. Pancreatitis.
2. Hypotension.
3. Chronic renal insufficiency.
4. Acute renal failure.
5. Diabetes mellitus.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 21980**]
Dictated By:[**Name8 (MD) 19393**]
MEDQUIST36
D: [**2129-1-24**] 15:05
T: [**2129-1-24**] 19:33
JOB#: [**Job Number 29294**]
ICD9 Codes: 5849, 2767, 5990, 2765, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2473
} | Medical Text: Admission Date: [**2109-4-24**] Discharge Date: [**2109-5-12**]
Date of Birth: [**2109-4-24**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**Known lastname 2398**] [**Known lastname 25731**] is a former
2.06-kilogram product of a 32 and [**7-1**] week gestation
pregnancy born to a 40-year-old gravida 2, para 1 (now 2),
woman.
PRENATAL SCREENS: Blood type A positive, antibody negative,
Rubella immune, rapid plasma reagin nonreactive, hepatitis B
surface antigen negative, and group B strep status unknown.
The pregnancy was complicated by elevated blood pressures.
The mother went into spontaneous labor. Rupture of membranes
occurred two hours prior to delivery. The mother was treated
for unknown group B strep status with antepartum antibiotics.
The infant by spontaneous vaginal delivery. Apgar scores
were 8 at one minute and 9 at five minutes. He was admitted
to the Neonatal Intensive Care Unit for treatment of
prematurity.
PHYSICAL EXAMINATION ON PRESENTATION TO NEONATAL INTENSIVE
CARE UNIT: Weight was 2.060 kilograms (50th percentile),
length was 44 cm (50th percentile), and head circumference
was 31.5 cm (50th percentile). In general, a nondysmorphic
preterm infant. Skin intact. No rashes or lesions. Head,
eyes, ears, nose, and throat examination revealed anterior
fontanelle open and flat. Symmetric facial features.
Positive red reflex bilaterally. Palate was intact. Chest
revealed mild subcostal retractions and audible grunting.
Lungs with slightly diminished breath sounds. Cardiovascular
examination revealed no murmurs. A regular rate and rhythm.
Pulses were 2+ and equal. Abdomen revealed no
hepatosplenomegaly. A 3-vessel cord. No masses.
Genitourinary revealed testes descended bilaterally. Normal
phallus. The anus was patent. Trunk and spine were intact.
Extremity examination revealed moving all extremities and
well perfused. The hips were stable. Neurological
examination revealed activity and reflexes consistent with
gestational age.
SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM (INCLUDING
LABORATORIES):
1. RESPIRATORY ISSUES: [**Known lastname 2398**] had increased work of
breathing over the first few hours in the Neonatal Intensive
Care Unit. He was placed on continuous positive airway
pressure. He maintained adequate oxygenation on room air.
He remained on continuous positive airway pressure through
day of life two. He briefly required nasal cannula oxygen on
day of life three and then weaned to room air on day of life
four and continued on room air throughout the remainder of
his Neonatal Intensive Care Unit admission. He had mild apnea
of prematurity, with the last episodes on [**2109-4-27**]; he never
required methylxanthine treatment. At the time of
discharge, he was on room air with comfortable respirations
with a rate of 30 to 50.
2. CARDIOVASCULAR ISSUES: [**Known lastname 2398**] has maintained normal heart
rates and blood pressures. No murmurs have been noted during
admission.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: [**Known lastname 2398**] was
initially nothing by mouth. Enteral feedings were started on
day of life two and gradually advanced to full volume. He
has been breast feeding or feeding expressed breast milk
fortified to 24 calories per ounce. At 48 hours prior to
discharge, he has been almost exclusively breast feeding and
manifests better coordination with breast than bottle feeds.
After discharge, we recommend that supplementation, if needed,
be accomplished with expressed breast milk fortified to 24 per
ounce with cow-milk-based formula powder such as Enfamil or
Similac. He would be a good candidate for a supplemental
nursing system rather than bottled supplements.
Serum electrolytes were checked in the first week of life and
were within normal limits. Discharge weight was 2.425
kilograms, with a length of 49.5 cm, and a head circumference
of 33.25 cm.
4. INFECTIOUS DISEASE ISSUES: Due to the unknown etiology
of the respiratory distress, and unknown group B strep status
of the mother, [**Name (NI) 2398**] was evaluated for sepsis at the time of
admission. His white blood cell count was 14,400 with a
differential of 27% polymorphonuclear cells and 0% band
neutrophils. A blood culture was obtained prior to starting
intravenous ampicillin and gentamicin. The blood culture was
no growth at 48 hours, and antibiotics were discontinued.
5. GASTROINTESTINAL ISSUES: [**Known lastname 2398**] required treatment for
unconjugated hyperbilirubinemia with phototherapy. His peak
serum bilirubin occurred on day of life six, a total of
14.4/0.3 mg/dL. He continued on phototherapy for
approximately eight days. His rebound bilirubin on [**2109-5-5**] was 9.3 total over 0.5 direct. A repeat on [**2109-5-7**] had a total of 11, a direct of 0.2, for an indirect of
10.8. He appears clinically well, and our impression was
that this was likely prolonged physiologic jaundice as well as
possibly breast milk jaundice.
6. HEMATOLOGIC ISSUES: Hematocrit at birth was 60% and on
[**5-1**] (day of life 7) was 52.2%. [**Known lastname 54539**] blood type is A
positive, and his direct Coombs was negative. He did not
receive any transfusions of blood products during admission.
7. NEUROLOGIC ISSUES: [**Known lastname 2398**] has maintained a normal
neurological examination during this admission, and there
were no neurologic concerns at the time of discharge.
8. SENSORY/AUDIOLOGY ISSUES: A hearing screen was performed
with automated auditory brain stem responses, and [**Known lastname 2398**]
passed in both ears.
9. PSYCHOSOCIAL ISSUES: The parents have been involved
during discharge, and there were no social concerns at the
time of discharge.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Primary pediatrician is Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], [**Location (un) 2312**] Pediatric Associates, [**Apartment Address(1) 54540**], [**Location (un) 538**], [**Numeric Identifier 41119**] (telephone
number [**Telephone/Fax (1) 37109**]; fax number [**Telephone/Fax (1) 37110**]).
CARE A RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: On demand breast feeding or breast feeding and
supplementation if needed with mom's milk fortified to 24
calories per ounce with powdered cow-milk-based formula.
2. Medications: Ferrous sulfate (25 mg/mL solution), 0.2 mL
by mouth once per day.
3. Car seat position screening was performed - [**Known lastname 2398**] was
observed in his car seat for 90 minutes without any episodes
of bradycardia or oxygen desaturation.
4. State newborn screen was sent on [**4-27**] and on [**2109-5-7**] with no notification of abnormal results to date.
5. Parents have declined hepatitis B vaccine at this time.
IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) born at less than 32 weeks gestation; (2) born
between 32 and 35 weeks gestation with 2/3 of the following:
plans for day care during respiratory syncytial virus season,
with a smoker in the household, neuromuscular disease, airway
abnormalities, or with school-age siblings; and/or (3) with
chronic lung disease.
Influenza immunization should be considered annually in the
Fall for all infants once they reach six 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 to protect the
infant.
DISCHARGE INSTRUCTIONS/FOLLOWUP: Visit with primary
pediatric provider within five days of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 32 and 6/7 weeks gestation.
2. Respiratory distress secondary to retained fetal lung
fluid, resolved.
3. Status post sepsis evaluation.
4. Status post unconjugated hyperbilirubinemia.
5. Apnea of prematurity, resolved.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**First Name (Titles) **] [**Last Name (Titles) 42702**] 50-563
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2109-5-12**] 07:11
T: [**2109-5-12**] 10:45
JOB#: [**Job Number 54541**]
ICD9 Codes: V290, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2474
} | Medical Text: Admission Date: [**2177-10-13**] Discharge Date: [**2177-11-17**]
Date of Birth: [**2177-10-13**] Sex: M
Service: NEONATOLOGY
HISTORY: This is the 1.315 kg product of a 28 [**1-9**] week twin
gestation, born to a 27-year-old GI P0-II mother. Prenatal
screens notable for maternal blood type A positive, antibody
surface antigen negative, group B strep unknown. This is a
Ultrasound at 23 weeks showed size discordance, attributed to
twin-twin transfusion syndrome. Subsequent ultrasound showed
increasing oligohydramnios but good biophysical profiles.
The mother completed steroid therapy. These patients were
delivered by cesarean section. Twin I emerged apneic but
minutes.
1. Respiratory: The child was intubated and given 2
doses of surfactant, and rapidly weaned to CPAP and then
nasal cannula. Intermittently the child had to go back on
CPAP for increased spelling. He was started on caffeine and
subsequently weaned onto nasal cannula on DOL #16 and onto RA on
DOL#34. He is currently on caffeine. He has occasional spells.
2. Fluids, electrolytes and nutrition: He was initially
nil by mouth and started on intravenous fluids. His
feeds were advanced as tolerated .He is currently tolerating
150 cc/kg of PE28 with ProMod po/pg.
3. Infectious Disease: The patient had started antibiotics.
Culture were negative at 48 hours, and these were
discontinued. When he had increased spells, repeat CBC and
blood cultures were done, but no further antibiotics were
started. He is currently off all antibiotic therapy.
4. Cardiovascular: He never required blood pressure
support, although he did have a murmur and was given a course
of indomethacin. His murmur persisted. An echocardiogram
was performed, which showed that he had a mild biventricular
outflow obstruction, probably secondary to hypovolemia, but
no structural heart disease and no duct. Repeat ECHO on DOL#28
revealed improved but mild biventricular hypertrophy, which will
need to be followed as an outpatient at the Cardiology Clinic.
5. Hematology: He received a blood transfusion of 50 cc/kg
since his hematocrit was relatively low and his
echocardiogram was consistent with hypovolemia. He did
require phototherapy for hyperbilirubinemia, however, at this
time, he is off of phototherapy, with normal bilirubin
levels.
6. Neurology: HUS on [**10-15**] and [**10-23**] were within normal limits
Follow up HUS on [**2177-11-13**] revealed caudothalamic groove cyst
PHYSICAL EXAMINATION: He is 2.170kg, he is non-dysmorphic.
His cardiac examination shows a II/VI systolic murmur, regular
rate and rhythm. His lung examination is clear bilaterally.
His abdomen is soft and nondistended. The rest of his physical
examination is within normal limits.
CONDITION AT THE TIME OF THIS SUMMARY: Stable.
FOLLOW UP
1. Paediatric Cardiology in mid [**Month (only) **] to F/U biventricular
hypertrophy- parents will need to call for appointment
2. ROP screen on [**2177-11-19**]
MEDICATION
Caffeine 15mg po/pg qd
Vit E 5 IU po/pg qd
Ferrinsol 0.15cc po/pg qd
DIAGNOSIS LIST:
1. Prematurity
2. Status post twin-twin transfusion
3. Mild apnea of prematurity
4. Status post rule out sepsis
5. Mild biventricular hypertrophy
6. Right subependymal cysts with resolved bilateral germinal
matrix haemorrhages
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-477
Dictated By:[**Name8 (MD) 45197**]
MEDQUIST36
D: [**2177-10-31**] 17:56
T: [**2177-11-1**] 00:00
U: [**2177-11-17**] 09:00
JOB#: [**Job Number 35882**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2475
} | Medical Text: Admission Date: [**2154-12-14**] Discharge Date: [**2155-1-4**]
Date of Birth: [**2074-11-21**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Delta MS, respiratory distress
Major Surgical or Invasive Procedure:
R chest tube place
Intubation and mechanical ventilation
R IJ central line placed
L SC central line placed
PICC line placed
History of Present Illness:
80yo M with h/o hyperlipidemia, RA, new diagnosis of
glioblastoma multiforme (grade 4) p/w altered mental status and
respiratory distress. He was diagnosed in [**Month (only) 1096**] with GBM (by
biopsy) in the setting of increasing confusion, memory loss. He
was started in [**Month (only) 1096**] on high dose radiation therapy at which
time he was also started on high dose decadron w/ q3day taper
(most recently on 3mg); last radiation session was late
[**Month (only) 1096**]. He also recently had a port placed through which he
was receiving avastin (last 2 weeks ago). His family reports
mildly productive cough (cold sx) beginning approximately 1 week
ago; he had a CXR 3-4 days ago which reportedly was negative for
pneumonia and took atovaquone.
.
After the onset of these pulmonary symptoms, he later developed
left knee "bursitis" last week for which he received injection
most recently yesterday by PCP (presumably steroid injection).
He had largely been bed bound over the last few days [**1-4**] to left
knee pain. Beginning this morning, he was very exhausted. He
took a nap this morning and when he awoke, he was confused,
somnolent, lethargic. His wife called EMS and he was
transferred to [**Hospital1 18**] ED. En route to the ED, he was noted to be
in a.fib with RVR for which he received diltiazem.
.
In the ED initial vitals were T 96.7 HR 112 BP 105/67 RR 28 O2
sat 85% RA. CXR showed multifocal PNA at RUL, RLL, LLL. He was
placed on NRB and shortly thereafter O2 sats again dropped to
the 80s, thus he was intubated 4:30 pm. Blood cultures were
drawn and he received levofloxacin 750g IV x1, vancomycin 1g IV
x1, ceftriaxone 1g IV x1, and azithromycin 500mg x1. He also
received 10mg IV decadron. He was initially normotensive, but
dropped pressure at 6:30 pm into 70s requiring initiation of
phenylephrine gtt. Over his entire ED course, received total 5L
NS.
.
Head CT demonstrated "no new findings" and was reportedly
reviewed by [**Hospital1 18**] neurosurgery however there is no note in
chart/OMR. Additionally he was seen by his neurologist who
follows him at [**Hospital1 2025**], however there is no documentation of this.
Past Medical History:
# Grade 4 glioblastoma multiforme left temporal lobe; s/p high
dose radiotherapy, previously on high dose steroids, recently
tapered. Recently placed Portacath with steristrips still
present.
# Rheumatoid arthritis; on remicade until recently
# L knee bursitis
# Hyperlipidemia
Social History:
Lives at home with wife. [**Name (NI) **] and daughter-in-law (who is [**Name8 (MD) **] MD)
live locally. Smoking, Etoh history unknown.
Family History:
nc
Physical Exam:
S: Temp: 97.2 BP: 99/69 HR: 138 a. fib RR: 22 O2sat 92% AC
500/19 PEEP 14 FiO2 1.0
GEN: Intubated, unresponsive on minimal sedation
HEENT: Pupils pinpoint, symmetric, unresponsive to light,
scleral mildy icteric, dry MM, Multiple pinpoint white plaques
on roof of mouth
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
CHEST: Portacath site right anterior chest with steri strips in
place, mildly erythematous, no significant increase
warmth/induration/fluctuance
RESP: Clear anteriorly, decrease BS right laterally, no
wheezing/rales
CV: irreg irreg, no mrg appreciated
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 1+ pedal edema b/l, right foot cooler than left 1+ DP on
right, 2+ DP on left, palpable PT pulses b/l, left knee with
small effusion, increased warmth without significant increased
erythema
SKIN: appears mildly jaundiced
NEURO: Downgoing toes b/l. DTRs [**Name (NI) 20772**] throughout
including biceps, patellar, achilles.
Pertinent Results:
ADMISSION LABS
[**2154-12-14**] 04:45PM BLOOD WBC-6.0 RBC-3.78* Hgb-11.7* Hct-34.3*
MCV-91 MCH-31.0 MCHC-34.1 RDW-13.6 Plt Ct-74*
[**2154-12-14**] 04:45PM BLOOD Neuts-80* Bands-6* Lymphs-9* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2154-12-14**] 04:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2155-1-2**] 02:38AM BLOOD Plt Ct-179
[**2155-1-2**] 02:38AM BLOOD PT-14.6* PTT-35.5* INR(PT)-1.3*
[**2154-12-14**] 04:45PM BLOOD PT-13.3 PTT-31.5 INR(PT)-1.1
[**2154-12-14**] 04:45PM BLOOD Plt Smr-VERY LOW Plt Ct-74*
[**2154-12-14**] 04:45PM BLOOD Glucose-98 UreaN-44* Creat-1.1 Na-138
K-5.3* Cl-105 HCO3-23 AnGap-15
[**2154-12-14**] 04:45PM BLOOD CK(CPK)-52
[**2154-12-14**] 04:45PM BLOOD CK-MB-NotDone
[**2154-12-14**] 04:45PM BLOOD Calcium-8.0* Phos-3.7 Mg-2.7* UricAcd-3.4
[**2154-12-14**] 10:47PM BLOOD calTIBC-146* VitB12-1418* Folate-3.5
Ferritn-1409* TRF-112*
[**2154-12-14**] 10:47PM BLOOD TSH-0.69
[**2154-12-15**] 06:26AM BLOOD Cortsol-26.9*
[**2154-12-14**] 06:50PM BLOOD Type-ART pO2-60* pCO2-50* pH-7.30*
calTCO2-26 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
[**2154-12-14**] 07:15PM BLOOD Lactate-2.2*
[**2154-12-15**] 12:25AM BLOOD O2 Sat-98
[**2154-12-15**] 12:25AM BLOOD freeCa-1.10*
Brief Hospital Course:
Note: the majority of this hospital course refers to the
patient's ICU course. He was on the medical floor for 16 hours
prior to discharge and was stable during this time.
.
# Septic Shock: Met criteria for septic shock. On presentation
had clear pulmonary source of infection. Initial sputums grew
out pneumococci. Patient relatively immunocompromised due both
to cancer diagnosis and chronic steroid use secondary to brain
tumor.
On admission patient had central line placed, CVPs maintained
[**7-15**]. Patient needed pressors to maintain BP initially. On
levophed, but developed some tachyarrhythmnias (Afib with RVR)
so was switched to neo. Initially covered with Zosyn, levoflox
and vanco. Patient was continued on atovaquone for PCP
[**Name Initial (PRE) 6187**]. Patient was also intubated on presentation, and
maintained on AC. Patient had EKGs without signs of ischemia,
and multiple sets of normal cardiac enzymes. Pressors were
largely weaned by HD #3. He did rarely require brief periods of
neosynepherine, due to too-rapid diuresis.
The patient had a normal cortisol stim test.
Historically, it was noted that the patient had a red left
knee a few days prior to admission. This knee was tapped by
ortho and found to be floridly septic. He was taken to the OR
and washed out by Ortho (please see seperate op note for full
accounting of this procedure). This infection was found to be
MSSA, which also grew out of his blood and eventually out of his
R chest chemo-port, which was removed by surgery. He was
maintained on a 6week course of Nafcillin for this staph
infection. A TEE demonstrated no signs of endocarditis.
Infectious disease was consulted and assisted with his
antibiotic regimen.
The patient completed a full 14d course of Levoflox for
pneumonia. The patient also had a full course of Clinda for a
question of toxic shock syndrome or aspiration pneumonia. His
Vanco was d/c'd after 5d due to only MSSA growing out. On [**12-20**]
his pre-existing R chest chemo port was noted to be purulent and
was removed by surgery. This grew out MSSA. Once more, the
nafcillin was continued for 6week total course.
A [**12-21**] culture grew out yeast and he was started on a course
of fluconisol as per ID. He recieved a full Ophtho eval which
demonstrated no ocular involvment.
Planned course of treatment is for nafcillin for total of 6
weeks to end [**1-30**], fluconazole for 2 weeks total to end [**1-9**], and
ceftriaxone to end [**1-10**].
.
# Afib c RvR: New-onset afib in the face of sepsis,
hypotension, infection. Patient initially controlled with
boluses of Diltiazem or Lopressor. Often returned into Afib
during times of increased activity or stress. Used
neosynepharine which seemed less arrhythmagenic. Amiodarone was
tried initially for control, but the patient became to
bradycardic on this [**Doctor Last Name 360**]. As patient was weaned from pressors
he was begun on a regimen of metoprolol which seemed to control
his rate well. He did ocassionally return to RVR, which was
treated with boluses of dilt or lopressor with good effect. He
was then restarted on amiodarone [**1-1**] and responded to it well.
Due to his brain tumor he was note anticoagulated during his
time in the ICU. The risks and benefits were discussed. It was
felt that the risks of ICH outweighed the benefits of stroke
prevention at this time. Plans were made to readdress this issue
once the patient's mental status improved.
.
# Septic Arthritis: As above, had septic arthritis of L knee
treated via washout by ortho on [**12-17**]. Nafcillin x6weeks per ID
started on [**12-19**]. Nafcillin is scheduled to finish on [**1-30**].
Patient did have a swollen L wrist later in his course, but this
was tapped by Ortho and never grew out any bacteria.
Plastics-hand was consulted and felt clinically that this was
not a septic joint, instead just a manifestation of his chronic
RA.
Ortho also felt it was not prudent to washout his R knee, which
was clinically asymptomatic during his ICU course. His L knee
healed well and the staples and drain were removed without
incidence. He has been signed off from direct ortho care, and
is weight-bearing as tolerated at time of ICU discharge.
.
#Respiratory status: Patient was maintained on ARDS-style
ventilation while on the ventilator. He has a bronchoscopy on
[**12-18**] which showed diffuse thick bloody sputum greatest in the R
LL. By [**12-19**] the patient was changed to pressure support
ventilation. The patient was activily diuresed at this time,
with good effect and improving respiratory status. The patient
tested negative for legionella and influenza. The patient was
quickly weaned to CPAP+PS of [**4-7**], but was difficult to wean
fully from the vent due mainly to his mental status. He was
extubated on [**12-24**] with great success.
On [**12-25**] the patient was noted to have an increasing o2
requirement and a CXR demonstrated a moderate-sized R
pneumothorax. Thoracic surgery was consulted and placed a chest
tube. This tube was intermittantly to wall-suction, water-seal
or clamped. On [**1-2**] it was d/c'd, with the pneumothoax smaller
in size.
.
#GBM: Head CTs compared to his baseline [**Hospital1 2025**] scans showed no
interval change. He was maintained on his baseline 3mg of
Dexamethasone while inpatient here. It appears that neurooncs
original plans were to taper the dexamethasone. We were unable
to contact primary neuro-oncoligist to discuss steroid taper but
this should be discussed with Dr. [**Last Name (STitle) **] when he becomes
available.
.
#Anemia/thrombocytopenia: Had anemia of chronic disease,
admitted with thrombocytopenia attributed to Avastin and
timador. His thrombocytopenia was asymptomatic during his
hospital course, and steadily improved. His anemia was mild,
and did require occasional transfusion.
.
# Hyperglycemia: Intitally hyperglycemic in face of sepsis,
controlled with SS insulin and resolved on its own.
.
#R Chest wound: Con't to drain purulent material s/p removal of
port. Surgery recommended QID dilute([**12-6**]) Dakin's solution and
close f/u. Any fluctuant areas must be debrided.
.
#Mental Status: The patient presented with altered mental
status felt to be due to sepsis. He did take some days to
awaken from his intubated and sedated state. He continued to be
Aox1-2 in the MICU, with symptoms consistent with delerium. A
repeat head CT showed no change; his delerium was felt to be
mainly post-septic and ICU related and appeared to be slowly
intervally improving each day.
.
#Prophylaxis: Patient was initially on pneumoboots and then
Heparin SC, a bowel regmimen and a Gi prophlyaxsis throughout
his hospital course.
.
# Electrolytes: The patient required extensive repletion of his
potassium during his ICU course, often requiring q6hr lyte
checks and 100-200meq of K+ per day. This was felt to be mostly
due to a diarrhea and thus GI loss, and was resolving at the end
of his hospital course as diarrhea resolved.
.
# Nutrition: The patient was maintained on TF while intubated,
and also s/p intubation as he failed his initial speech and
swallow exams. On [**1-3**] he passed his speech and swallow bedside
test.
.
#LFTs: Patient had elevated LFTs on presentation which were
attributed to sepsis. This abnormality resolved as the
patient's clinical picture improved. He should continue on
weekly LFT checks due to his continuing nafcillin.
.
# PT/OT: after extubation the patient was followed actively by
PT and OT.
Medications on Admission:
# Naproxen prn
# Mepron (prophylaxis)
# Hydrocodone
# Dexamethasone 3mg
# Avastin (last received 2wks ago, due on Monday [**2154-12-16**])
# Lipid lowering [**Doctor Last Name 360**] (wife unsure of name)
# Timador (was previously on this, but was stopped [**1-4**] to
thrombocytopenia)
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2
times a day).
4. Atovaquone 750 mg/5 mL Suspension Sig: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H
(every 6 hours) as needed for cough.
9. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 2 weeks: last day [**1-9**].
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold for HR<50 and SBP<100.
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): [**Hospital1 **] until [**1-7**] then 400mg daily.
12. Famotidine 10 mg/mL Solution Sig: Twenty (20) mg Intravenous
Q12H (every 12 hours).
13. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours).
14. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2)
grams Intravenous Q6H (every 6 hours) for 6 weeks: last day
[**1-30**].
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
16. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5)
units Subcutaneous twice a day.
17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding
scale Subcutaneous four times a day: sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Septic Shock
Community Aquired Pneumonia
Respiratory Failure
Acute Renal Failure
Septic Arthritis (L Knee)
Bacteremia
Infected R Chest Catheter
Afib with RVR
Delerium
Anemia
Thrombocytopenia
Hyperglycemia
Pneumothorax (R)
Hypokalemia
Transaminitis
Secondary:
# Grade 4 glioblastoma multiforme left temporal lobe; s/p high
dose radiotherapy, previously on high dose steroids, recently
tapered. Recently placed Portacath with steristrips still
present.
# Rheumatoid arthritis; on remicade until recently
# L knee bursitis
# Hyperlipidemia
Discharge Condition:
fair - multifactorial delirium with waxing and [**Doctor Last Name 688**] mental
status A+Ox1-2
Discharge Instructions:
You were admitted for pneumonia and multiple infections
including of your knee and blood stream. you were treated with
several antibiotics and had a stay in the intensive care unit
which required intubation. Currently you are being treated for
these infections and are on tube feedings and slowly eating
again.
Regarding your brain tumor, we felt that this issue, while
serious, was stable during your stay here. It is very important
that you followup with your neuro-oncologist Dr. [**Last Name (STitle) **] at
[**Hospital1 2025**]. You need to discuss with him whether you should be on
blood thinners.
.
Followup Instructions:
f/u with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 1005**] of orthopedic surgery at ([**Telephone/Fax (1) 15940**] to schedule a followup appointment in 1 month.
f/u with your outpatient rheumatologist in [**1-6**] weeks.
f/u with your outpatient neurooncologist Dr. [**Last Name (STitle) **] on Monday
by phone - he should be involved in deciding steroid taper and
deciding about anticoagulation.
Some of your labs will be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of infectious
disease at ([**Telephone/Fax (1) 1353**] (phone ([**Telephone/Fax (1) 17490**]), she will
contact you regarding followup.
ICD9 Codes: 5070, 5849, 2930, 2760, 2724, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2476
} | Medical Text: Admission Date: [**2153-10-22**] Discharge Date: [**2153-10-25**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Gadolinium-Containing Agents / Demerol
/ Morphine / Haldol
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
mast cell degranulation flare
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 61 yo F with Mast Cell Degranulation Syndrome s/p 3
intubations, htn, depression, GERD and erosive OA who presents
with SOB, CP, epigastric pain and n/v/d consistent with her
typical mast cell degranulation attacks.
.
Pt was admitted twice since [**2153-9-3**]; in [**Name (NI) **] pt was
intubated prophylactically for laryngeal edema in the context of
a flare. Last admission was in early [**Month (only) 359**] and pt was sent
home on a steroid taper which was completed 4 days PTA and a
Z-pack completed 1 wk PTA. Pt reports the day PTA, she
developed worsening epigastric pain which bores through to her
back, constant squeezing chest pain, wheezing, and shortness of
[**Month (only) 1440**]. While she has similar symptoms at baseline, these
symptoms worsened gradually over the day yesterday and she went
to the ED. She also had diarrhea x 4 BM yesterday, x2 today,
and vomitting x 2 today. She reports a chronic productive cough
of yellow-green sputum and several weeks of low grade fevers and
night sweats. She denies wt loss.
.
ROS was notable for ha similar to her typical headaches and
stiff neck. Pt denies photophobia, confusion, dysuria,
hematuria, melena, bloody stool. She is unaware of any
particular stressor (no falls, recent illness).
.
In the [**Name (NI) **] pt had an EKG showing sinus tach. VS were 97.4 120
141/89 24 97% RA. Pt received epi 0.3 1:1000 SQ epi, 2mg iv
dilaudid x 2, 50iv benadryl x1 and 25mg x1, Solumedrol 80mg,
Zofran 8mg, albuterol neb, ativan iv lmg. CXR no pneumonia, no
acute process. Symptoms intitially got better then recurred.
.
On the floor, pt reports symptoms have improved from the ED. She
now reports [**7-12**] epigastric pain, unchanged. Her wheezing has
improved. She reports her breathing is uncomfortable and
worrisome, but not yet at the point of intubation.
Past Medical History:
PMH:
- Mast Cell Degranulation Syndrome as above - sx for >10 [**Month/Year (2) 1686**] but
dx 6 [**Month/Year (2) 1686**] ago. Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **], allergist at [**Hospital1 112**],
#[**Telephone/Fax (1) 21735**]. Also followed here by Dr. [**Last Name (STitle) 79**] in GI ;has had LFT
abnl with attacks in past. Has been intubated three times, most
recently [**9-10**]. Hospitalized 10 times in [**2152**] for attacks.
- MI after given wrong dose of epi in anaphylaxis
- HTN - pt reports is episodic and exacerbated during flares
- Erosive osteoarthritis
- GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]
- Paradoxical Vocal Cord Dysfunction viewed on fiberoptic
laryngoscopy
- spinal stenosis
- anemia - ? iron deficiency; received 2 transfusions in the
past
- Hemorrhoids
- ADHD
- depression/anxiety - hospitalized once after husband's
divorce.
- pt reports EGD demonstrated vegetable bezoar (?[**12-7**]).
- h/o hyperparathyroidism with nl Ca, low nl Vit D [**2151**]; never
had BMD
- h/o MRSA infection (porthacath associated)
- h/o L wrist cellulitis concerning for necrotizing fasciitis
s/p what appears to have been a fasciotomy
- portacath placed [**3-8**] - d/c'd [**2-3**] MRSA infection
- portacath placed [**2151-6-9**]
.
PSH:
- s/p cholecystectomy
- s/p tonsillectomy
- Status post hysterectomy and oophorectomy
Social History:
Pt lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. She is divorced after 37 yr marriage.
Her son [**Name (NI) **] is her HCP [**Telephone/Fax (1) 21738**]; he lives in [**Location **] ME .
She denies every using ETOH/recreational drugs / smoking. Pt
reports frustrated mood but no current depression; no SI/HI.
Family History:
Mother died of MI @ 76, Sister w/ breast cancer and bilateral
mastectomy.
Physical Exam:
Vitals - 98.2 168/96 107 20 98% on 2L
GENERAL: obese woman with cushingoid face, eyes closed, easily
distracted, in mild respiratory distress
HEENT: NC, AT, MM dry, tongue appears red but not obstructive.
no cervical lymphadenopathy. Neck supple. End expiratory
wheeze in tracheal area; no stridor currently.
CARDIAC: tachycardiac, regular no m/g/r
LUNG: CTAB. No wheezes.
ABDOMEN: soft, mild tenderness to palpation diffusely. No CVAT.
No spinal tenderness.
EXT: warm, 2+pulses, trace edema
SKIN: many bruises on arm, larm bruise on L breast after fall
prior to last admission.
Pertinent Results:
[**2153-10-22**] 07:05AM GLUCOSE-251* UREA N-11 CREAT-0.8 SODIUM-140
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-28 ANION GAP-13
[**2153-10-22**] 07:05AM CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-2.0
[**2153-10-22**] 07:05AM WBC-8.8 RBC-3.52* HGB-10.4* HCT-30.3* MCV-86
MCH-29.6 MCHC-34.4 RDW-15.3
[**2153-10-22**] 07:05AM PLT COUNT-247
[**2153-10-22**] 07:05AM PT-12.1 PTT-26.8 INR(PT)-1.0
[**2153-10-22**] 12:35AM NEUTS-74.0* LYMPHS-19.0 MONOS-5.7 EOS-1.2
BASOS-0.2
Brief Hospital Course:
61 yo F with Mast Cell Degranulation admitted for likely acute
mast cell degranulation attack.
.
# Mast Cell Degranulation: Pt's symptoms were classic for a
flare (CP, SOB, ha, n/v). On admission, pt was started on
solumedrol 80 IV Q8, Famotidine 20 mg Q12H and she continued
home Gastrocrom 300 mg Oral qid, cromolyn, fexofenadine. She was
given supportive cocktail of Dilaudid 2mg IV q-4h, Benadryl 50mg
IV q4h, Ativan 1mg IV q3h, Albuterol nebs q4h. On day 2 of
admission, she reported increasing difficulty breathing and her
tongue was moderately edematous and erythematous. She requested
an epi pen, which was given with no effect as well as
supplements from her cocktail. After an hour she still exhibited
signs of acute respiratory distress and she requested
prophylactic intubation. She was intubated and transferred to
the MICU. Per anesthesia, there was no sign of laryngeal edema
and intubation was easy. However, anesthesia team noted that
prophylactic intubation is necessary in this pt given her
cushingoid habitus and difficult intubation if laryngeal edema
was present. After return from MICU to the floor, pt was
transitioned to PO medications and started a 2 wk course of
steroid taper, starting at 60 mg PO prednisone QD.
.
# Chronic pain - after pt's extubation, pt demanded IV Dilaudid
and threatened multiple times to leave the hospital AMA. She
also refused PO pain medications at this time, stating that they
do not work. She complained of headache and chest pain. The team
counseled her that headaches do not require IV pain medicines
unless they are very serious and require imaging. She replied
that she knew this was a mast flare and they required IV
Dilaudid only. At this time, she had no shortness of [**Month/Day/Year 1440**],
wheezing, pruritus, neuro sx, or any other symptoms. She
appeared well and was pacing about the room. She was finally
convinced to take PO medications, including multiple extra doses
of Benadryl and Ativan. Pt reports that at baseline, she takes
Dilaudid at home for headaches.
.
# Chest pain/SOB - While sx were classic for flare, CXR was
obtained to r/o infx which showed no signs of pna or congestion.
PCP was considered given pt's chronic steroids, and sputum
obtained during intubation was negative. LDH was not checked due
to chronic elevation. Pt's allergist at OSH was also contact[**Name (NI) **]
re:PCP prophylaxis with Bactrim but allergist never responded.
Per providers at [**Hospital1 18**], PCP prophylaxis has been discussed
without resolution.
.
# diarrhea - pt complained of diarrhea on admission, but did not
supply stool sample until day prior to discharge. Given pt's
recent exposure to antibx (z-pack as outpt), C dif was checked
and was negative.
.
# anemia - HCT 30, MCV 86; baseline HCT 30-35. Per pt, has been
told she has iron deficiency in the past. Colonoscopy in [**2151**]
showed hemorrhoids. Pt was recommended to consider iron
replacement as an outpt.
.
# HTN: pt was continued on her home dose of diltiazem. Her bp
ran high, but per pt, this is normal for her flares.
.
# chronic steroids/iatrogenic [**Location (un) **] - per pt, is on steroids
>50% of year. Pt has very cushingoid appearance that per
multiple providers, has increased over the past year. HbA1c was
6.1%; she was treated with an insulin SS while on high dose
steroids. Pt continued Ca/Vit D, and pt was recommended to get
BMD as outpt. Bactrim prophylaxis was considered, and pt was
counseled to discuss with her allergist risks/benefits.
.
gastritis/GERD - cont ranitidine, omeprazole [**Hospital1 **]
.
# Depression/anxiety: - team discussed contribution of severe
anxiety to her flares. Team recommends outpt psychiatry
follow-up. Pt continued home Duloxetine, Ativan, Doxepin.
.
# ADHD - pt continued home Amphetamine-Dextroamphetamine
.
# Osteoarthritis: - pt continued home Plaquenil
.
# hx of hyperPTH with nl ca - etiologies most often due to Vit d
deficiency .
- pt now on Vit d/ca. Pt was recommended BMD as outpt.
.
.
MICU COURSE: [**10-23**] - [**10-24**]
.
On the floor, pt reports symptoms have improved from the ED. She
now reports [**7-12**] epigastric pain, unchanged. Her wheezing has
improved. She reports her breathing is uncomfortable and
worrisome, but not yet at the point of intubation.
.
Since admission she was given Solumedrol 80mg IV q8H x 3 with
plan to transition to a prednisone taper the day of transfer.
She was also on a supportive cocktail of Dilaudid 2mg IV q-4h,
Benadryl 50mg IV q4h, Ativan 1mg IV q3h with planned transition
to po. Day of transfer to the MICU, patient complained of
worsening SOB without concomitant CP. Her O2 sat remained > 92.
Given epi-pen, diphenhydramine IV, Ativan IV and Dilaudid IV.
Code blue was called for elective intubation. ABG with pH 7.42,
pCO2 40, pO2 526, HCO3 27 while being bag-masked. Patient was
intubated by anesthesia on the floor without complication and
transported to the MICU for further management. Upon transfer,
patient was following commands.
.
# Shortness of [**Month/Year (2) 1440**]: This represented the 4th intubation for
the patient. Per the intubating anesthesiologist, there was no
evidence of tracheal or laryngeal edema. Of not the patient was
without desaturation by pulse-oximetry or ABG. Thus, not truly
hypercarbic or hypoxic respiratory failure. In the past, patient
has been on steroid tapers which seemingly have helped her
flairs. The patient was briefly placed on pressure support and
continued on her regimen of Q4H ipratroprium/albuterol, steroids
IV, diphenhydramine IV q6 and ranitidine for possible H2
component. The patient was subsequently extubated without
complication.
.
# Mast Cell Degranulation: Pt initially stated that her
presenting symptoms are consistent with her flairs. The patient
was continued on solumedrol 80 IV BID; transition to PO
prednisone post-extubation, Famotidine IV, continued pt on home
Gastrocrom 300 mg Oral qid, cromalyn, fexofenadine. Once
extubated the pt was continued on her home cocktail of Dilaudid
2mg IV q-4h, Ativan 1mg IV q3h, her scheduled diphenhydramine,
Albuterol nebs q4h and Zofran. The pt was continued on insulin
SS while on steroids.
.
Medications on Admission:
Zolpidem 10 mg PO HS prn insomnia
Hydroxyzine HCl 25 mg PO QID
Ranitidine HCl 300 mg PO HS
Duloxetine 60 mg Capsule once a day
Hydroxychloroquine 200 mg PO BID
Fexofenadine 180 mg PO BID
Omeprazole 20 mg [**Hospital1 **]
Cromolyn 100 mg/5 mL Solution 600 mg PO QID
Diltiazem HCl Sustained Release 180 mg PO DAILY
Hydromorphone 4 mg every four 4 hours as needed for pain.
Amphetamine-Dextroamphetamine SR 15 mg once a day.
Promethazine 12.5 mg TID prn nausea
Doxapine 50 mg [**Hospital1 **]
Epi pen prn
Gastrocrom 30Ml (3amps) QID
Iron
Ca/Vit D
Miralax PRN
Discharge Medications:
1. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
2. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at
bedtime.
4. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Cromolyn 100 mg/5 mL Solution Sig: Six (6) PO twice a day.
9. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
10. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
11. Amphetamine-Dextroamphetamine 15 mg Capsule, Sust. Release
24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day.
12. Promethazine 12.5 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for nausea.
13. Doxepin 50 mg Capsule Sig: One (1) Capsule PO at bedtime.
14. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1)
Intramuscular as needed.
15. Gastrocrom 100 mg/5 mL Solution Oral
16. Iron Oral
17. CALCIUM 500+D Oral
18. Miralax Oral
19. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day for 13 days: 60mg x 1 days
40mg x 2 days
20mg x 2 days
10mg x 4 days
5mg x 4 days.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Mast cell degranulation flare
Respiratory failure
Hypertension
GERD
Depression/anxiety
Discharge Condition:
Hemodynamically and respiratory stable to home.
Discharge Instructions:
You were admitted to the hosptial for a mast cell degranulation
flare.
Blood tests were done, which showed that you are anemic, meaning
you have low blood counts. Your level of anemia is unchanged
from your baseline.
You were treated with IV steroids (solumedrol) for 24 hours, and
switched to prednisone. You were also treated with dilaudid,
benadryl, albuterol nebulizers, zofran and ativan. Your other
home medications were continued.
You should follow up with your allergist, Dr. [**Last Name (STitle) **], and your
primary care doctor after leaving the hospital.
If you develop shortness of [**Last Name (STitle) 1440**], severe wheezing or chest
pain, please go to the ED or call your doctor immediately.
Followup Instructions:
Please call your allergist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) **]) and make
an appointment for within 2 weeks of leaving the hospital.
Please also call your primary care doctor, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 21748**]. Please discuss with him your anemia. Please also
discuss with him the bennefits of a bone mineral density scan
for you, a tool to screen for osteoporosis.
Completed by:[**2153-10-27**]
ICD9 Codes: 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2477
} | Medical Text: Admission Date: [**2137-5-22**] Discharge Date: [**2137-5-24**]
Date of Birth: [**2071-3-16**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Percocet
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
failure to decannulate
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
66 F with history of CAD s/p CABG [**2118**], PCI recently, OSA,
bipolar, on [**1-27**] went to [**Hospital1 336**] for an elective left hip
replacement, which was complicated with post-op AFIB with RVR
that required cardioversion. She became septic, had a VAP
secondary to pseudomonas, UTI [**2-22**] VRE. She improved, was trached
and pegged, and transferred to [**Hospital **] [**Hospital **] Rehab. She was
there for 2 months, where they could not decannulate her. Bronch
was done at [**Hospital1 **] - tracheomalacia was seen in the subglottic
region to trach. She was transferred here for evaluation of
tracheal stenosis after failed attempts at decannulation.
.
She was changed from a 6 uncuffed to a 7 cuffed trach. En route
in ambulance, she had SOB with frothy secretions. She had to
stop at [**Hospital 17679**] medical center for trach management, CT chest
was done to assess for PE, she was suctioned and doing fine,
then transferred here.
.
She was admitted to the IP service. She has been trached for [**4-25**]
months. She went for bronch today and IP found severe
supraglottic edema compatible with GERD. IP decided not to do
anything with her trach until this edema was fixed first. She
was started on PPI. She had a trach change this afternoon, in
which her trach was downsized back down to 6 uncuffed. She was
going to be discharged and seen in 4 weeks by IP.
.
She decannulated herself today by coughing up her trach today,
and a respiratory code was called on [**4-23**] at 1430 when she became
hypoxemic. IP came and changed her trach to a 7 cuffed trach,
bronched her, saw frothy secretions in the trachea. She was
significantly hypoxic: 7.37 / 53 / 54 / 32, and was hypertensive
220/120 during the code. Blood / mucus was suctioned from her
bronchi, and she was sitting up and coughing. She may have
negative pressure pulmonary edema or diastolic dysfunction. She
had normal vitals and was transferred to MICU green for
monitoring.
.
Past Medical History:
s/p CABG
Left total hip replacement
Bipolar disorder
Depression
AFIB
Chronic constipation
Trach and PEG
HIT on Fragmin (Arixtra
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
VS: 99.3 / 120/65 / 90 / 34 / 97% on
PS 400 / 20 / 8 / 8 / 0.8
GEN: Alert, in good mood, communicates clearly
HEENT: Trach site clean with minimal erythema
LUNGS: Diffuse rhonchi bilaterally
HEART: RRR, no m/r/g
ABD: Soft, +BS, ND NT
EXTR: No c/c/e
NEURO: Gait not tested
Pertinent Results:
[**2137-5-24**] 08:06AM BLOOD Hct-29.8*
[**2137-5-24**] 04:30AM BLOOD WBC-6.5 RBC-3.17* Hgb-9.6* Hct-28.7*
MCV-91 MCH-30.3 MCHC-33.4 RDW-19.3* Plt Ct-291
[**2137-5-23**] 02:49PM BLOOD WBC-8.8 RBC-3.82* Hgb-11.6* Hct-34.3*
MCV-90 MCH-30.3 MCHC-33.7 RDW-18.9* Plt Ct-349
[**2137-5-23**] 12:35AM BLOOD WBC-11.8* RBC-4.08* Hgb-12.3 Hct-36.4
MCV-89 MCH-30.0 MCHC-33.6 RDW-19.0* Plt Ct-351
[**2137-5-24**] 04:30AM BLOOD Neuts-74.7* Lymphs-17.9* Monos-3.7
Eos-3.2 Baso-0.5
[**2137-5-23**] 02:49PM BLOOD Neuts-79.7* Lymphs-14.4* Monos-3.4
Eos-2.2 Baso-0.2
[**2137-5-23**] 12:35AM BLOOD Neuts-88.5* Bands-0 Lymphs-7.4* Monos-3.3
Eos-0.6 Baso-0.2
[**2137-5-24**] 04:30AM BLOOD Anisocy-2+ Macrocy-1+ Microcy-1+
[**2137-5-23**] 02:49PM BLOOD Anisocy-2+ Macrocy-1+ Microcy-1+
[**2137-5-23**] 12:35AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2137-5-24**] 04:30AM BLOOD Plt Ct-291
[**2137-5-24**] 04:30AM BLOOD PT-13.4* PTT-30.5 INR(PT)-1.2*
[**2137-5-23**] 02:49PM BLOOD Plt Ct-349
[**2137-5-23**] 02:49PM BLOOD PT-13.1 PTT-50.3* INR(PT)-1.1
[**2137-5-23**] 12:35AM BLOOD Plt Smr-NORMAL Plt Ct-351
[**2137-5-23**] 12:35AM BLOOD PT-12.9 PTT-30.4 INR(PT)-1.1
[**2137-5-23**] 02:49PM BLOOD Ret Aut-2.4
[**2137-5-24**] 04:30AM BLOOD Glucose-112* UreaN-22* Creat-1.0 Na-141
K-3.3 Cl-103 HCO3-32 AnGap-9
[**2137-5-23**] 02:49PM BLOOD Glucose-209* UreaN-22* Creat-1.1 Na-136
K-3.6 Cl-97 HCO3-31 AnGap-12
[**2137-5-23**] 12:35AM BLOOD Glucose-129* UreaN-26* Creat-1.1 Na-138
K-4.1 Cl-97 HCO3-33* AnGap-12
[**2137-5-23**] 02:49PM BLOOD ALT-7 AST-15 LD(LDH)-199 CK(CPK)-50
AlkPhos-87 Amylase-52 TotBili-0.8
[**2137-5-23**] 02:49PM BLOOD Lipase-31
[**2137-5-24**] 08:06AM BLOOD proBNP-2166*
[**2137-5-23**] 02:49PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2137-5-24**] 04:30AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8
[**2137-5-23**] 02:49PM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.9 Mg-2.0
UricAcd-11.6* Iron-38
[**2137-5-23**] 12:35AM BLOOD Calcium-9.8 Phos-3.9 Mg-2.0
[**2137-5-23**] 02:49PM BLOOD calTIBC-330 Ferritn-280* TRF-254
[**2137-5-23**] 02:49PM BLOOD TSH-1.8
[**2137-5-24**] 02:27AM BLOOD Type-ART Tidal V-400 PEEP-8 FiO2-80
pO2-90 pCO2-47* pH-7.43 calTCO2-32* Base XS-5 AADO2-451 REQ
O2-75 Intubat-INTUBATED Vent-IMV
[**2137-5-23**] 02:48PM BLOOD Type-ART pO2-54* pCO2-53* pH-7.37
calTCO2-32* Base XS-3 Intubat-NOT INTUBA
[**2137-5-24**] 02:27AM BLOOD Glucose-98 K-3.2*
[**2137-5-24**] 02:27AM BLOOD freeCa-1.19
Brief Hospital Course:
66 F with history of COPD with respiratory failure on
tracheostomy since [**1-27**] following L total hip replacement. She
was brought in to be evaluated by interventional pulmonary for
failure to decannulate. Bronchoscopy show supraglottic edema in
addition to tracheal stenosis. Plan was to start her on PPI and
follow up with interventional pulmonary in 4 weeks. On the
medicine floor, she coughed up her trach tube and a respiratory
code was called. She was recannulated and transferred to medical
ICU for overnight monitoring. THroughout the night, her blood
pressure was slightly low. It was likely medication related as
it resolved by itself in the morning. She also had slight
hematocrit drop, likely related to traumatic recannulation of
her trach. She was initially on SIMV +PS 400 x20, PEEP 8, PSV 8
and FiO2 of 0.80. Her CXR show interstitial edema, likely from
negative pressure during her decannulation. Her pulmonary edema
resolved w/ positive pressure and she was eventually weaned to
trach mask again.
Medications on Admission:
ASA 81 QD
Lipitor 80 QD
Zyprexa 5 [**Hospital1 **]
Paxil 10 QD
MVI
Combivent 6puff QID
Colace 100 [**Hospital1 **]
Senna 2 QHS
Lactulose 30 [**Hospital1 **]
Lasix 30 [**Hospital1 **]
Aldactone 30 [**Hospital1 **]
Metoprolol 25 [**Hospital1 **]
Ativan 1 q4 prn
Zegerid 40'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
4. Paroxetine HCl 10 mg/5 mL Suspension [**Hospital1 **]: Ten (10) mg PO
DAILY (Daily).
5. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Cap PO DAILY
(Daily).
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Six
(6) Puff Inhalation Q6H (every 6 hours).
7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day).
8. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO BID (2
times a day).
9. Furosemide 20 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2 times a
day).
10. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day): hold for BP<100.
11. Lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
12. Zolpidem 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime).
13. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
14. Spironolactone 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
15. Ibuprofen 100 mg/5 mL Suspension [**Hospital1 **]: Six Hundred (600) mg
PO Q8H (every 8 hours) as needed for pain.
16. Fluticasone 50 mcg/Actuation Aerosol, Spray [**Hospital1 **]: One (1)
Spray Nasal DAILY (Daily).
17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
18. Fondaparinux 2.5 mg/0.5 mL Syringe [**Last Name (STitle) **]: 2.5 mg Subcutaneous
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**]
Discharge Diagnosis:
supraglottic edema likely from gastroesophageal reflux and
tracheal stenosis
Discharge Condition:
stable on trach mask.
Discharge Instructions:
Please call DR.[**Doctor Last Name 14680**] office [**Telephone/Fax (1) 10084**] to schedule a repeat
bronchoscopy in 4 weeks. Call if you develop any problems with
your trach tube.
Continue PPI [**Hospital1 **].
Please continue all medications prior to admission.
Followup Instructions:
schedule bronch in 4 weeks( DR.[**Doctor Last Name 14680**] office [**Telephone/Fax (1) 10084**])
Completed by:[**2137-5-24**]
ICD9 Codes: 4280, 4019, 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2478
} | Medical Text: Admission Date: [**2121-7-29**] Discharge Date: [**2121-8-1**]
Date of Birth: [**2054-3-5**] Sex: M
Service: MEDICINE
Allergies:
codiene
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Embolization of bleeding
History of Present Illness:
67 year old male presents with bright red blood per rectum. He
had a screening colonoscopy on [**2121-7-21**] at [**First Name8 (NamePattern2) 1495**] [**Hospital **]
Hospital, at which time a large adenoma in the cecum
was removed. Also noted to have L sided diverticulosis. Reports
distention and cramping since the colonoscopy, then at 6pm
yesterday had BRBPR x [**2-2**] before presenting to the ER. In the
ER,
he had multiple more episodes.
Past Medical History:
-HTN
-Bladder CA in [**2114**] s/p BCG q3 months for two years now under
surveillance. s/p Transurethral resection of the bladder for
cancer [**2114**]
-IBS
-OSA
-GERD
Social History:
Works as a Latin teacher. Denies tobacco, alcohol, illicit
drugs.
Family History:
Unremarkable for GI malignancy, PUD, IBD. M died of DM and
Gallbladder disease at age 86. F died of stroke at age 88.
Physical Exam:
Admission Physical Exam:
Vitals: P 90 BP 138/90 Pox 99 RA RR 12
General: Alert, oriented, no acute distress, lying in bed
HEENT: Sclera anicteric, mucous membranes dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, Non tender, markedly distended. + bowel sounds,
no
rebound tenderness or guarding
Rectal: BRB on the glove
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII grossly intact
Skin: No rash.
Physical exam on discharge:
98.2, 157/84, 78, 18, 99%RA
GEN Alert, oriented, no acute distress
HEENT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission Labs:
[**2121-7-29**] 10:50PM WBC-8.1 RBC-3.73* HGB-12.2* HCT-33.9* MCV-91
MCH-32.6* MCHC-35.9* RDW-13.1
[**2121-7-29**] 10:50PM NEUTS-80.1* LYMPHS-14.6* MONOS-3.8 EOS-1.2
BASOS-0.3
[**2121-7-29**] 10:50PM PLT COUNT-147*
[**2121-7-29**] 10:18PM LACTATE-1.2
[**2121-7-29**] 08:10PM GLUCOSE-109* UREA N-14 CREAT-0.8 SODIUM-144
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-29 ANION GAP-13
[**2121-7-29**] 08:10PM estGFR-Using this
[**2121-7-29**] 08:10PM ALT(SGPT)-25 AST(SGOT)-24 ALK PHOS-85 TOT
BILI-0.4
[**2121-7-29**] 08:10PM LIPASE-36
[**2121-7-29**] 08:10PM ALBUMIN-4.4
[**2121-7-29**] 08:10PM WBC-5.9 RBC-4.45* HGB-14.2 HCT-40.5 MCV-91
MCH-31.8 MCHC-35.0 RDW-13.3
[**2121-7-29**] 08:10PM NEUTS-73.1* LYMPHS-19.6 MONOS-4.6 EOS-1.9
BASOS-0.7
[**2121-7-29**] 08:10PM PLT COUNT-161
[**2121-7-29**] 08:10PM PT-12.1 PTT-33.0 INR(PT)-1.1
Imaging:
CTA ABD & PELVIS Study Date of [**2121-7-29**]
IMPRESSION:
1. Active extravasation of contrast within the cecum at the
site of recent adenoma resection, findings consistent with the
source of active lower GI bleed.
2. Sigmoid diverticulosis without evidence of acute
diverticulitis.
3. Stable left adrenal adenoma.
4. Bilateral renal cysts and right renal cortical thinning as
previously
characterized on prior MR. [**Name13 (STitle) **] hydronephrosis or suspicious
renal mass.
ECG Study Date of [**2121-7-30**] 6:41:22 AM
Sinus rhythm. Within normal limits. No significant change
compared
to previous tracing of [**2116-4-6**].
Radiology Report [**Numeric Identifier 7536**] EMBO NON NEURO Study Date of [**2121-7-30**]
FINDINGS:
1. Conventional SMA anatomy.
2. Area of active extravasation within the right cecum
corresponding to CTA findings. This is arising from a distal
branch of the ileocolic artery.
Multiple projections and angiograms were performed including
selective
catheterization of four fourth-order branches. The exact source
of bleeding was difficult to identify; however, a dominant
branch was identified demonstrating extravasation from a small
side branch.
3. Coil embolization with two coils of the dominant distal
ileocolic branch to stasis successfully.
Discharge Labs:
[**2121-8-1**] 04:00PM BLOOD Hct-35.3*
[**2121-8-1**] 07:55AM BLOOD WBC-5.5 RBC-3.94* Hgb-12.0* Hct-34.8*
MCV-89 MCH-30.5 MCHC-34.5 RDW-14.5 Plt Ct-132*
[**2121-8-1**] 07:55AM BLOOD Plt Ct-132*
[**2121-8-1**] 07:55AM BLOOD Glucose-96 UreaN-8 Creat-0.8 Na-142 K-3.3
Cl-106 HCO3-28 AnGap-11
[**2121-8-1**] 07:55AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9
[**2121-7-31**] 05:01AM BLOOD Type-[**Last Name (un) **] pH-7.41
[**2121-7-31**] 05:01AM BLOOD Lactate-0.5
[**2121-7-31**] 05:01AM BLOOD freeCa-1.13
Brief Hospital Course:
Mr. [**Known lastname 6483**] is a 67 year old male who is presenting with bright
red blood per rectum in the setting of a recent colonoscopy with
polypectomy.
#) BRBPR: Patient presented with BRBPR in setting of recent
polypectomy and was admitted to the ICU. He underwent CTA, which
showed active extravasation in the cecum at polypectomy site. He
subsequently went to IR. Per report, SMA, ileocolic, and
selective catheterization of 4th order distal branches performed
where active extravasation was seen. Distal branch supplying
area of extravasation identified and coiled successfully. The
surgical team followed, although no surgical intervention was
needed. He was briefly hypotensive on admission. Hematocrits
were followed initially every four hours and then every 12 hours
when levels stabilized. The patient was transfused a total of 6
units of packed red cells and one unit of platelets. Lactate on
presentation of 1.2 which trended down to 0.5. The patient was
hemodynamically stable for 24 hours with a stable hematocrit
when transferred from the ICU to the medicine floor.
Hematocrits were stable on the floor and patient was
hemodynamically stable without further episodes of bleeding. He
will follow up with his primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]
after discharge.
#) HTN: Home antihypertensives initially held in setting of GIB
and hypotension, however systolic blood pressures quickly became
elevated to 130s-150s. The patient was then restarted on his
home medications valsartan and verapamil. He had no further
episodes of hypotension and remained hemodynamically stable.
#) OSA: Patient has obstructive sleep apnea. He was placed on
home CPAP overnight without issue.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Valsartan 80 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Verapamil SR 180 mg PO Q24H
5. Ibuprofen Suspension 400 mg PO TID:PRN pain
Discharge Medications:
1. Valsartan 80 mg PO DAILY
2. Verapamil SR 180 mg PO Q24H
3. Omeprazole 20 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Docusate Sodium 200 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: GI Bleed post polypectomy
Secondary: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 6483**],
You were admitted to [**Hospital1 69**] with a
gastrointestinal bleed after a polyp removal. You were treated
with embolization of the bleeding vessel and blood transfusions
as needed. The bleeding subsequently stopped.
Medication changes:
-Please stop taking Ibuprofen for pain, you may take Tylenol up
to 4 grams per day
-Please take colace 100-200 mg [**Hospital1 **] as needed for constipation
Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] as instructed below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 1730**]
Location: [**Location (un) **] ASSOCIATES
Address: [**Street Address(2) **], [**Apartment Address(1) 86334**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) 27929**]
Appt: [**8-7**] at 11am
Department: DIV. OF [**Month (only) 864**]
When: TUESDAY [**2121-8-19**] at 1 PM
With: [**Doctor First Name 23138**] [**First Name8 (NamePattern2) 23139**] [**Name8 (MD) 815**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2479
} | Medical Text: Admission Date: [**2193-2-25**] Discharge Date: [**2193-2-28**]
Date of Birth: [**2142-7-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
50yo man w/ sarcoidosis & HTN who presents with SSCP since 2pm.
Of note, pt was seen in [**Hospital1 18**] ED on [**2193-2-22**] w/ HTN urgency, which
was noted incidentally as he was being prepped for an outpatient
lung biopsy scheduled for same day, though the procedure was
cancelled due to pt's HTN. The patient's dose of lisinopril was
increased & he was discharged home. He reports being in his USOH
until the day of presentation when, while walking up stairs, he
developed [**10-25**] SSCP radiating to jaw & l arm. Associated w/
diaphoresis & light-headedness. He initially presented to [**Hospital 26580**]
hospital, where his EKG was reportedly unchanged from
priors--though I do not have these to confirm this finding. His
TropI was 1.97. He received asa 81mg (?x2), nitro, lovenox,
morphine and lopressor and was to transferred to [**Hospital1 18**] ED. Prior
to transfer his pain had improved to [**1-24**].
.
In [**Hospital1 18**] ED, VS 97.8, 64, 143/98, 18, 97% on RA. His pain was
[**6-25**]. EKG showed LAD, LAFB, IVCD, new Q waves lateral precordial
leads (V4 &5), TWI in III, flattened TW in avF and V1, V3, V4,
and ?V5, also ~1mm STE in lead II. Cardiology was consulted. The
patient's nitro was increased and heparin gtt was started. Pt
also received IV morphine. Pain reportedly resolved, thus, pt
was not started on integrillin.
.
He arrived on the floor and reported a pain of [**2195-2-18**]. His nitro
gtt was increased and he was given morphine 4mg IV x2 w/o
significant change. His EKG showed no change from than in the
ED. Integrillin gtt was started for refractory pain. A plavix
load was also given.
Past Medical History:
- Sarcoidosis--affecting abd & lungs (dx'd at [**Hospital1 112**] years ago)
- HTN
- CVA 2yr ago --> residual r sided weakness/ pfo v. asd/ stress
in [**2189**] (may have been done at [**Hospital1 112**])
- H/o DVT
- Chronic pain
- l adrenal adenoma
- s/p splenectomy, cholecystectomy, ? adrenalectomy
- asthma
Social History:
From [**Location (un) 17927**]. Divorced. Lives w/ mom who is his HCP.
Family History:
N/C
Physical Exam:
VS - 97.6, 52, 133/94, 16, 96%
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP not elevated.
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM. Areas of induration throughout abd.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
EKG demonstrated EKG showed LAD, LAFB, IVCD, new Q waves lateral
precordial leads (V4 &5), TWI in III, flattened TW in avF and
V1, V3, V4, and ?V5, also ~1mm STE in lead II. Significantly
changed from prior.
.
OTHER TESTING:
AP UPRIGHT CHEST: The study is compared to a chest radiograph
from [**2-22**], [**2193**]. Additional history not provided on
requisition includes sarcoid. The cardiac, mediastinal, and
hilar contours are unchanged given differences in technique
with tortuosity of the thoracic aorta and prominence of the
hila. Mild cardiomegaly is stable. The previously noted vague
opacity in the left mid lung is not as well seen on the current
study; however, please note that the previous study was a
dedicated PA and lateral chest. No other areas concerning for
consolidation are identified. The left costophrenic angle has
been excluded; however, no large pleural effusions are noted.
There is no pulmonary vascular congestion.
.
Echo: The left atrium is mildly dilated. No atrial septal defect
is seen by 2D or color Doppler. The right atrial pressure is
indeterminate. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is moderately dilated.
The aortic arch is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. There is no aortic valve stenosis. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.
OSH: tropi 1.97, CK 310 WBC 17.4, DDimer 1.4 (<1.3 nml), hct 45
Trop-T: 0.94
Comments: cTropnT: Notified [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 2357 On [**2193-2-25**]
cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
.
Cardiac catheterization: 20 % LAD, mild disease in the LCX and
mild disease in the RCA with thrombotic occlusion of the distal
wrap around PDA "dottered with balloon" with improvement in flow
and partial resolution of thrombus
.
Cardiac Enzymes
[**2193-2-25**] 09:45PM BLOOD cTropnT-0.94*
[**2193-2-25**] 09:45PM BLOOD CK(CPK)-529*
[**2193-2-26**] 06:30AM BLOOD CK-MB-56* MB Indx-11.5*
cTropnT-1.59*[**2193-2-26**] 06:30AM BLOOD CK(CPK)-485*
[**2193-2-27**] 05:44AM BLOOD CK-MB-11* MB Indx-7.1* cTropnT-1.13*
[**2193-2-27**] 05:44AM BLOOD CK(CPK)-154
[**2193-2-28**] 06:30AM BLOOD CK(CPK)-83
.
MISC
[**2193-2-26**] 06:30AM BLOOD Triglyc-119 HDL-42 CHOL/HD-5.2
LDLcalc-152*
.
CBC
[**2193-2-25**] 09:45PM BLOOD WBC-17.6* RBC-4.71 Hgb-14.2 Hct-42.3
MCV-90 MCH-30.1 MCHC-33.5 RDW-14.3 Plt Ct-460*
[**2193-2-26**] 06:30AM BLOOD WBC-18.8* RBC-4.41* Hgb-13.4* Hct-39.7*
MCV-90 MCH-30.4 MCHC-33.8 RDW-14.4 Plt Ct-397
[**2193-2-26**] 01:15PM BLOOD Hct-37.3* Plt Ct-388
[**2193-2-27**] 05:44AM BLOOD WBC-16.0* RBC-4.07* Hgb-12.8* Hct-36.9*
MCV-91 MCH-31.5 MCHC-34.8 RDW-14.6 Plt Ct-345
[**2193-2-28**] 06:30AM BLOOD WBC-15.4* RBC-4.25* Hgb-13.0* Hct-39.1*
MCV-92 MCH-30.5 MCHC-33.2 RDW-14.3 Plt Ct-392
.
Chem 7
[**2193-2-25**] 09:45PM BLOOD Glucose-85 UreaN-12 Creat-0.9 Na-140
K-4.2 Cl-105 HCO3-25 AnGap-14
[**2193-2-26**] 06:30AM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-139
K-3.8 Cl-102 HCO3-25 AnGap-16
[**2193-2-27**] 05:44AM BLOOD Glucose-136* UreaN-8 Creat-0.8 Na-137
K-3.5 Cl-104 HCO3-28 AnGap-9
[**2193-2-28**] 06:30AM BLOOD Glucose-100 UreaN-10 Creat-1.0 Na-139
K-3.9 Cl-105 HCO3-28 AnGap-10
Brief Hospital Course:
The patient was admitted with an NSTEMI for cardiac
catheterization. On cardiac catheterization, an RCA thrombus
with thrombotic occlusion of distal wrap around PDA was found.
Angioplasty was attempted but unsuccessful. During the
procedure, the patient developed CP and with small ST elevation
on EKG. CP was reduced with morphine but was in some pain after
catheterization with EKG rvealing some resolution of ST
elevations in V3-V4. He was started on heparin, integrilin and
nitro drips. He was also started on Simvastatin, Aspirin, Plavix
Troprol XL and nicotine patch and tolerated all of these
medications well. He was monitored in the CCU overnight. His
cardiac enzymes were followed and continued to trend down. He
was transfered to the floor. On the floor, he had mild [**2-24**]
constant "aching" chest pain that patient reported was chronic,
related to severe sarcoid and unlike his CP on admission or in
the cath lab. An echo was obtained showing a normal EF and no
wall motion abnormalities. A lipid panel was obtained with an
elevated LDL 152. Simvastatin 40mg daily was started. He was
discharged with baseline CP with cardiology and pulmonology
follow up.
Medications on Admission:
oxycontin 80mg q12hr
lisinopril 20mg daily (?)
xanax 2mg [**Hospital1 **]
prevacid 30mg qd
prozac 20mg qd
norvasc 10mg
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Xanax 2 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Prevacid 30 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:*2*
4. Prozac 20 mg Capsule Sig: One (1) Capsule PO once a day.
5. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day.
9. 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:*2*
10. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Non-ST Segment Elevation Myocardial Infarction.
Discharge Condition:
improved
Discharge Instructions:
You were admitted for chest pain. You had a heart attack because
of a blockage in one of your coronary arteries. A stent was not
placed due to the inability to pass through the clot. Instead,
you were given medications to stabalize the clot and prevent
further clot formation.
.
If you have chest pain, significant worsening of shortness of
breath or extreme sweating (diaphoresis), you should call your
doctor and come to the emergency room.
.
The following changes were made to your medications. You should
take all other medications as previously prescribed.
1. Start taking Aspirin daily
2. Take Plavix every day for one month
3. Start taking Toprol Xl daily.
4. Nicotine patch.
Followup Instructions:
Please call [**Telephone/Fax (1) 1989**] to arrange a follow up appointment
with Dr. [**Last Name (STitle) 171**] (cardiology) in the next 1-2 weeks.
.
You should also follow up with your primary care provider [**Last Name (NamePattern4) **].
[**Last Name (STitle) 1057**] on 10:45 on Februaruy 29, [**2193**]. Please call [**Telephone/Fax (1) 37774**] if
you need to reschedule this appointment.
.
You should also make an appointment to see your pulmonologist in
the next 2-3 weeks.
ICD9 Codes: 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2480
} | Medical Text: Admission Date: [**2131-9-16**] Discharge Date: [**2131-10-5**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation in the medical intensive care unit
History of Present Illness:
52 y/o woman with IDDM, diabetic polyneuropathy, HTN, [**Doctor Last Name 933**],
Hepatitis C who has been extremely depressed at home, stating
that "she wants to die" and refusing to take her medications per
her daughter who brought her to the [**Name (NI) **] for nausea, vomiting,
AMS. On arrival in the ED, she was found to be febrile to 101.6,
tachy to 131, hemodynamically stable, yet somnolent and oriented
only to person. Her initial labs were remarkable for a glucose
of 1300, a gap of 31, ketonuria, and a K of 6.3. Her ECG did not
show any ischemic changes, but did have diffuse peaked TW
changes. She was given IV insulin 5 U push, put on 5 U per hour
infusion, given 6 litres of NS bolus, calcium gluconate,
levaquin and flagyl emperically. Her UA was negative, CXR clear.
Blood cultres were sent times two.
Past Medical History:
1. IDDM diagnosed in [**2127**], followed at [**Last Name (un) **] by Dr. [**Last Name (STitle) **]. No
recent HbA1c on file.
2. Diabetic polyneuropathy
3. Hypertension
4. Grave's disease, on tapazole
5. Reactive airway disease
6. Seronegative arthritis, followed in rheumatology
7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
no on antiviral therapy
8. GERD
9. Migraines
10.Bilateral knee arthroscopy in [**5-24**]
11.s/p TAH and pelvic floor surgery with bladder lift
Social History:
She lives at home with her 2 daughters, aged 24 and 21. No sick
contacts. She is a life-long non-smoker. No EtOH.
Family History:
Positive for DM, mother died of colon cancer.
Physical Exam:
per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
T 101.6 115 141/92 29 100% on RA
Gen - somnolent but arousable to voice
HEENT - non-icteric, EOMI, PERRLA, MM dry
CV - tachy, reg, no m/r/g
Lungs - CTA anteriorly, poor compliance with exam
Abd - diminished BS, Soft, NT, ND
Ext - no edema or rash, dry skin
Neuro - somnolent but arousable to voice, moves all four,
oriented to person only
Pertinent Results:
ED Labs:
Glucose 1356
BUN 31
Cr 1.5
Na 126
K 6.3
HCO3 13
anion gap of 31
ketonuria
EKG: no ischemic changes but positive peaked T waves
UA negative
CXR clear
.
Admission Labs:
149 I 120 I 11
--------------< 139
3.4 I 23 I 0.7
.
pH
7.32 pCO2
33 pO2
47 HCO3
18 BaseXS
-8
.
Trop-*T*: <0.01
CK: 28 MB: Notdone
Ca: 8.9 Mg: 2.1 P: 2.3 D
ALT: 16 AP: 133 Tbili: 0.4 Alb: 3.3
AST: 18 [**Doctor First Name **]: 15 Lip: 12
TSH:<0.02 Free-T4:2.5
.
12.1
18.8 >----< 343
36.2
PT: 12.5 PTT: 22.0 INR: 1.1
Lactate:5.5
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
.
Cultures:
blood cultures negative except [**2131-9-21**]: coag neg staph
CSF cultures negative
Urine cultures negative
Sputum: 2+ gm pos cocci, 1+ gm pos rods
.
CSF:
ANALYSIS WBC RBC Polys Lymphs Monos Macroph
4th 10 609* 67 12 0 21
1st 17 7650* 67 23 0 10
HSV Negative
.
Thyroid: FT4 2.5 to 0.9
HIV Negative
.
Imaging:
CXR Portable AP [**9-16**]: Portable semi-upright chest radiograph
reviewed. The lungs are grossly clear. The pleura are normal
without pneumothorax. The heart and mediastinal contours are
within normal limits. Pulmonary vasculature is normal. The
right subclavian central venous catheter overlies the lower SVC.
.
CT Spine: negative for fracture
Head CT: negative
.
MRI head:
Diffusion images demonstrate no evidence of acute infarct. The
ventricles and extraaxial spaces are normal in size. There are
no focal signal abnormalities or evidence of age inappropriate
brain or medial temporal atrophy. Following gadolinium, no
abnormal parenchymal, vascular, or meningeal enhancement seen.
Mild mucosal thickening is seen in both mastoid air cells.
Again noted is occipitalization of C1 with mild tonsillar
ectopia.
IMPRESSION: No significant change or evidence of acute infarct.
No enhancing lesions. No mass effect, hydrocephalus, or focal
signal abnormalities.
.
EEG:
This is an abnormal EEG in the waking and sleeping stages
due to the bursts of generalized slowing seen in drowsiness.
This is a
nonspecific finding which may be observed with deep midline
subcortical
dysfunction, or could represent a state of altered sleepiness.
.
Right upper ex ultrasound: no DVT
Brief Hospital Course:
52 year old woman with IDDM, HTN, [**Doctor Last Name 933**], Hep. C, depression
admitted with altered mental status thought likely due to DKA.
HOSPITAL COURSE BY PROBLEM
.
1) DM1- DKA on admission. In the ICU, pt was started on insulin
gtt and seen by the [**Last Name (un) **] consult team. Weaned off insulin gtt
within a few hours as her AG closed and started on NPH 70/30.
DKA thought secondary to medication non compliance. However, an
evaluation for occult infection was also performed as well (see
below). She was transferred to the floor and was stable.
Subsequently she had a hypoglycemic seizure. She was seen by
neuro and transferred back to the MICU. She was intubated
briefly for airway protection. Her blood glucose stabilized and
she was transferred back to the floor. We adjusted her insulin
regimen so that she now is getting glargine 33mg qhs and insulin
humalog sliding scale FOUR times a day. She has very close
followup with [**Last Name (un) **].
.
2) Infectious Diseases - The pt was febrile to 101.6 in ED with
occasional fevers while in the ICU and on the floor. The pt was
pan-cultured several times (see above). C.diff was also sent
given the pt's diarrhea, however was negative. Had leukocytosis
on admission which trended down. She had fevers after her
seizure so an LP was performed. It showed 10 WBCs which, in the
setting of a seizure and altered mental status - she was treated
for presumed meningitis with vanco and meropenem for 10d. Her
fevers stopped and she successfully completed her antibiotics.
.
3) Psych: The patient had a flat affect and even was catatonic
briefly during her stay. She was evaluated closely by the
neurologists and psychiatrists. We performed multiple imaging
modalities and lab studies. Her only metabolic abnormality was
thyroid disease (see below). We started remeron 30mg qhs and
then zoloft 25mg qd during her stay. She had significant
improvement in her mood. She had also experienced some
dementia/neurocognitive deficits associated with this
depression. The etiology was unclear. However, given the lack
of imaging abnormalities and her improvement, it was thought not
to be neurologic in origin. We scheduled her for neurocognitive
testing as an outpatient. We also scheduled her for a VNA and
also "best" program to help with her mood and deficits. Her
family was counseled substantially on the importance of
assisting the patient with her illnesses.
.
3) HTN - As the pt was hypotensive on admission, BP meds were
held while in the ICU, but were restarted once transferred to
the floor with good result.
.
4) [**Doctor Last Name 933**] disease - On admission, had an undetectable TSH and
elevated free T4, likely [**2-22**] medication non-compliance. Pt's
hyperthyroid state may have contributed to compliants of
diarrhea. Methimazole was restarted and [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs, the pt
will likely need RAI ablation of thyroid for more definitive
treatment in the future. Will recheck TFTs in four days to check
for response on methimazole treatment.
.
5) Reactive Airways disease - The pt was continued on outpatient
meds.
.
6) Hepatitis C - LFTs stable. The pt has never been on antiviral
therapy.
Medications on Admission:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Methimazole 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-22**]
Drops Ophthalmic PRN (as needed).
5. Zomig 2.5 mg Tablet Sig: One (1) Tablet PO qday prn.
6. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed.
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Serevent Diskus Inhalation
12. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO twice a
day.
13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
14. Flovent 220 mcg/Actuation Aerosol Sig: Two (2) Inhalation
twice a day.
15. HYZAAR 100-25 mg Tablet Sig: One (1) Tablet PO once a day.
16. Hyoscyamine Sulfate 0.375 mg Tablet Sustained Release 12HR
Sig: One (1) Tablet Sustained Release 12HR PO twice a day.
17. Insulin
Take 80 units qam and 90 units qpm, as directed by your PCP
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-22**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 unit* Refills:*2*
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12HR Sig:
One (1) Capsule, Sust. Release 12HR PO BID (2 times a day).
Disp:*60 Capsule, Sust. Release 12HR(s)* Refills:*2*
5. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Flovent 220 mcg/Actuation Aerosol Sig: Two (2) inh Inhalation
twice a day.
Disp:*1 unit* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*
9. Remeron 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
10. Methimazole 10 mg Tablet Sig: Three (3) Tablet PO once a
day.
Disp:*90 Tablet(s)* Refills:*2*
11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
Disp:*15 Tablet(s)* Refills:*2*
15. Insulin Glargine 100 unit/mL Solution Sig: Thirty Three (33)
Units Subcutaneous at bedtime.
Disp:*1 Bottle* Refills:*2*
16. Humalog 100 unit/mL Solution Sig: variable units
Subcutaneous at breakfast, lunch, AND dinner: Take blood sugar
at each meals. Adjust insulin dose as follows:
if blood glucose=61-80 take 0 units, if 81-120 take 4u, if
121-160 take 6u, if 161-200 take 8u, if 201-240 take 10u, if
241-280 take 12u, if 281-320 take 14u, if 321-360 take 16u, if
361-400 take 18u.
Disp:*1 bottle* Refills:*2*
17. Humalog 100 unit/mL Solution Sig: variable units
Subcutaneous at bedtime: check blood sugar at nighttime. if
61-200, give 0 units. if 201-240 give 2u, if 241-280 give 3u,
if 281-320 give 4u, if 321-360 give 5u, if 361-400 give 6u.
Disp:*1 bottle* Refills:*2*
18. Insulin Syringes (Disposable) Syringe Sig: One (1)
syringe Miscell. four times a day: Please provide patient with
a syringe that goes up to 50 units. .
Disp:*120 syringes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 2256**]
Discharge Diagnosis:
1. Insulin Dependent Diabetes Mellitus (type 1)
2. Diabetic polyneuropathy
3. Hypertension
4. Grave's disease, on tapazole
5. Reactive airway disease
6. Seronegative arthritis, followed in rheumatology
7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
no on antiviral therapy
8. GERD
9. Migraines
10.Bilateral knee arthroscopy in [**5-24**]
11.s/p TAH and pelvic floor surgery with bladder lift
12.Major Depression
13.hypoglycemic seizure
14.possible CNS infection
15. Anemia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital with extremely high blood
sugar levels. You were treated in the ICU with insulin and
transferred to the floor. You then experienced a seizure and
were transferred back to the ICU. You were followed very
closely by the neurologists and the psychiatrists, and we think
your seizure was related to hypoglycemia. We also treated you
with IV antibiotics. You were showing symptoms of depression
which we treated medically. You improved during your stay.
.
It is extremely important for you to keep all of your followup
appointments. We have made some adjustments to your insulin
medications so you very much need to keep your appointments at
[**Last Name (un) **]. Your family has agreed to help you with your
medications and we also are sending a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **]
in your care.
.
Please check your blood sugars FOUR times a day and use the
appropriate amount of insulin to balance your blood sugar
levels. If you have an extremely high level (>400) please
contact your doctor immediately. If you have a low level (<60)
please eat some crackers and drink 4 oz of juice. Recheck your
blood sugar in 15 minutes and if it continues to be low, please
call your doctor or visit an emergency department.
.
If you experience chest pain, shortness of breath, severe
abdominal pain, nausea, vomiting, or fever please call your
doctor or visit an emergency department.
.
Please follow up with your primary care provider and your [**Name9 (PRE) **]
doctor within 1 week of discharge.
.
It is very important for you to have a colonoscopy in the next
three months.
Followup Instructions:
You need to call your physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7537**], to schedule an
appointment within the next week. He can be reached at
[**Telephone/Fax (1) **].
Please keep your appointment with Dr.[**Name (NI) 102660**] [**Name (STitle) **]
Practitioner, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2489**], on [**10-9**] at 1:00pm.
[**Telephone/Fax (1) **]
Please keep your appointment with Dr. [**Last Name (STitle) **] at [**Last Name (un) **] on
[**2131-11-28**] at 8:30am
Colonoscopy: Provider: [**Name10 (NameIs) **] WEST,ROOM FOUR GI ROOMS
Date/Time:[**2131-10-10**] 8:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2131-11-30**] 9:00
Please undergo neurocognitive testing with Provider: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2131-10-16**] 8:30
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 7907, 4019, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2481
} | Medical Text: Admission Date: [**2200-3-11**] [**Month/Day/Year **] Date: [**2200-3-14**]
Date of Birth: [**2149-10-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
abd pain, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
50 y.o. man with DM2, HTN, hypercholesterolemia, psoriasis, p/w
acute on chronic abd pain. Patient says that he has had about 6
weeks of lower abdominal pain, loose stools, with scant BRBPR.
He had a coloscopy done [**3-6**] which showed "mild colitis". He
was in his usual state of health, with some improvement in his
abdominal pain, good appetite after the colonoscopy until day
prior to admission when while driving from NY to [**Location (un) 86**] on
business he started to feel unwell with nausea and upper
abdominal pain. He pulled over to vomit, unsuccessfully, and
continued to drive. He tried to go to work but felt so ill he
went back to his hotel, where he vomited 5 times (no blood), the
pain worsened to ~[**7-25**], and he decided he needed to seek help.
.
In the ED he presented with RUQ, LUQ, and epigastric abd pain
today with fever to 102.2 and chills, with an initial lactate of
5.0.
Rectal exam in the ED showed brown Guaiac + stool. His GI doc in
NY was called and faxed reports of the biopsies from his
colonoscopy show eosinophils, rectal biopsies show
chronic/active colitis. GI doctor [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **] (Dr. [**Last Name (STitle) **], home
phone [**Telephone/Fax (1) 71993**]).
He was treated with levo and flagyl, followed by Vanco and
Zosyn, anzemet, MS for pain, and IVF. CXR was negative for
acute processes or free air and a CTA with gastrograffin showed
no explantion for the patient's symptoms. UA was negative.
.
ROS basically negative. No recent travel, camping, changes in
routine. Recent sick contact with daughter who has "flu"
symptoms and multiple sick contacts at work. Does say that he's
had about 1 month of aching joint pains which effects most of
his joints, aches daily, and which he associates with a new
increase in the size, spread, and severity of his psoriasis.
Has not spoken to a doctor about it as he was more concerned
about his GI symptoms.
Past Medical History:
Psoriasis
HTN
hyperlipidemia
OSA (on bipap)
DM (on oral meds)
tonsilectomy
Social History:
Married to NP, works in publishing. Has two children 4 & 6.
Lives in [**Location **], where he receives his medical care. Quit tobacco 4
years ago, drinks ~ 1x/month on business. No drugs.
Family History:
Mother alive, well. Father died at age 49 with MI. Brother
alive has had multiple MIs.
Physical Exam:
VS: 102.3 109/53 92 21 94% on RA
GEN: middle-aged man, diaphoretic, ill-appearing
HEENT: OP clear, MMM, PERRLA, EOMI
CV: heart sounds distant
PULM: CTAB
ABD: obese, firm, NT, +BS, +hepatomegaly
EXT: no edema, +2 DP pulses
NEURO: alert, oriented, CN grossly intact
Pertinent Results:
Initial labs:
[**2200-3-11**] 04:09PM LACTATE-2.1*
[**2200-3-11**] 12:07PM CK(CPK)-524*
[**2200-3-11**] 12:07PM CK-MB-3 cTropnT-<0.01
[**2200-3-11**] 12:07PM CK-MB-3 cTropnT-<0.01
[**2200-3-11**] 02:58AM GLUCOSE-214* UREA N-12 CREAT-1.1 SODIUM-137
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-21* ANION GAP-18
[**2200-3-11**] 02:58AM ALT(SGPT)-16 AST(SGOT)-23 CK(CPK)-477* ALK
PHOS-58 AMYLASE-52 TOT BILI-1.3
[**2200-3-11**] 02:58AM LIPASE-33
[**2200-3-11**] 02:58AM CK-MB-3 cTropnT-<0.01
[**2200-3-11**] 02:58AM CALCIUM-7.0* PHOSPHATE-2.0* MAGNESIUM-1.2*
[**2200-3-11**] 02:58AM WBC-5.7 RBC-4.12* HGB-12.6* HCT-35.7* MCV-87
MCH-30.5 MCHC-35.2* RDW-13.7
[**2200-3-11**] 02:58AM NEUTS-88.1* BANDS-0 LYMPHS-7.1* MONOS-3.1
EOS-0.9 BASOS-0.8
[**2200-3-11**] 02:58AM PT-13.6* PTT-24.3 INR(PT)-1.2*
[**2200-3-10**] 08:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2200-3-10**] 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2200-3-10**] 08:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2200-3-10**] 05:45PM CK(CPK)-116
[**2200-3-10**] 05:45PM ALT(SGPT)-21 AST(SGOT)-23 ALK PHOS-82
AMYLASE-86 TOT BILI-1.2
[**2200-3-10**] 05:45PM LIPASE-51
[**2200-3-10**] 05:45PM CK-MB-3 cTropnT-<0.01
[**2200-3-10**] 05:45PM CORTISOL-33.7*
[**2200-3-10**] 05:45PM CRP-14.6*
[**Month/Day/Year **] labs:
[**2200-3-14**] 06:02AM BLOOD WBC-4.7 RBC-3.95* Hgb-10.9* Hct-32.7*
MCV-83 MCH-27.5 MCHC-33.3 Plt Ct-250
[**2200-3-14**] 06:02AM BLOOD Neuts-71.5* Lymphs-12.7* Monos-5.7
Eos-9.7* Baso-0.2
[**2200-3-14**] 06:02AM BLOOD Plt Ct-250
[**2200-3-14**] 06:02AM BLOOD Glucose-210* UreaN-11 Creat-1.1 Na-140
K-3.9 Cl-103 HCO3-25 AnGap-16
[**2200-3-14**] 06:02AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.5
[**2200-3-12**] 05:03AM BLOOD VitB12-289 Folate-18.8 Ferritn-320
[**2200-3-13**] 07:23AM BLOOD Lactate-1.7
strongyloides negative
Imaging:
RUQ US [**3-11**]
Markedly limited examination due to above described factors.
Echogenic liver likely due to fatty infiltration, however other
liver diseases such as cirrhosis/fibrosis cannot be excluded. No
obvious gallstones or wall thickening is demonstrated.
CT [**3-11**]
IMPRESSION:
1. No definite acute inflammatory pathology is identified
within the abdomen or pelvis to account for the patient's
symptoms. The colon is normal in appearance. There is no free
air or free fluid.
2. A single celiac lymph node is borderline in terms of size
criteria for pathologic enlargement (measuring 10 mm in short
axis). The significance of this finding is unclear, and CT
followup may be needed to assess for interval change.
3. Fatty infiltration of the liver.
4. Distention of the gallbladder, which may be related to
prolonged fasting related to symptoms.
.
CXR [**3-10**]
IMPRESSION: No acute cardiopulmonary process. No evidence of
free air.
Brief Hospital Course:
50 y.o. man with DM2, HTN, hypercholesterolemia, psoriasis, p/w
acute on chronic abd pain.
.
#Colitis- Patient's recent colonoscopy c/w colitis and positive
for eosinophils. The ddx for this is ischemic (unlikely given CT
scan distribution although does have risk factors : DM, high
cholesterol, fam hx heart disease), inflammatory ( more likely
given his history of psoriasis, joint pain and age), allergic
(possible given eos) v infectious (possible given fever). GI was
consulted. Stool O/P were negative. Strongyloides was negative.
Patient was treated with 2 week course of ciprofloxacin and
clindamycin. As his symptoms resolved and hematocrit was stable,
patient was discharged home with GI follow-up in [**State 531**].
.
#Fever: Patient febrile, diaphoretic but never hypotensive. Peak
lactate 5.9 and trended down to 1.7. No clear cause on abd CT -
no free air to suggest perforation, other possible sources of
infection. Ucx did show 10-100,000 colonies of enterococcus but
pt has no dysuria or increased frequency and repeat urine
culture was negative. RUQ US negative for cholecystitis. Colitis
was most likely reason for fever and suggests a more infectious
or inflammatory cause for the colitis.
.
#joint pain: per patient affects multiple joints on an almost
daily basis. There may be some association with acute worsening
psoriasis. ?new psoriatic arthritis v IBD. Patient does have
some slight psoriatic nail changes but no dactylitis.
.
# HTN- continue losartan and held HCTZ as patient was
dehydrated. HCTZ restarted on [**State **].
.
# Hypercholesterolemia- continued lipitor
.
# OSA- continue BIPAP-pt brought his own machine.
.
# Depression- continued celexa and klonopin qhs with xanax prn
.
# DM2- held metformin given his elevated lactate and
dehydration. Covered with RISS and out on diabetic diet.
Metformin was restarted on [**State **] as his lactate was 1.7.
.
# Friction blisters- Pt developed allergic reaction to pressure
of BP cuff. Localized blisters present that began to look
infected. Patient was started on clindamycin.
Medications on Admission:
Glucophage 1000 q hs, 500 q am
lipitor 20
hyzaar 20
celexa 20
klonopin
xanax PRN
[**State **] Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. HYZAAR Oral
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
6. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
7. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
8. Glucophage 500 mg Tablet Sig: One (1) Tablet PO qam.
Disp:*30 Tablet(s)* Refills:*2*
[**State **] Disposition:
Home
[**State **] Diagnosis:
colitis
[**State **] Condition:
stable, afebrile.
[**State **] Instructions:
You were admitted with vomiting and bloody diarrhea. The cause
of your colitis is not clear and you should follow-up with your
GI doctor [**First Name (Titles) **] [**Last Name (Titles) **]. You have been started on antibiotics
for your bowel and left arm infection.
Please take all medications as directed.
Please follow-up with all outpatient appointments.
Please return to the ED if you experience fever > 101, worsening
diarrhea, bleeding, abdominal pain, vomiting, chest pain or any
other concerning symptoms.
Followup Instructions:
Please follow-up with your primary care doctor within the next
1-2 weeks.
.
You should also follow-up with the gastroenterologist.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
ICD9 Codes: 0389, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2482
} | Medical Text: Unit No: [**Numeric Identifier 73599**]
Admission Date: [**2127-6-27**]
Discharge Date: [**2127-6-29**]
Date of Birth: [**2127-6-27**]
Sex: M
Service: NB
HISTORY: Baby boy [**First Name8 (NamePattern2) **] [**Known lastname 73589**], triplet number 3,
delivered at 35-1/7 weeks gestation with a birth weight of
2435 grams, and was admitted to the newborn intensive care
nursery for management of prematurity.
The mother is a 40-year-old gravida 2, para 0 now 3 woman,
with estimated date of delivery [**2127-8-2**]. Prenatal
screens included blood type O positive, antibody screen
negative, hepatitis B surface antigen negative, rubella
immune, RP nonreactive, and Group B strep unknown. This
pregnancy was by in [**Last Name (un) 5153**] fertilization which resulted in a
dichorionic triamniotic triplet gestation. The mother's
maternal history was noted for anemia, asthma treated with
albuterol, and GER treated with Protonix. This pregnancy has
been followed with the growth of triplet 1 and 2 slowing down
which precipitated delivery by cesarean section for
intrauterine growth restriction of triplet 1 and 2. This baby
emerged with a good cry, just dried and bulb suctioned, did
not require oxygen, pinked up nicely on his own. Apgars 9 and
9 at 1 and 5 minutes respectively.
PHYSICAL EXAMINATION: At discharge: Weight 2365 grams (50th
to 75th percentile). Length 47.5 cm (50th to 75th
percentile). Head circumference 35 cm (greater than the 90th
percentile). Anterior fontanel: Open, soft, flat. Sutures
approximated. No cleft. Red reflex positive in both eyes.
Breath sounds clear, equal, with easy work of breathing. No
murmur. Normal pulses and perfusion. Abdomen: Soft, no
hepatosplenomegaly, no masses. Three-vessel cord. Spine
intact. No dimple. Hips stable. Normal male. Testes
descended. Normal tone and reflexes for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Has always been on room without respiratory
distress. Respiratory rate 30s to 60s. No apnea, bradycardia,
or desaturations.
Cardiovascular: No murmur. Heart rate ranges in the 120s to
130s. Recent blood pressure 64/30 with a mean of 43.
Fluids, electrolytes, nutrition: started ad lib feeds
following birth, is taking Enfamil 20 calories per ounce ad
lib, every 4 hours, taking about an ounce to an ounce and a
half, is spitting a little bit, is voiding and stooling
appropriately. Discharge weight: 2365 grams.
GI: Has mild jaundice. Bilirubin to be drawn tomorrow morning
on [**2127-6-30**].
Hematology: No blood work was drawn. Hematocrit unknown. The
baby is [**Name2 (NI) **] and well- perfused.
Infectious disease: No sepsis risk factors. No labs drawn.
Neurology exam is age appropriate.
Hearing screening has not been performed, will need to be
done prior to discharge.
CONDITION ON DISCHARGE: Stable preterm infant.
DISCHARGE DISPOSITION: Transfer to newborn nursery.
PRIMARY PEDIATRICIAN: Pediatrician has not yet been
identified.
CARE AND RECOMMENDATIONS:
1. Ad lib feedings: Enfamil 20 with iron, follow weight and
feeding volume, may need 24 calorie.
2. Medications: None.
3. Car seat position screening test needs to be done prior
to discharge.
4. Newborn screen to be drawn on [**2127-6-30**] with
bilirubin.
IMMUNIZATIONS: He has not received any immunizations.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age, 35-1/7 weeks preterm
infant.
2. Triplet number 3.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2127-6-29**] 00:52:17
T: [**2127-6-29**] 06:14:46
Job#: [**Job Number 73600**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2483
} | Medical Text: Admission Date: [**2180-3-28**] Discharge Date: [**2180-3-31**]
Date of Birth: [**2127-1-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
abdominal pain, hypotension, diarrhea, and fever
Major Surgical or Invasive Procedure:
Central line
History of Present Illness:
53yo female with a history of asthma presents with abdominal
pain, hypotension, and fever.
.
Approximately 2 weeks ago, patient developed dysuria and low
abdominal pain. She describes her abdominal pain as being sharp
in character, located in the right side of her abdomen, without
radiations, and without any clear exacerbators or relievers.
This was thought secondary to a urinary tract infection, and she
was treated wtih a 10 day course of ciprofloxacin. Her dysuria
resolved, but her abdominal pain persisted. At the same time,
she was diagnosed with bacterial vaginosis for which she was
treated with metronidazole. After completing her course of
ciprofloxacin, she was subsequently diagnosed with a yeast
infection for which she was treated with a topical antifungal
medication. Then approximately 2 days ago, she developed fevers
and chills with a Tmax of 102.7 on this day of admission.
Additional symptoms include right-sided low back pain, nausea,
generalized abdominal pain, and watery diarrhea which started on
the day of admission. On additional review of systems, she
denies recent travel, sick contacts, or dietary changes. She is
in a monogamous relationship with her male partner of three
years. Has a possible history of chlamydia but no other STDs
that she is aware of. Her last menstrual period was in [**Month (only) 958**]
[**2179**] and was previously regular.
.
She initially presented to [**Hospital3 **] Hospital where her vital
signs were 90/54, HR 109, RR 22, Pulse ox 98% RA. She received
dilaudid .5mg IV x 1, morphine 4mg IV x 2, phenergan 12.5mg IV x
2, tylenol 650mg PO x 1, zofran 4mg IV x 2. She had pelvic US
and CT Abd/Pelvis that demonstrated ovarian cyst. She received
zosyn x 1. Upon arrival in the [**Hospital1 18**] ED, temp 99.9, HR 80, BP
78/44, RR 20, and pulse ox 98% on room air. Her exam was notable
for mild RLQ and LLQ tenderness. Labs were notable for a normal
WBC at 8.5, hematocrit at 34, contaminated UA with 11-20 epis.
She received 2L NS with improvement in her BP from 70s to 80s.
She also received metronidazole 500mg IV x 1 and zofran 2mg IV x
2. OB-gyn was consulted, and she was thought to have likely C.
diff colitis and recommended treatment for C. diff. Her ovarian
cysts were thought likely benign. Surgery was consulted and
recommended broad spectrum coverage with vanc / zosyn / flagyl
and consideration of a repeat CT scan with oral and IV contrast.
.
Upon arrival to the [**Hospital Unit Name 153**], she describes her abdominal pain as
[**2181-4-12**] in pain, sharp and crampy in character, located in her
lower abdomen. Her primary complaint is her frequent loose and
watery stools.
Past Medical History:
1. Asthma
2. s/p Choledocalcystectomy
3. s/p Endometrial Ablation
4. G2P2 s/p SVD x 2 with uncomplicated pregnancies and
deliveries
Social History:
Home: lives in [**Hospital3 **], alone
Occupation: employed in real estate on [**Hospital2 **] [**Hospital3 **]
EtOH: Denies
Drugs: Denies
Tobacco: Denies
Family History:
nc
Physical Exam:
On admission
Gen: uncomfortable appearing but no acute distress
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: hypoactive BS, soft, tender to deep palpation in suprapubic
area, no guarding
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 5/5 strength
throughout. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
GYN EXAM: bimanual exam without cervical motion tenderness or
adnexal tenderness
Pertinent Results:
[**2180-3-28**] 07:25PM BLOOD WBC-8.5 RBC-3.62* Hgb-11.0* Hct-32.0*
MCV-88 MCH-30.3 MCHC-34.3 RDW-13.2 Plt Ct-141*
[**2180-3-28**] 07:25PM BLOOD Glucose-87 UreaN-10 Creat-0.9 Na-138
K-3.6 Cl-112* HCO3-20* AnGap-10
[**2180-3-29**] 04:14AM BLOOD Albumin-2.5* Calcium-6.1* Phos-2.1*
Mg-1.4* Iron-5*
[**2180-3-28**] 07:25PM BLOOD ALT-20 AST-24 AlkPhos-34* TotBili-1.2
[**2180-3-28**] 09:02PM BLOOD Lactate-1.9
.
[**2180-3-28**]
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2180-3-29**]):
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
CT abd/pelvis OSH films [**2180-3-28**]:
IMPRESSION:
1. No acute pathology to explain patient's symptoms.
2. Liver hypodensities, which are too small to characterize and
some of which are incompletely evaluated.
3. 3.7 cm right adnexal cystic lesion. Pelvic ultrasound in six
weeks is
recommended to ensure resolution.
4. Fibroid uterus.
4. Choledochojejunostomy with expected air within the biliary
system.
.
CXR [**2180-3-28**]:
IMPRESSION: Right IJ central line terminating in the mid SVC.
Brief Hospital Course:
53yo female with a history of asthma and s/p
choledocalcystectomy presents with hypotension, abdominal pain,
diarrhea, fever.
.
1. Sepsis/hypotension: The pt's hypotension was likely secondary
to sepsis or severe volume depletion from C difficile. Of note
patient is normally in low 90s systolic. Pt's systolics were in
the 80s most of her first evening in the [**Hospital Unit Name 153**] with no changes in
mental status. She was bolused with LRs. The next morning she
dropped her SBP to 66 but was mentating fine and responded to 2L
of LR. After aggressive volume resuscitation, her BP have now
been stable on the floor. SBP 100s range (i.e. at her
baseline), mentating well and feeling well.
2. C diff: Likely related to antibiotic use, reports she was
given recent antibiotic course x 10 days for UTI. Pt was
febrile in the ED and had symptoms of sepsis and severe volume
depletion. Her WBC was normal at [**Hospital1 **] but elevated at an OSH.
Patient stool came back positive for c. diff x2. She was
started on IV flagyl and oral vancomycin. She is doing well on
oral regimen with decreased bowel movements to 3-4 per day,
taking good po's. She will complete 2 week course po
vancomycin. She plans to discuss with her local providers her
hx of UTIs -- she understandably is wary of future antibiotics
for UTIs. I informed her that though I don't have her outpt
records, generally uncomplicated bladder infections should be ~3
day course antibiotics, longer if there are symptoms of
pyelonephritis. Recommmended that urine cultures be checked
when she has dysuria in the future to confirm that she actually
has an infection.
3. Asthma Stable and under adequate control. Patient was
continued on home regimen.
.
4. Anemia: The etiology of her anemia is unclear in our records
but is chronic per pt. Her HCT has been stable here and she has
not required transfusion. She has known iron deficiency and her
iron should be restarted after she completes her course of
flagyl.
.
5. Ovarian cyst: pt reports she has known cyst and we recommend
f/u with her PCP and gynecologist for this. She was given a
copy of her abdominal CT report.
.
7. CODE: FULL CODE
.
8. COMM: [**Name (NI) **]; [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7111**] [**Telephone/Fax (1) 36501**]
Medications on Admission:
1. Zolpidem prn
2. Singulair
3. Combivent
4. s/p cipro x 10 days
5. s/p metronidazole x 4-5 days
6. s/p topical antifungal therapy
7. ? ferrous sulfate
Discharge Medications:
1. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 14 days: OK to give in different formulation
depending on pharmacy availability (such as liquid).
Disp:*56 Capsule(s)* Refills:*0*
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Combivent 18-103 mcg/Actuation Aerosol Sig: [**12-10**] Inhalation
four times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis
Hypotension (resolved)
Clostridium difficile colitis
Discharge Condition:
stable
Discharge Instructions:
You had had a severe infection from C. difficile colitis and
should continue taking the oral vancomycin for 2 weeks.
Please seek medical attention if you develop abdominal pain,
fevers, worsened diarrhea.
Followup Instructions:
Follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Known firstname **] [**Last Name (NamePattern1) 36502**]
in the next 1-2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2180-4-4**]
ICD9 Codes: 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2484
} | Medical Text: Admission Date: [**2167-2-17**] Discharge Date: [**2167-2-22**]
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Progressive shortness of breath and chest
pain on exertion for the past two to three years.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 46945**] is a 78 year old
male with a two to three year history of shortness of breath
and chest pain on exertion, who visited his primary care
physician for routine physical examination in [**2166-9-11**],
at which time he related to his primary care physician the
aforementioned episodes of chest pain and shortness of
breath. He was subsequently sent for a stress test, as well
as an echocardiogram and cardiac catheterization in [**Month (only) 1096**].
The cardiac catheterization showed a 50% lesion in the left
anterior descending as well as subtotal occlusion of the
diagonal 1 and diagonal 2 arteries. The right coronary
artery was also occluded with no collateral flow to the
distal portion from the left system. Based on these cardiac
catheterization results, the patient was referred for
coronary artery bypass graft surgery. He currently states
that he has chest pain and shortness of breath on exertion,
which is relieved by nitroglycerin as well as rest.
PAST MEDICAL HISTORY: 1. Hypertension; 2. Gastroesophageal
reflux disease; 3. Psoriasis; 4. Prostate cancer; 5.
History of silent myocardial infarction.
PAST SURGICAL HISTORY: 1. Transurethral radical
prostatectomy in [**2117**]; 2. Colonoscopy with removal of rectal
polyps in the [**2124**].
MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg q. day; 2.
Atenolol 25 mg q. day; 3. Steroid cream; 4. Sublingual
nitroglycerin as needed; 5. Nitrodur patch; 6.
Hydrochlorothiazide 50 mg q. day; 7. Avapro 75 mg q. day; 8.
Legatrin prn for leg pain.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient denies any history of tobacco
use. He states that he has been drinking two to three
glasses of liquor per week for approximately 50 years. He
lives by himself in [**Hospital1 **], [**State 350**] and was a retired
letter carrier.
FAMILY HISTORY: Non-contributory.
PHYSICAL EXAMINATION: The height was 5 feet 9 inches, weight
183 lb, heartrate 58 in sinus bradycardia and the blood
pressure was 133/69. In general, Mr. [**Known lastname 46945**] was a well
dressed and well nourished male who had mild shortness of
breath but was in no acute distress and appearing his stated
age. His skin showed some psoriatic patches on the upper
back, no rashes, and good skin turgor. His pupils were
equally reactive and reactive to light and accommodation.
Extraocular muscles were intact. His buccal mucosa was
normal as was his dentition. His neck was supple with no
jugulovenous distension. He also had no thyromegaly. He did
have some left cerebral lymphadenopathy with some tenderness.
His heart showed a regular rate and rhythm with normal S1 and
S2 and no murmurs, rubs or gallops. His lungs were clear to
auscultation bilaterally with no wheezes, rhonchi or rales.
His abdomen was soft, nontender, nondistended without rebound
or guarding. His extremities were warm, dry and well
perfused with no peripheral edema, cyanosis or calf
tenderness. He had no varicosities. Gross neurological
examination showed that gross motor and sensory systems were
intact and there were no deficits. On pulse examination, the
patient had 2+ carotid pulses with no bruits. He had 2+
femoral, dorsalis pedis and radial pulses bilaterally, and a
2+ posterior tibial pulse on the left and 1+ posterior tibial
pulse on the right.
HOSPITAL COURSE: The patient was admitted to the Operating
Room on [**2167-2-17**] where he underwent a coronary artery
bypass graft times three. For full details of this procedure
please refer to the dictated operative report. In summary,
the left internal mammary was anastomosed to the left
anterior descending with saphenous vein grafts to the right
coronary and diagonal arteries. The patient tolerated the
procedure well and was transferred to the Cardiosurgical
Intensive Care Unit in normal sinus rhythm with a rate of 85
beats/minute, a nitroglycerin drip of 1.5 mg/kg/min, and a
Propofol drip at 30 mcg/kg/min. Later that day, the patient
was extubated in the Intensive Care Unit without incident,
and was cooperative with deep breathing exercises. Over
night the patient required volume and Hespan for low urine
outputs to which he responded well. On postoperative day #1
he was off all drips, and deemed stable and ready to transfer
to the regular floor. Once on the floor the patient did
experience frequent bursts of sinus tachycardia with
heartrate to the 120s, which seemed to correlate with
incisional discomfort during coughing. The blood pressure
remained stable during these episodes and he was asymptomatic
other than his incisional pain. He was encouraged to use
more pain medication as he had previously been using as he
had been refusing multiple doses, and this had good effect
when started. By postoperative day #3, the patient had been
working with physical therapy, and was deemed safe for
discharge to home. Diuresis and beta blockade were
continued, and beta blockade was titrated in order to better
control his heartrate. By postoperative day #5 the patient
was doing quite well, and at this time was deemed stable and
ready for discharge home. [**Hospital6 407**]
services were arranged in order that they may evaluate the
patient for a couple of visits after he first returns home.
PHYSICAL EXAMINATION ON DISCHARGE: The patient's temperature
was 98.9 F with a heartrate of 80 in sinus rhythm and a blood
pressure of 110/70 and a room air oxygen saturation of 96%.
His heart showed a regular rate and rhythm. His lungs were
clear to auscultation bilaterally. His abdomen was soft,
obese, nontender and nondistended. He had continued to have
some minimal peripheral edema, however, this had been
resolving quite well.
MEDICATIONS ON DISCHARGE:
1. Enteric coated Aspirin 325 mg q. day
2. Colace 100 mg b.i.d.
3. Potassium 20 mEq q. day for seven days
4. Lasix 20 mg q. day for seven days
5. Lopressor 75 mg b.i.d.
6. Vicodin 1 to 2 tablets every 4 to 6 hours as needed for
pain
Of note, the patient was instructed to resume his
preoperative Hydrochlorothiazide when his course of Lasix was
complete.
CONDITION ON DISCHARGE: The patient was stable.
DISCHARGE INSTRUCTIONS: Activity was as tolerated. Diet was
a cardiac heart healthy diet.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass graft times three on [**2167-2-17**].
2. Hypertension
3. Gastroesophageal reflux disease
4. Psoriasis
5. Prostate cancer status post transurethral resection of
prostate
6. Rectal polyps
FOLLOW UP: The patient was instructed to follow up with his
cardiologist or primary care physician in approximately one
to two weeks time to review his medications and physical
condition. His follow up with Dr. [**Last Name (STitle) **] was scheduled in
three weeks time.
Dictated By:[**Name8 (MD) 11089**]
MEDQUIST36
D: [**2167-3-14**] 14:41
T: [**2167-3-14**] 15:10
JOB#: [**Job Number 46946**]
ICD9 Codes: 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2485
} | Medical Text: Admission Date: [**2163-3-13**] Discharge Date: [**2163-3-18**]
Date of Birth: [**2101-4-18**] Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived / Peanut
Attending:[**First Name3 (LF) 4373**]
Chief Complaint:
Mental status change
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61yo RH F with known brain metastases who was transferred from
[**Hospital 4199**] Hospital after medline was called this morning. She
presented there after waking this morning. Her boyfriend reports
that she kept saying, "I don't want to go" over and over. He
found this odd but she was able to walk and he noted no shaking
or facial droop and he just thought she wasn't feeling well.
Later in the morning, he went back into her room to tell her
that her brother had called. She was unresponsive with her eyes
closed and did not respond to shaking. He called lifeline and
she was brought to [**Last Name (un) 4199**]. Their documentation reports focal
seizure activity en route with right gaze deviation, for which
she
received valium 5mg IV. This continued there and at 12:50pm and
1:10pm, she was given a total of 260mg IV of phenobarbital,
which ceased seizure activity. No exam is documented in the
included notes. She also received avalox 400mg IV.
Labs showed a leukocytosis to 16 with 97% pmn's. Head CT showed
decreased size in the left occipital hyperdensity and decreased
edema, compared to her prior scans. There was also a 0.4cm right
cerebellar mass with no edema, where there had been prior to
whole brain radiation. She had a stable L frontal meningioma.
Transferred to [**Hospital1 **] for further managment. In ED, seen by
neurology. Patient has been on decadron, but nevertheless
elevated WBC (here 22K) was felt to be due to infection. Given
cerebellar metastases, no LP was done. Patient was empirically
treated for bacterial meningitis with vancomycin and
ceftriaxone. She was also loaded with Keppra. Decadron was also
continued.
She has had no convulsive activity at [**Hospital1 **]. She is awake and
alertbut non-verbal.
Past Medical History:
Known metastatic breast cancer, s/p L mastectomy, s/p
chemotherapy and treated 13 cyles of whole brain radiation [**2-8**]
HTN
Seizure disorder
Rhuematoid arthritis
Social History:
She was smoking 1 pack of cigarettes per week for 4 years. She
does not drink alcohol or use illicit drugs. Her brother lives
in the city near her and a son lives in [**Name (NI) 4444**], MA.
Family History:
Her maternal grandfather had [**Name2 (NI) 499**] cancer while her paternal
grandfather had stomach cancer. Her mother died of [**Name (NI) 2481**]
disease while her father passed away after a stroke. Her brother
and sister are healthy, and so are her four children.
Physical Exam:
Gen Awake, NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted
Pertinent Results:
Labs:
WBC 22.5 (94% N), hct 43
134 97 40 92
4.8 26 0.9
lactate: 3.1-> 2.7
UA negative
EKG:NSR, NA, NInt, no acute ischemic changes
CHEST (PORTABLE AP) [**2163-3-12**] 6:42 PM
Single bedside AP examination labeled "up" is compared with
recent study dated [**2163-2-10**]. There has been interval removal of
the nasogastric tube and left subclavian central venous
catheter; the overall appearance is otherwise unchanged. The
lung volumes are relatively low, but the lungs are clear. The
cardiomediastinal silhouette and pulmonary vessels are within
normal limits. There is no pleural effusion. Noted are surgical
clips projected over the left upper abdomen and left axilla.
MR HEAD W & W/O CONTRAST [**2163-3-13**] 1:35 PM
1. Moderate decrease in the FLAIR hyperintensity and size of the
enhancing lesion in the left occipital lobe.
2. No significant change in the size of the enhancing lesions in
the pons; mild decrease in the FLAIR hyperintensity in the right
cerebellar hemisphere, with no significant change in the size of
the enhancement.
3. A small focus of increased signal on the DWI and FLAIR
sequences in the left medial occipital lobe with no definite
enhancement- can represent another focus of metastasis, a small
infarct or T2-shine through artifact.
Please see the details above.
4. Unchanged left frontal small extra-axial enhancing lesion,
that can represent meningioma or dural metastasis.
5.The study is limited for accurate assessment of any small new
lesions, due to patient motion artifacts.
EEG Study Date of [**2163-3-13**]
Largely normal portable EEG for drowsiness and sleep. No clear
normal waking background was evident. The slowing appeared
likely to be part of sleep. An excessive drowsiness or
medication-related encephalopathy cannot be excluded. There were
no areas of prominent focal slowing, and there were no
epileptiform features. A tachycardia was noted.
TTE (Complete) Done [**2163-3-14**] at 9:35:19 AM FINAL
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). 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. No masses or vegetations are seen on
the aortic valve. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**2-2**]+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
There is an anterior space which most likely represents a fat
pad. IMPRESSION: No cardiac source of embolism identified.
Preserved global and regional biventricular systolic function.
Mild to moderate mitral regurgitation.
Brief Hospital Course:
61yo F with known brain mets who presented after focal status
[**2163-3-13**] that ceased with phenobarbital, no clear seizure
activity since transfer to [**Hospital1 18**].
#) Seizure. Neurology consulted upon admission and followed
patient during stay. Started on Keppra per Neurology
recommendations. Ativan was ordered PRN seizure activity but
was not needed during inpatient stay. EEG was performed and
revealed slowing secondary to medication effect but no further
eleptiform activity. Discussed whole brain radiation with
outside Radiation Oncologist who stated the radiation completed
thus far was appropriate and adequate and she did not need
further whole brain therapy. Upon discharge will be continued
on Keppra, Ativan PRN seizure activity and on a decadron taper.
#) Breast Ca: Followed by outside oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]; s/p
chemotherapy and chest/supraclavicular radiation. Has also
completed 13 or 14 rounds of WBT per Dr. [**Last Name (STitle) 77183**]. He
confirmed this was an appropriate amount and will not require
further whole brain therapy at this time. Discharged to
follow-up with primary oncologist.
#) Leucocytosis: Liikly due to steroids. Other considerations
included metastatic disease as there was no obvious source of
infection at this time. No symptoms or signs of infection
during inpatient stay.
#) HTN: Continued outpatient Atenolol daily.
#) Thrombocytopenia- HIT ab was sent ([**2163-3-13**]) and was negative.
[**Month (only) 116**] be drug related or marrow involvement of cancer, but would
expect other lines to be down as well. Keppra has been reported
to cause thrombocytopenia but incidence has not been fully
documented. Stably low during inpatient stay. Would recommend
rechecking at follow-up appointment with Dr. [**First Name (STitle) **] on [**2163-3-23**] and
to have repeat CBC in one week upon discharge to monitor for
stability. [**Month (only) 116**] also follow-up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on this
issue.
# Outside physicians:
Dr. [**Last Name (STitle) **], PCP
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Oncologist, [**Hospital3 **] [**Telephone/Fax (1) 74124**]
Dr. [**Last Name (STitle) 77183**], Radiation oncologist, [**Hospital3 **]
[**Telephone/Fax (1) 77184**]
Medications on Admission:
Per Prior Discharge Summary:
Keppra 500mg [**Hospital1 **]
Dexamethasone 4mg TID
Lisinopril 10mg daily
Metoprolol 25mg TID
Per PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]:
Atenolol 25mg po daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for SBP < 100 or HR < 50
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Dexamethasone 2 mg Tablet Sig: 1-3 Tablets PO As directed:
Please continue 6mg [**Hospital1 **] for 4 days, then decrease to 4mg [**Hospital1 **].
Dr. [**First Name (STitle) **] (primary oncologist) may want to change this dose
5. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q5MIN PRN
() as needed for seizures.
6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for fever or pain.
7. Maalox 200-200-20 mg/5 mL Suspension Sig: Five (5) mL PO
three times a day as needed for heartburn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary: Metastatic breast cancer
Secondary: Hypertension, Rheumatoid arthritis
Discharge Condition:
Hemodynamically stable and afebrile
Discharge Instructions:
You were admitted to [**Hospital1 18**] after being transferred from an
outside hospital after having a seizure. Once your mental
status improved, you were discharged to an extended care
facility for continued rehabilitation. You should follow-up
with your primary oncologist and PCP.
Please take all medications as prescribed.
Please keep all outpatient appointments.
Please seek medical advice if you notice increased confusion,
seizure, fever, chills, difficulty breathing, chest pain or
other symptoms which are concerning to you.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital3 **] Oncology
Wednesday, [**2163-3-23**] at 10:45AM
[**Street Address(2) 77185**]
[**Location (un) 2199**], MA
[**Telephone/Fax (1) 74124**]
Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] early next week to schedule a
follow-up appointment in the next 2-3 weeks. The facility staff
may help you with this. His number is [**Telephone/Fax (1) 77186**]
ICD9 Codes: 2761, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2486
} | Medical Text: Admission Date: [**2158-12-26**] Discharge Date: [**2158-12-30**]
Date of Birth: [**2109-5-21**] Sex: M
Service: MEDICINE
Allergies:
naproxen / penicillin G
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49 yo male w/ EtOH cirrhosis with h/o multiple prior upper GI
bleeds from esophageal and gastric ulcers transferred from [**Hospital1 **] with hematemesis. Patient has a history of medication
non-compliance and per notes continues to drink EtOH. He was
transferred From [**Hospital3 **] after an EGD there did not
achieve adequate hemostasis.
Patient tells me got up this morning around 8am, had a vitamin
shake with ensure, that he usually takes three times a day. Then
went to the shower, and after felt a bit "queazy", and thats
when he vomited out the milkshake, but no blood, just food. Then
got dressed, sat down, and 1/2 hour later stared feeling
nauseated, went to the brathroom, and that's when blood came out
- not as much as last time, but about [**1-8**] a pint - bright red
blood. No diarrhea, had a normal bowel movement last night,
muddy dark look to the stool.
Since last admission he had several small episodes of emesis,
but no new bleeding since EGD.
In terms of drinking, had not had a drink in a week in a half.
He had episodes of withdrawal when he was drinking in the past.
But had no withdrawal episodes lately.
He is otherwise complaint-free, thirsty and hungry.
At [**Hospital1 **], he was admitted to the MICU, given D5NS, potassium, at
100cc/hr. He was seen by GI - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was started on
octreotide drip, protonix IV BID, received FFP and vitamin K.
Was deemed hemodynamicallly stable for transfer to [**Hospital1 18**].
Of note, he was recently transferred from [**Hospital1 **] to [**Hospital1 18**] at
beginning of [**Month (only) **] for the same indication. At that time he
was intubated, with active bleeding, thought to be arterial at
GE junction. He had an EGD here. Patient was treated with
octreotide drip for 72 hours and [**Hospital1 **] iv pantoprazole. Pt was
given cipro 500mg [**Hospital1 **], with plan for 1 week course. Pt had
repeat EGD showing 3 grade [**1-8**] esophageal varices. Overlying one
of the varices was a linear ulcer with 3 clips distally. No
active bleeding. Few other smaller ulcers at
GEJ that looked like peptic injury. Stomach filled with food and
old blood which obscured view. No active bleeding. There was
some evidence of protal HTN gastropathy in body/fundus. There
was a 4mm polyp at junction of duodenal sweep. No biopsies taken
because of recent significant GI bleed.
Patient reports that he was doing well since discharge.
Prior to transfer, patient was noted to have some hives on his
chest -for this he was given solumedrol, also given ativan 1mg
for anxiety.
On arrival, the vitals were - afebrile, HR 103, BP 170/85 99% on
Room air.
Past Medical History:
(per OSH chart):
- EtOH and Hep C cirrhosis, c/b varices w/ variceal bleeds,
ascites
- Hypertension
- hyperlipidemia
- Diabetes
- Hemochromatosis
- Anxiety
- EtOH abuse
- ostearthritis
- Depression
- Peripheral vascular disease
Social History:
graduated from [**Last Name (un) 90683**] [**Location (un) **], former financial manager,
but is currently unemployed. Lives with a roommate. Divorced.
Has been to rehab before (Garcenold, [**Doctor Last Name **] Point, [**Hospital1 **])
- Tobacco: No
- Alcohol: Currently denies actively drinking.
- Illicits: None.
Family History:
Has a maternal uncle who was an alcoholic. Paternal uncles were
also alcoholic.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: 96.7, P: 101, BP: 170/85, RR: 16, 100% on RA
WD, WN, NAD, mild tremor that gets worse with movement.
HEENT: PERRLA, EOMI
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezing, rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, mildly bulging flanks
without a fluid wave. Palpable liver tip and splenomegaly.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities spontaneously, nonfocal grossly.
Gross intention tremor in upper extremities and upper body.
.
PHYSICAL EXAM ON DISCHARGE:
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no spider
angiomas
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no asterixis
Neuro: CNs2-12 intact, motor function grossly normal; A+O x3
Pertinent Results:
ADMISSION LABS:
[**2158-12-26**] 10:24PM BLOOD WBC-3.0* RBC-3.17* Hgb-9.4* Hct-28.4*
MCV-90 MCH-29.8 MCHC-33.3 RDW-15.9* Plt Ct-34*#
[**2158-12-26**] 10:24PM BLOOD PT-15.2* PTT-33.8 INR(PT)-1.4*
[**2158-12-26**] 10:24PM BLOOD Glucose-152* UreaN-17 Creat-0.9 Na-137
K-4.2 Cl-97 HCO3-28 AnGap-16
[**2158-12-27**] 02:28AM BLOOD ALT-36 AST-86* AlkPhos-112 TotBili-4.8*
[**2158-12-26**] 10:24PM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2
DISCHARGE LABS:
[**2158-12-30**] 07:10AM BLOOD WBC-4.2 RBC-3.12* Hgb-9.5* Hct-28.6*
MCV-92 MCH-30.3 MCHC-33.1 RDW-16.6* Plt Ct-60*
[**2158-12-30**] 07:10AM BLOOD PT-17.8* PTT-32.8 INR(PT)-1.7*
[**2158-12-30**] 07:10AM BLOOD Glucose-96 UreaN-22* Creat-1.2 Na-135
K-3.5 Cl-97 HCO3-28 AnGap-14
[**2158-12-30**] 07:10AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.2
[**2158-12-30**] 07:10AM BLOOD ALT-28 AST-72* LD(LDH)-193 AlkPhos-91
TotBili-4.2*
EEC [**2158-12-27**]
Normal EEG in the waking state. There were no focal
abnormalities or epileptiform features.
CT HEAD W/O CONTRAST [**2158-12-27**]
No acute intracranial process. Chronic atrophy and microvascular
disease.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
49yo male w/ EtOH cirrhosis with h/o multiple prior upper GI
bleeds from esophageal varices and gastric ulcers transferred
from [**Hospital3 **] with hematemesis. His Hct was stable and
here he did not require further intervention. His course was
complicated by grand mal seizure (toxic/metabolic vs EtOH w/d).
He was discharged home with Hepatology and PCP [**Last Name (NamePattern4) 702**].
#) Upper GI bleed: due to sequelae of cirrhosis.
Had an episode of Upper GI bleed, was scoped at OSH, which
showed marked telangiectasia of R cardia, portal hypertension
gastropathy, initially increasing bleeding, with spurting of
blood. 5 clips were placed. At the end of procedure no active
bleeding was noted. Here, his hematocrit remained stable and he
had no episodes of further bleeding. H.Pylori was negative. He
was treated with pantoprazole and octreotide gtt. He was also
given ceftriaxone IV (switched to PO Cipro) for 1 week of
post-variceal bleed prophylaxis. Continued on Nadolol and PPI.
He was discharged home and will f/u for repeat EGD.
#) Seizure: Toxic/metabolic vs. EtOH withdrawal.
Patient had a tonic clonic seizure on [**2158-12-28**] at 0200 am. He
was given 2 mg IV ativan which resolved the seizure. Etiology
was thought to be alcohol withdrawal. He was seen by the
neurology service who recommended EEG and CT head which were
unremarkable. It was felt that the etiology was possibly EtOH
w/d (though per his report his last drink was 10 days prior),
vs. electrolyte disturbance (his Mg and K were low). He has no
further seizures and Neurology did not feel that he needed
further workup/follow-up.
#) Cirrhosis: due to EtOH/HCV.
He was followed by the Hepatology team while he was in house.
His diuretics were held in the setting of Cr above baseline. He
had no asterixis ro evidence of ascites at the time of
discharge. He was started on Lactulose and Rifaximin this
admission. He will have electrolytes checked [**Last Name (un) **] after d/c
which will be faxed to his Hepatologist, and he will f/u with
Hepatology [**Last Name (un) **] thereafter.
#) [**Last Name (un) **]: likely prerenal.
Cr at baseline is 0.8 but rose to 1.4. Responded to IV
fluid/albumin so hepatorenal syndrome unlikely. His diuretics
were held. Cr at discharge was 1.2. he will have
electrolytes/Cr checked soon after discharge, which will be
faxed to Hepatology.
#) Alcoholism: ongoing issue.
He does have baseline intentention tremor, without asterixis. He
was monitored on CIWA; did have a seizure this admission 9see
above). He was given daily thiamine/ folate/ multivitamin.
#)Anxiety/Depression: stable.
He was continued on home celexa 20 mg po daily.
#) Transitional issues
-PCP f/u: ten days after d/c (Dr. [**Last Name (STitle) 1693**], [**2158-1-9**])
Instructed to have CHEM10/LFTs/coags checked at that visit and
faxed to Dr. [**Last Name (STitle) **].
-next EGD: [**2158-1-16**]
-Hepatology f/u: [**2158-1-17**] Dr. [**Last Name (STitle) **] (diuretics may be restarted
then)
-pending labs/studies: none
Medications on Admission:
1. Celexa 20mg PO
2. Furosemide 40mg PO daily
3. Magnesium tablet 1 PO daily
4. Nadolol 40mg PO daily
5. Omeprazole 20mg PO BID
6. Trental 400mg PO TID
7. Aldactone 50mg PO BID
8. Sucralfate 1g PO before each meal and at bedtime
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. magnesium Oral
3. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Trental 400 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO three times a day.
6. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*1 bottle* Refills:*2*
11. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 4 days: total course of antibiotics is 7
days (last day is [**2159-1-2**]).
Disp:*14 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
[**2158-1-9**]
Please check CBC/diff, CHEM10, PT/INR, AST, ALT, AlkPhos,
T.bili.
Fax results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (fax [**Telephone/Fax (1) 4400**], phone
[**Telephone/Fax (1) 2422**]).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Upper gastrointestinal bleed
Alcoholic cirrhosis complicated by varices
Seizure
.
Secondary:
Hypertension
Diabetes
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Name13 (STitle) **],
.
You were transferred to [**Hospital3 **] Medical center from another
hospital because you vomited blood. You had an endoscopy where
a bleeding ulcer was visualized and the bleeding was stopped.
Since admission, your blood counts have been stable and you have
not vomited any more blood.
.
During the hospitalization, you had a seizure. It was due to a
number of things including alcohol withdrawal, sleep deprivation
and some lab abnormalities. The seizure resolved with medicines
and did not happen again. The neurologists evaluated you, and
per, their recommendations, you had an EEG and CAT scan of the
head both of which were normal. You do not need to see a
neurologist as an outpatient.
.
Please seek emergent help for:
-bleeding from te rectum, vomiting blood
-confusion, lethargy
-chest pain, shortness of breath
-fever >100.4, chills
-increased abdominal girth, swelling
.
We also spoke with you about quitting drinking alcohol. You
were not interested in help with enrolling in a treatment
program. We highly encourage you to stop drinking as alcohol
use will cause progression of your liver disease, low blood
counts, more bleeds from your intestinal tract and possibly more
seizures. We know it is difficult, but we think you should
really strongly consider quitting drinking.
.
We have made the following changes to your medications:
-STOP Lasix (this will likely be restarted at your outpatient
appointment)
-STOP Aldactone (this will likely be restarted at your
outpatient appointment)
-INCREASE Omeprazole from 20mg daily to 40mg twice per day
-START Folic acid 1mg daily
-START Thiamine 100mg daily
-START Lactulose 30ml three times per day (you need to be moving
your bowels 2-3 times per day)
-START Rifaximin 550mg twice per day
-START Ciprofloxacin twice a day (an antibiotic; last day is
[**2159-1-2**])
.
On discharge, you will follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1693**].
Please have labs checked at that visit (lab slip has been
provided) and make sure these labs are sent to your Liver
doctor, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Fax [**Telephone/Fax (1) 4400**], phone [**Telephone/Fax (1) 2422**].
You will see Dr. [**Last Name (STitle) **] as an outpatient as well, because you
need to have a repeat EGD (upper endoscopy), see appointment
below.
.
It was a pleasure taking care of you. We wish you all the best
and happy holidays!
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] H.
Location: [**Hospital1 **] PHYSICIAN SERVICES
Address: 100 [**Last Name (un) **] WAY, [**Location (un) 10068**],[**Numeric Identifier 10069**]
Phone: [**Telephone/Fax (1) 49260**]
Appointment: Tuesday [**2159-1-9**] 11:15am
.
[**2159-1-16**] 02:30p [**Doctor Last Name **] [**Doctor Last Name **],EAST PROCEDURES (Endoscopy)
[**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
ENDOSCOPY SUITES
You will be called about more information
.
Department: LIVER CENTER
When: WEDNESDAY [**2159-1-17**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
ICD9 Codes: 5849, 5715, 2724, 4019, 311, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2487
} | Medical Text: Admission Date: [**2142-10-24**] Discharge Date: [**2142-11-9**]
Date of Birth: [**2074-2-21**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: This is a 68 year old gentleman
who is status post coronary artery bypass graft times three
in [**2121**] with a five year history of exertional chest and
throat discomfort. The patient underwent cardiac
catheterization in [**2137**] which revealed patent bypass graft.
The patient underwent a follow up stress test in [**2142-5-22**]
which showed ischemic ST changes. The patient had a cardiac
catheterization in [**2142-6-22**] which showed occluded vein
grafts of the right coronary artery with native three vessel
coronary artery disease and an ejection fraction of 33%. The
patient was referred to Dr. [**Last Name (STitle) **] for operative treatment.
PAST MEDICAL HISTORY: 1. Status post coronary artery bypass
graft times three in [**2121**]; 2. Hypercholesterolemia; 3.
Noninsulin dependent diabetes mellitus; 4. Arthritis; 5.
Depression; 6. Hypertension; 7. Hard of hearing; 8.
Gastroesophageal reflux disease; 9. Enlarged prostate; 10.
Anxiety; 11. Status post left rotator cuff repair in [**2134**];
12. Status post left parotidectomy in [**2140**].
MEDICATIONS:
1. Atenolol 25 mg p.o. q. day
2. Glucotrol 5 mg p.o. q.d.
3. Lipitor 20 mg p.o. q.d.
4. Celebrex 100 mg p.o. b.i.d.
5. Enteric coated Aspirin 325 mg p.o. q.d.
6. Vitamin E
7. Vitamin B
8. Multivitamin
9. Norvasc 5 mg p.o. q.d.
10. Cardura 2 mg p.o. q.d.
11. Zoloft 100 mg p.o. q.d.
12. Folate
13. Vitamin B12
14. Fish oil
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was admitted to [**Hospital6 1760**] on [**2142-10-24**] and was
taken to the Operating Room with Dr. [**Last Name (STitle) **] for a redo
sternotomy and redo coronary artery bypass graft times three,
left internal mammary artery to left anterior descending,
saphenous vein graft to obtuse marginal and saphenous vein
graft to posterior descending artery. The patient tolerated
the procedure well and was transferred to the Intensive Care
Unit in stable condition. Please see the operative note for
further details. The patient initially required Levophed
drip for maintenance of the blood pressure. In the Intensive
Care Unit the patient had several short runs of nonsustained
ventricular tachycardia for which he was started on
Amiodarone infusion. She was weaned and extubated from
mechanical ventilation on the first postoperative evening and
postoperative day #1 the patient was transferred from the
Intensive Care Unit to the floor. On the evening of
postoperative day #1 into postoperative day #2 the patient
became progressively hypoxic without improvement with
diuretics, pain control or nebulizer treatment. The morning
of postoperative day #2 the patient was transferred from the
floor back to the Intensive Care Unit for hypoxia. Prior to
transfer the patient was found to be hypotensive and
significantly hypoxic and was electively intubated prior to
transfer. Intubation was without complications. Upon
arrival to the Intensive Care Unit the patient underwent a
bronchoscopy which showed normal mucosa, copious thin
secretions and a small plug in the left lower lobe. A sputum
sample was sent from the bronchoscopy. Chest x-ray after
intubation showed diffuse interspace disease, right greater
than left. The patient was empirically started on
antibiotics, Levofloxacin, Vancomycin and Flagyl. The
patient remained significantly hypoxic, requiring paralytics
and sedation and pressure control ventilation. The patient
underwent a transesophageal echocardiogram which showed
severely depressed left ventricular systolic function with
ejection fraction of 20 to 25% with inferior akinesis,
lateral hypokinesis, moderately depressed right ventricular
systolic function, moderate mitral regurgitation and mild
tricuspid regurgitation. Paralytics were discontinued on
postoperative day #3. On postoperative day #4 pulmonary
medicine consult was obtained due to the patient's continued
respiratory failure, fevers of unknown origin and diffuse
patchy infiltrates on chest x-ray, the Pulmonary Medicine
Team's feelings were that the respiratory failure was either
due to aspiration pneumonia or Amiodarone toxicity or
atypical pneumonia. The Pulmonary Team recommended again
using steroids, recommended discontinuing Amiodarone.
Considering the present management, the patient was
pancultured for his continued fever spikes of 102. All of
the cultures from that time were negative with the exception
of a sputum sample done during bronchoscopy which was
positive for Methicillin-sensitive Coagulase positive
Staphylococcus which was minimal growth. All subsequent
sputum, blood and urine cultures were negative. On
postoperative day #4 the patient had a pulmonary artery
catheter placed to rule out cardiogenic pulmonary edema that
showed a cardiac output of 7.2 and a cardiac index of 3.17,
SVR of 715. The pulmonary artery catheter was removed as it
was felt that the patient had adequate cardiac output. On
postoperative day #4, the patient was switched from pressure
control ventilation to conventional ventilation with assist
control and subsequent to SIMV. The patient's sedation was
slowly weaned down. The patient continued to have improving
oxygenation over the next several days. The patient's
positive end-expiratory pressure and sedation were weaned.
The patient's fever curve continued to defervesce. The
patient had no further atrial or ventricular ectopy. It was
thought that the patient did not require any anti-arrhythmic
therapy. On postoperative day #6 the patient again spiked a
fever to 102.9. Blood cultures were sent which were
negative. The patient's central line was removed. The
patient continued on triple antibiotic therapy. The
patient's white count during this time remained steady in the
13 to 15 range. By postoperative day #8 the patient
continued to have fevers. The patient was weaning on the
ventilator and had been weaned down to CPAP with pressure
support, required Diamox for metabolic alkalosis. Sedation
had been weaned off, however, the patient was agitated and
not following commands, restless in the bed. A neurological
consult was obtained which neurology felt that the majority
of his problem was probably due to metabolic and infectious
causes, however, felt that it could be due to a stroke and
recommended an magnetic resonance imaging scan at a future
date to further delineate this. However, by postoperative
day #9, the patient's mental status had improved. The
patient began to follow commands and move all extremities to
command, and their recommendations were changed to consider
the magnetic resonance imaging scan if the patient did not
continue to progress. The patient continued to progress from
a neurologic standpoint. By postoperative day #9, the
patient was weaned and extubated from mechanical ventilation
and continued to improve from a pulmonary standpoint, was
able to tolerate nasal cannula by the morning of
postoperative day #10 and required some pulmonary toilet,
encouragement with coughing and deep breathing. It was noted
about this time that the patient had an area of skin abrasion
on his lower coccyx and gluteal cleft. Duoderm was applied
and subsequent skin care specialist evaluated the patient and
felt that it was a Stage 2 ulcer and recommended continuing
Duoderm. The patient continued to improve, neurologically.
He was quickly weaned off of oxygen to room air by
postoperative day #11. Fever curve decreased by
postoperative day #11, temperature maximum was 98. The
patient continued to have episodes of confusion and delirium,
however, he was following commands and moving all extremities
equally. The patient's delirium continued to improve. The
patient's antibiotics were weaned. The Vancomycin and the
Flagyl were discontinued as the patient had no positive
culture, was continued on the Levofloxacin. The patient was
tolerating a regular diet without signs or symptoms of
aspiration. The patient began walking with physical therapy,
ambulating in the Intensive Care Unit. By postoperative day
#13, the patient was transferred from the Intensive Care Unit
to the regular floor. He remained hemodynamically stable and
was able to ambulate with assistance, on room air and by
postoperative day #15 the patient was deemed stable for
discharge to a rehabilitation facility. The patient will be
discharged on postoperative day #16.
CONDITION ON DISCHARGE: Temperature maximum 96.5, pulse 78
in sinus rhythm, blood pressure 95/60, respiratory rate 18,
room air oxygen saturation 95%, patient's weight on [**11-8**] was 90.1 kg. Preoperatively the patient weighed 100 kg.
The patient was awake, alert and oriented times three, moving
all extremities equally. Heart regular rate and rhythm
without rub or murmur. Respiratory breath sounds are clear
bilaterally. Abdomen, positive bowel sounds, soft,
nontender, nondistended, tolerating regular diet.
Extremities were warm and well perfused, no edema. The
pressure ulcer over the gluteal cleft is covered with
Duoderm. There is some mild erythema. There is no
fluctuance. The sternal incision is clean and dry. The
sternum is stable. Staples are intact. Left leg, vein
harvest incision is clean and dry. Steri-Strips are intact.
LABORATORY DATA: Laboratory data revealed white blood cell
count 13.1, sodium 136, potassium 5.0, chloride 98,
bicarbonate 29, BUN 27, creatinine 1.1, glucose 104. The
patient has a chest x-ray pending for [**11-8**].
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. b.i.d.
2. Colace 100 mg p.o. b.i.d.
3. Enteric coated Aspirin 325 mg p.o. q. day
4. Plavix 75 mg p.o. q. day
5. Percocet 5/325 one to two p.o. q. 4 hours prn
6. Lipitor 20 mg p.o. q. day
7. Prevacid 30 mg p.o. q. day
8. Zoloft 100 mg p.o. q. day
9. Lasix 20 mg p.o. q. day times seven days
10. Glipizide 5 mg p.o. q. day
11. Regular insulin sliding scale for blood sugar 120 to 150,
give 1 unit subcutaneously, for blood sugar 150 to 200 give 3
units subcutaneously, for blood sugar 201 to 250 give 5 units
subcutaneously, for blood sugar of 251 to 300 give 7 units
subcutaneously, for blood sugar of 301 to 350 give 9 units,
subcutaneous, for blood sugar greater than 350 give 11 units
subcutaneously.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease
2. Status post redo coronary artery bypass graft times three
3. Postoperative respiratory failure due to Amiodarone
toxicity versus aspiration pneumonia
4. Postoperative atrial fibrillation
5. Postoperative Stage 2 pressure ulcer on gluteal fold
CONDITION ON DISCHARGE: The patient is to be discharged to
rehabilitation in stable condition.
FOLLOW UP: The patient should follow up with the Dr. [**Last Name (STitle) 29480**]
in one to two weeks, the patient should follow up with Dr.
[**First Name (STitle) **] in one to two weeks. The patient should follow up
with Dr. [**Last Name (STitle) **] in one month. The patient should have the
staples removed from the sternal incision on postoperative
day #21 which is [**11-14**].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2142-11-8**] 17:13
T: [**2142-11-8**] 20:48
JOB#: [**Job Number 29481**]
ICD9 Codes: 5070, 5185, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2488
} | Medical Text: Unit No: [**Numeric Identifier 60165**]
Admission Date: [**2131-12-19**]
Discharge Date: [**2131-12-19**]
Date of Birth: [**2060-9-8**]
Sex: M
Service: TRA
HISTORY: Trauma.
PRESENT ILLNESS: Mr. [**Known lastname **] is a 71-year-old man who was
transferred from an outside hospital after he fell down 4 to
10 stairs at home. He arrived in an intubated condition
without a pulse.
PHYSICAL EXAMINATION: On arrival, the patient was intubated
and pale in appearance. There was no heart beat on palpation
or auscultation. The lungs were clear on a ventilator. The
abdomen was soft. Extremities were cool and pale.
PERTINENT X-RAYS: None.
PROCEDURES PERFORMED:
1. Right groin cordis placement.
2. Emergency room thoracotomy.
3. Exploratory laparotomy.
4. Transesophageal echocardiography.
CONCISE SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname **] was brought
by Med-flight to the [**Hospital1 69**] in
an intubated condition after being unstable at an outside
hospital for several hours. On arrival, he did not have a
palpable pulse and an ACLS protocol was initiated. He did
have a narrow complex rhythm; and given that an emergency
room thoracotomy was undertaken. After the thoracotomy, and
cardiac massage and ACLS protocol a heart beat was obtained.
The patient was emergently transferred to the operating room
where the patient's heart stopped again. With further
resuscitation, the heart beat was regained again. At this
time, a small laparotomy was conducted elucidating
serosanguineous ascites type of fluid. An exploratory
laparotomy was then conducted which was negative for any
abdominal source of bleeding. The abdomen was closed with a
[**Location (un) 5701**] bag, and the patient was transferred to the intensive
care unit in an unstable condition. Within 1 hour of transfer
to the intensive care unit the patient had a PEA arrest. ACLS
protocol was initiated and was unsuccessful. The patient was
declared dead at that time.
CONDITION ON DISCHARGE: Death.
DISCHARGE STATUS: Expired.
DISCHARGE DIAGNOSES:
1. Multiple trauma.
2. Emergency room thoracotomy.
3. Exploratory laparotomy.
4. Cardiac arrest.
5. Cirrhosis and ascites.
FOLLOW-UP PLANS: None.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 22102**]
MEDQUIST36
D: [**2132-1-18**] 13:22:39
T: [**2132-1-19**] 10:55:45
Job#: [**Job Number 60166**]
ICD9 Codes: 4275, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2489
} | Medical Text: Admission Date: [**2168-8-10**] Discharge Date: [**2168-8-22**]
Date of Birth: [**2100-3-21**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Tetracycline / Erythromycin Base / Latex
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
nausea/vomiting/diaphoresis
Major Surgical or Invasive Procedure:
Exploratory laparotomy, lysis of adhesions.
History of Present Illness:
68 F presents to [**Hospital1 **] ED with nausea, vomiting, diaphoresis and
distended abdomen after recent laparoscopic assisted right
colectomy on [**2168-8-2**]. She was discharged from [**Hospital1 18**] on [**2168-8-6**]
after in stable condition. She was
doing well, tolerating a regular diet until yesterday when she
developed the aforementioned symptoms.
Past Medical History:
Her past medical history is notable for heart disease, status
post myocardial infarction in [**2167-8-28**]. She had some stents
placed and was on aspirin and Plavix. She was also noted to
have
pulmonary embolism around this time and has been started on
Coumadin and since then, her Plavix has been discontinued. She
also has a history of hypertension and diabetes.
Past surgeries include a lumbar fusion, tonsillectomy, deviated
septum repair, appendectomy, cholecystectomy, hysterectomy and
bladder suspension as well as several orthopedic surgeries
include rotator cuff surgery and arthroscopies. The patient
does
not smoke or drink. She is retired and lives with her husband.
There is a history of colon cancer in her father. [**Name (NI) **] mother
died of a myocardial infarction.
Review of systems is notable for a history of interstitial
cystitis and arthritis as well as remote history of depression.
Social History:
Lives with husband
Active lifestyle- regularly goes to gym
Family History:
Non-contributory.
Physical Exam:
Afebrile, VSS
Alert, oriented x 3, NAD
RRR
CTAB
Abdomen soft, appropriately mildly tender, steristrips in place
LE warm, no edema
Brief Hospital Course:
Ms. [**Known lastname 2784**] presented to ED on [**8-10**] with nausea, vomiting,
diaphoresis and distended abdomen. She received an exploratory
laporatomy with lysis of adhesions for a small bowel obstruction
that was found to be the cause of her symptoms. See Dr. [**Name (NI) 45689**] operative note for details.
Patient was intubated in the ED d/t inability to protect airway
and aspiration. Bronchoscopy was performed after surgery and
she was found to have very little aspiration contents in her
lower airways. She was admitted to the ICU after surgery d/t
intubation and need for neosynephrine for BP control. While in
the ICU she was successfull weaned off neosynephrine, and
required lopressor for tachycardia. She had a drop in her Hct
to 24 and required one unit of blood. She spiked a fever so was
given a treatment of cipro, vancomycin, and flagyl. She was
successfuly extubated on POD 5 and experienced resp distress
that responded with Lasix.
She was transferred out of the unit on POD 6. She had episodes
of non-responsiveness on the floor for which she received
several cardiac work-ups, psychiatry saw her and recommended
discontinuing her narcotic pain medicine and her
benzodiazepines. She also had a work-up with Neurology which
included a 24 hour EEG, MRI and MRA of her head, and several lab
tests. All of these were negative.
At the time of discharge, she was stable and no longer
experiencing these episodes of non-responsiveness. Neurology and
her primary team felt that she was able to return to home.
Physical therapy saw the patient and recommended home PT.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Venlafaxine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Disp:*20 Suppository(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. Codeine Sulfate 15 mg Tablet Sig: One (1) Tablet PO every
4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
stable
Discharge Instructions:
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.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-29**] weeks. Please call
[**Telephone/Fax (1) 2981**] to make appointment.
Please contact your PCP for [**Name Initial (PRE) **] outpatient MRI of your spine.
Neurology recommended this because they feel it is possible that
a bulging disc could be contributing to your generalized
weakness
Completed by:[**2168-8-22**]
ICD9 Codes: 0389, 5849, 5070, 4280, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2490
} | Medical Text: Admission Date: [**2135-1-16**] Discharge Date: [**2135-1-22**]
Date of Birth: [**2084-4-17**] Sex: M
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: 50 year old male diagnosed with
a left subdural hematoma on [**2135-1-14**]. Was discharged on
[**2135-1-15**]. The patient was found to be unresponsive in his
car by his brother. There was an empty ETOH bottle also
found in the car.
PAST MEDICAL HISTORY: Seizure disorder, hypertension,
gastroesophageal reflux disease, depression, hepatitis C and
ETOH.
PAST SURGICAL HISTORY: Api.
MEDICATIONS AT HOME:
1. Dilantin 300/100/100.
2. Atenolol 100 q d.
3. Paxil 20 mg q d.
4. Prilosec.
PHYSICAL EXAMINATION: 91, sinus rhythm; blood pressure,
155/94; 100% room air sat. Opens eyes to voice. Follows
commands. Oriented to person. Knows he is in the hospital.
Pupils are equal, round, and reactive to light. Extraocular
movements full. Face, symmetric. Tongue, midline.
Tremulous bilateral upper extremities. Positive right
pronator drift. Motor strength, [**4-25**] on the right except for
+ triceps, 4+ grasp and 4+ extensor hallucis longus. Motor
strength on the left is 5 throughout.
CAT scan shows expanding left subdural hematoma with mass
effect causing a midline shift.
LABORATORY: Dilantin, 32.3; ETOH, 23; platelet level, 125.
All other labs, within normal limits>
HOSPITAL COURSE: Taken to Operating Room on [**2135-1-16**] for
craniotomy and evacuation of subdural hematoma. No
complications.
Was monitored in the Intensive Care Unit for close
neurological observation and blood pressure control. Was
placed on CIWA scale for possibly ETOH withdrawal.
Repeat head CT showed well drained hematoma.
Postoperative day #3, was transferred to Floor.
Neurologically improved. Moved all extremities. No drift
noted. Strength, [**4-25**] bilateral.
However, the patient had some behavior issues related to
withdrawal. At one point, became extremely agitated and
combative. Was sedated with additional Ativan with good
effect. He was slowly weaned from the CIWA protocol with
success.
PT was consulted and evaluated the patient and recommended
rehabilitation.
MEDICATIONS AT THE TIME OF DISCHARGE:
1. Folic Acid 1 mg p.o. q d.
2. Multi Vit one cap p.o. q d.
3. Thiamin 100 mg p.o. q d.
4. Lopressor 25 mg p.o. b.i.d.
5. Protonics 40 mg p.o. q d.
6. Heparin 5,000 units subcutaneous tissue b.i.d.
7. Percocet one to two tabs p.o. q 4 to 6 prn.
DISPOSITION: The patient is neurologically stable and will
be discharged to rehabilitation.
FOLLOW UP: A follow up with Dr. [**First Name (STitle) **] with a repeat head CT in
one month and staples to be removed on Monday, [**2135-1-24**].
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2135-1-21**] 14:00
T: [**2135-1-21**] 15:18
JOB#: [**Job Number 46189**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2491
} | Medical Text: Admission Date: [**2143-4-3**] Discharge Date: [**2143-4-5**]
Date of Birth: [**2093-11-21**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Abdominal Pain, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 year old female with HIV (Last CD4 500's, VL undetect), BLE
paralysis, h/o DVT, and h/o rectal cancer with multiple
complications with ostomy, nephrostomies, and multiple
SBO's/ileus who presented to the ED with vomiting and SOB. She
is being transferred the the [**Hospital Unit Name 153**] for hypotension.
.
She is frequently admitted to OMED for SBO's. She occasionally
can manage this at home with bowel rest and IV fluids. Over the
past 5 days, she again developed nausea, vomiting, abdominal
pain, and liquid output from her ostomy. She therefore stopped
eating and took IV fluids at home. She felt slightly better
last night and had dinner, but then had recurrence of her
abdominal pain. She also had the new onset of shortness of
breath. Also reports poor urine output x 1 day.
.
She was taken to [**Hospital1 **]. She was found to be 92% on room
air. She refused an NG tube as it makes her vomiting worse.
Labs were notable for creatinine of 3.8 (from baseline of 0.8),
hyperkalemia, and hyponatremia. CXR was reportedly clear with
possible linear atelectasis. KUB was unremarkable. UA showed
WBC and bacteria, but at her baseline. ECG was significant for
QTc prolongation to 514. There was concern for PE given her
SOB/hypoxia and paralysis, and she was empirically started on a
heparin gtt for PE (no CTA given ARF). She was given 2L IVF.
She had a large amount of emesis (1L) and her shortness of
breath resolved. She was given a dose of ceftriaxone and
transferred to our ED.
.
In our ED, initial vitals were 97.6 90 108/70 18 100% 4L. She
had a renal ultrasound that showed no hydronephrosis and
nephrostomy tubes in place. LENIs were negative for DVT. She
was signed out to OMED, and then became hypotensive to the
80's/40's. She was started on levophed and SBP increased to the
130's. Her HR dropped to the 40's initially but improved to
60-70. She was given vancomycin and zosyn and 1.7 more liters
of IVF (for a total of 3.7L). She has had 700cc output from her
nephrostomy tubes. She continues on a heparin gtt. She has a
20g PIV and a port. Her current vitals are afebrile, 130/70,
65, 100%3L.
.
Currently, she has no complaints--she states that her ileostomy
output increased shortly after her arrival to the [**Location (un) 620**] ED and
that her abdominal pain symptoms began to resolve gradually
since then. She states that her abdominal pain is currently at
baseline and that she would like to start advancing her diet.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
ONCOLOGIC HISTORY:
# Rectal cancer:
- late [**2139**]: 6 months of intermittent rectal bleeding, rectal
pressure and a sensation of incomplete emptying.
- [**2141-1-26**]: colonoscopy revealed a polyp in her sigmoid colon and
a 2.5 cm distal rectal mass arising from the anal verge in the
posterior rectum with a large area of induration.
- [**2141-1-31**]: CT torso revealed an exophytic rectal mass measuring
4.8 x 3.8 cm, bulging posteriorly into the presacral space and
anteriorly towards the uterus. There were enlarged lymph nodes
in the perirectal fat adjacent to the mass, a 9-mm enhancing
lymph node in the left pelvic sidewall, and enhancing lymph
nodes
in the right external iliac region. There was also a 7-mm
hypodensity in the caudate lobe of the liver. Rectal ultrasound
on [**2141-1-31**] and rectal MRI on [**2141-2-7**] were compatible with T3
disease. There were at least four abnormal perirectal lymph
nodes seen on MRI, in addition to multiple bilateral enlarged
pelvic sidewall lymph nodes, concerning for extensive disease.
- [**2141-2-20**]: began chemoradiation
- [**2141-3-10**]: 5-FU was discontinued due to mucositis, neutropenia,
and abdominal cramping
- [**2141-3-13**]: 5-FU was restarted at a reduced dose
- [**2141-3-22**]: 5-FU was again stopped due to mucositis, perirectal
skin changes, diarrhea, and electrolyte abnormalities.
- [**Date range (3) 70844**]: Radiation was also held
- [**2141-3-27**]: 5-FU was restarted at a further reduced dose
- [**2141-3-31**]: completed radiation
- [**2141-4-3**]: completed chemotherapy
- [**Date range (3) 70845**]: hospitalized for bowel rest and the
initiation of TPN due to presumed radiation enteritis.
- [**2141-5-31**]: found to be HIV positive and began on HAART
- [**Date range (1) 70846**]: required hospitalization for an SBO, underwent
laparotomy, ileocecectomy, end-ileostomy, and placement of [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] tube on [**2141-6-16**]. Pathology from this surgery revealed
severe radiation-induced acute ischemic enteritis. She recovered
from this surgery, but continued to require TPN.
- [**7-/2141**]: Once her CD4 count had recovered, she underwent
laparotomy, lysis of adhesions, ileal resection,
proctosigmoidectomy, colonic jejunal pouch to near-anal
anastomosis with EEA, takedown splenic flexure, resection of
ileostomy and creation of new end-ileostomy. Pathology from the
surgical specimen revealed no residual carcinoma and all 14
lymph nodes sampled were free of disease.
- [**9-/2141**], [**10/2141**]: Subsequent imaging of the abdomen & pelvis
showed no evidence of recurrence.
- [**2142-2-14**]: CT abdomen showed "hyperdense thickening in the lumen
near the anastomatic site, new since the earlier study. Local
recurrence cannot be excluded, although possibly the appearance
is associated with endoluminal debris."
.
OTHER MEDICAL HISTORY:
# HIV.
# Short gut syndrome secondary to bowel surgery for CA.
# Obstructive renal failure from radiation fibrosis, in the past
necessitating b/l nephrostomy tubes.
# Lower extremity neuropathy, likely secondary to radiation
fibrosis, uses a wheelchair since 4/[**2141**].
# Pancreatic insufficiency.
# Anemia.
# Chronic pain.
# LLE DVT: dx [**3-/2142**], was on warfarin.
Social History:
Lives with her husband and 4 children in [**Location (un) 17566**], does not
smoke or drink alcohol. On long-term disability.
Family History:
Her father died at 72 of MI. Her mother alive and well. Remote
family history of breast, colon cancer. Her daughter has
ulcerative colitis.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.8 90 113/75 17 99%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
Vitals 98.4 65 71/49 12 93%RA
General Appearance: Well nourished, No acute distress, Thin
Head, Ears, Nose, Throat: Normocephalic, moist mucous membranes
Cardiovascular: RRR, no murmurs
Respiratory / Chest: Clear bilaterally ; port site clean and
dry on R chest
Abdominal: Soft, Non-tender, Bowel sounds present, ileostomy and
nephrostomy c/d/i
Extremities: Warm extremities with no LE edema
Pertinent Results:
Blood Counts
[**2143-4-3**] 10:41AM BLOOD WBC-10.9 RBC-3.53* Hgb-10.7* Hct-33.4*
MCV-95 MCH-30.4 MCHC-32.2 RDW-15.9* Plt Ct-268
[**2143-4-5**] 04:37AM BLOOD WBC-3.8* RBC-2.90* Hgb-8.9* Hct-27.0*
MCV-93 MCH-30.6 MCHC-32.9 RDW-15.8* Plt Ct-240
.
Coags
[**2143-4-3**] 07:35AM BLOOD PT-14.6* PTT-40.3* INR(PT)-1.3*
[**2143-4-5**] 04:37AM BLOOD PT-12.6 PTT-25.7 INR(PT)-1.1
.
Chemistry
[**2143-4-3**] 10:41AM BLOOD Glucose-113* UreaN-32* Creat-2.3*# Na-133
K-3.5 Cl-103 HCO3-17* AnGap-17
[**2143-4-4**] 03:47AM BLOOD Glucose-80 UreaN-20 Creat-1.3* Na-138
K-3.4 Cl-110* HCO3-20* AnGap-11
[**2143-4-5**] 04:37AM BLOOD Glucose-73 UreaN-11 Creat-0.9 Na-137
K-3.9 Cl-108 HCO3-21* AnGap-12
.
Microbiology
[**Hospital1 **]-[**Location (un) 620**] URINE CULTURE [**2143-4-2**]
>100,000 org/ml KLEBSIELLA PNEUMONIAE
AMPICILLIN R >=32
AMP/SULBAM S 4
CEFAZOLIN S <=4
CEFOXITIN S <=4
CEFTAZIDIME S <=1
CEFTRIAXONE S <=1
CIPROFLOXACIN S <=0.25
ERTAPENEM S <=0.5
GENTAMICIN S <=1
IMIPENEM S <=1
LEVOFLOXACIN S <=0.12
PIP/TAZ S <=4
TOBRAMYCIN S <=1
TRIM/SULFA S <=20
.
IMAGING:
[**4-3**] LENIS: Limited examination, with wall-to-wall flow and
augmentation seen in bilateral superficial/deep femoral and
popliteal veins. Calf veins not visualized.
.
[**4-3**] RENAL U/S IMPRESSION: Normal kidneys, with nephrostomy
tubes in expected position.
.
[**4-4**] CT Abd/Pelvis
1. No CT evidence for cystitis; however, evaluation is limited
both by
underdistension of the bladder as well as significant likely
radiation-related changes in the lower pelvis.
2. Unchanged appearance of small bowel loops with focal areas of
thickened
wall and folds likely related to radiation-related changes
without bowel wall dilatation.
Brief Hospital Course:
HOSPITAL COURSE
This is a 49yo F PMHx HIV, rectal CA c/b bilateral nephrostomies
& ileostomy, p/w vomitting, admitted to MICU for hypotension,
found to have UTI, started on antibiotics w clinical
improvement, stable and discharged home.
.
ACTIVE
#. Hypotension / UTI: On admission, patient was found to have
SBPs in the 70s with an intact mental status and without signs
of ischemia / poor perfusion. Patient was fluid resuscitated
and started on levophed given concern for sepsis. On review of
chart and discussion w PCP, [**Name10 (NameIs) **] was found that patient baseline
pressures were SBP 80s. Patient weaned off pressors and
pressures remained in 80s-90s during daytime hours, dipping into
70s at night. Patient was found to have a Klebsiella UTI based
on cultures from [**Hospital1 **]-[**Location (un) 620**]. She was was initially treated with
Daptomycin and Zosyn given recent VRE and Klebsiella UTIs, once
sensitivities returned, abx were narrowed to cefpodoxime.
.
#. Vomiting: Patient reported vomitting prior to admission,
which had resolved by the time of admission w subsequent
increase in her ostomy output to baseline. It was uncertain
whether this represented a resolved viral gastroenteritis or
ileus (as she has a history of ileus).
.
#. Acute renal failure: Creatinine was elevated to 3.8 on
admission from baseline of 0.8. Urine lytes were c/w prerenal
state, and Cr trended down w fluid resuscitation. No signs of
obstruction on renal ultrasound. Given patient's b/l
nephrostomy tubes, case was discussed w urology who did not
believe additional management was warranted. At discharge Cr
was 0.9.
.
INACTIVE
#. Rectal cancer: No evidence of recurrence by CT [**11/2142**] or CEA
[**2143-2-12**].
.
# HIV: Last CD4 534, VL <48 copies on [**2143-3-21**]. Continued
outpatient antiretrovirals.
.
TRANSITIONAL
1. Code - Patient remained full code
2. Pending - At discharge, admission blood cultures remained
pending. Discharge summary was faxed to PCP to alert that these
values would need to be followed up.
3. Transfer of Care - Patient scheduled for follow-up w PCP who
was notified of the details of this admission via email.
4. Barriers to Care - Per PCP, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] baseline low SBPs
(80s-90s), should be kept in mind when treating future
infections so as not to over aggressively treat
Medications on Admission:
1. abacavir-lamivudine 600-300 mg once a day.
2. ritonavir 100 mg DAILY
3. darunavir 400 mg Tablet [**Name Initial (NameIs) **]: Two (2) Tablet PO DAILY (Daily).
4. methadone 5 mg Tablet: Alternate two (10mg) and three (15mg)
tabs every six hours.
5. hydromorphone 4 mg: Four (4) Tablet PO Q2H prn pain
6. pregabalin 150 mg [**Hospital1 **]
7. loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID
8. diphenoxylate-atropine 2.5-0.025 mg Tablet [**Hospital1 **]: 1 Tablet PO
three times a day as needed for High ostomy output (>5L).
9. ondansetron 4 mg Tablet q8h prn
10. lansoprazole 30 mg Daily
11. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) [**Hospital1 **]: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
12. pentoxifylline 400 mg Tablet Extended Release [**Hospital1 **]: One (1)
Tablet Extended Release PO three times a day: Compounded with
vitamin E 100 Units.
13. zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS prn
14. mirtazapine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS prn
15. lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO HSprn.
16. cyanocobalamin (vitamin B-12) 1000 mcg (Daily).
17. ergocalciferol (vitamin D2) 50,000 unit once a week.
18. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
19. magnesium oxide 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID
20. magnesium sulfate 4 % IV infuse 2g if Mg <1.5.
Discharge Medications:
1. abacavir-lamivudine 600-300 mg Tablet [**Hospital1 **]: One (1) Tablet PO
once a day.
2. ritonavir 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
3. darunavir 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
4. methadone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12
hours): Alternate with 15mg for every 6 hour dosing.
5. methadone 5 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Q 12H (Every
12 Hours): Alternate with 10mg dose for every 6 hour dosing.
6. Dilaudid 4 mg Tablet [**Hospital1 **]: Four (4) Tablet PO q2.
7. pregabalin 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a
day.
8. loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO three times a
day as needed for diarrhea.
9. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
10. magnesium oxide 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3
times a day).
11. cyanocobalamin (vitamin B-12) 500 mcg Tablet [**Hospital1 **]: Two (2)
Tablet PO DAILY (Daily).
12. ergocalciferol (vitamin D2) 50,000 unit Capsule [**Hospital1 **]: One (1)
Capsule PO 1X/WEEK (WE).
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) [**Last Name (STitle) **]: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
15. ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
16. magnesium sulfate 4 gram/100 mL Piggyback [**Last Name (STitle) **]: Two (2) gram
Intravenous once: if Mg<1.5.
17. zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia.
18. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime
as needed for insomnia.
19. lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
20. diphenoxylate-atropine 2.5-0.025 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO three times a day.
21. cefpodoxime 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every
12 hours) for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Urinary Tract Infection
Secondary:
HIV
Short gut syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Mrs. [**Known lastname 70847**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the ICU with low blood
pressure. You were briefly given IV medications to increase
your blood pressure, and antibiotics to treat a urinary tract
infection. You improved and are now ready for discharge.
During this hospitalization the following changes were made to
your medications:
-STARTED cefpodoxime (to be continued for a total of 14 days)
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: FRIDAY [**2143-4-12**] at 11:40 AM
With: [**First Name8 (NamePattern2) 3679**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5990, 2761, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2492
} | Medical Text: Admission Date: [**2129-1-5**] Discharge Date: [**2129-1-23**]
Date of Birth: [**2081-6-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Intraventricular hemorrhage
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation
NG tube placement
A-line placement
Central Line Placement
History of Present Illness:
Pt is a 47 F h/o stroke, vp shunt in place, mental retardation
who is a nursing home patient and ([**Hospital1 **] of state) Pt was in her
usual state of health when she was noted to become acutely
unresponsive with a concomitant rise in her respiratory rate. Pt
was noted to vomit at that time and was brought urgently to OSH.
As part of the OSH's workup, pt received head CT revealing a
large intraventricular bleed. She was transferred by ALS and
arrived at [**Hospital1 18**] hyperthermic to 105, seizing during transfer,
and tachycardic to 170's. She was emergently intubated and
central access placed. As pt was noted to have hr in the 170s
she was given adenosine for ? a.flutter then noted to be sinus
tach. To control her seizures, pt was given propofol but
continued to seize. She was subsequently loaded on dilantin.
Seizures were ultimately controlled with versed. In [**Name (NI) **], pt was
hypotensive to 80's. She was transferred to the MICU initially
on neo with pressures in the 90s. Initial lactate measured in
the ED was 10.4. Pt received 4 liters of IV fluid and follow up
lactate improved to 5. Pt covered empirically with
ceftriaxone/vanco and tx to the MICU for further evaluation and
treatment.
Past Medical History:
Mental retardation
Hydrocephalus
Ventricular drain
Asthma
DM - non insulin dependent
CVA(unknown residuals)
Social History:
Resides at [**Hospital 2251**] Nursing and Rehab center
Family History:
unknown: Pt is [**Hospital1 **] of the state.
Physical Exam:
expired
Pertinent Results:
[**2129-1-5**] 10:14PM LACTATE-5.3*
[**2129-1-5**] 10:10PM GLUCOSE-130* UREA N-15 CREAT-1.0 SODIUM-144
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-22 ANION GAP-18
[**2129-1-5**] 10:10PM WBC-16.0* RBC-3.94* HGB-11.4* HCT-33.4*
MCV-85 MCH-29.0 MCHC-34.2 RDW-14.8
[**2129-1-5**] 10:10PM NEUTS-67.9 LYMPHS-20.9 MONOS-10.6 EOS-0.1
BASOS-0.5
[**2129-1-5**] 10:10PM PLT COUNT-268
[**2129-1-5**] 07:39PM LACTATE-7.2*
[**2129-1-5**] 05:00PM GLUCOSE-171* UREA N-18 CREAT-1.2* SODIUM-145
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-19* ANION GAP-27*
[**2129-1-5**] 05:00PM estGFR-Using this
[**2129-1-5**] 05:00PM CALCIUM-9.3 PHOSPHATE-1.2* MAGNESIUM-1.7
[**2129-1-5**] 05:00PM WBC-15.6* RBC-4.19* HGB-11.9* HCT-35.7*
MCV-85 MCH-28.3 MCHC-33.2 RDW-13.8
[**2129-1-5**] 05:00PM NEUTS-82.4* LYMPHS-13.0* MONOS-4.2 EOS-0.2
BASOS-0.3
[**2129-1-5**] 05:00PM PLT COUNT-336
[**2129-1-5**] 05:00PM PT-13.0 PTT-42.4* INR(PT)-1.1
[**2129-1-5**] 05:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2129-1-5**] 05:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2129-1-5**] 05:00PM URINE RBC-[**5-10**]* WBC->50 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2129-1-5**] 05:00PM URINE HYALINE-0-2
[**2129-1-5**] 04:58PM LACTATE-10.4*
Brief Hospital Course:
Pt was admitted from the ED to ICU. She was hypertensive,
hyperthermic, and tachycardic with rates in the 170 range. Pt
exhibited roving eye movements and right sided clonus. She was
not responsive. Over the course of her hospitalization, pt
experienced intermittent fevers, hypotension, rhabdomyolysis.
She was evaluated by neurology and neurosurgery, both services
concluding that there was not any meaningful recovery expected.
As the patient is a [**Hospital1 **] of the state, affidavits were generated
and the patient's case was presented before the courts. The
patient was subsequently made CMO and expired shortly
thereafter.
Medications on Admission:
Valproic acid, geodon, prozac,
metformin, albuterol, enolase, senna, bisacodyl, MOM
(all doses unknown)
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2493
} | Medical Text: Admission Date: [**2128-7-31**] Discharge Date: [**2128-8-2**]
Date of Birth: [**2128-7-31**] Sex: F
Service: NB
HISTORY: This infant was born at 34 and 6/7 weeks gestation
by Cesarean section after failed induction for IUGR for
maternal hypertension.
PRENATAL HISTORY: Mother is a 29 year-old, prima gravida,
EDC [**2128-9-5**]. Prenatal screens: Blood type A positive,
antibody negative. HBSAG negative. RPR nonreactive. Rubella
immune. GBS unknown. Maternal history was notable for
asthma which was treated with Albuterol and Advair as well as
chronic hypertension which required treatment with Nifedipine
starting at 16 to 20 weeks gestation. This pregnancy was
complicated by intrauterine growth restriction, admitted in
early [**Month (only) **] with worsening hypertension and treated with
full course of betamethasone and discharged home on bedrest.
Mother was readmitted on [**2128-7-30**] for induction of labor due
to intrauterine growth restriction and hypertension. The
induction prompted fetal heart rate decelerations, therefore,
the infant was delivered by Cesarean section. Mother
received intrapartum antibiotic prophylaxis times greater
than 4 hours, due to premature delivery with unknown GBS
status. Artificial rupture of membranes for clear fluid
occurred at the time of delivery. There was no maternal
fever. There was a nuchal cord x1. The baby emerged with
spontaneous cry and required only brief blow-by oxygen and
routine care in the operating room. Apgars were 8 and 8 at 1
and 5 minutes. The infant was then transferred to the NICU
for continued care for prematurity.
PHYSICAL EXAMINATION: Measurements at birth: The weight is
2080 grams which is 25th to 50th percentile. Length 46 cm
which is 25th to 50th percentile. Head circumference 32 cm
which is 50th percentile.
HOSPITAL COURSE BY SYSTEMS: Respiratory: The infant had mild
grunting, flaring and retracting on admission to the NICU.
This quickly resolved on the newborn day. The infant has
remained stable on room air since that time. She had mild
apnea of prematurity. Her last episode was [**8-4**].
She has now completed a 5 day countdown.
Cardiovascular: The infant has maintained cardiovascular
stability while in the NICU. She does not have a murmur and
has normal heart rates and blood pressures.
Fluids, electrolytes and nutrition: The infant was started
on IV fluids on admission to the NICU due to mild respiratory
distress. The infant started enteral feedings on the newborn
day and weaned off of IV fluids as well. She has always been
fully po. She is presently taking ad lib p.o. feeds of
breastmilk or Enfamil 20. The most recent weight is 2040
grams. No electrolytes have been measured on this infant.
Gastrointestinal: Hyperbilirubinemia treated with
phototherapy. Peak bilirubin 12.7/0.3. Rebound bilirubin
7.9/0.3
Infectious disease CBC and blood culture were screened on
admission to the NICU due to the transitional respiratory
distress. The CBC was benign. There was no left shift. The
blood culture remains negative at 48 hours. The infant was
not started on any antibiotic therapy.
Neurology: The infant has maintained a normal neurologic
examination for gestational age.
Sensory:
Audiology: A hearing screen was passed.
Psychosocial: A [**Hospital1 18**] social worker has been in contact with
the family. If there are any concerns, the social worker can
be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Discharge home with parents.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, telephone number
[**Telephone/Fax (1) 37304**].
CARE RECOMMENDATIONS: Ad lib p.o. feedings by breast or
supplement with E-20 with iron at discharge.
Medications: None.
Iron supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age. All infants
fed predominantly breast milk should receive Vitamin D
supplementation at 200 i.u. (may be provided as a multi-
vitamin preparation) daily until 12 months corrected age.
Car seat position screening will need to be done prior to
discharge.
State newborn screen: sent x 2
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine given [**8-7**].
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 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.
FOLLOWUP: Dr. [**Last Name (STitle) **] in [**12-27**] days.
DISCHARGE DIAGNOSES:
1. Prematurity, born at 34 and 6/7 weeks gestation.
2. Transitional respiratory distress resolved.
3. Sepsis ruled out.
4. Apnea of prematurity, resolved.
5. Hyperbilirubinemia, treated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2128-8-2**] 02:33:23
T: [**2128-8-2**] 05:30:22
Job#: [**Job Number 75054**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2494
} | Medical Text: Admission Date: [**2139-7-8**] Discharge Date: [**2139-7-14**]
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a very pleasant 81 year
old white male with a history of coronary artery disease,
status post coronary artery bypass graft times one in [**2127**],
who has been followed by his cardiologist for heart murmur
over the past several years. On a routine physical
examination two weeks prior to admission, echocardiogram
revealed severe mitral regurgitation with flail leaflet. He
was referred for cardiac catheterization and then for redo
sternotomy, mitral valve replacement, with Dr. [**Last Name (STitle) **]. He
was complaining of increased fatigue and shortness of breath
on exertion over a several month period. He denied chest
pain or pressure. Cardiac echocardiogram on [**2139-6-8**], showed
posterior mitral valve prolapse with four plus mitral
regurgitation, moderate tricuspid regurgitation, moderate
biatrial enlargement, flail mitral valve prolapse posterior
leaflet. Cardiac catheterization on [**2139-6-15**], showed left
main 50 percent, left anterior descending coronary artery 40
percent, right coronary artery 40 percent, widely patent
functioning left internal mammary artery to the left anterior
descending coronary artery, dilated left ventricular
cardiomyopathy with an ejection fraction of 49 percent,
significant mitral regurgitation, mild to moderate pulmonary
hypertension.
PAST MEDICAL HISTORY: Coronary artery disease, status post
coronary artery bypass graft times one on [**2128-11-8**], with left
internal mammary artery to left anterior descending coronary
artery.
Hyperlipidemia.
Mitral regurgitation.
Diverticulitis.
Dilated cardiomyopathy.
Congestive heart failure.
Gastroesophageal reflux disease.
History of myocardial infarction.
Hard of hearing, left greater than right.
Prostate cancer, status post radiation treatment.
PAST SURGICAL HISTORY: Implantation of a dual chamber
permanent pacemaker four years ago.
Coronary artery bypass graft times one in [**2127**].
Left fourth finger surgery eight years ago.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.125 mg once daily.
2. Monopril 20 mg once daily.
3. Atenolol 25 mg once daily.
4. Zocor 10 mg once daily.
5. Multivitamin once daily.
6. Nitroglycerin sublingual p.r.n.
7. Maalox p.r.n.
PHYSICAL EXAMINATION: Vital signs revealed heart rate 61,
normal sinus rhythm, blood pressure 98/55, height six feet
four inches tall, weight 175 pounds. In general, an 81 year
old male in no acute distress, appearing stated age. Skin
well hydrated, no rashes or lesions. Head, eyes, ears, nose
and throat examination - The pupils are equal, round and
reactive to light and accommodation. Extraocular movements
are intact. Normal buccal mucosa. Full upper and lower
dentures. Neck is supple with no jugular venous distention,
question thyromegaly. Chest clear to auscultation
bilaterally. Sternum stable. Sternal incision is well
healed. The heart is regular rate and rhythm, S1 and S2,
positive III/VI murmur heard best at the apex radiating to
the left axilla. The abdomen is soft, nontender,
nondistended, normoactive bowel sounds. Extremities are
warm, no edema or cyanosis, varicosities on the right thigh
and right calf with some on the left calf as well.
Neurologically, cranial nerves II through XII are grossly
intact.
HOSPITAL COURSE: The patient was admitted on [**2139-7-8**], with
diagnosis of coronary artery disease, mitral regurgitation,
elevated cholesterol, congestive heart failure, dilated
cardiomyopathy. He underwent a redo sternotomy with mitral
valve replacement, number 31 porcine tissue valve, under
general anesthesia. Operating room course was uneventful
with cardiopulmonary bypass time of 76 minutes, cross clamp
time of 48 minutes, MAP up on transfer out of the operating
room, MAP was 67 and CVP 12, PAD 17. He was AV paced at a
rate of 88 per minute. He was transferred to the Intensive
Care Unit on a Dobutamine drip and Neo-Synephrine drip. The
underlying heart rhythm on transfer was a complete heart
block with junctional escape beats. He was extubated on the
evening of his operative day. Postoperative day number one
was significant for a 16 beat run of ventricular tachycardia
treated with Lidocaine and Magnesium. He continued to be AV
paced with an internal pacer with a rate of 87. Both his
Dobutamine and Neo-Synephrine have been weaned and his vital
signs are stable on no intravenous drip medications. On
postoperative day number two, there were no significant
events. The patient was seen by the electrophysiology
doctors [**First Name (Titles) **] [**Last Name (Titles) 28067**] of his pacemaker which showed that
he does need a new generator but his current pacer is
appropriate with occasional AV pacing at 61 necessary. He
was also on a small Neo-Synephrine drip at 0.5 for blood
pressure support which was weaned throughout the day on
postoperative day number two and off completely by
postoperative day number three. On postoperative day number
three, the patient was transferred to the inpatient floor for
recovery in stable condition. He continues to be AV paced at
times with an internal pacemaker with some occasional ectopy
and premature ventricular contractions. He was followed by
physical therapy throughout his hospital course and was found
to be safe for home by physical therapy on postoperative day
number five. On [**2139-7-13**], postoperative day number five, he
was transfused with one unit of packed red blood cells for a
hematocrit of 24.8. On postoperative day number six, the
patient was stable, ambulating independently in the hallways
and was discharged home with visiting nurses.
CONDITION ON DISCHARGE: On discharge, physical examination
revealed lungs were clear. Cardiovascular regular rate and
rhythm with no murmurs, rubs or gallops, occasional AV paced
with underlying sinus rhythm. Incision is clean, dry and
intact. Sternum is stable. Abdomen positive bowel sounds,
positive bowel movement. Laboratories on discharge revealed
white blood cell count 4.7, hematocrit 27.9, platelet count
119,000. Sodium 137, potassium 4.7, chloride 103,
bicarbonate 26, blood urea nitrogen 20, creatinine 0.9,
glucose 99. Chest x-ray on the day of discharge shows small
bilateral pleural effusions with atelectasis at bilateral
bases, no evidence of pneumothorax seen.
DISCHARGE STATUS: Home with visiting nurse.
DISCHARGE DIAGNOSES: Status post mitral valve replacement on
[**2139-7-8**].
Coronary artery disease, status post coronary artery bypass
graft in [**2127**].
Elevated cholesterol.
Congestive heart failure.
Dilated cardiomyopathy.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. twice a day times seven days.
2. Potassium Chloride 20 mEq twice a day for seven days.
3. Colace 100 mg p.o. twice a day.
4. Aspirin 325 mg once daily.
5. Vitamin C 500 mg twice a day.
6. Atenolol 25 mg once daily.
7. Percocet one to two tablets q4-6hours p.r.n.
8. Ferrous Sulfate 150 mg once daily.
FOLLOW UP: Appointment with Dr. [**First Name (STitle) 1356**] in one to two weeks.
Appointment with Dr. [**Last Name (STitle) 14522**] in two to three weeks,
cardiologist, for evaluation and plans for new battery in
pacemaker within one month. Follow-up also with Dr. [**Last Name (STitle) **]
in approximately four weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) 28068**]
MEDQUIST36
D: [**2139-7-14**] 17:00:18
T: [**2139-7-14**] 18:47:58
Job#: [**Job Number 28069**]
ICD9 Codes: 4240, 4280, 4254, 9971, 4271, 2859, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2495
} | Medical Text: Admission Date: [**2155-7-23**] Discharge Date: [**2155-7-24**]
Date of Birth: [**2101-10-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Chief complaint: acute renal failure, hyperkalemia
Reason for ICU admission: Hypotension not responsive to 4L NS
.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 1356**] is a 53 year old male with CAD s/p MI, HTN, type 2 DM,
PVD, who [**Known lastname 1834**] right groin exploration and femoral patch
redo last week who presented to clinic today with fatigue for
one week. He denies fevers, chills, nausea, vomiting, shortness
of breath, diarrhea, constipation, abdominal pain. He does
report significant surgical incision pain at right groin without
significant drainage. In addition, he reported one hour of chest
pressure several days ago while at rest which resolved and has
not recurred.
.
In the ED, vitals were T 98.1, 74/47, 69, 18, 100% on RA. He was
given 4LNS with only transient improvements of his blood
pressure. In the ED, his blood pressure 70s-90s/ 50s-60s. A fast
exam was performed in the ED and was negative. His bedside echo
was unremarkable. He was not given antibiotics.
.
Upon arrival to the MICU, patient denied chest pain,
lightheadedness, thirst, fevers, chills, dysuria, cough,
shortness of breath, diarrhea, or any other concerning symptoms.
Past Medical History:
CAD s/p MI
HTN
DM, Type 2
Hyperlipidemia
Peripheral Vascular Disease s/p L SFA stent/angioplasty [**8-26**]
Arthritis
Spinal spenosis
Chronic back pain
Bilateral knee surgery
S/p liver orthotopic liver [**Month/Year (2) **] for ETOH cirrhosis
Social History:
Patient is a retired cook. He smoked 2 PPD for 40 years, but has
since quit. He is a former alcoholic, but has been sober for 6
years
Family History:
Father died 42 years old from MI.
Physical Exam:
VS: HR 68, BP 118/60, RR 19, 96% on RA
Gen: NAD, well appearing
HEENT: EOMI, moist mucous membranes
CV: RRR, no m/r/g, distant heart sounds
Pulm: CTA b/l, no crackles, wheezes
Abd: obese, soft, NT, ND
Ext: severe right groin tenderness along the upper aspect of the
surgical incision, +warm, but no visible drainage, right sided
2+pitting edema
Neuro: AxOx3, moving all extremities
Pertinent Results:
[**2155-7-24**] 05:00AM BLOOD WBC-5.1 RBC-2.80* Hgb-8.3* Hct-25.6*
MCV-91 MCH-29.6 MCHC-32.5 RDW-14.8 Plt Ct-217
[**2155-7-23**] 02:35PM BLOOD WBC-5.8 RBC-2.97* Hgb-8.9* Hct-26.7*
MCV-90 MCH-29.8 MCHC-33.1 RDW-15.4 Plt Ct-266
[**2155-7-23**] 09:45AM BLOOD WBC-8.1 RBC-2.69* Hgb-8.3* Hct-24.6*
MCV-92 MCH-30.7 MCHC-33.5 RDW-15.1 Plt Ct-265
[**2155-7-24**] 05:00AM BLOOD Neuts-66.2 Lymphs-26.2 Monos-5.3 Eos-1.8
Baso-0.5
[**2155-7-23**] 02:35PM BLOOD Neuts-69.0 Lymphs-24.2 Monos-4.9 Eos-1.6
Baso-0.4
[**2155-7-24**] 05:00AM BLOOD Plt Ct-217
[**2155-7-24**] 05:00AM BLOOD PT-12.8 PTT-29.1 INR(PT)-1.1
[**2155-7-23**] 02:35PM BLOOD Plt Ct-266
[**2155-7-23**] 02:35PM BLOOD Plt Ct-266
[**2155-7-23**] 02:35PM BLOOD PT-13.0 PTT-28.4 INR(PT)-1.1
[**2155-7-23**] 09:45AM BLOOD Plt Ct-265
[**2155-7-24**] 03:46PM BLOOD UreaN-28* Creat-2.1* Na-137 K-5.3*
Cl-109* HCO3-21* AnGap-12
[**2155-7-24**] 05:00AM BLOOD Glucose-56* UreaN-30* Creat-2.1* Na-138
K-5.3* Cl-107 HCO3-21* AnGap-15
[**2155-7-23**] 10:44PM BLOOD Glucose-199* UreaN-34* Creat-2.2* Na-136
K-5.3* Cl-108 HCO3-20* AnGap-13
[**2155-7-23**] 07:31PM BLOOD Glucose-181* UreaN-36* Creat-2.2* Na-136
K-5.9* Cl-109* HCO3-20* AnGap-13
[**2155-7-23**] 02:35PM BLOOD Glucose-147* UreaN-43* Creat-2.8* Na-135
K-5.5* Cl-103 HCO3-24 AnGap-14
[**2155-7-23**] 09:45AM BLOOD UreaN-40* Creat-2.7* Na-132* K-6.2* Cl-99
HCO3-24 AnGap-15
[**2155-7-24**] 05:00AM BLOOD ALT-17 AST-17 LD(LDH)-195 CK(CPK)-41
AlkPhos-36* TotBili-0.2
[**2155-7-23**] 02:35PM BLOOD ALT-19 AST-17 AlkPhos-45 TotBili-0.2
[**2155-7-23**] 09:45AM BLOOD ALT-20 AST-19 AlkPhos-43 TotBili-0.2
[**2155-7-23**] 02:35PM BLOOD Lipase-11
[**2155-7-24**] 05:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-7-24**] 05:00AM BLOOD Albumin-3.4 Calcium-8.6 Phos-3.2 Mg-2.2
[**2155-7-23**] 10:44PM BLOOD Calcium-8.2* Phos-2.7 Mg-1.6
[**2155-7-23**] 07:31PM BLOOD Calcium-7.5* Phos-2.9 Mg-1.6
[**2155-7-23**] 02:35PM BLOOD Albumin-3.8
[**2155-7-23**] 09:45AM BLOOD Albumin-4.1 Calcium-9.4 Phos-4.1 Mg-1.8
[**2155-7-23**] 09:45AM BLOOD tacroFK-5.4
[**2155-7-23**] 02:35PM BLOOD LtGrnHD-HOLD
[**2155-7-23**] 10:48PM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP
[**2155-7-23**] 02:36PM BLOOD Comment-GREEN TOP
[**2155-7-23**] 10:48PM BLOOD Lactate-1.2
[**2155-7-23**] 02:36PM BLOOD K-5.2
.
CXR-IMPRESSION: Normal chest radiograph
.
u/s groin-IMPRESSION: Hematoma without evidence for
pseudoaneurysm.
Brief Hospital Course:
Mr. [**Known lastname 1356**] is a 53 yo male with PVD, HTN, HL, CAD s/p MI, s/p
liver [**Known lastname **] for alcoholic cirrhosis, admitted to the MICU
for hypotension.
.
Hypotension. Patient had significant hypotension in the ED that
required 4L of NS to normalize, and patient is now normotensive
in the MICU. Perhaps hypotension is related to overdiruesis with
home lasix dose, and med effect from several antihypertensives,
however there is concern for early sepsis in this patient who is
immunosuppressed with cellcept and prograf. Patient has
significant right groin pain, making the surgical site the most
likely source of infection. Normal lactate is reassuring.
Significant blood loss is less likely given Hct is stable over
the past week. Another possibility is cardiac etiology of
hypotension given transient chest pressure several days ago, but
this seems less likely in the setting of unchanged EKG. PT
covered with vanco/zosyn overnight. He was switched to
bactrim/cipro in am. U/S showing hematoma but no sign of
abscess. Pt given IVF and home diuretics and anti-hypertensives
held with good effect. Home BP meds except ACEI and diuretic
were resumed upon discharge.
.
Acute Renal failure. Patient has baseline creatinine between 1.8
and 2, now with rising Creatinine to 2.8. He likely has
pre-renal ARF as it responded to 4LNS bolus, though it remains
above baseline. Prograf may be causing the elevated Cr as well,
but dose was lowered today. Cr returned to near baseline.
Prograf and cellcept continued.
.
Hyperkalemia. Likely secondary to renal failure and groin
hematoma resorption. No EKG changes. Pt got 2 doses of
kayexylate. He will have labs drawn in a few days and results
will be sent to his hepatologist. In addition, his baseline K is
around 5.
.
Right groin wound. Patient is s/p femoral graft removal and
replacement due to infection last week. Now with significant
wound tenderness. No clear evidence of drainage. U/S showing
small hematoma, no sign of abscess. Cilostazol 50mg [**Hospital1 **].
Per vascular, pt may stop the cipro and resume his normally
scheduled dosing of bactrim.
.
S/p Liver [**Hospital1 **]. Patient is s/p liver [**Hospital1 **] in [**2150**]
for alcoholic cirrhosis. Currently on prograf and cellcept.
Prograf dose reduced today from 5 mg [**Hospital1 **] to 4 mg [**Hospital1 **].
Immunosuppressants continued. Bactrim ppx continued.
.
CAD s/p MI. Patient has EKG without ischemic change. S/p chest
pressure 4 days ago.
- consider echo if not clear source of hypotension
.
HTN.
- hold home antihypertensives (Lisinopril, atenolol, nifedepine)
.
DM, Type 2.
- NPH and ISS
- follow fingersticks
.
Hyperlipidemia.
- continue lipitor
.
Peripheral Vascular Disease s/p L SFA stent/angioplasty [**8-26**]
Cilostazol 50 mb [**Hospital1 **]
- vascular following
.
Medications on Admission:
Fosamax 70 mg weekly
Atenolol 50 mg daily
Lipitor 40 mg daily
Cilostazol 50 mb [**Hospital1 **]
Cipro 500 q 12 hours
Nexium 40 mg daily
Tricor 145 mg daily
Lasix 20 mg every other daily
Hydromorphone 2-4 mg q 4-6 hours
NPH 48 q am, 28 qpm with HISS
Lisinopril 5 mg daily
Cellcept [**Pager number **] mg [**Hospital1 **]
Nifedipine 30 mg daily
Viagra prn
Tacrolimus 4 mg [**Hospital1 **]
Detrol LA 4 mg [**Hospital1 **]
Trazodone 100 mg prn insomnia
Bactrim [**Hospital1 **]
Aspirin 325 daily
Calcium Carbonate 1500 [**Hospital1 **]
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for PVD.
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
6. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
10. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours.
14. Nifedipine 30 mg Tablet Extended Rel 24 hr (2) Sig: One (1)
Tablet Extended Rel 24 hr (2) PO once a day.
15. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO twice a day.
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: see
below Subcutaneous twice a day: 48 units qam
28 units qpm.
17. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous as directed.
18. Outpatient Lab Work
chemistry panel, including potassium. to be done [**7-26**].
Fax results to Patient Phone: ([**Telephone/Fax (1) 1582**] Patient Fax:
([**Telephone/Fax (1) 12173**]
Discharge Disposition:
Home
Discharge Diagnosis:
Major:
hypotension due to hypovolemia
acute renal failure
hyperkalemia
.
s/p R.femoral vascular surgery
s/p liver [**Telephone/Fax (1) **]
Discharge Condition:
stable
Discharge Instructions:
You were admitted for low blood pressure and fatigue. For the
low blood pressure you were given IVF and your home diuretics
were stopped. Your low blood pressure resolved. You also were
evaluated by the vascular surgery team and [**Telephone/Fax (1) 1834**] a groin
ultrasound that showed a small hematoma but no evidence of
infection or aneurysm. In addition, you had mild renal failure
that resolved with the above treatments.
.
You should not take your lasix or lisinopril until you see your
liver doctor. However your other blood pressure medications,
atenolol and nifedipine should be resumed upon discharge.
.
You should see your liver doctor within 1 week of discharge.
.
Please continue to take you medications as prescribed and follow
up with the appointments below.
.
You also had elevated blood potassium. For this you were given a
dose of kayexylate. You should be sure to have this blood level
checked either at your PCP or liver doctor's office within 2
days.
.
Followup Instructions:
Please make sure you follow up the liver service within 1 week
of discharge.
.
Please also be sure to follow up with your PCP.
.
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2155-7-31**] 4:00
.
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2155-8-19**] 10:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2155-8-19**] 10:00
ICD9 Codes: 5849, 2767, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2496
} | Medical Text: Admission Date: [**2150-8-10**] Discharge Date: [**2150-8-21**]
Date of Birth: [**2095-9-11**] Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Optiray 350
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54F with metastatic melanoma presenting with fatigue. Pt reports
she was seeing her [**First Name3 (LF) 3390**] yesterday and felt extremely fatigue and
generally unwell. Pt referred to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for IVF. In [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], stool guiac positive. Hct found to be 25. Pt transferred to
[**Hospital1 18**] for further mgmt. Pt denies pain. Recently admitted
[**Date range (1) 62150**] with pleuritic chest pain and also had issues with n/v
during that admission. Pt discharged on regimen of PO reglan and
zofran. She reports nausea pretty well controlled. Reports last
emesis >1wk ago. Reports relatively poor PO intake with liquids
> solid foods. Denies CP, SOB, lightheadedness. Denies urinary
symptoms. Reports baseline constipation, last BM 3 days ago
which was loose. Pt denies evidence of blood in stool or with
BMs. This morning, pt reports feeling relatively better. Denies
pain.
Past Medical History:
PAST MEDICAL HISTORY:
Metastatic melanoma with known lung metastases
Hypopituitarism secondary to ipilimumab tx
Diabetes Mellitus Type 2
Hypertension
Atrial fibrillation s/p ablation [**2149-2-5**]
h/o DVT &PE s/p IVC filter [**2144**]
h/o catheter-associated IJ thrombus [**2150-2-11**]
s/p Cholecystectomy
s/p tonsillectomy
s/p C-section
Thyroid nodule
Osteoporosis
Vitamin D deficiency
PAST ONCOLOGIC HISTORY:
- [**2140**]: diagnosed with right shoulder melanoma
- [**2145-3-21**]: presented with hemoptysis, bilateral DVT, PE, lung
mass biopsy revealed metastatic melanomam. IVC filter placement.
- [**2145-5-21**]: underwent chemotherapy. Disease progression noted.
- [**2145-9-20**]: enrolled in MDX-010/ipilimumab study
- [**2146-5-22**]: CT evidence of disease progression with enlarging
right paratracheal and retrocaval nodes
- [**2146-6-21**]: restarted MDX-010, completing 3 cycles of therapy.
Follow-up CTs showed minimal interval progression
- [**2147-9-21**]: began ipilimumab on compassionate access trial,
found to have autoimmune hypophysitis [**1-22**] ipilimumab and
protocol was subsequently discontinued. She was found not to
have the specific BRAF mutation.
- [**2148-3-21**]: started phase 1 RAF265 clinical trial with dose
reduction x2 for nausea, vomiting and neuropathy.
- [**2149-2-5**]: therapy held due to atrial flutter unrelated to
study drug, requiring cardiac ablation on [**2149-2-11**]. Drug
could not be restarted. She was taken off study on [**2149-2-19**].
- [**2149-3-12**]: started trial of sorafenib and bortezomib.
Completed 6 cycles of therapy.
- [**2149-12-1**]: CT showed disease progression with peritracheal
pleural-based and retroperitoneal metastatic foci with several
new right pleural and diaphragmatic foci. Treatment options
were discussed and high-dose IL-2 was chosen given the small
chance of a durable complete response. She passed eligibility
testing with PFTs notable for FEV-1 1.66 or 71% predicted.
- [**0-0-0**]: Admitted for first cycle of IL-2. She
received [**8-4**] doses on week 1, complicated by tachycardia and
pulmonary edema.
- [**2150-2-11**] - [**2150-2-14**]: Admitted with left neck pain, found to have
catheter-associated IJ thrombus, treated with Lovenox
Social History:
Married, lives in [**Hospital1 392**]. She has 3 adult children. She used
to do clerical work but has not recently been employed. Remote
smoking history. No history of EtOH abuse, no drug use.
Family History:
Mother had breast cancer and died of PE at age 62. Father died
of an MI at 61. One brother with a dx of melanoma, which was
completely excised.
Physical Exam:
Admission PE:
Vitals: 98.1, 100-110s, 120s/50-60s, 18, 95-99% RA
GENERAL: pleasant obese woman, lying in bed, in NAD
HEENT: PERRLA, anicteric sclera, dry membranes
CARDIAC: regular rhythm, tachycardic to 100s
LUNG: bibasilar inspiratory rales, otherwise CTAB, no wheezes or
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: obese, soft, nondistended, +BS, nontender
EXTREMITIES: moving all extremities well, no LE edema, no
obvious deformities
NEURO: grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge PE:
Physical Exam:
Vitals: Tmax 98.3, 102/70, P101 96% RA BS 117-190
GENERAL: pleasant obese woman, lying in bed, in NAD
CARDIAC: regular rhythm, tachycardic to 117s
LUNG: Good air movement bilaterally, no wheezes or rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: obese, soft, nondistended, +BS, mild RUQ tenderness.
RLQ superficial firmness that is tender. normoactive BS.
EXTREMITIES: moving all extremities well, trace symmetric LE
edema, no obvious deformities
NEURO: grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs:
[**2150-8-10**] 06:40PM WBC-9.9 RBC-3.28* HGB-9.3* HCT-29.2* MCV-89
MCH-28.2 MCHC-31.7 RDW-14.4
[**2150-8-10**] 06:40PM NEUTS-74.5* LYMPHS-19.9 MONOS-4.5 EOS-0.8
BASOS-0.4
[**2150-8-10**] 06:40PM PLT COUNT-477*
[**2150-8-10**] 06:40PM PT-12.3 PTT-33.7 INR(PT)-1.1
ENDOCRINE
[**2150-8-18**] 07:00AM BLOOD TSH-1.3
[**2150-8-18**] 07:00AM BLOOD Free T4-1.3
[**2150-8-18**] 07:00AM BLOOD Cortsol-7.2
Discharge Labs:
[**2150-8-18**] 07:00AM BLOOD WBC-8.8 RBC-3.03* Hgb-8.5* Hct-26.3*
MCV-87 MCH-28.1 MCHC-32.3 RDW-15.3 Plt Ct-311
[**2150-8-18**] 07:00AM BLOOD Glucose-60* UreaN-11 Creat-0.8 Na-137
K-4.3 Cl-96 HCO3-26 AnGap-19
IMAGING:
MRI Head [**2150-8-18**]: No findings to suggest metastatic disease to
the brain.
CT Abd/Pelv [**2150-8-19**]:
1. Overall, worsening disease burden with increase in right
lower lung pleural lesion with multiple new mesenteric nodules
as well as metastatic lesions within the ascending colon and
small bowel. No evidence of bowel obstruction.
2. Right paraaortic lesion is stable.
3. Soft tissue nodules in the anterior abdominal wall appear
smaller.
Brief Hospital Course:
HOSPITAL COURSE
54F with metastatic melanoma s/p treatment with ipilimumab with
complicating hypophysitis presenting with fatigue, nausea,
abdominal pain. Initially thought due likely secondary to
combination of anemia and dehydration from poor PO intake. Pt
recieved IVF and 1unit PRBC, but to minimal relief of symptoms
of nausea and fatigue. Patient also had intermittent low grade
fevers around 100.5 during admission initially thought to be
from atelectasis. Given hx of hypophysitis [**1-22**] previous
treatment with ipilimumab, AM Cortisol was drawn. It was found
to be low-normal. After consultation with outpatient
endocrinology it was agreed that cortisol response was
inadequate. Patient's prednisone was increased from 5mg to 10mg
to improvement of fatigue and nausea. During admission patient
was noted to have LLE DVT and started on subQ Lovenox. Anti-Xa
level was drawn after 3rd dose and found to be within range for
dosing. Patient was discharged on day 12 of hospitalization with
followup with Heme-Onc ([**2150-8-26**]), Endocrine ([**2150-8-25**]) and GI
([**2150-8-26**]).
ACTIVE ISSUES:
# FATIGUE/NAUSEA: Initially thought to be from combination of
dehydration and anemia. Did not improve markedly after IVF and
PRBC. MRI negative for brain metastases. Nausea was treated
with Zofran and Reglan. Patient has hypophysitis [**1-22**] previous
treatment with ipilimumab for metastatic melanoma. AM Cortisol
was drawn and found to be low normal. After consultation with
outpatient endocrinology it was agreed that cortisol response
was inadequate. Patient's prednisone was increased from 5mg to
10mg to improvement of fatigue and nausea.
# ABDOMINAL PAIN: Likely combination of progression of disease
and adrenal insufficiency. CT Abd/Pelv demonstrated multiple new
mesenteric nodules as well as metastatic lesions within the
ascending colon and small bowel with no evidence of bowel
obstruction. At discharge, patient's pain was controlled on
morphine.
# LOW GRADE FEVERS: Initially thought to be be related to
atelectasis; Had been unlikely that pt had PNA in setting of no
leukocytosis and no coughing. Pt was at high risk for PE, but
recent scans had been negative. No source of infection had ever
been found. After increase in prednisone dosage, intermittent
fevers resolved.
# LLE DVT: Found on LENI due to leg swelling. Initially treated
with Heparin gtt and then transitioned to Lovenox. Due to
patient obesity, Anti-Xa level was sent after third dose of
Lovenox and found to be within acceptable limits. Patient sent
out on twice daily Lovenox SubQ.
# DM: Patient came in on Levemir, which was changed over to
Lantus. However, BS were noted to be persistently low likely due
to decreased PO intake so Lantus was titrated downwards. After
resolution of nausea and lethargy, patient began to take POs
again and Lantus was again titrated. Patient was discharged with
followup with [**Hospital **] Clinic on [**2150-8-25**].
# SINUS TACH: Chronic baseline in 100-110s, with bursts to 140s
with minimal exertion during admission. Pt with h/o aflutter s/p
ablation seen by cardiology with persistent sinus tach on
diltiazem. Unclear origin but chronic tachy in 100-110s
documented >6months. Not much improvement after 1u pRBC
transfusion [**8-13**], so does not seem to be related to anemia. EKG
sinus without change from prior. No evidence of DVT and holding
off on CTA to r/o PE as pt had CTA a little over a week ago
negative for PE. Converted Diltiazem to PO metop tartrate with
somewhat better HR control, which was then transitioned to
succinate. Pt continued with HR in 100-110s on metop succinate
100mg QD.
# HYPOTENSION: One episode of SBPs down to 80s on [**8-13**], improved
to SBPs 90s-120s with better HR control and s/p small IVF
boluses.
# R PLEURAL EFFUSION: on CXR, likely in some part related to
known melanoma mets to the R lung. Seems most likely to have
atelectasis as well and seems less likely underlying infiltrate.
Pt was intermittently with small O2 requirements (up to 2L NC),
but easily weaned to RA with sats in mid to high 90s.
# CONSTIPATION: Despite bowel regimen of docusate, senna, and
miralax, patient was intermittently constipated throughout
admission. Patient sent home with prescriptions for docusate,
senna, miralax and lactulose.
# ANEMIA: Pt with new anemia since 6/[**2149**]. Prior Hb 10-12 range
without any evidence of anemia prior to 1/[**2149**]. Pt with Hb of 12
in [**5-/2150**], now with Hb stable in [**7-30**] range. Pt with guiac
positive stool per OSH report. Pt without hematochezia or
melena. Recent iron studies [**2150-7-28**] more c/w anemia of chronic
disease: iron mildly low with normal ferritin and low TIBC.
Unclear that this normocytic normochromic anemia would be from
blood loss via GI tract. Hemolysis labs unremarkable. Retic
count not elevated and seems more c/w anemia of inflammation.
Spoke with GI regarding scope for workup of possible
melanomatous mets to bowel as cause of guiac + stool and they
said that in setting of hemodynamic stability and stable H/H,
will set up with OP f/u with GI first in clinic and then to get
scope. S/p 1u pRBCs [**8-13**]. H/H stable after transfusion.
INACTIVE ISSUES:
# Metastatic melanoma: no current treatment. Communicated with
OP onc team and discharged with followup with Heme/Onc on
[**2150-8-26**].
# Neuropathy: chronic likely [**1-22**] chemotherapy, continued
neurontin
# GERD: continued ranitidine
TRANSITIONAL ISSUES:
# [**Month/Day (2) 269**] to visit patient for Lovenox teaching
# f/u with GI for clinic evaluation in order to set up scope to
evaluate of intestinal mets from melanoma as cause of guiac +
stool ([**2150-8-26**]).
# f/u with OP oncologist, Dr. [**Last Name (STitle) **] ([**2150-8-26**])
# f/u with endocrine re: hypophysitis with adrenal insufficiency
([**2150-8-25**])
# f/u with [**Last Name (un) **] re: insulin dosage.
# Pt's iron supplementation discontinued on discharge as it was
contributing to significant constipation and pt's anemia workup
seems most c/w anemia of chronic disease so iron supplementation
unlikely to help.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN pain
2. Calcium Carbonate 500 mg PO DAILY
3. Diltiazem 60 mg PO TID
plesae hold for HR<60
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 900 mg PO TID
6. Metoclopramide 10 mg PO QAC/HS PRN nausea
7. Mirtazapine 45 mg PO HS
8. Multivitamins W/minerals 1 TAB PO DAILY
9. PredniSONE 5 mg PO DAILY
10. Pyridoxine 50 mg PO DAILY
11. Ranitidine 150 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. Senna 1 TAB PO BID constipation
hold if has loose bowel movement
14. Polyethylene Glycol 17 g PO DAILY
hold if has loose bowel movement
15. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting
16. Morphine SR (MS Contin) 15 mg PO Q12H for pain
not taking
17. Morphine Sulfate IR 7.5-15 mg PO Q6H:PRN breakthrough pain
not taking, but has
18. Ferrous Sulfate 325 mg PO DAILY
19. detemir 34 Units Bedtime
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 900 mg PO TID
4. Metoclopramide 10 mg PO QAC/HS PRN nausea
5. Mirtazapine 45 mg PO HS
6. Polyethylene Glycol 17 g PO DAILY
hold if has loose bowel movement
7. Pyridoxine 50 mg PO DAILY
8. Ranitidine 150 mg PO BID
9. Senna 1 TAB PO BID constipation
hold if has loose bowel movement
10. Vitamin D 1000 UNIT PO DAILY
11. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN pain
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting
14. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
15. Enoxaparin Sodium 120 mg SC Q12H
RX *enoxaparin 120 mg/0.8 mL Inject one syringe subcutaneous
every twelve (12) hours Disp #*60 Syringe Refills:*2
16. detemir 20 Units Bedtime
17. Lactulose 30 mL PO BID:PRN constipation
RX *lactulose 10 gram/15 mL 30 mL by mouth [**Hospital1 **]:PRN Disp #*30
Container Refills:*0
18. Morphine Sulfate IR 7.5-15 mg PO Q6H:PRN breakthrough pain
RX *morphine 15 mg 0.5-1 tablet(s) by mouth q6h:PRN Disp #*60
Tablet Refills:*0
19. PredniSONE 10 mg PO DAILY
RX *prednisone 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Adrenal insufficiency
Secondary diagnosis:
Metastatic melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 4886**],
It was a pleasure taking care of you in the hospital. You were
admitted with fatigue. Initially, we had thought this was
partially from dehydration and in part from your anemia. We gave
you one unit of blood and fluids. You had issues with a fast
heart rate during your hospital stay, although this seems to be
a chronic issue. We changed your diltiazem to metoprolol to
better control this.
Despite these treatments, you continued to feel vague symptoms
of nausea, abdominal pain and fatigue. We did a test to measure
a hormone called cortisol and found it to be relatively low.
When we increased your prednisone (which acts in a similar way
to cortisol), your symptoms seemed to dramatically improve.
During your stay, you also developed a blood clot in your left
leg. We are treating this with the blood thinner Lovenox, which
is the injection you are receiving in your abdomen.
Your blood sugars were running low while you were here, so we
decreased your Levemir dosing to 20u at night (instead of 34u).
Please check your blood sugars three times a day and bring these
numbers to your [**Last Name (un) **] provider at your [**Name9 (PRE) 702**] appointment.
If your sugars are >200 but <300, you can increase your levemir
to 24u, if they're >300 but <400 you can increase to 28u, and if
they're >400 you should return to 34u. If your sugars are lower
than 80 you should decrease your dose to 18.
With improvement of your fatigue, abdominal pain and nausea, we
discharged you on day 12 of your hospital stay.
Please follow-up at the appointments listed below. You should
see your endocrinologist ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) to adjust your
prednisone as needed. We would like you to see the GI doctors to
possibly get a colonoscopy because of the positive test for
blood in your stool.
Please see the attached list for any changes to your home
medications.
Followup Instructions:
Department: Endocrinology, [**Last Name (un) **] Diabetes Center
Name: Dr. [**First Name4 (NamePattern1) 2398**] [**Last Name (NamePattern1) **]
When: Tuesday [**2150-8-25**] at 3:30 PM
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2150-8-26**] at 9:00 AM
With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], 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: MEDICAL SPECIALTIES
When: FRIDAY [**2150-9-4**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2150-8-26**] at 2:30 PM
With: [**Year (4 digits) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**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: WEDNESDAY [**2150-8-26**] at 2:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) 7880**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Cardiology
Appt: [**2150-8-31**] 11:20a
With: [**Doctor Last Name **]
Where: SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Completed by:[**2150-8-21**]
ICD9 Codes: 5789, 2851, 4589, 5180, 4019, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2497
} | Medical Text: Admission Date: [**2133-7-13**] Discharge Date: [**2133-7-16**]
Date of Birth: [**2114-11-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
motorcycle accident
Major Surgical or Invasive Procedure:
none
History of Present Illness:
18M s/p motorcycle collision. Pt was accelerating, "popped a
wheelie" and was thrown from m/c. Pt was wearing full face
helmet. GCS 15 on arrival. CT scans showed extensive left sided
pulmonary contusions, grade 5 splenic laceration, left
clavicular/scapular fx, and mild hemoperitoneum.
Past Medical History:
PMH: none
PSH: none
[**Last Name (un) 1724**]: none
Social History:
Smokes ~1ppd, rare EtOH
Family History:
non-contributory
Physical Exam:
On admission in the trauma bay:
T 99.2, HR 100, BP 145/86, RR 18, O2Sat 98%RA
GEN - NAD, A&O
HEENT - pupils 2mm and PERRL
CVS - tachy, regular
PULM - CTAB, chest symmetric, no crepitus
ABD - soft, nondistended, +LUQ tenderness; FAST exam negative
EXTREM - warm/dry, no edema, no deformities; L shoulder pain and
decreased ROM but 5/5 strength and sensation in all extremities
On discharge:
T 97.8, HR 92, BP 140/70, RR 18, O2Sat 97%RA
GEN - NAD, A&Ox3
CVS - RRR, no M/R/G
PULM - coarse breath sounds b/l with rhonchi in bilateral lower
lung fields bilaterally
ABD - minimal LUQ tenderness, soft, nondistended
EXTREM - warm/dry, no C/C/E; LUE in sling; 5/5 strength &
sensation in all extremities
Pertinent Results:
[**2133-7-13**] 02:20AM BLOOD WBC-25.8* RBC-5.17 Hgb-15.2 Hct-43.6
MCV-84 MCH-29.4 MCHC-34.8 RDW-13.1 Plt Ct-212
[**2133-7-13**] 04:56AM BLOOD Hct-41.1
[**2133-7-13**] 09:59AM BLOOD Hct-37.7*
[**2133-7-13**] 04:31PM BLOOD Hct-37.1*
[**2133-7-13**] 10:20PM BLOOD Hct-36.5*
[**2133-7-14**] 03:47AM BLOOD WBC-11.5*# RBC-4.24* Hgb-12.4* Hct-35.8*
MCV-85 MCH-29.3 MCHC-34.6 RDW-12.9 Plt Ct-162
[**2133-7-14**] 09:40PM BLOOD Hct-35.2*
[**2133-7-15**] 09:15AM BLOOD WBC-10.9 RBC-4.24* Hgb-12.3* Hct-36.4*
MCV-86 MCH-28.9 MCHC-33.7 RDW-12.9 Plt Ct-184
[**2133-7-13**] 02:20AM BLOOD PT-14.2* PTT-24.3 INR(PT)-1.2*
[**2133-7-14**] 03:47AM BLOOD Glucose-105* UreaN-10 Creat-0.8 Na-139
K-3.8 Cl-105 HCO3-24 AnGap-14
[**2133-7-14**] 03:47AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9
IMAGING:
CXR [**2133-7-13**]: Overlying trauma board limits evaluation. Lung
volumes are low. Diffuse nodular and hazy opacity of the left
lung is most consistent with pulmonary contusions. There is no
pleural effusion or pneumothorax. Cardiomediastinal silhouette
is within normal limits. A left clavicular fracture is noted,
partially obscured by the trauma board. There is marked gaseous
distension of the stomach.
CT Torso [**2133-7-13**]:
IMPRESSION:
1. Shattered spleen extending to the hilum, consistent with
grade V splenic injury with surrounding small amount of
hemoperitoneum which is also seen within the right and left
paracolic gutters.
2. Extensive pulmonary contusion of the left lung with multiple
pneumatoceles.
3. Areas of ground-glass density within the right lower lobe,
which may also represent contusion versus aspiration.
4. Large distended fluid-filled stomach for which NG tube
placement is
recommended.
5. Left clavicular and left scapular fracture.
XR L clavicle & scapula [**2133-7-13**]:
IMPRESSION:
1. Left mid clavicle displaced fracture.
2. Incompletely evaluated left lung opacities, as above.
Brief Hospital Course:
The patient was admitted to the ACS surgery service under Dr.
[**Last Name (STitle) **].
His hospital course is as follows by systems:
NEURO - The patient's pain was initially difficult to control.
He received IV narcotics but still had significant pain and
splinting. The Acute Pain Service was consulted by the ICU team
and they placed an epidural a started a PCA. Later when
tolerating good POs, his epidural was discontinued and he was
transitioned to oral pain medications with adequate pain
control.
CVS - Due to the patient's extensive splenic laceration, his
hemodynamics were monitored closely in the ICU for 2 days. He
remained hemodynamically stable during his hospital stay. There
were no other issues.
PULM - Because the patient sustained extensive bilateral
pulmonary contusions, his respiratory status was monitored
closely. Aggressive pulmonary toilet and IS use was
encouraged/implemented and he was gradually weaned off of
supplemental oxygen. He had no further respiratory problems.
FEN/GI - Because of the severity of the patient's splenic lac,
he was admitted to the ICU and made NPO and maintained on IV
fluids. His activity level was restricted to bedrest. He was
allowed to eat on HD2 and he tolerated his diet well. He stayed
on bedrest in the TSICU until HD2 and was then transferred to
the floor. His activity level was then liberalized on HD3 and he
was able to ambulate independently without problems. GI
prophylaxis with famotidine was implemented until the patient
was tolerating good POs, upon which it was discontinued.
GU - The patient's urine output was monitored closely with a
Foley catheter. His urine output remained adequate and the foley
was discontinued on HD3 after the epidural was discontinued. He
was able to void without problems.
HEME - Serial hcts were stable and the patient did not require
transfusions.
ID - The patient's initial WBC on admission was 25.8. This
normalized to 10.9 by HD3. He remained afebrile and there was no
evidence of any infectious problems.
ENDO - no issues
MUSCULOSKELETAL - The orthopedics service was consulted for the
patient's clavicular fracture. Their recommendations were to
apply a sling for comfort for 2 weeks and follow up as an
outpatient in [**2-17**] weeks.
Medications on Admission:
none
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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
splenic laceration
left clavicle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**3-23**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Continue to wear your sling for at least 2 weeks.
Continue to take stool softeners and drink plenty of fluids
while on narcotics to prevent constipation
AVOID VIGOROUS ACTIVITY, ESPECIALLY CONTACT SPORTS UNTIL YOU ARE
SEEN IN [**Hospital **] CLINIC!
Followup Instructions:
Please call ([**Telephone/Fax (1) 2537**] to schedule a follow-up appointment
in [**12-17**] weeks the Acute Care Surgery clinic.
Please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ [**Telephone/Fax (1) 1228**] to schedule a
follow-up appointment with Dr. [**Last Name (STitle) 1005**] (orthopedics) in [**2-19**]
weeks.
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2498
} | Medical Text: Admission Date: [**2139-2-26**] Discharge Date: [**2139-3-17**]
Service: SURGERY
Allergies:
Sulfonamides / E-Mycin
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal pain: The patient was admitted to [**Hospital1 18**] for
acute-on-chronic cholecystitis with cholelithiasis.
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy [**2139-2-27**].
[**Last Name (un) 1372**]-intestinal tube (dobhoff) placement [**2139-3-3**].
[**Last Name (un) 1372**]-intestinal tube (dobhoff) repositioning [**2139-3-16**].
History of Present Illness:
The patient is an 86 yo F with a history of MRSA cholecystitis
s/p cholecystostomy tube on [**2-1**] which subsequently "fell out"
while inhouse but was not replaced as the patient's clinical
status had improved. The patient was discharged to a
rehabilitation facility on vancomycin via a PICC Line
complicated by a (L)UE DVT now on anticoagulation therapy. She
was brought to [**Hospital1 18**] on [**2-26**] with a two-day history of nausea
and vomiting of stomach contents of food and fluids.
Past Medical History:
Hypertension, diverticulitis, lactose intolerance, glaucoma,
right L5 radiculopathy, DJD, C. difficile colitis, Atrial
fibrillation, MRSA cholecystitis.
Social History:
Lives in [**Location (un) **] alone, her daughters live in the same
building. [**Doctor First Name 5464**], contact number [**Telephone/Fax (1) 102135**]. [**Name2 (NI) 4084**] smoked,
denies any EtOH use. Has VNA who comes in 2 days/week.
Family History:
Brothers with diabetes
Physical Exam:
Upon discharge:
VS: T: 98.0 PO, BP: 184/94, HR: 88, RR: 20, SaO2: 96% RA
GEN: Elderly female very sleepy today but easily arousable. In
NAD.
HEENT: Dubhoff in place in (R) nare. Sclerae anicteric. O-P
intact.
NECK: Supple. No lymphadenopathy.
CV: Irregularly, irregular no m/r/g
Resp: CTA b/l anteriorly
Abd: soft NT/ND
EXT: Anasarcic upper and lower extremities but improving,
patient has Ace wraps in place for her LE edema
Neuro: sleepy today but able to answer questions appropiately.
Pertinent Results:
[**2139-3-16**] 05:10AM BLOOD WBC-10.6 Hct-26.1*
[**2139-3-15**] 04:53AM BLOOD WBC-11.2* RBC-3.17*# Hgb-8.8*# Hct-27.0*
MCV-85 MCH-27.8 MCHC-32.5 RDW-15.7* Plt Ct-1031*
[**2139-3-2**] 06:52AM BLOOD WBC-15.0* RBC-2.88* Hgb-8.0* Hct-24.7*
MCV-86 MCH-27.8 MCHC-32.4 RDW-14.6 Plt Ct-431
[**2139-2-26**] 01:00AM BLOOD WBC-9.3 RBC-3.62* Hgb-10.0* Hct-30.7*
MCV-85 MCH-27.5 MCHC-32.4 RDW-14.7 Plt Ct-644*
[**2139-3-16**] 05:10AM BLOOD PT-22.6* PTT-26.3 INR(PT)-2.2*
[**2139-2-26**] 01:00AM BLOOD PT-33.8* PTT-32.2 INR(PT)-3.5*
[**2139-3-16**] 05:10AM BLOOD Glucose-115* UreaN-23* Creat-1.4* Na-142
K-3.5 Cl-99 HCO3-37* AnGap-10
[**2139-2-26**] 01:00AM BLOOD Glucose-102 UreaN-10 Creat-0.6 Na-141
K-3.5 Cl-104 HCO3-26 AnGap-15
[**2139-3-16**] 05:10AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.5*
[**2139-2-28**] 04:19AM BLOOD Calcium-7.8* Phos-3.2 Mg-0.9*
[**2139-3-11**] 05:50AM BLOOD calTIBC-153* VitB12-1035* Folate-11.5
Ferritn-297* TRF-118*
.
ECHO [**3-10**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60%). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with borderline normal free wall function. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. 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 to moderate ([**12-12**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion
Brief Hospital Course:
OPERATIONS DURING ADMISSION
[**2-27**] Laparoscopic Cholecystectomy
CONSULTATIONS DURING ADMISSION
Geriatrics
Neurosurgery
Speech/swallow
Infectious Disease
BRIEF HOSPITAL COURSE BY PROBLEM
1. Acute on chronic cholecystitis: The patient was admitted to
[**Hospital1 18**] as mentioned above with concerns for acute-on-chronic
cholecystitis. She underwent a RUQ Ultrasound and a HIDA Scan,
both of which had results concerning for acute-on-chronic
cholecystitis.
She thus had PICC line placed on [**2-27**] and was started on IV
antibiotics. On [**2-27**] she was taken to the operating room where
she underwent a laparoscopic cholecystectomy. The procedure was
uneventful, she was extubated in the OR, and brought to the
floor after an uneventful stay in the PACU.
On [**3-1**] she triggered for poor UOP; she was started on diuresis
and thought to be in acute renal failure. her JP drain was
removed. Infectious disease was consulted for antibiotic
advice; they recommended either discontinuing antibiotics,
monitoring clinically and checking blood cultures off
vancomycin, or continuing empiric antibiotic therapy, but
re-scan abdomen and follow labs. The later course was followed
ultimately with IV Vanco and Zosyn continued until [**2139-3-10**], when
all antibiotics were finally discontinued.
2. Post-operative Delerium: Unfortunately, the patient's
postoperative recovery was complicated by prolonged delerium.
Geriatrics was consulted on 3/22to help manage her delerium.
This most likely occurred in the setting of acute renal failure.
They recommended to hold her gabapentin, hold her prozac, give
PRN haldol for delirium, f/u nutrition labs and amylase/lipase.
3. Acute renal failure: In the setting of postoperative
period; resolved.
4. Aspiration: The patient was seen multiple times by speech
and swallow for concerns with aspiration. On [**3-12**] they advanced
her diet to soft diet, 1:1 supervision, alternate sips w/food.
Unfortunately, the patient has very little appetite. She had a
dophoff feeding tube placed and was advanced to goal tube feeds
of 45 cc/hr and is tolerating that rate, though with some
diarrhea from the tube feeds and initially with nausea and
vomiting that required decreasing or holding her tube feeds
initially, and then restarting them back. Patient went to IR to
have dobhoff repositioned post-pyloric. She tolerated the tube
feeds without nausea or vomiting since dobhoff repositioned.
5. T12/L1 fracture: The patient had a known T12/L1/
compression fracture. She was seen by neurosurgery for help in
management; initially on [**3-10**] they recommended a TLSO brace, but
then when they saw the patient again on [**3-12**] they decided that
she did not need the TLSO brace as the compression factures were
stable on XR.
6. DVT: The patient was admitted with a known DVT of her LUE.
Her INR was initially supratherapeutic, and so her coumadin was
dosed daily until her INR became therapeutic once again.
7. Anasarca: The patient developed increasing anasarca
throughout her hospital stay; this is most likely secondary to
poor nutritional status in the setting of illness, though she
does have some valvular heart disease on Echo, documented on
[**3-10**]. She was placed in [**Male First Name (un) **] hose, which she did not tolerate,
then her legs were wrapped with ACE bandage, and she was started
on a gentle dose of diuresis. ACE bandages applied alternating
Q8Hours on with Q4Hours off.
8. Anemia: The patient was noted to be anemic throughout her
hospital stay. This is likely a combination of chronic disease,
acute blood loss anemia. She received a transfusion of 1 UPRBC
on [**2139-3-14**] with appropriate increase in HCT. Her stools were
guaiaced; a single hemocult was positive on [**3-16**].
9. Thrombocytosis: The patient also developed a worsening
thrombocytosis of unclear etiology.
10. Throughout her stay, the patient was followed by both
physical therapy and Speech/Language Pathology.
11. Code Status: DNR/DNI confirmed by daughter [**2139-2-28**].
On [**2139-3-17**], the patient was doing well, afebrile with stable
viral signs. The patient was tolerating dobhoff tube feeds at
goal with minimal PO intake, voiding with assistance, and pain
was well controlled. A standard PIV was placed, and the CVL
discontinued. The patient was discharged to the skilled nursing
facility East Point in [**Location (un) **], Mass.
Medications on Admission:
Zantac 20 Po daily, Gabapent 100 PO TID, HCTZ 12.5 PO QAM,
Latanoprost 0.005%
1 gtt to each eye [**Last Name (LF) **], [**First Name3 (LF) **] 81 PO daily, Coumadin 2.5 PO daily,
Lopressor 25 Po BID, Prozac 10 PO daily, Colace, Senna, Dulcolax
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
6. Xopenex 0.63 mg/3 mL Solution for Nebulization Sig: One (1)
neb Inhalation Q4-6 HOURS PRN.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever or pain.
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO QSUNMONWEDFRI
().
15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO QTUETHUSAT ().
16. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Zofran 4 mg Tablet Sig: One (1) Tablet PO TID PRN.
18. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection
Subcutaneous ASDIR (AS DIRECTED): As directed per Humalog
Insulin Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
1. MRSA Enterococcus acute on chronic cholecystitis
2. Post-op delerium
3. History of (L)UE DVT on Coumadin
4. Anemia
5. Ansarca
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day with assistance, and drink adequate amounts of fluids.
Avoid lifting weights greater than [**4-19**] lbs until you follow-up
with your surgeon.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment
with Dr. [**First Name (STitle) 2819**] (Surgery) in [**1-13**] weeks.
Please call ([**Telephone/Fax (1) 17909**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) 172**] (PCP) in 2 weeks.
Completed by:[**2139-3-17**]
ICD9 Codes: 2930, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2499
} | Medical Text: Admission Date: [**2132-3-17**] Discharge Date: [**2132-4-1**]
Service: CARDIOTHORACIC
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
coming for aspirin desensitization prior to cath, found to have
LMand 3VD referred for CABG
Major Surgical or Invasive Procedure:
[**3-17**] Cardiac catheterization
[**3-20**] CABG x 4 (LIMA->LAD, SVG->OM, SVG->L PLV, SVG->PDA)
History of Present Illness:
This is a 83 y/o M with h/o BPH, HTN, carotid stenosis who
presents for aspirin desensitization prior to cardiac cath after
positive MIBI.
Of note patient was referred to Dr [**First Name (STitle) **] for evaluation of
peripheral vascular disease. [**2131-11-19**] he was going up
stairs to pick up his mail, then he had a flash of light and
fell. He may have lost consciousness for a short period of time.
During this fall he dislocated his right shoulder and fx his
left shoulder. He denied any chest pain, palpitations,
headaches, shortness of breath or any other symptoms associated
with the episode.
After being seen by Dr [**First Name (STitle) **], stress MIBI was performed that
showed Moderate, reversible defects of the distal anterior and
septal walls respectively in addition to left ventricular cavity
dilatation consistent with subendocardial ischemia consistent
with LAD territory.
He also had a carotid ultrasound that reported carotid stenosis
with velocities >200 specially on the left side.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
At cath patient was found to have 60% LM, occluded LAD, 80% LCx,
60-70% RCA. Pt also found to have L renal artery stenosis
Past Medical History:
PAST MEDICAL HISTORY:
Bilateral hernias
BPH
Hypertension
Recent syncopal episode with fall resulting in bilateral
shoulder and arm fractures. [**2131-10-31**]
Peripheral vascular disease,
Carotid artery stenosis.
Social History:
Married. Lives with his wife. Distant history of smoking chewing
tobacco. Alcohol occasionally. Initially work in construction.
He has 5 children
Family History:
Mother with DM. No history of premature heart disease or sudden
death.
Physical Exam:
Admission
BP 159/64 HR 56 RR 16 Sats 96 % on RA
General: well developed, pleasant, well nourished. Oriented to
person, place and time.
HEENT: pupils equal and reactive to light. External ocular
movements preserved. No JVD appreciated. no thyromegaly. Moist
oral mucosa.
+ Left side carotid bruit.
Lungs: occasional crackles in both bases.
Cardiovascular. Palpation of PMI showed to be located in the 5th
intercostal space, mid clavicular line. Regular rate and rhythm,
s1-s2 normal. Soft holosystolic murmur in the apex radiated to
the axilla. No S3 or S4 appreciated. No rubs.
Abdomen: BS+, soft non tender, non distended. obese. no
hepatomegaly appreciated.
Extremities: no clubbing, no cyanosis. 1+ lower extremity edema.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge
VS 97.8 HR 52SR BP150/56 RR 18 O2sat 92% RA
Gen NAD
Neuro A&Ox3 nonfocal exam
Pulm Clear but dim throughout
CV RRR no murmur. Sternum stable, incision CDI
Abdm soft, NT/ND/+BS
Ext warm 2+pedal edema bilat Skin multiple tears from tape
Pertinent Results:
[**2132-3-17**] 09:52PM WBC-9.8# RBC-3.44* HGB-10.9* HCT-32.0* MCV-93
MCH-31.8 MCHC-34.2 RDW-13.4
[**2132-3-17**] 09:52PM PLT COUNT-206
[**2132-3-17**] 09:27PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2132-3-17**] 06:00PM GLUCOSE-136* UREA N-21* CREAT-1.0 SODIUM-139
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-32 ANION GAP-8
[**2132-3-17**] 06:00PM ALT(SGPT)-11 AST(SGOT)-15 CK(CPK)-39 ALK
PHOS-59 AMYLASE-49 TOT BILI-0.5
[**2132-3-17**] 06:00PM ALBUMIN-3.4 CALCIUM-8.4 CHOLEST-146
[**2132-3-17**] 06:00PM PT-13.2* PTT-31.9 INR(PT)-1.1
[**2132-3-28**] 06:40AM BLOOD WBC-9.5 RBC-3.05* Hgb-9.1* Hct-28.8*
MCV-95 MCH-29.9 MCHC-31.7 RDW-13.7 Plt Ct-398
[**2132-3-28**] 06:40AM BLOOD Plt Ct-398
[**2132-3-25**] 02:55AM BLOOD PT-13.0 PTT-28.0 INR(PT)-1.1
[**2132-3-28**] 06:40AM BLOOD Glucose-104 UreaN-46* Creat-2.0* Na-141
K-4.6 Cl-103 HCO3-32 AnGap-11
CHEST (PA & LAT) [**2132-3-26**] 5:15 PM
CHEST (PA & LAT)
Reason: evaluate pleural effusion
[**Hospital 93**] MEDICAL CONDITION:
83 year old man s/p CABGx4
REASON FOR THIS EXAMINATION:
evaluate pleural effusion
PA AND LATERAL CHEST RADIOGRAPHS
INDICATION: Status post CABG, evaluate pleural effusion.
COMPARISON: Series of radiographs, most recent dated [**2132-3-22**].
FINDINGS: Again noted right internal jugular approach central
venous catheter device with the distal tip projected over the
right atrium. Cardiac silhouette is enlarged and mediastinum is
mildly widened, consistent with post-operative state, not
overtly changed from previous examination. Lung volumes are
improved on this study, however, still evident a left lower lung
atelectasis with moderate-sized left pleural effusion. Pulmonary
vascularity is normal.
IMPRESSION: Not significantly changed degree of left lower lobe
atelectasis and moderate-sized pleural effusion. Improved lung
volumes bilaterally.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
RENAL U.S. [**2132-3-24**] 10:08 AM
RENAL U.S.
Reason: Assess kidney's
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with ATN
REASON FOR THIS EXAMINATION:
Assess kidney's
INDICATION: 83-year-old with ATN assess kidneys.
RENAL ULTRASOUND: No prior studies for comparison. The right and
left kidneys measure 9.5 and 10.1 cm respectively. There is an
approximately 2cm exopohytic, hypoechoic mass off the mid to
lower pole of the right kidney, concerning for a neoplasm. No
other solid or cystic lesions. No hydronephrosis.
IMPRESSION:
1) 2-cm exophytic hypoechoic mass off the mid to lower pole of
the right kidney, concerning for malignancy; MRI is recommended
for further characterization.
2) No hydronephrosis. Cortical echogenicity is somewhat
difficult to evaluate but appears likely within normal limits.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
PATIENT/TEST INFORMATION: Echo
Indication: Intraoperative TEE for CABG procedure
Height: (in) 65
Weight (lb): 167
BSA (m2): 1.83 m2
BP (mm Hg): 145/78
HR (bpm): 56
Status: Inpatient
Date/Time: [**2132-3-20**] at 09:47
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aorta - Descending Thoracic: *2.8 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 7 mm Hg
Tricuspid Valve - Peak TS Velocity: 2.0 m/sec
TR Gradient (+ RA = PASP): >= 17 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Low normal
LVEF. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Mildly dilated ascending aorta. Focal
calcifications in ascending
aorta. Simple atheroma in aortic arch. Mildly dilated descending
aorta.
Complex (>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild thickening of mitral valve chordae. Mild
(1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient was
under general anesthesia throughout the procedure. The patient
appears to be in sinus rhythm. Results were personally reviewed
with the MD caring for the patient.
Conclusions:
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2.Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is mildly dilated. There are simple
atheroma in the
aortic arch. The descending thoracic aorta is mildly dilated.
There are
complex (>4mm) atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is
seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
Post Bypass
1.Patient is being AV paced.
2. Biventricular systolic function is unchanged.
3. Mild mitral regurgitation persists.
4. Aorta intact post decannulation.
5. On arrival to the CRSU acute ST elevation seen in the
inferior leads. TEE examination did not show any new wall motion
abnormalities in either the right or left ventricle. No evidence
of aortic dissection. Mild mitral regurgitation seen. Dr [**Last Name (STitle) **]
aware of findings.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2132-3-20**] 14:01.
Brief Hospital Course:
Mr. [**Name13 (STitle) 72457**] was admitted for aspirin desensitization which he
tolerated. Cardiac catheterization on [**3-17**] showed LM and 3VD and
he was referred for CABG. He awaited plavix wash out. He had a
history of a syncopal episode for which he was seen by
cardiology with no indication for pacer found. He was taken to
the operating room on [**3-20**] where he underwent a
CABGx4(LIMA->LAD, SVG->OM, LPLV, PDA). He was transferred to the
cardiac surgery ICU in critical but stable condition. He was
extubated later that same day. He was seen by nephrology for a
rising creatinine. The patient did well in the immediate post-op
period, he remained in the ICU for several days to monitor his
renal function. On POD 4 he was transferred to the floors after
his creatinine plateaued at 3.5. Over the next several days his
renal function improved, his activity level was advanced with
nursing and PT help. And on POD8 it was decided he was stable
and ready to discharge to rehabilitation.
Medications on Admission:
Plavix 75
Diovan 80
terazosin 5,
hydrochlorothiazide 25
finasteride 5
iron 65
multivitamin
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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
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:*0*
6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
CAD
HTN
BPH
Infrarenal AAA
melanoma
syncopal episode [**11-4**] with bilat shoulder and arm fractures
SBO s/p repair
s/p excision of melanoma on face
bilat hernia s/p repair
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, rednes or drainage from incision or weight gain
more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**First Name (STitle) **] 2-3 weeks
Dr. [**Last Name (STitle) 8430**] 2-3 weeks
Dr. [**First Name (STitle) **] 4 weeks
Patient will need an MRI of his kidneys as an outpatient when
her creatinine has improved secondary to an inconclusive finding
on a renal ultrasound during her stay.
Completed by:[**2132-3-28**]
ICD9 Codes: 9971, 2767, 5845, 5180, 5119, 4019 |
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