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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2600
} | Medical Text: Admission Date: [**2169-3-1**] Discharge Date: [**2169-3-4**]
Date of Birth: [**2097-7-12**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**3-1**]: T1-T3 laminectomies and T2-T3 TUMOR RESECTION
History of Present Illness:
71-year-old woman who was discovered to have an incidental
thoracic intramedullary and extramedullary mass. Workup was
motivated by shortness of breath which led to a thoracic MRI, on
which this lesion was discovered. It does not seem that that
has been fully explained. She notes some difficulty walking and
unsteadiness when first getting up, but this resolves with
further ambulation. She also notes pain in the left lateral
thoracic region between T1 and T4. It does seem to be radicular
in nature. She denies difficulty with bowel or bladder
function. Her symptoms have not progressed significantly
over the last six months or so.
Past Medical History:
Significant for hypercholesterolemia, hysterectomy, and
bilateral oophorectomy, mitral valve prolapse and lung disease,
right-sided breast mass s/p excision (benign), tonsillectomy
Social History:
She is not working. She does not smoke. She does not drink
alcohol. She is married.
Family History:
Significant for cancer, which her mother has.
Physical Exam:
On examination, her motor strength is [**3-30**] in hip flexion,
extension, quadriceps, hamstrings, dorsiflexion, and plantar
flexion bilaterally. Her sensory examination was intact with
respect to the modality of light touch and proprioception. In
particular, there was no sensory level in the upper thoracic
region. There was no point tenderness. Her reflexes were
hypoactive, but symmetric. There is no clonus on either side.
Babinski is downgoing bilaterally.
[**2169-3-4**]: the patient was neurologically intact. strength was
full. sensation was intact. incision wa clean and dry and
closed with staples.
Pertinent Results:
MRI T-SPINE [**2169-3-1**]
Status post resection of meningioma at T1-T3 level. Except for a
small linear component of enhancing tissues adjacent to and at
the posterior aspect of T2 and T3 vertebral bodies, most of the
mass has been removed with decrease in mass effect on the spinal
cord. Fluid is seen in the surgical cavity along the left
paraspinal region. No abnormal signal seen within the spinal
cord in the region of surgery.
[**2169-3-1**] 06:15PM TYPE-ART PO2-173* PCO2-43 PH-7.39 TOTAL
CO2-27 BASE XS-1
[**2169-3-1**] 06:15PM GLUCOSE-101 LACTATE-1.5
[**2169-3-1**] 06:15PM freeCa-1.11*
[**2169-3-1**] 05:54PM GLUCOSE-102* UREA N-13 CREAT-0.5 SODIUM-144
POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-26 ANION GAP-10
[**2169-3-1**] 05:54PM estGFR-Using this
[**2169-3-1**] 05:54PM CALCIUM-7.7* PHOSPHATE-4.7* MAGNESIUM-1.7
[**2169-3-1**] 05:54PM WBC-6.2 RBC-3.55* HGB-11.4* HCT-32.2* MCV-91
MCH-32.2* MCHC-35.6* RDW-13.1
[**2169-3-1**] 05:54PM PLT COUNT-175
[**2169-3-1**] 05:54PM PT-13.0 PTT-23.3 INR(PT)-1.1
[**2169-3-1**] 04:01PM TYPE-ART PO2-206* PCO2-40 PH-7.41 TOTAL
CO2-26 BASE XS-1 INTUBATED-INTUBATED
[**2169-3-1**] 04:01PM GLUCOSE-97 LACTATE-1.4 NA+-142 K+-3.6 CL--110
[**2169-3-1**] 04:01PM HGB-10.7* calcHCT-32 O2 SAT-98
[**2169-3-1**] 04:01PM freeCa-1.09*
[**2169-3-1**] 01:14PM TYPE-ART PO2-216* PCO2-42 PH-7.37 TOTAL
CO2-25 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2169-3-1**] 01:14PM GLUCOSE-103 LACTATE-1.2 NA+-142 K+-3.5
CL--111
[**2169-3-1**] 01:14PM HGB-10.9* calcHCT-33
[**2169-3-1**] 01:14PM freeCa-1.07*
CHEST (PORTABLE AP) Study Date of [**2169-3-2**] 5:31 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] TSICU [**2169-3-2**] 5:31 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 94343**]
Comparison is made with prior study performed a day earlier.
There are lower lung volumes. A small left pleural effusion has
increased. Cardiac size is top normal. Mild vascular congestion
is new. There is no evident pneumothorax. Subcutaneous emphysema
towards the left in the neck is more conspicuous than before.
Left superior paraspinal soft tissue abnormality is more
conspicuous than any prior study and is consistent with
postoperative changes with possible hematoma.
Brief Hospital Course:
Pt electively presented and underwent T1-T3 laminectomies and
resection of tumor at T2-T3. She tolerated this procedure very
well with no complications. Post operatively she remained
intubated and was transferred to the ICU for further care
including Q1 neuro checks and SBP control less than 140. She had
a post operative MRI that showed good resection of tumor. On
post operative exam she was moving all extremities with good
strength and her surgical site was clean and dry. She was
extubated without difficulty on POD#1. On exam she remained
full strength with only slight weaknes of her left grip 5-/5.
She was transferred to the floor in stable condition and her
foley catheter was removed and she was able to void on her own.
She was seen by physical therapy and cleared for home with
family support. She will be discharged home in stable condition
on [**2169-3-4**].
Medications on Admission:
Simvastatin
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain: do not exceed 4 grams in 24
hours will cause liver failure.
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: do not drive while taking this
medication- do not take if lethargic.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
T2-T3 meningioma
Discharge Condition:
Activity as tolerated. No lifting greater than 10 pounds. Keep
surgical site clean and dry for 10 days.
Activity as tolerated. No lifting greater than 10 pounds. Keep
surgical site clean and dry for 10 days.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound clean and dry / No tub baths or pool swimming
for two weeks from [**2169-3-1**] the date of your surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? If you are required to wear one, wear your cervical collar or
back brace as instructed.
?????? You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in [**6-4**] days [**2169-3-1**] for removal
of your staples and a wound check. This appointment can be made
with the Nurse Practitioner. Please make this appointment by
calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**] to be seen in 6 weeks.
??????You will need x-rays thoracic spine prior to your appointment.
Completed by:[**2169-3-4**]
ICD9 Codes: 2720, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2601
} | Medical Text: Admission Date: [**2131-10-11**] Discharge Date: [**2131-10-12**]
Date of Birth: [**2074-1-10**] Sex: F
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
female who has a known history of cerebral aneurysm diagnosed
by CAT scan on [**2131-10-6**]. The patient was scheduled
for Interventional Radiology procedure on [**10-12**]. On the
morning of [**10-11**], the patient called the EMS complaining
of vomiting and headache. The patient was brought to [**Hospital6 1760**] where she was noted to be
lethargic and unresponsive. The patient was intubated. CT
scan showed a large amount of blood and question of rupture,
giant aneurysm. ICB drain was placed, and the patient was
brought to the Surgical Intensive Care Unit for further
management.
PAST MEDICAL HISTORY: Chronic osteoarthritis. Peptic ulcer
disease. Migraines. Chronic thrombophlebitis.
Hypertension. Bipolar disorder.
ALLERGIES: MYCOSTATIN, CECLOR, CLINDAMYCIN, BACTRIM.
PHYSICAL EXAMINATION: General: The patient was intubated
and sedated. Triple flexing to pain in the lower extremities
and grimacing to pain with vigorous sternal rub. HEENT:
Pupils 1.5 mm and fixed on the right and sluggish on the
left. Corneal reflexes were absent. The patient had no
doll's eyes. Faint and inconsistent gag reflex. Chest was
clear to auscultation. Cardiovascular: The patient was
tachycardiac to 112. Abdomen: Nontender and nondistended.
Obese.
LABORATORY DATA: White count 19.9, hematocrit 44.1, platelet
count 388,000; sodium 144, potassium 3.5, chloride 107, CO2
26; coags with a PT of 12.7, PTT 27.8, INR 1.1.
Head CT showed massive subarachnoid hemorrhage with
intracerebral blood surrounding the area of the right frontal
area, consistent with giant aneurysm rupture. The patient
underwent left frontal-external ventricular drain placement
which subsequently clotted and required a second drain
placement. The patient went to Interventional Radiology
where the patient had an arteriogram and coiling of her
aneurysm.
The patient was transported back to the Surgical Intensive
Care Unit, where in the afternoon she blew both pupils, was
unresponsive to painful stimulation, had negative gag,
corneal, and cold caloric response. The patient was seen by
Neurosurgery attending who discussed the case with the
family. An EEG was obtained which showed no activity, and a
cerebral blood flow study which showed no blood flow. The
patient was declared brain dead on [**10-12**], at 18:40. The
family was aware that the Organ Bank had been contact[**Name (NI) **]. The
patient was not an organ donor.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] M. 14-133
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2131-10-16**] 14:25
T: [**2131-10-16**] 14:19
JOB#: [**Job Number 102639**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2602
} | Medical Text: Admission Date: [**2162-9-16**] Discharge Date: [**2162-9-20**]
Date of Birth: [**2079-1-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2162-9-16**]:
1. Aortic valve replacement with a 27-mm [**Company 1543**] Ultra
aortic valve bioprosthesis, serial #[**Serial Number 90120**].
2. Coronary artery bypass grafting with reverse saphenous
vein graft from aorta to distal right coronary artery.
History of Present Illness:
The patient is an 83-year-old gentleman referred to me by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for severe critical aortic stenosis and
single-vessel coronary artery disease.
The patient was admitted following aortic valve replacement and
coronary artery bypass grafting.
Past Medical History:
Aortic Stenosis
Dyslipidemia
Hypertension
Coronary Artery Disease
Anemia
TIA
Primary Open Angle Glaucoma
BPH
Osteoarthritis Shoulder
Social History:
-Tobacco history: None
-ETOH: Occasional
-Illicit drugs: None
Retired
Family History:
No family history of premature CAD
Physical Exam:
VS:
General: 83 year-old male in no apparent distress.
HEENT: normcephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2
Resp: decreased breath sounds otherwise clear
GI: benign
Extr: warm 1+ edema
Incision: sternal and left lower extremity incision clean dry
intact, no erythema
Neuro: awake, alert oriented
Pertinent Results:
[**2162-9-18**] WBC-14.4*# RBC-2.95* Hgb-9.6* Hct-28.3* MCV-96
MCH-32.4* MCHC-33.8 RDW-13.7 Plt Ct-100*
[**2162-9-18**] WBC-14.4*# RBC-2.95* Hgb-9.6* Hct-28.3* MCV-96
MCH-32.4* MCHC-33.8 RDW-13.7 Plt Ct-100*
[**2162-9-17**] WBC-8.4 RBC-2.81* Hgb-9.2* Hct-27.2* MCV-97 MCH-32.8*
MCHC-33.9 RDW-14.0 Plt Ct-112*
[**2162-9-16**] WBC-6.0 RBC-2.69* Hgb-8.9* Hct-26.1* MCV-97 MCH-32.9*
MCHC-34.0 RDW-13.7 Plt Ct-82*#
[**2162-9-18**] Glucose-96 UreaN-19 Creat-1.1 Na-131* K-4.7 Cl-99
HCO3-23
[**2162-9-17**] Glucose-99 UreaN-14 Creat-1.0 Na-133 K-4.4 Cl-104
HCO3-24
[**2162-9-16**] UreaN-15 Creat-1.0 Na-136 K-4.1 Cl-109* HCO3-23
CXR
[**2162-9-18**]:
Tubes and catheters have been removed. Allowing for low lung
volumes, the mediastinal silhouette and vascularity are normal.
There is no evidence of pneumothorax. Minimal atelectasis is
present at the left lung base.
IMPRESSION: Minimal left basilar atelectasis, no evidence of
pneumothorax.
TTE:
PREBYPASS
The left atrium and right atrium are normal in cavity size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. Left ventricular wall
thicknesses and cavity size are normal. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). Severe
(4+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
POSTBYPASS
LV function now appears hyperdynamic. RV systolic function
appears normal. There is a well seated, well functioning
bioprosthesis in the aortic postion. No AI is visualized. The
remaining study is unchanged from prebypass.
Brief Hospital Course:
Mr.[**Known lastname 90058**] was brought to the operating room on [**2162-9-16**] where
he underwent Aortic valve replacement with a 27-mm [**Company 1543**]
Ultra aortic valve bioprosthesis, serial #[**Serial Number 90120**]. Coronary
artery bypass grafting with reverse saphenous vein graft from
aorta to distal right coronary artery. Please refer to operative
report for further surgical details. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU intubated and sedated in stable but
critical condition. He awoke neurologically intact and was
extubated without incident. He weaned from pressor support, was
hemodynamically stable. Beta blocker/Statin/Aspirin and
diuresis were initiated. He was gently diuresed toward the
preoperative weight. POD#1 he was transferred to the telemetry
floor for further recovery. Lines and drains were discontinued
per protocol without complication. His pacing wires were delayed
being removed due to mild thrombocytopenia and his ASA and
Aggrenox were held until his platlet count improved. Mr.[**Known lastname 90058**]
has a history of BPH, his foley was discontinued on POD2 but he
was unable to void. Therefore the foley was repalaced and again
discontinued 24hrs later afterwhich he successfully voided. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD #4 he was ambulating freely, the wound was healing and
pain was controlled with oral analgesics. The patient was
discharged to home with VNA in good condition with appropriate
follow up instructions advised.
Medications on Admission:
tamsulosin 0.4 mg qHS, finasteride 5 mg Daily, multivitamin
Daily, fluticasone 50 mcg/Actuation Spray Nasal [**Hospital1 **], metoprolol
succinate 50 mg Daily, Aggrenox 200-25 mg ER [**Hospital1 **],
hydrochlorothiazide 50 mg Daily, colestipol 1 gram Daily, Fish
Oil 1,000 mg Daily, amlodipine 10 mg Daily, lisinopril 40 mg
Daily, aspirin 81 mg Daily, atorvastatin 40 mg Daily
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig:
One (1) Cap PO BID (2 times a day).
Disp:*60 * Refills:*2*
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Ext Release 24 hr(s)* Refills:*2*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking narcotics.
Disp:*60 Capsule(s)* Refills:*2*
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
14 days.
Disp:*14 Tablet(s)* Refills:*0*
9. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 14 days.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Aortic Stenosis
Dyslipidemia
Hypertension
Coronary Artery Disease
Anemia
TIA
Primary Open Angle Glaucoma
BPH
Osteoarthritis Shoulder
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**]
Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Date/Time:[**2162-10-19**] 2:45 in the
[**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Cardiologist Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 31097**] [**Telephone/Fax (1) 90060**] in [**5-18**] 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:[**2162-9-20**]
ICD9 Codes: 4241, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2603
} | Medical Text: Admission Date: [**2114-4-3**] Discharge Date: [**2114-4-13**]
Date of Birth: [**2047-10-15**] Sex: M
Service: Cardiac Surgery
CHIEF COMPLAINT: Unstable angina.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 23**] is a 66-year-old
male with a past medical history of coronary artery disease,
type 2 diabetes mellitus, hypertension, and
hypercholesterolemia who came to [**Hospital1 190**] with unstable angina.
He was in his usual state of health and doing well with
cardiac rehabilitation until about one week ago when he had
two episodes of chest pain. He cardiologist had increased
his Zestril from 2.5 mg to 5 mg, and his atenolol to 150 mg
p.o. q.d. The patient continued with cardiac rehabilitation
until the a.m. of admission (which was [**2114-4-3**]) when
he had two episodes of resting angina at 1:15 a.m. and at
3 a.m., relieved by one sublingual nitroglycerin. He was
referred to cardiac catheterization for his unstable angina.
PAST MEDICAL HISTORY: (His past medical history includes)
1. Coronary artery disease. He had a cardiac
catheterization in [**2113-12-19**] with percutaneous
transluminal coronary angioplasty and stent of the left
anterior descending artery and the first obtuse marginal. He
had a catheterization in [**2114-1-19**] with percutaneous
transluminal coronary angioplasty of first obtuse marginal
in-stent stenosis and subsequent brachy treatment with stents
placed distal and proximal to the first obtuse marginal.
2. Type 2 diabetes mellitus; he was diagnosed 10 years ago.
3. Hypertension.
4. Hypercholesterolemia.
5. Erectile dysfunction.
MEDICATIONS ON ADMISSION: His medications on admission
included amitriptyline 25 mg p.o. at bedtime, atenolol 150 mg
p.o. q.d., lisinopril 5 mg p.o. q.d., enteric-coated
aspirin 325 mg p.o. q.d., Lipitor 10 mg p.o. q.d.,
metformin 1000 mg p.o. b.i.d., Glucovance 500 p.o. b.i.d.,
insulin 40 units q.d., Humalog sliding-scale, Claritin p.r.n.
ALLERGIES: The patient is allergic to TETRACYCLINE AND ITS
DERIVATIVES. He is allergic to ALMONDS, PEACHES, POLLEN, and
OAK TREES.
SOCIAL HISTORY: The patient lives with his wife at home. He
does not smoke and does not drink any alcohol.
FAMILY HISTORY: The patient's father died of lung cancer.
His mother had hypertension, hypercholesterolemia, and died
of died of brain cancer.
REVIEW OF SYSTEMS: On admission he denied fevers, chills,
nausea, vomiting, dizziness, or cough. He denied bright red
blood per rectum. He denied melena. He denied urinary
symptoms.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
temperature of 98, blood pressure of 140/84, pulse of 54,
respiratory rate of 18, oxygen saturation of 96% on room air.
In general, a pleasant male in no acute distress. Head,
eyes, ears, nose, and throat revealed anicteric.
Cardiovascular examination revealed a regular rate and
rhythm. First heart sound and second heart sound. A [**1-24**]
murmur consistent with mitral regurgitation. Pulmonary
revealed clear breath sounds anteriorly and laterally. The
abdomen was soft, nontender, and nondistended, positive bowel
sounds. Extremities revealed right groin site was clean,
dry, and intact; no bruits. Pulses were 2+ bilaterally.
Neurologically alert and oriented times three, mentating
well.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed a white blood cell count of 8.2,
hematocrit of 38.7, platelets of 285. INR of 1.1, PTT of 29,
PT of 12.4. Sodium of 137, potassium of 4.5, chloride
of 100, bicarbonate of 27, blood urea nitrogen of 20,
creatinine of 1.1, blood sugar on admission was 333.
Creatine kinase was 71. Troponin I was less than 0.3.
RADIOLOGY/IMAGING: The patient underwent a cardiac
catheterization; please see full report for complete results.
Briefly, the patient had 50% in-stent restenosis of the left
anterior descending artery, 90% ostial stenosis of the
circumflex. Right coronary artery with no significant
obstructive disease.
He also underwent an echocardiogram; please see full report
for complete details. Briefly, the patient had no wall
motion abnormalities noted. He had mild aortic stenosis
seen. Atrial septal defect secondary to evidence of
right-to-left flow. The atrial septal defect was small. His
ejection fraction was 55%.
HOSPITAL COURSE: On [**4-5**], the patient was taken to the
operating room and he underwent a coronary artery bypass
graft times three; left internal mammary artery to left
anterior descending artery, saphenous vein graft to obtuse
marginal, left radial to ramus intermedius. Please see the
Operative Note for full details. The patient was told the
operation went well and was transferred from the operating
room to the Cardiothoracic Intensive Care Unit.
At the time of transfer the patient was in normal sinus
rhythm. He had an arterial line, a central venous pressure
right atrial catheter, two ventricular pacing wires, two
atrial pacing wires, two mediastinal chest tubes, and one
pleural chest tube.
Intravenous drips included "cariporide" (study drug),
nitroglycerin, and propofol. Shortly after being in the
Cardiothoracic Intensive Care Unit, the patient was started
on Nipride for increased blood pressure and an insulin drip
for a blood sugar of greater than 194.
The patient did well in the immediate postoperative period.
He was weaned off his sedation, and he was weaned from the
ventilatory and extubated successfully. On postoperative
day one, the patient was weaned off Nipride drip. He
continued on the insulin drip, and he was restarted on half
of his dose of Lantus insulin. He continued to do well.
On postoperative day two, the patient became confused. He
was given Haldol, and after approximately 24 hours his
confusion resolved. He was restarted on his Nipride for
hypertension.
On postoperative day three, the patient went into a rapid
atrial fibrillation which converted to normal sinus rhythm as
the amiodarone bolus and drip was started. His temperature
spike on that day was 101.8, and he was found to have a
urinary tract infection; for which he was started on a 5-day
course of Levaquin 500 mg p.o. q.d.
On postoperative day four, the patient again went into atrial
fibrillation at a rate of 100 to 130. He received an
additional amiodarone bolus and was started on p.o.
amiodarone. He then converted to normal sinus rhythm. A
heparin drip was started on that day.
On postoperative day five, the patient was transferred to
[**Hospital Ward Name 121**] Six. By this time, the insulin drip, Nipride drip, and
amiodarone drip had been weaned off. He was on p.o.
amiodarone, and he had been started on Imdur on [**4-7**] for
his arterial graft site. Once transferred to the floor, the
patient's Lopressor dose and Imdur dose had been increased
due to hypertension and also frequent episodes of atrial
fibrillation. He continued on his p.o. dose of amiodarone as
well.
On postoperative day six, the patient was noted to have
increased blood sugars and was also noted to have right arm
thrombophlebitis in the antecubital area. The patient was
started on Ancef 1 g intravenously q.8h., and the patient's
blood sugars were being covered by a sliding-scale insulin.
Also the patient was being followed by the [**Hospital **] Clinic. On
a daily basis the patient had been seen by Physical Therapy.
His activity level had increased with the assistance of
Physical Therapy and the nursing staff.
The patient was due to be discharged from the hospital on
postoperative day seven after 24 hours of antibiotics for his
thrombophlebitis and reassessment of the patient's blood
sugars.
PHYSICAL EXAMINATION ON DISCHARGE: Vital signs revealed
temperature of 98.1, heart rate of 98 (atrial fibrillation),
respiratory rate of 18, blood pressure of 151/67. Blood
sugar at this time was 300. Skin revealed right antecubital
thrombophlebitis, erythematous. Chest incision was intact
with slight redness in the lower pole of the incision. Left
radial artery incision was intact with slight redness with
clear drainage in the distal end. Cardiovascular examination
revealed irregularly irregular with a blowing murmur heard
best at the apex. Chest was clear to auscultation. Abdomen
was soft, positive bowel sounds. Extremities revealed
palpable pulses in the bilateral arms and feet. Bilateral
fingers were cool. Feet were warm. Neurologically, alert
and oriented times three. Pupils were equal, round, and
reactive to light. He had a right facial droop (which is his
baseline).
COMPLICATIONS/SIGNIFICANT EVENTS:
1. Postoperative atrial fibrillation; being treated with
amiodarone and Coumadin; also on Lopressor.
2. Postoperative thrombophlebitis of the right arm; being
treated with intravenous Ancef.
3. Postoperative urinary tract infection; has been on a
5-day course of p.o. Levaquin.
4. Hyperglycemia; being treated with sliding-scale as well
as his regular insulin regimen of Glargin 52 units
subcutaneous q.h.s. and Humalog insulin sliding-scale.
MEDICATIONS ON DISCHARGE: (Medications on discharge
included)
1. Metoprolol 75 mg p.o. b.i.d.
2. Docusate sodium 100 mg p.o. b.i.d.
3. Enteric-coated aspirin 325 mg p.o. q.d.
4. Isosorbide mononitrate 90 mg p.o. q.d.
5. Amiodarone 400 mg p.o. t.i.d. (through [**4-15**]; then
amiodarone 400 mg p.o. q.d.).
6. Ferrous gluconate 324 mg p.o. t.i.d.
7. Glargin insulin 52 units subcutaneous q.h.s.
8. Metformin 100 mg p.o. b.i.d.
9. Humalog insulin sliding-scale.
10. Vitamin C 500 mg p.o. b.i.d.
11. Percocet one to two tablets p.o. q.4h. p.r.n. for pain.
12. Acetaminophen 650 mg p.o. q.4h. p.r.n. for pain.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft times three.
3. Type 2 diabetes mellitus.
4. Hypertension.
5. Hypercholesterolemia.
6. Erectile dysfunction.
CONDITION AT DISCHARGE/DISPOSITION: Condition on discharge
was pending; as he will be discharged on [**4-13**] pending
blood glucose control and a 24-hour course of intravenous
antibiotics for his thrombophlebitis. He will be discharged
to home at that time with [**Hospital6 407**] services
for INR checks, as he will be on Coumadin. Dose of Coumadin
was pending.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) 70**] in two weeks. He was to follow up with his
primary care physician in two weeks, and he was to follow up
with the [**Hospital **] Clinic for insulin adjustments on [**5-1**]. He
also had another follow-up appointment at [**Hospital **] Clinic on
[**5-16**]. The patient was also to follow up in the [**Hospital 409**]
Clinic in two weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 4060**]
MEDQUIST36
D: [**2114-4-12**] 12:27
T: [**2114-4-12**] 15:30
JOB#: [**Job Number 4061**]
ICD9 Codes: 4111, 9971, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2604
} | Medical Text: Unit No: [**Numeric Identifier 73073**]
Admission Date: [**2139-5-20**]
Discharge Date: [**2139-5-22**]
Date of Birth: [**2139-5-20**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname **] was a 40-
2/7ths week infant born on [**2139-5-20**] to a 26-year-old
gravida 2, now para 2 mother by spontaneous vaginal delivery
with Apgar's of 9 at 1 minute and 9 at 5 minutes. Her birth
weight was 2.765 grams (6 pounds 1 ounce). Prenatal screens
are [**Year (4 digits) **] type B-, antibody negative, rubella immune, RPR
nonreactive, hepatitis surface antigen negative, HIV positive
and group B strep positive.
ANTEPARTUM COURSE: The maternal history and pregnancy were
notable for HIV. The mother's HIV is well controlled. She
was on medication only during her last pregnancy and this
pregnancy to decrease the risk of vertical transmission of
HIV. The mother was treated with Combivir and [**Name (NI) 43379**] at 18
weeks gestation and received AZT 4 hours prior to delivery.
Mom reports 100% compliance with medications during
pregnancy. The maternal CD4 count was 641 and with a viral
load of less than 50 on [**2139-5-5**] or 38 weeks gestation.
There is a history of genital HSV and the last outbreak was
prior to 18 weeks gestation. The mother is on Valtrex.
PHYSICAL EXAMINATION: Upon admission to the neonatal
intensive care unit, the baby's weight was 2.765 grams (6
pounds 1 ounce) and appropriate for gestational age. Her
length was 20 inches and her head circumference was 34 cm.
Generally, the infant was well appearing, non-dysmorphic, in
no acute distress. She had good tone. The anterior fontanelle
was soft and flat. She was moving all extremities well. The
palate was intact. Red reflex present b/l. Breath sounds were
clear to auscultation
and she had no O2 requirement. Her heart had a regular rate
and rhythm, no murmur. Femoral pulses were symmetric. There
was no hepatosplenomegaly. She had normal female genitalia.
The anus was patent. The spine was straight. The hips were
stable. She had a positive suck, positive palmar, positive
plantar reflex.
Respiratory: Breath sounds clear and equal without issues
during this admission.
Cardiovascular: She had a regular rate and rhythm and no
murmur.
Fluids, electrolytes, and nutrition. The baby is ad lib
demand feeding and tolerating Carnation Good Start well. Her
birth weight was 2.765 grams (6 pounds 1 ounce). Her
discharge weight is 2700 grams (5 pounds 15 ounces).
Infectious disease. The patient was seen by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
[**Hospital3 1810**] infectious disease service. According to
their consult, AZT for the first 6 weeks of life has been
shown to decrease perinatal transmission of HIV by
approximately two-thirds. Given mom's low viral load of less
than 50, the risk of HIV is very low. The baby was placed on
AZT 2 mg/kg per dose every 6 hours x6 weeks. HIV/DNA/PCR was
sent in the first 48 hours, the second set to be sent at 1-2
months and a third set at 2-4 months. The infant is
considered HIV negative when 2 HIV/DNA/PCRs at or beyond 1
month of age with a third performed at greater than 4 months
of age are all negative. Urine for CMV was sent and results
are pending. As mentioned previously, mom was group B strep
positive and received greater than 4 hours of intrapartum
antibiotics. The [**Hospital3 **] cultures remain negative and the baby
has not required any antibiotic. Urine culture for CMV was
sent and results are pending. The HIV/DNA/PCR results are
pending.
Gastrointestinal. A serum bilirubin on day of life 2 was
2.9/0.3, an ALT (performed for monitoring of AZT tolerance)
was 15 on [**2139-5-20**].
Neurology. The baby has maintained a normal neurological exam
during admission.
Hematology. The infant received no [**Year (4 digits) **] products during this
admission. The CBC on [**2139-5-20**] showed a white count of
7.5, a hematocrit of 62.6 (36 polys, 0 bands, 54 lymphs),
platelets were 271,000. A repeat hematocrit on [**2139-5-22**]
was 56.1.
Psychosocial. The mother is invested and involved.
Discharge activities is stable.
DISCHARGE DISPOSITION: Home. Pediatric provider: [**First Name8 (NamePattern2) 5321**]
[**Last Name (NamePattern1) **], [**Hospital6 **], [**Location (un) 86**], MA, phone [**Telephone/Fax (1) 73074**].
CARE RECOMMENDATIONS:
1. Ad lib feedings of Carnation Good Start.
2. Newborn screening sent on [**2139-5-22**] (results pending).
3. Hepatitis B vaccine administered [**2139-5-22**].
4. Hearing screen status. Hearing screening was performed on
with automated brainstem response. The baby passed L ear; R
ear referred for further evaluation.
5. Car seat testing not applicable.
FOLLOWUP RECOMMENDATIONS:
1. Pediatric appointment with Dr. [**First Name (STitle) **] within 2 days of
discharge.
2. CHAP (infectious disease clinic) at [**Hospital3 1810**],
appointment [**2139-6-2**] at 9:30 a.m., phone [**Telephone/Fax (1) 73075**]. The appointment is with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 50148**] are the doctors that [**Name5 (PTitle) **] be following her.
MEDICATIONS: Zidovudine (AZT) 5.5 mg every 6 hours for 6
weeks.
IMMUNIZATIONS RECOMMENDED: 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 all household contacts and out of home
caregivers.
DISCHARGE DIAGNOSES:
1. Term appropriate for gestational age female.
2. Risks for vertical transmission of HIV -- d/c'd on AZT.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 71194**]
Dictated By:[**Name8 (MD) 73076**]
MEDQUIST36
D: [**2139-5-22**] 11:23:03
T: [**2139-5-22**] 12:11:24
Job#: [**Job Number 73077**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2605
} | Medical Text: Admission Date: [**2141-1-5**] Discharge Date:[**2141-1-14**]
Date of Birth: [**2141-1-5**] Sex: M
Service: NEONATOLOGY
INTERIM DISCHARGE SUMMARY - [**2141-1-9**]
HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname **], twin #1, delivered at 34-5/7
weeks' gestation and was admitted to the newborn intensive
care nursery for management of prematurity. Admission weight
2165 grams (25-50th percentile), length 45.5 cm (25-50th
percentile), head circumference 32.5 cm (50-75th percentile).
Mother is a 29-year-old gravida 1, para 0, now 2 woman with
estimated date of delivery [**2141-2-11**]. Prenatal
screens included blood type B positive, antibody screen
negative, hepatitis B surface antigen negative, rubella
immune, RPR nonreactive and group B strep positive. The
pregnancy was conceived with Clomid resulting in twin
gestation. The pregnancy was essentially uncomplicated until
day of delivery when the mother presented in preterm labor.
She was treated with nifedipine. The delivery was by cesarean
section due to breech position of twin #2. On this twin,
membranes were ruptured at delivery for clear fluid. This
infant emerged crying, was dried, stimulated and bulb
suctioned. Apgar scores were 8 and 9 at one and five minutes,
respectively.
ADMISSION PHYSICAL EXAMINATION: Patient awake, alert,
resting comfortably on open warmer in no distress. Anterior
fontanel open, flat. Ears, eyes, nose and throat: Within
normal limits. Lungs clear. Breath sounds equal bilaterally.
No murmur. Normal S1, S2. Femoral pulses +2. Abdomen soft,
nondistended, no hepatosplenomegaly, no masses. Normal
preterm male genitalia with testes descended bilaterally.
Patient anus. Moves all extremities equally. Back straight.
Normal tone, strength and activity for gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: No respiratory distress. He has been in
room air since admission with comfortable work of
breathing, no apnea of prematurity.
1. CARDIOVASCULAR: Heart rates range in the 130s-160s, no
murmur. Recent blood pressure 75/57 with a mean of 63.
2. FLUIDS, ELECTROLYTES AND NUTRITION: He was initially
N.P.O. and maintained on D10W by peripheral IV, started
feeds on day of life 1, is now taking breast milk 24
cals/ounce or Enfacare 24. ad lib amounts, taking between
with a minimum of 120 cc/kg/day, voiding and stooling
appropriately. Weight at time of discharge was 2190 grams.
3. GI: Bilirubin on day of life 3: Total 13.8, direct 0.3.
He was started on phototherapy. On day of life 4, the
total bili was down to 10 with a direct of 0.3, and the
phototherapy was discontinued. A rebound bilirubin at 5
days of life was 9.6/0.3
4. HEMATOLOGY: Hematocrit on admission 55%. Mother and baby B+
DAT negative.
5. INFECTIOUS DISEASE: A CBC and blood culture were drawn
on admission. He was not treated with antibiotics. The
initial CBC showed a white count of 10.1 with 15 polys,
no bands, and platelets of 200,000.
6. NEUROLOGY: Exam is age appropriate. Head ultrasound is
not indicated.
7. SENSORY - AUDIOLOGY: Hearing screen prior to discharge was
passed.
8. CIRCUMCISION: Done on [**2141-1-14**].
9. IMMUNIZATIONS: Parents deferred until visit with
pediatrician.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, [**Hospital1 **] -
[**Location (un) **], [**University/College 70860**], [**Location (un) 86**], [**Numeric Identifier 6422**], telephone
number ([**Telephone/Fax (1) 56620**]. Parents have appt for [**1-18**].
VNA to come to home within 2 days of discharge.
Medications: None. Iron supplementation is recommended
for preterm and low birthweight infants until 12 months
corrected age. All infants fed predominantly breast milk
should received vitamin D supplementation at 200
international units (may be provided as a multivitamin
preparation) daily until 12 months corrected age.
3. Car seat position screening test to be performed prior
to discharge.
4. State newborn screen was sent on day of life 3. Results
are pending.
DISCHARGE DIAGNOSES:
1. Prematurity at 34-5/7 weeks' gestation
2. Physiologic jaundice
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
MEDQUIST36
D: [**2141-1-16**] 17:43:11
T: [**2141-1-16**] 18:17:04
Job#: [**Job Number 75672**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2606
} | Medical Text: Admission Date: [**2145-10-3**] Discharge Date: [**2145-10-19**]
Date of Birth: [**2109-4-22**] Sex: F
Service: [**Location (un) **] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 36 year old female
with history of renal cell carcinoma with metastatic disease to
the spine, status post nephrectomy with medical therapy
complicated by drug-induced pneumonitis. She presented with
progressive dyspnea, acute onset on the morning of admission. The
patient was on 3 liters of oxygen at home for the past seven
days. She noted her breathing to be increasingly labored with
tachypnea. The patient denied any chest pain, palpitations,
diaphoresis, nausea, or vomiting. She does have a history of
chronic cough with clear sputum. Of note, the patient felt more
comfortable sitting up and leaning forward. In the Emergency
Department, ultrasound of her lower extremities were performed to
evaluate for thrombus. A chest computerized tomography scan
showed moderate-sized pericardial effusion and the patient was
admitted to the Coronary Care Unit.
PAST MEDICAL HISTORY: 1. Renal cell carcinoma diagnosed in
[**2142-12-12**] during workup for miscarriage. The patient
had a nephrectomy at that time. In [**2143-4-11**] the patient
was started on interleukin 2 therapy. From [**2144-9-10**] to
[**2144-12-11**] the patient was started on PTK/787
chemotherapy, from [**2145-2-10**] to [**2145-8-10**] the patient
was enrolled in a clinical trial and was treated with
CTI-779/Interferon, however, this was stopped in [**2145-8-10**]
secondary to question of pneumonitis. Since then the patient
has been on 3 liters of oxygen at home. Then in [**2145-8-10**]
the patient was found to have spinal metastases. She was
status post radiation therapy to L2 to C3. Of note, in
[**2145-9-10**] the patient had a bronchoscopy with biopsy with
no evidence of carcinoma to her lungs. 2. Anemia of chronic
disease.
ADMISSION MEDICATIONS:
1. Famotidine 20 mcg t.i.d.
2. Tizanidine 6 mg t.i.d.
3. Tessalon pearls 100 mg q. 4 hours prn cough
4. Oxycodone 5 mg q. day
5. Fentanyl patch 25 mcg per hour q. 3 days
6. Zoloft 100 mg q. day
7. Zomira 4 mg intravenously q. 3 to 4 hours
8. Celebrex 100 mg t.i.d.
9. Clonazepam 0.25 to 0.5 q.h.s.
10. Decadron 40 mg taper
ALLERGIES: Keflex, Zithromax, Penicillin, Iodine,
Prednisone-all cause hives.
SOCIAL HISTORY: The patient lives at home with her husband and
five year old son. [**Name (NI) **] son will be starting first grade this
week, this is a very important milestone for her. Of note, her
parents are here from [**Location 8398**]in [**Location (un) 86**] to provide
supportive care. The patient denies any alcohol or tobacco use.
FAMILY HISTORY: No history of cancer.
PHYSICAL EXAMINATION: Temperature 99.4, blood pressure
107/55, heartrate 93, respiratory rate 28, oxygen saturation
99% on 4 liters nasal cannula. In general the patient
appears frail and tachypneic with mild respiratory distress,
leaning forward. Head, eyes, ears, nose and throat:
Normocephalic, atraumatic, panting, dry mucous membranes.
Neck: Supple, cachectic with persistent slow eye movements,
unable to assess for jugulovenous pressure. Cardiovascular:
Muffled heartsounds, faint S1 and S2, no rub appreciated.
Lungs, poor air movement, faint crackles bilaterally at bases
left greater than right. Abdomen, soft, nontender,
nondistended. Extremities, wasted 2+ dorsalis pedis pulses,
warm and well perfused, no edema.
LABORATORY DATA: White blood count 14.6, hematocrit 40.0,
platelets 420, PT 13.4, INR 1.2. Chem-7 with sodium 138,
potassium 4.2, chloride 101, bicarbonate 28, BUN 10,
creatinine 0.5, glucose 121. Studies: 1. Chest x-ray,
diffuse interstitial thickening involving all portions of the
lung without favoring any distribution. Interval development
of pleural effusion from [**2143-7-12**], new right T6 fracture.
Examination features of congestive heart failure/pulmonary
edema, superimposed on persistent interstitial changes of
pneumonitis. 2. Lower extremity doppler, no evidence of
deep vein thrombosis. 3. Chest computerized tomography
scan, new moderate pericardial effusion with associated
interstitial and alveolar opacities. Question of underlying
interstitial metastatic process in the lungs which can not be
distinguished from other inflammatory process such as drug
reaction. 4. Electrocardiogram, normal sinus rhythm at 86
beats/minute, normal axis, normal intervals, TWI/flattening
in 1, AVL, AVR, V1 to V2, no ST elevations.
ASSESSMENT/PLAN: This is an unfortunate 36 year old female with
metastatic renal cell carcinoma to the spine, now with
progressive dyspnea times one day. Computerized tomography scan
with evidence of pericardial effusion. The patient is admitted
to Coronary Care Unit for pericardial drain placement.
HOSPITAL COURSE: 1. Coronary Care Unit course - The patient was
in the Coronary Care Unit from [**2145-10-3**] to [**2145-10-11**]. The patient was admitted to Coronary Care Unit and noted
to have a moderate pericardial effusion and was tapped for 470 cc
of straw-colored fluid with the drain left in place. Over the
next few days the drain continued put out 150 to 200 cc of fluid.
In the meantime, the cytology came back positive for malignant
cells. On [**10-7**], the patient had a pericardial window
performed with removal of drainage tube. In the Coronary Care
Unit the patient's heartrates had been in the 90s to 115 with
blood pressure of 85 to 100/40s to 50s. She required numerous
small fluid boluses secondary to low blood pressure and low urine
output. She had increasing oxygen requirement, hence the
pericardectomy SaO2 96 to 97% on 6 liters with 70% nebulizer
scoop mask. The patient desatted to the low 80s when she had
occasional coughing spells which caused diaphoresis and
increasing pain. The patient was on Celebrex, Zanaflex, Fentanyl
patch 50 mcg/hr and Oxycodone for pain control.
2. Pulmonary - After pericardiectomy the patient was transferred
to the medical floor. Her shortness of breath was not improving
and she required and had increasing oxygen requirement now to 6
liters of oxygen plus 100% scoop mask. After discussion with
Oncology, Dr. [**Last Name (STitle) **] and the pulmonology attending it was decided
that the patient would have a repeat bronchoscopy and repeat
biopsy to diagnose her pulmonary interstitial disease. On
[**10-13**], the patient had bronchoscopy with biopsy. Pathology
returned positive for carcinoma in the lymphatic system. The
patient continued to have periods of coughing and shortness of
breath where she would desat down to the low 80s. A repeat chest
x-ray following bronchoscopy revealed no evidence of
pneumothorax. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**], Palliative RN was consulted. Per her
recommendations, Ativan and inhaled 1% Lidocaine was used to
try to depress the cough.
Following many lengthy discussions with the patient and family it
was decided that code status be changed from full code to Do-Not-
Resuscitate/ Do-Not-Intubate, on [**2145-10-18**]. At this time
the patient's pulmonary status was progressively deteriorating.
She was tachypneic to the 40s and very agitated. We attempted to
diurese the patient with Lasix, however, there was little
improvement in her respiratory status. On [**2145-10-18**] a
Morphine and Ativan drip were started. The patient was no longer
responsive, however, her respiratory rates were now in the
mid 20s with decreased work of breathing.
3. Cardiovascular - Echocardiogram following the pericardiectomy
showed resolution of the pericardial effusion. She continued to
be hypotensive down into the mid 70s to 80s. The patient was
given some normal saline boluses as well as gentle rehydration
with intravenous fluids. However, this was eventually stopped
secondary to increased pulmonary and lower extremity edema
although there is no evidence of congestive heart failure.
4. Pain - Initially the patient's pain was well controlled on a
Fentanyl patch 50 mcg/hr with Oxycodone for breakthrough pain.
However, the patient's pain requirement increased throughout her
stay. Given the patient's pain and increased agitation, Morphine
drip was started on [**10-18**] with better control of her pain.
5. Heme - The patient's hematocrit continued to decrease during
this stay. On [**10-17**], the patient was transfused with 1
unit of packed red blood cells with a hematocrit of 30.2.
6. Oncology - On [**2145-10-14**], the results of the
transbronchial biopsy was discussed with the patient and her
family. Present were her oncologist (Dr. [**Last Name (STitle) **], the attending
physician (Dr. [**Last Name (STitle) **] as well as medicine resident (Dr. [**Last Name (STitle) **]. [**Doctor Last Name **]),
the patient's husband and her mother. The patient understood
that her condition was terminal with poor prognosis, and that
she would not be considered for a mini-allo BMT, due to the
severity of her disease. She understood that her life expectancy
was likely measured in days to weeks and that there was no role
for further chemotherapy, only palliative. At that time the
family was looking into hospice care for the patient, but the
patient's condition progressively worsened over the next several
days. The patient had a long discussion with her husband on
[**10-18**] and it was decided that her code status would be
changed from full code to Do-Not-Resuscitate/Do-Not-Intubate. One
of the family's concern was about the well-being of the patient's
five year old son.
[**Name (NI) 15110**] to progressive discomfort with tachypnea and cough, the
patient required increasing doses of opiates, ativan, and
oxygen therapy. She was switched to morphine and ativan drip
for comfort after further discussion with the family. Her family
was present on [**10-19**] at 3 PM when the patient died.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 37489**]
MEDQUIST36
D: [**2145-10-20**] 15:06
T: [**2145-10-20**] 17:54
JOB#: [**Job Number 37490**]
cc:[**Last Name (STitle) 37491**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2607
} | Medical Text: Admission Date: [**2200-10-21**] Discharge Date: [**2200-10-31**]
Date of Birth: [**2137-9-11**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
headache, fever
Major Surgical or Invasive Procedure:
LP on [**2200-10-21**]
History of Present Illness:
This is a 62yo M with NSCLC stage IV s/p [**Doctor Last Name **]/taxol followed by
maintenance bevacizumab as part of DF-HCC 09-069, found to have
brain mets and completed WBRT on [**2200-9-2**], now presenting with
severe and progressive headache and fever. His last chemo
bevacizumab was in [**2200-7-14**]. States he has been having
headaches since 2 months, are intermittent. Now worse, waking
up at night. Pt also has dizziness associated with HAs. Also
endorses fever for 2 days. The pain is diffuse. It comes on
gradually and lasts for several hours, then resolves entirely.
Endorses bluury vision and photophobia but denies neck pain.
Currently, pt is on a Dexamethasone taper per his RadOnc and
NeuroOnc recommendations.
In the ED, his initial VS were: 101.2 100 132/85 16 96% RA. On
physical exam, CNII-[**Doctor First Name 81**] were intact, tongue deviates slightly to
right. BUE strength and sensation intact and symmetric, BLE
strength and sensation intact and symmetric. Dysmetria on
finger-nose-finger, R>L. Labs notable for normal WBC, baseline
Hct and Na of 127. CXR showed likely a superimposed acute
interstitial process on the baseline severe emphysema, could be
atypical infection such as viral or fungal etiologies though
edema in the setting of emphysema may also present in this
manner. CT head showed stable compared with priors, known mets
remain CT occult, no acute process. LP was performed, CSF
showed Protein 44, Glucose 39, WBC 33 (Poly 1, Lymph 13,
Mono 8 Eos 0, Mesothe 6 and Macroph 72), RBC 3. UA was neg.
Blood cultures and CSF culture were submitted. Lactate was 2.2.
Pt was given 2L NS, Vancomycin, CTX and Ampicillin for possible
meningitis. Pt was also given Tylenol and 2 Percocets for pain
and fever. On transfer, VS were T 98.3 HR 75 O2 sat 94%on 2l nc
BP 101/51.
On arrival to the MICU, pt states to be "fine" except for the
persistent headaches. denies n/v currently. denies neck pain.
no other complaints.
ROS: per HPI, otherwise neg except endorses chronic diffuse
weakness and hand numbness. also endorses nausea/vomiting this
am. endorses reflux symptoms. denies CP, dyspnea, abd pain. no
cough, myalgias. admits to bloody stools during chemo but none
since. no urinary complaints, diarrhea or constipation.
Past Medical History:
[**Doctor First Name 27119**]
Emphysema (per CT)
Pulmonary Fibrosis (per CT)
FEV1/FVC 105%
Tobacco use
Motor vehicle collision requiring exploratory lap in [**2158**]
Low back pain, herniation of L4-L5 with compression of L5 nerve
root
Osteopenia
Lung nodule, found [**2193**]
Hyperglycemia (HbA1C 6.4 on [**2200-10-10**])
Past Oncologic History:
- NSCLC stage IV non-squamous EGFR wt
- [**4-/2199**] developed bilateral supraclavicular neck swelling and
tenderness which he attributed to muscular strain
- [**5-/2199**] presented to PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for neck swelling
- [**2199-5-21**] thyroid/neck US: normal thyroid gland, multiple
bilateral enlarged lymph nodes measuring 2.2 x 1.6 x 2.2cm at
the
largest.
- [**2199-6-3**] lymph node FNA: negative for malignancy and just
showed necrotic debris and macrophages. Given the very high
suspicion for malignancy, possibly lymphoma, he was subsequently
referred for excisional lymph node biopsy.
- [**2199-7-4**] left cervical lymph node excision that revealed a
poorly differentiated carcinoma with osteoclast-like giant cells
that was strongly immunoreactive for cytokeratin AE1/AE3/CAM
5.2,
cytokeratin 7 and TTF-1. It was not reactive for cytokeratin
20,
S100 and MART 1. Consistent with NSCLC.
- [**2199-7-23**] CT Torso: showed substantial lymphadenopathy present
in the chest, specifically a 2.5 x 1.5 cm right upper
paratracheal node, a right mediastinal 9 x 14 mm node, a
prevascular node measuring 2.1 x 1.2 as well as bilateral hilar
and subcarinal adenopathy. He had a 1.6 x 1.2 cm right
supraclavicular node as well as a left 1.5 cm x 9 mm
supraclavicular node. Within the lungs, there was irregular
mass
in the right upper lobe measuring 2.1 x 1.3 mm. Bilateral
severe
emphysema, and bibasilar ground-glass opacities in the lower
lobe
described as fibrosis in the peripheral distribution. Within the
abdomen, the adrenals were unremarkable and in the pelvis there
was no intraabdominal or pelvic lymphadenopathy. There is a T12
benign hemangioma, but no other bony disease.
- [**2199-8-5**] bone scan: no evidence of osseous metastatic disease.
- [**2199-8-5**] MRI brain: No intracranial metastases
- [**2199-8-9**] CT torso for trial baseline: Unchanged from [**2199-7-23**].
- [**2199-8-15**] Signed consent for DF-HCC trial 09-069, B12 injection
- [**2199-8-22**] started cycle 1 Paclitaxel 200mg/m2 IV, Carboplatin AUC
6, Bevacizumab 15mg/kg IV. This is Arm B in the study.
- [**2199-9-5**] C1D15 ANC 420, grade 4 neutropenia
- [**2199-9-12**] C2D1 Paclitaxel 150mg/m2 IV, Carboplatin AUC 4.5,
Bevacizumab 15mg/kg IV (dose reduced per protocol)
- [**2199-10-1**] CT scans with 32.7% decrease in target lesions, PR by
RECIST.
- [**2199-10-3**] C3D1 Paclitaxel 150mg/m2 IV, Carboplatin AUC 4.5,
Bevacizumab 15mg/kg IV (dose reduced per protocol)
- [**2199-10-24**] C4D1 09-069 Paclitaxel 150mg/m2 IV, Carboplatin AUC
4.5, Bevacizumab 15mg/kg IV (dose reduced per protocol)
- [**2199-11-11**] Staging scans with 37% decrease versus baseline
- [**2199-11-14**] C5D1 Bevacizumab (15mg/kg) maintenance
- [**2199-12-5**] C6D1 Bevacizumab (15mg/kg) maintenance
- [**2199-12-23**] CT Torso with ongoing PR by RECIST
- [**2199-12-26**] C7D1 Bevacizumab (15mg/kg) maintenance
- [**2200-1-16**] C8D1 Bevacizumab (15mg/kg) maintenance
- [**2200-2-4**] CT Torso with ongoing PR, 40% decrease from baseline
- [**2200-2-6**] C9D1 Bevacizumab (15mg/kg) maintenance
- [**2200-2-27**] C10D1 Bevacizumab (15mg/kg) maintenance, taken off
trial due to travel plans, will remain under long term follow up
for 09-069 for survival data.
- [**2200-3-27**] CT (prelim) with stable disease
- [**2200-3-27**] C11D1 Bevacizumab (15mg/kg) maintenance
- [**2200-4-17**] C12D1 Bevacizumab (15mg/kg) maintenance
- [**2200-5-8**] C13D1 Bevacizumab (15mg/kg) maintenance
- [**2200-5-29**] CT Torso with slight interval increase in 2 known
lesions, no new sites of disease
- [**2200-6-5**] C14D1 Bevacizumab (15mg/kg) maintenance
- [**2200-7-3**] C15D1 Bevacizumab (15mg/kg) maintenance
- [**2200-7-31**] HELD C16 bevacizumab for new neurologic signs
- [**2200-8-12**] MRI showed new T1 hyperintense hyperenhancing lesions
in the right basal ganglia and parietal lobes are concerning for
metastatic disease. The parietal lobe lesions raised concern for
leptomeningeal disease.
- [**2200-8-22**] Started whole brain XRT with 3000 cGy
- [**2200-9-2**] completed whole brain XRT
Social History:
lives with his ex-wife and daughter. Originally he is from
[**Country 5142**]. He does smoke approximately ten cigarettes a day for the
last 40 years. He does not drink alcohol now, but used to drink
fairly heavily in the past. denies IVDU.
Family History:
mother with [**Name2 (NI) **].
Physical Exam:
VS- T 97.8 BP 116/68 HR 72 RR 18 O2 sat 96% on 2L weight
161 lbs height 69"
Gen- well-aapearing, NAD
HEENT- EOMI, PERRL, anicteric sclera, MMM, OP clear
Neck- no nuchal rigidity
CV- RRR, no murmurs
Resp- CTAB, no wheezes or crackles
Abd- soft, nontender
Ext- no edema
Neuro- CNII-CNXII intact, strength and sensation intact
throughout
Skin- no rashes
Pertinent Results:
Labs:
[**2200-10-21**] 09:20AM BLOOD WBC-8.5 RBC-4.64 Hgb-14.7 Hct-42.3 MCV-91
MCH-31.6 MCHC-34.7 RDW-14.8 Plt Ct-117*
[**2200-10-21**] 09:20AM BLOOD Neuts-83* Bands-4 Lymphs-9* Monos-2 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2200-10-21**] 09:20AM BLOOD PT-12.0 PTT-24.7 INR(PT)-1.0
[**2200-10-21**] 09:20AM BLOOD Glucose-117* UreaN-23* Creat-0.8 Na-127*
K-4.0 Cl-89* HCO3-26 AnGap-16
[**2200-10-21**] 09:20AM BLOOD Calcium-8.7 Phos-2.4* Mg-1.7
[**2200-10-21**] 09:33AM BLOOD Lactate-2.2*
UA: neg
Micro:
Blood cultures: pnd
CSF culture: pnd
Imaging:
CT head:
IMPRESSION: Stable head CT examination demonstrating mild
atrophy and chronic small vessel ischemic change. Known brain
metastases remain CT occult.
CXR: IMPRESSION: There is likely a superimposed acute
interstitial process on the baseline severe emphysema.
Diagnostic considerations favor an atypical infection such as
from viral or fungal etiologies in light of the clinical history
provided. Please note, edema in the setting of emphysema may
also present in this manner. Correlate clinically.
Brief Hospital Course:
Mr. [**Known lastname 24529**] was a 62 year-old man with NSCLC stage IV with brain
mets, completed WBRT [**2200-9-2**], who presented with severe headache
and fever on [**10-21**] and transferred to the MICU on [**10-22**] due to
worsening hypoxia and new b/l infiltrates. In the MICU, the
patient was treated with cefepim+vanco+azithro to cover HAP and
CAP. Also started on bactrim to cover PCP (chronic steroid use
due to brain mets). The patient was ruled-out for tuberculosis.
.
Over Mr. [**Known lastname 25039**] MICU stay he became increasingly more hypoxic
and required 100% FiO2 via facemask at all times. Desaturations
to the high 70s with small movements even with facemask in
place. Given hypoxia, fndings on imaging and an elevated BDG the
working diagnosis was PCP [**Name Initial (PRE) 1064**]. Continued treatment with
bactrim and completed course of vanc/cef/azithro for empiric
coverage of HCAP.
.
Given the severity of the patient's infectious process and the
poor prognosis of his malignancy; goals of care were adressed
and the patient was made DNR/DNI. Despite treatment, his
clinical status did not improve. Patient expressed the wish to
remain alive until his family could arrive from [**Country 5142**] although
did not want to be intubated. On [**2200-10-31**], the patient's
family arrived from [**Country 5142**]. Over the course of that day his
respiratory status continued to deteriorate and he passed away
quietly and peacefully on [**2200-10-31**].
Medications on Admission:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO twice a day.
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
6. clindamycin phosphate 1 % Solution Sig: One (1) application
Topical at bedtime: apply to scalp nightly for rash at bedtime.
7. fluocinonide 0.05 % Solution Sig: One (1) application Topical
once a day: [**Doctor Last Name **] to scalp rash as needed.
8. ketoconazole 2 % Shampoo Sig: One (1) application Topical
once a day: apply to scalp daily in shower.
9. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Tablet
Sig: One (1) Tablet PO twice a day: with food.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
12. acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. trazodone 50 mg Tablet Sig: one half Tablet PO at bedtime
as needed for insomnia.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2200-11-1**]
ICD9 Codes: 4019, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2608
} | Medical Text: Admission Date: [**2161-10-16**] Discharge Date: [**2161-10-16**]
Date of Birth: [**2093-7-29**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68F h/o metastatic RCC and a history of depression found
unresponsive by family this AM with open pill bottles. Patient
was last seen in her normal state last night. Family initiated
CPR (of note patient always had a pulse) and called EMS. EMS
found her to be hypothermic and hypotensive but with a pulse.
They gave her 2mg Narcan, 1L NS, and brought her to [**Hospital3 **].
On arrival at [**Hospital3 **] she was hypotensive and hypothermic.
Pupils fixed and dilated. Rectal temp was 90.1. Foley inserted,
stiff neck collar placed, intubated with a #7 ETT, OG #18
inserted. An acetaminophen level was 140. Combined CCB and
acetaminophen overdose was felt to be the most likely diagnosis.
She was intubated and given 1 amp of calcium gluconate, 1 mg of
glucagon, started on NAC, and started on triple pressors
(dopamine, norepinephrine, vasopressin).
At [**Hospital3 **] the patient, received 1 amp of calcium gluconate,
glucagon 1mg, 10mg of decadron, and started on NAC therapy.
She was then sent by [**Location (un) **] to [**Hospital1 18**] for further evaluation
and transfer. On the flight she received 10mg of decadron.
On arrival at the [**Hospital1 18**] ED her initial vital signs were 70s/40s
and HR in 100s, rectal temp 90.2. Found to be intubated, not
sedated, flaccid, 4-5 mm dilated fixed post surgical pupils. Her
blood sugars rose from 290s to 300s and she was started on an
insulin gtt.
EKG showed an incomplete RBBB QRS 134. Some bicarb was given to
test to see if she had any component of a sodium channel
blockade but her QRS did not significantly improve. An echo
showed a globally hypokinetic heart and a FAST ultrasound showed
a large GB with sludge and wall distention felt likely [**12-30**] to
her large fluid resuscitation. CT of chest showed no PE but
possible aspiration PNA and she was started on vanc/zosyn.
Past Medical History:
renal cell carcinoma s/p nephrectomy and lobectomy
hypertension
hyperlipidemia
h/o CVA
GERD
asthma
anxiety
depression
Social History:
lives with husband
Family History:
NC
Physical Exam:
VS: 78/49 hr 105 rr 20 sat 100%/FiO2 100%
Vent Settings: CMV 500 x 20 PEEP 6 FiO2 100%
GEN: nonresponsive
HEENT: intubated, vomit on face
PULM: coarse
CARD: tachy regular
ABD: soft
EXT: cold, no edema
NEURO: nonresponsive, no gag reflex, pupils fixed dilated, no
caloremic reflex
Pertinent Results:
[**2161-10-16**] 10:47AM BLOOD WBC-11.7* RBC-3.17* Hgb-10.2* Hct-32.4*
MCV-102* MCH-32.2*# MCHC-31.5# RDW-13.4 Plt Ct-454*
[**2161-10-16**] 08:48AM BLOOD WBC-16.4* RBC-4.01* Hgb-11.7* Hct-41.8
MCV-104* MCH-29.1 MCHC-27.9* RDW-13.6 Plt Ct-502*
[**2161-10-16**] 10:47AM BLOOD Neuts-90.3* Lymphs-8.4* Monos-0.7*
Eos-0.3 Baso-0.2
[**2161-10-16**] 08:48AM BLOOD Neuts-88.7* Lymphs-9.0* Monos-1.9*
Eos-0.2 Baso-0.2
[**2161-10-16**] 10:47AM BLOOD Plt Ct-454*
[**2161-10-16**] 10:47AM BLOOD PT-15.0* PTT-30.0 INR(PT)-1.3*
[**2161-10-16**] 08:48AM BLOOD Plt Ct-502*
[**2161-10-16**] 08:48AM BLOOD PT-13.8* PTT-22.8 INR(PT)-1.2*
[**2161-10-16**] 10:47AM BLOOD Glucose-293* UreaN-11 Creat-0.9 Na-143
K-2.6* Cl-113* HCO3-16* AnGap-17
[**2161-10-16**] 08:48AM BLOOD Glucose-310* UreaN-12 Creat-1.0 Na-137
K-3.6 Cl-108 HCO3-16* AnGap-17
[**2161-10-16**] 10:47AM BLOOD ALT-11 AST-8 LD(LDH)-111 CK(CPK)-18*
AlkPhos-49 TotBili-0.1
[**2161-10-16**] 10:47AM BLOOD Albumin-2.3* Calcium-6.1* Phos-3.8#
Mg-1.2*
[**2161-10-16**] 08:48AM BLOOD Calcium-7.5* Phos-5.5* Mg-1.6
[**2161-10-16**] 08:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-67*
Bnzodzp-NEG Barbitr-POS Tricycl-NEG
[**2161-10-16**] 12:52PM BLOOD Type-ART pO2-271* pCO2-58* pH-7.06*
calTCO2-17* Base XS--14
[**2161-10-16**] 11:52AM BLOOD Type-ART Temp-33.5 Rates-20/ Tidal V-500
PEEP-5 FiO2-100 pO2-257* pCO2-44 pH-7.15* calTCO2-16* Base
XS--13 AADO2-434 REQ O2-73 -ASSIST/CON Intubat-INTUBATED
[**2161-10-16**] 10:39AM BLOOD Type-ART Temp-33 Tidal V-500 FiO2-100
pO2-292* pCO2-50* pH-7.11* calTCO2-17* Base XS--14 AADO2-393 REQ
O2-67 Intubat-INTUBATED Vent-SPONTANEOU Comment-CORE
[**2161-10-16**] 12:52PM BLOOD Lactate-4.2* K-2.1*
[**2161-10-16**] 11:52AM BLOOD Lactate-3.7* K-2.1*
[**2161-10-16**] 10:39AM BLOOD Lactate-3.7*
[**2161-10-16**] 09:06AM BLOOD Lactate-3.6*
[**2161-10-16**] 11:52AM BLOOD O2 Sat-97
[**2161-10-16**] 10:39AM BLOOD O2 Sat-97
[**2161-10-16**] 12:52PM BLOOD freeCa-1.31
[**2161-10-16**] 11:52AM BLOOD freeCa-1.55*
[**2161-10-16**] 10:39AM BLOOD freeCa-1.05*
Brief Hospital Course:
68F metestatic RCC found unresponsive after suspected toxic
ingestion of multiple medications including amdlodipine, tylenol
and ativan.
# Shock: distributive, [**12-30**] toxic metabolic ingestion of multiple
medications most significant for CCB. Treated with four pressors
including norepinephrine, dopamine, vasopressin and
neosynephrine with MAPs of ~60. Given a total of 16L of IVF.
Lactates continued to trend up. She was terminally extubated as
below.
# Toxic Overdose: suspected CCB +/- tylenol and benzos. Unclear
if intentional, suspected based on history of depression and
patient's known metastatic renal cell carcinoma. Toxicology
consulted. HIE insulin gtt started and blood sugars monitored
q15min. Given aggressive IVF with NS and then D5W + 150meq HCO3.
Intralipid rescue therapy was started, and the 21-hour NAC
protocol started as well. Calcium chloride was given to maintain
a normal ionized calcium in the setting of a CCB overdose. A
dose of flumazenil was given with concern for a benzo component
of her overdose. She remained nonresponsive with fixed dilated
pupils and no corneal reflex - higher doeses were planned but
not pursued based onconversations with famiy re goals of care .
# Aspiration PNA: seen on CT scan, patient found with vomitus on
face. Hypothermic. Treated with vanc/zosyn.
# Goals of Care and Expiration: discussions with the family
(including her granddaughter who is her HCP) it was agreed that
she would not want extraordinary measures taken and that she
would not want to be kept alive on machines. Social work was
brought in to the discussion and the services of the clergy were
offered but declined.
Two additional family meetings were held to discuss her
situation and her grandaughter who was the HCPO stated that her
grandmother would never want aggressive [**Last Name (un) 28015**] if there was even
a chance she would not be able to return home to a normal life.
She was adamant and in fact made her grandtr and not her husband
the HCP because she trusted her to carry out these wishes. We
discussed that there were other tests we could do including
brain imaging to evaluate extent of damage to try to be sure
extent of injury, but family stated it was not needed and that
we had already gone past want Mrs [**Known lastname 61078**] [**Name (STitle) 88360**] have wanted.
After the family had the opportunity to say goodbye she was made
comfort measures only and her pressors, fluids and antibiotics
were stopped. She was terminally extubated and started on a
morphine drip. She expired at 3:45pm surrounded by her two
granddaughters.
Case reported to ME's office due to possible suicidal ingestion
(though family felt unlikely) and death in less than 24
admission and case was accepted.
Medications on Admission:
amlodipine
ativan
lunesta
lisinopril
tylenol
butalbital
paroxetine
Discharge Medications:
N/A
Discharge Disposition:
Expired
Facility:
[**Hospital1 69**]
Discharge Diagnosis:
PRIMARY:
1. Toxic Overdose
2. Respiratory Failure
3. Distributive Shock
4. Aspiration Pneumonia
SECONDARY:
1. Renal Cell Carcinoma
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 5070, 4019, 311, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2609
} | Medical Text: Admission Date: [**2185-6-30**] Discharge Date: [**2185-8-6**]
Date of Birth: [**2130-5-31**] Sex: M
Service: MEDICINE
Allergies:
ceftriaxone
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD
Sigmoidoscopy
Paracentesis
History of Present Illness:
Mr. [**Known lastname 88628**] is a 55 year old man recently admitted to [**Hospital1 18**] with
acute alcoholic hepatitis and found to be cirrhotic. His course
was complicated by hepatic encephalopathy and hepatorenal
syndrome. He was discharged to [**Hospital **] [**Hospital **] rehab two weeks ago. Pt
reports that he was improving and was about to be discharged
home from rehab, but over past week has been noticing that his
abdomen has becoming more and more distended. He has also been
gaining weight but does not know exactly how much. Pt reports
that his appetite has been decreasing over past week. Two days
ago he began to experience abdominal pain, which slowly
progressed until last night when it reached an [**6-29**]. Pain was
described as a stabbing sensation in the midline of abdomen,
nonradiating. Pt denies any fever or chills, nausea, vomitting
or change in bowel habits. No dysuria or change in urination
frequency.
.
In [**Name (NI) **], pt was given a paracentesis which did not show infection
and U/S of abdomen, which revealed decreased flow in portal
system.
.
On floor pt's vitals were stable, reports that abdominal pain
has been improved.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
RETINOSCHISIS - BULLOUS
Low Back Pain
Lower Extremity Joint Pain
Alcohol-induced liver cirrhosis.
History of tonsillectomy as a child.
Esophageal varices diagnosed on endoscopy.
Hepatic encephalopathy.
Ascites without SBP.
Social History:
Worked in an insurance company as a finance researcher (stat
cruncher) for 22 years up until 5 years ago when he was fired.
Became depressed and began drinking. Drank off and on often
trying to quit, but coming back to it after 2-4 months. Denies
smoking, no other drugs. He is married with 2 kids, one
graduated from college recently and the other is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1573**] in
high school.
Family History:
+ father alcoholic, no family h/o liver disease; family history
remarkable for diabetes
Physical Exam:
On initial presentation:
VS - Temp 97.3 F, BP 152/88, HR 108, R 14, 100 O2-sat % RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, systolic murmur best heard over
RUSB no RG, nl S1-S2
ABDOMEN - distended, hepatospenomegaly, slightly tender to
palpation midline, no rebound/guarding
EXTREMITIES - WWP, no c/c/ 3+ edema to the thighs, 2+ peripheral
pulses (radials, DPs)
SKIN - no rashes or lesions jaundiced
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-24**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Prior to Discharge: Patient Expired
Pertinent Results:
Admission Labs:
[**2185-6-30**] 11:35AM WBC-28.8* RBC-2.85* HGB-10.2* HCT-31.0*
MCV-109* MCH-35.7* MCHC-32.9 RDW-17.5*
[**2185-6-30**] 11:35AM NEUTS-91* BANDS-0 LYMPHS-2* MONOS-4 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2185-6-30**] 11:35AM PLT SMR-NORMAL PLT COUNT-242
[**2185-6-30**] 11:35AM PT-16.8* PTT-27.0 INR(PT)-1.5*
[**2185-6-30**] 11:35AM AMMONIA-67*
[**2185-6-30**] 11:35AM ALBUMIN-3.4*
[**2185-6-30**] 11:35AM LIPASE-50
[**2185-6-30**] 11:35AM ALT(SGPT)-83* AST(SGOT)-95* ALK PHOS-465* TOT
BILI-7.6*
Studies:
[**2185-6-30**] RUQ Ultrasound: 1. No flow detected within the main,
left, and right portal vein which can be due to thrombosis or
extremely slow flow. Contrast-enhanced CT or MR is recommended
for further evaluation. This was discussed by phone with Dr.
[**Last Name (STitle) 88629**] at 4:15 pm, [**2185-6-30**]. 2. Chronic liver disease with
splenomegaly and moderate volume ascites. 3. Gallbladder wall
thickening likely due to underlying chronic liver disease. No
evidence of acute cholecystitis.
[**2185-7-1**] MRI abdomen: 1. The central portal veins are patent with
appropriate direction of flow. 2. Moderate ascites. 3. Nodular
liver consistent with cirrhosis. No concerning focal liver
lesions. 4. Retroperitoneal varices, predominantly infrarenal.
[**2185-7-6**] ECG: Sinus tachycardia. The tracing is marred by
baseline artifact. There is prominent voltage in leads I and aVL
for left ventricular hypertrophy, more prominent as compared to
the previous tracing of [**2185-5-25**]. The rate has increased. There is
diffuse ST-T wave flattening. No diagnostic interim change.
[**2185-7-6**] CT abd/pelvis: 1. Diffuse dilation and air-fluid levels
of the entire small bowel with no transition point, most
consistent with ileus. Small bowel measures up to 4.8cm in
diameter, likely stable in size when compared to the KUB of
[**2185-7-4**], given differences in technique. 2. Moderate
amount of ascites, unchanged in amount since [**2185-7-1**]
abdominal MRI. Cirrhotic liver with varices, unchanged. 3.
Stable L1 vertebral body compression fracture.
[**2185-7-8**] TTE: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional and excellent
global biventricular systolic function. Mitral regurgitation
with normal valve morphology.
[**2185-7-11**] UGI study/barium swallow: The study was extremely
limited due to the patient's immobility. With this limitation in
mind, barium was introduced into the esophagus and freed slowly
into the stomach. Once within the stomach, barium is seen
pooling and does not transit any further despite a one-hour wait
time. Again, this is likely consistent with the patient's known
diagnosis of ileus. Evidence for distal obstruction was not
obtained due to patient's discomfort and the likelihood that the
transit of the barium into the small bowel would
take many hours.
[**2185-7-15**] Ascites cytology: NEGATIVE FOR MALIGNANT CELLS.
[**2185-7-23**] RUQ Ultrasound: 1. Large volume ascites. 2. No intra- or
extra-hepatic biliary dilatation. 3. Echogenic liver consistent
with fatty infiltration. More serious forms of liver
cirrhosis/fibrosis cannot be ruled out on the basis of this
study.
EGD [**7-8**]
Impression: An NG tube and Dubboff were indentified going in
from the esophagus all the way into the small bowel. Large
amount of liquid was seen in the 2nd portion that was aspirated
with the suction channel.
Otherwise normal EGD to third part of the duodenum
sigmoidoscopy [**7-8**]
Mildly dilated colon up to the splenic flexure
Otherwise normal sigmoidoscopy to splenic flexure
Brief Hospital Course:
Mr. [**Known lastname 88628**] is a 55 year old man with a history of alcoholic
cirrhosis diagnosed in [**2185-5-20**] complicated by hepatic
encephalopathy and hepatorenal syndrome who presented with
abdominal pain from an ileus and had a prolonged hospitalization
complicated by respiratory distress requiring MICU transfer.
While in the MICU the patients condition continued to
decompensate despite supportive care. Multiple family meetings
took place between MICU team and patient's wife. The patient was
made DNR/DNI and moved to the general medical floor. On the
general medical floor, the patient continued to decline with a
calculated MELD consistently >40 and a rising bilirubin. Durring
family meeting between floor team and patient's wife, he was
made comfort measures only and he was enrolled into an in
hospital hospice program. He expired on [**2185-8-6**].
#. Ileus: MRI and CT demonstrated dilated bowel without
obstruction. He was treated with reglan, erythromycin, and
methylnaltrexone with unclear benefit. He had an NGT to suction
and endoscopic decompression was attempted as well. After
approximately 2 weeks his ileus resolved and he began passing
stools. He was on TPN until resolution of his ileus and then was
started on tube feeds. Following making the patient comfort
measures only on the medical floor, the patient removed his
feeding tube and it was determined that the tube should not be
replaced.
#. Leukocytosis: Although he never had any definitive source or
culture data he was empirically treated with a full course of
Vanc/Meropenem/flagyl completed [**7-11**]. Multiple diagnostic
paracenteses were negative for SBP. Cdif toxin was negative on
multiple occassions. Serial Chest X-rays were negative for
pneumonia. The patient's white count started to trend upwards
again a few days after stopping antibiotics and the patient
spiked a fever and therefore he was started again on broad
coverage with vanc/meropenem/flagyl [**7-22**]. His BPs began to fall
and his lactate level increased to 6. His lactate level improved
after receiving 2 units of pRBCs. It is unclear if the benefit
was because of increased oxygen delivery or increased
intravascular volume. Nevertheless he continued to have low
blood pressures in the 80s systolic despite colloids and
crystalloids. The only culture data that became positive was a
urine culture showing 10,000-100,000 colonies of VRE. The U/A
from the same time was negative for LE or nitrite. It was
unclear if this was colonization vs true infection as the
patient had no symptoms of UTI. Following the decision to make
the patient comfort measures only, his antibiotics were
discontinued.
#. Hypernatremia: Likely related to lack of access to free
water. This resolved after free water flushes were increased.
#. Decreased Urine Output: He had hepatorenal syndrome during
his previous hospitalization with creatinine peak of 5.7. During
this hospitalization he may have had HRS as well as a component
of intravascular volume depletion. He was treated with midodrine
and octreotide again throughout this hospitalization. Urine
lytes showed urine Na < 10. Creatinine continued to trend
upwards despite albumin challenge.
#. Altered Mental Status: Likely due to hepatic encephalopathy.
He was continued on lactulose and rifaximin after his ileus had
resolved. See above transition to comfort measures only.
#. Respiratory Distress: He required MICU transfer although he
did not require intubation. He had substantial improvement after
a 9 liter paracentesis on [**7-20**] and was then was able to tolerate
room air. See above transition to comfort measures only.
#. EtoH Cirhosis: He initially presented [**5-/2185**] with EtoH
hepatitis. He completed a prednisone taper. See above transition
to comfort measures only.
#. Sinus Tachycardia: Likely related to intravascular volume
depletion in the setting of total body volume overload. He had
only minimal response to albumin. See above transition to
comfort measures only.
# Anemia: Stable, no evidence of bleed. See above transition to
comfort measures only.
# Goals of Care: He and his wife shifted focus to a more
comfort-focused approach. Pressors were not initiated.
Medications that are uncomfortable (e.g SC octreotide) were
discontinued. However other interventions that make the patient
more comfortable were continued. See above transition to comfort
measures only.
TRANSITIONAL ISSUES:Patient Expired
Medications on Admission:
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
LACTULOSE - (Prescribed by Other Provider) - 10 gram/15 mL
Solution - 30 mL(s) by mouth twice a day
MIDODRINE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth two times a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
PREDNISONE - (Prescribed by Other Provider) - 30 mg Tablet - 1
Tablet(s) by mouth once a day
RIFAXIMIN [XIFAXAN] - (Prescribed by Other Provider) - 550 mg
Tablet - 1 Tablet(s) by mouth twice a day
ACETAMINOPHEN - (Prescribed by Other Provider) - 325 mg Tablet -
1 Tablet(s) by mouth every six (6) hours as needed for pain
CYANOCOBALAMIN (VITAMIN B-12) - (Prescribed by Other Provider) -
100 mcg Tablet - 0.5 (One half) Tablet(s) by mouth once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth once a day
SENNOSIDES - (Prescribed by Other Provider) - 8.6 mg Tablet - 1
Tablet(s) by mouth once a day
THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth once a day
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Alcoholic Cirrhosis
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
ICD9 Codes: 5070, 486, 0389, 2760, 5849, 4254, 2859, 2768, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2610
} | Medical Text: Admission Date: [**2175-11-2**] Discharge Date: [**2175-11-6**]
Date of Birth: [**2131-4-16**] Sex: F
Service: MEDICINE
Allergies:
Calcitonin
Attending:[**First Name3 (LF) 4421**]
Chief Complaint:
Left femur fracture
Major Surgical or Invasive Procedure:
Fixation with intramedullary nail, Bone biopsy.
History of Present Illness:
44 F with history of squamous cell cancer of the thigh, and
metastatic to bone and lung, s/p local resection and
chemotherapy presents with spontaneous left femur fracture. The
patient was a direct transfer from [**Hospital3 22439**] to the
orthopedic service by Dr. [**Last Name (STitle) 1005**].
.
On arrival to [**Hospital1 18**] the patient was found to be clinically
unstable with a HR in the 115 range, RR of about 8, and
somnolence. She was having difficulty completing sentences
during interview. However, she did state that on [**2175-11-1**] she
experienced an atraumatic fracture of her femur, which was
corroborated by accompanying records.
.
Of significance, she is a Jehovah's Witness and refuses to
accept any human blood products. Her most recent hematocrit from
the OSH is 20.2. She has also had profoundly abnormal
electrolytes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
The patient's attending physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and much of
the following information has been obtained from his notes. She
has had a subepidermal cyst on the inner thigh for nearly 15
years. 9 years ago, it ruptured through the surface of the skin
and drained non-smelly material. In recent months, 2
mushroom-like masses eroded through the surface of the skin at
separate sites overlying the large subepidermal cyst. A 3rd site
began to drain foul-smelling material.
.
In addition to this large inner left thigh mass, a similar
smaller mass developed several years ago on the lateral aspect
of her left knee. While this mass has never eroded or drained
throught the skin, she feels that an aspect of this mass has
begun to thin the overlying skin, in a similar manner to how her
left inner thigh mass behaved before it spontaneously drained
through the skin.
.
On [**2175-6-5**], CT scan of the pelvis and thigh obtained at [**Hospital1 83480**] showed a cavitated thick-walled soft tissue
mass in the superficial soft tissues of the mid left thigh with
air fluid level and a superior focus that appeared to be
draining to the skin. The wall of the cystic mass varied in
thickness from 5 to 12 mm; its superior portion was 3.5 cm in
diameter while its inferior portion was 6.5 cm in diameter; the
longitudinal dimension of the lesion was 9.1 cm. Surrounding
subcutaneous fat was edematous and skin appeared thickened.
Underlying muscle and bone appeared normal. Pelvic images were
said to be normal, with enlarged "hyperemic" lymph nodes in the
left groin. The largest node measured 24 and 18 mm. In addition
to this left inner thigh mass was a subcutaneous bilobed 4 x 2.2
cm nodule in the lateral soft tissues just above the knee,
lateral to the lateral femoral condyle.
.
On [**2175-6-6**], the cyst was drained by fine needle aspiration, and
material was sent for cell block preparation. This showed
"poorly differentiated non-keratinizing SCC with necrosis and
acute inflammation." Additionally, an incisional biopsy of 1 of
the mushroom-like masses was obtained. The biopsy specimen
measured 1.0 x 0.5 x 0.3 cm; the surface was "focally
hemorrhagic and slightly friable." This showed "ulcerated
basosquamous cell carcinoma."
.
Metastatic workup revealed adenopathy involing the iliac vessles
and superficial inguinal region. She underwent excision of the
mass on [**2175-7-18**] at [**Hospital1 18**]. The surgeon recovered eight inguinal
and femoral lymph nodes, two of which showed metastatic tumor
without clear-cut extracapsular extension. He also excised 12
lymph nodes from the true pelvis, one of which again showed
tumor, but no clear-cut extension. Finally, 12 proximal left
common iliac lymph nodes were all normal. Her primary tumor was
a deeply invasive squamous cell carcinoma, which was at least 17
cm in size with negative margins. Within the left pelvis,
although only one lymph node was positive, there was a second
lymph node, which showed tumor within the afferent lymphatics
but not within the true lymph node sinuses or parenchyma. She
was evaluated for XRT, but decided against it as she felt the
chance of recurrence was low and the risks were high.
.
Iron deficiency anemia - During workup for her SCC she underwent
an endoscopy and colonoscopy which showed no cause for her
anemia. She was treated with IV iron dextran and epo which
brought her Hct to the low 30's.
Social History:
She is a Jehovah's Witness. She lives in [**Hospital1 6687**] with her
husband. She is a bookkeeper. Denies tobacco, alcohol, or drug
use.
Family History:
Her father and sister have had sebaceous cysts. There are a
number of non-immediate family members with history of cancer;
details are lacking
Physical Exam:
General: Very drowsy, frequently sleeping
HEENT: Sclera anicteric, dry MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs
Abdomen: Linear scar, NT, ND, No rebound or guarding, No HSM
GU: foley in place
Ext: Left mid medial thigh with area where tissue removed and
Right thigh with area of discoloration from skin graft
placement. Right LE cool to touch but with 2+ DP pulse. Left hip
and thigh no sign of hematoma, nontender to touch.
Neuro: Pupils constricted. Tongue midline; patient too tired to
assess strength exam.
Pertinent Results:
ADMISSION LABS:
[**2175-11-2**] 05:06PM PT-32.5* PTT-33.1 INR(PT)-3.3*
[**2175-11-2**] 05:06PM HCT-15.8*
[**2175-11-2**] 05:06PM CALCIUM-9.8 PHOSPHATE-1.8* MAGNESIUM-1.5*
[**2175-11-2**] 05:06PM estGFR-Using this
[**2175-11-2**] 05:06PM GLUCOSE-139* UREA N-14 CREAT-0.6 SODIUM-128*
POTASSIUM-3.3 CHLORIDE-92* TOTAL CO2-26 ANION GAP-13
[**2175-11-2**] 07:41PM HGB-8.3* calcHCT-25
[**2175-11-2**] 07:41PM PO2-50* PCO2-38 PH-7.44 TOTAL CO2-27 BASE
XS-1
[**2175-11-2**] 07:51PM FIBRINOGE-300
[**2175-11-2**] 07:51PM PT-24.4* PTT-24.4 INR(PT)-2.3*
[**2175-11-2**] 08:05PM HCT-19.5*
[**2175-11-2**] 08:06PM HGB-6.6* calcHCT-20
[**2175-11-2**] 08:38PM freeCa-1.25
[**2175-11-2**] 08:38PM HGB-7.1* calcHCT-21
[**2175-11-2**] 08:38PM GLUCOSE-120* LACTATE-2.2* NA+-127* K+-3.1*
CL--93*
[**2175-11-2**] 08:38PM TYPE-ART PO2-124* PCO2-35 PH-7.46* TOTAL
CO2-26 BASE XS-2 INTUBATED-NOT INTUBA
[**2175-11-2**] 10:47PM CALCIUM-9.2 PHOSPHATE-2.1* MAGNESIUM-1.4*
[**2175-11-2**] 10:47PM GLUCOSE-129* UREA N-13 CREAT-0.6 SODIUM-130*
POTASSIUM-3.1* CHLORIDE-95* TOTAL CO2-24 ANION GAP-14
.
.
PERTINENT LABS/STUDIES:
.
WBC: 18.7 -> 22.1 -> 26.5
Hct: 15.8 -> 19.5 -> 20.5 -> 21.6 -> 20.6
INR: 3.3 -> 2.3 -> 1.2
Na: 128 -> 129
Cr: 0.6
ALT: 77 -> 91
AST: 125 -> 148
LDH: 3965 -> 4115
Alk Phos: 412 -> 523
Ca: 9.8 -> 11.0
Phos: 1.8 -> 1.6
.
Femur XRay ([**11-3**]): There is an oblique fracture at roughly the
mid diaphyseal level with nearly one shaft width lateral
displacement of the distal fragment. No additional fracture is
seen. IMPRESSION: There is an oblique/transverse fracture of
the mid femoral shaft.
.
CXR ([**11-4**]): As compared to the previous radiograph, a
double-lumen Port-A-Cath has been placed in right pectoral
position. The tip of the catheter projects over the inflow tract
of the right atrium. The pre-existing massive bilateral hilar
and mediastinal masses have slightly increased in size, there is
no obvious narrowing of both the right and the left main
bronchus. The pre-existing retrocardiac atelectasis is less
severe than on the previous examination. There still is the
suggestion of a small left-sided pleural effusion. New focal
parenchymal opacities that would suggest infectious lung disease
are not present. No evidence of bone destruction.
.
.
DISCHARGE LABS:
.
[**2175-11-6**] 12:00AM BLOOD WBC-26.5* RBC-2.42* Hgb-6.8* Hct-20.6*
MCV-85 MCH-28.2 MCHC-33.1 RDW-24.7* Plt Ct-135*
[**2175-11-6**] 12:00AM BLOOD Plt Ct-135*
[**2175-11-6**] 12:00AM BLOOD Glucose-145* UreaN-14 Creat-0.6 Na-129*
K-4.2 Cl-92* HCO3-27 AnGap-14
[**2175-11-6**] 12:00AM BLOOD Calcium-11.0* Phos-1.6* Mg-2.2
Brief Hospital Course:
44 yo female with metaststic squamous cell carcinoma of the left
mid medial thigh s/p excision in [**7-6**] admitted with fracture of
femur
.
# Fracture of Femur: On admission, the patient was found to have
a pathologic fracture of her femur. She had a Hct 15.8 and INR
3.3. She was taken emergently to the OR, where she underwent
fixation with intramedullary nail, and bone biopsy (results
pending) with minimal blood loss. She received 10mg IV vit K
preop and 10mg SC post-op. She was extubated and was
transferred to the ICU, where she had tachycardia. She was
oriented and awake with SBP 115s; she recieved IVFs; morphine
PCA. Post op, she was found to have a leukocytosis of 18, Na
127, hct 20.5, and received Ancef. On [**11-3**], the patient was
transferred to the oncology service, where her pain was
initially controlled with a Morphine PCA. She was subsequently
transitioned to long acting po pain regimen with morphine iv for
breakthrough pain. She was maintained with lovenox for dvt ppx.
Ortho recs for further follow up are:
(1) Femur fracture:
- Weight bearing activity as tolerated, under the direction of
physical therapy
- Continue lovenox for 4 weeks
(2) Shoulder nondisplaced fracture of the acromion:
- Range of motion as tolerated
- Sling for comfort
- Follow up with outpatient surgeon
.
# Hyponatremia: The patient's Na on admission was 128. Urine
lytes were consistent with SIADH, which was thought to be
secondary to post-op pain. Patient received continous IVFs in
the SICU, and iv electrolyte repletions. She remained
asymptomatic. Na on discharge was 129.
.
# Chronic iron-deficiency anemia: Patient was continued on
ferrous sulfate supplements. As she is Jehova's witness she
refused any blood transfusions. Procrit was started [**11-5**]. She
was started on Epoetin Alfa 10,000 UNIT SC on Monday, Wednesday,
and Friday. Her Hct on discharge was stable at 20.6.
.
# Metastastic squamous cell carcinoma: The patient has a
history of invasive squamous cell carcinoma, for which she is
treated by her primary oncologist on [**Hospital1 6687**], Dr. [**First Name (STitle) 7049**], and
for which she is also followed at [**Hospital1 18**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She
should follow up with Dr. [**First Name (STitle) 7049**] regarding further chemotherapy.
Per orthopeadic surgery, it is okay to resume chemotherapy
within 1 week.
.
# Electrolytes: Patient had persistent hypokalemia to 2's and
hypophosph to 1's. She was repleted aggressively. Calcium
levels remained stable at 9.2-10.4. Potassium, Phosph, and Ca
on discharge were: 11.0, 1.6, and 2.2.
.
# Sinus Tachycardia: Patient was persistently tachycardic with
HR in 130s-150s. This was thought to be secondary to her
anemia, pain, and anxiety. She was treated w/ procrit, pain
medications, and ativan. An evaluation for etiologies such as
PE or infection was planned, and the importance of this was
explained. However, the patient was anxious to return to
[**Hospital3 22439**], and her primary attending (Dr. [**Last Name (STitle) **] is
comfortable with pursuing further evaluation at that
institution. Patient refused blood cultures as an inpatient.
Please check blood cultures and a CT-PA upon arrival to
[**Hospital3 **].
.
# Leukocytosis: The patient's WBC has increased from 18.7 to
26.5. Urine cultures were negative and the patient refused
blood cultures. CXR not significant for focal parenchymal
opacities. The patient has remained afebrile since admission,
and the patient has not had any focal signs of infection.
Please check blood cultures upon arrival to [**Hospital1 6687**].
.
# Blood pressure: In SICU, patient's antihypertensive
medications were held. While on the floors, patient remained
normotensive. Her home dose of Labetalol was restarted on
[**2175-11-6**], but we continued to hold Amlodipine. Please restart
this medication if the patient again becomes hypertensive.
.
# Left Lower Extremity Edema: The patient has had progressive
left lower extremity edema on this admission up to her hip. Per
the husband's report, the patient often develops edema in this
leg, as this is the site of her prior surgery. However, on
[**2175-11-6**], the edema was more than the husband had noticed in the
recent past. A LE U/S was planned, although the patient wished
to pursue further evaluation at [**Hospital3 22439**]. Please
check at LLE U/S upon arrival to [**Hospital3 22439**].
Medications on Admission:
1. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
2. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety/nausea.
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours):
6. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One
(1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily)
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
10. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
11. Oral Wound Care Products Gel in Packet Sig: Fifteen (15)
ML Mucous membrane TID (3 times a day) as needed for mucositis.
12. Normal Saline Please administer 4L of NS at 250cc per hour
daily.
13. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO QID (4 times a day).
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for prefers pill, not liquid.
5. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
6. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet
Sustained Release PO Q12H (every 12 hours).
7. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet
Sig: One (1) PO four times a day.
8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
9. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
10. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
11. 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.
12. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
13. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
14. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for anxiety or nausea.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Left femur fracture
Right shoulder fracture
Anemia
Metastatic Squamous Cell Carcinoma
Discharge Condition:
Stable: T 96.1; 124/68; HR 136; 95/RA
Discharge Instructions:
You were transferred to [**Hospital1 18**] because of your Left femur
fracture. You went through surgery to repair this fracture.
You tolerated the surgery well. Your hematocrit prior and after
the surgery was low. You refused blood transfusion and so we
treated you with a medication called erythropoietin so that you
can make more red blood cells. Your electrolytes were low and
so we repleted many of your electrolytes.
The following changes have been made to your medications:
(1) We increased the dose of your MS Contin from 30mg twice a
day to 45 mg twice a day
(2) We have changed your Morphine pain medication from PO to IV,
when you are able to tolerate PO medication you can switch back
(3) We have changed your PO Zofran IV
(4) We have started you on tylenol for pain and multivitamin
(5) We have started you on lovenox for prophylaxis of deep vein
thrombosis; this should be continued for four weeks
(6) We have started you on erythropoietin 10,000U Mon, Wed, Fri.
You will receive your first dose at [**Hospital3 22439**]
(5) We have restarted your labetalol, but have held your
amlodipine. The doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) 6687**] [**Name5 (PTitle) **] decide when to
restart this.
This is a very sedating medication take only as prescribed.
Please do not take morphine while driving or operating a motor
vehicle.
If you should experience worsening pain, lightheadedness, fevers
> 101, chills or any concerning symptom please call your primary
care physician or return to the emergency room.
Followup Instructions:
You are being transferred to [**Hospital3 **] for further
medical care.
They should continue your Lovenox and start your erythropoietin.
They should also continue to evaluate the cause of the
asymmetrical swelling of your lower extremities, as well as the
cause of your fast heart rate.
They will need to follow up with your shoulder fracture. They
will also need to check your electrolytes as these were depleted
during your hospitalization. Your serum sodium should also be
followed as these levels were low. They will decide if you
should restart your amlodipine.
Your oncologist will decide when to restart your chemotherapy
cycle, in conjunction with Dr. [**Last Name (STitle) **], who is aware of these
arrangements.
Completed by:[**2175-11-6**]
ICD9 Codes: 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2611
} | Medical Text: Admission Date: [**2187-5-18**] Discharge Date: [**2187-5-20**]
Date of Birth: [**2128-2-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
dypsnea and somonolence
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59 y/o man h/o HIV on HAART (last CD4 868, vL <48 in [**2187-5-16**])
who presented to the ED tonight with increasing shortness of
breath for 1-2 months. He reports that his CPAP machine broke
recently and he therefore has not been using it at home. During
this time, he reports increasing somnolence, also endorsing
dreams and hallucinations during the day. People with whom he
lives have become increasingly concerned in the last several
days and today advised him to come the emergency room for
evaluation. On review of systems, he denies cough or sputum
production. He denies chest pain or pressure, but he does
endorse increasing dyspnea during the last several weeks.
.
Initial vital signs in the ED were T 98.3, HR 109, sat 95% on
4L. Patient reportedly fell asleep while talking to ED
physicians and was noted to snore loudly. An EKG showed sinus
tachycardia with a RBBB that is unchanged from prior. Labs were
remarkable for normal CBC with white count of 9.6 (70% polys).
BMP was also normal (creatinine at baseline 1.4), with normal
LFTs and lipase. His pro-BNP was 169 and troponin was flat. A
d-dimer came back elevated at 915 and so CTA was done that
showed no evidence of PE or other acute process. Urine and serum
toxicology screens were negative. ABG showed 7.35/57/46. Blood
cultures were taken. Patient given Levo, ceftriaxone, Flagyl for
treatment of possible pneumonia. He was a admitted to the ICU
for somnolence and need for positive pressure ventilation.
Vitals at time of admission were sat 99% on 4L, T 99.6, BP
136/73, HR 103.
Past Medical History:
1) HIV - diagnosed [**2167**]. complicated by HIV encephalopathy
2) Bipolar disorder - SA at 19yo by OD on aspirin
3) Peripheral neuropathy - ?[**2-13**] B12 def vs HIV
4) Lipodystrophy
5) Hypertriglyceridemia
6) OSA - not on CPAP (sleep study [**1-/2177**] AHI 59.9)
7) GERD
8) Asthma - PFTS normal [**7-16**]
9) Seborrheic dermatitis
10) Rotator cuff tendinitis, Bicep tendinitis
11) LBP, chronic neck pain/spasm s/p MVA
12) Erectile Dysfunction
13) Renal cysts (seen on ultrasound)
14) Evidence of prior HBV (neg HBsAg, pos HBsAb, pos HBcAb)
15) Arthritis
16) Colonic polyps
17) Deviated septum surgery
[**95**]) Excision of perianal papilloma ([**2176-8-29**]). Normal anal pap
smear [**2-17**].
19) Tonsillectomy
20) Low testosterone
21) Scrotal abscess [**2-/2183**]
22) Fatty liver by Ultrasound
23) Vitamin B12 deficiency
24) Verrucous hyperkeratosis
Social History:
Per OMR Born in [**Location (un) **], MA. Previously worked as pharmacy
technician and bus driver. Now on disability and lives [**Location (un) 111723**]Apartment Program x past 11 years. Father[**Name (NI) **] one child,
not involved in his care. Has two [**Name (NI) 1685**] sisters, [**Name (NI) **] and
[**Name2 (NI) **]. Both his mother and twin sister are deceased.
Tobacco - 60 pack year history, no longer smokes
Alcohol - denies
Drugs - denies. No past history of IVDU
.
Family History:
Per OMR, grandmother received ECT; father had schizophrenia.
Mother and [**Name2 (NI) 1685**] sister with bipolar disorder. Otherwise,
denies sudden cardiac death, coronary artery disease.
Physical Exam:
T 99.9, BP 132/79, HR 97, RR 27, sat 99% venti-mask FiO2 40%
General: obese, middle-aged man, slightly diaphoretic, becomes
dyspneic with minimal exertion in bed
HEENT: posterior oropharynx poorly visualized secondary to large
tongue
Neck: large diameter, supple
Lungs: poor air movement in posterior fields, no focal wheezes
Heart: distant s1/s2
Abdomen: obese, soft, non-tender
Extremities: 1+ pitting edema in lower extremities, pink skin
?[**2-13**] venous stasis disease
Neurological: moving all extremities, AAOx3, concentration
intact
.
Pertinent Results:
[**2187-5-19**] 12:49AM BLOOD WBC-8.8 RBC-3.69* Hgb-13.8* Hct-42.1
MCV-114* MCH-37.4* MCHC-32.8 RDW-17.7* Plt Ct-329
[**2187-5-18**] 10:40AM BLOOD Glucose-137* UreaN-23* Creat-1.4* Na-145
K-4.5 Cl-103 HCO3-31 AnGap-16
[**2187-5-19**] 01:11PM BLOOD Na-146* K-3.7
[**2187-5-18**] 10:40AM BLOOD D-Dimer-915*
[**2187-5-18**] 10:40AM BLOOD TSH-0.55
[**2187-5-18**] 10:40AM BLOOD Calcium-10.0 Phos-3.8 Mg-2.4
[**2187-5-18**] 10:40AM BLOOD cTropnT-<0.01
[**2187-5-19**] 12:49AM BLOOD CK-MB-9 cTropnT-<0.01
[**2187-5-19**] 12:49AM BLOOD CK(CPK)-291
[**2187-5-18**] 01:53PM BLOOD Type-ART O2 Flow-5 pO2-46* pCO2-57*
pH-7.35 calTCO2-33* Base XS-3 Intubat-NOT INTUBA Comment-NC
[**2187-5-18**] 08:46PM BLOOD Type-ART pO2-86 pCO2-47* pH-7.43
calTCO2-32* Base XS-5
[**2187-5-18**] 10:46AM BLOOD Lactate-1.4
[**2187-5-18**] 08:46PM BLOOD Lactate-1.2
[**2187-5-18**] 10:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-5-18**] 10:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
Brief Hospital Course:
59 y/o man h/o HIV on HAART (well-controlled), morbid obesity,
OSA presents with worsening shortness of breath and somnolence.
.
# Dyspnea/somnolence. Likely secondary to hypercarbia/hypoxemia
from worsening obstructive sleep apnea in the setting of poor
compliance with home CPAP. There was no evidence of pulmonary
infection, CHF or drug intoxication (serum/urine tox negative).
Pt reports severe leak from his BiPAP mask at home and having to
adjust it >6x per night. Pt was placed on home BiPAP and mental
status was much improved by the morning. Pt is on complex
medication regimen and would benefit from medication
reconciliation and simplification with psychiatry as outpatient.
.
# HIV: continue home HAART regimen.
.
# Bipolar disorder with anxiety and significant depression s/p
ECT in [**2187-1-12**]. Pt was reporting hallucinations on
presentation and was taking Pramiprexole TID. This was
decreased to qhs only to prevent dopaminergic side effects.
Otherwise, he was continued on his home psych regimen. We
recommend psych follow up for simplication of his regimen and
changing to meds that are more weight neutral
.
# Hypertension: poorly controlled, increased amlodipine to 10mg
daily
.
# Nephrogenic DI: On day 2 of admission, Na rose to 150 and
corrects easily when patient is alert and has adequate access to
fluids. Na came down to 146 and pt should be continued on low
sodium and low protein diet in addition to 5L of fluid intake
per day
.
# FEN. Low-sodium diet.
.
# Prophylaxis. Heparin subcutanous, Tylenol prn, bowel regimen.
.
# Access. PIVs.
.
# Communication. [**Name (NI) **] [**Name (NI) **] (sister): [**Telephone/Fax (1) 111724**].
.
# Code status. DNR but intubation okay.
Medications on Admission:
ABACAVIR-LAMIVUDINE [EPZICOM] - 600 mg-300 mg Tablet - 1
Tablet(s) by mouth daily
ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - [**1-13**] Tablet(s) by
mouth every four (4) hours as needed for back pain Do not drive
or drink alcohol on this medication
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth Qday
AMPHETAMINE-DEXTROAMPHETAMINE [ADDERALL XR] - 15 mg Capsule,
Sust. Release 24 hr - 1 Capsule(s) by mouth qam
CITALOPRAM - 40 mg Tablet - 2 Tablet(s) by mouth qam
ESZOPICLONE [LUNESTA] - 3 mg Tablet - 1 Tablet(s) by mouth at
bedtime
ETRAVIRINE [INTELENCE] - 100 mg Tablet - two Tablet(s) by mouth
twice daily In place of Fosamprenavir
FAMOTIDINE - 20 mg Tablet - 1 Tablet(s) by mouth HS
FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 145 mg Tablet - 1
Tablet(s) by mouth Daily
HYDROCORTISONE - 2.5 % Cream - Apply thin layer to affected area
2-3 times per day
KETOCONAZOLE [NIZORAL] - 2 % Shampoo - Daily WASH FACE, HAIR AND
CHEST LEAVE ON FOR 2 MIN EVERY DAY
LAMOTRIGINE - 150 mg Tablet - 2 Tablet(s) by mouth at bedtime
LORAZEPAM - 1 mg Tablet - 2 Tablet(s) by mouth at bedtime
LORAZEPAM [ATIVAN] - 2 mg Tablet - 1 Tablet(s) by mouth x 1 1
hour before MRI
MIRTAZAPINE - 30 mg Tablet - 2 Tablet(s) by mouth at bedtime
OMEGA-3 ACID ETHYL ESTERS [LOVAZA] - 1 gram Capsule - 2
Capsule(s) by mouth twice a day
OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - 2
Tablet(s) by mouth every 6 hours as needed for pain
PRAMIPEXOLE [MIRAPEX] - 0.125 mg Tablet - 1 Tablet(s) by mouth
three times a day
RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - One Tablet(s) by mouth
twice daily This is to replace Tenofovir
STAVUDINE - 40 mg Capsule - 1 Capsule(s) by mouth twice a day
UREA [CARMOL 40] - 40 % Cream - Apply to the feet once to twice
per day
.
Medications - OTC
CYANOCOBALAMIN [VITAMIN B-12] - 1,000 mcg Tablet - 1 Tablet(s)
by
mouth Daily
VITAMIN E - 400 unit Capsule - 1 Capsule(s) by mouth four times
a
day
Discharge Medications:
1. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Amphetamine-Dextroamphetamine 5 mg Capsule, Sust. Release 24
hr Sig: Three (3) Capsule, Sust. Release 24 hr PO qAM ().
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs ().
7. Etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. Lunesta 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
10. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
11. Lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
12. Mirtazapine 30 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Stavudine 20 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
16. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO QID (4
times a day).
18. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Somnolence secondarily to Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for being very sleepy and having
hallucinations. Initially there was concern about your breathing
so you were admitted to the ICU. In here we started you on BiPAP
with your home settings and a new mask and worked beautifully
for you. You were able to have a good night sleep and you woke
up, probably after your CO2 level improved with the pressure of
the machine. We ruled you out for a heart attack. changed
Pramipexole to qhs only given that you were having
hallucinations and those improved.
.
You need to follow up with your psychiatry next Thursday and
tell him about your hallucinations and the change in the
medication we did (Pramepixole).
.
You need to follow up with your PCP within the next two weeks.
.
If you have problems with your mask call your
Pulmonologist/Sleep doctor: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD at ([**Telephone/Fax (1) 513**] and
he can help you with your mask.
.
It is important that you lose weight watching your diet. If you
lose more than [**10-26**] pounds call your pulmonologist for a new
mask. Losing weight will improve your sleep.
Followup Instructions:
You need to follow up with your psychiatry next Thursday and
tell him about your hallucinations and the change in the
medication we did (Pramepixole).
.
You need to follow up with your PCP within the next two weeks.
.
If you have problems with your mask call your
Pulmonologist/Sleep doctor: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD at ([**Telephone/Fax (1) 513**] and
he can help you with your mask.
Appointments indicated below:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2187-5-21**] 10:00
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2187-5-21**]
8:35
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2187-5-24**] 2:00
ICD9 Codes: 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2612
} | Medical Text: Admission Date: [**2151-3-12**] Discharge Date: [**2151-3-16**]
Date of Birth: [**2112-4-22**] Sex: M
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
38-year-old African-American man with recently diagnosed
hypertension presented with 5 days of headache, found to have
SBP in 200-210, admitted to MICU on nitroprusside drip.
.
Mr. [**Known lastname 86556**] initially presented to his PCP [**Last Name (NamePattern4) **] [**2151-3-8**] with a
new, dull, constant headache, was found to have BP 200/120, Cr.
1.5, aldosterone 61, renin 1.9. Serum metaneprhine fraction was
normal; 24-hr urine metanephrine pending. He was started on
lisinopril 20 mg qday. Three days later, BP was still high, and
his lisinopril was increased to 40 mg qday and labetolol 100 [**Hospital1 **]
was added. Outpatient nephrologist suggested renal MRI for
further work-up of his elevated creatinine. He went back to the
PCP's office the day of admission when his BP was found to be
unchanged; labetolol was added. With persistent headache, he
presented to the ED. He denies any visual changes, chest pain,
shortness of breath, weakness.
.
In ED, initial BP was 200-210/110-120, HR in the 50s. Exam,
including optic disc exam, was unremarkable. Cr. was 1.8. He was
started on nitroprusside at 0.25 mcg/kg/min and his SBP dropped
quickly to 160. Nitroprusside was decreased to 0.15 mcg/kg/min.
By transfer to MICU, his BP was 180/100, HR 70s. He received one
Percocet for his headache.
.
ROS: Denies fever, chills, night sweats, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
hypertension
Social History:
No smoking. Social drinker
Family History:
Mother and brother have hypertension
Physical Exam:
GENERAL: muscular young man in NAD
HEENT: EOMI, PERRL, OP moist without lesion
CARDIAC: RR, normal S1/S2, no m/r/g
LUNG: CTAB
ABDOMEN: soft, NT, ND, BS present
EXT: no c/c/e
NEURO: awake, alert, oriented x 3
Pertinent Results:
Admission labs:
[**2151-3-12**] 03:20PM WBC-6.3 RBC-4.96 HGB-13.6* HCT-41.2 MCV-83
MCH-27.3 MCHC-32.9 RDW-12.6
[**2151-3-12**] 03:20PM NEUTS-65.1 LYMPHS-24.4 MONOS-5.2 EOS-5.0*
BASOS-0.3
[**2151-3-12**] 03:20PM PLT COUNT-253
[**2151-3-12**] 03:20PM PT-11.9 PTT-25.5 INR(PT)-1.0
[**2151-3-12**] 03:20PM GLUCOSE-134* UREA N-17 CREAT-1.8* SODIUM-140
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-30 ANION GAP-11
[**2151-3-12**] 03:20PM SED RATE-11
[**2151-3-12**] 06:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2151-3-12**] 06:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2151-3-12**] 06:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
Discharge labs:
[**2151-3-16**] 06:20AM BLOOD WBC-7.3 RBC-5.20 Hgb-14.5 Hct-44.6 MCV-86
MCH-27.8 MCHC-32.4 RDW-12.6 Plt Ct-340
[**2151-3-16**] 06:20AM BLOOD Plt Ct-340
[**2151-3-16**] 06:20AM BLOOD Glucose-90 UreaN-16 Creat-2.3* Na-137
K-4.3 Cl-97 HCO3-32 AnGap-12
[**2151-3-16**] 06:20AM BLOOD Calcium-9.9 Phos-5.1* Mg-2.6
[**2151-3-16**] 06:20AM BLOOD TSH-1.6
[**2151-3-13**] 02:03PM BLOOD HIV Ab-NEGATIVE
Imaging:
Renal U/S w/ doppler: IMPRESSION:
1. No hydronephrosis, nephrolithiasis, or renal mass lesion.
Renal parenchyma is normal in appearance.
2. Doppler interrogation of the kidneys demonstrates normal
velocities in the main renal arteries. Resistive indices are
within normal limits in the
interlobar arteries, though there are characteristic
tarud/parvus waveforms, suggesting possible renal artery
stenosis or fibromuscular dyhsplasia. Further evaluation with
MRI should be considered.
N/C Head CT: IMPRESSION: No acute intracranial process.
Admission ECG: Sinus rhythm. Left axis deviation. Early
repolarization. No previous tracing available for comparison.
Brief Hospital Course:
38-year-old African-American man with recently diagnosed
hypertension presented with 5 days of headache, found to have
SBP in 200-210, admitted to MICU on nitroprusside drip.
.
# HTN: His SBP was in the 170s on arrival to the MICU. The
nitroprusside was discontinued after 2 hours, after the
initiation of labetolol 200 mg PO bid. His SBP remained in
140s-160s overnight then increased to 180s-190s. Labetolol was
uptitrated to 200 mg PO tid. His headache decreased but still
persisted. No visual changes, chest pain, shortness of breath.
Blood pressure rose back to 200. Nitroglycerin drip was
started. Labetalol was uptitrated; HCTZ was added. Hydralazine
was given for short-acting effect. The next morning the
nitroglycerin was titrated off and the patient did well. He was
transferred to the floor on labetalol 600mg [**Hospital1 **], amlodipine 10mg
daily and HCTZ 25mg daily. He did well with SBPs to in the 140
to 160 range. His headaches improved. He was discharged with
close follow-up to repeat BP checks.
.
# Acute kidney injury: Cr. 1.8, from 1.5 at PCP's office on
Monday. Recent increase might be due to initiation of ACE
inhibitor, so his lisinopril was held. Renal ultrasound should
normal appearing kidneys, but was concerning for possible RAS or
fibromuscular dysplasia. FENa was 1.1%. Nephrology was consulted
and saw rare muddy-brown casts concerning for ATN. Concerning
for FSGS as well. HIV was negative. His Cr initially
stabilized, then rose slightly to 2.3 on the day of discharge.
However, he was making good amounts of urine and had no
electrolyte disturbances. He was discharged with instructions
to follow-up closely with his PCP with repeat lab tests. He
will also see a nephrologist, Dr. [**Last Name (STitle) 86557**]. He should a kidney
MRA as an outpatient once his creatinine clearance has improved.
Medications on Admission:
lisinopril 40 mg qday
labetolol 100 mg [**Hospital1 **]
Discharge Medications:
1. Labetalol 300 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Blood pressure cuff
Please provide patient with home blood pressure cuff
Discharge Disposition:
Home
Discharge Diagnosis:
Diagnosis: hypertensive emergency
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted with very high blood pressure and headaches
and were found to have an elevated creatinine, a marker for
abnormal kidney function. Your blood pressure is now better
controlled, but you continue to have below-normal kidney
function. You need to follow-up closely with your primary care
doctor to ensure that your kidney function improves and your
blood pressure is well-controlled.
.
You were started on three medications to control your blood
pressure:
- Labetalol, 300mg tablets, 2 tablets twice a day
- Amlodipine, 10mg tablets, 1 tablet once a day
- Hydrochlorothiazide (HCTZ), 25mg tablets, 1 tablet once a day
.
We are also giving you a prescription for a blood-pressure cuff.
You can be blood pressure cuffs at most drug stores. You can
use this to monitor you blood pressures at home.
.
Your headaches have improved with better blood pressure control.
If you have recurrent headaches, check your blood pressure and
call your doctor. If your headache is severe and you can't get
a hold of your doctor, you should go to an emergency department.
.
Your kidney function remains below normal. Please have your
blood drawn Thursday at the [**Location (un) **] [**Hospital1 **] office so
that the results will be ready for your appointment Friday. If
you go to the lab there, they will have the order for your lab
work to be done.
Followup Instructions:
Appointment #1
MD: [**First Name4 (NamePattern1) 41875**] [**First Name8 (NamePattern2) **] [**Location (un) **]
Specialty: Internal Medicine/ PCP
[**Name Initial (PRE) 2897**]/ Time: Friday, [**3-19**], 1:30pm
Location: [**Location (un) 2274**] [**Location (un) **]. [**Location (un) 2129**], [**Location (un) 86**].
Phone number: [**Telephone/Fax (1) 2261**]
Please follow-up with the nephrologist, Dr. [**Last Name (STitle) 86557**], [**3-31**]
at 3pm.
Completed by:[**2151-3-16**]
ICD9 Codes: 4019, 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2613
} | Medical Text: Name: [**Known lastname 1193**], [**Known firstname 1194**] Unit No: [**Numeric Identifier 1195**]
Admission Date: Discharge Date: [**2186-3-7**]
Date of Birth: [**2099-9-1**] Sex:
Service:
ADDENDUM: This dictation covers the portion of the patient's
admission from [**2186-2-27**] to [**2186-3-7**]. The
previous dictation should be completed by the earlier team.
SUMMARY OF HOSPITAL COURSE CONTINUED: This is an 86-year old
female with atrial fibrillation, a flailed posterior mitral
valve leaflet, severe mitral regurgitation, receiving
tailored treatment to optimize hemodynamics. A family
meeting was held to discuss a plan and the possibility of
future surgery. Hospital course from [**2186-2-27**] to
[**2186-3-7**] by problem:
1. CARDIOVASCULAR: Coronary artery disease: The patient had
a coronary catheterization which demonstrated clean
coronary arteries.
Pump: The patient was off pressors and inotropic agents
starting on [**2186-2-27**]. Diuresis was continued using
Lasix and then with the addition of Zaroxolyn. The patient
was also started on low-dose ACE inhibitor and did well with
good diuresis and resolution of her generalized anasarca.
Diuretics were discontinued on [**3-4**] as the patient's
creatinine bumped to 1.3, and she developed a contraction
alkalosis and appeared somewhat dehydrated. The patient was
given minimal intravenous fluid resuscitation and responded
appropriately.
Rhythm: The patient was maintained on a digoxin. Beta
blocker was titrated up. She was also maintained on a
heparin drip.
1. PULMONARY: The patient remained intubated, having periods
of apnea when attempts to wean intubation were attempted.
After much discussion with family, and team, as well as
palliative care specialists the decision was made to
extubate the patient without reintubation and without a
tracheostomy on [**3-5**]. The patient was optimized and
was weaned from the ventilator with good results on
[**2186-3-5**]. The patient remained extubated.
2. GASTROINTESTINAL: The patient was maintained on tube
feedings. Following her extubation she underwent a
swallow evaluation on [**3-6**] which she failed. The
patient refused to even open her mouth. It was
recommended that the patient have a percutaneous
endoscopic gastrostomy or feeding tube placed. Her
daughter declined nasogastric tube or percutaneous
endoscopic gastrostomy tube at this time, and hospice was
initiated.
3. INFECTIOUS DISEASE: The patient had finished her
ampicillin course for her enterococcus urinary tract
infection with good results.
4. DISPOSITION: Multiple family meetings were held. Dr. [**Last Name (Prefixes) 1196**] represented Surgery and spoke to the family
regarding the decision that the patient would not be a
surgical candidate for her posterior mitral valve leaflet
flail resulting in severe mitral regurgitation. Based on
this information, the family decided not to pursue
reintubation once the patient was extubated to maintain
her do not resuscitate status. Social Work consultation
was obtained to provide the family with support.
After extubation, the patient was transferred to the floor on
[**3-5**]. It was noted that she had decreased
responsiveness. The family moved toward a hospice-type
situation at that time. The patient expired on [**2186-3-7**].
[**First Name8 (NamePattern2) 1197**] [**First Name4 (NamePattern1) 1198**] [**Last Name (NamePattern1) **], M.D. [**Doctor First Name 1199**]
Dictated By:[**Last Name (NamePattern1) 1200**]
MEDQUIST36
D: [**2186-7-20**] 12:48:41
T: [**2186-7-21**] 09:23:16
Job#: [**Job Number 1201**]
ICD9 Codes: 4240, 5990, 2765, 496, 4280, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2614
} | Medical Text: Admission Date: [**2135-7-27**] Discharge Date: [**2135-8-20**]
Date of Birth: [**2085-9-21**] Sex: F
Service: MED
Allergies:
Penicillins / Sulfonamides
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fever and low back pain
Major Surgical or Invasive Procedure:
endotracheal intubation & mechanical ventilation
tracheostomy
History of Present Illness:
49 yo morbidly obese female who weighs 310 lb with hx of IDDM,
MRSA bacteremia, and low back pain was transferred from [**Hospital1 **]
[**Location (un) 620**] today. Pt initially presented to [**Hospital1 **] [**Location (un) 620**] with 16
hour history of fevers and left low back pain. She also
complained of dysuria and abdominal discomfort 3 days prior to
admission and was seen by her PCP but her urine culture was
negative. The night prior to admission, she experienced fever
of 101.5, chills, and diaphoresis. She was initially admitted
to [**Hospital1 **] [**Location (un) 620**] for evaluation of her fever and flank pain. She
was initially treated with Levaquin but was started on
Vancomycin 1g q12 once the blood culture grew out MRSA. Blood
culture was positive for MRSA on multiple occasion and showed no
growth on [**7-25**]. Patient continued to spike fever with Tm=105.1
on [**2135-7-26**]. At that time Gentamycin was added for synergy after
ID consult. TEE was done which was negative for any valvular
vegetation. Patient has left paraspinal tenderness with high
grade MRSA bacteremia of unknown source, MRI of the L spine was
recommended to rule out epidural abscess. However, patient is
claustrophobic and can only do either open MRI or MRI under
general anesthesia. For that reason, patient was transferred to
[**Hospital1 18**] to have the MRI done under general anesthesia. Dr.
[**Last Name (STitle) 1338**] from neurosurgery is aware of her. Today, pt was on 2L
oxygen but came to the hospital with 5L. Patient now requiring
face mask to keep her saturation.
Past Medical History:
Non insulin dependent diabetes
Hypertension
Status post cholecystectomy
Obesity
Asthma
Fibromyalgia
Social History:
Mother lives with her at home- she has been sick recently with
cellulitis [**Month (only) **]-[**Month (only) 116**], requiring hospitalization. No recent
travel. Works as case manager at facility/NH for MR patients.
Patients on case load have been MRSA/VRE positive. Denies
tobacco, ETOH, drugs. HCP is mother: [**Telephone/Fax (1) 95392**]
Family History:
noncontributory
Physical Exam:
VS: T 101.2 BP 134/50 HR 102 R 24-40's O2 sat 5 L
Gen: breathing in labor with face mask, diaphoretic
HEENT: PERRL, EOMI, MMM, sweaty
Lungs: distant breath sound, crackle on right posterior exam,
diffuse wheezing.
Cor: distant heart sound, murmurs appreciated at outside
hospital but difficult to assess with her heavy rapid breathing
and oxygen.
Abd: Obese, difficult to assess liver, spleen.
Ext: 1+ edema bilaterally.
Musc: Warm to touch and slight erythema of left lumber
paraspinal region. +Tenderness to palpation.
Neuro: Alert, oriented. CN II-XII grosssly intact.
Pertinent Results:
[**2135-7-28**] 04:42AM BLOOD WBC-10.6 RBC-4.20 Hgb-11.3* Hct-34.5*
MCV-82 MCH-27.0 MCHC-32.9 RDW-14.5 Plt Ct-277
[**2135-8-3**] 04:58AM BLOOD Neuts-80.6* Lymphs-11.6* Monos-5.6
Eos-1.9 Baso-0.4
[**2135-7-28**] 04:42AM BLOOD PT-12.8 PTT-31.6 INR(PT)-1.1
[**2135-7-28**] 04:42AM BLOOD Plt Ct-277
[**2135-8-18**] 04:30AM BLOOD Eos Ct-740*
[**2135-7-28**] 04:42AM BLOOD Glucose-123* UreaN-12 Creat-0.5 Na-141
K-3.2* Cl-98 HCO3-32* AnGap-14
[**2135-7-29**] 04:30AM BLOOD ALT-63* AST-53* LD(LDH)-230 AlkPhos-321*
TotBili-0.9
[**2135-7-28**] 04:42AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9
[**2135-7-28**] 01:06AM BLOOD Type-ART Temp-38.6 Rates-/30 O2-100
pO2-102 pCO2-53* pH-7.39 calHCO3-33* Base XS-5 AADO2-576 REQ
O2-92 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2135-7-28**] 01:57AM BLOOD Type-ART Temp-38.3 Rates-/30 O2-100
pO2-82* pCO2-55* pH-7.39 calHCO3-35* Base XS-6 AADO2-594 REQ
O2-95 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2135-7-28**] 01:06AM BLOOD Lactate-1.1
Brief Hospital Course:
Ms [**Known lastname 8520**] had positive blood cultures from OSH for MRSA, here
she had multiple blood cultures which were pertinent only for 1
bottle of coag neg staph. She did have persistently positive
sputum for MRSA with sparse gram negative rods speciated as
klebsiella & enterobacter. Urine negative, TEE negative, CT
abdomen unrevealing. tagged WBC scan negative.
Was on Vanc for 28 days & Cipro for 14 days. Had persistent
fevers to 102, ? was for drug fever vs persistent PNA.
CT scan showed RLL & LLL consolidation. Bronch & BAL was done.
Was intubated for worsening tachypnea, required sedation while
intubated [**2-28**] agitation.
Was extubated ~[**8-11**], but developed stridor & ? neg pressure pulm
edema requiring urgent reintubation.
Was trached on [**8-19**] & tolerated wean to trach collar well.
Infectious disease service followed here & helped manage
antibiotic regimen.
Medications on Admission:
Vancomycin 1.5 gm q.12
Gentamycin 100 mg IV q.8
HCTZ 25 mg qd
ASA 325 mg qd
Advair 50/500
Vasotec 10 mg qd
[**Doctor First Name **] 60 mg qd
Avandia 4 mg qd
Prilosec 40 mg qd
Lopressor 12.5 mg [**Hospital1 **]
RISS
Heparin 5000 units sq tid
Senna 2 tablets q hs
Lactulose prn
Effexor 150 mg qd
Singulair 10 mg qd
Nortriptyline 10 mg qhs
Tylenol prn
Ibuprofen prn
Morphine sulfate 4 mg IV q2h prn
Lasix prn responding well
Lanazolid ordered at OSH but never received.
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: 1-2 puffs Inhalation
Q6H (every 6 hours) as needed.
2. Salmeterol Xinafoate 50 mcg/DOSE Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Lorazepam 2 mg/mL Syringe Sig: 0.5-1.0 mg Injection Q4H
(every 4 hours) as needed for agitation/anxiety.
6. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Pneumonia
2. MRSA
3. Respiratory failure - resolved
4. s/p tracheostomy
Discharge Condition:
good
Discharge Instructions:
1. Trach collar maintenance
2. Physical therapy/occupational therapy to increase your
strength
Followup Instructions:
Call case management department here at [**Hospital3 **] for help
finding a new primary care physician
ICD9 Codes: 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2615
} | Medical Text: Admission Date: [**2192-4-9**] Discharge Date: [**2192-4-18**]
Date of Birth: [**2141-1-4**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
transfer from outside hospital for treatment of PE
Major Surgical or Invasive Procedure:
IVC filter placement on [**2192-4-9**]
History of Present Illness:
51 year-old Russian speaking F transferred from [**Hospital1 **] Needman with
concerns of GI bleed and new PE. She was admitted on [**2192-4-7**] to
OSH after 1 week of daily rectal bleeding with each bowel
movement. She also started noticing clots of blood from the
rectum as well. She gradually started experiencing dizziness but
denies syncope. Symptoms also associated with left sided chest
pressure, palpitations, and mild pleuritic chest pressure not
worse with bleeding. Of note, patient had a left ankle in cast
from recent ankle fracture in late [**Month (only) 956**]. She has been less
mobile as a result. Also, she flew here from [**Location (un) 3156**] in early
[**Month (only) 956**]. She denies a previous history of bleeding or clotting.
AT OSH, she was found to have a hematocrit of 14.8 and received
7 units PRBCs for GIB. An EGD showed mild gastritis without
active bleeding and a colonoscopy was normal. A CT chest showed
PE. CT abd/pelvis was normal except for large fibroid. An echo
was also within normal limits.
Upon arrival to ICU, the patient was feeling fatigued and
endorsed left sided chest pressure. She described the chest
pressure as a burning, [**5-8**] pain, that was worse with breathing.
Denied dizziness, fever/chills, abd pain, vaginal bleeding,
rectal bleeding but endorsed some mild nausea.
Past Medical History:
-uterine fibroids
-iron defiency anemia
Social History:
From [**Location (un) 3156**], recently returned to US in [**2192-1-31**]. Denies
smoking, alcohol, or drug use. Previously worked as an
accountant.
Family History:
mother died of breast ca at 42, father died of liver cancer NOS
Physical Exam:
Admission Physical Exam:
Vitals: T:98.6 BP:110/73 P:97 R:20 18 O2:98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dryMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 1/6 SEM best heard
at llsb, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
REctal: per surgery note, internal and external hemorrhoids
Ext: left ankle in cast below knee, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
DISCHARGE
Pertinent Results:
ADMISSION LABORATORY STUDIES:
[**2192-4-9**] 04:47PM BLOOD WBC-10.2 RBC-4.49 Hgb-13.5 Hct-38.6
MCV-86 MCH-30.1 MCHC-35.0 RDW-13.7 Plt Ct-179
[**2192-4-9**] 04:47PM BLOOD PT-12.3 PTT-25.7 INR(PT)-1.0
[**2192-4-9**] 04:47PM BLOOD Glucose-71 UreaN-8 Creat-0.7 Na-137 K-3.5
Cl-107 HCO3-18* AnGap-16
[**2192-4-9**] 04:47PM BLOOD LD(LDH)-199 CK(CPK)-81 TotBili-2.2*
[**2192-4-9**] 04:47PM BLOOD Calcium-7.6* Phos-2.8 Mg-1.9
DISCHARGE LABORATORY STUDIES:
[**2192-4-18**] 05:45AM BLOOD WBC-4.5 RBC-4.19* Hgb-12.5 Hct-37.4
MCV-89 MCH-29.8 MCHC-33.4 RDW-14.1 Plt Ct-221
[**2192-4-14**] 06:15AM BLOOD Glucose-90 UreaN-16 Creat-0.9 Na-137
K-3.9 Cl-104 HCO3-25 AnGap-12
[**2192-4-18**] 05:45AM BLOOD PT-13.0 PTT-59.0* INR(PT)-1.1
CTA from [**Hospital1 **] [**Location (un) 620**]
IMPRESSION:
1. RIGHT-SIDED PULMONARY EMBOLUS AT JUNCTION OF RIGHT MIDDLE AND
LOWER LOBE PULMONARY ARTERIES AND EXTENDING INTO LOWER AND
MIDDLE LOBE BRANCHES,
2. SMALL AREA OF DEPENDENT DENSITY IN THE DESCENDING COLON OF
UNCERTAIN SIGNIFICANCE ON THIS SINGLE PHASE EXAM. REPEAT
DEDICATED GI-BLEEDING PROTOCOL. INCLUDING PRE-CONTRAST AND
DELAYED POST CONTRASTPHASES THROUGH THE ABDOMEN COULD BE
PERFORMED IF CLINICALLY INDICATED.
3. BILATERAL SMALL EFFUSIONS.
4. SMALL AREA OF LOBULATED SOFT TISSUE IN THE LEFT BREAST [**Month (only) **]
REFLECT AN INTRAMAMMARY LYMPH NODE BUT IS NONSPECIFIC.
CORRELATION WITH CLINICAL HISTORY IS ADVISED.
5. LEFT NINTH RIB ANTERIOR FRACTURE.
6. MULTIPLE ARTERIAL PHASE ENHANCING LESIONS WITHIN THE LIVER.
WHILE NONSPECIFIC, THESE ARE LIKELY TO REFLECT HEMANGIOMAS.
FURTHER ASSESSMENT WITH ULTRASOUND COULD BE OBTAINED.
7. MULTIPLE UTERINE FIBROIDS.
[**2192-4-12**] Ultrsounds of Lower Extremities:
- No evidence for DVT in right or left lower extremity.
Brief Hospital Course:
Ms. [**Known lastname 89278**] presented with profound anemia and an acute pulmonary
embolus after recovering from a recent ankle fracture. On
presented to [**Hospital1 **] [**Location (un) 620**] and to [**Hospital1 18**] it was a bit unclear why
she was so anemic. However, on review of her history and lab
studies she had evidence of chronic blood loss anemia worse over
the few days prior to presentation. Upper, lower, and capsule
endoscopies revealed no source of bleeding other than internal
hemorrhoids. The best estimate at her presentation included
worsening constipation/hemorrhoids and a DVT/PE while recovering
from her recent ankle fracture. Fortunately, she improved with
treatments for each of these conditions and is being discharged
to follow-up with her new PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**4-20**]. Management of
specific medical problems outlined below:
1. Acute pulmonary embolism:
- thought to be provoked from immobility with cast on left leg
and recent plane flight from [**Location (un) 3156**].
- given the bleeding and anticoagulation a retrievable IVC
filter (OptEase IVC filter) was placed on admission. As outlined
below, she will probably do well on anticoagulation but the
filter was left in place while this is being determined. If she
does not have any complications on anticoagulation this should
be removed. This can be arranged by calling [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6745**] in the
Radiology Care Unit at [**Telephone/Fax (1) 6747**].
- despite profound anemia on presentation she was treated with
many days of anticoagulation while hospitalized and had no drop
in her hematocrit. She was discharged on Lovenox and warfarin
and should have a 3 month warfarin course for a provoked DVT/PE.
She was started on warfarin 5mg on [**4-17**], 5mg on [**4-18**], and will
see Dr. [**Last Name (STitle) **] on [**4-20**] for repeat check. Her last INR was 1.1 on
[**4-18**].
2. Chronic blood loss anemia
- thought to be from a slow bleed internal hemorrhoids
- she was advised to take water, fiber, and stool softeners as
needed to avoid constipation. If the hemorrhoids continue to
bleed she may need referral to a surgeon for consideration of
banding or surgery.
3. Ankle fracture
- cast removed while hospitalized and placed in a walking boot.
She will follow-up with the Orthopedic Surgery Team on [**5-10**].
Contact information: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP. Phone:
[**Telephone/Fax (1) 1228**].
4. Breast lymph node
- at [**Hospital1 **] [**Location (un) 620**] she was noted to have an abnormal left breast
lymph node on her CT angiogram (description under the results
section of this discharge summary). She should have routine
mammogram with mention of the lymph node while ordering as she
may need a breast ultrasound.
TRANSITION ISSUES:
- check hematocrit and INR at 4/22 visit
- arrange for evaluation of breast lymph node at 4/22 visit
Medications on Admission:
Medications prior to admission:
- none
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO as directed.
Disp:*30 Tablet(s)* Refills:*2*
3. warfarin 1 mg Tablet Sig: Thirty (30) Tablet PO as directed.
Disp:*30 Tablet(s)* Refills:*2*
4. Lovenox 60 mg/0.6 mL Syringe Sig: Fifty (50) mg Subcutaneous
twice a day.
Disp:*10 syringes* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Multifactorial anemia, acute on chronic, GI bleeding,
hemorrhoids, gastritis
Acute pulmonary embolism
Iron deficiency
Left ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 89278**],
You were admitted with severe anemia. We think this was from a
slow bleed from your hemorrhoids. As we discussed you should
take water, fiber, and stool softeners as needed to avoid
constipation. If your hemorrhoids continue to bleed or you need
more transfusions you may need to see a surgeon for
consideration of surgery for your hemorrhoids.
While here you were also noted to have a blood clot in your
lungs. We are discharging you on warfarin (Coumadin) and
Lovenox. Please take 5mg of warfarin (Coumadin) daily and have
Dr. [**Last Name (STitle) **] adjust these medicines at your appointment on Friday.
In case you need to come off your blood thinners, you also have
an IVC filter in place to prevent further blood clots from
travelling to your lungs. You will need to have this removed in
the next few weeks. Dr. [**Last Name (STitle) **] can help you get this removed by
calling [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6745**] in the Radiology Care Unit at
[**Telephone/Fax (1) 6747**].
You will also need to use your boot while walking until seen by
the Orthopedic Surgery Team on [**5-10**] as below.
The only other change to your medications was that we started
you on vitamin D for your bone health.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Appointment: Friday [**4-20**] at 3:20PM
**Please arrive 30 minutes early to finish your registration
process**
Department: ORTHOPEDICS
When: THURSDAY [**2192-5-10**] at 8:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2192-5-10**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please call registration to update your information. Their
number is [**Telephone/Fax (1) 10676**] and they are open Monday thru Friday,
7:30AM-6:00PM.**
To have your IVC filter removed, please call Call the Radiology
Care Unit at [**Telephone/Fax (1) 6747**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6745**] can you help arrange
this.
ICD9 Codes: 2851, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2616
} | Medical Text: Admission Date: [**2185-5-30**] Discharge Date: [**2185-5-31**]
Date of Birth: [**2136-12-17**] Sex: M
Service: Trauma
HISTORY OF PRESENT ILLNESS: Patient is a 48-year-old male
with a past medical history significant for anxiety, bipolar
disorder, alcoholism, and multiple suicide attempts. He came
into the Trauma service as trauma activation on [**2186-1-29**]
with a Zone II neck injury penetrating to the platysma. This
was done after imbibing alcohol, taking a knife, and make
several attempts at slashing his throat anteriorly. He was
hemodynamically stable without hypoxia and was phonating
well, and protecting his airway, and was brought in by
ambulance.
VITALS ON PRESENTATION: Temperature 98.2 rectally, heart
rate 68 and regular, blood pressure 132/780, breathing at 18,
and saturating 100% on 2 liters nasal cannula.
PHYSICAL EXAM: In no acute distress. Obvious alcohol on his
breath. Extraocular movements are intact. Pupils were equal
and symmetric and briskly reactive. Midface is stable.
Oropharynx is normal. His neck: On the anterior neck, he
had multiple slash wounds relatively superficial laterally
over the left sternocleidomastoid contiguous into the
anterior and middle portion of his neck over the thyroid
cartilage. There is exposure of the platysma and thyroid
cartilage. There was no major vascular injury, no pulsatile
mass, and no crepitus noted. The wound extended again into
the right lateral neck, however, it became much superficial
at this point as well. His lungs were clear to auscultation
bilaterally. His sternum was otherwise unremarkable. His
abdomen was soft and nontender. His pelvis was stable. All
of his extremities were otherwise normal with a normal
vascular exam. His back was without any obvious injury.
Patient received a laboratory drawn, which showed his
admission white count 7.6, hematocrit 41.5 repeated to be
39.8 on the morning of [**2185-5-31**]. His platelet count on
admission was 227. His urinalysis was negative. His
chemistries on admission: Sodium 146, potassium 3.9,
chloride 110, bicarb 29, anion gap 11, glucose 86. Serum
LFTs were unremarkable on hospital day #2. This was the
request of the psychiatry service. His albumin was 4.1. His
lipase on admission 20. His valproic acid level was 15 and
relatively low. His serum ethanol level was 197 on
admission. Urine tox was otherwise negative.
Upright chest x-ray done on [**2185-5-30**] showed no radiographic
evidence of acute cardiopulmonary abnormality.
The patient was thereafter explored at the bedside with Dr.
[**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**] and myself, [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. It was felt
that the neck wound could be irrigated and closed. There is
no evidence of violation of the trachea. Once this was
achieved, we obtained an ORL consultation, who did [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18474**]
scope nasopharyngeal examination revealing no evidence of
injury to the airway or to trachea or vocal cords.
Under their recommendations, the patient was placed in an ICU
setting for continuous pulse oximetry monitoring and neck
evaluations. He was started on decadron 10 mg IV q.6 for 24
hours empirically to protect against any airway edema,
however, there was no edema on examination. Patient was
phonating well, protecting his airway without difficulty, and
talking well.
Patient did have an inpatient psychiatry evaluation. It was
deemed that patient would require admission to the Psychiatry
service once deemed hemodynamically stable and cleared. He
was placed on a proton-pump inhibitor prophylaxis per the ORL
consultation for some mild reflux that was seen as well.
Over the next 24 hours, the patient was in the CSRU receiving
neck and pulse checks, and continuous pulse oximetry. He
remained quite stable. There was no evidence of progression
of his wounds. The next day laboratory studies were
otherwise normal. His vital signs were stable. His
examination was otherwise unremarkable. His neck was flat
with good apposition of the soft tissues with the suture
repair. He was deemed appropriate and stable for dismissal
to the Psychiatry service for further evaluation and workup
of his mental illness with his active suicidal ideation and
suicide attempt.
DISMISSAL DIAGNOSES FROM THE TRAUMA SERVICE:
1. Status post self-inflicted knife wounds to anterior neck
to zones I and II with violation of the platysma and exposure
of the thyroid cartilage. No evidence of airway compromise.
No evidence of major vascular or neurological injury. The
patient had no evidence of esophageal injury by clinical
examination.
2. Selective non-operative management for Zone II penetrating
trauma neck trauma was opted for.
3. Status post suicide attempt with active suicidal ideation.
SECONDARY DIAGNOSES:
1. Major depression.
2. Anxiety.
3. Dipolar disorder.
4. Psychosis, not otherwise specified.
5. Possible ethanol intoxication on a CIWA protocol.
MAJOR INVASIVE PROCEDURES: Bedside nasopharyngeal [**Last Name (un) 18474**]
scope evaluation by the ORL service to evaluate his airway
and larynx, which was otherwise unremarkable.
DISCHARGE MEDICATIONS TO THE PSYCHIATRY SERVICE:
1. Protonix 40 mg p.o. q.d.
2. Percocet 5/325 1-2 tabs p.o. q.4-6h. prn.
3. Colace 100 mg p.o. b.i.d.
He does not require continuous pulse oximetry. He may have a
diet as tolerated. His activity is as tolerated. He should
have suture removal in seven days in the Trauma Clinic. Call
[**Telephone/Fax (1) 274**] for further followup. Otherwise, bacitracin
should be applied to the wound as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2185-5-31**] 12:24
T: [**2185-5-31**] 12:34
JOB#: [**Job Number 55691**]
ICD9 Codes: 311, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2617
} | Medical Text: Admission Date: [**2113-4-26**] Discharge Date: [**2113-5-10**]
Date of Birth: [**2039-11-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
Central venous line placement
(Attempted EGD, patient unable to tolerate w/ low oxygenation)
History of Present Illness:
73 year old male with history of renal transplant, CAD, PVD, DM
presenting with marked fatigue, poor appetite, nonproductive
cough and generalized weakness/failure to thrive. He was
admitted to the MICU on [**2113-4-26**], see H/P from that date for
details. He was found to have profound anemia with HCT of 18.7
(baseline high 20s-30s), acute renal failure with creatinine of
5.5 (baseline [**1-29**]), new cerebellar lesion on CT head, and RLL
pneumonia. While in the ICU, he was treated with cefepime,
vancomycin and azithromycin for pneumonia in an immunosuppressed
patient. He developed acute shortness of breath after admission
and evaluation revealed pulmonary edema (though imaging
suggestive of noncardiogenic etiology), and was diuresed. LOS
fluid balance at transfer was approximately negative 800 cc. He
was transfused 3 units of blood, had negative stool guaiacs,
iron studies consistent with anemia of chronic disease and iron
deficiency, and had negative hemolysis labs (haptglobin 677). He
was started on IV iron supplementation for plan of 8 doses.
Hematocrit at transfer 24.5, and CT torso did not reveal
intra-abdominal source of blood loss. Renal transplant service
followed the patient and his acute renal failure was thought to
be due to dehydration/pre-renal azotemia with ATN. His
creatinine mildly improved after the blood transfusions and some
diuresis to 4.5 at transfer. His rapamycin level was elevated
and his doses were held with plan to restart once <8. Troponin
was elevated at 0.16-0.18, thought to be due to renal failure
and anemia. Lastly, neurology/stroke was consulted regarding the
cerebellar lesion seen on CT scan and his falls at home. His
neuro exam was nonfocal and the lesion was thought to be a
chronic infarct vs. metastases as opposed to an acute lesion.
.
Currently, the patient continues to complain of weakness/fatigue
and generalized feeling "unwell." He feels his breathing is
better, but not baseline. He complains of back pain, leg pain,
neck pain and a headache--all are chronic per him. He is
concerned about having to be transferred in the bed as opposed
to the chair because he cannot lay down comfortably.
Past Medical History:
1. DM
2. HTN
3. hypercholesterolemia
4. CAD s/p MI ([**2104**])
5. severe osteoarthritis of the hips/shoulders/knees
6. spinal stenosis
7. ESRD s/p LRRT ([**9-/2105**])
8. PVD s/p R SFA-tib/peroneal trunk NRSVG (99), jump graft from
R tib/peroneal trunk to distal R PT NR cephalic VG ([**4-/2105**]), PTA
of R SFA-PT bypass ([**10-2**]), angioplasty L CIA ([**11/2104**]), L CFA-PT
[**Name (NI) **] with in-situ SVG ([**1-29**]), b/l TMA, b/l sesamoidectomies
9. lung adenoca s/p VATS/wedge resection of nodule
10. BPH
11. diastolic heart dysfunction
12. Klebsiella bacteremia/urosepsis ([**2-2**])
Social History:
Smoked cigarettes until [**2083**]. No ETOH. He lives at home.
Retired, but was previously a truck driver.
Family History:
Significant for lung cancer in the patient's father who
developed this at age 75, but subsequently died of a stroke.
Physical Exam:
gen-sitting up in chair, uncomfortable/fatigued
HEENT-EOMI, MM dry, R IJ in place-c/d/i, JVP could not be
assessed, neck thick
chest-[**Month (only) **] BS at bases, R>L, RLL crackles, otherwise clear.
heart-RRR, no M/R/G, nl S1 S2
abd-obese, soft, nontender over graft, + BS
ext-marked LE edema of both legs--4+ pitting to knees, L>R. Legs
wrapped in kerlex bilaterally. right LE with necrotic ulcer,
5-6 cm diameter on dorsal foot.
.
Pertinent Results:
admission labs:
8.9>----<381
18.7
.
mcv 69
.
139 99 97
-------------< 147
3.9 21 5.5
.
other important labs
.
PTH [**4-30**]: 226
.
aldolase - [**4-29**]: 3.9
PARVOVIRUS B19 ANTIBODIES (IGG & IGM): [**4-27**]: negative
.
esr [**4-30**]: 60
.
MICRO
urine culture [**4-26**] no growth
blood culture [**4-26**] no growth
legionella ab negative [**4-27**]
sputum culture: [**4-30**]: contaminated
.
imaging.
.
venous ultrasound [**5-2**]: IMPRESSION: No DVT in the left leg.
.
TTE [**4-27**]
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Diastolic
function could not be assessed because of significan mitral
valve disease. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. There
are three moderately-thickened aortic valve leaflets. There is
mild aortic valve stenosis (area 1.2-1.9cm2). The mitral valve
leaflets are moderately thickened. There is severe mitral
annular calcification. There is mild functional mitral stenosis
(mean gradient 8 mmHg) due to mitral annular calcification. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Symmetric LVH with preserved global biventricular
systolic function. Mild aortic stenosis. Mild non-rheumatic
mitral stenosis.
.
CT abdomen / chest / pelvis
1. Lungs show interlobular septal thickening and bilateral
perihilar alveolar
opacities, which given lack of interstitial abnormality on CT
from [**2113-2-27**], is most suggestive of non cardiogenic pulmonary edema
given normal heart
size and lack of pleural effusion.
2. Cholelithiasis without evidence of cholecystitis.
3. Sigmoid diverticulosis, without evidence of diverticulitis.
4. Stable appearance of transplanted kidney within the left
lower quadrant.
No stone, hydronephrosis, or perinephric fluid collection.
5. Bladder wall thickening, which may be secondary to
under-distension;
however, recommend correlation with UA to exclude cystitis.
6. Generalized atrophy of the muscles, especially involving
bilateral
iliopsoas, which may account for patient's lower extremity
weakness.
7. Diffuse atherosclerotic disease involving the aorta and
branch vessels.
Brief Hospital Course:
73 y.o male with h.o renal transplant in [**2104**], CAD, diastolic
dysfunction, PVD, DM, HTN, severe OA presented to the ED from
home with six weeks of productive cough, nausea, decreased po
intake, generalized weakness.
.
# Failure to thrive / poor PO intake
Poor PO intake / nausea / vomiting initially had a very long
differential, including med toxicity (sirolimus), uremia,
depression, diabetic gastroparesis, peptic ulcer disease,
colonic mass, obstruction, and chronic mesenteric ischemia.
EGD, small bowel follow through, and gastric empyting study were
all attempted, but could not be performed given poor room air
saturation (for EGD) and back pain / not tolerating procedure
(when laying flat for SBFT and GE study). Reglan 5 mg QID was
started emperically; after 3 days his diet improved, and all
nausea / vomiting ceased spontaenously. Regarding depression,
patient was also started on citalopram and mirtazipine, which he
tolerated well. The patient did report being sad after learning
about his future right AKA.
.
# Anemia secondary to chronic renal disease
Admission hct was 18.7. This was considered [**1-28**] to renal
failure. He was transfused 3 units PRBCs in the MICU. Stools
were guaiac negative. On the medical floor his HCT remained
stable, however he was transfused another unit of PRBCs to help
with his generalized weakness. He received 8 days of IV iron
repletion as well, and was continued on PO iron repletion
thereafter.
.
# Acute on chronic diastolic heart failure/bacterial pnemonia
He was admitted with respiratory distress, secondary to acute on
chronic diastolic CHF. He was diuresed with IV lasix and
received vancomycin/cefepime / flagyl initially and then
levofloxacin for his RLL infiltrate on CXR. He diuresed well
and no longer required oxygen supplementation. He completed a 7
day course of antibiotics for the pneumonia. He was diuresed
aggressively with 120 mg IV daily lasix, and then was backed
down after re-initiation of renal failure.
.
# Acute on Chronic Renal failure, autolgous renal transplant
Renal transplant was consulted. He was thought to have ATN [**1-28**]
to anemia and hypotension. His rapamycin level was also found
to be elevated, secondary to med toxicity with azithromycin.
His rapamycin was held until the level was < 8. His renal
function improved daily. His other immunosuppressants,
including prednisone and mycophenolate mofetil were continued.
When the rapamycin / sirolimus level was < 8, he was restarted
at his home dose, 3mg / day. Bactrim prophylaxis was changed to
single strength daily.
.
After diuresis and a low creatinine of 2.8, his creatinine
trended up again to 4.0. His FeUrea at the time was low, and
lasix was held. He was instructed to hold his lasix for 2 days
post discharge and then restart at the initial home dose, 40 mg
[**Hospital1 **] PO.
.
His PTH was checked. Renal adjusted his calcitriol dose.
.
# Weakness / Muscle Aches
The differential for his weakness was quite extensive: anemia,
depression, renal failure, polymyalgia rheumatica, motor nerve
dysfunction.
.
On arrival, head CT showed a cerebellar hypodensity. Neurology
was consulted, who thought this was consistent with prior
chronic CVA changes and did not represent an acute CVA. Given
his gait difficulty and muscle atrophy on CT, spinal cord
impingement was considered. Head MRI with gadolinium was
recommended non acutely to better evaluate this and rule out the
unlikely possibility of a primary lung metastasis; the MRI was
witheld due to ARF, decreased GFR, and as mentioned above, the
patient's inability to tolerate MRIs. This can be performed as
an outpatient or a PET scan can be done to rule out metastasis.
.
Because of weakness, muscle atrophy, diffuse aches, and
moderately elevated CK, his home statin was stopped.
.
Given shoulder aches and weakness, ESR ~ 60, patient was thought
to potentially have PMR. His prednisne dose was increased to 10
mg / day. After no response after 2 days of treatment, the
prednisone was dropped back to 3 mg / day.
.
His weakness improved as his diet and mood improved. The statin
can probably be restarted as an outpatient, given his severe PAD
and presumed CAD.
.
His neurontin was stopped initially in the MICU. Given lack of
symptomatic changes with respect to peripheral neuropathy, we
kept holding off on this medication.
.
# PAD
Vascular surgery determined right AKA the best management
option. The team's preference was to rehab the patient before
surgery with diet. He will revisit w/ Dr. [**Last Name (STitle) 21080**] in [**1-29**]
weeks.
.
# Wound care
The wound care team was consulted, and left recommendations
regarding the ulcers on his feet/legs as well as sacrum.
Dressings were changed and decompression of the sacral wounds
was utilized.
.
# DM type 2 uncontrolled with complications
Transitioned to lantus and blood sugars ranged 100-200. The
wife and patient were agreable to humalog prandial dosing as
well with sliding scale. This change was made when the patient
was not taking POs well, such that long acting lantus could be
dosed unchanged and humalog used for mealtime BS control.
Medications on Admission:
amlodipine 10mg daily
asa 81mg daily
doxazosin 4mg [**Hospital1 **]
lasix 40mg [**Hospital1 **]
Isosorbide dinitrate 30mg daily
lipitor 60mg daily
metoprolol 75mg [**Hospital1 **]
niaspan SR 500mg qhs
humalog SS
NPH 38units Qam, 36units Qpm
iron
calcitriol 0.25mg daily
cellcept 1000mg TID
prednisone 3mg daily
rapamnue 3mg qhs
bactrim 800/160mg daily
zaroxolyn 2.5mg every third day
epo 4,000 units/wkly
neurontin 100mg [**Hospital1 **]
percocet 5/325 1-2 tabs q6h prn
protonix 40mg daily
colace
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Doxazosin 1 mg Tablet Sig: Four (4) Tablet PO every twelve
(12) hours.
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: START
taking this medication on [**5-12**].
Disp:*60 Tablet(s)* Refills:*2*
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QHS (once a day (at bedtime)).
8. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty (60) units
Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
9. Insulin Lispro 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous three times a day: please take 10 units with each
meal; also follow sliding scale.
Disp:*qs * Refills:*2*
10. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO Q
TU/TH/SA/[**Doctor First Name **] ().
Disp:*16 Capsule(s)* Refills:*2*
12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF
(Monday-Wednesday-Friday).
Disp:*12 Capsule(s)* Refills:*2*
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection
once a week.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
18. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*112 Tablet(s)* Refills:*2*
19. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
20. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
21. Outpatient Lab Work
Full Chemistry panel, Na, K, Cl, HCO3, BUN, CREAT, Calc, mag,
phos
22. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
23. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
24. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1) Congestive heart failure, acute on chronic diastolic
2) Acute on chronic renal failure
3) Anemia, transfusion dependent
4) Failure to thrive
5) Diabetes Mellitus
6) Spinal Stenosis
.
Secondary
1) Esophagitis
2) Remote hx of lung cancer
Discharge Condition:
Stable. Chronically ill. Tolerating POs well.
Discharge Instructions:
You were admitted to the hospital with poor eating and
generalized lethargy. You were found to have severe anemia and
renal failure and congestive heart failure. You were treated
with blood transfusions and adjustment of your medications.
.
We attempted to study why you are not able to reliably eat, but
you were not able to tolerate the different studies required to
do so. We started you on a new medication called reglan, and
you began to tolerate foods better. You should continue to take
this medication 30 minutes before each meal and at bedtime.
.
If you experience the following please return for evaluation or
call your primary care doctor: fevers, chills, pain with
urination, lightheadedness, nausea, vomiting, diarrhea,
shortness of breath.
.
PLEASE have your labs checked in 1 week, fax to Dr. [**First Name (STitle) 805**] at
the [**Hospital **] Clinic [**Telephone/Fax (1) 12142**].
.
MEDICATION CHANGES
1) Lantus + humalog insulin
Your insulin has been changed.
Take 60 units of lantus at night. If you are not eating, please
take only 30 units of lantus. Check your blood sugar with each
meal and bedtime. Take 10 units of humalog insulin with each
meal. Take an additional amount of humalog per the sliding
scale you are being provided.
2) START Reglan 5 mg, 30 minutes before each meal and at bedtime
3) START citalopram 10 mg daily
4) START mirtazipine 15 mg at night
5) STOP LIPITOR
6) CHANGE CALCITRIOL -
0.5 mcg on MON / WED / FRI
0.25 mcg on TUE / THURS / SAT / SUN
7) STOP zaroxolyn
8) LASIX - continue with your regular dose 40 mg [**Hospital1 **], BUT WAIT
TO START UNTIL [**2113-5-12**]
9) STOP neurontin
10) START bactrim single strength every day for prophylaxis
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500mL / day
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27555**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2113-5-18**]
2:00
.
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2113-6-1**] 11:20
.
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2113-6-5**] 3:30
.
Dr. [**First Name (STitle) **]: [**6-23**] @ 10:30am, [**Hospital **] Clinic
ICD9 Codes: 486, 5849, 5859, 4280, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2618
} | Medical Text: Admission Date: [**2137-5-27**] Discharge Date: [**2137-6-6**]
Date of Birth: [**2095-5-8**] Sex: M
Service: UROLOGY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26022**] is a 42 year old
white male with a history of metastatic testicular carcinoma
diagnosed in [**2125**] status post left
radical orchiectomy followed by four cycles of Bleomycin,
Etoposide, and Cisplatin. Mr. [**Known lastname 26022**] was also diagnosed
with HIV in [**2123**] and has been on long standing
anti-retroviral therapy since that time. His recent CD4
count was 702 and his viral load was 1060. The patient had
been free from recurrence of his testicular cancer until
approximately six months ago when he presented with low back
pain after going on an HIV "drug holiday".
At the time of his presenting low back pain, the patient also
had symptoms of malaise and a low grade fever. His work-up
at the time was notable for significant retroperitoneal
lymphadenopathy by CT scan. Multiple CT guided percutaneous
biopsies were performed and these were not diagnostic
revealing follicular hyperplasia.
With a continuously rising alpha fetoprotein level, last
measured at 214, open surgery was recommended.
PAST MEDICAL HISTORY:
1. Metastatic non-seminoma testicular carcinoma.
2. Human Immunodeficiency Virus.
3. Noninsulin dependent diabetes mellitus.
4. Depression.
PAST SURGICAL HISTORY:
1. Left radical orchiectomy in [**2125**].
2. Status post lipectomy.
3. Status post atypical nevus excision.
MEDICATIONS ON ADMISSION:
1. Flonase.
2. Zantac.
3. Acyclovir.
4. Kaletra.
5. Epivir.
6. Effexor.
7. AndroGel
8. Chloral hydrate.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Temperature 95.9 F.; blood pressure
126/68; pulse 72; respiratory rate 16; oxygen saturation 98%
on room air. In general, the patient is a pleasant,
moderately obese white male in no apparent distress. HEENT:
Clear oropharynx, moist mucous membranes. Anicteric sclerae.
Neck: Soft, no masses, no lymphadenopathy, no bruits. Lungs
are clear to auscultation and percussion bilaterally. Heart
is regular rate and rhythm, normal S1, S2, no murmurs.
Abdomen soft, obese, nontender. Left abdominal scar, well
healed. No hepatosplenomegaly. Normoactive bowel sounds.
No cyanosis, clubbing or edema. Two plus dorsalis pedis
pulses bilaterally.
LABORATORY: The white blood cell count was 9.6, hematocrit
40.2, platelet count 325, INR 1.0. CD4 count 702. Glucose
93. BUN 18, creatinine 0.6. AST 14, ALT 18; alkaline
phosphatase 89, amylase 55. Total bilirubin 0.4, direct
bilirubin 0.1, indirect bilirubin 0.3.
His AFP was 214.3, which was up from 199.7 in [**2137-2-9**],
and 110.7 in [**2137-1-12**].
The HIV viral load was 1,060.
IMAGING: CT scan study obtained in [**2137-3-12**], revealed
significant retroperitoneal, inguinal and pelvic
lymphadenopathy. The lymphadenopathy has been overall
stable, although there has been one para-aortic lymph node
which increased in size from 2.6 by 2.1 centimeters to 3.4 by
3.2 centimeters.
The preoperative chest x-ray was within normal limits.
The preoperative EKG demonstrated normal sinus rhythm at a
rate of 78 beats per minute.
HOSPITAL COURSE: On the date of admission, the patient was
taken to the Operating Room where he underwent a bilateral
retroperitoneal pelvic lymph node dissection. The estimated
blood loss from the procedure was 1500 cc. The specimens
sent included the lymph nodes as well as the left gonadal
vein.
Intraoperatively, a Foley catheter was placed along with an
nasogastric tube.
Postoperatively, the patient was admitted to the surgical
Intensive Care Unit intubated and sedated. His postoperative
creatinine was 0.8; his postoperative hematocrit was 37.7.
The following morning, postoperative day one, the patient was
extubated and subsequently transferred to a regular hospital
floor the following afternoon. The patient had adequate
urine output, but did have significant pain issues
necessitating a pain service consultation to manage this.
Thereafter, the patient's pain was tolerable. The
nasogastric tube was removed on postoperative day five, along
with the Foley catheter. The patient began eating at that
time and Physical Therapy and Occupational Therapy were
consulted to [**Year (4 digits) **] with transferring and personal care
needs.
The patient was becoming increasingly depressed at this time,
concerned that he was not able to care for himself, and
mobilize as easily as he had been prior to his surgery.
On postoperative day seven, the patient was ready to be
discharged when a large amount of serous fluid began draining
from his inferior abdominal incision. Approximately 700 cc
of serous fluid were expressed and the patient was sent for a
CT scan to evaluate fascial dehiscence. Abdominal
examination at this time revealed that the staples were
intact, that the abdomen was soft, and that there was no
erythema nor palpable masses at the incision site.
The CT scan did not suggest evidence of fascial dehiscence,
although it did indicate that there were was a moderate
amount of intra-abdominal ascites present. The serous fluid
was sent for evaluation, revealing a creatinine level of 1.0
and amylase level of 35 and a triglyceride level of 23.
The patient was diuresed with Lasix as needed and a rectal
bag was secured over the abdominal incision to collect the
drainage. The abdominal drainage persisted throughout
postoperative day eight and postoperative day nine, although
it diminished significantly on postoperative day ten.
At this time, it was felt that a repeat CT scan was not
necessary and the patient was sent home on postoperative day
ten with the visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with wound care and
care of the abdominal drain and collection of the abdominal
drain contents.
DISCHARGE DIAGNOSES:
1. Recurrent metastatic left testicular carcinoma.
2. Postoperative ascites and incisional drainage
3. Postoperative ileus
4. Human Immunodeficiency Virus.
5. Depression.
6. Obstructive sleep apnea.
7. Gastroesophageal reflux disease.
DISCHARGE MEDICATIONS:
1. Furosemide 40 mg p.o. q. day times seven days.
2. Potassium chloride 40 mEq p.o. q. day times seven days.
3. Ibuprofen 400 mg p.o. q. eight hours p.r.n. pain.
4. Kaletra as directed.
5. Epivir as directed.
6. Acyclovir as directed.
7. Ranitidine as directed.
8. Effexor as directed.
9. Chloral hydrate as directed.
10. AndroGel as directed.
11. Flonase as directed.
DISCHARGE INSTRUCTIONS:
1. The patient was told to follow-up with Dr. [**Last Name (STitle) 9125**] in one
to two weeks for staple removal.
2. He was told to see Dr. [**Last Name (STitle) 9125**] earlier if there was
significant output from the abdominal drainage bag.
3. The patient was also told to follow-up with his primary
care physician regarding his HIV issues as needed.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Home with services.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**]
Dictated By:[**Last Name (NamePattern1) 26023**]
MEDQUIST36
D: [**2137-6-27**] 11:18
T: [**2137-7-4**] 23:12
JOB#: [**Job Number 26024**]
ICD9 Codes: 2851, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2619
} | Medical Text: Admission Date: [**2122-1-29**] Discharge Date: [**2122-1-30**]
Date of Birth: [**2040-1-4**] Sex: F
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy [**2122-1-29**]
History of Present Illness:
82 yo female with multiple medical comorbidities now presenting
to the emergency room with abdominal pain. Began to have
diarrhea, nausea, and vomiting one week prior to admission.
Daughter gave her Imodium on Monday ( 3 days prior to admission)
to stop the diarrhea. Since 2 days ago not able to have bowel
movements or flatus. Developed abdominal pain 48 hours prior to
admission, colicky in nature in the mid epigastric region, rated
[**2-24**] in severity. No fevers or chills. No dysuria, no chest
pain, no shortness of breath. WBC 3 days prior to admission at
OSH where she presented to the ED was 15.3. CT scan at OSH
showed distended small bowel, no fluid or bowel wall thickening.
Past Medical History:
1. s/p left index finger PIP Jt avulsion with
developing boutanier deformity s/p short arm cast placement
[**2119-12-11**]
2. Diabetes Mellitus type 2
3. CAD s/p CABG X4 vessels, s/p NSTEMI in [**2-/2120**] with DES to
OM2. Post cath course c/b bleeding.
4. A.fib, currently in NSR
5. CHF EF 40-50% in [**2116**]
6. COPD
7. s/p Bilateral BKA (R was 16 yrs ago, L was 6 yrs ago)
8. hypercholesterolemia, obesity
9. CRI (baseline was 1.1, in [**11-21**] ranged 1.1-1.7)
Social History:
Patient is a widower but lives with her daughter. widowed last
year. Her son is also involved in care.
Former tobacco user, has not used tobacco in many years.
No alcohol or illicit drug use.
Wheelchair and bedbound at baseline; however, able to perform
simple ADLs (cooking, bathroom, dressing, hygiene)
Family History:
Mother, 2 sisters, and 1 brother with diabetes
Father died of CAD at age 64
Physical Exam:
98.6 88 151/46 18 95% RA
Lungs Clear bilaterally
Heart RRR
ABD soft 2 midline scars no rebound tenderness, mo tenderness at
palpation
Rectal no blood brown guaiac neg stool
Ext BKA R side AKA left side
Pertinent Results:
[**2122-1-29**] 05:43AM BLOOD WBC-16.2* RBC-4.15* Hgb-12.0 Hct-37.0
MCV-89 MCH-28.9 MCHC-32.4 RDW-15.0 Plt Ct-342
[**2122-1-28**] 11:24PM BLOOD Glucose-95 UreaN-24* Creat-1.0 Na-140
K-3.6 Cl-99 HCO3-26 AnGap-19
[**2122-1-28**] 11:24PM BLOOD PT-12.2 PTT-24.7 INR(PT)-1.0
[**2122-1-29**] 05:43AM BLOOD ALT-18 AST-20 LD(LDH)-201 CK(CPK)-43
AlkPhos-76 Amylase-15 TotBili-0.6
[**2122-1-29**] 06:02PM BLOOD Glucose-140* Lactate-1.7 Na-134* K-3.7
Cl-110
Last Colonoscopy [**2114**]
Findings:
Protruding Lesions Non-bleeding internal hemorrhoids were noted
Excavated Lesions Multiple diverticula were seen in the sigmoid
colon. The colonoscopic examination was otherwise normal to the
cecum.The terminal ileum appeared normal.
Last Echo [**2118**]
Conclusions:
Views were extremely limited. The left atrium is moderately
dilated. The right atrium is moderately dilated. Overall left
ventricular systolic function cannot be reliably assessed. No
aortic regurgitation is seen.
Mild to moderate ([**11-18**]+) mitral regurgitation is seen. There is
borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion
RADIOLOGY ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
CT ABDOMEN W/O CONTRAST [**2122-1-29**] 2:23 AM
IMPRESSION:
1. Marked diffuse small-bowel dilatation with extensive
pneumatosis, air in mesenteric vessels, and portal venous air
consistent with ischemic bowel and concerning for bowel
infarction. Note: study is limited by lack of IV contrast, and
therefore an embolic or thrombotic event to a mesenteric vessel
cannot be excluded, particularly given evidence of extensive
background vascular disease.
2. At least two sub 5 mm pulmonary nodules seen in the right
lower lobe. In the absence of malignancy, one-year follow up
would be recommended to document stability.
Brief Hospital Course:
The patient was admitted to the surgical intensive care unit
under the care of Dr. [**Last Name (STitle) **]. Resuscitation was initiated and
a central line placed. The CT findings concerning for ischemic
bowel were discussed with the patient and her family and
non-operative intervention was decided upon despite a discussion
of the likely mortality of her condition. She remained with
supportive treatment overnight with IV antibiotics, IV
hydration, and NGT decompression. Discussions regarding her
condition and prognosis were again held with the patient and her
family and at this point operative intervention was agreed upon.
The patient was taken to the operating room and an exploratory
laparotomy perfomed. Please see operative dictation for
details. She was found to have a necrotic, non-viable small
bowel too extensive for resection. She was taken back to the
surgical ICU and discussions were held with the patient and her
family. A comfort-only course was then persued and the patient
expired later that day.
Medications on Admission:
Amiodarone 200'
Cozaar 50 '
Imdur 60'
Plavix 75'
Lipitor 20'
Neurontin 1200'
Toprol 25'
Protonix 40'
Lasix 60'
Covient ih
Insulin 34 am
16 pm
ASA 81'
MVI
Discharge Disposition:
Expired
Discharge Diagnosis:
Ischemic bowel
Discharge Condition:
Expired
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
ICD9 Codes: 4280, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2620
} | Medical Text: Admission Date: [**2149-10-23**] Discharge Date: [**2149-11-7**]
Date of Birth: [**2084-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal Ca
Major Surgical or Invasive Procedure:
1. Bronchoscopy.
2. Left thoracoscopy with pleural drainage and talc
poudrage
3. Flexible bronchoscopy ([**10-29**])
History of Present Illness:
66-year-old gentleman with
metastatic esophageal cancer who recently returned to the
hospital with shortness of breath and was found to have a
left pleural effusion. This was tapped and unfortunately
found to be cytologically malignant. He was seen yesterday in
the outpatient department with worsening dyspnea and an x-ray
showed reaccumulation of the fluid.
Past Medical History:
Esophageal Ca s/p bronchoscopy, right exploratory thoracotomy
and mediastinal LN sampling on [**2149-10-1**]
HTN
DM II
GERD
Crohn's colitis
Dysphagia
Social History:
The patient did not smoke cigarettes, however, he did smoke
pipes since age 18 but he has not smoked pipes lately. He drinks
wine occasionally. He is self employed and runs his own
business. He has not had any toxic chemical exposures.
Family History:
Mother had breast cancer at age 65, father with multiple
myeloma, sister also had breast cancer at age 58, brother with
acid reflux who receives yearly EGD but has had no evidence of
cancer. No other cancers in the family. The patient
is here at his appointment with his wife and two children, a son
and a daughter. His daughter lives nearby. His son lives in
[**State 2748**]. The patient lives in [**Hospital1 1474**] with his wife.
Pertinent Results:
.
PATH:
[**2149-10-27**] [**-5/4334**] PLEURAL FLUID
SUSPICIOUS.
Scattered highly epitheloid cells, present singly and in
small groups, suspicious for adenocarcinoma, in a background
of blood and mesothelial cells.
CXR [**2149-11-5**]: IMPRESSION: Mild improvement in the previously
identified pulmonary vascular redistribution. Focal hazy
opacities at the lung bases appear stable with improvement in
the left perihilar opacity. Pleural thickening versus loculated
effusion again noted on the right.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2149-11-6**] 06:15AM 50* 33* 1.2 140 4.3 100 35* 9
CHEMISTRY TotProt Albumin 3.0*
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2149-11-6**] 06:15AM 8.1 3.00* 9.6* 29.1* 97 32.0 33.0 15.0
392
Brief Hospital Course:
pt was admitted for increased dyspnea at home and was taken to
the OR for Bronchoscopy, Left thoracoscopy with pleural drainage
and talc poudrage. [**Doctor Last Name 406**] and chest tube to sxn.
On the post op noc pt developed increased shortness of breath
and desaturation to 75% w/increased oxygen requirement. Pt was
emergently transferred to the CRSU for acute pulmonary
managemnt. CXR showed left lung collapse. Pt was bronched for
copious purulent secretions. Post bronch sats improved but still
w/ high O2 requirement. Started on emperic zosyn, vanco. Pt w/
resp decompensation on NIV. Pt w/ oliguria on IV levo w/ map
~mid 60's w/ worsening resp acidosis requiring intubation.
Pt underwent serial bronchoscopies and aggressive diuresis once
his hemodynamics stabilized. Intermittant rapid afib requiring
iv amiodarone w/re-bolus in addition to IV lopressor and
diltiazem drip after cardiology consult.
[**Doctor Last Name 406**] and chest tube remained to sxn w/ minimal drainage and CT
was d/c'd on POD# 5. [**Doctor Last Name 406**] was d/c'd on POD#10.
Multiple family discussions were had w/ family and decision
regarding code status made -DNR.
Once cardiolpulmonary status was optimized, pt was extubated on
POD#7 and remained in the ICU for continued pul tiolet.
Pt transferred out of ICU on POD#10.
Pt noted to be in an asyptomatic brady escape rhythm w/ rate in
the 30's on amiodarone, lopressor and dilt po. Cardiology was
reconsulted and dilt was d/c'd and amiodarone and lopressor were
decreased w/ approp increased rate response. PT was maintained
on supplemental tube feed via j-tube and po's as tolerated. able
to ambulate w/ walker, supervision and supplemental oxygen.
Pt's oral hypoglycemic agents were resumed but pt was
consistently hypoglycemic therefore his metformin was d/c'd and
his glyburide dose was cut in [**12-23**] and avandia was unchanged.
Pt was d/c'd to home w/ [**Month/Day (2) 269**], home PT, O2. He will follow up with
his PCP [**Last Name (NamePattern4) **]: glucose control.
Medications on Admission:
ASA 81 Qday
Zyban 150 [**Hospital1 **]
Amlodipine 5 Qday
Asacol 400 TID
HCTZ 25 Qday
Metformin 850 [**Hospital1 **]
Celebrex 100 Qday
Metoprolol 50 [**Hospital1 **]
Avandia 8 Qday
Glyburide 10 [**Hospital1 **]
Lipitor 80 Qday
Senna
Ativan
Pantopraozole 40', Amiodarone 200'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
8. fingersticks
check finger sticks before meals and at bedtime.
9. tube feeds
nutren 1.5 w/ fiber
6 cans per day via pump
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*300 ML(s)* Refills:*0*
11. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**First Name9 (NamePattern2) 269**] [**Hospital1 1474**]
Discharge Diagnosis:
Recurrent malignant left pleural effusion
Esophageal Ca
HTN
DM 2
GERD
Crohns
Discharge Condition:
deconditioned. requires [**Name (NI) 269**], PT, home oxygen and supplemental
tube feeding.
Discharge Instructions:
Call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 170**] if you have any chest
pain, shortness of breath, fever, chills, nausea, vomiting,
inability to take food or tolerate tube feed.
check you finger sticks before meals and at bedtime and call
your PCP if they are >200- your blood sugar was too low to
restart your metformin in the hospital.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] and Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2150-1-28**]
11:00
Please follow up with Dr. [**Last Name (STitle) 696**] in one month. Call his
office, ([**Telephone/Fax (1) 32070**], to arrange an appointment.
Completed by:[**2149-11-10**]
ICD9 Codes: 486, 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2621
} | Medical Text: Admission Date: [**2161-4-1**] Discharge Date: [**2161-4-6**]
Date of Birth: [**2091-5-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
PICC placement for TPN
History of Present Illness:
69 year-old woman with a history of CAD, CHF, AVM, achalasia
anemia, new large brain mass affecting sella turcica and
impinging on optic chiasm who presents with melena. Patient was
seen at [**Company 191**] today from rehab. Patient had been constipated for 5
days without BM, then last night was given 4 enemas and is now
incontinent of stool, diarrhea. At [**Company 191**] she was noted to have
guaiac positive melanotic stools. She was therefore sent to ED.
Here only complaint at this time is generalized fatigue. She
denied any LH, dizziness, syncope. No CP, SOB, abd pain. States
that she has had some recent nausea, but no vomiting.
.
Recently admitted for work-up or large brain mass which was
found to be pituitary adenoma on biopsy. To be seen by Dr. [**Last Name (STitle) 724**]
next week.
.
In the ED she was NG lavage and was positive for bright red
blood clots and coffee grounds. ECG showed questionable ST
elevations in V1-2 unchanged. 2 large bore IV's were placed. IV
PPI was given. Also given levoquin given WBC of 16.6.
.
In the MICU the patient's hct was monitored and remained stable.
She was continued on IV PPI and underwent EGD that showed Grade
4 esophagitis with contact bleeding in the lower third of the
esophagus. She was kept NPO.
Past Medical History:
1. Coronary artery disease with history of V. fib arrest, S/P
LAD stent and repeat cath in [**10/2159**]
2. CHF - EF 30-35% in [**2159**].
3. Osteoporosis - early menopause, no history of hip fractures
but verterbral compression fractures noted earlier this month.
4. Depression
5. History of colonic AVM and anemia of chronic blood loss
6. S/P Appendectomy
7. Hypertension
8. H/o achalasia, peptic stricture at EG junction
9. h/o TAH and bilateral oopherectomy in her 30s
Social History:
Soc: Patient lives with her brother and sister-in-law. She has
60 pack-year tobacco history but quit 20 yrs ago; denies EtoH
and drug use
Family History:
FHx - multiple members in the family with who has had early TAH
and bilateral oopherectomy
Physical Exam:
T 97.5 BP 116/59 HR 98 RR 16 O2sats 100% RA
Gen: Chronically ill appearing, cachectic, NAD
HEENT: NG tube in place, dry mm, PERRL, EOMI
Lungs: CTAB
Heart: Tachy no m/r/g
Abd: Soft, NT, ND + BS, no HSM
Ext: No edema, normal peripheral pulses
Neuro: A&O times 3, sensation intact, strength normal, moving
all 4 extremeties
Pertinent Results:
NG lavage in ED- 300cc with small amount of coffee grounds.
After CXR revealed NG tube in esophagus this was removed.
.
ECG: Sinus tachy at 107nl axis, nl intervals, LVH, Twave
inversion in lateral leads old.
.
CXR- NG tube is curled in the esophogus
.
EGD [**4-2**]:
Dilation at the lower third of the esophagus
Grade 4 esophagitis in the lower third of the esophagus
Erythema in the stomach body compatible with NG trauma
Food in the antrum
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
A/P 69 year-old woman with a history of CAD, CHF, AVM, achalasia
anemia, new large brain mass affecting sella turcica and
impinging on optic chiasm who presents with melena.
.
# [**Name (NI) 4056**] Pt has a long history of GIBs from AVM's. Also history of
achalasia and peptic stricture, which caused NGT to become
curled in esophagus and had to subsequently be removed. Pt
admitted with guaiac positive stool and positive NG lavage. She
was admitted to the MICU for close monitoring of her hct and
vital signs. She was given 2 large bore IVs. Her hct was
monitored q 4hr and remained stable. She was kept NPO and given
IV PPI [**Hospital1 **] per GI. She underwent EGD that showed grade 4
esophagitis. GI recommended QID sucralfate and [**Hospital1 **] PPI. Given
her achalasia and poor PO intake they recommended that the
patient receive TPN for nutritional repletion given low albumin.
Once nutritionally replete may need G-tube in medium term. She
was advanced to a regular diet and started on TPN following PICC
placement. She was transferred to a regular medicine floor.
Her hct trended down to 24.9 and given her cardiac history she
was transfused one unit of packed RBCs. She had an appropriate
bump in her hct to 29.8 and this remained stable >30 since.
.
# [**Name (NI) 27035**] Pt with recent luekocytosis during her last
hospitalization but normalized on discharge. Admitted with WBC
of 16 with left shift. She received a dose of levaquin, however
her leukocytosis resolved and she was afebrile. There was no
obvious signs of infection. CXR showed no pneumonia. Her
leukocytosis resolved and she remained afebrile. Blood cultures
were sent and remained NGTD. Levofloxacin was discontinued given
no clear infectious source. On the day prior to discharge, Ms.
[**Name14 (STitle) 27036**] had leukocytosis with a U/A consistent with a UTI (see
below). Her WBCs at time of discharge remain 12.7 but this is
only after 1 day of treatment. CXR done was read as:
"IMPRESSION: Markedly limited study secondary to positioning. As
best can be determined there is no definite new focal opacity.
There is a new indwelling PICC line as above" and the
leukocytosis upon discharge is being attributed to a UTI.
.
# UTI: On the day prior to discharge, Ms. [**Name14 (STitle) 27036**] had
leukocytosis with a U/A consistent with a UTI. At time of
discharge she has gram negative rods growing (speciation and
sensitivities pending at time of discharge which should be
followed post-discharge). We started a course of Bactrim and
she should continue this for 3 days and have follow up U/A and
cultures in a week's time.
.
# Hyponatremia- Patient was initially hyponatremic to 132 on
admission. Resolved with hydration so it was thought to be
secondary to hypovolemia.
.
# Brain Mass- Worked up recently completed. Recent biopsies
showed pituitary adenoma. TSH/T4, [**Last Name (un) 104**] stim were normal during
last admission. LH/FSH were low. Of note, sutures removed by
neurosurg on day of discharge.
-- Follow up with Dr. [**Last Name (STitle) 27037**] no urgent need for intervention.
-- Outpatient appointment scheduled and please call to confirm
this.
.
# CHF- EF 30-35%. No signs of failure at this time.
-- Watch for need of lasix given fluid resusitation
.
# Anemia- Chronic Fe deficicient anemia, likely from chronic
GIB. Iron supplemntation was restarted following endoscopy.
.
# [**Name (NI) **] Pt with no recent chest pain or ECG changes.
-- cardiac enzymes negative x2
-- No ASA given UGIB
.
# FEN- Patient was initially kept NPO for her procedure. Given
her achalasia, the patient is only able to tolerate small
amounts of food at one time. Her GI doctors [**Name5 (PTitle) 2985**] that she had
had significant worsening of her nutritional status with low
albumin and weight loss. It was felt that she will likely need
a feeding tube for nutritional support as she is unable to meet
her needs by mouth, however GI did not want to place a tube
while her nutritional status was so poor. Therefore, a PICC was
placed for TPN. She will likely need a few weeks of TPN to
improve her nutritional status prior to g-tube placement. She
was advanced to a regular diet given there was no
contraindication to this and she was started on TPN.
.
# PPx- Pneumoboots (held Heparin s/p GIB); ambulate with PT
daily
.
# Access- 2 PIV's
.
# Code- DNR/DNI
.
# Dispo- To rehab today
.
Medications on Admission:
1. Calcium Carbonate 500 mg TID
2. Citalopram 10 mg Tab Qday
3. Ferrous Sulfate 325 mg qday
4. Mirtazapine 7.5 mg QHS
5. Nortriptyline 20 mg QHS
6. Simvastatin 40 mg Qday
7. Sucralfate 1 g [**Hospital1 **]
8. Ergocalciferol (Vitamin D2) 50,000 unit PO QSat
9. Oxycodone 5 mg prn
10. Zolpidem 5 mg qhs
11. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
12. Nexium 40 mg [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
UGIB
Grade 4 esophagitis
Pituitary adenoma
Anemia
Achalasia
.
Secondary:
CAD
CHF
HTN
Discharge Condition:
Stable
Discharge Instructions:
Please continue to take your medications as directed.
.
If you experience blood in your stool, difficulty breathing,
chest pain, fainting, high fevers or other concerning symptoms
call you doctor or come to the emergency room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2161-4-6**]
2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2161-4-14**] 10:20
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] WEST Date/Time:[**2161-4-15**]
9:45
ICD9 Codes: 5990, 2761, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2622
} | Medical Text: Admission Date: [**2105-1-1**] Discharge Date: [**2105-1-23**]
Date of Birth: [**2051-6-5**] Sex: F
Service: SURGERY
Allergies:
Cellcept / Ampicillin / Penicillins
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
53 yo woman w/ h/o kidney transplant [**2076**], pancreas transplant
[**2-1**], w/ rejection [**6-3**].
DX: cmv pneumonitis
respiratory distress
Secondary DX: HTN, Left foot 4th metatarsal fx
Major Surgical or Invasive Procedure:
[**2105-1-9**] Bronchoalvelar lavage
[**2105-1-16**] NG tube placement
[**2105-1-21**] Picc line insertion
History of Present Illness:
52F s/p pancreas [**2-1**], and LRRT ('[**76**]), with fevers, N/V & ARF
(Creat 3.4) Pateint reports hx of sick contacts and prior
episode in [**7-/2104**] which resolved in house (pt had unrevealing
colonoscopy at the time).
Past Medical History:
Diabetes, hypertension.
Kidney transplant in [**2076**].
Pancreas after kidney transplant [**2104-1-29**],
chronic anemia
legally blind,
pancreas rejection [**2104-4-30**] treated with ATG,
left foot fracture [**2104-4-30**].
Pancreas transplant was done in [**State **].
PAST SURGICAL HISTORY: Ovarian cystectomy, bilateral nipple
duct resection, multiple rotator cuff surgical tears as well
as the pancreas after kidney [**2104-1-29**] and liver-related
kidney transplant in [**2076**].
Allergies:Penicillin, ampicillin, CellCept and MSG.
Social History:
Patient lives with her husband. She has 2 children and one
granchildren.
Family History:
Unremarkable
Physical Exam:
General: Patient in no apparent distress.
HEENT: Neck supple. legally blind. No adenopathies, oropharinx
clear
Lungs: Clear to Auscultation bilaterally
Cardiovascular: Regular rhythm, s1-s2 normal, sistolyc ejection
murmur mainly audible in 2 RParasternal border, no radiated to
the neck
Abdomen: BS + , soft, no distended,
Extremities: no edema, + pulses bilaterally, left foot banded
Neurological: legally blind, alert, oriented, non focal,
movilizes 4 extremities spontaneusly.
Lymphoid exam: No cervical, supraclavicular axillary or inguinal
adenopathy, no palpable spleen.
Pertinent Results:
[**2105-1-22**] 05:35AM BLOOD WBC-4.6 RBC-2.74* Hgb-8.6* Hct-25.6*
MCV-93 MCH-31.2 MCHC-33.4 RDW-19.8* Plt Ct-322
[**2105-1-21**] 04:45AM BLOOD WBC-4.4 RBC-2.77* Hgb-8.7* Hct-25.8*
MCV-93 MCH-31.2 MCHC-33.6 RDW-19.7* Plt Ct-226
[**2105-1-19**] 06:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2105-1-19**] 06:55PM URINE Blood-SM Nitrite-NEG Protein-500
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2105-1-13**] 12:15 pm URINE
**FINAL REPORT [**2105-1-14**]**
URINE CULTURE (Final [**2105-1-14**]):
YEAST. >100,000 ORGANISMS/ML..
Brief Hospital Course:
53 year old female with DM (s/p renal and pancreatic transplant,
on immunosuppression, blindness in both eyes) who presented on
[**2105-1-1**] with nuasea, vomiting, diarrhea, headache and fevers.
Fever work was initiated including Blood, urine, and stool
cultures along with CMV viral load were all sent. Abd US, CXR,
CT sinuses, abd, pelvis all negative. Pateint remain febrile
despite all initial culture returning negative except CMV viral
load of 58,000 copies. On hospital day patient was transferred
to SICU for shortness of breath, tachypneaa nd hypoxemia.
Pateint was subsequqnetly started on albuterol nebullizer,
continous face mask and serial CXR. An [**2105-1-7**] echocardiagram
showed left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). A [**2105-1-7**] portable CXR
showed mild interstitial edema with moderate cardiomegaly has
increased as has mediastinal vascular engorgement indicating
elevated central venous volume. A repeat on [**1-8**] showed
satisfactory nasogastric tube position, worsening congestive
heart failure and persistent left lower lobe atelectasis. A
[**2105-1-9**] bronchoavleaolar lavage showed increased secretions but
no other significant findings.
A [**1-9**] CT chest showed
1.Mild-to-moderate CHF with cardiomegaly and bilateral pleural
effusions with bibasilar patchy atelectasis.
2. Small pericardial effusion.
3. Somewhat nodular appearance within the ground glass opacity
consistent
with CMV pneumonitis. Radiographically, fungal infections and
miliary
tuberculosis are in the differential diagnosis.
4. Left lower lobe pneumonia.
On [**2105-1-11**] urine culture was positive for yeast and antifungal
treatement was started. [**1-12**] repeat CMV viral load [**Numeric Identifier 30501**]. Repeat
urine culture along with sputum on [**2105-1-13**] showed yeast.
After a ten day course in ICU pt returned to floor [**2105-1-17**].
Antifungal where discontinued per ID recommendation after [**1-19**]
urine culture showed no evidence of yeast. [**1-16**] CMV viral load
was 10,600. Patient pertinent issue on the floor was ongoing
nausea which improved after several days of adjusting tube feeds
and antiemetics treatment. After stable course on floor patient
was prepared for discharge rehab with appropiate followup
schedule.
Today on [**2105-1-23**], patient feels cofortable and
awaiting rehab.Patient is a febrile, VSS. Patient will leave
with a foley, TFs . Please make sure patient is on a ConAir bed
for sensitivity of skin, and increase risk for break down skin.
Discharge Medications:
1Prednisone 5 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
2. Folic Acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
3. Therapeutic Multivitamin Liquid [**Year (4 digits) **]: Five (5) ML PO DAILY
(Daily).
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Year (4 digits) **]: [**12-1**]
Tablets PO 3X/WEEK (MO,WE,FR).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection [**Hospital1 **] (2 times a day).
9. Fluconazole 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours).
10. Epoetin Alfa 10,000 unit/mL Solution [**Hospital1 **]: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
11. Tacrolimus 1 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times
a day) for 2 doses.
12. Sirolimus 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
13. Hydrochlorothiazide 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
14. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: 2.5 Tablets PO TID (3
times a day).
15. Ganciclovir Sodium 500 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln
Intravenous DAILY (Daily) for 5 days: 150mg iv q day.
16. Metoclopramide 10 mg IV Q6H:PRN
17. Insulin SS Insulin SC Sliding Scale Breakfast Lunch Dinner
Bedtime Regular Regular Regular Regular Glucose Insulin Dose
Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL [**12-1**] amp D50
[**12-1**] amp D50 [**12-1**] amp D50 [**12-1**] amp D50 61-120 mg/dL 0 Units 0 Units
0 Units 0 Units 121-160 mg/dL 3 Units 3 Units 3 Units 1 Units
161-200 mg/dL 5 Units 5 Units 5 Units 3 Units 201-240 mg/dL 7
Units 7 Units 7 Units 5 Units 241-280 mg/dL 9 Units 9 Units 9
Units 6 Units 281-320 mg/dL 11 Units 11 Units 11 Units 8 Units
321-360 mg/dL 13 Units 13 Units 13 Units 10 Units > 360 mg/dL
18. Hydralazine 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q 6HRS PRN
().
19. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
53 yo woman w/ h/o kidney transplant [**2076**], pancreas transplant
[**2-1**], w/ rejection [**6-3**].
DX: cmv pneumonitis
respiratory distress
Discharge Condition:
good
Discharge Instructions:
Patient is to call Transplant surgery immediately at
[**Telephone/Fax (1) 673**] if any fevers, chills, nausea, vomiting, increase
abdominal pain. Patient or caregiver should call immediately if
any change in mental status, increase in abdominal girth, any
increase diarrhea
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2105-2-2**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2105-2-5**] 1:30
F/u with Dr. [**Last Name (STitle) 12636**] from Podiatry in clinic in 4weeks. Please
call [**Telephone/Fax (1) 543**]
Completed by:[**2105-1-23**]
ICD9 Codes: 5849, 4280, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2623
} | Medical Text: Admission Date: [**2141-5-22**] Discharge Date: [**2141-5-27**]
Date of Birth: [**2080-9-18**] Sex: M
Service: CT [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 60 year old
gentleman who initially presented with hematemesis,
hemoptysis and on work-up was found to have a left lower lobe
mass. He previously underwent bronchoscopy with washings
which showed to be negative for malignant cells and showed
atypical bronchial epithelial cells, likely to be reactive.
PAST MEDICAL HISTORY:
1. Rectal fissure.
2. Lumpectomy of the left breast nodule.
3. Knee surgery.
4. Hand surgery.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: The patient had no home medications.
REVIEW OF SYSTEMS: The review of systems was essentially
negative.
PHYSICAL EXAMINATION: On admission, showed a gentleman in
no acute distress; afebrile. Chest was clear to auscultation
bilaterally. Heart has a regular rate and rhythm. Abdomen
is benign, no mass. Extremities were well perfused and warm.
HOSPITAL COURSE: The patient was taken to the Operating
Room the day of admission. He underwent a left bronchoscopy
and lower lobectomy of the left side. The operation was
subsequently complicated by a postoperative bleeding. The
patient had to be taken back to the Operating Room where a
repair of the left pulmonary artery was performed.
The patient was then transferred to the CSRU, intubated, in
stable condition. Vascular Surgery Service was also
consulted. During the operation, the patient received 13
units of packed red blood cells, four units of fresh frozen
plasma and one unit of platelets with an estimated blood loss
of 1500 cc.
The patient remained to be stable on the floor with
subsequent monitoring of hematocrit within a normal stable
range. He is successfully extubated on [**5-24**] and
hypertension transferred to the floor in stable condition
where the Pain Service is managing his epidural with very
good effect and he is tolerating a regular p.o. diet and is
making adequate amount of urine.
His recovery was essentially unremarkable. His epidural was
successfully discontinued and he is discharged to home on
[**5-27**] with instructions to follow-up with Dr. [**Last Name (STitle) 952**] in
the office within the next one to two weeks.
He is discharged to home with pain medication which is
percocet.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home without service.
DISCHARGE DIAGNOSES: Left lung mass status post resection.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Name8 (MD) 6276**]
MEDQUIST36
D: [**2141-5-29**] 10:50
T: [**2141-6-2**] 16:28
JOB#: [**Job Number 47948**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2624
} | Medical Text: Admission Date: [**2164-10-9**] Discharge Date: [**2164-10-15**]
Date of Birth: [**2108-2-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 56-year-old man known
to the Neurosurgery service with a past medical history of a
right tentorial subdural hematoma in the past status post an
assault in [**2164-6-12**], who returned on [**2164-10-9**] as a transfer
from [**Hospital 1474**] Hospital with several days with difficulty with
gait, dysarthria, and dragging of the left foot. Patient
denied headache at the time, confusion, weakness of
extremities other than a baseline right upper extremity
weakness that was a result of a motor vehicle accident the
patient had 20 years ago.
Patient at [**Hospital 1474**] Hospital underwent CAT scan of the brain
that showed a left acute on chronic subdural hematoma with
some minimal midline shift and mass effect, and a small
chronic right frontoparietal subdural hematoma.
PAST MEDICAL HISTORY: Patient just has a past medical
history of depression for which he takes Celexa and
Wellbutrin at home as well as Klonopin as needed.
PHYSICAL EXAMINATION: On admission, patient had equal and
reactive pupils. His extraocular motions were intact. His
visual fields were full. Face was symmetric. Tongue was
midline. Patient had no drift of the left upper extremity,
but had a drift of the right upper extremity again secondary
to his baseline brachial plexopathy. He had full grips
bilaterally. Lower extremities were [**4-16**] throughout. Toes
were downgoing bilaterally and his sensory is grossly intact.
Patient was admitted to the Neuro ICU for q.1h. neuro checks
and possible OR for evacuation of his subdural. Patient
continued to remain confused at times during his stay in the
ICU. Was afebrile. Neurological status was pretty much
unchanged. Patient was placed on Dilantin on [**2164-10-10**] for
seizure prophylaxis.
On [**10-11**], patient was taken off the Nipride drip that he was
placed on for high blood pressure since admission to the
hospital. Patient was medically cleared for surgery on
[**10-11**].
Patient went to the operating room for left craniotomy,
evacuation of subdural hemorrhage on [**10-12**]. Estimated blood
loss was 100 cc. Patient tolerated procedure well and was
recovered in the ICU. Postoperative head CT showed good
evacuation of the subdural and no enlargement of the right
subdural hematoma.
Patient's diet was advanced on [**10-13**]. Patient was out of bed
with Physical Therapy. Blood pressures were kept under
control with p.o. pain medication status post OR. Speech and
word finding difficulties improved postoperatively. Patient
remains motor intact except for the baseline right upper
extremity weakness status post surgery. Patient was
transferred to the floor on [**10-13**]. Foley was D/C'd. Patient
was out of bed with Physical Therapy and patient was felt to
be safe to return home as per rehab services.
Patient was discharged on [**10-15**] with repeat head CT in three
weeks and followup office visit with Dr. [**Last Name (STitle) 739**] in
three weeks.
MEDICATIONS ON DISCHARGE:
1. Wellbutrin 150 p.o. q.a.m.
2. Celexa 20 mg 0.5 tablet p.o. q.d.
3. Pepcid 20 mg p.o. b.i.d.
4. Dilantin 100 mg p.o. t.i.d.
5. Oxycodone/acetaminophen 5/325 p.o. q.4-6h. prn.
FOLLOW-UP INSTRUCTIONS: The patient was instructed to
followup with Dr. [**Last Name (STitle) 739**] for Dilantin wean in the
future as well as for repeat head CT.
CONDITION ON DISCHARGE: Patient is neurologically stable at
time of discharge.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D.
[**MD Number(1) 743**]
Dictated By:[**Last Name (NamePattern1) 27454**]
MEDQUIST36
D: [**2164-10-15**] 14:50
T: [**2164-10-16**] 08:12
JOB#: [**Job Number 51762**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2625
} | Medical Text: Admission Date: [**2137-5-7**] Discharge Date: [**2137-5-29**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Fall, ICH
Major Surgical or Invasive Procedure:
s/p L burr hole
s/p L hemiarthroplasty
History of Present Illness:
The patient is an 86 yo M transferred from OSH s/p fall from
standing, on ASA/Plavix/Coumadin. At OSH diagnosed with SDH and
L femur fx. On arrival to [**Hospital1 18**], it was noted that the patient
was becoming increaingly less responsive and he was intubated
for airway protection. A repeat head CT demonstrated worsening
SDH with midline shift. The patient received Proplex, FFP,
dilantin, and mannitol.
Neurosurgery was involved immediately and there was discussion
with the patient's wife regarding going to the OR for evacuation
of the SDH; the wife declined surgery and the patient was
admitted to the T-SICU for close observation.
Past Medical History:
-Afib
-PNA
-MI
-s/p [**Hospital1 **] to L main and distal L main coronary artery [**3-11**] @
[**University/College **]-Hitchcock
-depression
-COPD on home O2
Social History:
Lives with wife in [**Location (un) 3844**]
No tobacco/EtOH
Family History:
N/C
Physical Exam:
GEN: Elderly male, boarded and collared
VS: 117/64 78 18 100% NRB
Initial GCS 13 --> 6
HEENT: PERRL, lac to occiput
NECK: Trachea midline
COR: s1s2 RRR
RESP: CTAB
ABD: soft, NT, ND
EXT: LLE shortened, distal pulses intact but cool skin, ABI=1
NEURO: MAE
SKIN: cool, dry
RECTAL: tone WNL, guaiac +
Pertinent Results:
[**2137-5-7**] 11:50PM TYPE-ART PO2-141* PCO2-39 PH-7.47* TOTAL
CO2-29 BASE XS-5
[**2137-5-7**] 10:00PM TYPE-ART PO2-72* PCO2-45 PH-7.45 TOTAL
CO2-32* BASE XS-6
[**2137-5-7**] 10:00PM GLUCOSE-114* LACTATE-1.8
[**2137-5-7**] 08:36PM GLUCOSE-135* UREA N-31* SODIUM-137
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-28 ANION GAP-15
[**2137-5-7**] 08:36PM CALCIUM-8.3* PHOSPHATE-4.1 MAGNESIUM-1.8
[**2137-5-7**] 08:36PM OSMOLAL-308
[**2137-5-7**] 08:36PM WBC-6.2 RBC-3.22* HGB-10.0*# HCT-28.0*#
MCV-87 MCH-31.2 MCHC-35.8* RDW-15.4
[**2137-5-7**] 08:36PM PLT COUNT-137*
[**2137-5-7**] 08:36PM PT-13.7* PTT-31.9 INR(PT)-1.2*
[**2137-5-7**] 08:36PM FIBRINOGE-241
[**2137-5-7**] 08:30PM TYPE-ART PO2-304* PCO2-47* PH-7.43 TOTAL
CO2-32* BASE XS-6
[**2137-5-7**] 05:06PM TYPE-ART O2-100 PO2-86 PCO2-38 PH-7.48* TOTAL
CO2-29 BASE XS-4 AADO2-606 REQ O2-97 COMMENTS-NON-REBREA
[**2137-5-7**] 05:04PM TYPE-[**Last Name (un) **] PO2-27* PCO2-51* PH-7.41 TOTAL
CO2-33* BASE XS-4 COMMENTS-GREEN TOP
[**2137-5-7**] 05:04PM GLUCOSE-103 LACTATE-1.6 NA+-141 K+-4.1
CL--100
[**2137-5-7**] 05:04PM HGB-13.8* calcHCT-41 O2 SAT-50 CARBOXYHB-2
MET HGB-0
[**2137-5-7**] 05:04PM freeCa-1.09*
[**2137-5-7**] 05:00PM GLUCOSE-105 UREA N-32* CREAT-1.0 SODIUM-139
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-28 ANION GAP-15
[**2137-5-7**] 05:00PM AMYLASE-47
[**2137-5-7**] 05:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2137-5-7**] 05:00PM URINE HOURS-RANDOM
[**2137-5-7**] 05:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2137-5-7**] 05:00PM WBC-9.0 RBC-4.27* HGB-13.8* HCT-38.1* MCV-89
MCH-32.3* MCHC-36.3* RDW-15.2
[**2137-5-7**] 05:00PM PLT COUNT-101*
[**2137-5-7**] 05:00PM PT-18.2* PTT-31.4 INR(PT)-1.7*
[**2137-5-7**] 05:00PM FIBRINOGE-331
[**2137-5-7**] 05:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2137-5-7**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
.
CT torso: 1. Multiple large mediastinal lymph nodes.
2. Evidence of lung fibrosis with interstitial and alveolar
changes, consistent with history of interstitial lung disease.
3. Acute comminuted left femoral neck fracture.
.
CT c-spine: IMPRESSION: No evidence of acute fracture or
spondylolisthesis. Degenerative change is seen within the
cervical spine.
.
CT head: IMPRESSION: Large left subdural hematoma with blood
tracking along the falx and left tentorium. There is mass effect
upon the left lateral ventricles. Rightward shift of normally
midline structures with approximately 9 mm shift of the septum
pellucidum concerning for subfalcine herniation. Although the
ambient cisterns appear patent, they are narrowed and there is
concern for impending uncal herniation.
.
Brief Hospital Course:
The patient was admitted to the T-SICU. His mental status
improved and he was extubated. Repeat CT scans of the head
showed stable SDH and shift. On HD 9 a head CT showed decrease
in attenuation of the frontal aspect of the left subdural
hematoma, but an increase in volume of the collection. The
maximal width of the subdural hematoma had increased and there
was an increase in mass effect on the left brain. He returned to
the T-SICU for closer monitoring and remained stable, with a
waxing and [**Doctor Last Name 688**] mental status. On HD 14 a repeat head CT
showed slight worsening of the shift and the patient was
minimally responsive, not communicative. He was taken to the OR
and a L burr hole was placed for evacuation of hematoma. His
mental status improved from a pre-op GCS of 5 to a post-op GCS
of 10. He should be continued on Dilantin with a goal level of
15 (corrected for albumin).
The day prior to discharge, a head CT revealed: Compared to [**5-21**], [**2137**], there has been removal of the left intracranial
drainage catheter. The left subdural hematoma has largely been
evacuated with a small amount of heterogeneously dense blood
products layering along the left temporal and frontal lobes.
There has been no significant change in left to right subfalcine
shift measuring approximately 4 mm. The appearance of the
ventricles and sulci has not significantly changed and there is
no evidence of hydrocephalus. There remains pneumocephalus
around the burr hole site which has slightly improved. There are
no new areas of hemorrhage and no evidence of infarction. The
[**Doctor Last Name 352**]/white matter differentiation appears preserved and the
basal cisterns patent. The paranasal sinuses are pneumatized and
the orbits are unremarkable. IMPRESSION: Status post removal of
left intracranial drainage catheter. Otherwise, stable
appearance of the head.
Other issues for this hospitalization included:
# Cardiac: The patient was s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 2 to the L main coronary
artery in [**2137-3-6**] at [**Hospital3 27447**] Center;
however, due to the acute intracranial hemorrhage, Plavix was
held initially during his course. It was restarted briefly after
discussion between Neurosurgery and Cardiology, held for
surgery, and will need to be restarted [**2137-5-28**] per Neurosurgery.
He was restarted on ASA 81mg QD post-operatively. He has a
history of atrial fibrillation and was in afib with a slow
ventricular response at the time of transfer. He was
hemodynamically stable, with a systolic blood pressure in the
90s which has been largely his baseline (90s-110s).
# Respiratory: The patient spiked a fever and a CXR was
concerning for PNA. He was started on Levaquin on [**2137-5-16**] (HD
10); sputum cx revealed coag + staph and Vanco was started on
[**2137-5-18**].
# L femur fracture: The patient underwent L hemiarthroplasty and
tolerated the procedure well; he has been cleared by Orthopedics
to be weight-bearing as tolerated when able. He can follow up
with the orthopedic surgeon, Dr. [**Last Name (STitle) **] [**Name (STitle) 7376**], in 6 weeks.
# GI: A PEG was placed on [**5-17**] and tube feeds were started, now
at goal.
.
Medications on Admission:
Plavix, Lisinopril, Zoloft, Detrol, Coumadin, Zocor, Lasix, ASA,
Duoneb
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4
hours) as needed.
8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Phenytoin 100 mg/4 mL Suspension Sig: 200 mg PO Q12H (every
12 hours).
11. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
Scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66960**]Healthcare
Discharge Diagnosis:
1. Subdural hematoma
2. Femur fracture
3. Pneumonia
4. Atrial fibrillation
5. CAD
6. COPD
Discharge Condition:
Fair
Discharge Instructions:
As per your wife's request, you are being transferred to
[**Hospital3 27447**] Center for continued care.
Followup Instructions:
* Orthopedics: Dr. [**First Name (STitle) **] [**Name (STitle) 7376**] ([**Telephone/Fax (1) 2007**] in 6 weeks
* Neurosurgery: Dr. [**Last Name (STitle) 739**] ([**Telephone/Fax (1) 88**] in 6 weeks if
desired; otherwise you may follow up in [**Location (un) 3844**] if more
convenient
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
ICD9 Codes: 486, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2626
} | Medical Text: Admission Date: [**2103-6-10**] Discharge Date: [**2103-6-22**]
Date of Birth: [**2072-10-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2103-6-14**] Aortic Valve Replacement with a [**Street Address(2) 6158**]. [**Male First Name (un) 923**]
Mechanical Valve. Mitral Valve Repair with 28mm [**Company 1543**] Future
Ring with Repair of Anterior Leaflet of Mitral Valve. Repair of
Two Aortic Root Abscesses.
[**2103-6-18**] Placement of PICC Line
History of Present Illness:
This is a 30 year old white male with past medical history
significant for alcohol abuse, presented to OSH with a 10 day
history of progressive shortness of breath. Patient stated that
he had cold symptoms, dizziness and a question of a tick bite a
couple of weeks ago. His PCP suspected [**Name9 (PRE) **] disease and started
on Doxycycline as an outpatient which he took for a week. Had
mild resolution of his symptoms but started becoming short of
breath again, presented to ER HR 115, BP 122/65 and 100% on 2l
O2 and was given Azithromycin for pneumonia. CXR revealed
bilateral effusions. An echocardiogram revealed a moderately
dilated left ventricle with an ejection fraction of 60-65%. The
echocardiogram was also notable for severe AI with a large 23mm,
multilobulated vegetation on the aortic valve, and moderate MR
with a 7mm vegetation on the anterior leaflet, with perforation
of the leaflet. Given the above findings, he was transferred to
the [**Hospital1 18**] for cardiac surgical intervention.
Past Medical History:
- History of ETOH Abuse
- s/p Tympanostomy Tubes
- s/p Dental surgery
Social History:
Occupation: Manual labor
Tobacco: 1ppd, denies drug use
ETOH: h/o ETOH abuse
Family History:
Non-contributory
Physical Exam:
Admission:
Vitals: Pulse:104, Resp:21, O2 sat: 95% on RA, BP: 115/56
General: WDWN male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Fine basilar crackes bilaterally [x]
Heart: RRR [x] Irregular [] Murmur III/VI systolic and
diastolic murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x], palpable liver edge
Extremities: Warm [x], well-perfused [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: Transmitted murmur
Pertinent Results:
[**2103-6-10**] WBC-14.6* RBC-3.47* Hgb-10.9* Hct-34.0* Plt Ct-646*
[**2103-6-10**] Neuts-82.2* Lymphs-13.9* Monos-2.3 Eos-1.3 Baso-0.3
[**2103-6-10**] PT-14.1* PTT-27.6 INR(PT)-1.2*
[**2103-6-10**] Glucose-104* UreaN-13 Creat-0.8 Na-138 K-4.5 Cl-100
HCO3-26
[**2103-6-10**] ALT-13 AST-18 LD(LDH)-281* AlkPhos-61 TotBili-0.4
[**2103-6-13**] %HbA1c-5.5 eAG-111
[**2103-6-10**] HBsAg-NEGATIVE, HBsAb-NEGATIVE
[**2103-6-10**] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
[**2103-6-10**] HCV Ab-NEGATIVE
[**2103-6-14**] Intraop TEE:
PRE BYPASS The left atrial appendage emptying velocity is
depressed (<0.2m/s). No thrombus is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is moderate
global left ventricular hypokinesis (LVEF = 35 %). The right
ventricle displays borderline normal free wall function. The
number of aortic valve leaflets cannot be determined - likely
there are three. The aortic valve structure is essentially
destroyed. Aortic leaflet prolapse is present. There is a large
vegetation on the aortic valve. An aortic annular abscess is
seen at the point where the right coronary cusp contacts the
ascending aorta. There is also a likely abscess at the junction
of the anterior mitral leaflet and aortic annulus.. Severe (4+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric. The mitral valve leaflets are mildly thickened. There
is a perforation of the anterior mitral valve leaflet near its
base at the point where the prolapsing aortic valve leaflet
contacts it. Moderate to severe (3+) mitral regurgitation is
seen at the coaptation point of the mitral valve leaflets,
likely from annular dilitation and partialo disruption of the
base of the anterior mitral leaflet. There is a small
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is receiving epinephrine,
norepinephrine, and milrinone by infusion. He was initially
a-paced. The left ventricle displays moderate global hypokinesis
with an ejection fraction of 35%. The right ventricle displays
normal free wall systolic function. A mitral valve annuloplasty
ring is in situ that appears well seated. There is trace
valvular mitral regurgitation. The anterior leaflet perforation
has been repaired. The maximum gradient across the mitral valve
is 16 mmHg with a mean of 5 mmHg at a cardiac output of 7.5
liters per minute. There is a bileaflet prosthesis in the aortic
position. It also appears well seated. Both leaflets can be seen
moving freely. Trace valvular regurgitation is seen. A small
perivalvular jet cannot be completely ruled out. The maximum
pressure gradient across the aortic valve was 58 mmHg with a
mean of 33 mmHg at a cardiac output of 8 liters/minute. The
effective orifice area of the aortic valve was 1.6 cm2 . The
proximal ascending aorta appears inrtact but the other thoracic
aortic segments could not be seen.
[**2103-6-18**] Head MRI:
1. DWI hyperintensity within the central and precentral sulci
bilaterally, demonstrating restricted motion of the ADC maps,
contains the signal attributes for infarct, however, this would
represent a highly unusual true infarction, as it does not
follow a vascular distribution.
2. Multiple foci of hyperintense signal within the
periventricular white matter on FLAIR are nonspecific and
unlikely to account for the patient's symptoms.
[**2103-6-19**] Transthoracic ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is severe global left ventricular hypokinesis
(LVEF = 30 %). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. There is
abnormal septal motion/position. A bileaflet aortic valve
prosthesis is present. No masses or vegetations are seen on the
aortic valve, but cannot be fully excluded due to suboptimal
image quality. Mild (1+) aortic regurgitation is seen
(pyhsiologic pattern with bileaflet prosthesis). A mitral valve
annuloplasty ring is present. The mitral annular ring appears
well seated with normal gradient. No mass or vegetation is seen
on the mitral valve. No mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
OR Tissue culture sent to lab in [**State **] + for step viridans
Brief Hospital Course:
Mr. [**Known lastname 85379**] was admitted to the cardiac surgical service. Pan
cultures were obtained and the ID service was consulted to
assist in the antimicrobial management of his endocarditis.
Broad spectrum antibiotics were continued per ID
recommendations. Dental evaluation showed no evidence of active
infection. He remained hemodynamically stable on medical
therapy. Prior to surgical intervention, pancultures remained
negative. On [**6-14**], Dr. [**Last Name (STitle) **] performed an aortic valve
replacement with repair of mitral valve and repair of several
aortic root abscesses. For surgical details, please see
operative note. Following the operation, he was transferred to
the CVICU for invasive monitoring. Within 24 hours, he was
extubated but did experience some confusion along with word
finding difficulty. He was also noted to have a left facial
droop and left upper extremity weakness. Urgent CT scan was
initially unremarkable. Over the next 24 hours, he maintained
stable hemodynamics with slight improvement in his mental
status. On postoperative day two, he transferred to the step
down unit. Follow up MRI on [**6-18**] was performed and
suspicious for infarction but inconclusive. His neurologic
function continued to improve daily and he now has [**4-9**] left UE
and LE strength. He no longer requires a walker to ambulate. A
second follow up head MRI was done today which revealed small
area of subacute infarct in the right precentral gyrus.
Operative cultures remained negative however cultures sent to
state lab in [**State **] which grew out Strep Veridans - per ID
recommendations IV ceftriaxone 2gms q 24hrs x 4 weeks from
operative date [**2103-6-14**]. A Mid line was placed for longterm
antibiotic coverage.
He was anticoagulated for mechanical AVR on 5mg coumadin- INR
2.7. Dr. [**Last Name (STitle) 85380**] will be dosing coumadin starting [**2103-6-25**].
Medications on Admission:
Transfer meds: Vancomycin, Ceftriaxone, Aspirin 81 qd,
Metoprolol 25 tid, Captopril 6.25 tid, Lasix 40mg IV bid, KCL 40
meq [**Hospital1 **], MVI, Thiamine, Folate
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. 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. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
Two (2) gms Intravenous Q24H (every 24 hours) for 3 weeks.
Disp:*21 doses* Refills:*0*
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal 2.5-3.0 for mech AVR.
Disp:*30 Tablet(s)* Refills:*2*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
CBC/diff, Bun/Creat, LFT's weekly and fax to infectious disease.
[**Telephone/Fax (1) 1419**]
8. Outpatient Lab Work
INR daily starting on [**2103-6-25**] and call results to
Dr. [**Last Name (STitle) 85380**] for coumadin dosing
Fax [**Telephone/Fax (1) 85381**]
phone [**Telephone/Fax (1) 85382**]
Discharge Disposition:
Home with Service
Facility:
TBA
Discharge Diagnosis:
Endocarditis of Aortic and Mitral Valves
Aortic Insufficiency, Mitral Regurgitation
Aortic Root Abscess
History of ETOH Abuse
Discharge Condition:
Alert and oriented x3 - residual strength deficit but improving
left upper and lower extremity.
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions: Sternal - healing well, no erythema or drainage
Extremities- no edema. RUE midline
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.
You will need to cover you intravenous line with plastic wrap to
shower.
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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:
The following appointment has beeen scheduled for you
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2103-7-25**] at 1:15pm [**Telephone/Fax (1) 170**]
Plaese call to arrange the following appointments
Dr. [**First Name4 (NamePattern1) 751**] [**Last Name (NamePattern1) 85380**] [**Telephone/Fax (1) 85382**] in 2 weeks
Please consult Dr. [**Last Name (STitle) 85380**] for a Cardiologist and please call
for appointment to be seen in 2 weeks
Laboratory monitoring required: Weekly CBC with diff, BUN/Cr,
AST, ALT, Alk phos, Tbili ***All laboratory results should be
faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. All
questions regarding outpatient antibiotics should be directed to
the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**] MD
in when clinic is closed.
Your INR will be checked on [**2103-6-25**] and the results called to
Dr. [**Last Name (STitle) 85380**] [**Telephone/Fax (1) 85382**] for coumadin dosing or fax
[**Telephone/Fax (1) 85381**].
Completed by:[**2103-6-22**]
ICD9 Codes: 5119, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2627
} | Medical Text: Admission Date: [**2115-2-15**] Discharge Date: [**2115-2-17**]
Date of Birth: [**2037-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
L. pleural effusion
Major Surgical or Invasive Procedure:
s/p VATS decortication
History of Present Illness:
The patient is a delightful, 77-year-old gentleman who has
developed progressive dyspnea. He has been found to have a
left-sided pleural effusion. Thoracentesis demonstrated no
evidence of malignancy or infection on pathological and
microbiological examination. He has not had any documented
episodes of infections recently to suggest that this was a
parapneumonic effusion. He did have a few small, relatively
superficial lung nodules in the left lower and left upper lobe.
He was admitted for thoracoscopy with evacuation of pleural
effusion, takedown of adhesions and partial lung decortication.
Past Medical History:
glaucoma, BPH, total knee replacement, loss of hearing right
ear, bronchitis.
Physical Exam:
AF, VSS
NAD
RRR
CTAB CT incisions dressed
warm no edema
Pertinent Results:
[**2115-2-17**] 01:53AM BLOOD WBC-8.0 RBC-2.99* Hgb-9.4* Hct-26.6*
MCV-89 MCH-31.5 MCHC-35.5* RDW-13.4 Plt Ct-338
[**2115-2-17**] 01:53AM BLOOD Plt Ct-338
[**2115-2-17**] 01:53AM BLOOD Glucose-106* UreaN-11 Creat-0.7 Na-130*
K-4.6 Cl-99 HCO3-23 AnGap-13
[**2115-2-17**] 01:53AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.8
Brief Hospital Course:
The pt was taken to the operating room where a VATS drainage and
decortication was preformed. The pt tolerated the procedure
well. The pt remained intubated overnight and was transfered to
the CSRU in stable condition at the end of the procedure. There
were no complications.
The pt's post operative course was uncomplicated. He was
extubated POD #1. On POD# 2 his chest tubes were removed. At
the time of discharge he was ambulating on his own with out
difficulty, had good pain control on oral pain medications, had
O2 sats greater then 92 % on Room air, had return of bowel and
baldder function and was tolerating a regular diet.
Medications on Admission:
[**Last Name (un) 1724**]: Lisinopril 40', Lasix 40', Combivent, Claritin 10',
eyedrops
Travatan one drop right eye, Trisopt one drop right eye both
daily
Discharge Medications:
1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
2. Home Meds
OK to resume home medications
Take a stool sofener while taking pain medications
Discharge Disposition:
Home
Discharge Diagnosis:
s/p VATS decortication
Discharge Condition:
good
Discharge Instructions:
Call Clinic or return to the ED for T>101.5. Any redness or
drainage from the wound. Shortness of breath or anything else
that is of concern to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 952**] in Clinic in [**2-16**] weeks. Call for an
appointment on Monday. [**Telephone/Fax (1) 170**]
Completed by:[**2115-2-18**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2628
} | Medical Text: Admission Date: [**2168-6-4**] Discharge Date: [**2168-6-14**]
Date of Birth: Sex: M
Service:Tramsplant Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 40 year-old
male with a history of insulin dependent diabetes status post
pancreatic transplant in [**8-23**] who presented to an outside
hospital on the a.m. of [**2168-6-4**] complaining of nausea,
vomiting and abdominal pain. The patient reported that he
was reported to be in both lower quadrants of his abdomen
with some radiation to the back. The pain was constant and
severe. The patient denied any fevers or chills. The
patient reported he had several episodes of emesis. While in
the Emergency Department he was having dry heaves, but was no
longer having productive emesis. The patient had several
formed bowel movements. He continued to pass flatus. The
urinary symptoms. He also denied any changes in his bowel
movements. He had no diarrhea. He had no bright red blood
per rectum.
PAST MEDICAL HISTORY: 1. Insulin dependent diabetes status
post pancreatic transplant complicated by postop nausea and
vomiting for several months. 2. Retinopathy and neuropathy
secondary to his diabetes.
MEDICATIONS: 1. Prograf 3 mg b.i.d. 2. Rapamycin 5 mg
q.d. times three days and then 2 mg q.d. (Rapamycin was
restarted four days prior to admission after several months
on hold). 3. Prednisone 5 q.d. 4. Bactrim single strength
one q.d. 5. Aspirin 325 mg po q.d. 6. Neurontin 300 mg po
b.i.d. 7. Ultram 50 mg b.i.d.
ALLERGIES: Codeine.
SOCIAL HISTORY: No tobacco and rare alcohol.
PHYSICAL EXAMINATION: Vital signs on admission were 100.3,
117, 98/62, 20 and 95% on room air. General, the patient was
lying still on side in severe pain. HEENT within normal
limits. Cardiac regular rate and rhythm, but tachycardic.
Lungs clear to auscultation bilaterally. Abdomen distended
with decreased bowel sounds, extremely tender with guarding
of the right abdomen. The rest of the abdomen was tender,
but with no guarding. Rectal examination guaiac negative
with no mass and a normal prostate. Extremities warm with 2+
pulses.
LABORATORY: CBC was 6.5, 34 and 192. Differential was 86.9
neutrophils with no bands. Chem 7 was
142/3.7/100/24/24/1.3/176. AST 48, ALT 52, alkaline
phosphatase 89, total bilirubin 0.7, amylase 64 and lipase
16. PT 13.4, PTT 27.4, INR 1.3.
HOSPITAL COURSE: The patient was taken emergently to the
Operating Room for an exploratory laparotomy after
intravenous resuscitation. In the Operating Room the patient
was found to have a volvulus with about 70 cm of ischemic
jejunum and mesenteric venous thrombosis. The patient's
perfusion was noted to be improved after the lysis of
adhesions with doppler signals throughout small bowel. The
pancreatic transplant appeared normal. The patient tolerated
the procedure well and was transferred to the CICU with a
plan to return him for a second look in 24 hours. The
patient was returned to the Operating Room on the morning of
[**2168-6-6**] during which the patient's ischemic jejunum was found
to be nonviable and resected. The patient was left with 210
cm of small bowel. Please refer to the operative note for
details on the surgery. The patient was thereafter returned
to the CICU for continued monitoring. The patient was
transferred out of the CICU on postoperative day number [**3-25**].
On postop day number [**5-27**] the patient was CAT scanned
following some fever. CAT scan revealed some bilateral
pleural effusions and some slight small bowel wall thickening
adjacent to the patient's anastimotic site, but no
explanation for the fever. The patient's stool was sent for
C-diff testing, the results ultimately being negative. The
patient's central line also being discontinued. The catheter
tip was sent for cultures, but ultimately grew no organism.
The patient ultimately successfully had his nasogastric tube
discontinued and his diet advanced to regular and was deemed
stable for discharge to home on [**2168-6-14**]. By the time of
discharge the patient was afebrile. He was tolerating a
regular diet and was having regular bowel movements.
DISCHARGE CONDITION: Stable.
FOLLOW UP: The patient was to follow up with Dr. [**Last Name (STitle) **] in
clinic.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Doctor Last Name 14026**]
MEDQUIST36
D: [**2168-9-20**] 22:26
T: [**2168-9-21**] 06:27
JOB#: [**Job Number 32626**]
ICD9 Codes: 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2629
} | Medical Text: Admission Date: [**2154-5-20**] Discharge Date: [**2154-7-1**]
Date of Birth: [**2135-12-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Status post Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2154-5-20**] Bifrontal craniotomies
[**2154-5-24**] Trach, PEG, IVC filter
[**2154-5-28**] ORIF facial fractures part I:
1. Extraction of teeth numbers 3, 10, 12, 19 and 32.
2. Placement of upper and lower arch bars.
3. Open-reduction internal fixation of right mandibular
posterior body fracture.
4. Debridement of comminuted left mandibular body fracture.
5. Reconstruction plating of left mandibular continuity
defect.
6. Open-reduction internal fixation of palatal fracture.
7. Layered closure of complex lower lip and oral
lacerations measuring 10 cm in total.
[**2154-6-6**] Part II facial repair:
Second stage open reduction, internal fixation of
displaced pan facial fractures via coronal bilateral rim and
bilateral maxillary gingival buccal sulcus incisions.
[**2154-6-26**] Lumbar puncture
[**2154-6-26**] PICC placement
History of Present Illness:
18 year old male status post motor vehicle crash; was an
unrestrained intoxicated driver of a roll over motor vehicle at
4:30AM on the day of admission which by report he was driving a
stolen vehicle at high speeds when he hit a guard rail. He was
taken to an outside hospital, where he was intubated for low
GCS. He was found to have a subdural hematoma and transferred to
[**Hospital1 18**] for trauma evaluation.
Past Medical History:
None
Social History:
Worked in a supermarket and as a landscaper. Heavy ETOH (all
weekend)use. Percocet abuse. No known cocaine abuse.
Family History:
Father: diabetes, hypertension, high cholesterol. Mother: not
known (adopted). No known family history of seizure,
developmental delay.
Physical Exam:
Physical Exam on Admission:
Limited to sedation/paralytics
T 102.7, P 118, BP 144/65, R 28, Sat 100% vented
General: Sedated, NAD. Intubated
Neck: Cervical collar on, Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, ND, BS+
Extrem: Warm and well-perfused.
Pertinent Results:
Upon admission:
[**2154-5-20**] 11:45PM TYPE-ART PO2-115* PCO2-34* PH-7.41 TOTAL
CO2-22 BASE XS--1
[**2154-5-20**] 11:45PM GLUCOSE-147* LACTATE-1.5 K+-4.1
[**2154-5-20**] 06:45PM WBC-18.3*# RBC-4.06* HGB-12.5* HCT-34.6*
MCV-85 MCH-30.9 MCHC-36.3* RDW-14.1
[**2154-5-20**] 06:45PM WBC-18.3*# RBC-4.06* HGB-12.5* HCT-34.6*
MCV-85 MCH-30.9 MCHC-36.3* RDW-14.1
[**2154-5-20**] 06:45PM PLT COUNT-217
[**2154-5-20**] 06:45PM PT-14.7* PTT-25.2 INR(PT)-1.3*
[**2154-5-20**] 09:40AM ASA-NEG ETHANOL-87* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CT Head [**2154-5-20**]
IMPRESSION:
1. Generalized brain edema with mild effacement of the basilar
cisterns but no definite sign of herniation.
2. Small bifrontal acute subdural hemorrhages and possible
subdural blood
along the tentorium.
3. Punctate hyperdensities in the left frontal lobe may
represent developing manifestations of diffuse axonal injury or
possibly hemorrhagic contusion.
4. Extensive facial trauma, described in detail on concurrently
performed
facial bone CT.
5. 8 mm radiopaque foreign body in the left occipital scalp
subcutaneous
tissues.
CT Sinus/Mandible [**2154-5-20**]
IMPRESSION:
1. Bilateral [**Last Name (un) **]-orbital ethmoidal complex fractures.
2. Bilateral Le Fort I/II and III complex fractures.
3. Bilateral mandibular fractures, with extensive comminution of
the left
mandibular angle and ramus, with malocclusion of the teeth.
4. Small bifrontal acute subdural hemorrhages, described in
detail on
concurrently performed head CT.
5. Periorbital hematoma bilaterally, and small right extraconal
hematoma.
Intact globes.
6. Extensively comminuted nasal bone fractures.
CT cervical spine [**2154-5-20**]
IMPRESSION: No cervical spine fracture or malalignment.
POST- OP Head CT [**2154-5-20**]
IMPRESSION: Status post bifrontal craniotomy, and evacuation of
bifrontal
subdural hematomas with residual pneumocephalus. Persistent
severe
diffuse cerebral edema with evidence of diffuse axonal injury.
Status
post interval placement of right ventriculostomy catheter.
MRI Head [**2154-5-21**]
IMPRESSION:
1. Extensive post-surgical change as described above. No new
intracranial
hemorrhage is identified.
2. Slow diffusion in the parietal cortices, medial margin of the
left
occipital cortex, thalami and supratentorial white matter as
described above.
These areas of slow diffusion likely are related to cortical
contusion and
diffuse axonal injury.
3. Right-sided ventriculostomy catheter in place with
normal-sized
ventricles.
4. Nearly complete opacification of the paranasal sinuses.
MRI cervical spine [**2154-5-21**]
IMPRESSION:
1. No evidence of vertebral body fracture or ligamentous injury.
2. No spinal cord signal abnormality identified.
REPEAT HEAD CT [**2154-5-24**]
IMPRESSION: Status post craniectomies. No change in ventricular
size or
evidence of new hemorrhage. Brain edema and signs of mild
central herniation
again identified and have not changed. The vessels cisterns are
still
partially visualized.
Repeat head CT [**2154-6-23**]
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Resolution of the previously noted bifrontal extra-axial
fluid collection.
3. Evaluation for infectious processes is limited on the present
study due to
lack of IV contrast.
4. S/p ORIF of facial fractures, with dense material in the
maxillary sinuses
as described above, incompletely assessed on the present study.
Brief Hospital Course:
He was admitted to the Trauma Service; Neurosurgery and Plastics
consulted given his injuries:
[**5-20**]: [**Last Name (LF) 14938**], [**First Name3 (LF) **], 23% saline started per recommendation of
Neurosurgery, Bolt placed, CPP 55-60 given high ICP was taken to
OR for bifrontal craniectomies
[**5-21**]: Dilantin 150 tid started after received loading dose;
given Mannitol and Lasix *1; underwent CT head, MRI head and
spine.
[**5-22**]: Mannitol held, last dose [**2071-4-29**] pm. cervical, thoracic and
lumbar spine cleared radiographically. Back on Labetalol gtt for
SBP > 160. Temp to 102 at [**2074**], blood, sputum and urine sent, no
CSF sent per neurosurgery.
[**5-23**]: Tmax 105; arctic sun cooling, ?central vs infectious
source, he was pan cultured including CSF; continued shivering,
started on propofol drip; follow osms, Na 158
[**5-24**]: PEG, Trach and IVC filter placed; ventricular drain was
accessed and therefore repeat CT head done
[**5-25**]: lost a-line last night, multiple attempts at replacement
difficult and unsuccessful due to posturing/muscle rigidity. [**Month (only) 116**]
require brief paralysis if a-line necessary, currently ok to
follow cuff pressures (are reliable) per primary team and
neurosurgery, not currently on gtt for BP control. Will switch
Dilantin to Keppra due to [**Month (only) 5162**], needs multi-day titration per
Neurology. EVD raised to 15 per neurosurgery. 2 units PRBCs for
HCT 24 given head injury. Weaned to trach mask.
[**5-26**]: Restarted propofol gtt for agitation; back on PS
ventilation; cooling blanket
[**5-27**]: CT head no hydrocephalus; EVD D/ced; Pre-op for OR with
plastics in AM, Lasix *3.
[**5-28**]: Had fever to 101.6 o/n with some hypertension requiring
hydralazine x 2 and labetalol. Head CT concerning for worsening
cerebral edema s/p EVD pulled yesterday. Started on mannitol.
New fever concerning for new infection: New left subclavian [**Month/Year (2) 14938**]
placed and R SCCVL pulled with culture of catheter tip sent. Pt
was pan cultured. Also stopped dilantin (pt almost therapeutic
on Keppra.)Went to OR with plastics for repair mandibular
fracture. Was again febrile to 101.3 upon arrival. APAP and
cooling blanket. Mandible fracture path with gpcs, gnr, gpr- d/w
plastics resident who explained was basically intra-oral swab-
no concern osteo. Did recommend adding Unasyn for mandible
fracture/wire which was continued until 5 days. Post op from
mandible fracture was hypertensive to 190s and HR 130s. ?
secondary to pain. Aggressive pain control with fentanyl,
Roxicet. Labetalol for BP -> vital signs stabilized.
[**5-29**]:CT Head with no significant changes, continue Unasyn; trach
mask, increased metoprolol, temp 100, osmol 319-322, Na 152-
held one dose of mannitol
[**5-30**]:Increased Lopressor to 75 tid, Mannitol continued.
[**5-31**]: Received Lasix 20 mg IV x 3 secondary to decreased urinary
output; off mannitol; Keppra changed to 1500 [**Hospital1 **]; transferred
from Trauma ICU to Neuro stepdown unit.
[**6-3**]: vomited in AM, large gastric bubble; GT vented; CT
head:left small extra-axial collection overlying the left
inferior frontal lobe is slightly larger, measuring 7 mm (
previously, 5 mm). No other interval change. CT Abd:No
obstruction. Two locules of free air in the upper abdomen, may
be related to instrumentation/related to G-tube.
[**6-6**]: OR phase 2; Vanc x 48 hours for BCx G+C, stopped [**6-8**] due
to growth of contaminants; PICC changed over
[**6-8**]: GNR in PICC tip culture, switched to Zosyn
[**6-9**]: 1unit of blood from JP drain, neuro status unchanged,
perrl, spontaneous movement all 4 ext RLE much less than others.
stat head CT: unchanged but motion artifact-no new hemorrhage,
similar hypodensities in frontal lobe, known cerebral edema, JP
wrapped around frontal sinus. 10 pm repeat head CT extra-axial
CSF collection
PICC tip culture +Enterobacter, pan sensitive, switched to Cipro
until [**6-16**]
[**6-14**]: JP self d/c'ed
[**6-20**]: fever, with mental status blunting, CXR, UA, urine/blood
culture
[**6-22**]: fever spike again to >102, CXR, UA, urine/blood culture;
Neurosurgery re-consulted for an LP
[**6-23**]: CT scan sinuses negative, GPC grown from blood cultures
6/29: TTE No valvular pathology or pathologic flow identified,
Vancomycin started.
[**6-26**]: LP performed and fluid sent for culture. Final culture
would later come back with no growth. PICC line placed
[**6-27**]: continuing to spike [**Month/Day (2) 5162**] daily, awaiting blood culture
speciation, failed Passy Muir evaluation
[**6-30**]: Blood Culture final 1 out of the 4 bottles with
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
[**7-1**]: Vancomycin stopped. Preparation for discharge to rehab
ongoing; medically stable for transfer today to [**Hospital3 **]
if bed available.
Medications on Admission:
None
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day) as needed for dry eyes,
swelling: Apply to both eyes.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) MG
PO BID (2 times a day): hold for loose stools.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): via feeding tube.
6. Levetiracetam 100 mg/mL Solution Sig: 1500 (1500) MG PO BID
(2 times a day).
7. Ibuprofen 100 mg/5 mL Suspension Sig: Four Hundred (400) MG
PO Q6H (every 6 hours) as needed for T>101: Notify MD [**First Name (Titles) **] [**Last Name (Titles) 5162**]
>101.
8. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day): via feeding tube.
9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) MG PO every 4-6 hours as needed for fever.
11. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO every six (6) hours.
12. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Oxycodone 5 mg/5 mL Solution Sig: 5-10 MG PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Motor vehicle crash
Bialteral subarachnoid hemorrhages
Diffuse axonal injury
LeFort II fractures
[**Location (un) **]
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Followup Instructions:
Follow up in 1 month with Dr. [**First Name (STitle) **], Neurosurgery. Call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up in 2 weeks with Dr. [**First Name (STitle) **], Plastic surgery. Call
[**Telephone/Fax (1) 5343**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2154-7-3**]
ICD9 Codes: 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2630
} | Medical Text: Admission Date: [**2193-9-29**] Discharge Date: [**2193-10-4**]
Date of Birth: [**2115-1-23**] Sex: F
Service: SURGERY
Allergies:
Opioid Analgesics
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
exploratory laparotomy
pneumococcal vaccine administration
History of Present Illness:
73F with known PVD who presented on [**9-29**] with 2-3 days of bright
red blood per rectum & crampy abdominal pain. The pain
localizes to her lower abdomen & has been worsening. She denied
f/c, n/v, but does report progressive anorexia over last 24
hours.
Past Medical History:
PMH: CAD s/p MI, GIB, HTN, ^chol, Hypothyroid, Carotid Dz
PSH: CABG, SAH, Open [**Last Name (un) **], Appy, TAH
Social History:
lives alone in 2 story house
no toxic habits
Family History:
noncontributory
Physical Exam:
T 100.8 P 110 BP 151/80 RR 16 98% RA
Alert, toxic
anicteric
tachy
CTA bilat
Soft +RLQ rebound tenderness
Rectal: guaiac +, hemorrhoid +
no CCE
Pertinent Results:
[**9-29**] CT abdomen: Portal venous and mesenteric venous gas
extending from the region of the cecum, with question of cecal
pneumatosis. The findings are suspicious for bowel ischemia.
Extensive calcific atherosclerotic disease. Marked stranding
surrounding the rectum and probable rectal thickening,
incompletely evaluated due to the lack of contrast in this area.
The findings are suggestive of proctitis of uncertain etiology.
Multiple hypodense liver lesions, many of which demonstrate
characteristics consistent with hepatic cysts although some of
which are too small to accurately characterize.
[**2193-9-28**] 05:00PM BLOOD WBC-16.1*# RBC-3.96* Hgb-12.6 Hct-36.5
MCV-92 MCH-31.7 MCHC-34.4 RDW-14.0 Plt Ct-189
[**2193-9-28**] 05:00PM BLOOD Neuts-91.8* Bands-0 Lymphs-5.2* Monos-2.8
Eos-0.1 Baso-0.1
[**2193-9-28**] 05:00PM BLOOD PT-15.1* PTT-25.8 INR(PT)-1.6
[**2193-9-28**] 05:00PM BLOOD Glucose-134* UreaN-36* Creat-2.0* Na-139
K-4.8 Cl-107 HCO3-16* AnGap-21*
[**2193-9-28**] 05:00PM BLOOD CK(CPK)-128 CK-MB-3 cTropnT-<0.01
[**2193-9-28**] 07:25PM BLOOD Lactate-3.7*
Brief Hospital Course:
[**9-28**]: Admitted to SICU for close HD monitoring, serial exams &
IV resuscitation.
[**9-29**]: Taken to OR because of concerning physical exam &
persistent acidosis. See op note for details, but briefly, a
normal cecum was found, sigmoidoscopy showed a normal rectum,
and aspiration of a hepatic cyst was performed.
[**9-30**]: NGT removed. Transferred to floor.
[**10-1**]: Abdominal pain improved. No positive stool cultures.
Started on PO diet, which she tolerated.
[**10-2**]: Diet advanced w/o complication. Rehab screen started.
[**10-4**]: Pneumococcal vaccine given prior to trasnfer to [**Hospital 100**]
Rehab.
Medications on Admission:
plavix 75', toprol 50', asa, synthroid 75', lipitor 20', ativan
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-27**]
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while using narcotics.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
CAD s/p MI s/p CABG
HTN
^chol
hypothyroid
Discharge Condition:
good
Discharge Instructions:
Diet as tolerated. No bathing (showers okay, pat wound dry), no
lifting objects heavier than a gallon of milk, and no driving
until your follow up appointment.
Contact your MD if you develop fevers > 101, increasing redness
or drainage about your incisions, or if you have any questions
or concerns.
Followup Instructions:
Contact Dr [**Last Name (STitle) 15645**] office at ([**Telephone/Fax (1) 9000**] to arrange a follow
up appointment in about 1 week.
Completed by:[**2193-10-4**]
ICD9 Codes: 5789, 2762, 4019, 412, 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2631
} | Medical Text: Admission Date: [**2137-9-8**] Discharge Date: [**2137-9-11**]
Date of Birth: [**2079-5-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
PCI with placement of drug eluting stent in RCA
History of Present Illness:
This is a 58 year old African American male with a history of
type II diabetes, hypertension and hyperlipidemia who presented
as a transfer from [**Hospital3 **] with an inferior STEMI. He
woke up this morning at 5:30am with central substernal chest
pain which he described as pain/pressure. The pain did not
radiate to either arm or jaw and was not accompanied by
shortness of breath, nausea, vomiting, or diaphoresis. He
presented to [**Hospital3 **] at 3:45pm where he was diagnosed
with an inferior MI and given ASA 325, 600mg plavix, started on
a heparin drip. His blood sugars at [**Hospital3 **] were ~500
and he was started on an insulin drip. He was transferred to
[**Hospital1 18**] for emergent cardiac catheterization.
.
On arrival at [**Hospital1 18**] he was reporting [**5-19**] pain, characterized as
"gas-like". Cardiac catheterization was achieved using a right
radial approach. Coronary angiography showed 100% occlusion in
the RCA, 40% occlusion in the left main, and a clean circumflex.
A single DES was placed in the RCA and he was started on
integrilin.
.
He arrived to the CCU alert and oriented and without any current
complaints. He was without any chest pain, shortness of breath
or nausea.
.
He reports one similar episode of chest pain approximately one
year ago at which time he was diagnosed with a pneumonia.
Otherwise no prior episodes of chest pain and no anginal
symptoms.
.
He noticed that his blood sugars were high over the last few
days but otherwise no recent change in his health. He has
recently been feeling well without any particular recent
illnesses or stresses.
.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia,+Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2137-9-8**]: 1x DES to RCA
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Diabetes x 7 years
Hypertension
Hyperlipidemia
History of Pneumonia
Social History:
- Tobacco history: never smoker
- ETOH: rare
- Illicit drugs: none
Originally from [**Country 2045**]. Works as a cook [**Location (un) 90560**] Plaza
hotel. Lives with his wife. [**Name (NI) **] five children ages 25-40, all in
the area and very supportive.
Family History:
-Father died of MI at 71
-Mother living with hypertension
-Multiple family members with diabetes
-Sister with breast cancer
Otherwise non-contributory. No other family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Admission Exam
VS: T=98.5 BP= 154/89 HR= 85 RR= 18 O2 sat= 98% Wt 63kg Ht 165cm
(5'5")
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge Exam
On day of discharge, BP was elevated (SBP 150s-170s/80s-90s), HR
60s. Cardiac exam showed RRR, no m/r/g, lungs clear.
Pertinent Results:
Admission Labs
CK(CPK)-3623* CK-MB-158* cTropnT-10.46*
cTropnT-0.22*
Na 132 K 4.1 Cl 97 HCO3 26 BUN 23 Cr 1.3 Gluc 581
PERTINENT LABS:
Cardiac Enzymes
[**2137-9-9**] 04:49AM BLOOD CK(CPK)-2877*
[**2137-9-9**] 03:30PM BLOOD CK(CPK)-1771*
[**2137-9-9**] 04:49AM BLOOD CK-MB-120* MB Indx-4.2 cTropnT-7.88*
[**2137-9-9**] 03:30PM BLOOD CK-MB-51* MB Indx-2.9
HbA1c
[**2137-9-9**] 04:49AM BLOOD %HbA1c-12.2* eAG-303*
DISCHARGE LABS:
[**2137-9-11**] 05:55AM BLOOD WBC-5.2 RBC-4.19* Hgb-11.8* Hct-33.2*
MCV-79* MCH-28.2 MCHC-35.7* RDW-13.5 Plt Ct-145*
[**2137-9-11**] 05:55AM BLOOD Glucose-143* UreaN-18 Creat-1.0 Na-142
K-3.6 Cl-107 HCO3-29 AnGap-10
[**2137-9-11**] 05:55AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
PERTINENT STUDIES
Cardiac Cath ([**2137-9-8**]):
1. Selective coronary angiography of this right dominant system
demonstrated single vessel coronary artery disease with
associated left
main disease. The LMCA had a cleft like 40-50% stenosis. The
remainder
of the LAD and LCx were free of angiographically significant
disease.
There were faint left to right collaterals. The RCA was occluded
proximally prior to the acute marginal.
2. Limited resting hemodynamics demonstrated moderate to severe
systemic
arterial hypertension (184/89mmHg).
3. Rhythm during the case was a junctional rhythm with
isorhythmic
dissociation from a slightly slower atrial escape rhythm. There
were
episodes of ventricular bigemeny.
TTE ([**2137-9-9**]): LVEF = 50. Prominent symmetric left ventricular
hypertrophy with regional systolic dysfunction c/w CAD (PDA
distribution). Dilated ascending aorta.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: 58 year old male with history of
type II DM and HTN presenting with an inferior MI now s/p 1x DES
to RCA.
# CAD/Inferior MI: Patient presented with chest pain EKG pattern
(ST elevations in III > II and ST elevations in V4R) suggestive
of right ventricular infarct. Cardiac cath showed 100% RCA
occlusion 40% left main, clean circ. Pt is now s/p DES.
Following cath junctional rhythm on arrival to the CCU which
converted to sinus. Additionally he had 2 runs of non-sustained
V tach during which he was hemodynamically stable with
spontaneous conversion to sinus. He was started on aspirin,
lisinopril, carvedilol, atorvastatin and prasugrel with plan to
continue prasugrel for 1 year post stent. Given multi vessel
disease patient will need stress test in 1 week to assess 40%
left main disease for possible cardiac surgery.
# ?Infiltrative cardiomyopathy: Patient's [**2137-9-9**] TEE showed
echogenic texture with ground glass appearance, concerning for
possible infiltrative cardiomyopathy. SPEP and UPEP were sent
and were pending at time of discharge. Patient was scheduled
for outpatient cardiac MRI to further evaluate.
# Acute kidney injury: Creatinine 1.3 on admission. Patient's
home lisinopril dose was decreased from 60 mg to 40 mg and his
home HCTZ and metformin were held. He was given gentle
hydration and creatinine returned to baseline. He was asked to
restart his home dose HCTZ when he leaves the hospital.
CHRONIC DIAGNOSES:
# DM: Pt has 7 year history of type II diabetes on metformin at
home. HgbA1c was 12.2%. He was initially started on insulin gtt
for blood sugars in the 500s. When glucose improved he was
transitioned to a SQ regimen of 10 units of Lantus with a
sliding scale. Lantus was increased to 15U qAM on HD2. On
discharge, he was restarted on his home metformin and asked to
follow up with his PCP about blood sugar control.
# HTN: Home HCTZ, atenolol and amlodipine were held. Lisinopril
was decreased from 60mg to 40 mg in the setting of acute kidney
injury. Carvedilol 6.25 [**Hospital1 **] was started.
# Hyperlipidemia:
Pt started on high dose atorvastatin 80mg PO daily
TRANSITIONAL ISSUES:
- Patient maintained full code status throughout hospitalization
- HbA1c 12% on admission, pt will likely need to start insulin
regimen at home
- Medication changes:
- Atenolol and amlodipine were stopped
- Lisinopril decreased from 60mg daily to 40mg daily
- HCTZ held during hospitalization, pt asked to resume after
discharge
- Simvastatin changed to atorvastatin 80mg daily
- Started carvedilol 6.25mg [**Hospital1 **], ASA 325mg daily, Prasugrel
10mg daily
- F/u SPEP and UPEP (results pending at discharge)
- F/u stress echo on [**2137-9-17**] to assess left main vessel disease
- F/u cardiac MRI on [**2137-10-10**] for question of infiltrative
myopathy
Medications on Admission:
Atenolol 50mg daily
Lisinopril 60mg daily
Metformin 500mg daily (no longer on glyburide)
Amlodipine 10mg daily
Simvastatin 40mg daily
K-Dur 20mEq twice daily
Hydrochlorothiazide 50mg daily
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once
a day.
7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: ST elevation myocardial infarction
Secondary Diagnosis: Type II Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 90561**]
It was a pleasure taking care of your during your recent
admission to [**Hospital1 69**]. You were
admitted because of a myocardial infarction, also known as a
heart attack. You were taken immediately to the operating room
where the clogged arteries in your heart were opened, and a
stent was placed to ensure that the arteries remain open. After
this procedure, you were stabilized in the intensive care unit,
and you recovered well.
Many changes were made to your medications. You were
started on several new medications. These are: aspirin 325mg,
atorvastatin 80mg (instead of your home simvastatin), carvedilol
6.25mg (instead of your home atenolol), and prasugrel 10mg.
Your lisinopril was decreased to 40mg once daily.
Your atenolol, simvastatin, and amlodipine were stopped.
Please follow up with your primary care doctor about whether
these medications should be restarted in the future.
While you were in the hospital, your blood sugars were
controlled with insulin. Your HgbA1c was 12%, which is high,
suggesting that you need to control your blood sugars better.
You should discuss this with your primary care doctor.
You will follow-up with your primary care doctor as well
as a new cardiologist. You will need to have a stress test in
one week, which has already been ordered. You will also need an
MRI scan of the heart before your appointment with your
cardiologst, Dr. [**First Name (STitle) **], on [**10-10**]. Please see
below for the times and locations of your scheduled
appointments.
It was a pleasure taking care of you at [**Hospital1 18**], and we wish you a
speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) 90562**],[**First Name3 (LF) **] A., MD
Specialty: INTERNAL MEDICINE
Location: [**Hospital **] MEDICAL CENTER
Address: [**State 11413**]., #235, [**Location (un) **],[**Numeric Identifier 8235**]
Phone: [**Telephone/Fax (1) 90563**]
Appointment: Monday [**9-16**] at 2:40PM
Department: CARDIAC SERVICES
When: THURSDAY [**2137-10-10**] at 10:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 4271, 4254, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2632
} | Medical Text: Admission Date: [**2175-1-29**] Discharge Date: [**2175-2-10**]
Date of Birth: [**2100-3-19**] Sex: F
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Bleeding at right AV fistula site.
HISTORY OF PRESENT ILLNESS: The patient is a 74-year old
female with end-stage renal disease secondary to IDDM and
hypertension; on hemodialysis every Monday, Wednesday and
Friday at the [**Location (un) **] Hemodialysis Unit. Her attending is
Dr. [**Last Name (STitle) **]. She was transferred to [**Hospital1 18**] for bleeding from her
AV fistula site. The first time was spontaneously. The second
time was secondary to the patient disturbing the dressing.
The bleeding was controlled in the ED with a stitch. She was
in her usual state of health, although had an extra
hemodialysis session for volume overload.
REVIEW OF SYSTEMS: No complaints, though the patient has
dementia.
PAST MEDICAL HISTORY: Significant for Alzheimer's with
vascular dementia, right AV fistula, post angioplasty, recent
admission in [**2174-12-1**] for mental status changes and
question encephalopathy and hypercalcemia.
PAST SURGICAL HISTORY: Cholecystectomy and a nephrectomy.
MEDICATIONS AT HOME: Aricept 10 mg p.o. at bedtime, aspirin
81 mg p.o. daily, Cozaar 100 mg p.o. daily, Norvasc 5 mg p.o.
daily, insulin daily, Zantac daily, Glucotrol 5 mg p.o.
daily, Renagel 2400 mg p.o. t.i.d., Nephrocaps 1 p.o. daily,
Sensipar 30 mg p.o. daily, hydralazine 100 mg p.o. q.a.m. and
50 mg at bedtime.
FAMILY HISTORY: Unable to obtain.
PHYSICAL EXAMINATION: Temperature 98.2, BP 148/78, heart
rate 75, respiratory rate 20, O2 saturation 100% on room air,
weight 139.8 pounds. She was alert and oriented x1. In no
acute distress. Lungs clear. Positive systolic murmur.
Regular rate and rhythm. Abdomen is soft and nontender with
positive bowel sounds. No lower extremity edema bilaterally.
Right upper extremity AV fistula is positive for thrill, and
this was palpable at the proximal aspect of the fistula.
LABORATORY DATA ON ADMISSION: White count was 7.3,
hematocrit 32.5, platelet count 174, creatinine 9.3, BUN 61,
with a potassium of 7.7 (which was hemolyzed), calcium was
9.7, magnesium 2.1, and a phosphorous of 5.
HOSPITAL COURSE: The patient was admitted for bleeding of
her AV fistula while in HD. This was stitched. She was taken
to the OR by Dr. [**First Name (STitle) **] [**Name (STitle) **]. The patient underwent an
excision and repair of right arm AV graft pseudoaneurysm with
a 6-mm PTFE jump graft. The patient tolerated the procedure
well and was extubated and transferred to the recovery room
in stable condition. Noted that it was okay to use the upper
arm portion of the AV graft for dialysis.
The patient was sent directly from the OR to dialysis. Her AV
fistula was cannulated on the upper without any problem. She
underwent hemodialysis without any problems; 0.5 liters were
ultrafiltrated.
The patient was admitted to the medical surgical unit after
hemodialysis. Noted that the patient was having mental status
changes. She appeared confused, only responded to painful
stimuli and sternal rub. She was shouting. Her O2 saturation
dropped to the mid 80s. She was put on an 02 nonrebreather.
ABGs were sent off as well as a full set of labs. O2
saturation improved to 100%. A central line was placed.
She was transferred to the SICU for monitoring. During
evaluation, the daughter was [**Name (NI) 653**]. It was noted that the
daughter stated that the patient's behavior was typical, that
she has dementia. She had a waxing and [**Doctor Last Name 688**] level of
consciousness. She received no sedation. Neurology was
consulted. A head CT was done. ABGs were done as well; pH was
7.39, pO2 420, pCO2 45. Head CT demonstrated no acute
intracranial hemorrhage, and the recommendations from
neurology included MRI/MRA to evaluate for stroke. They
recommended treating empirically with vancomycin and
ceftriaxone for infection, as it was felt that it was unsafe
to perform a LP due to a low platelet count and coagulopathy.
No antiepileptics were recommended. Of note, during
hemodialysis the patient had a low blood pressure of 70/40.
This responded to Trendelenburg position and a fluid bolus.
She is normally anuric. Her blood sugar was normal. The
patient was also transfused with 2 units of packed red blood
cells for a hematocrit of 20. Hematocrit increased to 28. The
patient was transferred back to the medical surgical unit.
Seizure was likely secondary to uremia. A temporary dialysis
catheter was placed in radiology as the right AV graft
thrombosed. The patient continued to receive hemodialysis via
the temporary catheter.
The patient returned on [**2-1**] to the OR for thrombectomy
of the right upper arm AV graft with fluoroscopy. The surgeon
was Dr. [**First Name (STitle) **] [**Name (STitle) **], assisted by Dr. [**First Name8 (NamePattern2) 30642**] [**Name (STitle) **]. The
patient received local with MAC. Impression included proximal
stenosis, and a venography was recommended with possible
dilatation of more proximal stenosis.
On [**2-2**], IR was unable to perform a venogram secondary
to the patient being uncooperative and agitated. This was
felt to be secondary to her dementia. She remained on IV
antibiotics for possible infectious etiology for seizure;
although this was less likely, this was a low probability.
The patient had episodes of semi appropriate responses and
answers to questions.
On [**2-6**], the patient underwent a right arm AV
fistulogram and a venogram via the right common femoral vein
catheter. A catheter was placed with the SVC that
demonstrated an approximately 2-cm occlusion extending from
the right brachiocephalic vein to the upstream portion of the
superior vena cava. Extensive venous collaterals were
demonstrated at the right upper chest, shoulder, and the
right upper arm. The recanalization of occlusion with a 0.035
glide wire was unsuccessful.
On [**2-8**], the patient underwent an MRI of the chest and
mediastinum to evaluate the left arm for future access to
rule out central stenosis. This study demonstrated a widely
patent left subclavian vein, internal jugular vein,
brachiocephalic vein, and superior vena cava. An occlusive
thrombus was noted within the right brachiocephalic vein with
partially occlusive thrombus in the right subclavian vein. No
flow was seen in the right internal jugular vein. Enhancement
of the vessel walls suggested subacute age, probably within 2
weeks. A 2.5-cm peripheral lung lesion with T2 hyperintense
center and rim enhancement was noted. Findings were noted to
be possibly related to infection; although given thrombus
seen within the central right veins, a septic emboli and
infarct were also amongst the differential diagnoses. The
differential diagnoses included neoplasm. After discussion of
MRI findings with the patient's daughter, a chest CT without
contrast was done to evaluate the left upper lobe lesion.
This was confirmed by CT. A left upper lobe peripheral
pleural based mass like opacity was noted. A small cavitation
was seen on the reformatted images. Given this rapid
development compared to a chest radiograph from [**2174-12-16**] a neoplasm seemed unlikely.
PLAN THIS HOSPITAL COURSE: The patient was evaluated by
physical therapy. PT recommended for strengthening and
safety. The patient's daughter called and noted that the
patient was unsafe at home. She was afraid to take the
patient home and wanted the patient to be placed in a nursing
home. Social service was consulted and followed along
closely. The patient has been living at [**Hospital3 2558**] and
did have a bed to return to. Throughout the remainder of this
hospital stay the patient was relatively cooperative. She did
have a one-to-one sitter. A one-to-one sitter was stopped
after her left groin temporary hemodialysis catheter was
removed. Her vital signs were stable. She continued on
vancomycin and ceftriaxone for empiric treatment for
meningitis; although this was felt to be low probability, and
her mental status changes were attributed to uremia and
dementia. An EEG was recommended by neurology. It was felt
that this could be done as an outpatient.
On physical exam, the patient's right upper extremity graft
site was open to air with sutures without any redness,
drainage or bleeding. She required assist with all areas of
ADL. Appetite was good. Blood sugars were controlled with her
regularly scheduled insulin.
DISCHARGE PLAN: The plan was to discharge to [**Hospital3 2558**]
on [**2175-2-10**] on the following medications.
DISCHARGE MEDICATIONS: Donepezil 5 mg p.o. at bedtime,
losartan 50 mg p.o. daily, amlodipine 5 mg p.o. daily,
hydralazine 25 mg p.o. q.6h., glipizide 5 mg p.o. b.i.d.,
enteric coated aspirin 81 mg p.o. daily, Zantac 150 mg p.o.
daily, Senna, Calcet 30 mg p.o. b.i.d., insulin sliding
scale, Colace 100 mg p.o. b.i.d., Thiamine 100 mg p.o. daily
(Thiamine was recommended by neurology for possible
Wernicke's encephalopathy).
DISCHARGE DIAGNOSES: Included end-stage renal disease,
diabetes, hypertension, dementia, left upper lung nodule,
right brachiocephalic occlusive thrombus, status post
creation of right upper extremity arteriovenous graft and
repair of right upper extremity arteriovenous fistula
pseudoaneurysm.
DISCHARGE FOLLOWUP: The patient was scheduled to follow up
with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2175-2-16**].
DISCHARGE CONDITION: Stable.
DISCHARGE LABORATORY DATA: Labs on [**2-9**] included a
white blood cell count of 8.2, hematocrit of 26.5, platelet
count of 255. Sodium 140, potassium 4.7, chloride 100,
bicarbonate 29, BUN 22, creatinine 4.9 and a glucose of 97.
CPK was drawn; this was 120. Calcium was 7.3, magnesium of
1.7, phosphorous of 3.1, albumin of 3.4. Vancomycin level on
[**2-2**] was 18.9.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2175-2-10**] 15:28:26
T: [**2175-2-10**] 16:53:52
Job#: [**Job Number 94023**]
ICD9 Codes: 5856, 496, 2767, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2633
} | Medical Text: Admission Date: [**2120-7-18**] Discharge Date: [**2120-7-30**]
Date of Birth: [**2049-6-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Right Medial Tibial Plateau Fracture
Major Surgical or Invasive Procedure:
Hemodialysis x2
History of Present Illness:
Patient is a 71 year old female with PMHx significant for IDDM,
ESRD, CAD, and HTN p/w with knee swelling, pain and limited ROM.
Patient reports that her pain developed over the course of 7
weeks and progressively got worse over time. She cannot recall
any particular event that could have caused trauma however she
does mention that when she uses an elevator at home that she
occasionally develops bruises on her knee from the apparatus.
She used to ambulate with a walker and but has recently been
unable to use it due to the pain. She was recently discharged
from [**Hospital1 18**] on [**2120-6-20**] after being admitted for lower extremity
cellulitis (MSSA, psuedomonas, sensitive to zosyn, clinda,
oxacillin, erythro, gent, bactrim. resistant to PCN). At this
point she was treated with a course of vancomycin and unasyn
however was transitioned to ciprofloxacin and dicoxacillin. She
had her R knee tapped during the hospitalization and only 444
WBC, but many thousand RBC (?traumatic). Xray of the knee at the
time showed tibial osteopenia and an U/S neg for DVT. Soon after
she developed nausea/vomiting following taking the dicloxacillin
and returned to the health center to be given injections of
vancomycin to finish her course. Since then the patient reports
that her redness on the leg has diminished greatly but the pain
has never subsided requiring a total of 6 percocet per day and
intermittent motrin.
.
Patient presents on this admission with persistent right knee
pain, swelling, warmth, and limited range of motion, which has
progressively gotten worse since [**Month (only) 205**] especially after her taps.
She was seen by her rheumatologist earlier today and was sent to
the ER for further work-up to r/o infection, internal
derrangement, and better pain control. She states that she has
been wheelchair bound since [**Month (only) 205**] and is unable to use her walker
since she is not able to bear weight on her right knee.
.
Patient complains of dyspnea/SOB on admission but denies any
fevers, chills, chest pain, SOB, abdominal pain, or N/V/D.
Remaining review of systems was unremarkable.
.
In the ED, the patient was seen by the Ortho consult team and
her right leg was placed in a brace for tibial plateau fracture.
Past Medical History:
1. ESRD/CRI - Patient receives HD @ "[**Last Name (un) 96929**]" center in [**University/College **]
- M/W/F.
2. IDDM - Course has been complicated by polyneuropathy,
nephropathy, retinopathy, and Charcot foot bilaterally
- patient does not check her FS at home, she received 70 u in am
and 30 u in pm of 70/30. Followed by Dr. [**First Name (STitle) 1313**] ? in [**Last Name (un) **].
3. Peripheral vascular disease
4. AF - Pt is s/p pacemaker placement. She is not anticoagulated
due to multiple falls.
5. Anemia
6. Hyperlipidemia
7. Cirrhosis secondary to cholestasis
8. Hypertension
9. Coronary artery disease- Pt had three vessel disease on
cardiac cath from [**2111**]. She is s/p NSTEMI in [**2110**].
Stress test '[**12**]. Moderate, fixed perfusion defect in the
inferior wall. Mild global hypokinesis.
10. Dilated ischemic cardiomyopathy- Pt's most recent echo was
[**2119-6-26**]. EF 40%; mod LA/RA dilation; mild LVH/mild global HK
(most prominent in the septum); 1+ MR. Mod pulmonary HTN
11. Adrenal adenoma
12. S/P TAH for leiomyoma
13. Right facial droop in [**7-/2119**] for which she declined workup
or treatment.
14. Depression
15. s/p mechanical fall, L elbow/olecranon Fx on [**2120-1-6**] -
conservative management
Social History:
Pt lives in her own home in [**Location (un) 1110**]. She has 24 hour help at this
time, although recently helper can't come in over the weekend,
the son has been speding more time with her. The patient rare
walks with a walker and mostly gets about in a wheelchair. She
is very close with her daughter, [**Name (NI) 2808**], who visits often and
her son, [**Name (NI) 96930**], who is her healthcare proxy. His phone number
is [**Telephone/Fax (1) 96931**]. DNR/DNI. Pt used tobacco in the past - quit 24
years ago. Denies ETOH or drug use.
Family History:
Fa - DM, CAD; Ma - Breast Ca;
Physical Exam:
vital signs: T 98.4 BP 120/70 HR 84 RR 20 O2Sat 96% on 2L
General: obese, sleepy, NAD, brace on her right knee
HEENT: PERRLA, dry mucous membranes
Neck: No lymphadenopathy/thyromegaly
Lungs: minimal crackels and wheesing, poor inspiratory effort
dialysis catheter site on right chest wall-intact, no
erythema/tenderness
Heart: RRR, nl s1 and S2, no s3/s4, no m,r,g
Abdomen: Obese, soft, non-tender/non-distender, +BS. No
hepatosplenomegaly.
Extremities: Right leg in brace, knee not examined; DP/PT pulses
not palpable, poor sensory exam, diabetic foot ulcers
Brief Hospital Course:
- R tibial plateua fracture: followed by Orhto and deemed
inoperable. Worked with PT/OT and was unable to pivot on one
foot and will required acute rehab with HD services.
- ESRD: recieved hemodialysis x2
- IDDM: intermittent hypoglyxemia so regular 70/30 doses of 70U
am 30U pm were hjalved to 35U am 15U pm with good results
- Pain: manage with standing morphine 30U SR PO Q12 hr and PRN
oxycodone for breakthrough pain
- UTI: asymptomatic UTI with UCx treated with Bactrim x5d
Medications on Admission:
1. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(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. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
Disp:*15 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
7. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*0*
11. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
Disp:*80 Tablet(s)* Refills:*0*
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48 ().
Disp:*30 Capsule(s)* Refills:*0*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Disp:*1 1* Refills:*0*
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
20. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: One (1) Subcutaneous [**Hospital1 **]: give 35U am and 15U pm.
Disp:*30 1* Refills:*0*
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(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. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
Disp:*15 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
7. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*0*
11. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
Disp:*80 Tablet(s)* Refills:*0*
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48 ().
Disp:*30 Capsule(s)* Refills:*0*
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Disp:*1 1* Refills:*0*
16. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*1*
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
20. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: One (1) Subcutaneous [**Hospital1 **]: give 35U am and 15U pm.
Disp:*30 1* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary: Right Medial Tibial Plateau fracture
Secondary: Insulin dependent diabetes mellitus, End stage renal
disease requiring hemodialysis, coronary artery disease,
hypertension, diabetic foot ulcers, anemia
Discharge Condition:
The patient was admitted with a right medial tibial plateau
fracture that was deemed inoperable by the orthopedics service.
She was stabilized medically and begun on her regular home
medication regimen. She is currently s/p two hemodialysis
treatments and her course has only been complicated by
intermittent episodes of hypoglycemia in the 70-80's which
required reducing her insulin regimen from 70am/30pm to
35am/15pm, treated UTI with Bactrim, and constipation treated
with colace, senna, enema.
Discharge Instructions:
Please have your nurse administer all medications as noted. You
will be transfered to a facility where your rehabilitation will
be monitored and you will be able to have your hemodialysis as
normally scheduled M/W/F and please hold BP meds those mornings.
Please adhere to a diet that is low in sodiuma, fats, and
sugars. Please speak to you healthcare provider in the extended
care facility if you develop fevers, chills, night sweats,
nausea, vomiting, diarrhea, or change in your mentation.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 1-[**Telephone/Fax (1) 250**] when you
are finished with your rehabilitation. Also, please call to make
an appointment with the orthopedics department following your
evaluation at the extended care facility.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2120-7-23**]
ICD9 Codes: 5990, 5856, 2875, 2762, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2634
} | Medical Text: Admission Date: [**2198-12-4**] Discharge Date: [**2198-12-14**]
Date of Birth: [**2153-12-22**] Sex: M
Service: [**Last Name (un) 7081**]
DISCHARGE DIAGNOSIS: Tragal stenosis and diaphragmatic
hernia.
MAJOR INVASIVE PROCEDURES: Diaphragmatic hernia repair.
HISTORY OF PRESENT ILLNESS: This is a 41 year-old male who
had a motor vehicle accident in [**2198-3-21**] with a coma. He
had a left chest tube placed and was seen to have a right
wrist fracture. He had a long course in the hospital which
was complicated by intubated resulting in tracheal stenosis.
He also had a left diaphragmatic hernia and was discharged
home on [**2198-10-21**] and was readmitted for nausea and
vomiting. He was admitted to an outside hospital with this
condition and then transferred here to the [**Hospital1 346**] for the management of tragal
stenosis and treatment of his hernia repair.
PAST MEDICAL HISTORY: Notable for asthma, OSA, obesity,
hypoventilation syndrome and diabetes x2, morbid obesity,
peripheral neuropathy, hyperlipidemia, depression. Patient
was status post tracheostomy x2, gastrostomy tube and
inferior vena cava filter placement.
MEDICATIONS: The patient is on Pepcid 20 b.i.d.,
subcutaneous heparin 500 t.i.d., enalaprilat 1.2 grams q 6
p.r.n., Haldol 0.5 IV q 4, Dilaudid 1 dose IV q 4, Ativan x1
IV q 2, Phenergan, Advil and albuterol. The patient was
taking all these medications in his rehab facility.
SOCIAL HISTORY: The patient is an ex-smoker, quit in [**2185**].
He has a 40 year-pack history. Occupation is a house painter.
He lives alone in a rehab facility in [**State 2748**].
FAMILY HISTORY: Denies any family history in his family.
REVIEW OF SYSTEMS: Remarkable for shortness of breath.
Everything else is within normal limits.
The patient was admitted on [**2198-12-4**] and was
admitted to the thoracic surgery service under Dr. [**Last Name (STitle) 952**]. He
was initially started on total parenteral nutrition the next
day after admission. Interventional pulmonology was consulted
on the [**2198-12-5**] for a bronchoscopy to be done to
assess the patient's trachea. It did notice tracheal stenosis
with mild supraglottic edema. The larynx was normal and
showed normal vocal cords. He had mild tracheal stenosis 2 cm
below the vocal cords which involved the cricoid and the
first tracheal ring. After performing the bronchoscopy and
consulting with interventional pulmonology it was felt that
patient should undergo repair of his diaphragmatic hernia
which was done. An x-ray was more of a priority during this
admission because of his tracheal stenosis. Patient was pre-
opped on the [**12-6**]. He was started on his total
parenteral nutrition. On the 17th the patient was taken to
the OR for left diaphragmatic hernia repair with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) 952**]. Patient tolerated the procedure
well without any major postoperative complications or any
intraoperative complications. He was typed and crossed for 2
units and consent was obtained. Chest x-ray preoperatively
was clear with no cardiopulmonary disease. There was
diaphragmatic hernia which was notable. In the OR the patient
was placed under general anesthesia. He had 1 liter of output
and had 3500 cc of Crystalloid with about 100 cc of estimated
blood loss. A left chest tube was placed into the patient's
thorax. A chest x-ray was obtained immediately
postoperatively which showed atelectasis at the base of the
left lung which increased slightly. Basal pleural drain was
in place. The right lung was clear. His cardiomediastinal
silhouette was the same as preoperatively. There was tracheal
narrowing noted and the nasogastric tube was also placed. It
was passed into the stomach. The patient had no pneumothorax
postoperatively. On the 21st the patient was then placed on
water seal and again there was no pneumothorax. A left sided
PICC was placed with the tip in the superior vena cava but
the mediastinal and hilar contours remained stable. An x-ray
was again obtained on [**12-12**] which again showed a
moderate size loculated left anterior hydropneumothorax and
smaller posterior pleural air and fluid collection which
remained unchanged. The cardiac and mediastinal silhouette
was also noted. After this the patient had his chest tube
remained on [**12-12**]. A post pull chest x-ray was obtained
which showed slight pneumothorax on the left chest. The
following day on the 23nd the patient underwent another chest
x-ray which showed no significant interval change. There was
a mid right pneumothorax which was unchanged in size and
morphology. However, the right lung remained clear. The
patient had no complaints of shortness of breath, abdominal
pain, nausea, vomiting or dyspnea on exertion throughout his
hospital course and immediately postoperatively. The patient
did well and on the [**12-13**] his PICC was removed as
we did not feel that he needed any intravenous antibiotic or
IV hydration for an extensive period of time. A peripheral
was placed. Total parenteral nutrition was also discontinued
on the [**12-12**]. Patient was started on a regular
diet which he tolerated well.
Patient is being discharge in stable and healthy condition.
He is ambulating with his walker. He is afebrile. His vital
signs are stable. He is making good urine. He is ambulating
and voiding appropriately and he had 1 bowel movement prior
to discharge. Patient was instructed. He is to follow up with
Dr. [**Last Name (STitle) 952**] in 2 to 3 weeks for evaluation and postoperative
assessment. He was told that if was to get increased nausea
or vomiting he was to come to the emergency room along with
any temperature greater than 101.5, any increased pain, any
increased abdominal distention that may occur, any chest pain
or shortness of breath that he may experience. Patient is
also to be discharged on pain medications and instructed to
not drive or operate heavy machinery. He is also told not to
lift more than 10 pound object at any one time as this can
cause pressure along his incisions in the skin. Again patient
is being discharged in good condition without any significant
issues.
LABORATORY DATA: He did not require any transfusions during
his hospital course. His hematocrit remained in the 33.2 to
38.8 requiring no transfusions. His white count remained
within normal limits except for the postoperative period on
postoperative day 0 when it was 15.2 immediately
postoperative. Cultures were obtained on this patient. Urine
culture which was notable on the 15th showed pseudomonas
enterococcus. The patient was then placed on vancomycin and
Zosyn for the treatment of this urinary tract infection. On
the 21st another culture was obtained which showed
contamination. Blood cultures from the 22nd and [**12-13**] also pending. The catheter tip from the PICC line
was also sent for culture and is pending. Sputum shows
greater than 25 polynuclear neutrophils and greater than 10
epithelial cells by 100x field. There was noted to be
contamination of the upper respiratory secretions.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern1) 29268**]
MEDQUIST36
D: [**2198-12-14**] 09:15:12
T: [**2198-12-14**] 10:08:11
Job#: [**Job Number 70077**]
ICD9 Codes: 5990, 4019, 5180, 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2635
} | Medical Text: Admission Date: [**2196-9-26**] Discharge Date: [**2197-1-11**]
Date of Birth: [**2196-9-26**] Sex: M
Service:
HISTORY: Baby [**Name (NI) **] [**Known lastname 52222**] is a former 25-1/7 week
gestation male admitted to the Newborn Intensive Care Unit
after deliver at 2:22 a.m. Obstetricians were Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] of Maternal Fetal Medicine.
Mom is a 29-year-old G1 P0 now 2 mom. This pregnancy was
conceived with in-[**Last Name (un) 5153**] fertilization assistance and was
diamniotic-dichorionic twins. Estimated date of confinement
[**2197-1-8**].
Prenatal screens: Blood type AB+, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella immune, group B Strep status unknown.
Fetal ultrasounds were unremarkable on two occasions. This
pregnancy was uncomplicated until 22-2/7 weeks gestation when
the mother developed preterm labor on [**2196-9-6**]. She
was noted to have cervical changes at the time. She was
treated with bed rest, magnesium sulfate, indomethacin, and
betamethasone. She remained hospitalized on bed rest. Early
on in the morning at delivery, she was noted to have labor
once again and to be fully dilated. No maternal fetal was
reported. Rupture of membranes was at time of delivery.
Cesarean section was performed by Dr. [**Last Name (STitle) **]. The infant
emerged with good cry and respiratory effort. He received
stimulation, bulb mouth and nose, and then received bag mask
ventilation. He was intubated with a 2.5 endotracheal tube.
Lung sounds were noted to have poor compliance with bagging.
Apgar scores were 7 at 1 minute and 8 at five minutes. The
infant was transferred to the Neonatal Intensive Care Unit
for management of prematurity.
PHYSICAL EXAM ON ADMISSION: Pink, appropriate for
gestational age, 25-1/7 week gestation male, breathing with
mild retractions over the ventilator. Vital signs: Heart
rate of 148, respiratory rate 60s, blood pressure 39/20 with
a mean of 28, oxygen saturation 98% on 100% O2. Birth weight
787 grams (50th percentile), length 35 cm (50th percentile),
head circumference 23.5 cm (50th percentile). Anterior
fontanel soft and flat. Sutures mobile. Faces normal.
Eyelids open. Palate intact. Red reflex deferred. Breath
sounds decreased in both bases. Stiff compliance equal.
Cardiac: Equal S1, S2, no murmur. Perfusion fair except to
left lung. Left leg noted to blanch. Transiently starting
in the delivery room with slow improvement over the first 30
minutes of life, back to normal, and capillary refill
slightly decreased diffusely. Abdomen is soft with no
organomegaly. Three vessel umbilical cord normal. Phallus:
Testes undescended. Bruising noted on the dorsal side of the
penis. Hips stable. Skin: Bruising noted over the left
lower rib cage. Two small spots in the back and left foot.
Neurological: Normal tone for gestational age. Infant
active with symmetrical movements of upper and lower
extremities.
HOSPITAL COURSE BY SYSTEMS:
Respiratory: Shortly after admission to the Newborn
Intensive Care Unit, the baby was placed on a high frequency
ventilator starting with a mean airway pressure of 10, delta
P of 22 and a FIO2 of 48%. He subsequently received four
doses of Surfactant and remained on the high frequency
ventilator until day of life 28 when he transitioned to the
conventional ventilator.
On day 35, he transitioned to CPAP. On day 45, he required
reintubation for apnea and bradycardia after receiving
Fentanyl for removal of a Broviac at the bedside. He
remained intubated for about 48 hours and again transitioned
to CPAP. He then came off CPAP on day of life 51
intermittently requiring nasal cannula O2 for several days
and then by day of life 54 was in room air.
Caffeine citrate was started on day of life 24 as he was
weaning off his ventilator settings. He remained on caffeine
citrate until day of life 63. At the time of the discharge,
he has been stable on room air with no further respiratory
distress, no apnea, or bradycardia, or desats for greater
than five days. His baseline respiratory rate is 30s-60s
with breath sounds clear and equal.
Cardiovascular: Upon admission to the Newborn Intensive Care
Unit, the infant's mean arterial blood pressure dropped below
25 requiring normal saline boluses x2, and initiation of
dopamine infusion. Dopamine maxed out at 15 mcg/kg/minute.
He was treated on day of life one with indomethacin for
presumed patent ductus arteriosus.
On [**9-29**], an echocardiogram showed a continued patent
ductus arteriosus of 2 mm in size. A second course of
indomethacin was initiated. After that course, a repeat
echocardiogram was done on [**9-30**], which showed a
persistent moderate patent ductus arteriosus of 1.5 mm in
size. The second course of indomethacin was extended and
received one additional dose of indomethacin on [**10-1**].
A fifth dose was planned, but was not given secondary to an
intestinal perforation on [**10-2**]. He again required
pressor support in response to his decompensation secondary
to the perforation. He ultimately was transferred to the
[**Hospital3 1810**] for further evaluation and possible
surgery to ligate the PDA and/or bowel exploration.
Upon arrival, he was re-echoed, and the PDA was found to be
small less than 1 mm restrictive flow with a 40 mm gradient
most likely clinically insignificant. The ligation was not
performed after discussion with Cardiology, General Surgery,
and Neonatology. His clinical condition ultimately
stabilized, and as he recovered from the perforation, he
returned to the [**Hospital1 69**] for
further care. He has had no further cardiovascular issues.
His baseline heart rate is 130s-170s with blood pressure
means 60s-70s/30s-40s with means in the 40s-50s.
Baby was started on caffeine citrate as he weaned on his vent
settings for apnea and bradycardia of prematurity. This was
discontinued on day of life 28.
Fluids, electrolytes, and nutrition: Upon admission to the
Newborn Intensive Care Unit, the infant was started on
intravenous fluids of D5W at 120 cc/kg/day. A UAC and double
lumen UVC were placed shortly after admission. Initial D
stick upon admission was 40. He received a D10W bolus at
that time. D sticks were stable. Initial electrolytes
revealed a sodium of 140, potassium 3.4, chloride 106, total
CO2 of 29, and ionized calcium of 1.2.
At the time of his intestinal perforation, a peripheral
arterial line was placed. He was transferred to the
[**Hospital3 1810**]. While there, a Broviac was placed for
nutritional support. Of note, he was never enterally fed
prior to perforation. Enteral feedings were introduced on
day of life 25 and advanced to full feedings by day of life
34. Calories are increased to 30 calories/ounce with ProMod,
and he demonstrated adequate growth following the 10th
percentile. He currently is feeding breast milk or E26 with
4 calories of Enfamil powder and 2 calories of corn oil. He
p.o. feeds well and breast feeds when his mom is available.
He is voiding and stooling via his ostomy.
Discharge weight 2490, just greater than 10th percentile.
Head circumference 33 cm, 25th percentile. Length 47 cm,
25th percentile.
Gastrointestinal: The infant was started on phototherapy on
day of life 10 for a bilirubin of 2.12. Phototherapy was
increased to double phototherapy on day of life five for a
bilirubin of 3.4.4. Bilirubin under double phototherapy
prior to transfer to [**Hospital3 1810**] was 5.4.0.8.
Late on day of life five on [**10-1**], he was noted to have
a small dusky area on the abdomen which spread quickly over
most of the abdomen. A KUB confirmed free air in the bowel.
Dr. [**Last Name (STitle) 37080**] from [**Hospital3 1810**] and Surgical team
evaluated the infant and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain was placed on
the left side of the abdomen and the bowel was externalized
onto the right side of the abdomen at the bedside at the [**Hospital1 1444**]. The infant was then
transferred to [**Hospital3 1810**] several days later for
possibly for further surgery.
As his condition stabilized, surgical procedure was not
required, and he returned ultimately to the [**Hospital1 346**] for further care. He has completed
bowel rest and treatment for his necrotizing enteral colitis
with triple antibiotics. Feedings were ultimately resumed
and advanced. He currently is passing stool via his ostomy.
Incision sites are well-healed. Parents are well educated in
caring for his ostomy. He has had some loose watery stools
on [**2206-1-7**]. This has improved. The plan is to followup
with Dr. [**Last Name (STitle) 37080**] at the [**Hospital3 1810**] for closure.
Telephone number is [**Telephone/Fax (1) 38454**].
Hematology: Baby's blood type is A positive, Coomb's
negative. Baby received six blood transfusions during his
hospitalization. He also received platelet transfusions, the
first being on day of life three for platelet count of 77
during his second course of indomethacin and second platelet
transfusion on day of life six for a platelet count of
108,000. His last hematocrit on [**1-5**] was 31 with
reticulocyte count of 3.1.
Infectious disease: Complete blood count with differential
and blood cultures were drawn shortly after admission to the
Neonatal Intensive Care Unit. White blood cell count was
4700, hematocrit of 41.5, platelet count of 233, 7% polys,
and 1% bands. The infant received 48 hour course of
ampicillin and gentamicin at that time. Repeat blood culture
was sent on day of life five in association with abdominal
symptoms. Hematocrit was 42, white cell count 40.2, platelet
count 229 with 53 polys and 235 bands. The infant was
started on ampicillin, gentamicin, and clindamycin. Blood
culture remained negative. There was also peritoneal fluid
ultimately sent, which remained negative. Antibiotic
coverage was changed to Zosyn while at [**Hospital3 1810**],
and he completed a full three week course for necrotizing
enterocolitis.
On [**11-20**], day of life 45, he had sepsis evaluation at the
time of removal of his Broviac. At that time, he required
reintubation. He ultimately received three days of
Vancomycin and gentamicin. Blood cultures were negative and
the CBC was benign.
[**Known lastname **] has very sensitive skin. He has had a rash which
developed at the site of his cardiac monitor leads. This has
improved with change to location of the leads. He has had no
further issues with infection.
Sensory: Audiology screening was performed automated
auditory brain stem responses. Baby passed.
Ophthalmology: [**Known lastname **] had serial eye examinations which showed
extensive retinopathy of prematurity in the right eye, stage
3+ disease requiring laser treatment. The plus disease has
resolved. His exam on [**1-9**] showed resolving plus disease in
the right eye. The left eye has stage 3 zone 2 for 1 o'clock
hour and is resolving. Plan is to have followup with Dr.
[**Last Name (STitle) **] in one week after discharge, telephone number
[**Telephone/Fax (1) 50314**].
Psychosocial: Parents have been visiting daily. Are quite
pleased with [**Known lastname 52224**] progress and look forward to transition
home. They have been followed by a social worker while here
in the NICU. Her name is [**Name (NI) 553**] [**Name (NI) 15513**]. She can be reached at
[**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with family.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital 1426**]
Pediatrics, [**Telephone/Fax (1) 37802**].
CARE RECOMMENDATIONS: Feedings at discharge: Continue
breast milk or Enfamil 26 calories as described above.
MEDICATIONS:
1. TobraDex ophthalmic ointment one ribbon to right eye
t.i.d.
2. Atropine ophthalmic 1% ointment one drop to right eye
b.i.d.
3. Ferrous sulfate 25 mg/mL 0.25 mL p.o. q.d. This equals 3
mg/kg/day.
Car seat position screening has not been done at the time of
this dictation.
IMMUNIZATIONS RECEIVED:
1. [**11-25**] hepatitis B vaccine.
2. [**11-25**] DTaP.
3. [**11-25**] HIB.
4. [**11-25**] IPV.
5. [**1-6**] Synagis.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: 1) Born at less than 32
weeks, 2) born between 32 and 35 weeks with two of three of
the following: daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, or 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.
FOLLOW-UP APPOINTMENTS:
1. Primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within several days
of discharge.
2. Dr. [**Last Name (STitle) 37080**] at the [**Hospital3 1810**] Surgery.
3. Dr. [**Last Name (STitle) 21357**] at Neurology at [**Hospital3 1810**].
4. Dr. [**Last Name (STitle) **] of Ophthalmology in [**Location (un) **] Ophthalmology.
5. VNA referral is also being activated.
6. Follow up in the Infant Followup Program at the [**Hospital3 18242**].
DISCHARGE DIAGNOSES:
1. Former premature 25-1/7 week twin #1 of two.
2. Status post respiratory distress syndrome.
3. Status post necrotizing enterocolostomy with ileostomy and
[**Location (un) 1661**]-[**Location (un) 1662**] drain.
4. Status post laser surgery right eye.
5. Status post interventricular hemorrhage.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 52225**]
MEDQUIST36
D: [**2197-1-10**] 01:59
T: [**2197-1-10**] 04:49
JOB#: [**Job Number 52226**]
ICD9 Codes: 769 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2636
} | Medical Text: Admission Date: [**2191-2-28**] Discharge Date: [**2191-3-8**]
Date of Birth: [**2153-2-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Stroke/Migraines
Major Surgical or Invasive Procedure:
[**2191-3-1**] - Minimally Invasive ASD Closure
History of Present Illness:
This 37-year-old patient with recent cerebrovascular accident
was found to have a large atrial septal defect with a
left-to-right shunt. Since her stroke, she has been placed
Aspirin and Warfarin without further neurological incident. In
view of the history of the stroke and the finding of the atrial
septal, she was electively admitted for closure of the same
through a minimally invasive approach. Prior to surgical
intervention, Coumadin was stopped and she was admitted for
heparinization.
Past Medical History:
Atrial Septal Defect, History of Stroke, Migraine Headaches
Social History:
Homemaker. Lives with husband and 4 children. Never smoked.
Drinks a few alcoholic beverages per month.
Family History:
Noncontributory
Physical Exam:
72 SR 100/60 69" 150
GEN: NAD
HERAT: RRR, Nl S1-S2
LUNGS: CTA
ABD: Benign
EXT: Warm, well perfused, no c/c/e. 2+ pulses
Pertinent Results:
[**2191-2-28**] 08:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2191-2-28**] 10:30PM PT-15.2* INR(PT)-1.4*
[**2191-2-28**] 02:37PM ALT(SGPT)-19 AST(SGOT)-36 LD(LDH)-408* ALK
PHOS-36* TOT BILI-0.5
[**2191-2-28**] 02:37PM WBC-7.0 RBC-4.00* HGB-13.2 HCT-37.8 MCV-95
MCH-32.9* MCHC-34.8 RDW-12.6
[**2191-2-28**] 02:37PM %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE
[**2191-2-28**] 02:37PM PLT COUNT-188
[**2191-2-28**] Admit Chest x-ray: The heart is not enlarged. The lungs
show no evidence of acute infiltrate, pleural effusion, or
pneumothorax.
[**2191-3-7**] 06:25AM BLOOD WBC-5.1 RBC-2.76* Hgb-9.3* Hct-26.3*
MCV-95 MCH-33.9* MCHC-35.5* RDW-13.2 Plt Ct-136*
[**2191-3-8**] 06:30AM BLOOD Glucose-83 UreaN-6 Creat-0.7 Na-140 K-4.3
Cl-106 HCO3-27 AnGap-11
[**2191-3-7**] 06:25AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
[**2191-3-7**] Echo: The left atrium is mildly dilated. No residual
flow across the interatrial septum is identified. The estimated
right atrial pressure is 16-20 mmHg. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal. The
right ventricular cavity is mildly dilated with normal freewall
motion. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2191-3-6**] Chest x-ray: The heart, lungs, and mediastinum are
within normal limits with no interval change compared to
[**2191-3-4**].
Brief Hospital Course:
Mrs. [**Known lastname 55205**] was admitted to the [**Hospital1 18**] on [**2191-2-28**] for surgical
management of her atrial septal defect. On admission, Heparin
was initiated as Coumadin was held for several days prior to
admission. Routine preoperative evaluation was performed and she
was cleared for surgery. On [**2191-3-1**], Mrs. [**Known lastname 55205**] was taken to
the operating room where she underwent a minimally inavsive
closure of her atrial septal defect.
For further surgical details, please see seperate dictated
operative note. Following the operation, she was brought to the
CSRU for invasive monitoring. Within 24 hours, she awoke
neurologically intact and was extubated without incident. She
gradually weaned from Neosynephrine and chest tubes were removed
without complication. Heart rate was mostly sinus bradycardia
with periods of junctional rhythm. On postoperative day two, she
transferred to SDU. The remainder of her hospital stay was
complicated by polyuria, polydipsia and symptomatic hypotension
with complaints of nausea and dizziness. A postoperative
echocardiogram was unremarkable. Given concern for diabetes
insipidus and/or adrenal insufficiency, the Endocrine service
was consulted. Urine osmolality and [**Last Name (un) 104**] stim test was
performed. All lab work was within normal limits. She was
discharged to home on POD #6.
Medications on Admission:
Aspirin 81 qd
Coumadin
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 weeks.
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
VNA Carenetwork
Discharge Diagnosis:
ASD - s/p Minimally Invasive ASD closure
Postop Junctional Rhythm
Postop Symptomatic Hypotension with Polydipsia and Polyuria
History of Stroke
History of Migraine Headaches
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeks.
6)No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1290**] in 1 monnth ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr. [**Last Name (STitle) 5051**] in 2 weeks.
Follow-up with pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) 32996**] in [**3-13**] weeks.
Please call all providers for appointments
Completed by:[**2191-3-8**]
ICD9 Codes: 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2637
} | Medical Text: Admission Date: [**2132-5-13**] Discharge Date: [**2132-6-2**]
Date of Birth: [**2056-11-26**] Sex: M
Service: SURGERY
Allergies:
Ibuprofen / Aspirin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
LOA, subtotal colectomy, ileocecal anastomosis
History of Present Illness:
75 YOM with CAD and MI, HTN, DM2, s/p cholecystectomy [**35**] days
prior to admission who presented with diffuse lower quadrant
abdominal pain. Patients states the pain is
relapsing/remitting, and was associated with 6 days of
constipation, as well as decreased appetitie and distention. Of
note, patient was seen in an ED in [**Last Name (un) 11560**] 9 days prior to
admission, given a suppository and felt relief after a large BM.
Patient was seen again in ED 2 days prior to admission with no
relief after suppository.
Past Medical History:
CAD s/p MI [**2127**]; cardiac cath at that time w/o significant
disease; ETT [**2131-2-7**] w/ a reversible inferior defect (EF 49%).
s/p pacemaker [**4-8**] for bradycardia
DM II
CHF (EF 49% on recent MIBI)
HTN
Hypercholesterolemia
H/o Gastric cancer s/p resection [**2127**]
Prostate cancer
Carpal Tunnel syndrome s/p release
Open cholecystectomy [**4-/2132**]
Hyperlipidemia
Stage III CKD-Cr 1.7
Social History:
Lives with wife. Denies EtOH or drug use. Remote h/o tobacco
>25yrs ago.
Family History:
No history of premature coronary artery disease or sudden death.
Mother had pacemaker.
Physical Exam:
Tm Tc HR BP RR O2 sat
Gen: A/Ox3, pleasant in NAD
CV:
Lungs:
Abdomen:
Wound:
Ext:
Pertinent Results:
[**2132-5-13**] 08:50PM URINE HOURS-RANDOM
[**2132-5-13**] 08:50PM URINE GR HOLD-HOLD
[**2132-5-13**] 08:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2132-5-13**] 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2132-5-13**] 01:00PM GLUCOSE-100 UREA N-15 CREAT-1.7* SODIUM-137
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
[**2132-5-13**] 01:00PM estGFR-Using this
[**2132-5-13**] 01:00PM LIPASE-15
[**2132-5-13**] 01:00PM PHOSPHATE-3.8
[**2132-5-13**] 01:00PM WBC-10.5# RBC-5.09 HGB-13.1* HCT-42.6 MCV-84
MCH-25.7* MCHC-30.7* RDW-14.4
[**2132-5-13**] 01:00PM NEUTS-70.4* LYMPHS-24.1 MONOS-4.9 EOS-0.5
BASOS-0.2
[**2132-5-13**] 01:00PM PLT COUNT-464*#
Brief Hospital Course:
Patient is a 75 YOM with CAD s/p Mi, DM2, HTN, who presented
with abdominal pain. Review of CT demonstrated stricture in the
splenic flexure and resulting large bowel obstruction.
Intraoperatively a cecal perforation was noted. Patient
underwent a subtotal colectomy with ileosgimoid anastamosis.
During the postoperative period, patient developed oliguric
renal failure, for which nephrology was consulted. Their
impression was prerenal azotemia with progression to ATN.
Patient eventually became anuric and was transferred to the ICU,
where urine output improved with fluid boluses. Patients
condition improved and he was transferred to the floor, where he
was noted to have several loose stools daily. These were
negative for Cdiff. The patient developed an ileus and an NG
tube was placed. He was sent for a gastrograffin enema to check
the integrity of his anastomosis. He was unable to tolerate the
entire procedure, but there was no leak up to point of splenic
flexure. Patient's condition improved, he was able to tolerate a
regular diet without nausea. On the day of discharge, as small
area on the superior aspect of his incision was draining. This
was found to be negative for flora on gram stain. Cultures were
sent.
Medications on Admission:
Tylenol 1000 mg
Meds-Plavix 75 mg
Norvasc 5 mg
Provochol
Metoprolol 25 mg
Imdur 60 mg
Diovan
Folic Acid
Protonix
Glucotrol XL 2.5 mg
Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for prn pain.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for Prophylaxis.
5. Psyllium 1.7 g Wafer Sig: [**12-5**] Wafers PO DAILY (Daily) as
needed for loose stool.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for loose stool.
8. Glucotrol XL 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One
(1) Tab,Sust Rel Osmotic Push 24hr PO once a day.
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
9. Pravachol 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Imdur 60 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*
11. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Outpatient Physical Therapy
Evaluation and Treatment
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
1.) Large bowel obstruction with cecal perforation requiring
LOA, subtotal colectomy and ileocecal anastomosis
2.) Acute Renal failure
3.) Postoperative Ileus
Discharge Condition:
Stable
Discharge Instructions:
Patient should return to ED if he experiences uncontrollable
pain, shortness of breath, bleeding, increased output from
wound, redness around wound, fever, or other concerning
symptoms. He should contact Dr.[**Name (NI) 1482**] clinic at
[**Telephone/Fax (1) 2981**] if his loose stool worsens, he develops a fever,
notices bloody stool, or has other concerns.
Followup Instructions:
Patient should follow up with general surgery clinic in [**12-5**]
week. Call [**Telephone/Fax (1) 2981**] to schedule appointment with Dr.
[**Last Name (STitle) **]. Patient has wound culture results pending which you
can discuss with Dr. [**Last Name (STitle) **].
Completed by:[**2132-6-4**]
ICD9 Codes: 5849, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2638
} | Medical Text: Admission Date: [**2176-3-26**] Discharge Date: [**2176-4-2**]
Date of Birth: [**2154-6-12**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Penicillins / Hydromorphone
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
back/knee pain, "sickle cell crisis"
Major Surgical or Invasive Procedure:
exchange-transfusion 12 units
History of Present Illness:
Mr. [**Known lastname 65556**] is a 21 y/o man with sickle-cell anemia who presents
from OSH with 2 days of severe pain, mostly localized to his
lower back and knees bilaterally. He also has a headache that
started this AM, localized to the R occipital region. He states
that the onset of pain began 2d ago when he was carrying water
into the house from outside. He was dressed in a coat and denies
feeling cold at that time. He denies traumatic injury from heavy
lifting. He recalls that he drank alcohol on Saturday, but did
not feel dehydrated and has been drinking the "regular" amount
of fluid. He attempted to treat the pain initially with
oxycodone and excedrin, but it did not resolve.
.
Hence on [**2176-3-25**], he went to [**Hospital3 4107**] where he was
evaluated and started on dilaudid and IVF. Because of his
elevate WBC count (20->25), and concern for meningitis he was
transferred to [**Hospital1 18**] for further w/u and pain management.
.
He states this pain is similar in location and severity to
sickle-cell crises he has had in the past. On ROS, he denied CP,
SOB, cough, sinus conjestion, sore throat, N/V, diarrhea,
constipation, and urinary symptoms. ROS otherwise normal.
.
His most recent crisis was approximately in [**Month (only) **]. of last year.
His regular triggers for sickle-cell crises include dehydration
and sometimes cold.
.
In the [**Hospital1 18**] ED, he was continued on dilaudid and evaluated with
CXR and MRI of the back. he was also given IV fluids and a dose
of Levofloxacin.
Past Medical History:
Sickle cell anemia: Treated last year with hydroxurea and folic
acid, but that was stopped due to "swelling and pain" in feet.
Last crisis about 6 months ago.
Social History:
Attends college, studies computer engineering and technology.
Denies smoking/IVDU. Occasional social alcohol.
Family History:
Parents in good health. Two siblings, neither with SCA.
Physical Exam:
VS T:99.0 P:98-101 BP:138-155/76-91 RR:16-18 O2Sat:100% 4LPM NC
GENERAL: Young man lying in bed with eyes closed in moderate
discomfort.
Skin: warm and dry throughout. Some additional warmth over knees
bilaterally.
NECK: Supple, no LAD. No rigidity.
HEENT: normocephalic, sclerae white, PERRL, EOMI, visual fields
full, no diplopia, mmm, OP clear.
HEART: No carotid bruits bilaterally. +S1S2, tachycardic. [**2-26**]
holosystolic murmur best heard at LUSB.
LUNGS: CTAB. Thorax symmetric. Normal diaphragmatic excursions
and I:E of 1:3.
ABD: +BS soft, NT/ND, -HSM.
EXT: Thin, -c/c/e. ppp
MS: A&Ox3.
Neuro: CNs grossly intact. No focal deficits throughout.
Pertinent Results:
CXR Admission: Patchy right lower and possible patchy left lower
lung opacities. Mild cardiomegaly with vascular redistribution
consistent with volume overload.
.
CXR Portable [**2176-3-26**]: 1. Bilateral lower lobe consolidations.
Pulmonary infarcts may be a possibility in this patient with
sickle cell crisis
2. Absence of splenic [**Last Name (LF) 65557**], [**First Name3 (LF) **] be secondary to
autosplenectomy.
.
CXR [**2176-3-27**]: 1. Increased bibasilar pleural effusions and/or
atelectasis.
2. Diffuse increase in bony density. Sclerotic changes in the
right humerus which may represent prior bony infarcts.
.
CXR [**2176-3-28**]: Progression of pneumonia and sickle crisis.
.
CT Chest: Multilobar pneumonia, with possible pneumococcal
etiology. Some
of the consolidation may also be due to the sickle cell crisis.
.
MRI Lumbar/Thoracic Spine: 1. No evidence of epidural abscess.
2. Heterogeneous signal within the L2 through L4 vertebral
bodies, raising the possibility of bone infarcts.
3. Evidence of T12-L1 laminectomy.
.
EKG: Sinus tachycardia, rate 130. Non-specific ST-T wave
abnormalities are present. No previous tracing available for
comparison.
.
ECHO: The patient is tachycardic. Normal biventricular size and
systolic
function. Mild pulmonary hypertension. Mildly elevated pulmonic
valve velocity c/w trivial PS (vs high output).
.
KUB: There are distended loops of large bowel, partially filled
with stool. There is no definitive evidence of obstruction. The
patient is rotated, limiting evaluation for stones or osseous
abnormalities. Osseous structures appear grossly unremarkable.
.
Labs at OSH:
Na 139 K 4.1 Cl 106 HCO3 30 BUN 7 Creat 0.6 Glu 122
WBC 26 Crit 28.6 Platelet 331
75N 14L 11M 4nucleated RBCs
Ca 8.7
Total Bili 2.4
Direct Bili 0.4
ALT 32 AST 47 Alk Phos 121
.
Labs on admission:
.
[**2176-3-26**] 05:07AM PT-15.6* PTT-27.0 INR(PT)-1.4*
[**2176-3-26**] 05:07AM PLT COUNT-236
[**2176-3-26**] 05:07AM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL
OVALOCYT-OCCASIONAL SICKLE-1+ SCHISTOCY-OCCASIONAL
STIPPLED-OCCASIONAL HOW-JOL-OCCASIONAL PAPPENHEI-OCCASIONAL
ELLIPTOCY-OCCASIONAL
[**2176-3-26**] 05:07AM NEUTS-78* BANDS-7* LYMPHS-8* MONOS-1* EOS-0
BASOS-1 ATYPS-1* METAS-0 MYELOS-3* PROMYELO-1* NUC RBCS-15*
[**2176-3-26**] 05:07AM WBC-30.4* RBC-3.04* HGB-9.1* HCT-26.0* MCV-86
MCH-30.0 MCHC-35.1* RDW-21.8*
[**2176-3-26**] 05:07AM calTIBC-287 HAPTOGLOB-<20* FERRITIN->[**2170**]
TRF-221
[**2176-3-26**] 05:07AM IRON-77
[**2176-3-26**] 05:07AM CK-MB-2 proBNP-515*
[**2176-3-26**] 05:07AM ALT(SGPT)-37 AST(SGOT)-64* LD(LDH)-933*
CK(CPK)-143 ALK PHOS-156* TOT BILI-2.5* DIR BILI-0.5* INDIR
BIL-2.0
[**2176-3-26**] 05:07AM GLUCOSE-120* UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-21* ANION GAP-19
[**2176-3-26**] 05:44AM RET MAN-20.9*
[**2176-3-26**] 09:07AM LACTATE-1.2
[**2176-3-26**] 06:33PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2176-3-26**] 06:33PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2176-3-26**] 06:33PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2176-3-26**] 09:20PM PLT COUNT-206
[**2176-3-26**] 09:20PM HGB A-0 HGB S-93.7* HGB C-0 HGB F-6.3*
[**2176-3-26**] 09:20PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-3+
MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-3+ TARGET-1+
SICKLE-3+
[**2176-3-26**] 09:20PM WBC-28.3* RBC-2.59* HGB-7.8* HCT-21.6* MCV-84
MCH-30.0 MCHC-35.9* RDW-22.0*
[**2176-3-26**] 11:29PM freeCa-1.24
[**2176-3-26**] 11:29PM O2 SAT-94
[**2176-3-26**] 11:29PM GLUCOSE-111* LACTATE-0.8 NA+-138 K+-3.7
CL--104
[**2176-3-26**] 11:29PM TYPE-ART O2-40 PO2-105 PCO2-45 PH-7.38 TOTAL
CO2-28 BASE XS-0
.
Labs at Discharge:
[**2176-4-2**] 05:22AM BLOOD WBC-13.8* RBC-3.25* Hgb-9.8* Hct-28.3*
MCV-87 MCH-30.0 MCHC-34.5 RDW-17.1* Plt Ct-405#
[**2176-4-2**] 05:22AM BLOOD Plt Ct-405#
[**2176-4-2**] 05:22AM BLOOD Ret Aut-8.4*
[**2176-4-2**] 05:22AM BLOOD Glucose-87 UreaN-8 Creat-0.6 Na-140 K-4.2
Cl-104 HCO3-25 AnGap-15
[**2176-4-2**] 05:22AM BLOOD LD(LDH)-378* TotBili-1.4
[**2176-4-2**] 05:22AM BLOOD Calcium-9.3 Phos-4.5 Mg-2.0
[**2176-4-2**] 05:22AM BLOOD Hapto-157
Brief Hospital Course:
This is a 21 y/o man with sickle-cell anemia who presented with
two days of severe pain in his lower back and knees similar to
previous pain he has experienced during sickle-cell crises. His
hospital course was complicated by respiratory distress, with
concern for acute chest syndrome vs. PNA. He received an
exchange-transfusion of 12 units, three days of vancomycin and
was started on a 14-day course of levofloxacin. He was
discharged in stable condition, with good oxygen saturations and
markedly reduced pain.
.
Sickle-Cell crisis: The pt.'s crisis was treated with IV fluid
and pain was managed with narcotic medications. He was intitally
started on a Dilaudid PCA, but this was switched to Fentanyl
when the pt. began to have a pruritic and myoclonic reaction. He
tolerated the fentanyl well, and was switched to prn percocet
with good pain control prior to discharge.
.
Acute Chest Syndrome vs. PNA: His WBC count trended up from
initial presentation at OSH. CXR showed patchy opacities. During
his first hospital day, he experienced hypoxia to 78% on room
air and 92% on 70% face mask. He was transferred to the MICU for
concerns of altered mental status and hypoxia. In the MICU, the
pt. was treated for hypoxic respiratory distress. He received a
three-day course of vancomycin and was started on a 14-day
course of levofloxacin for possible PNA. He received 2 units of
PRBC. He was continued on O2 supplement by shovel face mask. TTE
showed normal EF and mild pulm hypertension likely [**2-22**] to
PNA/acute chest indicating that CHF was unlikely to be the cause
of his hypoxia. CT chest confirmed PNA/acute chest syndrome.
With continuing abx, blood transfusion (2 units in the CCU),
IVF, and pain control, the patient improved marginally; in
discussion with Heme/Onc it was decided to place a R groin line
and initiate exchange transfusion, with subsequent marked
improvement clinically. He was weaned down to nasal cannula O2.
The patient was started on clears and advanced diet as
tolerated. The R groin line was pulled prior to transfer to the
floor without difficulty, an occlusive dressing was left in
place. Back on the medicine floor, the pt. continued to improve,
with clear lung sounds and a reduction in his leukocytosis at
time of discharge. He was discharged on day [**8-2**] of levofloxacin
with instructions to finish the course.
.
Ileus: The pt. had symptoms of abdominal pressure, as well as a
KUB concerning for obstruction vs. ileus. These symptoms were
thought to be likely due to narcotic use. He was started on a
standing bowel regimen. He had a large BM which relieved his
symptoms and had no further episodes of constipation while in
hospital.
.
Coagulopathy: On admission, the pt. had an elevated INR of 1.4
with unclear etiology. This increased to 2.3, and the patient
received one dose vit K. The INR was reduced to 1.2 at time of
discharge.
<BR>
Anemia: Pt. had a crit of 26.0 on admission that fell to 21.6
prior to first transfusion. This was likely due to long standing
sickle-cell disease, and hemolysis labs were consistant with
intravascular hemolysis. His retic count was markedly elevated
at 20, but his baseline reticulocyte count was not known. The
crit was much improved to 28.3, and trending up at time of
discharge. Hemolysis labs were also much improved.
<BR>
4) FEN: Pt. received house diet. He was maintained on aggressive
IVF until the day prior to discharge.
<BR>
5) PPx: Ambulate qid, bowel regimen prn.
<BR>
6) Dispo: To home with hematologic f/u.
Medications on Admission:
Oxycodone prn
Excedrin prn
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*36 Tablet(s)* Refills:*0*
3. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: acute chest syndrome, sickle-cell crisis
Discharge Condition:
VSS, no O2 requirement.
Discharge Instructions:
Please return to the emergency room if you feel shortness of
breath, severe pain, severe cough, extreme fatigue, or other
concerning symptoms.
.
Make sure to attend your appointment with Dr. [**First Name (STitle) **].
Followup Instructions:
You have the following appointment scheduled:
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD. Hematology. [**Hospital1 65558**]. [**Location (un) 2129**]. [**Telephone/Fax (1) 65559**]. Thursday, [**2176-4-11**].
2:30 PM.
.
To consider whether you could restart on hydroxurea.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2176-4-3**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2639
} | Medical Text: Admission Date: [**2109-8-24**] Discharge Date: [**2109-8-30**]
Service: MED
Allergies:
Aspirin / Codeine
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Central Line Placement
History of Present Illness:
82 year old woman with metastatic cancer, presumed pancreatic
but w/o tissue diagnosis, who presents with two week history of
weakness. Pt has been has had decreased food intake and is
never hungry and has been losing weight. Recently she has
become more short of breath and is on oxygen at home. She said
she has not been able to move around either. At night she gets
short of breath. She has had no nausea, vomiting, or diarrhea.
No cough, or chest pain. She had a similar presentation at her
[**Hospital **] clinic on [**2109-8-16**]. At that time she also complained of having
increased anxiety attacks as well as palpitations. In the ED
the CXR was read as new pleural effusion, but CXR on [**7-24**] was
read as suggestive of bilateral pleural effusion. It is,
however, more apparent than in prior and pt. has a newly
elevated wbc.
Past Medical History:
Probable metastatic pancreatic cancer to the lungs, LN,
and left adrenal. No tissue diagnosis CA19.9 NL, ECRP NL
anxiety attacks
Diabetes for 15 years although this has been more difficult
to control over the past two months.
Hypertension, ??GAP-7??
Endometrial cancer in [**2097**] status post TAH-BSO for grade 1
adenocarcinoma.
Angina by report although the patient just states that she
has weakness.
Palpitations.
Cholecystectomy in [**2095**].
Diverticulitis status post colon resection (partial) in [**2095**].
Left knee meniscal tear that the daughter says needs
replacement.
Social History:
She lives at home with her son. She was born in [**Country 3399**] and then
lived in [**Country **] until she immigrated to the US in [**2071**]. She has
never smoked. She has never drunk significant amount of alcohol.
She lives in [**Location 11270**]. She is Sephardic Jew. She has a
significant secondhand [**Location **] from family members who [**Name2 (NI) **].
Family History:
Significant for a large number of cousins with a
variety of cancer. Paternal cousin: Ovarian, paternal cousin:
[**Name (NI) **], paternal cousin: Stomach, paternal cousin: Breast,
maternal uncle: Prostate. No history of pancreatic cancer in
the family.
Physical Exam:
A large woman who appears tired but is in NAD
98.2 166/68 73 18 99% 4l
HEENT: No icterus, EOMI.
CARD: RRR, Nl S1 S2 no M/G/R
Pulm: Decreased breath sounds, increased exp. phase, slight
wheezing
Abd: Obese, +BS, soft, NT
EXT: Trace edema, 2+ post tibial
Pertinent Results:
[**2109-8-24**] 02:00PM
WBC-12.9*# HCT-43.3 PLT COUNT-408
MCV-93 MCH-29.7 MCHC-31.9 RDW-13.5
NEUTS-86.4* LYMPHS-9.2* MONOS-3.9 EOS-0.3 BASOS-0.2
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025 BLOOD-NEG
NITRITE-NEG PROTEIN-TR GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG
UROBILNGN-NEG PH-5.0 LEUK-NEG
Brief Hospital Course:
82 year old woman with metastatic cancer, presumed pancreatic
but w/o tissue diagnosis, who presents with symptoms of
weakness, O2 dependence and anorexia that are consistent with
advanced pancreatic cancer with lung metastases. She had a
similar presentation at her [**Hospital **] clinic on [**2109-8-16**]. Of concern is
her elevated wbc and increased new pleural effusions on CXR vs
prior from [**2109-7-24**], though pt is afebrile. It is difficult to
evaluate her lungs due to the extensive metastatic infiltration.
Patient was noted to have an asytolic arrest on the floor with
elevated K in the 6 [**Hospital 98175**] transfered to the MICU service
after CODE BLUE was called. After the arrest, pt remained
non-reponsive and CT scan demonstrated diffuse brain edema c/w
anoxic brain injury. Pt requiring increasing pressor suppot,
spiked high fevers, and had an elevated wbc which was concerning
for sepsis.
Pt's clinical course deteriored at the patient expired on
[**2109-8-30**].
Medications on Admission:
Darvocet-N 650-100 Q6H Prn
oxybutynin 5mg qd
captopril 12.5 [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Celebrex 200mg QD
senna [**Hospital1 **]
Compazine 10mg Q8h PRN Nausea
Protonix 40mg QD
meclizine 12.5mg TID
metoprolol 50mg [**Hospital1 **]
Zyprexa 2.5mg QD
Ranitidine 150mg QD
Ativan 1-1.5mg [**Hospital1 **]
Megace 800 mg QD on [**8-16**] not taken due to N & diarrhea
Insulin 75/25
Discharge Medications:
N/A
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Pancreatic Cancer
Asystolic Arrest
Septic Shock
Probable metastatic pancreatic cancer to the lungs, LN,
and left adrenal. No tissue diagnosis CA19.9 NL, ECRP NL
Hypertension
Endometrial cancer in [**2097**] status post TAH-BSO for grade 1
adenocarcinoma.
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2640
} | Medical Text: Admission Date: [**2126-6-5**] Discharge Date: [**2126-6-8**]
Date of Birth: [**2067-10-24**] Sex: F
Service: CCU
CHIEF COMPLAINT: The patient was transferred from an outside
hospital for mental status changes, acute renal failure,
hyperkalemia, and hypotension.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
female with a long history of coronary artery disease,
congestive heart failure, and arrhythmias, who found down in
her home by her husband. [**Name (NI) **] the outside hospital records,
the husband noticed mental status changes for approximately
two weeks and occasional dyspnea. It was not known at the
time she was admitted, but later it was learned that the
patient had been taking Aldactone starting approximately two
weeks ago at the time that her mental status changes began to
occur. The patient was found on the floor outside of her
bathroom, apparently just after she stood from the toilet.
She was brought to the Emergency Room with a systolic blood
pressure of 80, with no response to 2 liters of fluid in the
Emergency Room. She was found to have a potassium of 6.9, a
BUN 53, and creatinine 2.9; although, her baseline is a
creatinine of 1. She was noted to have wide complex QRS on
her electrocardiogram, was mildly obtunded, and was placed on
dopamine at 4.5 mcg/min for pressure support. Her right
upper quadrant was noted to be painful on physical
examination. Laboratories there were notable for a
bicarbonate of 18, flat creatine kinases, and elevated
digoxin level at 2.5, an INR greater than 7.5, and a
hematocrit of 29. A head CT was performed to rule out
cerebrovascular accident. This was limited by artifact, but
was negative for acute processes. A rushed echocardiogram
showed an ejection fraction of approximately 25%. At the
outside hospital she was given D-50 and insulin times two,
and Kayexalate p.o. and p.r. for her hyperkalemia, as well as
2 units of packed red blood cells for a slightly low
hematocrit of 29.7, and 2 units fresh frozen plasma, as well
as vitamin K for her elevated INR, then transferred to [**Hospital1 1444**].
Upon arrival, the patient complains of right upper quadrant
pain on and off which lasts five minutes at a time, is dull,
is rated [**3-28**] in intensity, and possibly occurs more often
after meals. She reports that Tylenol helps this pain. She
also complains of diarrhea times one month, ultimately loose
and watery, as well as specks of bright red blood in her
stool, but no melena, hematemesis, nausea or vomiting. She
does report a slight decrease in her appetite and p.o.
intake, but does report food fluid intake and increased
thirst. She thinks she may have increased her intake of
salty foods recently. She has been Imodium for her diarrhea.
The rest of her review of systems was remarkable for the
absence of chest pain and palpitations, the presence of
shortness of breath for approximately three weeks,
three-pillow orthopnea, paroxysmal nocturnal dyspnea two
weeks ago, and increased lower extremity edema for several
weeks. She has had no change in her weight but has not
checked this precisely. She denies fevers, chills, and night
sweats, rash, genitourinary complaints.
Regarding her fall, she has recollection of the actual event,
but says that she probably lost consciousness. She reports
leg pain prior to the event, and is unable to clarify clearly
beyond saying that they were weak (left greater than right).
PAST MEDICAL HISTORY: (Significant for)
1. Myocardial infarction in [**2120**] which led to cardiogenic
shock and a new left bundle-branch block. She was
catheterized at that time and had a stent placed to her
proximal left circumflex, and distal right coronary artery
was occluded to 100% at that time. She had an episode of
ventricular tachycardia post myocardial infarction which
required lidocaine, and an episode of atrial fibrillation
which required DC cardioversion.
2. She had a coronary artery bypass graft in [**2120**] which
included a left internal mammary artery to her left anterior
descending artery, and saphenous vein graft to her first
obtuse marginal, and saphenous vein graft to a posterior
descending artery, as well as mitral valve repair.
3. She had a follow-up catheterization in [**2123**] which showed
2-vessel disease with a totally occluded left internal
mammary artery to left anterior descending artery graft as
well as a totally occluded saphenous vein graft to first
obtuse marginal, and saphenous vein graft to right posterior
descending artery graft. The catheterization also showed
severe systolic and diastolic dysfunction bilaterally, and
moderate pulmonary hypertension, and moderate-to-severe
mitral regurgitation.
4. Therefore, she had a follow-up coronary artery bypass
graft in [**2123**] and had a saphenous vein graft to her left
anterior descending artery and her first diagonal and her
first obtuse marginal, as well as a mitral valve replacement
with mechanical valve.
5. She had a pacemaker placed in [**2123**] by Dr. [**Last Name (STitle) 73**].
This pacemaker is a Prodigy DR7860B, atrial lead 4068,
ventricular lead 4024; it is a DDD-type pacer.
6. She also has had an atrial flutter ablation in [**2124**], and
atrial flutter DC cardioversion in [**2124-11-18**], and
atrial fibrillation DC cardioversion in [**2126-4-19**].
7. Stress MIBI in [**2125-11-19**] which showed severe
inferolateral defects, now fixed in contrast to an [**2121-11-19**] study where they were reversible.
8. In [**2125-1-17**], the patient had an echocardiogram
which showed a dilated left ventricular global hypokinesis
and akinesis including the right ventricle, significant
mitral regurgitation over her valve prosthesis, significant
tricuspid regurgitation, mild pulmonary hypertension, and
interval decreased function since her last study with an
ejection fraction of less than 20%.
9. Hypertension.
10. Type 2 diabetes with the last hemoglobin A1c of 8.4 in
[**2126-1-17**]. Hemoglobin A1c were as high as 11.
11. Hypercholesterolemia.
12. Peripheral vascular disease with a claudication and the
requirement that she occasionally have catheterizations by
brachial artery.
13. Depression.
14. Dysfunction uterine bleeding with a thick endometrium
noticed on a [**2125-11-19**] ultrasound.
15. Obesity.
16. Allergic rhinitis.
17. Recent admissions to [**Hospital1 **] [**First Name (Titles) **]
[**Last Name (Titles) 7941**] of her INR and for an atrial fibrillation
cardioversion.
FAMILY HISTORY: Family history was difficult to obtain, but
was negative for coronary artery disease.
SOCIAL HISTORY: The patient has a 70-pack-year history; now
smokes five cigarettes a day. Does not drink alcohol. Takes
no drugs. Lives with her husband.
ALLERGIES: CECLOR causes hives.
MEDICATIONS ON ADMISSION: Medications at home include
Vasotec 2.5 mg p.o. b.i.d., atenolol 25 mg p.o. q.d.,
amiodarone 400 mg p.o. b.i.d., gemfibrozil 600 mg p.o.
b.i.d., digoxin 0.25 mg p.o. Monday through [**Last Name (Titles) 2974**], potassium
chloride 20 mg p.o. b.i.d., Warfarin 5 mg p.o. q.d.,
Lasix 20 mg p.o. b.i.d., Ativan 1 mg p.o. p.r.n. for
insomnia, trazodone 50 mg p.o. q.h.s., Zoloft 150 mg p.o.
q.d., Lipitor 10 mg p.o. q.d., albuterol MDI p.r.n., and no
oral hypoglycemics for diabetes.
REVIEW OF SYSTEMS: See History of Present Illness.
PHYSICAL EXAMINATION ON ADMISSION: On physical examination
vitals were temperature of 97.6, pulse 60, blood
pressure 93/34 (on 3 mcg/min of dopamine), respirations 18,
saturation 98% on 2 liters nasal cannula. In general, this
was a tired, obese female in no acute distress with slightly
inappropriate and delayed answers to questions.
Cardiovascular showed a regular rate and rhythm, a
mechanical-sounding S1, and a holosystolic murmur throughout
her precordium. No rubs or gallops. HEENT examination
showed jugular venous distention to the angle of her jaw at
45 degrees. Pupils were equal, round, and reactive to light.
Extraocular movements were intact. Oropharynx showed
slightly dry mucous membranes. She had cavities bilaterally.
She was normocephalic and atraumatic from her fall.
Pulmonary examination showed crackles bilaterally, left
greater than right, halfway up. Abdominal examination had
normal active bowel sounds, obese, firm, mild tenderness in
her right upper quadrant and right lower quadrant
intermittently. Extremities showed pitting edema as well as
bruises and petechiae in her upper extremities and left
shoulder bruises anteriorly and posteriorly related to a
fall. Her rectal examination showed heme-positive brown
stool. Neurologically, she was alert and oriented times
three, although slightly drowsy and sometimes slightly off
subject when she replied to questions. Cranial nerves II
through XII were intact. Strength was [**3-23**] throughout. Deep
tendon reflexes were 2+ in her knees, deferred in her upper
extremities because of multiple IVs, and decreased at her
ankles. Babinski was equivocal. Finger-to-nose and
heel-to-shin were intact. Alternating movements were intact.
LABORATORY DATA: (At the outside hospital) Showed a sodium
of 138, a potassium that declined from 6.9 to 5.7 with
several interventions, a bicarbonate that fell from 20 to 17
over the course of her stay, BUN 53, and creatinine of 2.9,
and an elevated phosphorous at 5.5, and a low hematocrit
at 33.3, platelets of 143, a white blood cell count of 8.5.
Initial INR of 4.1, D-dimer positive, digoxin 2.5,
fibrinogen 335. Creatine kinase 67, MB 2.2, troponin less
than 0.05. Urinalysis revealed trace blood, 500 protein, 2
to 5 white blood cells.
RADIOLOGY/IMAGING: A V/Q scan was low probability which
showed cardiomegaly. This was probably done because she had
an arterial blood gas of 7.25/39/38.5 which probably
represented a venous blood gas.
Chest x-ray showed increased heart size, mild redistribution
in the upper perihilar vessels, but no pulmonary edema or
effusions.
Head CT showed motion artifacts, but was otherwise within
normal limits.
Renal ultrasound showed normal kidneys at 12.4 cm and
12.2 cm.
Electrocardiogram showed possibly tiny P wave after pacer
spikes and AV-pacing, with a wide QRS at 0.24.
LABORATORY ON ADMISSION: Laboratories at [**Hospital1 346**] were a sodium of 141, potassium 3.9,
chloride 109, bicarbonate 16, BUN 50, creatinine 2.1.
Calcium 8.8, phosphorous 5.2. Normal liver function tests.
An INR of 2. A digoxin of 1.1. A white blood cell count
of 8.5, a hematocrit of 32.1, platelets 141.
RADIOLOGY/IMAGING: Electrocardiogram here showed dual pacer
spikes before V-paced QRS. No evidence of atrial activity.
The rate of 63, axis was left, QRS was 0.16 seconds in
duration. She had T wave flattening in I, L, V5, and V6. ST
changes were not interpreted secondary to her V-pacing.
HOSPITAL COURSE BY SYSTEM: The patient was admitted to the
Coronary Care Unit.
1. CARDIOVASCULAR: As far as her systolic function, the
patient rapidly weaned off dopamine with no drop in her blood
pressure. The patient was given a gentle bolus of 250 cc of
normal saline because of possible intravascular volume
depletion with decreased p.o. intake. Her digoxin was
restarted when her digoxin level returned to [**Location 213**]. Her ACE
inhibitor was restarted when her creatinine returned to 1.5.
Coreg was also started for her congestive heart failure.
As far as her electrical function, her amiodarone was
continued. Her pacer was interrogated, and it was found that
despite the apparent absence of P activity on her
electrocardiogram, the patient was AV-pacing at 60. Her rate
was turned up to 70 at this time, and her intrinsic rate off
pacing was noted to be a ventricular at 30.
As far as valve disease, the patient was heparinized and
coumadinized. Heparin was continued until her INR was
therapeutic at 3.2 on [**6-8**]. Then her heparin was
discontinued, and with adequate anticoagulation for her
mitral valve she was sent home.
Of note, therapy for her urinary tract infection was adjusted
from ciprofloxacin to Macrobid because it was believed the
latter medication would be less disruptive of valve flora and
have less influence on her INR.
As far as coronary arteries, the patient's Lipitor and
gemfibrozil were continued as well as her aspirin. She was
beta blocked with Coreg. Given that her troponin and
creatine kinases were flat at the outside hospital, we had no
concern over any coronary ischemia.
2. GASTROINTESTINAL: The patient was noted to have
heme-positive stool, but no gross blood, and her hematocrit
remained stable throughout her stay. She also developed
diarrhea, and as a result studies for C. difficile, fecal
leukocytes, and stool cultures, and ova and parasites were
sent. Stool cultures were pending at this time. Fecal
leukocytes were negative. Ova and parasites were negative,
and the patient was given Imodium on the last day of her
hospitalization to control her symptoms. She was to follow
up with Gastroenterology as an outpatient to evaluate her
heme-positive stool.
3. RENAL: The patient's acute renal failure resolved over
the period of several days with a normal potassium and then a
potassium requiring supplementation, which was her baseline
state. Her phosphorous normalized. She had a normal urine
output. Studies done to evaluate her renal failure showed a
prerenal state with urine sodium less than 10. At
discharge, her renal function was normal with a creatinine
of 1.
4. PULMONARY: The patient was given one small dose of Lasix
for volume overload and shortness of breath. She then had no
further pulmonary issues.
5. FLUIDS/ELECTROLYTES/NUTRITION: The patient had
electrolytes repleted as indicated and was restarted on her
daily Lasix 20 mg p.o. b.i.d.
6. GENITOURINARY: The patient was noted to have a urinary
tract infection with 17 white blood cells and moderate
bacteria; although, her nitrite remained negative. She was
treated initially for this with ciprofloxacin then changed to
nitrofurantoin upon discharge.
7. ENDOCRINE: The patient was monitored regarding her blood
sugars and followed with a regular insulin sliding-scale
which was not needed as her blood sugars remained normal.
8. NEUROLOGY: The patient's lethargy resolved over the
course of 1.5 days, and at discharge she was fully alert and
interactive.
In summary, it was felt that her hyperkalemia, acute renal
failure, change in mental status, and hypotension were all
related to initiation of Aldactone, possibly complicated by
polypharmacy in general. With discontinuation of the
Aldactone and supportive care, her acute renal failure
resolved. Her hyperkalemia resolved. Cardiac function and
hypotension returned to her baseline state, and her mental
status changes also resolved. The patient was then
re-anticoagulated for her mitral valve and was ready for
discharge.
CONDITION AT DISCHARGE: Condition on discharge was stable.
CODE STATUS: Full code.
DISCHARGE DIAGNOSES:
1. Acute renal failure with hyperkalemia and metabolic
disarray including depressed cardiac function an mental
status changes.
2. Mitral valve replacement, on anticoagulation.
3. Coronary artery disease, status post multiple
catheterizations, and bypass surgeries, and pacemaker
placement.
4. Hypertension.
5. Diabetes.
6. Hypercholesterolemia.
7. Occult gastrointestinal bleeding.
8. Diarrhea of unknown etiology possibly related to her
medications.
MEDICATIONS ON DISCHARGE:
1. Vasotec 2.5 mg p.o. b.i.d.
2. Amiodarone 400 mg p.o. b.i.d.
3. Gemfibrozil 600 mg p.o. b.i.d.
4. Potassium chloride 20 mg p.o. b.i.d.
5. Digoxin 0.25 mg p.o. Monday through [**Month (only) 2974**]
6. Coumadin 5 mg p.o. q.d.
7. Lasix 20 mg p.o. b.i.d.
8. Ativan 1 mg p.o. p.r.n. for insomnia.
9. Trazodone 50 mg p.o. q.h.s.
10. Zoloft 150 mg p.o. q.d.
11. Lipitor 10 mg p.o. q.d.
12. Aspirin 325 mg p.o. q.d. (which was to be held until she
is evaluated by Gastroenterology for a gastrointestinal
bleed).
13. Coreg 3.125 mg p.o.
14. Protonix 40 mg p.o. b.i.d. (to be used until she is
evaluated by Gastroenterology).
15. Imodium 1 tablet p.o. q.6h. p.r.n. for diarrhea.
16. Miconazole powder to a groin rash t.i.d.
17. Albuterol inhaler p.r.n.
18. Macrobid 100 mg p.o. q.i.d.
DISCHARGE FOLLOWUP: Follow-up appointments were arranged
with Dr. [**Last Name (STitle) 120**] (her cardiologist) in four days, and she was
to schedule a Gastroenterology follow-up appointment on her
own or through Dr. [**Last Name (STitle) 120**].
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. [**MD Number(1) 4062**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2126-6-8**] 15:23
T: [**2126-6-9**] 07:33
JOB#: [**Job Number 13571**]
ICD9 Codes: 5849, 2767, 4280, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2641
} | Medical Text: Admission Date: [**2169-2-23**] Discharge Date: [**2169-3-1**]
Date of Birth: [**2107-2-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Chief Complaint: Mental status changes and hypoxia, found down
Major Surgical or Invasive Procedure:
Bronchoscopy x 2
History of Present Illness:
Patient is a 62 yo female with PMHx sig. for HTN, CHF, asthma
who was brought to OSH after being found down. She lives with
her niece, the niece's daughter and husband. She had been
complaining of an URI infection for the last 1.5 weeks with
symptoms of fatigue and cough. No fevers or other complaints as
far as the niece knows. She was bedridden for the first 3 days
or so but had been improving, enough to clean the house
yesterday. Overnight, her niece had heard a thump and found the
patient on the floor, with her bifold closet off the runner. She
was complaining of L arm pain. She was also confused, repeatedly
calling for help and asking about her dead dog. She has had her
flu and H1N1 shots this year.
.
The patient was taken to [**Hospital 8125**] Hospital. There, she became
increasingly altered without focal neuro deficits. She had
multiple imaging studies. Head and neck CT scans were negative.
X-rays showed a L humeral fracture. Her labs, inc. chemistries
and cardiac enzymes, were normal except for Cr of 1.3. She
received 1 mg of ativan, 2 mg of morphine, and ???dilantin. On
the way over in the ambulance, pt had reportedly son[**Name (NI) 7884**]
respirations with desaturations, requiring bagging in the
ambulance.
.
In the ED, she only responded to painful stimuli, no gag reflex.
Mental status did not improve with 0.4 mg of Narcan. She was
intubated for airway protection and ventilatory support. She had
some frank blood in the ETT, though the intubation was not
difficult. Labs were sig. for neg serum tox screen, mild
leukocytosis of 11.7, Cr 1.2. Lactate was 1.4. 1st of cardiac
enzymes were neg. CXR and CTA showed pneumonia, no PE. CT head
showed no acute process. X-rays showed comminuted fracture of
the left proximal humerus fx, no hip fractures. ED failed
multiple LP attempts. Patient was acyclovir, vanc, CTX,
levaquin, and flagyl. VS on transfer were: 97.2, 102, 108/67,
20, 96% on 40% FiO2, AC 500 x 20.
.
ROS: Unable to obtain.
Past Medical History:
HTN
CHF
Asthma
Social History:
Pt lives with her niece's family. She used to work for the
state, caring for the mentally challenged. She is active at
home, helping with chores and going to the gym. She is a remote
smoker, no etoh, no recreational drugs.
Family History:
Heart disease.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Sedated on 15 of versed.
HEENT: PERRL, sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds anteriorly
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur at USBs
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
Labs on admission ([**2169-2-23**]):
.
[**2169-2-23**] 07:48AM BLOOD WBC-11.7* RBC-3.70* Hgb-11.9* Hct-35.1*
MCV-95 MCH-32.1* MCHC-33.8 RDW-12.4 Plt Ct-443*
[**2169-2-23**] 07:48AM BLOOD Neuts-82.6* Lymphs-12.9* Monos-3.3
Eos-0.8 Baso-0.4
[**2169-2-23**] 07:48AM BLOOD PT-12.1 PTT-24.9 INR(PT)-1.0
[**2169-2-23**] 07:48AM BLOOD Glucose-154* UreaN-21* Creat-1.2* Na-141
K-4.0 Cl-107 HCO3-23 AnGap-15
[**2169-2-23**] 07:48AM BLOOD CK(CPK)-306*
[**2169-2-23**] 03:15PM BLOOD ALT-23 AST-27 LD(LDH)-256* CK(CPK)-421*
AlkPhos-68 TotBili-0.3
[**2169-2-23**] 07:48AM BLOOD cTropnT-<0.01
[**2169-2-23**] 03:15PM BLOOD CK-MB-7 cTropnT-0.20*
[**2169-2-23**] 07:52PM BLOOD CK-MB-5 cTropnT-0.09*
[**2169-2-24**] 04:20AM BLOOD Albumin-2.9* Calcium-7.7* Phos-2.7
Mg-1.5*
[**2169-2-23**] 07:48AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.8
[**2169-2-24**] 04:20AM BLOOD VitB12-459 Folate-14.0
[**2169-2-24**] 04:20AM BLOOD TSH-0.60
[**2169-2-23**] 07:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2169-2-23**] 09:46AM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-100
pO2-386* pCO2-48* pH-7.31* calTCO2-25 Base XS--2 AADO2-291 REQ
O2-54 -ASSIST/CON Intubat-INTUBATED
[**2169-2-23**] 07:53AM BLOOD Lactate-1.4
[**2169-2-23**] 07:04PM BLOOD Lactate-1.0
[**2169-2-24**] 04:43AM BLOOD Lactate-0.9
.
Labs on discharge ([**2169-3-1**]):
[**2169-2-28**] 07:00AM BLOOD WBC-6.3 RBC-3.50* Hgb-11.2* Hct-33.1*
MCV-95 MCH-32.1* MCHC-34.0 RDW-12.1 Plt Ct-498*
[**2169-2-28**] 07:00AM BLOOD Glucose-88 UreaN-13 Creat-0.6 Na-143
K-3.7 Cl-105 HCO3-29 AnGap-13
.
MICROBIOLOGY:
.
[**2169-2-23**] BLOOD CULTURE Blood Culture, No growth
[**2169-2-23**] BLOOD CULTURE Blood Culture, No growth
.
[**2169-2-23**] URINE URINE CULTURE-FINAL INPATIENT No Growth.
[**2169-2-23**] URINE Legionella antigen negative
.
[**2169-2-23**] CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-FINAL NEGA.TIVE
.
[**2169-2-23**] 8:50 pm CSF;SPINAL FLUID Site: LUMBAR PUNCTURE
Source: LP TUBE#3.
GRAM STAIN (Final [**2169-2-23**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary):
.
[**2169-2-24**] 6:00 am Influenza A/B by DFA
Source: Nasopharyngeal swab.
**FINAL REPORT [**2169-2-24**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2169-2-24**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2169-2-24**]):
Negative for Influenza B.
.
[**2169-2-23**] 3:49 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2169-2-23**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2169-2-25**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
.
[**2169-2-23**] Respiratory viral culture negative
.
.
REPORTS:
CXR [**2169-2-23**]
1. ET tube ending in the right main stem bronchus. Recommend
withdrawal.
2. NG tube with sideport in the distal thoracic esophagus.
Recommend advancement.
3. Incompletely imaged left humeral head fracture.
4. Left lower lobe ill-defined opacity, likely representing
pneumonia.
.
CTA CHEST [**2169-2-23**]:
1. No pulmonary embolism or acute aortic pathology.
2. Scattered ill-defined nodular opacities within the lungs,
likely
infectious in etiology.
.
CT HEAD [**2169-2-23**]:
No acute intracranial process. Sinus disease as noted above.
.
RADIOGRAPH OF L HUMERUS [**2169-2-23**]:
IMPRESSION: Comminuted fracture of the right proximal humerus
.
AP BL HIPS [**2169-2-23**]:
IMPRESSION: No fracture or dislocation.
.
MR HEAD [**2169-2-23**]:
1. No evidence of acute intracranial process.
2. Nonspecific T2/FLAIR hyperintensities in the periventricular
and
subcortical white matter, likely due to chronic small vessel
ischemic disease.
3. Right parotid enhancing nodule. Differential includes
pleomorphic
adenoma. Clinical correlation recommended.
.
ROUTINE EEG [**2169-2-24**]:
IMPRESSION: This is an abnormal routine EEG due to a mildly slow
and
disorganized background. There were no focal, lateralized or
epileptiform abnormalities noted. The background is suggestive
of a
mild encephalopathy.
.
ECG [**2169-2-24**]:
Sinus rhythm. Delayed precordial R wave transition. There is
variation in
precordial lead placement as compared with previous tracing of
[**2169-2-23**].
Otherwise, no diagnostic interim change.
.
CT C-SPINE W/O CONTRAST [**2169-2-24**] (PRELIM):
There are no acute fractures. There is multilevel degenerative
disease of the cervical spine with loss of the normal cervical
lordosis.
Anterior osteophytes and disc space narrowing are present at
multiple levels, most pronounced at C5-C6 with moderate-severe
neural foraminal narrowing on both sides.
.
ECHO ([**2169-2-28**]):
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The estimated cardiac index is normal (>=2.5L/min/m2).
There is no left ventricular outflow obstruction at rest or with
Valsalva. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
mild [1+] mitral regurgitation. There is no mitral valve
prolapse. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
Brief Hospital Course:
52 yo female with history of hypertension, congestive heart
failure, and asthma with an upper respiratory tract infection
who presented with acute mental status changes and left proximal
humerus fracture s/p fall and was found to have pneumonia,
intubated for airway protection and respiratory distress.
.
# Respiratory distress: She was not requiring high amounts of
oxygen initially. CT chest showed scattered nodular infiltrates
suggestive of pneumonia. It was unclear whether this was a
bacterial superinfection from her viral URI, aytpical pneumonia,
or aspiration pneumonia secondary to her acute mental status
changes. CTA did not reveal a PE. Microbiology work-up for
respiratory infection, including influenza DFA, urine legionella
antigen, MRSA swab, and sputum culture, was negative.
Bronchoscopy with broncheoalveolar lavage showed no organisms.
Patient was extubated and remained stable. She was empirically
treated for severe community-acquired pneumonia with
ceftriaxone, vancomycin, and levofloxacin, then transitioned to
ceftriaxone and doxycycline given concern for QT prolongation on
levofloxacin, for a 7-day total course of antibiotics. Patient
was also treated with oseltamivir x 5 days despite negative
influenza A. Antibiotics and oseltamivir were stopped on day of
discharge due to patient's resolved respiratory symptoms and
completed course.
.
# Acute mental status changes: Her presentation was initially
concerning for meningitis/encephalitis, however CSF was negative
for growth of any organisms. Head CT and MRI did not show any
acute pathology. EEG showed mild encephalopathy without
evidence of seizure. She had received Ativan, morphine, and
possibly Dilantin at the OSH; however, she was altered prior to
arrival and had a negative tox screen. Her mental status
returned to baseline after extubation. She was kept on
telemetry on the floor and had no recorded events. Her
transthoracic echo was normal without valvular abnormalities.
In the end, her change in mental status was thought to be
possibly due to a concussion from a mechanical fall as pt denied
loss of sensation, chest pain, shortness of breath, dizziness,
palpitations or any prodrome to fall. Patient insisted that she
simply lost her balance and may have tripped over one of her
dogs sleeping on the floor. She was at her baseline, alert and
oriented, on discharge.
.
# Left proximal humeral fracture: Patient suffered a fracture
of her left proximal humerus s/p her fall at home. Orthopedic
consult recommended a sling for her arm, and she was given
Percocet and Tylenol as needed for her pain. She was discharged
with home PT and has a scheduled appointment with ortho in 2
weeks.
.
# Hypertension: Her antihypertensives were held initially in
the ICU on sedation, then restarted on the floor with normal
blood pressure on discharge.
.
# Congestive heart failure: She was not noted to be
volume-overloaded on exam throughout her hospitalization. Her
TTE showed a left ventricular ejection fraction > 55%.
Medications on Admission:
Atenolol 25 mg daily
Verapamil SR 240 mg daily
Triamterene 37.5 and HCTZ 25 daily
ASA 325 mg daily
Montelukast 10 mg daily
Advair 500/50
Piroxicam 1 cap daily
KCl 20 meq daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day): Please take for constipation while on Percocet.
Disp:*12 * Refills:*0*
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed for wheeze.
6. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
10. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
11. Piroxicam 10 mg Capsule Sig: One (1) Capsule PO once a day.
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for pain for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
13. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day:
Please take for constipation while on Percocet.
Disp:*10 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Syncope
Pneumonia, community acquired
Proximal Humerus Fracture
Altered Mental Status
.
Secondary:
Hypertension
Chronic Diastolic Congestive Heart Failure
Asthma
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**] with altered mental status after a
fall at home. You were found to have pneumonia and were
admitted to the ICU for respiratory distress. You were given
antibiotics for your pneumonia and Tamiflu for possible
influenza. You were also found to have a fracture of your arm
(left humerus). You were evaluated by the orthopedic doctors
but [**Name5 (PTitle) **] surgery is needed, and you will see them in their office
in 2 weeks.
.
You had several medical tests to determine if there was a cause
to your falling, including a study of your heart
(echocardiogram) and to screen for seizures (EEG) and these did
not show any signficant abnormalities.
.
Please take the following medications:
START Tylenol 325mg 1-2 tablets three times a day as needed for
pain.
START Percocet every 8 hours as needed for pain.
Please discuss restarting your KCl 20meq pill per day with your
PCP.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Name (NI) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 58182**] for an
appointment within the next week.
.
Please also keep the following appointments:
.
Appointment #1
MD: [**Name (NI) **] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine/ PCP
[**Name Initial (PRE) 2897**]/ Time: Monday, [**3-13**], 3:45pm
Location: [**State **], Suite A, [**Location (un) 2498**] MA
Phone number: [**Telephone/Fax (1) 58182**]
.
Appointment #2
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Specialty: Nurse Practitioner/ Orthopedics
Date/ Time: Thursday, [**3-9**], 12pm
Location: [**Location (un) **], [**Location (un) 86**]. [**Hospital Ward Name 23**] Building, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 1228**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
ICD9 Codes: 486, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2642
} | Medical Text: Admission Date: [**2188-8-19**] Discharge Date: [**2188-8-28**]
Date of Birth: [**2125-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
intubation
central line placement
History of Present Illness:
63 yo with ESRD, DM, CAD, CHF, who presents after an episode of
syncope today. The patient went to the commode today felling
fine, but then suddenly fell forward and hit her head and her
left arm. She thinks that she might have fallen asleep and only
recalls mild lightheadedness which is a common symptom for her
when she gets up to the commode. She did not loose consciousness
and recalls the event in detail. She was not able to get up from
the floor becaus eof the weakness in her legs at baseline until
her husband came to help her. She then had one episode of
non-bloody vomitus. Her husband called EMS who brought her to
[**Hospital6 **].
At [**Hospital1 34**] the patient reportedly was lethargic and a head CT was
done that was negative for bleed. The patient reported pain in
her L arm and a humerus XR showed a comminuted surgical neck
fracture with less than half shaft width of lateral
displacement. A CT of her spine was negative for fracture. A CXR
was read as CHF. The patient was transfered to [**Hospital1 18**] for further
management.
.
ED course: CXR was done and showed new R perihilar and RLL
infiltrate. The patient underwent a CTA that did not show any PE
but confirmed a right lower lobe as well as dependent right
upper lobe and medial left lower lobe infiltrate that was
concerning for infection. The pt was given Vanco, Levo and
Flagyl.
.
ROS: negative for CP, SOB, cough, secretions, abdominal pain,
diarrhea, constipation, f/c/ns, weight loss, dysuria, changes in
the color of the urine or stool. The patient reports that she
was feeling a little weaker since her recent admission for coag
neg bacteremia but had been feeling fine otherwise.
Past Medical History:
1. DM2 since her 40s, dialysis since [**2-3**]
2. ESRD [**2-1**] DMII, on MWF HD, followed by Dr. [**First Name (STitle) 805**]
3. h/o MRSA cellulitis of bilateral LE
4. HTN
5. Hyperlipidemia
6. Hypothyroidism
7. CAD s/p CABG [**2179**], NSTEMI in [**9-2**] during admission; echo [**3-4**]
with EF 35%, moderate to severe MR
8. Anemia
9. Osteoporosis
10. Depression
11. h/o right hip fx s/o ORIF
12. PVD
13. Sleep apnea
14. On Home 3L O2, PFTs [**2186**] with restrictive pattern, pulmonary
HTN
15. R Charcot Foot
16. Restless Leg Syndrome
17. Pulmonary hypertension
Social History:
The patient lives with her husband who is her primary caregiver.
She denies past or present tobacco use. She denies alcohol or IV
drug use. Patient previously worked as a secretary.
Family History:
Father - Deceased with MI at 60
Sister - Breast cancer
Mother - 60s, CAD
Son with DM
Physical Exam:
VS T 97.5 BP 104/90 HR 71 RR 21 O2Sat 99% on NRB
Gen: NAD, AAOx3
HEENT: NC/AT, PERRLA, dry mm
NECK: no LAD, JVD not visulized, no carotid bruit
COR: S1S2, regular rhythm, SEM II/VI over LUSB, no r/g
PULM: limited due to patients limited ability to turn; decreased
breathsounds in R base, crackles b/l
ABD: + bowel sounds, soft, nd, nt, indurated area L lateral to
the umbilicus, umbilical hernia
Skin: warm extremities, no rash, 0.5cm dry open wound on L
malleolus,
EXT: dopplerable DP, charcot deformity of the R foot, trace
edema, no CVA tenderness
Neuro: following commands, PERRLA, reflexes 2+ b/l inupper
extremities, 1+ patella, absent achilles reflex
Pertinent Results:
EKG: SR, LA, HR 70, borderline PR interval, intraventricular
conduction delay with QRS prolongation to 170ms. No change from
prior.
.
CTA:
1. No PE.
2. Marked cardiomegaly with evidence of right heart dysfunction
and
congestion.
3. Consolidation of much of right lower lobe, as well as
dependent right upper lobe and medial left lower lobe may be due
to aspiration or infection.
4. Small-moderate partially loculated right pleural effusion.
5. Chronic right hemidiaphragmatic elevation.
6. Evidence of pulmonary arterial hypertension.
.
CT head: negative for bleed, old left parietal infarct.
CT spine: negative for fracture
.
XR humerus L: comminuted surgical neck fracture with less than
half shaft width of lateral displacement.
CONCLUSION:
1. Consolidation in the right lower, right upper and medial left
lower lobe, slightly increased in extent compared to prior
examination, may be due to infection or aspiration.
2. Small right pleural effusion.
3. Pulmonary arterial hypertension.
4. Large pelvic cystic mass, probably arising from the right
adnexal region. This finding is concerning for ovarian
malignancy, considering presence of ascites and omental
nodularity.
5. Old fracture deformities of inferior right pubic ramus, right
lower posterior ribs. Impacted fracture of the left humeral neck
and fracture of the right humeral neck, dedicated films can be
obtained if clinically indicated.. L3 compression fracture new
since [**2186-8-31**].
6. Thyroid nodule.
7. Left adrenal nodule.
Brief Hospital Course:
A/P: 63 yo with ESRD, DM, CAD, CHF, s/p syncopal event
presenting with hypercarbic respiratory failure, mild fluid
overload and L humerus fracture.
.
# Hypercarbic respiratory failure. Was intubated for airway
protection and hypercarbic respiratory failure thought to be due
to CHF and restrictive lung disease due to body habitus
(kyphoscoliosis/abdominal distention) and splinting from pain.
Patient has chronic CO2 retention at baseline and also O2
dependent with 3Lat baseline. Was treated with dialysis and was
extubated on [**8-25**]. Patient breathing comfortably on [**3-2**] L NC at
time of discharge.
.
# Syncopal event. This was thought to be due to a vasovagal
episode after micturation. No evidence of carotid stenosis, no
significant aortic valve disease on recent ECHO. Cardiac
enzymes were only mildly elevated with peak CK-MB of 12 on [**8-10**].
Troponins peaked at 0.8 on [**8-25**].
.
# Abdominal mass/ascites. This is likely be to ovarian cancer.
Elevated CEA and CA-125 are consistent with malignancy. Patient
was seen by gyn oncology who felt she was not a surgical
candidate - this was discussed with the pt. and her family and
they understood this and the uncertain but likely very poor
prognosis. They elected to treat symptomatically, and not
pursue specific further therapy.
.
# DM: Patient was treated with an insulin sliding scale during
ICU stay. She will need to resume her home dose of 37 [**Location 18993**] at night if her po intake increases and her blood
sugars are elevated. At the time of discharge she was being
managed on SSI alone.
.
# ESRD. Patient received dialysis during hospitalization, and
should continue TIW as outpatient.
.
# Humerus fracture. Patient suffered a humerus fracture during
syncopal episode. There was a mild displacement. She was
treated with Morphine prn and Tylenol RTC for pain control. She
was seen by orthopedic surgery and her arm was placed in a sling
- they recommended nwb and maintenance of arm in sling with
outpatient follow up in 4 weeks.
.
# Code:Pt. and family elect DNR/DNI. No pressors per family.
Medications on Admission:
Amlodipine 5 mg once a day
Aspirin 81 mg once a day
B complex once a day
Cozaar 50mg 4 times a week
Digoxin 125mcg, [**1-1**] alternating with 1 tablet po Q4days
Gabapentin 200mg QHS
Klonopin 1mg, 1 tablet QHS, 2mg before dialysis
Lipitor 10 mg--1 tablet(s) by mouth at bedtime
Mirapex 0.125 mg--[**1-1**] tablet(s) by mouth at 6pm and again QHS
Nephrocaps 1 capsule(s) by mouth once a day
Synthroid 50 mcg--1 tablet(s) by mouth once a day
TOPROL XL 100 mg--1 tablet(s) by mouth at bedtime
ZOLOFT 100 mg--1 tablet(s) by mouth q am
Daypro 600mg, 2 tbl with food
Calcium Acetate 667 mg 2tb TID W/MEALS
Clopidogrel 75 mg Tablet
Sevelamer 800 mg 3 Tablet PO TID
Glargine 37U, HISS
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
3. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO Q6pm and
QHS ().
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q6H (every 6 hours) as needed.
12. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale units, insulin Subcutaneous ASDIR (AS DIRECTED): see
attached sliding scale. units, insulin
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
14. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain.
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
20. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Likely ovarian cancer
Lt. humeral fracture
Multilobar, community-acquired pneumonia
Hypercarbic respiratory failure requiring mechanical ventilation
Discharge Condition:
stable
Discharge Instructions:
Take all medications as prescribed.
Call the Orthopedic department at [**Hospital1 **] to arrange a follow up
appointment for four weeks from the time of discharge:
([**Telephone/Fax (1) 2007**]
Call the Gynecology Department at [**Hospital1 18**] to arrange follow up
should you elect to pursue further treatment for the abdominal
mass that was found during this admission:
([**Telephone/Fax (1) 18994**]
Call and arrange a follow up appointment with your primary
doctor for within one month of leaving the hospital
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2188-9-16**] 11:10
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**],MD MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 457**]
Date/Time:[**2188-9-30**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2189-1-1**] 11:00
ICD9 Codes: 4280, 486, 5856, 4589, 2449, 2930, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2643
} | Medical Text: Admission Date: [**2147-10-15**] Discharge Date: [**2147-12-25**]
Date of Birth: [**2095-11-26**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
Left sided plegia
Major Surgical or Invasive Procedure:
[**11-8**] brain biopsy
History of Present Illness:
Mr. [**Known lastname **] is a 51 y/o male in previously good health until
approximately 2 weeks prior to admission. While down in [**Location (un) 80056**] in [**Month (only) 216**] visiting his children when he developed some
left sided-weakness and numbness. He underwent a brain biopsy
at a [**Hospital 5170**] hospital on [**2147-10-5**] which revealed a preliminary
DX of grade II Astrocytoma. The pt was then transferred to an
[**Hospital 26110**] rehab facility via Medivac (due to the hurricane) on
[**2147-10-8**]. He subsequently was discharged on [**2147-10-14**]. From there
he while traveling to [**Location (un) 86**], MA he developed acute shortness of
breath on [**2147-10-14**], Upon landinghe was taken to an outside ED and
later transferred to [**Hospital1 18**] where he was intubated for airway
protection and dyspnea. He was found to have a small PE. While
in [**Hospital1 18**] ED his neurologic status and exam deteriorated. He
became more lethargic, not following commands, and without
spontaneous speech. Physical exam revealed a dense left
hemiplegia.
Past Medical History:
1. hypertension
2. Demyelinating brain/cns disease
3. right frontal craniotomy on [**2147-10-3**]([**Location (un) 5770**])
4. E-Coli UTI [**10-23**] ->Levoquin
Social History:
Lives at home with family; per ex wife no tobacco/EtOH/IVDU.
Family History:
non-contributory
Physical Exam:
Amission Exam:
T:98.7 BP: 122/83 HR: 56 R 16 O2Sats 100% 2LNC
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**4-9**] EOMs could not be adequately assessed
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: lethargic, not following commands.
Orientation: not oriented.
Recall: none.
Language: no spontaneous speech
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 could not be effectively
tested.
VIII: could not be tested.
IX, X: not tested.
[**Doctor First Name 81**]: not tested
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength could not be tested. Pronator drift could not
be tested
Patient withdraws to noxious stimuli with all 4 extremities
right
> left
Sensation: not tested
Toes downgoing bilaterally
right frontal incision c/d/i
On Discharge:
See hosp course for d/c exam
Pertinent Results:
Labs on Admission:
[**2147-10-15**] 12:15AM BLOOD WBC-11.7* RBC-3.78* Hgb-11.3* Hct-32.8*
MCV-87 MCH-30.0 MCHC-34.6 RDW-13.0 Plt Ct-580*
[**2147-10-15**] 12:15AM BLOOD Neuts-67.4 Lymphs-26.6 Monos-4.3 Eos-1.1
Baso-0.6
[**2147-10-15**] 12:15AM BLOOD PT-11.8 PTT-27.9 INR(PT)-1.0
[**2147-10-15**] 12:15AM BLOOD Glucose-113* UreaN-25* Creat-0.5 Na-138
K-4.1 Cl-101 HCO3-27 AnGap-14
[**2147-10-15**] 12:15AM BLOOD CK(CPK)-73
[**2147-10-15**] 12:15AM BLOOD cTropnT-<0.01
[**2147-10-15**] 12:15AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.2
[**2147-10-15**] 06:04AM BLOOD Phenyto-2.3*
Labs On Discharge:
[**2147-12-20**] 06:15AM BLOOD WBC-3.6* RBC-3.30* Hgb-10.4* Hct-29.9*
MCV-91 MCH-31.5 MCHC-34.7 RDW-17.2* Plt Ct-822*
[**2147-12-20**] 06:15AM BLOOD Neuts-52.2 Lymphs-30.0 Monos-7.0 Eos-9.0*
Baso-1.8
[**2147-12-5**] 05:40PM BLOOD PT-13.2 PTT-65.6* INR(PT)-1.1
[**2147-12-20**] 06:15AM BLOOD Glucose-92 UreaN-3* Creat-0.4* Na-140
K-3.9 Cl-103 HCO3-26 AnGap-15
[**2147-12-20**] 06:15AM BLOOD ALT-21 AST-19 LD(LDH)-177 AlkPhos-91
TotBili-0.3
[**2147-12-20**] 06:15AM BLOOD Albumin-3.6 Calcium-9.2 Phos-4.5 Mg-1.9
[**2147-12-5**] 05:40PM BLOOD Triglyc-146 HDL-45 CHOL/HD-5.2
LDLcalc-160*
[**2147-11-30**] 06:30AM BLOOD TSH-0.18*
[**2147-11-30**] 06:30AM BLOOD T4-5.5 T3-85 calcTBG-0.95 TUptake-1.05
T4Index-5.8 Free T4-1.1
[**2147-11-28**] 10:50AM BLOOD HBsAb-POSITIVE HBcAb-POSITIVE
[**2147-11-29**] 08:00PM BLOOD HBsAg-NEGATIVE
[**2147-11-29**] 08:00PM BLOOD AMA-POSITIVE Smooth-NEGATIVE
[**2147-11-29**] 08:00PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2147-11-28**] 10:50AM BLOOD antiTPO-103*
[**2147-12-5**] 05:40PM BLOOD PEP-POLYCLONAL IgG-2285* IgA-370 IgM-310*
IFE-NO MONOCLO
[**2147-11-18**] 02:05PM BLOOD HIV Ab-NEGATIVE
[**2147-12-19**] 05:13AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2147-11-18**] 12:40PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-141*
Polys-7 Lymphs-84 Monos-9
Test Name Result
Reference Range
--------- ------
---------------
Multiple Sclerosis Profile
Cerebrospinal Fluid (CSF) IgG Index 0.44 Index
<=0.85
IgG, CSF 4.40 mg/dL
<=8.1
Albumin, CSF 20.60 mg/dL
<=27.0
IgG/Albumin, CSF 0.21 ratio
<-0.21
Synthesis Rate, CSF 0.00 mg/24 h
<=12
IgG, S 1570 mg/dL (High)
[**Telephone/Fax (1) 56322**]
Albumin, S 3250 mg/dL
3200-4800
IgG/Albumin, S 0.5 ratio (High)
<=0.4
Serum Bands 0 bands
CSF Bands 0 bands
CSF Olig Bands 0 bands
<4
Interpretation
--------------
The oligoclonal band assay detected 3 or less IgG bands in the
CSF,
which are not present in the serum.
This is a Negative result.
EKG([**10-14**]):
Sinus bradycardia. Early repolarization. No previous tracing
available for
comparison.
XXXXXXXXXXXXXXXXXXXXXXXXX
BIOPSY: Brain, frontal lobe, right, biopsy: Subcortical white
matter with sharply demarcated zones of demyelination. See
note. Note: Luxol fast blue and Bodian stains show sharply
demarcated areas of demyelination with preserved axons.
Immunohistochemical stains for CD68 and CD3 show dense
infiltration of macrophages and scattered T cells in areas of
demyelination. Immunostain for SV40 ([**Male First Name (un) 2326**] virus) is negative.
These findings are consistent with multiple sclerosis in the
appropriate clinical context.
Imaging:
CTA Chest([**10-15**]):
IMPRESSION: Small peripheral pulmonary embolus within the right
lower lobe.
Head CT([**10-15**]):
IMPRESSION: Extensive edema of the hemispheres, with involvement
of the
corpus callosum, compatible with the reported history of
glioblastoma
multiforme.
LE Ultrasound ([**10-15**]):
IMPRESSION: No evidence of lower extremity DVT.
MRI Head ([**10-15**]):
IMPRESSION:
1. Extensive bifrontal vasogenic edema with two small foci of
enhancement.
Findings are nonspecific and may correspond to the reportedly
biopsy-proven glioblastoma multiforme. Given the overall paucity
of enhancement, hemorrhage or necrosis, however, lymphoma
remains a distinct possibility.
2. Small amount of blood products along the right frontal lobe
biopsy tract.
3. Unusual pattern of non-enhancing uniform T1- and
T2-hyperintensity
confined to the right basal ganglia, of unclear etiology, but
likely secondary to the adjacent extensive tumor and peritumoral
edema, perhaps on the basis of altered perfusion (though there
is no evidence of frank infarction); a less likely consideration
is direct tumor infiltration.
COMMENT: Focused MRI with spectrscopy, arterial-spin label
perfusion, and
dynamic susceptibility perfusion analysis has been recommended,
to better
characterize both the primary process and the findings in the
ipsilateral
basal ganglia.
MR [**First Name (Titles) **] [**Last Name (Titles) 430**]([**10-19**]):
Redemonstration of extensive bifrontal edema infiltrating the
corpus callosum, with small areas of posterior enhancement.
Overall, the
appearance favors glioblastoma over lymphoma, although
encephalitis can have the same imaging appearance. Correlation
with prior MR examinations is critical to evaluate the evolution
of these findings in the setting of the patient's biopsy and
possible ischemic event. 2. Abnormal pectroscopic evaluation
demonstrating high choline in all three regions selected, which
can be seen in malignant brain tumors but also can be seen with
lymphoma and demyelination, as well as infectious processes. 3.
Normal MR perfusion study with no definite areas of
hyperperfusion to definitely suggest malignancy. 4. Failed
arterial spin labeling.
MR BRAIN [**11-27**]: IMPRESSION:
1. No specific evidence of intracranial infection; though subtle
findings of infection may be obscured by the global
abnormalities, above. 2. New opacification of the sphenoid
sinuses, and thickening of the right
frontal sinus; though these findings may be "passiv," related to
prolonged
supine positioning and/or intubation, infection cannot be
excluded. 3. Extensive bifrontal edema infiltrating the corpus
callosum with small foci
of marginal enhancement, dorsally, overall stable, with no new
enhancing
focus seen. 4. Further pathologic T1-hyperintensity within the
right basal ganglia, and in cortex overlying the zones of white
matter edema, of uncertain clinical significance. Though this
may relate to a primary infiltrative neoplastic (or
demyelinative) process, secondary ischemic or neurodegenerative
processes remain differential considerations.
CT Torsoe: 1. No obvious neoplastic process identified in the
chest, abdomen or pelvis. 2. Small left upper lobe pulmonary
nodule is unchanged compared to [**2147-10-15**]. In the
absence of malignancy or significant risk factors (ie smoking),
no further follow-up is needed. If this history does exist,
follow- up in one year is recommended.
MR BRAIN [**12-12**]: 1. No significant change in extent of white
matter FLAIR hyperintensity and right basal ganglia T1
hyperintensity from recent MRI from [**11-15**]. Improvement
compared to [**2147-10-2**]. 2. Sphenoid sinusitis.
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] after immediate transfer from
[**Location (un) 6692**] airport for respiratory distress. His presentation is
quite complicated. Per OSH records, and discussions with
ex-wife, [**Name (NI) **] [**Name (NI) **]. Mr. [**Known lastname **] was apparently visiting with his
family in [**Location (un) 5770**], LA, when he developed left sided weakness
and sensory deficits. He was hospitalized at [**Hospital 80057**]
Medical Center in Merron, LA. During this hospitalization, he
was discovered to have significant bilateral frontal brain mass.
He subsequently underwent right sided biopsy to identify
pathology. Per OSH pathology identified Grade II astrocytoma. He
was apparently hospitalized for 4 weeks, but then needed to be
med-evac from LA because of the hurricane warnings. He was then
transferred to a rehab facility in [**Location (un) 80058**], [**State 26110**](St.
[**Hospital 6783**] Medical Center). Apparently because the patient's
ex-wife resided in MA, she requested he be transferred to MA, as
he had no friends/family in [**State 26110**]. During his medical flight
to MA, he experienced SOB and desaturations and upon landing was
taken to an OSH ED where he was intubated and later transferred
to [**Hospital1 18**] after a subsegmental PE was identified.
He was initially managed in the ICU for two days secondary to
his respiratory status issues, but after several subsequent
stable blood gasses and no further issues with respiration; he
was weaned to extubation. After he was extubated, he was
transferred to floor status on [**10-18**]. Neuro-oncology and
radiation oncology consults were obtained, and secondary to the
inadequacy of documentation provided, it was recommended to
pursue an additional biopsy. However, due to lack of legal
documentation to identify the ex-wife as the health care proxy,
guardianship and guidance was initiated with the legal
department. In the interim however, various specialized MRI and
PET scans were ordered to further interrogate the pathology of
his intracranial mass. Results are listed previously in this
document. His initial pathology was reviewed by another outside
pathologist and the slides were sent here for review and the
final descision, as above, is a demyelinating process and not
oncologic. With this new information he was transfered to the
neurology service for further evaluation and treatment. He had
an LP which was unremarkable and negative for oligoclonal bands.
He had an extensive evaluation for causes. Sginificant but
unrelated findings incluided evidenve of prior Hep B infection
and low TSH and eleveated TPO antibody. These findings were
discusse with GI and endocrien respectively and recommmended
following labs periodically.
For his demyelinating lesion he completed 5 days of 1gm/day IV
solumedrol and 5 days of IVIG without any response. He had
another MRI without significant change and then underwent
Cytoxan induction. Heme/Onc was consulted to help manage this.
During induction he was aggresively hydrated, treated with mesna
and had daily UA's. He had minimal amount of RBC's in urine
which cleared with hydration and resolved after finishing the
course of cytoxan. He will follow-up with neurology clinic
where they will discuss continuing cytoxan at that time. He
should have a follow-up CBC w/Dif in 1 week.
His discarge neuro exam is significant for abulia, but oriented
x3. He has significant left facial weakness, with intact
extra-ocular movemnts. PERRL and tongue midline. Strength exam
is difficult due to motor impersistance but on the right side he
can move agaist resistance. Left UE is flaccid paresis and LE
is antigravity. He has brisk reflexes on the left side.
Sensation is intact throughout but he does extinguish with
bilateral stimulation.
Medications on Admission:
Lopressor 50mg [**Hospital1 **]
Folic Acid 1mg daily
Protonix 40mg daily
Thiamine 100mg daily
Dilantin 100mg daily
decadron 4mg Q6H
Percocet 7.5/325 prn
Phenergan injection prn
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Methylphenidate 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Acetaminophen 160 mg/5 mL Solution Sig: Four (4) tsp PO Q6H
(every 6 hours) as needed. tsp
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
Tower [**Doctor Last Name **] Center
Discharge Diagnosis:
Demyelinating CNS disorder
Discharge Condition:
Neurologically Stable
Discharge Instructions:
You were admitted because of severe weakness of your left arm
and leg. This is from a condition that destroys the lining of
your nerves of your brain. You will need regular follow-up with
the neurology doctors.
Followup Instructions:
CBC w/dif in 2wks
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Last Name (un) **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2148-1-18**] 10:00
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2148-1-16**]
12:20 [**Hospital Ward Name 23**] [**Location (un) **]
ICD9 Codes: 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2644
} | Medical Text: Admission Date: [**2145-12-3**] Discharge Date: [**2145-12-7**]
Date of Birth: [**2070-2-19**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
coma
Major Surgical or Invasive Procedure:
made CMO
History of Present Illness:
75yo woman w HO HTN was in her USOH i.e., fully functional and
parttime employed until 9pm [**2146-11-1**] when the son talked to her
on the phone. THis AM, son called her and she did not respond.
At noon the family went to her place and found her unresponsive
incontinent for stool and urine. Did not move her right side. TX
to our ED.
Of note she had been seen by a neurologist for right sided
"tingling" in the last months. They say, pt had a brain MRI as
well but the family is unable to provide more info.
Past Medical History:
HTN
Tingling right arm?
Social History:
Lives alone.
Smoking: none
ETOH: rare
Illicit drugs: none
Family History:
not able to be obtained
Physical Exam:
Vitals: 98, 187/108, 18, 99% intubated
Breathes over the vent.
HEENT: The neck feels supple. Hard to appreciate any carotid
bruits.
Pulmonary: Clear to auscultation bilaterally, no crackles or
wheezes.
Cardiovascular: Regular rate and rhythm
Abdomen: soft, non-tender, non-distended, negative bowel sounds.
MENTAL STATUS
GCS: 6
eyes (none)
verbal (none)
motor (localizes)
CRANIAL NERVES:
Corneal reflex present on the left. Eye position midline. Pupils
are equal in size (3mm) and react directly and indirectly to
light. Nystagmus not present. Conjugated deviation is not
present. Oculocephalic testing not done due to neck in collar.
MOTOR:
Tone- both side hypertonic. Responds w localization w the left
but on the right only withdraws the leg and moves the arm away
from the stimulus weakly.
SENSATION:
As above
REFLEXES:
Right brisker. Present on the rest of the joints.
TOES:
Equivocal
Pertinent Results:
[**2145-12-3**] 07:50PM TYPE-ART TEMP-38.9 RATES-/14 TIDAL VOL-500
PO2-553* PCO2-42 PH-7.42 TOTAL CO2-28 BASE XS-3
INTUBATED-INTUBATED VENT-CONTROLLED
[**2145-12-3**] 02:30PM URINE COLOR-Straw APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2145-12-3**] 02:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2145-12-3**] 02:30PM URINE RBC-[**4-29**]* WBC-[**1-22**] BACTERIA-MANY
YEAST-NONE EPI-<1
[**2145-12-3**] 02:11PM GLUCOSE-172* UREA N-20 CREAT-0.7 SODIUM-138
POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-24 ANION GAP-20
[**2145-12-3**] 02:11PM CK(CPK)-424*
[**2145-12-3**] 02:11PM cTropnT-<0.01
[**2145-12-3**] 02:11PM CK-MB-10 MB INDX-2.4
[**2145-12-3**] 02:11PM CALCIUM-9.8 PHOSPHATE-3.8 MAGNESIUM-1.7
[**2145-12-3**] 02:11PM WBC-11.0 RBC-4.31 HGB-14.1 HCT-40.5 MCV-94
MCH-32.7* MCHC-34.8 RDW-12.9
[**2145-12-3**] 02:11PM NEUTS-70 BANDS-19* LYMPHS-7* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2145-12-3**] 02:11PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2145-12-3**] 02:11PM PLT COUNT-296
[**2145-12-3**] 02:11PM PT-13.0 PTT-23.5 INR(PT)-1.1
[**2145-12-3**] NCHCT: large left temporal, parietal, and occipital
intraparenchymal hemorrhage, with extension into the ventricles
and midline shift with prominence of the right lateral
ventricles.
[**2145-12-5**] NCHCT: 1. No change in the degree of extensive
intraparenchymal and subarachnoid hemorrhage compared to the
prior study.
2. Slight increase in the amount of surrounding edema and
subfalcine and uncal herniation, left-to-right.
Brief Hospital Course:
Mrs. [**Known lastname 104190**] was admitted to the neuro ICU for management of
the intracerebral hemorrhage. She was started on mannitol for
impending herniation, and antibiotics for UTI, dilantin for
seizure prophylaxis, and antihypertensives for BP control.
Despite interventions, she continued to decline, and after
multiple family discussions regarding the patient's wishes, she
was made comfort measures only and died shortly afterwards.
Medications on Admission:
ASA
Cozaar
Amitriptilin
alprazolam
atenolol
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
ICD9 Codes: 431, 5990, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2645
} | Medical Text: Admission Date: [**2111-12-15**] Discharge Date: [**2111-12-19**]
Date of Birth: [**2034-9-2**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Polytrauma following MVC
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77F unrestrained driver of MVC vs pole. Pt reports becoming
tired and closing her eyes for a second; does not feel she had a
syncopal episode. Airbag deployed and intrusion of engine was
noted by EMS. Pt was nonambulatory at scene with GCS 15. Pt was
transported by ambulance from the scene and complained of right
chest pain on arrival to [**Hospital1 18**] ED.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
Social History:
Retired from optics industry. Former smoker with 25 pack-year
history. Reports [**3-13**] alcoholic drinks per week. Denies illicits.
Family History:
Non-contributory
Physical Exam:
On admission:
T 98.9 HR 81 BP 121/84 RR 18 O2Sat 100%RA
GCS 15
Gen: NAD. Secured on backboard with c-collar in place.
HEENT: Head atraumatic. PERRL, EOMI. TMs and oropharynx clear.
Mid-face stable.
Neck: C-collar in place.
CV: RRR.
Chest: Right anterolateral chest wall tenderness to palpation.
Clavicles stable. No crepitus. CTA bilaterally.
Abd: Soft, NT, ND.
Pelvis: Stable.
Ext: Compartments soft. Warm, well-perfused. Distal pulses
intact.
Pertinent Results:
On admission:
Labs:
WBC-13.8* RBC-4.94 Hgb-14.1 Hct-42.4 MCV-86 MCH-28.5 MCHC-33.2
RDW-14.0 Plt Ct-317
PT-9.9 PTT-29.1 INR(PT)-0.9
Glucose-152* UreaN-24* Creat-1.0 Na-143 K-3.2* Cl-104 HCO3-28
AnGap-14
AST-34 AlkPhos-104 TotBili-0.2
Lipase-67*
Tn-<0.01
Albumin-4.6 Calcium-9.9 Phos-2.5* Mg-2.3
Imaging:
[**12-15**] CT head: negative
[**12-15**] CT torso: 1. Sternal fracture, and four contiguous right
anterolateral rib fractures. 2. Within the lungs, a 1.9-cm
predominantly ground glass lesion in the right upper lobe with
spiculated margins has an appearance concerning for
bronchoalveolar carcinoma and further evaluation is recommended.
Multiple left lung nodules ranging in size from 8 mm to 3.5 cm
are noted. The largest of these does not have definitely benign
features and further evaluation is warranted. 3. There is no
traumatic injury of the abdomen or pelvis. A large left adnexal
cyst measures 8.1 cm and would be better evaluated by pelvic
ultrasound on a non-emergent basis. 4. Small enhancing focus
within the tail of the pancreas (4 mm) which might be better
evaluated by MRCP on a non-emergent basis
[**12-15**] CT cspine: Unilateral perched facet on left at C5-6.
Thyroid nodule, nonemergent ultrasound recommended muliple
ground glass nodule in lung apices, rec comparison with priors,
no f/u recommended in absence of risk factors such as smoking.
[**12-15**] MRI cspine: Abnormal signal surrounding posterior and
anterior ligaments at C5-6 as well as within muscle c/w
ligamentous injury and muscle strain. There is no bone edema.
The ventral csf is effaced by disc at C5-6 but there is no cord
edema.
Brief Hospital Course:
Following initial trauma evaluation and imaging, the patient was
admitted to the Trauma/Surgical floor with the following
injuries:
1. C5-C6 unilateral left perched facet
2. Sternal fracture with associated retrosternal hematoma
3. Right anterolateral rib fractures [**5-17**]
Given her age and need for close monitoring of respiratory and
neurologic status, the patient was subsequently transferred to
the Trauma Surgical ICU. Pain was managed using a dilaudid PCA.
Aggressive pulmonary toilet was encouraged. She remained
hemodynamically stable with good oxygen saturation on nasal
cannula.
An Ortho/Spine consult was obtained with recommendation for
surgical intervention with c-collar to remain in place until
that time. The patient requested a 2nd opinion, which was
requested from Neurosurgery. Neurosurgery recommended operative
management versus traction placement. The patient opted for
management with traction. Patient was monitored on the ACS
service. OT and PT evaluated the patient and reccomended
discharge to home without services.
Patient was discharged to home on HD5 tolerating a regular diet,
pain with good control on po pain medication, making good urine
output, c-collar in place ambulating independently with stable
vitals signs. Patient instructed to leave c-collar in place for
6 weeks and to follow up with neurosurgery and [**Hospital 2536**] clinic as per
discharge information.
Medications on Admission:
1. Pravastatin 20mg daily
2. Metoprolol XL 100mg daily
3. Losartan/HCTZ 50/12.5mg daily
4. Calcium supplement
Discharge Medications:
1. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
Discharge Disposition:
Home With Service
Facility:
Walpople vna
Discharge Diagnosis:
1. C5-C6 unilateral left perched facet
2. Sternal fracture with associated retrosternal hematoma
3. Right anterolateral rib fractures [**5-17**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen and evalated in the ED after a motor vehicle crash
into a pole. You sustained the following injuries:
1. C5-C6 unilateral left perched facet
2. Sternal fracture with associated retrosternal hematoma
3. Right anterolateral rib fractures [**5-17**]
Given your age and need for close monitoring of respiratory and
neurologic status, you were transferred to the ICU. When stable
you were transfered to the floor for further observation. You
were discharged home on HD 5 with a c-collar in place per
neurosurgery and orthopaedic surgery reccomendations.
-Please do not drive until cleared to do so by a physician
[**Name10 (NameIs) 21421**] do not drive while taking narcotic pain medictaions
-Leave c-collar in place for 6 weeks unless instructed
differently by neurosurgery
-Please call your physician or return to the Emergency Deparment
for increased pain, mental status changes, fever greater than
101.4, nause, vomiting, vision changes, numbness or tingling in
your extremities or diarreha.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 739**] in clinic. Please call
[**Telephone/Fax (1) 58980**] to schedule appointment. Please call with
questions.
Please follow up with [**Hospital 2536**] clinic. Please call [**Telephone/Fax (1) 600**] to
schedule an appointment in the next 2-3 weeks.
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2646
} | Medical Text: Admission Date: [**2185-10-17**] Discharge Date: [**2185-10-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP and papillotomy with removal of 3 gallstones:
Details as follows:
1. A single periampullary diverticulum with small opening was
found at the major papilla.
2. Cannulation of the biliary duct was successful and deep with
a sphincterotome using a free-hand technique.Three round stones
ranging in size from 4mm to 6mm that were causing partial
obstruction were seen at the lower third of the common bile
duct. The CBD was mildly dilated to 10 mm.
3. The intrahepatic cholangiogram was normal with no filling
defects.
4. A sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire.
5. Three stones and sludge were extracted successfully using a
12 mm balloon.
History of Present Illness:
87 yo M who was admitted to the vascular surgery service on
[**2185-10-17**] with intermittent epigastric pain w/ eating x ~1 week.
He also had several episodes of vomiting after eating which
releaved the pain. CTA at OSH found questionable evidence of
aortic dissection in 3 areas and he was transferred to [**Hospital1 18**] for
further care. On further review of CT scan after admission it
was determined that the patient had stable endovascular
ulcerations and not an aortic dissection.
.
On further investigation of abdominal pain the patient was found
to have elevated LFT's and bilirubin and was found to have
suggestion of cholecystitis and choledocholithiasis on MRCP. He
was treated with ERCP and sphincterotomy with extraction of
three stones and sludge on [**2185-10-19**].
.
Following ERCP he was transferred to the MICU for concern for
hypertensive urgency vs emergency. He was treated with
metoprolol and captopril as well as NTG drip with goal MAP of
85. Mental status change felt to be [**3-4**] combination of pain
medications and underlying dementia.
Past Medical History:
PMH:
1. Prostate CA s/p XRT
2. Hypercholesterolemia
3. Low back pain
.
PSH: Prostate surgery (lower midline scar)
Social History:
Retired from state legislature. Lives with his wife near
[**Name (NI) 1474**]. Plays golf frequently. Smoked 1PPd x 30 yrs but quit
30 years ago. Drinks an alcoholic beverage 1- 2 x month. No hx
of heavy EtOH use. No hx of tatoos or IVDU.
Family History:
father w/ CVA in 80s
Physical Exam:
Vitals:
Gen: well appearing, nad
HEENT: no scleral icterus, EOMI, op - mmm
Neck: no lad
Lungs: clear bilaterally
Cards: distant heart sounds, regular, no murmurs
Abd: + bs, soft, non-tender, no hsm
Ext: no edema
Neuro: aao x 3, no asterixis
Skin: no jaundince, no telangiectasias
Pertinent Results:
[**2185-10-19**] 06:05AM BLOOD WBC-7.0 RBC-4.03* Hgb-13.7* Hct-38.9*
MCV-97 MCH-33.8* MCHC-35.1* RDW-13.5 Plt Ct-182
[**2185-10-19**] 06:05AM BLOOD Plt Ct-182
[**2185-10-19**] 06:05AM BLOOD Glucose-105 UreaN-13 Creat-1.0 Na-140
K-3.9 Cl-106 HCO3-24 AnGap-14
[**2185-10-19**] 06:05AM BLOOD ALT-124* AST-38 AlkPhos-126* Amylase-23
TotBili-1.2
[**2185-10-19**] 06:05AM BLOOD Albumin-3.3* Calcium-8.7 Phos-1.7* Mg-2.2
[**2185-10-18**] 02:40AM BLOOD Lipase-15
[**2185-10-17**] 08:00AM BLOOD Lipase-15
.
[**2185-10-17**] RADIOLOGY Final Report
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2185-10-17**] 10:35 AM
Reason: eval for gallbladder path
COMPARISON: None.
[**Doctor Last Name **] scale and doppler images of the right upper quadrant. The
liver is unremarkable in echotexture without evidence of focal
lesion. There is hepatopetal flow demonstrated in the portal
vein. Multiple shadowing stones are noted within the
gallbladder. There is no son[**Name (NI) 493**] [**Name2 (NI) 515**] sign, biliary duct
dilatation, or pericholecystic fluid to suggest acute
cholecystitis. The common bile duct measures 4 mm. The pancreas
is grossly unremarkable. The right kidney is unremarkable
without hydronephrosis. No ascites is seen.
.
IMPRESSION:
.
Cholelithiasis without evidence of acute cholecystitis.
.
MRCP (MR ABD W&W/OC) [**2185-10-18**] 5:45 PM
INDICATION: Transaminitis, hyperbilirubinemia.
COMPARISON: CT from [**Hospital 1474**] Hospital dated [**2185-10-17**]. Right upper
quadrant ultrasound from [**2185-10-17**].
TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen
were obtained on 1.5 Tesla magnet including dynamic 3D imaging
obtained prior to, during, and after the uneventful intravenous
administration of 0.1 mmol/kg of gadolinium-DTPA. Multiplanar 2D
and 3D reformations along with subtraction images were generated
on an independent workstation.
.
MRI OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST:
Gallbladder is distended and filled with innumerable small
gallstones. The extent of gallbladder distention is unchanged
compared to the recent CT and ultrasound, however,
circumferential gallbladder wall edema appears markedly
increased in the interval. In addition, there is a sliver of
pericholecystic fluid identified. After administration of
contrast, there is subtle hyperemia within the hepatic
parenchyma surrounding the gallbladder fossa. All these findings
suggest acute cholecystitis in the appropriate clinical setting.
.
No intra- or extra-hepatic biliary duct dilatation is
demonstrated. Within the distal common bile duct, at least three
intraluminal round filling defects, measuring up to 2 mm in
diameter are identified adjacent to one another, likely
representing nonobstructing stones. Common bile duct is smooth
in contour and normal in caliber without evidence of caliber
change. Incidentally noted, the right posterior hepatic duct
originates from the proximal left hepatic duct.
.
The liver, spleen, adrenal glands are within normal limits.
Within the uncinate process of the pancreas is a branching T2
hyperintense cystic lesion measuring approximately 1 x 1 cm
which appears to communicate with the main pancreatic duct and
likely represents dilated side branches. The main pancreatic
duct is normal in caliber and smooth in contour. Pancreatic
parenchyma enhances normally and is normal in signal intensity.
.
Multiple well-circumscribed T2 hyperintense lesions within the
cortices of both kidneys are consistent with cysts, the majority
of which are simple in nature. A 2.3-cm cyst within the
interpolar region of the right kidney contains a single
septation but without internal enhancement or nodularity. Both
kidneys demonstrate preservation of corticomedullary
differentiation with normal enhancement. There is no
hydronephrosis or solid renal masses.
.
A moderate-sized hiatal hernia is present. Visualized bowel
loops otherwise appear unremarkable.
.
Diffuse atherosclerotic disease is seen throughout the abdominal
aorta, which otherwise is normal in caliber. As noted on the
recent CT, three atherosclerotic ulcers are seen within the
descending aorta, one at the aortic hiatus, one at the level of
the renal arteries, and a third just inferior to the renal
arteries. None of these ulcers appear to project beyond the
confines of the aortic wall. No dissection is identified or
aneurysmal dilatation. There is focal high- grade narrowing
involving the celiac artery and SMA origins, which was
visualized on the recent CT, and secondary to atherosclerotic
disease. No collaterals are identified. Subcentimeter porta
hepatis lymph node is identified. No pathologically enlarged
mesenteric or retroperitoneal lymph nodes are seen. No free
fluid is seen within the abdomen.
.
A T1 and T2 hyperintense lesion within the L3 vertebral body is
consistent with a vertebral hemangioma.
.
Multiplanar 2D and 3D reformations were essential in providing
multiple perspectives for the dynamic series.
.
IMPRESSION:
1. Gallbladder appearance is concerning for acute cholecystitis
in the appropriate clinical setting. HIDA scan can be performed
for further evaluation.
2. Choledocholithiasis with three nonobstructing stones seen in
the distal common bile duct.
3. Approximately 1-cm branching cystic structure within the
uncinate process of the pancreas likely representing dilated
side branches, but IPMN remains in the differential. Six-month
followup MRCP is recommended to evaluate for stability of this
finding.
4. Celiac and SMA origin stenoses. Diffuse atherosclerotic
disease involving the abdominal aorta without aneurysmal
dilatation or dissection.
5. Moderate-sized hiatal hernia.
.
[**2185-10-20**] Echocardiogram:
Conclusions: EF 50%
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic
dysfunction with hypokinesis of the basal inferior and
inferolateral segments.
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The
mitral valve leaflets are structurally normal. An eccentric,
posteriorly
directed jet of mild (1+) mitral regurgitation is seen. The
estimated
pulmonary artery systolic pressure is normal.
Brief Hospital Course:
87 yo M who was admitted to the vascular surgery service on
[**2185-10-17**] with epigastric pain and concern for aortic dissection
on CT scan at OSH. On further review of CT scan after admission
it was determined that the patient had stable endovascular
ulcerations and not an aortic dissection. He was also found to
have choledocholithiasis and was treated with ERCP and
sphincterotomy. He was transferred to the MICU following ERCP
for hypertensive urgency which resolved with medications.
1) Choledocolithiasis s/p ERCP: On evaluation of his abdominal
pain he was found to have evidence of cholycystitis and
choledocholithiasis. He had ERCP, three stones were removed and
sphincterotomy performed. Since stone removal and decompression
he has been pain free and afebrile. Felt unlikely to have been
cholecystitis as following ERCP he remained afebrile without
leukocytosis or fever. Initially he was treated with levaquin
and flagyl however this was stopped following ERCP. In addition
his LFT's continued to improve and were essentially normal prior
to discharge with AST 23 ALT 68. He will need cholecystectomy
in the future and will follow up with general surgery.
2)Endovascular ulcerations of abdominal aorta - initially
admitted from OSH with concern for aortic dissection however
after further review of CT scan it was determined that he had
stable endovascular ulcerations not requiring surgery. He
should follow up with vascular surgery and have repeat CT scan
in 6 months.
3) Hypertensive urgency: Following ERCP there was concern as he
became very hypertensive with associated confusion requiring
admission to the MICU and IV antihypertensives. While patient
denies history of hypertension, he reportedly had been
hypertensive since admission. His blood pressure was controlled
in the ICU and he was discharged on lisinopril 10mg daily,
toprol xl 100mg daily and doxazosin2mg [**Hospital1 **]. He will follow up
with his PCP
4) hematemasis: started on the evening of [**10-20**] post ERCP with
approximately 50-100 cc hemoptysis. ERCP fellow contact[**Name (NI) **],
patient bolused with 1L NS and PPI IV BID started. Hct remained
stable since with no recurrent episodes of bleeding throughout
the rest of his admission. He was discharged on prilosec [**Hospital1 **].
5) likely CAD: suggested by regional LV systolic dysfunction on
TEE. Patient currently on home statin and beta-blocker.
Recommended that he start ASA in one week, holding for time
being [**3-4**] ERCP and post op hematemasis
6) Altered mental status: initially with increased confusion and
mental status change following ERCP. Thought to be most likely
due to pain medciations given during surgery. Per discussions
with patients wife and son he returned to his baseline prior to
discharge.
7) Hypercholesterolemia: restarted pravachol at home dose prior
to discharge. This medication was held throughout admission due
to elvated liver enzymes in the setting of choledocholithiasis.
8) Prostate cancer s/p prostatectomy: No acute issues.
9)Code: Full
Medications on Admission:
pravachol 20mg daily
tylenol prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Pravastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day:
Please do not start taking this medicine until one week after
discharge in order to allow your body time to heal. Aspirin
increases your risk for bleeding. On [**2185-10-30**] you can start
taking one enteric coated aspirin daily on .
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary:
1. Abdominal Aorta Dissection - 3 focal areas of ulceration
2. Accelerated Hypertension.
3. Cholecystitis.
4. Choledocholithiasis.
5. Regional LVSD - basal inferior/inferolateral.
6. Celiac and SMA origin high grade stenoses.
7. Hematemesis.
8. Right Carotid Artery Stenosis.
Secondary:
1. Prostate CA s/p XRT.
2. Hypercholesterolemia.
3. Chronic Low Back Pain.
4. Hypertension
Discharge Condition:
Good
Discharge Instructions:
Call Vascular Surgery or General Surgery with any new abdominal
pain, back pain, nausea, vomiting.
Followup Instructions:
Call Vascular Surgery Dr. [**Last Name (STitle) **]/[**Doctor Last Name **] office at
[**Telephone/Fax (1) 2395**] to schedule follow up and CT scan in 1 month.
Call General surgery Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 600**] to schedule follow
up visit in 2weeks
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2647
} | Medical Text: Admission Date: [**2187-2-8**] Discharge Date: [**2187-2-16**]
Date of Birth: [**2112-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Procanbid / Norpace / Zestril / Celebrex / Betapace / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain on Exertion
Major Surgical or Invasive Procedure:
[**2187-2-9**] CABG X 2 (LIMA->LAD, SVG->OM)
[**2187-2-8**] Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 108521**] is a delightful 75 year old gentleman with a
history of a past myocardial infarction who reports new chest
pain and dyspnea over the past couple of months. He has a past
history of atrial fibrillation with tachy brady syndrome for
which a permenant pacemaker was placed. He underwent a stress
test in [**12-30**] which was stopped secondary to fatigue and chest
pain. His ejection fraction was noted to be 39% on scan. Mr.
[**Known lastname 108521**] was admitted today for a follow-up cardiac
catheterization which revealed an 80% stenosed left main
coronary artery, a 50% stenosed proximal right coronary artery
and an ejection fraction of 35%. Due to the severity of his
disease, the cardiac surgical service was consulted for surgical
revascularization.
Past Medical History:
Hypercholesterolemia
Tachy-brady syndrome
Atrial fibrillation
Myocardial infarction
Depression
Carotid artery stenosis
S/P Paer implantation [**2175**]
GERD
Osteoarthritis
Social History:
Lives with daughter in [**Name (NI) 3146**]. Retired chef. Quit smoking 40
years ago after a 30 pack year history. Drinks a couple of
glasses of wine per week.
Family History:
No known coronary artery disease
Physical Exam:
Ht 69" Wt 210 lbs
VS: 105 AF BP 155/70 96% room air oxygen saturation
GEN: Laying flat in bed s/p catheterization in no apparent
distress.
NEURO: Moves all extremities, nonfocal.
LUNGS: CLear
CARDIAC: Irregular rhythm, no murmur.
ABD: Soft, nontender, nondistended, normoactive boel sounds.
EXT: Warm, well perfused. No edema, no varisocities.
PULSES: 2+ radial, femoral, dorsalis pedis and posterior tibial
bilaterally.
Pertinent Results:
[**2187-2-8**] 10:30AM INR(PT)-1.3
[**2187-2-8**] 08:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2187-2-8**] 01:30PM GLUCOSE-127* UREA N-18 CREAT-0.8 SODIUM-142
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-28 ANION GAP-12
[**2187-2-8**] 01:30PM ALT(SGPT)-10 AST(SGOT)-17 ALK PHOS-73
AMYLASE-21 TOT BILI-0.8 DIR BILI-0.2 INDIR BIL-0.6
[**2187-2-8**] 01:30PM WBC-6.7 RBC-3.89* HGB-11.6* HCT-35.1* MCV-90
MCH-29.8 MCHC-33.1 RDW-13.8
[**2187-2-16**] 07:15AM BLOOD WBC-10.2 RBC-3.41* Hgb-10.4* Hct-31.5*
MCV-92 MCH-30.5 MCHC-33.1 RDW-13.8 Plt Ct-290
[**2187-2-16**] 07:15AM BLOOD PT-20.8* PTT-114.7* INR(PT)-2.7
[**2187-2-16**] 07:15AM BLOOD Glucose-167* UreaN-25* Creat-1.0 Na-139
K-3.7 Cl-98 HCO3-33* AnGap-12
[**2187-2-8**] CXR
No previous films are available on PACS for direct comparison at
this time. There is a mild thoracic scoliosis convex to the
right. There is slight cardiomegaly with LV predominance but no
evidence for CHF. A dual chamber right sided pacemaker is
present with atrial and ventricular leads in situ, in good
location. The lungs are clear. There is minimal blunting of
posterior costophrenic angle. Degenerative changes are present
in the thoracic spine and there are surgical clips in the right
upper abdomen presumed s/p cholecystectomy.
[**2187-2-14**] CXR
AP & lateral chest views have been obtained in this patient now
demonstrating status post sternotomy, and the presence of
multiple surgical clips in the left-sided anterior mediastinum
are consistent with bypass surgery. A right-sided permanent
pacer in anterior axillary position is connected to two
intervavitary electrodes terminating in positions compatible
with right atrial appendage and apical portion of right
ventricle correspondingly. There is no evidence of pneumothorax.
The right-sided diaphragm is well delineated, but the left-sided
diaphragm is obliterated and blunted. Lateral pleural sinus is
consistent with postoperative pleural effsion of moderate
degree. Review of the patient's radiologic records demonstrates
that the preoperative chest examination in PA & lateral
technique was performed on [**2187-2-8**], then demonstrating
mild cardiac enlargement, moderately widened and elongated
thoraic aorta with calcium deposits in the wall. The pulmonary
vasculature did not demonstrate any congestive pattern. The
right-sided permanent pacer with dual-electrode system existed
already at that time. Comparison of today's fourth postoperative
examination, now in PA/lateral technique, demonstrates
considerable postoperative mediastinal widening to persist, and
the left lower lobe atelectasis-pleural density is new and has
not normalized as yet. Further postoperative follow-up exam is
advised. There is no evidence of remaining pneumothorax.
[**2187-2-8**] Cardiac Catheterization
1. Selective coronary angiography revealed a right-dominant
system. The LMCA was calcified with an 80% lesion. The LAD and
Lcx both had mild disease. The RCA had a 50% ostial lesion with
no flow limiting stenoses.
2. Left ventriculography revealed a moderately decreased
ejection
fraction (EF 35%) with global hypokinesis. There was 1+ mitral
regurgitation.
3. Resting hemodynamics revealed mild/moderately elevated left
and
right-sided filling pressures (RA mean 9mmHg, PA mean 28mmHg,
PWCP mean
13mmhg). The estimted cardiac index was 2.0 l/min/m2. There
was no
gradient on pull back across the aortic valve.
[**2187-2-8**] EKG
Atrial fibrillation, average ventricular rate 100-115, and
rate-related left bundle-branch block. Non-specific
repolarization abnormalities. Compared to the previous tracing
of [**2176-2-19**] the overall ventricular rate is slightly faster and
rate-related left bundle-branch block is new.
[**2187-2-14**] EKG
Atrial fibrillation with a ventricular response of 93. Left
bundle-branch
block. Compared to the previous tracing of [**2187-2-9**] the
ventricular response has slowed. Otherwise, no diagnostic
interim change.
[**2187-2-8**] Carotid duplex ultrasound
Minimal plaque with bilateral less than 40% carotid stenosis.
[**2187-2-9**] Pathology
Cardiac tissue consistent with atrial appendage, with myocyte
hypertrophy.
Brief Hospital Course:
Mr. [**Known lastname 108521**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2187-2-8**] for a cardiac catheterization. This was
significant for an 80% stenosed left main coronary artery, a 50%
stenosed right coronary artery and an ejection fractionof 35%.
Due to the severity of his disease, the cardiac surgical service
was consulted for surgical revascularization and Mr. [**Known lastname 108521**]
was worked-up in the usual preoperative manner. His coumadin was
stopped and his INR was allowed to drift towards normal. A
carotid duplex ultrasound was obtained which showed less then a
40% stenosis in the bilateral internal carotid arteries. On
[**2187-2-9**], Mr. [**Known lastname 108521**] was taken to the operating room where he
underwent coronary artery bypass grafting to two vessels.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. His pacemaker was interrogated
following surgery and was found to be functioning within normal
limits. He remained in atrial fibrillation which was treated
with diltiazem and digoxin for rate control. Mr. [**Known lastname 108521**] had
some postoperative delerium which resolved over several days
without further workup. On postoperative day two, Mr. [**Known lastname 108521**] [**Last Name (Titles) **]e neurologically intact and was extubated. Coumadin was
started for anticoagulation for atrial fibrillation. Gentle
diuresis was initiated. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. Heparin was started while his INR was subtherapeutic
on coumadin. On postoperative day four, Mr. [**Known lastname 108521**] was
transferred to the cardiac surgical step down unit for further
recovery. He continued to work with physical therapy for
postoperative mobility. As his INR became therapeutic on
coumadin, his heparin was discontinued. His chest tubes were
removed per protocol. Mr. [**Known lastname 108521**] continued to make steady
progress and was discharged home on postoperative day seven. He
will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his
primary care physician as an outpatient.
Medications on Admission:
Cardizem 120mg once daily
Multivitamin
Lopressor 100mg once in the morning and 75mg once in the evening
Coumadin 3mg once daily adjusted for INR btween 2.0-3.0
Aspirin 81mg once daily
Zantac 150mg once daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO once a day
for 1 doses: NO COUMADIN ON [**2-16**], and [**2-17**], then give 1mg on
[**2-18**]. INR to be drawn on [**2-19**], and called to Dr.[**Name (NI) 9920**] office
for continued dosing.
Disp:*90 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
CAD
AFib
Discharge Condition:
good
Discharge Instructions:
no lifting > 10 # or driving for 1 month
no creams or lotions to any incisions
may shower, no bathing or swimming for 1 month
Followup Instructions:
with Dr. [**Last Name (STitle) **] in 4 weeks
with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 2 weeks
with Dr. [**Last Name (STitle) **] in [**3-1**] weeks
Completed by:[**2187-3-22**]
ICD9 Codes: 4111, 4271 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2648
} | Medical Text: Admission Date: [**2203-10-17**] Discharge Date: [**2203-11-7**]
Date of Birth: [**2142-6-14**] Sex: M
Service: MEDICINE
Allergies:
Sulfamethoxazole/Trimethoprim / Aspirin
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Transfer to [**Hospital1 18**] for PEG placement
Major Surgical or Invasive Procedure:
Placement of left subclavian central line (removed), and right
internal jugular central line (removed)
Right sided thoracentesis for pleural effusions
History of Present Illness:
61 year-old male with longstanding DM type 1 with triopathy,
status post CRT [**2196**] (baseline creat 2.9-3.0 in [**3-/2203**]),
recurrent UTIs with MDR organisms, history of MRSA sepsis/osteo,
initially transferred on [**10-17**] from [**Hospital3 2737**] for PEG
placement.
*
He was originally admitted to [**Hospital1 **] on [**2203-10-4**] with mental
status changes. His w/u was remarkable for VRE UTI (only 1000
colonies) and a LLL pneumonia. He was initially started on
Cefepime, changed to Imipenem and Flagyl. A repeat urine culture
grew Burkholderia cepacia sensitive to Zosyn, and Zosyn therapy
was initiated on [**10-12**]. Blood cx negative. A follow-up CXR
showed resolution of his LLL pneumonia. A tagged WBC scan was
also performed and negative for infection. He remained
disoriented despite treatment of his infection, and he was felt
to be continually scratching his left biceps and having facial
twitching. Neurology was consulted. Head CT showed mild atrophy
but was otherwise negative. MRI showed marked atrophy, as well
as subtle changes in the posterior limb of the internal capsule
that could possibly represent small subacute punctate infarcts.
EEG was requested, but deferred [**12-29**] "scheduling difficulties".
Per neurology, Mr. [**Known lastname 1001**] was loaded with Dilantin for possible
seizure activity, with some subsequent improvement in his mental
status.
*
Still at the OSH, his Hct on admission was noted to be 25, and
he was transfused 2 units of PRBCs. He failed a bedside swallow
evaluation, and a barium swallow showed evidence of penetration
and aspiration. An NGT was placed. The patient reportedly did
not want a PEG tube, but was deemed incompetent to make
decisions by psychiatry. While in the hospital, he was begun on
Risperdal and Celexa was increased.
*
On the day of transfer ([**10-17**]), his lab work was remarkable for
a HCO3 drop 20-->15, with development of an anion gap acidosis.
He was started on IVF with dextrose, and given 1 amp of sodium
bicarbonate. On arrival to [**Hospital1 18**], he was hemodynamically
stable. However, his initial lab work was remarkable for an
anion gap of 22, with HCO3 of 9, glucose of 362. ABG done
7.23/22/50 (?arterial). U/A positive for ketones. Of note,
standing insulin had been held at outside hospital. He was
given insulin SC X few doses, then started on insulin drip on
the floor on [**10-18**], along with IVF, with eventual closure of his
gap. Coincident with the metabolic derangements, however, he was
noted to have declining mental status (responsive only to pain
at time of transfer), and he was transferred to the MICU for
further care.
*
In the MICU, he was continued on the insulin drip overnight,
discontinued on [**10-19**] at 1000 after overlap with NPH. AG closed.
[**Last Name (un) **] consulted, with recommendation to start Lantus. Regarding
his mental status, neurology was consulted. LP was performed
with OP 9, WBC 4, RBC 0, TP 93, Gluc 145, gram stain negative,
cryptococcal antigen negative, cultures pending. He was loaded
with Dilantin on [**10-18**] at night pending EEG on [**10-19**].
Preliminary report negative for seizure activity. Per neurology,
Dilantin was tapered off.
Past Medical History:
1. DM type 1 with triopathy
2. Status post cadaveric renal transplant in [**2196**]
3. Chronic renal insufficiency with baseline creatinine 2.9-3.0
in [**3-/2203**]
4. Peripheral neuropathy
6. Hypertension
7. CAD, LVEF >55% in [**3-/2203**]
8. GERD
9. Hypercholesterolemia
10. History of MRSA osteomyelitis/sepsis
11. History of recurrent UTIs with MDR organisms
*
Other past surgical history:
Status post right THR
Status post left BKA
Status post open chlecystectomy
Social History:
Widowed, ex-meat cutter, no TOB, no ETOH, no IVDU
Family History:
Mother with DM and PM and Father with PM
Physical Exam:
VITALS: Tm 99.2, Tc 98.9, HR 60s-70s, BP 120-170/50-60s, RR high
teens to low 20s, Sat 98-100% on RA.
I/O: + 450 last 24 hours, then + 1700 cc today
GEN: Caucasian male, in NAD. Answers questions, recognizes his
name, not oriented to place or time. Makes eye contact.
[**Name (NI) 4459**]: Pupils sluggish, reactive. Dry MM.
NECK: No cervical LN.
RESP: Limited examination, clear anteriorly.
CVS: RRR. Normal S1, S2.
GI: BS +. Soft, non-tender.
EXT: 2+ pedal edema RLE. Left BKA.
NEURO: Moves all 4 extremities.
Pertinent Results:
Micro:
[**2203-10-19**] BLOOD CULTURE x2 negative
[**2203-10-19**] CSF SPINAL FLUID GS negative, cultures negative
[**2203-10-19**] CSF CRYPTOCOCCAL ANTIGEN negative
[**2203-10-18**] BLOOD CULTURE x 4 bottles negative
*
Labs:
[**10-25**] Trop 0.14
[**10-26**] Trop 0.16 CK-MB 2
[**10-26**] Trop 0.16
[**10-27**] Trop 0.20
Relevant imaging studies:
OSH:
CXR [**10-4**] with LLL pneumonia, resolved on CXR [**10-10**]
Tagged WBC scan negative
CT head: Atrophy, no focal disease
MRI head: MArked atrophic changes, possible subacute punctate
infarcts.
*
[**Hospital1 18**]:
[**10-18**] CXR: Probable bibasilar pneumonia
[**10-18**] Renal transplant U/S: Normal
[**10-19**] CT head: No intracranial hemorrhage. No major vascular
territorial infarction.
[**10-19**] EEG: Bursts of generalized slowing consistent with
encephalopathy. .
[**10-20**] MRI with gadolinium, stroke protocol: Mild-to-moderate
brain atrophy and a chronic lacune in the posterior limb of the
left internal capsule unchanged from the previous MRI of [**2202-3-31**].
There are no MRI signs of posterior encephalopathy seen. No mass
effect or hydrocephalus noted. No acute infarcts are seen.
[**10-24**] EGD: Gastric antrum, mucosal biopsy - negative for H.
pylori
[**10-27**] CT sinuses: No air-fluid levels to suggest acute
sinusitis. Mild mucosal thickening in the paranasal sinuses, as
described.
[**10-28**] V/Q Scan: Indeterminate lung scan. There are bilateral
areas of decreased perfusion within the lung bases,
asymmetrically with a larger defect on the right. Although the
pattern of this perfusion could be explained by bilateral
pleural effusion, in the face of these abnormalities, it is
difficult to exclude a pulmonary embolism.
[**10-31**] CT Chest without contrast: 1. Large bilateral pleural
effusions with associated compressive atelectasis that are
little changed when compared to [**2202-4-18**]. Otherwise, clear
lungs. 2. Slightly dilated esophagus 3. Dilatation of the
extrahepatic biliary system with a probable calcified filling
defect in the distal common duct. Clinical correlation is
advised.
Brief Hospital Course:
ASSESSMENT AND PLAN: 61 yo male with longstanding DM type 1 with
triopathy, s/p CRT in [**2196**] on immunosuppression, transferred
from OSH with UTI, change in mental status, in DKA. DKA
resolved. Also being anticoagulated for left DVT, likely PE.
Moderate to large pleural effusions bilaterally s/p right
thoracentesis. Pt has had chronic complaints of chest pain x >1
month, with negative work-ups, pain likely due to combination of
costochondritis plus possible PE. Pt also with UGIB,
esophagitis, duodenitis, duodenal ulcer not actively bleeding,
and Hct stable on anticoagulation. Treated for UTI with Zosyn,
however, pt found to have new UTI during admission with fever,
which was treated w/ Meropenem.
*
1) PE/DVT/Chest pain:
- Pt complaining of chest pain which he reports to have had for
greater than 1 month, pleuritic or with exertion. EKGs showed
no changes from baseline, no ischemic changes. He had elevated
cardiac enzymes, which were felt to be secondary to his poor
renal clearance in addition to possible demand ischemia as they
were drawn during a period of anemia/UGIB. He had lower
extremity dopplers which were positive for DVT in left
superficial femoral vein, extending to beginning of popliteal.
A V/Q scan was performed as the pt was unable to have a CTA due
to his renal status; however, the study was suboptimal, unable
to perform ventilation portion of study - on perfusion scan,
unable to visualize bases [**12-29**] bilateral pleural effusions,
therefore unable to r/o PE's. The pt was started on Heparin;
Coumadin was started [**11-1**] at 3 mg, then increased to 5 mg to
reach therapeutic INR of 1.7.
- The patient also had bilateral pleural effusions which were
present on chest CT's from a year ago. On [**2203-11-1**], an
ultrasound guided thoracentesis of right pleural effusion was
performed, 1.2L was removed. Pleural fluid showed no PMN's or
organisms, LDH ratio indicative of transudative process, pleural
cx's NEGATIVE bacteria, fungus, AFB smear, and cytology NEGATIVE
for malignancy.
- Pt also had reproducible CP on palpation over sternum,
possible costochondritis. Rib Xray [**10-31**] negative for fracture.
*
2) ID: The patient completed 2 week course of Zosyn for UTI as
described above on [**10-22**]. However, the pt subsequently became
febrile [**10-25**] accompanied by change in mental status, increased
WBC - now has been afebrile with much improved mental status and
decreasing WBC. Broad spectrum abx started [**10-27**], with
Vancomycin renally dosed (discontinued) and Zosyn; however,
[**10-26**] Urine Cx results + for non-fermenter not pseudomonas,
intermediate sensitivity to Zosyn, sensitive to Meropenem.
Ruled out for PNA, sinusitis, C. diff, line infection. Zosyn was
therefore discontinued, and pt was treated with Meropenem 500
[**Hospital1 **] IV x7 days, completed [**11-7**]. The patient also had yeast on
UA/UCx, and was started on Fluconazole [**11-5**] x ~10 day course.
The pt was subsequently afebrile with normal WBC, stable mental
status.
.
ID Work-up:
- Central line d/c'd [**10-27**], placed [**10-18**]; new RIJ placed [**10-26**].
- C.diff negative [**10-26**] - diarrhea, likely from GI blood.
- Blood cultures 11/22, 23 negative
- [**10-25**] KUB: No free air or obstruction
- [**10-27**] CXR: Small bilateral pleural effusions
- [**10-27**] CT Sinuses: No acute sinusitis; some paranasal sinus
thickening
- [**10-27**] Catheter tip: NO SIGNIFICANT GROWTH
- [**10-25**], 30 Blood cultures NO GROWTH
*
3) GI: Upper GI bleed coffee ground emesis [**10-22**], and again on
[**10-25**], requiring transfusions of PRBC's, total 4 units. EGD was
performed [**10-24**], and showed esophagitis, duodenitis, duodenal
ulcer, no active bleeding. An NGT was placed for gastric
decompression, d/c'd [**10-27**]. Hct stable on anticoagulation.
[**10-24**] EGD Biopsy negative for H. Pylori, Protonix PO BID,
Sucralfate QID.
- The pt also developed fleeting RUQ pain. Incidental finding
on chest CT [**10-31**], showed dilatation of the extrahepatic biliary
system with a calcific density in the expected location of the
distal common duct. RUQ resolved, LFT's and bilirubin normal
except for increased Alk Phos ([**10-18**] 208, [**11-3**] 439, [**11-4**] 452).
The pt may have some common bile duct stone/obstruction, given
CT finding, however, he has declined ERCP despite discussing
possibility for progression to infection.
*
4) DM type 1/DKA:
- DKA resolved. Basal insulin had been held at OSH (transferred
only on RISS). Pt's blood sugar was quite labile, fluctuating
depending upon PO status, infectious states, and had period of
both low FSG's to 30's necessitating D50, as well as
hyperglycemia to 477. He had FSG's checked qACHS, and at 3AM.
His current regimen includes Glargine 18 u at NOON daily, as
well as sliding scale included.
*
5) Delta MS:
- The pt had an extensive work-up for initial changes in mental
status, including an EEG which showed no epileptiform activity,
LP with elevated protein and glucose, no evidence of infection,
normal OP, negative cultures, negative for CMV, [**Male First Name (un) 2326**] Virus, VZV.
MRI showed mild-to-moderate brain atrophy and a chronic lacune
in the
posterior limb of the left internal capsule unchanged from the
previous MRI of [**2202-3-31**], no MRI signs of posterior encephalopathy
seen, no mass effect or hydrocephalus noted, no acute infarcts.
- The pt's mental status changes were attributed to combination
of acute infection as well as hyperglycemia/DKA. He
demonstrates mental status deterioration when febrile or
infected, and when blood sugars are either elevated or low. The
pt now at his new baseline, is awake and alert, speaking
fluently, and cooperative with exam.
*
6) S/p renal transplant:
- The pt's immunosuppresion regimen was adjusted several times
during course of admission. Regimen on discharge includes:
** Tacrolimus 1.5 mg [**Hospital1 **]
** Sirolimus 2 mg MWF, 1 mg TThSaSun
** Prednisone 4 mg qd
- The pt's Cr slightly increased during admission to peak of
2.9. This may have been in the context of taking sublingual
Tacrolimus while NPO, which per pharmacy causes greater
bioavailability of drug and possible renal effect. Cr
subsequently decreased to 2.6. Medications were adjusted for
CrCl <30.
*
7) Heme/Anemia: Upper GI bleed, plus anemia of chronic disease.
Hct decreased acutely in context of coffee ground emesis, with
Hct down to low of 20; received 1 unit PRBC's [**10-22**] after
initial GIB, and an additional 3 units [**10-26**]. Pt was on Epogen,
decreased steadily from 8000 units 3X/week to [**2197**] units
3x/week. Hct remained stable for the last several weeks of
admission, even while therapeutic on anticoagulation. Last Hct
prior to discharge was 36.2
*
8) FEN:
- Pt was initially NPO while he had initial mental status
changes. However, after treatment for DKA/hyperglycemia and
infections, he passed a bedside speech and swallow with no
aspiration, was allowed to commence PO diet.
*
9) CV: Patient with HTN, CAD.
-Pt had elevated blood pressures during last few weeks of
admission. Hydralazine had been d/c'd [**10-26**] and amlodipine
decreased to 5 qd in context of GI bleed and anemia. However,
amlodipine was increased back to 10 as pt subsequently
hypertensive. Lasix 20 mg qd was also started [**11-3**] secondary to
HTN
*
10) DERM: The pt was seen by dermatology for a scaling plaque,
possible squamous cell CA on left temple. Will need to schedule
excisional biopsy as outpatient in derm clinic [**Telephone/Fax (1) 1971**].
*
11) Psych: Pt seen by psych consult [**10-31**] for possible
depression, no active suicidal ideation, but expressed desire to
not pursue major interventions to prolong life; he is not
denying any specific procedures at this time. Per psychiatry,
pt does not appear to be suicidal, and his wishes to limit
invasive procedures is reasonable. Celexa increased to 30 mg
qd.
*
12) PT/OT: Evaluated by PT/OT during admission, rehab
recommmended for ambulation and mobilization given left BKA,
deconditioning.
Medications on Admission:
MEDS on admission to OSH (presumed)
Feosol 325 mg daily, Colace 100 mg daily, Senokot 1 tab qhs,
Flomax 0.4 mg qhd, Reglan 10 mg PO BID, Lopressor 75 mg twice
daily, Norvasc 10 mg daily, Plavix 75 mg daily, Nexium 40 mg
daily, Celexa 10 mg daily, Lasix 20 mg IV daily, Hydralazine 10
mg PO q6hours, Cefepime 1 gm IV daily, Prednisone 5 mg daily,
MVI daily, Tacrolimus 0.5 mg [**Hospital1 **], Heparin 5000 units SC BID
Humulin N 10 units qam, 5 units qhs
*
MEDS at time of transfer:
Rapamune 3 tabs 1 mg PO daily
Protonix 40 mg IV daily
Tacrolimmus 0.5 mg PO BID
Dilantin 300 mg PO qhs
Norvasc 10 mg PO QD
Zosyn 2.25 gm IV q6 hours (day 6 on transfer)
Lopressor 125 mg PO BID
Celexa 20 mg daily
Risperidone 0.5 mg PO BID
RISS
*
Current meds in MICU:
Metoprolol 75 mg PO BID
Pantoprazole 40 mg IV Q24H
Amlodipine 10 mg PO DAILY
Citalopram Hydrobromide 20 mg PO DAILY
Phenytoin 100 mg IV Q12H for 2 days, then 100 mg IV daily for 2
days
Daptomycin 300 mg IV Q48H day 2
Piperacillin-Tazobactam Na 2.25 gm IV Q6H
Docusate Sodium (Liquid) 100 mg PO BID
Epoetin Alfa 4000 UNIT SC QMOWEFR Start: HS
Senna 2 TAB PO BID:PRN
Folic Acid 1 mg IV DAILY
Sirolimus 3 mg PO DAILY
Heparin 5000 UNIT SC TID
Tacrolimus 1 mg PO BID renal transplant
Thiamine HCl 100 mg IV DAILY
Insulin SC
Glargine 10 units qhs (to receive first dose tonight)
*
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for 1 weeks.
7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP <110.
10. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed: please give 1/2 hr prior to PT.
11. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 1 weeks: perianal area.
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
16. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO QMOWEFR (Monday
-Wednesday-Friday).
17. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO QTUTHSA
([**Doctor First Name **],TU,TH,SA).
18. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
19. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
20. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 weeks.
21. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 18 units Glargine at NOON daily.
22. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
23. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed.
24. Outpatient Lab Work
Please check Tacrolimus and Sirolimus levels q3 days, please
send results to transplant center at [**Telephone/Fax (1) 20303**] or
[**Telephone/Fax (1) 673**].
25. Outpatient Lab Work
Please check coags/INR twice weekly, and adjust Coumadin level
accordingly.
26. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday): [**2197**] u MWF.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 20304**] Rehabilitation & Nursing Center - [**Location (un) 2498**]
Discharge Diagnosis:
Type I diabetes, cadaveric renal transplant, left DVT/?PE on
anticoagulation, pleural effusions, upper GI bleeds (resolved)
from esophagitis/duodenitis/duodenal ulcer, UTI and yeast in
urine
Discharge Condition:
Stable
Discharge Instructions:
Please continue taking your medications as written. Please call
your physician if you have any worsened chest pain, shortness of
breath, palpitations, cough, fever, urinary symptoms, vomiting
blood/"coffee ground" material, lightheadedness/dizziness,
confusion, other worrisome symptoms
Followup Instructions:
Please call Dr. [**Location (un) 20305**] for follow-up appointment once
discharged from Wedgemere [**Telephone/Fax (1) 20306**].
You will need your blood levels of Tacrolimus and Rapamycin
drawn every 3rd day, and results sent to Tranplant Center -
[**Telephone/Fax (3) 20307**]
Please call for an appointment to be seen in [**Hospital 2652**] clinic
after discharge from Wedgemere, for biopsy of lesion on left
temple, [**Telephone/Fax (1) 1971**]
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2203-11-7**]
ICD9 Codes: 486, 5990, 5119, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2649
} | Medical Text: Admission Date: [**2183-3-10**] Discharge Date: [**2183-3-19**]
Date of Birth: [**2138-3-21**] Sex: F
Service: ICU
HISTORY OF PRESENT ILLNESS: This is a 44-year-old female
with AIDS, hepatitis C, pancytopenia, recent acute renal
failure, who was transferred from [**Hospital3 3583**] after
developed perfuse epistaxis. Briefly, the patient says that
she has had increased fatigue for approximately one month and
for the past two months (seven times), she has had epistaxis
that stops with packing of the nose with cotton and lasts for
approximately two hours without any preceding trauma and
occurs in either nostril. The night prior to admission, she
may have blown her nose and then developed perfuse epistaxis
with clots that would not stop despite nasal packing. She
called EMS and was taken to [**Hospital3 3583**] where per report,
the right nostril had a large clot. Initial vital signs were
100/80 with a heart rate of 100. At [**Hospital3 3583**] she
received one liter of normal saline, Zofran 8 mg and had
packing placed. Initial hematocrit at that hospital was 24.4
with a platelet count of 18. She was transferred to [**Hospital1 **] where she received a six pack of platelets
and was transfused two units of packed red blood cells for an
initial platelet count of 13 and a hematocrit of 19. Of
note, she also received clindamycin for nasal packing
prophylaxis.
REVIEW OF SYSTEMS: Positive for lower extremity edema since
[**2182-12-12**], as well as increasing fatigue for
approximately one month. Negative for falls,
lightheadedness, loss of consciousness, sensation of cold,
sinus headaches, chest pressure, shortness of breath, cough,
abdominal pain, nausea, vomiting, diarrhea, constipation,
dark stools, bloody stools, dysuria, easy bruising or
bleeding aside from epistaxis. Of note, the patient does
note that her urine has been dark for approximately one week
and she does note some bleeding when flossing her teeth.
PAST MEDICAL HISTORY:
1. HIV. Last CD4 count 41 with a viral load of greater than
100,000 on [**2183-3-5**]. She was diagnosed in [**2165**]. She
was initially treated with high dose AZT in [**2166**] complicated
by bone marrow suppression. She then received combination
therapy and despite this her CD4 count has never been greater
than 400 and since having been on triple drug regimens, she
has never had complete viral suppression. Most of the more
recent regimens were discontinued because of gastrointestinal
side effects. Her opportunistic infections include
Cryptosporidium and candidal esophagitis, Salmonella and
herpes labialis. Her risk factors include intravenous drug
use.
2. Hepatitis C cirrhosis followed by Dr. [**Last Name (STitle) **]. On [**2183-3-7**] the HCV viral load was negative. Genotype 111. She
is HCV arthropathy and has received interferon once a week.
3. Open cholecystectomy.
4. Pancytopenia on Neupogen twice per week.
5. Acute renal failure of unknown cause since [**2183-2-10**].
6. Depression.
7. Gastroesophageal reflux disease.
8. Mitral valve prolapse since childhood.
9. Seizure disorder. Most recently grand mal seizure five
years ago.
10. Gastroparesis.
MEDICATIONS AT THE TIME OF ADMISSION:
1. Aldactone 50 mg q.d.
2. Lexapro 40 mg q.d.
3. Protonix 40 mg q.d.
4. Bactrim three times a week.
5. Neurontin 700 mg q.d.
6. Neupogen twice per week.
7. Lasix 20 mg q.d.
8. OxyContin 40 in the morning, 30 at night.
9. Trazodone 5 mg po q.h.s.
ALLERGIES: Kaletra causes diarrhea and nausea and Prinivil
causes fatigue. Nelfinavir causes fatigue and Denavir causes
arthritis. T20 causes serum sickness. DDI causes peripheral
neuropathy. Abacavir causes nausea. Tenofovir causes
headache and disorientation.
SOCIAL HISTORY: Lives with husband on disability. Smokes
one pack of cigarettes per day. No intravenous drug use for
15 years. No alcohol use.
FAMILY HISTORY: Significant for a brother with myocardial
infarction at age 45. Primary care doctor is Dr. [**Last Name (STitle) 4390**].
PHYSICAL EXAM ON ADMISSION: Blood pressure 128/86. Heart
rate 89 and regular. Respiratory rate 16. Oxygen saturation
99% on room air. Temperature 96.5. General: No apparent
distress. Nose packing in place, appropriate, alert and
oriented times three. Head, eyes, ears, nose and throat:
Pupils equal, round and reactive to light bilaterally.
Extraocular movements intact. Nose packing in place with a
visible clot and a posterior pharynx, ? petechia ? With dried
blood on the roof of the mouth. Cardiovascular: Regular rate
and rhythm, 2/6 systolic murmur best heard at the apex with
radiation to the axilla. Split S1 increased with
inspiration, nondisplaced point of maximal impulse,
midsystolic click midway through the systolic phase. Lungs:
Few crackles at the bases, otherwise, clear to auscultation
bilaterally. Abdomen soft, nontender, nondistended with
normal active bowel sounds, no hepatosplenomegaly.
Extremities: 2+ lower extremity edema, warm, 2+ dorsalis
pedis pulses bilaterally.
LABORATORY DATA AT THE TIME OF ADMISSION: White blood cell
count 7.8, hematocrit 19.7, platelet count 13, baseline
platelets ranging from 30 to 60s. Baseline white blood cell
count 2.0. Baseline hematocrit grater than 30.
Differential: 88% neutrophils, 0% bands, 9% lymphocytes, INR
1.0. Chem-7: 136, 3.8, 105, 25, 33, 2.6 and 141. Baseline
creatinine .7 on [**2182-12-16**], 1.2 on [**2183-1-6**],
2.7 on [**2183-3-5**]. AST 69, ALT 15, LDH 207, alkaline
phosphatase 116, total bilirubin 0.2, amylase 74. Urinalysis
with large blood, 500 protein, 500 red blood cells, TSH 4.3,
albumin 2.0.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was initially
admitted to the Medical Intensive Care Unit given perfuse
epistaxis in the setting of thrombocytopenia with drop in
hematocrit to 19.
1. Epistaxis: Patient had nasal packing in place and was
evaluated by the ENT Service. The packing was removed on
[**2183-3-15**] with adequate hemostasis achieved. She was
transferred out of the Medical Intensive Care Unit to the
Acove Service on [**2183-3-13**].
2. Thrombocytopenia: The patient has a baseline
thrombocytopenia in the 30s to 60,000 range. However, there
seems to have been an acute or subacute process leading to
symptomatic thrombocytopenia. There was thought to be
possibly due to decreased hepatic function, versus reaction
to Bactrim. A bone marrow biopsy was performed on [**2183-3-17**] demonstrating hypolobulated megakaryocytes with an
adequate number of megakaryocytes suggesting that steroids
might be beneficial as the diagnosis of ITP was considered.
It should also be noted that DIC/HUS was also considered, but
felt to be less likely given the lack of schistocytes on the
peripheral smear or LDH haptoglobin and INR consistent with a
DIC picture. The Hematology Consulting Team recommended
beginning prednisone at 1 mg/kg for one week to empirically
treat the clinical diagnosis of ITP. This was begun on [**3-19**], [**Numeric Identifier 16252**]. In the meantime, Neupogen was continued twice a
week in order to stimulate the granulocyte line. The
antiplatelet antibody results are still pending and IVIG was
considered, but it was felt that prednisone would be a first
fine [**Doctor Last Name 360**].
3. Acute renal failure: The patient had acute renal failure
with protein in the urine and decreased albumin the serum
suggesting a nephrotic syndrome. Of note, her Lasix dose had
been decreased from 40 to 20 in the week prior to admission.
As stated above, HUS was considered given the
thrombocytopenia, renal failure, anemia and low grade fevers,
however, given the findings on peripheral smear, as well as
the findings mentioned above, this was felt to be less
likely. Throughout the [**Hospital 228**] hospital course, she was
mildly oliguric with a urine output of approximately 20-30 cc
per hour. This was augmented with the use of Lasix 40 mg po
q.d., as well as Aldactone 100 mg po q.d. with prn doses of
Lasix 40 intravenously with an average urine output
subsequently of 500 cc. A renal biopsy was performed on
[**2183-3-14**] to better elucidate the cause of the renal
failure. The renal biopsy preliminary results are consistent
with a membranoproliferative disease, as well as a
immunofluorescence pattern consistent with
glomerulonephritis.
Of note, there was no evidence of FSGS which would be present
in the setting of HIV nephropathy, nor was there any evidence
of hypertensive nephropathy and thus ACE inhibitors were not
initiated. There was also no evidence for ATN. It was the
thought at the time of dictation, that the glomerulonephritis
picture could be secondary to hepatitis C or a subclinical
infection. However, it seems that hepatitis C would be an
unlikely culprit given that her viral load was undetectable
and this had been a chronic issue, but the renal failure was
a subacute issue. At the time of discharge, the patient's
creatinine was 2.7. It should be noted that the creatinine
was not increased by Lasix nor did it increase over the
course of the [**Hospital 228**] hospital stay.
4. HIV: The patient was followed by both Dr. [**Last Name (STitle) 724**], as well
as the Infectious Disease Service. Initially she had not
been antiretroviral therapy, but four days prior to
discharge, she was started on two protease inhibitors
(atazanavir 400 mg q.d., as well as fosamprenavir). We
attempted to administer T20 subcutaneously, however, the
pharmacy did not stock this fusion inhibitor in house, thus,
she will begin the T20 as an outpatient. Azithromycin was
continued for outpatient regimen once per week. Although,
Bactrim was held initially given the side effect of
thrombocytopenia, at the time of discharge, the patient was
restarted on Bactrim Double Strength once a day on Tuesday's
and Friday's which was a decrease from the previous dosing of
three times per week.
5. Anemia: The patient was transfused to a hematocrit goal
of greater than 27. She was hemodynamically stable without
transfusion for 72 hours prior to discharge.
6. Leukocytosis: Given that the patient receives Neupogen
on Tuesday's and Friday's, it was felt that the transient
leukocytosis on Wednesday's and Saturday's were secondary to
Neupogen injection the night prior. It should be noted that
at baseline the patient is leukopenic. Given that the
leukocytosis did persist, the Neupogen was discontinued on
[**2183-3-17**]. Other causes of infection were also
considered such as Clostridium difficile, which was negative
times three. Chest x-ray's were unrevealing, as was urine
culture. The patient did have a low grade temperature which
did not exceed 100.1. It was felt that this could be
secondary to drug fever in the setting of Neupogen
administration.
7. Hepatitis C: Interferon was held at this time. It is
thought that the hepatitis C is currently suppressed,
however, given the initiation of steroids at reasonably high
doses, the viral load should be closely monitored.
8. Hepatitis C cirrhosis: The Lasix and Aldactone were
continued as above.
9. Pain Control: The patient has diffuse pain throughout
all of her joints, as well as her head. She was initially
maintained on a Dilaudid PCA with no basal rate and prn rate
of .05. Her pain was very well-controlled with the PCA and
she was weaned down to a Dilaudid dose per day of .5 mg.
This was converted to po form of 2 mg at the time of
discharge, as well as continuing the standing medication
OxyContin 40 mg q.a.m. and 30 mg q.p.m.
10. Depression: She was continued on citalopram.
11. Sinusitis: It was initially thought that the patient
might have sinusitis as a result of the nasal packing. She
had been on Unasyn for a five day course. This was changed
to levofloxacin for a total of ten days. She had five days
remaining at the time of discharge.
12. Intravenous access: Given the patient's difficult
intravenous access, a peripheral line was attempted, but
unsuccessful. As a result, a right femoral line was placed
under standard protocol on [**2183-3-14**]. This was
discontinued on [**2183-3-17**] at the time that a PICC line
was placed by Interventional Radiology. This is a single
lumen PICC and was left in place at the time of discharge for
potential platelet transfusions.
13. Fluid, electrolytes and nutrition: She was maintained on
Renagel and Tums for hyperphosphatemia and hypocalcemia.
14. Prophylaxis: A proton pump inhibitor, Colace, senna,
ambulation and Pneumoboots were used.
FINAL DIAGNOSES:
1. HIV.
2. Hepatitis C.
3. Membranoproliferative nephropathy presumed immune related
thrombocytopenia.
RECOMMENDED FOLLOW-UP: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], [**Hospital **] Medical
Building, [**Telephone/Fax (1) 457**] on [**2183-3-25**] at 11:30 a.m.
MAJOR SURGICAL INVASIVE PROCEDURES:
1. Bone marrow biopsy on [**2183-3-17**]
2. CT guided renal biopsy on [**2183-3-14**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home with PICC line care. Prescription
for daily CBC check, as well as typed and screened for
platelets at [**Hospital 3320**] Hospital.
DISCHARGE MEDICATIONS:
1. Azithromycin 600 mg, 2 tablets once per week on Sunday's.
2. Colace 100 mg capsule, 1 capsule po b.i.d.
3. Fexofenadine 60 mg, 1 po b.i.d.
4. Gabapentin 300 mg capsule, 2 capsules po q.d.
5. >.........< 10 mg tablet, 4 tablets po q.d.
6. Nystatin 100,000 units/mL suspension, [**4-21**] mL po t.i.d.
7. Nicotine 20 mg/J patch q.d.
8. Atazanavir 200 mg, 2 capsules po q.d.
9. Calcium carbonate 500 mg, 2 tablets t.i.d.
10. Nasal Ocean Spray.
11. >..........< 800 mg, 1 po t.i.d.
12. Fosamprenivir 700 mg tablet, 2 tablets po b.i.d.
13. Miconazole cream to affected areas q.h.s.
14. Lasix 40 mg po q.d.
15. Levofloxacin 250 mg, 1 po q.d. for five days.
16. Enfuvirtide 90 mg subcutaneously b.i.d.
17. Spironolactone 100 mg po q.d.
18. Prednisone 60 mg po q.d. for seven days to be reassessed
by Dr. [**Last Name (STitle) 724**].
19. Dilaudid 2 mg tablet, 1 po t.i.d. prn pain.
20. OxyContin 40 mg q.a.m., 30 mg po q.p.m.
21. Bactrim Double Strength 1 q. Tuesday, 1 q. Friday.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], M.D. [**MD Number(1) 15234**]
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2183-3-19**] 04:36
T: [**2183-3-23**] 21:10
JOB#: [**Job Number 16253**]
ICD9 Codes: 2875, 4240, 2851, 5849, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2650
} | Medical Text: Admission Date: [**2192-7-2**] Discharge Date: [**2192-7-9**]
Service: MEDICINE
Allergies:
fentanyl / OxyContin
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
corevalve placement
Major Surgical or Invasive Procedure:
[**2192-7-3**] Corevalve placement
History of Present Illness:
Ms. [**Known lastname 91257**] is a [**Age over 90 **]yo caucasian female with h/o CAD s/p LAD
stent in [**2184**] and known aortic stenosis. She reports worsening
shortness of breath after ambulating [**1-23**] block, though noteable
for limited activity due to multiple ortho procedures
necessitating cane. She denies chest pain, lightheadedness, or
syncopal episodes, but admits fatigue with doing usual household
activities and shortness of breath when reaching up. She was
seen
in consultation for surgical aortic valve replacement and was
deemed not a surgical candidate due to her history of Childs A
liver disease. She has continued on medical therapy alone and
both patient and family report worsening fatigue and shortness
of
breath of late. She now also admits to chest discomfort after
walking 50 feet, and with light housework. After informed
consent, she was screened for the Corevalve/TAVR. She met all
inclusion criteria and did not meet any exclusion criteria.
Warfarin was held 4 days prior to admission.
Today, she was taken to the OR and corevalve procedure was
completed under general anesthesia. She had successful placement
of the corevalve device with post-placement TEE in the OR
showing trace peri-valvular aortic regurgitation and also 1+
mild central aortic regurgitation. She recieved 3500 ml of IVF
with production of >1100 cc of urine during the case. Also
recieved 20 mEq of K repletion and 1 unit of pRBCs because of
estimated blood loss of 100 cc at the groin access sites. Was
sedated with propofol and had a muscle relaxant at the start of
the case only.
She was noted to have ST depressions on telemetry during the
case in a V5 lead and then ST elevations when the lead was
changed to V1 position. An EKG on arrival to the CCU showed new
LBBB with expected ST elevations in V1-V3 and ST depressions in
V5-6. She arrives to the CCU intubated and sedated although
opens eyes to voice. Her right femoral groin site is oozing and
left groin site still has femoral sheath in place.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY: STEMI [**2184**] s/p PCI
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD [**2184**]
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- aortic stenosis
- Hep C (2/2 blood transfusion [**2155**])
- spinal stenosis
- osteoarthritis
- cataract extraction
- choley
- liver bx
- bilateral TKA's (right x2)
- bilateral THA's (twice each)
- left leg shorter than right (congenital)
- skin cancer right mandible area, s/p excision
Social History:
Lives with her husband in their daughter's home. Seven steps to
enter. Walks with cane due to multiple ortho issues, husband
frail. [**Name2 (NI) 4084**] smokers, occasional EtOH, denies illicits.
Daughter - [**Name (NI) 391**] [**Name2 (NI) **] ([**Telephone/Fax (1) 91258**])- -Kensington,NH. Sons x
2 ([**Name2 (NI) 2498**], MA, [**Location (un) 61361**], CO)
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.7, BP 140-190/60s HR 66-76 sinus, RR 14, O2 sat > 98%
CMV PEEP 5, FiO2 50%
GENERAL: frail elderly female, intubated and sedated
HEENT: NCAT. Sclera anicteric. PERRL, 1 mm bilaterally.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: lying flat, no JVD appreciated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VII holosystolic murmur, No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Femoral 2+ radial 2+ DP 2+ PT 2+
Left: Femoral 2+ radial 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM:
VS: Tm 98.2 HR 70 BP 145/59 RR 16 O2 100%RA I/O 1460/2300
Weight 56.6kg
GENERAL: Elderly woman in chair. NAD
HEENT: PERRLA, no ertyhema, MMM, no LAD, JVD non elevated
CHEST: CTABL
CV: S1,S2. RRR, [**2-27**] midpeaking systolic murmur with crisp S2
ABD: Soft, NT, ND, NABS, No rebound or guarding. No HSM, No
[**Doctor Last Name **] sign. BM this am
EXT: wwp, no edema. Bilteral groin sites clean and dry
NEURO: CNII-XII intact. [**5-26**] strenth throughout
SKIN: No rashes
PSYCH: Calm, pleasant
Pertinent Results:
ADMISSION LABS:
[**2192-7-2**] 01:10PM BLOOD WBC-5.6 RBC-4.44 Hgb-13.6 Hct-41.0 MCV-92
MCH-30.5 MCHC-33.1 RDW-13.4 Plt Ct-175
[**2192-7-2**] 01:10PM BLOOD PT-11.0 PTT-29.1 INR(PT)-1.0
[**2192-7-3**] 04:06PM BLOOD Fibrino-191
[**2192-7-2**] 01:10PM BLOOD Glucose-90 UreaN-22* Creat-0.7 Na-142
K-4.1 Cl-104 HCO3-31 AnGap-11
[**2192-7-2**] 01:10PM BLOOD ALT-48* AST-48* CK(CPK)-141 AlkPhos-71
TotBili-0.6
[**2192-7-2**] 01:10PM BLOOD proBNP-3666*
[**2192-7-3**] 05:02PM BLOOD Calcium-7.7* Phos-2.6* Mg-1.5*
[**2192-7-2**] 01:10PM BLOOD Albumin-4.3
[**2192-7-3**] 12:46PM BLOOD Type-ART pO2-425* pCO2-35 pH-7.50*
calTCO2-28 Base XS-4 Intubat-INTUBATED Vent-CONTROLLED
[**2192-7-2**] 11:39AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2192-7-2**] 11:39AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
.
MICRO:
[**7-2**] URINE CULTURE NEGATIVE
.
IMAGING:
[**2192-7-5**] POST-COREVALVE ECHO:
LEFT ATRIUM: Marked LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Mild symmetric LVH. Mild (non-obstructive) focal
hypertrophy of the basal septum. Small LV cavity. Normal
regional LV systolic function. Overall normal LVEF (>55%). TDI
E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Aortic CoreValve. AVR well seated, normal
leaflet/disc motion and transvalvular gradients. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. [**Male First Name (un) **] of the mitral chordae (normal variant). No
resting LVOT gradient. Calcified tips of papillary muscles. Mild
to moderate ([**1-23**]+) MR. [Due to acoustic shadowing, the severity
of MR may be significantly UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. There is mild (non-obstructive)
focal hypertrophy of the basal septum. The left ventricular
cavity is small. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. An aortic
CoreValve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet/disc motion and
transvalvular gradients. No aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. Mild to moderate
([**1-23**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Biatrial abnormality. Well-seated, normally
functioning aortic CoreValve. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Increased left ventricular filling pressure.
Mild to moderate mitral regurgitation. Mild pulmonary artery
systolic function.
Compared with the prior study (images reviewed) of [**2192-6-7**], a
well-seated, normally functioning aortic CoreValve prosthesis is
now present. The severity of pulmonary artery systolic
hypertension has decreased from moderate to mild.
Brief Hospital Course:
Ms. [**Known lastname 91257**] is a [**Age over 90 **] year old female with history of coronary
artery disease (CAD) status post drug eluding stent (DES) to
LAD, Childs class A liver disease and known critical aortic
stenosis ([**Location (un) 109**] < 0.6) demonstrating worsening symptoms who was
admitted to the CCU after elective corevalve procedure. She did
well post-operatively.
ACTIVE ISSUES:
# Critical symptomatic aortic stenosis: Underwent corevalve
procedure on [**2192-7-3**], no immediate complications. Intubated for
the procedure and then extubated without issues. Recieved
plavix load with 300 mg prior to procedure and then was
continued on 75 mg daily. Intraoperatively, was noted to have
ST changes on telemetry and post-procedure 12-lead EKG
demonstrated new left bundle branch block (LBBB) with expected
ST changes. However, this spontaneously resolved within a few
hours. For the first 48 hours post-operatively, she had labile
blood pressures and required alternating nitroglycerin drip and
phenylephrine drip for hyper and hypotension respectively. This
variability resolved and her blood presures were stable from
120-150s for several days before discharge. Was discharged on
aspirin 81 mg daily, plavix 75 mg daily, metoprolol succinate 50
mg daily, and valsartan 80 mg daily.
# hypertension: Periprocedurally her pressures were labile and
she was initially hypertensive to the 240s and required a nitro
drip to lower her BP. She subsequently became hypotensive and
the nitro was discontinued and neosynephrine was started. After
about 48 hours post procedure, her pressures normalized and her
home anti-hypertensive medications were slowly re-introduced and
uptitrated. At the time of discharge, she was on valsartan 80mg
PO Daily and Metoprolol Succinate 50 mg daily.
CHRONIC ISSUES:
# CAD: Not an active issue during this hospital stay. Her home
medications were initially held periprocedurally, but slowly
restarted when her pressures stabilized. She will be discharged
on aspirin 81mg, plavix 75mg, valsartan 80mg PO Daily, and
metoprolol succinate 50 mg dialy.
# mobility is impaired due to multiple surgeries: TKR, spinal
stenosis, congenital leg length deformity. Physical therapy saw
patient and recommended short term Rehab for improved ambulation
and strength training. The patient was screened by PT and will
be discharged to rehab. We will continue pain control with with
tylenol and oxycodone prn.
# Childs class A liver disease: Due to hep C but has never been
treated for hepC. no history of decompensations and no symptoms
or signs during this admission.
Transitional Issues:
# Physical Therapy as per Rehab
# CONTACT: [**Name (NI) 391**] [**Name2 (NI) **] ([**Telephone/Fax (1) 91258**])
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Metoprolol Tartrate 50 mg PO BID
2. Valsartan 80 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Vitamin D Dose is Unknown PO DAILY
6. Multivitamins Dose is Unknown PO DAILY
7. Vitamin E Dose is Unknown PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Valsartan 80 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Vitamin E 200 UNIT PO DAILY
7. Clopidogrel 75 mg PO DAILY
Start: In AM day of surgery. Do not give if direct aortic
approach
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp<100 or hr<50
10. Senna 1 TAB PO BID:PRN constipation
11. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
Langdon Place of [**Location (un) **], NH
Discharge Diagnosis:
PRIMARY DIAGNOSIS
aortic stenosis
CAD s/p LAD stenting ([**2184**])
hypertension
hyperlipidemia
hepatitis C from transfusions in [**2155**]
spinal stenosis
osteoarthritis
cholecystectomy [**2171**]
bilateral total knee replacements
bilateral total hip replacements x 2
congenital left leg shorter than right
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 91257**],
You were admitted to the hospital for an elective procedure for
severe symptomatic aortic stenosis, a narrowing of the aortic
valve. You had a percutaneous transcatheter aortic valve
replacement with the corevalve procedure. You went through this
successfully and afterwards the ultrasound of your heart showed
improved flow across the aortic valve and decreased pressures.
You received 1 unit of packed red blood cells during your stay
and had no complications. You have progressed nicely and are now
ready for discharge.
The following changes were made to your medications:
- START taking clopidogrel (plavix) 75 mg daily to help prevent
clots
- CHANGE metoprolol to long acting. Now you are taking
metoprolol succinate 50 mg daily
You should keep all of the follow-up appointments listed below.
You should bring your medications to each appointment so that
your doctors [**Name5 (PTitle) **] update their records and adjust the doses as
needed.
Please refer to the additional discharge information sheets
provided. Important to note is:
1. Weigh yourself daily - notify doctor if you should gain more
that 3 lbs in 2 days, or 5 lbs in 5 days.
2. Inspect your groin sites daily to monitor for infection
(redness, drainage, pain)
It was a pleasure taking care of you.
Followup Instructions:
Please make sure you have follow up appointment with Dr. [**Last Name (STitle) **]
in clinic within the next two weeks.
Please follow up with your primary care doctor after you are
discharged from Rehab.
ICD9 Codes: 4241, 4168, 412, 2724, 4019, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2651
} | Medical Text: Admission Date: [**2126-8-14**] Discharge Date: [**2126-8-28**]
Date of Birth: [**2090-6-5**] Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient was a 36-year-old
female with past medical history significant for hepatitis B
and C diagnosed in [**2126-7-15**] who was transferred from the
[**Hospital6 **] for potential liver transplantation.
She was admitted at [**Hospital6 **] from [**7-29**] to
intravenous heroin until [**7-28**] when she voluntarily entered
detoxification program and was started on methadone. On [**7-29**], the patient began to experience sweats, fevers, chills,
nausea, vomiting and was noted to be mildly jaundiced. She
was sent to the [**Hospital6 **] Emergency Department
from detoxification, afebrile and with a blood pressure of
100/60 and respiratory rate of 50s. Her LFTs were markedly
1.5. A right upper quadrant ultrasound was done which showed
a normal liver, normal bile ducts and no ascites. She was
initially treated with Vitamin K, methadone and Phenergan,
and on [**8-8**] was begun on lamivudine for hepatitis B
treatment after her hepatitis panel came back positive for a
hepatitis B surface antigen and negative hepatitis B surface
antibody. She was also found to have a positive hepatitis C
antibody. The patient's INR rose to 3.3 and she was
transfused with two units of fresh frozen plasma during the
course of her admission.
The patient's liver work-up at [**Hospital6 **] included
[**First Name8 (NamePattern2) **] [**Doctor First Name **], anti-smooth muscle antibody, iron studies and
ceruloplasmin, all of which were negative. The patient was
also found to be hepatitis A, antibody negative. On [**8-11**],
the patient was discharged from [**Hospital6 **] to home
with gastrointestinal follow-up. Her INR at discharge was
3.55. The following day, the patient presented to the [**Hospital 11694**]
Hospital Emergency Department. Her LFTs on admission were as
follows: ALT 382, AST 376, alkaline phosphatase 165, T
bilirubin 31, direct bilirubin 15.7. Her ammonia was 105 and
her INR was 5. The patient had a head CT and toxicology
screen, both of which were negative. She was treated with
Vitamin K and lactulose. She also got Narcan without effect.
She was transferred back to [**Hospital6 **] on [**8-12**]
with the following vital signs: She was afebrile with a
pulse of 86. Respiratory rate of 20. Blood pressure 147/81.
At [**Hospital6 **], she was treated with lactulose,
Vitamin K, lamivudine and her mental status was noted to be
significantly depressed compared to her discharge the day
prior and she was reported to have been intermittently
responsive with nonsensible speech and unable to follow
verbal commands. She was treated with increasing doses of
lactulose without significant improvement in her mental
status. That in essence, was the [**Hospital 228**] medical course
prior to her arrival at the [**Hospital6 2018**] on [**8-14**].
When she arrived here, her physical examination was as
follows: Her vitals were as follows: Temperature 97.4.
Pulse 82. Respiratory rate 17. Blood pressure 108/49,
saturating 100% on room air. In general, she appeared to be
an ill-appearing woman, who appeared her stated age. She was
in no apparent distress and had marked jaundice. Her head,
eyes, ears, nose and throat exam was significant for the
following: Her sclera were icteric bilaterally. Her pupils
equal, round and reactive to light. Her oropharynx was
clear. Her mucous membranes were moist. She had no cervical
adenopathy. She had no jugular venous distention and she had
no thyromegaly. Her lungs were clear to auscultation
bilaterally. Her heart was regular rate and rhythm with a
2/6 systolic ejection murmur. Her abdomen was soft with mild
right upper quadrant tenderness. She was nondistended with
good bowel sounds and no hepatosplenomegaly. Her extremities
revealed 1+ edema in her hands. There was no clubbing or
cyanosis. She had 2+ pedal pulses. Neurologically she was
alert and oriented times two. She did have difficulty with
attention, but was able to follow most verbal commands. Her
muscle strength was [**5-19**] throughout. Her sensation was
grossly intact. Her deep tendon reflexes were [**2-17**]+.
Cerebellar function was depressed. The patient was not able
to do finger to nose and she did have asterixes. Her skin
exam was significant for marked jaundice, but there were no
rashes and no spider angiomata that was appreciated.
LABORATORIES ON ADMISSION: Significant for a INR of 8.7.
Her PTT was 66 and her PT was 35.4. Her Chem-7 was notable
for a potassium of 5.9. Her CBC was within normal limits.
Her calcium, magnesium and phosphorus were all within normal
limits. Her liver function tests were as follows: ALT 254,
AST 204, alkaline phosphatase 124, LDH 458, albumin 2.6,
total bilirubin 30.3, direct bilirubin 14.0 and ammonia 80.
HOSPITAL COURSE: The Liver Service was consulted on the
night of her admission regarding possible transplantation.
We initially treated her for a Grade [**1-16**] hepatic
encephalopathy with lactulose. Regarding her risk for
cerebral edema and increase in intracranial pressure, the
decision was made to perform neurologic checks every two
hours and to address the issue of ICP monitoring if she did
develop signs of intracranial pressure, and if the decision
was made to place the monitor, we would then further consider
possible mannitol and intubation with hyperventilation. For
her liver failure, the patient did not meet the [**First Name4 (NamePattern1) 3728**]
[**Last Name (NamePattern1) 1688**] criteria for liver transplantation. However, we did
initially send off transplant laboratories with the
possibility of her qualifying for a transplantation. We also
continued her on the lamivudine.
For her coagulopathy, we attributed that to her liver
failure. She was continued on Vitamin K and the decision was
made to transfuse her with fresh frozen plasma if she
developed any evidence of active bleeding or if the decision
was made to transfuse her prior to procedures. Essentially,
the [**Hospital 228**] hospital course was significant for a waxing
and [**Doctor Last Name 688**] mental status consistent with her hepatic
encephalopathy. Her encephalopathy, on a day to day basis,
varied from Grade 4 to Grade 1. During the second week of
her admission, the patient had two days of significant
lucidity at which time she was alert and oriented times three
and was able to show some incite into the nature of her
current medical status, however, the following day, she was
noted to have significantly depressed mental status and was
unable to follow verbal commands. We continued to treat her
aggressively from a medical standpoint once it was determined
that she would not qualify for a liver transplantation based
on her drug use history. Per Liver Service, our medical
management included lactulose, enemas and oral preparations
through her nasogastric tube. We also treated her with
neomycin. She continued on her lamivudine throughout the
course of her hospitalization.
Additionally, from a gastrointestinal standpoint, given the
fact that her course was somewhat different from typical
patient's with acute hepatitis B leading to fulminate hepatic
failure, we re-sent a ceruloplasmin to verify that this
patient had no other underlying comorbidities that could be
contributing to her liver failure. The patient's
ceruloplasmin did come back as lower than normal limits. At
that point, the decision was made to consult Ophthalmology
for the possibility of Kayser-Fleischer rings and to check a
serum and urine copper. The patient's serum copper came back
within normal limits and Ophthalmology did find
Kayser-Fleischer by direct ophthalmoscope on her exam and at
the time of this dictation, the urine copper was still
pending. Given the finding on physical exam, on [**8-23**],
the patient was started on penicillamine and pyridoxine for
possible Wilson's disease.
The Hematology Service was consulted on [**8-23**] to address
the issue of elevated prothrombin and partial thromboplastin
time in this patient. There was concern about her worsening
coagulopathy as she had some improvement in her mental
status, yet did not seem to show any rebound in her synthetic
function in her liver. The Hematology consults felt that the
patient's thrombocytopenia might be secondary to low
thrombopoietin production given her liver dysfunction and
also felt that there might be some underlying low grade DIC
also involved, however, they agreed with our decision to not
transfuse the patient with any blood products in the absence
of active bleeding.
Despite aggressive medical management with lactulose,
neomycin, lamivudine, total parental nutrition, the patient's
condition continued to deteriorate. Her mental status never
returned to its baseline and her synthetic function of her
liver as measured by her INR never reversed. On [**8-28**],
the decision was made during rounds that the patient had
essentially exhausted medical management and further
treatment would be medically futile. This information was
passed onto the patient's mother who acknowledged the
patient's poor prognosis and agreed to reconsider the
patient's code status and agreed with the team that the
patient should be made "Do Not Intubate, Do Not Intubate."
The mother, additionally, felt that the patient had suffered
a considerable amount and favored making the patient comfort
measures only. Later that afternoon, all medications were
discontinued. The patient's TPN was discontinued and
intravenous fluids were discontinued. The patient passed
away later in the evening with a reportedly low blood
pressure secondary to hypotension and apnea leading to
cardiac arrest. Her death was pronounced by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2413**]
on the evening of [**2126-8-28**]. At this time, we are
trying to obtain permission from the patient's mother or son
for postmortem examination.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Doctor Last Name 111018**]
MEDQUIST36
D: [**2126-9-4**] 22:48
T: [**2126-9-4**] 22:48
JOB#: [**Job Number 111019**]
ICD9 Codes: 2875, 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2652
} | Medical Text: Admission Date: [**2167-12-29**] Discharge Date: [**2168-1-7**]
Date of Birth: [**2105-6-4**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Haldol / Darvon / Keppra
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Altered mental status, ? hematemesis
.
PCP: ?Dr. [**Last Name (STitle) **], [**Hospital1 **] Community Health
Major Surgical or Invasive Procedure:
intubation
central venous line attempt
arterial line
History of Present Illness:
62yoF with h/o EtOH/Hep C cirrhosis, psychotic, seizure d/o
(none x many years), multiple admission for GI bleeds (portal
gastropathy, grade 4 rectal varices) who now presents from rehab
with altered mental status and ?hematemesis. She has been at
acute rehab from [**12-26**] and was reportedly doing well until early
this morning when she was found to be somnolent/lethargic. There
is some verbal report of perhaps hematemesis although amount and
frequency is unknown (not documented on transfer paperwork). She
was, thus, taken directly to [**Hospital1 18**] ED for further evaluation and
management. Per verbal rehab report, she had been receiving all
of her medications as prescribed upon discharge; it is unclear
if she had been having regular BMs. No report of increased
cough, BRBPR, but additional ROS unclear.
.
Of note, she was admitted [**Date range (1) 99376**] for GI bleed. An EGD on
[**2167-12-19**] showed portal gastropathy only without any evidence of
active bleeding. There was no evidence of varices.
.
Prior to her most recent hospitalization, she was admitted
[**Date range (1) 99375**] for a signficant LGIB s/p TIPS at which time she
presented with black stools, lethargy, and confusion. Hospital
course in [**11/2167**] was complicated by respiratory failure [**2-13**] to
nosocomial pneumonia and pulmonary edema transiently requiring
intubation.
.
In the ED, initial vitals revealed T 101.2 BP 178/113 HR 137 RR
24 O2 sat 100%. She was noted to have BRB in her mouth without
any obvious source of bleed within the oral cavity. She was
noted to have altered mental status and was intubated for airway
protection in this setting. A CT head was performed and read is
pending. She received octreotide 50mcg IV x1, protonix 40mg IV
x1, vitamin K 10mg SC x1, 2 units of FFP. Additionally, she
received ceftazidime 1g IV x1, flagyl 500mg IV x1, and
vancomycin 1g IV x 1. It appears that blood culture x1 was
collected, but not UA/culture.
.
Abdominal U/S in the ED demonstrated interval decrease in the
proximal, mid and distal TIPS velocity, but did show normal
wall-to-wall flow was noted within the TIPS and the main portal
vein and its branches. The TIPS device demonstrates abnormal
pulsatile flow suggesting the presence of possible right heart
failure.
.
Pt admitted to the ICU [**1-1**] for further management of her
altered mental status (s/p intubation for airway protection),
SIRS and probable sepsis and ? GIB. After uneventful 1d course
with improved MS (alert, oriented x2) pt transferred back to
floor [**1-2**].
.
ROS: Unable to obtain from patient.
Past Medical History:
1) Iron deficiency anemia
2) GI bleed - presumed secondary to hemorrhoids, s/p TIPS; also
w/ known portal gastropathy
3) Sigmoid diverticulosis
4) Schatzki's ring
5) Duodenal polyps and duodenitis
6) MGUS
7) ?Etoh/ HCV cirrhosis followed by Dr. [**Last Name (STitle) 497**]
8) Psychotic disorder
9) polysubstance abuse - etoh, cocaine, marijuana
10) COPD
11) ?? h/o Complex partial seizures
Social History:
History of tobacco and EtOH abuse. She is originally from
[**State 3908**], and changed her name when she became a practicing
Muslim. She worked as an administrative assistant when she was
younger, but is now on SSDI (for schizophrenia and seizure
disorder, per pt, both now quiescent). She was most recently
discharged to rehab on [**2167-12-26**].
Family History:
Mother: asthma, grandmother with diabetes, HTN. No family
history of liver disease or bleeding disorders. Great aunt with
epilepsy.
Physical Exam:
VS: Temp: 99.9 BP: 146/86 HR: 89 NSR RR: 15 O2sat 100%
GEN: Intubated, sedated.
HEENT: Pupils equal, 2.5mm, minimally reactive to light,
+scleral icterus, blood in OP with ?small anterior tongue
laceration
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or [**Date Range **] nodules
RESP: Anteriorly w/ rhonchorus BS likely transmitted from upper
airway, no wheezes
CV: RRr, S1 and S2 wnl, no m/r/g appreciated
ABD: nd, +b/s, soft, nt, no masses, no appreciable ascites
EXT: 1+ dorsal hand edema b/l and dorsal foot edema b/l, 2+ DP
and PT pulses b/l
SKIN: no rashes
NEURO: Unable to assess CN II-XII. Pt. unable to cooperate w/
full neuro exam given mental status/sedation. Downgoing toes
b/l.
RECTAL: Guaiac + brown stool per ED eval.
Pertinent Results:
[**2167-12-29**] 06:30AM PT-18.4* PTT-48.9* INR(PT)-1.7*
[**2167-12-29**] 06:30AM PLT COUNT-124*#
[**2167-12-29**] 06:30AM NEUTS-87.3* LYMPHS-8.3* MONOS-3.0 EOS-1.0
BASOS-0.3
[**2167-12-29**] 06:30AM WBC-12.1* RBC-3.21* HGB-10.5* HCT-30.9*
MCV-96 MCH-32.9* MCHC-34.2 RDW-17.6*
[**2167-12-29**] 06:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2167-12-29**] 06:30AM ALBUMIN-2.4* CALCIUM-9.1 PHOSPHATE-4.0
MAGNESIUM-1.5*
[**2167-12-29**] 06:30AM CK-MB-NotDone cTropnT-0.14*
[**2167-12-29**] 06:30AM LIPASE-82*
[**2167-12-29**] 06:30AM ALT(SGPT)-37 AST(SGOT)-54* CK(CPK)-68 ALK
PHOS-83 AMYLASE-101* TOT BILI-5.2*
[**2167-12-29**] 06:30AM GLUCOSE-117* UREA N-33* CREAT-1.5* SODIUM-139
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15
[**2167-12-29**] 06:44AM HGB-10.9* calcHCT-33
[**2167-12-29**] 06:44AM LACTATE-1.7
[**2167-12-29**] 06:51AM GLUCOSE-107*
[**2167-12-29**] 06:51AM TYPE-ART PO2-304* PCO2-33* PH-7.50* TOTAL
CO2-27 BASE XS-3
[**2167-12-29**] 06:53AM AMMONIA-105*
[**2167-12-29**] 09:44AM PT-17.9* PTT-50.6* INR(PT)-1.6*
[**2167-12-29**] 09:44AM HCT-26.4*
[**2167-12-29**] 11:10AM HGB-9.7* calcHCT-29
[**2167-12-29**] 11:10AM TYPE-ART PO2-521* PCO2-37 PH-7.43 TOTAL
CO2-25 BASE XS-1
[**2167-12-29**] 12:00PM URINE MUCOUS-MANY
[**2167-12-29**] 12:00PM URINE MUCOUS-MANY
[**2167-12-29**] 12:00PM URINE RBC-7* WBC-52* BACTERIA-FEW YEAST-NONE
EPI-0
[**2167-12-29**] 12:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
[**2167-12-29**] 12:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2167-12-29**] 12:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2167-12-29**] 12:00PM URINE OSMOLAL-449
[**2167-12-29**] 12:00PM URINE HOURS-RANDOM UREA N-504 CREAT-65
SODIUM-92
[**2167-12-29**] 06:28PM HCT-24.6*
[**2167-12-29**] 06:39PM TYPE-ART PO2-474* PCO2-35 PH-7.50* TOTAL
CO2-28 BASE XS-4
[**2167-12-29**] 07:45PM CK-MB-NotDone cTropnT-0.10*
[**2167-12-29**] 07:45PM CK-MB-NotDone cTropnT-0.10*
[**2167-12-29**] 07:45PM CK(CPK)-42
[**2167-12-29**] 10:30PM HCT-23.8*
[**2167-12-29**] 10:44PM O2 SAT-99
[**2167-12-29**] 10:44PM TYPE-ART PO2-180* PCO2-25* PH-7.50* TOTAL
CO2-20* BASE XS--1
Discharge labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2168-1-6**] 06:00AM 6.9 2.38* 7.4* 23.0* 97 31.0 32.1 18.9*
118*
BASIC COAGULATION (PT, PTT, INR)
[**2168-1-6**] 06:00AM 21.0*1 57.6* 2.0*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2168-1-6**] 06:00AM 102 19 1.1 135 4.9 104 23 13
ENZYMES & BILIRUBIN ALT AST AlkPhos TotBili
[**2168-1-6**] 06:00AM 21 31 68 3.4*
.
EKG: Sinus tachycardia to rate 136. Nml axis, nml intervals.
Poor R wave progression. TW flattening V1, ?TW inversion V2.
.
Repeat EKG in ICU: NSR rate 84, nml intervals and axis. TWI in
II, III, aVF (new), TW flattening in V1-V2, TWI V3-V6 (all old
though more pronounced from prior).
.
[**2167-11-28**] Echo:
-Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF 60-70%).
-The right ventricular cavity is dilated.
-Right ventricular systolic function appears depressed.
-The ascending aorta is mildly dilated.
-There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen.
-The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse.
-There is moderate pulmonary artery systolic hypertension.
-There is no pericardial effusion.
.
Imaging:
[**2167-12-29**] CXR: Diffuse course linear opacities likely sequelae of
aspiration pneumonitis. No significant change from prior
([**2167-12-19**]).
.
[**2167-12-29**] Liver U/S:
1. Interval decrease in the proximal, mid and distal TIPS
velocity. Six-week followup is recommended to ensure the
stability of the TIPS function.
2. Normal wall-to-wall flow was noted within the TIPS and the
main portal vein and its branches demonstrate appropriate flow.
3. The TIPS device demonstrates abnormal pulsatile flow
suggesting the presence of possible right heart failure.
4. Small bilateral pleural effusion is noted.
.
[**2167-12-29**] CT head : No evidence of acute intracranial process.
Left-sided NGT in place; R>L opacification of nasal passage &
visualized nasopharynx. Mild mucosal thickening in right
maxillary sinus.
.
EEG: encephalopathy, no e/o seizure activity
.
Studies:
[**2167-12-19**] EGD:
1. Schatzki's ring
2. Erythema and congestion in the stomach body and fundus
3. Erythema and congestion in the first part of the duodenum
compatible with duodenitis
4. Otherwise normal EGD to second part of the duodenum
.
[**2167-11-25**] Colonoscopy: Grade 4 internal & external hemorrhoids.
Brief Hospital Course:
62yoF with h/o EtOH/hepC cirrhosis presents with altered mental
status, fever, blood in mouth, ? hematemesis. In the MICU,
patient was intubated for airway protection given altered mental
status. On transfer to floor, patient still confused but
returning towards baseline on lactulose and started on IV
antibiotics for GNR in urine and sputum and GPC in prs/clusters
in sputum. She received one unit of blood for decreased Hct
thought to be [**2-13**] oropharyngeal bleeding, etiology unclear, but
stabilized bleeding after extubation. Liver service is
involved, no endoscopy indicated at this time.
.
HOSPITAL COURSE BY PROBLEM:
.
# Altered mental status: The patient was admitted from rehab
with altered mental status. She was intubated for airway
protection in the ED. Per extended care facility she has been
taking lactulose and rifaximin although he hepatic
encephalopathy could be contributing as the ammonia on
presentation was 105 which is higher than previously (50-80, but
? in setting of encephalopathy). She was continued on lactulose
and refamixin during her hospital stay. Although the patient has
a history of seizures ( she is not on any medication?) and did
present with possible tongue trauma and oral bleeding, an EEG
was performed which did not show any seizure activity. Utox was
negative making drug abuse unlikely despite recent history of
crack cocaine abuse. CT head negative for bleed/acute
intracranial process. She did receive empirc coverage for
meningitis in the ED with ceftazadine and Vanco given fever on
presentation although she did not have any meningeal symptoms.
Meningitis was later thought to be less likely. A CXR was
performed to evaluated for PNA as a possible cause of AMS and
was found to be unchanged from prior. A CT chest did not
pulmonary edema but no focal infiltrate suggestive of PNA. SBP
was also thought to be unlikely without ascites on ultrasound of
the abdomen and without abdominal tenderness. Evaluation of
her TIPS showed decreased flow but per the hepatology team a
revision of TIPS would likely worsen her encephalopathy. She was
ultimately found to have a enterobacter UTI and was initially
started on Zosyn and Vanc. The enterobacter was then found to be
resistant to Zosyn - Sensitive to cefepime and Meropenem only-
and she was switched to Cefepime. Her mental status improved to
baseline. She had repeat U/A on 12.24 that showed clearance of
infection. Plan for 14d course for complicated UTI/PNA, for 6
more days on d/c. Hepatology followed and decided against
reevaluation of TIPs given clinical improvement with lactulose
and treatment of UTI.
.
# Fever: WBC count elevated to 12.1 with 87% neutrophils. Was
febrile on presentation to ED concerning for infection.
Additionally she was tachycardic to 130s. She was admitted to
the ICU for SIRS and s/p intubation. at least meets criteria for
SIRS and likely even sepsis (source not yet clear). Her fever ws
found to be due to a UTI described above and resolved with
antibiotics. Notably, sputum gram stain did show GPC's and
GNR's, but only GNR's grew on culture; clinically the patient
did not appear to have pneumonia. She was only kept on Cefepime
as well as vanc for sputum MRSA given her improvement for
treatment of her UTI/PNA, as above
.
# Respiratory: Patient reportedly not in respiratory distress on
presenation, but rather intubated for airway protection given
severely depressed mental status. She was never hypoxic in the
ICU or on the floor. CXR does show reticular opacities stable
from most recent CXR previously billed as aspiration
pneumonitis. CT showed pulmonary edema and she was given lasix
IV, then transitioned to pre-admission diuretics.
.
# ?upper GI bleed: HCT trending down and +blood removed form
oropharynx. Patient with known grade 4 rectal varices however
guaiac + brown stools. Also recent EGD showed e/o portal
gastropathy, but w/o e/o varices. She was started on octreotide
in ED for ? variceal bleed. Blood in NGT looks old so perhaps
old from recent bleed/EGD. Other blood in mouth bright red and
perhaps from tongue/mouth trauma.
- q8h hcts
- a-line placed; CV line attempt failed
- Appreciated liver involvement
- [**Hospital1 **] PPI
.
# Bleeding: Patient was found to have oozing in posterior
throat, central line and PICC site after transfer to the floor.
She did not appear to have uremia with a normal BUN. Her PTT was
elevated and her platelets were decreased. She had received PPx
heparin and heparin flush through PICC last night and her PLT
have trended down although not by 50%. She was evaluated for HIT
- a HIT Ab was sent and was negative. Heparin administration was
discontinued. She was also given FFP for elevated PTT and
likelihood of liver dysfunction.
- was given 1 U pRBCs on [**1-3**] and another on 12.27 day of
discharge with stable hct of ~21-23 at discharge. Goal hct >21.
.
# Elevated troponin: Normal CK and CK-MB. Troponin elevated to
0.14 (up from previous baseline even in setting of CRI), now
trending down. Given dilated, hypokinetic RV, may be elevated in
the setting of failure. Does have poor R wave progression on EKG
which is old as are, EKG now back at baseline.
.
# EtOH/Hep C cirrhosis: Platelets 124 and within previous
baseline. Coags in the ED revealed INR of 1.7 which is also c/w
baseline. Albumin 2.6 on [**12-25**] (not sent in ED). AST mildly
elevated, ALT, alk phos normal. T.bili elevated to 5.2 which is
actually slightly down from baseline. MELD of 22 on admission.
- continue lactulose and rifaximin po
- held lasix/sprinolactone initially, then restarted, but on day
of discharge had hyponatremia to 128. Pt. thought to be
hypovolemic, so diuretics discontinued and given 1U pRBCs
- will follow up in first week of [**Month (only) **] with Dr. [**Last Name (STitle) 497**] to
determine whether diuretics need to be restarted
.
# Acute on CRF: Appears to have had progessively worsening
function since spring, [**2167**]. Currently within most recent
baseline. Etiology not entirely clear. It does not appear to
have been worked up previously although there has been ? HRS on
old d/c notes. No other clear e/o cryoglobulinemia, but does
have hep C. FEUrea 35.7%, borderline prerenal on [**12-29**]; lasix
held for the past 2 days so unlikely to be pre-renal still.
Patient has not been hypotensive, making ATN unlikely. Urine eos
positive but sparse and no peripheral eosinophilia or rash,
making AIN equivocal; however, the patient was on Zosyn which
could cause AIN.
- cryoglobulin levels negative
- C3, C4 levels wnl
- will f/u with Dr. [**Last Name (STitle) 1366**] in renal as outpt.
.
# Anemia: High normal MCV, elevated RDW. Baseline fluctuates
somewhat, but generally runs mid-upper 20s to low 30s. Of note,
hct was 30.9 on presentation from 28.9 upon discharge on [**12-26**].
As above, likely secondary to chronic GI sources (portal
gastropathy, hemorrhoids).
-continue [**Hospital1 **] Hct monitoring
- pt likely transfusion dependent to certain extent; transfuse
to maintain Hct >21 or if acute drop, e/o bleeding
-continue iron supplementation
.
# H/O seizure d/o: No documented history of seizures while at
[**Hospital1 **]. Has been off antiepileptic meds per OMR notes since at least
[**2165**]. Given AMS and tongue trauma, ? postictal although seems
less likely given has yet to clear.
- EEG negative for seizure
.
# COPD: Rhonchorus BS anteriorly likely transmitted from upper
airway. Without e/o bronchospasm on exam currently.
- Continue albuterol/ipratropium MDI via ETT prn
.
# Psychotic disorder: Schizophrenia per pt. in old notes. Not on
any neuroleptic meds. Appears to have received olanzapine on
prior admissions. Has "allergy" to haldol.
- olanzapine prn started with olanzapine in evenings standing.
.
# F/E/N: Replete lytes PRN. NPO.
.
# PPx: Bowel regimen, PPI, sq Heparin
.
# Access: PICC
.
# Code Status: Full
.
# Communication: Daughter [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) 99377**] [**Telephone/Fax (1) 99373**],
[**Telephone/Fax (1) 99378**]
D/c'd to [**Hospital1 **] [**1-7**] with instructions to follow lytes and hct
and for PT.
Medications on Admission:
1. Rifaximin 400 mg tid
2. Lactulose 30 ML PO TID-QID; titrate to 4 BMs daily
3. Nystatin 5 ML PO QID prn
4. Ipratropium Bromide nebs q6h
5. Albuterol Sulfate nebs q6h prn
6. Pantoprazole 40 mg PO daily
7. Furosemide 20 mg PO daily
8. Spironolactone 50 mg daily
9. Ferrous Sulfate 325 mg PO daily
Discharge Medications:
1. Rifaximin 200 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3 times a
day).
2. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO QID (4
times a day).
3. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Year (2) **]: Five (5) ml PO DAILY
(Daily).
4. Albuterol 90 mcg/Actuation Aerosol [**Month/Year (2) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB, cough, wheezing.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Two (2)
Puff Inhalation QID (4 times a day) as needed for SOB, cough,
wheezing.
6. Olanzapine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for agitation.
7. Olanzapine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at
bedtime).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Cefepime 1 gram Recon Soln [**Month/Year (2) **]: Five Hundred (500) mg
Intravenous once a day for 5 days.
10. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Year (2) **]: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 5 days.
11. Ensure Plus Liquid [**Month/Year (2) **]: Two (2) bottles PO three times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses
1) Hepatic Encephalopathy
2) UTI
3) Pneumonia
4) Altered Mental Status
5) anemia
secondary diagnoses:
1) Iron deficiency anemia
2) GI bleed - presumed secondary to hemorrhoids, s/p TIPS; also
w/ known portal gastropathy
3) Sigmoid diverticulosis
4) Schatzki's ring
5) Duodenal polyps and duodenitis
6) MGUS
7) ?Etoh/ HCV cirrhosis followed by Dr. [**Last Name (STitle) 497**]
8) Psychotic disorder
9) Remote polysubstance abuse - etoh, cocaine, marijuana
10) COPD
11) Complex partial seizures
Discharge Condition:
good, tolerating pos, satting well on RA, afebrile, sitting in
chair with assist
Discharge Instructions:
You came to the hospital due to a change in your mental status
as well as blood in your mouth. You were in the ICU for part of
your hospital stay due to concern for your mental status and
breathing, and you were found to have both a respiratory and
urinary tract infection for which you are being treated.
Additionally, your mental status is altered due to your liver
disease. Please take antibiotics as prescribed for 6 more days
and continue lactulose and rifaxamin, titrated to [**3-15**] loose
bowel movements per day.
Please call your physician or return to the hospital for any of
the following: bright red blood per rectum, black, tarry
stools,chest pain, shortness of breath, inability to tolerate
food, fever >101 or other concerns.
Followup Instructions:
You have the following appointments which you should attend
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2168-1-15**] 2:20
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2168-1-18**] 9:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
ICD9 Codes: 0389, 5990, 2761, 5849, 5070, 5859, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2653
} | Medical Text: Admission Date: [**2140-6-30**] Discharge Date: [**2140-7-20**]
Date of Birth: [**2082-4-6**] Sex: F
Service: LIVER TRANSPLANT SURGERY SERVICE
ADMITTING DIAGNOSIS: Fevers.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
female status post right donor hepatic lobectomy on [**2139-11-23**], complicated by postop biliary leak requiring a Roux-
en-Y hepaticojejunostomy to the left lateral segment duct on
[**2140-1-29**]. Status post multiple embolization coils
within liver,coiling of small bile ducts from
segment IV leaking into perihepatic space. Transhepatic
catheter was placed for a small contained leak at the
anastomosis. An ERCP performed on [**2140-5-25**] demonstrating
no leakage of the cystic duct remnant and biliary stents
removed.
The patient currently has a JP drain in place and left PTC
tube that is capped. The patient states that for the past 2
days, she has been experiencing temperatures ranging from
100.2-102.5. The patient has decreased appetite x2 days, but
thirsty, occasional left lower quadrant sharp pain, abdominal
pain x a few seconds, but subsides on its own--"feels like a
grinding" sensation. Lower quadrant pain is not positional.
Tylenol relieves sensation. No chills. No nausea or vomiting.
No shortness of breath. No sustained abdominal pain.
PAST MEDICAL HISTORY: Hypertension, history of migraines,
history of MRSA and bile gastritis, history of biliary leak,
status post right lobe hepatic donation [**2139-11-23**],
history of C. diff.
PAST SURGICAL HISTORY: Status post right hepatic lobectomy
and cholecystectomy on [**2139-11-23**], status post Roux-en-
Y hepaticojejunostomy to left lateral segment [**2140-1-29**], status post TAH/BSO, status post PICC line placement
[**2140-5-20**].
ALLERGIES: Ethylene, heparin agents, vancomycin, Zosyn,
meropenem.
MEDICATIONS ON ADMISSION: Vancomycin 250 q.i.d., Levaquin
500 once daily, Imitrex p.r.n., Mirapex 0.025 at bedtime,
atenolol 90 mg q. a.m., Protonix 40 mg b.i.d., clonazepam 1.0
at bedtime, Tylenol p.r.n., Colace 100 mg b.i.d., calcium, a
multivitamin and senna.
SOCIAL HISTORY: Living with sister in [**Name (NI) **]. No alcohol.
No tobacco. No substance abuse.
REVIEW OF SYSTEMS: The patient has had positive loose stools
x1 month, intermittent, 2 times a week, 6 stools a day
intermittently. Patient is on vancomycin 250 q.i.d. finishing
course with C. diff. The patient was supposed to have
elective cholangiogram.
PHYSICAL EXAM: The patient is afebrile at 99.1, heart rate
76, BP 102/71, respirations 20, 97% on room air. HEENT:
Pupils equal, round and reactive to light. EO movements are
full. No icterus. MOUTH: Tongue midline. Moist mucosa. Uvula
symmetric. NECK: Supple. No palpable nodes. No carotid bruits
bilaterally. LUNGS: Clear to A&P bilaterally. CV: Regular
rate and rhythm. Normal S1, S2, without murmurs, rubs.
ABDOMEN: Positive bowel sounds, with a JP drain, dark green
fluid in color. Left PTC capped. Incision site--both sites
are intact. Soft, nontender. No organomegaly. EXTREMITIES: No
C/C/E, +2 AT and dorsalis pedis.
LABS ON ADMISSION: WBC 7.9, hematocrit 31.9, platelets 142,
PT 14.1, PTT 27.0, INR 1.3. On [**6-30**], UA was obtained which
was negative. Sodium 137, 3.6, 100, bicarbonate 29, BUN and
creatinine 15 and 0.7, glucose 137. Patient had an ALT of 54,
AST 83, alkaline phosphatase 1861, total bilirubin 0.7.
HOSPITAL COURSE: Spoke to infectious disease who recommended
starting Zyvox 600 b.i.d. and aztreonam 2 gm x2 prior and
after cholangiogram, which was scheduled on the 15th. CT
abdomen with and without contrast was obtained the evening of
admission, which demonstrated interval mild increase in the
amount of biliary duct dilatation, with new pneumobilia.
Given the patient's recent increase in alkaline phosphatase,
biliary duct ischemia with mild stricture cannot be excluded.
Cholangitis should also be considered given the patient's
history of a fever. 2) Interval improvement in the size of
previously identified biloma and liver infarction. 3)
Interval resolution of the patient's pleural effusion.
On [**2140-7-1**], the patient also had a HIDA scan
demonstrating no definite biliary leak identified, prominence
of the left lateral intrahepatic biliary system, the left
medial biliary ducts less prominent, but no evidence to
suggest exclusion, multiple photopenic foci, corresponding
with areas of known fluid collection seen on the prior cross-
sectional studies.
On hospital day 2, the patient was febrile with rigors. No
nausea, vomiting. The T-tube had not drained due to a kink.
The patient was on linezolid and aztreonam. JP and T-tube
sites were without any redness. On [**2140-7-1**], the patient
had a cholangiogram demonstrating exchange for new 5 French
pigtail catheter, drained the intrahepatic bile duct to
segment III. No dilated ducts in this region.
Nonvisualization of the duct from segment II. Attempt will be
made to access percutaneously the bile duct to segment II via
ultrasonographic guidance in a few days, which was discussed
with Dr. [**Last Name (STitle) **].
Cultures obtained on admission and hospital day 1 for fevers:
Urine culture demonstrated less than 10,000 organisms. Blood
culture demonstrated no growth from [**2140-7-1**]. Also,
stool was collected, demonstrating no C. diff. Fluid was
collected from the JP drain, demonstrating Staph aureus coag-
positive.
The patient continued on linezolid, aztreonam, and also
patient continued on vancomycin for C. diff. The patient
became very emotional, very anxious, and psychiatry did see
patient on [**2140-7-4**]. Psychiatry made some
recommendations with regards to checking labs, as well as
medication suggestions.
On [**2140-7-8**], it was requested by the transplant team to
place a second PTBD tube into the bile duct from segment II,
which was performed on [**2140-7-8**]. There were no
complications. Total contrast used was 50 ml of Optiray.
There was placement of an 8 French PTBD tube into the duct of
segment II, connected to external drainage bag. The tip of
the catheter appears located along the JP drain. Replacement
of a clogged 5 French pigtail PTBD catheter by a new one,
same as before. The catheter is in the duct of segment III
and was capped, performed by Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Doctor Last Name 19595**] and
Dr. [**First Name11 (Name Pattern1) 6339**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 19420**].
On [**7-9**], a CT abdomen and pelvis with contrast were
performed to evaluate placement of percutaneous transhepatic
catheters. Impression: There was a new expansile
retrohepatic, mixed high attenuation collection with mass
effect on the IVC and adjacent liver, consistent with a
hematoma. Small to moderate serosanguineous fluid is seen
throughout the abdomen and pelvis. A nonenhancing hypodense
irregularity of the liver margin and to the aforementioned
collection, the appearance of which tear/laceration of the
liver capsule and/or parenchymal liver injury is possible. 3)
There is irregular attenuation of the proximal intrahepatic
left main duct portal vein. A small focus of high attenuation
seen on series 2, image 18 at the periphery at the
retrohepatic collection could indicate an element of active
extravasation from material entry. These findings were
conveyed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 49634**] from the transplant team.
The patient continued on triple-antibiotics, linezolid,
aztreonam, vancomycin. Infectious disease followed the
patient while the patient was in the hospital making daily
recommendations. On [**2140-7-13**], the patient was
transferred from Far-10 to ICU because of complaints of
abdominal pain and back pain. Also, the patient had
hematocrit drop that evening. A CT abdomen and pelvis were
performed demonstrating features consistent with ongoing
active bleeding into retrohepatic hematoma. These findings
have been communicated to the ordering physician. [**Name10 (NameIs) **] patient
had a hematocrit of 27.2, WBC 11.4, platelets 129. The
patient received 1 unit of packed red blood cells and 2 units
of FFP. The patient was transferred back from ICU to regular
floor, and physical therapy and occupational therapy, as well
as nutrition were consulted.
On hospital day 16, patient afebrile, vital signs stable,
appears comfortable. Diet was advanced. The patient was
transferred to the regular floor on [**2140-7-15**]. The
patient did received Dilaudid p.r.n. for abdominal
pain/discomfort. The patient had calorie counts while being
an inpatient, and it was discussed among the team and to the
patient, that the patient did have poor intake, and that the
patient needed to improve her p.o. intake in order for her to
be discharged. Antibiotics were discontinued, and her labs
had been stable. Today, [**7-20**], her labs are the following:
WBC 10.1, hematocrit 35.3, platelets 208, PT 15.8, 30.5, INR
1.7, sodium 133, 3.6, 95, 30, bicarbonate 30, BUN and
creatinine of 5 and 0.4, and glucose 94. The patient has ALT
of 16, AST 24, alkaline phosphatase of 653 from 719 from the
previous day.
So, the patient will be able to be discharged to home without
physical or occupational services. The patient does have a
pigtail that put out overnight 10 cc, and JP drain 175. The
patient will be leaving on the following medications: Tylenol
500-1,000 mg p.o. q. 6 h. p.r.n., atenolol 125 mg p.o. once
daily, calcium carbonate 500 b.i.d., clonazepam 0.5 mg at
bedtime, Benadryl 25 p.o. q. 6 h. p.r.n., Colace 100 mg
b.i.d., Dilaudid 0.5-1 mg q. 4 h. p.r.n., multivitamin 1 once
daily, nortriptyline 10 mg at bedtime, Protonix 40 mg p.o. q.
12, Paxil 0.25 mg at bedtime, senna 1-2 tabs p.o. b.i.d. or
p.r.n., ursodiol 300 mg b.i.d., Vitamin D 400 units p.o. once
daily.
The patient should follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2140-7-27**] at 11:40 a.m. located in the LM [**Hospital Unit Name **], [**Location (un) 20682**], telephone #[**Telephone/Fax (1) 673**]. The patient should also
follow-up with outpatient psychiatry which a date and time
will hopefully be given to her before she is discharged. The
patient should call transplant surgery immediately at [**Telephone/Fax (1) 30335**] if any fevers, chills, nausea, vomiting, abdominal pain,
diarrhea, decreased energy, sustained decreased appetite,
difficulty with urination or bowel movements, also any
increased shortness of breath, chest pain, lower extremity
swelling. Patient will needs labs, unless otherwise, on
Mondays and Thursdays with the following labs: CBC, chem-10,
AST, ALT, alkaline phosphatase, albumin, total bilirubin and
rapamycin level. These should be faxed immediately to [**Telephone/Fax (1) 24749**].
FINAL DIAGNOSES: History of bile leak and small perihepatic
fluid collection with hematoma in the posterior hepatic
space, who presented with fevers.
ADDENDUM: On [**2140-7-13**], after the CAT scan that was
performed which found hematoma of the posterior hepatic
space, an angiogram was performed demonstrating no evidence
about the source of hepatic artery bleeding. There was a
small pseudoaneurysm at the branch of the midhepatic artery
measuring 5 mm in size, and successful placement of central
venous catheter to the right internal jugular vein with the
tip in the superior vena cava. Currently, the patient will be
going home. The patient may be going home in a couple of days
based on patient's nutrition. She has a very poor intake, and
nutrition is seeing her, but in order for us to discharge her
to home, the patient needs to improve on her p.o. nutrition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2140-7-20**] 11:47:31
T: [**2140-7-20**] 13:09:22
Job#: [**Job Number 49635**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2654
} | Medical Text: Admission Date: [**2106-3-31**] Discharge Date: [**2106-4-6**]
Date of Birth: [**2026-7-5**] Sex: M
Service: NEUROLOGY
Allergies:
Tetanus Toxoid / Penicillins / [**Year (4 digits) 13401**]
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
R sided hemiparesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79yo RH M who was last known well at his nursing home around
noon-ish, when he ate lunch. He then had the abrupt onset of
right facial droop and right arm weakness and has been unable to
speak since. By report, he was hypoxic in the 70s and
hypotensive; on arrival, bp was 90s/50s and he was placed on a
NRB.
He was recently discharged on coumadin, since he has an aortic
valve. His NH documentation shows last INR on [**3-29**] of 1.5. He
has
been treated recently for C Diff, with last day of flagyl due
tomorrow.
Past Medical History:
- Seizure disorder on dilantin; unclear etiology
- Rheumatic heart disease, s/p MVR ~[**2087**]
- CAD, s/p CABG
- AS s/p AVR
- HTN
- Dyslipidemia
- Spinal stenosis
- Status post C1-C5 Anterior fusion [**2097**]
- Status post L2-5 Decompressive surgery [**2097**]
- Status post C2-4 Posterior fusion [**2102**]
- OA s/p left knee arthroplasty in [**2097**]
- Neuropathy
- B12 deficiency
- Hospitalized at [**Hospital1 18**] [**7-22**] for food aspiration and esophageal
impaction, aspiration PNA, and dilation of esophageal ring
- BPH s/p TURP
- Chronic bilateral carpal tunnel syndrome
Social History:
Lived at home w/ wife but currently at [**Hospital1 **] for rehab. No hx of
tobacco, EtOH or drug abuse. However,most recently in nursing
home.
Family History:
No family history of seizures
Physical Exam:
PE
VS 99.6 89/50-150s/60s after fluid bolus 12 100%
Gen Awake, cooperative, NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted
NEURO
MS Eyes closed, rouses to verbal stimuli. Does not follow
commands or speak. Drowsy.
CN
CN I: not tested
CN II: No blink to threat on the right. Pupils 3->2 b/l. CN III,
IV, VI: Eyes deviated to the left, full EOM to oculocephalics
CN V: b/l corneals
CN VII: R facial droop
CN VIII: opens eyes to voice
CN IX, X: palate rises symmetrically, but choking on saliva
CN [**Doctor First Name 81**]: unable to assess
CN XII: unable to assess
Motor
R arm flaccid. Moves left arm purposefully to pain. The right
externally rotates to noxious stimuli. b/l triple flexion in the
legs
Sensory grimaces to noxious stimuli throughout
Reflexes
Br [**Hospital1 **] Tri Pat Ach Toes
L 2 2 2 1 0 up
R 0 0 0 1 0 up
Coordination unable to assess
Gait deferred
CODE STROKE SCALE:
Neurologic (NIHSS): 22
1a. LOC: 2
1b. LOC questions: 2
1c. LOC commands: 2
2. Best gaze: 2
3. Visual: 2
4. Facial Palsy: 3
5a. Left arm: No drift (0)
5b. Right arm: 4
6a. Left leg: No drift (0)
6b. Right leg: no drift (0)
7. Limb ataxia: x
8. Sensory: no sensory loss bilaterally (0)
9. Language: 3
10. Dysarthria: 2
11. Extinction/inattention: None (0)
Pertinent Results:
CT BRAIN PERFUSION [**2106-3-31**] 5:30 PM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS
1. Extensive acute MCA territory infarction extending
posteriorly into the occipital pole, with mass effect on left
lateral ventricle. No hemorrhage or herniation.
2. Saddle embolus at the left M1-M2 bifurcation with poor
filling of both superior and inferior M2 divisions. No PCA
filling defect seen.
3. Underlying ventriculomegaly out of proportion to sulcal and
fissural prominence.
4. Fluid in the sphenoid sinuses, more on the left.
5. Massive OPLL at C2-3 level causing narrowing of spinal canal
above the level of C3-4 laminectomy.
6. Small right pleural effusion.
Brief Hospital Course:
His LOC rapidly deteriorated after CT & he was intubated. He
was not a candidate for t-[**MD Number(3) 6360**] the large size of the
infarct, nor endovascular intervention given the absence of
large vessel occlusion and MTT/CBV mismatch on CTP indicating
lack of a salvageable tissue. His infarct was most likely
cardioembolic secondary to Afib and subtherapeutic INR.
The patient was admitted to the SICU, under the care of
neurology. Over the following days, he developed several
complications. His R foot and lower leg became ischemic. He
developed a fulminent sepsis, despite broad spectrum empiric
antibiotic therapy, requiring pressures and aggressive fluid
rescusitation. There was significant peripheral edema as a
consequence of third spacing. His respiratory drive decreased
and required more pressure support from the ventilator. The C
diff infection was insufficiently controlled, he continued to
have diarrhea with HCO3- and Na+ loss, despite Vancomycin and
Flagyl. He had a prolonged episode of Ventricular Tachycardia
with hypotension on the eve of [**2106-4-5**], spontaneous
reconversion, started on Amiodarone.
Neurologically he slowly declined, only grimacing weekly to pain
on the L, not withdrawing his left arm or leg anymore. The
prognosis of his dense L MCA stroke was very poor with respect
to quality of life and meaningful recovery - and the family
decided to withdraw care and focus on comfort. He died 4 hours
later. Family was notified. No autopsy.
Medications on Admission:
Coumadin 1mg daily
Dulcolax, fleet enema, colace
Seroquel 50mg qhs
Flagyl 500mg TID (last due [**4-1**])
Tamsulosin
Lipitor 20
Senna
Dilantin 100mg TID
Prilosec
Discharge Medications:
None - patient deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Large left middle cerebral artery infarct
Discharge Condition:
Deceased
Discharge Instructions:
None.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2106-4-6**]
ICD9 Codes: 0389, 4271, 5849, 2761, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2655
} | Medical Text: Admission Date: [**2136-8-15**] Discharge Date: [**2136-8-24**]
Date of Birth: [**2079-8-31**] Sex: F
Service: MEDICINE
Allergies:
Sulfatrim / Sulfa (Sulfonamide Antibiotics) / Tape [**1-9**]"X10YD
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
colonoscopy/EGD [**8-18**]
IJ CVL [**8-17**]
Intubation [**8-17**]
History of Present Illness:
56 y.o female with pmhx of HCV/ETOH cirrhosis decompensated in
the past with grade 1 varices in [**2129**], small amount of ascites,
and encephalopathy with recent diagnosis of metastatic
adenocarcinoma ( thought to be a pancreaticobilliary source) who
recieved a [**8-2**] EUS with FNA and now presenting with
hematochezia and altered mental status. The husband accompanies
the patient reports that she seemed to be more confused the last
2 days. Yesterday they noted that she had dark-colored stools
that appeared to be like blood. The patient is uncooperative
with exam right now and has no specific complaints.
.
Initial Vitals in the ED was 97.3 92 97/76 16 97% and she was
given Octreotide drip, Pantoprazole drip and Ceftriaxone.
Patient was noted to have SBP's into the 80's, given IV NS and
BP stablized with SBP at approx. 110. Patient had 1 20 G PIV and
left IO placed because of difficult access.
On arrival to the MICU, the patient is sleeping and does not
want to answer questions. She denies pain, and says she has
noticed dark blood in her stools for a couple of "days." She
refuses to answer further questions and denies confusion. "Just
leave me alone."
Review of systems:
Patient will not answer, could not be fully obtained
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Hep C
EtOH abuse
Depression
Cirrhosis
L humerus fracture s/p ORIF [**2129-1-12**]; s/p removal of hardware and
repair of left humerus nonunion w/ bone graft and locking plate
[**2129-7-13**] s/p washout and debridement on [**7-22**] and [**7-25**].
Social History:
Did not drink alcohol for 3 years until a recent admission in
6/[**2136**]. Smokes abou5-6 cigarettes/day. Lives with her husband
in [**Location (un) 686**].
Family History:
NC
Physical Exam:
Admission
Vitals: T:99.0 BP:110/80 P:95 R:12 18 O2:87% RA
General: Sleeping, oriented X2-3, no acute distress. Does not
want to answer questions, wants to sleep
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: does not comply with neurologic exam. Spontaneously
moving all limbs.No asterxis
Rectal: dark red/maroon blood in the rectal vault
.
Discharge Exam:
General: Lethargic, one word responses, appeared to be in no
acute distress. Oriented x0
HEENT: Sclera anicteric, MM moist, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM heard best
at LUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Pertinent Results:
Admission Labs
[**2136-8-15**] 07:06PM HGB-9.3* calcHCT-28
[**2136-8-15**] 06:57PM GLUCOSE-85 UREA N-17 CREAT-0.7 SODIUM-137
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13
[**2136-8-15**] 06:57PM ALT(SGPT)-41* AST(SGOT)-81* ALK PHOS-122* TOT
BILI-2.7*
[**2136-8-15**] 06:57PM ALBUMIN-3.0*
[**2136-8-15**] 06:57PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2136-8-15**] 06:57PM WBC-7.7 RBC-2.84* HGB-9.1* HCT-27.5* MCV-97
MCH-31.9 MCHC-33.0 RDW-16.1*
[**2136-8-15**] 06:57PM NEUTS-74.9* LYMPHS-17.2* MONOS-4.8 EOS-2.8
BASOS-0.4
[**2136-8-15**] 06:57PM PLT COUNT-103*
[**2136-8-15**] 06:57PM PT-17.5* PTT-32.1 INR(PT)-1.6*
[**2136-8-15**] 05:25PM GLUCOSE-88 UREA N-19 CREAT-0.7 SODIUM-129*
POTASSIUM-GREATER TH CHLORIDE-105 TOTAL CO2-23
[**2136-8-15**] 05:25PM GLUCOSE-88 UREA N-19 CREAT-0.7 SODIUM-129*
POTASSIUM-GREATER TH CHLORIDE-105 TOTAL CO2-23
[**2136-8-15**] 05:25PM ALT(SGPT)-65* AST(SGOT)-213* ALK PHOS-117*
TOT BILI-2.7*
[**2136-8-15**] 05:25PM ALBUMIN-3.2*
[**2136-8-15**] 05:25PM WBC-11.2*# RBC-3.05* HGB-9.8* HCT-29.6*
MCV-97 MCH-32.3* MCHC-33.2 RDW-16.0*
[**2136-8-15**] 05:25PM NEUTS-74.9* LYMPHS-17.2* MONOS-4.8 EOS-2.9
BASOS-0.2
[**2136-8-15**] 05:25PM PLT COUNT-148*#
.
Studies:
EGD [**2136-8-17**]: 4 cords of grade III large esophageal varices were
seen starting at 20 cm from the incisors in the upper third of
the esophagus and gastroesophageal junction. The junctional
varix had red whale signs. The varices were not bleeding.
Severe portal hypertensive gastropathy seen throughout the
stomach with cherry red spots without signs of active bleeding
or oozing. retroflexed revealed small hiatal hernia with small
gastric varices on lesser curvature left undisturbed. Normal
duodenal bulb and second portion
.
Colonoscopy [**2136-8-17**]: Moderate left sided diverticulosis without
signs of active bleeding, otherwise normal colonoscopy to the
cecum. Retroflexion in the rectum revealed hyertrophy of anal
papila and one cord of rectal varices without signs of active or
recent bleed, moderate internal hemorrhoids left undisturbed.
.
Micro:
[**2136-8-17**] URINE CULTURE-Neg
[**2136-8-16**] URINE CULTURE-neg
Brief Hospital Course:
56 y.o female with pmhx of HCV/ETOH cirrhosis decompensated in
the past with grade 1 varices in [**2129**], small amount of ascites,
and encephalopathy with recent diagnosis of metastatic
adenocarcinoma ( thought to be a pancreaticobilliary source) who
received a [**8-2**] EUS with FNA and who presented with
hematochezia and altered mental status.
.
Active Issues
#Hematochezia- Rectum revealed maroon stools. Patient placed on
Octreotide, Pantoprazole drips and started on Ceftriaxone ppx.
Differential included variceal bleed, diverticulosis. Hct
dropped from 35 to 28. Intubated without complication and
underwent EGD which revealed severe esophageal and gastric
varices with diverticulosis on colonoscopy. No role in TIPS per
hepatology given underlying malignancy. CT torso also carried
out which verified malignancy metastases, with enlarged nodes by
liver and pancreas unknown primary. Pt was transferred to the
floor, where her symptoms were controlled with oral morphine for
pain and SL zydas for agitation. There was no blood noted
.
Pain: See above. After being transferred to the floor, patient
was controlled on IV and PO morphine. Eventually switched to all
PO meds. Standing morphine has had to be uptitrated, and at
discharge she was receiving 7.5mg of concentrated SL MS q2h,
with an additional [**5-17**] q1h:breakthrough pain. It is difficult
to assess patient as she is usually sedated, however, she can
become anxious/agitated in the morning and when prompted, will
occasionally report that she has abdominal pain.
.
#Confusion-thought to be multifactorial including hepatic
encephalopathy and delirium post sedation. Was extubated on [**8-17**]
and patient remained agitated and delirious pulling out her
central line placement. A family meeting took place with the
patient's sister and husband who were health care proxies. Poor
prognosis due to underlying malignancy and cirrhosis were
explained to them. Reported that she has weeks to months to
live. Systemic chemo was offered but cons outweighed pros given
that the main concern for the health care proxies were the
comfort of the patient. Therefore, on [**8-18**] she was placed as
comfort care only and lactulose, rifaximin,ceftriaxone, PPI, lab
draws were stopped.
.
#Adenocarcinoma- thought to be from pancreatic- biliary source.
.
Transitional Issues:
#Stymptom control: Pt has been transitioned to all PO meds. Will
need to uptitrate PO morphine and SL zydas as needed
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Fluoxetine 20 mg PO DAILY
3. Gabapentin 600 mg PO TID
4. Lactulose 30 mL PO TID
5. OxycoDONE (Immediate Release) 5-10 mg PO Q8H:PRN pain
6. Pantoprazole 40 mg PO Q24H
7.alprazolam 0.25 mg tablet 1 tablet(s) QHS
8.cholestyramine-aspartame 4 gram Packet 1 packet by mouth
qdaily
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] nursing care center
Discharge Diagnosis:
Primary Diagnosis:
Metastatic pancreatic adenocarcinoma
Anemia
Gastrointestinal bleed
chronic pain
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the ICU because you had blood in your stool
and you were confused. You were treated with blood transfusions
and medicine to make you stop bleeding. A camera was used to
look at your esophagus, stomach, and your colon. This showed
many areas that could potentially bleed, though none were
bleeding at the time. When your blood count was stable, you were
transferred to the [**Doctor Last Name 3271**] [**Doctor Last Name 679**] service.
Your pain was well controlled while you were here. You were
comfortable and your symptoms were controlled. We are sending
you on medication to take by mouth for your pain, and a seperte
medication for any confusion/anxiety or agitation.
Medications to START:
Morphine Concentrate 7.5mg q2h
Morphine Concentrate 5-10mg q1h PRN:Pain
Olanzapine 5mg q8h
Olanzapine
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
ICD9 Codes: 5789, 2851, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2656
} | Medical Text: Admission Date: [**2139-10-14**] Discharge Date: [**2139-11-21**]
Date of Birth: Sex: F
Service:
DIAGNOSES:
1. Diabetes mellitus
2. Necrotizing fasciitis
3. Peripheral vascular disease
4. Neuropathy
5. Congestive heart failure
6. Septicemia
SUMMARY: This 73-year-old woman was admitted with extensive
necrotic tissue on the left lower extremity. She had
previously undergone arterial reconstruction in the right
lower extremity. Arteriography demonstrated occlusion of the
superficial femoral artery with reconstitution of the
popliteal artery and two vessel run-off.
After extensive discussion with the family, it was agreed to
attempt arterial reconstruction and excessive debridement of
the left lower extremity understanding that the area of
necrosis was quite large, but since the foot appeared to be
spared, it was worth an attempt. The patient subsequently
underwent several operative procedures in an attempt to
salvage the left lower extremity. This included arterial
reconstruction with a superficial femoral to peroneal vein
graft followed by extensive debridement of necrotic skin and
subcutaneous tissue on [**2139-10-21**]. She subsequently underwent
additional debridement on [**2139-10-28**], [**2139-11-2**], [**2139-11-5**] and
[**2139-11-9**]. At that point, it was apparent that foot salvage
was not possible and because of the extensive loss of
subcutaneous tissue, below knee amputation was not possible.
The patient underwent above knee amputation on [**11-11**] and her
postoperative course continued to be complicated by sepsis,
congestive heart failure and pneumonia and the subsequently
expired on [**2139-11-21**].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Last Name (NamePattern4) 27015**]
MEDQUIST36
D: [**2140-3-31**] 16:01
T: [**2140-4-1**] 08:14
JOB#: [**Job Number 27016**]
ICD9 Codes: 0389, 2765, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2657
} | Medical Text: Admission Date: [**2144-8-17**] Discharge Date: [**2144-8-21**]
Date of Birth: [**2065-9-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Chief Complaint: abdominal pain, nausea
Major Surgical or Invasive Procedure:
ERCP [**2144-8-17**] with sphincterotomy and stent placement
History of Present Illness:
This is a 78 year old woman with PMH of HTN, asthma, pemphigus
vulgaris, and sarcoidosis, who was transferred from [**Hospital1 3325**] with evident cholangitis after calling an ambulance and
presenting with complaints of feeling poorly since the prior day
only, with abdominal pain, nausea, and some vomiting during that
time.
At [**Hospital3 3583**], RUQ U/S showed gallstones and dilated CBD,
as well as the following labs: AST: 165, ALT: 114, AP: 149,
Total Bili: 5.2, and WBC: 27.6. With suspicion for cholangitis,
she was given Zosyn and Zofran, and transferred to [**Hospital1 18**] for
further management.
.
In the ED, initial vs were: T100.3, P 118, BP 112/57, R 18, O2
sat 98%. She was given 1 L NS, zosyn X 1 and zofran. Her labs
were notable for leukocytosis of 32.5, AST: 147, ALT: 112, AP:
161, TBili: 5.1, Albumin: 3.7. Right upper quadrant U/S showed
gallstones and a dilated common bile duct. Surgery saw pt in
the ED and recommended ERCP, with which the ERCP team agreed,
and she was sent to the [**Hospital Unit Name 153**] in anticipation of an ERCP
procedure.
.
On the floor, she was seen briefly before procedure and was
cheerful and conversant and in no apparent distress. She went
quickly to procedure where a biliary stent was placed with good
drainage; sphincterotomy was performed; CBD had been dilated to
8mm. On her return she continued to report that she was feeling
well without abdominal pain, subjective fever, breathing
difficulty, or nausea.
Past Medical History:
Past Medical History:
HTN
asthma
bullous pemphigoid
sarcoidosis
osteoporosis
.
Past Surgical History:
Right TKR [**5-5**]
Social History:
Social History: lives with husband; non-smoker
Family History:
No significant history
Physical Exam:
Physical Exam:
Vitals: (on return from procedure) T: 99.4 BP: 104/51 P: 97 R:
17 18 O2: 97%3L
General: Alert, oriented, no acute distress; observed sleeping
prior to exam and pt noted to snore audibly
HEENT: icteric sclera, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, intact air movement
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, slight distension, bowel sounds
present, no guarding and no tap tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: 1 2cm bulla on medial side of 3rd toe on R foot; no other
rashes or bullae in limited exam, no sarcoid nodules appreciated
Pertinent Results:
[**2144-8-17**] 05:47PM LACTATE-2.1*
[**2144-8-17**] 05:45PM GLUCOSE-107* UREA N-13 CREAT-1.2* SODIUM-136
POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-20* ANION GAP-18
[**2144-8-17**] 05:45PM ALT(SGPT)-112* AST(SGOT)-147* CK(CPK)-180*
ALK PHOS-161* TOT BILI-5.1*
[**2144-8-17**] 05:45PM LIPASE-212*
[**2144-8-17**] 05:45PM cTropnT-0.02*
[**2144-8-17**] 05:45PM CK-MB-5
[**2144-8-17**] 05:45PM ALBUMIN-3.7 CALCIUM-8.3* PHOSPHATE-3.0
MAGNESIUM-1.8
[**2144-8-17**] 05:45PM WBC-32.5* RBC-4.32 HGB-13.2 HCT-37.4 MCV-87
MCH-30.5 MCHC-35.2* RDW-13.7
[**2144-8-17**] 05:45PM NEUTS-82* BANDS-14* LYMPHS-1* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2144-8-17**] 05:45PM PLT SMR-NORMAL PLT COUNT-175
[**2144-8-17**] 05:45PM PT-15.0* PTT-31.2 INR(PT)-1.3*
[**2144-8-17**] 05:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-NEG PH-7.0 LEUK-NEG
[**2144-8-17**] 05:45PM URINE RBC-[**10-16**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2144-8-17**] 05:45PM URINE GRANULAR-0-2
[**2144-8-17**] 05:45PM URINE AMORPH-FEW
RUQ U/S:
FINDINGS: There is no evidence of focal lesions in the liver.
The
gallbladder appears normal. There is no evidence of wall edema
in the
gallbladder. There are multiple mobile gallstones. The CBD
measures 7 mm in
maximum diameter. There is no intrahepatic biliary duct
dilatation. In the
visualized portion of the right kidney, there is a simple cyst
measuring 2.6
cm. Main portal vein is patent.
IMPRESSION: Cholelithiasis without signs of cholecystitis
.
ERCP:
ERCP: Images demonstrate cannulation of the common bile duct
with a large
stone in the distal CBD and post-obstructive dilatation. A
plastic biliary
stent was placed. Please refer to the operative note for further
details.
IMPRESSION: Distal CBD stone.
.
Blooc Culture:
[**2144-8-17**] 5:45 pm BLOOD CULTURE #1.
**FINAL REPORT [**2144-8-21**]**
Blood Culture, Routine (Final [**2144-8-21**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
ESCHERICHIA COLI. 2ND MORPHOLOGY. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ESCHERICHIA COLI
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ <=1 S 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final [**2144-8-18**]):
GRAM NEGATIVE ROD(S).
Brief Hospital Course:
Hospital Course:
.
# Cholangitis: Patient underwent urgent ERCP from the MICU with
distal CBD stone identified. Sphincterotomy was performed with
successful stent placement. She tolerated the procedure well
with improvement in her LFTs and abdominal pain. Surgery was
consulted and recommended laparoscopic cholecystectomy in the
next 4-6 weeks. Follow up was arranged. However, 1 day after
admission, her blood culture returned positive for GNR.
Cefepime was started empirically. Her blood cultures cleared
and the GNRs returned as E. coli and Klebsiella sensitive to
Cipro. She was started on cipro and tolerated well. She will
require follow up ERCP in [**5-4**] weeks, and to complete 14 days of
ciprofloxacin 500mg q12.
.
# Sarcoidosis: Outpatient follow up
.
# Asthma: Home Advair was continued.
.
# Hypertension: Restarted Diltiazem at 120mg daily to be
uptitrated by the PCP at their discretion.
.
# Pemphigus Vulgaris: Stable during this hospitalization
.
# Osteoporosis: Continued Evista, calcium, vitamin D
.
Code: DNR/DNI
Medications on Admission:
Medications:
- advair 500
- evista 60mg
- diltiazem 420?
- iron 65 mg
- ecotrin 81mg
- folic acid 800mg
- fish oil 1200mg
- tylenol PM
- aleve
- MVI
- calcium and vitamin D
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
3. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain,fever.
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days: through [**2144-8-31**].
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Choledocholithiasis
Bacteremia, gram negative rod
Asthma
Sarcoidosis
Osteoporosis
Discharge Condition:
Good, afebrile, hemodynamically stable
Discharge Instructions:
You were admitted with infection of the biliary system with
obstruction due to gallstones. You underwent an intervention
called "ERCP" which cleaned out the stone and the associated
infection (cholangitis). Also, your blood grew bacteria
(E.coli, Klebsiella) for which we're treating with 14 days of
antibiotics. Because a stent was placed in your bile duct, you
will need to return in [**5-4**] weeks to have this re-assessed (see
below). Moreover, because this was caused by gallstones, you
will need to have your gallbladder removed to prevent further
episodes. You have an appointment arranged with our surgeon to
discuss this further.
.
Please resume all home medications and take all medications as
prescribed and keep all follow up appointments. Return to the
hospital with fevers/chills, abdominal pain, yellowing of skin,
or any concerning symptoms.
Followup Instructions:
Appointment #1
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23388**]
Specialty: Family Practice / PCP
Date and time: Wednesday, [**8-26**], 3pm
Location: [**Last Name (un) **], [**Location (un) 22287**] (building 9, [**Apartment Address(1) **])
Phone number: [**Telephone/Fax (1) 23387**]
Appointment #2
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Surgery
Date and time: Wednesday, [**9-2**], 3pm
Location: [**Hospital Ward Name 516**], [**Location (un) 8661**] building, [**Location (un) 470**], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 2998**]
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2799**], next week to schedule
your repeat endoscopy in [**5-4**] weeks.
ICD9 Codes: 7907, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2658
} | Medical Text: Admission Date: [**2155-10-21**] Discharge Date: [**2155-10-30**]
Date of Birth: [**2138-5-28**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
s/p pedestrian struck
Major Surgical or Invasive Procedure:
[**2155-10-22**]: ORIF R proximal tibia fx
[**2155-10-22**]: I&D ex-fix and cement spacer L open distal tibia
History of Present Illness:
Ms. [**Known lastname 80053**] is a 17 year old female who was a pedestrian struck
by a car traveling approximately 45-50mph. She was taken to the
[**Hospital1 18**] for further evaluation.
Past Medical History:
Denies
Social History:
Lives with parents
High School Student
Family History:
n/a
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: C-collar in place. LLE +3-4 cm open wound above
ankle. RLE 1cm pokehole. +pulses, SILT Bilateral feet.
Pertinent Results:
[**2155-10-29**] 04:28PM BLOOD Hct-30.6*
[**2155-10-27**] 06:19AM BLOOD WBC-7.0 RBC-3.30* Hgb-10.1* Hct-28.0*
MCV-85 MCH-30.7 MCHC-36.2* RDW-15.4 Plt Ct-239#
[**2155-10-27**] 06:19AM BLOOD Plt Ct-239#
[**2155-10-22**] 02:50PM BLOOD PT-13.9* PTT-34.9 INR(PT)-1.2*
[**2155-10-29**] 04:28PM BLOOD Glucose-116* UreaN-17 Creat-0.7 Na-137
K-4.8 Cl-101 HCO3-27 AnGap-14
[**2155-10-27**] 06:19AM BLOOD Glucose-117* UreaN-11 Creat-0.5 Na-139
K-4.0 Cl-105 HCO3-26 AnGap-12
[**2155-10-29**] 04:28PM BLOOD Calcium-9.0 Phos-4.2 Mg-1.8
[**2155-10-27**] 06:19AM BLOOD Calcium-8.7* Phos-4.0 Mg-2.0
[**2155-10-21**] 10:17PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Ms [**Known lastname 80053**] presented to the [**Hospital1 18**] on [**2155-10-21**] after being struck
by a car. She was evaluated by the orthopaedic and trauma
surgery services. She was found to have a right open proximal
tibia fracture, a left open distal tibia fracture, bilateral
inferior pubic rami fracture, a right sacral body fracture, a
small left pneumothorax, and bilateral pulmonary contusions.
She was admitted to the T/SICU for further monitoring, and later
that day she was taken to the operating room and underwent an
I&D with ORIF of her right proximal tibia fracture and an I&D
with external fixator placement and cement spacer of the left
open distal tibia fracture. She tolerated the procedures well,
was extubated transferred to the T/SICU for further monitoring.
Her cervical collar was cleared by trauma surgery. On [**2155-10-23**]
she was transferred from the T/SICU to the floor. On [**2155-10-24**]
she was transfused with 4 units of packed red blood cells due to
acute blood loss anemia. On [**2155-10-26**] she was transferred to the
care of the orthopaedic surgery service. The patient was being
followed by physical therapy for out of bed transfers. Physical
therapy recommended that the patient go to a rehab facility upon
discharge. The rest of her hospital stay was uneventful with her
lab data and vital signs within normal limits and her pain
controlled. She is being discharged today in stable condition.
The patient is to return to the orthopaedics clinic on [**11-6**], [**2154**] for evaluation of her injuries and her external
fixation device. On that clinic visit it will be determined what
type of surgical intervention will be necessary as well as the
potential date of the surgery. The patient will likely return to
[**Hospital 1319**] Rehab for ongoing care s/p surgery.
Medications on Admission:
denies
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p pedestrian struck
Right open proximal tibia fracture
Left open distal tibia fracture
Bilateral inferior pubic rami fracture
Right sacral body fracture
Left pneumothorax
Bilateral Pulmonary contusions
Acute blood loss anemia
Discharge Condition:
Stable
Discharge Instructions:
Continue to be non-weight bearing on both your legs
Please take all medications as prescribed
If you have any increased redness, drainage, or swelling, or if
you have a temperature greater than 101.5, please call the
office or come to the emergency department.
Physical Therapy:
Activity: As tolerated, out of bed daily
Right lower extremity: Non weight bearing
Left lower extremity: Non weight bearing
Treatments Frequency:
Pin care daily to external fixator with 1/2 strength hydrogen
peroxide and normal saline
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2155-11-6**] 8:00
Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2155-11-6**] 8:20
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2659
} | Medical Text: Admission Date: [**2190-10-30**] Discharge Date: [**2190-11-23**]
Date of Birth: [**2120-11-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
Invasive ventilation
History of Present Illness:
69 y/o male with CAD s/p CABG, atrial fibrillation s/p BIV pacer
and on warfarin, CHF (EF >55% in [**2188**]), DM type 2, p/w acute
onset of right flank pain this morning. Pain intermittently
radiates to groin. Reports increased abdominal pressure and
weight gain of eight lbs in recent weeks, and also endorses
headache and dyspnea on exertion (cannot climb single flight of
stairs without having to stop). Denies trauma, hematuria,
dysuria, dark stools, constipation, chest pain, palpitations,
fevers or chills. Reports history of kidney stone many years
ago.
.
In the ED, initial vs were: T98.6 60 150/61 18 94% RA. Abdominal
CT revealed markedly abnormal R kidney with evidence of
renal/perirenal hemorrhage. Patient was seen by Urology, who
recommended medical admission for reversal of INR, pain control,
and serial Hct checks and repeat CT in two days. Patient was
given morphine & dilaudid with good analgesic effect.
.
On the floor, patient appears comfortable, but requesting
further pain medications
Past Medical History:
- Hypertension
- Hyperlipidemia
- Systolic heart failure, history of low EF with improvement on
TTE [**12/2188**] (LVEF>55%)
- Hx of inducible VT, s/p upgrade to a BiV ICD [**2186**]
- CAD s/p CABG [**2163**]; s/p DES to LAD in [**2186**]; history of MI
- Atrial fibrillation/flutter
- Diabetes mellitus, diagnosed 7 years ago, HgA1c 8.5% in [**August 2190**]
- OSA on CPAP with 3 liters O2
- ? Reactive airway disease
- Chronic renal insufficiency, stage 3 disease, baseline Cr ~2.8
- history of Strep bovis bacteremia c/b acute renal failure [**2188**]
- Hypothyroidism
- Bronchitis
- s/p resection of benign colon polyps
-s/p cholecystectomy
- Gout
- GERD
Social History:
Patient is retired previously worked as a manager in a paint
factory. Remote 40 pack-year tobacco history. No EtOH use, no
illicit drug use. Lives with wife at home
Family History:
Brother also with CABG at age 60 doing well. Mother died during
childbirth, father died of cirrhosis that pt thinks was alcohol
related.
Physical Exam:
Vitals: T:97.3 BP:132/80 P:81 R:20 O2:95 on 2L FSG: 284
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no conjunctival
pallor or injection
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, + wheezes with forced
expiration, no crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Scattered erythematous spots at sites of insulin
administration. Tense, obese abdomen, distended, bowel sounds
present, tender to deep palpation on RLQ and R flank, abdominal
exam limited by habitus, no shifting dullness or fluid wave
appreciable, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes or ulcers
Neuro: CNII-XII intact, no focal abnormalities
Motor: 5/5 strength in UE and LE
Sensation: intact bilaterally in LE and UE
DTR: 2+ bilaterally
Coordination: [**Doctor First Name **] intact
Gait: not assessed
Pertinent Results:
On admission:
[**2190-10-30**] 09:45AM BLOOD WBC-13.7*# RBC-4.49* Hgb-12.8* Hct-38.6*
MCV-86 MCH-28.6 MCHC-33.2 RDW-16.8* Plt Ct-175
[**2190-10-30**] 09:45AM BLOOD Neuts-86.1* Lymphs-7.9* Monos-4.3 Eos-1.1
Baso-0.6
[**2190-10-30**] 09:45AM BLOOD PT-25.7* PTT-27.1 INR(PT)-2.5*
[**2190-10-30**] 09:45AM BLOOD Glucose-215* UreaN-38* Creat-2.8* Na-146*
K-4.5 Cl-111* HCO3-24 AnGap-16
[**2190-10-30**] 09:45AM BLOOD ALT-14 AST-17 AlkPhos-115 Amylase-66
TotBili-0.3
[**2190-10-30**] 09:45AM BLOOD Lipase-33
CT: CT ABDOMEN WITHOUT IV CONTRAST: The patient is status post
median sternotomy with right atrial and left ventricular pacing
leads as well as right ventricular AICD lead; these are
incompletely visualized on the current study. There are new
moderate right and tiny left pleural effusions with adjacent
relaxation atelectasis. No nodules seen in the visualized lung
bases.
Assessment of the solid organs is limited due to lack of IV
contrast
administration. The non-enhanced liver demonstrates a tiny 5-mm
hypodensity along the left dome of the liver (2:10), too small
to accurately characterize. No gallbladder is seen probably due
to prior surgical removal. The nonenhancing spleen, pancreas,
adrenal glands, left kidney, and the non-opacified stomach and
small bowel appear unremarkable. Again note is made of extensive
colonic diverticulosis, without evidence of diverticulitis.
There is very abnormal appearance to the right kidney which is
expanded and demonstrates heterogeneous appearance with multiple
densities. Areas of high density likely represent subcapsular
and intraparenchymal acute hemorrhage. It is difficult to
discern the kidney margin, however, note is made that previously
seen indeterminate 12 mm lesion which is partially exophytic
arising from the upper pole of the right kidney currently
measures approximately 22 mm (300B:47) and is separate from the
current hemorrhagic process. There is also extracapsular
extension of the hemorrhage from the lower pole of the right
kidney into the perinephric space which is expanded and causes
mass effect on the adjacent IVC and duodenum. No nephrolithiasis
and no definite hydronephrosis is noted.
The abdominal aorta contains mural calcifications as well as
mural
calcifications along the origin of the major abdominal arteries,
without
aneurysmal dilatation. No lymph node enlargement is seen meeting
size
criteria for adenopathy.
CT PELVIS WITHOUT IV CONTRAST: The urinary bladder, prostate,
seminal
vesicles, and rectum appear unremarkable on this non-enhanced
study. There is sigmoid diverticulosis, without evidence of
diverticulitis. There are
bilateral fat-containing inguinal hernias. No pelvic fluid, free
air, or
adenopathy is noted.
OSSEOUS STRUCTURES: Degenerative changes are noted along the
visualized
thoracolumbar spine, particularly noted at the L2-3 and L5-S1
levels which
causes some narrowing of the spinal canal. No region of bony
destruction is seen concerning for malignancy. Degenerative
changes are also noted at the sacroiliac joints and the hips.
IMPRESSIONS:
1. Markedly abnormal right kidney, with likely subcapsular and
intraparenchymal acute hemorrhage. There is marked heterogeneous
appearance to the kidney, making delineation of the parenchyma
difficult. There is also extracapsular extension of hemorrhage
from the lower pole. No stone or hydronephrosis seen. Etiology
indeterminate; possibilities include trauma, underlying mass
(not previously seen in [**2188**]), or AV malformation. If cardiac
pacer is MRI compatible and patient's GFR allows administration
of IV gadolinium, MRI may be helpful. Preexisting small upper
pole mass (cf. Impression #2 ) likely not involved in this acute
process.
2. Increased size of right upper pole nodule from 12 to now 22
mm since
[**2188-6-19**].
3. Moderate right pleural effusion.
Brief Hospital Course:
This is a 69yo man with history of CABG, atrial fibrillation
with pacer/defibrillator on coumadin, systolic CHF, and DMII who
p/w acute onset of R-sided flank pain on [**2190-10-30**] found to have
retroperitoneal hemorrhage possibly from renal cyst, transferred
to ICU on day of admission for hypoxia, hypotension, oliguric
acute renal failure with ATN requiring HD, and concern for ACS.
.
(#) Hypoxia. On day 1 of admission the patient triggered for an
episode of guaic positive emesis and hypoxia to the 80's. This
was thought to be post-tussive emesis with aspiration. He was
started on an 8 day course of azithryomycin, vancomycin, and
ceftriaxone to cover for community acquired pneumonia and
culture positive Klebsiella pneumonia. By the time he arrived to
the ICU his CXR also showed signs of volume overload. Following
which, his Hct was noted to drop and he required aggressive
volume and blood product resuccitation. For volume overload,
caused by aggressive IVF and blood procduct resucitation,
diuresis was attempted, but he developed an oliguric renal
failure in the setting of his hypotension and was unable to
produce sufficient UOP for diuresis. He was started on CVVH
given his hypotension which was complicated by numerous filter
clottings. Blood pressure improved and HD was initated. His
kidneys showed some recovery and aggressive diuresis was
undertaken. Volume status improved and he was extubated. He
was weaned to nasal canula. Given improvement in his
respiratory state he was called out to the floor where with
continued diuresis he was weaned off nasal canula to room air.
(#) POSSIBLE UGIB: Pt had episode of guaiaic positive emesis in
context of severe cough and post-tussive emesis. Shortly
afterwards, his GI secretions cleared. He was started on [**Hospital1 **]
ppi and required no further intervention.
.
(#) Retroperitoneal bleed: Pt initially presented with R flank
pain, CT scan noted right retroperitoneal bleed possibly from
renal cyst rupture. Coumadin was reversed with FFP, but given
worsening renal failure repeat CT was obtained which showed
enlarging of the hematoma. Hct also noted to drop a nadir of
20.2 (38.6 on admission) He was given aggressive volume and
blood product resucitation. He was given 3 units of RBCs,
8units FFP, and 1 units plasma. Following which his Hct
remained generally stable although lower than baeline thought to
be precipitated by overphlebotomization and poor hematopoesis in
the setting of pneumonia and renal failure.
.
(#) Acute renal failure on Chronic Kidney Injury: He has history
of chronic renal funciton with baselin creatinine likely in mid
2s, which was abruptly worsened in the setting of hypotension
and he developed oliguric ATN. He required hemodialysis
throughout his hospitalization. With conversion of ATN to
non-oliguric variety, HD was held to observe return of renal
function. Renal function was slowly improving at the time of
discharge.
.
(#) Myocardial Ischemia: On transfer to the ICU, ST changes were
noted on ECG which were considered to be artifact by the cards
fellow. MI was ruled out. He was continued on statin. ASA was
held given the acute bleed.
.
(#) Fever/Leukocytosis - He was noted to have a Klebsiella
pneumonia (pansensitive) treated with ceftriaxone and pan
sensitive Enterococcus UTI treated with Vancomycin. All blood
cultures were negative, although he was noted to have a pyogenic
skin/line infection at the site of central LIJ.
.
# CHF (h/o systolic dysfunction, though normalized on [**2188**]
echo): Pt reports history of mild edema and recent weight gain.
Known systolic dysfunction although LVEF in [**2188**] >55%. ECHO was
repeated given concern of change in heart failure in setting of
possible MI, which showed EF of 35%. Another repeat ECHO was
performed to showed improvement with EF 45-50%.
.
#Atrial fibrillation: Pt had history of inducible VT, s/p
upgrade to a BiV ICD [**2186**] (defibrillated 1x). During this
hospitalization he had several episodes of wide complex afib
(confimred by EP). HR control with home dose of amiodarone was
continued. Metoprolol was started and uptitrated to maintain HR
<100.
.
# DMII: Pt's insulin regimen was changed throughout the course
of his hospitalization several times to maintain BG between
100-200. [**First Name8 (NamePattern2) **] [**Location (un) 805**] of [**Last Name (un) **] folows his DM, as pt is on a
study drug for kidney disease
.
#HTN: After hypotension was addressed, pt's became hypertensive.
Metoprolol was uptitrated. He was also started on nitrate.
Home diovan was held given his changing renal function.
.
#Hypothyroidism: He was continued on levothyroxine sodium 125
mcg
.
#Gout: The patient was continued on home dose of alloprunol,
adjusted dose given changing renal fucntion.
.
=
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================================================================
Post discharge to do at rehab
Please draw Chem 7 and fax to Dr. [**Last Name (STitle) **] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]
([**Last Name (un) **]) Phone number ([**Telephone/Fax (1) 817**].
Please follow finger stick blood sugars and adjust insulin
accordingly
Medications on Admission:
folic acid 800mg 1 tab daily
simvastatin 40 mg bedtime
warfarin 5mg a day
aspirin 81mg 1 tab daily
diovan 320 mg 1 tab daily
metoprolol tartrate 50mg 2 tabs daily
calcitriol 25 mg 1 tab daily
allopurinol 100mg 1 tab daily
amiodarone 200 mg 1 tab daily
furosemide 20 mg three times a week
levoxyl 125 mg daily
insulin lantus 44 units am
humalog sliding scale at meals 7-13 units
insulin novalog 46 units bedtime
symlin pen 120/units before lunch and dinner
Discharge Medications:
1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
5. Outpatient Lab Work
Please check HCT and chem-10 three times per week m/w/f for the
next two weeks and fax results to [**Telephone/Fax (1) 8474**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
6. humalog 100U/ml sliding scale up to 20units premeals as
directed
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day: Please take in the morning.
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once 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. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO three
times a day: With meals.
15. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
16. Epoetin Alfa 3,000 unit/mL Solution Sig: 3000 (3000) Units
Injection QMOWEFR (Monday -Wednesday-Friday).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary:
retroperitoneal hemorrhage
Aspiration pneumonia
Acute renal failure
Acute tubular necrosis
Acute systolic heart failure
Secondary:
Chronic renal insufficiency
Atrial fibrillation
Congestive heart failure
Diabetes Type II
CABG
Discharge Condition:
Stable, Afebrile
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2190-10-30**] for sudden onset right
flank pain. A CT scan showed bleeding in the right kidney. You
developed a pneumonia and were treated with a course of
antibiotics. Your blood pressure was low resulting in kidney
injury that required temporary hemodialysis. There was a concern
that you may be having a heart attack although the blood tests
were negative for this.
Please continue your home medications with the following
changes:
1. CHANGE your dose of lasix to 20mg once a day
2. STOP taking valsartan (diovan)
3. STOP taking coumadin (Warfarin)
4. INCREASE metoprolol to 50mg three times per day
5. Decrease lantus to 40U every morning
6. Stop Symlin (discuss this with your primary care doctor)
Weight yourself each morning and if weight increases >3 pounds
contact MD.
You should have your blood drawn three times per week and the
results faxed to Dr. [**Last Name (STitle) **].
.
Please return to the emergency department for fever, chills,
shortness of breath, or worsening symptoms.
Followup Instructions:
Please have a potassium, Creatinine and BUN drawn three times
per week and faxed to Dr. [**Last Name (STitle) **].
.
1. [**First Name8 (NamePattern2) **] [**Location (un) 805**]
[**Hospital1 18**]-Division of Nephrology View Map
[**Last Name (NamePattern1) 439**], LMOB Suite #7
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 673**]
Thursday [**12-9**] 4:30PM
2. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location:CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **]
Address:[**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone:[**0-0-**]
Please follow up with Dr. [**Last Name (STitle) **] in [**1-29**] weeks
3. [**Doctor First Name **] Das
[**Hospital1 69**] View Map
[**Location (un) 830**], [**Hospital Ward Name 23**] [**Location (un) **]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 921**]
Please call to schedule a follow up appointment in 3 months. You
will need an order to get a CT scan done before this meeting -
please inform the secretary of this when you schedule an
appointment.
Completed by:[**2190-11-23**]
ICD9 Codes: 5070, 5845, 5789, 5990, 2851, 2449, 2749, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2660
} | Medical Text: Admission Date: [**2196-12-7**] Discharge Date: [**2196-12-14**]
Service: MEDICINE
Allergies:
Scopolamine
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
Right Foot Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 85yo F with a PMH significant for CAD, HTN,
hyperlipidemia s/p MI and CVA with residual right-sided weakness
who presents with right heel pain. Patient states that the pain
began 2 nights ago and awoke her from her sleep. She states that
she has had pain in that foot before but nothing like this. She
states that the pain bothered her at rest but was worse with
weight bearing. She states that it is a sharp pain. She denies
any trauma to the foot. She states that the foot is not sore to
the touch. She is not able to wiggle her toes at baseline [**1-29**]
CVA, however, she reports that he sensory funtion is intact. She
states that she has swelling on and off in her LE at baseline.
.
Pt initially presented to her PCP who referred her to the ED for
concern over her what seemed to be cold foot. In the ED, initial
vitals were T: 99.2 BP: 116/68 P: 95 RR: 16 O2: 100% RA. The
patient was evaluated by vascular surgery who did not feel that
this was a vascular issue. US of the RLE was negative for DVT
and x-rays of the foot were unrevealing. An EKG was performed
that showed flattened T waves in V4-6, cardiac enzymes were sent
and the patient was found to have a troponin leak and elevated
CK, .54 and 231 respectively. Patient denied any chest pain or
shortness of breath. While in the ED the patient was hypotensive
to 78/32 and was responsive to a 500cc bolus of NS. Patient
given ASA and started on heparin gtt. Transferred to [**Hospital Unit Name 153**] for
ROMI.
.
On arrival in [**Hospital Unit Name 153**], vitals T: 100.1 BP: 98/57 HR: 101 RR: 18
O2sat: 100% 2L. Patient complains solely of right heel pain.
.
ROS: + runny nose, occasional palpitations, swelling in legs,
occasional numbness and tingling in hands and toes
Past Medical History:
-CAD s/p inferior MI [**2186**], NSTEMI [**11-29**]; known 3VD ([**11-29**] cath)
-CVA with residual left hemiparesis '[**86**]
-HTN
-Hyperlipidemia
-Chronic gastritis
-Vasovagal episodes
-Questionable R CEA '[**86**]
-CHF:diastolic and systolic dysfunction (TTE in [**2195-11-27**]:
LVEF 20-25%, 1+AR/2+MR/2+TR, impaired diastolic)
Social History:
Lives with daughter [**Name (NI) 41890**] [**Location (un) 6409**]. Has 17 children.
Currently attends [**Last Name (un) 35689**] Adult Day Care Center.
Tobacco: denies
Alcohol: denies:
Illicit drug use: denies
Family History:
Denies any h/o CVA, MI. Does not know cause of parents' deaths.
Physical Exam:
VS: Temp: 100.1 BP: 98/57 HR: 101 RR: 18 O2sat: 100% 2L
GEN: pleasant, comfortable, NAD
HEENT: NC, AT, EOMI, anicteric, MMM, OP without lesions
NECK: no supraclavicular or cervical lymphadenopathy, JVD to
level of ears
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: soft, NT, ND, no masses or hepatosplenomegaly
EXT: mild, non-pitting edema bilat R>L, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **], dopplerable
pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 4/5 strength on right, [**4-30**] left.
No sensory deficits to light touch appreciated.
Pertinent Results:
[**2196-12-7**] 02:00PM BLOOD WBC-6.1 RBC-3.45* Hgb-10.2* Hct-31.3*
MCV-91 MCH-29.6 MCHC-32.7 RDW-14.6 Plt Ct-277
Neuts-70.4* Lymphs-20.6 Monos-6.5 Eos-1.7 Baso-0.8 Plt Ct-277
Glucose-93 UreaN-26* Creat-0.9 Na-141 K-3.2* Cl-101 HCO3-31
AnGap-12 Calcium-8.1* Phos-3.4 Mg-1.8
[**2196-12-7**] 02:00PM BLOOD CK(CPK)-231* CK-MB-7 cTropnT-0.33*
[**2196-12-7**] 07:50PM BLOOD CK(CPK)-218* cTropnT-0.51* CK-MB-6
[**2196-12-8**] 01:57AM BLOOD CK(CPK)-187* CK-MB-4 cTropnT-0.53*
proBNP-3235*
[**2196-12-8**] 05:20AM BLOOD CK(CPK)-179* CK-MB-4 cTropnT-0.56*
[**2196-12-8**] 11:52AM BLOOD CK(CPK)-180* CK-MB-3 cTropnT-0.58*
[**2196-12-8**] 09:52PM BLOOD CK(CPK)-158* CK-MB-3 cTropnT-0.63*
[**2196-12-7**] 02:05PM BLOOD Lactate-1.5
[**2196-12-8**] 10:25PM BLOOD O2 Sat-87
[**12-7**] CXR IMPRESSION: No radiographic evidence of pneumonia or
CHF. Persistent small bilateral pleural effusions. No change
from [**2196-1-11**].
UNILAT LOWER EXT VEINS RIGHT [**2196-12-7**] 2:38 PM
IMPRESSION: No deep vein thrombosis in the right lower
extremity.
ECHO:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is severe regional left ventricular systolic dysfunction
with akinesis of the basal and mid-inferolateral segments, and
near-akinesis of the mid-septum and distal LV segments/apex.
There is mild hypokinesis of the remaining segments (LVEF =
20-25%). No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. The tricuspid regurgitation jet is eccentric and may be
underestimated. There is moderate pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w multivessel CAD. Mild aortic regurgitation.
Moderate mitral regurgitation. Moderate-to-severe tricuspid
regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2195-12-2**],
left ventricle is now dilated. The other findings are similar.
Brief Hospital Course:
A/P: This is an 85yo F with a PMH significant for CAD, HTN,
hyperlipidemia s/p MI and CVA with residual right-sided weakness
who presented with right heel pain.
1. ROMI/Ischemia/CAD: The patient had a PMH with CAD s/p
inferior MI [**2186**], NSTEMI [**11-29**]; She has known three vessel
disease, with her last study in [**2192**]. She has declined
intervention or CABG ever since. It was felt that Trop and mild
CK elevation could be due to failure rather than ACS however she
also had new pseudonormalization of T waves in leads V4-V5 which
were concerning for ischemia and flipped R waves and loss of R
wave progression on repeat ekg. Given that the patient refused
further intervention she was medically managed with asa, statin,
beta-blocker and ACE-I. She remained asymptomatic and denied CP
or SOB throughout the hospitalization once transferred to the
floor.
.
2.CHF acute on chronic systolic failure--the patient had a
repeat echo performed during this admission (see results above).
Her lasix was transiently held upon leaving the [**Hospital Unit Name 153**] due to
hypotension. The patient had evidence of fluid overload upon
stopping the diuretics which were slowly added back at a lower
dose due to the patient's lower BP. This will need to be
titrated back up in the outpatient setting. The discharge dose
is lasix 40mg po bid. She did not require any K repletion on
this regimen so this will need to be re-evaluated as an
outpatient as well.
3. HTN: The patient was hypotensive to 80s on admission. All of
her BP meds were initially held and then titrated back during
her stay. The patient did not tolerate a high dose of
beta-blocker and was discharged on Toprol XL 25mg po daily. She
was discharged on the rest of her incoming meds besides lasix at
the previous dose and frequency.
Medications on Admission:
Lasix 80 mg qam, 40 mg qom
KCl liquid one tablespoon daily
Toprol-XL 100 mg daily
Lisinopril 10 mg daily
Imdur 30 mg daily
Lipitor 80 mg daily
Plavix 75 mg daily
Aspirin 325 mg daily
Pantoprazole 40 mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
7. Toprol XL 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*
8. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 35689**] Day Care
Discharge Diagnosis:
Hypotension
Non ST elevation Myocardial infarction
History of Coronary artery disease, native
Acute on chronic systolic heart failure
Plantar fasciitis
New diagnosis of peripheral vascular disease
History of Gastroesophageal reflux disease
History of Hyperlipidemia
Discharge Condition:
Stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Take the medicines as prescribed.
Keep your appointments
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3511**] Date/Time:[**2197-1-3**]
10:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2197-2-27**]
9:30
You will be discharged with home PT and OT.
ICD9 Codes: 4589, 4280, 4439, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2661
} | Medical Text: Admission Date: [**2146-4-12**] Discharge Date: [**2146-4-22**]
Date of Birth: [**2080-11-19**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Cephalosporins
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
transfered here for epicardial abscess management
Major Surgical or Invasive Procedure:
Intubated, R-SCV placed, A-line, Pacer Wire placed, PICC line
History of Present Illness:
65 y.o. M with steroid dependent COPD/asthma, recurrent
pulmonary infections due to MRSA/pseudomonas, s/p [**Hospital 39700**]
transferred from [**Hospital3 **] on [**2146-4-12**] with endocarditis
and complete heart black with temporary pacer with no escape
rhythm.
.
Patient was admitted to [**Hospital1 **] on [**4-9**] with presumed COPD
exacerbation and CHF. Overnight he became more tachypnic with
hypercarbic respiratory failure and was intubated in the morning
of [**4-10**]. He was also found to have [**3-23**] second paused and
responded to atropine. Patient was also hypotensive to 80s
during the episode and then recovered to SBP of 100s. Patient
was also found with with 3:4 Wenckebach rhythm varying with
Mobitz pattern rhythm, then PAF with tachyarrhythmia 1-teens,
with 4-5 second pauses. TEE was performed on [**4-10**]. He went into
patient was found to be in in complete heart block. Luckily, by
that point he had a single temporary V wire inserted through R
IJ on [**4-10**]. Since then patient with no escape rhythm.
.
Patient has severe undelrying COPD (FEV1 0.79) requiring chronic
high dose steroids. He was started on high dose solumedrol at
[**Hospital1 **]. Patient was also found to be bacteremic with MRSA [**3-22**]
BCx upon initial admission with less than 24 hours, started on
Vanco and Levo. Gentamycin was added the next day for synnergy.
Patient also with 4/23 GNR in his sputum. Patient was recently
treated for MRSA bacteremia and sepsis back in [**10-23**]. Presumed
source was IV thrombophlebitis. Patient was also found to have
lung septic embolic. Patient underwent 6 week course of Vanco IV
and 4 week of Linezolid (for presumed improved pulmonary
penetration). Repeat CT on [**1-/2146**] showed improvement of
pulmonary cavitations on chest CT.
.
Patient was transfered to [**Hospital1 18**] for further management. On the
morning of transfer patient with Hct from 33 to 27 with minimal
coffee ground emesis and guiac positive stools. Hct appears to
be stable @ 27 upon repeat.
ROS: upon arrival to CCU, patient is intubated, he stays he is
in mil pain. He denies any cp, sob. No fevers/chills.
Communication is limited due to intubation but he appears lucid.
Past Medical History:
# NO known CAD
# HTN
# COPD - FEV1 .79 ~ 29%, requiring persistent high dose steroids
and mulitiple admission to [**Hospital3 **]/[**Hospital1 1872**] Rehab. CO2
33 on [**4-9**] with pH of 7.39, CO2 63, pO2 74, HCO3 38, Sats 94%.
# Multiple cavitary lession- NOS - in lungs after MRSA skin
infection in [**2145-10-19**], appears to be improved [**1-/2146**]
# MRSA septicemia - [**10-23**] from IV line Tx with Vanco 6 weeks,
then Linezolid x 4 weeks with septic emboli to the lungs.
# Pseudomonas in sputum
# Cervical disk disease - C4-5 discectomy [**2142-9-18**]
- chornic management with moderate narcotics
# ? epidrual abscess or a large disk herniation - due to
complain of increased neck pain detected on MRI on [**12/2145**]
---- repeat CT on [**4-11**] showed no evidence of epidural mass
although a small epidural abscess may not be excluded if very
small and unable to be picked up by CT resolution
---- C3-C4 small posterior protrusion, also milD dorSal bulging
consistent with degenerative narrowing of C5-C6 narrowing of
left C6 foramen, same @ C6-C7.
# Chronic Hepatitis C -s/p succesful IFN therapy 8 years ago
# Chronic Anemia -
# Multiple surgeries including ventral hernia repair s/p bullet
wound in 20s.
# Chronic Anxiety and depression
# Nl renal function - Cr 0.7 upon admission to [**Hospital1 **] [**4-9**]
# Recurrent epistaxis - s/p septal repair - thus no
anticoagulation
Social History:
SHx: h/o tobacco, no etoh. No IVDU. Chronic narcotic use. Lives
alone. single.
.
Family History:
FHx: emphysema in mother, no other known CAD
Physical Exam:
Vitals: wt 61.5 97.1 HR 60 BP 102/60 RR 15 100%
Gen: awake, frail, elder gentleman, ETT, NAD
HEENT: anicteric, left inferio-medial conjuctival hemorrhage, MM
dry, R IJ cordis with pacer wire, no JVD appreciated on L side,
NECK: no adenopathy
CV: RRR, nl S1, S2, unable to appreciate murmur given increased
AP diameter of chest.
Chest: diffuse rales, no wheezes, no crackles, mechanical breath
sounds, barrel chested.
Abd: + BS - faint, snt/nd, no masses
Ext: no edema, no cyanosis, no clubbing
Skin: both hand (palms) and feet(soles) with Osler nodes and
[**Last Name (un) **] lesions.
Vasc: + 1 DP b/l
Pertinent Results:
Labs:
from OSH:
[**4-9**] BCx x 2 - total 6 cultures, each day + for MRSA
[**4-10**] Sputum: GNR, staph
[**4-12**]
146/4.4 109/32 45/0.8 Ca7.7 Alb 1.5 tProt 5.5 tBili 1.8 Dbili
0.8 AlkPhos 117 ALT 67 AST 85
WBC 16K 22% B [**4-9**] -> 22.2 -> 16.3 -> 13.7 @ [**Hospital1 18**]
Hct 33 -> 27.2 Plt 112
Trop [**4-9**] 0.52 -> 0.49 -> 0.71
BNP 756 [**4-9**]
.
Labs:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2146-4-21**] 05:04AM 17.1* 3.84* 10.8* 32.4* 84 28.1 33.4
19.1* 91
[**2146-4-12**] 12:30PM 13.7* 3.29* 8.6* 28.9* 88 26.2* 29.8*
16.3* 90
Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos
[**2146-4-12**] 12:30PM 95* 3 0 2 0 0 0 0 0
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2146-4-21**] 05:04AM 120* 23* 0.4* 136 3.7 100 32 8
.
HEMOLYSIS LABS:
Fibrino FDP D-Dimer
[**2146-4-20**] 03:17PM 40-80
[**2146-4-18**] 06:02AM 40-80
[**2146-4-18**] 06:02AM 132* 2753
.
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili
[**2146-4-20**] 03:17PM 438* 2.2
Hapto
[**2146-4-20**] 03:17PM 25
.
HEPATITIS:
HCV Ab
[**2146-4-19**] 05:09PM POSITIVE
[**2146-4-19**] 5:09 pm IMMUNOLOGY Source: Line-aline.
HCV VIRAL LOAD
>700,000 IU/ml.
.
MICRO:
[**4-20**] SPUTUM: *FINAL REPORT [**2146-4-22**]**
GRAM STAIN (Final [**2146-4-20**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2146-4-22**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
.
[**4-19**] SPUTUM: 5:09 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2146-4-19**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
STAPH AUREUS COAG +. MODERATE GROWTH.
.
[**4-12**] BCX:
[**2146-4-12**] 12:10 pm BLOOD CULTURE Random.
**FINAL REPORT [**2146-4-18**]**
AEROBIC BOTTLE (Final [**2146-4-17**]):
[**2146-4-15**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13478**] AT 7:00 AM.
PSEUDOMONAS AERUGINOSA.
.
[**Date range (1) 11757**] BCX: NO GROWTH
.
[**4-16**] BCX:[**2146-4-16**] 6:34 pm BLOOD CULTURE
**FINAL REPORT [**2146-4-22**]**
AEROBIC BOTTLE (Final [**2146-4-22**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2146-4-20**]):
STAPH AUREUS COAG +.
.
5/2BCX:
[**2146-4-19**] 5:22 pm BLOOD CULTURE
AEROBIC BOTTLE (Preliminary):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci
5/3BCX: Pending
.
[**4-13**]: TEE: Large mobile anterior leaflet mitral valve vegetation
with leaflet perforation and moderate-severe mitral
regurgitation. Echolucent space consistent with an abscess in
the interatrial septum posterior to the aortic root and color
flow consistent with fistulous connection into the right atrium.
Smaller mobile vegetation on the tricuspid valve.
.
[**4-13**]: CT head: Two small foci of increased density within the
right frontal lobe. The study is limited by the lack of a
non-contrast acquisition, however, these findings could
represent enhancing vessels versus small foci of extra-axial
hemorrhage or cortical enhancement.
.
[**4-13**]: CT neck: Multiple cavitating and noncavitating pulmonary
nodules at the right and left lung apices, and bilateral pleural
effusions. The findings are consistent with septic emboli. No
definite evidence of epidural abscess.
.
[**4-17**]: Chest CT:
IMPRESSION:
1. Numerous nodular opacities throughout the lungs, many of
which are cavitary consistent with septic emboli. The largest is
within the right middle lobe measuring 3.6 x 3.0 cm with an
air-fluid level.
2. Small bilateral pleural effusions.
3. Striated, hyperdense nephrograms bilaterally concerning for
renal failure.
.
[**4-17**] RUQ US:
FINDINGS: Multiple small 3-5 mm likely polyps are present within
the gallbladder. No stones are identified. The gallbladder wall
is mildly thickened measuring 5 mm. There is moderate ascites in
the right upper quadrant. No shadowing gallstones are
identified. The common bile duct is not clearly identified, and
thus is likely not dilated. The proximal pancreas is normal.
IMPRESSION: Edematous gallbladder wall likely secondary to third
spacing. No gallstones identified. Right upper quadrant ascites.
.
[**4-18**] CXR:
PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH:
The endotracheal tube is seen at the thoracic inlet. The carina
is not well visualized. There is no significant change in
positioning compared to prior study. Pacer wire is again noted
and unchanged. Right-sided PICC line tip is seen within the
distal SVC.
Again noted are multiple bilateral cavitary opacities (better
seen on recent CT), consistent with multifocal infection and
possible septic emboli that are unchanged compared to prior.
Brief Hospital Course:
A/P: 65 y.o. M with severe steroid dependent COPD, recent MRSA
cellulitis in [**10-23**] with pulmonary septal emboli/cavitations,
myocardial abscess, MV vegetation, [**Last Name (un) 1003**] lessions and MRSA
bacteremia, intubated for increasing tachypnea and hypoxia.
.
# Valves/Mitral Valve: MRSA bacterial endocarditis
w/paravalvular abscess, vegetations - seen on TEE with
myocardial abscess. Pt had evidence of septal emboli in
conjuctivae, fingertip, lungs, spleen, spine, and 2 foci in
brain. Pt did not have any neurological deficits and no signs of
hemorrhage in brain. He was closely followed by ID. He was
started on Vanc and completed 5 days of Gentamycin for Abx
synergy. His blood cultures cleared from [**4-13**] as well as
remained afebrile. His blood cultures were followed daily, his
WBC fluctuated without any specific pattern but remained
elevated. CT [**Doctor First Name **] was following pt for possible surgery but the
following concerns for sugery included; 1. inability to suspend
new valve, 2. persistent bacteremia 3. lack of CHF or urgency
for surgery 4. septic emboli 5. poor PFTs 6. GIB. Per the
Brother, if surgery was a possibility then to proceed with
surgery. However, per the pt he did not want any heroic
measures. There was a tentative plan for OR on [**5-2**], awaiting
for Brain foci to mature, improve his nutrition as his albumin
was 1.5. Multiple discussions were had with CT surgery, Dr.
[**Last Name (STitle) **], Dr. [**Last Name (STitle) 66985**] regarding surgical intervention. On [**4-21**]
there was a discussion with the pt whom did not want to proceed
with surgery, and did not want to be intubated. The pt
understood completely that without the surgery he would die. The
pt was adamant that he did not want to proceed with the surgery
nor remain intubated. The pt was lucid and it was agreed upon
with the brother and medical team to proceed with extubation.
The pt expired the following morning on [**4-22**] at 6am.
.
.
# Rhythm/Complete Heart Block - Patient with complete heart
block; initial presentation was with tachy/brady arrythmias,
pacer wire placed for severe bradycardia w/ intermittent
block-->eventual CHB. Wire place [**4-10**]. Transition from EMS pacer
to CCU pacer showed evidence of CHB w/o escape rhythm.
- paced @ 60, no issues, per ID will leave temporary wire in
- EP: s/p screwed in R V - VVI wire with external RSCL pacer -
[**4-13**]. On day of extubation the pt had many episodes of pacer
not capturing in setting of respiratory distress.
.
# Pump - patient with no h/o CHF, per prelim echo appears to
have nl EF with +1MR, echo here showed + 3 MR. Pt did not have
any evidence of fluid overload. Captopril 6.25 TID to help with
MR, however it was held on several occasions for hypotension.
.
# CAD - patient with + troponins, flat CKs and no ischemic EKG
changes@ OSH, peak CK 24, peak Trop .71, most likely due to
myocardial abscess and associated myocardial necrosis. No ASA
was given in the setting of GIB and possible surgery. He was not
on Lipitor, BB, and Ace as no prior known disease.
.
# Respiratory failure - most likely due to severe underlying
COPD, ?flair. Currently intubated due to respiratory distress
(tachypneic to 40, shallow breathing, tiring out): hypercarbic
respiratory failure (per ABG). Pt was kept intubated for
>10days. Pulmonary was consulted in setting of possible
extubation. He was maintained on steroids and weaned to 10mg
Prednisone daily. He was also found to have pseudomonas in his
sputum and treated w/10days of Aztreonam. He continued to show
psuedomonas in his sputum cultures following Aztreonam
treatment. However, pt requested to be extubated. On [**4-21**] post
extubation, pt eventually had respiratory distress, his O2 sats
dropped to 70s and expired early morning on [**2146-4-22**].
.
# MRSA bacteremia - primary bacteremia vs secondary bacteremia
from pulmonary cavitation vs ? epidural abscess. Pt was
continued on Vanco with 6 days of Gent synergy. Daily
surveillance cultures were followed, as well as fever curve and
WBC. Endocarditis as mentioned above. On [**4-19**] started to have
fevers, his A line was resited, his PICC was kept in place as
difficulty with access and possible interference with pacer
wires. Plan for PICC line removal when BCX returned as started
to have new + blood cultures from [**4-19**]. However, pt shortly
expired post extubation on [**2146-4-22**] in am.
.
# ? epidural abscess - patient evaluated by IR @ [**Hospital1 **], it may
be one of the sources for recurrent septicemia. Percutaneous C&S
of pre-vertebral Abnormality @ C5 was enteretained. However,
patient is very high risk and there is no neurological
involvement. Also, previous MRI w/o evidence of abscess, CT of
cervical vertebrae could not exclude a small epidural abscess.
repeat CT [**4-13**] showed no clear evidence in C3-4, but ? of
abscess in L4 region. As there was no neurological deficits and
given his more pressing MV endocarditis no further w/u for spine
done. Continued IV Vanco.
.
# Anemia - patient with admission Hct of 33, this AM with a drop
to 27.2 of almost 6 points. Hct here of 28.9. NGT with minimal
coffee grounds initially that resolved. He had a few episodes of
BRBPR as well as ~200cc blood from ETT. He received 2 UPRBC as
well as a bag of platelets. Stool were grossly positive for
ocult blood. GI was consulted and advised to stop ASA, protonix
IV BID. He was ruled out for a retroperitoneal bleed with CT on
[**4-14**]. His HCT was followed closely. Hemolysis labs were checked
and showed a mild DIC picture, but no schistocytes, stable PLTs.
Heme was consulted for persisten Thrombocytopenia. Most likely
etiology was poor synthetic function rather than DIC picture or
loss. Heme recommended supportive care as needed with clotting
factors in setting of bleeding. Pt remained HD stable and did
not require further transfusions beyond [**4-15**].
.
# Hypernatremia - patient appears dehydrated with free water
deficit of 2.4L
- give 1/2 NS x 2L over next 24 hours
- high BUN with high bicarb suggest contraction alkalosis as
well vs. baseline given severe COPD. His hypernatremia
resolved.
.
# Elevated INR - [**1-20**] to old HepC, vs malnutrition (alb 1.2) vs.
current levo, vs infiltrative/embolic liver disease, vs recently
started statin
- d/c statin, continue to follow, reverse if needed for
procedures with FFP, IVF
- vitamin k 10mg x1 on [**4-12**] - improving INR
- nutrition consult
.
# HCP - [**Name (NI) **] [**Name (NI) 66986**]: [**Telephone/Fax (1) 66987**]
.
# DNR
Medications on Admission:
Prednisone 10 mg QD
Albuterol nebs [**Hospital1 **]
Spririva 18 mcg QD
Fentanyl 50 mcg q72
Ativan 0.5 mg PO BID
KCl 20 mg QD
Advair 500/50 1 puff [**Hospital1 **]
Ranitidine 150 mg QD
Percocet 3/325 1 tab po TID
Vitamin D 50,000 po Qwk
.
from [**Hospital1 **]:
Methylpred 40 mg IV q8
Vanco 1 gm q12
Levquin 500 mg IV qd
Gentamicin 60 mg IV q8
Lipitor 80 QD
Fentanyl patch 50 mcg every 72 hrs
Protonix 40 IV QD
ECASA 325
NTP 0.5
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2146-4-23**]
ICD9 Codes: 2875, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2662
} | Medical Text: Admission Date: [**2150-7-10**] Discharge Date: [**2150-7-22**]
Date of Birth: [**2067-2-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Demerol / Warfarin
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
lower leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo f w/ a hx/of htn, OA and myelodysplastic syndrome who
presents with c/o severe right leg and knee pain since tuesday.
Pt was seen by rheumatlogy and was started on prednisode taper
and increased oxycodone frequency with no effect pt unable to
ambulate 2nd pain. Initially right foot pain sevearl weeks ago
with great two swelling; evaluated for gout and had uric acid on
[**6-11**] was 3.2. Seen by pcp who [**Name9 (PRE) 30692**] tramadol then pt
improved but pain returned. Pt seen by rheumologist who started
on prednisone, which has been tapering prednisone and now down
to 10mg/daily (although pt did not take for last few days b/c of
pain and associated nausea). Although foot pain improveed, pain
continued to increase in the R knee and lower leg over the last
3 days ago. Pt unable to weight bear (at baseline pt is abulator
w/out a walker since hip replacement). Pt says pain is like an
ache. Finally pain was intolerable despite oxycodone and
tramadol and pt was brought by family to ED.
.
In the ED, initial vitals were 98.2 103 140/59 18 97%. Patient
given 2 of morphine, 2 zofran and 650 tylenol. US showed right
DVT. She was started on lovenox; she has a warfarin allergy.
Patient discussed with BMT attending and she had refused
treatment for MDS. He recommended admission to medicine.
.
On arrival to the floor pt VS were stable 98.8 128/62 108 18
96%. Pt was having pain in the leg and appeared very
uncomfortable but otherwise had no other complaints.
.
Review of sytems:
(+) Per HPI feels hot but denies fever, chills, night sweets.
Does acknowledge nausea no vomitting which is associated with
pain. Has some constipation w/pain meds she's been taking for
leg.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied vomiting, diarrhea, or
abdominal pain. No recent change in bowel or bladder habits, no
blood or melena. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Right colon adenoCA in [**Month (only) 205**]/[**2146**] s/p right colectomy in
[**Month (only) **]/[**2146**]
- Myelodysplastic syndrome
- Hypertension
- Osteopenia
- Multiple thyroid nodules followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 2177**]
- s/p TAH-BSO in [**2124**] d/t left ovarian cyst - a benign
cystadenoma
- s/p appendectomy
- s/p THR at [**Hospital3 **] Hosp [**Month (only) **]/[**2148**]
Social History:
She lives alone and is almost completely independent until
worsening of her pain two days ago. She has two daughters. She
endorses occasional ETOH, denies smoking.
ADLS: independent
IADLS: independent
Services at home: daughter helps with shopping
Assistive Device: none
Family History:
Brother who had leukemia and died at the age of 69. Two sisters
with breast cancer, diagnosed in their 80s. Brother with a
stroke, CAD, not premature. Mother with ?stomach cancer.
Physical Exam:
Physical Exam on Admission:
VS: 98.2 103 140/59 18 97%
GENERAL: Pt appears uncomfortable in bed. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No LAD. mucus membranes mildly dry
NECK: Supple, JVP not elevated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: +BS, soft, NTND, moderately obese abdomen. No HSM or
tenderness appreciated on exam. No abdominial bruits
appreciated.
EXTREMITIES: WWP, +2 pulses pedal and radial bilateral. R knee
appears moderately swollen. no erythema appreciated on R leg,
cord not palpated. R leg did not feel warmer than left. R Leg
held carefully by pt, painful to move.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Physical Exam on Discharge:
Pertinent Results:
LABS on day of Discharge:XXXX
.
.
[**2150-7-10**] 08:38AM BLOOD WBC-10.9 RBC-3.30* Hgb-9.9* Hct-28.9*
MCV-88 MCH-30.1 MCHC-34.3 RDW-16.5* Plt Ct-71*
[**2150-7-10**] 08:38AM BLOOD Neuts-56 Bands-6* Lymphs-18 Monos-7 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-0 Blasts-10*
[**2150-7-10**] 08:38AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2150-7-10**] 08:38AM BLOOD Plt Smr-VERY LOW Plt Ct-71*
[**2150-7-11**] 06:04AM BLOOD PT-14.4* PTT-38.5* INR(PT)-1.2*
[**2150-7-13**] 10:24AM BLOOD Fibrino-1030*
[**2150-7-10**] 08:38AM BLOOD ESR-26*
[**2150-7-10**] 08:38AM BLOOD Glucose-148* UreaN-13 Creat-0.7 Na-139
K-4.1 Cl-102 HCO3-27 AnGap-14
[**2150-7-13**] 03:18AM BLOOD ALT-16 AST-33 LD(LDH)-693* AlkPhos-241*
TotBili-0.7
[**2150-7-12**] 06:10AM BLOOD proBNP-1604*
[**2150-7-11**] 06:04AM BLOOD Calcium-8.4 Phos-1.9* Mg-2.1
[**2150-7-14**] 04:11AM BLOOD Albumin-2.6* Calcium-8.0* Phos-1.7*
Mg-2.4
[**2150-7-13**] 03:18AM BLOOD Hapto-470*
[**2150-7-10**] 08:38AM BLOOD CRP-225.3*
[**2150-7-12**] 09:20AM BLOOD Type-ART pO2-62* pCO2-32* pH-7.50*
calTCO2-26 Base XS-1
[**2150-7-12**] 09:20AM BLOOD Lactate-1.7
[**2150-7-12**] 09:20AM BLOOD O2 Sat-93
[**2150-7-12**] 09:20AM BLOOD freeCa-1.10*
[**2150-7-11**] 06:04AM BLOOD WBC-11.1* RBC-3.26* Hgb-9.5* Hct-28.6*
MCV-88 MCH-29.3 MCHC-33.3 RDW-16.4* Plt Ct-63*
[**2150-7-12**] 06:10AM BLOOD Neuts-37* Bands-22* Lymphs-24 Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* Blasts-11*
[**2150-7-11**] 04:08AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2150-7-11**] 04:08AM URINE Blood-TR Nitrite-NEG Protein-75
Glucose-NEG Ketone-50 Bilirub-SM Urobiln-4* pH-6.5 Leuks-NEG
[**2150-7-11**] 04:08AM URINE RBC-1 WBC-1 Bacteri-MOD Yeast-NONE
Epi-[**1-23**]
[**2150-7-11**] 04:08AM URINE CastGr-0-2
.
C diff negative x3
Blood cultures no growth to date
.
---------------
[**2150-7-10**] KNEE (AP, LAT & OBLIQUE) RIGHT X-Ray: There are no
signs of acute fractures or dislocations. There is no joint
effusion. No focal lytic or blastic lesions are present. No
significant degenerative changes are identified. Vascular
calcifications are seen within the medial soft tissues.
.
[**2150-7-10**] Bilateral lower extremity venous ultrasound:
Duplicated mid right superficial femoral vein, with DVT within
only one of these vessels. Otherwise unremarkable.
.
[**2150-7-10**] CXR (PA and Lat): Cardiomegaly is stable. Right lower
lobe atelectasis has almost resolved. Small left pleural
effusion with adjacent atelectasis has markedly improved. There
is no evident pneumothorax. There is S-shaped scoliosis. The
aorta is tortuous.
.
[**2150-7-12**] KUB: There is mild distention of multiple small bowel
loops that are air filled. There is some gas in the colon. There
are few air-fluid levels. Moderate-to-severe degenerative
changes are in the lumbar spine. There is a right hip
prosthesis.
.
[**2150-7-13**] CT Torso W/Contrast: 1. New multifocal airspace
opacities in the lungs, most severe in the right lower and
middle lobes, which may be infectious. However, a short interval
followup is suggested to assess for resolution.
2. Focal filling defect within a segmental branch of right upper
lobe,
suspicious for pulmonary embolism.
3. Left breast calcified nodule, which is unchanged from prior
study, and
mammographic correlation is again suggested.
4. Mild dilation of both small and large bowel loops, with
evidence of a
prior bowel resection. These findings could reflect an ileus.
5. Cholelithiasis, within a distended gallbladder. No
gallbladder wall
thickening or pericholecystic fluid.
.
[**2150-7-13**] TTE: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>65%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild pulmonary artery systolic hypertension.
.
[**2150-7-13**] CXR: Low lung volumes with bibasilar consolidations,
right more than left, could represent atelectasis, however,
superimposed infection/aspiration is not excluded.
.
[**2150-7-13**] CT Head W/Out Contrast: IMPRESSION: Normal
non-contrast CT of the head.
.
[**2150-7-14**] LUE U/S: Large hematoma which extends from the
antecubital space distally through most of the forearm. No
discrete fluid collection identified.
.
[**2150-7-14**] RUQ U/S: Cholelithiasis with no sign of cholecystitis.
.
[**2150-7-21**] TTE: The left atrium is mildly dilated. The estimated
right atrial pressure is 0-5 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve. 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. There is mild pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad. IMPRESSION: Normal
biventricular systolic function. No vegetations seen.
.
[**2150-7-21**] CXR (PA and Lat): Consolidation largely in the right
middle lobe has improved since [**7-15**] though not entirely
cleared. Small bilateral pleural effusions are unchanged. Mild
cardiomegaly is longstanding. Left PIC catheter tip ends just
before the junction with the right brachiocephalic vein.
Brief Hospital Course:
Pt is a 83 yo f w/ a hx/of htn, OA and myelodysplastic syndrome
who presents with c/o severe right leg and knee pain since
tuesday. Pain became intolerable despite oxycodone and tramadol
and pt was brought by family to ED.
.
In the ED, initial vitals were 98.2 103 140/59 18 97%. Patient
given 2 of morphine, 2 zofran and 650 tylenol. US showed right
LE DVT. She was found to have a RLE DVT and started on lovenox.
On [**7-12**], she was transferred to the MICU after nausea, vomiting,
respiratory distress and multifocal pneumonia. Had CTA of torso
that showed a chronic PE and multifocal pneumonia and CT abdomen
showed ileus. Febrile on admission to MICU, was tachycardic to
the 130's.
.
MICU [**Location (un) **] COURSE
# Hypoxia: The original thought by the floor team prior to
transfer was PE given that the patient was admitted for DVT.
She was sent for a CTA which showed what was read as chronic PE
and a multifocal PNA. She was started empirically by the floor
team on vancomycin, cefepime, and flagyl for the PNA. This on
top of her chronic pleural effusion are the likely reasons for
her hypoxia. The patient had an ECHO done on the 23rd that
showed EF of >65% and trace MR. We continued the abx for her
PNA, and for double coverage of pseudomonas, we started
tobramycin. None of her Cxs grew anything. The patient did not
require intubation while in the ICU. For the PE and h/o DVT,
the patient had originally started lovenox, however given her
MDS and the dropping platelet count, we had to stop the
anticoagulation. She is now currently speaking with palliative
care as she has had some difficulty deciding on whether she
would like an IVC filter (as she currently cannot be
anticoagulated).
.
# Sepsis: Patient with fever, tachycardia, tachypnea, hypoxia
consistent with SIRS and likely source her MF PNA. Currently
hemodynamically stable, however, so no shock. We continued his
antibiotics as above. As his C-diff was negative, we d'ced the
flagyl on the day of transfer. She remains on tobramycin, vanc,
and CFP. Tobramycin peak and trough were ordered for her next
dose on the floor as this was requested by pharmacy. We
monitored the patient's lactate which remained normal. We did
not have to put in a CVL as she did not require pressors.
.
# Abdominal Distension: ABd ct read shows ileus vs partial
obstruction. Patient may also be impacted given stool in rectum.
Out of concern of abdominal infx, we checked lfts and lipase
which were wnl. Only an alk phos was elevated. We dropped an
NGT which was putting out up to 1L over 12 hours at first. The
output drastically reduced over 3 days, and we also prescribed a
very aggressive bowel regimen with colace, senna, lactulose PR.
We did not have to manually disimpact her. On the day of
transfer, her NGT output slowed, and we were able to clamp it.
She started on sips and tolerated that well. We started
lactulose via NGT. -We also checked a C-diff and started flagyl
empirically, but d/c'ed it after the c-diff was negative
.
# Tachycardia: Sinus tachycardia in setting of fever, right knee
pain, and PE.
We have been treating fever with Tylenol PO/PR. We did a TTE
which showed no RV strain. Finally, she is still deciding on an
IVC filter as above for possible future PE.
.
# MDS: Has 11 blasts (highest to date) and 22 bands concerning
for progression of disease. Dr. [**Last Name (STitle) 410**] has been following, and
as per his recommendations, we have restarted her on procrit.
There is ongoing discussion currently regarding possible
treatment of her MDS. Dr. [**Last Name (STitle) 410**] is following, and has been
speaking with her regarding her IVC filter as well. ideally,
her counts will recover and there will be a possibility of
restarting anticoagulation for her clots. We have had to
transfuse her on the unit (transfusion threshold of Hct of 21)
and received platelets x 1 for a PICC line placement, but our
threshold is 20.
.
ON RETURN TO THE FLOOR:
Once fever came down, tachycardia improved. Pt had BM in the
MICU with help of enemas. NG tube was removed and diet advanced.
Stopped methylnatrexone. For multifocal pneumonia, pt was on
vancomycin, cefepime, and tobramycin (planning for 10 day
course); tobramycin d/c'ed on [**7-17**]. MICU team spoke with Dr.
[**Last Name (STitle) 410**] who wanted a permanent IVC filter placed instead of
anticoagulation due to her thrombocytopenia and risk of
bleeding. Pt declined. Lovenox was stopped, and Procrit was
started. Palliative care was consulted regarding her refusal of
IVC filter. After further discussion w/patient, pt decided that
she wanted to be made DNR/DNI. She is not receiving any
anticoagulation given low platelets. She was given platelets for
PICC line placement and has been receiving them regularly along
with pRBC as needed. Leg pain was significantly improved and pt
was advancing diet as tolerated. Pt continued to spike low grade
fevers in the evenings which were controlled with tylenol but no
infectious source could be identified; may be related to MDS. Pt
also had diarrhea after agressive treatment of her ileus but
this improved with time and pt was C diff negative x3. Echo
showed no vegetations and nl EF. Repeat CXR showed improving
consolidation. Repeat blood cultures were negative. and final
repeat C diff was negative. A follow-up CT of the abdomen and
pelvis was declined by the patient.
.
After several family meetings with the pt, family members, Dr
[**Name (NI) 410**] (pt's hematologist), the geriatric fellow, social work
and primary medicine team the patient and her family decided to
return home with hospice services.
.
Pt initially was full code however, after speaking with
palliative care and other healthcare providers, she stated that
she wanted to be made DNR/DNI. This change was made in her code
status during this admission.
.
Medications on Admission:
Prednisone 10mg
Amlodpine 5mg
Oxycodone 2.5mg Q4 prn (for leg pain)
Procrit weekly
Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. Zofran 8 mg Tablet Sig: 0.5 - 1 Tablet PO every eight (8)
hours as needed for nausea.
Disp:*8 Tablet(s)* Refills:*2*
3. Procrit Weekly
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Primary:
DVT
Fever
Chronic PE
.
Secondary:
Ileus
Multifocal pneumonia
Transfusion dependent Myelodysplastic Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for severe left leg pain in
the knee area. You were found to have and blood clot in the vein
in your leg. Because you had an allergy to coumadin, you were
treated with lovenox. You also experienced recurring fevers
while you where in the hospital. Unfortunately you developed
severe constipation, nausea and vomiting in addition to
pneumonia. You were transferred for a few days to the intensive
care unit. You received antibiotics and blood and platelet
transfusions. Your symptoms improved and you were transferred
back to the regular medicine floor. You had a bout of
significant diarrhea concerning for infection but infection
workup was negative. You symptoms improved, you completed your
antibiotics and you were able to be discharged from the hospital
to home with hospice services.
.
The following changes were made to your medications...
- Please START taking Tylenol and Zofran as needed for nausea.
- Please STOP taking prednisone and amlodipine
- Please CONTINUE taking Procrit.
Please be sure to take all medication as prescribed.
.
Please be sure to keep all follow-up appointments with your PCP,
[**Name10 (NameIs) **] hematologist (Dr. [**Last Name (STitle) 410**] and other health care providers.
.
Followup Instructions:
Please be sure to keep all follow-up appointments with your PCP,
[**Name10 (NameIs) **] hematologist (Dr. [**Last Name (STitle) 410**] and other health care providers.
.
Department: GERONTOLOGY
When: TUESDAY [**2150-7-28**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 0389, 5070, 5119, 4019, 2859, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2663
} | Medical Text: Admission Date: [**2194-6-9**] Discharge Date: [**2194-6-16**]
Date of Birth: [**2125-3-26**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Neosporin Scar Solution / Bacitracin
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior/posterior thoracolumbar fusion with instrumentation
History of Present Illness:
Ms. [**Known lastname 49985**] has a long history of back pain. She has
attempted conervative therapy and surgical therapy but has
developed a flat back syndrome. She is electing to proceed with
surgical correction.
Past Medical History:
PMHx:
hx of afib (currently in sinus rhythm)
TIA X 3, no neuro deficit
spinal stenosis
hx skin cancer
ankle fracture [**3-13**]
PSHx:
anterior portion of surgery yesterday [**2193-5-6**]
D&C
colonoscopy
ear lobe surgery
Social History:
Denies tobacco
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2194-6-14**] 05:20AM BLOOD WBC-7.9 RBC-3.38* Hgb-11.1* Hct-30.9*
MCV-92 MCH-32.7* MCHC-35.7* RDW-16.4* Plt Ct-147*
[**2194-6-13**] 05:10AM BLOOD WBC-8.4 RBC-2.77* Hgb-9.2* Hct-25.4*
MCV-92 MCH-33.4* MCHC-36.5* RDW-16.7* Plt Ct-143*
[**2194-6-12**] 12:51AM BLOOD WBC-7.5 RBC-3.27* Hgb-10.6* Hct-29.3*
MCV-90 MCH-32.5* MCHC-36.3* RDW-17.6* Plt Ct-105*
[**2194-6-11**] 04:00PM BLOOD WBC-6.1 RBC-3.21* Hgb-10.7* Hct-29.8*
MCV-93 MCH-33.3* MCHC-35.9* RDW-17.2* Plt Ct-134*
[**2194-6-10**] 05:20AM BLOOD WBC-7.2 RBC-2.63*# Hgb-9.3* Hct-25.9*
MCV-99*# MCH-35.3*# MCHC-35.8* RDW-12.9 Plt Ct-160
[**2194-6-13**] 05:10AM BLOOD Glucose-134* UreaN-16 Creat-0.9 Na-137
K-4.1 Cl-103 HCO3-27 AnGap-11
[**2194-6-12**] 12:51AM BLOOD Glucose-241* UreaN-21* Creat-0.8 Na-139
K-4.6 Cl-107 HCO3-24 AnGap-13
[**2194-6-10**] 05:20AM BLOOD Glucose-186* UreaN-23* Creat-1.0 Na-139
K-5.0 Cl-104 HCO3-28 AnGap-12
[**2194-6-13**] 05:10AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.6
Brief Hospital Course:
Ms. [**Known lastname 49985**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2194-6-9**] and taken to the Operating Room for L5-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 she returned to the operating room for a
scheduled T9-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the SICU in a
stable condition. Postoperative HCT was low and she was
transfused PRBCs with good effect. A bupivicaine epidural pain
catheter placed at the time of the posterior surgery remained in
place until postop day one. She was kept NPO until bowel
function returned then diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Foley was removed on POD#3 from the second procedure.
She was fitted with a TLSO brace. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
HCTZ
quinapril
simvastatin
escitalopram
metoprolol
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
2. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] of [**Location (un) 1821**]
Discharge Diagnosis:
Thoracic kyphosis
Post-op acute blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are out of bed. You may take it off while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: as tolerated
Thoracic lumbar spine: when OOB
Must have TLSO brace when out of bed.
Treatment Frequency:
Please continue to change the dressing daily.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2194-6-16**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2664
} | Medical Text: Admission Date: [**2114-7-26**] Discharge Date: [**2114-8-8**]
Date of Birth: [**2054-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
CC - worsening appetite, ascites, worsening renal function
Major Surgical or Invasive Procedure:
TIPS
Therapeutic paracentesis
Fluoroscopy guided [**Last Name (un) **]-duodenal tube placement
History of Present Illness:
HPI: 60 y/o male with chronic liver failure [**1-17**] to Hep C/EtOH
cirrhosis, diagnosed 3 years ago admitted on [**7-26**] for worsening
ascites, poor appetite, worsening renal function. Pt had no
history of SBP or had not required paracentesis due to efficacy
of diuretics. Pt was ruled out for SBP with a
diagnostic/therapeutic paracentesis on [**7-27**]. Pt received 2 units
of PRBCS on [**7-29**] for Hct drop to 22 but his HCT has remained
stable since. Pt had a NJ tube placed on [**7-26**] by for nutrition
that was was replaced on [**7-30**] with EGD. EGD at that time showed
retained food in the stomach and also erythema, congestion,
friability and petechiae consistent with severe portal
gastropathy. Varices at the middle third of the esophagus, lower
third of the esophagus and gastroesophageal junction were also
noted. Given these findings and refractory ascites and concern
for renal dysfunction with diuretic use, it was decided that pt
should undergo TIPS.
Past Medical History:
PMH -
1. Cirrhosis
2. Hep c, [**2107**]
3. Ascites - no SBP, no paracentesis
4. Varices, grade 2 - no UGIB
5. CRI (Cr 1.8 -> 2.1)
6. Cholilithiasis
PSH -
1. s/p appy 30 yrs ago
2. Inguinal hernia repair, [**2112**]
3. Adenoids
4. L ankle fracture, [**2095**]
Social History:
SH - Pt is married, lives with his wife. [**Name (NI) **] two sons, healthy.
H/o heavy EtOH use, quit [**2103**]. Prior h/o smoking, quit [**2088**].
Prior IVDA, quit [**2088**]'s. Marijuana in past.
Family History:
FH - Cirrhosis in father, mother, and brother [**1-17**] EtOH; no
cancer
Physical Exam:
PE:
Vitals: AF 98.1 104/50 90 20 97% on RA I/O 1185+505/775 (24 hr)
General: A&O x 3, cachectic, NAD
HEENT: NC/AT, EOMI, sclera anicteric, NJ tube in place, top set
of dentures, MMM, OP clear
Neck - supple
Chest - CTAB anteriorly
CV - RRR s1 s2 normal, no m/g/r
Abd - distended, not tense; mild tenderness to palpation on R
over paracentesis site w/ min surrounding ecchymosis; good BS;
reducible umbilical hernia, left inguingal hernia palpable-
mildly tender
Ext - no c/c/e, pulses 2+ b/l
Skin - multiple spider angiomas over chest, palmar erythema
Neuro - Pt AO x 3, CN II-XII grossly intact; motor and sensation
wnl; no asterixis
Pertinent Results:
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p TIPS + parecentesis on [**2114-8-1**].
REASON FOR THIS EXAMINATION:
eval for possible TIPS failure; need liver u/s WITH DOPPLER;
please mark spot for paracentesis
INDICATION: 60-year-old post TIPS on [**8-1**], now with
increasing ascites.
COMPARISON: [**2114-8-2**].
Ascites is again noted throughout the abdomen which does not
appear significantly changed compared to the study of one day
earlier. A spot was marked in the right lower quadrant for
paracentesis to be performed by the clinical team. Grayscale
images demonstrate a nodular shrunken appearing liver. The
gallbladder is unremarkable. Pulsed color Doppler images
demonstrate a patent TIPS catheter with wall-to-wall color flow.
Flow velocity in the proximal portion of the TIPS is 93 cm per
second.
IMPRESSION:
No significant change in the extent of large amount of ascites
throughout the abdomen. Patent TIPS with wall-to-wall color
flow.
[**2114-7-26**] 07:15PM BLOOD WBC-2.5* RBC-2.76* Hgb-10.0* Hct-28.3*
MCV-103* MCH-36.4* MCHC-35.5* RDW-15.1 Plt Ct-64*
[**2114-7-27**] 05:35AM BLOOD WBC-2.2* RBC-2.55* Hgb-9.4* Hct-25.9*
MCV-101* MCH-36.9* MCHC-36.3* RDW-15.1 Plt Ct-57*
[**2114-7-27**] 12:18PM BLOOD Hct-29.6*
[**2114-7-28**] 05:50AM BLOOD WBC-2.8* RBC-2.47* Hgb-8.9* Hct-25.4*
MCV-103* MCH-36.0* MCHC-35.0 RDW-15.3 Plt Ct-50*
[**2114-7-28**] 01:00PM BLOOD Hct-25.0*
[**2114-7-28**] 09:12PM BLOOD WBC-2.9* RBC-2.65* Hgb-9.5* Hct-27.5*
MCV-104* MCH-35.7* MCHC-34.5 RDW-15.0 Plt Ct-44*
[**2114-7-29**] 05:55AM BLOOD WBC-2.3* RBC-2.28* Hgb-8.3* Hct-22.6*
MCV-100* MCH-36.5* MCHC-36.7* RDW-14.8 Plt Ct-44*
[**2114-7-30**] 05:07AM BLOOD WBC-3.1* RBC-3.21*# Hgb-11.1*# Hct-30.6*#
MCV-95 MCH-34.6* MCHC-36.3* RDW-17.2* Plt Ct-52*
[**2114-7-31**] 01:16AM BLOOD Hct-32.8*
[**2114-7-31**] 05:15AM BLOOD WBC-5.1# RBC-3.14* Hgb-11.0* Hct-29.9*
MCV-95 MCH-34.9* MCHC-36.7* RDW-16.7* Plt Ct-48*
[**2114-8-1**] 01:02AM BLOOD Hct-28.5*
[**2114-8-1**] 04:55AM BLOOD WBC-4.3 RBC-3.12* Hgb-10.7* Hct-29.8*
MCV-95 MCH-34.2* MCHC-35.8* RDW-16.4* Plt Ct-45*
[**2114-8-1**] 07:57PM BLOOD WBC-6.5# RBC-3.23* Hgb-11.3* Hct-30.7*
MCV-95 MCH-35.0* MCHC-36.9* RDW-16.5* Plt Ct-54*
[**2114-8-2**] 01:10AM BLOOD Hct-31.6*
[**2114-8-2**] 04:15AM BLOOD WBC-6.1 RBC-3.29* Hgb-11.1* Hct-32.1*
MCV-98 MCH-33.8* MCHC-34.6 RDW-16.8* Plt Ct-51*
[**2114-8-2**] 05:00PM BLOOD Hct-30.1*
[**2114-8-3**] 06:15AM BLOOD WBC-3.2* RBC-3.15* Hgb-11.1* Hct-30.6*
MCV-97 MCH-35.3* MCHC-36.4* RDW-16.3* Plt Ct-51*
[**2114-8-4**] 06:00AM BLOOD WBC-3.3* RBC-3.09* Hgb-10.4* Hct-30.1*
MCV-98 MCH-33.7* MCHC-34.5 RDW-16.6* Plt Ct-40*
[**2114-8-5**] 05:50AM BLOOD WBC-2.1* RBC-2.64* Hgb-8.8* Hct-25.8*
MCV-98 MCH-33.5* MCHC-34.3 RDW-16.7* Plt Ct-48*
[**2114-8-5**] 03:12PM BLOOD Hct-27.1*
[**2114-8-6**] 05:32AM BLOOD WBC-2.4* RBC-2.91* Hgb-9.9* Hct-28.6*
MCV-99* MCH-34.0* MCHC-34.5 RDW-16.7* Plt Ct-59*
[**2114-8-7**] 06:10AM BLOOD WBC-2.3* RBC-2.64* Hgb-9.0* Hct-26.2*
MCV-99* MCH-34.2* MCHC-34.5 RDW-17.0* Plt Ct-48*
[**2114-8-7**] 05:31PM BLOOD WBC-3.4* RBC-2.79* Hgb-9.4* Hct-27.8*
MCV-100* MCH-33.8* MCHC-34.0 RDW-17.3* Plt Ct-51*
[**2114-8-8**] 05:40AM BLOOD WBC-2.6* RBC-2.77* Hgb-9.7* Hct-27.9*
MCV-101* MCH-34.8* MCHC-34.6 RDW-16.8* Plt Ct-47*
[**2114-7-26**] 07:15PM BLOOD Glucose-123* UreaN-28* Creat-1.7* Na-135
K-3.4 Cl-102 HCO3-24 AnGap-12
[**2114-7-27**] 05:35AM BLOOD Glucose-103 UreaN-25* Creat-1.5* Na-133
K-3.5 Cl-104 HCO3-24 AnGap-9
[**2114-7-28**] 05:50AM BLOOD Glucose-100 UreaN-22* Creat-1.3* Na-137
K-4.1 Cl-108 HCO3-21* AnGap-12
[**2114-7-29**] 05:55AM BLOOD Glucose-167* UreaN-22* Creat-1.3* Na-132*
K-4.0 Cl-106 HCO3-22 AnGap-8
[**2114-7-30**] 05:07AM BLOOD Glucose-91 UreaN-24* Creat-1.4* Na-133
K-4.2 Cl-105 HCO3-24 AnGap-8
[**2114-7-31**] 05:15AM BLOOD Glucose-89 UreaN-33* Creat-1.5* Na-132*
K-4.2 Cl-104 HCO3-20* AnGap-12
[**2114-8-1**] 04:55AM BLOOD Glucose-94 UreaN-41* Creat-1.6* Na-132*
K-4.2 Cl-104 HCO3-20* AnGap-12
[**2114-8-1**] 07:57PM BLOOD Glucose-86 UreaN-37* Creat-1.3* Na-134
K-4.2 Cl-106 HCO3-18* AnGap-14
[**2114-8-2**] 04:15AM BLOOD Glucose-87 UreaN-35* Creat-1.3* Na-133
K-4.8 Cl-108 HCO3-17* AnGap-13
[**2114-8-3**] 06:15AM BLOOD Glucose-179* UreaN-34* Creat-1.2 Na-134
K-3.8 Cl-109* HCO3-20* AnGap-9
[**2114-8-4**] 06:00AM BLOOD Glucose-108* UreaN-32* Creat-1.1 Na-136
K-3.7 Cl-108 HCO3-23 AnGap-9
[**2114-8-5**] 05:50AM BLOOD Glucose-115* UreaN-29* Creat-1.1 Na-135
K-3.2* Cl-106 HCO3-22 AnGap-10
[**2114-8-6**] 05:32AM BLOOD Glucose-130* UreaN-23* Creat-1.1 Na-136
K-4.1 Cl-107 HCO3-24 AnGap-9
[**2114-8-7**] 06:10AM BLOOD Glucose-127* UreaN-25* Creat-1.1 Na-135
K-4.0 Cl-107 HCO3-22 AnGap-10
[**2114-8-8**] 05:40AM BLOOD Glucose-119* UreaN-29* Creat-1.2 Na-135
K-3.8 Cl-108 HCO3-23 AnGap-8
Brief Hospital Course:
This is a 60 y/o male who was initially admitted for management
of his cirrhosis, c/w ascites and increasing creatinine on the
diuretics and poor po intake. He had several
therapeutic/diagnostic paracentesis while in-house, which were
all negative for SBP. The diuretics were held initially [**1-17**]
worsening renal function, and were started again after
stabilization of his renal function. He had an NJ tube placement
at the beginning of his admission for poor nutritional status
for supplementation. During his stay, he developed a decreased
Hct (responsive to transfusion) and guiac positive stools. He
had an EGD which confirmed grade II varices (pt already with h/o
esophageal varices) and portal gastropathy. Due to his NJ tube
placement, the varices were not banded. He had a TIPS procedure
to alleviate the portal HTN. His TIPS was complicated by
post-procedure hypotension, for which he required an overnight
MICU stay with pressors to increased his blood pressure. He was
transferred back to the floor after stabilization. His Cr
dropped and stabilized after his TIPS [**1-17**] increased renal
perfusion and improvement in renal function. He had no further
episodes of bleeding, or decreased Hct. He was started on
lactulose s/p TIPS [**1-17**] risk of encephalopathy, although he had
no symptoms of encephalopathy at the time of discharge. He was
also restarted on low-dose diuretics for his ascites, as his
renal function was stable. His main issue was his poor
nutritional status, for which he was continued on TF and po
intake as much as possible. He had an episode of choking on food
s/p EGD with resulting aspiration PNA, for which he was started
on appropriate antibiotics. Speech and swallow evaluated the pt
following this, and recommended ground solids and thin liquids
(as pt had no aspiration risk with thin liquids). He was
discharged on [**2114-8-8**] in stable condition with VNA services to
aid with the TF, which he will continue for the time being. A
RUQ u/s showed a patent TIPS with good flow prior to discharge.
He will follow-up with Dr. [**Last Name (STitle) 497**] as scheduled and the
nutritionist when he sees Dr.[**Last Name (STitle) 497**].
Secondary issues -
1. New left-inguinal hernia - during his stay, the pt noted a
new left groin mass, which was nontender and not painful. Upon
exam, this was a new left inguinal hernia, which was reducible
while the pt was supine. Transplant surgery was consulted, who
decided to take the pt to the OR. His surgery was scheduled,
however cancelled several times [**1-17**] to the high risk. He will
instead follow-up with Dr. [**First Name (STitle) **] upon discharge to plan for
surgery in the future for the left inguinal hernia.
2. Aspiration PNA - by CXR and pt's symptoms of non-productive
cough, and recent choking s/p EGD. Pt was started on
Levo/Flagyl, and was discharged with these to complete a 14-day
course.
Medications on Admission:
MEDS -
1. CaCO3 600 mg qd
2. Protonix 40 mg qd
3. Nadolol 40 mg qd
4. Aldactone 25 mg qd
5. Bumex 1 mg qd
6. Mycelex troch 10 mg qd
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
2. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day) as needed for as needed for thrush.
Disp:*90 Troche(s)* Refills:*1*
3. Tubefeeds
Nepro Full strength
Sig: Sixty (60) cc/hr from 7PM to 11AM QD
per nasal-duodenal tube (=4 cans qQ)
Disp: One (1) month supply (44 cans), Eleven (11) refills
4. Pump Pole
Pump Pole for tube feeding
Disp: One (1)
5. NGT Supplies
[**Last Name (un) 1372**]-duodenal tube supplies
Disp: One (1) month supply, eleven (11) refills
6. Outpatient Lab Work
Please check a chemistry 7 panel this [**Last Name (LF) 2974**], [**2114-8-10**]
and fax results to Dr.[**Name (NI) 948**] office [**Telephone/Fax (1) **]
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for aspiration pneumonia for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*1*
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary - s/p TIPS, Abdominal Ascites, Hepatitis C cirrhosis ,
Endstage liver disease
Secondary-
Chronic renal insufficiency
Malnutrition
Discharge Condition:
Good, ongoing ascites [**1-17**] liver failure, afebrile, HD stable
Discharge Instructions:
Continue taking your medications as directed. Call your doctor
or 911 if you have fever, chills, severe abdominal pain, fail to
urinate.
Continue to weigh yourself daily. If you gain more than 2lbs,
call your doctor for further advice in terms of your diuretic
doses.
Continue working with visiting nurses on your tubefeeds. Limit
sodium intake to 2 grams a day if possible.
Follow up with your doctor as previously directed.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2114-8-15**] 3:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2114-9-10**] 3:20.
Completed by:[**2114-8-11**]
ICD9 Codes: 5070, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2665
} | Medical Text: Admission Date: [**2109-1-20**] Discharge Date: [**2109-1-23**]
Date of Birth: [**2023-8-19**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / NSAIDS
Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catherization
Inferior Vena Cava Filter Placement (outside hospital)
Aspirin Densensitazation
History of Present Illness:
Mr. [**Known firstname 90223**] is a 85-year-old male with CAD s/p PTCA LCx
([**2092**]), HLD, AAA, PE, PAD, COPD that was transferred to [**Hospital1 18**]
for c. cath with complicated OSH course consisting of anemia
secondary to GIB, bilateral PE not on anticoagulation, and
NSTEMI with reduction of EF, and acute systolic heart failure.
Pt is transferred to the CCU prior to cardiac cath for ASA
desensitization protocol.
.
He was admitted on [**2109-1-10**] for SOB at [**Hospital3 1443**]
Hospital (contact number [**Telephone/Fax (1) 90224**]). [**Name2 (NI) **] oximetry was in
the low 80s at home responsive to home O2 via NC. He endorses
feeling cold type symptoms with coughing for quite a few weeks
but became more dyspneic with increasing cough and clear sputum
production. Chest CT showed new bilateral pulmonary emboli.
Venous US was negative for DVT. An IVF filter was placed on
[**1-10**] in setting of inability to anti-coagulate with anemia.
Admission labs were also notable for Hgb/Hct of 6.6/24.2 and
guaiac positive stool. He was treated for a presumed GIB. He was
transfused 3 units of pRBC. Endoscopy performed on [**1-11**] was
unremarkable. Colonoscopy was attempted on [**1-10**] but unable to
be performed secondary to stool in bowel. Colonoscopy
subsequently performed on [**1-17**] showed diverticulosis and
diminutive polyp x 1, which showed fragments of adenoma.
Labs were also significant for 3 sets of elevated troponins and
CPKs. ECHO on [**1-15**] showed EF 35 % (last EF on [**2108-3-6**] showed
EF 60 %). Stress test showed large area of ischemia extending
from the anterior wall and anterior apex of inferior wall. There
was evidence of prior small lateral wall infarction with
significantly depressed LVEF. His latest CXR showed mild CHF.
Additional studies included abdominal US showing AAA that is
stable compared to prior exam on [**2108-10-4**].
Hospital course also complicated by flash pulmonary edema on
[**2109-1-12**].
The patient was also treated for pneumonia although viral URI
was favored with fever 100.2 in setting of chronic prednisone
therapy although no infiltrate noted. He was treated with
moxifloxacin 400 mg PO qD for a 10-day course. CXR did not
suggest pneumonia.
.
Pt describes an ASA allergy consisting of redness on his face,
and rash diffusely many years ago.
.
On arrival to CCU, he was afebrile, with VS HR 76, BP 106/70, RR
20, 93% 3LNC, repeated at 98%. Pt denies chest pain, chest
pressure, or SOB. He says that he has felt overall weak since he
was admitted to the OSH, but that this has gotten better.
.
On review of systems, he endorses overall weakness as above. He
says that he has had black stools for the past year, but that
the doctors [**Name5 (PTitle) **]'t been able to figure out why. He states that
he went to the OSH because he knew that his [**Name5 (PTitle) **] counts were
low. He denies fever or chills, but continues mild cough with
yellow sputum.
He also endorses previous leg cramping.
He denies any prior history of stroke, bleeding at the time of
surgery, myalgias, joint pains, hemoptysis, or red stools. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope. He is able to
walk 3 blocks with having to stop 2-3 times, which is unchanged
in the past year. He performs all of his ADL's and lives on his
own.
Past Medical History:
- CAD s/p MI in [**2092**] with PTCA to of Lcx
- bilateral pulmonary embolism s/p IVC filter placement
([**2109-1-10**]) with prior history of PE 1 year ago (previously
treated with Coumadin)
- HLD
- PVD (last ABIs in [**12-3**] showing moderate right PVD)
- Temporal arteritis
Followed by Dr. [**Last Name (STitle) **] of [**Hospital6 2561**]
- AAA (4.8 cm on [**2107-7-13**])
- [**Female First Name (un) 564**] esophagitis
- longstanding anemia with recent transfusion-dependent anemia
secondary to ?GIB.
- osteopenia
- history of hemorrhoids
- history of prostate cancer s/p TURP in past
- history of GI bleeding (gastric antrum)
- depression
- right wrist fracture in past
Social History:
-Tobacco history: He has smoked 1 ppd for 63 years.
-ETOH: social drinking
-Illicit drugs: none
Patient had been widowed for a number of years. The patient has
an adoptive son who helps with his care. He shops on his own,
and performs all of his own ADL's.
Family History:
His three brothers all had MI at various ages - 36,42, and 58.
No family history of DVT/PE.
Physical Exam:
VS: T 97.4 BP 106/70 HR 76 RR 20 O2 sats 93 % on 3 L NC -->
repeated at 98%
GENERAL: Pleasant, elderly male, sitting up in bed, NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pale, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP not elevated
CARDIAC: Distant heart sounds, RRR, S1/S2 not appreciated. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. Poor air
exchange throughout, no wheezing noted or crackles
ABDOMEN: +BS, Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm, dry, no [**Location (un) **], apparent mm wasting, + clubbing
on hands and feet.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ PT 2+, unable to palpated DP
Left: Carotid 2+ PT 2+, unable to palpated DP
Pertinent Results:
[**2109-1-20**] 08:41PM %HbA1c-6.5* eAG-140*
[**2109-1-20**] 05:42PM GLUCOSE-121* UREA N-27* CREAT-1.1 SODIUM-137
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-30 ANION GAP-13
[**2109-1-20**] 05:42PM ALT(SGPT)-54* AST(SGOT)-23 CK(CPK)-26* ALK
PHOS-72 TOT BILI-0.2
[**2109-1-20**] 05:42PM CK-MB-2 cTropnT-0.04*
[**2109-1-20**] 05:42PM CALCIUM-8.6 PHOSPHATE-4.4 MAGNESIUM-2.1
CHOLEST-195
[**2109-1-20**] 05:42PM TRIGLYCER-152* HDL CHOL-40 CHOL/HDL-4.9
LDL(CALC)-125
[**2109-1-20**] 05:42PM WBC-7.0 RBC-4.59* HGB-10.5* HCT-34.5* MCV-75*
MCH-23.0* MCHC-30.6* RDW-19.4*
[**2109-1-20**] 05:42PM PLT COUNT-442*
[**2109-1-20**] 05:42PM PT-11.9 PTT-23.0 INR(PT)-1.0
.
EKG's:
OSH EKG dated [**2109-1-14**] at 0:51:06 showing NSR, vent rate 77 bpm,
PR 166 ms, QRS 92 ms, QTc 463 ms, R axis - 27. Q waves in III,
aVR, aVF, V1. TWI in I, II, III, avF, V4,V5,V6. Flattening in
V3. J-point elevation in V1 and V2 vs. sub-mm ST elevation.
Sub-mm ST depression in V6.
Admission EKG similar to OSH EKG with extensive ST-T changes, ?
left anterior hemiblock. Q-waves are not present as documented
above except in V1. V4 showing < 1mm ST depression.
.
2D-ECHOCARDIOGRAM:
ECHO [**12-3**] showing EF 55 %, Trace AI, mild MR.
OSH ECHO ([**2109-1-15**]):
-Left ventricle: hypokinesis of apical anterior, apical
inferior, basal inferolateral, and apical wall. Wall thickness
mildly increased. EF estimated 35 %.
- Mitral valve: Mild regurgitation
- Tricuspid valve: mild regurgitation
- Aorta: root exhibited mild dilatation
.
Abdominal US: Significant for infrarenal abdominal aortic
aneurysm (4.5 cm x 4 cm). Similar US seen on prior on [**2108-10-4**]
.
Colonoscopy ([**2109-1-17**]): 70 cm polyp
.
ETT:
Stress myoview [**7-1**]: normal scans. Mild inferior base
hypokinesis. EF 60 %.
.
CARDIAC CATH: prior from [**2092**] not available
[**2109-1-21**] prelim: 1. Coronary angiography in this right-dominant
system demonstrated three-vessel disease. The LMCA had a distal
80% stenosis. The LAD had a 50% mid stenosis and a 50% stenosis
of D1. The LCx had a 90% mid
stenosis. The RCA was occluded proximally and filled distally
via
left-to-right collaterals.
2. Limited resting hemodynamics revealed normal systemic
arterial [**Year (4 digits) **]
pressures with SBP 106mmHg and DBP 56mmHg.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease and left main disease.
Brief Hospital Course:
NSTEMI: Patient reported chest pain in setting of shortness of
breath, which appeared to be multifactorial. Denied any chest
pain but does endorsed shortness of breath which improved.
Complete cardiac biomarker set unavailable from outside records,
but appears had NSTEMI given biomarker elevation, EKG changes,
and decreased EF resulting in acute heart failure (60's to 30's
EF). Nuclera stress at OSH showed large area of ischemia
extending from anterior wall and anterior apex of inferior wall
with evidence of prior small lateral wall infarction. He was
transferred to [**Hospital1 18**] for consideration of cardiac catherization,
but first required aspirin desensitization as has documented
aspirin allergy. Left cardiac ICU after aspirin
desensitization. Cardiac catherization confirmed triple vessel
disease with RCA occlusion and LAD 80% occlusion. Patient was
informed of necessity of coronary artery bypass, and declined
surgical intervention multiple times. Based on patient wishes,
optimized medical management and defered surgical treatment.
* Medical management with Atorvastatin 80 mg qhs, Carvedilol
6.25 mg PO BID, ASA 325 mg PO qday, Captopril 12.5 mg TID.
* [**Month (only) 116**] want to switch short acting captopril to longer acting
lisinopril as an outpatient.
Acute systolic heart failure (last EF 35 %):
Patient developed acute systolic heart failure given EF decline
from 60 % ([**2108-3-6**]) to 35 %. Most likely from ischemic event
as above. His dry weight in unknown, and he has experienced
weight loss in the past 3 months of about 20 lbs. At the OSH,
had flash pulmonary edema and an oxygen requirement which
resolved in house. Discharge weight steady at 140 lbs and
physical exam suggested euvolemia.
* Continued medical management with Captopril 12.5 mg PO TID,
Carvedilol 6.25 mg PO BID. [**Month (only) 116**] want to change short acting
captopril to longer acting lisinopril as an outpatient.
* Deferred use of spironolactone as borderline hyperkalemia at
4.7.
Bilateral pulmonary embolisms, recurrent s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter
placement: He has had second episode of pulmonary embolism in
past year. Uncertain as primary imaging report not available to
classify as segmental, subsegmental but overall did not appear
to cause hemodynamic instability at presentation. Etiology
unknown. Given advanced age, 20-lb weight loss, and chronic
tobacco abuse, would suspect that neoplasm high on differential.
Other etiologies like immobility or recent surgery not present
to explain recurrence, and no family history of thrombosis. Had
heparin gtt in house. Discharged with 10 days worth of
enoxaparin injections with bridging therapy with coumadin to
treat PE.
* Follow up CBC/ Coag panel
* Discuss with patient duration of anticoagulation (life long?)
* Confirm age appropriate cancer screening on outpatient basis
per above
* consider thrombophilia work-up as outpatient
* IVC filter in place
Microcytic Anemia: Has a history of anemia at baseline.
Admission to OSH Hct 24 and post-transfusion OSH Hct 33 status
post 3U pRBC. At [**Hospital1 18**], Hct stable in the low to mid 30's. [**Month (only) 116**]
have had marrow suppresion in setting of viral illness, as well
as GI [**Month (only) **] loss given history of adenomas. Hematology consult
at OSH impression was ACD vs. other process with consideration
for bone marrow biopsy as outpatient for unclear reasons. His
EPO level was elevated, which could suggest chronic hypoxemia in
setting of COPD vs. renal cell carcinoma vs. appropriate
response to anemia. Flow cytometry also not suggestive of
abnormal myeloid maturation or an increased blast population or
lymphoproliferative disorder. SPEP performed but results were
not available upon transfer. No hypercalcemia or bony
involvement to suggest MM. He does have a history of prior GIB
in the stomach antrum. OSH Colonoscopy and EGD showed
diverticuli and polyp consistent with adenoma but no active
source of bleeding. At [**Hospital1 18**], patient excxlaimed he has had a
20lbs weight loss, as well as night sweats a few times a week
for the last month. Concern for malignancy, but discussion with
PCP is that he is aware of these symptoms and has performed age
appropriate screening for this patient. Did have a history of
prostate cancer, but not complaints of bone pain at [**Hospital1 18**].
* Need to follow-up final pathology of polyp from OSH
* Check CBC on follow up
COPD : Patient has long tobacco history and continues to smoke.
No evidence for active COPD exacerbation. CXR demonstrated
diaphragmatic flattening consistent with COPD. Discharged home
on albuterol and tiotropium. Counseled on tobacco cessation but
patient not interested in quitting. Additionally, at OSH was
treated with a 10-day course of avelox for low grade fever in
setting of prednisone usage with no infiltrate on CXR or CT.
* continued albuterol/tiotropium at home.
* F/u with PFT's prn
Abnormal ALT: Incidentally patient's ALT elevated to 204 on
[**2109-1-10**] with downtrend to 51 on [**2109-1-20**]. Per OSH report
Abdominal US showed no liver pathology. ALT on admission 204
now trended to 50s prior to discharge.
* Follow up LFT's as an outpateint
CHRONIC ISSUES
Temporal arteritis: No active issues. Continued prednisone 10mg
daily.
Weight loss
Broad differential for weight loss including depression given
prior history, poor access to food, underlying chronic illness,
and possible occult neoplasm. Follow up per above.
* Defer to outpatient work-up
Asymptomatic AAA: AAA noted on OSH US significant for
infrarenal abdominal aortic aneurysm (4.5 cm x 4 cm) stable from
prior US dated [**2108-10-4**].
* Defer to further outpatient management.
TRANSITIONAL ISSUES: Code status in house changed to DNR/DNI
confirmed with patient. Should reconfirm with patient as an
outpatient and make sure power of attorney/living will paper
work is up to date. Patient counseled on necessity of
continuing aspirin, and that if he discontinues use for even one
day may experience recurrence of allergic reaction given history
of allergy. Patient understood necessity to take daily.
COMM: [**Name (NI) **], son [**Telephone/Fax (1) 90225**] ([**Doctor First Name 429**])
PENDING LABS: OSH colonoscopy pathology for adenoma. [**Hospital1 3793**] Hospital (contact number [**Telephone/Fax (1) 90224**]).
.
Medications on Admission:
A. Home medications
Plavix 75 mg PO qD
Diltiazem 180 mg PO qD
Zetia 10 mg PO qD
Simvastatin 20 mg PO qD
Prednisone 10 mg PO qD
Iron supplement
nitro SL prn
.
B. Medications on transfer to [**Hospital1 **]
Plavix 75 mg PO daily
Zetia 10 mg PO daily
Simvastatin 20 mg PO daily
Captopril 12.5 mg PO TID
Carvedilol 6.25 mg PO BID
Nitroglycerin 0.1 mg/hr (2.5 mg) TD qHS
Prednisone 10 mg PO qD
.
.
ALLERGIES: SEVERE ALLERGY TO ASPIRIN --> rash, redness on face
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
3. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
4. captopril 12.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation PRN as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation at bedtime.
Disp:*1 inhaler* Refills:*0*
10. 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:*0*
11. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
twice a day for 10 days.
Disp:*20 syringes* Refills:*0*
12. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN as needed for chest pain: If chest pain not
resolved after 3 doses, call your doctor, report to the nearest
ED, or call 911.
Disp:*30 tabs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
Primary:
Pulmonary Embolism
Coronary Artery Disease (Severe)
Non ST Elevation Myocardial Infarction
Iron Deficiency Anemia
.
Secondary:
Chronic Obstructive Pulmonary Disease
History of PE 1 year ago
Hyperlipidemia
Peripheral Vascular Disease
Temporal arteritis
Abdominal Aortic Aneursym
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 90226**],
You originally presented to another hospital because of
shortness of breath. There, you were found to have multiple
medical problems, including [**Name2 (NI) **] clots in your lungs as well as
evidence of a minor heart attack based on [**Name2 (NI) **] tests.
Additionally, you were found to have very low red [**Name2 (NI) **] cell
count. You were given bags of [**Name2 (NI) **] to replete your low counts,
and placed on [**Name2 (NI) **] thinners in an attempt to treat the clots in
your lungs. Your small heart attack affected the way your heart
could pump, and as a result the doctors at your [**Name5 (PTitle) **] hospital
suggested you come to [**Hospital1 **] for further
evaluation
At [**Hospital1 **], you had a procedure called a cardiac catherization.
This is a procedure where a catheter is inserted in the large
vessel in your groin, and wired to the heart. Dye was injected
to analyze the vessels in your heart, known as the coronary
arteries. There evidence of severe coronary artery disease,
which causes the [**Hospital1 **] vessels to become blocked off. This
finding was concering, as it increases your risk of a severe
heart attack. Your doctors informed [**Name5 (PTitle) **] of this finding, and
suggested you have surgery known as a "Triple Bypass" surgery,
to circumvent the blocks in your coronary arteries. However,
after you were told about the risks and benefits of having the
surgery, you decided this is not a procedure you would want
performed at this time.
Because you declined to have the surgery, we have attempted to
medically optimize your medication regimen. It is important to
continue to take your medications as prescribed, to help reduce
your risk of having another, larger, heart attack in the future.
Additionally, you have been placed on medication to treat the
[**Name5 (PTitle) **] clots in your lungs. The first medication is called
"Lovenox" or "Enoxaparin". It is injection you give yourself
twice a day. The second drug is called "Warfarin" or
"Coumadin". It is a pill you will take to help keep your blodo
thin. As warfarin takes some time to work, it is important you
take enoxaparin in the interim to help keep your [**Name5 (PTitle) **] thin
while warfarin starts to work in your body. Please use the
enoxaparin injections for 10 days or as arranged by your PCP.
[**Name10 (NameIs) **] is unclear why your red [**Name10 (NameIs) **] cell count was low when you
came to the hospital. It is importnat you follow up with your
primary care doctor for further evaluation of this issue.
The following is your NEW LIST of medications. Please
discontinue taking any medications that are not on this list,
and adhere to the medication dosing.
Your were "desensitzed" to Aspirin, this means that if you
continue to take it everyday you will not have an allergy to it.
HOWEVER if you miss even a single dose please call your PCP to
discuss whether or not he wants you to take the next dose BEFORE
you take it.
Acetaminophen 325 mg Tablet 1 Tablet by mouth every 6 hours as
needed for pain.
Carvedilol 3.125 mg Tablet 2 Tablets by mouth [**Hospital1 **] 2 times a day
Warfarin 1 mg Tablet 3 Tablets by mouth once Daily at 4 PM.
Captopril 12.5 mg Tablet 1 Tablet by mouth three times a day.
Atorvastatin 80 mg Tablet 1 Tablet by mouth at night
Prednisone 5 mg Tablet 2 Tablet by mouth DAILY
Aspirin 325 mg Tablet 1 tablet by mouth daily
Omeprazole 20 mg tablet 1 tablet by mouth daily
Albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
1 Inhalation as needed for shortness of breath or wheezing.
Tiotropium bromide 18 mcg Capsule, w/Inhalation Device
1 Inhalation at bedtime.
Enoxaparin 60 mcg 1 injection 2x a day for 10 days
Nitroprusside 0.4 sublingual as needed for chest pain
It has been a pleasure taking care of you Mr. [**Known lastname 90226**]!
Followup Instructions:
It is very important that you see your PCP. [**Name10 (NameIs) 357**] arrange for
follow up within the week. They can be reached at:
Dr. [**First Name (STitle) **] KO
#[**Telephone/Fax (1) 39260**]
Additionally, it is importnat that you follow up with your
cardiologist within the month for discussion of your cardiac
issues. Please call your cardiologist and arrange for follow
up.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]
ICD9 Codes: 4280, 496, 3051, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2666
} | Medical Text: Admission Date: [**2109-9-11**] Discharge Date: [**2109-9-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension, MS change
Major Surgical or Invasive Procedure:
Endotracheal intubation
A-line placed
IJ line placed in ED
History of Present Illness:
[**Age over 90 **] year old woman with h/o HTN, TIA/syncope, right hilar mass,
osteoporosis BIBA from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] for hypotension, lethargy.
Patient developed diarrhea the day prior to admission, on d.o.a,
had one episode of green/bilious emesis. Patient noted to be
more lethargic, temp >100 per NH reports and [**Last Name (un) **] called EMS.
Of note, patient had been on Cefpodoxime for a UTI (started
[**2109-9-5**]). NH vitals: 100.3, HR 120, BP 70/40, RR 20. Patient
denied abdominal pain.
.
In the ED: Tmax 102.2 HR 96, BP 102/46, RR 28, 98% 2 L. Sepsis
protocol initiated, central line placed via R subclavian,
intubated for airway protection, initially R mainstain
intubation, subsequently pulled back with appropriate placement.
Patient started on IV Vanco, Cipro and Flagyl. CXR clear without
pna or infiltrates, U/A negative. She received ~2.5 L of fluid
in the ED and transferred to the East ICU via ambulance. Patient
sedated with IV Ativan/Etomidate, 1 amp of bicarb, 1 amp of Ca
gluconate, 10 U of insulin, 1 amp of D50 for potassium of 7.0,
also given 30 kayexalate. Remained tachy in ED, 99-113, BP came
up to 120s-130s, urine output increased [**2043-11-29**] from 7:20 to
9:40--70 ccs over 2.5 hrs. Bowel movement trace guiaic positive
in ED. Admitted to [**Hospital Ward Name 332**] ICU.
Past Medical History:
HTN
TIA
R Hilar mass, cystic
Hx of syncope
osteoporosis
Social History:
Lived in [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], a nursing home. Healthcare proxy: son
Family History:
noncontributory.
Physical Exam:
Upon arrival to [**Hospital Unit Name 153**]:
Gen: Elderly woman intubated in [**Hospital Unit Name 153**], nonresponsive
Heent: moist mucous membranes, PERRL, ~2mm->1.5mm
Neck: supple, no JVD appreciable
Chest: CTA b/l, no wheezing/rales/rhonchi
CVS: nl S1 S2, distant, regular, no m/r/g appreciated
Abd: soft, distended, tympanic to percussion, no HSM
appreciated, BS+
Ext: cool upper and lower ext, no edema, no cyanosis, trace
distal pulses b/l
Neuro: intubated and sedated, grimaces to painful stimuli
Skin: dry, cool to touch, no rashes, skin breakdown
.
Pertinent Results:
HEME
[**2109-9-11**] 06:30AM
WBC-13.7* RBC-3.85* HGB-12.2 HCT-35.7* MCV-93 MCH-31.7 MCHC-34.2
RDW-14.8;
DIFF: NEUTS-61 BANDS-9* LYMPHS-18 MONOS-8 EOS-0 BASOS-0 ATYPS-0
METAS-4* MYELOS-0
repeat:
[**2109-9-11**] 11:34AM
WBC-7.9 RBC-2.90* HGB-9.0*# HCT-27.2* MCV-94 MCH-31.1 MCHC-33.1
RDW-14.9
DIFF: NEUTS-43* BANDS-19* LYMPHS-17* MONOS-17* EOS-0 BASOS-0
ATYPS-2* METAS-0 MYELOS-1* PROMYELO-1*
.
CARDIAC
[**2109-9-11**] 06:30AM CK-MB-2 cTropnT-0.07*
[**2109-9-11**] 06:30AM CK(CPK)-62
[**2109-9-11**] 01:16PM CK-MB-4
[**2109-9-11**] 01:16PM CK(CPK)-175*
.
CHEMISTRIES
[**2109-9-11**] 06:30AM GLUCOSE-141* UREA N-75* CREAT-3.0* SODIUM-145
POTASSIUM-6.1* CHLORIDE-114* TOTAL CO2-12* ANION GAP-25*
[**2109-9-11**] 07:11AM GLUCOSE-133* LACTATE-6.7* NA+-147 K+-6.5*
[**2109-9-11**] 07:51AM LACTATE-4.3* K+-7.1*
[**2109-9-11**] 09:30AM LACTATE-5.7* K+-4.5
[**2109-9-11**] 11:08AM LACTATE-3.7*
[**2109-9-11**] 11:46AM LACTATE-3.3*
[**2109-9-11**] 01:37PM LACTATE-3.2*
.
[**Last Name (un) **] STIM
baseline value not rcvd; 40 mins and 60 mins values.
[**2109-9-11**] 03:30PM CORTISOL-27.9*
[**2109-9-11**] 03:50PM CORTISOL-27.8*
.
BLOOD GASSES
.
URINE
[**2109-9-11**] 07:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
ARTERIAL BLOOD GASSES ON ASSIST CONTROL INTUBATION UNLESS NOTED:
[**2109-9-11**] 11:08AM
TEMP-36.3 RATES-5/ TIDAL VOL-400 PEEP-5 O2-100
PO2-61* PCO2-27* PH-7.27* TOTAL CO2-13* BASE XS--12 AADO2-640
REQ O2-100
.
[**2109-9-11**] 01:37PM
TEMP-36.3 RATES-16/10 TIDAL VOL-400 PEEP-5 O2-100
PO2-304* PCO2-23* PH-7.32* TOTAL CO2-12* BASE XS--12 AADO2-401
REQ O2-69
.
[**2109-9-11**] 03:35PM
TEMP-36.3 TIDAL VOL-400 PEEP-5 O2-50
PO2-118* PCO2-20* PH-7.32* TOTAL CO2-11* BASE XS--13
.
[**2109-9-11**] 05:58PM
TEMP-36.3 RATES-16/10 TIDAL VOL-400 PEEP-5 O2-100
PO2-112* PCO2-20* PH-7.27* TOTAL CO2-10* BASE XS--15 AADO2-596
REQ O2-96
Brief Hospital Course:
This was a [**Age over 90 **] yo woman with six day history of cephalosporin tx
for a UTI, who presented with fulminant diarrhea, vomiting, and
increasing lethargy. She also soon developed hypotension. She
was intubated for airway protection and received pressors and
fluids to maintain pressure. Cultures were sent. We changed the
code status to DNR based on medical futility, d/w son (health
care proxy) who agreed. However, her son felt that we should
continue maximal care otherwise.
.
Notable features of her course include an increasingly distended
abdomen and, initially, unresponsiveness without sedation. Her
abdomen was visualized via KUB and showed large air collections,
although the radiologist was unable to determine with certainty
whether this was inside or outside the bowel. She was not stable
enough to go to CT for further evaluation. Additionally she was
not an appropriate surgical candidate because of her continued
instability.
.
C. diff toxin was positive x2. Blood, stool and urine cultures
were otherwise all negative. She was treated with PO
metronidazole, PO vancomycin and IV vancomycin. Vancomycin
troughs were monitored and were supratherapeutic even on PO
vanco alone. We continued with PO metronidazole and PO
vancomycin, accounting for reduced clearance.
.
Over the first several days of her admission she improved
clinically somewhat. She was soon able to respond with head nods
and shakes to questions; and could move hands and feet on
request. She was significantly overbreathing her ventilator, and
eventually was weaned off assist control and put on pressure
support. However, her abdomen continued to be distended and
tympanic. She stopped putting out stool. Her pressures did not
continue to improve. She then became less interactive. She
became more hypotensive and was given multiple fluid boluses and
was put back on levophed. She had an ovoid pupil and was
minimally interactive on the morning of the 3rd, and her
condition continued to worsen. By the end of her admission she
was more than 30 liters net positive, but this did not stop her
hypotension. In the evening she begin to have increasing
arrhythmias; and her pressures dropped into systolics in the 30s
in the first hours of [**2109-8-19**]. After discussion with her son,
there was agreement that the goals of care should change; she
was extubated, and she expired.
.
Medications on Admission:
Kayexalate 1 time dose given last week, remeron 15 qHS, HCTZ
12.5 MWF, lisinopril 2.5 daily, actinel 35 qWk, compazine,
heparin SC BID, cefpedoxime 200 mg [**Hospital1 **], planned 7 day course
since [**9-5**], prilosec 20 [**Last Name (LF) 244**], [**First Name3 (LF) **] 81 daily, multivitamin.
Discharge Medications:
N/A.
Discharge Disposition:
Expired
Discharge Diagnosis:
Severe sepsis secondary to C. dificile infection.
Discharge Condition:
Expired.
Discharge Instructions:
N/A.
Followup Instructions:
N/A.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 0389, 2762, 5859, 486, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2667
} | Medical Text: Admission Date: [**2152-4-9**] Discharge Date: [**2152-5-2**]
Date of Birth: [**2091-4-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Type A Aortic Dissection
Major Surgical or Invasive Procedure:
[**2152-4-9**] - Redo-sternotomy, Replace Ascending aorta and hemiarch,
Aortic Valve Replacement, Reimplantation of vein graft to
posterior descending artery, Fem-Fem Bypass, Left lower leg
fasciotomy. Chest left open.
[**2152-4-10**] - EGD
[**2152-4-11**] - Exploratory Laparotomy with abdomen left open.
[**2152-4-12**] - Right Colectomy left in discontinuity
[**2152-4-13**] - Sternal Closure
[**2152-4-14**] - Abdominal washout, subtotal colectomy.
History of Present Illness:
65 year old male who developed acute onset of lower extremity
tingling associated with chest pain radiating to his back. His
wife felt that he "looked lousy" and called 911 who brought him
to [**Hospital **] Hospital. A CTA Torso there revealed an aortic
dissection of the ascending aorta and extending to the
bifurcation, and involving the L carotid. Also,
his left leg was noted to be cold and pulseless. He was
hemodynamically stable, alert and oriented. They started a
nipride drip for BP management and transferred him to [**Hospital1 18**] for
operative intervention. During transport, the nipride was shut
off due to hypotension.
Past Medical History:
Coronary artery disease
Bypass surgery to two vessels ~11y ago (at [**Hospital3 **])
Peptic ulcer disease - H.Pylori (no operative intervention, no
massive hemorrhage)
Hypertension
Hyperlipidemia
Social History:
Current smoker. Lives with wife.
Family History:
non contributory
Physical Exam:
HR 85, 136/42 on esmolol gtt, 17, 95% on FM
Alert, no acute distress except mild confusion / lethargy. lying
flat on
stretcher
neck supple with midline trachea. moderate plethora while lying
flat. Bilateral carotid bruits, L>R
Clear lungs
Regular rate and rhythm
soft, Nontender, nondistended
Left lower extremity cool below knee and cold below ankle.
absent sensation from
mid-shin distally. unable to wiggle toes but able to extend
ankle. foot mottled/white. no pulses in femoral, popliteal,
Dorsalis pedis,
or posterior tibial.
Left upper extremity cool to touch throughout with absent
pulses. delayed cap
refill
Right leg and arm warm with pulse with intact 2+ palp pulses
throughout
Pertinent Results:
[**2152-5-1**] 07:05AM BLOOD WBC-6.5 RBC-3.03* Hgb-8.9* Hct-27.3*
MCV-90 MCH-29.4 MCHC-32.7 RDW-15.3 Plt Ct-506*#
[**2152-4-9**] 08:00PM BLOOD WBC-13.8* RBC-4.10* Hgb-13.2* Hct-37.1*
MCV-91 MCH-32.2* MCHC-35.5* RDW-12.7 Plt Ct-206
[**2152-4-10**] 06:04AM BLOOD Neuts-81.2* Lymphs-15.4* Monos-2.4
Eos-0.9 Baso-0.1
[**2152-4-10**] 04:40AM BLOOD Neuts-82.5* Lymphs-13.7* Monos-3.3
Eos-0.2 Baso-0.3
[**2152-5-1**] 07:05AM BLOOD Plt Ct-506*#
[**2152-4-26**] 03:25AM BLOOD PT-14.5* PTT-24.8 INR(PT)-1.3*
[**2152-4-9**] 08:00PM BLOOD Plt Ct-206
[**2152-4-9**] 08:00PM BLOOD PT-14.9* PTT-30.9 INR(PT)-1.3*
[**2152-4-11**] 10:15AM BLOOD Plt Ct-35*
[**2152-4-24**] 03:31AM BLOOD Fibrino-598*
[**2152-4-9**] 08:00PM BLOOD Fibrino-171
[**2152-4-25**] 04:56PM BLOOD ESR-109*
[**2152-4-22**] 02:15AM BLOOD Ret Aut-4.1*
[**2152-5-1**] 07:05AM BLOOD Glucose-83 UreaN-25* Creat-1.0 Na-138
K-5.0 Cl-102 HCO3-27 AnGap-14
[**2152-4-13**] 03:17AM BLOOD Glucose-103 UreaN-44* Creat-2.3* Na-137
Cl-107 HCO3-24
[**2152-4-9**] 08:00PM BLOOD UreaN-22* Creat-1.1
[**2152-5-1**] 07:05AM BLOOD ALT-73* AST-33 LD(LDH)-276* AlkPhos-433*
Amylase-106* TotBili-1.1
[**2152-4-17**] 04:19AM BLOOD ALT-76* AST-147* AlkPhos-332*
TotBili-9.6*
[**2152-4-10**] 09:31AM BLOOD ALT-69* AST-122* AlkPhos-31* TotBili-1.0
[**2152-5-1**] 07:05AM BLOOD Lipase-68*
[**2152-4-9**] 08:00PM BLOOD Lipase-21
[**2152-4-9**] 08:00PM BLOOD cTropnT-<0.01
[**2152-5-1**] 07:05AM BLOOD Albumin-2.9* Mg-2.3
[**2152-4-10**] 09:31AM BLOOD Albumin-1.6* Mg-2.0
[**2152-4-9**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2152-4-12**] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**Known lastname 1447**],[**Known firstname 177**] [**Medical Record Number 80641**] M 61 [**2091-4-11**]
Radiology Report CHEST (PA & LAT) Study Date of [**2152-4-28**] 9:06 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2152-4-28**] 9:06 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 80642**]
Reason: evaluate left effusion
[**Hospital 93**] MEDICAL CONDITION:
61 year old man with s/p asc aorta replacement
REASON FOR THIS EXAMINATION:
evaluate left effusion
Final Report
CHEST RADIOGRAPH
INDICATION: Status post aortic replacement. Evaluation of
left-sided pleural
effusion.
COMPARISON: [**2152-4-25**].
FINDINGS: The extent of the left-sided pleural effusion has
minimally
decreased. The secondary left basilar atelectasis is unchanged
in extent.
The right-sided pleural effusion is distributed differently than
on the
previous examination; however, its extent should also be
unchanged. Also
unchanged is the size of the cardiac silhouette. No focal
parenchymal opacity
suggestive of pneumonia.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: FRI [**2152-4-28**] 6:50 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 1447**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 80643**]Portable TEE
(Complete) Done [**2152-4-10**] at 5:32:23 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (LF) 80644**], [**First Name3 (LF) **]
Department of Anesthesia and Cr
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Location (un) 830**], [**Hospital Ward Name 1826**] 407
[**Location (un) 86**], [**Numeric Identifier 718**]
[**Last Name (LF) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2091-4-11**]
Age (years): 60 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic dissection. H/O cardiac surgery. Left
ventricular function. Right ventricular function. Valvular heart
disease.
ICD-9 Codes: 799.02, 441.00, V43.3
Test Information
Date/Time: [**2152-4-10**] at 17:32 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2009AW000-1: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Findings
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: RV not well seen. Normal RV systolic function.
AORTA: Descending aorta intimal flap/aortic dissection. Flow in
false lumen.
AORTIC VALVE: AVR leaflets move normally. No AR.
MITRAL VALVE: Mitral valve leaflets not well seen. Trivial MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
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 sedated for the TEE. Medications
and dosages are listed above (see Test Information section). No
TEE related complications. Suboptimal image quality - poor echo
windows. The patient appears to be in sinus rhythm. Emergency
the patient.
Conclusions
Limited study performed in ICU during emergent chest
re-exploration and exploratory laparotomy. Overall left
ventricular systolic function is normal (LVEF>55%). RV
demonstrates normal free wall contractility. A mobile density is
seen in the descending aorta consistent with an intimal
flap/aortic dissection. There is flow in the false lumen. The
aortic valve prosthesis leaflets appear to move normally. The
AVR is well seated. No aortic regurgitation is seen. The mitral
valve leaflets are not well seen. Trivial mitral regurgitation
is seen. There is no pericardial effusion.
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] were notified in person at
the time of the examination.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2152-4-24**] 12:28
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 1170**] on [**2152-4-9**] via transfer from [**Hospital **] Hospital for emergent
surgical management of a type A aortic dissection. He was taken
directly to the operating room where he underwent a redo
sternotomy with an aortic valve replacement, replacement of his
ascending aorta and hemiarch, a fem-fem bypass and a left leg
faciotomy. Please see both vascular and cardiac surgery
operative notes for details. Postoperatively he was taken to the
intensive care unit for monitoring. His chest was later opened
at the bedside for decreased oxygenation and hypotension. He
required multiple blood product transfusions for anemia and
coagulopathy. He developed bloody diarrhea and the
gastroeneterolgy service was consulted. An
esophagogastroduodenoscopy was performed which showed erosive
and ulcerative lesions but an otherwise normal study. A proton
pump inhibitor was continued. The general surgery service was
consulted who performed an exploratory laparotomy and left his
abdomen opened due to compartment syndrome. On postoperative day
two, his lactate became elevated and his abdomen was again
explored. A necrotic right colon was found which was resected.
On [**2152-4-13**], he was taken to the operating room where his chest
was washed out and successfully closed. He also had subtotal
coloectomy was performed due to necrotic bowel and again his
abdomen was unable to be closed due to edema o n [**2152-4-14**]. He
remained intubated and sedated. On [**2152-4-16**] he was taken back to
the operating room again by the general surgery service where he
underwent a cholecystectomy, an end ileostomy and VAC closure of
his abdomen. He was then allowed to wake from sedation. As he
was slow to wake, the neurology service was consulted. A CT scan
showed no acute intracranial abnormalities. An MRI was
recommended. A carotid ultrasound was performed which showed the
inability to evaluate right carotid artery and a less than 40%
stenosis of the left internal carotid artery. There as no
evidence of dissection. He required reintubation for respiratory
distress. Bilateral pleural effusions were noted and
subsequently drained. He was later extubated without difficulty.
An ophthalmology consult was obtained due to a dilated pupil who
found him to have bilateral loss of vision due to non-arteritic
ischemic neuropathy. He will need a work-up as an outpatient to
determine the degree of visual loss. The rheumatology service
was consulted who felt that there was no evidence of vasculitis
based on pathology from aorta. Over the next several days, he
continued to progress and was transferred to the floor. He
worked with physical therapy daily and slowly began to regain
strength. He was ready for discharge to rehab on [**2152-5-2**].
Sternal incision - sternum stable mild erythema at upper pole no
drainage, sutures and staples removed [**5-1**] and [**5-2**]
Left leg fasciotomy with sutures no erythema no drainage,
sutures to be removed at office visit with Dr [**Last Name (STitle) 3407**]
Abdominal incision, VAC to be placed at rehab and changed every
three days - Size:13cm x 3 cm, Bed:10% necrotic tissue,90% pink,
Exudate:serosang, Edges:not intact inferior edge, There is a
small deeper open area where the necrotic tissue has
been debrided, wound evaluation at follow up with Dr [**First Name (STitle) **]
Multiple pressure ulcers on back of head, area scabbed no
drainage, non tender
Medications on Admission:
Aspirin 81
Prilosec 40
Lipitor
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**First Name (STitle) **]: One (1) ml
Injection TID (3 times a day).
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**First Name (STitle) **]: Five (5)
ML PO Q6H (every 6 hours) as needed for pain.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
4. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
5. Combivent 18-103 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) puffs
Inhalation four times a day.
6. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
7. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Type A aortic dissection s/p repair
Coronary artery disease s/p coronary artery bypass graftingx2
Hypertension
Peptic ulcer disease (H. Pylori)
Hyperlipidemia
Ischemic bowel s/p resection
Abdominal compartment syndrome
Compartment syndrome s/p fasciotomy
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving - follow up with opthamology for visual assessment
7) Vac dressing to abdomen - please change every 3 days call Dr
[**First Name (STitle) **] for any issues with abdominal incision [**Telephone/Fax (1) 673**]
8) Call with any questions or concerns [**Telephone/Fax (1) 170**].
Followup Instructions:
Please call to schedule appointment
Dr [**Name (NI) 70277**] after discharge from rehab
Dr [**First Name (STitle) **] [**Telephone/Fax (1) 170**] - [**2152-5-15**] at 1:30pm - [**Doctor First Name **] Ste 2A
Dr [**First Name (STitle) **] [**Name (STitle) **] [**Hospital 464**] clinic [**Telephone/Fax (1) 253**] [**Hospital Ward Name 23**] [**Location (un) 6332**] [**2152-5-12**] Friday - at 2:30pm
Dr [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**2152-5-11**] at 3pm [**Doctor First Name **] [**Location (un) 436**]
[**Telephone/Fax (1) 673**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3407**] Friday [**5-12**] at 1130 [**Last Name (NamePattern1) **] Ste 5B
[**Telephone/Fax (1) 1241**]
Ostomy nurse - [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 11198**] call to schedule appointment for
1 month [**Telephone/Fax (1) 80645**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2152-5-2**]
ICD9 Codes: 2851, 5119, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2668
} | Medical Text: Admission Date: [**2160-8-23**] Discharge Date: [**2160-9-9**]
Date of Birth: [**2082-3-31**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
Left suboccipital craniotomy
Right external ventricular drain
Tracheostomy
PEG
History of Present Illness:
78yo Chinese-speaking M h/o HTN, DM2, CRI and smoking
presented with N/V and complaining of dizziness on [**8-23**]. He was
well upon going to bed [**8-22**] but awoke on [**8-23**] at 2am complaining
that he did not feel well. At 3:30am, he tried to go to the BR
but fell onto his knees. He was then helped back to bed but then
experienced N/V and tinnitus in both ears and vertigo. He was
brought to the ED in the morning when symptoms persisted when
sitting up or standing.
In the ED, his V/S were 97.2 120 (in new onset afib) 150/70 10
95% ra. Neuro exam was "non-focal" and CT of the head was
negative for acute bleed or signs of infarction and the patient
was admitted to medicine for syncope workup. The morning of
[**8-24**],
the patient vomited again and was somnolent, per the hospitalist
note. He opened his eyes to his daughter, denied dizziness,
headache or CP but was not sure of the year and he was
hypertensive. His neuro exam at this time by medicine was
"somnolent. Opens eyes to daughter command. Follows commands.
With symmetric grip strength. Toes down bilaterally. Moves all
4.
Can't identify year or week." He was sent for MRI with and
without gadolinium to r/o posterior circulation stroke. When
this
showed a cerebellar infarct, neurology consult was called.
Exam at this time showed the patient unable to be aroused with
voice or sternal rub. He opened his eyes for 4-5 seconds to
nailbed pressure to his toes but he did not follow commands.
With
coaxing from his wife, he squeezed her hand on the left but then
let go. Pupils were 2->1.5mm bilaterally but sluggish. Gaze was
midline. He had no blink to threat and oculocephalics were
unable
to be assessed. Corneal reflexes were intact b/l. He had
preferential turning of the head to the right. Tongue was
midline. On motor exam, his right leg was hypotonic and
externally rotated. His right arm was hypotonic and the left was
slightly anti-gravity. Both arms localized to pain, L>R. His
legs
withdrew to pain, again L>R. He had a babinski on the R but not
on the left. He was unable to walk.
After neuro evaluation, stat neurosurgery consult was called.
The
patient was sent for stat CT. While there, around 9:30pm, while
being seen with the neurosurgery team, the ED attending was
called to the resuscitation room by the neurosurgery team after
the patient vomited in the scanner and had "decreased MS" since.
CT showed large evolving L cerebellar infarct and potential
brainstem infarction, with mass effect on the brainstem and
likely cerebellar herniation. The patient was intubated for
airway protection, confirmed by postintubation CXR, and admitted
to the SICU.
Overnight, the patient underwent emergent left suboccipital
craniotomy with placement of EVD on the right. Postop CT showed
postsurgical pneumocephalus in the left cerebellum, possible
left
mass effect, s/p R EVD with new right lateral ventricle
hemorrhage. The patient was transferred back to the SICU and
placed on mannitol, propofol gtt, nicardipine gtt, nitroglycerin
gtt and in the morning of [**8-25**], started on dexamethasone 4mg IV
q6. He is now transferred to our care from the neurosurgery
service.
Past Medical History:
DM2 (HgbA1c 6.0% [**6-/2160**])
HTN
Tobacco abuse
CRI (followed by Dr. [**Last Name (STitle) **], b/l Cre 1.5)
gout
cataracts
glaucoma
s/p left inguinal hernia repair
h/o TB (while in [**Country 651**] in his 30's, denies ever being treated)
Social History:
Retired machinist, moved to the United States 13 years ago from
[**Country 651**]. He
lives with his wife. His daughter lives nearby. Long-time
smoker. He denies any alcohol or illicit drug use.
Family History:
deferred
Physical Exam:
Opens eyes to voice. Blinks to threat on the left. Pupils
reactive. Moves left side spontaneously. Trace but inconsistent
movement of right side. Does not follow commands.
Pertinent Results:
[**2160-9-8**] 04:08AM BLOOD PT-18.7* PTT-53.5* INR(PT)-1.8*
Brief Hospital Course:
The patient was admitted to medicine after a possible syncopal
episode, with dizziness and vomiting. Head CT in the ED was
negative. He was found to be in atrial fibrillation with RVR and
placed on metoprolol for rate control.
The morning of [**8-24**],the patient vomited again and was somnolent,
per the hospitalist
note. He opened his eyes to his daughter, denied
dizziness,headache or CP but was not sure of the year and he was
hypertensive. His neuro exam at this time by medicine was
"somnolent. Opens eyes to daughter command. Follows commands.
With symmetric grip strength. Toes down bilaterally. Moves all
4.
Can't identify year or week." A posterior circulation stroke was
considered by the medicine team and a stat neurology consult was
called when MRI revealed "Multifocal areas of acute infarction
most pronounced in the left superior cerebellar territory
suggesting an embolic source to the basilar artery".
Exam at this time showed the patient unable to be aroused with
voice or sternal rub. He opened his eyes for 4-5 seconds to
nailbed pressure to his toes but he did not follow commands.
With
coaxing from his wife, he squeezed her hand on the left but then
let go. Pupils were 2->1.5mm bilaterally but sluggish. Gaze was
midline. He had no blink to threat and oculocephalics were
unable
to be assessed. Corneal reflexes were intact b/l. He had
preferential turning of the head to the right. Tongue was
midline. On motor exam, his right leg was hypotonic and
externally rotated. His right arm was hypotonic and the left was
slightly anti-gravity. Both arms localized to pain, L>R. His
legs
withdrew to pain, again L>R. He had a babinski on the R but not
on the left. He was unable to walk.
After neuro evaluation, stat neurosurgery consult was called.
The
patient was sent for stat CT/CTA. While there, around 9:30pm,
while
being seen with the neurosurgery team, the ED attending was
called to the resuscitation room by the neurosurgery team after
the patient vomited in the scanner and had "decreased MS" since.
CT showed large evolving L cerebellar infarct and potential
brainstem infarction, with mass effect on the brainstem and
likely cerebellar herniation. The patient was intubated for
airway protection, confirmed by postintubation CXR, and admitted
to the SICU. CTA was unable to be obtained.
Postoperatively, the patient continued ICU care, with intubation
and was placed briefly on dexamethasone, and he was then
transferred back to the neurology service. His blood pressure
was allowed to autoregulate, to allow for adequate perfusion of
the brain, with the hope of reducing damage to any surrounding
zone of ischemia. He was placed on mannitol and dexamethasone
was discontinued. Postop CT showed: "1) S/p left suboccipital
craniotomy, with expected postoperative change in the left
cerebellar hemisphere in the region of evolving infarct.
Differences in obliquity and positioning compared to the
preoperative scan make assessment for interval change in mass
effect and potential cerebellar herniation difficult. 2)
Interval placement of right intraventricular catheter, with
layering hemorrhage within the right lateral ventricle and small
amount of hemorrhage along the entry tract"
Repeat MRI/A on [**8-25**] showed "A large left PCA infarct as well as
an acute infarct within the left cerebral peduncle. Relating to
the left PCA infarct, there are scattered infarcts within the
left thalamus.Interval development of intraparenchymal and
intraventricular blood, some of which relates to the recent
surgeries.
MRA: Nonvisualization of the left posterior cerebral artery
consistent with the acute left posterior cerebral artery
infarct. Small basilar artery. Poor visualization of the distal
V4 segment of the left vertebral artery."
From the time of his admission to the ICU, extensive discussions
were carried out with the family, informing them of the
patient's extremely guarded prognosis. He remained comatose off
sedation throughout. Hospital course was complicated by
ventilator-associated pneumonia and on [**8-29**], the patient was
started on cefepime, with sputum culture positive for GNRs. He
also intermittently went into afib with rapid ventricular
response, for which he was placed on diltiazem or labetalol
drip, with the restriction that it not lower his blood pressure
beyond goal of 150-160 systolic.
He was extubated but was not able to be weaned off of facemask.
After discussion with the family, he received a trach/PEG. Their
desire though is for him to be DNR but not DNI.
He was evaluated by cardiology for atrial fibrillation with
rapid ventricular response and placed on oral amiodarone and
labetalol for rate control, as well as enalapril for blood
pressure management. Despite these medications, he has been
difficult to control, but for the most part, his pulse rate has
stayed below 100. He transiently and asymptomatically drops his
heart rate to 40s. He is now discharged on coumadin, with goal
INR [**12-28**], to minimize the risk of cardiac embolism, particularly
to the posterior circulation, where another embolic stroke would
be devastating.
Neurologically, he has most likely reached his baseline and it
remains likely that he will enter a persistent vegetative state.
His prognosis remains guarded. Follow-up head CT's have been
stable. The most recent, on [**9-7**], showed: "Again seen are
changes within the left suboccipital region from hemicraniotomy.
There is some prolapse of left cerebellum through the craniotomy
defect, though this is unchanged in comparison to prior study.
Again seen is an area of parenchymal edema within the left
occipital region, corresponding to area of infarct, which has
increased slightly in comparison to prior study. There is
slightly increased mass effect on the left occipital [**Doctor Last Name 534**] of the
left lateral ventricle compared to the prior study. There is
stable appearance of foci of intraventricular hemorrhage.
Additionally there is continued evolution of blood products
within the right frontal lobe in the area of the prior
ventriculostomy catheter tract. The caliber of the ventricles is
otherwise unchanged in comparison to prior exam. No new foci of
intracranial hemorrhage are identified. The soft tissue and
osseous structures are stable in appearance." Goal sbp is <160.
In terms of pulmonary, the patient was started on [**9-7**] on
ceftriaxone/vancomycin for the possibility of pneumonia. He has
been having low-grade fevers and there was possibly an
infiltrate on chest x-ray. There is no clear evidence for or
against a pneumonia; he should complete a 7-day course (ie, 5
more days, as written) and then discontinue antibiotics. He
should receive chest PT, pulmonary toilet and trach care.
Nutrition: tube feeds as written.
He will be seen in neurology clinic with the stroke fellow and
attending.
Medications on Admission:
Methyldopa 250mg [**Hospital1 **]
Nifedipine XL 60mg QD
Allopurinol 100mg QD
Triamterene/HCTZ 37.5/25mg 1 tab QD
Lisinopril 40mg [**Hospital1 **]
Actos 30mg QD
Aspirin 325mg QD
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
3. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed.
4. Acetylcysteine 10 % (100 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed.
5. Enalapril Maleate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection QACHS: Per insulin sliding scale.
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 5 days.
14. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) Intravenous Q24H (every 24 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4415**]
Discharge Diagnosis:
Stroke
Atrial fibrillation
Discharge Condition:
Stable
Discharge Instructions:
Continue to take all medications as prescribed. Return to ER
with any recurrent symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 843**] [**Name8 (MD) 844**], MD Phone:[**Telephone/Fax (1) 10533**]
Date/Time:[**2160-10-13**] 11:15
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2160-10-22**] 1:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2160-9-8**]
ICD9 Codes: 5859, 4019, 2749, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2669
} | Medical Text: Admission Date: [**2162-3-3**] Discharge Date: [**2162-3-11**]
Date of Birth: [**2103-12-5**] Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
woman with a history of chronic major depression on monamine
oxidase inhibitors with a recent increase in dose.
In the weeks prior to admission the patient had been feeling
more depressed than usual, and on the day prior to admission
had visited her psychiatrist who increased her Nardil from
30 mg per day to 60 mg per day. According to her husband she
might not have been taking her Nardil regularly the previous
week. That night she had difficulty sleeping and was trying
to sleep in a separate room from her husband. At
approximately 2 a.m. the husband heard a scream and went to
the room to find that she had fallen between the bed and the
wall. He pulled her out. Her eyes were closed. She was
unresponsive, and there was no noted twitching. In
retrospect, he examined the house and could not find evidence
to support that she had taken any additional medications.
The Emergency Medical Service was called, and en route she
apparently had a witnessed tonic-clonic seizure for two
minutes with urinary incontinence. A blood sugar measured at
that time was 127 mg/dL.
On arrival to the [**Hospital3 10310**] Hospital at approximately
4 a.m. on [**2162-3-3**], the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 2611**] Coma Scale
score was 5. There was noted rigidity. Her temperature was
100 degrees. Her pulse was 93, and the respirations were 29
per minute. Pupils were 3 mm. The patient was sedated,
paralyzed, and intubated. Her blood pressure was 142/92 and
her oxygen saturation was 100%. The patient was transferred
to the [**Hospital1 69**] by Med-Flight to
evaluate for possible intracranial hemorrhage.
According to her husband who is a psychiatrist, the patient
has had fluctuating mental status for some time marked by
somnolence at times, and there was one episode where she
collapsed and was unresponsive for several minutes which was
attributed to the Nardil and to orthostatic hypotension. She
also has had recent insomnia, hypersomnia, and mild agitation
at times. There was no known suicidal ideation. There were
no known co-ingestants, and there was no known recent change
in diet.
After arrival at the [**Hospital1 69**],
the patient remained rigid but moved all four extremities.
No seizure activity was noted. The patient was given
activated charcoal for gastrointestinal decontamination,
cyproheptadine for the possibility of serotonin syndrome,
intravenous benzodiazepines for sedation, intravenous fluids,
ceftriaxone for the possibility of meningitis, a single dose
of vecuronium 6 mg (to perform a lumbar puncture), and 1 unit
of fresh frozen plasma for the lumbar puncture.
PAST MEDICAL HISTORY:
1. Depression; there is no history of overdose.
2. Orthostatic hypotension.
3. Abnormal liver function tests with mildly transaminases
several months ago.
4. Possible febrile seizures as a child.
5. Heme-positive stools.
MEDICATIONS ON ADMISSION: Xanax 0.25 mg p.o. q.i.d.,
phenelzine 30 mg to 60 mg p.o. q.d., Florinef.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is from Rivi??????re, [**State 350**].
Attended [**University/College **] Divinity School and worked as a chaplain and
as an art teacher until stopping secondary to depression in
the middle [**2150**]. She lives at home with her husband, a
psychiatrist medical doctor. She is gravida 3, para 3 with
three daughters. She has smoked one pack per day for 15
years and drinks approximately two drinks per night of
alcohol. She denies drug use. She denies being hit, hurt or
threatened at home and feels safe at home.
FAMILY HISTORY: The patient's mother had a mitochondrial
disease diagnosed by muscle biopsy which presented late in
life. The patient has a family history of cardiomyopathy,
myopathy, coronary artery disease, myocardial infarction.
There is no known history of seizures. The patient is left
handed.
REVIEW OF SYSTEMS: Initially, the review of systems was
unable to be performed secondary to the patient's mental
status. A later review of systems was significant only for
fatigue and depression increased over the past few months as
well as the recent changes in mental status noted in the
History of Present Illness.
PHYSICAL EXAMINATION ON PRESENTATION: The vital signs on
presentation revealed a temperature of 102.5, a pulse of 80,
a blood pressure of 155/70, a respiratory rate in the 20s,
and an oxygen saturation of 100%. In general, the patient
was intubated and agitated at times. Examination of the head
revealed that the pupils were equal, round, and reactive to
light at 3 mm. There were no roving eye movements. The neck
had increased muscle tone. There was no lymphadenopathy.
Lungs were clear to auscultation bilaterally with no rales or
wheezes. Heart examination revealed a regular rate and
rhythm with no murmurs, rubs or gallops. Abdominal
examination revealed a soft and nontender abdomen with no
hepatosplenomegaly, and normal active bowel sounds.
Extremity examination revealed increased tone in all four
extremities. Muscular rigidity was greater in the lower
extremities than in the upper extremities. Neurologic
examination revealed toes were upgoing bilaterally. Deep
tendon reflexes were 3+ in all extremities with no ankle
clonus. The patient withdrew to pain in all four
extremities, but did not respond to voice. Pulses were 2+ in
all four extremities. The skin was pale and without bruises.
There was no costovertebral angle tenderness.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory
studies with a complete blood count which revealed a white
blood cell count of 9.4, a hematocrit of 34.5, a hemoglobin
of 11.6, a platelet count of 245. Serum chemistries revealed
a sodium of 148, a potassium of 3.2, a chloride of 98, a
bicarbonate of 28, a blood urea nitrogen of 22, a creatinine
of 0.7, and a glucose of 141. Magnesium was 1.4, phosphate
was 3.5, and calcium was 8.4. There was a slight
coagulopathy with an INR of 1.5, a PT of 14.6, and a PTT
of 23.5. The erythrocyte sedimentation rate was 5.
Fibrinogen was 225. A urinalysis revealed trace ketones, 3
to 5 white blood cells per high powered field, trace
proteins, 0 white blood cells per high powered field. Liver
function tests were abnormal with an ALT of 83, an AST
of 975, an alkaline phosphatase of 511, and a total bilirubin
of 0.7. Albumin was 3.9, amylase was 119, and lipase of 31.
Serum toxicology screen was negative, and the urine
toxicology screen was positive only for benzodiazepines. An
arterial blood gas revealed a pH of 7.48, a PCO2 of 32, and a
PO2 of 457. A lumbar puncture performed in the Emergency
Room revealed a protein of 34, a glucose of 95, only 1 white
blood cell, and 5 red blood cells; only 15 cells total. A
Gram stain of the cerebrospinal fluid showed no polys and no
microorganisms. Culture of the cerebrospinal fluid later
proved negative. Serum and urine were sent to outside
laboratories to screen for sertraline, fluoxetine,
paroxetine, and venlafaxine. The results of those studies
were pending at this time. The patient's creatine kinase
was 110, with a CK/MB fraction of 4, and cardiac troponin of
less than 0.3.
RADIOLOGY/IMAGING: An electrocardiogram revealed a normal
sinus rhythm and was otherwise unremarkable.
A CT of the head and cervical spine without contrast was
performed in the Emergency Room and showed no evidence of
acute intracranial hemorrhage of mass effect. It showed a
fracture of the left facet of C6 with unknown chronicity. No
cord compression of canal impingement.
A chest x-ray obtained in the Emergency Room showed
satisfactory placement of endotracheal and nasogastric tubes
as well as bibasilar atelectasis.
HOSPITAL COURSE: The patient was transferred to the
Intensive Care Unit for airway protection.
Note: Dictation ended after 16.9 minutes.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 34724**]
Dictated By:[**Doctor Last Name 39130**]
MEDQUIST36
D: [**2162-3-11**] 18:16
T: [**2162-3-12**] 14:27
JOB#: [**Job Number 22759**]
ICD9 Codes: 2768, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2670
} | Medical Text: Admission Date: [**2141-12-19**] Discharge Date: [**2141-12-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Melena, Upper GI bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
84yoF with Alzheimer's Dementia, HTN presents to the ED with
anemia. Per PCP, [**Last Name (NamePattern4) **]. [**Name (NI) 5351**], pt was in usual state of health
until night PTA when she was noted to be pale, nauseous. Hct
found to be 22 but given that pt was HD stable without melena,
hematochezia, abdominal pain, weakness or dizziness, they
decided to transfer her to hospital in am. Of note, pt was
started on celebrex 200mg qd on [**10-19**] and it was recently
increased to 400mg qd for her osteoarthritis.
.
In the ED, vital signs were T 98.1, HR 89, BP 114/60. NG lavage
was done in the ED and revealed 10cc of bright red blood which
cleared immediately with saline. Rectal exam showed black tarry
stools. She was type and crossed, and ordered for 2U PRBCs.
.
On arrival to ICU, pt without complaint. She states that she
does not know why she is here. She denies dizziness,
lightheadedness, abdominal pain, nausea, emesis, black or bloody
stools.
Past Medical History:
* atrial fibrillation?
* Alzheimer's Dementia
* HTN
* hx of bilateral lower ext edema
* DJD
* h/o Skin cancer: squamous cell, melanoma
* s/p appendectomy as a [**Country **]
* s/p TAH
Social History:
Resident in [**Location (un) **], [**Location (un) 538**] ([**Telephone/Fax (1) 25425**])
- Needs help with all ADLs
- hx of [**2-13**] ppd smoking
Family History:
NC
Physical Exam:
Vitals: T 97.3 BP 160/74, HR 84, R 18, O2 100% RA
Gen: NAD
HEENT: MMM, Clear OP
Neck: supple, no JVD noted, no bruits
CV: irregularly irregular, S1, physiologic split S2, no murmurs
Chest: CTA BL BS
Abd: +BS, soft, nontender in all 4 quadrants, no bruits
Ext: warm, 1+ DP, old healed scar on medial left calf
Neuro: A&Ox1--able to converse fluently, says she knows the
date, hospital, and president of U.S., but unable to name. Did
not know why she was brought to the hospital "I was sick."
Otherwise grossly normal.
Pertinent Results:
[**2141-12-19**] 11:40AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2141-12-19**] 11:40AM BLOOD CK(CPK)-35
[**2141-12-19**] 11:40AM BLOOD Glucose-111* UreaN-35* Creat-0.8 Na-141
K-4.5 Cl-107 HCO3-24 AnGap-15
[**2141-12-21**] 11:30AM BLOOD Glucose-86 UreaN-15 Creat-0.7 Na-142
K-4.2 Cl-107 HCO3-24 AnGap-15
[**2141-12-19**] 11:40AM BLOOD WBC-8.8 RBC-2.34* Hgb-6.9* Hct-19.9*
MCV-85 MCH-29.6 MCHC-34.9 RDW-15.9* Plt Ct-328
[**2141-12-21**] 11:30AM BLOOD WBC-7.6 RBC-3.45* Hgb-10.0* Hct-29.4*
MCV-85 MCH-29.0 MCHC-34.0 RDW-16.3* Plt Ct-314
.
EGD:
Grade 4 esophagitis in the whole Esophagus
Small hiatal hernia
Erythema and erosion in the stomach body compatible with
gastritis
Otherwise normal EGD to second part of the duodenum
.
Brief Hospital Course:
The patient was admitted for an Upper GI bleed. The patient was
transfused a total of 2U of PRBC with stabilization of HCT. EGD
showed Grade IV esophagitis. Her HCT remained stable on the
floor. She will be discharged on [**Hospital1 **] protonix and carafate 1 gm
QID. She should avoid ASA and NSAIDS (including cerebrex) in the
future. She can be given Tylenol in the future for her OA.
.
She was continued on the remained of her medical regimine.
Medications on Admission:
* Celebrex 400mg qday (started at 200mg on [**2141-10-19**], increased to
400mg on [**2141-12-15**])
* Zyprexa 2.5mg qAM
* Lasix 20mg qday
* ASA 325mg qday
* MVI
Discharge Medications:
1. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis
Upper GI bleed secondary to Grade 4 Esophagitis
Secondary Diagnoses:
* Alzheimer's Dementia
* HTN
* hx of bilateral lower ext edema
* DJD
* h/o Skin cancer: squamous cell, melanoma
* s/p appendectomy as a [**Country **]
* s/p TAH
Discharge Condition:
stable, no further evidence of bleeding
Discharge Instructions:
Please contact your primary care provider should you have any
lightheadedness, blood in your stools, black stools, or any
other complaints.
In the future, do not take aspirin anymore. In addition, please
try to avoid Celebrex and use tylenol instead.
Followup Instructions:
Please follow up with your primary care doctor within 1-2 weeks.
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2671
} | Medical Text: Admission Date: [**2111-8-21**] Discharge Date: [**2111-8-25**]
Date of Birth: [**2027-8-26**] Sex: M
Service: MEDICINE
Allergies:
Levaquin / Lorazepam
Attending:[**First Name3 (LF) 86897**]
Chief Complaint:
Chills, lower abdominal Pain
Major Surgical or Invasive Procedure:
Right IJ central line
History of Present Illness:
The patient is an 83M with h/o MDS and s/p cysto dilation of
anterior urethral stricture 1 month ago, currently self-cathing
for urine who presents with fever and dysuria. He saw his
oncologist in clinic today and reported that over the past week,
he has been having pain every time he self-caths and has been
leaking urine. He has had low grade temps in the morning but on
morning of admission, his temperature was 99.9 and he had
shaking chills.
.
In the ED inital vitals were, 8 100 86 109/41 18 100% ra. His UA
was consistent with UTI and he was started on cefepime. His
blood pressures were low, in the 80s, and he was given 3L IVF.
Given that he was also anemic, he was transfused 2 units pRBCs.
A RIJ was placed.
.
On arrival, he is comfortable and vitals are stable.
.
Review of systems: see metavision
Past Medical History:
Past Oncological History:
Myelodysplastic syndrome s/p 4 cycles Azacitidine (last dose in
[**2111-5-6**]); baseline immunosuppressed with white cell count ~
2, and hematocrit in the mid 20's with frequent need for red
cell transfusions
Other Past Medical History:
CAD s/p CABG
Dyslipidemia
Parkinson's disease
Depression/Anxiety
Myelodysplastic syndrome
Hard of Hearing
Social History:
Married, lives at home with wife. Retired [**Name2 (NI) **] worker.
- Tobacco: remote
- Alcohol: none
- Illicits: none
Family History:
Non-contributory
Physical Exam:
Vitals T:97.3 BP:120/48 HR:71 RR:15 02 sat:95% RA
GENERAL: NAD, well appearing
SKIN: warm and well perfused, ecchymosis bilaterally on upper
and lower extremities
HEENT: NC/AT, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, nontender supple neck, no LAD, no JVD. Hard of hearing
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
GU: Foley in place draining clear yellow urine, no scrotal edema
EXT: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
FEX ON DISCHARGE
Vitals - Tm: 99.5 Tc: 97.4 BP:130/58 HR:68 RR:20 02 sat:98%RA
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: EOMI, PERRLA, anicteric sclera, pink conjunctiva, MMM,
nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. No gross change to senosory or motor
exam.
Pertinent Results:
BLOOD
[**2111-8-21**] 04:30PM BLOOD WBC-6.2# RBC-2.18* Hgb-8.6* Hct-25.2*
MCV-116*# MCH-39.5*# MCHC-34.1 RDW-20.4* Plt Ct-32*
[**2111-8-22**] 03:14PM BLOOD WBC-4.7 RBC-2.73* Hgb-10.0* Hct-29.4*
MCV-108* MCH-36.5* MCHC-33.9 RDW-21.9* Plt Ct-22*
[**2111-8-25**] 06:17AM BLOOD WBC-4.6 RBC-2.98* Hgb-10.7* Hct-32.8*
MCV-110* MCH-35.8* MCHC-32.5 RDW-20.3* Plt Ct-31*
[**2111-8-21**] 04:30PM BLOOD Neuts-76* Bands-7* Lymphs-12* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2111-8-21**] 04:30PM BLOOD PT-14.6* PTT-38.2* INR(PT)-1.3*
[**2111-8-22**] 03:14PM BLOOD Fibrino-594*
[**2111-8-21**] 04:30PM BLOOD Glucose-117* UreaN-22* Creat-1.1 Na-139
K-3.7 Cl-106 HCO3-26 AnGap-11
[**2111-8-23**] 06:50AM BLOOD Glucose-96 UreaN-11 Creat-0.8 Na-142
K-3.8 Cl-112* HCO3-22 AnGap-12
[**2111-8-25**] 06:17AM BLOOD Glucose-97 UreaN-14 Creat-0.8 Na-142
K-3.5 Cl-106 HCO3-26 AnGap-14
[**2111-8-22**] 03:07AM BLOOD ALT-16 AST-31 LD(LDH)-161 AlkPhos-213*
TotBili-1.2
[**2111-8-22**] 03:07AM BLOOD Albumin-2.4* Calcium-6.5* Phos-2.6*
Mg-1.7
[**2111-8-25**] 06:17AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1
[**2111-8-21**] 04:54PM BLOOD Lactate-1.6
[**2111-8-22**] 08:53PM BLOOD freeCa-1.12
URINE
[**2111-8-21**] 04:30PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.013
[**2111-8-21**] 04:30PM URINE Blood-LG Nitrite-POS Protein-100
Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2111-8-21**] 04:30PM URINE RBC-39* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
[**2111-8-24**] 11:19AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.008
[**2111-8-24**] 11:19AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2111-8-24**] 11:19AM URINE RBC-143* WBC-143* Bacteri-NONE Yeast-NONE
Epi-0
MICROBIOLOGY
Urine Cx [**2111-8-21**]:
URINE CULTURE (Final [**2111-8-24**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA OXYTOCA
| |
AMPICILLIN/SULBACTAM-- 16 I 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I <=16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Blood Cx [**2111-8-21**]: NGTD, pending
Blood Cx [**2111-8-23**]: NGTD, pending
Blood Cx [**2111-8-24**]: NGTD, pending
Urine Cx [**2111-8-24**]: NGDD, pending
REPORTS
EKG [**2111-8-21**]:
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
CXR [**2111-8-21**]:
The tip of the right IJ line lies at the cavoatrial junction. No
evidence of a pneumothorax is present. The patient is status
post CABG. The heart remains enlarged, no failure is
present.
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
83 yo M with h/o MDS and uretheral stricture with
self-intermittent catheterizing admitted FOR with sepsis
secondary to UTI.
ACTIVE PROBLEMS
# Sepsis secondary to urinary source: Presented to ED with
chills, abdominal pain and low grade fever. Became hypotensive
and had grossly positive UA in in setting of uretheral dilation
for stricture and self-catheterization. Patient was started on
vancomycin and cefepime. Received IVF's and blood transfusion
with recovery of blood pressure. Switched off vancomycin after
GS showed no gram positive organism. Culture grew pan-sensitive
klebsiella and switched to ciprofloxacin to complete 15 day
course. Will complete 14 day course.
# [**Last Name (STitle) 87781**]truction: Patient followed by Dr. [**Last Name (STitle) **] as
outpatient. Underwent TURP earlier this year for obstruction
followed by dilation of urinary stricture in [**Month (only) 216**]. Has been
self catheterizing at home since. Foley was placed on admission.
Upon arrival to the floor, foley was removed with plan to
bladder scan periodically and straigh cath as needed. Patient
did not tolerate plan as he complained of continuous 'leaking'
with continued burning sensation. Additional UA was obtained,
which still showed large blood and WBC. Culture pending at time
of writing. After speaking with urology, chronic foley was
placed until patient follows up with Dr. [**Last Name (STitle) **] as outpatient.
# MDS: Previously treated with azacitidine, last dose 6/[**2110**].
Did receive blood transfustion early in hospitalization.
Remained markedly thrombocytopenic during stay, but stable in
low 20's. Plan to continue follow up with outpatient oncologist.
# Relative Hypocalcemia: Noted to be hypocalcemic on admission
to 6.5. Albumin noted to be low at 2.4. Ionized calcium normal
at 1.14. By discharge total calcium recovered to 8.4.
CHRONIC PROBLEMS
# CAD: Stable, admission EKG showed no ischemic changes. Home
simvastatin was reduced from 80mg to 40mg. Metoprolol was held
in setting of hypotension, but restarted on discharge. Patient
was not treated with ASA considering low platelets.
# Elevated Alk Phos: Has been in 200's since [**Month (only) 404**]. No u/s
here in system. Patient without RUQ pain. [**Doctor Last Name **] deferred to
outpatient setting.
# Depression: Continued home mirtazapine and sertraline.
# Parkinsons: Continued home carbidopa-levodopa.
OUTSTANDING STUDIES
-Urine Cx from [**8-24**]
-Final reports of blood cultures
TRANSITIONAL ISSUES
-Will need continued following for chronic urinary retention as
patient did not tolerate intermittent self catheterization and
currently has a chronic foley catheter.
-Please note simvastatin was reduced from 80mg to 40 mg.
Medications on Admission:
Medications on Transfer:
Docusate Sodium 100 mg PO BID [**8-22**] @ 0035
Sertraline 100 mg PO/NG DAILY [**8-22**] @ 0035
Fluticasone Propionate NASAL 2 SPRY NU DAILY [**8-22**] @ 0035
Mirtazapine 30 mg PO/NG HS
Carbidopa-Levodopa (25-100) 1 TAB PO/NG TID
Multivitamins 1 TAB PO/NG DAILY [**8-22**] @ 0035
Vancomycin 1000 mg IV Q 12H [**8-22**] @ 0035
CefePIME 1 g IV Q24H [**8-22**] @ 0035
Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever [**8-22**] @ 0035
Simvastatin 40 mg PO/NG DAILY [**8-22**] @ 0035
Potassium Chloride Replacement (Oncology) IV Sliding Scale
Magnesium Sulfate Replacement (Oncology) IV Sliding Scale
Phytonadione 5 mg PO/NG ONCE Duration: 1 Doses [**8-22**] @ 1023
Home Medications:
Darbepoetin Alfa 300 mcg/0.6 mL Injection Syringe 300mcg sc
Simvastatin 80 mg Oral Tablet
Sertraline 100 mg Oral Tablet
Amoxicillin 250 mg Oral Capsule TAKE 1 CAPSULE DAILY
fluticasone 50 mcg Nasal Spray, Susp Nasal 2 Spray,Once Daily
metoprolol succinate ER 25 mg 0.5 Tablet Once Daily
mirtazapine 15 mg Tab Oral 2 Tablet(s) , at bedtime
carbidopa-levodopa 25 mg-100 mg 1 Tablet(s) 8 am, 12 noon, 4pm
Tylenol 325 mg Tab Oral 2 Tablet(s) Every 4-6 hrs, as needed
One Daily Multivitamin Tab Oral 1 Tablet(s) Once Daily
Discharge Medications:
1. darbepoetin alfa in polysorbat Injection
2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
4. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 (One half) Tablet Extended Release 24 hr PO once a day.
9. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 days: Take through [**2111-9-3**].
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Primary: Sepsis due to a urinary source
Secondary: Urinary retention, MDS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 76405**],
You were admitted to the hospital because you were having
chills, fevers, and abdominal pain. We found that you had a bad
urinary tract infection and you went to the ICU because your
blood pressure was low. We treated you with antibiotics and your
blood pressure recovered. You continued to have problems with
urinary leakage, so after speaking with the urologists, we
decided to leave a foley catheter in place until you can follow
up with your urologist. Please note the following changes to
your medications.
START: Ciprofloxacin 500mg twice daily through [**2111-9-3**]
DECREASE: Simvastatin to 40mg daily
STOP: Amoxicillin while taking cipro unless instructed otherwise
by your urologist.
It has been a pleasure taking care of you.
Followup Instructions:
The following appointments have been scheduled for you:
Department: Oncology
When: [**2111-9-4**] at 12 PM
With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 65559**]
Fax: [**Telephone/Fax (1) 6808**]
Department: SURGICAL SPECIALTIES
When: MONDAY [**2111-8-31**] at 1 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 86898**]
ICD9 Codes: 5990, 0389, 2762, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2672
} | Medical Text: Admission Date: [**2144-6-9**] Discharge Date: [**2144-6-17**]
Service: MED
Allergies:
Sulfonamides / Ticlid / Persantine / Aspirin / Benadryl /
Xylocaine / Prevacid
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
respiratory distress and weakness
Major Surgical or Invasive Procedure:
pericardial window
History of Present Illness:
This 86 year old man with h/o Afib(on warfarin), CHF, CAD(s/p
AMI '[**33**]), and PVD, developed a fever 1 wk prior to admission,
and since his primary physician had relocated, he opted to treat
himself with amoxicillin 1000 mg tid, using pills that he kept
for dental procedures. His fever resolved, but he developed
myalgias and arthralgias as well as increasing dyspnea. He
presented to the ED and an echocardiogram on [**6-10**] revealed a
large pericardial effusion, EF-30%, most of fluid in posterior.
region. Tamponade physiology. Pulsus 22-25. Pt. went to OR for
pericardial window, approx. 1 liter of blood tinged fluid was
drained(gram stain neg./prelim. cx neg for malignant cells). Pt
was extubated on [**6-12**], without incident.
Past Medical History:
Afib(on warfarin)
CHF
CAD(s/p AMI '[**33**])
PVD
Pulm. HTN
asthma
gout
CEA('[**36**])
CVA('[**35**])
hypothyroidism
Social History:
no tobacco or EtOH
Lives with wife, a receptionist
Retired pharmacist
Physical Exam:
T: 97.2 HR: 77 (A Fib) RR: 22 BP: 110/47 O2sat: 99 4L NC
Gen: in NAD.
HEENT: PERRL, neck supple
Lungs: diffuse crackles, few wheezes in B middle to lower lobes
Chest: CT in place with dry dressing. Heart irregular rhythm. No
murmurs
Abd: +mass R middle to lower quadrant. Soft, non-tender. +BS
Ext: 1+ edema to mid-calf. Ecchymoses, varicose veins B
Neuro: A&Ox3. Non-focal
Pertinent Results:
Brief Hospital Course:
Prior to going to the Operating Room for the pericardial window
procedure, he was given 2 units of FFP and coumadin(INR-1.8) was
held. His Nitrates and HCTZ were also temporarily held. Mr [**Known lastname **]
was eventually weaned from the ventilator and extubated on
[**2144-6-12**] after a transient episode of tachycardia and O2
desaturation that required lopressor and increase in his O2.
His BP remained stable, his JVD and edema decreased, and a
repeat ECHO on [**2144-6-11**] showed sm. pericardial effusion, RA/[**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 7151**] dilated, mod-severe TR/MR, severe apical hypokinesis,
mild hypokinesis of rest of LV After extubation in the CCU, pt
stabilized and was returned to floor. Initially, pt was dyspnic,
but denied pain, N/V/HA/fevers. CT remained in place, and was
removed [**6-15**] by cardiac surgery without complications. Pt
started on ethacrinic acid and HCTZ on [**6-15**] to aid in diuresis
(this regimen is one of the only ones he tolerates due to
multiple drug reactions), with close attention paid to
electrolytes. The right lung showed a pleural effusion, but the
patient elected to attempt to reduce the effusion with diuresis
alone and not to perform thoracentesis. Pt had physical therapy
daily, and improved significantly in the few days after being
returned to the floor. When INR came down to patient's baseline
on [**6-16**], pt was restarted on his home dose of coumadin (2 mg po
qd 5 days of the week, 3 mg 2 days of the week). The patient
stated his MD [**First Name (Titles) 7152**] [**Last Name (Titles) 7153**] his INR at 1.3 to avoid
nosebleeds at higher INRs, but it was explained that a range of
[**1-21**] was required for prevention of stroke in patients with
A-fib. Pt understood. On the day of discharge to [**Hospital 38**]
Rehabilitation Center, his INR was 3.1, so coumadin was held,
with plan to have daily INR checks until it stabilizes, then
restart in rehab. Pt conitnued to have good O2 saturations well
and was eating. Pt told medical team that his arthritis and back
pain was well controlled with the Tylenol regimen, therefore, pt
was told he should follow up as an outpt by talking to his PCP
and asking him/her to make a referral for pain management if
patient wants to explore pain management further. During
hospital stay, pt had foley catheter, which was removed. Pt's UA
showed microhematuria, asymptomatic, without any complications
in course. Pt to follow up with PCP (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to see
in interim before re-eatablishing with new geriatrician, Dr.
[**Last Name (STitle) **] to repeat UA in [**2-20**] weeks to look for persistent
hematuria, and subsequent w/u of bladder/renal pathology if
positive. Pt to go to rehab, with close follow up with his
electrolytes, BUN/Cr, and INR.
Medications on Admission:
Lactulose 30 ml PO Q8H:PRN
Metoprolol 50 mg PO BID hold for SBP<100, HR<55
Morphine Sulfate 1-5 mg IV Q4-6H:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Multivitamins 1 CAP PO QD
Allopurinol 100 mg PO QOD
Pyridoxine HCl 50 mg PO QD
Albuterol-Ipratropium [**12-20**] PUFF IH Q6H
Senna 1 TAB PO BID
Bisacodyl 10 mg PO QD:PRN
Calcium Carbonate 500 mg PO TID
Docusate Sodium 100 mg PO BID
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QOD (every
other day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Pyridoxine HCl 25 mg Tablet Sig: Two (2) Tablet PO QD (once a
day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for please give until bm.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-20**]
Puffs Inhalation Q6H (every 6 hours).
12. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO qam ().
13. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: Three
(3) Capsule, Sustained Release PO qhs ().
14. Ethacrynic Acid 25 mg Tablet Sig: Four (4) Tablet PO QD
(once a day).
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
16. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
17. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO QD EXCEPT
MONDAY AND THURSDAY (): please hold until INR stabilizes.
18. Warfarin Sodium 2 mg Tablet Sig: 1.5 Tablets PO MONDAY AND
THURSDAY ONLY (): please hold until INR stabilizes.
19. Morphine Sulfate 8 mg/mL Syringe Sig: One (1) Injection
Q4-6H (every 4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. Pericardial effusion s/p pericardial window
2. AFib
3. CAD
4. UGI bleed secondary to duodenal ulcers
5. Ashtma
6. Gout
7. Hypothyroidism
8. CVA
9. OSA
10.Pulmonary HTN
11. H/O AMI in [**2133**]
12. PUD
13. CEA in [**2136**]
14. CHF
Discharge Condition:
stable
Discharge Instructions:
1. please take all your medications.
2. If you feel short of breath, or have any problems breathing,
come back to the hospital.
3. If you have fevers, chills, nausea, or vomiting, chest pain,
come back to the hospital immediately.
4. You need to have very strict monitoring of your INR DAILY
since you were re-started on it in the hospital. You are
currently not taking coumadin right now, but once your INR
stabilizes, you should re-start your coumadin. You should also
have daily checks of your electrolytes, BUN/Cr
5. Continue Tylenol for your back pain, and tell your primary
care doctor you would like a referral for a consultation on pain
management. Please contact Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 719**] to
confirm your appointment.
6. At the rehab center, ask for nebulizers to help you breath
better, and ask to be taught how to use a spacer, so that you
can use the inhalers better
Followup Instructions:
Primary care doctor appointment:
Dr. [**Last Name (STitle) **] [**7-21**]. Mrs. [**Known lastname **] will be called for exact
time.
[**Telephone/Fax (1) 719**] to speak to assistant of Dr. [**Last Name (STitle) **]
Cardiology appointment:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2144-6-25**] 9:00
ICD9 Codes: 4280, 412, 4168, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2673
} | Medical Text: Admission Date: [**2183-10-2**] Discharge Date: [**2183-10-4**]
Date of Birth: [**2115-3-22**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Adhesive Tape / Iodine
Attending:[**Doctor Last Name 1857**]
Chief Complaint:
Syncope and chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 3311**] is a 68 yo man with a history of severe CAD s/p MI,
3V CABG (LIMA-LAD, SVG-RCA, sequential SVG-D1-OM) in [**2169**] and
multiple PCIs who presents with acute onset chest pain. The
patient states that he was in his usual state of health when he
woke up this morning [**10-2**]. He was in his kitchen when the next
thing he knew he woke up on the floor. He denies any prodrome
including dizziness, lightheadedness, vertigo, focal weakness,
or aura. He does not know how long he was unconscious, but when
he awoke he was experiencing acute onset [**10-8**] retrosternal
chest pain. The pain was diffuse and located at the midline. It
was not positional and was not acutely associated with nausea or
vomiting. It did radiate up to his jaw, which alarmed him since
this was exactly what he experienced when he had his MI. He does
not think he fell on his chest. He was able to get up on his
own, climb the stairs, and call EMS.
He was brought to [**Hospital3 **] where he was given ASA and
nitro SL without relief of his chest pain. He was started on a
TNG drip but still complained of [**10-8**] pain. EKG showed
ventricularly paced rhythm with no acute ST or QRS changes from
prior. A Troponin-I measurment was 0.14. Myoglobin was 103. His
INR was 4.3. An ABG on 2L NC at that time was 7.32/46/95/24/Sat
97%. He was subsequently transferred to [**Hospital1 18**] for possible
catheterization.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
He denies recent fevers, chills or rigors. He is unable to walk
very far due to left leg pain, but states this is due to an
established neuropathy. 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.
Past Medical History:
-CAD s/p MI
-CABG [**2169**] (LIMA-LAD, SVG-RCA, SVG-D1-OM)
-Hypertension
-Hyperlipidemia
-Atrial tachycardias, s/p ablation, followed by atrial
fibrillation/flutter with AV nodal ablation s/p pacer [**2177**], on
warfarin
-Neuropathy
-Gout
-Depression and anxiety
Social History:
significant for the absence of current tobacco use (smoked from
age 16-46 at 1 ppd). There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Gen: WDWN middle aged Caucasian male in NAD, mild distress,
mildly diaphoretic. Oriented x3. Mood, affect appropriate.
Pleasant.
VS: T 96.6, BP 126/77, HR 84, RR 21, O2 sat 100% on 5 L/min NC
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 7 cm. No carotid bruits.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal rate. Normal S1, S2, no murmurs, rubs or gallops.
Chest: Pacemaker palpable in L upper chest; Resp were unlabored,
no accessory muscle use. No crackles, wheeze, rhonchi.
Abd: soft, NT/ND, No HSM or tenderness. No abdominial bruits.
Ext: No clubbing, cyanosis or edema. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2183-10-2**] 02:32PM WBC-6.9 RBC-4.44* HGB-14.0 HCT-40.8 MCV-92
MCH-31.4 MCHC-34.2 RDW-16.3*
[**2183-10-2**] 02:32PM PLT COUNT-145*
[**2183-10-2**] 02:32PM PT-37.2* PTT-54.8* INR(PT)-4.1*
[**2183-10-2**] 02:32PM GLUCOSE-138* UREA N-25* CREAT-1.6* SODIUM-141
POTASSIUM-5.3* CHLORIDE-108 TOTAL CO2-27 ANION GAP-11
[**2183-10-2**] 02:32PM ALT(SGPT)-11 AST(SGOT)-20 LD(LDH)-216
CK(CPK)-131 ALK PHOS-138* AMYLASE-105* TOT BILI-0.4
[**2183-10-2**] 02:32PM LIPASE-44
[**2183-10-2**] 02:32PM ALBUMIN-4.2 CALCIUM-8.6 PHOSPHATE-3.0
MAGNESIUM-2.0
[**2183-10-2**] 02:32PM CK(CPK)-131 CK-MB-12* MB INDX-9.2
cTropnT-0.14*
[**2183-10-2**] 05:38PM CK(CPK)-127 CK-MB-14* MB INDX-11.0*
cTropnT-0.20*
[**2183-10-3**] 06:42AM CK(CPK)-96 CK-MB-NotDone cTropnT-0.12*
[**2183-10-3**] 06:42AM Mg-2.0 Cholest-137
[**2183-10-3**] 06:42AM Triglyc-151* HDL-43 CHOL/HD-3.2 LDLcalc-64
LDLmeas-74
ECG [**2183-10-2**] 2:27:24 PM
Ventricular paced rhythm at 69 bpm with indeterminate underlying
cardiac rhythm, possibly atrial fibrillation. Compared to
previous tracing of [**2183-7-26**] no diagnostic change.
[**2183-10-2**] CXR In comparison with the study of [**2183-7-24**], there is no
change in the appearance of the heart and lungs, or the
pacemaker device. No evidence of acute pneumonia.
[**2183-10-3**] Rib xray: There is a dual lead left-sided pacemaker with
distal lead tips in right atrium and right ventricle. Median
sternotomy wires are seen. There is cardiomegaly which is
stable. No focal consolidation is seen. Markers have been placed
over the right lower rib cage, in this location, no focal
fractures are seen. There are no lytic or blastic lesions.
Degenerative changes of the lumbar spine are present.
Brief Hospital Course:
Mr. [**Known lastname 3311**] is a 68 yo man with CAD s/p CABG and multiple
subsequent PCIs who presented with a syncopal episode followed
by acute onset [**10-8**] CP not relieved by nitrates, slightly
elevated cardiac enzymes in the setting of acute renal
insufficiency.
1) Chest pain: Given strong history of CAD, his chest pain was
initially concerning for cardiac ischemia/ACS and arrhythmia and
he was admitted to the cardiac ICU. His cardiac enzymes were
minimally elevated (CKMB to 14, TnT to 0.20 with a rise and
falling pattern, in contrast to minimal abnormalities in the
past at 0.02) and consistent with a NSTEMI, however his chest
pain was very atypical in that it was constant and not relieved
by nitrates. He has had a recent catheterization in [**Month (only) 216**] with
no treatable lesions (and in fact complicated by perforation of
the RCA during attempted angioplasty of a chronic total
occlusion), and CTA had shown no evidence of aortic dissection.
He was transferred to the floor for further management. His
chest pain was improved with Dilaudid and Ativan. The benefits
of repeat cardiac catheterization were not felt to outweigh the
risks, and he was treated medically. He was discharged the
following day on medical management with ASA, lovastatin,
metoprolol and isosorbide.
2) Syncope - concerning for possiblity of VT/VF arrhythmia given
lack of prodromal symptoms in a patient with significant
CAD/prior MI. There was no evidence of VT at rate greater than
180 on pacemaker interrogation, however concern would be for
slower VT. Other possiblity is orthostatic hypotension although
less likely given lack of prodrome and generally feeling well.
His ICD was reset to trigger at VT >140bpm.
3) Chronic Systolic and Diastolic heart failure: with slightly
reduced EF of 45-50% on recent echo. No evidence for CHF
exacerbation at this time, although patient does have elevated
right-sided filling pressures as evidenced by elevated JVP. He
was continued on metoprolol.
4) Atrial fibrillation s/p pacemaker- paced rhythm in 70's. His
warfarin was held as INR supratheraputic. He was set up for
outpatient INR recheck and monitoring of Coumadin dosing.
5) Acute renal insufficiency - currently at baseline creatinine
compared with prior admission in [**Month (only) 205**], however consistently
elevated above baseline one year ago which was normal,
suggesting possibly interval worsening of renal failure vs.
hypertensive nephropathy.
6) Gout: no acute issues; he was continued on allopurinol daily.
7) Hypertension - currently well controlled; he was continued on
metoprolol
8) Hyperglycemia- elevated blood sugar during this admission,
however patient has not been diagnosed or treated in the past,
with A1C of 5.5% in [**7-5**] therefore not hyperglycemic usually.
9) Hyperlipidemia - he was continued on lovastatin and
gemfibrozil.
10) Anxiety and depression - diagnosed following the death of
his wife, 5 years ago. Patient states that symptoms improved at
this time. He was continued on outpatient regimen of citalopram
and chlordiazepoxide.
11) Thrombocytopenia: stable and not worsened from prior values.
Medications on Admission:
ASA 325 mg daily
metoprolol 37.5 mg [**Hospital1 **]
lovastatin 40 mg daily
isosorbide mononitrate 90 mg daily
warfarin 5 mg daily
gemfibrozil 600 mg [**Hospital1 **]
gabapentin 300 mg tid
allopurinol 300 mg daily
mirtazapine 30 mg qhs prn
citalopram 20 mg daily
zolpidem 5 mg qhs prn
chlordiazepoxide 5 mg q8h prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
3. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Mirtazapine 15 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for insomnia.
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
11. Chlordiazepoxide HCl 5 mg Capsule Sig: One (1) Capsule PO
every eight (8) hours as needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1) Chest Pain with rise and fall of cardiac biomarkers
consistent with a small non-ST segment elevation myocardial
infarction
2) Syncope
Secondary Diagnoses:
3) Coronary artery disease, S/P coronary artery bypass grafting,
percutaneous coronary interventions, and prior myocardial
infarction
4) Hypertension
5) Hyperlipidemia
6) Atrial fibrillation, s/p atrioventricular node ablation and
pacemaker implantation
7) Peripheral neuropathy
8) Gout
9) Chronic renal insufficiency
10) Chronic thrombocytopenia
Discharge Condition:
Good
Discharge Instructions:
1)You were admitted to the hospital because you lost
consciousness and then had chest pain. You were evaluated with
blood tests to check for a heart attack and you had several
EKG's. Neither of these showed that you had a significant heart
attack. You had your pacemaker checked to evauluate for any
arrhythmias that could have caused your fainting episode. None
were seen but your pacemaker was reset to be more sensitve.
2)You should have an echocardiogram next week to further
evaluate your heart. You should be called on Tuesday to
schedule this appointment but if you don't hear from someone by
mid afternoon please call to schedule this at [**Telephone/Fax (1) 3312**].
3)Your coumadin was stopped during this admission because your
INR was elevated at 4.1 on admission. You should continue to
hold your coumadin over the weekend because your INR was still
elevated at 3.6 on saturday. Please have your blood level
rechecked on Tuesday at Dr.[**Name (NI) 3313**] office.
4)None of your other medications were changed during this
admission.
5) Please call and schedule the follow up appointments listed
below.
6) Please call your doctor or return to the emergency department
if you experience any worsening of your symptoms including chest
pain, loss of consciousness, shortness of breath or any other
concerning symptoms.
Followup Instructions:
1)You should have an echocardiogram next week. Please call
[**Telephone/Fax (1) 3312**] to schedule if you do not hear from someone by mid
afternoon.
2)Please call and schedule an appointment to be seen by your
cardiologist at the soonest available appointment.
3)Please call Dr. [**Last Name (STitle) 3314**] to schedule an appointment to see
him within two weeks of discharge.
[**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339
ICD9 Codes: 412, 2749, 2724, 4280, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2674
} | Medical Text: Admission Date: [**2192-10-17**] Discharge Date: [**2192-10-23**]
Date of Birth: [**2118-4-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Nsaids / Ambien
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
left heart catheterization, intravascular ultrasound, placement
of intra aortic balloon [**2192-10-17**]
Urgent coronary artery bypass grafts x3(LIMQA-LAD,SVG-OM1->OM2)
[**2192-10-18**]
History of Present Illness:
This 74 year old female with known coronary disease was referred
to [**Hospital1 18**] for elective intravascular ultrasound of left main and
left anterior descending disease as wire tracings at outside
catheterization was inconclusive for vascular significance.
Past Medical History:
type 2 diabetes mellitus
hypertension
hyperlipidemia
abd. aortic aneurysm (3.2cm)
gastroesophageal reflux
Obesity
prior renal failure with NSAID use
s/p lumbar laminectomy
s/p cervical laminectomy
Depression
s/p Bilateral knee replacement
s/p Appendectomy
s/p Tonsillectomy
s/p Cystocele/Rectocele repair
Social History:
Tobacco: Prior light smoker. Quit in [**2168**].
ETOH: (-)
Illicits: (-)
Residence: Widowed. Lives with one of her daughters. [**Name (NI) **] home
services.
Family History:
-Sister with CABG in her early 60's.
-Brother with coronary stents in his early 60's.
-Mother died of CHF at age 88.
-Father died from an MI at age 72.
Physical Exam:
Admission:
Pulse: 65 Resp:Intubated O2 sat: 95%
B/P Right: 140/84 Left: 140/63
Height: 5'4" Weight:210 pounds
General: intubated and sedated on propofol with IABP 1:1 on
dopamine and neo drips for b/p
Skin: Dry [x] intact [x]
HEENT: PERRLA [x]
Neck: Supple [x]
Chest: Lungs clear bilaterally [x] intubated
Heart: RRR [x] Irregular [] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] obese no palpable masses
Extremities: Cool perfused [] Edema none Varicosities: None [x]
Neuro: intubated and sedated - propofol stopped briefly - able
to
open eyes to command - grasp with both hands to voice, withdraws
to painful stimuli with all 4 extremties
Pulses:
Femoral Right: IABP Left: +1
DP Right: D Left: D
PT [**Name (NI) 167**]: D Left: D
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2192-10-21**] 02:44AM BLOOD WBC-11.8* RBC-3.13* Hgb-10.0* Hct-27.5*
MCV-88 MCH-31.8 MCHC-36.3* RDW-14.2 Plt Ct-154
[**2192-10-17**] 12:26PM BLOOD WBC-18.9* RBC-4.65 Hgb-13.8 Hct-41.4
MCV-89 MCH-29.6 MCHC-33.2 RDW-13.1 Plt Ct-279
[**2192-10-21**] 02:44AM BLOOD Glucose-129* UreaN-13 Creat-0.8 Na-138
K-4.0 Cl-104 HCO3-26 AnGap-12
[**2192-10-17**] 07:30AM BLOOD Glucose-126* UreaN-15 Creat-0.8 Na-140
K-4.4 Cl-104 HCO3-26 AnGap-14
[**2192-10-18**] 05:21AM BLOOD CK-MB-7
[**2192-10-17**] 07:23PM BLOOD CK-MB-6 cTropnT-0.06*
[**2192-10-17**] 12:26PM BLOOD CK-MB-2 cTropnT-<0.01
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. 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. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. Mild to moderate tricuspid
regurgitation is present. There is a well position intra-aortic
balloon pump catheter in the descending thoracic aorta
POSTBYPASS
Biventricular systolic pressure remains preserved. The remaining
study is unchanged from prebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2192-10-18**] 11:2
Brief Hospital Course:
At catheterization she developed hypotension during ultrasound
and an intra aortic balloon was placed and pressors begun. She
continued to be mildly hypotensive after that and medications
were adjusted. On [**10-18**] she was taken to the Operating Room
where revascularization was undertaken as noted in the operative
note. She weaned from bypass with the balloon in place, Neo
Synephrine and Propofol infusions. She transiently lost foot
pulses, but these returned. She was stable, the intra aortic
balloon was removed on POD 1 and she was aggressively diuresed
for fluid overload.
A Lasix infusion was continued for 48 hours and she was
extubated on POD 2. CTs and pacing wires were removed on POD 3,
she remained stable. Beta blockade was resumed and oral
diuretics begun. Physical Therapy was consulted for mobility
and strength. She continued to make good progress and was
cleared for discharge to [**Hospital 54752**] [**Hospital **] Nursing Home an Rehab
on [**10-24**]. All follow up appointments were made.
Medications on Admission:
ATENOLOL 100 mg QHS
ATORVASTATIN 40 mg QHS
ISOSORBIDE MONONITRATE 60 mg QAM
OLMESARTAN 20 mg QHS
ASPIRIN 325 mg QHS
OMEPRAZOLE MAGNESIUM 20 QHS
.
METFORMIN 500 mg TID
CYMBALTA 60 mg Daily
CALCIUM CARBONATE 600/VIT D3 400U QHS
Discharge Medications:
1. influenza vaccine tr-s 10 (PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose) for 1 doses.
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
9. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. metformin 500 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 doses.
15. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
16. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 54752**] Rehab & Skilled Nursing Center - [**Location (un) 1110**]
Discharge Diagnosis:
coronary artery disease
obesity
noninsulin dependent diabete mellitus
s/p coronary artery bypass grafts
s/p bilateral total knee replacement
hyperlipidemia
hypertension
depression
gastroesophageal reflux
s/p cystocoele repair
s/p lumbar laminectomy
s/p cervical laminectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema:1+
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) **] at [**Hospital1 **] (for Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**])
on Thurs [**11-15**] @9:00 AM
Cardiologist:Dr. [**Last Name (STitle) 4610**] ([**Telephone/Fax (1) 6256**]) on [**12-4**] @ 1:30 pm
Please call to schedule appointments with:
Primary Care Dr. [**Name (NI) **] [**Name (STitle) 22980**] ([**Telephone/Fax (1) 6256**]) in [**4-2**] 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:[**2192-10-23**]
ICD9 Codes: 486, 2762, 4019, 2875, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2675
} | Medical Text: Admission Date: [**2178-1-7**] Discharge Date:
Service: GEN SURGER
HISTORY OF PRESENT ILLNESS: The patient is an 85 year old
woman who presents for a right hemicolectomy for resection of
carcinoma of the cecum. The patient was initially found to
be anemic on routine physical examination by her primary care
physician and further workup included a colonoscopy which
revealed a mass in the cecum as well as diverticulosis. The
mass was biopsied and revealed an adenoma with high grade
dysplasia. The patient admits to intermittent melena, no
bright red blood per rectum. She has mild constipation, no
diarrhea, no weight loss, no fevers or chills, no history of
chest pain, shortness of breath, dizziness, syncope, nausea
or vomiting.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Breast cancer in the past which was resected and she had
a left mastectomy in [**2152**], and a right lumpectomy in [**2168**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Norvasc 5 mg p.o. q.d.
2. Butoptic one to two drops to each eye b.i.d. for
prevention of glaucoma.
3. Trusopt 2% one drop each eye for prevention of glaucoma
which runs in her family.
SOCIAL HISTORY: Significant for thirty pack year history of
tobacco. She quit fifteen years ago. Socially ETOH, less
than two drinks per week. She lives alone in [**Location (un) 686**].
REVIEW OF SYSTEMS: On review of systems, she does get short
of breath upon walking one flight of stairs. Otherwise, the
review of systems was noncontributory.
PHYSICAL EXAMINATION: On physical examination, her
temperature was 97.8, heart rate 100, blood pressure 128/78,
respiratory rate 16, and she was saturating 96% in room air.
She is mildly obese, alert, oriented times three, pleasant in
no apparent distress. The pupils are equal, round, and
reactive to light and accommodation. Sclera were anicteric.
Mucous membranes were moist. No lymphadenopathy. The neck
was supple with no carotid bruits. The lungs were clear to
auscultation bilaterally. She had a regular rate and rhythm.
The abdomen was soft, nontender, protuberant, but
nondistended, positive bowel sounds. She had no cyanosis,
clubbing or edema. Her pulses were palpable bilaterally.
HOSPITAL COURSE: The plan was for a right hemicolectomy. The
patient tolerated the procedure well, however, on transfer to
the floor from the Post Anesthesia Care Unit, the patient was
found to be unresponsive and almost apneic. On workup, she
was found to be hypercarbic which was presumed to be most
likely due to narcotics from her epidural. The epidural was
immediately capped and an electrocardiogram, chest x-ray were
done which were essentially within normal limits. Once the
epidural was capped, the patient's respiratory rate increased
to 30 and she was saturating 91% on 50%. She had bilateral
crackles at the bases and was tachycardic.
She was brought to the Post Anesthesia Care Unit for more
frequent and closer monitoring. Her narcotics and epidural
were stopped. The patient was closely monitored and her
oxygen saturations came up, however, she continued to have
respiratory difficulty and, on repeat blood gases although
there was some improvement, she was found to be acidotic and
still hypercarbic and breathing with difficulty.
Hence, after supportive therapy was maintained for a couple
of hours, the decision was made to intubate the patient and
transfer to the Intensive Care Unit. She was extubated on
the following day, postoperative day two, tolerated
extubation well.
She had a slight temperature of 101.7 and remained slightly
tachycardic but that was her baseline and her oxygen
saturations remained within normal limits in the mid to low
90s which was around her baseline. Her temperature came down
on its own. The patient was transferred to the floor on
postoperative day number two.
On postoperative day number three, the patient did well.
However, that evening she awoke short of breath, denied any
chest pain, tingling in her arms, nausea, vomiting or
dizziness. She was saturating 94% on four liters. She did
have crackles at the bases bilaterally and some rhonchi. The
decision was made to give her some Lasix in which case she
quickly responded and shortness of breath dissipated.
Another electrocardiogram was done which again was within
normal limits.
The patient did well the following. Vital signs were all
stable. She was saturating well. Her nasogastric tube was
taken out and she was started on sips. She continued to do
well. On postoperative day five, she started to develop some
burping and had still not passed any flatus. Her abdomen
became slightly distended. She was kept NPO. However, on
postoperative day six, she passed large amounts of stool and
decision was made to start her again on clears. She
tolerated clears well.
On postoperative day seven, she was advanced to a soft
regular diet and was discharged to rehabilitation in stable
condition. Her vital signs were all stable. She was
afebrile. A Clostridium difficile had been sent given she
had multiple loose bowel movements, which is still pending.
She will follow-up with Dr. [**Last Name (STitle) 957**].
DISCHARGE DIAGNOSIS: Right hemicolectomy for cecal mass.
MEDICATIONS ON DISCHARGE:
1. Trusopt 2% one drop O.U. t.i.d.
2. Butoptic one to two drops O.U. t.i.d.
3. Norvasc 5 mg p.o. q.d.
4. Tylenol #3 one to two tablets p.o. q4-6hours p.r.n. pain.
5. Zinc 220 mg p.o. q.d.
6. Multivitamin.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (NamePattern1) 2649**]
MEDQUIST36
D: [**2178-1-15**] 10:08
T: [**2178-1-15**] 10:19
JOB#: [**Job Number 24811**] and [**Numeric Identifier 24812**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2676
} | Medical Text: Admission Date: [**2118-9-28**] Discharge Date: [**2118-10-6**]
Date of Birth: [**2053-5-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Dyspnea on exertion and palpitations
Major Surgical or Invasive Procedure:
[**9-28**] CABG x 2(LIMA, SVG->PDA), Mechanical AVR, RF Maze, LAA
oversew
History of Present Illness:
65 year old female with coronary artery disease as well as
aortic and mitral valve disease. She has experienced
palpitations (paroxysmal atrial fibrillation) over the past 5
years. Positive exercise tolerance test in [**2116**] and underwent
stenting to her LAD. She has been followed by serial
echocardiograms for her valvular disease. A recent cardiac
catheterization was significant for three vessel disease. She
admits to dyspnea with moderate ecertion. She presents for
surgical revascularization.
Past Medical History:
CAD s/p LAD stenting in [**2116**]
Diabetes
Hypercholesterolemia
Hypothyroid
Arthritis
PAF
Hysterectomy
Social History:
Lives with daughter. Active [**Name2 (NI) 1818**]. 1 ppd for 50 years. No
alcohol use.
Family History:
Maternal uncles with premature CAD
Physical Exam:
GEN: WDWN in NAD
BP:112/59 SR 73 Afebrile
HEENT: Poor dentition, OP benign
NECK: Supple, No JVD
LUNGS: Clear
HEART: RRR, + holosystolic murmur
ABD: Benign
EXT: No edema, no varicosities
NEURO: Nonfocal
Pertinent Results:
[**2118-10-3**] 12:58PM BLOOD WBC-10.0 RBC-3.66* Hgb-11.4* Hct-33.3*
MCV-91 MCH-31.1 MCHC-34.1 RDW-14.0 Plt Ct-138*
[**2118-10-6**] 07:15AM BLOOD PT-19.5* INR(PT)-2.7
[**2118-10-6**] 07:15AM BLOOD UreaN-21* Creat-0.8 K-4.7
[**2118-10-6**] CXR
PA and lateral chest compared to earlier postop film since
[**9-29**], most recently [**10-4**]. The large
postoperative cardiomediastinal silhouette, large left pleural
effusion and left lower lobe collapse are unchanged since
[**10-3**]. Small right pleural effusion has decreased. Right
lung is grossly clear. There is no pneumothorax. The patient has
had median sternotomy and AVR.
[**2118-9-28**] EKG
Normal sinus rhythm with occasional atrial pacing and diffuse T
wave flattening which is non-specific. Compared to the previous
tracing of [**2118-9-19**] the downsloping ST segment depressions in the
anterior leads are no longer present and the occasional atrial
pacing is new.
Brief Hospital Course:
Ms. [**Known lastname 13662**] was admitted to the [**Hospital1 18**] on [**2118-9-28**] for elective
surgical management of her aortic valve and coronary artery
disease. She was taken to the operating room where she underwent
coronary artery bypass grafting to two [**Last Name (LF) 56207**], [**First Name3 (LF) **] aortic valve
replacement with 1 19mm ST. [**Male First Name (un) 923**] regent valve, a radiofrequency
MAZE procedure and a left atrial appendage over sew.
Postoperatively she was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Ms. [**Known lastname 13662**] [**Last Name (Titles) **]e neurologically intact and was extubated. Amiodarone and
coumadin were started. Her drains were removed. She was then
transferred to the cardiac surgical step down unit for further
recovery. Ms. [**Known lastname 13662**] was gently diuresed towards her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperative strength and mobility. She
developed some brief episodes of self limited rate controlled
atrial fibrillation. Beta blockade was started in addition to
her amiodarone and titrated for optimal heart rate and blood
pressure control. As her INR was slow to increase, heparin was
started as a bridge to coumadin. He Lasix was increased for mild
pleural effusions. Ms. [**Known lastname 13662**] continued to make steady progress
and was discharged home on postoperative day eight. She will
follow-up with Dr. [**Last Name (STitle) **], her cardiologist and her primary care
physician as an outpatient. Dr. [**Last Name (STitle) **] will monitor her INR for
coumadin dosing as an outpatient with a goal INR of 2.0-3.0. She
will also have a repeat chest x-ray with her primary care
physician [**Last Name (NamePattern4) **] 1 week for follow-up of her pleural effusions.
Medications on Admission:
Metformin 850mg twice daily
Asppirin 81mg once daily
Plavix 75mg once daily
Coumadin 7.5mg daily
Lopressor 25mg twice daily
Digoxin 0.25mg once daily
Lisinopril 10mg once daily
Synthroid 50mcg once daily.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 10
days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO ONCE (once) for 1
doses: 7.5 mg today, INR to be drawn [**10-7**] with results to Dr.
[**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*0*
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 5 days: 400mg QD x 5 days, then 200 QD.
Disp:*45 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
13. 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*
Discharge Disposition:
Home With Service
Facility:
VNA CARE [**Location (un) **]
Discharge Diagnosis:
CAD s/p LAD stent [**2116**]
NIDDM
Hyperlipidemia
Hypothyroid
arthritis
PAF
s/p hystectomy
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, or
shortness of breath or chest pain.
Shower, wash incision with soap and water and pat dry.
No driving or lifting more than 10 pounds until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 3-4 weeks
Dr. [**Last Name (STitle) 62479**] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks, Dr. [**Last Name (STitle) **] also to follow INR and dose coumadin
Please get chest x ray in next 1-2 weeks and discuss results
with Dr. [**Last Name (STitle) **] at [**Hospital1 **].
Completed by:[**2118-11-21**]
ICD9 Codes: 2449, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2677
} | Medical Text: Admission Date: [**2169-1-5**] Discharge Date: [**2169-1-11**]
Date of Birth: [**2085-6-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
ERCP [**2169-1-6**]
PICC line placement [**2169-1-9**]
History of Present Illness:
83 year old female with a history of biliary obstruction due to
tumor with metal stents presenting to an OSH on [**1-3**] with an
episode of weakness/incontinence found to have polymicrobial
bacteremia/sepsis. The patient was treated for a UTI on [**12-21**]
with Macrobid. On [**2169-1-2**] she was being assisted to the
bathroom by her husband and became acutely weak and incontinent
of urine. She was taken to the OSH ED where she had a fever of
104 and a SBP in the 70s (per report). Full ROS at OSH was
negative. Patient does not remember the episode and cannot
provide further history at this time.
No discharge summary or hospital course was provided by the OSH.
From the provided data, her blood cultures from the OSH are
positive for E. coli, Klebsiella a 3rd GNR and GPC. She was
treated initially with levofloxacin, but changed to Imipenim and
gentamicin with improvement in her clinical status. A CT of the
abdomen demonstrated persistent biliary dilatation concerning
for stent obstruction. There were also questionable liver
lesions with decreased enhancement surrounded by increased
enhancement concerning for abscess. She also developed AF with
RVR necessitating a diltiazem gtt.
The patient was transferred to [**Hospital1 18**] on [**2169-1-5**] for ERCP
evaluation of her metal biliary stents given CT findings. She
is afebrile and clinically stable on transfer.
Currently, she complains of irritation by the Foley, but denies
headache, blurry vision, dry mouth, thirst, difficulty/pain with
swallowing, chest pain, shortness of breath, palpitations,
nausea, heartburn, vomiting, abdominal pain, diarrhea,
constipation (though notes no BM in 1 week), new weakness,
numbness or tingling.
Past Medical History:
-Biliary obstruction/malignant stricture s/p ERCP X 2 and 2
metal stents--last placed in [**9-12**]. Thought to be
cholangiocarcinoma, no clear pathologic diagnosis made. By
report, evaluated by surgical team, thought not to be a surgical
candidate.
-Diabetes mellitus, type 2
-Hypertension
-Coronary artery disease
-Parkinson's disease
-diastolic CHF
-Vaginal Carcinoma
-s/p Cholecystectomy
-Urosepsis d/t E. coli and Proteus
-Bacteremia due to VRE in [**9-12**] treated with 2 week course of
Linezolid
-Bacteremia due to E. coli in [**9-12**] treated with 2 week course of
Ceftriaxone.
-Atrial fibrillation
-Hyperlipidemia
Social History:
lives with husband in [**Name (NI) 3320**] no children. Dependent for
ADLs--has VNA and husband cares for her, no tobacco or drugs,
occassional alcohol. Retired tax examiner for the state.
Family History:
mother died of heart disease
Physical Exam:
VS: 98.3 136/63 p67 R20 99RA
Gen: elderly female, non-toxic.
HEENT: PERRL, OP clear, MMM
Neck: No JVP
Car: RRR. No mrg.
Resp: CTA-ant/lat
Abd: soft, nontender, nondistended + BS
Ext: [**1-6**]+ LE edema B.
Neuro: CN II-XII intact. Masked facies. Non-focal.
Skin: warm/well perfused, several dry patches, no rash, no
jaundice. Area L hip bandaged for superficial pressure ulcer.
Pertinent Results:
Admission Labs:
[**2169-1-5**] 06:04PM WBC-25.6*# RBC-4.26 HGB-11.5* HCT-35.4*
MCV-83 MCH-27.1 MCHC-32.6 RDW-17.7*
[**2169-1-5**] 06:04PM NEUTS-91.3* LYMPHS-6.0* MONOS-2.5 EOS-0
BASOS-0.1
[**2169-1-5**] 06:04PM PLT COUNT-120*#
[**2169-1-5**] 06:04PM PT-14.0* PTT-20.6* INR(PT)-1.2*
[**2169-1-5**] 06:04PM ALT(SGPT)-8 AST(SGOT)-27 LD(LDH)-152 ALK
PHOS-139* TOT BILI-1.1
[**2169-1-5**] 06:04PM GLUCOSE-111* UREA N-36* CREAT-0.8 SODIUM-142
POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-25 ANION GAP-11
[**2169-1-5**] 06:04PM ALBUMIN-2.8* CALCIUM-9.8 PHOSPHATE-2.7
MAGNESIUM-1.9
OSH ([**Date range (1) 69929**]-[**Date range (1) **]) Labs
WBC 26.6(87P,8B)->33.7(84P,6B)->30.1(87P,7B)->25.2
HCT 37.6->28.7->30.5->31.8
Plt 245->201->109->93
PT/INR ([**1-5**]) 11.4/1.1
Cr 1.44->1.32->1.08->0.75
Alb 1.9
TB 1.9->1.5->1.2
AP 198->134->128
AST 46->35->30
ALT <5->24->7
TNI 0.12 ([**2169-1-2**])
BNP 733 ([**1-3**])->1508 ([**1-4**])
UA: neg LE, neg nit, 1+ gluc, trace acetone, 1.015
OSH Micro:
[**2169-1-2**]: Blood culture-E. coli (Amp R, Cipro R, [**Last Name (un) **] Augmentin,
Aztreonam, Cefazolin, Cefoxitin, Ceftriaxone, fent, imipenem,
zosyn)
[**2169-1-2**]: Urine culture-negative
[**2169-1-2**]: Blood cluture: K. pneumonia, other GNR
[**2169-1-4**]: Blood culture: GNR, GPC
[**2169-1-4**]: Blood culture: GPC
[**2169-1-4**]: Sputum culture: Yeast
OSH studies:
1. CXR: vascular congestion in right upper lung, unchanged since
[**1-3**] without active lung disease.
2. CT abd/pelvis ([**1-3**]): double biliary stent catheter in place
with evidence of continued biliary obstruction throught the
liver--not improved. Liver shows areas of decreased enhancement
in posterior right lobe and in the anterior left lobe with no
definite mass effect seen suspicious for possibility of
infections at that site. In the anteriormost portion of the
left lobe, a low area of decreased enhancement surrounded by
increaseed enhancement extend over a diameter of 2 cm which
could represent early formation of an abscess even though no
clear-cut abscess is definitely identified. Spleen is
unremarkable. Large amount of retained stools in rectum
compatible with fecal impaction.
3. CT head without contrast: no actue abnormality identified,
sinus disease and left mastoiditis. Small vessel disease
ECGs:
[**1-2**]: Sinus tachycardia at 112 bpm with PACs, TWI in III, no ST
changes. Q waves in II/III/aVF
[**1-3**]: NSR, axis change from [**1-2**]
[**1-4**]: AF with RVR, maintained axis change from [**1-2**]
[**2169-1-5**]: NSR, normal axis (same as [**1-4**]), normal intervals, TWI
V1-V4 (new), biphasic T waves V5-V6, poor baseline d/t
Parkinson's tremor but otherwise, no ST changes.
.
Cardiac Echo [**2169-1-6**]:
IMPRESSION: Normal left and right ventricular systolic function.
Mild mitral regurgitation. Evidence of elevated left sided
filling pressures.
.
ERCP [**2169-1-6**]:
Biliary Tree: There were multiple filling defect that appeared
like sludge in the upper third of the common bile duct, right
main hepatic duct and left main hepatic duct,within the metallic
wallstents.
Procedures: Multiple stone fragments and sludge were extracted
successfully using a 11 mm balloon.
Impression: Stent obstruction by stones and sludge was found -
stents were dredged using a balloon.
(stone extraction)
.
CXR for PICC placement:
PORTABLE UPRIGHT CHEST RADIOGRAPH: The left PICC terminates over
the mid
right atrium and can be pulled back 4 to 5 cm to the lower SVC.
The
nasogastric tube has been removed. The cardiomediastinal is
stable and within
normal limits. The lungs are clear.
.
LE Dopplers [**2169-1-6**]:
IMPRESSION:
1. No DVT of the right lower extremity.
2. Probable thrombus of a deep vein of the left calf, likely one
of the
paired posterior tibial veins.
.
CT Abd [**2169-1-6**]:
IMPRESSION:
1. Intrahepatic biliary ductal dilatation with peri-biliary
enhancement
consistent with cholangitis. Anteriorly in the left lobe,
multiple hypodense
collections with enhancing rims, consistent with multiple
abscesses. The
largest measures approximately 2 cm and may be amenable to
percutaneous
sampling if desired, but is not likely amenable to catheter
drainage at its present size.
2. Vague region of parenchymal enhancement at the apex of
dilated ducts could represent obstructive tumor mass, but its
margins are difficult to define.
3. Interval increase in small bilateral pleural effusions, small
pericardial effusion, and small amount of ascites.
4. Interval increase in size of enhancing pericardial lymph
node.
5. Evidence of thrombosis of the posterior right portal vein,
resulting in
heterogeneous perfusion of the posterior right lobe of the
liver.
6. 9-mm pancreatic hypodensity, not previously visualized. While
it is too
small to characterize, findings suggest a cystic lesion such as
a dilated side branch or an isolated cystic lesion. If desired,
this can be further
evaluated with MRCP.
.
MICRO:
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2169-1-11**]):
Feces negative for C.difficile toxin A & B by EIA.
.
Blood Culture [**2169-1-5**] (multiple bottles):
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
.
Blood cultures [**2169-1-6**]: continued positive with above.
Blood cultures [**Date range (1) 105716**]: results still pending; please
follow up final results.
.
Urine culture: negative
MRSA screen: negative
.
Discharge labs:
WBC 11.3 Hgb 9.8 HCT 29 PLT 340
Na 142 K 3.9 Cl 105 HCo3 32 BUN 7 Cr 0.5 Glu 84
PT 20 PTT 38.5 INR 1.9
.
[**2169-1-10**] CPK 10 AST 26 ALT 6 AlkPh 135 Tb 1.4
Brief Hospital Course:
83 year old female with history of biliary obstruction,
polymicrobial bacteremia from cholangitis presented with biliary
sepsis. Patient was transferred from [**Hospital3 3583**] in
[**Location (un) 3320**], MA.
.
# Sepsis/Biliary obstruction/Liver abscesses: At the OSH she was
hypotensive with leukocytosis and polymicrobial bacteremia, with
E. coli, Klebsiella, GPC, and VRE from blood cultures. Had
negative UA/Urine culture and CXR for pneumonia. Source is
biliary, with additional concern for liver abscess on CT scan.
Culture data was faxed from the OSH and showed: 1) enterococcus
sensitive to gent and streptomycin, 2) E.coli sensitive to gent,
imipenem, and cephalosporins, and 3) Klebsiella pansensitive
except to amp. On transfer to the floor from [**Hospital Unit Name 153**], she was
transitioned to linezolid and gentamicin alone.
.
The repeat CT abd/pelvis showed multiple abscesses in the liver
adjacent to where the stents are placed in the anterior portion
of the left lobe. The largest collection is 1.5 cm; additionally
there are a couple of subcm foci. Also seen is intrahepatic
ductal dilation/cholangitis. The radiologist also suspects a
mass centrally at the porta hepatis as intrahepatic ductal
dilation is present (but no mass is visualized). Per radiology
none of the collections would be amenable to drainage.
She underwent ERCP on [**2169-1-6**] and had both sides of her stents
flushed with sludge removed.
.
ID was consulted, and antibiotics were changed from Linezolid
and Gent to Ceftriaxone and Daptomycin on [**1-10**] due to the
duration of treatment that will be required. Patient will
follow up with [**Hospital **] clinic and have repeat imaging of her liver to
ensure clearance of infection/abscesses.
**She will also need weekly lab monitoring on Daptomycin:**
CBC, LFT's, CPK, BUN/Cr
Please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] of Infectious Disease at
[**Telephone/Fax (1) 432**].
At the time of discharge, several blood cultures remain pending,
please follow up final results.
.
# Diarrhea
Patient was noted to have ongoing loose stools for which patient
has a flexiseal. Patient has been tested and resulted c-diff
negative x 1.
.
# Cholangiocarcinoma: Discussion with family to clarify goals of
care revealed that patient is not planning on surgery or
chemo/XRT given extremely poor prognosis of cancer.
.
# Atrial fibrillation: Paroxysmal. She was continued on digoxin.
The patient has remained in normal sinus rhythm. CHADS score is
4, and she was placed on Lovenox with transition to coumadin.
- resumed Lovenox [**2169-1-9**] s/p PICC placement for coumadin bridge
- INR 1.9 at time of discharge
- Coumadin dosing: 5 mg po q 1600 since [**2169-1-9**].
Please follow INR and titrate coumadin dosing as appropriate.
.
# Left lower extremity DVT: The patient was noted to have
right>left lower extremity swelling so lower extremity dopplers
were obtained which showed a probable thrombus of a deep vein of
the left calf, likely one of the paired posterior tibial veins.
The patient was started on a heparin gtt with a goal PTT of
50-70, and then transitioned to Lovenox/coumadin.
- on lovenox/coumadin
.
# Diastolic CHF/ECG changes: The patient had a positive single
troponin value at the OSH and 2 measured/elevated BNP levels.
Has LE edema and is on chronic Lasix at home. ECG from [**2169-1-2**]
to [**2169-1-3**] demonstrated a change in axis and co-incides with
chills/rigors/shortness of breath noted in one of the consultant
notes. ECG here with new TWI V1-V4 and maintainance of new axis
since [**1-2**]--cycled enzymes; Trp 0.05 but CK-Mb remained
negative. She was continued on aspirin and a statin. A TTE was
obtained which showed an EF of >55%, but elevated PCWP.
- Currently appears euvolemic and BUN/Cr stable
- restarted Lasix [**1-10**]
.
# Concern for aspiration: There was concern that the patient
aspirated her pm meds so her meds were changed to IV and speech
and swallow c/s was requested. She had an NGT placed, which she
self-d/c'd. She remained NPO until [**2169-1-9**] when Speech and
swallow cleared patient for modified diet.
S+S Recommendations:
Regular Diabetic/Consistent Carbohydrate Consistency: Ground;
Nectar prethickened liquids 1. PO intake of nectar thick liquids
and ground solids. 2. Pills crushed with puree. 3. 1:1
supervision with all pos. 4. Continue Q8 oral care.
.
# Parkinson's Disease: She was continued on Sinemet.
.
.
CODE: DNR/DNI
Access: PICC
Dispo: d/c'd to [**Hospital 169**] Center, [**Location (un) 3320**].
Medications on Admission:
Medications at home: simvastatin 10 mg daily, lasix 40 mg daily,
omeprazole 40 mg daily, albuterol 2 puffs/4x day, singulair 10
mg daily, MVI, prazosin 2 mg [**Hospital1 **], mirapex 0.375 mg tid,
carbidopa/levodopa 25/100 mg three times per day
Medications at transfer from rehab: Albuterol neb q4h, SSI,
Lovenox, Protonix 40 mg IV daily, simvastatin 10 mg qhs,
singulair 10 mg daily, MVI, Aspirin 81 mg daily, gentamicin 120
mg IV daily since [**1-3**], nystatin, imipenim/cilastin 250 mg IV
q6h, pramipexole 0.375 mg tid, sinemet 25/100 mg three
times/day, digoxin 0.25 mg IV q4h X 4 doses (received X 4),
vancomycin 1 gm IV q24h, digoxin 0.125 mg po daily, propafenone.
Diltiazem gtt stopped [**2169-1-5**] at 12 am. Phenylephrine ordered,
unclear if received.
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebs
Inhalation Q6H (every 6 hours) as needed for wheezing.
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) inj Subcutaneous
Q12H (every 12 hours) for until INR >2 days.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: please follow INR and titrate dose accordingly.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. 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.
13. 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.
14. CeftriaXONE 1 g IV Q24H Start: In am
15. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
16. Insulin Regular Human 100 unit/mL Solution Sig: One (1) per
sliding scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
# Biliary sepsis
# Biliary obstruction
# Liver abscesses
# Cholangiocarcinoma
# Paroxysmal atrial fibrillation
# Left lower extremity DVT
# Chronic diastolic CHF
# Parkinson's disease
Discharge Condition:
stable
Discharge Instructions:
Please seek medical attention if you develop fevers, chills,
changes in mental status, abdominal pain, or any other concerns.
Followup Instructions:
Please continue to take antibiotics as prescribed. You will
need to follow up with Infectious Disease doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]
and have repeat imaging to determine the total duration of
antibiotics.
.
Patient will need weekly lab monitoring on Daptomycin:
CBC, LFT's, CPK, BUN/Cr
Please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] of Infectious Disease at
[**Telephone/Fax (1) 432**].
.
Appointment:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2169-2-13**] 10:00
ICD9 Codes: 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2678
} | Medical Text: Admission Date: [**2143-1-27**] Discharge Date: [**2143-1-30**]
Date of Birth: [**2143-1-27**] Sex: F
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**Known lastname 21212**] [**Known lastname **] is the former 2.28
kg product of a 36 and 2/7th week gestation pregnancy born to
a 37-year-old G4, P3 now 4 woman.
PRENATAL SCREENS: Blood type O+, antibody negative, Rubella
immune, RPR nonreactive. Hepatitis B surface antigen
negative. Group beta strep unknown in this pregnancy, but
was negative in three prior pregnancies.
Pregnancy was uncomplicated. The mother had a normal
amniocentesis. EDC [**2143-2-22**]. The infant was born by
spontaneous vaginal delivery after nine hours of ruptured
membranes, clear fluid, no maternal fever. There was no
intrapartum antibiotic treatment. Apgars were 9 at 1 minute
and 9 at 5 minutes. The infant was transferred to the
newborn nursery where she had some difficulty maintaining
body temperature and was noted to have two episodes of
cyanosis, one spontaneous and one associated with choking.
She was transferred to the Neonatal Intensive Care Unit for
further evaluation.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 2.28 kg, head circumference 29 cm, length 17
inches. Overall appearance consisted of 36 weeks gestation,
well appearing, non dysmorphic. Anterior fontanelles soft
and flat. Palate intact. Red reflex present bilaterally.
Breath sounds clear and equal, regular rate and rhythm with a
grade 1/6 systolic murmur, audible along the left sternal
border, consistent with a closing patent ductus arteriosus,
2+ femoral pulses. Benign abdomen with no hepatosplenomegaly,
no masses. Normal female external genitalia. Normal back and
extremities with stable hips. Skin pink and well perfused.
Responsive with slightly decreased tone.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. CARDIOVASCULAR AND RESPIRATORY: The murmur noted on
admission resolved by day of life 2. After an initial dusky
episode with apnea and sats in the 60s on admission, the
infant remained in room air and maintained oxygen saturations
greater than 98%. She was cold on admission. After rewarming
she had no further significant desats for the remainder of
her Neonatal Intensive Care Unit admission.
2. FLUIDS, ELECTROLYTES AND NUTRITION: The infant has been
breast feeding ad lib. She has had some difficulty with
breastfeeding and has required some supplemental bottles. She
has been maintaining glucoses in the normal range. Discharge
weight is 2.085 kg.
3. INFECTIOUS DISEASE: Due to the unknown etiology of the
cyanotic episodes, this infant was evaluated for sepsis. A
white blood cell count was 17,600 with 65% polys, 0% bands,
28% lymphocytes. A blood culture was obtained prior to
starting intravenous ampicillin and gentamicin. The baby was
treated for two days and the antibiotics were discontinued
with negative cultures at 48 hours.
4. GASTROINTESTINAL: Serum bilirubin was obtained on day of
life 2 when clinical jaundice was observed. Total was 8.4 mg
per dl over 0.2 direct. Repeat serum bilirubin on day of
life 3 is 11.5 total over 0.3 direct, then 12.5 total 0.3
direct 12 hours later. Blood type is A+ Coombs micro
positive.
5. HEMATOLOGICAL: Hematocrit at birth was 46.7%. The
infant did not receive any transfusions of blood products.
6. NEUROLOGICAL: The infant has maintained a normal
neurological exam throughout admission and there are no
neurological concerns at the time of discharge.
DISCHARGE CONDITION: Good
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Apartment Address(1) 38803**], [**Location (un) 55**], [**Numeric Identifier 38804**]. Phone number
([**Telephone/Fax (1) 38805**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Breast feeding ad lib or supplemented with formula or
expressed mother's milk as needed.
2. No medications.
3. Car seat position screening was performed successfully
prior to discharge.
4. State newborn screen sent on day of life 3 with no
notification of abnormal results to date.
5. Hepatitis B vaccine administered on [**2143-1-29**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: 1) born at less than 32
weeks, 2) born between 32 and 35 weeks with plans for daycare
during RSV season with a smoker in the household or with
preschool siblings or 3) with chronic lung disease.
Influenza immunization should be considered annually in the
fall for 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.
DISCHARGE DIAGNOSES:
1. Prematurity at 36 and 2/7th weeks gestation
2. Transitional respiratory distress
3. Apnea associated with hypothermia
4. Suspicion for sepsis ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37233**], M.D. [**MD Number(1) 36463**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2143-1-30**] 07:08
T: [**2143-1-30**] 07:29
JOB#: [**Job Number 38806**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2679
} | Medical Text: Admission Date: [**2102-12-22**] Discharge Date: [**2102-12-29**]
Date of Birth: [**2033-9-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2102-12-25**]
1.Urgent off-pump coronary artery bypass graft x3; left
internal mammary artery to left anterior descending
artery, and saphenous vein graft obtuse marginal and
right coronary arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
This 69 year old male with past medical history significant for
hypertension and hyperlipidemia presenting with exertional
substernal chest pressure. Symptoms were reliable relieved with
5 mins of rest and he denies ever having pain at rest. He was
recently seen by Dr. [**Last Name (STitle) 1911**] and had an abnormal stress
test. He underwent cardiac cath that showed 3VD and 70% distal L
main disease. He was kept in-house for urgent coronary artery
bypass grafting. Preoperatively, he was noticed to have some
coagulopathy with abnormally high prothrombin time and, hence,
hematology was consulted and the decision was made to proceed
with off-pump coronary artery bypass grafting to avoid possible
anticoagulation issues with the cardiopulmonary bypass.
Past Medical History:
Hyperlipidemia
hypertension
pilonidal cyst removed
dental extraction 2 months ago
prostatitis age 38
Past Surgical History:
tonsillectomy
Social History:
Had a 25 pack/ year history of smoking and quit 30 years ago. He
drinks alcohol occasionally.
Family History:
Notable for his mother who had a heart attack in her 60s.
Physical Exam:
Pulse:57 Resp:16 O2 sat:99/RA
B/P Right:143/62 Left:141/62
Height:5'[**01**]" Weight:166 lbs
General:
Skin: Dry [x] [**Year (2 digits) 5235**] [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 [**Year (2 digits) 5235**] [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: dop
Radial Right: palp Left: palp
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2102-12-25**] TTE
Pre-procedure:
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 [**Month/Day/Year 5236**].
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-procedure:
The patient is in sinus rhythm, on no inotropes.
Preserved biventricular systolic fxn.
Trace AI. No MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**].
[**2102-12-26**] 02:56AM BLOOD WBC-16.3* RBC-3.34* Hgb-10.2* Hct-28.0*
MCV-84 MCH-30.4 MCHC-36.3* RDW-12.5 Plt Ct-179
[**2102-12-26**] 02:56AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-133
K-4.1 Cl-103 HCO3-23 AnGap-11
[**2102-12-25**] 11:51PM BLOOD Glucose-111* UreaN-13 Creat-0.8 Na-134
K-4.1 Cl-104 HCO3-23 AnGap-11
[**2102-12-29**] 06:19AM BLOOD WBC-10.5 RBC-2.96* Hgb-9.1* Hct-25.1*
MCV-85 MCH-30.6 MCHC-36.1* RDW-13.0 Plt Ct-261
[**2102-12-28**] 04:33AM BLOOD WBC-11.0 RBC-2.72* Hgb-8.2* Hct-22.8*
MCV-84 MCH-30.1 MCHC-36.0* RDW-12.3 Plt Ct-200
[**2102-12-29**] 06:19AM BLOOD Plt Ct-261
[**2102-12-29**] 06:19AM BLOOD PT-13.2 PTT-82.6* INR(PT)-1.1
[**2102-12-28**] 04:33AM BLOOD Plt Ct-200
[**2102-12-28**] 04:33AM BLOOD PT-13.4 PTT-84.1* INR(PT)-1.1
[**2102-12-29**] 10:30AM BLOOD Fact V-PND Fact IX-PND Fact [**Doctor First Name 81**]-PND Fac
XII-PND
[**2102-12-25**] 11:15AM BLOOD FacVIII-44*
[**2102-12-29**] 06:19AM BLOOD Glucose-141* UreaN-14 Creat-0.8 Na-134
K-3.8 Cl-99 HCO3-24 AnGap-15
[**2102-12-28**] 04:33AM BLOOD Glucose-114* UreaN-15 Creat-0.8 Na-133
K-3.7 Cl-97 HCO3-29 AnGap-11
Brief Hospital Course:
69 yo male with PMHX of HTN, Hyperlipidemia, and negative
cardiac history who presented with chest pain on exertion.
Stress test performed on [**12-21**] was positive and cath on [**12-22**]
revealed three vessel disease with left main stem involvement.
Hemaology was consulted preoperatively for elevated PTT(150)and
ACT(360) with questionable etiology/anticoagulation management.
The decision was made to proceed
with off-pump coronary artery bypass grafting to avoid possible
anticoagulation issues with the cardiopulmonary bypass. He was
taken to the operating room on [**2102-12-25**] where he underwent an
urgent off-pump coronary artery bypass graft x3; left
internal mammary artery to left anterior descending artery, and
saphenous vein graft obtuse marginal and right coronary
arteries. See operative note for full details. He was
transferred to the CVICU in stable condition. POD1 the patient
was extubated and weaned off all vasoactive medications. Chest
tubes and pacing wires were removed per cardiac surgery
protocol. He was transferred to step down unit in stable
condition on POD1. Hematology had various coagulopathy studies
pending at the time of discharge and plts were 261 PTT 82.6 adn
Factor V; Factor IX; Factor [**Doctor First Name 81**]; Factor XII were pending. These
will be followed up at [**Hospital 91021**] clinic appointment. He is to
be on Plavix for 3 months for Off pump CABG. He was working
with physical therapy for strength and mobility. At the time of
discharge on POD 4 he was ambulating without assistance,
tolerating a full oral diet and his incisions were healing well.
It was felt that he was safe for discharge home with VNA
services and all appropriate follow up appointments were
arranged.
Medications on Admission:
AMLODIPINE 10 mg daily
ERGOCALCIFEROL (VITAMIN D2)50,000 unit once per week
LISINOPRIL 30 mg daily
METOPROLOL SUCCINATE 25 mg Daily
PRAVASTATIN 40 mg daily
ASPIRIN 81 mg daily
CHOLECALCIFEROL (VITAMIN D3) 2,000 unit Daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months: For off pump CABG.
Disp:*90 Tablet(s)* Refills:*0*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 5 days.
Disp:*5 Tablet, ER Particles/Crystals(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **]: Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2103-1-30**] 1:15pm
in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2103-1-9**] 11:00
[**Hospital **] Clinic: Dr. [**Last Name (STitle) **],[**First Name3 (LF) 569**] on [**2103-3-2**] at 10:00 AM
[**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Cardiologist: Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**] on [**1-22**] at 10:20 at
[**Location (un) **] office
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 17029**] in [**5-16**] weeks [**Telephone/Fax (1) 17030**]
**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:[**2102-12-29**]
ICD9 Codes: 2761, 2724, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2680
} | Medical Text: Admission Date: [**2108-8-10**] Discharge Date: [**2108-8-21**]
Date of Birth: [**2041-8-20**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: On [**8-13**], the patient
underwent coronary artery bypass grafting times three with
LIMA to left anterior descending, saphenous vein graft to OM
and right posterior descending artery. The patient's
ejection fraction was 50-55%.
PAST MEDICAL HISTORY: Chest pain. Vertigo. Claudication.
Peripheral vascular disease. Status post bilateral iliac
stents. Hypercholesterolemia.
HOSPITAL COURSE: Postoperatively the patient's course was
complicated by serosanguinous sternal drainage which was
treated with Keflex. Upon discharge, the patient's condition
was stable. Lungs were clear. Incision was clean with no
drainage. The patient's ambulatory status was level [**2-23**].
DISCHARGE MEDICATIONS: Aspirin 81 mg p.o. q.d., Ranitidine
150 mg p.o. b.i.d., Lipitor 10 mg p.o. q.d., Keflex 500 mg
p.o. q.i.d. for 7 more days, Lopressor 50 mg p.o. b.i.d.,
Percocet 5 [**11-22**] tab p.o. q.3-6 hours p.r.n.
DISPOSITION: The patient is arranged to have visiting home
nursing care for postoperative wound care and vital sign
monitoring.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) **] in [**1-22**]
weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2108-8-21**] 08:35
T: [**2108-8-21**] 08:24
JOB#: [**Job Number **]
ICD9 Codes: 4111, 496, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2681
} | Medical Text: Admission Date: [**2118-2-28**] Discharge Date: [**2118-3-3**]
Date of Birth: [**2037-3-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 yo man with CAD and carotid disease s/p stents, sCHF EF 45%
in [**1-17**], hypothyroidism presents for evaluation after having his
metoprolol dose increased. He was in his usual state of health
until 3 days PTA when he had an episode of full body shaking and
rapid breathing. The next day he went to his PCP who increased
his metoprolol dose and told him that it would be fine to take
the increased dose until his appointment with Dr. [**First Name (STitle) 437**] on [**3-2**].
However, because pt was anxious about increased dose of
metoprolol, he came to ED.
.
In triage, BP was in systolic 90s, which was attributed to the
recent BBKer increase. He then dropped his BP to systolic 60s,
no symptoms except darkening in his vision, unclear etiology,
and was given 1 liter IVF. He responded appropriately with
repeat BP 90/46 and HR in 70s. ECG was V-paced and without
changes. CXR in ER showed mild interval increase in bibasilar
effusions with persistent findings of mild congestive heart
failure. Patient was discussed with Dr. [**First Name (STitle) 437**] and who
recommended reducing metoprolol tartrate to 12.5 mg [**Hospital1 **]. The
patient was about to be admitted to the general medicine floor,
when his BP dropped again to systolic 80s. He was instead
admitted to the MICU for further investigation and management.
.
On arrival to the unit, the patient appeared comfortable. He had
no complaints. While in the unit, he received more fluid and his
bp remained stable (85-150)/(51-81). He was asymptomatic.
Infectious w/u was neg and he was transfered to the floor.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope
[**Last Name (NamePattern4) **]dical History:
CAD: s/p RCA and LAD intervention by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
[**9-/2112**], s/p proximal LAD Cypher stent placed by Dr. [**First Name (STitle) **] on
[**4-/2115**]
sCHF with EF 45% in [**2118-1-9**]
Complete heart block s/p PPM
s/p AV replacement with bioprosthetic valve and MV repair in
[**2111**] (Aortic valve replacement using #21 [**Last Name (un) 3843**]-[**Doctor Last Name **]
tissue
valve and mitral valve ring annuloplasty using #26 [**Last Name (un) 3843**]
ring by Dr. [**Last Name (Prefixes) **])
PVD- s/p R ICA stent by Dr. [**First Name (STitle) **] in [**9-/2112**]
Hypertension
Hyperlipidemia
Afib
Sick sinus syndrome s/p pacemaker in [**2111**]
Hypothyroidism
GERD
Non-Hodgkins Lymphoma [**2091**] s/p CHOP and radiation
BPH
COPD
Depression
Microscopic hematuria
Social History:
Lives by himself in [**Location (un) **]. Wife passed away 2 years ago.
Very lonely. Has one son, but not very close. No tobacco,
alcohol, or any Illicit drugs. Walk [**3-13**] miles daily, and tried
to live a healthy life. Moved here from Sicily in [**2068**]. Worked
in construction, food industry, tailoring.
Family History:
No family hx CAD, HTN, or DM
Physical Exam:
ICU Admission Exam:
Vitals: T: 97.6 BP:151/80 P:74 R:16 O2:100%
General: Alert, oriented, emotional
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP to the angle of mandible. No LAD
Chest: Linear mid-sternal scar; Clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: RRR, II/VI SEM. Anterolaterally displaced PMI.
Abdomen: soft, NDNT, +BS
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
.
Floor Transfer Exam:
97.9 107/58 (85-150)/(50-80) 83 (50-83) 97% RA I/O: 1110/625
Gen: WDWN middle aged man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
Neck: Supple with JVP of 14-16 cm.
CV: RRR, 3/6 systolic murmur. No m/r/g. No thrills, lifts. No S3
or S4.
Chest: Mild kyphosis. Resp were unlabored, no accessory muscle
use. Decreased breath sound at the bases, no crackles, wheezes
or rhonchi.
Abd: Soft, NTND.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, or xanthomas.
Pulses: Right: Carotid 2+ DP 1+ PT 1+; Left: Carotid 2+ DP 1+
PT 1+
Pertinent Results:
[**2118-2-28**] 05:03PM WBC-7.5 RBC-4.43* HGB-13.0* HCT-37.7* MCV-85
MCH-29.3 MCHC-34.4 RDW-15.0
[**2118-2-28**] 05:03PM NEUTS-81.4* LYMPHS-10.5* MONOS-6.4 EOS-1.4
BASOS-0.4
[**2118-2-28**] 05:03PM PLT COUNT-255
[**2118-2-28**] 05:03PM proBNP-2638*
[**2118-2-28**] 05:03PM GLUCOSE-104 UREA N-28* CREAT-1.3* SODIUM-140
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
[**2118-2-28**] 08:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2118-2-28**] 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
Blood cx ([**2118-2-28**], [**2118-3-1**]): neg
.
Imaging:
[**2-28**] Chest XRay: Mild interval increase in bibasalar effusions
with persistent findings of mild congestive heart failure.
[**2118-3-3**] 06:20AM BLOOD WBC-7.8 RBC-4.55* Hgb-12.9* Hct-38.7*
MCV-85 MCH-28.5 MCHC-33.4 RDW-14.9 Plt Ct-236
[**2118-3-1**] 03:09AM BLOOD PT-15.1* PTT-33.4 INR(PT)-1.3*
[**2118-3-3**] 06:20AM BLOOD Glucose-86 UreaN-19 Creat-1.1 Na-138
K-4.3 Cl-103 HCO3-27 AnGap-12
[**2118-3-1**] 03:09AM BLOOD ALT-22 AST-26 LD(LDH)-198 CK(CPK)-44
AlkPhos-71 TotBili-0.8
[**2118-2-28**] 05:03PM BLOOD proBNP-2638*
[**2118-3-1**] 03:09AM BLOOD CK-MB-4 cTropnT-0.02*
[**2118-3-1**] 03:09AM BLOOD TSH-3.1
[**2118-3-2**] 06:30AM BLOOD Cortsol-11.2
Brief Hospital Course:
ICU Course:
Mr. [**Known lastname 34083**] is a 80 yo male with HTN, HL, SSS, hypothyroidism,
CAD s/p MI, here s/p rigors two days ago and transient
hypotension that responded to IVFs in the ED.
.
#.Hypotension: The patient presented with hypotension in setting
of recently doubling metoprolol dose, so this is likely
secondary to medication effect. His blood pressure was fluid
responsive. He reported subjective rigors 2 days prior to
presentation, but has no documented fevers, and no leukocytosis
or localizing symptoms to suggest infectious etiology. His
urinalysis was clear. CXR showed no focal consolidations
suggestive of PNA. Given the patient's level of anxiety, there
may be a strong psychiatric component to this hypertension that
led to an increase in his metoprolol dosage two days ago. All
antihypertensives and diuretics were held during ICU stay and
patient's BP stabilized. The patient had received 1 L normal
saline in the ED, and further boluses were held given his
history of CHF. His metoprolol was re-started at 12.5 mg po bid
w/ normalization of blood pressured prior to discharge.
.
#.CAD/CHF: The patient has an EF of 45% from an ECHO in [**1-/2118**],
secondary to ischemic cardiomyopathy. CXR on [**2-28**] showed
evidence of chronic mild CHF, and BNP was mildly elevated. ASA
and statin were continued, beta blocker and lasix were held
initially due to hypotension. Lasix was decreased from 20 mg po
qam and 10 mg po qafternoon to just the am dose.
.
#.Hypothyroidism: Levothyroxine was continued at home dose. TSH
was checked to rule out hypothyroidism as cause of hypotension,
and was normal at 3.1.
.
#.Chronic renal insufficiency. Cr ranged 1.2-1.6 during his last
admission in [**2118-1-9**], and was stable at 1.2. Medications were
renally dosed.
.
#. PAF: The pt has a h/o PAF but was in sinus rhythm during this
admission. No anticoagulation given his fall risk. Metoprolol
12.5 mg po bid re-started prior to discharge.
.
#. Dispo: We recommended that he have a VNA for blood pressure
monitoring and medication help but he refused this service. He
was evaluated by physical therapy and they deemed him to be
stable on his feet. As noted in the HPI, he walks [**3-13**] miles
daily.
Medications on Admission:
1. Aspirin 81 mg PO Qday
2. Atorvastatin 10 mg PO Qday
3. Clopidogrel 75 mg PO Qday
4. Levothyroxine 50 mcg PO Qday
5. Metoprolol Tartrate 25 mg PO BID
6. Lasix 20 mg QAM and 10 mg QHS
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypotension
Secondary:
Valvular heart disesae (s/p AVR, MV repair)
Complete heart block s/p pacemaker placement
Systolic heart failure (EF 45)
Coronary artery disease
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You came in with low blood pressure. You were given fluids and
your blood pressure medicine was stopped. Your blood pressure
improved and you had no symptoms.
We made the following changes to your medications:
- Metoprolol: we changed the dose of this medication for your
blood pressure.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please seek immediate medical attention if you have chest pain,
shortness of breath, light-headedness, palpitations, fever or
any other concerning symptoms.
Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**]. You can call
his office at [**Telephone/Fax (1) 18099**] to schedule an appointment.
Please follow-up with your cardiologist, Dr. [**First Name (STitle) 437**] (tel
[**Telephone/Fax (1) 62**]). You have an appointment to have your pacemaker
checked on [**3-16**] at 9AM and an appointment with Dr. [**First Name (STitle) 437**] on
[**3-16**] at 10:20AM in [**Hospital Ward Name 23**] [**Location (un) 436**].
ICD9 Codes: 2724, 4280, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2682
} | Medical Text: Admission Date: [**2113-7-25**] Discharge Date: [**2113-7-28**]
Date of Birth: Sex:
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 51472**] was a 63 year old
man who was found in his bathroom around noon on the day of
admission. He was found to be minimally responsive to
questions. After he was transferred to the [**Hospital1 346**], he progressively got worse in his
mental status and could only respond to noxious stimuli.
Initially, he was brought to a local hospital where a CT
confirmed a large bleed inside his brain. Cervical spine was
cleared and the patient was intubated before being transferred to
the [**Hospital1 69**].
Neurologic examination at the time of admission: The patient
was unresponsive and could only respond with withdrawal to deep
noxious stimuli. He did not respond to any other
stimulation. His cranial nerve examination revealed severe
papilledema with pupils one to two mms bilaterally. The tone
of his musculature was normal in all limbs and no rigidity
was noted. His reflexes were spread and crossed in the lower
extremity, especially when it was applied to the right
patella. No reflexes could be seen on the left. His toes
were upgoing on both sides.
HOSPITAL COURSE: At the time of admission, CAT scan of his
head showed a large, acute, intracranial hemorrhage with
surrounding edema centered in the left basal ganglion. The
area of acute hemorrhage measured six by four cms. The edema
extended anteriorly to the left frontal lobe. This created a
mass effect on the left lateral ventricle and there was a
rightward shift of the midline by approximately one cm. No
skull fracture was noticed.
Mr. [**Known lastname 51473**] condition gradually deteriorated and on [**7-28**], the patient's status was changed to comfort measures
only. He expired a little later that day.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-279
Dictated By:[**Doctor Last Name 51474**]
D: [**2113-9-12**] 08:30
T: [**2113-9-13**] 03:34
JOB#: [**Job Number 51475**]
ICD9 Codes: 431, 4019, 412, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2683
} | Medical Text: Admission Date: [**2156-5-2**] Discharge Date: [**2156-5-8**]
Date of Birth: [**2132-10-27**] Sex: F
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 42678**] is a 23-year-old woman with a history of type 1
diabetes, idiopathic dilated cardiomyopathy with an ejection
fraction of 20%, and a recent hospitalization for MRSA
bacteremia and acute renal failure. The patient initially
presented to [**Hospital6 1708**] for exacerbation of
her CHF and was hospitalized from [**2156-3-27**] to [**2156-4-6**].
During the hospitalization, she was found to have MRSA
bacteremia felt secondary to line infection. Transthoracic
echocardiogram was limited but without vegetations. The patient
was treated with vancomycin, gentamicin. She was discharged on
[**2156-4-6**] and re-presented to [**Hospital1 **] on
[**2156-4-12**] in acute renal failure, which was felt to be
secondary to gentamicin-induced acute tubular necrosis. Her ACE
inhibitor and diuretics have been held since that admission. Her
renal function has continued to improve since that admisssion
(Cr peak 5.4, then 4.2 on d/c from [**Hospital1 18**] [**4-16**]).
She was brought to the ED with worsening dyspnea and decreased
exercise tolerance. States SOB started suddenly at about 10 pm
last night. She had no chest pain, diaphoresis, or
lightheaded-ness. She was unable to recall changes in her
weight, but reported increased LE edema. Her diet is unchanged.
Note is made of a conversation w/ Dr. [**Last Name (STitle) 4048**] 5 d ago complaining
of increasing LE edema.
In the Emergency Department, pt p/w O2sat 81% on RA, HR 126,
RR60, BP 135/101 & the patient received 40 mg furosemide
intravenously with diuresis of 1.5 liters. She briefly required
non-invasive positive airway pressure ventilation as well. An
ABG was done on bipap (7.50//40/497/32/7) however a repeat ABG
briefly off O2 (was on NRB w/ 8L O2 not 15L) was 7.51/37/75/31/5
and she desated down to the 80%. Also, serum glucose 872 for
which she has been receiving Insulin (10 U x 3). UA negative for
ketones.
ROS: walks about 3 blocks before getting SOB, sleeps on [**11-21**]
pillows at night (has been stable), positive PND, denies calf
pain or swelling, abd pain, N/V/diarhhea/F/C/dysuria. C/O cramps
in legs b/l.
Past Medical History:
1. DM1 diagnosed 3 years ago
2. Dilated cardiomyopathy with an ejection fraction of 15 to 20
percent, systolic congestive heart failure in [**2155-7-21**] at
which time a coronary catheterization revealed clean coronary
arteries, history of LV thrombus in [**2154-3-20**].
3. Morbid obesity with recurrent RLL pneumonia
4. Cholecystitis, satus post cholecystectomy.
5. ARF- due to gentamicin-induced ATN, resolving
Social History:
Social History: The patient is on disability and lives at home
with her mother. The patient last worked for [**Location (un) 86**] Public
Schools 2 years ago. The patient swims approximately 3 times per
week. Denies tobacco, alcohol, or IV drug use. The patient is
sexually active with men having 5 sexual partners in her life
and using condoms regularly.
Family History:
Family History: History of diabetes in grandmother and uncle.
History of dilated cardiomyopathy in father and grandmother. [**Name (NI) **]
history of coronary artery disease or cancer.
Physical Exam:
T 98.4 HR 113 BP 110/80 RR 40 SpO2 100% NRB (15L)
General: tired-appearing, anxious
HEENT: NCAT, anicteric, nl conjunctivae, PERRL, clear OP
Neck: supple, FROM, JV (prior to lasix-at clavicle while
upright- but difficult to assess now), no carotid bruit
Neck: no anterior cervical, posterior cervical, supra- or
infraclavicular, axillary, or inguinal adenopathy
Heart: tachy, normal S1 and S2, no S3, S4
Lungs: poor effort, CTA b/l No rhonchi/wheezes
Abd: protuberant, normal bowel sounds, soft, NT, ND
Back: no CVA tenderness, horizontal scar at lumbar area
Vasc: carotid, radial, femoral, dorasalis pedis pulses are brisk
and equal
Extremities: there is no rash, clubbing, or cyanosis; there is
trace ankle edema, Calves are symmetric, nontender, no cords,
[**Last Name (un) 5813**] sign negative
Pertinent Results:
[**2156-5-2**] 12:20AM WBC-8.4# RBC-3.48* HGB-10.3* HCT-33.2* MCV-95
MCH-29.6 MCHC-31.0 RDW-14.6
[**2156-5-2**] 12:20AM NEUTS-78.4* LYMPHS-17.4* MONOS-2.2 EOS-1.4
BASOS-0.5
[**2156-5-2**] 12:20AM PLT COUNT-409
[**2156-5-2**] 12:20AM PT-14.7* PTT-25.8 INR(PT)-1.4
[**2156-5-2**] 12:20AM D-DIMER-1427*
[**2156-5-2**] 12:20AM TSH-1.8
[**2156-5-2**] 12:20AM FREE T4-2.0*
[**2156-5-2**] 12:20AM VANCO-3.1*
[**2156-5-2**] 12:20AM DIGOXIN-0.7*
[**2156-5-2**] 12:20AM GLUCOSE-872* UREA N-25* CREAT-2.3*#
SODIUM-128* POTASSIUM-4.4 CHLORIDE-86* TOTAL CO2-23 ANION
GAP-23*
[**2156-5-2**] 12:37AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2156-5-2**] 03:57AM LACTATE-3.6* K+-3.3*
[**2156-5-2**] 04:39AM TYPE-ART TEMP-36.7 PO2-497* PCO2-40 PH-7.50*
TOTAL CO2-32* BASE XS-7 INTUBATED-NOT INTUBA COMMENTS-BIPAP
On BiPAP (settings not recorded) 7.50 / 40 / 497 / 32 / 7
Bipap Glu:609 Lactate:2.1
Comments: Verified O2Sat: 99
On NRB 8L: 7.51/37/75/31/5
glucose 373
CXR: bilat increased pulmonary interstitial markings and
cephalization of pulmonary vasculature, no PNA
Brief Hospital Course:
1. Shortness of breath
In the ED, she had an elevated ddimer but subsequent LENI([**5-2**])
were negative, and no CTA was performed secondary to renal
failure. The CXR and clinical presentation were c/w CHF, and
she was diuresed aggressively (with fluid/salt restriction) with
marked improvement in her respiratory status over several days,
initially in MICU and then transferred to the floor. She had a
TTE on [**5-4**] showing an EF of 15-20%, with LA and RA dilation,
severe dilatation of the LV, mild RV free wall hypokinesis,
3+MR, 2+TR,and moderate PA systolic HTN. On discharge her lung
exam was clear, O2 sats 97-99% RA and CXR showed resolution of
CHF findings. She did have an episode of acute dyspnea on [**5-5**]
overnight with clear lung exam and high O2 saturations,
differential PND vs. OSA vs. PE (but completely resolved). She
was begun on captopril 6.26 tid, toprol decreased to 25 mg qd,
and no aldactone given renal failure for now.
2. Acute on chronic renal insufficiency
Noted to have baseline Cr of 1.3, peak in 5's after gent
toxicity, trended down during admission. Appeared to increase
slightly in setting of aggressive diuresis, at which time she
was put on maintenance lasix 20 mg po qd, and beginning to trend
down again by discharge. She will be discharged on lasix 30 mg
po qd, with aldactone to possibly be added as outpatient if
renal failure continues to improve or stabilizes.
3. Blood pressure
On ACE, BB, and lasix, her blood pressures were 90s/50s or palp.
She tolerated this well with no lightheadedness or orthostasis.
4. Apnea
In MICU noted to have multiple episodes of sleep apnea per RNs,
and an episode of shortness of breath at night on the floor in
setting of resolved CHF exacerbation, argues towards possible
OSA. She has been set up for an outpatient sleep study.
5. MRSA line infection
Documented at OSH, subsequent surveillance blood cultures here
have been negative and no documented endocarditis. However, per
past notes, to finish 6 week course of vancomycin on [**2156-5-12**].
This was dosed by levels when Cr quite elevated, however when
beginning to recover this was dosed 1g iv qd per pharmacy.
6. DM1
On lantus 110u qhs with regular insulin sliding scale, with fsbg
in high 100s-low 200s. She may have component of insulin
resistance from obesity on top of type 1 DM, given very high
insulin requirements which still leave her with non-ideal
glycemic control. This will need continued adjustment as an
outpatient.
7. FEN
Initially with hyponatremia, resolved gradually with diuresis
and fluid restriction, likely from CHF, continued diabetic/low
sodium/renal diet. Continued calcium carb, iron, ascorbic acid.
8. Prophylaxis: SQ heparin, colace/senna, PPI.
9. Vascular Access: L PICC which can be pulled after finish
vancomycin course.
Medications on Admission:
1. Calcium carbonate 1,000 mg tid with meals.
2. Iron sulfate 325 tablet qd
3. Ascorbic acid 500 mg qd
4. Multivitamin 1 capsule qd
5. Colace 100 mg qd
6. Metoprolol succinate 37.5 mg qd
7. Amlodipine 5 mg. qd
8. Currently not receiving lisinopril 5 mg while renal function
returns to baseline
9. Glargine 110 U QHS
10. Lispro tid c meals and at bed time
11. digoxin 0.25 qd- not on last discharge summary but pt
reports taking at home
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
4. Insulin Glargine 100 unit/mL Solution Sig: One Hundred-Ten
(110) units Subcutaneous once a day.
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO QD (once a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) g Intravenous
once a day for 5 days.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Disp:*120 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
1. Congestive heart failure exacerbation
2. Dilated cardiomyopathy
3. Diabetes mellitus type 1
4. Acute renal failure
5. Chronic renal insufficiency
6. Obesity
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself daily. Please call your primary care doctor, Dr.
[**Last Name (STitle) 4048**], at [**Telephone/Fax (1) 250**] for new shortness of breath or if you
notice a >3lb weight gain.
Followup Instructions:
Please call your primary care doctor for a followup in the next
week.
You also have the following appointments scheduled:
Provider: [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2156-5-20**] 9:00. It is very
important that you make this appointment.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **]/DR. [**First Name (STitle) **] Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 6856**] Date/Time:[**2156-6-25**] 2:00 for sleep
study.
ICD9 Codes: 4254, 2761, 5849, 7907, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2684
} | Medical Text: Admission Date: [**2159-5-14**] Discharge Date: [**2159-5-17**]
Date of Birth: [**2087-12-13**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Nsaids
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Obstructive sleep apnea
Major Surgical or Invasive Procedure:
septoplasty with outfracture and cautery of inferior nasal
turbinates
History of Present Illness:
71 yo M with h/o obstructive sleep apnea was taking CPAP at
home. He had elective septoplasty procedure and outfracture and
cautery of nasal turbinates.
Past Medical History:
OSA, Gout, GERD, HTN, Hypercholestrolemia
Family History:
Married
Physical Exam:
Patient has both packs removed from his nose. He doesnt have
blood in his throat.No difficulty in breathing.
Pertinent Results:
[**2159-5-14**] 10:45AM PTT-58.8*
[**2159-5-14**] 10:45AM PLT COUNT-223
[**2159-5-14**] 10:45AM WBC-8.1 RBC-5.17 HGB-14.8 HCT-42.4 MCV-82
MCH-28.5 MCHC-34.8 RDW-14.2
[**2159-5-14**] 12:15PM PT-13.3 PTT-23.2 INR(PT)-1.2
[**2159-5-14**] 12:28PM PLT COUNT-235
[**2159-5-14**] 12:28PM WBC-9.2 RBC-5.02 HGB-14.1 HCT-39.6* MCV-79*
MCH-28.1 MCHC-35.6* RDW-13.2
[**2159-5-14**] 12:28PM CALCIUM-9.2 PHOSPHATE-3.3 MAGNESIUM-1.9
[**2159-5-16**] 03:16AM BLOOD PT-13.3 PTT-23.7 INR(PT)-1.2
Brief Hospital Course:
Patient had bleeding from his nose postop in PACU. He had an
epistat placed in his left nose and a meracell packing in right
nose. [**Name (NI) **] PTT was 58. He mentioned that couple of years
ago he had to get Vitamin K before a surgical procedure. Patient
was transfered to ICU for observation. Hematology was consulted
and they recommeneded that patient doesnt need any treatment.
They wanted coags to be normalized. Patient didn't have any
bleeding in ICU. His left epistat was removed on POD#1 and he
didn't bleed. His Right meracell packing was taken out on POD#2.
Patient was transfered to regular floor. He has been tolerating
soft solid diet. He has been afebrile and ambulating. He will be
discharged to home on [**2159-5-17**]
Medications on Admission:
Aspirin
Discharge Medications:
Aspirin
Percocet
Keflex
Discharge Disposition:
Home
Discharge Diagnosis:
Septoplasty, nasal turbinate outfracture/cautery, and postop
bleed
Discharge Condition:
Stable
Discharge Instructions:
Please do not do any heavy excercise, blowing of nose or
excessive sniffing for 1 month. If there is bleeding again,
please contact us [**Name (NI) 2678**].
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) 1837**] in one week
Completed by:[**2159-5-16**]
ICD9 Codes: 4019, 2749, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2685
} | Medical Text: Admission Date: [**2147-12-21**] Discharge Date: [**2147-12-24**]
Date of Birth: [**2091-5-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 56 year-old male with a history of GERD who recently
quit smoking who presented to clinic with a 40 lb weight loss,
polyuria, polydipsia and lethargy. Blood glucose was critically
high, unreadable. Of note, patient was seen in office 2 months
ago for routine visit, glucose was 140 at that time. Patient was
sent to the ED.
.
In the ED, blood glucose was 1009, Cr 2.6, K+ 5.5, had
ketonuria, gap of 41. CXR showed no infiltrate, urine was
negative other than ketones. WBC 10.1, hct 55, plt 199. Serum
Osm 392. ABG 7.3/40/102. Lactate 2.8. Received 4L NS total,
10units regular insulin and started on insulin gtt at 6units/hr.
Repeat lytes: glc 665, Cr. 2.1, K 4.1, gap 30.
.
On transfer to the floor patient reports symptoms as above.
Denies fever, chills, diarrhea, dysuria. Endorses blurred
vision. Of note, patient mild confused and some history was
obtained from girlfriend.
.
ROS: Positive as above for weight loss, polyuria, polydipsia and
fatigue. The patient denies any fevers, chills, nausea,
vomiting, abdominal pain, diarrhea, constipation, melena,
hematochezia, chest pain, shortness of breath, orthopnea, PND,
lower extremity oedema, cough, urgency, dysuria, gait
unsteadiness, focal weakness, headache, rash or skin changes.
.
Past Medical History:
GERD
Tobacoo use - recently quit
Osteoarthritis
PTSD
Hyperlipidemia
Social History:
Lives alone, has a girlfriend, has a daughter who is not living
with him. Smoking a pack every two days. Drinking half of a
bottle of wine on weekends, otherwise none. No drugs. Previous
history of cocaine. No IV drugs.
Family History:
Diabetes in mother, father and brother. HTN in parents.
Physical Exam:
On Presentation:
Vitals: T:98 BP:140/82 HR:100 RR:16 O2Sat: 97% on 2L
GEN: well-nourished, no acute distress, fidgits
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear. Fundi no visualized as patient cannot
cooperate. Peripheral veins have clear margins.
NECK: No JVD, no bruits, no cervical lymphadenopathy, trachea
midline
COR: tachycardic at 100, 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, no palpable cords
NEURO: Slightly confused with slurring of words. Moving in bed.
Oriented to [**Last Name (un) 18709**], place and year.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2147-12-21**] 04:46PM WBC-10.1# RBC-6.68* HGB-17.7# HCT-55.7*#
MCV-83 MCH-26.5* MCHC-31.7 RDW-13.9
[**2147-12-21**] 04:46PM NEUTS-87.4* LYMPHS-9.3* MONOS-2.8 EOS-0.4
BASOS-0.2
[**2147-12-21**] 04:46PM PLT COUNT-199
[**2147-12-21**] 04:46PM GLUCOSE-1009* UREA N-53* CREAT-2.6*#
SODIUM-140 POTASSIUM-5.5* CHLORIDE-89* TOTAL CO2-16* ANION
GAP-41*
[**2147-12-21**] 04:46PM CALCIUM-11.5* PHOSPHATE-8.8* MAGNESIUM-3.5*
[**2147-12-21**] 04:46PM OSMOLAL-392*
[**2147-12-21**] 05:36PM TYPE-ART PO2-102 PCO2-40 PH-7.30* TOTAL
CO2-20* BASE XS--5
[**2147-12-21**] CT head w/o contrast:
CT HEAD WITHOUT INTRAVENOUS CONTRAST: There is no evidence of
infarction,
hemorrhage, loss of [**Doctor Last Name 352**]-white matter junction differentiation,
shift of
normally midline structures, or edema. The ventricles, sulci and
cisterns
appear to be of normal appearance and contour. Osseous
structures are grossly unremarkable. Mastoid air cells and
paranasal sinuses are clear.
IMPRESSION: Normal study
[**2147-12-21**] 2 view CXR:
FINDINGS: PA and lateral views of the chest are obtained. Lungs
are clear
bilaterally demonstrating no evidence of pneumonia or CHF.
Cardiomediastinal silhouette appears normal aside from a
somewhat unfolded thoracic aorta. No pleural effusion or
pneumothorax is seen. The visualized osseous structures appear
intact. No free air seen below the diaphragm.
IMPRESSION:
No acute intrathoracic process.
Brief Hospital Course:
This is a 56 year-old male with a history of GERD, tobacco use,
who presents with hyperglycemia and metabolic acidosis and
polyuria, polydipsia, fatigue and weight loss consistent with
new onset diabetes and HHS with a component of DKA. Likely HHS
with some element of ketosis from prolonged hyperglycemia
(duration of symptoms 2 months) and severe beta cell
dysfunction. Less likely to be DKA/DMI give late onset and very
strong family history.
.
# Hyperglycemia/Metabolic Acidosis: Mixed picture of HHS and
DKA. No prior history of diabetes. Blood glc 1009, anion gap 35,
ketonuria. ABG 7.30/40/102. Corrected sodium was 155. Based on
age, type II much more likely. HbA1c came back at 15, consistent
with long-standing but unrecognized DM.
The patient was treated in the ICU with a insulin drip that was
titrated off and the patient, with the assistance of the [**Last Name (un) **]
diabetes consult service, was transitioned to a program of
lantus and lispro. The patient underwent extensive diabetes
teaching and was discharged with VNA to further help him with
his DM mangement. The patient will f/u with [**Last Name (un) **] closely as
an outpatient.
.
# Acute Renal Failure: Cr 2.6 on admission. Likely [**1-8**] to severe
volume depletion in the setting of his severe hyperglycemia.
Further Resolved with IVF and DM management.
.
# Hypernatremia: On admission, was 140 ?????? which was artifically
lower given dilutional effect of hyperglycemia. Corrected to
155. Patient was treated with free water with resolution of
hypernatremia.
.
# Hypercalcemia/Mag/Phos: Likely [**1-8**] to profound dehydration.
Resolved.
.
# Dyslipidemia: LDL 246, started simvastatin 40mg daily.
.
# GERD: Continue home PPI
.
# Code: FULL
Medications on Admission:
Omeprazole 20mg qd
Ranitidine 150mg [**Hospital1 **]
Hydrocortisone topical
Naproxen prn
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
3. Naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
4. Hydrocortisone Acetate Topical
5. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units
Subcutaneous at bedtime.
Disp:*20 vials* Refills:*10*
6. Humalog 100 unit/mL Solution Sig: One (1) units Subcutaneous
three times a day: Use per sliding scale as instructed with
meals.
Disp:*30 vials* Refills:*8*
7. glucometer with test strips, lancets Sig: One (1) unit as
directed: Prescription for patient to obtain a glucometer, 100
lancets with 10 refills, 100 test stripc with 10 refills.
Disp:*1 units* Refills:*2*
8. Insulin Needles (Disposable) 29 x [**12-8**] Needle Sig: One (1)
needle Miscellaneous four times a day: Use as directed.
Disp:*100 needles* Refills:*10*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
DKA/HHS
Newly diagnosed diabetes
Acute Renal Failure
Altered Mental Status
Hypovolemia
Hypernatremia
Hyperkalemia
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to the ED if you are having blood sugars greater than 500
not responsive to insulin sliding scale administration at home,
fevers, chills, confusion, vomitting, vision changes, weakness.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2148-2-13**] 11:20
Patient to arrange f/u with [**Hospital **] clinic for diabetes
management with Dr. [**Last Name (STitle) 14116**] at [**Telephone/Fax (1) 12648**]
ICD9 Codes: 5849, 2762, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2686
} | Medical Text: Admission Date: [**2181-11-24**] Discharge Date: [**2181-11-24**]
Date of Birth: [**2103-3-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Dyspnea, abdominal distention.
Major Surgical or Invasive Procedure:
Internal jugular line placement.
History of Present Illness:
78 year old female with multiple medical problems, pertinently
including CAD status post CABG, hypertension, and type 2
diabetes, with multiple recent hospitalizations for different
resistant infections, including MSSE, MRSE and strep viridans
bacteremia thought to be secondary to decubitus ulcer with
associated osteomyelitis for which she is on a 6 week course of
vancomycin, last discharged to nursing home on [**2181-11-12**] after a
hospitalization for anemia of chronic inflammation, renal
failure, and an E. Coli UTI resistant to levofloxacin and
treated with a 2 week course of pip-tazo which was completed on
[**11-27**], presenting from the nursing home with a couple of days of
dyspnea and tachypnea with LLL infiltrate on CXR, as well as 1
week of vomiting and abdominal distention.
.
In the ED, labs notable for acute renal failure, leukocytosis,
elevated lactate. Her abdomen was tensely distended. She had
an IJ line placed and code sepsis intitiated. Started on
levophed for hypotension.
Past Medical History:
1) CAD status post CABG [**2169**]
2) Hypertension
3) Type 2 diabetes
4) Pulmonary fibrosis
5) Traumatic Brain Injury: Spring [**2181**], complicated by
subdural, subarachnoid, and intraparenchymal hemorrhages. Since
that time she has been non-verbal and bed bound with a PEG tube
for feedings in a nursing home.
6) Seizure disorder
7) Recurrent DVTs
Social History:
Italian decent, speaks Italian with some English. Now non-verbal
following TBI. Children involved in care. Lives in a [**Hospital1 1501**]/Rehab.
All ADLs done for her. No tobacco, EtOH, or drug use. Widowed
18mo ago, has 3 children.
Family History:
brother w/ hematologic cancer
brother w/ throat cancer
brother w/ lung ca
no known h/o seizures, stroke
Physical Exam:
BP 107/68, HR 70s, RR 28, 90% on NRB.
GENERAL: Agonal appearing obese caucasian female, non-verbal.
HEENT: Moist MM. Anicteric sclerae.
NECK: Flat JVP.
LUNGS: Rhonchi bilaterally.
COR: RR, normal rate, difficult to auscultate over coarse BS.
ABD: Tensely distended, without bowel sounds.
EXTR: [**1-15**]+ edema on left > right.
Pertinent Results:
[**2181-11-24**] 09:25AM BLOOD WBC-20.1*# RBC-3.47* Hgb-10.1* Hct-29.4*
MCV-85 MCH-29.1 MCHC-34.3 RDW-17.3* Plt Ct-429#
[**2181-11-24**] 09:25AM BLOOD PT-17.5* PTT-47.3* INR(PT)-1.6*
[**2181-11-24**] 09:25AM BLOOD Glucose-136* UreaN-115* Creat-3.9*#
Na-140 K-6.5* Cl-94* HCO3-20* AnGap-33*
[**2181-11-24**] 12:50PM BLOOD ALT-29 AST-18 AlkPhos-251* Amylase-138*
TotBili-0.3
[**2181-11-24**] 12:50PM BLOOD Albumin-2.3* Calcium-8.9 Phos-7.0*#
Mg-5.1*
[**2181-11-24**] 12:50PM BLOOD Cortsol-53.9*
[**2181-11-24**] 09:58AM BLOOD Lactate-4.8*
Brief Hospital Course:
78 year old female with multiple medical problems, including CAD
status post CABG, hypertension, and type 2 diabetes, with
multiple recent hospitalizations for different resistant
infections, including MSSE, MRSE and strep viridans bacteremia
thought to be secondary to decubitus ulcer with associated
osteomyelitis, presenting with sepsis. She was agonal on
arrival to the MICU, with audible coarse breath sounds. In
discussion with the family, they were clear about wanting to
keep her comfortable and NOT pursuing any further aggressive
treatments. They understood that treatment would likely entail
continued pressors, possibly dialysis, intubation, etc, and they
understand that without these treatments, Mrs. [**Known lastname **] would
likely pass away relatively soon. Given her deteriorated
quality of life, they opted for comfort measures, which were
pursued with the initiation of a morphine drip, and
discontinuation of levophed. Within an hour of arrival to the
MICU she became apneic, her blood pressure dropped, and she
became bradycardic and then pulseless. She was pronounced dead
at 4 p.m., an hour after arrival to the MICU. Her family was in
the room, as was the Priest.
Medications on Admission:
Not recorded.
Discharge Medications:
N/A.
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Acute renal failure
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 0389, 486, 5849, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2687
} | Medical Text: Admission Date: [**2149-4-20**] Discharge Date: [**2149-4-29**]
Date of Birth: [**2126-4-3**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
MVA complaining of back pain.
Major Surgical or Invasive Procedure:
Anterior T11 corpectomy with T10-12 fusion
Posterior thoracolumbar fusion T8-L1
History of Present Illness:
Mr. [**Known lastname 53387**] was involved in a high speed MVA where he sustained a
T11 burst fracture. He had no left leg movement in the EW and
sensation was patchy throughout both lower extremities.
Past Medical History:
None
Social History:
+ alcohol socially
Family History:
N/C
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; reflexes intact at biceps, triceps and
brachioradialis
LLE- 0/5 strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation patchy
RLE- 5/5 strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation patchy
Pertinent Results:
[**2149-4-28**] 07:00AM BLOOD WBC-13.2* RBC-3.08* Hgb-9.5* Hct-27.5*
MCV-90 MCH-30.9 MCHC-34.5 RDW-14.9 Plt Ct-337
[**2149-4-27**] 07:00AM BLOOD WBC-14.9* RBC-3.24* Hgb-9.9* Hct-28.0*
MCV-87 MCH-30.7 MCHC-35.5* RDW-15.4 Plt Ct-303
[**2149-4-26**] 10:28PM BLOOD WBC-16.0* RBC-3.27* Hgb-10.2* Hct-28.2*
MCV-86 MCH-31.3 MCHC-36.2* RDW-15.3 Plt Ct-275
[**2149-4-24**] 04:59AM BLOOD WBC-10.6 RBC-2.77* Hgb-8.9* Hct-25.0*
MCV-90 MCH-32.2* MCHC-35.7* RDW-12.6 Plt Ct-204
[**2149-4-23**] 06:24PM BLOOD WBC-14.9*# RBC-3.02* Hgb-9.5* Hct-27.6*
MCV-91 MCH-31.6 MCHC-34.6 RDW-12.7 Plt Ct-212
[**2149-4-27**] 07:00AM BLOOD Glucose-118* UreaN-7 Creat-0.5 Na-137
K-4.0 Cl-100 HCO3-31 AnGap-10
[**2149-4-24**] 04:59AM BLOOD Glucose-140* UreaN-8 Creat-0.6 Na-138
K-4.2 Cl-102 HCO3-29 AnGap-11
[**2149-4-23**] 06:24PM BLOOD Glucose-180* UreaN-11 Creat-0.5 Na-141
K-4.1 Cl-107 HCO3-26 AnGap-12
[**2149-4-22**] 01:32AM BLOOD Glucose-109* UreaN-18 Creat-0.7 Na-142
K-3.8 Cl-107 HCO3-26 AnGap-13
[**2149-4-27**] 07:00AM BLOOD Calcium-8.0* Phos-3.3 Mg-2.1
[**2149-4-23**] 10:28PM BLOOD Calcium-7.8* Phos-4.2 Mg-1.8
[**2149-4-22**] 01:32AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.5
Brief Hospital Course:
Mr. [**Known lastname 53387**] was admitted to the trauma service for evaluation of
his T11 burst fracture, Grade 1 liver laceration and corneal
abrasion. He was informed and consented for the T11
vertebrectomy and elected to proceed. He was subsequently taken
to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a anterior thoracotomy with T11
vertebrectomy and T10-12 stabilization. A chest tube was placed
post-operatively which was managed with suction. He was then
taken back to the OR for posterior stabilization spanning T9-L1.
During this case the chest tube was removed. Please see
Operative Notes for procedures in detail.
The Grade 1 liver laceration will be managed non-operatively by
the Trauma service and no further follow up was required. He
was given erythromycin for his corneal abrasion.
Post-operatively he was administered antibiotics and pain
medication. His catheter and drain were removed POD 3 and he
was able to take PO's. He was able to work with physcial
therapy to improve his strength and balance. At the time of
discharge he had no movement of his left leg and sensation
remained patchy. His pain was well controlled and he remained
afebrile throughout his hosptial course. He will return to
clinic in ten days. He was discharged in stable condition.
Medications on Admission:
None
Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: One (1) application
Ophthalmic QID (4 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
9. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
T11 fracture with spinal cord injury
Grade 1 liver laceration
Corneal abrasion
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Activity as tolerated
Thoracic lumbar spine: when OOB
Treatments Frequency:
Please continue to change the dressing daily with dry, sterile
gauze.
Followup Instructions:
Please follow up in the Spine Clinic to schedule an appointment.
Please call [**Telephone/Fax (1) 11061**].
Completed by:[**2149-4-29**]
ICD9 Codes: 2851, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2688
} | Medical Text: Admission Date: [**2153-8-15**] Discharge Date: [**2153-8-26**]
Date of Birth: [**2090-1-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Fever, hemoptysis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI: Mr. [**Known lastname 4427**] is a 63 y/o male with metastatic esophageal
adenocarcinoma with extensive bone marrow involvement and
secondary DIC admitted with fever, hypoxia and hemoptysis. He
recently started cycle 6 of oxaliplatin and 5FU, which was given
early due to developing DIC. On the day prior to admission he
had generalized malaise and fatigue with leg weakness. On the
evening prior to admission he developed fever of 101.4 followed
by early morning nausea and non-bloody vomiting and two episodes
of couging up small amount of bright red [**Known lastname **] as well as
continued fever.
He also reports having pain in his left shoulder which is new in
the past 24 hours, before that he had pain in his right
shoulder. In addition, he developed a painful, bruised and
swollen finger yesterday which is improving today. He denies
any mucosal bleeding. He has been consipated, denies any [**Known lastname **]
in his stool. He also denies dyspnea, chest pain, abdominal
pain.
Past Medical History:
ONCOLOGIC HISTORY:
- [**3-/2153**] - presented to [**Hospital3 **] complaining of lower
abdominal pain and constipation. CT performed and showed
lymphadenopathy in the paraesophageal, celiac, periportal, and
retroperitoneal regions.
- Admitted to [**Hospital3 **] on [**2153-4-24**] for hematemesis,
anemia
(HCT 22%) and DIC (INR 3.0). EGD performed and showed a bleeding
distal esophageal mass. Biopsy showed moderate-poorly
differentiated adenocarcinoma with invasive signet ring
features.
Was transfused FFP and pRBC's and transferred to [**Hospital1 18**].
- [**Hospital1 18**] admission ([**Date range (3) 46504**]): treated with radiation
2600
cGy and one cycle of oxaliplatin 100 mg/m2, day 1 and 5-FU 800
mg/m2/day x96 hours, days [**12-17**] beginning on [**2153-4-27**]. He
received
a second cycle of oxaliplatin 100 mg/m2 day 1 and 5-FU 1000
mg/m2
per day for 96 hours beginning [**2153-5-22**]. His third and fourth
cycles were given [**2153-6-11**] and [**2153-7-2**].
- Peripheral smear showed evidence of myelophthisic picture
(nucleated RBCs and WBC precursors) suggesting possibility of
bone marrow involvement.
- A bone marrow biopsy was performed on [**2153-5-21**] and was positive
for metastatic carcinoma.
Social History:
Works as a dye maker x 26 years. No smoking. Social drinking.
Lives at home with his wife.
Family History:
Mother had gastric ca and died of emphysema. Has 4 brothers, one
died of CAD/MI, also had aortic stenosis which was untreated.
One brother has hemachromatosis. Has a healthy daughter.
Physical Exam:
Vital Signs: T: 97.6 BP: 130/78 HR: 90 RR: 20 02 sat: 95RA
GENERAL: appears diaphoretic, A&O x3, no acute distress
HEENT: Sclera anicteric, pupils 2mm and reactive, no mucosal
bleeding
NECK: Supple with full range of motion, no mass or thyromegaly
CHEST: scattered crackles in the mid lung zones bilaterally, no
wheezing.
COR: RRR, 2/6 systolic murmur
ABD: Soft, non distended, RUQ to palpation but otherwise non
tender, no rebound or guarding, normoactive bowel sounds.
EXT: No edema, clubbing or cyanosis. Pain with palpation of
right shoulder joint margin, no redness/warmth or swelling of
shoulder. Pain with active and passive motion. Fourth finger
of right hand with swelling and bruising of the proximal IP
joint.
Pertinent Results:
[**2153-8-15**] 10:30AM [**Month/Day/Year 3143**] WBC-5.1 RBC-3.08* Hgb-9.8* Hct-30.4*
MCV-99* MCH-31.7 MCHC-32.2 RDW-17.5* Plt Ct-62*
[**2153-8-17**] 03:17AM [**Month/Day/Year 3143**] WBC-4.4 RBC-2.56* Hgb-8.2* Hct-24.7*
MCV-97 MCH-32.2* MCHC-33.3 RDW-18.6* Plt Ct-63*
[**2153-8-15**] 10:30AM [**Month/Day/Year 3143**] Glucose-159* UreaN-32* Creat-0.8 Na-134
K-4.9 Cl-99 HCO3-24 AnGap-16
[**2153-8-17**] 03:17AM [**Month/Day/Year 3143**] Glucose-140* UreaN-27* Creat-0.4* Na-137
K-3.8 Cl-103 HCO3-24 AnGap-14
[**2153-8-16**] 04:01AM [**Month/Day/Year 3143**] Neuts-88* Bands-2 Lymphs-6* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2153-8-15**] 10:30AM [**Month/Day/Year 3143**] PT-19.7* PTT-36.1* INR(PT)-1.8*
[**2153-8-17**] 03:17AM [**Month/Day/Year 3143**] PT-15.2* PTT-26.6 INR(PT)-1.3*
[**2153-8-15**] 05:15PM [**Month/Day/Year 3143**] FDP->1280*
[**2153-8-17**] 03:17AM [**Month/Day/Year 3143**] FDP-320-640*
[**2153-8-15**] 10:30AM [**Month/Day/Year 3143**] Fibrino-101*#
[**2153-8-17**] 03:17AM [**Month/Day/Year 3143**] Fibrino-330
[**2153-8-16**] 04:01AM [**Month/Day/Year 3143**] ALT-135* AST-304* LD(LDH)-1610*
AlkPhos-202* TotBili-2.8*
[**2153-8-17**] 03:17AM [**Month/Day/Year 3143**] CK(CPK)-244*
[**2153-8-17**] 03:17AM [**Month/Day/Year 3143**] Calcium-8.2* Phos-2.1* Mg-2.7*
[**2153-8-16**] 04:01AM [**Month/Day/Year 3143**] HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE, HCV Ab-NEGATIVE
[**2153-8-16**] 04:01AM [**Month/Day/Year 3143**] CEA-9978*
[**2153-8-16**] 09:31PM URINE [**Month/Day/Year **]-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-6.5 Leuks-NEG,
CastGr-1*
Brief Hospital Course:
Mr. [**Known lastname 4427**] is a 63 y/o male with metastatic esophageal
adenocarcinoma with extensive bone marrow involvement and
secondary DIC admitted with fever, hemoptysis, evidence of
alveolar hemorrhage and DIC.
1. Respiratory Distress
On admission to the ICU, he met sepsis/sirs criteria with most
likely sources of infection being pulmonary. Other possible
source given RUQ pain on exam would be hepato-biliary. There was
no diarrhea to suggest fecal source. UA was without evidence of
infection. He did have joint pain but no physical evidence to
suggest septic joint. He was placed on broad antibiotics
coverage with vanc/zosyn and azithromycin to cover atypicals.
Cultures were sent, but with no clear source of infection. RUQ
ultrasound to evaluate liver/gallbladder showed no acute
processes. His elevated LFTs were deemed to be most likely from
new liver mets seen on CTA of chest. The respiratory distress
was likely secondary to diffuse alveolar hemorrhage (see
hemoptyis section below). His oxygenation improved initially, as
did his DIC parameters, after treatment with oxaliplatin and
5-FU. However, after transfer to the floor, his respiratory
status worsened, and given the worsening DIC it was likely that
diffuse alveolar hemorrhage may have redeveloped. Pulmonary was
consulted and felt that antibiotics could be stopped, as there
was no clear infectious pulmonary process. Despite a second
course of chemotherapy with irinotecan and docetaxol, his
respiratory status continued to worsen. Goals of care were
changed to DNR/DNI with no escalation of care for ICU transfer
or non-invasive positive pressure ventilation. Given the
worsening DIC, he was started on morphine drip for comfort. He
passed away on the morning of [**8-26**].
2. Disseminated Intravascular Coagulopathy
His DIC was most likely secondary to his metastatic esophageal
cancer; it has improved/resolved with chemo in the past. His DIC
parameters improved with transfusion of 2 bag of plts, 2U FFP, 5
IV Vit K, and 2x PRBCs and showed initial improvement after
oxaliplatin and 5-FU in the ICU. However, after several days he
again developed DIC, and salvage chemotherapy with irinotecan
and docetaxol was unsuccessful.
3. Hemoptysis
His hemoptysis was most likely [**1-15**] alveolar hemorrhage from DIC
given appearance on chest CT. Repeat cxr did not show
progressive hemorrhage, but patient continued to have episodes
of hemmoptysis. His respiratory status worsened after transfer
to the floors, eventhough the hemoptysis episodes became less
frequent.
4. Shoulder Pain
His shoulder pain was concerning for potential bleeding into
joint, metastasis, or septic joint. However, there was no
evidence of septic joint. Xray of the shoulder showed
degenerative changes with no fractures.
5. Metastatic Esophageal Adenocarcinoma with Bone Marrow
Involvement
For his metastatic esophageal adenocarcinoma, he received cycle
6 of oxaliplatin and 5-FU. When DIC developed again, he was
given irinotecan and docetaxol. Despite this, his coagulopathy
continued to worsen and overall status declined until goals of
care shifted to comfort measures.
6. S/p AVR
His AVR, bovine valve, was stable and he was not on any
anticoagulation at baseline.
7. Prophylaxis
He was placed on pneumoboots, PPI [**Hospital1 **] for prophylaxis, and a
bowel reg.
8. Goals of Care
As his respiratory status worsened, code status was addressed
and changed to DNR/DNI. On the night of [**8-25**], he became less
responsive, likely secondary to hypoxia and/or hypercarbia from
respiratory failure. Goals of care were discussed with family
and they did not want escalation of care (no ICU transfer, no
non-invasive positive pressure ventilation). On the morning of
[**8-26**], his breaths became more agonal and morphine was increased,
titrated to comfort. He passed away on the late morning of [**8-26**].
Time of death was 11:50 AM.
Medications on Admission:
Dilaudid- 2-4 mg q 4h PRN pain
Metoprolol 25 mg Tablet [**Hospital1 **]
MS Contin 15 mg Q12 hr
Ondansetron 8mg [**Hospital1 **] x 2 days after chemo and Q8hrs prn nausea
Protonix 40mg Q12 hrs
Compazine 10 mg Q 6 hour PRN nausea/vomiting
Bisacodyl 5 mg DAILY (Daily) PRN constipation (not using)
Colace 100 mg ID
Senna 8.6 mg Tablet [**Hospital1 **] PRN constipation (not currently using)
Discharge Medications:
Deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased.
Discharge Condition:
Deceased.
Discharge Instructions:
Deceased.
Followup Instructions:
Deceased.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2153-8-26**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2689
} | Medical Text: Admission Date: [**2113-7-27**] Discharge Date: [**2113-8-3**]
Date of Birth: [**2048-5-19**] Sex: M
Service: MEDICINE
Allergies:
Tetanus Diphtheria / Lisinopril / Mavik
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Short of breath
Major Surgical or Invasive Procedure:
ABG
History of Present Illness:
65 M with/o severe COPD and many hospialization - here with
gradually worsening shortness fof breath, at rest and worsened
with minimal exertion. No cough, chest pain, fevers. Last
discharged on [**2113-7-5**] from [**Hospital1 18**] after Rx of COPD exacerbation
and on high dose prednisone taper. He reports doing well when he
was on 60 mg --> down to 40 mg of prednisone, when he dropped
dose to 30mg / day as a part of the taper, he started getting
progressively worse in terms of breathing. Called pulmonologist
who restarted him on 60 mg prednisone. Patient noted some
improvement but still was dyspneic at rest and hence came to ER.
ROS
All other systems negative except as noted above and/or in
medical resident's note
Past Medical History:
1. Severe COPD
2. Anemia, normal C-scope
3. On home oxygen 2 liters
4. Vocal cord squamous dysplasia.
5. Hypertension.
6. Obstructive sleep apnea -->does not use CPAP.
7. Myocardial infarction diagnosed in [**2112-7-30**], as per the
patient.
8. Lower extremity venous stripping at age 28.
9. C7 neuroma.
10. History of esophageal obstruction.
11. Status post knee surgery.
12. Alcohol abuse and dependence, status post several
rehabilitation stays
13. Hospitalization [**2-4**] at [**Last Name (un) 883**] for "MRSA" --+MRSA sputum
here [**1-4**]
14. Rectus sheat hematoma
15. h/o CHF x 2 per patient with shortness of breath and leg
edema, also a/w wheezing.
Social History:
Drinks 8-10 beers per day, no history of severe withdrawals.
Smokes 2 cigarettes per day, former 80 pack year history of
smoking. He is married and lives with wife with no pets and no
drug use.
Family History:
Mother had a DVT and diabetes. Father died of coronary artery
disease at age 35.
Physical Exam:
VITALS: T 97.5, HR 90, BP 130/78, RR 20, O2 sat 95% on 2L O2
(NC)
GEN: Alert. Pleaseant man. Mildly dyspneic at rest.
Eyes: no pallor or icterus, PERRL.
ENT: Supple neck. I could not appreciate JVD, but his neck is
thick. Slight use of accessory muscles to breathe.
CV: S1, 2 - normal. No murmus/rubs or gallops.
LUNGS: Diffuse, prolonged expiratory phase with wheezing. No
crackles. Poor air entry bilaterally equal.
ABD: Obese, soft, Non-tender, non distended. Umbilical hernia.
EXT: 1+ bilateral pitting edema, periankle.
Skin - no rash/ulcer
GU - no catheter.
NEURO: Alert, oriented. Fluent speech.
Psychiatric - appropriate, [**Last Name (un) 664**]
Heme/lymph - no cervical or supra-clavicular LN.
Pertinent Results:
[**2113-7-31**] 2:51 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2113-7-31**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH OROPHARYNGEAL FLORA.
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.
MOLD. 1 COLONY ON 1 PLATE.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
[**2113-7-27**] 7:20 pm BLOOD CULTURE VENIPUNCTURE # 2.
**FINAL REPORT [**2113-8-2**]**
AEROBIC BOTTLE (Final [**2113-8-2**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2113-8-2**]): NO GROWTH.
[**2113-7-27**] 4:35 pm BLOOD CULTURE RIGHT ARM VENIPUNCTURE.
**FINAL REPORT [**2113-8-2**]**
AEROBIC BOTTLE (Final [**2113-8-2**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2113-8-2**]): NO GROWTH.
.
CXR - No acute cardiopulmonary process including no pulmonary
edema or pneumonia
AP chest compared to [**2113-2-23**] through [**2113-7-27**] and
[**2113-7-28**].
Hyperinflation indicates COPD. There is no pneumonia or
pulmonary edema and no pleural effusion or cardiac enlargement.
[**2113-8-3**] 06:30AM BLOOD WBC-16.2* RBC-3.50* Hgb-9.6* Hct-30.0*
MCV-86 MCH-27.5 MCHC-32.1 RDW-16.7* Plt Ct-338
[**2113-7-27**] 04:35PM BLOOD WBC-10.3 RBC-3.77* Hgb-10.2* Hct-31.4*
MCV-83 MCH-27.0 MCHC-32.3 RDW-17.4* Plt Ct-533*
[**2113-7-30**] 04:40AM BLOOD WBC-20.4* RBC-3.75* Hgb-10.4* Hct-31.5*
MCV-84 MCH-27.9 MCHC-33.1 RDW-16.5* Plt Ct-437
[**2113-7-27**] 04:35PM BLOOD Neuts-92.6* Lymphs-5.0* Monos-2.2 Eos-0
Baso-0.3
[**2113-7-31**] 04:55AM BLOOD PT-11.3 PTT-23.0 INR(PT)-1.0
[**2113-8-3**] 06:30AM BLOOD Glucose-87 UreaN-24* Creat-0.9 Na-136
K-3.8 Cl-92* HCO3-40* AnGap-8
[**2113-7-27**] 04:35PM BLOOD Glucose-127* UreaN-21* Creat-0.9 Na-132*
K-4.3 Cl-92* HCO3-28 AnGap-16
[**2113-7-30**] 04:40AM BLOOD ALT-35 AST-24 LD(LDH)-261* AlkPhos-77
TotBili-0.3
[**2113-7-27**] 04:35PM BLOOD CK-MB-7 cTropnT-<0.01 proBNP-61
[**2113-8-1**] 06:35AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.8*
[**2113-7-30**] 04:40AM BLOOD calTIBC-514* Ferritn-17* TRF-395*
[**2113-7-29**] 11:09AM BLOOD Type-ART O2 Flow-2 pO2-82* pCO2-45
pH-7.41 calTCO2-30 Base XS-2 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2113-8-3**] 02:13PM BLOOD Type-ART O2 Flow-2 pO2-67* pCO2-49*
pH-7.47* calTCO2-37* Base XS-10 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2113-7-29**] 12:03AM URINE Hours-RANDOM Creat-119 Na-LESS THAN
[**2113-7-29**] 12:03AM URINE Osmolal-52
Brief Hospital Course:
The patient was treated for COPD exacerbation - and required [**Hospital **]
transfer to aggressive management with continous nebs. THe flare
was likely precipitated by ongoing smoking, taper of prednisone
and possible MRSA and pseudominas pneumonia vs colonization. He
was given IV steroids,Aggressive nebs, albuterol, O2. Continued
fluticasone - salmeterol, atrovent, fexofenadine, montelukast.
Evantually was changed over to prednisone. Smoking cessation
counselling was done as well. Doxycycline and levofolxacin were
started for possible lung infection. The patiet was also
diuresed in the ICU with removal of 6 liters that caused
metabolic alkalosis. The patient was advised to stop lasix and
not to resume it till seen by PCP [**Last Name (NamePattern4) **] 1 week. He likely has
Diastolic CHF and pulm HTN. Elevation of legs was recommended.
HTN was managed with verapamil at home doses.
He has iron def anemia - will defer to PCP for follow up and
furthr evaluation.
Smoking - extensively conselled about the risks of ongoing
smoking especially given that he is on home O2. He was also
advised everyone in the house should not smoke for due to fire
[**Doctor Last Name 13205**]. On buproprion. Nicotin patch was prescribed.
OSA -he is not compliant with CPAP at home. Discussed with Dr
[**Last Name (STitle) **], his pulmonologist and the plan is to see him in sleep
clinic. Dr [**Last Name (STitle) **] [**Name (STitle) **] will call patient with a pulmonary and
sleep clinics. The patient tolerated CPAP in hosp well.
DNR/ DNI as per ICU attending discussion with patient.
o not resuscitate (DNR/DNI) No shock/CPR or intubation.
Pressors/central line okay
Medications on Admission:
1. O2 tank.
2. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-31**] puff Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
3. Atrovent 0.02 % Solution Sig: 1-2 puffs Inhalation every six
(6) hours.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **].
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID .
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6Hours as needed for cough.
14. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Take 3 tabs daily for one week, then 2 tabs daily for
one week, then 1 tab daily after that.
15. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QD () as needed for smoking
cessation.
16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY
17. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY
18. Verapamil 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q12H (every 12 hours)
19. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-31**] puff Inhalation
every four (4) hours.
Discharge Medications:
1. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 10 days.
[**Month/Day (2) **]:*20 Capsule(s)* Refills:*0*
2. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): for 10 days; then decrease to 55 mg PO daily for 7
days; then 50 mg po daily for 7 days; then 45 mg po daily for 7
days. Then discuss with your doctor.
[**Last Name (Titles) **]:*50 Tablet(s)* Refills:*0*
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Last Name (Titles) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal
TID (3 times a day) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO HS (at bedtime).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation every six (6) hours as needed for wheezing.
15. Albuterol Inhalation
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
19. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
21. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
22. Diazepam 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for uncomfortable w/ cpap.
[**Hospital1 **]:*8 Tablet(s)* Refills:*0*
23. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
[**Hospital1 **]:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company **]
Discharge Diagnosis:
Chronic obstructive pulmonary disease exacerbation
Methicillin resistant staphylococcus and pseudomonas pneumonia
Obstructive Sleep Apnea
Congestive heart failure, diastolic; pulmonary hypertension
Metabolic alkalosis
Iron deficiency anemia
Discharge Condition:
stable
Discharge Instructions:
Return to the hospital if you notice any new symptoms of concern
to you.
Use the CPAP machine at home as instructed when you sleep.
Keep your appointments. The pulmonary doctor will call you for
an appointment with the pulmonary clinic and sleep clinic.
Take the medications as instructed.
Please discuss with your primary doctor about completely
stopping smoking.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2113-10-30**] 9:30
[**Last Name (LF) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2205**] - [**2113-8-8**] at 11 AM.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD - ([**Telephone/Fax (1) 513**] - The doctor witll call you
with an appointment with sleep and pulmonary clinic. Please call
this number if you do not hear from them in the next 1 week.
ICD9 Codes: 4280, 2761, 4019, 4168, 3051, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2690
} | Medical Text: Admission Date: [**2153-1-9**] Discharge Date: [**2153-2-16**]
Date of Birth: [**2153-1-9**] Sex: F
Service: NB
This is an interim summary covering from [**Date range (1) 58676**]/[**2152**]
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is the former 3.25-
kilogram product of a 34-3/7 weeks gestation pregnancy born
to a 35-year-old G7, P3 woman. Prenatal screens: Blood type
B negative, antibody 3 plus positive, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative,
toxoplasmosis negative. The EDC was [**2153-2-17**]. The
prenatal course was significant for late prenatal care,
advanced maternal age, insulin dependent-gestational diabetes
requiring NPH and Humulin insulin. A hemoglobin A1C was 7.1
percent. It was unclear if the etiology was gestational
diabetes versus type 2.
The mother presented in preterm labor and received
betamethasone on [**12-10**] and [**2152-12-11**]. RH sensitization was
noticed on [**2152-11-30**] to be in [**Last Name (un) 31425**] midzone 2. On
[**2152-12-11**], she was admitted for worsening zones concerned
approaching zone 3, but a repeat amniocentesis during this
admission showed that she was again in midzone 2. There was
concern at the day of delivery for worsening isoimmunization,
and the mother was taken to cesarean section on [**2153-1-9**] at
20:48 hours. Infant emerged active, required bulb suction,
and blow-by O2 for a short period. Apgars were 7 at one
minute and 8 at five minutes.
She was brought to the Neonatal Intensive Care Unit for
further care. Of note, the mother was on an insulin drip at
the time of delivery. There were no sepsis risk factors.
Mother is GBS negative. There was no maternal fever, rupture
of membranes occurred at the time of delivery.
PHYSICAL EXAMINATION UPON ADMISSION TO THE NEONATAL INTENSIVE
CARE UNIT: Weight 3.25 kg (90th percentile), head
circumference 34 cm (over the 90th percentile), length 47 cm
(50-75th percentile). General: Active, pale infant in mild
respiratory distress. Head, eyes, ears, nose, and throat:
Anterior fontanel is open and flat, symmetric facial
features. Palate intact. Chest: Mild intercostal/subcostal
retractions. Breath sounds are coarse bilaterally.
Cardiovascular: Normal S1, S2, no murmur. Femoral pulses
are plus 2. Abdomen is soft, nontender. Liver palpable, but
does not seem distended. Extremities: Well perfused. Skin:
Pink without rashes. Spine intact. Neurologic: Appropriate
tone and reflexes.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: Respiratory: [**Known lastname **] had persistent respiratory
distress and was placed on continuous positive airway
pressure shortly after admission to the Neonatal Intensive
Care Unit. She was transitioned to room air on day of life
two and continued in room air for the remainder of her
Neonatal Intensive Care Unit admission. She has had
occasional oxygen desaturations associated with feeding.
Cardiovascular: A soft murmur was noted upon admission to
the Neonatal Intensive Care Unit. A cardiac echocardiogram
was performed on [**2153-1-15**] showing no patent foramen ovale,
mild tricuspid regurgitation, and a structurally normal
heart. With the onset of the Staphylococcus aureus
bacteremia, a cardiac echocardiogram was repeated and showed
a small right atrial clot, which had resolved on follow-up
echocardiogram on [**2153-1-29**]. The murmur remains audible at
the time of discharge. [**Known lastname **] has maintained normal heart
rates and blood pressures.
Fluid, electrolytes, and nutrition: [**Known lastname **] was initially
nothing by mouth and treated with intravenous fluids.
Enteral feeds were started on day of life number three and
gradually advanced to full volume. At the time of this
dictation, she is taking Neosure 22 calories/ounce orally and
per gavage. Recent weight is 4.040 kilograms. Serum
electrolytes were checked in the first week of life, within
normal limits.Feeding team from [**Hospital1 **] to evaluate her on
[**2-19**], if there is not significant improvement.
Infectious disease: [**Known lastname **] had a CBC upon admission to the
Neonatal Intensive Care Unit with a normal white blood cell
count and differential. On day of life seven, due to
lethargy, a blood culture was obtained and subsequently grew
Staphylococcus aureus. Four subsequent blood cultures were
obtained and were positive. The first negative culture was
on [**2153-1-22**]. She was initially started on vancomycin and
gentamicin, but was changed to oxacillin once the
sensitivities were known. She also received a five day
course of rifampin at the recommendation of the Infectious
Disease consult team.
The current plan is for a six week total course of oxacillin
from the first negative blood culture. A Broviac central
venous catheter was placed and it is indwelling in the right
femoral vein. She is currently on day 26/42 days of oxicillin
Hematological: [**Known lastname **] underwent a double volume exchange
transfusion shortly after birth for initial bilirubin of
10.8/0.4. She tolerated the exchange transfusion well. She
is blood type O positive, direct antibody test positive. She
has also received several transfusions of packed cells since
the exchange transfusion. Her most recent hematocrit was 26
percent on [**2153-1-16**]. Reticulocyte count at that time was
1.1 percent. She is being treated with supplemental iron.
Gastrointestinal: [**Known lastname **] had unconjugated hyperbilirubinemia
in association with her hemolytic disease. Peak serum
bilirubin after the double volume exchange transfusion was on
day of life three with a total of 15.6/0.5 mg/dl. She
received phototherapy for approximately one week. Her
rebound bilirubin off phototherapy was a total of 1.9/0.6.
Renal: Renal and abdominal ultrasound were performed looking
for a possible clot or foci for the Staphylococcus aureus
sepsis. The renal portion of the abdominal ultrasound was
normal.
Neurology: [**Known lastname **] has maintained a normal neurological exam
during admission. There is some concern for her slow advance
to full oral feedings. But this may be secondary to her early
difficult course.
Sensory: Audiology: Hearing screening was performed with
automated auditory brain stem responses.
CONDITION AT DISCHARGE: Good.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 732**], [**Hospital **] [**Hospital 38299**]
Medical Associates, [**Location (un) 8985**], MA.
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: Hepatitis
B vaccine was administered on [**2153-1-18**].
DISCHARGE DIAGNOSES: Prematurity at 34-3/7 weeks gestation.
Transitional respiratory distress.
RH isoimmunization.
Large for gestational age.
Staphylococcus aureus bacteremia.
Status post intercardiac clot.
Unconjugated hyperbilirubinemia.
Hemolytic anemia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2153-2-12**] 01:29:30
T: [**2153-2-12**] 04:25:37
Job#: [**Job Number 58677**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2691
} | Medical Text: Unit No: [**Numeric Identifier 63174**]
Admission Date: [**2191-10-25**]
Discharge Date: [**2191-11-2**]
Date of Birth: [**2191-10-25**]
Sex: F
Service: NB
DISCHARGE DIAGNOSIS:
1. Premature female infant 34-4/7 weeks gestation.
2. Respiratory distress syndrome, status post surfactant
administration.
3. Physiologic jaundice.
4. Status post immature feeding pattern.
This is an interim summary covering from [**2191-10-31**]
through the day of day of discharge, [**2191-11-2**]. Please
see prior dictation for complete admission history.
During this interim time period the hospital course was as
follows:
1. RESPIRATORY: Infant remained in room air with no apnea of
prematurity.
2. CARDIOVASCULAR: No murmur was appreciated. There were no
cardiovascular issues.
3. FEEDING AND NUTRITION: On the day of discharge she
weighed 2.155 kilograms, was feeding ad lib demand, all
p.o. of Enfacare 24 calories per ounce formula.
4. HEMATOLOGIC: Admission hematocrit was 56.5%. Infant had a
peak bilirubin of 10.2 for which she underwent
phototherapy. Her rebound bilirubin on [**11-1**] was
4.1/0.2.
Hearing screen performed and passed on [**11-1**].
Hepatitis B immune vaccine administered on [**10-28**].
Patient was being discharged home to her family. Mother
deferred on visiting nurse service.
Follow up appointment will be made for Dr. [**Last Name (STitle) 11622**] of
[**Hospital **] Pediatrics within 5 days of discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2191-11-2**] 09:44:34
T: [**2191-11-2**] 10:29:22
Job#: [**Job Number 63175**]
ICD9 Codes: 769, 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2692
} | Medical Text: Admission Date: [**2186-10-4**] Discharge Date: [**2186-10-9**]
Date of Birth: [**2143-1-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1580**]
Chief Complaint:
coffe-ground emesis and hematemesis, and melana
Major Surgical or Invasive Procedure:
EGD [**10-4**]
History of Present Illness:
This is a 43 yom with history of Cirrhosis with HCV and
alcoholism who presented to [**Hospital1 8**] hosptial yesterday morning
for melena and coffee ground emesis. Patient states symptoms
began at 330pm two days ago while at work. He began to feel
nauseous and had one bout of coffee ground emesis. He went home
and had around 15 more coffee ground emesis along with several
melanotic stools which he describes as black, loose and tarry.
He remained at home until 5am yesterday when he reported to the
[**Hospital 8**] hospital ED. Patient reports [**6-17**] more bouts of
coffee ground emesis and melena at [**Hospital 8**] hospital.
In the [**Hospital 8**] Hospital ED, patient vomited 200cc BRB and had
one episode of melena with BRBPR. He received
Octreotide/Protonix gtt and CTX for SBP PPx. He received 3L NS
and given 2u FFP and 2u PRBC. Patient was admitted into ICU.
HCT on admission 25.8 which dropped to 22.9 and 22.4. Patient
received 4uPRBC during this drop. Endoscopy was performed which
showed no active bleeding but did show esophageal and gastric
varices. Given his likely recurrence of variceal bleeding, the
patient was thought to be a TIPS candidate and was transferred
to [**Hospital1 18**] for further evaluation.
At the MICU pt had 2 large bore IVs placed. Hepatology was
consulted. EGD was performed and found to have 3 cords of grade
II varices were seen in the lower third of the esophagus. There
were stigmata of recent bleeding (red [**Location (un) **]). 4 bands were
successfully placed. His Hct remained stable s/p total of 6units
pRBCs at around 31. Patient was kept on octreotide drip, PPI
[**Hospital1 **], ceftriaxone for bacteremia from variceal bleed. After EGD
patient was started on sucralfate and diet was advanced. Pt's
Hct was stable and was transferred to the floor.
.
Pt currently says that he feels week currently, and dizzy, and
his stomach feels "sore" from vomitting. Pt last had emesis at
[**Hospital 8**] hospital.
.
ROS: denies CP, futher n/v, cough, f/ch, hematuria, current
melana, SOB, no pedal edema, denies any other symptoms
Past Medical History:
HCV
EtOH
Cirrhosis
Variceal bleed in [**2185**]
Social History:
Lives with 25yo son.
Drinks 8 [**Name2 (NI) 17963**]/day. 12 on weekend days.
Smokes 1ppd.
No drugs
Works for Shaws.
Family History:
Nc
Physical Exam:
T 99.4 Hr 75 BP 118/72 RR 13 SpO2 98% 2 L NC
GEN: Slim man in NAD
HEENT: NC/AT No scleral icterus. Dry MM
Lungs: CTAB
HEART: RRR No M/R/G
Abd: Normoactive BS. Soft. NT/ND.
Extrem: No cyanosis/clubbing/edema
Neuro: Alert and oriented X 3. No hallucinations. No agitation.
No anxiety.
Pertinent Results:
[**2186-10-4**] 05:21PM BLOOD WBC-4.6 RBC-3.93* Hgb-11.1* Hct-32.1*
MCV-82 MCH-28.4 MCHC-34.6 RDW-17.0* Plt Ct-60*
[**2186-10-5**] 03:21AM BLOOD WBC-3.9* RBC-3.73* Hgb-10.6* Hct-30.7*
MCV-82 MCH-28.6 MCHC-34.7 RDW-16.7* Plt Ct-56*
[**2186-10-4**] 05:21PM BLOOD PT-19.4* PTT-37.1* INR(PT)-1.8*
[**2186-10-5**] 03:21AM BLOOD Glucose-82 UreaN-10 Creat-0.6 Na-135
K-3.4 Cl-103 HCO3-23 AnGap-12
[**2186-10-5**] 03:21AM BLOOD Calcium-6.9* Phos-2.3* Mg-1.8
STUDIES
EGD [**2186-10-4**]:
Impression: Varices at the lower third of the esophagus
(ligation)
Varices at the fundus. Granularity and abnormal vascularity in
the whole stomach compatible with portal hypertensive
gastropathy
.
Doppler U/S of Abdomen [**2186-10-5**]:
IMPRESSION:
1. Diffusely heterogeneous hepatic echogenicity and coarse
texture consistent with cirrhosis. A small approximately 1-cm
left hepatic lobe lesion. Further characterization with MR is
recommended. Small hepatic lesions may remain son[**Name (NI) 5326**]
occult in the setting of background cirrhosis.
2. Trace Ascites.
3. Gallbladder sludge and stones. No evidence of acute
cholecystitis.
4. Reanalized paraumbilical vein with varicoid segment measuring
up to 2 cm.
Brief Hospital Course:
#. UGIB: Patient was admitted to the MICU from [**Hospital 8**]
Hospital for ?TIPS procedure given gastric varices. 2 large bore
IVs were placed. Type and cross for 4 units was sent. Hepatology
was consulted. Performed EGD and found non-bleeding varices and
gastropathy as above. 4 bands were placed on esophageal varices.
Hct remained stable s/p total of 6units pRBCs at around 31.
Patient was kept on octreotide drip, PPI [**Hospital1 **], ceftriaxone for
bacteremia from variceal bleed. After EGD patient was started on
sucralfate and diet was advanced. Pt's Hct remained stable on
the floor. Pt was started on nadalol. Pt's octreotide gtt was
d/c'd. Pt had no futher episodes of bleeding. Appointments were
made to have a repeat EGD in 2 wks.
#. Cirrhosis: Patient with evidence of cirrhosis from MR [**First Name8 (NamePattern2) 767**] [**Hospital1 **]. Cirrhosis likely [**3-11**] EtOH and HCV. Patient remained
with good mental status throughout MICU course. No need for
lactulose. The cause for decompesnation was investigated. Pt had
a normal AFP 4.1, and liver MRI done which showed marked
nodularity without any masses suggestive of HCC. It was
recommended given the diffuse abnormality, followup MRI in four
months is suggested. HIV was also negative.
#. EtOH abuse: Patient was started on CIWA protocol and did not
require valium overnight but did receive versed and fentanyl for
procedure. Received MVI, thiamine, folate.
Medications on Admission:
Meds at home:
Prilosec OTC QD
.
Meds on transfer:
Ceftriaxone 1 gm IV Q24H
Octreotide Acetate 50 mcg/hr IV infusion
Pantoprazole 40 mg PO Q12H
Sucralfate 1 gm PO QID
Folic Acid 1 mg PO DAILY
Multivitamins 1 TAB PO DAILY
Thiamine 100 mg PO DAILY
Acetaminophen 325-650 mg PO Q6H:PRN
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- ruptured esophageal varices - causing hematemesis and melana
Secondary diagnosis:
- End-stage liver disease
- Hepatitis C
- alcohol abuse
- history of previous variceal bleed
Discharge Condition:
good, vitals stable, Hct stable, no longer having
hematemsis/coffe-ground emesis
Discharge Instructions:
You were vomitting blood because of decompensated liver disease,
i.e., worsening of your cirrhosis. The liver disease caused the
pressure in the vessesls of the esophagus to get higher until
they burst under pressure. These esophageal varices were banded
under EGD(endoscopy) and you were given medications to stop the
bleeding. You were monitered until you were stable to go home.
You should completely stop drinking all together.
Medication changes:
- nadalol 20mg once per day to decrease the pressure of these
esophageal blood vessesls
- take sucrulfate 1g four times a day for 2 weeks to help
protect your stomach
- your prilosec was increased to twice per day
- also take thiamine, folate, and a multivitamin everyday
If you begin vomitting blood again or have coffee-ground like
vomit, have a temp > 100.4, dark-black tarry stools, become
confused, or your abdomen becomes significantly swollen - then
return to the ED immediately.
Followup Instructions:
Your have an appointment with your new Liver doctor Dr. [**Last Name (STitle) **], who
you met in the hospital, on [**10-24**], at 2:00pm as below
([**Telephone/Fax (1) 2422**]).
Your follow up EGD is on [**10-27**], be at the clinic by 9:00am
(Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2186-10-27**] 10:00).
Dr. [**Last Name (STitle) 696**] will be doing this EGD (Phone:[**Telephone/Fax (1) 463**])
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]
Completed by:[**2186-11-14**]
ICD9 Codes: 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2693
} | Medical Text: Admission Date: [**2129-6-28**] Discharge Date: [**2129-6-29**]
Date of Birth: [**2064-1-17**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
pericardial effusion
Major Surgical or Invasive Procedure:
Aborted PCI
Pericardiocentesis
Cardioversion
History of Present Illness:
65-year-old male with paroxysmal atrial fibrillation and was s/p
PVI at [**Hospital3 **] Medical Center in [**2124**]. Since then, he
was treated with low dose Flecainide with occasional break
through atrial fibrillation until a few weeks ago when he
developed atrial fibrillation with rapid ventricular response
and wide QRS complex. His Flecainide was discontinued and he
was started on Metoprolol as well as Xarelto for
anticoagulation. He has been taking the Xarelto daily since
[**5-4**] with no missed doses. He was scheduled for
cardioversion at the end of [**Month (only) 547**], however converted
spontaneously and is now referred for repeat pulmonary vein
isolation procedure. Of note, the patient self stopped Xarelto
with last dose on Sat [**6-25**].
The patient went for the repeat PVI on [**6-28**]. Prior to PVI he
developed pericardial effusion without clear evidence of
perforation. This was in the setting of getting 10,000 units of
heparin. Interventional cardiology was called and did a
pericardiocentesis with 250 cc of bright red blood returned. A
drain was placed. TTE following the procedure showed trivial
effusion and the drain was without accumulation. He was started
on colchicine and sent to CCU for further monitoring and
evaluation.
On arrival to the floor, patient slightly somnolent complaining
of chest soreness around pericardial drain.
REVIEW OF SYSTEMS
Per HPI. Currently, feels soreness around pericardial drain
site.
Past Medical History:
- paroxysmal atrial fibrillation s/p PVI [**2124**]
- hypertension
- prostate cancer - followed conservatively
Social History:
Married and works repairing medical equipment.
Tobacco: none
ETOH: [**3-11**] drinks/night
Illicits: none
Family History:
mother has atrial fibrillation at age [**Age over 90 **].
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T= 97.2 BP= 96/57 HR= 66 RR= 19 O2 sat= 100% RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. No xanthalesma.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. Anterior examination.
ABDOMEN: Soft, NTND. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Warm, well perfused. 2
sheaths in left groin, no hematoma present.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: radial 2+, DP 2+
Left: Carradial 2+, DP 2+
DISCHARGE PHYSICAL EXAM:
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, No(t) Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Sedated, Tone: Not assessed
Pertinent Results:
Admission Labs:
[**2129-6-28**] 07:00AM BLOOD WBC-6.0 RBC-5.04 Hgb-15.8 Hct-49.5 MCV-98
MCH-31.4 MCHC-32.0 RDW-12.8 Plt Ct-267
[**2129-6-28**] 07:00AM BLOOD Neuts-63.0 Lymphs-28.6 Monos-5.4 Eos-1.8
Baso-1.3
[**2129-6-28**] 01:51PM BLOOD Hct-42.8
[**2129-6-29**] 03:49AM BLOOD WBC-7.2 RBC-3.95* Hgb-12.7*# Hct-39.4*
MCV-100* MCH-32.0 MCHC-32.1 RDW-12.9 Plt Ct-207
[**2129-6-28**] 07:00AM BLOOD PT-12.2 PTT-37.2* INR(PT)-1.1
[**2129-6-28**] 07:00AM BLOOD Glucose-119* UreaN-19 Creat-1.0 Na-144
K-4.2 Cl-108 HCO3-29 AnGap-11
[**2129-6-29**] 03:49AM BLOOD Glucose-110* UreaN-21* Creat-1.1 Na-141
K-4.2 Cl-106 HCO3-26 AnGap-13
[**2129-6-29**] 03:49AM BLOOD Calcium-8.0* Phos-4.6* Mg-1.9
Pericardial Fluid
[**2129-6-28**] 10:50AM OTHER BODY FLUID WBC-7600* Hct,Fl-34* Polys-78*
Lymphs-18* Monos-4*
[**2129-6-28**] 10:50AM OTHER BODY FLUID TotProt-3.8 Glucose-110
LD(LDH)-179 Amylase-23 Albumin-2.8
[**2129-6-28**] 10:50 am FLUID,OTHER PERICARDIAL.
GRAM STAIN (Final [**2129-6-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2129-6-29**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
[**2129-6-28**] 10:50 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERICARDIAL.
Fluid Culture in Bottles (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2129-6-29**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by [**Doctor Last Name 13478**],J (CCU)[**2129-6-29**] AT
1017.
ECHO ([**6-28**]):
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad. There
are no echocardiographic signs of tamponade.
No prior study available for comparison.
ECHO ([**6-29**]):
Focused study s/p pericardiocentesis: There is trivial
pericardial effusion of no hemodynamic significance located
anteriorly to the right and left ventricle.
Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
65-year-old male with atrial fibrillation who presented for
pulmonary vein isolation complicated by pericardial effusion.
ISSUES:
# Pericardial effusion: Likely complication of heparin bolus
and micro-perforation during procedure. He underwent
pericardiocentesis with a drain placement. Repeat TTE
demonstrated little pericardial fluid and drain was removed.
Echo on day of discharged showed only trivial pericardial
effusion. Colchicine (10d course) was initiated for pericarditis
prophylaxis. No evidence of HD instability.
# Atrial fibrillation: s/p aborted pulmonary vein isolation
procedure complicated by pericardial effusion. The patient
underwent electrical re-synchronization. He is anticoagulated
with rivaroxaban. He will need to continue his antiplatelet
medications upon discharge and follow up for a repeat pulmonary
vein isolation procedure. Sheaths were removed without
complication. Held metoprolol while in house for relative
hypotension, and discharged on succinate metoprolol 25mg qd. EP
follow up should be scheduled within 1-2 weeks.
# HTN: Patient was on metoprolol succinate and losartan as
outpt. These meds were held due to relative hypotension on
admission. The patient was discharged home with metoprolol
succinate 25mg qd.
TRANSITIONAL ISSUES:
1. FOLLOW-UP
Instructions to the patient, "Dr.[**Name (NI) 29750**] office will call
you with an appointment. If you do not hear from them in 1 week
please call [**Telephone/Fax (1) 62**]. Please see your primary care physician
[**Name Initial (PRE) 176**] 1 week of discharge. The number to set up the appointment
is [**Telephone/Fax (1) 12551**] (YEGHIAZARIANS, VARTAN)".
2. Follow-up pericardial fluid cultures: One bottle showed GRAM
POSITIVE COCCI IN PAIRS AND CLUSTERS, the other bottle
demonstrated no growth (preliminary read). We deferred on
treatment considering most likely a contaminant, but the second
bottle final read needs to be followed up.
3. Titrate losartan and metoprolol if hemodynamics tolerate in
outpatient setting.
Medications on Admission:
LOSARTAN - 100 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a day
RIVAROXABAN [XARELTO] - 20 mg Tablet - 1 Tablet(s) by mouth once
a day
ASPIRIN - 325 mg Tablet - 1 Tablet(s) by mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet Extended
Release - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. rivaroxaban 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
atrial fibrillation
pericardial effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for pulmonary vein isolation as treatment of
your atrial fibrillation. During the procedure it was noted that
you had a fluid collection around your heart. This was likely a
complication of your procedure. You had this drained and
multiple ultrasounds of your heart which showed that the fluid
was not reaccumulating.
While you were here you had a cardiac resynchronizion with
return in your heart rate to a normal rhythm.
Your blood pressure was a little low while you were here. You
should stop your losartan until you follow up with your primary
care physician and he gives you instructions on if you should
restart this medication. Your metoprolol succinate dose will be
decreased. Again, you should follow up with your primary care
physician to see if this can be changed back to your previous
levels. You should continue your aspirin and rivaroxaban as
previously prescribed. Please take your medications as listed on
the attached sheet.
Followup Instructions:
Dr.[**Name (NI) 29750**] office will call you with an appointment. If you
do not hear from them in 1 week please call [**Telephone/Fax (1) 62**].
Please see your primary care physician [**Name Initial (PRE) 176**] 1 week of
discharge. The number to set up the appointment is [**Telephone/Fax (1) 12551**]
(YEGHIAZARIANS, VARTAN)
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2694
} | Medical Text: Admission Date: [**2168-6-13**] Discharge Date: [**2168-6-23**]
Date of Birth: [**2095-2-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 yo M with ILD, OSA, presents from Siani with question of
repeat PNA in the setting of rapidly progressing interstitial
lung disease. Patient was discharged from the [**Hospital Ward Name **]
[**2168-5-28**] to [**Location (un) 511**] Siani following a long hospital course.
Briefly, patient was admitted to the VA [**2168-4-18**] for respiratory
distress, intubated [**2168-4-20**] and brought to the [**Hospital1 **] for a second
opinion on [**2168-5-9**]. He was found to have rapidly progressing
interstitial lung disease and underwent tracheostomy placement
[**2168-5-13**]. Course was complicated by bacterimia and he was
treated for a MDR klebsiella VAP with cefepime until [**6-2**] and
vancomycin until [**2168-5-30**]. While at rehab, patient was treated
for cdiff colitis.
Per report, patient has been declining since weekend with
increased secretions and increased respiratory rate. [**6-13**]
patient was found to have saturations in the 80s on vent,
breathing 30-40/min. Per EMS he improved slightly after being
taken off the vent and bagged while en route.
In the ED initial vitals at 16:10 98.2 114 113/65 36 99%.
Respiratory rate remained in the 40s, pulling large tidal
volumes, currently denies any pain or shortness of breath.
Lowest reported blood pressure in the ED was 90/45, which
recovered with 1L NS. Patient's highest temperature was 99.9.
CXR prelminary demonstrated new left-sided consolidation and
baseline interstitial lung disease. Patient was given 2g IV
cefepime, 1g vancomycin and 750mg levofloxacin. He was also
given 1g acetaminophen.
On arrival to the MICU, patient is still tachypnic with tidal
volumes in the 25L/min range. He denies any chest pain and is
in no acute distress. He states that at baseline he coughs
frequently, although denies any aspiration events. Patient is
extremely hard of hearing at baseline and is unable to
communicate well unless by lipreading.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Prostate Cancer s/p XRT and hormone Rx
PMR
Hypertension
Morbid Obesity
Type II DM
OSA - did not tolerate CPAP
Interstitial lung disease (UIP/IPF) but no definitive diagnosis
as never had bronch/bx, trach course as per HPI.
Social History:
Smoked until [**2145**] 90pkyrs, former EtOH use, No IVDU, retired
from truck driving, worked in Navy for 4 years, no known
asbestos exposure. Lived with wife in [**Name (NI) 112230**]. One son from
previous marraige.
Family History:
No CAD, no DM, No cancers
Physical Exam:
Admission PE:
Vitals: Temp = 98.2, HR = 114, BR = 113/65, RR = 36, O2sat = 99%
General: Alert, oriented, tachypnic
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP unable to see due to collar, no LAD
CV: tachycardic irregular rate/ rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Diminished at bases with crackles.
Abdomen: soft, non-tender, obese, Gtube present without
erythema, bowel sounds present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Skin: per report: large decubitus ulcer, not visualized due to
patient discomfort.
Discharge exam:
General: Alert, oriented, tachypneic
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP unable to see due to collar, no LAD
CV: tachycardic irregular rate/ rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Diminished at bases with crackles.
Abdomen: soft, non-tender, obese, Gtube present without
erythema, bowel sounds present, no organomegaly
GU: foley in place, flexiseal in place draining stool
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, 5/5 strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred, finger-to-nose intact
Skin: per report: large decubitus ulcer, not visualized due to
patient discomfort.
Pertinent Results:
[**2168-6-13**] 09:29PM TYPE-ART PO2-78* PCO2-46* PH-7.46* TOTAL
CO2-34* BASE XS-7
[**2168-6-13**] 04:53PM TYPE-[**Last Name (un) **] PEEP-5 PO2-64* PCO2-46* PH-7.45
TOTAL CO2-33* BASE XS-6 INTUBATED-INTUBATED
[**2168-6-13**] 04:44PM PO2-114* PCO2-42 PH-7.49* TOTAL CO2-33* BASE
XS-8 COMMENTS-GREEN TOP
[**2168-6-13**] 04:44PM LACTATE-2.5*
[**2168-6-13**] 04:43PM URINE HOURS-RANDOM
[**2168-6-13**] 04:43PM URINE UHOLD-HOLD
[**2168-6-13**] 04:43PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2168-6-13**] 04:43PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
[**2168-6-13**] 04:43PM URINE RBC-27* WBC-12* BACTERIA-MANY YEAST-NONE
EPI-0
[**2168-6-13**] 04:30PM GLUCOSE-178* UREA N-51* CREAT-0.9 SODIUM-141
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-30 ANION GAP-14
[**2168-6-13**] 04:30PM estGFR-Using this
[**2168-6-13**] 04:30PM cTropnT-<0.01
[**2168-6-13**] 04:30PM proBNP-4396*
[**2168-6-13**] 04:30PM WBC-12.7* RBC-2.83* HGB-7.9* HCT-25.9* MCV-91
MCH-28.1 MCHC-30.7* RDW-15.1
[**2168-6-13**] 04:30PM NEUTS-86.3* LYMPHS-8.3* MONOS-4.7 EOS-0.6
BASOS-0.1
[**2168-6-13**] 04:30PM PLT COUNT-362
[**2168-6-13**] 04:30PM PT-33.1* PTT-28.6 INR(PT)-3.2*
ECG
Baseline artifact. Atrial fibrillation with rapid ventricular
rate and
multifocal ventricular premature contractions. Left axis
deviation with left anterior fascicular block. Generally poor R
wave progression suggests prior anterior myocardial infarction.
Diffuse repolarization abnormalities in the limb leads. Compared
to the previous tracing of [**2168-5-19**] the rate is much faster and
now tachycardic. Ventricular ectopy is new. Depolarization and
repolarization abnormalities are similar.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
109 0 100 310/395 0 -43 44
CXR: [**2168-6-13**]
FINDINGS: The patient is status post tracheostomy, which
appears unchanged.
A PICC line terminates in the superior vena cava, as before,
inserted via
right-sided approach. The cardiac, mediastinal and hilar
contours appear
unchanged including widening of the vascular pedicle, perihilar
fullness, and cardiomegaly. A moderate-to-severe interstitial
abnormality suggests known interstitial lung disease without
significant change. This appearance includes confluent
opacification at the lung bases. Because of severe background
lung abnormality, it is difficult to exclude a superimposed
edema or pneumonia.
IMPRESSION: Similar severe widespread predominantly interstitial
opacification, most confluent at the lung bases; although there
is no definite change, subtle superimposed process could be
readily obscured by a severe background abnormality.
CXR: [**2168-6-14**]
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Low lung volumes with massive bilateral diffusely
distributed
reticular or reticulonodular opacities. The presence of small
pleural
effusions cannot be excluded. Tracheostomy tube is unchanged.
Moderate
cardiomegaly. No pneumothorax.
[**2168-6-13**] 04:30PM BLOOD proBNP-4396*
[**2168-6-13**] 04:30PM BLOOD WBC-12.7* RBC-2.83* Hgb-7.9* Hct-25.9*
MCV-91 MCH-28.1 MCHC-30.7* RDW-15.1 Plt Ct-362
[**2168-6-14**] 03:30PM BLOOD WBC-12.3* RBC-2.78* Hgb-7.7* Hct-25.2*
MCV-91 MCH-27.6 MCHC-30.5* RDW-15.2 Plt Ct-357
[**2168-6-16**] 05:00AM BLOOD WBC-11.4* RBC-2.68* Hgb-7.6* Hct-24.7*
MCV-92 MCH-28.2 MCHC-30.7* RDW-15.2 Plt Ct-333
[**2168-6-18**] 06:13AM BLOOD WBC-10.3 RBC-2.79* Hgb-7.7* Hct-25.3*
MCV-91 MCH-27.7 MCHC-30.5* RDW-15.4 Plt Ct-352
[**2168-6-20**] 04:59PM BLOOD WBC-13.5* RBC-3.14* Hgb-8.7* Hct-28.9*
MCV-92 MCH-27.6 MCHC-30.0* RDW-16.0* Plt Ct-425
[**2168-6-21**] 05:59AM BLOOD WBC-12.6* RBC-2.98* Hgb-8.2* Hct-27.6*
MCV-93 MCH-27.5 MCHC-29.7* RDW-16.3* Plt Ct-388
[**2168-6-22**] 02:57AM BLOOD WBC-16.0* RBC-3.19* Hgb-8.8* Hct-29.5*
MCV-92 MCH-27.7 MCHC-30.0* RDW-16.9* Plt Ct-411
[**2168-6-23**] 05:33AM BLOOD WBC-12.6* RBC-3.17* Hgb-9.0* Hct-29.2*
MCV-92 MCH-28.4 MCHC-30.8* RDW-17.1* Plt Ct-358
[**2168-6-14**] 04:46AM BLOOD PT-39.7* PTT-28.8 INR(PT)-3.9*
[**2168-6-15**] 06:26AM BLOOD PT-24.5* PTT-27.1 INR(PT)-2.3*
[**2168-6-17**] 06:07AM BLOOD PT-14.8* PTT-23.5* INR(PT)-1.4*
[**2168-6-22**] 02:57AM BLOOD PT-31.7* PTT-36.1 INR(PT)-3.1*
[**2168-6-21**] 05:59AM BLOOD PT-28.7* INR(PT)-2.8*
[**2168-6-22**] 02:57AM BLOOD PT-31.7* PTT-36.1 INR(PT)-3.1*
[**2168-6-23**] 05:33AM BLOOD PT-28.7* PTT-34.1 INR(PT)-2.8*
[**2168-6-20**] 04:59PM BLOOD Glucose-149* UreaN-30* Creat-0.7 Na-140
K-4.8 Cl-96 HCO3-39* AnGap-10
[**2168-6-21**] 05:59AM BLOOD Glucose-140* UreaN-30* Creat-0.8 Na-141
K-4.2 Cl-99 HCO3-38* AnGap-8
[**2168-6-22**] 02:57AM BLOOD Glucose-145* UreaN-30* Creat-0.8 Na-139
K-4.3 Cl-99 HCO3-36* AnGap-8
[**2168-6-23**] 05:33AM BLOOD Glucose-157* UreaN-32* Creat-0.9 Na-140
K-4.2 Cl-98 HCO3-36* AnGap-10
Brief Hospital Course:
73 yo M with ILD, OSA, presents from Siani with question of
repeat PNA in the setting of rapidly progressing interstitial
lung disease.
# Respiratory distress: Pt initially fit SIRS criteria with
tachypnea and leukocytosis. PNA was suspected by leukocytosis
and history of frequent cough, as well as potential aspiration
risk. PT was recently treated for MDR klebsiella VAP with
cefepime until [**6-2**] and vancomycin until [**2168-5-30**]. It appears that
the previous culture grew two strains of klebsiella, only one
was sensitive to cefepime, so it was possible that it was
incompletely treated. Also possible is PE, but less likely
given supratherapeutic INR. Pt's sputum culture grew Pseudomonas
and received 8 days of meropenem for presumed HCAP. Albuterol
and ipratropium MDIs were also given during course along with
Lasix diuresis. Pt's respiratory status improved throughout
sstay and tolerated 2 hour periods off of the ventilator by the
end of course. On the day on his planned discharge ([**6-22**]) he was
noted to have secretions which were thought to be [**12-31**] fluid
status. A CXR was performed which was slightly improved from
prior. Sputum Cx were sent, however there was low concern for
infection given he had finished his 8 day course of meropenem
the day prior. His lasix 40mg IV BID was restarted out of
concern for fluid overload. This was transitioned to 80mg PO BID
in anticipation of discharge. Electrolytes and weights should be
monitored and lasix dose should be adjusted.
Of note, on the day of discharge it was noted that his sputum
culture had grown Pseudomonas so [**Hospital 100**] Rehab was called and the
physician taking care of him there was personally advised to
continue Meropenem for a total of two weeks (with a planned stop
date of [**2168-6-30**]) in an effort to completely and optimally treat
this Pseudomonas.
Finally, there were multiple family meetings with the patient's
wife and the patient - he is aware that he is chronically
critically ill and that his likelihood of completely coming off
the ventilator is guarded at best; he (and his wife) elect to
continue pursuing rehab at this time, although the idea of
hospice was introduced during this hospitalization - neither he
nor his wife is ready to consider complete transition to
palliative care at this time.
# C-diff by report: Pt was found to be C. diff toxin positive at
previous hospitalization at OSH, and was continued on Flagyl at
[**Hospital1 18**] with flexiseal in place.
[**2168-7-5**] was the projected date to stop Flagyl (2 weeks
after completion of meropenem).
# Atrial fibrillation: Pt's CHADS2 score of 4, but
anticoagulation was held initially due to supratherapeutic INR.
Coumadin restarted once INR was below <2. Pt was rate controlled
with Metoprolol Tartrate 25 mg PO TID. His INR was difficult to
control likely due to antibiotic therapy and decreased hepatic
clearance. His warfarin was decreased to 2.5 and eventually held
for multiple doses given a supratheraputic INR. Today INR was
2.8 and warfarin can be restated at 2.5mg. INR should be
rechecked on [**2168-6-25**] and warfarin dose can be adjusted at that
time.
# Anemia: 28.6 at discharge on [**5-28**]. Unsure if this is anemia
of chronic disease versus occult bleed from elevated INR. Guaiac
stools were negative and no obvious acute bleeding was found
during MICU stay. Hematocrit remained stable.
# Polymyalgia rheumatica: Was previously treated with prednisone
15mg PO daily, but was never given PCP [**Name Initial (PRE) **]. We discontinued
hydroxycholoroquine in the setting of treating pneumonia along
with titrating down pt's prednisone from 15mg to 10mg PO daily.
Bactrim PCP prophylaxis was given.
# Type II DM: Pt was on MetFORMIN (Glucophage) 1000 mg PO BID,
Pioglitazone 30 mg PO DAILY and NPH 4 Units Breakfast, NPH 4
Units Dinner with ISS pre-admission. We continued pt on ISS and
serum glucose remained in mid 100s.
# History of hypothyroidism: TSH 2.0 from [**5-10**] and was on
Levothyroxine Sodium 300 mcg PO DAILY upon admission. Pt was
discharged on this dose with recommendations for follow-up on
TSH at rehab.
# Hyperlipidemia: unknown control. Pt was discharged on home
dose of Simvastatin 40 mg PO DAILY and Niacin 250 mg PO TID
# Right sided PICC: PICC line terminates in the superior vena
cava, as before, inserted via right-sided approach. Pt was
discharged with PICC.
# Tube feeds: G tube in place. Pt tolerated Isosource 1.5 Cal
Full strength at 70cc/hr.
# Rash in perianal area: Pt's decubitus wound was dressed with
following regimen: Cleanse area around flexiseal with foam
cleanser and pat dry. Apply criticade clear, then wrap xeroform
gauze around flexiseal.
# Med rec:
- Continue Acetaminophen 650 mg PO Q6H:PRN fever/ pain
- Hold Docusate Sodium 100 mg PO BID:PRN constipation
- Hold Senna 1 TAB PO BID:PRN constipation
- Hold ALPRAZolam 0.25 mg PO TID:PRN anxiety
- OxycoDONE (Immediate Release) 5 mg PO/NG Q8H:PRN pain
- Hold Albuterol-Ipratropium [**11-30**] PUFF IH Q2H:PRN dyspnea
Transitional Issues:
- Complete two weeks of Meropenem (last day [**2168-6-30**]) for
Pseudomonas treatment.
- Consider further Prednisone titration if his PMR symptoms are
adequately controlled on 10mg q24h - ideally would like to
titrate Prednisone off if possible.
- TSH level in 6 months for followup
- monitor INR while on coumadin
- DISCONTINUE Flagyl on [**2168-7-5**] (end of 2 week course for
C. diff)
- DNR. Discussion had with patient who does not wish to pursue
palliative care at this time.
- Monitor I&O while on lasix, adjust lasix dose as needed.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from [**Location (un) 511**] Siani list.
1. Levothyroxine Sodium 300 mcg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Pioglitazone 30 mg PO DAILY
4. PredniSONE 15 mg PO DAILY
5. Simvastatin 40 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. NPH 4 Units Breakfast
NPH 4 Units Dinner
Insulin SC Sliding Scale using REG Insulin
9. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
10. Niacin 250 mg PO TID
11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
12. MetRONIDAZOLE (FLagyl) 500 mg PO Q 8H
13. Miconazole 2% Cream 1 Appl TP Q8H
to perianal area
14. Furosemide 20 mg IV BID
15. Loperamide 2 mg PO/NG Q8H
16. Albuterol-Ipratropium [**11-30**] PUFF IH Q6H
17. Metoprolol Tartrate 25 mg PO TID
18. CefePIME 1 g IV Q12H
19. Acetaminophen 650 mg PO Q6H:PRN fever/ pain
20. Docusate Sodium 100 mg PO BID:PRN constipation
21. Senna 1 TAB PO BID:PRN constipation
22. ALPRAZolam 0.25 mg PO TID:PRN anxiety
23. OxycoDONE (Immediate Release) 5 mg PO/NG Q8H:PRN pain
24. Lorazepam 0.5 mg IV Q8H:PRN anxiety
25. Albuterol-Ipratropium [**11-30**] PUFF IH Q2H:PRN dyspnea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever/ pain
2. Aspirin 81 mg PO DAILY
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
4. Glargine 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 300 mcg PO DAILY
6. Lorazepam 0.5 mg IV Q4H:PRN anxiety
7. Metoprolol Tartrate 25 mg PO TID
8. MetRONIDAZOLE (FLagyl) 500 mg PO Q 8H
9. Niacin 250 mg PO TID
10. Meropenem - restarted after d/c in communication with [**Hospital 100**]
Rehab (last day to be [**2168-6-30**])
10. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
11. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
12. Simvastatin 40 mg PO DAILY
13. Albuterol-Ipratropium [**11-30**] PUFF IH Q6H
14. Albuterol-Ipratropium [**11-30**] PUFF IH Q2H:PRN dyspnea
15. Docusate Sodium 100 mg PO BID:PRN constipation
16. Loperamide 2 mg PO Q8H
17. Miconazole 2% Cream 1 Appl TP Q8H
to perianal area
18. Senna 1 TAB PO BID:PRN constipation
19. Warfarin 2.5 mg PO DAILY16 Duration: 1 Doses
20. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
21. 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.
22. Furosemide 80 mg PO BID
23. Ipratropium Bromide MDI 6 PUFF IH QID
24. Albuterol Inhaler 6 PUFF IH Q4H:PRN dyspnea/ wheeze
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Ventilator associated pneumonia
Interstitial lung disease
Clostridium difficile colitis
Atrial fibrillation
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:
Dear Mr. [**Known lastname **],
It was our pleasure caring for you at the [**Hospital1 18**].
You were admitted to the [**Hospital1 69**]
for treatment of pneumonia. Your sputum cultures confirmed that
you had a pneumonia and you tolerated the 8 day course of
antibiotics very well. Your respiratory status improved during
your stay. You also had fluid in your lungs which made it
difficult for you to breate; we gave you diuretics to help
remove this fluid.
After several discussions, you decided to go back to rehab to
help you transition off the ventilator.
Followup Instructions:
You will be followed by the physicians at the rehabilitation
center.
ICD9 Codes: 4019, 4168, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2695
} | Medical Text: Admission Date: [**2114-10-3**] Discharge Date: [**2114-10-9**]
Date of Birth: [**2055-7-5**] Sex: F
Service: UROLOGY
Allergies:
Latex
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
large right renal mass tumoral thrombus extending into the right
renal vein, hepatic vein, and inferior vena cava
Major Surgical or Invasive Procedure:
Dr.[**Name (NI) 11306**] PROCEDURES:
1. Right open radical nephrectomy.
2. Retroperitoneal lymph node dissection
3. Inferior vena cava removal (dictated by and performed by
Dr. [**First Name (STitle) **].
Dr.[**Name (NI) 670**] PROCEDURE PERFORMED: Mobilization the liver and
takedown of the caudate lobe off the inferior vena cava,
resection of the infrahepatic inferior vena cava down to the
bifurcation of
the common iliac veins.
History of Present Illness:
59F with recently diagnosed large right renal mass with tumoral
replacement of the right kidney and tumoral thrombus extending
into the right renal vein, hepatic vein, and inferior vena cava
now s/p right radical nephrectomy with resection of IVC and
RPLND. She intially presented to her PCP back in [**6-13**] with vague
symptoms of fatigue and back pain. In the month following she
reported some abd discomfort and bloating and peripheral edema.
She was sent for CT abd/pelvis which then revealed the renal
mass which was highly suspicious for renal cell carcinoma. In
the setting of IVC involvement the decision was made to proceed
with tumor debulking as opposed to tissue biopsy. Prior to
surgery she was sent for staging with CT chest and bone scan
which did not show evidence of metastasis.
Past Medical History:
PMHx:
-HLD
-osteopenia
-basal cell carcinoma of forehead s/p excision [**2114**]
-superficial melanoma s/p excision [**2093**]
-cervical cancer
-h/o PUD and h.pylori
PSHx:
-s/p hysterectomy and appendectomy [**2081**]
Social History:
SocHx:
-30 py smoker - quit [**2102**]
-occasional etoh
-no IVDA
Family History:
FamHx:
-sister - breast cancer
Physical Exam:
WdWn pleasant female, NAD, AVSS
Abdomen soft, nt/nd
appropriate tenderness along large incision line with
staples/surgical skin clips. Localized erythema c/w with skin
clips. No evidence hematoma, infection.
extremities soft w/out pitting, calf pain. Bilateral lower
extremities w/out pitting to palpation to proximal tibia areas.
Pertinent Results:
[**2114-10-8**] 08:15AM BLOOD WBC-7.1 RBC-2.90* Hgb-9.1* Hct-26.5*
MCV-91 MCH-31.3 MCHC-34.3 RDW-14.2 Plt Ct-363#
[**2114-10-7**] 10:10AM BLOOD WBC-7.0 RBC-2.63* Hgb-8.5* Hct-24.1*
MCV-91 MCH-32.2* MCHC-35.2* RDW-13.9 Plt Ct-234
[**2114-10-7**] 08:53AM BLOOD WBC-6.7 RBC-2.90* Hgb-9.3* Hct-26.5*
MCV-91 MCH-32.0 MCHC-35.0 RDW-14.0 Plt Ct-265
[**2114-10-7**] 10:10AM BLOOD Glucose-134* UreaN-12 Creat-1.0 Na-142
K-4.3 Cl-106 HCO3-27 AnGap-13
[**2114-10-7**] 08:53AM BLOOD Glucose-147* UreaN-11 Creat-1.0 Na-141
K-4.0 Cl-105 HCO3-30 AnGap-10
[**2114-10-6**] 04:10AM BLOOD Glucose-118* UreaN-13 Creat-0.9 Na-141
K-4.0 Cl-105 HCO3-29 AnGap-11
[**2114-10-4**] 12:40AM BLOOD Type-ART pO2-196* pCO2-40 pH-7.41
calTCO2-26 Base XS-1
[**2114-10-3**] 06:59PM BLOOD Type-ART pO2-344* pCO2-45 pH-7.37
calTCO2-27 Base XS-0
[**2114-10-3**] 04:38PM BLOOD Type-ART pO2-221* pCO2-39 pH-7.33*
calTCO2-21 Base XS--4
[**2114-10-3**] 04:38PM BLOOD Glucose-212* Lactate-4.9* Na-136 K-4.9
Cl-113*
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the TSICU and then to the general
urology service after undergoing the above listed procedures
with Dr. [**Last Name (STitle) 3748**] and Dr. [**First Name (STitle) **]. No concerning intraoperative
events occurred; please see dictated operative note for details.
The patient received perioperative antibiotic prophylaxis. Ms.
[**Known lastname **] was recoved in the TSICU afte surgery and kept intubated
until POD1 where she was successfully weened and extubated. She
was transferred to the general surgical floor from the TSICU in
stable condition on POD2. Pain was well controlled with an
epidural managed by the Acute Pain service and she was hydrated
for urine output >30cc/hour, provided with pneumoboots and
incentive spirometry for prophylaxis, and kept on subcutaneous
heparin. On POD2 she was out of bed to chair and by POD3 she was
ambulating. On POD2 her nasogastric tube was clamped and on POD3
it was discontinued alltogether. With the gradual passage of
flatus her diet was slowly advanced, epidural discontinued and
she was transitioned to oral pain medications. Her labs were
monitored daily and she did not require any blood transfusions.
Urethral Foley catheter was removed without difficulty and the
remainder of the hospital course was relatively unremarkable.
The patient was discharged in stable condition, eating well,
ambulating independently, voiding without difficulty, and with
pain control on oral analgesics. On exam, incision was clean,
dry, and intact, with no evidence of hematoma collection or
infection. The patient was given explicit instructions to
follow-up with Dr. [**Last Name (STitle) 3748**], Dr. [**First Name (STitle) **] and her PCP.
Medications on Admission:
Allergies:
-latex
Home medications:
-cyclobenzaprine
-diclofenac
-vicodin 2.5mg / 500
-raloxifene
-simvastatin
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): Hold for SBP < 100, HR < 55 .
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PREOPERATIVE DIAGNOSIS: Renal cell carcinoma with a caval
thrombus and extension of tumor.
POSTOPERATIVE DIAGNOSIS: Renal cell carcinoma with a caval
thrombus and extension of tumor.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Please also refer to the provided written instructions on
post-operative care, instructions and expectations made
available from Dr. [**Last Name (STitle) 3748**]??????s office.
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor
-To help manage your Blood pressure (control hypertension) we
have started you on a NEW medication called METOPROLOL listed
here.
metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): Hold for SBP < 100, HR < 55 . A prescription
"script" has been provided.
-Please keep a blood pressure log and review this medication and
log with your surgeons and PCP.
Disp:*45 Tablet(s)* Refills:*2*
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-Resume all of your pre-admission/home medications except as
noted. Do not take Aspirin or Non-steroidal anti-inflammatories
(ibuprofen, etc.) unless advised to do so.
-Call your Urologist's and Vascular Surgeon's office to
schedule/confirm your follow-up appointment in 3 weeks AND if
you have any questions.
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-If you have been prescribed IBUPROFEN (the ingredient of Advil,
Motrin, etc.) , you may take this and Tylenol together
(alternating) for additional pain control---please try TYLENOL
FIRST and take the narcotic pain medication as prescribed if
additional pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark tarry stools)
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool-softener, NOT a laxative
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.ks time.
Followup Instructions:
-Call Dr.[**Name (NI) 11306**] office at ([**Telephone/Fax (1) 8791**] for follow-up AND if
you have any urological questions. Dr. [**Last Name (STitle) 3748**]??????s Nurse
Practitioner [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22714**] may be reached at the same number.
-You will follow-up in [**8-12**] days for post-operative evaluation
and Surgical skin clip (staple) removal
Please call and arrange follow up with Dr. [**First Name (STitle) **]
Please call your PCP for an appointment as well:
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 91619**]
Completed by:[**2114-10-9**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2696
} | Medical Text: Admission Date: [**2137-7-24**] Discharge Date: [**2137-8-10**]
Date of Birth: [**2105-1-4**] Sex: M
Service: SURGERY
Allergies:
Quinolones / Reglan / Fluconazole
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
cc:[**CC Contact Info 69648**]
Major Surgical or Invasive Procedure:
[**2137-7-25**]: Irrigation and debridement of bilateral ischiorectal
abscess.
[**2137-8-2**]: Cardiac Catheterization
[**2137-8-6**]: Exploratory laparotomy; Lysis of adhesions; Creation of
end ileostomy.
History of Present Illness:
This is a 32 yo man w/ severe crohn's disease on prednisone who
was transferred to [**Hospital1 18**] from a referring facility for a gluteal
abscess. The abscess was present for ~3 months prior to
admission; he failed outpatient therapy of antibiotics. CT at
referring facility demonstrated large loculated
perianal/peri-rectal abscess; transferred to [**Hospital1 18**] for surgical
evaluation.
On arrival c/o gluteal pain, denies fevers/chills, N/V,
abdominal pain, CP, SOB.
Past Medical History:
Crohn's disease x 20 years
Gluteal abscess x 3 months
s/p colonic resection x 2 (last [**2131**])
Social History:
Denies smoking, moderate EtOH, no drug use
Family History:
+FH crohn's disease
Physical Exam:
Admission Exam
97.7 106 121/85 22 100% RA
NAD, A&Ox3
RRR
CTAB
Abd: soft, mildly distended, mild non-localized tenderness
Rectal: R peri-anal induration and tenderness
Ext: WWP, no edema
Pertinent Results:
Admission Labs
[**2137-7-25**] 05:40AM BLOOD WBC-24.4* RBC-3.27* Hgb-8.1* Hct-24.4*
MCV-75* MCH-24.6* MCHC-32.9 RDW-24.7* Plt Ct-934*
[**2137-7-28**] 06:45AM BLOOD Neuts-96.5* Bands-0 Lymphs-1.7*
Monos-1.6* Eos-0.2 Baso-0
[**2137-7-25**] 05:40AM BLOOD Glucose-94 UreaN-5* Creat-0.3* Na-140
K-4.1 Cl-105 HCO3-19* AnGap-20
[**2137-7-25**] 05:40AM BLOOD ALT-12 AST-16 LD(LDH)-218 AlkPhos-120*
TotBili-0.4
[**2137-7-25**] 05:40AM BLOOD Albumin-2.4* Calcium-7.4* Phos-2.5*
Mg-2.7*
[**2137-7-25**] 02:09PM BLOOD Type-ART Rates-/34 O2 Flow-6 pO2-44*
pCO2-42 pH-7.30* calTCO2-21 Base XS--5 Intubat-NOT INTUBA
[**2137-7-25**] 03:06PM BLOOD Lactate-1.4
Post-Code labs results:
Culture Results
[**2137-7-25**] 10:30 am ABSCESS Site: RECTAL PERI-RECTAL.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. MODERATE
GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
PROTEUS SPECIES. RARE GROWTH.
[**2137-7-29**] 7:31 pm URINE CULTURE (Final [**2137-7-30**]): NO GROWTH.
[**2137-7-30**] 1:04 am SPUTUM Site: ENDOTRACHEAL RESPIRATORY
CULTURE (Final [**2137-8-1**]): RARE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH.
Imaging:
Pre-Op EKG:Sinus tachycardia @ 103. Normal ECG except for rate
Post Op CXR [**7-25**]: Substantial opacification LLL and RML raises
concern for recent aspiration and developing pneumonia. No
pneumothorax or appreciable pleural effusion is present.
Post Op EKG: Wandering baseline. Sinus tachycardia @140. ST-T
wave changes may likely be due to wandering baseline. Cannot
exclude ischemia. Compared to the previous tracing of [**2137-7-25**] the
rate is faster.
CTA CHEST W&W/O C &RECONS [**2137-7-26**] 8:38 AM:
1) No evidence of pulmonary embolism.
2) Severe bilateral opacities mostly in the dependent portions
of the lungs likely related to aspiration/aspiration pneumonia.
Clinical correlation recommended.
3) Fatty liver.
CHEST PORT. LINE PLACEMENT [**2137-7-29**] 9:24 PM
SUPINE AP VIEW OF THE CHEST: The left subclavian central venous
catheter has been withdrawn with the tip now lying at the
cavoatrial junction. Endotracheal tube and nasogastric tube
remain in unchanged positions. There is improved aeration in the
left lower lobe. Persistent bibasilar opacities likely reflect
aspiration or pneumonia. Mild pulmonary edema persists. There is
no pneumothorax. Probable small left pleural effusion is
unchanged.
ECHO Study Date of [**2137-8-1**] : LA normal size. LV normal wall
thickness, cavity size, LVEF (>60%). There may be mild inferior
hypokinesis. RV chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a very small pericardial effusion.
Excerpts of Operative Reports/Procedures:
[**2137-7-25**]
PREOPERATIVE DIAGNOSIS: Perirectal abscess.
POSTOPERATIVE DIAGNOSIS: Bilateral ischiorectal abscess.
PROCEDURE: Irrigation and debridement of bilateral
ischiorectal abscess.
INCISION: Bilateral circumanal incisions were made outside the
sphincter on both lateral aspects.
FINDINGS: There was a large amount of pus in the rectum which
went up the ischiorectal fossa on both sides and communicated
posteriorly across the coccyx.
Cardiac Catheterization [**2137-8-2**]:
1. No angiographically apparent coronary artery disease.
2. Normal systemic pressure.
[**2137-8-6**] Colonoscopy
Findings:
Mucosa: Friability, pesudopolyps and cobblestoning with contact
bleeding were noted in the rectum. These findings are compatible
with Colitis.
Other Normal ileum above the ileo-rectal anastomosis
Impression: Friability, pesudopolyps and cobblestoning in the
rectum compatible with Colitis. Normal ileum above the
ileo-rectal anastomosis
[**2137-8-6**]
PREOPERATIVE DIAGNOSES: Proctitis from Crohn's disease and
rectal fistula.
POSTOPERATIVE DIAGNOSES: Proctitis from Crohn's disease and
rectal fistula.
PROCEDURE:
1. Exploratory laparotomy.
2. Lysis of adhesions.
3. Creation of end ileostomy.
DESCRIPTION OF PROCEDURE: The abdomen was opened without
injuring any underlying bowel. There were noted to be some
adhesions to the side walls.
These were taken down sharply and with the [**Last Name (un) 4161**], again there
were no injuries to the bowel. The distal end of the ileum was
localized and the ileorectal anastomosis was also localized.
Approximately 20 cm proximal to the ileorectal anastomosis the
ileum was divided. The distal segment was left as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3379**]
pouch and the proximal segment was brought out as the end of the
[**Last Name (NamePattern4) 9341**] in the right lower quadrant. This [**Last Name (NamePattern4) 9341**] site was
previously marked by the stomal therapy nurse. [**First Name (Titles) **] [**Last Name (Titles) 69649**]s was achieved. There were no injuries to the small
bowel.
Next the stoma was opened with electrocautery. Hemostasis was
achieved along the wound edges. A [**Doctor Last Name **] ileostomy was fashioned
in a standard 2 layer [**Doctor Last Name **] ileostomy fashion. Vicryl sutures
were used to evert the edges. A stoma appliance was applied. The
patient was awakened in the operating room. He tolerated the
procedure well without any complications. All sponge counts,
needle counts were correct at the end of the case times
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2137-7-24**] and underwent an
incision and drainage on [**2137-7-25**]. He subsequently
underwent a colonoscopy and diverting end ileostomy on [**8-6**], [**2136**]. During his hospitalization he was cared for by the
surgical, gastroenterology, endocrine and electrophysiology
teams.
Respiratory:
In the PACU he was tachycardic to the 140s and had increased
oxygen requirements with rapid shallow breathing. He was
treated with lopressor, EKG changes resolved. CXR was
suggestive of an aspiration event. CTA was obtained which was
negative for PE. Respiratory problems resolved by POD #2; though
patient remained persistently tachycardic through most of his
hospital course.
Cardiovascular:
On HD 6 ([**2137-7-29**]) @ 6:30 PM Mr. [**Known lastname **] was found unresponsive in
cardiac arrest. He was defibrillated for a wide-complex VF
resembling torsades then compressions were started. Patient was
intubated and transferred to the ICU. Cardiac enzymes were
obtained and were negative for an ischemic event. He was
extubated on [**7-30**] and transferred to the floor on [**7-31**].
The cardiology/electrophysiology team was consulted. The
etiology of cardiac arrest is believed to be acquired prolonged
QT syndrome; possibly due to use of quinolone antibiotics,
Reglan, and/or fluconazole. A cardiac catheterization was
performed and was negative for coronary artery disease.
Electrolytes were aggressively repleted, all QT prolonging drugs
were discontinued. Mr. [**Known lastname **] was monitored on telemetry for
the remainder of his hospitalization; notable only for sinus
tachycardia, improved after treatment with BB and resolved after
diverting ileostomy.
GI:
Ischiorectal abscess was drained. As he continued to drain
large amounts of fecal and purulent discharge from his abscess,
a diverting end-ileostomy was performed to help with wound
healing. Initially prednisone was continued at 30 mg/day. GI
was consulted who performed a colonscopy which revealed only a
small amount of colon remained (rectum), friability,
pseudopolyps and cobblestoning of remaining rectum consistent
with colitis; and normal ileum above the competent ileo-rectal
anastomosis. GI recommended decreasing prednisone by 5 mg/week.
He will follow-up with Dr. [**First Name4 (NamePattern1) 1939**] [**Last Name (NamePattern1) 1940**] for further care of
his Crohn's Disease.
ID: abscess drained; cultures grew [**Female First Name (un) **], cornybacterium and
proteus. Patient initially treated with unasyn and fluconazole;
these were discontinued after the cardiac arrest. After
diverting ileostomy, patient was afebrile and without
leukocytosis.
Endocrine: given long term steroid use, Mr. [**Known lastname **] was seen by
endocrine, started on calcium and Vit D supplementation and will
follow-up as an outpatient with Endocrinology and have a BMD
scan performed.
Neuro/Pysch: patient was continued on prn ativan for anxiety,
percocet for pain control.
Medications on Admission:
Prednisone 30 mg po daily
Augmentin/Cipro x 2 months
Percocet
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*1*
3. Potassium Chloride 20 mEq Packet Sig: One (1) PO DAILY
(Daily).
Disp:*30 * Refills:*1*
4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*1*
5. Prednisone 5 mg Tablet Sig: see steroid taper instructions
Tablet PO once a day: You are being started on a steroid taper.
You will take 25 mg (five tablets) through [**8-14**]. From [**8-14**]
through [**8-21**] take 20 mg (4 tabs). [**8-23**] through [**8-29**] take 15 mg (3
tabs). [**8-30**] through [**9-5**] take 10 mg (2 tabs). [**9-6**] through [**9-12**]
take 1 tab. .
Disp:*95 Tablet(s)* Refills:*0*
6. CALCIUM 500+D 500-200 mg-unit Tablet Sig: Three (3) Tablet PO
once a day. Tablet(s)
7. 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*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Primary Diagnosis:
Bilateral ischiorectal abscess
Crohn's Disease
s/p diverting end ileostomy
.
Secondary Diagnoses:
Acquired QT Prologation (now resolved)
s/p cardiac arrest
Discharge Condition:
Good. Afebrile. Decreased drainage from abscess. Normal
cardiac function.
Discharge Instructions:
You were hospitalized at the [**Hospital1 18**] for an ischiorectal abscess
(infection with a pus collection) that fistulized (communicated)
with your bowel. The abscess was surgically drained, however
because of the fistula, a diverting ileostomy was performed to
drain your stool into a bag in order to help the abscess heal.
Your hospital stay was complicated by a cardiac arrest where
your heart stopped functioning properly for a short period of
time(minutes). Because of this episode, you were intubated and
then watched in the ICU for several days. From reviewing the
records, it appears your heart when into an abnormal rhythm
called "torsades de pointes." We believe this was due to
'acquired QT prolongation' where some medications you were
prescribed lengthened a particular part of the cardiac cycle.
It is very important you avoid these medications in the future:
these include quinolone antibiotics (levofloxacin/Levaquin,
ciprofloxacin, moxifloxacin, gatifloxcin), reglan, and
fluconazole. Please inform all your current and future
healthcare providers (doctors, nurses, emergency personnel) that
you had this problem and should NOT prescribed medications with
a side effect of prolonging the QT interval. As a part of the
evaluation of your cardiac arrest, you underwent a cardiac
catheterization to look at the arteries in your heart - the
arteries were normal (no clogged arteries).
You should follow-up as detailed below with: the surgeons that
drained your abscess and performed your ileostomy operation; the
GI physicians to manage your Crohn's Disease; and endocrine. We
have also scheduled you with an appointment with a primary care
physician in [**Hospital6 733**].
Take all medications as prescribed. You have been started on a
steroid taper. You need to decrease your prednisone by 5 mg
each week (you are currently taking 25 mg; you will then taper
to one week of 20 mg a day; then you'll taper to one week of 15
mg daily, etc). The GI physcians and the endocrine physicians
will re-evaluate you after the taper is complete/near complete.
You have been started on a betablocker for heart rate control
(your primary care physician and you can decide whether to
continue this). You have been prescribed ativan as needed for
anxiety and percocet as need for pain. Percocet may make you
drowsy and can make you constipated. You should not drive or
operate heavy machinery when taking percocet. If you become
constipated, you can take a stool softner. If your pain is
mild, you can take acetaminophen (tylenol) or ibuprofen (motrin)
instead.
You should take calcium and vitamin D supplementation to
increase the strength of your bones, as prednisone decreases
[**Hospital6 500**] strength. This can either be through pills (like vitamins)
or liquid supplements (like Boost or Ensure). You should take
1200-1500 mg of elemental calcium each day and 800 units of
vitamin D each day.
It is extremely important that you keep well hydrated and take
in as much fluids as your put out in your urine and stool. You
can advance your diet as tolerated, starting with softer foods
and eventually eating normal food. If you have a limited
appetite, you should take BOOST shakes to ensure you get enough
nutrition, as good nutrition is essential to healing.
You can take [**Last Name (un) **] baths up to twice daily to help with wound
healing. (Fill up the bath tub with warm water and sit in it
for 15-20 mins.)
Follow the instructions of the [**Last Name (un) 9341**] nurse [**First Name (Titles) 4120**] [**Last Name (Titles) 9341**]
care.
You should be seen by your doctor or return to the hospital for:
*increased discharge from your abscess/wound
*increased pain at the site of your abscess/wound
*redness around or red streaks extending from your abscess/wound
or your stoma
*persistent fever >102
*nausea, vomiting, no output from your stoma, bloody stools
*lightheadedness/feeling like you might pass out
*chest pain/shortness of breath
*if you lose consciousness
*other symptoms that concern you.
Followup Instructions:
You should follow-up in 1 week with either Dr. [**Last Name (STitle) **] in Surgery.
Please call the Trauma Clinic at [**Telephone/Fax (1) 6439**] to make an
appointment.
Primary Care Appointment: Provider: [**Name10 (NameIs) 8741**] [**Name8 (MD) 9529**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2137-8-21**] 1:30
-Please call [**Hospital3 **] ([**Doctor First Name **]) at [**Telephone/Fax (1) 250**] to
update your insurance information.
Endocrine followup: Provider: [**Name10 (NameIs) **] DENSITY TESTING
Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2137-8-23**] 8:40; Provider: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 16051**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2137-8-23**] 9:30. [**Hospital Ward Name 23**]
Clinical Center, [**Location (un) 436**].
Gastroenterology: Dr. [**First Name4 (NamePattern1) 1939**] [**Last Name (NamePattern1) 1940**] on Friday, [**2137-9-6**] at 3PM.
-Please contact the GI office at [**Telephone/Fax (1) 1983**] to update
registration information and obtain directions. Please bring
your insurance card and copay to the appointment.
Completed by:[**2137-8-13**]
ICD9 Codes: 5070, 2762, 4275, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2697
} | Medical Text: Admission Date: [**2139-3-20**] Discharge Date: [**2139-3-28**]
Date of Birth: [**2060-1-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
decreased exercise tolerance
Major Surgical or Invasive Procedure:
[**2139-3-20**] s/p Aortic valve replacement (21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Supra
Porcine)
History of Present Illness:
79 year old female with known aortic stenosis followed by serial
echocardiograms who presented to clinic in [**2139-1-12**] for
evaluation for aortic valve replacement given recent
echocardiographic evidence of severe
aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] 0.76. She has a long standing
history of heart murmur. She has noted mild decrease in exercise
tolerance over the last several years. She denies exertional
shortness of breath, chest pain and syncope. She presents this
morning for aortic valve replacement.
Past Medical History:
Hypercholesterolemia
Aortic Stenosis
Hypercoagulable state (Heterozygous for Factor V leiden)
Uterine Prolapse, pessary ring in place
Microscopic Hematuria - currently undergoing evaluation
History of Small Bowel Obstruction
Anxiety/Depression
History of Rosacea
s/p SBO requiring surgery [**5-18**]
s/p C-section x 1
Social History:
Lives with: Husband
Occupation: Retired
Tobacco: small amount of smoking greater than 25 years ago
ETOH: occasional, no history of excessive intake
Family History:
Siblings with valve replacements and bypass surgery in their
60-70's. Daughter with history of DVT.
Physical Exam:
Pulse: 83 Resp: 20 O2 sat: 100%
B/P Right: 103/61 Left: 106/59
General: Elderly female in NAD, appears younger than stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x], no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 4/6 systolic ejection
murmur
radiating to carotids and precordium
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: trace/Varicosities: GSV suitable, no varicosities
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: transmitted murmurs
Pertinent Results:
[**2139-3-24**] 06:15AM BLOOD WBC-10.7 RBC-3.73* Hgb-11.0* Hct-33.1*
MCV-89 MCH-29.6 MCHC-33.3 RDW-16.2* Plt Ct-130*
[**2139-3-25**] 06:45AM BLOOD PT-15.1* INR(PT)-1.3*
[**2139-3-20**] 11:48AM BLOOD PT-14.2* PTT-40.1* INR(PT)-1.2*
[**2139-3-25**] 06:45AM BLOOD UreaN-20 Creat-0.5 K-3.6
[**2139-3-24**] 06:15AM BLOOD Glucose-104* UreaN-24* Creat-0.5 Na-141
K-3.9 Cl-102 HCO3-33* AnGap-10
[**2139-3-26**] 09:40AM BLOOD PT-31.1* INR(PT)-3.1*
[**2139-3-25**] 06:45AM BLOOD PT-15.1* INR(PT)-1.3*
Prebypass
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. There are simple atheroma in the
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). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
mild valvular mitral stenosis (area 1.5-2.0cm2). Mild to
moderate ([**12-13**]+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results on [**2139-3-20**] at 830am.
Post bypass
Patient is A paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Bioprosthetic
valve seen in the aortic position. Leaflets seem to move well
and the valve appears well seated. No aortic insufficiency seen.
The images post bypass are not of great quality due to extreme
rotation of the heart to the left. Mean gradient across the
valve is 10 mm Hg. Mild mitral regurgitation persists. Aorta is
intact post decannulation.
Brief Hospital Course:
Admitted same day surgery and underwent aortic valve
replacement. See operative report for further details. She
received cefazolin for perioperative antibiotics. Post
operatively she was transferred to the intensive care unit for
management. In the first twenty four hours she was weaned from
sedation and awoke neurologically intact. She remained
intubated due to respiratory acidosis and on post operative day
one was extubated. She continued to progress and was ready for
transfer on post operative day two to the floor. Physical
therapy worked with her on strength and mobility. She developed
atrial fibrillation which was treated with betablockers and
amiodarone. She was started on coumadin for anticoagulation due
to atrial fibrillation as well as amiodarone. She had
fluctuating INRs but settled on a dose of 1 mg coumadin.
She was deemed ready for discharge to [**Location (un) **] Health Rehab by
Dr. [**Last Name (STitle) **] on post operative day eight.
Medications on Admission:
Citalopram 20mg po daily
Simvastatin 40mg po daily
ASA 81mg po daily
MVI 1 tab po daily
Caltrate Plus 1 tab po daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. Caltrate Plus 600-400 mg-unit Tablet Sig: One (1) Tablet PO
once a day.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
Coumadin follow-up through [**Hospital 2274**] [**Hospital3 **] once
discharged from rehab with results to [**Telephone/Fax (1) 55854**] (conf. w
[**Doctor First Name **]), Dr. [**Last Name (STitle) 86612**] to follow, first INR draw [**2139-3-29**] in rehab
with rehab to dose until discharge and follow closely secondary
to fluctuating INRs,
dx: atrial fibrillation, INR goal [**1-14**]
9. 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 until further instructed.
Disp:*120 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
11. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days: for urinary tract
infection.
Disp:*4 Tablet(s)* Refills:*0*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days: titrate as needed for diuresis of [**12-12**].5L negative daily
toward pre-operative wt of 59 kgs.
Disp:*14 Tablet(s)* Refills:*2*
13. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day for 1
doses: first INR draw [**2139-3-29**] in rehab with rehab to dose until
discharge and follow closely secondary to fluctuating INRs, dx:
atrial fibrillation, INR goal [**1-14**].
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] healthcare rehab
Discharge Diagnosis:
Aortic Stenosiss/p AVR
Hypercholesterolemia
Hypercoagulable state (Heterozygous for Factor V leiden)
Uterine Prolapse, pessary ring in place
Microscopic Hematuria - currently undergoing evaluation
History of Small Bowel Obstruction
Anxiety/Depression
Rosacea
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2139-4-23**] 1:00
Please call to schedule appointments
Primary Care Dr [**First Name4 (NamePattern1) 17728**] [**Last Name (NamePattern1) **] in [**12-13**] weeks [**Telephone/Fax (1) 17465**]
Cardiologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19**] in [**12-13**] weeks
Coumadin follow-up through [**Hospital 2274**] [**Hospital3 **], first
INR draw [**2139-3-27**], results to [**Telephone/Fax (1) 55854**] (conf. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]), Dr.
[**Last Name (STitle) 86612**] to follow
Completed by:[**2139-3-28**]
ICD9 Codes: 4241, 2762, 9971, 5990, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2698
} | Medical Text: Admission Date: [**2176-6-4**] Discharge Date: [**2176-6-11**]
Date of Birth: [**2108-4-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Overdose
Major Surgical or Invasive Procedure:
pt intubated prior to arrival at [**Hospital1 18**]
History of Present Illness:
History of Present Illness: 68yo female with stage IV melanoma
presents w/ OD (suicide attempt)
.
Patient was last seen normal at around noon yesterday. She went
to take a nap around 3pm and was woken up by her husband at
430pm. [**Name2 (NI) **] husband found that she was minimally responsive with
shallow breathing and slow HR. Her husband reports finding
empty and near-empty pill bottles in her medicine bag so he
called EMS and she was taken to OSH ED. He reports that she
took "alot" of percocet, ambien and xanax in what was an
apparent suicide attempt given her diagnosis of stage IV
melanoma. No one witnessed the ingestion and the drug
identities were based on how much was left in each bottle. The
patient does not have a history of suicide attempts but has
mentioned SI in passing in the last year. Per her husband, she
has always said she would never do that to him though.
.
On arrival to the OSH, she was found to be altered. She
received naloxone and activated charcoal with minimal response.
She underwent a CT head, which was negative for an acute
intracranial process. Given her AMS, she was intubated and
sedated for airway protection and then transferred to [**Hospital1 18**] for
ICU care. Of note, lab work at OSH was apparently normal as was
EKG.
.
On arrival to [**Hospital1 18**] ED, she was intubated and sedated. Lab work
is currently pending. EKG showed some small ST-depressions in
V4-V6. Patient in no apparent distress in the ED. Vital signs
on transfer were HR- 48, BP- 159/83, RR- 16, SaO2- 100% on
mechanical ventilation. Patient was afebrile.
.
On arrival to the floor, vital signs were stable. Patient
intubated and sedated. Family at bedside
Past Medical History:
2. Depression- no history of suicide attempts
3. Hyperlipidemia
4. Cervical cancer- underwent TAH about 30 years ago
5. Migraines
Social History:
- Tobacco: None
- Alcohol: [**11-25**] drink per night
- Illicits: None
Family History:
No cancers, heart disease. Mother- "drug and EtOH problems".
Possible history of suicide attempts on mothers side.
Physical Exam:
Admission
General: Intubated, sedated
HEENT: Sclera anicteric, MMM. Pinpoint pupils. Intubated
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
Neuro: Sedated
.
Discharge:
VS: afebrile 128/88 54 20 99RA
GEN: AAOx3. Pleasant.
HEENT: eomi, perrl, MMM.
Neck: No LAD. JVP WNL.
RESP: CTA B. No WRR.
CV: RRR. No mrg.
ABD: +BS. Soft, NT/ND.
Ext: No CEE.
Neuro: CN 2-12 intact.
Pertinent Results:
[**2176-6-9**] 06:00AM BLOOD WBC-3.9* RBC-3.95* Hgb-12.3 Hct-36.3
MCV-92 MCH-31.1 MCHC-33.8 RDW-12.5 Plt Ct-148*
[**2176-6-9**] 06:00AM BLOOD Glucose-81 UreaN-8 Creat-0.7 Na-142 K-4.5
Cl-112* HCO3-21* AnGap-14
[**2176-6-5**] 12:50AM BLOOD ALT-15 AST-25 LD(LDH)-135 CK(CPK)-33
AlkPhos-52 TotBili-0.3
[**2176-6-5**] 04:14AM BLOOD ALT-19 AST-27 LD(LDH)-198 CK(CPK)-34
AlkPhos-55 TotBili-0.4
[**2176-6-5**] 12:50AM BLOOD CK-MB-2 cTropnT-<0.01
[**2176-6-5**] 04:14AM BLOOD CK-MB-2 cTropnT-<0.01
[**2176-6-9**] 06:00AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.0
Tox screen:
[**2176-6-5**] 12:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2176-6-5**] 12:50AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Urine:
[**2176-6-6**] 11:38PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-4* pH-5.5 Leuks-SM
[**2176-6-6**] 11:38PM URINE RBC-19* WBC-11* Bacteri-FEW Yeast-NONE
Epi-0
URINE CULTURE (Final [**2176-6-9**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
BETA STREPTOCOCCUS GROUP B. 10,000-100,000
ORGANISMS/ML..
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
CSF:
[**2176-6-7**] 02:56PM CEREBROSPINAL FLUID (CSF) WBC-7 RBC-0 Polys-1
Lymphs-96 Monos-0 Macroph-3
[**2176-6-7**] 02:56PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-7* Polys-1
Lymphs-97 Monos-0 Macroph-2
[**2176-6-7**] 02:56PM CEREBROSPINAL FLUID (CSF) TotProt-50*
Glucose-56
[**2176-6-7**] 02:56PM CSF HERPES SIMPLEX VIRUS PCR-Negative
CSF Culture:
GRAM STAIN (Final [**2176-6-7**]):
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 [**2176-6-10**]): NO GROWTH.
Brief Hospital Course:
Assessment and Plan
#. Overdose/Mental Status - It was determined that the patient
had overdosed on Ambien and Xanax. Toxicology was consulted. She
was initially intubated for airway protection and then extubated
in the ICU once she became more alert. She was persistently
somnolent and confused, however. Her EKG showed no persistent
abnormalities. CT Head was normal. She had an LP performed. The
CSF culture was negative. It is noted that there were 7 WBC in
one vial, 4 WBC in another vial, with lymphocyte predominance.
While this is a slightly abnormal result, pt does not have any
evidence of CSF infection, and it is reassuring that her mental
status has cleared, and the cultures are negative. Furthermore,
it is reassuring that the herpes PCR is negative as well. These
results were discussed with a Neurology attending on call, and
agreed that while results are mildly abnormal, are not of
significant concern. It is possible that pt may have had a
recent viral infection vs a seizure while sedated from overdose,
which may have led to this result. This is not a
contraindication for discharge to inpatient psychiatric care,
and would not be a contraindication to ECT if otherwise
indicated. The patient was kept on suicide precautions with a
1:1 sitter, and psychiatry was consulted, who placed pt on
Section 12. Pt is medically stable for transfer to inpatient
psychiatry.
.
#Fever: The patient was febrile to 101 while in the ICU. Her
urine culture grew enterococcus as well as Group B Beta-strep.
She was treated with ampicillin x 3 days.
#. Stage IV melanoma- Patient currently followed at MD
[**Location (un) 4223**]. Currently on a trial for new monoclonal antibody.
The patient's family reports that she is currently free of
disease.
#. Hyperlipidemia- The patient was continued on her
atorvastatin.
#. Migraine headaches - pt has a long history of migraine
headaches, usually daily. These symptoms are not new, and her
current migraines are typical for her. She was treated with
imitrex intermittently (every other day), and with ibuprofen and
compazine on other days to avoid using triptans daily.
Medications on Admission:
1. Paroxetine 20mg daily
2. Lipitor 10mg daily
3. Simvastatin 10mg daily
4. Prednisone- 5mg daily
5. Ambien 10mg- 1-2 tabs qHS
6. Dextroamphet 10mg- 1 tab [**Hospital1 **]
7. Xanax- 1mg q2-4hrs
8. Percocet 5-325mg- 1 tab QID prn pain
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 1 days.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea or HA.
7. Imitrex 25 mg Tablet Sig: One (1) Tablet PO as directed as
needed for Migraine headaches: 1 tab po q day, may repeat x1, if
needed. Use every other day.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, headache.
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain/Headache.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
# Overdose of medications; narcotics, benzodiazepine
# Suicide attempt
# Chronic migraine headaches
# Depression
# Stage IV melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after an overdose of medications. You required
intubation, and were transferred to our ICU. You were
monitored, and the breathing tube was removed as you began to
wake up from the medications. You were evaluated by psychiatry,
and will be transferred to their service for ongoing care.
Followup Instructions:
Please follow up with your PCP after discharge from Psychiatry
for further management of your migraine headaches.
ICD9 Codes: 5990, 2768, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 2699
} | Medical Text: Admission Date: [**2183-11-5**] Discharge Date: [**2183-11-18**]
Date of Birth: [**2158-6-4**] Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 25-year-old
male who paramedics responded to and found him lying in the
road. The patient was a helmeted driver of a motor vehicle
struck by car which subsequently left the seen. The patient
was found prone and unconscious with positive loss of
consciousness approximately five minutes. Upon arrival, the
ambulance personnel noticed that the patient was conscious
and alert to self but somewhat confused about the events
leading up to the accident. He was complaining of left wrist
and right hip pain. The right leg was noted to be externally
rotated. The patient was immobilized and had a collar
placed.
The patient was seen in the Emergency Department and had a
CAT scan of the head and cervical spine and of the abdomen.
The patient had a negative CAT scan of the head and cervical
spine. The patient received an AP chest film which was
normal. He had no pneumothorax and no fractures.
AP of the pelvis showed a fracture within the proximal
diaphyses of the right femur. The patient was given a CT of
the pelvis with contrast. On note, there was hemoperitoneum
seen tracking into the pelvis in addition to the fracture
fragment visualized to the right femur. A large burst
fracture of the liver through the right lobe was noted. The
fracture sank through the capsule and through a large portion
of the right lobe of the liver. Extensive hemorrhage was
noted tracking down into the pelvis. Also noted on the
opposite spleen, a moderate sized right kidney perinephric
hematoma was noted. A small area of capsular rupture was
seen in the lower pole of said kidney without evidence of
extravasation of intravenous contrast. The left kidney was
normal.
Note: An addendum will follow.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-205
Dictated By:[**Last Name (NamePattern1) 45564**]
MEDQUIST36
D: [**2183-11-18**] 14:30
T: [**2183-11-18**] 14:38
JOB#: [**Job Number 45565**]
ICD9 Codes: 5119 |
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