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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2500
} | Medical Text: Admission Date: [**2113-10-12**] Discharge Date: [**2113-10-18**]
Date of Birth: [**2039-11-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
throat tightness with exertion
Major Surgical or Invasive Procedure:
[**2113-10-12**] cabg x3 (LIMA to DIAG, SVG to OM, SVG to distal LAD)
History of Present Illness:
73 yo male with anginal symptoms and abnormal nuclear stress
test. Referred for cardiac cath.
Past Medical History:
NIDDM
neuropathy
HTN
elev. lipids
PVD with left iliac/bil. SFA and tibial dz)
prostate Ca (s/p resection [**2090**])
anxiety
prior appendectomy
Social History:
retired from hotel business
quit smoking 10 years ago
[**2-4**] glasses wine/day
Family History:
non-contrib.
Physical Exam:
5'[**16**]" 205#
NAd
HR 66 RR 20 right 183/74 left 173/79
skin/HEENT unremarkable
neck supple with full ROM and no carotid bruits appreciated
CTAB
RRR no murmur
soft, NT, ND, + BS
extrems, warm, well-perfused, no edema or varicosities noted
neuro grossly intact
2+ bil. fems/ radials
dopplerable right DP/PT
1+ right PT, 1+ left DP
Pertinent Results:
[**2113-10-16**] 06:45AM BLOOD WBC-7.3 RBC-3.12* Hgb-10.3* Hct-29.9*
MCV-96 MCH-32.9* MCHC-34.4 RDW-12.9 Plt Ct-169#
[**2113-10-16**] 06:45AM BLOOD Plt Ct-169#
[**2113-10-16**] 06:45AM BLOOD Glucose-234* UreaN-16 Creat-0.9 Na-138
K-4.2 Cl-101 HCO3-33* AnGap-8
[**2113-10-16**] 06:45AM BLOOD Calcium-9.2 Phos-2.4* Mg-2.2
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 74125**], [**Known firstname 49107**] [**Hospital1 18**] [**Numeric Identifier 74126**] (Complete)
Done [**2113-10-12**] at 10:34:34 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2039-11-4**]
Age (years): 73 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Congenital heart disease. Left
ventricular function. Mitral valve disease.
ICD-9 Codes: 746.9, 440.0, 396.9
Test Information
Date/Time: [**2113-10-12**] at 10:34 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW05-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.22 >= 0.29
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Sinus Level: 2.4 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic
interatrial septum. PFO is present. Normal/small IVC diameter
(<=1.5cm) with respiratory collapse (estimated RAP 0-5mmHg).
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
LV wall thickness. Normal LV cavity size. Mild regional LV
systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. A patent foramen ovale is present. The
estimated right atrial pressure is 0-5mmHg. Left ventricular
wall thicknesses and cavity size are normal. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal and mid inferior wall hypokinesis and
thinning.. Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no pericardial effusion.
POST CPB:
Improved LV focal systolic function. EF = 50-55%
No other change
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
RADIOLOGY Final Report
CHEST (PA & LAT) [**2113-10-16**] 10:36 AM
CHEST (PA & LAT)
Reason: eval ptx s/p ct d/c
[**Hospital 93**] MEDICAL CONDITION:
73 year old man s/p CABG
REASON FOR THIS EXAMINATION:
eval ptx s/p ct d/c
CHEST PA AND LATERAL.
COMPARISON: [**2113-10-12**], chest portable line placement.
HISTORY: Pneumothorax and status post CABG.
FINDINGS: There has been interval removal of ET tube, Swan-Ganz
catheter, NG tube, and chest tubes. There is no pneumothorax. A
small area of left lower lobe atelectasis is identified, and
slightly smaller in appearance since prior exam. There are no
focal consolidations or effusions identified.
IMPRESSION: Area of left lower lobe atelectasis, slightly
improved. No evidence of pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2113-10-17**] 9:23 AM
??????
Brief Hospital Course:
Admitted [**10-12**] and underwent CABG x3 with Dr. [**Last Name (STitle) **].
Transferred to the CVICU in stable condition on titrated
neosynephrine and propofol drips. Extubated later that day and
transferred to the floor on POD #1 to begin increasing his
activity level. Gently diuresed toward his preoperative weight.
Chest tubes and pacing wires removed without incident. Beta
blockade slowly titrated, and he was restarted on his home
diabtes medications. He continued to do well and he was ready
for discharge [**Last Name (un) **] eon POD #6.
Medications on Admission:
atenolol 25 mg daily
zocor 40 mg daily
plavix 75 mg daily
ASA 81 mg daily
diamicron MR 60 mg daily
actos 15 mg daily
Vit. B12 200 mg daily
selenium one tab daily
aerobic oxygen 20-30 gtss daily
aflush free niacin 500 mg daily
Vit. ? E 400 IU daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
9. Niacin Flush Free 100-400 mg Capsule Sig: One (1) Capsule PO
once a day.
10. diamicron MR 60 mg Sig: One (1) once a day.
11. Selenium 25 mcg Tablet Sig: One (1) Tablet PO once a day.
12. Vitamin B-12 100 mcg Tablet Sig: Two (2) Tablet PO once a
day.
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
1 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
CAD s/p cabg x3
NIDDM
neuropathy
HTN
elev. lipids
PVD
prostate Ca
anxiety
PSH: prostate resection [**2090**]
appendectomy
Discharge Condition:
good
Discharge Instructions:
SHOWER DAILY and pat incisions dry
no lotions, creams , or powders on any incision
nodriving for one month
no lifting greater than 10 pounds for 10 weeks
call surgeon for fever greater than 101, redness, or drainage
Followup Instructions:
see Dr. [**First Name (STitle) **] in [**1-3**] weeks
see Dr. [**Last Name (STitle) **] in [**2-4**] weeks [**Telephone/Fax (1) 170**]
Completed by:[**2113-10-18**]
ICD9 Codes: 4019, 2720, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2501
} | Medical Text: Admission Date: [**2199-4-19**] Discharge Date: [**2199-4-26**]
Date of Birth: [**2134-1-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Bactrim / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 65 yo F w/ h/o COPD/emphysema, HTN, OSA, who presented
with acute worsening of dyspnea. Ms. [**Known lastname 35914**] reported dypsnea
worse than her baseline and diaphoresis, but denied productive
cough, chest pain, fevers, sick contacts, abdominal pain,
bloody/black stools. Patient is poor historian. Per EMS
documentation, patient found at home, with labored breathing,
with RR of 39 and O2 sat of 97%. In the ED she had a Tmax of
99.6, RR 26-36, O2 sat in mid-90s on nebulizer. With persistent
dyspnea she was started on non-invasive ventilation in the ED.
She received solumedrol 125 mg IV x1, ceftriaxone 1g IV, and
azithromycin 500 gm PO.
.
At home, Ms. [**Known lastname 35914**] uses home oxygen (uncertain of amount) and
Bi-PAP.
.
Ms. [**Known lastname 35914**] was admitted for a COPD exacerbation on [**3-8**],
thought to be secondary to non-compliance with home O2 and
possible URI.
.
Given severity of dyspnea, minimal improvement with nebulizer
treatments, she was admitted to the ICU for non-invasive
ventilation and frequent nebulizer treatments.
.
In the MICU, she was initially placed on non-invasive
ventilation. But due to increased work of breathing, rising
PCO2, and increased acidosis she was intubated on night of
admission.
.
She was extubated on [**2199-4-21**]. she did well over the last 24
hours. she was continued on CTX and azithro for pnumonia. her
steroids were changed to PO. when I saw her, she was sitting in
a chair. pt denies any trouble breathing. however she says that
she has not yet walked and hence cant really tell if her
breathing is at baseline. she denies any CP, paslpitations,
dizziness, N/V/D/pain in [**Last Name (un) 103**]. her appetite is good. had a BM
today. pulled foley today and is yet to void.
Past Medical History:
COPD/emphysema
OSA
HTN
hyperlipidemia
GERD
schizophrenia
depression
s/p R ankle ORIF
obesity
s/p T & A
Social History:
Lives alone, close friend [**Doctor First Name **] is very supportive. Former
tobacco 1ppd x 40 years, now "occasional smoking" few
cigs/monthly. Has an estranged brother in FL.
Family History:
mother-deceased brain CA
father-deceased suicide
sister-deceased PE
Physical Exam:
98 62 113/56 22 93% on 2L NC
Gen: obese, using accessory muscles of respiration
HEENT: EOMI, PERRL, difficult to assess JVD
CV: RRR, 3/6 SEM at RUSB;
Resp: wheeze b/l, no crackles, decreased breath sounds L base
Abd: obese, soft, NT, no organomegaly appreciated
Ext: no LE edema
Neuro: A&Ox3
Pertinent Results:
[**2199-4-19**] 12:45PM PT-12.2 PTT-27.2 INR(PT)-1.0
[**2199-4-19**] 12:45PM PLT COUNT-407#
[**2199-4-19**] 12:45PM HYPOCHROM-1+ MICROCYT-2+
[**2199-4-19**] 12:45PM NEUTS-83.4* LYMPHS-11.9* MONOS-3.8 EOS-0.5
BASOS-0.4
[**2199-4-19**] 12:45PM WBC-15.9*# RBC-5.19 HGB-13.2 HCT-41.0 MCV-79*
MCH-25.4* MCHC-32.1 RDW-15.7*
[**2199-4-19**] 12:45PM CK-MB-NotDone cTropnT-<0.01
[**2199-4-19**] 12:45PM CK(CPK)-53
[**2199-4-19**] 12:45PM estGFR-Using this
[**2199-4-19**] 12:45PM GLUCOSE-129* UREA N-20 CREAT-0.6 SODIUM-139
POTASSIUM-4.8 CHLORIDE-97 TOTAL CO2-27 ANION GAP-20
[**2199-4-19**] 12:58PM LACTATE-0.6
[**2199-4-19**] 03:39PM TYPE-ART PO2-69* PCO2-67* PH-7.32* TOTAL
CO2-36* BASE XS-5
[**2199-4-19**] 07:54PM TYPE-ART TEMP-38.3 RATES-20/ PEEP-5 PO2-81*
PCO2-59* PH-7.35 TOTAL CO2-34* BASE XS-4 INTUBATED-NOT INTUBA
COMMENTS-O2 DELIVER
[**2199-4-19**] 09:42PM LACTATE-1.9
[**2199-4-19**] 09:42PM TYPE-ART TEMP-37.8 PEEP-5 PO2-91 PCO2-69*
PH-7.30* TOTAL CO2-35* BASE XS-4 INTUBATED-NOT INTUBA
COMMENTS-O2 DELIVER
[**2199-4-19**] 10:52PM TYPE-ART TEMP-38.1 RATES-/20 PEEP-8 PO2-87
PCO2-60* PH-7.33* TOTAL CO2-33* BASE XS-3 INTUBATED-INTUBATED
Brief Hospital Course:
65 yo F w/ history of COPD, recent flare one month ago, and HTN,
who presents with repeat flare requiring intubation, now
extubated.
.
Respiratory Distress: most likely COPD exacerbation from
underlying PNA. has a h/o non compliance with meds in past. this
might also have played a role. pt was intubated for 24 hours and
then extubated without complications. she was treated with
azithromycin for 5 days and CTX for 7 days. she also received IV
steroids in the unit and then was given PO steroids. she was
discharged on a steroid taper. she was continued on albuterol
and ipratropium nebs and inhalers. she continued to satt about
93% on 2 L O2 by NC which is her baseline. she worked with PT
and was able to walk and climb stairs without desatting.
.
HTN: continued lisinopril, amlodipine, metoprolol
.
Schiz/Depression: continued risperidone, prozac.
.
Rash: continued nystatin powder.
.
FEN: regular diet
.
Access: PIV
.
PPx: PPI, SC Heparin
.
Comm: with patient, friend [**Doctor First Name **] at [**Telephone/Fax (1) 98815**].
.
Code: Full
Medications on Admission:
Prozac 80 mg PO daily
Risperidone 2 mg PO daily
Lisinopril 40 mg PO daily
Amlodipine 5 mg PO daily
Trazodone 200 mg PO qHS
Atorvastatin 20 mg PO daily
Albuterol INH Q6H
Atrovent INH Q6H
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
2. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
5. Trazodone 50 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime) as needed for insomnia.
6. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-23**]
MLs PO Q6H (every 6 hours) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
16. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Please take for 3 days from [**Date range (1) 604**].
Disp:*3 Tablet(s)* Refills:*0*
17. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 1 days: Please take for 1 day on [**2199-4-27**].
Disp:*2 Tablet(s)* Refills:*0*
18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Please take for 3 days from [**Date range (1) 605**]. .
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
COPD exacerbation
Discharge Condition:
Stable
Discharge Instructions:
please take all medications as prescribed.
If you have chest pain, shortness of breath, nausea, vomitting,
dizziness, cough, fever please call your primary doctor or go to
the emergency room
Followup Instructions:
Please make a follow up appointment with your PCP Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 98816**]) within 2 weeks of discharge
Completed by:[**2199-6-26**]
ICD9 Codes: 486, 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2502
} | Medical Text: Admission Date: [**2137-3-28**] Discharge Date: [**2137-4-5**]
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
male who presented to the Emergency Department with bright
red blood per rectum. He has a history of arteriovenous
malformation, and colonic adenoma, as well as iron deficiency
anemia. He reports developing bloody diarrhea on [**2137-3-27**], at which time he presented to the Emergency Department.
He stated he had one episode of watery diarrhea but denies
hematemesis or coffee-grounds emesis. He also denied
abdominal pain, fever, chills, or back pain.
REVIEW OF SYSTEMS: Review of systems was negative for chest
pain for shortness of breath. He denies any recent travel,
but he is currently on antibiotics for upper respiratory
infection type symptoms and presumed bronchitis. The patient
also reportedly has a sick contact who was treated for bloody
diarrhea and presumed to have Salmonella.
On presentation to the Emergency Department, the patient had
a blood pressure in the 90s to 80s systolic. The patient was
responsive to fluids. His stool was noted to be bright red
with clots. Nasogastric lavage was negative. The patient
was admitted to the Intensive Care Unit for hypovolemic
shock.
PAST MEDICAL HISTORY:
1. Cerebrovascular accident in [**2128-9-17**] with
residual left lower extremity weakness.
2. The patient reportedly has 50% carotid stenosis
bilaterally.
3. Colonic adenoma, status post right colectomy in [**2130**].
4. Asthma with an FEV1 of 1.14 and peak flow of 400.
5. History of lung lesion.
6. Chronic renal insufficiency with a baseline creatinine
of 1.8 to 2.
7. Claudication.
8. Hypertension.
9. Type 2 diabetes.
10. History of Klebsiella pneumonia.
11. Question of colonic arteriovenous malformation.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Flovent 220 mcg 4 puffs b.i.d.,
Serevent 2 puffs b.i.d., albuterol p.r.n., prednisone
taper 10 mg p.o. q.d., Zithromax, Norvasc 5 mg p.o. q.d.,
aspirin 325 mg p.o. q.d.
SOCIAL HISTORY: The patient is from [**Location (un) 3825**] and does not
speak English. He has a very supportive and large family who
are with him at all times and interpret for him. He lives
with his wife and family. She denies tobacco or alcohol use
and has never used intravenous drugs.
FAMILY HISTORY: Family history is significant for a niece
recently treated for Salmonella.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on
admission revealed a temperature of 96.8, heart rate of 88,
blood pressure of 112/56, respiratory rate of 20, satting
100% on room air. The patient is pleasant, awake, alert and
oriented times three, in no acute distress. Pupils were
notable for cataracts. There was no jugular venous
distention. No lymphadenopathy. The oropharynx was clear,
and mucous membranes were moist. Heart had a regular rate
and rhythm. Normal first heart sound and second heart sound.
A 2/6 systolic ejection murmur. Chest revealed inspiratory
and expiratory wheezes bilaterally. No rales. The abdomen
was soft, nontender, and nondistended. Bowel sounds were
present. Extremities had no edema, cool, 1+ distal pulses
bilaterally. Neurologic examination was grossly nonfocal
with mild right lower extremity weakness and normal cranial
nerve examination.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed a white blood cell count of 22.6,
hematocrit of 22.4, platelets of 325. Differential of
85 neutrophils, 1 band, 4 eosinophils. INR of 1.4. Sodium
of 132, potassium of 4.8, chloride of 105, bicarbonate of 15,
blood urea nitrogen of 59, creatinine of 2.9, blood sugar
of 192.
RADIOLOGY/IMAGING: Electrocardiogram revealed sinus rhythm
at 86 with no ST-T wave changes.
HOSPITAL COURSE:
1. GASTROINTESTINAL: The patient was admitted to the
Intensive Care Unit for fluid resuscitation and close
monitoring secondary to lower gastrointestinal bleed. It was
felt that the bleed was likely secondary to infectious
colitis, possibly provoking another source of bleed. His
stool was sent for fecal cultures on [**3-28**], with the main
concern being Salmonella given a sick contact. The patient
was empirically treated with ciprofloxacin to cover
Salmonella and Flagyl to cover Clostridium difficile given
his recent course of azithromycin for bronchitis.
The patient underwent tagged red blood cell scan on [**2137-3-29**], which revealed a right colonic source of bleeding. A
follow-up angiography was negative for bleeding.
Over the next several days the patient required 12 units of
packed red blood cells transfusion to support hematocrit. A
Surgical consultation was obtained on [**3-30**], but no
intervention was planned given the fact that angiography was
negative. The patient underwent an abdominal CT on [**3-30**]
which revealed no free air, no perforation, scattered
diverticula, but no evidence of diverticulitis.
After a stable hematocrit in the middle 30s for 24 hours, the
patient was transferred to the floor on [**3-31**]. Once
admitted to the floor, the patient received a GoLYTELY bowel
preparation for colonoscopy to look for a source of bleeding.
A colonoscopy was attempted on [**4-1**], but the preparation
was inadequate. The patient's hematocrit remained stable,
and stool was guaiac-negative by that point.
On the evening of [**4-1**], the patient had a maroon bowel
movement followed by bright red blood per rectum, and he was
transferred back to the Intensive Care Unit.
A repeat tagged red blood cell scan showed bleeding source in
the stomach, but a follow-up nasogastric tube was negative,
leading the team to believe that the tagged scan was a false
positive. The Interventional Radiology as well as Surgical
teams were called to evaluate the patient but neither wanted
to intervene. The patient's hematocrit remained relatively
stable in the low 30s with a blood transfusion of 1 unit.
On [**4-3**], the patient underwent a colonoscopy after a
repeat bowel preparation. Colonoscopy revealed a diverticula
in the transverse colon with fresh clot. Aggressive washing
did not remove the clot, and the area was not intervened on
further. Neither the Surgical team or the Interventional
Radiology felt that intervention was needed.
On [**4-4**], the patient was again called out to the floor.
His hematocrit was monitored for an additional 24 hours. It
remained stable, and the patient had no further
guaiac-positive stools.
The patient was discharged on [**4-5**]; but, of note, after
his discharge stool cultures from the [**4-1**] were positive
for giardiasis. The patient was called at home and started
on Flagyl to treat Giardia.
2. HEMATOLOGY: The patient was transfused a total of 13
units of packed red blood cells during this hospitalization.
After initial transfusion of 12 units, he developed a
DIC-type picture and required 2 units of fresh frozen plasma
and 1 unit of platelets with resolution of coagulopathy.
3. RHEUMATOLOGY: Of note, on [**4-3**] the patient developed
a hot, swollen, and painful left knee. The knee was tapped
and was positive for gout crystals. Due to contraindication
to oral steroids given his recent significant
gastrointestinal bleed, on [**Month (only) 547**] the knee joint was injected
with corticosteroids resulting in resolution of symptoms.
4. PULMONARY: The patient has a history of asthma as well
as an ill-defined lung nodule. A CT scan done on admission
was concerning for some interstitial lung disease concerning
for bronchiolitis obliterans-organizing pneumonia. The
patient's respiratory status was stable throughout this
hospitalization and further workup was deferred to the
outpatient setting.
5. CARDIOVASCULAR: The patient has a history of
hypertension, but when admitted was in hypovolemic shock.
After fluid resuscitation and stabilization, his blood
pressure was systolic in the 190s/70s. His Norvasc was
restarted without much result and was changed to
Lopressor 12.5 mg b.i.d. with good affect.
6. INFECTIOUS DISEASE: As noted above, the patient was
initially empirically treated for approximately four days
with ciprofloxacin and Flagyl upon admission for Clostridium
difficile and Salmonella. This was stopped after a few days
of negative stool cultures.
On [**4-3**], the patient spiked a temperature that was
thought to be secondary to his right internal jugular line
that was placed on approximately [**3-28**]. When the patient
was transferred out to the floor on [**4-4**], the line was
promptly removed. The patient had no further episodes of
fever.
After discharge, stool cultures were positive for Giardia,
and the patient was treated with Flagyl.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed, likely secondary to
diverticula.
2. Giardia.
3. Asthma.
4. Chronic renal insufficiency.
5. Anemia.
6. Gout.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. b.i.d.
2. Flovent.
3. Serevent.
4. Lopressor 12.5 mg p.o. b.i.d.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE FOLLOWUP: To follow up with his primary care
physician.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2137-4-11**] 16:27
T: [**2137-4-12**] 08:21
JOB#: [**Job Number 91036**]
ICD9 Codes: 2765, 2762, 2875, 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2503
} | Medical Text: Admission Date: [**2163-7-29**] Discharge Date: [**2163-8-13**]
Date of Birth: [**2117-4-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac cath s/p two stents placement (one in OM1 and one in mid
RCA)
ETT placement
NG tube placement
temporary dialysis catheter placement
Cardiac catheterization
Pericardiocentesis
Endotracheal intubation
Temporary and permanent HD catheter placement
Initiation of Hemodialysis
History of Present Illness:
The pt is a 46 yo Spanish speaking only male with PMH of DM
(last HbA1C 9.2 on [**2162-10-28**]) complicated by polyneuropathy,
hypertension, hypercholesterolemia presented with chest pain.
Patient recently came back from a trip to [**Male First Name (un) 1056**] with his
wife, had an episode of diffuse chest pressure with radiation
and numbness to left arm which resolved without any intervention
about 2 weeks ago while on vacation. The chest pressure and
pain returned two days ago, initially with diffuse chest pain
[**9-27**] radiating to neck, arms, back, and LLQ of abdomen, but
this morning the pain was more localized to the left sided of
his chest and LLQ of abdomen with radiation to the back. He has
been taking Motrin 600mg PO q6h prn for his pain, which didn't
help. The pain was associated with nausea and vomiting,
diarrhea, and occasional chills, no fever or diaphoresis. Per
daughter and wife, he also had recent sick contact: his
granddaughter was having flu-like symptoms with fever, headache,
N/V/D. Because of his unresolving chest pain, he came the [**Hospital1 18**]
ED where ECG was obtained which showed 1-2mm ST elevation in the
inferior leads. Decision was made to take him to the cath lab
directly without his lab results.
.
In the Cath Lab: he was found to have normal LMCA, multiple
serial 70% stenosis in the LAD, Lcx diffuse disease: 90% OM1
stented, 70% OM2; 90% Mid RCA stented, 60% distal RCA
unintervened. He was brought to [**Hospital1 1516**] service initially and
found to have a Cr of 6.1 (baseline 2.4), and K of 6.4, he was
transferred the CCU service for further management of his
cardiac and renal issues. On presentation to CCU, he is
hemodynamically stable, he felt like he needs to urinate, but
really can't when he tries, and he has been have these symptoms
for more than half a year. Foley cath was placed, and he was
started on dialysis.
Past Medical History:
1. Diabetes complicated by polyneuropathy since the age of 19;
Last A1C was 9.2
2. Hypertension
3. hypercholesterolemia
4. schizophrenia diagnosed many years ago per family, but never
took any meds.
5. Carpal tunnel syndrome.
6. Depression (not on meds)
.
Social History:
The patient does not smoke and he does not drink alcohol. He
lives with his wife.
Family History:
Significant for myocardial infarction in his father at the age
of 49.
Physical Exam:
Admission PE:
VS: T 95.1, BP 132/77 (equal on both sides), BP 79, RR 25, 97%
on 2L NS
GEN: lying flat, speaks no English, NAD
HEENT: PERRL. MMM. OP clear. no JVD and no bruits
HEART: RRR no m/r/g. distant heart sounds, no m/r/g appreciated.
LUNGS: CTA anteriorly, no wheezing/rales/rhonchi
ABD: soft, slightly distented, NT, +BS,
Ext: 1+ DP pulses Left side, non-palpable, but dopplerable DP on
the right, no C/C/E
NEURO: A&O x 3. No focal deficits, no sensation to touch in
lower extremity bilaterally in stocking glove distribution
Pertinent Results:
Admission Labs:
[**2163-7-29**] WBC-22.8 Hgb-10.1 Hct-29.7 MCV-89 Plt Ct-281
[**2163-7-29**] Neuts-89.5 Bands-0 Lymphs-6.1 Monos-4.1 Eos-0.2
Baso-0.1
[**2163-7-29**] PT-13.3 PTT-23.8 INR(PT)-1.2
[**2163-7-29**] UreaN-77 Creat-6.1 Na-127 K-6.4 Cl-93 HCO3-16 Gap-24
[**2163-7-29**] Glucose-348 UreaN-78 Creat-6.0 Na-127 K-6.6 Cl-95
HCO3-16
AnGap-23
[**2163-7-29**] 04:34PM CALCIUM-8.2* PHOSPHATE-6.0* MAGNESIUM-2.3
[**2163-7-29**] CK(CPK)-171 CK-MB-15
[**2163-7-29**] 02:25PM cTropnT-0.28*
[**2163-7-29**] Type-ART O2 Flow-2 pO2-71* pCO2-32* pH-7.32*
calTCO2-17 Base XS-
-8
[**2163-7-29**] WBC-21.4 Hgb-8.8 Hct-25.0 MCV-87 Plt Ct-277
.
Other labs:
[**2163-7-29**] CK 171 ->134->124-> 113 ([**2163-7-30**])
[**2163-7-29**] CKMB 15->13->12->8 ([**2163-7-30**])
[**2163-7-31**] TSH-6.5* Free T4-1.3
[**2163-7-30**] PTH-146
[**2163-7-31**] HBsAb-POSITIVE HBcAb-NEGATIVE [**Doctor First Name **]-NEGATIVE HCV
Ab-NEGATIVE
[**2163-7-31**] pericardial fluid, TotProt- 4.5 Glucose- 51
LD(LDH)-3636
Amylase-35 Albumin- 2.5
WBC-[**Numeric Identifier 28577**] RBC-2556 Polys-90 Lymphs-0 Monos-6 Macro-4
[**2163-8-2**] calTIBC 187* Ferritn 1031* TRF 144* Iron 16*
[**2163-7-30**] HbA1C 7.2
[**2163-7-30**] Cholest 201* Triglyc 191* HDL 43 LDLcalc 120
[**2163-8-11**] HBsAg negative; HBsAb negative; HBcAb negative; HCV ab
negative
[**2163-7-31**] [**Doctor First Name **] negative
.
Micro:
PERICARDIAL FLUID ([**2163-7-31**]):
GRAM STAIN (Final [**2163-7-31**])
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2163-8-1**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
Sputum ([**2163-7-31**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STREPTOCOCCUS PNEUMONIAE.HEAVY GROWTH.BEING ISOLATED FOR
SENSITIVITIES.
RESPIRATORY CULTURE (Preliminary):
STREPTOCOCCUS PNEUMONIAE.HEAVY GROWTH.
Possible penicillin resistance by oxacillin screen.
Resistance to be confirmed by MIC testing.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
.
SENSITIVITIES ([**2163-8-4**]): MIC expressed in MCG/ML
STREPTOCOCCUS PNEUMONIAE
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 0.12 S
CIPROFLOXACIN--------- <=0.25 S
ERYTHROMYCIN---------- =>1 R
GENTAMICIN------------ 4 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM------------- <=0.25 S
PENICILLIN------------ 0.25 I
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
ENTEROCOCCUS SP.
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ S
.
[**2163-8-7**] STOOL FINAL REPORT [**2163-8-8**]
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2163-8-8**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2163-8-8**] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2163-8-8**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2163-8-10**]: CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2163-8-11**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
Imaging:
ECG ([**2163-7-29**]): SR at 75, normal interval, nomral axis, 1-2mm ST
elevation on lead II, II, AvF (inferor leads)
.
Cath Report ([**2163-7-29**]):
co-dominant
LMCA: normal
LAD: multiple serial 70% stenosis with intervening normal
segements (seen in all three arteries)
LCX: diffuse disease, 90% OM1 (lower pole)-> stented -> 0%
residual, 70% OM2
RCA: 90% mid (hazy) with 60% distal diffuse disease-> spot
stented the mid RCA ->0% residual. Left distal diffuse disease
untreated.
.
Radiology:
CXR ([**2163-7-29**]):
1. Enlarged cardiac contour consistent with cardiomegaly and/or
pericardiac effusion.
2. Widened mediastinum of unknown etiology warrants further
evaluation with CT
3. Left lower lobe retrocardiac consolidation/atelectasis.
.
Echo ([**2163-7-30**]):
Conclusions:
1. The left ventricular cavity size is normal. There is mild
global left
ventricular hypokinesis with inferior akinesis. Overall left
ventricular
systolic function is mildly depressed.
2. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
3. There is a large, circumferential, pericardial effusion.
There are no
echocardiographic signs of tamponade.
4. There is a large pleural effusion.
.
CT chest ([**2163-7-30**]):
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Large pericardial effusion.
3. Bilateral pleural effusions, moderate on the right and small
on the left,with corresponding bilateral lower lobe atelectasis.
.
Pericardiocentesis ([**2163-7-31**]):
COMMENTS:
1. Pericardiocentesis was successfully performed, yielding 465cc
of
cloudy yellow fluid without resistance or complication. No
additional
catheters were placed as a pulmonary artery line and radial
arterial
line were already in place.
2. Hemodynamic studies were notable for near equalization of
right
atrial and pericardial pressures with mean 25 and 24mmHg,
respectively.
Post-procedural pericardial pressures were 8 mmHg with mean
right atrial
pressures of 19mmHg.
3. Postprocedural echo was immediately performed and showed
small
residual pericardial effusion, measured less than 1 cm in
posterior
diameter (over 2 cm circumferential pericardial effusion was
demonstrated prior to procedure).
4. Pericardial drain was left in place.
FINAL DIAGNOSIS:
1. Successful pericardiocentesis with reduction of pericardial
pressures.
2. Persistently elevated right atrial pressures suggestive of
diastolic
dysfunction and/or volume overload.
.
Echo ([**2163-7-31**]): post-pericardiocentesis
Conclusions:
There is mild symmetric left ventricular hypertrophy. There is
mild regional left ventricular systolic dysfunction with
inferior and inferolateral hypokinesis. Overall left ventricular
systolic function is mildly depressed. Right ventricular chamber
size and free wall motion are normal. There is a moderate to
large sized pericardial effusion. There is right ventricular
diastolic collapse/compression, consistent with impaired
fillling/tamponade physiology. Overall left ventricular systolic
function is mildly depressed (limited views so regional function
not adequately assessed). There is a very small residual
pericardial effusion. There are no echocardiographic signs of
tamponade.
.
Echo ([**2163-8-1**]):
Conclusions:
There is 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 are mildly thickened. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is a small partially echo dense pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared to the prior study of [**2163-7-31**], the pericardial effusion
now appears similar to slightly larger (views technically
suboptimal for comparison).
.
Chest Xray ([**2163-8-1**]):
IMPRESSION:
Lines and tubes, position as described. Slight decrease in
width of cardiac contour, which may be due to partial drainage
of pericardial effusion.
.
Echo ([**2163-8-2**]):
Conclusions:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. There is a small
circumferential pericardial effusion without echocardiographic
evidence for tamponade physiology..
Compared with the prior study (images reviewed) of [**2163-8-1**],
the findings are similar.
.
Chest xray ([**2163-8-2**]):
Mildly enlarged cardiac silhouette is slightly smaller. There is
no pneumothorax. Small bilateral pleural effusions unchanged.
Bibasilar atelectasis, greater on the left, has improved since
[**2163-8-1**], and worsened on the right.
.
Renal U/S ([**2163-8-6**]):
1. No evidence of hydronephrosis.
2. 2.6-cm cyst in the interpolar region of the left kidney.
.
Gradual improvement on CXR with CXR on [**2163-8-6**] showed:
Bibasilar atelectasis have improved. ET tube in standard
position. NG tube with tip in the stomach. Small right pleural
effusion is stable. Left subclavian vein catheter with tip in
the superior cavoatrial junction. Cardiomediastinal contour is
unchanged.
.
Discharge Labs:
[**2163-8-13**] WBC-18.7 Hgb-10.6 Hct-31.6 MCV-89 Plt Ct-533
[**2163-8-13**] Glucose-179 UreaN-26 Creat-6.5 Na-133 K-5.2 Cl-97
HCO3-22
AnGap-20
[**2163-8-13**] CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-2.3 Uric acid 6.4
.
Brief Hospital Course:
The pt is a 46 yo Spanish speaking only male with PMH of DM
(last HbA1C 9.2 on [**2162-10-28**]) complicated by polyneuropathy,
hypertension, hypercholesterolemia presented with chest pain s/p
cath with two stents placement in OM1 and mid-RCA, now developed
ARF on CRI, respiratory failure, and pneumonia/UTI.
.
1. CAD - Patient s/p cath with two stents placement in OM1 and
mid-RCA. Chest pain thought to be due to IMI. That night,
patient continued to have chest pain and pressure on the left
side of his chest and abdomen. Determined to have large
pericardial effusion with acute renal failure. ASA 325mg and
Plavix 75mg were continued.
.
2. Pericardial effusion - Following cath, chest xray showed a
widened mediastinum. Chest CT indicated a large pericardial
effusion. That night, patient had decreasing oxygen saturation
(85%) and the decision was made to intubate. The following
morning, a pulmonary artery (Swanz-Ganz) catheter was inserted
via the right internal jugular vein. Hemondynamic measurements
indicated a PAP- 44/28, CO- 3.6, and CI -1.8. Urine output
resumed following procedure.
.
3. Resp. failure/intubation --> Due to dropping O2 sat following
cath, patient was found to have large pericardial effusion,
small pleural effusion, and bibasilar atelectasis. The decision
was made to intubate. Post-pericardiocentesis patient was found
to have normal arterial blood gases. Since, he has been sedated,
restrained, and kept on CMV. Ongoing trials of CPAP+PS have
returned high RSBI values. On [**2163-8-6**], patient extubated without
difficulty and supplemented with 3L oxygen by nasal cannulae.
Patient encouraged to continue incentive spirometry. Since, he
has shown improved O2 sats requiring less supplemental oxygen.
Patient discharged wit O2 sat 97% on room air.
.
4. Pneumonia - After being intubated, patient developed
ventilator acquired pneumonia on [**2163-8-1**]. Empiric treatment with
vanc/cefipime was initiated. Sputum cultures indicated heavy
growth of S. Pneumo and some Psuedomonas. Patient then started
on Vanc/Zosyn. Psuedomonas determined to be pan-sensitive. S.
Pneumo sensitive to bactrim, vanc, levaquin. Central line
removed and tip cultured which showed no growth to date. New
blood cultures were sent. All subsequent cultures are negative.
Patient continues to have elevated WBC. We d/c'ed zosyn on
[**2163-8-7**] and started cipro. On [**2163-8-8**], patient noted to have
decreasing WBC and afebrile past 24hrs. Patient given 10day
course of total antibiotics, including Vanc and Cipro.
.
5. UTI - On [**2163-8-3**], patient found to have abnormal UA. Culture
was positive to enterococcus. Patient started on Vanc.
Enterococcus sensitive to vanc. Vanc trough checked before
dialysis and dose given after dialysis. Patient treated for
10days.
.
6. ARF on CRI- Most likely contributed to recent motrin overuse
for pain, decreased CO, and contrast during cath on top of
already compromised renal function given poorly controlled
diabetes. After cath, patient noted to have elevated BUN (78),
Cr (6.6), and K (6.2) requiring emergent dialysis with CVVH to
his right femoral. Nephrocaps were started. Since
pericardiocentesis, patient has started producing minimal urine
output and noted decrease in BUN (30) and Cr (2.6). Due to
elevated right atrial filling pressures, patient will be
aggressively diuresed on CVVH. In consultation with nephrology
for short term hemodialysis, patient underwent insertion via IR
on left jugular tunneled catheter for hemodialysis. Dialysed
each day since [**2163-7-30**]. Nephrology adjusting electrolytes as
needed. Nephrocaps given each day. On [**2163-8-5**], patient
developed anuria. Bladder scan indicated no urine in the
bladder. Renal u/s showed no evidence of hydronephrosis and
incidental 2.6-cm cyst in the interpolar region of the left
kidney. Per nephrology, patient will need a-v fistula for
short-term dialysis. Transplant surgery deferred placement of av
fistula for at least 1month. Instead, they indicated a desire
for a tunneled permcath placement. He went to the OR for
permcath insertion by transplant surgery on [**2163-8-12**]. At this
time, his temporary vascular catheter was removed. He was
discharged from the hospital on [**2163-8-13**] after dialysis. He is
scheduled to begin outpatient dialysis on tueday, [**2163-8-16**].
He will be on Tues/Thurs/Sat schedule.
.
7. Diarrhea - Onset occurred on [**2163-8-5**], patient noted to have
rapid watery, loose stools immediately after receiving tube
feeds. Unable to culture due to loose consistency and inability
to pass a rectal tube. Empiric treatment with flagyl for C.
Difficile initiated on [**2163-8-6**]. Cultures for C. diff have been
negative, but were taken after initiation of treatment. Flagyl
given for 5days, completed on [**2163-8-12**].
.
8. Anemia - Patient dropped hct to 25 on [**2163-7-30**] requiring
transfusion of 1 unit PRBCs. Since then, patient with stable
Hct/Hgb. On [**2163-8-2**], patient experienced drop in Hgb to 8, and
Hct to 24. He was transfused 2units PRBCs. Hgb/Hct now stable.
Per nephrology, Epo intiated. Hemoglobin and Hematocrit stable
at time of discharge.
.
9. HTN - Blood pressure meds held due to volume status with
elevated right filling pressures. While on CVVH, patient has
tolerated well with no episodes of hypotension. Patient
restarted on Metoprolol 12.5mg [**Hospital1 **]. Blood pressure unstable and
was titrated accordingly. Nephrology was consulted about
additional anti-hypertensives usage. They recommend BB, but will
reassess after more dialysis sessions.Advised to hold off on
ACEI because nephrology feels patient has chance to regain
kidney function after short course of dialysis. Continued
elevated blood pressures prompted addition of Norvasc 5mg. He
was transitioned to metoprolol 100mg PO bid and norvasc 5mg PO
qday upon discharge.
.
10. Elevated LFTS/transaminitis - Patient noted to have
increasing ALT and AST until pericardiocentesis likely secondary
to shock liver (ischemic hepatitis). Since procedure, patient
noted to have decreasing ALT/AST. LFTs monitored daily.
.
11. DMT2 - Patient with complication of polyneuropathy and
likely nephropathy (Urine alb/Cr ratio in [**2158**] was 2800 (nl
0-30)) on nephrocap. Blood sugar in the 300s, held oral
glycemic agents, initially on insulin drip overnight,and has
been switched to SSI with FS qid. Will continue neurontin for
polyneuropathy. Due to recent VAP, patient will be switched to
SSI and fixed scale. Elevated blood glucoses prompted adjustment
of Fixed Scale Insulin. Restarted on glipizide 10mg PO qd.
[**Last Name (un) **] center to be consulted on discharge. Before discharge,
patient was educated about insulin injections and blood glucose
monitoring.
.
12. Hyperlipidemia - On admission, we continued Lescol XL and
lofibria at home dose and checked lipid panel in the am
(fasting). Due to elevated LFTs (ALT and AST), patient was
discontinued off Lescol XL and Lofibria. Previously, patient
non-adherent to lipid therapy. LFTs monitored throughout
admission.LFTs shown to be decreasing. On [**2163-8-10**], we restarted
patient on Lipitor 10mg, and he was told to follow up with PCP
to titrate up as tolerated.
.
13. Nutrition - on regular, renal, diabetic, cardiac diet
.
14. DVT prophylaxis - PPI, bowel regimen, subQ heparin
5000units tid. d/c'ed subq heparin once patient ambulating.
.
15. Activity - ambulating with walker, PT recommend home w/PT
.
16. Code - full code
Medications on Admission:
Lescol XL 80mg PO qday (not very compliant due to GI upset)
lofibra 200mg PO qday (not very compliant due to GI upset)
Glipizide 10mg PO qday
Avandia 8mg PO qday
Nephrocaps 1 cap PO qday (hasn't been taken them for three
months)
Uni-daily (multivit)1 tab PO qday
Lasix 20mg PO qday
Atenolol 50mg PO qday
Ativan 2mg PO bid
Neurontin 400mg PO qday
Ducolax
Discharge Medications:
1. Equipment
Rolling walker with seat and brakes
Diagnosis: Cardiac rehabilitation with chronic polyneuropathy
and balance deficit
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
Disp:*30 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*2*
8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Insuline NPH
15 Units in the am and 10 units in the pm
Sliding scale insulin with humalog [**First Name8 (NamePattern2) **] [**Last Name (un) **] diabetic
recommendation
11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED): with hemodialysis.
12. Lancets Misc Sig: One (1) Miscell. four times a day.
Disp:*120 lancets* Refills:*2*
13. Truetrack Test Strip Sig: One (1) Miscell. four times
a day.
Disp:*120 strips* Refills:*2*
14. Insulin Syringe 0.5cc/28G Syringe Sig: One (1) Miscell.
five times a day.
Disp:*180 syringe* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
caregroup vna
Discharge Diagnosis:
Primary diagnosis
1)Inferior myocardial infarction s/p cath with cypher stents x2.
2)Acute renal failure on chronic renal insufficiency.
3)Respiratory failure
4)Pericardial effusion
5)Pneumonia
6)UTI
.
Secondary diagnosis
1. Diabetes complicated by polyneuropathy since the age of 19;
Last A1C was 9.2
2. Hypertension
3. Hypercholesterolemia
Discharge Condition:
The patient was discharged hemodynamically stable, afebrile with
appropriate follow up.
Discharge Instructions:
Please call your doctor or seek medical attention in the ED if
you experience chest pain, shortness of breath, fever, chills,
sudden loss of vision, or any other concerning symptoms.
.
Please take all your medications exactly as prescribed and
described in this discharge paperwork.
We have made the following changes to your medications:
1) Please stop taking your Lescol XL and Lofibria. Instead we
have started you on Lipitor 10 mg once a day, please discuss
with your PCP and titrate up your Lipitor as tolerated.
2) Please start taking Aspirin 325 mg once a day.
3) Please start taking Plavix 75 mg once a day.
It is very important that you take ASA and Plavix everyday to
keep your the stents open in your heart. DO NOT MISS A SINGLE
DOSE!
4) Please stop taking your Atenolol 50 mg. Instead, please take
Metoprolol 100mg by mouth twice a day and Norvasc 5 mg once a
day. Please discuss with your PCP or cardiologist to titrate up
your blood pressure medications.
5) Please stop taking Avandia. Instead, please take Glipizide XL
10mg once a day and insulin injections accordingly.
6) Please monitor your blood sugars at least four times a day
with the glucometer as indicated by the nurse.
7) Please start taking Nephrocaps 1 capsule per day.
.
You have been scheduled for dialysis starting Tuesday, [**2163-8-16**] at 4pm at [**Location (un) **]. You will be on a Tues/Thurs/Sat
dialysis schedule.
Also, please follow up with the doctors we have listed below.
Followup Instructions:
[**Hospital **] Clinic: Tuesday, [**2163-8-16**] at 4pm ([**Location (un) **]).
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:Monday,[**2163-8-29**] 8:40
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20670**], MD Phone: [**Telephone/Fax (1) 21993**], Date/Time:
friday,
[**2163-8-26**] at 4:15pm
[**Last Name (un) **] Diabetes Ceneter: Wednesday, [**2163-9-28**] at 10am.*
*They will call you at home if there is an earlier appointment
available. We recommend you take the earlier appointment if
possible.
.
Please call [**Hospital **] clinic [**Telephone/Fax (1) 3637**] to follow up with Dr.
[**First Name (STitle) 4102**] [**Name (STitle) 4090**](Nephrologist) for an appointment within a month of
discharge.
.
Please follow up with Dr. [**Last Name (STitle) **] (Cardiologist) by calling
[**Telephone/Fax (1) 4022**] within a month of discharge.
Completed by:[**2163-8-13**]
ICD9 Codes: 5849, 5990, 5119, 2724, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2504
} | Medical Text: Admission Date: [**2102-10-17**] Discharge Date: [**2102-10-17**]
Date of Birth: [**2055-11-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
ventricular tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46yo woman with PMH of vfib arrest thought secondary to
Prinzmetal's angina, recently discharged from CCU one week ago,
and HTN, was transferred to [**Hospital1 18**] from [**Hospital6 5016**]
([**Telephone/Fax (1) 63088**]) after ventricular tachycardia. The patient
was last admitted on [**10-7**] with chest pain. She was noted to have
STE in the anterior leads at an outside hospital, sent to
cardiac catheterization here. At cath, she was noted to have
mild irregularity of her coronary vessels but no stenosis. She
was maintained on nitrates and norvasc with improvement of her
chest pain, and was discharged on [**10-10**]. This morning, she noted
chest pain at 2am. EMS was called; while in the field she
entered VT. At the OSH, she was defibrillated x 3 without
success, but entered "fine vfib." In total, per OSH chart, she
received defibrillation x 7, was loaded with amiodarone, and
returned to NSR. She was in VT/VF for approximately 30mins with
some component of CPR.
.
Upon arrival, she had minimal neurologic functioning. She was
admitted to the CCU.
Past Medical History:
Prinzmetal's angina
coronary vasospasm
hypertension
Social History:
Denies tobacco, ETOH, IVDA
employed at [**Company 63085**]
5 children
Family History:
no CAD
Physical Exam:
Per neurology note,
Vitals: hypotensive, HR 90's, RR 16, O2 99%
Gen: intubated, breathing deeply, very high frequency tremor of
her lower lip and tongue
Heart: RRR
Lungs: CTA anteriorly
ABD: obese, soft
EXT: cannot palpate peripheral pulses
MS: unresponsive to voice or sternal rub.
CN: pupils 2 mm and unresponsive, absent doll's, absent
corneals,
absent gag, no grimace to nasal tickle. Is breathing agonally
spontaneously. Did not test cold calorics.
Reflexes: trace throughout, toes mute
[**Last Name (un) **]: does not withdraw or posture to deep stim
Pertinent Results:
Labs:
CBC: WBC-23.6*# RBC-4.67# Hgb-14.2# Hct-41.3# Plt Ct-275#
Diff: Neuts-80* Bands-3 Lymphs-10* Monos-0 Eos-0 Baso-0 Atyps-0
Metas-6* Myelos-1* NRBC-2*
Coags: PT-13.4* PTT-31.7 INR(PT)-1.2
Chem10: Glucose-365* UreaN-16 Creat-1.4* Na-135 K-5.4* Cl-101
HCO3-8* Calcium-8.5 Phos-7.6*# Mg-2.2
Enzs: ALT-107* AST-329* CK(CPK)-8773* AlkPhos-98 TotBili-0.6
Albumin-4.2
Card enzs: CK-MB-364* MB Indx-4.1 cTropnT-4.92*
Tox: [**Last Name (un) **]-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ABG:
[**2102-10-17**] 06:22AM BLOOD Type-ART Temp-37.2 Rates-/0 Tidal V-600
PEEP-5 FiO2-100 pO2-385* pCO2-26* pH-7.26* calHCO3-12* Base
XS--13 AADO2-306 REQ O2-57 Intubat-INTUBATED Vent-CONTROLLED
[**2102-10-17**] 08:16AM pO2-108* pCO2-30* pH-7.16* calHCO3-11* Base
XS--16
[**2102-10-17**] 09:31AM Temp-36.7 Rates-22/22 Tidal V-600 PEEP-5
FiO2-50 pO2-92 pCO2-36 pH-7.20* calHCO3-15* Base XS--12
-ASSIST/CON Intubat-INTUBATED
[**2102-10-17**] 11:50AM pO2-155* pCO2-34* pH-7.08* calHCO3-11* Base
XS--19
Lactate: 7.7 -> 7.8 -> 14.8
freeCa-1.15
ECHO - There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is severe global
left ventricular hypokinesis (ejection fraction 20-30 percent).
Right ventricular chamber size is normal. Right ventricular
systolic function appears depressed. The mitral valve leaflets
are structurally normal. There is a trivial/ physiologic
pericardial effusion.
EEG - This is a markedly abnormal routine EEG due to the
presence
of the absence of a clear background activity. The described low
voltage fast activity could represent cable artifacts throughout
the
record. The underlying background activity cannot be excluded.
This
finding represents the midline subcortical dysfunction and is
consistent
with a severe encephalopathy. There were no epileptiform
discharges
seen. A sinus tachycardia was noted.
EKG - Sinus tachycardia.
Consider Anteroseptal myocardial infarct, age indeterminate
Since previous tracing of same date, sinus tachycardia present
Brief Hospital Course:
Assessment - 46yo woman with Prinzmetal's angina, HTN, s/p
prolonged ventricular fibrillation arrest, with minimal
neurologic functioning on admission, absent brainstem reflexes
except for some spontaneous agonal breathing, made CMO by
family.
Hospital course - The patient presented s/p vfib arrest, minimal
neurologic functioning. ECHO showed severe LV hypokinesis. The
patient was maintained on pressors and a ventilator initially.
She was seen by the neurology service, who assessed her poor
function as a result of hypoxic injury in the setting of her
arrest. Status epilepticus was originally in the differential,
but EEG was c/w severe encephalopathy, and had no epileptiform
discharges. Her prognosis was discussed with her family, who
decided to make the goals of care comfort measures. She was
taken off the ventilator and all medications except morphine and
tylenol, and she died soon thereafter with her extended family
at the bedside. The family requested an autopsy.
Medications on Admission:
Lisinopril
Iron
[**Month/Day/Year **]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiogenic shock
Ventricular fibrillation cardiac arrest
Prinzmetal's angina
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2505
} | Medical Text: Admission Date: [**2101-9-21**] Discharge Date: [**2101-9-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18141**]
Chief Complaint:
fever and hypotension
Major Surgical or Invasive Procedure:
Insertion of peripherally inserted central catheter
Revision of right nephrostomy tube
History of Present Illness:
This is an 86 year-old female with a history of Alzheimer's
dementia, recurrent urinary tract infections and urosepsis in
the setting of bilateral obstructing nephrolithiasis, S/P right
nephrostomy tube placement who presented from nursing home with
fever and hypotension. At baseline, she is non-verbal, G-tube
dependent and unable to perform ADLs. Ms. [**Known lastname **] was previously
admitted on [**5-10**] with urosepsis (E. coli & Strep milleri). She
had bilateral obstructing renal stones requiring percutaneous
nephrostomy tube on the right and also found to have a
uterosigmoid fistula. She was treated with sepsis protocol, 1
week of steroids and 2 week antibiotic course.
The pt's daughter notes that about 4 days prior to admission,
her urine color has changed and she has been looking around the
room less. She was started on ciprofloxacin and metronidazole 4
days PTA.
In the ED temperature was 102.8, BP 66/48, HR 104. Lacatate was
6.0. After discussion with family regarding code status, she was
started on the sepsis protocol, receiving 2L of NS, and started
on piperacillin/tazobactam, vancomycin, and metronidazole as
well as dopamine. On arrival to MICU, BP 97/44, HR 92, 99% on
100% NRB. Pt is non-conversant and so the daughter states that
she would want the pt intubated if this was thought to be
related to a reversible cause.
.
While in the MICU, patient was found to have mild right and
moderate left hydronephrosis on renal ultrasound. She
subsequently went to interventional radiology, where right
nephrostomy tube was changed, and no new left nephrostomy
inserted due to resolution of left hydronephrosis. She was
initially started on broad spectrum antibiotics and pressors but
was eventually stabilized and transferred on
piperacillin/Tazobactam
Past Medical History:
1. Alzheimers
2. Aspiration pneumonia
3. UTI
4. Uterosigmoid fistula
5. B/L obstructing renal stones s/p right nephrostomy tube
6. GERD
7. Osteoarthritis
8. Depression
9. vitamin B12 deficiency
10. hyperlipidemia
11. TB treated 50 years ago
12. DVTs in superficial veins [**5-10**] and [**6-9**] (superfical femoral
and distal cephalic), on warfarin
13. apical cardiac thrombus
Social History:
Lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Daughter very involved in her care.
Family History:
non-contributory
Physical Exam:
T 96.9 HR 100 BP 74/34 RR 20 O2 sat 99% on 100% NRB, on 10
mcg/kg/min dopamine
Gen: somnolent, responds to painful stimuli, but otherwise not
responding.
HEENT: PERRL.
Neck: No LAD or thyromegly.
CV: regular and tachycardic with no m/r/g
Lungs: Crackles at bases bilaterally.
Abd: soft, NT, ND active BS, no hepatosplenomegly, J tube in
place, no drainage
ext: warm and sweaty, with 2+ DP pulses, No clubbing, cyanosis
or edema.
neuro: increased tone in neck and arms with decreased tone in
legs. Does not follow commands.
Pertinent Results:
Labs on admission: WBC 47.9 (90% neutrophils, 3% bands, 2%
lymphs), Hgb 10.9, Hct 31.2, Plt 300
PT 54.3, PTT 49.7, INR 6.5
BMP remarkable for creatinine 3.1, BUN 61, glucose 116,
potassium 5.8, bicarb 19, lactate 6
.
TTE [**2101-6-9**]:
Overall left ventricular systolic function is moderately
depressed (ejection fraction 30-40 percent) secondary to
extensive apical akinesis. A moderate sized thrombus is seen in
the apex of the left ventricle. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. Trivial MR, mod [**Last Name (un) 6879**], small pericardial effusion. There
are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2101-5-31**], an apical left ventricular thrombus is now
evident.
.
Renal ultrasound ([**9-21**]): 1. Right-sided nephrostomy tube with
decompression of the right collecting system, with only mild
upper pole hydronephrosis seen.
2. New moderate-to-severe left-sided hydronephrosis. Given
patient's history of sepsis, this is concerning for an
obstructing nephropathy. Discussed with Dr. [**Last Name (STitle) 6812**] following
completion of the study.
.
CXR ([**9-21**]): 1. Fluid overload. 2. Indistinctness of the left
hemidiaphragm, which may represent atelectasis and/or
consolidation.
.
Nephrostomy check ([**9-23**]): Uneventful change of right
percutaneous pigtail nephrostomy catheter. No hydronephrosis.
Persistent obstruction of the distal right ureter. Interval
resolution of left hydronephrosis, obviating the need for left
percutaneous nephrostomy at this time.
.
PICC line placement ([**9-26**]): Successful placement of a 5-French
double lumen 34 cm PICC by way of the right basilic vein with
the tip in the distal SVC. The line is ready for use.
.
ECHO ([**9-27**]): 1. The left atrium is moderately dilated.
2. The left ventricular cavity size is normal. No masses or
thrombi are seen in the left ventricle. Overall left ventricular
systolic function is mildly depressed. Basal inferior
hypokinesis is present.
3. The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
5. There is a small pericardial effusion with fibrin/thrombus on
the surface of the heart.
6. Compared to prior study on [**2101-6-9**], the LV apical thrombus
is no longer seen and the PA pressure is now normal. LV function
may have improved.
.
Blood cultures:
10/18 1/4 bottles E coli sensitive to ceftriaxone & pip/tazo
[**9-22**] negative
.
CVC Catheter tip no growth
.
Stool negative for C diff X 4
.
Urine
[**9-21**]: > 100,000 organisms/mL E coli sensitive to pip/tazo &
ceftriaxone
[**9-23**]: > 100,000 organisms/mL yeast
.
Labs at discharge: WBC 11.4, Hgb 11.1, Hct 32.4, Plt 307
PT 19.5, PTT 51.1, INR 1.9
BMP remarkable for creatinine 0.6, BUN 16, glucose 112, bicarb
30, sodium 136
lactate returned to [**Location 213**] 1.1 on [**9-21**]
cortisol stim test within normal limits while in ICU
Brief Hospital Course:
Ms. [**Known lastname **] is a 87 year old female with a history of Alzheimer's
and prior urosepsis who presented with sepsis from a urinary
source once again and who is now status post right nephrostomy
tube & on antibiotics.
.
# Sepsis: The patient's presentation was most consistent with
urosepsis. Her right nephrostomy tube was changed by IR on
[**9-23**]. Left hydronephrosis found on initial ultrasound was
resolved by the time of IR intervention, and a left nephrostomy
tube was not needed. The patient was initially in the MICU but
was transferred on PIP/TAZO, having received 5 days, on [**9-25**].
Her blood cultures as well as urine cultures show E. Coli
sensitive to PIP/TAZO and ceftriaxone.
- On arrival to the floor, her antibiotic was changed to
ceftriaxone 1g IV q24 since strain is susceptible on culture
data. Ceftriaxone was started on [**9-25**], and the plan is to
continue the antibiotic until [**10-4**].
- The patient had a PICC line placed without problem on [**9-26**]
for IV antibiotics.
- Her white count has steadily decreased and she has been
afebrile for several days.
- The patient should have an outpatient renal ultrasound in a
few weeks in order to reassess the functionality of the
nephrostomy tube and to ensure that hydronephrosis has not
reaccumulated on the left side.
.
# Leukocytosis: The patient's white count continues to decrease,
and the patient continues to be afebrile. A slight increase in
her white blood cell count two days ago is likely related to
blockage of nephrostomy tube (nurse [**First Name (Titles) **] [**Last Name (Titles) 67863**] in closed
position and corrected this). Also, many white blood cells still
in urine (nephrostomy < regular UA).
- She is on ceftriaxone to continue until [**10-4**] as above.
- As patient is afebrile, will not treat for yeast in the urine
at this point.
.
# H/o DVTs and apical ventricular thrombus on last ECHO: The
patient was on warfarin prior to admission but this was held
temporarily due to high INR on admission. Her warfarin was
restarted on the floor, and her INR is now 1.9.
- There is no longer a thrombus seen on ECHO which was done on
[**9-27**]. Therefore, the patient is to stop anticoagulation on [**10-5**]
per Dr. [**First Name (STitle) **].
- Since the patient's INR is now 1.9, we will discontinue her
heparin today. She will continue on coumadin 5 mg QHS with INR
monitoring at her nursing home.
- Her goal INR is 1.5-2.5.
.
#) FEN: The patient initially presented with hypernatremia,
which has resolved. It is likely that her hypernatremia is
related to dehydration and resolved once her free water deficit
was repleted.
- The patient should continue on tube feeds with free water
replacement, which she is tolerating well. Changed on [**9-27**] to
Replete with fiber with goal 55 cc/hour and decreased frequency
of free water boluses (150 cc every 6 hours).
.
# Uterosigmoid Fistula: The patient was previously evaluated by
gyn/surgery and thought to be not a candidate for surgery.
.
# ARF: The patient's acute renal failure seems to have resolved
with stabilization of blood pressure and resolution of sepsis.
Her creatinine is now back to normal.
.
# Code: After extensive discussion with patient's daughter,
patient is DNR/DNI.
.
# comm: The patient's daughter is her HCP.
- Daughter [**Name (NI) **]: [**Telephone/Fax (1) 67860**] OR [**Telephone/Fax (1) 67861**].
- Grandson [**Name (NI) **]: [**Telephone/Fax (1) 67862**]
Medications on Admission:
ASA 325mg PO
Lansoprazole 30mg
B12 1000mcg q 3 months
Cipro 250mg PO
Flagyl 500mg PO TID
Coumadin 5mg PO
MVI
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 150 mg/15 mL Liquid [**Telephone/Fax (1) **]: One [**Age over 90 1230**]y
(150) mg PO BID (2 times a day) as needed.
3. Warfarin 5 mg Tablet [**Age over 90 **]: One (1) Tablet PO HS (at bedtime).
4. Albuterol Sulfate 0.083 % Solution [**Age over 90 **]: One (1) treatment
Inhalation Q6H (every 6 hours).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed.
7. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
8. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback [**Last Name (STitle) **]: One
(1) g Intravenous Q24H (every 24 hours) for 6 days: Until
[**2101-10-4**].
Disp:*QS solution* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Urosepsis now status post revision of right nephrostomy tube
Discharge Condition:
Hemodynamically stable and afebrile on room air
Discharge Instructions:
Please take all medications as prescribed. Please call your
doctor or return to the emergency room should you experience any
of the following symptoms: fever > 100.5, chills, abdominal pain
or discomfort, difficulty breathing, decline in mental status,
or any other concerning symptoms.
Followup Instructions:
You should see Dr. [**First Name (STitle) **] within the next one week. Her clinic
number is [**Telephone/Fax (1) 18145**].
Completed by:[**2101-9-28**]
ICD9 Codes: 5849, 4280, 5990, 2760, 311, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2506
} | Medical Text: Admission Date: [**2155-4-3**] Discharge Date: [**2155-5-15**]
Date of Birth: [**2089-8-26**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Severe nausea and vomiting.
Major Surgical or Invasive Procedure:
Induction of Hemodialysis
Plasmapheresis
Kidney Transplant [**2155-4-17**]
[**2155-5-1**] small bowel obstruction, ex lap with LOA
History of Present Illness:
A 65 year-old woman with history of end-stage renal disease
scheduled for LRRT [**2155-4-8**] presenting with uremic symptoms. She
was admitted for induction of hemodialysis to prevent dialysis
disequilibrium after receiving her transplant.
.
In the ED, her vital signs were 98.3, 118/62, 90, 13, and 98%
RA. She received zofran 4 mg IV x1 and was sent directly to
dialysis before arrival to the floor. At dialysis she had 0.5 kg
removed via a right tunnelled line that had been placed one week
ago for plasmapheresis (she underwent plasmaphereis to remove
antibodies against daughter's antigens-- daughter will provide
the donor kidney).
Upon arrival to the floor from HD, she feels much better. She
denies nausea or vomiting, and is looking forward to eating
dinner. She denies chest pain, shortness of breath, or
lightheadedness. ROS is positive for vertigo, worse with sitting
and standing, that she says has been ongoing for three months.
She says she was seen by ENT yesterday for evaluation of the
vertigo and was prescribed acyclovir for ?Zoster infection,
which she has not yet started. However, it appears the vertigo
developed several weeks before she started immunosuppressants
(which she started one week ago). She denies facial rash or
burning. ROS otherwise unremarkable.
Past Medical History:
- End-stage renal disease, likely due to lithium toxicity
- Questionable history of temporal arteritis versus polymyalgia
rheumatica on prednisone
- Severe bipolar disorder, controlled with Lamictal and Celexa
- Hyperparathyroidism with hypercalcemia related to lithium
- Vertigo, on meclizine
- Gastroesophageal reflux disease
- Cholecystectomy in [**2144**]
- Right knee replacement in [**2144**]
- Left benign breast tumor resection 20 years ago
- Status post appendectomy
- History of difficult intubation
- [**2155-4-17**] living related renal transplant
-[**2155-5-1**] ex lap, LOA for SBO
Social History:
She used to work as secretary at the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] company, and
is retired since [**2146-4-9**]. She lives with her son and she has
four children. The patient denies any history of tobacco
smoking, alcohol abuse, or drug use.
Family History:
Her grandfather and one of her uncles suffered from Bright
disease. Her mother's sister died of breast cancer. Her uncle
had a history of melanoma, which was metastatic. Her father died
at age of 84 from congestive heart failure. Her mother died from
a severe stroke.
Physical Exam:
On Admission:
Vitals: 98.9, 144/78, 83, 18, 100% RA
General: a middle-aged woman in no apparent distress, with
appropriate affect, calm and cooperative
HEENT: EOMI, PERRLA, CNII-XII grossly intact
Neck: supple, no LAD
Heart: RRR, normal S1/S2
Lungs: CTA bilaterally, no crackles at bases
Abdomen: overweight, non-tender, normal bowel sounds
Legs: no pitting edema; 2+ DP pulses
Skin: no rashes
Neuro: AAOx3, moving all extremities
Pertinent Results:
[**2155-5-15**] 06:00AM BLOOD WBC-8.9 RBC-3.47* Hgb-10.4* Hct-30.1*
MCV-87 MCH-30.1 MCHC-34.7 RDW-18.5* Plt Ct-546*
[**2155-5-12**] 06:33AM BLOOD PT-12.8 PTT-23.9 INR(PT)-1.1
[**2155-5-15**] 06:00AM BLOOD Glucose-73 UreaN-25* Creat-0.7 Na-136
K-4.9 Cl-104 HCO3-23 AnGap-14
[**2155-5-10**] 05:27AM BLOOD ALT-64* AST-38 AlkPhos-162* TotBili-0.4
[**2155-5-14**] 06:44AM BLOOD Calcium-9.9 Phos-2.4* Mg-1.6
[**2155-5-13**] 05:30AM BLOOD tacroFK-6.9
[**2155-5-14**] 06:44AM BLOOD tacroFK-6.7
[**2155-5-15**] 06:00AM BLOOD tacroFK-6.4
Brief Hospital Course:
A 65 year-old woman with history of ESRD scheduled for LRRT
[**2155-4-8**] presenting with nausea and vomiting and emergent
induction of hemodialysis. She underwent HD without complication
and plasmapheresis to prevent transplant rejection. She received
Rituximab. Her transplant was postponed to 4/9/9 because it
seemed that she still had positive antibodies against her
daughters kidney, this however, turned out to be not
significant. She was continued on her immunosuppressant regimen
(cellcept/tacrolimus. She had an episode of fevers/chills and
was temporarily on vanc/zosyn, however, the sxs resumed and her
cultures remained negative.
On [**2155-4-17**] she underwent living related renal transplant from
her daughter. It was noted that she had a very thin posterior
fascia and peritoneum. Therefore, the
kidney was ultimately intraperitoneal in the retroperitoneal
space. The iliac vessels were soft without significant plaque.
The donor kidney had a single renal artery with an early
bifurcation and a single renal vein and a single ureter. The
kidney pinked up and produced urine. Please refer to operative
note. Postop, she was sent to the SICU due to volume overload
and respiratory difficulty. Respiratory function improved. Urine
output was excellent.
She received plasmapheresis postop transplant for HLA
desensitization related to transplant for 3 more treatments
postop for a total of none treatments. A total of 3 doses of
ATG were given postop op. Solumedrol was tapered. Prograf was
titrated to trough levels. Cellcept continued at 1 gram [**Hospital1 **].
Creatinine dropped to 0.6. Luminex was sent on [**4-22**]. Urine
output average 1.5 liters per day. BP was elevated to
180's/120s. Lopressor was uptitrated and Norvasc was started. BP
improved. Diet was advanced and tolerated. PT worked with her
and recommended a walker.
On postop day 4, she developed ecchymosis around incision with
extension to right hip and lower abdomen. She also started to
drain sero-sanguinous fluid from her incision.
On [**2155-4-21**], she fell in the bathroom after standing up from the
toilet striking her nose against the wall. She denied passing
out. She was alert and oriented. A stat head CT was done showing
no acute intracranial process. A sinus/[**Last Name (un) **]/max CT showed
questionable nondisplaced fracture of the nasal bone. She
developed bruising over her nose with mild-mod swelling. A
developed a frontal headache that was treated with tylenol and
iv pain medication.
She developed dizziness prompting a neurology consult on [**4-28**].
It was felt that this was not a vestibular process, but rather
findings were suggestive of cervical spondylosis with myelopathy
with dorsal column involvement, with impaired functional
position sensation given history of reduced range of motion of
the neck, upper motor neuron weakness at the deltoids, triceps,
and iliopsoas, reduced vibratory sensation, and brisk reflexes
throughout. Recommendations were for the her to wear a soft
cervical collar at all times for two weeks (if tolerated), then
at least at nightwhile sleeping thereafter.
Around postop day 6, her abdomen appeared distended and she
complained of nausea. The incision started to oozed at the
inferior edge. This was opened at the inferior edge. She
continued to have diffuse bruising aroun the RLQ. She developed
nausea with vomiting that appeared bilious. LFTs increased (alt
144, ast 148, alk phos 296, t.bili 6.8). LFTs were monitored
daily with continued rise. Hepatitis screening was done. This
was negative for HAV, HBsAG, HCV. Hemolysis workup was negative.
Liver duplex was done twice noting a small amount of perihepatic
fluid, no intra or extra-hepatic bile duct dilatation. GGT was
elevated suggestive of liver/biliary source of increased alk
phos that rose to 500 with t.bili of 4.9.
A KUB was done showing distended loops of small bowel. An NG
tube was place. Abd CT ([**4-25**])revealed distended small bowel with
decompressed distal small bowel and relatively decompressed
colon consistent with small bowel obstruction. There was a
transition point in RLQ. There was no evidence of perforation.
Normal liver without biliary abnormalities. Small amount of
perihepatic ascites. She was kept NPO. LFTs fluctuated daily.
She received IV hydration. She started to have flatus and bowel
movements. Bowel movements increased in frequency. On [**4-29**], the
NG tube was removed. KUB revealed persistenly dilated loops of
small bowel and air fluid levels. KUBs continued to show
distended loops with air fluid levels despite BMs.
Nausea/vomiting and diarrhea continued. The NG was replaced.
LFTs improved. On [**5-1**], she was taken to the OR by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] for exploratory laparotomy and lysis of adhesions.
Postop diagnosis was small bowel obstruction. A wound vac was
applied to the lower portion of the incision that was opened.
Despite the vac, the wound continued to drain serous fluid. The
wound vac was discontinued and a gauze dressing was applied.
Drainage stopped and a topical dry gauze dressing was applied as
the wound healed.
She remained npo with an NG tube in place. Given prolonged npo
status, TPN was started. She developed watery diarrhea. Stool
cultures were negative. A CMV viral load was negative. Cellept
decreased to 500mg 3x/day.
Imodium was started. Diarrhea resolved. NG was removed and diet
slowly advanced and tolerated. TPN was discontinued. Ensure
supplements were tolerated tid. Imodium was discontinued.
On [**5-13**], hematocrit was 22.6. She was given 2 units of PRBC with
a hct increase to 28. She stabilized at 30.
PT recommended rehab was recommended. She was screened and
accepted at NE [**Hospital1 **]. Prograf was increased to 6mg [**Hospital1 **] on [**5-15**]
for a trough level of 6.4. Goal trough prograf level is 10. She
was left on prednisone 20mg qd due to high sensitivity to her
donor. She will require labs on [**5-16**] for chem 7 and a trough
prograf with results called to [**Telephone/Fax (1) 673**]. Labs should then be
done every Monday and Thursday.
Medications on Admission:
Lanthanum 1000 mg PO TID W/MEALS
Lamotrigine 250 mg PO DAILY
Calcitriol 0.25 mcg alternating with 0.5 mcg PO EVERY OTHER DAY
Meclizine 25 mg PO BID
Mycophenolate Mofetil 500 mg PO BID
Citalopram Hydrobromide 40 mg PO DAILY
Omeprazole 20 mg PO BID
Colestid 1 gram Oral DAILY
PredniSONE 5 mg PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Tacrolimus 2 mg PO Q12H
Sodium bicarbonate 1 teaspoon PO BID
Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
neb Inhalation Q6H (every 6 hours) as needed for sob/cough.
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
14. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
15. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day.
16. Outpatient Lab Work
stat Labs [**5-16**] for chem 7 and trough prograf level am
call results to [**Telephone/Fax (1) 673**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
End-stage kidney disease secondary to lithium toxicity
smal bowel obstruction
Diarrhea
incision cellulitis
Fall
.
Secondary Diagnoses
Temporal arteritis versus polymyalgia rheumatica on prednisone
Severe bipolar disorder, controlled with Lamictal and Celexa
Vertigo
Gastroesophageal reflux disease
Discharge Condition:
stable
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you experience
fever, chills, nausea, vomiting, abdominal pain/distension,
worsening diarrhea or decreased urine output
Labs every Monday and Thursday
No heavy lifting
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2155-5-14**] 10:30
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2155-5-20**] 9:00
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2155-5-27**] 10:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5457**] Call to schedule
appointment
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 673**] Call to schedule
appointment
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 673**] Call to schedule
appointment
Completed by:[**2155-5-15**]
ICD9 Codes: 5856, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2507
} | Medical Text: Admission Date: [**2163-1-23**] Discharge Date: [**2163-1-25**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
aphasia, increasing somnolence
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 86yo female with history of mild HTN and anemia
presenting with acute altered mental status found to have large
left intracranial hemorrhage. She was in usual state of health
today and was doing well when she awoke this morning. Around
845am after her two sons had a verbal argument she was heard
falling to kitchen floor. When her sons came to the room they
found her awake, eyes open and able to move all extremities.
She
was non-verbal and did not seem to understand what they were
saying. EMS was called and she bacame more somnolent when they
arrived. She was taken to an OSH where upon arrival she had
emesis, questionable sz activity and She was intubated. GCS 3.
CT showed large left BG bleed. She received manitol and
dilantin
and was transferred to [**Hospital1 18**] for neurosurgical evaluation. Upon
arrival she was again noted to be GCS 3 off sedation. She had a
repeat CT showing large left BG hemorrhge with 10mm of midline
shift and mild left uncal herniation. Neurosurg was consulted
and felt surgical intervention was not indicated. Neurology was
consulted to aid in continuing of care.
ROS:
unable to obtain
Past Medical History:
according to sons she is very active and has not chronic medical
issues. She told them her BP was a little high but she was
never
on meds.
She has mild anemia
Social History:
Lives with 2 sons, one of which was recently diagnosed with
rectal cancer. It has been stressful to her. No tobacco.
Occaisonal EtOH
Family History:
Cancer, HTN
Physical Exam:
PE:
HEENT AT/NC, MMM no lesions; NG with brownish drainage
Neck Supple, no bruits
Chest CTA B
CVS RRR,
ABD soft, NTND, + BS
SKIN
NEUROLOGICAL
MS: exam on sedation
No eye opening or grimace with sternal rub
Left pupil 3 and nonreative, right 1 and minimal reactive, trace
corneal relfex bilateral, trance gag, no occulocephalics
RUE flaccid, no withdrawl
RLE Triple flex v. withdrawl to pain
LUE withdrawl to pain
LLE withdrawl to pain
Toes up bilateral
Pertinent Results:
[**2163-1-24**] 02:58AM BLOOD WBC-12.1* RBC-3.17* Hgb-10.0* Hct-28.6*
MCV-90 MCH-31.4 MCHC-34.8 RDW-14.2 Plt Ct-180
[**2163-1-23**] 12:30PM BLOOD WBC-11.2* RBC-3.54* Hgb-10.5* Hct-32.2*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.1 Plt Ct-231
[**2163-1-24**] 02:58AM BLOOD Plt Ct-180
[**2163-1-24**] 02:58AM BLOOD PT-12.7 PTT-25.9 INR(PT)-1.1
[**2163-1-24**] 02:58AM BLOOD Glucose-149* UreaN-13 Creat-0.9 Na-139
K-4.8 Cl-106 HCO3-22 AnGap-16
[**2163-1-24**] 02:58AM BLOOD Triglyc-58 HDL-79 CHOL/HD-2.3 LDLcalc-88
[**2163-1-24**] 02:58AM BLOOD Phenyto-23.6*
Imaging:
CT head:
IMPRESSION:
1. Large left basal ganglia hemorrhage with areas of hypodensity
concerning for hyperacute bleeding. Subfalcine herniation of
approximately 12 mm and mild left-sided uncal herniation is
noted.
2. Effacement of the left lateral ventricle and dilation of the
right lateral ventricle. Bilateral intraventricular hemorrhage
identified. Diffuse left- sided sulcal effacement.
Brief Hospital Course:
Pt is a 86 yo LHF with mild HTN, anemia presenting with large
left basal ganglia hemmorhage, with intraventricular extension,
likely secondary to HTN. The patient has very poor prognosis of
meaningful recovery.
She was intubated at an OSH and sent to [**Hospital1 18**]. She was admitted
to the neuro-ICU for further care. She was started on mannitol.
Given the over poor prognosis and hope of recovery, a pallative
consult was initiated. The team met with the family about
withdrawal of care. It was decided to extubate the patient on
[**2163-1-24**] and make the patient comfort measures only. She was
discharge to home hospice. We informed the family that she may
not make the journey home but they wanted to try. She will be
transported home today
Medications on Admission:
iron tabs
Discharge Medications:
Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO q4:prn:
2-4mg as needed for comfort, if iv fails.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 83590**] Hospice
Discharge Diagnosis:
Left basal ganglia hemorrhage
Discharge Condition:
Non responsive, negative dolls eyes, no corneal or gag reflexes,
agonal breathing
Discharge Instructions:
You were admitted after a fall and an inability to speak. You
continued to worsen. You were taken to an outside hospital were
you were intubated and were found to have a very large bleed.
You were sent to [**Hospital1 18**] for further care. The prognosis of
recovery was very poor you were made comfort care and sent home
with hospice.
Followup Instructions:
none
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2508
} | Medical Text: Admission Date: [**2178-8-22**] Discharge Date: [**2178-9-14**]
Date of Birth: [**2093-4-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lactose
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Intubation for mechanical ventillation [**2178-8-26**], extubated on
[**2178-8-28**]
PICC line placed by interventional radiology [**2178-8-27**]
History of Present Illness:
Ms. [**Known firstname 636**] [**Known lastname 107551**] is 85 year old woman with history of HTN, CAD
s/p MI, PAF (not on coumadin), CVA who presents from her nursing
home with several days of decreased po intake, hyponatremia,
increased leg edema, and now lower blood pressures. Per her
aide the patient has had chronic left lower leg edema (history
of L hip fracture) and in the last several weeks has developed
new RLE edema. She has also had significant decrease in
appetite in the last several weeks to the point that this week
she was only eating a few bites at each meal. Per medical
records her electrolytes were checked on [**2178-8-20**] which revealed a
sodium of 123. She was subsequently started on NaCl tablets (1
po bid) on [**2178-8-21**]. Today her aide was concerned that she was
having episodes of decreased responsiveness. She called the
patient's daughter and the nursing home subsequently transferred
her to [**Hospital1 18**] ED for further evaluation.
.
In ED initial vital signs were HR 79 BP 68/45 T 99.8 RR 20 SpO2
98% 4L. Physical exam was positive for elevated JVD and lower
extremity edema. Labs were significant for Na 122, Cr 0.2,
Lactate 0.8, UA positive for [**10-2**] WBC and many bacteria. CXR
was concerning for a right middle lobe infiltrate. She was
started empirically on vancomycin, azithromycin, and
ceftriaxone. She was given a total of 3 L IV NS for her
hypotension with only a minimal response. A right IJ CVL was
placed and levophed was started. Vital signs prior to transfer
to the ICU were HR 124 BP 121/52 (on 0.25 levophed) RR 17 SpO2
97% NRB.
.
On arrival to the ICU floor patient denies specific complaints.
On questioning she admits to feeling cold. She admits to an
occasional cough at night productive of white sputum. She
reports a history of chest pain but no recent episodes. She
reports that when sitting up she occasionally feels lightheaded.
She denies any loss of consciousness. She endorses having a poor
appetite due to early satiety. She denies fever, nausea,
abdominal pain, diarrhea, vomiting, rash.
.
At baseline she is alert and oriented, nonambulatory and
dependent for most ADLS. She is incontinent of bowel and
bladder. Her baseline blood pressures range from 101-118/66-70.
Past Medical History:
HTN
CVA multiple (most recent [**2173**])
CAD s/p MI
Atrial fibrillation (not on coumadin)
Recurrent UTIs (hx of VRE)
Delirium
Depression
Osteoporosis
Glaucoma
L hip fracture
Social History:
Patient has been a resident of [**Location 583**] House Rehab since [**10-24**].
She is divorced. She is nonambulatory and dependent of most
ADLs. She has two children (one daughter in [**Name (NI) **] and a son in
[**Name2 (NI) **]). She has a remote smoking history. She smoked at most a few
cigarettes per day and quit in the [**2147**]. No recent history of
any alcohol use.
Family History:
Non-contributory
Physical Exam:
ED initial vital signs were HR 79 BP 68/45 T 99.8 RR 20 SpO2 98%
4L
GA: Cachectic, fatigued, AOx3 (unable to state date/day of week
but knew it was beginning of [**2178-8-19**])
HEENT: PERRLA 2mm-->1mm. very dry MM. no LAD. elevated JVD. neck
supple, R IJ in place
Cards: irregular heart beat, distant heart sounds, no MRG
Pulm: poor inspiratory effort but decreased breath sounds in
RML, no crackles, wheezes, rhonchi
Abd: soft, NT, +BS. no rebound, no guarding, no suprapubic or
CVA tenderness
Extremities: L leg shortened, bilateral legs externally rotated,
RUE contracted, bilateral feet are cool, [**1-21**]+ edema BLE
symmetric,
Skin: warm, dry, no rashes, no ulcers
Neuro/Psych: slow speech, flat affect, appears tired, PERRL,
EOMI, faint R sided nasolabial fold flattening, follows simple
commands, answers questions appropriately, moves all four
extremities. Denies numbness.
Pertinent Results:
ADMISSION LABS:
[**2178-8-22**] 01:15PM BLOOD WBC-13.2* RBC-3.80* Hgb-11.6* Hct-36.2
MCV-95 MCH-30.6 MCHC-32.1 RDW-13.9 Plt Ct-198
[**2178-8-22**] 01:15PM BLOOD Neuts-94.7* Lymphs-3.2* Monos-1.8*
Eos-0.1 Baso-0.2
[**2178-8-22**] 01:15PM BLOOD PT-12.3 PTT-30.5 INR(PT)-1.0
[**2178-8-22**] 01:15PM BLOOD Glucose-107* UreaN-9 Creat-0.2* Na-122*
K-3.4 Cl-84* HCO3-28 AnGap-13
[**2178-8-22**] 05:08PM BLOOD ALT-39 AST-55* LD(LDH)-260* CK(CPK)-63
AlkPhos-58 TotBili-0.3
[**2178-8-22**] 05:08PM BLOOD CK-MB-9 cTropnT-0.06* proBNP-8601*
[**2178-8-23**] 01:33AM BLOOD CK-MB-9 cTropnT-0.07*
[**2178-8-22**] 05:08PM BLOOD Albumin-3.0* Calcium-7.5* Phos-3.0
Mg-1.2*
[**2178-8-23**] 01:33AM BLOOD Osmolal-253*
[**2178-8-22**] 05:08PM BLOOD TSH-0.68
[**2178-8-23**] 01:33AM BLOOD Cortsol-28.2*
[**2178-8-22**] 06:26PM BLOOD Type-ART pO2-189* pCO2-79* pH-7.24*
calTCO2-36* Base XS-3
MICROBIOLOGY:
[**2178-8-22**] Blood Cultures x 2: negative
[**2178-8-23**] Blood Cultures: negative
[**2178-8-22**] Urine Culture: negative
[**2178-8-22**] Urine Legionella: negative
[**2178-9-5**]: CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final
[**2178-9-5**]):
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
[**2178-8-22**] CXR:
Limited study due to lack of lateral view and patient's
positioning. Incompletely evaluated left retrocardiac opacity.
If clinically feasible, recommend repeat with PA and lateral
chest radiographs for better evaluation. Patchy right base
opacity, raises concern for infection and/or aspiration.
Prominent bronchi with peribronchial thickening are noted in the
right infrahilar region, suggestive of bronchiectasis and
possible chronic inflammation.
[**2178-8-22**] HEAD CT:
1. Limited study by motion artifacts, but no evidence of
hemorrhage.
2. Moderate global atrophy, likely age related.
Moderate-to-significant
chronic microvascular ischemic disease.
3. Fluid in left mastoid air cells.
[**2178-8-23**] CHEST CT:
1. Moderate-to-large right and moderate left simple-appearing
pleural
effusions with intrafissural fluid on the right. There
collapse/consolidation of both right and left lower lobes,
likely related to compression atelectasis, although
superinfection cannot be excluded.
2. Soft tissue anasarca.
3. Severe mitral annular calcification.
4. 4-mm right middle lobe pulmonary nodule is likely benign;
however, if the patient is at high risk for intrathoracic
malignancy, a followup chest CT in one year can be obtained to
document stability [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] Society guidelines.
[**2178-8-25**] TTE:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation (however may be underestimated due to
shadowing). There is moderate posterior leaflet mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
[**2178-8-27**] MRI C/T SPINE:
1. No high-grade cervical or thoracic spinal canal narrowing.
2. High signal within the central mid-thoracic spinal cord may
represent a
syrinx or prominent central canal.
3. Hetrogeneous thoracic aorta flow void, which may represent
low flow or
artifact.
[**2178-8-27**] MRI HEAD:
There is no evidence of acute infarct or mass. Again
demonstrated
is extensive increased FLAIR/T2 signal within the cerebral white
matter and brainstem compatible with underlying microvascular
changes. There is a focal chronic lacunar infarct in the left
pons without diffusion restriction. A region of susceptibility
artifact within the left thalamus has no correlate on the recent
CT and shows no surrounding edema, likely a remote focus of
hemorrhage or a small microcalcification. There is no evidence
of acute hemorrhage. Major intracranial flow voids are
preserved. Again demonstrated is fluid within the left greater
than right mastoid air cells.
IMPRESSION:
1. Age-related volume loss with microvascular changes. No
evidence of acute intracranial pathology.
2. Persistent left greater than right mastoid effussions.
[**2178-8-27**] US RUE:
Thrombosis of the left brachial vein
[**2178-9-3**] EEG: Abnormal EEG due to the slow and disorganized
background.
This indicates a widespread encephalopathy. Medications,
metabolic
disturbances, and infection are among the most common causes.
There
were no persistent areas of focal slowing, but encephalopathies
may
obscure focal findings. There were no clearly epileptiform
features.
An abnormal cardiogram was noted intermittently.
[**9-10**] CXR:
1. Tracheostomy approximately 2.7 cm above the carina.
2. Unchanged appearance of bilateral pleural effusions, right
greater than
left with associated atelectasis and retrocardiac opacity.
DISCHARGE LABS:
WBC Hgb Hct Plt Ct
[**2178-9-14**] 5.3 7.8 24.6 331
Glucose UreaN Creat Na K Cl HCO3
[**2178-9-14**].1 140 3.9 105 30
Brief Hospital Course:
HYPERCARBIC RESPIRATORY FAILURE:
Shortly after admission Ms. [**Known lastname 107551**] had an episode of
unresponsiveness in the ICU, similar to what had been happening
in the nursing home according to her health aide. Her ABG
revealed hypercarbia of pCO2 79. She is without any known
chronic lung disease, though recent labs from [**2178-8-20**] did show
HCO3 of 38 suggesting this may be a chronic process. She had
altered mental status and required non-invasive ventillation.
Her acid-base status normalized and her mental status improved
for several days.
However, overnight from [**Date range (1) 3923**]/10, she developed
unresponsiveness and apnea with hypercarbic respiratory failure
requiring intubation for a PCO2 of 78. She was extubated on
[**2178-8-28**] without any complications. On [**2178-9-4**] she was again
found to be hypercarbic, this time to 132. She was again
re-intubated. It was felt that her hypercarbic respiratory
failure was not fully reversible and she underwent trach/PEG
placement on [**9-9**] without complications.
Prior to discharge she was weaned to pressure support [**7-23**] with
FiO2 of 35%.
Health Care Associated Pneumonia:
She received a seven-day course of vancomycin and cefepime for
healthcare-associated pneumonia beginning on admission. Given
her multiple episodes of hypercarbic respiratory failure and
concern for repeated need for intubation, the family decided to
proceed with tracheostomy which was done without complication.
NUTRITION, DECREASED PO INTAKE:
Ms. [**Known lastname 107551**] has had low PO intake in the weeks preceeding her
admission and had poor intake initially in house, as well. Her
hyponatremia and hypovolemia on admission was consistent with
this (a so called tea-and-toast diet). Albumin was 3.0 on
admission. She had a swallow evaluation on [**2178-8-25**] which showed
no overt signs of aspiration. Given need for long term
intubation family wished for gastric feeding tube placement.
She had a PEG placed on [**9-9**] without complication and tube feeds
were running at goal.
SEPSIS:
Ms. [**Known lastname 107551**] was hypotensive to 68/45 on admission. She was
started on levophed after BP did not improve significantly with
3L IVF. She was started empirically on vancomycin, meropenem
and azithromycin in the MICU for possible sepsis. Blood
cultures were negative. UA showed [**11-2**] WBC but was negative
for LE and nitrites and urine culture returned negative. She
was continued on vancomycin and cefepime for possible [**Company 191**]
pneumonia and was weaned from levophed by [**2178-8-24**]. Transthoracic
echo from [**2178-8-25**] showed EF 55% with no wall motion abnormalities
and minimal valvular disease, suggesting against cardiogenic
source for hypotension. She ulitmately was c. diff positive
([**9-5**]) which likely explains her sepsis. She was treated for
severe c/ diff with iv flagyl and po vancomycin (day 1 = [**9-5**])
for a total of 2 weeks. Last day should be [**9-18**].
RUE DVT:
Ultrasound of the right upper extremity was ordered to evaluate
swelling, and
She was started on lovenox 40 mg [**Hospital1 **] to treat the DVT. Her
family remarked she has had bleeding complications while on
coumadin in the past and has a history of hemorrhagic CVA.
DEPRESSION:
Ms. [**Known lastname 107551**] was suspected of being depressed over the last few
weeks to months. Her family was concerned her wishes to be
DNR/DNI and her refusal for a feeding tube, which were both
expressed to mulitple housestaff and nurses, were the result of
her depression and that these are not her true wishes. She was
started on mirtazipine 15 mg QHS on [**2178-8-25**] for its effects on
mood as well as appetite and sleep, as she had also been having
sleeping difficulties. This medication was discontinued on
[**2178-8-26**] given concern that it had contributed to respiratory
depression. Geriatrics was consulted on [**2178-8-26**] to help address
the issue of depression and general goals of care with the
family. They recommended starting no new meds for now given
concern for polypharmacy on patient's mentation. TSH was
checked and was 0.68.
ATRIAL FIBRILLATION: Patient occasionally had rapid ventricular
response. She was maintained on Metoprolol 12.5mg po bid. Her
blood pressure tends to drop with this dose, so she often
required a 500cc fluid bolus after AM metoprolol. Would hold
metoprolol if systolic BP<100.
CODE: FULL -confirmed with patient and health care proxy
Medications on Admission:
Acetaminophen prn
KCl 20 meq M,W,F
NaCL 1 tablet [**Hospital1 **] po (started on [**2178-8-21**])
Ramipril 10 mg po daily
Genteal lube 0.3% 1 gtt each eye
Cranberry fruit 425 mg 1 cap po bid
Oyster Shell Calcium w vitamin D 1 tab po bid
Prilosec 20 mg po bid
Brimonidine tartrate 1 gtt each eye q12h
Metoprolol 100 mg po bid
Detrol LA 4 mg po qhs
Lipitor 40 mg po qhs
Senna 2 tabs po qhs
Travatan Z Benzal 0.004% 1 gtt each eye qhs
Fosamax qSunday
Fleet Enema daily prn constipation
Bisacodyl 10 mg PR prn constipation
Milk of Magnesium 30 mL daily prn constipation
Prochlorperazine 10 mg tablet q6h prn nausea
Discharge Medications:
1. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) tab PO Q6H
(every 6 hours) as needed for pain,fever.
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H
(Every 12 Hours).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Last day [**9-18**].
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Last day [**9-18**].
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
16. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day) as needed for
abdominal pain.
17. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
19. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
20. Lipitor 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
21. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis:
Hypercarbic respiratory failure
Septic shock secondary to Clostridium Difficile Colitis
Urinary tract infection
Health care associated pneumonia
Secondary diagnosis:
Atrial Fibrillation
Malnutrition
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 107551**],
It was a pleasure caring for you in the hospital. You were
admitted with a low blood pressure. You were found to have C
diff, an infection of your bowels causing this low blood
pressure. You are being discharged on Vancomycin and Flagyl for
this infection. You also had a urinary tract infection, and a
pneumonia. You were unable to breathe by yourself, so you were
intubated, and subsequently received a trach and peg. You will
be receiving tube feeds through the peg.
We made multiple changes to your medications. Please see the
attached list.
Followup Instructions:
Please follow up with your primary care doctor.
Completed by:[**2178-9-14**]
ICD9 Codes: 486, 5070, 2761, 2762, 4019, 412, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2509
} | Medical Text: Admission Date: [**2148-11-4**] Discharge Date: [**2148-11-15**]
Date of Birth: [**2074-11-29**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Penicillins
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
PICC line placement
PEG tube placement/Upper Endoscopy
History of Present Illness:
73 year-old man with a mechanical aortic valve and atrial
fibrillation, on coumadin and plavix, recent CVA of unclear
type, and prostate cancer. He was admitted [**11-4**] to an OSH with
lightheadeness and CT showed L parietal IPH of 2.6 cm. He was
transferred to [**Hospital1 18**] for neursurgical evaluation.
At [**Hospital1 **], neurosurgery did not think any surgical intervention was
needed. Anticoagulation was reversed with FFP and he was
admitted to the ICU.
In the ICU, CXR suggested likely aspiration pneumonitis, but
given low-grade fevers blood cultures were drawn and Unasyn
started. Repeat CT showed unchanged hematoma with surrounding
vasogenic edema but no obvious underlying mass. Neurosurgery
continued to follow and recommended only neuro checks every 4
hours. They recommended starting lovenox 2 weeks after the bleed
event and follow-up repeat CT scan 2 days after with follow up
in Dr.[**Name (NI) 935**] clinic 1 month after the bleed. They agreed with
starting subcutaneous heparin immediately.
Past Medical History:
- Aortic insufficiency and root dilation secondary to rheumatic
fever, left ventricular outflow tract reconstruction including a
mechanical aortic valve and a biosynthetic aortic root graft at
[**Hospital1 2025**] [**2127**]
- CHF (details unknown)
- Type II Diabetes, on metformin at home
- Atrial Fibrillation, on coumadin at home
- R Frontal CVA [**2148-9-3**] (hospitalized at [**Hospital **]
Hospital); discharged from rehab early [**Month (only) 359**]. Residual
swallowing difficultly, L UE and LE weakness. Unclear if embolic
vs. hemorrhagic.
- Prostate cancer, s/p prostatectomy
- Diverticulitis, s/p resection
- R shoulder surgery, details unknown
Social History:
Living with girlfriend [**Name (NI) 3551**] (rents room from her, also lived
with her prior to the stroke). She helps him climb stairs and
generally requires full care at home since his stroke. Has
nursing and PT/OT and speech VNAs at home. No alcohol,
cigarettes, or illicit drug use.
Family History:
Daughter denies any significant family history/unknown.
Physical Exam:
GENERAL: Cachectic male sleeping sitting up, awakes to verbal
stimuli but falls asleep between questions.
HEENT: Normocephalic, atraumatic. No scleral icterus. PERRL 4 to
2mm. Will not look to extreme right and with ?absent vision in
right upper and lower fields. Mucous membranes dry. OP clear.
Neck: Supple, no thyromegaly. Somewhat firm R sided posterior
cervical lymph node, nontender and mobile. No other adenopathy.
CARDIAC: Regular rhythm with frequent PVCs, normal rate. Normal
S1, S2. +prominent mechanical click. No murmurs, rubs or
[**Last Name (un) 549**]. JVP flat when upright.
LUNGS: CTAB except for slight crackles at bilateral bases.
ABDOMEN: NABS. Soft, ND. No HSM. Reports mild diffuse TTP, no
rebound.
EXTREMITIES: Slight non-pitting edema around ankles. No calf
pain, 2+ dorsalis pedis/ posterior tibial pulses. No axillary
adenopathy. Does have small bilateral subcentimeter inguinal
nodes.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&O to person and year, not place or date. Appropriate.
CN 2-12 grossly intact except for ? slight right sided neglect.
Preserved sensation throughout. Does not fully cooperate with
strength exam, but appears symmetric - best exam currently [**4-7**]
in elbow flex, extend, wrist extend, and grip in UEs and
generally symmetric; 4-/5 in L dorsi and plantarflexion and [**4-7**]
in R dorsi and plantarflexion. 1+ reflexes, equal BL. Gait
assessment deferred
PSYCH: Slow in responding to questions, otherwise appropriate.
Pertinent Results:
[**2148-11-12**] 06:20AM BLOOD WBC-10.6 RBC-3.59* Hgb-9.1* Hct-27.0*
MCV-75* MCH-25.2* MCHC-33.6 RDW-19.0* Plt Ct-308
[**2148-11-11**] 07:20AM BLOOD PT-13.2 PTT-27.8 INR(PT)-1.1
[**2148-11-12**] 06:20AM BLOOD Glucose-116* UreaN-22* Creat-1.0 Na-132*
K-4.4 Cl-94* HCO3-31 AnGap-11
[**2148-11-11**] 07:20AM BLOOD ALT-28 AST-23 AlkPhos-78
[**2148-11-4**] 08:35PM BLOOD TSH-1.4
[**2148-11-11**] 07:20AM BLOOD CRP-88.6*
[**2148-11-11**] 07:20AM BLOOD ESR-55*
________________________________________________
[**2148-11-5**] 3:55 pm BLOOD CULTURE (x4) Source: Venipuncture.
Blood Culture, Routine
VIRIDANS STREPTOCOCCI. further identification on request.
FINAL SENSITIVITIES. Sensitivity testing performed by
Sensititre.
SENSITIVITIES: MIC expressed in MCG/ML
VIRIDANS STREPTOCOCCI
CLINDAMYCIN----------- =>2 R
ERYTHROMYCIN---------- =>4 R
PENICILLIN G---------- 0.5 I
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final [**2148-11-6**]):
GRAM POSITIVE COCCI IN LONG CHAINS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] #[**Numeric Identifier 83961**] [**2148-11-6**] 11:50AM.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name 17975**] CC6D [**2148-11-6**] 11:45AM.
Aerobic Bottle Gram Stain (Final [**2148-11-6**]):
GRAM POSITIVE COCCI IN LONG CHAINS.
_______________________________________________
STUDIES:
CT head [**11-4**]: Large focus of intraparenchymal blood with
surrounding edema in the left parieto-occipital area. Comments
regarding evolution of this finding are not possible without the
comparison study. These findings raise the possibility of an
underlying mass (mets, primary or vascular malformation) which
would be better assessed with MRI.
CXR at OSH: Mild cardiomegaly. Valve prosthesis. Mild vascular
congestion. Ill defined L basilar density - small pleural
effusion or infiltrate/atelectasis of LLL.
ECG [**11-5**]: regular atrial rhythm with frequent PACs (overall rate
90) ?sinus with somewhat unusual P wave axis. LAD/LAFB. no
significant change compared to old.
L Rib films [**11-8**]: no fracture or metastates
CT TORSO [**11-8**]:
CHEST CT WITH IV CONTRAST: The patient is status post aortic
valve and aortic root replacement. The descending thoracic aorta
is measures up to 4.3 cm in diameter. There is trace pericardial
fluid. Mediastinal lymph nodes measure up to 10 mm. The central
pulmonary arteries opacify normally. The airways are patent
bilaterally to the subsegmental level.
There is bibasilar atelectasis, left greater than right.
High-density
material within the left lower lobe is likely related to
aspiration from the recent modified barium swallow. There is
fluid within the left lower lobe bronchus. The nasogastric tube
courses through the esophagus to terminate in the stomach. There
are no focal pulmonary masses or nodules.
CT ABDOMEN WITH IV AND ORAL CONTRAST: There is a large
wedge-shaped filling defect of the spleen with a small amount of
perisplenic fluid. Fluid extends into the left paracolic gutter.
Small hypodense lesions in the liver, too small to characterize,
measure up to 11 mm in diameter are identified. The gallbladder,
pancreas and adrenals are There is a wedge-shaped defect in the
right kidney, concerning for infarct. A left renal cyst arising
from the interpolar region measures 5.9 cm in diameter. Surgical
clips at the gastroesophageal junction, result in streak
artifact at this level.
There is hypodense lesion in the midline anterior mesentery
(image 102 of
series 2) closely associated with the mesenteric vessels. This
is of
uncertain etiology. The stomach, small bowel and colon are
normal in caliber. There is no pneumatosis. There is evidence of
prior bowel surgery with the anastomosis in the midline abdomen
and a distal colonic anastomosis in the pelvis.
The psoas muscles are symmetric, without evidence of abscess.
The abdominal aorta is tortuous with atherosclerotic
calcifications that extend into the iliac arteries.
CT PELVIS WITH IV AND ORAL CONTRAST: There is gas in the
non-dependent
portion of the urinary bladder. A left inguinal hernia contains
nondilated
bowel. There are surgical clips in the left inguinal region
which likely
relates to prior herniorrhaphy. The patient has had a
prostatectomy.
There are no osseous lesions concerning for malignancy. A
lucency in the
right transverse process of L1 may relate to may be a congenital
finding or relate to prior fracture. There are degenerative
changes of the thoracic and lumbar spine.
CT TORSO
1. Fluid in the left lower lobe bronchus. High-density left
lower lobe
consistent with aspiration of barium from a modified barium
swallow.
2. Left lower lobe atelectasis/consolidation.
3. Large wedge-shaped hypodense splenic lesion and right kidney
wedge-shaped defect consistent with infarcts.
4. Low-attenuation focus in the mesentery associated with
mesenteric vessels. This is of unclear etiology, but could be
infarct. There are no secondary signs of bowel ischemia.
5. Gas in the non-dependent portion of the urinary bladder which
may be
related to instrumentation. Please correlate clinically.
6. Left inguinal hernia containing non-dilated small bowel.
7. No evidence of malignancy of the chest, abdomen, or pelvis.
Transesophageal ECHO [**2148-11-11**]
IMPRESSION: Probable vegetation on bileaflet AVR supporting
ring. Trace aortic regurgitation. Mitral valve prolapse with
mild mitral regurgitation. Dilated descending thoracic aorta.
MR thoracic and lumbar spine without contrast [**2148-11-13**]
1. Likely discitis and osteomyelitis at L2-3 without associated
soft tissue mass or epidural extension. The spinal canal is
patent throughout the thoracic and lumbar spine. Clinical
correlation and gallium scan can help for further assessment.
2. Additional degenerative changes of the lumbar spine without
significant
neural impingement.
Brief Hospital Course:
# Intraparenchymal bleed: New large focus of intraparenchymal
blood with surrounding edema in the left parieto-occipital area
seen on head CT, concerning for intraparenchymal bleed vs
underlying mass from metastasis, primary tumor, or vascular
malformation, better assessed by MRI but was not obtained due to
concern for mechanical aortic valve. This new area on L not
involved with old infarct area on R. Clopidogrel and Coumadin
were held and pt was given 2 units of FFP. INR trended down
appropriately. S/P 10mg IV Vit K at OSH. Neurosurg consulted but
did not recommend intervention, but reversal of anticoagulation
and frequent neuro checks. Repeat CT head with contrast showed
stable and unchanged hematoma with associated edema on L. Pt on
Keppra for prophylaxis for a total 1 month course. SBP was
maintained less than 140. NSurg recs with plan to start re-start
coumadin 1 week prior to repeat CT scan and follow up with Dr.
[**First Name (STitle) **] at [**Hospital1 **] on [**2148-12-5**] for follow-up of intraparenchymal bleed.
#Endocarditis: Patient had blood cultures form [**2148-11-5**] and
[**2148-11-6**] that were [**4-6**] positive for viridans streptococcus. A
TEE was performed that demonstrated vegetation on the ring of
his prosthetic aortic valve, with no evidence of valve
malfucntion. PR interval was slightly prolonged at admission,
but improved with antibiotic coverage. He was treated with
vancomycin (started [**2148-11-6**]) and gentamicin (started [**2148-11-8**])
with plan for minimum 6 week course of vancomycin and 2 week
course of gentamicin. He received a total of 1 week's worth of
antibiotics while in the hospital.
# Atrial valve replacement: Planned to restart coumadin 1 week
prior to neurosurgery appointment as above.
# Confusion: Per daughter, not far from post-CVA baseline.
Unclear if this new event has affected his baseline. TSH was
normal. The patient remained somewhat confused after this event,
somewhat somlemnent but easily arousable. Consistently oriented
to person and place. He has limited short term memory but
remained able to remember faces and names of family members.
The patient has bilateral hearing aides and glasses, which
improved his confusion.
# Weight loss: In setting of possible met to brain, had CXR and
CT torso to eval for malignancy, which was not seen. PSA to eval
for prostate ca was normal. TSH was normal. This was thought to
be secondary to indolent infection and patient's swallowing
difficulties after his first stroke in [**Month (only) 462**].
# RLL aspiration pneumonitis: Patient on 1000 mg Q12h
vancomycin (started [**2148-11-6**]) and gentamycin 70 mg q12h (started
[**2148-11-8**]) for endocarditis. Clinical exam improving. Patient is
also on clindamycin 600 q8h for aspiration pneumonia, but this
was stopped given improvement of clinical picture and
endocarditis source of infection. Urine legionella antigen was
negative.
# Anemia: Iron studies consistent with anemia of chronic
disease.
# h/o CHF: Unclear status of this. Was not an active issue
inpatient.
# h/o CAD: CE's unimpressive x2, without EKG changes. Plavix (on
due to ASA allergy) was held as above.
# DM: Daughter reports on insulin but unclear how much. Started
on sliding scale but BS's in the 100's consistently throughout
his hospital stay.
# Nutrition: Had difficulty swallowing at baseline, that had
been an issue since his stroke in [**Month (only) 462**]. The patient failed
speech and swallow x2, and a peg tube was placed for nutrition.
He was started on fibersource HN with goal of 70mL/hr for total
of [**2154**] kcals 89g protein a day
#Code status, goals of care: Discussed with daughter and
patient, however the daughter appeared not to fully comprehend
the full scope of the patient's disease. Currently, the patient
and his family indicated that they are full code. Would like
all acute care, but would probably not want long-term
ventilation or intensive care. Given the patient's critical
illness and poor long-term prognosis, further future discussions
concerning his goals of care are warranted.
EMERGENCY CONTACT: Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 83962**] or
[**Telephone/Fax (1) 83963**]).
Medications on Admission:
Home Medications:
Plavix 75mg daily
Omeprazole 20mg daily
Lasix 40mg daily
Coumadin 6.5mg daily
Insulin therapy per daughter (unknown how much or what type)
Folic Acid
Meds on transfer from ICU to medical floor:
Heparin 5000 UNIT SC TID
Vancomycin 1000 mg IV Q 12H
Potassium Chloride PO/NG Sliding Scale
Clindamycin 600 mg IV Q8H
Insulin Sliding Scale
Sarna Lotion 1 Appl TP QID:PRN itch
Pantoprazole 40 mg IV Q24H
LeVETiracetam 500 mg IV BID
Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
Senna 1 TAB PO BID:PRN Constipation
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation. Tablet, Delayed Release (E.C.)(s)
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Levetiracetam 500 mg/5 mL Solution Sig: One (1) 500 mg IV
Intravenous [**Hospital1 **] (2 times a day) for 1 months.
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**1-5**] Adhesive Patch, Medicateds Topical QD (): 12h on 12h off.
10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: 1000
(1000) mg Intravenous Q 12H (Every 12 Hours) for 5 weeks: for 6
total weeks of therapy (5 in-hospital), re-eval at 6 weeks.
11. Diphenhydramine HCl 50 mg/mL Solution Sig: 12.5 mg IV
Injection Q 12H (Every 12 Hours).
12. Gentamicin 40 mg/mL Solution Sig: Seventy (70) mg IV
Injection Q12H (every 12 hours) for 7 days: for 14d total
course.
13. Clindamycin Phosphate 150 mg/mL Solution Sig: Six Hundred
(600) mg IV Injection Q8H (every 8 hours) for 10 days: for 14
total days, 4 completed in-hospital.
14. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day:
start [**2148-11-28**], 1 week prior to CT scan & appointment with
neurosurgery.
15. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
Scale Injection ASDIR (AS DIRECTED): Sliding Scale, Standard
for your institution.
16. line care
Standard PICC line care with daily flush.
17. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain: re-eval pain and narcotic requirement as
needed.
18. Outpatient Speech/Swallowing Therapy
Please provide S/S Therapy daily.
19. Outpatient Physical Therapy
Please provide daily PT to help patient sit and stand.
20. Formula Feeds
PEG tube feeds full-strength Fibersource HN, now at 25 ml/hr
since [**49**] AM, advancing by 10 mg/hr q8h until 70 ml/hr to max
[**2154**] kcal/day. Flush PEG with 130 ml water q6h and after feeds.
21. Bladder care
Patient has been retaining urine, please bladder scan q12h and
straight catherize for >600cc
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary Diagnoses:
Mechanical aortic valve endocarditis
Intraparenchymal Hemorrhage, L parieto-occipital lobe
Secondary Diagnoses:
Aspiration Pneumonia
Splenic and Renal Infarction
Osteomyelitis/Discitis at L2-L3
Discharge Condition:
Hemodynamically and Neurologically Stable, Pneumonia resolving.
Will require long-term antibiotics and physical therapy.
Discharge Instructions:
You were hospitalized for a type of stroke called an
Intraparenchymal Hemorrhage. This stroke was probably caused by
endocarditis, an infection we discovered on your mechanical
aortic valve. We are treating this infection with antibiotics,
which you will continue to receive for at least 6 weeks. The
infection in your heart has also caused additional impaired
function of your lumbar spine, spleen and R kidney. Endocarditis
probably caused this stroke and the stroke you suffered in
[**Month (only) **].
During your admission, you also had a picc intravenous line
placed to give you your antibiotics. This will remain in place
until you finish your course. Also, you had a gastric tube
placed to help give you nutrition as we found you to be severely
weak and malnourished when you came to the hospital.
Take all medications as prescribed, and keep all follow up
appointments. You will require substantial physical therapy in
order to improve your functional status at the rehab center.
Followup Instructions:
Follow-up appointments with Neurosurgery
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2148-12-5**] 1:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2148-12-5**] 2:15
If you experience further symptoms such as increased
confusion/weakness, worsening pain on inspiration, worsening
back pain, fever >100.4, or any other concerning symptoms,
please see a doctor or return to the hospital immediately.
Completed by:[**2148-11-15**]
ICD9 Codes: 431, 5070, 2761, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2510
} | Medical Text: Admission Date: [**2125-9-18**] Discharge Date: [**2125-10-8**]
Date of Birth: [**2088-6-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Shellfish Derived
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Thrombocytopenia
Major Surgical or Invasive Procedure:
Right IJ line
PICC line placement
History of Present Illness:
This is a 37 year old female who presented to OSH with 5 days of
LLQ/left flank pain. She was initially seen at [**Hospital3 **] on [**9-14**] and was diagnosed with a ruptured ovarian cyst
on TVUS; she was discharged on oxycodone-APAP. On [**9-15**] she
developed subjective fevers/rigors, increased pain, and
shortness of breath with exertion. Over the weekend her pain
became more diffuse, across the upper abdomen. She then
re-presented on [**9-18**] to [**Hospital6 33**], where workup
included a CT abdomen/pelvis with evidence of pyelonephritis.
She was given a dose of levofloxacin, IV hydromorphone, and a
undefinded amount of IVF. Her labs also showed platelets of 69K,
low WBC, and low hematocrit around 32 (substantially different
from normal values on [**9-14**]). No blood or urine cultures were
obtained. DIC labs were sent and revealed high fibrinogen, a
mildly elevated INR, smear with occasional schistocytes. She was
transferred to [**Hospital1 18**] for further management.
In the [**Hospital1 18**] ED, her initial vitals were: 100.4F, HR 124, BP
134/92, RR 18, Sat 99% (on room air). Repeat labs again
demonstrated platelets of 60K, stable hematocrit at 31, elevated
D-dimer, fibrinogen pending. Also apparently with new decrease
in renal function. Heme-onc was called and advised to wait on
anticoagulation; they would see the patient in the ICU.
Clinically, she looks well except for back pain, which has been
responding to hydromorphone. Vitals prior to transfer are:
145/90 100 18 98RA. In the ED she received 3L NS,
Piperacillin/Tazobactam 4.5 gm IV, vancomycin 1gm IV,
hydromorphone, and acetaminophen 1gm.
Review of systems: + chronic headaches with new frontal
headaches for four days. No vision or hearing change. No URI
symptoms. No N/V or diarrhea. No blood in stool. No
constipation. Mild urinary urgency on friday, no dysuria, or
hematuria. Mild ankle swelling s/p sprain. No weakness. "razor
burn on legs" Pt reports easy bruising. H/o bleeding with TAH
requiring repeat operation for internal bleeding. No h/o of
bleeding with dental work. no history of clots.
Past Medical History:
-melanoma in situ excised 11 years prior to presentation, no
recurrence
-endometriosis
-migraines
-R radial nerve damage from compression
-s/p TAH/USO 8 yrs ago, c/b need for 3 units PRBC due to
bleeding at a ligation site
-chronic anemia
Social History:
She is currently unemployed. She smokes 1 PPD since a teenage,
and drinks socially. She is here alone, and denies any recent
travel or insect/tick bites.
Family History:
Father has history of mesenteric vein thrombosis s/p small
intestine resection; with h/o factor V leiden with unknown
genetic profile. No further history of clotting or bleeding
disorders in family.
Physical Exam:
GENERAL: Pleasant, young white female in moderate distress
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. Dry MM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. 1/6 SEM in
LUSB no rubs or [**Last Name (un) 549**]. JVP= 2 cm above clavicle.
LUNGS: crackles R > L base, good air movement biaterally.
ABDOMEN: NABS. Soft, ND. BL upper quad tenderness, greatest in
RUQ. gaurding in RUQ without rebound. No HSM Left CVA
tenderness.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: 1mm erthyematous macules at sites of follicules on BL
shins. No ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout except [**2-1**] with
left hand grip. [**12-1**]+ reflexes, equal BL. Gait assessment
deferred. NL coordination.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-3.7* RBC-2.98* Hgb-10.4* Hct-31.2* MCV-105* RDW-14.6 Plt
Ct-60*
Na 138, K 3*, Cl 109*, HCO3* BUN 21*, Cr 1.2*, Glu 92
PT-13.5* PTT-25.5 INR(PT)-1.2*
ALT-25 AST-24 LD(LDH)-466* AlkPhos-104 TotBili-0.4
On Discharge:
WBC-12.2* RBC-3.04*# Hgb-9.2*# Hct-29.0*# MCV-95 RDW-17.8* Plt
Ct-183
19.3* PTT-31.8 INR(PT)-1.8*
Other Important Labs:
Lupus-NEG ACA IgG-11.4 ACA IgM-16.6*
AT III-70
ANCA-NEGATIVE B
RheuFac-65*
C3-89* C4-8*
HIV Ab-NEGATIVE
FACTOR V LEIDEN-Test negative
=============
MICROBIOLOGY
=============
Blood Cultures*23: No Growth To Date
Urine Culture * 9: No Growth To Date
===============================
Radiology AND OTHER STRATEGIES
===============================
ECG [**2125-9-18**]:
Sinus tachycardia. Poor R wave progression is probably a normal
variant.
Diffuse T wave changes that are non-specific. No previous
tracing available for comparison.
Chest Radiograph [**2125-9-18**]:
IMPRESSION: Mild interstitial edema. Small left effusion.
Ultrasound of Abdomen [**2125-9-18**]:
IMPRESSION:
1. Enlarged and heterogeneous left kidney, consistent with given
history of
pyelonephritis, with a number of hypoechoic areas in the upper
pole
potentially suspicious for abscess. No evidence of
hydronephrosis.
2. Nondistended gallbladder with gallbladder wall edema likely
secondary to
third spacing. No specific son[**Name (NI) 493**] evidence for
cholecystitis.
3. The CBD is dilated measuring 0.8 cm without intrahepatic bile
dilatation.
4. Patent portal vein.
CT Abdomen and Pelvis W/Contrast [**2125-9-18**]:
IMPRESSION:
1. Severe acute left pyelonephritis with marked renal edema,
evolving foci of hypoperfusion, parenchymal necrosis,
inflammatory phlegmon or early abscess formation.
2. Multiple pulmonary nodules measuring up to 4 mm in the left
lower lobe.
In the setting of infection, these could reflect septic emboli
or other
infectious processes. Followup chest CT to document resolution
is
recommended.
3. Bilateral pleural effusions and basilar consolidations could
reflect
atelectasis and/or superimposed pneumonia.
4. Gallbladder wall edema, pericholecystic fluid and
pericholecystic hepatic parenchymal hyperemia, unchanged from
prior ultrasound. While these findings are felt likely reactive
in the setting of other abnormalities (particularly since the
gallbladder does not appear distended), by imaging this is
equivocal for acute cholecystitis, and therefore if there is
clinical concern a HIDA scan may be considered.
MRI Abdomen W and W/O Contrast [**2125-9-18**]:
IMPRESSION:
1. Acute infarction involving much of the upper pole and
interpolar region of the left kidney, coexistent pyelonephritis
is possible. Two small discrete regions of fluid signal
intensity may be explained by necrosis, although abscess
formation cannot be excluded.
2. Irregularity of bilateral renal arteries though confidence in
that finding is low due to motion and potential artifact -
fibromuscular dysplasia or vasculitis can have this appearance.
A repeat study of the renal arteries is suggested when the
patient is more stable.
3. Gallbladder wall edema is commonly seen with third spacing of
fluid.
Common bile duct dilated to 9 mm, but has normal distal smooth
tapering and
there is no evidence of cholelithiasis or choledocholithiasis.
4. Small bilateral pleural effusions and atelectasis and/or
consolidation at the lung bases.
CT Chest W/O Contrast [**2125-9-22**]:
IMPRESSION:
1. Diffuse ground-glass opacity primarily within the bilateral
upper lobes.
Differential diagnosis includes atypical infectious pneumonia,
such as PCP,
[**Name10 (NameIs) 84655**] pneumonia and pulmonary edema/hemorrhage.
2. Bilateral pleural effusions, left greater than right.
3. Emphysematous changes.
TTE [**2125-9-24**]:
Conclusions
No thrombus/mass is seen in the body of the left atrium. A
patent foramen ovale is present. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2125-9-18**], a
patent foramen ovale is seen.
MRA Kidney W/ and W/O Contrast [**2125-9-24**]:
IMPRESSION:
1. Enlarged left kidney, with large, wedge-shaped areas of
liquefactive
necrosis at the upper pole and interpolar region. The areas of
involvement
are unchanged in size and appearance. While abscesses cannot be
completely
excluded, the presence of preserved capsular enhancement, and
the absence of extensive edema or perinephric inflammatory
changes is more consistent with multifocal infarct. Given the
clinical presentation, MR findings are most consistent with
multiple renal infarcts in the setting of pyelonephritis.
2. Normal renal vasculature, with no abnormalities of the renal
arteries to
suggest fibromuscular dysplasia or vasculitis. Widely patent
left renal vein without filling defect.
3. Moderate left and small right pleural effusions with
atelectasis.
Bilateral Lower Extremity Ultrasounds [**2125-9-25**]:
IMPRESSION:
1. No evidence of DVT in the lower extremities.
CTA Chest W/ and W/O Contrast [**2125-9-26**]:
IMPRESSION:
1. No pulmonary embolus. No aortic dissection.
2. Resolved right pleural effusion and persistent but now
slightly loculated moderate left pleural effusion with
associated atelectasis.
3. Decreased ground-glass opacification in the background of
persistent
emphysema.
4. Incompletely characterized right kidney abnormality
RUQ Ultrasound [**2125-9-28**]:
IMPRESSION:
1. Non-distended gallbladder, with no pericholecystic fluid or
cholelithiasis. No specific son[**Name (NI) 493**] evidence for
cholecystitis.
2. Persistent dilatation of the common bile duct without
intrahepatic bile
duct dilatation. No son[**Name (NI) 493**] evidence for choledocholithiasis
within the
visualized common duct.
Chest Radiograph [**2125-10-2**]:
IMPRESSION: Small stable left pleural effusion, with no evidence
of
pneumothorax.
MRI Abdomen W/ and W/O Contrast [**2125-10-4**]:
IMPRESSION:
1. No new areas of infarction within the left kidney compared to
multiple
prior studies. Areas of T2 signal hyperintensity within the
lateral
interpolar region and upper pole of the left kidney
corresponding to stable
areas of absent contrast enhancement in addition to striated
enhancement
within the left lower pole. These findings represent features of
both
pyelonephritis and infarction. Small vessel vasculitis should be
included in the differential.
2. Resolution of right pleural effusion with decrease in size of
small left
pleural effusion.
Brief Hospital Course:
37 year old female with acute onset thyrombocytopenia and sepsis
likely secondary to renal infarction and pyelonephritis.
1) SIRS/Sepsis: Patient initially presented with left flank
pain, tachycardia, low WBC, and low platelets. Based on OSH
non-contrast CT scan it appeared this was consistent with
pyelonephritis. She was started on cefepime, flagyl and
vancomycin [**9-19**]. With concern for worsening abdominal pain a
repeat contrast abdominal and pelvic CT was performed. It showed
severe acute left pyelonephritis with marked renal edema and
evolving foci of hypoperfusion, parenchymal necrosis,
inflammatory phlegmon or early abscess formation. Urology was
consulted given concern for a need for acute surgical
management. They suggested a concern for renal vein/artery
thrombosis due to the appearance of multifocal necrosis in the
kidney. MRI revealed no acute thrombosis but was suggestive of
an acute infarction involving much of the upper pole and
interpolar region of the left kidney without being able to rule
out coexistent pyelonephritis. The patient's white count
eventually trended up from a nadir of 2.5 to the 9's and she was
transitioned from cefepime, vancomycin, and metronidazole to
oral ciprofloxacin. All cultures remained negative but she did
complete a fourteen day course of antibiotics for a suspected
pyelonephritis. Vasculitis was also considered as an etiology
for her SIRS but no clear evidence for a particular syndrome was
found. Her blood pressures stabilized and she was completely
hemodynamically stable for > 1 wk prior to discharge. She did
remain febrile despite negative cultures, which was thought most
likely due to inflammation secondary to her necrotic kidney.
Prior to discharge her fever curve had been trending down and
she did not become more febrile after antibiotics were stopped.
Cultures similarly remained negative. Repeat MRI of kidney was
obtained to look for an abscess or closed space infection and
was negative.
2) Left renal infarcts: Given patient's family history of factor
V leiden mutation there was some concern that she could have a
thrombophilia predisposing her to clot. Agitated saline TTE
revealed a PFO, which raised concern for paradoxical
embolization but work up for VTE was unremarkable. Severe
pyelonephritis could also cause renal infarction but as reported
above cultures never impressively reenforced a pyelonephritis.
Similarly septic emboli were thought extremely unlikely given
persistently negative blood cultures. Investigation for factor
V leiden mutation was negative and no clear reason for
hypercoagulability was found. The patient was nevertheless
anticoagulated as the benefits of anticoagulation were felt to
outweigh the risks. Therefore, she was started on coumadin and
discharged on this as well as enoxaparin for bridge as she was
not yet therapeutic. Renal function remained essentially stable
after the patient was hydrated on her day of presentation. The
patient will follow up in hematology for further
hypercoagulability work-up.
3) Thrombocytopenia: The patient was transferred partially due
to concern for DIC or TTP due to her thrombocytopenia.
Hematology/Oncology was consulted and thought low platelets
were not consistent with DIC or TTP and she did not have
diagnostic numbers of schistocytes or a low fibrinogen. Most
likely etiology of her thrombocytopenia was thought to be marrow
suppression secondary to SIRS/sepsis. Ultimately her platelet
count recovered and was normal at the time of discharge. She
did receive one unit of platelets during an IJ placement.
4)Pulmonary edema/Pleural effusions: Initial CXR showed
pulmonary edema with a small pleural effusion. A BNP was 6587.
An echocardiogram was performed with concern for cardiovascular
compromise and it showed a normal ejection fraction, normal wall
motion, and 1+MR. It was felt the patient's pulmonary edema and
effusions were secondary to fluid resuscitation. She had one
episode of desaturation to 88% when she laid flat in her CT
scan. She intermittently required 2 Liters NC for comfort. Her
difficulty breathing was felt to be due to her abdominal pain
causing pain upon deep inspiration and fluid overload. Her pain
was controlled and patient was auto-diuresing >150cc/hr upon
transfer to the floor. She continued to auto-diurese on the
floor and eventually came off of oxygen entirely. Better pain
control significantly improved her respiratory function and
prior to discharge her pulmonary exam was normal and she was
ambulating without desaturations. CT showed a persistent,
loculated pleural effusion, and given persistent fevers, a
thoracentesis was attempted but as the effusion was steadily
decreasing in size interventional pulmonology and interventional
radiology thought it was too small to drain safely. As it
continued to decrease in size and the patient WBC count and
fevers were down trending this was not pursued further.
5) Abdominal pain: This was initially controlled with morphine
and morphine SR. She appeared to be very drowsy and her RR
decreased on this regimen, so the ms contin was discontinued.
She continued to have significant pain, so a morphine PCA,
maximum dose of 4 mg/hr, that was started and the patient's pain
improved significantly. It was assessed that her pain was
consistent with post-embolization syndrome, which includes
fever, abdominal pain secondary to the clearance process of
necrotic tissue. Eventually she was reestablished on a regimen
of morphine SR, morphine IR, and gabapentin with good
improvement in her pain. She will likely need these for the
next few months as her body clears necrotic tissue from her
kidney.
6) Persistent sinus tachycardia: The patient informs us that she
has exhibited fast heart rates for years. The patient did not
appear volume down as her CVP remained high. It was felt that
the tachycardia was due to pain, fever and the overall stress
response of sepsis. The tachycardia improved to the low 100s
after the administration of the PCA and remained there through
the day of discharge.
7) GERD: PPI held in setting of decreased plts. Ranitidine [**Hospital1 **]
started and then discontinued when platelet count recovered as
it was thought this was no longer indicated.
The patient had a PICC for IV access that was discontinued prior
to discharge. She was tolerating a full diet prior to
discharge. She was full code.
Medications on Admission:
Neurotin 300 qam, 1500 qpm
Protonix daily
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) as needed for pain for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 1 months.
Disp:*180 Tablet(s)* Refills:*0*
3. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours) for 1 months.
Disp:*90 Tablet Sustained Release(s)* Refills:*0*
4. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 1 months.
Disp:*60 syringe* Refills:*0*
5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day as
needed for constipation.
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Renal infarctions of unclear significance
? Pyelonephritis
Patent foramen ovale
Pleural effusion
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with back pain and were found
to have had injuries due to poor blood flow to parts of your
kidney. It is unclear exactly why this occurred but we suspect
you may have some predisposition toward forming blood clots.
Therefore, you have been started on blood thinners to prevent
futher such events. You have been started on coumadin as a long
term blood thinner, you are being discharged on enoxaparin, a
blood thinner, while we await your coumadin level to be
therapeutic. You will need to see a hematologist as an
outpatient to complete your clotting disorder workup.
You had fevers in the hospital. Because of the imaging findings
in your kidney we could not rule out a kidney infection.
Therefore, you received 14 days of therapy for a presumed kidney
infection. You completed this prior to discharge. Your
continued fevers and pain are likely due to an inflammatory
reaction as your body breaks down the portions of kidney tissue
that died. You can take acetaminophen for these fevers as
needed. Unfortunately, this inflammatory reaction also causes
pain, which we have treated with multiple pain medicines.
You will need follow up with a primary care provider and
coumadin clinic to follow how thin your blood is. You will also
need follow up with a kidney doctor to follow your kidney
function, a hematologist to assess you for a predisposition to
clotting and help manage this, and a rheumatologist as some of
your tests suggest a possible autoimmune disorder. We have
scheduled these appointments for you.
Your medications have been changed. You have been started on
coumadin, a blood thinner, that you will need to take until your
are told to stop by a doctor. Your blood has not yet been
thinned enough by coumadin so you are also being discharged on
ENOXAPARIN(LOVENOX), which will keep your blood thin until your
coumadin levels are adequate. When your coumadin levels are
adequate for 24 hours you can stop the enoxaparin. You have
also been started on MORPHINE sustained release and immediate
release for pain. You should not drive while using these
medications as they can make you sleepy. You were also started
on GABAPENTIN (NEURONTIN) to help manage your pain.
Please seek immediate medical attention if you experience chest
pain, shortness of breath, abdominal pain, or any change from
your baseline health status
Followup Instructions:
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Specialty: PCP
Date and time: Friday, [**2125-10-12**] at 1:45 pm
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 250**]
MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
Specialty: Nephrology
Date and time: Wednesday, [**2128-11-7**]:00
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg, [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 721**]
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6944**]
Specialty: Hematology
Date and time: Wednesday, [**Month (only) 1096**]
Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg, [**Location (un) 436**]
Phone number: [**Telephone/Fax (1) 68451**]
ICD9 Codes: 5849, 5119, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2511
} | Medical Text: Admission Date: [**2129-6-17**] Discharge Date: [**2129-6-21**]
Date of Birth: [**2082-10-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Anterior STEMI
Major Surgical or Invasive Procedure:
none
History of Present Illness:
46yo M with hyperlipidemia, no known CAD, and +FHx who was
transferred from [**Hospital **] Hospital with an acute MI. Developed
[**10-3**] CP at 4pm while playing tennis. Taken to [**Location (un) **] where
EKG showed STE in anterolateral leads. Started on ASA, BB,
Plavix, and Integrilin, and Benadryl. Developed rapid AF just
before cath. Cath at [**Location (un) **]-occluded mid-LAD, 2 stents placed,
and 40% OM1. SBP dropped to 80-90 in cath lab, started on
dopamine gtt. Converted to NSR upon revasc. No further CP
post-cath. Required 100% NRB, rapid desat on RA. Cr 1.5,
baseline 0.9-1.1. En route, developed 20-30 beat run of VT, for
which he was started on a lidocaine gtt. Upon arrival,
lidocaine gtt stopped, DA gtt at 8 to maintain BP in 90s.
Bedside TTE: EF 35%, severe apical akinesis, no regurg.
Intermittent runs of VT.
Past Medical History:
hyperlipidemia
no known CAD, nl EKG stress test in [**2121**]
nephrolithiasis (ureate stone), s/p lithotripsy ([**2123**])
Social History:
dentist
married, 3 children
nonsmoker
Family History:
mother- MI/CABG @65yo
Physical Exam:
general: ill-appearing man, lying in bed, somnolent but easily
arousable to name
HEENT: small scleral hemorrhage medial L eye, PERRL
Neck: supple, no JVD
Pulm: bibasilar crackles
CV: irregular rhythm--frequent PVCs, nl S1/S2, no murmur, +S3
Abd: soft, NT, ND, +BS throughout
R groin: arterial sheath in place, some oozing
Ext: warm, no edema, DP pulses palpable b/l
Pertinent Results:
EKG (6:50pm,pre-cath)- AF @ 115bpm, nl axis, STE V2-V6, I, aVL
(11pm, post-cath)- NSR@80bpm, nl axis, poor R wave
progression, resolution of STE
Cardiac cath- 30% proxLAD, TO midLAD (2 zeta stents), 80% OM1,
RCA
nl; PCWP 19
TTE- EF 30-35%, severe apical hypokinesia, no valvular regurg
CXR- pulmonary edema
[**2129-6-17**] 10:53PM BLOOD WBC-20.1*# RBC-4.58* Hgb-14.0 Hct-39.5*
MCV-86 MCH-30.5 MCHC-35.4* RDW-12.7 Plt Ct-288
[**2129-6-17**] 10:53PM BLOOD Glucose-169* UreaN-16 Creat-1.0 Na-139
K-4.8 Cl-108 HCO3-21* AnGap-15
[**2129-6-18**] 05:40AM BLOOD CK-MB-291* MB Indx-15.9* cTropnT-1.24*
[**2129-6-17**] 11:10PM BLOOD Type-MIX pO2-148* pCO2-40 pH-7.29*
calHCO3-20* Base XS--6
Brief Hospital Course:
1) STEMI: Mr. [**Known lastname **] suffered a large anterior STEMI. He is s/p
cardiac cath at the OSH with 2 stents placed to his STEMI, and
resolution of ST elevation and chest pain upon
revascularization. He experienced intermittent runs of VT en
route to [**Hospital1 18**] and had evidence of cardiogenic shock upon
arrival. TTE revealed depressed EF and apical akinesis. He was
continued on ASA, Integrilin, and Plavix, and started on
high-dose statin. He was initially diuresed with Lasix for his
pulmonary edema. He was weaned from dopamine the next day with
the help of IV fluids to replete his volume. He was started on
heparin gtt for the indication of apical akinesis and low EF.
His cardiac enzymes continued to trend down. He was chest
pain-free throughout his admission. He was also started on a
beta blocker and ACE inhibitor during this admission. TTE on
[**6-20**] showed improved EF of 45% and residual apical akinesis.
Heparin gtt was discontinued. The patient's follow-up plan
includes cardiology f/u in 2 weeks and cardiac rehabilitation
program in [**3-30**] weeks. He was also instructed to follow up with
his PCP.
.
2) VT: The patient had frequent, intermittent, non-sustained
runs of VT. The decision was made to monitor the patient
without treatment as he was hemodynamically stable and VT can be
expected within 48 hours of MI--AIVR vs. NSVT. His electrolytes
were repleted as necessary. The VT resolved within 48 hours.
The patient remained hemodynamically stable throughout his
admission.
.
3) ARF: On admission, the patient had an elevated creatinine of
1.5, likely secondary to hypoperfusion, with possible
contribution from the dye load received in cardiac
catheterization. It had returned to [**Location 213**] by the time of
discharge.
.
4) Dispo: The patient was discharged to home with a plan to
follow up with his PCP and Dr. [**Last Name (STitle) **] for Cardiology within the
next 2 weeks.
Medications on Admission:
ASA 325mg po qd
Plavix 75mg po qd
Integrilin gtt
Lidocaine gtt
Dopamine gtt
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY
(Every Other Day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Anterior ST elevation myocardial infarction
Discharge Condition:
good
Followup Instructions:
Cardiology
PCP
Completed by:[**2129-8-3**]
ICD9 Codes: 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2512
} | Medical Text: Admission Date: [**2123-12-22**] Discharge Date: [**2124-1-1**]
Date of Birth: [**2065-9-20**] Sex: F
Service: MEDICINE
Allergies:
Morphine Sulfate / Metformin
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Found down/multiple metabolic abnormalities
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central line placement
History of Present Illness:
Patient is a 58 yo f with pmh of htn, dm2, osa, was brought to
the [**Hospital1 18**] ED after she was found down at her [**Hospital3 **]
facility. Patient said she fell out in the kitchen on a banana
on the "5th" and couldn't get up due to pain in her back and
sob. She was found by EMS covered in stool, urine, and banana
peels. Patient was alert on arrival to ED but unable to describe
episode. Of note, has 3L of O2 at home.
.
In ED, temp was 91 tympanic. Sodium was found to be 164, given
4L of IVF (last 2 were 1/2 NS with K). Her glucose was found to
be critically high so she was started on an insulin drip. Also,
in ed, she was found to have lateral st depressions and
hypokalemia. Cardiology was called and recommended asa, bb and
cycle enzymes.
.
Recent hospitalizations include [**3-17**] for GI bleed, fall,
hypercarbic resp. failure. [**9-14**] with med overdose, hypotension.
[**3-/2117**] fall, ?rhabdo. [**1-/2116**] r knee replacement. [**1-/2115**] left knee
replacement.
Past Medical History:
DM II
HTN
Anxiety
Depression
Narcotic dependence
Hypercholesterolemia
OSA
Social History:
Lives alone in housing for disabled ([**Hospital3 **]. She
attends day program. no smoking, no EtOH, no drugs.
Family History:
Non-contributory
Physical Exam:
T 96.7 BP 145/56 P 79 RR 16 O2 95% 2L NC
Alert, awake, no respiratory distress
PERRLA, EOMI
Erythematous rash on right breast
No LAD
CTA anteriorly
RRR, s1 s2 no m/r/g
Abd: soft nt/nd +bs, no palpable hepatomegaly
Ext: 2+ dp pulses, no edema, right shoulder bruise
Neuro: AOx3, 4/5 strength in upper and lower extremities
Pertinent Results:
LABS:
[**2123-12-22**] 12:35PM BLOOD WBC-12.0*# RBC-4.01* Hgb-11.4* Hct-36.5
MCV-91 MCH-28.4 MCHC-31.2 RDW-16.5* Plt Ct-307
[**2123-12-31**] 07:00AM BLOOD WBC-4.6 RBC-3.49* Hgb-9.9* Hct-31.5*
MCV-90 MCH-28.4 MCHC-31.5 RDW-17.0* Plt Ct-268
[**2123-12-22**] 12:35PM BLOOD Neuts-90.3* Bands-0 Lymphs-6.2* Monos-3.0
Eos-0.1 Baso-0.3
[**2123-12-22**] 12:35PM BLOOD PT-15.5* PTT-21.7* INR(PT)-1.4*
[**2123-12-31**] 07:00AM BLOOD PT-11.4 PTT-27.2 INR(PT)-1.0
[**2123-12-22**] 11:32AM BLOOD Glucose-640* UreaN-76* Creat-2.0* Na-164*
K-2.9* Cl-113* HCO3-25 AnGap-29*
[**2123-12-25**] 03:13AM BLOOD Glucose-239* UreaN-42* Creat-1.5* Na-148*
K-3.4 Cl-110* HCO3-30 AnGap-11
[**2123-12-29**] 06:55AM BLOOD Glucose-195* UreaN-16 Creat-1.1 Na-146*
K-4.4 Cl-108 HCO3-29 AnGap-13
[**2123-12-30**] 07:15AM BLOOD Glucose-122* UreaN-14 Creat-1.2* Na-138
K-3.6 Cl-101 HCO3-29 AnGap-12
[**2123-12-31**] 07:00AM BLOOD Glucose-115* UreaN-14 Creat-1.2* Na-148*
K-4.5 Cl-109* HCO3-30 AnGap-14
[**2123-12-22**] 11:32AM BLOOD ALT-2047* AST-302* CK(CPK)-520*
AlkPhos-240* Amylase-115* TotBili-0.8
[**2123-12-23**] 03:20AM BLOOD ALT-1188* AST-157* LD(LDH)-495*
CK(CPK)-386* AlkPhos-164* Amylase-82 TotBili-0.6
[**2123-12-29**] 06:55AM BLOOD ALT-210* AST-42* LD(LDH)-393*
AlkPhos-146* Amylase-64 TotBili-0.4
[**2123-12-22**] 09:43PM BLOOD Lipase-95*
[**2123-12-29**] 06:55AM BLOOD Lipase-53
[**2123-12-22**] 05:45PM BLOOD CK-MB-13* MB Indx-2.7 cTropnT-0.15*
[**2123-12-22**] 09:43PM BLOOD CK-MB-12* MB Indx-2.4 cTropnT-0.18*
[**2123-12-23**] 03:20AM BLOOD cTropnT-0.23*
[**2123-12-24**] 06:00AM BLOOD CK-MB-5 cTropnT-0.20*
[**2123-12-22**] 11:32AM BLOOD Albumin-3.8 Calcium-9.6 Phos-4.1 Mg-2.6
[**2123-12-23**] 03:20AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.9
[**2123-12-30**] 07:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.6
[**2123-12-23**] 03:20AM BLOOD VitB12-1736* Folate-18.2
[**2123-12-23**] 03:20AM BLOOD TSH-1.3
[**2123-12-23**] 03:20AM BLOOD Free T4-1.1
[**2123-12-22**] 09:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2123-12-22**] 11:29AM BLOOD Lactate-2.3*
.
CT HEAD W/O CONTRAST [**2123-12-22**] 3:36 PM
No evidence of acute intracranial pathology including no sign of
intracranial hemorrhage. No evidence of subdural hematoma.
Probable mild brain atrophy.
.
CHEST (PORTABLE AP) [**2123-12-22**] 1:43 PM
No evidence of pneumonia.
.
ECG Study Date of [**2123-12-22**] 11:34:12 AM
Baseline artifact. Sinus rhythm with ventricular premature beat.
Consider left ventricular hypertrophy. Diffuse ST-T wave
abnormalities, cannot exclude in part, ischemia but clinical
correlation is suggested. Since the previous tracing of [**2123-11-15**]
ventricular ectopy and ST-T wave abnormalities are now present.
.
ANKLE (AP, MORTISE & LAT) RIGHT [**2123-12-23**] 3:37 PM
No fracture or dislocation detected about the right ankle.
.
ECHO Study Date of [**2123-12-23**]
The right atrium is moderately dilated. There is moderate
symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF 70%). There
is no ventricular septal defect. The right ventricular cavity is
dilated. Right ventricular systolic function appears depressed.
The aortic arch is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen. There
is no pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of [**2123-3-23**], the right heart [**Doctor Last Name 1754**] are dilated, and the
right ventricle is hypokinetic.
.
PERSANTINE MIBI [**2123-12-28**]
Mild reversible perfusion defect involving the distal anterior
wall and
septum (LAD territory). Normal left ventricular cavity size and
systolic
function. Calculated LVEF of 53%.
.
STRESS Study Date of [**2123-12-28**]
No angina or ischemic EKG changes. Nuclear report sent
separately.
Brief Hospital Course:
58yo female with who was found down with hyperglycemia, ARF, EKG
changes and metabolic abnormalities, altered mental status.
.
# Mental status changes:
Originally attributed to acute metabolic issues, and appears to
have improved as they resolved. However, per report, patient is
still not at baseline. Given significant atrophy on head CT in
a 58 year old, acute delerium overlying early onset dementia is
likely possibility. Also carries diagnosis of bipolar disorder,
which may be playing a role. Also she is found to have UTI (see
below) and this too may contribute. However, patient scored
26/28 on the Folstein MMSE and now with new finding of R-sided
deafness, question of whether some of patient's confusion is not
being able to hear what is being asked of her. Consider getting
in touch with pt's psychiatrist or have inpatient psychiatry see
patient for further evaluation.
- paxil and seroquel qhs
- zyprexa TID prn
.
# Hypernatremia:
Original anion gap of 26, hypokalemia 2.9, and hypernatremic at
164. Hypernatremia may be from no access to free water and
glycosuria (although hyperglycemia often causes hyponatremia).
Hypokalemia also likely from hyperglycemia. Anion gap likely
from starvation ketosis, less likely DKA, or toxic ingestion.
After 4L IVF (mostly 1/2NS) patient's sodium decreased to 157.
Due to the rapid decrease of 6 in 6 hours, stopped fluids for 2
hours took po's. Then started D5W at 100 ml/hr for a free water
defecit of 6 L. Corrected too quickly to 149, drip shut off
[**12-23**], but Na back to 155 morning of [**12-24**], and D5W restarted
while encouraging pt to take free water. Na now 148 with PO and
IV free water. Urine Na and urine osmolality not concerning for
diabetes insipidus. Patient had persistent free water depletion
due to poor PO fluid intake. Na repeatedly corrected with IV
free water administration and PO fluids.
- poor IV access, cont to encourage PO intake
- monitor daily lytes
.
# UTI:
Proteus mirabilis in urine on culture.
-10 day course of bactrim DS started [**12-24**], has 3 more days left.
.
# OSA:
Significant restrictive disease and severe OSA on sleep study
with hypoxemia. TTE demonstrating RA and RV dilatation, but
suggesting relatively normal right sided filling pressures.
Tolerating BiPap at recommended settings. Sleep service
consulted with recommendation on BiPAP listed below. [**Hospital 110971**] Medical to came into the hospital and set her up with
her home equipment (BIPAP 18/11, flexi-fit mask) and she will
need 4L supplemental oxygen. Anything other than those settings
is not adequate and she will need to remain non-supine during
sleep.
-BiPAP 18/11
O2 bled in at 4L
No backup rate
Needs to sleep on her side at all times
-albuterol nebs prn
-low dose klonipin for comfort while using BiPAP
-followup at [**Hospital1 18**] Sleep Center in 1 month
.
# NSTEMI:
In ICU, patient noted to have ST depressions laterally, with
elevated troponin and CK CK 520, MB 13, Trop 0.16, has trended
down. Almost certainly due to metabolic derangements described
above. Cardiology consult service followed from admission. TTE
showed new RV dysfunction and dilated right atrium and
ventricle. TTE abnormalities concerning for PE (but no hypoxia,
tachycardia etc to suggest dx), also could be from her pulmonary
hypertension. Restart stain on discharge. MIBI stress negative
for ST changes or anginal symptoms. Nuclear portion with mild
reversible perfusion defect involving the distal anterior wall
and septum (LAD territory), more apparent compared to previous
study in [**2117**]. Cardiology deferred catherization given patient's
comorbidities, stability of perfusion defect, lack of symptoms.
Study was reviewed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Cardiology. He
thought it was a difficult study to interpret because of the
large amount of attenuation that is present in this large woman,
but he could not identify any ischemia. The fixed defect of the
anterior wall is relatively characteristic of breast
attenuation, which is confirmed by the normal wall motion.
.
Pulmonary specialist who has followed her outpatient, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], was concerned that if she has any underlying heart disease
her severe sleep apnea could cause a fatal arrythmia or a
recurrent infarction from recurrent desaturations and persistant
pulmonary hypertension. This was discussed with Cardiology who
reiterated that the MIBI results likely did not represent a new
perfusion defect and it was due to attenuation of signal from
body habitus. Also, catherization would necessitate
anticoagulation with plavix which would be risky given patient's
non-compliance with medications in the past.
-continue ASA, BB, ACEi
-held statin due to transaminitis, restarted on discharge
-will followup with [**Hospital1 18**] Cardiology outpatient
.
# Elevated LFT's:
ALT>AST, not likely shock liver as no evidence of hypotension
and based on enzyme distribution pattern. Trending down at
discharge.
-continue to monitor
-held statin due to transaminitis, restarted on discharge
.
# Hypothermia:
No EKG abnormalities to suggest hypothermia, warmed nicely with
bear hugger in ICU, likely related to being found down for
prolonged period of time.
.
# ARF:
Admitted with acute on chronic renal failure with Cr 2.0, while
baseline .9- 1.1. Cr 1.2 at discharge. Initial urine lytes
suggested prerenal etiology and renal function improved with
IVF.
- restarted ACEi given improvement in renal function
- renally dosed meds
- trend renal function outpatient
- monitor urine output
.
# DM
Now titrated back to home dose of NPH (34U/29U) with sliding
scale. Pt had elevated FS in setting of receiving D5W for
hypernatremia. Insulin regimen titrated accordingly.
- NPH and humalog sliding scale
- encourage concommittant free water PO intake
- on ACEi
.
# HTN:
Stable
- on ACEi, BB
.
# Back pain:
Extensive evaluation by ortho, neuro, L4/L5 djd
- cont lidoderm patch
.
# Hypercholesterolemia:
- held atorvastatin pending improvement of LFTs, restarted at
discharge
.
# FEN:
- diabetic, heart healthy diet
.
# PPX: sc heparin, ppi
.
# CODE: Full Code
.
# Contact: [**Name (NI) **] [**Name (NI) 1968**] [**Telephone/Fax (1) 110972**]
.
# DISPO:
PT/OT cleared patient, recommended 3-4x treatments per week. She
will need BiPAP machine at home prior to discharge from [**Hospital1 1501**],
they should contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Pulmonary Division at
[**Hospital1 18**] for notification of dispo status and information regarding
the BiPAP machine.
- DC to [**Hospital 8218**] Rehab
- f/u with [**Hospital1 18**] Cardiology
- f/u with [**Hospital1 18**] Sleep Clinic in 1 month with [**First Name9 (NamePattern2) 110973**] [**Location (un) **]
([**Telephone/Fax (1) 612**])
- f/u with [**Hospital1 18**] Pulmonary
Medications on Admission:
albuterol inhaler
atorvastatin 40'
clonazepam .5'''
ditropan 5'''
ferrous sulfate 325'
flovent 220 mcg
ibuprofen 400''''prm\n
lidoderm patch
lisinopril 20''
loraz prn (not to be used with clonaz)
mvi
nph 34/29
paxil 40'
protonix 40''
seroquel 100'
toprol xl 50''
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed.
11. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
12. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD () as needed for
back pain.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed.
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
19. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for use with BiPAP.
20. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
21. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 34
units in AM and 26 units in PM Subcutaneous once a day.
22. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: SLIDING
SCALE Subcutaneous with meals and bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 10283**] Center - [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Altered mental status
Hypernatremia
UTI
OSA
NSTEMI
Transaminitis
HTN
Acute renal failure, now resolved
DMII
Back pain
.
SECONDARY DIAGNOSES:
Hypercholesterolemia
Psych/Depression
GI bleed
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital after being found down and
unresponsive at home. You were treated in the intensive care
unit. You were stabilized and transferred to the medicine floor.
Your sodium level remains high and you are to drink water (at
least 8 glasses per day) to keep yourself well hydrated. You
have severe sleep apnea with decrease in oxygenation levels in
your blood at night. You were seen by Sleep specialist and were
instructed to remain on your side while sleeping.
.
Please take all your medications as prescribed. Please return to
the ED if you experience chest pain, shortness of breath,
nausea/vomiting, confusion.
.
Please go to all your followup appointments for further medical
management.
.
DC to [**Hospital 8218**] Rehab.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D.
Date/Time:[**2124-1-10**] 3:50
Provider: [**Name10 (NameIs) 706**]
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2124-2-8**] 4:00
Provider: [**Name10 (NameIs) **] FERN, RNC
Date/Time:[**2124-1-18**] 11:00
[**Hospital1 18**] Sleep Clinic in 1 month with [**First Name9 (NamePattern2) 110973**] [**Location (un) **]
([**Telephone/Fax (1) 612**])
Completed by:[**2124-1-1**]
ICD9 Codes: 5849, 5990, 2760, 2720, 2768, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2513
} | Medical Text: Admission Date: [**2171-3-8**] Discharge Date: [**2171-3-24**]
Date of Birth: [**2090-5-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillin V
Attending:[**First Name3 (LF) 30062**]
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
Placement of ET tube
Placement of NG tube
Placement of central line
History of Present Illness:
80 y/o F with h/o CAD s/p MI with stents in [**2164**], Htn, HL and
recent bout of pneumonia, transferred to [**Hospital1 18**] from OSH where
she was found to have a leukocytosis of 137K with 88%
lymphocytes. She had been in USOH after discharge on [**3-1**] from
recent admission for pneumonia at [**Hospital **] hospital, where she had
been treated with antibiotics and steroids. For the past [**1-20**]
days, she has been experiencing dizziness, lightheadedness,
nausea, cough, and diarrhea. She saw her PCP earlier today, who
found her to have orthostatic hypotension, and checked labs
revealing leukocytosis to 113K with 84% lymphocytes and many
atypical lymphs. She was referred to [**Hospital **] Hospital, where
repeat labs showed WBC of 137K, with 88% lymphocytes and
moderate smudge cells. Labs at [**Hospital1 **] were also notable for
BUN/creat of 30/1.2.
.
Of note, she was recently admitted to [**Hospital 1281**] Hospital from [**2-24**] for pneumonia, and was discharged on antibiotics (completed
course on [**3-5**]) and prednisone (last dose of 30 mg taken on
[**3-7**]).
.
In the [**Hospital1 18**] ED, initial VS were 97.3, 82, 128/66, 18, 98%RA.
Exam was notable for irregularly irregular heart rhythm. Labs
revealed leukocytosis of 96.3K with 88% lymphocytes and no
bands. Hct and Plts were normal. LDH was 332, and uric acid 7.8.
Lactate was 2.4. Troponin was negative. ECG showed atrial
fibrillation at ~80 bpm, LAD, TWI in I, aVL, V4-V6, and Q waves
in V1-V2. Patient was given 1L IVF, in addition to another liter
given at the OSH. She was also given ceftriaxone and
azithromycin for possible infiltrate (vs. resolving PNA) on CXR.
.
While on the floor this morning, the team noted that she was
hypotensive to 90s/60s and she was started on vancomycin and
cefepime for coverage of possible HCAP. Heme/onc also saw the
patient and reviewed her blood smear and saw that she had smudge
cells consistent with CLL but also some immature lymphocytes.
This in conjunction with a rapid rise in her WBC count over the
past year made cause for concern that she might have an immature
clone, and her blood was sent for flow cytometry.
.
This evening, the patient subsequently developed an extremely
rapid heart rate of 130s-140s while continuing to drop her
pressures, which nadired at 78 systolic on the floor and spiked
a temperature of 101.1. She also developed some respiratory
distress and wheezing and was given a duoneb. The patient
continued to mentate throughout, and complained of dizziness and
lightheadedness whenever she moved. She reported some mild
shortness of breath but no chest pain. She was bolused 1L on the
floor without improvement of her blood pressures and was
transferred to the ICU for further management.
Past Medical History:
-CAD s/p MI and stent placement x2 in [**2164**] (First stent [**2164-8-30**],
2nd [**2164-10-10**])
-Htn
-HL
-atrial fibrillation (never on warfarin, [**2-20**] past GI bleed)
-hx of hemolytic anemia in [**2165**] (confirmed by PCP), Rx'd
rituximab (not confirmed by PCP patient does not remember)
-iron deficiency anemia
-s/p appendectomy
-s/p hysterectomy
-s/p L shoulder arthroscopy [**2166**]
-s/p tonsillectomy
Social History:
Lives at home with children/grandchildren. Works as customer
service representative at [**Doctor First Name **] book distributor. Past
smoker, quit ~10 years ago. Denies current or past etoh or
illicit drug use. Performs all her own ADLs, and remains active
with her employment.
Family History:
Sister has "heart disease." Father also had heart disease, and
mother had colitis/ileitis. Her children are adopted.
Physical Exam:
ON ADMISSION:
Vitals: T:97.5 BP:108/50 P:76 R:18 O2:95% RA
General: Pleasant well-appearing elderly female. Alert,
oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated. No cervical or supraclavicular
lymphadenopathy.
Lungs: CTAB, no wheezes, rales, ronchi
CV: Irregularly irregular. Normal S1/S2. +[**3-24**] holosystolic
murmur most prominent at apex. No rubs. No S3/S4
Abdomen: no splenomegaly or hepatomegaly. soft, NT/ND, BS
present, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No axillary or inguinal lymphadenopathy
Neuro: 5/5 strength upper and lower extremities, proximally and
distally. Sensation to light touch grossly intact throughout. CN
[**3-2**] grossly intact
.
ON DISCHARGE:
Pertinent Results:
ADMISSION LABS:
[**2171-3-7**] 11:45PM BLOOD WBC-96.3* RBC-4.85 Hgb-14.1 Hct-41.1
MCV-85 MCH-29.0 MCHC-34.3 RDW-15.6* Plt Ct-261
[**2171-3-7**] 11:45PM BLOOD Neuts-12* Bands-0 Lymphs-88* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2171-3-7**] 11:45PM BLOOD PT-12.3 PTT-24.3 INR(PT)-1.0
[**2171-3-7**] 11:45PM BLOOD Glucose-98 UreaN-28* Creat-1.0 Na-142
K-4.0 Cl-104 HCO3-25 AnGap-17
[**2171-3-7**] 11:45PM BLOOD ALT-18 AST-27 LD(LDH)-332* AlkPhos-39
TotBili-0.5
[**2171-3-7**] 11:45PM BLOOD Albumin-4.0 Calcium-8.4 Phos-3.6 Mg-2.4
UricAcd-7.8*
.
DISCHARGE LABS:
................................................................
MICROBIOLOGY:
**All blood, urine, and sputum cultures negative**
................................................................
IMAGING:
................................................................
PATHOLOGY:
[**2171-3-8**] CXR: Right middle lobe opacity may represent atelectasis
or pneumonia. Small right pleural effusion.
.
[**2171-3-10**] B/l LE LENI: No DVT of the bilateral lower extremity.
.
[**2171-3-11**] TTE: The left atrium is dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity is unusually small. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded. Left
ventricular systolic function is hyperdynamic (EF>75%).
Diastolic function could not be assessed. There is a moderate
resting left ventricular outflow tract obstruction. There is no
ventricular septal defect. Right ventricular chamber size is
normal. with normal free wall contractility. The number of
aortic valve leaflets cannot be determined. The aortic valve is
not well seen. Significant aortic stenosis is present (not
quantified). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is systolic anterior motion
of the mitral valve leaflets. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. There is an anterior space
which most likely represents a prominent fat pad.
IMPRESSION: Moderate LVH, small, hyperdynamic left ventricle
with consequent development of an LVOT gradient as the mitral
valve, chordae and papillary muscle contact the interventricular
septum during systole. The severity of the obstruction cannot be
determined but is probably moderate to severe. Diastolic
dysfunction probably present. The RV is not well seen but is
probably normal in size and function. There is calcific aortic
stenosis, again the severity cannot be determined on the basis
of this echo. There is at least mild mitral regurgitation.
.
[**2171-3-12**] TTE: Moderate to severe (3+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. Compared with the
prior study of [**2171-3-11**], left ventricular systolic function is
less dynamic and a resting LVOT gradient is no longer seen. The
heart rate is much slower and the severity of mitral
regurgitation has increased. Pulmonary artery systolic
hypertension is now identified.
.
[**2171-3-18**] TTE: The aortic valve is thickened. Severe aortic valve
stenosis is suggested with a peak velocity of 4m/s (64 mmHg).
.
[**2171-3-18**] Renal U/S: No hydronephrosis and no stones.
Brief Hospital Course:
80 y/o F with h/o CAD s/p MI with stents in [**2164**], Htn, HL and
recent bout of pneumonia, transferred to [**Hospital1 18**] from OSH where
she was found to have a leukocytosis of 137K with 88%
lymphocytes concerning for leukemia. She developed hypotension
and respiratory distress in the setting of Afib with RVR, and
was tranferred to the ICU for further management. The patients
condition continued to deteriorate, her renal function
consistent with ATN. A TEE demonstrated severe LVOT
obstruction. After a family discussion regarding goals of care
the patient was made comfort measures only and extubated on the
[**2-22**] and passed the following night.
.
ACTIVE ISSUES:
#. Goals of Care: After discussion with patient's family,
decision was made to change patient's status to comfort measures
only, as her family did not feel she would have wanted continued
aggressive treatment without making improvement. The patient
was extubated on the night of [**2171-3-22**], and started on a morphine
gtt titrated to comfort. All other medications were stopped.
She was made comfortable with a morphine gtt, scopolamine patch,
lorazepam and sublingual levsin. She expired the following
evening with her daughter at bedside.
.
# Respiratory distress/Shock: Initially felt to be secondary to
sepsis considering the patient's recent treatment for pneumonia,
small infiltrate on CXR, and sputum positive for GNRs. She was
started on vanc/cefepime/cipro for possible HCAP, and the
vanc/cipro were later stopped. On [**3-17**] she was febrile to 103
and antibiotics were broadened from cefepime to
vanc/zosyn/cipro. She required pressor support. She was
intubated on [**3-11**] due to worsening respiratory distress. An ECHO
revealed a hyperdynamic LV with consequent development of an
LVOT gradient at the mitral valve. Repeat ECHO showed severe AS,
and much of her symptoms were felt to be due to this. Dr. [**Last Name (STitle) **]
was asked to evaluate for possibility of percutaneous
valvuloplasty. However, subsequent TEE demonstrated that
patient's cardiac dysfunction was secondary to significant LVOT
obstruction, and that her aortic valve was not significantly
stenosed. She was given increased volume with hopes of
increasing cardiac output, without significant improvement.
.
# Atrial Fibrillation: Patient was initially anticoagulated with
aspirin only, due to history of upper GIB. The patient's home
atenolol was switched to metoprolol which was uptitrated. She
continued to have RVR and was started on an amiodarone gtt and
heparin gtt. On [**3-11**] she developed SVT vs. VT (rate 200/minute),
pulse present. Shock delivered - returned to atrial fibrillation
with slower rate (<100). The amiodarone was eventually switched
to PO and the heparin gtt was stopped due to coffee grounds from
NG tube.
.
# [**Last Name (un) **]: FENA 0.2%. Urine sediment showed 30-40 monomorphic RBCs
per HPF, 3-5 WBCs, several granular casts, and a few muddy brown
casts, consistent with ATN. This was felt likely due to poor
renal perfusion in the setting of hypotension.
.
# CLL: Peripheral smear showed smudge cells and immature
lymphoctyes, concerning for acute transformation. She was
started on allopurinoal and IVF due to elevated uric acid and
risk of tumor lysis. Flow cytometry later came back confirming
CLL.
.
# GI Bleed: Pt with h/o erosive gastritis seen on an EGD in
[**2161**]. She had intermittent coffee-ground material suctioned from
her NG tube. Protonix drip was started. She required
intermittent RBC transfusions.
.
# CAD, MI s/p stenting:
.
# Hypertension: Anti-hypertensives were initially held in the
setting of sepsis.
.
# Hyperlipidemia: Continued simvastatin.
.
TRANSITIONAL ISSUES
The patient expired
Medications on Admission:
1. amlodipine 5 mg daily
2. atenolol 50 mg daily
3. calcium 500 mg daily
4. furosemide 20 mg PO 3x/week
5. iron ? dose
6. levothyroxine 50 mcg daily
7. lomotil 2.5mg PRN
8. prilosec 20 mg PRN daily
9. simvastatin 20 mg daily
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
ICD9 Codes: 5845, 4271, 4280, 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2514
} | Medical Text: Admission Date: [**2158-11-5**] Discharge Date: [**2158-11-16**]
Date of Birth: [**2097-8-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 922**]
Chief Complaint:
Congestive heart failure
Major Surgical or Invasive Procedure:
[**2158-11-7**] Aortic valve replacement(21 mm ON-X, Mitral valve
replacement 25/33 On-X Conform-X mechanical valve).
History of Present Illness:
Mr.[**Known lastname **] is a 59-year-old gentleman who is well known to
Dr.[**Last Name (STitle) 914**] for previous consultations for surgical correction
of his aortic valve and mitral valve. In [**2156-11-10**] he had a
septic left wrist. He subsequently became bacteremic and
developed endocarditis and hip osteomyelitis. He had a very
complex series of events which includes end-stage renal disease
secondary to glomerulonephritis for which he underwent kidney
transplant in [**2137**], which had failed subsequently and was
removed in [**2143**]. He is currently receiving hemodialysis every
Monday, Wednesday, and Friday. Dr.[**Last Name (STitle) 914**] had initially seen
Mr.[**Known lastname **] in [**2157-2-10**] for MSSA endocarditis, however, he
was not a surgical candidate at that time. On [**2158-10-3**] he
presented complaining of 5 days of abdominal pain and 3 months
of abdominal distention. He has received clearance from GI and
general surgery and now presents for surgery.
Past Medical History:
h/o mitral endocarditis
h/o aortic endocarditis
h/o septic wrist
endstage renal failure on hemodialysis
s/p Renal transplant in [**2137**]
s/p transplant nephrectomy in [**2143**].
Hypertension
Atrial fibrillation
Coronary artery disease
Diastolic CHF with remote history of systolic CHF
h/o MSSA Endocarditis
h/o VRE septic arthritis.
h/o Left wrist MSSA arthritis
s/p Right femoral neck fracture
s/p right hip hemiarthroplasty [**2157-1-11**]
s/p Right Prosthetic hip infection with explantation [**2-18**]
h/o Ischemic colitis/ileitis
s/p subtotal colectomy and terminal ileal resection with
diverting loop ileostomy and gastrostomy tube placement.
s/p Revision left radiocephalic arteriovenous
fistula,endarterectomy radial artery
s/p Removal right hip hemiarthroplasty.
s/p Right ring finger closed reduction percutaneous pinning
for mallet finger.Left index and long ring finger PIP joint
manipulation
Social History:
Owner of a clothing store in [**Location (un) 4398**]. Patient has been
hospitalized/in rehab since [**2156-12-10**]. Prior to this, he lived in
[**Location **] with his mother and brother. [**Name (NI) **] current tobacco and
alcohol use but notes intermittent tobacco use in the past (~3
pack-years). Denies illicit drug use. HIV negative [**2156-12-27**]
Family History:
Positive for cancer (father-prostate), [**Name (NI) 2481**] (mother).
Father deceased. Brother has fibromyalgia. Daughter in good
health.
Physical Exam:
admission
Pulse: 81 AF Resp: 16 O2 sat:99% RA
B/P Right: 94/41
General:A&O x3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur: HSM IV/VI, II/VI at RSB
Abdomen: Soft [x] non-distended [] non-tender [] bowel
sounds[-]+ ascites, RLQ colostomy bag. +Gastric- external
fistula
C/D/I
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none Right: 2+ Left:2+
Pertinent Results:
[**11-10**] Echo: The left atrium is markedly dilated. The right atrium
is markedly dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF 60%). The right
ventricular free wall is hypertrophied. 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. The aortic root
is mildly dilated at the sinus level. A bileaflet aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. A bileaflet mitral valve prosthesis is present. The
mitral prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. The tricuspid valve leaflets
are mildly thickened. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a small to moderate sized pericardial effusion. The
effusion appears circumferential. There are no echocardiographic
signs of tamponade. Compared with the findings of the prior
study (images reviewed) of [**2158-10-3**], the aortic and mitral
valves have been replaced. The left ventricular ejection
fraction is increased. The right ventricle remains dilated and
hypocontractile. A small-to-moderate pericardial effusion is now
present.
[**2158-11-14**] 06:15AM BLOOD WBC-4.3 RBC-2.90* Hgb-8.5* Hct-26.6*
MCV-92 MCH-29.2 MCHC-31.9 RDW-19.0* Plt Ct-101*
[**2158-11-5**] 04:44PM BLOOD WBC-4.1 RBC-4.00* Hgb-11.8* Hct-36.8*
MCV-92 MCH-29.5 MCHC-32.0 RDW-20.3* Plt Ct-114*
[**2158-11-14**] 06:15AM BLOOD PT-24.8* PTT-45.1* INR(PT)-2.4*
[**2158-11-13**] 12:12PM BLOOD PT-22.8* PTT-37.1* INR(PT)-2.2*
[**2158-11-13**] 01:39AM BLOOD PT-22.6* PTT-84.1* INR(PT)-2.1*
[**2158-11-12**] 03:00AM BLOOD PT-19.4* INR(PT)-1.8*
[**2158-11-14**] 06:15AM BLOOD Glucose-87 UreaN-18 Creat-4.2*# Na-132*
K-3.7 Cl-95* HCO3-30 AnGap-11
[**2158-11-5**] 04:44PM BLOOD Glucose-87 UreaN-35* Creat-6.6*# Na-136
K-5.3* Cl-99 HCO3-25 AnGap-17
[**2158-11-15**] 08:30AM BLOOD WBC-5.0 RBC-2.91* Hgb-8.6* Hct-26.6*
MCV-91 MCH-29.6 MCHC-32.4 RDW-19.0* Plt Ct-115*
[**2158-11-16**] 04:29AM BLOOD Hct-31.0*
[**2158-11-15**] 08:30AM BLOOD Plt Ct-115*
[**2158-11-16**] 04:29AM BLOOD PT-35.6* INR(PT)-3.6*
[**2158-11-15**] 08:30AM BLOOD Glucose-82 UreaN-28* Creat-5.5*# Na-132*
K-4.4 Cl-94* HCO3-27 AnGap-15
[**2158-11-16**] 04:29AM BLOOD Na-133 K-3.8 Cl-96
Brief Hospital Course:
Mr. [**Known lastname **] was admitted prior to surgery for surgical work-up,
IV Heparin bridge and [**Known lastname 2286**]. On [**11-7**] he was brought to the
Operating Room where he underwent aortic and mitral valve
replacement. Please see operative report for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours he was weaned
from sedation, awoke neurologically intact and extubated. He did
require pressors for hemodynamic support for several days
post-op while in the CVICU.
[**Month/Year (2) **] was continued post-op while being followed by renal
until discharge. Chest tubes and epicardial pacing wires were
removed per protocol. Cardiology was consulted to evaluate the
patient's second degree AV block (not felt to be a candidate for
pacemaker). Heparin was initiated as a bridge until the INR was
therapeutic on Coumadin. He was finally weaned off pressors on
post-op day six and was transferred to the telemetry floor for
further care.
Physical Therapy worked with patient during post-op period for
strength and mobility. He was ambulatory and has a good home
support system and was, therfor, discharged to home. Coumadin
was titrated for target INR 3-3.5. This will be managed by
[**Hospital6 733**] [**Hospital 197**] Clinic ([**Telephone/Fax (1) 2173**]).
On post-op day 10 he was discharged to home with the appropriate
medications and follow-up appointments.INR today 3.4 . First
blood draw by VNA is tomorrow [**11-17**].He will resume HD schedule of
M-W-F.
Medications on Admission:
Medications at home:
- LISINOPRIL 2.5mg(1),- WARFARIN - 2 mg Tablet - up to 3 (three)
Tablet(s) by mouth daily (AFib)- B COMPLEX-VITAMIN C-FOLIC ACID
[NEPHROCAPS] - 1 mg (1),- CINACALCET [SENSIPAR] - 60(1)
- CIPROFLOXACIN - 500 (1),- EPOETIN ALFA [EPOGEN] - at HD TIW;
dosage uncertain
- PROTONIX 40mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
cad.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily) as needed for CRF.
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for cholesterol.
6. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS) as needed for CRF.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
10. Outpatient Lab Work
Please draw PT/INR on [**11-17**] , [**11-18**] and then [**11-20**] and phone
result to [**Hospital 18**] [**Hospital6 733**] [**Hospital 197**] Clinic at
617=[**Telephone/Fax (1) **]. Target INR 3.0-3.5
11. Protonix 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:*1*
12. Coumadin 2 mg Tablet Sig: one-half Tablet PO once today for
1 days: dose today 1 mg ( half tab)[**11-16**], then all further daily
dosing per coumadin clinic [**Telephone/Fax (1) 2173**].
Disp:*50 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
h/o Aortic endocarditis
h/o mitral endocarditis
h/o septic arthritis wrist
mitral regurgitation
aortic stenosis
aortic regurgitation
s/p Aortic and Mitral Valve Replacement
end stage renal failure on hemodialysis
h/o right hip abscess,hemiarthroplasty and removal of hardware,
debridements
s/p subtotal colectomy for ischemic gut
s/p carpal tunnel releases
s/p right hand finger surgeries
s/p multiple revisions of AV fistulae
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
sternum clean and healing well, no drainage
Edema:
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2158-12-12**] at 1:45 PM ([**Telephone/Fax (1) 170**])
Cardiologist: Dr.[**Last Name (STitle) 171**] on [**2158-11-27**] at 8:40 AM ([**Telephone/Fax (1) 62**])
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) **] in [**5-15**] weeks ([**Telephone/Fax (1) 250**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: mechanical valves
Goal INR 3 - 3.5
First blood draw on [**2158-11-17**]
Call results to [**Hospital 18**] [**Hospital 197**] Clinic at [**Telephone/Fax (1) 2173**]
Completed by:[**2158-11-16**]
ICD9 Codes: 5856, 2761, 4280, 4168, 3051, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2515
} | Medical Text: Admission Date: [**2194-2-21**] Discharge Date: [**2194-3-1**]
Date of Birth: [**2146-9-1**] Sex: M
Service: Transplant [**Doctor First Name **]
HISTORY OF PRESENT ILLNESS: Patient is a 47 year-old male
with polycystic kidney disease and impending renal failure.
PHYSICAL EXAMINATION: He is a well-developed male in no
acute distress. He is 268 pounds with a blood pressure of
133/86. Heart rate is 106. Neck is supple without masses.
Heart is regular rate and rhythm with S1 and S2 clearly
heard. No murmur, rub or gallop were appreciated. His lungs
were clear to auscultation bilaterally. His abdomen was
soft, distended and the kidneys and liver are easily palpable
bilaterally. Bowel sounds are normal and present.
Extremities are with 1 to 2+ edema bilaterally.
LABORATORY DATA: Hemoglobin is 10.8 with a hematocrit of
34.2. His potassium is 5.2; BUN is 54 and creatinine is 4.7.
HOSPITAL COURSE: The patient was admitted to the operating
room for an elective bilateral nephrectomy and right Perma-
cath placement. He tolerated the procedure well and was taken
to the postoperative care unit where he was noted to have
postoperative potassium of 7.4. It should also be noted that
his bilateral kidneys, each kidney weighed about 35 pounds
and the total amount of fluid loss during the procedure,
secondary to removal of the kidneys, was estimated to be
roughly 5 liters. Renal was consulted in the PACU. The
patient was maintained intubated, at which time he was
dialyzed to remove the potassium which was performed on
postoperative day number zero. After the dialysis was
completed, his potassium had dropped down to 6.0 and patient
was being maintained at this time in the surgical intensive
care unit. On the morning of postoperative day number 1, the
patient was extubated. He did well. He was also dialyzed
again and this brought his potassium down on postoperative
day number 2 to 4.7. On postoperative day number 2, it was
also noted that his hematocrit had dropped to 24 from a
previous level of 30.5. He was followed for this. His value
remained stable. It was 25.2 on the following day. By
postoperative day number 3, pressors had been weaned off.
The patient was tolerating clears. On postoperative day
number 4, the patient was transferred to the floor. On
postoperative day number 5, the patient was noted to be
passing flatus and had 2 bouts of emesis on the previous
evening while taking in clears. The patient was made n.p.o.
again. Urinalysis was continued and his hematocrit was
followed. On postoperative day number 6, one of the
[**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drains was discontinued. He was
advanced to a regular diet which he tolerated well. His
hematocrit was still stable. Now it was slowly increasing
and it was up to 26.2 on postoperative day number 7. Patient
was still receiving dialysis. Hematocrit remained stable.
The patient was discharged home on postoperative day number
8, tolerating a regular diet, after both of his [**Location (un) 1661**]-[**Location (un) 1662**]
drains had been removed.
DISCHARGE STATUS: To home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES: Status post bilateral nephrectomy
(open) complicated by hyperkalemia.
DISCHARGE MEDICATIONS: Calcium acetate 667 mg, take 2 caps
p.o. t.i.d. with meals. Dilaudid 2 mg take one tablet p.o.
q. 3 to 4 prn. Colace 100 mg take one p.o. b.i.d. B-complex
vitamins. Vitamin C and Folic acid capsules, take one p.o.
q. Day. Panprazolol 40 mg delayed released, take one p.o. q.
Day.
FOLLOW UP: The patient is to follow-up with Dr. [**First Name (STitle) **] in
his office.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 5032**]
MEDQUIST36
D: [**2194-5-12**] 21:17:32
T: [**2194-5-13**] 05:50:36
Job#: [**Job Number 5033**]
cc:[**Last Name (NamePattern4) 3433**]
ICD9 Codes: 5856, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2516
} | Medical Text: Admission Date: [**2178-5-8**] Discharge Date: [**2178-5-9**]
Date of Birth: [**2121-7-17**] Sex: F
Service: C-MED
HISTORY OF PRESENT ILLNESS: The patient awoke at 4 a.m. with
sharp chest pain radiating to her back associated with mild
dyspnea. She states that the pain in similar to her prior
angina; not pleuritic, but worse with recumbency. The pain
not relieved by morphine, intravenous nitroglycerin,
sublingual nitroglycerin, and the patient was referred to
[**Hospital1 69**] for further evaluation.
PAST MEDICAL HISTORY: (The patient is a 56-year-old female
with a past medical history significant for)
1. Coronary artery disease, status post distant percutaneous
transluminal coronary angioplasty; a [**2170-2-13**]
catheterization with an ejection fraction of 50%; an [**2168-8-13**] catheterization with an ejection fraction of 60%, 50%
first diagonal, right coronary artery proximal 50%; a [**2167-8-13**] catheterization with an ejection fraction of 70%,
70% first diagonal, first obtuse marginal 80%, right coronary
artery middle 60%.
2. Type 2 diabetes mellitus.
3. Peripheral vascular disease, status post left below-knee
amputation.
4. History of congestive heart failure; [**2178-2-13**]
echocardiogram showing an ejection fraction of greater than
55%, no focal wall motion abnormalities.
5. Status post cholecystectomy.
6. History of gastrointestinal bleed.
7. Ovarian cancer, status post total abdominal
hysterectomy/bilateral salpingo-oophorectomy.
8. Hip fracture.
ALLERGIES: Her allergies are to PENICILLIN, CEPHALOSPORIN,
ERYTHROMYCIN and IBUPROFEN.
MEDICATIONS ON ADMISSION: Her medications include insulin,
Levoxyl 200 mg p.o. q.d., Plavix 75 mg p.o. q.d.,
[**Doctor First Name **] 60 mg p.o. q.d., isordil 80 mg p.o. t.i.d.,
Aldactone 100 mg p.o. b.i.d., Lasix 40 mg p.o. q.d.,
Norvasc 5 mg p.o. q.d., Lopressor 50 mg p.o. q.d.,
K-Dur 20 p.o. q.d., Lopid 600 mg p.o. b.i.d., Ativan 1 mg
p.o. b.i.d., Epogen.
SOCIAL HISTORY: Prior tobacco, no ethanol.
FAMILY HISTORY: Family history was noncontributory.
REVIEW OF SYSTEMS: On review of systems, she mentions a
history of cerebrovascular accident following prior
catheterization.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, blood
pressure was 112/60, heart rate of 70, saturation of 92% to
93% on room air. Temperature was 99.5. She was a pleasant,
blind female in no apparent distress. Jugular venous
distention of 7 cm to 8 cm. Carotids were without bruits.
The lungs were clear to auscultation bilaterally. Heart was
beating with a regular rate and rhythm. Normal first heart
sound and second heart sound with a 3-component friction rub.
The abdomen was soft and nontender. There were no bruits.
Symmetric radial pulses bilaterally.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories from
the outside hospital revealed creatine kinase of 74, troponin
was negative. Hematocrit of 32. Creatinine of 1.4.
RADIOLOGY/IMAGING: Electrocardiogram showed normal sinus
rhythm at a rate of 67, Q wave in III and F, V1 and V3;
similar to prior. Peaked T waves with J point elevation in
V1 through V3; more prominent than [**2177-1-13**].
HOSPITAL COURSE: In general, this is a 56-year-old female
with longstanding type 2 diabetes presenting with chest pain
with pericardial friction rub consistent with pericarditis.
An echocardiogram was obtained which left ventricular
function and pericardial effusion essentially unchanged from
two months prior. The patient was ruled out for myocardial
infarction by enzymes. Her pericarditis was treated with
aspirin 650 mg p.o. q.i.d. because of her allergy to
ibuprofen.
The patient was still experiencing pain which she described
as more pleuritic and constant on the morning of discharge
and was reassured that this pain would resolve within a few
days. She was to follow up with her primary care physician
in one to two weeks or sooner if her pain does not begin
improving.
MEDICATIONS ON DISCHARGE:
1. Levoxyl 200 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d.
3. [**Doctor First Name **] 60 mg p.o. q.d.
4. Isordil 80 mg p.o. t.i.d.
5. Aldactone 100 mg p.o. b.i.d.
6. Lasix 40 mg p.o. q.d.
7. Norvasc 5 mg p.o. q.d.
8. Lopressor 50 mg p.o. q.d.
9. K-Dur 20 p.o. q.d.
10. Lopid 600 mg p.o. b.i.d.
11. Ativan 1 mg p.o. b.i.d.
12. Epogen.
13. Aspirin 650 mg p.o. q.i.d.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Type 2 diabetes mellitus.
3. Peripheral vascular disease.
4. Pericarditis.
DISCHARGE FOLLOWUP: She was to follow up with her
cardiologist, Dr. [**Last Name (STitle) 24717**], in one month.
CODE STATUS: Full code.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Name8 (MD) 4430**]
MEDQUIST36
D: [**2178-5-9**] 12:22
T: [**2178-5-10**] 10:40
JOB#: [**Job Number 43533**]
cc:[**Telephone/Fax (1) 105247**]
ICD9 Codes: 4254, 4280, 486, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2517
} | Medical Text: Admission Date: [**2125-2-5**] Discharge Date: [**2125-2-26**]
Date of Birth: [**2079-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
headache, hypertensive urgency
Major Surgical or Invasive Procedure:
Lumbar Puncture
Hemodialysis
History of Present Illness:
History of Present Illness: 45M with DMI, ESRD on HD, and
multiple admissions for hypertensive urgency/emergency admitted
with hypertensive urgency which developed suddenly at HD today.
He was [**4-19**] of the way through HD when suddenly had onset of
severe headache [**11-25**] and ? of chest pain. Pt also endorses
photophobia, denies [**Month/Year (2) **] contacts or and fevers, chills, night
sweats. Pt reports that usually his hypertensive urgency is
associated c nausea and vomiting but these were not prominent
symptoms during this episode. Pt lives in rehab so always takes
his medicines. He has had multiple admissions in the past for
hypertensive urgency or emergency but per the pt he does not
know why he has had trouble controlling his BPs (denies h/o
nonadherence).
.
In the ED, initial V/S 99.6 84 [**Telephone/Fax (2) 104346**]0%. R subclavian CVL
placed due to poor peripheral access. CT head showed no evidence
for mass or acute [**Telephone/Fax (2) **]. Patient refused LP. MRI/A chest ordered
to exclude aortic dissection but not performed due to time
constraints (CTA not ordered b/c contrast could not be given
through central line). Given labetalol 10 mg IV, morphine (total
of 8 mg IV), percocet 2 tab, and benadryl 25 mg PO (due to
itching from morphine). Chest pain resolved prior to transfer,
headache persisted but improved. Vital signs prior to transfer
166/82, 73, 98% RA.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
[**Telephone/Fax (2) 1440**]. 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:
-DMI complicated by gastroparesis A1c 6.7% 3/09
-ESRD on HD TuThSa at [**Location (un) **] [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Location (un) 805**]
-Recurrent HTN emergency/urgency
-Chronic L flank pain since [**2119**] with multiple admissions
and extensive work-up, possibly due to diabetic thoracic
polyneuropathy
-Chronic diastolic CHF
-Esophagitis on EGD [**10-21**] with negative H. Pylori
-Depression, prior suicide attempt
-Fibromyaglia
-Mod-severe cognitive deficits per neuropsych testing in [**2121**]
-R foot ulcer s/p R foot operation - bone excision
-HBV surface ab and core ab pos
Social History:
Per [**Year (4 digits) **], confirmed c pt: Currently at [**Hospital 4310**] rehab for PT in
regards to left knee pain. The patient graduated from high
school and worked as a janitor. He was born in [**Male First Name (un) 1056**] and
moved to United States in [**2093**]. He is currently on disability.
He is divorced and lives alone. He has never smoked. He does not
drink alcohol currently. Reports he has 4 children 2 girls, 2
boys.
Family History:
per [**Year (4 digits) **]: Mother is 65 with diabetes (now deceased); two brothers
with diabetes; three sisters, one with hypertension and one with
gestational diabetes. Mother with ovarian cancer. No history of
CAD
Physical Exam:
Vitals: T:98.3 BP:194/98 P:76 R:20 O2:98%RA
General: Alert, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: crackles @ R base
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. very dry skin over lower legs.
Neuro- CN2->12 [**Year (4 digits) 20691**] [**Year (4 digits) 5235**], strength [**Year (4 digits) 5235**] in UE and LE b/l
Pertinent Results:
LABS ON ADMISSION:
[**2125-2-5**] 04:20PM WBC-4.6 RBC-4.79 HGB-12.7*# HCT-38.6* MCV-81*
MCH-26.5* MCHC-32.8 RDW-16.9*
[**2125-2-5**] 04:20PM NEUTS-65.0 LYMPHS-24.4 MONOS-7.1 EOS-3.1
BASOS-0.4
[**2125-2-5**] 04:20PM PLT COUNT-121*
[**2125-2-5**] 04:20PM GLUCOSE-183* UREA N-11 CREAT-4.3*# SODIUM-139
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-32 ANION GAP-14
[**2125-2-5**] 04:20PM CK(CPK)-82
[**2125-2-5**] 04:20PM CK-MB-NotDone cTropnT-0.30*
[**2125-2-5**] 04:20PM WBC-4.6 RBC-4.79 HGB-12.7*# HCT-38.6* MCV-81*
MCH-26.5* MCHC-32.8 RDW-16.9*
.
CT OF THE HEAD WITHOUT CONTRAST
HISTORY: Sudden onset of severe headache.
Comparison is made with [**2124-11-1**].
There is no acute intracranial hemorrhage or acute transcortical
infarction.
The ventricles and sulci are unchanged in size and
configuration. No bony
lesions are seen.
Impression: No evidence for mass or acute [**Month/Day/Year **]
.
MRA CHEST
CLINICAL INDICATION: A 45-year-old man with end-stage renal
disease on
hemodialysis, DM1, hypertension, and heart failure with severe
hypertension,
chest pain. Rule out aortic dissection.
TECHNIQUE: Multiplanar T1- and T2-weighted MR images were
acquired on a 1.5
Tesla magnet without the administration of intravenous
gadolinium.
COMPARISON EXAM: Chest radiograph on [**2125-2-5**].
FINDINGS:
Central vein catheter in place with tip in SVC.
The aorta is of normal caliber with no evidence of dissection,
intramural
hematoma, or atherosclerotic ulcer. No intraluminal filling
defects are seen.
The aorta measures 2.8 x 2.7 cm at the ascending portion, 2.5 cm
at the arch,
and 1.9 x 1.8 cm at the descending portion. The main pulmonary
artery is
enlarged and measures maximally to 3.0 cm.
There is cardiomegaly with enlargement of all four [**Doctor Last Name 1754**].
Heart otherwise shows no gross abnormalities. No pericardial
effusion. No pleural effusions are evident. Decrease in size of
mediastinal lymphadenopathy that was seen on prior CT.
Mediastinal vasculature is otherwise unremarkable.
No abnormal marrow signal is evident. Soft tissues show no
abnormalities.
Pleural surfaces are clear. Visualized portions of the upper
abdomen show no abnormalities.
IMPRESSION:
1. No evidence of aortic dissection or acute aortic
abnormalities.
2. Cardiomegaly.
3. Enlarged main pulmonary artery which may be related to
pulmonary
hypertension, of which no causes are identified on this study.
.
STUDY: CT of the head without contrast.
HISTORY: A 45-year-old male with elevated blood pressure,
headache, and
vomiting. Assess for head [**Doctor Last Name **].
COMPARISONS: [**2125-2-5**].
TECHNIQUE: Non-contrast MDCT images of the head were obtained
and displayed
in 5-mm axial reconstructions.
FINDINGS: This study is mildly degraded by patient motion. There
is no acute intracranial hemorrhage, shift of normally midline
structures,
hydrocephalus,or obvious large vascular territorial infarction.
Cavum septum pellucidum et vergae is noted and unchanged. The
density values of the brain parenchyma are maintained. The
visualized paranasal sinuses and mastoid air cells appear well
aerated. The soft tissues and osseous structures are
unremarkable.
Moderate calcification involving the cavernous portions of the
carotid
arteries and the vertebral arteries, left greater than right,
are evident
bilaterally.
IMPRESSION: No acute intracranial hemorrhage or mass effect.
.
EXAMINATION: Brain MRI.
HISTORY: 45-year-old male presents with severe headache.
COMPARISON: Head CTs [**2121-12-6**] through [**2125-2-6**].
TECHNIQUE: Sagittal T1, axial T2 FSE, T2, GRE, FLAIR, diffusion,
3D
time-of-flight MRA sequences through the brain were obtained.
FINDINGS: There are scattered periventricular and T2
hyperintensities within the bihemispheric white matter. There is
extensive T2 signal abnormality throughout the pons. There is no
acute infarct. Incidental note is made of a cavum septum
pellucidum and vergae.
MRA: The intracranial internal carotid arteries are normal, as
are the middle and anterior cerebral arteries. The posterior
circulation is normal. Minimal flow signal within the proximal
V3 segment of the left vertebral artery is likely artifactual.
IMPRESSION:
1. Scattered T2 hyperintensities throughout the bihemispheric
white matter
and more extensive confluent changes throughout the pons may be
secondary to severe microvascular ischemic disease in this
patient with a history of
chronic type 1 diabetes, end-stage renal disease on [**Year (4 digits) 2286**] and
poorly
controlled hypertension.
2. No intracranial hemorrhage, vascular malformation or other
acute
abnormality.
Lumbar Puncture: Opening pressure was 27 cm of water
[**Doctor Last Name 3271**] [**Doctor Last Name **] Virus, Qualitative Real Time PCR
EBV DNA, QL PCR Not Detected
Herpes Simplex Virus, Type 1 & 2 DNA, Real-Time PCR
HSV 1 DNA Not Detected
HSV 2 DNA Not Detected
Gastric Emptying Study:
IMPRESSION: Normal gastric emptying study, with no
scintigraphic evidence of reflux.
Brief Hospital Course:
45 yo male h/o DMT1, ESRD, on HD, presenting with hypertensive
urgency/emergency in setting of worst headache of his life.
# Headache: Given history the concern was for intracranial [**Doctor Last Name **]
initially. Head CT was without bleeding, and Head MRI/MRA/MRV
was without bleeding or vascular malformation or venous
thrombosis. Patient initially refused LP. Since his headache
persisted for four days without resolution and reported left eye
blurriness, and left eye pain. Neurology was consulted and they
thought the pain may be from a migraine or a vascular phenomenon
and less likely intracranial [**Doctor Last Name **]. They recommended an LP to
rule out [**Doctor Last Name **] or infection given his vague symptoms. Fioricet
was started to treat his headache. On day 5 of his
hospitalziation, his headache resolved, however 24 hours later
his headache returned during [**Doctor Last Name 2286**]. Given the non-specific
headache, an LP was performed after patient ultimately
consented. First attempt at bedside was unsuccessful. He
eventually underwent an LP under fluoroscopic guidance at
interventional radiology with CSF only notable for a mildy
elevated opening pressure of 27 cm H2O. He notably had only 1
wbc, 0 rbcs, and negative culture, Cryptoccocal Ag, EBV and HSV
viral PCRs.
The headache persistently had an unclear etiology. The leading
differential was vasospasm vs. migraine vs. HTN vs. ?HD related
(since it was more prominent on HD days). It was decided to
discontinue his nifedipine and start verapamil, as verapamil is
more vasoactive; this medication would help vasospasm, migraine,
and HTN etiology. His headaches persisted despite these
interventions. Pain was consulted and felt that dilaudid may be
helpful. It was felt that an injection would not be helpful,
given the diffuse nature of his headaches. Fioricet was
discontinued, as it did not appear to be effective any more. He
was continued on full dose verapamil and dilaudid prn. His HTN
medication was aggressively uptitrated with the thought this
this would help his headaches. This moderately controlled his
headaches. He also had severe nausea and vomiting that was
controlled with reglan, compazine, and zofran, which was also
thought to help his headaches. He was given a trial of high flow
oxygen as well in case the etiology was cluster headache, but
this was not successful.
Of note, the patient was felt to be quite sensitive to opiates
and benzos. On the day of his IR guided LP, he received 1 mg of
IV Ativan, which decreased his RR to 8 and he appeared very
sleepy. He also received 4 mg IV morphine to help control his
HA, but he also developed decreased RR to 8 and the same
sleepiness. He was not given these medications any more.
Since the etiology of his headache was unclear, it was felt
that placing the patient on a regimen that he could take at home
would be the best for him, rather than IV dilaudid. Pain was
re-consulted. He was started on low dose MS-contin [**Hospital1 **] and 25 mg
topomax [**Hospital1 **]. Approximately 36 hours after these medications were
started the patient was completely somnolent and responsive to
sternal rub only. He was given Narcan 0.4 mg approximately three
times over the course of his somnolence and woke up briefly. He
remained in this state for nearly 72 hours. It was felt the
patient was on too much sedating medication causing this
deleterious effect. All opiates, topomax, and gabapentin were
all d/c'd. He was given an extra day of HD in hopes that this
would clear some of the medication that has built up in his
system. He remained hemodynamically stable and protected his
airway. These medications should be re-started only if
absolutely necessary and with extreme caution. He was not given
any more sedating medication and only given standing tylenol,
1000 mg q 8H. Surprisingly, tylenol by itself appeared to
control his headaches in the days leading up to discharge. He
was headache free in the last 24 hours of his admission.
It is truly unclear what the cause of his headaches are. It is
still speculated that HD may be the cause, as small studies have
demonstrated HD may cause headaches. It is unclear what the
treatment for this is. Also, HTN headaches did not show a clear
pattern, it is striking how when his blood pressure is ideally
controlled, his headaches have cleared. Nevertheless, his
headaches have resolved for the time being and further follow-up
with his PCP is in order.
# Hypertension: His hypertension was most pronounced on
hemodialysis days with SBPs in the 200s frequently. As a
result, his antihypertensive regimen was aggressively increased.
He began to take all of his anti-hypertensives everyday of the
week, including on HD days. He continued to have very high blood
pressures after this regimen. His BP medications were increased
to maximal doses. A clonidine patch was added at 0.1 mg q
weekly. He continued to have episodes of sbp to the 200s
occuring after [**Hospital1 2286**] in the setting of a severe headache. He
was transferred to the MICU for closer monitoring. His MICU
course was uneventful as his blood pressure decreased with IV
hydralazine x 1 and po labetalol, along with taking his BP
medications. He did not need an IV drip for blood pressure. He
was then started on Minoxidil 10 mg po BID. Near the end of his
hospitalization, his blood pressure was lower than expected with
levels in the low 100s. Minoxidil was decreased to 5 mg [**Hospital1 **]. It
was also noted that he was not wearing his clonidine patch for
several days in the setting of well controlled blood pressures.
After consultation with renal on the day of discharge, his
current regimen is as follows:
--Lisinopril 80 mg po daily (To be held the mornings prior to
HD)
--Valsartan 320 mg qhs
--Carvedilol 25 mg po BID
--Minoxidil 5 mg po BID (To be held the mornings prior to HD)
---Close follow up with his bp is highly recommended.
# Nausea/Vomiting: This was initially thought to be due to
gastroparesis, but a GES was performed which showed normal
motility. His N/V were felt to be secondary to his severe
headaches. His metoclopramide was continued, as was compazine
and zofran. At times, despite these medications, he continued
to have nausea and vomiting. This proved quite difficult to
manage his blood pressure, as he would vomit his medication.
Once this was controlled, his blood pressure and headaches, and
eventually his nausea and vomiting improved. He was discharged
on metoclopramide 5 mg PO TID. Further evaluation of this
standing medication should be evaluated by his PCP at his next
visit.
# Cranial Nerve III Palsy: Diplopia was initially reported on
[**2-11**]. On further questioning the patient reports his symptoms
began on [**2-7**] after the ophtho exam. Neuro initially evaluated
and feels likely third nerve palsy from diabetes. LP negative
besides increased ICP of 27 mm Hg. Optho re-consulted [**2-18**] and
confirmed complete CN3 palsy as the cause of diplopia and
complete ptosis of left eye. It was felt that this may be
reversible, but if not, it can be surgically corrected. He will
follow up with Neuro-optho in the outpatient.
# DM1: continued home 75/25 plus HISS. He was given half his
standing dose when not tolerating PO.
# CKD: continued HD. Pt continued on sevelamer alone (phoslo
discontinued).
# Neuropathy: gabapentin was increased to TID initially, but
when patient became somnolent for several days, this medication
was discontinued. Of note, he was on a very high dose for HD
patients (300 mg TID). It was felt this may have contributed to
his somnolence. Caution should be made in the future if this
medication were to be re-started. He was continued on a
lidocaine patch for chronic left flank pain.
# Depression: During an episode of severe pain, the patient
stated he wanted to "kill himself." Since he has a history of
suicidal attempts, a 1:1 sitter was attempted. Through the
course of the day, growing concern that he would act on his
ideations by the sitter. Psychiatry was consulted and felt he
was not suicidal at this time, and the sitter was discontinued.
He was continued on citalopram. Social work actively consulted
the patient and helped him deal with his many social problems.
[**Name (NI) **] is to be followed with psychiatry in rehab.
# Low grade fever: A fever of 100.5 was noted during his
hospitalization. He was pan-cultured which was NGTD at time of
discharge. A chest x-ray did not show any acute finding. He was
not given antibiotics and his fevers resolved.
# Access: He had a right central line during this
hospitalization which was pulled prior to discharge. He has a
left AV fisula used for HD.
# Code: Full
Medications on Admission:
Medications (per d/c summary [**2125-1-2**], pt could not confirm)
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Glycopyrrolate 1 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Please
apply 12 hours on and 12 hours off to left flank.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
12. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
14. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO at bedtime.
15. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Hold for SBP<100.
16. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Hold for SBP<100.
17. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO once a day:
Only on HD days.
18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
19. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Six
(6) units Subcutaneous with breakfast daily.
20. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Five
(5) units Subcutaneous with dinner daily.
21. Insulin sliding scale
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Insulin
Humalog Mix 75-25 suspension.
6 units subcutaneously with breakfast daily and 5 units
subcutaneously with dinner daily.
8. Insulin
Humalog sliding scale with breakfast lunch and dinner daily
9. Reglan 5 mg Tablet Sig: One (1) Tablet PO three times a day.
10. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
14. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSAT (every Saturday).
16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
17. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
18. Lisinopril 40 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Location (un) 1121**] - [**Location (un) 4310**]
Discharge Diagnosis:
primary: Hypertensive emergency, Headache NOS
secondary: ESRD, DM1
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to [**Hospital1 18**] for headache and elevated blood
pressures. We were concerned that your headache might be from a
[**Hospital1 **] in your head but the ct scan of your head did not show any
bleeding. We asked for your permission to look at your
cerebrospinal fluid to confirm that you did not have a [**Hospital1 **] in
your head, but you initially refused. We told you that if we
miss [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in your head that could result in another larger
head [**Last Name (NamePattern4) **] later, possibly even deadly, and you said you
understood this risk. We did check an MRI of your head to see if
we could see any blood vesels likely to [**Last Name (NamePattern4) **] and that showed
did not show a source of bleeding. Your headaches eventually
resolved after addition of fioricet, but then then returned in
[**Last Name (NamePattern4) 2286**]. A lumbar puncture was eventually performed by
interventional radiology and your CSF fluid was negative for
bleeding or infection. Your nifedipine was also discontinued
and switched to verapimil to help your headache. Your headache
continued to persist. The pain service was consulted and a very
strong medication, Dilaudid was suggested. We stopped your
fiorcet as this did not appear to help your pain anymore, and
gave you dilaudid for your pain. This helped your headaches
mildly. We tried to change your pain medication to different
drugs (ms contin and low dose topomax), but this made you very
sleepy for several days. We stopped all of these medications
plus all strong sedating medications, such as dilaudid,
gabapentin, and ambien. You were continued on tylenol alone for
pain control, and surprisingly, this alleviated your headaches.
You are advised to not take these sedating medications any more
as it is very difficult for your body and kidneys to process
these medications. On the day of discharge, you were headache
free.
Your blood pressure was also very high during this hospital
stay. It appeared to be quite higher on your hemodialysis days.
We continued all of your medications on your [**Last Name (NamePattern4) 2286**] days. We
also increased the dosage of several of your medications as well
as added new medications that are listed below. During your
hospital stay, you were briefly transferred to the intensive
care unit for closer evaluation of your elevated blood pressure.
You were monitored closely and your blood pressures decreased.
You were transferred back to the general floor. More blood
pressure medications were added and your blood pressure became
ideally controlled. Your new regimen is below.
You also developed double vision which we feel is secondary to a
nerve in your eye that is not working correctly caused by your
diabetes. This may reverse, but you may need surgery in the
future to correct this. You will be followed up by
Neuro-opthomology for further evaluation of this.
When you came in you also had chest pain, but we do not think
you had a heart attack.
You also had significant nausea and vomiting during your
hospital stay. We gave you strong medications to help this. You
eventually were able to tolerate food and medications. You will
be discharged on a home dose of an anti-nausea medication,
reglan.
When you go back to rehab, your new medications are as follows:
YOUR NEW BLOOD PRESSURE REGIMEN:
Verapamil 240 mg every 12 hours
Valsartan 320 mg every night
Lisinopril 80 mg daily
Minoxidil 5 mg twice a day
Clonidine patch 0.1 mg to be applied every saturday (keep on all
week)
PAIN CONTROL:
Lidocaine 5% patch, apply 12 hours on and 12 hours off as needed
for flank pain
Tylenol 1000 mg every eight hours for headache. Do not take more
than 4 grams of tylenol in 24 hours
STOP: Gabapentin (this may make you sleepy)
Phoslo
Glycopyrrolate
You are to contact your primary care doctor or go to the
emergency room if you experience severe headaches that are not
relieved with medication, sudden loss of vision or severe eye
pain, confusion, chest pain, or any other symptom that is
concerning to you.
Followup Instructions:
Please continue your [**Last Name (NamePattern4) 2286**] three times per week.
You should call the [**Hospital 9786**] clinic:
[**University/College **] School of Dental Medicine, [**Hospital1 37861**], [**Location (un) 86**],
[**State 350**] [**Telephone/Fax (1) 27823**]
Appointment #1
MD: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Specialty: PCP
[**Name Initial (PRE) 2897**]/ Time: Monday, [**3-26**] at 1:45pm
Location: [**Hospital **] [**Hospital **] HEALTH CENTER, [**Last Name (un) **], [**Location (un) **],[**Numeric Identifier 104347**]
Phone number: [**Telephone/Fax (1) 65443**]
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **]
Specialty: Neuro-Ophthalmology
Date/ Time: [**Last Name (NamePattern1) 2974**], [**3-23**] at 7:00 AM
Location: [**Hospital 13128**] Infirmary, [**Last Name (NamePattern1) 79237**], [**Location (un) 86**]
[**Numeric Identifier 18228**]
Phone number: ([**Telephone/Fax (1) 104348**]
Special instructions for patient: Please call ([**Telephone/Fax (1) 104349**]
before your appointment to register with [**Hospital 13128**]
Infirmary.
Appointment #3
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3209**]
Specialty: Podiatry
Date/ Time: [**Last Name (NamePattern1) 2974**], [**3-30**] at 1:00pm
Location: [**Street Address(2) 8667**], Entrance through [**Hospital Ward Name 121**] building to
the [**Hospital Unit Name **] [**Location (un) 470**] Phone number: ([**Telephone/Fax (1) 4335**]
ICD9 Codes: 5856, 3572, 311, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2518
} | Medical Text: Admission Date: [**2149-4-28**] Discharge Date: [**2149-5-5**]
Date of Birth: [**2110-1-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 39 year old
male with a past medical history of chronic myelogenous
leukemia, status post unrelated allogeneic bone marrow
transplant that has been complicated by chronic graft-versus-
host disease (hypopigmentation, mild ulceration, and
thrombocytopenia). The patient states that he began feeling
unwell approximately nine days prior to admission but
worsened significantly over the weekend prior to admission,
specifically complaining of fever to 101, complicated by
myalgias, fatigue and an unproductive cough as well as
shortness of breath. He was seen in the [**Hospital 3242**] Clinic on
[**4-24**], at which time he had an ANC of 3700 and a chest
film that did not reveal any infiltrate. He was seen in
clinic today as a follow up with an unchanged chest film but
found to be hypoxic to approximately 89 percent on room air.
He denies any headache, rhinorrhea, pleuritic chest pain,
nausea, vomiting, abdominal pain, changes in bowel or bladder
habits. Of note the patient was noted to have a flare of his
graft- versus- host disease flare ([**2149-1-6**]). He was seen
by pulmonary who felt he had a component of Bronchlitis
obliterans and was treated with Prednisone 40 mg which was
tapered slowly back down to 5 mg last month. The symptoms
appeared to develop approximately one week after having tapered
down to 5 mg, in particular the muscle aches, pain, fatigue and
low-grade fever. This progressed to a dry cough and worsened
fever as above.
PAST MEDICAL HISTORY: The patient's past medical history is
notable for chronic myelogenous leukemia. It was diagnosed
in [**2146-12-8**]. He is status post a match-unrelated
allogeneic bone marrow transplant in [**2147-10-8**]. It has
been complicated by graft-versus-host disease as mentioned
above as well as cytomegalovirus colitis, bronchiolitis
obliterans-organizing pneumonia, hemolytic uremic syndrome,
and mouth ulcers as well as thrombocytopenia.
MEDICATIONS ON ADMISSION: The patient's medications on
admission are Prednisone 5 mg q. day and Acyclovir 400 mg
p.o. b.i.d., Pentamidine q. month and folic acid q. day.
ALLERGIES: His allergies are to Amphotericin and to
Ampicillin.
SOCIAL HISTORY: The patient is married, works as a computer
analyst. He works with his wife and three children. He has
no history of tobacco use or intravenous drug use. He does
not drink alcohol.
FAMILY HISTORY: Notable for the absence of cancer or lung
disease.
LABORATORY DATA: Laboratory data on admission revealed
sodium 141, potassium 3.7, chloride 105, bicarbonate 26, BUN
19, creatinine 1.6, glucose 86. His white count is 7.4 with
46 percent neutrophils and 7 percent bands as well as 99
percent lymphocytes. Hematocrit is 26.1 and platelets are
27. His ALT is 39, AST is 54. His alkaline phosphatase is
101, creatinine 1.0. Chest film does not reveal any evidence
of infiltrate or effusion.
HOSPITAL COURSE: Pneumonia - A high resolution chest
computerized tomography scan did not reveal any acute
changes, though the nasal swabs were positive for respiratory
syncytial virus. The patient was transferred to the Medical
Intensive Care Unit for aerosolized Ribavirin and Synagis
treatment. The patient received one dose of Synagis as well
as a course of Ribavirin therapy which he tolerated well.
The patient received five days of Ribavirin in all. The
patient defervesced and had improved oxygenation. A repeat
viral culture from a repeat nasopharyngeal aspirate again
revealed respiratory syncytial virus. Infectious disease
consult was obtained for further assistance. Follow up chest
computerized tomography scan was essentially unchanged from
the prior admission study. Again, noted were bronchial wall
thickening and scarring of the right lower lobe that was
unchanged from the prior study with no significant air
trapping and no adenopathy. Overall there was no
computerized tomography scan evidence for acute infectious
process or inflammatory process. However, given the
patient's immunocompromised status and out of concern for
possible superimposed bronchitis or pneumonia, the patient
was treated with a seven day course of Levofloxacin in
addition to the treatment for his Ribavirin. The patient's
cytomegalovirus viral load was found to be negative. His
prednisone dose was also increased to 40mg qd.
Thrombocytopenia - The patient has thrombocytopenia which is
thought to be secondary to chronic graft-versus-host disease.
The patient's platelets on admission were 27. The patient
received platelets on [**5-1**], as well as on [**4-29**], one
unit.
Graft-versus-host disease - The patient has a history of
bronchiolitis obliterans-organizing pneumonia. There was
concern that his hypoxia in addition to being caused by
respiratory syncytial virus infection may also have had an
component of graft-versus-host disease as well, in particular
given the drop in his platelet count on admission. Therefore
Prednisone dose was increased to 40 mg q. day and was tapered
slowly. The patient's Prednisone dose is 30 mg at the time
of discharge.
Anemia - The patient's hematocrit is stable over the course
of hospitalization. His hematocrit on admission was 29, the
patient received 2 units of packed red blood cells on [**5-1**], and his hematocrit remained stable.
Chronic renal insufficiency - The patient had an elevated
creatinine on admission of 1.6. It is felt that his baseline
creatinine is 1.1 to 1.2. Etiology was unclear for his
elevated creatinine on admission. The patient was discharged
in stable condition.
DISCHARGE DIAGNOSIS: Respiratory syncytial virus.
Extensive chronic GVHD.
Pneumonia.
Status post allogeneic bone marrow transplant with extensive
chronic graft-versus-host disease.
Anemia.
Thrombocytopenia.
FOLLOW UP: The patient will follow up with his oncologist
following discharge.
DISCHARGE MEDICATIONS:
1. Acyclovir 400 mg p.o. q. 12.
2. Folic acid 1 mg q. day.
3. Protonix 40 mg q. day.
4. Levofloxacin 500 mg q. day to complete his seven day
course.
5. Prednisone
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 9811**]
Dictated By:[**Last Name (NamePattern1) 8188**]
MEDQUIST36
D: [**2149-7-1**] 18:43:16
T: [**2149-7-1**] 20:29:17
Job#: [**Job Number 37210**]
ICD9 Codes: 5849, 2875, 2765, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2519
} | Medical Text: Admission Date: [**2175-8-11**] Discharge Date: [**2175-8-11**]
Date of Birth: [**2146-4-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
failure to protect airway, EtOH intoxication
Major Surgical or Invasive Procedure:
Endotracheal intubation
Oral Gastric Tube
History of Present Illness:
Pt is a 29yo M who presented to ED tonight after going out on
Landsdowne St. Pt was reportedly in a bar, drinking EtOH, awake
and conversant. He then began vomiting, and wandered outside
where bystanders said he continued vomiting "black material" and
soon became unable to ambulate. 911 was called by bystanders. He
was brought to the ED by ambulance where he was noted to have
pinpoint pupils, urinary incontinence and no gag reflex. He was
intubated for airway protection at that point. Per the ED
resident, there were no witnessed aspiration events or episodes
of oxygen desaturation. VS were stable - Tm 98.6, HR 73-90, BP
97-164/50-109, RR 12-20, O2 sats 100% on vent (as well as on
NRB). Meds in ED include etomidate 20mg IV x1, succinylcholine
100mg IV x1, ativan 2mg IV x1, versed 4mg total, and propofol
gtt. He was given 2L NS and made 1150 UOP prior to arrival in
[**Hospital Unit Name 153**].
Past Medical History:
None
Social History:
Admits to social binge drinking.
Family History:
Non-contributory
Physical Exam:
VS - T BP 102/43, HR 80, RR 18, sats 100%
AC FiO2 40%, 600 x 18, PEEP 5, Ppeak 21
Gen: WDWN young male, sedated, intubated.
HEENT: NCAT. Pupils pinpoint, minimally rxtive. Sclera
anicteric. MM dry.
Neck: Supple, no JVD.
CV: RR, normal S1, S2. No m/r/g.
Resp: CTAB, no rhonchi, wheezes or rales.
Abd: Soft, NTND. + BS. No HSM.
Ext: 2+ PT/radial pulses bilaterally. Skin warm, dry. No edema.
Neuro: Sedated.
Pertinent Results:
ADMISSION LABS:
[**2175-8-11**] 03:17PM GLUCOSE-62* UREA N-18 CREAT-0.8 SODIUM-143
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-21* ANION GAP-17
[**2175-8-11**] 03:17PM CALCIUM-8.7 PHOSPHATE-2.8 MAGNESIUM-2.0
[**2175-8-11**] 05:42AM TYPE-ART TEMP-37 RATES-12/ TIDAL VOL-600
O2-100 PO2-540* PCO2-49* PH-7.26* TOTAL CO2-23 BASE XS--5
AADO2-148 REQ O2-34 INTUBATED-INTUBATED VENT-CONTROLLED
[**2175-8-11**] 03:45AM URINE HOURS-RANDOM
[**2175-8-11**] 03:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2175-8-11**] 03:45AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2175-8-11**] 03:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2175-8-11**] 02:55AM GLUCOSE-100 UREA N-23* CREAT-1.0 SODIUM-142
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-21* ANION GAP-21*
[**2175-8-11**] 02:55AM ALT(SGPT)-26 AST(SGOT)-25 LD(LDH)-169 ALK
PHOS-76 TOT BILI-0.4
[**2175-8-11**] 02:55AM CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.6
[**2175-8-11**] 02:55AM ALBUMIN-5.2*
[**2175-8-11**] 02:55AM OSMOLAL-365*
[**2175-8-11**] 02:55AM ASA-NEG ETHANOL-277* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2175-8-11**] 02:55AM WBC-12.1* RBC-4.94 HGB-15.8 HCT-45.2 MCV-92
MCH-32.1* MCHC-35.0 RDW-13.9
[**2175-8-11**] 02:55AM NEUTS-66.7 LYMPHS-26.9 MONOS-5.0 EOS-1.1
BASOS-0.4
[**2175-8-11**] 02:55AM PLT COUNT-225
[**2175-8-11**] 02:55AM PT-13.1 PTT-32.4 INR(PT)-1.1.
.
DISCHRGE LABS:
[**2175-8-11**] 03:17PM BLOOD Glucose-62* UreaN-18 Creat-0.8 Na-143
K-4.0 Cl-109* HCO3-21* AnGap-17
[**2175-8-11**] 02:55AM BLOOD ALT-26 AST-25 LD(LDH)-169 AlkPhos-76
TotBili-0.4
.
IMAGING:
Chest X Ray [**8-11**]: PORTABLE CHEST: The patient is intubated with
the endotracheal tube terminating approximately 5 cm above the
carina in appropriate position. The heart size and mediastinal
contours are within normal limits. The pulmonary vasculature is
unremarkable. The lungs are clear without focal consolidation,
pleural effusion, or pneumothorax. Surrounding soft tissues and
osseous structures are unremarkable.
IMPRESSION: Endotracheal tube in standard position. Clear lungs.
.
CT Head [**8-11**]: FINDINGS: There is no evidence of hemorrhage,
shift of normally midline structures, mass effect, hydrocephalus
or infarction. There is preservation of the normal [**Doctor Last Name 352**]/white
matter distinction. The ventricles, sulci and basal cisterns are
symmetric. Small fluid levels are noted in both maxillary
sinuses with aerosolized secretions on the left. There is also
mild mucosal thickening of the ethmoid sinus. The mastoid air
cells are clear. The surrounding soft tissues and osseous
structures are unremarkable. There is no evidence of fracture.
IMPRESSION: No evidence of hemorrhage. Fluid levels and
aerosolized secretions of the maxillary sinuses are consistent
with sinusitis
Brief Hospital Course:
EtOH Intoxication: Initial EtOH level was 277 on admission.
The patient arrived to the ICU intubated and on propofol with an
OG tube. Overnight, the patient tolerated the intubation well
on AC. In the AM, the patient was switched to pressure support
and the propofol was weaned. He was extubated successfully and
OG tube was taken out without incident. He did experience some
nausea and vomitting. Over the course of the day, his mental
status improved and he felt better. On discharge, he had
returned to baseline.
.
Metabolic Anion Gap Acidosis: On admission the patient had a
low bicarb (21), and an anion gap of 17. The etiology was
likely ethanol related. He did not have ketones in his urine,
and it was not thought likely to other injections. An GHB level
was drawn and was pending on discharge. A repeat chem 7 showed
near resolution of the gap with IVF.
.
Nutrition: Once the patient was extubated, he was able to
slowly tolerate liquids, and was discharged with a regular diet.
.
Code Status: The patient was full code.
.
Outstanding Issues:
1. Binge drinking - must provide appropriate counceling.
.
2. GHB level: still pending on discharge.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol Intoxication requiring airway protection with
endotracheal intubation
Discharge Condition:
Stable
Discharge Instructions:
1) Please return to ER for persistent vomiting, severe headache,
confusion, dizziness or any other concerning symptoms.
2) You were seriously ill after a drinking binge. Please
refrain from drinking alcohol, particularly more than 2 drinks
at a time.
3) You should follow-up with a primary care doctor. You may
call Heathcare Associates at [**Hospital1 1170**] to obtain a new PCP by calling [**Telephone/Fax (1) 250**].
Note: we had extensive discussions with the patient and his
family about the dangers of binge drinking and the close call
that he had with this event. Specifically, that his alcohol
poisoning could have led to his death had he vomited and
aspirated prior to coming to the hospital.
Followup Instructions:
1) You should follow-up with a primary care doctor. You may
call Heathcare Associates at [**Hospital1 1170**] to obtain a new PCP by calling [**Telephone/Fax (1) 250**].
ICD9 Codes: 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2520
} | Medical Text: Admission Date: [**2114-9-19**] Discharge Date: [**2114-9-25**]
Date of Birth: [**2035-5-30**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
loss of balance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 79 year-old R-handed man with hx of prostate ca s/p
brachytherapy, HTN, HL, headaches and bladder ca s/p resection
surgery [**2114-8-13**] who presented with a R inraparenchymal
hemorrhage.
Patient reports that he felt unsteady on his feet since his
resection surgery at the end of [**Month (only) 216**], and for the last 3 weeks
he had a sense of urinary urgency, for which he was "rushing to
the bathroom". On [**9-9**] he started noticing that he was "tilting
to the left, even when sitting", and that he then fell multiple
times in an effort to get to the bathroom. His urologist
prescribed him for nitrofurantoin for presumed UTI. He went to
the ED on [**9-11**] where he was given IVF and sent home with a
diagnosis of "dizziness". He still felt very unsteady and fell
that night in the bath and hit the back of his head without LOC.
He then continued to feel off balance, but no focal
numbness/weakness/tingling. When his dizziness and unsteadiness
did not improve, he went to see his PCP [**Last Name (NamePattern4) **] [**9-13**], who told him he
should go the ED, which he did. There, he was admitted with
plans for IVF and urological exam. He was started on IV
ceftriaxone for his UTI (confirmed on U/A and found on UCx to be
proteus sensitive to ceftriaxone) and was monitored. On [**9-18**]
OSH
notes some uncoordination in his L arm, and ordered a head CT.
Per the pt, his son had insisted that an MRI be done "for many
days of the admission", and it was only done on [**9-18**]. Patient
denies any new neurological sx at that time. The MRI showed a R
frontal IPH, and he was transfer to [**Hospital1 18**] was arranged for [**9-19**].
.
On neuro ROS, the pt denies current headache, loss of vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- magnesium oxide 200mg QD
- meloxicam 7.5mg QD
- MVI QD
- nitrofurantoin (started on [**9-13**] by urologist)
- prilosec 20mg QD
- simvastatin 5mg QD
- vicodin 5/500mg Q6H PRN pain
Social History:
Lives with wife in a house with no stairs, he does much
of the daily activities around te house because his wife has MS.
He smoked a 1/2ppd from age 16 to his early 60's, denies alcohol
or drug use, his children live close by.
Family History:
his father died of lung cancer (was a smoker) at age
65; mother died from an ischmemic/embolic stroke at age 52; his
oldest brother had lung cancer (was a smoker).
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: T: 97.9 P:84 R: 19 BP: 139/64 SaO2: 100%RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally, but skin on legs cool.
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Alert, oriented x 2 (knew the hospital name,
year
and month, but thought it was Monday instead of Wednesday, and
couldn't recall the date). Able to relate history without
difficulty. Attentive, able to name DOW backward without
difficulty, but for [**Doctor Last Name 1841**] had one omission and one error.
Language
is fluent with intact repetition and comprehension. Normal
prosody. There were no paraphasic errors. Pt. was able to name
both high and low frequency objects. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt. was able to register 3
objects and recall [**1-18**] spontaneously and [**2-15**] with cues at 5
minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect.
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted. Slowed RAMs in L hand
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5- 5 4+ 5- 5 5 4 4+ 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
.
-Sensory: Decreased vibratory, temperature and proprioceptive
sensation from mid shins down; increased pinprick sensation in
same distribution. Otherwise, above mid shins no deficits to
light touch, pinprick, cold sensation, vibratory sense,
proprioception throughout. No extinction to DSS.
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally; pt's natural toe position
is up, no tensor fascia lata contraction seen bilaterally.
.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
.
-Gait: Deferred, pt in ICU for cerebral hemorrhage.
on discharge
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Patient is convinced he is at his house, but otherwise is awake
and oriented
Mild left pronator, mild 5- weakness at left delt, tri. Mild Ip
weakness
Pertinent Results:
ADMISSION LABS:
[**2114-9-19**] 03:10PM BLOOD WBC-6.9 RBC-4.15* Hgb-13.4* Hct-40.1
MCV-97 MCH-32.4* MCHC-33.5 RDW-12.0 Plt Ct-280
[**2114-9-19**] 03:10PM BLOOD PT-12.7 PTT-31.2 INR(PT)-1.1
[**2114-9-19**] 03:10PM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-141
K-4.2 Cl-101 HCO3-29 AnGap-15
[**2114-9-19**] 03:10PM BLOOD ALT-29 AST-27 CK(CPK)-27* AlkPhos-140*
TotBili-0.3
[**2114-9-19**] 03:10PM BLOOD CK-MB-2 cTropnT-<0.01
[**2114-9-19**] 03:10PM BLOOD Calcium-9.6 Phos-4.0 Mg-2.4 Cholest-147
[**2114-9-19**] 03:10PM BLOOD %HbA1c-5.2 eAG-103
[**2114-9-19**] 03:10PM BLOOD Triglyc-94 HDL-49 CHOL/HD-3.0 LDLcalc-79
DISCHARGE LABS:
IMAGING:
CT HEAD [**2114-9-19**]: IMPRESSION: Stable appearance of right frontal
intraparenchymal hemorrhage.
ECHO [**2114-9-20**]: Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: No intracardiac source of thromboembolism
identified. Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. No clinically significant valvular disease.
Indeterminate pulmonary artery systolic pressure.
CAROTIDS [**2114-9-20**]: normal
Brief Hospital Course:
79 year-old R-handed man with hx of prostate ca s/p
brachytherapy, HTN, HL, headaches and bladder ca s/p resection
surgery [**2114-8-13**] who presented from an OSH with a R
inraparenchymal hemorrhage. Upon review of his imaging, there
is no evidence of obvious malignancy or vasculitis that would
cause his hemorrhage, nor is there evidence that this is
obviously a venous clot. There are some small DWI lesions in
the ACA territory that are suggestive of an embolic infarct with
subsequent hemorhagic conversion. His hemorrhage could also
likely be from amyloid. In addition, his subdural hematoma
could have been caused by his head strike, but could also be
from a rupture of his more frontal hematoma into the subdural
space. He will need close close monitoring to ensure he is
stable and then likely rehabilitation.
.
# NEURO: patient was evaluated for possible cause of his stroke.
His echo was unremarkable and his carotid duplex showed 0%
stenosis bilaterally. It is likely that the bleed is a result
of amyloid but we are not sure. We stopped his statin as it was
low dose and there is some increased risk of bleeding, and there
is not a significant benefit for this medication. The patient
did well and continued to improve - he does have a fixed belief
that he is in his home, despite being aware of the evidence that
he is not - likely reduplicative paraamnesia as a result of his
bleed. This should likely improve.
# CARDS: we held pt's home dose simvastatin as he was only on
5mg and we felt that amyloid was a likely source of his bleed,
making his statin contraindicated. We got an echo, which was
unremarkable and kept pt's SBP <160. He had one episode of
chest pain and his tpns and EKG were normal. We did start him
on a baby aspirin and metoprolol as he was hypertensive and was
placed on an aspirin for prophylaxis
# ID: patient came from OSH with a documeted proteus UTI. He
had been started initially on macrobid as an outpatient, which
was continued at the OSH until [**9-17**], when he was started on
ceftriaxone. We continued him on the ceftriaxone for a planned
7 day course.
# CODE/CONTACT: Full [**Name2 (NI) 7092**]; [**Name (NI) 2048**] (wife) [**Telephone/Fax (1) 90938**] or son
[**Telephone/Fax (1) 90939**]
PENDING RESULTS:
TRANSITIONAL CARE ISSUES:
Pt will need rehabilitation, but is the primary caregiver for
his wife who is at home with MS. Social work was involved and
spoke with his family. He was seen by PT and they indicated
that he would need rehab and he was set up for an acute [**Last Name (un) **].
Medications on Admission:
- magnesium oxide 200mg QD
- meloxicam 7.5mg QD
- MVI QD
- nitrofurantoin (started on [**9-13**] by urologist)
- prilosec 20mg QD
- simvastatin 5mg QD
- vicodin 5/500mg Q6H PRN pain
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for prophylaxis.
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Primary: right sided frontal hemorrhage
Secondary: hx of bladder and prostate ca
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Patient is convinced he is at his house, but otherwise is awake
and oriented
Discharge Instructions:
Dear Mr. [**Known lastname 90940**],
You were seen in the hospital for difficulty with your balance.
You were found to have had a right sided bleed in your brain
causing you to have some left sided weakness. You were
monitored, and when it was determined your bleed was stable you
were able to be sent to a rehabilitation facility to get
stronger and improve your balance.
You were dicharged to a rehab facility
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2114-11-19**] at 3:00 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
ICD9 Codes: 431, 5990, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2521
} | Medical Text: Admission Date: [**2128-5-23**] Discharge Date: [**2128-6-1**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Right sided weakness and difficulty speaking.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a 76 year old woman of unknown handedness who was
brought to the hospital unaccompanied by ambulance and is unable
to relate a history at this time. She was reportedly found
sitting on a sidewalk this afternoon at about 2PM, alert awake
and non-verbal with right-sided weakness. According to the EMS
notes, the patient was able to give her name but had a right
facial, right arm, and leg flaccidity. She was taken to [**Hospital 1474**]
Hospital where her BP at 3:15 was 238/100 with HR of 52. A NC
head CT showed a 2x3 LEFT subcortical hemorrhage. The patient
received 10mg Labetalol and by 4:30 BP 133/66 with HR 37. She
also received a bolus of dilantin. She was then transferred to
[**Hospital1 18**] for management.
Past Medical History:
No known PMH, but pt does not see doctors. She has fallen twice
in the last year, but has not seen a doctor after these events
Social History:
Pt lives with her mentally retarded daughter. She has a friend
who drives her to the store, etc. Her daughter has a guardian
who makes her medical/financial decisions.
Family History:
Unknown
Physical Exam:
T 98.9 HR 41 BP 102/62 RR 16 Sat 100 FiO2 100%
Gen Lying in gurney, eyes open. Left gaze preference.
HEENT AT/NC, MMM no lesions, no bruits
Neck Supple, no thyromegaly, no [**Doctor First Name **], no bruits
Chest CTA B, breathing is labored.
CVS RRR w/o MGR
ABD soft, NTND, + BS
EXT no C/C/E. no rashes or petechiae, no asterixis
Neuro Opens eyes to voice. Lifts left hand up to command to show
two fingers. No blink to threat on right. There is a right
facial. The right arm is flaccid. She squeezes with the left
hand to command. The RIGHT leg is externally rotated and
flaccid. The RIGHT ankle is in plantar flexion. The LEFT leg
moves to foot
tickles. Both legs internally rotate toward noxious stimuli. The
left ankle is in plantar flexion.
Pertinent Results:
[**2128-5-23**] 06:05PM BLOOD WBC-5.7 RBC-5.00 Hgb-14.7 Hct-42.7 MCV-85
MCH-29.5 MCHC-34.5 RDW-14.9 Plt Ct-168
[**2128-5-23**] 06:05PM BLOOD PT-12.7 PTT-26.9 INR(PT)-1.1
[**2128-5-23**] 06:05PM BLOOD Glucose-147* UreaN-15 Creat-0.6 Na-138
K-4.4 Cl-106 HCO3-20* AnGap-16
[**2128-5-24**] 02:58AM BLOOD ALT-13 AST-18 LD(LDH)-189 CK(CPK)-59
AlkPhos-74 Amylase-157* TotBili-0.4
[**2128-5-23**] 06:05PM BLOOD cTropnT-0.11*
[**2128-5-23**] 08:21PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2128-5-23**] 06:05PM BLOOD CK(CPK)-86
[**2128-5-23**] 08:21PM BLOOD CK(CPK)-70
[**2128-5-23**] 06:05PM BLOOD CK-MB-NotDone
[**2128-5-24**] 02:58AM BLOOD CK-MB-NotDone
[**2128-5-24**] 02:31PM BLOOD CK-MB-NotDone
[**2128-5-23**] 06:05PM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0
[**2128-5-24**] 02:58AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.1 Mg-2.0
Cholest-144
[**2128-5-24**] 02:58AM BLOOD Triglyc-121 HDL-47 CHOL/HD-3.1 LDLcalc-73
[**2128-5-24**] 02:58AM BLOOD TSH-2.5
[**2128-5-24**] 02:57PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2128-5-24**] 02:57PM URINE RBC-[**11-8**]* WBC-[**2-22**] Bacteri-FEW Yeast-NONE
Epi-0
[**2128-5-23**] 08:21PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2128-5-23**] 08:21PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
CT head [**5-23**]:IMPRESSION: Stable appearance of an area of
increased attenuation in the left basal ganglia consistent with
intraparenchymal hemorrhage, with slight shift of normally
midline structures to the contralateral side and mass effect on
the left lateral ventricle.
CT head [**5-24**]:Again seen is evidence of intraparenchymal
hemorrhage in the left putamen, measuring just slightly larger
compared to prior study, however, not appearing significantly
changed. No significant change in mass effect on left lateral
ventricle or slight rightward shift. No new areas of hemorrhage
identified.
-------
CXR [**5-25**]
1. New pulmonary edema.
2. Left lower lobe consolidation/atelectasis with small left
pleural effusion.
3. Dislocation of the left shoulder.
TTE:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Tissue
velocity imaging E/e' is elevated (>15) suggesting increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. The left ventricular
inflow pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
Brief Hospital Course:
1. Left putaminal hemorrhage: Her exam stayed fairly stable
thoroughout her course, except that her mental status improved
significantly. Her ICH was stable on repeat neuroimaging, with
no significant mass effect. It was measured as roughly 2x1.3 cm
and appeared to originate in the left putamen. There was no
intraventricular spread. The location was very typical for
hypertensive hemorrhage, and her admission blood pressure was
extremely elevated. She does not regularly seek medical care so
she may be chronically experiencing uncontrolled hypertension.
She had a repeat CT 24 hours after admission which showed a
stable bleed and amount of edema. Her BP was treated initially
with a nicardipine drip. This was quickly weaned and she was
treated with IV hydralazine. This was transitioned to oral
hydralazine and captopril with aggressive titration. She had
received a dose of labetalol at the OSH and presented extremely
bradycardic in the high 30s. This was a sinus bradycardia. It
was either due to her hypertension(no evidence of high ICP to
suggest [**Location (un) 3484**] repsonse) or to the beta blockade. We decided
not to use further beta blockers given this response. The
bradycardia resolved on day 1 of her stay.
She continued to have right arm weakness, but started to regain
some use of her right leg. Her speech was extremely dysarthric,
but she was able to tell us her name and other short answers,
but did not speak fluently. She was following commands.
2.Pulmonary: She was initially intubated for airway protection.
She was quickly weaned from the ventilator and extubated. She
later developed pulmonary edema on chest X-ray. She was given
several doses of lasix during her stay and responded well. As
she has possibly long standing HTN and an enlarged heart on CXR,
she likely has some element of CHF. An echo was performed and
demonstrated a normal ejection fraction, but evidence of
diastolic dysfunction.
3.Cardiac: As above, she had BP controlled with a goal SBP of
less than 150 given her bleed. This was achieved as above
without problems. [**Name (NI) 227**] her probable CHF and bradycardia with
labetalol, she was put on an ACE-I with good tolerance. She was
found to have diastolic dysfunction as discussed above.
4.Ortho: The patient was found to have a dislocated left
shoulder on CXR. The ortho service felt this was likely chronic
given lack of pain and good ROM, and no operative management was
recommended.
5.GI: She had a post-pyloric feeding tube placed and tolerated
tube feeds well. She refused placement of a PEG tube. A repeat
speech and swallow evaluation, including videoswallow
evaluation. Final recommendations were:
1. Remain NPO at this time, with NG tube in place for nutrition,
hydration & meds.
2. Speech therapy at rehab for:
a. aphasia remediation
b. Po trials of purees (no more than [**2-21**] oz) with deep
pressure to tongue to trigger repeat swallows.
c. Repeat video swallow within 1-2 weeks, according to
treating clinician, prior to po diet advancement or d/c of NG
tube.
6. GNR in eyes: The pt developed a purulent discharge from her
eyes. Swab revealed GPC and GNR. She was started on cipro ophth
gtt.
Medications on Admission:
None
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) 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. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day).
8. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q4H
(every 4 hours) for 5 days.
9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
-left putaminal intraparenchymal hemorrhage
-hypertension
Discharge Condition:
Stable. Neurologic examination notable for anterior aphasia,
right-sided hemiplegia.
Discharge Instructions:
Please continue all medications as prescribed. Please attend all
follow-up appointments. If the pt experiences fever, worsening
weakness, or other concerning symptoms, have her return to the
emergency department for evaluation.
Followup Instructions:
Neurology: Please call [**Telephone/Fax (1) 1694**] to schedule a follow-up
appointment in [**Hospital 878**] Clinic with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. The
clinic will have to be contact[**Name (NI) **] so that demographic information
may be updated prior to scheduling of the appointment.
Primary Care Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time: [**2128-6-29**] 1:30
ICD9 Codes: 431, 4280, 5180, 5119, 4168, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2522
} | Medical Text: Admission Date: [**2189-3-29**] Discharge Date: [**2189-4-2**]
Date of Birth: [**2117-3-31**] Sex: M
Service: MEDICINE
Allergies:
Coumadin
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Dyspnea, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 yo Cantonese and Spanish speaking male with metastatic
pancreatic cancer was admitted from the ED with dyspnea, altered
mental status, and hyponatremia. History was obtained from
patient's son and [**Name (NI) **] as patient could not give complete
history.
.
Patient was recently admitted to the OMED service 4/22-24/09
with tachycardia and hypotension thought related to dehydration.
He was given IVF and 2 units pRBCs with improvement in his blood
pressure and heart rate. He was also treated with a 7-day course
of levofloxacin for presumed community-acquired pneumonia. [**Name (NI) 1094**]
son reports that his cough improved, but he gradually developed
increasing lower extremity edema and abdominal swelling.
Associated symptoms include worsening mental status and fatigue.
On review of systems, he denies fevers, shaking chills, night
sweats, abdominal pain, back pain, chest pain, and sick
contacts.
.
Of note, during his last admission, palliative care was
consulted for assistance with goals of care. Although the
patient has refused palliative chemotherapy and XRT, he has not
further discussed or re-addressed code status. He remains full
code.
.
Upon arrival to the ED, temp 98.4, HR 100, BP 122/70, and pulse
ox 97% on 2L. His exam was notable for increased edema and
ascites. His labs were notable for hyponatremia with a sodium of
103, elevated lactate to 6.6, and hyperkalemia to 5.5. He
received 1L IVF, vancomycin 1 g IV x 1, and zosyn 4.5g IV x 1.
Past Medical History:
1. Prostate cancer [**2183**] s/p resection
2. Hypertension
3. Atrial fibrillation off coumadin
4. Thalaseemia
5. CVA, multiple TIAS
6. Metastatic pancreatic cancer
Social History:
- Home: lives at home with wife and daughter [**Name (NI) **]; moved here
from [**Country 651**] in [**2168**]
- Occupation: worked in hotels and supermarkets
- EtOH: Denies
- Drugs: Denies
- Tobacco: Denies
Family History:
Denies any history of cancer in the family.
Physical Exam:
T 97.4, HR 82, BP 105/55, RR 19, O2sat 99%RA
Gen: Somnolent male difficult to arouse from sleep but in NAD
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: Anterior breath sounds notable for rales at right base
and diminished breath sounds at left base.
ABD: Soft, nl BS, mildly distended, unable to appreciate fluid
wave
EXT: 2+ pitting LE edema extending to lower back and 1+ of upper
extremities b/l. 2+ DP pulses BL
SKIN: No lesions
NEURO: Arousable but not oriented. PERRL, unable to elicit rest
of neuro exam as pt too obtunded
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2189-3-29**] 01:40PM BLOOD WBC-27.2*# RBC-5.57# Hgb-11.4* Hct-34.3*
MCV-62* MCH-20.4* MCHC-33.1 RDW-23.7* Plt Ct-565*#
[**2189-3-29**] 01:40PM BLOOD Neuts-88* Bands-6* Lymphs-1* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2189-3-29**] 01:40PM BLOOD PT-15.3* PTT-32.6 INR(PT)-1.3*
[**2189-3-29**] 01:40PM BLOOD Glucose-65* UreaN-21* Creat-0.8 Na-103*
K-6.6* Cl-73* HCO3-19* AnGap-18
[**2189-3-29**] 01:40PM BLOOD ALT-41* AST-147* CK(CPK)-113 AlkPhos-684*
TotBili-1.4
[**2189-3-30**] 05:30AM BLOOD Albumin-2.1* Calcium-7.3* Phos-3.6 Mg-1.7
[**2189-3-29**] 01:40PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-4071*
[**2189-3-30**] 05:30AM BLOOD Osmolal-244*
[**2189-3-30**] 10:49AM BLOOD Cortsol-25.2*
[**2189-3-29**] 01:50PM BLOOD Lactate-6.0*
.
[**2189-4-1**] 05:31AM BLOOD WBC-25.5* RBC-4.58* Hgb-9.3* Hct-28.2*
MCV-61* MCH-20.3* MCHC-33.0 RDW-24.6* Plt Ct-458*
[**2189-4-1**] 05:31AM BLOOD Glucose-50* UreaN-21* Creat-0.8 Na-127*
K-4.3 Cl-98 HCO3-16* AnGap-17
[**2189-3-30**] 05:30AM BLOOD ALT-35 AST-96* LD(LDH)-765* AlkPhos-496*
TotBili-1.5
[**2189-4-1**] 05:31AM BLOOD Calcium-7.6* Phos-3.5 Mg-1.9
[**2189-3-31**] 08:14AM BLOOD Osmolal-259*
[**2189-4-1**] 02:04PM BLOOD Lactate-4.0*
.
[**2189-3-29**] EKG: Atrial fibrillation, ST-T changes are nonspecific,
Since previous tracing of [**2189-3-18**], T wave flattening noted.
.
[**2189-3-29**] CXR: Increasing left effusion/consolidation. Please refer
to CT
abd/pelvis performed subsequently for further details.
.
[**2189-3-29**] CT Abd/Pelvis:
- Marked interval progression of metastatic disease as detailed
above with increased disease burden in the pancreas, liver and
diffuse implants in the abdomen. Please see above for details.
- Stable multiple hypodense lesions in both kidneys.
- Bilateral pleural effusions, moderate, left greater than
right.
- Minimal ascites. Moderate anasarca.
- Small nonobstructing bilateral renal calculi.
.
[**2189-3-29**] CT Head: No acute intracranial process. MR is more
sensitive in the
detection of small masses.
Brief Hospital Course:
71 yo man with history of metastatic pancreatic cancer was
admitted with dyspnea, new ascites, and profound hyponatremia.
.
# Hyponatremia: Profound hyponatremia likely etiology of altered
mental status with improvement in lethargy with cautious
correction. Pt initially on hypertonic saline as thought to have
component from dehydration. However, per renal assessment,
appears to have baseline mild SIADH exacerbated by excessive po
fluid intake at home due to diagnosis of dehydration given at
last admission. Pt placed on 800cc to 1L fluid restriction with
improvement to likely baseline of 126-128.
.
# Hypotension: Per Renal, likely new baseline in setting of
progressive chronic disease. Ddx hypovolemia given tachycardia
but little response to fluid boluses. Initial concern of
hypoperfusion given elevated lactate but persistence of lactate
likely [**12-29**] to malignancy.
.
# Dyspnea: Infiltrate on CXR initially treated as HAP with vanco
and zosyn. Switched to cefpodoxime prior to discharge as MRSA
screen negative and pseudomonas unlikely given clinical picture.
Legionella negative. Rapid respiratory viral Ag test negative.
Prior to discharge, switched to cefpodoxime as MRSA screen
negative and low clinical suspicion for pseudomonas pneumonia.
Plan to complete 8-day today course of antibiotics, last dose on
[**2189-4-6**]. Small bilateral effusions on imaging (ddx parapneumonic
v. malignancy) may also have contributed to dyspnea.
.
# Bandemia: Likely [**12-29**] pneumonia, stable to mildly improved. No
other localizing sx. Urine cultures negative with no growth on
blood cultures to date. C. diff toxin test ordered but no sample
sent; unlikely etiology.
.
# Guaiac positive stools: Patient was found to have guiac
positive stools, likely related to his history of GI cancer and
it is unclear if he has any GI tract involvement of his cancer.
In light of guiac positive stools, held off on any
anticoagulation at this time.
.
# Splenic Vein Thrombosis
Patient has newly diagnosed splenic vein thrombosis. Unclear if
this represents a spontaneous thrombosis or is related to tumor
invasion. Family made aware of diagnosis, but anticoagulation
held as pt is poor candidate given his poor PO intake, multiple
comorbidities, and reported allergy to coumadin.
.
# Fluid overload: [**Month (only) 116**] be [**12-29**] increased metastatic disease, low
albumin. [**Month (only) 116**] have some diastolic dysfunction not assessed on
prior echo. [**Month (only) 116**] also have third-spacing [**12-29**] hyponatremia.
Nephrotic syndrome unlikely given U/A. ? of new ascites which is
likely related to his increased metastatic disease. Started on
high protein diet.
.
# Metastatic pancreatic Cancer: Evidence of progression of CT
abdomen/pelvis. Of note, OB positive stool seen in the setting
of known GI malignancy but with relatively stable Hct. He has
been offered palliative chemotherapy and radiation treatment,
which he has declined. Family meeting was held with palliative
care and oncologist Dr. [**Last Name (STitle) **] present. Decision made to discharge
pt home with hospice but to remain full code given hope of
seeing son who will be arriving from [**Location (un) 6847**] in 2 weeks.
.
# Afib: Off coumadin given h/o allergy. Was in RVR during
hospitalization but not rate controlled given low-running BP
although he remained hemodynamically stable.
.
# Nutrition: Speech & swallow and Nutrition recommended high
protein, pureed solids, nectar-thick liquids. Maintained on 1L
fluid restriction.
.
# DVT ppx: Pneumoboots.
.
# Code: FULL, as discussed at family mtg.
Medications on Admission:
Levofloxacin 750mg PO daily x 5 days (4/24-28/09) to complete
7-day course
Discharge Medications:
1. Cefpodoxime 100 mg/5 mL Suspension for Reconstitution Sig:
Two Hundred (200) mg PO twice a day for 4 days.
Disp:*1600 mg* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Hyponatremia
- Hospital acquired pneumonia
Secondary
- Metastatic pancreatic cancer
- Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for increasing cough and lethargy. You were
treated for a pneumonia, and we are giving you a prescription to
complete an antibiotic course at home. You were also found to
have a very low sodium level. This is thought to be due to an
underlying metabolic problem which was exacerbated by too much
water intake at home. You should not drink more than 800 cc of
water daily.
.
Please note that we found a blood clot in your splenic vein.
However, you were not started on blood thinners as the risks
outweighed the benefits.
.
The following changes were made to your medications:
- cefpodoxime - this is an antibiotic to treat your pneumonia.
.
As discussed during the family meeting, you will be sent home
with hospice care. Please seek medical attention if you develop
fevers or chills, increased difficulty breathing, chest pain, or
any other concerning symptoms.
Followup Instructions:
You have the following upcoming appointments already scheduled:
- [**Name6 (MD) **] [**Name8 (MD) **], MD. Phone:[**Telephone/Fax (1) 22**]. Date/Time:[**2189-4-3**] @
1:00pm.
- [**Name6 (MD) **] [**Name8 (MD) **], MD. Phone:[**Telephone/Fax (1) 22**]. Date/Time:[**2189-4-29**] @
1:30pm.
Completed by:[**2189-4-2**]
ICD9 Codes: 486, 2767, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2523
} | Medical Text: Admission Date: [**2152-10-19**] Discharge Date: [**2152-10-20**]
Date of Birth: [**2101-4-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
knee injury s/p fall
Major Surgical or Invasive Procedure:
ORIF L tib plateau
History of Present Illness:
51 y/o w/ DM2, alcohol abuse, charcot's foot s/p neuropathy,
presented with tibial plateau fracture. Pt had ankle fusion
about one month ago for charcot's foot. He was treated at rehab
for ~ 10days, and discharged ~10 days ago. Pt fell yesterday
evening down 8 stairs. He reportedly drank some alcohol
yesterday at lunch. He had 8 beers and 3 hard liquor 4 days
ago. Pt came to ED this morning, had negative X-ray and was
found to have subtle tibial fracture on CT. Pt was seen by
orthopedics, initially had knee aspiration for effusion, which
showed ~8000 WBC, 200,000 RBC, with no crystals. Pre-op got
versed, underwent general anesthesia with a total of 2 mg
midazolam, 200 mg propofol, and nerve block for procedure. He
had tibial fracture repair with metal plate placement, and ankle
screw tightening. In [**Name (NI) 13042**], pt was found to have CIWA 24, HTN to
SBP 200, tachycardia to 140-150s, tremulous, headache. No
hallucinations. Got 10 mg diazepam with some improvement HR
120s, HTN 150-160s.
Pt is aware of his alcohol problem, said he "could drink a lot",
>10 beers at party. He denies withdrawal seizure or DT.
Most recent set of vitals prior to transfer to MICU: afebrile,
100% 3L 12 HR 115 BP 145/69. Access is right PIV.
Past Medical History:
DM2 x17 yrs (on glyburide/metformin)
Venous insufficiency (on daily lasix 20 mg tid)
Boarderline HTN (not actively treated)
Gout (off colchicine)
HLD (on simvastatin)
Social History:
Cig: Prior 1 ppd x20 yrs hisotry; Quit 15 years ago.
ETOH: Occasional
Illicits: Denies
Worked as a Machinist for aerospace products. Has not worked
since [**Month (only) 958**].
Family History:
Father passed away of pancreatic cancer at age 50s and mother is
alive, healthy. Siblings all healthy.
Physical Exam:
ADMSSION EXAM
General: Alert, oriented X2, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN2-12 grossly intact, muscle strenth intact in UE and
right LE, LLE not tested.
DISCHARGE EXAM
VS: Temp 100.8, HR 94, BP 158/78, RR 22, O2 sat 98% on RA
GEN: AOX3, nontremulous
Otherwise exam not changed from admission
Pertinent Results:
[**2152-10-20**] 04:45AM BLOOD WBC-7.0 RBC-2.75* Hgb-8.2* Hct-24.3*
MCV-88 MCH-30.0 MCHC-34.0 RDW-14.6 Plt Ct-178
[**2152-10-20**] 04:45AM BLOOD PT-14.8* PTT-24.8 INR(PT)-1.3*
[**2152-10-20**] 04:45AM BLOOD Glucose-115* UreaN-19 Creat-1.8* Na-141
K-4.1 Cl-104 HCO3-28 AnGap-13
[**2152-10-19**] 05:45PM BLOOD ALT-9 AST-18 LD(LDH)-187 AlkPhos-139*
TotBili-0.4
[**2152-10-20**] 04:45AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.8
[**2152-10-19**] 05:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2152-10-20**] 12:33AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
PERTINENT IMAGING
[**10-19**] ANKLE X-ray:
1. Lateral tibial plateau fracture with dense joint effusion.
This could be confirmed with a CT as discussed with the ED
staff.
2. Neuropathic changes of the ankle with unchanged hardware.
[**10-19**] Knee X-ray
1. Lateral tibial plateau fracture with dense joint effusion.
This could be confirmed with a CT as discussed with the ED
staff.
2. Neuropathic changes of the ankle with unchanged hardware.
[**10-19**] CT LE
1. Schatzker type 2 fracture of the lateral tibial plateau, with
small
lipohemarthrosis.
2. Intact quadriceps tendon.
3. Diffuse mild periostitis. Correlate clinically for
hypertrophic
osteoarthropathy or venous stasis.
Brief Hospital Course:
51 yo M w/ ho DM2, alcohol abuse, presented with knee pain after
fall, found to have tibial plateau fracture, s/p surgical
reductiona and repair, with recovery complicated by concerns for
alcohol withdrawal.
#) Tibial plateau fracture
Mr. [**Known lastname 27081**] was admitted to the Orthopedic service on [**2152-10-19**] for
left tibial plateau fracture after being evaluated in the
emergency room. He underwent open reduction internal fixation
of the left tibial plateau fracture without complication on
[**2152-10-19**]. He was extubated without difficulty and transferred to
the recovery room in stable condition. He had adequate pain
management and worked with physical therapy while in the
hospital.
OUTPATIENT ISSUES
- STARTED Levonox 40 mg sc qd while on case.
- STARTED calcium carbonate 500 mg qd, vitamin 800 mg qd
- Please consider starting alendronate 70 mg qweek
Per ortho recommendation: Clinical trial data supports that two
weeks following fracture is a safe time to initiate
bisphosphonates and it should not interfere with bone healing.
Patients who have been treated with bisphosphonates starting at
two weeks following fracture have been shown to have decreased
incidence of recurrent fracture and decreased overall mortality.
While bisphosphonates are indicated and safe for most patients
with osteoporosis related fractures, there are exceptions.
Contraindications to bisphosphonates include renal failure with
creatinine clearance less than 35 ml/minute, esophageal
dysmotility including strictures or achalasia, active
esophagitis or gastritis, esophageal or gastric ulcers,
hypocalcemia, or inability to comply with dosing instructions.
Please note that controlled GERD is NOT a contraindication to
bisphosphonates. While we have ordered this medication on
discharge, it is up to your discretion to discontinue it if you
feel that it is contraindicated for your patient. For the
majority of patients at average risk of suffering an
osteoporosis related fracture, the current data supports
treatment with bisphosphonates for a total of five years.
.
#) Fever
Pt developed fever to 101.7. Blood, Urine culture no growth.
CXR shows no evidence of pneumonia. Pt is otherwise
asymptomatic. Given the recent operation with instrumentation,
inflammatory response secondary to trauma is the most likely
eetiology. Infection needs to be monitored, but still early to
attribute fever to surgery induced infection now.
.
#)Charcot's foot
Pt had recent operation for charcot's foot. He has been closely
followed by podiatry at [**Hospital1 18**]. There was a new ulcer on the
left big toe, and was evaluated by podiatry in the ED.
OUTPATIENT ISSUES:
- Pt need to complete a 10 day's course of augmentin
- Pt need daily wet-to-day dressing change for left big toe
until evaluated by his podiatrist.
.
#) Alcohol withdrawal
Pt was found to be confused, tremulous, with HR of 135 and
elevated BP to 200/109, with improvement after 10 mg of valium.
The timing of presentation is most consistent with
post-anesthesia effect. However, given his alcohol history,
alcohol withdrawal cannot be ruled out. Pt denied hx of
withdrawal seizure and DT in the past. Pt received iv thiamine.
He was placed on CIWA protocol post-op, had a total of 10 mg
Valium X3 overnight, and remained low CIWA score > 16 hours
before discharge.
.
#) Anemia
It was found that pt has profound normocytic anemia with Hct of
24.9, baseline 34.8 since admission in [**Month (only) **], that has never been
addressed per our records. Given the normal RDW, it is hard to
attribute that completely to alcohol use. Would need to
initiate workup for anemia in an outpatient setting. Given the
high ALP and progressing renal insufficiency, would need to rule
out multiple myeloma as well.
OUTPATIENT ISSUES:
- Please consider anemia workup
- Please consider colonoscopy if pt has not had one
.
#) Acute on chronic renal insufficiency
Pt presented with Cr 1.8 on this admission. Pt had recent ATN
in [**Month (only) 216**], with Cr on discharge of 1.2. Pt did not respond to
fluid overnight. Given the protein on UA, it is unclear whether
this is new baseline secondary to his diabetes. Of note, his
A1c in [**Month (only) **] was 6.2. We held his lasix since admission. Pt will
need work-up ideally from a nephrologist.
OUTPATIENT ISSUES
- HELD lasix
- Pt need nephrology workup
.
#) Type 2 Diabetes
Per record, pt has 17 yr type 2 diabetes, with complication of
charcot's foot. Pt takes glyburide-metformin 5-500 [**Hospital1 **] at home.
We discontinued his oral anti-glycermic medication, and started
him on sliding scale insulin.
OUTPATIENT ISSUES:
- HELD oral anti-glycemic medication
- STARTED sliding scale insulin
- Please CONSIDER STARTING ACEI in the setting.
.
CHRONIC ISSUES
#) Venous insufficiency
Pt has documented venous insufficiency and presumatively takes
lasix 20 mg tid at home. We held his lasix given concerns for
renal insufficiency.
.
#) Gout
Documented hx of gout. Joint fluid analysis does not support
acute flare. Pt not currently on treatment.
.
#) Hyperlipidemia
Not active issue, continued home dose simvastatin 10 mg qd
.
TRANSITIONAL ISSUES
Pt declares a full code. He will need to set up an orthopedics
appointment for post-op followup.
Medications on Admission:
lasix 60mg daily
glyburide-metformin 5-500 [**Hospital1 **]
percocet 5-325 1 tab q6hr prn
simvastatin 10mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours) for 14 days.
Disp:*14 * Refills:*0*
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain: please hold for sedation or RR < 8.
Disp:*30 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
10. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q2H PRN () as
needed for CIWA >10.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 1475**]
Discharge Diagnosis:
L tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with assistance.
Discharge Instructions:
Dear Mr. [**Known lastname 27081**],
You came to our hospital for knee pain after a fall from the
stairs. In the ED, we found that you had a tibial plateau
fracture. You were seen by orthopedics and underwent tibial
plateau repair with a metal plate. While you were in the OR,
you ankle screw from the previous operation was also adjusted.
You tolerated the procedure well. You had an elevated blood
pressure and heart rate after the surgery, likely due to pain
and the anesthesia medications, so you were observed in the ICU
overnight. Your blood pressure and heart rate improved.
We felt that you can continue your recovery at a rehabilitation
facility. While you were in the hospital, we found that your
kidney function was worse than expected for your age, and your
blood count was low. We will notify your primary care doctor.
But you should discuss them with both your PCP and doctors at
the rehab.
MEDICATION CHANGES:
- Please stop taking lasix until further workup for your kidney
function.
- Please STOP taking oral diabetes medication,
glyburide/metformin, until further workup for your kidney
function.
- In the meantime, please make sure that your blood sugar is
being checked at rehab, and treated according with sliding scale
insulin.
- Please make sure that the rehab doctors aware [**Name5 (PTitle) **] [**Name5 (PTitle) **]
experience alcohol withdrawal, and will be treated accordingly.
- You will take a medication called enoxaparin to help prevent
blood clots while you recover from surgery.
- Please take a multivitamin, thiamine, and folic acid
- Please take augmentin to complete a 10 day course to treat the
lesion on your toe
- You may take oxycodone as needed for pain
- While you are on pain medication, you should take medications
such as colace and senna to soften your stools and prevent
constipation
INSTRUCTIONS FOR WOUND CARE:
-Keep Incision dry.
-Do not soak the incision in a bath or pool.
-Keep pin sites clean and dry.
-Sutures/staples will be removed at your first post-operative
visit.
-Please call [**Telephone/Fax (1) 1228**] and schedule an appointment with
[**Doctor Last Name **], the NP in 2 weeks.
It has been a pleasure taking care of you at [**Hospital1 18**]. It is our
recommendation that you should consider stop drinking alcohol
given the repeated injuries you had and impact on your overall
health. We wish you a speedy recovery.
Activity:
-Continue to be non weight bearing on your left leg.
-You should not lift anything greater than 5 pounds.
-Elevate left leg to reduce swelling and pain.
-Do not remove splint/brace. Keep splint/brace dry.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications unless otherwise directed. Take
all medications as instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
In order to decrease your risk of fracture you have been started
on calcium and vitamin d. In addition, we have also recommended
that you start taking Fosamax (alendronate sodium) 70 mg once a
week to further decrease your risk of having a fracture. You
should take the first dose of this medication starting two weeks
after you are discharged from the hospital. It is very important
that Fosamax (alendronate sodium) is taken with a full glass of
water first thing in the morning, on an empty stomach, with no
lying down or eating for at least 30 minutes following
administration. Following discharge, please be sure to talk with
your primary care doctor and inform them that you have been
started on this medication
Followup Instructions:
Please call [**Telephone/Fax (1) 1228**] and schedule an appointment with
[**Doctor Last Name **], the NP in 2 weeks.
Please call your podiatrist and schedule an appointment within
10 days. The phone number is ([**Telephone/Fax (1) 4335**].
Please follow-up with your PCP on discharge from rehab.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5859, 2749, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2524
} | Medical Text: Unit No: [**Numeric Identifier 69356**]
Admission Date: [**2109-8-3**]
Discharge Date: [**2109-8-18**]
Date of Birth: [**2109-8-3**]
Sex: M
Service: Neonatology
HISTORY: Baby boy [**Known lastname 69352**] is a former 34-week gestational
age premature infant who is discharged home on day of life
#15 at corrected gestational age of 36 and 1/7 weeks. He was
delivered at 34 weeks gestation, twin 2, due to
polyhydramnios as well as evolving maternal PIH. Mother is a
33-year-old G1/P0 (to 2). This twin gestation pregnancy
conceived by IUI. EDC [**2109-9-14**].
PRENATAL SCREENS: Blood group O+, antibody negative, RPR
nonreactive, rubella immune, hepatitis B antigen negative,
GBS unknown.
COMPLICATIONS: Pregnancy was complicated by polyhydramnios
of twin 2 (this twin) and also by evolving maternal PIH. Mother
was admitted on the day prior to delivery and received a full
course of betamethasone.
DELIVERY COURSE: The infant was delivered on [**8-3**] by C-
section. Rupture of membranes at delivery. No maternal fever
or intrapartum antibiotics. Baby emerged with spontaneous
cry. Central cyanosis blow-by oxygen was given for several
minutes with improvement in color. Apgar's were 8 and 8. He
was transferred to the neonatal intensive care unit secondary
to prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Weight 3005 grams, more
than 90th percentile; length 47%, more than 80th percentile;
head circumference 34%, more than 90th percentile. Anterior
fontanelle soft and fat. Red reflexes present bilaterally.
Palate intact. No increased work of breathing. Breath sounds
clear. Regular rate and rhythm. No murmur. Two + peripheral
pulses, including femoral's. Abdomen benign without
hepatosplenomegaly or masses. A 3-vessel cord noted. Normal
male genitalia for gestational age. Testes descended
bilaterally. Normal back and extremities with stable hips.
Skin pink and well perfused. Alert and responsive. In no
acute distress.
LABORATORY DATA ON ADMISSION: CBC with white blood cell
count 17.5 thousand, 75 neutrophils, 3 bands, 15 lymphocytes,
7 monocytes, hematocrit 58.4, platelets 226.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The infant was initially placed on nasal
cannula O2. A chest x-ray was consistent with moderate
hyaline membrane disease. He progressed to CPAP due to
increased respiratory distress and was intubated and treated
with a total of 3 doses of
surfactant. He was extubated to CPAP by day of life
#3. He remained on CPAP until day of life #4, and was
weaned to nasal cannula oxygen. He has been in room air since
day of life #7; which was [**2109-8-10**]. He was followed
for apnea of prematurity. His last spell was on
[**8-13**], and he has remained spell-free since then.
1. CARDIOVASCULAR: He remained clinically stable through his
hospital course.
1. FLUIDS, ELECTROLYTES, NUTRITION, GASTROINTESTINAL: He was
initially started on intravenous fluids at 60 cc/kg of D-
10-W. He was kept n.p.o. due to respiratory distress.
Feeds were introduced on day of life #2, and he quickly
progressed to full feeds by day of life #5. He remained
at p.o. feeds since then, and demonstrated an excellent
weight gain. His discharge weight was 2920 grams. He was
followed for hyperbilirubinemia, and his bilirubin peaked
on day of life #4 at 15.4/0.4. He was treated with
phototherapy, and phototherapy was discontinued on [**8-4**] since his follow-up bilirubin on [**8-10**] was 9.4.
1. INFECTIOUS DISEASE: Due to prematurity and respiratory
distress, a CBC and blood culture were drawn on
admission. CBC was reassuring. He was treated with
ampicillin and gentamicin IV until blood cultures were
no growth at 48 hours. Antibiotics were discontinued on day
of life #3.
1. NEUROLOGY: Appropriate clinical exam. No head ultrasounds
were done.
1. HEMATOLOGY: Initial CBC was reassuring. No blood products
were given during his hospital stay.
1. AUDIOLOGY: The infant passed newborn hearing screen on
both ears prior to discharge.
1. OPHTHALMOLOGY: No exam was done due to no risk for
retinopathy of prematurity.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital 1426**]
Pediatrics, ([**Telephone/Fax (1) 56268**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: Full p.o. feeds with breast milk,
Similac 24.
2. Medications: Discharged home on infant multivitamins 1 cc
p.o. once a day and iron sulfate as Fer-In-[**Male First Name (un) **] 0.3 cc
once a day.
3. He passed a car seat test prior to discharge.
4. State newborn screen was done on [**2110-8-17**]; and
the results are pending.
5. He was given hepatitis B vaccine on [**8-8**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: (1) born at less than 32
weeks; (2) born between 32 and 35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings; (3) with chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life)
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW-UP APPOINTMENTS: Scheduled with primary care doctor.
DISCHARGE DIAGNOSIS:
1. Prematurity at 34 weeks, resolved.
2. Respiratory distress, resolved.
3. Rule out sepsis, resolved.
4. Hyperbilirubinemia, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name (STitle) 69357**]
MEDQUIST36
D: [**2109-8-19**] 10:58:26
T: [**2109-8-19**] 11:58:12
Job#: [**Job Number 69358**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2525
} | Medical Text: Admission Date: [**2175-1-26**] Discharge Date: [**2175-2-3**]
Date of Birth: [**2110-9-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain, progressive DOE
Major Surgical or Invasive Procedure:
[**2175-1-26**] Cardiac cath
[**2175-1-27**] Coronary artery bypass grafting x5, with the left
internal mammary artery to left anterior descending artery, and
reverse saphenous vein graft to the posterior descending artery,
diagonal artery, and sequential reverse saphenous vein graft to
the first and second obtuse marginal artery.
History of Present Illness:
64 yo Chinese man (Mandarin) with a history CAD, s/p prior
attempt of RCA stenting in [**2167-11-9**] while in [**Country 651**]
complicated by dissection and subsequent IMI, now with angina at
very low exertion. A stress MIBI completed in [**2174-11-8**]
demonstrated a moderated inferior wall defect with partial
reversibility and hypokinesis. His ECG demonstrated prior
inferoposterior MI with inferior Q waves and tall R waves. He
has continued to experience chest pain since his MI, which
occurs only with exertion usually after walking 5 minutes at a
slow pace and sooner if he walks briskly. He has not had to use
nitroglycerin and it resolves with rest. He also reports a rapid
heart beat when he has the chest pain, but can occur without the
chest pain. He denies any lower extremity edema, orthopnea, PND,
dyspnea on exertion, palpitations, lightheadedness, dizziness,
presyncope, or syncope. He was admitted today for left heart
catherization and found to have 3 vessel disease. Csurg was
consulted for evaluation for CABG.
Past Medical History:
Coronary artery disease s/p Mycoardial infarction
Diabetes Mellitus
Hypertension
Dry skin
Right lower leg injury
Mild CVA
Social History:
Race: Chinese (Mandarin speaking)
Last Dental Exam:over two year ago, permanent upper partial,
lower permanent dentures
Lives with: He emigrated 2 years ago from [**Country 651**]. He is a
retired teacher and lives in [**Location 27256**] with his wife and
daughter [**Name (NI) **]. His daughter speaks [**Name2 (NI) 483**].
Contact: daughter [**Name (NI) **] [**Name (NI) **] (cell) [**Telephone/Fax (1) 85591**]
Occupation: Retired teacher
Cigarettes: Smoked no [x] yes [x] last cigarette _1998____ Hx:
Other Tobacco use:none
ETOH: < 1 drink/week [x] [**2-14**] drinks/week [] >8 drinks/week []
Illicit drug use - none
Family History:
No history of premature CAD or sudden cardiac death.
Physical Exam:
Pulse:80 SR Resp: 16 O2 sat:98% on RA
B/P Right: Left:135/73
Height:5'4" Weight: 175#
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA x EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []last BM [**1-26**]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: yes left lower leg
Neuro: Grossly intact [x]through interpreter
Pulses:
Femoral Right:+2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:doppler Left:Doppler
Radial Right: +2 Left:+2
Pertinent Results:
[**2175-1-26**] Cardiac cath:
Left ventriculography: mitral regurgitation; LVEF %;
Coronary angiography: right dominant
LMCA: No angiographically-apparent CAD.
LAD: Mid vessel long 60-70% stenosis. Origin diagonal 40%.
LCX: Proximal 50% before large OM1. Lower pole large OM1 with
focal 80% stenosis and upper pole origin 50% stenosis,
RCA: Proximal 20%, distal diffuse total occlusion with faint
right to right collaterals and left to right collaterals
robustly fill the PDA retrogradely where there is a mid vessel
50% lesion.
.
[**2175-1-26**] Carotid U/S: Right ICA <40% stenosis. Left ICA <40%
stenosis.
.
[**2175-1-27**] Echo: PREBYPASS: Normal LV systolic function with LVEF >
55%, no segemental wall motion abnormalities. The left atrium is
normal in size. Left ventricular wall thicknesses and cavity
size are normal. Right ventricular chamber size and free wall
motion are normal. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion. Normal coronary sinus. Intact IAS. No
clot seen in LAA.
POSTBYPASS: Preserved LV systolic function. No segmental wall
motion abnormalities. No dissection seen after aortic cannula
removed. Otherwise unchanged.
.
[**2175-1-31**] CXR: Heart size is normal. Mediastinal silhouette is
stable. There is improved aeration of the left lower lobe with
minimal area of atelectasis present. There is no pneumothorax
and appreciable pleural effusion demonstrated. No pulmonary
edema is seen. Wedge compression fractures are noted on the
lateral view, unchanged since [**2175-1-26**].
Brief Hospital Course:
Mr. [**Known lastname **] was admitted following his cardiac cath which revealed
severe three vessel coronary artery disease. He underwent
pre-operative work-up after cath and on [**1-27**] he was brought to
the operating room where he underwent a coronary artery bypass
graft x 5. Please see operative report for surgical details. He
was then transferred to the CVICU for invasive monitoring in
stable condition. Within 24 hours he was weaned from sedation,
awoke neurologically intact and extubated. Patient remained in
the ICU for several days for aggressive pulmonary toilet. In
addition had periods of agitation and confusion but resolved
quickly and never had any focal deficits. On post-op day three
he was transferred to the step-down unit for further care. Chest
tubes and epicardial pacing wires were removed per protocol. He
worked with physical therapy for strength and mobility. Over
next couple of days he appeared to be doing well and was
discharged to home on post-op day five with the appropriate
medications and follow-up appointments. He does not have
insurance to cover VNA services and will contact office
immediately of any concerns.
Medications on Admission:
ISOSORBIDE MONONITRATE 30 mg once a day
LOSARTAN 50 mg Tablet once a day
METFORMIN 1500 mg Tablet Extended Release once a day
METOPROLOL SUCCINATE 50 mg Tablet Extended Release daily
SIMVASTATIN 20 mg Tablet once a day
ASPIRIN 325 mg Tablet once a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
7. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day) for 10 days.
Disp:*40 Tablet Extended Release(s)* Refills:*0*
8. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 5
Past medical history:
s/p Mycoardial infarction
Diabetes Mellitus
Hypertension
Dry skin
Right lower leg injury
Mild CVA
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema Trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2175-3-9**] at 3:45p
Cardiologist: Dr. [**Last Name (STitle) 171**] on [**2175-3-8**] at 2:40p
Wound check: [**Hospital Unit Name **], [**Hospital Unit Name **] on [**2175-2-9**] at 10:45a
Please call to schedule appointments with your
Primary Care Dr. [**First Name9 (NamePattern2) **] [**Name (STitle) 437**] in [**4-13**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2175-2-1**]
ICD9 Codes: 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2526
} | Medical Text: Admission Date: [**2158-5-27**] Discharge Date: [**2158-6-13**]
Date of Birth: [**2104-3-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54 yo male s/p unwitnessed fall down 12 stairs. (+) EtOH.
Transported to an area hospital where found to have intracranial
hemorrhage and was then transferred to [**Hospital1 18**] for further care.
Past Medical History:
EtOH abuse
Seizure history
Schizoaffective disorder
Family History:
Noncontributory
Physical Exam:
Upon admission:
BP: 103/80 70 14 100%
Gen: WD/WN, NAD.
HEENT: Pupils: brisk 4-2 mm b/l Pupils, mid-position /
conjugate
Neck: in cervical collar
Neuro:
Intubated / No eye opening to voice or noxious, PERRL 4-2mm
bilaterally, conjugate gaze, trace corneals bilaterally,
localizes briskly with LUE, no movement noted to RUE or B/L
LE's.
PR equivocal bilaterally / no clonus noted.
Pertinent Results:
[**2158-5-27**] 06:31PM TYPE-ART PO2-163* PCO2-38 PH-7.40 TOTAL
CO2-24 BASE XS-0
[**2158-5-27**] 03:39PM LACTATE-0.8
[**2158-5-27**] 03:25PM GLUCOSE-102 UREA N-3* CREAT-0.6 SODIUM-133
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-22 ANION GAP-15
[**2158-5-27**] 03:25PM CALCIUM-7.4* PHOSPHATE-2.4* MAGNESIUM-2.1
[**2158-5-27**] 03:17AM WBC-15.7* RBC-3.94* HGB-11.1* HCT-33.3*
MCV-85 MCH-28.2 MCHC-33.3 RDW-15.3
[**2158-5-27**] 01:50AM PLT COUNT-470*
[**2158-5-26**] 11:11PM ASA-NEG ETHANOL-265* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**5-27**]: CT Head left SDH measures up to 5 mm thick. left sided
SAHs. mild sulcal effacement and mass effect on lt lat
ventricle. no midline shift. rt parietal subgaleal hematoma. fxr
through squamous portion of rt temporal bone, rt zygomatic arch,
likely lateral wall rt maxillary sinus. chronic sinus mucosal
dz.
.
[**5-27**] CT CSpine: No C-spine fx. Multilevel DJD. Compression
deformities of T1 and T2 superior end [**Last Name (LF) **], [**First Name3 (LF) **] be chronic.
.
[**5-28**]: Repeat CT Head: WET READ: no new hemorrhage
.
[**5-28**]: Repeat CT CSpine: WET READ: Lucency lateral body of dens
on right side, ? associated cortical irregularity- only on
coronal images.
.
[**5-30**] Chest AP
Lung volumes have improved though there is still moderate
atelectasis at both lung bases. Upper lungs clear. Heart size
top normal. No appreciable
pleural effusion.
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery, Orthopedic
Spine, Plastics and ENT were consulted given his multiple
injuries. He underwent CT imaging from head to toe and was then
transferred to the Trauma ICU for close monitoring. He remained
in the ICU for approx 1 week and was extubated after several
days. A Dobbhoff was placed and tube feedings were initiated.
His subarachnoid and subdural hemorrhages were managed non
operatively; he was loaded with Dilantin and started on a
standing dose; the Dilantin will need to continue until he
follows up in neurosurgery clinic in 4 weeks. Serial head CT
scans were followed and remained stable. Of note due to his high
blood alcohol level at time of admission he was activity having
delirium tremors requiring benzodiazepines for control.
Psychiatry was consulted and made several recommendations
pertaining to use of the benzodiazepines. It was felt that he
was had high levels of diazepam in his blood further
contributing to his delirium and it was recommended that they be
stopped and that his clonazepam be restarted at a lower dose
than his home dose. He is currently on clonazepam 1 mg [**Hospital1 **] and
his Zyprexa was restarted at HS. His mental status improved
significantly; he is awake and cooperative with care. He is
oriented to himself.
His cervical spine dens fracture was also managed non
operatively with a hard collar. This will need to be worn for at
least 4-6 weeks at which time he will follow up in Spine clinic
for repeat CT imaging.
Plastics was consulted for the facial fractures and these were
also considered non operative. He will follow up in 2 weeks in
Plastic Surgery clinic.
ENT was also consulted for temporal bone fracture; no operative
intervention warranted. he will require an outpatient audiogram
after discharge in the next several weeks.
Once he was transferred to the nursing unit and as his mental
status improved patient inadvertently removed his Dobbhoff. A
bedside swallow evaluation was done and he was able to tolerate
without signs of aspiration. His diet was upgraded from NPO with
tube feedings to a soft diet. Dietary supplements were added as
well. He does have a robust appetite.
On evening before schedule discharge to rehab he was noted with
a fever spike after his central line was removed. A complete
fever workup was done which included blood cultures which did
come back positive for Gram positive cocci in clusters. He was
started on Vancomycin. Infectious Disease was consulted; it was
recommended that he undergo repeat imaging of his head and
cervical spine and a tagged white cell scan. Results of the
tagged white cell scan revealed infectious source as the left
knee. He was taken to the operating room for washout, a drain
was left in place for a couple of days. His Nafcillin was
recommended by ID to continue for another 4 weeks.
A PICC line was placed for this purpose.
He was evaluated by Physical therapy and is being recommended
for rehab after his acute hospital stay. Social work was
consulted for coping and EtOH related issues.
Medications on Admission:
metoprolol 50", trazadone 100 qhs, Zyprexa 20', Doxepin 25',
Clonazepam 1"", Zoloft(unsure dose..started 50')
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-10**]
hours as needed for pain.
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units
Injection TID (3 times a day).
4. Clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. Erythromycin Ethylsuccinate 200 mg/5 mL Suspension for
Reconstitution Sig: One Hundred (100) MG PO Q6H (every 6 hours).
10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day): Check levels weekly and prn
based on dose changes.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for SBP<110/HR <60.
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) GM
Intravenous Q4H (every 4 hours) for 4 weeks.
16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall
Subdural hemorrhage
Subarachnoid hemorrhage
Facial fractures
C2 fracture right lateral body
MSSA Bacteremia
Infected left knee
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
The cervical collar must continue to be worn for at leat [**4-10**]
weeks until told to discontinue by Spine Surgery.
The Dilantin will need to continue until follow up with
Neurosurgery
in 4 weeks.
Continue the antibiotics for a total of 4 weeks.
DO NOT blow your nose or drink through a straw because of your
facial fractures.
Followup Instructions:
Follow up next week in clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP for Dr.
[**Last Name (STitle) **], Orthopedics. Call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks with Orthopedic Spine Surgery, call
[**Telephone/Fax (1) 3736**] for an appointment.
Follow up in 2 weeks with Plastic surgery for your facial
fractures; call [**Telephone/Fax (1) 5343**] for an appointment.
Follow up in 2 weeks with ENT; an audiogram as an outpatient to
assess hearing function is needed. Call [**Telephone/Fax (1) 2349**] for an
appointment.
Follow up in 4 weeks with Dr. [**Last Name (STitle) 548**], Neurosurgery, call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a follow up head CT scan for this appointment.
Completed by:[**2158-6-21**]
ICD9 Codes: 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2527
} | Medical Text: Admission Date: [**2102-10-13**] Discharge Date: [**2102-10-22**]
Date of Birth: [**2074-11-11**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Called by Emergency Department to evaluate cerebellar lesion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 27 yo R handed man with a PMH of UC on steroids
who was transferred from Neurosurgery after presenting with a
cerebellar hemorrhage. He had been having HA bitemporally as
well as occipitally for almost 4 months and had been evaluated
by an outside neurologist. He had a Head CT at that time which
was negative and was started on amitriptyline and Imitrex for
migraines. His HA did not improve with these medications. The
severity progressed and he had daily HA's which would wake him
up from sleep. He would also have N and vomiting at times as
well as severe dizziness.
He was recently in [**State 108**] and there had worsening of these
symptoms. He was seen in an outside ED and received IVF and was
discharged. He then follow-ed up with his Neurologist and had an
MRI/MRA which was reportedly normal.
Then on the day of presentation to the ED he had severe HA with
N and dizziness. He was found to have a cerebellar hemorrhage.
He has not had any history of trauma or injury. His general ROS
is significant for intermittent chills and a 15 lb weight loss
in the last month. He denied change in bowel habit, rash or
joint pains but does feel diffusely weak.
Past Medical History:
UC
Social History:
Occupation: electrician
Denies: Smoking, EthOH or drug abuse
Engaged
Family History:
-no history of vascular malformations, ICHor stroke
Physical Exam:
VITALS: T 97.4 HR 70 BP 137/76 RR 22 sO2 94% RA
GEN: well developed, NAD
HEENT: mmm
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema, LLE
tatoo
MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect.
Oriented to place, month, day, and date, person.
Memory: Language: fluent; repetition: intact; Comprehension
intact; no dysarthria, no paraphasic errors. Prosody: normal; No
Apraxia. No Neglect.
CRANIAL NERVES:
II: Visual fields are full to confrontation, pupils equally
round and reactive to light both directly and consensually,
3-->2 mm bilaterally.
III, IV, VI: Extraocular movements intact with R beating and
upgaze nystagmus. No ptosis.
V: Facial sensation intact to light touch and pinprick.
VII: Facial movement symmetrical; no facial droop.
VIII: Hearing intact to finger voice bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
MOTOR SYSTEM: Normal bulk and tone bilaterally. No adventitious
movements, no tremor, no asterixis.
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
No pronator drift. No rebound.
REFLEXES:
B T Br Pa Pl
Right 2+--------->
Left 2+--------->
Toes: downgoing bilaterally.
SENSORY SYSTEM: Sensation intact to light touch, pin prick,
temperature (cold) in all extremities.
COORDINATION: Normal [**Last Name (LF) 11140**], [**First Name3 (LF) **], HTS. No dysmetria or
pastpointing.
GAIT: not tested
Pertinent Results:
[**2102-10-13**] 03:00AM BLOOD WBC-12.3* RBC-5.38 Hgb-17.0 Hct-49.3
MCV-92 MCH-31.6 MCHC-34.5 RDW-12.1 Plt Ct-302
[**2102-10-14**] 03:33AM BLOOD WBC-11.4* RBC-4.82 Hgb-15.6 Hct-42.6
MCV-88 MCH-32.4* MCHC-36.7* RDW-12.5 Plt Ct-289
[**2102-10-15**] 02:30AM BLOOD WBC-10.2 RBC-4.99 Hgb-16.0 Hct-45.8
MCV-92 MCH-32.2* MCHC-35.0 RDW-12.1 Plt Ct-326
[**2102-10-16**] 04:28AM BLOOD WBC-12.8* RBC-4.97 Hgb-16.0 Hct-45.8
MCV-92 MCH-32.2* MCHC-35.0 RDW-12.1 Plt Ct-328
[**2102-10-17**] 04:31AM BLOOD WBC-15.3* RBC-4.89 Hgb-15.9 Hct-43.5
MCV-89 MCH-32.5* MCHC-36.6* RDW-12.6 Plt Ct-316
[**2102-10-16**] 04:28AM BLOOD PT-11.7 PTT-27.4 INR(PT)-1.0
[**2102-10-15**] 02:30AM BLOOD PT-12.6 PTT-28.9 INR(PT)-1.1
[**2102-10-13**] 03:00AM BLOOD PT-13.4* PTT-30.2 INR(PT)-1.2*
[**2102-10-13**] 03:00AM BLOOD Glucose-131* UreaN-19 Creat-1.1 Na-138
K-4.6 Cl-101 HCO3-26 AnGap-16
[**2102-10-17**] 04:31AM BLOOD Glucose-142* UreaN-15 Creat-1.0 Na-138
K-4.2 Cl-98 HCO3-28 AnGap-16
[**2102-10-16**] 04:28AM BLOOD ALT-14 AST-13 LD(LDH)-166 AlkPhos-77
TotBili-0.2
[**2102-10-16**] 04:32PM BLOOD ALT-33 AST-32 LD(LDH)-355* AlkPhos-95
TotBili-0.2
[**2102-10-17**] 04:31AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.2
[**2102-10-16**] 04:32PM BLOOD TSH-0.27
[**2102-10-16**] 04:32PM BLOOD CRP-0.2
Angio:
No aneurysm or vascular malformation of the arteries of the
posterior circulation.
MR [**Name13 (STitle) **]:
There are two hemorrhagic foci of the left cerebellar hemisphere
which produce mass effect on the fourth ventricle and evidence
of mild hydrocephalus. No definite enhancement is seen within
the areas of hemorrhage. The differential diagnosis includes
hemangioblastoma and hemorrhagic metastasis, though an
underlying vascular malformation cannot be entirely excluded,
particularly given the prominent fine vascular structures of
right cerebellar folia. A conventional angiographic study is
recommended to exclude the possibility of a vascular
malformation, as we discussed by telephone today ([**2102-10-13**]).
As the left cerebellar hemorrhage and signal abnormality appears
located in the substance of the cerebellum, intraventricular
masses including choroid plexus papilloma and ependymoma are
considered much less likely.
CT Torso:
1. No evidence of malignancy.
2. Two tiny hypodense foci of the liver up to 4 mm in size are
too small to definitively characterize but could be cysts or
hemangiomas.
3. Mild wall thickening of the rectosigmoid consistent with
provided history of ulcerative colitis. Given this history,
colonoscopy could be performed if there is continued concern for
occult malignancy.
Scrotal US:
Normal scrotal ultrasound.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the ICU for close monitoring given
the location of his bleed. He was kept NPO for 3 days given
concern for a possible emergent hemi-craniotomy. He was then
transfered to the Neurology Service for further work-up of his
ICH.
He underwent a malignancy work-up consistent of a CT torso and
scrotal US. Both were negative. An ESR and CRP were both
checked and where WNL. He was maintained with a MAP < 130 and
his headache was treated with MS Contin and Dilaudid for breath
through as well as topamax.
Since arrival to the floor:
The patient has had an ECHO cardiogram that did not show a
source for embolic stroke. There was no ASD, PFO or visible
thrombus.
The patient has been having fluctuating nausea and vomiting.
Repeat head CTs have been esssentially unchanged. These
symptoms were attributed to eating atypical foods from outside
the hospital superimposed on colitis and a cerebellar
hemorrhage.
There was concern that the patient's dietary supplements (taken
to facilitate body building) may have contributed to his stroke.
He takes NO-explode from GNC. This apparently provides amino
acid substrates for nitric oxide synthesis that then causes
vasodilation. We hypothesize that ingestion of this substance,
superimposed on a congenital malformation may have caused the
bleed.
Ultimately there was no clear provoking mechanism, other than
the possibility of the dietary supplement, which could account
for a hemorrhage in a 27 year old male. The patient will have a
follow up MRI and it will be decided by the Stroke and
Neurosurgery attendings if he needs a follow up angiogram.
The patient was discharged with recommended follow up with the
neurosurgeons, the stroke neurology service, his
gastroenterologist and his primary care doctor.
Medications on Admission:
Prednisone 20 mg po daily, resumed 5 days prior
-Amitriptyline 20 mg po qhs for headaches
-Imitrex prn
Discharge Medications:
1. Outpatient Physical Therapy
For ataxia
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Morphine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*120 Tablet Sustained Release(s)* Refills:*2*
5. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily) as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*90 Tablet(s)* Refills:*0*
8. Phenergan 12.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebellar hemorrhage
Discharge Condition:
Good - walking has improved remarkably, though still cannot walk
tandem.
Discharge Instructions:
Please call neurologist if your headaches get suddenly worse, or
if your vomiting recurs and does not respond to medications;
please call if you walking or coordination worsen, or if you
have new neurological symptoms (visual or hearing problems,
trouble speaking or swallowing, numbness, tingling or weakness,
falls, or dizziness).
Please take all prescribed medications.
You may need a repeat cerebral angiogram - your neurologist will
help facilitate this. You should call [**Telephone/Fax (1) 327**] to schedule
a repeat MRI/A of the brain in 2 weeks - try to make this before
your neurology appointment if possible.
Followup Instructions:
Neurology: Please call the office of Dr. [**First Name (STitle) **] [**Name (STitle) **] to
schedule a follow-up appointment within 2 weeks. The number to
call is ([**Telephone/Fax (1) 7394**].
Neurosurgery: Please call the office of Dr. [**First Name (STitle) **]
[**Name (STitle) 739**] to schedule a follow-up appointment within 3 weeks
from discharge. The number to call is ([**Telephone/Fax (1) 88**].
Please call your gastroenterologist for a follow-up appointment
and to schedule a colonoscopy as an outpatient (one year from
your last scope).
Please call your primary care physician on [**Name9 (PRE) 766**] (Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 21479**]) to schedule a follow-up appointment; please
mention that you were just discharged from the hospital.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2102-10-22**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2528
} | Medical Text: Admission Date: [**2141-2-18**] Discharge Date: [**2141-2-21**]
Date of Birth: [**2073-7-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
cold numb rt. leg below knee
Major Surgical or Invasive Procedure:
LASER thrombectomy to atheromatous debris of both vessels
balloon angioplasty
cardiac cath
Past Medical History:
67 y/o with hx. CAD s/p CABG [**2118**] (all grafts occluded), LAD
stenting [**2136**], PVD s/p Lt. carotid stenting [**2136**], PMR, HTN, HCL,
who presented with acute onset of N/V/D while at a casino last
evening. This was her anginal equivalent in the past, so she
became concerned for new MI. Shortly thereafter, she noted that
her legs felt weak, that her rt. foot was numb, white, and she
couldnt move it. She presented to the ED and was found to have a
cold, white, pulseless foot. [**Year (4 digits) **] sx. was consulted and felt
that she should go emergently to catheterization. Heparin gtt
was started. On evaluation by the intverventionalist fellow in
the ED, she had already regained some color of the foot, with
some blanching, and return of sensation to normal. Rt. DP and PT
were faintly dopplerable at this time.
.
In the cath lab (retro LFA to the coronaries and contralateral
PT and DP) she was found to have:
.
AO: 70% ulcerated vessels at the bifurcation
Renals: bilateral single vessels with rt. 90% lesion
Rt LE: CIA and EIA normal, CFA and SFA normal. Popliteal free of
disease. Rt. AT occluded mid vessel with PT occluded proximally
(both from the patent PA).
She underwent LASER thrombectomy catheter to atheromatous debris
of both vessels, and then balloon angioplasty to the same with
return of flow.
.
Coronary anatomy as follows:
LMCA normal
LAD previous stent patent, mid segment 70% lesion with
bifurcation D2
LCX: non-dominant without critical lesion; OM2 60% lesion after
bifurcation
RCA dominant with proximal occlusion; distal L to R collaterals
remain
,
Optiray 312 mL. She got a dose of mucomyst prior to prodcedure
and [**11-22**] normal saline gtt was started for planned total 2 L
Social History:
Social history is significant for the absence of current tobacco
use.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Blood pressure was 143/90 mm Hg while supine. Pulse was 73
beats/min and regular, respiratory rate was 12 breaths/min.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 6 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed 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+
Brief Hospital Course:
67 y/o with hx. CAD and PVD s/p CABG and carotid stenting p/w
cold rt. foot. Her active issues during this hospital course
includes:
.
## Acute thromboembolic occlusion of Right and left LE: PT s/p
thrombectomy/atherectomy and balloon angioplasty. Initially, pt.
had significant bleeding at sheath post procedure requiring
advancement of sheath to hub and pressure dressings, manual
pressure; heparin stopped, but Integrilin continued. She was
able to amubulate well. The next day, she then underwent
thrombectomy/atherectomy of left with good results bilaterally.
She was discharged on asa, plavix and lovenox bridge to
coumadin.
.
.
Outpatient follow-up:
Pt was instructed to have her INR checked by VNA and faxed to
Dr.[**Name (NI) 129**] office, who will be managing her coumadin. Dr.
[**Last Name (STitle) 120**] was notified.
.
Appointments were made for additional [**Last Name (STitle) 1106**] imaging as per
Dr. [**First Name (STitle) **].
Medications on Admission:
ASA
Plavix
Metoprolol 50 [**Hospital1 **]
Allopurinol
Colchicine
HCTZ
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 days.
Disp:*8 syringes* Refills:*2*
2. 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*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 3 doses: Please take on evening of [**2-21**] and [**2-22**].
Disp:*2 Tablet(s)* Refills:*0*
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Please start on evening of [**2141-2-23**].
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
peripheral [**Location (un) 1106**] disease
coronary artery disease
.
Secondary:
hypertension
dyslipidemia
Discharge Condition:
stable, ambulating, pain free
Discharge Instructions:
You had clots in the arteries in your leg which required urgent
intervention and thrombectomy.
.
Please call 911 or go to the emergency room if you have any
symptoms of foot/leg pain, coolness, numbness in your
extremities, chest pain, shortness of breath, palpatations, or
any other concerning symptoms.
.
Please take all medications as prescribed.
.
In addition, you will need to take blood thinners. There are two
medications.
1) Coumadin is the oral blood thinner and you will need to have
your blood levels checked regularly to ensure that the level is
within range. Too high or too low levels can be dangerous.
Please have your coumadin levels checked by the visiting nurses.
Make sure that they fax the results to Dr.[**Name (NI) 129**] office. He
wil adjust the dose for you.
2) While your coumadin levels become therapeutic, you will need
to take injections of an immediate acting blood thinner called
Lovenox. Once your coumadin level is within range, you will not
need to take lovenox any more.
Followup Instructions:
Please attend all follow-up appointments as noted below:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2141-3-9**] 9:30
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-7-11**]
1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2141-7-11**] 4:00
ICD9 Codes: 4019, 2724, 2749, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2529
} | Medical Text: Admission Date: [**2158-3-14**] Discharge Date: [**2158-3-17**]
Date of Birth: [**2105-12-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
relatively asymptomatic /migraines
Major Surgical or Invasive Procedure:
[**2158-3-14**] minimally invasive ASD repair
History of Present Illness:
52 year old male with RBBB and ASD diagnosed in [**1-4**]. Echo
showed
LVEF 60%, [**Last Name (un) **], secundum ASD with left to right shunt. Nuclear
stress test done to rule out ischemia with normal perfusion and
EF 69%. Referred for ASD closure. Presents today for pre-op
work-up.
Past Medical History:
atrial septal defect
PMH:
right bundle branch block
right plantar fasciitis
borderline hypertension
migraines/ visual disturbance
Meniere's dz
Social History:
Lives with: alone
Occupation: solar energy
Tobacco: none
ETOH: social
Family History:
Father MVR x2 (first at age 50), mother with MVR
Physical Exam:
Pulse: 68 Resp: 18 O2 sat: 100
B/P Right: 144/87
Height: 5'[**57**]" Weight: 175 lbs
General: well-devloped male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
[X]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
Prebypass
A left-to-right shunt across the interatrial septum is seen at
rest. A secundum type atrial septal defect is present. There is
mild symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is moderately dilated with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. The main pulmonary artery is
dilated. The branch pulmonary arteries are dilated. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results on [**2158-3-14**] at 830am
Post bypass
Patient in sinus rhythm. Biventricular systolic function is
unchanged. Pledgets seen in the region at the site of the
secundum ASD. No flow demonstrated across the interatrial
septum.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2158-3-14**] 15:22
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2158-3-14**] where the patient underwent closure of
atrial septal defect via thoracotomy.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Cefazolin was
used for surgical antibiotic prophylaxis. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes 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 3 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to home in
good condition with appropriate follow up instructions.
Medications on Admission:
Triam/HCTZ 37.5mg qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 4 weeks.
Disp:*84 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
atrial septal defect
PMH:
right bundle branch block
right plantar fasciitis
borderline hypertension
migraines/ visual disturbance
Meniere's dz
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in [**1-26**] weeks at [**Hospital1 **] [**Telephone/Fax (1) 6256**]
Primary Care Dr. [**Last Name (STitle) **],NOBITA [**Telephone/Fax (1) 77899**] in [**11-26**] weeks
Cardiologist Dr. [**Last Name (STitle) 4610**] in [**12-28**] weeks [**Telephone/Fax (1) 6256**]
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2158-3-17**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2530
} | Medical Text: Admission Date: [**2146-3-10**] Discharge Date: [**2146-4-27**]
Date of Birth: [**2117-12-8**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents / Dilaudid
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, tachycardia.
Major Surgical or Invasive Procedure:
[**2146-3-10**]: Ultrasound-guided pancreatic pseudocyst drainage with
drain placement.
.
[**2146-3-18**]: CT-guided drainage of upper abdominal pseudocyst
.
[**2146-4-14**]: Ultrasound-guided fluid aspiration of a left flank
collection.
.
[**2146-4-14**]: Ultrasound-guided placement of left pleural pigtail
catheter.
.
[**2146-4-21**]: Ultrasound-guided left flank fluid collection
drainage with placement of a 8-French [**Last Name (un) 2823**] pigtail catheter.
History of Present Illness:
Patient is a 28M well-known to the West 2 surgical service. He
was discharged [**2146-3-9**] after a prolonged hospital course for
gallstone pancreatitis. This was complicated by DVT,
respiratory/renal failure requiring mechanical ventillatory
support and CVVHD, and pancreatic necrosis requiring
percutaneous drainage. He improved and was discharged yesterday
to a rehabilitation facility. Today, he returns with tachycardia
and increased abdominal pain. The patient states that he began
to experience abdominal pain yesterday afternoon while working
with PT. He states that this pain is similar to the epigastric
pain he has experienced all along only worse. He rated this as
an [**9-6**] though currently [**7-7**]. He states that he was able to eat
dinner (grilled chicken) without difficulty. He was eating
breakfast this morning and became nauseated while eating grapes.
He had several episodes of non-bilious emesis and was brought to
[**Hospital1 18**] for further care given increased abdominal pain and
tachycardia.
Past Medical History:
PMH: Gallstone pancreatitis as above, obesity, congenital
blindness in right eye, left common iliac DVT .
PSH: Laparoscopic cholecystectomy [**1-5**]
Social History:
Recently married. He lives with his wife and their dog. No kids.
Works as an investment manager. Never smoker. Rare alcohol.
Smokes marijuana, denies other drugs.
Family History:
Diverticulosis in both of his parents. DM in grandmother. HTN in
father. [**Name (NI) **] 2 sisters and one brother.
Physical Exam:
On Admission:
VS: 99.4 150 136/88 28 100%RA
General: awake and alert, diaphoretic and sweaty
CV: Tachycardic
Lungs: Tachypnic, CTA bilaterally
Abdomen: Obese, soft, (+) palpable phlegmon in RUQ, (+) diffuse
tenderness greatest in epigastrium, no rebound/guarding,
hypoactive BS
Ext: warm, no edema.
.
At Discharge:
VS: T 99.2 HR 93 BP 106/54 RR 18 SaO2 98% RA
GEN: Deconditioned in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **].
LUNGS: Slightly decreased at bases, otherwise clear.
COR: RRR
ABD: Protuberant. (L) LQ abdominal JP drain (into pancreatic
pseudocyst) patent/intact. (L)flank drain patent/intact. Both
drains with scant output. Prior sub-umbilical drain site clean,
healed without drainage. BSx4. Soft/NT/ND.
EXTREM: WWP; mild LE edema, no cyanosis, clubbing.
NEURO: A+Ox3. Very deconditioned. Requires assistance with gait.
Pertinent Results:
On Admission:
[**2146-3-10**] 08:28PM TYPE-ART PO2-138* PCO2-42 PH-7.55* TOTAL
CO2-38* BASE XS-13 INTUBATED-NOT INTUBA
[**2146-3-10**] 08:28PM freeCa-0.98*
[**2146-3-10**] 05:10PM OTHER BODY FLUID AMYLASE-[**Numeric Identifier **]
[**2146-3-10**] 05:10PM PT-20.2* INR(PT)-1.9*
[**2146-3-10**] 02:50PM WBC-22.5* RBC-3.31*# HGB-8.5*# HCT-28.0*#
MCV-85 MCH-25.7* MCHC-30.4* RDW-18.2*
[**2146-3-10**] 02:50PM PLT COUNT-511*
[**2146-3-10**] 02:07PM GLUCOSE-196* UREA N-19 CREAT-1.3* SODIUM-134
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-30 ANION GAP-15
[**2146-3-10**] 02:07PM CALCIUM-7.7* PHOSPHATE-6.2* MAGNESIUM-1.5*
[**2146-3-10**] 01:52PM PT-22.6* PTT-33.6 INR(PT)-2.1*
[**2146-3-10**] 07:29AM WBC-30.7*# RBC-4.67# HGB-11.7*# HCT-39.7*#
MCV-85 MCH-25.0* MCHC-29.4* RDW-17.4*
[**2146-3-10**] 07:29AM NEUTS-89* BANDS-3 LYMPHS-2* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2146-3-10**] 07:29AM PLT SMR-VERY HIGH PLT COUNT-818*#
[**2146-3-10**] 05:46AM GLUCOSE-149* LACTATE-2.5* NA+-136 K+-4.6
CL--99* TCO2-17*
.
Prior to Discharge:
[**2146-4-27**] PT/INR: 31.9/3.2
.
IMAGING:
[**2146-3-10**] AP CXR: Low lung volumes with LLL consolidation, could
reflect atelectasis, however, pneumonia cannot be excluded.
.
[**2146-3-10**] CTA CHEST W&W/O C&RECONS, ABD/PELVIC CT W/CONTRAST:
1. Minimal interval increase in size of right upper quadrant
pancreatic pseudocyst. Interval decrease in size of remaining
loculated fluid collections.
2. No pulmonary embolism present. Large bilateral pleural
effusions with associated compression atelectasis.
3. Increased amount of abdominal and pelvic free fluid.
.
[**2146-3-11**] BILAT LOWER EXT VEINS:
1. Persistent non-occlusive thrombus in the left common femoral
vein.
2. No right lower extremity DVT.
3. Small right popliteal cyst.
.
[**2146-3-15**] CXR:
Cardiomediastinal silhouette is unchanged as well as there is no
change in extremely low lung volumes and bilateral pleural
effusions, left more than right. There is mild prominence of the
vasculature that appears to be more pronounced than on the prior
study and might represent some degree of volume overload. The
right internal jugular line tip appears to be atleast at the
cavoatrial junction, but also may be present in the proximal
right atrium.
.
[**2146-3-16**] ABD/PELVIC CT W/CONTRAST:
1. Enlargement of the previously seen fluid collection and
appearance of the numerous new large collections in the
peritoneum. The drained collection has significantly decreased
in size.
2. Increase in pleural effusions: Left moderate and right
minimal size, findings are accompanied by compressive
atelectasis.
3. Minimal residual of the left common femoral vein and left
external iliac vein thrombus.
.
[**2146-3-17**] AP CXR:
In comparison with the study of [**3-15**], there is still extremely
low lung volumes. Hazy opacification at the left base is
consistent with pleural fluid. Obscuration of the hemidiaphragm
suggests volume loss in the left lower lobe. The right lung is
essentially clear and there is no evidence of pulmonary vascular
congestion. The tip of the right IJ catheter is difficult to see
but appears to be in the mid-to-lower portion of the SVC.
.
1. Markedly decreased size of drained collection anterior to the
stomach and surroiunding the left hepatic lobe. New extensive
stranding and fluid within the gastrohepatic ligament and porta
hepatis, possibly induced by leakage from one of the adjacent
collections or recurrent pancreatitis. Slight re-accumulation of
fluid within the previously drained collection in the anterior
abdomen, now measuring 14.3 x 1.6 x 5.4 cm. Otherwise, overall
decrease in multiple remaining peritoneal and extraperitoneal
fluid collections compared to the prior study.
2. Persistent bile duct dilation likely secondary to
pancreatitis. Increased attenuation of patent portal vein from
adjacent new inflammation. Persistent marked attenuation of the
splenic vein. Smaller splenic infarcts.
3. Unchanged bilateral pleural effusions and associated
compressive atelectasis.
4. Unchanged thrombus within the left external iliac and common
iliac veins.
.
[**2146-3-28**] CXR:
Stable size of left pleural effusion with associated
consolidation which likely represents atelectasis but
superimposed infection cannot be excluded.
.
[**2146-4-13**] ABD/PELVI CT W/CONTRAST:
1. In this patient with known history of necrotizing
pancreatitis, there is enhancement of the distal body and tail
of the pancreas with non visualization of the remainder of the
pancreas. Multiple extensive peripancreatic fluid collections
have decreased in size since the prior study.
2. A small fluid collection adjacent to the inferior edge of
right lobe of liver measuring 4.9 x 3.2 x 2.0 cm, is new since
the prior study.
3. Unchanged left femoral vein thrombosis. Infrarenal IVC filter
in place.
4. Mild interval improvement in the small-to-moderate left
pleural effusion. Compressive atelectasis of the left lower
lobe is unchanged.
.
[**2146-4-15**] CXR:
Status after withdrawal of a left-sided chest tube. Minimal
apical and lateral basal pneumothorax without evidence of
tension. Unchanged minimal atelectasis at the left lung base. No
other changes. Normal cardiac silhouette.
.
[**2146-4-18**] CXR:
1. Low lung volumes with left basilar subsegmental atelectasis,
likely related to the recent abdominal surgery and ongoing
intra-abdominal process.
2. No appreciable residual left pneumothorax.
3. Left-sided PICC likely at the junction of that axillary and
subclavian vein; this may need to be advanced into a more
central vein, depending on the indication for its use.
.
[**2146-4-20**] ABD/PELVIC CT W/O CONTRAST:
1. Slightly decreased size of dominant central abdominal fluid
collection with left drain in satisfactory position. Right
catheter has been removed.
2. Other fluid collections are little changed [**2146-4-13**].
3. Resolving left pleural effusion with pleural air secondary to
left thoracic drain placement and removal. No new peripancreatic
fluid collection.
4. Hypodensity of the blood pool relative to the ventricular
myocardium is suggestive of anemia.
5. Moderate biliary dilatation likely secondary to CBD
obstruction by pseudocyst is similar to [**2146-4-13**].
.
MICROBIOLOGY:
FLUID/WOUND CULTURES:
[**2146-4-21**] 10:15 am FLUID,OTHER LEFT FLANK ABSCESS.
**FINAL REPORT [**2146-4-25**]**
GRAM STAIN (Final [**2146-4-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final [**2146-4-25**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2146-4-25**]): NO ANAEROBES ISOLATED.
.
[**2146-4-16**] 4:30 pm FLUID,OTHER LEFT JP DRAIN FLUID.
**FINAL REPORT [**2146-4-19**]**
GRAM STAIN (Final [**2146-4-16**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 10PM [**2146-4-16**].
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final [**2146-4-19**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
[**2146-4-14**] 9:51 am PERITONEAL FLUID
GRAM STAIN (Final [**2146-4-14**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO DR.[**First Name (STitle) **] [**Doctor Last Name **] ON [**2146-4-14**] AT
03:50 PM.
FLUID CULTURE (Final [**2146-4-17**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2146-4-18**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2146-4-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
.
[**2146-4-14**] 9:57 am PLEURAL FLUID
GRAM STAIN (Final [**2146-4-14**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2146-4-17**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-4-20**]): NO GROWTH.
ACID FAST SMEAR (Final [**2146-4-15**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
.
[**2146-4-5**] SWAB GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC
CULTURE-FINAL:
[**2146-4-5**] 3:09 pm SWAB PSEUDO CYST FLUID.
**FINAL REPORT [**2146-4-11**]**
GRAM STAIN (Final [**2146-4-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2146-4-7**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-4-11**]): NO GROWTH.
.
[**2146-3-28**] 9:25 am PERITONEAL FLUID
**FINAL REPORT [**2146-4-1**]**
GRAM STAIN (Final [**2146-3-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2146-4-1**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6976**] @ 1:20 PM ON [**2146-3-29**].
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
RARE GROWTH OF THREE COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2146-4-1**]): NO ANAEROBES ISOLATED.
.
[**2146-3-23**] 10:43 pm FLUID,OTHER DRAIN FLUID.
**FINAL REPORT [**2146-3-28**]**
GRAM STAIN (Final [**2146-3-24**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2146-3-27**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2146-3-28**]): NO ANAEROBES ISOLATED.
.
[**2146-3-10**] FLUID,OTHER GRAM STAIN-FINAL; WOUND CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL:
GRAM STAIN (Final [**2146-3-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2146-3-13**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2146-3-16**]): NO GROWTH.
.
BLOOD & URINE CULTURES:
[**2146-4-18**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-15**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-14**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-4-12**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-28**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-28**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-23**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-23**] URINE CULTURE-FINAL: NO GROWTH.
[**2146-3-23**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-19**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-19**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-18**] FLUID CULTURE: NO GROWTH - FINAL.
[**2146-3-17**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-17**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-13**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-10**] BLOOD CULTURE: NO GROWTH - FINAL.
[**2146-3-10**] BLOOD CULTURE: NO GROWTH - FINAL.
.
RESPIRATORY/OTHER CULTURES:
[**2146-4-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL:
Upper respiratory contamination.
[**2146-4-13**] CATHETER TIP-IV WOUND CULTURE-FINAL: NO SIGNIFICANT
GROWTH.
[**2146-4-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL:
Upper Respiratory Contamination.
[**2146-3-10**] MRSA SCREEN MRSA: NEGATIVE.
Brief Hospital Course:
The patient was re-admitted on [**2146-3-10**] back to the General
Surgical Service for evaluation and treatment of abdominal pain
and tachycardia. Admission abdominal/pelvic CT revealed minimal
interval increase in size of right upper quadrant pancreatic
pseudocyst, but decrease in size of remaining loculated fluid
collections. Large bilateral pleural effusions with associated
compression atelectasis were noted, as well as increased amount
of abdominal and pelvic free fluid. He was admitted to the SICU,
made NPO, started on vigorous IV fluid rescusitation, a foley
was placed, and he received IV pain medication with good effect.
He had a very long, and complicated hospital course.
.
In the process of repairing his florid necrotizing pancreatitis
secondary to his history of severe gallstone pancreatitis, he
ultimately developed recurrent pseudocyts, which have plagued
him throughtout his hospital stays since [**48**]/[**2145**]. To date, these
pseudocyts have been managed largely with percutaneous catheter
drainage of the pseudocysts. Initially, during this admission,
this was the approach to managing the patient's recurring
pseudocyts. The patient underwent drainage of pancreatic
pseudocysts on [**2146-3-10**] and [**2146-3-18**], Ultrasound and CT-guided,
respectively. However, he developed an accumulating posterior
retroperitoneal cyst, which continued to progress, and there was
evidence of a disconnected pancreatic remnant within it. The
recent drainages of the other satellite lesions have dried them
up. The main retroperitoneal cyst continued to grow in size, and
became symptomatic for him. He was unable to eat full meals and
has a diminished capacity to keep food down, as well as a poor
appetite. He also repeatedly spiked temperatures.
.
Given his history of a left lower extremity acute deep venous
thrombosis, Vascular Surgery was consulted. In lieu of planned
surgical intervention on [**2146-4-5**] for treatment of the above
pseudocyst with adhesions, the patient underwent placement of a
Bard G2 inferior vena cava filter, which went without
complication. Then on [**2146-4-5**], the patient underwent external
drainage of pancreatic pseudocyst and extended adhesiolysis,
which also went well without complication (see Operative Note).
After a brief, uneventful stay in the PACU, the patient was
returned to the floor NPO with an NG tube, on IV fluids and TPN,
with a foley catheter and two JP drains in place (one in the
pseudocyst and one in the abdomen to drain ascites), he was
continued on a Fentanyl patch and was given a Morphine PCA with
good effect. He was hemodynamically stable.
.
NEURO: Upon admission, the patient received IV pain medication
PRN transitioned to a Morphine PCA with good effect and adequate
pain control. When tolerating oral intake, he was transitioned
to oral pain medications. After the surgery on [**2146-4-5**], the
Chronic Pain Service was consulted. His pain was controlled once
the Fentanyl dose was increased to 75mcg/72Hr plus the Morphine
PCA. When again tolerating a diet post-operatively, the PCA was
discontinued, and he was started on oral pain medication in
addition to the Fentanyl patch with continued good effect. He
remained neurologically intact.
.
CV: Upon admission, tachycardia responded to vigorous IV fluid
rescusitation and beta-blockade with Metoprolol 50mg TID.
Metoprolol was increased to 75mg TID with eventual excellent
rate and BP control. By discharge, the Metoprolol was decreased
to 50mg [**Hospital1 **]. The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
.
PULMONARY: Tachypnea on admission. Chest CTA revealed large
bilateral pleural effusions with associated compression
atelectasis. Tachypnea resolved with diuresis with Lasix and
supplemental oxygen. He was given Albuterol and Atrovent
nebulizer treatments, good pulmonary toilet and use of the
incentive spirrometry were encouraged, and the patient received
chest PT with improvement in overall respiratory status. Able to
wean off supplemental oxygen. CXR on [**3-17**] revealed still
extremely low lung volumes. Hazy opacification at the left base
is consistent with pleural fluid. Obscuration of the
hemidiaphragm suggests volume loss in the left lower lobe. The
right lung was essentially clear and there was no evidence of
pulmonary vascular congestion.
Starting on [**4-12**], he spiked a temperature to 103 PO and his WBC
increased from 13 to 23,000. He had a CT abdomen performed
which demonstrated a left pleural effusion
on the upper cuts of the abdomen. Thoracic surgery was consulted
for management of the pleural effusion. On [**2146-4-14**], he underwent
ultrasound-guided thorocentesis and placement of left pleural
pigtail catheter. Plural fluid for culture, gram stain,
cytology, chemistries, and AFB was sent. The pleural pigtail
catheter was removed on [**4-15**]; post-removal CXR revealed minimal
apical and lateral basal pneumothorax without evidence of
tension. Unchanged minimal atelectasis at the left lung base. A
follow-up CXR on [**2146-4-18**] showed continued low lung volumes with
left basilar subsegmental atelectasis, likely related to the
recent abdominal surgery and ongoing intra-abdominal process. No
appreciable residual left pneumothorax was seen. The patient
remained stable from a pulmonary standpoitn thereafter.
Respiratory toilet, incentive spirrometry, and frequent
ambulation was encouraged.
.
GU/FEN: On admission, the patient was made NPO and he received
vigorous IV fluid rescusitation. A foley catheter was placed.
Allowed clears on [**3-11**] and [**3-12**], but an NG tube was placed on
[**3-13**] for increased abdominal distension and emesis resulting
with 1400mL bilious output. After successful clamp trial
overnight, the NG tube was discontinued on [**3-15**] in the morning.
Given persistent problems with tolerating oral intake, a PICC
was placed, and TPN was started on [**2146-3-14**]. With the decision
to proceed to surgery, TPN was continued through [**2146-4-12**]. When
not NPO for procedures, his diet was advanced back to low fat
regular with good tolerability and intake. When the foley
catheter was removed after surgery, he was able to void without
problem. Patient's intake and output were closely monitored, and
IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
.
GI: Admission liver and pancreatic enzymes were elevated.
Shortly after admission, the patient underwent ultrasound-guided
pseudocyst drainage measuring 1.7 liters of fluid with a
drainage catheter left in place to gravity on [**2146-3-10**]. Liver
and pancreatic enzymes began trending down. Follow-up
abdominal/pelvic CT on [**3-16**] demonstrated enlargement of the
previously seen fluid collection and appearance of the numerous
new large collections in the peritoneum. The drained collection
had significantly decreased in size. On [**3-18**], the patient
returned to Interventional Radiology for drainage of an anterior
collection, and placement of a new drainage catheter to gravity.
The previous drain was removed, and upper abdominal pseudocyst
was succesfully drained with a catheter left in place to
gravity. Unfortunately, as noted above, he developed an
accumulating posterior retroperitoneal cyst, which continued to
progress, and there was evidence of a disconnected pancreatic
remnant within it. He underwent external drainage of pancreatic
pseudocyst and extended adhesiolysis as described above. A (L)
flank drain was left in place. After the surgery, his symptoms
improved.
.
ID: Admission blood cultures were negative. [**3-10**] fluid culture
had no growth. On [**3-17**] after receiving FFPs, the patient mounted
a fever with a Tmax 101.5 PO. Blood cultures were negative.
Fluid cutlure from the [**3-18**] drainage also revealed no growth.
The patient's white blood count and fever curves were closely
watched for signs of infection. Admission MRSA screen was
negative. After the [**2146-4-5**] surgery, cultures from the peritoneal
fluid on [**4-14**], the (L) JP on [**4-19**], and the flank drain on [**4-21**]
all grew out MRSA. The patient had been started on empiric IV
Vancomycin, Ciprofloxacin, and Flagyl when he spiked a
temperature on [**4-14**]. Fluconazole for empiric coverage after the
thorocentesis was started on [**4-15**]. Flagyl, Cipro, and
Fluconazole were discontinued on [**4-16**]. Cipro restarted on [**4-21**].
Infectious Disease was consulted for discharge antibiotic
recommendations; their input was greatly appreciated. Cipro was
discomntinued, and oral Levofloxacin and Flagyl started on [**4-26**]
with Vancomycin continued. At discharge, the patient was sent
home on a two week course oral Linezolid, and a total of four
weeks of oral Levofloxacin and Flagyl.
.
ENDOCRINE: The patient's blood sugar was monitored throughout
his stay when he was on TPN; sliding scale insulin was
administered accordingly. He did not require exogenous insulin.
.
HEMATOLOGY: Upon admission, Coumadin was stopped, and the
patient received 5 untis of Fresh Frozen Plasma (FFPs) prior to
fluid collection drainage in Intervention Radiology. On [**3-17**],
FFPs were again administered in preparation for IR drainage of a
large anterior abdominal fluid collection, but was stopped after
the patient experienced severe lower back pain after initiation
of the second unit of FFP. On [**3-18**], he received a total of 4
units of FFPs prior to IR drainage of the aforementioned
collection. Prior to [**2146-4-5**] surgery, the patient received 2
units of PRBCs for a HCT of 22.2. He did not require any further
blood products after this date. At discharge, his HCT was 23.7.
.
PROPHYLAXIS: History left common iliac DVT and HITs. Repeat
duplex ultra-sound on admission confirmed persistent
non-occlusive thrombus in the left common femoral vein; no right
DVT was seen. Chest CTA did not reveal a PE. On admission,
Coumadin stopped, and Agatroban started. After the drainage of
the collection on [**3-10**], Agatroban was stopped, and Coumadin
restarted. Coumadin also restarted after reversal for second
collection drainage. After the surgery on [**2146-4-5**], the patient
was restarted on Argatroban. He was again converted back to
Coumadin prior to discharge, at which time the INR was
therapeutic at 3.2 on a Coumadin dose of 2.5mg daily. INR goal
2.5 with a therapeutic range of [**3-2**].
.
MOBILITY: The patient worked with Physical and Occupation
therapy extensively. By discharge, he was able to ambulate
independently. He was discharge home with PT and OT services.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with minimal assistance, voiding without
assistance, and pain was well controlled. He was discharged
home with VNA and PT services. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever.
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
7. Methyl Salicylate-Menthol Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for back pain.
8. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
9. Methadone 10 mg Tablet Sig: Two (2) Tablet PO twice a day.
10. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
sliding scale Subcutaneous ASDIR (AS DIRECTED).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for btp.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Adjust dose according to INR. .
16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please adjust daily dose according to INR.
17. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
[**Hospital1 **]:*60 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
[**Hospital1 **]:*60 Capsule(s)* Refills:*2*
3. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Over-the-counter.
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Hospital1 **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*11*
5. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO every 4-6 hours as
needed for pain.
[**Hospital1 **]:*120 Tablet(s)* Refills:*0*
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for pain.
[**Hospital1 **]:*10 Patch 72 hr(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours.
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
[**Hospital1 **]:*120 Tablet(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 4 weeks.
[**Hospital1 **]:*84 Tablet(s)* Refills:*0*
12. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 weeks.
[**Hospital1 **]:*28 Tablet(s)* Refills:*0*
13. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 14 days.
[**Hospital1 **]:*28 Tablet(s)* Refills:*0*
14. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO daily in the
evening or as directed by PCP.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO As directed by
PCP: **This Prescription should only be used if advised by your
PCP.**.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] homecare VNA
Discharge Diagnosis:
1. Necrotizing gallstone pancreatitis.
2. Multiple pancreatic pseudocysts.
3. Non-occlusive thrombus in the left common femoral vein.
4. Left Pleural effusion
5. Anemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
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 [**6-6**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD (Hematology).
Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2146-5-18**] 2:00. Location: [**Hospital Ward Name 23**] 7,
[**Hospital Ward Name 516**].
.
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-5-26**] 2:45.
Location: [**Hospital Ward Name 23**] 4, [**Hospital Ward Name 516**].
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Infectious Disease). Phone:
([**Telephone/Fax (1) 6732**]. Date/Time: Friday, [**2146-5-27**] at 10:00AM. Location:
[**Last Name (un) 6752**] GB, [**Last Name (NamePattern1) 439**], [**Hospital1 18**] [**Hospital Ward Name 517**].
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time:
Friday, [**2146-5-27**] at 11:30AM. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Please call ([**Telephone/Fax (1) 84361**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 84362**] (PCP) in [**3-2**] weeks.
Completed by:[**2146-4-27**]
ICD9 Codes: 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2531
} | Medical Text: Admission Date: [**2156-11-10**] Discharge Date: [**2156-11-17**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p Aortic valve replacement (23mm [**Company **] mosaic ultra
porcine valve) [**11-10**]
History of Present Illness:
[**Age over 90 **] year old female with history of aortic stenosis followed by
serial echos. Referred for surgical evaluation
Past Medical History:
Aortic Stenosis
Hypertension
Elevated lipids
Arthritis
Urinary incontinence
Cataracts
Osteoporosis
Hemorrhoids
s/p BOOP [**2140**]
Urinary tract infections
s/p right cataract laser treatment
tonsillectomy
hysterectomy
appendectomy
Social History:
Retired school teacher
Lives with spouse
[**Name (NI) 1139**] denies
ETOH denies
Family History:
non contributory
Physical Exam:
[**Age over 90 **] yo women in NAD
HR 80 RR 16 BP 122/35
Lungs CTAB
Heart RRR Holosystolic murmur
Sbdomen soft, NT, NT, +BS
Extrem war, trace BLE edema
Neuro grossly intact
No varicosities
Pertinent Results:
[**2156-11-16**] 06:25AM BLOOD WBC-7.4 RBC-3.10* Hgb-10.2* Hct-29.7*
MCV-96 MCH-32.8* MCHC-34.3 RDW-15.4 Plt Ct-185
[**2156-11-16**] 06:25AM BLOOD Plt Ct-185
[**2156-11-14**] 02:55AM BLOOD PT-11.6 PTT-31.5 INR(PT)-1.0
[**2156-11-16**] 06:25AM BLOOD Glucose-95 UreaN-37* Creat-1.1 Na-133
K-4.4 Cl-103 HCO3-24 AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 93116**] (Complete)
Done [**2156-11-10**] at 11:55:33 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2064-7-21**]
Age (years): [**Age over 90 **] F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Patient with AS for AVR
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2156-11-10**] at 11:55 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW-:1 Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *4.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *76 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 43 mm Hg
Aortic Valve - Valve Area: *0.4 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
ascending aorta. Normal descending aorta diameter. Simple
atheroma in descending aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Trace AR.
MITRAL VALVE: [**Pager number **] (2+) MR.
TRICUSPID VALVE: Mild to [**Pager number 1192**] [[**12-2**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the ascending aorta.
There are simple atheroma in the descending thoracic aorta. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation
is seen. [**Month/Day (2) **] (2+) mitral regurgitation is seen. There is no
pericardial effusion.
Post CPB: A prosthetic valve is seen in the aortic position. No
AI, no leak. MR [**First Name (Titles) 19947**] [**Last Name (Titles) 1192**]. Good biventricular systolic
fxn. Aorta intact. Other parameters as pre-bypass.
CHEST (PORTABLE AP) [**2156-11-15**] 4:17 PM
CHEST (PORTABLE AP)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with s/p AVR
REASON FOR THIS EXAMINATION:
evaluate effusion
INDICATION: Status post aortic valve replacement.
COMPARISON: [**2156-11-12**].
UPRIGHT AP CHEST: Sternotomy wires are unchanged, as is
cardiomegaly and the heavily calcified aorta. [**Month/Day/Year **] bilateral
pleural effusions are increased in volume from [**11-12**].
The upper lungs are well aerated, but there is bibasilar
atelectasis related to the effusions. The right IJ sheath has
been removed. No pneumothorax.
IMPRESSION: [**Month (only) **] bilateral pleural effusions are increased
in volume compared to [**11-12**].
Brief Hospital Course:
She was taken to the operating room on [**11-10**] where she underwent
an AVR. She was transferred to the ICU in critical but stable
condition on neosynephrine and propofol. She was seen by GU
immediately postop for hematuria in the setting of known bladder
tumor. CBI was started. She remained intubated overnight and was
extubated on POD #1. Her hematuria resolved. Her neo was weaned
to off on POD #4. She was transfused. She was transferred to the
floor on POD #5. She was seen by EP for afib with bradycardia,
and they recommended telemetry monitoring at rehab. She was
ready for discharge to rehab on POD #6.
Medications on Admission:
Dipyridamole ER 200", Lisinopril 40', Nifedipine 30', Lipitor
10', Omeprazole 20", Zyrtec 10', Nasocort AQ 55 mcg 2/nostril',
ca++ 500', FeSO4 325', MVI 1'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Dipyridamole 50 mg Tablet Sig: Four (4) Tablet PO twice a
day: 200 mg [**Hospital1 **].
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Cap(s)
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
9. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Hypertension
Elevated lipids
Arthritis
Urinary incontinence
Cataracts
Osteoporosis
Hemorrhoids
s/p BOOP [**2140**]
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:
Please call to schedule all appointments
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr [**Last Name (STitle) **] after discharge
from rehab ([**Telephone/Fax (1) 250**])
Dr [**Last Name (STitle) **] after discharge from rehab
Dr. [**Last Name (STitle) **] after discharge from rehab
Completed by:[**2156-11-16**]
ICD9 Codes: 9971, 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2532
} | Medical Text: Admission Date: [**2103-6-26**] Discharge Date: [**2103-6-26**]
Date of Birth: [**2103-6-26**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Known lastname 52013**] was born
at 26 and 5/7 weeks gestation to a 24 year old, Gravida II,
Para 1, now II woman, by emergent cesarean section for
suspected chorioamnionitis and a nonreassuring fetal heart
rate. The infant died in his parent's arms at 14 hours of
age from overwhelming sepsis and extreme prematurity.
The mother's prenatal screens were blood type A positive,
antibody negative, Rubella immune, RPR nonreactive, hepatitis
surface antigen negative. Group B strep unknown. The
antibody status was unknown.
The maternal history is remarkable for uncomplicated
pregnancy until [**2103-6-14**] when the mother was involved in a
motor vehicle accident and several hours later the mother had
bright red vaginal bleeding and premature rupture of
membranes. At that time, she was admitted to [**Hospital3 38285**] and then transferred to [**Hospital1 190**] on [**2103-6-15**]. She received a complete course of
betamethasone and a one week course of antibiotics.
Her medical history is also remarkable for migraine
headaches, treated with Doxepin and Zyrtec. Her course at
[**Hospital1 69**] was uneventful until the
morning of delivery when she presented with fetal tachycardia
and an elevated white blood cell count. The fetal heart rate
tracing evolved to be non reassuring. A cesarean section was
done. The infant emerged without respiratory effort and low
tone. Apgars were two at one minute, six at five minutes and
seven at ten minutes. The infant required intubation in the
delivery room.
PHYSICAL EXAMINATION: The admission physical examination
reveals an extremely premature, pink infant. Anterior
fontanel open and flat. Non dysmorphic facies. Mild
retractions. Poor air entry. Coarse breath sounds. No
murmur. Present femoral pulses. Flat and soft, nontender
abdomen without hepatosplenomegaly. Normal phallus. Left
testis palpated in the canal. Stable hip examination. Fair
perfusion and fair tone and activity for gestational age.
His birth weight was 1,100 grams (75th percentile); birth
length was 37 cms (75th percentile); head circumference 24
cms (25 percentile).
HOSPITAL COURSE: Neonatal Intensive Care Unit course by
systems: 1.) Respiratory status: The infant was initially
placed on IMV and required increasing support for oxygenation
and was changed to the high frequency ventilator. He had
several episodes during the day requiring hand bagging with
good response and being able to be placed back on the
ventilator. However, at approximately 12 hours of age, he had
significant desaturations requiring prolonged episodes of
hand bagging and despite several manipulations of the
ventilator and continued hang bagging, he was unable to be
oxygenated. He had progressive respiratory and metabolic
acidosis. His last arterial blood gas was pH of 7.21, PC02
of 41, P02 of 21, bicarbonate of 18 and base deficit of -12.
He also received two doses of surfactant. Chest x-ray two
hours prior to death showed nine rib expansion with flattened
diaphragm and homogenous hyaline membrane disease. No evidence
of pneumothorax.
2.) Cardiovascular status: The infant had progressive
hypotension. He required three normal saline boluses of 10
cc per kg each. He required Dopamine infusion, to a maximum
of 26 mcg/kg per minute and Dobutamine to a maximum of 10
mcg/kg per minute. He also received three infusions of sodium
bicarbonate for his metabolic acidosis.
On chest x-ray, he had a normal cardiothoracic silhouette.
3.) Fluids, electrolytes and nutrition: The infant had some
initial hypoglycemia which resolved with continuous
intravenous fluid. He had an umbilical arterial line, an
umbilical venous line placed. The tips of both lines were
approximately [**Company 5249**]-7. He was on intravenous fluids of 80 cc
per kg per day of parenteral nutrition and [**12-7**] normal saline.
His electrolytes at eight hours of age were sodium of 136;
potassium of 5.0; chloride of 106 and bicarbonate of 20. His
ionized calcium level was 1.09.
4.) Gastrointestinal: There were no issues.
5.) Hematology: The infant's hematocrit at the time of
admission was 44.5. A follow-up at ten hours of age was 42.
The infant did receive 15 cc per kg of packed red blood
cells. His platelets at the time of admission were 254. Ten
hours of age they were 136,000. The infant's blood type is
AB positive, DAT negative.
6.) Infectious disease: At the time of admission, the
infant's white blood cell count was 5.0 with a differential
of 30 polys and 0 bands. A follow-up complete blood count
done at 12 hours of age showed a white blood cell count of
1.2 with a differential of 16 polys and 32 bands and
nucleated red blood cells of [**Pager number **]. A blood culture drawn on
admission was growing gram negative rods.
The infant was started on ampicillin and gentamicin at the
time of admission.
7.) Neurology: No testing was completed during the infant's
Neonatal Intensive Care Unit stay.
8.) Psychosocial: The mother has been followed by [**Name (NI) **] [**Name (NI) **]
during her antepartum stay.
The infant was pronounced at 22:18 by Dr. [**Last Name (STitle) **]. The
primary pediatrician is Dr. [**First Name8 (NamePattern2) 15406**] [**Last Name (NamePattern1) 52014**] of [**Location (un) 1468**], MA.
DISCHARGE DIAGNOSES:
Extreme Prematurity, 26 and 5/7 weeks gestation.
Respiratory distress syndrome.
Hypotension.
Gram negative rod sepsis.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2103-6-27**] 02:47
T: [**2103-6-27**] 05:21
JOB#: [**Job Number 52015**]
ICD9 Codes: 769, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2533
} | Medical Text: Admission Date: [**2165-12-9**] Discharge Date: [**2165-12-15**]
Date of Birth: [**2096-2-29**] Sex: M
Service: CARDIOTHORACIC SURGERY
CHIEF COMPLAINT: Elective coronary artery bypass grafting.
PROCEDURE PERFORMED:
1. Coronary artery bypass graft time one, aortic valve
repair, mitral valve repair.
HISTORY OF PRESENT ILLNESS: This is a 69 year old Caucasian
male admitted with multiple episodes of congestive heart
failure with prior multiple admissions, all of which have
been medically managed. The patient had first episode of
congestive heart failure approximately three years ago
requiring hospitalization. The patient was subsequently
re-evaluated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for a potential coronary
artery bypass graft procedure.
The patient had a formal cardiac catheterization at the [**Hospital6 14475**] on [**2165-10-2**]. The patient
noted recent increased chest pain and increased dyspnea and
lightheadedness. An echocardiogram done at that time
demonstrated findings of severe aortic stenosis, and 80
millimeter aortic valve gradient and also moderate aortic
regurgitation.
The catheterization revealed significant two vessel coronary
artery disease, significant aortic and mitral valve disease.
There was 60% distal left anterior descending stenosis.
There was a 70% stenosis of the non-dominant right coronary
artery. There is evidence of one over two severe aortic
stenosis and moderate aortic regurgitation. There was
evidence of moderate mitral valve regurgitation. Ejection
fraction at that time was noted to be 58%.
PAST MEDICAL HISTORY:
1. Significant for congestive heart failure times two years,
2. Aortic stenosis.
3. Mitral valve regurgitation.
4. Status post percutaneous transluminal coronary
angioplasty and stent approximately five years ago.
5. Status post myocardial infarction.
6. Coronary artery disease.
7. Insulin dependent diabetes mellitus.
8. Status post appendectomy.
9. Status post partial gastrectomy.
10. Status post repair of umbilical hernia in [**11-22**]. Status post repair of ventral hernia.
12. Status post T4 and T5 surgical disc decompression and
disc fusion.
MEDICATIONS ON ADMISSION:
1. Gemfibrozil 600 mg p.o. twice a day.
2. Diltiazem 120 mg once a day.
3. Dilantin 100 mg four times a day.
4. Ranitidine 150 mg twice a day.
5. Furosemide 20 mg q. day.
6. Zocor 20 mg q. day.
7. Atenolol 25 mg q. day.
8. Glucotrol 2.5 mg q. day.
9. Klonopin 0.5 mg twice a day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a retired military and is
actually a construction worker. The patient states that he
lives alone. The patient has a remote tobacco use, quitting
approximately 20 years ago. Prior to that point, he smoked
five packs per day. The patient states he has occasional
alcohol use.
PHYSICAL EXAMINATION: The patient was afebrile; pulse 70;
blood pressure 140/60; weight 214 pounds. In general, he was
well appearing, slightly anxious but in no apparent distress.
HEENT: Mucous membranes were moist. Extraocular movements
intact. Neck examination was supple; no masses were
palpated. Lung examination clear to auscultation
bilaterally; no wheezes or rhonchi noted. Cardiac
examination is regular rate and rhythm with III-IV/VI
systolic ejection murmur noted at the left lower sternal
border. Abdominal examination: The patient is obese with
midline surgical scar, well healed. Positive bowel sounds,
soft, nontender, nondistended. Extremity examination with no
edema. Extremities were warm. Pulses were two plus femoral
pulse bilaterally and one plus posterior tibial and two plus
radial pulse bilaterally. There were no carotid bruits
noted.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. On [**2165-12-3**], the patient underwent a coronary
artery bypass graft times one / aortic valve repair / mitral
valve repair. The aortic valve was replaced using a 23
[**Last Name (un) 3843**] [**Doctor First Name **] tissue valve. The mitral valve ring
angioplasty was done using a #28 [**Doctor Last Name **] annuloplasty band
and the coronary artery bypass grafting was done with a
reverse saphenous vein graft from the aorta to the left
anterior descending coronary artery.
The patient tolerated the procedure well and there were no
complications during the case. The procedure was performed
by Dr. [**Name (STitle) **] and was assisted by Dr. [**Last Name (STitle) 14968**] and Dr.
[**Last Name (STitle) 14969**].
Postoperatively the patient was stable and was sent to the
CSRU on a dobutamine and propofol drip. The patient was
extubated on the same day of surgery. This was done without
any complications. Postoperative day number one, the patient
was weaned off of his dobutamine completely. The patient did
have an episode of bradycardia requiring pacing. He had an
underlying junctional rhythm of approximately 44 to 48 beats
per minute and he was able to maintain his blood pressure
with this rate without the need for further pressors.
The patient was weaned off his oxygen to two litres nasal
cannula and was able to maintain his oxygen saturation to
greater than 95%.
On [**12-12**], postoperative day two, the patient was
transferred out of the CSRU to the Floor. The patient was
doing quite well clinically, denying any chest pain,
shortness of breath, nausea, vomiting, or weakness. The
patient continued to have bradycardia with a junctional
rhythm.
The patient was seen by Cardiology for a full evaluation of
his bradycardia. The patient was determined to have a sinus
node dysfunction but remained asymptomatic with a stable
junctional escape rhythm. The patient was also seen by
Electrophysiology Service and it was determined that there
was no need for an immediate pacemaker placement. The
patient was placed on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Event Monitor.
On postoperative day number three, the patient continued to
do well and was tolerating clear liquids and was pacing
flatus. The patient's pain was well controlled with oral
medication and he had been out of bed and ambulating with
Physical Therapy.
On [**2165-12-13**], which is postoperative day number four,
the patient had his wires pulled and there were no
complications associated with this procedure.
Over the next couple of days, the patient continued with
improvement in his physical status progressing to walking
independently and being able to walk up and down stairs
without any difficulty.
The patient continued to remain in a junctional rhythm but
remained asymptomatic.
On postoperative day number six, the patient continued to do
well clinically. He was tolerating his diet without any
difficulty. Blood pressure maintained approximately at
120/60 although he was still in a junctional skip rhythm
approximately 40 to 60 beats per minute. The patient
remained asymptomatic. The pain was well tolerated on oral
pain medications.
There were no events recorded by the [**Doctor Last Name **] of Hearts Monitors.
As a result, the patient was discharged to home to follow-up
with his primary care physician in one to two weeks and the
Cardiothoracic Team in approximately four weeks.
DISPOSITION: The patient was discharged to home to
follow-up with his primary care physician in one to two
weeks.
The patient was instructed to follow-up with De. [**Doctor Last Name **]
in four weeks. The patient was also additionally instructed
to follow-up with his Cardiologist in six weeks.
DISCHARGE INSTRUCTIONS:
1. The patient was advised that he was allowed to shower but
not allowed to take a bath or swim for one month.
2. The patient was instructed not to apply lotions, cream,
ointments, or powders to his surgical incision.
3. The patient was also advised not to lift anything heavier
than ten pounds for one month.
4. The patient was instructed not to drive for one month.
5. The patient was also asked to return in three weeks for
removal of his staples.
6. The patient will be discharged with home nursing care for
medications, incision checks, vital sign monitoring.
DISCHARGE DIAGNOSES:
1. Status post mitral valve repair.
2. Status post aortic valve repair.
3. Status post coronary artery bypass graft times one.
4. Coronary artery disease.
5. Congestive heart failure.
6. Aortic stenosis.
7. Mitral regurgitation.
8. Status post percutaneous transluminal coronary
angioplasty with stent placement.
9. Noninsulin dependent diabetes mellitus.
10. Myocardial infarction.
11. Status post appendectomy.
12. Status post prostate surgery.
13. Neuropathy.
14. Status post partial gastrectomy for gastric ulcers.
15. Status post bilateral inguinal hernia repair.
16. Status post umbilical hernia repair.
17. Status post ventral hernia repair.
18. Status post C4, C5 disc-fusion.
19. Status post subdural hematoma approximately four years
ago.
20. Status post cerebrovascular accident at time of subdural
hematoma.
21. Status post lipoma removal.
MEDICATIONS ON DISCHARGE:
1. Furosemide 40 mg p.o. twice a day.
2. Potassium chloride 20 mg p.o. twice a day.
3. Colace 100 mg p.o. twice a day.
4. Ranitidine 150 mg p.o. twice a day.
5. Aspirin 325 mg p.o. q. day.
6. Percocet 5/325, one to two tablets p.o. q. four to six
hours p.r.n. pain.
7. Gemfibrozil 600 mg tablets, one tablet p.o. twice a day.
8. Simvastatin 20 mg tablets p.o. q. day.
9. Glipizide 2.5 mg p.o. q. day.
10. Clonazepam 0.5 mg p.o. twice a day.
11. Phenytoin 100 mg tablets p.o. four times a day.
12. Captopril 12.5 mg tablets p.o. three times a day.
CONDITION ON DISCHARGE: The patient is in stable condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 846**]
MEDQUIST36
D: [**2165-12-15**] 09:45
T: [**2165-12-15**] 20:14
JOB#: [**Job Number 14970**]
ICD9 Codes: 4280, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2534
} | Medical Text: Admission Date: [**2178-7-8**] Discharge Date: [**2178-7-11**]
Date of Birth: [**2101-10-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Abdominal pain, fever, chills
Major Surgical or Invasive Procedure:
ERCP
Right Internal Jugular Venous Central Line
History of Present Illness:
Mr. [**Known lastname 69523**] is a 76 year-old male with recent diagnosis of
pancreatic mass presumed to be cancer s/p biliary obstruction
with stent placement and sphincterotomy presented to the who
presented to the emergency department on [**2178-7-8**] with epigastric
pain, fever, chills and s/p fall. He denied nausea, vomiting,
diarrhea, chest pain.
On the morning of presentation, he had lost his balance while
using the toilet and hit the back on the toilet. He did not hit
his head. He denied dizziness but reported some shaking chills
and nausea. He went to an appointment with Dr. [**Last Name (STitle) **], his
oncologist, and was found to have a 101.3 fever in clinic and
was sent to the emergency department.
Mr [**Known lastname 69523**] was diagnosed in [**Month (only) 205**], when he started to notice
jaundice and have pruritus. He went to his PCP and [**Name Initial (PRE) **]/S was
performed the next day showing biliary obstruction. ERCP was
performed twice ([**6-8**] and [**6-25**]) and on [**6-25**] and obstruction was
relieved with a metal stent and pruritus resolved. He has had a
few biopsies but the samples have been inadequate. Thus, he
currently does not have a tissue diagnosis. He had been seen by
the surgeon, Dr. [**First Name (STitle) **] [**Name (STitle) **] and deemed not operatable
because his pancreatic head mass causing near complete
encasement and narrowing of the superior mesenteric vein and
abutting both the portal venous confluence, as well as the
duodenum.
.
Past Medical History:
Coronary atery disease s/p CABG
Porcine AVR
Bilateral carotid endarterectomies
Cataracts
Pancreatitis in [**2175**]
GERD
HTN
"Irregular heartbeat"
Social History:
Lives at home with his wife. [**Name (NI) **] six children that live
locally. Retired employee for GE. Prior smoker (100 pack year
history) but quit 5 years prior. Previously drank [**2-1**]
beers/night but has not drunk over the past month.
Family History:
Mother had jaundice and possibly cancer in her 70s
Physical Exam:
Physical Exam Documented On Admission:
Vital Signs: 99.3 76 136/48 17 100% on 2L NC
Weight: 144 Lbs, Height: 66 Inches, BMI: 23.2 kg/m2,
general: pleasant elderly male with mild jaundice in NAD
Head: Non-traumatic, no lesion
HEENT: PERRLA, EOMI, MMM, no thrush. Conjuctiva pale and with
mild jaundice
Neck: Supple, FROM
LN: no cervical, submandibular, supraclavicular LAD
Lungs: clear bilaterally, no wheezes or rubs
Cardiac: RRR, nl S1/S2, no m/r/g.
Abd: soft, NT, ND, no hepatosplenomegaly, nl BS, no ascites
CNS: CN nl, A&O x3, no asterixis
Ext: no edema, no rash, no [**Location (un) **] erythema
Skin: mild jaundice down to mid abdomen
Pertinent Results:
[**2178-7-8**] 11:32PM GLUCOSE-153* UREA N-7 CREAT-0.6 SODIUM-141
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-23 ANION GAP-14
[**2178-7-8**] 10:09PM COMMENTS-GREEN TOP
[**2178-7-8**] 10:09PM LACTATE-1.3
[**2178-7-8**] 10:09PM HGB-11.9* calcHCT-36 O2 SAT-92
[**2178-7-8**] 09:10PM COMMENTS-GREEN TOP
[**2178-7-8**] 09:10PM LACTATE-1.3
[**2178-7-8**] 09:10PM O2 SAT-93
[**2178-7-8**] 08:13PM COMMENTS-GREEN TOP
[**2178-7-8**] 08:13PM LACTATE-1.2
[**2178-7-8**] 07:51PM PT-14.1* PTT-24.7 INR(PT)-1.2*
[**2178-7-8**] 07:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2178-7-8**] 07:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2178-7-8**] 05:55PM GLUCOSE-104 UREA N-8 CREAT-0.8 SODIUM-132*
POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-27 ANION GAP-15
[**2178-7-8**] 05:55PM estGFR-Using this
[**2178-7-8**] 05:55PM ALT(SGPT)-50* AST(SGOT)-84* LD(LDH)-279* ALK
PHOS-367* AMYLASE-68 TOT BILI-2.3*
[**2178-7-8**] 05:55PM LIPASE-192*
[**2178-7-8**] 05:55PM ALBUMIN-2.9* CALCIUM-8.8 PHOSPHATE-3.0
MAGNESIUM-1.8
[**2178-7-8**] 05:55PM CORTISOL-41.8*
[**2178-7-8**] 05:55PM CRP-14.0*
[**2178-7-8**] 05:55PM WBC-21.2* RBC-4.37* HGB-13.7* HCT-37.8*
MCV-87 MCH-31.4 MCHC-36.3* RDW-16.7*
[**2178-7-8**] 05:55PM NEUTS-82.6* LYMPHS-12.6* MONOS-4.5 EOS-0.1
BASOS-0.2
[**2178-7-8**] 05:55PM PLT COUNT-306
[**2178-7-8**] 05:52PM COMMENTS-GREEN TOP
[**2178-7-8**] 05:52PM LACTATE-2.3*
Sinus rhythm with ventricular premature depolarizations.
Compared to
previous tracing ventricular ectopic activity is now evident.
Otherwise,
no major change.
Sinus bradycardia. Compared to previous tracing cardiac rhythm
is now
sinus mechanism. Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 [**Telephone/Fax (3) 73398**]/462.85 91 -46 -34
TRACING #2
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**]
Brief Hospital Course:
Mr. [**Known lastname 69523**] is a 76 year-old man with new pancreatic mass seen
int he emergency department for fever, epigastric pain, nausea
and chills.
.
1) Sepsis/ Cholangitis: In the emergency department, he was
hypotensive to the 70s systolic despite 4L IVF and his WBCs were
found to be 21. Lactate was initially 2.3. Sepsis code was
called, and he was given levophed. A central line was placed
for administration of fluids after which time his blood pressure
improved to 127/4. He was started empirically on Flagyl and
Levoquin for cholangitis and he was subsequently transferred to
the Medical Intensive Care Unit. After his transfer, he was
afebrile and his blood pressure remained stable with a systolic
blood pressure on the low 100s. He was started on ampicillin to
cover for enterococcus.
An ERCP was performed which revealed a previously placed
biliary metal stent whic was blocked with debris and sludge.
Cannulation of the metal stent in biliary duct was performed and
the sludge and debris were extracted successfully using a 8.5 mm
balloon. A 10 cm by 10 Fr plastic biliary stent was placed
successfully into the metal stent. Bile flow was seen. The
gastroenterology clinic will call Mr. [**Known lastname 69523**] to schedule a
follow-up ERCP for stent removal. He was transferred to the
floor on [**2178-7-10**] and he continued to remain afebrile and
normotensive. He was switched to oral antibiotics and
discharged with a two week course.
.
2) Pancreatic Mass- No tissue diagnosis has been obtained at
this point. Previous FNA biopsies have been unrevealing and
current metal stent preclues a biopsy with subsequent ERCP. Mr.
[**Known lastname 69523**] is followed by Dr. [**Last Name (STitle) **]. He has been seen by surgeon
Dr. [**First Name (STitle) **] [**Name (STitle) **] who deemed the mass unresectable on the
basis of CT findings of a pancreatic head mass causing near
complete encasement and narrowing of the superior mesenteric
vein and abutting both the portal venous confluence, as well as
the duodenum. Mr. [**Known lastname 69523**] has an appointment with radiation
oncology to determine if cyberknife is possible to be used in
conjunction with chemotherapy with a curative intent. He will
subsequently follow-up in oncology clinic with Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) **] to determine chemotherapy options.
.
3) Atrial Fibrillation- Mr. [**Known lastname 69523**] has intermittent atrial
fibrillation during this hospitalization. His metoprolol was
initially witheld due to hypotension but was restarted upon
transfer to the floor. He did have episodes tachycardia to 120s
prior to starting metoprolol. He was continued on his home
digoxin and a level was found to be 0.4mg. He was discharged on
his previous home regimen on metoprolol and digoxin.
Also, given his paroxysmal atrial fibrillation during this
admission and his presumed hypercoagulability due to pancreatic
cancer, Mr. [**Known lastname 69523**] was started on Lovenox to be continued after
discharge. Lovenox was chosen in favor of Coumadin given that
it may be more easily discontinued prior to diagnostic
procedures. He was advised to follow-up with Dr. [**Last Name (STitle) **] for
further management of anticoagulation.
.
4) Hyperglycemia - Fingersticks have ranged during his
admission between 122-211. [**Month (only) 116**] be due to pancreatic mass. He
was advised to follow-up with his primary care provider [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] to further evaluate hyperglycemia.
.
5) s/p Fall- This fall was thought to be due to weakness in the
setting of his sepsis.
Medications on Admission:
Lisinopril 10mg PO qday
Toprol 25 mg PO qday,
Digoxin 0.25 mg PO qday
Meclizine 25mg PO QID.
Discharge Medications:
1. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO QID (4 times
a day).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks: Continue taking until [**2178-7-22**].
[**Month/Day/Year **]:*28 Tablet(s)* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks: Continue taking until [**2178-7-22**].
[**Month/Day/Year **]:*90 Tablet(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
[**Month/Day/Year **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 2 weeks: Continue taking until [**2178-7-22**].
[**Month/Day/Year **]:*112 Capsule(s)* Refills:*0*
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: 0.7 ml Subcutaneous [**Hospital1 **]
(2 times a day): Please continue this medication until otherwise
directed by your doctor.
[**Last Name (Titles) **]:*60 syringes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Sepsis
Cholangitis
Pancreatic Mass
Elevated Blood Sugar
Paroxysmal Atrial Fibrillation
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for fever, abdominal pain, near loss of
consciousness, and nausea and were found to have very low blood
pressure. You were thought to have sepsis (Systemic infection)
from an infection in your bile ducts. You were admitted to the
intensive care unit and started on medications to control your
blood pressure. You were given antibiotics. You had an ERCP
which showed blockage in the stent in your bile duct. This
blockage was drained and a smaller plastic stent was placed.
Gastroenterology will call to you to schedule a follow-up
appointment for possible removal of this stent.
You should continue taking antibiotics to complete a 2 week
course on [**2178-7-22**].
Also, you were noted to have elevated blood sugar (up to
180-200) during your admission. You should follow-up with Dr.
[**Last Name (STitle) **] about this because this could be a sign that you are
developing diabetes.
The following medications were started: Ciprofloxacin 500mg by
mouth twice a day, Metronidazole 500mg by mouth 3 times a day,
ampicillin 250mg by mouth every 6 hours. These are anitbiotics
that should be taken until [**2178-7-22**].
You were also started on the blood thinner Lovenox 70mg
injection twice a day. You should take this medication until
otherwise directed by your doctors.
You should call your doctor or go the emergency room if you have
fever, chills, nausea, vomiting, abdominal pain, diarrhea,
dizziness, lightheadedness, loss of consciousness or any other
symptoms that concern you.
Followup Instructions:
You should attend your appointment on [**2178-7-22**] with Radiation
Oncology at 10:00 AM. ([**Telephone/Fax (1) 8082**]
You should attend your appointment with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] on
[**2178-7-29**] at 2:00pm Phone:[**Telephone/Fax (1) 22**]
You should follow-up with Dr. [**Last Name (STitle) **] as soon as possible. Please
call to make an appointment.
ICD9 Codes: 5990, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2535
} | Medical Text: Admission Date: [**2187-8-17**] Discharge Date: [**2187-8-25**]
Date of Birth: [**2131-3-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
[**Last Name (un) **]-utero fistula
Major Surgical or Invasive Procedure:
[**8-17**]: Exploratory laparotomy, extensive lysis of
adhesions, low anterior resection with colorectal
anastomosis, rigid sigmoidoscopy, retracted colostomy
takedown and loop ileostomy formation, and bilateral ureteral
stents.
1. Exploratory laparotomy
2. Extensive lysis of adhesions
3. Low anterior resection with colorectal anastomosis
4. Rigid sigmoidoscopy
5. Retracted colostomy takedown
6. Loop ileostomy formation
7. Cystoscopy with placement of bilateral open-ended ureteral
catheters.
History of Present Illness:
56 yo F with multiple medical issues presents to the [**Hospital1 18**] for
surgical treatment of persistent colouterine fistula
demonstrated on enema study. Medical issues are listed in the
past medical history section of this document.
Past Medical History:
Afib with RVR on coumadin
LV dysfunction with CHF (EF 45-50%)
asthma with restrictive lung disease
R upper lobe nodule
CRI
Morbid obesity (lost 115lbs)
osteoarthritis with osteopenia
Charcot deformity of the r foot
urosepsis
.
PSH:
coloureteral fistula s/p diverting loop colostomy ([**11-27**])
Foot surgery to repair right charcot deformity
Left hip replacement ([**4-28**])
Social History:
Patient [**3-25**] ppd smoker, also drinks 2-3 vodka's per day until
recently. Reports being off tob/etoh since at rehab
Family History:
NC
Physical Exam:
Height: 5'6", weight: 182lb
VS: 97.0po, 93/59, 80, 16, 97RA
Gen: alert and oriented, no acute distress
CV: Afib, hemodynamically stable
Pulm: slight crackles on right side
Abd: soft, nontender, non-distended
Ext: no c/c/e
Pertinent Results:
Admission Labs
[**2187-8-17**] 08:53PM GLUCOSE-153* UREA N-23* CREAT-1.1 SODIUM-141
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-26 ANION GAP-11 CALCIUM-9.0
PHOSPHATE-4.2 MAGNESIUM-1.3* WBC-10.9# RBC-3.75* HGB-11.2*
HCT-33.5* MCV-89 MCH-29.8 MCHC-33.4 RDW-14.8 NEUTS-89.7* BANDS-0
LYMPHS-7.7* MONOS-2.0 EOS-0.5 BASOS-0.2 PLT COUNT-260 PT-14.9*
INR(PT)-1.3* PH-7.35 GLUCOSE-123* LACTATE-0.9 K+-3.6 HGB-9.1*
calcHCT-27 freeCa-1.21 GLUCOSE-110* LACTATE-1.1 K+-3.5
HGB-9.1* calcHCT-27
.
[**2187-8-17**] 8:55 PM CHEST PORT. LINE PLACEMENT
IMPRESSION: Interval placement of right internal jugular line
and nasogastric tube. No evidence of acute cardiopulmonary
process.
.
[**2187-8-18**] ECHO
Conclusions:
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
estimated right atrial
pressure is 5-10 mmHg. Left ventricular wall thickness, cavity
size, and
systolic function are normal (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes and global
systolic function. Mild mitral regurgitation. Mildly dilated
ascending aorta.
.
PATHOLOGY REPORT SPECIMEN SUBMITTED: PELVIC WALL SCAR,
RECTOSIGMOID DONUT [**2187-8-22**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/nbh
DIAGNOSIS:
I. Soft tissue, pelvic wall scar (A):
Dense fibrous tissue with mucin and calcification.
No epithelium or tumor seen.
II. Colon, rectosigmoid donuts (B-J):
Two segments of colon with peritoneal fibrous adhesions.
Keratinized squamous epithelium with focal active inflammation
consistent with colostomy stoma.
No tumor.
.
Digoxin: [**2187-8-19**] 03:32AM BLOOD -1.4, [**2187-8-20**] 11:47AM -1.1,
[**2187-8-24**] 07:35AM -1.0
.
COAGULATION RESULTS
[**2187-8-17**] 08:53PM BLOOD PT-14.9* INR(PT)-1.3*
[**2187-8-18**] 02:41AM BLOOD PT-13.7* INR(PT)-1.2*
[**2187-8-18**] 11:31AM BLOOD PT-14.5* PTT-28.0 INR(PT)-1.3*
[**2187-8-19**] 03:32AM BLOOD PT-18.2* PTT-35.9* INR(PT)-1.7*
[**2187-8-21**] 03:19AM BLOOD PT-16.8* PTT-35.8* INR(PT)-1.5*
[**2187-8-22**] 04:49AM BLOOD PT-18.2* PTT-30.7 INR(PT)-1.7*
[**2187-8-23**] 06:27AM BLOOD PT-25.6* PTT-34.5 INR(PT)-2.6*
[**2187-8-24**] 07:35AM BLOOD PT-20.6* INR(PT)-2.0*
.
DISCHARGE LABS:
Brief Hospital Course:
HD#1 POD #0 s/p explorator laparotomy with LOA, colostomy
takedown, LAR, loop ileostomy. Operative findings included
multiple fistulae in the pelvis to the uterus. Received 4500 CC
of crystalloid during the operation, with 260 u/o.
HD#2 Unable to meet PACU criteria for transfer to floor due to
low urine output, not responding to 500c fluid bolus for low
urine output. Attending notified, levophed was started,
Swan-Ganz catheter was placed, one unit of PRBC was transfused,
and the patient was transferred to the care of the SICU with a
CVP of 15-16
HD#3 Throughout the day the patient had her heart rate
maintained by use of lopressor, with levophed ordered to
maintain MAP > 65 with minimal O2 requirements. Maintaining
appropriate urine output was obtained by provided IV hydration.
Evidence of good peripheral perfusion was evident. The patient
had started to mobilize fluid and diurese much third-space
fluid.
HD#4 The patient's NG tube ouput was reduced, and the tube was
clamped. Antibiotics were stopped, a central venous line was
placed, and the patient's oxygenation requirement was maintained
by 2 liters of O2, delivered by nasal cannula. The patients
ostomy appliance had leaked into the midline wound; the wound
was cleaned in the OR, with a new ostomy appliace reseated.
The patient was weaned off levophed, and her labs improved
substantially. Diuresis was assisted by two doses of lasix that
day.
HD#5 The patient had done well overnight, NG tube was d/c'ed.
Her pain was controlled by PCA. She was transferred to the
floor, her diet was advanced to clears, and she was started on
her home lasix dose. Her respiratory status improved
substantially, and she was tolerating Room Air appropriately.
PT evaluation was obtained for evaluation after her ICU course.
HD#6 The patient tolerated liquid diet on the floor, her wound
appeared erythematous with stable cellulitis, and she showed
excellent improvement otherwise, including increased ostomy
function (amount + flatus). PT assisted the patient in stair
training for dispo home. Cefazolin was started for the stable
cellulitis
HD #7 The patient was able to void independently without
difficulty, the wound demonstrated decreased erythema on the
Cefazolin. Ostomy nurse was on board to make sure the patient
had an improved device that would least hamper her home care.
She was able to tolerate oral pain medication without
difficulty.
HD #8 The patient had very minimal erythema of the wound area,
her operative drains were removed, and VNA services were set up
for her. She was ambulating independently without difficulty,
and tolerating an appropriate diet.
HD #9 The patient was stable for discharge: PCP was informed
regarding the patient
s need for an INR check after her hospital stay, her wound was
treated with outpatient Keflex and dressing (Aquacel AG [**Hospital1 **]) per
wound care nursing. Given her excellent improvement during her
hospital stay, she was discharged home with VNA services.
Medications on Admission:
Digoxin 250 mcg po daily
Lasix 20mg po daily
Lopressor 25mg po daily
Wellbutrin 150mg po twice daily
Coumadin 7.5mg po daily
Seroquel prn - Insomnia
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 5
days: Please take every day at 6pm.
Disp:*5 Tablet(s)* Refills:*0*
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
4 weeks: to prevent constipation while taking narcotic pain
medication.
Disp:*56 Capsule(s)* Refills:*0*
7. Keflex 250 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
8. Outpatient Lab Work
Please check INR on Monday
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1411**] VNA/[**Company 1519**] Phone
Discharge Diagnosis:
Colouterine fistula
Discharge Condition:
Good
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.
Activity: No heavy lifting of items [**11-5**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications except for your
coumadin. You need to take your new prescription of coumadin
and do as directed. You will also need to follow up in [**Hospital 197**]
clinic and check your INR on Monday. 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:
PCP is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13075**], P: [**Telephone/Fax (1) 19980**], address [**First Name8 (NamePattern2) 69511**]
[**Location (un) 620**], [**State 350**]. You are to follow-up for INR lab draw on
Monday [**2187-8-27**]. You should have your INR checked 2x weekly.
1. Please follow up with Dr. [**First Name (STitle) 2819**]. Call ([**Telephone/Fax (1) 6347**] to make
an appointment.
2. Need to get blood drawn on Monday [**8-27**] to check INR.
3. Need to follow up with your primary care physician in the
next week. Call [**Telephone/Fax (1) 68961**].
ICD9 Codes: 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2536
} | Medical Text: Admission Date: [**2158-7-13**] Discharge Date: [**2158-8-31**]
Date of Birth: [**2092-6-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Pancytopenia
Major Surgical or Invasive Procedure:
Subclavian central venous catheter placement and removal
Bone marrow biopsies
- Right subclavian triple lumen central venous catheter
placement and removal
- Bone marrow biopsies (three)
- Lumbar puncture and intrathecal methotrexate
History of Present Illness:
66yo M w/ PMH s/f HTN, seasonal allergies, osteoarthritis s/p L
TKA and R THA who is transferred from outside hospital with
pancytopenia, recent weight loss (semi-intentional), and found
to have blasts on peripheral smear by OSH hematologist. He
reports feeling mostly well prior to admission. He developed
headache last weekend that he felt was related to his sinuses,
given his h/o seasonal allergies. He then developed a sore
throat earlier this week. He went to the VA to be evaluated for
possible sinusitis/URI and CBC was checked which revealed WBC of
1.8. He was referred to OSH for further management. He was
evaluated in the ED and a hematologist was consulted who
examined the peripheral smear. Smear showed 50% lymphocytes, 28%
blasts, 2% metamyelocytes, 5% NRBCs. No clear cut Auer rods but
some blasts with significant granularity. Patient was transfused
2u PRBCs, started on allopurinol, 1/2NS w/ bicarb and K at OSH
and transferred here for further diagnostic workup. Of note, pt.
travels often to West Coast and spent 10 weeks in [**State 15946**] this
spring, returning [**2158-2-23**]. He reports allergic symptoms and
lots of dust. Also of note, pt. reports trying to lose weight
recently with 9-10lb weight loss in last 1-2 months. Denies
fever, chills, night sweats, fatigue, unintentional weight loss,
lymphadenopathy. Denies rash, joint pain, nausea, vomiting,
productive cough, diarrhea, BRBPR, melena.
Past Medical History:
Osteoarthritis, s/p L TKA, R THA
h/o negative colonoscopy-last [**2154**]
Hypertension
Seasonal Allergies
GERD
Social History:
Never married, no children. Lives alone. Retired fireman.
U.S.M.C. veteran. Denies ever smoking, no EtOH, no illicits.
Travelled to [**State 15946**] for 10 weeks, returning 4/[**2157**].
Family History:
Thinks he had an uncle w/ liver cancer. Father died of AAA,
mother of ?CHF. Multiple family members w/ CVA as cause of
death. No known h/o hematologic malignancies.
Physical Exam:
VS: 99.4 132/90 115 18 94%RA 231lbs
Gen: alert, anxious M appearing stated age in NAD
HEENT: NC/AT, PERRL, EOMI, OP w/o exudate/erythema, MM moist, no
oral lesions, good dentition, no scleral pallor
Neck: supple, no submental, submandibular, supraclavicular,
ant/post cervical, pre/post auricular LAD
Skin: No rash, well healed vertical incision over L knee,
bandaid over L chest
Cor: Tachycardic but regular, no murmurs/rubs/gallops, +S1/S2
Lungs: CTAB, good air entry b/l, no rales/rhonchi/wheezes
Abd: slightly firm, nontender, nondistended, +BS, no
hepatosplenomegaly, no rebound or guarding
Extremities: warm, no clubbing or edema, +onychomycosis on all
toenails
Pertinent Results:
Admission Labs:
[**2158-7-13**] 05:48PM BLOOD WBC-2.3* RBC-3.69* Hgb-10.5* Hct-31.8*
MCV-86 MCH-28.4 MCHC-32.9 RDW-17.1* Plt Ct-30*
[**2158-7-13**] 05:48PM BLOOD Neuts-16* Bands-1 Lymphs-20 Monos-0 Eos-2
Baso-0 Atyps-1* Metas-0 Myelos-0 Blasts-60* NRBC-5* Other-0
[**2158-7-13**] 05:48PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+
Ovalocy-2+
[**2158-7-13**] 05:48PM BLOOD PT-13.2 PTT-24.6 INR(PT)-1.1
[**2158-7-13**] 05:48PM BLOOD Fibrino-665*
[**2158-7-21**] 12:04AM BLOOD Fibrino-607*
[**2158-7-14**] 03:30PM BLOOD ESR-45*
[**2158-7-17**] 12:00AM BLOOD Gran Ct-163*
[**2158-7-13**] 05:48PM BLOOD Glucose-102* UreaN-25* Creat-1.0 Na-141
K-4.4 Cl-102 HCO3-31 AnGap-12
[**2158-7-13**] 05:48PM BLOOD ALT-47* AST-37 LD(LDH)-396* AlkPhos-125
TotBili-1.1
[**2158-7-13**] 05:48PM BLOOD Albumin-4.3 Calcium-9.6 Phos-4.3 Mg-2.1
UricAcd-5.2
[**2158-7-14**] 06:00AM BLOOD TSH-1.5
[**2158-7-14**] 06:00AM BLOOD [**Doctor First Name **]-NEGATIVE
.
Discharge Labs:
.
Pathology:
[**7-13**] Flow cytometry:
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD2, CD3, CD4,
CD5, CD7, CD8, CD10, CD13, CD14, CD15, CD19, CD20, CD33, CD34,
CD41, CD11c, CD56, CD64, HLA-DR, KAPPA, LAMBDA, CD71, GlycA,
CD45, CD117.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast yield.
An abnormal population of events cluster within the blast gate.
They comprise of approximately 37% of all events. These 'blasts'
express CD7, CD34, CD13 (dim), CD33, CD11c(dim) and CD71. CD19
expression is equivocal. They are negative for CD20, CD10, CD3
(and other T-cell markers except CD7), CD64, CD14 and CD56.
Lymphoid gated events are unremarkable.
INTERPRETATION
Increased blasts with predominantly myeloid markers, consistent
with acute myeloid leukemia. Morphological review shows blasts
(~58%) with high N:C ratio, rare Auer rods, scant paucigranular
cytoplasm, irregular nuclear contours, and open chromatin.
Findings discussed with Dr. [**Last Name (STitle) **] on [**2158-7-14**].
.
- [**7-14**] Bone Marrow: By morphology and immunophenotype, the
blasts appear to be of early myeloid differentiation (FAB M1-2).
However, cytogenetics and other molecular findings are necessary
and should be correlated for an appropriate current WHO based
classification.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are
decreased in number and are normochromic and normocytic with
mild anisopoikilocytosis. Occasional ovalocytes, dacrocytes and
polychromatophilic cells seen, 2 nucleated RBCs, 100 nucleated
cells seen. The white blood cell count appears decreased.
There is a predominance of large, immature forms with high
nuclear cytoplasm ratio, scant agranular cytoplasm, prominent
nucleoli and fine chromatin consistent with blast forms. Rare
Auer rod identified. Platelet count appears decreased. Large
forms are seen. Giant forms are not present. Differential
shows 6% neutrophils, 0% bands, 0% monocytes, 28%
lymphocytes, 2% eosinophils, 0% basophils, 63% blasts seen.
- Aspirate Smear:
The aspirate material is adequate for evaluation. The M:E ratio
is 1.9:1. Erythroid precursors show normoblastic maturation
with occasional megaloblastoid forms, irregular nuclear
contours, and rare nuclear buds. Myeloid precursors consist of
a predominance of blast forms. Megakaryocytes are present in
decreased numbers; abnormal forms are seen and include small
hypolobated forms. Differential shows: 62% Blasts, 0%
Promyelocytes, <1% Myelocytes, 0% Metamyelocytes, 0%
Bands/Neutrophils, <1% Plasma cells, 3% Lymphocytes, 33%
Erythroid.
Blasts comprise 62% of the aspirate and are large with fine
chromatin, prominent nucleoli and scant cytoplasm.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation. Prominent
aspiration artifact is present. The overall cellularity of ~
70% with 80% blasts. The M:E ratio estimate is normal.
Erythroid precursors are decreased and exhibit normoblastic
maturation. Myeloid elements are decreased and consist of
predominantly blasts, without maturing hematopoiesis.
Megakaryocytes are markedly decreased.
Marrow clot section is similar to the biopsy.
Special Stains:
Iron stain is adequate for evaluation. Storage iron is normal.
Sideroblasts are present. Ringed sideroblasts are absent.
.
- [**7-14**] Cytogenetics: KARYOTYPE: 46,XY[20]
INTERPRETATION:
No cytogenetic aberrations were identified in 20
metaphases analyzed from this unstimulated specimen.
This normal result does not exclude a neoplastic
proliferation.
Mosaicism and small chromosome anomalies may not be
detectable using the standard methods employed.
-------------------INTERPHASE FISH ANALYSIS, 100-300
CELLS-------------------
nuc ish(D5S23,D5S721,EGR1)x2[100],(D7Z1,D7S522)x2[100],
(D20S108x2)[100]
FISH evaluation for a 5q deletion was performed with the
Vysis LSI EGR1/D5S23, D5S721 Dual Color Probe ([**Doctor Last Name 7594**]
Molecular) for EGR1 at 5q31 and D5S721/D5S23 at 5p15.2 and
is interpreted as NORMAL. Two EGR1 hybridization signals
were observed in 100/100 nuclei examined, which is within
the normal range established for this probe in the
Cytogenetics Laboratory at [**Hospital1 18**]. Up to 3% of cells in
normal samples can show apparent 5q deletion using this
probe set. A normal EGR1 FISH finding can result from
absence of a 5q deletion, from a 5q deletion that does not
involve the region to which this probe hybridizes, or from
an insufficient number of neoplastic cells in the specimen.
FISH evaluation for a 7q deletion was performed with the
Vysis D7S522/CEP7 Dual Color Probe ([**Doctor Last Name 7594**] Molecular) for
D7S522 at 7q31 and CEP7 (D7Z1) (chromosome 7 alpha
satellite DNA) at 7p11.1-q11.1 and is interpreted as
NORMAL. Two D7S522 hybridization signals were observed in
100/100 nuclei, which is within the normal range
established for this probe in the Cytogenetics Laboratory
at [**Hospital1 18**]. Up to 3% of cells in normal samples can show
apparent 7q deletion using this probe set. A normal
D7S522 FISH finding can result from the absence of a 7q
deletion, from a 7q deletion that does not involve the
region to which this probe hybridizes, or from an
insufficient number of neoplastic cells in the specimen.
FISH evaluation for a 20q deletion was performed with the
Vysis LSI D20S108 Probe ([**Doctor Last Name 7594**] Molecular) at 20q12 and is
interpreted as NORMAL. Two hybridization signals were
observed in 98/100 nuclei examined, which is within the
normal range established for this probe in the Cytogenetics
Laboratory at [**Hospital1 18**]. Up to 8% of cells in normal samples
can show apparent 20q deletion using this probe set. A
normal 20q FISH finding can result from absence of a 20q
deletion, from a 20q deletion that does not involve the
region to which this probe hybridizes, or from an
insufficient number of neoplastic cells in the specimen.
.
Bone marrow [**2158-7-27**]: Peripheral Blood Smear:
The smear is adequate. Erythrocytes are decreased and exhibit
moderate anisocytosis and poikilocytosis. Scattered microcytes,
echinocytes, elliptocytes, dacrocytes and red cell fragments are
seen. Rare shistocytes are seen on scanning. The white blood
cell count appears markedly decreased and includes large
immature myeloid forms consistent with blasts. Lymphocytes
include small mature and large reactive forms. Platelet count
appears moderately decreased. Large forms are seen. Differential
count shows 0% neutrophils, 0% bands, 4% monocytes, 89%
lymphocytes, 0% eosinophils, 7% blasts.
Aspirate Smear: The aspirate material is adequate for evaluation
and is predominantly comprised of large atypical myeloid forms
with one to several prominent nucleoli consistent with blasts.
Erythroid precursors are markedly decreased. Rare maturing forms
are present. Maturing myeloid precursors are greatly decreased
in number. Megakaryocytes are present in normal numbers.
Differential (300 cells) shows: 72% Blasts, 2% Promyelocytes,
<1% Myelocytes, <1% Metamyelocytes, <1% Bands/Neutrophils, 3%
Plasma cells, 18% Lymphocytes, 5% Erythroid.
Clot Section and Biopsy Slides: The biopsy material is adequate
for evaluation. The overall cellularity is approximately 40% and
is comprised almost entirely of large blast forms present in
large clusters. The blasts comprise 70-80% of overall marrow
cellularity. The remainder of the cellular components are made
up of lymphocytes, plasma cells and rare maturing myeloid and
erythroid precursors. Megakaryocytes are present.
.
- Bone marrow [**2158-8-16**]: <<<< >>>
.
Imaging:
- [**7-14**] TTE: The left atrium is elongated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. 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. There is no mitral
valve prolapse. No mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Biatrial dilation.
.
- [**7-14**] CXR: No previous images. There is some apparent
hyperexpansion of the
lungs suggesting some chronic pulmonary disease. However, no
evidence of
acute pneumonia, vascular congestion, or pleural effusion.
Right subclavian PICC line extends to the mid portion of the
SVC. No evidenceof pneumothorax.
.
- [**7-20**] CXR: Aside from atelectasis in the left base the lungs
are clear. There are low lung volumes. Cardiomediastinal
contours are normal. Right PICC tip is in the mid SVC.
.
- [**7-24**] CT Chest w/o con: 4.5-mm right lower lobe nodule. Suggest
repeat examination in six months.Multifocal subsegmental
atelectasis, not obstructive. Coronary calcification.
.
- [**2158-7-28**] CT chest/abd/pelvis: No abnormal interstitial lung
process or site of infection identified. Interval increase in
number of mediastinal nodes extensively, but no single
pathologically enlarged lymph node.
.
- [**2158-7-30**] CTA chest: 1. Limited CT examination due to respiratory
artifact. No proximal or segmental pulmonary emboli identified.
More distal branches obscured due to poor filling and breathing
artifact. If a high clinical concern for embolus, a dedicated
V/Q scan could be obtained if patient is able to tolerate as the
lungs. Slightly increased linear atelectasis. 2. Unchanged small
mediastinal lymph nodes of uncertain etiology. 3.
Atherosclerotic calcification within the coronary vessels.
Small-to-moderate hiatal hernia. 4. Stable right-sided pulmonary
nodules as detailed above; can be followed in six months as
suggested on initial [**2158-7-24**] CT chest.
.
- [**2158-8-15**] CT abdomen/pelvis: Mild delayed right nephrogram with
high-density filling defect within the posterior calices of the
right upper pole, most consistent with underlying clot. There is
mild right hydronephrosis and proximal-mid hydroureter with
abrupt cutoff of contras column in the mid-distal ureter. This
may reflect more distal intraureteral clot, although a focal
obstructing lesion cannot be
completely excluded. Can consider correlation with follow up CT
or further
evaluation with dedicated MR urogram or ureteroscopy as needed.
-[**2158-8-16**] Bone marrow biopsy: MARKEDLY HYPOCELLULAR BONE MARROW
WITH FEATURES CONSISTENT WITH CHEMOTHERAPY-INDUCE MARROW
ABLATION. THERE IS NO MORPHOLOGIC EVIDENCE OF INVOLVEMENT BY
ACUTE MYELOID LEUKEMIA.
-[**2158-8-23**] Renal u/s: Mild to moderate right and mild left
hydronephrosis.
-[**2158-8-24**] MRI C and T spine, brachial plexus: No abnormal
cervical or thoracic spine enhancement. Limited study by
motion, but grossly normal MR appearance of the brachial plexus
bilaterally.
-[**2158-8-26**] CT chest w/o contrast: Redemonstration of tiny
pulmonary nodules as detailed above, the largest of which is
approximately 5 mm. Would recommend repeat evaluation with a
dedicated CT of the chest in approximately six months.
-[**2158-8-27**] Bone marrow biopsy: Hypocellular marrow with erythroid
dominant elements. Diagnostic features of involvement by acute
myeloid leukemia are not seen, By immunohistochemical stains,
CD34 reactive blasts comprised <5% of overall marrow
cellularity. E-cadherin expression is present in scattered
clusters of early erythroid precursors, while Glycophorin A
highlights numerous maturing erythroid forms.
-[**2158-8-28**] Urine cytology: Rare cluster of atypical but
degenerated urothelial cells.
Brief Hospital Course:
66yo M w/ unrelated PMH presented to OSH, found to have
pancytopenia w/ blasts in smear, transferred and found to have
AML on flow cytometry and bone marrow biopsy.
.
# AML: Patient was admitted and found to be pancytopenic but
asymptomatic except a chronic non-productive cough that was
attributed to seasonal allergies. He underwent TTE which showed
normal LVEF. He underwent bone marrow biopsy on [**7-14**] which
confirmed diagnosis of AML. A triple lumen subclavian CVL was
placed on [**7-14**]. He was started on 7+3 induction therapy on [**7-14**].
He tolerated the infusion well and his ANC fell to 0 on [**7-22**]. He
was thrombocytopenic and developed gingival bleeding with PLT in
the 30s and was transfused as needed. He was also anemic and
transfused as needed. Repeat bone marrow showed
hypercellularity. Patient was started on MEC therapy and
tolerated it well. His ANC remained 0. Repeat bone marrow on D14
of MEC showed hypocellularity. His counts gradually increased
and antibiotics were discontinued, he had been on broad coverage
with vancomycin, cefepime, and ambisome (spent a lot of time in
[**State 15946**]) and remained on these antibiotics until he was no
longer neutropenic or febrile. Counts continued to increase and
at the time of discharge pt was no longer neutropenic and WBC
was 4.1. Bone marrow biopsy on [**2158-8-28**] showed no clonal
cytogenetic aberrations and <5% blasts. However, skin biopsy
for a purple-pink papular rash on both forearms with biopsy was
consistent with leukemia cutis. Considering his bone marrow
response and the resolution of this rash, it was thought to be
rseolved. He will followup with Dr. [**Last Name (STitle) **] for futher
treatment.
.
# Febrile Neutropenia: As counts decreased, the patient was
febrile without obvious source in urine or lungs and was started
on cefepime and vancomycin and levofloxacin which had been
prescribed for cough was discontinued. Given the concern for
hemorrhoids and possible minor anal mucosal tear, see below,
Flagyl was added. Micafungin was added on day 4 after first
spike given continued fevers. Pt. felt well and was ambulatory,
taking PO during this time. Patient clinically improved, but
then developed high fevers, rigors, and whole-body rash,
respiratory distress (see ICU course below). He was pan-scanned
again, and CT sinus showed sinusitis. Coccidio, beta-glucan,
galactmannan, histoplasmosis, legionella, blood fungal cultures
were sent and were all eventually negative. ID was consulted and
suggested removing cefepime and micafungin as they might cause
rash. He was placed on vancomycin, meropenem, and ambisome (for
aspergillus and coccidiomycosis coverage). Patient had risen
LFTs which eventually trended down. He improved clinically and
antibiotic coverage was stopped on [**8-26**] when patient had been
afebrile for several days and ANC >1000. Beta glucan from [**8-26**]
was >500. ID was consulted again and advised to recheck beta
glucan, as it may have been an erroneous result, since he was
asymptomatic and had stable lesions on chest CT from [**8-26**], and
also requested a mycoF/lytic culture. These results are to be
followed up as an outpatient and no antifungal coverage or
liver/spleen imaging were advised unlses the he spiked a fever,
which he did not do.
.
# Guaiac positive stool: Patient reported hard and painful BM
during induction therapy. Bloody streaks were seen on stool,
minimal blood in toilet. Platelets transfused, Hct stable. Bowel
regimen increased and further BMs were guaiac neg and soft for
the rest of his hospital course.
#hematuria: noted to have hematuria [**8-15**] in the setting of
thrombocytopenia. CT abd/pelvis showed mild R hydronephrosis
and proximal-mid hydroureter on [**8-15**]. Hematuria resolved as
thrombocytopenia resolved, platelets were transfused for <10.
F/u ultrasound showed bilateral hydronephrosis in the setting of
increasing creatinine, urology was consulted concerning the
hydronephrosis and advised that he follow up as an outpatient
for a hematuria workup.
.
#Thrombocytopenia: pt had low platelets as expected and was
transfused PRN for platelets <10. On [**8-20**], had urticarial
reaction to crossmatched platelets that improved with tylenol,
PRA assay positive. Thrombocytopenia improved without
intervention as the rest of counts went up as well.
#Acute kidney injury: Patient's creatinine was elevated starting
[**8-24**] from baseilne of 0.9 to 1.8 on [**8-29**] despite removal of
nephrotoxic vancomycin and ambisome on [**8-26**]. Renal was
consulted and considering FeNa of 2.1, was thought to be due to
AIN, although it is unclear which medication caused this. He
did have a drug rash earlier in his hospital course, thought to
be related to micafungin or meropenem, but it is unclear what
caused the AIN. He will followup with renal service as an
outpatient.
#L 4th and 5th finger numbness: Patient had noted this
consistently for a week and mentioned it on [**2158-8-24**]. MRI T and
C spine and brachail plexus were ordered to eval for CNS spread
of disease, in addition LP was done. No lesions on MRI and no
evidence of CNS disease. Numbness may be [**12-27**] ulnar neuropathy,
he will follow up in neurology clinic and may get an EMG.
.
ICU Course ([**Date range (1) 29638**])
Hypoxia: Pt with increased O2 demand and some respiratory
distress which lead to his brief transfer from the onc service
to the [**Hospital Unit Name 153**]. Pt was initially given nebs, changed from NC to
facemask, and given IV lasix. He was redosed with lasix with
good urine output. CXR showed no change and ECHO was obtained.
Pt O2 requirement stabilized and he was titrated down to lower
dose nasal cannula.
.
Febrile Neutropenia: Temp of 101.4 at time of ICU transfer.
Broad spectrum antibiotics were continued but elevated LFTs
raised concern over the administration of fluconazole. Because
of the pts significant travel history to some fungal endemic
regions it was determined to treat emperically with Ambisome so
this was started and Fluconazole D/Ced. Near the end of the
first Ambisome infusion pt spiked a fever above 104 and had
chills/rigors. This calmed down with demerol and tylenol and was
thought likely due to the infusion vs an infectious cause.
.
Pancytopenia: This was thought [**12-27**] to AML and chemo with Hgb low
on ICU presentation. Over brief ICU course 1 unit of PRBC was
initially given followed by 2 units PRBC the next day. Pt had
mild temp at time of beginning of the 2nd transfusion but it was
administered in spite of this. Hct responded appropriately to
these infusions.
.
Medications on Admission:
Home:
Diovan 80mg PO daily
Aspirin 81mg PO daily
Omeprazole 20mg PO daily
Multiple vitamins, incl. MVI, B complex
.
On transfer:
Allopurinol 300mg PO daily
Ambien 5mg PO QHS prn insomnia
Colace 100mg PO BID
Dulcolax 10mg PO QAM prn constipation
Milk of Magnesia Q6h prn constipation
Mylanta 30ml PO Q4h prn
Procardia XL 30mg PO daily
Protonix 40mg PO daily
Reglan 10mg IV Q6h prn nausea
Robitussin 10mL PO Q4h prn cough
Tylenol 650mg PO Q6h prn
Zofran 4mg IV Q8h prn nausea
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
3. nifedipine 30 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
4. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for coughing.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Acute Myelogenous Leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 86903**], you were admitted to the [**Hospital1 827**] because you had low blood count. We obtained a
bone marrow biopsy which showed that you had acute myelogenous
leukemia. You were started on chemotherapy. Your cell counts
dropped as expected, and you developed a fever. We did CT scans
of your sinus, chest, and abdomen to look for a source of
infeciton. We treated you with many antibiotics. One of the
antibiotics gave you a rash, which resolved after we stopped it.
You had a repeat bone marrow biopsy which still showed leukemia,
so you underwent a second round of chemotherapy. While you white
blood cell counts were at their nadir, you have difficulty
breathing and spiked high fevers with rigors for many days. We
continued with medications to treat bacterial or fungal
infections. You eventually got better and did not have any more
fevers and your white blood cell counts increased (including
neutrophil count) and we stopped your antibiotics. We did a
final bone marrow biopsy which showed <5% blasts, indicating a
good response. You will follow up with Dr. [**Last Name (STitle) **] on Friday
to discuss the next steps in your treatment.
Your creatinine was increasing (number that shows kidney
function), which we think is likely due to acute interstitial
nephritis (allergic reaction in your kidneys likely from
medications). You should follow up with urology clinic and
renal clinic about this and the blood in your urine you had a
couple of weeks ago. You should also follow up in neurology
clinic so they can check on the numbness in your left hand.
Your sutures can be taken out in one week (around [**9-7**]), this
can be done at clinic.
.
We made the following changes to your medications:
stop taking diovan
start taking nifedipine (procardia)
start taking acyclovir
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 162**] & [**Hospital1 **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2158-10-2**] 4:00 (neurology-finger numbness)
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2158-9-25**] 3:00 (renal-kidneys)
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2158-9-1**] 2:00 (oncologist-leukemia)
[**2158-11-3**] 02:00p [**Last Name (LF) **],[**First Name3 (LF) 275**] C. (urology, for blood in your
urine)
Completed by:[**2158-9-1**]
ICD9 Codes: 5789, 5180, 5849, 2724, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2537
} | Medical Text: Admission Date: [**2119-8-18**] Discharge Date: [**2119-9-1**]
Date of Birth: [**2051-4-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Removal of tunneled hemodialysis catheter and placement of
another.
Insertion and removal of left internal jugular central venous
line.
Insertion and removal of femoral central venous line.
History of Present Illness:
68 yo F with history of afib on coumadin, systolic CHF with EF
15%, CAD, DM2 on insulin, s/p L AKA, p/w fall out of bed this
morning. Pt fell two feet out of bed onto wooden floor onto her
R side. Happened early this morning while she was sleeping. C/O
R sided rib pain, headache (though denies head trauma or LOC),
and pain at L AKA stump (which is chronic). Denies any
LH/dizziness or other prodromal symptoms. Of note, pt had 3
admissions over the past month for SOB and volume overload, was
treated with HD.
.
In the ED vitals notable for SBP 79-94, HR 79. She was given a
500ml bolus of fluid and her SBP went up to 99. She was given
morphine 4mg IV x1 and percocet 5/325mg x2 for pain as well as
nebs. She had CXR, CT head, C spine and abdomen/pelvis for
trauma work up, all of which was negative. She was admitted to
the floor for pain control and placement.
.
On arrival to the floor, she trigerred for hypotension with BP
78/doppler. Satting mid-high 90s on RA. EKG was v-paced.
Currently, she complains of headache and R-sided rib pain and
upper sternal pain. Denies LH/dizziness, chest pain, SOB,
abdominal pain. A 500cc bolus was started and BP improved
quickly to 90/doppler and remained stable.
.
ROS: As above, otherwise denies fever, chest pain, abdominal
pain, diarrhea, constipation. No nausea/vomiting. No
arthralgias, numbness/tingling in extremities.
Past Medical History:
1. CHF with EF of 15% s/p BiV pacer on coumadin, recently
admitted for CHF exacerbation in [**7-23**]
2. ESRD - on HD since [**2119-8-1**], *EDW 64.4 kg*
3. CAD s/p MI & CABG x 2 ([**2108**] and revised in [**2118**])
4. DMII x 4yrs on insulin
5. s/p L AKA
6. Hypothyroidism
7. a-fib
Social History:
Lives at home with daughter. Remote smoking history less than
2-3yrs total, pt has not smoked in over 30yrs. There is no
history of alcohol abuse.
Family History:
non-contributory
Physical Exam:
VITAL: T 98.4, BP 78/dop-->90/dop (s/p IVF), HR 81, RR 22, 100%
2L--> 99% RA
GEN: fatigued obese female lying in bed, spanish-speaking,
A+Ox3, NAD
HEENT: PERRL, EOMI, OP clear, MMM
NECK: supple
CV: distant heart sounds, RRR, II/VI holosys murmur at LSB, no
M/G/R
PULM: mild bibasilar rales, no wheeze
ABD: Soft, NT, ND, +BS, obese
EXT: s/p L AKA, trace RLE edema, 2+ R DP pulse by doppler
Pertinent Results:
[**2119-8-18**] 01:40PM GLUCOSE-206* UREA N-28* CREAT-3.1* SODIUM-135
POTASSIUM-5.7* CHLORIDE-93* TOTAL CO2-32 ANION GAP-16
[**2119-8-18**] 01:40PM WBC-7.3 RBC-3.70* HGB-9.9* HCT-33.8* MCV-91
MCH-26.8* MCHC-29.3* RDW-17.4*
[**2119-8-18**] 01:40PM PT-16.0* PTT-24.9 INR(PT)-1.4*
MICRO:
[**8-28**] BCx: NGTD
[**8-27**] BCx: NGTD
[**8-26**] Fem line tip: Klebsiella Pn., pan R (I to gent)
[**8-26**] HD line: no signif growth
[**8-24**] BCx: coag neg staph
[**8-23**] Bcx: NGTD
[**8-22**] BCx: NGTD
[**8-21**] UCx: no growth
[**8-21**] BCx: NGTD
[**8-21**] Stool O+P: + for strongyloides
[**Date range (1) 67624**] BCx: + for coag neg staph (MRSE)x3
.
STUDIES:
.
[**2119-8-18**] EKG: v-paced at 71 bpm, unchanged from prior
.
[**2119-8-18**] CT head without contrast:
no acute process
.
[**2119-8-18**] CT C spine without contrast:
no cervical spine fx or malalignment, though slightly limited by
pt motion. probable small tracheal diverticulum at level of C7.
irregular soft tissue density material at level of C6 most
likely represents thickened secretions or mucous.
.
[**2119-8-18**] CT abdomen/pelvis:
IMPRESSION:
1. No acute traumatic injury in the abdomen or pelvis.
2. Moderate-sized simple right pleural effusion and adjacent
compressive atelectasis.
3. Trace ascites.
4. Extensive vascular calcification.
.
[**8-22**] TTE:
IMPRESSION: Mild ventricular hypertrophy with severe global
systolic dysfunction and severe diastolic dysfunction. No
echocardiographic evidence of endocarditis. Mild mitral
regurgitation. Moderate pulmonary hypertension.
.
[**8-25**] CXR
A right dual lumen internal jugular central venous
line and left pacemaker leads are in unchanged position.
Moderate cardiac enlargement is stable. Increased interstitial
markings consistent with mild interstitial edema are unchanged,
however, a small right-sided pleural effusion has mildly
increased in size.
.
[**8-27**] UE DOPPLERS:
IMPRESSION: Partially occlusive thrombus in the right internal
jugular vein.
.
[**8-30**] CT Chest: 1. Moderate cardiac decompensation as evidenced
by interstitial and alveolar edema, moderate-sized right pleural
effusion, and cardiomegaly. No acute consolidative process.
2. No evidence of tracheobronchomalacia.
3. No evidence of pulmonary embolism.
Brief Hospital Course:
Pt is a 68 yo female with afib, systolic CHF with EF 15%, CAD,
DM2 on insulin, s/p L AKA admitted following mechanical fall.
1.MRSE Bacteremia: On admission, pt was hypotensive in ED and
on floor, found to have GPCs (grew MRSE) in blood on [**6-13**],
[**8-24**], transferred to MICU on [**8-21**], started on Vanco which should
be continued for 14 days after last positive culture which was
[**2119-8-26**] (a fem line tip). This fem line tip from [**8-26**] also grew
pan-resistant Klebsiella which was thought to be a contaminant.
TTE this admission was negative. Pt had a left IJ placed after
cultures cleared which was removed at D/C. Pt briefly required
levophed in MICU. On arrival to the floors, her pressures
continued to improve and she was restarted on home doses of
lisinopril and carvedilol with SBP on day of d/c in 110s. Pt
discharged to continue vanco dosed at HD on Tues, Thurs, Sat to
end [**9-9**].
.
2. Chronic ischemic CM: EF 15% s/p [**Hospital1 **] V pacer also s/p MI and
CABGX2 IN [**2108**] AND [**2118**]. Hypotension resolved at discharge, was
likely from bacteremia. Pt discharged on home regimen of
Lisinopril, Carvedilol, ASA.
.
3. RUE DVT: Discovered [**8-27**] after tunneled HD catheter taken out
[**8-26**]. Pt was on heparin gtt until d/c. Pt restarted on
coumadin 2 days prior to discharge. Given Coumadin 5mg Daily at
d/c with INR to be repeated Tues [**9-5**] at dialysis. INR at
discharge 1.9.
.
4. [**Name (NI) 39621**] Pt on heparin gtt here, discharged on coumadin.
.
5. DM2: Pt continued on home dose Glargine 12 units Daily here
with Humalog SS and discharged on same.
.
6. CKD: ESRD, presumed [**3-18**] DM on HD x 1 month prior to admission
T/Th/Sa. HD continued in house and pt discharged on same home
schedule. Continued Sevelamer.
.
7 Anemia: HCT stable and 31.5 at discharge.
.
8. Hypothyroidism: Pt continued on Levothyroxine.
.
9. Strongyloides: Diagnosed by stool O and P in MICU after
eosinophilia was noticed. Pt given ivermectin x 2 doses (full
course for uncomplicated infxn).
.
10. FULL CODE, confirmed on MICU admission
Medications on Admission:
Levothyroxine 125 mcg Tablet PO DAILY
Aspirin 325 mg Tablet PO DAILY
Docusate Sodium 100 mg Capsule Capsule PO BID
Sevelamer HCl 400 mg Tablet PO TID W/MEALS
Carvedilol 3.125 mg Tablet PO BID
Warfarin 9 mg Tablet PO once a day.
Lisinopril 2.5 mg Tablet PO DAILY
Lantus 12u qHS.
Humalog sliding scale
Albuterol neb Q6H as needed for wheezing.
Tramadol 50 mg PO Q6H as needed for pain.
Zolpidem 5 mg Tablet PO HS as needed for for sleep.
Lorazepam 0.5 mg Tablet PO HS as needed for anxiety.
Guaifenesin [**6-24**] mL PO Q6H PRN as needed for cough.
Senna 8.6 mg Tablet PO BID as needed for constipation.
Bisacodyl 10 PO Q24 PRN as needed.
Lactulose 15 mL PO Q4H PRN as needed
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
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. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*1*
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
Disp:*30 neb* Refills:*2*
9. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
Disp:*200 units* Refills:*2*
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever or pain.
Disp:*80 Tablet(s)* Refills:*2*
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
Disp:*100 ML(s)* Refills:*2*
13. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for constipation.
Disp:*20 Tablet(s)* Refills:*1*
14. Humalog 100 unit/mL Solution Sig: One (1) sliding scale
Subcutaneous three times a day: see attached sliding scale.
Disp:*1 bottle* Refills:*2*
15. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO
every four (4) hours as needed for constipation: For severe
constipation.
Disp:*90 mL* Refills:*1*
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
Disp:*20 Adhesive Patch, Medicated(s)* Refills:*0*
18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
Disp:*80 nebulizations* Refills:*2*
20. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q12H (every 12 hours) as needed.
Disp:*30 Tablet Sustained Release(s)* Refills:*1*
21. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
22. Outpatient Lab Work
INR check Tues [**2119-9-5**] at Hemodialysis.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
MRSE bacteremia
Secondary diagnoses:
s/p fall
RUE DVT
CHF with EF 15%
Atrial fibrillation
DM type 2
ESRD on HD
Hypothyroidism
Anemia
Strongyloides
Discharge Condition:
Stable. O2 sat 100% on RA.
Discharge Instructions:
You were admitted after a fall at home. While you were here, you
were found to have low blood pressures which required your
transfer to the ICU. For the last few days, your blood
pressures have been good and we have been able to restart you on
your home doses of Lisinopril and Carvedilol. We think that
your low blood pressures were caused by an infection in your
blood which is being treated with antibiotics until [**9-9**]. You
will get your antibiotics when you go to dialysis on Tuesday,
Thursday and Saturday. Please do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 1988**]
dialysis sessions. You will also have your INR checked at
hemodialysis on Tuesday [**9-5**]. This is a mark of your coumadin
level.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if you have a weight
change > 3 lbs.
Adhere to 2 gm sodium diet.
Please call your doctor or return to the ED if you have any
chest pain, increasing shortness of breath, fever, chills,
swelling in your legs, loss of consciousness, confusion,
diarrhea or any other concerning symptoms.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] (cardiology) Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2119-9-4**] 10:00
Provider: [**Name10 (NameIs) 16244**] [**Last Name (NamePattern4) 16245**], MD (endocrinology)
Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2119-9-4**] 3:40
Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in
the next 2 weeks. The office number is [**Telephone/Fax (1) 12473**].
Please continue Hemodialysis Tues, Thurs, Sat and have your INR
checked at dialysis Tues [**2119-9-5**].
Completed by:[**2119-9-1**]
ICD9 Codes: 5856, 4280, 4589, 2767, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2538
} | Medical Text: Admission Date: [**2159-4-21**] Discharge Date: [**2159-5-15**]
Date of Birth: [**2083-5-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
Fatigue for one week. Transferred to CCU with hypoxic distress
in context of AF with RVR, developed PNA and transferred to MICU
with stabilized AF.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 70654**] is a 75M with a history of coronary artery disease
s/p CABG x3 ([**University/College **] Presbyterian NY, [**2145**]), PTCA x2 stents
(DES: proximal LAD and SVG to PDA, [**2156**]) as well as
assymptomatic PAF on coumadin who presented to [**Hospital1 18**] on [**2159-4-21**]
with fatigue for the last 5 days. He did not endorse shortness
of breath or chest pain, only generalized fatigue. Other ROS
were negative and notable for the absence of fevers, chills,
productive cough, sick contacts, recent travel or other
complaints.
In the ED, initial vitals: 97.8 65 132/78 16 97. CXR showed a
small new right pleural effusion. EKG showed atrial fibrillation
at a rate of 114, and ST depression II, III, AVf, V4-V6. He was
given Aspirin and placed on Oxygen. Cardiac biomarkers were
negative x 3. He was loaded with dofetilide for chemical
cardioversion of his a fib and went into NSR after the first
dose. The following morning he developed worsening dyspnea and
was found to be hypoxic with O2 sats in the 70s on RA. He
triggerred for hypoxia and was found to have expiratory wheezes
and crackles at the base. Chest x-ray showed severe scoliosis
and opacities within both lower lobes. VBG showed pH 7.42, pO2
53, pCo2 30. He was placed on a non-rebreather with O2 sats that
returned to 92%. The team felt that his symptoms were either CHF
versus pneumonia, with CHF more likely because he did not have a
white count or fever at the time. He was diuresed with 20 mg IV
lasix x 3 and had 2 L of urine output. He remained on the
non-rebreather throughout the afternoon despite the diuresis. He
was given nebulizers and ordered doxycycline and augmentin for
possible community acquired pneumonia (although he did not
receive antibiotics). At 6:30 pm nightfloat came to evaluate the
patient and was concerned. An ABG showed pH 7.42 pO2 66 and pCO2
54. Vanc and cefipime were started and the CCU was called to
evaluate the patient.
The patient was found to be tachypneic and uncomfortable, using
increase work of breathing. He was sating 92% on the
non-rebreather. He was transferred for hypoxic respiratory
distress. In the CCU he endorsed chills, but denied fever, chest
pain, palpitations, nausea, cough, abdominal pain, HA, dysuria,
myalgias, melena.
Respiratory status continued to be tenuous in the CCU requiring
face mask during the day, and BiPap overnight. Patient was not
intubated due to concerns about ability to wean from the vent.
He was treated empirically with broad spectrum.
CCU course notable for increasing respiratory distress requiring
BiPap for comfort. Initially used overnight only with face mask
during the day but increasingly requiring BiPap. Was seen by his
outpatient pulmonologist who agreed with current plan, and felt
patient likely to be difficult to wean from the vent if
intubated. +6L LOS (not counting insensible losses). Admission
weight 53.1kg, currently weighs 56.1 kg(but unreliable as bed
weight with sheets etc). Patient had intermittent A. Fib with
RVR requiring boluses of diltiazem for rate control.
Past Medical History:
1. coronary artery disease
-CABG in [**2145**]: SVG to RPDA; SVG sequentially to diagonal and OM;
no LIMA graft
-Cath in [**2156**] notable for occlusion of a vein graft to the right
PDA treated with a DES and a subsequent elective native vessel
LAD PCI
2. PAF: rate controlled with atenolol and on warfarin
3. Dyslipidemia
4. Hypertension
5. OSA on BiPAP 11cm insp and 9cm exp pressures
6. Tuberculosis as a child, status post left upper lobe
lobectomy
7. BPH
8. Severe kyphoscoliosis
9. Chronic sinususitis
Social History:
- Married, Lives in [**Location 745**] with Wife, Three Children
- Holocaust survivor
- Retired child psychologist at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Location (un) **] in NY
- Tobacco history: Denies
- ETOH: Denies
- Illicit drugs: Denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
- Father: Killed during Holocaust
- Mother: Died in 90s, no known medical history
- Sister: [**Name (NI) **] [**Name (NI) 3730**], 50s.
Physical Exam:
Gen: Pleasant. NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with full EJ and JVP slightly above clavicle
CV: normal S1, S2. No m/r/g.
Chest: Sever Kyphoscoliosis. Patient appeared uncomfortable
breathing, increased work, + accessory muscle use, + expiratory
wheezes and decreased breath sounds on right and left bases. +
egophony and + fremitus on right base.
Abd: Soft, NTND. No HSM or tenderness.
Ext: 1+ Pedal/Ankle Edema Bilaterally.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Lab Data on Admission
[**2159-4-21**] 08:50AM BLOOD WBC-6.3 RBC-3.91* Hgb-12.2* Hct-36.9*
MCV-94 MCH-31.2 MCHC-33.0 RDW-15.0 Plt Ct-141*
[**2159-4-21**] 08:50AM BLOOD Neuts-67.3 Lymphs-24.0 Monos-5.5 Eos-2.6
Baso-0.6
[**2159-4-21**] 08:50AM BLOOD PT-28.1* PTT-37.9* INR(PT)-2.8*
[**2159-4-21**] 08:50AM BLOOD Glucose-120* UreaN-34* Creat-1.2 Na-142
K-4.3 Cl-102 HCO3-33* AnGap-11
[**2159-4-21**] 08:50AM BLOOD ALT-41* AST-36 LD(LDH)-211 CK(CPK)-70
AlkPhos-140* TotBili-0.4
[**2159-4-21**] 08:50AM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-3733*
[**2159-4-21**] 08:50AM BLOOD TSH-2.6
Pertinent Labs from During the Admission
[**2159-4-22**] 05:30AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.9
[**2159-4-23**] 03:43AM BLOOD VitB12-728 Folate-19.0
[**2159-4-23**] 03:43AM BLOOD ASA-NEG Acetmnp-10.0 Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2159-4-22**] 06:45PM BLOOD Lactate-1.2
[**2159-4-23**] 04:00AM BLOOD freeCa-1.13
Blood Gas, Lactate, Cardiac Enzymes
[**2159-4-21**] 08:50AM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-3733*
[**2159-4-21**] 08:50AM BLOOD cTropnT-<0.01
[**2159-4-21**] 01:07PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2159-4-21**] 09:18PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2159-4-22**] 07:24PM BLOOD CK-MB-3 cTropnT-<0.01
[**2159-4-23**] 03:43AM BLOOD CK-MB-3 cTropnT-<0.01
[**2159-4-23**] 03:15PM BLOOD CK-MB-4 cTropnT-<0.01
[**2159-4-24**] 03:57AM BLOOD CK-MB-3 cTropnT-<0.01
[**2159-4-27**] 05:30AM BLOOD proBNP-4224*
[**2159-4-22**] 01:13PM BLOOD Type-[**Last Name (un) **] Temp-37.0 pO2-30* pCO2-53*
pH-7.37 calTCO2-32* Base XS-3
[**2159-4-22**] 06:45PM BLOOD Type-ART pO2-66* pCO2-34* pH-7.42
calTCO2-23 Base XS--1
[**2159-4-23**] 04:00AM BLOOD Type-[**Last Name (un) **] Temp-38.4 pO2-60* pCO2-59*
pH-7.40 calTCO2-38* Base XS-8 Intubat-NOT INTUBA
[**2159-4-23**] 05:19PM BLOOD Type-[**Last Name (un) **] Temp-36.3 Rates-/25 FiO2-80 O2
Flow-12 pO2-42* pCO2-53* pH-7.40 calTCO2-34* Base XS-5 AADO2-495
REQ O2-81 Intubat-NOT INTUBA Comment-NEBULIZER
[**2159-4-24**] 02:14PM BLOOD Type-ART Temp-36.6 pO2-51* pCO2-42
pH-7.48* calTCO2-32* Base XS-6 Intubat-NOT INTUBA
[**2159-4-24**] 03:37PM BLOOD Type-ART Temp-36.6 Rates-/26 O2 Flow-12
pO2-54* pCO2-43 pH-7.45 calTCO2-31* Base XS-4 Intubat-NOT INTUBA
Comment-NON-REBREA
[**2159-4-26**] 05:03PM BLOOD Type-[**Last Name (un) **] pO2-30* pCO2-57* pH-7.33*
calTCO2-31* Base XS-1
[**2159-4-27**] 05:33AM BLOOD Type-[**Last Name (un) **] pO2-49* pCO2-57* pH-7.31*
calTCO2-30 Base XS-0
[**2159-4-22**] 06:45PM BLOOD Lactate-1.2
[**2159-4-23**] 04:00AM BLOOD Lactate-2.1*
[**2159-4-23**] 05:19PM BLOOD Lactate-1.4
[**2159-4-24**] 02:14PM BLOOD Lactate-1.6
[**2159-4-26**] 05:03PM BLOOD Lactate-0.9
Other Reports
EKG [**2159-4-21**]
Atrial fibrillation with premature ventricular contractions and
uncontrolled ventricular response. Compared to tracing #2 the
heart rate is faster.
Rate PR QRS QT/QTc P QRS T
114 0 104 330/424 0 16 -164
CXR [**2159-4-21**]
COMPARISON: Multiple prior chest radiographs from [**2157-1-5**],
[**2157-3-2**], and [**2159-1-17**]. CTA chest was performed on [**2157-3-10**].
CHEST RADIOGRAPH, PA AND LATERAL VIEWS: The patient is status
post median sternotomy, CABG, and coronary artery stenting.
Severe scoliosis of the thoracolumbar spine, with deformity of
the left rib cage, again limits evaluation. Left lung volume is
chronically small. Left pleural thickening with calcification is
as before. On the right, there is small pleural effusion which
is new since [**2159-1-17**]. There may be subtle ill-defined opacity
in the right lung base. No overt pulmonary edema is seen.
Cardiac enlargement is unchanged.
IMPRESSIONS: Evaluation limited by spine and ribcage deformity.
New small right pleural effusion and subtle opacity in the right
lung base, which could represent aspiration, atelectasis, and/or
developing consolidation.
Echo [**2159-4-23**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with infero-lateral
hypokinesis. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-13**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images
unavailable for review) of [**2158-6-13**], no definite change.
CARDIAC CATH performed on [**2156-10-4**] demonstrated:
1. Coronary angiography in this right dominant system
demonstrated a normal LMCA with collaterals to RPL. The LAD had
a 90% proximal lesion with competitive flow. The LCX system had
an occluded
OM. The RCA was not selectively engaged.
2. Graft angiography showed a patent SVG to diagonal and OM. The
SVG to RPDA had a 99% proximal stenosis.
3. Limited resting hemodynamics as detailed above revealed
mildly
elevated filling pressures.
4. PCI of SVG-RPDA with 3.5 X 28 mm Cypher DES and no residual
stenosis or complications (see PTCA comments for detail).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent SVG-diagonal-OM graft.
3. Proximal stenosis of SVG-RCA, successful PCI with Cypher
drug-eluting stent.
CARDIAC CATH performed on [**2156-10-6**] demonstrated:
1. Successful stenting of the proximal LAD with 2.5 X 13 Cypher
[**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 7930**] to 3.0 with no residual stenosis.
2. Distal LAD myocardial bridge with compression during systole
but
normal flow at diastole.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful stenting of the proximal LAD with Cypher DES.
CXR [**2159-4-22**]
IMPRESSIONS: FINDINGS: Comparison is made to prior study from
[**2159-4-21**]. Study is markedly limited due to patient
positioning and the severe scoliosis. Allowing for this,
however, there appears to be opacities within both lower lobes
which are worrisome for consolidation or pneumonia. The
consolidations on the right side are much more apparent than on
the study from yesterday. Aspiration cannot be excluded.
CXR [**2159-4-27**]
FINDINGS: As compared to the previous radiograph, the volume of
the right hemithorax has decreased. As a consequence, there is
increased crowding of the right perihilar vessels. However,
there is no clear evidence of pneumonia (the film strongly
resembles the examination performed on [**2159-4-24**], 8:03
a.m.). Unchanged marked asymmetry of the chest wall given the
extreme scoliosis. Unchanged size of the cardiac silhouette.
CT chest [**2159-4-28**]
1. Moderate right pleural effusion with adjacent
telectasis/consolidation.
2. Scattered ground-glass opacities with enlarged heart. These
findings are most likely representative of pulmonary edema.
3. Calcified left pleural plaques consistent empyema.
4. Prominent abdominal vessels are limited due to lack of
intravenous
contrast but suggestive of varices. Clinical correlation is
recommended.
5. Marked thoracic cage distortion due to scoliosis.
Pleural fluid [**2159-4-29**]
NEGATIVE FOR MALIGNANT CELLS.
CXR [**2159-5-10**]
As compared to the previous radiograph, the lung volumes are
unchanged. Presence of a minimal right-sided pleural effusion
cannot be
excluded. Minimally increased diameters of the pulmonary vessels
in the right upper lobe could indicate mild overhydration.
Unchanged size of the cardiac silhouette. Unchanged aspect of
the left lung.
DISCHARGE LABS:
[**2159-5-15**] WBC-7.7 RBC-3.72* Hgb-11.2* Hct-35.0* MCV-94 Plt Ct-335
[**2159-5-15**] PT-29.5* PTT-37.2* INR(PT)-2.9*
[**2159-5-15**] Glucose-94 UreaN-44* Creat-1.2 Na-142 K-4.1 Cl-96
HCO3-38* [**2159-5-15**] Calcium-9.3 Phos-3.8 Mg-2.1
Brief Hospital Course:
Brief Hospital Course
Professor [**Known lastname 70654**] is a 75 YOM with paroxysmal atrial
fibrillation and coronary artery disease who presented with 5
days of fatigue and was found to be in Atrial fibrillaton with
RVR. Patient was admitted to the cardiology service and
dofetilide was initiated given atrial fibrillation. On HD#1
patient develope hypoxic respiratory distress reguiring transfer
to the CCU where he was treated for community acquired pneumonia
with Vancomycin, Cefepime, and Doxycycline given concern for QT
prolongatoin. During his stay in the CCU he was intermittently
in atrial fibrillation with RVR and would intermittently develop
respiratory distress reguiring BiPap. Patient was eventually
transferred to the MICU for more intensive management of his
pulmonary issues. There the patient completed his course of
antibiotics and was diuresed. Slowly the patients breathing
improved and on [**5-4**] was transfered to the general medical
floor.
Hypoxic Respiratory Distress:
On presentation to the hospital patient was at baseline
pulmonary status. Initial CXR with question of RLL opacity. On
HD#1 patient developed hypoxic respiratory failure which
[**Hospital 70655**] transfer to the CCU and broad spectrum antibiotics to
treat RLL pneumonia visualized on CXR. Further patient became
febrile prior to transfer. Initially patient was thought to have
RLL infiltrate c/w pneumonia and high fever. Patient was treated
for probable RLL pneumonia with Vancomycin, Cefepime, and
Doxycycline completing an 8 day course. On transfer to the MICU
the patient appeared to have superimposed pulmonary edema from
volume resuscitation as evidenced by LOS fluid balance, interval
weight, and clinical exam. MICU attempted low dose lasix
overnight [**4-27**] for diuresis and monitored respiratory status,
with 700cc out and no worsening in creatinine. Non-contrast CT
showed moderate right sided pleural effusion. Based upon
patient's respiratory distress, he underwent a 1.5L
thoracentesis on [**4-29**] with interval improvement in respiratory
status. Patient has limited reserve given prior pneumonectomy
and severe kyphoscoliosis and may not tolerate small volumes of
fluid. A Urine legionella was negative. Blood cultures negative
(finalized). Sputum cultures contaminated. Pleural fluid
appeared transudative and cultures NGTD. The patient was
maintained on nebulizers as needed. The patient underwent
aggressive diuresis with IV lasix and was negative
approximately 6 liters for his MICU stay (though even from
admission weight). The patient initially required BiPap around
the clock. He was weaned to a shovel mask and eventually to a
nasal cannula with diuresis. He continued on BiPap at night
with his home settings. Based upon radiographic images, there
was concern that patient may be aspirating. He was evaluated by
speech and swallow who cleared the patient for solids and thin
liquids; pills whole with puree. After diuresis patient
continued to improve, no longer needing BiPAP during the day.
Patient was transferred to the general medical floor where
diuresis was continued. The patient was maintained on nasal
cannula 1-2L for a week, and finally weaned down to RA, satting
mid90s on discharge. The patient was discharged on Lasix and
Aldactone.
Atrial fibrillation:
On admission to the hospital patient was found to be in atrial
fibrillation. With therapeutic INRs for the past two months.
Decision was made to start dofetilide. Patient initially
converted to sinus rhythm prior to transfer to CCU. During CCU
stay patient was paroxysmally in atrial fibrillation which was
intermittently controlled with diltiazem. The patient was
continued on dofetilide per EP recommendations, and daily EKGs
were initially obtained to monitor for QT prolongation. The
patient's diltiazem was up-titrated as tolerated. At the time
of leaving the MICU, he was on Diltiazem Extended Release 240mg
PO BID. He was in sinus rhythm. On the floor, the patient was
intermittently in afib. He was started on Metoprolol 25mg PO BID
for better heart rate control. He was intermittently in afib and
junction rhythm (rate 60s-80s). Dofetilide was discontinued on
[**5-14**]. He was discharged on Dilt 240mg PO BID, Metoprolol 25mg PO
BID.
Metabolic alkalosis:
Thought to be secondary to aggressive diuresis with lasix
(contraction alkalosis). Correction may help respiratory status
by preventing compensatory hypoventilation. On his last day in
the MICU, he was started on acetazolamide 250 mg [**Hospital1 **].
Junctional Bradycardia:
Likely secondary to beta-blockers. The patient was started on
Metoprolol, as recommended by EP. The patient was noted to be in
a junctional rhythm, but was not bradycardic.
Coronary artery disease:
post CABG and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2. ST depressions on EKG (stable, but
worsened with tachycardia to 150s). No active chest pain.
Cardiac enzymes negative. The patient was continued on aspirin
81 mg and his home dose Lipitor.
Hypernatremia:
The patient was intermittently hypernatremic while in the MICU,
most recently with Na 146 on [**5-4**] free water deficit of 1.4L. He
intermittently received D5W X 1000 cc and PO intake was
encouraged.
OSA: Continued Home BiPAP
Hyperlipidemia: Continued Atorvastatin
Medications on Admission:
(per DC Summary [**2159-1-18**])
1. Atenolol 50 mg Once Daily
2. Atorvastatin 20 mg Once Daily
3. Fluticasone 50 mcg One Nasal Spray Daily
4. Lorazepam 0.5 mg 1-2 Tablets PO Once Daily PRN anxiety,
insomnia.
5. Mirtazapine 7.5 mg PO HS
6. Nifedipine 60 mg Once Daily
7. Nitroglycerin 0.3 mg SL PRN Chest Pain
8. Risedronate 35 mg once weekly
9. Warfarin 5 mg Tablet Once Daily
10. Aspirin 325 mg Tablet Once Daily
11. Os-Cal 500 + D 500 mg(1,250mg) -400 unit, Twice Daily
12. Lactobacillus Rhamnosus One Capsule PO Once a Day
13. Bipap
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
3. Lactobacillus Rhamnosus (GG) 10 billion cell Capsule Sig: One
(1) Capsule PO once a day as needed for constipation.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for Insomnia/anxiety.
Disp:*60 Tablet(s)* Refills:*0*
6. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*120 Capsule, Sustained Release(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
([**Doctor First Name **],TU).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
(MO,WE,TH,FR,SA).
10. Os-Cal 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO twice a day.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash for 10 days.
Disp:*1 container* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Aldactone 25 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Diastolic Heart Failure
Paroxysmal Atrial [**Hospital 9343**]
Health care Associated Pneumonia
Restrictive Pulmonary Disease secondary to kyphoscoliosis
CAD
HTN
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 70654**],
.
It was a pleasure caring for you while you were hospitalized
with fatigue and shortness of breath. During your stay your
breathing became extremely labored [**Hospital 70656**] transfer to the
Intensive Care Unit were you were treated with antibiotics for
pneumonia. While in the ICU your breathing was slow to improve
so you were also diuresed with IV diuretics (lasix). Slowly your
breathing improved and you were transfered to regular medical
floor. Throughout this time your heart rate was in and out of
atrial fibrillation. Electrophysiology recommended Diltiazem and
Metoprolol for good rate control. You were also on Dofetilide
which was stopped since it did not keep you in a normal heart
rhythm.
.
Please take all your medications as prescribed and keep all of
your follow up appointments. Weigh yourself every morning, and
call your physician if your weight goes up more than 3 lbs. You
should also have lab work checked at your visit on [**2159-5-18**] to
ensure your kidney function and electrolytes are normal.
.
The following changes were made to your medication regimen:
#. CHANGE Atenolol to Metoprolol 25mg by mouth twice daily
#. STOP Nifedipine
#. START Diltiazem 240mg by mouth twice daily
#. START Miconazole powder twice a day as needed for you groin
rash
#. Start Lasix 20mg daily on [**2159-5-17**] (Call PCP and stop if you
feel lightheaded or dizzy)
#. Start Aldactone 12.5mg daily on [**2159-5-17**] )Call PCP and stop if
you feel lightheaded or dizzy)
#. We also increased your mirtazapine to 30mg at nighttime
#. DECREASE your aspirin to 81 mg daily
Followup Instructions:
PCP: [**Name10 (NameIs) **] have been set up to see a Nurse Practitioner, as well
as your primary care physician in the next week:
Provider: [**Name10 (NameIs) **] FERN, RNC
Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2159-5-18**] 9:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD
Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2159-5-25**] 10:30
.
Cardiology: Please follow-up with Dr. [**Last Name (STitle) **]
Date/Time: [**6-15**] at 2pm
Phone: [**Telephone/Fax (1) 62**]
.
Other Appointments:
ORTHO XRAY (SCC 2)
Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2159-6-14**] 10:40
.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (ortho spine)
Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2159-6-14**] 11:00
.
PULMONARY FUNCTION LAB
Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2159-6-15**] 11:10
.
DR. [**Last Name (STitle) **]
Phone: [**Telephone/Fax (1) 612**]
Date/Time:[**2159-6-15**] 11:30
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]
ICD9 Codes: 5119, 2760, 4280, 2724, 311, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2539
} | Medical Text: Admission Date: [**2126-4-29**] Discharge Date: [**2126-5-7**]
Date of Birth: [**2075-5-18**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 52-year-old male who
was referred in by Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] of cardiology for
outpatient cardiac catheterization due to a positive stress
test. He had a history of upper abdominal pain after walking
quickly for the past 3-4 years. He had no symptoms at rest
and he was referred for stress testing which was done on [**4-18**], which showed moderate reversible septal apical and apical
anterior defects. He was seen by Dr. [**Last Name (STitle) 911**] in cardiology and
referred for cardiac catheterization. He denied
claudication, orthopnea, edema, PND or lightheadedness.
PAST MEDICAL HISTORY: Anxiety, hypercholesterolemia,
hypertension.
PAST SURGICAL HISTORY: Includes appendectomy, status post
bilateral cataract surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS: At the time of catheterization were Atenolol 50
mg po q d and Aspirin 325 mg po q d.
Cardiac catheterization was done on [**4-29**] which showed a
normal left main, 100% occluded LAD after the diagonal I and
a 70% lesion at the origin of the diagonal I, 90% focal OM1
lesion and a non dominant right coronary artery with an 80%
mid lesion. Dr. [**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) 1537**] of cardiac surgery was called to
evaluate him for a hybrid procedure, possibly doing off pump
bypass to his distal LAD followed by possible PCI to diagonal
I and OM1.
Of note, patient had no MR on his catheterization and his
ejection fraction was normal at approximately 60%.
On [**4-30**] he was seen by the cardiac surgery team who noted the
results of his cardiac catheterization.
PHYSICAL EXAMINATION: He was neurologically intact.
REVIEW OF SYSTEMS: Otherwise unremarkable from prior noted
medical history. He had no lymphadenopathy or thyromegaly.
His lungs were clear. His heart was regular rate and rhythm
with a normal S1 and S2 and no murmur. He had positive bowel
sounds and no hepatosplenomegaly. He had no clubbing,
cyanosis or edema in his extremities and he had 1+ bilateral
throughout peripheral pulses. His neurologic exam was non
focal.
HOSPITAL COURSE: He was monitored and seen by the cardiology
service under the care of Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] over the next
couple of days. On [**5-2**] he underwent off pump coronary
artery bypass grafting times one with a LIMA to the LAD and a
small anterior thoracotomy with endoscopic LIMA harvest using
the ASOP computer. He was transferred to cardiothoracic
Intensive Care Unit on a Neo-Synephrine drip at 0.8
mcg/kilo/min and a Propofol drip which was titrated on
postoperative day #1. It is noted that he went to the
catheterization laboratory postoperatively the night before
his LIMA to the LAD graft was occluded. No intervention was
done at that time but he was stented with a 90% improvement
in his flow. Please refer to the cardiac catheterization
report. He was on Levophed drip at 0.1 mcg/kilo/min. He was
in sinus rhythm in the 80's with a blood pressure of 102/47.
He remained sedated and intubated after the cath laboratory.
He received Plavix and Aspirin. His chest tubes, pacing
wires and Foley remained in place at that time.
Postoperatively he remained sedated on Propofol with a plan
to wake him up during the day and plan to take him back to
the cath lab for stenting of his circumflex which had been
preoperatively planned. He remained on sliding scale insulin
and plans were made to wean him to extubate him. When the
patient went back to the cath lab the decision was to
revascularize the OM1 and defer the LAD [**Female First Name (un) 899**] anastomosis for
later with stenting performed to the OM1.
On postoperative day #2 the patient was extubated with blood
pressure of 105/52, he was 104, sinus tachycardia. He
continued on his Plavix and Aspirin. His BUN was 9 with
creatinine of 0.7 and potassium of 4.5. CK went from 698 to
530 with MB fractions of 9 to 0.2%. Chest tubes remained in
place. He had no other issues. He remained on his Levophed
drip at 0.1 mcg/kilo/min to titrate and keep his blood
pressure in at least the 85-90 range.
The plan was to discontinue his Swan later in the day if his
blood pressure issues had been resolved. He is to remain
tachycardic off the Levo. The plan was to restart his beta
blocker and wean his O2 and have aggressive pulmonary toilet.
Also noted that while his platelet count was low, it was
90,000 on the morning of postoperative day #2 which was up
from 84,000 the day prior and hematocrit stabilized at 27.3.
Zantac was discontinued. Patient was switched to Protonix.
Diet was advanced. His Swan was discontinued later in the
day and he kept his pacing wires and chest tubes in place.
He was evaluated by physical therapy even though he remained
in the ICU. He was in sinus rhythm in the 90's on
postoperative day #3. His Levophed was down to 0.04
mcg/kilo/min with plans to wean off during the day. He was
satting 100%, extubated on nasal cannula. His hematocrit
dropped slightly to 24.5 with a white count of 11.7. His INR
was 1.2, his potassium dropped slightly to 3.1 which was
noted and he remained in the ICU for monitoring. On
postoperative day #4 he was alert and oriented, remained in
the ICU again, had no neurologic deficits. He was off all
pressors and his beta blocker was restarted. He finished his
perioperative antibiotics, his hematocrit rose to 30.9 and
continued on his aspirin and Plavix as well as his Lopressor
25 mg [**Hospital1 **] and was satting well with blood pressure of 91/52
and heart rate of 97.
He was seen again by physical therapy and the case manager on
postoperative day #4. It was determined by PT that he was
safe for discharge to home one he was medically stable. He
remained in sinus rhythm and continued to ambulate with PT
and expressed his desire to go home. Given that he was a
young man and was motivated, this seemed like a reasonable
proposition and the patient was discharged to home on [**2126-5-7**]
on the following medications.
DISCHARGE MEDICATIONS: Colace 100 mg po bid, Plavix 75 mg po
q d, Aspirin 325 mg po q d, Protonix 40 mg po q d, Percocet
5/325 1-2 tablets po prn q 4 hours as needed for pain,
Metoprolol 75 mg po bid and Vioxx 50 mg po q d times 10 days.
DISCHARGE DIAGNOSIS:
1. Status post off pump coronary artery bypass grafting
times one.
2. Status post stenting postoperatively for planned hybrid
procedure with a stent to the OM.
3. Hypertension.
4. Hypercholesterolemia.
5. Anxiety.
The patient was discharged to home in stable condition on
[**2126-5-7**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2126-12-3**] 11:20
T: [**2126-12-6**] 11:21
JOB#: [**Job Number 34058**]
ICD9 Codes: 4111, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2540
} | Medical Text: Admission Date: [**2172-10-3**] Discharge Date: [**2172-10-6**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 83 year old
gentleman with a history of coronary artery disease, type 2
diabetes mellitus and osteomyelitis of his right foot in [**2171**]
with Methicillin resistant Staphylococcus aureus
Staphylococcus aureus, who was transferred from [**Hospital3 38285**] on [**2172-10-3**] to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] for an elevated white blood cell count, fever and
hypotension. Previously that afternoon at [**Hospital3 38285**], Mr. [**Known lastname **] was found to be hypotensive with a blood
pressure of 70/40 with a white blood cell count of 31,000 and
right lower extremity cellulitis.
On arrival to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **], the
patient was afebrile with a temperature of 99.1, blood
pressure 112/49 on Dopamine, a pulse of 80, breathing at 20
and saturating at 97% in room air. His physical examination
at that time was remarkable for conjunctival exudates, clear
lungs, sinus tachycardia and right lower extremity edema,
erythema and induration.
Admission white blood cell count was 28,100, hematocrit 31,
platelet count 164,000 with 83% polycytes and 10% bands.
Partial thromboplastin time was 42.1 and an INR of 4.2 on
admission. Sodium was 132, potassium 5.2, chloride 100,
bicarbonate 27, BUN 39 and creatinine 1.9. In the Emergency
Room, an electrocardiogram showed sinus rhythm of 90 beats
per minute, first degree A-V block, T wave inversion in I and
AVL and T wave flattening in III and AVF.
The patient was admitted directly to the Medical Intensive
Care Unit at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for
circulatory support with a Dopamine drip, with intravenous
antibiotics for presumed sepsis. At that point, he was
treated with cefazolin. In addition, the patient received a
total of five liters of intravenous fluid for cardiovascular
resuscitation. His Coumadin was held at that time for an INR
of 4.2. He was ruled out for a myocardial infarction by
cardiac enzymes.
In addition, the patient had lower extremity noninvasive
ultrasounds which were negative for deep vein thrombosis. In
the Medical Intensive Care Unit at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **], the patient's blood pressure rapidly resolved
and he was successfully weaned from the Dopamine drip within
12 hours. With a stable blood pressure, he was transferred
to the floor for further management of his infection,
diabetes mellitus and blood pressure.
PHYSICAL EXAMINATION: On arrival to the floor, Mr. [**Known lastname **] was
afebrile with a temperature of 98.6, blood pressure 116/60,
heart rate 82, respiratory rate 18 and oxygen saturation 94%
in room air. General: Pleasant, elderly appearing male
sitting upright in a chair, speaking with a visitor, in no
acute distress, appearing very comfortable. Head, eyes,
ears, nose and throat: Normocephalic, atraumatic, pupils
equal, round, and reactive to light and accommodation,
exotropia of both eyelids, left greater than right and
bilateral conjunctivitis, oropharynx moist and clear. Neck:
No jugular venous distention appreciated, supple without
lymphadenopathy, no bruits. Cardiovascular: Regular rate
and rhythm, pronounced S1, soft S2 and no mechanical click
appreciated, no murmur, rub or gallop. Lungs: Bilateral
bibasilar crackles but no wheezes or rhonchi. Abdomen:
Soft, obese, nontender, nondistended, positive bowel sounds,
no costovertebral angle tenderness. Extremities: 3+ pitting
edema, erythema and warmth of right lower extremity
two-thirds of the way up the calf but no crepitus or
discoloration appreciated, no tenderness to palpation; both
feet were cool and there was good capillary refill in both
lower extremities. Neurologic examination: Alert and
oriented times three, moving all extremities symmetrically,
sensation grossly intact.
LABORATORY DATA: On admission to the medicine floor, white
blood cell count was 13.2, hematocrit 28.2, platelet count
131,000, INR 3, sodium 137, potassium 4.4, chloride 104,
bicarbonate 26, BUN 30, creatinine 1.3 and glucose 147.
Calcium, magnesium and phosphorous were normal. Creatinine
kinase was 604. Chest x-ray on [**2172-10-3**] showed a
subtle opacity in the right middle lobe without air
bronchograms, mild cardiomegaly but no congestive heart
failure; the right middle lobe opacity was of uncertain
significance. A repeat PA and lateral film was obtained,
however, was not available for final read at the time of
discharge.
Urine culture on [**2172-10-3**] was negative. Blood
cultures on the same day grew one out of four bottles of
group B streptococcus, the sensitivities of which were
pending at the time of discharge.
HOSPITAL COURSE: 1. Infectious disease: The patient was
switched to intravenous vancomycin 1 gram every 12 hours for
a history of Methicillin resistant Staphylococcus aureus in
the past of the same right lower extremity. He received
approximately six doses of vancomycin, with improvement in
the erythema and edema of his right lower extremity. As
mentioned earlier, the patient's blood cultures grew one out
of four bottles from [**2172-10-3**], group B streptococcus,
sensitivities of which were pending at the time of discharge.
In addition, the patient was continued to be treated with
erythromycin ointment for his conjunctivitis and he had a
follow-up chest x-ray for a questionable right middle lobe
infiltrate, the final read of which was not available by the
time of discharge.
2. Cardiovascular: The patient's blood pressure was stable,
running between 110 and 120/50 to 70 his entire time on the
floor. He required no Dopamine or pressors. He was
restarted on his Zestril and Coreg. In addition, he was
continued on aspirin.
3. Hematologic: The patient has a history of a mitral valve
replacement with a mechanical valve, per the patient. He was
being anticoagulated. However, on the floor, his last INR
was 1.4 and his target should be 3. At that point, he was
started on a heparin drip and, to bridge him to therapeutic
anticoagulation, warfarin. This heparin drip was continued
at the time of transfer to [**Hospital1 2436**].
The patient, throughout his first day, was continued on a
warfarin dose of 5 mg at bedtime and, on the day of
discharge, was increased to 7.5 mg at bedtime every other day
alternating with 5 mg every other day, the dose that he
originally came in on. In addition, during the interim, the
patient was treated with subcutaneous heparin for deep vein
thrombosis and pulmonary embolism prophylaxis.
4. Endocrine: The patient has type 2 diabetes mellitus. He
was covered with a regular insulin sliding scale on the floor
and restarted on his preadmission insulin dose of NPH 22
units in the morning and 6 units in the evening, and regular
insulin 8 units in the morning. His blood sugars generally
ran between 150 and 320.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Sepsis and bacteremia with group B streptococcus.
2. Coronary artery disease, status post coronary artery
bypass grafting and mitral valve replacement with mechanical
valve in [**2169**].
3. Right lower extremity cellulitis, questionable
osteomyelitis.
4. Diabetes mellitus.
5. Anemia.
DISCHARGE MEDICATIONS:
Aspirin 325 mg p.o.q.d.
Coreg 12.5 mg p.o.b.i.d.
Colace 100 mg p.o.b.i.d.
Erythromycin 0.5% ophthalmic ointment one application
o.u.q.i.d.
Eucerin cream.
Heparin drip dosed to a partial thromboplastin time of 60 to
80 as bridge to an INR of 3.
Insulin NPH 22 units q.a.m. and 6 units q.p.m.
Regular insulin 8 units q.a.m.
Zestril 5 mg p.o.q.d.
Warfarin 5 mg p.o.q.o.d.
Warfarin 7.5 mg p.o.q.o.d.
Protonix 40 mg p.o.q.d.
Vancomycin 1 gm i.v.q.12h.
FOLLOW-UP PLAN: Mr. [**Known lastname **] is to be transferred back to
[**Hospital3 **]. There, he requires the following
interventions:
1. Anticoagulation with a heparin drip for a target partial
thromboplastin time of 60 to 80 until INR can be brought up
to the target of 3 with his warfarin.
2. Echocardiogram given group B streptococcus bacteremia and
history of mitral valve replacement with a mechanical valve
to rule out thrombus.
3. Plain films and magnetic resonance imaging scan of right
foot in addition to an erythrocyte sedimentation rate to rule
out osteomyelitis of that foot.
4. Prolonged antibiotics for the group B streptococcus
bacteremia and possible osteomyelitis.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2172-10-6**] 14:07
T: [**2172-10-6**] 15:10
JOB#: [**Job Number **]
cc:[**Hospital3 **]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2541
} | Medical Text: Admission Date: [**2189-5-29**] Interim Date: [**2189-8-13**]
Date of Birth: [**2189-5-29**] Sex: M
Service: This is an interim summary covering the period, [**2189-5-29**]
to [**2189-8-13**].
HISTORY OF PRESENT ILLNESS: [**Known lastname 48325**] [**Known lastname 48326**]-[**Known lastname 449**] is a former
26 and [**2-27**] week infant who is being transferred to [**Hospital3 18242**] for repair of his bilateral inguinal [**Known lastname 41231**]s.
[**Known lastname 48325**] was born at 26 and 2/7 weeks by cesarean section for
preterm labor, premature rupture of membranes and breech
presentation. His mother is a 38 year old, Gravida IV, Para
II, now III woman. Her prenatal screens are blood type 0
positive, antibody negative, Rubella immune, RPR nonreactive,
hepatitis surface antigen negative and Group B strep unknown.
This pregnancy was complicated by a large uterine fibroid,
subchorionic hemorrhage, and cervical shortening. The mother
was treated with bed rest. She had rupture of membranes five
days prior to delivery. No maternal fever was noted.
However, due to the previous identified issues, decision was
made to deliver by cesarean section.
PAST OBSTETRIC HISTORY: Remarkable for loss of a 24 week
gestation infant at one day of life in [**2175**]. She then had a
term delivery in [**2176**].
The infant emerged without spontaneous respiratory effort.
His apgars were three at one minute, seven at five minutes
and seven at ten minutes. He required intubation in the
delivery room. The birth weight was 880 grams (50th
percentile). The birth length was 34 cms (25 to 50th
percentile) and the birth head circumference was 24 cms (25
to 50th percentile).
PHYSICAL EXAMINATION: Reveals an extremely premature infant
with bruising but pink centrally and with good perfusion.
Anterior fontanel soft and flat. Eyes with extensive
pupillary membrane. Breath sounds squeaky and coarse
initially, slightly decreased on the left. Heart with
regular rate and rhythm, no murmur. Abdomen: Flat, three
vessel umbilical cord. No organomegaly. Testes high in the
canals. Generalized low tone, consistent with gestational
age. Bruising of the upper and lower extremities, right
greater than left; some edema of the right upper arm.
Bruising of both feet and a stable hip examination.
HOSPITAL COURSE: Neonatal Intensive Care Unit course by
systems:
Respiratory status: [**Known lastname 48325**] was intubated in the delivery
room. He received two doses of Surfactant. He weaned to
nasopharyngeal continuous positive airway pressure on day of
life 33 and successfully weaned to nasal cannula oxygen on
day of life 52 and then weaned to room air on day of life 64,
where he has remained. He was treated with caffeine citrate
for apnea of prematurity from day of life 14 to day of life
66. He continues to have one to three episodes of apnea and
bradycardia in each 24 hours period.
On examination, he has some baseline mild subcostal
retractions. Lung sounds are clear and equal.
Cardiovascular status: [**Known lastname 48325**] required significant pressor
support for blood pressure with Dopamine and Dobutamine from
the time of admission until day of life #12. Since that
time, he has remained normotensive. He received some stress
doses of hydrocortisone on day of life #4 and #5. He was
also treated with a course of Indomethacin on day of life one
and two for a presumed patent ductus arteriosus.
A cardiac echo on [**2189-6-8**] revealed a patent foramen ovale
with left to right shunting and an otherwise structurally
normal heart. On examination, he has a one to two over six
systolic ejection murmur at the left upper sternal border. He
is pink and well perfused, consistent with peripheral
pulmonic stenosis.
Fluids, electrolytes and nutrition: Enteral feeds were begun
on day of life 15 and reached full volume feeding by day of
life 28. He was then increased to a maximum calorie enhanced
breast milk formula of 30 calories per ounce with added
Pro-Mod. At the time of transfer, his nutrition plan is 24
calories per ounce Enfamil on an ad lib schedule. He is
taking 120 to 140 cc per kg per day. His measurements on
[**2189-8-12**] are weight of 2,980 grams; length 48.5 cms and head
circumference of 32.5 cms.
His last electrolytes on [**2189-7-29**] were sodium of 144; potassium
of 4.6; chloride of 110; bicarbonate 24; BUN 15; creatinine
0.4. Increasing alkaline phosphatase levels to 540 from 436
prompted the initiation of Calciferol on day of life #62. He
is receiving 250 i.u. each day to provide 400 i.u. per kg per
day, combined with nutrition and supplementation. His
follow-up alkaline phosphatase one week after beginning the
Calciferol was 380. At that time, which was [**2189-8-6**], the
calcium was 10.2 and phosphorus was 6.4.
[**Known lastname 48325**] had a [**Hospital3 1810**] dental consultation by Dr.
[**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 36153**] on [**2189-7-29**]. He had two lower central incisor
natal teeth. Both became loose since that time and were
easily removed.
Gastrointestinal: [**Known lastname 48325**] was treated with phototherapy for
hyperbilirubinemia from day of life one to day of life 31.
His peak bilirubin occurred on day of life number one and was
total of 9.1, direct of 0.4.
An abdominal ultrasound done on [**2189-6-3**] for refractory
hypotension showed grossly normal kidneys and renal arteries.
[**Known lastname 48325**] has bilateral inguinal [**Known lastname 48327**], which is the reason
for his transfer.
Hematology: [**Known lastname 48328**] last hematocrit on [**2189-7-27**] was 24,
prompting a transfusion of packed red blood cells of 15 cc
per kg. That was his fifth transfusion of packed cells
during his Neonatal Intensive Care Unit stay.
He is blood type 0 positive, DAT negative. He is receiving
supplemental iron of 2 mg/kg per day of elemental iron.
Infectious disease: Ampicillin and Gentamycin were started
at the time of admission for sepsis suspected. He completed
14 days of these antibiotics for presumed sepsis. The blood
cultures did remain negative. On day of life 15, he was
started on Oxacillin for cellulitis of the left arm. After
five days of treatment of Oxacillin, clinical deterioration
prompted a change in antibiotic coverage to Vancomycin,
Gentamycin and Ceftazidime. At this time, day of life 19,
tracheal aspirate was positive for E. coli and Klebsiella.
At this time, the infant's mother was also being treated with
Gentamycin and Clindamycin for incisional infection. [**Known lastname 48325**]
completed an additional ten days of this antibiotic therapy.
Both blood and cerebrospinal fluid remained negative for
infection. At this time, the mother's breast milk showed
rare growth of pseudomonas and breast milk pumping was
discontinued. [**Known lastname 48325**] has remained off antibiotics since that
time. He did complete a seven day course of topical Nystatin
for a monilial diaper rash on [**2189-7-2**].
On routine skin surveillance cultures, the infant is positive
for pseudomonas.
Neurology: The first head ultrasound on [**2189-6-2**] showed a
question of a left germinal matrix hemorrhage. Follow-up
ultrasounds on [**6-9**] and [**2189-6-29**] were completely within normal
limits.
Sensory: Audiology -- hearing screening was performed with
automated auditory brain stem responses and the infant passed
in both ears.
Ophthalmology: The eyes were examined most recently on
[**2189-7-29**], revealing regressing stage I retinopathy of
prematurity, two to three clock hours, o.u. Follow-up
examination is scheduled in two to three weeks.
Psychosocial: Parents have been very involved in the
infant's care throughout the Neonatal Intensive Care Unit
stay.
The infant is being transferred to the [**Hospital3 1810**]
operating room for bilateral herniorraphy in good condition. The
primary pediatrician has not yet been identified by the family.
CARE AND RECOMMENDATIONS:
Feedings: Enfamil 24 calories per ounce on an ad lib
schedule.
MEDICATIONS:
Iron sulfate 25 mg/ml (0.35 cc) p.o. q. day.
Vitamin E 5 i.u. p.o. q. day.
Calciferol 250 i.u. p.o. q. day.
The infant has not yet had a car seat position screening
test.
Last state newborn screen was sent on [**2189-7-24**] and was
completely within normal limits. A previous specimen on
[**2189-6-14**] revealed a low thyroxine of 2.6 and so thyroid study
tests were done and they revealed a T4 level of 4 and a TSH
level of 4.8. At that time, an endocrine consult was
obtained from [**Hospital3 1810**] endocrine service and, at
that time, they felt that this required no treatment. It was
most likely thought to be euthyroid sick syndrome. Follow-up
thyroid function tests were within normal limits.
The infant has received the following immunizations:
Hepatitis B vaccine #1, [**2189-7-19**]; DtaP [**2189-7-31**]; HIB [**2189-7-31**];
IPV [**2189-8-1**]; pneumococcal 7-Valent conjugate vaccine [**2189-7-31**].
RECOMMENDED IMMUNIZATIONS:
Synagis-RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria:
1.) Born at less than 32 weeks.
2.) Born between 32 and 35 weeks with plans for day care
during the RSV season, with a smoker in the household or with
preschool siblings.
3.) With chronic lung disease.
Influenza immunization should be considered annually in the
Fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
INTERIM DIAGNOSES:
Status post prematurity at 26 and 2/7 weeks gestation.
Status post respiratory distress syndrome.
Apnea of prematurity.
Status post hyperbilirubinemia.
Status post hypotension.
Status post presumed patent ductus arteriosus.
Status post presumed sepsis.
Patent foramen ovale.
Status post lower central incisor natal teeth, times two.
Pseudomonas colonization.
Retinopathy of prematurity.
Anemia of prematurity.
Bilateral inguinal [**Known lastname 41231**]s.
Chronic lung disease.
Peripheral pulmonic stenosis.
Vitamin B deficiency.
Status post left arm cellulitis.
Status post Klebsiella/E. coli pneumonia.
Status post monilial diaper rash.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 36864**]
MEDQUIST36
D: [**2189-8-12**] 04:30
T: [**2189-8-12**] 06:03
JOB#: [**Job Number 48329**]
ICD9 Codes: 7742, 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2542
} | Medical Text: Admission Date: [**2193-9-23**] Discharge Date: [**2193-10-14**]
Date of Birth: [**2117-10-5**] Sex: M
Service: ACOVE
HISTORY OF THE PRESENT ILLNESS: The patient is a 75-year-old man
with a history of CHF (EF 30-40% as of [**2193-6-2**]), CAD, status
post inferior MI in [**2183**], hypertension, dyslipidemia, COPD,
insulin-dependent diabetes mellitus, and chronic renal failure
presenting with bilateral purple color changes and edema of his
lower extremities present since the end of [**Month (only) 205**]. The history was
obtained through his wife as the patient only speaks [**Name (NI) 8230**].
Since the end of [**Month (only) 205**], his legs have been purple colored,
swollen, and tender to the touch, left greater than right. His
wife reports that he has been on multiple antibiotics for
presumed cellulitis starting with amoxicillin 500 mg b.i.d. from
[**2193-8-15**] to [**2193-8-21**] followed by Zithromax 500 mg starting
[**2193-8-21**] followed by 250 mg p.o. q.d. on [**2193-8-22**] through
[**2193-8-26**]. However, per the medical records these antibiotics
were actually for bronchitis.
On [**2193-9-10**], he visited Dr. [**First Name (STitle) **], a cardiologist, who was
concerned about possible cellulitis and he was started on
cephalexin 500 mg t.i.d. There was concern that the edema and
erythema could be due to a DVT, but on [**2193-9-12**], Mr.
[**Known lastname **] had venous duplexes negative for lower extremity DVT
bilaterally. His wife states that the discoloration is neither
improving nor worsening. She states that he feels "okay",
although has complained of decreased appetite. She also states
that he had long-standing lower extremity edema bilaterally as
well as numbness bilaterally. He also complains of orthopnea
(sleeps in a Lazy Boy chair) and PND.
PAST MEDICAL HISTORY:
1. Paroxysmal atrial fibrillation.
2. CHF (echo in [**2193-6-4**]: LVEJ 30-40%, mild symmetric LVH,
severe hypokinesis of the inferior septum, inferior free
wall, and posterior wall, 1+ AR, 1+ MR, 1+ TR).
3. CAD, status post anterior MI in [**2183**].
4. Chronic renal failure with a baseline creatinine of 2.4.
5. Insulin-dependent diabetes mellitus.
6. COPD.
7. Hypertension.
8. Dyslipidemia.
9. Diabetic retinopathy.
10. Diabetic neuropathy.
11. Diabetic nephropathy.
12. Gout.
13. Urinary retention, likely secondary to BPH.
14. Status post bilateral cataract surgery in [**2189**].
15. Hyperkalemia in [**2193-5-2**] attributed to prerenal azotemia.
16. Bronchitis treated with antibiotics in [**2193-8-2**].
FAMILY HISTORY: Father with "heart congestion", died at the
age of 70 from pneumonia. Mother died at age 82 of an
unknown cause. Brother died at 75 years old from an MI.
SOCIAL HISTORY: The patient moved from [**Location (un) 6847**] in [**2149**].
Worked as a cook in the U.S. Has five grown children.
Reports [**Age over 90 **] year pack year history; however, quit smoking in
[**2183**] after his heart attack, denied alcohol.
ADMISSION MEDICATIONS:
1. Prednisolone eyedrops b.i.d.
2. Neurontin 100 mg t.i.d.
3. Metoprolol 25 mg b.i.d.
4. Avapro 75 mg q.d.
5. Flomax 0.4 mg q.d.
6. Fludrocortisone 0.1 mg q.d.
7. Lasix 80 mg p.o. q.d.
8. Senokot b.i.d.
9. Nexium 40 mg q.d.
10. Ferrous gluconate 325 mg q.d.
11. Allopurinol 100 mg q.d.
12. Colchicine 0.6 mg q.d. p.r.n. gout.
13. Lipitor 20 mg q.d.
14. Coumadin 2 mg q.d.
15. Oxycodone 5/325 one to two tablets q. four to six hours
p.r.n. pain.
16. Fluticasone propionate 110 micrograms two puffs b.i.d.
17. Albuterol sulfate/Ipratropium two puffs q.i.d.
18. Insulin NPH 46 units q.a.m., 20 units q.p.m., as well as
a regular insulin sliding scale.
ALLERGIES: The patient reports an allergy to Levaquin which
is manifested by a severe headache.
REVIEW OF SYSTEMS: The patient reports increased fatigue,
weakness, no fevers, chills, or night sweats. No shortness
of breath, a productive cough of light yellow sputum, history
of hypertension, orthopnea, PND, lower leg extremity,
however, currently denied chest pain, denied nausea,
vomiting, diarrhea, bright red blood per rectum, melena, or
abdominal pain. The patient does report urinary hesitancy,
no dysuria, however. Does report urinary dribbling.
PHYSICAL EXAMINATION ON ADMISSION: General: Appears stated
age, resting comfortably in bed, in no apparent distress.
Vital signs: Temperature 98.6, blood pressure 155/71, pulse
70, respiratory rate 22, 97% on room air. HEENT: The pupils
were asymmetric, not round; oropharynx clear without exudate;
no lymphadenopathy. Lungs: Crackles two-thirds of the way
up on the left, one-half of the way up on the right; some
decreased crackles with cough. Cardiovascular: Regular rate
and rhythm. No murmurs, rubs, or gallops. Laterally
displaced PMI; JVD not elevated. Abdomen: Positive bowel
sounds, soft, nontender, distended, no hepatosplenomegaly.
Vascular: 2+ femoral and popliteal pulses bilaterally,
unable to assess DP and PT pulses secondary to bilateral
edema of lower legs. Skin: Purple colored area on both
lower extremities two-thirds of the way up of the calf on the
left, half way up the calf on the right; scaling skin over
areas of color. Neurologic: The pupils were asymmetric and
not round. The extraocular movements were intact. No facial
droop. Facial movements were symmetric.
LABORATORY/RADIOLOGIC DATA: On admission, the patient had a
BUN of 47, creatinine 2.0, glucose 130. White blood cell
count 9.7, hematocrit 38.4, platelets 142,000.
HOSPITAL COURSE: 1. CORONARY ARTERY DISEASE: The patient
is status post MI in [**2183**]. An echocardiogram in [**2193-6-2**]
showed an EF of 30-40%, down from 45% in [**2193-5-2**]. When
the patient was admitted, he was taking a beta blocker, a statin,
and [**First Name8 (NamePattern2) **] [**Last Name (un) **]. Repeat echocardiogram on [**2193-9-24**],
hospital day number two, showed a moderate regional left
ventricular systolic dysfunction with an ejection fraction of
30-40% as well as severe hypokinesis of the inferior septum,
inferior wall, inferolateral walls. There was 1+ MR, AR, and TR
were noted. Compared to the study of [**2193-6-5**], there have been
no significant changes.
To optimize medical management, his dose of Valsartan was
increased to 150 mg p.o. q.d. He was started on an aspirin 325
mg p.o. q.d. Cardiology was consulted. On hospital day number
three ([**2193-9-25**]), the patient had a Persantine MIBI showing a
moderate sized reversible defect involving the lateral wall.
There was a severe fixed defect involving the base of the
inferior wall. There was global hypokinesia with an EF of 41%.
It was determined that the patient needed a cardiac
catheterization which was planned for hospital day number five
([**2193-9-27**]) but was postponed due to an INR of 2.1. The
catheterization was then rescheduled for hospital day number
eight ([**2193-9-30**]) but due to creatinine elevation to 2.9 as well
as the patient developing pneumonia, it was decided that the
patient would go home and follow-up with his cardiologist to
schedule a catheterization as an outpatient.
Due to the increased creatinine, the Valsartan was discontinued
on [**2193-9-29**] through [**2193-10-3**], at which point his
creatinine had normalized so the Valsartan was restarted at a
lower dose. However, the creatinine increased again. The
Valsartan was discontinued.
On hospital day number 12 ([**2193-10-4**]), he became
hypotensive to 70/palpable which was likely secondary to
dehydration. He was transferred to the MICU in the early morning
of [**2193-10-5**] (hospital day number 13) where he responded to
rehydration with normal saline. The MICU cardiac enzymes were
elevated, likely reflecting an acute MI. He was returned to the
floor on [**2193-10-7**].
2. ATRIAL FIBRILLATION: The patient has a history of paroxysmal
atrial fibrillation; however, during his hospitalization, the
patient was in sinus rhythm. The patient arrived on Coumadin,
was switched at one point to heparin in order to have the cardiac
catheterization, but once it was determined that he would not
have catheterization on this admission, he was put back on
Coumadin.
3. CONGESTIVE HEART FAILURE: The patient arrived with 2+ lower
extremity edema bilaterally thought to be due to fluid overload.
The patient was switched from his Lasix 80 mg p.o. q.d. to 40 mg
IV b.i.d. with good effect. He was also put on 2 gram per day
sodium chloride diet and fluid-restricted to 2 liters of water
per day. As he diuresed, the Lasix was decreased and eventually
he was returned to his home dose of 80 mg p.o. q.d. However,
once the creatinine increased, his Lasix was discontinued.
4. PNEUMONIA: Upon arrival at the hospital, the patient did
report a productive cough and had a history of bronchitis in
[**Month (only) 216**] of this year. His chest x-ray, however, at that time was
clear for infiltrates. On [**2193-9-27**] (hospital day
number five), his 02 saturations dropped to 88-90% on room air. A
chest x-ray still showed no changes and it was believed that
these saturations were due to CHF and he was given Lasix 40 mg IV
times one. However, on hospital day number six ([**2193-9-28**]), the patient had shaking chills, cough productive of sputum
and a chest x-ray that showed chronic bronchial and bronchiolar
abnormalities at the lung bases which could be due to either
recurrent or chronic aspiration or a persistent atypical
infection. At that point, he was started on ceftriaxone and
azithromycin. Sputum initially showed gram-positive clusters in
pairs and gram-negative rods. The patient was started on
ceftazidime and vancomycin. The sputum grew out pan sensitive
Pseudomonas and the antibiotics were then changed to
ceftazidime and ciprofloxacin.
At one point, the patient was started on vanco but it was thought
to be causing a drug fever and the vancomycin was discontinued.
When the patient was still feeling poor with the cough still
productive of sputum on hospital day number 17 ([**2193-10-8**]),
concern was raised of the possibility of the patient having TB.
The patient was placed in a negative pressure room. A PPD was
placed and sputum was obtained for AFB culture and smear. The
PPD was negative and as of this dictation, two sputums have been
obtained, both negative by smear for AFB. In addition, on
[**2193-10-8**] (hospital day number 17), the patient had an
abdominal chest CT which showed persistent multifocal pneumonia
but no evidence of bowel obstruction or abscess. The patient
will be discharged from the hospital and receive seven additional
days of cipro and ceftazidime in the rehabilitation facility.
5. INSULIN-DEPENDENT DIABETES MELLITUS: At home, the patient
takes NPH before breakfast and dinner as well as a sliding scale
of regular insulin. These medications were continued but on
hospital day number three when the patient was n.p.o. for the
MIBI, the patient had an episode of hypoglycemia to a glucose of
38. The hypoglycemia was resolved with an amp of D50 and food.
The patient's NPH was decreased and has been adjusted daily since
then.
6. ELECTROLYTES: When the patient was admitted, he was
taking Florinef for hypokalemia. The Florinef was discontinued
due to concern that it was exacerbating his CHF. When his sodium
began to drop and his potassium started to rise, a low dose
cortisone stimulation test was performed which showed that he was
not adrenally insufficient.
7. ACUTE ON CHRONIC RENAL FAILURE: The patient has a known
creatinine baseline of 2.4. When the patient was admitted,
his creatinine was 2.0. On [**2193-9-30**], his
creatinine bumped to 2.9 and Renal was consulted. His [**Last Name (un) **]
was discontinued. His creatinine normalized and the [**Last Name (un) **] was
started at a lower dose which then caused another bump in the
creatinine. At that point, the [**Last Name (un) **] was again discontinued.
All medications were renally dosed.
8. VASCULAR: The patient reported intermittent bilateral
leg pain. There was concern that this might represent
arterial insufficiency versus diabetic neuropathy. On
hospital day number four ([**2193-9-26**]), the patient
had Doppler studies of both lower extremities showing
essentially normal Doppler flow through the legs. His
Neurontin was increased from 100 mg t.i.d. to 300 mg t.i.d.
and was eventually decreased back down to 100 mg t.i.d. given
his renal failure. In addition, a chest CT of the abdomen on
[**2193-10-8**], showed findings concerning for chronic
aortic dissection involving a short segment of the descending
aorta. However, this appearance was unchanged from [**2193-1-2**] so it was decided not to pursue this further.
9. VENOSTASIS: Legs show violaceous changes consistent with
chronic venostasis. The patient was treated with diuresis,
TEDS, and Eucerin cream.
10. CELLULITIS: On hospital day number three, [**2193-9-25**], the medial side of his left calf had increasing warmth
and erythema. He was placed on Ancef for several days.
11. SKIN ULCERS: The patient developed small ulcers on both
heels and the patient's legs were placed in waffle boots.
The patient also developed erythema over the sacrum and the
patient was given a therapeutic mattress and encouraged to be
out of bed to chair.
12. BENIGN PROSTATIC HYPERTROPHY: The patient has a history
of BPH, treated with Flomax. On [**2193-9-30**], the
patient complained of inability to empty his bladder and a
Foley was placed. The next day, the patient had an eight
hour voiding trial and was able to void without difficulty.
The Foley was discontinued.
13. GOUT: The patient reports a history of gout, although
it is not clear if this has ever been confirmed by aspiration
or crystal analysis. On [**2193-10-3**] (hospital day number
11), the patient reported pain on the side of the ankle and a
Rheumatology consultation was obtained over concern that this
might represent a flare of gout. Aspiration of the left
ankle produced only a few drops of fluid which showed no
crystals, only a few polys on Gram's stain and grew no
organisms on culture. It was deemed unlikely for his pain to
be due to gout. An x-ray of his ankle was obtained showing
no fracture dislocation. His pain was most likely
multifactorial, being a combination of stasis dermatitis and
neuropathy from diabetes.
DISCHARGE DISPOSITION: The patient will be discharged to a
rehabilitation facility.
CONDITION ON DISCHARGE: Fair.
DISCHARGE MEDICATIONS:
1. Prednisolone acetate 1% drops, one drop to both eyes
twice a day.
2. Flovent 110 micrograms two puffs b.i.d.
3. Combivent two puffs q. six hours.
4. ASA 325 mg p.o. q.d.
5. Calcium acetate 667 mg p.o. t.i.d. with meals.
6. Gabapentin 100 mg p.o. t.i.d.
7. Allopurinol 100 mg p.o. q.d.
8. Lipitor 20 mg p.o. q.d.
9. Flomax 0.4 mg p.o. q.h.s.
10. Ciprofloxacin 500 mg p.o. q. 24 hours.
11. Metoprolol 12.5 mg p.o. b.i.d.
12. Warfarin 2 mg p.o. q.d.
13. Nitroglycerin 0.4 mg sublingual p.r.n. chest pain.
14. Percocet 5/325 mg p.o. q. four to six hours p.r.n. pain.
15. Insulin NPH as directed, a regular sliding scale as
directed.
16. Ceftazidime 2 grams IV q. 24 hours.
17. Atrovent nebulizer q. six hours p.r.n. shortness of
breath or wheezing.
18. Albuterol nebulizers q. four to six hours p.r.n.
shortness of breath or wheezing.
19. Hydromorphone 0.5 to 2.0 mg q. three to four hours p.r.n.
pain.
20. Nexium 40 mg p.o. q.d.
21. Dulcolax 10 mg p.o. q.d.
22. Colace 100 mg p.o. b.i.d.
23. Ferrous gluconate 300 mg p.o. q.d.
24. Senna 8.6 mg p.o. b.i.d.
DISCHARGE DIAGNOSIS:
1. Pseudomonal pneumonia.
2. Acute on chronic renal failure.
3. Coronary artery disease, status post myocardial
infarction.
4. Paroxysmal atrial fibrillation.
5. Congestive heart failure.
6. Insulin-dependent diabetes mellitus.
7. Chronic obstructive pulmonary disease.
8. Hypertension.
9. Dyslipidemia.
10. Diabetic retinopathy.
11. Diabetic neuropathy.
12. Diabetic nephropathy.
13. Gout.
14. Urinary retention, likely secondary to benign prostatic
hypertrophy.
15. Bilateral cataract surgery in [**2189**].
16. Hyperkalemia in [**2193-5-2**] attributed to prerenal
azotemia.
17. Bronchitis in [**2193-8-2**], treated with antibiotics.
DISCHARGE INSTRUCTIONS: Please take all medications as
directed. If the patient feels increasingly short of breath
or cough worsens, call the primary care physician. [**Name10 (NameIs) **] the
patient feels any chest pain or pressure go to the Emergency
Room. The patient is to see his primary care physician
within two weeks. The patient should also follow-up with his
cardiologist, Dr. [**First Name8 (NamePattern2) 1026**] [**Name (STitle) 1016**], call [**Telephone/Fax (1) 13450**] for an
appointment. The patient should also schedule a chest x-ray
in six to eight weeks. The patient also has an appointment
with Dr. [**Last Name (STitle) **] on [**2193-10-15**] at 1:45. The patient has
an appointment with Dr. [**First Name8 (NamePattern2) 3122**] [**Name (STitle) 1860**] on [**2193-10-21**] at
1:30. The patient also has an appointment with Dr. [**First Name8 (NamePattern2) 2197**]
[**Last Name (NamePattern1) 10895**] on [**2193-12-5**] at 1:00 p.m.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 44883**]
MEDQUIST36
D: [**2193-10-11**] 02:04
T: [**2193-10-11**] 18:17
JOB#: [**Job Number 44884**]
ICD9 Codes: 4280, 5849, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2543
} | Medical Text: Admission Date: [**2172-9-24**] Discharge Date: [**2172-10-5**]
Date of Birth: [**2103-8-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2172-9-24**] cardiac catheterization
[**2172-9-25**] IABP
[**2172-9-25**] CABG x3(LIMA-LAD, SVG-OM, SVG-PDA)
History of Present Illness:
60 year old male complains of noticing mild dyspnea with
exertion, more noticeable as compared to last year. He also
describes occasional chest pain that is responsive to SL
nitroglycerin. This typically occurs after a large meal, but may
also happen with exertion. He has used [**3-20**] nitro over the past
four months. He was referred for left heart catheterization.
He was found to have left main disease and was referred for
cardiac surgery. On the night before going to the operating room
for revascularization he experienced further chest pain with EKG
changes and an IABP was placed.
Past Medical History:
Past Medical History:
Hypertension
Hyperlipidemia
[**2167**]: presumed CAD by ETT (RCA ischemia)
LV mural thrombus consistent with MI, on Coumadin
Type 2 Diabetes Mellitus
Osteoarthritis
Obesity
Glaucoma s/p surgery bilaterally
Bilateral cataract surgery with lens implants
Past Surgical History:
s/p tonsillectomy
Social History:
Race:Caucasian
Last Dental Exam: 1 year ago, upper dentures, bottom native
teeth
Lives with: wife who has [**Name (NI) 2481**], diagnosed in her early
60's
Contact: [**Name (NI) **](son) cell: [**Telephone/Fax (1) 90847**]
Occupation: retired post office worker
Cigarettes: Smoked no [x] Other Tobacco use:denies
ETOH: < 1 drink/week [x]
Illicit drug use:denies
Family History:
Family History: Premature coronary artery disease- Father died
from an MI at age 75. Mother died from a stroke at age 74.
Physical Exam:
Pulse:64 Resp:16 O2 sat:100/RA
B/P Right:96/64 Left:120/56
Height:5'[**72**]" Weight:228 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm []x, well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right2+: Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit none pulses Right: 2+ Left:2+
Pertinent Results:
Admission Labs:
[**2172-9-24**] 03:16PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.032
[**2172-9-24**] 03:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-7.5 LEUK-NEG
[**2172-9-24**] 02:20PM GLUCOSE-100 UREA N-17 CREAT-1.0 SODIUM-137
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13
[**2172-9-24**] 02:20PM ALT(SGPT)-17 AST(SGOT)-18 LD(LDH)-193 ALK
PHOS-43 AMYLASE-37 TOT BILI-2.3*
[**2172-9-24**] 02:20PM LIPASE-28
[**2172-9-24**] 02:20PM ALBUMIN-3.6
[**2172-9-24**] 02:20PM %HbA1c-6.2* eAG-131*
[**2172-9-24**] 02:20PM WBC-6.5 RBC-4.19* HGB-14.5 HCT-39.9* MCV-95
MCH-34.6* MCHC-36.4* RDW-13.2
[**2172-9-24**] 02:20PM PLT COUNT-160
[**2172-9-24**] 02:20PM PT-15.1* PTT-23.5 INR(PT)-1.3*
[**2172-9-24**] 10:45AM GLUCOSE-111* UREA N-17 CREAT-0.9 SODIUM-137
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14
Cardiac Catheterization: [**2172-9-24**]
1. Coronary angiography in this right dominant system
demonstrated left
main and 1 vessel disease. The LMCA had a 95% distal stenosis.
The LAD
had minimal luminal irregularities, and D1 40% stenosis. The LCX
had
minimal irregularities. The RCA had a proximal 100% stenosis
with distal
vessel filling via right to right collaterals.
2. Due to differential blood pressure in both arms, left
subclavian
angiogram was performed. It was widely patent.
3. Left ventriculography was defferred.
4. Limited resting hemodynamics revealed normal systemic
systolic and
diastolic pressures. (106/60 mmHg)
FINAL DIAGNOSIS:
1. Left Main and one vessel coronary artery disease.
disease.
Carotid US: [**2172-9-24**]
IMPRESSION: 40-59% stenosis in the right internal carotid artery
and no
evidence of significant carotid artery stenosis in the left
internal carotid artery
[**2172-10-4**] 04:13AM BLOOD WBC-9.3 RBC-3.33* Hgb-11.3* Hct-31.8*
MCV-96 MCH-33.9* MCHC-35.4* RDW-16.3* Plt Ct-245
[**2172-10-3**] 04:05AM BLOOD WBC-11.0 RBC-3.49* Hgb-11.8* Hct-32.8*
MCV-94 MCH-33.7* MCHC-35.9* RDW-17.6* Plt Ct-223
[**2172-10-2**] 04:07AM BLOOD WBC-9.7 RBC-3.53* Hgb-12.0* Hct-33.0*
MCV-93 MCH-34.0* MCHC-36.4* RDW-17.4* Plt Ct-194
[**2172-10-5**] 03:57AM BLOOD PT-33.1* INR(PT)-3.3*
[**2172-10-4**] 04:13AM BLOOD PT-42.1* INR(PT)-4.3*
[**2172-10-3**] 11:49AM BLOOD PT-51.0* INR(PT)-5.4*
[**2172-10-3**] 04:05AM BLOOD PT-48.1* PTT-36.7* INR(PT)-5.1*
[**2172-10-2**] 04:07AM BLOOD PT-37.8* INR(PT)-3.8*
[**2172-10-1**] 04:34AM BLOOD PT-23.6* INR(PT)-2.2*
[**2172-9-30**] 04:21AM BLOOD PT-16.8* PTT-30.3 INR(PT)-1.5*
[**2172-9-29**] 03:54AM BLOOD PT-17.2* PTT-29.1 INR(PT)-1.5*
[**2172-9-28**] 02:48AM BLOOD PT-16.2* PTT-31.8 INR(PT)-1.4*
[**2172-10-5**] 03:57AM BLOOD UreaN-26* Creat-1.1 Na-139 K-4.2 Cl-104
[**2172-10-4**] 04:13AM BLOOD UreaN-27* Creat-1.2 Na-136 K-3.4 Cl-100
[**2172-10-3**] 04:05AM BLOOD Glucose-105* UreaN-30* Creat-1.2 Na-141
K-4.1 Cl-103 HCO3-27 AnGap-15
Brief Hospital Course:
Mr [**Known lastname **] was admitted for cardiac catheterization and found to
have left main and right coronary artery disease. Cardiac
surgery was consulted and he was scheduled for surgery the
following day. He had further angina the night before surgery so
an IABP was placed. He was brought to the operating room on
[**2172-9-25**] for coronary bypass grafting, please see operative report
for details. In summary he had: coronary bypass grafting x3 with
left internal mammary artery to left anterior descending artery,
reverse saphenous vein graft to obtuse marginal artery and
reverse saphenous vein graft to posterior descending artery. His
bypass time was 81 minutes with a crossclamp time of 59 minutes.
He tolerated the operation well and was transferred to the
cardiac surgery ICU in stable condition. He was transfused
multiple units of packed red blood cells for bleeding in the
immediate post-op period. He initially required hemodynamic
support with IABP, Levophed and Vasopressin. Drips and IABP
were weaned and the patient was extubated on POD 2. He
developed post-op a-fib and was started on amiodarone. He has a
history of thrombus and coumadin was resumed. He was noted to
have a small amount of sternal drainage and was started on
Kefzol. Drainage resolved and he will not be discharged on
antibiotics.
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 10 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home with VNA in good condition with
appropriate follow up instructions. [**Location (un) 2274**] Post Office Square
will continue to follow coumadin.
Medications on Admission:
ATENOLOL 50 mg Tablet - 1 Tablet(s) by mouth daily (AM)
GLIPIZIDE 5 mg Tablet - 1/2-1 Tablet(s) by mouth every morning
LISINOPRIL 10 mg Tablet - 1 Tablet(s) by mouth every morning
NITROGLYCERIN [NITROSTAT] 0.4 mg Tablet, Sublingual - 1
Tablet(s)
sublingually every five minutes for chest discomfort. Call 911
if
pain persists longer than 15 minutes
SIMVASTATIN 80 mg Tablet - 1 Tablet(s) by mouth every evening
SPIRONOLACTONE 25 mg Tablet - 1 Tablet(s) by mouth every morning
WARFARIN 2.5 mg Tablet - 2 Tablet(s) by mouth daily as directed
by [**Location (un) 2274**] coumadin clinic. Last dose [**2172-9-19**] pre cath/ICD
Medications - OTC
ASPIRIN 325 mg Tablet - 1 Tablet(s) by mouth every morning
MULTIVITAMIN Dosage uncertain
--------------- --------------- --------------- ---------------
Plavix - last dose:None
Coumadin: Last dose [**2172-9-20**]
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication
Goal INR 2-2.5
First draw [**2172-10-6**]
Results to phone [**Telephone/Fax (1) 90848**], [**Hospital 2274**] [**Hospital **] clinic- [**Doctor First Name **] for
Dr. [**Last Name (STitle) 6512**]
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
[**Hospital 2274**] [**Hospital **] clinic to manage for goal INR 2-2.5.
Disp:*30 Tablet(s)* Refills:*2*
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then
200mg daily.
Disp:*120 Tablet(s)* Refills:*2*
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
10. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
s/p coronary bypass grafting x3
PMHx: Hypertension, Hyperlipidemia, [**2167**]: presumed CAD by ETT
(RCA ischemia), LV mural thrombus consistent with MI, on
Coumadin, Type 2 Diabetes Mellitus, Osteoarthritis, Obesity,
Glaucoma s/p surgery bilaterally, Bilateral cataract surgery
with lens implants, s/p tonsillectomy
Discharge Condition:
Alert and oriented x3 non-focal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE appt, [**Last Name (NamePattern1) 439**], 2A Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2172-10-13**] 11:00
Surgeon:[**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2172-10-28**] at 1:45
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6512**] on [**10-16**] at 9:50am
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 639**],[**First Name3 (LF) 640**] N. [**Telephone/Fax (1) 644**] in [**4-21**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication
Goal INR 2-2.5
First draw [**2172-10-6**]
Results to phone [**Telephone/Fax (1) 90848**], [**Hospital 2274**] [**Hospital **] clinic- [**Doctor First Name **] for
Dr. [**Last Name (STitle) 6512**]
Completed by:[**2172-10-5**]
ICD9 Codes: 2760, 4111, 2851, 9971, 4254, 412, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2544
} | Medical Text: Admission Date: [**2178-10-17**] Discharge Date: [**2178-10-20**]
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
resp distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo female with recent dx of metastatic adenocarcinoma of the
gallbladder with invasion of hte right colon and with liver
metastasis now s/p ccy and right colectomy presents from her
rehab facility with worsening resp status. Pt initally admitted
to [**Hospital1 18**] [**Last Name (un) 4068**] on [**2178-8-29**] with abd pain. CT scan showed mass
in BG. Pt underwent open laparotomy. Her post-op course was
complicated by GI bleed felt to be [**2-5**] erosions at anastomotic
site, CHF with labile BP after diresis, hypercarbic resp
failure, PNA with highly resistent Enterobacter, Pseudomonas and
MRSA, treated with 14 days of Vanc, Aztreonam and Flagyl. She
was discharged to rehab facility on [**10-12**] with the regimen of 4
hours on Bipap and 4 hours off due to her hypercarbic resp
failure. Over the last day, pt required continuous BIPAP and
has had worsening resp status.
.
In [**Name (NI) **], pt found to have ABG of 7.25/81/145. Pt received
Vanc/Levo/Flagyl for presumed PNA and elevated WBC. Pt is
DNR/DNI.
Past Medical History:
htn
secondary av block s/p pacemaker
avr tissue
hypothyroidism s/p thryoidectomy
polymyalgia rheumatica
osteoarthritis
GI bleed
Social History:
unable to obtain
Family History:
unable to obtain
Physical Exam:
95.3 65 120/73 22 100% on BIPAP 50%
GEN: somnelent but arousable; answers to name. Responds to yes,
no.
HEENT: MM dry
NECK: supple, elevated JVD
CV: distant heart sounds, regular, no murmurs
PULM: difficult to assess due to bipap, no rales or rhonchi at
bases
ABD: well healed scar at midline; gtube intact
EXT: anasarca, right arm more edematous than left; bilateral LE
edema to knees
NEURO: somnelent. Moving all ext.
Pertinent Results:
.
134 93 80
-------------< 154
4.7 32 1.1
14.4 > 11.7 < 290
35.8
N:88.8 L:8.0 M:2.6 E:0.1 Bas:0.4
PT: 11.7 PTT: 33.0 INR: 1.0
proBNP: [**Numeric Identifier **]
CXR: Cardiac failure. Small left pleural effusion with adjacent
retrocardiac atelectasis/consolidation.
UE US: No evidence of DVT in the right upper extremity.
Brief Hospital Course:
89 yo f with metastatic cholangiocarcinoma p/w worsening
hypercarbic resp failure.
.
# RESP FAILURE:
Pt had ongoing hypercarbic resp failure requiring intermittent
BIPAP at nursing home, then requiring full time bipap on
admission. Resp failure was [**2-5**] decompensated CHF, which was
evident on physical exam and on xray. Her BNP was over 60,000.
The goal was to diurese her with IV lasix but this was limited
by her low bp.
.
She was afebrile but she had leukocytosis with left shift, which
raises the possibility of PNA also. She was pan-cultured and
started emperically on vanc and meropenem.
.
She continued to decompensate, becoming acidemic, hypoxic and
hypercarbic. She developed acute renal failure from diuresis
and poor foward flow. The family decided, given the patients
multiple medical problems including a poor prognosis from
metastatic cholangiocarcinoma and end stage heart failure, to
make the patient comfort measure only.
.
The patient expired on [**2178-10-20**] at 4:35 AM.
.
# UTI: culture sent. Covered emperically with vanc and
meropenem.
.
# Cholangiocarcinoma: Pt has metastasis to liver and colon, s/p
ccy and right colectomy. There were no futher plans for
intervention.
.
# PMR: chronic steroids
Medications on Admission:
florinef 0.1 mg daily
lopresor 12.5 daily
lovenox 40 daily
prednisone 5 daily
lasix 40 [**Hospital1 **]
synthroid 125 daily
mag-ox
timoptic eye gtt
Discharge Medications:
Pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Pt expired.
Discharge Condition:
Pt expired.
Completed by:[**2178-12-14**]
ICD9 Codes: 5859, 5990, 4280, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2545
} | Medical Text: Admission Date: [**2161-8-16**] Discharge Date: [**2161-9-3**]
Date of Birth: [**2161-8-16**] Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] ([**Known lastname 449**]) [**Known lastname **] is an ex-33 week baby boy twin
gestation born to a 39-year-old G8, P5 woman whose pregnancy
was complicated by preterm labor requiring admission at the
end of [**Month (only) 205**] treated with magnesium sulfate and betamethasone.
Mother was readmitted several days prior to admission with
contractions. Progression of labor prompted C-section due to
fetal positioning. Maternal history was notable for recurrent
UTIs for which mother was treated with [**Name (NI) 62403**].
Prenatal screens were complete and unremarkable: O-positive,
HBsAg-negative, RPR nonreactive, rubella
immune, and GBS unknown.
At the time of delivery, baby 1 emerged, was vigorous, given
blow-by O2 and stimulated with Apgars of 8 and 9 and brought
to the NICU for prematurity.
PHYSICAL EXAM ON ADMISSION: Baby was noted to be pink,
active, and nondysmorphic, well saturated, and perfused in
room air. Skin: Without lesions. HEENT: Within normal limits.
Cardiovascularly: Normal S1, S2 without murmurs. Lungs were
clear to auscultation. Looked comfort appearing. Abdomen:
Benign. Hips: Normal. Genitalia: Normal preemie male. Testes
in canals bilaterally. Neuro exam was nonfocal and age
appropriate with spine intact. Birth weight was 2,205 grams.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Patient
was admitted to the NICU and always maintained on room air.
No ventilatory support was ever indicated. No surfactant
given. Patient never received oxygen therapy. No apnea.
Cardiovascular: Patient has been stable with normal heart
rates and stable blood pressures.
Fluid, electrolytes, and nutrition: On day of life #1,
patient was NPO and receiving IV fluids of D10W. On day of
life #2, patient started with p.o./pg feeds. On day of life
#16, patient achieved full p.o. feeds of breast milk and/or
Enfamil Premature 24 every 3 hours with a current weight of
2,595 grams.
Gastrointestinal: On day of life #4, patient was noted with
hyperbilirubinemia of 11.2/0.4. Phototherapy x1 was started.
Phototherapy was discontinued on day of life #6 with a
rebound bilirubin then obtained of 7.1/0.3. Phototherapy was
never reinstituted.
Hematology: Patient with no known set up. Never transfused
throughout this hospital stay.
Infectious disease: Patient was started on ampicillin and
gentamicin on day of life 0 for 48-hour rule out for rule out
sepsis. Blood cultures currently negative to date. Initial
CBC was unremarkable.
Neurologically: Patient has a normal physical exam with
normal reflexes normal of normal suck, grasp, and morrow.
Head ultrasound was not indicated for this infant.
Sensory exam: Hearing screen is recommended prior to
discharge.
Ophthalmology: Eye exam was not indicated for this ex33 week
baby, who was maintained on room air and had a birth weight
of 2,205 grams.
Psychosocial: The [**Hospital1 18**] social worker is involved with the
family. The contact social worker can be reached at [**Telephone/Fax (1) **].
Patient is currently in stable condition at the time of
discharge.
DISCHARGE DISPOSITION: Is to home with home. Primary care will
be with [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 43361**], PNP, [**Hospital1 **] Primary Care Center.
CARE AND RECOMMENDATIONS: Feeds at discharge: Patient will
be continued on 24-calorie Enfamil and/or breast milk p.o. ad-
lib. Patient is currently on no medications. Patient needs
car seat test prior to discharge to home. Newborn screen
initially done on [**8-19**] showed elevated 17-
hydroxyprogesterone of 63.7. Repeat newborn screen sent on
[**8-24**], was normal.
IMMUNIZATIONS: Patient received the 1st hepatitis B vaccine
on [**8-25**].
IMMUNIZATIONS RECOMMENDED: Besides the normal pediatric
schedule, Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 3: 1. Born at less than 32 weeks, 2. Born between
32 and 35 weeks with 2 of the following: Daycare during the
RSV season, a smoker in the household, neuromuscular disease,
airway abnormalities, or school-age siblings, or 3. With
chronic lung disease.
1. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
FOLLOW UP: Follow-up appointments to be scheduled by parents
with pediatrician.
DISCHARGE DIAGNOSES:
1. Rule out sepsis, status post antibiotics x48 hours with
blood cultures negative to date.
2. Hyperbilirubinemia now resolved status post phototherapy.
3. Prematurity
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Last Name (NamePattern1) 62404**]
MEDQUIST36
D: [**2161-9-2**] 11:31:40
T: [**2161-9-2**] 11:51:42
Job#: [**Job Number 62405**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2546
} | Medical Text: Admission Date: [**2162-5-3**] Discharge Date:
Date of Birth: [**2108-11-18**] Sex: F
Service: MED
DISCHARGE DATE: Pending.
HISTORY OF PRESENT ILLNESS: This is a 53 year old woman nine
months status post cadaveric renal transplant for adult
polycystic kidney disease with postoperative course
complicated by pericardial effusion status post drainage and
eventual window followed by reactivation CMV infections and
then MRSA bacteremia endocarditis status post two courses of
vancomycin. She presents two weeks after completion of her
second course of vancomycin after waking up the morning prior
to admission with temps to 103. She took four Tylenol and the
temperature came down to 99. She went to sleep but woke up
the morning of admission with persistent temperature, called
her cousin to bring her into the Emergency Room and was also
noted to have confusion, lethargy with some nausea, vomiting,
diarrhea, headaches and generalized achiness all over. She
denied any focal symptoms of cough, runny nose or chronic
sinusitis. She was short of breath but has a history of
asthma, unclear if changed from baseline. She did become
dyspneic while talking to us on examination but denied chest
pain, abdominal pain, dysuria.
PAST MEDICAL HISTORY: Status post cadaveric renal transplant
in [**2161-8-3**] for adult polycystic kidney disease, type
II diabetes, currently on sliding scale insulin at home.
Hypertension.
Hypercholesterolemia.
Status post recurrent MRSA endocarditis in the mitral valve
Status post CMV reactivation treated with Valcyte and has had
negative titers post-treatment.
Asthma.
GERD.
Status post pericardial effusion, status post drainage and
window in [**2162-1-3**].
Status post TAH for fibroids.
Status post tubal ligation.
ALLERGIES: Zestril causes tongue and lip swelling,
Pentamidine causes bronchospasm, Bactrim and dapsone causing
[**Doctor First Name **]-[**Location (un) **] syndrome.
MEDICATIONS ON ADMISSION: Sliding scale insulin, tacrolimus
7 mg [**Hospital1 **], prednisone 5 mg qd, Advair [**Hospital1 **], albuterol prn,
Lasix 40 mg po qd, atorvastatin po qd, Aciphex 20 mg po qd,
Procrit 10,000 units q Friday and Neurontin 300 mg qhs.
SOCIAL HISTORY: She is the oldest of three daughters married
to her third husband. She has adult children and lives with
her husband.
FAMILY HISTORY: Positive for adult polycystic kidney disease
and diabetes.
PHYSICAL EXAMINATION: On admission, temperature was 104.4.
blood pressure 140/52, heart rate 120, respiratory rate 18,
sating 98 percent on room air. In general, she was confused,
ill-appearing in no acute distress, talking complete
sentences with mild dyspnea. HEENT - pupils were equal, round
and reactive to light. There were moist mucous membranes.
Extraocular muscles were intact. Heart was regular and
tachycardic with normal S1 and S2, [**2-6**] murmur loudest at the
apex. Pulmonary exam was clear to auscultation bilaterally
with no wheezes, rales or rhonchi. Abdomen was soft,
nontender, nondistended with positive bowel sounds, positive
palpable kidney in her right lower quadrant. Extremities - no
edema, no splinter, [**Last Name (un) 1003**] or Osler lesions. Neurologic exam
- she was initially oriented times two. Cranial nerves were
intact and good strength and sensation in all four
extremities.
LABORATORY: On admission, white count was 10.8, hematocrit
28.0, platelets 209, sodium 138, K 4.3, chloride 101, bicarb
22, BUN 43, creatinine 2.6, glucose 299, calcium 8.8,
magnesium 1.5, CK 46, troponin 0.20. Albumin was 3.7. INR was
1.5. ALT was 8, AST 12, amylase 32, alkaline phosphatase 91,
LDH 338, lipase of 15 and total bilirubin of 0.9. EKG was
sinus tachycardic at 106 as well as left axis, no LVH, T wave
inversions in AVL and T wave flattening in V5 through V6.
Chest x-ray showed linear atelectasis within the mid left
lung zone, probable pulmonary arterial hypertension and
pericardial effusion.
HOSPITAL COURSE: This is a 53 year old woman with adult
polycystic kidney disease status post renal transplant in
[**2161-8-3**] complicated by MRSA endocarditis of the mitral
valve in [**Month (only) 956**] and [**2162-3-4**] with also a pericardial
effusion requiring window in [**2162-1-3**] who presents with
fever, mental status changes and acute renal failure. The
patient was initially admitted to the MICU, was started on
vancomycin, Zosyn and ceftriaxone and had TEE done in the
Emergency Department. TEE confirmed mitral valve vegetations
that were changing in size from her previous TEE. Later that
evening in the MICU, the patient had an LP done with 700
white blood cells and poly predominance and 200 white blood
cells, initially gram stain negative for 4+ PMNs. She also
initially had CT and MRI of the head which were essentially
negative. Blood cultures drawn in the Emergency Department
came back later that evening with two out two and then four
out of four gram positive cocci in pairs and clusters which
apparently turned into MRSA. The patient's mental status
improved and the patient was transferred to the floor.
PROBLEM LIST: MRSA bacteremia: The patient continued to
have positive blood cultures during her hospitalization. The
patient was continued on vancomycin, started on rifampin and
was also treated with a seven day course of gentamicin to
help try to clear her of her MRSA bacteremia as she did
continue to have temperature spikes and had a PICC line
placed to continue these antibiotics. Blood cultures remained
stable but she did have positive blood cultures, on [**5-3**],
four out of six on day of admission, on [**5-6**] two out of
two, [**5-7**] and 5 were still negative, [**5-9**] was one out of
two with MRSA, [**5-11**] four out of four negative and [**5-14**]
one out of one is MRSA. At the time of this dictation, [**5-17**]
and [**5-18**] cultures are still pending. Of note, the patient
did have CSF culture grow MRSA later on in the course even
with the negative gram stain. This was attributed likely to a
high grade bacteremia that penetrated the blood-brain
barrier. The patient's mental status improved by the
following morning. The patient eventually had an MRI of her C-
spine, L-spine and T-spine to rule out any parameningeal
focuses and this was done and showed no definite evidence of
an abscess. She did have some mild degenerative disc disease
in her cervical spine but was otherwise stable. The patient
did have the initial TEE in the Emergency Room which showed
LVEF of 55 percent and mild thickening of the aortic valve
but no masses or vegetations are seen on the aortic valve.
The mitral valve leaflets were mildly thickened with a large
1.5 x 1.2 cm calcified mass on the atrial side of the base of
the posterior mitral valve leaflet consistent with a healed
vegetation and there was also a large 1.5 x 1.0 cm calcified
mass on the atrial side of the base of the anterior mitral
valve leaflet consistent with a healed vegetation. There was
a small 0.5 filamentous, mobile echodensity associated with
the base of the anterior mitral valve leaflet on the atrial
side consistent with a vegetation but no mitral valve abscess
was seen at the time and there was moderate to severe 3+ MR
seen during this TEE. Otherwise, there was no evidence of an
effusion and was otherwise stable. She was followed initially
by CT Surgery and seen for evaluation for possible surgery.
However, surgery was deferred at this time as she continued
to have transiently positive blood cultures and they wanted
her bacteremia cleared prior to surgery as she would present
a risk of infection of her eventual bioprosthetic valve. The
patient was continued on vancomycin, rifampin and completed a
seven day course of gentamicin for synergy and cultures
remained stable. The patient did eventually have a repeat TEE
to evaluate any further changes in her valve and that did
show that the mitral valve leaflets were moderately
thickened. There was a large complex vegetation 2 x 2 cm on
the posterior leaflet of the mitral valve with mobile
elements. In addition, there are moderate to large mobile
vegetations involving the anterior mitral leaflet and leaflet
base. A perivalvular involvement could not be excluded. There
was moderate to severe 3+ MR again seen and there was
moderate 2+ TR with severe pulmonary artery systolic
hypertension but no other vegetations or effusions were
noted. The patient had a normal LVEF of greater than 55
percent. However, it was noted that LV function may be
depressed given the severity of the MR which was not
reflected in the echo results. As the valve appearance was
changing with vegetations, plans again for surgery were noted
but however, we are waiting for at least two weeks negative
blood cultures on antibiotics prior to moving to surgery
because of the concern of risk of infecting the valve. Also,
there were concerns with the high grade bacteremia that she
had and if she had any other focal processes that weren't
being appropriately treated or drained. The patient had an
MRI of her pelvis which showed a large subcutaneous
collection with extension to the right lateral abdominal wall
musculature. The complex fluid collection is nonspecific and
may represent an abscess or hemato seroma.
The patient had this finding also confirmed on ultrasound of
her transplanted kidney which showed right lower quadrant
transplant kidney showing evidence of little or no diastolic
flow peripherally and restrictive indices near 1.0. Again was
noted the large collection just lateral to the transplant
kidney which did show evidence of a hematocrit effect within.
Findings were consistent with hemorrhage within a lymphocele
and most likely an infected lymphocele. The kidney showed
evidence of polycystic kidney disease.
Eventually, the patient had a repeat chest x-ray which just
showed resolving CHF after some diuresis was added in terms
of IV Lasix. She also had a white blood cell scan looking for
any occult signs of infection that weren't being properly
addressed. She had mild diffusely increased uptake in the
right lung which could represent a pulmonary inflammatory
process. She also had a large focus of abnormal uptake in the
right abdominal pelvic wall which could represent an abscess
and she had diffusely increased uptake in the right
hemipelvis which appeared anterior to the right ileum, also
possibly another site of an abscess. These findings were
attributed to possible right-sided pneumonia versus CHF
versus an abdominal wall collection which was planned to be
drained.
It was initially aspirated by CT-guided means with 300 cc
which was sent for studies and confirmed that she had 4+ PMNs
and positive gram positive cocci in pairs and clusters on the
gram stain but negative culture. As no drain was placed, the
patient had this reevaluated by ultrasound and as it was
still present on that evaluation, the patient had a drain
placed in this to continue to aspirate and drain this fluid
collection. Repeat aspiration showed no organisms, again 4+
PMNs and a negative culture. Otherwise, the mass that was a
finding on the white blood cell scan in the right hemipelvis
was likely attributed to her new transplanted kidney which
may have suffered some ATN or other source as nothing else
was evidenced on the MRI that she had. She also had
eventually a CT of her chest to evaluate mild uptake in the
right lung and also some episodes of dyspnea with exertion
and Pulmonary was involved at this time. There was evidence
of patchy foci of peripheral ground-glass opacification
within the right lower lobe that was attributed to likely
pneumonia. The patient did have one sputum sample sent which
was a poor sample and only grew out moderate Staph aureus.
Otherwise, the rest of the cultures remained negative. She
also had a band-like area of opacity within the lingula which
appeared improved and was attributed to residual focal
atelectasis versus scar. The patient also had a small
persistent pericardial effusion and resolution of a small
right pleural effusion. There was note of a 2 cm diameter low-
density lesion within the spleen. However, the patient did
have this evaluated on ultrasound and MRI of her abdomen of
which nothing else was made of note.
The patient was started on Levaquin based on these findings
initially and the patient responded well to these.
Eventually, there was concern that some of her respiratory
symptoms may be related to pneumonia and/or sinusitis. The
patient was transitioned to an Augmentin regimen which should
cover better for sinusitis and for pneumonia and she is to
continue on this to complete a two week course. The patient
did eventually have an MRI of her abdomen to evaluate her
original kidney of concern but there may be pockets of
infection that don't get appropriate vascular supply and
antibiotic treatment. The MRI of the abdomen was essentially
normal with numerous bilateral renal cysts consistent with
her history of polycystic kidney disease. No enhancing solid
lesions were seen in the kidneys to suggest infection or
malignancy. There was interval decrease in size of the right
lower quadrant abdominal wall collection after drainage and a
right adrenal adenoma. Otherwise, the patient was continued
on vancomycin and rifampin which she will continue
indefinitely prior to surgery and indefinitely after surgery.
She will continue to follow with Infectious Disease team. The
patient did have viral studies sent from her CSF which
remained negative. She had a CMV viral load sent which was
also negative here. She had HSV culture sent from her lip
swab which was positive for HSV-1. She completed a seven day
course of acyclovir for this. The patient also had her left
upper extremity fistula from her hemodialysis evaluated by
ultrasound and there was no evidence of any infectious tract
at that site either. There is no history of a graft placement
at that site either. She had that placed in [**2156**]. Otherwise,
the patient will continue on vancomycin and rifampin again
for an indefinite course of length, continue to have close
Infectious Disease and Transplant follow-up and the eventual
plan for a valve replacement as concern for continued
vegetations and infection and worsening heart failure
secondary to increasing mitral regurgitation.
Acute and chronic renal failure: The patient is status post
transplant for adult polycystic kidney disease with baseline
creatinine of about 1.5-2 since surgery. She was continued on
the immunosuppressive regimen of tacrolimus and prednisone
and levels were followed steadily. The tacrolimus was
titrated up once she was started on rifampin because of
concern for the cytochrome P450 metabolism system. Her levels
remain stable at the dose she is currently on. However, this
may be titrated further as she initially came in with acute
renal failure which was attributed to ATN. The patient was
hydrated initially with minimal response with a steady
creatinine. Eventually, she started diuresing on her own and
starting making output on her own and her creatinine started
to improve and so her initial presentation of acute renal
failure was attributed to ATN. However, after creatinine
improved, the patient was completing her course of seven days
of gentamicin and the patient's creatinine started to rise
further. There is unclear source of patient's present acute
renal failure. It could be gentamicin toxicity versus
acyclovir toxicity versus forward flow versus over-diuresis.
Currently, the patient has started back on some IV hydration
in addition to her Lasix trying to maintain her urine output
and hydration. Her blood pressure medicines are decreased to
try to help improve forward flow. The gentamicin and acylovir
have been discontinued and we will continue to follow it.
Currently, her creatinine seems to be plateauing. She
recently had her transplant evaluated during her ultrasound-
guided drainage and found no focal abnormality but may
consider reevaluating if creatinine continues to rise.
Continue to follow levels of her immunosuppressive regimen
closely with rising creatinine and this was all managed
closely with her renal transplant team. Again, her urine
output was continued to be followed closely also. The patient
did have a Foley placed and did have urinary tract infection
and urine culture consistent with yeast. Her Foley is
currently being discontinued and we will continue to recheck
her UA and urine culture after the Foley is removed to make
sure she has cleared the yeast. If not, we may consider
treating this UTI. Again, we will continue to follow her
creatinines and urine output closely and follow all the
levels of her antibiotics and immunosuppressive regimen as
closely as we can.
CHF: The patient has elevated right heart pressures on the
TEE likely secondary to worsening left heart failure from
valvular disease. The patient was started on aggressive
diuresis and after-load reduction initially to which she
responded well. Because of her angioedema to ACE inhibitors,
she was started on hydralazine and nitrates with Lasix and
her blood pressure came under much better control and
diuresis improved. Currently, we have just maintained on
Lasix and decreasing doses of hydralazine and nitrates to
improve her forward flow for kidney perfusion, but otherwise
her respiratory status is stable. The patient had follow-up
chest x-rays which confirmed improving congestive heart
failure.
Asthma: The patient has a history of asthma, stable on her
home regimen of Advair and albuterol. She was given
occasional nebs for occasional asthma exacerbations which
were short term and responded well to the inhalers. This can
continue to be followed.
Sinusitis: The patient has a history of chronic sinusitis,
continued on [**Doctor First Name **], started on Beconase here while Flonase
is not on the formulary. She was started on Augmentin for her
pneumonia and sinusitis coverage as discussed above.
Anemia: The patient has known chronic disease anemia
secondary to her renal disease and chronic infectious state.
The patient's iron studies confirmed that the patient did
require a couple of transfusions. She did receive one unit on
[**5-4**], 2 units on [**5-13**]. She had a repeat level today with
goal hematocrit greater than 30. She did have likely some
evidence of hemolysis early in her course secondary to her
valve with slightly elevated platelets. However, her crit
remained stable after transfusions. She did also have some
mildly guaiac positive stools but these are also stable and
would continue to be followed.
Type II diabetes: The patient was stable and initially
controlled on oral regimen before her transplant and now just
on sliding scale insulin at home. However, for better
control, the patient was started on Glargine which 11 units
seemed to control her pretty well with sliding scale insulin
as needed in between. She was continued to be followed for
episodes of hypoglycemia with worsening renal failure and
concern for prolonged elevated levels of her long-acting
insulin.
CONDITION ON DISCHARGE: Good. The patient has no O2
requirements and is afebrile at this time.
DISCHARGE STATUS: Discharged to Rehab.
DISCHARGE DIAGNOSES: MRSA bacteremia.
Status post renal transplant secondary to adult polycystic
kidney disease.
Urinary tract infection.
Pneumonia.
Sinusitis.
HSV-1 infection.
Abdominal wall abscess.
Acute and chronic renal failure.
Anemia.
CHF.
Asthma.
Type II diabetes.
DISCHARGE MEDICATIONS: Will be dictated at the time of final
discharge.
FOLLOW UP: The patient will follow up with her transplant
nephrologist, Dr. [**Last Name (STitle) **], as previously scheduled and the
patient will follow up with her transplant surgeon, Dr.
[**Last Name (STitle) 28184**], as previously scheduled and the patient will have CT
Surgery follow up.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 28185**]
Dictated By:[**Doctor Last Name 14365**]
MEDQUIST36
D: [**2162-5-19**] 10:38:34
T: [**2162-5-19**] 14:36:17
Job#: [**Job Number 28186**]
ICD9 Codes: 4280, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2547
} | Medical Text: Admission Date: [**2112-10-24**] Discharge Date: [**2112-11-2**]
Date of Birth: [**2083-11-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Scrotal abscess
Major Surgical or Invasive Procedure:
Incision and drainage of peroneal abscess
Trans-esophageal echocardiogram
History of Present Illness:
28 year-old male previously healthy male with history of IVDU,
who initially presented with a peroneal abscess and concern for
peroneal necrotizing fasciitis, and multiple sepitc lung emboli.
The abscess was first noted as a small pimple 5 days prior to
presentation ([**10-19**]) and has progressively enlarged and become
more painful. He had severals days of fevers and chills and
started experiencing pleuritic chest pain, worse with
inspiration. He also complained of cough prior to presentation.
The day he presented, he noted an area of induration and
erythema on left shin.
.
Patient underwent I&D of abscess on [**2112-10-24**]. An idurated,
purulent area in the scrotal raphe and an area on the left
buttock were opened. Pustular sinus tracts with necrotizing
soft tissue wre found and debrided. Following procedure,
patient was admitted to the SICU for close monitoring given
concern for SIRS/sepsis. Patient initially treated with
clindamycin, piperacillin-Tazobactam, gentamicin, and
vancomycin. Patient grew GPC in [**5-30**] bottles. Pt had CXR which
showed hypodensities, concerning for septic emboli. On CT chest
he was found to have numerous bilateral pulmonary nodules, all
concerning for septic embolic, infarcts, and disseminated
infection felt secondary to abscess. TTE was negative for
vegatations.
.
ID was consulted and felt that the source of the bacteremia and
septic emboli was likely his scrotal abscess. The recommended
continuing broad spectrum antibiotics because of polymicrobial
nature of scrotal abscesses, including clindamycin to cover for
necrotizing fasciitis. The gentamycin was discontinued.
.
Overnight, on [**10-26**], oxygen saturation decreased to mid to high
80s on 4L NC. Patient was noted to have increased work of
breathing. He was transitioned to NRB and oxygen saturation
improved to low 90s, but patient continued to have increased
WOB. He was transitioned to BIPAP mask and his breathing
symptoms improved. Given worsening respiratory status and
persistent tachycardia, patient underwent CTA to assess for PE,
which showed no PE, but does show worsening right sided
non-hemorrhagic pleural effusion.
.
On transfer to the MICU, patient is comfortable and feels like
his breathing is more comfortable on BIPAP. Scrotal pain is
well controlled with current regimen. Patient reports having
fevers and chills overnight.
.
Review of systems:
(+) Per HPI. Constipation, has not moved bowels since admission.
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
wheezing. Denies chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias.
Past Medical History:
Left shoulder surgery [**2099**]
No history of skin infections
Social History:
- Tobacco: 1 ppd x 16 years
- Alcohol: None currently
- Illicits: History of IV heroin use, last injected 5 months
ago.
Currently incarcerated for the past 4 months.
Family History:
Noncontributory
Physical Exam:
Physical Exam on Admission:
Vitals: Tm: 101.1, Tc: 99.3, BP: 138/73 P: 89 R: 21 O2: 98% on
BIPAP
General: On BIPAP, appears comfortable
HEENT: Sclera anicteric, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachy, regular rhythm, no murmurs/rubs/gallops
Lungs: Dull at bases b/l R > L, coarse breath sounds b/l, no
wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley in place, scrotal wound packed with wet to dry
dressings, no drainage or surrounding erythema
Ext: warm, well perfused, 2+ pulses, 3 cm x 3cm area of
induration noted on left anterior shin, non-fluctuant
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Physial Exam on Discharge:
Vitals: T98.7, BP:144/84, HR:101, RR:20, O2st: 94%RA
General: breathing comfortably on room air
CV: RRR, no M/R/G
LUNGS: rales in right lung base and right middle lobe
GU: foley removed, scrotal wound packed
Ext: Anterior shin wound packed with wick
Exam otherwise unchanged from admission
Pertinent Results:
Lab Results on Admission:
[**2112-10-24**] 08:30PM BLOOD WBC-22.4* RBC-4.55* Hgb-14.6 Hct-42.1
MCV-93 MCH-32.1* MCHC-34.8 RDW-11.3 Plt Ct-248
[**2112-10-24**] 08:30PM BLOOD Neuts-81* Bands-1 Lymphs-13* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2112-10-24**] 08:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2112-10-24**] 08:30PM BLOOD Glucose-127* UreaN-10 Creat-0.7 Na-137
K-4.1 Cl-103 HCO3-23 AnGap-15
[**2112-10-25**] 06:10PM BLOOD HIV Ab-NEGATIVE
[**2112-10-26**] 02:42AM BLOOD Type-ART pO2-62* pCO2-44 pH-7.39
calTCO2-28 Base XS-0
[**2112-10-24**] 08:38PM BLOOD Lactate-1.4
Studies:
[**10-24**] Skin Biopsy: DIAGNOSIS:
1. Skin and soft tissue, scrotal raphe; debridement (A-C):
1.Cutaneous acute inflammation with abscess formation, tissue
necrosis, and surface bacterial organisms.
2.Special stains for microorganisms in process, to be reported
in an addendum.
2. Skin, left buttock; debridement (D-E):
1.Cutaneous acute inflammation and abscess formation with tissue
necrosis.
2.Special stains for microorganisms in process, to be reported
in an addendum.
[**10-24**] ECG: Sinus tachycardia. Left axis deviation. No previous
tracing available for
comparison.
[**10-24**] CXR: IMPRESSION: Ill-defined nodular opacities primarily
within the lung bases. Findings are concerning for infectious
process such as septic emboli, and a CT can be obtained for
further evaluation.
[**10-25**] transthoracic Echo: The left atrium is dilated. The right
atrium is moderately dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). There is a mild
resting left ventricular outflow tract obstruction. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a very small pericardial
effusion.
No vegetation seen (cannot definitively exclude).
[**10-26**] CTPA: IMPRESSION:
1. No pulmonary embolism within the limitations of the study.
2. Numerous pulmonary nodules compatible with septic emboli.
Bilateral lower lobe peripheral heterogenous opacities are now
largely obscured by atelectasis are indeterminate but could also
be due to septic emboli with possible infarction.
3. Small-to-moderate bilateral pleural effusions, increased from
the study
one day prior.
4. Regions of low attenuation within bilateral atelectasis,
concerning for
pneumonia.
[**10-26**] LLE U/S: IMPRESSION: Serpiginous-appearing hypoechoic
structure left anterior shin,
possibly representing a fluid collection or alternatively
superficial
thrombophlebitis of a markedly distended venous structure.
Clinical
correlation is recommended.
[**10-30**] CXR: IMPRESSION:
1. Lung volumes remain low. There is more focal patchy nodular
opacity at
the left apex as well as in the right upper to mid lung which
appears somewhat cavitary and may reflect known septic emboli
which are now radiographically visible. More focal patchy
opacity at the right lung base is also present and could
represent a combination of compressive atelectasis, pneumonia
and/or evolving septic embolic areas. The more rounded
appearance to the right costophrenic angle is slightly less
apparent on the current examination but still could represent
loculated pleural fluid. The heart remains enlarged but
unchanged which may reflect cardiomegaly or pericardial
effusion. Interval improvement in aeration at the left lung base
with no definite left pleural effusion identified on the current
examination. Stable mediastinal contours. No evidence of
pulmonary edema.
.
[**10-31**] TEE: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque to 45 cm from the incisors.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
No mass or vegetation is seen on the mitral valve. No
vegetation/mass is seen on the pulmonic valve. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: No valvular pathology or pathologic flow identified.
[**11-2**] CXR: IMPRESSION:
1. New left PICC with the tip at least at the estimated location
of the
cavoatrial junction but possibly 1-2 cm beyond this. No evidence
of
procedural complication.
2. Possible persistent right loculated pleural effusion.
Followup with
conventional PA and lateral radiograph is recommended when
clinically
feasible.
Lab results on Discharge:
[**2112-11-2**] 06:30AM BLOOD WBC-14.3* RBC-3.88* Hgb-12.1* Hct-36.7*
MCV-95 MCH-31.2 MCHC-33.0 RDW-12.1 Plt Ct-511*
[**2112-11-1**] 06:20AM BLOOD UreaN-9 Creat-0.6
[**2112-10-29**] 03:14AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.2
[**2112-10-31**] 04:40PM BLOOD Vanco-18.0
[**2112-10-27**] 04:37AM BLOOD Type-ART pO2-81* pCO2-52* pH-7.43
calTCO2-36* Base XS-8
Brief Hospital Course:
Primary Reason for Hospitalization: Patient is a 28 year-old,
previously healthy, incarcarated male with history of IVDU, who
initially presented with a peroneal abscess and concern for
perineal necrotizing fasciitis, and multiple septic lung emboli.
The perineal wound was drained and showed no necrotizing
fasciitis. Cultures from the wound and blood grew MRSA and
patient began treatment with vancomycin. A wound on patient's
anterior left shin was incised and drained as well. He required
a brief ICU stay for respiratory distress but was never
intubated. His fever and shortness of breath resolved and
patient went to teh floor. TEE showed no vegetations and patient
was discharged to complete a 6-week course of vancomycin.
.
ACUTE CARE:
.
1. MRSA bacteremia: Patient had a perineal and buttock wound
that grew MRSA in culture and blood cultures that grew MRSA as
well. He was found to have radiographic evidence of septic
emboli and was febrile with shortness of breath as well. He was
started on a course of IV vancomycin. Patient received a TEE
which showed no vegetations. He was discharged to complete a
6-week course of vancomycin.
.
2. Perineal wound and other buttock and shin wound: Patient's
initial complaint was a tender, erythemetous wound involving the
scrotum and perineum. It started off as a pimple-sized lesion
and grew to involve a large area. Surgery evaluated and debrided
the wound because of concern for necrotizing fasciitis, which
was not present. The wound grew MRSA and patient recieved
vancomycin and wet-to-dry dressing changes. The additional
wounds on the left anterior shin and left buttock were incised
and drained and had daily dressing changes as well. He was
dishcarged with instructions for antibiotics and dressing
changes to continue.
.
3. Lung Septic Emboli: Patient had septic emboli to the lung as
evidenced by chest CT. He showed no neurologic signs suggesting
brain lesions. Because of the lung lesions, patient had a period
of respiratory distress requiring Bipap in the unit. This and
patient's fever resolved with antibiotics and he did not require
intubation. He was weaned to room air and previous pain
experienced with respiration was greatly decreased. IP evaluated
patient for a small loculated pleural effusion associated with
the involved lung, and it was found to be too small to drain.
CTPA showed no PE on this admission as well
.
CHRONIC CARE:
.
1. IVDU history: Patient was informed about the possibility of
infection with IVDU and he was made aware that the current
damage to his veins from this history interferes with vascular
access.
.
TRANSITIONS IN CARE:
1. FOLLOW UP: Patient will follow up with the medical system
within the department of corrections. He should receive follow
up with infectious disease upon finishing the 6-week course of
vancomycin.
2. CARE TRANSITION: Per request of the DOC, patient will be
transferred to [**Hospital1 **] to complete his inpatient care.
he should be continued on heparin SC for DVT ppx.
3. VACULAR ACCESS: Patient has a PICC line placed. It was
initially placed 2 cm too far in as seen on CXR, but was
retracted 2cm and is OK to use for IV abx now that it is
properly positioned.
4. CODE STATUS: presumed full
Medications on Admission:
none
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
4. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: hold for sedation or RR<10.
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for dyspnea.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/pain: do not administer more than
4g per day.
9. vancomycin 1,000 mg Recon Soln Sig: [**2100**] ([**2100**]) mg
Intravenous three times a day for 6 weeks: 6 weeks of therapy to
be completed with last day [**2112-12-7**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary: MRSA bacteremia
Secondary: Septic emboli to the lungs
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 82864**],
You were admitted to the hospital because you developed a large
abscess on your scrotum. We also found wounds on your left shin
and left buttock and areas of infection in the lungs as well.
The cultures from the wound grew a bacteria called MRSA, and you
were found to have this growing in your blood stream as well.
The bacteria spread from one the above-mentioned skin wounds to
the blood and went to the lungs and other wounds from there. We
did an ultrasound of your heart that showed no infection in the
heart itself.
MRSA is a bacteria that is very resistant to most antibiotic
treatment, which is why you are being given vancomycin
intravenously, which does work agaist this bacteria. You will
need to continue this antibiotic for a total of 6 weeks.
Please start the following medications:
1. START Vancomycin 2g IV q8hr (to be completed [**2112-12-7**])
2. START Dilaudid 2mg 1-2 tablets by mouth every 6 hours as
needed for pain
** This medication can cause sedation and drowsiness
3. START Docusate 100mg by mouth twice daily for constipation
4. START Heparin 5000 units subcutaneously three times daily if
you are not ambulating
5. START Ipratropium nebulizer as needed for shortness of breath
or wheezing
6. START Ranitidine 150mg by mouth twice daily for heartburn
7. START Tylenol as needed for pain (do not exceed 4g in one
day)
Followup Instructions:
Please follow-up with the doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 5119, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2548
} | Medical Text: Admission Date: [**2152-11-25**] Discharge Date: [**2152-12-6**]
Date of Birth: [**2152-11-25**] Sex: M
Service: Neonatology
Baby [**Name (NI) **] [**Known lastname 65151**] [**Name2 (NI) **] was the 1740 g product of a 31-3/7 week twin
gestation born to a 24-year-old G2, P1 now 3 mother.
PRENATAL SCREENS: A+, antibody negative, RPR nonreactive,
rubella immune, hepatitis surface antigen negative, GBS
unknown.
This pregnancy was complicated by spontaneous twin gestation then
premature rupture of membrane of other twin on [**11-15**].
Mother was transferred from [**Hospital3 3765**] to [**Hospital3 **]
where treated with magnesium sulfate. Complete course of
betamethasone. She remained at [**Hospital1 18**] until delivery.
On day of delivery, mother developed preterm labor. Delivered by
repeat cesarean section. No maternal fever. Adequate
intrapartum antibiotics. Abdominal rupture of membranes of
this twin at delivery for clear fluid. Infant emerged with
spontaneous cry, requiring blow-by O2 and routine care in OR.
Apgars were 8 and 9.
PHYSICAL EXAMINATION ON ADMISSION: Weight 1740 g, 75th
percentile; length 40 cm, 25th percentile; head circumference
30 cm, 50th percentile. Nondysmorphic with overall appearance
consistent with his estimated gestational age. Anterior
fontanel soft, open and flat. Red reflex deferred. Palate
intact. No grunting, flaring, or retracting noted. Symmetric
decreased breath sounds. Regular rate and rhythm. Peripheral
pulses 2+, including femorals. Abdomen: Benign without
hepatosplenomegaly. No masses. Normal male genitalia for
gestational age. Testes descended bilaterally. Normal back
and extremities with hips deferred. Skin: Pink and well
perfused.
HISTORY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Infant was admitted to the newborn intensive care
unit and placed on CPAP. With escalating respiratory needs,
infant was intubated, received 2 doses of surfactant and weaned
over the next 4 days. He transitioned to CPAP by day of life #4.
Remained on CPAP for 2 days. Transitioned to nasal cannula,
where he continues to be up to 125 cc in 100% O2 with
saturations less than or equal to 94%. Infant has occasional
apnea bradycardia of prematurity but does not require
methylxanthine therapy at this time.
Cardiovascular: Has had no issues.
Fluids and electrolytes: Birth weight was 1740 g. Was
initially started on 80 cc per kg per day of D10W. Enteral
feedings were initiated on day of life #3. Full enteral
feedings were achieved by [**2152-12-4**]. He was currently
taking 150 cc per kg per day of breast milk 24 calorie. His
discharge weight is 1640g. Recent HC on [**12-4**] w=29.5cm,
L=41.5 cm.
GI: Peak bilirubin was on day of life 3, 7.9/0.3. He required
phototherapy. This issue has since resolved with his most
recent bilirubin being 6.3/0.2 on [**12-3**].
Hematology: Hematocrit on admission was 50. Infant has not
required any blood transfusions.
Infectious disease: CBC and blood culture were obtained on
admission. ANC on initial CBC was 710. His white blood cells
were 7.1, 10 polys, 0 bands. Platelet count was 302. A repeat
in 24 hours had a white count of 15.2, 58 polys, 0 bands with
a platelet count of 250. Infant received 48 hours of
ampicillin, gentamicin and has since had no further issues.
Neurology: Had ultrasound performed on [**12-5**]; was
within normal limits.
Sensory: Hearing screen was not performed but should be done
prior to discharge.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: [**Hospital6 5016**].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Hospital1 3597**],
[**State 350**].
CARE RECOMMENDATIONS: Continue advancing enteral caloric
intake as needed to promote weight gain.
MEDICATIONS: Not applicable.
CAR SEAT POSITION SCREENING: Has not yet been performed.
STATE NEWBORN SCREEN: Has been sent per protocol most
recently on [**11-28**].
IMMUNIZATIONS RECEIVED: Infant has not received any
immunizations at this time.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: 1) born at less than 32
weeks, 2) born between 32 and 35 weeks with 2 of the
following: day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school-age siblings, or 3) with chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the 1st 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home care givers.
DISCHARGE DIAGNOSES:
1. Prematurity, born at 31-3/7 weeks, Twin II.
2. Respiratory distress syndrome, resolved
3. Rule out sepsis with antibiotics.
4. Transient neutropenia. resolved
5. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2152-12-5**] 21:25:19
T: [**2152-12-5**] 21:53:15
Job#: [**Job Number 65153**]
ICD9 Codes: 769, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2549
} | Medical Text: Admission Date: [**2166-1-22**] Discharge Date: [**2166-1-23**]
Date of Birth: [**2113-5-14**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for stent/coiling of L MCA aneurysm
Major Surgical or Invasive Procedure:
[**2166-1-22**]: Cerebral angiogram with stent assisted coiling of the
L MCA aneurysm
History of Present Illness:
52F with incidental finding of L MCA aneurysm (5mm) and R MCA
aneurysm (1mm).
Past Medical History:
1. HIV: on Truvada and Lexiva, last CD4 count 868; acquired from
blood transfusion; diagnosed ~8 years ago
2. Sickle cell anemia
Social History:
Works in childcare. Smokes 1 ppd x30 years. No EtOH or illict
drug use.
Family History:
Dad passed away from stroke at age 56. Mom is healthy. Sister
had a ruptured aneurysm.
Physical Exam:
Pre-angio:
Awake, alert, oriented x3, MAE full motor.
Upon discharge:VSS AF
She is awake alert oriented with PERRL [**4-14**] bilaterlly, non focal
neuros exam. Her distal pulses are full and her groin sites are
benign. She is tolerating po and voiding freely.
Pertinent Results:
Head CT [**2166-1-22**]:
FINDINGS: Imaging degraded by metallic star artifact from the
aneurysm coil pack. Allowing for this limitation, there is no
evidence of hemorrhage, edema, mass, mass effect, or infarction.
The ventricles and sulci are normal in size and configuration.
The basal cisterns appear patent and there is preservation of
[**Doctor Last Name 352**]-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses,
mastoid air
cells, and middle ear cavities are clear. No facial or other
extracranial soft tissue abnormality is seen.
IMPRESSION: No evidence of acute intracranial process
Brief Hospital Course:
52F who was admitted for an elective stent assisted coiling of
the L MCA aneurysm. Patient was given Plavix 600mg PO x1 prior
to the case. Left femoral access was acheived for Aline
monitoring. Stent placement and coiling was acheived without
complication. Post-angio she was transferred to the ICU for
monitoring. The left sheath remained in place. She was started
on a Heparin drip at 700 cc/hr for a PTT goal of 60-80. A post
angiogram head CT was completed and was normal. SHe advanced in
her diet and her pain controlled. Her groin sites remained
intact and the left groin microsheath was removed. She was
discharged to home on.
Patient was discharged on ASA and Plavix for one month.
Medications on Admission:
Truvada 200/300mg 1 tab daily, Colace, Flexeril 10mg [**Hospital1 **],
Oxycodone PRN, folic acid 1mg daily, Flovent 2 puffs [**Hospital1 **],
Wellbutrin 150mg [**Hospital1 **], Flonase daily, Prilosec daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain/fever.
2. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
3. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): please do not
take your omeprazole while on plavix . Capsule, Delayed
Release(E.C.)(s)
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
8. Pepcid 40 mg Tablet Sig: One (1) Tablet PO twice a day:
please use pepcid in place of your omeprazole while on plavix. .
Disp:*60 Tablet(s)* Refills:*2*
9. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-13**]
Tablets PO Q6H (every 6 hours) as needed for Headache.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left MCA aneurysm
Right MCA aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily for one month.
?????? Take Plavix (Clopidogrel) 75mg once daily for one month.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 6 months with a MRI/MRA
([**Doctor Last Name **] protocol). Please call [**Telephone/Fax (1) 4296**] to make this
apointment.
Completed by:[**2166-1-23**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2550
} | Medical Text: Admission Date: [**2185-1-14**] Discharge Date: [**2185-1-18**]
Date of Birth: [**2130-12-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
mitral valve endocarditis
Major Surgical or Invasive Procedure:
Mitral valve replacement(31-mm [**Company 1543**] Mosaic mitral valve
bioprosthesis),Tricuspid valvuloplasty(28-mm [**Doctor Last Name **] MC3
valvuloplasty ring),Closure of patent foramen ovale. [**2185-1-14**]
History of Present Illness:
This 54 year old female was seen originally in [**10-16**] for mitral
valve endocarditis (strep oralis). She was treated with
intravenous antibiotics, however, was readmitted [**2184-12-14**] in
congestive heart failure. At that time, she was diuresed and
surgical planning began. She completed her antibiotics
(penicillin) on [**2185-1-3**] and her PICC line was removed. She
presents today for surgical management of her mitral and
tricuspid valve disease.
Past Medical History:
Iron Deficiency Anemia
s/p Cesarean Section
Endocarditis
pulmonary hypertension
h/o congestive heart failure
h/o Cervical osteomyelitis
h/o Septic arthritis
h/o Splenic and renal spetic emboli
s/p Vein stripping surgery
Social History:
Remote tobacco as a teenager. Denies ETOH. Employed at Target.
Family History:
Non-contributory
Physical Exam:
Admission:
T 96.7 BP 112/75 P 61 R12 wt 160lbs
Gen: well appearing, NAD
Heent:anicteric, op clear
Neck:supple, no LAD
Lungs: CTAB, no crackles
CV: RRR nl S1 and S2 III/VI holosystolic murmur
Abd:soft, NT, ND, +BS
Ext: no edema
Neuro:nonfocal
Pertinent Results:
[**2185-1-14**] ECHO
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present.
The mitral valve is abnormal. There is a torn anterior leaflet
at the A2 and all regurgitation is seen through this tear. There
is a moderate-sized vegetation on the mitral valve. Severe (4+)
mitral regurgitation is seen.
The tricuspid valve does not appear to have any vegetations and
there is Moderate to severe [3+] tricuspid regurgitation is seen
with dilated IVC (28mm) and no change in diameter with
respiration seen. There is flow reversal in the hepatic vein as
well. There is severe pulmonary artery systolic hypertension.
There is a small pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**Known firstname **]
[**Known lastname 12130**] at 8AM.
[**2185-1-17**] 06:52AM BLOOD WBC-5.2 RBC-2.88* Hgb-8.6* Hct-26.3*
MCV-92 MCH-29.9 MCHC-32.7 RDW-17.7* Plt Ct-155
[**2185-1-17**] 06:52AM BLOOD Glucose-94 UreaN-25* Creat-0.9 Na-134
K-4.0 Cl-97 HCO3-26 AnGap-15
Brief Hospital Course:
Ms. [**Known lastname 12130**] was admitted to the [**Hospital1 18**] on [**2185-1-14**] for surgical
management of her valve disease. She was taken directly to the
operating room where she underwent mitral valve replacement
using a porcine prosthesis, tricuspid valve repair, PFO clsoure
and ligation of the left atrial appendage. Please see operative
note for details. Postoperatively she was taken to the intensive
care unit for monitoring. She weaned from bypass on Epinephrine,
vasopressin, neo synephrine and Propofol. She later awoke
neurologically intact and was extubated. Pressors were weaned
off and she remained hemodynamically stable.
Aspirin, lipitor and beta blockade were resumed. On
postoperative day one, she was transferred to the step down unit
for for further recovery. She was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperative strength and mobility.
Benadryl was given for a rash she had prior to admission with
good relief.
Operative cultures were negative for aerobic growth and
perioperative cephalosporins were discontinued on the fourth
postoperative day. She continued to make steady progress and was
discharged home on POD 4.
Arrangements for follow up, post discharge instructions and
medications were discussed with the patient prior to discharge.
Medications on Admission:
Atorvastatin 20', lopressor 25", lasix 40', KCL, PCN G completed
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
s/p mitral valve replacement, tricuspid annuloplasty, closure of
patent foramen ovale, ligation of left atrial appendage
mitral valve Endocarditis
h/0 congestive heart failure
Pulmonary hypertension
iron deficiency anemia
patent foramen ovale
h/o Septic arthritis
h/o splenic septic emboli
h/o renal septic emboli
Discharge Condition:
Good
Discharge Instructions:
report any redness of, or drainage from incisions
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
No lotions, creams or powders to incisions
Shower daily, no bathing or swimming.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month and off all narcotics.
take all medications as directed
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-11**] weeks.
Please follow-up with primary care physician [**Last Name (NamePattern4) **] [**1-12**] weeks.
Call all providers for appointments.
Completed by:[**2185-1-18**]
ICD9 Codes: 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2551
} | Medical Text: Admission Date: [**2149-2-23**] Discharge Date: [**2149-2-28**]
Date of Birth: [**2079-11-15**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Transfered from OSH for evaluation of intracranial and
extracranial vasculature for possible surgical intervention
after stoke
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
Mr. [**Known lastname 40015**] is a 69-year-old right handed male with
diabetes, hypertension, hyperlipidemia, obesity and prostate
cancer status post resection, s/p radiation treatments who
presents with slurred speech and right hand weakness which began
acutely on [**2148-2-16**].
On [**2-15**] he was talking with his wife on the phone when he
noticed the slurred speech. He also had word finding difficulty.
He could think of what he wanted to say but was having trouble
getting the words out. He did not have trouble understanding
others. The word finding trouble improved over 4 days. He still
has intermittent dysarthria. On [**2-15**] he also had acute onset of
right hand weakness. He was having trouble holding onto objects.
This right hand weakness improved over several days and is now
100% better. He also had 3-4 episodes of several minutes of
horizontal diplopia. This resolved if he closed either eye. He
had diplopia if he looked either to the right or left. He has
never had diplopia before.
Pt denied headache, vertigo, dysphagia, gait unsteadiness.
He
takes aspirin 81mg daily at home.
His family took him to [**Hospital1 18**] [**Location (un) 620**] on [**2-21**] and he was
admitted to the floor. On exam he had dysarthria and right
pronator drift. CT brain did not show an acute infarct or bleed.
Neurology Consult was concerned about a lacunar stroke causing
clumsy hand/dysarthria syndrome. He was started on Plavix 75mg
daily and aspirin 325mg [**Hospital1 **]. His blood pressure meds were held
originally. Later his Lisinopril 10mg and Metoprolol 25mg [**Hospital1 **]
was
restarted. On [**2-23**] his SBP was 110's -120's. Zocor was given at
80mg qhs but was decreased to 40mg qhs. MRI/MRA brain showed a
subacute infarct of the left cortical motor strip near the hand
region. He has severe stenosis of the M1 and M2 branches of the
left MCA. There is 100% occlusion of the left common carotid
artery and greater than 90% occlusion of the right internal
carotid artery. His right vertebral artery is stenotic. His left
vertebral artery is patent.
Patient was in acute renal failure, probably prerenal in
etiology. His Cr was 2.1 and improved to 1.2 with iv hydration.
On admission he was anemic with a Hct of 30. On [**2-23**] his Hct
dropped to 26. He was hemodynamically stable. Patient was guaic
positive in the [**Hospital1 18**] ED, but did not appear to be actively
bleeding. Patient has complained that at home he was having
bright red blood in the toilet bowl four days per week.
On [**2-23**] patient was transferred to the [**Hospital1 18**] [**Location (un) **] trauma
ICU.
ROS: +Bright red blood per rectum occuring four days per
week. + weight loss. Denies fever, chills, chest pain, SOB,
coughing, diarrhea, constipation, nausea, vomiting. Rest of
review of systems was negative.
Past Medical History:
1. Diabetes.
2. Hypertension.
3. Hyperlipidemia.
4. Obesity.
5. History of prostate cancer status post resection.
Prostate cancer was diagnosed in [**2147**]. He has received 37
radiation treatment
6. Glaucoma
Social History:
He quit tobacco 20 years ago, prior to that he smoked 20 packs
per day x20 years. He drinks alcohol occasionally. He denies
illicit drug use. He lives at home with his wife. [**Name (NI) **] has 2
step-daughters.
Family History:
Mother has a history of MI.
Physical Exam:
VS: SBP 153/65 P 65 R 18 02 98%
Gen: obese
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: regular rate and rhythm, no murmurs,
Abd: soft, non-distended, non-tender, no mass, positive bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: alert and oriented x3, fluent, intact comprehension,
intact naming, repetition, knowledge, spelling, follows crossed
body commands, no neglect
CN: visual fields full to confrontation, pupils equal, round,
and
reactive, extraocular movements intact, intact light touch,
mild asymmetry of right corner of his mouth, otherwise no facial
symmetry, intact t/u/p, [**6-16**] SCM and trapezius
Motor: normal tone and bulk of all four extremities, no tremor
D B T WE WF FE FF
Left 5 5 5 5 5 5 5
Right 5 5 5 5 5 5 5
IP Q H DF PF
Left 5 5 5 5 5
Right 5 5 5 5 5
Sensory: intact light touch and pinprick of all four extremities
intact proprioception of LE
no extinction
Romberg deferred
Reflex: T BR B K A toes
Left 1 1 2 2 2 down
Right 1 1 1 2 2 mute
Coord: Intact finger-nose-finger, heel-shin bilaterally
Gait: deferred
Pertinent Results:
[**2149-2-23**] 10:08PM BLOOD WBC-7.9 RBC-3.41* Hgb-9.8* Hct-28.0*
MCV-82 MCH-28.6 MCHC-34.9 RDW-14.0 Plt Ct-262
[**2149-2-24**] 02:59PM BLOOD WBC-7.6 RBC-3.44* Hgb-10.0* Hct-28.6*
MCV-83 MCH-29.0 MCHC-34.9 RDW-14.2 Plt Ct-259
[**2149-2-23**] 10:08PM BLOOD PT-12.0 PTT-24.0 INR(PT)-1.0
[**2149-2-23**] 10:08PM BLOOD Glucose-99 UreaN-28* Creat-1.3* Na-138
K-4.5 Cl-106 HCO3-23 AnGap-14
[**2149-2-24**] 02:54AM BLOOD Glucose-118* UreaN-24* Creat-1.2 Na-138
K-5.0 Cl-104 HCO3-27 AnGap-12
[**2149-2-23**] 10:08PM BLOOD ALT-14 AST-15 LD(LDH)-157 CK(CPK)-65
AlkPhos-69 TotBili-0.2
[**2149-2-23**] 10:08PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2149-2-24**] 02:54AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2149-2-24**] 10:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2149-2-23**] 10:08PM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.5 Mg-2.0
[**2149-2-23**] 12:34PM BLOOD %HbA1c-6.3*
Brief Hospital Course:
Mr. [**Known lastname 40015**] was admitted to the ICU for closer monitoring. His
hospital course by problem is as follows:
Neuro:
His CTA showed Total occlusion of the left internal carotid
artery, marked stenosis at the right common carotid artery
bifurcation and occlusion of the proximal right vertebral
artery. His perfusion studies showed a prolonged mean transit
time consistent with left middle cerebral arterial territory
ischemia. Outside hospital MRI was reviewed, and confirmed small
cortical subacute infarcts in the MCA distribution. It was
discussed with him that the likely mechanism for his symptoms
was a stroke due to total occlusion of the right ICA. After
discussion of the risks and benefits with the patient, it was
decided to start heparin/coumadin for 4-6 weeks till the clot
from the R ICA stabilizes and then switch to an antiplatelet.
This was instituted after discussion with GI, given the BRBPR.
The L ICA could be considered for surgery in [**3-16**] months after he
has recovered from his current stroke and is more stable for
surgery. He continued to have BRBPR and after discussion
anticoagulation was stopped and he was started on Aggrenox (no
sxs of angina)
His blood pressure was target at SBP 120-180. Keep SBP <220 and
DBP <110 and MAP < 130. The HOB was initially maintained less
than 30 degrees. He was switched from ASA/Plavix to Aggrenox
[**Hospital1 **]. His A1c was 6.3 and his LDL was 48. His Zocor was kept at
80mg and not decreased given concern for potential increased
risk of stroke after reductions in statin dose. His LDL should
be maintained less than 70 over the long term. He will need OP
follow-up of LFT's LDL and TG. He was also maintained euthermic
and euglycemic. His A1c was 6.3. He was also monitored on tele
without events and ruled out for an MI with CE x 3.
A TTE was negative for a PFO and his repeat Carotid dopplers
showed 80 to 99% stenosis of the R ICA and complete occlusion of
the L ICA. Vascular surgery was consulted and recommended a CEA
in [**5-18**] week. Neurology advised to postpone for 3 months to
reduce the risk of futher complications given the recent stroke.
After a colonoscopy for his GI bleeding he was started on a
heparin drip with a goal PTT maintained between 50 and 70. He
had an episode of BRBPR on [**2-25**] with about 50cc of stool and
blood. He remained hemodynamically stable and his Hct was also
stable. The heparin was stopped. He was discharged on aggrenox
[**Hospital1 **] given his apparent bleeding complication to full
anticoagulation. He will follow up with Dr. [**Last Name (STitle) **] in
vascular clinic in 4 weeks to discuss likely CEA.
GI:
He was admitted with a history of GI bleeding but no prior
colonoscopy. He therefore had the procedure on [**2-24**] which showed
radiation proctitis, multiple AVM's, as well as a clot which was
cauterized. He was started on Mesalamine PR per GI for
proctitis. The patient was anticoagulated, but then had
recurrent GI bleeding (hemodynamically stable), and heparin was
stopped. GI did not feel repeat colonoscopy would be of value.
There were polyps noted on his colonoscopy, and he will require
a repeat colonoscopy for purposes of polypectomy in a few months
as arranged by his PCP.
Cardiovascular:
The patient's metoprolol and lisinopril were held on admission.
His lisinopril was re-started at a low dose prior to discharge.
His metoprolol was held given his recent episodes of GI
bleeding. His BP medications will require further titration as
an outpatient.
Heme:
He was anemic on admission, and therefore was tranfused 1 unit
PRBC on [**2-24**]. Serial hematocrits following the transfusion were
stable. Fe studies were consistent with Iron deficiency as well
as chronic disease. His retic count was normal.
Endo:
Given his recent stroke and renal insufficency at the OSH, his
oral hypoglycemics where held on admission. He was treated with
SSI as needed and restarted on Glucophage on [**2-25**].
Rheumatology:
The patient reported a history of gout in his left great toe,
and reported similar pain in his left ankle. The joint was noted
to be warm, edematous with marked tenderness to palpation in the
absence of trauma or infection. He was not started on on
colchicine for this likely exacerbation of acute gouty arthritis
due to his anticoagulation and GI bleeding. He was started on a
short course of prednisone for gout. He was also provided a
short course of vicodin for pain control. He was instructed to
call his PCP if the left ankle pain should worsen, or if he
should develop any fevers or rashes.
Ophtho:
He was maintained on his home regiment of Glaucoma medications.
Medications on Admission:
TRANSFER MEDICATIONS:
1. Zocor 40 mg daily.
2. Aspirin 325 mg daily.
3. Plavix 75 mg daily.
4. Insulin sliding scale.
HOME MEDICATIONS:
Metoprolol 25 mg p.o. b.i.d.
Metformin 500 mg p.o. t.i.d.
lisinopril 20 mg daily,
aspirin 81 mg daily,
glipizide 20 mg p.o. daily,
Cosopt eye drops 1 drop OU b.i.d.
Alphagan eye drops OU b.i.d.
Lumigan eye drops OU q.h.s.
Discharge Medications:
1. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
2. Brimonidine 0.15 % 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 Q24H (every 24 hours).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Mesalamine 1,000 mg Suppository Sig: One (1) Suppository
Rectal DAILY (Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
10. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12
hr Sig: One (1) Cap PO twice a day.
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 3 days: Do not drive or operate
machinery while taking this medication.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
left MCA cortical infarct
Bilateral Carotid Stenosis
Gastrointestinal Bleeding
Acute Gout
Discharge Condition:
Stable, right pronator drift. Slight R nasolabial flattening.
Discharge Instructions:
You were admitted for a stroke and found to have narrow arteries
leading to your brain as well as gastrointestinal bleeding. Your
bleeding was stopped with cauterization during colonscopy and
you were started on coumadin to prevent further strokes.
Please take all medications as prescribed.
Call your doctor or 911 immediately if you have any blood in
your stoool, unusually dark or black stools, dizziness,
palpitations, sweating, shortness of breath, chest pain, new
weakness, difficulty speaking, tingling, numbness or any other
concerning symptoms.
Followup Instructions:
Please see your primary care doctor (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) next
week, you should have a repeat hematocrit checked and discuss
your treatment for gout. You will need a follow up colonscopy in
[**5-18**] months (off aggrenox 1 week prior) for removal of polyps
noted on your colonoscopy performed here in the hospital.
You have a follow up appointment with the Stroke Center at [**Hospital1 18**]
[**Hospital Ward Name **], [**Hospital Ward Name 23**] Building, [**Location (un) 858**].
With Dr. [**First Name (STitle) **] [**Name (STitle) **]
Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2149-3-24**] 4:00
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (vascular surgery) for a follow
up appointment in four weeks to plan a carotid endarterectomy.
Office Phone: ([**Telephone/Fax (1) 18181**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
ICD9 Codes: 2749, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2552
} | Medical Text: Admission Date: [**2155-10-27**] Discharge Date: [**2155-11-3**]
Date of Birth: [**2073-2-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2155-10-28**] - Aortic valve replacement (21mm St. [**Male First Name (un) 923**] Porcine
Tissue Valve)
History of Present Illness:
82 yo F with history of Atrial fibrillation who has been
followed with serial echocardiograms for her known aortic
stenosis over the past couple of years. Pt
has been experiencing worsening shortness of breath and
exertional chest pain. Most recent echo in [**Month (only) **] of this year
revealed significant aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] 0.7cm2,
[**1-10**]+MR/TR, mild pulmonary HTN and a normal EF. She now presents
for surgical evaluation for possible aortic valve replacement.
Past Medical History:
Past Medical History:
Hypertension
Hyperlipidemia
Aortic Stenosis
Afib s/p cardioversions
SVT ablation [**2142**]
Severe bilateral hearing loss (wears bilat hearing aides)
Macular degeneration
Arthritis
chronic diastolic heart failure
multiple lipomas
obesity
(?)Colitis
(?)Vertigo
Past Surgical History:
s/p hysterectomy
s/p left Total knee replacement [**2151**]
s/p right cataract surgery
carpal tunnel release (B)
Social History:
Occupation: Retired
Last Dental Exam: 4 months ago
Lives with: alone-[**Location (un) **] ; daughter in [**Name (NI) **]
Race Caucasian
Tobacco: denies
ETOH:rare social
Family History:
father with CHF died at 71; uncles with CAD
Physical Exam:
Pulse:54 Resp:18 O2 sat: 100%
B/P Right:164/68 Left:
Height: 5'3" Weight:180
General:NAD, obese
Skin: Dry [x] intact [x]multiple fatty tumors, arms,
chest;ecchymotic areas on arms;mult.small healed scars
HEENT: PERRLA [x] EOMI [x]anicteric sclera; OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [**4-14**] harsh SEM radiates
throughtout precordium to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]: no HSM/ CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema: tr bil.
Varicosities: None []mult. spider veins
Neuro: Grossly intact
Pulses:
Femoral + bil.
DP 2+ bil.
PT + bil.
Radial 2+ bil.
Carotid Bruit: murmur radiates to bil. carotids
Pertinent Results:
[**2155-10-27**] Cardiac Cath
1. Selective coronary angiography of this right dominant system
revealed
no obstructive coronary artery disease. The LMCA was normal. The
LAD and
LCX had minor luminal irregularities. The RCA had no
angiographically
apparent stenoses.
2. Limited resting hemodynamics revealed moderate systemic
arterial
hypertension with a central aortic pressure of 178/74 mm Hg.
[**2155-10-27**] Carotid Ultrasound
No plaque or hemodynamically significant stenoses.
[**2155-10-27**] Femoral Ultrasound
1. 1 cm pseudoaneurysm arising from the right common femoral
artery. No AV
fistula identified.
2. Widely patent right femoral artery and common femoral vein.
[**2155-10-28**] ECHO
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Mild to moderate ([**1-10**]+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen.
POSTBYPASS
Biventricular systolic function remains normal. There is a well
seated bioprosthesis in the aortic position. No AI is visualized
but echo windows are limited. The MR is now mild. TR remains
unchanged
[**2155-10-31**] 05:50AM BLOOD WBC-15.6* RBC-3.63* Hgb-10.5* Hct-31.6*
MCV-87 MCH-28.8 MCHC-33.1 RDW-16.4* Plt Ct-173
[**2155-10-31**] 05:50AM BLOOD PT-14.7* PTT-30.2 INR(PT)-1.3*
[**2155-10-31**] 05:50AM BLOOD Glucose-126* UreaN-24* Creat-1.1 Na-139
K-4.3 Cl-102 HCO3-27 AnGap-14
Brief Hospital Course:
Ms. [**Known lastname 9250**] was admitted to the [**Hospital1 18**] on [**2155-10-27**] for surgical
management of her aortic stenosis. As she had been off her
coumadin for 5 days prior to admission, she was placed on
heparin for anticoagulation for her atrial fibrillation. She
underwent a cardiac catheterization in preparation for surgery
which revealed clean coronaries. A carotid duplex ultrasound was
performed which showed no significant internal carotid artery
stenosis. As she had a large hematoma from her cardiac
catheterization, and ultrasound was performed which showed 1 cm
pseudoaneurysm arising from the right common femoral artery, no
AV fistula identified and a widely patent right femoral artery
and common femoral vein. On [**2155-10-28**], she was taken to the
operating room where she underwent an aortic valve replacement
using a 21mm St. [**Male First Name (un) 923**] tissue valve. Please see operative note
for details. Postoperatively she was taken to the intensive care
unit for monitoring. Within 24 hours, she had awoke
neurologically intact and was extubated. She was weaned from her
pressors and transferred to the step down floor. Her chest
tubes and wires were removed and her coumadin was restarted.
She was diuresed toward her pre-operative weight of 180 lbs.
Her oral intake was bolstered by ensure shakes. She was seen by
physical therapy and it was determined that she would benefit
from going to rehab at discharge. By post-operative day four
she was ready for discharge to rehab.
Medications on Admission:
COUMADIN 2.5'except 5 SUNDAYS, Centrum Silver', Ocuvite',
amidoarone 200', tylenol", ASA 81', simvastatin 20'
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: for INR goal of [**2-11**] for afib.
Disp:*30 Tablet(s)* Refills:*0*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14
days: titrate as clinically indicated.
Disp:*14 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health care
Discharge Diagnosis:
Aortic stenosis s/p AVR
Hypertension
Hyperlipidemia
Aortic Stenosis
Afib s/p cardioversions
SVT ablation [**2142**]
Severe bilateral hearing loss (wears bilat hearing aides)
Macular degeneration
Arthritis
chronic diastolic heart failure
multiple lipomas
obesity
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Please report all wound issues to
you surgeon at ([**Telephone/Fax (1) 1504**],
2) Report any fever greater then 100.5
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) Please shower daily. Wash wound(s) with soap and water. No
lotions creams or powders to incisions for 6 weeks.
5)
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**Last Name (STitle) 3321**] in [**2-11**] weeks.
Please follow-up with Dr. [**First Name (STitle) 3322**] in [**2-11**] weeks. [**Telephone/Fax (1) 13687**]
Please call all providers for appointments.
Completed by:[**2155-11-1**]
ICD9 Codes: 4168, 4019, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2553
} | Medical Text: Admission Date: [**2184-10-19**] Discharge Date: [**2184-11-2**]
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Tetracyclines
Attending:[**First Name3 (LF) 23347**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Hemodialysis
Right IJ central venous catheter placement attempt
Right femoral central venous catheter placement
Left IJ hemodialysis catheter removal, temporary catheter
placement, and permanent catheter placement
Left arm PICC placement
History of Present Illness:
Ms. [**Known lastname 94952**] is a [**Age over 90 **] yo female with ESRD on HD who comes in with
3 days of intermittent RUQ pain (chronic), + nausea, no
vomiting. She visited her PCP, [**Name10 (NameIs) 1023**] documented a T about 100 and
was concerned about abd pain on exam. He sent her to the ED
where she denied current abd pain. She was noted to have a
slight leukocytosis, and had a CXR showing chronic effusions but
better than usual. KUB was negative. UA with epi's. During
her stay, she then spiked a fever to 102 and her pressure
dropped down to 80 systolic. Got .5L fluid x 2 with no
improvement in her pressures. A right femoral line was placed
after failure to place a right IJ. She received a dose of vanc
and cipro. An abdominal CT was largely unremarkable.
Of note, she was recently started on dialysis in the middle of
[**Month (only) 359**] with a HD catheter placed. She was also seen 2 weeks
ago for LE cellulitis in the ED. She was given a 10 day course
of levofloxacin.
Vitals in ED: T 102 HR 65 BP 84/36 97% on 4LNC RR 24
On the floor, she is comfortable and pleasant. She denies SOB,
f/c, chest pain, cough, HA. She reports urinary frequency with
incomplete voiding, but denies dysuria.
Past Medical History:
AFib
Tachy-brady s/p PPM [**3-9**]
CKD stage IV b/l ~Cr 2.2
SCC leg and neck s/p radiation [**1-9**]
4+ TR
2+ MR
[**First Name (Titles) **] [**Last Name (Titles) **] HTN
Hypothyroidism
HTN
IBS
Anemia b/l Hct ~34%
Diverticulosis
Social History:
Retired. No current alcohol or tobacco use. Dtrs very active in
her care. Lives in house in [**Location (un) 10059**] with live-in aide.
Family History:
Noncontributory
Physical Exam:
vitals: T 95.4 BP 92/D P 64 R 24 98%2L
gen: pleasant, NAD
heent: Anicteric. OP clear. MM dry.
neck: supple, no elevated jvp. L subclavian catheter c/d/i.
[**Location (un) **]: CTAB
cv: RRR, 2/6 SEM at LLSB
abd: soft NT/ND +BS
extr: 2+ LE edema. Fragile skin with some tears on R forearm. R
1st MTP with erythema and swelling although no TTP. Ostomy bag
over former site of femoral line with small amt serous fluid.
PICC in L antecub.
neuro: Alert, oriented to [**Hospital1 18**], [**Month (only) **]. CN II-XII grossly
intact. Moving all extremities.
Pertinent Results:
Admission Labs:
[**2184-10-19**] 01:40PM BLOOD WBC-12.3*# RBC-3.09* Hgb-11.4* Hct-35.8*
MCV-116* MCH-36.8* MCHC-31.8 RDW-20.2* Plt Ct-131*
[**2184-10-19**] 01:40PM BLOOD Neuts-89.4* Lymphs-5.6* Monos-4.6 Eos-0.2
Baso-0.1
[**2184-10-19**] 06:50PM BLOOD PT-26.7* PTT-38.8* INR(PT)-2.7*
[**2184-10-19**] 06:50PM BLOOD Glucose-108* UreaN-24* Creat-2.2* Na-144
K-3.9 Cl-100 HCO3-29 AnGap-19
[**2184-10-19**] 06:50PM BLOOD ALT-17 AST-34 AlkPhos-197* TotBili-1.2
[**2184-10-19**] 06:50PM BLOOD Lipase-25
[**2184-10-19**] 06:50PM BLOOD Albumin-3.6 Calcium-9.0 Phos-2.4* Mg-1.5*
Interval Labs:
[**2184-10-19**] 11:28PM BLOOD WBC-11.4* RBC-2.46* Hgb-9.0* Hct-27.9*
MCV-114* MCH-36.6* MCHC-32.2 RDW-21.3* Plt Ct-113*
[**2184-10-26**] 05:56AM BLOOD WBC-6.3 RBC-2.34* Hgb-8.5* Hct-26.1*
MCV-112* MCH-36.2* MCHC-32.4 RDW-20.4* Plt Ct-112*
[**2184-10-31**] 05:20AM BLOOD WBC-7.3 RBC-2.20* Hgb-8.1* Hct-25.2*
MCV-115* MCH-36.7* MCHC-31.9 RDW-20.0* Plt Ct-184
[**2184-10-21**] 05:34AM BLOOD PT-40.2* PTT-45.3* INR(PT)-4.4*
[**2184-10-25**] 04:08AM BLOOD PT-16.0* PTT-37.1* INR(PT)-1.4*
[**2184-10-20**] 10:40AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.024
[**2184-10-20**] 10:40AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM
[**2184-10-20**] 10:40AM URINE RBC-[**10-21**]* WBC-[**10-21**]* Bacteri-MANY
Yeast-NONE Epi-011/25/08 05:56AM BLOOD VitB12-1392* Folate-11.9
Discharge Labs:
******
Micro Data:
[**2184-10-19**] blood cultures: 4/4 bottles positive for MRSA
[**2184-10-20**] blood cultures: 2/4 bottles positive for MRSA
[**2184-10-20**] catheter tip: positive for MRSA
[**2184-10-20**] urine culture: GRAM POSITIVE BACTERIA. 10,000-100,000
Alpha hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
Blood cultures 11/20, [**10-21**], [**10-22**], [**10-23**], [**10-25**]: no growth
Imaging:
CXR [**2184-10-19**]: 1. Cardiomegaly with mild pulmonary edema and
moderate-sized bilateral pleural effusions, right greater than
left.
2. Interval placement of left-sided hemodialysis catheter with
the tip within the right atrium.
3. Unchanged right-sided dual-chamber pacemaker.
CT Abd/Pelvis [**2184-10-19**]:
1. No evidence of abcess or acute abdominal process.
2. Bilateral pleural effusion, right greater than left,
measuring simple
fluid attenuation. Trace pericardial effusion and small amount
of abdominal / pelvic ascites.
3. Possible sludge or stone in the gallbladder without evidence
of
cholelithiasis.
4. Sigmoid diverticulosis without evidence of diverticulitis.
Echo [**2184-10-25**]: Right atrial pressure is 10-15mmHg. LVEF>55%.
Increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular cavity is moderately dilated with mild global
free wall hypokinesis. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] There is abnormal septal motion c/w
right ventricular pressure and volume overload. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
to severe pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. No vegetations seen.
Right foot plain films ([**10-25**]): No acute fracture. Soft tissue
swelling along the medial aspect of the foot centered at the
first MTP joint.
CXR ([**10-25**]): Moderate bilateral pleural effusion, right greater
than left, continues to increase.
Brief Hospital Course:
1) Septic shock: Secondary to MRSA infection of HD catheter. The
catheter was removed and subsequent blood cultures were all
negative. TTE showed no vegetations. She initially required
levophed for hypotension and was treated with vancomycin and
cefepime, but the cefepime was stopped after cultures showed
MRSA in the blood. She had a temporary IJ HD line placed, which
was later changed to a permanent line. A PICC was also placed
for access and antibiotics. She was weaned off the levophed and
transferred out of the ICU, where she remained afebrile and
hemodynamically stable, with SBP improved to 110s. Due to the
fluids received for resuscitation, she was significantly
hypervolemic, with pleural effusions and anasarca. She was
weaned off supplemental O2 and continued on HD, where some of
the excess fluid was removed. The vancomycin will continue at HD
for two weeks after the first negative blood culture, ie, until
[**11-4**]. Her PICC was removed at discharge.
2) Gout: Painful and swollen right 1st MTP noted and podiatry
was consulted. Steroids were avoided due to her recent septic
shock. She responded well to a 4 day course of indomethacin.
3) Macrocytic anemia: Initial hematocrit drop in setting of IV
fluid resuscitation. Patient was guaiac negative. She remained
stable in the mid to upper 20s, although this was below her
prior baseline. B12 and folate were normal. She was given epo at
HD, and later iron was added.
4) Afib with tachy-brady: Metoprolol was held throughout the
admission as the patient had no hypertension or tachycardia. Her
INR was initially supratherapeutic and vitamin K was given. It
later became subtherapeutic and her warfarin was restarted.
5) Post-herpetic neuralgia: Patient had intermittent pain under
L breast that responded well to capsaicin cream, tylenol and
warm compresses. As an outpatient, she can be evaluated for
long-term therapy, such as with gabapentin or venlafaxine.
6) Abdominal pain: Noted intermittently and often not
reproducible on exam. Thought to be related to IBS or
constipation, or possibly fluid shifts from HD. She was kept on
an aggressive bowel regimen to relieve constipation.
[**Hospital 100**] Rehab to do:
[ ] blood transfusion (2 u pRBCs) with hemodialysis on [**11-5**]
[ ] hemodialysis [**11-5**]
[ ] follow INR
Medications on Admission:
1. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] to each eye ().
2. Citalopram 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Lactaid 3,000 unit Tablet Sig: One (1) Tablet PO QAC ().
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablespoon
powder PO once daily as directed.
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Warfarin 2.5 mg
8. Nystatin 100,000 unit/g Cream Sig: One (1) application
Topical twice a day as needed for itching.
9. Metoprolol Tartrate 12.5 [**Hospital1 **]
10. Citracal + D 315-200 mg-unit Tablet two [**Hospital1 **]
11. Senna 8.6 mg qhs
Discharge Medications:
1. Cyclosporine 0.05 % Dropperette Sig: One (1) Ophthalmic [**Hospital1 **]
(2 times a day): to each eye.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Polyethylene Glycol 3350 100 % Powder Sig: One (1) tablespoon
PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Lactaid 3,000 unit Tablet Sig: One (1) Tablet PO before
meals.
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
11. Citracal + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO
twice a day.
12. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for shoulder pain.
13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
18. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
20. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous HD PROTOCOL (HD Protochol) for 1 doses: Give at HD
on [**11-5**].
21. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3
times a day).
22. Trazodone 50 mg Tablet Sig: 0.75 Tablet PO HS (at bedtime)
as needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Septicemia from Methicillin Resistant Staphylococcus Aureus
Secondary:
End stage renal disease
Atrial fibrillation
Irritable bowel syndrome
Post-herpetic neuralgia
Chronic anemia
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to [**Hospital1 18**] due to an infection called MRSA in
your bloodstream, that initially was treated in the ICU. You
received IV fluids and an antibiotic called vancomycin, which
controlled this infection. We were able to remove some of your
excess fluid build up with dialysis, and this will continue as
an outpatient.
Please take all medications as prescribed and go to all follow
up appointments. We have made the following medication changes:
- Increased your citalopram (Celexa) dose.
- Restarted your atorvastatin (for high cholesterol) and
pantoprazole (stomach acid blocker).
- Stopped your metoprolol as your blood pressure and heart rate
were not elevated.
- You will receive a dose of vancomycin at your next dialysis
session ([**11-5**]).
- You have been started on tylenol, capsaicin cream for pain
control
- You have been started on trazodone for sleep
- You have been started on simethicone for gas
If you experience fevers, chills, difficulty breathing,
confusion, chest pain, vomiting, diarrhea, or any other
concerning symptoms, please seek medical attention or come to
the ER immediately.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Followup Instructions:
Please call your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 719**] to schedule
a follow up appointment.
Continue your dialysis Monday, Wednesday and Friday at [**Hospital 100**]
Rehab.
Your INR will be followed at [**Hospital 100**] Rehab.
[**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]
ICD9 Codes: 5856, 5119, 2749, 2449, 4168, 4280, 2875, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2554
} | Medical Text: Admission Date: [**2164-2-20**] Discharge Date: [**2164-3-11**]
Date of Birth: [**2120-8-12**] Sex: F
Service: MEDICINE
Allergies:
Topiramate / Aripiprazole / Shellfish / Bee Pollen
Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
[**2164-2-20**] EGD without intervention
[**2164-2-29**] Diagnostic/therapeutic paracentesis
[**2164-3-1**] Diagnostic/therapeutic paracentesis
[**2164-3-4**] Diagnostic paracentesis
[**2164-3-7**] Diagnostic/therapeutic paracentesis
[**2164-3-8**] EGD with Dobhoff placement with sedation
[**2164-3-9**] Diagnostic/therapeutic paracentesis
History of Present Illness:
Ms. [**Known lastname 45209**] is a 43F with a history of alcoholic cirrhosis s/p
TIPS 6 weeks ago (gradient 17->10), active alcoholism, and
recect UGIB attributed to duodenal varix who was discharged
[**2164-1-16**] after IR guided embolization of a sentinel bleed from a
duodenal varix. During her most recent admission the pt was
tachycardic, hypotensive and required multiple blood
transfusions and underwent EGD that showed only mild portal
gastropathy and colonoscopy that showed a large volume of blood
in the colon and grade 1 external/internal hemorrhoids. She
subsequently underwent CTA that showed duodenal varicies that
were embolized.
Following this, patient was in her normal state of health until
she started having BRBPR as well as light-headedness and
presented to OSH where she had a crit of 18.8 blood [**Month/Day/Year **] of 279.
She was also found to be hypotensive to as low as 80/44 but was
said to be mentating well. She was given 1 unit of FFP, 1 unit
of pRBC's, started on an octreotide drip, and given 1 dose of
40mg IV pantoprazole and was transferred to [**Hospital1 18**] for further
evaluation and management.
.
In the ED, initial VS were: 98.9 118 84/55 12 100% RA
She was noted to have BRBPR on rectal exam as well as dark blood
from her vagina, pelvic exam was significant for dark red blood
from her cervical os, she was dosed with IV 2gram Ceftriaxone,
continued on her octreotide drip, and had blood from OSH
hanging. Her crit was 22.3 (baseline mid 20's), PLT ct of 44
(fluctuates between 40's and low 120's), lactate of 2.5, Serum
[**Hospital1 **] of 164, Cr of 0.7. Prior to transfer to the MICU her BP was
98/54.
On arrival to the MICU, patient is alert and confirms the above
history. She states that she had the sudden onset of BRBPR along
with the feeling of generalized weakness. She denies significant
abdominal pain although described mild abdominal discomfort such
as hunger cramps. No N/V/D, no hematemesis, states she has had a
few recent falls related to her generalized weakness and perhaps
her [**Hospital1 **] intake. She denies LOC but did hit her nose on her
coffee table and had a minor nose bleed. Otherwise describes no
blood in her urine but has had small amounts of dark blood from
her vagina but states that she hasn??????t had an ordinary period in
over a year. She denies fevers, chills, CP, SOB, focal numbness,
weakness, or tingling.
Past Medical History:
- Alcoholic cirrhosis s/p TIPS
- s/p cholecystectomy [**2153**]
- Gastroesophageal reflux disease
- Bipolar disorder
- HTN
- Depression/anxiety
- Recent burns to both hands [**11/2163**] (housefire) s/p skin
grafting from R thigh
Social History:
She lives with her husband and 2 children, ages 16 and 17.
Smokes 1 pack every few weeks. Used to be an accountant.
Describes a few beers daily. Denies other drug use.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress although appears
uncomfortable
HEENT: moderately icteric sclerae, dry MM, oropharynx clear,
EOMI, PERRL, no sinus tenderness
Neck: supple, JVP not elevated, no LAD
CV: Rapid rate and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: Foley with icteric urine
Ext: warm, well perfused, 2+ pulses, trace BLE edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally
.
DISCHARGE PHYSICAL EXAM:
VS 97.6 (99.7) 117/74 (110-122/66-79) 113 (103-131) 20 97RA
(97-99RA)
I/O: PO 1500 + TF 1075 / UOP 1250 + BMx6
GENERAL: appears older than stated age, NAD, comfortable in bed
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: Tachycardic, SEM at RUSB. +S4.
LUNGS: Unlabored breathing, poor air movement. Decreased breath
sounds at right lung base to halfway up lungfields, with
bibasilar crackles.
ABDOMEN: Less distended and slightly tighter. Soft, non-tender.
EXTREMITIES: Warm and well perfused, trace edema
Pertinent Results:
ADMISSION LABS:
[**2164-2-20**] 11:00AM WBC-3.4* RBC-2.48* HGB-7.3* HCT-22.3* MCV-90
MCH-29.5 MCHC-32.9 RDW-19.0*
[**2164-2-20**] 11:00AM NEUTS-83.5* BANDS-0 LYMPHS-7.9* MONOS-7.4
EOS-0.7 BASOS-0.6
[**2164-2-20**] 11:00AM PLT COUNT-44*
[**2164-2-20**] 11:00AM GLUCOSE-167* UREA N-26* CREAT-0.7 SODIUM-126*
POTASSIUM-3.5 CHLORIDE-94* TOTAL CO2-23 ANION GAP-13
[**2164-2-20**] 11:00AM ALT(SGPT)-27 AST(SGOT)-67* ALK PHOS-112* TOT
BILI-6.3*
[**2164-2-20**] 11:00AM ALBUMIN-2.2* CALCIUM-6.9* PHOSPHATE-3.1
MAGNESIUM-1.3*
[**2164-2-20**] 11:00AM ASA-NEG ETHANOL-164* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2164-2-20**] 11:00AM PT-18.7* PTT-36.8* INR(PT)-1.8*
[**2164-2-20**] 11:00AM FIBRINOGE-113*
[**2164-2-20**] 07:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-2* PH-6.0
LEUK-NEG
[**2164-2-20**] 07:02PM URINE RBC-<1 WBC-14* BACTERIA-NONE YEAST-NONE
EPI-1
[**2164-2-20**] 11:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
DISCHARGE LABS:
[**2164-3-11**] 05:45AM BLOOD WBC-10.5 RBC-2.56* Hgb-7.8* Hct-25.3*
MCV-99* MCH-30.3 MCHC-30.7* RDW-21.9* Plt Ct-94*
[**2164-3-11**] 05:45AM BLOOD PT-31.1* PTT-44.9* INR(PT)-3.0*
[**2164-3-11**] 05:45AM BLOOD Glucose-123* UreaN-15 Creat-0.7 Na-137
K-4.2 Cl-104 HCO3-25 AnGap-12
[**2164-3-11**] 05:45AM BLOOD ALT-10 AST-30 AlkPhos-95 TotBili-3.7*
[**2164-3-11**] 05:45AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.5*
.
MICROBIOLOGY:
[**2164-2-20**] Blood cultures x2: no growth
[**2164-2-20**] Urine culture: no growth
[**2164-2-22**] Urine culture: no growth
[**2164-2-22**] Blood cultures x2: no growth
[**2164-2-24**] Blood cultures x2: no growth
[**2164-2-24**] Stool C. diff PCR: POSITIVE
[**2164-2-24**] Stool bacterial culture: no growth
[**2164-2-29**] Peritoneal fluid gram stain and culture: no growth
[**2164-3-1**] Peritoneal fluid gram stain and culture: no growth
[**2164-3-1**] Blood culture: no growth
[**2164-3-1**] Urine culture: YEAST
[**2164-3-4**] Urine culture: no growth
[**2164-3-4**] Blood cultures x2: no growth to date
[**2164-3-4**] Peritoneal fluid gram stain and culture: no growth
[**2164-3-7**] Peritoneal fluid gram stain and culture: no growth
[**2164-3-9**] Peritoneal fluid gram stain and culture: no growth
.
.
IMAGING:
[**2164-2-20**] RUQ US FINDINGS: The liver is diffusely echogenic,
consistent with chronic liver disease. There is a simple hepatic
cyst in the left lobe measuring 2.5 cm. The spleen is enlarged
measuring 15 cm. There is no ascites.
COLOR FLOW AND PULSE WAVE DOPPLER: The TIPS shunt is widely
patent with
wall-to-wall flow throughout. The flow velocities in the
proximal, mid and
distal portion of the TIPS shunt are 55.1, 180, and 116 cm/sec
respectively. These velocities previously were 133, 157 and 105
cm/sec respectively. The main portal vein has normal hepatopetal
flow. There is stable, expected reversal of flow within the left
portal vein. The right portal vein is patent. The hepatic veins
are patent.
IMPRESSION: Patent TIPS shunt with wall-to-wall flow throughout.
.
[**2164-2-20**] CXR:
FINDINGS: Endotracheal tube ends approximately 6.3 cm from the
carina, just above the level of medial heads of the clavicles.
Consider advancing the ET tube by another 2.5 cm for a better
seating. Bilateral lungs are remarkable for mild pulmonary
vascular congestion, prominent bilateral hila and azygos vein
which is likely from volume overload, given clinical setting.
Heart size is top normal. No pneumothorax or pleural effusion.
.
[**2164-2-21**] ABD CT:
CT ABDOMEN: There are small bilateral pleural effusions with
adjacent
compressive atelectasis and lingular atelectasis. No pericardial
effusion.
An echogenic focus at the hepatic dome (2B:97) is incompletely
imaged and
apparently new from [**2164-1-11**], too small to characterize. The
liver is
shrunken and nodular, compatible with known cirrhosis. A 2.1 cm
hypodensity in the left hepatic lobe is a cyst seen on prior
ultrasounds. A TIPS shunt is in place. The patency cannot be
assessed on this study, but it is patent on ultrasound [**2164-2-20**].
The gallbladder is absent. The spleen is enlarged to 13.8 cm.
The pancreas and bilateral adrenal glands are normal. The
kidneys enhance symmetrically and excrete contrast promptly
without hydronephrosis. A gastric diverticulum at the posterior
stomach (2A:18) is unchanged. High-density material in the
duodenum is likely related to coiling of duodenal varices,
performed [**2164-1-11**].
The small bowel is normal in course and caliber without
obstruction. There is large bowel wall thickening, predominantly
in the right colon with a large amount of adjacent stranding,
increased from [**2164-1-11**]. The findings are concerning for
colitis, probably infectious or inflammatory, less likely
ischemic given the distribution. There is a small amount of
perihepatic fluid. There is no free air. The aorta is of normal
caliber throughout. The main portal vein, splenic vein, and
proximal SMV are patent. Extensive portosystemic shunts are
again seen. The aorta is of normal caliber throughout. No
pathologically enlarged mesenteric or retroperitoneal lymph
nodes are identified.
CT PELVIS: The rectum and sigmoid colon are normal. The bladder
is normal,
with a Foley catheter in place. The uterus is normal. A small
amount of free fluid in the cul-de-sac is probably tracking down
from the abdomen. There is no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS: No bone finding suspicious for infection or
malignancy is seen.
IMPRESSION:
1. Findings concerning for colitis, likely infectious or
inflammatory, less likely ischemic given the distribution.
2. Cirrhosis with stigmata of portal hypertension including
ascites,
extensive portosystemic collaterals. A TIPS shunt is in place.
.
[**2164-2-20**] EGD
Findings: Esophagus:
Protruding Lesions 1 cords of grade I varices were seen in the
lower third of the esophagus.
Stomach:
Mucosa: Diffuse erythema and congestion of the mucosa were
noted in the stomach. These findings are compatible with portal
hypertensive gastropathy.
Other No active bleeding.
Duodenum:
Protruding Lesions Non bleeding varices were seen in the first
part of the duodenum.
Impression: Varices at the lower third of the esophagus
No active bleeding.
Erythema and congestion in the stomach compatible with portal
hypertensive gastropathy
Varices at the first part of the duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations: [**Hospital1 **] PPI
Octreotide drip
keep hct above 25
duplex for TIPS patency
If rebleeds, would get IR evaluation for TIPS pressure gradient
measurement and angioplasty if elevated gradient
.
[**2164-2-23**] CXR PA/lat: PA and lateral chest radiographs demonstrate
opacification of the left lower lobe with air bronchograms. The
patient has been entubated. There is also bibasilar atelectasis.
The heart size is mildly enlarged. Prominence of the azygos vein
and pulmonary vasculature is unchanged from [**2-20**].
IMPRESSION: Likely left lower lobe pneumonia.
.
[**2164-2-25**] CXR portable: Left PICC terminates in the mid superior
vena cava. The cardiac silhouette is enlarged and accompanied by
increased vascular pedicle width, increased pulmonary vascular
congestion, and bilateral perihilar haziness suggestive of
edema. Additionally, there persist opacities within the right
middle and right lower lobes suggestive of atelectasis.
Previously reported left lower lobe opacities have slightly
improved and could be due to either atelectasis or improving
infection.
.
[**2164-2-28**] EKG: Sinus rhythm. Prominent QRS voltage but does not
meet criteria for left ventricular hypertrophy. Since the
previous tracing of [**2164-2-20**] the rate is slower. Otherwise,
probably unchanged.
.
[**2164-2-29**] Abdominal ultrasound ascites search: A limited
examination of the four quadrants of the abdomen was performed.
A moderate amount of ascites is seen and a mark was made at the
right lower quadrant for a paracentesis to be performed by the
clinical staff.
IMPRESSION: Moderate ascites. The right lower quadrant was
marked for a
paracentesis to be performed by the clinical staff.
.
[**2164-2-29**] Portable abdominal x-ray: A single supine frontal view
of the abdomen demonstrates a non-specific bowel gas pattern
with gas in non-dilated loops of small bowel and large bowel. A
TIPS shunt is in place in the right upper quadrant of the
abdomen. Surgical clips adjacent to the TIPS shunt are
consistent with prior cholecystectomy. Evaluation for a small
amount of free air is limited due to supine positioning;
however, there is no evidence of a large amount of free
intraperitoneal air. Generalized increased opacification of the
abdomen is consistent with ascites. No portal venous gas is
appreciated.
IMPRESSION: Non-specific bowel gas pattern without evidence of
obstruction or ileus. No free air detected; however, a left
lateral decubitus film, upright film or CT would be more
sensitive for a small amount of free intraperitoneal air.
.
[**2164-2-29**] Portable chest x-ray: Single supine view was submitted
for review, this limits the evaluation of free air. There are
low lung volumes. Cardiac size is top normal. Left PICC tip is
in the mid SVC. There is no pneumothorax. If any, there is a
small right pleural effusion. Bibasilar atelectases, larger on
the right side. Streaky atelectases are also present in the left
upper lobe. There is mild vascular congestion. TIPS projects in
the right upper quadrant.
.
[**2164-2-29**] CT ABD/PELVIS W/O CONTRAST:
1. Resolution of colonic wall thickening, which was compatible
with colitis.
2. Slight increase in ascites, however likely due to fluid
overload given
interval development of anasarca and increased stranding of the
intra-abdominal fat.
3. No intra-abdominal abscess.
4. Bibasilar atelectasis, wedge-shaped volume loss at right lung
base may
indicate a small infiltrate.
5. Chronic findings including TIPS shunt (cannot assess patency
due to lack
of contrast), large gastric diverticulum, multiple secondary
findings
indication of cirrhosis and portal hypertension.
.
[**2164-3-1**] IR-guided diagnostic/therapeutic paracentesis:
Uneventful diagnostic and therapeutic ultrasound-guided
paracentesis yielding 2.35 liters of yellow ascitic fluid.
.
[**2164-3-4**] Portable abdominal x-ray: In comparison with the study
of [**2-29**], there is again generalized haziness of the abdomen
consistent with extensive peritoneal fluid. A TIPS shunt is in
place.
There is dilatation of gas-filled loops of small bowel that
appear to be out of proportion to the large bowel gas. This
raises the possibility of a
partial or early small-bowel obstruction. If this is a serious
clinical concern, CT would be the next imaging procedure.
Although there is no definite free intraperitoneal gas, though
this also could be evaluated on CT.
.
[**2164-3-4**] CT ABD W/O CONTRAST:
1. Cirrhotic liver with evidence of portal hypertension with
splenomegaly,
increased ascites, and extensive varices.
2. Bilateral small pleural effusions with overlying atelectasis.
3. Stable appearance of large gastric diverticulum.
4. Stable left paraaortic lymph node.
.
[**2164-3-6**] EKG: Sinus tachycardia. Consider left ventricular
hypertrophy by voltage. ST-T wave abnormalities of strain and/or
ischemia. Since the previous tracing of [**2164-2-28**] the rate is
faster. ST-T wave abnormalities are more prominent.
.
[**2164-3-6**] CT HEAD W/O CONTRAST: No evidence of hemorrhage or
infarction. Prominent ventricles and sulci for age.
.
[**2164-3-7**] EKG: Sinus tachycardia. Since the previous tracing ST
segment depressions may be less prominent. T wave abnormalities
persist.
.
[**2164-3-7**] IR-guided diagnostic/therapeutic paracentesis:
Ultrasound-guided therapeutic and diagnostic paracentesis with
removal of 2 L of straw-colored fluid.
.
[**2164-3-8**] EGD: A 10F nasojejunal feeding tube was placed in a
standard fashion. The tube was subsequently bridled. No
complication occured. The estimated blood loss was 2 cc.
Otherwise normal EGD to third part of the duodenum. Dobhoff is
okay to use.
.
[**2164-3-9**] CXR PA/lat: Persistent lower lung volume. Mild
cardiomegaly is accentuated by low lung volumes. Pulmonary edema
has improved, now mild. Large right lower opacity is a
combination of pleural effusion and atelectasis. This has
improved from prior study. The lower lung atelectasis has
improved. There is no pneumothorax or pleural effusion. Left
PICC tip is in the upper-to-mid SVC. NG tube is out of view
below the diaphragm. Of note, the opacity in the right lower
lobe could be due to atelectasis but superimposed infection
cannot be excluded in the appropriate clinic setting.
.
[**2164-3-9**] Abdominal ultrasound: Large amount of loculated ascites
is seen in the abdomen.
.
[**2164-3-9**] IR-guided paracentesis: Ultrasound-guided therapeutic
and diagnostic paracentesis with removal of 3L of blood tinged
ascitic fluid.
.
[**2164-3-10**] CXR (portable): Left-sided PICC line overlies mid/distal
SVC. An NG-type tube extends beneath the diaphragm beyond the
inferior edge of the film, likely extending into the duodenum.
Cardiomediastinal prominence, right effusion, underlying right
base collapse and/or consolidation, and diffuse increased
vascular markings are grossly unchanged.
.
[**2164-3-10**] LLE Ultrasound with Doppler: No DVT in the left lower
extremity.
Brief Hospital Course:
Ms. [**Known lastname 45209**] is a 43 year old lady with a hx of alcoholic
cirrhosis s/p TIPS 6 weeks prior to presentation, active
alcoholism, and recent duodenal varix bleed s/p IR guided
embolization, who was admitted with BRBPR and relative
hypotension, from a presumed upper GI bleed; she then developed
C. diff colitis, healthcare associated pneumonia and SBP.
Hospital course was also complicated by hyponatremia, a fall
without loss of consciousness, and tachycardia.
.
.
ACTIVE ISSUES:
# Upper GI bleed: Patient presented with hematochezia c/b
hypotension: Patient with prior history of gastrointestinal
bleeding from varices s/p IR-guided embolization ([**1-15**]) and EGD
with injection of glue to duodenal varix in third part of
duodenum ([**1-24**]) now presenting with BRBPR and relative
hypotension. Hematocrit was 18 at OSH and she received 2 units
PRBCS prior to transfer to [**Hospital1 18**]. Here she received two more
units of PRBCs. She was started on octreotide, pantoprazole and
ceftriaxone. She underwent liver US which showed a patent TIPS.
She then underwent EGD without clear source of bleeding. For the
rest of hospitalization, her hematocrit remained stable ~25.
.
# Colitis: While in the MICU, the patient had low grade fevers
and reent history of gastrenteritis-like illness. She complained
of severe abdominal pain, so a CT scan was obtained, showing
possible colitis. Her ceftriaxone was switched to ciprofloxacin
and Flagyl was also started for treatment of presumptive
infectious colitis. Soon after transfer to the floor, the
patient developed severe diarrhea, with stool sample positive
for C. diff. Ciprofloxacin was discontinued. She was treated
with vancomycin PO and Flagyl IV for the rest of her hospital
course. Even though the patient was counseled that opioids put
her at risk for developing toxic megacolon and could lead to
severe complications including death, she preferred receiving
low-dose opioids for pain control; these were tapered off. On
[**3-4**], she developed increasing abdominal distention with no
bowel movements overnight; x-ray and CT imaging were negative
for toxic megacolon. The patient's diarrhea and abdominal pain
improved. Stool studies for other infectious etiologies were
negative. The patient will need to continue vancomycin for a
4-week-long tapered course.
.
# HCAP: On arrival to the floor from the MICU, patient was noted
to have shortness of breath and chest discomfort, along with a
leukocytosis. CXR revealed a left lower lobe pneumonia. She was
treated with cefepime IV and vancomycin IV for healthcare
associated pneumonia. Dyspnea improved.
.
# Spontaneous bacterial peritonitis: After transfer from MICU to
the floor, patient developed increasing leukocytosis along with
worsening abdominal distention and pain. She underwent
diagnostic paracentesis on [**2-29**] that was consistent with SBP.
She continued cefepime and Flagyl IV, which had been started for
her HCAP and C. diff, respectively. When repeat
diagnostic/therapeutic tap on [**3-1**] showed worsening WBC count in
ascitic fluid, there was concern for translocation of bacteria
from the gut or from perforation. Abdominal CT from [**2-29**] did not
show obvious perforation or free air and did show an improving
colitis. She was transferred back to the MICU for closer
observation and management. In the MICU, fluconazole for
coverage of fungal infection of ascites was added to her
antimicrobial regimen. Transplant surgery was consulted who
felt this was not a perforation, and did not need surgical
intervention. Patient was watched in ICU until [**2164-3-3**] with
improvement of her abdominal exam. She was then transferred back
to the floor. She underwent three more paracenteses, which
showed signs of improving infection with resolving ascitic
leukocytosis. Abdominal pain improved.
.
# Hyponatremia: Patient has a history of hyponatremia related to
her cirrhosis. She presented with sodium of 126, which trended
down and nadired at 120. On presentation, she also had low
plasma Osm of 254 and appeared to be total body fluid
overloaded. She was place on fluid restriction, but did not want
to adhere to a low sodium diet. With reinstitution of her
diuretics and fluid restriction, sodium increased to the 130s
and remained stable.
.
# [**Last Name (un) **]: Patient's Cr trended up to peak at 4.5 during her
hospital stay from 0.7 on admisison. Etiology was prerenal
azotemia, but there was also concern for hepatorenal syndrome.
Patient was aggressively volume resuscitated with Albumin and
her Cr decreased to 0.7, where it stabilized.
.
# Tachycardia: On the day prior to discharge, patient developed
sinus tachycardia, along with a sensation of shortness of
breath. The rest of her physical exam was significant for volume
overload. CXR showed pulmonary edema. EKG was consistent with
sinus tachycardia, and LLE U/S showed no evidence of DVT. She
was diuresed with IV Lasix, and her tachycardia and dyspnea
resolved. There was also a high component of anxiety in her
symptoms.
.
.
CHRONIC ISSUES:
# Alcoholic Cirrhosis: Patient with chronic cirrhosis secondary
to alcohol ongoing alcohol abuse s/p TIPS with significant
esophageal and duodenal varices. No prior hx of esophageal
variceal bleed. MELD at discharge was 21. She continued
lactulose and rifaximin. She was counseled extensively regarding
necessity of a relapse prevention to maintain and document
sobriety after discharge in order to be considered a transplant
candidate. While in house, a Dobhoff was placed and tube feeds
started for supplemental nutrition.
.
# Active Alcoholism: Patient with [**Last Name (un) **] level of 274 at OSH. She
was placed on CIWA scale though she did not require
benzodiazepines during this admission. As above, she was
counseled extensively regarding need to maintain sobriety for
overall health and transplant consideration.
.
# Uterine Bleeding: Patient with low volume dark blood from her
cervical os per ED pelvic exam. Per ED, patient is otherwise
amenorrheic so they have raised concern for possible DIC. Since
hospitalization no further bleeding from vagina. Pelvic
ultrasound should be considered for further evaluation as an
outpatient.
.
.
TRANSITIONAL ISSUES:
# Patient should continue vancomycin PO for four weeks, tapered
as described.
# Commitment to a relapse prevention program, and documented
sobriety for three months is necessary for patient to be
considered a transplant candidate. This was discussed
extensively with the patient, her husband, and her [**Last Name (un) **].
# Please consider pelvic ultrasound for further evaluation of
uterine bleeding as an outpatient.
# PICC was left in place per request of rehab facility. Pt is
currently not on any IV medications. It should be removed as
soon as possible to reduce risk of line infection.
# Pt has Foley catheter in place currently. A voiding trial can
be attempted as pt gains strength to use a bedside
commode/bathroom.
# Code: full
# HCP: husband [**Name (NI) **] [**Telephone/Fax (1) 45334**]
Medications on Admission:
- furosemide 60 mg PO DAILY
- lactulose 10 gram/15 mL - 30 ML PO QID
- rifaximin 550 mg PO BID
- folic acid 1 mg PO DAILY
- thiamine HCl 100 mg PO DAILY
- multivitamin PO DAILY
- spironolactone 150 mg PO BID
- omeprazole 40 mg PO DAILY
- lorazepam 0.5 mg PO Q8H prn anxiety
Discharge Medications:
1. furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three
times a day: titrate to [**2-23**] BMs per day.
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. spironolactone 50 mg Tablet Sig: Three (3) Tablet PO once a
day.
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Severe Anxiety.
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
11. vancomycin 125 mg Capsule Sig: One (1) Capsule PO see taper:
-1 tab QID for 7 days ([**Date range (1) 30341**])
-1 tab [**Hospital1 **] for 7 days ([**Date range (1) 35542**])
-1 tab daily for 7 days ([**Date range (1) 45335**])
-1 tab every other day for 7 days ([**Date range (1) 45336**])
-1 tab every 3 days for 14 days ([**Date range (1) 45337**]).
Disp:*62 Capsule(s)* Refills:*0*
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
13. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
14. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary diagnosis:
Upper GI bleed
.
Secondary diagnoses:
Healthcare associated pneumonia
Severe C. diff colitis
Spontaneous bacterial peritonitis
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 45209**],
It was a pleasure to participate in your care here at [**Hospital1 1535**]. You were admitted with an upper
GI bleed, which stablized. You then developed several
infections, including a pneumonia, colitis and spontaneous
bacterial peritonitis. All these infections were treated with
appropriate antibiotics. You improved clinically and were then
discharged to a rehab facility so that you can continue to
regain your strength.
Please make the following changes to your medications:
START Vancomycin by mouth:
125 mg by mouth four times per day for 7 days ([**Date range (1) 30341**])
125 mg by mouth twice daily for 7 days ([**Date range (1) 35542**])
125 mg by mouth once daily for once 7 days ([**3-25**]-/12)
125 mg by mouth every other day for 7 days ([**Date range (1) 45336**])
125 mg by mouth every 3 days for 14 days ([**Date range (1) 45337**])
Continue to take all of your other medications as prescribed.
Please see below for your follow-up appointments.
Followup Instructions:
Department: LIVER CENTER
When: FRIDAY [**2164-3-30**] at 10:00 AM
With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: LIVER CENTER
When: FRIDAY [**2164-5-4**] at 3:20 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: 5789, 486, 2761, 5849, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2555
} | Medical Text: Admission Date: [**2135-1-26**] Discharge Date: [**2135-1-27**]
Date of Birth: [**2083-7-10**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admission for coiling of R ICA/PCOMM aneurysm
Major Surgical or Invasive Procedure:
Cerebral angiogram and coiling of right ICA and PCOM aneurysms
History of Present Illness:
Patient with known PCom aneurym who presened for an elective
coiling.
Past Medical History:
Past medical history is significant for schizophrenia and
hypertension.
Social History:
Lives alone, long history of smoking
Physical Exam:
she is a middle-aged woman with masked
facies. She is awake, alert, oriented x3. Her extraocular
movements are intact. Her face is symmetric. Facial sensation
is intact bilaterally. Palate elevation is symmetric. Tongue
is
in the midline with no fasciculations. Motor strength, normal
tone and bulk, and 5/5 strength in all four extremities. She
has
a tremor in her extremities consistent with her use of Haldol.
Reflexes are [**1-21**] and symmetric. Gait was normal.
On discharge:
nonfocal neuro exam. Angio site was dry and soft. palpable
pulses.
Brief Hospital Course:
Ms. [**Known lastname 104775**] was admitted to [**Hospital1 18**] on [**1-26**] to undergo an elective
coiling of a right Pcom and right ICA aneurys.
Angio and coiling were successful withought significant
complications. There was some post-angio oozing from the site
which stopped and on [**1-27**] the site was soft to touch and dry.
She was discharged home on ASA on [**2135-1-27**] from the ICU.
Medications on Admission:
HCTZ, Haldol
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
4. haloperidol 5 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
5. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
HS (at bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
R ICA aneurysm (unruptured)
R PCOMM aneurysm (unruptured)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with coiling:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed. Please keep
your dressing on for 24 hours then you may remove.
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Roo
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 4 weeks for follow-up.
No imaging is needed at that time. Please call [**Telephone/Fax (1) 4296**] to
make this appointment.
Completed by:[**2135-1-27**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2556
} | Medical Text: Admission Date: [**2140-4-4**] Discharge Date: [**2140-4-7**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Percocet / Codeine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain; Transfer from [**Hospital1 **] for possible STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent to distal left
anterior coronary artery
History of Present Illness:
Ms. [**Known lastname 32687**] is an 89 y/o F with h/o HTN and DM who was
transferred to [**Hospital1 18**] for concern of possible STEMI.
.
She woke up this morning feeling well until she went down and
saw that her basement had flooded. Approx. 30 minutes later,
when she was addressing the flooding, she developed substernal
chest pain. She described this pain as [**8-30**] squeezing, located
in the center of her chest and radiating to her left breast.
She denied shortness of breath, diaphoresis, or palpitations.
.
She initially presented to [**Hospital3 **], where EKG was
concerning for ST elevations in V3-V5. She was given a SL NTG
and then started on a nitro gtt. She also received 1 dose of
5mg IV lopressor, ASA, lipitor 80mg. She also was started on
plavix 600mg and a heparin gtt (4000unit bolus followed by gtt
at 850 units/hr). Transfer to [**Hospital1 18**] for cardiac cath was
arranged.
.
In the cath lab at [**Hospital1 18**], she was noted to have diffuse
calcification in the proximal and mid LAD with a 70-80% stenosis
in the distal LAD that was stented with Minivision BMS. She was
also noted to have 70% stenosis in the origin of the left
circumflex but given the distribution of her EKG changes, this
was not felt to be the culprit lesion and was not intervened on.
She had only moderate luminal irregularities of her RCA.
.
On arrival to the CCU, the patient's VS were T= 97.7 BP= 127/64
HR= 60 RR= 18 O2 sat= 97%. She complained of some slight
discomfort in her chest 0.5/10, which she felt could be due to
having to lay flat for an extended period of time. She denied
any other complaints at that time.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, cough,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. She does admit to excessing bleeding during a hysterectomy
many years ago, chronic joint pains [**2-23**] OA, foot pains and hand
numbness [**2-23**] diabetic neuropathy, chronic back pain, and vision
loss related to macular degeneration. She also reports chornic
overactive bladder symptoms for the past 3 years. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, or syncope. Of note, the patient does report some
intermittent chest discomfort at home, which she describes as
indigestion and has treated with antacids. She does report some
chronic lightheadedness.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
.
PMH:
HTN
NIDDM
s/p C section x 4
s/p TAH
h/o L knee surgery, neck/back surgery, and L shoulder surgery
and L wrist surgery [**2-23**] trauma
Social History:
-Tobacco history: Smoked for 40 years from ages 14 to 55.
-ETOH: Rare
-Illicit drugs: Denies
Lives alone. Has a son who is a firefighter. Used to work in a
hospital as an aid on a neuro floor.
Family History:
2 sisters died on [**Name (NI) 5290**] in their 70's. Pt is unsure of any other
cardiac history.
Physical Exam:
VS: T= 97.7 BP= 127/64 HR= 60 RR= 18 O2 sat= 97%
GENERAL: WDWN 89 y/o F in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma
noted.
NECK: Supple with no obvious JVD noted.
CARDIAC: 2/6 systolic ejection murmur most noted at the RUSB. No
r/g noted. No S3 or S4 appreciated.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB
anteriorly.
ABDOMEN: Obese. Soft, NTND. No HSM or tenderness. Bowel sounds
present. No abdominial bruits.
EXTREMITIES: No c/c/e.
PULSES:
Right: DP dopplerable PT dopplerable
Left: DP dopplerable PT dopplerable
Pertinent Results:
[**2140-4-7**] 06:20AM BLOOD WBC-8.2 RBC-4.16* Hgb-13.1 Hct-37.7
MCV-91 MCH-31.5 MCHC-34.7 RDW-12.8 Plt Ct-201
[**2140-4-7**] 06:20AM BLOOD Glucose-148* UreaN-18 Creat-0.6 Na-140
K-4.0 Cl-104 HCO3-26 AnGap-14
[**2140-4-5**] 06:20AM BLOOD CK(CPK)-67
[**2140-4-4**] 08:42PM BLOOD CK(CPK)-103
[**2140-4-4**] 03:29PM BLOOD CK(CPK)-96
[**2140-4-5**] 06:20AM BLOOD CK-MB-NotDone cTropnT-0.32*
[**2140-4-4**] 08:42PM BLOOD CK-MB-14* MB Indx-13.6*
[**2140-4-4**] 03:29PM BLOOD CK-MB-17* MB Indx-17.7* cTropnT-0.62*
[**2140-4-7**] 06:20AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.6
[**2140-4-5**] 06:20AM BLOOD Triglyc-130 HDL-44 CHOL/HD-3.4 LDLcalc-79
.
Persantine STress [**2140-4-6**]:
INTERPRETATION:
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a fixed, moderate
reduction in photon counts involving the mid and distal anterior
wall, distal septum,distal inferior wall and the apex. There is
also a reversible, mild reduction in photon counts involving the
mid and basal inferolateral walls.
Gated images reveal akinesis of the apex, distal anterior wall,
distal septum, distal inferior wall and the mid anterior wall.
The calculated left ventricular ejection fraction is 48% with an
EDV of 94 ml.
IMPRESSION:
1. Fixed, large, moderate severity perfusion defect involving
the LAD
territory.
2. Reversible, small, mild perfusion defect involving the LCx
territory.
3. Normal left ventricular cavity size. Mild systolic
dysfunction with akinesis of the apex, distal anterior wall,
distal septum, distal inferior wall and the mid anterior wall.
.
ECHO [**2140-4-5**]:
The left atrium is normal in size. There is moderate regional
left ventricular systolic dysfunction with focal severe
hypokinesis to akinesis of the distal [**1-24**] of the left ventricle.
The remaining segments contract normally (LVEF = 35-40 %). The
estimated cardiac index is borderline low (2.0-2.5L/min/m2). No
masses or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The remaining left ventricular segments contract
normally. Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets are mildly thickened (?#). There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. 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: Suboptimal image quality. Focal regional left
ventricular dysfunction which may be consistent with stress
cardiomyopathy (Takotsubo) or mid/distal wrapaound LAD
infarction. Moderate pulmonary hypertension. Minimal aortic
stenosis.
.
Cardiac Catheterization [**2140-4-4**]:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated two
vessel disease. The LMCA had no angiographically apparent
disease. The
LAD had diffuse calcification in the proximal and mid vessel
with 70-80%
stenosis distally. There was a 70% stenosis in the origin
diagonal
branch. The LCx had a retroflexed 70% ostial stenosis that
appeared most
severe on the initial injections but improved with IC
nitroglycerin. The
RCA had moderate luminal irregularities.
2. Limited resting hemodynamics revealed mild systemic arterial
systolic
hypertension with SBP 145 mmHg.
3. Successful PTCA and stenting of the distal LAD with a 2.25x12
mm
MiniVision BMS with excellent results (see PTCA Comments).
4. Successful closure of the R common femoral arteriotomy with a
6F
Perclose Proglide device.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful stenting of the dfistal LAD with a MiniVision BMS
3. Successful closure of the R-CF arteriotomy with Perclose
proglide
Brief Hospital Course:
# STEMI: The patient developed sudden onset of SSCP on the
morning of admission in the setting of seeing her basement
flooded. ECG did show findings concerning for STEMI, with ST
elevations in the lateral leads. She was taken to the cath lab,
where she had stenting of the distal LAD performed. There was
some concern about additional disease in the left circumflex so,
in the days following catheterization, the patient underwent
stress testing. Nuclear stress did show a small reversible
defect in the left circumflex territory as well as a large fixed
defect in the LAD territory. She was discharged with cardiology
follow-up. She was discharged on full-dose ASA, plavix,
metoprolol, and a statin.
# HTN: Was normotensive on arrival to CCU. At discharge, was
continued on her hyzaar. Was also started on metoprolol as
above.
# DM: Sliding scale insulin while in-house. Restarted on oral
hypoglycemics at discharge.
Medications on Admission:
Losartan-Hydrochlorothiazide 50-12.5mg One (1) Tablet PO once a
day
Metformin 500mg [**Hospital1 **]
Glipizide 2.5mg [**Hospital1 **]
Centrum multivitamin daily
Caltrate
Fish Oil
B12
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:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Losartan-Hydrochlorothiazide 50-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day: Every 5 minutes for a total of 3 [**Hospital1 4319**].
If you still have chest pain after 3 [**Hospital1 4319**], call 911. .
Disp:*25 tablets* Refills:*0*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO twice a day.
9. Fish Oil Oral
10. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
11. Caltrate 600 600 mg (1,500 mg) Tablet Oral
12. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Hypertention
Diabetes Mellitus Type 2
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You had a heart attack and your heart is weak. You will need to
be on new medicines to keep the chest pain from coming back and
to help your heart heal.
Activity restrictions:
Please follow the exercise program that physical therapy
discussed with you. No lifting more than 10 pounds for one week.
No driving for 2 days. Weigh yourself every morning, call Dr.
[**Last Name (STitle) 31187**] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3
days.
Medication changes:
1. Restart your Metformin, Glypizide and your Losartan/HCTZ
2. continue with Caltrate, Fish oil, B12 and your multivitamin
3. START taking a full aspirin, 325 mg daily, and Plavix 75 mg
daily for at least one month and possibly longer. These
medicines keep the stent open and prevent another heart attack.
Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix and aspirin for any
reason unless Dr. [**Last Name (STitle) **] tells you to.
4. Start taking Atorvastatin to lower your cholesterol and help
the heart recover.
5. Start taking Metoprolol to keep your heart rate low and help
your heart recover.
6. Take Nitroglycerin under your tongue if you have the chest
pressure/heartburn again. Take each tablet 5 minutes apart while
sitting down. If you still have the symptoms after 3 [**Last Name (STitle) 4319**], call
911.
7. Start Ranitidine to protect your stomach from the Plavix and
aspirin.
.
Please call Dr. [**Last Name (STitle) **] if you have any chest pain or heartburn at
home.
Followup Instructions:
Dr. [**Last Name (STitle) 10165**] [**Name (STitle) 31187**] Phone: [**Telephone/Fax (1) 31188**] Date/Time: Tuesday [**4-12**] at 12;00pm
.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time: [**5-17**] at
10:40am.
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2557
} | Medical Text: Admission Date: [**2195-2-4**] Discharge Date: [**2195-2-8**]
Date of Birth: [**2136-2-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
exertional angina
Major Surgical or Invasive Procedure:
[**2-4**] CABG x 3 (LIMA->LAD, SVG->OM, Ramus)
History of Present Illness:
58 yo M with recent angina, abdnormal ETT referred for cardiac
cath which showed LM disease. He was transferred for urgent
CABG.
Past Medical History:
lipids
HTN
hypospadias
Social History:
works as bus mechanic
lives with wife and daughter
Family History:
father with CABG at age 62, redo at age 85
Physical Exam:
NAD
RRR No M/R/G
Lungs CTAB anteriorly
Abd benign
Extrem warm, no edema
Pertinent Results:
[**2195-2-8**] 04:10AM BLOOD WBC-6.6 RBC-3.40* Hgb-8.6* Hct-25.2*
MCV-74* MCH-25.4* MCHC-34.2 RDW-16.8* Plt Ct-117*
[**2195-2-8**] 04:10AM BLOOD PT-12.6 PTT-26.3 INR(PT)-1.1
[**2195-2-8**] 04:10AM BLOOD Plt Ct-117*
[**2195-2-8**] 04:10AM BLOOD Glucose-97 UreaN-20 Creat-1.1 Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 275**] [**Hospital1 18**] [**Numeric Identifier 70827**] (Complete)
Done [**2195-2-4**] at 7:04:24 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2136-2-14**]
Age (years): 58 M Hgt (in):
BP (mm Hg): 120/70 Wgt (lb):
HR (bpm): 60 BSA (m2):
Indication: coronary artery disease
ICD-9 Codes: 402.90, 786.05
Test Information
Date/Time: [**2195-2-4**] at 19:04 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.1 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Left Ventricle - Lateral Peak E': 0.14 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 7 < 15
Aorta - Ascending: 2.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A ratio: 2.00
Mitral Valve - E Wave deceleration time: 220 ms 140-250 ms
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Focal
calcifications in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient appears to be in sinus rhythm. Resting
bradycardia (HR<60bpm). Results were personally reviewed with
the MD caring for the patient.
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
No atrial septal defect is seen by 2D or color Doppler.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. There is no pericardial effusion.
POST_BYPASS:
Preserved biventricular systolic function. LVEF 55%
Aortic contour is well preserved.
Trivial MR, TR
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician
?????? [**2191**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Mr. [**Known lastname 43027**] was taken emergently to the operating room on [**2-4**]
where he underwent a CABG x 3 (LIMA->LAD, SVG->OM, SVG->RAmus).
He was transferred to the SICU in critical but stable condition.
He was extubated later that evening, and transferred to the
floor the following morning. He continued to do well
postoperatively. Chest tubes and pacing wires removed without
incident. He made good progress and was cleared for discharge to
home with services on POD #4. Pt. to make all folllow up appts.
as per discharge instructions.
Medications on Admission:
asa, lipitor, cartia, triamterene, zantac, piroxicam, MVI
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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. 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*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 5 days.
Disp:*5 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
CAD
lipids
HTN
hypospadius
s/p knee cyst excision
Discharge Condition:
Good,
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting or driving until follow up with surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] [**0-0-**] Follow-up appointment should be in 2
weeks
[**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Pt. to get an appt with a local cardiologist and be seen in [**2-14**]
weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2195-2-9**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2558
} | Medical Text: Admission Date: [**2138-11-9**] Discharge Date: [**2138-11-18**]
Date of Birth: [**2072-5-5**] Sex: F
Service:
CHIEF COMPLAINT: Fever.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
female with a history of multiple myeloma recently admitted
to [**Hospital1 69**] with
methicillin-resistant Staphylococcus aureus line infection.
She returns with fever since the night prior to admission to
103, positive cough, sore throat, no shortness of breath or
chest pain, makes very little urine, no nausea, vomiting or
diarrhea, positive fevers and chills. She also reports a
skin lesion on her left lower extremity x 3 days. Prior to
admission she was otherwise in her usual state of health
until the day prior to admission.
PAST MEDICAL HISTORY: 1. Multiple myeloma diagnosed in [**2135**];
status post VAD x 4; status post autologous bone marrow
transplant. 2. Recurrent streptococcus infections on
penicillin prophylaxis. 3. Total abdominal hysterectomy and
bilateral salpingo-oophorectomy. 4. Status post
appendectomy. 5. Status post tonsillectomy. 6. Perforated
tympanic membrane. 7. Carpal tunnel syndrome. 8. Recently
discharged from [**Hospital1 69**] after
admission for a bleeding dialysis catheter which was placed
by interventional radiology and subsequently developed a
methicillin-resistant Staphylococcus aureus line infection
and has been on vancomycin since then. 9. End-stage renal
disease on dialysis.
MEDICATIONS ON ADMISSION: Vancomycin dosed at dialysis;
Protonix 40 mg p.o. q.d.; Tums 500 mg p.o. b.i.d.; Renagel;
Ambien 5 mg p.o. q.h.s.; penicillin V 500 mg p.o. b.i.d.
ALLERGIES: Sulfa.
SOCIAL HISTORY: The patient lives alone; no alcohol or
tobacco use. She is a retired math teacher.
FAMILY HISTORY: Prostate cancer in her father. Hypertension
and breast cancer in her mother.
REVIEW OF SYSTEMS: As per history of present illness.
PHYSICAL EXAMINATION: On admission her blood pressure was
102/50, pulse 115, respiratory rate 16, O2 saturation 97% on
two liters, temperature 101. Head, eyes, ears, nose and
throat examination showed no jugular venous distension, dry
mucous membranes with oral petechiae. Cardiovascular
examination showed a regular rate and rhythm, slightly
tachycardic, normal S1 and S2, positive S4. Lungs had
bibasilar crackles with left chest field positive for
crackles and dullness to percussion. The abdomen was soft,
nontender and nondistended with normal active bowel sounds.
Extremities were warm with no edema, positive multiple
bruises and a 3 x 2 cm erythematous nonpruritic plaque with
central clearing on the left lower extremity.
LABORATORY DATA: On admission the white blood cell count was
1.9, hematocrit 24.1, platelet count 19, granulocytes 1,100,
partial thromboplastin time 33.6, INR 1.3. Sodium was 127,
potassium 4.3, chloride 94, bicarbonate 22, BUN 33,
creatinine [**5-24**].
Chest x-ray showed left lower lobe superior portion with
evidence of consolidation.
IMPRESSION: The patient is a 66-year-old female with
multiple myeloma, end-stage renal disease,
methicillin-resistant Staphylococcus aureus line infection
admitted for treatment of pneumonia.
HOSPITAL COURSE: 1. Infectious disease: The patient is
chronically receiving doses of IVIG as an outpatient due to
poor immune response secondary to the multiple myeloma. She
was admitted with no evidence of neutropenia, however was
given antibiotic coverage in the Emergency Department with
ceftriaxone and gentamicin which was changed to levofloxacin
for renal dosing with 250 mg q.o.d. The day following the
patient's admission she began to spike a fever once again,
however she was feeling significantly better and her
breathing was substantially better.
The following day she started to develop some mild
respiratory distress. Chest x-ray was consistent with
worsening pneumonia now with bilateral infiltrates as well as
some overlying pulmonary edema. IVIG was administered to
increase her immune globulin and her immune response to the
pneumonia.
2. Renal: The patient has chronic renal failure on
hemodialysis and was dialyzed the Monday following the first
day of her admission. Following the administration of IVIG
the patient began to have increasing respiratory distress
likely due in part to the worsening pneumonia, however also
likely due to worsening pulmonary edema due to fluid
overload. The patient was emergently dialyzed on the night
of [**2138-11-10**] and transferred to the medical intensive care
unit for further management of her volume status as well as
respiratory status. The medical intensive care unit course
will be dictated by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], M.D. [**MD Number(1) 7775**]
Dictated By:[**Name8 (MD) 4630**]
MEDQUIST36
D: [**2138-11-19**] 14:06
T: [**2138-11-21**] 08:35
JOB#: [**Job Number 7785**]
ICD9 Codes: 486, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2559
} | Medical Text: Admission Date: [**2158-5-10**] Discharge Date: [**2158-5-19**]
Date of Birth: [**2103-6-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Compazine / Sulfa(Sulfonamide Antibiotics) / Percocet / morphine
/ tannins / pollen /hay
Attending:[**First Name3 (LF) 15850**]
Chief Complaint:
esophageal spasm.
Major Surgical or Invasive Procedure:
[**2158-5-10**]
Upper GI Endosacopy and Esophagogastrectomy.
History of Present Illness:
The patient is a 54-year-old professor of nursing who has
distal esophageal adenocarcinoma. The patient initially
developed what she described as esophageal spasms in [**2157-12-22**]. These gradually became worse and she underwent an upper GI
endoscopy, which showed a 2 cm adenocarcinoma at approximately
35cm from the incisors. She underwent a CT scan, which showed no
evidence of regional lymphadenopathy. She has been seen and
followed by a medical oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 92480**] who guided
her course of radiation therapy. The patient is now referred
here
for repeat discussion regarding surgery. Fortunately, the
patient has had no weight loss, and she is in an otherwise
relatively good state of health.
Past Medical History:
-anaphylaxis at 17 with tracheostomy
-meningitis at 25
-mild hypertension
-obesity,
-cholecystitis w/ lap ccy
-pancreatitis in [**2142**]
-hemorrhoid repair
-resection of a malignant salivary gland tumor & XRT in [**2147**]
-tonsillectomy at 5
-two cesarean sections
-hemifacial spasm
.
Social History:
She is a non-smoker.
She drinks wine occasionally.
Her family history is unremarkable.
Family History:
non contributory.
Physical Exam:
On examination, the patient is a healthy appearing woman who
breaths comfortably at rest, her vital signs are normal. Her
examination is notable for a right parotidectomy scar with some
soft tissue induration most likely secondary to radiation. She
has no papillary, cervical, or supraclavicular lymphadenopathy.
RRR on CV. CTAB on RESP. ABD soft, NT/ND, no masses or bruits.
The remainder of her examination is essentially unremarkable.
.
VS 147/63, 76, 97.1, 18, 100% RA
height 66'5'' and weight 235 lbs
Gen: NAD, A&O X 3
Neck: no masses, no JVD
Chest: CTAB, no increased WOB
Abd: soft, NT/ND, normoactive BS, no masses, no bruits, obese
Extrem: moves all to gravity, no c/c/e, w/w/p, pulses WNL
Pertinent Results:
[**2158-5-10**] 04:20PM WBC-12.0*# RBC-3.65* HGB-11.8* HCT-35.7*
MCV-98 MCH-32.3* MCHC-33.0 RDW-16.5*
[**2158-5-10**] 04:20PM PLT COUNT-277
[**2158-5-10**] 04:20PM GLUCOSE-138* UREA N-10 CREAT-0.7 SODIUM-142
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15
[**2158-5-10**] 04:20PM CALCIUM-8.7 PHOSPHATE-4.7* MAGNESIUM-1.6
[**2158-5-16**] CXR :
Enteric tube has been removed from the neo esophagus which is
now moderately distended with air and fluid, and a larger
caliber than it was when a drainage tube was in place. There is
no right pleural effusion or pneumothorax, basal pleural tube
still in position. A small left pleural effusion is stable.
Lungs are clear aside from persistent moderately severe left
lower lobe
atelectasis, in one of the lung bases, probably the right.
Moderately severe right lower lobe atelectasis is new. Left lung
is grossly clear.
Brief Hospital Course:
Ms. [**Known lastname 28678**] was admitted to the hospital and taken to the Operating
Room where she underwent an esophagogastrectomy. She tolerated
the procedure well and returned to the SICU in stable condition.
She had an epidural catheter placed for pain control which was
effective and she maintained stable hemodynamics. She was using
her incentive spirometer effectively and remained free of any
pulmonary issues.
Following transfer to the Surgical floor she continued to make
good progress and was discharged to home [**2158-5-19**] eating a soft
diet, walking safely on her own, urinating and having bowel
movements comfortably, and having stable vital signs and
physical examination findings.
She will follow-up in clinic with Dr. [**Last Name (STitle) 7343**] in a few weeks with
imaging at that time.
Medications on Admission:
Atenolol 25 mg PO Qdaily
CARBAMAZEPINE - 200 mg Tablet Extended Release 12 hr - Tablet(s)
by mouth at bedtime as needed for for facial spasm
Slo-Mag 71mg PO twice daily
FAMOTIDINE - 20 mg Tablet - Tablet(s) by mouth twice a day
OMEPRAZOLE - 40 mg Capsule, Delayed - Capsule twice a day
ACETAMINOPHEN - 325 mg Tablet - Tablet(s) by mouth every six (6)
hours as needed for pain
MV-FA-CA-FE-MIN-LYCOPEN-LUTEIN [CENTRUM] - (Prescribed by Other
Provider) - 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet -
Tablet(s) by mouth once a day
Discharge Medications:
1. carbamazepine 200 mg/10 mL Suspension Sig: Two Hundred (200)
mg PO QHS PRN () as needed for FACIAL SPASMS.
2. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
Disp:*500 mg* Refills:*2*
3. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) mls PO
Q6H (every 6 hours).
Disp:*1000 mls* Refills:*2*
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): place
over right chest, on for 12 hours, off for 12 hours.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*2*
8. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
9. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
11. ondansetron HCl 4 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Carcinoma of the esophagus.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 15931**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101 or chills
-Increased shortness of breath, cough or chest pain
-Nausea, vomiting
-Increased abdominal pain
-Incision develops drainage
-Remove chest tube and j-tube site bandages Thursday and replace
with a bandaid, changing daily until healed.
Pain
-Tylenol as needed
-Take stool softners or a gentle laxative to help keep you
regular
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Diet:
Soft solids.
Eat small frequent meals. Sit up in chair for all meals and
remain sitting for 30-45 minutes after meals
Flush J-tube every 8 hours with 30 mls of water 3 x/day
Daily weights: keep a log bring with you to your appointment
NO CARBONATED DRINKS
Danger signs
Fevers > 101 or chills
Increased shortness of breath, cough or chest pain
Incision develops drainage
Nausea, vomiting (take anti-nausea medication)
Increased abdominal pain
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2158-6-8**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15855**], MD [**Telephone/Fax (1) 2348**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
Completed by:[**2158-5-19**]
ICD9 Codes: 5180, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2560
} | Medical Text: Admission Date: [**2167-5-12**] Discharge Date: [**2167-5-16**]
Date of Birth: [**2110-7-1**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 56-year-old male with
no past medical history brought by EMS to the Emergency
Department. He claims he passed out while driving. He
apparently crashed into a tree. He admits to feeling dizzy
before passing out. He denies any chest pain, but was tired
fast "while mowing the lawn last week and has been tired
more" over the past couple weeks. He admits to palpitations
the night before he mowed the lawn last week. He denies any
jaw pain.
He denies any previous history of syncope. The patient had
eaten today and did not skip any meals. He does not have any
PND, peripheral edema, or orthopnea. He does not describe a
blackout associated with this event. The patient has no pain
currently. He was restrained in his automobile when the
accident happened. He denies any airbag release or
windshield damage. He has not gone a day without drinking
alcohol, he admits. His last drink of alcohol was at noon
today.
PAST MEDICAL HISTORY: The patient has not been to a doctor
in a couple of years. He is status post an appendectomy.
FAMILY HISTORY: Father had a pacemaker in his 70s, died at
age of 85. Mother is 83 and healthy. Siblings are in the
their 50s and healthy. His two children are both healthy.
SOCIAL HISTORY: The patient is an electrician who lives with
his wife in [**Name (NI) 13588**]. He has a positive history of cigar
smoking. He drinks one six pack a beer a day, if not more.
He denies any illicit drugs. He is sexually active with his
wife.
MEDICATIONS:
1. Multivitamin.
2. Aspirin one a day.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: No weight loss, fever, chills, headaches,
facial droop, seizures, focal weakness, discharge, nausea, or
vomiting. Positive fatigue as above in the history of
present illness.
PHYSICAL EXAMINATION: Vital signs: Temperature is 97.3,
heart rate 46, blood pressure 115/74, oxygen saturation is
97% on room air. In general, he is alert and oriented times
three in no apparent distress. [**Hospital1 1516**] pads are on him. HEENT:
Normocephalic, atraumatic. Extraocular movements are
intact. Anicteric. Neck: No jugular venous distention,
bruits, no lymphadenopathy. Chest was clear to auscultation
bilaterally, no rales, rhonchi, or wheezing. Cardiovascular:
Irregular and slow, S1, S2, no murmurs, rubs, or gallops.
Abdomen: Positive bowel sounds, soft, nontender,
nondistended, no hepatosplenomegaly. Extremities: No
clubbing, cyanosis, or edema. Neurologic: Alert and
oriented times three, no asterixis, nonfocal neurologic
examination.
LABORATORIES AND DIAGNOSTICS ON ADMISSION: Complete blood
count revealed a white count of 6 with a hematocrit of 35.7,
platelet count of 265, and a MCV of 94. Coagulation profile
revealed an INR of 1.3, PT of 13.9 and a PTT of 28.7. Chem-7
revealed a glucose of 87, sodium of 139, potassium 3.9, a
bicarbonate of 23, chloride of 103, BUN of 13, creatinine of
0.7 with a calcium of 9.2, phosphorus of 4.6, and magnesium
of 2. Cardiac enzymes were negative x3.
Chest x-ray revealed an enlarged heart. CT scan of the head
revealed no hemorrhage or mass.
An electrocardiogram revealed a normal sinus rhythm of 100
with escape beat at 40, complete heart block and no ST-T wave
changes.
ASSESSMENT: This is a 56-year-old man with syncope found to
have A-V block status post a motor vehicle accident.
HOSPITAL COURSE: The following is the summary of the
[**Hospital 228**] hospital course by problems.
1. Complete heart block: The patient remained asymptomatic
during his hospital stay. On the day of admission, the
patient underwent a right IJ central line placement so that a
temporary pacer wire could be inserted into his right
ventricle. [**Hospital1 1516**] pads and an external pacer were maintained
on the patient until a permanent pacemaker was placed the
following day. The patient underwent placement of a DDD
pacemaker without any complication. The following settings
were made: A lead sensing P greater than 2.8 millivolts,
threshold less than 0.5 volts at 0.5 milliseconds. Impedance
579 oms. V lead: Sensing R of [**12-12**] millivolts, threshold 1
volt at 0.5 milliseconds, impedance 625 oms.
The patient was treated with Vancomycin 1 gram x3 to
prophylax against possible infection. Lyme serologies were
checked and were negative. The TSH was checked, and it was
normal. An echocardiogram was checked and revealed evidence
of a dilated cardiomyopathy, but no evidence of an
infiltrative process. The findings of this echocardiogram
are further commented on in the next section.
2. Dilated cardiomyopathy: The patient was found to have a
dilated cardiomyopathy with an ejection fraction of 15% on
echocardiogram. The echocardiogram also revealed left atrial
elongation, moderate left ventricular dilation, septal
inferior, anterior, and apical akinesis with lateral
hypokinesis, a left ventricular thrombus could not be
excluded, ventricular free wall motion was relatively
preserved. The aortic root was mildly dilated, A-V leaflets
were normal, and V leaflets were normal, and there was
trivial tricuspid regurgitation, and no effusion.
As a result, the patient was started on carvedilol 3.125 mg
po bid and low dose captopril which was later changed to
lisinopril 5 mg po q day. The patient underwent a cardiac
catheterization to rule out ischemic cardiomyopathy. His
coronary arteries were without significant lesions. The
patient had no complications from his cardiac
catheterization.
3. Status post motor vehicle collision: The patient
underwent a CT scan which revealed no abnormalities in his
head. His neurologic status remained stable throughout his
hospital stay.
4. Alcohol abuse: The patient was given Valium 10 mg po q8h
for the first 24 hour to prophylaxis against alcohol
withdrawal. His LFTs and pancreatic enzymes were checked,
and these were not grossly abnormal. He was also written for
prn Ativan as per CIWA scale, but this was not needed.
5. Coronary artery disease: Patient had a lipid profile
which revealed a HDL of 106, LDL of 64, total cholesterol of
182. As a result of this and his cardiac catheterization
results, the patient was continued on his aspirin.
DISCHARGE STATUS: Home.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Carvedilol 3.125 mg po q day.
2. Lisinopril 5 mg po q day.
FOLLOW-UP PLANS:
1. The patient is to followup with Dr. [**Last Name (STitle) **] at [**Hospital 191**] Clinic
in the next 2-4 weeks to see if his heart failure regimen
could be titrated up. At that time, we will also perform an
initial PCP visit and health maintenance screening.
2. The patient was given phone numbers for the Congestive
Heart Failure Clinic and Alcoholics Anomynous, and was asked
to followup with both so that his alcoholic cardiomyopathy
can be managed more effectively.
3. The patient is to followup with Electrophysiology in the
Device Clinic. Moreover, it should be kept in mind that the
patient might likely need a conversion to a biventricular
assist device in the future.
4. Patient was strongly encouraged to stop drinking, and the
cardiac risks related to this were fully explained.
[**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**]
Dictated By:[**Last Name (NamePattern1) 1595**]
MEDQUIST36
D: [**2167-5-16**] 14:02
T: [**2167-5-21**] 07:23
JOB#: [**Job Number 103704**]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2561
} | Medical Text: Admission Date: [**2105-12-12**] Discharge Date: [**2105-12-17**]
Date of Birth: [**2061-10-20**] Sex: M
Service: [**Year (4 digits) 662**]
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
benzodiazepine overdose, decreased alertness.
Major Surgical or Invasive Procedure:
intubation for airway protection
History of Present Illness:
44M with hx of AIDS, CD4 84 on HAART, substance abuse, HCV, anal
CA s/p XRT, depression with multiple suicide attempts in the
past who was found down by his mother and admitted for suspected
benzo overdose. Per mother's report, she tried to contact the
pt this morning but after she got no answer she went to his
apartment where she found him unconscious. EMS was called and
they stated that he was periodically apneic. He was given Narcan
and woke up briefly.
In the ED the pt was lethargic, though hemodynamically
stable. He later became agitated and started vomiting. He was
intubated for airway protection. UDS was + for benzos, cocaine,
amphetamines. He received activated charcoal for suspected
overdose and Flagyl to cover for aspiration. The pt was
successfully extubated in the ICU on [**12-13**], with propofol for
sedation stopped at around noon. The pt however remained
somnolent. The pt also was noted to be febrile to 101.5, his t.
bili was noted to be elevated at admission.
Past Medical History:
* AIDS by CD4 (CD4 128, HIV VL<50, [**7-30**], on abacavir,
atazanavir, lamivudine, reports missing 1 dose/week typically)
* HCV not currently treated due to his polysubstance abuse and
depression
* Invasive Anal Carcinoma treated with chemo/XRT; recent high
grade lesion found and treated; followed in Anal dysplasia
clinic
* Substance abuse-last used cocaine and ETOH 2 weeks ago
* L arm amputee secondary to compression injury and ischemia
after drug overdose, [**2096**]
* Depression with multiple suicide attempts
* Bone marrow toxicity secondary to Bactrim/AZT
* Chronic Thrombocytopenia
* MRSA scrotal abscess x2
* h/o testicular cellulitis, [**6-11**]
* COPD (FEV1 83% of predicted on [**4-9**])
* erosive gastritis on EGD, [**2103-2-14**]
* s/p multiple sexual and physical trauma
Social History:
lives alone in section 8 housing, social support from mother in
[**Name (NI) 2251**]
recently lost job as receptionist at [**Hospital 86**] Living Center
cocaine, EtOH abuse, most recently used 2 weeks ago
10 pack year smoking hx
Pt has been in multiple fights, where he has been severely
beaten
and injured.
Family History:
Depression
Substance abuse
Physical Exam:
VS: Tm 101.5 Tc 98.9 BP 107/65(90-125/45-70) p 105(90-105)
rr 22(16-37) rr 22(16-37) 96-99% RA
I/O 3860/1560
Gen: pt responds verbally to questions, follows commands, then
closes his eyes. he responds very slowly.
HEENT: pupils 2mm PERRL, OP clear
Neck: no bruits, no LAD
CV: RRR, 2/6 systolic murmur loudest at LLSB.
Chest: CTA
Abd: soft, NT/ND, NABS
Ext: no edema; left arm amputated below elbow
Pertinent Results:
ABD US [**2105-12-15**]:
IMPRESSION:
1. Stable adherent gallbladder sludge.
2. Small amount of ascites.
3. Splenomegaly.
There is no intra- or extra-hepatic biliary ductal dilatation
.
CXR Pa/Lat [**2105-12-15**]:
Marked improvement of the left lower lobe consolidation probably
indicating improving pneumonia.
.
[**2105-12-12**] 05:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**4-11**]
[**2105-12-12**] 05:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-NEG
[**2105-12-12**] 05:10PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2105-12-12**] 05:10PM PT-14.0* PTT-29.9 INR(PT)-1.3
[**2105-12-12**] 05:10PM PLT SMR-VERY LOW PLT COUNT-54*
[**2105-12-12**] 05:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2105-12-12**] 05:10PM NEUTS-64 BANDS-0 LYMPHS-28 MONOS-6 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2105-12-12**] 05:10PM WBC-4.6 RBC-5.03 HGB-17.9# HCT-49.8 MCV-99*
MCH-35.6* MCHC-36.0* RDW-14.9
[**2105-12-12**] 05:10PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-POS mthdone-NEG
[**2105-12-12**] 05:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2105-12-12**] 05:10PM CALCIUM-7.7* PHOSPHATE-3.8 MAGNESIUM-1.9
[**2105-12-12**] 05:10PM LIPASE-79*
[**2105-12-12**] 05:10PM ALT(SGPT)-224* AST(SGOT)-591* CK(CPK)-2683*
ALK PHOS-102 AMYLASE-76 TOT BILI-6.0*
[**2105-12-12**] 09:57PM GLUCOSE-100 UREA N-26* CREAT-0.7 SODIUM-139
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
[**2105-12-12**] 09:57PM ALT(SGPT)-226* AST(SGOT)-608* LD(LDH)-374*
ALK PHOS-100 TOT BILI-5.5*
Brief Hospital Course:
A/P:
.
44M with hx of AIDS, CD4 of 84, substance abuse, depression and
hx of suicide attempts who presents with benzo overdose,
intubated for airway protection, developed PNA and fever, and
jaundic during ICU stay which quickly resolved.
.
1. benzo overdose/Altered mental status:
Assessed to be [**3-11**] overdose. The urine was pos for benzo,
cocaine and amphetamines.
The pt was intubated in the ED for airway protection and
admitted to [**Hospital Unit Name 153**]. He was ventilated overnight, then successfully
extubated on [**12-13**]. The pt remained somnolent, requiring loud
verbal stimuli to arouse. This was thought [**3-11**] depression as
well as resolving acute illness. The LOC continued to improve.
Given the clear explanations for mental status changes, further
work-up was deferred including LP to rule out meningitis and
head CT. ID consultants agreed with this decision. The pt was
monitored on a CIWA scale as an inpatient for 4 days, and he
demonstrated no clear symptoms of withdrawal.
.
2. PNA:
The pt was noted to be febrile to 101.5 in the ICU, his CXR
showed LLL infiltrate. Levo/flagyl was initially started and the
pt responded well with the infiltrate mostly resolved by CXR on
[**12-15**]. The coverage was narrowed to levoflox alone to continue a
10 day course. Bld Cx were negative. [**Last Name (un) **] Cx showed enterococci
Sensitive to levo, assessed to be colonization by ID. stool
negative for C.diff. Pt was afebrile x48 hours at discharge.
.
3. Elevated LFTs/cholestatic jaundice:
Likely acalculous cholecystitis. On reviewing the pt's previous
labs, he has had elevated AST and ALT in the past, likely [**3-11**]
his HAART regimen or hepatitis. However, his bilirubin has not
been this elevated in the past. AST/ALT peak on [**12-12**] 608/224. T.
bili elevated to 6 at admission. The bilirubin and liver enzymes
continued to trend down over the hospital stay. RUQ US
demonstrated no evidence of stones or ductal dilatation but
showed sludge.
4. HIV/AIDS:
Recent testing done on [**2105-11-12**] at his PCP's visit. CD4 84 (8%)
down from 126 and VL now detectable at 10,800 copies.
Lamivudine/Abacavir/Atazanavir is home regimen. The pt reports
good compliance but according to past notes, misses approx one
dose per week. His HIV genotyping is pending to assess for
resistance mutations. Per ID consultants the ART was held in the
setting of acute illness and will be restarted as an outpt. OI
prophylaxis was continued with atovaquone, biaxin, famvir. The
pt sees Dr. [**First Name (STitle) 3640**] for ID last seen [**2105-7-30**].
.
5. Depression:
s/p suicide attempt. pt is involuntary admit. Outpt Pschiatrist
is Dr. [**Last Name (STitle) 7339**]. The psychiatry team was consulted and followed
along. His psych meds were held for sedation during the
admission per recs, including the effexor, wellbutrin and
trazodone. CIWA scale with diazepam was continued for possible
benzo withdrawal, although the pt demonstrated no clear symptoms
of withdrawal since the admission. 1:1 sitter was continued
because of suicidal intent.
.
6. Thrombocytopenia:
Chronic, baseline between 43-75; follow and transfuse for<10
unless active bleeding
.
7. Rhabdomolysis:
Likely [**3-11**] being down for several hours. CK was trended and
declined without any other symptoms. No renal problems
developed.
8. FEN: NPO until extubated
9. PPx: pneumoboots, PPI, bowel regimen
10. Comm: pt's mother, [**Name (NI) **], [**Telephone/Fax (1) 7340**]
11. Access: PIVx2, RtH 18, RLA 20.
Medications on Admission:
Meds: per OMR
* trazodone 400mg qhs
* Valium 5-10mg qhs prn
* Effexor XR 2 caps qd
* Welbutrin SR 150mg qd
* Abacavir 300mg [**Hospital1 **]
* Atazanavir 400mg qd
* Atovaquione 750mg/5ml, 10cc qd
* Biaxin 500mg qd
* Famvir 250mg [**Hospital1 **]
* Motrin 800mg tid
* Lamivudine 150mg [**Hospital1 **]
* Niferex 50mg qd
* Senna
* Viagra prn
* Androgel qd
* benedryl prn
* compazine prn
* hibiclens qd
* imodium prn
* Nizoral qd
* sarna prn
* Xylocaine q2hrs prn
.
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
2. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Famvir 250 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Benzodiazepine drug overdose
Pneumonia
Discharge Condition:
stable, afebrile for 48 hours, breathing comfortably
Discharge Instructions:
Please take all medicines as directed and note that it is very
important to attend all of your follow up appointments.
.
If you have any symtoms of fevers or chills, or coughing that is
severe, please call your doctor.
.
Please note that you are taking a new [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic,
Levofloxacin for six days after you leave the hospital becuase
you had a pneumonia.
Followup Instructions:
You have an apointment to see the Infectious Diseases physician,
[**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2105-12-17**] 11:00.
.
You have an appointment to see your primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7341**] on Thursday, [**12-24**] 1:30. If you have questions,
please call [**Telephone/Fax (1) 250**].
ICD9 Codes: 5070, 2875, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2562
} | Medical Text: Admission Date: [**2141-7-9**] Discharge Date: [**2141-7-12**]
Service: SURGERY
Allergies:
Digoxin
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
red blood per rectum
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
87 Y/O CF with PMH of rectum adenoma with high grade dysplasia
without the evidence of invasion by tumor in either submucosa or
muscularis propria, s/P chemo-radion therapy (the last
radio-therapy in [**2141-3-17**]), radiation proctitis, DM, and H/O
A-fib on ASA underwent transanal endoscopic microsurgical
excision of left lateral polypoid lesion encompassing 50% of the
rectal wall in
[**2141-6-23**]. Her CA was located in the distal rectum on the lowest
valve of [**Location (un) 36413**] in the left lateral position. After incision,
the wound was not closed. Hemostasis was assured after piecemeal
excision of the polypoid lesion. Pt was D/Ced 7days after
surgery.
Pt stated that for the past few days she had constipation with
hard stool. Her last "BM" is in Saturday, which was "black"
hard
stool (of note, she reported that the black stool occurred every
time of her "BM" even before surgery). Around 12:00 middle
night
today, pt got up to go to bathroom to have "BM". He found hard
black stool. Then one hour later, she had a large amount bright
red blood per her rectum without stool. Since then, she
continues
bleeding from her rectum and she had to [**Location (un) **] pad that always
wet.
Pt denied any dysphagia, Abd pain, vomiting, hematemesis, faint,
light head, dizzy, CP, palpitation, SOB, sweaty.
Past Medical History:
Past Medical History:
Rectal cancer s/p chemotherapy and radiation at OSH
DM
Afib
Glaucoma
moderate pulmonary artery systolic hypertension
Low EF (50%)
PSH:
transanal endoscopic microsurgical excision for rectum CA
hysterectomy
Social History:
She currently resides at the [**Hospital **] [**Hospital **] Nursing Home.
She has a remote history of tobacco use, denies EtOH & illicit
drugs.
Family History:
Her sister had breast cancer.
Physical Exam:
At Admission:
P/E: T 99 P 127-144, BP 76/61, SaO2 100 at 2L/min, R 15\
Pt [**Name (NI) **]3 comfort
HEENT:PREEL, oral dry
NECK:supple, no JVD, No LN
LUNG:B/L BS clear no crackles
CVS:S1/S2 irregular irregularity, tachy, no murmur
Abd:slight distend, no guard, no tender, BS present
Ext: No pitting edema
Rectum: tone was normal, no stool in her rectum, but red blood
presents in my gloves
In ED surgeon preformed anoscopy and found continues red blood
came form rectum
.
At Discharge:
T: 98.1 HR 74 BP 116/78 RR 20 O2sat 99%2L
HEENT: MMM
Neck: supple
CVS: irregularly irregular, reg rate, no murmurs
Lungs: slight decreased breath sounds at the bases, R>L,
otherwise clear
Abd: soft, NT, ND
Ext: no edema
Pertinent Results:
HCT [**7-12**]: 28.8 (stable on serial labs)
[**2141-7-9**] 09:47AM GLUCOSE-139* UREA N-20 CREAT-1.3* SODIUM-144
POTASSIUM-4.9 CHLORIDE-115* TOTAL CO2-21* ANION GAP-13
[**2141-7-9**] 09:47AM CALCIUM-7.6* PHOSPHATE-3.9 MAGNESIUM-2.0
[**2141-7-9**] 04:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2141-7-9**] 04:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2141-7-9**] 04:40AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2141-7-9**] 04:20AM PT-14.7* PTT-24.6 INR(PT)-1.3*
Brief Hospital Course:
Mrs. [**Known lastname 103044**] was admitted to the ICU from the emergency
department due to hematocrit of 18, and unstable hemodynamic
status. Gastroenterology was consulted. Once resuscitated,
patient underwent a sigmoidoscopy which revealed radiation
proctitis, clotted blood in rectum. No active bleeding
visualized. She was transfused with PRBC's and her hct increased
appropriately. Patient passed a few blood clots per rectum
during the course of the admission however hct's were followed
serially and were found to be stable at 28 on discharge.
Patient had one trigger event as her heart rate increased to 140
beats per minute. Patient remained asymptomatic and her heart
rate returned to [**Location 213**] after IV metoprolol. This episode
thought likely secondary to long duration between last diltiazam
dose and first extended release diltiazam dose. EKG without
change. Labs were drawn at the time of the trigger and her
electrolytes were found to be within normal limits, troponin
<0.1, CK MB 4. Patient stable on discharge.
Medications on Admission:
Diltiazem 120', Lasix 40 [**Doctor First Name **]/Tu/Th/Sat, Lasix 20 M/W/F, Vit C
250', FeSO4 325', Metoprolol 25'', VitD 300U'', TUMS 500''',
Lipitor 10 qHS, Travatan 0.004% qHS, Cosopt'', Combivent INH'',
Genteal eye gtt''', ISS
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day). Tablet(s)
2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QTUTHSA
([**Doctor First Name **],TU,TH,SA).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QMOWEFR
(Monday -Wednesday-Friday).
5. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig: One
(1) Drop Ophthalmic [**Hospital1 **] (2 times a day).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) as needed for soa.
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
wheeze/soa.
8. Gentamicin 0.3 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*1*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Lower GI bleed
Acute blood loss anemia
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* 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. Bright red blood per rectum.
* 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.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) 1120**] [**Telephone/Fax (1) 160**] in [**12-20**] weeks.
Completed by:[**2141-7-12**]
ICD9 Codes: 2851, 2724, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2563
} | Medical Text: Admission Date: [**2186-5-21**] Discharge Date: [**2186-5-24**]
Date of Birth: [**2125-9-25**] Sex: F
Service: ACOVE
HISTORY OF PRESENT ILLNESS: This is a 60 year-old female with
a history of peptic ulcer disease and lower back pain was
recently prescribed Motrin 400 tid for the past two months.
She was in her usual state of health until three days prior
to admission when she noted an increase in her left lower
back pain along with weakness, malaise and headache, possibly
a fever as well. She had dull right upper quadrant pain for
two to three days.
On the morning of admission the patient had a syncopal event
after a bowel movement. She then presented to the [**Hospital1 346**] EW. In the EW the patient had one
large melanotic stool and a repeat syncopal event. Blood
pressure at that time was 30/palp. The patient was
resuscitated with normal saline and NG lavage revealed
coffee-grounds and clear with normal saline. She was started
on a two unit transfusion of packed red blood cells and seen
in consultation by the gastroenterology service with plans
for EGD in the morning.
PAST MEDICAL HISTORY:
1. Peptic ulcer disease in the remote past.
2. Lower back pain.
MEDICATIONS AT HOME:
1. Zantac.
2. Ambien.
3. Motrin 400 milligrams po tid.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is from [**Country 11150**], in the US for one
year. She lives with her son. She denies alcohol or tobacco
use. Denied herbal medications.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit for close observation. Her ICU
course was uncomplicated without further transfusion. EGD was
performed in the morning of [**2186-5-23**] which revealed
erythema, congestion and friability pre pylorically which was
consistent with gastritis. There was diverticulum in the
posterior bulb and the distal bulb as well. There were also
signs consistent with duodenitis.
After a stable and acute course the patient was felt stable
for transfer to the medical floor.
Physical examination at the time of transfer to the medical
floor. Vital signs - pulse 79, blood pressure 139/65, O2
saturation 100%, respiratory rate 23. Examination - in
general no apparent distress. HEENT exam - pupils are equal,
round and reactive to light. Anicteric sclerae. Mucous
membranes are moist with no lymphadenopathy. Chest is clear
to auscultation bilaterally. Cardiovascular - regular rate
and rhythm with S1, S2, no murmurs, rubs, or gallops. Abdomen
- soft, nontender, nondistended, normoactive bowel sounds.
Back revealed no spinous process tenderness. There is
tenderness to palpation bilaterally of the paraspinal muscle
of the lumbar region. Extremities - no cyanosis, clubbing or
edema. Neurologically - cranial nerves II through XII are
grossly intact. Motor was [**5-14**] bilateral upper and lower
extremities. Further neurologic examination was hindered by
language barriers despite the use of the patient's son as
translator.
LABORATORY DATA: At the time of admission [**2186-5-21**] at 10 in
the morning hematocrit 19.4 after two units of packed red
blood cells 31.8. The patient's hematocrit remained stable at
around 31 thereafter. Liver function tests ALT 6, AST 10,
alkaline phosphatase 50, total bilirubin 0.1, lipase 31, H
pylori antibody was sent in and was negative.
FURTHER COURSE IN HOSPITAL: Upon transfer to the medical
floor the patient's hematocrit remained stable. She was
followed closely. Initially she was maintained on strictly
NPO for 24 hours following the endoscopy. She was then
advanced to clears which she tolerated well with no change in
her hematocrit. She was also maintained on Protonix IV and
was strictly prohibited from using Ansaids.
For her lower back pain the etiology remained unclear and was
difficult to determine given the language barriers as
described above. There were no red flags for urgent MRI or
imaging at that time. She was given analgesia with Tylenol.
Her back pain did slowly resolve over the remaining days of
the hospitalization in the general medical floor.
On [**2186-5-24**] the patient's hematocrit was stable, she was
tolerating a po diet and her back pain was mostly resolved.
She was deemed to be stable for discharge home with close
follow up by her primary care physician within one week.
DISCHARGE INSTRUCTIONS: The patient was advised not to take
any Ansaids, Motrin, Advil or ibuprofen. She was advised to
return to the ER or contact the [**Name (NI) 191**] triage phone number
should she experience any weakness, numbness, tingling,
dizziness, lightheadedness.
DISCHARGE MEDICATIONS:
1. Protonix 40 milligrams 40 milligrams po bid times two
weeks and then q day times one month.
FOLLOW UP APPOINTMENTS: She will follow up with her PCP, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] on [**2186-5-30**] and with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17185**] of the
Gastroenterology service on [**2186-7-3**].
FINAL DIAGNOSIS:
1. Gastric ulcers.
2. Duodenal ulcers.
3. Anemia requiring transfusion.
4. Hemodynamic instability.
5. Lower back pain.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 2665**]
MEDQUIST36
D: [**2186-5-28**] 16:59
T: [**2186-5-29**] 10:12
JOB#: [**Job Number 39007**]
ICD9 Codes: 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2564
} | Medical Text: Admission Date: [**2102-3-20**] Discharge Date: [**2102-4-3**]
Date of Birth: [**2056-10-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
diahhrea
Major Surgical or Invasive Procedure:
paracenteisis
central line placement
History of Present Illness:
45M with hx of DM type I, ESRD on HD, HTN who presents with 6
days of watery, nonbloody diarrhea. Of note, patient finished 14
day course of vanc/levo/ceftaz for foot ulcer (MRSA and
Enterobacter positive). Then 2 days later (approx 8 days ago),
he started to develop diarrhea. He was started on flagyl 6 days
ago and diarrhea at first improved, but has now worsened. He
states that he has approximately 3 diarrheal BM per day. These
are watery, smell like medication and non bloody. denies f/c,
abd pain, recent travel or ill contacts. Also denies any recent
URIs. Denies any chest pain, SOB, abdominal pain.
Past Medical History:
1)DM type 1
2)Primary sclerosing cholangitis - biopsy at OSH on [**2102-1-15**] was
strongly suggestive of PSC; also patient had secondary
hemosiderosis diagnosed by stainable iron laden Kuppfer cells.
No evidence of malignancy was seen at this time. No evidence of
cirrhosis
3)ESRD on HD - gets dilyzed at "The Dialysis Center" at
[**Location (un) 108889**]
4)HTN
5)Peripheral vascular disease
6)Foot Ulcers - s/p recent debridement - gangrene and
osteomyelitis. Previous to this, he was found to be growing out
MRSA and Enterobacter
7) MRSA bacteremia
.
Social History:
- denies smoking or drinking history
- immigrant from [**Location (un) 4708**]
Family History:
Mother - died 5 months ago; she had diabetes w/ renal
involvement
Sister with diabetes
Physical Exam:
PE: Admission vitals to ED
VS: T: 99.3 HR: 112 BP: 161/85 RR: 16
GEN: Jaundiced middle aged male
HEENT: Sclera icteric. Tongue yellow underneath; no lesions in
mouth
CHEST: Lungs CTA B/L. Old fistual in R subclavian region.
CV: +s1+s2 SEM heard at RUSB and LUSB
ABD: +BS. Soft NT. Mildly distended. Areas of shifting dullness
noted on percussion. (-) [**Doctor Last Name 515**] sign.
EXT: Several fingers on both hands have dry gangrene and are
deformed; Multiple lesions on both arms - look excoriated.
Others look like tophi. HD Fistula on L arm.
Pertinent Results:
RUQ USG:
1. Gallbladder filled with sludge with no definite shadowing
stones. There is an apparent common duct stent. Please correlate
with patient's history. No intrahepatic biliary ductal
dilatation is seen.
2. Ascites.
3. Possible echogenic right renal medulla
.
EKG: NSR; LAD; TWI: I, AVL - both old; Late R wave progression
.
[**2102-3-23**]
IMPRESSION: Large soft tissue defect in the second toe with
irregularity at the second metatarsal bone, periosteal reaction,
as well as heterotopic bone formation with cortical
irregularity. The findings are suspicious for osteomyelitis,
however, correlation with time course from the surgery is
recommended.
.
[**2102-3-23**]: US of Abdomen:
CONCLUSION:
1. Distended gallbladder with sludge and small [**Doctor Last Name 5691**] like
stones as well as edema in the wall. In the presence of massive
ascites, wall edema cannot be used as a sign of acute
cholecystitis and there were no other findings to suggest this,
but if clinical concern remains, a radionuclide biliary scan
would be recommended for further evaluation.
2. Massive ascites. An appropriate spot was marked in the right
lower
quadrant for paracentesis by the clinical team.
3. Atrophic kidneys and heavily calcified hepatic and splenic
arteries suggestive of underlying diabetic vasculopathy.
.
[**2102-3-23**]: Scrotal US:
CONCLUSION: The findings suggest chronic ischemia on the right
testis with minimal detectable flow but slightly diminished
testicular volume compared to the normally vascularized left
side. This would be atypical for torsion and raises the
possibility of arterial insufficiency, possibly related to
underlying diabetic vascular disease. The findings were relayed
to the urologists shortly after completion of the study.
.
[**2102-3-29**]:
1. Extensive intraabdominal ascites, unchanged appearance.
2. No evidence of bowel perforation. No evidence of obstruction.
3. Marked vascular calcifications in the heart and through the
abdomen and pelvis including the subcutaneous tissues.
4. Small-to-moderate left pleural effusion with continued left
greater than right perihilar ground-glass opacity suggesting CHF
5. Addendum: Distal ileum and proximal colonic edema - DDx
ischemia, infection or inflammation
Brief Hospital Course:
INITIAL ASSESSEMENT AND HOSPITAL COURSE BY THE FLOOR TEAM: 45 yo
on HD for ESRD, primary sclerosing cholangitis s/p
vanco/Levo/Ceftaz presents with diarrhea x 1 week. On [**3-27**] with
increased confusion and somnolence.
.
On [**2102-3-27**], patient developed increased somnolence and confusion.
This occurred shortly after dialysis. A trigger was called; his
ABG was OK - 7.51/39/126 on RA with HCO3 of 32 -> since this was
shortly after dialysis, renal service indicated that his acid
base status was not equilibriated at this time.
- Head and Abd CT (especially in light of hiccups - considered
whether blood or other sources for diaphragmatic irritation)
- head CT did not find any masses or bleeds; extensive
intracranial calcifications were found.
- Abd CT was negative for retroperitoneal bleed; it did show
layering high density material in the GB and extensive ascites,
but a pocket could not be found to tap via US.
- stopped baclofen which has high incidence of AMS particulary
in renal failure patients
- CXR showed improving paramediastinal haziness and LLL opacity
? atelectasis or fluid collection.
- patient got 1g IV of Vancomycin - concern here was for
subtherapeutic vanco levels.
.
On [**2102-3-28**]: patient was sent for US guided paracentesis -
cultures and chemistries were sent.
.
# Diarrhea
- from admission to - [**3-28**] patient has continued to have diarrhea
- C Diff negative x 3 - sent a 4th
- C Diff B toxin pending as of [**2102-3-28**]
- [**3-23**]: had whitish diarrhea
- [**3-24**]: 2 green diarrheal episodes o/n
.
- patient was intially treated with with flagyl. Through he was
receiving flagyl as outpatient, it may not have been adequately
dosed. Hence, we increased his flagyl dose to 500mg PO BID.
([**2102-3-24**] is day # 5 of Flagyl at this dose)
.
- on [**3-24**], with his rising WBC count despite Levo/unasyn/flagyl,
we started him on PO vanco 250 PO Q 6 for likely flagyl
resistant C Diff. On [**2102-3-27**], the vanco dose was increased to
500mg PO Q6 because of the high WBC count an inability to curb
his diarrhea.
.
- also must consider that this could be secondary to his
sclerosing cholangitis/?UC as patient has been having on and off
diarrhea since diagnosis past [**Month (only) **].
.
- [**3-24**]: stopped flagyl and started PO vanco. Sent for vanco
level. Also changed Unasyn over to Meropenem - given patient's
history of Enterobacter and MRSA.
.
# Leukocytosis:
- unclear etiology at this time
- potential sources include his gall bladder, MRSA bacteremia,
abscess, foot, C Diff (B toxin), drug reaction
- [**2102-3-28**]: getting US guided paracentesis for diagnostic and
therapeutic purposes
.
# ESRD: ? [**2-23**] diabetes
- on M, W , F hemodialysis
.
# Chronic Cholangiolitis:
- reevaluation of pathology here revealed chronic cholangiolitis
adn obstructive biliary disease
- patient had stent placed on [**2102-3-22**] because of a dominant
stricture near the ampulla via ERCP
.
Dx at OSH: PSC: - suggested by
---- prominent ductal proliferation
---- intra and extracellular cholestasis
---- hepatocyte "feathery degeneration
---- fibrosis by trichrome stain with architectural distortion
---- [**Doctor First Name **], AMA, SMA negative
---- also patient had secondary hemosiderosis diagnosed by
stainable iron laden Kuppfer cells. No evidence of malignancy
was seen at this time. No evidence of cirrhosis.
.
- On admission, since patient was s/p biliary stent, he was
started on 5 days of Unasyn - also because of his foot ulcer
infection - discontinued once sensitivities arrived from OSH.
- stopped colestipol and ursodiol on [**2102-3-24**]
.
# ESRD / Cirrhosis:
- patient is being evaluated for combined hepatorenal transplant
- his cousin is potential match - he has an appointment at [**Hospital1 2025**] -
also determining if he would like to be evaluated here.
.
- ? etiology of cirrhosis: denies EtOH, ? PSC, Ischemia, ? R
heart failure
.
# Abdominal pain:
- improved after 1L taken off by paracentesis
- US of abdomen and testicles - > showed decreased blood flow to
his right testicle which is likely chronic in nature -> and
could be accounting for his pain
-> appreciate urology recs: do not feel that thsi is
epididymitis or orchitis at this time.
- s/p ERCP
- Hct stable
.
# Foot:
- s/p surgery and 2 weeks of abx for ? osteomyelitis at OSH
Vanco/Ceftaz/Levo
- wet to dry dressing changes.
- podiatry took to OR on [**2102-3-24**] -> partial debridement - poor
bleeding
- vascular surgery holding on angiography + intervention [**2-23**]
increased WBC ct
- [**2102-3-28**] at this time, podiatry does not think that his
leukocytosis is due to foot infection
.
# MRSA Bacteremia:
- Cx Positive at OSH - blood cultures pending here
- Start on Vancomycin ([**3-28**] is day #9) - IV with HD.
- checking Vanco level
- also on PO vanco for the ? C Diff -> increased on [**2102-3-27**]
- pt missed some vanco doses with HD/multiple procedures
.
# HTN:
- started on metoprolol
- added ACE-I on [**2102-3-25**] for continued HTN
- consider adding nifedipine, hydral for acute HTN that is hard
to ctrl
.
# DM
- started on NPH 8 qAm, 8 qPm as well as SSI
- FS QID
- renal, diabetic diet
~2:30 AM of [**2102-3-31**], A code blue was calld after the patient was
found pulseless and unresponsive. Per nursing report he was
confused earlier in the day with NGT draining dark bloody
material but had stable vitals and was mentating. He has a h/o
cirrhosis, ESRD on HD, SBP, type 1 DM, PVD, bacteremia, poss
CDiff, and recent diarrheal epidose.
.
Chest compressions were started, he was intubated, and a cordis
was placed in his R groin. He received IVF's wide open and 2 of
Epi and 2 of Atropine were given for Asystolic code which turned
into PEA. The patient was then noted to have a pulse but was
bradycaric. He was pulseless for at least 15 mins. He was also
given 1 amp of bicarb and calium. He was then transferred to
SICU.
.
Upon arrival to the SICU the patient was again noted to be
pulseless, and chest compressions were resumed and he was given
IVF's and Atropine x1, then started on a Dopamine drip and
resumed a pulse. He was given several amps of bicarb and several
grams of Calcium. He subsequently had another PEA arrest when
chest compressions were resumed for several minutes and pulse
was regained after IVF's. An A-line was placed and after labs
returned pt was given 4U of PRBC's, 2U FFP, and Vasopressin was
added for BP support.
.
CXR was noted to have diffuse pulmonary edema/infiltrates, trach
was noted to have pink frothy fluid from it. His NGT was
suctioned with blood, which did not clear with lavage and GI was
called for possible UGIB +/- aspiration and subsequent asystolic
arrest. Given pulm edema on CXR IVF's were held and pressors
were titrated for MAP of 60-65. He was also noted to have a temp
of 90 and was placed on a bear hugger. The patient's family was
notified, as well as the ICU attending on call who evaluated the
patient.
.
Patient required 2 pressors for hypotension. He had fixed
dilated pupils and remained unresponsive. ICU attending met
with the family and a decision was made that given patient's
neurologic exam CPR was not indicated. Family requested to
maintain patient on ventillator and pressors for ~2-3 days to
see if there is any improvement. Neurologic exam remained
unchanged, the only sign of brainstem function was episodic
intermittent spontaneous breathing. After a family meetint
evening of [**4-2**], CT scan of head was performed which showed
bilateral thalamic infarct and moderate edema consistent with
anoxic brain injury. Family requested that patient be extubated
and taken off pressors with goals of care changed towards
comfort measures. He expired [**2102-4-3**].
Medications on Admission:
.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Anoxic brain injury
ESRD
Primary sclerosing cholangitis
htn
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2102-4-3**]
ICD9 Codes: 4275, 5856, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2565
} | Medical Text: Admission Date: [**2121-9-22**] Discharge Date: [**2121-9-27**]
Date of Birth: [**2037-1-16**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
PICC line placed
History of Present Illness:
The patient is an 84 year old Russian speaking female with
diastolic CHF and several recent admissions for heart failure
exacerbations, who presented to the ED today with pre-syncope.
She was discharged home yesterday, [**2121-9-21**], after being
effectively diuresed with a lasix drip. This morning her VNA
nurse came to the house. As she got up to open the door, the
patient fainted and the VNA nurse caught her. She was put in a
chair and immediately awoke. She did not have any chest pain,
nausea, vomiting, or diaphoresis. The VNA nurse took the
patient's blood pressure, which was reportedly very low, and she
was brought to the ED in an ambulance.
.
During her last admission, in addition to treatment for a heart
failure exacerbation, she was also worked up for restricitve
cardiomyopathy. She had monoclonal bands in her unrine and her
serum, and a bone marrow biopsy was performed as part of the
workup for restrictive cardiomyopathy. An oncology consult was
obtained. The other working diagnosis had been aymloidosis, but
the bone marrow biopsy results were going to be analyzed before
investigating amyloid disease.
.
While VNA was at her home, the patient stood up this morning and
her blood pressure decreased dramatically to 60/palpation,
resulting in near syncope. She was brought to the [**Hospital1 18**] ED for
this reason.
.
In the ED her blood pressure was 92/65, HR 74, RR 18, saturating
98% on 4L NC. She recieved 500cc of iv fluids. She looked dry on
exam. Her hematocrit was 36, up from 31. She is being admitted
to [**Hospital1 1516**] for observation.
.
When she came to the floor, she did not have any dizziness and
she was hemodynamically stable.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
Diastolic Congestive Heart Failure, thought to be restrictive
cardiomyopathy (multiple myeloma versus cardiac amyloid)
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Hiatal Hernia
- GERD
- Syncopal episode in remote past
Social History:
Lives at home alone, but has VNA services 3x/wk. Has home health
aide and homemaker to help with household chores. States can
only walk 10 ft and do minimal cooking for self [**12-17**] SOB. Denies
any falls at home.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
No family history of CHF, sudden cardiac death
Physical Exam:
Admission Exam
VS: T=96.3 BP=100/66 HR=70 RR=20 O2 sat=98 2L
GENERAL: Cachectic female.
HEENT: NCAT. Sclera anicteric. Mucous membranes dry.
NECK: Supple with JVD to the jaw line
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, Distant heart sounds. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c. 2+ pitting edema in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**] to
level of thigh.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+
Left: Carotid 2+ Radial 2+
Pertinent Results:
[**2121-9-22**] 12:45PM CK-MB-10 MB INDX-6.5* proBNP-[**Numeric Identifier 24248**]*
[**2121-9-22**] 12:45PM cTropnT-0.41*
[**2121-9-22**] 12:45PM CK(CPK)-154
Brief Hospital Course:
HYPOTENSION/CHF: JVD, distant heart sounds, low voltage on EKG,
enlarged RA and LA, lower extremity edema, pulm edema on CXR,
suggest congestive heart failure, possibly restrictive in
nature. Pt's bone marrow path results returned positive for MM
and CLL. Amyloidosis also of consideration in this patient with
renal failure, monoclonal spike, anemia, possible restrictive
HF. The patient's pre-syncopal episode was likely due to
orthostatic hypotension. Pt was given gentle fluid boluses
initially. Pt had brief episode of hypotension on the floor and
was briefly started on Levophed. She was transfered to the CCU
for close monitoring. In the CCU, Levophed was d/c-ed, and pt
stabalized with lasix gtt. Over the next few days, several
liters of fluid was removed. She appeared significantly more
euvolemic on exam. Pt's "air hunger" and SOB was treated
symptomatically with lasix and morphine.
.
# Multiple Myeloma/CLL: Bone marrow biopsy report returned
positive for MM and CLL. It did not reveal amyloidosis but that
does not conclusively rule out the diagnosis. Oncology team
notified patient and family and did not reccomend any
therapeutic treatment given her poor performance status,
multi-organ failure. Palliative care was consulted and met with
family and patient to discuss goals of care. Decision was made
to make patient DNR/DNI and to focus on goals of comfort.
Patient was given morphine for air-hunger and continued on lasix
drip for symptoms of heart failure.
.
# CORONARIES: No EKG changes consistent with acute ischemia. No
chest pain. Troponin leak likely due to combination of demand
ischemia and chronic kidney disease resulting in decreased
troponin clearance. Troponin steady since admission. Continued
ASA, atorvastatin. Atorvastatin was discontinued on [**9-24**] after
palliative care family meeting.
.
# RHYTHM: Pt with first degree AV nodal block on EKG on
admission. EKG during hypotensive episode was bradycardic.
Patient had short runs of unsustained VT (5-10 beats) few times
daily. Metoprolol tartrate was started at 6.25mg TID, but was
frequently held due to low BP. Transitioned to toprol 12.5mg.
.
# CKD: Cr. baseline 1.0 in [**6-/2121**], 1.4-1.5 in [**7-/2121**], now
1.8-1.9. On this admission creatinine is 2.1-2.2 range. Cr has
been gradually trending up over the last few months. Bence [**Doctor Last Name 49**]
proteins found in urine on prior admission. Patient likely has
pre-renal azotemia from heart failure complicated with
underlying renal insuficiency from MM/Amyloid.
.
# Hyperlipidemia- Continued home atorvastatin.
.
# GERD- Continued home PPI.
.
# Goals of Care: Heme/Onc did not feel that there were any
therapeutic options for patient's MM/CLL/Possible amyloid.
Palliative care was consulted and helped family make decisions
about end of life care. Patient was made DNR/DNI with a focus on
comfort. She was given morphine 0.5mg-2mg for SOB and air-hunger
symptoms. Patient eventually passed with her daughter at the
bedside.
Medications on Admission:
atorvastatin 10 mg daily
omeprazole 20 mg daily
aspirin 81 mg daily
torsemide 20 mg daily
metolazone 5 mg daily
metoprolol succinate 25 mg daily
spironolactone 25 mg daily
potassium chloride 10 mEq [**Hospital1 **]
nitroglycerin 0.3 mg Tablet SL as needed
alendronate 35 mg qSaturday
Senna Daily
Discharge Medications:
Patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Heart Failure
Multiple Myeloma
CLL
Renal Failure
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
deceased
ICD9 Codes: 5849, 4589, 5859, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2566
} | Medical Text: Admission Date: [**2188-11-27**] Discharge Date: [**2188-12-2**]
Date of Birth: [**2144-12-16**] Sex: M
Service: MEDICINE
Allergies:
Levaquin in D5W
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Unresponsiveness/hypoglycemia
Major Surgical or Invasive Procedure:
-Mechanical Ventilation
History of Present Illness:
This is a 43yoM with history MEN1 s/p splenectomy and subtotal
pancreatectomy who presents after being found unresponsive.
Patient was intubated on arrival to MICU so history was obtained
from partner. Pt apparently was feeling more depressed over last
2 weeks. Yesterday apparently pt and partner got into an
argument. Pt was last seen at 10am on [**11-27**]. Pt was contact[**Name (NI) **]
via phone at 12pm on [**11-27**]. Patient was then found at home at
730pm and was unresponsive. Blood sugar was taken which was
"critically low." EMS was called who also found pt with low
blood sugar. Pt was given amp of D50 as well as narcan without
improvement of MS and was then intubated for "airway
protection."
.
In [**Name (NI) **], pt was found to be continually hypoglycemic. Started on
D10 gtt. Head CT was negative. Pt admitted for further work-up
.
In MICU, pt was intubated/sedated continued on glucose drip
until blood sugars had normalized and patient's mental status
had improved. Post-extubation psychiatry was consulted given
patient's partner's concern for worsening of his depression a
sectioned 12 was placed and the patient was given a 1:1 sitter.
Patient now states that he had several appointments on the day
of admission adn was unable to eat and that was why his blood
sugar was low. Has had several episodes of hypoglycemia in the
past, but never this severe.
.
Review of systems: Patient currently feeling well with no HA,
dizziness, thirst, dysuria, change in bowel or bladder habits,
CP, SOB, abdominal pain nausea or vomitting.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. multiple endocrine neoplasia (type 1) - genetic testing
confirmed per medical records
2. metastatic gastrinoma, Zollinger-[**Doctor Last Name 9480**] syndrome
3. insulin dependent type 1 diabetes (diagnosed at age 16, h/o
DKA with hospitalizations)
4. stage II CKD (diabetic nephropathy) - baseline creatinine
1.4-1.6
5. s/p parathyroidectomy (x 3, [**2172**]-[**2176**]) with re-implantation
to arm
6. GERD/gastritis
7. unilateral right adrenalectomy (for pheochromocytoma with
adrencortical hyperplasia, [**11/2174**])
8. sub-total pancreatectomy (MD [**Location (un) 4223**] with pathology
demonstrating islet cell tumor, [**2174**])
9. s/p splenectomy ([**11/2174**])
10. depression
Social History:
He normally lives in [**Location 3615**], but has been staying with his
partner in [**Name (NI) 86**]. He smoked approximately two packs per week
from [**2172**] to [**2182**] and quit in [**2182**]. He denies any alcohol use.
He denies IV drug use. He does smoke marijuana regularly.
Family History:
His father had an [**Name (NI) 58955**] and subsequent gastrinoma. He denies
any other family history of malignancy.
Physical Exam:
Physical Exam on Arrival to MICU
General Appearance: No acute distress, Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
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 : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
)
Abdominal: Soft, Bowel sounds present, Tender: mildly,
throughout
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
ON DISCHARGE:
Vitals: 97.3, 134/93, 70, 18, 16
I/O: NR
General: A and ox3
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: non-focal.
Pertinent Results:
[**2188-11-27**] 09:49PM BLOOD WBC-14.7*# RBC-4.50* Hgb-13.1* Hct-39.8*
MCV-88 MCH-29.1 MCHC-32.9 RDW-14.3 Plt Ct-393
ADMISSION LABS:
[**2188-11-27**] 09:49PM BLOOD Neuts-76.2* Lymphs-14.1* Monos-7.6
Eos-1.4 Baso-0.6
[**2188-11-27**] 09:49PM BLOOD PT-13.1 PTT-25.5 INR(PT)-1.1
[**2188-11-27**] 09:49PM BLOOD Glucose-16* UreaN-21* Creat-1.7* Na-143
K-3.9 Cl-110* HCO3-19* AnGap-18
[**2188-11-27**] 09:49PM BLOOD ALT-30 AST-33 AlkPhos-230* TotBili-0.2
[**2188-11-27**] 09:49PM BLOOD Calcium-10.2 Phos-2.5* Mg-1.9
[**2188-11-27**] 09:42PM BLOOD Lactate-2.7*
[**2188-11-27**] 09:49PM BLOOD Lipase-9
[**2188-11-28**] 01:23AM BLOOD TSH-0.54
[**2188-11-28**] 01:23AM BLOOD Cortsol-18.8
[**2188-11-28**] 01:23AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2188-11-28**] 12:48AM BLOOD C-PEPTIDE-PND
[**2188-11-27**]
- CT head w/o contrast: No acute intracranial hemorrhage, edema,
mass effect or major vascular territorial infarction. [**Doctor Last Name **]-white
matter differentiation is preserved. There is no shift of
normally midline structures. The ventricles and sulci are normal
in size and configuration. There is no fracture. Imaged
paranasal sinuses and mastoid air cells demonstrate mucus
retention cyst or polyp in the floor of the right maxillary
sinus is not completely imaged. Right parietal scalp lipoma is
again noted.
IMPRESSION: No acute intracranial process.
DISCHARGE LABS
[**2188-11-30**] 06:40AM BLOOD WBC-10.2 RBC-4.28* Hgb-12.2* Hct-37.5*
MCV-88 MCH-28.5 MCHC-32.5 RDW-14.4 Plt Ct-388
[**2188-12-1**] 06:33AM BLOOD Glucose-155* UreaN-20 Creat-1.7* Na-138
K-5.1 Cl-103 HCO3-26 AnGap-14
[**2188-11-29**] 03:34AM BLOOD ALT-20 AST-21 AlkPhos-210* TotBili-0.3
[**2188-12-1**] 06:33AM BLOOD Calcium-10.3 Phos-3.8 Mg-1.9
[**2188-11-28**] 01:23AM BLOOD TSH-0.54
[**2188-11-28**] 01:23AM BLOOD Cortsol-18.8
Brief Hospital Course:
43 yoM with history of severe depression, MEN 1a s/p
pancreatectomy who presents after unresponsive episode.
# Unresponsive episode: patient was found unconscious at home by
his partner, EMS was called and found to have a SBG in the 40s
was given dextrose and naracan, intubated and brought to the ED.
Patient was admitted to the ICU where he continued to recieve
dextrose gtt until alert enough for extubation 24 hours later.
Patient was transfered to the floor where he was followed by
[**Last Name (un) 387**] consult service and had his basal glargine titrated to 12
units QAM with a tighter humalog sliding scale. Thyroid,
coritisol and c-peptide (pending) were sent as patient had
history of MEN1 all of which were normal. Patient reports
hypoglycemia was unitentional and from forgetting to eat.
Psychiatry was consulted and felt patient lacked appropriate
insight into his illness and were concerned that his actions may
have been suicidial in intent. Patient was secontioned 12 and
was to be admitted to inpatient psychiatry. Patient was alert
and oriented and medically clear prior to transfer to
psycihatry.
.
# Leukocytosis: felt to be stress demargination and resolved by
MICU admission.
.
# Depression: Patient has signifcant history of depression under
outpatient management and past history of suicide attempts.
Psychiatry was consulted out of concern that patient's
hypoglycemia was intentional. Patient continues to have an
increased level of risk given his demonstrating impaired
judgment and impulsiveness resulting in serious medical
consequences, his previous history of suicide
attempt, ongoing unchanged psychosocial stressors, and expressed
concerns about safety outside of the hospital by his outpatient
providers. Patient was section 12'd and to be admitted to
inpaitent psychiatry.
.
# Diabetes: Patient was seen by inpatient [**Last Name (un) **] service and
had his basal galargine titrated to 12 units daily with an
uptitrated sliding scale. Paitent will continue to have [**Last Name (un) 387**]
consultation while in inpatient psychiatry and was medically
cleared for transfer to psychiatry. His most reccent sliding
scale was
Glargine 12 units SC every AM
Humalog sliding scale to as below:
Breakfast Lunch Dinner
71-110 4 5 5
111-150 5 6 6
151-200 7 7 7
[**Telephone/Fax (2) 58956**]51-400 9 9 9
>400 call your doctor
.
# Vomitting: patient with 2 episodes of vomitting intact food
several hours after eating post extubation. This was felt to be
from possible gastroperesis though patient without a known
history of these symptoms. He was treated with Zofran PRN with
good effect and medically cleared for inpatient psychiatric
admission.
.
# MEN1: patient with history of pheochromcytoma, gastrinoma and
hyperparathyroidism diagnosed as MEN1 syndrome status
post-pancreatectomy and spleenectomy. Patient has insulin
diabetes as discussed above as well as peristantly elevated
gastrin levels. he was maintained on his home regimen of
pantoparazole 40 mg [**Hospital1 **] with good effect and medically clear for
inpatient psychiatric admission.
.
# HYPOTHYROIDISM: secondary to idodine ablation of grave's
disease, stable on home regimen of levothyroxine 150 mcg for 9.5
doses weekly.
.
TRANSITIONAL ISSUES:
-patient is not on Ace/[**Last Name (un) **] for diabetic nephropathy due to
history of hyperkalemia - should followup as outpatient with his
nephrologist.
-consider having gastric emptying study to evaluate for
gastroperesis.
Medications on Admission:
Per OMR
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) in each
nostril daily Can decrease to 1 spray daily in each nostril once
symptoms controlled
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth daily at
bedtime
INSULIN GLARGINE [LANTUS] - (Dose adjustment - no new Rx) - 100
unit/mL Solution - 15 units SC every AM
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - per sliding
scale three times daily as directed
KETOTIFEN FUMARATE - 0.025 % Drops - 1 drop(s) in the affected
eye(s) twice a day as needed for allergy symptoms
LAMOTRIGINE - 100 mg Tablet - 1 Tablet(s) by mouth daily
LEVOTHYROXINE - 150 mcg Tablet - 9.5 Tablet(s) by mouth weekly
LIPASE-PROTEASE-AMYLASE [CREON] - 24,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000
unit Capsule, Delayed Release(E.C.) - [**7-23**] Capsule(s) by mouth up
to 6 times daily before meals and snacks as directed: 8 caps
before meals 6 before snacks
LORAZEPAM - 1 mg Tablet - 1.5 Tablet(s) by mouth four times
daily
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth twice a day - No Substitution
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomnia ; may take additional dose if needed after
one hour
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - to be
used as directed up to five times daily
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 3 Capsule(s)
by mouth daily; to replace previous Vit D prescriptions
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Ten (10) Capsule, Delayed
Release(E.C.) PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for headache.
4. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day)
as needed for anxiety.
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. insulin glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 12 units daily in the AM.
9. dextrose 50% in water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
13. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
15. insulin glargine 100 unit/mL Solution Sig: One (1) 1
Subcutaneous once a day: 12 units daily.
16. levothyroxine 75 mcg Tablet Sig: Three (3) Tablet PO 1X/WEEK
(SA).
17. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO
2X/WEEK (MO,WE).
18. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,FR).
19. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous
three times a day: CHANGE Glargine 15 units SC every AM to 12
units SC every AM
CHANGE Humalog sliding scale to as below:
Breakfast Lunch Dinner
71-110 4 5 5
111-150 5 6 6
151-200 7 7 7
[**Telephone/Fax (2) 58956**]51-400 9 9 9
>400 call your doctor.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
PRIMARY:
Hypoglycemia
SECONDARY:
-MEN-1 status post surgical excision of gastrinomas, parathyroid
resection, right adrenalectomy for pheochromocytoma, splenectomy
in [**2174**],
-type 1 diabetes,
-pancreatic insufficiency on enzyme supplements
-[**Doctor Last Name **] disease s/p radioiodine ablation
-Hypothyroidism
-cataracts
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 58871**],
It was a pleasure taking care of you while you were in the
hospital. You were admitted for severe hypoglycemia requiring
intubation and a stay in the intensive care unit. Your blood
sugar was aggressively treated we were able to stabilize you and
discharge you from the ICU. You were seen by our diabetes
experts who have ajusted your sliding scale for better glucose
control. You were also seen by our psychiatrists who felt you
should be observed in the inpatient setting for the time being.
The following changes were made to your medications:
CONTINUE Fluticasone - 50 mcg 2 sprays(s) in each nostril daily
CONTINUE Gabapentin 300 mg before bed
CONTINUE Ketotifen 0.025% 1 drop(s) in the affected eye(s) twice
a day as needed for allergy symptoms
CONTINUE Lamotrigine 100 mg daily
CONTINUE Levothyroxine 150 mcg, 9.5 Tablet(s) by mouth weekly
CONTINUE Creon [**7-23**] Capsule up to 6 times daily before meals and
snacks as directed: 8 caps before meals 6 before snacks
CONTINUE Lorazeopam 1 mg - 1.5 Tablet(s) by mouth four times
daily
CONTINUE Pantoprazole - 40 mg Tablet, Delayed Release twice
daily
CONTINUE Trazodone 50 mg as needed for insomnia
CHANGE Glargine 15 units SC every AM to 12 units SC every AM
CHANGE Humalog sliding scale to as below:
Breakfast Lunch Dinner
71-110 4 5 5
111-150 5 6 6
151-200 7 7 7
[**Telephone/Fax (2) 58956**]51-400 9 9 9
>400 call your doctor
Followup Instructions:
Department: PSYCHIATRY
When: TUESDAY [**2188-12-2**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Department: [**Location (un) 1947**]
When: WEDNESDAY [**2188-12-3**] at 10:40 AM
With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2188-12-8**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2567
} | Medical Text: Admission Date: [**2121-11-1**] Discharge Date: [**2121-11-6**]
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Cholangitis, sepsis, admitted to ICU for monitoring prior to
ERCP
Major Surgical or Invasive Procedure:
[**11-1**]: ERCP
History of Present Illness:
83 y/o male with history of choledocolithiasis in [**2113**] s/p ERCP
and sphincterotomy who presents with malasie and dark colored
urine x 5 days. He denies symptoms abdominal pain, n/v, chills,
cp, sob, dysuria. Denies weight loss, had poor appetite this
week. called his PCP after noticing the dark urine and was told
to go to OSH. He was evaluated at [**Hospital1 **] Ed which revealed
elevated LFT's, total bili 12.5, U/S with CBD dilation, sludge,
and distended gallbladder wall with pericholecystic fluid. Was
transfered to [**Hospital1 18**] for ERCP.
.
In ED was hypotensive 94/50 and febrile, requiring levophed
through a peripheral IV. He received 4L NS in ED, his BP
recovered and levophed was d/c'd. He got one dose unasyn and was
transfered to the [**Hospital Unit Name 153**] for monitoring prior to ERCP in AM.
Past Medical History:
1. CAD s/p CABG in [**2110**].
2. Billroth II gastrectomy in [**2077**].
3. ERCP on [**2114-4-12**].
4. Herniorrhaphy times two.
5. Hypertension
Social History:
SH: Lives in [**Location 27252**], MA with one of his 4 sons. Wife
passed away 10 years ago, has 9 children. Team photographer for
the [**Location (un) 86**] Red Sox.
Family History:
Non-contributory
Physical Exam:
VS T:99.8 HR:81 BP:118/62 O2sat 98%RA
GEN: A/O, nad, well appearing, jaundiced
HEENT: icteric sclera, sublingual icterus
CV: RRR s1, s2, 2/6 systolic murmur heard in axilla
RESP: CTA bl
ABD: soft, NT, ND, no masses. prior scars noted on abd and chest
EXT: + pulses distally, warm, no erythema or swelling
SKIN: icteric, no rashes
Pertinent Results:
CXR [**11-1**]: FINDINGS: There has been no significant change from
the patient's prior examination of [**2113**]. There is no new
infiltrate. Patient is status post a median sternotomy.
Cardiomediastinal contours are within normal limits. IMPRESSION:
No evidence of acute disease in the chest.
.
ERCP [**11-1**]: Sludge and CBD stones cleared. Tolerated procedure
well.
.
[**2121-10-31**] 08:40PM BLOOD Lactate-3.3*
[**2121-11-1**] 02:29AM BLOOD Lactate-3.4*
[**2121-11-3**] 07:00AM BLOOD calTIBC-127* VitB12-[**2104**]* Folate-6.7
Ferritn-790* TRF-98*
[**2121-10-31**] 08:30PM BLOOD Lipase-15
[**2121-10-31**] 08:30PM BLOOD ALT-194* AST-170* AlkPhos-394* Amylase-51
TotBili-9.6* DirBili-7.8* IndBili-1.8
[**2121-11-1**] 04:57AM BLOOD ALT-160* AST-135* LD(LDH)-242
AlkPhos-312* Amylase-57 TotBili-7.2*
[**2121-11-6**] 06:55AM BLOOD ALT-52* AST-51* AlkPhos-168* Amylase-38
TotBili-1.6*
[**2121-11-1**] 02:30AM BLOOD Glucose-102 UreaN-21* Creat-1.3* Na-135
K-4.0 Cl-106 HCO3-14* AnGap-19
[**2121-11-6**] 06:55AM BLOOD Glucose-95 UreaN-13 Creat-0.9 Na-137
K-3.6 Cl-105 HCO3-26 AnGap-10
[**2121-10-31**] 08:30PM BLOOD PT-15.1* PTT-27.9 INR(PT)-1.4*
[**2121-11-3**] 07:00AM BLOOD PT-12.3 PTT-26.9 INR(PT)-1.1
[**2121-10-31**] 08:30PM BLOOD WBC-12.3*# RBC-4.19* Hgb-12.4* Hct-36.6*
MCV-87 MCH-29.5 MCHC-33.8 RDW-14.9 Plt Ct-181
[**2121-11-1**] 05:32PM BLOOD WBC-17.1* RBC-4.46* Hgb-12.9* Hct-38.3*
MCV-86 MCH-29.0 MCHC-33.8 RDW-15.1 Plt Ct-114*
[**2121-11-6**] 06:55AM BLOOD WBC-8.3 RBC-3.65* Hgb-10.4* Hct-30.3*
MCV-83 MCH-28.5 MCHC-34.3 RDW-15.3 Plt Ct-190
.
Blood Cultures [**11-1**]
MORGANELLA MORGANII
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- 4 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 R
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
Hosptial Course, by Problem:
.
#Ascending Cholangitis/Choledocolithiasis: had ERCP with
sphincterotomy; stones and sludge removed. Needs f/u with PCP
for discussion of cholecystectomy.
.
#Bacteremia: blood cultures at OSH grew pan-S E coli. Pt
initially on Unasyn; however, patient spiked on the floor. CTX
added. Repeat blood cultures grew Morganelli (R) to Unasyn and
(S) to CTX. Was eventually transitioned to PO
Augmentin/Cefpodoxime. Will complete a total of a 10 day
course. ID consulted and agreed with plan.
.
#Anemia: Fe studies c/w Anemia of Chronic Disease. Remained
stable in house.
Medications on Admission:
Metoprolol 25mg po BID
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
1. Ascending Cholangitis
2. Choledocolithiasis
3. Morganella/E. Coli bacteremia
4. Anemia of Chronic Disease
Secondary Diagnoses
1. Hypertension
2. h/o CAD s/p CABG
3. h/o Billroth II
Discharge Condition:
stable, afebrile
Discharge Instructions:
Please contact Dr. [**Last Name (STitle) **] should you develop any worsening
abdominal pain, nausea, vomiting, diarrhea, fevers, chills,
sweats, or any other serious complaints.
Please take your antibiotics are prescribed for the next 5 days.
Followup Instructions:
Please call dr. [**Last Name (STitle) **] as soon as possible to make a follow-up
appointment.
ICD9 Codes: 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2568
} | Medical Text: Admission Date: [**2159-9-21**] Discharge Date: [**2159-9-26**]
Date of Birth: [**2094-6-15**] Sex: F
Service: .
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
female with a past medical history of meningioma resection in
[**2147**] with subsequent recurrence and radio surgery and then
status post a cerebrovascular accident, who presented to the
Emergency Room after being found sitting in front of her
lobby, aphasic and with left sided weakness. Head CT scan in
the Emergency Room shows bleed in the left parasagittal area
right next to where the meningioma had been resected. The
patient was admitted to the Medical Intensive Care Unit for
close neurological observation.
Her INR was reversed. The patient was alert and oriented
times three. She had trouble finding words and is able to
speak with good fluency. She does require some reminding and
has some lapses in short term memory. She is moving all
extremities times four strongly. She is able to
independently get out of bed to the chair.
PHYSICAL EXAMINATION: She had a low grade temperature on
post hospital day number one. Heart rate was in the 70s.
She had no ectopy. Blood pressure was stable in the 120s to
140s. Her lungs were clear to auscultation. Her abdomen
was nondistended, nontender. Positive bowel sounds.
She had a repeat CT scan which showed no further
extravasation of blood or clot. She did have an MRI scan
with contrast that showed some minimal enhancement in the
tumor bed. She was then neurologically stable and
transferred to the regular floor.
PAST MEDICAL HISTORY:
1. Depression.
2. Melanoma.
MEDICATIONS:
1. Coumadin.
2. Klonopin.
3. Prozac.
4. Prilosec.
5. Protonix.
6. Zocor.
HOSPITAL COURSE: She was seen by Physical Therapy and
Occupational Therapy and found to be safe for discharge to
home. She will follow-up with Dr. [**First Name (STitle) **] in one month with a
repeat MRI scan.
DISCHARGE MEDICATIONS:
1. Klonopin 0.5 mg p.o. twice a day.
2. Prozac 40 mg p.o. q. day.
3. Macrodantin 50 mg p.o. four times a day.
4. Famotidine 20 mg p.o. twice a day.
5. Levetiracetam 500 mg p.o. twice a day.
CONDITION AT DISCHARGE: Stable at the time of discharge.
DISCHARGE INSTRUCTIONS:
1. She will have a home safety evaluation.
2. She will follow-up with Dr. [**First Name (STitle) **] in one month with a repeat
MRI scan.
Her neurologic status is stable at the time of discharge.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2159-9-26**] 10:27
T: [**2159-9-27**] 18:01
JOB#: [**Job Number 108831**]
ICD9 Codes: 431 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2569
} | Medical Text: Admission Date: [**2160-6-18**] Discharge Date: [**2160-6-21**]
Date of Birth: [**2076-10-24**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Motrin / Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonscopy
Mesenteric Angiography without embolization
History of Present Illness:
83 y/o PMHx of sick sinus s/p PCM, GERD, h/o LGIB and
diverticulosis who presented after 2 episodes BRBPR this
morning. Pt reported feeling well the night before with good
appetite and normal BM. However, after the episodes of BRBPR, he
felt dizzy with change in position and called his PCP prior to
coming into the ED.
.
In the ED, initial vs were: T 97.7 HR 70 BP 173/70 RR 16 Sats
99% on RA. Rectal exam revealed a scant amount of bloody stool.
He was given Protonix 40mg IV, 1L NS IVF, 2 large PIV placed and
he was typed and crossed for 4u prbcs. GI was consulted and
recommended admission for c-scope.
.
On arrival to the ICU, pt was feeling well and denying CP, SOB,
abd pain, nausea or lightheadedness. He denied any further
episodes of BRBPR or recent use of NSAIDs
.
Review of systems:
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies rhinorrhea or congestion. Denies productive cough
or shortness of breath. Denies chest pain palpitations, nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits.
Past Medical History:
1)hx of LGIB in [**2-22**] and [**9-21**] with c-scope showing
diverticulosis & internal hemmorrhoids
2)Sick sinus syndrome s/p pacemaker
3)Hyperlipidemia
4)GERD
5)Asthma
6)Wilson's disease carrier
Social History:
Pt lives alone in [**Location (un) 3146**] Beach, widowed, 2 children (live in
[**Hospital1 **] and [**Location (un) **]), 4 grandchildren (ages 15-24); formerly
worked in real estate and bartending; denies tobacco and drug
use, occ alcohol.
Family History:
4 of 6 sibs with pacemakers, brother died of stroke at 81yo,
father w/ stroke at 62yo, brother w/ CAD and colon ca, mother w/
cancer, father w/ wilson's disease
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2160-6-18**] 09:17PM HCT-33.9*
[**2160-6-18**] 05:12PM HCT-31.7*
[**2160-6-18**] 01:39PM HCT-32.7*
[**2160-6-18**] 10:40AM LACTATE-1.6 K+-4.2
[**2160-6-18**] 10:30AM GLUCOSE-100 UREA N-13 CREAT-1.0 SODIUM-138
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-28 ANION GAP-12
[**2160-6-18**] 10:30AM WBC-6.0 RBC-4.30* HGB-11.9* HCT-37.2* MCV-87
MCH-27.8 MCHC-32.1 RDW-14.4
[**2160-6-18**] 10:30AM NEUTS-71.5* LYMPHS-21.6 MONOS-5.3 EOS-1.3
BASOS-0.3
[**2160-6-18**] 10:30AM PLT COUNT-260
[**2160-6-18**] 10:30AM PT-12.7 PTT-29.1 INR(PT)-1.1
[**2160-6-21**] 08:00AM BLOOD WBC-5.8 RBC-3.74* Hgb-10.6* Hct-32.5*
MCV-87 MCH-28.3 MCHC-32.5 RDW-14.2 Plt Ct-244
IMAGING:
Mesenteric Arteriography:
Provisional Findings Impression: [**First Name9 (NamePattern2) 46497**] [**Doctor First Name **] [**2160-6-19**] 11:18 PM
Mesenteric arteriography including selective arteriograms of
SMA, [**Female First Name (un) 899**],
ileocolic, right colic, middle colic arteries were performed and
no active
contrast extravasation was noted concerning for bleeding.
Therefore no
intervention was performed.
Colonoscopy:
Impression: Diverticulosis of the whole colon with active
bleeding in the ascending colon with 2 visible clots
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Recommendations: The cause of bleeding is most likely
diverticula in the ascending colon.
Recommend emergent angiogram for possible embolization
Continue to follow serial crit
Brief Hospital Course:
83 y/o M with PMhx of sick sinus syndrome s/p PCM,
diverticulosis and lower GI bleed who presents with BRBPR.
BRBPR: Found to be secondary to diverticulosis. Patient's
hematocrit remained stable without the need for blood
transfusion. No active bleeding in ICU or on floor. Colonscopy
performed showed bleeding in ascending colon. Patient was
transferred from colonoscopy suite directly to angiography for
possible intervention. Angiography did not show active bleeding
so no intervention was performed. Patient was monitored for 24
more hours and no active bleeding occured. Patient's hematocrit
remained stable. He tolerated po's and had brown bowel
movements. He was discharged with close follow up with his PCP.
Hyperlipidemia: continued home simvastatin 20mg daily.
Anxiety/Depression: continued home Citalopram 10mg daily.
Medications on Admission:
Citalopram 10mg
Omeprazole 20mg
Simvastatin 20mg
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diverticulosis s/p bleed from ascending colon
Secondary:
SSS s/p PPM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you had a lower gastro-intestinal
bleed found to come from diverticulosis. Your bleeding resolved
on its own and no intervention was performed. Your blood levels
remained stable.
You should continue your medications as prescribed with the
following important changes.
1. Omeprazole 40 mg to be taken daily
Followup Instructions:
You have the following appointments scheduled:
***NOTE***Dr. [**Last Name (STitle) 46498**] will contact you [**Name (NI) 766**] to make your
appointment sooner than what is scheduled below. If you do not
hear from them on [**Name (NI) 766**], please call [**Telephone/Fax (1) 1579**] to schedule a
hospital follow up appointment in [**2-16**] weeks.
You do not need to follow up with gastroenterology at this time.
Department: CARDIAC SERVICES
When: [**Date Range **] [**2160-7-21**] at 1:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DERMATOLOGY
When: TUESDAY [**2160-7-22**] at 1:30 PM
With: [**Name6 (MD) 6821**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: [**Location (un) **] [**2160-10-13**] at 11:30 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1579**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
ICD9 Codes: 2851, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2570
} | Medical Text: Admission Date: [**2192-4-4**] Discharge Date: [**2192-4-7**]
Date of Birth: [**2149-8-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Diabetic Ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 42-year-old man with history of T1DM, HCV,
polysubstance abuse (alcohol, cocaine, heroin), and bipolar
disorder who initially presented with nausea, lethargy, and
increased thirst/polyuria x 3 days. He was apparently kicked
out of his sober house and did not have access to his
medications. He reports then going on an EtOH and drug binge,
whereby he consumed "a couple bottles" of vodka and a "gram or
two" of cocaine each day. He also takes suboxone for prior
heroin abuse, but did not take it during this time given
inability to access home medications. On day 3 of this binge he
presented to the [**Hospital1 18**] ED with glucose levels >700s.
.
In the ED, initial VS afebrile HR 91, BP 112/72 RR 14 SaO2
100% RA. He was a/ox2 to person and place but not date. Labs
notable for an anion gap of 23, as well as hyperkalemia to 6.4
with peaked T-waves on EKG, normal QRS. He received calcium
gluconate, IVF, kayexalate, albuterol, an bicarbonate with
improvement of K to 4.2. He was transferred to the MICU where
he was placed on an insulin gtt with improvement of his serum
glucose and lowering of anion gap to 5. He was initially
lethargic in the MICU but gradually became more interactive; he
was able to tolerate po intake without nausea/vomiting and was
transitioned to subcutaneous insulin.
.
Upon transfer to the floor, the patient continues to feel "worn
out" but denies headache, n/v/d, abdominal pain, fevers, chills,
vision changes, chest pain, dyspnea, polyuria.
.
Past Medical History:
# Type 1 diabetes (followed at [**Last Name (un) **])
# Chronic Hepatitis C (referred to Liver Center)
# Polysubstance abuse
-- heroin overdose in [**2177**], [**2181**], has been on suboxone provided
by [**Hospital 1680**] Hospital, Dr. [**Last Name (STitle) 93335**]; last used a few months ago
-- alcohol abuse (drinks vodka), does not report history of DTs
-- active cocaine use (last use prior to this admission)
-- percocet/painkillers (last use a few months ago)
# Bipolar disorder
-- History of suicide attempts (cutting, drug OD)
# Cardiac cath in [**2189**] with non-obstructive coronary disease
-- (thought to be cocaine-induced)
# Depression
# Dyslipidemia
# s/p appendectomy
Social History:
Recently kicked out of sober house for relapses. Previously
lived with girlfriend of 6 years, [**Doctor Last Name 1060**], but had period of
homelessness s/p an altercation with her. Has a 9 year old
daughter. Previously worked in construction, currently
unemployed. Active cocaine use ([**2-12**] grams per day prior to
admission). On suboxone for heroin abuse history. EtOH abuse.
Smokes cigarettes only when drinking.
Family History:
Both parents were alcoholics.
Brother is recovering alcoholic.
Father died of liver cancer.
Physical Exam:
PHYSICAL EXAM AT ADMISSION:
VS - Temp 98.2 F, BP 108/60, HR 67, R 18, O2-sat 97% RA
GENERAL - Lethargic man in NAD, appropriate, eyes closed while
talking, falls asleep mid-sentence
HEENT - NC/AT, PERRLA 3-->2 mm bilaterally, EOMI, sclerae
anicteric, MM dry, OP clear
NECK - supple, no thyromegaly, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, two tattoos on each upper arm
LYMPH - no cervical LAD
NEURO - A&Ox3, CNs II-XII grossly intact, muscle strength 5/5
throughout, sensation grossly intact throughout
PHYSICAL EXAM AT DISCHARGE:
VS: 97.1, 114/64, 65, 16, 97% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN +tattoos. no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-14**] throughout, sensation grossly intact throughout, steady gait
Pertinent Results:
Labs On Admission:
[**2192-4-4**] 02:35PM BLOOD WBC-5.5# RBC-4.89 Hgb-14.4 Hct-44.7
MCV-91 MCH-29.4 MCHC-32.2 RDW-13.9 Plt Ct-173
[**2192-4-4**] 02:35PM BLOOD Neuts-84.3* Lymphs-10.8* Monos-4.0
Eos-0.6 Baso-0.4
[**2192-4-4**] 02:35PM BLOOD PT-12.7 PTT-23.6 INR(PT)-1.1
[**2192-4-4**] 02:35PM BLOOD Glucose-748* UreaN-22* Creat-1.4* Na-125*
K-6.4* Cl-85* HCO3-17* AnGap-29*
[**2192-4-4**] 02:35PM BLOOD ALT-43* AST-32 AlkPhos-99 TotBili-0.7
[**2192-4-4**] 02:35PM BLOOD Lipase-13
[**2192-4-4**] 02:35PM BLOOD cTropnT-<0.01
[**2192-4-4**] 02:35PM BLOOD Albumin-4.5 Calcium-9.4 Phos-4.6* Mg-2.5
[**2192-4-4**] 09:14PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-4-4**] 02:37PM BLOOD Glucose-GREATER TH Lactate-1.6 Na-127*
K-6.4* Cl-85* calHCO3-17*
.
Other Relevant Labs:
[**2192-4-5**] 10:03AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.033
[**2192-4-5**] 10:03AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-50 Bilirub-NEG Urobiln-1 pH-6.0 Leuks-NEG
.
Labs On Discharge:
[**2192-4-7**] 07:05AM BLOOD WBC-3.3* RBC-3.96* Hgb-11.5* Hct-34.4*
MCV-87 MCH-29.0 MCHC-33.4 RDW-14.1 Plt Ct-131*
[**2192-4-7**] 07:05AM BLOOD Glucose-131* UreaN-12 Creat-0.7 Na-134
K-4.0 Cl-103 HCO3-28 AnGap-7*
[**2192-4-7**] 07:05AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.0
.
.
Imaging / Studies:
# CHEST (PORTABLE AP) ([**2192-4-4**] at 3:54 PM):
FINDINGS: Single frontal view of the chest was obtained. Lungs
are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. Cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION: No acute cardiopulmonary process.
.
# ECG ([**2192-4-4**] at 2:17:34 PM):
Sinus rhythm. Normal tracing. Compared to the previous tracing
of [**2191-8-24**] no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
73 164 86 [**Telephone/Fax (2) 93338**] 67
.
Brief Hospital Course:
The patient is a 42 year old man with a history of Type 1 DM,
polysubstance abuse, chronic HCV, and bipolar disorder who
presented with DKA after being without insulin x 3 days.
# DIABETES/DKA: The patient initially presented with serum
glucose levels >700s and AG=23 metabolic acidosis with urine
ketones, consistent with DKA. Etiology was likely secondary to
poor adherence to insulin, with contribution from active
polysubstance abuse. Infectious etiologies were ruled out. In
the MICU the patient was started on insulin gtt at 0.1 units/kg
[**First Name8 (NamePattern2) **] [**Last Name (un) **] protocol, given IVF, and electrolytes were checked
every 3 hours. By the morning after admission, the patient's
anion gap had closed. He was transferred onto the medicine
floor on subcutaneous insulin. On the floor his glucose levels
came down from the mid-200s and remained stable in the mid-100s.
His electrolytes were checked [**Hospital1 **] with repletion as needed. He
was continued on IV fluids and tolerated a regular diabetic
diet. At discharge the patient appeared euvolemic on exam with
stable electrolytes (K 4.0, Ca 8.1, Mg 2.0, P: 3.7).
.
# LETHARGY: The patient was initially lethargic in the MICU,
thought to be secondary to toxic ingestion although Utox
negative. Infectious etiologies for lethargy were ruled out
given lack of fever/leukocytosis, and a nonfocal neuro exam. On
transfer he was alert and oriented x 3 with mental status much
improved. Lethargy resolved on the floor.
.
# HYPERKALEMIA: Hyperkalemia 6.2 resolved with kayexalate,
calcium gluconate and insulin. On transfer K was 4.1, no peaked
T waves seen on EKG. His potassium was repleted on the floor,
along with other electrolytes, to good effect. On discharge K
was 4.0.
.
# POLYSUBSTANCE ABUSE: The patient has a history of
polysubstance abuse including cocaine, narcotics and EtOH but
has no known history of DTs or withdrawal seizures. He endorsed
active cocaine and EtOH use prior to this admission, although
urine tox was negative in the ED. He was placed on CIWA and
closely monitored. Although he endorsed some anxiety and
tremulousness, he did not trigger the CIWA scale during his
stay. He received 0.5 mg lorazepam once for anxiety. Both the
medicine and MICU teams attempted to reach his prescribing
psychiatrist, Dr. [**Last Name (STitle) 14611**] at [**Hospital 1680**] Hospital for confirmation of
home dose of suboxone. These efforts were met without success
and the patient received suboxone 8mg/2mg during this
hospitalization.
# HOMELESSNESS: Social work was consulted to assess the
patient's living situations in the context of his recent
homelessness. He refused social work help for placement at a
sober house and was discharged on his own [**Location (un) **] to a friend's
house in [**Hospital3 **].
.
# DEPRESSION: His home Buproprion was initially held in the MICU
due to concern for seizure risk in the setting of possible
withdrawal. On the floor this medication was restarted
successfully. He denied any active suicidal or homicidal
ideation.
.
# BIPOLAR DISORDER: He was kept on his home dose of Quetapine
throughout his stay with no active bipolar symptoms.
.
# CHRONIC HEPATITIS C: The patient's LFTs were stable during
this hospitalization. He is seen by his PCP for chronic
hepatitis C and was also referred to the Liver Center where he
will receive outpatient follow-up.
.
# HYPERLIPIDEMIA: He was kept on his home statin during this
hospitalization.
.
LABS/STUDIES PENDING AT DISCHARGE:
-- Blood cultures x 2 ([**2192-4-4**])
-- MRSA screen ([**2192-4-4**])
.
TRANSITIONAL CARE ISSUES:
-- None
Medications on Admission:
buprenorphine-naloxone 8 mg-2 mg 1 tablet sublingual TID
buproprion hcl 100 mg tablet po qhs
insulin glargine - 100 unit/mL - 26 units qHS
insulin lispro - 100 unit/mL - sliding scale
quetiapine 100 mg po qhs
simvastatin 20 mg po qPM
aspirin 81 mg daily
multivitamin daily
Discharge Medications:
1. buprenorphine-naloxone 8-2 mg Tablet, Sublingual Sig: One (1)
Tablet Sublingual TID (3 times a day).
2. bupropion HCl 100 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO at bedtime.
3. quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
8. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: Before meals and at bedtime
according to sliding scale.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Diabetic Ketoacidosis
Diabetes Mellitus Type 1
Polysubstance Abuse
Secondary Diagnoses:
Chronic Hepatitis C
Bipolar Disorder
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital after presenting with
dangerously high glucose levels in your blood (diabetic
ketoacidosis). This was most likely due to your missed insulin
doses. You were admitted to the medical intensive care unit
where you received IV fluids and insulin. We also corrected the
levels of potassium, magnesium, and phosphate in your blood.
You improved with these treatments and were transferred to the
medical floor. Your glucose levels came down and were stable
for the remainder of your stay. Your mental status also improved
and you became more alert and awake during the course of your
hospitalization.
While in the hospital, you received your home suboxone dose. We
did not make any changes to your home medications. Please
continue to take them as previously prescribed.
You will need a follow-up appointment with your PCP soon after
discharge. The details are below.
Followup Instructions:
You will need a followup appointment with your PCP, [**Name10 (NameIs) **] [**Known firstname 449**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] after discharge. You should call on Monday
to schedule this appointment. His office can be reached at
[**Telephone/Fax (1) 250**].
You also have the following appointments at [**Hospital1 18**] in the near
future.
Department: ORTHOPEDICS
When: FRIDAY [**2192-4-20**] at 10:45 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2571
} | Medical Text: Admission Date: [**2122-9-3**] Discharge Date: [**2122-9-10**]
Date of Birth: [**2059-1-8**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Motrin / Nsaids / Aspirin / Dilantin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
62yo F w/ a PMH of ESRD on HD s/p failed kidney transplant, DVT
(associated w/ HD cath), and HTN who presents to the ED today
after being found on her neighbors stoop confused and apparently
topless. History is primarily taken from EMS reports as the
patient recalls little of the event. Apparently she was feeling
her usual self when she went to HD today. She remembers the ride
home but she states she got off at the wrong street. The next
thing she remembers was being evaluated by EMS. Of note, her FS
was apparently 69 in the field but she is not taking insulin
currently. No history of incontinence, tongue laceration, injury
or LOC. It is not clear how long she was unattended prior to
being found. She had a similar presentation in [**1-13**] with
question of seizure activity but was eventually thought not to
be having seizures. Also reports blood in her urine last night,
and abdominal pain. Reports occasionaly missing her medications,
but always taking her statin and coumadin. Recent change in
coumadin from 5 to 7mg.
In the ED her vitals were 97.6, 108, 200/100, 100% RA. FS was in
100s on arrival. She received 5mg IV and 100mg PO of metoprolol
which slowed her rate and lowered her BP to more appropriate
levels. She did have episodes of sinus tach up into the 130s
during EJ placement attempts. However, this resolved prior to
transfer. She was evaluated by neurology in the ED who felt that
she was primarily encephalopathic without focality but could not
rule out a seizure.
Past Medical History:
1. Diabetes mellitus.- unclear hx, not on medication, nl [**Name (NI) **]
2. End-stage renal disease secondary to diabetes mellitus s/p
failed dual kidney transplant
3. Hemodialysis.
4. Hypertension.
5. Hyperlipidemia.
6. Thrombosis of bilateral IVJ (catheter placement)-- DVT
associated with HD catheter RUE on anticoagulation
7. SVC syndrome [**1-13**], s/p thrombectomy, on anticoagulation,
hospitalization complicated by obturator hematoma and required
intubation, PEG and Trach with VAP, and questionable seizure
8. Currently, in hemodialysis.
9. Osteoarthritis.
10. Arthritis of the left knee at age nine, treated with ACTH
resulting in secondary [**Location (un) **].
11. rheumatic fever as child
12. Afib with RVR
Past Surgical History:
1. Kidney transplant in [**2119**].
2. Left arm AV fistula for dialysis.
3. Removal of remnant of AV fistula, left arm.
4. Catheter placement for hemodialysis.
5. Low back surgery (unspecified)
Social History:
-lives with her nephew [**Name (NI) **], but does not know his number
-Brother is HCP
-[**Name (NI) 1139**]: 10pkyr [**Name2 (NI) 1818**], recently quit but states that she has
restarted and smoking 5 cigs per day
-denies etoh/illicits
Family History:
Mother and sister with diabetic mellitus.
Kidney failure in mother, sister
Physical Exam:
VS: 96.7, 155/84, 83, 20, 98%RA
GEN: Well appearing, NAD
HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema
or exudate
NECK: Supple, no LAD, no appreciable JVD
CV: RRR, normal S1S2, systolic murmur at lower sternal border,
no rubs or gallops, 2+ pulses
PULM: CTAB, no w/r/r, good air movement bilaterally
ABD: Soft, ND, mild suprapubic tenderness without rebound or
guarding, normoactive bowel sounds, no organomegaly, no
abdominal bruit appreciated
EXT: Warm and well perfused, full and symmetric distal pulses,
no pedal edema
NEURO: AOx2, trouble with date. Memory [**1-8**] at 2min. Language
fluent. Strength 5/5 in all extremities. Sensation intact to
light touch diffusely. DTRs 2+ bilaterally in patella and
biceps, toes down going. Gait deferred. Seems confused about her
history
Pertinent Results:
[**2122-9-3**] 01:50PM BLOOD WBC-8.7 RBC-3.84*# Hgb-12.5# Hct-37.0
MCV-96 MCH-32.5* MCHC-33.8 RDW-15.5 Plt Ct-254#
[**2122-9-10**] 07:59AM BLOOD WBC-9.2 RBC-4.33 Hgb-14.1 Hct-42.7
MCV-99* MCH-32.5* MCHC-33.0 RDW-15.4 Plt Ct-451*
[**2122-9-3**] 02:46PM BLOOD PT-17.1* PTT-28.0 INR(PT)-1.6*
[**2122-9-10**] 07:59AM BLOOD PT-22.3* INR(PT)-2.1*
[**2122-9-3**] 01:50PM BLOOD Glucose-88 UreaN-15 Creat-4.9* Na-140
K-3.9 Cl-97 HCO3-28 AnGap-19
[**2122-9-8**] 07:45AM BLOOD Glucose-88 UreaN-60* Creat-12.2*# Na-139
K-4.0 Cl-97 HCO3-22 AnGap-24
[**2122-9-10**] 07:59AM BLOOD Glucose-199* UreaN-47* Creat-9.7*# Na-139
K-4.0 Cl-92* HCO3-26 AnGap-25*
[**2122-9-3**] 01:50PM BLOOD ALT-13 AST-16 AlkPhos-58 TotBili-0.5
[**2122-9-3**] 01:50PM BLOOD Calcium-10.1 Phos-3.8 Mg-1.9
[**2122-9-10**] 07:59AM BLOOD Calcium-9.7 Phos-7.0* Mg-2.3
[**2122-9-7**] 07:30AM BLOOD VitB12-1032* Folate-GREATER TH
[**2122-9-7**] 07:30AM BLOOD TSH-1.2
[**2122-9-4**] 05:40AM BLOOD PTH-401*
[**2122-9-3**] 01:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2122-9-3**] 07:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005
[**2122-9-3**] 07:30PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2122-9-3**] 07:30PM URINE RBC-0-2 WBC-[**6-16**]* Bacteri-FEW Yeast-NONE
Epi-[**11-26**]
[**2122-9-4**] 01:30AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
Urine cx ([**9-3**], [**9-4**], [**9-6**]): mixed flora consistent with
contamination
Blood cx ([**9-4**]): 2 negative, 1 NGTD
Cdiff ([**9-6**]): negative
CXR [**2122-9-3**]:
IMPRESSION: No evidence of acute cardiopulmonary process
Head CT without Contrast [**2122-9-3**]:
IMPRESSION: No hemorrhage or acute edema.
EEG [**2122-9-4**]:
IMPRESSION: This is an abnormal routine EEG due to the slow
background,
generalized bursts of slow activity, and multifocal slow
transients with
triphasic features. These findings suggest a widespread
encephalopathy
afecting both cortical and subcortical structures. Medications,
metabolic disturbancies and infections are among the most common
causes.
There were no lateralized or epileptiform features noted.
Abdominal CT with contrast [**2122-9-4**]:
IMPRESSION: No evidence of abdominal inflammatory process, or
other specific CT finding to explain abdominal pain.
Head CT without Contrast [**2122-9-6**]: (prelim)
Limited study, despite being repeated, no acute intracranial
hemorrhage
appreciated.
MRI Head without contrast [**2122-9-7**]:
CONCLUSION: No definite interval change in the appearance of the
brain
compared to the prior study.
Brief Hospital Course:
1) Altered mental status: Pt with similar presentations in the
past. Labs to evaluate for a toxic-metabolic cause were
unrevealing. She was initially treated with Cipro for a
suspected UTI, but stopped on day 2 as this drug can lower the
seizure threshold and urine grew mixed flora. Head imaging with
CT and MRI was unrevealing. EEG showed generalized slowing. On
the morning of [**9-5**] during her HD treatment, she became very
agitated, confused, and then unresponsive. Her arms were
clutched to her chest in fists and her eyes were deviated to the
left. She was given 1 mg of Ativan and remained disoriented and
somnolent, presumably postictal. Of note, she was also dialyzed
earlier on the day of admission. Neurology was consulted and
felt her presentation was due to fluid and electrolyte shifts
with HD and recommended [**Date Range 13401**] for her apparent seizure.
Dilantin was avoided due to prior drug related angioedema. She
remained confused and agitated, and her somnolence increased.
She was vomiting and minimally responsive to sternal rub. She
was transferred to the MICU for observation, received IV haldol
for agitation, and was called out the next day as she remained
stable. She subsequently received HD two more times with no
adverse reaction. Her mental status improved and she was A&Ox3
at discharge, although likely with some chronic cognitive
deficits. Her sertraline was held during this admission as well
as on discharge, and can be addressed as an outpatient.
2) ESRD on HD: She was continued on her Tu/Th/Sat HD schedule.
She was continued on nephrocaps and cinacalcet and started on
sevelamer.
3) History of DVT/SVC syndrome: Her INR was initially
subtherapeutic at 1.6 and she was bridged on a heparin drip.
With warfarin 5mg daily, it improved to 1.9. However, her
heparin and warfarin were held when her mental status
deteriorated. Once CT head showed no bleed, her heparin was
continued. When decision was made to not perform LP, her
warfarin was restarted and heparin was stopped due to a
therapeutic INR of 2.2.
Medications on Admission:
ATORVASTATIN - 20 mg by mouth once a day
B COMPLEX-VITAMIN C-FOLIC ACID 1 Capsule(s) by mouth once a day
CINACALCET 90 mg by mouthonce a day
DARBEPOETIN ALFA IN POLYSORBAT - 40 mcg/mL Solution - once per
week weekly
LISINOPRIL - 5 mg by mouth daily
METOPROLOL TARTRATE - 100 mg by mouth daily
SERTRALINE 100 mg by mouth hs
WARFARIN - - 7 mg by mouth once a day
Tylenol 3 PRN pain
Discharge Medications:
1. Levetiracetam 250 mg Tablet [**Date Range **]: One (1) Tablet PO QHD (each
hemodialysis).
Disp:*12 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Date Range **]: One (1) Cap
PO DAILY (Daily).
4. Atorvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
5. Darbepoetin Alfa In Polysorbat 40 mcg/0.4 mL Pen Injector
[**Date Range **]: One (1) Subcutaneous once a week.
6. Lisinopril 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
7. Levetiracetam 250 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Sevelamer HCl 800 mg Tablet [**Date Range **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): Take with meals.
Disp:*90 Tablet(s)* Refills:*2*
9. Cinacalcet 90 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
10. Warfarin 5 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Warfarin 2 mg Tablet [**Date Range **]: One (1) Tablet PO once a day: Take
at same time as 5mg pill.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Caregroup
Discharge Diagnosis:
Primary: Altered mental status, seizure history
Secondary: End stage renal disease, status post renal transplant
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with confusion. This occurred after
your dialysis. It is possible that you had a seizure during your
confusion. It is not clear what caused the confusion, but it has
improved greatly, with no problems after your last dialysis.
Please take all medications as prescribed and go to all follow
up appointments. We are holding your sertraline (Zoloft) for now
as this might have contributed to your confusion. We have
started you on [**Last Name (LF) **], [**First Name3 (LF) **] antiseizure medication, with
assistance from the neurologists. We are also starting
sevelamer, a medication to help your electrolytes. Note that you
should take your metoprolol twice daily.
If you experience any confusion, seizures, weakness, fevers, or
any other concerning symptoms, please seek medical attention or
come to the ER immediately.
Followup Instructions:
Primary Care: Dr. [**Last Name (STitle) **], ([**Telephone/Fax (1) 45314**], Wed [**9-16**], 1pm
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2122-10-16**] 2:00
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **], Neurology Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2122-11-10**] 4:30
Completed by:[**2122-9-10**]
ICD9 Codes: 5856, 5990, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2572
} | Medical Text: Admission Date: [**2171-11-22**] Discharge Date: [**2171-11-29**]
Date of Birth: [**2119-6-25**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: [**Known firstname 449**] [**Known lastname 4643**] is a
52-year-old male patient who was admitted to [**Hospital6 31672**] on the morning of [**2171-11-22**] with the
complaint of new onset of chest pain. He was being rule out
for myocardial infarction, and he was ultimately ruled out.
He was transferred here to [**Hospital1 188**] later that day for definitive treatments of unstable
angina.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus.
2. Diabetic neuropathy.
3. Diabetic retinopathy.
4. The patient has had four episodes of pancreatitis, most
recently in [**Month (only) 547**] of the year [**2169**].
5. He is status post laser treatment to his right eye. He
is status post cataract removal.
6. He is status post femur fracture.
7. The patient also admits to significant alcohol intake
daily.
8. Hypertension.
9. Hypercholesterolemia.
10. Smoker.
SOCIAL HISTORY: The patient is a smoker.
ALLERGIES: The patient states that he has an allergy to
ETHER.
MEDICATIONS:
1. Insulin 70/30, 10 units subcutaneously q.a.m. and q.p.m.
2. Glucotrol 20 mg p.o.q.d.
3. Lipitor 10 mg p.o.q.d.
4. Timoptic eye drops 0.5% to the right eye t.i.d.
5. Alphagan 0.2% to the right eye t.i.d.
6. Trusopt 2% to the right eye as well t.i.d.
7. The patient takes Naprosyn p.r.n. neuropathy pain.
From the outside hospital, the following medications were
added:
1. Aspirin 325 mg p.o.q.d.
2. Lovenox.
3. Lopressor.
4. Nitroglycerin paste.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: Well-developed male in no acute distress. Vital
signs were stable on admission. Neck was unremarkable.
Lungs were clear to auscultation, diminished bilateral bases.
Heart revealed S1 and S2 with positive S3 and negative
murmur. Abdomen was obese and benign. Femoral pulses are 2+
bilaterally. He had no peripheral edema.
HOSPITAL COURSE: The patient was taken to the Cardiac
Catheterization Laboratory, where he was found to have
significant three-vessel coronary artery disease, as well as
a left ventricular ejection fraction of 55%. He was taken to
the operating room later in the day, [**2171-11-22**]. He
underwent coronary artery bypass grafting times three with a
LIMA to the LAD, saphenous vein to the OM, saphenous vein to
the RCA by Dr. [**Name (NI) **]. Postoperatively, the patient was
transported from the operating room to the cardiac surgery
recovery unit on IV Neo-Synephrine drip. The patient was
also started on an insulin drip due to hyperglycemia. The
patient was weaned from mechanical ventilator and extubated
early in the day on postoperative day #1. The patient
remained hemodynamically stable on the Neo-Synephrine drip.
On postoperative day #2, the patient had been weaned off the
Neo-Synephrine. Blood pressure had been stabilized. He had
been started on some diuretic, as well as Lopressor. The
insulin drip had been discontinued. The patient was
transferred to the telemetry floor on postoperative day #2.
Over the next few days, the patient had a low of discomfort
with any physical activity, and he was very slow to progress
with cardiac rehabilitation. He also had some troubles with
elevated blood glucose, requiring sliding scale insulin
coverage as well as routine doses of 70/30 insulin. The
patient was also somewhat anemic with a hematocrit of 22.3 to
the 22.7 range. However, this was stable. He remained
hemodynamically stable. The patient remained very slow to
progress from the physical therapy standpoint. Today,
postoperative day #7, physical therapy evaluation felt that
he is at a level 5 and stable to be discharged home today.
[**Hospital **] Clinic consultation was obtained due to his continued
requirement for increased insulin doses in addition to his
baseline coverage and his insulin regimen has been changed
per the [**Hospital **] Clinic consultation.
CONDITION ON DISCHARGE: The patient's condition today,
[**11-22**], is as follows: Temperature 98.9, pulse 72,
respiratory rate 18, blood pressure 118/56. Room air oxygen
saturation is 98 percent. Most recent laboratory values
include a hematocrit of 22.7 on [**2171-11-28**], as well
as potassium of 4.6, BUN 22, creatinine 0.9, also from
[**11-28**].
The patient's chest x-ray is still pending at this point from
today.
PHYSICAL EXAMINATION: NEUROLOGICAL: The patient is alert
and oriented with no apparent deficits. PULMONARY: Lungs
were clear to auscultation bilaterally. CORONARY
EXAMINATION: Regular rate and rhythm. ABDOMEN: Obese and
benign. Sternum stable. Sternal incision clean, dry, and
intact. EXTREMITIES: Extremities are warm with no
peripheral edema noted. Incision in his leg is clean, dry,
and intact.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o.b.i.d.
2. Potassium chloride 20 mEq p.o.q.d.
3. Lopressor 25 mg p.o.b.i.d.
4. Colace 100 mg p.o.b.i.d.
5. Zantac 150 mg p.o.b.i.d.
6. Enteric coated aspirin 325 mg p.o.q.d.
7. Dilaudid 2 to 4 mg p.o.q.6h. p.r.n. pain.
8. Ferrous sulfate 325 mg p.o.t.i.d.
9. The patient's eye drops, which are unchanged from his
preoperative drops and insulin is NPH insulin 10 units
subcutaneously q.a.m. and 8 units subcutaneously q.h.s. as
well as a sliding scale regular insulin subcutaneously before
breakfast and before dinner only with the sliding scale as
follows: 0 to 50 for a blood sugar equal 0 units; 51 to 100
equals 1 unit; 101 to 150 equals 2 units; 151 to 200 equals 3
units; 201 to 250 equals 4 units; 251 to 300 equals 5 units;
301 to 350 equals 6 units; and 351 to 400 equals 7 units.
10. Glucotrol 20 mg p.o.q.d.
The patient is to be discharged home today. The patient is
to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28191**] in one month. He is to
followup with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4640**]
in four weeks. He is also to followup with
Dr. [**Known firstname 449**] [**Last Name (NamePattern1) 1295**], primary cardiologist in three to four
weeks.
DISCHARGE DIAGNOSIS: Coronary artery disease.
DISCHARGE CONDITION: Stable.
[**First Name8 (NamePattern2) 412**] [**Last Name (NamePattern1) **], MD [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2171-11-29**] 12:14
T: [**2171-11-29**] 12:17
JOB#: [**Job Number 31673**]
ICD9 Codes: 4111, 3572, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2573
} | Medical Text: Admission Date: [**2129-3-5**] Discharge Date: [**2129-3-8**]
Date of Birth: [**2061-12-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
HEADACHES AND CONFUSION
Major Surgical or Invasive Procedure:
Craniotomy with evacuation SDH
History of Present Illness:
HPI: 67 y/o female in previous state of good health until
[**2129-3-3**]
when she started experiencing headaches and mild weakness on her
right arm/leg. She denies any fall or head trauma, but head CT
from outside hospital showed 18mm thick left frontal subdural
hematoma with approximately 12mm of midline shift. The
collection appears subacute/chronic in nature. She was
transferred to [**Hospital1 18**] ER for neurosurgical evaluation.
Past Medical History:
PMHx:
hypothyroidism
PSHx:
skin grafts age 36
Social History:
Social Hx:
denies tobacco, EtOH, and IVDU
Family History:
Family Hx:
noncontributory
Physical Exam:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-13**] bilaterally EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date but periodic
confusion which has increase over the past 6 - 12 hours per
family.
Recall: [**1-13**] objects at 5 minutes.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-16**] on left side, right arm 4-/5
biceps/triceps, deltoids; right leg - [**4-16**]
quads/hams/iliopsoas/gastroc.
Right sided pronator drift
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
ON DISCHARGE - NEURO EXAM NON FOCAL
INCISION CLEAN AND DRY
Pertinent Results:
CT/MRI:
head CT: 18mm thick left frontal subdural hematoma with
approximately 12mm of midline shift. The collection appears
subacute/chronic in nature.
[**2129-3-5**] 11:00AM GLUCOSE-106* UREA N-17 CREAT-1.1 SODIUM-142
POTASSIUM-5.3* CHLORIDE-106 TOTAL CO2-26 ANION GAP-15
[**2129-3-5**] 11:00AM WBC-7.5 RBC-4.08* HGB-13.4 HCT-38.5 MCV-94
MCH-32.8* MCHC-34.8 RDW-12.2
[**2129-3-5**] 11:00AM NEUTS-80.0* BANDS-0 LYMPHS-15.6* MONOS-3.2
EOS-1.0 BASOS-0.2
[**2129-3-5**] 11:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2129-3-5**] 11:00AM PLT SMR-NORMAL PLT COUNT-208
[**2129-3-5**] 11:00AM PT-12.4 PTT-21.8* INR(PT)-1.0
Brief Hospital Course:
Pt was admitted to the neurosurgical service for left sdh. She
was brought to the OR for evacuation emergently. Pt underwent
the procedure and awoke from anesthesia without complication.
She was transferred to a regular floor and seen by PT OT. She
was deemed safe for d/c home. Her dilantin will continue until
follow up. Pt agrees with plan for discharge home. She is
tolerating po/voiding freely and passing flatus.
Medications on Admission:
Medications prior to admission:
evista 60mg po qd
xanax 1mg po prn
levoxyl 75mcg po qd
aspirin 81 mg po qd
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed: DO NOT DRIVE OR OPERATE HEAVY
MACHINERY WHILE TAKING THIS MEDICATION.
Disp:*40 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
MAKE SURE YOU TAKE THIS MEDICATION WHILE TAKING NARCOTICS TO
AVOID CONSTIPATION.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? you have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing as
ordered
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE RETURN TO YOUR PRIMARY CARE OFFICE BY [**2129-3-18**] AT THE
LATEST / NO SOONER THAN TH [**2129-3-15**] / REMEMBER TO BRING YOUR SKIN
STAPLER REMOVER TO THAT OFFICE VISIT.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2129-3-7**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2574
} | Medical Text: Admission Date: [**2133-3-4**] Discharge Date: [**2133-3-12**]
Date of Birth: [**2059-1-24**] Sex: M
Service: SURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Type I endoleak, rupture
Major Surgical or Invasive Procedure:
[**3-4**]: endo repair of ruptured AAA w occlusion of L iliac and
R-->L fem-fem bypass
History of Present Illness:
Mr. [**Known lastname 39719**] is a 74-year-old gentleman who underwent
endovascular triple A repair in [**2129**] and failed to comply with
follow-up CT angiograms. He was
admitted to [**Hospital1 **]-[**Hospital1 **] 1 month ago requiring coronary artery
bypass graft and, at that time, underwent CTA which revealed
migration of his Endograft with a large type 1 proximal endo
leak. He was scheduled for elective repair in
endovascular fashion for next week. However, presented to his
local hospital this evening with abdominal pain and evidence on
non-contrast CT for aneurysm rupture. He was transferred to
[**Hospital1 18**] for treatment.
Past Medical History:
Coronary Artery Disease
Mitral Regurgitation
Heart Failure (systolic)
Paroxysmal Atrial Fibrillation
Renal Insufficiency
Peripheral Vascular disease
Hypertension
Chronic Anemia
AAA s/p Endovascular stent [**2129**]
Myocardial Infarction [**2109**]
Gout
Osteoathritis
Venous ligation
GI bleeding
Social History:
retired, worked in plastics factory,
Married lives with spouse
[**Name (NI) 1139**] - quit 25 years ago, 80 pack year history
Denies ETOH
Family History:
Brother and mother deceased from [**Last Name **] problem
Physical Exam:
98.6, 120/70, 57, 99%RA (Uses O2 at night for comfort)
GEN: NAD
CARDs: RRR
Lungs: CTA
ABD: soft, +BS
Neuro: A+OX3
EXT: no edema
Pulses B/L DP/PT dop
Pertinent Results:
[**2133-3-11**] 08:55AM BLOOD WBC-9.9 RBC-3.58* Hgb-9.8* Hct-30.8*
MCV-86 MCH-27.5 MCHC-31.9 RDW-15.4 Plt Ct-242
[**2133-3-11**] 08:55AM BLOOD Plt Ct-242
[**2133-3-11**] 08:55AM BLOOD Glucose-43* UreaN-27* Creat-1.7* Na-137
K-3.8 Cl-104 HCO3-24 AnGap-13
[**2133-3-11**] 08:55AM BLOOD Calcium-8.1* Phos-1.6* Mg-2.1
Brief Hospital Course:
Patient transferred from OSH directly to [**Hospital1 18**] OR and underwent
Endovascular repair of ruptured abdominal aortic aneurysm using
aorta uni-iliac graft (Zenith 32 x125) with occlusion of the
contralateral left iliac artery( 18 mm [**Doctor Last Name 4726**] Excluder) and
subsequent right to left fem-fem bypass graft with 8mm ringed
PTFE.
Extension right CIA with 18X 54 Zenith limb.
Patient remained intubated and transferred to ICU for
management.
Renal consulted for Acute on chronic RF. Cr 3.6 (baseline 3.0).
POD 2- Extubated, afebrile, Pain controlled with Dilaudid. B/L
DP/PT pulses.
POD [**2-8**]- Transferred to vascular unit. VSS. B/L groins C/D/I,
Foley draining dk urine. Cr 2.4. Renal following,
ATN/prerenal-resolving.
POD [**4-12**]- VSS. Physical therapy consulted. Non contrast CT
obtained showing good placement of graft. Patient with CP-
relieved with Nitro. ECG/Enzymes negative.
Cr 2.1. Tolerating diet. No diet or fluid restrictions. Coumadin
restarted at his home dose.
POD7 VSS, Lungs with rales. Chest X-ray showing small pleural
effusion. No CHF, no pneumonia. Lasix given. Foley d/ced. Rehab
referral for discharge to rehab.
POD8 No overnight events. VSS. Cr 1.7. Patient incontinent of
urine. UA sent. Lungs clear. Transfer to rehab when bed
available.
Medications on Admission:
aspirin 81', Metoprolol 37.5"', Isosorbide Mononitrate 30',
Nitroglycerin 0.4mg tab PRN, Ambien 5mg PRN, atrovent, percocet,
renagel 800"', amiodarone 200', flovent", colace 100", mucinex
600", famotadine 20", coumadin 1'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): D/C when INR therapeutic.
2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q6H (every 6 hours) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for Pain.
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): Hold HR<60.
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
13. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
14. Follow blood sugars
Hypoglycemia
Follow BS 3-4X per day
15. Labwork
Follow INR, CBC, electrolyte panel weekly/prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] health care
Discharge Diagnosis:
Type I endoleak, rupture
[**3-4**]: endo repair of ruptured AAA w occlusion of L iliac and
R-->L fem-fem bypass
PMH: MI, gout, OA, CAD, HTN, AF, CRI, anemia
PSH: vv ligation, CABG, EVAR '[**29**], s/p CABGx4(LIMA->LAD,
SVG->PDA, radial to OM1, OM2)/MV repair [**2133-2-4**]
Discharge Condition:
Good. Cr 1.7. HCT 30.8
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**1-10**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-13**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] CARDIAC SURGERY LMOB 2A Date/Time:[**2133-3-18**]
1:15
You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2133-4-7**] at
815am. You will have an ultrasound at this visit. Do not eat or
drink for 6 hours prior to visit/ultrasound. Call [**Telephone/Fax (1) 1241**]
with any questions.
Completed by:[**2133-3-12**]
ICD9 Codes: 4240, 5845, 2762, 496, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2575
} | Medical Text: Admission Date: [**2175-8-23**] Discharge Date: [**2175-8-29**]
Date of Birth: [**2100-9-8**] Sex: M
Service: NEUROLOGY
Patient is a 74 year old male with a past medical history of
hypertension, coronary artery disease status post coronary
artery bypass graft, congestive heart failure with known
ejection fraction of 35%, hypercholesterolemia, and atrial
fibrillation status post cardioversion one year ago, not on
Coumadin therapy at the present moment, who presented on
[**2175-8-23**] as a transfer from [**Hospital **] Hospital with weakness,
slurred speech. The patient was transferred to [**Hospital1 346**] for TPA thrombolytic therapy. Here
magnetic resonance scan demonstrated evidence of a right
sided MCA stroke. After obtaining a signed informed consent from
the family, the patient was given 0.9 mg/kg of TPA according to
the DIFFUSE protocol and at 3:30 a.m.
During the initial presentation, he never complained of chest
pain, shortness of breath. After TPA did have improvement of
his left sided facial weakness but was noted to have left
sided hemineglect and hemiparesis which remained severe
status post TPA. He was transferred to the Intensive Care
Unit for further monitoring. On [**2175-8-24**], the patient began
to complain of an episode of chest pain which began that
morning. The pain was described as centered over the left
chest "raking" [**7-9**] in severity, lasting about 30 minutes not
associated with any nausea, vomiting, diaphoresis,
palpitations or shortness of breath. For this pain, the
patient received 2 mg of intravenous morphine and was started
on intravenous nitroglycerin drip. He was also given aspirin
and Plavix. He had his cardiac enzymes including CK and
troponin cycled times three and was ruled out for myocardial
infarction.
At that time he was not heparinized, but he was started on
Coumadin. He was receiving intravenous Metoprolol 10-15 mg
intravenous for heart rate greater than 70 in the
Neurosurgical Intensive Care Unit for rate control of his
atrial fibrillation. He was pain-free on the intravenous
nitroglycerin drip until approximately 9:00 p.m. on [**2175-8-25**].
At that time, he had a recurrent episode of chest pain, same
description lasting minutes, which resolved on its own.
Per the patient's cardiologist, Dr. [**Last Name (STitle) 8421**], the patient has a
history of coronary artery bypass graft performed [**3-/2168**] with
left internal mammary artery to left anterior descending,
saphenous vein graft to right posterior descending artery,
saphenous vein graft to OM-1/diagonal.
Follow-up catheterization on [**2173-3-30**] showed severe three
vessel disease, ejection fraction of 50%, saphenous vein
graft to right posterior descending artery graft occluded,
saphenous vein graft OM-1 graft occluded with diagonal open.
Left internal mammary artery to the left anterior descending
graft was patent at that time.
PAST MEDICAL HISTORY:
1. Status post right middle cerebral artery stroke status
post thrombolytic therapy with TPA in [**8-2**].
2. Coronary artery disease status post coronary artery
bypass graft 7 years ago with left internal mammary artery to
left anterior descending, saphenous vein graft to right
posterior descending artery, saphenous vein graft to
OM-1/diagonal. Follow-up catheterization [**3-30**] with severe
three vessel disease, ejection fraction 50%, saphenous vein
graft to right posterior descending artery occluded,
saphenous vein graft to OM-1 occluded but diagonal open.
Left internal mammary artery to left anterior descending
patent at that time.
3. History of chronic atrial fibrillation status post
cardioversion approximately two years ago. The patient noted
to be in normal sinus rhythm on Cardiology office visit in
[**2175-2-28**]. However, on presentation with his acute stroke
was found to be in atrial fibrillation, not on Coumadin.
4. Hypercholesterolemia.
5. Status post cholecystectomy.
ALLERGIES:
The patient reports allergies to penicillin resulting in
rash.
MEDICATIONS:
1. Sotalol 80 mg p.o. q.d.
2. Atenolol 25 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Norvasc 5 mg p.o. q.d.
5. Isosorbide.
6. Enteric coated aspirin 81 mg p.o. q.d.
SOCIAL HISTORY: The patient denies any smoking. He is
retired from work in advertising.
FAMILY HISTORY: The patient reports positive family history
of coronary artery disease and cancer.
PHYSICAL EXAMINATION: Upon admission, temperature 98.8,
blood pressure 133/70, heart rate 64, oxygen saturation 98%
on room air. General appearance, well developed, well
nourished white male noticeable left sided facial droop, no
acute distress. HEENT examination: Normocephalic atraumatic
with exception of left sided facial droop, mucous membranes
moist. Neck supple, no masses or lymphadenopathy. Carotid
pulses 1+, no carotid bruits. Lungs: Clear to auscultation
bilaterally, no rhonchi, rales, wheezes. Cardiovascular
examination: Irregularly irregular, S1, S2 auscultated, no
murmurs, rubs or gallops. Abdomen: Soft, nontender,
nondistended, positive bowel sounds. Neurological
examination: Mental status alert, oriented to person, place,
month, year, President. Cranial nerves: Left sided facial
droop, left hemianopsia versus visual neglect. Sensory
examination: Positive left sided neglect, his hand was the
examiner's. Coordination: Finger-nose-finger and
heel-to-shin intact on the right. Examination of gait was
deferred. Reflexes: Brachioradialis 1+ bilaterally, biceps
bilaterally, patellar 3+ bilaterally, no ankle jerk reflex is
noted, left sided flexor response equivocal, right sided
withdrew.
LABORATORY: Upon admission showed white blood count 8.1,
hemoglobin 13.7, hematocrit 39, platelets 175. Serum
chemistry showed sodium 139, potassium 3.7, chloride 107,
bicarbonate 26, BUN 17, creatinine 0.9, glucose 126, calcium
9.0. Coagulation profile showed PT 12.6, PTT 30.4, INR 1.12.
Cardiac enzymes showed CK 53, troponin less than 0.10.
Electrocardiogram showed atrial fibrillation with ventricular
response of 65 beats/min.
Magnetic resonance scan showed area of diffusion, swelling
and right MCA in one branch. The vessels were poor flow over
the right MCA and ICA.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. Cerebrovascular accident, the patient was felt to have a
right middle cerebral artery ischemic stroke in the setting
of atrial fibrillation with significant left sided
hemiparesis. While he was outside the FDA approvement of her
TPA he qualified for the DIFUFE study and was consented to a
trial of TPA thrombolysis. He was given TPA without any
complications. Immediately post TPA infusion, he was noted
to have slight resolution of his left sided facial weakness
and asymmetry. However, his dense left sided hemiparesis
remained. He was monitored TPA in the Neurosurgical
Intensive Care Unit for several days. On [**2175-8-25**] follow-up
CT scan showed hemorrhagic transformation of his infarct.
Therefore, aspirin and Coumadin therapy were withdrawn.
Initially he found a swallow evaluation and so nasogastric
tube was placed and he was fed through nasogastric tube per
Nutrition recommendations.
Over the course of the next several days his neurological
status improved somewhat with increased sensation and tone in
his left side. He had follow-up speech swallow evaluation on
[**2175-8-28**] and was able to tolerate soft puree foods, thin
liquids, able to tolerate having his meds crushed in puree
food with the understanding that he would be fed in the bolt
upright position. On [**2175-8-28**], the patient's outpatient dose
of Lipitor was reinstated. On [**2175-8-29**] after discussion with
Neurology staff, he was able to tolerate initiation of
aspirin 81 mg p.o. q.d. In terms of restarting the patient
for anticoagulation on Coumadin in light of his history of
stroke and atrial fibrillation, it was felt that the bleeding
risk and evidence of hemorrhagic transformation on CT was too
great to tolerate the benefit of anticoagulation therapy.
The patient is to have a follow-up head CT performed around
[**2175-9-7**]. Pending results of that CT Neurology to
decide whether initiation of heparin and Warfarin therapy is
appropriate. If after initiation of aspirin therapy, if the
patient has any changes of alertness or left sided weakness a
STAT head CT should be checked.
[**First Name8 (NamePattern2) 1785**] [**Last Name (NamePattern1) 10220**] with coordinate 30 day follow-up magnetic
resonance scan. She can be contact[**Name (NI) **] at [**Telephone/Fax (1) **], as the
patient will need transportation for that magnetic resonance
scan from his rehabilitation facility or other if he goes
home.
At the time of discharge, the patient's neurological status
was that he was alert with fluent speech, mild dysarthria.
He is noted to have left sided facial droop but left facial
sensation was intact. He had some improvement in his left
lower extremity strength, rated [**1-4**]. However, left upper
extremity strength remained 0/5.
2. Coronary artery disease, the patient has a known history
of coronary artery disease status post coronary artery bypass
graft several years ago. In light of his stroke and overall
medical picture it is felt that his chest pain to be managed
medically although there may be an ischemic component to his
chest pain, it was felt that the patient would likely be a
candidate for cardiac catheterization or possible Persantine
MIBI as an outpatient, notably 6-8 weeks status post
cerebrovascular accident and status post his rehabilitation.
Therefore, he is managed medically with beta blocker therapy
which was titrated up by his blood pressure. He is also
started on Ace inhibitor. He was continued on Lopressor and
Imdur. In the interim, symptomatic chest pain should be
managed with sublingual nitroglycerin +/- morphine sulfate as
needed for pain control.
3. History of atrial fibrillation, although the patient had
history of atrial fibrillation status post cardioversion to
normal sinus rhythm several years ago, and was known to be in
normal sinus rhythm on recent outpatient office visit [**2-/2175**]
on presentation to hospital with this event he was noted to
be back in atrial fibrillation. He was not taking Coumadin
for unknown reasons.
4. In light of his cerebrovascular accident possibly
secondary to embolic disease, it was felt important to follow
the patient's atrial fibrillation and perhaps cardiovert him
back to normal sinus rhythm. However, he was unable to be
anticoagulated secondary to the hemorrhagic transformation of
his infarct. Therefore, the patient is to have follow-up CT
scan on [**9-7**] for check of interval change of his infarct
and in regard to its hemorrhagic changes. If it is stable,
Neurology will decide whether the patient is able to tolerate
anticoagulation with Coumadin and heparin. Once his INR is
greater than 2.0, likely would proceed with transesophageal
echocardiogram to rule out embolus or clot and then be loaded
on Amiodarone for chemical cardioversion back into normal
sinus rhythm. Pending this process, the patient will be rate
controlled with beta blocker therapy.
5. Urinary tract infection. The patient complained of
abdominal pain on the morning of [**2175-8-22**]. Urinalysis at
that time was suggestive of urinary tract infection.
Therefore, he was started on Levofloxacin 250 mg p.o. q.d.
At the time of discharge he will have one remaining day of
therapy to complete a 3 day course.
6. Hyperglycemia. Although the patient has no history of
diabetes per se it was noted during his hospitalization that
he had elevated blood glucose levels. In order to provide
the tightest glucose control, he was monitored on q.i.d.
finger sticks and Regular insulin sliding scale.
7. Activity level. The patient was evaluated by both
Physical Therapy and Occupational Therapy status. He is felt
to be a good candidate for outpatient rehabilitation.
8. Code status: The patient is DNR/DNI.
CONDITION ON DISCHARGE: The patient still with dense left
sided hemiparesis although somewhat improved upon
admission and improved status post thrombolysis. Discharge
pain is being managed medically with aspirin, beta blocker,
Lipitor, Ace inhibitor therapy. Recurrent chest pain should
be managed with nitroglycerin and morphine. The patient is
felt to be a good candidate for Physical Therapy and
rehabilitation and was discharged to an acute rehabilitation
facility.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSIS:
1. Atrial fibrillation.
2. CVA/cerebral artery occlusion, unspecified.
3. Congestive heart failure, systolic, chronic.
4. Coronary artery disease, unspecified vessel.
5. Urinary tract infection.
6. Hypercholesterolemia
DISCHARGE MEDICATIONS:
1. Regular insulin sliding scale.
2. Nitroglycerin 0.3 mg tablets sublingual one tablet
sublingual q.5 minutes p.r.n. as needed for chest pain for a
total of 3 doses.
3. Protonix 40 mg p.o. q. day.
4. Lipitor 10 mg p.o. q.d.
5. Milk of Magnesia 30 cc oral q.6h. as needed for GI upset.
6. Captopril 25 mg p.o. t.i.d.
7. Imdur 30 mg p.o. q.d.
8. Senna one tablet p.o. b.i.d.
9. Dulcolax 10 mg rectal suppository h.s. p.r.n.
constipation.
10. Colace 100 mg p.o. b.i.d.
11. Levofloxacin 250 mg p.o. q.24h. times one day, a total of
3 day course for urinary tract infection.
12. Metoprolol Tartrate 100 mg p.o. t.i.d.
13. Aspirin 81 mg p.o. q.d.
FOLLOW-UP PLANS: The patient instructed to call his primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], for follow-up appointment within
7-10 days after discharge to rehabilitation. He is also
instructed to call Neurology to schedule follow-up with
either Dr. [**First Name (STitle) **] or Dr. [**Last Name (STitle) **], the phone number for
Neurology is [**Telephone/Fax (1) 44**]. Finally, he should schedule a
follow-up with his primary cardiologist, Dr. [**Last Name (STitle) 8421**]. Dr.
[**Last Name (STitle) 8421**] then can initiate therapy for cardioversion of the
patient's atrial fibrillation pending Neurology
recommendations on anticoagulation. Finally, the patient
already has an appointment scheduled for follow-up magnetic
resonance scan at the [**Hospital Ward Name 517**] Clinical Center in the
basement, phone number [**Telephone/Fax (1) 50198**]. Appointment is
scheduled for [**2175-9-20**], at 11:00 a.m.
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) **]
Dictated By:[**MD Number(4) 50199**]
MEDQUIST36
D: [**2175-8-29**] 14:41
T: [**2175-8-29**] 15:59
JOB#: [**Job Number 50200**]
cc:[**Hospital1 50201**]
ICD9 Codes: 5990, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2576
} | Medical Text: Admission Date: [**2144-12-5**] Discharge Date: [**2145-1-27**]
Date of Birth: [**2081-11-5**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Haloperidol
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
tremors, difficulties with balance
Major Surgical or Invasive Procedure:
1. Posterior cervical laminotomy C3 bilateral.
2. Posterior cervical laminectomy C4 to C7.
3. Posterior thoracic laminectomy T1.
4. Posterior cervical instrumentation C3-T1.
5. Posterior cervical thoracic arthrodesis C3-T1.
6. Autograft augmentation for fusion.
7. Allograft augmentation for fusion
.
Paracentesis, thoracentesis, lumbar puncture, mechanical
ventilation, nasogastric tube, tracheostomy placement, and
central line placement and removal
History of Present Illness:
A 63 year-old man w/ history of Hepatitis C and cirrhosis, and
hepatocellular carcinoma who presented to ED w/ increasing gait
unsteadiness, tremor, and resultant fall PTA. The tremor was
first noted 2mo ago, w/ difficulty shaving. This has progreesed
to significant UE and LE tremor b/l, w/ significant worsening
[**12-22**] wks PTA. Pt has had difficulties w/ writing, tying
shoelaces. No difficulties opening doors. Pt. also had
increasing gait unsteadiness for past 5 weeks, that has become
worse over the past 2-3 days. 2 d PTA, pt fell as he was
pivoting. His legs felt weak and gave out. There was no vertigo,
lightheadedness, tinnitus, hearing loss, changes in vision. No
urinary or bowel incontinence. W/ fall pt hit his hip and knee,
no head trauma. He does not feel like he has slowed down or it
takes pt more time to complete tasks. He denies fevers, chills,
cough, dysuria, abdominal pain. He denies any abdominal pain or
bright red blood per rectum. No hematemesis. There is no
unilateral weakness, no changes in vision, no difficulty
producing or understanding speech. Of note, pt. has had one
episode of AH yesterday, single voice, unintelligeble. He denies
SI, HI. There is no paranoid ideation.
.
Pt reports multiple medication non-adherence issues. He has not
been taking lactulose TID for over 2mo and has taked it QD for
1mo w/ none over past week. Has 1bm/day. In addition, has been
taking bupropion XL 150mg TID inappropriately, sometimes taking
2 tablets at a time if he has to leave the house, vs two tablets
as prescribed. In addition, pt. has hx of being treated w/
Risperdone last year, 1mg [**Hospital1 **] for 3mo.
.
In the ED, initial vitals were T:98.9 BP:139/72 HR:72 RR:15
O2Sat:98% on RA. Abdominal ultrasound was performed without any
acute abnormality. Lithium level was normal. Peripheral IV was
placed and patient was admitted for further evaluation. Li level
was 1.1
.
INTERVAL HPI PRIOR TO DISCHARGE:
Past Medical History:
- Bipolar disorder: Diagnosed in [**2129**], past suicide attempt in
the 70s during a manic phase or s/t to drug and alcohol abuse.
Had been stable on Wellbutrin and Lithium since [**29**] and 93
respectively, except for during a trial of IFN therapy in [**2138**]
where hospitalization was required.
- HCV: Genotype unknown. Liver biopsy in [**9-/2144**] showed stage 4
cirrhosis and small well-differentiated hepatocellular
carcinoma. Found to have grade 1 esophageal varices on EGD in
4/[**2143**]. Developed hepatic encephalopathy in [**2142**] requiring
hospitalization at [**Hospital1 2025**], started on lactulose with good effect.
Past treatments include peg interferon and ribavirin in [**2139**].
These meds were discontinued due to suicidal ideation.
- HCC: Recently noted 1.4 cm enhancing lesion on liver imaging,
proved to be small, well-differentialed HCC on bx in [**9-26**].
- Hypothyroidism. On levothyroxine as an outpatient.
Social History:
He lives [**Location (un) **] w/ wife, who is a nurse. [**First Name (Titles) **] [**Last Name (Titles) 23165**]
beverage for 30 years. No tobacco use ever.
Family History:
Patient recalls no history of neurologic or autoimmune diseases.
Physical Exam:
Vitals: T:97.3 BP:132/71 HR:64 RR:18 O2Sat:100% on RA
GEN: Pleasant well-nourished male, NAD
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: No JVD
COR: RR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E
NEURO:
.
Alert, oriented to: name, [**Hospital1 **], [**2143**], [**12-5**], President [**Last Name (un) 2450**]. Naming, repetition, immediate and 5min
recall intact. Days of week in reverse intact. Clock drawing
intact. No micrographia. Nl affect.
.
CN: VF intact to confrontation, EOMs intact, no nystagmus, PERRL
4->2mm, facial sensation intact b/l, symmetric face, intact
orbicularis occuli, intact mmmm, LLLL, KKKK. Tongue and uvula to
midline. Intact to finger rub b/l. Shoulder shrug intact.
.
Motor: Strength 5/5 throughout. nl bulk, increased tone, trace
cogwheel rigidity at brachialis b/l. None distally or LE. No
clonus.
.
Sensory: Intact to LT, proprioception and temperature. Pin-prick
no tested.
Coordination: slightly imparired FTN, HTS intact. Intention
tremor in UE and LE b/l w/ flexion at elbow and knee. No
nystagmus. Positive romberg, wide based gait. No dysarthria.
Negative pronator drift. Pt. could not do heel to toe.
Asterixis present in hands and feet b/l.
Reflexes: DTRs 3+ throughout, except at R patellar, 2+. Down
going toes b/l.
Pertinent Results:
Admission labs:
[**2144-12-5**] 01:50PM BLOOD WBC-5.6 RBC-3.71* Hgb-12.8* Hct-36.9*
MCV-99* MCH-34.6* MCHC-34.8 RDW-14.1 Plt Ct-92*
[**2144-12-5**] 01:50PM BLOOD Neuts-68.7 Lymphs-14.2* Monos-8.6
Eos-8.0* Baso-0.6
[**2144-12-5**] 01:50PM BLOOD PT-13.8* PTT-30.1 INR(PT)-1.2*
[**2144-12-5**] 01:50PM BLOOD Glucose-93 UreaN-17 Creat-0.9 Na-137
K-4.1 Cl-105 HCO3-24 AnGap-12
[**2144-12-5**] 01:50PM BLOOD ALT-225* AST-291* LD(LDH)-380*
AlkPhos-198* TotBili-2.3*
[**2144-12-5**] 01:50PM BLOOD Albumin-3.3* Calcium-9.3 Phos-3.0 Mg-1.6
.
Discharge labs:
[**2145-1-27**] 05:10AM BLOOD WBC-2.0* RBC-2.39* Hgb-8.4* Hct-25.1*
MCV-105* MCH-35.1* MCHC-33.5 RDW-15.6* Plt Ct-83*
[**2145-1-27**] 05:10AM BLOOD PT-17.4* PTT-42.6* INR(PT)-1.6*
[**2145-1-27**] 05:10AM BLOOD Glucose-95 UreaN-16 Creat-0.6 Na-141
K-4.1 Cl-111* HCO3-25 AnGap-9
[**2145-1-27**] 05:10AM BLOOD ALT-47* AST-97* LD(LDH)-240 AlkPhos-105
TotBili-1.7*
[**2145-1-27**] 05:10AM BLOOD Albumin-2.8* Calcium-7.9* Phos-2.5*
Mg-2.0
[**2145-1-18**] 02:12PM BLOOD TSH-3.7
[**2145-1-18**] 02:12PM BLOOD T4-5.7
.
MICROBIOLOGY (positive studies)
[**2145-1-7**] 11:44 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2145-1-14**]**
Blood Culture, Routine (Final [**2145-1-14**]):
FUSOBACTERIUM NUCLEATUM.
Anaerobic Bottle Gram Stain (Final [**2145-1-11**]):
GRAM NEGATIVE ROD(S).
.
SELECTED IMAGING:
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2144-12-5**] 6:14 PM
RIGHT UPPER QUADRANT ULTRASOUND: The liver is uniform in
echotexture, and demonstrating minimal nodularity. No focal
lesions are identified. The portal vein demonstrates normal
hepatopetal flow, with wall-to-wall flow seen. Its Doppler
signal is normal. There is no biliary ductal dilatation. The
common bile duct is normal, measuring 2 mm. Splenomegaly is
again noted, with the spleen measuring up to 16.9 cm. The
gallbladder demonstrates mild wall thickening, and a small
amount of pericholecystic fluid, but there is no gallbladder
distention or gallstones. There is no ascites. IMPRESSION: 1.
Widely patent main portal vein demonstrating appropriate
direction of flow. 2. Cirrhosis and splenomegaly. No ascites. 3.
Non-distended, mild gallbladder wall thickening and
pericholecystic fluid. Findings likely due to hypoproteinemia
and chronic liver disease.
.
MR HEAD W & W/O CONTRAST Study Date of [**2144-12-6**] 8:27 PM Images
of the brain appear normal. There is no evidence of hemorrhage,
edema, masses, mass effect or infarction. There is no abnormal
intracranial enhancement after contrast administration. There
are no diffusion abnormalities. There are two extracranial
incidental findings. First, there is a disk herniation with
severe [**Date Range **] canal narrowing at C4-5 with compression of the
[**Date Range **] cord. Secondly, there is a 16 mm mass apparently arising
within the deep lobe of the left parotid gland. This is
hyperintense on the long TR images and enhances intensely after
contrast administration. The most likely diagnosis is a
pleomorphic adenoma, but consultation with Otorhinolaryngology
may be indicated. CONCLUSION: Normal brain MR. [**First Name (Titles) **] [**Last Name (Titles) 23166**]e disc disease with disk herniation and cord
compression at C4-5. This is incompletely imaged on this brain
MR examination. There is a 16 mm mass apparently arising from
the deep lobe of the left parotid, probably a pleomorphic
adenoma.
.
MR CERVICAL SPINE W/O CONTRAST Study Date of [**2144-12-8**] 12:53 PM
FINDINGS: Vertebral body height is grossly preserved. There is a
grade 1 anterolisthesis at C4/5. Discogenic bone marrow changes
are seen in the endplates ([**Last Name (un) 13425**] type II at C4/5 and C5/6; [**Last Name (un) 13425**]
type I at C6/7). Multilevel spondylosis is present, as detailed
below. At C3/4, there is a broad-based disc/osteophyte complex,
which flattens the [**Last Name (un) **] cord and results in severe [**Last Name (un) **]
canal stenosis. Right uncovertebral joint osteophytes are larger
than the left, resulting in severe right and moderate left
neural foramen narrowing. At C4/5, the level of the grade 1
anterolisthesis, there is a broad-based disc/osteophyte complex
which compresses the [**Last Name (un) **] cord and results in severe [**Last Name (un) **]
canal stenosis. There is mild narrowing of the right neural
foramen and moderate to severe narrowing of the left neural
foramen. At C5/6, there is a broad-based disc/osteophyte
complex, which contacts but does not definitively deform the
[**Last Name (un) **] cord. There is mild to moderate [**Last Name (un) **] canal stenosis.
The right neural foramen is mildly narrowed. At C6/7, there is a
disc/osteophyte complex, which flattens the anterior [**Last Name (un) **]
cord. Thickening of the ligamentum flavum is also present. There
is moderate [**Last Name (un) **] canal stenosis. There is severe narrowing of
the left neural foramen. There is subtle high signal in the
[**Last Name (un) **] cord from C3/4 through C4/5, which may represent edema or
myelomalacia. The imaged portion of the posterior fossa appears
unremarkable. No signal abnormalities are identified in the
imaged paravertebral soft tissues. IMPRESSION: 1. Spondylosis
resulting in severe [**Last Name (un) **] canal stenosis at C4/5 and
moderate-to- severe [**Last Name (un) **] canal stenosis at C3/4, with
compression of the [**Last Name (un) **] cord. Edema or myelomalacia in the
cord at the affected levels. 2. Grade I anterolisthesis at C4/5.
.
MR HEAD W & W/O CONTRAST Study Date of [**2144-12-16**] 5:37 PM
FINDINGS: There have been no significant changes since the
previous study. There is no evidence of hemorrhage, edema,
masses, mass effect, or infarction. There are no diffusion
abnormalities. The ventricles and sulci appear normal in caliber
and configuration. There is no abnormal enhancement after
contrast administration. Incidentally noted is mucosal
thickening in the ethmoid air cells. Again noted is a mass
either within or immediately posterior and deep to the left
parotid gland. This may represent a pleomorphic adenoma or a
seventh nerve schwannoma. CONCLUSION: Normal brain MR. [**First Name (Titles) 2325**] [**Last Name (Titles) 23167**]d mass again identified. A preliminary report was issued
that read postoperative day #5 after laminectomy. No acute
process seen.
.
CT CHEST W/CONTRAST Study Date of [**2144-12-18**] 1:51 PM CT CHEST WITH
IV CONTRAST: There is no axillary, mediastinal, or hilar
lymphadenopathy. Heart and pericardium are grossly unremarkable.
Note is made of bilateral moderate atelectasis and trace pleural
effusions. No clear consolidation. No definite pulmonary nodules
or masses are seen. Coronary artery calcifications are also
noted. CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST: Moderate
ascites is present. No focal hepatic mass is seen. The
gallbladder is moderately distended with some gallbladder wall
edema, although it is unclear whether this may be secondary to
third spacing/NPO status. Please correlate clinically. The
spleen, adrenal glands, and kidneys appear unremarkable aside
from multiple low- density lesions seen within the left kidney,
the largest of which measures approximately 4.5 cm with
appearances consistent with cysts, and the smaller ones are too
small for accurate characterization, particularly given the
motion artifact during the study. A post-pyloric enteric tube is
seen, with the tip at the junction of the third-fourth portions
of the duodenum. Spleen and pancreas appear grossly
unremarkable. There is diffuse edema within the mesentery and
omentum. Left gastric varices are seen. No abdominal
lymphadenopathy is evident. CT OF THE PELVIS WITH ORAL AND IV
CONTRAST: Rectal tube and Foley catheter are present, with a
decompressed appearance to the bladder. Small-to-moderate pelvic
free fluid, tracks down from the abdomen. Assessment of the
large bowel is grossly unremarkable. Examination of osseous
structures does not show lytic or sclerotic lesions concerning
for malignancy. Upper thoracic pedicle screws are seen, but not
clearly visualized or characterized on this study. Degenerative
changes of the lumbar spine are seen, with a focal scoliosis
with an S-shape in the lumbar spine, left convex at L3 and right
convex at L4-5, with transitional vertebral body anatomy and
slight anterolisthesis of L3 on L4. Multiplanar reformatted
images were also reviewed in our interpretation, supporting
these findings. IMPRESSION: 1. Moderately distended gallbladder
with mild edema. This may be secondary to third spacing, given
the moderate amount of ascites and mesenteric edema seen. Please
correlate clinically. 2. Moderate bilateral atelectasis. 3. No
other focal infectious source identified.
.
MR [**Name13 (STitle) **] W& W/O CONTRAST Study Date of [**2144-12-23**] 2:01 PM The
patient is status post C7-T1 surgery, with hardware noted,
causing artifacts, limiting accurate assessment to some extent.
Grade 1 anterolisthesis of C4 over C5 is again noted and
unchanged. Post-surgical changes are noted, in the posterior
spinous soft tissues, from C3-T1 level, with moderate amount of
fluid in the soft tissues. Ther eis thin linear enhancement of
the dura posteriorly. However, there is no abnormal irregular or
rim enhancement, to suggest an abscess in this location. There
is no evidence of epidural abscess. There is mild compression on
the posterior aspect of the cord, C3 level, from the orientation
of the ligamentum flavum thickening, which is unchanged. There
is mild narrowing of the size of the cord at the level of C3-C4
which is again unchanged. Minimal increased signal intensity, at
C3-4 level in the cord is unchanged and likely related to edema
or encephalomalacia. Multilevel degenerative changes noted in
the intervertebral disc spaces are unchanged. There are small
areas of edema, related to [**Last Name (un) 13425**] type 1 endplate changes at C5-6
and C6-7 levels, again not significantly changed. No pre- or
para-vertebral soft tissue swelling or masses are noted.
IMPRESSION: 1. Status post surgery from C3-T1 level. 2.
Postoperative changes noted in the posterior spinous soft
tissues with moderate amount of fluid/edema. No evidence of
abscess 3. No evidence of epidural abscess. 4. Persistent
moderate indentation/compression on the posterior aspect of the
[**Last Name (un) **] cord at the level of C3, as seen on the sagittal
sequences, not well assessed on the axial sequences due to
hardware artifacts. 5. Multilevel degenerative changes in the
cervical spine, as described above and not significantly changed
compared to the prior study. 6. Linear area of increased signal
in the cervical cord at C3-4 likely related to myelomalacia.
Mild enhancement of the dura noted posterior, likely related to
post-surgical changes.
.
MR HEAD W/O CONTRAST Study Date of [**2145-1-16**] 3:00 PM FINDINGS:
Comparison was made with the previous MRI of [**2144-12-23**]. No evidence
of acute infarct seen. No signs of hypoxic brain injury are
identified on diffusion images. The ventricles and sulci are
normal in size. There is mild prominence of extra-axial spaces
with prominence of pachymeninges which is unchanged from
previous CT examination of [**2145-1-11**]. No midline shift is
identified. Small foci of T2 hyperintensity in the right frontal
lobe are nonspecific nature and unchanged from previous study.
There is a left parotid mass identified, which could be due to
pleomorphic adenoma and is unchanged from previous study.
IMPRESSION: No acute intracranial abnormalities or change seen
since the previous MRI of [**2144-12-23**] and CT of [**2145-1-11**].
.
VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2145-1-25**] 9:35 AM
FINDINGS: Video oropharyngeal swallow evaluation was performed
in conjunction with the speech and swallow division. Exam was
slightly limited by underlying cervical fusion hardware. Thin
liquid, Nectar-thick liquid, pureed consistency barium, &
one-half of a cookie coated were administered. The oral phase
demonstrated moderate oral residue with early spillage. The
pharyngeal phase demonstrated vallecular and piriform sinus
residue. There was penetration into the laryngeal vestibule with
thin liquids but not nectar thick liquids. There was no
aspiration. IMPRESSION: Several episodes of penetration with
thin liquids. There was no aspiration.
.
Brief Hospital Course:
63M with a history of ESLD, HCC, HCV, distant alcoholism,
bipolar disorder compicated by SI, and medication non-compliance
who was admitted on [**2144-12-6**] for gait unsteadiness, tremor, and
falls. In brief, he reported more than a month of increasing
gait unsteadiness culminating in falls and more recently tremor
and difficult with fine motor tasks. Just prior to admission he
developed gastroenteritis and stopped taking lactulose. He
presented to the [**Hospital1 18**] ED encephalopathic. Further work up on
admission revealed several problems. [**Name (NI) **], he was
encephalopathic on admission with asterixis and confusion. He
improved somewhat with lactulose and rifamixin. Second, he was
not taking his medications as ordered. In particular he was
taking bupropion more on an as needed basis - not taking it at
times and taking high doses to tolerate leaving the house. His
lithium level was WNL on admission. Third, he was noted to have
[**Name (NI) **] stenosis which was believed to explain some of his
symptoms. He ultimately underwent C3-7 laminectomy on [**2144-12-11**].
His post- op course was complicated by dramatic altered mental
status. He was persistently delirius and was treated with high
doses of haloperidol and subsequently developed what appeared to
be NMS. On [**2145-1-6**] a code blue was called on the patient for
apneic PEA arrest. Compressions were initiated promptly. He was
intubated and a large mucus plug was suctioned out of his lungs.
He was transfered to the MICU where he was therapeutically
cooled for 24hrs. He was successfully re-warmed and EEG at that
time was consistent with profound encephalopathy. He underwent
bronchoscopy which showed thick, pus-like mucus in the airways
which grew out oral flora. He was treated with a course of
vancomycin and piparacillin/tazobactam. A single blood culture
grew Fusobacterium and he was treated with PCN. He developed
anuric renal failure which was treated with mitodrine,
octreotide, albumin, and IVF and ultimately recovered to
baseline renal function. He had a prolonged intubation and is
now s/p tracheostomy and successfully extubated. He had
hypernatremia which was treated with free water boluses in his
tube feeds and IVF. Finally, his encephalopathy was aggressively
treated with lactulose, rifamixin, quetiapine, and sedation. He
is now weaned off sedation and stable on lactulose and rifamixin
as well as quetiapine. At the time of transfer back to medicine
he was tolerating tube feeds, alert, afebrile, and stable. On
the the [**Doctor Last Name 3271**] [**First Name4 (NamePattern1) 679**] [**Last Name (NamePattern1) 4869**] his respiratory and nutrition
status were optimized and his encephalopathy improved. He
remains on treatment for encephalopathy with both GI
decontamination and neuroleptics. His deconditioning remains an
issue. He is being dischared to skilled rehabilitation.
.
# Hepatic encephalopathy. Pt. w/ marked asterixis on exam on
admission. Most likely cause was felt to be lactulose
non-adherence. There was no evidence of infection on admission.
CXR, UA, UCx, and BCx were WNL. Patient was noted to have
significant asterixis and slight attention deficit on exam. He
was restarted on scheduled lactulose and rifaximin was added.
The gait instability and tremor were felt to be possible
manifestation of the encephalopathy but did not improve with
treatment while his mental status did. Ultimately this was found
to be [**12-21**] [**Month/Day (2) **] cord stenosis (see below) which was treated
surgically. His mental status has cleared significantly with
aggressive bowel regimen and discontinuation of home bupropion
and lithium. He is also s/p NMS from haloperidol given
post-operatively earlier this admission. He will continue
lactulose 60 mL PO Q4H and titrate to >4BM daily + clear mental
status, rifaximin 400 mg PO TID for bowel decontamination, and
quetiapine fumarate 50 mg PO Q6H:PRN for agitation per psych as
well as standing doses (see below). His doses of quetiapine can
be titrated down for over-sedation.
.
#. PO access: S/p prolonged hospitalization. Pulled out multipe
Dophoffs. Now that mental status improved doing very well but
caloric intake is still low. He has repeated passed speach and
swallow evaluations, including on the day of discharge. He was
dischaged on supervised POs with soft solids and thickened
liquids. He will need ongoing nutrition consults.
.
#. Respiratory status: S/p prolonged intubatation now extubated
with tracheostomy placed on [**2145-1-13**]. Doing well with cuff in
place on FiO2 35%. Notable history of aspiration PNA and mucus
plugging which resulted in a PEA arrest (see below). For now on
standing albuterol and iptropium nebs Q6hrs with excellent
effect. Will go to rehab with trach in place and be weaned
there.
.
#. Weakness / deconditioning. Likely a combination of
deconditioning from being bed-ridden for several weeks, upper
motor deficits s/p cervical [**Date Range **] stenosis treated with
laminectomy, and catabolic state. He will require intensive PT
to regain functioning. He is discharged to rehab for this
purpose.
.
# Tremor/Gait instability. Initially improved slightly with
lactulose, suggesting hepatic encephalopathy as a contributor,
but Pt continued to have severe clonus and tremors as well as
worsening gait instability. Tremors were felt to be [**12-21**] to Li
toxicity and this was discontinued. To rule out other causes of
ataxia, B12, folate, and RPR were obtained which were all
normal. Pt. underwent an MRI of head which showed a normal
brain, but incidentally provided evidence of C4,5 [**Month/Day (2) **] cord
compression. MRI of spine showed extensive [**Month/Day (2) **] cord
compression w/ myelomalacia at C3 to C7 levels. Neurology was
consulted who felt patient's gait instability and and clonus
were most likely due to chronic [**Month/Day (2) **] cord compression at these
levels. Ortho-spine consultation was obtained emergently. On
[**12-9**], patient was noted to have worsening gait difficulties and
more pronouced clonus. The clonus was felt to be due to [**Month/Year (2) **]
cord compression. A decision was made to perform [**Month/Year (2) **] cord
decompression to prevent further cord deterioration. On [**12-11**]
patient underwent posterior cervical laminotomy C3 to T1 and
posterior cervical instrumentation C3-T1, posterior cervical
thoracic arthrodesis C3-T1, autograft and allograft augmentation
for fusion. The post operative course complicated by severe
encephalopathy and NMS (see below).
.
# NMS and Post-op encephalopathy: Pt. undergone C3-T1
laminectomy, instrumentation and [**Month/Year (2) **] fusion on [**2144-12-11**] and
was delerious post operatively w/ decompensation of hepatic
encephalopathy. Pt. continued to be unresponsive w/ low grade
temperatures despite marginal improvement w/ haldol (>40mg) and
lactulose. Developed tachypnea, hypertension, tachycardia and
low grade temps. CK > 1400, but pt had been w/ persistent
thrashing for ~ 1wk. QTc 450. Haldol has been d/c [**12-17**] 1400 last
dose. CKs trending down w/ supportive treatment. Ultimately
believed to be consistent with NMS [**12-21**] haloperidol. Psych
recommended switch to Seroquel for agitation and bipolar.
.
# Bipolar d/o. Patient was euthymic on admission until the time
of surgery with no sx of mania or depression. Pt reported recent
auditory halucinations. Lithium dose was reduced then DCed given
concern for tremor. Wellbutrin was also decreased and then DCed
during the post operative course due to the persistent delerium.
Ultimately was started on Quetiapine Fumarate 100 mg PO QAM and
200 mg PO HS with good control of symptoms. This can be
decreased as needed for sedation.
.
#. Cirrhosis: History of HCV and distant alcohol abuse. Known to
have HCC, although seems to be limited disease. Pt with
relatively preserved synthetic function. Will being evaluated
for liver transplant as an outpatient. Plan is to continue
management of encephalopathy with lactulose and rifamixin. Of
note, has known grade I esophageal varices as of [**2-24**]. Not on
Bblocker. On PPI.
.
# Left parotid mass. 1.6cm incidental finding on MRI.
Outpatient follow up with ENT recommended.
.
MICU Course:
# Cardiac / PEA arrest / hemodynamics: On [**1-7**] the patient had a
witnessed PEA arrest. CPR was initiated promptly, the patient
was intubated and given epi/atropine. A large mucous plug was
suctioned from the ET tube, with subsequent restoration of
perfusing rhythm and the patient was transfered to the medical
ICU for further managment. The patient was cooled and then
rewarmed the following day per protocol. Early in the morning
of [**1-8**] the patient became hypotensive, received several IV
fluid boluses, and eventually required levophed to support his
blood pressure. The levophed was weaned off the following day.
Cardiac enzymes trended down post-arrest. Echo was
hyperdynamic without evidence of cardiogenic shock. On [**1-11**],
peri-intubation, the patient had an episode of AF with RVR and
aberrancy that responded to Ca2+.
.
# Respiratory/Ventilation: On transfer to the MICU the patient
had a bronchoscopy showing thick, yellow secretions concerning
for infection, and was started vancomycin and zosyn for a 5 day
course for hospital acquired pneumonia. The patient was
successfully extubated on the morning of [**1-10**], but was
reintubated on [**1-11**] secondary to respiratory distress and
inability to handle secretions. As the latter circumstance was
felt to be unlikely to change the patient had a trachesotomy
placement on [**1-13**]. Placement was complicated by some minor
bleeding for which ENT was consulted and evaluated the patient.
No pharyngeal source was found. On discharge from the MICU the
patient was tolerating his trach collar very well with a
passy-muir valve in place.
.
# Mental Status: The patient had an altered mental status for
most of his MICU stay. Initially this was felt to be secondary
to both cirrhosis and PEA arrest (and anoxic brain injury to
unknown extent) contributing. The patient had an EEG after his
PEA arrest that showed a severe encephalopathy. On the morning
of [**1-10**] following extubation, the patient's mental status was
noted to be the same as that pre-code. CT head was
unremarkable. An MRI on [**1-16**] head showed no evidence of anoxic
brain injury. The patient had multiple episdoes of agitation
and multiple medications were tried. Eventually psychiatry was
consulted and recommended using seroquel, which worked well. In
addition, the patient's lactulose was also uptitrated to 60 mg
Q4H. On the day of transfer out of the MICU, the patient's
mental status had improved markedly.
.
# Renal Failure: Post cardiac arrest the patient was anuric.
This etiology was likely combination of acute tubular necrosis
in the setting of PEA arrest and hepatorenal syndrome. He
received mitodrine, octreotide, and albumin for HRS.
His renal function slowly improved.
.
# Fusobacterium bacteremia: One of two blood culturs drawn on
[**1-7**] grew out Fusobacterium. ID was consulted and the patient
was treated with a 2 week course of penicillin G that ended on
[**2145-1-21**].
.
# Hypernatremia: Likely hypovolemic hypernatremia in the setting
of recent ATN and current HRS. Resolved with free water boluses
through the NG tube. Hypernatremia worsened again with
acceleration of tube feeds and improved with increased free
water boluses and holding of tube feeds due to the patient's
inability to maintain an upright posture.
.
# Thrombocytopenia: The patient had a low platelet count that
was stable. Initial considerations were HIT vs. splenic
sequestration. Smear on [**1-14**] showed no evidence of DIC. The
patient was switched from an H2 blocker to a PPI. His platelets
remained low, but stable.
.
# Cirrhosis: Hep C stable. Lactulose was increased. Rifaxamin
was held when the patient was on vancomycin and zosyn and
resumed when these medications were stopped. Hepatology
followed the patient during his MICU stay and resumed care for
the patient on transfer back to the medical floor.
Medications on Admission:
#. Bupropion XL 150mg TID, but not taken as prescribed. Will
need to verify with psychiatrist in AM
#. Esomeprazole 40mg daily
#. Lactulose 10mg/15mL TID, not taking as prescribed.
#. Levothyroxine 75mcg daily
#. Lithium 600mg [**Hospital1 **] per pharmacy, but 450 CR [**Hospital1 **] in OMR, which
is a more appropriate for [**Hospital1 **] dosing.
#. Spironolactone 50mg daily
#. Vitamin D daily
#. Milk Thistle 400mg daily
#. Omega-3 Fatty acids daily
Discharge Medications:
1. Valsartan 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily):
please hold for sbp < 90.
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
7. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Sixty (60) ML PO Q4H
(every 4 hours).
8. Quetiapine 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QAM (once a
day (in the morning)) as needed for agitation.
9. Quetiapine 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
10. Rifaximin 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times
a day).
11. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**11-20**] Sprays Nasal
QID (4 times a day) as needed: for nasal dryness.
12. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO every
eight (8) hours as needed: Not more than 2 grams daily.
13. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) treatment
Inhalation Q6H (every 6 hours).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) treatment Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
15. Quetiapine 25 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for agitation: Not more than 500 mg total
seroquel per day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: Hepatic encephalopathy (resolving), [**Month/Day (2) **] cord
compression C3 to C7 status post laminectomies, lithium toxicity
(resolved), neuroleptic malignant syndrome (resolved), left
parotid mass
.
Secondary: [**Month/Day (2) **] and hepatitis C cirrhosis, bipolar disorder
Discharge Condition:
Stable vital signs, tolerating POs, breathing on trach mask and
intermittently on room air
Discharge Instructions:
You were admitted to [**Hospital1 18**] with tremors, difficulty with balance
and hepatic encephalopathy (an imbalance of chemicals in your
brain due to the liver disease). An MRI of your brain and neck
were done to determine whether the abnormalities in your gait an
the tremors were due to problems with your brain or the [**Hospital1 **]
cord. You were found to have [**Hospital1 **] cord compression and
underwent cervical spine laminectomy and [**Hospital1 **] fusion. Your
post operative course was complicated by severe encephalopathy.
This was partially due to an allergy to haloperidol causing a
condition called neuroleptic malignant syndrome. You should not
take this medication ever again.
We treated your encephalopathy with high doses of lactulose,
rifaximin, antibiotics and supportive treatment. You were so
sick that you needed to be placed on a breathing machine
(ventilator). Ultimately an artificial airway called a
tracheostomy was placed in your neck to help you breathe. Your
tremors improved with discontinuing lithium. We ultimately
changed your lithium and bupropion with quetiapine (Seroquel).
.
Also, we noted a mass in your left parotid gland (salivary
gland) that is most appears benign. Nevertheless, you follow up
with an ear nose and throat specialist for this.
.
We have you on a new medical regimen. Please take your
medications as ordered.
.
Please attend your follow up appointments.
.
Please call your doctor or come to the emergency department if
you experience chest pain, shortness of breath, worsening
encephalopathy, fevers, difficulty tolering feedings, or other
concerning symptoms
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in the Liver Center ([**Location (un) 858**]
[**Hospital Unit Name **] at [**Hospital1 18**]) on [**2145-2-16**] at 8:15 am. Please
call [**Telephone/Fax (1) 2422**] if there is a problem with this appointment.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2145-2-16**] 8:15
.
Please follow up with your primary psychiatrist, Dr. [**Last Name (STitle) 23168**],
within 1-2 weeks of discharge from rehab. Please call Dr. [**Name (NI) 23169**] office for an appointment.
.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5456**],
within 1-2 weeks of discharge from rehab. Please call
[**Telephone/Fax (1) 5457**] for an appointment.
.
Please follow up the mass in your parotid gland (likely benign)
with an ENT within 3 months of discharge. The [**Hospital **] clinic at
[**Hospital1 18**] can be reached at ([**Telephone/Fax (1) 6213**]. Your PCP can also help
you find an ENT.
Completed by:[**2145-1-27**]
ICD9 Codes: 4275, 5845, 9971, 7907, 5715, 2875, 2930, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2577
} | Medical Text: Admission Date: [**2140-10-25**] Discharge Date: [**2140-10-28**]
Date of Birth: [**2099-9-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
"I'm in DKA"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 36072**] is a 41 yo M with PMH significant for [**Doctor Last Name **] diagnosed
at age 31 and multiple episodes of DKA who presented to the ED
on [**10-24**] reporting that he was in DKA. He reported that he had
malaise, "ketone breath," and didn't feel well in the 3-4 hours
before he came to the hospital. He had clear colored emesis on
the day of presentation and then some deep red colored, guaiac
positive emesis in the ED. He indicated that he had "fallen of
the horse" in the days before his presentation, not taking his
insulin and eating poorly. He denied having fevers, chills,
headache, URI, SOB, cough, CP, abd pain, diarrhea, black or
bloody stools during that time. Denies recent alcohol or drug
use.
Past Medical History:
- maturity-onest diabetes of the young ([**Doctor Last Name **]), on insulin
- Gitelman's syndrome, followed in renal clinic, managed by a
high-potassium diet
- chronic kidney disease stage III (creatinine 1.2-1.6),
secondary to [**Doctor Last Name **] and Gitelman's syndrome
- neuropathy, likely secondary to diabetes
- abnormal LFTs, unclear etiology
- renal cysts
- absent dorsal pancreas, atrophic head and uncinate process
only
Social History:
Patient lives with his wife. [**Name (NI) **] does not work; he is on
disability. Used to be a hotel manager. He denies smoking,
drinking, or illicit drug use.
Family History:
Parents alive and healthy with no cardiac hx. No FH of DM,
Gitelman's syndrome, cancer, cardiac problems.
Physical Exam:
ADMISSION EXAM
Vitals: 96.7, 102, 116/67, 100/2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DC EXAM
VSS. AAOx3. Foley removed.
Pertinent Results:
ADMISSION LABS: [**2140-10-25**] 12:03AM
WBC-30.5*# RBC-5.43 Hgb-15.1 Hct-42.7 MCV-79* MCH-27.9
MCHC-35.5* RDW-13.8 Plt Ct-328
Neuts-73* Bands-4 Lymphs-15* Monos-5 Eos-1 Baso-0 Atyps-0
Metas-1* Myelos-1*
PT-12.3 PTT-27.2 INR(PT)-1.0
Glucose-427* UreaN-28* Creat-1.8* Na-136 K-3.4 Cl-96 HCO3-5*
AnGap-38*
ALT-18 AST-15 LD(LDH)-225 CK(CPK)-170 AlkPhos-146* TotBili-0.2
CK-MB-27* MB Indx-15.9* cTropnT-0.05*
Albumin-4.1 Calcium-9.0 Phos-3.7 Mg-1.2*
Type-[**Last Name (un) **] pO2-86 pCO2-22* pH-7.01* calTCO2-6* Base XS--25
Intubat-NOT INTUBA
Glucose-412* Lactate-3.5* Na-139 K-4.4 Cl-102
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
URINE Blood-SM Nitrite-NEG Protein-30 Glucose-1000 Ketone-150
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0
URINE Hours-RANDOM Creat-39 Na-40 K-31 Cl-18
DISCHARGE LABS [**2140-10-28**]
WBC-6.2 RBC-4.57* Hgb-12.8* Hct-35.7* MCV-78* MCH-27.9
MCHC-35.8* RDW-14.5 Plt Ct-202
Glucose-307* UreaN-13 Creat-1.2 Na-141 K-4.3 Cl-106 HCO3-27
AnGap-12
Calcium-9.0 Phos-2.8 Mg-1.3*
Triglyc-126 HDL-38 CHOL/HD-4.8 LDLcalc-119
Blood cxs all negative for growth.
RADIOGRAPHY
CXR: Persistent right lower lung opacity. Recommend repeat
conventional chest radiograph views including shallow obliques
to exclude
sclerotic rib lesion.
Brief Hospital Course:
Mr. [**Known lastname 36072**] is a 41 yo M with [**Doctor Last Name **] and Gitelman's syndrome who
presented with DKA, bloody emesis, and troponin leak in the
setting of no known cardiac disease.
# DKA
Precipitant of the DKA appears to have been medication
non-adherence. There were no signs of infection on exam,
infectious work-up including CXR, UA, urine and blood cxs was
completely negative. Pt was admitted to the ICU, given fluids,
insulin, K and Phos. The anion gap closed and he was transferred
to the floor. He was started on his home insulin regimen and his
AM dose was increased to 40 units of glargine.
# Troponin leak
In the setting of volume depletion secondary to DKA, the patient
was found to have a troponin of 0.09 that subsquently trended
downward x2. This was thought to be demand related ischemia [**3-16**]
coronary artery disease. The patient was scheduled for an outpt
stress echocardiogram. He was started on simvastatin 20mg QHS
and 81mg of aspirin daily.
# Hematemesis
Pt had hematemesis x1 in the ED in the context of profuse
vomitting and wretching and then had clear, guaiac negative
emesis. Had guaiac negative stool and no further episodes of
hematemsis. This was attributed to a likely small [**Doctor First Name **]-[**Doctor Last Name **]
tear. GI follow-up did not seem necessary at the time of
discharge- pt will be followed by PCP and can see GI if
necessary.
#Anemia
Microcytic anemia present on and off over the past several
years. Normal iron studies in [**Month (only) **], stable during
hospitalization. Defer to outpt work-up as necessary.
#Neuropathy
Neuropathy in lower extremities b/l [**3-16**] DM. Present for 9 years.
Stable during hospitalization. Continued baclofen 40mg [**Hospital1 **].
#Gitelman's syndrome
Cr 1.8 at presentation, then returned to baseline of 1.5 with
fluids. Renal disease otherwise stable during hospitalization.
Followed closely by renal clinic.
# Concern for sclerotic rib lesion on CXR
Patient has a right-sided opacity on CXR seen on this admission
and previously in [**2139**]. Suggest outpt follow-up.
TRANSITIONAL ISSUES:
- Started simvastatin 20mg, will need f/u LFTs and CK in 3
months
- To have stress test on outpt basis
- CXR follow-up of possible sclerotic rib lesion found
incidentally on CXR
- Medication list contains two types of Vitamin D, pt denied
taking either. To discuss with PCP if this is necessary
Medications on Admission:
-Lantus 100 unit/mL Sub-Q
30 units daily, in the morning
-Aspirin 81mg
-Humalog 100 unit/mL Sub-Q
sliding scale for humalog three times a day to be dosed only
with meals starting with sugar 51-100 and further titrated,
states that only uses it once a week and should be at 2U,
increasing by 2U for every 50 increase in glucose
-baclofen 20 mg Tab 2 Tablet(s) by mouth twice a day
-oxycodone 15 mg Tab 1 Tablet(s) by mouth [**Hospital1 **] prn pain (taking
2-3 times weekly)
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
3. baclofen 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. oxycodone 15 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
5. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous qAM (each morning).
6. Humalog 100 unit/mL Solution Sig: One (1) administration
Subcutaneous three times per day at mealtime: Sliding scale for
humalog three times a day to be dosed only with meals starting
with sugar 51-100 and further titrated as instructed.
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 5450**] & So. N.H.
Discharge Diagnosis:
Primary: Diabetic ketoacidosis
Secondary:
[**Doctor First Name **]-[**Doctor Last Name **] tear (causing blood in the vomit)
Troponin leak (cardiac enzymes in the blood)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 36072**],
It was a pleasure to take care of you during your stay at [**Hospital1 18**].
You were admitted here for an episode of Diabetic Ketoacidosis
(DKA). You were treated for this in the intensive care unit
where you received fluids and insulin to control the DKA. Your
DKA resolved and you were transferred to the general medical
floor.
During the DKA, cardiac enzymes were identified in your blood.
This suggests that heart muscle was injured during the episode.
These enzymes declined on their own, which means that you DID
NOT have a heart attack. It does indicate that you may have
narrowing of the arteries in the heart and an increased risk of
heart attack in the future. For this reason, we would like you
to have a cardiac stress test after your hospitalization. It has
been scheduled for you (see below). You should see Dr. [**Last Name (STitle) **]
after the stress test to go over the results. She will consider
sending you to see a cardiologist if necessary. Your cholesterol
was tested and was elevated. You should start taking simvastatin
for cholesterol as instructed below, to decrease your risk of
heart attack.
You did also vomit some blood during your hospitalization. This
occured after you had been vomiting profusely and wretching.
This blood very likely came from a small tear at the border
between your esophagus and stomach. Your bleeding resolved and
you red blood cell levels were stable, so we were not concerned
about further bleeding. We did not feel that an endoscopy was
necessary, but you may discuss this with Dr. [**Last Name (STitle) **], especially if
you have symptoms of vomiting blood or abdominal pain.
The following changes have been made to your medications:
1. START taking SIMVASTATIN 20mg at bedtime
2. Increase your morning Insulin Glargine (Lantus) dose to 40
units tomorrow morning
3. Please continue taking your Baclofen 20mg twice daily, as you
have been doing.
4. Your medication list contains two different types of vitamin
D, ergocalciferol and cholecalciferol, which you state that you
are not taking. Please discuss with your primary care physician
and nephrologist whether you are supposed to be taking these.
You should have your liver function tests drawn in about three
months, or as recommended by Dr. [**Last Name (STitle) **].
Please remember to attend your follow-up appointments as shown
below:
Followup Instructions:
Please be sure to keep all of your followup appointments as
scheduled below.
Department: CARDIAC SERVICES
When: MONDAY [**2140-11-7**] at 1 PM
With: STRESS TESTING [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please arrive at least five minutes early for this appointment.
Do not have food or caffeine for 3 (three) hours before the
test. Please wear comfortable shoes and clothing for the
treadmill.
Name: [**Last Name (LF) 10088**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
Appointment: TUESDAY [**11-8**] AT 9AM
Department: [**Hospital3 249**]
When: THURSDAY [**2140-11-10**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital 9380**] CLINIC
When: TUESDAY [**2141-1-17**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2140-11-2**]
ICD9 Codes: 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2578
} | Medical Text: Admission Date: [**2163-9-15**] Discharge Date: [**2163-10-2**]
Date of Birth: [**2109-3-22**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
H/A, N/V x3days
Major Surgical or Invasive Procedure:
Transpenoidal pituitary rsxn([**9-21**])
History of Present Illness:
54F c/o H/A in frontal region of head since Tuesday morning
unrelieved with NSAIDS. She began vomiting Tuesday afternoon and
reports nausea and vomiting since. She denies falls or head
trauma. Denies difficulty walking, dizziness.
Past Medical History:
1. Rheumatic heart disease; status post mitral valve replacement
and tricuspid valve replacement in [**2156**] complicated by
postoperative heart block and now status post pacemaker.
2. Dilated cardiomyopathy with an ejection fraction of 40% to
45%.
3. Paroxysmal atrial fibrillation; status post cardioversion.
4. Status post atrial septal defect in [**2133**].
5. Hypertension.
6. Hypothyroidism.
7. Anemia.
Social History:
She is a homemaker and lives with husband and children in
[**Name (NI) 1468**]. Quit smoking 3 years ago, 4pack per year history. No
IVDU, No EtOH
Family History:
Heart disease
Physical Exam:
On Admisson:
Gen: Comfortable, NAD.
HEENT:Atraumatic, Normocephalic Pupils: PERRL EOMs full
Neck: Supple.
Neuro:
Mental status: Awake and alert x3, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-18**] throughout. No pronator drift
Sensation: Intact to light touch.
Toes downgoing bilaterally
Coordination: Heel to shin
Exam on Discharge:
AOx3, full strength and power throughout all extremities.
Pertinent Results:
Labs on Admission:
[**2163-9-15**] 10:00AM BLOOD WBC-11.0# RBC-4.15* Hgb-12.1 Hct-35.1*
MCV-85 MCH-29.1 MCHC-34.5 RDW-15.7* Plt Ct-303
[**2163-9-15**] 10:00AM BLOOD Neuts-80.0* Lymphs-15.5* Monos-3.2
Eos-0.9 Baso-0.3
[**2163-9-15**] 10:00AM BLOOD PT-43.3* PTT-33.2 INR(PT)-4.8*
[**2163-9-15**] 10:00AM BLOOD Glucose-105 UreaN-13 Creat-0.7 Na-142
K-3.0* Cl-100 HCO3-35* AnGap-10
[**2163-9-16**] 04:20AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1
[**2163-9-15**] 08:04PM BLOOD LH-4.1 Prolact-13 TSH-2.2
[**2163-9-15**] 08:04PM BLOOD T4-7.9 Free T4-1.1
[**2163-9-15**] 08:04PM BLOOD Cortsol-30.2*
[**2163-9-15**] 10:00AM BLOOD Digoxin-0.4*
Labs on Discharge:
[**2163-9-29**] 10:55AM BLOOD WBC-18.3* RBC-4.17* Hgb-12.4 Hct-35.9*
MCV-86 MCH-29.7 MCHC-34.5 RDW-16.1* Plt Ct-458*
[**2163-9-30**] 09:10AM BLOOD PT-23.3* PTT-45.7* INR(PT)-2.3*
[**2163-9-29**] 10:55AM BLOOD Glucose-141* UreaN-14 Creat-0.8 Na-144
K-3.3 Cl-102 HCO3-32 AnGap-13
[**2163-9-29**] 10:55AM BLOOD Calcium-9.9 Phos-3.5 Mg-2.3
Imaging:
Head CT ([**9-15**]):
IMPRESSION: Hyperdense sellar mass extending to suprasellar
region, most
likely a pituitary macroadenoma. MRI of sella would be helpful
for further
evaluation.
Head CTA([**9-15**])
IMPRESSION:
1. Sellar mass with suprasellar extension and potential mass
effect upon the optic chiasm. MRI is recommended if possible to
further evaluate these
structures. Diagnostic possibilities include macroadenoma, with
or without
hemorrhage, and less likely a Rathke's cleft cyst.
2. No evidence of intracranial hemorrhage. However, the density
of hte lesion itself may reflect prior bleeding. Pituitary
apoplexy cannot be excluded on CT imaging. Normal CTA circle of
[**Location (un) 431**].
Cards ECHO([**9-16**])
IMPRESSION: Normal global and regional left ventricular systolic
function. Mild global right ventricular systolic dysfunction.
Mechanical mitral valve prosthesis with borderline-high
gradients. Normally-functioning tricuspid annuloplasty ring.
Mild pulmonary hypetension.
CXR [**9-20**]:
IMPRESSION:
1. No acute cardiopulmonary abnormality.
2. Unchanged cardiomegaly.
3. Subsegmental atelectasis left lung base.
Head CT [**9-21**]:
NOTE ADDED IN ATTENDING REVIEW:
1) No short-interval change in hyperattenuating, round primarily
intrasellar mass with suprasellar extension, remodeling the
dorsum sellae; dDx includes macroadenoma, perhaps with
hemorrhage, as well as intrasellar
craniopharyngioma or Rathke cyst.
2) Possibly low-lying cerebellar tonsils (unrelated), which
should be
clarified at time of MRI.
Head CT [**9-28**]:
IMPRESSION:
1. No acute intracranial abnormality.
2. Posteroperative chcanges of trans-sphenoidal resection of
pituitary mass, with decreased volume of mass within the sella
turcica.
Brief Hospital Course:
Patient was admitted on [**9-15**] via ED with complaint of Nausea and
vomiting for three days. Head ct was performed and a pituitary
mass identified.
Dx:Non-hem. pituitary lesion. After adequate work up and
consults with opthomology for visual field testing and
endocrinology, transpenoidal pituitary resection was conducted
on [**9-21**]. Post operatively her neuro exam was completely intact,
but there was question as to her pacemaker working appropriated.
It was interrogated, and deemed appropriate. Diuretic therapy
was withheld for several days post operatively to ensure the
absence of DI symptoms. She was restarted on Lasix on [**9-28**] at
60mg twice daily, as she appeared to be adequately diuresed
after surgery. Serum sodium and osm, as well as urine sodium,
osm, and specific gravity remained stable during
hospitalization, only requiring one dose of vasopressin on
POD#3. On POD#5, systemic heparin drip was started for her
mechanical valve. Coumadin was restarted on [**2163-9-27**]. She
received the following doses, 10mg, 10mg, 15mg, and 5mg during
her hospitalization. On [**10-2**] she was discharge to home without
the need of services with a INR of 2.5 and direction to follow
up with PCP on [**Name9 (PRE) 766**] AM for blood drawing to ensure adequate
INR level.
Medications on Admission:
Levothyroxine 75mcg', Digoxin 125mcg', Lopressor 50mg", Cartia
XT 120mg', Lisinopril 20mg', Lasix 120mg',Coumadin 5mg', Lipitor
10mg'.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain.
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
13. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: One (1)
Injection once a day: Inject into the muscle daily on days that
you feel ill and/or unable to take your oral steroid medication.
Disp:*QS 4 doses* Refills:*0*
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary Mass
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General 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.
?????? You may continue to take your oral anticoagulation as
prescribed before hospitalization. Please be sure to follow up
with your PCP in the next couple days for blood drawing to
ensure an appropriate blood level
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
If on any day you do not feel well enought to take your oral
steriods; be sure to take the injection version as prescribed.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast.
You also have the following appointments scheduled:
Endocrine:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37077**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2163-10-14**] 4:00
ICD9 Codes: 4254, 4168, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2579
} | Medical Text: Admission Date: [**2137-3-13**] Discharge Date: [**2137-3-26**]
Service:
NOTE: She was transferred to the [**Hospital1 139**] service from the
Medical Intensive Care Unit following her admission on [**2137-3-10**]. Therefore, I will provide a brief summary of her
History of Present Illness and Medical Intensive Care Unit
course.
HISTORY OF PRESENT ILLNESS: The patient presented to [**Hospital1 1444**] on the day of admission with
epigastric pain with radiation to her back which lasted
approximately two hours and then resolved spontaneously. In
addition, the patient had dark stools one day prior to
admission and moderate shortness of breath.
The patient was found to be hypotensive in the Emergency
Department with a blood pressure of 93/44 which responded to
IVFs. She was also given 1 unit
of packed red blood cells as her hematocrit was found to be
16.2 (down from 28.1) on last check on [**2137-2-26**].
23, [**2136**].
Gastroenterology was consulted in the Emergency Department
but did not wish to scope the patient immediately on
admission as she had a negative nasogastric lavage and
grossly guaiac-positive stool. After receiving the normal
saline and packed red blood cells, the patient became
increasingly short of breath. She required intubation for
respiratory distress after reversal of her do not
resuscitate/do not intubate order.
An electrocardiogram on admission was significant for 2-mm ST
depressions in V4 through V6 with no ST elevations. The
patient was admitted to the Medical Intensive Care Unit for
further management.
The patient then received 4 units of packed red blood cells
over the evening. On the morning of [**2137-3-14**] she
self-extubated. By that time, her hematocrit had increased
dramatically to 32.1. She was continued NPO on twice per day
proton pump inhibitor over the next two days.
On [**3-15**], the patient was significantly more stable and
underwent an esophagogastroduodenoscopy which showed
esophagitis without bleeding, nonbleeding angiectasias in the
antrum and stomach body, lack of blood in the stomach, and
nonbleeding angiectasias in the proximal duodenal bulb, with
no blood in the duodenum. The GI team felt that more
angiectasias were most probably in the small intestinal tract
and were the most likely cause of the patient's bleeding.
In the Medical Intensive Care Unit, the patient's respiratory
status was stable following self-extubation on 2 liters nasal
cannula. She had initially been started on Zosyn on
admission as she was extremely ........ and had persistent
bilateral consolidations on her chest x-ray. However, it was
discontinued on [**2137-3-15**] as it was felt the pneumonia
was simply remnant on the radiographic imaging.
The patient's creatinine began increasing following
admission, and on transfer to the [**Hospital1 139**] team on [**2137-3-15**] was 1.7 (up from a baseline of 0.7). This was felt to
be secondary to dehydration secondary to her Lasix and NPO
status.
An echocardiogram was performed on [**3-14**] to evaluate the
patient's cardiac status which showed the left and right
atrium to be normal size, dilated left ventricular cavity
with global hypokinesis with a LV ejection fraction of 10% to
20%, 1 to 2+ atrial regurgitation, 2+ mitral regurgitation,
2+ tricuspid regurgitation, and no pericardial effusions.
On [**2137-3-15**] before being transferred to the [**Hospital1 139**] team,
the patient was started on hydralazine and isosorbide
dinitrate for afterload reduction.
PAST MEDICAL HISTORY:
1. Congestive heart failure (with a left ventricular
ejection fraction of 10% to 20%).
2. Hypertension.
3. Chronic obstructive pulmonary disease.
4. Anemia; the patient had diverticulosis on past
colonoscopy and a gastrointestinal bleed per the History of
Present Illness.
5. Recurrent pneumonia.
6. Diverticulosis.
7. Status post shingles.
8. Trigeminal neuralgias.
9. Status post periorbital cellulitis.
10. Status post cholecystectomy.
11. Status post appendectomy.
12. Abdominal aortic aneurysm; which on last imaging was 4.5
cm in diameter and present along 8 cm of the aortic length.
A Surgery consultation was obtained on admission, but the
patient and her family declined to proceed with surgery.
13. Left tibial rod status post trauma.
ALLERGIES: OxyContin (which causes nausea and vomiting).
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg by mouth once per day.
2. Aspirin 81 mg by mouth once per day.
3. Serevent twice per day.
4. Lisinopril 2.5 mg by mouth once per day.
5. Lasix 40 mg by mouth once per day.
6. Combivent 1 to 2 puffs q.4h. as needed.
7. Neurontin 100 mg by mouth at hour of sleep.
8. Lipitor 10 mg by mouth once per day.
9. Desipramine 50 mg by mouth at hour of sleep.
SOCIAL HISTORY: The patient is the mother of nine children.
She currently lives with her daughter. She [**Hospital1 18038**] one pack
per day for 60 years but quit 3 years ago. Occasional
alcohol in the past but none currently.
PHYSICAL EXAMINATION ON PRESENTATION TO MEDICAL INTENSIVE
CARE UNIT: Vitals revealed her temperature was 97.7, her
blood pressure was 133/48, her heart rate was 104, her
respiratory rate was 23, and oxygen saturation was 100% on 4
liters nasal cannula. In general, a pale/cachectic lady.
Mildly tachypneic but appeared to be comfortable. Head,
eyes, ears, nose, and throat examination the pupils were
equal, round, and reactive to light. The oropharynx was
pale. The mucous membranes were moist. Edentulous. Neck
with positive jugular venous pulsation to the angle of the
jaw. Lungs revealed bilateral rales (right greater than
left) two thirds of the way up the lungs. Right base
bronchial sounds. No wheezing. Decreased breath sounds
throughout. Cardiac examination revealed tachycardic. A
regular rhythm. First heart sounds and second heart sounds.
No murmurs. The abdomen was soft, nontender, and
nondistended. Positive bowel sounds. Positive hepatojugular
reflux. Extremities revealed 1+ lower extremity edema to the
knees. Positive presacral edema. Neurologically, alert and
oriented times three. Moved all extremities.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count 15.1, her hematocrit was 16.2, and her platelets
were 420. INR was 1.3. Chemistries revealed sodium was 135,
potassium was 4.4, chloride was 95, bicarbonate was 33, blood
urea nitrogen was 32, creatinine was 1.2, and blood glucose
was 147. Albumin was 2.6, her amylase was 46, and her lipase
was 21. Creatine kinase was 31. Troponin was 0.15.
PERTINENT RADIOLOGY/IMAGING: Abdominal computed tomography
revealed stable abdominal aortic aneurysm without evidence of
rupture. Persistent consolidations including effusions in
the lung bases (right greater than left). No evidence of
congestive heart failure.
SUMMARY OF HOSPITAL COURSE: Please above History of Present
Illness for summary of the Medical Intensive Care Unit
course.
1. GASTROINTESTINAL BLEED ISSUES: The patient's hematocrit
remained fairly stable after she was moved to the floor until
the time of discharge. Throughout this time, she appeared to
be fairly hemoconcentrated. She required no further
transfusions. The patient did have one stool during this
time which was melanotic in nature and guaiac-positive. The
patient was continued on pantoprazole 40 mg intravenously
twice per day initially and then switched by mouth proton
pump inhibitor twice per day. It was recommended by
Gastroenterology that she follow up with an outpatient
colonoscopy in two to three months. However, this will not
be happening as the patient was discharged to home on
hospice.
2. DECOMPENSATED CONGESTIVE HEART FAILURE ISSUES: On [**2137-3-17**] the patient had two episodes of presumed flash
pulmonary edema. These responded to Lasix, morphine, and
sublingual nitroglycerin. A chest x-ray at that time showed
the volume overload, and the patient's lungs were consistent
with congestive heart failure.
The decision was made to move her to [**Hospital Ward Name 121**] Three and begin on
a nesiritide drip. The patient was continued on the
nesiritide drip which was titrated to a maximum dose of 0.02
until [**2137-3-25**]. A Congestive Heart Failure
consultation was obtained. The patient was also diuresed
with high-dose Lasix. The patient was also continued on
hydralazine for afterload reduction. Initially, the patient
was continued on her low-dose beta blocker, but this was
discontinued as they felt that she may have some component of
COPD which was worsening.
The Renal Service also became involved in the patient's care,
and suggested that she be loaded on high-dose Digoxin. She
was eventually started on low dose Digoxin and received this
for a total of three days. However, as it was not helping
the patient and she was being discharged home on hospice, it
was discontinued. On [**2137-3-25**], all of the patient's
diuretics were discontinued as she was appearing mildly dry
on examination, evidence of acute CHF had resolved on chest
x-ray, and her BUN and creatinine were becoming more
elevated.
Further workup for the cause of the patient's cardiomyopathy
and congestive heart failure were considered. It was
discussed if she should undergo a Persantine MIBI or
dobutamine echocardiogram. However, in discussion with the
patient and her family, she did not wish to pursue any
invasive interventions if a reversible defect was found.
This was felt to be a most reasonable decision given the
patient's worsening acute renal failure at this time which
would most probably not tolerate a dye load. The patient was
adamant about not wanting to ever be on dialysis. In
addition, given her recent gastrointestinal bleed the patient
would be a very high risk candidate for anticoagulation.
3. RENAL ISSUES: The patient had worsening acute renal
failure in the Medical Intensive Care Unit. This was felt to
be prerenal in nature which was confirmed by her fractional
secretion of sodium.
After moving to the floor, this improved slightly when the
patient was able to begin taking by mouth fluids. However,
during the last few days of admission, the patient's acute
renal function once again worsened. It continued to appear
prerenal in nature. In addition, the patient had extremely
large amounts of protein in her urine with a protein to
creatine ratio on [**2137-3-25**] of 7.8.
The Renal team was involved in evaluating possible causes for
the patient's proteinuria. Serum protein electrophoresis and
urine protein electrophoresis were sent which were negative.
The possibility was discussed if this was related to her
congestive heart failure; however, high-grade proteinuria
such as this is not seen with congestive heart failure.
Given her condition and desire to avoid any invasive
procedures, a renal biopsy was not pursued.
On [**2137-3-26**], the patient's urinalysis showed an
infection. At that time, her Foley catheter was removed and
she was started on a course of ciprofloxacin.
4. CHRONIC OBSTRUCTIVE PULMONARY DISEASE ISSUES: The
patient's shortness of breath did not appear to be related to
a chronic obstructive pulmonary disease exacerbation. She
had no increase in her cough or sputum production. She was
continued on her home inhalers.
5. HYPERCHOLESTEROLEMIA ISSUES: The patient was continued
on her atorvastatin.
6. PROPHYLAXIS ISSUES: Bowel regimen, proton pump
inhibitor, and pneumatic boots.
7. CODE STATUS ISSUES: Do not resuscitate/do not intubate.
CONDITION AT DISCHARGE: Poor but stable.
DISCHARGE STATUS: After a long discussion with the patient
and her family, it was clear their wish was for her to be
discharged to home on hospice to spend time with her family.
It was felt the patient would be an extremely poor candidate
for any cardiac intervention if a reversible defect was found
on testing given her worsening acute renal failure and recent
gastrointestinal bleed making her a poor candidate for
anticoagulation. Given her multiple system organ
dysfunction, it was felt that continued progress was
unlikely. The patient was very adamant in her desire to be
discharged to home. She felt comfortable on 2 to 2 liters
nasal cannula and wished to spend time with her family.
DISCHARGE DIAGNOSES:
1. Severe cardiomyopathy of unknown etiology.
2. Congestive heart failure (with a left ventricular
ejection fraction of 10% to 20%).
3. Chronic obstructive pulmonary disease.
4. Gastrointestinal bleed.
5. Anemia.
6. Acute renal failure.
7. Osteopenia.
MEDICATIONS ON DISCHARGE:
1. Salmeterol Diskus 1 inhalation q.12h.
2. Eyedrops 1 to 2 drops ophthalmic as needed.
3. Docusate 100 mg by mouth twice per day.
4. Hydralazine 20 mg by mouth q.6h.
5. Pantoprazole 40 mg by mouth once per day.
6. Lasix 40 mg by mouth once per day.
7. Albuterol 1 to 2 puffs inhaled q.4h. as needed.
8. Ipratropium 1 puff inhaled q.6h. as needed.
9. Senna one tablet by mouth twice per day as needed.
10. Isosorbide dinitrate 10 mg by mouth three times per day.
11. Phenergan 12.5 mg by mouth q.4-6h. as needed for nausea.
12. Ciprofloxacin 500 mg one tablet by mouth once per day
(for six days).
13. .......... 20 mg/mL solution 5 mg to 20 mg by mouth
q.2-3h. as needed (for dyspnea or anxiety).
14. Hyoscyamine sulfate 0.125 mg dissolving tablets one
tablet by mouth q.4h. as needed.
15. Ativan 0.5 mg one to two tablets by mouth q.4h. as
needed.
16. Albuterol nebulizers q.4-6h. as needed.
17. Atrovent nebulizers q.6h. as needed.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient will be
followed by hospice and will follow up with her primary care
physician (Dr. [**Last Name (STitle) **] as needed.
[**First Name8 (NamePattern2) **] [**Doctor First Name **], M.D.
Dictated By:[**Name8 (MD) 315**]
MEDQUIST36
D: [**2137-3-27**] 09:36
T: [**2137-3-28**] 10:23
JOB#: [**Job Number 55274**]
ICD9 Codes: 5070, 4280, 4254, 496, 5849, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2580
} | Medical Text: Admission Date: [**2101-1-26**] Discharge Date: [**2101-1-26**]
Date of Birth: [**2039-8-24**] Sex: F
Service:
DISCHARGE DIAGNOSIS: Intracerebral hemorrhage.
HISTORY OF PRESENT ILLNESS: This is a 61[**Hospital 4622**] [**Hospital 6107**]
Nursing Home resident, who was found unresponsive and with
emesis over her face at 3 p.m. yesterday. Her blood pressure
was 210/120. She was intubated at the field without any
medication. The patient was then taken to [**Hospital 487**] Hospital,
where a noncontrast head CT showed a right basal ganglia
hemorrhage extending into all her ventricles.
At baseline, the nursing home staff reports that the patient
is ambulatory and interacts with others. She became a
nursing home resident after having had an epidural abscess in
[**2100-5-6**]. History was obtained from notes that accompany
the patient today.
REVIEW OF SYSTEMS: Unable to obtain.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Diabetes.
3. Hypertension.
4. History of urinary tract infections.
5. History of epidural abscess.
6. Hypothyroidism.
7. Alcohol abuse.
ALLERGIES: Unknown.
MEDICATIONS:
1. Multivitamin.
2. Toprol XL.
3. Vitamin D.
4. Colace.
5. Levoxyl.
6. Epogen.
7. Insulin.
SOCIAL HISTORY: She lives in a nursing home. She has a
history of alcohol abuse. Her husband has a history of drug
use and alcohol abuse.
FAMILY HISTORY: Unknown.
PHYSICAL EXAMINATION: Temperature 98.2, pulse of 91, blood
pressure is 85/47. She is intubated. Generally, she is
unresponsive. HEENT: She has no carotid bruits.
Cardiovascular: She has a 3/6 systolic ejection murmur at
the apex radiating to her neck. Chest: Her lungs were clear
to auscultation bilaterally. Abdomen was soft, nontender,
nondistended. Extremities shows no clubbing, cyanosis, or
edema. Neurologic examination was performed under no
sedation. She is unresponsive to pain. She had a right
surgical pupil. Her left pupil was 4 mm and nonreactive.
She had no reaction to visual threat. She had no corneal gag
or oculocephalic reflexes. Motor examination: She had a
flaccid tone with no movement to pain. Sensory examination:
She has no response to painful stimuli. Reflexes are [**1-9**] and
symmetric throughout. Her toes were mute bilaterally.
Coordination and gait: We are unable to test.
ASSESSMENT AND PLAN: This is a 61-year-old African-American
female with hypertension, coronary artery disease, diabetes,
and epidural abscess with a right basal ganglia hemorrhage
with extension to the ventricles. This is most likely
secondary to hypertension. At this time her examination is
concerning for brain death.
HOSPITAL COURSE: Patient was evaluated by Neurosurgery. At
the time of admission, they felt that intervention is not
warranted based on that she already appeared brain dead.
When she was examined on the morning of [**1-26**] at 7:30
a.m. by the Stroke team, she met criteria for brain death
including lack of brain stem reflexes as well as lack of
response to nystagmus from cold water stimulation. She did
exhibit triple response reflexes in her lower extremities
bilaterally.
A repeat head CT was performed in the morning which showed
massive edema of the brain with cerebellar herniation and
brain stem herniation. Six hours after initial brain death
exam, a repeat brain death examination was performed. Again,
no brain stem reflexes were elicited and apnea test was
performed at this time. The apnea test show that she did not
take any spontaneous respirations. Her initial ABG had a
pCO2 of 46 and afterwards, her pCO2 was 66, this is after 17
minutes, she had no respirations at all. Her oxygenation was
sufficient during this time.
Patient was declared brain dead and the organ bank was
[**Name (NI) 653**], who declined organ donation except for corneas.
She was then extubated at approximately 2:45, and was
declared dead at that time. Her husband had been [**Name (NI) 653**]
and was brought in to see her. She will be transferred to a
funeral home.
[**First Name8 (NamePattern2) 4224**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 10209**]
MEDQUIST36
D: [**2101-1-27**] 09:08
T: [**2101-1-27**] 10:01
JOB#: [**Job Number 52930**]
ICD9 Codes: 431, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2581
} | Medical Text: Admission Date: [**2172-11-6**] Discharge Date: [**2172-11-16**]
Date of Birth: [**2114-6-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
AVASTIN
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
s/p RUL lobectomy
Major Surgical or Invasive Procedure:
[**2172-11-6**]
1. Right thoracotomy.
2. Right upper lobectomy.
3. Hand sewn closure of right upper lobe bronchial stump.
4. Buttressing of bronchial closure with intercostal muscle
flap.
[**2172-11-8**], [**2172-11-9**], [**2172-11-10**] Bronchoscopy
History of Present Illness:
58yo M with a stage III non-small-cell lung cancer diagnosed
over a year
ago. He was treated with chemoradiation therapy and was
documented to have persistent nodal disease in the mediastinum.
He therefore was treated to a definitive dose of radiation
therapy. However, he had persistent FDG avid disease in the lung
and after lengthy discussion, he was brought to the operating
room today for attempted pulmonary resection. Before the
operation, we met on several occasions and discussed both the
conduct and risks of the operation. He was well aware of the
risks including respiratory failure, pneumonia, inability to
completely resect the tumor, bronchopleural fistula and
death.
Past Medical History:
CAD, MI, HTN, HLD, COPD (FEV1 69% [**2171**]), CVA
PSHx: hip repair, elbow fracture repair
Social History:
Polish speaking. Former 40 year pack history. No etoh, no drugs.
Currently unemployed but former factory worker in Poland.
Family History:
sister with CAD. No family history of cancers
Physical Exam:
BP: 151/76. Heart Rate: 92. Weight: 170.4. Height: 70.75. BMI:
23.9. Temperature: 97.5. Resp. Rate: 18. O2 Saturation%: 100.
Gen: AAOx3, NAD
HEENT: no cervical or supraclavicular LAD, mucous membranes
moist, no icterus
Neuro: CN 2-12 grossly intact
CV: RRR, nml s1/s2
Resp: CTAB
Abd: soft, nt/nd, no masses
Ext: no c/c/e
Pertinent Results:
[**2172-11-6**] 03:26PM BLOOD WBC-12.0*# RBC-2.93* Hgb-9.2* Hct-27.9*
MCV-95 MCH-31.3 MCHC-32.9 RDW-16.3* Plt Ct-308
[**2172-11-8**] 01:42AM BLOOD WBC-11.3*# RBC-3.01* Hgb-9.1* Hct-27.6*
MCV-92 MCH-30.3 MCHC-33.0 RDW-15.9* Plt Ct-284
[**2172-11-14**] 05:40AM BLOOD WBC-9.2 RBC-2.80* Hgb-8.5* Hct-25.2*
MCV-90 MCH-30.4 MCHC-33.8 RDW-14.6 Plt Ct-418
[**2172-11-6**] 03:26PM BLOOD Glucose-179* UreaN-24* Creat-1.2 Na-139
K-5.1 Cl-110* HCO3-21* AnGap-13
[**2172-11-10**] 02:21AM BLOOD Glucose-132* UreaN-16 Creat-1.0 Na-136
K-4.1 Cl-104 HCO3-25 AnGap-11
[**2172-11-15**] 04:47AM BLOOD Glucose-111* UreaN-17 Creat-1.5* Na-140
K-4.0 Cl-100 HCO3-30 AnGap-14
[**2172-11-6**] 03:26PM BLOOD Calcium-8.4 Phos-3.7 Mg-1.2*
[**2172-11-15**] 04:47AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.6
Imaging:
[**2172-11-9**] CT Chest:
IMPRESSION:
1. Peristent postoperative right middle lobe atelectasis. No
evidence of
right middle lobe torsion. The middle lobe bronchus is occluded,
but the
right middle lobe pulmonary artery and draining vein are intact.
The findings
thus most likely reflect mucus impaction.
2. Postoperative changes in the right hemithorax, including
nonhemorrhagic
layering pleural fluid, additional fluid interposed between the
superior
segments of the right lower lobe and the mediastinum, and a
small right apical
pneumothorax. The upper lobe bronchial stump is unremarkable.
Two chest
tubes, one anterior and one posterior, are in expected position.
3. Moderate emphysema.
[**2172-11-10**] CXR
There are two chest tubes seen on the right side with each one
ending near the right lung apex. The right mid lung opacity
representing an
unresolved collapsed right middle lobe is unchanged. There are
no new
opacities which are of concern. Endotracheal tube terminates
approximately
4.7 cm above the carina and is adequately placed. Gastric tube
is seen to
course through the diaphragm into the stomach and is appropriate
in position.
Small right apical pneumothorax is unchanged. Overall, no
interval relevant
changes.
[**2172-11-15**] CXR :
Overall appearance of the chest is stable with minimal residual
subcutaneous emphysema in the right lateral soft tissues. A tiny
amount of residual air within the surgical bed at the right apex
in this patient status post right upper lobectomy. No focal
airspace consolidation is seen to suggest pneumonia. No
pulmonary edema or pleural effusions. Slight nodularity of the
right lateral pleura particularly at the base is likely
postoperative in etiology.
Brief Hospital Course:
The patient was admitted to the thoracic surgery service on
[**2172-11-6**] after he underwent a thoracotomy and RUL lobectomy.
Neuro: Post-operatively, the patient had an epidural with good
effect but with some hypotension and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications.
CV: The patient was initially hypotensive to the SBPs 80s
immediately post-op and he was placed on neo up to 0.5mcg. He
was monitored in the PACU overnight and was stable to be
transferred to the floor on POD1. On the floor, his BPs have
remained stable off neo but he was placed again on the neo when
he was intubated and sedated in the SICU. Once transferred to
the floor again, he remained off all pressors. Vital signs were
routinely monitored.
Pulmonary: The patient was initially stable from a pulmonary
point of view post-op. His post-op CXR showed RML collapse but
aerated RLL. However, on POD 2 on the floor, the patient began
to desat to mid 80s on room air. A CXR was obtained and showed
RML as well as RLL collapse. He was transferred to the SICU on
[**2172-11-8**] to undergo a bronchoscopy with BAL, which was sent for
studies. For the bronch, he was intubated and sedated. He had a
repeat bronch on [**2172-11-9**] and [**2172-11-10**] AM and suctioned out more
mucous from his RLL and RML. He was stable from a pulmonary
standpoint thereafter and extubated on [**2172-11-10**] after CXR showed
good stable RLL. His CT was placed to waterseal on [**11-10**] and
removed on [**11-11**]. Post-pull CXR was stable. He was transferred to
the floor on [**11-12**] and his pulmonary status remained stable,
although with desat to the mid 80s on ambulation. He has not
been anle to wean off of oxygen but his requirements are
decreasing daily. For that reason he will be sent home with
oxygen at 1-2 liters per minute and can gradually wean off over
time.
GI/GU: Post-operatively, the patient was given IV fluids. His
diet was advanced when appropriate once extubated in the SICU,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement. Foley was removed on [**11-12**]. Intake
and output were closely monitored. His Cr was elevated to 1.6,
FeNa was 0.7%, showing a likely pre-renal etiology. He was
bolus'd w/ 500cc NS two times on [**11-13**] and [**11-15**].
ID: Post-operatively, the patient was not placed on any
antibiotics. However, upon transfer to the SICU, he was started
on vanc, zosyn, and tobra for empiric coverage of HAP. He was
switched to PO augmentin once tolerating PO and due to a rising
Cr.
Cultures only showed respiratory flora but a 10d course of
antibiotics was planned.
The patient's temperature was closely watched for signs of
infection. He had a temperature of 101.3 on [**11-14**] and fever
workup was sent but have so far been negative.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on [**2172-11-16**] , he was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. His incision was healing well.
Medications on Admission:
ALBUTEROL SULFATE""PRN, AMLODIPINE 10',ATENOLOL 100',
ATORVASTATIN 80', ADVAIR 500-50', LISINOPRIL 40' NITROGLYCERIN
0.4prn, PROCHLORPERAZINE MALEATE 10"'prn nausea, TIOTROPIUM
BROMIDE 18', WARFARIN 5'
Discharge Medications:
1. Home oxygen
O2 1-2 liters continuous Dx COPD
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*7 Disk with Device(s)* Refills:*2*
4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**1-12**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for angina.
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 caps* Refills:*2*
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 MDI* Refills:*2*
8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): Hold for SBP < 100, HR < 60.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours): thru 11//[**9-20**].
Disp:*6 Tablet(s)* Refills:*0*
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Stage III A non-small-cell lung cancer.
Post op atelectesis
Acute blood loss anemia
Stage III A non-small-cell lung cancer.
Post op atelectesis
Acute blood loss anemia
Stage III A non-small-cell lung cancer.
Post op atelectesis
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough (it is normal to cough up
blood tinge sputum for a few days) or chest pain
-Incision develops drainage
-Continue to use your incentive spirometer 10 times an hour
while awake
Pain
-Acetaminophen 650 every 6 hours as needed for pain
-Dilaudid 2 mg every 3-4 hours as needed for pain
-No driving while taking narcotics
-Take stool softners with narcotics
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-No lotions or creams to incision site
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
-Oxygen via nasal cannula at 1-2 liters per minute. The VNA
will monitor your saturations and help you wean off.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2172-12-1**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes earlier to the Radiology Department on
the [**Location (un) **] in the [**Hospital Ward Name 23**] Clinical Center for a chest Xray.
Completed by:[**2172-11-16**]
ICD9 Codes: 5180, 2851, 4019, 2724, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2582
} | Medical Text: Admission Date: [**2189-6-18**] Discharge Date: [**2189-6-26**]
Date of Birth: [**2117-5-7**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: This is a 72 year old man with a
history of coronary artery disease, status post coronary
artery bypass graft, diabetes mellitus type 2, and end-stage
renal disease secondary to diabetes mellitus, who presents
with 24 to 36 hour history of chest pain, similar to that
which he has had in his past myocardial infarction. On two
days prior to admission, the pain began in his chest
associated with nausea but no shortness of breath or
diaphoresis. The pain continued until the next morning when
it was relieved by Nitroglycerin. The patient went to
dialysis and was pain free during dialysis. The patient was
transferred to [**Hospital1 69**] for
evaluation after hemodialysis.
Prior cardiac catheterization on [**2189-2-20**], had revealed
100% stenosis of the proximal right coronary artery, 60%
stenosis of the left main, 100% stenosis of the proximal left
anterior descending, 100% stenosis of the mid left anterior
descending, 70% stenosis of the first diagonal; 100% stenosis
of the proximal left circumflex; 40% stenosis of the left
internal mammary artery to left anterior descending, obtuse
marginal 1 to left anterior descending. All discrete
lesions. The D1 and left main coronary artery received
percutaneous transluminal coronary angioplasty with stents.
The saphenous vein grafts were known to be totally occluded.
Since then, the patient denies regular anginal chest pain at
home or shortness of breath. The patient does have severe
peripheral neuropathy secondary to his diabetes mellitus as
well.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis Tuesday, Thursday
and Saturday.
2, Diabetes mellitus type 2.
3. Peripheral neuropathy.
4. Status post myocardial infarction three years ago.
5. Status post coronary artery bypass graft in [**2184**] with
saphenous vein graft to the left circumflex marginal,
saphenous vein graft to the PDA and left internal mammary
artery to left anterior descending.
6. Status post cholecystectomy in [**2185**].
7. Status post spinal surgery with postoperative
meningitis.
8. History of cholesterol emboli.
9. History of hemorrhoidal bleeding.
PHYSICAL EXAMINATION: On admission, temperature 100.1 F.;
130/60; 85; 18; 98% on room air. The patient was in no acute
distress, appears comfortable, speaks easily. Neck revealed
no jugular venous distention, no carotid bruits and the neck
was supple. Lungs were clear to auscultation bilaterally.
Heart is regular rate and rhythm. III/VI systolic murmur at
the right upper sternal border. Abdomen distended but soft
and nontender. Positive bowel sounds. Extremities without
edema. Right foot with ulceration, gangrenous between the
first and second digits. The left foot has a Charcot
deformity. Pulses were Doppler-able bilaterally.
LABORATORY: White blood cell count of 8.9, hematocrit of
38.9, platelet count of 143, potassium 3.9, chloride 97,
bicarbonate 28, BUN 28, creatinine 4.6 and glucose 164. PT
13.3, PTT 28.0, INR 1.2. CK 116, MB 11, index 9.5, troponin
26.8. PSA 20.2.
Later CK were 89 and 98, troponin 23.6 and 38.9. Liver
function tests showed ALT 12, AST 25, LD 272, alkaline
phosphatase 216, total bilirubin 0.9, albumin 3.9, calcium
8.9, phosphorus 5.0, magnesium 1.8.
HOSPITAL COURSE:
1. Coronary artery disease: The patient had no elevation in
his CK although climbing troponin. He was taken to
catheterization on [**2189-6-19**], and received stents to his D1
and left circumflex. After catheterization, the patient did
well until about 12:30 a.m. on [**6-20**], when he was found to be
dyspneic, diaphoretic and in junctional bradycardia in the
50s, with [**Street Address(2) 93151**] elevation in the inferior leads, with ST
depressions in V5, V6, I and AVL. His blood pressure fell
and shortness of breath increased. The patient was intubated
and Dopamine started.
The patient was taken to the Catheterization Laboratory for a
relook at which time the re-look revealed left anterior
descending and left circumflex 100% occluded, and left main
without evidence of reocclusion. The left internal mammary
artery to left anterior descending was patent but distal left
anterior descending had diminished flow and it was stented at
that time in order to fill the right coronary artery through
collaterals.
An intra-aortic balloon pump and pacemaker were placed at
that time and he was transferred to the Cardiac Care Unit for
hemodynamic monitoring. The following day, the balloon pump
as well as the pacemaker were removed. The patient was
extubated on [**2189-6-22**] and the patient was returned to the
Floor on that day in stable condition. The patient had no
more chest pain throughout the hospital admission.
Pump: The patient had no signs of congestive heart failure
throughout this admission.
Electrophysiology Service: The temporary pacer placed during
the second trip to the Catheterization Laboratory was removed
and the patient remained event free on Telemetry.
2. Renal: The patient was continued on hemodialysis on
Tuesday, Thursday and Saturday.
3. Infectious Disease: The patient developed borderline low
grade fevers and actually did develop a temperature of 102.0
F., while in Cardiac Care Unit. Blood cultures and urine
cultures were taken, all of which revealed no growth.
The culture of his infected toe revealed Group B strep,
moderate growth, probable Enterococcus moderate growth and
Diphtheroids heavy growth. An Infectious Disease
consultation was called which recommended that the patient be
placed on Flagyl 500 mg p.o. q. eight hours and Levaquin 250
mg p.o., four times a day. As for his toe infection,
Podiatry and Vascular were both consulted. Vascular felt
that the patient was not a candidate for any invasive
treatments at this time including amputation. Podiatry
suggested x-ray of his toes to determine if there was any
possibility of osteomyelitis in the toe. The dressings were
changed and Podiatry followed the patient throughout his
admission.
4. Hematologic: The patient's hematocrit hovered around 28
the entire admission, however, fell slightly to 26 at one
point. The patient may receive blood in Dialysis for falling
hematocrit. There was no evidence of any bleed.
5. Neurologic: On [**2189-6-24**], the patient complained of
extreme lower extremity weakness on the right side. Prior to
admission, he has been able to ambulate with a walker and on
that day he stated that he could not move his leg. A
neurologic consultation was called and since the patient also
had an episode of bowel incontinence that morning, there was
a concern for cauda equina syndrome or sciatic nerve
compression, or some L5-S1 lesion. Neurology suggested and
MRI without contrast which was ordered for [**2189-6-25**].
The patient did regain some movement of his right lower
extremity and now is able to lift it and move against
gravity.
6. Diabetes mellitus: The patient was maintained on Lentis
26 units q. h.s. as well as covering sliding scale during the
day.
The patient was discharged in stable condition to [**Hospital3 103798**] in [**Hospital1 8**].
DISCHARGE MEDICATIONS:
1. Neurontin 1500 mg q. day divided as follows: 300 mg p.o.
at breakfast; 600 mg p.o. at 16:00; 600 mg p.o. at 21:00 each
day.
2. Flagyl 500 mg p.o. q. eight hours.
3. Levaquin 250 mg p.o. q.o.d.
4. Compazine 25 mg p.r. q. 12 hours.
5. Lantus 26 units q. h.s.
6. Tums one tablet p.o. three times a day.
7. Aspirin 81 mg p.o. q. day.
8. Protonix 40 mg p.o. q. day.
9. Nephrocaps one capsule p.o. q. day.
10. Lisinopril 5 mg p.o. q. day.
11. Plavix 75 mg p.o. q. day times 30 days.
12. Heparin 5000 units subcutaneously q. 12 hours.
13. Zoloft 50 mg p.o. q. day.
14. Ambien 5 mg p.o. q. h.s.
15. Imdur 30 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
2. He may possibly get an MRI in the future of his toe in
order to determine the depth of infection, if infection is
worsening.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**]
Dictated By:[**Last Name (NamePattern1) 4525**]
MEDQUIST36
D: [**2189-6-25**] 17:45
T: [**2189-6-25**] 18:16
JOB#: [**Job Number 103799**]
ICD9 Codes: 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2583
} | Medical Text: Admission Date: [**2120-6-10**] Discharge Date: [**2120-6-15**]
Date of Birth: [**2055-6-29**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
Fatigue, nausea and vomiting
Major Surgical or Invasive Procedure:
Cystoscopy with fulguration for bleeding points and evacuation
of large volume clot from bladder.
Bilateral nephrostomy tube placement
History of Present Illness:
The patient is a 64 yo F with metastatic breast Ca to brain,
vertebrae and ribs, presenting for recent fatigue, nausea, and
vomiting and found to have ARF. She noted hematuria associated
with right flank pain for 2 days, during which she passed clots.
She was seen today by her oncologist NP who noted abnormal labs
consistant with ARF. In the ED her creatinine was noted to have
risen [**Last Name (un) 834**] 1.0 to 6.1 in 10 days and her potassium was 6.1. An
EKG was performed which showed peak Ts, but she denies
palpitations, CP, and SOB. The pt has recently had MS [**First Name (Titles) 4245**] [**Last Name (Titles) 102819**]d with brain and spinal mets s/p XRT. She denies
frequency and urgency, but has had mild dysuria. over the past
few days. She denies fever, chills, and denies nausea currently.
.
In the ED, she received calcium gluconate 1 amp x1, bicarb 1 amp
x 1, D5 1 amp IV x 1, and 7 units regular insulin. Repeat K was
5.9.
.
Past Medical History:
1.Breast cancer with metastases to the bone, pelvis, spine, and
brain: Diagnosed in [**2112**] after a car accident when the lesion
was noted on an MRI.
- She was treated at that time with chemo and radiation
including Adriamycin.
- She was diagnosed with metastatic cancer to bone and her
vertebrae and ribs in the back in [**2114**].
- Chemo therapy included Herceptin, Navelbine & Zometa.Also has
had recent XRT (radiation to T12-L5). Had whole brain radiation
earlier this month ([**Date range (1) 94270**]/07) for bilateral frontal masses.
2. Hypertension.
3. GERD.
4. Cataracts
.
PAST SURGICAL HISTORY:
1. Breast reduction in [**2102**].
2. Breast cancer in [**2112**] status post meniscectomy.
3. Left hip replacement seven to eight years ago.
4. Multiple tendon releases and carpal tunnel release in
bilateral hands over the years.
Social History:
- Works as an administrative assistant at the statehouse. She
lives alone, has
3 children; her daughter and son-in-law live downstairs with
two children and
her son lives upstairs from her with children.
- She is divorced for over 30 years.
- She quit tobacco 32 years ago. She notes an occasional drink
and denies any
drugs.
Family History:
N/C
Physical Exam:
(Only post-procedure physical exam available below)
Vitals - T97.8 HR 73 RR 12 BP 162/81 O2 100% on CMV 600x20, FiO2
100%, PEEP 5
General - intubated, sedated, not responsive to sternal rub
HEENT - PERRL, ET tube in place
Neck - JVD difficult to appreciate
CV - RRR, no murmur, rub or gallop
Lungs - clear to auscultation anteriorally
Abd - soft, NT/ND, ++ BS; 3-way foley in place
Ext - warm feet, 2+ DP pulses b/l, no edema
Neuro: unresponsive to sternal rub
Skin: scar over L breast
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC
RDW Plt Ct
[**2120-6-10**] 09:30AM 10.3 3.45* 10.9* 31.5* 91 31.5 34.5
17.9* 159
UREA N-118* CREAT-6.6*# SODIUM-132* POTASSIUM-6.1* CHLORIDE-99
TOTAL CO2-14* ANION GAP-25*
ALBUMIN-3.6 CALCIUM-8.5 PHOSPHATE-8.6*# MAGNESIUM-2.4
ALT(SGPT)-22 AST(SGOT)-26 LD(LDH)-362* ALK PHOS-66 TOT BILI-0.3
PT-10.9 PTT-28.4 INR(PT)-0.9
.
URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.023
URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-<1
.
IMAGING
.
CT abd/pelvis: 1. Lingular consolidation and ill-defined
bibasilar nodularity that may be inflammatory in nature. A
followup chest CT in three months is recommended to assess for
stability. Small area of tree-in-[**Male First Name (un) 239**] configuration in the right
lower lobe may reflect sequelae of aspiration.
2. Bilateral hydroureteronephrosis. High-density material in the
distended urinary bladder suggestive of a hematoma which may
potentially be the underlying cause of ureteral obstruction.No
obstructing urinary tract calculi identified .
3. Diffuse sclerotic bony metastases.
.
Renal/bladder U/S: 1. Hydronephrosis, right greater than left.
2. Presumed hematoma within the bladder lumen. Please correlate
with subsequently performed CT.
Brief Hospital Course:
64 year old female with metastatic breast cancer admitted for
acute renal failure and hyperkalemia, found to have b/l
hydronephrosis and bladder hematoma.
.
# Acute Renal Failure: Pt found to have abdominal/pelvis mets,
explaining compression of ureters. She went for cystoscopy with
plan to place b/l stents. A 250cc old blood clot was removed.
There was mild bleeding from the mass at the bladder neck which
was cauterized. During this event, the ureteral orifices might
have been cauterized which were difficult to identify because of
her distorted anatomy. No stents could be placed due to her
anatomy but a 22F three-way foley with continuous bladder
irrigation which showed clearing after the procedure. She then
had b/l percutaneous nephrostomy tubes placed by IR to solve the
primary cause of her ARF. Nephrology also followed the patient
for her post-obstructive ARF. Her creatinine dramatically
improved after the procedures back down to its baseline. She
remains with nephrostomy tubes. Foley was removed. Her
hyperkalemia was managed and improved with improved renal
function. Repeat renal ultrasound showed near complete
resolution of hydronephrosis.
.
# Respiratory failure: Patient required re-inbuation after
dropping O2 sats and being unresponsive post-cystoscopy. This
reason is unclear as there was not excessive sedation during
procedure per urology and extubation was uneventful post-OP.
There were no signs of infection; her WBC is stable, and she has
been afebrile throughout. CXR done in PACU did not show any
acute findings compared to recent CXR VBG of 7.03/84/95 is
suggested of acute hypercarbic respiratory failure. She was
likely oversedated, especially in setting of ARF reducing
clearance of sedating meds. She was extubated in the ICU and did
very well following this, with excellent O2 sats on room air by
the time of discharge.
.
# MS changes: She had CT head on [**6-11**] following decreased
responsiveness after her procedure. Repeat CT was also
performed the following day. There were hyperdensities in the
frontal lobes, subarachnoid hemorrhage vs. hemorrhage into known
frontal mets. Neurosurgery was consulted and did not feel that
this was the cause of acute MS changes that prevented
extubation. No neurosurgical interventions were done. The
patient does have some baseline impaired MS. [**Name14 (STitle) **] and
electrolyte derangements from ARF were the most likely
contributors to her depressed mental status. Following
treatment and transfer back to the floor, her mental status
cleared back to baseline.
.
# Metastatic Breast Cancer (including brain metastases): Her
Keppra was continued for seizure ppx. She should continue twice
daily after discharge. No seizure occurred during this
admission.
.
# Hypertension: Her anti-hypertensive meds were adjusted as
needed. She will likely be discharged on metoprolol alone.
.
# Anemia: Hct baseline of 33, here has been trending down since
admission. This was likely due to gross hematuria and the 250 cc
blood clot found in the bladder. Hemolysis labs showed elevated
LDH but low-normal total bilirubin. Retic count is low at 0.8.
Anemia is likely due to marrow suppression and acute blood loss
from bladder. She required one unit PRBC transfusion and
responded appropriately.
Medications on Admission:
- Keppra 1000 mg twice daily
- Amlodipine 10mg daily
- Metoprolol 50mg [**Hospital1 **]
- Protonix
- Senna
- Colace
- Tylenol p.r.n.
- Trazodone 25 q.h.s. insomnia.
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
2. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Acute renal failure
Bilateral hydronephrosis
Breast cancer (metastatic)
Respiratory failure
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of an obstruction that was blocking
your urine flow. You had a procedure to help drain out your
urine.
Please keep all of your appointments with your doctors and take
[**Name5 (PTitle) **] of your medications as prescribed.
Return to the hospital if you note bloody or thick drainage from
your nephrostomy tubes, if you have back or abdominal pain, if
you have fevers, or if you notice any new symptoms that you are
concerned about.
The following medication changes were made while you were here:
We stopped your amlodipine, and we decreased your dose of
Metoprolol. Your doctors [**Name5 (PTitle) **] adjust these medications further
in the future.
Followup Instructions:
You have the following upcoming appointments:
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2120-6-17**] 10:10
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2120-6-17**]
3:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2120-6-20**]
8:45
Also, please make a followup appointment with urology in [**12-23**]
weeks. Please call ([**Telephone/Fax (1) 4376**] to set up this appointment
with Dr. [**Last Name (STitle) **].
ICD9 Codes: 5849, 2767, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2584
} | Medical Text: Admission Date: [**2107-3-14**] Discharge Date: [**2107-3-18**]
Date of Birth: [**2024-12-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
- Right internal jugular central line placement and removal.
- Two units of packed red blood cells transfused.
History of Present Illness:
Patient is an 82 year old male with history of CVA with left
sided hemiparesis, status post G-tube placement, diabetes
mellitus, and coronary artery disease who presents with fever
and hypotension. Patient is a resident at [**Hospital 100**] Rehab and was
in his usual state of health until yesterday evening at 7 pm
when he developed vomiting. At the time, his vital signs were at
baseline, and his exam was unremarkable. Through the night,
patient continued to have vomitus. The on call physician was
[**Name (NI) 653**] and prescribed levaquin 500 mg through his g-tube.
This morning, he was found to be hypotensive to 70/40, and a
temperature of 102. EMS was called.
.
In the [**Hospital1 18**] emergency room, his inital vital signs were:
temperature of 102.1, systolic blood pressures of 70's-80's,
heart rate of 116, respiratory rate of 22, and oxygen saturation
of 86% on 4 liters nasal cannlua. His white blood cell count was
22, lactate 4.7, creatinine of 3.8, and anion gap of 12. An
urine analysis demonstrated over 50 white blood cells. A chest
x-ray was unremarkable. Blood and urine cultures were drawn. He
was given 5 liters of normal saline and a right intravenous
jugular line was placed. He was started on levaquin 750 mg and
flagyl 500 mg, as well as a levophed drip. His blood pressure
increased to 85/52 and he was then transferred to MICU for
further management.
.
Patient not able to provide review of systems due to acute
illness.
Past Medical History:
- CVA with left-sided hemiparesis [**9-27**]
- Chronic renal insufficiency (creatinine 1.2 [**12-28**])
- Coronary artery disease
- Anemia
- Diabetes mellitus
- Prostate cancer
- History of c. difficile infection in setting of antibiotic
treatment
- Urinary tract infection ([**2106-12-21**]--E coli, treated per notes)
Social History:
Patient lives at [**Hospital 100**] Rehab. He was formerly an immunologist
in Russian, and has a PhD in that field. He has a supportive
daughter that is very involved in his care. He is Russian
speaking, and has been limited in activity since his stroke in
10/[**2105**]. He has some baseline dementia.
Family History:
Non-contributory.
Physical Exam:
Temp 97.4
BP 87/41
Pulse 110
Resp 19
O2 sat 100% nrb
Gen - awake, but not responding to questions
HEENT - anicteric, mucous membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - awake, no purposeful movements
Skin - No rash
Rectal in ED: stool guaiac negative
Pertinent Results:
[**2107-3-14**] 07:42PM PT-16.0* PTT-40.2* INR(PT)-1.4*
[**2107-3-14**] 05:33PM CORTISOL-104.0*
[**2107-3-14**] 05:26PM TYPE-ART PO2-129* PCO2-29* PH-7.39 TOTAL
CO2-18* BASE XS--5
[**2107-3-14**] 05:26PM LACTATE-3.4* NA+-135 K+-5.2 CL--108
[**2107-3-14**] 05:01PM CK(CPK)-167
[**2107-3-14**] 05:01PM CK-MB-6 cTropnT-0.14*
[**2107-3-14**] 05:01PM CORTISOL-97.3*
[**2107-3-14**] 04:03PM O2 SAT-65
[**2107-3-14**] 03:24PM URINE HOURS-RANDOM CREAT-46 SODIUM-17
[**2107-3-14**] 03:24PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2107-3-14**] 03:24PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2107-3-14**] 03:24PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0-2 RENAL EPI-0-2
[**2107-3-14**] 02:20PM TYPE-MIX
[**2107-3-14**] 02:20PM O2 SAT-95
[**2107-3-14**] 01:40PM CORTISOL-97.6*
[**2107-3-14**] 11:07AM TYPE-[**Last Name (un) **] PO2-34* PCO2-38 PH-7.32* TOTAL
CO2-20* BASE XS--5 INTUBATED-NOT INTUBA
[**2107-3-14**] 11:07AM GLUCOSE-95 LACTATE-4.3*
[**2107-3-14**] 10:30AM URINE HOURS-RANDOM
[**2107-3-14**] 10:30AM URINE UHOLD-HOLD
[**2107-3-14**] 10:30AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.009
[**2107-3-14**] 10:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2107-3-14**] 10:30AM URINE RBC-[**2-23**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**2-23**]
[**2107-3-14**] 09:19AM COMMENTS-GREEN TOP
[**2107-3-14**] 09:19AM LACTATE-4.7*
[**2107-3-14**] 09:10AM GLUCOSE-48* UREA N-118* CREAT-3.8*#
SODIUM-139 POTASSIUM-4.2 CHLORIDE-111* TOTAL CO2-16* ANION
GAP-16
[**2107-3-14**] 09:10AM estGFR-Using this
[**2107-3-14**] 09:10AM ALT(SGPT)-31 AST(SGOT)-23 CK(CPK)-50 ALK
PHOS-119*
[**2107-3-14**] 09:10AM LIPASE-8
[**2107-3-14**] 09:10AM cTropnT-0.10*
[**2107-3-14**] 09:10AM CK-MB-NotDone
[**2107-3-14**] 09:10AM ALBUMIN-1.9*
[**2107-3-14**] 09:10AM WBC-22.2*# RBC-2.54*# HGB-7.4*# HCT-22.8*#
MCV-90 MCH-29.0 MCHC-32.2 RDW-14.7
[**2107-3-14**] 09:10AM NEUTS-64 BANDS-16* LYMPHS-4* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-10* MYELOS-2*
[**2107-3-14**] 09:10AM HYPOCHROM-OCCASIONAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2107-3-14**] 09:10AM PLT COUNT-419#
.
Blood cultures: (two separate cultures positive for E. Coli)
[**2107-3-14**]
ESCHERICHIA COLI. CEFUROXIME SENSITIVITY CONFIRMED.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2107-3-16**]: No growth to date x2.
[**2107-3-17**]: No growth to date.
.
Urine culture:
[**2107-3-14**]: E. coli
[**2107-3-16**]: No growth, final.
.
Stool studies:
[**2107-3-17**]: Negative for c. difficile.
.
Chest x-ray
[**2107-3-15**]:
FINDINGS: In comparison with the study of [**3-14**], there is little
overall
change. Enlargement of the cardiac silhouette persists with
relatively mild
elevation of pulmonary venous pressure. This discordance
suggests the
possibility of cardiomyopathy or pericardial effusion.
Tortuosity of the
aorta is seen, but no evidence of pleural effusion or acute
pneumonia.
Right IJ catheter again is seen in place.
IMPRESSION: Little change.
.
EKG [**2107-3-15**]:
Baseline artifact. Sinus tachycardia. Left axis deviation. Left
anterior
fascicular block. Right bundle-branch block. Since the previous
tracing
no significant change.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
100 154 144 388/458 29 -72 54
.
Discharge Labs:
Sodium 146 Chloride 115 BUN 95 Glucose 338 AGap=16
Potassium 4.2 HCO3 19 Creatinine 2.4
Ca: 8.3 Mg: 2.0 P: 2.8
WBC 28.0 Hb 11.0 HCT 34.7 Plt: 344
N:78 Band:5 L:10 M:0 E:0 Bas:0 Metas: 4 Myelos: 3 Nrbc: 1
Neuts: SL. TOXIC GRANULATION
Neuts: FEW DOHLE BODIES
PT: 15.0 PTT: 32.7 INR: 1.3
.
Brief Hospital Course:
Patient is an 82 year old male with past medical history
significant for prior CVA with resultant left-sided
hemi-paresis, coronary artery disease, and renal insufficiency
who presented with hypotension and fever, found to have
urosepsis secondary to e. coli infection.
.
# Septic shock: At time of admission, patient met SIRS criteria.
He was initially continued on levophed and intravenous fluids
with a goal mean arterial pressure of over 60. Levophed was
quickly weaned off and the patient remained hemodynamically
stable. Urine and blood cultures returned positive for e. coli.
Antibiotic treatment was initiated with vancomycin and zosyn,
but was changed to ceftriaxone when sensitivites returned. At
time of admission, there was evidence of end-organ injury with
an elevated lactate of 4.7 on admission, which normalized
following resuscitation. He remained hemodynamically stable
during after admission to the intensive care unit, and was
transferred to the regular medical floor. Surveillance cultures
demonstrated no growth at time of discharge. His foley was
discontinued.
He will need to complete 14 days total of antibiotic therapy
(ceftriaxone)-- [**3-27**] will be his last day of treatment.
* Cultures will need to be followed up from [**Hospital 100**] Rehab.
.
# Renal failure: Patient's creatinine was elevated to 3.8 at
time of admission, with a BUN of 118. This was felt to likely
pre-renal in setting of sepsis and hypotension, likely leading
to acute tubular necrosis. His creatinine continued to trend
downward during his admission, and was 2.4 at time of discharge.
He continue to have good urine output. A renal ultrasound
demonstrated no evidence of obstruction or hydronephrosis. His
foley was discontinued and he was able to void without
difficulty.
* He will need a basic chemistry panel checked on the day after
discharge to ensure that his creatinine is stable or improving.
He will also need a basic chemistry panel checked 4-5 days after
discharge as well.
* He may benefit from gentle intravenous fluids if his
creatinine does not continue to improve or rises.
.
# Elevated troponin: Patient's cardiac enzymes bumped during his
stay. An EKG showed no acute changes. The bump in cardiac
enzymes was felt to be demand ischemia in setting of sepsis and
hypotension. His cardiac enzymes were trended and his troponin
peaked at 0.22. The elevated troponin may also have been due to
his acute renal failure. He reported no chest pain or other
symptoms.
- He was continued on an aspirin and statin.
- His beta-blocker was re-introduced at a low dose and titrated
up to his home dose once his blood pressure normalized.
- He was kept on telemetry but this was stopped after there were
no significant abnormalities.
.
# Anemia: By report to the intensive care team, patient was
anemic prior to his admission, though his baseline hematocrit
was unknown. There was no clear source of evidence of bleeding,
although there was a question of possible blood tinged vomitus
at rehab. He had no emesis during his stay. He was transfused
two units of packed red blood cells for a hematocrit of 22, with
appropriate bump in his hematocrit, which remained stable during
his stay. His stools were guaiac negative.
* Appropriate work up, if desired and not previously completed,
should be done on an outpatient basis.
* He should have a complete blood count checked with his labs at
one and 4-5 days after admission.
.
# History of clostridium difficile infection: Patient had
history of c. difficile infection, but had completed treatment
prior to admission. He was started on flagyl during his stay
given concerns about c. difficile infection, however his stool
was found to be c. difficile negative. His significant
leukocytosis was concerning for possible recurrent infection,
but he had no diarrhea, and his abdominal exam remained benign.
* Given that he is on ceftriaxone for his urinary and blood
stream infection, he should be monitored carefully for any
evidence of c. difficile recurrence and re-started on flagyl in
that event.
.
# Diabetes Mellitus: Patient was hypoglycemic at time of
admission, and initially did not require very much insulin.
After his tube feeds were re-started, his blood sugars then rose
to the 200's to 300's. His lantus was re-started at about half
of his home dose, 20 units, on the day prior to discharge. A
sliding scale of humalog was also used.
* His finger sticks should be monitored closely, and his lantus
dose will likely need to be increased as his infection improves.
.
# Leukocytosis: Patient developed significant leukocytosis
during his stay, with a WBC elevated to 40. At time of
discharge, it had trended downward to 28. This was felt to be
multifactorial due to his e. coli infection, and cortisol
stimulation testing that was completed while in the intensive
care unit. C. difficile infection was also considered, and he
should be monitored carefully for evidence of his. A
differential also revealed a few bands, however much improved
from time of admission.
* A complete blood count should be drawn the day and 4-5 days
after discharge to monitor his leukocytosis to ensure that it is
trending downward.
.
# Anxiety, depression: Patient's home doses of zoloft and xanax
were restarted prior to discharge.
.
# Gout: Patient's home medications of allopurinol and colchinine
were helding during his admission and may be re-started when
indicated.
.
# Hypernatremia, fluid status: Patient became markedly
hypernatremic during his stay, likely due to insensible losses
and aggressive normal saline resuscitation during his intensive
care unit stay. He was given D5 fluids to treat his
hypernatremia, and free water flushes were increased to 300 mL
q4 hours. His sodium improved slowly to 146 at time of
admission.
* He will need a basic chemistry panel checked the day after
admission, and again in [**3-26**] days to ensure that his sodium is
stable and within a normal range.
.
# Prophylaxis: A proton pump inhibitor was continued, and
heparin subcutaneous was used for DVT prophylaxis. Mouth care
was maintained with mouth swabs and moisturing agents.
.
# Nutrition: Nutrition was consulted and tube feeds were
re-started at their recommendation. Speech and swallow was
consulted, and it was felt that he should continue his NPO
status. A video swallow may be of assistance to further evaluate
this if desired, on an outpatient basis. His tubefeeding was as
follows: Nutren Renal Full strength, 45 ml/hr, with free water
flush 300 mL water every 4 hours.
.
# Access: A right internal jugular line was pulled prior to
discharge, and peripheral IV was kept in place.
.
# Code: Patient's code status was DNR/DNI based on discussions
with family.
Medications on Admission:
Colchcine 0.6 mg daily
Tramadol 25 mg per shift as needed
Tramadol 50 mg TID
Clonazepam 0.5 mg QHS
Clonazepam 0.25 mg QAM
Allopurinol 100 mg
Acetaminophen 650 mg TID
ASA 81 mg
Glargine insulin 44 units
Sertraline 50 mg daily
Bisacodyl 10 mg M,W,F
Miconazole Nitrate 2% topical [**Hospital1 **] PRN
Omeprazole 20 mg daily
Selenium 1 application 2x week
Metoprolol 50 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Note change in dose. If indicated, may be reduced to 81 mg.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Note new medication.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. CeftriaXONE 1 gm IV Q24H
5. Ceftriaxone 1 gram Piggyback Sig: One (1) Intravenous once a
day for 9 days: Last day will be [**3-27**].
6. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime: Will need to be titrated upward as
indicated.
7. Clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day: PRN
constipation, Mon, Wed, Fri.
12. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: One (1) Mucous membrane twice a day: For mouth
pain, avoid swallowing.
14. Miconazole Nitrate 2 % Lotion Sig: One (1) Topical twice a
day: PRN.
15. Selenium Sulfide 1 % Shampoo Sig: One (1) Topical twice a
week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnoses:
- Sepsis secondary to E. Coli urinary tract infection
- Acute renal failure
Secondary diagnoses:
- Prior CVA
- Diabetes mellitus
- Anemia
- Hypernatremia
- Coronary artery disease
- Prior c. difficile and urinary tract infections
Discharge Condition:
Discharge vitals: Blood pressure
Oxygen 100% on room air.
Discharge Instructions:
You were admitted due to low blood pressure and a fever. It was
found that you had a serious infection in your urine and blood,
and you were given antibiotics and fluids to treat this. You
were admitted to the intensive care unit and monitored
carefully. You will need to complete 14 days of antibiotics
total.
.
Please return to the hospital or discuss further with your
doctor if you develop low blood pressure, fevers, diarrhea,
chest pain, shortness of breath, or other concerning symptoms.
.
Your insulin dosing has been reduced, and will need to be
adjusted regularly as your needs change in the setting of your
infection.
.
You will need to continue on ceftriaxone until [**3-27**].
Followup Instructions:
The physicians at your facility will be following you closely
and monitoring your electrolytes, hematocrit, and white blood
cell count. Your insulin will also need to be adjusted. You will
complete two weeks total of antibiotic therapy.
ICD9 Codes: 5845, 5990, 2760, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2585
} | Medical Text: Admission Date: [**2165-7-16**] Discharge Date: [**2165-8-12**]
Service: MEDICINE
CHIEF COMPLAINT: Melena, lethargy.
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
male with a history of coronary artery disease status post
coronary artery bypass graft in [**2158**], insulin-dependent
diabetes mellitus who had a recent colonoscopy in [**2165-5-30**]
with three polypectomies who had been doing well post
procedure and presented to the Emergency Department on [**7-16**] with black stools times 10 to 12 days and increasing
fatigue. The patient also admits to periods of episodic
confusion but no bright red blood per rectum.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft in [**2158**], status post percutaneous transluminal
coronary angioplasty in [**2158**].
2. Hypertension.
3. High cholesterol.
4. Gout.
5. History of polio, question of bulbar polio.
6. Colonic polyps status post polypectomy times three in mid
[**2165-5-30**].
7. Dementia.
8. Non-insulin-dependent diabetes mellitus.
9. Osteoarthritis.
10. History of urinary incontinence.
MEDICATIONS ON ADMISSION:
1. Lasix 20.
2. Imdur 60.
3. Zebeta 10.
4. Folgard 1.
5. Allopurinol 300 daily.
6. K-Dur 20.
7. Lipitor 10.
8. Plavix 75.
9. Aricept 5.
ALLERGIES: Iodine dye, Bextra.
PHYSICAL EXAMINATION: Temperature 99.5, heart rate 88, blood
pressure 113/43, respiratory rate 22, oxygen saturation 95%
on two liters. General: Well-appearing, slightly confused
but oriented in no acute distress. HEENT: Pupils equal,
round and reactive to light. Sclerae anicteric. Oropharynx
clear. Moist mucosal membranes. Neck: Jugular venous
pressure approximately 9 cm. No lymphadenopathy. No bruits.
Chest: Lungs clear to auscultation bilaterally.
Cardiovascular examination: Regular rate and rhythm. No
murmurs, rubs or gallops. Abdomen slightly distended,
non-tender, bowel sounds slightly decreased. No
costovertebral angle tenderness. Rectal examination showed
occult blood positive in the Emergency Department.
Extremities: No edema, good dorsalis pedis pulses
bilaterally. Skin: No rashes. Neurologic examination:
Alert and oriented times three with some reinforcement.
Patient had slurred speech. Patient was found to have
positive asterixis. Strength was [**6-3**] upper and lower
extremities bilaterally.
LABORATORY EXAMINATION: White count 10.5 with 63% polys, 29%
lymphs. Hematocrit was 25.8, platelet count 258,000. Sodium
133, potassium 5.3, chloride 96, bicarb 23, BUN 67,
creatinine 5.6, glucose 96. Urinalysis was negative for
infection.
RADIOLOGY: Renal ultrasound performed showed a distended
bladder, some simple kidney cysts. Chest x-ray on admission
showed no acute infiltrates and slight cardiomegaly.
ELECTROCARDIOGRAM: Showed normal sinus rhythm at a rate of
86 with flat T-waves. No new EKG changes.
HOSPITAL COURSE: The patient was admitted to the Surgical
Intensive Care Unit
[**Unit Number **]. Gastrointestinal bleed: The patient had 10-12 days of
melena with a history of recent colonoscopy and
polypectomies. An nasogastric lavage in the Emergency
Department was negative for blood. The patient was
transfused to keep his hematocrit above 30. He was placed on
intravenous proton pump inhibitor and aspirin and Plavix were
held. An esophagogastroduodenoscopy was performed. The
findings were normal esophagus. The stomach had a submucosal
nodule of 5 mm of benign appearance in the antrum. No lesion
was seen that could have been responsible for patient's
melena. The patient continued to require transfusions off
and on throughout his hospital course. He bled
intermittently with melanotic to maroon liquid stools with
clots requiring up to five units of blood within one 24 hour
period. A repeat colonoscopy was performed on [**8-5**] to
assess for signs of bleeding. The patient was found to have
a small rectal polyp and a 5 cm ulcerated bleeding mass at
the ileocecal valve. This mass subsequently was found on
pathology to be a plasmacytoma. The patient continued to
bleed after the colonoscopy and the patient continued to
receive multiple units of blood in order to keep his
hematocrit above 30.
2. Multiple myeloma: The patient was thought to be in acute
renal failure in the Emergency Department. This was a new
development as his baseline creatinine had been 0.8 to 1.0.
He was found to have a significant amount of protein in the
urine based on the SSA study. Serum protein electrophoresis
showed 1% monoclonal light chain, however, urine protein
electrophoresis showed greater than 80% light chain disease.
The patient was started on therapy for his multiple myeloma.
He received two four day bursts of high dose Decadron at 40
mg a day with a rest of four days in between the two bursts.
He also received five treatments of plasmapheresis in order
to decrease the load of light chains in the serum. The
Hematology/Oncology Team considered adding another [**Doctor Last Name 360**] to
the patient's chemotherapeutic regimen, however, due to the
patient's hemodynamic instability and continuous
gastrointestinal bleeding, no other [**Doctor Last Name 360**] was added. The
patient underwent a bone marrow biopsy which showed 50%
plasma cell infiltration in the bone marrow.
3. Acute renal failure: The patient was found to be in
acute renal failure upon presentation to the Emergency
Department. This was found to be secondary to myeloma kidney
and overwhelming light chain protein load on the patient's
kidneys. He was started on hemodialysis and was seen by the
Renal consult team. The patient's renal failure continued
throughout his admission. He required hemodialysis on
Mondays, Wednesdays and Fridays and his kidneys did not
respond to therapy for the myeloma nor did they respond to
the hemodialysis because patient continued to have virtually
no urine output throughout his hospital stay.
4. Coagulopathy: Over the course of the [**Hospital 228**] hospital
stay, he developed a coagulopathy. He has had a rising PTT,
PT and slightly elevated INR. This was found to be secondary
to the plasmapheresis and the patient was treated with subcu
and oral vitamin K. He was given fresh frozen plasma and the
last two sessions of plasmapheresis were followed by fresh
frozen plasma transfusions. In addition, the patient was
found to have a thrombocytopenia which was also felt to be
related to his increased bleeding. He was taken off all
heparin products including heparin flushes and heparin with
dialysis. Heparin antibody was ordered. He was transfused
with platelets twice while bleeding. The decreased platelets
were felt to be secondary to nutrition, uremic platelets and
bone marrow infiltration. Inhibitor studies were ordered.
5. Tachycardia: On [**8-7**] the patient was found to be
tachycardic while at hemodialysis. His rate was 160 to 210.
An EKG showed narrow complex tachycardia consistent with new
onset atrial fibrillation. The patient was otherwise
hemodynamically stable with a blood pressure of 90-105
systolic, however, he was found to have 250 cc of maroon
blood per rectum. He was seen by the Medical Intensive Care
Unit team and was transferred to the Medical Intensive Care
Unit.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 9609**]
MEDQUIST36
D: [**2165-8-12**] 13:16
T: [**2165-8-12**] 13:37
JOB#: [**Job Number 103225**]
ICD9 Codes: 5845, 2851, 2765, 2875, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2586
} | Medical Text: Admission Date: [**2174-3-3**] Discharge Date: [**2174-3-5**]
Date of Birth: [**2102-12-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
AICD firing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 71 y.o male with history of [**Known lastname 15196**] disease
s/p aortic valve replacement, non-ischemic cardiomyopathy with
EF of 30% whose icd fired last night multiple times. Patient
reports that around 2 am he was using a urinal and felt a
"thump" when his ICD fired. He was assymptomatic and did not
have any chest pain, lightheadedness, or shortness of breath.
He was sent to [**Hospital **] Hospital where EKG/strip captured fast VT
(>200 bpm; K+ 4.1, Troponin-I 0.08). Mr. [**Known lastname **] had similar
episode in [**Month (only) 404**] and was started on amio in that setting. He
was sent to [**Hospital1 18**] for further evaluation.
.
In the [**Hospital1 18**] ED initial VS were HR 75, BP 94/72, RR 14, 99% 2L
NC. He was given a 500 cc NS bolus. He was seen by EP who
recommended lidocaine gtt at 4mg/min.
.
On arrival to the floor, the patient was comfortable and
assymptomatic. Interrogation of his ICD revealed he had been
shocked 6 times between [**3-2**] 21:58 and [**3-3**] 05:37. He had been
shocked out of afib into sinus rhythm.
.
On further review, the patient reports being admitted to [**Hospital **]
Hospital within the past month, discharged to [**Hospital1 **] for rehab
on [**2-4**] where he was started on albuterol and his blood pressure
medications were uptitrated for hypertension. He was then
transfered to [**Location (un) 169**] in [**Location (un) 1411**] for further rehab. On
review of systems he reports worsening vision with difficulty
[**Location (un) 1131**] small print for the past couple of weeks and
intermittant lightheadedness on sitting up that resolved about 5
days ago. Also positive for constipation with last bowel
movement 3 days ago. He denied any increased orthopnea, PND,
chest pain, shortness of breath, cough, fevers, chills, recent
flu-like illnesses or rashes. No nausea, vomiting, abdominal
pain, BRBPR, melena, or diarrhea. All other review of systems
were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes - none, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-Non-ischemic cardiomyopathy s/p BiV-ICD [**2167**], c/b pocket
hematoma
-Mechanical AVR for [**Year (4 digits) 15196**] disease
-Hx of atrial arrythmias, failed dofetalide and amiodarone,
recent failed cardioversion [**2173-12-23**]
-s/p AV junctional ablation and Pulm vein isolation
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD:
[**Company 1543**] BiV ICD, Concerto C154DWK
Atrial fibrillation
Aortic valve replacement
3. OTHER PAST MEDICAL HISTORY:
OSA compliant with BiPap
hypertension
hyperlipidemia
reactive airway disease
osteoarthritis
BPH
h/o chronic UTIs
h/o torn right quadriceps s/p surgical repair
Social History:
-Tobacco history: none, never
-ETOH: none
-Illicit drugs: none
Retired software engineer. Is married. Wife is currently at
[**Location (un) 169**] in [**Location (un) 1411**] with him recovering from pneumonia.
Patient has been undergoing rehab and has been confined to bed
and wheelchair - not yet walking again.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. History of hypertension and stroke on
mother's side of the family. Father had "lung problems".
Physical Exam:
VS: T= 96.5 BP= 81/61 HR= 84 RR=22 O2 sat= 100% 3L NC
GENERAL: Morbidly obese 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, no lymphadenopathy. JVP difficult to assess due
to habitus.
CARDIAC: RRR, normal S1, mechanical S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, obese, NT. No HSM or tenderness. No abdominial
bruits.
GU: Foley catheter in place
EXTREMITIES: No c/c/e. DP pulses 2+ bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission Labs:
[**2174-3-3**] 06:40AM BLOOD WBC-4.6# RBC-3.84* Hgb-11.6* Hct-33.1*
MCV-86 MCH-30.3 MCHC-35.1* RDW-14.4 Plt Ct-289
[**2174-3-3**] 06:40AM BLOOD Neuts-51.7 Lymphs-36.3 Monos-9.7 Eos-1.9
Baso-0.3
[**2174-3-3**] 06:40AM BLOOD PT-16.5* PTT-23.8 INR(PT)-1.5*
[**2174-3-3**] 06:40AM BLOOD Glucose-133* UreaN-20 Creat-1.5* Na-130*
K-4.6 Cl-95* HCO3-23 AnGap-17
[**2174-3-3**] 06:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.7
[**2174-3-3**] 01:50PM BLOOD TSH-2.8
[**2174-3-3**] 01:50PM BLOOD Free T4-1.7
[**2174-3-3**] 06:40AM BLOOD CK-MB-4 cTropnT-0.04*
[**2174-3-3**] 06:40AM BLOOD CK(CPK)-115
[**2174-3-3**] 01:50PM BLOOD CK-MB-4 cTropnT-0.03*
[**2174-3-3**] 01:50PM BLOOD CK(CPK)-106
[**2174-3-3**] 07:56PM BLOOD CK-MB-4 cTropnT-0.03*
[**2174-3-4**] 04:29AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2174-3-4**] 04:29AM BLOOD CK(CPK)-88
[**2174-3-3**] ECG: Baseline artifact. A-V paced rhythm with A-V
conduction delay and ventricular premature beats. Since the
previous tracing of [**2174-1-22**] there is probably no significant
change but baseline artifact on both tracings makes comparison
difficult.
[**2174-3-3**] AP CXR - IMPRESSION: No definite acute intrathoracic
abnormality. Limited study due to lack of imaging of the
costophrenic angles. Repeat imaging can be obtained if
clinically warranted.
[**2174-3-4**] Transthoracic Echo - The left atrium is markedly
dilated. The right atrium is markedly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF= 20%). No masses or thrombi are
seen in the left ventricle. The aortic root is mildly dilated at
the sinus level. A bileaflet aortic valve prosthesis is present.
The aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Dilated left ventricle with severe global systolic
dysfunction. Normally-functioning bileaflet aortic prosthesis.
Moderate mitral regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2173-10-20**], LV
systolic function has further deteriorated. Severity of mitral
regurgitation has increased. Pulmonary pressures are slightly
higher.
Brief Hospital Course:
Mr. [**Known lastname **] is a 71 year old male with non-ischemic
cardiomyopathy and history of atrial tachycardias, s/p failed
cardioversion and dofetelide who presents with multiple episodes
of v-tach/v-fib for which he was shocked with his AICD.
# V-tach/V-fib storm - Etiology of increased frequency of shocks
was unclear. There was no evidence for infection, exacerbation
of pulmonary disease, or worsening heart failure on
presentation. He was ruled out for an MI. The patient was
started on a lidocaine drip in the ED that was continued for 24
hours without further episodes of VT or VF. He was noted to be
difficult to arose the morning after admission that may have
been related to lidocaine toxicity. These symptoms resolved
later in the morning after the drip was stopped. EP also
recommended reloading the patient with amiodarone 400 mg [**Hospital1 **] for
2 weeks followed by 400 mg daily (instead of the previous 300 mg
daily), starting mexilitine 150 mg [**Hospital1 **], and starting magnesium
oxide 400 mg [**Hospital1 **]. He was continued on an aspirin and
beta-blocker.
# Heart failure - The patient's ejection fraction at last echo
was 30%. Repeat ECHO on this admission showed worse EF of 20%
with increased MR and higher pulmonary pressures. He did not
appear clinically volume overloaded and was likely actually
somewhat volume deficient. He was initially continued on lasix
80 mg PO BID, but lasix was discontinued due to worsening
hyponatremia. His beta-blocker was changed from carvedilol to
metoprolol to have decreased blood pressure effect as the
patient's systolic blood pressures were 80-100, and also to have
decreased pulmonary effect given his history of reactive airway
disease. He was started on a lower dose of carvedilol prior to
discharge. Spironolactone and losartan were continued at his
prior doses. He was placed on a 1.5L fluid restriction.
# Anticoagulation for aortic valve - The patient's INR on
presentation was 1.5. Goal INR is 2.5-3.5 given that he has a
mechanical aortic valve. He was not receiving his coumadin at
[**Location (un) 169**] for unclear reasons. He was started on a heparin
gtt and his coumadin was restarted.
# Hypertension/Hypotension: Patient's systolic blood pressure
was in the 80s on presentation. He likely has a low blood
pressure at baseline given his poor EF. He was continued on a
beta-blocker and [**Last Name (un) **] given its beneficial properties in patients
with heart failure.
# Hyponatremia: The patient's serum sodium was 130 on
presentation and dropped to 121 the following day. Urine sodium
was less than 10, indicating that the patient was appropriately
sodium avid. His hyponatremia was likely due to aggressive
diuresis and free water excess from IV medicactions (lidocaine,
heparin).
# Chronic Kidney disease - Creatinine at on presentation was
1.5, at the patient's baseline. Medications were renally dosed.
# Anemia - Normocytic, hematocrit at 33, appears at or above
baseline.
# Hyperlipidemia - Patient was placed on his prior regimen of
atorvastatin 10 mg daily
# Obstructive Sleep apnea - Patient was given BiPAP per his home
regimen.
# Obstructive and reactive airway disease: Patient was continued
on advair, montelucast, flonase, and ipratropium that he was on
at rehab. He was not given albuterol given his tachyarrhythmias
on presentation.
# Back pain - Patient had previously been on a lidocaine patch,
however, per pharmacy, IV lidocaine and mexiletine have similar
effects. This was not an issue for the patient during this
admission.
# BPH - Continued finasteride and flomax
# History of chronic UTIs - Patient was restarted on
nitrofurantoin which he was previously on for chronic
suppression.
# FEN: Low Na, heart healthy diet. 1.5L fluid restriction.
Replete lytes as needed.
# CODE: Full, confirmed with patient
Medications on Admission:
(From OMR with [**Location (un) 169**] changes noted):
amiodarone 300 mg daily
simvastatin 20 mg daily (was atorvastatin 10 mg previously)
carvedilol 25 mg [**Hospital1 **] (was 12.5 [**Hospital1 **] previously)
flomax 0.8 qhs
advair 250/50 [**Hospital1 **]
furosemide 80mg [**Hospital1 **]
losartan 25 mg daily
flonase 1 spray NU [**Hospital1 **]
nitrofurantoin 50mg daily - not receiving at [**Location (un) 169**]
protonix 40 mg [**Hospital1 **] (was omeprazole 20 [**Hospital1 **] previously)
proscar 5mg qd
spironolactone 25mg qd
warfarin 9mg STTS, 8mg MWF - not receiving at [**Location (un) 169**]
aspirin 81mg qd
calcium carbonate 500 mg [**Hospital1 **] - not receiving at [**Location (un) 169**]
multivitamin daily
.
fluid restriction 1L daily
Duonebs QID
singulair 10 mg daily
dulcolax 10 mg supp prn
miralax 17 g daily
colace 100 mg [**Hospital1 **]
tylenol 650 mg PO prn pain
potassium chloride 20 mEQ daily
lidocaine patch 5% daily
xanax 0.25 mg PO TID
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as
needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
16. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
20. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO twice a
day.
21. Losartan 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
22. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for anxiety.
23. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
24. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center - [**Location (un) 1411**]
Discharge Diagnosis:
Primary Diagnoses:
1. Ventricular tachycardia s/p ICD firing
2. Non-ischemic cardiomyopathy
3. Hyponatremia
Secondary Diagnoses:
1. Hypertension
2. Obstructive sleep apnea
3. Hyperlipidemia
4. Reactive airway disease
5. Benign prostatic hypertrophy
6. History of chronic urinary tract infections
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital because your heart went into a
very fast rhythm and your ICD fired multiple times. You were
started on a new medication intravenously and then transitioned
to a pill form called mexiletine. Your amiodarone dose was also
increased. You did not have any more fast heart rates or
shocks.
The following changes were made to your medications:
1. Increase amiodarone to 400 mg twice a day for 2 weeks (until
[**3-18**]) then take 400 mg daily
2. Start taking mexiletine 150 mg twice a day
3. Start taking magnesium oxide 400 mg twice a day
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-3-10**] 8:40
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2174-3-22**] 11:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-6-16**]
9:30
ICD9 Codes: 4271, 4254, 2761, 5859, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2587
} | Medical Text: Admission Date: [**2134-1-11**] Discharge Date: [**2134-1-22**]
Date of Birth: [**2070-3-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Lisinopril
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
chest pain and shortness of breath
Major Surgical or Invasive Procedure:
AVR/MAZE
History of Present Illness:
63 yo M with CAD, known AS (EF 40%, Peak gradient 88, mean
gradient 54, [**Location (un) 109**] 0.7), Atrial Fibrillation s/p cardioversion on
[**2133-12-24**] who presents from [**Hospital3 **] ED with flash
pulmonary edema.
Of note, further history per him: he states he started to have
chest pain and shortness of breath this past Thursday and was
told by the RN to double his lasix from 20 po qd to 20 po bid.
He states, on Thursday through Saturday, he felt okay with this
medication change, however on Sunday night, he stayed awake all
night burping and had to sit up straight in his bed to breath.
He also complained of PND/orthopnea. This went away and then
again this PM, his wife and him went out to dinner and he ate
salty foods including baked potato and lamb chops and went home
to lay down in bed and awoke with chest pressure and feeling as
though he had to gasp for air. He was also diaphoretic, but
denied any N/V/LH.
He called 911 with approximately 1 hr of SOB/CP and via
paramedics, he was found to be in acute pulmonary edema en route
to the ED. He of note called Dr. [**Last Name (STitle) **] with these complaints
and told to go to the ED stat. He was noted to be pale and
diaphoretic and initial VSS were BP 180/110, HR 120's, and 100%
on NRB. He was immediately given Lasix 100mg IV x 1, Nitrospray
x 3 en route and taken to [**Hospital3 **]. At [**Hospital3 **],
CXR was consistent with pulmonary edema and he was given nitro
tabs as well as he was started on a nitro gtt with BP falling
into 80-100's with HR 70's. He was also given Morphine 1mg IV x
1, phenergan, and albuterol. His nitro was stopped once his MAPs
decreased. His UOP with the Lasix 80IV x 1 was ~750cc. He was
transferred to [**Hospital1 18**] directly to the floor for further
management.
He currently denies any chest pain or shortness of breath and
feels comfortable now. He states at baseline, he cannot walk up
steps without SOB and sleeps on 2 pillows which has been stable.
Past Medical History:
1. Aortic stenosis (EF 40%, Peak gradient 88, mean gradient 54,
[**Location (un) 109**] 0.7)
2. Atrial Fibrillation - on amio, s/p DC cardioversion on
[**2133-12-24**]
3. CAD- mild (30% rca and 30% om1- [**11-29**])
4. BPH
5. GERD
6. TIA - [**2123**]
7. HTN
8. sciatica
9. chronic anemia ? early MDS
10. Bell's palsy
Social History:
Social History: lives with wife, daughter, and granddaughter,
retired park ranger, from [**Male First Name (un) **], no smoking, occasional
alcohol, no drugs.
Family History:
Family History: brother had heart problems when young
Physical Exam:
5' 6" 89 kg. PE: 98.4, 96/60, 70, 24, 100% on 2L (97% on RA)
Gen- lying in bed in NAD, AAOx3
Neck- JVD ~7cm at 30 degrees, supple
HEENT- moist MM, OP clear
CV- RR, nl S1, no S2 appreciated, +3/6 SEM at RUSB, radiation to
carotids bilaterally, +pulsus parvus et tardus
Chest- mild bibasilar crackles
Abd- soft, NT/ND, +BS
Ext- no C/C/E +2pulses bilaterally
Pertinent Results:
[**2134-1-11**] 06:10AM PT-14.0* PTT-25.4 INR(PT)-1.2
[**2134-1-11**] 06:10AM PLT COUNT-327
[**2134-1-11**] 06:10AM HYPOCHROM-1+
[**2134-1-11**] 06:10AM NEUTS-79.8* LYMPHS-13.7* MONOS-4.9 EOS-1.2
BASOS-0.4
[**2134-1-11**] 06:10AM WBC-11.3* RBC-3.75* HGB-11.2* HCT-33.4*
MCV-89 MCH-29.8 MCHC-33.4 RDW-14.9
[**2134-1-11**] 06:10AM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-1.9
[**2134-1-11**] 06:10AM CK-MB-NotDone cTropnT-<0.01
[**2134-1-11**] 06:10AM CK(CPK)-74
[**2134-1-11**] 06:10AM GLUCOSE-119* UREA N-24* CREAT-1.2 SODIUM-143
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-31* ANION GAP-11
[**2134-1-11**] 12:45PM URINE MUCOUS-RARE
[**2134-1-11**] 12:45PM URINE RBC-109* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2134-1-11**] 12:45PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
[**2134-1-11**] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2134-1-11**] 06:00PM PT-13.8* PTT-28.5 INR(PT)-1.2
[**2134-1-11**] 06:00PM PLT COUNT-347
[**2134-1-11**] 06:00PM HYPOCHROM-1+
[**2134-1-11**] 06:00PM NEUTS-76.8* LYMPHS-15.3* MONOS-5.2 EOS-2.2
BASOS-0.4
[**2134-1-11**] 06:00PM WBC-10.4 RBC-3.87* HGB-11.3* HCT-34.2* MCV-89
MCH-29.1 MCHC-32.9 RDW-14.9
[**2134-1-11**] 06:00PM TRIGLYCER-56 HDL CHOL-41 CHOL/HDL-2.8
LDL(CALC)-64
[**2134-1-11**] 06:00PM VIT B12-383
[**2134-1-11**] 06:00PM ALBUMIN-3.7 CHOLEST-116
[**2134-1-11**] 06:00PM ALT(SGPT)-15 AST(SGOT)-17 ALK PHOS-65
AMYLASE-64 TOT BILI-1.3 DIR BILI-0.4* INDIR BIL-0.9
[**2134-1-11**] 06:00PM GLUCOSE-120* UREA N-21* CREAT-1.1 SODIUM-140
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-28 ANION GAP-9
[**2134-1-11**] 06:14PM O2 SAT-97
[**2134-1-11**] 06:14PM TYPE-ART PO2-91 PCO2-43 PH-7.40 TOTAL CO2-28
BASE XS-0 INTUBATED-NOT INTUBA
[**2134-1-11**] 06:14PM TYPE-ART PO2-91 PCO2-43 PH-7.40 TOTAL CO2-28
BASE XS-0 INTUBATED-NOT INTUBA
[**2134-1-11**] 06:52PM %HbA1c-6.0*
[**2134-1-21**] 07:05AM BLOOD WBC-9.2 RBC-3.07* Hgb-8.7* Hct-27.8*
MCV-91 MCH-28.5 MCHC-31.5 RDW-15.4 Plt Ct-413
[**2134-1-22**] 06:05AM BLOOD PT-18.2* PTT-81.2* INR(PT)-2.1
[**2134-1-21**] 07:05AM BLOOD Glucose-81 UreaN-19 Creat-1.2 Na-138
K-4.9 Cl-101 HCO3-32* AnGap-10
[**2134-1-21**] 07:05AM BLOOD Mg-2.7*
[**2134-1-21**] 07:05AM BLOOD WBC-9.2 RBC-3.07* Hgb-8.7* Hct-27.8*
MCV-91 MCH-28.5 MCHC-31.5 RDW-15.4 Plt Ct-413
[**2134-1-22**] 06:05AM BLOOD PT-18.2* PTT-81.2* INR(PT)-2.1
[**2134-1-21**] 07:05AM BLOOD Glucose-81 UreaN-19 Creat-1.2 Na-138
K-4.9 Cl-101 HCO3-32* AnGap-10
[**2134-1-21**] 07:05AM BLOOD Mg-2.7*
[**2134-1-21**] 07:05AM BLOOD WBC-9.2 RBC-3.07* Hgb-8.7* Hct-27.8*
MCV-91 MCH-28.5 MCHC-31.5 RDW-15.4 Plt Ct-413
Brief Hospital Course:
A/P: 63 you M with PMHX of critical AS (EF 40%, Peak Gradient
88, Mean Gradient 54, [**Location (un) 109**] 0.7), nonobstructive CAD, Afib on
amiodarone s/p DC cardioversion [**2133-12-24**], HTN who presents with
flash pulmonary edema to OSH and transferred here for further
management.
1. COR- non-obstructive CAD history.
- ?cause for chest pain likely from critical AS instead of
obstructive coronary disease.
- will continue to ROMI
- continue ASA for now, pt states has not been held yet
pre-operatively. Will need to discuss with surgeons in AM if
want to continue ASA.
- continue lipitor but increase dose to 80 qd (as too late now
but can help progression of AS disease)
- hold carvedilol temporarily as BP now 90's likely secondary to
overdiuresis and multiple NTG tablets. And pt is pre-load
dependent with his critical AS and thus should not bring down BP
too much.
2. PUMP- Critical AS with EF 40%, Peak Gradient 88, Mean
Gradient 54, [**Location (un) 109**] 0.7
- Possibly, pt in CHF secondary to high salt intake at dinner
today. However, pt has also been having chest pain for the past
few days and may have coronary cause for CHF.
- Pt diuresed will with over 750 cc out.
- Pt appears euvolemic to hypovolemic now and since pre-load
dependent, will not diurese further.
- Continue lipitor for critical AS
- AVOID nitrates in critical AS patients, will be cautious with
carvedilol and holding parameters for SBP<100.
- [**Month (only) 116**] be able to proceed with surgery as clinically not in CHF
anymore. Contact CT surgery in AM.
- ?cath in AM to further assess for critical AS pre-operatively.
Will keep NPO for now.
3. Rhythm- LBBB with LAD. Currently in NSR. Hx of Afib s/p
cardioversion [**12-24**].
- continue amiodarone.
- If afib recurs, consider repeat cardioversion.
- Coumadin was held per CT surgeons in anticipation for cath on
[**1-13**]. Will continue to hold for now. Can rediscuss with attg in
AM of ?starting heparin gtt.
4. HTN - pt now relatively hypotensive given overdiuresis, lots
of nitro.
- hold cozaar/carvedilol (with BP parameters) until SBP>100.
5. Hx of TIA- continue ASA, lipitor.
6. PPX- SC heparin tid, PPI
7. Full CODE
Pt cathed on [**1-11**] which revealed mild diffuse disease with LAD
30%, CX 40%, RCA 40%, LVEDP 19, right dominant.
Referred to Dr. [**Last Name (STitle) **] for AVR/ Maze procedure and left atrial
appendage stapling , which he underwent on [**2134-1-12**]. Pt received
a [**Street Address(2) 6158**]. [**Male First Name (un) 923**] mechanical valve. Pt. had a brief period of
hypotension at induction per Dr.[**Name (NI) 3502**] operative note.
Transferred to CSRU in stable condition on Epinephrine, Insulin,
Nitroglycerin, and Levophed drips. Extubated in evening, and
remained on low-dose epi and levophed drips on POD #1. Pt went
back into afib and amiodarone and carvedilol were restarted.
Lasix diuresis started also. Chest tubes were DCed on POD #2
heparin was started for mech . valve anticoag. on POD #3, and
paciding wires DCed. Also unsuccessful at cardioversion.
Coumadin was also started and EP consult obtained. Transferred
to [**Hospital Ward Name 121**] 2 on POD #4 and began work with PT/ ambulation. POD #5
foley was replaced for retention. Had been restarted on Flomax.
Remained on heparin drip while coumadin dosing to elevate INR
took place. Also seen by case management for VNA eval on POD #6.
Continued to work with PT for increasing activity level. Taking
po percocet for incisional discomfort. Coreg and lasix both
increased on POD #9. DC ed home in stable condition on POD #10
with INR 2.1.
Medications on Admission:
1. ASA 81 qd
2. Amiodarone 200 [**Hospital1 **]
3. Lipitor 10 qd
4. Flomax 0.4 qd
5. Carvedilol 25 po bid
6. Cozaar 75 [**Hospital1 **]
7. Folate 400 mcg daily
8. Coumadin held on [**1-6**].
9. lasix 20 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO BID (2 times a day): [**Hospital1 **] x 2
weeks then QD.
Disp:*45 Capsule, Sustained Release(s)* Refills:*2*
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): [**Hospital1 **] x 2 weeks then QD.
Disp:*45 Tablet(s)* Refills:*2*
9. Warfarin Sodium 2 mg Tablet Sig: as directed Tablet PO once a
day: pt to take 5 mg Fri/Sat/Sun. Then as directed by [**Hospital 197**]
clinic .
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
s/p AVR/ Maze proc.
AS
AFib
HTN
BPH
GERD
TIA
anemia,
Bell's Palsy
legally blind
Discharge Condition:
good
Discharge Instructions:
INR check [**1-23**] and [**1-25**] with results to [**Hospital 119**] [**Hospital 197**]
clinic
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
[**Hospital 409**] clinic in 10 days
Dr [**First Name (STitle) **] in [**12-31**] weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2134-2-15**]
ICD9 Codes: 4280, 2765, 4019, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2588
} | Medical Text: Admission Date: [**2108-10-23**] Discharge Date: [**2108-12-25**]
Date of Birth: [**2108-10-23**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 59821**] is a 1.075 kg product of a 28
[**1-14**] week twin gestation born to a 20 year old primiparous
mother from [**Name (NI) 6687**]. The mother was admitted to the [**Hospital1 1444**] with cervical shortening in
mid [**Month (only) 359**]. She received tocolysis and betamethasone. There
were no sepsis risk factors identified. Her prenatal screens
included blood type O positive, antibody negative, hepatitis
B surface antigen negative, RPR nonreactive, Rubella immune,
Group B strep unknown. Delivery was by cesarean section.
Apgars of this twin was 8 and 9 at 1 and 5 minutes. She was
pink and active. She was given blow-by oxygen and stimulation
and brought to the NICU after visiting with her parents. On
examination, the infant was active, nondysmorphic. She was
well saturated and well perfused in room air. Her skin was
pink without lesions. Her anterior fontanelle was open and
flat. Her palate was intact. Her mucous membranes were moist
and pink. Her chest was comfortable, clear, mild tachypnea.
CV - no murmur, normal S1 and S2. Capillary refill was 2-3
seconds. Abdomen - benign. Genitalia - normal premature
female. Neurologic - nonfocal, age appropriate. Hips - stable
without clicks. Anus was patent.
Admission weight, as I said, was 1.075 kg. Head circumference
was 26.5, 50th percentile. Length was 36 cm, 25th-50th
percentile. Weight is 50th percentile for gestational age as
well.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: The
baby was placed on CPAP 6 cm with mask, FIO2 30 percent,
weaned to room air and remained on CPAP 5-6 cm to day of life
7 at which time she weaned to room air. She was started on
caffeine on day of life 1 and continued on caffeine through
day of life 28. She has had no spells off caffeine. Her
respiratory rate at this point is comfortable between 30 and
60 breaths per minute, nonlabored.
Cardiovascular: Initially, the baby received one normal
saline bolus. A UVC line was placed for central access. That
remained in place until day of life 7 at which time it was
replaced with a peripherally inserted central catheter. That
remained in place through day of life 14 for optimal
parenteral nutrition as enteral feeds advanced. On day of
life 2, a cardiac murmur was noted and an echocardiogram was
requested to rule out a patent ductus arteriosus. A small
restrictive duct was noted. However, she remained
hemodynamically stable. A repeat echocardiogram on day of
life 7 showed a small residual PDA with some left to right
flow. There was no treatment at that time either. Due to a
persistent flow murmur at the end of [**Month (only) 1096**], a cardiac
evaluation was performed which included a chest x-ray, a
hyperoxia test, four extremity blood pressures and a repeat
echocardiogram. These were all normal. The ductus was noted
to be closed at this time. The murmur was felt to be due to
peripheral pulmonic stenosis. The baby continues with
generalized edema. She is hemodynamically stable with apical
pulse noted to be 130's-150's.
Fluids, Electrolytes and Nutrition: The infant was started
on parenteral nutrition on day of birth. She continued on PN
through day of life 14 via central access. Trophic feeds were
started on day of life 5 and advanced to full feeds by day of
life 14 with mother's milk. Calories were increased gradually
over time with a maximum of 30 calories per ounce with ProMod
with good weight gain. Lytes were noted to be in the normal
range while on IV fluids. Calories were begun to be weaned on
day of life 52. She is currently on Similac 24 calories per
ounce, progressed from PG to PO feeds and has been all PO
feeds for 72 hours prior to discharge and currently taking
Similac 24 calorie po ad lib with a range of 140-160
cc/kg/day. She has normal urine output, stooling regularly
with the addition of prune juice. Her discharge weight was 2825
grams. Her head circumference 47 cm and length 18.5 in at
discharge.
GI: The infant is status post physiologic jaundice and
received phototherapy from day of life 1 through 6 for a peak
bilirubin of 5.3/0.3. There has been no history of feeding
intolerance and requires prune juice to stool regularly.
Hematologic: Initial CBC was obtained on admission which
revealed a white count of 7.4 with 17 polys, 0 bands, 64
lymphs. Hematocrit was 37.7, 306,000 platelets. She received
no blood products during her hospitalization. She was started
on iron and vitamin E at day of life 14 for anemia of
prematurity. The last hematocrit was obtained on [**12-5**] which
was 26 with a reticulocyte count of 5.6 percent.
Infectious Disease: The infant was initially ruled out for
sepsis with negative blood cultures. She received 48 hours of
ampicillin and gentamicin. She was noted to have a Monilial-
type diaper rash on day of life 20 and received nystatin
cream for five days for this. On routine surveillance
cultures, the infant was noted to be colonized with
methicillin resistant staph aureus and she remained
asymptomatic from this colonization.
Neurology: Serial head ultrasounds were obtained at one week
and one month of age. These were noted to be normal.
Sensory: Audiology hearing screening was performed with
automated auditory brainstem responses and the baby passed
with both ears.
Ophthalmology: ROP - The baby has had serial eye exams
starting on [**11-27**], repeated weekly since that time and noted
to have Stage 1, Zone 3 with three clock hours on the right
and one clock hour on the left. The last exam was on [**12-17**]. Follow-up is planned for two weeks following discharge Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Weymonth phone ([**Telephone/Fax (1) 59822**].
Psychosocial: Social worker has been involved with this
family. This mother and father live on [**Name (NI) 6687**] and were
able to visit on weekends only. They participated in care
regularly on weekends.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 45938**], Family
Practice, on [**Hospital1 6687**] phone ([**Telephone/Fax (1) 59823**] Fax ([**Telephone/Fax (1) 59824**].
CARE RECOMMENDATIONS AT TIME OF DISCHARGE: Feedings at this
time - continue with Similac 24 calorie po ad lib. The
average intake is 150 cc/kg/day. Medications include iron.
The current dose is 0.25 ml of 25 mg/ml. Car seat position
screening was performed and infant passed. State newborn
screening were sent [**2108-10-26**] [**2108-11-6**] and [**2108-12-4**]. The results
were in the normal range. Immunizations received include
hepatitis B vaccine No. 1 on [**12-3**]. On [**12-23**], the infant received
Hemophilus influenza B, IPV, pneumococcal conjugate vaccine
and Prevnar. On [**12-24**], the infant received the DTaP vaccine.
Synergist prophylaxis should be continued through the cold
and flu season on a monthly basis. Influenza immunization is
recommended 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. Follow-up appointments recommended are follow-up
with pediatrician, Dr. [**Last Name (STitle) 45938**], Ophthalmology appointment
following discharge and wick information has been provided
for the family as well.
DISCHARGE DIAGNOSES: Prematurity at 28 1/7 weeks, twin No.
1, respiratory distress syndrome, rule out sepsis, anemia of
prematurity, physiologic jaundice, apnea of prematurity,
retinopathy of prematurity, MRSA colonization.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 54678**]
MEDQUIST36
D: [**2108-12-24**] 19:06:16
T: [**2108-12-24**] 20:06:07
Job#: [**Job Number 59825**]
ICD9 Codes: 769, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2589
} | Medical Text: Admission Date: [**2178-3-6**] Discharge Date: [**2178-3-10**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
gentleman with a history of hypertension who had an episode
of [**8-1**] sharp substernal chest pain one hour prior to
admission. It occurred at rest. No shortness of breath. No
radiation. No nausea, vomiting, or diaphoresis. The patient
had a similar episode for two hours one day prior to
admission.
At baseline, the patient does not have any exertional rest
angina, orthopnea, or dyspnea on exertion. The patient was
admitted to the [**Hospital 1474**] Hospital three years ago with
similar chest pain and was cleared to go home.
The patient was brought to [**Hospital 1474**] Hospital by Emergency
Medical Service today. An electrocardiogram showed 1-mm to
2-mm ST elevations in leads II, III, V5, and V6. The patient
was given aspirin, Lopressor, nitroglycerin, and started on a
heparin drip. The patient was given morphine, and the pain
decreased to [**4-1**].
He was med flighted to [**Hospital1 69**]
for cardiac catheterization. At that time, his blood
pressure was 200/100. During catheterization, right atrial
pressure was 7, pulmonary artery pressure was 30/15, and
wedge pressure was 20. Catheterization revealed a 100%
totally occlusion of the first obtuse marginal, status post
cypher stent placement. There was diffuse left anterior
descending artery and right coronary artery disease. The
patient was started on Plavix and Integrilin. No chest pain
on arrival to the Coronary Care Unit. Electrocardiogram
showed resolution of ST elevations. The patient continued to
be hypertensive; however, he had a good response to
intravenous Lopressor and nitroglycerin.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
MEDICATIONS AT HOME:
1. Lopressor 50 mg by mouth twice per day.
2. Imdur 30 mg by mouth once per day.
3. Aspirin.
ALLERGIES: PENICILLIN (unsure of the reaction).
SOCIAL HISTORY: The patient was a prior carpenter. He is
widowed. He denies tobacco. He denies any drug use. He
uses occasional alcohol.
FAMILY HISTORY: No family history of coronary artery
disease.
PHYSICAL EXAMINATION ON PRESENTATION: On examination,
temperature current was 98.7 degrees Fahrenheit, his heart
rate was 60, his respiratory rate was 15, his blood pressure
was 124/84, and his oxygen saturation was 100% on 2 liters.
Ins-and-outs positive one liter. The patient was comfortable
and in no apparent distress. Head, eyes, ears, nose, and
throat examination revealed pupils were equal, round, and
reactive to light and accommodation. The extraocular
movements were intact. The neck was supple. There was 8 cm
of jugular venous pulsation. The lungs were clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. There were no murmurs,
rubs, or gallops. The abdomen was soft, nontender, and
nondistended. There were normal active bowel sounds.
Extremities revealed the lower extremity was cool with 2+
dorsalis pedis pulses bilaterally. There was needed.
Neurologically, alert and oriented times three. There were
no focal signs. Groin status post catheterization revealed
right venous and arterial sheath with no hematoma.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram prior to
catheterization revealed a normal sinus rhythm at 60 beats
per minute. There was a normal axis and normal intervals.
There were ST elevations in II greater than III and F/V6. No
T wave inversions. There were 1-mm ST depressions in V3.
Status post catheterization, resolution of ST elevations. T
wave flattening was present in II, III, and aVF, and V4
through V6.
Cardiac catheterization on [**2178-3-6**] status post
first obtuse marginal stent, left anterior descending artery
80% mid, first diagonal 70%, second diagonal 70% at the
origin, left circumflex 100% at the first obtuse marginal,
right coronary artery 70% at the origin and 90% mid.
PERTINENT LABORATORY VALUES ON PRESENTATION: Creatine kinase
on admission to [**Hospital1 69**] was 175.
White blood cell count was 9.4, his hematocrit was 42.3, and
his platelets were 218. Chemistries revealed sodium was 138,
potassium was 4.1, chloride was 102, bicarbonate was 27,
blood urea nitrogen was 25, and his creatinine was 1.5.
ASSESSMENT: The patient is an 84-year-old gentleman with a
history of chronic renal insufficiency, hypertension, and
hypercholesterolemia who presented with an inferolateral
distribution myocardial infarction involving the first obtuse
marginal. The patient is status post cypher placement.
SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. CORONARY ARTERY DISEASE ISSUES: The patient was
continued on aspirin and was started on Plavix. He was
continued on statin, beta blocker, and ACE inhibitor.
The patient had an echocardiogram 24 hours after the event
which showed mild left atrial dilation, mild regional left
ventricular dysfunction, impaired left ventricular
relaxation, an ejection fraction of 45% to 50%, and
hypokinesis at the basal inferior wall and basal mid
inferolateral walls.
The patient was to have a follow-up echocardiogram in four to
six weeks and was to follow up with Dr. [**Last Name (STitle) **] for further
management.
2. CHRONIC RENAL INSUFFICIENCY ISSUES: The patient's
creatinine trended down during this admission and was at 1.3
at the time of discharge. The patient was to have his
creatinine monitored as an outpatient.
DISCHARGE STATUS: To home.
CONDITION AT DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg by mouth once per day.
2. Plavix 75 mg by mouth once per day.
3. Lipitor 20 mg by mouth once per day.
4. Protonix 40 mg by mouth once per day.
5. Lisinopril 5 mg by mouth once per day.
6. Atenolol 50 mg by mouth once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**Last Name (STitle) **] and his primary care physician
within two weeks of discharge.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 2706**]
MEDQUIST36
D: [**2178-5-30**] 10:32
T: [**2178-5-30**] 10:51
JOB#: [**Job Number 53247**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2590
} | Medical Text: Admission Date: [**2133-6-10**] Discharge Date: [**2133-6-16**]
Date of Birth: [**2072-10-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain, presyncoble episode and dizziness
Major Surgical or Invasive Procedure:
[**2133-6-12**] Coronary artery bypass graft x 5 (Left internal mammary
artery to left anterior descending. Saphenous vein graft to
ramus, Saphenous vein graft to OM1 to OM2, Saphenous vein graft
to PLV)
[**6-10**] Cardiac Cath
History of Present Illness:
60 year old male with a history of hypertension, psoriatic
arthritis who has suffered from "costochondritic chest pain"
with exertion over the past few years. Finally underwent stress
test with exercise portion showing ischemic ST changes. Echo
portion unrevealing. Went to diagnostic cath with severe LMCA
70-80% stenosis, otherwise with 70-80% lesions in LAD, Cx, RCA.
He is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Psoriatic arthritis
Gastroesophageal reflux disease
Depression
s/p right Rotator cuff repair
Social History:
He is an LPN.
He has a male partner x23 years. They are currently not sexually
active(His partner is HIV positive). They have not had sexual
relations since his HIV diagnosis, Mr. [**Known lastname 31620**] last HIV test
was five years ago.
+ tobacco/He smokes one-half pack a day for 15 years.
+ ETOH use.
Occasional recreational drug use (Marijuana 2-3x/week).
Family History:
His father died of a heart attack at age 63.
His mother had [**Name2 (NI) 499**] cancer at age 64. Paternal grandmother
with cancer 82.
No known h/o sudden cardiac death.
Physical Exam:
Pulse:72 Resp:18 O2 sat:100/RA
B/P Right:169/97 Left:141/91
Height:5'9" Weight:144 lbs
General: NAD, WGWN
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] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit: no bruits
Pertinent Results:
Echo [**2133-6-12**]: Pre-CPB: No spontaneous echo contrast is seen in
the left atrial appendage. Overall left ventricular systolic
function is low normal (LVEF 50-55%). Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion. Post-CPB: The patient is
in SR, on noinotropes. Preserved biventricular systolic fxn.
Trace MR, no AI. Aorta intact.
Carotid U/S [**2133-6-11**]: Right ICA no stenosis. Left ICA <40%
stenosis.
Cardiac cath [**2133-6-10**]: 1. Selective coronary angiography of this
right dominant system revealed left main and two vessel coronary
artery disease. The LMCA was found to have a 70-80% distal left
main stenosis. The LAD had diffuse 40% stenosis with 40%
stenosis at the origin of a larger 2nd diagnonal branch. The LCX
had 70-80% proximal and mid-LCX stenosis extending to include
origins of 1st and 2nd OM. The ramus has a 70% proximal
stenosis, but is a small vessel. There are multiple sequential
50% stenosies within the proximal and distal RCA with a 70%
stenosis in mid-RCA. 2. Limited resting hemodynamics revealed
systemic arterial normotension with central aortic pressure of
130/77.
Admission:
[**2133-6-10**] 12:35PM PT-12.4 INR(PT)-1.0
[**2133-6-10**] 03:00PM PLT COUNT-265
[**2133-6-10**] 03:00PM WBC-11.2* RBC-4.34* HGB-13.3* HCT-38.8*
MCV-89 MCH-30.7 MCHC-34.4 RDW-13.9
[**2133-6-10**] 03:00PM %HbA1c-5.8 eAG-120
[**2133-6-10**] 03:00PM calTIBC-348 VIT B12-473 FERRITIN-53 TRF-268
[**2133-6-10**] 03:00PM ALBUMIN-3.9 CALCIUM-7.3* MAGNESIUM-2.2
IRON-59 CHOLEST-183
[**2133-6-10**] 03:00PM ALT(SGPT)-3 AST(SGOT)-5 CK(CPK)-60 ALK
PHOS-5* AMYLASE-2 TOT BILI-0.5 DIR BILI-0.1 INDIR BIL-0.4
[**2133-6-10**] 03:00PM GLUCOSE-107* UREA N-11 CREAT-0.3* SODIUM-129*
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-26 ANION GAP-11
[**2133-6-10**] 04:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-NEG
Discharge:
[**2133-6-16**] 04:50AM BLOOD WBC-11.5* RBC-3.47* Hgb-10.7* Hct-31.2*
MCV-90 MCH-30.9 MCHC-34.4 RDW-14.0 Plt Ct-266
[**2133-6-16**] 04:50AM BLOOD Plt Ct-266
[**2133-6-16**] 04:50AM BLOOD Glucose-128* UreaN-19 Creat-1.1 Na-140
K-4.6 Cl-101 HCO3-29 AnGap-15
Radiology Report CHEST (PORTABLE AP) Study Date of [**2133-6-15**] 7:38
AM
INDICATION: Status post CABG, follow up bilateral
pneumothoraces.
Final Report: [**MD Number(3) 25633**] x-ray showing bilateral pneumothoraces,
unchanged from prior exam. There is also unchanged lung
scarring. Cardiomediastinal and hilar contours appear normal.
IMPRESSION: Stable appearance of bilateral pneumothoraces.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42222**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Brief Hospital Course:
Mr. [**Known lastname 9035**] was initially admitted to the cardiology serviceto
work up exertional chest pain for several years. He underwent
stress testing which showed ischemic ST changes. He was then
brought for a cardiac catheterization which revealed severe left
main and three vessel disease. Cardiac surgery was consulted and
he underwent usual pre-operative work-up. On [**6-12**] he was brought
to the operating room where he underwent a coronary artery
bypass graft x5. Please see operative report for surgical
details. In summary he had: Urgent coronary artery bypass graft
x5: Left internal mammary artery to left anterior ascending
artery; saphenous vein sequential graft, obtuse marginal-1 and
2; saphenous vein grafts to ramus; saphenous vein graft
to posterior left ventricular branch. Endoscopic harvesting of
the long saphenous vein. His cardiopulmonary bypass time was92
minutes with a crossclamp of 81 minutes. He tolerated the
operation well and following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. He was
hemodynamically stable in the immediate post-op period, was
weaned from sedation, awoke neurologically intact and was
extubated. On post-op day one he was started on beta-blockers
and diuretics and was gently diuresed towards his pre-op weight.
Also on post-op day one he was transferred to the step-down
floor for further recovery. All tubes lines and drains were
removed per cardiac surgery protocol. The remainder of his
hospital course was uneventful. Over several days, beta blockade
was advanced as tolerated. He remained in a normal sinus rhythm.
He continued to make clinical improvement with diuresis and was
eventually cleared for discharge to home on postoperative day 4.
Medications on Admission:
CLOBETASOL - (Prescribed by Other Provider) - Dosage uncertain
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth once a day
(started one week ago)
SIMVASTATIN 10mg 1tab po qhs (one week ago started)
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release(E.C.) - 1 Tablet(s) by mouth twice a day
SERTRALINE - (Prescribed by Other Provider) - 100 mg Tablet - 1
Tablet(s) by mouth once daily
NAPROXEN SODIUM [ALEVE] - OTC prn joint pain
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. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
4. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Lopressor 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 5
Past medical history:
Psoriatic arthritis
Gastroesophageal reflux disease
Depression
s/p right Rotator cuff repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet as needed
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage.
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the
chart.
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check: Cardiac surgery office Wednesday [**6-24**] at 10:15 am
Surgeon: Dr. [**First Name (STitle) **] on Monday [**7-6**] at 1:15 pm
Cardiologist: Dr[**Name (NI) 3733**] [**Telephone/Fax (1) 62**] on [**7-17**] at 1:20 pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-10**] weeks [**Telephone/Fax (1) 250**]
**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:[**2133-6-16**]
ICD9 Codes: 2761, 2768, 4019, 2724, 3051, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2591
} | Medical Text: Admission Date: [**2125-5-21**] Discharge Date: [**2125-5-31**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Thalamic bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 year old with h/o CAD, HL, HTN, AF s/op Coumadin, BG bleed
[**4-20**] (gait unsteadiness, confusion, vertigo, found moderate L
BG ICH with IV extension, also had microbleeds on GRE* so
Coumadin stopped indefinitely), was discharged with many
medications (including amiodrarone, atenolol and aspirin),
failed
follow-up. He was discharged home with services but after a few
days went to inpatient rehab for several weeks. He now takes no
medications other than stool softeners.
7 months ago his daughter came to collect her parents with the
bad snowstorms in NH as they had no power. They were taken to
LA,
[**State 4565**] for 7 months but he kept saying he wanted to go back
to NH. Apparantly all meds and all medical care was put on hold.
2 weeks ago they finally moved back to their house in NH. Of
note, his wife says that other than his bleed and his colon
surgery, he has no past medical history whatsoever.
At baseline, he walks with a cane, has a walker but doesn't use
it. His R leg was the weaker leg since the bleed. Some modest
daily exercise on a local trail in [**Last Name (un) **]. He was able to his
bills
and was reportedly still very sharp. His speech was mildly
slurred.
This past week he asked weird questions ("it's Tuesday right" x2
when it was Wednesday), and he has been complaining of dizziness
for several months, on standing. This AM he stayed in bed, and
his wife found him struggling to get upright. Later he rolled
out
of bed on the floor. The neighbors were alarmed, 911 was called.
In HFH CT scan reveiled L thalamic/GP bleed.
ROS AS above. Constipation. Dizziness with standing.
Past Medical History:
-axillar abscess, s/p I & D
-PAF
-CAD, s/p CABG [**2116**] with peri-operative DVT
-chronic RLE edema
-SNHL secondary to bomber in WWII
-HCV
-HTN
-HLD
-hemicolectomy for perforated diverticulitis '[**10**].
-R knee arthroscopy
Social History:
As above. Has son in FL and daughter in CA. Wife is close to
86 and is here with him. Smoked from '[**55**]-'[**60**], none since. No
alcohol. Live in NH, they have known their neighbors for many
years.
Physical Exam:
Cardiac S1S2 remote heart tones but with low-pitched
pansystolic murmer. Pulm clear. Abdomen supple. Extremities
warm.
NE Alert, drifts off when left alone. Just mildly inattentive
but
sufficiently cooperative. Oriented. Naming intact (limited
testing). Comprehension intact for neurological exam
instructions. Mild perseveration.
Severely dysarthric speech, short sentences, fluent.
PERRL, EOMI, dense R visual neglect, registers finger movements
in R visual field though. R facial droop. Tongue straight.
Formal strength testing complicated but appears 4+ on R. L full.
R sided dense hemineglect, but no extinction to DSS. Sensation
intact to touch, and joint position sense intact (L more
reliable).
Reflexes 1+ symm, R patellar 2+, L 1+, toe up on R (old?).
Gait deferred.
Pertinent Results:
Echo: Severe AS, trace AR, LVH, EF >75%, mild LAE.
CT w/o contrast:
1. Large hemorrhage in the left basal ganglia extending in the
left thalamus
and lateral ventricles bilaterally. Mild shift of normally
midline
structures.
2. Mild mucosal thickening in the ethmoid air cells, and left
maxillary
sinus.
[**2125-5-21**] 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2125-5-21**] 11:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2125-5-21**] 11:00AM PT-14.2* PTT-30.3 INR(PT)-1.2*
[**2125-5-21**] 11:00AM PLT COUNT-102*
[**2125-5-21**] 11:00AM NEUTS-51.3 LYMPHS-43.4* MONOS-4.3 EOS-0.4
BASOS-0.5
[**2125-5-21**] 11:00AM WBC-4.0 RBC-4.64 HGB-14.2 HCT-42.1 MCV-91
MCH-30.7 MCHC-33.8 RDW-14.2
[**2125-5-21**] 11:00AM URINE GR HOLD-HOLD
[**2125-5-21**] 11:00AM URINE HOURS-RANDOM
[**2125-5-21**] 11:00AM CK-MB-NotDone cTropnT-<0.01
[**2125-5-21**] 11:00AM CK(CPK)-71
[**2125-5-21**] 11:00AM estGFR-Using this
[**2125-5-21**] 11:00AM GLUCOSE-125* UREA N-23* CREAT-0.9 SODIUM-137
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2125-5-21**] 06:40PM PLT COUNT-96*
Brief Hospital Course:
Patient admitted to neurology ICU service for monitoring of left
basal ganglia hemorrhage with intraventricular extension due to
hypertension and medication noncompliance.
Neuro: He required restraints for agitation and got 5mg zyprexa
the 1st night. On hospital day 2 he was more somnolent,
speeking less, and no longer oriented to self. Repeat head CT
was unchanged and somnolence was attributed to medication
effect.
CV: Repeat echo was requested given h/o critical aortic stenosis
per the wife and the medication noncompliance to evaluate for
heart failure or other changes. SBP was kept below 160. He had
some tachypnea as high as 32 reported but CXR was negative for
pulmonary edema. He had no other signs such as WBC elevation or
fever to indicate occult pneumonia. Metoprolol low dose of
12.5mg [**Hospital1 **] was started pngt.
Resp: Stable
FEN/GI: Pt was too somnolent and dysarthric for swallow eval.
NGT was placed.
There were no active heme, endocrine, renal, or infectious
issues.
Neurology Floor Course: The patient was transferred to th
eneurology floors on 06/ 11/ 09. He required feeds through the
NGT till 06 17 09. Then the decision for PEG was made and the pt
finally received G tube on 06 17 09.
Medications on Admission:
Ocuvite, Amiodarone, Atenolol, Simvastatin, Terazosin, ASA.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]- [**Location (un) 8957**]
Discharge Diagnosis:
Basal ganglia bleed (LEFT)
CAD
HLD
HTN
AF
Discharge Condition:
His examination at discharge is remarkable for his left gaze
preference, crossing the midline. He has right hemiparesis and
facial weakness.
Discharge Instructions:
You have had a brain bleed. The reason for the bleed seems to be
uncontrolled hypertension.
In addition, you have required tube feeds given your inability
to swallow. Finally, you received a G-tube that will ensure you
meet your nutritional goals.
You have had a brain bleed. The reason for the bleed seems to be
uncontrolled hypertension.
In addition, you have required tube feeds given your inability
to swallow. Finally, you received a G-tube that will ensure you
meet your nutritional goals.
Followup Instructions:
You will follow up with Dr. [**Last Name (STitle) **] in the stroke clinic on
[**2125-7-17**] 3:30 pm. Phone:[**Telephone/Fax (1) 2574**]
ICD9 Codes: 431, 4019, 4241, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2592
} | Medical Text: Admission Date: [**2129-4-4**] Discharge Date: [**2129-4-25**]
Date of Birth: [**2129-4-4**] Sex: F
Service: NB
HISTORY: This is a 33 and [**2-19**] week baby girl, [**Name2 (NI) **] to a 33
year-old, G3, P1 now 2 mother via Cesarean section for repeat
due to preterm labor. Mom's prenatal labs are as follows: 0
negative, antibody negative, RPR nonreactive. Hepatitis
BSHAG negative. Rubella immune. Mother received RhoGAM times
2. Mother had normal prenatal course. 1st trimester fetal
ultrasound notable for 2 vessel umbilical cord.
Mother's GBS status was unknown. She had no fever, rupture of
membranes less than 12 hours, no intrapartum antibiotics.
Baby was [**Name2 (NI) **] with Apgars of 7 and 7 at 22:45. She received
blow-by oxygen in the delivery room.
On admission, Girl ([**Doctor First Name **]) [**Known lastname 72805**] birth weight was 2400 grams
(75 to 90th percentile). Length was 47.5 cm. Head circumference
32 cm. Discharge weight is 2.640 grams.
HOSPITAL COURSE: Respiratory: The baby transitioned to room
air almost immediately and remained on room air for her
entire NICU stay. No apnea of prematurity, no spells.
Cardiovascular: Baby has a murmur, consistent with PPS. She
never required pressor therapy. She never required imaging
of the heart.
Fluids, electrolytes and nutrition: On the first day of life,
the baby was started on IV fluids and started feeding the
next day, breast milk or Special Care 20. The baby was on all
breast milk or formula by day of life 3. She has had no
feeding intolerance. Her discharge formula is breast milk 20
calorie, no supplementation, and she takes p.o. very well.
Gastrointestinal: Hyperbilirubinemia. On day of life 2,
maximum total bilirubin was 7.3, Rx with phototherapy. Rebound
bili after discontinuing phototherapy was 5.7 on day of life.
Hematology: CBC and blood culture on day of birth: WBC 12.7K,
hematocrit 50.9%, PLT= 279K, normal differential. She had
no transfusions. There was no clinical indication for repeated
Hct.
Infectious disease: Blood culture on birth day had no growth.
Thus ampicillin and gentamycin therapies were discontinued
after 48 hours. No evidence of sepsis.
Neurology: Neurobehavioral examination appropriate for GA.
No indication for routine cranial ultrasound screen.
Audiology: Hearing screening was performed; however, the
patient referred both ears bilaterally and will have a follow-
up hearing test.
Ophthalmology: Red reflex bilaterally. No indication for ROP
screening examination.
CONDITION ON DISCHARGE: Stable, healthy appearing infant.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 3446**], [**Hospital1 1474**].
Phone number [**Telephone/Fax (1) 53417**].
FEEDING AT DISCHARGE: Breast milk 20 calorie with iron
supplementation at 2 mg/kg per day and multi-vitamins.
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 test passed.
State newborn screening status: On [**4-11**], her newborn
screen was normal. On [**4-18**], the test was repeated and
results have not yet returned. The newborn screen was
repeated as per protocol here at [**Hospital3 **] based on
gestational age.
IMMUNIZATIONS: She received hepatitis B vaccine on [**4-18**].
Synagis is not indicated for this patient; however, 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 ROTA virus 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: Follow-up with Dr. [**Last Name (STitle) 3446**] on [**4-26**] at 11 a.m.
and [**Hospital6 **] will come by on Wednesday.
DISCHARGE DIAGNOSES:
1. Prematurity at 33 and 4/7 weeks.
2. Sepsis, ruled out.
3. Hyperbilirubinemia, status post phototherapy.
4. Two vessel umbilical cord.
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**]
Dictated By:[**Last Name (NamePattern1) 63827**]
MEDQUIST36
D: [**2129-4-25**] 16:57:40
T: [**2129-4-25**] 17:45:31
Job#: [**Job Number 72806**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2593
} | Medical Text: Admission Date: [**2150-3-9**] Discharge Date: [**2150-3-16**]
Date of Birth: [**2108-4-25**] Sex: F
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
CC: epigastric pain
Major Surgical or Invasive Procedure:
Cardiac catheterization w/ DES placed to proximal and mid RCA
Intubation and mechanical ventilation
R IJ placement and removal
History of Present Illness:
41yo F with Type I DM, HTN, hx renal transplant 4 years ago, and
recent admit for left heel cellulitis who presents after
developing CP that woke her from sleep at 3AM today. Has had
stuttering CP for 2 days but it has been constant since 3am.
Felt very weak and fatigued. Husband found her crawling up the
stairs of their home this AM, did not have the energy to change
her clothes. Took her to ER in pajamas. Has felt SOB and
fatigued for several weeks. Has had epigastric pain for the last
2 days which she thought was gas pain or her gastroparesis. Took
Tums w/ no relief. Developed back/shoulder pain o/n, again no
relief.
.
Came to ER in AM. Found to be hypotensive w/ SBP 87/46 (last BP
[**Last Name (un) **] was 146/79), HR 95, temp 96.3. Got EKG in ER which showed
ST elevations in II, III, avF and ST depressions in I, avL. Got
ASA, ativan, 1L NS, plavix 300x1, and heparin gtt. In cath lab,
found to have occluded RCA with difficult stent placement (no
reflow) that eventually required IC nipride injection to
establish flow.
.
During the procedure, pt's mived venous O2 sat dropped to 37%
and her CI fell to less than 2.0. She became agitated and had
mental status changes, making her unable to comply with keeping
her leg straight. She was intubated for SOB and agitation. After
intubation, MV02 improved to 58%. ABG 7.18/27/373 w/ bicarb 11,
BE -16. Sent to CCU for further monitoring.
Past Medical History:
PMH:
ESRD s/p LRRT 4 years ago
Type I DM since [**58**] yo, triopathy
HTN
CRI
PVD
Left LE ulcer/cellulitis with recent admit
Gastroparesis
Hyperlipidemia
.
[**Doctor First Name 147**] HX:
Laser treatment to eye
hx right breast lump s/p resection
LRRT in [**2146**]
Social History:
Lives w/ husband in [**Name (NI) 16848**], MA. + tobacco in past, no tob or
EtOH currently.
Family History:
+ CAD, hypercholesterolemia, HTN, cancer
Physical Exam:
VS: T 94.7, BP 106/63 (161/87), HR 94-104, RR 19-22, sats 100%
Vent: AC Tv 450 (actual 500), RR 10, Fi02 60%, PIP 16, Peak 14
HEENT: Sclera anicteric.
NECK: Neck supple, no appreciable JVD
LUNGS: CTA anteriorly and at bases, no crackles, wheezes,
rhonchi.
HEART: Tachycardic, regular. Normal S1, S2. No m/r/g.
ABD: Soft, NTND. + BS, no masses. Scar in LLQ from kidney
transplant.
EXT: No edema. 2+ PT, DP pulses bilaterally.
NEURO: Sedated, but moving all 4 ext spontaneously.
SKIN: No rashes.
Pertinent Results:
LABS on admission:
MICRO:
[**2150-3-9**]: blood cx negative
[**2150-3-9**]: urine cx negative
[**2150-3-10**]: blood cx (mycolytics/fungal isolators) negative
[**2150-3-10**]: blood cx negative x2
[**2150-3-10**]: urine cx negative
[**2150-3-11**]: C diff negative
[**2150-3-13**]: urine cx negative
[**2150-3-15**]: C diff pending
.
IMAGING:
[**2150-3-9**] CATH:
RA 19/21/17
RV 32/19
PA 32/21/26
WEDGE 25/28/22
AORTA 99/61/74
CO/CI 3.9/2.7 -> 2.27/1.54
SVR 1169
.
1. Selective coronary angiography revealed a right dominant
system with severe diffuse disease. The LAD was totally occluded
in the mid-vessel. There was a diffusely diseased bifurcating
large diagonal up to 70%. The LCX had a 70% lesion in the mid
vessel. There was a totally occluded OM. The RCA was 100%
occluded proximally, which was thought to be the culprit lesion.
2. Hemodynamics post intervention revealed elevated filling
pressures
(RVEDP 19 mm Hg, PCWP mean 22 mm Hg) with hemodynamics
consistent w/
RV infarction. Initially patient was somewhat hypotensive,
requiring
dopamine. Post intervention, patient's blood pressure improved
and
dopamine was discontinued. Post intervention CI was 2.01, with
arterial pH of 7.17. Repeat CI was 1.5 with a arterial pH of
7.23; at that time patient had SBP >120.
3. Patient became increasingly agitated post intervention with
mental
status changes and metabolic acidosis. She was unable to lay
flat with sheaths in her groin. She was intubated and sent to
the CCU.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated filling pressures consistent with RV infarction.
3. Low cardiac index and acidemia without hypotension.
.
[**2150-3-9**] ECHO: There is symmetric left ventricular hypertrophy.
There is severe regional left ventricular systolic dysfunction
(EF 25%) with akinesis of the inferior wall, infero-septum and
apex. The antero-septum is hypokinetic. The basal to mid
anterior and lateral walls move best. There is moderate
spontaneous echo contrast seen in the LV cavity but no masses or
thrombi are seen. There is severe global right ventricular free
wall hypokinesis. The pulmonary artery
systolic pressure could not be determined. There is a small to
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade. IMPRESSION: Severe,
regional LV systolic dysfunction c/w multivessel CAD. RV
systolic dysfunction.
.
[**2150-3-9**] CXR: Endotracheal tube tip in satisfactory position
.
[**2150-3-9**] CXR: There has been interval placement of a right
internal jugular vascular catheter, with the tip terminating in
the region of the junction of the superior vena cava and right
atrium. There is no evidence of pneumothorax, and there has
otherwise been no significant change since the recent study of
several hours earlier.
.
[**2150-3-9**] RENAL U/S: Unremarkable transplant kidney without
hydronephrosis.
.
[**2150-3-10**] CXR: AP single view of the chest obtained with patient
in semi-upright position is analyzed in direct comparison with a
similar previous study obtained on [**2150-3-9**]. The
patient remains intubated, the ETT in unchanged position. The
same holds for an internal jugular approach central venous line
terminating at the cavo-atrial junction and a Swan-Ganz catheter
approached from below terminating in the main pulmonary artery.
NG tube reaches stomach. Patient is less inflated during this
exposure in comparison with the previous study. There is no
evidence of new parenchymal densities or CHF but the pulmonary
vasculature is slightly more crowded. The lateral pleural
sinuses remain free.
Brief Hospital Course:
41yo F w/ DMI s/p LRRT [**2146**] and recent hospitalization for L
heel ulcer, presents w/ inferior STEMI with course complicated
by ARF.
.
# ISCHEMIA: Ms. [**Known lastname **] presented with an inferior STEMI. On
admission CK 361, MB 18, MBI 5.0, trop 2.66). She was taken
straight to the cath lab where she was found to have diffuse
disease, but total occlusion of her RCA which was felt to be the
culprit lesion. Two [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] were placed in the RCA, but they
were unable to establish good reflow post-stenting. IC nipride
was injected and good flow was eventually established. She was
also started on Reopro in the cath lab. PA sats were as low as
37% intra-procedure, but improved to 59% after intubation. ABGs
in cath lab showed an acidemia (pH 7.18) and her lactate was
9.1. IABP was not placed secondary to her severe PVD. In the
cath lab, she initially required a dopamine gtt to keep her BP
up, but by the end of the procedure, she had to be given nipride
to control her BP. Her CO and CI were low and overnight,
dobutamine was added for inotropy. With the addition of
dobutamine, her PA sats improved to 70%, her lactate came down
to 1.3, and her UOP improved to 40cc/hr. Her enzymes peaked at
CK of 1124, MB of 34, and troponin of 6.35. She had persistent
ST elevations on EKG after her intervention, and they remained
on EKG throughout the rest of her hospitalization. She remained
chest pain free after her extubation, although she had
intermittent episodes of epigastric discomfort that were not
associated with any EKG changes. These were felt to most likely
be related to her gastroparesis and GERD. She was continued on
aspirin and plavix after the placement of her stents. She was
continued on her outpatient dose of pravachol for secondary MI
prevention. She was started on coreg with good effect on her BP
and HR. Despite her depressed EF, an ACE inhibitor was not
started given her acute renal failure. It was felt that the
decision to start an ACE inhibitor could be delayed to the
outpatient setting. She will follow-up with Dr. [**Last Name (STitle) **] in [**1-19**]
weeks.
.
# PUMP: An ECHO was performed in the cath lab and showed an EF
of 20-25%, with apical and inferior akinesis and a small
pericardial effusion. A repeat TTE on the floor was unchanged,
with no increase in pericardial effusion and no evidence
tamponade physiology. She unfortunately did not show any
improvement in her EF, either. Her CO and CI were low on
transfer from the CCU, and dobutamine was started with
improvement in both. The dobutamine was able to be weaned off on
[**2150-3-10**]. She had minimal urine output for the first several days
of her hospitalization, which caused her to become volume
overloaded. She was not diuresed, however, due to her renal
failure and Renal never felt that HD was indicated. She
eventually began to autodiurese and mobilize her extra fluid on
her own. She was advised to follow a low [**Date Range **] diet in order to
prevent further fluid accumulation. For medical management of
her heart failure, she was started on coreg but ACE inhibitors
had to be held secondary to her renal failure. ECHO confirmed an
akinetic apex, but it was not felt to be acute thus there was no
need for anticoagulation currently. She will need a repeat echo
in 1 month's time, at which time, if she has not had improvement
in her EF, she will be considered for placement of an ICD.
.
# RHTYHM: She remained in NSR for most of her stay. She
displayed a prolonged PR interval during her first hospital day,
but her PR was back down to 0.186 by [**3-10**]. She was monitored on
telemetry while she was here and had frequent EKGs which showed
slowly resolving ST elevations in the inferior leads.
.
# ARF: Renal was consulted because of her history of a living
related donor renal transplant and her chronic
immunosuppression. It was felt that her ARF was multifactorial,
with components of ATN, prerenal azotemia, and contrast-induced
nephropathy. Her Cr peaked at 4.3 and then trended down. She
never became anuric, but her immunosuppression did have to be
held for several days based on elevated troughs and likely poor
clearance. Despite becoming fluid overloaded, she never
developed any respiratory symptoms and was able to remain on RA
without any changes in her oxygen saturation. Renal helped
manage her electrolytes, with the intermittent use of bicitra
and phoslo. She was restarted on her immunosuppression once her
CrCl began to improve. She will follow up with renal in [**1-19**]
weeks after discharge, but will have her immunosuppression
levels checked by her PCP in order to guage the changes in the
doses of her immunosuppression with the improvement of her
creatinine.
.
# METABOLIC ACIDOSIS: On admission, she had a pure anion gap
metabolic acidosis, likely related her elevated lactate from
hypoperfusion. The gap was slow to resolve, however, in spite of
improvement in her lactate. It was felt that early renal failure
was also a component as it required the addition of bicitra to
bring her gap back to normal.
.
# ANEMIA: She was anemic on admission. Anemia workup revealed a
mixed picture, likely ACD as well as iron deficiency. She was
started on iron supplementation as well as Epo injections
briefly. Her Hct improved and renal decided she no longer needed
the Epo injections, but did recommend that she continue on iron
supplements.
.
# DM TYPE I: Ms. [**Known lastname **] is a lifelong diabetic with poor glucose
control. Since [**2147**], her HgbA1c has not been <11.3. She was
originally started on an insulin gtt and [**Last Name (un) **] was consulted
for help in managing her insulin regimen. She was titrated off
the insulin gtt and started on Lantus QAM with a RISS. Her
fingersticks were under modest control on this regimen, and the
patient liked this regimen more than the regimen of NPH that she
had been taking at home.
.
# LEFT HEEL ULCER: Ms. [**Known lastname **] had recently been admitted for a
deep L heel ulcer. Podiatry was notified of her admission and
consulted on her while she was here. She was originally started
on vancomycin and zosyn because she was febrile on admission and
there was concern for sepsis, given her hypotension, low SVR,
and fevers. However, her heel ulcer seemed to be healing and she
became afebrile. Her hemodynamics began to improve and she
became afebrile, so vancomycin and zosyn were discontinued.
Podiatry felt that she needed continued abx as she was at high
risk for infection so she was started on PO dicloxacillin which
she seemed to tolerate well. Podiatry also recommended that she
be seen by vascular surgery as an inpatient, and they
recommended imaging (MRI/MRA) but the patient refused. She will
be set up to see vascular surgery as an outpatient once her ARF
resolves and she is more willing to take IV contrast again.
Podiatry also made recommendations as to optimal wound care for
her L heel ulcer. She will follow-up with Dr. [**Last Name (STitle) **] in [**7-27**]
after discharge.
.
#. FEN: She was given a cardiac, heart healthy, low [**Last Name (LF) **], [**First Name3 (LF) **]
diet. She received no IVF during her stay due to her volume
status. She did, however, receive two units of pRBCs because of
an acute drop in her hematocrit after her catheterization. Her
electrolytes were checked regularly and were repleted to keep
her K >4 and Mg >2.
.
#. ACCESS: Originally, she had a venous and arterial sheath left
in place post-catheterization. They were pulled and she was
given a R IJ and a R art line instead. Once she was called out
of the unit, both her central line and arterial line were pulled
and she was managed on the floor with just peripheral IV access.
.
#. PPX: Pneumoboots for DVT prophylaxis. She was given a PPI for
her GERD/GI issues. No bowel regimen was needed given her
diarrhea. Incentive spirometer.
.
#. CODE: FULL
.
#. DISPO: Home w/ services (home PT and VNA for wound care).
Follow-up appointments were scheduled with: cardiology, GI,
vascular surgery, renal, podiatry and [**Last Name (un) **].
Medications on Admission:
Tacrolimus 2mg PO BID
sirolimus 4mg PO QD
pravastatin 10mg PO QD
Bactrim 1 DS TIW
Percocet PRN
ranitidine 150mg [**Hospital1 **]
silvadene 1% cream topical [**Hospital1 **]
D/c [**2-9**] from podiatry on abx:
dicloxacillin 500mg PO QID x 2weeks
levofloxacin 500mg PO QD x 2weeks
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Pravastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 3 weeks.
Disp:*84 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
Inferior ST elevation MI
Systolic heart failure (EF 20-25%)
Acute renal failure
.
Secondary diagnosis:
L heel ulcer
Diabetes mellitus type I
Discharge Condition:
Good. Afebrile, BP stable, chest pain free.
Discharge Instructions:
1. Please call your PCP or go to the nearest ER if you develop
any of the following symptoms: chest pain, palpitations,
shortness of breath, difficulty breathing, epigastric pain or
burning, fevers, chills, leg swelling or numbness, increase in
weight, decreased urination, or any other worrisome symptoms.
2. Please take all your medications as prescribed, especially
your aspirin and plavix. These medications need to be taken
every day to help keep your stents open.
3. Please keep all your follow-up appointments.
Followup Instructions:
1. Please follow-up with your PCP [**Last Name (NamePattern4) **] 1 week. You will need to
have all of your electrolytes checked, including your BUN and
Cr. Please ask to have these faxed to your kidney doctors.
[**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 250**].
2. Please follow-up with Dr. [**Last Name (STitle) **] (cardiology) on [**2150-3-24**] at
11:30 in [**Hospital Ward Name 23**] 7. Phone # ([**Telephone/Fax (1) 5909**].
3. Please follow-up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2625**]
(vascular surgery) on [**2150-4-8**] at 2:30 PM
4. Please follow-up with Dr. [**Last Name (STitle) **] (podiatry) in Provider:
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2150-3-18**] 9:30
5. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9978**] ([**Hospital **] clinic) on
[**2150-3-19**] at 8:30 AM on the [**Location (un) **] [**Telephone/Fax (1) 2378**].
6. Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D./Dr. [**Last Name (STitle) 4920**]
(renal) on [**2150-3-27**] 9:50 AM at the [**Hospital Unit Name **] [**Location (un) 436**]
[**Telephone/Fax (1) 23134**].
7. Please follow-up with [**Name6 (MD) **] [**Last Name (NamePattern4) 25130**], M.D.
(gastroenterology) on [**2150-5-11**] at 11:00am. If you have any
questions or need to reschedule this appointment, please call
his office at [**Telephone/Fax (1) 1954**].
8. Please follow-up for a repeat echocardiogram of your heart on
[**2150-4-15**] 11:00 AM at the [**Hospital Ward Name 2104**] building [**Location (un) **] of [**Hospital1 1535**] [**Hospital Ward Name 516**]. The day after your
echocardiogram, please call Dr.[**Name (NI) 5907**] office and inquire
about a follow-up appointment to review the results.
Completed by:[**2150-3-17**]
ICD9 Codes: 4271, 4280, 5185, 5845, 2762, 3572, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2594
} | Medical Text: Admission Date: [**2147-12-6**] Discharge Date: [**2147-12-9**]
Date of Birth: [**2110-3-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
lethargy, DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
37F with PMH DM1, transferred from OSH for lethargy and DKA. Pt
relates that last week she developed severe headaches for which
her PCP got an MRI and diagnosed her with cluster headache. She
had a tooth filled 3 week prior, and last week damaged the tooth
opening a bottle with it. Her dentist again filled the tooth
last Friday and over the past week she has been treated for a
right sided tooth infection, initially with amoxicillin, but she
developed worsened pain and was switched to flagyl. On Saturday
she noted significantly increased right sided facial swelling
and pressure. Two days prior to admission, she experienced
drainage of purulent material from the gums surrounding the
infected tooth. Denies fever, chills, diarrhea, dysuria, pelvic
pain, cough, sputum production. She concommitently developed
fatigue, lethargy, vomiting, nausea with decreased PO intake.
She has been taking her usual insulin regimen of lantus 16 Qhs
plus mealtime lispro 3-5unit SS, with finger sticks not above
208. At the OSH, labs included glucose 389, AG 18, for which she
got 4L IVF, 6U IV insulin, started on insulin gtt.
.
In the ED inital vitals were, T 98.9 HR 115 BP 118/74 RR 20 Sat
100%RA, FSG 172. Insulin drip was stopped but was restarted with
D5NS @ 150cc/hr at 9:15pm for AG 18, glucose 201. Patient got a
total of 5L in ED. UA showed ketones, no clear evidence for UTI.
Lactate 1.4, WBC 12.6, Bicarb 8, K+ 3.2, repleted with 40units
K+. Given metoclopramide and ondansetron for nausea (2 episodes
of vomitting in the ED), morhine for pain, and unasyn 3gm for
tooth infection. No evidence of molar abscess, per ED. CXR
showed no signs of infection.
.
Prior to transfer, most recent VS:T 98.6, Pulse: 100, RR: 18,
BP: 122/74, O2Sat: 100.
.
On arrival to the ICU, VS T 97.8, HR 100, BP 112/75, RR 24, Sat
100%RA, FS 217. Patient was comfortable without complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies cough, shortness of breath, or wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Migraines
PID
type 1 diabetes
Social History:
Ms. [**Known lastname **] works as a practice manager at the podiatry clinic at
[**Hospital1 18**]. She lives with her husband and 2 children. She has a
history of smoking (1 pack/3-4days), quit several years ago.
Reports rare social alcohol, denies recreational drugs.
Family History:
Mother and father are both healthy. No history of breast
cancer, no family history of diabetes.
Physical Exam:
Admission Exam:
Vitals: VS T 97.8, HR 100, BP 112/75, RR 24, Sat 100%RA, FS 217.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. 1st molar on top
right with drilled hole, no current erythema or purulent
drainage. Missing 3rd molar on top right.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, 2/6 systolic
murmur over LLSB, rubs, gallops
Abdomen: soft, non-tender, mildly 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:
Na 137, K 3.2, Cl 111, bicarb 8, BUN 8, Cr 0.6, Gluc 177 Anion
Gap: 18
Lactate 1.4
WBC 12.6 (N 68.7%), hgb 11.7, hct 34.7, plt 244
UA: 150 ketones, glucose 1000, few bacteria, neg leuks and
nitrates, 7 epi.
.
Micro: [**2147-12-6**] blood cultures x2 no growth to date
.
Images: [**2147-12-6**] CXR: The lungs are clear. The cardiomediastinal
and hilar
contours are normal. There are no pleural effusions or
pneumothorax.
Minimal atelectasis in the left lower lobe.
IMPRESSION: No acute cardiopulmonary process.
.
EKG [**2147-12-7**]: sinus tachycardia [**Company 3257**]-wave inversions, no
priors
.
EKG [**2147-12-7**]: Sinus rhythm. Compared to the previous tracing of
[**2147-12-7**] the
ischemic-appearing ST-T wave changes have improved but ST-T wave
abnormalities persist. Followup and clinical correlation are
suggested.
QTc 417.
Brief Hospital Course:
37F with PMH DM1, admitted to the ICU for lethargy and DKA.
.
# DKA/DMI: Patient presented to OSH with elevated BG >300, urine
ketones, and an AG of 18 as well as nausea, vomitting, h/o
fever. DKA appears to have been instigated by tooth infection.
Patient has no other obvious source of infection, CXR showed no
signs of acute process. Nausea managed with reglan. Electrolytes
(K+, phos, Ca+, Mg) checked frequently and repleted as needed.
Patient was maintained on an insulin drip with D5W given BG<200.
AG trended: 18->12->11. Drip stopped briefly overnight for
decreased BG in 60s. Restarted and in the morning, patient was
transitioned over to home regimen of 16units glargine and HISS
with dicontinuation fo D5W. Patient was given a DM diet. AG
reopened slightly to 14 and HISS was uptitrated. 8pm AG
normalized to 10. Urine hcg negative, trop neg x2. ECG x2 both
showing sinus tachycardia with t-wave inversions. No suggestion
of cardiac event. [**Last Name (un) **] was consulted, who made some revisions
to her insulin sliding scale and will arrange for outpatient
follow-up for the patient with her regular [**Last Name (un) **] provider. [**Name10 (NameIs) **]
note, her A1C is >11.7 and the patient acknolwedges poor
follow-up with [**Last Name (un) **] in the past (yearly, at best).
.
# Mixed anion gap and nonanion gap acidosis: Patient has an AG
acidosis with AG of 18 on presentation, which can be explained
by the DKA/ketoacidosis. Her delta gap is 2 (18/16), suggesting
a mixed acidosis. Her non anion gap acidosis is possibly
multifactorial: vomitting vs. hyperchloremic (Cl 111) likely due
to IVF resuscitation. Nausea was managed with reglan and NS
fluids were avoided. Bicarb on presentation was 8, and within a
day improved to 20. DKA was treated as above.
.
# Hypokalemia: In ED, patient with K+ 3.2. Got 40meq repletion,
just prior to arrival to floor. Patient at risk for low
potassium with treatment for DKA. Potassium was checked q4h
while on insulin drip and repleted as needed. Her potassium
levels stabilized.
.
# Tachycardia: Patient remained in the 90s-100s HR. Given DKA,
she was likely volume depleted. Patient does have signs of a
tooth infection, so sepsis is possible, however blood pressures
remain in the 110s/80s. Patient had elevated HR and increased
WBC. Not febrile or hypothermic, breathing at a comfortable
rate. She was maintained on IVFs initially and monitored on
telemetry, without events. 2 EKGs showed sinus tachycardia with
t-wave inversions. Patient denied chest pain, has been nauseous
(attributed to DKA and infection), and trops negative x2.
Patient was treated for her infection and volume resuscitated,
with resolution of tachycardia.
.
# Tooth infection: Patient with recent instrumentation and
evidence of tooth infection for which she has been treated with
ampicillin and flagyl with continued symptoms. She was given an
initial dose of unasyn 3gm in the ED (D1 [**2147-12-6**] in PM), which
was continued q6h during hospitalization. Patient was with some
gum swelling on exam but no tenderness or purulent drainage. WBC
12.6 on admission and decreased to WNL thereafter. She was
transitioned to Augmentin upon transfer from the ICU to the
regular medicine floors without issues.
# Anemia: During this admission the patient's hct trended down
to a nadir of 26 on the day of discharge. There was no evidence
of bleeding. On review of prior hospitalizations the patient's
hct does range from the high 20's to low 30's. MCV was normal,
which suggests ACD. The patient was notified that she should
have her anemia further evaluated as an outpatient, and was
educated about signs and symptoms of bleeding.
Medications on Admission:
Glargine 16U Qhs
Lispro Insulin
Discharge Medications:
1. insulin glargine 100 unit/mL Cartridge Sig: Sixteen (16)
Subcutaneous at bedtime.
2. Humalog 100 unit/mL Cartridge Sig: See attached scale
Subcutaneous four times a day.
3. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetes, type I
Diabetic ketoacidosis
Dental infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with diabeticketoacidosis that likely
developed due to a tooth infection. You were treated with IV
fluids, insulin and antibiotics and you improved.
Followup Instructions:
Please call [**Last Name (un) **] Diabetes Center ([**Telephone/Fax (1) 3258**] to schedule a
follow up appointment within the next month.
Please call [**Hospital3 249**] [**Telephone/Fax (1) 250**] to schedule a
follow up appointment with your primary care doctor in the next
two weeks.
ICD9 Codes: 2768, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2595
} | Medical Text: Admission Date: [**2106-8-23**] Discharge Date: [**2106-8-25**]
Date of Birth: [**2056-8-6**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 50-year-old male with
poorly controlled hypertension and hyperlipidemia with atrial
fibrillation refractory to cardioversion. The patient has
been cardioverted every few months since [**2103-5-3**], but
unfortunately remains in normal sinus rhythm for a few weeks
after cardioversion. A radiofrequency ablation was attempted
in [**2106-5-3**] but was aborted due to an episode of
hypotension in the catheterization laboratory.
He was admitted on [**2106-8-2**] and underwent an elective
radiofrequency ablation which was complicated by septal
perforation and cardiac tamponade with hypotension. A
pericardial drain was placed and drained for a few hours. It
was pulled after a repeat echocardiogram demonstrated no
re-accumulation of fluid.
He was then discharged home on [**2106-8-4**] and was without
complaints until three days prior to the current admission
when he noticed increased shortness of breath, chest pain,
and presyncopal symptoms. He followed up with his primary
care physician who sent him in for a transthoracic
echocardiogram which showed re-accumulation of pericardial
fluid.
He was brought to the catheterization laboratory at [**Hospital1 1444**] where he was found to have
equalization of pressures (right atrial was 17, right
ventricular was 40/25, pulmonary capillary wedge pressure
was 22, pulmonary artery pressure was 42/25). A
pericardicentesis was performed in which 350 cc of bloody
fluid was withdrawn. He was then admitted to the Coronary
Care Unit for hemodynamic monitoring and treatment with the
pericardial drain in place.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Asthma.
3. Hyperlipidemia.
4. Gout.
5. Atrial fibrillation.
6. Spinal cord injury, status post motor vehicle accident.
7. Peptic ulcer disease without symptoms for the last 20
years.
MEDICATIONS ON ADMISSION: Outpatient medications included
Lipitor 10 mg p.o. q.d., Losartan 100 mg p.o. q.d.,
atenolol 50 mg p.o. q.d., Rythmol 225 mg b.i.d.,
probenecid 500 mg p.o. b.i.d., aspirin 81 mg p.o. q.d.
ALLERGIES: ZESTORETIC causes gastrointestinal upset.
PENICILLIN (allergic reaction during childhood). ALLOPURINOL
causes facial swelling.
PAST SURGICAL HISTORY:
1. Neck surgery secondary to motor vehicle accident.
2. Laryngeal polyps which were removed as a teenager.
SOCIAL HISTORY: He denies any tobacco use, occasional
alcohol use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission to the Coronary Care Unit revealed a temperature
of 100.1, blood pressure was 134/89, heart rate was 79 in
normal sinus rhythm, respiratory rate was 25, oxygen
saturation was 97% on room air. Swan numbers were pulmonary
artery pressure of 19/13, a CPP of 8. In general, the
patient was in no apparent distress. He was mildly obese and
was in moderate pain. Head, eyes, ears, nose, and throat
revealed the oropharynx was clear. Mucous membranes were
moist. There were no carotid bruits, and he had anicteric
sclerae. His chest was clear to auscultation bilaterally.
The pericardial drain was in place without any hematoma.
Cardiovascular examination revealed he was a regular rate.
He had a normal first heart sound and second heart sound.
There were murmurs, rubs or gallops. Abdominal examination
revealed his abdomen on examination was soft, nontender, and
nondistended. Normal active bowel sounds. There was no
hepatosplenomegaly. His extremities demonstrated no
cyanosis, clubbing or edema. His right femoral sheath was in
place; there was no hematoma or bruit. There were 2+
dorsalis pedis pulses and posterior tibialis pulse
bilaterally. His skin was warm and dry.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
revealed a white blood cell count of 12.5, hemoglobin
was 12.3, hematocrit was 35.9, platelets were 410. Chemistry
revealed sodium was 135, potassium was 3.8, chloride was 103,
bicarbonate was 22, blood urea nitrogen was 16, creatinine
was 0.9, blood glucose was 102. PT was 13.9, INR was 1.4.
Pericardial fluid revealed total protein of 5.3, LDH was 585,
glucose was 101, amylase was 38, albumin was 3.2.
IMPRESSION: This is a 49-year-old male with recurrent atrial
fibrillation refractory to medications and cardioversion.
Radiofrequency ablation performed earlier this month was
complicated by septal perforation and tamponade. He returns
now with re-accumulation of fluid and cardiac tamponage
physiology, status post pericardiocentesis.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit with a pericardial drain in place which had
previously drained 350 cc in the catheterization laboratory.
About 50 cc were drained overnight, and a repeat
echocardiogram was done in the morning which showed a trivial
effusion. Therefore, the drain was pulled on [**2106-8-24**]
without complications.
The patient was started on his outpatient drug regimen and
started on a prednisone taper in order to decrease
pericardial inflammation. He was transferred to the floor on
the evening of [**2106-8-24**] in stable and improved
condition.
A follow-up echocardiogram was done on the day of discharge
which showed a normal ejection fraction, a decrease in size
of the effusion, with a thickened pericardium demonstrating
early constrictive physiology. The patient was asymptomatic
throughout his hospital course, denying any shortness of
breath or syncopal symptoms while out of bed.
Given his history of atrial fibrillation, he was monitored
closely on telemetry and demonstrated no arrhythmias.
CONDITION AT DISCHARGE: Condition on discharge was stable
and improved.
DISCHARGE DIAGNOSES:
1. Atrial fibrillation, status post radiofrequency ablation.
2. Cardiac tamponade.
3. Hypertension.
4. Hyperlipidemia.
5. Gout.
6. Asthma.
7. Remote history of peptic ulcer disease.
MEDICATIONS ON DISCHARGE:
1. Atenolol 50 mg p.o. q.d.
2. Lipitor 10 mg p.o. q.d.
3. Probenecid 500 mg p.o. b.i.d.
4. Rythmol 225 mg p.o. b.i.d.
5. Protonix 40 mg p.o. q.d.
6. Prednisone taper 50/50, 40/40, 30/30, 20/20, [**11-11**], [**6-6**].
The patient was to discontinue Losartan until follow-up
appointment. The patient was to discontinue aspirin for the
next 30 days.
DISCHARGE FOLLOWUP:
1. The patient was scheduled for a transthoracic
echocardiogram on [**2106-9-7**] at 11 a.m.
2. The patient was to schedule a follow-up appointment with
Dr. [**Last Name (STitle) **] in two to four weeks after discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2106-8-25**] 17:54
T: [**2106-8-31**] 09:16
JOB#: [**Job Number 102493**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2596
} | Medical Text: Admission Date: [**2192-11-30**] Discharge Date: [**2192-12-14**]
Date of Birth: [**2124-2-13**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 68 year-old
male with a history of diabetes, hypertension,
hypercholesterolemia and known coronary artery disease
transferred to [**Hospital1 69**] from an
outside hospital on [**2192-11-30**] after presenting there with
shortness of breath and found to have a troponin leak. The
patient reported that on the day prior to his transfer here
he experienced shortness of breath while walking to his gym,
which resolved after about fifteen minutes of rest. The
patient experienced the same symptoms later that day while at
his home. He called his primary care physician and was told
to go to the Emergency Department. The patient denied any
chest pain, chest pressure, radiating pain, lightheadedness,
palpitations, headache, nausea, vomiting, diaphoresis or
paroxysmal nocturnal dyspnea.
The patient was reported to have had a Persantine nuclear
study in [**2192-8-23**], which showed fixed irreversible
diffusion abnormalities, distal and anterior wall
abnormalities, and fixed apical abnormalities. The patient
was also reported to have had an echocardiogram performed one
year prior to his current symptoms, which showed an ejection
fraction of less then 25%. An MRI performed on [**11-7**] showed
increased left ventricular cavity size with extensive left
ventricular septal dysfunction, right ventricular systolic
functions were within normal limits. There was no myocardial
scarring or infarct noted. There was disease in the left
main proximal left anterior descending coronary artery,
middle left circumflex and proximal right coronary artery.
The ejection fraction was noted to be 29% with a cardiac
output of 6.7 and a cardiac index of 3.2.
After one day admission at the outside hospital the patient
was transferred to the [**Hospital1 69**]
for cardiac catheterization.
PAST MEDICAL HISTORY: Remarkable for hypertension, type 1
diabetes, prostate cancer, coronary artery disease,
hypercholesterolemia, hyperthyroidism, intermittent
claudication (barely one block, up until [**Month (only) 205**] able to walk
nine holes of golf) and neuropathy.
PAST SURGICAL HISTORY: Prostatectomy, bilateral cataracts,
CEA four years prior, arthroscopic left knee surgery,
appendectomy and tonsillectomy.
MEDICATIONS: Humalog insulin 17 units in the morning and
Lantus insulin at 6 units at night, Captopril 100 mg po
b.i.d., Prilosec 10 mg po q day, Levoxyl 100 micrograms po q
day, Lasix 200 mg po q day, aspirin 81 mg po q day, Lipitor
10 mg po q day, vitamin E 400 mg po b.i.d., Pletal 50 mg po q
day.
ALLERGIES: The patient is allergic to sulfa drugs.
FAMILY HISTORY: The patient's father died of an myocardial
infarction at age 54. He had diabetes. Grandfather had
myocardial infarctions. The mother was reported to have
chronic obstructive pulmonary disease.
SOCIAL HISTORY: The patient is an ex-smoker. He quit 23
years ago. He had a total eighty packs a year history. The
patient quit alcohol eight years prior. He use to two drinks
per day.
HOSPITAL COURSE: The patient was admitted to the [**Hospital1 346**] on [**2192-11-30**] and scheduled to have a
cardiac catheterization. This was performed on the day of
admission with a finding of diffuse disease of the left
anterior descending coronary artery proximally with total
occlusion distally, mild to moderate disease of the left
circumflex, and 60% stenosis of the mid right coronary
artery. Cardiothoracic Surgery consultation was requested
and the patient was scheduled for a coronary artery bypass
graft on [**2192-12-4**]. The patient underwent the procedure
without complications and had four vessel bypass with the
left internal mammary being grafted to the left anterior
descending coronary artery and the saphenous vein graft to
the obtuse marginal, right coronary artery - PD and DX. The
patient was then transferred to the CSRU for continued
monitoring. He had an uneventful stay in the CSRU with only
notable issues being his blood sugar control. The patient
was seen by the [**Hospital **] [**Hospital 982**] Clinic consultation team with
recommendations made on his diabetic medication management.
The patient was transferred to the CP Surgery floor on postop
day number three, but had to be returned for blood glucose
control with blood glucose over 400. His blood sugar was
quickly brought under control on an insulin drip. His
regimen by mouth optimized and the patient transferred once
again to the CP Surgery floor on postop day number four.
During the [**Hospital 228**] transfer from the surgery floor back to
the unit on postoperative day number three his left thigh
incision was noted to have dehisced. The wound was
reapproximated with interrupted sutures. The patient's wound
was unfortunately contaminated with urine before closure. On
postoperative day number five the patient was noted to have
an episode of nonsustained ventricular tachycardia. A
cardiology consultation was requested. The cardiology team
was of the opinion that the patient needed to be risk
stratified, but given the evolving infection in his left
thigh wound it would not be possible to consider the
placement of an implantable defibrillator. The benefits of
beta blockers were discussed with the patient, but given the
patient's history of fatigue and other side effects with beta
blockers treatment was not initiated at that time. On
postoperative day number six the patient's left thigh wound
was noted to have some erythema and the patient was started
on Keflex. An echocardiogram was also performed. On
postoperative day number seven the decision was made to
change the patient's antibiotic medication from Keflex to
Ciprofloxacin. His blood sugar remained well controlled.
Following three days on antibiotic therapy the patient's
thigh wound appeared only minimally improved, although his
white count was beginning to trend downward. It was
ultimately decided that it would be best to open the wound
and begin packing with wet to dry dressings. The patient's
blood sugar remained well controlled.
The patient had no further episodes of nonsustained
ventricular tachycardia, although he did have a brief run of
paroxysmal atrial fibrillation. By postoperative day number
ten the patient was in stable condition and ready for
discharge to a skilled nursing facility. The patient's wound
was opened, well irrigated and then packed prior to
discharge.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg po b.i.d.
(started [**2192-12-11**]). Ibuprofen 400 mg po t.i.d. prn,
Albuterol - ipratropium one to two puffs q 6 hours prn,
Atorvastatin 10 mg po q day, Protonix 40 mg po q day,
Captopril 25 mg po t.i.d., Levoxyl 100 micrograms po q day,
Milk of Magnesia prn, Percocet one to two tablets po q 4 to 6
hours prn, Tylenol 325 to 650 mg po q 4 to 6 hours prn,
enteric coated aspirin 325 mg po q day, Lasix 40 mg po
b.i.d., Colace 100 mg po b.i.d., insulin Glargine 36 units at
bedtime, Humalog insulin sliding scale (the patient will also
need potassium prn).
FOLLOW UP: The patient is to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] in clinic four weeks following discharge. The
patient is also to follow up with the Electrophysiology
Service for evaluation for his need for an implantable
defibrillator. The patient will also need to follow up with
his primary care physician two to four weeks following
discharge. The patient is scheduled to come back to the
Medical Center for a wound check in two weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease requiring coronary artery bypass
graft.
2. Wound infection.
3. Arrhythmia.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2192-12-14**] 09:28
T: [**2192-12-14**] 09:37
JOB#: [**Job Number **]
ICD9 Codes: 4280, 9971, 4271, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2597
} | Medical Text: Admission Date: [**2160-8-8**] Discharge Date:
Date of Birth: [**2135-10-6**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 24 year old man
who was brought by his friends to the Emergency Room because
they found his lethargic and confused. Family members found
an empty bottle of rubbing alcohol and Excedrin P.M.
(contained Tylenol and Benadryl). It is likely that the
patient took the above medication approximately two to three
hours prior to presentation to the Emergency Room.
On initial evaluation, the patient was unresponsive, he could
not answer questions. He was febrile, tachycardiac and
hypotensive. A nasogastric tube was placed but was pulled
back by the patient. The patient required sedation with 10
mg of morphine and 8 mg of Versed. His Tylenol level was
found to be 216. Charcoal as well as Mucomyst were given.
The patient vomited the Mucomyst twice and was electively
intubated to protect his airway. He was given Reglan and
droperidol before Mucomyst. This was given again through the
nasogastric tube, with good results.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: The patient has no known drug allergies.
PAST MEDICAL HISTORY: Ulcerative colitis.
SOCIAL HISTORY: The patient reports drinking approximately
three to four alcoholic beverages per week. He smokes
one-half pack of cigarettes per day. He recently broke up
with his partner.
LABORATORY DATA: Admission white blood cell count was 9.8
with 28 neutrophils, 59 lymphocytes, 10 monocytes, 4
eosinophils and 2 atypicals, hematocrit 43.7, platelet count
343,000, INR 1.2, partial thromboplastin time 24.9, sodium
144, potassium 2.4, chloride 105, bicarbonate 29, BUN 9,
creatinine 0.8 and glucose 142. Urinalysis had no ketones,
no white blood cells and no red blood cells. Calcium was
7.5, phosphorous 2.1 and magnesium 1.5. Toxicology screen
revealed an acetaminophen level of 216.4, aspirin negative;
following administration of morphine and Versed in the
Emergency Room, benzodiazepines and opiates were positive.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 97, heart rate 76, blood pressure
126/76, respiratory rate 10 and oxygen saturation 99% on 100%
FiO2, tidal volume 650 and PEEP of 5. General: Patient was
sedated and intubated white young male with black mouth,
occasionally moving extremities. Head, eyes, ears, nose and
throat: Anicteric sclerae, pupils 4 mm and reactive
bilaterally, mouth with charcoal, no lymphadenopathy. Chest:
Clear to auscultation bilaterally, no wheezes, crackles or
rhonchi. Cardiovascular: Tachycardiac, normal S1 and S2, no
murmur, rub or gallop appreciated. Abdomen: Soft,
nontender, nondistended, positive bowel sounds. Extremities:
No lower extremity edema, good distal pulses. Neurologic:
patient unable to cooperate with examination.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit with a diagnosis of attempted
suicide with Tylenol and Benadryl. One day following
admission to the Medical Intensive Care Unit, the patient was
transferred to the floor for further management. During this
hospitalization, the patient's issues included:
1. Pulmonary: Initially, the patient was intubated for
airway protection. He was quickly weaned from ventilatory
support and extubated within 12 hours of intubation. While
on the floor, the patient did not have any respiratory
issues.
2. Overdose with acetaminophen and Benadryl: The patient
was initially treated with charcoal and Mucomyst 70 mg/kg.
During the hospitalization, the patient's acetaminophen
dropped from 216 to 69 to undetectable within 36 hours of
admission. His liver function tests initially revealed an
INR of 1.4, ALT 57 and AST 41. Thirty-six hours following
admission, INR was 1.3, AST 33 and ALT 56. By that time, the
patient had received eight doses of Mucomyst. At that time,
the patient was judged not to have sustained significant
liver damage secondary to his overdose. His Mucomyst was
stopped, the nasogastric tube discontinued and the patient
was rapidly advanced on his diet. He is currently able to
tolerate good oral intake.
Psychiatry was involved in the patient's evaluation. This
afternoon, he is medically cleared and his disposition
depends upon the psychiatrists' recommendations.
DISCHARGE MEDICATIONS: None.
CONDITION ON DISCHARGE: Medically stable.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] J. 12-409
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2160-8-10**] 12:01
T: [**2160-8-10**] 12:06
JOB#: [**Job Number 3852**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2598
} | Medical Text: Admission Date: [**2151-10-29**] Discharge Date: [**2151-11-4**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old
male with known coronary artery disease, hypertension,
hypercholesterolemia, and paroxysmal atrial fibrillation who
presented with chest pain radiating to his back since 4 p.m.
on the day of admission. Symptoms started while straining to
have bowel movement. Symptoms associated with diaphoresis,
but no shortness of breath and no other associated symptoms.
He initially presented to [**Hospital3 1280**] Hospital in [**Location (un) 47**]
where he was ruled out for myocardial infarction, and because
chest x-ray showed mediastinal widening a CT angiogram was
performed that suggested the ascending aortic dissection. He
was given morphine and transferred to [**Hospital1 190**] Emergency Department.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Paroxysmal atrial fibrillation.
4. Hypercholesterolemia.
5. Myocardial infarction; percutaneous transluminal coronary
angioplasty and stent to the left anterior descending artery
in [**2149-1-20**] and percutaneous transluminal coronary
angioplasty of the right coronary artery in [**2149-2-17**].
MEDICATIONS ON ADMISSION: Coumadin, amiodarone 200 mg p.o.
q.d., Imdur 100 mg p.o. q.d., Cozaar 50 mg p.o. q.a.m. and
25 mg p.o. q.p.m., atenolol 25 mg p.o. q.d., aspirin 81 mg
p.o. q.d.
ALLERGIES: He is allergic to SULFA.
SOCIAL HISTORY: He is married, lives with his wife; very
functional, still drives. No smoking. No alcohol.
FAMILY HISTORY: Family history was noncontributory.
REVIEW OF SYSTEMS: No palpitations. No fevers or chills.
No nausea or vomiting. No dizziness. No headache. No
shortness of breath.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were
afebrile, pulse 60, blood pressure 155/76 (which was
identical in the right and left arm), oxygen saturation 97%
on 2 liters, respiratory rate 18. In general, he was in no
acute distress. HEENT revealed pupils were equal, round, and
reactive to light. Extraocular movements were intact. The
patient was pale. Neck with jugular venous distention
elevated 4 cm above the clavicle while at 45 degrees. Lungs
were clear to auscultation bilaterally. Cardiovascular had a
regular rate and rhythm. No murmurs. No rubs. There was an
S4 gallop. The abdomen was soft, mildly distended,
nontender, positive bowel sounds. Extremities had no edema.
Distal pulses were felt, 2+ dorsalis pedis, posterior
tibialis, femoral, and radial. Neurologically, he was alert
and oriented times four with no focal deficits.
LABORATORY DATA ON ADMISSION: White blood cell count 13,
hematocrit 45, platelets 157. INR was 2.5. Troponin was
less than 0.3. Chem-7 with sodium of 146, potassium 4.2,
chloride 104, bicarbonate 29, BUN 22, creatinine 1.5, and
glucose 101.
RADIOLOGY/IMAGING: Thoracic CT angiogram performed at the
outside hospital showed recalcification of the aortic wall,
thickened wall to distal descending aorta and transverse
aorta with question of hematoma versus dissection.
Electrocardiogram was sinus rhythm with left axis deviation,
and LAFB. There was left ventricular hypertrophy with poor R
wave progression as well as diffuse T waves abnormalities
felt to be nonspecific in the setting of left ventricular
hypertrophy.
IMPRESSION: This is a 79-year-old with known coronary artery
disease, hypertension, and atrial fibrillation who presents
with aortic dissection.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: The patient was admitted to the Coronary
Care Unit. Intensive blood pressure control was obtained
with intravenous nitroprusside and labetalol. The
Cardiothoracic Surgery team was consulted.
The CAT scan from the outside hospital did not demonstrate a
visible flap, so it was unclear whether the aortic dissection
involved the ascending aorta. Therefore, a transesophageal
echocardiogram was performed. Prior to the procedure the
patient was intubated with propofol used for sedation.
The transesophageal echocardiogram showed left ventricular
hypertrophy with good left ventricular function, thickened
AV, trivial AR, and a calcified aorta with hematoma and
dissection starting in the upper ascending aorta extending
along the arch and continuing through the descending thoracic
aorta. Again, no flap was identified.
Spine MRA was performed to determine the extent of the
intramural hematoma. The hematoma was seen extending from
the aortic valve involving the entire ascending aorta, arch
of the aorta, and entire descending aorta down to the level
of the renal arteries where the study stopped. It was
postulated that this likely arose from a defect in the
descending aorta, probably a plaque rupture. Because there
was no repairable defect seen in the ascending aorta, surgery
was not recommended by the Cardiothoracic Surgery team.
[**Hospital 49578**] medical management was continued. He was weaned
off nitroprusside. Intravenous labetalol was changed to p.o.
He was restarted on Losartan and atenolol and started on
amlodipine. Furosemide was also added.
His blood pressure was difficult to control and required
escalating doses of the above. Final hypertensive regimen is
listed below under discharge medications. His blood pressure
on discharge was approximately 120/70.
From the standpoint of his known coronary artery disease, the
patient ruled out for myocardial infarction by enzymes. We
continued his Zocor. However, we discontinued his aspirin
given his known aortic defect.
On the day after admission, the patient was found to be in
atrial fibrillation although he was admitted in normal sinus
rhythm. We continued amiodarone. However, he remained in
atrial fibrillation. Still, we felt it necessary to
discontinue his Coumadin given his aortic dissection. In
addition, we reversed his anticoagulation with fresh frozen
plasma and vitamin K. His INR at the time of discharge
was 1.1.
2. GASTROINTESTINAL: The patient's aortic dissection
occurred in the context of straining to have a bowel
movement. He has chronic constipation and takes Metamucil.
In order to attempt to prevent future straining, we
instituted an aggressive bowel regimen and this should be
continued as an outpatient. He did have two bowel movements
during this admission without straining.
3. HEMATOLOGY: As mentioned above, we reversed the
patient's anticoagulation and feel that he should remain
without any anticoagulation or platelet inhibiting agents for
the time being. His hematocrit on admission was 44, but this
decreased to 35. It was stable at 35 for several days and
then slowly increased and was 39 on the day before discharge.
It is recommended his hematocrit be followed as an
outpatient.
4. PULMONARY: The patient was electively intubated for the
purpose of the transesophageal echocardiogram and was
extubated the next day once it was determined that he would
not be going to surgery. He desaturated slightly with
increased oxygen requirements, and a chest x-ray showed
pulmonary edema. This was treated with furosemide with
complete clinical and radiographic resolution.
Of note, the patient has documented DLCO on recent pulmonary
function tests performed at the [**Hospital6 1708**]
about six weeks ago, and this was thought to be secondary to
amiodarone use. This is the suspected reason for his
slightly impaired oxygenation despite adequate diuresis.
5. CODE STATUS: He was full code.
DISCHARGE STATUS: He was discharged to home with [**Hospital6 3429**] services to check blood pressure and
medication compliance.
CONDITION AT DISCHARGE: Discharge condition was good.
DISCHARGE FOLLOWUP INSTRUCTIONS: He was told to have
follow-up appointment with Dr. [**Last Name (STitle) 2257**] (his cardiologist) on
[**11-11**]. He should have minimal activity for the next
four weeks. He should continue an bowel regimen and avoid
straining. He should not plan any significant travel until
[**Month (only) 404**] of next year.
MEDICATIONS ON DISCHARGE:
1. Losartan 50 mg p.o. b.i.d.
2. Labetalol 300 mg p.o. b.i.d.
3. Atenolol 25 mg p.o. q.d.
4. Furosemide 20 mg p.o. q.d.
5. Amlodipine 5 mg p.o. q.d.
6. Amiodarone 200 mg p.o. q.d.
7. Zocor 20 mg p.o. q.d.
8. Zoloft 50 mg p.o. q.d.
9. Allopurinol 100 mg p.o. b.i.d.
10. Prevacid 15 mg p.o. q.d.
11. Colace 100 mg p.o. b.i.d.
12. Metamucil q.d.
He should discontinue aspirin for now, but this should be
reconsidered in another four to eight weeks. He should
discontinue Coumadin for now and possibly reconsider starting
this again in one year or perhaps discontinue this
permanently.
DISCHARGE DIAGNOSES:
1. Aortic dissection.
2. Hypertension.
3. Atrial fibrillation.
4. Congestive heart failure.
5. Anemia.
6. Constipation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2151-11-3**] 15:01
T: [**2151-11-6**] 14:09
JOB#: [**Job Number 100673**]
ICD9 Codes: 4280, 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2599
} | Medical Text: Admission Date: [**2100-10-31**] Discharge Date: [**2100-11-3**]
Date of Birth: [**2055-7-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
spiral endoscopy
History of Present Illness:
45 yo M h/o ulcerative colitis s/p colectomy with ileoanal
renastamosis, HCM (EF-75%, resting gradient of 130mmHg),
presenting with BRBPR. The patient noticed dark stools 3 days
prior to admission and his frequency increased from his normal
of [**4-26**] per day to 5-6 per day and were beginning to have small
amounts of bright red blood. The morning prior to admission, his
stools became bright red and increased in frequency to 7 stools.
He is unable to quantify the amount.
He was notably hospitalized for GI bleed in [**Month (only) 205**] for five days.
He initally presented with a Hct of 22 and received 6 units of
prbcs and 2 units of ffp during hospital stay. Two CTAs, EGD,
and a push enteroscopy at that time revealed no source of
bleeding. The bleeding eventually resolved on its own and was
thought to be secondary to NSAID-induced ulcers somewhere in the
small bowel or perhaps had begun to heal by the time he was
imaged. His Mct on discharge was 32.
He underwent capsule endoscopy after admission that revealed
focal areas of erythema in the mid jejunum and ileum. However,
no active bleeding site was identified. His last Hct prior to
this admission was 39.5 on [**9-9**].
In the ED, initial VS: 98.7 95 145/84 20 100% RA. Rectal exam
showed [**Month/Year (2) **] blood and he notably had general pallor. Labs were
notable for a 12.5 point Hct drop (27 from 39.5) NG lavage was
negative. He was transfused 2 units of prbcs and received 40 mg
IV protonix. GI was consulted and since NG lavage was negative,
did not feel the need to scope immediately. EKG: LVH, q waves;
general palor. He has 2 PIVs (16G and 18G). Last vitals prior to
transfer: 131/79 76 13 100% RA.
Upon arrival to the ICU, patient feels well and denies
lightheadedness, sob, chest pain, nausea, vomiting, abdominal
pain.
Past Medical History:
- UC s/p colectomy w/ileoanal anastomosis, ileostomy takedown
and
the resection of ileoanal stricture
- Asthma
- Anxiety
- hypertrophic cardiomyopathy (resting gradient of 130mm Hg)
Social History:
Remote alcohol use drinking 10-14 beers/day for 5-6 years. Quit
15 years ago, and now drinks 1-2 times per year. H/o smoking 3
ppd for 4-5 years, however quit 10 years ago, just prior to his
UC diagnosis. Originally from [**Country 4754**]. Married. Lives in [**Hospital1 392**]
and works in construction.
Family History:
Notable for a brother with ulcerative colitis who died of an MI
at age of 60, uncle with [**Name2 (NI) 499**] cancer, Brother with prostate and
gastric cancer, and sister with breast cancer.
Physical Exam:
Admission Physical:
VS: Temp: 97.6 BP:123/69 HR: 75 RR: 16 O2sat 96% RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no jvd,
no carotid bruits,
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, 2/6 systolic murmur heard best at base
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, old
surgical scars present
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII grossly intact. 5/5 strength throughout.
No sensory deficits to light touch appreciated.
Pertinent Results:
[**2100-10-31**] 11:59PM HCT-26.8*
[**2100-10-31**] 07:24PM HGB-10.0* calcHCT-30
[**2100-10-31**] 07:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2100-10-31**] 07:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2100-10-31**] 07:15PM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-<1
[**2100-10-31**] 07:00PM GLUCOSE-100 UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-27 ANION GAP-9
[**2100-10-31**] 07:00PM estGFR-Using this
[**2100-10-31**] 07:00PM WBC-9.5 RBC-3.01*# HGB-9.3*# HCT-27.0*#
MCV-90 MCH-31.0 MCHC-34.6 RDW-14.8
[**2100-10-31**] 07:00PM NEUTS-73.5* LYMPHS-21.3 MONOS-3.7 EOS-1.0
BASOS-0.5
[**2100-10-31**] 07:00PM PLT COUNT-215
[**2100-10-31**] 07:00PM PT-13.5* PTT-22.5 INR(PT)-1.2*
Brief Hospital Course:
45 yo M h/o ulcerative colitis s/p colectomy with ileoanal
renastamosis p/w recurrent BRBPR and a 13 point Hematocrit drop
admitted to ICU for close monitoring.
#. GI Bleed: Unclear source as prior studies (endoscopy,
enteroscopy, and CT) were unable to identify source. Admitted
with 12.5 Hct drop, [**Month/Day/Year **] blood on rectal and negative NG
lavage. Surgery, GI and IR consulted. No clear blush on CTA.
Enteroscopies did not show any bleeding. Hct remained stable.
Patient wanted to leave and was discharched after being
medically cleared by the ICU team and GI team with plan for f/u
with GI.
#. Hypertrophic Cardiomyopathy: Resting gradient of 130 mm of
Hg. Recently diagnosed in last admission. Cardiology consulted.
Plan to be followed by cardiology in the outpatient per patient.
Initially held metoprolol given GI bleed but it was restarted
once pt was hemodynamically stable.
#. Anxiety: Ativan prn
# H/o Asthma: Patient has been on advair in past, however has
not required medication in quite some time. Written for
albuterol prn while in-patient
Medications on Admission:
Toprol 50mg po daily
Discharge Medications:
1. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
primary:
1. GI bleeding
.
secondary:
1. ulcerative colitis, status post ileoanal pouch w/ ileostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for bleeding from your pouch.
You underwent small bowel enteroscopy/spiral endoscopy with the
GI doctors which did not show a source of the bleeding. If
future episodes of bleeding occur, you may require repeat
evaluation and consideration of open enteroscopy.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- none
.
Please seek medical evaluation for any lightheadedness,
dizziness, bleeding, fevers, chest pain, shortness of breath,
abdominal pain, nausea/vomiting, or any other concerns.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 25350**] to schedule an appointment
with your primary care doctor in [**1-23**] weeks.
.
The GI doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 138**] [**Name5 (PTitle) **] for a follow-up appointment. Please
call [**Telephone/Fax (1) 11048**] to schedule this appointment if you do not
hear from them.
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2100-11-22**] 4:20
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22561**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2101-1-4**]
4:00
ICD9 Codes: 5789, 4254, 4241 |
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